Med Surg III Sepsis and Shock Test

What is the pathophysiology of septic shock?

Widespread infection exacerbation → vasodilation, permeable (leaky) capillaries → decreased BP

Which client should the nurse consider is at risk of​ sepsis? (Select all that​ apply.) A.A client with an intravenous catheter B.A client with a peptic ulcer C.A client with a surgical wound D.A client with a sexually transmitted infection E.A client undergoing frequent pulse oximetry

A,B,C,D Portals of entry for infection may include the following​ systems: urinary,​ respiratory, gastrointestinal,​ integumentary, and female reproductive. Conditions that may lead to sepsis​ include, but are not limited​ to, intravenous​ catheters, surgical​ wounds, sexually transmitted​ infections, and peptic ulcerations. Pulse oximetry is not an invasive procedure and is not a portal of entry for sepsis.

Which finding should the nurse expect while assessing a client with​ sepsis? (Select all that​ apply.) A.Leukocytosis B.Hypertension C.Tachypnea D.Bradycardia E.Confusion

A,C,E Clinical manifestations of sepsis include mental status changes such as​ confusion, tachypnea, and either leukocytosis or leukopenia. The client will have hypotension as fluid leaves the intravascular space. The client will experience​ tachycardia, not bradycardia.

Which clinical manifestation should the nurse recognize as an indicator of early septic​ shock? (Select all that​ apply.) A.Warm, flushed skin B.Oliguria C.Alert and oriented mental status D.Weakness E.Hypotension

A,D,E Early, or​ warm, signs of septic shock include​ weakness, hypotension, and​ warmed, flushed skin. The nurse should be cognizant of these signs in order to prevent worsening of the​ client's condition. Oliguria and changes in mental status are signs of​ late, or​ cold, septic shock.

Which pulmonary manifestation can be caused by systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? A. Edema B. Fibrosis C. Embolism D. Hypertension

D. Hypertension SIRS and MODS affect the respiratory system and lead to pulmonary hypertension. Pulmonary edema is caused by fluid accumulation in the air spaces. Pulmonary fibrosis is a respiratory disorder caused by scars in the lung tissues or inhalation of airborne toxins. A pulmonary embolism is caused by blood clots or blockage in the pulmonary arteries.

Pericardial Tamponade S/S

Muffled Heart Sounds Decreased BP Narrowing pulse pressure Poor cardiac contractility

What is SIRS criteria (Systemic Inflammatory Response Syndrome)?

Must meet 2/4 of the criteria Temp > 38 or < 36 Pulse > 90 Resp > 20 WBC > 12,000 or < 4000 Altered Mental Status

Cardiogenic shock treatment

Nitroglycerin - used to manage chest pain by causing vasodilation (opening up blood vessels for oxygenation) Ionotropic Drugs Dobutamine - improve cardiac output Dopamine , epinephrine - used to increase BP Diuretics - for fluid in the lungs.

What is a distinctive stage of the Progressive stage of shock?

Patients are hypotensive

3 Types of obstructive shock

Pericardial Tamponade PE Tension Pneumothorax

What electrolyte is given to people taking diuretics?

Potassium

What is the purpose of cultures?

Right drug for the right bug

A patient is on IV Norepinephrine for treatment of septic shock. Which statement is FALSE about this medication? A. "The nurse should titrate this medication to maintain a MAP of 65 mmHg or greater." B. "This medication causes vasodilation and decreases systemic vascular resistance." C. "It is used when fluid replacement is not unsuccessful." D. "It is considered a vasopressor."

B. "This medication causes vasodilation and decreases systemic vascular resistance." The answer is B. This statement is FALSE because this medication causes vasoconstriction (not vasodilation) which INCREASES systemic vascular resistance.

PE S/S

Shortness of breath Clear lungs sounds (perfusion problem) Chest pain Cough Tachypnea Hypotension

What is the most common cause of neurogenic shock?

Spinal cord injury above level of T6

Where is the best place to assess for fluid overload?

The lungs Crackles and SOB

What are the 3 types of distributive shock?

Anaphylactic Septic Neurogenic

A patient with a fever is lethargic and has a blood pressure of 89/56. The patient's white blood cell count is elevated. The physician suspects the patient is developing septic shock. What other findings indicate this patient is in the "early" or "compensated" stage of septic shock? Select all that apply A. Urinary output of 60 mL over 4 hours B. Warm and flushed skin C. Bradypnea D. Tachycardia

B, D Oliguria (option A) is in the late stage or uncompensated when the kidneys are starting to fail

The nurse is caring for a client with infection. Which condition should the nurse consider as a precursor to septic​ shock? A.Multiple-organ dysfunction syndrome​ (MODS) B.Systemic inflammatory response syndrome​ (SIRS) C.Deep vein thrombosis​ (DVT) D.Disseminated intravascular coagulation​ (DIC)

B.Systemic inflammatory response syndrome​ (SIRS) SIRS, which is a precursor to​ sepsis, can occur as a complication of virtually any infection of any body tissue. In​ infection-related SIRS, the infection triggers a systemic inflammatory response that leads to a series of adverse​ events, including​ vasodilation, increased capillary​ permeability, and hypercoagulability. These lead to​ DIC, DVT,​ MODS, and ultimately death.

