Well... That's Not Good
A patient suddenly develops wheezing, hives, swelling of the lips and tongue, and hypotension shortly after receiving an antibiotic.
What is anaphylactic shock?
A lactate level greater than this value suggests tissue hypoperfusion and possible severe sepsis.
What is 2.0 mmol/L
A new patient's heart rate is unvalidated in Epic as 142, but the patient is sitting int heir room watching TV. Before validating it, the nurse should do this.
What is check the patient/verify lead placement?
A patient develops hives, wheezing, and hypotension after receiving an antibiotic. This medication should be given immediately.
What is epinephrine?
A patient with a chronic indwelling Foley Catheter presents with fever and confusion.
What is UTI d/t indwelling foley, causing sepsis?
A trauma patient arrives after a moto vehicle crash with cool clammy skin, tachycardia, low blood pressure, and suspected internal bleeding.
What is hypovolemic shock?
This lab must be drawn before antibiotics in suspected sepsis to identify the infection source.
What are blood cultures?
A patient's automatic BP cuff reads 72/40, but the patient appears comfortable and in NAD. The nurse should first do this before assuming the patient is unstable.
What is do a manual BP?
A patient meets sepsis criteria and has a lactate of 4.2. One of the first treatments should be this rapid IV therapy.
What is fluid resuscitation/fluid bolus?
A patient becomes restless and anxious, even though their oxygen saturation is normal.
What is an early sign of hypoxia
A patient suddenly develops chest pain, severe shortness of breath, hypotension, and distended neck veins. Imaging later shows a large blood clot in the pulmonary artery.
What is obstructive shock?
This elevated lab value may indicate kidney dysfunction and poor perfusion in a shock patient.
What is creatinine?
A blood pressure obtained with an incorrect cuff size may produce this type of inaccurate reading.
What is falsely high or falsely low blood pressure?
A trauma patient arrives with suspected bleeding. The nurse should prioritize placing these.
What are two large-bore IVs?
An elderly patient presents with new confusion and weakness, but no fever.
What is possible sign of infection/sepsis in older adults?
After a cervical spinal cord injury, a patient develops hypotension, bradycardia, and warm dry skin.
What is neurogenic shock?
An ABG showing low pH and low bicarbonate sugests this dangerous condition often seen in shock.
What is metabolic acidosis?
The tech grabs the patients temperature and it reads 94.2 degrees F, but they appear in no obvious distress. Before documenting this temperature, you suspect this happened:
What is the patient just drank ice water?
(happens genuinely all the time lol)
A septic patient remains hypotensive despite fluid resuscitation. THe next type of medication often required is this.
What are vasopressors?
A patient with a recent knee replacement has new fever and tachycardia, but blood pressure and respiratory rate is normal.
What is suspected sepsis?
A patient with severe infection has warm flushed skin, bounding pulses, and tachycardia, but later becomes cool, hypotensive, and altered.
This change indicates progression from compensated to this life-threatening stage.
What is decompensated septic shock?
A septic patient initially had a lactate of 3.8. After fluid resuscitations, you repeat the test and the lactate is now 5.1
This worsening result suggests this dangerous process:
What is worsening tissue hypoperfusion (progressing shock)
A patient's oxygen saturation reads 82%, but the patient is sleeping comfortably with warm hands, appears in no distress. These are common other places you can attempt to place a pulse oximeter:
Where is the ear?
Where is the forehead?
Where is the toe?
What is spinal immobilization/c-spine stabilization?
A patient with an infection now has a lactate of 4.5, hypotension, and altered mental status.
What is septic shock?