hi class my name is Professor Paula and we are going to talk today about critical alterations in perfusion and we are going to talk today about pathophysiology epidemiological and Theological risk of altered profusion we will describe um impact on overall health some clinical presentations of some conditions uh role of the nurse and how to apply nursing process number one critical condition is shock shock is the lifethreatening condition and occures as a result of circulatory failure which leads to tissue hypoxia celal death and organ dysfunction categories of shock distributive shock hypmic shock cardiogenic shock and obstructive shock distributive shock as a result of decreased systemic vascular resistant as per Fusion systemic vascular resistance or svr the amount of force that the vascular exerts to circulated blood when vessels are dilated the systemic vascular resistance is lower a decreased systemic vascular resistance inhibits the body's ability to circulate blood to the vital organs in distribu shock the blood vessels become floppy which decreases the amount of blood that flows to the organs hypmic shock happen as a result of loss of 25 to 30% of circulating blood type blood volume cardiogenic shock systemic hyper hyperperfusion as a result of decreased cardiac output an obstructive shock occures when blood flow um is block disrupting circulation to the major arteries and we are going to talk about each of these type of the shock a little bit more okay number one we're going to talk about dis distributive shock when decreased svr systemic vascular resistance and perfusion there is four subcategories of uh distributive shock septic shock anaphylactic shock neurogenic shock and toxic shock septic septic shock inflammatory mediators are released in conjunction with cyto that results in initial increased card cardiac output however the cardiac output and svr become very low as septic shock Advanced anaphylactic shock the same low cardiac output and low systemic vascular resistance uh occures in response to to severe hyper sensitivity to allergen like food medication uh beasting uh meditated by IM imunoglobulin e uh increasing vascular per permeability and Vasa dilation and decreased svr neurogenic shock associated with trauma to the cervical spine clients becomes hypertensive as a result of peripheral Vasa dilation along with Brady arthia flush skin that is warm to the touch and temperature disregulation there is um an imbalance between the sympathetic and parasympathetic regulation of the Heart and Vascular smooth m a smooth muscle CTIC output is decreased with Venus and arterial Vasa dilation and loss of sympathetic tone in the circulatory system toxic shock results from uh the use of nasal or vaginal tampons Burns soft tissue or postsurgical infections and dialysis catheter the excessive activation of the cin and inflammatory cells result in manifestation including hypertension Rush resembling a sunburn fever and ultimately organ failure related to vascular permeability next one is hypmic shock occures when intravascular volume is decreased by 25 to 30% resulting in poor cardiac output um hypmic shock it's not enough blood volume low cardiac output decreased contractility because the cells switch from aerobic to anerobic metabolism causing lactic acidosis the lactic acidosis result in decreased contrac ility of the heart and reduces the blood body's ability to respond to water pressures worsening the body's ability to adequately peruse hemorrhagic shock caused by insufficient perfusion of blood and oxygen to the body tissue resulting in imbalanced oxygen supply and demand and of course we're talking about a hemorrhagic shock if the patient has bleeding cardiogenic shock circulatory failure and hyperperfusion caused by cardiac dysfunction leading to myocardial esea decreased myocardial contractility results in decreased cardiac output and systemic hypoperfusion in response to decrease cardia output the body's compensatory mechanism activate sympathetic nervous system causing V constriction and takic cardia in attempt to meet the oxygen demands of the The myocardium obstructive shock occures when blood flow is blocked and circulation to the major organs is disrupted anatom anatomical obstruction of the great vessels of the heart leads to decreased Venus return increased after load and decreased cardiac output what can be reasons for obstructive shock it's can be pulmonary embolism pulmonary hypertension tension numor mechical ventilation with high peep aortic dissection pericardial tonate pericardial Fusion or cardiac Mass shock has four stages first stage is initial stage two little oxygen in the blood to feed organs body switches from aerobic to an from aerobic to anerobic metabolism increased lactic acid then compensatory stage aldosterone released to M maintain uh blood pressure V constrictions to shine blood to vital organs increased heart rate sympathetic nervous system release kahol means to compensate for low oxygen Progressive stage igura altered level of Consciousness P cool clammy skin electrolyte imbalance and hypertension and refractory stage irreversible cellular and organ failure and impending death iology again we have distributive shock hypmic shock obstructive and cardiogenic and distributive shock includes sepsis anaphylactic neurogenic and toxic shock and distributive is the most common type of um sepsis what can cause sepsis pancrea IES Burns infection um in older adults UTI can cause sepsis a patients after surgery maybe who has peritonitis it can cause sepsis too um neurogenic it's a spinal cord trauma ganar injury cerebral hemorrhage anaphylactic