Hypovolemic Shock
What are crystalloids.
What is a crystalloid and what solutions would be used?
Crystalloid would be IVF with electrolytes this would include isotonic, hypotonic, hypertonic. The solution that would be used would be LR or NS.
name the 4 stages of shock
what are initial, non-progressive (compensatory), progressive, and refractory.
what are symptoms of each
initial - minimal symptoms BP is not effected, lactate 0 no pH imbalance
non-porgressive, BP begins to lower, HR slightly elevated. O2 a little lower, possible fever, lactate 1-2, slight pH imbalance
progressive - hypotension, tachycardia, lactate 4 or more, pH imbalance (acidosis)
refractory - significant hypotension, tachycardia, acidosis, lactate 4 or more, treatment ineffective for hypotension management.
Cardiogenic shock can develop from acute conditions and chronic conditions, name a few conditions in which cardiogenic shock would be a concern?
what are MI, cardiomyopathy, heart failure, and endocarditis
What are some of the classic signs of Anaphylactic Shock?
What are respiratory distress, cyanosis, hypotension and decreased breath sounds, wheezes, even stridor.
A. What is your FIRST nursing intervention.
B.What is the most common reason for anaphylactic shock to occur?
A. NRB 100% O2
B. Anti infectives (antibiotics) Drug used to treat #1 is Epinephrine
Edema, blanchable eyrathema, blisters (open or closed) are classic signs of what type of burn?
what is partial thickness superficial.
What burn would be seen with lethrary charred white/pale assessment, absent of pain, decreased cap refill, severe edema
what is full thickness loss
due to the massive stress response on the body what can a client develop as a result of burns and how is it treated?
what is curlings ulcer and suclrafate (Carafate)
For your client admitted with possible hypovolemic shock, what classifies a client as being IN hypovolemic shock?
what is 15-30% of decreased circulating fluid volume.
Knowing the first line of treatment is fluids, what should the nurse consider when considering fluid replacement?
Size of the IV should be a 18 gauge for rapid fluid administration.
distributive shock deals with the loss of vaso-tone and the inability of the vessels to move blood. what shocks fit this criteria
what is anaphylactic, neurogenic, and septic.
Obstructive shock deals with the in ability to move blood int he vessels, what shocks would fit under this?
hypovolemic (loss of blood/fluid) and cardiogenic (loss of ventricular squeeze, HTN, cardiac tamponade).
When assessing a client who presents in cardiogenic with hypotension, tachycardia, perpherial edema, adn JVD, what will be the most important assesment for adequate perfsion?
what is urinary output greater than 30ml/hr
Anaphylactic Shock typically results from what pathophysiology response?
what is exposure to antigens that cause antibody release.
A. Besides Epinephrine what other medications (and class) would be given?
A. Diphenhydramine (Benadryl) and steroids (prednisone)
Clients presents with burns on 45% of their body; hypovolemia and burn shock are possible. What are the key assessments for fluid volume resuscitation.
what are blood pressure, heart rate, urine output, and urine specific gravity.
Which one of these is the most accurate
what is urine specific gravity
Hypovolemic shock can also be caused by what other major condition?
what are BURNS
Hypovolemia (NOT related to burns) can be treated with fluid and what other rapid infusion?
What is PRBC's, what do we need to keep in mind when giving PRBC's to prevent a hemolytic reaction.
if a transfusion reaction was suspected what are your nursing interventions?
stop the infusion, call the MD and run saline, administer O2 if needed.
what is MODS
this is when your client is experiencing organ failure in 2 or more organs (usually vital organs).
Keep in mind what nursing interventions for each organ? What else should the nurse keep in mind s the treatment plan
Lungs - hypoxia (usually first to be effected)
Liver - jaundice
Brain - AMS
Renal - oliguria/anuria
offering support for the clients emotional stability, and answering ll questions as they navigate end of life care.
In your client with cardiogenic shock who presents with hypotension its essential to get the BP up quickly. What do you anticipate the MD ordering to assist in BP management?
what is vasopressors and inotropes
name a one of each?
norepinephrine and dobutamine
what other drusg can we see ordere for cardiogenic shock?
diuretics, and morphine
What are key teaching aspects for a client who has suffered anaphylactic shock?
What is wearing a med alter bracelet and carrying a epi pen every where.
In assessing your burn patient what are key assessment findings that would suggest the possibility of a inhalation injury?
what is singled nose hairs, black char on the nose/lips, drooling, hypoxia and restlessness.
Besides fluids and respiratory what other major concerns are we assessing for with our burn clients and the complication associated with it?
What is hyperkalemia (cardiac arrhythmia), pain (resp. distress due to opioid).
what are the most important assessment when caring for a shock client to determine stability?
what are HR, Tachycardia, AMS- Lethargic mental status, urine - Decreased urine output, flushed skin due to vasodilation and increased cap permeability
neurogenic shock usually presents with an obvious brain injury, however what vital signs present (hint it is different then typical shocks)
what is bradycardia and hypotension.
Anytime shock is suspected (regardless of the type of shock) what labs would be obtained immediately to help with diagnosis?
what are ABG, CBC, CMP, and Lactate
what type of medication or exposure is most signifcant in anaphylactic reactions/shock?
what are antibiotics
What is the first nursing intervention upon assessing a client who presents with a chemical burn?
what is to clean/wash the site immediately with water.
what are some chemicals that can cause chemical burns?
gasoline, lime, hydrofluoric acid, battery acid, cement,
besides fluids, PRBCs, and colloids such as albumin what other drug can be given to assist in vasoconstriction to increase BP, hint this also occurs normally in our body
what is Angiotention II
how does it work?
this then release of aldosterone and (ADH) antidiuretic hormon, which leads to vasoconstriction and increasing the clients BP
After beginning a blood trasnfusion you assess your client and assess the following: your client is febrile, c/o chills, urine appears red-tinged, shortness of breath, and some lower back pain. what is the client experiencing?
what is a hemolytic reaction.
which shock is most closely associated with the complication with an overstimulation of the clotting system AKA DIC?
what is septic shock
what labs should we pay closely attention too?
platelets first as these will decrease when the liver begins to fail.
what is the cardinal sign that airway management has become a big concern?
what is stridor
Skin grafting maybe used in massive or deep burns, what type of graft would come from self, human (donor), and different species?
what is autologous, allogous, and xenograft or heterograft.