Shock

A 6 year old girl who is being treated for shock is pulseless with an irregular heart rate of 32 bpm. Which intervention is priority?

Initiate cardiac compressions The American Heart Association emphasizes the importance of cardiac compressions in pulseless clients with arrhythmias, making this the priority intervention in this situation. Current AHA recommendations are for defibrillation to be administered once followed by five cycles of CPR. The AHA now recommends against using multiple doses of epinephrine because they have not been shown to be helpful and may actually cause harm to the child.

The nurse is assessing a young child and suspects that the child is experiencing warm shock based on assessment of which of the following?

Normal blood pressure for age Bounding pulses Capillary refill less than 2 seconds Signs of warm shock include normal blood pressure for age, bounding pulses, and capillary refill of less than 2 seconds. However, the child may rapidly deteriorate into cold shock, manifested by a decreased level of consciousness and cool, clammy skin.

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment

Oxygen at 2L/min by nasal cannula In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%.

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular funciton. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is

Blood pressure By the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be monitored closely before the blood pressure drops

The nurse is assessing an acutely ill patient. When prioritizing the patient's care, the nurse should recognize that the patient is at risk for hypovolemic shock when

Fluid circulating in the blood vessel decreases. Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and the pulse is fast but weak.

A nurse is caring for a client who has arrived at the emergency department in shock? The nurse intervenes based on the knowledge that which of the following is the most common cause of shock?

Hypovolemia Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.

Progressive stage

Involves metabolic acidosis, lethargy and rapid, shallow respirations.

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis?

Irreversible The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis.

A client receives alteplase (t-PA). It is most important for the nurse to intervene when

The client's Glasgow Coma Score changes from 15 to 13. Alteplase is a thrombolytic. It is important for the nurse to assess for bleeding. A change in Glasgow Coma Score may indicate cerebral hemorrhage. Bleeding at venous puncture sites and possibly in the joints is less critical. A normal sinus rhythm with few premature ventricular contractions may be an improvement in the client's cardiac status and indicates lysis of thrombi in the coronary arteries.

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next

administers oxygen by nasal cannula at 2 liters per minute The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse to address physiological needs first by administering oxygen.

A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcomes does the nurse note as the result of inadequate compensatory mechanisms?

organ damage When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death.

The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks "what causes the body to go into shock?" Given the client's condition, which statement is most correct?

"The client is in shock because the blood volume has decreased in the system" Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock, where the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma, frequently occurs with accidents.

When vasoactive medications are administered, the nurse must monitor vital signs at least how often?

15 minutes When vasoactive medications are administered, the nurse must monitor vitals frequently

The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report?

24 The pulse pressure is the numeric difference between systolic and diastolic blood pressure. By subtracting the two numbers, the physician would be told 24. The pulse pressure does not report quality of the pulse.

The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?

5% albumin Typically, if colloids are used to treat tissue hypoperfusion, albumin is the agent prescribed. Albumin is a plasma protein; an albumin solution is prepared from human plasma and is heated during production to reduce its potential to transmit disease. The disadvantage of albumin is its high cost compared to crystalloid solutions.

The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client?

Adrenergic drugs Adrenergic drugs are the main medications used to treat shock due to their actions on the receptors of the sympathetic nervous system.

Which colloid is expensive but rapidly expands plasma volume?

Albumin Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure.

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors?

Aorta Arterial baroreceptors are located in the carotid sinus and the aorta.

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?

Aortic insufficiency A history of aortic insufficiency contraindicates use of the IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli.

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is:

Blood pressure By the time blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at the risk for shock must be monitored closely before the blood pressure drops.

Which of the following is a clinical characteristic of neurogenic shock?

Bradycardia The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.

Anaphylactic shock

Caused by an identifiable offending agent such as a bee sting

Septic shock

Caused by bacteremia in the blood and presents with a tachycardia.

The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing?

Compensatory stage In the compensatory stage of shock, the BP remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. In all other stages, hypotension is present as compensatory mechanisms no longer suffice to maintain normal blood pressure.

What is negative effect of IV nitroglycerin for shock management that the nurse would asses for in a client?

Decrease blood pressure. A potentially serious side effect of IV nitroglycerin (Tridil) is hypotension. Blood pressure needs to be monitored frequently according to the manufacturer's recommendation and institutional policy.

The nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the different categories of shock. Which of the following is a category of shock?

Distributive The four main categories of shock are hypovolemic, circulatory (distributive), obstructive, and cardiogenic, depending on the cause.

The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock?

Distrubtive Three types of distributive shock are neurogenic, septic, and anaphylactic shock.

Compensatory stage

Encompasses decreased urinary output, confusion, and respiratory alkalosis.

A client presents to the emergency department after being stung by a bee, complaining of difficulty breathing. What vasoconstrictive medication should be given at this time?

Epinephrine Anaphylactic shock is caused by a severe allergic reaction, such as to a bee sting, when patients who have already produced antibodies to a foreign substance (antigen) develop a systemic antigen- antibody reaction; specifically, an immunoglobulin E (IgE)- medicated response. Intramuscular epinephrine is administered for its vasoconstrictive action.

Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply.

