NR341 Content Review Exam 2

Chapter 8: Hemodynamics

Blood Flow to Tissues and Organs

• Tests include capillary refill, BP, O2 stats, urinary output, HR, and BP (monitor systolic BP if it is below 90).

Central Line Associated Bloodstream Infection (CLABSI) Bundle:

• Hand hygiene
• Full barrier precautions: Cover the patient from head to foot
• Chlorhexidine skin antisepsis: Unless the patient is allergic (Betadine can be used)
• Optimal catheter site selection: Subclavian, Femoral, Internal jugular
• Dressing
• Safe disposal of sharps
• Daily review of line necessity: Ensure the patient actually needs a central line
  • Reasons for central line:
    • TPN (Total Parenteral Nutrition)
    • Dialysis
    • Drip (pressors)
    • Monitoring CVP (Central Venous Pressure)

Central Venous Pressure (CVP)

• How assessed: Obtained from a central line (IJ or subclavian) in the vena cava; measures right atrial pressures and assesses preload on the right side of the heart.
• Normal levels: 2-6 mmHg
• Causes of abnormal levels:
  • Hypovolemia
  • Heart failure
  • Hypervolemia
  • Cardiac tamponade
  • Pulmonary embolism
  • Pleural effusion
• Treatment:
  • Low CVP: Fluids, Blood
  • High CVP: Dialysis, Diuretics

Chapter 12: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome

Stages of Shock:

• Stage 1: Hypoperfusion Stage
  • Checking cardiac output is the only way to identify this stage
• Stage 2: Compensatory Stage
  • Blood pressure decreases slightly, heart rate increases slightly
  • Sympathetic nervous system secretes epinephrine and norepinephrine, causing vasoconstriction
    • Cold extremities
    • Skin: Body uses blood from skin to compensate, risk of pressure ulcers
    • GI: Peptic ulcers, decreased peristalsis, paralytic ileus
    • Kidney: Decreased urine output
    • Liver
  • Cortisol secretion from adrenal glands (above kidneys)
    • Secretions: aldosterone, cortisol, sex hormones
    • Blood sugar increases
• Stage 3: Progressive Shock
  • Anaerobic metabolism, high lactic acid
  • Dysrhythmias due to sodium-potassium pump malfunction
  • Body starts to swell
  • Brain ischemia: Infarction
• Stage 4: Refractory Shock
  • Multiple Organ Dysfunction Syndrome (MODS)

Hypovolemic Shock:

• Causes:
  • Blood loss
  • Excessive water loss
• Signs and Symptoms:
  • Low BP
  • Increased HR
  • Low CVP
  • Cool skin
• Treatment:
  • Replace blood or fluids

Anaphylactic Shock:

• Causes:
  • Hypersensitivity (e.g., peanuts)
• Signs and Symptoms:
  • Extreme inflammation
  • Low BP
  • High HR
  • CVP unaffected
  • Warm skin
• Treatment:
  • Epinephrine

Cardiogenic Shock:

• Causes:
  • Trauma to the heart (e.g., MI)
• Signs and Symptoms:
  • Low BP
  • High HR
  • High CVP
  • Cool skin
• Medications to treat:
  • Diuretics
  • Vasodilators
  • Dobutamine (increases cardiac contractility)
  • Balloon pump
  • LVAD (Left Ventricular Assist Device)

Septic Shock:

• Signs and Symptoms (need 2 or more to be considered sepsis):
  • Temperature >38°C or <36°C (or >100.4°F or <95°F)
  • HR >90
  • Respirations >20 or CO2 <32
  • WBC >12,000 or <4,000
  • Bandemia (presence of baby neutrophils)
• Sepsis Bundle:
  • Measure lactic acid levels (indicative of anaerobic metabolism)
    • Normal: <2
    • Abnormal: >2