Chapter 67 - Shock & Hemodynamic Monitoring
A patient is brought to the emergency department (ED) after multiple bee stings. On assessment, the nurse finds that the patient has edema on the lips and tongue as well as chest pain, dizziness, wheezing, and stridor. What type of shock should the nurse document this as? Septic shock Neurogenic shock Anaphylactic shock Obstructive shock
Anaphylactic shock Explanation (pg 1636) Anaphylactic shock is an acute, life-threatening hypersensitivity reaction to a sensitizing substance that, in this case, is insect venom. The reaction quickly causes massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. As capillary permeability increases, fluid leaks from the vascular space into the interstitial space. The consequences of these pathophysiologic processes include edema on the lips and tongue, chest pain, wheezing, and stridor. Sepsis is a systemic inflammatory response to a documented or suspected infection. Neurogenic shock is a hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic (T5) vertebra or above. Obstructive shock develops when a physical obstruction to blood flow occurs with decreased cardiac output.
When planning for home care of a patient who has just recovered from shock, what appropriate measures should the nurse follow? Select all that apply. Allow the patient to resume work. Arrange for transitional care units. Admit to rehabilitation center. Refer to home health care agencies. Assure rapid recovery with self-care.
Arrange for transitional care units. Admit to rehabilitation center. Refer to home health care agencies. Explanation (pg 1648) Patients recovering from shock often require diverse services after discharge. Such services aim at maintaining continuity of care and monitoring the patient for indications of complications. These can include admission to transitional care units, rehabilitation centers, or home health care agencies. The patient may not be able to resume work, because recovery takes time. Self-care is not sufficient, because specialized monitoring and care may be needed.
A patient's intraaortic balloon pump (IABP) has shut off. What finding should the nurse identify as being the reason the pump automatically turned off? Occlusion of the renal arteries Blood backed up into the catheter Head of the bed at a 60 degree angle Obstruction in a lower extremity vessel
Blood backed up into the catheter Explanation (pg 1612) If the balloon develops a leak, the pump will automatically stop. Signs of a leak include blood backing up into the catheter. Occlusion of the renal arteries will cause a reduction in urine output but will not cause the IABP to automatically turn off. Elevating the head of the bed greater than 45 degrees could cause arterial trauma but will not cause the IABP to automatically turn off. An obstruction in a lower extremity vessel could be caused by a thromboembolism, but this condition will not cause the IABP to automatically turn off.
A patient with an invasive blood pressure measuring device has a reading that is significantly higher than the one measured two hours ago. What should the nurse do first? Flush the line Raise the head of the bed Check transducer placement Perform a dynamic response test
Check transducer placement Explanation (pg 1605) The nurse should check the placement of the transducer, because transducers placed lower than the phlebostatic axis will produce falsely high readings. The line does not need to be flushed. Raising the head of the bed will not correct the falsely elevated reading. Performing a dynamic response test may be necessary if moving the transducer continues to produce a falsely elevated reading.
The nurse identifies that pulmonary artery catheterization is contraindicated for patients with a history of what? Select all that apply. Coagulopathy Cardiogenic shock Fulminant myocarditis Endocardial pacemaker Mechanical tricuspid valve
Coagulopathy Endocardial pacemaker Mechanical tricuspid valve Explanation (pg 1607) Pulmonary artery catheterization helps to monitor and manage the care of patients who are at high risk for hemodynamic compromise. Pulmonary artery catheterization may cause trauma in the blood vessels and worsen symptoms of coagulopathy. Pulmonary artery catheterization increases the risk of trauma in patients with mechanical tricuspid valves and endocardial pacemakers; therefore, it is contraindicated in the patient with coagulopathy, mechanical tricuspid valve, and transvenous pacemaker. Pulmonary artery catheterization is performed in patients with cardiogenic shock and fulminant myocarditis to detect the risk of heart failure.
The nurse is preparing a patient for arterial pressure-based cardiac output (APCO) measuring. What patient criteria must be met before this measuring device can be used to determine the patient's stroke volume variation (SVV)? Spontaneous respirations and placement of an arterial line Continuous cardiac monitoring and application of oxygen via face mask Controlled mechanical ventilation and fixed respiratory rate and tidal volume Nasal intubation and positive end expiration pressure setting on the ventilator
Controlled mechanical ventilation and fixed respiratory rate and tidal volume Explanation (pg 1607) Stroke volume variation (SVV) is the variation of the arterial pulsation caused by heart-lung interaction. It is a sensitive indicator of preload responsiveness when used on select patients. SVV is used only for patients on controlled mechanical ventilation with a fixed respiratory rate and a fixed tidal volume of 8 mL/kg. SVV is not used on patients who have spontaneous respirations even though an arterial line does need to be in place. The patient may have continuous cardiac monitoring but the patient needs to be intubated rather than provided with oxygen via a face mask. The patient needs to be intubated; however, nasal intubation is not identified as a requirement. It is not identified that the patient needs to be receiving positive end expiration pressure through the ventilator.
When examining a patient with cardiogenic shock, which signs of peripheral hypoperfusion does the nurse expect? Select all that apply. Cyanosis Cold skin Weak pulse Bradycardia Hypertension
Cyanosis Cold skin Weak pulse Explanation (pg 1633) Cyanosis, cold skin, and a weak pulse are the signs of peripheral hypoperfusion in cardiogenic shock. Bradycardia and hypertension are not seen in cardiogenic shock; instead, tachycardia and low blood pressure are noted
What laboratory finding fits with a medical diagnosis of cardiogenic shock? Decreased liver enzymes Increased white blood cells Decreased red blood cells, hemoglobin, and hematocrit Increased blood urea nitrogen (BUN) and serum creatinine levels
Increased blood urea nitrogen (BUN) and serum creatinine levels Explanation The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, while white blood cell levels do not typically increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia.
