Visual acuity function week chapter shock shock systemic syndrome

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MDC 4 – Exam 2 Review – August/2021

• Inter: elevate HOB, bronchodilators, energy-conserving measures, encourage deep breathing

3) ARDS: acute respiratory failure w/ hypoxemia even w/ 100% O2 (refractory hypoxemia)-Features:  pulmonary compliance, dyspnea, bilateral pulmonary edema, dense pulmonary infiltrates on X-ray
• Risk Factors: sepsis, burns, pancreatitis, trauma, transfusion, aspiration, drowning. Direct injury to lung tissue.

4) Chest Trauma: - Protect airway, cervical spine until ruled-out (log roll)
• Flail chest: paradoxical inward movement of the thorax during inspiration w/ outward movement during expiration (paradoxical chest movement)
- Older adults have a higher mortality rate
• S/S: dyspnea, cyanosis, tachycardia, hypotension, pain, anxiety, SOB, clear secretions when coughing,  work of breathing
• Inter: O2 (humidified), pain management,

• Pneumothorax: air in the pleural space causing loss of negative pressure in chest cavity- Rise in chest pressure, and a reduction in vital capacity l/t lung collapse
- Deviation of the trachea away from midline
- Reduced or absent breath sounds,  cx expansion unilaterally

• High Pressure Alarms causes: - PIP reaches the set alarm limit (10-20mmHg above baseline)

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(½ total in 24h: ½ in the 1st 8h and the other ½ in the remaining 16h)
- Calculate from time of injury
- 2 large IVs or central lines
- Urine output: most sensitive assessment for cardiac output & tissue perfusion- Goal: 0.5mL/kg or 30mL/hr
- Do not give diuretics in the resuscitate phase
- ≥ 25% extensive burn / systemic

- Focus on fluid resuscitation

8) Fasciotomy: relieves pressure and allows normal blood flow

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- Focus on nutrition
- Daily weight,  caloric intake to prevent weight loss
• Curling’s ulcers: acute gastroduodenal r/t the stress of severe injury. - May occur within 24h d/t reduced GI blood flow and mucosal damage - PPIs, H2 blockers are given
- Hydrotherapy BID

16) Shock: is a systemic syndrome, perfusion is not met

17) Hypovolemic Shock: total body fluid  in all fluid compartments
- Loss of vascular volume, results in  MAP and RBCs
• Risk Factors: hemorrhage, trauma, GI ulcer/bleed, sx, liver ds, Ca therapy, diarrhea, dehydration, burns

19) Obstructive Shock: cardiac function  by noncardiac factor- Caused by cardiac tamponade
• S/S: hypotension, anaerobic cellular metabolism

20) Distributive Shock: blood volume is not lost but distributes to the interstitial tissues• Anaphylactic: exposure to allergens results in an antigen/antibody reaction. Causes: Abx, food, latex, insect stings
•Neurogenic: loss of tone causes massive vasodilation. Causes: SCI, head trauma, anesthesia neurogenic shock is the ONLY bradycardic shock
• Septic: toxins cause massive vasodilation. Causes: gram pos/neg bacteria
• S/S: hypotension, tachycardia,  capillary leak

b) Nonprogressive Stage:  MAP of 10-15mmHg from baseline- Moderate vasoconstriction,  HR,  pulse pressure/UO
• S/S: restlessness, tachycardia,  RR,  UO, rising DBP, 2-5%  in O2, - Mild acidosis/hyperkalemia

c) Progressive Stage:  MAP > 20mmHg from baseline- Anoxia/ischemia of nonvital organs
- Hypoxia of vital organs

26) Systemic Inflammatory Response Syndrome (SIRS): widespread inflammation
• Criteria: Temp >100.4F or <96.8, Pulse > 90bpm, RR > 20/min or PaCO2 <32mmHg, WBC >12.000 or < 4000 mm3
- Pt w/ sepsis has 2 or more SIRS criteria & one of the following: hypotension, oliguria, + fluid balance,  cap. refill, hyperglycemia,  creatinine, changes in mental status

27) DIC: excessive clotting, reduces perfusion & gas exchange
-  Oxygen saturation causing widespread hypoxia/ischemia
• S/S: rash, SOB, pallor, hypotension, hematuria, hematochezia, petechia, ecchymoses• Tx: remove underlying cause, monitor VS, O2 therapy, anticoagulants, IV fluid resuscitation

- A-fib patients need enoxaparin and if bleeding keeps occurring then place filter at vena cava

- Barrel and volume trauma result from mechanical ventilation

What would you do as a nurse, what is your role in that situation?

a. call Rapid response, start IV access, get supplies in the room (crash cart, suction,

3. An older adult client arrives in the emergency department after falling off a roof. The nurse observes “sucking inward” of the loose chest area during inspiration and a “puffing out” of the same area during expiration. Arterial blood gas (ABG) results show severe hypoxemia and hypercarbia. Which procedure does the nurse prepare for?

c. Endotracheal intubation

7. When assessing a client who has suffered a burn injury, the nurse classifies the burn as a full thickness burn based on the observation of which characteristics?

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10. A nurse in a burn treatment center is caring for a client admitted with severe burns to both lower extremities and is schedule for an escharotomy. The client spouse asks the nurse what the procedures entails. Which nursing statement is appropriate?

A. Large incisions will be made in the eschar to improve circulation B. I can call the doctor back if you want me to
C. A piece of skin will be removed and grafted over the burned area D. Dead tissue will be surgically removed

25. A vena cava is one of the preventions used for pts with pulmonary embolism to prevent further PE? TRUE
26. Which IV fluid is the best choice for a pt in hypovolemic shock? 0.9% Normal saline 27. A pt with a tension pneumothorax and cardiovascular compression is at risk for distributive shock? FALSE
28. Norepinephrine is often used for patients in distributive shock due to its ability to cause increased MAP without change to vascular tone
29. MAP
a. systolic blood pressure and 2 times the diastolic and then divide by three
b. Example: BP 100/50
i. 100 + 2(50) =200 than you divide by 3 and you have 66.66 so round to 67