Okay so now we're going to talk about shock and the monitoring of shock.

We got to include a lot of those hemodynamic monitoring lines and start seeing the severe emergent cases of patients when we do not fix them soon enough or when they're really a Critical So what is shock, well shock by itself means that you have a decrease in oxygenation and perfusion and it causes your body to switch from the aerobic with oxygen metabolism to the anaerobic without oxygen and when you don't have oxygen to the cells begin to die.

and this death is going to release more toxins and so the anaerobic metabolism and the cell death is going to release things like lactic acid lactic acid also.

Causes pain so.

Let's look at these types of shot.

There are several types of shock I do not need you to memorize each of these or put them into categories or anything like that the reason these are divided into categories is because if they fall in that category they kind fall into the same look presentation treatment piece Now we are going to learn this and a.

Categorical form at meeting we're going to talk about some of them now and then we're going to really go in-depth with cardiogenic when we get to cardiac and we're going to talk more about neurogenic when we get to neuro.

We're going to talk over all about shock here now..

Even though the cause of shock is going to differ the predictability of shock very much remains relatively the same tell us the same course the stages if you do not intervene it's going to progress to mods or death so.

Relatively speaking we just have to look at these differences and those signs and symptoms what makes them unique and how do you identify and treat them.

Prevention is best always remember that let's see if we can identify and go through it.

Alright so talking about the pathophysiology remember our body has compensatory mechanisms built in the goal of our body is to keep us within homeostasis it wants to keep our blood pH level for instance into that 7.35.

To 7.45 right so it wants to keep our pH balanced in addition our body works to ensure that are potassium level stays between 3.5 and 5 are sodium between 135 and 145 and the list goes on.

To do this our body has a set of normals it has a normal respiratory rate we have a normal blood pressure we have a normal heart heart rate respiratory rate we have normal body temperatures we have a system in place to correct are electrolytes and so it's all about our compensatory mechanisms.

For instance, If I eat a bucket of popcorn from the movies why don't I have a.

Sodium level of 180 because my body understands that I've just eaten a bunch of salt and then it tells my kidneys and my body to say hey I better release some salt, pee a little bit dilute it down make me thirsty. activates these compensatory mechanism to equal me out okay.

Now if you can remember from previous lectures in earlier semesters we have some main compensatory mechanisms one our endocrine system is a really big part there is a lot of our hormones and releasing agents that are happening within our body.

That are keeping us within balance it stimulates our adrenals and it stimulates our thyroid in different areas to keep us in a homeostasis point.

In addition to our endocrine system and are hormones we have our respiratory system which picks up super quickly.

helps us to breath faster or slower deeper or more shallow to maintain our acid-base balance and then of course we have our kidneys which is all about the acid in the bicarbs and again keeping that acid levels the way it should be.

Now in addition to this we really have to look at our gas exchange and perfusion.

Our oxygen is.

Floating around in our body it's a in the arterial system remember it rides then that blood cells going to go to our organs, circle back to the heart once it's mostly unloaded and then it refills it does the gas exchange between oxygen and CO2 gas.

If our body does not have enough red blood cells.

Well we're not going to have enough oxygen if we don't have enough hemoglobin.

on the red blood cell.

We would not have the right amount of oxygen carrying capability.

Iron is another one because our oxygen binds to the iron so if you don't have.

Iron even if you have enough red blood cells you will not have the oxygen available to feed your organs brain heart and keep you sustainable.

If any of those are true unfortunately.

Are lacking oxygen lacks perfusion.

And then it starts to die and you switched over to that anaerobic metabolism building up your lactic acid.

All of those metabolites from the cell destruction can cause more death, More problems and it can shut all of your organs down permanently so we will talk about the stages of shock and those stages of shock are a predictable pattern as well so basically you go worse worse worse, worse.

Alright so.

In order to identify this is not just a stage as we do have to talk about your mean arterial pressure now you were introduced to this in a previous semester last semester you hit it a little bit harder in the semester we very rarely look at a systolic diastolic blood pressure by itself we have to put the pieces together which involved the mean arterial pressure or map.

This really is a better picture of your cardiac output and it's a better picture of how your patients doing remember cardiac output is how much blood do you have circulating out into your body every minute so that's a course important too.

It is affected by your blood volume how much you have in there.

But it also depends on the size of your vessels okay and the Integrity of your vessels and when I say vessels I mean your veins and arteries.

so sized meaning as a basic restricted or dilated.

and Integrity meaning do I have a cut in my Bleeding Out.

