Shock, Sepsis, and Multiple Organ Dysfunction Syndrome (Iggy ch. 37 & Urden ch. 34)

Which type of shock has the following hemodynamic manifestations: increased cardiac output (CO), increased cardiac index (CI), decreased right atrial pressure (RAP), decreased systemic vascular resistance (SVR), and decreased pulmonary artery occlusion pressure (PAOP)? Septic Cardiogenic Anaphylactic Neurogenic

Septic - Clinical manifestations of septic shock include increased cardiac output (CO) and cardiac index (CI), decreased systemic vascular resistance (SVR), decreased right atrial pressure (RAP), and decreased pulmonary artery occlusion pressure (PAOP).

A client with septic shock is to receive dopamine at 18 mcg/kg/min. The client's weight is 154 pounds. How many mcg/min does the nurse administer?

1260 mcg/min - First convert pounds to kilograms: 154 lb ÷ 2.2 = 70 kg. Then, 70 kg × 18 mcg/kg/min = 1260 mcg/min.

The client in shock has the following vital signs: T 99.8°F, P 132 beats/min, R 32 breaths/min, and BP 80/58 mm Hg. Calculate the pulse pressure. *Normal Pulse Pressure?*

22 mm Hg *Pulse pressure is the difference between the systolic and diastolic blood pressure.* For example, if resting blood pressure is 120/80 mmHg, then the pulse pressure is 40 mmHg.

A nurse is working on a spinal cord injury unit and has just finished shift report. Which patient should be seen first? 24-year-old man who has not had a bowel movement since yesterday 28-year-old woman who is complaining of being cold 32-year-old man whose blood pressure is 84/40 mm Hg and heart rate is 60 beats/min 18-year-old woman whose dose of low-molecular-weight heparin is due

32-year-old man whose blood pressure is 84/40 mm Hg and heart rate is 60 beats/min - The 32-year-old man is in danger of *neurogenic shock* and needs to be evaluated. - Constipation is an issue, but a patient who has had it for 1 day is not the priority patient. - The patient complaining of cold and the patient who needs low-molecular-weight heparin are important, but the hypotension coupled with the bradycardia signifies a problem with sympathetic nervous system integrity.

Which problem places a person at highest risk for septic shock? Kidney failure Cirrhosis Lung cancer 40% burn injury

40% burn injury - A client with 40% burn injury is at highest risk for septic shock and possible death. *The skin forms the first barrier to prevent entry of organisms into the body.* - Although the client with kidney failure has an increased risk for infection, his skin is intact, unlike the client with burn injury. - *Although the liver acts as a filter for pathogens, the client with cirrhosis has intact skin, unlike the burned client.* - The client with lung cancer may be at risk for increased secretions and infection, but risk is not as high as for a client with open skin.

The nurse is caring for a client in the refractory stage of cardiogenic shock. Which intervention does the nurse consider? Admission to rehabilitation hospital for ambulatory retraining Collaboration with home care agency for return to home Discussion with family and provider regarding palliative care Enrollment in a cardiac transplantation program

Discussion with family and provider regarding palliative care - When caring for a client in the refractory stage of cardiogenic shock the nurse considers discussing palliative care with the family and provider. *In this IRREVERSIBLE phase, therapy is NOT effective in saving the client's life, even if the cause of shock is corrected and mean arterial pressure temporarily returns to normal.* A discussion on palliative care would be considered. - Rehabilitation or returning home is unlikely. - *The client with sustained tissue hypoxia is NOT a candidate for organ transplantation.*

The nurse notes that the patient's arterial blood gases reflect hypoxia, respiratory alkalosis, scattered crackles, and distended jugular veins. Heart tones are distant, but an S3 and S4 are noted despite scant amounts of concentrated urine output. The nurse anticipates the administration of which therapy? Isotonic saline Amiodarone Furosemide Sodium bicarbonate

Furosemide - The patient is experiencing cardiogenic shock and would require furosemide. - Administration of fluids (isotonic saline) and sodium bicarbonate would be contraindicated at this time. - *Amiodarone would only be indicated if the patient were having dysrhythmias.*

What is a priority nursing diagnosis for the patient in shock regardless of the phase or type? Deficient fluid volume Ineffective breathing pattern Ineffective tissue perfusion Imbalanced nutrition: less than body requirements

Ineffective tissue perfusion - *Ineffective tissue perfusion is the priority nursing diagnosis for a patient in shock.* - Deficient fluid volume is important in hypovolemic shock. Ineffective breathing pattern and imbalanced nutrition are also important but are not the priority diagnosis.

Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? Localized erythema and edema Low-grade fever and mild hypotension Low oxygen saturation rate and decreased cognition Reduced urinary output and increased respiratory rate

Low-grade fever and mild hypotension - *Low-grade fever and mild hypotension in a postoperative client indicate very early sepsis. With treatment, the probability of recovery is high.* - Localized erythema and edema indicate local infection, NOT sepsis. - A low oxygen saturation rate and decreased cognition indicate SEVERE sepsis - Reduced urinary output and increased respiratory rate indicate active (not early) sepsis.

