Shock - Quia
Transcript of Shock - Quia
1/3/2008
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MedicalMedical--Surgical Surgical Nursing CareNursing Care
Second EditionSecond Edition
Karen Burke
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Chapter 13Chapter 13Caring for Clients Experiencing Caring for Clients Experiencing Shock, Trauma, or Critical Shock, Trauma, or Critical IllnessIllness
Priscilla LeMoneElaine Mohn-Brown
ShockShockLifeLife--threatening conditionthreatening conditionInadequate blood flow and oxygen to tissues and cellsInadequate blood flow and oxygen to tissues and cells
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Stages of ShockStages of Shock
CompensatedCompensatedProgressiveProgressiveIrreversibleIrreversible
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Compensated ShockCompensated Shock
Decreased blood volume reduces cardiac output or Decreased blood volume reduces cardiac output or vasodilation occursvasodilation occursBlood pressure drops and normal tissue perfusion is Blood pressure drops and normal tissue perfusion is not maintainednot maintained
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Baroreceptors stimulate the sympathetic nervous Baroreceptors stimulate the sympathetic nervous system to release epinephrine and norepinephrinesystem to release epinephrine and norepinephrine
Compensated ShockCompensated Shock
Arterial blood vessels constrict, heart rate and Arterial blood vessels constrict, heart rate and strength of heart to contract increases, venous return strength of heart to contract increases, venous return increasesincreasesReninRenin––angiotensin system is activated, increasingangiotensin system is activated, increasing
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ReninRenin angiotensin system is activated, increasing angiotensin system is activated, increasing blood pressure and circulating blood volumeblood pressure and circulating blood volume
Antidiuretic hormone is released to increase blood pressureAntidiuretic hormone is released to increase blood pressure
Progressive ShockProgressive Shock
Compensatory mechanisms fail and organ functions Compensatory mechanisms fail and organ functions deteriorate deteriorate
CardiovascularCardiovascular——decreased cardiac output results in decreased cardiac output results in decreased oxygenation of cell and tissue ischemiadecreased oxygenation of cell and tissue ischemia
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RespiratoryRespiratory——increased carbon dioxide results in increased carbon dioxide results in respiratory acidosisrespiratory acidosisGastrointestinal systemGastrointestinal system——ulceration of mucosa results in ulceration of mucosa results in stress ulcers and sepsis, paralytic ileusstress ulcers and sepsis, paralytic ileusLiverLiver——failure leads to hypoglycemia, bacterial infectionsfailure leads to hypoglycemia, bacterial infections
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Progressive ShockProgressive ShockNeurologicNeurologic——decreased blood flow leads to decreased level decreased blood flow leads to decreased level of consciousness, coma, cerebral edema, and brain damageof consciousness, coma, cerebral edema, and brain damageRenalRenal——reduced blood flow causes oliguria and failurereduced blood flow causes oliguria and failureSkin and temperatureSkin and temperature——vasoconstriction leads to pale skin vasoconstriction leads to pale skin and mucous membranes, activation of sweat glands and mucous membranes, activation of sweat glands
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produces cool and clammy skin, body temperature produces cool and clammy skin, body temperature decreasesdecreases
Irreversible ShockIrreversible Shock
Multiple organ dysfunction syndrome (MODS)Multiple organ dysfunction syndrome (MODS)——tissue and cellular deathtissue and cellular death
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BOX 13BOX 13--11 Manifestations Found in Each Stage of Shock.Manifestations Found in Each Stage of Shock.
