If abruptly discontinued, isotonic dextrose can be administered for 1-2 hours to prevent rebound hypoglycemia (watch for weakness, faintness, sweating, shaking, feeling cold, confusion, & increased HR)

Guidelines for discontinuing TPN

• decrease infusion rate
• monitor VS
• notify MD
• treat respiratory distress by sitting pt upright and administering O2 as needed

NSG interventions for Fluid Overload (P.C. of PN)

• hypovolemic
• cardiogenic
• neurogenic
• anaphylactic
• septic

List types of shock

A systolic bp of < 90 mm Hg is considered immediately reportable.

A previously stable bp that shows a downward trend of 5 mm Hg at each 15 min. reading should also be reported.

When would you report bp to MD?

Rise in lactic acid levels correlate with severity of shock.

Serum lactate level of >4 mmol/L = cause for concern

What role does lactic acid play in shock?

• Bp not sustained, SNS cannot maintain tone
• Anaerobic metabolism
• pooling, sludging, blood in capillary beds
• confused, decreased LOC, disoriented or unconscious
• Bp unobtainable, slow, irregular HR, RR
• Respiratory & cardiac arrest

Angina Pectoris

stable = relieved by rest and/or nitro

unstable = pre-infarction

Intractable/refractory = severe/incapacitating

variant (Prenzmetal's) = pain at rest (reverse ST seg.)

Silent Ischemia = ECG changes w/stress test; pt reports no pain

Clinical syndrome characterized by episodes/paroxysms of pain/pressure in anterior chest.

Caused by insufficient coronary blood flow resulting in a decreased O2 supply when there is increased myocardial demand for O2 in response to physical exertion or emotional stress.

Angina Pectoris

EKG = T wave inverted, ST seg depressed

[image]

• lasts 3-5 mins, transient
• vasoconstriction, increased HR, increased contractility & Bp R/T increased O2 needs of the heart
• myocardial cells become ischemic w/in 10 secs of coronary artery occlusion
• after several mins. of ischemia, heart pumping function is reduced
• reductino of pumping depreives ischemic cells of O2 & glucose (produce lactic acid which impairs L ventricular function = pain develops)
• If blood flow restored w/in 20 mins, no permanent damage.

• Immobility causes calcium to leave bones, causes hypercalcemia (muscle weakness, N&V, confusion -- inceased calcium level)
• diet: limit dairy products & other sources of calcium
• importance of hydration
• danger of renal calculi
• watch for pulmonary edema

SCI: Fluid & Electrolyte balance

• range of motion prevents joint stiffness
• special mattress
• pressure sores common (brings them back to hospital)
• may require surgical procedures, flaps, wound vacs, etc.
• the pt doesn't always know this because they can't feel it.
• they can burn themselves & not know it

SCI: Skin integrity, mobility

Hypernatremia

normal sodium level = 135-145 meq/L

*If you've got a Na problem, you've got a fluid problem

*Brain does not like it when sodium is messed up.

Dehydration: too much sodium, not enough water

causes: hyperventilation, heat stroke, DI

S&S: dry mouth (already exp. a mild level of dehydration), thirsty, swollen tongue (severe cases), neuro changes

TX: restrict sodium, dilute client w/IV fluids, daily weights, I&O, lab work

hyponatremia (dilution!)

Too much water; not enough Na

*Brain does not like it when Sodium is messed up

causes: vomiting or sweating then drinking H2O for fluid replacement (replaces water & dilutes blood), psychogenic polydypsia (loves to drink), D5W (sugar & water), SIADH (too many letters = too much water)

S&S: headache, seizure, coma, neuro changes

TX: hypertonic saline (packed w/particles) - if having neuro probs.; 3% NS or 5% NS = client needs Na, not water

Normal potassium = 3.5 - 5.0 mEq/L

hyperkalemia

*if kidneys not working well, serum K+ will rise

causes: kidney troubles, aldactone (makes you retain k+)

S&S: Begins with muscle twitching, then proceeds to weakness, then flaccid paralysis

ECG: bradycardia, tall/peaked T waves, prolonged PR intervals, flat or absent P waves, widened QRS conduction blocks ventricular fibrillation

*Life threatening arrythmias!*

TX: dialysis, calcium gluconate (decreases arrythmias), glucose & insulin (insulin carries glucose & k+ into cell), watch for hypoglycemia & hypocalcemia w/insulin, kayexalate

Women: SCI won't affect fertility

• can become prenant & bear a child
• tremendous difficulty raising one
• BCP's C/I becuase of danger of clots (educate about contraception)
• If sexually active, need another method of BC.