Which shock state includes hypotension despite adequate fluid resuscitation along with perfusion abnormalities such as lactic acidosis, oliguria, or acute change in mentation? Neurogenic Cardiogenic Anaphylactic Septic

Septic - *Septic shock includes hypotension despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status.* - Patients who are receiving inotropic or vasopressor agents may not be hypotensive at the time that perfusion abnormalities are measured. - *Neurogenic, anaphylactic, and cardiogenic shock are NOT refractory to fluid resuscitation.*

The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? Hypotension Bradypnea Heart blocks Tachycardia

Tachycardia - *Tachycardia is an early symptom of shock.* Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. - *Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be NORMAL.* Early in shock, the client displays rapid, not slow, respirations. *Dysrhythmias are a LATE sign of shock; they are related to lack of oxygen to the heart.*

What typical sign/symptom indicates the early stage of SIRS? Pallor and cool skin Blood pressure 84/50 mm Hg Tachypnea and tachycardia Respiratory acidosis

Tachypnea and tachycardia - Early signs/symptoms of systemic inflammatory response syndrome include rapid respiratory rate, leukocytosis, and tachycardia. - *In the early stage of septic shock, the client is usually warm and febrile.* - Hypotension does not develop until later in septic shock due to compensatory mechanisms. - Respiratory alkalosis and not acidosis occurs early in shock because of an increased respiratory rate.

Collaborative Care: Sepsis

eat shit.

Cardiogenic Shock *(What it is, dysfunction of?)* *(As left ventricular contractility declines, _____)*

- *Cardiogenic shock is due to failure of the heart to effectively pump blood forward. It can occur with dysfunction of the right or the left ventricle, or both.* - The lack of adequate pumping function leads to *decreased tissue perfusion and circulatory failure.* It occurs in approximately 5% to 8% of the patients with an ST segment myocardial infarction (MI), and it is the leading cause of death of patients hospitalized with MI. - *As left ventricular contractility declines and ventricular compliance decreases, an increase in end-systolic volume results in blood backing up into the pulmonary system and the subsequent development of pulmonary edema.* Pulmonary edema causes impaired gas exchange and decreased oxygenation of the arterial blood, which further impair tissue perfusion. *Death caused by cardiogenic shock results from cardiopulmonary collapse or multiple-organ failure.*

Cardiogenic Shock: Treatment *(Drug therapy ; Surgical)* *(Inotropic drug of choice? Hypotensive drug of choice?)* *(intraaortic balloon pump use?)*

- *Inotropic agents are used to increase contractility and maintain adequate blood pressure and tissue perfusion. Dobutamine is the inotrope of choice.* - *A vasopressor, preferably norepinephrine, may be necessary to maintain blood pressure when hypotension is severe.* NOTE: As both of these therapies increase myocardial oxygen demand, the *lowest possible doses should be used.* - *Diuretics may be used for preload reduction.* Vasodilating agents are used for preload and afterload reduction only in specific situations in conjunction with an inotrope or when the patient is no longer in shock. *Antidysrhythmic agents* should be used to suppress or control dysrhythmias that can affect CO. *Intubation and mechanical ventilation are usually necessary to support oxygenation.* - The intraaortic balloon pump (IABP) is used to decrease myocardial workload by improving myocardial supply and decreasing myocardial demand. - Nursing interventions include limiting myocardial oxygen demand, enhancing myocardial oxygen supply, maintaining adequate tissue perfusion, providing comfort and emotional support, and preventing and maintaining surveillance for complications. Measures to limit myocardial oxygen demand include administering analgesics, sedatives, and agents to control afterload and dysrhythmias; positioning the patient for comfort; limiting activities; providing a calm and quiet environment and offering support to reduce anxiety; and teaching the patient about the condition. Measures to enhance myocardial oxygen supply include administering supplemental oxygen, monitoring the patient's respiratory status, administering prescribed medications, and managing device therapy.

Types of Shock *(4 groups)*

- *More than one type of shock can be present at the same time!* For example, trauma caused by a car crash may trigger hemorrhage (leading to *hypovolemic shock*) and a myocardial infarction (leading to *cardiogenic shock*). - *Hypovolemic shock* occurs when too little circulating blood volume decreases MAP, resulting in inadequate total body PERFUSION and GAS EXCHANGE. Common problems leading to hypovolemic shock are *dehydration and poor CLOTTING with hemorrhage.* - *Cardiogenic shock* occurs when the heart muscle is unhealthy and pumping is impaired. *Myocardial infarction is the most common cause of direct pump failure.* Any type of pump failure decreases cardiac output and MAP. - *Distributive shock occurs when blood volume is NOT lost from the body but is distributed to the interstitial tissues where it cannot perfuse organs.* It can be caused by blood vessel dilation, pooling of blood in venous and capillary beds, and increased capillary leak. All these factors decrease MAP and may be started either by nerve changes (neural-induced) or by the presence of some chemicals (chemical-induced). - *Obstructive shock* is caused by problems that impair the ability of the normal heart to pump effectively. *The heart itself remains normal, but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle.* The most common cause of obstructive shock is *cardiac tamponade.*

Review of Gas Exchange and Tissue Perfusion *(Perfusion is r/t ____ ; Factors that influence MAP)* *(Increases in total blood volume or CO increase/decrease MAP?)* *(Vasodilation increases/decreases BP?)*

- *Perfusion is related to mean arterial pressure (MAP).* The factors that influence MAP include: • Total blood volume • Cardiac output (amount of blood pumped by the heart per minute; HR x SV) • Size and integrity of the vascular bed, especially capillaries - Total blood volume and cardiac output are directly related to MAP, so *increases in either total blood volume OR cardiac output raise MAP.* *Decreases in either total blood volume OR cardiac output lower MAP.* - *The size of the vascular bed is inversely (negatively) related to MAP.* * This means that increases in the size of the vascular bed lower MAP and decreases raise MAP* - *When blood vessels DILATE and total blood volume remains the same, blood pressure DECREASES and blood flow is slower.* When blood vessels CONSTRICT and total blood volume remains the same, blood pressure INCREASES and blood flow is faster. - FIG. 37-1 Interaction of blood volume and the size of the capillary bed affecting mean arterial pressure (MAP).

