TCRN REVIEWED QUESTIONS AND ANSWERS, Exams of Nursing

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TCRN REVIEWED QUESTIONS AND

ANSWERS

Describe the process of Obstructive Shock. - CORRECT ANSWER-Myocardium contracts against high afterload - > Sympathetic over activity leads to vasoconstriction in order to maintain BP - > Despite normal BP, organs are poorly perfused due to a reduction in blood flow - > Back pressure leads to venous congestion List the 4 Classifications of Shock - CORRECT ANSWER- Hypovolemic Distributive Cardiogenic Obstructive Describe hypovolemic shock - CORRECT ANSWER-Lack of Volume Describe distributive shock - CORRECT ANSWER-Mal- distribution of blood (vasodilation) Describe cardiogenic shock - CORRECT ANSWER-Inadequate cardiac output Describe obstructive shock - CORRECT ANSWER-Inability of blood to enter or exit the heart adequately What is another name for early hypovolemic shock? - CORRECT ANSWER-Compensatory Shock The adrenergic system is active during the _____ phase of shock. - CORRECT ANSWER-Compensatory

The _____ system is active after the phase of shock has passed to bring the body back to a state of homeostasis. - CORRECT ANSWER-Cholinergic Another name for the sympathetic system is _____. - CORRECT ANSWER-Adrenergic system Another name for the parasympathetic system is _____. - CORRECT ANSWER-Cholinergic system What is the name of the process in which glycogen stores in the liver are broken down into glucose? - CORRECT ANSWER-Glycogeonolysis What is the process in which glucose in the serum is converted to glycogen for storage in the liver? - CORRECT ANSWER- Glyconeogenesis What is the term for the speed at which electricity moves through the heart? - CORRECT ANSWER-Automaticity What is the role of alpha receptors in the adrenergic (sympathetic) system? - CORRECT ANSWER- Vasoconstriction, Glycogeonolysis, Diaphoresis What is the role of the alpha receptors in the cholinergic (parasympathetic) system? - CORRECT ANSWER- Vasodilation, Glyconeogenesis, Dry Skin Sympathetic vs. Parasympathetic is also known as what? - CORRECT ANSWER-Fight or Flight; respectively What is the role of Beta-One receptors in the adrenergic (sympathetic) system? - CORRECT ANSWER-Increased: heart rate, contractility, automaticity

What is the role of Beta-One receptors in the cholinergic (parasympathetic) system? - CORRECT ANSWER-Decreased: heart rate, contractility, automaticity What is the role of Beta-Two receptors in the adrenergic (sympathetic) system? - CORRECT ANSWER-Increased respiratory rate Bronchodilation What is the role of Beta-Two receptors in the cholinergic (parasympathetic) system? - CORRECT ANSWER-Decreased respiratory rate Bronchoconstriction What is another term for late shock? - CORRECT ANSWER- Decompensated shock What occurs during late or decompensated shock? - CORRECT ANSWER-Activation of the inflammatory system During late or decompensated shock and the activation of the inflammatory system, what do inflammatory mediators cause? (3 things) - CORRECT ANSWER-Vasodilation Increased capillary permeability Increased coagulation What are the signs of early or compensated hypovolemic shock? (8 signs/symptoms) - CORRECT ANSWER-Deceptively normal or slightly elevated blood pressure Narrowing Pulse Pressure Tachycardia (weak and thready) Tachypnea (deep and rapid) Normal serum lactate levels Cool and clammy skin CNS: anxious and restless Decreased urinary output

What are the signs of late or decompensated hypovolemic shock? (7 signs/symptoms) - CORRECT ANSWER-Decreased blood pressure Tachycardia (may not be palpable peripherally) Tachypnea (shallow and rapid) Serum Lactate > 2-4 mmol/L Cool, clammy and mottled skin CNS: loss of consciousness Anuria What is the average blood volume of an adult? - CORRECT ANSWER- 4700 - 5500 ml What is the average blood loss of a thoracic injury? - CORRECT ANSWER-2000 ml What is the average blood loss of an intra-abdominal injury? - CORRECT ANSWER-2000 ml What is the average blood loss of a tibial fracture? - CORRECT ANSWER-650 ml What is the average blood loss of a femur fracture? - CORRECT ANSWER-1000 ml What is the average blood loss of a pelvic fracture? - CORRECT ANSWER-3000 ml How many classes of hypovolemic shock are there? - CORRECT ANSWER- 4 Describe Class I hypovolemic shock: (8 answers) - CORRECT ANSWER-<750 ml of blood loss <15% of blood loss Pulse < Normal Blood Pressure RR is 14- 20

