Term 4 EAQ Ch 37 Care of patients with shock

Administer 500 mL intravenous colloid bolus over 30 minutes A resuscitation bundle is used for the treatment of sepsis. While several interventions are part of a bundle, the nurse prioritizes the interventions based on the assessment of the client. Establishing perfusion is a priority with this client, thus starting the IV fluid bolus should be the first priority in care. Obtaining blood cultures, especially prior to administering antibiotics, is also important along with placing an indwelling urinary catheter to monitor the client's response to fluid therapy. A cooling blanket is not part of the bundle and may not be an appropriate intervention.

A client admitted with pneumonia and possible sepsis has a blood pressure of 90/46 mm Hg, heart rate of 128 beats/min, respiratory rate of 28/min, temperature of 38.5° C, no urine output for 4 hours, and central venous pressure of 2 mm Hg. The client arouses to name but is not oriented. Which order does the nurse implement first? 1 Obtain blood cultures. 2 Insert an indwelling urinary catheter. 3 Apply a cooling blanket. 4 Administer 500 mL intravenous colloid bolus over 30 minutes

Obtains the client's description of the chest discomfort A description of the chest discomfort must be obtained first, before further action can be taken. Pain medication and oxygen therapy are not the first priority in this situation; an assessment is needed first. Remaining calm and staying with the client are important, but are not matters of highest priority.

A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? 1 Administers oxygen therapy 2 Obtains the client's description of the chest discomfort 3 Provides pain relief medication 4 Remains calm and stays with the client

"We are doing everything appropriate for your condition, and I am monitoring you closely." The client in shock should be reassured that appropriate treatment is being carried out. Reflecting the client's anxiety back to him or her at this time is not therapeutic, as the client has asked for information. Providing the physiologic rationale for the client's anxiety is not appropriate at this time, nor does it speak to the client's concerns. There is no indication that the client is losing blood, but in a shock state the blood pressure is low; however, this response does not answer the client's concern as to what will happen.

A client experiencing shock asks the nurse, "What is going to happen to me?" Which response is best for the nurse to convey? 1 "You seem quite anxious. What do you think will happen?" 2 "We are doing everything appropriate for your condition, and I am monitoring you closely." 3 "The shock condition is taking the blood away from your brain. That is why you are anxious." 4 "Your blood pressure is quite low, which happens when you lose a lot of blood.

Feeling of impending doom As shock progresses, tissue perfusion to the brain continues to be reduced, causing a sense of anxiety or that "something bad" is about to happen. Oliguria or anuria occurs in the nonprogressive stage rather than polyuria. A lack of perfusion to the skin results in cool, moist skin rather than warm skin. Due to decreased tissue perfusion, buildup of lactic or metabolic acid occurs; the arterial blood gases reflect metabolic acidosis at this time.

A client in the progressive or intermediate stage of hypovolemic shock will exhibit which manifestation? 1 Polyuria 2 Metabolic alkalosis 3 Moist, warm skin 4 Feeling of impending doom

Ask family members to stay with the client. Remain with the client. Reassure the client that everything is being done for him or her. Having a familiar person nearby may provide comfort to the client. The nurse should remain with the client who is demonstrating physiologic deterioration. Offering genuine reassurance supports the client who is anxious. The health care provider should be notified, and increasing IV and oxygen may be needed, but these actions do not support the client's psychosocial integrity.

A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? Select all that apply. 1 Ask family members to stay with the client. 2 Call the health care provider. 3 Increase IV and oxygen rates. 4 Remain with the client. 5 Reassure the client that everything is being done for him or her.

Wash the dishes in the dishwasher. Dishes should be washed in hot, soapy water or in a dishwasher to thoroughly cleanse them; there is no need to use disposable tableware. Water that has been standing longer than 15 minutes should be discarded; however, bottled water is not necessary. The client may be in the same room as, as well as touch, the family pet (with the exception of changing a litterbox—this should not be done); however, the client should wash the hands thoroughly with an antimicrobial soap after touching pets.

