H&H Quiz 3 - med/surg ch 69, shock stages, cardiogenic shock
When caring for a patient in shock, the nurse notifies the physician of the patient's deteriorating status when the patient's arterial blood gas results include which of the following findings? a.pH 7.48, partial pressure of arterial carbon dioxide (PaCO2) 33 mm Hg b.pH 7.33, PaCO2 30 mm Hg c.pH 7.50, PaCO2 50 mm Hg d.pH 7.38, PaCO2 45 mm Hg
ANS: B The patient's low pH despite a respiratory alkalosis indicates that the patient has severe metabolic acidosis and is experiencing the progressive stage of shock. Rapid changes in therapy are needed.
1. A patient is in hypovolemic shock. Select all the stages that a patient can enter when in shock: A. Proliferative B. Compensatory C. Exudative D. Initial E. Progressive F. Fibrotic G. Refractory
D. Initial B. Compensatory E. Progressive G. Refractory
11. Which stage of shock is irreversible and unmanageable? A. Progressive B. Initial C. Exudative D. Refractory
D. Refractory
DIC
Disseminated intravascular coagulation (pathological activation of coag cascade)
11. A patient is receiving treatment for an acute myocardial infarction. The nurse is closely monitoring the patient for signs and symptoms associated with cardiogenic shock. Which value below is associated with cardiogenic shock? A. Cardiac index 1.5 L/min/m2 B. Pulmonary capillary wedge pressure (PCWP) 10 mmHg C. Central venous pressure (CVP) 4 mmHg D. Troponin <0.01 ng/mL
The answer is A. A patient who has experienced an acute myocardial infarction is at risk for cardiogenic shock. A normal cardiac index should be 2.5-4 L/min/m2. Cardiac index is the specific cardiac output based on the patient's size. Any number less than 2.2 L/min/m2 can be associated with cardiogenic shock. All the other values are within normal limits. PCWP would be >18 mmHg in cardiogenic shock, and CVP would be high.
5. _____________ is the force the heart has to pump against to get blood out of the ventricle. A. Cardiac output B. Cardiac index C. Preload D. Afterload
The answer is D. Afterload is the pressure the ventricle must pump against to squeeze blood out. In other words, it's the force the heart has to pump against to get blood out of the ventricle.
8. During what stage of shock is the body unable to compensate for tissue perfusion and the body's cell start to experience hypoxic injury that result in __________capillary permeability? A. Refractory, increased B. Exudative, decreased C. Compensatory, increased D. Progressive, increased
The answer is D. During the progressive stage of shock, the body can NOT compensate any longer by utilizing the neural, hormonal and biochemical responses of the body as it did in the previous stage (compensatory). Therefore, the cells are NO longer perfused due to extremely low cardiac output. When the cells are no longer perfused they can't survive, so they experience HYPOXIC injury, and this results in INCREASED capillary permeability. The cell's ion pump will fail and lead to cell swelling and death. All the organs (due to the death of their cells) will begin to fail, and if very dynamic treatment is not implemented the patient will enter the last stage of shock, which is the refractory stage. This stage is irreversible.
6. True or False: If a patient with cardiogenic shock is given a medication that will decrease cardiac afterload, it will decrease stroke volume.
The answer is FALSE. If a patient with cardiogenic shock is given a medication that will decrease cardiac afterload, it will INCREASE (not decrease) stroke volume. HOW? Remember afterload is the resistance the ventricle must pump against to get blood out of the heart. If we DECREASE the resistance the heart must pump against (make it easier for the heart squeeze blood out of the ventricle), it will increase how much blood it will pump out, hence increase the stroke volume.
During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism causes: a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis
a) Metabolic acidosis
Cardiogenic Shock
"Pump" problem = ↓ CO = ↓ tissue perfusion
Systolic dysfunction
(inability to pump bld fwd)
Diastolic dysfunction
(↓ RV or LV filling)
cardiogenic shock caused by
- primary ventricular ischemia - structural problems - Dysrhythmias
5. A patient has been admitted with a spinal cord injury. The nurse anticipates neurogenic shock with a spinal cord injury at which level of the spine? a. T4 b. T6 c. T8 d. L2
ANS: A Neurogenic shock can occur with a spinal cord injury at the level of T5 or above.
