#1
Patho and clinical manifestations of the compensatory stage of shock.
What is:
Patho
• Vasoconstriction
• Increased sodium and water reabsorption
• Shunting of blood away from nonessential organs
• Increased glucose production
Clinical manifestations
• Restlessness, confusion
• Increased heart rate
• Tachypnea
• Respiratory alkalosis
• Oliguria
• Hyperglycemia
• Decreased bowel sounds
• Weak pulses
• Cool, moist skin
Causes and clinical manifestations of obstructive shock.
Obstructive shock is caused by a mechanical barrier to ventricular filling or ventricular emptying (increased afterload) causing decreased cardiac output such as with cardiogenic shock, cardiac tamponade, or pulmonary embolus.
Cinical manifestations are the result of decreased cardiac output and impaired peripheral perfusion: a decreased level of consciousness; decreased urine output; poor pulses; pale and cool skin; and decreased bowel sounds. Chest pain, nausea and vomiting, and shortness of breath are also common findings.
List 3 causes of distributive shock and clinical manifestations.
What is neurogenic, septic, and anaphylactic shock. Clinical manifestations include warm, dry skin and a flushed appearance due to systemic vasodilation.
What occurs during each disaster phase?
Mitigation, prepardness, response, and recovery
What is:
Mitigation includes activities that eliminate or reduce the chance of occurrence or the effects of an event if it occurs.
Preparedness, the next phase, is planning how to respond when an emergency or disaster occurs.
Response covers the period during and immediately following a disaster. During this phase, emergency responders and public officials provide emergency assistance to victims of the event and try to reduce the likelihood of further damage.
Recovery begins almost concurrently with response activities and is directed at restoring essential services and resuming normal operations.
Nursing actions for a client with a snakebite.
What is:
Continuous cardiac monitoring- Dysrhythmias may be present with elevated potassium in renal failure.
Administer IV fluids as ordered- IV fluids help maintain intravascular volume, preventing hypotension. The treatment of rhabdomyolysis involves administration of large volumes of IV fluids to flush the kidneys and maintain urine output.
Administer antivenin as ordered- Antivenin is the recommended treatment to counteract the neurotoxic and hemotoxic effects of venom.
Keep affected extremity immobilized in a functional position below the level of the heart- Reduces blood flow to the heart and the spread of the venom
Remove tight clothing and jewelry from affected extremity- These objects could act as a tourniquet if swelling is present
Keep patient calm- Enables identification of symptoms as related to the snakebite and not the autonomic manifestations of nausea, vomiting, tachycardia, diaphoresis, and diarrhea caused by the terror of a snake bite
Clinical manifestations of cardiogenic shock.
What is chest pain, diaphoresis, nausea, and vomiting. The decreased cardiac output, hypotension, and resulting compensatory mechanisms cause a decreased level of consciousness; decreased urine output; poor pulses; pale, cool skin; and decreased bowel sounds. Shortness of breath, crackles on auscultation, and decreased saturation of arterial blood with oxygen (SpO2) are evident as a result of pulmonary edema. Decreased cardiac output greatly impairs tissue perfusion, leading to anaerobic metabolism that produces lactic acid, as evidenced by increased lactate levels. Arterial blood gases reveal a metabolic acidosis.
Priority nursing actions during the emergent phase of burns (the first 24 hours)
During the emergent phase, the primary goal is to resolve immediate life-threatening issues resulting from the burn injury. These priorities include baseline diagnostic evaluation, airway management, fluid resuscitation, pain management, prevention of hypothermia, and initiation of wound care.
Patho/Clinical manifestations and treatment for a tension pnuemothorax.
What is accumulation of air or blood in the pleural space may result in a mediastinal shift and tracheal deviation toward the unaffected side, causing compression of the heart, vena cava, aorta, and unaffected lung.
Treatment include needle decompression followed with insertion of a chest tube.
Identify the order of the levels of PPE protection and explain what materials are used for each level.
