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Nursing 290 Quiz 2
Advanced Med Surg Quiz 2
| Question | Answer |
|---|---|
| What does PACU stand for? | post anesthesia care unit |
| How long will a patient remain in PACU? | until the patient has resumed motor and sensory function, is oriented, has stable VS and shows no evidence of hemorrhage or other complication of surgery. |
| What is the number one priority for a patient in PACU? | airway |
| What are the responsibilities of the PACU nurse? | assessment, maintaining patent airway, mantaining cardiovascular stability, releiving pain and anxiety, controlling nausea and vomiting, and facilitating discharge to home or hospital unit. |
| What assessments should the PACU nurse make? | assess drains/surgical dressing, assess infusions as well as IV site, assess VS |
| How often should VS be assessed in PACU? | every 15 minutes until stable |
| When should a systolic BP be reported? | below 90 unless consistent with pre-operative BP |
| The nurse should also report vital sign trends that are concerning. What trends would be concerning? | HR trending up or down. O2 sat trending or down. |
| What can create a problem for PACU nurse maintaining a patent airway? | muscle relaxation due to anesthesia can lead to hypopharyngeal obstruction (anesthesia causes the tongue to fall back and obstruct the airway). |
| What are 4 signs the airway has been obstructed? | choking, irregular respirations, decrease in O2 sat, cyanosis |
| How can you position the head to maintain patent airway? | the head can be tilted back with the jaw held closed. |
| If a patient comes back from PACU with an oral airway, when can it be removed? (oral airway is a tube inserted in the mouth that extends behind the tongue) | when evidence of a gag reflex returns. If they are awake and communicative, they have a gag reflex. |
| What should you do if the patient vomits? | turn head to the side and suction if needed. |
| What are sign of hemorrhage? | bleeding from incision, hypotension, tachycardia, disorientation, restlessness, anxiety, oliguria, pale/cool skin (r/t vasoconstriction)(however just cool skin may be r/t temp in OR) |
| What are appropriate interventions for hemorrhage? | apply pressure (not applicatble if bleeding is internal), elevate legs 20 degrees with knees straight head and back is level with floor, give blood transfusion, transfer back to OR. |
| What is a common cause of hypertension in a post op patient? | hypertension |
| What should you do for a patient who is hypertensive due to pain? | give analgesic |
| What are two additional problems that can cause hypertension in post op patient? | hypoxia and bladder distension |
| What should you you if your patient has hypertension due to hypoxia and is also presenting with increased respiration rate and increased heart rate? | check airway, give supplemental O2, if already on O2 increase rate. |
| What should you do if your patient is hypertensive due to bladder distention? | Palpate first to determine if bladder is distended. Make sure foley catheter is not kinked (you may also need to flush the foley if there is a mucus plug preventing urine from draining), if they are not cathed you should straight cath them |
| What are causes of dysrhythmias in a post op patient? | electrolyte imbalances (replace electrolytes but infuse slowly so kidneys don't shut down), altered respiratory function, pain, hypothermia (warm slowly), stress, analgesic agents, |
| What are appropriate interventions for releiving pain and anxiety? | assess patient comfort, administer analgesics as indicated (usually short acting opiods via IV), allow family to visit, address family and patient anxiety. |
| What is the FIRST thing should you do if the patient states they are naseaus? | turn them on their side, then provide antiemetics |
| What are some common antiemetics? | Reglan(metoclopramide), Compazine(prochlorperazine), Phenergan(promethazine), Dramamine(dimenhydrinate), Vistaril/Atarax(hydroxyzine), Transderm-Scop(scopolamine), Zofran(ondansetron) p.466 |
| What are complications associated with vomiting? | aspiration, compromised hemostaisis due to increased abdominal pressure(which can compromise suture lines and cause hemorrhage), myocardial ischemia and dysrhythmis due to increased central venous pressure, pain |
| What patient population is at greater risk for developing post-op complications? | elderly due to decrease in homeostatic mechanisms, and decreased physiologic reserves to manage stress, increased likelihood of confusion/delirium, decreased liver function can cuase patient to poorly metabolize anesthesia |
