Adults II exam 4 review

What is shock?

ischemia of tissues d/t less O2 being delivered. As a result, the tissues create energy through anaerobic metabolism *lactic acid) rather than aerobic metabolism (water and CO2) which overwhelms the body sending it to lactic acidosis

How is the Mean Arterial Pressure (MAP) measured?

• MAP= (CO*SVR) + CVP

  • CO= (HR*SV)

• It helps determine perfusion and can be affected by blood volume, cardiac contractility, and systemic vascular resistance

How does Systemic Vascular Resistance (SVR) affect MAP?

• When a vessel is vasoconstricted, the MAP increases and when its vasodilated, the MAP decreases

What are the 4 phases of shock?

• Initial

  • no manifestatinos, but there’s a gradual shift from aerobic to anareobic which starts to build up lactic acid in the body

• Compensatory

  • blood is shunted from non-vital organs to viral organs, hypotensive, tachycardia and tachypnea, impaired GI, oliguira, cool skin, V/Q mismatch

• Progressive

  • compensation starts to fail, mental status changes, severe hypotension, organ failure (no perfusion), profoundly acidotic and hypoxic

• Refractory

  • organ and system failure

What are general labs for shock?

• ABGs: metabolic acidosis

• Blood cultures: suspected infectious process

• DIC screen: risk of coagulation

• Glucose level: increased d/t stress response

• Lactate: lactic acidosis

• Liver enzymes: liver involvement

• CBC: bleeding, elevated WBC

• Cardiac enzymes: determines cardiogenic shock

What are general meds to help manage shock?

• Vasopressors

  • norepinephrine, phenylephrine, vasopressin, dopamine

  • cause vasoconstriction to bring up BP and increase CO

  • Risk for HTN, tachy, peripheral ischemia or necrosis (long-term use of norepinephrine)

• Positive inotropes

  • helps the lungs beat faster (cardiogenic shock)

• Vasodilators

• Bicarb (acidosis)

• Sedation and Paralytics

• Isotonic fluids

• Oxygen

What is the preferred way of administering meds in someone undergoing shock?

Central access since many of the drugs are incompatible, but remember to titrate the drugs to meet the parameters set and to wean patients off

What are the different forms of fluid loss that can cause hypovolemia?

• Diuresis, GI losses (n/v), blood loss, burns (fluid shifts d/t albumin), DKA (profound diuresis)

What are the indications for labs used to diagnose hypovolemic shock?

• Type and Screen: for suspected hemorrhage

• Lactate: if in high state of acidosis

• Chem panel: electrolytes (hemoconcentrated if fluid deficient), glucose (increased stress), renal labs (elevated d/t poor perfusion)

• CBC: concentrated d/t fluid loss or anemia if hemorrhage occurs

• Specific gravity: elevated

Why do you want to be cautious when using vasopressors to treat hypovolemic shock?

a person in hypovolemic shock is already undergoing vasoconstriction to try and increase the CO to vital organs. So, giving them vasopressors which cause vasoconstriction would have little to no effect

What position would you like to place hypovolemic shock patients?

Trendelenburg since it helps push blood back to the heart by elevation of the legs

What is cardiogenic shock most linked to?

HF since they both to do with dysfunctions of the heart leading to fluid backup and improper perfusion

Why would the CVP be increased in a person experiencing cardiogenic shock?

The CVP measures the pressure in the central veins and is determined by the volume. So, in cases like cardiogenic shock when there’s a backup of volume, the pressure in the central veins is increased which in turn increases the CVP

What are the indications for labs used to diagnose cardiogenic shock?

• Cardiac enzymes: indicate possible MI

• ABGs: metabolic acidosis

• Chem panel: electrolytes (hemodiluted), renal (elevated)

• BNP: elevated d/t volume overload

• Lactate: elevated

• Specific gravity: elevated d/t oliguria

What are the indications for the diagnostic tests used to diagnose cardiogenic shock?

• CXR: determine pulmonary edema

• EKG: check for MIs or dysrhythmias

• Echo: determine valve function

• Cardiac cath: look for potential blockages from an MI

What are the medical treatments for cardiogenic shock?

• Intra-aortic balloon pump (IABP): helps to improve perfusion of the myocardium

• Impella- helps the ventricles pump

• PCI- revascularize the myocardium to open blocked coronary arteries

What are the 3 forms of distributive shock?

• Septic

• Neurogenic

• Anaphylactic

Why does a person become bradycardic, hypovolemic, and hypotensive during neurogenic shock?

• Bradycardic: damage to the SNS and PSNS doesn’t allow for proper regulation

• Hypovolemic: since the vasodilation causes pooling of blood in the periphery, there’s a decrease in venous return mimicking hypovolemia

• Hypotensive: reduced venous return d/t vasodilation leads to decreased cardiac output

What are the frequent portals of entry that can trigger sepsis shock?

