NURSING > STUDY GUIDE > Rasmussen College PN3-Exam-3-Study-Guide-1_A Complete Guide for Exam Preparation-GRADED A+ (All)

Rasmussen College PN3-Exam-3-Study-Guide-1_A Complete Guide for Exam Preparation-GRADED A+

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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 sho

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