Respiratory and Cardiac changes during shock *(ARDS is caused by?)*

- *Respiratory changes* are first caused by compensatory mechanisms that try to maintain oxygenation with a rate increase. The lungs are susceptible to damage, and the complication of *acute respiratory distress syndrome (ARDS) may occur in septic shock.* ARDS in septic shock is caused by the continued systemic inflammatory response syndrome *(SIRS) increasing the formation of oxygen free radicals, which damage lung cells. ARDS in a patient with septic shock has a high mortality rate.*

Sepsis and Septic Shock defined *using the SIRS Criteria* *(Temp, Respirations/PaCO2, HR, WBC)* *(Sepsis is indicated by?)* *(Severe Sepsis is indicated by?)* *(Septic Shock is indicated by?)*

- *Sepsis occurs when microorganisms invade the body and initiate a systemic inflammatory response.*

Sepsis and Septic Shock *(Starts as ___ ; Develops into ___ )* *(Severe sepsis criteria)*

- *Sepsis* leading to *septic shock* is a complex type of *DISTRIBUTIVE shock* that usually begins as a *bacterial or fungal infection* and progresses to a critical emergency over a period of days. - As *progression* occurs, the pathologic problems occur faster and to a greater degree. *Thus control of sepsis and prevention of severe sepsis and septic shock are easier to achieve early in the process.* Failure to recognize and intervene in early sepsis is a major factor for progression to septic shock and death.

Shock *(characterized by ____ and _____)* *(Imbalance b/t _____ and ____)* *(Classifications of shock)*

- *Shock is an acute, widespread process of impaired tissue perfusion that results in cellular, metabolic, and hemodynamic alterations.* Ineffective tissue perfusion occurs when an *imbalance* develops between *cellular oxygen supply and cellular oxygen demand.* This imbalance can occur for a variety of reasons and eventually results in cellular dysfunction and death.

Stages of Shock: Progressive stage *(Occurs when baseline MAP is decreased by ___)* *(Vital organs develop ___, and less vital organs become ___)* *(Clinical findings- pulse, bp, skin, O2, ABG)*

- *The Progressive stage of shock occurs when there is a sustained decrease in MAP of more than 20 mm Hg from baseline.* Compensatory mechanisms are functioning but can no longer deliver sufficient oxygen, *even to vital organs.* - *Vital organs develop hypoxia, and less vital organs become anoxic (no oxygen) and ischemic (cell dysfunction or death from lack of oxygen).* As a result of poor PERFUSION and a buildup of metabolites, some tissues die. - Indications of the progressive stage include a WORSENING of changes resulting from decreased tissue PERFUSION. The patient may express a sense of "something bad" (impending doom) about to happen. He or she may be confused, and thirst increases. *Objective changes are a rapid, weak pulse; low blood pressure; pallor to cyanosis of oral mucosa and nail beds; cool and moist skin; anuria; and a 5% to 20% decrease in oxygen saturation.* Laboratory data may show a *low blood pH, along with rising lactic acid and potassium levels.*

Stages of Shock: Non-progressive stage *(Occurs when baseline MAP is decreased by ___)* *(Ongoing decrease in MAP triggers what organ to compensate by releasing what?)* *(Tissue hypoxia occurs in ____ organs)*

- *The nonprogressive stage of shock occurs when MAP decreases by 10 to 15 mm Hg from baseline.* Kidney and hormonal compensatory mechanisms are activated because cardiovascular responses alone are not enough to maintain MAP and supply oxygen to vital organs. - The ongoing decrease in MAP triggers the release of *renin*, antidiuretic hormone (ADH), aldosterone, epinephrine, and norepinephrine to start *KIDNEY compensation.* Urine output DECREASES, sodium reabsorption INCREASES, and widespread blood vessel CONSTRICTION occurs. *Together these actions compensate for shock by maintaining the fluid volume within the central blood vessels.* - Tissue hypoxia occurs in *nonvital organs (e.g., skin, GI tract)* and in the *kidney*, but it is NOT great enough to cause permanent damage. Buildup of metabolites from anaerobic metabolism causes *acidosis (low blood pH) and increased blood potassium levels.* - Objective changes include restlessness, tachycardia, increased respiratory rate, decreased urine output, *falling systolic blood pressure, rising diastolic blood pressure,* narrowing pulse pressure, cool extremities, and a 2% to 5% decrease in oxygen saturation. *Comparing these changes with the values and observations obtained earlier is critical to identifying this stage of shock.*

Septic Shock: Treatment *(Fluid replacement of choice?)* *(Glucose should be <___)* *(CVP should be > ___)*

- A patient in sepsis or septic shock requires immediate resuscitation of the hypoperfused state. - Specific interventions have been aimed at increasing cellular oxygen supply and decreasing cellular oxygen demand. *These treatments include administration of fluids, vasopressors, and possibly positive inotropic agents, initially given in the form of a protocolized, quantitative resuscitation to be implemented during the first 6 hours of treatment*

Cardiogenic Shock: *Lab/Diagnostic Tests* *(Normal lactate levels? Urine output/hr)* *(Troponin higher than ___ indicates MI)*

- An *echocardiogram (echo)* is a test that uses high frequency sound waves (ultrasound) to make pictures of your heart.

Anaphylactic Shock *(Results from? Leads to?)* *(Release of mediators causes?)* *(Peripheral vasodilation results in)*

- Anaphylactic shock, a type of *distributive shock,* is the result of an *immediate hypersensitivity reaction.* It is a life-threatening event that requires prompt intervention. The severe and systemic response leads to *decreased tissue perfusion* and *initiation of the general shock response.* - Numerous triggers have been identified such as foods, food additives, diagnostic agents, biologic agents, environmental agents, medications, and venoms. - Both immunologic and non-immunologic activation of the mast cells and basophils results in the *release of biochemical mediators.* - *The activation of the biochemical mediators causes VASODILATION;* increased capillary permeability; laryngeal edema; bronchoconstriction; excessive mucus secretion; *coronary vasoconstriction; inflammation;* cutaneous reactions; and constriction of the smooth muscle in the intestinal wall, bladder, and uterus. *Coronary vasoconstriction causes severe myocardial depression.* Cutaneous reactions cause stimulation of nerve endings, followed by itching and pain.

