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Med Surg exam #2

chapter 19, 14

What is shock? Inadequate tissue perfusion resulting in impaired cellular metabolism
What are the types of shock? hypovolemic, cardiogenic, distributive
What are the three subcategories of distributive shock? anaphylactic, septic, neurogenic
what are the three signs and symptoms stages? alarm- increased bp, decreased GI, GU, pupils ddilate , increase aldosterone, and increased metabolism.....restistance- cortisol returns normal, local adaptation begins....exhaustion-recovery or death out/out of resources
What is hypovolemic shock? inadequate blood volume to maintain the supply of oxygen and nutrients to body tissues Excessive shifts of plasma with pathologic states(burns, peritonitis, and intestinal obstruction)
What is cardiogenic shock? occurs when heart fails as a pump. Difficult to treat and usually results when diseased coronary arteries cannot meet the demand of the working myocardial cells. causes:dysrhythmias, cardiomyopathy, myocarditis, valvular disease
What is obstructive shock? impairment of adequate circulating blood flow.obstruction of the heart block venous return to the right side of the heart, prevents effective pumping. causes: tension pneumothorax, pericardial tampanade, embolus, aortic dissection, abdominal distention
What is distributive/vasogenic shock? excessive dilation of blood vessels or decreased vascular resistance causing the blood to improperly distribute. Complicated by increased permeability. plasma leaks into interstitial compartment decreasing intravascular blood volume
What is anaphylactic shock? a severe allergic reaction that results in the release of chemicals that dilate blood vessels and increase capillary permeability. fluid leaks out of capillaries into the tissues. can cause constriction of the bronchi and airway obstruction
What is septic shock? hypotension unresponsive to fluid resuscitation along with metabolic acidosis, oliguria and or coagulation disorders. increased permeability: leakage of plasma proteins and reduced intravascular volume, preload, and cardiac output
pathogenic organisms (bacteria, fungi, viruses, rickettsiae) release toxic substances that cause blood vessels to dilate and decrease vascular permeability is related to what type of shock? Septic shock
What is neurogenic shock? disruption in the nervous system affects the vasomotor center in the medulla. Signs and symptoms: pooling of blood in peripheral tissues with subsequent decreased venous return and cardiac output; bradycardia with hypotension
Injury or disease of the upper spinal cord, spinal anesthesia, depression of the vasomotor center from certain drugs is related to what type of shock? Neurogenic shock
What are the effects of shock on the respiratory system? tissue hypoxia and anoxia(absence of o2), respiratory failure, acute respiratory distress syndrome (ARDS)
What are the effects of shock on acid base balance? metabolic acidosis
What is the effect of shock on the cardiovascular system? Cardiovascular system Myocardial depression, disseminated intravascular coagulation (widespread clotting caused by sluggish flow of acidic blood combined with bacterial endotoxins or clotting factors released by destruction of red blood cells
What is the effect of shock on the neuroendocrine system? Release of catecholamines (epinephrine and norepinephrine), mineralocorticoids (aldosterone and desoxycorticosterone), glucocorticoids (hydrocortisone), and antidiuretic hormone; decreased level of consciousness when cerebral blood flow falls
What is the effect of shock on the immune system? depressed immune response
What is the effect of shock on the gastrointestinal system? decreased peristalsis, ischemia of intestinal submucosa, impaired liver function
What is the effect of shock on the renal system? reduced glomular filtration,decreased urinary output, inadequate renal perfusion, tubular necrosis, renal ischemia
What are the stages of shock? early, reversible, and compensatory stages/Intermediate (progressive) stage/ Irreversible (refractory) stage
What is early, reversible, compensatory stage of shock? activation of baroreceptors in the carotid arteries and the aorta stimulate the sympathetic nervous system
What is involved in sympathetic stimulation in the early, reversible and compensatory stage? increased hr, constriction of peripheral blood vessels and reduced blood flow to the kidneys, lungs, muscles, skin and GI tract.