Urinary Output >30 ml/hr CNS: slightly anxious Fluid Replacement: Crystalloid Describe Class II hypovolemic shock: (8 answers) - CORRECT ANSWER- 750 - 1500 ml of blood loss 15 - 30% of blood loss Pulse 100- 120 Normal Blood Pressure RR is 20- 30 Urinary Output 20-30 ml/hr CNS: Mildly anxious Fluid Replacement: Crystalloid Describe Class III hypovolemic shock: (8 answers) - CORRECT ANSWER- 1500 - 2000 ml of blood loss 30 - 40% of blood loss Pulse 120- 140 Decreased Blood Pressure RR is 30 - 40 Urinary output 5-20 ml/hr CNS: Anxious and confused Fluid Replacement: Crystalloid and Blood Describe Class IV hypovolemic shock: (8 answers) - CORRECT ANSWER->2000 ml of blood loss

40% of blood loss HR > Decreased Blood Pressure RR > Urinary output: negligible CNS: confused and lethargic Fluid Replacement: Crystalloid and Blood During which class of hypovolemic shock does blood pressure begin to decrease? - CORRECT ANSWER-Class III

Which class of hypovolemic shock should have consideration for blood replacement? - CORRECT ANSWER-Class III When evaluating the HR in hypovolemic shock, what should be considered? - CORRECT ANSWER-Patients taking beta- blockers will not present with an increase in heart rate Rather than Systolic or Diastolic BP, what are better indicators of shock? - CORRECT ANSWER-Pulse Pressure (PP) or Mean Arterial Pressure (MAP) How do you calculate the Mean Arterial Pressure (MAP)? - CORRECT ANSWER-Diastolic Pressure x2 PLUS Systolic Pressure x Divide the total by 3 Ex: 120/ 70+70+120 = 260, then divide by 3 = 86. What is the treatment for hypovolemic shock? - CORRECT ANSWER-Aggressive airway management Control Hemorrhage IV/IO Access Fluid Resuscitation Prevent Hypothermia Describe aggressive airway management in hypovolemic shock treatment: - CORRECT ANSWER-100% oxygen via non- rebreather with a goal of maintaining the SpO2 between 94% and 98% Consider intubation and mechanical ventilation (avoid excessive pressure to protect the blood pressure) Describe Hemorrhage control in hypovolemic shock. - CORRECT ANSWER-Apply direct pressure Apply splints Timely OR (operative) intervention

Describe the insertion point of an IO to the distal femur. - CORRECT ANSWER-Anterior midline above external epicondoyles, 1-3 cm above femoral plateau. What are some positioning techniques for inserting an IO in the distal femur? - CORRECT ANSWER-The knee should be slightly flexed, the hip externally rotated and flexed Where is the insertion point for an IO into the Distal Tibia? - CORRECT ANSWER-Just proximal to the medial malleolus What are some positioning techniques for inserting an IO in the distal tibia? - CORRECT ANSWER-Slightly abduct and externally rotate the hip, angle the needle 10-15% cephalad Where is the insertion point for an IO in the Humerus? - CORRECT ANSWER-Directly above the greater tuberosity What are some positioning techniques for inserting an IO in the humerus? - CORRECT ANSWER-Adduct the shoulder with the palm of hand over umbilicus, so the greater tuberosity is prominent. Insert the needle at a 90 degree angle directly into the greater tuberosity. Where is the insertion point for an IO in the proximal tibia? - CORRECT ANSWER-2 cm distal and slightly medial to the tibial tuberosity What are some positioning techniques for inserting an IO in the proximal tibia? - CORRECT ANSWER-Support the flexed knee by placing a towel under the calf List 4 ways to ensure IO placement: - CORRECT ANSWER- Needle should stand up on its own

