Medsurg Final Term PDF

EMERGENCY AND HIGH ALERT DRUGS Lopressor 10mg (2) Cardizem 20mg vial (2) THE CRASH CART...

EMERGENCY AND HIGH ALERT DRUGS Lopressor 10mg (2) Cardizem 20mg vial (2) THE CRASH CART Pronestyl (procainamide) 1g in 10 ml 100mg/ml Vial (1) A crash cart contains the equipment and medications that would be required to treat a patient in the first thirty HIGH-ALERT MEDICATIONS (HAM) by Australia minutes or so of a medical emergency. - Bear a heightened risk of causing significant harm when used Although crash carts can differ somewhat depending in error. upon their location, the basic crash cart will contain - Dangerous if not administered properly or if patient developed similar equipment. certain forms of rejection or reaction. - It is the responsibility of the charge nurse (or head nurse) to - Remember: Drug is any substance that produces reaction, it safeguard the crash cart. The crash cart must be checked may be pleasant or unpleasant, some can produce curative (low before and after each duty shift. Ideally, two charge nurses dose), and some can produce disability, complications, and should endorse what was used from the crash cart in the event event death (high doses) of a code. S Safety systems such as independent double checks, safe - The medication cart is designated for medications, while the administration of liquid medications, standardized order sets, crash cart is specifically for resuscitation. and medication charts. - A crash cart should be present in all units where there are P Potassium (drip never bolus) and other electrolytes, patients. psychotropic medications. I Insulin N Narcotics such as morphine, opioids, sedatives. Contents of the crash cart: A Antimicrobials (antibiotics). Top of the E-cart Advanced updated life support; in PH = AHA C Chemotherapeutic agents. H Heparin and other anticoagulants. Manual Shock - For pain, we usually used non-opioids such as acetaminophen Medications first, last resort would be opioids; opioids can cause muscle Oxygen supply, defibrillator with monitor, flaccidity. portable suction apparatus, - STAT meds should be given 30 minutes from the time it was sphygmomanometer, stethoscope, ordered. emergency crash cart check sheet, check list of cart contents, emergency drug 3 Formulas to reduce risk of high-alert medications information sheet. 1. Standardized error-prevention processes Drawer 1 Medications 2. Make errors apparent; do not tolerate this Drawer 2 Breathing and airway 3. Minimize the consequences of errors that reach the patient. Drawer 3 Circulation; IV supplies Drawer 4 Circulation; IV solutions and Tubing COMMON HIGH-ALERT MEDICATIONS by Institute for Safe Drawer 5 Cardiac, chest procedures Drawer 6 Special procedure trays Medication Processes (ISMP) 1. Insulin: Place in the vegetable compartment (insulin vial that is opened) not in freezer; should be placed in a container and Items in the Crash Cart: should be labelled. Airway (oral and nasal) all sizes 2. Opiates/opioids and narcotics (morphine) McGill forceps, large and small 3. Injectable potassium chloride or phosphate concentrate King Airway set (3) eliminates the need for 4. intravenous anticoagulants (such as heparin) laryngoscope and endotracheal tubes 5. NaCl solutions above 0.9% (hypertonic fluids; like Sodium Bag valve mask (adult and pediatric) 10% which is used for therapeutic abortion; given in amniotic Nasal cannula fluid. Non rebreather oxygen face masks (3 sizes) IV start packs DURING A CODE Normal saline solution (1000ml bags); should always - If there is enough manpower, just inform/announce the ED be present (scream CODE). IV tubing - Master/Leader of a code: Physicians Angiocaths (various sizes) - However, we can start chest compressions without the 10ml normal saline flush syringes (3) physicians order (30 compressions for adults then ventilate; but Gauze not simultaneously with compressions). Alcohol preps Monitor with defibrillator (preferred) or AED ORAL ORDERS Syringe nasal adaptor (nasal narcan atomizer) 1. Accept if it’s considered acceptable Syringes 2. We can carry out if it’s prescribed by a valid prescriber (A checklist confirming everything that should be on the cart) (physician) - Oral orders are accepted provided you have a witness Drugs in the Crash Cart: (licensed nurse or with high credibility; someone with authority) OR put the physician on speaker when on call in order for Aspirin Tablets; during emergency, patients might not everyone to hear. Then write the order while the physician is tolerate stating it, repeat the order of the physician to ensure it’s Nitroglycerin spray or tablets accurate, then confirm it if it’s correct. After that, start the Dextrose 50% (dextrose 25% if treating pediatrics) medications as soon as it is available. In a hospital setting, Naloxone (Narcan) 1mg/ml (6); antidote for there’s always a resident doctor. Call the resident doctor then sedatives/oversedation from opioids tell them to transfer the verbal/oral orders/write orders in the Epinephrine 1:10,000 (3) doctor’s order sheet then write it in medication administration Atropine Sulfate 1mg (3) record or MAR; If not written, it didn’t happen. Amiodarone 150mg Vial (4); cardiac in nature Remember: A legal order should be a written order but during EpiPen® (2) emergency, it’s okay to verbally order. Hydrocortisone (Solumedrol) 125mg vial; anaphylaxis - We can give drugs ordered verbally if emergency or if doctor Benadryl 50mg vial (2) is not around. Adenosine 6mg (4) EMERGENCY DRUGS May be repeated every 20 minutes to once every 4 hours as needed. 1. EPINEPHRINE (Adrenalin) IM: 0.1 to 0.5 mg (0.1 to 0.5 mL of 1:1000 solution). - Injectable vial, ampule, EPIPEN May be repeated every 10 to 15 minutes. also called adrenaline; a hormone that is secreted IV: 0.1 to 0.25 mg (1 to 2.5 mL of a 1:10,000 solution) once mainly by the medulla of the adrenal glands and that slowly and cautiously over 5 to 10 minutes; if severe functions primarily to increase cardiac output and to The dose may be repeated every 5 to 15 minutes as raise glucose levels in the blood needed and tolerated. - They are catecholamines; sister of norepinephrine; chemically, In some cases of severe anaphylaxis, an intravenous epinephrine is a catecholamine, a monoamine produced only by infusion of epinephrine (1 mg in 250 mL of D5W adrenal glands from amino acids phenylalanine and tyrosine (because they are sugar), or 4 mcg/mL) can be started - Mimics the action of the real hormone to run at 1 to 4 mcg/min (15 to 60 mL/hour). Used to treat a number of conditions including: 3 checks in medication administration: 1. Cardiac arrest; resuscitation 1. Check before opening (such as expiration date) 