Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
TL Shock
HESI Shock
| Question | Answer |
|---|---|
| Define Shock. | widespread serious reduction of tissue perfusion resulting in impaired cellular fuction |
| Name 3 things that affect the ability of the arteries to deliver blood to tissues. | Cardiac output, Peripheral vasomotor tone (to return blood to the heart), blood volume |
| Describe how we can get decreased blood pressure. | Reduction in cardiac output, blood volume or vasomotor tone |
| List clients who are at risk for the development of shock. | Very young and very old, Post MI, Severe dysrhythmia, adrenocortical dysfunction, blood loss/hemorrhage, burns, massive infection |
| What are the early signs of shock? What causes the early signs? | agitation and restlessness form cerebral hypoxia |
| Name four types of shock. | Cardiogenic, hypovolemic, vasogenic, septic |
| What is the most common type of shock? | Hypovolemic |
| What causes hypovolemic shock? | internal or external blood or fluid loss |
| What happens in cardiogenic shock? | Heart malfunction such as MI, dysrhythmia, or heart failure results in reduced cardiac output |
| Name some potential causes of venous pooling leading to vasogenic shock. | anaphylaxis, spinal cord injury, peripheral neuropathies |
| How does sepsis result in shock? | endotoxins released by bacteria cause vascular pooling, diminished venous return, and reduced cardiac output |
| Explain how positioning can help a client with cardiogenic shock in the presence of pulmonary edema. | placing the client in high fowlers with feet dependent decreases venous return to the left ventricle |
| What is the main focus of treatment for shock (with special considerations for cardiogenic shock)? | Rapid restoration of fluid volume |
| How is fluid restoration achieved in shock? | with whole blood, plasma, plasma substitute (colloid fluids), or Istotonic electrolyte IV solutions such as Lactated Ringers or Normal saline |
| Why is whole blood the rare choice for volume expansion? | because of a high risk for transfusions reactions |
| What is the first priority of care in cardiogenic shock? | restore cardiac function |
| Why isn’t fluid restoration the first priority in cardiogenic shock? | because infusion of volume expanders may result in pulmonary edema |
| What drugs would be employed to restore cardiac function in cardiogenic shock? | cardiotonic drugs like digoxin, dopamine (Intropin) to improve contractility; dopamine (Intropin) or norepinephrine(Lovaphed) for vasoconstriction |
| What serial measurements will we monitor q 15 minutes for the patient in shock? | CVP, urine ouput, heart rate, clinical and mental status |
| Other than fluid resuscitation what are 2 other probable treatments needed for shock? | oxygen administration and treat the underlying cause |
| What would numbers would you expect for pulse, respirations, and BP when the client is in shock? | pulse above 100, respirations above 24, Systolic BP below 80 |
| What changes would you anticipate in the client’s mental status and skin? | early shock: restlessness, hyperalert; Late shock: decreased alertness, lethargy, coma; Skin- cool and clammy, diaphoresis, pale; vaasogenic and early septic shock the skin is warm |
| What renal condition can develop rapidly in shock? | acute tubular necrosis |
| What fluid status changes may occur with shock? | imbalance between intake and output, decreased urine output, increased urine specific gravity <1.020, abnormal CVP <4 cm H20 |
| What assessments will the nurse monitor while her patient is in shock? | MAP, BP, pulse, RR, arrhythmias, urine output, CVP |
| What should the urine output be? | at least 30mL per hour |
| What should the CVP be? | In shock situations the HCP often orders fluids to elevate the CVP to 16-19 cm H20 CVP to compensate for decreased cardiac output |
| How often are assessments made for the client in shock? | every 15 minutes or more often as indicated by the client’s clinical condition |
| How are medications delivered to the client in shock? | IV since absorption by other routes would be altered |
| How should we position the client in shock? | Modified Trendelenberg: Head of bed flat, feet elevated 45 degrees |
| How do protect the client from falls? | keep the side rails up for all procedures – mental confusion |
| What blood tests will be required for the client in shock? | CBC, Lytes, BUN and Creatinine, ABGs |
| Name the vasopressors/ andrenergic stimulants that may be utilized for shock. | epinephrine (BronKaid), dopamine (Intropin), dobutamine (Dobutrex), norepinephrine (Levophed), or Isoproterenol (Isuprel) |
| How should vasopressors be administered during shock? What are the nursing responsibilities? | Adminsiter through pump, Monitor BP q 15minutes, monitor for IV site extravasation, Know HCPs prescribed target MAP (usually 80-90 mm Hg) |
| What is the formula for MAP? | (systolic BP plus diastolic BP times two) divided by three |
| What vasodilators may be employed to counteract precipitous increase in BP due to vassopressor administration? | hydralazine (Apresoline), nitroprusside (Nipride), labetalol (Normodyne, Trandate) |
| What are the nursing responsibilities for the administration of vasopressors and vasodilators in cases of shock? | Wait for a precipitous change in BP if prescribed together. If drop in BP, decrease the vasodilator rate first; then increase the vasopressor; If increase in BP, decrease vasopressor first; then increase the rate of the vasopressor |
| Why can’t we change infusion rates of vasopressors and vasodilators simultaneously? | they are potent/dangerous drugs that require the client to be weaned onto and off them |
| What can the nurse do to help the family of the person in shock? | contact support persons (family or spiritual advisor), keep the family up to date and offer realistic hope, collaborate with HCP before notifying family of medical interventions |
| What would the interventions be for a client with shock from a bee sting? | maintain patent airway, keep warm and free from restrictive clothing, elevate legs, Epinephrine 1: 1000, 0.2 to 0.5mL for mild cases or 1: 10, 000 5mL for severe cases, volume expanding fluids (except cardiogenic), |
| What drugs might be employed for shock? | digoxin, vasoconstrictors Levophed and dopamine |
Created by:
Perseverandovercome
Popular Nursing sets