4월 15일 강의.free

1.문맥고혈압 환자 Massive bleeding시 신규간호사 행동 중 중재할것 고르기

. Portal Hypertension환자 응급실에 왔을 때 질문할 것

How much alcohol do you drink?

What do you eat on typical Day?

너의 대변 색깔이 전보다 더 어두워 졌니?

2. portal. HT pt. 처음 질문해야 할 것?

평소 먹던 음식이 뭐냐?

stool color

indigestion의 frequency

3. portal HTN +gastroenteritis pt.가 BP 90/60 apical pulse 112 이다. priority?

U/O

abd. girth

말초 edema

varices occur most esophagus . stomach. gastric ulceration or erosion, risk for

hemorrhage from stomach.

4. PH 4.2, PCO2 30, HCO 22, PACO 90%  -> compensated Metabolic acidosis

5.  R. Alkalosis  보상 기전?

Ph 7.4   PCO2 35  HCO3 23

Ph 7.4   PCO2 55  HCO3 26

Ph 7.2   PCO2 36  HCO3 21

Ph 7.4   PCO2 20  HCO3 22

6.kussmaul respiration ABGA 맞는것?

①PH:7.25 -PCO2:38-HCO3:20

②PH:7.45 -PCO2:32-HCO3:26

③PH:7.25 -PCO2:45-HCO3:26

7.Septic shock NGN나오고 초기 처치 순서

measure anti

lactate level

culture

.Septic shock guidelines prioritize immediate recognition and the "1-hour bundle": measuring lactate, blood cultures, broad-spectrum antibiotics, and 30 mL/kg crystalloid for hypotension/lactate

mmol/L. Target mean arterial pressure (MAP) is

mmHg, with norepinephrine as the first-line vasopressor. Source control must be addressed immediately

Septic shock is a severe condition where infection causes dangerous hypotension and cellular dysfunction, leading to elevated blood lactic acid

due to tissue hypoxia,

8.Septic shock?

Vasodilation leads to decrease supply of O2 carried by blood to the major organ

Cardiomyopathy result from bacteria toxin leads to decrease cardiac output

When large amount of fluid is lost

When hemolysis occur, blood can't supply enough O2 to the tissue

9.septic shock sata

prepare intubation

may expection of 2 pack RBC tranasfusion when hb10

prepare vad

trendelenberg position

prepare culture and senstivity

septic shock.

patent airway. iv start. O2.antibiotics. wound drainage ande sputum culture.

aseptic technique any invasion procedure. examine bleeding. gums.injection site.

iv sites.elevate feet 30degree.  v/s every 5minutes. not leave the client.

Bacterial endotoxin inflammation. progresses  DIC.

Risk factors for septic shock include:

Diabetes .Diseases that weaken the immune system such as AIDS

Diseases of the genitourinary system, biliary system, or intestinal system

Leukemia .Long-term use of antibiotics .Lymphoma

Recent infection .Recent surgery or medical procedure.

Symptoms

Cool, pale extremities .High or very low temperature, chills

Lightheadedness .Low blood pressure, especially when standing

Low urine output (due to kidney failure) .Palpitations

Rapid heart rate .Restlessness, agitation, lethargy, or confusion

Shortness of breath

10.Septic shock?

Hb과 Hct 증가

U/O 감소,

WBC 증가

bun cr 증가

lactate 증가