NURS 208/ NURS208 Exam 1 | Questions and Answers | Latest 2025/2026 Update | GRADED A | 100% Correct | Verified.

NURS 208/ NURS208 Exam 1 | Questions and Answers | Latest 2025/2026 Update | GRADED A | 100% Correct | Verified. Question: What is the essence of nursing? caring Question: Which theory says that caring is central to nursing, its a moral idea rather than behavior, holistic, often used as a basis of nursing practice, and is not inherited? jean watson theory of caring Question: What are the barriers and threats to caring? different levels of nurses, procedure and skill oriented culture Question: Intrinsic factors unseen aspects of nursing that are the core of nursing 10 carative factors Question: What are the 10 carative factor? 1. Altruistic values (doing this for the right reason), Sensitivity to others, A warm, genuine, & empathetic helping-trust relationship (put yourself in their place), Interpersonal teaching-learning (interactive thing between you and patient, teach as you go and learn from your patient), Scientific problem solving (nursing process), Acceptance of own feelings (negative & positive) (put your values to the side and give everything to your patient), Acceptance of others' feelings (negative & positive) (not taking things personally, Providing for comfortable, private, safe environment, Assist the patient with attaining lower & higher order needs (Maslow/basics, spirituality, sexuality), Phenomenology of existential psychology (question of existence and being) Question: What do all of the carative factors help do? preserve the human dignity of the patient Question: Knowing one's internal states, preferences, resources, and intuitions self awareness Question: Recognizing one's emotions & their effects. emotional awareness Question: Managing one's internal states, impulses, and resources, self-control (impulse control) trustworthiness, conscientiousness, adaptability, & innovation, integrity, personal performance self regulation Question: Keep disruptive emotions and impulses in check self control Question: Maintaining standards of honesty & integrity trustworthiness Question: Taking responsibilities for personal performance conscientiousness Question: Adeptness at inducing desirable responses in others (good communicator-listen openly & sending convincing messages) social competence Question: QSEN quality and safety education in nursing Question: Are medical diagnoses (MD is the first place you need to look for a HCP) health care problems (HCP) Question: What is the starting point for the nursing dx? health care problems (HCP) Question: Reaction to stimulus (HCP); how patient reacts to stressor, problem, difficulty or illness. **Nurses take care of these. May not be related to medical problem; Nursing Dx comes from patient response human responses Question: True or false? An actual HCP can cause actual or potential responses. true Question: True or false? potential HCP can cause actual or potential responses. true Question: Which of the following describes the HCP the best: -thirst -low Na -anti-hypertensives -fluid volume deficit -congestive heart failure -congestive heart failure Question: Systematic, circular framework for planning & providing individualized nursing care to patients nursing process Question: Can nurses treat these independently: Weakness Anxiety Discomfort Self-care deficit (SCD) - eating, bathing Hopelessness Pain yes Question: What are the 5 steps of the nursing process? *use ADPIE assessment diagnosis planning interventions/implementations evaluation Question: Is the nursing diagnostic statement a whole statement? yes Question: What is the nursing diagnostic category? example? the first part of the nursing diagnosis; ex. acute pain Question: R and HR risk and high risk Question: RC risk for complications (or potential complications) Question: What does a nurse monitor in an RC diagnosis? example? a change in state; onset ex. decreased cardiac output Question: NIC nursing intervention classification Question: NOC nursing outcome classification Question: First part of the nursing process; most important; Must be accurate to get enough data to make a clinical judgment assessment Question: A way to communicate between nurses; Basically putting a label on what we're seen the patient is experiencing, so we can take care of it diagnosis Question: If the problem exists in the patient (display cues and symptoms) and it can be treated independently by the nurse; example? actual nursing diagnosis impaired physical mobility, anxiety Question: If the problem does not exist (no cues