2. Anaphylaxis; shock caused by immune system 2. Before transferring the medications 3. Superficial bleeding (if deep bleeding = surgery) 3. Before disposing 4. Bronchospasm (aminophylline can be used also); like - Take consent BEFORE preparing drug severe asthma or status asthmaticus - Nurses are unique because it’s their responsibility to 5. Hypoglycemia; epinephrine can indirectly cause sugar administer medications. rush because it stimulates glycogenolysis and gluconeogenesis and it inhibits insulin production Special Feature: EPINEPHRINE PEN (although salbutamol and dextrose are now preferred EpiPen is available for administration during severe for 4 &5) allergic disorders – EMERGENCY - No need to remove clothes Epinephrine - Actions: It increases heart rate; given to improved reduced How: cardiac output 1. Remove EpiPen autoinjector from its carrying tube It constricts blood vessels; because during shock, 2. Grasp the unit with the orange tip pointing downward there is vasodilation; increases BP but doesn’t improve 3. Form a fist around the unit with the orange tip down blood flow; prevents heart failure 4. With the other hand, remove the blue safety release cap It dilates air passages; broncho dilating effect 5. Hold the black tip near outer thigh It participates in the fight-or-flight response of the 6. Swing and jab firmly into outer thigh until a click are heard sympathetic nervous system with the device perpendicular to the thigh (90 degrees) 7. Wait 10 seconds to ensure drug is fully absorbed Usual Adult Dose for Shock (a state of multiple system failure) 8. Remove the unit and massage the area IV: 2 to 10 mcg/min (1 mg of epi in 250 mL of D5W); most 9. Replace EpiPen needle-end first into the device storage preferrable without bending the needle Endotracheal (if intubated): 1 mg (10 mL of 1:10,000) once, 10. Refer to the physician and then followed by 5 quick insufflations (to prevent the drug - Don’t forget to replace the needle to prepare for another from getting stuck in the tube). emergency Intracardiac: 0.3 to 0.5 mg (3 to 5 mL of 1:10,000) by direct injection into the left ventricular chamber once 2. HYDROCORTISONE (Solu-Cortef) - Vial Note: is a corticosteroid. It is commonly used to treat 1: 1,000 is equivalent to 1 mg/ ml; larger dose inflammation (swelling/critical swelling) of the skin, 1:10,000 is equivalent to 0.1 mg/ ml; preferred strength joints, lungs, and other organs. because it’s smaller since it’s more diluted Common conditions treated include asthma, allergies, 1: 1000 = 1mg/1mL and arthritis (works up to 3-6 months for arthritis). 1: 10,000 = 1mg/10mL It is also used for other conditions, like blood disorders and diseases of the adrenal glands. Usual Adult Dose for Asystole IV: 0.5 to 1 mg (5 to 10 mL of 1:10,000) once. Dosage: Hydrocortisone Succinate May be repeated every 3 to 5 minutes as necessary. Available at 100 mg vial, 250 mg vial, 500 mg vial and Endotracheal: 1 mg (10 mL of 1:10,000) once, followed by 5 at 1000 mg vial quick insufflations. Intracardiac: 0.3 to 0.5 mg (3 to 5 mL of 1:10,000) by direct Severe inflammation, adrenal insufficiency injection into the left ventricular chamber once. 100 – 500mg IM 50 – 100 mg IV as indicated Usual Adult Dose for AV Heart Block (bradycardic and will likely fall to asystole/flatline) For Shock (anaphylactic shock): IV: 0.5 to 1 mg (5 to 10 mL of 1:10,000) once. initial 50 mg/ kg IV and repeated in 4 hours. May be repeated every 3 to 5 minutes as necessary. Repeat every 24 hours prn until stable but not longer If there is inadequate response to 1 mg, then high dose than 72 hours therapy (2 to 5 mg) every 3 to 5 minutes. 3. ATROPINE SULFATE Usual Adult Dose for Asthma – Acute In general, atropine lowers the parasympathetic Subcutaneous: 0.1 to 0.5 mg (0.1 to 0.5 mL of 1:1000 solution). activity of all muscles and glands regulated by the May be repeated every 20 minutes to once every 4 parasympathetic nervous system hours as needed. - Promotes sympathetic activity; increases heart rate Therefore, it may cause swallowing difficulties and Usual Adult Dose for Allergic Reaction reduced secretions; because salivary glands are Subcutaneous: 0.1 to 0.5 mg (0.1 to 0.5 mL of 1:1000 solution). suppressed  It is an anticholinergic that inhibits acetylcholine at the Indications: parasympathetic neuro-effector junction, blocking 1. For metabolic acidosis (recall acid – base) vagal effects on the SA and AV nodes; prevents the 2. Urinary or systemic alkalinization; too acidic urine (normal action of acetylcholine urine pH is 6-8); corrects blood problem through urine; Be careful when used together with epinephrine 3. As antacid; if oral Can control of influence nervous system 4. For cardiac arrest; to correct acid-base imbalance that follows This drug is preferred for intubationl cardiac arrest Should be given only when ventilation is adequate; Atropine Sulfate for Resuscitation: because breathing helps adjust acidosis; acids are Injections of atropine are usually used in the treatment excreted through respiration of bradycardia and brady arrhythmia; improves heart Administer IV slow rate Available at 4.2% (5mEq/10mL) and 8.4% (10mEq/ Atropine blocks the action of the vagus nerve (Cranial 10mL and 50 mEq/ 50mL vial Nerve 10), a part of the parasympathetic system of the Oral forms also available heart whose main action is to decrease heart rate. Therefore, increases the heart rate 6. DOPAMINE Antidote for cholinesterase insecticide poisoning - Promotes mood and good fine motor activities; Dopamine can’t Preoperatively to diminish secretions and block cardiac cross Blood-Brain-Barrier vagal nerves; since it suppresses salivary glands a catecholamine neurotransmitter Also used as adjunct (additional but not primary) is produced in several areas of the brain, including the treatment of peptic ulcer disease and functional GI substantia nigra disorders such as irritable bowel syndrome; because it is also a neuro-hormone (comes from the brain) improves contractility of the muscles released by the hypothalamus. Its main function as a hormone is to inhibit the release of prolactin from the Additional info: anterior lobe of the pituitary - Narcosis: Loss of consciousness, loss of pain sensation, - Prolactin is abundant during postpartum for breastmilk muscle relaxation; patient experiences amnesia formation; dopamine can suppress breastmilk production; - Medication error = nurse’s fault prolactin is present in males but some only Dosage: Atropine Sulfate Dopamine Functions: in the brain Available at 0.05 mg/ml, 0.1 mg/ ml, 0.3 mg/ml, 0.4 1. important roles in behavior and cognition; mg/ml, 0.5 mg/ml, 0.8 mg/ml and 1.0 mg/ ml neurohormone ; influences mood 