Rasmussen College: PN 3 Exam 3 Study Guide_ LATEST,100% CORRECT
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PN3 Exam 3 Study Guide
Rasmussen College: PN 3 Exam 3 Study Guide_ LATEST
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 vol...
Rasmussen College: PN 3 Exam 3 Study Guide_ LATEST
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.
, ● 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.
● 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.
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