or symptoms) and it can be independently prevented by the nurse; example? risk NDx High Risk (HR) for altered respiratory function Question: Problems that we can identify and Dx, but can't independently take care of (can be potential or collaborative) RC Question: Problems exist in patient, but cannot be independently treated by the nurse. It is something the nurse primarily monitors for changes in status while carrying out the MD's orders. Actual Collaborative Problems Question: If there is a potential for a problem or complication to arise, but does not exist in the patient and it cannot be independently prevented by a nurse. It is primarily something the nurse monitors for onset. potential complications Question: What are the 5 parts of a nursing diagnosis? 1. NDC 2. descriptor R/T 3. primary etiology S/T 4. secondary etiology AEB 5. Defining Characteristic how do you tell if your NDx is correct? read it backwards is this nDx correct? Pain (Acute) -R knee R/T tissue trauma S/T fractured kneecap S/T fall AEB verbalizes "I hurt", sweating, & grimacing yes Question: Is this NDx correct? Fluid Volume Deficit R/T decreased oral intake R/T lack of desire to drink R/T effects of chemotherapy S/T cancer AEB decreased skin turgor, intake record less than 100cc per shift, & decreased urine output. yes Question: Plan what outcome you want your patient to have; reduce, eliminate, and alleviate the problem, and formulate goals and outcome criteria planning Question: what do you want your patient to have; Should be nurse centered, general, broad, and long range; Usually opposite of the NDC; keep it simple; 2-3 words If deficit, then goal is to increase & if risk Dx "Prevent" is goal DO NOT put "pt" in goal Ex. NDx: acute pain, abdomen ---NG: Relieve Pain Nursing goals (NG Question: Focused on what we want the pt to say, feel, or demonstrate, exhibit, do, look like... Should be specific, patient centered, behavioral, measureable, short range List of things that prove you met the goal Ex: Pain Pt will state "I am not hurting anymore". Pt will exhibit relaxed facial features. Pt will state pain rating below 4. •Should be what you want to see the patient exhibit after interventions have helped achieve a nursing goal Should prove that the nursing goal has been met nursing objective Question: Do we use positive or negative statements? positive Question: Be positive Be specific and measurable Use ranges Should be yes or no Include reasonable time frame Outcome criteria Question: What is BMCT used to remember? Outcome criteria Question: Out of BMCT, which one is optional? C, condition Question: What does BMCT stand for? Behavior Measure Condition Time frame Question: True or false? Nursing actions can only be delegates to nurses on the same level True Question: Which nursing action? Can decide to do these things with MD's order (compresses, increasing vital sign checks) Independent Question: Which nursing action? Must have an MD order to perform (giving meds, changing doses and frequency, start IV, ordering labs) Dependent Question: Which nursing action? Requires discussion and/or help of other disciplines working together with others, such as dietician or physical therapist Interdependent (collaborative) Question: What do you do during evaluation? Check to see if the interventions worked Question: What are the phases of evaluation? Identify expressed outcomes Assess patient Compare patient data with OC Relate OC to treatment effectiveness Draw conclusions Modify care plan Prescribed Tx Question: Three main functions of the lungs Gas exchange Oxygenation of blood Removal of waste products and carbon dioxide Lobes of the lungs 5 total, 3 on right, 2 on left Outer layer of lung where alveoli are Parenchyma Where is gas exchanged in the lungs? Alveolar unit Process of moving air into and out of the lungs Ventilation Movement of gases between the alveoli and the pulmonary capillaries Diffusion of gases Oxygen rich blood Saturated Oxygen poor blood Desaturated Saturated blood cells in the bloodstream and moved to the heart, then to every cell in the body Transport of gases What happens when there is a lack of hemoglobin? Oxygen has nothing to attach to What are some causes of transport problems? Malnutrition Low iron consumption Excessive bleeding Chemo Disease processes Anemia Why are people with anemia always tired? They don't get enough oxygen to their cells Desaturated blood is exchanged for saturated blood at the cellular level; exchange occurs between air and blood in the respiratory membrane Diffusion of gases What are the 3 things