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Types of ShockTypes of Shock
HypovolemicHypovolemicAnaphylacticAnaphylacticCardiogenicCardiogenicSepticSeptic
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SepticSepticNeurogenicNeurogenic
Causes of Hypovolemic ShockCauses of Hypovolemic Shock
Decrease in circulating blood volume due to:Decrease in circulating blood volume due to:Hemorrhage due to traumaHemorrhage due to traumaSurgerySurgeryGI bleedingGI bleeding
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HemophiliaHemophiliaPostpartum hemorrhagePostpartum hemorrhage
Causes of Hypovolemic ShockCauses of Hypovolemic Shock
Internal fluid shifts due to:Internal fluid shifts due to:Cirrhosis with ascitesCirrhosis with ascitesPleural effusionPleural effusionPancreatitisPancreatitis
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Intestinal obstructionIntestinal obstruction
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Causes of Hypovolemic ShockCauses of Hypovolemic Shock
Loss of body fluids due to:Loss of body fluids due to:VomitingVomitingDiarrheaDiarrheaNasogastric suctioningNasogastric suctioning
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DiureticsDiureticsDiabetes insipidusDiabetes insipidus
Loss of fluids through skin due to diaphoresis or Loss of fluids through skin due to diaphoresis or burnsburns
Causes of Anaphylactic ShockCauses of Anaphylactic Shock
Immunologic reaction from antigens due to:Immunologic reaction from antigens due to:Food allergiesFood allergiesStings and bites from insectsStings and bites from insectsSnake venomSnake venom
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Substances used to diagnose and treat diseaseSubstances used to diagnose and treat diseaseLatex, pollen, molds, food additivesLatex, pollen, molds, food additives
Causes of Cardiogenic ShockCauses of Cardiogenic Shock
Failure of heart’s pumping action or other cardiac Failure of heart’s pumping action or other cardiac disordersdisorders
Myocardial infarctionMyocardial infarction
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Causes of Septic ShockCauses of Septic Shock
Overwhelming infection produced by toxins due to:Overwhelming infection produced by toxins due to:Age, <1 year, >65 yearsAge, <1 year, >65 yearsDebilitating disease processesDebilitating disease processesSurgery, invasive lines or tubesSurgery, invasive lines or tubes
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Drug therapyDrug therapy
Causes of Neurogenic ShockCauses of Neurogenic Shock
Changes in sympathetic tone of blood vessels due to:Changes in sympathetic tone of blood vessels due to:Spinal cord injury above T6 levelSpinal cord injury above T6 levelHead injuryHead injurySpinal anesthesiaSpinal anesthesia
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Opiate drug overdoseOpiate drug overdoseInsulin reactionInsulin reaction
Pathophysiology of ShockPathophysiology of Shock
Alteration in one or more factor:Alteration in one or more factor:Adequate blood flowAdequate blood flowCorrect heart pumping actionCorrect heart pumping actionNormal blood vessel diameter to maintain tissue perfusionNormal blood vessel diameter to maintain tissue perfusion
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Disruption of normal cell functionDisruption of normal cell functionInadequate tissue perfusion to sustain normal cellular Inadequate tissue perfusion to sustain normal cellular metabolismmetabolismProlonged shock results in hypoxia and cell death, then Prolonged shock results in hypoxia and cell death, then organ failure and deathorgan failure and death
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Manifestations of Hypovolemic Manifestations of Hypovolemic ShockShock
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Pathophysiology and Pathophysiology and Manifestations of Anaphylactic Manifestations of Anaphylactic
ShockShockAntigenAntigen––antibody reaction stimulates mast cells to antibody reaction stimulates mast cells to release histamine and other mediators, causing:release histamine and other mediators, causing:
VasodilationVasodilation
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HypotensionHypotensionHypovolemiaHypovolemia
Inflammation, bronchoconstriction, and cutaneous Inflammation, bronchoconstriction, and cutaneous reactions occur, causing a lifereactions occur, causing a life--threatening eventthreatening event
BOX 13BOX 13--33 Manifestations of Anaphylactic Shock.Manifestations of Anaphylactic Shock.
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Pathophysiology and Pathophysiology and Manifestations of Cardiogenic Manifestations of Cardiogenic
ShockShockVentricles fail to pump blood into the circulatory Ventricles fail to pump blood into the circulatory systemsystem
Decreased stroke volumeDecreased stroke volume
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Blood backs up in lungs causing:Blood backs up in lungs causing:Pulmonary edemaPulmonary edemaHypotensionHypotensionCardiac failureCardiac failure
BOX 13BOX 13--44 Manifestations of Cardiogenic Shock.Manifestations of Cardiogenic Shock.
