NRNP 6566 WEEK 4 KNOWLEDGE CHECK (VERIFIED)

NRNP 6566 WEEK 4 KNOWLEDGE CHECK (VERIFIED) • Question 1 A 47 year old male admitted with an infected elbow wound. On his second day in the hospital you find him in his room confused and agitated. Vital signs are as follows: Temperature – 96.2 °F Pulse -140 beats per minute Respirations – 40 breaths per minute Blood Pressure – 90/40 mmHg Labs include a WBC count of 3,000 Pt weighs 185 pounds Further assessment of him includes: Urine output of 100cc for the last 8 hours Pulse oximetry of 88% on room air Pallor What is your working diagnosis? Corr ect There are 4 stages of sepsis. Ans Systemic Sepsis Severe Sepsis Septic Shock wer: Inflammatory Response Syndrome (SIRS) Criteria – any 2 of Meet SIRS criteria Sepsis criteria plus Severe sepsis the following: and have a possible evidence of organ criteria plus any one *Temperature over or documented system dysfunction of the following: 100.9 or less than source of infection *new need for *Tissue 96.8 *positive cultures or invasive or non- hypoperfusion *Heart rate over 90 possible infection invasive respiratory persists despite *Respirations over site intervention crystalloid fluid 20 per minute *BP less than 90 administered. *WBC over 12,000 or systolic, MAP less *need for less than 4,000 than 65, or Systolic vasopressors BP 40 mmHg less documented by BP than previous less than 90 systolic, documented BP MAP less than 65, or *New altered mental Systolic BP 40 status mmHg less than *Cr greater than 2 orprevious urine output less documented BP than 0.5cc/kg/hour * Lactate greater for 2 hours than 4 mm/L *Plateletssless than 100,000 *Lactate greater than 2 mm/L This patient meets the criteria for septic shock Temp – 96.2 Heart Rate 140 Respirations 40 WBC 3000 Source of infection – elbow wound o Question 2 A 50 year old woman is thought to be in septic shock. What physical assessment findings would you expect to find to confirm this type of shock? Correct Answer: Hypotension is the common finding in all shock states. In septic shock, you would also expect to find: Tachycardia Full bounding pulses Pink, warm, flushed skin Tachypnea Decreased urine output Fever Hemodynamic measures would indicate a decreased cardiac output, decreased systemic vascular resistance, and a decreased central venous pressure. o Question 3 Organ dysfunction – confused, urine output of 12 cc per hour (min 42 per weight) Blood pressure of 90/40 with a MAP of 56.5 A 56 year old man is thought to be in hypovolemic shock. What are the initial interventions for a patient in hypovolemic shock? Correct Answer: Initial treatment would include: *identify and stop fluid loss / bleeding if possible *Crystalloid fluid replacement – 0.9% NS or LR initially infuse 2 L of fluid and then reassess. *Hemorrhagic shock should be treated with a balanced infusion of packed red blood cells, plasma, and platelets. Type O negative PRBC can be administered until cross matched cells are available. *Vasopressors can worsen tissue hypoxia and are not initial treatment in hypovolemia or hemorrhage. o Question 4 Correct Answer: A 44 year old man is thought to be in cardiogenic shock. What are the initial interventions needed for a patient in cardiogenic shock? Initial treatment would include: *if STEMI is suspected – early and definitive restoration of coronary blood flow is the most important intervention (cardiology consult, alert cath lab) *Correction of electrolyte and acid base abnormalities (especially hypokalemia, hypomagnesemia, and acidosis) *Placement of central line (allows CVP monitoring, facilitate volume resuscitation, access for multiple infusions) *Dopamine, norepinephrine, and epinephrine are vasoconstricting drugs that help to maintain adequate blood pressure. Goal is MAP of 60-65. Dopamine increases myocardial contractility and increases but BP but it may increase myocardial oxygen demand. Dobutamine may be preferable if the systolic BP is higher than 80 mmHg since it does not effect myocardial oxygen demand as much as dopamine. Dopamine and dobutamine may cause tachycardia precluding their use in some patients. If hypotensive persists, a direct vasoconstrictor (norepinephrine) may be utilized. Norepinephrine will increase afterload and decrease cardiac output so their use is reserved for refractory hypotension and organ hypoperfusion. o Question 5 *Monitor electrolytes and acid base status* Fluid repletion can be monitored by measuring blood pressure, urine output, mental status, and peripheral edema. What is the mechanism of action and common side effects of dobutamine, norepinephrine, labetalol, and amiodarone? Correct Answer: Drug Mechanism of Action Side Effects Dobutamine Dobutamine directly increased heart rate, stimulates beta-1 increased blood receptors of the heart to pressure, increase myocardial ventricular ectopic contractility and stroke activity, volume, resulting in nervousness, increased cardiac output headache, nausea, vomiting, palpitations, Norepinephrine It stimulates α1 and α2 decreased heart rate adrenergic receptors to increased blood pressure cause blood vessel arrhythmias contraction confusion anxiety shortness of breath headache nausea and vomiting Labetalol Labetalol is a dual alpha Decreased heart rate (α1) and beta (β1/β2) Shortness of breath adrenergic receptor Chest pain blocker and competes Swelling of feet and legs with other Fatigue Catecholamines for Dizziness binding to these sites. Amiodarone Amiodarone is a class III See table below antiarrhythmic that works primarily by blocking potassium rectifier currents that are responsible for the repolarization of the heart during phase 3 of the cardiac action potential. Organ Amiodarone Side effects system Lungs Pulmonary toxicity Pulmonary fibrosis Chronic interstitial pneumonitis Organizing pneumonia ARDS Solitary pulmonary mass Thyroid May induce hypothyroidism and/or hyperthyroidism May aggravate pre-existing thyroid conditions Liver AST/ALT 2x normal If patients experience more than a two-fold elevation, drug therapy should be discontinued. LFTs should be monitored at baseline and every 6 months. Hepatitis and cirrhosis Heart Bradycardia and AV block Eyes Corneal micro-deposits Optic neuritis GI tract Nausea, anorexia, and constipation Skin Photosensitivity Blue discoloration CNS Various manifestations, esp. peripheral neuropathy (also ataxia, paresthesias, sleep disturbance, impaired memory, and tremor) GU tractEpididymitis and erectile dysfunction o Question 6 A 56 year old Caucasian man is seen in the office as a new patient. He complains of headaches occurring with increasing frequency and attributes them to increased stress at work. He denies any chest pain, shortness of breath, or dyspnea. He smokes one pack cigarettes per day and has two glasses of wine with dinner. Physical exam – obese main (BMI 30) in no apparent distress. BP R arm 168/98 L arm 170/94. HR 64 regular. No thryomegly or lymphadenopathy. Fundascopic exam reveals narrowing of the arteries and arteriovenous nicking. Cardiac exam reveals that his point of maximal impulse (PMI) if displaced 2 cm to the left of the midclavicular line (MCL). No murmurs noted. Lung and abdomen examinations are normal. What tests should be ordered for this patient ? Correct Answer: CMP and CBC at a minimum CMP - evaluate electrolytes and kidney function. Especially important when considering what medication to order and ensuring there is not a renal cause of the hypertension CBC - evaluate for Hemoglobin and Hematocrit. Looking to establish a baseline and assess for anemias