SIRS: How does edema occur?

- Capillary leak occurs, allowing plasma to leak into the tissues. This response causes swelling (edema).

Hypovolemic Shock *(Inadequate ___ ____ in _____ space)* *(Relative vs Absolute)* *(Hypovolemic shock always leads to ___ ___ if left untreated)*

- Hypovolemic shock occurs from *inadequate fluid volume* in the *intravascular space.* The lack of adequate circulating volume leads to *decreased tissue perfusion* and initiation of the general shock response. Hypovolemic shock is the most commonly occurring form of shock. Hypovolemic shock can result from absolute OR relative hypovolemia. -*Absolute hypovolemia occurs when there is a loss of fluid from the INTRAVASCULAR space EXTERNALLY* (Hemorrhage, GI loss (e.g., vomiting, diarrhea), Fistula drainage, Diabetes insipidus- polyuria) - *Relative hypovolemia* Results when fluid volume moves out of the vascular space into extravascular space (e.g., interstitial or intracavitary space) *Fluid shifts can be due to a loss of intravascular integrity, increased capillary membrane permeability, or decreased colloidal osmotic pressure (COP).*

Cardiogenic Shock: Assessment and Diagnosis *(Systolic BP, MAP, HR, PP, lungs, CO, etc.)*

- Initially, clinical manifestations reflect the *decline in CO.* These signs and symptoms include *systolic blood pressure less than 90 mm Hg, mean arterial pressure less than 65 mm Hg, or an acute drop in systolic or mean blood pressure of 30 mm Hg or more.* - *Tachycardia develops to compensate for the decrease in CO. A weak, thready pulse develops,* and diminished S1 and S2 heart sounds may occur as a result of the *decreased contractility.* - The respiratory rate increases to improve oxygenation. *ABG values at this point indicate respiratory alkalosis, as evidenced by a decrease in PaCO2.* - *As the left ventricle fails, auscultation of the lungs may disclose crackles and rhonchi, indicating the development of pulmonary edema.* Hypoxemia occurs, as evidenced by a fall in PaO2 and SaO2 as measured by ABG values.

Distributive Shock: Neurogenic Shock *(Results from loss of ____ ____ ; Leading to ___)* *(Spinal cord injury above ___)* *(Massive ____ r/t loss of ___ function)* *(Clinical manifestations: BP, HR, skin)*

- Neurogenic shock, a type of *distributive shock*, is the result of the *loss or suppression of sympathetic tone.* The lack of sympathetic tone leads to *decreased tissue perfusion and initiation of the general shock response.* Neurogenic shock is the most uncommon form of shock. - *Neurogenic shock can be caused by anything that disrupts the SNS. The most common cause is spinal cord injury (SCI).* Neurogenic shock may mistakenly be referred to as *spinal shock.* Spinal shock refers to loss of neurologic activity below the level of SCI, but it does NOT necessarily involve ineffective tissue perfusion. - A patient in neurogenic shock characteristically presents with *hypotension, BRADYCARDIA, and warm, dry skin.* The decreased blood pressure results from *massive peripheral vasodilation.*

Anaphylactic Shock: Treatment *(Type of fluid replacement used and why?)* *(Drug to reverse Vasodilation?)*

- Rapid volume replacement with crystalloid or colloid solutions is also used for patients with hypotension. Vasopressors may be necessary to reverse the vasodilation and increase blood pressure. *Corticosteroids are NOT effective in the immediate treatment of acute anaphylaxis.*

Septic Shock *(Sepsis-induced _____ that persists despite _____)*

- Septic shock is *sepsis-induced hypotension persisting DESPITE adequate fluid resuscitation.* It is the stage of sepsis and SIRS when multiple organ dysfunction syndrome *(MODS) with organ failure* is evident and poor CLOTTING with *uncontrolled bleeding occurs.* - *Even with appropriate intervention, the death rate among patients in this stage of sepsis is very high!* - *Severe hypovolemic shock and hypodynamic cardiac function are present as a result of an inability of the blood to clot because the platelets and clotting factors were consumed earlier.* Vasodilation and capillary leak continue from vascular endothelial cell disruption, and cardiac contractility is poor from cellular ischemia. *The signs and symptoms resemble the late stage of hypovolemic shock.*

Stages of Shock: Initial stage *(Occurs when baseline MAP is decreased by ___)* *(Cellular changes include increased ____ metabolism, leading to production of ____)* *( Two compensatory responses)*

- The *initial stage* is present when the patient's *baseline MAP is decreased by less than 10 mm Hg.* - Compensatory mechanisms are effective at returning systolic pressure to normal at this stage; thus oxygen PERFUSION to vital organs is maintained. - Cellular changes include *increased anaerobic metabolism* in some tissues with production of *lactic acid, although overall metabolism is still aerobic.* - The *compensation* responses of *vascular constriction and increased heart rate* are effective, and both cardiac output and MAP are maintained within the normal range. *Because vital organ function is NOT disrupted, the indicators of shock are difficult to detect at this stage.*

Stages of Shock: Refractory Stage and Multiple Organ Dysfunction Syndrome (MODS) *(s/s)*

