Critical Care Ch 12 Shock

After receiving handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2)96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the last hour. Given this report, the nurse obtains orders for treatment that include which of the following? Select all that apply. a. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is <5 mm Hg. b. Increase supplemental oxygen therapy to 60% Venturi mask. c. Administer 40 mg furosemide (Lasix) intravenously as needed if the urine output is less than 30 mL/hr. d. Administer acetaminophen (Tylenol) 650 mg suppository per rectum as needed to treat temperature >101° F.

a. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is <5 mm Hg. d. Administer acetaminophen (Tylenol) 650 mg suppository per rectum as needed to treat temperature >101° F. Fluid volume resuscitation is a priority in patients with severe sepsis to maintain circulating blood volume and end organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen. Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated. The fever may need to be treated.

The nurse is caring for a patient admitted with severe sepsis. The physician orders include the administration of large volumes of isotonic saline solution as part of early goal-directed therapy. Which of the following best represents a therapeutic end point for goal-directed fluid therapy? a. Central venous pressure >8 mm Hg b. Heart rate >60 beats/min c. Mean arterial pressure >50 mm Hg d. Serum lactate level >6 mEq/L

a. Central venous pressure >8 mm Hg Early goal-directed therapy includes administration of IV fluids to keep the central venous pressure at 8 mm Hg or greater. Additional therapeutic end points include a heart rate at less than 110 beats/min and a mean arterial blood pressure at 65 mm Hg or greater. Serum lactate levels are elevated in sepsis; target levels should be <2.2 mEq/L.

The nurse educator is presenting a lecture on crystalloid fluid replacement therapy in shock states. Which statement by a nurse indicates that the teaching has been effective? a. Lactated Ringer's should not be infused if lactic acidosis is severe. b. 3 mL of crystalloid is administered to replace 10 mL of blood loss. c. Administration of colloids is preferred over crystalloids. d. Solutions of 0.45% normal saline are used routinely in shock.

a. Lactated Ringer's should not be infused if lactic acidosis is severe. LR solutions contain lactate, which the liver converts to bicarbonate. If liver function is normal, this will counteract lactic acidosis. However, LR should not be infused if lactic acidosis is severe. To replace every 1 mL of blood loss, 3 mL of crystalloid is administered. There is no evidence to support colloid administration being more beneficial than crystalloid administration in shock states. Hypotonic solutions such as 0.45% normal saline are not administered in shock states as these solutions rapidly leave the intravascular space, causing interstitial and intracellular edema.

The nurse is caring for a patient in shock. Which is a priority action by the nurse? a. Ensure adequate cellular hydration. b. Maintain adequate tissue perfusion. c. Prevent third-spacing of fluids. d. Support mechanical ventilation.

b. Maintain adequate tissue perfusion. Care of a patient in shock is directed toward correcting or reversing the altered circulatory component and reversing tissue hypoxia. Restoring circulating intravascular volume is the priority in improving tissue perfusion and oxygen delivery.

Which hemodynamic values should the nurse anticipate in a patient who is in the initial stages of septic shock state? a. Low heart rate; high blood pressure b. High heart rate; low right atrial pressure c. High PAOP; low cardiac output d. High SVR; normal blood pressure

b.High heart rate; low right atrial pressure In septic shock, inflammatory mediators damage the endothelial cells that line blood vessels, producing profound vasodilation and increased capillary permeability. Initially this results in a high heart rate, hypotension, and low SVR, and subsequently in low right atrial pressure.

The nurse admits a patient to the coronary care unit in cardiogenic shock. The nurse anticipates administering which medication in an effort to improve cardiac output by increasing the contractile force of the heart? a. Dopamine (Intropin) b. Phenylephrine (Neo-Synephrine) c. Dobutamine (Dobutrex) d. Nitroprusside (Nipride)

c. Dobutamine (Dobutrex) Positive inotropic agents such as dobutamine (Dobutrex) are given to increase the contractile force of the heart in cardiogenic shock. Dopamine (Intropin) is used primarily in low cardiac output states to restore vascular tone and increase blood pressure, but not in cardiogenic shock. Neo-Synephrine would be contraindicated in cardiogenic shock, as the vasoconstriction it produces would exacerbate cardiac ischemia. Nitroprusside (Nipride), used for preload and after load reduction, can improve cardiac performance in shock states by its reduction of systemic vascular resistance.

The nurse is caring for a patient with hypovolemia. Which large volume crystalloid solution should the nurse anticipate the health care provider to order? Select all that apply. a. 5% dextrose b. Albumin c. Lactated Ringer's (LR) d. Normal saline

c. Lactated Ringer's (LR) d. Normal saline LR solution and 0.9% normal saline are isotonic solutions that are commonly infused to treat hypovolemia. Solutions of 5% dextrose in water and 0.45% normal saline are hypotonic and are not used for fluid resuscitation. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema. A systematic review of 30 randomized controlled trials found no benefit in giving colloids (e.g., albumin) over crystalloids and recommended against the administration of colloids in most patient populations.

The nurse is caring for a patient who has blood pooling in the capillary bed and arterial blood pressure too low to support perfusion of vital organs. Which symptoms should the nurse assess for? a. Acute respiratory distress syndrome (ARDS) b. Disseminated intravascular coagulation (DIC) c. Increased cerebral perfusion pressure d. Multisystem organ failure and/or dysfunction

d. Multisystem organ failure and/or dysfunction Maldistribution of blood flow refers to the uneven distribution of flow to various organs and pooling of blood in the capillary beds. This impaired blood flow leads to impaired tissue perfusion and a decreased oxygen supply to the cells, all of which contribute to multiple organ failure. Damage to the type II pneumocytes leads to ARDS. Consumption of clotting factors may cause DIC. Low arterial blood pressure leads to decreased cerebral perfusion pressure.

The nurse is caring for a patient in neurogenic shock. Which should the nurse assess for? a. Tachycardia b. Hypertension c. Hypoventilation d. Vasodilation

d. Vasodilation In neurogenic shock, there is an interruption of impulse transmission or blockage of sympathetic outflow, resulting in vasodilation, inhibition of baroreceptor response, and impaired thermoregulation. Interruption of sympathetic nerve innervation would result in bradycardia. Interruption of sympathetic nerve innervation would result in hypotension. Hypoventilation is not a physiological mechanism.

The nurse is caring for a patient with possible distributive shock. Which should the nurse look for on assessment? a. Blood loss and actual hypovolemia. b. Decreased cardiac output. c. Third-spacing of fluids into peritoneal space. d. Vasodilation and relative hypovolemia.

d. Vasodilation and relative hypovolemia. Distributive shock presents with widespread vasodilation and decreased systemic vascular resistance that result in a relative hypovolemia. Blood loss is associated with hypovolemic shock. Decreased cardiac output is a primary cause of cardiogenic shock. Primary internal sequestration of fluids that causes internal fluid loss is associated with hypovolemic shock.