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359 Cards in this Set
- Front
- Back
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Best prevention for Hepatitis A & E?
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Hand Washing
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Elevated in PSE?
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Ammonia
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Removal of acidic fluid?
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Paracentesis
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Extensive scarring of the liver?
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Cirrhosis
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Skin sign of clotting disorder?
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Petechiae
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Elevated in jaundice?
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Bilirubin
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4gm daily limit?
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Acetaminophen
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Yellowing of the skin?
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Jaundice
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Post exposure treatment of Hepatitis A & B?
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Immuneglobulin
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Prone to bleeding?
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Varices
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Decreases ammonia in the gut?
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Lactulose or Neosporin
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Test to guide treatment for Hepatitis C?
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Genotyping
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Elicited by having the pt extend arms?
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Asterixis
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Fluid in the peritoneal cavity?
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Ascites
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Avoid for six months after Hepatitis?
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Alcohol
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Results of damage to the liver's parenchyma cells directly or indirectly through obstruction of bile flow or blood supply? (acute or chronic with chronic more common, disease result of bacteria, virus, toxins, medications malnutrition)
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Liver disorder
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Ninth leading cause of death, more men, more African-Americans?
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Liver disorder
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Protein metabolism, low albumin and clotting factors?
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Effects of Hepatocellular failure
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Glucose metabolism - hypo or hyperglycemia (in regards to the liver)?
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Effects of Hepatocellular failure
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Decreased bile, decreased absorption of fats and vitamin k (in regards to the liver)?
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Effects of Hepatocellular failure
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Disturbed conversion of ammonia to urea by the liver?
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Effects of Hepatocellular failure
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Disturbed metabolism and excretion of bilirubin leading to yellow skin, dark urine, clay colored stools and itching, also caused from hemolysis, liver cell damage or obstruction to bile flow?
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Jaundice
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Impaired blood flow through the liver, puts pressure on the portal system, causes varices (especially esophageal), splenomegaly, and ascites (hypoalbuminemia)?
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Portal hypertension
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Elevated in jaundice, hepatitis, cell damage and obstruction?
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Total bilirubin
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Elevated in bile duct damage or obstruction also bone disease?
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Alkaline Phosphatase
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Elevated AST, ALT, GGTP are indications of?
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Liver cell damage
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Liver fails to create clotting factors?
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Liver cell damage
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Ammonia to assess for liver function, electrolytes and glucose, CBC for bleeding and nutritional anemia's?
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Liver labs
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This will show size, presence of ascites, blockages in ducts with doppler for blood flow?
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Abdominal U/S
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This will determine if it is cirrhosis or cancer?
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Liver biopsy
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RUQ pain, anorexia, dark urine, diarrhea, N/V, fatique, jaundice, joint pain?
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Signs and symptoms of Hepatitis
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Increased liver enzymes, ammonia, bilirubin, prothrombin time
decreases in albumin, globulin may have neutropenia or lymphopenia? |
Lab results Hepatitis
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Fecal-oral route?
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Hepatitis A & E
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Blood and body fluids?
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Hepatitis B,C & D
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GI distress, RUQ pain and tenderness, flu like aches?
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Pre-icteric stage of Hepatitis
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Jaundice, pruritis, dark urine, clay stools, increases in preicteric Sx?
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The Icteric stage of Hepatitis
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Labs return to normal, GI symptoms and pain resolve?
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Post-icteric stage of Hepatitis
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Causes may be unknown, usually involves contact with an infected person, food born or water born?
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Hepatitis A
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Incubates for four weeks before symptoms, PT remains infectious for up to ten days after Sx appear?
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Hepatitis A
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Most recover without treatment and become immune, good hand hygiene, sanitary precautions will prevent?
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Hepatitis A
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There is a two dose vaccine available?
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Hepatitis A
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Virus found in the stool before sx?
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Hepatitis A
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Poor hygiene, contaminated water, oral-anal sexual contact linked to outbreaks?
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Hepatitis A
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A positive anti HAV?
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Antibody to Hepatitis A
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Rest, small, frequent low fat meals?
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Tx Hep A
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Rx with an IM immuneglobulin post exposure?
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Hepatitis A
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Through blood and body fluids, including sexual contact with infected persons, needle sharing, acupuncture, hemodialysis, tatooing, piercing?
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Hepatitis B
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Lives 72hrs on surfaces, incubates 30-180 days, assess pt for liver disease and HIV, increased surface antigens before sx appear, symptoms last 4-12 months?
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Hepatitis B
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Three dose vaccine, wash hands, follow blood and body fluid precautions?
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Hep B
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Interferon, lamivudine, famciclovir for 12 months?
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Tx for chronic Hep B
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10% of cases develop into carrier states or chronic liver disease?
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Hep B
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Very similar to Hep A but lasts longer?
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Hep B
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Will perform blood tests to determine disease and carrier status?
