NURS 445 Test III Shock Neurologic Disorders – Questions
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Terms in this set (106)
Shock A life-threatening condition with inadequate blood flow.
Cardiac Output Volume of blood pumped by the heart per minute.
Distributive Shock Venous pooling or increased vascular capacity due to disease
states such as sepsis, anaphylaxis or neurogenic shock that
causes poor vascular tone and vasodilation
Obstructive Shock Mechanical barrier affecting heart's filling or emptying.
Hypovolemic Shock Inadequate circulating volume due to rapid fluid loss.
Cardiogenic Shock Inadequate heart pumping, often from a heart attack.
The inability of the heart to pump blood forward
Stages of Shock Progression from compensatory mechanisms to organ failure.
Initial stage Clinical manifestations are subtle or subclinical
Compensatory Stage The body attempts to maintain perfusion despite the shock.
Marked by the initiation of compensatory mechanisms to
maintain adequate volume, cardiac output, and blood flow to
the tissues.
Stages of shock - compensatory Neural •Hypotension detected and epi/Norepinephrine is
released
Endocrine •RENAL RELEASE OF RENIN TRIGGERING ACE
PATHWAY, AND RAAS, ADH
Chemical •HYPOXIA IN AORTA AND CAROTID ARTERIES
STIMULATES TACHYPNEA LEADING TO RESP ALKALOSIS
AND CAROTID ARTERIES VASOCONSTRICTION
Progressive Stage of shock Compensatory mechanisms begin to fail
Refractory Stage of shock This stage of shock is irreversible. Severe acidosis and organ
failure occur. Cell death and tissue damage occurs from too
little O2 reaching the tissues. T
, Multisystem Organ Failure (MODS) Failure of multiple organ systems due to shock.
Hypoxia Symptoms Restlessness, confusion, and irritability in early stages.
Late Symptoms of Shock Lethargy and coma indicating severe shock.
Cardiovascular S&S of shock Capillary Refill sluggish refill (>3 seconds) indicates poor
perfusion.
Tachycardia
Narrow pulse pressure
Renal S&S of Shock Oliguria Decreased urine output in early shock stages.
Respiratory S&S of shock Respiratory Acidosis CO2 levels due to inadequate ventilation.
Signs of Hypovolemic Shock Early Pale, cool clammy skin, weak pulses, delayed cap refill,
and decreased urine output.
Late - Lethargy, cyanotic kin hypotension, respiratory acidosis
Nursing Management of hypovolemic shock •Neurological status
•Vital signs
•Urine output
•Daily weights
•Hemodynamic readings
•Skin color and temperature
Nursing Actions for Hypovolemic Shock Maximize Oxygenation - 100% nonrebreather
IV Access - 2 large-bore
Fluid replacement - Normal saline
Lactated Ringer’s solution
Blood products
Cardiogenic shock S&S •Chest pain
•Diaphoresis
•Nausea and vomiting
•Decreased cardiac output
•Hypotension, ↓L O C, ↓urine output, weak pulses, cool skin,
↓bowel sounds
•SOB, crackles, ↓spO2= pulmonary edema due to Left vent HF
•ABG= metabolic acidosis
•↑lactate levels=Tissue hypoxia
Cardiogenic Nursing Assessments •Neurological status: AMS
•Vital signs:↓BP, ↑RR, ↑HR
•Hemodynamic parameters
•Breath sounds: crackles
•Urine output: Oliguria
•Skin color and temperature: cold, clammy
Distributive Shock septic, neurogenic, anaphylactic
Distributive Shock S&S •Warm, dry skin
•Flushed appearance
•Decreased cardiac output
•Decreased systemic vascular resistance
Neurogenic Shock Shock due to disruption leads to loss of vasomotor tone due
to brain injury, general or spinal anesthesia, or spinal cord
injury
With Clear Solutions
Save
Students also studied
Sherpath: Diabetes Mellitus Chapter 21 Test Case Study 4 (Short
30 terms 24 terms 22 terms
jesssbee Preview kenanderson2017 Preview Brittany182
Terms in this set (106)
Shock A life-threatening condition with inadequate blood flow.