- The *refractory stage* of shock occurs when too much cell death and tissue damage result from too little oxygen reaching the tissues. *Vital organs have extensive damage and cannot respond effectively to interventions, and shock continues. So much damage has occurred with release of metabolites and enzymes that damage to vital organs continues despite interventions.* - The sequence of cell damage caused by the massive release of *toxic metabolites* and enzymes is termed *multiple organ dysfunction syndrome (MODS).* These trigger small clots *(microthrombi)* to form, which block tissue PERFUSION and damage more cells, continuing the devastating cycle. *Liver, heart, brain, and kidney functions are lost FIRST.* The most profound change is damage to the heart muscle. - *Signs are a rapid loss of consciousness; non-palpable pulse; cold, dusky extremities; SLOW, shallow respirations; and unmeasurable oxygen saturation.* *Therapy, including fluid replacement, is NOT effective in saving the patient's life, even if the cause of shock is corrected and MAP temporarily returns to normal.*

SURVIVING SEPSIS CAMPAIGN *(To be completed within 3 hours: four things)* *(To be completed within 6 hours: three things)* *(CVP target should be > __)*

- The Surviving Sepsis Campaign is a global initiative to bring together professional organizations in reducing mortality from sepsis. - The purpose of the SSC is to create an international collaborative effort to improve the treatment of sepsis and reduce the high mortality rate associated with the condition

Adaptive Responses and Events During *Hypovolemic Shock* *(Initial, Non-progressive, Progressive, and Refractory Stage)*

- The basic problem of *hypovolemic shock* is a loss of vascular volume, resulting in a decreased mean arterial pressure (MAP) - If the events that caused the initial decrease in MAP are halted through compensatory actions, compensatory mechanisms provide adequate GAS EXCHANGE and PERFUSION without intervention. If events continue and MAP decreases further, some tissues function under anaerobic conditions. This condition increases lactic acid levels and other harmful metabolites (e.g., protein-destroying enzymes, oxygen free radicals) - When shock conditions continue for longer periods without help, the resulting increased metabolites cause so much cell damage in vital organs that they are unable to perform their critical functions. When this problem, known as multiple organ dysfunction syndrome (MODS), occurs to the extent that vital organs die, recovery from shock is no longer possible

Hypovolemic Shock: Clinical manifestations *(s/s)* *(If blood loss is >____%, blood volume is replaced with _______)* *(Which fluid replacement should NEVER be given with shock?)*

- The major goals of therapy for a patient in hypovolemic shock are to correct the cause of the hypovolemia, restore tissue perfusion, and prevent complications. *This approach includes identifying and stopping the source of fluid loss, administering fluid to replace circulating volume, and administering vasopressor therapy to maintain tissue perfusion until volume is restored.*

Sepsis and *Systemic Inflammatory Response Syndrome (SIRS)* *(4 criteria, must have at least __)* *(Temp, Respirations/PaCO2, HR, WBC)* *(s/s- O2, RR, urine output, LoC)*

- The most recent definition of *sepsis* is a life-threatening organ dysfunction resulting from a *dysregulated host response to infection.* It occurs as the presence of infection with systemic signs and symptoms. - Infectious organisms have entered the bloodstream. As their numbers increase, *widespread inflammation, known as systemic inflammatory response syndrome (SIRS), is triggered as a result of infection escaping local control.* With the organisms and their toxins in the bloodstream and entering other body areas, *inflammation becomes an enemy,* leading to extensive hormonal, tissue, and vascular changes and oxidative stress that *further impair GAS EXCHANGE and tissue PERFUSION.* - The WBCs produce many *pro-inflammatory cytokines. Fever and hypotension result from SIRS.* The reduced urine output and increased respiratory rate are the compensatory responses to impaired GAS EXCHANGE and PERFUSION. - *Signs and symptoms include a lower oxygen saturation, rapid respiratory rate, decreased-to-absent urine output, and a change in the patient's cognition and affect.* Appropriate and aggressive interventions at this stage can still prevent septic shock, although mortality after a patient reaches this stage is much higher than for sepsis and SIRS. At this point, the downhill course leading to septic shock is extremely rapid.

Neurogenic Shock: Treatment *(Volume replacement is indicated for BP < ___)* *(What drug for Bradycardia?)* *(Venous pooling can lead to?)*

- Treatment of neurogenic shock requires a careful approach. *The goals of therapy are to treat or remove the cause, prevent cardiovascular instability, and promote optimal tissue perfusion.* Cardiovascular instability can result from hypovolemia, bradycardia, and hypothermia. Specific treatments are aimed at preventing or correcting these problems as they occur. - Hypovolemia is treated with careful fluid resuscitation. *Volume replacement is initiated for systolic blood pressure less than 90 mm Hg or evidence of inadequate tissue perfusion.* The patient is carefully observed for evidence of fluid overload. - Vasopressors are used as necessary to maintain blood pressure and organ perfusion. - *Venous pooling in the lower extremities promotes the formation of deep vein thrombosis (DVT), which can result in a pulmonary embolism.* All patients at risk for DVT should be started on *prophylaxis therapy.* Prophylactic measures include monitoring of passive range-of-motion exercises, application of sequential pneumatic stockings, and administration of prescribed anticoagulation therapy.

Which clients are at immediate risk for hypovolemic shock? *Select all that apply.* Unrestrained client in a motor vehicle collision (MVC) Construction worker Athlete Surgical intensive care unit (SICU) client 85-year-old with gastrointestinal (GI) virus

1,4,5 - Clients who are immediate risk for hypovolemic shock include: *the unrestrained client in a (MVC), the SICU client, and the 85-year-old client with GI virus.* The client who is unrestrained in a MVC is prone to multiple trauma and bleeding. Surgical clients are at high risk for hypovolemic shock owing to fluid loss and hemorrhage. Older adult clients are prone to shock, especially if a gastrointestinal virus is present that results in fluid losses. - Unless injured or working in excessive heat, the construction worker and the athlete are not at risk for hypovolemic shock. They may, however, be at risk for dehydration.

