Critical Care Detailed Study Guide

CRITICAL CARE Detailed NUR 202 Study Guide Shock • Sepsis • Septic Shock • Hemodynamics • DIC • MODS • PICS SOURCE LIMIT This guide uses ONLY the four files you provided: the NUR 202 Critical Care PowerPoint, the instructor transcript, the UCSF Sepsis Guidelines PDF, and the Tucson Medical Center protocol PDF. No outside sources were used to add, correct, or update content. HOW “TAKE NOTE” IS MARKED The instructor’s emphasis is highlighted whenever she says or strongly signals: “remember,” “I want you to…,” “pay attention,” “important,” “202,” “NCLEX,” “test/exam,” “hint,” “distractor,” “first priority,” “I can’t stress this enough,” “100% on the exam,” or says something is knowledge-only/not being tested. SOURCE HIERARCHY FOR THIS GUIDE For exam emphasis, the 2026 instructor deck/transcript are treated as the primary course source. The UCSF document is dated 2024 and the TMC administrative orders are dated 2022, so they are clearly labeled as provided protocol/reference material rather than silently replacing the instructor’s 2026 course framing. Highlight Key Label Meaning [TAKE NOTE] Instructor explicitly emphasizes, repeats, or tells you to remember/pay attention. [EXAM / 202 / NCLEX] Instructor ties the concept to testing, prioritization, an NCLEX cue, distractor, or likely question style. [PRIORITY] What comes first, what is time-sensitive, or what immediate threat must be addressed. [DO NOT OVERSTUDY] Instructor says it is knowledge-only, will not be tested in depth, or does not require memorizing detailed lists/doses. [TEXTBOOK] Instructor specifically says the textbook highlights/recommends the point. [PROVIDED PROTOCOL] Material from the UCSF or TMC PDFs you uploaded; dates and scope are kept visible. [SOURCE NOTE] Auto-caption wording conflicts with the slides; the slide-supported wording is used without outside correction. 1. Instructor High-Yield: Read This First [TAKE NOTE] THE MAIN IDEA Shock is a PERFUSION problem, not simply a low-blood-pressure problem. The instructor repeatedly says not to treat one number; assess the whole patient and trend the response. [EXAM] WHAT SHE WANTS YOU TO DO Recognize cues ? identify the physiologic problem ? prioritize the threat ? choose the safest action ? evaluate whether perfusion actually improved. Expect application and clinical judgment more than simple recall. [TAKE NOTE] TREND > ISOLATED NUMBER For test questions, pay close attention to CHANGE FROM BASELINE: new confusion/restlessness, falling urine output, worsening capillary refill, rising respiratory rate/oxygen need, skin changes, MAP trend, and lactate trend. [TAKE NOTE] PUMP–VOLUME–VESSELS Use the instructor’s framework: VOLUME problem = hypovolemic; PUMP problem = cardiogenic; VESSEL-TONE/maldistribution problem = distributive; MECHANICAL BLOCK = obstructive. Classify first because treatment must match the cause. [PRIORITY] PRACTICAL SEQUENCE Support airway/breathing ? establish access + monitoring ? treat the cause ? restore circulation with the therapy that matches the shock state ? continuously reassess. [EXAM] HYPOVOLEMIC First priority: STOP THE LOSS. In hemorrhage, control bleeding and replace blood/volume; repeated crystalloid without hemorrhage control does not fix the cause. [EXAM] CARDIOGENIC Preserve myocardium, support oxygenation, improve cardiac output, and avoid flooding the lungs. Crackles/pulmonary edema should make you think before giving a large fluid bolus. [EXAM] NEUROGENIC Classic differentiator: spinal cord injury + hypotension + bradycardia + warm/dry skin. [EXAM — “100%”] ANAPHYLAXIS IM epinephrine is first-line. The instructor explicitly says this should be “100% on the exam.” Antihistamines/steroids are adjuncts and must not delay epinephrine in airway/circulatory compromise. [EXAM] SEPTIC SHOCK Recognize infection + organ dysfunction/hypoperfusion; cultures/lactate promptly, timely antibiotics, fluid resuscitation with reassessment, then norepinephrine first-line if hypotension persists. MAP target emphasized: about 65 mm Hg for most adults. [TAKE NOTE] FLUIDS ARE NOT “GIVE AND WALK AWAY” The instructor repeatedly says assess ? reassess. After fluids, look for improving perfusion AND for harm: new crackles, rising oxygen needs, dyspnea, hypoxemia, pulmonary edema. [TAKE NOTE] ARTERIAL LINE Never administer medications through an arterial line. A-line MAP is a target, but the patient’s mentation, urine output, skin perfusion and lactate tell you whether organs are actually being perfused. [TAKE NOTE] MODS Do not memorize an organ-failure list. Recognize multiple organs deteriorating together and understand that prevention is early recognition/treatment of shock and sepsis, restoration of perfusion, infection control, and prevention of secondary injury. Fast Shock-State Comparison Shock state Primary problem Clue pattern Priority concept Hypovolemic Too little circulating volume Fluid/blood loss; tachycardia; cool clammy skin; low urine output Cardiogenic Pump failure MI/HF/dysrhythmia + crackles/pulmonary edema + poor Improve pump; cautious fluids; avoid perfusion overload Obstructive Mechanical block Massive PE, tamponade, tension pneumothorax clues Support ABCs while obstruction is relieved Neurogenic Loss of sympathetic tone Spinal injury + hypotension + bradycardia + warm dry skin Protect spine + restore perfusion/vascular tone Anaphylactic Mediator-driven vasodilation + airway involvement Allergen + wheeze/edema + hypotension IM epinephrine FIRST Septic Infection + dysregulated response/vasodilation Infection + organ dysfunction + hypoperfusion Antimicrobials + fluids + norepinephrine if needed Stop loss + restore volume/blood 2. Every Strong Instructor “Take-Note” / Exam Cue This section is intentionally repetitive. It is a tracker of the instructor’s explicit emphasis so you can see what she repeatedly signals as