Rasmussen College - PN 3PN3-Exam-3-Study-Guide-1

Rasmussen College - PN 3PN3-Exam-3-Study-Guide-1 PN3-Exam-3-Study-Guide-1 Multisystem Failures Acute IIR cardinal signs Rubor = redness (due to vasodilation) Tumor = swelling (due to release of fluid containing RB ...

Rasmussen College - PN 3PN3-Exam-3-Study-Guide-1 PN3-Exam-3-Study-Guide-1 Multisystem Failures Acute IIR cardinal signs Rubor = redness (due to vasodilation) Tumor = swelling (due to release of fluid containing RBC and protein) Callor = heat (due to increase blood flow) Dollor = pain (swelling cause pain and pressure of the nerve endings) Types of all shock and complications Hypovolemic, cardiogenic anaphylactic, neurogenic, septic Hypovolemic Lack of circulating blood volume Blood loss, dehydration, burn, vasodilation due to neurogenic shock or anaphylactic shock, N/V diarrhea, NG suction. Drop of blood pressure Interventions: replace fluid! Monitor fluid replacement, monitor vital signs, assess S/S of fluid overload, WBC Hemoglobin and hematocrit., positioning for comfort. Cardiogenic Weakened forward pumping function of the heart, right, left, ventricles or both. MI, decreased cardiac output, irregular rate or rhythm Example if left ventricle is affected you will see pulmonary edema, adventives lung sounds HR > 100 bpm, weak or thready pulse, diminished heart sounds, dysrhythmia, cool moist pale skin, chest pain Renal failure, watch output > 30 ml a hour, 400 ml a day (less than that is oliguria, anuria is absent of urine) Generized edema, legs, arms face, watch weight (2 # in 24 hours or 5# a week sign of additional cardiac and/or kidney failure) Treatment: oxygen, mechanical intubation, diuretics, inotropic drugs (to stimulate the contractibility of the heart such as dopamine, dobutamine, inamrinone), ECG, morphine (improve coronary perfusion) Anaphylactic Occurs when an allergen such as food (shellfish, peanuts, chocolate strawberries and tomatoes)food additive, iodine, latex, mold fungus cats or medications (penicillin) insects (bees) venom, enter the body causing release of histamines (widespread antibody response), which results in capillaries dilation, and smooth muscle contracting. Life threatening situation. Difficult to diagnose, symptoms look like PE Comprehensive health history is important to prevent anaphylactic shock. Remember the different of sensitivity (rash) or allergy. History of an allergy can make second time worse. Prevent latex Washing hand with soap and water, avoid oil- based cream, prevent dust damp rag. Make sure they have an epipen, or administer epinephrine S/S Edema tongue airway, SOB, stridor, hypotension, anxiety. Neurogenic shock Absence or suppression of the sympathetic nervous system tone and is considered in the hypovolemic shock class. Caused by disruption of brain or hypothalamus, spinal cord injury at or above T6. Massive peripheral vasodilation, loss of temp regulation, loss of sympathetic tone in the heart, diminished baroreceptive responses to change blood pressure Paralysis, warm dry skin, (You do not see decreased reflexes with neurogenic shock). Treatment: reestablish blood volume, replace fluid! Monitoring fluid overload, medication inotropic and vasoconstriction meds (dopamine), low dose of corticosteroids, atropine if bradycardia, ECG, Glasgow coma scale, monitor MODS. Interventions prevent hypovolemic shock correct hypovolemia, promote normal temp, prevent hypoxemia, monitor ECG (dysrhytmias), identify patient at risk for neurogenic shock, patient with DVT. ( stress is related to increased sympathetic nervous system arousal and involves a wide physiological response) Septic shock Circulation and coagulation is altered severe sepsis is associated with one or more organ dysfunction. S/S Hypotension, blood pressure has a widened pulse, tachycardia, high temp, lactic acidosis, oliguria, mental status changes, cellular and humoral responses. Aches and chills, decreased skin perfusion It mimic SIRS, sign of at least one organ failure Diagnosis, WBC, identify the source, history Causes bowel surgery, severe malnutrition, multiple antibiotic therapy, multiple immune suppressant therapy (patient on chemo, radiation), prolonged hospitalization, nosocomial infection.!! Gram negative bacteria is a major cause of septic shock!! Treatment: antibiotic specific for the type, and fluid resuscitation. Main cause of shock Gram negative bacteria is a major cause of septic shock hypovolemia Interventions with Disseminated IV coagulations Excessive clotting and hemorrhage. Hypoxia, acidosis and shock occur. Interventions: clots and bleeding precautions. handle the patient very gently, changing positions very delicate. Avoid sharp objects, no IM injections, no razors Patient can have constipation, avoid straining ARDS management and treatment Treating underlying cause, promote gas exchange, oxygen, prevent further complications. Patient are intubated and on mechanical ventilation (to help prevent further damage of the lung) (book) bedrest, Stages of shock syndrome MODs assessment of patient- use what for assessing? Primary multiple organ dysfunction Major trauma to the chest, severe aspiration, inhaled fumes TOXIC shock can lead to SEPTIC shock caused by staphylococcus aurus Flu like symptoms, high fever, N/V, diarrhea, hyperactive bowels, abdominal pain, muscle and joint aches STRAWBERRY TONGUE, reddish rash, peeling of the skin in 7 to 10 days. This can cause necrotic vecitis severe infection of the muscle in the extremities of trunk -> gangrene is happening,-> amputation -> very high mortality rate. MODS Assess renal function, urine < 30 ml per hour or 400 ml per day Failure to control infection Persistent hypo perfusion Presence of necrotic tissue / abscess Altered oxygenation Coronary Artery Dysfunction  Cardiac Angiogram o Done via heart catheterization. It is an invasive procedure. It is the gold standard for diagnosing CAD o It directly visualizes the coronary artery anatomy. It assesses ventricular function and hemodynamic function.  Cardiac Rehabilitation Phases Cardiac Rehab Phases Description Phase I In the hospital after an MI. The nurse should get to know the patient. The nurse determines the ability of the patient to exercise and care for themselves. Phase II Transitional phase from the hospital to home. It focuses on increasing activity. Low intensity exercise program. Phase III Supervised variety of exercises with recording and assessments on the patient to see how well they tolerate activity. Phase IV Maintenance phase. Emphasizes the long-term life change. Exercise (no sedentary lifestyle). Diet.  CAD o Risk Factors: Modifiable vs. Non-Modifiable  Modifiable: Smoking, hyperlipidemia, hypertension (long term or chronic over 140/90), diabetes, obesity, diet, inactivity, stress, and alcohol  Non-Modifiable: Age, gender, family history, and ethnic background o Diagnostic Test Teachings  Electrocardiogram • 12-lead electrical recording of the heart used to determine areas of ischemia or infarction  Holter Monitor • Ambulatory ECG that monitors the patient to see if ischemia is present. Goes directly to the telemonitor nurse. Like a pager looking device. Relates the ischemic episode to what the patient is doing  Chest X-ray • Not diagnostic worthy, but can reveal clues of CAD  ECG Stress Test • Exercise induced stress test. It evaluates effectiveness of therapies. Shows how exercise is affecting the cardiac system  Labs • Creatine Kinase: looks overall if there is muscle damage in the body. It is a marker but is nondistinctive. • Troponin: a myocardial protein that is only released in circulation when there is a myocardial injury. It will rise quickly and remain elevated for 2 weeks.  STEMI ..................................................................................................... ............................................Continues