TCRN - SPECIAL SITUATIONS (SHOCK, PSYCHOSOCIAL ISSUES RELATED TO TRAUMA, SIRS & MODS) EXAM, Exams of Nursing

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TCRN - SPECIAL SITUATIONS (SHOCK, PSYCHOSOCIAL ISSUES RELATED TO TRAUMA, SIRS & MODS) EXAM 2024 Describe the process of Obstructive Shock. ==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 ==ANSWER==Hypovolemic Distributive Cardiogenic Obstructive Describe hypovolemic shock ==ANSWER==Lack of Volume Describe distributive shock ==ANSWER==Mal-distribution of blood (vasodilation) Describe cardiogenic shock ==ANSWER==Inadequate cardiac output Describe obstructive shock ==ANSWER==Inability of blood to enter or exit the heart adequately What is another name for early hypovolemic shock? ==ANSWER==Compensatory Shock The adrenergic system is active during the _____ phase of shock. ==ANSWER==Compensatory The _____ system is active after the phase of shock has passed to bring the body back to a state of homeostasis. ==ANSWER==Cholinergic Another name for the sympathetic system is _____. ==ANSWER==Adrenergic system Another name for the parasympathetic system is _____. ==ANSWER==Cholinergic system What is the name of the process in which glycogen stores in the liver are broken down into glucose? ==ANSWER==Glycogeonolysis What is the process in which glucose in the serum is converted to glycogen for storage in the liver? ==ANSWER==Glyconeogenesis What is the term for the speed at which electricity moves through the heart? ==ANSWER==Automaticity What is the role of alpha receptors in the adrenergic (sympathetic) system? ==ANSWER==Vasoconstriction, Glycogeonolysis, Diaphoresis What is the role of the alpha receptors in the cholinergic (parasympathetic) system? ==ANSWER==Vasodilation, Glyconeogenesis, Dry Skin Sympathetic vs. Parasympathetic is also known as what? ==ANSWER==Fight or Flight; respectively What is the role of Beta-One receptors in the adrenergic (sympathetic) system? ==ANSWER==Increased: heart rate, contractility, automaticity What is the role of Beta-One receptors in the cholinergic (parasympathetic) system? ==ANSWER==Decreased: heart rate, contractility, automaticity What is the role of Beta-Two receptors in the adrenergic (sympathetic) system? ==ANSWER==Increased respiratory rate Bronchodilation What is the role of Beta-Two receptors in the cholinergic (parasympathetic) system? ==ANSWER==Decreased respiratory rate Bronchoconstriction Describe Class III hypovolemic shock: (8 answers) ==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) ==ANSWER==>2000 ml of blood loss >40% of blood loss HR >140 Decreased Blood Pressure RR >35 Urinary output: negligible CNS: confused and lethargic Fluid Replacement: Crystalloid and Blood During which class of hypovolemic shock does blood pressure begin to decrease? ==ANSWER==Class III Which class of hypovolemic shock should have consideration for blood replacement? ==ANSWER==Class III When evaluating the HR in hypovolemic shock, what should be considered? ==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? ==ANSWER==Pulse Pressure (PP) or Mean Arterial Pressure (MAP) How do you calculate the Mean Arterial Pressure (MAP)? ==ANSWER==Diastolic Pressure x2 PLUS Systolic Pressure x1 Divide the total by 3 Ex: 120/70 70+70+120 = 260, then divide by 3 = 86.67 What is the treatment for hypovolemic shock? ==ANSWER==Aggressive airway management Control Hemorrhage IV/IO Access Fluid Resuscitation Prevent Hypothermia Describe aggressive airway management in hypovolemic shock treatment: ==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. ==ANSWER==Apply direct pressure Apply splints Timely OR (operative) intervention Describe the insertion point of an IO to the distal femur. ==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? ==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? ==ANSWER==Just proximal to the medial malleolus What are some positioning techniques for inserting an IO in the distal tibia? ==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? ==ANSWER==Directly above the greater tuberosity What are some positioning techniques for inserting an IO in the humerus? ==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? ==ANSWER==2 cm distal and slightly medial to the tibial tuberosity What are some positioning techniques for inserting an IO in the proximal tibia? ==ANSWER==Support the flexed knee by placing a towel under the calf List 4 ways to ensure IO placement: ==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? ==ANSWER==Fractures of the bone Previous attempts in the same bone Can IO access be long term? ==ANSWER==No Ideally, how soon should an IO be discontinued? ==ANSWER==3-4 hours In exceptional cases, how long can an IO be used? ==ANSWER==72-96 hours What is the dosage for transfusing whole blood in pediatric patients? ==ANSWER==20 ml/kg in the pediatric patient How does one unit of PRBC's affect the hemoglobin/hematocrit? ==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? ==ANSWER==250 ml per unit of PRBC's What is the dosage for transfusing PRBC's in the pediatric patient? ==ANSWER==10 ml/kg in the pediatric patient How does transfusing 1 unit of platelets change the platelet coung? ==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? ==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? ==ANSWER==20 minutes are