What laboratory finding correlates with a medical diagnosis of cardiogenic shock? Decreased liver enzymes Increased white blood cells Decreased red blood cells, hemoglobin, and hematocrit Increased blood urea nitrogen (BUN) and serum creatinine levels
Increased blood urea nitrogen (BUN) and serum creatinine levels Explanation (pg 1633) The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, whereas white blood cell levels typically do not increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia.
A patient with meningitis and seizures has a pulmonary arterial catheter inserted. The most recent central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurement is 48%. What should the nurse realize is the reason for this patient's measurement? Increased oxygen supply Decreased cardiac output Increased oxygen demand Decreased oxygen demand
Increased oxygen demand Explanation (pg 1609) A central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurement of 48% is low. Metabolic demand exceeds oxygen supply in conditions that increase muscle movement and metabolic rate, including physiologic states such as seizures. Central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurements greater than 80% are caused by increased oxygen supply. Even though a low central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurement is associated with a decreased cardiac output, the patient is not experiencing a health problem such as cardiogenic shock caused by left ventricular pump failure that supports decreased cardiac output as the reason for the low measurement. Central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurements greater than 80% are caused by decreased oxygen demand.
Vasopressin has been prescribed for a patient in septic shock. What nursing interventions are important for this patient? Select all that apply. Infuse at low doses. Do not titrate. Do not use with inotropic agents. Use in vasopressor-refractory patients. Do not use in patients with coronary artery disease.
Infuse at low doses. Do not titrate. Use in vasopressor-refractory patients. Explanation (pg 1644) Vasopressin should be infused in low doses without titrating it, because titration can cause dose-related adverse effects. Vasopressin is usually used for patients who are vasopressor-refractory, for replacing the stores of physiologic vasopressin that are often depleted in septic shock. Inotropic agents can be added with vasopressin to increase tissue perfusion. Vasopressin can be given to patients suffering from coronary artery diseases, but it should be used with caution.
When caring for a patient in acute septic shock, what should the nurse anticipate? Infusing large amounts of IV fluids Administering osmotic and/or loop diuretics Administering IV diphenhydramine (Benadryl) Assisting with insertion of a ventricular assist device (VAD)
Infusing large amounts of IV fluids Explanation Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. VADs are useful for cardiogenic shock not septic shock. Diphenhydramine (Benadryl) may be used for anaphylactic shock but would not be helpful with septic shock.
Which health problem is a contraindication for a Swan-Ganz catheter? Systolic heart failure Mechanical tricuspid valve Cardiogenic shock Acute myocardial infarction
Mechanical tricuspid valve Explanation (pg 1607) A contraindication for a pulmonary artery catheter is a mechanical tricuspid valve. Systolic heart failure, cardiogenic shock, and myocardial infarction are all indications for the use of a pulmonary artery catheter.
A patient in cardiogenic shock is being treated with vasopressor therapy (phenylephrine). Which interventions should the nurse perform to detect tissue perfusion compromise? Select all that apply. Monitor urine output. Monitor level of consciousness. Monitor serum lactate levels. Check musculoskeletal reflexes. Auscultate breath sounds.
Monitor urine output. Monitor level of consciousness. Monitor serum lactate levels. Explanation (pg 1643) Vasopressor drugs can cause severe peripheral vasoconstriction and an increase in systemic vascular resistance (SVR), further compromising the tissue perfusion. The increased SVR increases the workload of the heart and can harm a patient in cardiogenic shock by causing further myocardial damage. End-organ perfusion should be monitored by monitoring the urine output and level of consciousness. Serum lactate levels also indicate adequate tissue perfusion. Decreased tissue perfusion in shock leads to an elevation of lactate. Musculoskeletal reflexes and breath sounds are not affected by tissue perfusion.
A patient in neurogenic shock is receiving phenylephrine. Which nursing actions are appropriate when caring for this patient? Monitoring for signs of dyspnea and pulmonary edema Monitoring for signs of hypokalemia and hyperglycemia Monitoring for signs of reflex bradycardia and restlessness Monitoring for signs of hypothyroidism and Addison's disease
Monitoring for signs of reflex bradycardia and restlessness Explanation (pg 1643) Phenylephrine is α-adrenergic agonist and may cause bradycardia and restlessness due to central nervous system stimulation. β-adrenergic agonists such as epinephrine cause dyspnea and pulmonary edema. Phenylephrine does not increase the elimination of potassium levels or blood glucose levels. Therefore, the patient does not have risk of hypokalemia and hyperglycemia. Phenylephrine does not impair thyroid and adrenal gland functioning. Therefore, the nurse will not monitor for the signs of hypothyroidism and Addison's disease.
The nurse is monitoring a patient with neurogenic shock caused by a spinal cord injury. The nurse finds that the PaO2 is below 60 mm Hg. How should the nurse interpret this finding? Select all that apply. Need for higher oxygen concentrations Need for a different mode of oxygen administration Need for advanced pulmonary management Need for intubation and mechanical ventilation Need for more aggressive fluid therapy
Need for higher oxygen concentrations Need for a different mode of oxygen administration Need for intubation and mechanical ventilation Explanation (pg 1641) Arterial blood gases (ABGs) provide definitive information on ventilation and oxygenation status and acid-base balance. A PaO2 below 60 mm Hg indicates hypoxemia and the need for higher oxygen concentrations or for a different mode of oxygen administration. A rising PaCO2 with a persistently low pH and PaO2 indicate the need for advanced pulmonary management. Most patients in shock are intubated and on mechanical ventilation. Low PaO2 implies the need for ventilation and not fluid resuscitation.