| What interventions are appropriate for elderly post op clients? | monitor carefully/frequently. Assess confusion to exclude hypoxia, pain, hypotension, hypoglycemia, fluid loss. Assess need for lower dosages, assess hydration, anticipate extended time to recover from anesthesia. |
| What tool can we use to assess readiness for discharge or tranfer (it is simialr to APGAR score for neonates)? | Aldrete score. A score of 0-2 is given for each of the following catagories: activity, respiration, circulation, consciousness, O2 saturation.(ARCCO) |
| What must the Aldrete score be to transfer patient to step down un it? | 8 or more. If patient does not reach 8 they are transferred to intensive care. |
| What kind of information should you give before discharging a patient to home? (may also include a responsible adult in the teaching if appropriate) | written and verbal instructions regarding follow-up care, complications, wound care, activity, medications, diet. Also include perscriptions, phone numbers and actions to take if complications occur. Do not let patient drive home! |
| What should you do if you are the med surg floor nurse receiving a patient from the PACU? | Take report via telephone from the PACU nurse, gather your supplies and prepare your room. Supplies may include IV pump, telemetry box, wall suction canister, wire cutters, PCA pump, |
| What is the schedule for assessing vitals once the patient arrives on your unit? (according to book) | Upon arrival, then every 15 minutes for the first hour, every 30 minutes for the next two hours then less frequently if stable. |
| What are three interventions than should be done atleast every 2 hours to prevent respirtory complications? | coughing, deep breathing, incentive spirometer (however the coughing may be contraindicated for some patients since it increases intercranial pressure) |
| What else can the patient do prevent respiratory complications? | Ambulate |
| What are three respiratory complications that can occur in the post-op client? | atelectaisis, pneumonia and hypoxemia |
| What is atelectaisis and what are its signs and symptoms? | alveolar collapse distal to a mucus plug. Manifestations include decreased/diminished greath sounds, crackles, cough |
| What is pneumonia and what are its manifestations? | pneumonia is an infection of the lung tissue. It is manufested by fever/chills, tachycardia, tachypnea, productive cough, crackles, diminshed breath sounds at the bases of the lungs, pain and an increased white blood cell count. |
| What is hypoxemia and what are its manifestations? | Hypoxemia is insufficient oxygen in the arterial blood caused by atelectaisis or pneumonia. It can lead to cerebral dysfunction, myocardial ischemia and cardiac arrest. |
| How can opiod analgesics contribute to respiratory complications? | opiod analgesics can decrease respiratory rate |
| How can pain and immobility contribute to respiratory complications? | it can produce decreased lung expansion |
| What are three risk factors that can contribute to respiratory complications? | major surgery (especially abdominal surgery), obesity, preexisting pulmonary problems |
| What are three negative effects pain can cause? | Pain stimulates the stress response and can increase myocardial oxygen deman, increase platelet aggregation and depress the immune system. |
| What are the ways pharmacologic pain relief can be administered? | IV or oral opiod anagesics (including scheduled, PRN, PCA pump, epidural), intrapleural anesthesia(administered between the parietal and visceral pleura) and SQ pain management (delivers local anesthetic to the wound site through a pump) |
| What are some non-pharmacologic pain relief interventions? | guided imagery, music, position changes, distraction, applying cool washcloths to face or forehead, back massage. |
| What should you do after providing pain medication or other intervention? | reevaluate in 15-30 minutes for IV or 1 hour for PO med, document effectiveness and notify practitioner if intervention was ineffective |
| You should anticipate that the post op patient will have a fluid infusion for the first 24 hours or until cleared for PO intake. What patients should be monitored carefully for fluid volume excess? | patients with preexisting renal problems and patient with preexisting cardiac problems as well as the elderly |
| What are some interventions that can monitor fluid status? | record all I&O's as well as taking daily weights, assessing for edema and auscultating lung sounds |
| What labs should be monitered in the post op patient? | BUN, creatinine, serum elctrolytes, hemoglobin and hematocrit |
| What is the nurse's responsibility for the first surgical dressing change? | the first dressing change should be done by the surgeon the following day, however the nurse should notify the surgeon if the dressing needs to be changed earlier. |
