Term
|
Definition
| Indicator for tissue and organ perfusion |
|
|
Term
|
Definition
| Inadequate perfusion (blood flow) leading to inadequate oxygen delivery to the tissues. |
|
|
Term
| What is a late sign of shock? |
|
Definition
|
|
Term
|
Definition
| Tissues are under-perfused, decreased cardiac output, increased anaerobic metabolism, lactic acid is increasing |
|
|
Term
| Compensatory stage of shock |
|
Definition
| Reversible, SNS activated by low cardiac output, attempting to compensate for the decreased tissue perfusion |
|
|
Term
| Progressive stage of shock |
|
Definition
| Falling compensatory mechanisms; profound vasoconstriction from the SNS --> ISCHEMIA Lactic acid production is high --> metabolic acidosis |
|
|
Term
| Irreversible or Refractory stage of Shock |
|
Definition
| Cellular necrosis and multiple organ dysfunction syndrome may occur |
|
|
Term
| What are some general shock management interventions? |
|
Definition
Maintain airway
Oxygen (most important drug in shock)
Ventilation if needed
Establish IV access
Maintain body temperature |
|
|
Term
| What monitoring do you provide for patients with shock? |
|
Definition
Level of consciousness
Electrocardiogram (EKG)
Hemodynamic |
|
|
Term
| What are signs and symptoms of cardiogenic shock? |
|
Definition
Weak, thready pulse
Inspiratory crackles (left ventricular failure)
Dyspnea
Cool, moist skin (vasoconstriction)
Tachypnea (fighting lactic acid)
Oliguria (decreased urine output)
Mentation |
|
|
Term
| What are medication interventions given to a patient with acute pulmonary edema and their BP is above 90-100 mm Hg? |
|
Definition
Furosemide
Morphine
Nitroglycerin |
|
|
Term
| What are medication interventions for cardiogenic shock? |
|
Definition
Nitroprusside, Nitroglycerin, Milrinone, and Fenoldopam to dilate coronary vessels
and
Dopamine and dobutamine to enhance contractility |
|
|
Term
| What are some causes of hypovolemic shock? |
|
Definition
Blood loss (trauma)
Plasma loss (burn victims)
Water loss (vomiting, diarrhea, sweating, increased urine output, and increased respiratory loss) |
|
|
Term
| If a system that is supposed to be closed leaks, what happens to the pressure in it? |
|
Definition
|
|
Term
| What loss of cc's produce the beginning symptoms of hypovolemic shock? |
|
Definition
|
|
Term
| What loss of cc's begins failure of compensation in hypovolemic shock? |
|
Definition
|
|
Term
| What cc's is 40% of total blood volume? |
|
Definition
|
|
Term
| Decrease in intravascular volume, inadequate tissue perfusion, anaerobic metabolism, lactic acidosis, and cells soaking up water are all indicators of what kind of shock? |
|
Definition
|
|
Term
| What are signs and symptoms of hypovolemic shock? |
|
Definition
Decreased CVP
Decreased capillary refill
Decreased urine output
Anxiety and/or agitation
Confusion
Cool, clammy skin (vasoconstriction)
Absent bowel sounds (GI bleed) |
|
|
Term
| What are managing interventions for epitaxis (nose bleed)? |
|
Definition
Sit up, lean forward
Pinch nostrils together
Keep sitting in position
Keep quiet
Apply ice over nose
15 min adequate intervention |
|
|
Term
| What are signs and symptoms of internal bleeding? |
|
Definition
Pain, tenderness, swelling, and discoloration at injury site
Bleeding from any body orifice
Vomiting bright red blood or coffee ground emesis
Dark, tarry stools
Tender, rigid or distended abdomin |
|
|
Term
| What are some causes of GI bleeds? |
|
Definition
Peptic ulcers (75%)
Stress ulcers (Curlings or Cushings)
Mallory Weiss tears
Esophageal Varices
|
|
|
Term
| What are signs and symptoms of GI bleeding? |
|
Definition
Melena
Hematochezia
Occult blood
Hypovolemia
Mild epigastric or abdominal pain |
|
|
Term
| Medical assessment for GI bleeds include: |
|
Definition
H&H
Barium study
Endoscopy |
|
|
Term
|
Definition
1000-2000cc of room temperature normal saline
Removed by intermittent suction or gravity until returns clear
Iced salien lavage
80-90% will stop on own |
|
|
Term
| What medication interventions are used for GI bleeds? |
|
Definition
Proton Pump Inhibitors (Protonix)
Antacids
Histamine Blockers (Zantac)
Mucosal Barrier Enhancers (Carafate)
|
|
|
Term
| What is the "best practice" protocal for hypovolemic shock? |
|
Definition
Start 2 large bore IV's
If bleeding, apply pressure
Replace volume (isotonic crytalloids), platelets, colloids
Take VS every 5 minutes until stable
Do not leave patient alone |
|
|
Term
|
Definition
| Agent traumatizes endothelium causing necrosis and sclerosis or blood vessel |
|
|
Term
|
Definition
| For varices- rubber band placed on varix up 10 at one time |
|
|
Term
| What are the complications for endoscopic therapies? |
|
Definition
| Fever, bleeding, and ARDS |
|
|
Term
| What nursing responsibilities are in place when it comes to balloon tamponades for medical therapy? |
|
Definition
Maintain lumen pressures and patency
Deflate balloon q 8-12 hours
Watch for balloon rupture
Scissors at bedside
Irrigate |
|
|
Term
What medication is used to lower portal pressure?
