Week 4 - Shock & MODS Flashcards
Shock
- Syndrome characterized by decreased tissue __________ and impaired cellular __________
- Imbalance in supply/demand for ___ and nutrients
Shock
- Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism
- Imbalance in supply/demand for O2 and nutrients
Categories of Shock
-Hypovolemic Shock [absolute or relative]
-Cardiogenic Shock
-Obstructive shock
Distributive shock—
-Septic Shock
-Anaphylactic Shock
-Neurogenic Shock
-Hypovolemic Shock [absolute or relative]
-Cardiogenic Shock
-Obstructive shock
Distributive shock—
-Septic Shock
-Anaphylactic Shock
-Neurogenic Shock
Classifications of Shock
Low _________
- Cardiogenic
- Hypovolemic
Maldistribution/___________
- Septic
- Anaphylactic
- Neurogenic
Low blood flow
- Cardiogenic
- Hypovolemic
Maldistribution/Distributive
- Septic
- Anaphylactic
- Neurogenic
Low Blood Flow - Hypovolemic Shock
- Absolute hypovolemia: loss of __________ fluid volume
- Hemorrhage
- GI loss (e.g. severe vomiting, diarrhea)
- Diabetes insipidus
- Diuresis
- Absolute hypovolemia: loss of intravascular fluid volume
- Hemorrhage
- GI loss (e.g. severe vomiting, diarrhea)
- Diabetes insipidus
- Diuresis
Low Blood Flow - Hypovolemic Shock
- Relative hypovolemia
Results when fluid volume moves out of the vascular space into _____________ space (e.g., interstitial or intracavitary space)
– i.e. burns, ascitis, internal bleed
- Relative hypovolemia
Results when fluid volume moves out of the vascular space into extravascular space (e.g., interstitial or intracavitary space)
– i.e. burns, ascitis, internal bleed
Clinical Manifestations - Hypovolemic Shock
- _________ in BP, PP, SV, PAWP, CVP, CO
- ________ HR, SVR
- Decrease in UO
- Decrease SvO2/ScvO2
- Tachypnea
- Cool and diaphoretic
- Anxious, confused, agitated
- Decrease in BP, PP, SV, PAWP, CVP, CO
- Increase HR, SVR
- Decrease in UO
- Decrease SvO2/ScvO2
- Tachypnea
- Cool and diaphoretic
- Anxious, confused, agitated
Diagnostic Findings - Hypovolemic Shock
- CBC
- Electrolyte levels (eg, Na, K, Cl, HCO3, BUN,
creatinine, glucose levels)
- Prothrombin time, activated partial thromboplastin time
- ABGs
- Urinalysis (specific gravity)
- Blood type and cross-match
- Lactate levels
- CBC
- Electrolyte levels (eg, Na, K, Cl, HCO3, BUN,
creatinine, glucose levels) - Prothrombin time, activated partial thromboplastin time
- ABGs
- Urinalysis (specific gravity)
- Blood type and cross-match
- Lactate levels
Collaborative Care - Hypovolemic Shock
- Overall management goal: focus on stopping the loss of fluid and restoring ________
- Airway and oxygenation
- 2 large bore IV’s (16 Gauge)
- Fluid replacement (crystalloids or colloids)
- Possible: Arterial line
- Specific meds based on etiology
- Overall management goal: focus on stopping the loss of fluid and restoring volume
- Airway and oxygenation
- 2 large bore IV’s (16 Gauge)
- Fluid replacement (crystalloids or colloids)
- Possible: Arterial line
- Specific meds based on etiology
Low Blood Flow - Cardiogenic Shock - Precipitating causes:
- Primary ventricular ischemia
– ___ being most common cause - Structural problems
- Sustained dysrhythmias
- Primary ventricular ischemia
– MI being most common cause - Structural problems
- Sustained dysrhythmias
Clinical Manifestations - Cardiogenic Shock
- _________ in CO, BP, PP, UO
- _________in Myocardial O2 consumption, HR, SVR, PVR, PAWP, CVP
- Decrease in SvO2/ScvO2
- Tachypnea, pulmonary congestion
- Pallor, cool, clammy skin
- Anxiety, confusion, agitation
- Decrease in CO, BP, PP, UO
- Increase in Myocardial O2 consumption, HR, SVR, PVR, PAWP, CVP
- Decrease in SvO2/ScvO2
- Tachypnea, pulmonary congestion
- Pallor, cool, clammy skin
- Anxiety, confusion, agitation
Diagnostic Findings - Cardiogenic Shock
- CBC, Chem panel, Coag Panel
- Cardiac biomarkers
- ABG
- Lactate
- ECG: Dysrhythmias
- ECHO: Left ventricular dysfunction
- CXR: Pulmonary infiltrates
- CBC, Chem panel, Coag Panel
- Cardiac biomarkers
- ABG
- Lactate
- ECG: Dysrhythmias
- ECHO: Left ventricular dysfunction
- CXR: Pulmonary infiltrates
Collaborative Care - Cardiogenic Shock
- Correct _________ & ________ abnormalities
- _____________ monitoring (PA and art lines)
- Drug therapy
-Improve preload - Reduce afterload
- Improve contractility
- Circulatory assist devices (e.g., intra-aortic balloon pump, ventricular assist device)
- Correct electrolyte and acid-base abnormalities
- Hemodynamic monitoring (PA and art lines)
- Drug therapy
-Improve preload - Reduce afterload
- Improve contractility
- Circulatory assist devices (e.g., intra-aortic balloon pump, ventricular assist device)
Collaborative Care - Cardiogenic Shock
- Oxygenation and _______ protection
- Restore blood flow to the _________
- Thrombolytic therapy (t-PA)
- Emergency revascularization
- CABG or valve replacement
- Oxygenation and airway protection
- Restore blood flow to the myocardium
- Thrombolytic therapy (t-PA)
- Emergency revascularization
- CABG or valve replacement
Maldistribution of Blood Flow - Septic Shock
- Sepsis: is a life threatening organ dysfunction caused by dysregulated _______________________________
- Septic shock: ____________ despite fluid replacement; need vasopressors to keep MAP ≥ to 65 mmHg
- Sepsis: is a life threatening organ dysfunction caused by dysregulated host response to infection
- Septic shock: hypotension despite fluid replacement; need vasopressors to keep MAP ≥ to 65 mmHg
Sepsis Screening
SIRS Criteria:
- High or low temperature > 38 or < 36
- Heart Rate > __ bpm
- Respiratory Rate > ___ or PaCO2 < 32 mm Hg
- WBC’s >12 or < 4 , or with > 10% bands
Q SOFA Score of 2 or greater
- Altered mental status (GCS score <15)