exposure to an allergen and toxic soft tissue infection or postsurgical infection very talking about hypmic shock uh Hemorrhage can cause hypmic shock traumatic blood loss upper and lower GI bleed Rapture anoris pospartum bleed anti-coagulants non-hemorrhagic excessive diuresis Burns uh GI fluid loss obstructive it can be tension numor high levels of Peep cardiac tonate pulmonary embolism cardiac Mass aortic dissection cardiogenic acute Mii aortic dissection cardiac arhythmia medication overdose right ventricular failure metabolic acidosis electrolyte imbalance and Pulmonary embolism shock is a lifethreatening condition all body s symptoms at risk for failure and it's a higher mortality rate for older adults here is some clinical presentation for um different stages of shock and here is some uh um common clinical presentations for each shock because the clinical presentation for each type of shock May defer based on the underlying cause clinical manifestations can also vary based on what phase of shock the client is experiencing for example initial it's a subtle clinical subtle clinical manifestation pale skin clients reports feeling unwell or anxious and we know for example for talking about sepsis we know that patient has some infection uh if patient can have UTI patient can have pancreatitis compensator sympathetic nervous system is activated patient is breathing faster heart rate is going up uh maybe decrease some peripheral pulses BP is usually remain stable um or fluctuate and a increased capillary refill time and then a progressive phe and the client condition deteriorates altered level of Consciousness weak pulses skin pale or Ashen increased capillarity field uh time Alor or anura when we are talking about sepsis for example uh we usually call rapid response and we saying oh patient is septic when patient's blood pressure is going low but you notice that patient's blood pressure is going low it's already Progressive phase of the shock every the most sensitive Vital sign to uh um change of uh perfusion it is respiration rate if you see that your patient who has no uh lung issues no monia no um COPD maybe has pancreatitis maybe has UTI and suddenly the heart respirations rate is going higher and then heart rate you start thinking about maybe patients become septic and refractory it's a death in IM imminent uh client katos hypertension not responsive to V oppressors renal failure resulting in anura and respiratory failure despite oxygen therapy lap and diagnostic testing it is essential to determine Theology of the shock to guide the treatment lab testing and diagnostic studies are performed to determine iology and are monitoring through treatment to evaluate the effectiveness of treatment such as CBC electrolytes bu creatinine uh PT PT um uh pancreatic uh uh ferments uh blood urine and sputum cultures we looking for infection for example cardiac enzymes abgs um to check if the patient is maybe in acidosis or alkalosis um e uh ECG chest acccess C skin I want to talk just a little bit more about lactate or uh we also call it like lactic acid um like I said previously uh when shock happened tissue does not have enough oxygen and because not enough oxygen instead of aerobic a metabolism when we use o when the cells use um oxygen if they switch to anerobic metabolism and when anerobic metabolism metabolism happen a lot of lactic acids are producing and if if lactate is elevated we know that tissue does not have enough oxygen and we are uh when we see that lactate elevated we are thinking about uh for example again sepsis that is the uh number one but Weir we know as the patient is patient body is in shock that lactate will uh Elevate will be elevated what we can do as a nurse first of all we need to realize that shock is a lifethreatening um condition um if the patient is in shock in the hospital we will probably move the P not probably 100% his patient will go to ICU we will educate client family about our ICU routine and why we moving patient to ICU sometimes we're moving patient to ICU without even like major damage but we know it can happen and we need to monitor uh patient and profusion we need to monitor closely that's why I'm moving to ICU familiarize client family with the ICU environment we explain what you doing why are you doing tell p tell be honest with the family and patient what's going on and reinforce information regarding diagnosis treatment and prognosis of shock treatments and therapies IV fluids mechanical ventilation h Dynamic mon monitoring pulmonary AR artery catheter Central Venus C pressure arter line IV antibiotic uh neuropen frine IV to manage mean arterial pressure blood and blood products mechanical circulator support intra ortic balloon pump left ventricular assist device um nutrition hod dnamic monitoring specific treatments depend on the type of shock that the client is is experiencing flute resuscitation at least 30 ml per kilogram during the first um 3 hours begin uh IV antibiotic within 1 hour of recognizing the sign of septic shock first line of treatment for anaphylactic shock as I am a epinine further treatment um includes fluids uh I V crystalloids steroids antihistamines and nebulizer albuterol in hypmic shock it is important to determine whether the cause is hemorrhagic or not as soon as possible if so find and stop the source of bleeding and administer blood or blood products treatment for non-hemorrhagic hypmic shock is the rapid infusion of isotonic crystalloids for a total of 30 ml per kilogram Vasa pressors are not recommended in treatment of hypmic shock uh because it can worsen tissue perfusion cardiogenic shock treatment