Aspirate bone marrow (note the presence of marrow confirms placement, but the lack of marrow does not rule out placement) Push a 5-10 ml bolus of crystalloids; resistance should be minimal, and extravasation should not be evident (watch the calf area) Fluid may run via gravity, but an IV pump or pressure bag is needed to flow fast enough for resuscitation What are some contraindications of IO placement? - CORRECT ANSWER-Fractures of the bone Previous attempts in the same bone Can IO access be long term? - CORRECT ANSWER-No Ideally, how soon should an IO be discontinued? - CORRECT ANSWER- 3 - 4 hours In exceptional cases, how long can an IO be used? - CORRECT ANSWER- 72 - 96 hours What are some risks with long term IO usage? - CORRECT ANSWER-Higher rate of infection Dislodgement Which fluids are Chrystalloid? - CORRECT ANSWER-Normal Saline Lactated Ringers What is the replacement ratio for fluid loss in hypovolemic shock? - CORRECT ANSWER-3 ml of Crystalloid for each 1ml of blood loss 3: In hypovolemic shock, if blood loss is unknown, how much fluid bolus should an adult receive? - CORRECT ANSWER- 1 - 2 L of fluid

In hypovolemic shock, if blood loss is unknown, how much fluid should a child receive? - CORRECT ANSWER-20 ml/kg List some colloid fluids: - CORRECT ANSWER-Albumin, Hetastarch, Dextran What is a protein-based colloid? - CORRECT ANSWER- Albumin What are some non-protein-based colloids? - CORRECT ANSWER-Hetastarch Dextran In hypovolemic shock, what is the ratio of replacement for colloid fluids? - CORRECT ANSWER-1 ml of colloid fluid for each 1 ml of blood loss Compare intravascular persistence between crystalloid and colloid fluids. - CORRECT ANSWER-Crystalloid - poor intravascular persistence Colloid - good intravascular persistence Compare crystalloid and colloid fluids regarding hemodynamic stabilization. - CORRECT ANSWER-Colloid has prolonged hemodynamic stabilization, crystalloid has transient hemodynamic stabilization In comparing crystalloid and colloid fluids, which requires a larger infusion volume? - CORRECT ANSWER-Crystalloid requires a larger infusion volume Compare the risk of tissue edema between crystalloid and colloid fluids. - CORRECT ANSWER-Crystalloid has an obvious risk of tissue edema while Colloid has an insignificant risk of tissue edema.

Compare crystalloid and colloid fluids regarding the enhancement of capillary integrity. - CORRECT ANSWER- Crystalloid fluids have poor enhancement of capillary integrity. Colloid fluids have good enhancement of capillary integrity. Compare crystalloid and colloid fluids regarding the risk of anaphylaxis. - CORRECT ANSWER-Crystalloid fluids - No Risk of anaphylaxis Colloid fluids - Low to Moderate risk of anaphylaxis How do crystalloid fluids change colloid oncotic pressure? - CORRECT ANSWER-Crystalloid fluids reduce colloid oncotic pressure Describe the cost of crystalloid and colloid fluids. - CORRECT ANSWER-Crystalloid - Inexpensive Colloid - More expensive Describe whole blood transfusion. - CORRECT ANSWER- Contains all components (PRBC, Platelet, FFP, Cryoprecipitate) but may be deficient in clotting factors. Which blood component does NOT require an ABO status prior to transfusing? - CORRECT ANSWER-Platelets What is the typical volume of a unit of whole blood? - CORRECT ANSWER-500 ml per unit of whole blood What is the dosage for transfusing whole blood in pediatric patients? - CORRECT ANSWER-20 ml/kg in the pediatric patient How does one unit of PRBC's affect the hemoglobin/hematocrit? - CORRECT ANSWER-1 Unit of PRBC should raise the Hgb by 1 g/dL and teh hct by 3%

What is the typical volume of a unit of PRBC's? - CORRECT ANSWER-250 ml per unit of PRBC's What is the dosage for transfusing PRBC's in the pediatric patient? - CORRECT ANSWER-10 ml/kg in the pediatric patient How does transfusing 1 unit of platelets change the platelet coung? - CORRECT ANSWER-Transfusing 1 unit of platelets elevates the platelet count 5,000 to 10,000 u/dL What is the dosage for transfusing Platelets in the pediatric patient? - CORRECT ANSWER-1 unit of platelets for each 7- 10 kg in the pediatric patient How long does it take for Fresh Frozen Plasma to thaw? - CORRECT ANSWER- 20 minutes are required to thaw FFP Once thawed, within how many hours must FFP be transfused?