13. Which type of shock does the nurse suspect with a patient who is short of breath and has wheezes, rhinitis, and stridor? a. Cardiogenic shock b. Neurogenic shock c. Anaphylactic shock d. Septic shock
ANS: C A patient in anaphylactic shock exhibits shortness of breath, wheezes, rhinitis, and stridor, and often has swelling of the lips and tongue.
10. TRUE or FALSE: All types of shock during the compensatory (early) stage will cause a patient to experience cold and clammy (moist or sweaty) skin.
FALSE: Patients who have septic shock will actually experience warm and flushed skin during the early (compensatory stage) because of the vasodilation occurring with this type of shock. The other types of shock will have cold and clammy (sweaty) skin due to decreased perfusion to the skin.
________________ is the amount the ventricle stretches at the end of diastole. A. Preload B. Afterload C. Stroke Volume D. Contractility
The answer is A. Preload is the amount the ventricle stretches at the end of diastole (hence it's the amount the ventricles stretches once it's filled with blood and right before the contraction of the ventricle ....so it's the end-diastolic volume).
13. They physician orders a Dobutamine IV drip on a patient in cardiogenic shock. After starting the IV drip, the nurse would make it priority to monitor for? A. Rebound hypertension B. Ringing in the ears C. Worsening hypotension D. severe headache
The answer is C. Dobutamine increases contractility and cardiac output, BUT causes vasodilation due to the way it acts on receptors and this may make hypotension WORSE. The patient may be started on norepinephrine or dopamine if worsening of hypotension occurs.
A patient who has cardiogenic shock is experiencing labored breathing and low oxygen levels. A STAT chest x-ray is ordered. The x-ray results show pulmonary edema. The physician orders Furosemide IV. What finding would require immediate nursing action? A. Blood pressure 98/54 B. Urinary output 45 mL/hr C. Potassium 1.8 mEq/L D. Heart rate 110 bpm
The answer is C. Furosemide (Lasix) is a diuretic which wastes potassium. The nurse would want to ensure the potassium level is normal (3.5 to 5 mEq/L) before administering IV Furosemide. The nurse would need to notify the physician of the potassium level so supplementation can be provided.
Which patient below is at MOST risk for developing cardiogenic shock? A. A 52-year-old male who is experiencing a severe allergic reaction from shellfish. B. A 25-year-old female who has experienced an upper thoracic spinal cord injury. C. A 72-year-old male who is post-op from a liver transplant. D. A 49-year-old female who is experiencing an acute myocardial infarction.
The answer is D. An acute MI (heart attack) is the main cause of cardiogenic shock. It happens because a coronary artery has become blocked. Coronary arteries supply the heart muscle's cells with oxygenated blood. If they don't receive this oxygenated blood they will die, which causes the heart muscle to quit working (hence pumping efficiently). When the heart muscle fails to pump efficiently, cardiac output fails and cardiogenic shock occur.
A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? a) Arteriolar constriction occurs. b) The cardiac workload decreases. c) Contractility of the heart decreases. d) The parasympathetic nervous system is triggered.
a) Arteriolar constriction occurs.
Which hemodynamic results would the nurse expect to assess in a patient who is in neurogenic shock? a.Increased HR, decreased BP and pulse pressure b.Increased HR, BP, and pulse pressure c.Decreased HR, increased BP and pulse pressure d.Decreased HR, BP, and pulse pressure
ANS: D A patient in neurogenic shock would have a decreased HR, BP, and pulse pressure.
4. During what stage of shock does the body attempt to utilize the hormonal, neural, and biochemical responses of the body? A. Refractory B. Initial C. Proliferative D. Compensatory
The answer is D: the compensatory stage.
In the diagnostic criteria for sepsis, a patient is considered to have a fever if the temperature is higher than which of the following? a.37.7°C b.38.0°C c.38.3°C d.38.5°C
ANS: C In the diagnostic criteria for sepsis, a patient is considered to have a fever if the temperature is higher than 38.3°C.
