Exam (elaborations)
JCCC Nurs 225 Unit 3: Questions With Solutions (Precise)
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JCCC Nurs 225 Unit 3: Questions With Solutions (Precise)
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JCCC Nurs 225 Unit 3: Questions With Solutions(Precise)
What is shock? Right Ans - inadequate tissue perfusion
What are the components of perfusion? Right Ans - -Blood volume
-Cardiac pump
-Vasculature
What are the different types of shock? Right Ans - -Cardiogenic
-Hypovolemic
-Neurogenic
-Anaphylactic
-Septic
-Obstructive
Which shocks are distributive? Right Ans - -Septic
-Anaphylactic
-Neurogenic
Systemic Vascular Resistance (SVR) Right Ans - the pressure in the
peripheral blood vessels that the heart must overcome to pump blood into the
system
vasoconstriction= Right Ans - increased SVR
vasodilation= Right Ans - decreased SVR
Pulse oximetry Right Ans - non-invasive (indirect) measurement of oxygen
ABGs (SaO2) Right Ans - direct amount of arterial oxygen (95-100%)
Central venous oximetry monitoring (ScvO2/SvO2) Right Ans - -calculated
only by invasive central catheter
-measures amount of mixed venous oxygen bound to hemoglobin after tissues
have removed what they need (lower than 70 during shock)
How to figure out perfusion Right Ans - -oxygen content
,-vital signs
-"state" of the organs
What is the first thing you will see if kidneys are poorly perfused? Right
Ans - Decreased urine output
Signs of poor organ perfusion Right Ans - -Arrhythmias, Troponin, chest
pain
-Decreased LOC
-Decreased urine output & GFR, Increased creatinine
-Increased RR, Decreased SpO2
-Increased lactate
-Increased LFTs & bilirubin
Which physiologic components are common to all types of shock? Right
Ans - -Hypoperfusion
-Hypermetabolism
-Inflammatory response
What are the 3 stages of shock? Right Ans - -Compensatory
-Progressive
-Irreversible
Compensatory (1st stage) shock Right Ans - -Normal blood pressure (to
maintain CO)
-slightly tachycardic
- RR > 20 PC02<32
-respiratory alkalosis
-cool clammy skin
-hypoactive bowel sounds
-decreased urine output
-patient may become confused/agitated
-body shunts blood to brain, heart, and lungs
Nursing interventions for stage 1 of shock Right Ans - -Assess and reassess
-note changes from baseline
-reduce anxiety
-promote safety
, Progressive (2nd stage) shock Right Ans - -Blood pressure starts to drop
(MAP <65) Systolic <90 or -40 from baseline
-rapid, shallow respirations
-crackles
-dysrhythmias
-tachycardia (>150)
-mental status deterioration (lethargic)
- UO <0.5ml/kg/hr
-AKI
-mottled, petechiae
-DIC
- metabolic acidosis
Nursing interventions for stage 2 of shock Right Ans - -prevent
complications
-promote rest
-glycemic control
-specific management is based on type of shock
Medical interventions for stage 2 shock Right Ans - respiratory support:
possible vent
Vascular system: pressors or dilators
Fluids
inototropes if indicated
nutritional support
glycemic control
Irreversible (3rd stage) of shock Right Ans - -Organ damage so severe,
patient does not respond to treatment
-BP low despite medical interventions
-worsened acidosis by anaerobic metabolism
-MODS progresses to complete organ failure
How do you know when it is "irreversible?" Right Ans - Judgement that it is
irreversible can be made only retrospectively on the basis of the patient's
failure to respond to treatment
Nursing interventions for stage 3 of shock Right Ans - -carry out medical
treatments
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