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Hep B
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Post exposure will need two doses of immuneglobin?
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Hep B
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Healthcare and public safety workers, recreational IV drug users are at risk?
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Hep C
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After exposure, RNA detected, may be asymptomatic, within 6 months most produce antibodies?
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Hep C
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80% of infected people are asymptomatic?
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Hep C
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Incubation period is 14-180 days, mutating rapidly to multiple strains?
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Hep C
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3.9 million Americans infected, 70% develop chronic liver disease?
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Hep C
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Use safety engineered sharps, contact precautions, and sterilized equipment?
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Hep C
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Interferon, preintergeron alfa-2a and ribavirin
Type 1 is the hardest to treat Antibodies produced in 6 months? |
Hep C
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Quantative testing to determine how much viral load?
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Hep C
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HCV genotyping to assist with tx
Genotype 1 is most common and least respondant to treatment Types 2 & 3 are more treatable? |
Hep C
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Treatments have many complications similar to chemotherapy treatment for cancer?
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Hep C
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A common co-infection with Hepatitis B
Is detected by delta antigens or antibodies May lead to fulminant Hepatitis? |
Hep D
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Sx appear 15-60 days after exposure, incubation period is 2-9 weeks, rare in the US?
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Hep E
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Generally self-limiting
3% of pt's die from dehydration (25% pregnant women)? |
Hep E
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Good handwashing, boil drinking water, avoid ice, thoroughly cook meat and produce
Treat with immunoglobulin post exposure? |
Hep E
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Risk for infection, Hand Washing, Prophylactic, Report disease, Fatigue
You wanna give rest for immune function Nutrition is needed for healing Avoid alcohol for six months or longer May need medication teaching depending on the type? |
Tx of viral hepatitis
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Caused by meds or other substances, alcohol necrosis and inflammation of the liver, acute or chronic ingestion, acetaminophen 4g daily limit, toxins benzene carbon tetrachloride chloroform, poisonous mushrooms?
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Toxic Hepatitis
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Caused by blockage in the flow of bile, usually with a stone or stricture?
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Hepatobiliary Hepatitis
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Is a complication of choleliothiasis or pancreatitis?
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Hepatobiliary Hepatitis
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Removal of stone or insertion of stent sometimes with ERCP will solve the problem?
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Heptobiliary Hepatitis
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Extensive scarring of the liver usually caused by a chronic irreversible reaction to hepatic inflammation and necrosis?
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Cirrhosis
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Complications depend on the amount of damage sustained by the liver?
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Cirrhosis
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In compensation, liver has significant scarring but performs essential functions without causing significant symptoms?
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Cirrhosis
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Portal hypertension, ascites, bleeding esophageal varices, coag defects, jaundice, PSE, hepatorenal syndrome, spontaneous bacterial peritonitis?
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Complications of Cirrhosis or Liver Disorder
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Alcohol, Hep C, autoimmune hepatitis, stetohepatitis (fatty liver), drugs and toxins, biliary disease?
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Causes of liver disease
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Fatigue, weight change, GI symptoms, abdominal pain, liver tenderness, pruritis(due to bilirubin increase)?
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Early signs of liver disease
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Jaundice and icterous (bilirubin), dry skin, rashes, ptechiae, or ecchymosis (clotting), warm, bright red palms of the hands, spider veins (portal HTN), peripheral dependent edema of the extremities and sacrum (low albumin HTN)?
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Late signs of liver disease
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Ascites (low albumin-portal HTN), umbilicus protrusion, caput medusae (dilated abdominal veins), liver enlargement?
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Abdominal assessment of the pt with liver disease
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When liver disease is chronic, the liver will eventually?
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Atrophy
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Assess nasogastric drainage, vomit, stool for blood (clotting factors-varices), breath odor, amenorrhea, gynecomastia, testicular atrophy and impotence, enlarged spleen (portal HTN), neurological changes (PSE), asterixis (PSE)?
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Assessment of liver disease pt
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Enlarged spleen in liver disease is associated with?
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Portal HTN
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Neurological changes and asterixis is assoctiated with?
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PSE
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AST, ALT, LDH, alkaline phosphatase, serum bilirubin and urobili may be elevated
Total serum and albumin levels will be decreased? |
Labs liver disease
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Prothrombin time prolonged
platelet count low Decreased H&H and WBC Elevated ammonia and creatinine? |
labs liver disease
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Low sodium diet with limited fluid intake and vitamin supplementation?
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Liver disease
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Drug therapy are diuretics, aldactone and lasix, electrolyte replacement?
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Liver disease
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Is the insertion of trocar catherter into the abdomen to remove and drain ascitic fluid from the peritoneal cavity?
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Paracentesis
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Must observe for possibility of impending shock?
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Paracentesis
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Pressure sensitive valve for ascitic fluid to go from the abdomen into the SVA?