What happens to BP in the Compensatory stage of shock?

BP is normal

What are S/S of the Irreversible stage of shock?

BP remains low despite treatment Renal and liver dysfunction = metabolic acidosis Anaerobic metabolism contributes to high levels of lactic acid ATP reserves are destroyed Respiratory system dysfunction prevents adequate oxygenation and ventilation despite ventilatory support Multiple organ dysfunction syndrome leads to organ failure/death

What are S/S of the Compensatory stage of shock?

Blood pressure normal Heart rate > 100 Tachypnea Cold, clammy Urine output decreased Confusion and/or agitation

What is in the Sepsis protocol order set?

Blood, Wound, Sputum, Urine Cultures Antibiotics IV fluids (30 mg/kg) *Mostly LR Lactic Acid ] Vasopressors if needed

In ___________________ stage of shock, there is a certain "fight or flight" response where the body shunts blood from organs (skin, kidneys, GI tract) to the brain, heart, and lungs to ensure adequate blood supply to VITAL organs. A. Progressive B. Irreversible C. Compensatory D. End Stage

C. Compensatory

Who are the patient's that we need to watch for fluid overload?

Chronic Kidney Disease Heart Failure Young and Old Patient's

What are the 3 stages of shock?

Compensatory Progressive Irreversible

A client is progressing into the third stage of shock. The nurse will expect this client to demonstrate: Choose all that apply: a.) Intractable circulatory failure. b.) Neuroendocrine responses. c.) Demonstrating MODS. d.) Buildup of metabolic wastes. e.) Profound hypotension. f.) Increase in lactic acidosis.

c.) Demonstrating MODS. d.) Buildup of metabolic wastes.

Which collaborative intervention should the nurse implement to alleviate the worsening of hypotension in the client with​ sepsis? A.Oxygen B.Ventilation C.Antibiotics D.Intravenous​ (IV) fluids

D.Intravenous​ (IV) fluids IV fluids will help to raise the blood pressure in a client with sepsis. Oxygen helps with aciddashbase balance and breathing. Ventilation provides breathing support. Antibiotics eradicate the causative bacteria.

What is a potential complication of shock?

DIC

Tension pneumothorax S/S

Diminished or absent lung sounds on affected side Asymmetrical chest rise JVD (unless blood volume is low) Tracheal deviation

What is the goal of treating Compensatory shock?

Directed toward identifying the cause of the shock, correcting the underlying disorder so that shock does not progress, and supporting those physiologic processes that thus far have responded successfully to the threat

What is a cause of cardiogenic shock?

Heart is damaged and unable to supply sufficient blood to the body MI, Heart Failure, Cardiomyopathies.

Background for a PE

History of a DVT Birth control pill use (estrogen) Long travel Smoking

Cardiogenic Shock S/S

Hypotension, Rapid pulse and weak Decreased urine output Cool and clammy skin

MODS S/S

Hypotension, tachycardia, tachypnea, hypothermia, and hyperthermia

Where do most PE's start?

In the leg (DVT)

What type of fluids would someone need while in hypovolemic shock?

Isotonic (0.9% NS, LR)

Neurogenic Shock S/S

Low blood pressure Spinal cord injury about T6 Warm Dry Skin Bradycardia

What happens to a patient's BP in the Progressive stage of shock?

Mechanisms that regular BP can no longer compensate and the MAP falls below normal limits

What is the pathophysiology of the Irreversible stage of shock?

The point at which organ damage is so severe that the patient does not respond to treatment and cannot survive

S/S of DIC

Unexpected bleeding, hemorrhage Petechiae, purpura Hypoxia Hemolytic anemia Bleeding from IV sites Epistaxis

What happens to the body's circulation in the Compensatory stage of shock?

Vasoconstriction Increased heart rate Increased contractility

Nursing assessment of a client receiving serum albumin for treatment of shock should include: a.) Assessing lung sounds. b.) Monitoring glucose. c.) Monitoring the potassium level. d.) Monitoring hemoglobin and hematocrit.

a.) Assessing lung sounds. Rationale: Colloids pull fluid into vascular space. Circulatory overload could occur. The nurse should assess the client for symptoms of heart failure.