• CORRECT ANSWER-6 hours to transfuse FFP Describe cryoprecipitate. - CORRECT ANSWER-Rich in factor VIII, Fibrinogen, von Willebrand's Factor and Factor XIII What blood type is the universal donor for PRBC's? - CORRECT ANSWER-O Negative is the universal donor for PRBC's What is the universal donor type for FFP? - CORRECT ANSWER-AB Negative is the universal donor for FFP If a patient's blood type is A, what type of PRBC's and what type of FFP can they receive? - CORRECT ANSWER-Patient : Type A = PRBC - Type A and Type O FFP - Type A and Type AB

If a patient's blood type is B, what type of PRBC's and what type of FFP can they receive? - CORRECT ANSWER-Patient: Type B = PRBC - Type B and Type O FFP - Type B and Type AB If a patient's blood type is AB, what type of PRBC's and what type of FFP can they receive? - CORRECT ANSWER-Patient: Type AB PRBC - Type A, Type B, Type AB, Type O FFP - Type AB If a patient's blood type is O, what type of PRBC's and what type of FFP can they receive? - CORRECT ANSWER-Patient: Type O PRBC - Type O FFP - Type A, Type B, Type AB, Type O What type of Rh transfusions must a person with RN Neg. blood receive? - CORRECT ANSWER-A person with Rh NEG must receive Rh NEG blood if they may carry children in the future What type of transfusions can a person with Rh POS blood receive? - CORRECT ANSWER-A person with Rh+ may receive Rh- and Rh+ blood List 5 complications associated with PRBC's. - CORRECT ANSWER-Hypothermia Hyperkalemia Hypocalcemia Acidosis Coagulopathies Why is hypothermia a concern with PRBC transfusion? - CORRECT ANSWER-Hypothermia is a concern with PRBC transfusion becasue it:

Inhibits efforts to reverse metabolic acidosis and slows the clotting cascade. Why is Hyperkalemia a concern with PRBC transfusion? - CORRECT ANSWER-Hyperkalemia is a concern with PRBC transfusion because: It may affect cardiac contractility and drive arrhythmias Why is Hypocalcemia a concern with PRBC transfusion? - CORRECT ANSWER-Hypocalcemia is a concern with PRBC transfusion because: If more than 10 units of blood or blood products are given more than every 5 minutes, monitor calcium levels and be prepared to administer calcium chloride or calcium gluconate. Calcium is required for clotting. What electrolyte is required for clotting? - CORRECT ANSWER-Calcium is required for clotting. What does extravasation of calcium chloride or calcium gluconate cause? - CORRECT ANSWER-Extravasation of calcium chloride or calcium gluconate causes tissue necrosis. What is the pH of banked blood? - CORRECT ANSWER-The pH of banked blood is 7. Why is acidosis a concern with PRBC transfusion? - CORRECT ANSWER-The pH of banked blood is 7.1, acidotic. Acidosis can cause arrhythmias. Why are coagulopathies a concern with PRBC transfusion? - CORRECT ANSWER-PRBC's contain few clotting factors. What 4 negative impacts do traditional fluid rescuscitation (2L of crystalloid fluids followed by PRBCs) have? - CORRECT ANSWER-Hemodilation Coagulopathies

Organ Dysfunction Compartment Syndrome Describe damage control resuscitation. - CORRECT ANSWER- Attempts to reduce complications associated with traditional fluid restriction. Minimizes amount of crystalloid fluids used. Utilized PRBC's, Plasma and Platelets as opposed to PRBC's alone Compare Whole blood transfusion with Damage control resuscitation in regard to volume. - CORRECT ANSWER-One unit of Whole Blood = 500 mL Damage Control Resuscitation = 660 mL How does one unit of whole blood affect hematocrit compared to how damage control resuscitation affects hematocrit - CORRECT ANSWER-Hematocrit: Whole Blood = 38-50 % Damage Control = 29% Compare platelet count in whole blood vs. Damage control resuscitation - CORRECT ANSWER-Platelet Count: Whole Blood = 150,000-400, Damage Control = 87, Compare coagulation activity in whole blood vs. damage control resuscitation. - CORRECT ANSWER-Coagulation Activity: Whole Blood = 100% Damage Control = 65% Compare Fibrinogen content in whole blood vs. damage control resuscitation. - CORRECT ANSWER-Fibrinogen: Whole Blood = 1500 mg Damage Control = 750 mg