10. You're assessing your patient with cardiogenic shock, what signs and symptoms do you expect to find in this condition? Select all that apply: A. Warm, flushed skin B. Prolonged capillary refill C. Urinary output >30 mL/hr D. Systolic blood pressure <90 mmHg E. Crackles in lung fields F. Dyspnea D. Decreased BUN and creatinine G. Strong peripheral pulses H. Chest pain
B. Prolonged capillary refill D. Systolic blood pressure <90 mmHg E. Crackles in lung fields F. Dyspnea H. Chest pain Signs and symptoms of cardiogenic shock will be related to LOW cardiac output and decreased perfusion to organs/tissues. Capillary refill will be prolonged >2 seconds, urinary output will be <30 mL/hr, systolic blood pressure will be <90 mmHg, pulmonary edema will present with fluid in the lungs (hence crackles in the lungs), dyspnea, and chest pain (due to decreased blood flow to the heart muscle).
15. A patient with cardiogenic shock has an intra-aortic balloon pump. As the nurse you know that during ________ the balloon deflates and during _____ the balloon inflates in a section of the aorta. A. systole, diastole B. diastole, systole C. inspiration, expiration D. expiration, inspiration
The answer is A. An intra-aortic balloon pump is a balloon attached to the catheter inside a section of the aorta. It will inflate and deflate during systole (contraction) and diastole (relaxation). When the balloon deflates during systole it creates a suction-like pressure that will draw blood out of the weak heart and into the coronary arteries and systemic circulation (hence increasing cardiac output and blood supply to the heart muscle). When the balloon inflates during diastole it will create pressure that will push blood into the coronary arteries (hence further increasing blood supply to the heart muscle).
During shock, when a patient experiences a drop in cardiac output, the body tries to compensate by stimulating the sympathetic nervous system, which causes the release of _________ and ________. This will lead to? A. acetylcholine and dopamine, vasodilation B. epinephrine and norepinephrine, vasodilation C. dopamine and epinephrine, vasoconstriction D. norepinephrine and epinephrine, vasoconstriction
The answer is D. When a patient in shock experiences a drop in blood pressure (due to a drop in cardiac output), the baroreceptors (in the carotid and aortic arch) will sense this and stimulate the sympathetic nervous system. The SNS will release the neurotransmitters NOREPINEPHRINE and EPINEPRHINE and this will lead to VASOCONSTRICTION. By causing constriction of the vessels, it will temporarily increase cardiac output by increase the blood pressure and heart rate, which will in turn increase perfusion to cells.
2. Cardiac output is very important for determining if a patient is in cardiogenic shock. What is a normal cardiac output in an adult? A. 2-5 liters/minute B. 1-3 liters/minute C. 4-8 liters/minute D. 8-10 liters/minute
The answer is C. Cardiac output is the amount of blood the heart pumps per minute. The heart's cardiac output should be anywhere from 4-8 liters of blood per minute.
9. Select all the complications that can arise from the progressive stage of shock: A. Acute respiratory distress syndrome B. Extreme edema C. Elevated ammonia and lactate levels D. GI bleeding and ulcers E. Dysrhythmias F. Myocardial infraction G. Acute tubular necrosis H. Disseminated intravascular clotting
ALL options are correct. All these conditions can occur in the progressive stage of shock. Please watch the lecture to review the progressive stage of shock.
While evaluating the effects of treatment in a patient in shock, the nurse finds that the patient has orthostatic hypotension. This finding indicates a need for which of the following treatments? a.Additional fluid replacement b.Administration of antibiotics c.Administration of an inotropic drug d.Administration of supplemental oxygen
ANS: A A postural drop in BP is an indication of volume depletion and suggests the need for additional fluid infusions.
15. The nurse evaluates that fluid resuscitation for a patient in shock is effective on observing which of the following findings? a. Urinary output is 1 mL/kg/hour. b. Pulse pressure becomes narrower. c. Pulmonary artery occlusive pressure decreases. d. BP is within the patient's normal range.
ANS: A A urinary output of at least 0.5 mL/kg/hour indicates adequate renal perfusion, which is a good indicator of CO.
