Tissue Integrity: Burns Flashcards
Shock
Widespread abnormal cellular metabolism that occurs when oxygenation and tissue perfusion needs are not met to the level necessary to maintain cell function
Cardiovascular manifestations of shock
decreased cardiac output, increased pulse rate, thread pulse, decreased blood pressure, narrowed pulse pressure, postural hypotension, low CVP, flat neck and hand veins in dependent positions, slow capillary refill, diminished peripheral pulses
Respiratory manifestations of shock
increased RR, shallow depth of respirations, increased PaCO2, decreased PaO2, cyanosis
Early neuromuscular manifestations of shock
anxiety, restlessness, increased thirst
Late neuromuscular manifestations of shock
decreased central nervous system activity (lethargy to coma), generalized muscle weakness, diminished or absent deep tendon reflexes, sluggish pupillary response to light
Kidney manifestations of shock
decreased urine output, increased specific gravity, sugar and acetone present in urine
Integumentary manifestations of shock
cool to cold, pale to mottled to cyanotic, moist, clammy, mouth dry; pastelike coating present
Gastrointestinal manifestations of shock
decreased motility, diminished or absent bowel sounds, nausea and vomiting, constipation
Hypovolemic shock
occurs when too little circulating blood volume causes a MAP decrease, resulting in inadequate total body oxygenation
Distributive shock
occurs when blood volume is not lost from the body but it is distributed to the interstitial tissues where it cannot circulate and deliver oxygen
Capillary leak syndrome
response of the capillaries to the presence of biologic mediator that change blood vessel integrity and allow fluid to shift from the blood vessels into the interstitial tissues where they cannot deliver oxygen or remove tissue waste products
Hypovolemic shock results in
a decreased MAP and loss of oxygen-carrying capacity from the loss of circulating RBCs; slows blood flow resulting in decreased tissue perfusion; decreases the ability for the blood to oxygenate the tissue it reaches
Continued MAP decrease in hypovolemic shock
some tissues function under anaerobic conditions but lactic acid levels and other harmful metabolites increase; causes electrolyte and acid-base imbalances; reversible if the cause of shock is corrected within 1-2 hrs after onset
Hypovolemic shock adaptive responses: initial stage
decrease in baseline MAP of 5-10 mm Hg; increased sympathetic stimulation: mild vasoconstriction, increased heart rate
Hypovolemic shock adaptive responses: nonprogressive stage
decrease in baseline MAP of 10-15 mm Hg; continued sympathetic stimulation: moderate vasoconstriction, increased heart rate, decreased pulse pressure; chemical compensation: renin, aldosterone, and antidiuretic hormone secretion result in increased vasoconstriction, decreased urine output, and stimulation of the thirst reflex; some anaerobic metabolism in nonvital organs: mild acidosis, mild hyperkalemia
Hypovolemic shock adaptive responses: progressive stage
decrease in baseline MAP of >20 mm Hg; anoxia of nonvital organs; hypoxia of vital organs; overall metabolism is anaerobic: moderate acidosis, moderate hyperkalemia, tissue ischemia
Hypovolemic shock adaptive responses: refractory stage
severe tissue hypoxia with ischemia and necrosis; release of myocardial depressant factor from the pancreas; buildup of toxic metabolites; MODS; death
Nursing Safety Priority
RN rather than LPN or UAP should assess the VS of pt who is at risk for or suspected of having hypovolemic shock
Nursing Safety Priority
because changes in systolic BP are not always present in the initial stage of shock, use changes in pulse rate and quality as main indicators of shock presence or progression
Hypovolemic shock: pH
Normal 7.35-7.45; will be decreased: insufficient tissue oxygenation causing anaerobic metabolism and acidosis
Hypovolemic shock: PaO2
Normal 80-100; will be decreased: anaerobic metabolism
Hypovolemic shock: PaCO2
Normal 35-45; will be increased: anaerobic metabolism
Hypovolemic shock: lactic acid
normal 3-7 or 0.3-0.8; will be increased: anaerobic metabolism with buildup of metabolites
Hypovolemic shock: hematocrit
normal 37-52: will be increased: fluid shift, dehydration; or decreased: hemorrhage
