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Med Surg exam #2
chapter 19, 14
| Question | Answer |
|---|---|
| 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 |
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