NUR2790 Rasmussen Nursing III Exam 3-Questions with Correct
Answers/ Verified/ Latest Update 2024/2025
Inflammatory immune response - ✔️✔️Purpose:
-Control bleeding
-Remove waste products limit infection
-Promote healing
Local vasodilation
-Delivers increased blood flow to bring neutrophils, macrophages and clotting factors to damaged
area
--Edema, redness, heat and pain
Serious injuries: sustained response can damage vessels in area of injury
Prolonged response cause increase in permeability of capillaries
Systemic Inflammatory Response Syndrome (SIRS) - ✔️✔️Uncontrolled inflammation in multiple
organs that are far from the area of insult
Overwhelming self-defense mechanism
Re-increased activation of the inflammatory cell, such as neutrophils macrophages lymphocytes and
damage to the vascular epithelium, deterioration in distribution of nutrient to the organs, ends with
MODS
Causes of SIRS - ✔️✔️Infection
Pancreatitis
Ischemia
Trauma
Hemorrhagic shock
Aspiration of gastric contents
Massive transfusions
,Host defense deficiencies
Why the onset of inflammation? - ✔️✔️Failure to control source of the inflammation or infection
Release of mineral corticoids like aldosterone when fluids are lost due to fluid shifts to interstitial
spaces or hemorrhage
SIRS: What happens in the body - Renal response - ✔️✔️Hypovolemia leads to renin,
angiotensinogen, angiotensin 1 (vasopressor) to angiotensin II stimulation
-increase B/P
-aldosterone secretion
*kidney reabsorbs sodium (water follows)
*excretes potassium
Antidiuretic Hormone (ADH) secreted
-water absorption; decreased urinary output
SIRS criteria - ✔️✔️SIRS is defined as 2 or more of the following variables:
Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F)
Heart rate of more than 90 beats per minute
, Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO 2) of
less than 32 mm Hg
Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10% immature [band] forms)
Treatment of SIRS - ✔️✔️Treat the cause!
Treat hypotension with fluids and vasopressors
Sepsis - ✔️✔️A systemic response to infection; involves SIRS, results in endothelial (lining of blood
vessels) dysfunction and altered circulation and coagulation
Most common cause is gram-negative bacteria
Microorganism's toxins secrete endotoxins that stimulate capillary permeability
Hypotension, hypo-perfusion of organs
Sometimes the source of infection is never found
Severe sepsis associated with organ dysfunction***
Hypotension = septic shock
-Systolic less than 90, or a reduction of more than 40 mm Hg from baseline in the absence of other
causes of hypotension.
98.6F = 37C; Know conversions**
Fever is a common symptom, though it may be absent in elderly or immunosuppressed patients.
The hypothalamus resets in sepsis, so that heat production and heat loss are balanced in favor of a
higher temperature.
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