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83 Cards in this Set
- Front
- Back
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Define Shock.
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Syndrome characterized by decreased tissue perfusion & impaired cellular metabolism
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What are the two types of shock?
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Cardiogenic & Hypovolemic
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Cardiogenic shock can be caused by _________ or _________ dysfunction, resulting in compromised _______ _______.
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1) Systolic
2) Diastolic 3) Cardiac Output |
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List at least 3 precipitating causes of systolic dysfunction.
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1) MI (Myocardial Infarction)
2) Cardiomyopathies 3) Severe HTN 4) Blunt Cardiac Injury 5) Cardiac depression from sepsis |
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Diastolic dysfunction (impaired _______) results in a decrease of what cardiac action?
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1) ...filling
2) Stroke Volume |
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What are some early manifestations of Cardiogenic shock?
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1) Tachycardia
Hypotension Narrowed pulse pressure Increased myocardial O2 consumption Pulmonary congestion & crackles |
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Define Hypovolemic shock.
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Loss of intravascular fluid volume.
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What are absolute and relative volume loss?
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Absolute: blood/fluid is lost from the system
Relative: blood/fluid is re/misdirected within the system |
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Blood volume loss greater than what percent MUST be replaced regardless of other health factors?
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30%
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What signs and symptoms might a patient with hypovolemic shock display?
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1) Impairment of cognitive function
2) Decreased temperature 3) Slower capillary bed refill 4) Pallid colour of skin |
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What is the cornerstone of therapy for fluid replacement in a patient?
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Volume expansion with the administration of appropriate fluid
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What determines the choice of fluid replacement?
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Type & volume of fluid lost.
Patient's clinical status. |
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Describe the following for Normal Saline:
1) ___% NaCl 2) Mechanism of Action in body 3) Main Function/Use 4) Type of Shock used for |
1) 0.9% NaCl
2) fluid remains in intravascular space 3) initial volume replacement 4) most types of shock |
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What are the 3 main desired outcomes of transfusions?
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1) Maintain/replace lost blood
2) Provide deficient blood elements & improve coagulation 3) Maintain/improve O2 transport |
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Name and briefly describe 3 types of blood products, including the typical amount (mL) of one unit of each.
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1) Red cell concentrate (Packed RBCs)
-preferred for RBCs bc. component specific -200-250mL 2) Fresh Frozen Plasma (FFP) -rich in clotting factors -200-250mL 3)Platelets -can be kept @ room temperature for <5 days -30-60mL |
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When must the specimen collection occur within 96 hours prior to the scheduled transfusion?
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-recipient has been transfused within the past 3 months
-recipient has been pregnant within the past 3 months |
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For peripheral administration, what type of blood administration set and filter should be used?
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Y-type with 170-260 micron filter
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When administering blood products, how often should the tubing be changed?
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q24h or after 4 units of red cells
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Blood must be used within ____ minutes of removal from the Blood Bank.
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30 minutes
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What is the range of transfusion time for a unit of blood product?
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2 to 4 hours
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What would you look for when checking blood components before use?
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1) Signs of deterioration
2) Leakage* 3) Correct identification of patient (wrist band) 4) Matching labeling of blood pack on front and back. 5) Corresponds with Doctor's order 6) Color in bag and tubing segments is similar 7) Label: ABO, product number, expiry date *see next question |
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Describe the unique inspection steps for the following:
1) Red Cells 2) Plasma/cryoprecipitate 3) Platelets |
1) Black or purple coloring (hemolysis); large clots
2) murky/grayish (bacterial contamination); red (hemolysis); yellow (bilirubin) 3) discoloration (above); clumping |
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What would a lipemic (white or milky) color to blood products indicate for transfusion?
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NOT a contraindication. Proceed with use.
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If a blood pack is not used, what is the correct disposal procedure?
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Do NOT return to refrigerator
Do NOT dispose of in garbage DO return to Blood Bank to be recounted |
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How frequently should you monitor a patient receiving a blood transfusion?
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Do NOT leave within the first 15 minutes.
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When giving a patient a blood product via transfusion, what are some signs/symptoms of adverse reactions?
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itchiness
increased heart rate rapid breathing |
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What must you document about a transfusion?
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1) volume & type of product
2) time started, time completed 3) "chart copy" of blood component label 4) co-signature of independent double check 5) adverse reactions |
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What should you do if an acute transfusion reaction should occur?
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Stop the transfusion
Maintain the IV with saline solution Notify blood bank and doctor immediately recheck identifying tags and numbers monitor vitals/urine output provide treatment as physician proscribed Save bag and tubing, send to blood bank for examination Complete reaction report, document transfusion |
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Acute transfusion reactions are characterized by...
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Acute Hemolytic Response (reject blood)
Febrile (temperature spike) Allergic Circulation overload Sepsis Massive blood transfusion |
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What is an acute hemolytic response?