A client is receiving antineoplastic chemotherapy. Which measure does the nurse teach that will help prevent infection and sepsis? 1 Drink only bottled water. 2 Use disposable dishes. 3 Wash the dishes in the dishwasher. 4 Avoid being in the same room as the family pet

Naproxen (Naprosyn) Naproxen is a nonsteroidal antiinflammatory agent that poses a risk for bleeding. Captopril (for hypertension), furosemide (for heart failure), or omeprazole (prevents gastroesophageal reflux disease and gastrointestinal bleeding from stomach ulcers) do not pose risks for bleeding. Anticoagulants, aspirin, and NSAIDs should be questioned.

A client is scheduled for thoracotomy later today. Which entry noted on the medication reconciliation record poses a risk for perioperative hemorrhagic shock and causes the nurse to contact the provider immediately? 1 Captopril (Catapres) 2 Furosemide (Lasix) 3 Naproxen (Naprosyn) 4 Omeprazole (Prilosec

Multiple organ dysfunction syndrome (MODS) Shock that progresses to the refractory stage causes irreversible cell death and tissue damage, releasing toxic metabolites that cause organs to fail. Once the sequence of multiple organs begins to fail because of the buildup of metabolites and toxins, the client's condition is termed multiple organ dysfunction syndrome. MODS involves the presence of altered organ functions in two or more organ systems. In this client, four organs have "failed' with a fifth (the liver) imminent.

A client who underwent a radical colon resection for metastatic cancer has developed septic shock and remains neurologically unresponsive, unable to breathe without mechanical ventilator support, requires dialysis for renal function, is not tolerating tube feedings, and is beginning to show signs of hepatic failure. What condition does the nurse suspect the client has developed based on these clinical manifestations? 1 Late stage of septic shock 2 Multiple organ dysfunction syndrome (MODS) 3 Intercerebral hemorrhage 4 Adverse reaction to sedating agents

On prednisone (Deltasone) therapy for rheumatoid arthritis Clients who do not have intact immune systems are at highest risk for sepsis and septic shock including those who have had organ transplants, with HIV/AIDS, kidney or liver disease, the very old, and those with invasive lines and procedures. Prednisone, taken for autoimmune diseases such as rheumatoid arthritis, suppresses the immune system and prevents further damage to the joints. While obesity, surgery, and hospitalization for MI pose some risk for infection and sepsis, the use of corticosteroid medications is an actual risk for the development of sepsis and septic shock.

A client with which problem or condition is at highest risk for septic shock? 1 Obese 2 Post-uncomplicated appendectomy 3 Post-myocardial infarction 4 On prednisone (Deltasone) therapy for rheumatoid arthritis

Blood pressure Norepinephrine (Levophed) is a vasoconstrictor drug used in hypovolemic shock to increase perfusion and oxygenation. These drugs constrict the blood vessels and increase venous return. Urine production will not increase until blood pressure rises and perfuses the kidneys. Norepinephrine does not have any effect on a client's level of consciousness or blood glucose levels.

After norepinephrine (Levophed) is administered to a client with hypovolemic shock, which assessment factor is used to verify the effectiveness of the treatment? 1 Blood pressure 2 Urinary output 3 Level of consciousness 4 Blood glucose

Modified Trendelenburg Maintaining the client flat with the feet elevated (modified Trendelenburg) improves venous return and perfusion to the brain. Sims' position refers to lying on the left side with the top leg flexed, typically used for enemas and GI procedures. The lithotomy position is used for gynecologic examination and procedures. The head of bed elevated at 30 degrees describes a semi-Fowler's position used to prevent aspiration.

The nurse in the postanesthesia care unit is caring for a postoperative client whose heart rate suddenly increases to 122 beats/min and the blood pressure drops to 84/48 mm Hg. Which position does the nurse use to improve the client's blood pressure and organ perfusion? 1 Sims' 2 Lithotomy 3 Modified Trendelenburg 4 Head of bed 30 degrees, legs flat

Blood pressure 170/96 mm Hg Signs of excess vasoconstricting drugs include headache, hypertension, and decreased renal perfusion manifested by oliguria. While vasoconstricting medications and the shock state may cause tachycardia (heart rate greater than 100 beats/min), this client's heart rate is within normal range. Vasoconstricting drugs do not affect the respiratory rate; shock itself causes an increased respiratory rate in an effort to deliver more oxygen to the tissues.

