UNIT 3 Ch 67
Drug Nitroglycerin (Nitrol, Tridil)
Action Primarily dilates veins, reducing preload.
Types of Shock
Cardiogenic Hypovolemic Septic Anaphylactic
1. A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing a. a relative hypervolemia. b. an absolute hypovolemia. c. neurogenic shock from low blood flow. d. neurogenic shock from massive vasodilation.
1. d
1. What is the key factor in describing any type of shock? a. Hypoxemia b. Hypotension c. Vascular collapse d. Inadequate tissue perfusion
1. d. Although all of the factors may be present, regardless of the cause, the end result is inadequate supply of oxygen and nutrients to body cells from inadequate tissue perfusion.
10. Progressive tissue hypoxia leading to anaerobic metabolism and metabolic acidosis is characteristic of the progressive stage of shock. What changes in the heart contribute to this increasing tissue hypoxia? a. Arterial constriction causes decreased perfusion. b. Vasoconstriction decreases blood flow to pulmonary capillaries. c. Increased capillary permeability and profound vasoconstriction cause increased hydrostatic pressure. d. Decreased perfusion occurs, leading to dysrhythmias, decreased CO, and decreased oxygen delivery to cells.
10. d. Decreased myocardial perfusion leads to dysrhythmias and myocardial ischemia, further decreasing CO and oxygen delivery to cells. The kidney's renin-angiotensinaldosterone system activation causes arteriolar constriction that decreases perfusion. In the lung, vasoconstriction of arterioles decreases blood flow and a ventilation perfusion mismatch occurs. Areas of the lung that are oxygenated are not perfused because of the decreased blood flow, resulting in hypoxemia and decreased oxygen for cells. Increased capillary permeability and vasoconstriction cause increased hydrostatic pressure that contributes to the fluid shifting to interstitial spaces.
11. A patient with severe trauma has been treated for hypovolemic shock. The nurse recognizes that the patient is in the irreversible stage of shock when what is included in assessment findings? a. A lactic acidosis with a pH of 7.32 b. Marked hypotension and refractory hypoxemia c. Unresponsiveness that responds only to painful stimuli d. Profound vasoconstriction with absent peripheral pulses
11. b. During both the compensatory and the progressive stages of shock, the sympathetic nervous system is activated in an attempt to maintain CO and SVR. In the irreversible stage of shock, the sympathetic nervous system can no longer compensate to maintain homeostasis and a loss of vasomotor tone leading to profound hypotension affects perfusion to all vital organs, causing increasing cellular hypoxia, metabolic acidosis, and cellular death.
12. Priority Decision: A patient with acute pancreatitis is experiencing hypovolemic shock. Which initial orders for the patient will the nurse implement first? a. Start 1000 mL of normal saline at 500 mL/hr. b. Obtain blood cultures before starting IV antibiotics. c. Draw blood for hematology and coagulation factors. d. Administer high-flow oxygen (100%) with a non-rebreather mask.
12. d. In every type of shock there is a deficiency of oxygen to the cells and high-flow oxygen therapy is indicated. Fluids would be started next, blood cultures would be done before any antibiotic therapy, and laboratory specimens then could be drawn.
13. What abnormal finding should the nurse expect to find in early compensatory shock? a. Metabolic acidosis b. Increased serum sodium c. Decreased blood glucose d. Increased serum potassium
13. b. In early compensatory shock, activation of the reninangiotensin- aldosterone system stimulates the release of aldosterone, which causes sodium reabsorption and potassium excretion by the kidney, elevating serum sodium levels and decreasing serum potassium levels. Blood glucose levels are elevated during the compensatory stage of shock in response to catecholamine stimulation of the liver, which releases its glycogen stores in the form of glucose. Metabolic acidosis does not occur until the progressive stage of shock. At this stage compensatory mechanisms become ineffective and anaerobic cellular metabolism causes lactic acid production.
14. In late irreversible shock in a patient with massive thermal burns, what should the nurse expect the patient's laboratory results to reveal? a. Respiratory alkalosis b. Decreased potassium c. Increased blood glucose d. Increased ammonia (NH3) levels
14. d. In late irreversible shock, progressive cellular destruction causes changes in laboratory findings that indicate organ damage. Increasing ammonia levels indicate impaired liver function. Metabolic acidosis is usually severe as cells continue anaerobic metabolism and the respiratory alkalosis that may occur in the compensatory stage has failed to compensate for the acidosis. Potassium levels increase and blood glucose decreases. .