can be complex and based on the cause of shock and the status of the client the goal of the treatment is to restore optimal cardiac output and prevent organ damage um treatment focuses on V the pressors inotropes optimization of fluid St and treatment of the underlying cause or mechanical support if we're talking about the cardiogenic uh um shock happened because of Mi because patient has a blockage then we need to take patient to the heart calf and open the blockage because we need to treat underlying cause norrine is the first line uh of uh is a first line treatment inotropes such as the damine and uh melin melinon help with mytical contractivity diuretics can be given if the client is a hyper volic nutrition anal or par parental nutrition uh depending on the client's need and condition nutrition must be individualized for the client pre-existing conditions current condition and nutrient needs for optimal healing types of monitoring include continuous blood pressure heart rate oxygen saturation and urine output additional modalities may be used um to monitor fluid responsiveness like pulmonary artery C catheter or Central ven Venus pressure arterial pressure monitoring radial um artery most common used by but brachial and femoral Arters can also be used the catheter is connected to tubing uh that can uh contains pressurized 0.9 normal saling this system also consists of the transducer that is connected to the a monitor which displays a waveform and constant blood pressure reading you can see it on the picture I would not be able to tell you more about it because I never monitor that I saw them but I'm not an ICU nurse I never monitor that but uh you can see them only in ICU and when you're going to have your CR iCal care class you will definitely see them next critical condition is a cardiac tonate uh we were talking about pericarditis and when fluid is producing in a pericardial suck and when it's too much fluid that then heart cannot even pump it caused cardiac tant it's accumulation of fluid around the heart and the amount of fluid exate transdate or blood between the two pericardial layers in a healthy adult is less than 30 MLS cardiac component begins with a rapid accumulation of 2 to 300 MLS of fluid around the heart of the if the accumulation of fluid is slow the client may not present with manifestations until a high volume is reached and produce hemodynamic changes if the fluid accumulation occurs quickly the client will not be able to tolerate the condition and will go into cardiac arrest cardiac component is the lifethreatening condition it has three phases phase one accumulated fluid in the pericardial space ventricles Harden and cannot relax phase two cardiac output is decreased due to SVP not feeling uh the heart and phase three decreased cardiac output to the point of circulatory failure any condition that can inquire injure or inflame the pericardium can put the client at risk for developing cardiac tampon central line placement malignancies infection complications from Mi aortic dissection previous highrisk surgery aortic anoris M hypoparathyroidism kidney failure leukemia heart failure radiation to the chest cardiac tonate triggers anxiety restlessness and difficulty breathing and the client may have manifestations that will interfere with the client's daily living the clients must be treated immediately or death will occur um besides anxiety lence difficulty breathing also can be heart failure Ed Dem bleeding shock and death clinical presentation of cardiac tanet it is hypertension DVDs ve distension jugular ve dation DVDs and muffled heart sounds and are known as back triat diminished pulses dpia tpia palpitation La edema and sharp chest pain that can be felt in other areas abdomen neck back shoulder or other physical exam them findings another symptom is a pulses paradoxus pulses paradoxus can indicate that a pericardial infusion is the cause of the cardiac tonate pulses paradoxo is a fall of systolic blood pressure by greater than 10 during inspiration inflate um blood pressure C 20 above Peak systolic blood pressure and slow slowly deflate the cuff until the first katov sound is Audible and then record the reading observe client respirations in pulses parus the carat coov sounds Disappear With inspiration and return with expiration keep listening until the katov um sounds are audible on both inspiration and expiration note the systolic pressure uh when carat COV uh sounds are present for full respiratory cycle substract the second reading from the first one if there is 10 mm different or greater the client is exhibiting pulses paradoxes laps and diagnostic studies the echocardiogram is the best method to diagnose cardiac ton this can uh this can both confirm a pericardial infusion and determine the size of the infusion ECG will show takic cardia um uh chest x-ray can show an enlarged cardiac uh uh enlarged heart with a large amount of fluid volume also we can do MRI CT coronary and geographia right heart characterization and we can check creatin inas level renal Prof profile and calulation studies what we we should do treatments and therapies position client in the bed with a fat feet elevated provide oxygen volume uh resuscitation and V pressors pericardial synthesis is removing fluid from the pericardium to relieve pressure surrounding the heart the removal of the first small amount of fluid can lead to improved hemodynamics complications include infection numor drimia puncture of vessels and hepatic injury the pericardial fluid can be tested for cell count proteins and physical characteristics and also can be done surgery pericardial window