Seps-ational
This is the priority intervention for healthcare providers to prevent the incidence of septic shock in the hospitals.
Strict hand hygiene
This is the highest priority nursing action when providing care to a patient in shock.
ID early manifestations & treat the causes!
This type of intervention helps burn injury patients who may have sustained an intestinal mucosal injury and helps decrease GI motility.
Starting early enteral feedings
The normal range for Mean Arterial Pressure is ______, but less than _____ indicates hypoperfusion of the organs.
70-100
Less than 65
This type of pain is described as one of the most severe forms of acute pain and includes background/resting pain, procedural pain, or breakthrough pain.
Burn Pain
True or False:
It is okay if you need to grab the second blood culture after the IV antibiotic has already started.
False
This stage of shock is characterized by a potential drop in BP or MAP but is still within normal limits of baseline. Neurologic changes may be present like restlessness and apprehension.
Compensatory Stage
This is the second priority of care for a burn injury patient after establishing and maintaining cardiopulmonary status.
Fluid Status
This type of shock is often brought on rapidly after exposure to an allergen, and has manifestations of respiratory distress.
Anaphylactic Shock
The American Burn Association (ABA) recommends initiating fluid resuscitation for burns greater than this TBSA%.
20%
Shock is caused by _____ tissue perfusion. In order to treat patients rapidly and effectively, healthcare providers must ID and treat the ____ ______ to ensure they have the best recovery possible.
Underlying Causes
In this stage of shock, a nurse might assess cool and clammy skin.
A patient has been admitted to the ED with burns to his anterior and posterior torso, entire left arm, and entire left leg. He ways 160lbs. According to the ABA, how many milliliters of LR does the nurse expect to see ordered? (Round to the whole number)
Anterior Torso (18%) + Posterior Torso (18%) + Left Arm (9%) + Left Leg (18%) = 63%
Weight = 160lbs/2.2 = 72.7kgs
2mL LR x 72.7kg x 63% = 9160.2 = 9160mL
This type of fluid is responsible for pulling water into the blood vessels.
Albumin
Burns, diarrhea, vomiting, and hemorrhage are the most common causes of this type of shock.
Hypovolemic Shock
This level is always monitored within 3 hours for a patient who is being admitted to the hospital for treatment of sepsis to identify a baseline and trends.
Lactate Levels
This stage of shock includes organ damage that is so severe, the patient does not respond to treatment and cannot survive. MODS may be present. Experimental procedures and honesty about prognosis are imperative.
Irreversible Stage
This is a priority nursing intervention for a patient that has been brought into the ED with a burn injury.
Administer High-Flow 100% O2
This type of disturbances is the most common cause of cardiogenic shock.
Dysrhythmias
During this phase of burn injury, the nurse is focused on wound healing, psychosocial support, self-image, lifestyle, and restoring maximal functional abilities so that the patient can have the best quality life, both personally and socially.
Rehabilitation Phase
When this neurotransmitter is released during sepsis due to SNS stimulation, it increases the RR and depth, HR, and heart contractility.
Norepinephrine
MODS is characterized by the _______ stage of shock and dysfunction in _____.
Progressive Stage of shock
2 or more organs or organ systems
During this phase of burn injury, the nurse is focused on restoring fluid balance, preventing infection, modulating hypermetabolism, and promoting skin integrity.
Acute/Intermediate
These are nursing considerations when providing care for a patient who is seeking care of radiation burns.
Type, dose, and length of exposure to radiation.
These clinical manifestations are indicative of a patient exhibiting early symptoms of shock.
Increased RR
Restlessness
Pallor