| After the first dressing change, the nurse may be required to do subsequent dressing changes. What are the appropriate interventions to take when changing the dressing? | wash hands, provide for privacy, use sterile technique, assess and document, teach incision care to patient and/or caregiver |
| What are appropriate interventions when caring for a patient with a drain? | ensure drain is patent and functioning, record output(including amount, color, consistency and odor). Change the dressing as needed. |
| What kind of drain is just a tube sticking out of the surgical wound? | penrose |
| What kind of drain looks like a hamd grenade and works by compressing the drain to produce suction? | jackson pratt (JP) |
| What kind of drain od a round disk with a spring in the middle that is compressed to produce suction? | hemovac |
| What are potential complications of surgical wounds? | DVT, hematoma, infection (wound sepsis) and wound dehiscence and evisceration |
| How can DVT's be prevented? | early ambulation, anticoagulants (heparin, lovenox), compression stockings, leg exercises, adequate hydration, adoiding activities that constrict vessels behind the knees(blanket rolls, dangling at the edge of the bed) |
| What are 4 contributing factors to developing dvt's? | stress response, increased stomach acid, low cardiac output, venous staisis |
| What other factors can put patients at greater risk for developing DVT's? | prior history of DVT's, malignancies/Cancer, trauma, indwelling venous catheters (piccs and dialysis access ports) |
| What are the manifestations of hematoma? | bulging around incision, echymosis around incision |
| What is the treatment for hematoma? | if needed, surgical evacuation, can be done by surgeon removing several sutures or staples |
| What accounts for 77% of sugical patient deaths? | sepsis |
| How long can it take for evidence of wound infection to be apparent? | up to 5 days |
| What are the manifestations of wound infection? | fever/chills, increased WBC count, changes in charachter around the wound (reddness, swelling, warmth, tenderness, pain, purulent drainage) |
| What is sepsis? | Sepsis is systemic responce to infection triggering inflammation throughout the body. This inflammation creates microscopic blood clots that can block nutrients and oxygen from reaching organs, causing them to fail. |
| What are some treatments the surgoen may perform/order to treat wound infection? | removal of some of the sutures/staples, insertion of a drain, incision for drainage, antibiotics |
| What is wound dehiscence? | separation of the edges of a wound |
| What is wound evisceration? | protrusion of intestine through open incision (associated with abdominal surgery) |
| What should you do if your patient's wound eviscerates? | place patient in high fowlers, cover wound with sterile dressing soaked in saline, call the surgeon |
| What is the basic definition of shock? | inadequate tissue perfusion (to deliver oxygen and nutrients to support the vital organs' cellular function, affects all systems of the body) |
| Why does shock affect all of the systems of the body? | because all cellular activities run on oxygen |
| What is the byproduct produced when cells switch to anaerobic metabolism? | lactic acid |
| In shock the body innitially become hyperglycemic and then witches to hypoglycemia. What produces the innital hyperglycemia? | the body's response to stress, first the liver performs glycogenolysis breaking down glycogen to release glucose. Then the liver performs gluconeogenesis making sugar from animo acids. Eventually all of the liver stores are depleted causing hypoglycemia |
| Cell permeability changes and sodium and water enter cells. What does this cause? | this causes the cell to eventually rupture and die dumping contents into the bloodstream |
| What are the three feedback systems to work to regulate blood pressure? | neural, chemical, hormonal |
| What is the formula for mean arterial blood pressure? | cardiac output(CO) X systemic vascular resistence (SVR) |
| What is the normal range for MAP? | 70-110 |
| What is the minimum effective MAP? | 65 |
| What is stroke volume? | the amount of blood pumped by the left ventricle pumped by each contraction |
| What is the formula for cardiac output? | HR X SV |
| What are the three stages of shock? | compensatory, progressive and irreversible |
| In the compensatory stage of shock, the sympathetic nervous system releases catecholamines. What are the two catecholamines? | epi and nor-epi (stimulating the fight or flight response) |
| What does the epi and nor-epi affect the heart? | increases heart rate, increases BP, increases heart contractility which lead to increased cardiac output. |