Which type of shock can be treated by minimizing spinal cord trauma with stabilization? Septic shock Neurogenic shock Anaphylactic shock Hypovolemic shock
Neurogenic shock Explanation (pg 1645) Neurogenic shock is caused by severe injury to the spinal cord and results in loss of sympathetic stimulation of blood vessels. Apart from administering vasoconstrictor agents, minimizing the spinal cord trauma with stabilization is a supporting therapy for neurogenic shock. Septic shock occurs in response to a systemic infection. Obtaining the cultures before starting antibiotics is appropriate care for septic shock. A life-threatening allergic reaction to a sensitizing substance causes anaphylactic shock. Avoiding exposure to allergens is supportive therapy for anaphylactic shock. Excessive loss of intravascular fluid causes hypovolemic shock. Besides restoring fluid volume, correcting the cause of fluid loss is supportive therapy.
The nurse suspects that a patient with an arterial invasive device has a catheter-related infection. What action should the nurse take? Conduct a dynamic response test Administer an antipyretic as prescribed Apply warm soaks to the catheter insertion site Notify the health care provider and prepare for reinsertion
Notify the health care provider and prepare for reinsertion Explanation (pg 1606) If infection is suspected, the catheter should be removed and all equipment replaced. Because the nurse does not insert or remove an arterial line, the nurse should notify the health care provider about the infection and then prepare for reinsertion by obtaining and preparing new equipment. A dynamic response test is not indicated for a suspected catheter-related infection. There is no evidence that the patient has a temperature elevation so an antipyretic is not indicated at this time. Warm soaks may be applicable after the infected catheter is removed.
A patient with an arterial invasive device has a capillary refill of five seconds. What should the nurse do first? Elevate the limb on a pillow. Soak the hand in warm water. Notify the health care provider. Perform passive range of motion to the limb.
Notify the health care provider. Explanation (pg 1606) Normal capillary refill is three seconds. A refill time of five seconds indicates compromised arterial flow, which is an emergency. The health care provider should be contacted immediately. Elevating the limb on a pillow may further compromise arterial blood flow. Soaking the hand in warm water will not improve arterial blood flow. Passive range of motion to the limb with the arterial line would be contraindicated, because this could cause the catheter to dislodge
A patient is being prepared for insertion of an arterial measuring device. What should be done before the catheter is inserted into the patient's radial artery? Locate the phlebostatic axis Prepare a heparinized flush bag Occlude the radial and ulnar arteries Set an intravenous pump to deliver 15 mL/hr
Occlude the radial and ulnar arteries Explanation (pg 1606) Before inserting a line into the radial artery, an Allen test should be performed to confirm that ulnar circulation to the hand is adequate. In this test, pressure is applied to the radial and ulnar arteries simultaneously. The patient opens and closes the hand repeatedly until the hand blanches. When the pressure on the ulnar artery is released, the hand should return to a pink color within six seconds. If pinkness does not return within six seconds the ulnar artery is inadequate to maintain blood flow to the extremity and the radial artery should not be used for arterial line insertion. The phlebostatic axis is used to zero the arterial line, which would be done much later. Because of the risk of heparin-induced thrombocytopenia (HIT), heparinized saline should not be routinely used for the flush solution. The flush bag should be set to deliver 3 to 6 mL/hr.
A patient is placed under the care of a nurse. The nurse notices that his ScvO2/SvO2has increased. What does this usually indicate? Select all that apply. Stroke Improved perfusion Occlusion of the catheter Decreased metabolic rate Increased arterial oxygen saturation
Occlusion of the catheter Decreased metabolic rate Increased arterial oxygen saturation Explanation (pg 1609) Increased ScvO2/SvO2 is clinically significant and may indicate a clinical improvement in terms of increased arterial oxygen saturation, improved perfusion, and decreased metabolic rate. It may also indicate problems like sepsis. In sepsis, oxygen is not extracted properly at the tissue level, resulting in increased ScvO2/SvO2. Stroke or occlusion of the catheter does not increase the ScvO2/SvO2.
A patient is admitted to the ICU and is on assisted ventilation. Which is the best indicator of inadequate alveolar oxygenation? PETCO2 SpO2 PaCO2 ScvO2 or SvO2
PaCO2 Explanation (pg 1615) PaCO2 is the best indicator of alveolar hyperventilation or hypoventilation. Continuous PETCO2 monitoring can assess the patency of the airway and the presence of breathing. Continuous oxygen saturation (SpO2) provides objective data regarding tissue oxygenation. Central venous pressure (CVP) or pulmonary artery (PA) catheters with ScvO2 or SvO2 capability provide an indirect indication of the patient's tissue oxygenation status.
The nurse is caring for a patient who is experiencing cardiogenic shock as a result of myocardial infarction. Which nursing assessment finding is most concerning? PaO2 60 mm Hg Blood pressure 100/56 mm Hg Urine output 260 mL in eight hours Heart rate 96 beats/minute
PaO2 60 mm Hg Explanation (pg 1633) A PaO2 of 60 is below the normal 80 to 100 mm Hg. The patient experiencing cardiogenic shock will exhibit hypotension and tachycardia, and therefore a blood pressure of 100/56 mm Hg and heart rate of 96 would not apply. A
The nurse is caring for a 72-year-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be of most concern to the nurse? Restlessness, heart rate of 124 beats/minute, and hypoactive bowel sounds Mean arterial pressure of 54 mm Hg, increased jaundice, and cold, clammy skin PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites Agitation, respiratory rate of 32 breaths/minute, and serum creatinine level of 2.6 mg/dL
PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites Explanation Severe hypoxemia, lactic acidosis, and bleeding are clinical manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are clinical manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold/ clammy skin, agitation, tachypnea, and increased serum creatinine are clinical manifestations of the progressive stage of shock.
