Tissue Integrity: Burns

Question 1

Shock

Answer 1

Widespread abnormal cellular metabolism that occurs when oxygenation and tissue perfusion needs are not met to the level necessary to maintain cell function

Question 2

Cardiovascular manifestations of shock

Answer 2

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

Question 3

Respiratory manifestations of shock

Answer 3

increased RR, shallow depth of respirations, increased PaCO2, decreased PaO2, cyanosis

Question 4

Early neuromuscular manifestations of shock

Answer 4

anxiety, restlessness, increased thirst

Question 5

Late neuromuscular manifestations of shock

Answer 5

decreased central nervous system activity (lethargy to coma), generalized muscle weakness, diminished or absent deep tendon reflexes, sluggish pupillary response to light

Question 6

Kidney manifestations of shock

Answer 6

decreased urine output, increased specific gravity, sugar and acetone present in urine

Question 7

Integumentary manifestations of shock

Answer 7

cool to cold, pale to mottled to cyanotic, moist, clammy, mouth dry; pastelike coating present

Question 8

Gastrointestinal manifestations of shock

Answer 8

decreased motility, diminished or absent bowel sounds, nausea and vomiting, constipation

Question 9

Hypovolemic shock

Answer 9

occurs when too little circulating blood volume causes a MAP decrease, resulting in inadequate total body oxygenation

Question 10

Distributive shock

Answer 10

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

Question 11

Capillary leak syndrome

Answer 11

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

Question 12

Hypovolemic shock results in

Answer 12

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

Question 13

Continued MAP decrease in hypovolemic shock

Answer 13

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

Question 14

Hypovolemic shock adaptive responses: initial stage

Answer 14

decrease in baseline MAP of 5-10 mm Hg; increased sympathetic stimulation: mild vasoconstriction, increased heart rate

Question 15

Hypovolemic shock adaptive responses: nonprogressive stage

Answer 15

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

Question 16

Hypovolemic shock adaptive responses: progressive stage

Answer 16

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

Question 17

Hypovolemic shock adaptive responses: refractory stage

Answer 17

severe tissue hypoxia with ischemia and necrosis; release of myocardial depressant factor from the pancreas; buildup of toxic metabolites; MODS; death

Question 18

Nursing Safety Priority

Answer 18

RN rather than LPN or UAP should assess the VS of pt who is at risk for or suspected of having hypovolemic shock

Question 19

Nursing Safety Priority

Answer 19

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

Question 20

Hypovolemic shock: pH

Answer 20

Normal 7.35-7.45; will be decreased: insufficient tissue oxygenation causing anaerobic metabolism and acidosis

Question 21

Hypovolemic shock: PaO2

Answer 21

Normal 80-100; will be decreased: anaerobic metabolism

Question 22

Hypovolemic shock: PaCO2

Answer 22

Normal 35-45; will be increased: anaerobic metabolism

Question 23

Hypovolemic shock: lactic acid

Answer 23

normal 3-7 or 0.3-0.8; will be increased: anaerobic metabolism with buildup of metabolites

Question 24

Hypovolemic shock: hematocrit

Answer 24

normal 37-52: will be increased: fluid shift, dehydration; or decreased: hemorrhage

Question 25

Hypovolemic shock: hemoglobin

Answer 25

normal 12-18: will be increased: fluid shift, dehydration; or decreased: hemorrhage

Question 26

Hypovolemic shock: potassium

Answer 26

normal 3.5-5.0: will be increased: dehydration, acidosis

Question 27

Hypovolemic shock: best practice

Answer 27

ensure patent airway; start IV or maintain established IV; administer oxygen; elevate pts feet; head no higher than 30-degree angle; examine pt for overt bleeding; if overt bleeding present, apply direct pressure to site; administer drugs as prescribed; increase IV fluid rate of delivery; do not leave pt

Question 28

Hypovolemic shock: IV therapy

Answer 28

crystalloids (NS or LR); whole blood to replace large blood losses; PRBCs to replace moderate blood loss; plasma to restore osmotic pressure when Hgb and Hct are WNL

Question 29

Hypovolemic shock: drug therapy - vasoconstrictors

Answer 29

dopamine, norepinephrine: stimulate venous return by constricting blood vessels and decreasing venous pooling; increase cardiac output and MAP; improves perfusion and oxygenation

Question 30

Hypovolemic shock: drug therapy - inotropics

Answer 30

dobutamine: stimulates adrenergic receptors in the hear; improves heart muscle contractility

Question 31

Hypovolemic shock: drug therapy - myocardial perfusion

Answer 31

sodium nitroprusside: ensures heart is well perfused; dilates coronary blood vessels while minimally dilating systemic vessels

Question 32

Hypovolemic shock: monitoring pt

Answer 32

pulse, BP, pulse pressure, CVP, RR, skin and mucosal color, O2 sat, mental status, urine output