2. voluntary movement; consciously controlled Bradycardia 3. motivation, punishment and reward 0.5 – 1.0 mg IV push repeated every 3 – 5 minutes to 4. inhibition of prolactin production a maximum of 1.0 mg in children and 2.0 mg in adult 5. Sleep prn 6. Mood 7. Attention 4. AMIODARONE 8. working memory and learning Common brand: cordarone Is an anti-arrhythmic drug; treats arrythmias and IV acts on the sympathetic nervous system to produce dysrhythmias; regulates heart rhythm (pattern how increased heart rate and blood pressure. heart is beating) However, because dopamine cannot cross the blood- - Used when the nature of the problem is the heart brain barrier, dopamine given as a drug does not - Best indicator of normal heart rhythm is ECG (monitors sinus directly affect the central nervous system rhythm) L-DOPA (the precursor of dopamine) is often given - Amiodarone is contained in an amber colored container; because it crosses the blood-brain barrier relatively amber-colored medications should be kept away from light and easily; L-DOPA is given when dopamine is really heat. absent in the body like in Parkinson’s disease Indications: Dosage: 1. Life – threatening recurrent ventricular fibrillation Available at 40 mg/ml, 80 mg/ml, 160 mg/ml 2. Recurrent hemodynamically unstable ventricular tachycardia For IV infusion: 200 or 400 mg in (250 or 500ml) D5%W unresponsive to adequate doses of other antiarrhythmics. or NSS at 0.8 mg/ ml 3. Cardiac arrest; pulseless ventricular tachycardia or fibrillation Initially given at 1 – 5 mcg/kg/min titrate (adjust) to 1 – (happens after v-tach was not managed) 4 mcg/kg/min at 10 – 30 minutes intervals 4. Ventricular and supraventricular arrhythmias 5. Heart failure; because heart is the problem Computation: 1. Dopamine 400 mg in 500 ml D5%W to infuse at 4mcg/kg/min Give IV only when continuous ECG monitoring is in a 75 kg patient. How much will you give in cc/hr? available; monitor though cardiac monitor; this corrects Formula: the heart rhythm - Most common potential dysrhythmia: V-tach and V-fib Fluid volume x mcg/min x weight (in kg) x min = cc/hour or mL/hour Mix first dose of 150 mg in 100 mL D5%W Medication ordered x 1000 (constant) During cardiac arrest (flatline): 300 mg in 20-30 mL IV solution, IV push 500 mL x 4 mcg x 75 x 60 = 9,000,000 = 22.50 or 23 cc/hour 400 mg x 1000 400,000 5. SODIUM BICARBONATE Restores buffering capacity of the body and neutralizes Example given by Ma’am A: excess acids. - Buffer for acidosis; all acids are affected 250 mL x 2mcg x 48 x 60 = 1,440,000 = 7.2 or 7 cc/hour 200 x 1000 200,000 7. DOBUTAMINE (Dobutrex) inject it to the IV line so that clot will not form in the IV insertion - Cousin of epinephrine site. a sympathomimetic (adrenergic) drug used in the - S-saline, A-administer, S-saline, H-heparin; if IV line is ongoing treatment of heart failure and cardiogenic shock. or continuous, do not SASH. - Cardiogenic can be classified into intracardiac (disease is - SASH is used in hospital setting if a patient doesn’t have present in the heart such as coronary heart disease) and ongoing IV infusion such as KVO or if catheter is stand alone to extracardiac (external) prevent clot formation. Dobutamine is used to treat acute but potentially Cardiopulmonary bypass for heart surgery (this is an reversible heart failure (but doctors must know what open-heart surgery so there could be clot formation; caused heart failure), such as which occurs during heparin is given for prevention). cardiac surgery or in cases of septic or cardiogenic Hemofiltration shock. Indwelling central or peripheral venous catheterization Dobutamine can be used in cases of congestive heart failure (intracardiac) to increase cardiac output For IV Infusion Computation: It is not useful in ischemic heart disease because it 1. Heparin infusion to start at 18units/kg/hour to a patient with increases heart rate and thus increases myocardial 75kg weight. The heparin infusion comes in a 500mL bag with oxygen demand; in ischemic heart disease, heart is 25,000 units. Calculate the starting rate of the infusion compromised because it lacks blood supply (mL/hour). Do not give together with Heparin (because it can Heparin Infusion rate: increase the risk of bleeding when combined with Total units (in IV bag) = unit/hour dobutamine, which affects heart rate and blood flow) Total volume (mL) x (mL/hour) and Hydrocortisone (because it is a corticosteroid; it We are looking for the X can cause fluid retention and elevated blood pressure, Step 1: calculate starting units per hour which may be intensified by dobutamine’s effects, 18 units x 75kg = 1350 units/hour leading to cardiovascular instability) Step 2: Calculate rate of the infusion (solve for X) by cross multiplying. Dosage 25,000 units = 1350 units/hour Available at 12.5 mg/ ml in a 20 ml vial 500 mL x (mL/hour) Refractory (rest period of the heart) Heart Failure 500 mL x 1350 units/hour = 675,000 0.5 – 1 mcg/kg/minute IV infusion, titrate to optimal Step 3: Bring down 25,000 units (maximum) dosage of 2 -20 mcg/ kg/ min 675,000 = 27 mL/hour (this is the X) 25,000 8. HEPARIN is generally used for anticoagulation (works before a 2. Heparin infusion to start at 20units/kg/hour to a patient with clot forms/or when a clot begins to form so it doesn’t 81kg weight. The heparin infusion comes in a 250mL bag with become bigger) 25,000 units. Calculate the starting rate of the infusion - Thrombolytics: works after a clot has formed; can also work (mL/hour). when a formed clot is still small; breaks or dissolves a clot Acute coronary syndrome 20 units x 81 kg = 1620 units/hour Atrial fibrillation 25,000 units = 1620 units/hour Deep-vein thrombosis (Deep-vein thrombosis usually 250 mL x (mL/hour) happens in the lower extremities; manifested by swelling; no other obvious changes in the legs because 250 mL x 1620 units/hour = 405,000 we cannot see deep veins; it’s not superficial (added info: cut-down procedure uses deep veins are hard to 405,000 = 16.2 mL/hour or 16 mL/hour use) and pulmonary embolism (when a thrombus 25,000 detaches and travels to the heart until it reaches the pulmonary artery; it’s now called an Remember: Ma’am A wants to see 2 answers on the exam. embolism/embolus) - Very common especially among people who are confined to 9. INSULIN bed for a long period of time; or whose nature of job makes them stand, sit, and lie down for a long period of time (prolonged) a hypoglycemic agent; it functions to reduce blood - Deep-vein thrombosis is assessed or measured by leg glucose levels in the body. circumference of the affected area. For DVT: >2cm is significant. All types of insulin are given subcutaneously (because Aside from