The nurse is concerned about a patient's stroke volume. What determines stroke volume? Preload, afterload, and contractility Cardiac output, heart rate, and body surface area Afterload, cardiac output, and mean arterial pressure Cardiac index, mean arterial pressure, and blood pressure
Preload, afterload, and contractility Explanation (pg 1603) Preload, afterload, and contractility determine stroke volume (SV). Cardiac output and heart rate are used to determine stroke volume; however, body surface area is used to determine cardiac index. Mean arterial pressure is used to determine afterload, not stroke volume. Cardiac index is a more precise measurement of the efficiency of the heart's pumping action; it is not used to determine stroke volume.
Impedance cardiography is not indicated even though a patient needs to be monitored after the removal of a pulmonary arterial catheter. Which clinical finding was used to make this decision? Presence of generalized edema Blood pressure 198/120 mm Hg Distant lung sounds in both bases Pulse deficit of 8 beats/minute
Presence of generalized edema Explanation (pg 1610) Impedance cardiography (ICG) is not recommended in patients who have generalized edema or third spacing because the excess volume interferes with accurate signals. This measuring approach is not contraindicated in cases of hypertension. This measuring approach is indicated for early signs of pulmonary dysfunction, which could be occurring with distant lung sounds in both bases. This measuring approach is indicated for early signs of cardiac dysfunction, which could be occurring with a pulse deficit of 8 beats per minute.
Following coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery to repair the leak. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient assessment is the most important for planning nursing care? Cardiac index (CI) 5 L/min/m2 Central venous pressure 8 mm Hg Mean arterial pressure (MAP) 86 mm Hg Pulmonary artery pressure (PAP) 28/14 mm Hg
Pulmonary artery pressure (PAP) 28/14 mm Hg Explanation Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be due to the MI. The CI, CVP, and MAP readings are normal.
Following coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery to repair the leak. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient assessment is the most important for planning nursing care? Cardiac index (CI) 5 L/min/m2 Central venous pressure (CVP) 8 mm Hg Mean arterial pressure (MAP) 86 mm Hg Pulmonary artery pressure (PAP) 28/14 mm Hg
Pulmonary artery pressure (PAP) 28/14 mm Hg Explanation (pg 1639) Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be caused by the MI. The CI, CVP, and MAP readings are normal.
To obtain an accurate central venous pressure reading with a central venous catheter, a nurse should place the patient in what position? Left side-lying Right side-lying Supine and horizontal Supine with head of bed elevated 45 degrees
Supine and horizontal Explanation (pg 1605) To obtain an accurate central venous pressure (CVP) reading, the nurse should ensure that the patient is supine and in horizontal position so the zero reference point at the level of the right atrium (also known as the phlebostatic axis) is level with the zero mark on the manometer. If a patient is unable to lie flat, the manometer should be positioned so the zero reference is at the level of the right atrium and the degree of head elevation noted so there is consistency across measurements. Right or left side-lying and supine positions with the head of the bed elevated 45 degrees are all incorrect for obtaining a CVP reading.
Which hemodynamic value should the nurse use to determine a patient's left ventricular afterload? Central venous pressure Pulmonary arterial pressure Systemic vascular resistance Peripheral vascular resistance
Systemic vascular resistance Explanation (pg 1604) Systemic vascular resistance is an index of left ventricular afterload. Central venous pressure is an index of preload. Pulmonary arterial pressure and peripheral vascular resistance are indices of right ventricular afterload.
A patient with a heart rate of 68 beats/minute (bmp) has a stroke volume (SV) of 100 mL/beat. What is this patient's cardiac output (CO)? Record your answer to the nearest tenth decimal point. ____________ L
Explanation (pg 1603) Cardiac output (CO) is calculated by multiplying stroke volume (SV) by the heart rate (HR). For this patient, the nurse should multiply 100 mL/beat x 68 = 6800 mL or 6.8 L. A normal cardiac output is between 4 and 8 L/min.
The nurse is monitoring a patient in ICU. Which ScvO2/SvO2reading is a cause of concern in the patient? 68% 54% 72% 78%
54% Explanation (pg 1609) Normal central venous oxygen saturation or ScvO2/SvO2 is 60% to 80%. It denotes normal oxygen supply and metabolic demand. Any reading out of the normal range can cause danger to the patient. More than 80% denotes increased oxygen supply and decreased oxygen demand. Less than 60% denotes decreased oxygen supply and increased demand.
The nurse is assisting in the care of several patients in the critical care unit. Which patient is at greatest risk for developing multiple organ dysfunction syndrome (MODS)? 22-year-old patient with systemic lupus erythematosus who is admitted with a pelvic fracture after a motor vehicle accident 48-year-old patient with lung cancer who is admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia 65-year-old patient with coronary artery disease, dyslipidemia, and primary hypertension who is admitted for unstable angina 82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection
82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection Explanation A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Individuals at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.
What is the purpose of hemodynamic monitoring? Assess heart function Monitor cerebral perfusion Determine metabolic activity Ensure adequate oxygenation
Assess heart function Explanation (pg 1602) The purpose of hemodynamic monitoring is to assess heart function, fluid balance, and the effects of fluids and drugs on cardiac output (CO). Hemodynamic monitoring is not conducted to monitor cerebral perfusion, determine metabolic activity, or to ensure adequate oxygenation.
After morning report the nurse becomes concerned that a patient receiving intraaortic balloon pump therapy (IABP) is experiencing a complication. What did the nurse assess to make this clinical determination? Cool dry skin Increased thirst +1 pedal edema Absent bowel sounds
Absent bowel sounds Explanation (pg 1611) Movement of the balloon can block the mesenteric arteries, which can result in reduced or absent bowel sounds. Cool, dry skin, increased thirst, and +1 pedal edema are not identified as complications of intraaortic balloon pump (IABP) therapy.