needed for breathing? Intercostal muscles Diaphragm Nerves The ease at which the lungs expand (stretch ability/elasticity of the lungs); depends on what kind of disease process is going on if this will be effective Compliance If the lungs are too stretchy, the patient will have problems exhaling. This is because of COPD or emphysema Tendency to collapse back to its original size; if there is a lack, the lung never goes back to its original shape Recoil The result of the air-liquid interaction at each alveolus; the tendency of liquid to minimize the surface area by contracting; affects recoil Surface tension Reduces surface tension, increasing compliance allowing the lung to inflate much more easily Surfactant Contraction of the diaphragm and intercostal muscles Muscular effort Upper or lower respiratory tract? Conducting zone Upper respiratory tract Is the mouth or nose more efficient for breathing? Nose Cilia, turbinates, tonsils, saliva, and sneeze reflex are defense mechanisms of the Upper respiratory tract 6 parts of the upper respiratory tract Nose Mouth Nasopharynx Oropharynx Laryngopharynx Larynx Upper or lower respiratory tract? Respiratory zone Lower What are the 6 parts of the lower respiratory tract? Trachea Bronchus Primary, secondary, and tertiary bronchioles Alveolar ducts Alveoli Respiratory capillarity network Serous membrane that covers the lungs; thin layer of fluid between the lungs and the pleura; potential space that can fill with pus, blood (hemothorax, or air (pneumothorax) Pleura After diffusion at the lung, oxygen must attach to Hemoglobin 2 causes of insufficient has exchange Not enough hemoglobin Not enough RBC 4 causes of anemia Malnutrition Low iron consumption Bleeding Disease process Anytime you increase metabolic rate, you _____ the demand for oxygen Increase What are 4 major factors effecting oxygenation? Environmental Lifestyle Developmental Health status/psychological What does a high altitude to to the oxygen level? What does heat do to metabolic rate and oxygen? Higher metabolic rate, more oxygen What does cold do to metabolic rate and oxygen? Lower metabolic rate, less oxygen Does smoking constrict or dial aye blood vessels? Constrict What do drugs and alcohol do to oxygen? Impair oxygen by causing poor nutrition intake, can depress respiratory center (especially in overdose), decreases rate and depth of respirations What does an overdose in narcotics cause? Respiratory acidosis Which 2 age groups are most at risk? Very young Very old Decreased fluid volume from decreased intake of hemorrhage; dehydration Hypovolemia Do upper airway conditions usually stop breathing? No More serious, often chronic; patient may not get enough oxygen and this can cause death Lower airway conditions Is asthma placed in the COPS category? No What are the 9 lower respiratory conditions? Asthma COPD Chronic obstructive bronchitis Emphysema Pulmonary edema Pulmonary embolism Pneumonia Atelectasis Pneumothorax Aka reactive airway disease Asthma 4th major cause of death Smoking Type of pneumonia occurring in elderly or bed ridden patients who remind in the same position Hypostatic pneumonia Type of pneumonia where there is an inhalation of gastric contents, food, or other substances Aspiration pneumonia What causes a tracheal shift to the affected side? Atelectasis Air in the plural space Pneumothorax Blood in the pleural space (usually traumatic) Hemothorax Pneumothorax that the air can enter pleural space, but can't get out by the same route Tension pneumothorax What are the causes of pneumo/hemo/tension thoraxes? Trauma Rib fracture Spontaneous Disease process/illness Blisters popping in alveoli What are the clinical manifestations of pneumo/hemo/tension thoraxes? Sharp sudden chest pain SOB Increased respirations Dyspnea Asymmetrical chest movements Distended veins in neck Diminished or absent breath sounds on effected side Medical term for inadequate gas exchange by the respiratory system Respiratory failure How much air do you need to inspire to cough effectively? 