um pericardial window will be done not in emergency situation because pericardial synthesis will be done to save patient life but then after all the uh checking the fluid and for example we found the patient has a big mass and a fluid around the heart actually has some um cancer cells we know that this fluid will accumulate again and again and again that's why probably surgery and placement of pericardial window is necessary okay now we are going to talk about procedure call we are calling cabbage or coronary artery bypass craft cabbage is procedure that restores blood flow to the heart muscle caused by narrowing of the coronary arteries PL calcium and fat deposit clog the arteries restricting blood flow to the heart restricted blood flow causes angina or chest pain during cabbage surgery blood vessels are taken from the vein in the leg chest or arm and grafted into a section of the aorta and an area distal to the coronary artery blockage The graft open the artery to allow a clear blood flow to the heart muscle many times multiple graphs are used if there are multiple blockages okay uh when the when P patient needs cap cabbage surgery when patient has uh coronary artery disease um what can cause artery disease non-modifiable risk factors as age gender and family history but some modifiable um diabetes hypertension hypercholesteremia obesity unhealthy diet and smoking and we were talking about coronary arter disease and it's it is if it's just in the beginning and patient has a small blockage we can do ceriz and uh put a stand to open this blockage uh when ization is not able to help then patient need cabbage cabbage is a big surgery um what is the impact on overall health spiritual Financial environmental intellectual emotional physical so social it affect all parts of our life first of all it's it's a scary surgery patient can be anxious patient can be depressed we need to educate patient and family about the surgery uh we need to educate that patient will take some some time off from work because patient needs to recover uh patient needs to go through the rehab also after surgery we're talk talking about incisional pain muscle muscle pain throat pain chest tube discomfort because patients after those surgeries are coming um with a chest tube they thing in the hospital for a couple days um we need to educate patient about about everything about complications that can happen and what patient needs to do to prevent those complications before the surgery uh we are doing CBC liver enzymes and calulation studies CBC is done to determine if the client has any infection dehydration anemia or bleeding liver enzymes are done to examine the uh client's liver function and culation studies are done to determine if there are any bleeding issue or clotting problems the nurse must consider a variety of factors when caring for client going through cabbage a cabbage procedure first of all availability of resources patient who has a cabbage uh procedure supposed to go to ICU after the surgery for at least 24 hours we need to make sure that we have a bed available and we have a uh properly educated Personnel who is going to take care of this patient preap factors the same as um with any surgery we do document lab work inform consent history and physical and the post app fers hod dnamic monitoring recognize minimize manage and Report any complications nursing process first of all we're doing assessment recognizing cues monitor vital sides Airway and eyes and no hourly and Report abnorm normal results assess comfort and provide sedation as needed assess proper functioning and drainage of the chest tube assess lops and urine output as well as monitor for cardiac arthia analyzing cues close monitoring of H hemodynamic monitoring for signs of complications of the heart function hypo Valia bleeding pain anxiety and um Readiness for winning from the ventilator assess the need for transfusions assess abgs priortize hypothesis perform EKG if there are any changes in heart rhythm ensure pain is under control generate Solutions control pain closely monitor Vital Signs frequent client assessment and minimize the risk of surgical infection communication and teamwork are vital in caring for the client take action client is at high risk for infection monitor surgical site for redness fever pain warmth and swelling educate the client and family on wound care prepare client for discharge stress the importance of early mobilization and deep breathing and evaluate outcomes has the client improved decline or stayed the same what are the cues that support your evaluation medications stating to control cholesterol and typ platlet to pre prent trombosis formation aspirin 100 to 325 mg daily for life to prevent graft occlusion clapa gril or Plavix uh for or brinta for one year post up beta blockers to reduce heart rate and blood pressure to decrease the workload of the heart and improve blood flow continuous IV insulin may be needed to reduce postoperative complications even if the client is not diabetic prophylactic antibiotics during the procedure and 48 hours after the procedure to prevent infection nutrition nutrition is essential to lower the risk of infection as well as improve immune function the client is at risk of iatrogenic malnutrition related to deficiencies in protein and energy consumption client should be in uh internal nutrition 24 hours post post up providing 25 30 kilo calories and 1.5 2.5 gram of protein based on kilogram daily based on the client's [Music] um ideal body weight IV Therapy uh two large bore uh IVs placed in an arterial line for continuous blood pressure monitoring a central