Med Surg Exam 2: Shock Stages

• Med Surg Exam 2 covers chapters 55-57 and 11-13.

Stages of Shock

• Compensatory stage includes blood pressure within normal limits, adequate cardiac output, and a fight or flight response shunting blood to vital organs.
• Treatment involves addressing the underlying cause, fluid replacement, supplemental oxygen, and frequent assessments.
• Progressive shock stage shows blood pressure no longer compensated/hypotensive, MAP below normal limits, decreased mental status, rapid and shallow respirations, chest pain, liver failure, GI bleeding, and abnormal bruising.
• Treatment involves addressing the underlying cause, restoring tissue perfusion through fluid management, respiratory support, nutritional support, oral care if on ventilator, rest, and comfort.
• Irreversible/refractory shock stage shows organ damage, inability to maintain blood pressure or oxygenate, inability to maintain MAP, multiple organ dysfunction, and complete organ failure.
• Treatment includes respiratory, circulatory, and nutritional support, experimental treatments, and palliative care.

Types of Shock: Signs/Symptoms and Treatment

• Hypovolemic shock is the most common, characterized by decreased intravascular volume, blood volume, cardiac output, and perfusion.
• Treatment includes restoring volume with fluid and blood replacement, addressing the underlying cause, vasoactive medications, oxygen, and comfort measures.
• Septic shock is the most common type of distributive shock, has high mortality and is caused by infection.
• Treatment includes fluid replacement, pharmacologic treatment, and nutritional therapy.
• Anaphylactic shock involves severe allergic reaction with respiratory distress, hypotension, GI distress, skin or mucosal irritation, and cardiovascular compromise.
• Treatment involves removing the antigen if possible, fluid management, epinephrine and CPR.
• Neurogenic shock presents with hypotension, bradycardia, syncope, fainting, and dry warm skin.
• Treatment involves restoring sympathetic tone through spinal injury stabilization, cardiovascular and neurologic function support.

Myocardial Infarction (MI) Risk

• Patients with a history of MI are at high risk for another because the underlying coronary artery disease that caused the first MI is likely still present.

MODS (Multiple Organ Dysfunction Syndrome)

• Signs/symptoms include cool, mottled skin
• Those in septic shock are at the greatest risk.

Distributive Shock

• Cardiac output can be high, from a reduction in afterload and from the heart's increased effort to maintain perfusion with incompetent vasculature.
• Septic, neurogenic, and anaphylactic are the three types.

Signs/Symptoms of Decreased Perfusion

• Shortness of breath
• Dizziness
• Headache
• Altered mental status
• Chest pain
• Cool, clammy skin
• Decreased urine output

Surgical Options

• Salvage surgery aims to remove residual cancer tissue after initial treatment failure.
• Prophylactic surgery involves removal of non-vital tissues or organs at increased risk of developing cancer.
• Palliative surgery relieves symptoms and improves patient quality of life.
• Reconstructive surgery improves function or cosmetic effect after curative or extensive surgery.

Signs/Symptoms of Thrombocytopenia

• Easy bruising or bleeding
• Prolonged bleeding from cuts or wounds
• Petechiae
• Nose bleeds
• Heavy menstrual flows
• Blood in vomit, urine, or stool

Chemotherapeutic Reactions and Methods

• Chemotherapy uses cell kill and cell cycle methods, aiming to destroy cancer cells by interfering with cellular function and replication.
• Toxicity can occur in the GI, hematopoietic, renal, cardiopulmonary, reproductive, neurologic, cognitive, and cause fatigue.

Normal vs. Cancerous Cells

• Benign cells are non-cancerous.
• Malignant cells are characteristic of cancer and ignore growth-regulating signals.

Interventions for Hypercalcemia Risk

• A patient should increase fluid intake to 3-4 liters per day to promote calcium excretion and prevent kidney stones, and recommended fluids acidify urine like cranberry or prune juice.
• Restrict dietary calcium from dairy, calcium-fortified foods and calcium supplements.
• Use Etidronate, Corticosteroids, and Phosphate salts.

Perception of Palliative Care

• Palliative care improves the quality of life.

Central Focus of Hospice Care

• Hospice care focuses on making the patient comfortable in their final weeks or days.

