Critical Care Nursing Test 1 Shock

Front 1

Cardiac output formula

Back 1

CO = HR X SV

Normal = 4.0 to 8.0 Liters/min

Front 2

Left ventricle resistance to eject blood from heart

Back 2

SVR

Front 3

Reflects volume in R side of the heart

Back 3

Central Venous Pressure

Front 4

Volume of left side of heart

Back 4

Pulmonary Artery Pressure

PAS = systolic
PAD = diastolic

Front 5

Volume of filling of ventricle (heart stretch)

Back 5

Preload

Front 6

Resistance Left ventricle must overcome to circulate blood (as it contracts)

Back 6

Afterload

*increased in HTN, Vasoconstriction

Front 7

Difference between systolic and diastolic BP

Back 7

Pulse Pressure

Norm = 30mm - 40mm

Front 8

Average pressure which blood moves through the vasculature

Back 8

Mean Arterial Pressure

Norm = 70 - 105 mmHg

Front 9

MAP Formula

Back 9

systolic + (diastolic X 2) / 3

*next to BP on monitor

Front 10

Volume that leaves the heart when L ventricle contracts

Back 10

Stroke Volume

Normal = 70ml

Front 11

Signs of Shock (decrease in Mean Arterial Pressure)

Back 11

Early
Compensatory Signs
Progressive Signs
Refractory Signs

Front 12

Actual vs Relative Hypovolemic Shock

Back 12

Actual: blood or fluid leaving the body
• Intravascular volume deficit from an external source
• Ex: hemorrhagic and dehydration
Relative: the fluid is in the body but in the wrong place
• Intravascular volume deficit secondary to fluid shift into the interstium
• Ex: burns and ascites

Front 13

Type of actual hypovolemic shock

Back 13

Hemorrhagic Shock

*acute loss of blood volume

Front 14

Treatment of the 4 types of Hemorrhage

Back 14

• Class One
1. Less than 750ml’s blood loss
2. Normal vitals but anxious
3. Treat with crystalloids (LR and Normal Saline 0.9%NSS)
• Class Two
1. 750-1500 ml’s blood loss
2. Heart rate high, BP normal delayed capillary refill, 20-30 bpm, 20-30 ml’s per hour urine output(decreased), still anxious
3. Treat with crystalloids
• Class Three
1. 1500-2000 ml’s blood loss
2. Heart rate 121-140, BP low, delayed capillary refill, 30-40bpm, 5-15 ml’s urine output per hour(decreased) but now confused
3. Treat with crystalloids and blood

• Class Four
1. >2000 ml’s blood loss
2. Heart rate>140, BP 50-60 > 35 bpm, scant to no urine output per hour, now lethargic
3. Treat with crystalloids and blood

Front 15

Management of Hemorrage

Back 15

* control the source
* Restore O2 transport
* Provide metabolic/nutritional support
* Support individual organs/systems
* Control pain

Front 16

Management of Acute Hemorrage

Back 16

AirwayBreathingCirculationDisabilityExposure
• Give 02 to maintain pO2>80mmHg and O2 sats >94%; begin with 40% O2 via face mask
• Use the modified trendelenburg position( lower the head of the bed 20 degrees) to increase circulation
• Also can use pressurized suits such as PASG or MAST
• Ensure adequate vascular access by 2 large bore IV’s and type and cross blood type

Front 17

Indicated for anemia, O2 carrying capacity deficit, bleeding and surgery

Back 17

Blood Transfusions:
• 15 ml’s per every 15 mins usually to be given over no more than 4 hours
• Usualliy if it goes ok for the first 15 mins things are ok
• If a massive transfusion warm blood to prevent dysrhythmias and give platelets or fresh frozen plasma for every 10 units of RBC’s

Front 18

Types of Transfusion Reactions

Back 18

Acute Hemolytic
Febrile
Allergic
Overload
Sepsis

Front 19

Types of blood components

Back 19

Packed red blood cells
• Increase O2 carrying capacity
• 1 unit increases hemoglobin 1g and hematocrit 2-3%
• Normal hemoglobin in 11-13%
Whole blood
• Contains everything
Platelets:
• Give when low or a massive bleed
• Aides in clotting should be >10,000
Fresh Frozen Plasma
• Gives coagulation factors
Albumin
• For volume expansion
• A colloid so it draws fluid into the blood vessels
• Human plasma that is heated
Cryoprecipitate
• Fibrinogen, factor 1-8 and von Wildebran factor
Artificial Polyheme
• May cause an MI because it increases blood viscosity

