Small Animal Nursing I Exam 3 Review - Identifying Emergencies, Respiratory Support & CPR Basics, and Neonatal Care

1 - In need of immediate treatment and stabilization

2 - Needs non-urgent treatment: bleeding, V/D, contagion

3 - Those that can wait

Initial triage sorts patients into three groups which are

• A brief history to identify life-threatening injuries that need treatment

• A quick physical examination

• Target discussion with owners regarding CPR status and initial treatment

What does triage include?

Primary patient survery

Will provide brief information on the most important parts of the patient's condition based on the patient's "A, B, C's."

A - Airway or attitude

B - Breathing or bleeding

C - Cardiovascular or circulation

What does a patient's "A, B, C's" refer to in an emergency situation?

If a patient fails any assessment during the primary patient survey

At what point is emergency treated initiated?

• Is the patient breathing?

• If breathing, look and assess the quality of the respiration

• Is the pattern of breathing regular or irregular?

• Is the respiration shallow or deep?

• Is there increased abdominal effort?

• Is the rate normal or abnormal?

• Can you hear respiratory sounds associated with inspiration or expiration?

Describe a quality airway assessment during your primary patient survey

• Is the patient bright, alert and responsive?

• Quiet, alert and responsive or is the animal non-responsive?

• Is it interacting with its owners or other people/pets in the room?

Describe a quality assessment of a patient's attitude during your primary patient survey

Look - patient response, MM color, CRT

Listen - auscultate heart, lungs and trachea

Feel - pulse, limbs

After approaching the patient, what should you do to complete your primary patient survey?

Reduced blood volume and increase in cardiac contractility

What produces a pulse which is narrower and higher than normal?

Once it is determined that the patient does not require emergency treatment or after stabilization has occurred

When is the remainder of a patient triage completed?

Carbon monoxide poisoning, heat stroke or sepsis

What may brick red, brown or injected mucous membranes indicate?

• Diaphragmatic hernia

• Severe pulmonary contusions

• Pneumothorax (quiet dorsal lungs)

• Pleural effusion (quite ventrally)

What may decreased or dull lung sounds indicate?

Pulmonary edema or contusions

What may increased or harsh bronchovesicular sounds (wheezes) or crackles indicate?

Borborygmi

Loud, gurgling bowel sounds

A diaphragmatic hernia

What may borborygmi in the thorax indicate?

Shock

What may decrease mentation and tachycardia indicate?

Urinary blockage in dog/cats OR shock in cats

What may bradycardia indicate?

Weak pulse

If blood pressure is lower than normal and occurs with tachycardia, the patient will have a ____

CRT increases as pressure drops and decreases with sepsis

An increased capillary refill time may be associated with ____ while a decreased CRT may indicate _____.

Patient is interactive but not eager to do so

What does a dull mentation mean?

Decreased response to stimuli

What does an obtunded or delirious mentation mean?

Completely disconnected from the environment and reacts only to stimulus strong enough to threaten the body's integrity (noxious stimuli)

What does stuporous mentation mean?

Mydriasis

Increased dilation of the pupil

Anisocoria

Unequal pupil size

Irreversible mid-brain lesion

What might a patient having unresponsive, mydriatic pupils indicate?

Medullary injury

What might a patient having unresponsive midrange pupils indicate?

Acute cerebral injury such as a bleed or clot

What injury is associated with anisocoria?

• Pain

• Tympany (gas)

• Fluid (hemorrhage, ascites, inflammation)

What does abdominal palpation on a triage exam look for?

An arched back or "praying" posture

List signs of severe pain

Identifies non-life-threatening injuries after the patient is registered and

a detailed history is obtained

How does a secondary exam differ from an initial triage exam?

• Hydration

• Shock

• Quick assessment tests

• The need for first aid

What assessments should a secondary exam include?

• Tacky mucous membranes

• Prolonged CRT

• Lack of skin turgor

• Mental status deteriorates as patient dehydrates

What are the clinical signs of dehydration?

• Hemoconcentration

• Azotemia

• Hypernatremia

• Elevated albumin

List common laboratory abnormalities associated with dehydration

• Excess nitrogen, creatinine, and other waste products in the blood

• If azotemia is noted, urine specific gravity should be checked

What is azotemia, and what lab test should be performed if azotemia is noted?