So this should be a very quick reminder about the principles of vasodilation and construction.

Remember our body has sympathetic tone meaning our vessels are in a constant state of a yin and yang it's going to be not completely vasodilated it is not completely vasoconstricted we are in a medium spots and these.

Are body basically maintains that level and autonomicly it's going to be so constrict or dilate when it needs to as a compensation mechanism that makes sense.

So why is it important well we have to know and predict the next stage of the shocks which medications you should and should not give.

Based on the stages of shock what's going to cause them to get better or possibly kill them that's bad don't do that but you have to understand the concepts of this alright..

vasodilation, of course, is when the sympathetic tone relaxes and the vessel gets bigger vasodilate K what does that mean it means that after load the resistance has decreased and ultimately you will have less preload it brings down the amount of blood that is available to do that right atrium going in.

Now that does not mean you change any volume I didn't add or take away any fluid.

Just a vessel got bigger which changed which changed with the patient has for cardiac output.

Vasoconstriction very much the opposite of course our body senses that maybe our blood pressure is a little bit low and so what it does is it constricts and when you construct it it's more pressure more squeeze on the vessel.

And if you have.

Please it's going to increase the Afterload increase the preload and increase the blood pressure or the cardiac output.

now there is a max Point yes I know if you squeeze it to Hard No More can go in okay but let's keep us simple here if you guys are dilated should go down if you be so constrict it should go up.

Now let's talk about the stages of shock again I do not need you to memorize each and every piece I do not need you to make flashcards my test questions do not say like oh what would you find in the Progressive stage okay you have to know what these are what's going to come before or after predict it how are we going to stop it from progressing so that's what we're looking for all right now let's start with the initial stage.

The initial stage of shock are compensatory mechanisms are baroreceptors are constantly.

Listening for watching our mean arterial pressure it when it senses this just a very small change in our mean arterial pressure like 5 to 10 then it says hey.

my pressure is getting a little bit low and we better put some compensatory mechanisms in there so my blood pressure stays up.

Not very many people around continuous blood pressure monitoring it's usually done in a nice you setting with very invasive lines it's not like I'm a med surg for this stage will likely get Miss on a med-surg floor it's just well okay so.

Be mindful you have a person that's blood pressure drops a little bit how does our body compensate for the.

What's our initial well Our body says, alright we need to kick up our heart rate a little bit and we need to breathe a little faster.

Well that's small change that increase in my heart rate should kick out my cardiac output it should bring it up.

Because if I have the same amount of volume.

Beating faster.

My blood pressure should now sustain my body.

So that's what's happening you have an increase in your heart rate an increase in your respiratory rate and that should compensate and make your blood pressure go up.

Your patient is going to look the same its happening inside so besides maybe being a little elevated heart rate and respiratory rate and he still could be within normal if their normal heart rate of 60.

It might be 85.

If the respiratory rate is 12 to 14 which is most typical.

And now it's 18 to 20 believe it or not that's that significant change a couple reasons why this is Missed Especially on a med surg for one we do not watch for things all the time to we are taking Vital Signs every 4 hours and unless we deem that.

Really far off or never really looking at scrutinizing the trends of somebody's vitals which is a very bad because we are going to miss it.

If you see somebody has a heart rate of 85 your like Yep they're good.

But let's stay there their heart rate has been 60 for days why is it all the sudden 85.

That is significant.

Same thing with respiratory rates.

In addition we have things that mask So for instance beta blockers calcium channel blockers digoxin all these medications that are made to slow the heart rate.

Well are the patients taking those you're not going to see the compensatory mechanism kick in.

Likewise on your respiratory rate.

I think back to all the people that I've ever taken a respiratory rate.

And I'm certainly not going to ask anybody here but I hope you start doing it differently now.

How many of your patient care technician has how many of the people that's taking the respiratory rate are actually taking it?

Or I didn't looking at him saying yep 16 I actually once to turn on it and it's very interesting and I had to do it for months on this but it was either 16 or 18 those were the two that everyone charted and that was.

They would be a different floors so different patient care technician and nurses and they would have charted 16 or 18 on every patient all day on the entire unit.

So tell me how accurate this is so if you don't know that your patients Baseline respiratory rate is 12.

How are you going to recognize that it jumped to 20 and then do anything about.

So you have to do your vitals you have to be scrutinizing those vitals because otherwise you're going to miss this.

Again, your patient is going to look like they are doing well besides the heart rate in the respiratory rate.

So how are you going to recognize it by me very very into vital signs.

Don't forget that if the patient goes into an irregular Rhythm all heart rates have to be checked manually for one minute so if you have a patient that is in atrial fibrillation.

Cannot use a Automated machine to obtain your heart rate.

An accurate and you are going to have it completely wrong.

Some vital signs that tell you you have a heart rate of 60 when really it's 80 or you'll have other times you'll say it's 120 and it's 70 you have to do it manually for irregular Rhythm especially atrial fibrillation.

And then how do we fix it to fix it we need to figure out why the blood pressure has been going down are they bleeding are they dehydrated is this a cardiac issue you have to put the pieces together why are they there what are they most susceptible for and then intervene.

Alright so if we did not catch the initial stage and like I said that when is the most often missed we are going to head into the compensatory stage and this is where you really hope that you have a very prudent nurse and they are paying very close attention to their patients and their Vital Signs and they are discriminating the data.

This is when your map decreases by about 10 to 15 mm of mercury from Baseline.

Okay so what's happening are sympathetic nervous system are sympathetic is stimulate.

And it's more so stimulated than in the initial remember the initial it's just kicking up my heart rate and respiratory rate that's it.

Maintains the blood pressure.

Well if it cannot hold that and it continues to drop.

Now my compensatory stage is got to work a little bit harder so what happens in the body now.

Okay first of all when the map is low we have a decrease apply of oxygen to her organs. Those start to Die the switch over to anaerobic metabolism and so our body is going to try to fight this.

Sometimes this is great.

Other times it can be a little bit of a challenge for us.

So this decrease that 10 to 15 is now a large enough to trigger the renin-angiotensin system so it triggers the renin it triggers our antidiuretic hormone that you learned about in the endocrine area aldosterone again learned in endocrine last semester your epinephrine and norepinephrine and start the kidneys compensation process.

If you think about this you have a lot of chemicals being released.

Now in the initial stage is the respiratory compensation mechanism right because it was all about the breathing rate and heart rate now you have the kidneys kicking in.

It starts kicking in earlier than most people think it doesn't become optimal or at its best until like 3 days but it starts to work earlier than that you just won't see the full fledge effects of it for a while.

Still remember our renin-angiotensin system that antidiuretic hormone that means you don't pee to have this extra antidiuretic hormone aldosterone that is salt right now it says hold salt so we can hold water.

We have are epinephrine and norepinephrine that's happening from are adrenal glands and that is our sympathetic parasympathetic Yin vs. Yang type of response and it starting the kidneys starting to get it to function to help combat this blood pressure issue.

The norepinephrine and epinephrine are very potent very potent catecholamines okay and they're responsible for vasoconstriction their whole idea is to vasoconstrict like we talked about a couple slides ago and when it constricts its going to bring up your blood pressure and help Force additional perfusion oxygen blood flow to your kidneys.

That is all in that was non-vital type of organs or tissues okay now the combination of all these mechanisms together should maintain our blood pressure and our oxygen to our vital organs.

But unfortunately.

It's only worried about the vital organs and so in this stage our non-vital organs.

Tissue start becoming hypoxic and it starts building up those metabolites and we start seeing changes in our blood pH and our potassium.

Now hear it still might be relatively subtle maybe we're starting to see that potassium that was like a 3.5 everyday 3.5 3.8 now it's at like a 4.9 or a 5.1.

So it might be normal or just a little outside normal and you're like okay it's fine.

but Is it it? It might not be, your trending bad so you always want to look at Trends and not just the last one.

You want to look at Trends over the last 12 to 36 hours so you can get a complete picture.

Our body senses that drop in blood pressure in that map increases the anxiety and it also tells your body hey.

Start drinking fluids you're thirsty.

Blood pressure so it tells you to drink more, Even The Thirst compensation mechanism happens at the stage.

Heyo so if your person that's ever like me and I'm really really thirsty at the hot day it's because your body is sensing your blood pressure is taking an effect act your sympathetic nervous system is actually kicking in and it's telling you that you're thirsty.

kind of cool.

So does compensation mechanism right here if everything works okay if everything works your blood pressure should be restored it should compensate and put you back up to that Normal.

Okay.

When your blood pressure decreases our body is telling us to drink our bodies going to increase the heart rate it's going to increase our respiratory rate it's going to tell you not to pee as much.

Can you think of that that population that this might not be seen in.

your, elderly population.

Your elderly population.

response, their immune system.

Is remember compromised just because of their age so their bodies do not detect this as fast they may not ever have a thirsty compensation mechanism and this is why they go downhill quickly deteriorate quicker than somebody who's younger.

This is also why they become a priority patient and that the RN should be assigned to those elderly patient.

These patients right here sometimes begins to look like they're a little bit more in trouble why because you to start having some blood shunting going on because remember it's not caring about the non-vital organs like your kidneys don't need to pee, BUM and creatinine go up the feGFR goes down but then you also start having other things blood sugar's man my blood sugars have been great have been great they're doing so wonderful and then all the sudden you're checking blood sugars in they are 250.

Or 275 and it's out of the ordinary.

Well our body says hey our compensation mechanism is activated I need more energy it's going to start breaking down our glycogen stores from our bellies our gut.

Making your blood sugar rise giving you more energy available to fight the shock whatever the cause of it is.

so our blood pressures go up.

In addition, your blood pressure.

It starts to narrow the pulse pressure and if you remember what narrowing of the pulse pressure is it means the systolic starts to drop but the diastolic starts.

Either stay the same or could slightly increase as well.

now remember when switching over to that anaerobic metabolism we do have that lactic acid as a by-product lactic acid of course is not what our body needs our body likes to be in that homeostasis so as that lactic acid increases our bodies going to try to combat the lactic acid.

How does it do that.

If you remember acid does not like to float in the blood vessel and to compensate it's going to go into your cells Now what's your electrolyte is found most typically inside your cell

So the acid is going to hide inside the cell.

And your potassium is going to be kicked out of the cell.

That seems odd.

Do you have your blood vessel okay.

Do you have a bunch of acid floating around.

Acid acid acid and this is causing our pH balance to be disrupted.

So then what happens is I now have.

A bunch of cells here and inside these cells is potassium.

Do to compensate what's going to happen is this acid is going to go inside the cell.

And it says there's not room for both of us so potassium gets kicked out.

potassium outside.

What happens our pH level is trying to be maintained.

Potassium level starts to rise.

If we correct acid be mindful if you ever correct acid and acid now comes out of the cells and is neutralize your potassium is going to go back into your cell and then you could have hypokalemia as well so be very mindful of this switch and how that works.

Okay so.

Coming back sorry had to pause for a second that potassium and the hydrogen also known as lactic acid the acidity level are very closely related so be mindful of how those two affect one another.

Alright so.

Remember at acidity levels increase your potassium that means if it's still climbing that acid level is still climbing it's past the compensation point and potassium is going to rise too.

that is how it kind of affects one goes into the self the other one comes out kind of gets kicked out of the cell if you were.

Your patient here certainly is going to look a little different you might see some shunting in the extremities you're not going to be completely pale or cool or anything like that but you are going to possibly some of these changes and you might start seeing a little bit of.

Increase breathing more because of the acid level starting to climb the heart rate still going to be there so those are going to continue now you just have the addition of the urinary output changing and potassium pH starting to change so just be really mindful of those things.

the next part is the progressive stage so if you did not stop.

The shock effect stage 2 that you're going to progress to the progressive stage and this Progressive stage starts getting very very important to stop because the patient really deteriorates very quickly and they don't do so well so you have a map decrease now greater than 20 from the Baseline so this is where you're going to see this massive drop in your blood pressure or compensation mechanism from earlier is being overwhelmed and it can't keep up and so now remember before the non-vital organs we're not getting oxygen but the vital organs were, well now even the oxygen supply to the vital organs like your heart in your lungs.

are not getting enough to perfuse them

And so you start having vital organs that are now becoming anoxic and the cells in those are starting to die so you have heart cells dying of brain cells dying and it becomes very widespread right because you have the non-vital and the vital organs now starting to die and the damage which is happening in the non-vital organs is potentially permanent at this point so you can have permanent kidney damage for instance.

So this is for patients often say and I feel like I'm going to die that sense of impending doom.

It's hard to reverse the later they get it is harder to reverse the stages and so.

The earlier we can recognize the earlier you can respond.

Better off this patient is and unfortunately if you respond too late or you miss it.

the patient can have either lifelong damage or death.

What happens to the patient's Vital Signs here.

Well they get a lot worse now remember the initial stage of the non-progressive stage your heart rate kicked up the next day she caught up a little bit higher but what happens here is the heart rate is starting to get weak he doesn't have the same when you feel the part that's why we want to look at the quality of the pulse it's weaker it's ready it's rapid and what that means is less of a blood pressure this less blood flow going through there and so it becomes thready maybe you went from a plus two or plus 3 pulse to now A plus one or even Lower detectable maybe even a Doppler but usually thready + 1 okay.

Blood pressure is on the decline It's Goin Down it's affecting that pulse rate the quality of the pulse.

Your patient is very confused they are so thirsty I have seen people drink out of toilets before they are so thirsty.

The compensation mechanism is still trying it's just overwhelmed okay the skin here now is pale.

You definitely have that mean something happening you start seeing cyanosis specially around the lips the nail beds the oral mucosa the nail beds remember in the African African American population look at your nail beds you might be able to look at like the conjunctiva of the eye when you pull the eye down and then start looking there that could also be more pale, pallor.

You may not be producing any urine at this point because remember in the last stage our kidneys are already kicking in its already releasing the Epi the norepi the antidiuretic hormone the renin so it's still working it's still trying it's it's at Max Max release so now you're not going peeing here trying to save all of your neck and you're going to have.

Decreases in your oxygen so your oxygen is going to start falling in the initial stage or oxygen stays the same in your compensatory mechanism that oxygen it's probably going to be pretty close to staying the same, you might have went from like a 97 98% on room air to like, man, they are at 95 and you're like 95 is good enough no big deal.

If you look at the trends.

95 can be significant it is normal.

but it should peak your interest is to say why is it 95 if they're normally 99.

What happening?

and here you start seeing bigger drops maybe it's 92 why is my person yesterday need room air and today they're on 4 to maintain that same level of oxygen.

What's going on in the body that you cannot see.

Need to be asking yourself those types of questions because that's how you're going to identify who's going to crash on you who is going to need that rapid response whose organs are going to shut down..who is going to die if you don't intervene.

so in this one like I said the oxygen levels going to is going to decrease going to decrease quite a bit alright we might see it these people might start needing oxygen higher levels of oxygen maybe even progress up to a Venturi or a non-rebreather mask.

The pH is really going to start dropping here you're going to start getting outside that normal limits your lactic acid is climbing your potassium level is climbing so now if you think about this my pH is in a bad Zone.

What is a compensation mechanism a respiratory rate is going to be breathing real fast trying to breathe breathe out the acid what is the signs of an acidic person.

do you remember that from your fluid electrolytes and acid base balance?

Might want to go back and review that because what is my acidic person look like.

This is a life-threatening emergency you guys this Progressive stage of shock is it is very life-threatening if we don't stop this we already are having permanent damage to our non-vital organs our vital organs are switched over to the anaerobic metabolism they're not getting the oxygen perfusion that they need there are starting to die starting to die, you can't bring death back okay so we need to intervene very quickly now our vital organs can sustain this for a small, short period of time.

But if we don't respond quick enough we will start having multiple organs in distress or in dysfunction they like to change the name but you going to MODS First I might lose my kidneys. My BUN and creatinine begin to climb my kidneys are not able to filter my by-products egfr goes low next something else might start falling maybe it's my pancreas in my lipase goes up maybe it's my liver my ALT, AST, bilirubin, alk phos, albumin all those wonderful things that my liver controls.

Start to increase.

Maybe my lung start to decrease maybe my compensation mechanism for breathing is changed.

I could start having all sorts of organs that fail to determine if your organs are not working well look at your lab values that's the key lab values.

Now mods it's right in the name you guys multiple organs okay so it's more than one all right.

The more organs that fail.

The rate of death increases.

It is really more than two organs the chance of survival is very very low.

Okay so we got it intervene Our goal is to restore perfusion within one hour of recognizing these and so because of that we have some bundles that we're going to talk about your shortly as you can see there's a lot that stuff that's happening here are they don't look good they are changing rapidly.

And survival is.

Starting to decrease quite a bit.

Now the refractory stage refractory this is the final stage.

refractory just means your patients basically going to die and there's very very very few people that come back from Refractory stages and if they do they're going to have a consequence of some sort likely but this is severe tissue hypoxia and necrosis, meaning death, cells died vital and non-vital die And so you might be a dialysis patient for the rest of your life if you make it you might need supplements and help if your liver took a big enough hit you might need organ transplant most of these people do not make it okay this is where you have multiple organs they are shutting down I have so much lactic acid it is not what we call sustainable for Life the byproducts of this lactic acid in this anaerobic metabolism that's happening there so much cell destruction that it's triggering this really really vicious circle and it just keeps releasing these by-products that unfortunately are made to seek and Destroy other other cells and so it's like this Cascade of death inside the body.

In addition you certainly are going to have some microclots and these kind of course form in the liver brain heart and kidneys and when that happens you're susceptible to blood clots and more dysfunction.

Okay so like I said at the class can go everywhere these clots can get lodged it causes more problems with perfusion because if you get a clot large let's say to your liver then you don't have any blood flow going to your liver and then of course that you have more cell death and that can happen to any organ and a part of the body you can certainly start having Strokes you can have heart attacks and kidney damage and heart damage and all the above so at this point you're going to start having a match directly to your heart muscles all three layers remember you have your myocardium pericardium epicardium so now your heart is going to fail.

You might see a huge release in your your troponin levels you might start seeing that.

BNP start to rise because of that heart failure and really this patient is going to start declining lose Consciousness your pulses are going to be non-existence of you might you might start getting some with Doppler so they're going to start going away your extremities become cold and modeled than Dusky and this is the stage and the ominous sign where the respirations in the heart rate.

instead of being fast and and compensating.

Now they quit.

So now you start seeing bradycardia and you start seeing a lower heart rate and when you see that.

That patient is getting ready to die it's an ominous sign blood sugars here instead of being increased you have used up all the sugars your body has stored so your blood sugar is going to be low.

You ever have a patient that has been sick sick sick and all the sudden you start seeing hypoglycemia.

Not a good sign okay.

Oxygen levels are very low sometimes even unobtainable through a pulse oximeter.

so refractory stage hopefully you never get to this point because when you do this is basically they're getting ready to die chances of survival extremely low extremely low.

All right so how do you correct shock while you first have to identify it so we talk about these stages so shocked, these initial and Progressive and you're still compensatory Progressive and refractory the earlier you recognize and intervene less damage to the body better chance of survival makes sense.

so you have to be very oppressed to your compensatory mechanisms what's happening in the body and understanding that pathophysiology.

If you do not understand the pathophysiology up the shocks what's happening in the body you're dangerous.

You should not be working as a nurse on the floor if you do not get this concept.

You're putting your patients at risk if you do not understand this concept so if you are not understanding that after these lectures you need to come see me.

Do not try to memorize the chart in the book to say my patient is going to look like this that is not how it works and you're too late.

So please understand this concept what's happening in the body.

And if this doesn't make sense come see me and I will help you represent it over and over again until we get.

In your head of what's happening and why.

It's the only way you're truly going to know what's happening next if they're getting better if they're getting worse.

so correcting it stop it early so first we need to identify that there's a problem to you need to get some help on board right call those providers or that rapid response if you need to but get some help on board.

You need to figure out the cause so you know how to fix it because each one of those shocks.

there a different way to treat it to bring them back so shocked follows the same Progressive state.

But then it has to go more individual to what's causing it and then the treatments are a little bit different Now can you fix.

Well that's a good question.

Are there PRN medications that you can give to help correct.

Look for that cuz maybe there is.

If there isn't any and you can't.

Fix-It who are you going to call and is it a doctor call or is it a rapid response call depending on the situation.

How did I fix it.

Do we fix it with fluids which is often our first line type of medication that we give when we we certainly give oxygen for perfusion.

But we have to get the volume up are we giving up a vasopresser that's going to increase that afterload increase the resistance.

We have to figure out the cause what is the main underlying problems so we can go right to those areas and fix it.

And then you are the nurse what safety interventions are you going to implement to make sure that this patient stays safe.

Are you going to move them closer to the desk.

Are they now a fall risk.

Is my blood pressure low should they be getting up to walk to the bathroom.

Should you be measuring that intake and out take very careful.

Maybe this person isn't a diabetic should we be doing blood sugar.

What are the things that you are going to implement to identify and keep this person safe.

And if you're going to be looking for something.

If you're going to be watching out.

Well what are you going to do for education.

Because who are you going to educate are you going to educate your tech.

I hope so because they might be the ones doing your blood sugars or and emptying your Foley catheter for you.

And is it going to be the family because they're in the room the entire time.

And you don't want them getting up.

You need to start looking at all of these pieces.