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PN3 Exam 3 Study Guide complete solution
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PN3 Exam 3 Study Guide complete solutionExam 3 Study Guide
Shock Syndromes:
Shock is a systemic condition where there is an imbalance between the oxygen supply to the tissues/organs and the oxygen needs
of those tissues/organs. There are different types of shock. Any situation that decreases vascular volume, blood pressure, or cardiac
function can lead to shock.
Shock can be divided according to the cause. There are three main types of shock. Distributive shock is further divided into another
three categories.
Cardiogenic: pump (heart) failure
Hypovolemic: lack of circulating volume in the vascular space
Distributive: alteration in the vascular bed size
● Neurogenic: impaired sympathetic nervous system
● Anaphylactic: hypersensitivity response due to antigen-antibody reaction
● Septic: Due to systemic infection
Complications of each type
● Multiple Organ Dysfunction Syndrome (MODS)
● Disseminated Intravascular Coagulation (DIC)
● Acute respiratory Distress Syndrome (ARDS)
Treatment goals of each type
● Identify and treat the underlying cause
● Deliver oxygen to the tissues
● Maintain Circulation
● Monitor for complications
● Provide comfort and emotional support
4 stages of shock:
● Initial: decreased CO and impaired tissue perfusion
● Compensatory: activation of sympathetic nervous system (SNS)
● Progressive: every system in the body is affected and MOD happens
● Refractory: body will no longer respond to therapy
SIRS is a clinical response to a nonspecific insult. Regardless of the etiology of the insult, the body responses are similar. If the process cannot be
contained by the innate counter-inflammatory response, there is an increased activation of the inflammatory cells, including release of
neutrophils, macrophages, and lymphocytes; and additional damage to the vascular epithelium, deterioration in distribution of nutrients to the
organs, and subsequent complication of multiple organ dysfunction syndrome (MODS) or multiple organ failure (MOF). Conditions commonly
associated with SIRS include infection, pancreatitis, ischemia, trauma, hemorrhagic shock, aspiration of gastric contents, massive transfusions,
and host defense deficiencies
It is essential that you assess all patients at risk for SIRS, especially for the cardinal signs of the body’s inflammatory response. At least two or
more of the following findings will be present in SIRS:
● Change in temperature either higher than 38° C (100.4° F) or lower than 36° C (96.8° F)
● Pulse greater than 90 beats per minute
● Respiratory rate greater than 20 breaths per minute or a partial pressure of carbon dioxide (PC02) less than 32 mm Hg
● White blood cell (WBC) count higher than 12 × 103/mm3, or with more than 10% band cells
BOX 65-3: ASSESSMENT AND DIAGNOSIS OF SHOCK
Common clinical manifestations of the shock syndrome will vary according to the underlying cause, the stage of shock, and the individual
person’s response to shock. The exact course of events can be variable. Each person must be assessed individually prior to any intervention:
● Regardless of the type of shock, it leads to a systolic blood pressure (SBP) of less than 90 mm Hg and the narrowing of pulse
pressure that is inadequate to meet the tissue needs. (SBP may be elevated initially.)
● Early shock symptoms are subtle, requiring close surveillance to avoid overlooking their presence.
● All persons in shock are at risk of deterioration in status. Prompt intervention is required.
● Nurses must have a clear understanding of the pathophysiology of the different etiologies of shock.
● In all instances of shock following a trauma incident, consider hypovolemia or hemorrhage unless proven otherwise.
● Shock is a frightening experience for the patient and family. Effective psychological support is essential.
Symptoms include:
● Hypothermia
● Tachycardia or bradycardia
● Rapid thready pulse, slow capillary refill, or collapse of superficial veins in extremities
● Altered mental status—dissociation from normal thought processes, detached, a feeling of numbness, and impaired sensory-
emotional response. Loss of consciousness, restlessness, anxiety, irritability, and weakness may be present.
,PN3 Exam 3 Study Guide complete solution
● Clinical findings correlated with organs compromised by inadequate oxygen supply and the phases of the shock syndrome.
Examples:
○ a. Skin: cold, clammy, cyanotic, poor capillary refill, or warm dry skin due to pooling of blood in extremities.
Cyanosis (circumoral, earlobes, finger tips, or toes).
○ b. Kidneys: decreased urine output; anuria, or oliguria.
○ c. Lungs: dyspnea, crackles, or wheezes.
○ d. GI system: thirst, dry mucous membranes; nausea and vomiting; or decreased bowel sounds.
Acute Coronary Syndrome:
Unstable Angina (VS stable angina)
● Unstable angina: condition in which your heart doesn’t get enough blood flow and oxygen--may lead to a heart attack. DO
NOT KNOW THE TRIGGERS
● Stable angina: chest pain or discomfort that most often occurs with activity or emotional stress. KNOW WHAT
POTENTIAL TRIGGERS ARE. Usually a chronic condition that causes stable angina.
Non ST segment elevation myocardial infarction (NSTEMI)--> Indicates a partial thickness injury to the heart muscle. Less
severe than a STEMI. Partial occlusion of a major coronary artery
ST segment elevation myocardial infarction (STEMI)--> indicates a full thickness injury of the heart muscle.