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Peritoneiovenous shunt
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For dyspnea, elevate the head of the bed at least 30 degrees, or as high as the client wishes to help minimize shortness of breath
Client is encouraged to sit in a chair? |
Ascites
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Weigh client in a standing position because supine position can aggravate dyspnea?
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Ascites
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Radiologist creates a shunt between portal vein and hepatic vein bypassing the liver, may decrease survival and increase PSE bridge to a transplant?
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Transjugular intrahepatic protosystemic shunt (TIPS)
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Reduced platelets and clotting factors, varices which are prone to bleeding caused by portal HTN, decreased bile, less vitamin K?
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Potentials for hemorhage liver disease
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GI hemmorhages increase risk for?
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PSE
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Observe for signs of hemorrhage or shock
Replaced fluids and blood Anti ulcer meds Beta blockers, isordil - decrease portal HTN Give vitamin K and FFP? |
Nursing Care liver disease
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ICU transfer, IV vasopressin or octreotide to reduce blood flow
Endoscopy or sclerotherapy to prevent bleeding Balloon tamponade transfusions? |
Management of Hemorrhage liver disease
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Neurological changes that occur from increased levels of ammonia?
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PSe
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Exacerbated by electrolyte imbalance
GI bleeding High protein diet Infection Meds? |
PSE
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Signs and symptoms include asterixis or liver flap
personality changes changes in mentation and coordination Agitation? |
PSE
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Can progress to confusion, coma, cerebral edema, and death?
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PSE
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Follow ammonia levels
Low protein diet if elevated? |
PSE
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Decreases the ammonia in the gut in PSE or maintenance?
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Lactulose
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Decreases ammonia production in the gut
is an aminoglycoside Measure abdominal girth daily? |
Neomycin, ascites measure abdominal girth daily.
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Pruritis is treated with meds that bind bile acids
it is also important to prevent scratching What are the meds? |
Questran and Benedryl
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Give nutritionally as liver function allows?
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Protein
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Daily weights, monitor renal function (due to risk of failure), abstain from alcohol?
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Liver disease
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One of the most common tumors in the world. Highest in China and the Mediterranean?
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Liver cancer
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80% of these pts have cirrhosis?
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Liver cancer pts
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Monitor alpha-fetoprotein via ultrasound?
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Liver cancer
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Most common complaint is abdominal discomfort, sx of Hepatitis and liver failure?
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Liver cancer
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Tx's are mostly paliative and experimental?
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Liver cancer
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Used in the treatment in end stage liver disease
Primary malignant neoplasm of the liver? |
Liver transplant
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Obtained primarily from trauma victims that have not had liver damage?
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Liver transplant
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Arriving at surgery center in cool saline solution that preserves for up to 8 hours?
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Liver transplant
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Acute, chronic graft rejection
infection, hemorrhage, hepatic artery thrombosis, fluid and electrolyte imbalances Pulmonary atelectasis Acute renal failure Psychological maladjustment? |
Complications of liver transplant
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pH less than 7.35?
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Acidosis
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pH 7.35 - 7.45?
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Normal
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pH > 7.45?
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Alkalosis
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pCO2 > 45?
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Acidosis
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pCO2 45-35?
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Normal
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pCO2 < 35?
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Alkalosis
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Bicarb < 22?
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Acidosis
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Bicarb 22-26?
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Normal
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Bicarb > 26?
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Alkalosis
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pCO2?
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Acidic
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Bicarb?
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Alkaline
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pH?
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Neutral
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Respiratory tract delivers oxygen to the alveoli?
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Oxygen transport
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How many alveoli?
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300 million
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Passage of oxygen and carbon dioxide through a permeable cell wall of the alveoli?
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Diffusion
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Transport oxygen from the environment to the blood
Transport CO2 from blood to environment? |
Ventilation
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Filling of pulmonary capillaries with blood?
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Perfusion
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Low ventilation or high ventilation?
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V/Q mismatch
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Blood return to the left heart without oxygen?
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low ventilation or shunting
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Adequate oxygen with decreased blood supply?
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Dead space or high ventilation
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The ability of the lungs and thoracic structure to stretch?
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Compliance
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Requires more work to breath
Will have increased rate and depth Low compliance? |
Stiff lungs
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Pulmonary fibrosis
Atelectasis Pulmonary edema Pleural effusion Pneumothorax ARDS? |
Complications due to stiff lungs
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Hx, exam,
rate, depth and effort of breaths symetry or presence of orthopnea? |
Respiratory assessment
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Do they have:
Hemoptysis Clubbed fingers Chest pain-BNP Cough Sputum - amount, color Cyanosis? |
Respiratory assessment
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Crackles
Coarse (rhonchi) Wheeze Diminished Absent Stridor (noisy) ? |
Lung Sounds
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Difficult labored breathlessness
C/O shortness of breath Hallmark of respiratory failure Associated with activity Position Sudden or gradual? |
Dyspnea
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Diminshed lung sounds?