12. A patient stung by a bee develops severe respiratory distress and is in anaphylactic shock. Which medication will the nurse prepare to administer immediately? a. Epinephrine (Adrenalin) b. Crystalloid fluids c. Dexamethasone (Decadron) d. Diphenhydramine (Benadryl)
ANS: A Epinephrine is the medication of choice to treat anaphylactic shock.
Which of the following is a patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia? a.Normal mentation b.Increase in BP c.Verbalization of reduced anxiety d.Reduction in heart and respiratory rates
ANS: A Restoration of normal mentation is evidence that the patient has improved and that hypovolemia has been eliminated.
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock based on which of the following findings? a.Bradycardia b.Hypotension c.Cool, clammy skin d.A subnormal body temperature
ANS: A The normal sympathetic response to shock and hypotension is an increase in HR. The presence of bradycardia suggests unopposed parasympathetic function, as occurs in neurogenic shock.
3. A patient with hypovolemic shock has a urinary output of 15 mL/hour. What does the nurse understand is the compensatory physiological mechanism that leads to altered urinary output? a.Release of aldosterone, which increases serum osmolarity, causing release of antidiuretic hormone (ADH) b.Movement of interstitial fluid to the intravascular space, increasing renal blood flow c.Activation of the sympathetic nervous system, causing vasodilation of the renal arteries d.-Adrenergic receptor stimulation that causes increased CO as a result of increased HR and myocardial contractility
ANS: A The release of aldosterone and ADH leads to the decrease in urinary output by increasing the reabsorption of sodium and water in the renal tubules.
2. Which hemodynamic results would the nurse anticipate in a patient who is in cardiogenic shock? a.Increased heart rate (HR), blood pressure (BP), and cardiac output (CO) b.Increased HR, decreased BP and CO c.Decreased HR, BP, and CO d.Decreased HR, increased BP and CO
ANS: B A patient in cardiogenic shock would have an increased HR and a decreased BP and CO.
14. A patient with multiple traumas is brought to the emergency department. The nurse initiates two peripheral intravenous (IV) sites and begins fluid resuscitation with which of the following fluids? a. Dextran b. 0.9% saline c. 3.0% saline d. Dextrose 5% in water in one-half normal saline
ANS: B Fluid resuscitation is accomplished by using normal saline, that is, 0.9% saline.
While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on observing which of the following findings? a.Cold, mottled extremities b.Restlessness and apprehension c.An HR of 120 beats/min and cool, clammy skin d.A systolic BP less than 90 mm Hg and a widening pulse pressure
ANS: B Restlessness and apprehension are typical during the compensatory stage of shock.
25. To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, what should the nurse assess? a.Stool guaiac and bowel sounds b.Lung sounds and oxygenation status c.Serum creatinine and urinary output d.Serum bilirubin levels and skin colour
ANS: B The respiratory system is usually the system to show signs of MODS because of the direct effect of inflammatory mediators on the pulmonary system.
10. A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and CO. The nurse anticipates the administration of which of the following medications? a. Nitroglycerine (Tridil) b. Dobutamine c. Norepinephrine (Levophed) d. Sodium nitroprusside (Nipride)
ANS: B When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic vascular resistance and improve tissue perfusion.
The triage nurse receives a call from a community member who is driving an unconscious friend with multiple injuries after a motorcycle accident to the hospital. The caller states that they will be arriving in 1 minute. What will the nurse obtain in preparation for the patient's arrival? a.A litre of lactated Ringer's solution b.500 mL of 5% albumin c.Two 14-gauge IV catheters d.A retention catheter
ANS: C A patient with multiple traumas may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for two large-bore IV lines to administer normal saline.
During the initial management of any patient in shock, the nurse knows that which of the following is an appropriate intervention? a.Fluid resuscitation b.Administration of vasopressors c.Administration of inotropic agents d.Administration of high-flow oxygen
ANS: C An inotropic agent (e.g., dobutamine [Dobutrex]) is often added to offset the decrease in stroke volume.
Norepinephrine has been ordered for the patient in hypovolemic shock. Before administering the medication, the nurse ensures that which of the following has occurred? a.The patient's HR is less than 100 beats/min. b.The patient's urinary output is within the normal range. c.The patient has received adequate fluid replacement. d.The patient is not receiving additional sympathomimetic drugs.