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Body's rejection of blood product, may occur even if the blood is the correct type. Usually due to incompatible blood, mislabeling specimens, administering blood
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Signs/symptoms of adverse transfusion reaction:
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Chills, fever, flushing
Low back pain Tachycardia, tachypnea, hypotension Hemoglobinuria, acute jaundice, dark urine, bleeding Acute renal failure, shock, cardiac arrest, death |
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What is a "febrile" reaction? What is it characterized by?
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Fever as a result of leukocyte component of blood.
Sudden chills and fever Headache Flushing Anxiety Muscle Pain |
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What is septic shock?
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Maldistribution of blood flow.
Systemic inflammatory response to infection or presnce of sepsis **** |
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What is heart failure?
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The inability of the heart to pump enough blood to meet the need of the body.
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Compare left-sided vs. right-sided HF.
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Left (LUNGS):
Blood backs up to pulmonary veins Manifests as pulmonary edema & congestion (crackles) Right (BODY): Blood backs up to venous circulation Manifests as peripheral edema, liver/spleen enlargement |
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What are the common causes of HF?
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1) ischemia from CAD (coronary artery disease)
2) Increases BP Causes are divided into underlying diseases (CAD) or precipitating causes (anemia) |
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Compare systolic and diastolic HF.
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Systolic:
MOST COMMON Inability to pump blood Diastolic: Impaired ability of ventricle to fill during diastole |
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What is the left ventricular ejection fraction? (LVEF or EF)?
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A test used to meaure how well the heart pumps with each beat to determine if systolic or diastolic disfunction are present.
Normal: 70% Sys HF: <40% |
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How does the body respond to the heart not pumping sufficient blood?
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1) Dilation
2) Hypertrophy (increase muscle mass) 3) Sympathetic NS activation 4) Neurohormonal response (kidneys respond to decreased output by producing renin, therefore angiontensin I converts angiotensin II to aldosterone = increase BP) These only work short term and eventually actually increase the heart's workload. |
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What are the clinical manifestations of acute HF?
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PULMONARY EDEMA
Angitation, pallor, cyanotic (fingers blue) Cool, clammy skin Dyspnea (SOB) Wheezing and productive blood-tinged cough Increased heart rate Increased or decreased BP |
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What are the clinical manifestations of chronic HF?
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Fatigue
Dyspnea (Orthopnea (lying down) or Paraoxsymal nocturnal dyspnea (PND) (at night)) Tachycardia (HR racing) Edema Nocturia (Frequent Urination at night) Skin Changes Behavioral changes Chest pain Weight changes |
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Briefly describe the stages of HF.
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Stage A -High Risk for HF
Stage B -Diagnosed with systolic HF but have never had symptoms Stage C - Known HF with current or prior symptoms Stage D - Advanced symptoms |
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What can you do to decrease your risk of HF?
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Regular exercise
Quit smoking Treat hypertension Treat lipid disorders Discourage alcohol or illicit drug use ACE inhibitor if previous Heart attack or current diabetes or HTN Weight monitoring |
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Normal Sp02 is greater than ____%
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95%
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What are the 6 steps in the nursing process?
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1) Assessment
2) Diagnosis 3) Planning Outcomes 4) Planning Interventions 5) Implementation 6) Evaluation |
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What is nursing?
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Nursing...
includes health promotion integrates patient's subjective experience with objective data applies scientific knowledge to diagnoses and treatment provides a caring relationship that facilitates health |
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Describe the nursing focus compared to the medical focus.
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Nursing:
Caring behaviors Look at the person "In illness and in wellness" Medicine: Cure Look at the problem |
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Why is the nursing process important?
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promotes collaboration
Cost-efficient Help people understand what nurses do Required by professional standard to practice Increaes client participation It is dynamic, client centered, planned, outcome directed, critical thinking process, universally applicable |
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What are the three steps of data management in the Assessment Phase of the nursing process?
or What happens in the Assessment Phase of the nursing process? |
Collect Data (interview, observe, examine)
Validate Data with client and significant others (compare subjective and objective, validate conflicts) Organise & record data (initial and ongoing assessment, special purpose assessments) |
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What is the nurses' role in the Diagnosis phase of the nursing process?
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1) Sort, cluster, analyze data to determine present health status
2) write a precise statement describing collected information and contributing factors 3) Prioritize diagnoses 4) Decide which will respond to nursing care or require referral |
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What is the format for writing a diagnostic statement?
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Problem (P) - health problem
Etiology (E) - probably cause Signs/Symptoms (S) - cluster of data, including potential problems |
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What is determined during the Planning Phase of the nursing process?
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Outcomes: end goal or desired health status
Interventions: steps to achieve outcomes, short and long term goals |
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How should you evaluate your goals through the nursing process?
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They should be...
Realistic, Achievable, Measurable, Patient Centered, Mutually Set |
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What will occur in the Implementation Phase of the nursing process?
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Communicate the plan of care to other members of the healthcare team and carry out the interventions. Record the care given and the client's response.
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What should you consider when choosing an intervention?
