Type
SXS
Therapy
NSG DX
MISC
100
Shock that results from a change in size of the vascular space without an increase in blood volume.
What is Distributive (Vasogenic) or Warm shock
will also take - Neurogenic
100
Spinal cord injury (T5 or higher), drug OD, hypoglycemia, evaluate for fluid overload, bradycardia may require atropine, administer vasoconstrictor medications.
What is neurogenic
100
administer volume replacement, blood transfusion, and volume expanders; administer oxygen
What is Hypovolemia
100
A nursing diagnosis for hypovolemia or hypovolemic shock
What is Fluid Volume Deficit
100
Caused by hemorrhage, burns, dehydration?
The most common cause of shock?
What is Hypovolemic or hypovolemia
200
Shock that results from the heart's inability to adequately circulate blood (intravascular) volume.
What is Cardiogenic
200
Important to differentiate between hypovolemic & cardiogenic shock; How might the nurse determine the existence of cardiogenic shock?
What is History of MI (cardiomyopathy or pulm edema)
200
Monitor ECG, medications like vasopressors to increase cardiac output, evaluate hemodynamic parameters, administer digitalis preparations for pulm edema.
What is Cardiogenic shock
200
The nursing diagnosis that addresses poor (impaired) heart function and blood volume in a cardiogenic shock state?
What is Decreased Cardiac Output
200
The shock stage with vasoconstriction, shunting; BP low normal range, restless & agitated, pulse increased, MAP decreased 10-15 mmHg from baseline, decreasing pulse pressure; UOP slightly decreased; vital organs are perfused.
What is Compensatory stage (non-progressive)-Early
300
Shock that results from hypotension, tachycardia, oliguria, altered mental status, hypernatremia, increased HCT (hct may drop if pt actively bleeding), metabolic acidosis & an MAP <70.
What is Hypovolemic Shock
300
A nurse's responsibility to recognize the sxs of shock; list five assessment findings that occur in most shock victims.
What is: tachycardia; tachypnea; hypotension; cool-clammy skin; & decreased UOP
300
Treatment: 4 nursing interventions for shock patients.
What is Position supine, may elevate legs (modified trendelenburg)
Maintain airway, provide supplemental O2
Keep warm
Protect from falls
IV access & fluid resuscitation
Monitor MAP
300
An acceptable nursing diagnosis for a patient in shock?
What is: alterations in tissue perfusion
-anxiety
-knowledge deficit
-nutritional alterations/deficits
-self care management
300
MAP decreased 20mmHg or more, pallor, cold moist skin, oliguric, dyspneic, edema, dysrhythmias, weak-thready or absent pulses, decreased cardiac output, decreased tissue perfusion, reduced blood volume-circulatory deterioriation
What is Progressive stage or decompensated
400
During a mass casualty, a color is assigned to patients based on severity of injury. This color indicates the patient needs emergent care.
What is Red
Red indicates emergent, life-threatening injuries. Yellow is urgent major illness requiring care within an hour. Green indicates nonurgent patient who can self-treat. Black signifies the patient is dead or near death
Patients receive treatment based on the assessment of greatest chances for survival matched to resources available for medical intervention.
400
Name at least 3 risk factors that can cause shock
What is very old, very young
chronic progressive disease states (MI)
trauma
postop hemorrhage
400
The reason why patients with MODS can experience both primary and secondary MODS
What is
•Primary MODS results from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself.
•Secondary MODS is a consequence of widespread sustained systemic inflammation that results in dysfunction of organs not involved in the initial insult.
400
A pt has an allergic reaction, becomes confused, has difficulty breathing, hypotension and tachycardia. What nursing diagnosis will you plan to use for the care of this pt.
What is airway management
-anxiety
-______________
400
Unresponsiveness, BP not measurable, pulse slow & irregular, anuria, severe hypoxemia unresponsive to O2, metabolic acidosis; MODS
What is Refactory or irreversible (late) stage
500
Shock with increased venous capacity due to a loss of peripheral vasomotor tone. Cardiac function & blood volume may be normal.
What is: Neurogenic
500
MAIN ACTION in preventing microorganisms from invading the body and is ABSOLUTELY, POSITIVELY ESSENTIAL components of preventive nursing care...
What is: hand HYGIENE
WARSH YO HANES!
and stop being NASTY! :)
500
3 findings that indicate fluid resuscitation for hypovolemic shock hasn't been successful?
What is HCT (Lab)
500
Reduction in circulating blood volume, fluid loss from vomiting, diarrhea, ascites, third spacing, decreased blood flow to kidneys & brain & skin care plan nursing diagnoses.
What is F&E imbalance
Decreased Cardiac Output
-___________________
500
The first hour of emergent care, the “golden hour", focuses on THREE MAIN OBJECTIVES!
What is rapid assessment, resuscitation, and treatment of life-threatening injuries?