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NAC- Shock #2
| Question | Answer |
|---|---|
| compensatory stage | BP normal, tissue perfusion OK, CO2 OK |
| Compensatory s/s | pulse increased, resp. increased, cold and clammy skin, decreased urine output, increased confusion |
| compensatory m/m | fluid replacement, treat cause |
| n/c for compensatory | assess mental changes, LOC, VS, pulse pressure, I & O, reduce anxiety, promote safety |
| Progressive stage | body starts to decompensate |
| progressive stage indicators | MAP falls, CO2 falls, systolic BP uder 90, heart ischemic, pump failure, increased lactic acidosis, blood pools in tissue |
| progressive stage s/s | tachypnea, dec. perfusion, inc. resp, tachycardia, weak and thready pulse, hypotension, pulse pressure narrows, LOC dec., Oliguria |
| progressive stage m/m | fluid, NS, LR1/2 NS, vasoactive meds, nutritional support, H2 blocker |
| n/c for progressive stage | assess resp., cardiac, and neuro, VS, CVP, PAWP, Allen test, ABG's, electrolytes, Strict I&O, monitor fluids and meds, mech. vent., IABP, mon. for infection, cough and deep breathe, safety, education, minimize activities, keep fam. informed |
| Mean arterial pressure | 70-80, avg. pressure at which blood moves through vasculature |
| Irreversible Stage | organ damage, does not respond to m/m, Mult. organ failure, metabolic acidosis |
| irreversible stage m/m | fluid, NS, LR 1/2 NS, vasoactive meds, nutritional support, H2 blockers, may need dialysis |
| n/c for irreversible stage | same as for progressive stage, allow family frequent access and inform them of prognosis |
| p/t for irreversible stage | life support measures, end of life decisions |
| advanced s/s | dec. LOC, cyanosis, bradycardia, cool moist skin, labored resp., anuria, dec. BP |
| Progressive stage effects on the lungs | Resp. rapid and shallow, crackles, ARDS |
| Progressive stage effects on the heart | disrhythmias |
| Progressive stage effects on the brain | hypoxia, confusion, lethargic, LOC dec., pupils dilate, Reduced reactivity to light |
| Progressive stage effects on the kidneys | Urine < 30ml/hr, >BUN and creatnin, >K+ (because it leaks out of cells) |
| Progressive effects on the liver | < metabolism, > liver enzymes (SGOT, SGPT, LDH) > jaundice |
| Progressive stage effects on the GI | > ischemia (leads to stress ulcers) coffee ground BM's, peulitic ileus, < metabolic nutrients, start TPN after 4 days |
| Progressive stage effects on hema | Intravascular clotting (disseminatied intravascular clotting) |
| First priority with patient | Est. airway |
| Second priority with pt. | Stop bleeding |
| Thrid priority with pt. | treat hypovolemic shock. Mon. urine output |
| Fourth priority with pt. | Assess for head and neck injuries |
| Fifth priority with pt. | Assess for other injuries |
| Sixth priority with pt. | Splint fractures |
| Seventh priority with pt. | Thorough exam and assessment |
Created by:
kssgmom
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