the leg circumference, patients will complain of pain. we need to control the absorption; Only regular insulin Patients with DVT are also assessed using Homan’s test (pain can be given IV; we cannot give cloudy through IV in dorsiflexion); the patient is positive with Homan’s test if they - ® regular insulin (clear); NPH (Neutral Protamine Hagedorn) is experience pain in the calf muscle when the foot is dorsiflexed. intermediate-acting insulin (cloudy); intermediate can be given - Swelling, pain, and Homan’s test are classic indicators of DVTs maximum of 2 doses per day. Long-acting or very long-acting - The confirmatory test for DVT is duplex ultrasound, can stay in the body for 24-46 hours, it is given once a day only. venography, and angiography (uses contrast). - we give insulin using normal saline; never D5W. - DVT forms with inactivity in the legs (prolonged standing, and sitting) For IV Infusion Computation: - To prevent DVT, we encourage the patient to ambulate/walk; 1. Order: Insulin 100 units in 400 ml NSS to infuse at 4 units/ but when thrombosis has already developed, we don’t hour. Solve for gtts/ min. Note: drop factor is 20 encourage them to move because it may progress to pulmonary Formula for drops/min: embolism; we should prevent this; if able to move, let them Fluid volume x units/hour x drop factor = gtts/min move. If not, let them wear anti-embolic stockings/panty hose Medication ordered x 60 (constant) (as long as above the knee) - Hep-lock: not advisable in peripheral, but used in central. How 400 mL x 4 x 20 = 32,000 = 5.33 gtts/min or 5 gtts/min to hep-lock? Get a small amount of heparin in a syringe then 100 x 60 6000 If there’s no drop factor, use mL/hour formula R.A. 9165 Formula for mL/hour: An Act Instituting the Comprehensive Dangerous Unit/hour x fluid volume = mL/hour Drugs Act of 2002, Repealing Republic Act of 2002, Medication ordered Repealing Republic Act Np. 6425, otherwise known as the Dangerous Drugs Act of 1972. 4 units x 400 mL = 1600 = 16 mL/hour 100 units 100 SUBSTANCE DEPENDENCE Occurs when a person needs one or more drugs to be Shortcut (to know gtts/min; can be used for checking): able to function physically or psychologically. Abuse was primarily considered as the milder, earlier 16 = 5.33 gtts/min form of dependence by APA 3 (constant) The DSM-V replaced ‘substance abuse’ and ‘substance dependence’ with ‘substance use 3. Regular insulin 100 units in 100 mL NSS to infuse at 3 units disorders’ per hour. If there’s no drop factor, use mL/hour formula DRUG ADDICTION 3 units x 100 mL = 300 = 3 mL/hour Neurological; May involve: 100 units 100 1. using drugs despite the consequences, 2. being unable to stop using the drug (because of cravings), Shortcut: 3 = 1 gtts/min 3. neglecting social and work obligations because of the drug 3 use ADDITIONAL INFORMATION IN THE PPT DRUG DEPENDENCE Physical; May involve: FENTANYL 1. some or all the symptoms of addiction, Rapid acting opioid (synthetic or artificial); has similar 2, development of a high tolerance for the substance as the effect with morphine but it has shorter effect and body adapts to the drug, leading to a desire for larger doses for faster onset than morphine the same drug effect, Alleviates pain without causing loss of consciousness 3. physical symptoms of withdrawal when attempting to stop (analgesic) Used primarily as pain reliever for surgical and cancer DRUG ABUSE DRUG DEPENDENCE patients - Compulsive drug use despite - Physical phenomenon the Works by depressing CNS and respiratory functions the consequences body adapts mostly physically - Prioritizes drug use over - Part of addiction but may occur CARFENTANIL activities and responsibilities without it - Continuous using despite - May involve drugs that are not Synthetic opioid used in veterinary practice (for negative outcomes addictive but used for certain animals) conditions (such as Is 100-fold stronger version of fentanyl maintenance drugs) - Both fentanyl and carfentanil are derivatives of heroine (can - Withdrawal symptoms develop - Physical symptoms of cause addiction) when substance is not used withdrawal when attempting to - Physical and psychological stop. MORPHINE Narcotic analgesic (derivative of opioid) DRUG TOLERANCE Blocks pain impulse transmission in the CNS; also Diminished response to a drug which results in needing causes the brain to release large amounts of higher doses to achieve the same effect dopamine (which calms the body; relaxes muscles) Window period (usually 14 days); shifting from one Treats severe pain, depresses all phases of medication to another; done by prescriber respiration (both in the brain and diaphragm) Common in psych patients MEPERIDINE (Demerol) DRUG TOLERANCE DRUG DEPENDENCE Narcotic analgesic (phenylpiperidine) - Reduced response to drug - Reliance on the drug to avoid Works on the CNS to treat moderate to severe pain with controlled use withdrawal Commonly used for patients with abdominal pain - Charges with receptors or - Neuro adaptions leading to metabolism physiological reliance associated with biliary/hepatic/pancreatic conditions. - Requires higher doses for the - Maintains a specific level to same effect prevent withdrawal PETHIDINE - Mild or no withdrawal - Pronounced withdrawal Also know as meperidine and sold under the brand symptoms symptom (mostly physical) name Demerol among others - Can live without the drug develops if the drug is stopped. Is a fully synthetic opioid pain medication of the phenylpiperidine class - Drug tolerance does not necessarily lead to dependence but Also pronounced as bethidine occurs as part of the dependence process. INTRAVENOUS INFUSION IV set – for ordinary infusion Solu Set – usually used for pediatric or medications; makes use of drips (there are 4 micro drips in 1 drop); faster Blood Transfusion Set – used only for blood transfusion; consistency is cloud or opaque; rough inside so that when there is clot formation it will stick to the tubing; there is filter chamber; to filter clot. INTRAVENOUS THERAPY SHOCK a way of administering blood, medication, water, nutrients, and other fluids directly into the bloodstream An abnormal physiologic state (status; something that via the veins. can shift/change because of certain changes in the IV therapy allows administration of fluids to the body environment/body) when an imbalance exists between quickly and efficiently. the amount of circulating blood volume and the size of Although it is common, IV therapy is an invasive the vascular bed; we need to always relate the blood procedure that carries some risks hence, requires volume with the size of vascular bed/integrity of blood training and practice. vessels, especially