testable, high-priority, or not worth over-memorizing. Topic What she flags Lecture goal Know definitions, but more importantly recognize deterioration, connect it to physiology, choose a priority action, and reevaluate whether it worked. One-number warning “Remember, we do not treat one number.” Use the patient + trends. Throughout lecture Ask: What cue matters most? What complication are we preventing? What action is time-sensitive? What tells us treatment worked? NCLEX connection Not trivia. Think trend recognition, urgency, cause-directed intervention, and perfusion after treatment. Urine output Instructor repeatedly uses about 30 mL/hr as a bedside cue in the lecture; falling urine output may precede creatinine rise. Outcomes “I can’t stress this enough” — evaluate outcomes: mentation, urine output, MAP, cap refill, oxygenation, lactate. Pump-volume-vessels Use this framework to classify shock rather than memorizing disconnected lists. Cellular patho She says she will not test the detailed cellular cascade; know WHY lactate can rise and that it is a trend, not a diagnosis by itself. Early shock Early recognition is the most important nursing responsibility; do not wait for dramatic hypotension. Test questions Pay close attention to change from baseline. A new trend can matter more than the “most abnormal” isolated number. Older adults Subtle presentation: fever/tachycardia may be absent; acute mentation change can be mislabeled. Irreversible shock Exam/NCLEX can test psychosocial integrity: comfort, dignity, symptom control, family communication, no false hope. Classify the problem When a scenario appears, ask what is failing: volume, pump, obstruction, or vessel tone. 202 prioritization Match the intervention to the cause; do not reflexively treat a BP number. Hemorrhage Priority is stopping bleeding + replacing volume/blood; treat the cause and perfusion together. First-hour thinking Prioritizing questions reward actions that address the immediate threat and underlying physiologic problem. Crystalloid type She says she will not quiz you on balanced crystalloid vs normal saline details; knowledge only. Reassessment is the important nursing piece. Textbook point Textbook highlights passive leg raise to assess fluid responsiveness. Trendelenburg Remember: Trendelenburg is not a shock/fluid treatment; the auto-caption says “hyperkalemia,” but the slide clearly says shock/redistribution. Fluid harm Think about therapeutic goal AND potential harm; new crackles, respiratory distress, falling SpO?, rising O? need = wrong direction. Urine output again “I can’t stress this enough”: monitor urine output as a perfusion response. Vasoactive meds Do NOT memorize every dose. Understand purpose, priority sequence, desired effects, and nursing risks. Peripheral vasopressors Important sepsis update: do not delay vasopressor therapy solely for central access; closely monitor a peripheral site. 202 medication safety Always evaluate desired and adverse effects: MAP, rhythm, limb perfusion, IV site. Hypovolemic exam cue Red-box/NCLEX distractor: first priority is STOP THE LOSS. Hypovolemic exam questions Choose the intervention that addresses both cause and perfusion. Cardiogenic diagnostics Pay attention to ECG/biomarkers/lactate/echo as evaluation clues. Cardiogenic meds Know when vasoactive/inotropic therapy is effective and which is prioritized; not the drug-book level of detail. Hemodynamics For 202, know what MAP, CVP/filling pressure, cardiac output and SVR represent; combine them with bedside assessment and trends. Arterial line Key: never administer medication through an arterial line. MAP If MAP is not around the target, treatment may not be working — but MAP is not the final outcome. Monitor vs patient The monitor gives numbers; the patient tells you whether organs are being perfused. Outcome questions NCLEX/202 may ask which finding shows an intervention was ineffective; look for organ perfusion and signs of harm. Obstructive shock She says this will not be tested heavily. Know the distinctive clue and that definitive treatment relieves the obstruction. Neurogenic identification Classic exam question: spinal injury + hypotension + bradycardia + warm skin. Anaphylaxis Epinephrine always comes first; Benadryl is a common student trap. Anaphylaxis teaching Reinforce trigger avoidance and carrying/knowing how to use epinephrine. Sepsis over time 202 questions may unfold over time; notice the direction of mentation, BP, renal function, O? needs, urine output. Sepsis screening Very important: do not memorize SOFA scores for this course; know standardized screening exists and sepsis remains a clinical diagnosis. Sepsis labs Cultures ideally before antibiotics, but do not delay treatment in an unstable patient. Serial lactate = trend. Antibiotic timing She does not want antibiotic names. Know the timing framework: septic shock/probable definite sepsis ideally within 1 hour; possible sepsis without shock within 3 hours if concern persists. Cultures vs antibiotics 202 may test that cultures ideally come first, but if unstable the priority is timely antibiotics. 30 mL/kg Remember the initial 30 mL/kg within 3 hours framework for sepsis-induced hypoperfusion/septic shock AND reassess; do not “give and walk away.” Norepinephrine First-line vasopressor in septic shock; if MAP remains inadequate, vasopressin may be added as norepi requirements escalate. Peripheral start Restoring perfusion is more important than waiting for a central line; monitor the peripheral site closely. Sepsis bedside care “What a great select-all” — recognition, cultures/lactate, antibiotics, fluids, reassessment, vasopressor preparation, infection prevention. Older adult sepsis Sudden mentation change may be the first sign. DIC Knowledge-only: understand it can occur in critical care/sepsis and is BOTH a clotting and bleeding disorder; focus on nursing assessment. NGN case Identify the strongest cues, not every abnormal value. Ask what additional information you need and how to prevent worsening. Evaluation Do not evaluate success by whether the bag finished or antibiotic hung; evaluate the PATIENT. 