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Secretions
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Crackles?
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Moisture
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Absent? (lung sounds)
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Pneumothorax
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Stridor?
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Obstruction in the airway
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Elevate the head of the bed
Give oxygen Conserve energy Give broncodilaters Possible mechanical ventilation Repositioning? |
Interventions for dyspnea (respiratory issues)
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Chest X-ray
ABG CT scan Pulmonary angiogram Bronchoscopy and thorocentesis? |
Diagnostic tests respiratory
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PAo2 < 60
pCO2 > 50 pH <7.3? (perfusion and ventilation failure) |
Acute respiratory failure
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Treat cause
Respiratory support: O2 or vent Bronchodilators Steroids Atibiotics Anxiety agents? |
Respiratory tx
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Maintain oxygen support and safety
monitor for changes in assessment Nutrition Skin care / oral care ROM Pain vs sedation If vented assess readiness to wean? |
Nursing interventions for acute respiratory failure
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Lung response to insult or injury?
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ARDS
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Infiltrates
Alveolar hemorrhage Decreased compliance Refractory hypoxemia? |
ARDS
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Assess for neuro changes
Dyspnea, hyperventilation cough, tachycardia, fever increased vent pressure chest x-ray ABG ? |
Assessment ARDS
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ARDS pt's are at high risk for?
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Infection
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Pulmonary infections are at high risk for?
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ARDS
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High risk
Gram negative bacteria Malnutrition, impaired host decreased muscle strength, cough secretions? |
ARDS and infection
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Client can trigger ventilator to deliver breaths at preset volume or pressure and inspiratory flow rate; breaths will be delivered at preset rate if client does not initiate?
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Assist-control mode ventiliation - CMV
(ACMV)? |
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Mandatory breaths delivered by ventilator are synchronized with client's inspiratory effort?
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Synchronized intermittent mandatory ventilation (SIMV)
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Positive pressure is maintained in airways; all breaths are spontaneous?
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Continuous positive airway pressure (CPAP)
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Used in conjunction with other ventilator modes; positive airway pressure is maintained throughout respiratory cycle?
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Positive end-expiratory pressure (PEEP)
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The belt on address
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PEEP
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OFFERS VENTILATORY SUPPORT WITHOUT INTUBATION
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NIMV
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MASK SECURED TO FACE, BENEFITS MORE COMFORTABLE, LESS RISK OF INFECTION, LESS AIRWAY TRAUMA, MASKS CAN BE REMOVED TO EAT OR SPEAK
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NIMV
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LAST STEP BEFORE INTUBATION, MAY NOT B E ENOUGH
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NIMV
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INVASIVE, CAN BE PLACED ORALLY OR NASALLY
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ENDOTRACHIAL INTUBATION, A TUBE
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CHECK PLACEMENT WITH CO2 DETECTOR
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ENDOTRACHIAL TUBE
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AUSCULATION OF BILATERAL BREATH SOUNDS, CHEXT X-RAY, CHECK WITH CO2 DETECTOR
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CHECK PLACEMENT OF AN ENDOTRACHIAL TUBE
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SECURE WITH TAPE OR HOLDER, NUMBER ONE PRIORITY IS PRESERVATION AND SAFTEY OF
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ENDOTRACHIAL TUBE
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May need to sedate, restrain?
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Preservation of endotracheal tube
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Will place within eleven to fourteen days or two weeks after intubation?
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Trach
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Controls breathing through positive pressure system
Pushes air into the lungs? |
Ventilator system
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Will have doctors orders for rate, tidal volume, O2 concentration, inspiration/expiration ratio, and pressure?
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Ventilator
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Barotrauma?
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Hole blown through pt's lung. Pressure set to high.
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RT will take blood gases when?
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The pt's settings are stable
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Monitor tube, O2 saturation, lung sounds, mentation, VS, sedation, secretions, ventilator compatibility (do they need to be paralyzed?), will monitor all parameters every 1 to 2 hours?
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Monitoring the pt on a ventilator
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Examples of low ventilation would be?
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Asthma
Pneumonia |
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Test lookin for a pulmonary embolism?
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Pulmonary arteriogram
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Procedure that requires sedation and a physician to get a closer look at the bronchioles and possible biopsy?
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Bronchoscopy
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Bedside procedure to relieve the lungs of fluid and perform cultures?
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Thoracentesis
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Treatment for the pt with ARDS and respiratory failure is the same except for?
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ARDS pt gets surfactant
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NIMV?
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Non-invasive mechanical ventilation
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CMV?
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Control Mode Ventilation
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The ventilator decides everything?
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CMV mode
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The pt can trigger a breath and then the machine takes over
If the body chooses not to breath, the machine will take over and deliver a breath? |
Assist control
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Pt allowed to take their own breath and then machine synchronizes to that breath?
