Show:
Type
SXS
Therapy
NSG DX
MISC
100
Distributive (Vasogenic) or Warm shock will also take - Neurogenic
What is: shock that results from a change in size of the vascular space without an increase in blood volume
100
neurogenic
What is spinal cord injury (T5 or higher), drug OD, hypoglycemia, evaluate for fluid overload, bradycardia may require atropine, administer vasoconstrictor medications.
100
Hypovolemia
What is administer volume replacement, blood transfusion, and volume expanders; administe oxygen.
100
Fluid Volume Deficit
What is a nursing diagnosis for hypovolemia or hypovolemic shock
100
Hypovolemic or hypovolemia
What is caused by hemorrhage, burns, dehydration? What is the most common cause of shock?
200
Cardiogenic
What is Shock that results from the heart's inability to adequately circulate blood (intravascular) volume.
200
History of MI (cardiomyopathy or pulm edema)
What is important to differentiate between hypovolemic & cardiogenic shock; How might the nurse determine the existence of cardiogenic shock?
200
Cardiogenic shock
What is monitor ECG, medications like vasopressors to increase cardiac output, evaluate hemodynamic parameters, administer digitalis preparations for pulm edema
200
Decreased Cardiac Output
What is the nursing diagnosis that addresses poor (impaired) heart function and blood volume in a cardiogenic shock state?
200
Compensatory stage (non-progressive)-Early
What is the shock stage with vasoconstriction, shunting; BP low normal range, restless & agitated, pulse increased, MAP decreased 10-15 mmHg from baseline, decreasing pulse pressure; UOP slightly decreased; vital organs are perfused.
300
Hypovolemic Shock
What is shock that results from hypotension, tachycardia, oliguria, altered mental status, hypernatremia, increased HCT (hct may drop if pt actively bleeding), metabolic acidosis & an MAP <70.
300
tachycardia; tachypnea; hypotension; cool-clammy skin; & decreased UOP
What is: a nurse's responsibility to recognize the sxs of shock; list five assessment findings that occur in most shock victims.
300
Position supine, may elevate legs (modified trendelenburg) Maintain airway, provide supplemental O2 Keep warm Protect from falls IV access & fluid resuscitation Monitor MAP
What is treatment: name 4 nursing interventions for shock victims (pts)
300
Progressive stage or decompensated
What is MAP decreased 20mmHg or more, pallor, cold moist skin, oliguric, dyspneic, edema, dysrhythmias, weak-thready or absent pulses, decreased cardiac output, decreased tissue perfusion, reduced blood volume-circulatory deterioriation
400
Obstructive
What is shock caused by the physical impediment to the flow of blood.
400
very old, very young chronic progressive disease states (MI) trauma postop hemorrhage
What is name at least 3 risk factors that cause shock
400
Disturbed thought processes
What is a useful nursing diagnosis for changes in level of consciousness, restlessness & agitation, confusion & decreased responses.
400
Refactory or irreversible (late) stage
What is unresponsiveness, BP not measurable, pulse slow & irregular, anuria, severe hypoxemia unresponsive to O2, metabolic acidosis; MODS
500
Neurogenic
What is: shock with increased venous capacity due to a loss of peripheral vasomotor tone. Cardiac function & blood volume may be normal.
500
SOS - refer to powerpoint presentation (any of these is acceptable)
What is: an SOS learned today, name at least 3