A 50-year-old woman with a suspected brain tumor is scheduled for a computed tomography (CT) scan with contrast media. The nurse notifies the physician that the patient reported an allergy to shellfish. Which response by the physician should the nurse question? Infuse IV diphenhydramine prior to the procedure. Administer lorazepam (Ativan) before the procedure. Complete the CT scan without the use of contrast media. Premedicate with hydrocortisone sodium succinate (Solu-Cortef).
Administer lorazepam (Ativan) before the procedure. Explanation An individual with an allergy to shellfish is at an increased risk to develop anaphylactic shock if contrast media is injected for a CT scan. To prevent anaphylactic shock, the nurse should always confirm the patient's allergies before diagnostic procedures (e.g., CT scan with contrast media). Appropriate interventions may include cancelling the procedure, completing the procedure without contrast media, or premedication with diphenhydramine or hydrocortisone. IV fluids may be given to promote renal clearance of the contrast media and prevent renal toxicity and acute kidney injury. The use of an antianxiety agent such as lorazepam would not be effective in preventing an allergic reaction to the contrast media.
A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? Insulin infusion IV administration of epinephrine Aggressive IV crystalloid fluid resuscitation Administration of nitrates and β-adrenergic blockers
Aggressive IV crystalloid fluid resuscitation Explanation Patients in septic shock require large amounts of crystalloid fluid replacement. Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be).
A patient's localized infection has progressed to the point where septic shock now is suspected. What medication is an appropriate treatment modality for this patient? Insulin infusion Intravenous (IV) administration of epinephrine Aggressive IV crystalloid fluid resuscitation Administration of nitrates and β-adrenergic blockers
Aggressive IV crystalloid fluid resuscitation Explanation (pg 1636) Patients in septic shock require large amounts of crystalloid fluid replacement. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be). Nitrates and β-adrenergic blockers are used most often in the treatment of patients in cardiogenic shock.
What is a manifestation of the irreversible stage of shock? Delirium Areflexia Restlessness Alterations in the level of consciousness
Areflexia Explanation (pg 1639_ Areflexia or loss of reflexes is a manifestation of the irreversible stage of shock. The progressive state of shock is associated with delirium. Restlessness and altered levels of consciousness indicate that the patient is in the compensatory stage of shock.
A patient with an implanted ventricular assist device (VAD) is being prepared for discharge. To ensure the patient's safety, what should the nurse make sure is completed prior to the patient leaving the hospital? Home care referral Diet and activity teaching Battery charger in the home Oxygen condenser delivered
Battery charger in the home Explanation (pg 1613) In some cases, patients with ventricular assist devices (VADs) may go home. Preparation for discharge is complex and requires in-depth teaching about the device and the need to have a battery charger in the home. A home care referral can be made after the patient is discharged. Diet and activity teaching should occur before the patient is discharged however this is not directly related to the safety and functioning of the device. There is no information to suggest that the patient needs or will be prescribed oxygen therapy at home.
It is determined that a patient with ventricular failure caused by a myocardial infarction needs a ventricular assist device (VAD). What should the nurse do to prepare the patient for this procedure? Begin preoperative preparation Explain that this is an outpatient procedure Determine which laboratory will insert the device Schedule the procedure to occur within a few weeks
Begin preoperative preparation Explanation (pg 1612) Direct cannulation of the atria and great vessels occurs in the operating room through a sternotomy; therefore, the nurse begins preoperative preparation when it is determined that a VAD is needed. The patient has ventricular failure caused by a myocardial infarction and will not be discharged to have the ventricular assist device (VAD) implanted as an outpatient. The procedure is completed through a sternotomy in the operating room, not in a laboratory. The patient is acutely ill and will not be expected to wait several weeks for the device to be implanted.
A nurse is assessing a patient who is suspected of having hypovolemic shock. What are the conditions that can cause hypovolemic shock? Select all that apply. Bowel obstruction Tension pneumothorax Ruptured spleen Diabetes insipidus Valvular stenosis
Bowel obstruction Ruptured spleen Diabetes insipidus Explanation (pg 1633) Hypovolemic shock may be caused due to bowel obstruction, a ruptured spleen, or diabetes insipidus. Bowel obstruction causes relative hypovolemia by preventing fluid absorption for the bowel. A ruptured spleen may cause massive internal bleeding, leading to hypovolemia. Diabetes insipidus causes a marked increase in fluid loss through the kidneys, leading to hypovolemia. A tension pneumothorax and valvular stenosis may lead to cardiogenic shock.
A nurse is caring for a patient who is in a state of cardiogenic shock caused by myocardial infarction. The nurse uses pulse oximetry to monitor the oxygen saturation levels. Where should the nurse attach the pulse oximetry probe to get an accurate reading? Select all that apply. Ear Toes Nose Fingers Forehead
Ear Nose Forehead Explanation (pg 1647) Pulse oximetry is used to monitor oxygen saturation. The patient in a state of shock has poor peripheral circulation, and a peripheral reading may not be accurate. Therefore, the probe should be attached to the ear, nose, or forehead for a reliable measurement. Pulse oximetry readings obtained through the toes and fingers may not be accurate due to compromised peripheral circulation.
The nurse is administering oxygen therapy to a patient in septic shock. What are the possible factors that directly affect oxygen delivery in the patient and should be monitored? Select all that apply. Urine output White blood cells Cardiac output Available hemoglobin Arterial oxygen saturation
Cardiac output Available hemoglobin Arterial oxygen saturation Explanation (pg 1641) Oxygen delivery depends on cardiac output, available hemoglobin, and arterial oxygen saturation (SaO2). The amount of blood that the heart pumps to the body may decide the amount of oxygen delivered to the tissues. Hemoglobin, the protein content in red blood cells, is responsible for carrying oxygen molecules. Low hemoglobin means a low oxygen supply to the tissues. Arterial oxygen saturation indicates the total oxygen carried by the blood in the arteries and implies the level of tissue oxygenation. The urine output and white blood cells are also important parameters to be monitored in a patient who suffers from a shock. However, these do not impact the oxygen delivery directly.