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Pathophysiology and Pathophysiology and Manifestations of Septic ShockManifestations of Septic ShockAs bacteria are destroyed, endotoxins are releasedAs bacteria are destroyed, endotoxins are released
Damage tissuesDamage tissuesStarve cells of oxygen and nutrientsStarve cells of oxygen and nutrients
Histamine and other chemicals are releasedHistamine and other chemicals are released
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VasodilationVasodilationIncreased capillary permeabilityIncreased capillary permeabilityHypovolemia occursHypovolemia occurs
Microemboli form in capillaries causing cell damage Microemboli form in capillaries causing cell damage and deathand death
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BOX 13BOX 13--55 Manifestations of Septic Shock.Manifestations of Septic Shock.
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Pathophysiology and Pathophysiology and Manifestations of Neurogenic Manifestations of Neurogenic
ShockShockBlood vessels dilateBlood vessels dilate
Peripheral vasodilationPeripheral vasodilation
Blood poolsBlood pools
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Inadequate tissue perfusionInadequate tissue perfusion
Thermoregulation is impairedThermoregulation is impairedOrgan failure and death occurOrgan failure and death occur
BOX 13BOX 13--66 Manifestations of Neurogenic Shock.Manifestations of Neurogenic Shock.
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Complications of ShockComplications of Shock
Acute respiratory distress syndrome (ARDS)Acute respiratory distress syndrome (ARDS)Disseminated intravascular coagulation (DIC)Disseminated intravascular coagulation (DIC)
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Diagnostic Tests to Identify Type Diagnostic Tests to Identify Type of Shockof Shock
CBC, especially hemoglobin and hematocritCBC, especially hemoglobin and hematocritArterial blood gasesArterial blood gasesElectrolytes, especially serum sodium and potassiumElectrolytes, especially serum sodium and potassiumBlood glucose levelsBlood glucose levels
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Blood glucose levelsBlood glucose levelsBlood urea nitrogen and creatinineBlood urea nitrogen and creatinine
Diagnostic Tests to Identify Type Diagnostic Tests to Identify Type of Shockof Shock
Blood culturesBlood culturesWhite blood cell countWhite blood cell countSerum cardiac markersSerum cardiac markers
Creatine kinaseCreatine kinase
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Creatine kinaseCreatine kinaseCKCK--MBMBTroponinsTroponins
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Diagnostic Tests to Identify Type Diagnostic Tests to Identify Type of Shockof Shock
XX--raysraysComputerized tomography (CT) scansComputerized tomography (CT) scansMagnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)Peritoneal lavagePeritoneal lavage
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Peritoneal lavagePeritoneal lavage
Oxygen Therapy in ShockOxygen Therapy in Shock
Maintain patient airwayMaintain patient airwayAdminister oxygen via nonbreather mask at 12 to 15 Administer oxygen via nonbreather mask at 12 to 15 L/minL/minMaintain PaOMaintain PaO22 > 90 mm Hg> 90 mm Hg
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Maintain PaOMaintain PaO22 90 mm Hg 90 mm HgMonitor for respiratory distressMonitor for respiratory distressAnticipate endotracheal intubation and mechanical Anticipate endotracheal intubation and mechanical ventilationventilation
Nursing Management of Client Nursing Management of Client with Hypovolemic Shockwith Hypovolemic Shock
Initiate intravenous fluidsInitiate intravenous fluidsApply pneumatic antishock garments (PASG)Apply pneumatic antishock garments (PASG)
To raise blood pressure and stabilize pelvic and femoral To raise blood pressure and stabilize pelvic and femoral fracturesfractures
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Nursing Management of Client Nursing Management of Client with Anaphylactic Shockwith Anaphylactic Shock
Maintain patient airway and administer oxygenMaintain patient airway and administer oxygenAdminister epinephrine subcutaneously or Administer epinephrine subcutaneously or intravenouslyintravenouslyAdminister antihistaminesAdminister antihistamines
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Administer antihistaminesAdminister antihistaminesAdminister corticosteroidsAdminister corticosteroidsIf respiratory distress continues, administer If respiratory distress continues, administer aminophylline or nebulized albuterolaminophylline or nebulized albuterol