What events occur in early, reversible, compensatory stage of shock? decreased renal blood glow triggers the release of renin and produces angiotensin II. adrenal cortex secretes aldosterone, ADH release results in water retention, increased resp rate help eliminate excess CO2, and normalize blood ph
What are the symptoms of early, reversible, compensatory stage? irritability, restlesness,slightly increased bp,decreased pulse, orthostatic hypotension Pulse- increased-may be thready or bounding, increased rate respirations, decreased urine,cool and pale skin, decreased bowel sounds, increased blood sugar, thirst
What is intermediate(progressive) stage? cause of shock is not corrected or if compensatory mechanisms continue w/o reversing shock. blood becomesmore viscous or thick, causing clumps of rbc, platelets and proteins. deprived of o2 cells resort to anerobic metabolis and produce lactic acid
What are the symptoms of the Intermediate (progressive) stage? listlessness, confusion,weak and thready pulse, tachycardia, dysrhythmias,increased, deep, crackles respirations, subnormal temp, decreased urine, possible renal failure, cold pale, clammy skin. cyanosis, slow cap refill,dry mouth, thirst, edema,weakness
What is irreversible (refractory) stage? irreversible changes in vital organs as compensatory mechanisms fail. death is imminent even if patients are resuscitated, they still often die within a week or two
What are the symptoms of Irreversible (refractory) stage? Loss of consciousness, Blood pressure Systolic continues to fall; diastolic approaches zero, pulse Progressive slowing, irregular pulse,Respirations Slow, shallow, irregular, urine output minimal, cold clammy cyanotic skin
Tests and procedures that help establish type of shock, stage and the cause are what? Blood and urine studies, measurement of hemodynamic pressures, chest radiograph, ECG and continuous cardiac monitoring, pulse oximetry and arterial blood gases, and urine output
What does oxygenation have to do with shock? Brain cells begin to die after 4 minutes without oxygen, and oxygen consumption increases as delivery decreases in shock: poor prognosis paralytics, sedatives, and analgesics may be ordered to decrease o2 requirements
Fluid replacement and shock? Normal saline is usually administered initially depends on situation: Crystalloids provide replacement water and electrolytes for all fluid compartments colloids remain in the vascular system and draw fluid into the bloodstream
Assessment of a patient in shock? continoous monitoring of cardiac rate and rhythm, bp, rr, arterial blood gases, skin color, response to light, LOC, and response to commands, reflexes, auscultate lung and bowels
What is the primary nursing diagnosis for all patients in shock? altered tissue perfusion
monitor for Hypovolemia in shock patients, what are the symptoms? tachycardia, hypotension, tachypnea, decreased urine output, and decreased central venous pressure and pulmonary artery pressure
assess for fluid overload in shock patients, what are the symptoms? full, bounding pulse, dilute urin,e, increased rr, abnormal lung sounds, dyspnea, and edema
what are the medications to treat shock? antibiotics start within first hour- for septic shock vasopressors- increase tissue perfusion- (dopamine and noreepinephrine)
What is systemic inflammatory response syndrome (SIRS)? generalized inflammation that threatens vital organs, effects aredamage to the endothelium of blood vessels and hypermetobolic state, comes before DIC
What conditions lead to SIRS? shock,multiple transfusions, massive tissue injury, burns and pancreatitis
Diagnosis of SIRS is made when a patient manifests two or more of? temp less than 97 or more than 100.4. HR more than 90bpm, RR more than 20/min or Paco2 less than 32mm hg, WBC less than 4000 cells or more than 12,000 or more than 10% immature band neutrophils
SIRS manifestations? range from mild to severe. Sepsis- a pt has SIRS with a confirmed infection. If 3 or more organs fail the prognosis is very poor, multiple organ dusfunction syndrome is more than one organ begins to fail
Intracellular fluid? fluid within a cell, most of the bodys fluid found within the cell K+ and MG2+
Extracellular fluid? fluid outside the cell, mainly responsible for the transport of nutrients and wasted in body
What is water? largest portion of body weight, percentage is affected by age, sex and body fat. the percentage of body water decreases with age. females lower than males- women have more fat obese- lower % of water due to increased # fat cells