Front 20

Blood transfusion procedures

Back 20

• Consent signed
• Determine pt’s allergies and previous transfusion reactions
• Need orders *check dr’s order*
• Educate the pt
• Wash hands
• check cross match with another nurse looking 4 ABO group, RH type, client’s name, hospital #, and expiration date * on blood bag & client’s ID *
• administer immediately after receiving
• don’t warm unless risk of hypothermic response (then only with specific blood warmer)
• hang only with NSS * never add any meds to blood products*
• infuse over NO MORE than 4 hours
• take baseline vitals and 15 mins after
• use an 18 gauge needle
• change blood filter and tubing after every unit of blood
• Severe reactions most likely first 15 mins & first 50 ccs

Front 21

What do you do if transfusion reaction?

Back 21

STOP blood
*maintaine line with NSS
*Should occur within the 1st 15 mins or 50cc’s
*Change IV tubing
*Treat shock if present with Epi O2 and fluids
*Recheck cross match record with unit

Front 22

Types of Transfusion reactions

Back 22

Acute Hemolytic
• most severe
• causes cardiac arrest
• caused by ABO incompatibility reaction, destroys RBC’s
• s/s: fever, chills, flushing, tachycardia, hypotension, vascular collapse, low back pain
• to determine if the patient has this a urine sample in needed to check for hemoglobin uremia
Febrile
• most common
• a reaction to the antibodies in the donors WBC’s in the blood
• more common in those who have had a previous blood transfusion
• s/s: fever and chills w/o cardiac collapse
• treat by giving washed RBC’s
Allergic
• mild reaction
• sensitive to foreign proteins
• s/s: hives, uticaria, fever, flushing
• may treat with benedryl prior to prevent
Volume Overload
• too much preload
• blood is a colloid so it draws fluid into the blood
• give at a slower rate
• give Lasix to help with fluid
• s/s: pulmonary congestion, SOB, distended neck veins, railsm pink frothy sputum, restlessness, and hypertension
• treat by increasing the head of bed, morphine administration, give 02
Bacteremia/sepsis
• very rare
• bacterial cont. blood
• Infusion infection
• Fever, chills, vomiting, diarrhea, shock
• Treat with extra antibiotics, fluids, and vasopressors to increase the BP and send extra blood back to the lab

Front 23

Transfusion Reaction with facial flushing, hives/rash/urticaria, pruritus, severe SOB, bronchospasm

Back 23

Allergic

Front 24

Transfusion Reaction with low back pain, hypotension, burning sensation along vein, fever & chills, chest pain, tachypnea, tachycardia, apprehension, hemoglobinuria, immediate onset

Back 24

Hemolytic

Front 25

Transfusion Reaction with chills, fever, h/a, flushing, nausea, vomiting, increased anxiety, tachycardia, tachypnea

Back 25

Febrile

Front 26

Do if suspected hemolytic reaction

Back 26

Obtain 2 blood samples distal to infusion site

Obtain first UA test for hemoglobinuria

Give Mannitol with suspected renal involvement

Monitor fluid/electrolyte balance

Evaluate serum calcium levels

Front 27

Types of Shock

Back 27

Hypovolemic
--actual
--Relative
Cardiogenic
Distributive (circulatory)
--Neurogenic
--Septic
--Anaphylactic

Front 28

Type of Shock which is an antigen/antibody reaction
**and the sooner the symptoms appear the worse the reaction

Back 28

Anaphylactic Shock

Front 29

Types of Distributive (circulatory shock)

Back 29

Anaphylactic
Septic
Neurogenic

Front 30

Do to prepare for transfusion

Back 30

• Have Epi near
• O2 available
• Plan to withdraw blood
• Urine sample
• Insert a foley

Front 31

Type of Shock in which

All the volume is there but the heart can not pump it out

Decreased stroke volume

Pump failure is the cause not a problem in the vascularity

Back 31

Cardiogenic Shock

Ex: myocardial infarction, pericardial tamponade, and cardiomyopathies

Front 32

S&S of Cardiogenic Shock

Back 32

• Crackles in lungs especially the bases
* Pink frothy sputum
• Chest pain
• S3 and s4 heart sounds (Extra Heart Sounds – Gallops)
• Dysthrythmias
• Decreased CO
• Increased SVR