202/NCLEX style Application and clinical judgment are emphasized rather than memorization alone. MODS Do not memorize a fixed organ sequence; recognize multiple systems deteriorating together. PICS/transitions Know how to prepare patients/families for prolonged recovery, rehab, handoff, medication reconciliation, warning signs. Family communication Do not give false hope; explain what is happening, what therapies are doing, and support goals of care. Nurse role Nurses do not diagnose; support, assess, report, advocate, communicate. Final comparison Focus on priorities, not a long medication list: stop loss, improve pump, relieve obstruction, restore tone, give IM epi, treat infection/support perfusion. Rapid review Q2 Instructor says IM epinephrine for anaphylaxis “should be 100% on the exam.” Final “remember” Shock is about perfusion; don’t wait for dramatic hypotension; use trends; classify shock because treatment must match cause; reassess after treatment. 3. What She Says NOT to Overstudy Detailed cellular shock cascade: she says she will not test you on all of the ATP/membrane/microcirculation details. Know the connection to lactate, hypoperfusion, and organ dysfunction. Balanced crystalloids versus normal saline: she says this is knowledge-only/not something she will quiz in detail. The nursing emphasis is appropriate fluid resuscitation plus reassessment. Every vasoactive medication dose: she specifically says not to memorize every dose. Know the medication PURPOSE, priority sequence, nursing risks, desired effect, and adverse effect. Advanced hemodynamic values at a drug-calculation/textbook level: know what MAP, CVP/filling pressure, CO, and SVR represent and how to combine them with the bedside picture. SOFA scoring details: she says she is not teaching the SOFA scores; know standardized screening exists and that sepsis is still a clinical diagnosis. Thrombocytopenia details in the sepsis section: she says she is not testing that specific detail there. DIC in depth: knowledge-only in this lecture. Know it can complicate sepsis/shock and causes BOTH clotting and bleeding. Obstructive shock in depth: she says she will not really test obstructive shock heavily. Know the classic causes/clues and that definitive treatment relieves the obstruction. MODS organ order: she says you do not need to memorize the exact sequence. Recognize simultaneous/progressive multi-organ deterioration. Exact antibiotic names for sepsis: she explicitly says you do not need to remember which antibiotics are prescribed; know the TIMING and nursing actions. [EXAM STRATEGY] The repeated theme is not “memorize more.” It is: recognize a worsening trend, identify the failing physiologic component, choose the safest cause-directed action, and prove it worked by reassessing organ perfusion. 4. Clinical Judgment Framework for Shock 1. Recognize cues: new confusion, tachycardia, falling urine output, mottled/cool skin, increasing RR/O? need, MAP change, lactate trend. 2. Analyze cues: group them as impaired perfusion instead of treating each finding as unrelated. 3. Prioritize hypotheses: decide whether the primary problem is volume, pump, obstruction, or vascular tone/maldistribution. 4. Generate solutions: choose actions that address the immediate threat and underlying cause. 5. Take action: often several actions occur at once - oxygen, access, labs, calling for help, medications, fluids/blood, source control preparation. 6. Evaluate outcomes: mentation, urine output, cap refill, skin perfusion, respiratory status, MAP, lactate, and evidence of treatment harm. [TAKE NOTE] A normal BP does NOT rule out shock. The instructor repeatedly tells you to stop waiting for dramatic hypotension. Early cues before BP crashes System Cues emphasized Brain Anxiety, restlessness, new confusion, lethargy; acute change from baseline matters. Kidneys Declining urine output; can fall before creatinine rises. Skin/peripheral perfusion Cool or mottled skin, delayed capillary refill, weak pulses. Respiratory Tachypnea, increasing oxygen need, hypoxemia. Cardiovascular Tachycardia, narrowing pulse pressure, falling MAP; some older adults/beta-blocked patients may not become tachycardic. Laboratory Rising lactate, metabolic acidosis, worsening organ markers - interpreted in context, not alone. 5. Shock = Failure of Effective Tissue Perfusion Pump – Volume – Vessels – Obstruction Component Question to ask If it fails PUMP Can the heart move blood forward? Cardiogenic shock pattern. VOLUME Is there enough circulating blood/fluid? Hypovolemic shock pattern. VESSELS Is vascular tone/distribution adequate? Distributive shock pattern. OBSTRUCTION Is something mechanically blocking filling/outflow? Obstructive shock pattern. [TAKE NOTE] Classify first, then choose treatment. A fluid bolus that helps hypovolemia can worsen pulmonary edema in cardiogenic shock. Cellular pathophysiology - know the direction, not every detail Decreased tissue perfusion ? less oxygen reaches cells ? anaerobic metabolism ? less ATP and more lactate ? membrane/pump dysfunction and injury ? inflammation/microcirculatory dysfunction ? organ dysfunction. The instructor says this detailed cascade is not the testing focus; it explains WHY lactate and organ changes matter. [DO NOT OVERSTUDY] LACTATE Lactate is an early/serial TREND and one cue among several. It can support concern for impaired perfusion and show response, but it is not a stand-alone diagnosis of shock or sepsis. 6. Stages of Shock: A Continuum Finding Compensatory Progressive Irreversible Blood pressure May remain normal Hypotension; MAP often <65 Refractory despite support Mental status Anxiety/agitation/confusion Lethargy, worsening confusion Unresponsive Urine output Decreasing <0.5 mL/kg/hr may occur Anuria / renal failure Respiratory Tachypnea Rapid/shallow; hypoxemia Ventilatory failure Acid-base Early respiratory alkalosis may occur Metabolic acidosis Profound acidosis [EXAM] CHANGE FROM BASELINE The instructor says new restlessness/confusion, worsening cap refill, or declining urine output can tell you more about perfusion than one isolated BP. [PRIORITY — IRREVERSIBLE STAGE] Physiologic support may continue, but nursing care also shifts toward comfort, dignity, symptom control, honest family communication, and goals of care. Do not give false hope. 7. Practical First-Hour Approach + General Shock Management 1. Airway + oxygenation: support breathing; escalate respiratory support as needed. 2. Perfusion access: large-bore IV/IO when indicated; draw labs; continuous monitoring. 3. Treat the cause: stop bleeding, reperfuse myocardium, relieve obstruction, treat infection/allergy. 4. Restore circulation: fluids, blood, vasopressors, or inotropes according to the shock type. 5. Reassess: MAP, mentation, urine output, skin, lactate, respiratory status, and treatment harm. [EXAM] Prioritization questions usually reward the action that addresses the immediate threat AND the underlying physiologic cause. Fluid resuscitation: give it safely Crystalloids are first-line volume replacement in many shock states. Blood components are needed when oxygen-carrying capacity or clotting factors are lost. Use dynamic assessment when possible; passive leg raise is specifically highlighted by the textbook/deck as a way to assess fluid responsiveness. Watch for pulmonary edema, cardiovascular overload, hypothermia, and other complications. After fluids: reassess BP/MAP, lung sounds, oxygenation, urine output, mentation, skin perfusion, and signs of overload. [TEXTBOOK] PASSIVE LEG RAISE The instructor explicitly says the textbook highlights passive leg raise to evaluate whether the patient may respond to more fluid. [TAKE NOTE] TRENDELENBURG The 2026 slide says Trendelenburg is NOT indicated as a fluid treatment/redistribution strategy in shock. [SOURCE NOTE] The auto-caption transcript repeatedly says “Trendelenburg is not indicated as a treatment for hyperkalemia.” The PowerPoint clearly states “Do not use Trendelenburg as a fluid treatment” and links this to shock/fluid responsiveness, so the guide uses the slide wording. 8. Vasoactive Medications: Know the Purpose, Not Every Dose Medication/class Purpose in course material Nursing focus Norepinephrine vasopressor Vasoconstriction ? raises MAP; first-line vasopressor in septic shock Continuous BP/MAP, perfusion, rhythm, IV site. Vasopressin Adjunct vasoconstriction when norepinephrine requirement is escalating Trend MAP/perfusion and adverse effects. Dobutamine - inotrope Increases contractility/cardiac output Watch HR, rhythm, BP, ischemia. Nitroglycerin - vasodilator Reduces preload/afterload and myocardial oxygen demand in selected cardiac Watch for hypotension; selective use. situations [DO NOT OVERSTUDY] She does NOT want every vasoactive dose memorized. She DOES want purpose, priority, desired effect, adverse effect, and what the nurse monitors. [TAKE NOTE] PERIPHERAL VASOPRESSOR The 2026 deck says unstable septic shock should not have vasopressor initiation delayed solely to obtain central access. Peripheral initiation is acceptable with close site monitoring. [PRIORITY] EXTRAVASATION/ISCHEMIA RISK If a peripheral vasoactive infusion site becomes concerning, the instructor emphasizes immediate close assessment and escalation because tissue injury can be severe. 9. Hypovolemic Shock - “Stop the Loss” Pathophysiology and causes Reduced intravascular volume ? reduced venous return/preload ? lower stroke volume ? lower cardiac output ? impaired tissue perfusion. Common causes on the slide: hemorrhage, vomiting/diarrhea, diuresis/dehydration, burns/third spacing. Assessment pattern Tachycardia Weak pulses Cool, pale/clammy skin Anxiety/restlessness Decreased urine output Hypotension as shock progresses [EXAM — FIRST PRIORITY] STOP THE LOSS. In hemorrhagic shock, hemorrhage control + rapid vascular access + blood/volume replacement are the priority. Nursing priorities Control ongoing fluid or blood loss. Establish rapid large-bore IV access; IO may be used if IV access is not possible. Administer isotonic crystalloid and blood products as indicated. Warm large-volume fluids and monitor for hypothermia. Trend urine output, mental status, pulses, skin perfusion, BP/MAP, and lung sounds. Watch for complications of transfusion and over-resuscitation. [EXAM DISTRACTOR] Trendelenburg is not the shock treatment. The instructor says to look for the intervention that addresses the CAUSE and perfusion at the same time. 10. Cardiogenic Shock - Support Perfusion Without Flooding the Lungs Pump failure means the heart cannot generate enough forward flow. The systemic circulation is underperfused while pressure can back up into the pulmonary circulation. Causes and assessment clues Acute MI is a classic cause; severe dysrhythmias, cardiomyopathy, valvular disease, and mechanical complications can also contribute. Chest pain/ischemic symptoms, dysrhythmias, weak pulses, cool clammy skin, oliguria, altered mentation, elevated lactate. Crackles, pulmonary edema, and increasing oxygen needs are major differentiators from straightforward hypovolemia. [EXAM] If you give cardiogenic shock the same large blind fluid bolus as hypovolemic shock, pulmonary congestion can worsen. Crackles/pulmonary edema should make you pause. Nursing priorities Continuous ECG/hemodynamic assessment; obtain 12-lead ECG and cardiac biomarkers as ordered. Support oxygenation and rapidly report worsening crackles/pulmonary edema. Prepare for reperfusion or correction of the cardiac cause. Administer vasoactive/inotropic medications safely and reassess rhythm + perfusion. Fluids, when indicated, should be cautious, small, and reassessed. Mechanical circulatory support may be required if output remains inadequate. [PRIORITY] After MI, the instructor emphasizes preserving/reperfusing myocardium and supporting cardiac output. 11. Hemodynamic Monitoring - Translate the Numbers Into Physiology Measure What it represents How the instructor wants you to use it MAP Pressure available to perfuse organs Trend it, but do not call perfusion adequate from MAP alone. CVP / filling pressure Right-sided filling pressure and volume context Do not treat CVP alone; interpret with lungs, ventilation, right-heart function, and dynamic response. Cardiac output Blood pumped each minute; CO = HR × stroke Ask WHY output is low: empty patient, weak pump, ineffective rate, high afterload? volume SVR Vascular resistance/tone Low SVR + hypotension suggests vasodilation/need for tone support in context. [EXAM / 202] Know what the measurements REPRESENT and combine them with bedside assessment + trends. Do not treat a number in isolation. Arterial line Provides continuous beat-to-beat BP/MAP monitoring and repeated arterial sampling. Watch waveform/pressure system integrity, insertion-site bleeding, and distal circulation. Monitor response to vasopressor titration along with mentation, urine output, skin perfusion, and lactate. [DANGER] Never administer medications through an arterial line. The instructor repeats “never.” [TAKE NOTE] MAP The 2026 course material uses an initial MAP target around 65 mm Hg in septic shock, but repeatedly reminds you that a MAP near target does not guarantee adequate organ perfusion. Fluid decision using trends Pattern What it may suggest Question to ask Low filling + poor perfusion Possible low preload/volume deficit Is the patient fluid responsive? High filling + crackles/edema Congestion/pump failure Will more fluid worsen the lungs? Low cardiac output Poor forward flow Why are HR or stroke volume inadequate? Low SVR + hypotension Vasodilation Does the patient need vascular tone support? 12. Obstructive Shock - Recognize the Block Cause Mechanism / clues emphasized Definitive concept Massive pulmonary embolism Blocks pulmonary blood flow; sudden dyspnea, hypoxemia, RV strain Advanced therapy aimed at relieving/removing the obstruction. Cardiac tamponade Restricts ventricular filling; hypotension, JVD, muffled heart sounds may occur Pericardial drainage may be required. Tension pneumothorax Compresses great vessels/heart; severe distress, unilateral absent breath sounds, hypotension Decompression is required. [DO NOT OVERSTUDY] The instructor says she will not test obstructive shock heavily. Know the distinctive clue and that fluids/vasopressors may temporarily support perfusion but do NOT remove the obstruction. 13. Distributive Shock Overview The vascular space is excessively dilated and/or flow is maldistributed, creating relative hypovolemia and impaired tissue perfusion. The three subtypes emphasized are septic, neurogenic, and anaphylactic shock. Subtype Septic Distinctive concept Infection + dysregulated response ? vasodilation, capillary leak, maldistributed flow; treat infection and hemodynamics. Neurogenic Loss of sympathetic tone ? vasodilation and often bradycardia; warm/dry skin can be a clue. Anaphylactic Mediator release ? vasodilation/capillary leak + bronchospasm/airway edema; IM epinephrine first. [SOURCE NOTE] The auto-caption transcript says distributive shock can create “relative hyperkalemia.” The PowerPoint states “relative hypovolemia,” so this guide uses the slide-supported term. 14. Neurogenic Shock - The Shock With Bradycardia Often associated with spinal cord injury, spinal anesthesia, or neurologic disruption. Widespread vasodilation ? hypotension and relative hypovolemia. Bradycardia can occur because sympathetic stimulation is lost. Skin is often warm and dry rather than cool/clammy. Priorities in course material: protect/stabilize spine if traumatic, oxygenation, cautious fluids, vasopressor support, temperature control; treat symptomatic bradycardia per orders/protocol. [EXAM CLASSIC] Spinal cord injury + hypotension + bradycardia + warm/dry skin = neurogenic shock. The instructor says the NCLEX loves this combination. [TAKE NOTE] Keep neurogenic shock distinct from spinal shock: neurogenic = hemodynamic problem; spinal shock = temporary neurologic/reflex loss below the injury. 15. Anaphylactic Shock - IM Epinephrine First Rapid systemic allergic reaction causes vasodilation, capillary leak, bronchospasm, and possible upper-airway edema. The priority medication in the lecture/deck is intramuscular epinephrine. [EXAM — 100%] The instructor says the IM epinephrine answer “should be 100% on the exam.” Do not delay epinephrine for IV access, diphenhydramine, steroids, or albuterol when airway/circulatory compromise is present. What you may see Airway edema/facial or oropharyngeal swelling Wheeze/bronchospasm Hypotension/shock Skin or GI symptoms may occur Nursing priorities Give IM epinephrine first when anaphylaxis is present. Support airway and oxygenation; establish IV access and give fluids as needed after immediate stabilization. Antihistamines and other medications are adjuncts, not substitutes for epinephrine. Observe for recurrence and teach trigger avoidance + emergency plan/epinephrine access. Provided TMC Anaphylaxis/Allergic Reaction Administrative Order (dated 06/2022) [PROVIDED PROTOCOL] This is the 2022 Tucson Medical Center Base Hospital protocol you uploaded. It is a prehospital/administrative-order reference and is NOT silently substituted for the 2026 nursing lecture. TMC protocol element What the uploaded page states Immediate supportive care Oxygen to maintain O? saturation ?94%; primary/secondary survey as indicated; vital signs including FSBG/temperature as indicated. Unstable allergic reaction Signs of shock, severe respiratory distress, or airway compromise. Adult IM epinephrine 0.3–0.5 mL of 1 mg/mL; may repeat every 15 min, max 1 mg in the BLS section. ALS section lists 0.01 mg/kg IM max 0.5 mg and may repeat every 5 min for hypotension/airway edema. Stable respiratory involvement DuoNeb or albuterol; IV access/NS or LR if applicable; diphenhydramine; ALS may include IV diphenhydramine and methylprednisolone. Escalation Consider early airway management for unstable patients; if condition deteriorates call Medical Direction; transport to closest facility with notification. 16. Sepsis and Septic Shock - Recognize Early, Treat Quickly, Reassess Definitions from the 2026 lecture Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock: a subset of sepsis with profound circulatory and cellular/metabolic abnormalities requiring aggressive hemodynamic support. The course sequence: infection ? dysregulated immune response ? vasodilation + capillary leak ? maldistributed flow/cellular dysfunction ? organ dysfunction/shock. [TAKE NOTE] Sepsis is NOT simply “infection + fever.” Do not wait for fever or one abnormal biomarker. Look for infection plus organ dysfunction and impaired perfusion. Recognition: screen, assess, trend Use a standardized sepsis screening process for high-risk acutely ill patients. The 2026 deck says NEWS/NEWS2, MEWS, or SIRS are preferred over qSOFA as a single hospital screening tool. Sepsis remains a clinical diagnosis; no single biomarker rules it in or out. Collect blood cultures as soon as possible and ideally before antimicrobials. Measure lactate and trend serial lactate when elevated or in septic shock. Use capillary refill as an adjunct to other perfusion measures. [DO NOT OVERSTUDY] SOFA The instructor explicitly says she is not teaching the SOFA scores for the exam; know screening exists, but the nurse still assesses the patient. [EXAM] OLDER ADULTS Older patients may have no fever and may present with new delirium, weakness, or functional decline. New mentation change can be an early clue. Antibiotic timing + source control (2026 lecture) Clinical situation 2026 course/deck approach Septic shock Antimicrobials immediately, ideally within 1 hour of recognition. Probable/definite sepsis without shock Antimicrobials immediately, ideally within 1 hour. Possible sepsis without shock Rapid investigation; if concern persists, antimicrobials within 3 hours. Low likelihood of infection without shock May defer antimicrobials with close monitoring. Source requiring procedure Early source control, ideally within 6 hours when needed. [EXAM] CULTURES VS ANTIBIOTICS Cultures should ideally be obtained first, but if the patient is unstable, the instructor says the priority is timely antibiotics - do not delay lifesaving treatment just to finish cultures. [DO NOT OVERSTUDY] Do not memorize which antibiotics are prescribed for this lecture. Know the TIME-SENSITIVE administration framework. 17. Sepsis Hemodynamic Resuscitation + Vasopressor Sequence Fluids + perfusion targets in the 2026 deck Sepsis and septic shock are medical emergencies: begin treatment/resuscitation immediately. For sepsis-induced hypoperfusion or septic shock, at least 30 mL/kg IV crystalloid in the first 3 hours is suggested. Individualize volume and reassess frequently to avoid under- or over-resuscitation. Balanced crystalloids are preferred over normal saline for initial resuscitation in the 2026 deck, but the instructor says not to quiz the crystalloid-choice detail. After initial fluid, use dynamic measures such as passive leg raise when available. Initial MAP target in septic shock: about 65 mm Hg; the slide notes adults ?65 years may start with 60–65 mm Hg. Trend MAP, capillary refill, mentation, urine output, lung exam, serial lactate, and fluid responsiveness. [TAKE NOTE] Do NOT memorize “30 mL/kg and done.” The instructor repeatedly says: give the initial resuscitation, then reassess whether perfusion improved and whether the lungs tolerate the volume. 2026 septic shock vasopressor sequence Step Medication When/why 1 Norepinephrine FIRST LINE vasopressor. 2 Add vasopressin When norepinephrine requirement is escalating. 3 Add epinephrine If MAP remains inadequate despite norepinephrine + vasopressin. [TAKE NOTE] Peripheral vasopressor start is acceptable rather than delaying rapid MAP restoration for central access. Monitor the site closely. Bedside nursing bundle Recognize infection + organ dysfunction early. Obtain cultures and lactate promptly. Administer antimicrobials on time. Start ordered fluids and reassess response. Titrate vasopressors to MAP target when needed. Strict urine-output and perfusion trending. Prevent line, catheter, and ventilator infections. Communicate deterioration and source-control needs. [EXAM — SELECT ALL] The instructor repeatedly describes this bedside sequence as a strong select-all-that-apply style area. 18. Provided Sepsis References: UCSF 2024 vs. TMC 2022 [SOURCE CONTEXT] These PDFs are useful because you provided them, but they are older/different-scope references. The 2026 course deck explicitly presents newer adult sepsis standards, so use the 2026 lecture for exam emphasis where wording/timing differs. UCSF Sepsis Guideline PDF (page 1, dated 2/27/24) The uploaded UCSF flowchart uses a SIRS + suspected infection + organ dysfunction pathway and then starts a sepsis bundle. Area What the UCSF page shows SIRS screen Two or more: temp >38 or <36°C; HR >90; RR >20 or PaCO? <32 mmHg; WBC >12K or <4K or >10% bands. Suspected infection examples Bloodstream, pneumonia, skin/soft tissue, wound, UTI, bone/joint, endocarditis, abdominal, meningitis, other. Organ dysfunction examples Lactate >2 mmol/L, altered mental status, creatinine >2 mg/dL, hypotension, hypoxia <94%, mechanical ventilation, T bili >2, platelets <100, INR >1.5 or aPTT >60. 3-hour goals IV/IO + weight, lactate, blood cultures ideally before antibiotics, broad-spectrum antibiotics, and rapid 30 mL/kg IVF for hypotension or lactate ?4; repeat lactate if initially elevated. 6-hour goals Screen for septic shock after IVF; pressors for persistent hypotension with goal MAP ?65; document volume/tissue-perfusion reassessment. [SOURCE NOTE] The lecture’s 2026 deck says hospital screening preference is NEWS/NEWS2, MEWS, or SIRS over qSOFA and uses a more nuanced antimicrobial timing framework. Keep the UCSF 2024 page as a supplied reference, not as a replacement for the instructor’s 2026 exam emphasis. TMC Sepsis Administrative Order (page 2, dated 06/2022) TMC element What the uploaded protocol states Immediate supportive care Oxygen to keep O? sat ?94% (COPD history >92%); vital signs including FSBG; cardiac monitor if available; consider IV access. Inclusion Presumed infection source plus vital-sign criteria such as fever/hypothermia, HR >90, RR >20. BLS fluids NS/LR; 30 mL/kg bolus x1 at 100 mL/min; reassess hemodynamic and pulmonary status frequently; notify facility of “Sepsis Alert.” Volume-sensitive/cardiogenic considerations For cardiogenic shock/hypotension with suspected pulmonary edema: 250 mL boluses. CHF/ESRD: reevaluate and protocol gives reducedvolume guidance. Adult septic shock Protocol states initial treatment focuses on maximizing perfusion with IV fluid boluses; if fluid challenge fails or hypotension becomes life-threatening, consider vasopressors. It lists large-bore access/IO and push-dose epinephrine under the field protocol. Organ dysfunction concern SBP <90, new AMS, new O? requirement, cap refill >3 sec, decreased urine output, FSBG >140 in nondiabetic, jaundice without specified chronic cause. Escalation Arrange ALS intercept when applicable without delaying transport; call medical direction with deterioration; consider closest facility and receiving notification. [SOURCE NOTE] The TMC protocol is a 2022 prehospital administrative order. The 2026 NUR 202 deck teaches norepinephrine as first-line septic-shock vasopressor and says peripheral initiation is acceptable when rapid MAP restoration is needed. Keep these scopes/dates separate. 19. DIC - A Clotting AND Bleeding Disorder The lecture presents DIC as a shock/sepsis complication: widespread coagulation activation creates microthrombi/tissue ischemia while consuming platelets and clotting factors, so bleeding develops at the same time. Assessment clues Oozing from IV/invasive sites Petechiae/ecchymosis Hematuria or GI bleeding Falling platelets and fibrinogen Prolonged PT/aPTT Elevated D-dimer/fibrin degradation products Organ dysfunction from microvascular clotting [DO NOT OVERSTUDY] The instructor says DIC is knowledge-only in this lecture. Know the nursing assessment and the core concept: BOTH clotting and bleeding. [PRIORITY] Treat the underlying cause while supporting bleeding, perfusion, and organ function. 20. NGN Mini Case - Sepsis With Hypoperfusion Scenario from the deck: 72-year-old admitted with pneumonia; new confusion; T 38.3°C, HR 118, RR 28, BP 92/54, SpO? 91% on 2 L NC; falling urine output; lactate 3.8 mmol/L. Recognize the strongest cues New confusion Low BP/MAP concern Falling urine output Elevated lactate Tachypnea/increasing respiratory concern Pneumonia as infection source [EXAM] Do not select a cue simply because it is abnormal. Identify which findings are RELEVANT to impaired perfusion and organ dysfunction. Prioritize ? act ? evaluate Phase Course answer mindset Prioritize Sepsis with hypoperfusion; risk for worsening respiratory failure; risk for AKI/MODS. Act Support oxygenation; cultures + lactate; timely antimicrobials; crystalloid with reassessment; prepare vasopressor if hypotension persists. Evaluate MAP improves, mentation improves, urine output rises, cap refill/lactate trend improves, and no fluid overload develops. [TAKE NOTE] Do not judge success because “the fluids finished” or “the antibiotic was hung.” Evaluate whether the PATIENT improved. 21. Multiple Organ Dysfunction Syndrome (MODS) MODS is progressive dysfunction of multiple systems after severe systemic illness, commonly sepsis and prolonged shock. The instructor’s focus is recognizing systems deteriorating together, not memorizing a rigid organ order. System Deterioration pattern from course material Lungs ARDS / increasing ventilatory support; lungs may be among the first systems to show dysfunction. Kidneys AKI, oliguria/anuria. Brain Delirium ? coma. Liver Rising enzymes / jaundice. Coagulation DIC / bleeding-clotting abnormalities. [DO NOT OVERSTUDY] She says you do not need to memorize the exact organ sequence. Recognize multiple organs worsening together. [PRIORITY — PREVENTION] Best treatment is prevention: recognize shock/sepsis early, restore perfusion, control infection, avoid secondary injury, and support organ function. 22. After the ICU: PICS + Transitional Care Domain Possible post-ICU effects Physical Weakness, fatigue, deconditioning. Cognitive Memory, attention, executive-function changes. Mental health Anxiety, depression, PTSD symptoms, sleep disturbance. Functional/social Difficulty returning to roles; caregiver/family impact. Nursing/transitional priorities Medication reconciliation and clear handoff. Education on warning signs and follow-up. Rehabilitation/mobility support; involve PT/other disciplines as needed. Screen for cognitive, emotional, social, and caregiver needs. Prepare patient/family for a prolonged recovery rather than acting as if the critical illness ended at ICU transfer. [TAKE NOTE] The instructor asks what to “take home” from this slide: prepare the patient/family for recovery, reinforce medications/warning signs, coordinate rehab/resources, and give a strong handoff. 