Cardiac Output Volume of blood pumped by the heart per minute.
Distributive Shock Venous pooling or increased vascular capacity due to disease
states such as sepsis, anaphylaxis or neurogenic shock that
causes poor vascular tone and vasodilation
Obstructive Shock Mechanical barrier affecting heart's filling or emptying.
Hypovolemic Shock Inadequate circulating volume due to rapid fluid loss.
Cardiogenic Shock Inadequate heart pumping, often from a heart attack.
The inability of the heart to pump blood forward
Stages of Shock Progression from compensatory mechanisms to organ failure.
Initial stage Clinical manifestations are subtle or subclinical
Compensatory Stage The body attempts to maintain perfusion despite the shock.
Marked by the initiation of compensatory mechanisms to
maintain adequate volume, cardiac output, and blood flow to
the tissues.
Stages of shock - compensatory Neural •Hypotension detected and epi/Norepinephrine is
released
Endocrine •RENAL RELEASE OF RENIN TRIGGERING ACE
PATHWAY, AND RAAS, ADH
Chemical •HYPOXIA IN AORTA AND CAROTID ARTERIES
STIMULATES TACHYPNEA LEADING TO RESP ALKALOSIS
AND CAROTID ARTERIES VASOCONSTRICTION
Progressive Stage of shock Compensatory mechanisms begin to fail
Refractory Stage of shock This stage of shock is irreversible. Severe acidosis and organ
failure occur. Cell death and tissue damage occurs from too
little O2 reaching the tissues. T
, Multisystem Organ Failure (MODS) Failure of multiple organ systems due to shock.
Hypoxia Symptoms Restlessness, confusion, and irritability in early stages.
Late Symptoms of Shock Lethargy and coma indicating severe shock.
Cardiovascular S&S of shock Capillary Refill sluggish refill (>3 seconds) indicates poor
perfusion.
Tachycardia
Narrow pulse pressure
Renal S&S of Shock Oliguria Decreased urine output in early shock stages.
Respiratory S&S of shock Respiratory Acidosis CO2 levels due to inadequate ventilation.
Signs of Hypovolemic Shock Early Pale, cool clammy skin, weak pulses, delayed cap refill,
and decreased urine output.
Late - Lethargy, cyanotic kin hypotension, respiratory acidosis
Nursing Management of hypovolemic shock •Neurological status
•Vital signs
•Urine output
•Daily weights
•Hemodynamic readings
•Skin color and temperature
Nursing Actions for Hypovolemic Shock Maximize Oxygenation - 100% nonrebreather
IV Access - 2 large-bore
Fluid replacement - Normal saline
Lactated Ringer’s solution
Blood products
Cardiogenic shock S&S •Chest pain
•Diaphoresis
•Nausea and vomiting
•Decreased cardiac output
•Hypotension, ↓L O C, ↓urine output, weak pulses, cool skin,
↓bowel sounds
•SOB, crackles, ↓spO2= pulmonary edema due to Left vent HF
•ABG= metabolic acidosis
•↑lactate levels=Tissue hypoxia
Cardiogenic Nursing Assessments •Neurological status: AMS
•Vital signs:↓BP, ↑RR, ↑HR
•Hemodynamic parameters
•Breath sounds: crackles
•Urine output: Oliguria
•Skin color and temperature: cold, clammy
Distributive Shock septic, neurogenic, anaphylactic
Distributive Shock S&S •Warm, dry skin
•Flushed appearance
•Decreased cardiac output
•Decreased systemic vascular resistance
Neurogenic Shock Shock due to disruption leads to loss of vasomotor tone due
to brain injury, general or spinal anesthesia, or spinal cord
injury