SCI: Sexuality

• Biggest problem in traction & frames: staring at ceiling and floor, feel like going crazy
• injury will impose permanent limitations
• hard to maintain emotional equilibrium
• expect emotional outbursts, grieving, anger
• self-concept disturbance, altered family process ("Nothing is ever the same after the accident..."

SCI: Stimulation

• most responsibility on nurse to begin with 
• depending on location & nature of injury, can take increased responsibility
• must be able to direct others in how things need to be done

SCI: Hygiene

• immediate: paralytic ileus, require TPN
• may need NG decompression
• high incidence of stress ulcers
• proton pump inhibitors (protonix)
• may need tube feedings eventually

SCI: Nutrition

• Long term: problems w/anorexia (depression), bony, prone to breakdown

• Obesity (eating from boredom + no exercise)
  • harder to move, also more skin problems (skin breakdown in their folds)

SCI: Weight changes

• sildenafil (Viagra)
• tadalafil (Cialis)
• vardenafil (Levitra)

SCI: Erectile dysfunction

• separate long term care area
• transfers, ICU to acute care to rehab, stressful & frightening: less controlled atmosphere & new people each time
• many barriers still exist, despite progress w/architecture in public bldgs, educational institutions, ADA laws

SCI: Issues with Rehabilitation

• elevate HOB, identify & remove stimulus
• empty distended bladder (check for kink in tubing if foley)
• change position if pressure sore
• D/C sexual activity
• Disimpact, using nupercainal ointment

Treatment of Autonomic Dysreflexia

Autonomic Dysreflexia

• above level of injury, person feels parasympathetic response
• headache, flushing, sweating, vasodilatation
• message can't get down to lower areas

• oxygenation, attention to airway
• assess lungs & breathing pattern (high cervical injury not compatible w/life; paralysis of accessory muscles & diaphragm makes effective breathing difficult)
• attention to suctioning, hydration, nebulizer tx, position changes
• may require trach
• vulnerable to URI, atelectasis, pneumonia
• if need to be intubated, use nasotracheal tube because cannot manipulate cervical spine

SCI: Nursing Care

hypovolemic shock

• shock state resulting from decreased intravascular volume due to fluid loss
• impaired oxygenation from inadequate CO resulting from decreased intravascular volume
• loss of blood volume (hemorrhage, GI bleed), loss of intravascular fluid through skin (dehydration), loss of fluid from intravascular compartment (3rd spacing), vomiting, diarrhea

Neurogenic shock

• loss of sympathetic innervation prohibits vasoconstriction of blood vessels; vessels respond to parasympathetic signals, dilate
• inadequate venous return, cardiac output decreases, O2 carrying capacity decreases

TX varies by cause:

• careful fluid balance
• adrenergic drugs (pressors)
• Increase Bp and HR

TX for neurogenic shock

S&S of neurogenic shock

cardiac output x peripheral resistance

[systolic Bp + 2(diastolic Bp)] divided by 3

*Must exceed 65 mm Hg for cells to receive enough O2 & nutrients to sustain life.

Mean Arterial Pressure (MAP):

How is it calculated?

cardiogenic shock

Shock state resulting from impairment or failure of the myocardium; impaired ability of the heart to pump.

heart not pumping adequately (elderly, diabetics, anterior MI w/damage to L ventricle);

also noncoronary causes and ineffective cardiac funtion from cardiomyopathies, valvular damage, tamponade, dysrhythmias

• supplemental O2 
• CP: morphine
• hemodynamic monitoring, fluids
• monitor BNP, cardiac enzymes, telemetry
• dopamine, nitroglycerine, antidysrhythmics
• may need stent, thrombolysis, intra-aortic balloon pump or other ventricular assist. device

TX for cardiogenic shock:

• Traditional signs: lower Bp, increased HR, change in mentation, decresed UO (may not reveal problem soon enough!!!)