intravascular fluid? on blood vessels in the form of plasma or serum,fluid to kidneys, gut lungs and skin
Interstitial fluids? fluid surrounding cells, including lymph fluid, digestive secretions, sweat and csf
Electrolytes substance that develops and electrical charge when dissolved in water. Maintains balance between positive and negative charges. For every + charged cation, there is a - charged anion. cations and anions combine to balance one another
Sodium Most abundant electrolyte; primary electrolyte in extracellular fluid Major role in regulating body fluid volumes, muscular activity, nerve impulse conduction, and acid-base balance
Hyponatremia lower than normal sodium in the blood. can be sodium deficient or increase in body water that dilutes the na+ excessively. S/S-headache, muscle weakness, fatigue, apathy, confusion, abdominal cramps, and orthostatic hypotension
Hyponatremia medical treatment The usual treatment is restriction of fluids while the kidneys excrete excess water Diuretic: furosemide (Lasix) Sodium replacement therapy
Hyponatremia nursing care Administer prescribed medications and IV fluids Measure fluid intake and output and assess check urine specific gravity, ck mental status, weights, pitting edema and increased bp irrigate feeding tubes with normal saline
Hypernatremia Higher than normal concentration of sodium in the blood Very serious imbalance; can lead to death if not corrected Occurs when excessive loss of water or excessive retention of sodium
Signs and symptoms of Hypernatremia Thirst, flushed skin, dry mucous membranes, low urine output, restlessness, increased heart rate, convulsions, and postural hypotension, twitching
Hypernatremia medical treatment Oral or IV replacement of water slowly to restore balance A low-sodium diet often prescribed Lasix may be given to promote excretion of Na
Hypernatremia nursing care Encourage patients with hypernatremia to drink water closely monitor the infusion of iv fluids daily weights, skin turgor and assessing mucus membranes
Potassium Found mainly in the intracellular fluid; the major intracellular cation Important in maintaining fluid osmolarity and volume within the cell Essential for normal membrane excitability—a critical factor in transmitting nerve impulses
Aldosterone increases na+ retention, decreases potassium retention
ADH increases H2O
Hypokalemia Low serum K+. can only be measured in intravascular space-cant measure inside cell. May result in gastrointestinal, renal, cardiovascular, and neurologic disturbances Can cause abnormal, potentially fatal, heart rhythm
Hypokalemia signs and symptoms muscle cramps, dysrhythmias
Medical treatment for hypokalemia? potassium replacement by the iv or oral route
Nursing care for hypokalemia? Monitoring at-risk patients for decreased bowel sounds, a weak and irregular pulse, decreased reflexes, and decreased muscle tone Cardiac monitors may be used to detect dysrhythmias Administer oral or IV potassium
Hyperkalemia High serum potassium Patients at risk: decreased renal function, in metabolic acidosis, taking potassium supplements A serious imbalance because of the potential for life-threatening dysrhythmias
Signs and symptoms of hyperkalemia? Explosive diarrhea and vomiting; muscle cramps and weakness, paresthesia, irritability, anxiety, abdominal cramps, and decreased urine output, HR (Bradycardia first then tachycardia)
Addisons disease can cause what? hyperkalemia decrease aldosterone
Medical treatment for Hyperkalemia? Correct the underlying cause Restrict potassium intake Polystyrene sulfonate (Kayexalate) Intravenous calcium gluconate
Nursing care for Hyperkalemia? Patients with low urine output or those taking potassium-sparing diuretics must be monitored carefully for signs and symptoms Carefully monitor flow rate of IV fluids, which should not exceed 10ml hr through peripheral veins
Chloride An extracellular anion that is usually bound with other ions, especially sodium or potassium Functions are to regulate osmotic pressure between fluid compartments and assist in regulating acid-base balance
Hyperchloremia Usually associated with metabolic acidosis and hypernatremia
Hypochloremia Usually occurs when sodium is lost because chloride most frequently bound with sodium
Calcium Usually combined with phosphorus to form the mineral salts of the bones and teeth Ingested through the diet and absorbed through the intestine Promotes transmission of nerve impulses; helps regulate muscle contraction and relaxation