What symptoms should immediately reported? |
|
Definition
Vasopressin
Abdominal cramping, chest pain, and cardiac dysrhythmias |
|
|
Term
|
Definition
| Results from body's response to bacteria in the bloodstream |
|
|
Term
| What common bacteria are responsible for septic shock? |
|
Definition
| E. coli, pseudomonas, staph, strep |
|
|
Term
|
Definition
Temp is greater than 100.4 or lesser than 96.8
HR is greater than 90
Respirations are greater than 20
WBC is greater than 12,000 or 10% bands
|
|
|
Term
| Criteria for determination for sepsis |
|
Definition
| Considered present if 2 or more SIRS criteria are present along with any known infection and one or more of clinical manifestations |
|
|
Term
| What are the clinical manifestatons for SIRS? |
|
Definition
| Hypotension, urinary output is decreased, positive fluid balance, decreased capillary refill, and hyperglycemia |
|
|
Term
| Warm phase of septic shock |
|
Definition
| Hyperdynamic state, hypertensive, tachycardia, pink, and warm |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Results from severe allergic reaction, body responds to allergen by releasing histamine, which causes vessels to dilate and become "leaky" |
|
|
Term
| Patients with anaphylactic shock will develop: |
|
Definition
Hives (urticaria)
Itch
Wheezing and difficulty breathing (bronchospasm) |
|
|
Term
| What chemical released from the body during an allergic reaction accounts for these effects? |
|
Definition
|
|
Term
| Nursing interventions for anaphylactic shock include: |
|
Definition
Maintain patent airway
02, IV, ECG monitoring
Identify the cause |
|
|
Term
| What medication interventions are necessary for anaphylactic shock? |
|
Definition
Epinephrine
Antihistamines (benedryl)
Steroids (prednisone) |
|
|
Term
| What signs and symptoms are present in neurogenic shock? |
|
Definition
| Hypotension, bradycardia, hypothermia, and warm,dry extremeties. |
|
|
Term
| What medication is administered within the first 8 hours of neurogenic shock? |
|
Definition
|
|
Term
| What is the "zeroing" point on the body for a PAC? |
|
Definition
Phlebostatic axis
4th ICS, midaxillary line |
|
|
Term
| Hemodynamic Monitoring Arterial Lines |
|
Definition
| Provide for continous measurement of arterial blood pressure |
|
|
Term
| What are the uses for hemodynamic monitoring? |
|
Definition
| Accurate blood pressure, and access site for blood gases |
|
|
Term
| Nursing actions for hemodynamic monitoring of arterial lines include |
|
Definition
Maintain hand in a flexed position
Provide ROM exercises q 2-4 hours
Maintain sterility
Upon removal: hold pressure for 5-10 minutes |
|
|
Term
| What are complications of hemodynamic monitoring of arterial lines? |
|
Definition
| Infection, breakage of catheter, and bleeding |
|
|
Term
| What are the uses for hemodynamic monitoring of central venous pressure? |
|
Definition
| Measures central venous pressure to estimate blood/fluid volume status, and obtain blood samples |
|
|
Term
| What is the Swan-Ganz catheter used for? |
|
Definition
| Measures hemodynamic pressures within the heat and pulmonary vasculature |
|
|
Term
| What are complications of MODS to the brain? |
|
Definition
| Lethargy, coma due to poor perfusion and acidosis |
|
|
Term
| What are complications of MODS to the heart? |
|
Definition
| Decreased pump ability, decreased cardiac output, and dysrhythmia, infarct |
|
|
Term
| What are complications of MODS to the lungs? |
|
Definition
| ARDs, hypoxemia, and acidosis |
|
|
Term
| What are complications of MODS to the GI system? |
|
Definition
| Susceptible to septic shock, bowel ischemia, and ulcerations |
|
|
Term
| What are complications of MODS to the kidneys? |
|
Definition
|
|
Term
| What is the end goal for MODS? |
|
Definition
| Blood pressure within 10mm HG of normal, vital organ perfusion, and normal labs |
|
|
Term
| What are causes of disseminated intravascular coagulopathy? |
|
Definition
| Sepsis, shock, malignancy, trauma, burns, transfusion reaction, liver damage, OB complication, and snake bites |
|
|
Term
| What treatment interventions are necessary for DIC? |
|
Definition
| Blood products, IV heparin, and oxygen |
|
|
Term
| Disseminated Intravascular Coagulopathy (DIC) |
|
Definition
| Clotting factors are overworked by forming clots in the microcirculation and causing microthrombi. |
|
|
Term
v CVP, ^ SVR, v CO
Cold extremeties
Indication: |
|
Definition
|
|
Term
^ CVP, ^ SVR, v CO
Extremeties are cold
Indication: |
|
Definition
|
|
Term
v CVP, v SVR, variable CO
Extremeties are warm |
|
Definition
| Vasogenic/ Distributive shock |
|
|
Term
^ CVP, ^ SVR, and v CO
Extremeties are cold |
|
Definition
|
|
Term
|
Definition
| Increase blood pressure by increasing SVR |
|
|
Term
|
Definition
| Increase blood pressure by increasing CO by increasing myocardial contractility |
|
|