A client who is in the *progressive stage* of hypovolemic shock has all of the following signs, symptoms, or changes. Which ones does the nurse attribute to ongoing *compensatory* mechanisms? *Select all that apply.* A. Increasing pallor B. Increasing thirst C. Increasing confusion D. Increasing heart rate E. Increasing respiratory rate F. Decreasing systolic blood pressure G. Decreasing blood pH H. Decreasing urine output

A, B, D, E, H - *Compensatory mechanisms attempt to maintain perfusion and gas exchange to VITAL organs.* Thus these mechanisms shunt blood away from less vital organs and try to prevent further volume losses. - *The increasing pallor occurs because blood is shunted away from skin and mucous membranes to the heart, brain, liver, and lungs.* - *Increasing thirst and decreasing urine output (B,H) help to INCREASE blood volume by stimulating the patient to drink and by preventing fluid loss through the urine.* - *Increasing heart rate and respiratory rate (D,E) work to maintain gas exchange to those selected organs that continue to be perfused.* - Increasing confusion indicates the compensatory mechanisms are *failing* and that the brain is not being adequately perfused. - Decreasing systolic blood pressure also is an indication of worsening shock. - Decreasing blood pH is NOT a compensatory action; it is an indication of inadequate gas exchange.

A client thought to be at risk for *distributive shock* is given a drug that constricts blood vessels. What effect does the nurse expect the drug to have on the client's mean arterial pressure (MAP)? A. Increased MAP without a change in vascular volume B. Increased MAP by increasing vascular volume C. Decreased MAP from widespread capillary leak D. Decreased MAP by decreasing vascular volume

ANS: A - *Distributive shock occurs when blood volume is diverted from the vascular volume into other spaces but without being lost from the body.* Drugs that constrict blood vessels, especially arterioles, can keep the remaining vascular volume in place and reduce the size of the capillary bed. *These responses increase mean arterial pressure but do NOT expand the vascular volume.*

What therapies may be administered to decrease oxygen demand in the patient with multiple-organ dysfunction syndrome? Vasoactive and positive inotropic agents Diuretics and antidysrhythmic agents Crystalloids and antibiotics Antipyretics and sedative agents

Antipyretics and sedative agents - *Oxygen demand can be DECREASED in any of the following ways: administering sedation or paralytics, administering antipyretics and external cooling measures, and administering pain medications.* - Vasoactives, positive inotropes, crystalloids, and antidysrhythmics are used to support oxygen transport, NOT decrease oxygen demand.

A client with septic shock has been started on dopamine (Intropin) at 12 mcg/kg/min. Which response indicates a positive outcome? Hourly urine output 10 to 12 mL/hr Blood pressure 90/60 mm Hg and mean arterial pressure 70 mm Hg Blood glucose 245 mg/dL (13.6 mmol/L) Serum creatinine 3.6 mg/dL (318 mcmol/L)

Blood pressure 90/60 mm Hg and mean arterial pressure 70 mm Hg - A positive outcome of a Dopamine infusion started on a client with septic shock is a blood pressure of 90/60 mm Hg and a mean arterial pressure of 70 mm Hg. *Dopamine improves blood flow by increasing peripheral resistance, which increases blood pressure.* - Urine output less than 30 mL/hr or 0.5 mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the kidney and are a negative consequence of shock, not a positive response. - Although a blood glucose of 245 mg/dL (13.6 mmol/L) is an abnormal finding, dopamine increases blood pressure and myocardial contractility, not glucose levels.

A client is admitted to the hospital with two of the systemic inflammatory response syndrome variables: temperature of 95°F (35°C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate? Broad-spectrum antibiotics Blood transfusion Cooling baths NPO status

Broad-spectrum antibiotics - From the sepsis resuscitation bundle *the nurse initiates broad-spectrum antibiotics within 1 hour of establishing diagnosis.* - A blood transfusion is indicated for low red blood cell count or low hemoglobin and hematocrit. Transfusion is NOT part of the sepsis resuscitation bundle. Cooling baths neither are indicated because the client is hypothermic nor are this part of the sepsis resuscitation bundle. NPO status neither is indicated for this client nor is it part of the sepsis resuscitation bundle.

A client with hypovolemic shock has these vital signs: temperature 97.9°F (36.6°C); pulse 122 beats/min; blood pressure 86/48 mm Hg; respirations 24 breaths/min; urine output 20 mL for last 2 hours; skin cool and clammy. Which prescription order for this client does the nurse question? Dopamine (Intropin) 12 mcg/kg/min Dobutamine (Dobutrex) 5 mcg/kg/min Plasmanate 1 unit Bumetanide (Bumex) 1 mg IV

Bumetanide (Bumex) 1 mg IV - The prescription order the nurse questions is Bumetanide (Bumex0 1 mg IV). *A diuretic such as bumetanide will decrease blood volume in a client who is already hypovolemic.* This order must be questioned because this is not an appropriate action to expand the client's blood volume. - The orders other than Bumetanide are appropriate for improving blood pressure in shock and do not need to be questioned. *Dobutamine is generally given to INCREASE cardiac output. It's used in heart failure and cardiogenic shock.*

When caring for an obtunded client admitted with shock of unknown origin, which action does the nurse take first? Obtain IV access and hang prescribed fluid infusions. Apply the automatic blood pressure cuff. Assess level of consciousness and pupil reaction to light. Check the airway and respiratory status

Check the airway and respiratory status. - The nurse's first action when caring for an obtunded client admitted with shock is to check the client's airway and respiratory status. *When caring for any client, determining airway and respiratory status is the priority.* - The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client's mental status. *A mildly depressed level of consciousness or alertness may be classed as lethargy; someone in this state can be aroused with little difficulty. People who are obtunded have a more depressed level of consciousness and cannot be fully aroused.*

Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? Client receiving a blood transfusion Client with severe ascites Client with myocardial infarction Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion

Client with severe ascites - A client with severe ascites best demonstrates the problem with the highest risk for hypovolemic shock. *Fluid shifts from vascular to intraabdominal may cause decreased circulating blood volume and poor tissue perfusion.* - The client receiving a blood transfusion does not have as high a risk as the client with severe ascites. - Myocardial infarction results in tissue necrosis in the heart muscle, but no blood or fluid losses occur. - Owing to excess antidiuretic hormone secretion, *the client with SIADH will RETAIN fluid and therefore is NOT at risk for hypovolemic shock.*

The unlicensed assistive personnel (UAP) is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22 breaths/min. What does the supervising nurse do? Compare these vital signs with the last several readings. Request that the surgeon see the client. Increase the rate of intravenous fluids. Reassess vital signs using different equipment.

Compare these vital signs with the last several readings. - *The supervising nurse will take the vital sign trends into consideration. A BP of 90/60 mm Hg may be normal for this client.* - .Calling the surgeon is not necessary at this point, and increasing IV fluids is not indicated. The same equipment must be used when vital signs are taken postoperatively.

Which parameters are clinical manifestations of cardiogenic shock? Decreased pulmonary artery occlusion pressure Decreased right atrial pressure Decreased cardiac index to less than 2.2 L/min/m2 Decreased systemic vascular resistance

Decreased cardiac index to less than 2.2 L/min/m2 - Initially, clinical manifestations reflect the decline in cardiac output. Clinical manifestations include cardiac index less than 2.2 L/min/m2, increased pulmonary artery occlusion pressure, increased right atrial pressure, and increased systemic vascular resistance.

Which laboratory result is seen in late sepsis? Decreased serum lactate Decreased segmented neutrophil count Increased numbers of monocytes Increased platelet count

Decreased segmented neutrophil count - *A decreased segmented neutrophil count is indicative of LATE sepsis.* *The segmented neutrophils (segs) may no longer be elevated because prolonged sepsis may have exceeded the bone marrow's ability to keep producing and releasing new mature neutrophils.* - Serum lactate is INCREASED, not decreased, in late sepsis. - Monocytosis is usually seen in diseases such as tuberculosis and Rocky Mountain spotted fever. - An increased platelet count does not indicate sepsis. *Late in sepsis, platelets may decrease due to consumptive coagulopathy.*

The nurse is developing a care plan for the patient in cardiogenic shock. What is the goal for therapy? Increasing preload Decreasing afterload Increasing myocardial workload Increasing systemic vascular resistance (SVR)

Decreasing afterload - *The goal of therapy is to increase cardiac output by decreasing preload and afterload and increasing contractility.* - Increasing myocardial workload, preload, and systemic vascular resistance (SVR) would worsen cardiogenic shock

A nurse is consulting with a multidisciplinary team regarding renal impairment from sepsis. Which statement regarding kidney dysfunction is true? An increased creatinine level is the earliest sign of kidney impairment. Elevated peak levels of antibiotics can lead to kidney impairment. Hypotensive episodes do not affect kidney function. Increased production of erythropoietin may result in kidney impairment.

Elevated peak levels of antibiotics can lead to kidney impairment. - The frequent use of nephrotoxic drugs (eg, antibiotics) during critical illness intensifies the risk of progressive kidney impairment. - Elevated serum creatinine level is usually a LATE sign, but it is typically accepted as the index for kidney dysfunction. - Early oliguria is likely caused by decreases in kidney perfusion related to shock-like states (with hypotension). - Additional signs of kidney impairment may include decreased erythropoietin-induced anemia, vitamin D malabsorption, and altered fluid and electrolyte balance.

The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first? Administer the antibiotic immediately. Ensure that blood cultures were drawn. Obtain signature for informed consent. Take the client's vital signs.

Ensure that blood cultures were drawn. - The nurse's first action when planning to administer an antibiotic to a newly admitted patent in septic shock is to ensure that blood cultures were drawn. *Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered.* Antibiotics are NOT to be administered until after all cultures are taken. - A signed consent is not needed for medication administration. Monitoring the client's vital signs is important, but the antibiotic must be administered within 1 to 3 hours, because timing is essential.

The client with which problem is at highest risk for hypovolemic shock? Esophageal varices Kidney failure Arthritis and daily acetaminophen use Kidney stone

Esophageal varices - The client with esophageal varices is at highest risk for hypovolemic shock. Esophageal varices are caused by portal hypertension where the portal vessels are under high pressure. *With this high pressure, the portal vessels are prone to rupture, causing massive upper gastrointestinal tract bleeding and hypovolemic shock.* - As the kidneys fail, fluid is typically RETAINED, causing fluid volume excess, NOT hypovolemia. - Arthritis and daily acetaminophen use do NOT cause GI bleeding and hypovolemia. *Nonsteroidal anti-inflammatory drugs such as naproxen and ibuprofen may predispose the client to gastrointestinal (GI) bleeding and hypovolemia.* - Although a kidney stone may cause hematuria, massive blood loss or hypovolemia generally does not occur.