A patient is demonstrating signs of increased afterload. What should the nurse expect to be the effects of this hemodynamic parameter? Decreased heart rate Decreased cardiac output Decreased blood pressure Decreased carbon dioxide level
Decreased cardiac output Explanation (pg 1604) Increased afterload often results in a decreased cardiac output. Decreasing afterload will reduce the heart rate and blood pressure. Increased afterload increases oxygen needs of the heart. Increased afterload does not directly affect carbon dioxide level, which would affect the carbon dioxide level. The patient's respiratory status would determine carbon dioxide level.
When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? Increased serum albumin Decreased respiratory compliance Increased gastrointestinal (GI) motility Decreased blood urea nitrogen (BUN)/creatinine ratio
Decreased respiratory compliance Explanation Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism.
A patient with hypertension is prescribed a β-adrenergic blocking medication. What effect should the nurse expect this medication to have on the patient's heart? Increased oxygen use Increased stroke volume Decreased stroke volume Decreased cellular metabolism
Decreased stroke volume Explanation (pg 1604) A β-adrenergic blocking medication decreases stroke volume. Contractility is reduced by negative inotropes. An example of a negative inotrope is a β-adrenergic blocker. Since an increase in contractility increases stroke volume (SV) and myocardial oxygen requirements, a negative inotrope such as a β-adrenergic blocker will decrease stroke volume (SV). A β-adrenergic blocking medication will decrease rather than increase oxygen use. This medication does not affect myocardial cellular metabolism.
A patient is receiving 5% human serum albumin. The nurse should monitor for which complications associated with the infusion? Select all that apply. Bleeding Fluid overload Hyponatremia Urticaria Hyperchloremic acidosis
Fluid overload Urticaria Explanation (pg 1642) Colloidal solutions such as 5% human serum albumin may cause fluid and sodium retention, resulting in fluid overload. Therefore, to prevent the risk of fluid overload in the patient, the nurse should check for signs of fluid overload, or hypervolemia. Colloidal solutions can cause chills, fever, and urticaria. Therefore, the nurse should assess the patient for symptoms of urticaria in order to provide appropriate treatment. Unlike dextrose, human serum albumin does not increase the risk of bleeding in the patient. Human serum albumin causes sodium retention, so the nurse should check for the symptom of hypernatremia, not hyponatremia. Human serum albumin does not cause a decrease in plasma bicarbonate concentration and does not result in hyperchloremic acidosis.
What data are used to calculate stroke volume (SV) for a patient with arterial pressure-based cardiac output (APCO) monitoring? Height, BMR, age, gender Gender, age, height, weight BMI, BMR, blood pressure, heart rate Age, gender, blood pressure, heart rate
Gender, age, height, weight Explanation (pg 1607) Arterial pressure-based cardiac output (APCO) monitoring uses the arterial waveform characteristics along with patient demographic data including gender, age, height, and weight to calculate stroke volume (SV). Basal metabolic rate (BMR), body mass index (BMI), blood pressure, and heart rate are not used to calculate stroke volume with this measuring device. Heart rate is used to calculate continuous cardiac output (COO) and continuous cardiac index (CCI).
The nurse would recognize which clinical manifestation as suggestive of sepsis? Sudden diuresis unrelated to drug therapy Hyperglycemia in the absence of diabetes Respiratory rate of seven breaths per minute Bradycardia with sudden increase in blood pressure
Hyperglycemia in the absence of diabetes Explanation Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia.
A nurse has received the laboratory work of a patient who is suspected to have hypovolemic shock. What would be the laboratory findings if the patient is in the early stages of hypovolemic shock? Select all that apply. Increased glucose levels Increased sodium levels Decreased potassium levels Metabolic acidosis Increased liver enzymes
Increased glucose levels Increased sodium levels Decreased potassium levels Explanation (pg 1634) The patient may have increased glucose levels, increased sodium levels, and decreased potassium levels in the early stages of shock. Glucose levels increase due to the release of liver glycogen stores in response to sympathetic nervous system stimulation and cortisol. Sodium levels increase due to the increased secretion of aldosterone, causing renal retention of sodium. Potassium levels decrease because of the increased secretion of aldosterone, causing the renal excretion of potassium. Metabolic acidosis is a manifestation of late shock; respiratory alkalosis is seen in early shock due to hyperventilation. Increased liver enzymes indicate liver cell destruction in the progressive stage of shock.
A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? Acute pain Impaired tissue integrity Decreased cardiac output Ineffective tissue perfusion
Ineffective tissue perfusion Explanation The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses.
A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? Acute pain Impaired tissue integrity Decreased cardiac output Ineffective tissue perfusion
Ineffective tissue perfusion Explanation (pg 1633) The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. Ineffective tissue perfusion supersedes acute pain, impaired tissue integrity, and decreased cardiac output, because circulation is a priority. Acute pain may occur, but is not a priority at this time. Tissue integrity is not impaired.
When caring for a patient in acute septic shock, what should the nurse anticipate? Infusing large amounts of intravenous (IV) fluids Administering osmotic or loop diuretics Administering IV diphenhydramine (Benadryl) Assisting with insertion of a ventricular assist device (VAD)
Infusing large amounts of intravenous (IV) fluids Explanation (pg 1636) Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. Diphenhydramine may be used for anaphylactic shock, but would not be helpful with septic shock. VADs are useful for cardiogenic shock, not septic shock.