• The patient is dehydrated

• Azotemia can be considered prerenal due to decreased renal blood flow

What does a urine concentration above 1.050 indicate?

• A urine specific gravity of 1.012-1.018 in the dog, or 1.012-1.022 in the cat

• This value along with dehydration and azotemia suggests that renal disease is present

What is isosthenuria?

At less than 5% dehydration

When is dehydration not clinical detectable?

Mild dryness to mucous membranes

At 5% dehydration, a patient might present with

5% dehydration

Assess the % of dehydration of a patient with mild dryness to mucous membranes

• Mild loss of skin turgor

• Dry mucous membranes

• Possible mild tachycardia

At 7% dehydration, a patient might present with

7% dehydration

Assess the % of dehydration of a patient with dry mucous membranes, and mild loss of skin turgor

• Pronounced loss of skin turgor

• Dry mucous membranes

• Tachycardia

• Weak pulses

• Sunken eyes

At 10% dehydration, a patient might present with

10% dehydration

Assess the % of dehydration in a patient with pronounced loss of skin turgor, dry mucous membranes, tachycardia, weak pulses, and sunken eyes

• Severe loss of skin turgor

• Sunken eyes

• Shock

• Coma

• Death

At greater than 10% dehydration, a patient may present with

Greater than 10% dehydration

Dehydration status associated with shock, coma, or death

Hypovolemia

Loss of blood volume

• Shock

• Trauma

• Hemorrhage

• Profuse vomiting and diarrhea

Hypovolemia commonly occurs with

Tachycardia and prolonged CRT

*Because hypovolemia is an acute process, skin turgor may appear normal

Animals with hypovolemia tend to present with

• Tachycardia

• Weak pulses

• Hypotension

• Prolonged CRT

List clinical signs of severe hypovolemic shock

Quickly restore blood volume (IVC, blood transfusion, x-ray or ultrasound to identify the source of blood loss)

What is the goal of treating hypovolemia?

Replacement of the fluid deficit over several hours

What is the goal of treating dehydration?

Rapid rehydration with hypernatremia (high sodium) can lead to cerebral edema

Why should rehydration be accomplished gradually over 48-72 in a patient with severe hypernatremia?

• Packed cell volume (PCV)

• Total protein (TP)

• Blood glucose

• Blood gas analysis (high vs. low CO2; PaO2 80- 100 mmHg)

• Blood pressure

• Pulse oximetry

• FAST scan

List examples of emergent patient diagnostics

• Focused assessment with sonography in trauma

• Used to determine presence of fluid or air in body cavities

What is a FAST scan, and what is it used for?

• Emergency medications

• Needles and syringes

• Laryngoscope

• Endotracheal tubes

• Ambu bag

• Instrument packs

• Red rubber catheters

• Large-bore IV catheter

What should a crash cart be stocked with?

Altered blood flow or impaired delivery of oxygen to tissues

Define shock

• Depressed or anxious

• Tachycardic and tachypneic

• Hyperglycemia

List the early stages of shock

• Severe tachycardia

• Altered mental status

• Hypotension

• Pale mucous membranes

• Weak pulse

• Hypoglycemia

List the progressed stages of shock

• Massive vasodilation

• Hypotension

• Cardiac arrest

List the terminal stages of shock

Hypovolemic shock (decreased circulating blood volume)

Which type of shock is most common in dogs and cats?

Distributive shock

Decreased pressure due to vasodilation or pooling of blood

Anaphylaxis, heat stroke, and envenomation

List conditions associated with distributive shock

Obstructive shock

Type of shock that impairs venous return to the heart

Bloat

What condition is obstructive shock associated with?

Cardiogenic shock

Type of shock associated with weak pulses, cold extremities,

and pulmonary edema, or ascites

Cardiomyopathy, valvular heart disease, and arrhythmias

List conditions associated with cardiogenic shock

Septic shock

Type of shock characterized by severe infectious insult

• Pneumonia

• Parvovirus

• Gastric or intestinal perforation

• Infected bite wounds

List conditions associated with septic shock

Bright red mucous membranes and bounding pulses

A patient in septic shock might present with

Decreased blood pressure initiates an inflammatory response resulting in tissue hypoxia and damage that can progress to the entire body

What effect does shock have on the body?