arteries, because it is through the arteries mainly where we have to determine if there is INTRAVENOUS INFUSION enough circulation in the body (because through the Is injection of solution or medications into a vein (if arteries, blood is circulated to reach body organs artery, it’s called intraarterial) through an intravenous especially the vital ones); the force of the blood in the line, needle, or catheter. arteries depends largely on the integrity of the arteries, Blood may also be transfused through the intravenous amount of volume present, and pumping action of the line. heart - Hypovolemic shock is the most common types of shock PATHOPHYSIOLOGY OF SHOCK 1. Cellular effects of shock (speaks about what happens to the cells in the body during the state of shock; with shock, there is a problem with the circulating blood volume, integrity of blood vessels is changing) In the absence of oxygen (there could be hypoxemia or hypoxia), the cell will undergo Anaerobic (metabolism that doesn’t use oxygen) metabolism to produce energy source and with it comes numerous by-products like lactic acid - With normal aerobic metabolism, cells can produce lots of acids as a waste product for kidneys to discard (carbonic acid is for lungs to discard); but, with anaerobic metabolism, products that are acidic are doubled and it can become overwhelming (too much presence of acids in the body/organs); the work of the kidneys will also double. The cell will swell due to the influx of Na and H20, mitochondria will be damaged, lysosomal enzymes will be liberated (will exit the cells), and then cellular death ensues (sodium (Na) is found outside the cells not in the cells; it should be outside; permeability will change; if sodium enter cells, water will follow) 2. Organ System Responses - Cells comprise tissues, and tissues comprise organs; when cells are damaged, organs are also damaged When the patient encounters precipitating causes (what led to the development of shock) of shock, the circulatory function diminishes → there is decreased cardiac output → causing Hypotension and decreased tissue perfusion will result (if the amount of oxygen and DROP FACTOR blood in the arteries decreased because of decreased Number of drops it takes to make up one mL of fluid cardiac output, then the amount of oxygen and blood 20 drops per mL = clear fluids circulating in the vital organs of the body will also be 15 drop per mL = thicker plasma decreased thus causing organ damage) 10 drops per mL = much thicker substances such as blood Micro drip/set: has small needle (micro set) in the drip chamber; uses 60 drops per mL - The thicker the solution, the smaller the set Macro drip: normally uses 10-20 drops per mL STAGES OF SHOCK will change; if blood pressure drops, the rest of the body will follow 1. THE COMPENSATORY STAGE The overworked heart becomes dysfunctional (signs of - the body’s circulation is still compensating because of shunting arrythmia). of blood to the more vital organs Heart rate becomes very rapid (as high as 150 bpm) In this stage, the patient’s blood pressure is within Blood flow to the brain becomes impaired, the mental normal limits (the patient may already be tachycardic, status deteriorates due to decreased cerebral urine output might already decline, but bp is okay perfusion and hypoxia. because of increased ADH thus, volume is - In the progressive stage, the most evident signs are decreased maintained). Blood is shunted from the kidney, skin BP and level of consciousness and GIT to the vital organs- brain, liver and muscles Laboratory findings will reveal increased BUN and Creatinine (monitor kidneys; develops acute renal failure (AKI); different from chronic; renal failure during shock is classified as Pre-renal, because of inadequate blood supply leading to kidneys not functioning well). Urinary output decreases to below 30 mL/hour. Decreased blood flow to the liver impairs the hepatic functions (such as detoxify/ filter blood with the use of phagocytes, stores whatever is present in the blood, converts ammonia to urea, conjugate bilirubin to be used as part of bile) Toxic wastes are not metabolized efficiently (since liver is not functioning well due to decreased blood supply), resulting to accumulation of ammonia, bilirubin and lactic acids. The reduced blood flow to the GIT causes stress ulcers and increased risk for GI bleeding (monitor also for GIT; to prevent ulcer, this patient should be fed through NGT or TPN if able; we can also suggest physicians to Manifestations: order antacids or H2 blockers). Cold clammy skin (blood is shunted from skin to vital Hypotension, sluggish blood flow, metabolic acidosis organs) and generalized hypoxemia can interfere with normal Oliguria (blood is shunted from kidneys to vital organs; blood function (causing more damages) blood doesn’t become urine yet since it’s already not enough) Manifestations: Hypoactive bowel sounds (GIT (blood is shunted) is Low BP (will really have to monitor) also affected; there could be development of ulcer) Increased HR and pulse (will go further up) BP within normal limits Increased Respiratory rate (will go further up) LOC may or may not show signs of beginning Decreased LOC (will really have to monitor) deterioration (the patient is expected to be oriented, Decreased urine output (will further go down) coherent, and responsive) Impaired LFT, RFT (enzymes will all be elevated) HR increased Signs of ACIDOSIS (in ABG) Medical management: Medical Management: 1. IVF (start IV line as early as the nurse can; a safe IV fluid is isotonic solution; although it is considered a medication that Goals: should be ordered, during an emergency, it will not kill the patient; since the patient might likely experience shock, use 20- Optimize intravascular volume (make sure circulation gauge needle (especially if adult) because of the possibility of is treated) blood transfusion in case shock is not managed by simply IVF; support pumping action of the heart needs doctor’s order unless emergency) improve competence of the vascular system (through 2. Oxygenation (fluids first before oxygen because if fluids are the help of medications) not enough, how is the oxygen be distributed; be sure there is support respiratory functions (through medications and good circulation first; needs doctor’s order unless emergency) oxygen supplement) 3. Medication (wait for physician) 4. Supportive therapy Management: 1. Early nutritional support (otherwise patient may be deprived Nursing management: of nutrients; resume feeding, if possible, if not give supplemental monitoring of tissue perfusion & vital signs (monitor feeding though parenteral approach or NGT; enteral feeding is O2sat