Compare the amounts of anticoagulants / additives between whole blood and damage control resuscitation. - CORRECT ANSWER-Anticoagulants / Additives: Whole Blood = 63 mL Damage Control = 205 mL List 3 disadvantages to transfusing whole blood. - CORRECT ANSWER-Must be used within 24-48 hours for maximal effectiveness. Increased risk of disease transmission. Lacks a universal donor What is permissive hypotension? - CORRECT ANSWER- Providing minimal fluid resuscitation allowing the blood pressure to remain low What are advantages of permissive hypotension? - CORRECT ANSWER-Decreases liklihood of coagulopathy Less likely to cause hypothermia Decreases risk factors that cause acidosis Diminishes dislodgment of clots due to elevated pressure. What is the ideal pressure for survival? - CORRECT ANSWER- Approximately 70/40 mmHg What are the risk factors of permissive hypotension? - CORRECT ANSWER-Permissive hypotension can: Exacerbate head injuries Is not safe for pediatric or elderly patients What vital sign is non-predictive of the state of tissue perfusion in the acute traumatic setting? - CORRECT ANSWER-Blood Pressure is non-predictive of the state of tissue perfusion in the acute traumatic setting. Urinary output of less than _____ is an early sign of inadequate perfusion. - CORRECT ANSWER-0.5 ml/kg/hr

What 3 things must be considered when measuring urinary output in the trauma patient? - CORRECT ANSWER-Diabetes Insipidus Renal Failure Diuretic Therapies When assessing mental status in the trauma patient, what must be considered? - CORRECT ANSWER-Pre-Existing conditions Alcohol Drugs How often is invasive hemodynamic monitoring used in trauma? - CORRECT ANSWER-Hemodynamic Monitoring - No often - not used in many patients because of complications What does Central Venous Pressure (CVP) meausre? - CORRECT ANSWER-CVP measures Right Ventricular Preload What is the normal range for CVP? - CORRECT ANSWER- Normal CVP = 2-6 mmHg What does Pulmonary Wedge Pressure (PWP) measure? - CORRECT ANSWER-PWP measures Left Ventricular Preload / Right Ventricular Afterload What is the normal range for PWP? - CORRECT ANSWER- Normal PWP is 8-10 mm Hg What does Cardiac Index (CI) measure? - CORRECT ANSWER-CI measures cardiac output adjusted to body size. What is the normal range for CI? - CORRECT ANSWER- Normal CI = 2.5-4.0 L/minute/m What does DO2 measure? - CORRECT ANSWER-DO measures delivery of oxygen

What is the normal range for DO2? - CORRECT ANSWER- Normal DO2 is 500- 6 00 mL O2 / min / m _____ is a byproduct of inadequate tissue oxygenation. - CORRECT ANSWER-Lactate Describe mortality rates related to lacate. - CORRECT ANSWER-Patients whose lactate levels do not normalize have a higher mortality rate. _____ does not detect abnormal regional perfusion. - CORRECT ANSWER-Lactate _____ measures buffering capacity of the blood reflecting metabolism and depth of hemorrhagic shock. - CORRECT ANSWER-Base Defecit A base defecit of _____ is a marker of severe injury. - CORRECT ANSWER-Base Defecit > 6 mmol/L A base defecit of more than 5 mEq/L or a serum lactate level greater than 4.0 mmol/L indicates _____. - CORRECT ANSWER-Widespread Tissue Hypoperfusion List 5 interventions to prevent hypothermia. - CORRECT ANSWER-Warm fluids to ensure normal body temperature ( C or 98.8 F) Remove wet or blood soaked clothing/dressings Keep the patient covered (including the head) Increase the ambient temperature of the room Damage control surgery What is MODS? - CORRECT ANSWER-Multi-Organ Dysfunction Syndrome List 5 early signs of MODS. - CORRECT ANSWER-Fever

Tachycardia Dyspnea Infiltrates on the chest x-ray Hypermetabolism (Cardiac Index > 5, SVR less than 600, hyperglycemia) What are progressive signs of MODS between days 7 & 10. - CORRECT ANSWER-Bilirubin and creatinine climb Impared wound healing and skin breakdown What are progressive signs of MODS between days 14 & 21? - CORRECT ANSWER-Inotropes and volume required to maintain cardiovascular status Renal dysfunction worsens, dialysis required Death ensues 21-28 days after the initial insult What is the mortality in MODS with 1 organ failure? - CORRECT ANSWER-20% Mortality What is the mortality in MODS with 2 organs failing? - CORRECT ANSWER-54% Mortality What is the mortality in MODS with Four or More organs failing? - CORRECT ANSWER-70% Mortality List 6 findings associated with MODS. - CORRECT ANSWER- Cardiovascular: SBP<90, MAP< Lungs: Infiltrates on x-ray, persistent acidosis Lactate: greater than 4 mmol/L Liver: bilirubin > 2 mg/dL Hematology: Platelet count < 100,000, signs of coagulopathy Renal: Creatinine > 2 or urinary output < 0.5 mL/kg/hr What are the treatments for MODS? List 5 - CORRECT ANSWER-IV Insulin to keep glucose < 150 FSBS Q 1-2 hr Maintain normotension with vasopressors or inotropes