- Systolic blood pressure <100 mmHg
- Respiratory rate >22/min
SIRS Criteria:
- High or low temperature > 38 or < 36
- Heart Rate > 90 bpm
- Respiratory Rate > 20min or PaCO2 < 32 mm Hg
- WBC’s >12 or < 4 , or with > 10% bands
Q SOFA Score of 2 or greater
- Altered mental status (GCS score <15)
- Systolic blood pressure <100 mmHg
- Respiratory rate >22/min
Clinical Manifestations - Septic Shock
- Increased HR, RR
- Decreased BP, PP, SVR, CVP, PAWP
- Decreased CO, SvO2/ScvO2
- Temperature dysregulation
- ↓ Urine output
- Altered neurologic status, GI dysfunction, respiratory failure, myocardial dysfunction
- Increased HR, RR
- Decreased BP, PP, SVR, CVP, PAWP
- Decreased CO, SvO2/ScvO2
- Temperature dysregulation
- ↓ Urine output
- Altered neurologic status, GI dysfunction, respiratory failure, myocardial dysfunction
Diagnostic Findings - Septic Shock
- CBC: Increase or decrease in _____ and decreased _____
- Increased ______ levels
- Positive cultures (urine, sputum, blood)
- CBC: Increase or decrease in WBC’s and decreased platelets
- Increased lactate levels
- Positive cultures (urine, sputum, blood)
Collaborative Care - Septic Shock
- Surviving Sepsis 2018 bundle (1-3 hours)
- Measure ________, re-measure if elevated
- Pan culture and give ___________ as early as possible
- Fluid resuscitate for hypotension or lactate > 4; ___________ are preferred
- Goal CVP 8-12 mm Hg
- Urine output > 0.5ml/kg/hr & lungs clear
- Start vasopressors for hypotension refractory to fluids
- (e.g. Dopamine, norepinephrine [Levophed])
- Consider transfer to the ICU
- Surviving Sepsis 2018 bundle (1-3 hours)
- Measure lactate, re-measure if elevated
- Pan culture and give antibiotics as early as possible
- Fluid resuscitate for hypotension or lactate > 4; crystalloids are preferred
- Goal CVP 8-12 mm Hg
- Urine output > 0.5ml/kg/hr & lungs clear
- Start vasopressors for hypotension refractory to fluids
- (e.g. Dopamine, norepinephrine [Levophed])
- Consider transfer to the ICU
Collaborative Care - Septic Shock
- Hemodynamic monitoring (CLC with CVP and ScVO2 monitoring)
- Protective lung ventilation (low tidal volumes w/ pressure control)
- IV corticosteroids**
- Hemodynamic monitoring (CLC with CVP and ScVO2 monitoring)
- Protective lung ventilation (low tidal volumes w/ pressure control)
- IV corticosteroids**
Maldistribution of Blood Flow - Anaphylactic Shock
- Acute, life-threatening hypersensitivity reaction to a sensitizing substance
- Massive __________ (circulatory collapse)
- Release of vasoactive mediators
- ↑ Capillary __________
- Respiratory distress (Bronchospasm, laryngeal edema)
- Acute, life-threatening hypersensitivity reaction to a sensitizing substance
- Massive vasodilatation (circulatory collapse)
- Release of vasoactive mediators
- ↑ Capillary permeability
- Respiratory distress (Bronchospasm, laryngeal edema)
Clinical Manifestations - Anaphylactic Shock
- Sudden and worsens on _______ exposure
- Uneasy, apprehensive, anxious, impending doom
- Itching, flushing, urticaria (hives), angioedema
- Bronchoconstriction, excessive mucous, wheezing, stridor—laryngeal edema—
hypoxemia - Increase in __
- Decrease in __, PP, SVR, CVP, PAWP, CO, SvO2/ScvO2
- Sudden and worsens on repeat exposure
- Uneasy, apprehensive, anxious, impending doom
- Itching, flushing, urticaria (hives), angioedema
- Bronchoconstriction, excessive mucous, wheezing, stridor—laryngeal edema—
hypoxemia - Increase in HR
- Decrease in BP, PP, SVR, CVP, PAWP, CO, SvO2/ScvO2
Collaborative Care - Anaphylactic Shock
- Maintaining a patent _______
- Oxygen
- Endotracheal intubation or tracheotomy
- Nebulized bronchodilators
- ________ine
- Diphenhydramine (Benadryl)
- Aggressive _____ replacement
- Maintaining a patent airway
- Oxygen
- Endotracheal intubation or tracheotomy
- Nebulized bronchodilators
- Epinephrine
- Diphenhydramine (Benadryl)
- Aggressive fluid replacement
Maldistribution of Blood Flow - Neurogenic Shock
Hemodynamic phenomenon that can occur within 30 minutes of a ____________ injury at the fifth thoracic (T5) vertebra or above and can last up to 6 weeks
Can be in response to spinal __________
Results in massive vasodilation leading to pooling of _________ in __________
Hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic (T5) vertebra or above and can last up to 6 weeks
Can be in response to spinal anesthesia
Results in massive vasodilation leading to pooling of blood in vessels
Clinical Manifestations - Neurogenic Shock
- _________ in BP, PP, SVR, CVP, PAWP, CO, SvO2/ScvO2, bladder dysfunction
- Bradycardia**
- Dry skin**
- Temperature dysregulation (resulting in heat loss)**
- Poikilothermia (taking on the temperature of the environment)
- Decrease in BP, PP, SVR, CVP, PAWP, CO, SvO2/ScvO2, bladder dysfunction
- Bradycardia**
- Dry skin**
- Temperature dysregulation (resulting in heat loss)**
- Poikilothermia (taking on the temperature of the environment)
Collaborative Care - Neurogenic Shock
- __________ stability
- Treatment of the hypotension and bradycardia with __________ and atropine
- Fluids used cautiously as hypotension is generally not related to fluid loss
- Monitor and treat hypothermia
- Spinal stability
- Treatment of the hypotension and bradycardia with vasopressors and atropine
- Fluids used cautiously as hypotension is generally not related to fluid loss
- Monitor and treat hypothermia
Stages of Shock - No matter which type of shock they have:
[4]
- Initial Stage
- Compensatory Stage
- Progressive Stage
- Refractory Stage
Stages of Shock - Initial Stage
- Not clinically apparent
- Metabolism changes from aerobic to anaerobic
- __________ accumulates & must be removed by blood & broken down by liver