Nursing Management of Client Nursing Management of Client with Cardiogenic Shockwith Cardiogenic Shock
Administer oxygenAdminister oxygenAdminister vasopressor drugs and positive inotropic Administer vasopressor drugs and positive inotropic drugsdrugsAdminister diuretic drugsAdminister diuretic drugs
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Administer diuretic drugsAdminister diuretic drugsAdminister antidysrhythmic drugsAdminister antidysrhythmic drugsMonitor mechanical devicesMonitor mechanical devices
IntraIntra--aortic balloon pump (IABP)aortic balloon pump (IABP)Ventricular assist device (VAD)Ventricular assist device (VAD)
Nursing Management of Client Nursing Management of Client with Septic Shockwith Septic Shock
Obtain blood, urine, wound, sputum culturesObtain blood, urine, wound, sputum culturesAdminister intravenous fluidsAdminister intravenous fluidsAdminister antibiotic drugsAdminister antibiotic drugs
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Nursing Management of Client Nursing Management of Client with Neurogenic Shockwith Neurogenic Shock
Administer intravenous fluidsAdminister intravenous fluidsAdminister analgesic drugsAdminister analgesic drugs
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Client and Family Support in Client and Family Support in ShockShock
Client and Family Support in ShockClient and Family Support in ShockAcknowledge anxiety and fearAcknowledge anxiety and fearProvide comfort measuresProvide comfort measuresProvide time, space, and privacyProvide time, space, and privacy
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Provide anticipatory guidanceProvide anticipatory guidanceKeep family informedKeep family informed
Discharge TeachingDischarge TeachingAvoid known allergensAvoid known allergensNotify health care professionals of allergensNotify health care professionals of allergensAvoid wearing bright colors, perfumes, and scented hair Avoid wearing bright colors, perfumes, and scented hair sprays if allergic to insect stingssprays if allergic to insect stingsRead package labels if allergic to foodsRead package labels if allergic to foods
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Read package labels if allergic to foodsRead package labels if allergic to foodsWear MedicWear Medic--Alert bracelet or necklaceAlert bracelet or necklaceAdvise to carry an emergency kit for anaphylaxisAdvise to carry an emergency kit for anaphylaxisReview manifestations of anaphylaxisReview manifestations of anaphylaxisSeek medical attention immediately when symptoms Seek medical attention immediately when symptoms occuroccur
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IV Fluids Administered in ShockIV Fluids Administered in Shock
Replace fluids in a 3:1 ratio (300 mL for every 100 Replace fluids in a 3:1 ratio (300 mL for every 100 mL fluid loss)mL fluid loss)Crystalloid solutionsCrystalloid solutionsColloid solutionsColloid solutions
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Colloid solutionsColloid solutionsBlood and blood productsBlood and blood products
AutotransfusionAutotransfusion
Causes of TraumaCauses of Trauma
Injury caused by physical forceInjury caused by physical forceMotor vehicle crashesMotor vehicle crashesFallsFallsDrowningDrowning
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DrowningDrowningGunshotsGunshotsBurnsBurnsStabbingStabbingPhysical assaults, contact sportsPhysical assaults, contact sports
Common Traumatic InjuriesCommon Traumatic Injuries
Minor traumaMinor traumaFractures to collarboneFractures to collarboneSmall secondSmall second--degree burndegree burnCut requiring stitchesCut requiring stitches
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Major or multiple traumaMajor or multiple traumaAmputationAmputationMultipleMultiple--system injuriessystem injuries
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Common Traumatic InjuriesCommon Traumatic Injuries
Blunt traumaBlunt traumaInternal damage that does not break skinInternal damage that does not break skin
Penetrating traumaPenetrating traumaForeign object that pierces bodyForeign object that pierces body
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g j p yg j p yExternal appearance of wound does not determine internal External appearance of wound does not determine internal damagedamage
Common Environmental InjuriesCommon Environmental Injuries
HyperthermiaHyperthermiaHeat exhaustionHeat exhaustionHeat strokeHeat stroke
HypothermiaHypothermia
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ypypPoisoningsPoisonings