Front 33

Treatment for Cardiogenic Shock

Back 33

Limit fluids
IV's at KVO - Fluids of choice low in sodium

Drugs:

• Inotropic agents: increase the force of contractions
1. Digoxin IV if levels are subtherapeutic; only push
2. Dobutamine IV drip
• Preload and Afterload reducing agents
1. Diuretics such as Lasix (reduce preload)
2. IVP Morphine (decreases afterload)
3. Nitroglycerine drip (vasodilator)
*may also treat with oxygen

Temporary Mechanical Devices to treat with:

Intra aortic ballon pump (IABP)
• Cath with balloon inserted into aorta
• Balloon inflates during LV diastole
• Decreases LV afterload
• Increases coronary artery perfusion
VAD(ventricular assist device)
• short term
• external pumps may lead to coag problems

Front 34

S&S of Anaphylactic Shock

Back 34

• uneasiness
• uticaria (1st sign)
• hypotension
• tachycardia
• wheezing dyspnea
• stridor
• vomiting
• incontinence
* Edema of lips, tongur, periorbits

Front 35

Treatment for Anaphylactic Shock:

Back 35

• remove source
• ephinephrine
• airway open
• teach family to avoid, carry epi pen and wear a medical alert bracelet

Front 36

Shock that results from microorganism invasion
**most are gram negative

Back 36

Septic Shock

Front 37

S&S of Septic Shock

Back 37

Differential S/S:
• temp may be high or low
• WBC’s > 12,000 or <4,000 with bands >10%
• Increased urine output
• N/V
• Increased respiratory rate
• Bounding pulses
• Sweating

In Hyperdynamic Phase S/S:
• decreased BP or normal
• decreased SVR
• Increased CO
In Hypodynamic Phase
• Irreversible
• Decreased BP
• Increased SVR due to blood vessels clamp down to get blood to vital areas
• Decreased CO

Front 38

Treatment of Septic Shock

Back 38

• Identify the source by C&S’ing everything “PAN” culture
• Antibiotics
• Vasopressors such as dopamine and norepinephrine (Levophed) to decrease the HR and increase BP
• Also may give Xigis to prevent death from Severe Septic Shock

Front 39

Septic Shock but unable to find cause

Back 39

Systemic imflamatory response

Front 40

Rare type of shock that results from acute loss of sympathetic tone, begins within minutes and can last for weeks

Etiology
• Spinal cord injury above T6
• Spinal anesthesia
• Drugs
• Stress/pain

Back 40

Neurogenic Shock

Front 41

S&S of neurogenic shock

Back 41

• Decreased BP
• Decreased HR
• Decreased CO
• Decreased SVR
• Poikilothermia: warm dry flushed skin d/t loss of tone (take temp of environment)
• Usually hypothermic

Front 42

Treatment for neurogenic shock

Back 42

• judicious use of fluids
• vasopressors to increase BP
• Atropine IVP and maybe Isuprel IV drip to increase HR
• Cautious ambient temp regulation

Front 43

An abnormality of the circulatory system that results in inadequate cellular perfusion (BP not adequate to take O2 to organs)

Back 43

Shock

Front 44

Type of shock that causes decreased intravascular volume

Back 44

Hypovolemic

Front 45

Type of shock that causes decreased stroke volume (not a good cardiac output)

Back 45

Cardiogenic shock

Front 46

Type of shock that causes decreased Systemic Vascular Resistance (SVR) - vessels enlarging due to no resistance

Back 46

Distributive

Front 47

Types of Distributive Shock (some volume of blood but not enough to get it to body)

Back 47

Neurogenic

Septic

Anaphylactic

Front 48

Blood loss volume in classes of hemorrage

Back 48

Class I: <750mls
(crystalloid- LR or NSS)
Class II: 750 - 1500mls
(crystalloid)
Class III: 1500 - 2000mls
(crystalloid & blood)
Class IV: >2000mls
(crystalloid & blood (colloid))

Front 49

Blood types

Back 49

A+or-
B+or-
AB+or-
O+or-

Front 50

What does + or - mean on blood type

Back 50

If the patient has the Rh antibodies or not

Front 51

Universal Donor

Back 51

O-

Front 52

Universal Recipient

Back 52

AB+