line will need to be inserted as well um client teaching information regarding surgery incision care um CED risk factors medications when to seek emergency care and cardiac Rehabilitation next procedure is valve replacement valve replacement is done when a hard valve is no longer working properly valves allow the blood flow to pass to uh to an end from each chamber efficiently the four valves are uh mital bpit TripIt pulmonary valve and aortic valve the most commonly replaced valves are aortic and mital valves options for replacement are tissue and me and mechanical valves what are risk factors for valve disease a each family history it can be father mother brother or sister uh congenital heart disease obesity lack of exercise um with like with age when aging occurs vessels become stiff and thick because of the artherosclerosis high cholesterol hypertension endocarditis mardial infarction and rheumat Rheumatic uh fever clients with valve disease are at risk for stroke heart failure blood clots cardiac arrest and death valve replacement um is a highrisk surgery especially if client is of Advent age with multiple comorbidities and most of the time that what happen that is the case um and even we always wait all the risk and if we're talking about if the surger surgery will positively or negatively impact quality of life yes of course because surg surgery will um help with many symptoms um like with shortness of breast or chest pain um but we know that patient has who has a lot of comorbidities we need to wait all the risk because if the patient patient can actually um tolerate this surgery clinical presentations of WF disease is shortness of breath heart murmur irregular heartbeat chest pain exhaustion edema at the lower in the lower extremities um the echocardiogram is the most common test to diagnose valal disease heart disease this test allows visualization of how the blood flows through the valves and chambers of the heart what is the role of the nurse of course it is communication uh supply chain we need to have a maybe prosthetic valve or tissue is going to be uh replaced the damage valve uh we need to make sure that we have uh experienced Staffing who can take care of this patient um client safety it's uh such as prevent medical medication errors prevent surgical errors um retain fore an object wrong s side in correct client um evaluation uh communication is the vital to breakdown uh Silas that can exist between pre-operative operative and postoperative area client anxiety can impact morbidity and mortality client education enhance client preparation education uh continuation of care and improve client satisfaction through the whole process um always access clients symptoms clients pain educate about prach what to expect what what what going to happen um after the surgery the Cent stable they usually going to the regular floor not to ICU what are treatments you probably heard T Tower is trans catheter aortic Val uh implant is a minimally invasive option to remove the damage aortic valve the other option is open heart surgery pharmacological anti platlet therapy um patient can take aspirin 75 to 100 uh milligrams of um pavic pain management and anti anxiety medication nutrition diet begins slowly and um early as soon as the client stable we are monitoring a hemodynamics post up monitoring is vital to maintain adequate oxygen delivery to the tissue um we are monitoring Central vein pressure uh heart rate blood pressure pulse oxymetry respiratory rate and ECG interpretation uh Sometimes using pulmonary artery catheters um to monitor patient this invasive continuous monitoring device access oxygen delivery and utilization and identifi cardiac output and system systemic vascular resistance IV Therapy fluid management is essential to maintain extra cellular volume and a stable blood pressure monitor and treat fluid loss and fluid overload Vasa dilators and diuretics are often needed we are providing client teaching explanation of the procedure and what to expect pre and post operatively next condition we're going to cover is a cardio cardio pulmonary arrest it's electric malfunction within the heart sudden sensation of cardiac function client stops breathing and becomes unresponsive and death occurs within minutes without intervention cardia pulmonary arrest if we are doing ECG we can see some Rhythm some shockable Rhythm and some nonshockable Rhythm shockable Rhythm are ventricular fibrillation and takic cardia and nonshockable Rhythm are cardiac asy and pulseless electrical activity ventricular fibrillation occures when the lower chambers of the heart ventricles contract at an irregular rapid rate causing the heart to not pump blood uh to the rest of the body ventricular T cardia cures when the heart is beating at a rapid rate which prevents the chambers of the heart to fill with blood therefore not enough blood is pumped to the body there are two forms of vric tardia sustained and nonsustained nonsustained is when ventrical is intermittent lasting only a few seconds sustain is when ventricular takic cardia last longer than 30 seconds uh pulseless ventricle takic cardia occures when the ventricles of the heart contract a very rapid rate causing the contractions to be effective ventricular feeling is impaired along with cardiac output pulseless ventrical tardia can occur due to Mi other forms of heart disease and electrolyte imbalance that's telling us then we can see patient we see ventricular Taki cardia on ECG the first thing we're doing we're checking pulse if the patient has pulse or patient doesn't have pulse and the treatment is going to be different assistly flat line