The nurse is caring for a 29-year-old man who was admitted a week ago with multiple rib fractures, a pulmonary contusion, and a left femur fracture from a motor vehicle crash. After the attending physician tells the family that the patient has developed sepsis, the family members have many questions. Which information should the nurse include in explaining the early stage of sepsis? Antibiotics are not useful once an infection has progressed to sepsis. Weaning the patient away from the ventilator is the top priority in sepsis. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. The patient has recovered from sepsis if he has warm skin and ruddy cheeks.
Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. Explanation Patients with sepsis may be normovolemic but because of acute vasodilation, relative hypovolemia and hypotension occur. Patients in septic shock require large amounts of fluid replacement and may require frequent fluid boluses to maintain circulation. Antibiotics are an important component of therapy for patients with septic shock. They should be started after cultures (e.g., blood, urine) are obtained and within the first hour of septic shock. Oxygenating the tissues is the top priority in sepsis, so efforts to wean septic patients from mechanical ventilation halt until sepsis is resolving. Addititonal respiratory support may be needed during sepsis. Although cool and clammy skin is present in other early shock states, the patient in early septic shock may feel warm and flushed because of a hyperdynamic state.
The health care provider prescribes a dose of dobutamine for a patient in cardiogenic shock due to myocardial infarction. What appropriate actions should the nurse perform for safely administering the medication? Select all that apply. Monitor heart rate and blood pressure. Stop infusion if tachydysrhythmias develop. Always administer with sodium bicarbonate. Administer through a central line. Use a glass bottle for infusion.
Monitor heart rate and blood pressure. Stop infusion if tachydysrhythmias develop. Administer through a central line. Explanation (pg 1643) Doubutamine is a sympathomimetic medication. When used in therapy with dobutamine, the patient's heart rate and blood pressure should be continuously monitored, as they may worsen hypotension, requiring the addition of a vasopressor. The infusion should be stopped if tachydysrhythmias develop. The administration through a central line is recommended, because infiltration leads to tissue sloughing. The drug should not be administered with sodium bicarbonate, because it can get deactivated. Because dobutamine is not adsorbed in plastic containers, it is not necessary to administer the drug in glass bottles.
Which type of shock is associated with bradycardia? Septic shock Neurogenic shock Hypovolemic shock Anaphylactic shock
Neurogenic shock Explanation (pg 1635) Neurogenic shock is associated with bradycardia. Myocardial dysfunction and changes in body temperature are signs of septic shock. Reduction in preload, capillary refill and stroke volume are clinical manifestations of hypovolemic shock. Chest pain is seen in anaphylactic shock.
A patient in cardiogenic shock is prescribed a dose of sodium nitroprusside. What appropriate actions should the nurse perform to safely administer sodium nitroprusside? Select all that apply. Avoid using with D5W. Protect solution from light. Monitor the body temperature. Wrap infusion bottle with opaque covering. Monitor the serum cyanide levels and signs of cyanide toxicity.
Protect solution from light. Wrap infusion bottle with opaque covering. Monitor the serum cyanide levels and signs of cyanide toxicity. Explanation (pg 1643) Sodium nitroprusside is a vasodilator used in cardiogenic shock. The drug tends to release cyanide ions when exposed to sunlight. Therefore, it should be protected from exposure to sunlight by wrapping the infusion bottle with an opaque covering. The patient's serum cyanide levels should be checked, and the patient should be monitored for signs of cyanide toxicity. This includes metabolic acidosis, tachycardia, altered level of consciousness, seizures, coma, and almond smell on the breath. The medication should be reconstituted with D5W only. Monitoring vital signs like body temperature is important but may not directly impact the treatment being administered.
A patient is experiencing cardiogenic shock after an acute myocardial infarction. Why would an intraaortic balloon pump (IABP) be beneficial for this patient? Reduces pressure in the pulmonary artery Improves coronary artery vessel perfusion Enhances effectiveness of cardiac medications Provides time for an emergency angiogram to be performed
Provides time for an emergency angiogram to be performed Explanation (pg 1610) Indications for intraaortic balloon pump (IABP) therapy include acute myocardial infarction and cardiogenic shock. The use of the pump with this health problem allows time for emergent angiography. The pump is not used to reduce pressure in the pulmonary artery, improve coronary artery vessel perfusion, or to enhance the effectiveness of cardiac medications.
A nurse is examining a patient with anaphylactic shock due to an insect bite. What types of skin manifestations would the nurse expect to find? Select all that apply. Pallor Pruritus Flushing Urticaria Cold, clammy skin
Pruritus Flushing Urticaria Explanation (pg 1636) Insect bites may cause allergic reactions and anaphylactic shock. The skin manifestations may include pruritus, flushing, and urticaria caused by massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. Pallor and cold, clammy skin changes are usually seen in cardiogenic, hypovolemic, and obstructive shock caused by decreased circulatory volume and tissue perfusion.
A 64-year-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure 78/58 mm Hg, pulse 124 beats/minute, respirations 28 breaths/minute, and temperature 97.2° F (36.2° C). Which physician order should the nurse complete first? Obtain a 12-lead ECG and arterial blood gases. Rapidly administer 1000 mL normal saline solution IV. Administer norepinephrine (Levophed) by continuous IV infusion. Carefully insert a nasogastric tube and an indwelling bladder catheter.
Rapidly administer 1000 mL normal saline solution IV. Explanation Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be initiated after fluid resuscitation is initiated.
When a patient suffers from hypovolemic shock due to loss of blood, the nurse should administer large volumes of packed red blood cells (RBCs). What should be the appropriate course of action for the nurse? Warm the pack before administering. Check the patient's hypersensitivity to the product. Provide antibiotics based on the clinical condition. Replace clotting factors based on laboratory studies.
Replace clotting factors based on laboratory studies. Explanation (pg 1642) When administering large volumes of packed RBCs, it is important to replace clotting factors to prevent coagulopathy. Because the pack contains only RBCs and not the clotting factors, it should be given extrinsically. Generally, the crystalloid and colloid solutions are warmed before being administered to avoid hypothermia. However, packed red blood cells should not be warmed, because high temperature can damage the red blood cells. The blood products are almost always cross typed and matched before administration. Antibiotics are not related to the administration of RBCs.
A patient with a pulmonary arterial catheter for systolic heart failure is diagnosed with a urinary tract infection (UTI). The last central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurement was 89%. What should the nurse suspect is occurring with this patient? Sepsis Decreased cardiac output Increased oxygen demand Balanced oxygen supply and demand
Sepsis Explanation (pg 1609) The patient has a urinary tract infection, which can lead to sepsis. In sepsis, oxygen is not extracted properly at the tissue level, resulting in increased central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurements. Central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurements would be low if the patient was experiencing decreased cardiac output or increased oxygen demand. Central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurements would be between 60% and 80% if the oxygen supply and demand was balanced.
Which drug causes arterial and venous dilation? Dopamine Vasopressin Phenylephrine Sodium nitroprusside
Sodium nitroprusside Explanation (pg 1643) Sodium nitroprusside acts by dilating both the arteries and veins. It is used in the treatment of cardiogenic shock. Dopamine has inotropic activity. It increases the force of the heartbeat and is used in the treatment of cardiogenic shock. Vasopressin is a vasoconstrictor used mainly in the treatment of septic shock. Phenylephrine acts by constricting the peripheral nerves and is used in the treatment of neurogenic shock.
While planning the management of oxygen delivery in a patient with shock, what appropriate measures should the nurse undertake? Select all that apply. Encourage the patient to move around to increase lung expansion. Space activities that increase oxygen consumption. Monitor continuously by using a central venous catheter. Space activities that decrease oxygen consumption. Administer supplemental oxygen as prescribed.
Space activities that increase oxygen consumption. Monitor continuously by using a central venous catheter. Administer supplemental oxygen as prescribed. Explanation (pg 1641) To optimize oxygen supply and ventilation in a patient suffering from shock, the activities that increase oxygen consumption should be evenly spaced. Mixed venous oxygen saturation should be monitored through a central venous catheter. The patient should not exert energy by excessive moving around because it increases oxygen demand.
When managing a patient with shock, which appropriate actions should the nurse take as part of nutritional therapy? Select all that apply. Plan enteral feeding to meet at least 50 percent of calorie requirements. Start enteral nutrition within the first 24 hours. Wait until the patient recovers to start with enteral nutrition. Start a slow continuous drip of small amounts of enteral feedings. Start parenteral nutrition if enteral feedings are contraindicated.
Start enteral nutrition within the first 24 hours. Start a slow continuous drip of small amounts of enteral feedings. Start parenteral nutrition if enteral feedings are contraindicated. Explanation (pg 1644) Enteral nutrition should ideally begin within the first 24 hours. It is important because it enhances the perfusion of the (gastrointestinal) GI tract and helps to maintain the integrity of the gastrointestinal mucosa. Enteral feeding should be started with a slow continuous drip of small amounts of enteral feedings. If enteral feedings are contraindicated, parenteral feedings can be started. Enteral feeding should be planned to meet at least 80 percent of the total calorie requirements, but if it is not feasible, parenteral feeding should be started. Nutritional therapy should start as early as possible. The nurse should not wait for the patient to recover before starting nutritional therapy.
The nurse reviews the medical record of a patient with pneumonia and notes that the patient has hypotension, hypothermia, leukocytosis, and hypoxemia. What should the nurse infer from these findings? The patient has septic shock. The patient has neurogenic shock. The patient has cardiogenic shock. The patient has hypovolemic shock.
The patient has septic shock. Explanation (pg 1637) Septic shock is most commonly found in the patient having gram-negative bacterial infections, such as pneumonia. Because it is characterized by hypotension, hypothermia, leukocytosis, and hypoxemia in patients with infections, the nurse concludes that the patient has septic shock. Neurogenic shock is most commonly seen in the patient who has an injury. Cardiogenic shock is caused by cardiovascular disorders, such as a myocardial infarction and cardiomyopathy. Hypovolemic shock is caused by hemorrhage or trauma.
A patient receiving intraaortic balloon pump (IABP) therapy is having the catheter removed. What should the nurse ensure occurs during the procedure? The pump is turned off The pump remains turned on The patient is placed in a side-lying position The intravenous fluids are reduced to keep vein open status
The pump remains turned on Explanation (pg 1612) Pumping is continued until the line is removed even if the patient is stable. This reduces the risk of thrombus formation around the catheter. The pump should not be turned off. The patient does not need to be in the side-lying position for catheter removal. Intravenous fluids do not need to be reduced to keep vein open status for catheter removal.
During an assessment the nurse becomes concerned that a patient is experiencing decreased perfusion. Which findings did the nurse use to make this clinical determination? Select all that apply. Warm pink skin Temperature 99.5° F Urine output 10 mL/hr Hypoactive bowel sounds Respiratory rate 18 and unlabored
Urine output 10 mL/hr Hypoactive bowel sounds Explanation (pg 1610) A normal urine output is 30 mL/hr. A urine output of 10 mL/hr could indicate decreased perfusion to the kidneys. The patient with diminished perfusion to the gastrointestinal tract may develop hypoactive bowel sounds. Warm pink skin may indicate septic shock. A temperature of 99.5°F has no particular significance with perfusion. A respiratory rate of 18 and labored is considered within normal limits and does not indicate an issue with perfusion.