Signs that client is in a state of shock

• VS
• airway mgmt.
• O2 therapy
• IV access (2 lines)
• bedrest

General care for Shock Client:

• Hydralazine
• Nifedipine
• monitor Bp
  • client must know about this phenomenon
  • failure to resolve causes CVA, blindness, status epilepticus, death

Medications for autonomic dysreflexia:

Neurogenic shock

• develops as a result of the loss of autonomic nervous system function below the level of the lesion
• vital organs are affected, causing decreased Bp, decreased HR, decreased CO, as well as venous pooling in the extremities & peripheral vasodilation. Respiratory problems; unable to perspire
• low dose anticoagulant therapy, anti-embolism stockings or pneumatic compression devices

• muscles atrophy, bone loss
• paraplegics need to build up upper body for transfers, take weight off coccyx
• great advances in wheelchair design, sports for SCI pts.
• ROM to avoid deposits in joints, contractures
• braces to assist w/lower extremity strength
• May have problems w/muscle spasms: managed pharmacologically
• Spasticity affects same muscles that were flaccid during period of spinal shock: may peak at 2 years & then diminish (many have ongoing spasticity)

SCI:  Activity & Exercise

• patterns altered by lack of exercise, frustration, depression, anxiety about the future

SCI: Comfort, rest, & sleep

• loss of vasomotor control, so move toward temperature of environment
• cannot perspire below level of injury, at risk of overheating
• immobility: cannot generate heat

SCI: Temperature

• Foley to begin with to monitor fluid balance
• SCI damage affects bladder and bowel
• BLADDER: intermittent catheterization often best approach
• BOWEL: suppository or stimulation may cause reflex emptying or may need manual disimpaction

SCI: Elimination

• announce yourself when entering room
• time turning schedule to take meals & visitors into account
• pad bony prominences, inspect frequently!
• prism glasses, taped music, encourage visitors
• expect anger & frustration

NSG: Rotorest bed, stryker frames, turning frames

• pin care
• do not grasp vertical supports or bang device
• pt may expect full return of function when halo removed, may believe halo (& not injury) causing problems
• difficult adjustment when halo removed & scope of disability apparent

NSG: Halo vest

*provides immobilization of spine allowing early ambulation

• methylprednisolone: anti-inflammatory
• vasopressors: tighten up vasculature
• anticoagulants: avoid clots
• analgesics: pain
• muscle relaxants:
  • long term: Baclofen and Dantrium
  • short term: cyclobenzaprine (Flexiril) *in acute care with certain procedures

SCI: Meds

Autonomic Dysreflexia

• acute emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in normal people: 
  • distended bladder (most common)
  • distention/contraction of the visceral organs, expecially bowel (constipation)
  • stimulation of the skin (tactile, pain, thermal stimuli, pressure ulcer)
• EMERGENCY!!!

• remove the triggering stimulus & avoid complications
• immed. place pt in sitting position to decrease Bp
• rapid assessment to identify/alleviate cause
• bladder emptied via urinary catheter
• rectum examined for fecal mass
• skin examined; stimulus removed
• if these measures do not relieve the htn & excruciating headache, a ganglionic blocking agent is admin. slowly by IV route.

NSG: Autonomic Dysreflexia

• paroxysmal htn
• pounding headache, blurred vision
• sweating above level of injury
• flushing, splotchy face & neck
• nasal congestion
• bradycardia
• nausea

S&S of Autonomic Dysreflexia

• In neurogenic, may have hypotension & pooling of blood in extremities.
• bradycardia from unopposed vagus
• after being flat, may require tilt table, gradual position changes, elastic stockings
• circulation affected by immobility; pressure sores
• change position frequently, inspect skin at regualr intervals
• wheelchair: special cushion to distribute weight, "pushups", lifting wt. from chair
• tachycardia may indicate inflammatory process
• risk of phlebitis, DVT: elastic stockings, minianticoagulants, SCD, kinetic beds

SCI: Nursing Care: 

Circulation

• Meds: 
  • vasoactive meds = maintain Bp & CO (increased O2 demand of heart may cause decreased Bp or compromised perfusion)
  • sympathomimetics
  • vasodilators
  • antidysrhythmics
• Position: supine w/legs elevated
  • Modified Trendelenburg: lower extremities are elevated 20 degrees, knees are straight, trunk is horizontal, head is slightly elevated

