EDN: Shock and Acute Hemorrhage

Shock

It is a life-threatening condition that occurs when the body is not getting enough blood flow.

Shock

simply refers to inadequate tissue perfusion.

pump failure, blood volume, arterial resistance vessels, capacity of venous beds

This inadequacy to perfuse tissues is a result of one or more of the following:

septic, anaphylactic, neurogenic

changes in the arterial resistance vessels types of shock?

Bradycardia

what is the unique assessment for neurogenic shock among other types of shock?

Hemorrhagic shock

occurs when a significant amount of fluid is lost from the intravascular space. May result from hemorrhage, burns, GI losses, or fluid shifts.

cardiogenic shock

—occurs when the heart fails as a pump

distributive shock

—occurs as the result of a loss of vascular tone

Sepsis

characterized by a systemic inflammatory response in the presence of suspected or confirmed infection

Systemic inflammatory response syndrome (SIRS)

is the body’s systemic clinical response to an insult with an acute inflammatory reaction

hypovolemia unresponsive to fluid resuscitation, hypoperfusion, hypoxia

characteristics of septic shock?

SIRS, Sepsis, Severe Sepsis, Septic Shock

what is the progression of SIRS to Shock?

fever, warm, flushed skin

Early signs shown in septic shock?

cool clammy skin, low BP, tachycardia

Late signs shown in septic shock?

Hemorrhagic

actual blood loss

cardiac tamponade, tension pneumothorax, pulmonary embolism

examples of obstructive shock

supine with legs elevated

what is the position of the patient what undergone SHOCK?

Hypovolemic Shock

Occurs when significant amount of fluid is lost from intravascular space.

urine output of 25 ml/hour

what is the MOST INDICATIVE OF SHOCK?

to decrease blood loss and to increase intravascular volume

Goal of treatment for shock and hemorrhage?

PLR

what is the fluid of choice for shock & hemorrhage?

PNSS

what is the IV fluid to be given if the patient will undergo blood transfusion?

3:1 ration - 3 ml of c

what is the rule for crystalloid replacement for shock and hemorrhage?

LOC

—important indicator of shock because it reflects cerebral perfusion.

Narrow pulse pressure

—early in shock, the diastolic pressure may rise due to an initial vasoconstriction produced by release of catecholamines from the sympathetic nervous system, resulting to what ASSESSMENT?

fall in SBP below 80 mmHg or MAP below 60 mmHg

what is the BP characteristics indicative of shock?

urine output less than 25 ml/hr

indicate shock in a patient without renal dysfunction.

metabolic acidosis

this results because of anaerobic metabolism within the cells

pale, ashen, mottled, cold, and sweaty skin

what happens to the skin that indicates potent vasoconstriction

packed RBC or whole blood

are infused when there is hypovolemic shock because of blood loss

platelets and coagulation factors

are given when large amounts of blood are needed because replacement blood is deficient in clotting factors.

Head injuries

Maintain patient in supine position with the legs slightly elevated. (This position is contraindicated in patients with _____________

cool

A patient who is in septic shock should be kept ____ because high fever will increase the cellular metabolic effects of shock.

Vasopressors

may be indicated but should not be used in place of volume replacement except as dictated by cardiogenic or neurogenic shock states.

Trendelenburg

this position is NO longer recommended because of the potential for respiratory compromise caused by pressure from abdominal organs.

O-negative packed RBC

what blood type for blood transfusion in INITIALLY GIVEN?

ALTERED TISSUE PERFUSION

WHAT IS THE PRIORITY NURSING DIAGNOSIS FOR SHOCK & HEMORRHAGE?

IV dextran or Voluven

Colloids may also be given to patient with shock & hemorrhage like what examples?

Hemorrhage

It refers to rapid loss of circulating blood volume, usually 5 liters of blood volume is lost

5 liters.

in hemorrhage usually HOW MANY liters of blood volume is lost?

1. stop the blood transfusion

2. notify physician

3. KVO of plain NSS

Important Nursing Actions during blood transfusion when allergic reactions is suspected!

Penetrating trauma

is one of the leading causes of hemorrhage

crystalloids

what is the fluid management for class I and II hemorrhage?

crystalloid with blood transfusion

what is the fluid management for class III and IV hemorrhage?

gunshot wound

are the leading source of high-velocity penetrating trauma

Acute hemorrhage related to gunshot wound

what is the NURSING DX FOR hemorrhage?

Ballistics

It is the science of the motion of projectiles.

Wound Ballistics

study of projectile penetration of the tissues

1. weight of the bullet

2. velocity

3. gravitational acceleration

KE is computed based on : 3

• caliber of the gun

• type of bullet

• proximity of muzzle to the victim

amount of destruction is directly related to

Kinetic energy

is carried by the bullet and subsequently transferred into the tissues, causes damage in a GSW victim

the greater the kinetic energy of projectile, the greater the wounding potential

what is the RULE IN GUNSHOT WOUND related to severity?

will be transferred to the tissues, more damage

If a projectile does not exit the body, then all its kinetic energy _________

ONLY some of its kinetic energy is transferred to tissues, lesser damage

If the projectile exits the body, then ______

Entrance wound

is called V1 (inlet velocity) as the maximal point of energy

V1 inlet velocity

entrance wound or also known as ?

V2 outlet velocity

what is the exit would

zero or VO (no exit wound)

if the bullet does not exit the body, outlet velocity is

denser tissues like ribs

has a tendency to take up more energy, resulting in greater damage

specific gravity

the greater the _____________ the greater the damage. Example ribs it can shatter and damage nearby tissues!

vital organs

Hollow organs are lesser damage, but it is toxic because it the ______

Blood pressure

is the most important vital sign to be monitored in a patient who has a concussion

privileged communication

Any information shared between a nurse and a patient is considered ____________ and must remain CONFIDENTIAL, cannot be disclosed without the patient’s consent, and the LAW cannot force their disclosure. unless exceptions apply.

Subpoena

is a legal document issued by a court or government agency that commands a person or entity to appear in court, testify as a witness, or produce documents or other tangible objects for a legal proceeding. 

subpoena duces tecum

If a subpoena is issued, you may be legally required to testify or provide documentation. when you provide the patient’s chart what is that called?

breach of confidentiality

If no subpoena exists, voluntarily disclosing the shooter’s identity could be a ____________

Nursing documentation

is very important especially in medicolegal cases. Ensure reliability of contents and proper charting at all times.

subpoena ad testificandum

is a legal order requiring a person to appear in court and testify as a witness.

privileged communication

Anything that may have been divulged to you by the patient is not admissible in court because that is considered as _________

Hypotension

Hemorrhage patients have a risk of _________