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SIMV
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Setting on the ventilator where the pt will do the breathing
If the pt chooses not to breath, the ventilator will not breath for them (can be used as weaning mode)? |
CPAP
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Pt has to initiate a breath but when they do there is a pressure behind the breath delivered by the ventilator. This is all about the force behind the breath?
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Pressure control
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Added to a mode
Keeps the alveoli from collapsing so that air can get in Positive and expiratory pressure Can cause barotrauma? |
PEEP
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Just oxygen for weaning off a vent
ET tube still in place? |
T piece for weaning
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Vent weaning choice?
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CPAP
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Vent weaning choice?
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Pressure support
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Increased RR
Tachycardia Increased BP Decreased O2 saturation Mentation ABG's ? |
Vent weaning assessments
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Purposely paralyzed or sedated pts should be assessed for mentation how often?
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Every shift
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Impaired pts and pooled secretions
Mechanical ventilation? |
Risk factors for hospital acquired pneumonia
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Assess for lung sounds, sputum, fever, O2 sat, CXR, ABG, Sputum culture, WBC?
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Hospital acquired pneumonia
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leading cause of death in hospital acquired infections?
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VAP
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Mortality rate is 46%?
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VAP
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Prolongs hospitalization and ads an estimated >$40,000 dollars to hospital stay?
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VAP
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Elevate HOB for a goal of 45 degrees
continuously remove subglottic secretions Changing of circuit systems no oftener than q48hrs Hand washing before and after contact? |
VAP preventative care bundle
how to prevent ventilation acquired pneumonia |
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Suction with closed system for removal of secretions
Oral care q 12h Assess level of gastric content, and stress ulcer prophylaxis? |
Additional Preventative Care VAP
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To prevent aspirated pneumonia?
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Assess level of gastric content.
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Any pt in the hospital is at risk for stress ulcers and will need?
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Ulcer prophylaxis
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Fluid and Electrolyte management
Nutrition Antibiotics? |
Treatment for VAP
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Leading cause of VAP?
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Gram Negative Bacteria
Drug resistant bacteria |
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25% of traumatic deaths result from?
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Chest trauma
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Chest Trauma
A bruise to the lung? |
Pulmonary contusion
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Chest Trauma
Most common? |
Rib fracture
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Chest Trauma
A group of ribs that have been disconnected from the sternum? |
Flail chest
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Hard to determine extent of injury
possible bleeding in the lungs possible hypovolemic shock possible cardiac tamponade ? |
Challenges in chest trauma
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Treat promptly
Look for evidence of rib fractures Maintain airway/assess for hemoptysis May need surgery or ventilator ? |
DX TX Chest Trauma
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Risk for contusion or pneumothorax
Must treat pain Possible flail chest Need respiratory support Fluid electrolyte management? |
Rib fractures
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Surface layers that are keratinized?
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Epidermis
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Dense fibro-elastic connective tissue containing glands and hair follicles (does not grow back when lost)?
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Dermis
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Loose connective tissue consisting largely of adipose tissue?
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Hypodermis
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Barrier to infection?
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Skin
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Aesthetic containment?
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Skin
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Has sensitivity to light and deep touch
hot, cold and pain Temperature regulation Metabolic function - vitamin D production? |
Skin
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Burns from hot liquids?
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Scald
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Burns from direct contact with flame?
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Flame
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Burn from an explosion?
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Flash
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Burn from contact with chemicals?
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Chemical burn
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Burn from touching a hot object?
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Contact burn
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Burns from lightening
residential and industrial services? |
Electrical burn
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Dry, red, painful, blanching, (e.g. sunburn)?
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Superficial first degree burn
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Upper one third of the dermis
blisters, red, wet, painful, blanching is evident, heals in seven to fourteen days with minimal scarring? |
Superficial partial second degree burn
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Deep dermal involvement
blisters red or pink slow or absent blanching decreased sensation heals in 21 days or more may convert to a full thickness burn? |
Deep partial second degree burn
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Loss of all dermal elements and epithelial appendages
dry, leathery, firm, no blanching & insensate? |
Full thickness third degree burn
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Coagulation
Stasis Hyperemia ? |
Burn Zones
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Dead and will not heal?
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Zone of Coagulation
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Must keep balanced
good care will prevent coagulation? |
Zone of stasis
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Stable for the most part
will heal, must maintain? |
Zone of Hyperemia
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Surface area covered by a pts hand with fingers closed, whether adult or child?
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1%
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Adult arm surface area?
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9%
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Adult head surface area?
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9%
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Adult neck surface area?
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1%
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Adult leg surface area?
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18%
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Adult anterior trunk or posterior trunk surface area?
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18%
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Child head and neck surface area?
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18%
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Child arm surface area?
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9%
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Child leg surface area?
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14%
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Child anterior or posterior trunk surface area?