The nurse is administering continuous intravenous infusion of norepinephrine (Levophed) to a client in shock. Which finding causes the nurse to decrease the rate of infusion? 1 Blood pressure 170/96 mm Hg 2 Respiratory rate 22 breaths/min 3 Urine output of 70 mL/hr 4 Heart rate 98 beats/min

"I won't need help anymore to care for my cats and change the litter box." Protecting clients from infection and sepsis at home through education is an important nursing function. Clients need to understand the importance of good handwashing, balanced diet, rest and exercise, as well as staying away from large crowds and other sources of infection like dirt and animal litter boxes.

The nurse is instructing a client about infection prevention strategies to reduce the risk of sepsis. Which client response suggests further self-management teaching is needed prior to discharge? 1 "I will avoid crowds and large gatherings until I am better." 2 "I'll make sure the dishwasher is set on hot to wash and dry my dishes." 3 "I won't need help anymore to care for my cats and change the litter box." 4 "I guess I won't work in the garden for a few more months.

Initiate 0.9% saline solution infusion Isotonic solutions such as Ringer's lactate or normal saline may be used as volume expanders in hypovolemic shock. Red blood cells must be given with 0.9% saline to prevent clotting during infusion. While the volume of the blood in the bag is approximately 250 mL, it may vary; however, this is not essential to validate before initiating the transfusion. The nurse monitors for dark urine when an ABO transfusion reaction is suspected. Vital signs, especially a baseline temperature, are indicated prior to transfusion; a low blood pressure during shock states is expected.

The nurse is preparing to administer a transfusion of packed red blood cells to a client with hemorrhagic shock. Which action is essential before initiating the transfusion? 1 Check the volume of blood in the bag. 2 Monitor the client for dark-colored urine. 3 Measure the client's blood pressure. 4 Initiate 0.9% saline solution infusion

Starches Colloid solutions are mainly composed of larger molecules like starches and proteins. These molecules help to maintain the oncotic pressure of the intravascular fluid and prevent fluid loss. Salts, sugars, and minerals are components of crystalloids, not colloids.

What is the component of colloid solutions that is helpful in managing hypovolemic shock through the intravenous route? 1 Salts 2 Sugars 3 Starches 4 Minerals

Narrow pulse pressure Postural hypotension Decreased cardiac output In hypovolemic shock, total body fluid is reduced; therefore, the difference between systolic and diastolic pressure (pulse pressure) is decreased. Blood pressure in the body drops also causing postural hypotension. The decrease in blood volume causes a simultaneous decrease in cardiac output. There is a compensatory increase in pulse rate to restore cardiac output in shock. Peripheral pulses become weak in hypovolemic shock.

Which are cardiovascular manifestations of hypovolemic shock? Select all that apply. 1 Narrow pulse pressure 2 Postural hypotension 3 Decreased pulse rate 4 Decreased cardiac output 5 Bounding peripheral pulses

Hemophilia Malnutrition Diuretic therapy Specific risk factors for hypovolemic shock include hemophilia, malnutrition, and diuretic therapy. Hypovolemia can be caused by impaired clotting in clients with hemophilia and malnourishment. Excessive diuresis due to diuretic therapy can also cause reduction in blood volume. Clients with spinal cord injury have distributive shock in which the total blood volume is not reduced but fluid shifts from the central vascular space. In clients with myocardial infarction, cardiac function is impaired which causes cardiogenic shock.