Magnesium A cation found in bone (50% to 60%), intracellular fluid (39% to 49%)extracellular fluid (1%)Plays a role in the metabolism of carbohydrates and proteins, and neural transmission Important in heart, nerve, and muscle function
30-40% of magnesium ingested through the diet is? absorbed in the body and excreted through the kidneys
Hypomagnesemia decreased gastrointestinal absorption or excessive gastrointestinal loss, usually from vomiting and diarrhea, or increased urinary loss
Hypermagnesemia occurs most often with excessive use of magnesium-containing medications or intravenous solutions in patients with renal failure or preeclampsia of pregnancy
nonelectrolytes Other substances dissolved in the body fluids Urea, protein, glucose, creatinine, and bilirubin These solutes do not carry an electrical charge
Transport of water and electrolytes through membranes Separate fluid compartments and control movement of water and certain solutes Maintain unique composition of each compartment of the body while allowing transport of nutrients and wastes to and from cells
Diffusion The random movement of particles in all directions is for a substance to move from an area of higher natural tendency concentration to an area of lower concentration
Facilitated Diffusion A carrier protein transports the molecules through membranes toward an area of lower concentration
Active transport lower to higher concentration Requires expenditure of energy Many solutes, such as sodium, potassium, glucose, and hydrogen, are actively transported across cell membranes
Filtration Transfer of water and solutes through a membrane from an area of high pressure to an area of low pressure,Needed to move fluid out of capillaries into tissues and filter plasma through the kidneys
Osmosis less to more concentrated Involves movement of water only; If a fluid compartment has less water and more sodium, water from another compartment moves to the more concentrated compartment by osmosis to create a better fluid balance
Osmolality determined by number of dissolved particles per kg water Controls water movement by regulating the concentration of fluid in each body fluid compartment The intracellular fluid and extracellular fluid equalize because of the constant shifting of water
Kidneys Main regulator of fluid balance, osmolality of body fluids,volume of ecf, blood volume,& pH. The nephron-functioning unit of the kidney. Glomerulus-filtering portion of the nephron -responsible for secretion and reabsorption
Fluid deficit S/S decreased urine and natrual atrial factor,increased: thirst, ADH,aldosterone, HR an urine concentration
Kidney filtration Blood plasma entering the kidney via the renal artery is delivered to the glomerulus About 20% of plasma filtered into glomerular capsule Most remaining plasma leaves kidney through the renal vein
Kidney tubular reabsorption most of the glomerular filtrate is returned to the circulation Water and selected solutes move from the tubules into the capillaries Waste products remain in tubules for excretion, whereas most water and sodium is reabsorbed into the bloodstream
Kidney tubular secretion The last phase in the work of the kidneys The filtrate is transformed into urine Various substances—drugs, hydrogen ions, potassium ions, creatinine, and histamine—pass from the blood into the tubules
Renin Hormone secreted when blood volume or blood pressure falls Causes the release of Aldosterone. Acts on kidney tubules to increase reabsorption of sodium and water and decrease reabsorption of potassium
ADH Causes capillaries to reabsorb more water, so urine is more concentrated and less volume is excreted
ANF Atrial naturetic factor Hormone released by the atria in response to stretching of the atria by increased blood volume Stimulates excretion of sodium and water by the kidneys, decreased synthesis of renin, decreased
Thirst Increased plasma osmolality stimulates osmoreceptors in the hypothalamus to trigger the sensation of thirst More sodium and less water in the body make a person thirsty kidneys conserve water until osmolality returns to normal
Fluid and electrolyte imbalance caused from what? Vomiting, diarrhea, kidney diseases, diabetes, salicylate poisoning, burns, congestive heart failure, cerebral injuries, ulcerative colitis, and hormonal imbalances; the intake of drugs, such as diuretics and cathartics