Effects of Traumatic InjuryEffects of Traumatic Injury
Airway obstructionAirway obstructionPneumothoraxPneumothoraxHemorrhageHemorrhageHypovolemic shockHypovolemic shock
Musculoskeletal injuriesMusculoskeletal injuriesIntegumentary injuriesIntegumentary injuriesPsychologic effects on Psychologic effects on clientclient
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Hypovolemic shockHypovolemic shockNeurologic injuriesNeurologic injuriesGastrointestinal and Gastrointestinal and genitourinary injuriesgenitourinary injuries
clientclientPsychosocial effects on Psychosocial effects on familyfamily
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Emergency Treatment of Emergency Treatment of Traumatic InjuryTraumatic Injury
Assess to identify extent of injuriesAssess to identify extent of injuriesProvide life supportProvide life supportImmobilizeImmobilizeAdminister oxygenAdminister oxygen
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Administer oxygenAdminister oxygenControl bleedingControl bleedingStart IV fluidsStart IV fluidsTransportTransportEmergency surgeryEmergency surgery
Diagnostic Tests for Traumatic Diagnostic Tests for Traumatic InjuriesInjuries
Tests to rule out shockTests to rule out shockBlood alcohol levelsBlood alcohol levelsUrine drug screenUrine drug screenPregnancy testPregnancy test
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Pregnancy testPregnancy testDiagnostic peritoneal lavageDiagnostic peritoneal lavageComputerized tomography (CT scan)Computerized tomography (CT scan)Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)
Legal Investigation of Injuries Legal Investigation of Injuries Related to Criminal ActivityRelated to Criminal Activity
Identify, store, and properly transfer potential evidenceIdentify, store, and properly transfer potential evidenceDo not cut through clothing containing blood stains or Do not cut through clothing containing blood stains or bullet holesbullet holesPlace clothing in individual breathable containers and Place clothing in individual breathable containers and l b ll b l
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labellabelLabel bullets or knivesLabel bullets or knivesRecord entrance and exit wounds in chartRecord entrance and exit wounds in chartPhotograph woundsPhotograph woundsPlace paper bag over hands if presence of evidence in Place paper bag over hands if presence of evidence in suspectedsuspected
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AssessmentAssessmentPerform headPerform head--toto--toe assessmenttoe assessmentObtain brief history, allergies, past medical historyObtain brief history, allergies, past medical historyAssess vital signs every 5Assess vital signs every 5––10 minutes to hourly, to 10 minutes to hourly, to every 2every 2––4 hours4 hoursAssess for early signs of shockAssess for early signs of shock
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RestlessnessRestlessnessTachycardiaTachycardiaSlight anxietySlight anxiety
Assess late signs of shockAssess late signs of shockHypotensionHypotension
Assess urine outputAssess urine output
InterventionsInterventions
Insert nasogastric tube if risk of aspirationInsert nasogastric tube if risk of aspirationApply cardiac monitor to assess cardiac statusApply cardiac monitor to assess cardiac statusInsert intravenous lines and administer medications as Insert intravenous lines and administer medications as indicatedindicated
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indicatedindicatedMonitor for hypothermiaMonitor for hypothermiaAdminister tetanus prophylaxis if penetrating woundAdminister tetanus prophylaxis if penetrating woundMaintain strict aseptic techniqueMaintain strict aseptic technique
EvaluationEvaluation
Absence of infectionAbsence of infectionPreventing complications from immobilityPreventing complications from immobilityDocument healing of injuriesDocument healing of injuries
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Discharge TeachingDischarge Teaching
Determine potential home modificationsDetermine potential home modificationsReview medication administrationReview medication administrationGive information about dietsGive information about dietsDiscuss rehabilitation planDiscuss rehabilitation plan
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Discuss rehabilitation planDiscuss rehabilitation planEmphasize need for followEmphasize need for follow--up careup careDiscuss emotional changesDiscuss emotional changesProvide referrals as neededProvide referrals as neededProvide preventative educationProvide preventative education