Which are risk factors for hypovolemic shock? Select all that apply. 1 Hemophilia 2 Malnutrition 3 Diuretic therapy 4 Spinal cord injury 5 Myocardial infarction

Serum lactate level decreases to 3.3 from 4.2 mmol/L No single laboratory test confirms the presence of sepsis, although one of the hallmarks of sepsis is an increasing serum lactate level. The return of abnormal labs to normal and stabilization of the client's presentation are used to evaluate treatment effectiveness. An increase in serum creatinine clearance does not indicate the effectiveness of treatment for sepsis. A decrease in serum glucose would be expected, not an increase. The slight decrease in white blood cells may not signify the effectiveness of antibiotic therapy.

Which assessment data suggest that antibiotic therapy may be effective in the treatment of a client with sepsis? 1 Serum creatinine increases from 1.2 to 1.8 mg/dL 2 White blood cell count decreases from 15,000 to 13,500/mm3 3 Serum lactate level decreases to 3.3 from 4.2 mmol/L 4 Serum glucose increases from 112 to 146 mg/dL

Unrestrained in motor vehicle accident Surgical intensive care client 85-year-old with gastrointestinal virus The client who is unrestrained in a motor vehicle accident is prone to multiple trauma and bleeding. Surgical clients are at high risk for hypovolemic shock owing to fluid loss and hemorrhage. Older adult clients are prone to shock; a gastrointestinal virus results in fluid losses. Unless injured or working in excessive heat, the construction worker and the athlete are not at risk for hypovolemic shock; they may be at risk for dehydration.

Which clients are at immediate risk for hypovolemic shock? Select all that apply. 1 Unrestrained in motor vehicle accident 2 Construction worker 3 Athlete 4 Surgical intensive care client 5 85-year-old with gastrointestinal virus

Client who overdosed on bumetamide (Bumex) Hypovolemic shock results from decreased circulating blood volume; bumetamide, a potent loop diuretic, decreases blood volume. A myocardial infarction may lead to cardiogenic shock or heart failure, with resulting fluid volume excess rather than hypovolemia. Kidney failure results in increased blood volume (hypervolemia) as the failing kidney is unable to produce urine. BPH obstructs the outflow of urine into the bladder as prostatic tissue enlarges; blood volume is not reduced.

Which of these individuals may be at highest risk for hypovolemic shock? 1 Client with acute kidney failure 2 Client with myocardial infarction 3 Client who overdosed on bumetamide (Bumex) 4 Client with benign prostatic hyperplasia (BPH

Pancreas Myocardial depressant factor is secreted from the ischemic pancreas and is responsible for causing profound damage to the heart in MODS. The liver, brain, and kidneys, in addition to the heart, are severely damaged but they do not release myocardial depressant factors.

Which organ is responsible for releasing myocardial depressant factor that leads to heart damage as a result of multiple organ dysfunction syndrome (MODS)? 1 Liver 2 Brain 3 Kidney 4 Pancreas

Dizziness Dizziness or lightheadedness may indicate hypotension and possible shock. Thirst, rather than anorexia, is a symptom of hypovolemic shock. Mild pain may occur after a surgical procedure, but increases in pain should be reported because this may indicate further bleeding with tissue compression. Obvious bleeding, rather than serous drainage, should be reported to the provider.

Which sign of hypovolemic shock does the nurse instruct the client who had an outpatient surgical procedure to report immediately? 1 Dizziness 2 Lack of appetite 3 Mild pain at the site of the procedure 4 1-cm clear yellow drainage from incision

Sodium nitroprusside (Nitropress Sodium nitroprusside dilates the coronary arteries, enhancing myocardial perfusion and improving hypovolemic shock. Milrinone and dobutamine are both inotropic agents that act by increasing the force of heart muscle contractions. Phenylephrine is vasoconstrictor, not a vasodilator.