| How does the epi and nor-epi affect the lungs? | It increases respiration rate to increase O2 saturation |
| How does the epi and nor-epi affect the kidneys? | it increases renin-angiotensin activation which leads to an increased absorption of sodium and water which leads to an increased preload and decreased urine output. |
| How does the epi and nor-epi affect glucose? | the epi and nor-epi and cortisol increase blood glucose levels |
| What is the desired result of the activation of the sympathetic nervous system? | restoration of tissue perfusion and oxygenation |
| What happens to blood flow/circulation during the compensatory stage of shock? | the body shunts blood to vital organs including the brain, heart and lungs |
| What are the consequences of the body shunting blood to the vital organs? | decreased perfusion to other organs causing hypoxia. S&S include cool/clammy skin, hypoactive bowel sounds, decreased urine output, confusion(also due to respiatory alkalosis |
| What is the focus of medical management during the compensatory stage of shock? | identify the cause, treat accordingly |
| What is the best nursing management during the compensatory stage of shock? | recognize the signs of shock, early intervention will produce the best outcome. Unfortunaltely cellular damage occurs before a drop in BP is noted. |
| What are appropriate nursing interventions for a patient in the compensatory stage of shock? | minimize O2 demand to increase perfusion. sedation will decrease activity, opiod analgesic will decrease pain and VS, use supplemental O2 and/or mechanical ventilation, keep them warm, give PRBC transfusion, reduce anxiety, promote safety |
| How are VS affected by the compensatory stage of shock? | increased HR and RR, decreased BP and O2 sat. Pulse pressure will narrow, normal range is 30-40 mmhg |
| How is O2 sat measured in a patient in the compensatory stage of shock? | since the blood was shunted to vital organs, the finger probe will be ineffective. Continuous central venous oximetry will be used(SvcO2) and the normal value for SvcO2 is 70%. Sublingual capnometry may be used to measure PCO2 using a probe under tongue |
| What can be used to measure skeletal muscle oxygenation? | Near-infared spectoscopy measures skeletal muscle oxygenation. The normal value is greater than 80%. A probe is placed over the thenar muscle of the palm. My notes say we should KNOW THIS. |
| When does the patient move from the compensatory stage of shock to the progressive stage of shock? | When the compensatory systems are unable to maintain effective MAP. |
| How is clinical hypotension defined? | by a systolic BP lower than 90 or a decrease in systolic BP 40mmhg from baseline |
| During the progressive stage of shock there is a fluid shift, where does it go? | it moves from the intravascular space to the interstitial space |
| What other system is activated during the progressive stage of shock? | the coagulation system |
| What are the respiratory effects of the progressive stage of shock? | pulmonary edema (from the fluid shift) causing atelectaisis and crackles |
| What are the cardiovascualar effects of the progressive stage of shock? | myocardial ischemia leading to myocardial infarction. Also dysrhythmias |
| What are two tests that can determine myocardial ischemia? | myocardial creatine kinase(CK-MB) and cardiac troponin |
| What should be done for patient in progressive stage of shock knowing that dysrhythmias are an effect of the progressing stage of shock? | putthe patient on continuous cardiac monitor and get an EKG |
| What caused the fluid shift in the progressive stage of shock? | lactic acid is the biggest causative agent and the fact that vessels become more permeable. |
| What are neurologic effects of the progressive stage of shock? | declining LOC |
| What are renal effects of the progressive stage of shock? | Acute renal failure (ARF), may begin when MAP goes below 70. Urine output will be less than 30 ml/hr, BUN will be elevated and creatinine will be elevated. The glomerular filtration rate (GFR) will be decreased. |
| What are hepatic effects of the progressive stege of shock? | decreased liver perfusion causes decrease in drug and waste product(lactic acid and ammonia) metabolism. Filtration of bateria is also impaired increasing risk for infection. Patient may appear jaundiced. |
| What labs can confirm impaired hepatic function? | Liver enzymes will be elevated (AST, ALT) as well as HDL and bilirubin |
| What are gastrointestinal effects of progressive shock? | ulcers related to poor perfusion, GI bleed (gut is lined with bacteria), bacterial toxin translocation and septicemia via lymph system |
| What are hematologic effects of progressive shock? | activation of clotting cascade, widespread microthrombi, consumption of clotting factors, prolonged bleeding time and DIC |
