NSG-430
What is your initial nursing intervention for a client just admitted for septic shock? -
CORRECT ANSWER -OBTAIN CULTURES
N.I. for shock - CORRECT ANSWER -Crystalloids + colloid fluids, blood transfusion, mechanical ventilation Vosyn (vancomycin + Zosyn)
Tx for obstructive shock - CORRECT ANSWER -once stable, find and relieve obstruction.
What are the stages of shock - CORRECT ANSWER -initial compensatory progressive refractory
What happens during initial stage of shock? - CORRECT ANSWER -BP drops and lactic acid builds, pt becomes cool and clammy, except if they're septic
What is your goal during the compensatory stage of shock? - CORRECT ANSWER - correct tissue perfusion, correct the shock! to prevent progressive stage
What do you do during progressive stage of shock - CORRECT ANSWER -JUST
PREVENT MODS!!!!
DO NOT GIVE FLUIDS THEY WONT HELP!!
MOVE THEM TO ICU
GIVE THEM VOSYN= VANCO+ZOSYN even if nephrotoxic drugs are horrible at this time
What happens during progressive stage of shock? - CORRECT ANSWER --hypoxemia occurs -mental status changes occur
-ANASARCA: diffuse profound edema caused by fluid leakage, causes crackles.
-sustained hypo perfusion causes WEAK PERIPHERAL PULSES -hypoperfusion leads to renal ischemia, so antibiotics are bad BUT WE STILL GIVE
ZOSYN B/C WE WANT TO GET RID OF SEPSIS
What is happening during refractory stage of shock? - CORRECT ANSWER -patient is in MODS. Recovery is unlikely.
Diagnostic to identify that someone is in shock - CORRECT ANSWER -elevation of lactate
- / 1