LATEST HIGH ACUITY - sepsis / shock QUICK TEST PASS 2024

ailure to provide adequate perfusion or oxygenation to the body how to measure perfusion - capillary refill (3 seconds) - urinary output (30ml/hr) - vital signs (MAP & HR are huge) - LOC hypovolemic shock shock resulting from blood or fluid loss cause of hypovolemic shock - hemorrhage - dehydration - burns - diabetes insipidus - GI ulver/bleed general signs and symptoms of shock - increase HR - thready/weak - increase RR - shallow/rapid - decrease BP - decrease urine output - cold clammy skin - cyanosis - nausea/vomiting - no bowel sounds - acidosis (low pH, high CO2) - decrease/low O2 - anxious - thirsty - high lactic acid - high potassium - 3 sec cap refill - MAP 65 seconds management of hypovolemic shock - fluids (normal saline or lactated ringers) - oxygen replacement / monitoring ABGs - vasopressors if fluids don't work vasopressors for blood pressure management - norepinephrine - dobutamine - dopamine - phenylephrine labs to monitor for hypovolemic shock INR h&h coumadin (warfarINR) vitamin K protamine sulfate heP(TT)arin INR normal value 0.2-1.1 therapeutic is 2-3 aptt normal value 30-40 seconds GI signs and symptoms hematemesis hematochezia melena melena Black tarry stool - comes from higher up in GI tract hematemesis bright red blood in vomit - comes from higher up in GI tract (closer to mouth exit) hematochezia bright red blood in stool - lower in GI tract treatment for esophageal varices Sengstaken-Blakemore tube upper GI cause esophageal varices ulcers lower GI causes diverticulitis/losis colitis / polyps DON'Ts with esophageal varices - NG tube cardiogenic shock inadequate heart muscle / failure to pump cause of cardiogenic shock