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MedSurg II - SIRS & MODS

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olanjones's version from 2017-04-02 22:19

Shock

Question Answer
Cardiogeniccaused by a weak heart w/ either systolic or diastolic failure
Hypovolemicbleeding or loss of fluids (burns)
Neurogenicvasodilation of the vascular system
Septic shockcaused by an infection
Nursing care-Assess respiratory status, Admin O2 (anticipate intubation/mechanical ventilation)
-Establish IV access & begin crystalloid infusion
-Draw blood for lab (blood cultures, lactate, WBC)
-Assess for any life-threatening injuries
-Consider their vasopressor therapy if the patient is hypotensive after the fluid resuscitation
-Insert indwelling bladder catheter, & obtain a 12-lead EKG
Big difference btwn dobutamine & dopamineBoth drugs ↑ myocardial contractility, ↑stroke volume, ↓systemic vascular resistance; But dopamine also ↑HR & CO
Why are dobutamine & dopamine given via central lineTo prevent tissue sloughing (are given at mcg/kg/min)
*at ↑doses can cause vasoconstriction & tissue death
What are effects of epinephrine & norepinephrine ↑HR, contractility, & CO while ↓ SVR (beta adrenergic agonist – norepi has beta & alpha agonist effect)
How does epinephrine differ at ↑dosesbecomes an alpha adrenergic agonist - causes vasoconstriction
PhenylephrineAlpha adrenergic agonist - causes vasoconstriction ↑HR & SVR
Sodium nitroprusside↓BP, pre-load, & afterload by causing vasodilation (nitroglycerin also causes vasodilation)
What must be monitored for with nitroprussideSerum cyanide levels & cyanide toxicity (metabolic acidosis, tachycardia, altered LOC, seizures, coma, almond smell on breath)
- IV bag must be protected from light
What is special about IV nitroglycerinComes in glass bottle & specialty tubing needs to be used (wear gloves to avoid absorbing drug)
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SIRS & MODS

Question Answer
SIRSSystemic inflammatory response syndrome - from cytokines, free radicals, widespread endothelial injury, capillary permeability, tissue edema, & neutrophil entrapment in the microcirculation (leads to MODS)
Causes of SIRSmechanical tissue trauma, abscess formation, ischemic/necrotic tissue, microbial invasion, endotoxin release (gram -/+ bacteria)
SIRS manifested by 2 or+ of following conditions1. temp >38 C or <36 C
2. HR > 90 bpm
3. RR > 20 breaths/min
4. WBC count >12,000, <4,000, or >10% bands
Which system is usually 1st to show dysfunctionRespiratory - permeability of capillary, fluid moves -> alveolar space causing alveolar edema & aveoli collapse -> shunting (↓/no gas exchange in blood flow of lungs)
Cardio dysfunction-Myocardial depression -> massive vasodilation -> ↓SVR & BP; Albumin & fluid shift (d/t capillary permeability) out of the vascular space ↓preload
-Pt becomes warm, tachycardic, ↓cap refill, skin mottling, ↑central venous pressure & dysrhythmias
-PT is perfusing areas that are not consuming much oxygen while other areas may have blood shunted away from them
Neurologic dysfunction-Mental changes caused by hypoxemia, impaired perfusion, or effects of inflammatory mediators
-Pt shows confusion & agitation, disorientation, lethargy, coma, May become combative
Acute kidney injury-Caused by hypoperfusion, effects of inflam mediators; ↓perfusion activates SNS & RAAS -> systemic vasoconstriction & retention of sodium/water d/t aldosterone (Abx used to treat gram- bacteria can be nephrotoxic)
G.I. motility-Often ↓causing abdominal distention & paralytic ileus (in SIRS/MODS blood is shunted away from GI mucosa -> risk for ischemia)
-↓perfusion -> breakdown of mucosal barrier putting pt at risk for ulceration, GI bleeding, bacteria leaking from GI tract into circulation
Metabolic changes-> catabolic state & lean body mass loss (pt will be hyper metabolic ->liver dysfunction)
-Protein synthesis is impaired, liver can't make albumin -> to alteration in plasma oncotic pressure -> to fluid & protein leakage from the vascular space to the interstitial space (at this point, an albumin infusion will not normalize oncotic pressure)
Nursing careFocused around prevention & treatment of infection, Maintenance of tissue oxygenation, Nutritional & metabolic needs, & support of failing organs
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Table 67-10