| What are the four goals in the medical management of the progressive stage of shock? | PERFUSION, NUTRITION, GLYCEMIC CONTROL AND GI ULCER PROPHYLAXIS. |
| What is the goal of managing glycemic control? | maintining serum glucose level between 80 and 110 mg/dl decreases mortality and morbidity, patient may require continuous IV insulin |
| What drug classes can be given for GI ulcer prophylaxis? | antacids, H2 blockers, proton pump inhibitors |
| What should be the focus of nursing management for a client in the progressive stage of shock? | monitoring, administering meds etc, coordination of care with other members of the healthcare team, prevention of complications, promoting rest and comfort, supporting family members. |
| What complications should the nurse monitor for in a patient in the progressive stage of shock? | medication toxicity, infection (leading to sepsis r/t invasive vascular lines or the presence of a vent), thromi, emboli (r/t venous staisis), skin breakdown. |
| What are the characteristics of the irreversible stage of shock? | organ damage is so severe that that the patient does not respond to treatment and cannot survive. Renal and liver failure compounded by the release of necrotic tissue toxins creates an overwhelming acidosis. |
| One of the treatments of all stages of shock is fluid replacement aka fluid recuscitation. What is a crystalloid fluid? | It is a fluid that is capable of passing through a semi-permenable membrane. The opposite, al colloid fluid, is not capable of passing through a semipermeable membrane. Crystalloid solutions expant the interstitial space. Colloids expand plasma volume. |
| What are two isotonic crystalloid solutions? | .9NS and lactated ringers. Lactated ringers contains a lactate ion NOT lactic acid, the solution converts to bicarbonate to increase serum pH and make the serum more alkalotic (this is used to treat acidosis) |
| What is a hypertonic crystalloid solution used for fluid recisitation? | 3%NS (more "stuff than .9NS). This solution has an osmotic effect and pulls fluid into the intervascular space so you would need less of a hypertonic fluid than an isotonic fluid to achieve the desired effect. |
| What does a colloid solution do? | It is used to expand the fluid in the intravascular space (so does a hypertonic solution but the colloid solution has a longer duration because its molecules are too large to pass through capillary membranes. Less fluid is needed to expand volume.) |
| What are two negative aspects of colloid solutions? | they are significantly more expensive and have greater risk for anaphylactic/allergic reaction |
| What are the two types of colloid solution? | natural and synthetic |
| What is an example of a natural colloid solution? | albumen which is a plasma protein that everyone produces so it can be transfused |
| What are two examples of a synthetic colloid solutions? | hetastarch and dextran |
| What other action does dextran have that needs to be considered when selecting a colloid solution? | it can interfere with platelet aggregation |
| What type of fluid replacement would all blood products be considered? | colloid |
| What are six complications of fluid resusitation? | pulmonary edema, fluid volume excess, generalized edema, anaphylactic reaction(colloids), hypothermia (caused by rapid infusion of large volumes of fluid), and abdominal compartment syndrome related to third spacing |
| What action can be taken to reduce the risk of hypothermia when infusing la rge volumes of fluid? | warm the fluids before administration |
| How is abdominal compartment syndrome defined? | a leaking of fluid into the intra-abdominal cavity causing pressure of greater than 12 mmHg within the intra-abdominal cavity(normal pressure in the abdominal compartment is 0-5 mmHg) |
| What problems can abdominal compartment syndrome cause? | compromised venous return producing a decrease in cardiac output, elevation of the diaphragm interfereing with lung inflation and GI and renal dysfunction (intolerance to tube feeding, absent bowel sounds and decreased urine output) |
| What treatment is required in cases of abdominal compartment syndrome? | surgical decompression (fasciotomy (incision) with suction) |
| What is the normal range for central venous pressure? | 4-12 mmHg |
| How can venous O2 saturation (SvO2) be monitored in the critical care setting? | It is measured with central venous oximitry e.g. swan-ganz catheter placed peripherally and threaded through the heart and into the pulmonary artery to get the best reading of mixed venous saturation |