- Process requires O2 (unavailable)
- Not clinically apparent
- Metabolism changes from aerobic to anaerobic
- Lactic acid accumulates & must be removed by blood & broken down by liver
- Process requires O2 (unavailable)
Stages of Shock - Compensatory Stage
- Clinically apparent
- Attempts are aimed at overcoming consequences of anaerobic metabolism
and maintaining homeostasis - SNS response
- Decrease in organ and tissue __________ (e.g. renal – low UO, CNS – confusion)
- ________ble
- Clinically apparent
- Attempts are aimed at overcoming consequences of anaerobic metabolism
and maintaining homeostasis - SNS response
- Decrease in organ and tissue perfusion (e.g. renal – low UO, CNS – confusion)
- Correctable
Stages of Shock - Progressive Stage
- Begins when ______________ mechanisms fail
- See S/S of organ failure
- MUST implement aggressive interventions to prevent MODS
- Begins when compensatory mechanisms fail
- See S/S of organ failure
- MUST implement aggressive interventions to prevent MODS
Stages of Shock - __________ Stage
- MODS
- Brain (confusion, decrease LOC)
- Lungs (ARDS)
- Kidneys (AKI/Failure)
- Heart (Cardiovascular collapse)
- DIC
- Recovery unlikel
Refractory
MODS
- …is the progressive dysfunction of two or more organ systems
- …is the result of the uncontrolled ________ response to severe illness
or injury
-Most common cause: ________
- …is the progressive dysfunction of two or more organ systems
- …is the result of the uncontrolled inflammatory response to severe illness
or injury
-Most common cause: Sepsis
Diagnostic Criteria of MODS
- Pulmonary
- Dysfunction: hypoxia needing __ (at least 3-5 days)
- Failure: ____ (high FiO2 and high PEEP)
- Treatment: increase O2 delivery/decrease O2 consumption, protective lung modes, positioning
- Pulmonary
- Dysfunction: hypoxia needing MV (at least 3-5 days)
- Failure: ARDS (high FiO2 and high PEEP)
- Treatment: increase O2 delivery/decrease O2 consumption, protective lung modes, positioning
Diagnostic Criteria of MODS
- Cardiovascular
- Dysfunction: Decreased EF, arrhythmias, need for inotropic or vasopressor support, increase CVP & PAWP
- Failure: response refractory to inotropic or vasopressor support
- Treatment: Volume management, Vasopressors, IABP, VAD
- Cardiovascular
- Dysfunction: Decreased EF, arrhythmias, need for inotropic or vasopressor support, increase CVP & PAWP
- Failure: response refractory to inotropic or vasopressor support
- Treatment: Volume management, Vasopressors, IABP, VAD
Diagnostic Criteria of MODS
- CNS
- Dysfunction: ________ion, mild disorientation
- Failure: _________, hepatic encephalopathy, failure to wean, progressive coma
- Treatment: Maintain ________ blood flow, decrease cerebral O2 requirements
- CNS
- Dysfunction: Confusion, mild disorientation
- Failure: Seizures, hepatic encephalopathy, failure to wean, progressive coma
- Treatment: Maintain cerebral blood flow, decrease cerebral O2 requirements
Diagnostic Criteria of MODS
- Renal
- Dysfunction: Oliguria or rising creatinine
- Failure: Fixed specific gravity, require _______
- Treatment: Diuretics, Dopamine, CRRT
- Renal
- Dysfunction: Oliguria or rising creatinine
- Failure: Fixed specific gravity, require dialysis
- Treatment: Diuretics, Dopamine, CRRT
Diagnostic Criteria of MODS
- Hepatic
- Dysfunction: rise in _________ or liver enzymes
- Failure: Clinical _______ with bilirubin > 8-10 mg/dl, elevated _________ levels (NH3), hepatic encephalopathy
- Treatment: Maintain adequate tissue perfusion, provide nutritional support, cautious use of drugs metabolized by the liver
- Hepatic
- Dysfunction: rise in bilirubin or liver enzymes
- Failure: Clinical jaundice with bilirubin > 8-10 mg/dl, elevated ammonia levels (NH3), hepatic encephalopathy
- Treatment: Maintain adequate tissue perfusion, provide nutritional support, cautious use of drugs metabolized by the liver
Diagnostic Criteria of MODS
- Intestinal
- Dysfunction: ileus with intolerance to TF (> 5 days)
- Failure: Stress _____ requiring transfusions
- Treatment: Stress ulcer prophylaxis, enteral feedings
- Intestinal
- Dysfunction: ileus with intolerance to TF (> 5 days)
- Failure: Stress ulcers requiring transfusions
- Treatment: Stress ulcer prophylaxis, enteral feedings
Diagnostic Criteria of MODS
- Hematologic
- Dysfunction: Prolonged PT, PTT (> 25%), low platelets (50,000-80,000), increase in FDP’s, increase D-Dimer
- Failure: _____
- Treatment: observe for bleeding, replace factors as needed, minimize traumatic interventions
- Hematologic
- Dysfunction: Prolonged PT, PTT (> 25%), low platelets (50,000-80,000), increase in FDP’s, increase D-Dimer
- Failure: DIC
- Treatment: observe for bleeding, replace factors as needed, minimize traumatic interventions
What is DIC?
- Serious __________ & ________ disorder
- Always caused by an underlying disease process or condition
- Shock (Sepsis)
- Obstetric conditions (abrubtio placentae)
- Malignancies
- Tissue damage (burns, trauma)
- Serious clotting and bleeding disorder
- Always caused by an underlying disease process or condition
- Shock (Sepsis)
- Obstetric conditions (abrubtio placentae)
- Malignancies
- Tissue damage (burns, trauma)
Clotting Side [dic?]
- Initiating event
- SIRS—Inflammation
- Clotting cascade
- Fibrinogen—fibrin + platelet aggregation
- Deposited in the capillaries—thrombosis
- Organ ischemia, necrosis
- Initiating event
- SIRS—Inflammation
- Clotting cascade
- Fibrinogen—fibrin + platelet aggregation
- Deposited in the capillaries—thrombosis
- Organ ischemia, necrosis
DIC- What Do We See
- Clotting side (less obvious)
- Decrease perfusion to organs
- Low U.O.