A client in shock is prescribed an inotropic drug to act on alpha and beta receptors. The nurse will most likely be administering: a.) Dopamine. b.) Dobutamine. c.) Pavulon. d.) Milrinone.

a.) Dopamine.

A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98 F (36 C), heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40 mmHg. The healthcare provider suspects which type of shock? a.) Hypovolemic b.) Cardiogenic c.) Neurogenic d.) Distributive

a.) Hypovolemic

Which type of fluid is most appropriate for volume replacement for a patient with non-hemorrhagic hypovolemic shock? a.) Lactated Ringers (LR) b.) 10% Dextrose in Water (D 10 W) c.) One-half Normal Saline (1/2% NS) d.) Packed Red Blood Cells (PRBC)

a.) Lactated Ringers (LR)

The client in shock is prescribed an infusion of lactated Ringer's solution. The nurse recognizes that the function of this fluid in the treatment of shock is to: a.) Replace fluid, and promote urine output. b.) Draw water into cells. c.) Draw water from cells to blood vessels. d.) Maintain vascular volume.

a.) Replace fluid, and promote urine output

The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patient's a.) urine output is 40 ml over the last hour. b.) hemoglobin is within normal limits. c.) CVP has decreased. d.) mean arterial pressure (MAP) is 65 mm Hg.

a.) urine output is 40 ml over the last hour. Rationale: Assessment of end-organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level is not useful in determining whether fluid administration has been effective unless the patient is bleeding and receiving blood. A decrease in CVP indicates that more fluid is needed. The MAP is at the low normal range, but does not clearly indicate that tissue perfusion is adequate.

An intensive care nurse, is assessing a patient with suspected sepsis. Which predisposing factors would expect to be found in the patient with septic shock? a.) A 45 year old client with a history of renal insufficiency. b.) A client age 65, with a history of cancer who is recovering from an abdominal peritoneal resection. c.) A 27 year old with pyelonephritis responding to treatment with an antibiotic. d.) A 50 year old with community acquired tuberculosis.

b.) A client age 65, with a history of cancer who is recovering from an abdominal peritoneal resection.

A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first? a.) Insert two 14-gauge IV catheters. b.) Administer oxygen at 100% per non-rebreather mask. c.) Place the patient on continuous cardiac monitor. d.) Draw blood to type and crossmatch for transfusions.

b.) Administer oxygen at 100% per non-rebreather mask. Rationale: The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented.

Dobutamine (Dobutrex) is used to treat a client experiencing cardiogenic shock. Nursing intervention includes: a.) Monitoring for fluid overload. b.) Monitoring for cardiac dysrhythmias c.) Monitoring respiratory status. d.) Monitoring for hypotension.

b.) Monitoring for cardiac dysrhythmias. Rationale: Dobutamine is beneficial in cases where shock is caused by heart failure. The drug increases contractility, and has the potential to cause dysrhythmias.

The client experiences shock following a spinal cord injury. This type of shock is classified as: a.) Hypovolemic. b.) Neurogenic. c.) Cardiogenic. d.) Anaphylactic.

b.) Neurogenic.

A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a.) check the blood pressure. b.) obtain an oxygen saturation c.) attach a cardiac monitor. d.) check level of consciousness.

b.) obtain an oxygen saturation. Rationale: The initial actions of the nurse are focused on the ABCs, and assessing the airway and ventilation is necessary. The other assessments should be accomplished as rapidly as possible after the oxygen saturation is determined and addressed.

While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding a.) cold, mottled extremities. b.) restlessness and apprehension. c.) a heart rate of 120 and cool, clammy skin. d.) systolic BP less than 90 mm Hg.

b.) restlessness and apprehension. Rationale: Restlessness and apprehension are typical during the compensatory stage of shock. Cold, mottled extremities, cool and clammy skin, and a systolic BP less than 90 are associated with the progressive and refractory stages.

A 4.5 kg infant is admitted to the pediatric intensive care unit after 33 days of watery diarrhea. The infant is diagnosed with severe dehydration. The infant's skin is mottled and turgor is poor. Capillary refill is delayed, and there is an absence of tears with crying. Which intervention should be the priority action by the healthcare provider? a.) Calculate the mean arterial pressure b.) Draw blood for a complete blood count c.) Establish vascular access d.) Take a complete set of vital signs

c.) Establish vascular access Rationale:Vascular access should be established quickly in order to replace lost volume before shock progresses.

The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? a.) Antibiotics to treat the underlying infection. b.) Corticosteroids to reduce inflammation. c.) IV fluids to increase intravascular volume. d.) Vasopressors to increase blood pressure.

c.) IV fluids to increase intravascular volume. Rationale:Circulation and perfusion are addressed first so IV fluids will be started immediately. After blood cultures are obtained, broad-spectrum antibiotics should be administered without delay. Vasopressors are administered if the patient is not responding to the fluid challenge. Corticosteroids may be considered to address the inflammatory-induced vasodilation and capillary leakage.