required to thaw FFP Once thawed, within how many hours must FFP be transfused? ==ANSWER==6 hours to transfuse FFP Describe cryoprecipitate. ==ANSWER==Rich in factor VIII, Fibrinogen, von Willebrand's Factor and Factor XIII What blood type is the universal donor for PRBC's? ==ANSWER==O Negative is the universal donor for PRBC's What is the universal donor type for FFP? ==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? ==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? ==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? ==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? ==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? ==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? ==ANSWER==A person with Rh+ may receive Rh- and Rh+ blood List 5 complications associated with PRBC's. ==ANSWER==Hypothermia Hyperkalemia Hypocalcemia Acidosis Coagulopathies Why is hypothermia a concern with PRBC transfusion? ==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? ==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? ==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? ==ANSWER==Calcium is required for clotting. What does extravasation of calcium chloride or calcium gluconate cause? ==ANSWER==Extravasation of calcium chloride or calcium gluconate causes tissue necrosis. What is the pH of banked blood? ==ANSWER==The pH of banked blood is 7.1 Why is acidosis a concern with PRBC transfusion? ==ANSWER==The pH of banked blood is 7.1, acidotic. Acidosis can cause arrhythmias. Why are coagulopathies a concern with PRBC transfusion? ==ANSWER==PRBC's contain few clotting factors. What 4 negative impacts do traditional fluid rescuscitation (2L of crystalloid fluids followed by PRBCs) have? ==ANSWER==Hemodilation Coagulopathies Organ Dysfunction Compartment Syndrome Renal Failure Diuretic Therapies When assessing mental status in the trauma patient, what must be considered? ==ANSWER==Pre- Existing conditions Alcohol Drugs How often is invasive hemodynamic monitoring used in trauma? ==ANSWER==Hemodynamic Monitoring - No often - not used in many patients because of complications What does Central Venous Pressure (CVP) meausre? ==ANSWER==CVP measures Right Ventricular Preload What is the normal range for CVP? ==ANSWER==Normal CVP = 2-6 mmHg What does Pulmonary Wedge Pressure (PWP) measure? ==ANSWER==PWP measures Left Ventricular Preload / Right Ventricular Afterload What is the normal range for PWP? ==ANSWER==Normal PWP is 8-10 mm Hg What does Cardiac Index (CI) measure? ==ANSWER==CI measures cardiac output adjusted to body size. What is the normal range for CI? ==ANSWER==Normal CI = 2.5-4.0 L/minute/m2 What does DO2 measure? ==ANSWER==DO2 measures delivery of oxygen What is the normal range for DO2? ==ANSWER==Normal DO2 is 500-600 mL O2 / min / m2 _____ is a byproduct of inadequate tissue oxygenation. ==ANSWER==Lactate Describe mortality rates related to lacate. ==ANSWER==Patients whose lactate levels do not normalize have a higher mortality rate. _____ does not detect abnormal regional perfusion. ==ANSWER==Lactate _____ measures buffering capacity of the blood reflecting metabolism and depth of hemorrhagic shock. ==ANSWER==Base Defecit A base defecit of _____ is a marker of severe injury. ==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 _____. ==ANSWER==Widespread Tissue Hypoperfusion List 5 interventions to prevent hypothermia. ==ANSWER==Warm fluids to ensure normal body temperature (37 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? ==ANSWER==Multi-Organ Dysfunction Syndrome List 5 early signs of MODS. ==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. ==ANSWER==Bilirubin and creatinine climb Impared wound healing and skin breakdown What are progressive signs of MODS between days 14 & 21? ==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? ==ANSWER==20% Mortality What is the mortality in MODS with 2 organs failing? ==ANSWER==54% Mortality What is the mortality in MODS with Four or More organs failing? ==ANSWER==70% Mortality List 6 findings associated with MODS. ==ANSWER==Cardiovascular: SBP<90, MAP<65 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 ==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. ==ANSWER==Hypothermia Consumption Fibrinolysis 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? ==ANSWER==Volume is often insufficient and may contribute to fluid overload and pulmonary edema List some vasopressors that may be administered in neurogenic shock. ==ANSWER==Norepenephrine, Dopamine, Epinephrine, Phenylephrine or Vasopressin What is the goal MAP in patients with neurogenic shock? ==ANSWER==Goal MAP of 85-90 mm Hg Describe septic shock. ==ANSWER==Infection: Presence of micro-organisms in localized tissue causing a localized inflammatory response. Define Systemic Inflammatory Response Syndrome (SIRS) ==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. ==ANSWER==Presence or suspicion of infection with two of more of the SIRS criteria Define Severe Sepsis. ==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 _____. ==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. ==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? ==ANSWER==Presence of altered organ function in an acutely ill patient; homeostasis cannon be maintained without intervention. What are the treatments for