Fluid and electrolyte assess skin for? Moisture, turgor, and temperature reflect fluid balance. Dry, flushed skin—dehydration. Pale, cool, clammy skin—severe fluid volume deficit that occurs with shock. Moist, edematous tissue seen with excess fluid volume
Fluid volume excess S/S? irritability, decrease aldosterone, increase atrial naturetic factor, dilute urine, edema, decreased ADH, increased RR, increase urine output
Serum heatocrit Serum hematocrit Percentage of blood volume composed of red blood cells Serum creatinine A metabolic waste product Indicator of renal function
Serun creatinine A metabolic waste product Indicator of renal function Blood urea nitrogen (BUN)
serum albumin A plasma protein that helps maintain blood volume by creating colloid osmotic pressure
serum electrolytes Sodium, potassium, chloride, and calcium
dehydration total volume of body fluids less than normal. Dehydration occurs when fluid output exceeds intake for an extended period
Overhydration total volume of body fluids greater than normal. Overhydration occurs when fluid intake exceeds output. Various factors may cause this (e.g., giving excessive amounts of intravenous fluids or giving them too rapidly may increase intake above output
deficient flood volume Less water than normal in the body Isotonic extracellular fluid deficit Hypovolemia Hypertonic extracellular fluid deficit Dehydration Decreased intake, abnormal fluid losses, or both
Excess fluid volume An increase in body water Intracellular water excess Hypotonic fluid excess From renal or cardiac failure with retention of fluid, increased production of antidiuretic hormone or aldosterone, overload with isotonic
Respiratiry acidosis Respiratory system fails to eliminate the appropriate amount of carbon dioxide to maintain the normal acid-base balance Caused by pneumonia, drug overdose, head injury, chest wall injury, obesity, asphyxiation, drowning, or acute respiratory failure
nursing care for respiratory acidosis Assess Paco2 levels in the arterial blood Observe for signs of respiratory distress: restlessness, anxiety, confusion, tachycardia
Intervention for respiratory acidosis Encourage fluid intake Position patients with head elevated 30 degrees
Respiratory Alkolosis Low Paco2 with a resultant rise in pH Most common cause of respiratory alkalosis is hyperventilation Medical treatment Major goal of therapy: treat underlying cause of condition; sedation may be ordered for the anxious patient
Nursing care for Respiratory alkolosis? Intervention In addition to giving sedatives as ordered, reassure the patient to relieve anxiety Encourage patient to breathe slowly, which will retain carbon dioxide in the body
Metabolic acidosis? Body retains too many hydrogen ions or loses too many bicarbonate ions; with too much acid and too little base, blood pH falls. Causes are starvation, dehydration, diarrhea, shock, renal failure, and diabetic ketoacidosis
Nursing care for metabolic alkolosis Assessment of the patient in metabolic acidosis should focus on vital signs, mental status, and neurologic status Emergency measures to restore acid-base balance. Administer drugs and intravenous fluids as prescribed.
intervention for metabolic alkolosis Increase in bicarbonate levels or a loss of hydrogen ions
S/S metabolic allkolosis Signs and symptoms: headache; irritability; lethargy; changes in level of consciousness; confusion; changes in heart rate; slow, shallow respirations with periods of apnea; nausea and vomiting; hyperactive reflexes; and numbness of the extremities
Metabolic alkolosis nursing care Take vital signs and daily weight; monitor heart rate, respirations, and fluid gains and losses Assess motor function and sensation in the extremities; monitor laboratory values, especially pH and serum bicarbonate levels
Metabolic alkalosis Assessment Take vs and daily wt; monitor hr, resps, and fluid gains and losses Keep accurate I&O records. Assess motor function and sensation in the extremities; monitor lab values, especially pH and serum bicarbonate levels
Metabolic Alkalosis intervention use isotonic saline solutions rather than water for irrigating nasogastric tubes because the use of water for irrigation can result in a loss of electrolytes Provide reassurance and comfort measures to promote safety and well-being
Acid base balance CO2 and PH Same direction-Metabolic CO2 and PH Opposite direction-Respiratory PH increased-alkaline PH decreased-acidic PH Normal-compensated
Created by: 646600841
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