Famotidine (Pepcid) Nizatidine Lansoprazole Antacids, H2 blockers (Pepcid, Axid) and/or proton pump inhibitors (Prevacid) are prescribed to prevent ulcer formations by inhibiting gastric acid secretion or increasing gastric pH.

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes?

Head injury An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but his position is contraindicated for patients with head injuries.

Which phase of the psychological reaction to rape is characterized by fear and flashbacks?

Heightened anxiety phase During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks.

What is the major clinical use of dobutamine?

Increase cardiac output Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery.

When preparing a plan of care for a client in hypovolemic shock, which partial nursing diagnosis might be relevant to the patient's condition?

Ineffective Tissue Perfusion Hypovolemic shock is caused by the loss of intravascular fluids, including blood.

A patient is in teh progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with?

Intubation and mechanical ventilation Decompensation of the lungs increases the likelihood that mechanical ventilation will be needed.

Which positioning strategy should be used for the client diagnosed with hypovolemic shock?

Modified Trendelenburg A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood and can be used as a dynamic assessment of a client's fluid responsiveness.

The ICU nurse is caring for a patient in shock. What is one of the most important functions of the nursing role in caring for this patient?

Monitoring for complications and side effects of treatment General nursing measures include ensuring safe administration of prescribed fluids and medications and documenting their administration and effects. An important function of the nursing role is monitoring for complications and side effects of treatment and reporting them promptly.

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed?

Narrowed pulse pressure Pulse pressure correlates well with stroke volume. Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP. Decreased or narrowing pulse pressure is an early indication of decreased stroke volume.

A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock?

Neurogenic shock Injury to the spinal cord or head or overdoses of opioids, opiates, tranquilizers, or general anesthetics can cause neurogenic shock.

A nurse in the ICU receives report from the nurse in the ED about a new patient being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing?

Neurogenic shock Neurogenic shock can be caused by spinal cord injury. In this case, it resulted by diving into waters of unknown depth. The patient will present with a low blood pressure, bradycardia, and warm dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation.

A nurse caring for clients in a PACU assesses a client who is displaying signs and symptoms of shock. What is the priority nursing intervention for this client?

Place the client in a flat position with legs elevated 45 degrees. Placing the client in a flat position with the legs elevated 45 degrees uses gravity to help direct blood to the vital organs.

Hypovolemic shock

Presents with tachycardia and a probable source of blood loss.

Morphine sulfate has which of the following effects on the body?

Reduces preload In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filing pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload).

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock?

Septic In the early stage of septic shock, the blood pressure may remain normal, the heart rate tachycardic, the respiratory rate increased, and fever with warm, flushed skin.

When a client is in the compensatory stage of shock, which symptoms occurs?

Tachycardia The compensatory stage of shock encompasses a normal blood pressure, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.

The nurse has assessed a 6 year old child as having respiratory distress due to swelling of the epiglottis and surrounding structures. Which signs and symptoms would support this assessment?

The child is in tripod position. Inflammation and swelling of the epiglottis and surrounding are common in children ages 2 to 7 years. The child will attempt to improve his/her airway by sitting forward and extending the neck forward with the jaw up, in a "sniffing position" (tripod position).

A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is:

A myocardial infarction. Cardiogenic shock is seen most frequently as a result of a myocardial infarction.

The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stage?

A rapid, bounding pulse A rapid, bounding pulse is observed in a client in the initial stages of septic shock.

The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages?

A rapid, bounding pulse A rapid, bounding pulse is observed in a client in the initial stages of septic shock.

A large volume of intravenous fluids is being admistered to an elderly client who experienced hypvolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction?

Jugular venous distention When administering large volumes of fluid replacement, the nurse monitors the client for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. The nurse assesses for jugular vein distention. Decreased pulse rate, when the client is tachycardic as in hypovolemic shock, would indicate improvement. The client would also exhibit a positive increase in the fluid balance ratio when responding appropriately to treatment. The client should exhibit vesicular breath sounds.

The nurse is aware that fluid replacment is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis?

Lactated Ringer's Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.

The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion.

60 mm Hg Mean arterial pressure is cardiac output x peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients.

The ICU nurse is required to closely monitor four clients diagnosed with shock. During the shift assessment, the nurse documents the following values for the client. Which client is most stable?

Client C: Heart rate 115 beats per minute, systolic BP 129 mm Hg, urine output 60mL/hr. The stability of the client's condition is evidenced by a heart rate between 60 and 120 beats per minute, systolic BP between 90 and 139 mm Hg, urine output greater than 35 to 50mL/hr, and capillary refill time between 2 and 3 seconds.

The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by:

Cold, clammy skin and tachycardia. In the preshock stage, the patient begins to lose tissue perfusion but compensates initially. Therefore, early signs of shock are evident.

A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynaic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to:

Constrict blood vessels in the cardiorespiratory system. Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.

A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to:

Constrict blood vessels in the cardiorespiratory system. Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.

A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn medications would the nurse administer next?

ondansetron An antiemetic medication, such as ondansetron (Zofran), is administered for vomiting. It would be administered before loperamide (Imodium) for diarrhea so the client would be able to retain the loperamide.