2.5 liters Indicates a central disease process Central cyanosis Localized condition Peripheral cyanosis Normal respiration rate 12-20 Normal pulse range 60-100 Cuff too narrow High Cuff too wide Low Unsupported arm High Insufficient rest prior to assessment High Repeating assessment too quickly High systolic low diastolic Cuff wrapped too loosely/unevenly High Deflating cuff too quickly Low systolic or high diastolic Deflating cuff too slowly High diastolic Arm above heart level Low Right after meals, smoking, or while in pain High Failure to ID auscultatory gap Low systolic high diastolic Acid/base balance is maintained by which 3 systems Chemic buffer system Lungs Kidneys what does the chemical buffer system react to? increase/decrease in level of hydrogen (H+) high or low? pH of acidic low high or low? pH of alkaline high many hydrogen atoms means acidic few hydrogen atoms means alkaline HCO3- bicarb PO4- phosphate an attempt to get rid of excess carbon dioxide; Very deep gasping type of respiration associated with severe DKA Kussmaul's Respirations rhythmic waxing and waning of respirations from deep to very shallow breathing and temporary apnea; causes are CHF, Increased ICP, Overdose of certain drugs Cheyne-Stokes Respirations shallow breaths interrupted by apnea; Seen in patients with CNS disorder Biot's (cluster) Respirations patient will try to blow out more carbon dioxide when they are in respiratory acidosis Patients respirations will slow down to conserve carbon dioxide when they are in metabolic alkalosis which method takes the longest to regulate acid/base balance? kidneys when the need to breathe is because of a lack of oxygen? hypoxic drive what is the normal need to breathe because of? high levels of carbon dioxide what causes people with emphysema to breathe? low oxygen hypercapnic too much carbon dioxide what is the normal range for pH? 7.35-7.45 this is the pressure exerted by carbon dioxide in the arterial blood partial pressure, P what is the normal range for partial pressure? 34-45 mmHg what does bicarb do? acts as a base, accepts hydrogen ions what is the normal range for bicarb? 20-28 mEq/liter what secretes bicarb? kidneys what is the normal partial pressure of oxygen (PO2)? 80-100 mmHg the degree to which Hgb is saturated with oxygen oxygen saturation what is the normal oxygen saturation? 95-98% If pH and PCO2 are inverse respiratory problem If pH and HCO3 are directly proportional metabolic problem common causes of respiratory acidosis Asthma COPD CNS depression due to: anesthesia/narcotic overdose Kidneys retain HCO3 (compensation) Hyperventilation to blow off CO2 common causes of respiratory alkalosis Hyperventilation Fever Respiratory infection common causes of metabolic acidosis Renal failure Diabetic ketoacidosis (DKA) Starvation common causes of metabolic alkalosis Chronic use of antacids Prolonged vomiting with loss of hydrochloric acid (HCL) what are 9 interventions for respiratory problems? positioning oxygen therapy breathing exercises incentive spirometry (IS) splinting mobilization of secretions pain management hydration ted hose true or false? oxygen therapy has to be ordered by a doctor true what is a nurses job wen it comes to oxygen delivery systems? maintaining it do you breathe in or out into the spirometer? out what does incentive spirometry do? Practice increases inspiratory volume Maintains alveolar ventilation Prevents atelectasis TC & DB turning, coughing, and deep breathing drainage by gravity of secretions from various lung segments Postural drainage PVD percussion, vibration, & postural drainage -put on patients from developing blood clots in the leg (pulmonary embolism) -has pressure gradient that squeezes to move blood back to the heart -maintain them because they can roll up and actually act like a tourniquet; they should be taken off every 8 hours for 20 minutes; put on from the toe and work your way up TED Hose best for patients with oxygen PRN cylinders oxygen concentration for cannulas 24-48% flow rate for cannulas 2-6 L oxygen concentration for face mask 40-60% flow rate for face mask 5-8 L oxygen concentration for partial rebreather 60-90% flow rate for partial rebreather 6-10 L oxygen concentration for nonrebreather 95-100% flow rate for nonrebreather 10-15 L oxygen concentration for venturi 24-40 or 50% flow rate for venturi 4-10 L oxygen concentration for face tents 30-50% flow rate for face tents 4-8 L which method of oxygen delivery requires the least amount of oxygen? tracheostomy the state in which the patient feels threat to respiratory status R/T inability to cough effectively ineffective airway clearance Ineffective or absent cough Inability to remove airway secretions Abnormal breath sounds Abnormal rate, rhythm, and depth ineffective airway clearance the state in which patients experience actual or potential loss of adequate ventilation R/T altered breathing patterns ineffective breathing patterns Changes in respiratory rate or pattern (from baseline) Changes in pulse (rate, rhythm, quality) Orthopnea- patient has to sit up to be able to breathe (dypsnea) Tachypnea- rapid breathing