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18%
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ABC's/stop the burning process
Universal precautions Airway management Circulatory management One or more large bore IV's Initiate fluid resuscitation? |
Initial care of a burn pt
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Temperature and time exposure?
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What determines burn depth
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It is important to avoid in burn pts?
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Hypothermia
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Burns and trauma
ABC's of trauma take precedence When in doubt? |
Immobilize
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Water leaks from intravascular space to interstitial space resulting in what in burn tissue?
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Edema
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Maintain adequate urine output
30ml hr for adults 1ml per kg per hour for children Myoglobinuria 75ml/h? |
Fluid resuscitation burn pt
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Maintain adequate peripheral perfusion and adequate organ perfusion?
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Goal of fluid resuscitation burn pt
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Associated injury
Electrical Inhalation Delayed resuscitation Prior dehydration Alcohol/drug dependency or use Very deep burns? |
Pt Factors r/t increase in resuscitation requirements
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Burn PT
Shock (distributional vs. hypovolemic) Renal failure? |
Inadequate resuscitation
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Burn PT
Increased Edema Decreased in peripheral perfusion Pulmonary edema Cerebral edema Abdominal Compartment syndrome? |
Excessive resuscitation
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Diuresis and decrease in edema is seen 12-36 hours after what is reestablished?
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Intravascular flow
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Injury in an enclosed space
singed nasal hair cabonaceous sputum brassy or sooty cough hoarsness or stridor? |
Inhalation injury
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Approximately 250 times the affinity for hgb as oxygen
Must get O2 on? |
Carbon Monoxide
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Caused by thermal injury when the pt inhales super heated air?
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Injury above the glottis
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Caused by chemical injury when a pt inhales smoke from a fire?
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Below the glottis
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Burn PT
Decreased O2 delivery Decreased tissue perfusion r/t vasoconstriction Increased DVT and PE? |
Hypothermia
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Surgical release of eschar through circumferential full thickness burns to restore circulation?
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Escharatomies
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Partial thickness greater than 10%
Face, hands, feet or genitalia Full thickness any age Electrical or lightning Chemical inhalation Pre-existing D/O Trauma Social, emotional or rehabilititative intervention? |
Triage to a burn center
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Most common type of child abuse?
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Scald burns
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Typically involving the feet, legs and buttocks
Sparing in popliteal and groin areas Will have a straight line of demarcation with no splash marks? |
Abusive Scald burns
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Flow like pattern
Splash marks ? |
Accidental scald marks
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Contact
Low tension: 110-220 volts High tension: >1000 volts Electrical flash? |
Electrical injuries
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Surgical release, incision made to the faschia in order to release a compartment syndrome
Common to electrical injuries? |
Faschiotomy
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Acids - rust remover, drain cleaner & swimming pool cleaner
Alkalis - paint remover, drain and oven cleaner, cement and fertilizers Organics - gasoline and diesel ? |
Chemical burns
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Irrigate with copious amounts of water! (Moran lens for chemical eye burns)
? |
Treatment for chemical burns
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Extremes of age
Infection Nutrition Pressure Hypothermia ? |
Factors affecting burn wound conversion
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Gentle debidement
Repeated gentle debridement of burn wound is more effective than a singularly overaggressive approach? |
Burn wound care
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Wash wounds gently with warm water and antimicrobial soap
Use 4x4's or fingertips in a circular motion ? |
Burn wound care
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If transfer to burn center is greater than 24 hours remove large blisters that are?
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Greater than 2cm
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Removal of healing skin
damage to new blood vessels slow the wound closure? |
Too vigorous of debridement
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Autograft - meshed sheet
Allograft - cadaver skin Xenograft - pig skin Donor Sites ? |
Split-Thickness Skin Grafting (STSG)
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Prevent contractures by maintaining position and function
Restore function Return to work Best appearance possible ? |
Goals of rehabilitation
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These help flatten scars during the healing process which can take up to 1 year?
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Compression garment
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Oxygen delivery to the lungs
Circulation carried by hemoglobin Container is vascular bed Pump is the Heart ? |
Tissue Oxygenation
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Vascular bed increase
Blood volume decrease Pump failure ? |
Shock
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Sympathetic stimulation causes?
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Vasoconstriction in the vascular bed.
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Parasympathetic stimulation causes?
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Vasodilation in the vascular bed.
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Impaired tissue oxygenation
Anaerobic cellular function Impaired tissue function ? |
Common problems with shock
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Severity of the cause
Degree and success of compensation Success of intervention Preexisting state of health ? |
Things that affect the progression of shock
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A sustained decrease in MAP is triggered
Decreased tissue perfusion Anaerobic metabolism (lactic acid) Cellular dysfunction Organ failure Death ? |
The process of shock
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Fluid volume loss, blood loss, hemorrhage?
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Hypovolemic Shock
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Pump failure?