- Decrease LOC, confusion
- Cyanosis
DIC - Bleeding Side
- Fibrinolytic system activated—breakdown clots
- Create fibrin split (degradation) products
- FDP’s: Anticoagulant properties, inhibit normal clotting, consume platelets
- Clotting factors and platelets depleted— cannot form stable clots
- Bleeding (increase risk of hemorrhage)
- Fibrinolytic system activated—breakdown clots
- Create fibrin split (degradation) products
- FDP’s: Anticoagulant properties, inhibit normal clotting, consume platelets
- Clotting factors and platelets depleted— cannot form stable clots
- Bleeding (increase risk of hemorrhage)
DIC- What Do We See
- Bleeding side (more obvious)
- Bleeding
- Oozing at IV site
- ______ in urine or stool
- Petechia or ecchymoses
- Bleeding side (more obvious)
- Bleeding
- Oozing at IV site
- Blood in urine or stool
- Petechia or ecchymoses
Management of DIC
Primary Goal
- Treat ____________
- Early _________ of clotting and bleeding
Secondary Goal
- Heparin/Lovenox to stop _________
- Administration of ______ Products**
› Platelets
› Fresh frozen plasma (FFP)
› Cryroprecipitates
Primary Goal
- Treat underlying cause
- Early detection of clotting and bleeding
Secondary Goal
- Heparin/Lovenox to stop clotting
- Administration of Blood Products**
› Platelets
› Fresh frozen plasma (FFP)
› Cryroprecipitates
MODS - Collaborative Care
- Prognosis for MODS is ______
- Goal: Prevent the ___________ of MODS
- Early detection of signs of deterioration or organ dysfunction
MODS - Collaborative Care
- Prognosis for MODS is poor
- Goal: Prevent the progression of MODS
- Early detection of signs of deterioration or organ dysfunction
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?
A. Inspiratory crackles
B. Heart rate 45 beats/min
C. Cool, clammy extremities
D. Temperature 101.2° F (38.4° C)
B. Heart rate 45 beats/min
Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.
The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. What should the nurse obtain in preparation for the patient’s arrival?
A. A dopamine infusion
B. A hypothermia blanket
C. Lactated Ringer’s solution
D. Two 16-gauge IV catheters
D. Two 16-gauge IV catheters
A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer’s solution should be used cautiously and would not be prescribed until the patient has been assessed for liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool
Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective?
A. There are no signs of hemorrhage.
B. Hemoglobin is within normal limits.
C. Urine output 65 mL over the past hour.
D. Mean arterial pressure (MAP) is 72 mm Hg.
C. Urine output 65 mL over the past hour.
Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level and MAP are useful in determining
the effects of fluid administration, but they are not as useful as data indicating good organ perfusion. The absence of hemorrhage helps to prevent further fluid loss but does not reflect fluid balance.
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?
A. Check temperature every 2 hours.
B. Monitor breath sounds frequently.
C. Maintain patient in supine position.
D. Assess skin for flushing and itching
B. Monitor breath sounds frequently.
Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.
A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective?
A. No heart murmur
B. Skin is warm and pink
C. Decreased troponin level
D. Blood pressure of 92/40 mm Hg
B. Skin is warm and pink
Warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator, the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.
Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective?
A. Heart rate
B. Orientation
C. Blood pressure
D. Oxygen saturation
D. Oxygen saturation
Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.
Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)?
A. The patient’s serum creatinine level is high.
B. The patient reports intermittent chest pressure.
C. The patient’s extremities are cool, and pulses are 1+.
D. The patient has bilateral crackles throughout lung field
A. The patient’s serum creatinine level is high.
The high serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient’s diagnosis of cardiogenic shock.
When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients with shock, which action by the new RN indicates a need for more education?
A. Placing the pulse oximeter on the ear for a patient with septic shock
B. Keeping the head of the bed flat for a patient with hypovolemic shock
C. Maintaining a cool room temperature for a patient with neurogenic shock
D. Increasing the nitroprusside for a patient with cardiogenic shock and a high SVR
C. Maintaining a cool room temperature for a patient with neurogenic shock
Patients with neurogenic shock have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.
The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?
A. Skin cool and clammy
B. Heart rate of 118 beats/min
C. Blood pressure of 92/56 mm Hg
D. O2 saturation of 93% on room air
A. Skin cool and clammy
Because patients in the early stage of septic shock have warm and dry skin, the patient’s cool and clammy skin indicates that shock is progressing. The other information will also be reported but does not indicate deterioration of the patient’s status.
A patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider?
A. New onset of confusion
B. Decreased bowel sounds
C. Heart rate 112 beats/min
D. Pale, cool, and dry extremities
A. New onset of confusion
The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.
A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention prescribed by the health care provider should the nurse implement first?
A. Insert two large-bore IV catheters.
B. Provide O2 at 100% per non-rebreather mask.
C. Draw blood to type and crossmatch for transfusions.
D. Initiate continuous electrocardiogram (ECG) monitoring.
B. Provide O2 at 100% per non-rebreather mask.
The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for ransfusions should also be rapidly accomplished but only after actions to maximize O2 delivery have been implemented
The following interventions are prescribed by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first?
A. Give diphenhydramine.
B. Administer epinephrine.
C. Start continuous ECG monitoring.
D. Draw blood for complete blood count.
B. Administer epinephrine.
Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other nterventions are also appropriate but would not be the first ones completed.
Tissue Perfusion Assessment
The most accurate assessment of tissue perfusion in a patient in shock is:
their level of consciousness, urine output, and blood pressure
CVP is a measure of the pressure in the superior vena cava or ________, with a normal range of 2-8 mmHg. It is used to monitor the patient’s _____________ status and fluid status.
CVP is a measure of the pressure in the superior vena cava or right atrium, with a normal range of 2-8 mmHg. It is used to monitor the patient’s hemodynamic status and fluid status.
Signs of Hypovolemic Shock
Elevated ___________
decreased ___________
Elevated HR & RR
decreased urine output
Signs of low cardiac output
___________ skin
_____ pulse
delayed ___________
cool, clammy skin
weak pulse
delayed capillary refill
Shock Management
When concerned for shock, obtain ____________ before beginning antibiotics,
measure input/output every 1-2 hours, and monitor respiratory status every 2 hours
blood cultures
Norepinephrine (Levophed)
Norepinephrine is used to treat shock, and its use requires monitoring of blood pressure and adequate ___________ prior to initiation
fluid replacement
Cardiogenic Shock
Signs of cardiogenic shock include
_____tension
_____ extremities
________ edema.
hypotension
cool extremities
pulmonary edema.