• UTIs (Foleys)

• Pneumonia wounds

What do you wanna do before administering antibiotics for septic shock?

collect blood cultures

What would you give someone experiencing anaphylactic shock who isn’t responding well to epinephrine?

Isotonic fluids

How can cardiac tamponade cause obstructive shock?

The blood filling the pericardial sac compresses the heart making it impossible to pump and contract

What are a few system manifestations related to MODS?

• Resp

  • hypoxemia, dyspnea, tachypnea

• CV

  • hypotension, tachycardia, reduced CO and poor perfusion (cool skin)

• Renal

  • Oliguria, elevated BUN/creatinine, metabolic acidosis

• Hepatic

  • jaundice, elevated liver enzymes, hyperbilirubinemia, prolonged clotting time

• GI

  • Paralytic ileus, abd distention, hypoactive bowel sounds

• Hematologic

  • Thrombocytopenia, bleeding (petechiae, purpura, prolonged bleeding)

• Neuro

  • altered status (confusion, agitation), reduced GCS, seizures

Why are people with SIRS and MODS have a high metabolism

The inflammatory response increases the body’s energy demands, so the body enters a hypermetabolic state to keep up with the demand

What’s key for a nurse taking care of patients at risk for SIRS and MODS?

detection

What is a burn?

Injury to skin or other tissues caused by heat, chemicals, electricity, or radiation

What are the 4 types of burns?

• Thermal

  • flash, flame, contact, scaling

• Chemical

  • acids, alkalis, organic compounds

• Electrical

  • heat from electrical current

• Inhalation

  • chemicals, hot air, substances from fire

What are the different burn classifications?

• Partial thickness

  • 1st degree only involves the epidermis

  • 2nd degree involves the epidermis and dermis

• Full thickness

  • 3rd degree involves the epidermis, dermis, and muscle, fat, and bone

What is the rule of 9s?

It’s the percentage of what areas the burn has affected

• Head and neck: 9% w/ the front being 4.5% and the back being 4.5%

• Each arm: 9% w/ the front being 4.5% and the back being 4.5%

• Each leg: 18% w/ the front being 9% and the back being 9%

• Front of torso: 18% w/ the upper being 9% and the lower being 9%

• Back of torso: 18% w/ the upper being 9% and the lower being 9%

• Perineum: 1%

What are concerns with burns to the face and circumferential burns?

• Burns to the face: risk for inhalation injury

• Circumferential burns: can cause constriction since they encircle a whole-body part (chest, abdomen, extremity) and when they begin to heal, they form a non-elastic eschar which impairs the body part from stretching leading to constriction, swelling, and edema

What are the phases of burns?

• Emergent phase:

  • first 72 hrs after the burn

• Acute phase:

  • starts after 72 hrs and ends when partial-thickness wounds heal or full-thickness wounds are grafted

  • lasts wks-months

• Rehabilitation phase:

  • wounds have nearly healed and the person can participate in self-care

Why is a person at risk for hypovolemic shock when they’re in the emergent phase of a burn injury?

The burn causes fluid to shift from the intravascular space to the interstitial space leading to edema to the burn location and hypovolemia in the blood vessels

Why is a person at risk for being hyponatremic when they’re in the emergent phase of a burn injury?

Burn injuries can also cause leakage of electrolytes into the interstitial spaces and we know that sodium follows water, so sodium drifts from the intravascular pace to the interstitial space

Why is a person at risk for being hyperkalemic when they’re in the emergent phase of a burn injury?

Damage from the burns causes a release of potassium from muscle cells that gets into the serum/blood vessels

Why is a person’s immune system put in jeopardy during the emergent phase of a burn injury?

The skin which acts as a protective barrier has been removed and the inflammatory process reduces the availability of the immune systems

Why give a tetanus immunization to a burn victim?

They’re at increased susceptibility d/t their injured skin

What is the Parkland formula and how is it used?

It’s a way to determine how much fluid to give a person based on the extend of their burn injury

• (4mL x body surface area affected x weight (kg)= volume of mLs to give in the first 24 hrs

• Note that the recommending volume should be split with half being given in the first 8 hrs and the rest given over the next 16hrs

What’s the difference between the open method and closed method when giving wound care to a burn victim?

• Open: expose wound to air and use things like cream to dress the lining of the wound with no dressing, but big infection risk

• Closed: wounds are covered with sterile dressings giving a physical barrier

What are key things the nurse should take note of when performing wound care?

• Use sterile technique

• Give analgesia BEFORE and AFTER

What are nursing priorities for taking care of burn patients in the emergent phase?

• Manage airway

• Give O2

• Establish IV (central line)

• Replace fluid

• Strict I&Os

• Monitor for infection

• Perform wound care

• Prevent pressure injuries

• Report abnormal labs

• Give more food/calories d/t hypermetabolic state

During the acute phase of a burn injury, why do patients experience diruesis?

