PN3 Exam 3 Review

Systemic inflammatory response syndrome (SIRS)- As infectious organisms enter the blood stream and they cause widespread inflammation, as a result of infections escaping local control • If you’re caring for a client with suspected sepsis, what clinical manifestations will support that diagnosis? Temp more than 101 or less than 96.5, HR 90, abnormal WBC with increased bands (immature neutrophils), elevated lactic acid or lactate levels • RF for shock: altered mobility, decreased thirst response, diminished immune response • Taking care of patient going into DIC after burns, included in plan of care would be avoiding IM injections • Caring for someone with suspected sepsis, the first 3hours you want to administer antibiotics, draw lactic levels, and obtain blood cultures BEFORE initiating antibiotics. • Tx for DIC: fresh frozen plasma • Know lab levels! Normal Lactic acid level is 0.5-1.0 • Working at community center, some self-management measures nurse can teach older adults to prevent shock are drinking fluids on regular schedule (because of decreased thirst response) • Client suffers massive blood loss after trauma, how do you correlate blood loss with patient’s mean arterial pressure? Lower blood volume, lowers mean arterial pressure • Anaphylactic shock because of medication you gave, administer epinephrine • Client with hypovolemic shock, expected finding will be oliguria (little to no urinary output) • Types of shock that are distributed shock: neurogenic, anaphylactic, and septic shock • Following a motor vehicle collision, a client presents unconscious with head and neck injuries, his skin is room temp, his BP is 80/40, HR is 46, and respirations are 12. What kind of shock is this? Neurogenic shock • Client experiencing a bing sting, dyspnea, shows signs of hypoxia. Administer epinephrine first • Common cause of cardiogenic shot is myocardial infarction • Patient diagnosed with HF of LV they are at risk for cardiogenic shock • Interventions for hypovolemic shock; monitor IV fluid replacement, monitor VS, assess for fluid overload manifestations, and monitor Hgb & Hct levels • Patient has BP 90/60temp 101, HR 116, resp 24, post op abdominal incision that is warm and red-this is septic shock • *There will be dosage calc* • ST elevation indicates an MI, you would NOT see that on an EKG for someone with stable angina • Client reports new onset for chest pain- nurse should immediately perform a 12 lead EKG (do this for clients who report pain in jaw, back, shoulder, and SOB) • Giving new prescription for nitroglycerin to a patient, call 911 if 1 tablet does not relieve pain, take 2 more tabs 5 minutes apart while waiting • Any angiogram they will inject contrast dye • Patient prescribed beta blocker for coronary artery disease, these meds end in -olol