Hypovolemic Shock Fluid Resuscitation
Fluid resuscitation in hypovolemic shock requires ___________________ replacement,
typically with crystalloids such as normal saline or Ringer’s lactate.
aggressive fluid
Anaphylactic Shock
Anaphylactic shock is a severe, ___________ __________ reaction that can lead to airway obstruction, hypotension, and cardiovascular collapse.
whole-body allergic
- ADH and Hypovolemic Shock
Antidiuretic hormone (ADH) is released in response to hypovolemic shock to help
______________________________________
retain water and maintain blood pressure.
CVP is a measure of the pressure in the thoracic vena cava, which reflects the __________ status and _____________ of the patient.
CVP is a measure of the pressure in the thoracic vena cava, which reflects the volume status and cardiac function of the patient.
The normal range for CVP is ___ mmHg.
2-8
CVP is used to monitor the patient’s ___________ status, providing information about the volume status and cardiac function
hemodynamic
CVP Relationship to Shock States
Elevated CVP can indicate _____________ or _____________
low CVP can suggest _______________
Elevated CVP can indicate fluid overload or heart failure
low CVP can suggest hypovolemic shock
CVP is measured through a central venous catheter inserted into the superior vena cava or right atrium, and it is monitored along with oher vital signs to assess the patient’s overall hmodynamic status.
CVP is measured through a central venous catheter inserted into the superior vena cava or right atrium, and it is monitored along with other vital signs to assess the
patient’s overall hemodynamic status.
Pulmonary Artery Wedge Pressure (PAWP)
- Definition of PAWP
- PAOP and PAWP are both terms for pulmonary artery occlusion pressure, which is a measurement of blood pressure in the pulmonary artery. PAOP is also known as
pulmonary artery wedge pressure (PAWP).
- Definition of PAWP
- PAOP and PAWP are both terms for pulmonary artery occlusion pressure, which is a measurement of blood pressure in the pulmonary artery. PAOP is also known as
pulmonary artery wedge pressure (PAWP).
Signs of Hypovolemic Shock
Elevated Heart Rate
Hypovolemic shock causes the heart to beat faster to maintain ____________ & __________
Elevated Respiratory Rate
The body tries to compensate for _______________________ by increasing the respiratory rate.
Decreased Urine Output
The kidneys prioritize blood flow to ____________, leading to reduced urine production.
Recognizing the classic signs of hypovolemic shock, including elevated heart rate,
elevated respiratory rate, and decreased urine output, is crucial for early identification and prompt treatment to prevent further deterioration.
Elevated Heart Rate
Hypovolemic shock causes the heart to beat faster to maintain cardiac output and perfusion.
Elevated Respiratory Rate
The body tries to compensate for decreased oxygen delivery by increasing the respiratory rate.
Decreased Urine Output
The kidneys prioritize blood flow to vital organs, leading to reduced urine production.
Recognizing the classic signs of hypovolemic shock, including elevated heart rate,
elevated respiratory rate, and decreased urine output, is crucial for early identification and prompt treatment to prevent further deterioration.
Signs of Low Cardiac Output
Cool, clammy skin
Indicating poor peripheral perfusion due to decreased blood flow to the extremities.
Weak peripheral pulses.
Decreased cardiac output leads to reduced pulsation in the
peripheral arteries.
Decreased urine output
Reduced renal perfusion due to low cardiac output results in decreased urine production.
Altered mental status
Decreased blood flow to the brain can lead to confusion, lethargy, or agitation.
The key signs of low cardiac output are related to the body’s attempt to prioritize blood flow to vital organs, resulting in reduced perfusion to the extremities, kidneys, and brain.
Cool, clammy skin
Indicating poor peripheral perfusion due to decreased blood flow to the extremities.
Weak peripheral pulses.
Decreased cardiac output leads to reduced pulsation in the
peripheral arteries.
Decreased urine output
Reduced renal perfusion due to low cardiac output results in decreased urine production.
Altered mental status
Decreased blood flow to the brain can lead to confusion, lethargy, or agitation.
The key signs of low cardiac output are related to the body’s attempt to prioritize blood flow to vital organs, resulting in reduced perfusion to the extremities, kidneys, and brain.
Shock Management
- Obtain Blood Cultures
Obtain blood cultures before ________________ to identify the causative organism and guide appropriate antibiotic therapy - Measure Input and Output
Measure fluid intake and urine output every 1-2 hours to monitor tissue ___________ and detect signs of hypovolemia or fluid overload. - Monitor Respiratory Status
Monitor the patient’s respiratory rate, effort, and oxygen saturation every 2 hours to detect signs of respiratory __________ or impending respiratory failure.
- Obtain Blood Cultures
Obtain blood cultures before starting antibiotics to identify the causative organism and guide appropriate antibiotic therapy - Measure Input and Output
Measure fluid intake and urine output every 1-2 hours to monitor tissue perfusion and detect signs of hypovolemia or fluid overload. - Monitor Respiratory Status
Monitor the patient’s respiratory rate, effort, and oxygen saturation every 2 hours to detect signs of respiratory distress or impending respiratory failure.
Norepinephrine, also known as Levophed, is a potent vasoconstrictor medication used to treat shock.
It works by increasing blood pressure and improving organ perfusion in patients experiencing hypotension and hypoperfusion due to conditions like septic shock, cardiogenic shock, or hypovolemic shock.
However, it is important to ensure __________________ prior to initiating Norepinephrine therapy, as it can worsen hypoperfusion if the patient is volume-depleted.
adequate fluid replacement
Hypovolemic Shock Signs
Tachycardia
Elevated heart rate, often greater than 100 beats per minute, as the body tries to
compensate for decreased blood volume.
Tachypnea
Rapid and shallow breathing, often greater than 20 breaths per minute, as the body tries to increase oxygen delivery to tissues.
Decreased Urine Output
Reduced urine output, often less than 0.5 mL/kg/hour, as the body prioritizes blood
flow to vital organs over the kidneys.
These classic signs of hypovolemic shock are the body’s attempt to maintain perfusion to vital organs in the face of decreased blood volume.
Tachycardia
Elevated heart rate, often greater than 100 beats per minute, as the body tries to
compensate for decreased blood volume.
Tachypnea
Rapid and shallow breathing, often greater than 20 breaths per minute, as the body tries to increase oxygen delivery to tissues.