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Cardiogenic Shock
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Spinal cord injury
Pain and stress Loss of ability to maintain vascular tone? |
Neurogenic Shock
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Shock caused by an infection?
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Septic Shock
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Shock caused by an allergic reaction?
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Anaphalactic Shock
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Compensatory
Progressive Refractory (irreversible) ? |
Stages of Shock
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Begins after MAP falls 10 to 15mmHg
Circulating blood volume is reduced by 25-35% Able to maintain blood pressure and tissue perfusion to vital organs, thereby preventing cell damage? |
Compensatory stage of shock
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Stimulation of the sympathetic nervous system releases epinephrine from the adrenal medula and releases norepinephrine from the adrenal medula, causing vasoconstriction in the blood vessels?
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Compensatory stage of shock
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Renin angiotensin response occurs as the blood flow to the kidneys decreases?
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Compensatory stage of shock
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The hypothalmus triggers the release of aldosterone which promotes the reabsorption of water by the kidneys?
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Compensatory stage of shock
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The posterior pituitary gland releases antidiuretic hormone which increases renal reabsorption of water to increase vascular volume?
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Compensatory stage of shock
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As MAP falls, decreased capillary hydrostatic pressure causes a fluid shift from the interstitial space into the capillaries?
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Compensatory stage of shock
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Working together, mechanisms maintain MAP for a short period of time, perfusing the heart and brain
Unless shock is reversed, permanent damage will occur? |
Compensatory stage of shock
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Occurs after a sustained decrease of MAP of 20mmHg or more below normal levels and a fluid loss of 35-50%?
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Progressive stage of shock
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Compensatory mechanism no longer able to maintain MAP at a perfusing level?
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Progressive stage of shock
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The vasoconstrictive response that first helped sustain MAP limits blood flow to the point that cells become oxygen deficient
Affected cells switch from aerobic to anaerobic metabolism? |
Progressive stage of shock
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Throughout this period, vasoconstriction is increased
Perfusion is diminished Tissues become ishemic and anoxic PT will be acidic and hyperkalemic ? |
Progressive stage of shock
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Shock progresses to an irreversible stage
Anoxia is generalized Cellular death is widespread Damage cannot be reversed Death of cells Death of tissue Death of organs Death of the body ? |
Refractory stage of shock (irreversible)
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BP decrease of 10mmHg
Tachycardia Vasoconstriction Anaerobic metabolism Lactic acid production ? |
Shock Stimulus compensatory
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These have baroreceptors that are sensitive to blood pressure?
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The aortic arch and the carotid sinus
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When the aortic arch and the carotid sinus note a drop in blood pressure, they will initiate vasoconstriction and shunting of blood to which vital organs?
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The brain and the heart
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Changes may be subtle
Mild heartrate increase Respiratory rate increase Diastolic bp increase Pale cool skin Thirst and decreasing urine output? |
The beginnings of shock
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Arterial BP decreases 10-15mmHg
Renal barorecptors sense pressure change Hormone secretion ? |
Compensatory pathophysiology
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Pale skin
Muscle weakness Less urine output Decreased bowel sounds ? |
Non vital organs in the early stages of shock
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Retention of sodium, water
decrease in urine output ? |
Renin, ADH, Aldosterone
Action of hormones in shock |
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Vasoconstriction and increased shunting
Increased tissue hypoxia? |
Epinephrine and norepinephrine hormone action in shock
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Respiration increases because the alveoli aren't being perfused
Oxygen is not getting in so CO2 is not getting out, causing? |
Respiratory acidosis
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Metabolism in shock is producing lactic acid causing?
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Metabolic acidosis
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Anxiety, restlessness, lethargy, tachycardia, decreased blood pressure
weak, thready pulse, increase in respiratory rate/depth, crackles Decrease in UOP, cool, pale skin Decreased bowel sounds ABG are gonna show metabolic acidosis Increased potassium and abnormal glucose ? |
Assessment in compensatory stage of shock
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Oxygen, frequent assessments
Start NS or LR Correct their chemistry Call the doctor Treat the cause In this stage the process is still reversible? |
Intervention to compensatory stage of shock
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MAP is less than 20 from baseline
Compensation no longer delivering oxygen to vital organs Capillary permeability Hypoxia progresses to anoxia Ischemia, CELL DEATH IS LIFE THREATENING ? |
Progressive shock
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Peripheral pulses may be absent
Edema Increasing metabolic acidosis Decreased blood pressure, CO, LOC Increasing heart rate and respirations Anuria? |
Findings in Progressive shock
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O2
All systems are now involved Resolve the cause Drug therapy, dopamine for low bp Move to ICU Fluid therapy is not enough? |
Intervention for progressive shock
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Gonna give:
Dopamine Epinephrine Levophed Neosynepherine ? |
Vasoconstrictors given for progressive shock
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Atropine
Dobutamine Milrinone ? |
Contractility enhancing drugs given in progressive shock
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Nitroprusside
nitroglycerin ? |
Vasodilators used in titration to balance vasoconstriction in shock and they are used to perfuse the coronary arteries
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Colloids and crystalloids are volume expanders given in?
