Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism Imbalance in supply/demand for O2 and nutrients Classification of shock Cardiogenic Hypovolemic Distributive Obstructive Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2 Preload Right atrial pressure (RAP) or centrol venous pressure (CVP) = _____________ Pulmonary artery wedge pressure (PAWP)or left atrial pressure (LAP)=________ Pulmomary diastolic pressure (PADP)= _________________________________ Afterload Systemic vascular resistance (SVR)= (MAP –CVP) X 8O 8O Mean arterial pressure (MAP)= Systolic BP + 2 (Diastolic BP) =_________ 3 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3 Nursing Management: Shock and Multiple Organ Dysfunction Syndrome Sirs > MODS Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 4 Fig. 67-1. Relationship of shock, systemic inflammatory response syndrome, and multiple organ dysfunction syndrome. CNS, Central nervous system. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 5 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6 Definition Systolic or diastolic dysfunction Compromised cardiac output (CO) Precipitating causes Myocardial infarction Cardiomyopathy Blunt cardiac injury Severe systemic or pulmonary hypertension Cardiac tamponade Myocardial depression from metabolic problems Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 7 Early manifestations Tachycardia Hypotension Narrowed pulse pressure ↑ myocardial O2 consumption Person in cardiogenic shock What would you expect to see on physical exam? What about PAWP? Low or high? Urinary output? What lab studies helpful? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 8 Clinical Manifestations: Increased SVR, CVP, and PAWP Pulmonary congestion Cyanosis Cool, clammy skin Confusion/ agitation Decreased capillary refill time Initially, what clinical condition does this sound similar to? 9 Restore blood flow to the myocardium by restoring the balance between O2 supply and demand. Thrombolytic therapy ; Angioplasty with stenting Emergency revascularization Valve replacement Circulatory assist devices (e.g., intraaortic balloon pump, ventricular assist device Hemodynamic monitoring PAWP Intraaortic balloon pump (IABP) IABP Ventricular assist device VAD video Transplant (rarely Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 10 Drug therapy (e.g., diuretics to reduce preload); Medications (depends on cause cause): ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Aspirin heparin Dopamine Norepinephrine dobutamine Diuretics Vasodilators Amiodarone 11 Absolute hypovolemia: loss of intravascular fluid volume Hemorrhage GI loss (e.g., vomiting, diarrhea) Fistula drainage Diabetes insipidus Hyperglycemia Diuresis Relative hypovolemia Results when fluid volume moves out of the vascular space into extravascular space (e.g., interstitial or intracavitary space) Also known as _________ Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Fig. 67-3. The pathophysiology of hypovolemic shock. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13 Response to acute volume loss depends on Extent of injury or insult Age General state of health Clinical manifestations What signs/symptoms? _______, _______ ________in CO, _____ heart rate Inc or decrease in stroke volume, PAWP, urinary output If loss is >30%, blood volume is replaced. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 14 1) What is often the priority in the treatment of hypovolemic shock? 2) How might you recognize the development of hypovolemic shock? 3) What would you do about it? 15 Lab/ Diagnostic Tests: Find the source of blood loss ▪ CT, ultrasound, surgery CBC, electrolytes, blood gases, lactate level SpO2 Hourly urine output monitoring Treatment Stop source of fluid loss Restore circulating volume 16 Management focuses on stopping the loss of fluid and restoring the circulating volume. Fluid replacement is calculated using a 3:1 rule (3 mL of isotonic crystalloid for every 1 mL of estimated blood loss). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17 Neurogenic- hemodynamic phenomenon associated with spinal cord injury at T5 or above; anesthesia Anaphylactic-hypersensitivity reaction Septic-systemic inflammatory reaction Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 18 Hemodynamic phenomenon occuring after spinal injury at T5 or above Usually within 30 minutes of injury, can last up to 6 weeks Causes massive vasodilation without compensation secondary to the loss of sympathetic nervous system vasoconstrictor tone Can also be caused by spinal anesthesia 19 Clinical manifestations Bradycardia (from unopposed parasympathetic stimulation) Hypotension (from massive vasodilation) (dec BP, MAP) Hypothermia (due to heat loss) ▪ Initially, skin may be warm due to vasodilation ▪ Later, skin may be cool, depending on ambient temperature Bladder dysfunction Paralysis below level of lesion Bowel dysfunction 20 Clinical manifestations Temperature dysregulation (resulting in heat loss) Dry skin Poikilothermia (taking on the temperature of the environment) WHY? Late- skin cool and pale Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 21 Fig. 67-4. The pathophysiology of neurogenic shock. BP, Blood pressure. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 22 Treatment Depends on the cause If spinal cord injury, promote spinal stability Vasopressors and atropine for hypotension and bradycardia (respectively) Fluids administered cautiously Monitor for hypothermia 23 Treatment If spinal cord injury, promote spinal stability Vasopressors and atropine for hypotension and bradycardia (respectively) Fluids administered cautiously Monitor for hypothermia 24 Acute and life-threatening allergic reaction (hypersensitivity) reaction Can be caused by drugs, chemicals, vaccines, food insect venom Causes massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability 25 Clinical manifestations Anxiety, confusion, dizziness Sense of impending doom Chest pain Incontinence Swelling of the lips and tongue, angioedema Wheezing, stridor Flushing, pruritus, urticaria Respiratory distress and circulatory failure Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26 27 Epinephrine, diphenhydramine-block massive release of histamine Maintaining a patent airway ▪ Nebulized bronchodilators ▪ Intubation or cricothyroidotomy (video) maybe needed Aggressive fluid replacement IV corticosteroids if significant hypotension after 1 to 2 hours of aggressive therapy Copyright © 2011, 2007 by Mosby, Inc., an affiliate Elsevier Inc. 28 From Seton. Educational use only. 29 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 30 What are you worried about with a medication reaction? What are you watching for? 31 Sepsis: systemic inflammatory response to documented or suspected infection (SIRS) Severe sepsis = Sepsis + Organ dysfunction Presence of sepsis with hypotension despite fluid resuscitation Presence of tissue perfusion abnormalities •*Over 750,000 clients diagnosed with severe sepsis annually and 28% to 50% die Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 32 Course Septicemia (initially bacteremia) causes inflammatory cascade Main organisms > sepsis are gram-negative and gram-positive bacteria also parasites, fungi, and viruses > sepsis and septic shock. If gram positive infection (Staphylococcus and streptococcus), up to 50% mortality rate 33 34 Clinical manifestations ↑ Coagulation and inflammation ↓ Fibrinolysis > DIC ▪ formation of microthrombi ▪ obstruction of microvasculature Hyperdynamic state: inc CO and dec SVR Tachypnea/hyperventilation Temperature dysregulation *Warm shock > cold shock ↓ urine output; GI dysfunction Altered neurologic status Respiratory failure is common (ARDS) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 35 Fig. 67-5. The pathophysiology of septic shock. CNS, Central nervous system. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 36 Hemorrhagic Rash DIC Aftermath septic shock 37 Fluid replacement to restore perfusion ▪ Hemodynamic monitoring Vasopressor drug therapy Vasopressin for patients refractory to vasopressor therapy IV corticosteroids for patients who require vasopressor therapy, despite fluid resuscitation>maintain adequate BP Antibiotics after cultures obtained (e.g., blood, wound etc) Drotrecogin alfa (Xigris) *not used ;major side effect: bleeding Glucose less than 150 Stress ulcer prophylaxis with H2- receptor blockers and DVT prophylaxis **Question- when to give pressors in septic shock Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 38 From Seton. Educational use only. 39 Develops when physical obstruction to blood flow occurs with dec CO Restriction to diastolic filling of right ventricle due to compression Abdominal compartment syndrome Patient will have Dec CO PE Inc afterload Variable left ventricular filling pressures **Rapid assessment/immediate treatment critical *Fix the underlying problem is primary treatment Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 40 Early recognition and treatment is primary strategy. Mechanical decompression Radiation or removal of mass Decompressive laparotomy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 41 Thorough history and physical examination No single study to determine shock Blood studies ▪ Elevation of lactate ▪ Base deficit 12-lead ECG Chest x-ray Hemodynamic monitoring Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 42 Identify cause CBC BMP Arterial blood gases Blood cultures Cardiac enzymes (cardiogenic shock) Glucose DIC (Disseminated Intravascular Coagulation) screen: FSP, fibrogen level, platelet count, PTT and PT/INR, and D-dimer Lactic Acid Liver enzymes- ALT, AST, GGT 43 Electrolytes Sodium level increased early, decreased later if hypotonic fluid administered *Potassium decreased in early shock, then increased later with cellular breakdown and renal failure 44 DIC (Disseminated Intravascular Coagulation) screen: FSP, fibrogen level, platelet count, PTT and PT/INR, and D-dimer 45 Decreased cardiac output Fluid volume deficit Anxiety Fear LVAD implantation (23 minutes into clip Ineffective tissue perfusion: renal, cerebral, cardiopulmonary, gastrointestinal, hepatic, and peripheral Potential complication: organ ischemia/dysfunction 46 Usually not clinically apparent Metabolism changes from aerobic to anaerobic. Lactic acid accumulates and must be removed by blood and broken down by liver. Process requires unavailable O2. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 47 Clinically apparent Neural Hormonal Biochemical compensatory mechanisms Attempts are aimed at overcoming consequences of anaerobic metabolism and maintaining homeostasis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 48 Compensatory Shock Mean Arterial Pressure (MAP) blood pressure (but adequate to perfuse vital organs) cardiac output Sympathetic nervous system (SNS) stimulation > vasoconstriction. Blood flow to heart and brain maintained; blood flow to kidneys, GI tract, skin, and lungs diverted Dec blood flow to kidneys > activation of reninangiotensin system > sodium retention and potassium excretion 49 Baroreceptors in carotid and aortic bodies activate SNS in response to ↓ BP. Vasoconstriction while blood to vital organs maintained ↓ blood to kidneys activates renin–angiotensin system ↑ venous return to heart, CO, BP Impaired GI motility Risk for paralytic ileus Cool, clammy skin from blood Except septic patient who is warm and flushed Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 50 Shunting blood from lungs inc physiologic dead space. ▪ ↓ arterial O2 levels ▪ Inc. rate/depth of respirations ▪ V/Q mismatch SNS stimulation inc myocardial O2 demands. **If perfusion deficit corrected, patient recovers with no residual sequelae If deficit not corrected, patient enters progressive stage Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 51 Fig. 67-7. Compensatory stage: reversible stage during which compensatory mechanisms are effective and homeostasis is maintained. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 52 Begins when compensatory mechanisms fail Aggressive interventions to prevent multiple organ dysfunction syndrome **Hallmarks of ↓ cellular perfusion and altered capillary permeability ▪ Leakage of protein into interstitial space ▪ ↑ systemic interstitial edema Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 53 Altered capillary permeability (3rd spacing) Alveolar and pulmonary edema, ARDS, PA pressures cardiac output, coronary perfusion> arrhythmias & MI Movement of fluid from pulmonary vasculature to interstitium >pulmonary edema ▪ Bronchoconstriction & dec residual capacity Fluid moves into alveoli >Edema, dec surfactant inc V/Q mismatch ▪ Tachypnea; Crackles; inc work of breathing Acute tubular necrosis Jaundice, ALT,AST GGT DIC Cold, clammy skin Anasarca ▪ Fluid leakage affects solid organs and peripheral tissues. 54 Mucosal barrier of GI system becomes ischemic ▪ Ulcers ▪ Bleeding ▪ Risk of translocation of bacteria ▪ Decreased ability to absorb nutrients Liver fails to metabolize drugs and waste. ▪ Jaundice ▪ Elevated enzymes ▪ Loss of immune function ▪ Risk for DIC and significant bleeding Lactic acidosis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 55 Fig. 67-8. Progressive stage: compensatory mechanisms are becoming ineffective and fail to maintain perfusion to vital organs. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 56 Exacerbation of anaerobic metabolism Accumulation of lactic acid ↑ capillary permeability Profound hypotension and hypoxemia Tachycardia worsens. Failure one organ system affects others. Recovery unlikely Respiratory failure Unresponsive Anuria DIC hypothermia Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 57 Fig. 67-9. Irreversible or refractory stage: compensatory mechanisms are not functioning or are totally ineffective, leading to multiple organ dysfunction syndrome. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 58 Successful management includes Identification of patients at risk for shock Integration of patient’s history, physical examination, and clinical findings > diagnosis Interventions to control or eliminate cause of dec perfusion Protection of target and distal organs from dysfunction Provision of multisystem supportive care Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 59 General management strategies Ensure patent airway. Maximize oxygen delivery. Cornerstone of therapy for septic, hypovolemic, and anaphylactic shock = Volume expansion Isotonic crystalloids (e.g., normal saline) for initial resuscitation of shock Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 60 Volume expansion If the patient does not respond to 2 to 3 L of crystalloids, blood administration and central venous monitoring may be instituted. ▪ Complications of fluid resuscitation ▪ Hypothermia ▪ Coagulopathy Primary goal of drug therapy = Correction dec tissue perfusion Vasopressor drugs (e.g., norepinephrine) ▪ Achieve/maintain MAP >60 to 65 mm Hg. ▪ Reserved for patients unresponsive to fluid resuscitation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 61 *Nutrition vital to dec morbidity from shock. Initiate enteral nutrition within first 24 hours. Initiate parenteral nutrition if enteral feedings contraindicated or fail to meet at least 80% of caloric requirements Monitor protein, nitrogen balance, BUN, glucose, electrolytes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 62 ABCs: airway, breathing, and circulation Focused assessment of tissue perfusion Vital signs Peripheral pulses Level of consciousness Capillary refill Skin (e.g., temperature, color, moisture) Urine output Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 63 Goals for patient Assurance of adequate tissue perfusion Restoration of normal or baseline BP Return/recovery of organ function Avoidance of complications from prolonged states of hypoperfusion Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 64 Health promotion Identify patients at risk. ▪ Elderly patients ▪ Those with debilitating illness ▪ Those who are immunocompromised ▪ Surgical or accidental trauma patients Focused assessment of tissue perfusion Vital signs; Peripheral pulses; Level of consciousness Capillary refill; Skin (e.g., temperature, color, moisture) Urine output Planning to prevent shock ▪ Monitoring fluid balance to prevent hypovolemic shock ▪ Maintenance of hand washing to prevent spread of infection Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 65 Acute interventions Monitor patient’s ongoing physical/emotional status to detect subtle changes in patient’s condition. Plan/implement nursing interventions and therapy. Evaluate patient’s response to therapy. Provide emotional support to patient and family. Collaborate with members of health team when warranted Respiratory status Respiratory rate and rhythm; Breath sounds Continuous pulse oximetry ; Arterial blood gases Most patients -intubated and mechanically ventilated. Urine output Tympanic or pulmonary arterial temperature Skin: temperature, pallor, flushing, cyanosis, diaphoresis, piloerection Bowel sounds Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 66 Neurologic status: orientation and level of consciousness Cardiac status; Continuous ECG VS, capillary refill Hemodynamic parameters: central venous pressure, PA pressures, CO, PAWP Heart sounds: murmurs, S3, S4 Nasogastric drainage/stools for occult blood I&O, fluid and electrolyte balance Oral care/hygiene based on O2 requirements Passive/active range of motion Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 67 Assess level of anxiety and fear. Medication PRN Talk to patient Visit from clergy Family involvement Comfort measures Privacy Call light within reach Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 68 Normal or baseline, ECG, BP, CVP, and PAWP Normal temperature Warm, dry skin Urinary output >0.5 mL/kg/hr Normal RR and SaO2 ≥90% Verbalization of fears, anxiety Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 69 Systemic Inflammatory Response Syndrome (SIRS)- a systemic inflammatory response to a variety of insults, including infection, ischemia, infarction, and injury Characterized by generalized inflammation of organs Two or more of the following conditions: temperature >38.5°C (101.3 F) or <35.0°C (95.0 F); heart rate of >90 beats/min; respiratory rate of >20 breaths/min or PaCO2 of <32 mm Hg; and WBC count of >12,000 cells/mL, <4000 cells/mL, or >10 percent immature (band) forms 70 Results from SIRS Characterized by failure of two or more organ systems such that homeostasis can not be obtained without intervention Often culminates in ARDS Can cause massive vasodilation and myocardial depression Commonly manifests as changes in LOC Acute renal failure common 71 GI tract highly vulnerable to ischemic injury secondary to shunting in early stages At risk for ulceration and GI bleeding Potential for bacterial translocation from GI tract to cirulation Causes hypermetabolic state Failure of coagulation system manifests as DIC Electrolyte changes and fluid shifts 72 Care of the critically ill patient Invasive monitoring capabilities Bedside procedures possible 2 to 1 patient to nurse ratio Intensivists or pulmonary/ critical care physicians and advanced practice nurses 73 Post-surgical pathways often include going to ICU Certain medications, devices, and frequency of testing require placement in ICU Medications must be reconciled with any move to or from critical care to other level of care Notify family members 74 Audience Response Question When assessing a patient in shock, the nurse recognizes that the hemodynamics of shock include: 1. Normal cardiac output in cardiogenic shock. 2. Increase in central venous pressure in hypovolemic shock. 