Assessment of chest pain:
Including: Special populations assessment: elderly, women
Onset: When did the pain begin?
Location: Where is the pain?
Duration: How long does the pain last?
Characteristics:Describe the pain? Crushing, stabbing, ingestion like, dull, ache for example
Associating Factors: Other symptoms associated with the pain such as nausea and/or vomiting, weakness, fatigue,
breathlessness, syncope, cold and clammy?
Relieving Factors/Radiation: Does the pain radiate such as down the arm, up into the neck for example? Relieving factors: pain
stops when activity ceases, relieved by sitting forward or resting?
Treatment/Temporal factors: Use of GTN, pain was relieved by rest or decrease in physical activity. Pain non comparable to
previous ischemic chest pain
Severity (Intensity): A numerical scale (1 no pain- 10 worse pain experienced ) is used to gauge pain severity
Older adults: Typical chest pain→ Usually intense and unremitting for 30-60 minutes. Is retrosternal and often
radiates up to the neck, shoulder, and jaws, and down to the left arm. The chest pain is usually described as a
pressure sensation that can be perceived as squeezing, aching, burning, or even sharp. Anxiety, lightheadedness,
cough, nausea, profuse sweating, shortness of breath, wheezing, rapid or irregular heart rate,
fullness/indigestion/choking feeling
Women may or may not experience chest pain but may experience any of the symptoms above.
Treatments/Surgical Procedures
● Meds: Anticoagulatns, antiplatelets, ACE inhibitors, beta blockers, Calcium Channel Blocker, Statins, diuretics,
vasodilators, pain relievers (morphine), Nitroglycerin
● Surgeries: coronary angioplasty and stenting, coronary artery bypass surgery
Patient Education for Anginal Episodes
● Stop activity, sit or lie down.
● Place one nitroglycerin tablet under the tongue and allow to dissolve. (Do not chew or
swallow.)
● Tablet will cause a tingling sensation, heart pounding, flushing, and headache.
, PN3 Exam 3 Study Guide complete solution
● Stay in resting position for 15 to 20 minutes and get up slowly after taking nitroglycerin to
prevent fainting from postural hypotension.
● If angina is not relieved in five minutes, the dose may be repeated two times at five-minute
intervals for a total of three doses.
● If angina is not relieved after two doses, seek immediate medical attention.
● Report angina that increases in frequency, lasts longer, limits previous level of activity, and
occurs at rest.
● Carry tablets at all times in the original prescription container.
Pharmacology→(what Jenni told us to remember) MONA (Morphine, Oxygen, Nitro, Ativan)
Antiplatelet agents-Aspirin, Varopaxar
Nitrates-relax smooth muscles
Analgesics-Morphine-decreases sympathetic stress, in addition to providing some preload reduction.
Beta-adrenergic blocker-Esmolol, Metoprolol-Beta blockers have antiarrhythmic and antihypertensive properties, as well
as the ability to reduce ischemia. They minimize the imbalance between myocardial supply and demand by reducing
afterload and wall stress.
Glycoprotein IIB/IIIA inhibitors-Glycoprotein IIb/IIIa receptor antagonists include abciximab, eptifibatide, and tirofiban.
Glycoprotein IIb/IIIa antagonists prevent the binding of fibrinogen, thereby blocking platelet aggregation.
Anticoagulants-Heparin augments the activity of antithrombin III and prevents the conversion of fibrinogen to fibrin. It
does not actively lyse but is able to inhibit further thrombogenesis. This agent prevents recurrence of a clot after
spontaneous fibrinolysis.
Low molecular weight heparins-Lovenox
Adenosine diphosphate receptor antagonists-Thienopyridine adenosine 5'-diphosphate (ADP) antagonists approved for
antiplatelet activity in the United States include clopidogrel (Plavix), ticlopidine, prasugrel, and ticagrelor.
Modifiable Risk factors→ The major modifiable risk factors are hyperlipidemia, hypertension (blood pressure
greater than 140/90 mm Hg), cigarette smoking, diabetes mellitus, obesity, and sedentary lifestyle. In addition, the
remaining modifiable risk factors include low daily fruit and vegetable intake, alcohol consumption, and
psychosocial index
Cholesterol: purpose of each type→
Total cholesterol–a measure of the total amount of cholesterol in your blood, including low-density lipoprotein (LDL)
cholesterol and high-density lipoprotein (HDL) cholesterol.
LDL (bad) cholesterol–the main source of cholesterol buildup and blockage in the arteries
HDL (good) cholesterol–HDL helps remove cholesterol from your arteries Triglycerides–
another form of fat in your blood that can raise your risk for heart disease
Total Cholesterol Level
Less than 200mg/dL Desirable
200-239 mg/dL Borderline high
240mg/dL and above High
LDL (Bad) Cholesterol Level
Less than 100mg/dL Optimal
100-129mg/dL Near optimal/above optimal
130-159 mg/dL Borderline high
160-189 mg/dL High
190 mg/dL and above Very High
HDL (Good) Cholesterol Level
Less than 40 mg/dL A major risk factor for heart disease
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