ANS: C If vasoconstrictors are given to a hypovolemic patient, the peripheral vasoconstriction will further decrease tissue perfusion, so the nurse needs to ensure that the patient has received adequate fluid replacement before administration.
When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse? a.BP 88/56 mm Hg b.Apical pulse 110 beats/min c.Urinary output 15 mL for 2 hours d.Arterial oxygen saturation 90%
ANS: C The best data for gathering the adequacy of CO are those that provide information about end-organ perfusion such as urinary output by the kidneys.
22. When caring for the patient with cardiogenic shock and possible multiple-organ dysfunction syndrome (MODS), what information obtained by the nurse will help confirm the diagnosis of MODS? a.The patient has crackles throughout both lung fields. b.The patient complains of crushing chest pain at a level of 8 on a 10-point scale. c.The patient has an elevated ammonia level and confusion. d.The patient has cool extremities and weak pedal pulses.
ANS: C The elevated ammonia level and confusion suggest liver failure in addition to the cardiac failure.
11. Which of the following nursing interventions prevents the development of shock? a. Routine checking of stools for occult blood b. Keeping patients warm to prevent chilling or shivering c. Identifying situations in which patients are at risk for shock d. Frequent monitoring of patient status to detect compensatory changes
ANS: C To prevent shock, the nurse needs to identify patients at risk. In general, patients who are older, those with debilitating illnesses, and those who are immunocompromised are at an increased risk. Any person who sustains surgical or accidental trauma is at high risk for shock resulting from hemorrhage, spinal cord injury, and other conditions. Any patient who is at risk for decreased oxygen delivery or tissue hypoxia is also at risk for the development of shock.
6. The nurse determines that the patient in shock has progressed beyond the compensated stage when laboratory tests reveal which of the following results? a.Increased blood glucose levels b.Increased serum sodium levels c.Decreased serum calcium levels d.Increased serum potassium levels
ANS: D Decreased potassium is found in early shock because of increased secretion of aldosterone, causing renal excretion of potassium; however, when the patient's shock progresses beyond the compensated stage, the potassium increases because cellular death liberates intracellular potassium.
When caring for a patient in cardiogenic shock, the nurse evaluates the status of the patient, recognizing that which of the following is the goal of care? a.To lower the HR and control dysrhythmias b.To lower the BP and respiratory rate c.To improve oxygen exchange and increase urinary output d.To decrease cardiac workload and increase systemic perfusion
ANS: D For a patient in cardiogenic shock, the overall goal is to restore blood flow to the myocardium by restoring the balance between oxygen supply and demand by decreasing the cardiac workload and increasing systemic perfusion.
A patient is treated in the emergency department for shock following an automobile accident. The nurse knows that shock is a clinical syndrome in which cellular dysfunction and organ failure occur primarily as a result of which of the following conditions? a.Hypotension b.Loss of blood c.Severe infection d.Impaired tissue perfusion
ANS: D Shock is a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism, resulting in an imbalance between the supply of and demand for oxygen and nutrients.
What is an appropriate nursing intervention for a patient in shock with the nursing diagnosis of fear related to perceived threat of death? a.Arrange for a member of the clergy to visit the patient. b.Ask the physician to prescribe a sedative for the patient. c.Provide the patient with as much privacy with the family as possible. d.Place the patient's call bell where it can be easily reached
ANS: D The patient who is fearful should feel that the nurse is immediately available if needed.
2. During the __________ stage of shock, the signs and symptoms are very subtle. However, cells are experiencing _________ due to the lack of tissue perfusion, which causes the cells to switch from ___________ metabolism to _________ metabolism. A. Proliferative, hyperoxia, anaerobic, aerobic B. Initial, hypoxia, aerobic, anaerobic C. Compensatory, hypoxia, anaerobic, aerobic D. Fibrotic, hypoxia, aerobic, anaerobic
B. During the INITIAL stage of shock, the signs and symptoms are very subtle. However, cells are experiencing HYPOXIA (low oxygen), which causes the cells to switch from AEROBIC (with oxygen) metabolism to ANAEROBIC (without oxygen....there is none to really use) metabolism. This will produce a waste product called LACTIC ACID.