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Desired patient outcome
Characteristics of nursing diagnosis Research base associated with intervention Feasibility or success Acceptability to patient Capability of nurse |
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How do the phases of the nursing process overlap?
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Constant evaluation and assessment during implementation.
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How can unrelieved pain result in increased morbidity?
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1) Respiratory Disfunction
2) Increased HR & cardiac workload 3) Increased muscular contraction 4) Decreased GI motility & transit 5) Increased catabolism R.C.M.G Resp.Cardiac.Musc.GI Pain becomes the primary priority of the body and brain; it must be dealt with before the therapeutic process is able to move forward. |
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What are some barriers to effective pain management?
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1) Addiction
2) Fear of Respiratory Depression 3) Fear of precipitating death by using analgesics |
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Define Addiction.
Define Dependence. Define Tolerance. |
Addiction: neurobiological condition characterized by the desire to seek and use substances other than for the prescribed therapeutic value.
Dependence: physiological response to ongoing exposure to pharmacological agents that results in withdrawal syndrome when treatment is abruptly stopped. Tolerance: a state of adaption characterized by the need for an increased dose to maintain the same degree of therapeutic analgesia. |
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What factor may increase the likelihood of respiratory depression?
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If opioid is administered with other sedating drugs.
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What is the correlation between respiratory depression and drug tolerance?
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As tolerance increases, tolerance to the depressant effect also occurs.
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What is the rule of Double Effect?
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If an unwanted consequence occurs as a result of an action taken to achieve a moral good, the action is justified because the nurse's intent is to relieve pain and not hasten death.
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What is Nociception?
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"Acute Pain"
The activation of the primary afferent nerves with peripheral terminals that respond to noxious stimuli (tissue damage). |
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What are the dimensions of pain?
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Affective
Physiological Sensory Behavioral Cognitive |
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What kind of pain is usually responsive to opioid?
What kind of pain is usually responsive to non-opioids? |
Nociceptive and Neuropathic
Nociceptive |
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Describe neuropathic pain.
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Burning, shooting, stabbing
Sudden, intense, short-lived, lingering |
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When do you screen for pain?
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Vital Signs!
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What information should be included in a pain assessment?
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Pattern, Area, Intensity, Nature
Intensity: numeric/verbal rating scale or visual analogue scale |
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What is an example of subjective and objective data that could be collected in a pain assessment?
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They are one and the same! The patient's experience as they dictate through questionnaires, rating scales, comments...
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What does QUESTT stand for? When is it used?
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Question the Child
Use pain rating scale Evaluate behavior and physiologic signs Secure family's involvement Take cause of pain into account Take action and assess effectiveness |
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T/F
"Children always tell the truth about pain" "Children become accustomed to pain" "Behavioral manifestations reflect pain intensity" "Narcotics are more dangerous for children than for adults" |
FFFFFFFFFFFFFFFFFFFFFF
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What are some ways you can communicate with a child about their pain?
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"owie", "boo-boo", "hurt"
cries, screams, moans marking body parts or pointing to an area (doll or self) Stiff or tense body Difficult to comfort/console Flinches/moves if touched |
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What are some scales or indicators for assessing pain in cognitively impaired individuals?
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Vocalization
Facial expressions Breathing Body movements Body tension Consolability |
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Describe the proper use of the Wong-Baker FACES Pain Rating Scale.
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Explain to child that you want them to point to the face that matches their pain. Read all of the words below that describe each face, pointing as you do so.
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What are some considerations for treatment of pain in older adults (related to drug use).
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NSAIDS associated with high frequence of GI bleedings.
Possibility of dangerous drug interactions (GI upset, bleeds) Cognitive impairment |
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What is an equianalgesic dose?
When would one be provided? |
An alternate dose of another drug that is equivalent in pain-relieving effects compared with another analgesic.
For opiods. |
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What is pain?
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An unpleasant sensory or emotional experience that occurs because of potential or actual trauma
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Why is pain management in patients important?
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Cost efficiency
Patients go home faster Patients don't return for treatment Increase movement (prevent ulcers/pneumoia/DVT) Increase food capacity Affects patient psychy |
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What two types of tools do we have for healing pain?
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Pharmacologic and Nonpharmacologic
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What are the categories of pharmacological pain reducers?
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Opioids
NSAIDS Local Anesthetics (Na Blockers) Acetaminpohen Steroid/gabapentanoid |
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What are some pharmacological treatments for pain?
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1!) Therapeutic Use of Self (talk with, communicate with, care for patient, use of touch)
Others: Ice/Heat Ultrasound Spiritual Range of Motion Distraction |
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What is central sensitization of pain?
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When the entire nervous system becomes sensitized to a stimulus. The body amplifies pain signals because they involve the brain and spinal column.
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What are the three main categories and three subtypes of pain?
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Main:
Acute (decreases with time) Chronic (stays mostly constant) Malignant (increases with time) Subtype: Somatic Visceral Neuropathic (referred pain, sciatica, fibromialgia) |