Question Answer
Resp/ARDS Manis•Severe dyspnea •Tachypnea •PaO2/FIO2 ratio <200 •Bilateral fluffy infiltrates on DXR •PAWP <18 mm Hg •V/Q mismatch •Pulmonary hypertension •Increased minute ventilation •Decreased compliance •Refractory hypoxemia
Resp/ARDS ManagementOptimize O2 delivery ↓consumption, Mechanical ventilation - PEEP, Lung protective modes (pressure control inverse ratio ventilation, ↓tidal vol), Permissive hypercapnia, Positioning (continuous lateral rotation tx, prone positioning)
CV Manis• Myocardial depression •Massive vasodilation •↓SVR, BP •↓MAP •↑HR, Stroke vol •↑CO •Systolic, diastolic dysfunction, biventricular failure
CV ManageVolume management (central venous/PA cath for hemodynamic monitoring, APCO for minimally invasive, ↑preload via volume replacement, arterial pressure monitoring, maintain MAP >65 mmHg), Vasopressors, Intermittent/continuous SCVO2/SVO2 monitoring, Balance O2 supply/demand, Cont ECG monitoring, Circulatory assist devices, Venous thromboembolism prophy
CNS ManisAcute change in neuro status, Fever, Hepatic encephalopathy, Seizures, Confusion/disorientation/delirium, Failure to wean/Prolonged rehab
CNS ManageEval for hepatic/metabolic encephalopathy, Optimize cerebral blood flow, ↓Cerebral O2 requirements, Prevent secondary tissue ischemia, CCB (↓cerebral vasospasm)
Endocrine ManisHyperglycemia -> hypoglycemia
Endocrine ManageProvide continuous infusion of insulin & glucose to maintain blood glucose 140-180 mg/dL
Pre-Renal ManisRenal hypoperfusion – BUN/creatinine ratio >20:1, ↓Urine Na+ <20 mEq/L, ↑Urine specific gravity >1.020, ↑Urine osmolality (think: body is trying to retain fluid)
Intra-Renal ManisAcute tubular necrosis – BUN/creatinine ratio <10:1-15:1, ↑ Urine Na+ >20 mEq/L, ↓Urine osmolality, Urine specific gravity about 1.010 (think: body's filter is broken)
Renal ManageDiuretics [Loop diuretics (furosemide), May need to increase dosage due to ↓ glomerular filtration rate]; Continuous renal replacement therapy
GI ManisMucosal ischemia (↓Intramucosal pH, Potential translocation of gut bacteria, Potential abdominal compartment syndrome), Hypoperfusion → ↓ peristalsis, paralytic ileus, Mucosal ulceration on endoscopy, GI bleeding
GI ManageStress ulcer prophylaxis •Antacids (Maalox) •Proton pump inhibitors (omeprazole) •sucralfate (Carafate) Monitor abdominal distention, intraabdominal pressures, Dietary consultation, Enteral feedings (•Stimulate mucosal activity •Provide essential nutrients) & optimal calories
Hepatic ManisBilirubin >2 mg/dL (34 μmol/L) ↑ Liver enzymes (ALT, AST, GGT) ↑ Serum NH3 ↓ Serum albumin, prealbumin, transferrin, Jaundice, Hepatic encephalopathy
Hepatic ManageMaintain adequate tissue perfusion, Provide nutritional support (enteral feedings), Careful use of drugs metabolized by liver
Hematologic Manis↑Bleeding times, ↑PT, ↑PTT, ↓Platelet count (thrombocytopenia), ↑Fibrin split products, ↑D-dimer
Hematologic ManageObserve for bleeding from obvious and/or occult sites, Replace factors being lost (platelets), Minimize traumatic interventions, (IM injections, multiple venipunctures)
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