Hyperpnea- rapid breathing after exercise; body needs it Hyperventilation- increased depth of breathing ineffective breathing patterns patient has to sit up to be able to breathe (dypsnea) Orthopnea rapid breathing Tachypnea rapid breathing after exercise; body needs it Hyperpnea increased depth of breathing Hyperventilation reduction in one's physiologic capacity to endure activities to the degree desired or required activity intolerance Respiratory o Dyspnea o Excessively increased rate o SOB o Decrease in rate Pulse o Weak o Decreased o Excessively increased o Rhythm change o Failure to return to pre-activity level after 3 minutes Blood Pressure o Failure to increase with activity o Diastolic increased > 15 mmHg activity intolerance what causes activity intolerance? Pain Respiratory problems CHF can activity intolerance be R/T fatigue? no state in which patient is at risk for harm because of perceptual or physiologic deficit, lack of awareness of environmental hazards, or maturational age risk for injury is impaired gas exchange an independent function of nurses? no Passage of blood from point A to point B perfusion loss of living heart muscle as result of coronary artery occlusion myocardial infarction (MI) inability of heart to circulate blood effectively enough to meet the body's metabolic needs CHF abnormal rhythm of the heart dysrhythmia discrepancy between the apical & radial pulse pulse deficit open, clear, able to have things move through it patent hardening of arteries (old age) Arteriosclerosis plaques & clogging of arteries (starts in young children) Atherosclerosis DVT deep vein thrombus what does low fluid volume do? causes blood to be less mobile what does high fluid volume do? dilutes nutrients in patient and drowns in own fluids true or false? Doesn't fluctuate more than 0.2 kg (0.5 lb) in a day true 40-60% of body weight water any compound that when dissolved in water, separates into electrically charged ions electrolytes most common ions in the body Sodium (Na+) & calcium (Cl-) positive ions cations negative ions anions Na K Ca2 Mg2 H cations Cl HCO3 SO4 PO4 Proteinate anions Normal Electrolyte Values sodium 135-1454 mEq/L Normal Electrolyte Values potassium 3.5-5.0 mEq/L Normal Electrolyte Values chloride 95-108 mEq/L Normal Electrolyte Values calcium (total) 4.5-5.5 mEq/L Normal Electrolyte Values calcium (ionized) 56% of total Ca2+ (2.5 mEq/L) Normal Electrolyte Values magnesium 1.5-2.5 mEq/L Normal Electrolyte Values phosphate 1.8-2.6 mEq/L Normal Electrolyte Values serum osmolality 280-300 mOsm/kg water substances that do not have a charge nonelectrolytes most important nonelectrolyte glucose Makes up 2/3 of body fluid intracellular fluid (ICF) 40% of body weight intracellular fluid (ICF) what is mostly made up of K+, Mag+, SO4-, & PO4-? intracellular fluid (ICF) 1/3 of body fluid extracellular fluid what is mostly made up of Na+, Cl- , HCO3-? extracellular fluid Found in free or potential spaces such as around the brain, spinal cord, CSF, pleural spaces, synovial joint fluid, peritoneal fluid, and fluid in the free spaces of the abdomen transcellular true or false? Plasma and interstitial fluid have the same electrolytes and solutes, except for protein true salts; dissolve readily (NaCl & KCl) Crystalloids not readily dissolvable (proteins & glucose) Colloids dissolves solute; the component of a solution that can dissolve a solute; water solvent same osmolality as blood plasma; No movement of fluid or electrolytes between compartments; Normal Saline (0.9% NS); Ringers lactate isotonic lower concentration of solutes than normal body fluids; Net movement of water into cells (swollen red blood cells), lysis; D5 0.45% NS (D5 ½ NS); ½ Normal Saline (.45% NS) hypotonic higher concentration of solutes than is normal in body fluids; When ECF is hypertonic, there is net movement of water of out cells resulting in cell dehydration; Net movement of water out of cells (cellular dehydration); 3% saline hypertonic Movement of water, a pure solvent, through a semi-permeable cell membrane from an area of lesser concentration to an area of greater concentration osmosis is Osmolality inside or outside of the body? inside Measure of pulling power of plasma on water Osmolality what determines the pulling power? total concentration within a fluid compartment The pulling pressure is called osmotic pressure what has the greatest effect on serum osmolality sodium is Osmolarity inside or outside of the body? outside Colloid osmotic pressure is also called oncotic pressure Mechanism to maintain vascular volume; Keeps