Critical Care Hesi Review SG

ABG’s-refer to notes Dec. K+-confusion, lethargy, & irregular pulse Acute Kidney Injury Trauma (TBI)- ABCDE (airway, breathing, circulation, disability (glasgow coma score), expose patient) head inj, trauma to skull will result in bleeding, hematoma, infection, or seizures Nurs interventions: assess for change in LOC, visual disturbances, watch for CSF drainage from ears, & nose (if yellow halo) will show glucose on the strip Feet elevated while keeping head flat or elevated to no more than a 30-degree angle is the best position for hypovolemic shock s/s(hypotension, dec. UO, delayed cap refill, tachycardia, warm extremities, & bradycardia) Late signs of septic shock-lethargy, dec. UO, & rapid/shallow resp. Cardiogenic shock-inc. RR, tachycardia, hypotension Neurogenic shock-hypotension, bradycardia & warm extremities