Decreased Urine Output
Reduced urine output, often less than 0.5 mL/kg/hour, as the body prioritizes blood
flow to vital organs over the kidneys.
These classic signs of hypovolemic shock are the body’s attempt to maintain perfusion to vital organs in the face of decreased blood volume.
Fluid Resuscitation Dosing
- Initiate Crystalloid Solution
Begin fluid resuscitation with crystalloid solutions (e.g., normal saline, Ringer’s lactate) at a rate of 20 ml/kg over the first 60 minutes. - Monitor Patient Response
Closely monitor the patient’s vital signs, urine output, and other clinical indicators to assess the efficacy of the fluid resuscitation. - Adjust Fluid Rate
Based on the patient’s response, further adjust the fluid administration rate to maintain adequate perfusion and organ function. - Titrate to Hemodynamic Goals
The goal is to titrate fluid administration to maintain a mean arterial pressure (MAP) of at least 65 mmHg and urine output of at least 0.5 ml/kg/hour. - Avoid Fluid Overload
Monitor for signs of fluid overload, such as pulmonary edema, and adjust the fluid rate accordingly to prevent complications.
- Initiate Crystalloid Solution
Begin fluid resuscitation with crystalloid solutions (e.g., normal saline, Ringer’s lactate) at a rate of 20 ml/kg over the first 60 minutes. - Monitor Patient Response
Closely monitor the patient’s vital signs, urine output, and other clinical indicators to assess the efficacy of the fluid resuscitation. - Adjust Fluid Rate
Based on the patient’s response, further adjust the fluid administration rate to maintain adequate perfusion and organ function. - Titrate to Hemodynamic Goals
The goal is to titrate fluid administration to maintain a mean arterial pressure (MAP) of at least 65 mmHg and urine output of at least 0.5 ml/kg/hour. - Avoid Fluid Overload
Monitor for signs of fluid overload, such as pulmonary edema, and adjust the fluid rate accordingly to prevent complications.
Cardiogenic Shock
- Decreased Cardiac Output
Cardiogenic shock is characterized by a decrease in cardiac output due to impaired myocardial function. - Tissue Hypoperfusion
The decreased cardiac output leads to tissue hypoperfusion (low renal perfusion and decrease in urine output), which is a hallmark of cardiogenic shock. - Hypotension
One of the key signs of cardiogenic shock is hypotension, or low blood pressure. - Cool Extremities
As a result of the decreased perfusion, the patient’s extremities may feel cool (clammy) to the touch. - Pulmonary Edema
Cardiogenic shock can also lead to the development of pulmonary edema, or fluid buildup in the lungs. - Neuro Changes
Anxiety, confusion, agitation
- Decreased Cardiac Output
Cardiogenic shock is characterized by a decrease in cardiac output due to impaired myocardial function. - Tissue Hypoperfusion
The decreased cardiac output leads to tissue hypoperfusion (low renal perfusion and decrease in urine output), which is a hallmark of cardiogenic shock. - Hypotension
One of the key signs of cardiogenic shock is hypotension, or low blood pressure. - Cool Extremities
As a result of the decreased perfusion, the patient’s extremities may feel cool (clammy) to the touch. - Pulmonary Edema
Cardiogenic shock can also lead to the development of pulmonary edema, or fluid buildup in the lungs. - Neuro Changes
Anxiety, confusion, agitation
Anaphylactic shock is a severe, life-threatening allergic reaction characterized by _________, increased vascular permeability, and bronchospasm
vasodilation
Anaphylactic shock S&S - urticaria, angioedema, hypotension, and respiratory distress
Common triggers include foods, medications, insect stings/bites, and latex. Individuals with a history of allergies or asthma are at higher risk
Anaphylactic shock S&S - urticaria, angioedema, hypotension, and respiratory distress
Common triggers include foods, medications, insect stings/bites, and latex. Individuals with a history of allergies or asthma are at higher risk
Pathophysiology of Anaphylactic shock
Anaphylaxis is an ____-mediated reaction that triggers the release of histamine, leukotrienes, and other inflammatory mediators, leading to the characteristic symptoms.
IgE
Anaphylactic shock
Management
Immediate administration of _________, fluid resuscitation, and supportive care are essential. Airway management may be necessary in severe cases.
Prevention
Identifying and avoiding known triggers, carrying epinephrine auto- injectors, and prompt treatment of reactions are crucial for prevention.
Management
Immediate administration of epinephrine, fluid resuscitation, and supportive care are essential. Airway management may be necessary in severe cases.
Prevention
Identifying and avoiding known triggers, carrying epinephrine auto- injectors, and prompt treatment of reactions are crucial for prevention.
ADH in Hypovolemic Shock
In response to hypovolemic shock, the body increases the release of _______________ to help conserve fluid and maintain blood pressure. ADH acts on the kidneys to increase water reabsorption, reducing urine output and helping to restore fluid balance
antidiuretic hormone (ADH)
Neurogenic Shock
Loss of Sympathetic Tone
Neurogenic shock is characterized by a loss of sympathetic tone, leading to vasodilation and decreased peripheral vascular resistance.
Spinal Cord Injuries
Neurogenic shock is often seen in spinal cord injuries, where the disruption of the spinal cord impairs the body’s ability to maintain normal blood pressure and heart rate.
Vasodilation and Hypotension
The loss of sympathetic tone results in vasodilation, leading to decreased peripheral vascular resistance and hypotension, which are the hallmarks of neurogenic shock.
Bradycardia
In addition to hypotension, neurogenic shock is also characterized by bradycardia, as the parasympathetic nervous system becomes dominant in the absence of sympathetic tone.
Loss of Sympathetic Tone
Neurogenic shock is characterized by a loss of sympathetic tone, leading to vasodilation and decreased peripheral vascular resistance.
Spinal Cord Injuries
Neurogenic shock is often seen in spinal cord injuries, where the disruption of the spinal cord impairs the body’s ability to maintain normal blood pressure and heart rate.
Vasodilation and Hypotension
The loss of sympathetic tone results in vasodilation, leading to decreased peripheral vascular resistance and hypotension, which are the hallmarks of neurogenic shock.
Bradycardia
In addition to hypotension, neurogenic shock is also characterized by bradycardia, as the parasympathetic nervous system becomes dominant in the absence of sympathetic tone.
________ shock is a critical condition that requires prompt recognition and management to prevent further complications. Understanding the underlying pathophysiology, including the loss of sympathetic tone and the resulting vasodilation and hypotension, is crucial for providing appropriate treatment.