As the body heals, the capillaries become less permeable, so fluid starts to shift from the interstitial spaces to the vessels allowing for normal fluid passage

Why would a nurse need to monitor high glucose levels in burn patients during the acute phase?

A hyperglycemic state impends proper healing

When does fluid replacement therapies become more individualized?

Following 24hrs based on the patient’s response and usually during the acute phase

When would it be okay to contact PT/OT for burn injuries?

When dressing have been removed and the patient would possibly have splints to prevent contractures

What’s the difference between an allograft and an autograft?

• Allograft

  • A cadaver’s skin is temporality used to determine the site for the permanent skin graft

• Autograft

  • Skin is taken from one part of the patient’s body and meshed to the injury site

When would a cultured epithelial autograft (CEA) be used?

If there isn’t enough viable tissue to use for the autograft, a small sample of skin is taken, sent out to a lab where the skin cells are cultured and grown. Then when they’re made into a large enough sheet, they’re brought back and meshed to the site of injury

What are dermal substitutes when dealing with skin grafting?

They’re different types of materials made to mimic the dermis and is used as a bridge for a severely burned patient waiting on CEA

What is organ transplantation?

A procedure done when there’s a dysfunctional organ in an individual which is no longer responsive to other therapies

What are the different types of donors?

• Deceased (cadaver)

• Living

• Autologous (comes from themselves)

When are autologous donors most commonly seen?

With stem cell transplants

What are the different types of grafts?

• Autograft: same person

  • skin, hair, bone

• Allograft: person to person

  • kidney, lungs, heart, liver

• Isograft: identical twins

• Xenograft: one species to another

What organs need to be entirely transplanted?

• heart

• kidney

What organs need to be partially transplanted?

• Liver

• Lung lobes

What goes into determining donor eligibility?

• General: major disease testing (HIV, Hep, CMV), ABO compatibility, antibody panels, comorbidities

• Living donor: CXR, ECG, any testing related to the organ being donated

• Decreased donor: brain death testing, sufficient CV function

What situations would it be likely that the organ donor could donate multiple organs?

• Traumatic injury

• Massive brain hemorrhage

What organization do most teams use to set standards for recipient eligibility for organ donation?

United Network of Organ Sharing (UNOS)

What goes into determining recipient eligibility?

• HLA (Human Leukocyte Antigen testing), antibody panels, ABO compatibility, EKG, Echo, PFTs, Endoscopy, colonoscopy, etc.

What are the two major things nurses must look out for post-organ transplant?

infection and organ rejection

In what instance would immunosuppressive meds not be needed following an organ transplant?

If the person were to receive an autograft

If an organ recipient has an infection, why would their WBC count not spike up?

Their immune system is being suppressed so the WBC won’t be called upon to attach the infectious agents

What other labs can be used to detect infection in organ recipients?

• ESR and CRP to track inflammation

• Urine, sputum, and blood cultures

• Urinalysis

What factor differentiates organ rejection from organ transplant-induced infection?

The patient has pain at the site

How is GVHD different from organ rejection?

GVHD is different from rejection because it doesn’t indicate that the body is rejecting the organ, rather the donor's immune system is attacking the recipient

What was the Uniform Anatomical Gift Act-1968?

•Allowed individuals to gift their organs

What was the Uniform Determination of Death Act-1980?

•Provided a definition of brain death

What was the National Organ Transplant Act-1984?

•Created more regulation and the organ procurement networks

What would be done if the kidney transplant recipient is on dialysis?

They would be dialyzed close to the procedure to correct electrolyte and fluid balance

Why are lung transplant recipients at a higher risk of infection (pneumonia)?

Due to the presence of the ET tube post-op and the immunosuppressive therapy

What are the 3 major types of stem cell transplants?

• Allogenic: getting from another person

• Syngeneic: identical twin

• Autologous: getting from yourself

What is the pre-procedure of a stem cell-transplant?

• Give the donor G-CSF to increase the # of hematopoietic stem cells

• Then those stem cells are harvested through apheresis (blood is drawn out into a machine, spun, the stem cells in the blood are harvested, put in a separate bag and frozen)

• As the cells stay frozen, the patient undergoes high-dose chemo to eradicate any remaining infectious stem cells in their body

• After that, the healthy stem cells that were frozen are then put back in the patient’s body

What actions should be taken for stem-cell recipients if they’re staying home?

High likelihood of infection due to chemotherapy, so they usually have infusions with abx. ready to go if they’re staying home

Why are stem-cell recipients at high risk for GVHD?

Stem cells can create T and B cells that will attack the individual

What would rejection look like in a heart-transplant recipient?

It would look similar to HF, so edema, JVD, SOB, dysrhythmias, kidney issues

If a liver transplant recipient has hepatitis prior to the transplant, what would their treatment look like?

• They would be on some type of antiviral medication on top of the triple therapy