Signs/Symptoms of Impending Death

• Irregular, shallow breathing with periods of apnea (Cheyne-Stokes respiration)
• Noisy, wet-sounding respirations from accumulated secretions (death rattle)
• Decreased blood pressure and circulation leading to cool, mottled extremities
• Decreased urine output and bowel function
• Inability to swallow or take oral medications
• Increased sleepiness and decreased responsiveness
• Changes in neurological status like diminished reflexes
• Restlessness, confusion, agitation
• Vision changes like glassy, tearing eyes

Stages of Death and Dying (Kubler-Ross)

• Denial: Inability to accept the reality of the situation
• Anger: Feelings of rage, envy, and resentment
• Bargaining: Attempting to negotiate or delay the inevitable
• Depression: Feelings of great sadness, regret, fear, and preparation
• Acceptance: Coming to terms with the reality of the situation

Working with Families of Terminally Ill Patients

• Offer support and services, listen, communicate effectively, and respect spiritual and cultural wishes.

Complicated vs. Uncomplicated Grief and Mourning

• Complicated grief involves an intense, prolonged emotional response usually lasting longer than 1 year; continuous and ongoing grief keeps the patient from healing and gets worse.
• Uncomplicated grief involves a range of emotions moving toward adjustment with brief periods of relapse; it is tolerable, expected, and manageable.
• Mourning refers to individual, family, group, and cultural expressions of grief and associated behaviors.

Function of Keratin

• Keratin is an insoluble, fibrous protein that forms the outer barrier of the skin, repels pathogens, prevents excessive fluid loss, and hardens hair and nails.

Skin Tests

• Tzanck smear examines cells from blistering skin conditions like herpes zoster and varicella.
• Skin biopsy removes a small sample of skin to diagnose skin conditions, like skin cancer.
• Patch testing identifies substances to which a patient has developed an allergy.
• Scraping scrapes tissues from a suspected fungal infection.

Subcutaneous Tissue

• Functions of subcutaneous tissue: provides cushion, protects nerves/vascular structures, promotes skin mobility, molds body contours, insulates, and regulates body temperature.

Causes of Dark Spots in Aging Skin

• Dark spots or age spots on aging skin are caused by overactive pigment cells producing excess melanin, often triggered by prolonged sun exposure.

Treatment of Vitamin D Deficiency

• Treatment includes vitamin D supplements, dietary changes (milk/dairy products, fatty fish, egg yolks, fortified foods), and moderate sun exposure (15-30 minutes twice a week).

Skin Conditions with Genetic Component

• Psoriasis involves an overactive immune system and abnormal skin cell production.
• Atopic dermatitis (eczema) involves mutations in genes regulating the skin barrier function.
• Ichthyosis is characterized by dry, thickened, scaly skin due to mutations affecting skin proteins or lipid metabolism.
• Albinism involves little or no production of melanin.
• Epidermolysis bullosa makes the skin very fragile and blister easily due to defects in structural proteins.

Genetic Disorders

• Neurofibromatosis cases tumors to grow along nerves in the skin and throughout the body.

Skin Palpation Assessment

• Temperature, moisture, texture, skin turgor, capillary refill, and edema can be assessed.

CD4 Test in HIV Patients

• CD4 tests measure the number of CD4 cells (helper T cells) to determine progression of the disease and the state of the immune system

Fingernail Pitting

• Fingernail pitting is commonly caused by psoriasis due to rapid skin cell buildup and defective nail formation.

Beau's Line

• Beau's line is a deep groove across the nail that indicates temporary interruption in nail growth due to a systemic event or injury.

Medication for Zoster

• Antiviral therapy is used to treat herpes zoster (shingles), specifically acyclovir, valacyclovir, or famciclovir and is most effective when started within 72 hours of rash onset.

Kaposi Sarcoma and HIV

• Kaposi sarcoma is a malignancy of endothelial cells lining blood vessels, causing dark reddish-purple lesions.
• Endemic (African) KS is found predominantly in eastern half of Africa in men and resembles classic KS.
• Iatrogenic/organ transplant-associated KS affects transplant and immunosuppressed patients.
• AIDS-related or epidemic KS occurs with AIDS and is aggressive.

Presentation of Zoster

• Tingling, itching, or pain in a localized area on one side of the body 1-5 days before the rash
• A vesicular rash follows a dermatomal pattern confined to one side of the body, accompanied by severe nerve pain.
• Eye inflammation and vision issues can result if the ophthalmic branch of the trigeminal nerve is involved
• Fever, headache, malaise, and itching may also occur
• The rash progresses through stages of blisters, pustules, ulceration, crusting, and healing over 2-4 weeks, often leaving scarring.

Skin Graft

• A skin graft transplant healthy skin to cover a wound or defect, facilitates wound healing and minimize complications. Two types are free grafts and skin flaps.
• Free grafts are completely detached and requires establishing a new blood supply.
• Skin flaps are partially attached and maintains continuous blood supply.