Systemic inflammatory response syndrome (SIRS)

An inflammatory state resulting from shock that affects the entire body

• Causes widespread hypotension, tachycardia, tachypnea, and fever

• Increased WBC count as the immune system is activated

• Clotting cascade is initiated, causing greater impairment of blood flow to organs

• Spontaneous bleeding occurs as platelets are consumed

How does a systemic inflammatory response syndrome (SIRS) affect the body?

Disseminated intravascular coagulation (DIC)

One of the most serious complications of shock resulting in concurrent clotting and bleeding

Multiple organ dysfunction syndrome (MODS)

A complication of shock resulting in permanent organ failure and death

Brachycephalic airway syndrome and collapsing trachea

List structural problems of the respiratory system that patients may suffer from

• Pneumonia

• Hemorrhage

• Edema

• Cancer

List problems associated with the lung tissue that may cause respiratory issues in patients

Fractured ribs

*Patient will be taking shallow breaths

What is an example of an extra-pulmonary problem that may cause respiratory issues in patients?

Thoracic percussion or auscultation

What can help identify the presence of pleural effusion?

• Respiratory effort and pattern

• Mucous membrane color

• Patients with poor respiratory function may have pale, gray, or cyanotic MM

• Monitor O2 function in critical patients

Identify aspects of a respiratory assessment

Deoxyhemoglobin (<5 g/dL)

A significant amount of _____ is present when the patient appears blue

Certain drugs can interfere with respiration, and the patient may require intubation

Why is careful monitoring of sedated patients necessary?

Thoracocentesis and/or a drain (chest tube)

How is pleural effusion or pneumothorax treated?

• Chest tube

• Nasal prongs or cannulas

• Flow-by oxygen

• Face mask

• Oxygen cage

List methods of providing oxygen support to dyspneic patients

The percent of hemoglobin molecules that are saturated with oxygen

What does pulse oximetry measure?

• Poor perfusion to the probe site

• Hypothermia

• Interference from hair

• Skin pigmentation

• Patient movement

What are common errors that can effect a pulse oximetry reading?

Capnograph (end-tidal CO2)

Name the device that reflects the amount of CO2 present in expired air at exhalation

• Provides information about respiratory system function

• End-tidal CO2 reflects amount of CO2 present in expired air at exhalation

What is the function of a capnograph?

• Hypoventilation

• Rebreathing CO2 in an anesthetic circuit with exhausted soda lime

What is a high end-tidal CO2 reading associated with?

• Hyperventilation

• Decreased cardiac output

What is a low end-tidal CO2 reading associated with?

• Central line maintenance

• Central venous pressure monitoring

• Maintaining ventilator every 4-6 hours

• Keeping eyes moist

• Swabbing oral cavity

List methods of long-term support necessary for a ventilated patient

• Pressure ulcers

• Peripheral edema

• Edematous tongue

• Pneumonia

List complications associated with patients on a ventilator

Sudden loss of respiration and lack of perfusing heart rhythm

Define cardiopulmonary arrest (CPA)

• Underlying cardiac disorders or respiratory disease

• Severe trauma or shock

• Seizures

• Anemia

• Increased vagal tone

• Patients under general anesthesia

List common indications for CPR

Vagally mediated arrest

Increased parasympathetic nervous system stimulation associated with high levels of norepinephrine

• Patients with sudden tachycardia or bradycardia

• Pallor

• Alteration of pulse strength

• Increased respiratory effort

Some patients have respiratory arrest before cardiopulmonary arrest occurs. Which patients are predisposed?

• Continuous chest compressions (2 minute cycles)

• Ventilation

What are the components of basic life support (BLS)?

• Medications

• Defibrillation

• Open-chest procedures

What are the components of advanced life support (ALS)?

• Place in lateral recumbency with hand encircling the ventral chest

• Compressions performed directly over the heart

• 120 to 130 compressions per minute

Describe quality compressions of a cat or small dog

Cardiac pump

This CPR method uses direct compression of the heart's ventricles to contribute to forward blood flow

Thoracic pump

The passive movement of blood away from the body when the chest is compressed