Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NUR305 (2017) > Week 7 > Flashcards

Week 7 Flashcards

1
Q

Shock occurs when? (list at least 2 causes)

A
  • inability to meet metabolic demands of the tissue
  • hypoperfusion results in cellular dysfunction
  • there is a homeostatic imbalance between nutrient supply and demand
  • adaptive responses can no longer accommodate circulatory changes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Shock can be classified into 3 main umbrella(types) of categories. List them.

A
  1. Hypovolaemic
  2. Cardiogenic
  3. Distributive shock
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

why do we assess for acidaemia and what are we assessing for?

A

We assess acidaemia to see if compensatory mechanisms are being used.
When assessing for acidaemia you are assessing for:
-Ph
-serum lactate
-BE (base excess)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

what can increased lactate levels indicate?

A

it can be a warning sign of organ failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

List at least 4 early indications of shock?

A
  • tachycardia
  • altered consciousness
  • cold diaphoretic skin
  • tchypnoea
  • shallow resps
  • decreased urine output (<30mls/hr)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What can tachypnoea indicate in a person with shock?

A

Acidosis may be occurring

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

If a pt who is suffering from shock has shallow respirations, what could this indicate?

A

Alkolosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

In general terms what are the main things we should be doing if we suspect a pt may be suffering from shock?

A

we should be:

  • conducting a rapid assessment
  • so we can make a dx
  • to initiate and improve intervention
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

List at least 2 causes of hypovolaemic shock.

A 
Hypovolaemic shock can be a low volume of any fluid.
This can be caused by:
-bleeding-internal/external
-diarrhoea/vomiting
-dehydration
-burns
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

what is cardiogenic shock?

A

When an obstruction causes a blockage of circulation. This can also include PE, cardiac temponade.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the main management of hypovolaemic shock

A

Fluid resuscitation.
Fluid infused reflect fluid lost:
-burns =plasma
-massive haemorrhage = blood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

List at least 4 clinical manifestations of cardiogenic shock.

A
  • low CO
  • hypotension
  • severe pulmonary congestion
  • high CVP
  • oliguria
  • peripheral perfusion
  • anxiety
  • dyspnoea/tachypnoea
  • resp alkalosis/acidosis
  • distended neck veins
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what is another term used for Systemic Inflammatory Response Syndrome (SIRS)?

A

Septic shock

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Clinical manifestations of septic shock can be? (list 3)

A
  • infectious agents in blood causing haemodynamic compromise
  • ineffective tissue oxygen delivery
  • inappropriate vasodilation
  • normal or increased CO
  • hypovolaemic due to vasodilation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what is anaphylaxis?

A

a severe allergic reaction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Neurogenic shock can also be known as?

A

spinal shock

17
Q

List the aims of nursing care of a shocked patient.

A
  • rapid A-E assessment
  • support of pt (physical, emotional, psychological)
  • holistic care (family)
  • maintain communication (pt, family, staff)
  • interventions = fluids, obs, meds, transfer, scribe
18
Q

what does “on the floor and four more” mean?

A

blood on the floor and four more is chest , abdomen, pelvis and long bones.

19
Q

list the nursing practice for anaphylaxis?

A
  • assessment = accurate hx, allergies, time of onset
  • ABC
  • remove causative agent
  • secure airway
  • IM injection
  • early intubation (hear stridor intubate)
  • med administration = antihistamine & corticosteroids
20
Q

what is the nursing practice for sepsis?

A

similar to hypovolaemia

  • assessment
  • correct physiological deterioration
  • fluid management (don’t overload pt)
  • address underlying infection
  • administer Inotrope = vasopressin
21
Q

what is the nursing practice for Neurogenic shock?

A
  • ABC
  • stabilise neck/torso
  • consider fluids
  • resp assessment and monitor
  • maintain core temp
  • initiate NBM
  • pressure area care
22
Q

what would you be doing in a primary survey of shock?

A

A-E assessment

  • don’t forget c-spine control
  • temp control
23
Q

what would you be doing on a secondary survey of shock?

A
  • top to toe assessment
  • assessing pt for any other injuries/symptoms
  • continue A-E, obs
  • further assessments = cardio, neuro, resp
  • documentation
  • medications
  • fluid management
24
Q

List the early indications of shock. (List at least 4)

A
  • tachycardia
  • altered consciousness
  • cold diaphoretic skin
  • tachypnoea
  • shallow resps
  • decreased urine output
  • hypotension
  • lactate and acid base disturbances
25
Q

List some treatment pathways when dealing with shock.

A
  • fluid resus
  • medication management
  • theatre
  • rehabilitation
  • transfer =ICU, CCU, Spinal unit
26
Q

What is hypovolaemic shock?

A

When there is a decreased volume of blood circulating through the body. Causes include: bleeding, committing, dehydration, diarrhoea.

27
Q

What is distributive shock?

A

Shock that occurs when there is a maldistribution of circulation.
Such as: sepsis, anaphylaxis and neurogenic conditions.

28
Q

List the nursing management of shock

A
  • Fluid resuscitation
  • Monitor their observations
  • administer medications
  • treat the underlying cause
29
Q

List the nursing assessments that must be carried out on a pt presenting with shock.

A
  • frequent blood tests = for lactase, U+E, ABG’s
  • invasive observations = HR + BP via arterial line monitoring
  • cardiac output by central line
30
Q

What is the nursing management of hypovolaemia?

A
  • frequent assessment of condition and treatments required
  • increase O2 supply by : decreasing activity, BiPAP/CPAP, positioning
  • fluid resus
  • give inatropes
31
Q

What is the nursing management for sepsis?

A
  • fluid management
  • address underlying infection
  • administer Inatropes
32
Q

What is the nursing management for neurogenic shock?

A
  • ABC assessment
  • reps assessment and monitoring
  • ensure neck and torso are stabilised
  • pressure area care
  • fluid administration if required
  • monitor core temp
33
Q

List the nursing management for a pt with hypovolaemia

A
  • Minimize fluid loss
  • fluid replacement should be maintained
  • 2 large bore cannulae should be inserted
  • try to keep the pt warm
  • prepare pt for transfer
34
Q

what is the nursing management for anaphylaxis

A
  • pt hx
  • subjective data collection = time of onset
  • allergies
  • ABC assessment
  • secure airway
  • if able remove causative agent
  • administer medications (antihistamine/corticosteroids)
  • IM adrenaline
35
Q

what is the nursing management of sepsis

A
  • fluid management
  • address underlying infection
  • administer inatrope
36
Q

List what you would be doing on a secondary survey for shock

A
  • top to toe assessment
  • thorough assessment of any other injuries/symptoms
  • A to E assessment continued
  • observations continued
  • medication and fluid management
  • documentation

NUR305 (2017) (13 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions