Ch. 28 Shock and multiorgan dysfunction syndrome (MODS)

The nurse is reviewing a list of assigned patients. Which patient is at most risk for septic shock?

A 66-year-old woman with a gram-negative bacterial infection Septic shock is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Incidence of severe sepsis in older adults in the United States is 26.2 cases per 1,000, compared to 3 cases per 1,000 in the younger population. Predisposing factors in older adults include comorbidities and frequent and prolonged hospitalizations resulting from decreased immunity. Aging is an independent factor that increases the risk of death in patients with sepsis, increasing morbidity and mortality in older adult patients and associated with rapid progression of sepsis to severe sepsis and septic shock. The patient with traumatic head injury is at risk for neurogenic shock. The patient with myocardial infarction (MI) is at risk for cardiogenic shock. And the patient with tension pneumothorax is at risk for obstructive shock.

The nurse notes that a patient is prescribed plasma expanders to treat shock. Which other type of shock is this patient at risk for developing?

Anaphylactic shock Plasma expanders must be used with caution, because they may induce serious allergic reactions, including anaphylactic shock. Plasma expanders would not be considered for treatment of cardiogenic shock, distributive shock, or obstructive shock.

A patient is experiencing hypovolemic shock. Which substance is secreted by the kidneys that causes vasoconstriction, increasing peripheral vascular resistance and blood pressure?

Angiotensin II The kidney responds to the decrease in perfusion pressure by releasing renin I, the activation of the renin-angiotensin-aldosterone system (RAAS). Angiotensin II from this system stimulates aldosterone release from the adrenal cortex. Angiotensin II also causes vasoconstriction, increasing peripheral vascular resistance and blood pressure. Aldosterone increases the renal absorption of sodium, followed by water, leading to an increase in circulating intravascular fluid volume. Epinephrine is secreted from the adrenal medulla and sympathetic nerve endings to increase systemic vascular resistance and heart rate while decreasing vagal outflow. Antidiuretic hormone is released by the posterior pituitary gland to increase the permeability of the collecting tubules of the nephron to water, leading to water reabsorption.

The nurse uses the quick Sequential Organ Failure Assessment (qSOFA) to assess a patient demonstrating signs of septic shock. For which reason did the nurse use this assessment tool?

Assesses quickly and repeatedly The quick Sequential Organ Failure Assessment (qSOFA) is useful because it does not require laboratory tests and can be assessed quickly and repeatedly. The Sequential Organ Failure Assessment (SOFA) requires laboratory tests, places the patient into four potential categories of risk based on relative organ function, and evaluates the different systems believed to be involved in the pathogenic process of sepsis or influenced by the resultant organ failure.

Which medical conditions could lead to a patient developing distributive shock?

Barbiturate overdose Distributive shock results in impaired distribution of blood flow due to extensive vasodilation and loss of vascular tone. Septic shock, anaphylactic shock, and neurogenic shock are the different types of distributive shock. Causes of neurogenic shock include spinal injury, brain injury, barbiturate overdose, hypoglycemia, medications, severe pain, spinal anesthesia, and vasomotor center depression. Myocardial infarction (MI) could lead to cardiogenic shock. Pulmonary embolism could lead to obstructive shock. Postpartum hemorrhage could lead to hypovolemic shock.

A patient is receiving diagnostic tests to identify the location of a spinal cord injury. Which area should the nurse expect to cause the most severe neurogenic shock?

Cervical Neurogenic shock tends to occur more commonly in spinal cord injuries above T6, secondary to the disruption of the sympathetic outflow from T1-L2 and to unopposed vagal (parasympathetic) tone. The higher the spinal cord injury, the more severe is the neurogenic shock and the more extensive is neurologic peripheral manifestation. The cervical spine is the highest area of the spinal column; therefore, injuries in this area would be more severe. The thoracic spine, lumbar spine, and sacral spine are below the cervical spine in the spinal column; therefore, the effects of neurogenic shock will be less severe.

The nurse is caring for a patient in shock. Which body system failure could lead to multiple organ dysfunction syndrome in this patient?

Circulatory Shock is a failure of the circulatory system to maintain adequate tissue perfusion to support cellular metabolic needs. The resulting hypoxia and decreased oxygen delivery to cells shift the metabolism to anaerobic metabolism with increased production of lactic acid. Although shock is a failure of the circulatory system, as shock progresses, the respiratory, nervous, and endocrine systems will all begin to fail as well.

The nurse notes that a patient with septic shock has a drop in urine output. Which health problem should the nurse suspect is occurring with this patient?

Developing renal failure For patients with septic shock, urine output is a good indicator of renal perfusion and should be measured with an indwelling catheter. The onset of oliguria or anuria or a rising creatinine level may signal impending renal failure. Decreased cardiac output is associated with cardiogenic shock. A hypertensive crisis is not associated with any form of shock. Depleted intravascular volume is associated with hypovolemic shock.

A patient experiences hypoglycemia and there is evidence of a barbiturate overdose. Which type of shock is this patient at risk for developing?

Distributive shock Septic shock, anaphylactic shock, and neurogenic shock are the different types of distributive shock. Neurogenic shock is due to spinal injuries, brain injuries, barbiturate overdose, hypoglycemia, medications, severe pain, spinal anesthesia, and vasomotor center depression. Obstructive shock is primarily due to pulmonary embolism that results in right ventricular failure. Cardiogenic shock is primarily caused by myocardial infarction (MI). Hypovolemic shock occurs due to excessive loss of whole blood, as in trauma or internal bleeding, or loss of other body fluids from diarrhea, vomiting, diaphoresis, severe burns, or diuresis.

A patient is demonstrating signs of anaphylactic shock. Which medication should the nurse expect to be prescribed for this patient?

Epinephrine Epinephrine is vital to the management and treatment of anaphylaxis and should be given immediately. It can relieve the bronchospasm and reduce the vasodilation that is responsible for the pathogenesis of anaphylaxis. Diuretics, antibiotics, and beta blockers are not indicated in the treatment of anaphylaxis.

The nurse is caring for a patient in cardiogenic shock related to an acute myocardial infarction (MI). Which clinical manifestation should the nurse indentify that indicates worsening heart function?

Generalized cyanosis with cool skin and mottled extremities Clinical manifestations of cardiogenic shock include general cyanotic with cool skin and mottled extremities (as a result of poor tissue perfusion). The patient has rapid and faint, not slow and strong peripheral pulses that may be irregular if the patient has cardiac arrhythmia. The pulse pressure is low and tachycardic, not high and brachycardic. The heart sounds are low and distant, not loud and distant. The patient may also have peripheral edema and jugular distension as a result of right-sided heart failure and may have crackles in the lungs (associated with left-sided heart failure).

A patient receives burns to over 30% of total body surface area. If this patient loses 15% of total body fluid volume, for which type of shock should the nurse plan care for this patient?

Hypovolemic Hypovolemic shock, which is also called hemorrhagic shock, is a life-threatening condition that occurs when a patient loses more than 15% of the body's fluids. Fluid depletion is not characteristic of distributive shock, cardiogenic shock, or obstructive shock.

A female patient develops abnormal hemorrhaging approximately 12 hours after giving birth. Which type of shock is this patient at risk for developing?

Hypovolemic Postpartum hemorrhage, which can lead to hypovolemic shock, is a major cause of maternal death around the world. Cardiogenic shock is normally caused by a myocardial infarction (MI). Distributive shock is generally caused by an injury, infection, or an allergic response. Obstructive shock is generally caused by a pulmonary embolism.

A patient experiences dizziness when changing from a seated to a standing position. Which type of shock is this patient at risk of developing?

Hypovolemic The body's response to hypovolemia includes initial compensatory mechanisms to address the fall in perfusion pressure and to maintain cardiac output. Depleted intravascular volume is also suggested by orthostatic or postural hypotension. Depleted intravascular volume will put a patient at risk for developing hypovolemic shock. Depleted intravascular volume is not associated with cardiogenic shock, distributive shock, or obstructive shock.

The nurse is caring for a patient in cardiogenic shock. Which is the first and most important step when treating this patient?

Identify the cause. The first and most important step in treating a patient in cardiogenic shock is to identify the cause so that treatment can be initiated to address it. Maintaining a patent airway, listening for lung sounds, and obtaining blood pressure are all nursing interventions to be performed when treating a patient in cardiogenic shock, but identifying the cause is the first priority.

The nurse is caring for a patient with a myocardial infarction (MI). Which physiological response to cardiogenic shock after a myocardial infarction (MI) should the nurse expect?

Increased stroke volume Clinical manifestations of shock result from the body's attempt to maintain perfusion to the heart and brain. Cardiac output (CO) is dependent on stroke volume (SV) and heart rate (HR) as demonstrated by the following equation: (CO = SV x HR). With decreased cardiac output, the initial physiological response is to increase stroke volume, heart rate, or both via the sympathetic nervous system (SNS). Stimulation of the sympathetic nervous system also causes vasoconstriction of blood vessels to the skin and abdominal area, and vasodilation to the heart and skeletal muscle. During the compensatory phase of shock, the renin-angiotensin-aldosterone system (RAAS) responds as blood flow to the kidneys decreases. The RAAS causes reabsorption of water and sodium from the kidney tubules to increase circulating blood volume; therefore, decreasing urine output.

Which clinical finding is commonly associated with patients in cardiogenic shock?

Mottled extremities A patient with cardiogenic shock will have cyanotic cool skin and mottled extremities as a result of poor tissue perfusion. Bronchoconstriction is associated with anaphylactic shock. Increased respiratory rate is associated with septic shock. Bradycardia is associated with neurogenic shock.

A patient with a normal body fluid volume is experiencing systolic hypotension, bradycardia, and hypothermia. Which type of shock should the nurse suspect is occurring in this patient?

Neurogenic Manifestations of neurogenic shock include systolic hypotension, bradycardia, and hypothermia. Neurogenic shock needs to be differentiated from spinal shock and hypovolemic shock. Spinal shock is response of the spinal cord to a spinal cord injury. It involves temporary loss of reflex function below the level of injury and resolves gradually over 4-6 weeks. Tachycardia occurs in hypovolemic shock. Septic shock is characterized by altered mentation, hypotension, and increased respiratory rate. Anaphylactic shock is characterized by bronchoconstriction. Cardiogenic shock is characterized by a decrease in cardiac output.

Which statement explains the pathophysiology of sepsis?

Nonhomeostatic host response to infection Septic shock is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. This definition highlights the nonhomeostatic host response to infection as the core pathophysiology of sepsis, the potential lethality it presents, and the need for urgent recognition and treatment. Earlier definitions of sepsis and septic shock were based on the assumption that it was an excessive inflammatory response of the body to infection. Current research and international consensus recognize that sepsis involves early activation of both pro-inflammatory and anti-inflammatory responses, along with major modifications in nonimmunologic pathways.

A patient develops hypotension, tachycardia, and changes in level of consciousness. Which health problem is most likely causing this patient to develop obstructive shock?

Pulmonary embolism Obstructive shock is diagnosed when acute circulatory failure occurs as a result of obstruction of blood supply to central vessels of systems of pulmonary circulation, causing clinical symptoms of shock. Among the causes of obstructive shock is a pulmonary embolism that results in right ventricular failure. Myocardial infarction (MI) would lead to cardiogenic shock. Cerebral infarction could lead to neurogenic shock. Pulmonary hypertension is not a condition that would lead to shock.

Which aspect of an anaphylactic reaction results in laryngospasm and bronchoconstriction?

Release of histamine, leukotrienes, and bradykinins The release of histamine, leukotrienes, and other mediators cause diffuse non-vascular smooth muscle contraction, resulting in bronchoconstriction, respiratory difficulty, vomiting, or diarrhea. The interaction of antigen with IgE on basophils and mast cells triggers this release. Exposure to the antigen triggers IgE antibody production by the plasma cells.

The nurse is caring for a critically ill patient. Which assessment finding should the nurse identify that indicates the development of multiple organ dysfunction syndrome (MODS)?

Respiratory rate of 25 breaths/min One finding associated with the development of multiple organ dysfunction is a respiratory rate greater than 22 breaths/min in a patient who is critically ill. A respiratory rate of 18 breaths/min, a systolic blood pressure of 110 mmHg, and a score of 10 on the Glasgow Coma Scale are normal findings and not indicative of septic shock.

A patient is being treated in the intensive care unit for multiple organ dysfunction syndrome (MODS). Which type of shock is this patient most likely experiencing?

Septic shock Multiple organ dysfunction syndrome (MODS) is most commonly caused by septic shock due to failure of homeostasis or dysregulation of organ function. Distributive shock, hypovolemic shock, and obstructive shock are far less likely to deteriorate into MODS.

A patient is being treated for anaphylactic shock. Which statement best explains the reason for a patient to develop this type of shock?

Subsequent exposures to the allergen Anaphylaxis is an acute, life-threatening, IgE-mediated allergic reaction that occurs on re-exposure in individuals who are sensitive to an allergen or antigen. Anaphylactic shock occurs when the antibody IgE produced by plasma cells binds to membrane receptors on the mast cells and basophils. Subsequent exposure to the antigen results in the binding of the antigen to the antibody on the mast cells, leading to the release of histamine and other substances of anaphylaxis. Medication intolerance may produce some symptoms, but only an allergy to medications can lead to anaphylactic shock. Untreated skin lesions generally lead to worsening of the lesions, but generally do not lead to anaphylaxis. Initial exposure to an unknown allergen would typically not lead to anaphylactic shock, although re-exposure to that allergen could potentially lead to anaphylactic shock.

For which reason should a patient with multiple organ dysfunction syndrome (MODS) be prescribed a protein-rich diet?

Support hypermetabolic needs Metabolic support is highly important for critically ill patients, and protein-rich nutrition has been shown to support the hypermetabolic needs of such patients, resulting in a better outcome. Fluid resuscitation is accomplished by the use of volume expanders, inotropic agents, vasoactive agents, and mechanical ventilation. Infections are addressed with targeted antibiotics. A protein-rich diet will not help to preserve brain function.

Which process causes an increase in vascular permeability after the release of histamine and other substances of anaphylaxis?

Vasodilation Anaphylactic shock occurs when the antibody IgE produced by plasma cells binds to membrane receptors on the mast cells and basophils. Subsequent exposure to the antigen results in the binding of the antigen to the antibody on the mast cells, leading to the release of histamine and other substances of anaphylaxis (leukotrienes and bradykinin). These mediators cause increased vascular permeability through vasodilation as well as bronchoconstriction. Vasoconstriction, bronchodilation, and hyperperfusion are not processes associated with anaphylaxis.

A patient is diagnosed with neurogenic shock caused by a spinal cord injury. What medication should be given to stabilize blood pressure?

Vasopressor Neurogenic shock is treated with careful fluid replenishment and vasopressors to stabilize blood pressure. Atropine is given to increase the heart rate. Corticosteroids are given to decrease spinal cord edema. Crystalloids are given for fluid replenishment.

Which type of nutritional support maintains the hypermetabolic needs of a patient with multiple organ dysfunction syndrome (MODS)?

protein rich Metabolic support is highly important for critically ill patients, and protein-rich nutrition has been shown to support the hypermetabolic needs of such patients, resulting in a better outcome. Adjusting the diet to low sodium, fiber-rich, or gluten-free will have not benefit for a patient with multiple organ dysfunction syndrome (MODS).