and ABG or other blood tests with doctor’s preferred) order) 2. Aggressive hyperglycemic control with insulin (because sugar reduction of anxiety levels might shoot up due to stimulation of sympathetic administration of IVF/ ordered medications activities) and use of antacids, H2 blockers or anti-peptic agents 3. Aggressive intravascular support (IVF or blood transfusion; or promotion of safety (consent, place on bed with side by giving medications as prescribed by the doctors such as rails up, make sure there is a watcher) vasopressors) 2. THE PROGRESSIVE STAGE Nursing Management: - Also called decompensating stage Prevent complication (such as renal failure, stress In this stage, the mechanisms that regulate blood ulcers, liver failure; minor complications such as pressure can no longer compensate respiratory difficulty, risk for aspiration, bed sores) The mean arterial pressure falls. (systolic BP less than Promote rest and comfort 90mmHg or decrease of systole by 40mmHg); the bp Support family members 3. THE IRREVERSIBLE STAGE OF SHOCK - The body will give up; the patient might experience arrest; needs CPR. This stage represents the end point; there’s no going back but patient is not yet dead, just on the brink of death if not managed properly. there is severe organ damage that patients do not respond anymore to treatment. Survival is almost impossible to maintain. Despite treatment, the BP remains low, anaerobic metabolisms continue and multiple organ failure results. Management for all Types and Phases of Shock: Manifestations: Basic life support (patient might likely need Very BP low; bp cannot be heard/palpated resuscitation and even advanced life support, be ready Renal (anuria (less than 50mL in 24 hours; very with crash cart) unnoticeable) instead of oliguria) and liver failure Fluid replacement (start IV line) present (may be determined through blood tests) Vasoactive medications (vasopressors) Release of necrotic tissue toxins (leads to acidosis) Nutritional support Inadequate oxygenation (perfusion) due to respiratory system failure; monitor ABG GENERAL MANAGEMENT OF SHOCK: Ineffective cardiovascular system; monitor cardiac Maintain patent airway and adequate ventilation. functions; if bradycardia, it means the body is really Restore blood volume; administer fluid and blood giving up (lesser evil if tachycardia) replacements as ordered Administer drugs as ordered Medical Management: Minimize factors contributing to shock (i.e hypoxia) is the use of life supporting drugs like epinephrine Maintain continuous assessment of the client (adrenaline, 1;10,000) and investigational medications. Provide psychological support: reassure client to relieve apprehension, and keep family advised ASSESSMENT OF SHOCK Provide Nutritional support - not all the findings are the same Blood Transfusion - During a blood transfusion, the Take note: blood flows out of a hanging bag, into a tube, through Hypovolemic and Cardiogenic shock: Cool, pale, moist another tiny tube into a blood vessel, and into the blood skin stream. The whole process takes about 1 to 4 hours, Septic and Neurogenic shock: Warm (high depending on how much blood is given. temperature), dry, pinkish skin - There are different types of blood preparations. In general, - with septic and neurogenic shock, temperature is affected. what flows in our circulatory system is the natural blood that we With septic shock, because there is infection, there will be fever. know. It’s a special type of tissue that composed of plasma and With neurogenic shock, hypothalamus is affected since it’s part formed elements. The formed elements are composed of of the neuro system. various types of blood cells such as red blood cells/erythrocytes (majority; that’s why the color of the blood is red), white blood Pulse Tachycardia, due to increased sympathetic cells with 5 subgroups (neutrophils (most abundant), stimulation; Weak and thready (very thin eosinophils, and basophils, monocytes, and lymphocytes), and character like a thread); similar in all types of platelets (also known as thrombocytes) which are prime movers shocks when in comes to clotting and they are supported by clotting Blood Pressure Early stages: may be normal due to factors. Plasma is a mixture of fluids and solutes present in the compensatory mechanisms blood (91 – 94% of plasma is water and the rest are gasses, Later stages: systolic and diastolic blood pressures drop until hardly identifiable acids, hormones, electrolytes); mix them all together, it is blood. Respirations Rapid and shallow (gasping), due to tissue - Packed RBCs – composed of only red blood cells; usually anoxia and excessive amounts of CO2 (from given to anemic patients metabolic acidosis); RR is high but rhythm is - Platelets – used for dengue fever poor (also because of too much acids, lungs - not every patient needs the whole blood; the blood is is compensating) sometimes divided into what the patient only needed. LOC Restlessness and apprehension (sometimes - 1 bag of blood should be consumed in 4 hours or less; but it agitated), drowsiness, progressing to coma still depends on what type of blood cell is given. Blood should Urinary Output Decreases due to impaired renal perfusion not be given more than 4 hours because it is a living cell. It is kept cold but not frozen. Blood can be kept in the blood bank for Normal urine output (the younger the person, several months when preserved properly with the right the more water in the body): temperature. Adult – > 0.5 mL/kg/hour Child – > 1 mL/kg/hour - Blood should be given to patient warm, not cold. Always Neonate – > 2 mL/kg/hour (> 1 year monitor the patient receiving blood transfusion; check blood old) type, Rh factor (Rh negative blood is safer). - During a blood transfusion, ensure that there is a proper order Urine volume: from the doctor, even if emergency. Ensure proper process Anuria = < 100 mL/day (checking of blood and all, taking of vital signs before, during, Oliguria = < 400 mL/day and after (every 15 minutes in the first hour then 30 minutes in Polyuria = > 2 L/day the succeeding hour) Temperature Decreases in severe shock (except septic and neurogenic shock; septic shock typically NOTE: presents with hypotension, temperature Not all shock victims are placed in Trendelenburg's greater than 38.3 or < 36 degree Celsius, position as this could increase sudden blood flow to the tachycardia, and tachypnea. brain and heart send false stimulation on the brain- making it dilates the vessels and decrease cardiac  activity to reduce the increasing blood pressure. Traumatic hemorrhagic shock, resulting from acute Caution is also observed for those with spinal injuries. hemorrhage with