sepsis? ==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. ==ANSWER==Decreased cardiac output. List the signs of obstructive shock. ==ANSWER==Hypotension - AMS - Decureased UO - Sympathetic stimulation - Tachycardia - Cool clammy skin - Increased lactic acid levels - metabolic acidosis List 7 causes of obstructive shock. ==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? ==ANSWER==Roll patient onto her side What is the treatment for obstructive shock related to Tension Pneumothroax? ==ANSWER==Chest tube / needle decompression What is the treatment for obstructive shock related to cardiac tamponade? ==ANSWER==Pericardiocentesis What is the treatment for obstructive shock related to PE? ==ANSWER==Thrombolytics What is the treatment for obstructive shock related to aortic aneurysm or aortic stenosis? ==ANSWER==Surgical intervention What is the treatment for obstructive shock related to excessive PEEP? ==ANSWER==Readjust ventilator settings What is a crisis? ==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. ==ANSWER==Disruption of family / divorces Depression Failure to return as a productive member of society / job loss Economic Problems Social isolation How long does a full sleep cycle require? ==ANSWER==70-100 minutes How should you respond to a patient's loss of emotional control? ==ANSWER==Do not ridicule behavior Give the patient as much power as possible (ask for patient's views and preferences) Point out small achievements to help renew hope List 5 family responses to trauma. ==ANSWER==High anxiety Denial Anger Remorse Grief List some responses for high anxiety family response to trauma. ==ANSWER==Clarification and Restatements of information Information should be brief, explicit and straightforward Consider providing written information Ask family to repeat information to ascertain their understanding Identify key family members to direct communication to limit confusion. What are nursing responses to the denial family response to trauma? ==ANSWER==Find the delicate balance between the family's need to assimilate news with the need to deal with reality. Gently re-enforce reality Prolonged denial can be harmful, and may require more forceful confrontations of denial. What are some nursing responses to the anger family response to trauma? ==ANSWER==Anger may be directed at the patient, themselves, institution, health care team, God, society or life in general. Helps forestall pain in grief that will follow Anger needs to be given expression and to be accepted by the nurse without being taken personally Ask questions that help families realize the actual legitimacy of their anger, helping them to realize that fear, loss of control and guilt are driving anger What are some nursing responses to the remorse family response to trauma? ==ANSWER==Sorrow or guilt over the part of the family played may be displayed. Listen without judgment or rationalization. Avoid statements such as "you shouldn't blame yourself" or "All things happen for a reason" Encourage verbalization to defocus the issue and help the family work towards problem-solving. _____ is a necessary part of the response to trauma, and nurses should not rush to take care of this phase to make it better. ==ANSWER==Grief Is emotional pain necessary? ==ANSWER==Yes. Emotional pain is necessary to allow final healing. What interventions can be done for a grief family response to trauma? ==ANSWER==Non-judgmental listening. The nurse should not provide answers to families but ask questions like "what would it take to make you feel less guilty?, how will your family pull together to ensure everyone will be ok after this loss?" Avoid giving too much support, siding, blaming or assuming responsibility for others' feelings List the symptoms of depression. (8) ==ANSWER==Constant depressed mood and/or loss of interest or pleasure in life lasting more than 2 weeks Daily insomnia or hypersomnia Significant weight loss or weight gain Psychomotor agitation or retardation (fatigue) Feelings of worthlessness Excessive or inappropriate guilt (may be delusional) Diminished ability to make decisions Recurrent thoughts of suicide or death What are the treatments for depression? ==ANSWER==Antidepressants (may take 4-6 weeks to work) Verbal therapies Assess for SI (specific plan, time and instrument) and take precautionary measures. What is the typical onset of PTSD? ==ANSWER==3 months after the event (but can occur months or years afterward) Describe some symptoms of PTSD (7). ==ANSWER==Intense vivid memories Dreams/Flashbacks (often related to external cues) Patient may feel they are reliving the trauma Fear, grief and anger Avoidance phenomena that relates to thoughts or feelings associated with trauma or activities, places or people that arouse recollections of trauma Disintegration of relationships due to avoidance of close emotional ties, feeling detached and estranged from others Inability to fall asleep or stay asleep, outbursts of anger, difficulty concentrating, hypervigilance, exaggerated startle response List 5 Treatment goals for PTSD. ==ANSWER==Restore a sense of control to the individual Diminish the power of the traumatic event Reduce chronic hyperarousal Reduce feelings of guilt, anger and self-blame Restoring a sense of equilibrium What medications are prescribed for PTSD? ==ANSWER==SSRI TCA MAIO