Meds & NSG care for cardiogenic shock

hypocalcemia

normal labs: calcium 9.0 - 10.5 mg/dL

• causes: hypoparathyroidism, radical neck, thyroidectomy (not enough PTH)

Fluid challenge

• see if fluid administration improves circulation and O2 delivery
• IV fluids: 
  • Crystalloid fluids:
    •   NS; 3:1 rule: 2/3 will go out into the tissues, not stay in the circulation
    • LR: lactate usually converted to bicarbonate in liver, combats acidosis (reason to give it)
      • If liver is not being perfused well, lactate stays in circulation & can cause more harm than good
  • 3% NaCl can help to restore circulating volume

What to do when pt is in shock & doesn't appear to be improving:

• supplemental O2 nasal cannula or mask
• unconscious, respiratory distress: intubation and mechanical ventilation
• IV fluids to restore circulating blood volume and increase Cardiac Output
• NS most recommended

What to do to improve O2 delivery to pt in shock:

Circulatory, or Distributive, shock

shock state resulting from displacement of blood volume creating a relative hypovolemia & inadequate delivery of O2 to the cells;

maldistribution of circulating blood; 

Septic, neurogenic, & anaphylactic are all forms of this state of shock.

Heart & brain favored, Bp maintained

Systolic Bp > 90

Describe the compensated stage of shock:

reversible

• RR may increase, thirst, >20
• Urinary output may decrease
• Blood pressure still normal, though pulse pressure may narrow
• pulse pressure = difference between diastolic & systolic Bp
• Body temp may be up or down
• skin cool & pale, exception: septic & neurogenic
• Septic & neurogenic shock can actually result in pink & warm skin
• BS may be hypoactive, possible distention
• Liver: putting out more glucose in response to stress; glycogenolysis, insulin suppressed

Changes that occur in the more compensated stage of shock are:

• Place pt in Fowler's position
• offer reassurance
• monitor VS
• Prep for thoracentesis or chest tube insertion

NSG interventions:

Pneumothorax (Potential Complication of PN)

S&S: 

• replace tubing immediately
• notify physician
• replace cap/notify MD
• turn Pt on left side & in head-low position
• Administer O2

NSG Interventions:

Embolism (P.C. of PN)

What are the signs & symptoms of Embolism?

TPN therapy:

How long is it? What precautions are taken & what does nurse monitor?

S&S: coma, confusion, diaphoresis, elevated bg, thirst, fatigue, Kussmaul's Resp., restlessness, weakness

Nsg:

• Notify MD, 
• addition of insulin to PN solution may be prescribed
• monitor blood/urine glucose levels, urine output, LOC

PC of TPN:

Hyperglycemia (r/t glucose intolerance)

NSG Interventions?

S&S?

S&S: anxiety, diaphoresis, low Bp, weakness, shakiness

NSG: 

• Monitor for symptoms 
  • weakness, tremors, diaphoresis, h/a, hunger, apprehension
• Notify MD (isotonic dextrose may be admin for 1-2  hours)
• Gradual decrease of PN prior to d/c'ing (don't stop feedings too abruptly)

PC of TPN:

Rebound hypoglycemia

S&S?

NSG interventions?

Normal lab values:

Potassium 3.5 - 5.0 mEq/L

Hypokalemia

S&S: muscle cramps & weakness, **life threatening arrhythmias**, ECG changes: u waves, PVCs, ventricular tachycardia

causes of: vomiting, NG suction, diuretics, not eating

TX: Give K+, aldactone (potassium sparing), Eat K+

1. Compensated: Bp >90 systolic
2. Progressive: Bp < 90 systolic
3. Irreversible: not responding to TX

Describe the 3 stages of shock:

Compensated stage

In this stage of shock, homeostatic mechanisms work to improve tissue perfusion: sustained stress response.

S&S: subtle changes, restless, irritable, apprehensive but oriented; HR may be increased, bounding, >100

S&S:

cool skin, poor capillary refill, low Bp, orthostatic changes, problems with distribution of fluid volume.