soft tissue injury and, in addition, Place victim flat on the floor release of immune system activators. Hypovolemic shock in the narrow sense, resulting form a critical reduction in circulating plasma volume without acute hemorrhage (associated with dehydration; extreme vomiting, hyperemesis gravidarum, diarrhea). Traumatic hypovolemic shock, resulting from a critical reduction in circulating plasma volume without acute hemorrhage, due to soft tissue injury and the release of immune system mediators (worse than hypovolemic shock alone). Risk factors: 1. External Fluid Losses (something occurring outside the body): Trauma, Surgery, Vomiting, Diarrhea, Diuresis, THE BLOOD WARMER DI Is used to warm blood or other fluids, minimizing the 2. Internal fluid shifts: Hemorrhage, Burns, Ascites, risk of hypothermia. Blood is kept refrigerated for the Peritonitis, Dehydration preservation of the cells. - There is a distinction between external and internal fluid It is essential to warm blood to an appropriate losses. The cause of external fluid losses has something to do temperature to prevent hypothermia or hemolysis with something else other than the volume of circulation alone, it only affected the fluids. With internal fluid loses, the volume of THE FILTER CHAMBER circulation is the main issue. The filter chamber in the blood set removes clots, small clumps of platelets, and white blood cells formed Pathophysiology: during collection and storage. All blood administration tubing with a filter. Decreased blood volume (probably in the blood) All blood components must be transfused using the ↓ blood tubing/set with filter chamber. Decreased venous return to the heart (blood coming from the different part of the body and their journey back to the right INTRAUTERINE TRANSFUSION side of the heart) The doctor will identify the umbilical cord (with the help ↓ of ultrasound; because it doesn’t contain radioactive Decreased stroke volume (because the amount of blood materials), then inject the needle in the umbilical vein entering the heart is reduced) for the passage of blood transfusion. ↓ Decreased cardiac output EXCHANGE TRANFUSION ↓ In baby, we use the vein (leads to the heart) and artery Decreased tissue perfusion (leads away from the baby’s heart). Donor blood is given in the umbilical vein while the waste blood is obtained in the umbilical artery of the baby. The amount taken should be equivalent to the amount given. Can also be done to adults (those with sickle cell anemia). With Transfusion Reaction: STOP first the procedure and attend to the patient (check vital signs) Save the patient's first voided urine after the reaction Send patient's blood (in the opposite arm where blood is transfused) and urine samples to the laboratory - Hemorrhage: too much blood loss Send blood set/ tubing to laboratory for re-evaluation - The total blood volume in the body (normal sized adult) is 5 L Write an incident report or 5000 mL - the greater the number, the worse the condition. TYPES OF SHOCK Assessment findings: 1. HYPOVOLEMIC SHOCK Cold clammy skin (less blood circulating in the skin) This is the most common form of shock characterized Tachycardia (the heart beats faster when there is less by a decreased intravascular volume; cause is mainly volume to pump; it compensates) losses of volume (blood loss due to massive bleeding, plasma loss in cases of diarrhea without bleeding, burn Mental status changes (not obvious in the first stage of injuries because of extreme extravasation) the condition) Often an emergency condition especially when severe Tachypnea (once tachycardia starts, lungs will follow) blood or other fluid loss makes the heart unable to pump enough blood to the body. This type of shock can Medical Management: cause many organs to stop working (including vital - Other interventions that doesn’t involve/require surgery yet; organs). medications The major medical goals are to: Hypovolemic shock is divided into four subtypes: restore intravascular volume (give IVF to restore Hemorrhagic shock, resulting from acute volume and maintain pressure) hemorrhage without major soft tissue injury. redistribute the fluid volume  correct the underlying cause of fluid loss promptly (ex. Assessment findings: If bleeding, manage the bleeding); when we eliminate Angina (chest pains) the cause, the problem will resolve. Hemodynamic instability Dysrhythmias (heart beat is chaotic) Nursing Management: Primary prevention of shock is the most important Medical Management: intervention of the nurse. The goals of medical management are to: 1. limit further myocardial damage (if patient is experiencing Ways to recognize hypovolemic shock: cardiac condition, it should be treated first) and The age of the person (younger and older patients vary 2. Preserve and improve the cardiac function by increasing in terms of fluids in the body; younger people have cardiac contractility (may be done with the help of medications) more fluids; older people have lesser) The state of their overall health and their medical Nursing Management: history The nurse prevents cardiogenic shock by early The level of which the person’s blood volume has detection of patients at risk (those with cardiac dropped problems). The rapidity at which the loss of fluids or blood took Safety and comfort measures like proper positioning, place (ex. Dengue patient) putting up the siderails, and reduction of anxiety (limiting the news/information to the patient; limit the General nursing measures: visitors also; anything that can increase anxiety should safe administration of the ordered fluids and be avoided), frequent skin care and family education. medication; isotonic solution (safest IVF to be given) documenting their administration and effects; because 3. CIRCULATORY SHOCK sometimes it’s not working at all also called distributive shock Monitor the patient for signs of complications and occurs when the blood volume is abnormally displaced response to treatment. in the vasculature; instead of blood staying in the blood Oxygen is administered to increase the amount of O2 vessels, it got displaced. carried by the available hemoglobin in the blood; give first the volume (circulation) before oxygen so that it Risk factors for Septic Shock can be distributed. - Septic shock has really something to do with infection; we need to look at the chain of infection 2. CARDIOGENIC SHOCK Immunosuppression (like those patients with HIV occurs when the heart’s ability to contract and to pump AIDS) blood is impaired and the supply of oxygen is Extremes of age (65; too young and too old inadequate for the heart and tissues (poor blood have weak immune system) circulating, less oxygen circulating, poor