Final Study Guide
ADN 253 FINAL STUDY GUIDE
1. Describe the pathophysiology, assessment, signs and symptoms, nursing diagnosis, medical and nursing interventions for the patient with MODS.
Pathophysiology • Progressive impairment of 2 or more organ systems • Caused by immune system’s uncontrolled inflammatory response to a severe illness or injury o Inflammatory response: cytokines and chemokines out of control ▪ Peripheral vasodilation = hypotension ▪ Capillary leak/permeability = fluids shifts = edema ▪ Clotting cascade = emboli get stuck in capillary beds = tissue hypoxia • Can develop quickly following major surgery, trauma, or severe burns OR slowly in the case of infection the turns into sepsis. • Risk factors o Ages (very young or very old) o Chronic disease (DM, CA, renal insufficiency) o Immunosuppressant therapy o Multiple blood transfusions
Assessment & S/S of MODS • Signs of SIRS: 1. Temperature > 100.4 or < 96.8 2. HR > 90 beats/minutes 3. RR > 20 Breaths/minutes 4. WBC >12000 or < 4000 5. > 10% immature neutrophils (bands)
|Cardio |Pulse < 50, > 130 |
| |BP < 60/p, Vtach – Vfib |
| |( Cap refill; skin pale and cool, edema |
|Resp |Dyspnea, accessory muscle use, + sputum |
| |RR 6 or > 40, CXR = infiltrates, |
| |ABG = acidosis, hypoxemia, crackles, wheeze |
|Renal |Urine output 20-30cc/hr |
| |BUN > 100, Creat > 3.5 |
| |Anasarca (puffiness all over)
1. Describe the pathophysiology, assessment, signs and symptoms, nursing diagnosis, medical and nursing interventions for the patient with MODS.
Pathophysiology • Progressive impairment of 2 or more organ systems • Caused by immune system’s uncontrolled inflammatory response to a severe illness or injury o Inflammatory response: cytokines and chemokines out of control ▪ Peripheral vasodilation = hypotension ▪ Capillary leak/permeability = fluids shifts = edema ▪ Clotting cascade = emboli get stuck in capillary beds = tissue hypoxia • Can develop quickly following major surgery, trauma, or severe burns OR slowly in the case of infection the turns into sepsis. • Risk factors o Ages (very young or very old) o Chronic disease (DM, CA, renal insufficiency) o Immunosuppressant therapy o Multiple blood transfusions
Assessment & S/S of MODS • Signs of SIRS: 1. Temperature > 100.4 or < 96.8 2. HR > 90 beats/minutes 3. RR > 20 Breaths/minutes 4. WBC >12000 or < 4000 5. > 10% immature neutrophils (bands)
|Cardio |Pulse < 50, > 130 |
| |BP < 60/p, Vtach – Vfib |
| |( Cap refill; skin pale and cool, edema |
|Resp |Dyspnea, accessory muscle use, + sputum |
| |RR 6 or > 40, CXR = infiltrates, |
| |ABG = acidosis, hypoxemia, crackles, wheeze |
|Renal |Urine output 20-30cc/hr |
| |BUN > 100, Creat > 3.5 |
| |Anasarca (puffiness all over)