Key: degree of volume depletion

S&S of hypovolemic schock:

• assess fluid loss: careful I&O, GI losses, skin, renal
  • consider hidden losses: obstructed bowel, ascites, losses from weeping burns, fistulas, internal bleed
• Attention to BP, HR, RR, O2 sat
• Skin color, temp, LOC, cap. refill, mucous membranes, pallor, cyanosis

NSG care for pt in hypovolemic shock:

• transfuse packed cells to keep Hct >30%
• dobutamine infusion or norepinephrine to maintain Bp
• keep CVP 8-12, MAP >65
• Urine Output >0.5 ml/kg/hr
• Wean from vent, remove lines as quickly as possible
• tight glucose control, IV corticosteriods
• DVT & stress ulcer prophylaxis

Guidelines for septic shock:

shock

acute, widespread process of impaired tissue perfusion that results in cellular, metabolic, and hemodynamic derangement, leading to cellular dysfunction and death;

(when blood flow to tissues/cells, cardiac pump, vasculature or circulatory system & blood volume is inadequate/impaired, perfusion (adequate O2 & nutrients) to tissues is threatened/compromised)

IV crystalloids

electrolyte solutions that move freely between intravascular & interstitial spaces, i.e., 0.9% Sodium Chloride (NS), Lactated Ringer's Solution (helps buffer acidosis that occurs in shock)

(*hypertonic crystalloid solution: 3% sodium chloride)

colloids

large molecule IV solutions

Progressive stage of shock

Stage of shock in which compensation becomes ineffective or detrimental; shock perpetuates.

*Need aggressive mgmt. to rescute!*

Cardiovascular: ventricular failure

Neurologic: SNS dysfunction, cardiac & respiratory depression, thermoregulatory failure, coma

Eventually: Pulmonary: Acute Resp. failure (ARDS)

Renal: ATN

Hematologic: DIC

GI tract failure, hepatic, pancreatic

Altered dynamics in capillary bed, profound vasocontriction

SIRS (Systemic Inflammatory Response Syndrome)

MODS (multiple organ dysfunction syndrome)

S&S:

*listless, agitated, apathetic, confused, less *responsive, tachycardic, weak, irregular, thready, >150

*hypotension w/decreased pulse pressure

*systolic Bp <80-90 or decrease of 40 mm Hg

*Rapid, shallow resp.

*Oliguria, cold, clammy, maybe be cyanotic

*subnormal temp

*thirst if still alert

*hypoactive or absent bowel sounds

S&S of progressive stage of shock

• Hyperdynamic, progressive, "Warm phase"
  • vasodilatation, Bp maintained, febrile, warm, flushed skin, bounding pulse, RR increased, urine output adequate

• Hypodynamic, irreversible "cold phase"
  • vasoconstriction, cool, Bp drops, HR and RR rapid, anuric, organ failure 

What are the two phases of septic shock:

TX:

• culture urine, wounds, blood, check lines, incisions, etc.
• start on broad spectrum antibiotics until cultures come back
• IV fluids: crystalloids, colloids, & blood products
• CT scan, X rays to identify abscesses and infection

TX for septic shock:

• Itching, flushing, urticaria, full throat,
• anxiety, tight chest, faintness, 
• loss of consciousness
• severe upper airway obstruction
• edema leads to asphyxia
• lower airway wheezing, bronchospasm
• hypotension from profound vasodilation
• vascular collapse

S&S of anaphylactic shock:

(occurs slowly over 6-12 hours, or rapidly over 5-30 mins)

• epinephrine (Adrenalin), Epipen
  • vasoconstrictor
• diphenhydramine (Benadryl)
  • antihistamine
• albuteral (Proventil)
  • for bronchospasm

Meds given for anaphylactic shock:

• Keep pt warm (while avoiding overheating)
• avoid exposure & maintain normothermia (to prevent vasodilation)
• Pain control measures

NSG:  Objectives in PACU

Hypovolemic shock

Most common type of shock:

pallor, cool/moist skin, rapid breathing, cyanosis of lips, gums, tongue, rapid/weak/thready pulse, narrowing pulse pressure, decreased Bp, concentrated urine

S&S and TX for hemorrhage:

• IV fluids, blood/blood products, & medication that increases Bp
• volume replacement w/LR, 0.9 Sodium Chloride, colloids, or blood component therapy. 
• O2 admin
• meds to reduce peripheral vascular resistance

TX for hypovolemic shock: