Medical Topics: Arterial Lines, Shock, Sepsis

• The content covers various medical topics
• Including shock, sepsis, multiple organ dysfunction syndrome (MODS) along with burns
• It also goes into respiratory conditions and immunology
• It gives specific details to assist someone studying in the medical sector

Arterial Lines

• A thin catheter is used for real-time hemodynamic monitoring via artery insertion
• Inserted in the radial artery, use the Allen test to ensure ulnar artery functionality for perfusion
• Allen Test: patient clenches fist, pressure applied to radial & ulnar arteries, release ulnar pressure to check hand flush for arterial perfusion (positive result is flush within 15 seconds)
• Purpose: It offers continuous BP and ABG (arterial blood gas) information
• Monitor limb circulation (capillary refill, temperature, color) as well as fluid responsiveness and cardiac output
• Possible complications: thrombus, hemorrhage, air embolism, and infection

Shock

• It results from inadequate tissue perfusion, which impairs cellular function and leads to organ failure

Stages of Shock

• Initial Stage: MAP decreases by 5-10 mm Hg from baseline
• Characterized by mild vasoconstriction and increased HR to maintain cardiac output
• Compensatory Stage: Vasoconstriction and HR increase, MAP drops 10-15 mm Hg from baseline
• Mild acidosis and hyperkalemia may be present; treat underlying cause
• Progressive Stage: Organs experience hypoxia, MAP decreases by more than 20 mm Hg from baseline
• Moderate acidosis and hyperkalemia occur (MAP below normal limits, under 65)
• Lab results show that acidosis is always present and lactic acidosis above 2 indicates ischemia
• Rapid, shallow respirations, chest pain, mental status changes & AKI S/S, fluid management is crucial
• Refractory Stage: Severe tissue hypoxia, MODS, and possible death
• Acute metabolic and lactic acidosis occurs with elevated PT/PTT lab results
• Focus on patient comfort and family communication due to system failures

Types of Shock

• Hypovolemic Shock: Intravascular volume decrease of 15-30% causes include fluid and blood loss

• Assessment: look for fluid loss (diuresis, vomiting, diarrhea) or blood loss (surgery, trauma, GYN/OB causes & burns, DKA)

• Massive GI bleeding, 800 cc blood loss, or internal fluid loss requires Hgb & Hct lab tests

• Treatment: 0.9% sodium chloride or lactated ringers

• Symptoms: decreased BP, narrowed pulse pressure, postural hypotension

• Tachycardia (weak or thready pulse), tachypnea (progressive to >40/min), hypocarbia, hypoxia, and decreased urine output

• Expect Decreased CVP & WEDGE (Fluid) Preload, Increased PVR, SVR (Resistance) Afterload, and Decreased Cardiac Output

• Treatment: replace volume (crystalloids like Normal Saline or Lactated Ringers, colloids like Albumin, and blood products) use 2 large bore IVs, administer oxygen & be aware of pulmonary edema related to fluids

• Cardiogenic Shock: Ineffective heart pumping from cardiac failure

Cardiogenic Shock

• Causes include CHF and MI

• Hemodynamic Monitoring: indicates preload and PVR/SVR afterload increase while cardiac output decreases

• S/S: SOB , chest pain, JVD, crackles, altered LOC, pale & cool skin, and tachypnea

• Treatment: vasopressors (increase perfusion via vasoconstriction), vasodilators (reduce preload/afterload), diuretics (reduce fluid buildup), inotropes (Dobutamine improve contractility), intra-aortic balloon pump (increase cardiac output), and morphine sulfate (pain relief/vessel dilation)

• Distributive Shock: Characterized by widespread vasodilation and increased capillary permeability related to neurogenic septic & anaphylactic shock

Septic Shock

• An infection

• S/S: fever, hypercoagulation, tachycardia, hypotension or in severe cases hyperthermia and bounding pulse

• Reduced urine output due to decreased SVR & CO

• Hemodynamic Warm Stage (1st): Preload is normal-low, afterload decreases, cardiac output increases

• Hemodynamic Cold Stage (2nd): vasoconstriction develops which then lowers preload, increases afterload, and reduces cardiac output

• Treatment: broad-spectrum antibiotics after blood cultures, IV fluids; vasopressors, prevent stress ulcers (H2 Blockers & PPI's) & monitor lactate levels, give airway

• Anaphylactic Shock: Vasodilation & bronchoconstriction occur from allergen exposure (foods, meds, insect bites)

• S/S: Itching, hives, flushed/pale skin, wheezing, dyspnea, N&V, diarrhea, swollen tongue/throat, decreased CO, SVR, BP

• Treatment: Remove allergen, administer epinephrine (IM or SubQ for respiratory compromise), oxygen, antihistamines (Benadryl for mild reactions), albuterol (open airways), corticosteroids (reduce inflammation), and IV fluids

• ACE inhibitors can lead to angioedema with a Ace Cough, be aware

• Neurogenic Shock: Loss of communication between SNS & blood vessels affects vasomotor tone and blood pressure

• Causes: Spinal cord injury, gunshot wound, sports injury, any nervous system damage

• S/S: Dilated pupils, decreased LOC, hypotension, and bradycardia

• Goal: stabilize spine to restore sympathetic tone

• Treatment: immobilize spine, IV fluids (monitor overload), atropine for bradycardia, maintain airway and DVT prophylaxis

• Post Intensive Syndrome (PICS): Symptoms persist in ICU survivors for months or years anxiety and palpitations

Burns

• Burns are tissue damage caused by heat, radiation, chemicals or electricity with prevention as key
• To prevent follow smoke detectors, proper extinguisher use, protective clothing & sunscreen

Risk Factors

• Exposure to heat, flame, explosion, hot liquids, chemicals, radiation
• Older adults have more complications

Types

• Superficial (1st Degree): Epidermis damage (sunburn) characterized by red skin, pain, and sensitivity to heat, heals within 3-6 days

• Superficial Partial Thickness (2nd Degree): Epidermis & dermis (some parts) damage blisters, moderate edema, painful , heals in 2-3 weeks

• Deep Partial Thickness: extensive damage into dermis leads to red-white skin, rare blisters, heals in 2-6 weeks & may require grafting

• Full Thickness (3rd Degree): Complete epidermis/dermis damage extends into subcutaneous tissue and nerve damage

• Varied appearance (red, black, brown, yellow, white); severe edema, inelastic eschar, minimal/absent sensation & grafting

• Deep Full Thickness (4th Degree): Damge to all skin layers extends into muscle, tendons & bones with necrosis from gangrene

• Electrical Burns: From power lines, outlets = Do EKG's due to dysrhythmia risk

Nursing Care

• Assess breathing, establish airway immediately
• No fresh flowers allowed
• Standard precautions, increase protein
• With chemical burns treat by washing skin

Rule of Nines

• Quick method to estimate burn extent by body multiples of 9, use to measure and determine extent of burn

Parkland Formula

• Calculates fluid needed for burn patients (4mL x weight (kg) x TBSA% burns)
• Half given in first 8 hours, rest in next 16

Phases

• Emergent: Secure airway, may need oxygen or mechanical ventilation
• Acute: Fluid shift management includes resuscitation and urine output monitoring
• Rehab: Prevent contractures with therapy and address body image concerns

Major Burns Effects

• Fluid and electrolyte imbalances, pulmonary issues, cardiovascular, and GI issues

Major Burn Treatment

• RIC (rapid infusion cath) is used with isotonic solutions (Lactated Ringers)
• LRs are given to burn patients only

Complications of Major Burns

• Compartment Syndrome: peripheral circulation monitoring is essential due to muscle risk
• Curling's ulcer: gastric erosion increases risk, bowel sounds and abdominal distention need to be monitored
• Impaired Mobility: prevent, use PROM exercises, neutral positions & splints to increase mobility and reduce scarring/contractures
• Sepsis caused mostly by death following burn - assess for changes in condition, obtain wound cultures
• Airway Injury: Assess for hoarseness, cough, difficulty swallowing, wheezing support airway and ensure supplemental oxygen

Wound Care Nursing

• Premedicate before dressing changes and assess for odors, drainage, sloughing
• Apply Silver Sulfadiazine 1% = monitor for sulfa allergy
• Escharotomy/Fasciotomy: Relieve pressure from constriction/tissue

Comfort Management for Pain

• PCA (Patient Controlled Analgesia) and non-pharmacological methods for pain management

• Increase protein and carbs for healing and decreased GI motility

• Superficial Thickness: Document, sunburns

• INHALATION INJURY (LOSS OF AIRWAY): Assess for cough, a Brassy cough and client's drooling

• Administer Fentanyl IV for full burns to body to sustain deep and partial thickness

RESPIRATORY

• Check respiratory status via indicators of oxygenation and airway integrity

Diagnostic Tests

• PFT (Pulmonary Function Tests): Lung volume, capacities, diffusion, gas exchange, flow rates, and airway being measured, withhold inhalers 4-6 hrs prior
• ABG (Arterial Blood gasses): Status of oxygenation and acid-base balance assessed- perform Allen Test, hold pressure after puncture

ABG Values

• pH: Acidosis is <7.35 , Alkalosis is > 7.45

• CO2: Acidosis is >45 mm Hg, Alkalosis is <35 mm Hg

• HCO3: Acidosis is <22 mEq/L, Alkalosis is >26 mEq/L

• R: RESPIRATORY CO2 ↑ & pH ↓ = Respiratory Acidosis

• O: OPPOSITE CO2 ↓ & pH ↑ = Respiratory Alkalosis

• M: METABOLIC HCO3 ↓ & pH ↓ = Metabolic Acidosis

• E: EQUAL HCO3 ↑ & pH ↑ = Metabolic Alkalosis

• Respiratory Acidosis: retaining carbon dioxide, retain HCO3 as compensation

• Causes: respiratory depression, drugs, increased ICP

• S/S: altered LOC, hypoxia

• Respiratory Alkalosis: Breathing out too much CO2 - causes hyperventilation and kidneys to excrete bicarbonate

• Metabolic Acidosis: Too much acid, low pH - causes malnutrition

• Metabolic Alkalosis: Too little acid, not enough hydrogen ions

Chest Trauma

• Monitor: Vital Signs, O2 Sat & ABG's
• Causes: Blunt trauma (sternal/rib fractures), Flail Chest, Pulmonary Contusion, Penetrating Trauma) /Pneumothorax

O2 levels

• Normal: 94-100 % anything less = Hypoxia- Early S/S Restlessness/Anxiety/Tachycardia with extreme- Dyspnea

• Pneumothorax: excessive air in the lungs - Absent Breath Sounds/Decreased & Diminished, Tracheal Deviation

• Hemothorax: blood leakage into pleural space - Absent lung sounds on affected side due to embolism or thoracic surgery

• Flail Chest: free floating segment of the rib cage related to MVC

• Bronchoscopy view for abnormalities (tumors, inflammation) used to remove foreign bodies with monitored vitals, gag reflexes,

Chest Tubes

• Chest tube is inserted into the pleural space to drain fluid, blood or air - 4th or 5th intercostal space, mid or anterior axillary line

• inserted to rid of fluid and blood to relieve pressure, expand the lung and treat (Pneumothorax; Hemothorax; Empyema - infected, purulent fluid; Pleural Effusion - build up of fluid in pleural cavity)

• 1st Chamber: Drainage/Collection, note color

• 2nd Chamber: Water Seal-one way valve, air exits but can't re-enter

• 3rd Chamber: Suction Control- regulates air, dry or wet level of suction

• Acute Respiratory Failure ARF ( rapid deterioration) + HYPOXEMIA; BEST WAY FOR ACCURATE Hypoxemia = ABG; BEST WAY TO KNOW HYPERCAPNIA (increase Carbon Dioxide = ABG), treat underlying cause with mechanical ventilation

• Lung Abscess: Usually because of bacteria

• Sarcoidosis of The Lung/ Pleural Conditions: Monitor: VS, Secretions, changes in mental status, dehydration, fatigue

• Pulmonary Edema/ Lung Cancer: Administer oxygen, high-fowler position and listen to vitals and respiratory status

• Sleep Apnea/ Pneumonia/ PE/ Bronchitis: Encourage high-protein diet as prescribed and teach techniques

Chest Tube chambers

• -Collection- drainage: Monitor color & amount, should be slight
• 2-Water seal chamber - one way (air only), increase with expiration and decrease with inspiration
• 3-Suction chamber - regulate suction
• Monitor: Vitals, respiratory and excessive bleeding statuses.

Atelectasis

• Characterized by airway inflammation and edema, treat early with deep breathing

Nursing Interventions and Teaching

• Nursing Interventions: Monitor Oxygenation status and lung assessment with incentive breathing and good hygiene
• Teaching Show correct coughing and breathing with chest devices. Report any new lung symptoms quickly

Medication Protocols

• Medication Protocols: Antibiotics treat infections and inhaled/nebulized treatments give oxygen.

Ventilation

Mechanical is the next step in aiding ventilation and oxygenation if needed (can be positive or noninvasive based on patient assessment)

Acute Respiratory Distress Syndrome

• (ARDS) Is a complication due to major trauma (Burns, sepsis) leading fluid build up, can lead to rapid oxygen deficit

Pulmonary Conditions

• Pneumoconiosis/ Asthma/ TB can require long-term Meds + Lung hygiene, be compliant to help reduce mortality and comorbidities.

IIMUNOLOGY

• IDD (Genetic) problem is the immune response Manifestation- PIDD
• HIV (Acquired) prevent with condoms, PREP, hand hygiene and safe injection practices.
• S/S - flu-like and weight loss
• Treatment is - ART

(C) is to Detect how severe: VIRAL TEST, high means to bleeding test

• Stage of HIV: Stage 1:CD4 count is 500-1500 Stage 2: 200-400 3: BELOW 200 === AIDS!!!!!

Labs to check: Monitor Creatinine, Urine output, CNS, Cardiovascular S/S - Monitor for the Butterfly Rash Tests ANA(+) SLE - Health and Wellness Promotion, manage exacerbations with eating healthy, exercise, therapy, rest, and mild shampoos. Avoid hair chemicals like hair dye.

Treatment:

• Severe Allergic reaction (Anaphylaxis) wheezing, stridor, respiratory distress. = Epinephrine
• Mild Reactions: Antihistamines (Benadryl (drowsy) Zyrtec (non drowsy).
• Severe but not Respiratory distress like poison ivy === give Corticosteroids
• Treatment:
• Anaphylaxis:. Avoid this 2-5 Avoid before: Angio, Urticaria, Broncho Construction : Rebound can occur after 4 hours.