Levels A, B, C, D.
What is
Level A PPE highest include highest level of respiratory, eye, mucous membrane, and skin protection. It includes a totally encapsulating chemical protective suit, often called a “moon suit,” with a self-contained breathing apparatus (SCBA), gloves, and boots
Level B PPE greatest level of respiratory protection but a lower level of skin protection than Level A.
Level C PPE provides the same skin protection as Level B but a lesser level of respiratory protection than Levels A and B.
Level D PPE consists of a surgical gown, mask, and gloves
Calculate the fluid resuscitation volume for an adult patient weight: 70 kg with TBSA burned: 50% flame burn. Include the flow rate for the first 8 hours then the remaining 16 hours. What should the urine output be maintained at?
Daily double!!!
Resuscitation Calculation:
2 mL × 70 × 50 = 7,000 mL of lactated Ringer’s in the first 24 hours
First 8 hours: 3,500 mL, rate = 438 mL/hr
Next 16 hours: 3,500 mL, rate = 218 mL/hr
Urine output should be maintained at 0.5 ml/hr or 1ml/hr if myoglobin is present in the urine.
Clinical manifestations of early and late stages of septic shock.
What is:
Early stages of septic shock, sometimes termed hyperdynamic or warm sepsis, reflect the initial inflammatory response. The patient is tachycardic, with bounding pulses and warm, flushed skin, and is febrile. Blood pressure may be normal as a result of initial compensatory responses.
Late stages of septic shock, also referred to as hypodynamic or cold shock, are characterized by cool, pale skin; weak and thready pulses; and hypothermia. Tachycardia persists, but blood pressure remains low. Further signs of end-organ hypoperfusion, such as lethargy or coma and anuria, may be present.
Identify the characteristics of a superficial, superficial partial thickness deep partial thickness, and a full thickness burn.
Daily Double!!
What is
Superficial burns affect only the epidermal layer of the skin and are characterized by mild erythema and hypersensitivity, which typically resolve in 24 to 72 hours.
Superficial partial thickness burn - Entire epidermis and minimal damage to the dermis. Blisters that may be closed or open and weeping; pink or red; mild edema; blanches easily the wound is hypersensitive.
A deep partial-thickness burn involves the epidermis and extends into the deeper portions or bottom layers of the dermis. The patient often reports varying areas of pain and decreased sensation. Deep partial-thickness burns appear waxy and do not have the characteristic weeping blisters that are seen in superficial partial-thickness injuries.
Full thickness burn - A full-thickness burn involves destruction of the epidermis, the dermis, and portions of the subcutaneous tissue. All epidermal and dermal structures are destroyed, including hair follicles, sweat glands, and nerve endings.
List nursing actionc taken when suctioning an mechanically intubated client.
What is administer 100% oxygen via the ventilator, advance the in-line suctioning catheter down into the clients airway, intermittently press on the suction catheter button to suction while withdrawing the in-line suctioning catheter from the clients airway.
Clinical manifestations of hypovolemic shock.
In the early stages, blood pressure may remain within normal limits, but the HR is typically increased. The patient may present as restless or confused. Urine output decreases because of the reabsorption of sodium and water. The skin becomes pale, cool, and clammy. Pulses are weak, with sluggish capillary refill. Hyperventilation is present, producing a respiratory alkalosis. Decreased or hypoactive bowel sounds are present because of the shunting of blood to vital organs. Hyperglycemia is evident because of the initiation of the fight-or-flight response in the initial compensatory phase.
Later stages of shock produce more pronounced clinical manifestations, such as lethargy; hypotension; metabolic and respiratory acidoses; anuria; cold, cyanotic skin with weak or absent pulses; and dysrhythmias.
Clinical manifestations of compartment syndrome.
Clinical manifestations of compartment syndrome include progressive diminishing of the pulse, numbness, tingling, and complaint of pain with flexion and/or extension. This pain is often not proportional to the extent of the injury and is unrelenting despite appropriate administration of pain medication.