| What is the normal value of SvO2 (venous oxygen saturation) and why is it monitored? | The venous blood should be 75% saturated with oxygen(arterial blood should be 95-100% saturated)SvO2 is monitored because it is one of the earliest indicators of a threat to tissue perfusion(sepsis causes high SvO2 and lung or cadiac prob causes low SvO2) |
| What is the difference between SvO2 and ScvO2? | The difference is where the value is collected. The book only said that ScvO2 is measured with a CVP line and the normal values are slightly different with SvO2 and ScvO2. |
| What is a CVP line? | it measures PRESSURE (not O2 sat). It is used to measure a clients response to fluid replacement. Normal pressure 4-12 mmHg. |
| What is the most important thing to monitor in patients receiving large volumes of crystalloid solutions? | monitor the lungs for adventitious breath sounds and signs and symptoms of interstitial edema (e.g. abdominal compartment syndrome) |
| What does an arterial BP line do? | monitor arterial BP |
| What stimulates alpha adreneric receptors? | catecholamines: epi and nor-epi |
| Where are alpha adrenergic receptors located? | in blood vessels (arteries and veins) as well as smooth muscle in the GI tract, lungs kidneys and integumentary system |
| What are the effects of catecholamines (epi and nor-epi) on the alpha adrenergic receptor sites? | constriction: vasoconstriction, bronchioconstriction, decreased motility in GI tract, |
| Where are beta 1 receptors located? | heart (one heart, two lungs) |
| What happens when beta 1 receptors are stimulated? | heart rate and myocardial contraction increases |
| Where are beta 2 receptors located? | bronchioles/lungs, heart and skeletal muscles |
| What happens when beta 2 receptors are stimulated? | vasodilation in the bronchioles, heart and skeletal muscles |
| Which vasoactive receptor stimulators are used in the treatment of shock? | all of them can be used in various combinations however vital signs need to be monitored every 15 minutes or more often if necessary. |
| How are vasoactive medications administered in shock patients? | via central line ONLY becuase infiltration and extravasation of these drugs can cause tissue necrosis. PUMP must be used. |
| Vasoactive drugs in the critical care setting may be titrated frequently. What needs to be done each time a titration is made? | DOCUMENT each time the rate is changed |
| If you have an order to discontinue a vasoactive drug how should the drug be discontinued? | SLOWLY, never take them off abruptly |
| What does a (positive)inotropic agent do? | it increases the contractions of the heart (improves contractility, increases stroke volume, increases cardiac output) |
| What is a disadvantage of using an inotropic agent? | it increases the oxygen demand of the heart |
| What does a negative inotropic agent do? | decrease contractility and oxygen demand of the heart (not really discussed in this chapter but I thought of we're going to learn one we should learn the other too e.g. beta blocker, calcium channel blocker) |
| What are some positive inotropic agents discussed in the book? | Dobutrex/dobutamine, Inotropin/dopamine, Adrenalin/epinephrine, Primacor/milrinone |
| What does a vasodilator do? | stimulates beta 2 receptors, reduce preload and afterload and reduce oxygen demand of the heart |
| What is a disadvantage to using vasodilators? | hypotension |
| What vasodilators are discussed in the book? | Tridil/nitroglycerin, Nipride/nitroprusside |
| What is a vasopressor agent? | it increases blood pressure by vasoconstriction (stimulates alpha 1 receptor sites) also called anti-hypotensive agent |
| What are disadvantages of using vasopressor agents? | increased afterload, increased cardiac workload, compromised perfusion to the skin, lungs and GI tract |
| What vasopressor agents are mentioned in the book? | Levophed/norepinephrine, Inotropin/dopamine, Neo-Synephrine/phenylphrine, Pitressin/vasopressin |
| Nutritional support is an important part of the management of shock. What is the preferred method of nutritional support? | Enteral is preferred becuase it uses the GI system to support its integrity (e.g. OG, NG tube). Glutamine (an essential amino acid) is usually added to support immunologic function by feeding lymphocytes and macrophages. |
| Stress ulcers are common in acutely ill patients due to decreased perfusion to GI tract. What drugs can be administered to prevent ulcer formation? | antacids, H2 receptor blockers and proton pump inhibitors (they reduce gastric acid secretion and increase pH) |
| What H2 receptor blockers are discussed in the book? | Pepcid/famotidine and Zantac/ranitidine |
| What proton pump inhibitors are discussed in the book? | Prevacid/lansoprazole |
| What are the 5 classifications of shock? | hypovolemic, cardiogenic, septic, neurogenic and anaphylactic |