Neurogenic
Septic shock is a life-threatening condition that arises from a systemic inflammatory response to infection.
In the early stage of septic shock, there is a decrease in systemic vascular resistance (SVR) due to ___________ and decreased responsiveness to vasoconstrictors. This leads to hypotension and impaired tissue perfusion, which can rapidly progress to multi-organ dysfunction if left untreated
vasodilation
Septic Shock
Sepsis: systemic ____________ response to documented or suspected infection
Severe sepsis: sepsis complicated by ______________
Septic Shock
Sepsis: systemic inflammatory response to documented or suspected infection
Severe sepsis: sepsis complicated by organ dysfunction
Septic Shock
Presence of sepsis with hypotension despite _____________
Presence of inadequate tissue perfusion resulting in ________
Presence of sepsis with hypotension despite fluid resuscitation
Presence of inadequate tissue perfusion resulting in hypoxia
Septic shock
3 major pathophysiologic effects
- Vasodilation
- Maldistribution of blood flow
- Myocardial dysfunction
* Decreased ejection fraction
* Ventricular dilation
3 major pathophysiologic effects
- Vasodilation
- Maldistribution of blood flow
- Myocardial dysfunction
* Decreased ejection fraction
* Ventricular dilation
Septic Shock Manifestations
-Increased coagulation and inflammation
-Decreased fibrinolysis
-Formation of microthrombi
-Obstruction of microvasculature
-Hyperdynamic state: increased CO and decreased SVR
-Decreased urine output
-Increased coagulation and inflammation
-Decreased fibrinolysis
-Formation of microthrombi
-Obstruction of microvasculature
-Hyperdynamic state: increased CO and decreased SVR
-Decreased urine output
Septic shock S&S
Tachypnea/hyperventilation
Results in respiratory alkalosis
Respiratory failure develops in 85% of patients
Altered neurologic status
GI dysfunction, GI bleeding, paralytic ileus
Tachypnea/hyperventilation
Results in respiratory alkalosis
Respiratory failure develops in 85% of patients
Altered neurologic status
GI dysfunction, GI bleeding, paralytic ileus
Diagnostics
Thorough history and physical examination
- No single study to determine shock
- Blood studies
* Elevation of lactate
* Base deficit
- 12-lead ECG, continuous ECG monitoring
- Chest x-ray
- Continuous pulse oximetry
- Hemodynamic monitoring
Thorough history and physical examination
- No single study to determine shock
- Blood studies
* Elevation of lactate
* Base deficit
- 12-lead ECG, continuous ECG monitoring
- Chest x-ray
- Continuous pulse oximetry
- Hemodynamic monitoring
Disseminated Intravascular Coagulopathy (DIC)
DIC is a serious condition characterized by the widespread activation of the ____________ cascade, leading to thrombosis and bleeding
coagulation
Disseminated Intravascular Coagulopathy (DIC)
The pathophysiologic mechanisms of DIC involve an underlying condition that activates the __________ system, leading to excessive thrombin generation, consumption of clotting factors, and ultimately, impaired hemostasis
DIC can be triggered by various underlying conditions, such as sepsis, trauma, obstetric complications, malignancies, and severe liver disease
The pathophysiologic mechanisms of DIC involve an underlying condition that activates the coagulation system, leading to excessive thrombin generation, consumption of clotting factors, and ultimately, impaired hemostasis
DIC can be triggered by various underlying conditions, such as sepsis, trauma, obstetric complications, malignancies, and severe liver disease
Disseminated Intravascular Coagulopathy (DIC)
Signs of DIC include bleeding, bruising, petechiae, and organ dysfunction due to microvascular thrombosis. Patients may also present with laboratory findings of prolonged clotting times, low platelet count, andelevated D-dimer levels.
Treatment of DIC involves addressing the underlying cause and providing supportive care, which may include the administration of blood products, anticoagulants, and treatment of the primary condition.
Signs of DIC include bleeding, bruising, petechiae, and organ dysfunction due to microvascular thrombosis. Patients may also present with laboratory findings of prolonged clotting times, low platelet count, andelevated D-dimer levels.
Treatment of DIC involves addressing the underlying cause and providing supportive care, which may include the administration of blood products, anticoagulants, and treatment of the primary condition.
Nurses have the most influence in preventing which type of shock?
a. Cardiogenic.
b. Hypovolemic.
c. Septic.
d. Neurogenic.
c. Septic.
When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as which one of the following?
a. Decorticate posturing.
b. Decerebrate posturing.
c. Localization of pain.
d. Flexion withdrawal.
a. Decorticate posturing.
Four days after a patient has undergone a craniotomy to remove an astrocytoma of the temporal lobe, the dressing is removed and the nurse finds the patient crying. The patient tells the nurse, “I look awful and feel even worse.” The most appropriate nursing diagnosis for the patient is:
a. Grieving related to the patient’s ongoing fear of dying.
b. Disturbed body image related to postoperative change in appearance.
c. Ineffective denial related to unrealistic expectations about surgery.
d. Hopelessness related to emotional lability secondary to cerebral edema.
b. Disturbed body image related to postoperative change in appearance.
The nurse is teaching the family of a head injury patient to observe the patient for diabetes insipidus (DI). The family asks the nurse why this would be important. The best response by the nurse is which one of the following?
a. “When the patient’s urine output drops, they are at risk for kidney failure.”
b.“When the patient’s blood sugar is too low, they are at risk for side effects of hypoglycemia.”
c. “When the patient’s blood sugar is too high, they are at risk for side effects of hyperglycemia.”
d.“When the patient’s urine output is too high, they are at risk for hypotension.”
d.“When the patient’s urine output is too high, they are at risk for hypotension.”
A nurse is assessing a patient’s extraocular eye movements as part of a neurologic
examination. Which of the following cranial nerves is the nurse assessing? Select all that apply.
a.Optic (II).
b.Oculomotor (III).
c. Trochlear (IV).
d.Trigeminal (V).
e.Abducens (VI).
b.Oculomotor (III).
c. Trochlear (IV).
e.Abducens (VI).
A patient is experiencing hypovolemic shock. The nurse develops a nursing diagnosis of decreased cardiac output. Which of the following is an appropriate outcome for this problem?
a. Urine output of 0.5 ml/kg/hr.
b. Decreased peripheral edema.
c. Decreased CVP.
d. Oxygen saturation 89%
a. Urine output of 0.5 ml/kg/hr.