fluids in vascular compartment by pulling water back from interstitial space Colloid osmotic pressure or oncotic pressure about the pressure, not the solutes themselves; it is a mechanism to move solutes filtration pressure of liquid exerted within closed system on walls of the container it is contained in; this is blood pressure hydrostatic pressure what is hydrostatic pressure opposed by? osmotic pressure Difference between Osmotic pressure & Hydrostatic pressure filtration pressure which is higher? Venous hydrostatic pressure or arterial hydrostatic pressure arterial hydrostatic pressure atrial or venous end?hydrostatic pressure is greater than oncotic pressure and fluids and solutes move out of the capillaries atrial atrial or venous end?venous hydrostatic pressure is less than oncotic pressure, so fluids and wastes move back into the capillaries venous Movement of particles across cell membrane by chemical activity against the pressure gradient; uses energy active transport what are two examples of active transport? Na+/K+ pump Carrier molecules what carries glucose into the cell? insulin People feel thirsty when they lose how much of body water 0.5% The average adult intake mL/day total oral fluids intake mL total water in food intake 1000 mL total Water as a by-product of food metabolism 200 mL what are the four organs of water loss? kidneys skin lungs GI tract water loss where patient is aware Sensible water loss water loss where patient is unaware insensible water loss Necessary minimum to maintain body processes of kidneys, skin, lungs, and GI tract; 500 mL/day required; Total loss is approximately 1300 mL/day Obligatory loss Stored in pituitary gland -Regulates water excretion from the kidney -Released in response to changes in osmolality - Stops urine output -Increase in osmolality causes increase in ADH and kidneys conserve water -Put fluid from urine back into circulation -Decrease in osmolality causes suppression of ADH ADH` -Volume regulator -Released by the adrenal cortex (kidneys) -Result of dehydration -Sodium to be absorbed -Potassium to be excreted -Released by increase in potassium or dehydration -Counters dehydration -Causes sodium and water retentions -Respond to decreases in renal perfusion -If blood flow to kidney decreases, then these are released -Blood is diverted to the kidneys, also sodium and potassium are conserved aldosterone -Excreted by kidneys due to response to decreased blood flow to the kidneys -Causes blood to be diverted from other places & go to kidneys -Basically cause the kidneys to profuse more adequately -Renin is an enzyme -Angiotensin is hormone -Conserves sodium to restore blood volume -Excrete potassium -Angiotensin I and II are vasopressors that promote sodium and water retention and stimulate the release of aldosterone -Respond to decreases in renal profusion (how much blood is getting to the kidneys to make them work) Renin (enzyme)/angiotensin (beta oppressor) - Released from cells in the atrium of the heart - Response to hypervolemia & stretching of the atrial walls - promotes sodium wasting - Acts as a potent diuretic - Reducing vascular volume - Inhibits thirst by reducing fluid intake Atrial natriuretic factor (ANF) loss of Na+ Hyponatremia loss of water/excess Na+ Hypernatremia GI fluid loss Sweating Use of diuretics Hypotonic tube feedings Excessive drinking of water Excessive IV D5W administration Head injury AIDS Malignant tumors Hyponatremia Hyperventilation Fever Diarrhea Water depletion Parenteral administration of saline solutions Hypertonic tube feedings with adequate water Excessive use of table salt Conditions such as: Diabetes Insipidus (DI) Heat stroke Hypernatremia loss of K+ Hypokalemia Vomiting Gastric suction Diarrhea Heavy perspiration Use of K+ wasting drugs (ex. Diuretics) Poor intake of K+ Debilitated patients Alcoholics Anorexia nervosa Hyperaldosteronism Hypokalemia low Ca2+ Hypocalcemia Surgical removal of the parathyroid gland; conditions such as: Hypoparathyroidism Acute pancreatitis Hyperphosphatemia Thyroid carcinoma Inadequate vitamin D intake Malabsorption Hypomagnesemia Alkalosis Sepsis Alcohol abuse Hypocalcemia high Ca2+ Hypercalcemia Prolonged immobilization conditions such as Hyperparathyroidism Malignancy of the bone Paget's disease Hypercalcemia low Mg2+ Hypomagnesaemia Excessive loss from GI tract Nasogastric suction Diarrhea Fistula drainage Long term use of certain drugs Diuretics Aminoglycoside antibiotics Conditions such as: Chronic alcoholism Pancreatitis Burns Hypomagnesaemia high Mg2+ Hypermagnesaemia Abnormal