Prevent DVT with low-dose heparin, SCDs, compression stockings Prevent stress ulcers - H2 blockers or proton pump inhibitors List 6 factors that cause coagulopathy. - CORRECT ANSWER- Hypothermia Consumption Fibrinolysis Acidosis Dilution Blood Loss List 4 symptoms of abnormal clotting. - CORRECT ANSWER- Metabolic Acidosis Mottling Gangrene Organ Failure List 7 symptoms of abnormal bleeding - CORRECT ANSWER- Bruising Petechiae Purpura Epistaxis Bleeding Gums GI Bleeding Hematuria Describe what happens to platelet count with coagulopathy - CORRECT ANSWER-Platelet count decreases Describe whta happens to PT and PTT with coagulopathies. - CORRECT ANSWER-PT and PTT increase Describe what happens to the fibrinogen level with coagulopathies. - CORRECT ANSWER-Fibrinogen level decreases

Describe what happens to the D-Dimer in coagulopathies - CORRECT ANSWER-D-Dimer increases Describe what happens to Hemoglobin and Hematocrit levels in coagulopathies. - CORRECT ANSWER-Hemoglobin and Hematocrit decrease What are the treatments for coagulopathies? - CORRECT ANSWER-Prevention: Keep patient warm, minimize acidosis, prevent dilution, and early administration of clotting factors What are the pharmacologic treatments for coagulopathies? - CORRECT ANSWER-Heparin Aminocaproic acid (Amicar) Recombinant Factora VIIa Therapy What are the ways to control bleeding in coagulopathies? - CORRECT ANSWER-Limit venipuncture Apply direct pressure to bleeding sites Handle patient gently Define neurogenic shock. - CORRECT ANSWER-Failure of the sympathetic nervous system List 6 causes of neurogenic shock. - CORRECT ANSWER- Spinal cord injuries above T4-T Brain Injury Large doses of CNS depressants Hypoxia Lack of glucose / excessive insluin Vasovagal syndrome List the symptoms of neurogenic shock. (7) - CORRECT ANSWER-Hypotension (due to vasodilation) Glyconeogenesis Dry Skin Bradycardia

Decreased contractility Decreased automaticity Decreased respiratory rate What are the treatments for neurogenic shock? (5) - CORRECT ANSWER- 1 - 2 L fluid bolus Vasopressors Goal: MAP of 85-90 mm HG Atropine Assist with respirations as needed What are the risks of administering 1-2L fluid bolus in patient's with neurogenic shock? - CORRECT ANSWER-Volume is often insufficient and may contribute to fluid overload and pulmonary edema List some vasopressors that may be administered in neurogenic shock. - CORRECT ANSWER-Norepenephrine, Dopamine, Epinephrine, Phenylephrine or Vasopressin What is the goal MAP in patients with neurogenic shock? - CORRECT ANSWER-Goal MAP of 85-90 mm Hg Describe septic shock. - CORRECT ANSWER-Infection: Presence of micro-organisms in localized tissue causing a localized inflammatory response. Define Systemic Inflammatory Response Syndrome (SIRS) - CORRECT ANSWER-Signs of infection or inflammatory response with 2 or more of the following: Temp > 38 C or below 36 C HR > 90 RR > 20 or PaCO2 < 32 Acute AMS WBC > 12, < 4, or >10% bands (immature forms) Hyperglycemia (serum glucose >120 with no diabetes)