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Shock
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Incredibly sensitive drug used to perfuse the coronary arteries
Must titrate up a tiny bit at a time? |
Nitroprusside
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Albumin
Dextran Hetastarch Volume expanders Usually 5% ? |
Colloids
Crystalloids |
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I/O very important
Must use a foley and NG tube to monitor? |
Pt in shock
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Massive release of toxic metabolites
No response to intervention Multiple clot formation Ischemic pancreas releases myocardial depressant factor Respiratory failure Reduce coronary profusion Cerebral ischemia ? |
Refractory or irreversible stage of shock
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Multiple organ system failure and death?
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Refractory or irreversible stage of shock
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Dehydration
NPO, NG tubes, diuretics, vomiting, capilary leaking, blood loss, trauma, surgery, GI bleeds, anticoagulants? |
Causes of hypovolemic shock
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Look at vital signs, O2 saturations, bowel sounds, respirations, levels of consciousness, weakness, decreased urine output, dry skin, signs of bleeding?
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Hypovolemic shock assessment
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Impaired tissue perfusion
Decreased cardiac output Disturbed thought process DEFICIENT FLUID VOLUME ? |
Nursing diagnosis hypovolemic shock
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Restore volume
Reverse shock ? |
Goals in hypovolemic shock
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Stop bleeding
Replace fluids Replace electrolytes Use plasma expanders whole blood products Oxygen support and drug therapy? |
Interventions to hypovolemic shock
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Don't be taking lots of blood labs on a pt that is?
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Hypovolemic
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Pump failure
rapid onset high mortality ? |
Cardiogenic shock
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Myocardial infarction
Cardiomyopathy infection Valve disorders Heart failure ? |
Causes of cardiogenic shock
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Dysrhythmias
Drugs Cardiac Tamponade Cardiac Arrest ? |
Causes of cardiogenic shock
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statistical significance (< 0.05 level of significance)
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This is said to exist when the probability that the observed findings are due to chance is very low.
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Decreased urine output
Cold clammy skin Agitation, confusion Pulmonary congestion ? |
Findings in cardiogenic shock
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Altered tissue profusion
Impaired cardiac output Impaired gas exchange PAIN ? |
nursing diagnosis cardiogenic shock
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Increased cardiac output
Relieve pain Decrease need for oxygen Support cardiac pressure Profuse tissues Decrease heart rate ? |
Intervention goals for cardiogenic shock
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Different from other types
has two phases ? |
Septic shock
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First stage has long subtle changes?
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Septic shock
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Second stage has a sudden onset with rapid downhill progression - SIRS
Abnormal clotting ? |
Septic shock
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Bacteria gram
Virus Fungi ? |
Common causes of septic shock
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Hypotension, tachycardia, tachypenia, increased temperature, bounding temperatures, warm flush skin, irritability, restlessness, disorientation?
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Findings in septic shock
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Increased WBC
Decreased fibrogen and platelets Increased D-Dimer ABG's will show respiratory alkalosis ? |
Lab findings septic shock
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Activated protein C
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Xigris
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Important intervention in shock?
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Activated protein C
Xigris |
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Increased D-Dimer indicates a decrease in activated protein C, will result in?
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DIC
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oxygen
Cultures Antibiotics IV fluids Tylenol Vasopressors Xigris ? |
Septic shock interventions
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Change tubing caps
Change IV sites Change dressings Nurse and pt hygiene #1 handwashing ? |
Preventative care
Septic shock |
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Thousands of tiny clots
Clotting factors are all used up Hemorrhage - give platelets, FFP, blood Protein C - Xigris ? |
DIC
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Chemical induced
Sever Antigen/Antibody reaction Rapid onset ? |
Anaphylactic shock
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Massive histamine reaction
Decreased cardiac contractility Bronchiole infalmmation oxygen obstruction Edema Blood vessel dilation and collapse Dysrhythmia ? |
Anaphylactic shock
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Panic
Gasping Bradycardia Hypotension Loss of consciousness and death ? |
Anaphylactic shock
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Maintain airway/oxygen
Fluids, give epinephrine Vasoconstrictors, steroids, benadryl Cardiac contractility medications ? |
Anaphylactic shock
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Fluid shift
Capillary pores enlarge Fluid shifts out of cells and vascular bed and going into intracellular space (3rd spacing) Edema ? |
Capillary leak syndrome
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Loss of sympathetic stimulation
Loss of arterial blood pressure Muscle relaxation in blood vessel walls Causes CNS injury, Pain, Anesthesia, Stress ? |
Neurogenic shock
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Assess
Organize and implement interventions Evaluate response Provide emotional support ? |
Nursing care plan for shock
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