Shock
What are the stages of shock?
What is initial, compensatory, progressive and refractory?
SIRS-Sepsis-Septic shock-MODS
How do you rewarm and area suspected of possible frostbite?
What is immerse affected area in circulating water that is 98.6° to 104° F (37° to 40° C).
What is the most useful assessment to show that a burn victim is receiving adequate amounts of fluid?
Measuring urine output.
SAMPLE
What is A secondary assessment-
Signs and Symptoms
Allergies
Medications
Past Medical History
Last oral intake
Events leading up to the incident
A patient suspected of having hypovolemic shock has a BP of 112/72. What stage of shock is this patient in?
What is the compensatory stage?
What are two parameters to monitor for a patient diagnosed with sepsis?
What are Vital signs and coagulation studies?
Temperature at which active rewarming is discontinued.
What is 90-95 Degrees F (32.2-35 Degrees C)
This specific shock state occurs in major burns due to a massive capillary leak, causing a shift of plasma, proteins, and electrolytes into the interstitial space, leading to both intravascular depletion and tissue edema.
What is hypovolemic shock?
What can uneven chest rise and fall indicate after a trauma?
What is a flail chest?
This form of distributive shock, often resulting from a high spinal cord injury above T6, is characterized by the classic triad of hypotension, bradycardia, and warm, dry skin due to a sudden loss of sympathetic tone.
What is neurogenic shock?
Name five manifestations of septic shock.
•Increased coagulation and inflammation
•Decreased fibrinolysis
•Hyperdynamic state: increased CO and decreased SVR
•Decreased urine output
•Tachypnea/hyperventilation
•Altered neurologic status
•GI dysfunction, GI bleeding, paralytic ileus
A patient is brough into the ED with a core temperature of 105 degrees F. BP 86/52 Pulse 120. What action should the nurse plan to take first?
What is start to cool the patient.
What would be indicated if a patient initially came into the ED wheezing after smoke inhalation but during an assessment 20 minutes after admission the patient has no wheezing and lung sounds are decreased?
What is emergent intubation?
What color tag in a mass casualty indicates a patient needs to be assessed first?
What is red?
This life-threatening condition, characterized by a systolic blood pressure < 90 mmHg, pulmonary congestion, and a cardiac index < 2.2 L/min/m², results from the heart's inability to pump effectively, leading to inadequate tissue perfusion despite sufficient intravascular volume.
What is cardiogenic shock?
Name all the SIRS criteria.
•Temp >38°C (100.4°F) or < 36°C (96.8°F)
•Heart rate > 90
•Respiratory rate > 20
•WBC > 12,000/mm³, < 4,000/mm³, or > 10% bands
What are two nursing interventions for heat stroke?
•Stabilize ABCs
•Rapidly lower core temperature
•Monitor for dysrhythmias
•Administer 100% O2
•Ventilate with BVM or intubate with mechanical ventilation
•Continuous ECG and pulse ox
•Monitor labs; correct electrolyte and coagulation abnormalities
•Insert urinary catheter
A patient is admitted to the ED with full and partial thickness burns to his the front of his chest, his whole right arm and half of his right leg. What is the TBSA % that is burned?
What is 36%.
This ESI level is assigned to a stable patient expected to require only one type of resource, such as a prescription, a simple procedure, or a single set of diagnostic tests.
What is ESI level 4?
What are three manifestations of anaphylactic shock?
•Anxiety
•Confusion, dizziness
•Sense of impending doom
•Chest pain
•Incontinence
•Swelling of lips and tongue, angioedema
•Wheezing, stridor due to laryngeal edema
•Flushing, pruritus, urticaria
•Respiratory distress and circulatory failure
What lab value can indicate a patient may be developing MODS?
What is a high serum creatine level?
An elderly unhoused man is brought to the ED by paramedics after being found unresponsive on a park bench during a night where the temperature dropped to -10°C (14°F). His skin is cold, waxy, white, and firm to the touch on his fingers and toes. He is drowsy and confused.
Question: What are the four components of the initial nursing assessment for this patient, prioritized in order of urgency?
1. Airway & Breathing (A&B)
2. Circulation (C)
3. Neurological Status / Disability (D)
4. Core Temperature & Exposure (E)
A 35-year-old patient arrives with full-thickness burns to the entire posterior trunk and bilateral posterior legs. Using the Rule of Nines, the TBSA is calculated at?
The nurse anticipates this urgent surgical intervention, not only for wound management but to prevent distal ischemia and compartment syndrome.
What is 36%
What is escharotomy?
You have a patient that complains of chest pain and shortness of breath. On assessment you note diminished breath sounds on the right side. His RR is 28, O2 90% on 2L and BP 100/58.
What do you suspect is the cause?
What are two Actions you need to take?
What is a pneumothorax?
Actions- increase oxygen and prep for a chest tube.