Which vasodilator drug is often helpful in managing hypovolemic shock? 1 Milrinone (Primacor) 2 Dobutamine (Dobutrex) 3 Phenylephrine HCl 4 Sodium nitroprusside (Nitropress

Urine output increase from 5 to 35 mL/hr During shock, the kidneys and baroreceptors sense an ongoing decrease in mean arterial pressure and trigger the release of renin, antidiuretic hormone (ADH), aldosterone, epinephrine, and norepinephrine to start kidney compensation, which is very sensitive to changes in fluid volume. Renin, secreted by the kidney, causes decreased urine output. ADH increases water reabsorption in the kidney, further reducing urine output. These actions compensate for shock by attempting to prevent further fluid loss. This response is so sensitive that urine output is a very good indicator of fluid resuscitation adequacy. If the therapy is not effective, urine output does not increase. An increase in respiratory rate, increase in heart rate, and a decrease in core body temperature are not expected findings of successful fluid resuscitation.

Which vital sign change in a client with hypovolemic shock indicates to the nurse that the fluid resuscitation therapy is effective? 1 Urine output increase from 5 to 35 mL/hr 2 Heart rate increase from 62 to 76 beats/min 3 Respiratory rate increase from 22 to 26 breaths/min 4 Core body temperature decrease from 98.8° F (37.1° C) to 98.2° F (36.8° C)

The sympathetic nervous system is triggered by any type of shock and initiates the stress response Most manifestations of shock are similar regardless of what starts the process or which tissues are affected first. These common manifestations result from physiologic adjustments (compensatory mechanisms) in an attempt to ensure continued oxygenation of vital organs. These adjustment actions are performed by the sympathetic nervous system triggering the stress response and activating the endocrine and cardiovascular systems.

Why are the clinical signs and symptoms of most types of shock the same, regardless of what condition caused the shock to occur? 1 An increase in heart rate is always the first physiologic adjustment the body makes to all stress states. 2 Because blood loss occurs with all types of shock, the most common first clinical symptom is hypotension. 3 Every type of shock interferes with cellular oxygenation in the same sequence. 4 The sympathetic nervous system is triggered by any type of shock and initiates the stress response

Encourage fluids by mouth. The client is most likely hypovolemic from 24 hours of vomiting and diarrhea. The client needs IV fluids to replace intravascular fluid volume. Taking fluids by mouth will not be effective in quickly restoring the client's blood volume while nausea and diarrhea persist. The other responses are appropriate orders.

A client reports vomiting and diarrhea for 24 hours and feeling lightheaded and weak. The client has not been able to keep fluids down for the past 12 hours, and the client's skin is cool and moist to touch. Which provider order for this client does the nurse clarify? 1 Encourage fluids by mouth. 2 Oxygen by nasal cannula to maintain oxygen saturation >95%. 3 Call for decrease in mean arterial pressure >10 mm Hg. 4 Call for urine output <30 mL/hour.

Blood pressure 90/60 and mean arterial pressure (MAP) 70 Dopamine improves blood flow by increasing peripheral resistance, which increases blood pressure—a positive response. Urine output less than 30 mL/hr or 0.5 mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the kidney and is a negative consequence of shock, not a positive response. Although a blood glucose of 245 is an abnormal finding, dopamine increases blood pressure and myocardial contractility, not glucose levels.

A client with septic shock has been started on dopamine (Intropin) at 12 mcg/kg/min. Which response indicates a positive outcome? 1 Hourly urine output 10-12 mL/hr 2 Blood pressure 90/60 and mean arterial pressure (MAP) 70 3 Blood glucose 245 4 Serum creatinine 3.6 mg/dL

Measure hourly urine output. Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment; the nurse evaluates the results. Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed.

A postoperative client is admitted to the intensive care unit with hypovolemic shock. Which nursing action does the nurse delegate to an experienced nursing assistant? 1 Obtain vital signs every 15 minutes. 2 Measure hourly urine output. 3 Check oxygen saturation. 4 Assess level of alertness

22 Pulse pressure is the difference between the systolic and diastolic pressures. 80 (systolic) - 58 (diastolic) = 22 (pulse pressure)

The client in shock has the following vital signs: T 99.8° F, P 132, R 32, and BP 80/58. Calculate the pulse pressure. Record as a whole number.

