Shocking
True or false: patients can experience multiple types of shock at the same time
True
All group members: stand up, come to the front of class, and demo decerebrate posturing
Arms out straight away from body
This is the primary intervention for neurogenic bladder
Teach pt Clean intermittent catheterization
4 to 6 times daily
Urine residuals less than 500 mL
Monitor s/s UTI
This parameter tells us that fluid resuscitation has been effective
These 2 vital sign alterations are found in Cushing's triad
What are systolic HTN (wide pulse pressure), bradycardia, and bradypnea
In septic shock, when should broad spectrum antibiotics be administered
Within the first hour
A narrow pulse pressure indicates this type of shock
What is cardiogenic
Use of this medication class is of serious concern when considering brain injuries
What are anticoagulants
Name 2 s/s of spinal shock
↓reflexes, loss of sensation, absent thermoregulation, & flaccid paralysis below the injury
This system is often first system to show s/s in SIRS and MODS
What is the respiratory system
Name 3 s/s of post concussion syndrome
What are persistent headache, lethargy, personality and behavior changes, shortened attention span, decreased short-term memory, & changes in intellectual ability
Name 4 s/s of autonomic dysreflexia
HTN, throbbing HA, diaphoresis ↑ level of injury, bradycardia, piloerection, flushing skin ↑ level of injury, blurred vision/spots, nasal congestion, anxiety, & nausea.
Name an intervention for shock that helps improve organ perfusion and supports BP
What is administration of fluids
Explain why a pt in neuro shock must be kept warm
Patient will become hypothermic due to poikilothermia, start shivering, and put more stress on their body and CNS.
Name 4 interventions for autonomic dysreflexia
Elevate HOB 45-90
Monitor BP frequently
Give rapid onset nitroglycerin, nitroprusside, or hydralazine
Determining the cause
Immediate Foley w lidocaine/ check for kinks
Digital rectal examination w lido
Remove all skin stimuli → constrictive clothing and tight shoes.
What is the compensatory stage
Explain why a LP is contraindicated in cases of suspected ICP?
Increases the risk for herniation due to creating an area in the spinal cord of lower pressure
IV fluid boluses in this type of shock can be deadly
What is cardiogenic shock
Critical labs for this stage of shock include dangerously high lactate, urea, ammonia, and CO2
What is the refractory stage of shock
Name 2 nursing interventions that help pts with increased ICP
HOB 30
PRN suctioning
Injury prevention
Slow turns
Avoid hip flexion
Med admin (mannitol, hypertonic saline, antiseizure drugs, steroids, sedatives)
Explain why oxygen administration is beneficial in shock
Shock means poor tissue perfusion, so administering oxygen improves tissue oxygenation and slows the production of lactic acid
Explain how mannitol works
Mannitol is an osmotic diuretic that draws water out of tissues into the bloodstream, reducing swelling and promoting urine excretion.
Name 2 complications from vasopressor therapy
Infiltration & decreased coronary artery perfusion
Name 2 findings that suggest your pt is having increased ICP
What is a declining GCS, sluggish pupils, posturing, vomitting without nausea