Treatment for Lice

• Confirm the patient has lice
• Use OTC or prescription pediculicide (Permethrin, Malathion, Spinosad, Benzyl-alcohol)
• Comb hair with fine-toothed comb
• Wash all clothing, bedding, and personal items in hot water and dry on high heat
• Vacuum everything thoroughly
• Treat all peeps close to infested person to prevent re-infestation
• Educate on hygiene
• Retreat 7-10 days if lice still persist

Treatment for Acne Vulgaris

• Should be individualized
• First-line therapies: Tretinoin, Benzyl peroxide, and antimicrobial agents
• Retinoids are comedolytic, anti-inflammatory, and target acne-causing bacteria
• Inflammatory acne may need oral antibiotics (narrow spectrum)
• Severe cases: Oral isotretinoin
• Comedone extraction, skin care, avoid oil-based products, and use sun protectants

Teaching Post Skin Biopsy

• Keep the biopsy site clean and dry for at least 24 hours
• Clean with soap and water
• Use antibiotic ointment with bandage
• Change bandage daily until healed
• Avoid strenuous activity, swimming, or soaking
• Watch for signs of infection
• Take as needed pain meds

Family Teaching for a Child (ped) with Impetigo

• Highly contagious bacterial skin infection
• Keep open sores covered with clean, dry bandages
• Wash hands
• Avoid sharing items
• Clean crusty areas with soap and water and apply antibiotic ointment
• Complete full oral antibiotics
• Cut nails short and discourage picking
• Clean linens in hot water and disinfect touched items
• Don't take your child out until after 24 hours of antibiotic therapy

Phases of Burn Care

• Emergent (Resuscitative) phase is the initial 24-48 hours after a major burn injury and is characterized by burn shock.
• Acute phase is 48 hours to 3-4 weeks after the burn injury marked and is characterized by a hypermetabolic state, increased protein breakdown, and high risk of infections and organ failure.
• Rehabilitation phase occurs after the acute phase marked by wound healing, regaining lost muscle mass, and scar maturation.

Sulfamylon

• A topical antibacterial cream is effective against gram-negative bacteria that commonly infect burn wounds.
• It is applied directly to the burn area once or twice daily after cleaning and debridement.

Primary Concerns for 25% Surface Area Burns

• Hypovolemic shock from massive fluid losses and edema formation
• Impaired thermoregulation and increased metabolic demands
• High risk of infection due to loss of skin barrier
• Potential airway/respiratory issues if inhalation injury is present
• Electrolyte imbalances and nutritional deficiencies
• Pain management requirements
• Need for prompt surgical intervention like escharotomy or fasciotomy
• Potential for multi-organ dysfunction if not properly resuscitated

Types of Debridement

• Natural debridement involves the devitalized tissue separating from the underlying viable tissue randomly.
• Mechanical is used on wounds to physically remove devitalized or necrotic tissue
• Chemical may be preferred for patients who cannot tolerate surgery, have circumscribed areas of necrosis, or when more selective debridement is needed around viable tissue.
• Surgical is often used for burn injuries to rapidly remove devitalized or necrotic tissue.

Caring for a Patient With a Xenograft

• Monitor the graft site closely for signs of infection
• Keep the xenograft moist by applying prescribed antimicrobial ointments or dressings
• Avoid aggressive cleaning or scrubbing of the graft site
• Provide pain medication as needed

Active and Passive ROM

• ROM is essential for burn victims to prevent joint stiffness, contractures, and loss of mobility.

Infected Skin Graft Signs/Symptoms

• Increased pain, redness, swelling, warmth at the graft site
• Purulent or malodorous drainage from the wound
• Fever
• Elevated white blood cell count
• Graft failure or non-adherence to the wound bed
• Delayed healing

Greatest Risk from Burns

• Children 5 and younger
• Adults 20-59yo
• Occupations with fire hazards
• People in homes without fire alarms or fire safety

Treatment During Initial Phase of Burn

• Aggressive fluid resuscitation w/ crystalloids (lactated ringers)
• Monitor urine output, vitals, ABGs, labs to prevent shock and AKI
• Early admission of opioids for pain management
• Securing airway if necessary
• Removing constricting items, covering burns with clean dressings, prevent hypothermia
• Initiating nutritional support, tetanus prophylaxis, prevent infection

Diuresis Phase of Burns

• The diuresis phase occurs 24-48 hours after major burn injuries
• Massive fluid shifts reverse, moving fluids back into the vascular space, resulting in diuresis or increased urine output.

What is PCA

• PCA is a method that allows patients to self-administer prescribed doses of pain medication by activating an infusion pump.

Causes of PTSD

• Trauma/Traumatic events