3. Increase in systemic vascular resistance in all types of shock. 4. Variations in cardiac output and decreased systemic vascular resistance in septic shock. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 75 Audience Response Question The nurse determines that the patient in shock has progressed beyond the compensated stage when laboratory tests reveal: 1. Increased blood glucose levels. 2. Increased serum sodium levels. 3. Increased serum potassium levels. 4. Increased serum calcium levels. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 76 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 77 26-year-old man arrives via paramedics to ED with multiple gun shot wounds to abdomen. Unresponsive, BP 58/30, HR 146 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 78 Three units type O packed RBC given for profuse blood loss before surgery Surgery successful in removing bullets and repairing blood vessels Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 79 Surgeon estimated he lost at least 3 L of blood before surgery and 1 L more during surgery. He is admitted to ICU. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 80 1. What complications will you anticipate with this amount of blood loss? 2. What fluids can you expect to administer? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 81 3. What medications will likely be ordered? 4. What should you monitor hourly or every 2 hr? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 82 A client’s nursing diagnosis is Fluid Volume Deficit Related to Excessive Fluid Loss. Which action related to fluid management should be delegated to a nursing assistant? a. b. c. d. Administer IV fluids as prescribed by the physician. Provide straws and offer fluids between meals. Develop plan for added fluid intake over 24 hours. Teach family members to assist client with fluid intake. 83 The client also has the nursing diagnosis Decreased Cardiac Output related to decreased plasma volume. Which finding on assessment supports this diagnosis? a. b. c. d. Flattened neck veins when client is in supine position. Full and bounding pedal and post-tibial pulses. Pitting edema located in feet, ankles, and calves. Shallow respirations with crackles on auscultation. 84 Which of these clients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit? A 26-yr-old client with a basilar skull fracture who has clear drainage coming out of the nose. b. A 42-yr-old client admitted several hours ago with a headache and diagnosed with a ruptured berry aneurysm. c. A 46-yr-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due. d. A 65-yr-old client with an astrocytoma who has just returned to the unit after having a craniotomy. a. 85 You are monitoring blood administration to a trauma victim in shock. Which of the following assessments indicate a dangerous transfusion reaction? a. Red raised areas on the skin that itch b. An increase in body temp by 3 degrees c. Decreasing BP and dyspnea d. Increasing BP and pulse 86 A 17 yr old male presents to the Emergency Department via EMS. He was riding his dirt bike on a cross country trail when he struck a tree. He has bruising over his right upper quadrant and is complaining of severe pain with palpation. VS are 86/50, HR 122, RR 24 T 96.5 and his O2 sat is 94% on room air. The patient is cool and sweaty and appears confused. Hypovolemic Shock 87 A listless 2 year old is rushed into the Emergency Department in his mother’s arms. She relates he was eating a peanut butter cookie when he began crying and rubbing his mouth. Within seconds his lips and eyes became swollen and he developed a raised rash over his trunk and extremities. His breathing became labored and audible wheezing could be heard. His mother states he has never eaten nuts before. VS are BP 86/33 P185 R52 T 97.6 axillary and O2 Sat 88% on room air Distributive - Anaphylaxis 88 A 72 year old male is brought to the Emergency Department via EMS. He sustained a 10 foot fall from a ladder onto his back. He is awake and alert. BP is 80/50 P 55 R 26 T 96.6 O2 sat 91% on room air The patient complains of mid low back pain and decreased ability to move his legs. His legs are pink, warm and dry but you notice above his waistline that he is pale, cool and clammy. Distributive - Neurogenic 89 A 55 yr old diabetic female presents to the Emergency Department complaining of bilateral flank pain, foul smelling urine, vomiting and chills for 3 days. She is lethargic and her skin is pale and cool. VS are BP 90/60 P 112 T 96.6 R22 O2 sat 93% room air Septic Shock 90 A 68 yr old male presents to the Emergency Department complaining of severe midsternal chest pain that radiates to his left arm and jaw. He reports shortness of breath, nausea and dizziness. He is lethargic, pale and diaphoretic with mottled extremities. Rales are heard bilaterally upon auscultation of his lung sounds. VS are 72/50 P 118 T 96.8 R 22 O2 sat 89% on room air Cardiogenic Shock 91