function) Malnourishment - it’s not always the heart is the main problem, sometimes the Chronic Illness cause affects the heart leading to cardiogenic shock. Invasive procedures (because microorganisms are introduced) Risk factors: - Septic shock will occur if the infection has worsen causing 1. Coronary factor (the problem is not the heart, but the extreme and overwhelming amounts of microorganisms in the coronary artery that is supplying to the heart) : M.I. system (probably due to prolonged coronary artery disease) 2. Non-Coronary (problem present in the heart itself; Risk factors for Neurogenic Shock heart is the problem): Cardiomyopathies, Valvular - Anything that has something to do with nervous system damage (there is problem in one of the valves; like Spinal cord injury mitral valve prolapse), Cardiac tamponade Spinal anesthesia (when the anesthesia is given high (accumulation of fluids in the pericardial sac making in the spine; the higher we go, the nearer to the brain) the heart unable to expand well during beating Depressant action of medications resulting to less cardiac output), Dysrhythmias Glucose deficiency (impaired conduction system = heart not beating adequately) Risk factors for Anaphylactic Shock Drug (i.e. Penicillin) sensitivity Pathophysiology: Transfusion reaction Bee sting allergy (any) precipitating factor Latex sensitivity ↓ - When a patient develops anaphylactic reaction, we are looking Will cause decreased cardiac contractility (could be at 2 possibilities; 1st, if we give or exposed the patient to the external/internal and coronary/non coronary) allergen at small amounts first time, it will not cause anaphylactic ↓ reaction yet. But it will be present on the second, third or Decreased stroke volume and cardiac output subsequent exposure (especially if there is a gap of exposures); ↓ 2nd, first exposure but with overwhelming stimulus which causes Leading to 3 outcomes: immediate anaphylactic reaction 1. Damming (pooling) up of blood in the pulmonary vein (left 3.1. SEPTIC SHOCK side) because heart is weak; which will cause pulmonary congestion This is the most common type of circulatory shock and 2. Decreased blood pressure will cause decreased systemic is caused by widespread infection (in which the perfusion overwhelming amounts of microorganisms that are 3. Decreased pressure causes decreased perfusion of the causing the infection invaded the circulation and being coronary arteries leading to weaker contractility of the heart distributed to all parts of the body = septicemia) - Commonly, the microorganisms that causes septic shock are bacteria in nature  3.3. ANAPHYLACTIC SHOCK 1. The HYPERDYNAMIC PHASE This shock is caused by a severe allergic reaction High cardiac output with systemic vasodilatation. Occurs to a patient who has already produced The BP remains within normal limits. antibodies to a foreign substance and develops a Tachycardia (fast heartbeat) systemic antigen-antibody reaction (in subsequent Hyperthermic and febrile with warm, flushed skin and exposure, it will be present) bounding pulses (because infection in nature, patient - Extreme swelling will destroy the body in return (can cause manifests warm skin) bronchoconstriction that may result to respiratory difficulty); blood vessels will dilate causing leakage of plasma. 2. The HYPODYNAMIC or irreversible phase During anaphylaxis, the immune system releases a LOW cardiac output with VASOCONSTRICTION flood of chemicals called Histamine, that can cause the The blood pressure drops, the skin is cool and pale, body to go into shock. with temperature below normal. Histamine causes the blood vessels to expand, which Heart rate and respiratory rate remain RAPID! in turn causes dangerous drop in blood pressure. The patient no longer produces urine. Fluid can leak into the lungs, causing swelling (pulmonary edema). Anaphylaxis can also cause heart Medical Management: rhythm disturbances. Current treatment involves identifying and eliminating the cause of infection (massive antibiotic therapy Medical Management: especially with bacterial infection). Remove the causative antigen (the patient must know Fluid replacement must be instituted to correct their allergies/allergen; observe also skin tests) Hypovolemia Administer medications that restore vascular tone Intravenous antibiotics are prescribed based on culture Provide emergency support of basic life functions. and sensitivity. EPINEPHRINE is the drug of choice given to reverse - For septicemia, it’s really blood culture and sensitivity that must the vasodilatation (hydrocortisone can also be given; be done; best time to extract blood for culture and sensitivity test always prepare) is during fever (because it’s the sign of infection; there is Bronchodilators are also given presence of microorganisms) Nursing Management: Nursing Management: It is very important for nurses to assess history of The nurse must adhere strictly to the principles of allergies to foods and medications. Aseptic technique in her patient care (to prevent Drugs are administered as ordered and the responses external causes). to the drugs are evaluated Specimen for culture and sensitivity is collected. Symptomatic measures are employed for fever, inflammation and pain. IVF and medications are administered as ordered. 3.2. NEUROGENIC SHOCK This shock results from loss of sympathetic tone resulting to widespread vasodilatation (if sympathetic activity is weak, vasoconstriction is loss too = pressure of blood circulating will drop). The patient who suffers from neurogenic shock may have warm, dry skin and BRADYCARDIA (although heart attempts to compensate, muscles of the heart become weak which develops bradycardia) Good luck and study well! See you in the second semester if your name is on the list! – Kassy G Causes of Neurogenic Shock include: Spinal cord injury (most common cause); a spinal cord injury refers to the injury to the cord or nerve not the bones (vertebrae); can also be because of nerves and bones are damage due to trauma Autonomic nervous system toxins (history of infection) Guillain-Barre syndrome Spinal anesthesia (too much doses or too high location) Transverse myelitis Medical Management: Restoring sympathetic tone, either through the stabilization of a spinal cord injury (use of spine board) or in anesthesia Proper positioning Nursing Management: The nurse elevates and maintains the head of the bed at least 30 degrees to prevent neurogenic shock when the patient is receiving spinal or epidural anesthesia (but consider also the spinal procedure like leaking of CSF); if it’s epidural, it’s outside the dura-mater of meninges. If spinal, it’s on the sub-arachnoid (deeper).