is a response of electrical and mechanical activity within the heart um it is absence of activity therefore the heart stops pumping pulseless electrical activity occurs when there is no ventricular contractions or electrical activity um is not strong enough for the heart to conduct you will still see normal ECG but with no pulse some um ethology for Cardin ARS it can happen if the patient has es scheming heart disease hypop palmia myocardial dysfunction Vasa dilation that leads to septic shock heart failure cardiac tonate vul heart disease pulmonary embolism Airway obstruction the leading ethologist for cardiopulmonary arrest are heart disease arhythmia sepsis and Trauma out comes the worse when there is a delay in treatment cardiac Ares is the leading cause of death the leading cause of death for clients in the hospital is septic shock clients at greater risk for sudden cardiac deaths are those who have higher Baseline of C reactive protein levels use cocaine or have genetic risk factors some clinical presentations before heart stops and patient stop breathing and uh uh when unconsciousness you can see that patient can complain of fatigue weakness dizziness Syncopy chest pain and short of breath woman in palpitation back pain okay some um lab and diagnostic studies can be done for those at risk for alterations in the cardiopulmonary perfusion uh for example it can be D ACG coronary angiogram stress test chest x-ray CT skin or chest echo cardiogram because some of them can tell us why patient is actually getting cardiopulmonary arrest like for example if we doing glovs like um if if trapon are elevated we are probably assuming that patient has a that's why patient have can have may have cardiopulmonary arrest or um if BNP is elevated that because patient has CHF complete blood clown but blood count uh we're talking what if the patient uh hemoglobin is super low Maybe patient is bleeding somewhere metabolic panel lipid panel proin time a partial trop plastin time uh d dier d dier is for PE if a d dier is elevated we know that patient probably has PE and that can cause cardiopul pulmonary arrest um during the cardiac arrest CPR and defibrillation are the priority intervention to improve client outcomes in the hospital we def we always send um blood to the lab just to make sure what's going on right now what has been what changes happen uh from for example from the last set of labs but CPR and defibrillation is our priority but uh then we can do post resusitation lab test and just to uh uh based on client outcome what is the role of the nurse during cardia pulmanary arrest honestly that what is the role of the nurse during the code blue um when card pulmonary arrest happen especially if it's in a hospital and you push cold blue button you will see that with in seconds the the room is going to be full of people it going to be charge nurse rapid respond it's going to be doctor ICU nurses extra nurses from your floor PCA everybody's going to be there present Pharmacy will come chaplain will come it's going to be so many people what can be your your role if you are a nurse who had this patient that you Pro if you found this patient unresponsive you will push the call button and start CPR that is going to be your number one role but most of the time if something happen you're going to be by the computer answering questions because you're the one who knows the most about this patient unless unless the admitting physician will come and be present with you you can be first responder and start and start CPR and code blue you can be the one who can actually put another IV you can administer a medication you can assist with oxygen delivery and ventilator you can provide CPR you can start CPR and then switch or someone else will start CPR and then you will do that uh you can be the one who is actually recording record time Rhythm and action dur during the code you can be the leader or you can be client and family support and again usually if it's your patient You Are by the computer put orders in you are telling what's going on you know the most about this patient and you as the actually uh primary nurse for this patient you're probably going to be super nervous and uh emotional that it's going to be hard for you to do anything else besides giving information but if you just came to help not your patient you can help with anything medication administration cprs you can stay outside of the room you can grab family takeing take them to waiting area stay with them help them update them and during the CPR when CPR starts of course we are taking a rhythm and then depends if the rthm is shockable or not shockable um we're going to start if it's shockable we're going to provide shock then doing CPR we're also going to do epinephrine if it's not shockable we have to do CPR and and give epinephrine uh it's it's a different um step by step you can see it on the picture what we're doing first what we what we are doing second um usually uh code in the hospital is right is usually uh done by the critical care physician during the cardiopulmonary arrest we can defibrillate we can cardio aversion do cardio aversion medications use epinephrine Amal lidocain atropine sodium bicarbonate calcium magnesium dextrose uh it depends what's going on because when uh when cold cold if cardiopulmonary AR happen we're doing everything we checking um blood sugar maybe patient blood sugar is low we probably we need to do give dextral re checking all the blood electrolytes um IV Therapy oxygen therapy maybe even intubation therapeutic hyper thermia is going to be done after um and emergency medication during Cardiac