Rasmussen College: PN3-Exam-3-Study-Guide-1_LATEST
Multisystem Failures
Acute IIR cardinal signs
Rubor = redness (due to vasodilation)
Tumor = swelling (due to release of fluid containing RBC and
protein) Callor = heat (due to increase blood flow)
Dollor = pain (swelling cause pain and pressure of the nerve endings)
Types of all shock and complications Hypovolemic, cardiogenic anaphylactic,
neurogenic, septic
Hypovolemic
Lack of circulating blood volume
Blood loss, dehydration, burn, vasodilation due to neurogenic shock or
anaphylactic shock, N/V diarrhea, NG suction.
Drop of blood pressure
Interventions: replace fluid! Monitor fluid replacement, monitor vital signs, assess
S/S of fluid overload, WBC Hemoglobin and hematocrit., positioning for comfort.
Cardiogenic
Weakened forward pumping function of the heart, right, left,
ventricles or both. MI, decreased cardiac output, irregular rate or rhythm
Example if left ventricle is affected you will see pulmonary edema, adventives lung
sounds
HR > 100 bpm, weak or thready pulse, diminished heart sounds, dysrhythmia,
cool moist pale skin, chest pain
Renal failure, watch output > 30 ml a hour, 400 ml a day (less than that is oliguria,
anuria is absent of urine)
Generized edema, legs, arms face, watch weight (2 # in 24 hours or 5# a week
sign of additional cardiac and/or kidney failure)
Treatment: oxygen, mechanical intubation, diuretics, inotropic drugs (to
stimulate the contractibility of the heart such as dopamine, dobutamine,
inamrinone), ECG, morphine (improve coronary perfusion)
Anaphylactic
,Occurs when an allergen such as food (shellfish, peanuts, chocolate strawberries
and tomatoes)food additive, iodine, latex, mold fungus cats or medications
(penicillin) insects (bees)
, venom, enter the body causing release of histamines (widespread antibody
response), which results in capillaries dilation, and smooth muscle contracting.
Life threatening situation. Difficult to diagnose, symptoms look like PE
Comprehensive health history is important to prevent anaphylactic shock.
Remember the different of sensitivity (rash) or allergy. History of an allergy can
make second time worse. Prevent latex Washing hand with soap and water, avoid
oil- based cream, prevent dust damp rag.
Make sure they have an epipen, or administer
epinephrine S/S Edema tongue airway, SOB, stridor,
hypotension, anxiety. Neurogenic shock
Absence or suppression of the sympathetic nervous system tone and is considered in
the hypovolemic shock class.
Caused by disruption of brain or hypothalamus, spinal cord injury at or above T6.
Massive peripheral vasodilation, loss of temp regulation, loss of sympathetic tone in
the heart, diminished baroreceptive responses to change blood pressure
Paralysis, warm dry skin, (You do not see decreased reflexes with neurogenic shock).
Treatment: reestablish blood volume, replace fluid! Monitoring fluid overload,
medication inotropic and vasoconstriction meds (dopamine), low dose of
corticosteroids, atropine if bradycardia, ECG, Glasgow coma scale, monitor
MODS.
Interventions prevent hypovolemic shock correct hypovolemia, promote normal
temp, prevent hypoxemia, monitor ECG (dysrhytmias), identify patient at risk
for neurogenic shock, patient with DVT.
( stress is related to increased sympathetic nervous system arousal and involves a
wide physiological response)
Septic shock
Circulation and coagulation is altered
severe sepsis is associated with one or more organ dysfunction.
S/S Hypotension, blood pressure has a widened pulse, tachycardia, high temp, lactic
acidosis, oliguria, mental status changes, cellular and humoral responses. Aches and
chills, decreased skin perfusion It mimic SIRS, sign of at least one organ failure
Diagnosis, WBC, identify the source, history
Multisystem Failures
Acute IIR cardinal signs
Rubor = redness (due to vasodilation)
Tumor = swelling (due to release of fluid containing RBC and
protein) Callor = heat (due to increase blood flow)
Dollor = pain (swelling cause pain and pressure of the nerve endings)
Types of all shock and complications Hypovolemic, cardiogenic anaphylactic,
neurogenic, septic
Hypovolemic
Lack of circulating blood volume
Blood loss, dehydration, burn, vasodilation due to neurogenic shock or
anaphylactic shock, N/V diarrhea, NG suction.
Drop of blood pressure
Interventions: replace fluid! Monitor fluid replacement, monitor vital signs, assess
S/S of fluid overload, WBC Hemoglobin and hematocrit., positioning for comfort.
Cardiogenic
Weakened forward pumping function of the heart, right, left,
ventricles or both. MI, decreased cardiac output, irregular rate or rhythm
Example if left ventricle is affected you will see pulmonary edema, adventives lung
sounds
HR > 100 bpm, weak or thready pulse, diminished heart sounds, dysrhythmia,
cool moist pale skin, chest pain
Renal failure, watch output > 30 ml a hour, 400 ml a day (less than that is oliguria,
anuria is absent of urine)
Generized edema, legs, arms face, watch weight (2 # in 24 hours or 5# a week
sign of additional cardiac and/or kidney failure)
Treatment: oxygen, mechanical intubation, diuretics, inotropic drugs (to
stimulate the contractibility of the heart such as dopamine, dobutamine,
inamrinone), ECG, morphine (improve coronary perfusion)
Anaphylactic
,Occurs when an allergen such as food (shellfish, peanuts, chocolate strawberries
and tomatoes)food additive, iodine, latex, mold fungus cats or medications
(penicillin) insects (bees)
, venom, enter the body causing release of histamines (widespread antibody
response), which results in capillaries dilation, and smooth muscle contracting.
Life threatening situation. Difficult to diagnose, symptoms look like PE
Comprehensive health history is important to prevent anaphylactic shock.
Remember the different of sensitivity (rash) or allergy. History of an allergy can
make second time worse. Prevent latex Washing hand with soap and water, avoid
oil- based cream, prevent dust damp rag.
Make sure they have an epipen, or administer
epinephrine S/S Edema tongue airway, SOB, stridor,
hypotension, anxiety. Neurogenic shock
Absence or suppression of the sympathetic nervous system tone and is considered in
the hypovolemic shock class.
Caused by disruption of brain or hypothalamus, spinal cord injury at or above T6.
Massive peripheral vasodilation, loss of temp regulation, loss of sympathetic tone in
the heart, diminished baroreceptive responses to change blood pressure
Paralysis, warm dry skin, (You do not see decreased reflexes with neurogenic shock).
Treatment: reestablish blood volume, replace fluid! Monitoring fluid overload,
medication inotropic and vasoconstriction meds (dopamine), low dose of
corticosteroids, atropine if bradycardia, ECG, Glasgow coma scale, monitor
MODS.
Interventions prevent hypovolemic shock correct hypovolemia, promote normal
temp, prevent hypoxemia, monitor ECG (dysrhytmias), identify patient at risk
for neurogenic shock, patient with DVT.
( stress is related to increased sympathetic nervous system arousal and involves a
wide physiological response)
Septic shock
Circulation and coagulation is altered
severe sepsis is associated with one or more organ dysfunction.
S/S Hypotension, blood pressure has a widened pulse, tachycardia, high temp, lactic
acidosis, oliguria, mental status changes, cellular and humoral responses. Aches and
chills, decreased skin perfusion It mimic SIRS, sign of at least one organ failure
Diagnosis, WBC, identify the source, history