23. Family Communication, Palliative Principles, and Goals of Care Give clear, honest, repeated updates in language the family can understand. Explain what monitors/therapies are doing and invite questions. Promote family presence/participation when appropriate. Treat pain, anxiety, sleep disruption, and delirium risk. Clarify advance directives and patient goals when the course worsens. Use palliative-care principles alongside active treatment to reduce suffering. Use ethics/interdisciplinary resources for complex life-support decisions. [EXAM / NCLEX] Psychosocial Integrity and Management of Care remain testable in a highly physiologic ICU scenario. Do not give false reassurance. Nurses support and advocate; nurses do not diagnose. 24. High-Yield NCLEX Comparison + Rapid Review Shock state Clue pattern Priority concept Hypovolemic Fluid loss + tachycardia + cool clammy skin Stop loss + restore volume/blood Cardiogenic MI/HF + crackles/pulmonary edema + poor perfusion Improve pump; avoid overload Obstructive Shock + PE/tamponade/tension-pneumo clue Relieve obstruction Neurogenic Spinal injury + hypotension + bradycardia + warm skin Restore tone/perfusion; protect spine Anaphylactic Allergen + airway symptoms + hypotension IM epinephrine first Septic Infection + organ dysfunction + vasodilation/hypoperfusion Antimicrobials + fluids + norepi if needed Rapid-review questions from the deck 1. GI bleed + tachycardia + cool skin + hypotension: priority = large-bore IV access plus volume/blood replacement; hemorrhage control is essential. 2. Wheezing + facial swelling + hypotension after antibiotic: first medication = IM epinephrine. 3. Septic shock still hypotensive after initial fluid resuscitation: first-line vasopressor = norepinephrine. [EXAM] For every answer, ask: what physiologic problem makes this the safest and most effective next action? 25. Final Instructor Takeaways 1. Shock is a perfusion problem, not just a blood-pressure problem. 2. Early cues often appear before severe hypotension. 3. Classify the shock state so treatment matches the cause. 4. In sepsis, act quickly but use the 2026 timing + reassessment framework. 5. Evaluate response using mentation, urine output, MAP, skin perfusion, respiratory status, and lactate trends. 6. Critical care also includes prevention, communication, family support, goals of care, and recovery after the ICU. [TAKE NOTE — “IF YOU REMEMBER ANYTHING”] Do not wait for dramatic hypotension. Use trends. Classify the shock state. Match treatment to cause. Reassess whether the patient’s organs are actually being perfused. 26. Last-Minute Exam Checklist Can I recognize shock with a normal or not-yet-severely-low BP? Can I identify the important trend: mentation, urine output, cap refill, RR/O? need, MAP, lactate? Can I classify VOLUME vs PUMP vs VESSELS vs OBSTRUCTION? Do I know hypovolemic priority = stop loss + restore volume/blood? Do I know cardiogenic = improve pump/support oxygenation and be cautious with fluid because of pulmonary edema? Do I know neurogenic = spinal injury + hypotension + bradycardia + warm skin? Do I know anaphylaxis = IM epinephrine FIRST, and the instructor says this is “100%” exam material? Do I know septic-shock norepinephrine is first-line after initial fluids if hypotension persists? Do I know cultures ideally precede antibiotics, but unstable patients should not have antibiotics delayed? Do I know the 30 mL/kg in first 3 hours framework AND that reassessment is mandatory? Can I identify fluid harm: crackles, rising oxygen need, worsening SpO?, dyspnea/pulmonary edema? Do I know never to give medication through an arterial line? Can I explain why MAP alone is not enough to prove organ perfusion? Do I know DIC = clotting + bleeding and is knowledge-only here? Can I recognize MODS as several organ systems worsening together? Can I answer communication/goals-of-care questions without giving false hope or diagnosing? 27. Source-Only Clarifications / Auto-Transcript Conflicts The instructor transcript is auto-generated and contains obvious substitutions. The guide uses the PowerPoint wording when the supplied slide clearly resolves the same sentence. No outside source was used to repair these. Auto-caption issue How this guide handles it from supplied material “Distributive shock … relative hyperkalemia” PowerPoint says relative hypovolemia + maldistributed flow; guide uses the slide wording. “Trendelenburg is not indicated as treatment for hyperkalemia” PowerPoint says Trendelenburg is not a fluid treatment/redistribution strategy in shock; guide uses slide wording. “vasopressin” used where discussion clearly refers to vasopressors/norepinephrine PowerPoint names norepinephrine first-line and vasopressin as adjunct; guide follows the deck. “crystal voids / Krista Lloyd’s” PowerPoint says crystalloids/balanced crystalloids; guide uses slide term. “isotopes / vessel purchasers” PowerPoint uses inotropes/vasopressors; guide follows the deck. “hyperkalemia” appears in places describing volume status/shock Where the slide supplies the intended shock physiology, the guide uses the slide-supported term and flags the mismatch here. 28. Sources Used 202 Complex Care Critical Care Lecture.pptx - NUR 202 shock, sepsis, MODS instructor deck updated for 2026 course standards. Critical Care transcript.docx - auto-generated instructor lecture transcript. Sepsis Guidelines | UCSF.pdf - uploaded UCSF sepsis guideline screenshot/flowchart dated 2/27/24. TMC protocol.pdf - uploaded Tucson Medical Center Base Hospital administrative orders dated 06/2022 (anaphylaxis/allergic reaction, sepsis, snakebite). No outside sources used. [SCOPE NOTE] TMC SNAKEBITE PAGE The TMC PDF also contains a snakebite administrative order. Because the NUR 202 critical-care lecture content you supplied is focused on shock, sepsis, MODS, hemodynamics and anaphylaxis, the snakebite protocol is acknowledged as a supplied source but not treated as a core lecture study topic in this guide.