Critical Care Nursing, Medical Surgical
Nursing 3 Exam One (Answered) 2022
Graded A+
Prioritizing orders in the care of Hypovolemic Shock
Treatment of Underlying Cause (hemorrhage- stop bleeding, diarrhea/vomiting- meds to
stop those)
Fluid and Blood Replacement: At least two large-gauge IV lines are inserted to establish
access for fluid administration.
Fluids- Normal Saline, Lactated Ringers, Albumin, and plasma/RBC
In addition to administering fluids to restore intravascular volume, positioning the patient
properly assists fluid redistribution. A modified Trendelenburg position, also known as
passive leg raisingis recommended in hypovolemic shock.
What is most important in poison emergencies?
Airway stabilation
Carbon Dioxide Poisioning
S/S: headache, dizziness, confusion, palpitations, muscle weakness, intoxication coma,
death
Priority - assess carboxyhemoglobin levels
SPO2 will appear normal
Hypothermia puts people at risk for
What to remember with spontaneous v-fib?
Risk for hypoxia, acidosis, & dysrhythmias
Spontaneous V-fib: Must rewarm to > 32.2 (90F) before defibrillation
IVP who is screened?
Must screen every patient for this "Do you feel safe at home?"
Compensatory Shock
Normal BP
>100 bpm
>20 breaths per min
PaCO2 <32
Cold, Clammy
Decreased
Confused and/or agitated
Respiratory Alkalosis
, Progressive Shock
Systolic <90
MAP <65
Requires fluid resuscitation to support blood pressure
>150 bpm
Rapid, Shallow Respirations
Crackles
PaO2 <80 PaCO2 >45
Mottled, Petechiae
< 0.5 mL/kg/hr
Lethargy
Metabolic Acidosis
Irreversible Shock
Requires mechanical or pharmacologic support
Erratic
Requires intubation and mechanical ventilation and oxygenation
Jaundice
Anuric, Requires Dialysis
Unconscious
Profound Acidosis
Assessing MODS
Multiple organ dysfunction syndrome (MODS) is altered organ function in acutely ill
patients that requires medical intervention to support continued organ function. It is
another phase in the progression of shock states. MODS may be a complication of any
form of shock, but it is most commonly seen in patients with sepsis and is a result of
inadequate tissue perfusion.
Clinical Severity Assesment Tools: These clinical assessment tools include APACHE
(Acute Physiology and Chronic Health Evaluation); SAPS (Simplified Acute Physiology
Score); PIRO (Predisposing factors, the Infection, the host Response, and Organ
dysfunction); and SOFA score
Assessing Hypovolemic Shock
Hypovolemic shock can be caused by external fluid losses, as in traumatic blood loss,
or by internal fluid shifts, as in severe dehydration, severe edema, or ascites
Decreased intravascular volume
Decreased venous return
Decreased stroke volume, cardiac output, and tissue perfusion
Assessing Neurogenic Shock
Neurogenic shock can be caused by spinal cord injury, spinal anesthesia, or other
nervous system damage. It may also result from the depressant action of medications
or from lack of glucose (e.g., insulin reaction)
Normally, during states of stress, the sympathetic stimulation causes the BP and heart
rate to increase. In neurogenic shock, the sympathetic system is not able to respond to
body stressors. Therefore, the clinical characteristics of neurogenic shock are signs of
parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool,
moist skin seen in hypovolemic shock. Another characteristic is hypotension with
bradycardia, rather than the tachycardia that characterizes other forms of shock.
Nursing 3 Exam One (Answered) 2022
Graded A+
Prioritizing orders in the care of Hypovolemic Shock
Treatment of Underlying Cause (hemorrhage- stop bleeding, diarrhea/vomiting- meds to
stop those)
Fluid and Blood Replacement: At least two large-gauge IV lines are inserted to establish
access for fluid administration.
Fluids- Normal Saline, Lactated Ringers, Albumin, and plasma/RBC
In addition to administering fluids to restore intravascular volume, positioning the patient
properly assists fluid redistribution. A modified Trendelenburg position, also known as
passive leg raisingis recommended in hypovolemic shock.
What is most important in poison emergencies?
Airway stabilation
Carbon Dioxide Poisioning
S/S: headache, dizziness, confusion, palpitations, muscle weakness, intoxication coma,
death
Priority - assess carboxyhemoglobin levels
SPO2 will appear normal
Hypothermia puts people at risk for
What to remember with spontaneous v-fib?
Risk for hypoxia, acidosis, & dysrhythmias
Spontaneous V-fib: Must rewarm to > 32.2 (90F) before defibrillation
IVP who is screened?
Must screen every patient for this "Do you feel safe at home?"
Compensatory Shock
Normal BP
>100 bpm
>20 breaths per min
PaCO2 <32
Cold, Clammy
Decreased
Confused and/or agitated
Respiratory Alkalosis
, Progressive Shock
Systolic <90
MAP <65
Requires fluid resuscitation to support blood pressure
>150 bpm
Rapid, Shallow Respirations
Crackles
PaO2 <80 PaCO2 >45
Mottled, Petechiae
< 0.5 mL/kg/hr
Lethargy
Metabolic Acidosis
Irreversible Shock
Requires mechanical or pharmacologic support
Erratic
Requires intubation and mechanical ventilation and oxygenation
Jaundice
Anuric, Requires Dialysis
Unconscious
Profound Acidosis
Assessing MODS
Multiple organ dysfunction syndrome (MODS) is altered organ function in acutely ill
patients that requires medical intervention to support continued organ function. It is
another phase in the progression of shock states. MODS may be a complication of any
form of shock, but it is most commonly seen in patients with sepsis and is a result of
inadequate tissue perfusion.
Clinical Severity Assesment Tools: These clinical assessment tools include APACHE
(Acute Physiology and Chronic Health Evaluation); SAPS (Simplified Acute Physiology
Score); PIRO (Predisposing factors, the Infection, the host Response, and Organ
dysfunction); and SOFA score
Assessing Hypovolemic Shock
Hypovolemic shock can be caused by external fluid losses, as in traumatic blood loss,
or by internal fluid shifts, as in severe dehydration, severe edema, or ascites
Decreased intravascular volume
Decreased venous return
Decreased stroke volume, cardiac output, and tissue perfusion
Assessing Neurogenic Shock
Neurogenic shock can be caused by spinal cord injury, spinal anesthesia, or other
nervous system damage. It may also result from the depressant action of medications
or from lack of glucose (e.g., insulin reaction)
Normally, during states of stress, the sympathetic stimulation causes the BP and heart
rate to increase. In neurogenic shock, the sympathetic system is not able to respond to
body stressors. Therefore, the clinical characteristics of neurogenic shock are signs of
parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool,
moist skin seen in hypovolemic shock. Another characteristic is hypotension with
bradycardia, rather than the tachycardia that characterizes other forms of shock.
