Septic Shock
Nurse suspects a patient is going into septic shock, what is the priority intervention?
Obtain blood and urine cultures
What assessment finding for a patient with 3rd degree burns of the right arm would indicate the need for an escharotomy?
No radial pulse in the right arm
What interventions need done for a patient that is going to be therapeutic hypothermia after a cardiac arrest?
assist with intubation, insert a foley, place on cardiac monitoring
Patient develops cardiogenic shock, what intervention would reduce the complications of this shock?
Diuretic therapy to reduce preload
Post-op kidney transplant, Nurse is entering the room, what is her priority action?
Wash hands when entering the room
What are the clinical manifestations of a patient in septic shock?
Agitation, hypoxemia, decreased urine output, increase blood glucose
Patient in the emergent phase of burns, What lab should the nurse expect on this patient?
Low sodium, high potassium, high glucose and high hematocrit
Following an earthquake, what patients need to be seen first, after being triaged?
Patient with a red tag.
What complication due you need to be aware of in neurogenic shock?
hypothermia
What is the advantage of having live donor kidney transplant?
Immediate function because of minimal cold time.
What are the major pathophysiological effects of septic shock?
Maldistribution of blood flow
myocardial depresionWhy does the patient need ROM in the rehabilitation phase of burns?
Active and passive ROM maintains function of body parts
ROM shows patient that movement is possible
Patient comes in the ER with history of stable angina and now is diagnosed with MI. What are the priority nursing care for this patient?
relief of CP, monitoring for dysrhythmias, promoting rest and alleviating stress/anxiety
Patient is admitted with hypovolemic shock. How do we prevent the progression of the stages of shock and reduce mortality?
Determine and correct underlying causative factors
What complication would nurse look for with a patient post kidney transplant one month ago that is on immunosuppressive drugs and has chronic kidney disease?
Infection
What are the treatment goals of septic shock?
Recovery of organ function
Avoidance of kidney injury
Restoration of normal or baseline blood pressure
Patient had full thickness electrical burns to arms and legs, what is that patient at risk for?
AKI, dyshythmia, iceberg effect, bone fractures
What are the treatment goals of a patient with MODS?
treat infection, maintain tissue perfusion, provide nutritional support, provide support of individual failing organs
Patient is in hypovolemic shock due to flare up of ulcerative colitis. What type of fluid loss is this?
Absolute
Post-op kidney transplant, what assessment finding would needed treated immediately?
Fever and decreased urine output
What are complications of septic shock?
ARDS, DIC, respiratory failure, SIRS, pulmonary HTN
Patient was involved in house fire. What assessment findings would alert the nurse that the patient has an inhalation injury?
Singed nasal hairs
Darkened oral or nasal membranes
painful swallowing
History of being in an enclosed space
What are ways to prevent absorption of ingested poison?
Hemodialysis, gastric lavage, activated charcoal
What are signs of progressive stage of shock?
Decrease CO, anasarca, ventilation/perfusion mismatch
Patient had kidney transplant from unrelated cadaver donor, what interventions should be included in the plan of care?
Prepare the client for dialysis 3x a week