A patient who has pericarditis related to radiation therapy, becomes dyspneic, and has a rapid, weak pulse. Heart sounds are muffled, and a 12 mmHg drop in blood pressure is noted on inspiration. The healthcare provider's interventions are aimed at preventing which type of shock? a.) Distributive b.) Neurogenic c.) Obstructive d.) Cardiogenic

c.) Obstructive Rationale: Obstructive shock can be caused by anything that impedes the heart's ability to contract and pump blood around the body, as with cardiac tamponade.

Which of the following assessment findings is an early indication of hypovolemic shock? a.) Diminished bowel sounds b.) Increased urinary output c.) Tachycardia d.) Hypertension

c.) Tachycardia Rationale: Tachycardia is an early symptom as the body compensates for a declining blood pressure the heart rate increases to circulate the blood faster to prevent tissue hypoxia.

Multiple organ dysfunction syndrome (MODS) develops in severe sepsis as a result of systemic inflammatory response syndrome (SIRS), disseminated intravascular coagulation and damage to the endothelium. Which of the following statements best describes the management of MODS? a.) The use of proton pump inhibitors and H2 agents to increase the pH of the stomach inhibit the development of stress ulcers, an ileus and malabsorption issues. b.) Maintaining ventilator settings that ensure a tidal volume of at least 6 mL/kg of body weight will keep the lungs from being injured by endothelial damage. c.) There is no specific therapies for MODS other than supportive care and the early recognition of dysfunctional organ(s). d.) Much of the organ damage that occurs with MODS in the setting of severe sepsis is associated with pre-existing conditions.

c.) There is no specific therapies for MODS other than supportive care and the early recognition of dysfunctional organ(s).

Sepsis is the most common cause of disseminated intravascular coagulation (DIC). All of the following statements concerning this life threatening complications are true except: a.) The rapidity of onset is determined by the intensity of the trigger and is related to the condition of the patient's liver, bone marrow and endothelium. b.) In the early phase, the patient may demonstrate manifestations of thrombosis and micro emboli. c.) Though a coagulopathy is present, excessive blood loss rarely results in hemorrhagic shock. d.) The most critical intervention for DIC is the early identification and treatment of the underlying disorder.

c.) Though a coagulopathy is present, excessive blood loss rarely results in hemorrhagic shock.

A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of a.) cool, clammy skin. b.) shortness of breath. c.) heart rate of 48 beats/min) d.) BP of 82/40 mm Hg.

c.) heart rate of 48 beats/min Rationale: The normal sympathetic response to shock/hypotension is an increase in heart rate. The presence of bradycardia suggests unopposed parasympathetic function, as occurs in neurogenic shock. The other symptoms are consistent with hypovolemic shock.

A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of a.) nitroglycerine b.) dobutamine c.) norepinephrine d.) sodium nitroprusside

c.) norepinephrine Rationale:When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Dobutamine will increase stroke volume, but it would also further decrease SVR. Nitroprusside is an arterial vasodilator and would further decrease SVR.

A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is a.) activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries. b.) stimulation of cardiac -adrenergic receptors, leading to increased cardiac output. c.) release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. d.) movement of interstitial fluid to the intravascular space, increasing renal blood flow.

c.) release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. Rationale: The release of aldosterone and ADH lead to the decrease in urine output by increasing the reabsorption of sodium and water in the renal tubules. SNS stimulation leads to renal artery vasoconstriction. -Receptor stimulation does increase cardiac output, but this would improve urine output. During shock, fluid leaks from the intravascular space into the interstitial space.

When compensatory mechanisms for hypovolemic shock are activated, the nurse would expect which two patient findings to normalize? a.) Intensity of peripheral pulses and body temperature. b.) Peripheral pulses and heart rate (HR). c.) Metabolic alkalosis and oxygen saturation. d.) Cardiac output (CO) and blood pressure (BP).

d.) Cardiac output (CO) and blood pressure (BP).

The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2, blood pressure is 90/50 mmHg, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take? a.) Slow the IV infusion rate b.) Administer dopamine c.) No interventions are needed at this time d.) Increase the IV infusion rate

d.) Increase the IV infusion rate

What type of shock is sepsis?

distributive shock

What is the first line drug for anaphylactic shock?

epinephrine IM

What is the most common type of shock?

hypovolemic shock

Tension pneumothorax Treatment

needle decompression and chest tube insertion The lung should re-expand

Treatment for pericardial tamponade?

pericardiocentesis

Cardiogenic shock is a ______________ problem.

pump

What is an early treatment for neurogenic shock?

vasopressors