retention of magnesium, as in: Renal failure Adrenal insufficiency Tx with Mg salts Hypermagnesaemia loss or gain of water only osmolar loss or gain of water and electrolytes isotonic Fluid lost from intravascular department is caused by isotonic fluid volume deficits Shift of fluids into potential spaces of the body or free spaces and can't be used Third Spacing When free fluid is found in the abdomen, it is called ascites interventions for which kind of shock? - Limit fluids - Head of bed (HOB) up - Don't give fluids fast - Don't want to increase volume because the heart is already stressed - Reverse trendelenburg Give: oxygen, vasodilators, vasopressors, nitroglycerin, IABP circulatory shock which kind of shock? decreased fluid volume (bleeding, lack of intake) related to: • Hemorrhage • Dehydration • 3rd spacing Hypovolemic Shock what are the 4 stages of hypovolemic shock? Initial- no visible S & S 2. Compensatory: body tries to keep blood pressure up by increased pulse; restless, pale 3. Decompensatory: low blood pressure, high pulse, decreased LOC 4. Irreversible- death interventions for which kind of shock? - Reduce overload - Prevent anymore escape of fluids - IV access & run fluids rapidly - Give blood & blood products - Keep patient warm - Trendelenburg - Increase blood flow to vital organs - HOB down hypovolemic shock which kind of shock? -Blockage of flow to great vessels, such as heart or lungs -Oxygen supply cut off in the aorta or vena cava -Can happen rapidly -Pulmonary embolus -Pneumothorax -Hemothorax Obstructive Shock interventions for which kind of shock? Treat & remove cause - Embolectomy - Ventilation - Clot dissolving drugs - Chest tubes Obstructive Shock which kind of shock? - Decrease in vessel tone - Enlarged vascular compartment - Vasodilation - Not circulatory system Distributive Shock what are 3 types of Distributive Shock? neurogenic shock anaphylactic shock septic shock blood vessels don't get signals from the sympathetic nervous system; could occur from spinal injuries, extreme emotions, severe pain drug overdose, general anesthetics, etc. (massive vasodilation) Neurogenic shock caused by a severe systemic allergic reaction; its life threatening; causes massive vasodilation; decrease in blood pressure, etc. Anaphylactic shock 50% mortality rate; its caused by progressed infection; the whole body becomes involved, pus the heart under great stress, and the heart eventually gives up (ex. Toxic shock) septic shock interventions for which kind of shock? treat and remove cause, Embolectomy, clot dissolving drugs, chest tubes, ventilation obstructive contain all components (RBC, platelets, plasma, proteins) -about 500 mL -used for extreme blood loss -Rarely given whole blood About 250 mL -Removed plasma (90% removed) -Improve volume of patient and so we do not over load the patient -Also with the plasma removed, we lower risk of getting hepatitis or HIV Packed Red Blood Cells (PRBC) -RBC removed -Used to increase clotting times and increase volume Fresh Frozen Plasma (FFP) Can be from one donor or random out of many units -Increased risk of contracting HIV because of several donors -Given for bleeding, platelet deficiency, aplastic anemia platelets Contains fibrinogen -From plasma -Given for special d/s and deficiencies of specific factor -Given to people with hemophilia Specific Factors (Cryoprecipitate) Globulins and proteins -Given for burns, liver failure and volume expansion in shock or massive hemorrhage -Good for 3rd spacing patients -Patient can have fluid overload if given too fast albumin state in which a person who can take fluids experiences or is at risk of experiencing dehydration (be sure to pay attention to the R/T) Fluid Volume Deficit hands and feet being cold, lack of temperature regulation; decrease in nutrition and respiration at the peripheral cellular level because of decrease in capillary blood supply Altered Tissue Perfusion (peripheral) state in which the patient experiences reduction in the amount of blood pumped to hear resulting in compromised cardiac function Decrease Cardiac Output (RC: Cardiac/ Vascular Dysfunction) state in which an individual is at risk of experiencing disruption in circulation, sensation, or motion of an extremity. Always monitor patient with cast for this; can cut off circulation HR Peripheral Neurovascular Dysfunction person experiencing increased pressure in limited space, such as fascial envelope, which compromises circulation and function, usually in forearm or leg. Swelling occurs beyond stretching limits of skin. RC: Compartment Syndrome