International Normalized Ratio (INR) 7.9 Prolonged INR indicates that blood takes longer than normal to clot; this client is at risk for bleeding. PTT of 12.5 and a platelet value of 170,000/mm3 are both normal and pose no risk for bleeding. Although a hemoglobin of 8.2 g/dL is low, the client could have severe iron deficiency or could have received medication affecting the bone marrow.

The client with which lab result is at risk for hemorrhagic shock? 1 International Normalized Ratio (INR) 7.9 2 Partial thromboplastin time (PTT) 12.5 seconds 3 Platelets 170,000/mm3 4 Hemoglobin 8.2 g/dL

Ensure that blood cultures were drawn. Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. Antibiotics are not administered until after all cultures are taken. A signed consent is not needed for medication administration. Monitoring the client's vital signs is important, but the antibiotic must be administered within 1-3 hours; timing is essential.

The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first? 1 Administer the antibiotic immediately. 2 Ensure that blood cultures were drawn. 3 Obtain signature for informed consent. 4 Take the client's vital signs

Elevated d-dimer levels Plasma d-dimer levels rise during DIC as multiple fibrin clots break down. A reduction in red blood cells, hemoglobin, and hematocrit, rather than an increase (polycythemia), occur in DIC. Thrombocytopenia (a reduction of platelets) rather than thrombocytosis (an increased number of platelets) occurs along with reduced fibrinogen levels as these components are incorporated into the multiple small clots that develop in DIC.

When caring for a client with septic shock who has disseminated intravascular coagulation (DIC), the nurse anticipates which finding? 1 Polycythemia 2 Thrombocytosis 3 Elevated d-dimer levels 4 Elevated fibrinogen levels

Decreased segmented neutrophil count A decreased segmented neutrophil count is indicative of late sepsis. Serum lactate is increased in late sepsis. Monocytosis is usually seen in diseases such as tuberculosis and Rocky Mountain spotted fever. An increased platelet count does not indicate sepsis; late in sepsis, platelets may decrease due to consumptive coagulopathy.

Which laboratory result is seen in late sepsis? 1 Decreased serum lactate 2 Decreased segmented neutrophil count 3 Increased numbers of monocytes 4 Increased platelet count

Hydrocortisone (Solu-cortef) Fludrocortisone (Florinef) During severe sepsis, the body's immune response can become self-destructive if not controlled. Drugs that provide adrenal support during severe sepsis are IV hydrocortisone and oral fludrocortisone. IV penicillin, levofloxacin, and vancomycin are antibiotics that help to kill the bacteria causing the sepsis.

Which medications are often used to provide adrenal support for the client with severe sepsis? Select all that apply. 1 Penicillin 2 Levofloxacin (Levoquin) 3 Hydrocortisone (Solu-cortef) 4 Fludrocortisone (Florinef) 5 Vancomycin (Vancocin)

Client with severe ascites Fluid shifts from vascular to intraabdominal may cause decreased circulating blood volume and poor tissue perfusion. Volume depletion is only one reason why a person may require a blood transfusion; anemia is another. The client receiving a blood transfusion does not have as high a risk as the client with severe ascites. Myocardial infarction results in tissue necrosis in the heart muscle; no blood or fluid losses occur. Owing to excess ADH secretion, the client with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.

Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? 1 Client receiving a blood transfusion 2 Client with severe ascites 3 Client with myocardial infarction 4 Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion

Oliguria Compensatory mechanisms in the nonprogressive stage of shock result from increased sympathetic nervous stimulation and release of antidiuretic hormone (ADH); vasoconstriction and water retention to maintain fluid volume occur with oliguria as a result. Problems such as reduction in mean arterial pressure and tissue perfusion, hypoxemia, and acid-base imbalances occur in the compensatory phase, but compensatory mechanisms keep the pulse oximetry reading within 2-5% of baseline. Blood loss may occur in hemorrhagic or hypovolemic shock; this question addresses the overall shock state.

Which term best describes the symptoms that occur in the nonprogressive (compensatory) phase of shock? 1 Hypoxemia 2 Oliguria 3 Decreased tissue perfusion 4 Blood loss related to hemorrhage