When caring for a patient with cardiogenic shock and possible MODS, which information obtained by the nurse will help confirm the diagnosis of MODS?
a. The patient has scattered crackles throughout both lung fields.
b. The patient complains of 3/10 chest pain.
c. The patient has an elevated ammonia level and confusion.
d. The patient has cool extremities
c. The patient has an elevated ammonia level and confusion.
The QRS portion of the ECG complex represents:
a. Atrial depolarization.
b. SA node conduction.
c. Ventricular depolarization.
d. Ventricular repolarization
c. Ventricular depolarization.
The nurse is caring for a client with a permanent pacemaker. Which of the following
statements by the client would alert the nurse to a possible pacemaker failure?
A. “I am nauseated and may vomit.”
B. “I feel dizzy and light-headed.”
C. “I have a severe headache.”
D. “My feet are quite swollen.”
B. “I feel dizzy and light-headed.”
A nurse is interpreting a patient’s telemetry strip. If the PR interval measures four small blocks, how many seconds is the PR interval?
_____________________seconds
.16
In general, a CPP of ______ mmHg is considered ideal for maintaining optimal brain perfusion, but individual cases may vary.
< 50 mm Hg is associated with ischemia and neuronal death.
CPP < 30 mm Hg incompatible with life.
60–80
_____ = MAP - ICP.
CPP
__________ Shock
Signs: wheezing, chest pain, stridor.
__________ Shock
Low cardiac output signs.
Anaphylactic Shock
Signs: wheezing, chest pain, stridor.
Cardiogenic Shock
Low cardiac output signs.
_________ Shock
Bradycardia, warm and dry skin.
_________ Shock
Early stage: decreased systemic vascular resistance (SVR).
Neurogenic Shock
Bradycardia, warm and dry skin.
Septic Shock
Early stage: decreased systemic vascular resistance (SVR).
Assessing Shock
Key Indicators
Level of consciousness (LOC), ______ output, and blood __________ are crucial.
Hypovolemic Shock Signs
Elevated heart and respiratory rates, decrease urine output.
Key Indicators
Level of consciousness (LOC), urine output, and blood pressure are crucial.
Hypovolemic Shock Signs
Elevated heart and respiratory rates, decrease urine output.
Central Venous Pressure (CVP) - Used to monitor ___________ status.
hemodynamic
CVP measures the pressure within the right atrium, reflecting ___________ to the heart.
The typical range is _____ mmHg, but it can vary based on factors like age and volume status
CVP measures the pressure within the right atrium, reflecting venous return to the heart.
The typical range is 2-8 mmHg, but it can vary based on factors like age and volume status
Antidiuretic Hormone (ADH) in Hypovolemic Shock
1 Hypovolemia triggers ADH release from the pituitary gland.
2 ADH promotes water reabsorption in the kidneys, concentrating urine and preserving blood volume.
3 This helps maintain blood pressure and perfusion during shock.
Shock Management - Immediate Actions
Obtain blood cultures before antibiotics. Monitor I/O every 1-2 hours.
Fluid Resuscitation
Goal: restore tissue perfusion. Urine output target: 0.5mL/kg/hr.
Medication
Norepinephrine (Levophed) for treatment. Ensure adequate fluid replacement first
Stages of Shock
1 Compensatory
Body attempts to maintain perfusion.
2 Progressive
Compensatory mechanisms begin to fail.
3 Refractory
Shock resistant to treatment, organ failure begins.
Signs of Low Cardiac Output
1 Decreased Urine Output
Low urine production suggests inadequate renal perfusion.
2 Hypotension
Low blood pressure is a sign of reduced cardiac output.
3 Tachycardia
An elevated heart rate compensates for diminished cardiac output
Disseminated Intravascular Coagulopathy (DIC)
1 Endothelial Damage
Release of tissue factor, thrombin formation.
2 Clot Formation
Along epithelial walls, consumption of coagulation factors.
3 Regulatory Failure
Activation of fibrinolytic system, breakdown of thrombi.
4 Spontaneous Hemorrhage
Treatment: address underlying cause, may use blood products
Head Injury Assessment
ABC Assessment
First, assess airway and respiratory status.
Cranial Nerve Check
Assess eye movements for cranial nerves III, IV, VI.
Temperature Control
Maintain 96.8°F to 98.6°F to prevent increased ICP.
Signs of Head Injuries
Monitor Closely
* Headache
* N/V
* Dizziness
* Decrease in LOC
Monitoring Head Injuries
Vital Signs
Monitor closely. Elevated BP may indicate autonomiC dysregulation syndrome.
Intracranial Pressure (ICP)
Normal range: 5-15 mmHg.
Escalate if sustained above 20 mmHg.
Posturing
Observe for decorticate or decerebrate posturing.
Head Injury Management
Positioning
Elevate head 30 degrees to relieve edema and facilitate drainage.
Medication
Use osmotic diuretics like mannitol to decrease brain fluid.
Activity
Post-craniotomy: start with passive movements, progress as tolerated.
Cerebral Perfusion Pressure (CPP)
CPP = MAP - ICP
Normal Range
60-80 mmHg
Importance
Adequate CPP ensures proper brain perfusion
Norepinephrine (Levophed)in Shock Management
Vasopressor
Norepinephrine is a potent vasoconstrictor used to increase blood pressure in shock states.
Monitoring Considerations
Closely monitor blood pressure, heart rate, and peripheral perfusion during administration.
Fluid Resuscitation Dosing
Initial Bolus
Administer 20 ml/kg of crystalloid solution for rapid volume expansion.
Ongoing Assessment
Monitor vital signs, urine output, and fluid balance to determine further fluid requirements
Initial Assessment in Motor Vehicle Accidents
ABC Assessment
Prioritize airway, breathing, and circulation.
Vital Sign Monitoring
Check blood pressure, heart rate, respiratory rate, and oxygen saturation.
Neurological Evaluation
Assess level of consciousness, pupillary response, and motor function.
Post-Craniotomy Rehabilitation
1 Initial Phase
Passive range of motion exercises.
2 Progression
Gradually increase to active movement, as tolerated.
3 Avoid Strenuous Activity
Restrict strenuous exercise to prevent intracranial pressure elevation
Shock Assessment
Monitor LOC, urine output, and blood pressure closely.
Head Injury Care
Prioritize ABC, monitor ICP, and control temperature.
Continuous Monitoring
Vital signs and neurological status are crucial for both conditions.