A postoperative patient has a heart rate of 110 beats/min and blood pressure (BP) of 110/80 mm Hg (previously 130/60 mm Hg). Urine output has been 20 mL/h for the past 3 hours, capillary filling time is 5 seconds, the skin is cool, the neck veins are flattened, and the patient is complaining of thirst. The nurse suspects the may be experiencing which disorder? Hypovolemic shock Cardiac tamponade Cardiogenic shock Anaphylaxis

Hypovolemic shock - *The patient is experiencing hypovolemic shock as evidenced by decreased urine output, tachycardia, and increased capillary filling time.* - In cardiac tamponade, heart tones would be muffled and neck veins would be distended. - In cardiogenic shock, the blood pressure (BP) would be elevated and the neck veins would be distended. - With an allergic reaction, there would be signs of allergic response, such as *urticaria (rash)*, anxiety, and respiratory distress

The client with which laboratory result is at risk for hemorrhagic shock? International normalized ratio (INR) 7.9 Partial thromboplastin time (PTT) 12.5 seconds Platelets 170,000/mm3 (170 × 109/L) Hemoglobin 8.2 g/dL (82 mmol/L) *Normal levels for each!*

International normalized ratio (INR) 7.9 - A client with a prolonged INR of 7.9 places a client at risk for hemorrhagic shock. *Prolonged INR indicates that blood takes longer than normal to clot and increases the risk for bleeding.* - PTT of 12.5 seconds is low and puts this client at risk for CLOTTING. - A platelet value of 170,000/mm3 (170 × 109/L) is normal and poses no risk for bleeding. - Although a hemoglobin of 8.2 g/dL (82 mmol/L) is low, the client could have severe iron deficiency or could have received medication affecting the bone marrow. *A normal platelet count ranges from 150,000 to 450,000* *The normal range for hemoglobin is: 12-17* *Normal PTT are typically 25 to 35 seconds*

How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present? PaCO2 58 mm Hg Lactate 81 mg/dL (9.0 mmol/L) Partial thromboplastin time 64 seconds Potassium 2.8 mEq/L (2.8 mmol/L)

Lactate 81 mg/dL (9.0 mmol/L) - The client with septic shock and a lactate level of 81 mg/dL (9.0 mmoL/L) indicates that severe tissue hypoxia is present. *Poor tissue oxygenation at the cellular level causes anaerobic metabolism, with the by-product of lactic acid.* - Elevated partial pressure of carbon dioxide occurs with *hypoventilation,* which may be related to respiratory muscle fatigue, secretions, and causes other than hypoxia. - Coagulation times reflect the ability of the blood to clot, not oxygenation at the cellular level. - Elevation in potassium appears in septic shock due to acidosis, but this value is decreased and is not consistent with septic shock.

How does the nurse recognize that a positive outcome has occurred when administering plasma protein fraction (Plasmanate)? Urine output 20 to 30 mL/hr for the last 4 hours Mean arterial pressure (MAP) 70 mm Hg Albumin 3.5 g/dL (5.0 mcmol/L) Hemoglobin 7.6 g/dL (76 mmol/L)

Mean arterial pressure (MAP) 70 mm Hg - A MAP of 70 mm Hg means that a positive outcome has occurred when plasma protein fraction (Plasmanate) has been administered. *Plasmanate expands the blood volume and helps maintain MAP greater than 65 mm Hg, and a desired outcome in shock.* - Urine output needs to be 0.5 mL/kg/hr, or greater than 30 mL/hr. - Albumin levels reflect nutritional status, which may be poor in shock states due to an increased need for calories. - *Plasmanate expands blood volume by exerting increasing colloid osmotic pressure in the bloodstream, pulling fluid into the vascular space and does not improve an abnormal hemoglobin.* *The reference range for albumin is 3.5 to 5.5*

Sepsis-associated *mortality* with organ failure *( 1 organ = ___% ; 2 organs = ___%)* *( 3 organs = ___% ; 4 organs = ___%)*

More organs involved = higher mortality rate

The nurse reviews the medical record of a client with hemorrhagic shock, which contains the following information: Pulse 140 beats/min and thready, ABG respiratory acidosis, Blood pressure 60/40 mm Hg, Lactate level 63 mg/dL(7 mmol/L), Respirations 40/min and shallow. All of these provider prescriptions are given for the client. *Which does the nurse carry out first?* Notify anesthesia for endotracheal intubation. Give Plasmanate 1 unit now. Give normal saline solution 250 mL/hr. Type and crossmatch for 4 units of packed red blood cells (PRBCs).

Notify anesthesia for endotracheal intubation. - The nurse must first notify anesthesia for endotracheal intubation for this client with hemorrhagic shock. *Establishing an airway is the priority in all emergency situations.* - Although administering Plasmanate and normal saline, and typing and cross matching for 4 units of PRBCs are important actions, airway always takes priority.

A client recovering from an open reduction of the femur suddenly feels light-headed, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? Temperature Pulse Respiration Blood pressure

Temperature - A postoperative client's *temperature* may differentiate pulmonary embolism from early sepsis when the client complains of feeling light-headed and anxious. *A sign of early sepsis is low-grade fever.* - Both early sepsis and thrombus may cause tachycardia(pulse), tachypnea(respiration), and hypotension (blood pressure).

Which problem places a client at highest risk for sepsis? Pernicious anemia Pericarditis Post kidney transplant Client owns an iguana

Post kidney transplant - A client with post kidney transplant is the highest risk for sepsis. This client will need to take lifelong *immune suppressant therapy and is at risk for infection* from internal and external organisms. - *Pernicious anemia is related to lack of vitamin B12,* not to bone marrow failure *(aplastic anemia),* which would place the client at risk for infection. - Inflammation of the pericardial sac is an inflammatory condition that does not pose a risk for septic shock. - Although owning pets, especially cats and reptiles, poses a risk for infection, the immune-suppressed kidney transplant client has a greater risk for infection, sepsis, and death.

Which laboratory value provides information regarding the severity of impaired perfusion and helps determine the adequacy of therapies in the patient with septic shock and multiple-organ dysfunction syndrome (MODS)? Serum glucose Serum lactate Serum albumin Serum creatinine

Serum lactate - *Serum lactate levels provide information regarding the severity of impaired perfusion and the presence of lactic acidosis.* The values differ significantly in multiple-organ dysfunction syndrome (MODS) survivors and nonsurvivors.