Arrest are uh liin epinine atropine and naron next condition we're going to cover is abdominal aortic anism abdominal aortic Anis is a dilation of the aorta greater than 30 mm in diameter if the diameter is greater than 55 it is considered large and requires urgent treatment abdominal aortic anism occurs when the a walls is weakened and th thinning of the media and advantia occur due to the loss of of vascular smooth muscle if the pressure of the blood exceed the wall straightened then the risk of rapture increases risk factors for abdominal aortic anism are associated with aterosclerosis smoking sex more males than females and family history are risk factors smoking is the highest risk factor the mortality rate for clients with a r with a Rapture um abdominal ortic anism is 90% screamening for males 65 to 75 who smoke uh as ultrasound screening selective screening for males 65 to 75 who never smoked and no screen for female C clients also patient and and a high risk with a hypertension coronary artery disease per peripheral artery disease renal insufficiency COPD and CHF most abdominal aortic anism are associated with no manifestations abdominal atic anism is usually discovered on accident with an Imaging scan for another issue client may have an audible Brewer over anthm side or pulsating abdominal mass or palpable abdominal Mass a raptured Aortic on anism is the lifethreatening event requiring immediate medical and surgical interventions very high mortality rate greater than 90% and uh indications of bleeding from a Rapture uh abdominal aortic um first of all some some symptoms like sudden onset back and and abdominal pain noticeable abdominal distension signs and seems of hemorrhagic shock and also colon sign is umbilical emosis and Turner signs is a flank e kosis we need to provide client teaching about risk factors uh some lifestyle modifications uh if the patient already diagnosed we need to uh educate patient about plan and maybe talk about um if patient needs a surgery if patient needs a surgery we are talking about pre and post surgical care um also we need to provide emotional support because it's a big deal it's a life-threatening situation and patient can be anxious or depressed okay treatments and therapies they are depends on what size of anism and if the patient needs to have surgery or patients can be conservatively monitored patient can be on because it is uh uh patient can have some medications like statins beta blockers iron supplements supervis exercise program respiratory therapies definitely smoking sensation if the patient is smoking but if patient needs to have surgery that endovascular anism repair Evar or opener Anis repair will be done endovascular anism repair has better client outcomes shorter hospital stays and lower mortality rate less invasive and less blood loss Evar is the insertion of a bifur casit graft which is divided into two branches via the femoral and ilc arteries then the graft is attached with stance at the normal aorta at the level of the renal and iliac arterials walls The graft is covered to protect it from the intestines open repair is usually performed with a laparatomy with a large incision made into the abdomen to repair the abdominal aortic anism opal repair is used for clients whose vascular Anatomy is not conductive for Evar post up clients need to have additional CT scans one months 6 months and 12 months after surgery to observe for infection raptures and andeles next condition we're going to cover is Sy systemic inflammatory response syndrome it's called Sears systemic inflammatory response syndrome is caused by tissue injury or infection and you can see on this slide like if on the left side Sears like by trauma Burns or pancreatitis and on the right side some infections like B bacterior fungal parasitis viral and other when they combine together they can cause sepsis recognizing manifestations of Sears can deter progression of Sears to sepsis the criteria for sepsis include having at least two sear criteria components and having a known infection with positive cultures body temperature less than 26 or greater than 28 celsus heart rate greater than 90 Takia greater than 20 um and less than 32 and uh partial CO2 less than 32 and white blood cells less than 4,000 or greater than 12,000 or greater than 10% immature forms when Sears happen the CBC may show elevated or low white blood cells with draw blood cultures prior to initiation any antibiotics um Sears can affect clotting in in inside of the body do the importance of calulation testing treatment focuses on underlying cause of the Sears it can be surgical intervention such as a wood de breathing or absess drainage or pharmacological treatment if the patient has some infection and we're giving gram positive or gram negative antibiotic glucocorticosteroids we need to keep glucose uh under control because it's really hard to treat infection if the patient blood sugar is elevated V uh pressors and inotropes if indicated let's talk a little bit about multiple organ dysfunction syndrome uh mods multiple or organ dysfunction syndrome is defined as the process of dysfunction of two or more organs mods occures as a process rather than a single event if a client has injury sepsis Burns or tissue damage and the immune system does not balance the body it means homeostasis then organ failure will occur leading to multiple organ dysfunction syndrome and it is an extreme response to injury sepsis or Burns and it leads to constant release of immune mediators in the blood causing altered organ function and failure constant release of immune mediators results in oxidation stress