You're caring for a patient with cardiogenic shock. Which finding below suggests the patient's condition is worsening? Select all that apply: A. Blood pressure 95/68 B. Urinary output 20 mL/hr C. Cardiac Index 3.2 L/min/m2 D. Pulmonary artery wedge pressure 30 mmHg
The answer is B and D. When answering this question look for values that are abnormal and that point to worsening tissue perfusion (urinary output should be 30 mL/hr or greater....if it's lower than this it show the kidneys are not being perfused) and worsening cardiac output (the blood pressure and cardiac index are within normal limits BUT pulmonary artery wedge pressure is NOT). A pulmonary artery wedge pressure (also called pulmonary capillary wedge pressure) is the pressure reading of the filling pressure in the left atrium. A normal PAWP is 4-12 mmHg and if it's >18 mmHg this indicates cardiogenic shock. If it reads high, that means there is back-flowing of blood into the heart and lungs (hence the left ventricle is failing to pump efficiently and increasing the pressure in the left atrium).
9. A patient with cardiogenic shock has a blood pressure of 70/38. In addition, the patient is experiencing dyspnea with a respiratory rate of 32 breaths per minute and has an oxygen saturation of 82% on room air. On auscultation, you note crackles throughout the lung fields. You notify the physician. What order below would you ask for an order clarification? A. Dopamine IV stat B. Normal saline IV bolus stat C. Furosemide IV stat D. Place patient on CPAP (continuous positive airway pressure)
The answer is B. This patient with cardiogenic shock is experiencing a decrease in cardiac output (hence the blood pressure), so an order for Dopamine can help provide a positive inotropic effect (increase the contractility of the heart which will increase stroke volume and cardiac output). The patient is also experiencing pulmonary congestion due to the cardiogenic shock. The heart is failing to pump blood forward, so it is backing up in the lungs. This is leading to an increased respiratory rate, dyspnea, and low oxygen saturation. The order for Furosemide (which is a diuretic) will help remove the extra fluid volume from the lungs and the CPAP (continuous positive airway pressure) will help with oxygenation. The nurse would question the order for a normal saline IV bolus. This bolus would add more fluid to the lungs and further congest the fluids.
3. You're caring for a patient who is experiencing shock. Which lab result below demonstrates that the patient's cells are using anaerobic metabolism? A. Ammonia 18 µ/dL B. Potassium 4.5 mEq/L C. Serum Lactate 9 mmol/L D. Bicarbonate 23 mEq/L
The answer is C. A patient who is in shock will experience anaerobic metabolism because the cells can no longer use oxygen for energy due to the loss of tissue perfusion. Remember in shock, the cardiac output is too low to perfuse the cells of the organs and tissue. Therefore, the cells try to compensate by switching from aerobic metabolism to anaerobic, BUT this type of metabolism creates a waste-product called LACTIC ACID. A normal serum lactate is <1 mmol/L and lactic acidosis is >4 mmol/L.
. Based on this scenario, what stage of shock is this patient most likely experiencing: A 74-year-old patient is extremely confused and does not respond to commands or stimulation. The patient respiratory rate is 28 and labored, oxygen saturation 86%, heart rate 120, blood pressure 70/40, mean arterial pressure is 50 mmHg, and temperature is 97 'F. The patient's heart rhythm is atrial fibrillation. The patient's urinary output is 5 mL/hr. The patient's labs: blood pH 7.15, serum lactate 15 mmol/L, BUN 55 mg/dL, Creatinine 6 mg/dL. In addition, the patient is now starting to have slight oozing of blood around puncture sites.
The answer is C. This is the progressive stage. There are four stages of shock (in order): initial, compensatory, progressive, and refractory. The patient's body is experiencing major signs and symptoms of shock. This is not found in the initial stage of shock because the signs and symptoms are subtle. During the compensatory stage, the body (for a while) can compensate so major organs are not showing major signs and symptoms of failure as they are in this scenario (the kidneys are starting to fail based on the BUN, creatinine, urinary output). In addition, the body is no longer compensating because the blood pressure is very low along with the MAP (mean arterial pressure). A big sign is that the patient's mental status is altered. This represents that the brain is not being perfused very well. The MAP should be 60 or greater to provide adequate perfusion. The MAP here is 50 and this shows us the body is NOT perfusing the organs, so the cells will experience hypoxic injury. The patient is also starting to show early signs and symptoms of DIC due to the slight oozing of blood around puncture sites. The next stage (which is the last) is the refractory and this is where organs have failed or are about too. Death is imminent. This patient is not at that point but is getting close. This patient needs very dynamic treatment in order to survive.
