Shock and Multiple Organ Dysfunction Syndrome (Ch. 14)

Which of the following colloids is expensive but rapidly expands plasma volume?

Albumin

A client receives alteplase (t-PA). It is most important for the nurse to intervene when a) The client's cardiac rhythm changes to normal sinus with few PVCs. b) A small amount of bleeding occurs at venous puncture sites. c) The client's Glasgow Coma Score changes from 15 to 13. d) The client reports joint pain in the knees and elbows.

C

The nurse is monitoring a patient in the compensatory stage of shock. What lab values does the nurse understand will elevate in response to the release of aldosterone and catecholamines?

Sodium and glucose levels

medications to prevent ulcer formation

antacids, H2 blockers: famotidine(pepcid) ranitidine (zantac) PPI: lansoprazole (prevacid)

older adults are more likely to develop which type of shock?

cardiogenic

which position should be used for patient with hypovolemic shock?

modified trandelenburg (elevation of legs promotes return of venous blood)

primary cause of cardiogenic shock

myocardial infarction

Symptoms during the compensatory stage of shock

normal BP, tachycardia, decreased urinary output, respiratory alkalosis, confusion

Pt at increased risk of MODS

older, malnourished, coexisting diseases

How is CVP reading in hypovolemic shock typically affected?

typically low (increases with effective tx and significantly increased with fluid overload and HF

indicator of renal hypoperfusion

urinary output <30mL/hr or <300 mL in 12 hours is oliguria

What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk?

use strict hand hygiene techniques

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

Administer O2 by nasal cannula at 2L/min.

The nurse is caring for a patient newly diagnosed with sepsis. The patient has a serum lactate level of 6 mmol/L and fluid resuscitation has been initiated. What indicates that the fluid resuscitation received by the patient is adequate? CVP MAP Urine Output ScvO2

CVP of 8 to 12 mm Hg MAP > 65 mm Hg urine output > 0.5 mL/kg/hr ScvO2 > 70%.

The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find?

HR >100bpm crackles lethargy, mental confusion respirations >20 breaths/min respiratory alkalosis respirations rapid and shallow

You are caring for a client with a stage IV leg ulcer. You are closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that you should notify the physician of immediately?

HR >90bpm RR >20breaths/min

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

JVD Cardiovascular overload, difficulty breathing, pulmonary edema

fluid that helps treat acidosis

Lactated Ringer's lactate ion converted by liver to bicarbonate (thus assisting with acidosis)

A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to a)Encourage the family to touch and talk to the client. b) Inform the family that everything is being done to assist with the client's survival. c) Open up discussion among the family members about nursing home placement. d) Contact a spiritual advisor to provide comfort to the family.

a

The nurse is assisting the physician with placing a ventricular assist device (VAD). Which assessment finding would confirm the successful implementation?

Pedal pulse stronger

CI for IABP

aortic insufficiency, aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystem failure, chronic debilitating disease, bleeding disorders, history of emboli

etiologies of shock(3)

blood volume decreases the heart fails as an effective pump peripheral blood vessels massively dilate

During preshock, the compensatory stage of shock, which organ will always be protected?

brain

Most common and serious side effects of fluid replacement (2)

cardiovascular overload and pulmonary edema

Where are arterial baroreceptors (monitor arterial pressure) located

carotid sinus and aorta

which stage of shock: patient's BP remains within normal limits due to vasoconstriction, increased HR 100-150, respirations >20 increased cardiac contractility

compensatory

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers

continuous infusion of total parenteral nutrition (supplementation initiated within 24 h of start of septic shock; if client has reduced peristalsis-- parenteral feeding tube required

client sitting in bed experiences transient neurogenic shock following insertion of an intravenous catheter. what should the nurse do first

lay the client flat with the feet elevated (minimize pooling of blood and restore blood flow to the brain)

what is shock?

life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissue is inadequate

A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position?

modified trendelenburg

The nurse is caring for a client who is developing hypovolemic shock from a duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain?

modified trendelenburg position

three types of circulatory/distributive shock

neurogenic septic anaphylactic

For which of the following patients in shock would a nurse observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment?

overwhelming bacterial infection (septic shock)