causing an imbalance of antioxidants and free radicals decreased cellular oxygenation converts cells to anerobic metabolism which leads to loxic acidosis the increase in metabolic acid doses leads to immune or multiple organ dysfunction syndrome multiple organ dysfunction Syndrome causes the breakdown of muscle tissue and vital organs here are some risk F factors for multiple organ dysfunction syndrome chronic disease pre-existing organ dysfunction immunosuppressive therapy extreme age malnutrition cancer trauma alcoholism severe trauma and sepsis infection is the leading cause of mods especially after trauma it is emergency situation and it has highly mortality rate 40 to 50% death rate increases as the number of involved organs increase pralong recovery can cause damaging effects to the Aging adults mods can occur when a non-infectious or infectious process triggers an inflammatory response the symptoms vary according to the organs involved in the severity of the organ in involvement and the sequence is which the organs fail depend on the severe of each organ system um for example what s symptoms if it's respiratory disp leading to respiratory failure Cent client requires intubation and mechanical ventilation infil infiltrate on a chest x-ray cardiovascular tpia decreased blood pressure arithm decrease cardiac output renal decrease urine output and neura dialysis is required in increased creatinine levels hepatic increased B Rubin levels Gast Ines nausea vomiting blood Inger impaired wound healing central nervous system disorient disorientation confusion anxiety and agitation lab and diagnostic studies sequential organ failure assessment or sofa score assess the performance of several organ system in uh in the body and assigns a score based on a data obtained in each category the higher the sofa score the higher the likehood of mortality sofos score include respiratory system hepatic system like Billy Rubin cardiovascular system it's a a map um culation uh PL platelets results central nervous system it's a glasgo Coma Scale and renal system creatinine and urine output uh also we can do chest x-ray blood cultures abgs electrolytes bu creatin CBC PT and PT but again when we are doing all uh blood results we are checking what is the B Rubin level what is the creatinine level what is the combine all these results plus assessment and uh calculating the score and then hard the score the worse the situation again right here sofa scale a sequential organ failure assessment uh it is based on respiration calulation liever cardiovascular central nervous system like I said Glasgow Coma Glasgow scale and renal okay nurse is supposed to update the health care team on client's condition reposition client have every two hours provide Comfort frequent assessment utilize clinical judgment identify evidence-based solution for the deliver of Optimal Care and client and family education um patients with this syndrome most most of the time they're on uh mechanical ventilation and sedated patients are getting antibiotics and IV fluids IV crystalloid fluid supposed to go like 30 MLS per kilogram some medication such as norrine Vasa pressin epinine and dopamine nutrition it's probably going to be um through the NG tube or tpn and hod Dynamic monitoring and our last condition for this lecture is disseminated intervascular calulation diic DIC is a hyper calable state in the body trombosis and hamage occures at the same time a condition in which the blood clouds throughout the body blocking small blood vessels leading to organ failure some risk factors for DIC is pregnancy complications blood infection cancer blood transfusion reaction liver dysfunction Shock Trauma Burns and uh reversing the effects of DIC are difficult and mortality rate is high one of the reasons for DIC is a blood transfusion transfusion reaction can occur when administered blood products assess the client closely especially when starting a transfusion identify the manifestations of reaction immediately fever itching shortness of breast hives back pain and a low blood pressure transfusion Associated circulatory overload can occur when there is too much fluid or circulatory overload resulting in pulmonary edema typical response small variation and vital signs and but usually no reaction some abnormal response like Hy on eing it's a mild allergic reaction fever and chills fibr not hemolytic reaction acute hemolytic reaction bacterial contamination hypotension it's acute hemolytic reaction or bacterial contamination or an aelactic reaction or maybe acute lung injury and disia because of anaphylactic reaction acute lung um injury and volume overload any symptoms if patient is complaining about some flank pain or maybe feeling so hot or chills or eating you have to stop blood transfusion right away clinical presentation of DIC it's a bleeding around wounds at surgical sites and vuure sites osis hematomas PES uh tissue necrosis disne epistasis uh concal bleeding hypo Valia hypertension decreased cardiac output Taki cardia decreased level of Consciousness specific lap results PT PT and D dimer will be increased fibrinogen and platet count will be decreased as a nurse we will verify the lab tests have been done frequent assessment for bleeding collaborate with members of the healthcare team oxygen therapy client family education and support goals of care optimal oxygen delivery reversal of clotting prevent further injury hypmic shock Cardiac Arrest organ damage and loss of limp and treatments include fresh frozen plasma whole blood anti cogin and IV fluids this lecture is over if you you have any questions please email me and P mccn.edu