Assessment
A burn client in the emergent phase is SOB, voiding 17 ml/hr, and experiencing severe pain. The nurse notices that the client is experiencing poor perfusion from what assessment finding?
Voiding 17 ml/hr
45 minutes after spinal injury, this patient has a BP of 90/60 and a HR of 48
Neurogenic shock
What kind of precautions would someone with an electrical burn be under?
What is the best indicator that fluid resuscitation is effective after hypovolemic shock?
0.5-1 ml/hr
If a patient is experiencing obstructive shock, what will be the priority intervention?
Maintain airway
The nurse notices that her client who is currently NPO has a cap refill of 3 seconds, weak pulses, and has cool extremities. What are these assessment findings a sign of?
poor perfusion
A patient has a respiratory rate of 22 and a fever of 100.5, the patient has already been confirmed for pneumonia. What is this patient at risk for?
Sepsis
Patients blood pressure remains low after being given IV fluids and blood during hypovolemic shock, what should be given next?
Vasopressor
What are we evaluating for after interventions for hypovolemic shock?
Increase in BP, urine output, neurologic function, peripheral pulses
What is the expected fluid for the Parkland Burns Formula?
Isotonic crystalloid
The patient is hypotensive and tachycardia the nurse concludes that this is indicative for
Shock
When shock occurs in a patient with pulmonary embolism or abdominal compartment syndrome, what type of shock would that be?
Obstructive shock
Which drug is this?
USE: I raise the blood pressure “Dramatically” and treat severe hypotension, especially in cases of shock. I am contraindicated in cardiogenic shock because I increase the workload of the heart.
ACTION: “SQUEEZING” of the blood vessels, a vasoCONSTRICTOR
Norepinephrine
After administering IV fluids for a patient in hypovolemic shock per the Parkland Burn Formula, what are the goals for urine output?
0.5 to 1.0 mL/kg/hr of urine output
What primary type of fluid stabilizes a patient during hypovolemic shock?
Isotonic fluids
Give some signs and symptoms of how these different organs respond to poor perfusion.
Lungs
Heart
Renal
Neuro
GI
Lungs: ARDS, crackles and tachypnea
Heart: low HR,BP and CO
Renal: low UOP
Skin: pallor, cool and clammy
Neuro: low CPP, confusion, agitation
Gi: absent bowl sounds or hypoactive bowl sounds
If a patient comes in showing s/s of hypotension and poor perfusion (renal, GI, extremities, brain, lungs), what type of shock are they experiencing?
Obstructive shock
What should be the nurse's next step when the fluid resuscitation is unsuccessful for a patient who has a septic shock?
Vasopressor/norepinephrine
A patient comes in with burns to anterior right and left leg, anterior peri, and anterior thorax. The patient weight 120kg. What fluid rehydration would be given in the first 8 hours?
8880 ml
A patient has arrived to the ED with neurogenic shock. After administering vasopressin’s. The patient remains bradycardic. What is the next step the nurse should perform?
Administer atropine
The nurse is concerned that a patient is at risk for developing obstructive shock because of which assessment finding?
80-years-old with a history of atrial fibrillation
A patient has a circumferential 3rd degree burn on their left leg. What would tell you that the client has decreased perfusion?
Weak pulses unilaterally, skin is pallor, decreased sensation cap refill is greater than 3 sec and cold to touch
After giving a patient that is suspected septic a rapid bolus of NS 0.9%, the nurse realizes that after retaking the blood pressure and getting a hypotensive reading it is most appropriate to administer _____.
Vasopressors
Dopamine was administered to a neurogenic shock patient. To determine the effectiveness of this medication what clinical manifestations should we expect to see?
1. MAP greater than 65 mm Hg
2. Increased urine output
3. Increased blood pressure
The nurse understand that in cardiogenic shock, the goal is the _____ cardiac workload and ____ perfusion
Decrease, Increase