Interventions for Environmental Interventions for Environmental InjuriesInjuries
HyperthermiaHyperthermiaMove to cool placeMove to cool placeLoosen clothingLoosen clothingApply cool, wet towelsApply cool, wet towels
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Apply cooling blanket and oxygen for heat strokeApply cooling blanket and oxygen for heat strokeMonitor for renal failure and seizuresMonitor for renal failure and seizures
Interventions for Environmental Interventions for Environmental InjuriesInjuries
HypothermiaHypothermiaMove to warm placeMove to warm placeRemove wet clothingRemove wet clothingApply warm blankets, radiant heat lamp, warming blanketApply warm blankets, radiant heat lamp, warming blanket
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Administer warm intravenous fluids and warm peritoneal Administer warm intravenous fluids and warm peritoneal lavagelavageAdminister warm, humidified oxygenAdminister warm, humidified oxygenObserve for cardiac arrestObserve for cardiac arrest
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Interventions for Environmental Interventions for Environmental TraumaTrauma
PoisoningsPoisoningsIdentify the poisonIdentify the poisonCall the local poison control centerCall the local poison control centerAssess airway, breathing, and circulationAssess airway, breathing, and circulation
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Assist with administration of antidote or elimination Assist with administration of antidote or elimination methodmethodAdminister oxygen for inhaled poisonsAdminister oxygen for inhaled poisonsCleanse contaminated skin with waterCleanse contaminated skin with waterTeaching for poisoningTeaching for poisoning
ICU PsychosisICU Psychosis
Acute confusion after 2 to 3 days in ICUAcute confusion after 2 to 3 days in ICUManifestations:Manifestations:
Altered attention spanAltered attention spanMemory lossMemory loss
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yyConfusionConfusionVisual and auditory hallucinationsVisual and auditory hallucinations
ICU PsychosisICU Psychosis
Treatment:Treatment:Administer sedative or psychotropic drugsAdminister sedative or psychotropic drugsDecrease client’s sensoriperceptual problemsDecrease client’s sensoriperceptual problemsDecrease client’s sleep deprivationDecrease client’s sleep deprivation
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ICU Effects on FamilyICU Effects on Family
Fear of death of loved oneFear of death of loved oneAnxious about equipmentAnxious about equipmentAnxious about client’s potential for painAnxious about client’s potential for painWorry about finances and changes in family rolesWorry about finances and changes in family roles
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Worry about finances and changes in family rolesWorry about finances and changes in family roles
Interventions with Family Interventions with Family
Give status reportsGive status reportsGet involved in client’s careGet involved in client’s careAssess for signs of exhaustionAssess for signs of exhaustionObtain resources and referrals as neededObtain resources and referrals as needed
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Obtain resources and referrals as neededObtain resources and referrals as needed
Organ DonationOrgan Donation
Consent may be given by client, spouse, adult child, Consent may be given by client, spouse, adult child, parent, adult sibling, guardianparent, adult sibling, guardianOrgans that can be donated: Organs that can be donated:
kidneys, heart, lungs, pancreas, intestines, liver, corneas, kidneys, heart, lungs, pancreas, intestines, liver, corneas,
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y , , g , p , , , ,y , , g , p , , , ,bones, bone marrow, skinbones, bone marrow, skin
Encourage client and family to ask questions and Encourage client and family to ask questions and express feelingsexpress feelings
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Organ DonationOrgan Donation
Provide support by a grief counselor or clergyProvide support by a grief counselor or clergySignature must be obtained for organ donationSignature must be obtained for organ donationClient must be brain deadClient must be brain deadNotify Organ Procurement Organization withNotify Organ Procurement Organization with
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Notify Organ Procurement Organization with Notify Organ Procurement Organization with decision to proceeddecision to proceed
BOX 13BOX 13--1111 Brain Death Criteria.Brain Death Criteria.
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