Which stage of shock: mechanisms that regulate BP can no longer compensate and the MAP falls below normal limits

progressive stage

what clinical manifestation correlates with stroke volume

pulse pressure decreased SV= narrowed pulse pressure

what kind of pulse would you observe in a client in initial stages of shock

rapid, bounding pulse

Compensatory mechanisms during compensation stage(3)

release of catecholamines activation of renin-angiotensin-aldosterone system production of antidiuretic and corticosteroid hormones

appropriate colloid solutions for hypovolemic shock resulting from hemorrhage

salt-poor albumin hetastarch packed RBCs

Indicators of DIC as complication of shock

simultaneous widespread clotting + bleeding bruises/ecchymoses and bleeding/petechiae PT, aPTT prolonged clotting factors and platelets require replacement therapy

causes of neurogenic shock

spinal cord or head injury; overdose of opioids, opiates, tranquilizers, general anesthetic

external(fluid losses) causes of hypovolemic shock

trauma surgery vomitting diarrhea diuresis diabetes insipidus

major clinical use of dobutamine (Dobutrex)

increase cardiac output

the body must exceed ___ mmHg MAP for cells to receive oxygen and nutrients

65

type of shock that occurs from an antigen-antibody response

anaphylactic

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."

management of all phases of shock include:

1)support of respiratory system with supplemental O2 and/or mechanical ventilation fluid replacement to restore intravascular volume vasoactive meds to restore vasomotor tone and improve cardiac function nutritional support to address the metabolic requirements

typical colloidal solution administered for hypovolemic shock

5% albumin

normal ScvO2 (continuous central venous oximetry) value

70%

Systolic BP supporting diagnosis of shock

<80 mmHg

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? a) "Infuse I.V. fluids at 83 ml/hour." b) "Monitor urine output every hour." c) "Draw samples for hemoglobin and hematocrit every 6 hours." d) "Administer oxygen by nasal cannula at 3 L/minute."

A Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem

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: a) Dopamine (Intropin) intravenous solution b) Oxygen at 2 L/min by nasal cannula c) NS at 60 mL/hr via an intravenous line d) Morphine 2 mg intravenously

B

Early stage of septic shock symptoms

BP normal, tachycardia, inc. RR, fever, warm flushed skin

Most important measure of shock

Blood Pressure

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.)

A client has the following vital signs: temperature 101.4 degrees F, blood pressure 88/54, pulse 128 beats/minute, and respirations 34 breaths/minute. Physician orders are shown in the accompanying chart. The nurse first intervenes by a) Providing acetaminophen for the elevated temperature b) Obtaining the blood cultures c) Administering the Vancomycin d) Increasing DRLR to the prescribed rate

D.

The nurse is caring for a male patient in the early stages of sepsis. The patient is not responding well to fluid resuscitation measures and his hemodynamic status is worsening. Which of the following nursing interventions is most appropriate for the nurse to implement? a) Administer recombinant human activated protein C (rhAPC) (Xigris) as prescribed. b) Initiate enteral feedings as prescribed. c) Begin a continuous IV infusion of insulin per protocol. d) Administer norepinephrine as prescribed.

D. (vasopressors are used if fluid resuscitation does not restore an effective BP

CI colloid solution in hemorrhaging- 74/52BP, 124HR, RR 32 breaths/min

Dextran (interferes with platelet aggregation in clients in hypovolemic shock as a result of hemorrhage

Which stage of shock: organ damage is so severe that the patient does not respond to treatment and cannot survive

Refractory/ irreversible

3 physiologic response common to all shock states

activation of inflammatory response hypoperfusion of tissues must produce E through anaerobic metabolism

nursing intervention to decrease myocardial oxygen consumption

activity restriction to bedrest

patient receiving fluid replacement should be monitored frequently for:

adequate urinary output, changes in mental status, skin perfusion, changes in vital signs, lung sounds(crackles may indicate pulm edema)

While caring for a client in shock who is deteriorating, you are infusing IV fluids and most likely giving what kind of meds?

adrenergic drugs

Medications which prevent ulcer formation

antacids, H2 Blockers (Famotidine-Pepcid, Ranitidine-Zantac) proton pump inhibitors (Lansoprazole-Prevacid)

which stage of shock: compensatory mechanisms fail cellular hypoxia, coagulation defects, cardiovascular changes E supply falls below demand, pyruvic and lactic acid increase--> metabolic acidosis

decompensation stage

two actions of morphine sulfate that reduce cardiac workload

decrease cardiac filling pressure-- preload reduce pressure against which the heart muscle has to eject blood-- afterload

increased or decreased pulse pressure is early indicator of shock?

decreased/narrowed

what is pulse pressure

difference between systolic and diastolic pressure

In which type of shock does the patient experience a mismatch of blood flow to the cells?

distributive

elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which process? head injury myocardial infarction

head injury

internal (fluid shift) causes of hypovolemic shock

hemorrhage burns ascites peritonitis dehydration

positive inotropic effect:

increase the force of myocardial contraction

You are caring for a client in the compensation stage of shock. You know that in this stage of shock adrenaline and noradrenaline are released into the circulation. What positive effect does this have on your client?

increases myocardial contractility

expected treatment for patient in progressive stage of shock with lung decompensation

intubation and mechanical ventilation