| How do you know which classification of shock the patient is experiencing? | it is based on the INNITIAL CAUSE of the shock. Everyone in shock will eventually become hypovolemic etc.. |
| Which shock state results from decreased intravascular volume due to fluid loss? | hypovolemic shock |
| Which shock state results from impairment or failure of the myocardium? | cardiogenic |
| Which shock state results from overwhelming infection causing relative hypovolemia? | septic |
| Which shock state results from loss of sympathetic tone causing relative hypovolemia? | neurogenic |
| Which shock state results from severe allergic reaction producing overwhelming systemic vasodilation and relative hypovolemia? | anaphylactic |
| What is the pathophysiology of hypovolemic shock? | decreased blood volume produces decreased venous return which produces decreased stroke volume, decreased cardiac output and decreased tissue perfusion |
| How much intravascualr fluid needs to be lost to be considered hypovolemic shock? | 15-30% or 750-1500 ml |
| What are the two general causes of hypovolemic shock? | external(fluid loss) and internal (fluid shift) |
| What are some examples of external fluid loss? | trauma, surgery, vomiting, diarrhea, diuresis, diabetes insipidus |
| What are some examples of internal fluid shifts? | hemorrhage, burns, ascites, peritonitis, dehydration |
| How is hypovolemic shock managed? | treat the underlying cause, fluid and blood replacement, decision to transfuse is based on clinical picture rather than arbitrary number, fluid may be pulled from another compartment, and the drug desmopressin is used if due to URINARY losses. |
| What drug may be used if hypovolemic shock is caused by urinary loss from diabetes insipidus or excessive diuretic use? | desmopressin |
| What position is beneficial for patients experiencing hypovolemic shock? | modified trendelenburg: head and back parallel with floor and feet elevated, will help with venous return and will prevent pooling |
| When a chest tube is removed, do you need to worry about the hole in the pleural sac? | no, it closes itself very quickly |
| What is the pathophysiology of cardiogenic shock? | decreased cardiac contractility produces decreased stroke volume and decreased cardiac output which leads to pulmonary congestion, decreased systemic perfusion including decreased coronary artery perfusion |
| Cardiogenis shock results from an imapirment of the hearts ability to contract and pump blood and is usually caused by an acute event. What is an acute event that can lead to cardiogenic shock? | acute MI(especially anterior wall MI and left coronary artery blockage) |
| What are some non-coronary causes of cardiogenic shock? | hypoxemia, tension pneumothorax, pH imbalance causing dysrhythmias, electrolyte imbalance, pericarditis, large tumor in thoracic cavity |
| What is a tension pneumothorax? | a hole in lung but not in pleural sac around lung and it puts pressure on the heart and aorta and causes the trachea to shift. |
| What is the treatment for a tension pneumothorax? | chest tube? |
| What is the treatment for a coronary artery blockage? | take 'em to the cath lab |
| What is the first line of treatment for MI? | morphine, oxygen and nitro (along with hemodynamic monitoring) |
| What are the three desired effects of morphine in the treatment of acute MI? | decreased pain, vasodilation and decreased HR |
| What 2 lab markers will be monitored in patients with cardiogenic shock or acute MI? | CK-MB and troponin |
| Is fluid therapy used in cardiogenic shock? | sometimes but be careful because it will increase the workload of the heart |
| What is an intra-aortic balloon counterpulsation? | a mechanical assistive device used in the treatment of cardiogenic shock,it will mechanically pump the heart |
| What is a ventricular assistive device (VAD)? | a mechanical assistive device used in the treatment of cardiogenic shock, also mechanically pumps the heart |
| What is cardiopulmonary bypass (CPB)? | a mechanical assistive device used in the treatment of cardiogenic shock, the patient's blood is cycled through a bypass machine |
| What does the drug Dobutamine do in cases of cardiogenic shock? | increases HR and force of contraction to increase cardiac output (it is a beta 1 receptor agonist aka inotropic agent) |
| What does the drug nitroglycerin do in cases of cardiogenic shock? | vasodilator used to decrease the wokload of the heart |
| What does the drug dopamine do in cases of cardiogenic shock? | dopamine acts on alpha 1 (causing vasoconstriction to increase BP) and beta 1 receptor sites(increasing HR and force of contraction) |
| If a client has cardiogenic shock due to arrhythmias caused by pH imbal or electrolyte imbal what is focus of medical management? | correct imbalances |