Define Sepsis. - CORRECT ANSWER-Presence or suspicion of infection with two of more of the SIRS criteria Define Severe Sepsis. - CORRECT ANSWER-Sepsis associated with organ dysfuction, hypoperfusion or hypotesnsion including lactic acidosis, oliguria and acute alteration in mental status. In order for Sepsis to be Severe Sepsis, an infection must be present with any symptoms of organ dysfunction such as _____. - CORRECT ANSWER-SBP < 90 or MAP <65 Respiratory Insufficiency Creatining > 2 or UO < 0.5 mL/kg/hr Bilirubin > 2 Platelets < 100 Coagulopathy Lactate > 4 Define septic shock. - CORRECT ANSWER-The patient that meets criteria for severe sepsis AND is hypotensive (SBP < 90 which is not reversed with fluid resuscitation). Often includes, lactic acidosis, oliguria and AMS. What is the definition of MODS? - CORRECT ANSWER- Presence of altered organ function in an acutely ill patient; homeostasis cannon be maintained without intervention. What are the treatments for sepsis? - CORRECT ANSWER- Pulse Ox > 93% - consider intubation to reduce oxygen demand MAP > 65 & CVP of 8 - consider dobutamine, levophed or dopamine if fluids are ineffective Identify source and control it within 6 hours of presentation Administer antibiotics within 1 hour of arrival Transfuse PRBC for hgb < 7, hct<30

Define obstructive output. - CORRECT ANSWER-Decreased cardiac output. List the signs of obstructive shock. - CORRECT ANSWER- Hypotension - AMS - Decureased UO - Sympathetic stimulation

• Tachycardia - Cool clammy skin - Increased lactic acid levels - metabolic acidosis List 7 causes of obstructive shock. - CORRECT ANSWER- Pregnancy Tension Pneumothorax Cardiac Tamponade PE Aortic Aneurysm Aortic Stenosis Excessive Positive end expiratory Pressure (PEEP) What is the treatment for obstructive shock related to pregnancy? - CORRECT ANSWER-Roll patient onto her side What is the treatment for obstructive shock related to Tension Pneumothroax? - CORRECT ANSWER-Chest tube / needle decompression What is the treatment for obstructive shock related to cardiac tamponade? - CORRECT ANSWER-Pericardiocentesis What is the treatment for obstructive shock related to PE? - CORRECT ANSWER-Thrombolytics What is the treatment for obstructive shock related to aortic aneurysm or aortic stenosis? - CORRECT ANSWER-Surgical intervention What is the treatment for obstructive shock related to excessive PEEP? - CORRECT ANSWER-Readjust ventilator settings

What is a crisis? - CORRECT ANSWER-Acute emotional upset that may interfere with the ability to cope emotionally, cognitively or behaviorally, rendering the person unable to solve problems by usual devices. List symptoms that prolonged crisis may cause. - CORRECT ANSWER-Disruption of family / divorces Depression Failure to return as a productive member of society / job loss Economic Problems Social isolation Decreased pleasure in leisure activities PTSD What are the ways to approach an individual in crisis? - CORRECT ANSWER-Help the individual clarify perception of the event and focus on the immediate situation Help the person identify individual who can be counted on to assist in management of the problem Help the person identify health coping mechanisms as opposed to unhealthy coping mechanisms What are some potential questions to help an individual clarify perception of the event and focus on the immediate situation? - CORRECT ANSWER-What does this mean to you? What does it mean to your future? How does it affect you right now? What are some potential questions to help an individual identify people who can be counted on to assist in management of the proglem? - CORRECT ANSWER-Is there someone we can call to support you right now? Who is your most comfortable source of support? Who can you most trust? What are some potential questions to help a person identify healthy coping mechanisms vs. unhealthy coping mechanisms?

• CORRECT ANSWER-Have you experienced anything like this before? What do you usually do when you feel like this? Have you ever coped with high-anxiety situations in the past? What did you try? List the 3 stages of crisis. - CORRECT ANSWER-Initial Stressor Intermediate Phase Rehabilitation Phase Describe the initial stressor phase of crisis. - CORRECT ANSWER-The focus is on whether the patient will survive the injury. Describe the intermediate phase of crisis. - CORRECT ANSWER-Adjustment to physical or emotional disabilities Describe the rehabilitation phase of crisis. - CORRECT ANSWER-Difficulties reintegrating back into the family and community In regard to an alteration in body image, how might a patient take control? - CORRECT ANSWER-By refusing to participate in care or by being non-compliant How do you respond to a patient who is being non-compliant relating to an alteration in body image? - CORRECT ANSWER- Assess the patient's perception of wounds Ask the patient about perception of wounds Allow the patient to achieve control by answering only questions the patient raises Answer questions in an accurate, factual, truthful and reassuring manner