7. When the body is attempting to compensate for shock the adrenal cortex will release aldosterone due to the presence of angiotensin II. Select all the effects aldosterone will have on the body in attempt to increase cardiac output and maintain tissue perfusion: A. Increase blood volume B. Causes the kidneys to keep sodium and water C. Causes the kidneys to excrete sodium and water D. Cause the urine to have a low osmolality
The answers are A and B. Aldosterone will be released due to the presence of angiotensin II in the body (this is from the kidneys activating the renin-angiotensin system, which will cause major vasoconstriction in hopes of increasing blood pressure and cardiac output and hopefully perfusion to the kidneys). Aldosterone functions to cause the kidneys to KEEP sodium and water, which will INCREASE the blood volume. This will in turn increase the blood return to the heart and increase cardiac output. Because there will be a high amount of sodium in the urine, this will lead the urine to have a HIGH osmolality, which will cause the posterior pituitary gland to release ADH (anti-diuretic hormone). ADH will further cause the kidneys to keep water....in hopes of increasing blood volume even more.
You're precepting a new nurse. You ask the new nurse to list the purpose of why a patient with cardiogenic shock may benefit from an intra-aortic balloon pump. What responses below indicate the new nurse understands the purpose of an intra-aortic balloon pump? Select all that apply: A. "This device increases the cardiac afterload, which will increase cardiac output." B. "This device will help increase blood flow to the coronary arteries." C. "The balloon pump will help remove extra fluid from the heart and lungs." D. "The balloon pump will help increase cardiac output."
The answers are B and D. An intra-aortic balloon pump increases coronary artery blood flow and cardiac output.
4. Cardiac output is equal to the heart rate multiplied by the stroke volume. Treatment for cardiogenic shock includes medications that increase cardiac output. One of the factors that help determine cardiac output is stroke volume. Select all the factors that determine stroke volume? A. Cardiac Index B. Preload C. Pulmonary capillary wedge pressure D. Afterload E. Heart rate F. Contractility
The answers are B, D, and F. Cardiac output is determined by the person's heart rate times the stroke volume. Stroke volume is the amount of blood pumped from the left ventricle with each BEAT (50-100 ml). It's determined by the preload, afterload, and contractility of the heart. These factors in a patient with cardiogenic shock can be manipulated with medications to increase the cardiac output.
14. Which medications below are used in cardiogenic shock that provide a positive inotropic effect on the heart? Select all that apply: A. Nitroglycerin B. Sodium Nitroprussidde C. Dobutamine D. Norepinephrine E. Dopamine
The answers are C and E. Dobutamine and Dopamine are vasopressors that have a POSITIVE inotropic effect on the heart. This means these medications increase the strength of the heart's contractions (increases contractility), which increases stroke volume.
1. A patient is being treated for cardiogenic shock. Which statement below best describes this condition? Select all that apply: A. "The patient will experience an increase in cardiac output due to an increase in preload and afterload." B. "A patient with this condition will experience decreased cardiac output and decreased tissue perfusion." C. "This condition occurs because the heart has an inadequate blood volume to pump." D. "Cardiogenic shock leads to pulmonary edema."
The answers are: B and D. Cardiogenic shock occurs when the heart can NOT pump enough blood to meet the perfusion needs of the body. The cardiac output will be DECREASED, which will DECREASE tissue perfusion and cause cell injury to organs/tissues. In this condition, the heart is WEAK and can't pump blood out of the heart. This can be due to either a systolic (contraction) or diastolic (filling) issue along with a structural or dysrhythmia issue. In cardiogenic shock, there is NOT an issue with blood volume, but there is a problem with the heart itself.