Six Ps; passive pain at rest, along with pressure, paresthesia, pallor, paralysis, and pulselessness.
Priority actions during the first hour of a client being diagnosed with sepsis.
What is
• Measure lactate levels. Reassess if initial lactate is >2 mmol/L.
• Obtain blood cultures (prior to administering antibiotics).
• Administer broad-spectrum antibiotic.
• Administer 30 mL/kg of crystalloid if patient hypotensive or lactate level at least 4 mg/dL.
• Administer vasopressors if blood pressure is unresponsive during or after fluid resuscitation; maintain mean arterial pressure (MAP) at 65 mm Hg or above.
Patho of a type 1 hypersensitivity reaction (anaphylaxis).
The primary mediator of type I hypersensitivity reactions is immunoglobulin E (IgE). The first time a patient is exposed to an allergen, IgE is produced. The IgE antibodies attach to mast cells. The next time the patient is exposed to that specific allergen, it binds to the IgE antibodies that are attached to the mast cells. This causes the mast cell to degranulate, releasing histamine and other chemicals such as leukotrienes and prostaglandins that cause smooth muscle contraction, vasodilation, increased vascular permeability, bronchoconstriction, and edema.
Clinical indications for an escharatomy.
An escharotomy (surgical incision through eschar) is performed to relieve the pressure and should extend only through the eschar and into the immediate subcutaneous fat. This procedure may be performed at the bedside using a scalpel or an electrocautery device. In circumferential burns to the chest, pulmonary function may be restricted because of the inability of the chest wall to expand with ventilation.
Clinical manifestations of neurogenic shock.
A disruption in sympathetic nervous system stimulation causes an inability of vascular smooth muscle to constrict, resulting in decreased blood return to the heart and decreased cardiac output. Sympathetic nervous system interruption, with unopposed parasympathetic nervous system action, may result in transient, profound bradycardia in some patients.
Hypotension, profound bradycardia, peripheral vasodilation, warm and dry skin, changes in LOC, metabolic acidosis, and hypovolemia.
Identify two manuevers for opening the airway and state when they are indicated.
The chin-lift maneuver is another option for opening the airway. If the patient’s tongue has fallen backward and obstructed the airway, both maneuvers allow the airway to become unobstructed but the jaw thrust maneuver is always used for trauma patients when spinal cord injury is suspected to prevent primary or further injury to the spinal cord.
Indications for applying a hard cervical collar.
What is for any patient who has a suspected cervical–spinal cord injury or mechanism of injury could cause a cervical spinal cord injury.
A client is admitted with partial thickness burns to the entire right arm and hand, chest and abdomen, and right leg. Calculate an estimate of total body surface area burn to document.
What is 37% TBSA.
Classify each SALT triage category
What is
Idenify possible fluid and electrolyte (metabolic) complications during the emergent phase of burns.
Generalized dehydration- Plasma leaks through damaged capillaries (third spacing) and into interstitial spaces.
Reduction in blood volume- Secondary to third spacing, blood pressure falls, and cardiac output is diminished.
Decreased urinary output- Secondary to fluid loss and decreased renal blood flow
Hyperkalemia- Massive cellular trauma causes the release of potassium into extracellular fluid.
Hyponatremia- Large amounts of sodium are lost to third spacing, wound drainage, and shifting into cells as potassium is released.
Metabolic acidosis- Loss of bicarbonate ions accompanies the loss of sodium.
Elevated hematocrit- Plasma is lost to extravascular spaces, leaving the remaining blood very viscous.
What is the purpose of the primary and secondary surveys.
The primary survey begins immediately on the patient’s arrival to the hospital. The purpose of a rapid primary survey is to identify life-threatening conditions and simultaneously institute management of these conditions.
The secondary survey is performed after the primary survey is complete and lifesaving interventions have been initiated. This survey identifies the other injuries that the primary survey did not assess along with pertinent information about the patient such as other comorbidities.