Sepsis Assessment
Systemic Infectious Process Fever Hypotension Change in LOC Increased WBC Shift to the Left Tachycardia Tachypnea Hyperglycemia Edema Severe Sepsis and Septic Shock Assessment
Microthrombi DIC Decreased Oxygen Saturation Decreased WBC Oliguria High Output Heart Failure Multiple Organ Failure Types of Shock
Hypovolemic Depleted Volume Cardiogenic Pump Failure Obstructive Indirect Pump Failure Distributive Lost Vascular Tone Neurogenic Anaphylactic Septic Anaphylaxis Intervention
Assess Airway and Oxygen Needs Reassure Patient with Anxiety Supine Position Methylprednisolone (Solu-medrol) Epinephrine Diphenhydramine (Benadryl) Medical Alert Bracelet IV Solutions
Hypotonic (< 280 mOsm/L) 1/4 Normal Saline (0.225% NaCl) 1/2 Normal Saline (0.45% NaCl) Isotonic (280-300 mOsm) Normal Saline (0.9% NaCl) Lactated Ringer's (LR) Dextrose 5% in Water (D5W) Hypertonic (> 300 mOsm) 3% or 5% NaCl Dextrose 5% in 0.45% NaCl Dextrose 10% in Water (D10W) Metabolic Acidosis Interventions
Raise Plasma pH > 7.20 Treat Underlying Cause Sodium Bicarbonate Follow ABGs Continuously Monitor Patient Cardiac Tamponade
Fluid in the Pericardial Sac Pericarditis Decreased Cardiac Output Beck's Triad Hypotension Jugular Venous Distention (JVD) Distant Heart Sounds Pulsus Paradoxus Electrical Alternans Pericardiocentesis Blood Types and Compatibilities
No Antigens (Type O Blood) Universal Donor A Antigen (Type A Blood) B Antigen (Type B Blood) AB Antigen (Type AB Blood) Universal Recipient Rh (Rhesus) Antigen Never Rh+ to Rh- Blood Transfusion Obstetric Patient Blood Transfusion Administration
Proper Patient Identification Large Bore Needle Y Tubing Baseline Vital Signs Slow IV Infusion Monitor During First 15 Minutes or 50 mL of Blood Monitor for Reactions Do Not Add Anything To Same IV Line No Dextrose or Lactated Ringers Jehovah's Witnesses, No Transfusions Transfusion Reactions
Acute Hemolytic Febrile, Non-Hemolytic Mild Allergic Anaphylactic Circulatory Overload Sepsis Reaction Transfusion-Related Acute Lung Injury (TRALI) Massive Blood Transfusion Types of Blood Products
Whole Blood Packed Red Blood Cells Fresh Frozen Plasma Immunoglobulins Clotting Factors Albumin Platelets Use within 24 Hours Washing Removes Antibodies Irradiation Destroys WBCs Clotting Overview
Endothelial Cells are Damaged Platelets Respond to Exposed Collagen and Stick Platelets Release Recruiting Factors More Platelets are Attracted Soluble Fibrinogen Turns to Insoluble Fibrin Fibrin Seals the Clot Clot Dissolves Liver Produces Clotting Factors Coagulation Cascade Overview
Secondary Hemostasis Intrinsic Pathway Partial Thromboplastin Time (PTT) Heparin Extrinsic Pathway Prothrombin Time (PT) Warfarin Common Pathway Thrombin Convert Fibrinogen to Fibrin Stabilizes the Platelet Plug Disseminated Intravascular Coagulation (DIC) Assessment
Improper Initiation of Clotting Cascade Systemic Bleeding Petechiae, Purpura, Ecchymosis Change in LOC Increased PT and PTT Cyanosis Increased Fibrin Degradation Products (FDP) Decreased Platelets and Fibrinogen Disseminated Intravascular Coagulation (DIC) Interventions
Risk for Shock Renal Failure Treat Underlying Cause Manage Bleeding Maintain Fluid and Hemodynamic Balance Transfusion Oxygenation Heparin Drip Acute Pericarditis Assessment
Pericardial Sac Inflammation Sharp Chest Pain Increased with Inspiration Pain Decreased by Leaning Forward Pericardial Friction Rub Diffuse ST-Elevation T Wave Inversion Fever May Be Asymptomatic Cardiac Tamponade Acute Pericarditis Causes
Idiopathic Infection Trauma Cardiac Myocardial Infarction Autoimmune Diseases Uremia Tumor Radiation Acute Pericarditis Interventions
Treat Underlying Disorder Antibiotics Colchicine + NSAIDs Corticosteroids Place Patient Upright with Head of Bed at 45° Pericardiocentesis Pericardial Window Myocardial Infarction Assessment
Substernal Chest Pain Crushing or Dull Sensation Arm, Jaw, and Neck > 20 Minutes Unrelieved by Nitro Palpitations Diaphoresis Fear of Impending Doom Nausea and Vomiting Shortness of Breath Monitor for Arrhythmias Myocardial Infarction Diagnosis
12 Lead ECG ST Elevation Q Wave T Wave Inversion Troponin T and I CK-MB Early ECG Cardiac Stress Test View More
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