| Will all patients experiencing MI go into cardiogenic shock? | no |
| What is the focus of nursing management for a client with cardiogenic shock? | (from powerpoint) prevent cardiogenic shock, monitor hemodynamic status (circulation), admin meds and fluids, maintain intra-aortic baloon counterpulsation, ensure safety and comfort |
| Three of the shock types are further classified as circulatory shock, what three types are a type of circulatory shcok? | septic, neurogenic and anaphylactic |
| What causes circulatory shock? | systemic loss of vascular tone (systemic vasodilation causing decrease in BP and decrease in perfusion) book says blood volume pools in peripheral blood vessels causing hypovolemia then ineffective tissue perfusion |
| What is the pathophysiological pathway of circulatory shock? | A precipitating event causes vasodilation, which activates and inflammatory response creating a maldistribution of blood volume decreasing venous return, decreasing cardiac output whick leads to decreased tissue perfusion(shock) |
| Which type of circulatory shock is precipitated by exposure of a pathogen? | septic shock |
| Which type of circulatory shock is precipitated by exposure to an antigen? | anaphylactic shock |
| Which type of circulatory shock will be covered at a later time when we discuss spinal cord injuries? | neurogenic shock |
| Which type of shock has an underlying cause of infection? | septic |
| What is the medical management of septic shock? | treat the infection (but source is often unknown) replace all invasive devices(urinary catheter, IV, arterial lines etc), drain any abcesses, debride necrotic tissue, hemodynamic monitoring, labs(cultures, WBC's) and fluid therapy to raise BP |
| Coleman said a pulmonary artery catheter is used for hemodynamic monitoring, what is it? | a catheter fed down into right ventricle and into pulmonary artery to monitor mixed venous oxygen saturation (aka swan-ganz catheter) |
| What drugs are used in the medical management of septic shock? | antibiotics, Xigris(pulled from market), other vasoactive drugs and antiarrhythmic medications |
| What is the focus of nursing management of a client with septic shock? | hyperthermia (although it is a natural mechanism for fighting infection an antipyretic may be ordered for temp over 104), monitoring hemodynamic status, administering meds and fluids, monitoring labs(e.g. serum atb levels), ensuring safety and comfort |
| What are two drugs mentioned in class that may require serum antibiotic levels to be done? | vancomycin and topromycin |
| What is the temperature in which our book says a fever will be treated with anti-pyretic? | 104F |
| What is the focus of the medical management in the treatment of anaphylactic shock? | correct the underlying cause(stop the exposure to the antigen), hemodynamic monitoring, intubation or tracheotomy (if inflammatory response causes bronchospasm), fluid therapy and pharmcologic therapy |
| What drugs may be used in the treatment of anaphylactic shock? | epinephrine (to cause vasoconstriction), antihistamine such as benedryl(to reverse effects of histamine and decrease capillary permeability/preserves intravascular volume),albuterol or other bronchiodilator, other vasoactive medications |
| What are the effects of benedryl on a patient in anaphylactic shock? | reverses the effect of histamine and decreases capillary permeability to preserve intravascular volume |
| What is multiple organ dysfunction syndrome(MODS)? | another phase in progressive shock and is considered a complication of any type of shock. It is the presence of altered function in two or more organs and require interventions necessary to support continued organ function,can be primary or secondary |
| What is the mortality rate of MODS? | according to the powerpoint 75% (book says depends on the number of organs affected and if more than 4 organs are affected the mortality arte is 70%.(elderly patients are at increased risk)(early detection is key) |
| What is the treatment of MODS? | controlling the innitiating event, promoting adequate organ perfusion, providing nutritional support and promoting communication(this means ensure you know patient's wishes during treatment and teach patient about long rehab following recovery from MODS,) |
| Are the kidneys very sensitive to decreased perfusion? | yes |
| Are you always going to hold anti-pyretic until fever reaches 104? | no, physician may go ahead and order an antipyretic of the patient has a fever of 102 and is shaking uncontrollably |
| I am not going to put the eye and ear material in this study stack, I'm just going to read through it a couple of times. | Good luck! |
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