15. A patient with hypovolemic shock is receiving lactated Ringer's solution for fluid replacement therapy. During this therapy, which laboratory result is most important for the nurse to monitor? a. Serum pH b. Serum sodium c. Serum potassium d. Hemoglobin (Hgb) and hematocrit (Hct)
15. a. Lactated Ringer's solution may increase lactate levels, which a damaged liver cannot convert to bicarbonate. This may intensify the metabolic lactic acidosis that occurs in progressive shock, necessitating careful attention to the patient's acid-base balance. Sodium and potassium levels as well as hemoglobin (Hgb) and hematocrit (Hct) levels should be monitored in all patients receiving fluid replacement therapy
16. The nurse determines that a large amount of crystalloid fluids administered to a patient in septic shock is effective when hemodynamic monitoring reveals what? a. CO of 2.6 L/min b. CVP of 15 mm Hg c. PAWP of 4 mm Hg d. Heart rate (HR) of 106 bpm
16. b. The endpoint of fluid resuscitation in septic and hypovolemic shock is a central venous pressure (CVP) of 15 mm Hg or a PAWP of 10 to 12 mm Hg. The CO is too low and the heart rate is too high to indicate adequate fluid replacement.
17. When caring for a patient in cardiogenic shock, the nurse recognizes that the metabolic demands of turning and moving the patient exceed the oxygen supply when what change is revealed in hemodynamic monitoring? a. SvO2 from 62% to 54% b. CO from 4.2 L/min to 4.8 L/min c. Stroke volume (SV) from 52 to 68 mL/beat d. SVR from 1300 dyne/sec/cm5 to 1120 dyne/sec/cm5
17. a. A decreased mixed venous oxygen saturation (SvO2) indicates that the patient has used the venous oxygen reserve and is at greater risk for anaerobic metabolism. The SvO2 decreases when more oxygen is used by the cells, as in activity or hypermetabolism. All of the other values indicate an improvement in the patient's condition.
18. During administration of IV norepinephrine (Levophed), what should the nurse assess the patient for? a. Hypotension b. Marked diuresis c. Metabolic alkalosis d. Decreased tissue perfusion
18. d. As a vasopressor, norepinephrine may cause severe vasoconstriction, which would further decrease tissue perfusion, especially if fluid replacement is inadequate. Vasopressors generally cause hypertension, reflex bradycardia, and decreased urine output because of decreased renal blood flow. They do not directly affect acid-base balance.
19. When administering any vasoactive drug during the treatment of shock, the nurse should know that what is the goal of the therapy? a. Increasing urine output to 50 mL/hr b. Constriction of vessels to maintain BP c. Maintaining a MAP of at least 60 mm Hg d. Dilating vessels to improve tissue perfusion
19. c. Vasoactive drugs are those that can either dilate or constrict blood vessels and are used in various stages of shock treatment. When using either vasodilators or vasoconstrictors, it is important to maintain a mean arterial pressure (MAP) of at least 60 mm Hg so that adequate perfusion is maintained. The other goals would be appropriate only with either vasodilators or vasoconstrictors, not with all vasoactive drugs.
2. A 78-year-old man has confusion and temperature of 104° F (40° C). He is a diabetic with purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/minute; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of a. sepsis. b. septic shock. c. multiple organ dysfunction syndrome. d. systemic inflammatory response syndrome.
2. b
2. When shock occurs in a patient with pulmonary embolism or abdominal compartment syndrome, what type of shock would that be? a. Distributive shock b. Obstructive shock c. Cardiogenic shock d. Hypovolemic shock
2. b. Obstructive shock occurs when a physical obstruction impedes the filling or outflow of blood, resulting in reduced cardiac output (CO).
22. Priority Decision: What is the priority nursing responsibility in the prevention of shock? a. Frequently monitoring all patients' vital signs b. Using aseptic technique for all invasive procedures c. Being aware of the potential for shock in all patients at risk d. Teaching patients health promotion activities to prevent shock
22. c. Prevention of shock necessitates identification of persons who are at risk and a thorough baseline nursing assessment with frequent ongoing assessments to monitor and detect changes in patients at risk. Frequent monitoring of all patients' vital signs is not necessary. Aseptic technique for all invasive procedures should always be implemented but will not prevent all types of shock. Health promotion activities that reduce the risk for precipitating conditions, such as coronary artery disease or anaphylaxis, may help to prevent shock in some cases.
23. Which indicators of tissue perfusion should be monitored in critically ill patients by the nurse (select all that apply)? a. Skin b. Urine output c. Level of consciousness d. Activities of daily living e. Vital signs, including pulse oximetry f. Peripheral pulses with capillary refill
23. a, b, c, e, f. Skin (color, temperature, moisture), urine output, level of consciousness, vital signs (including pulse oximetry), and peripheral pulses with capillary refill should be monitored to evaluate tissue perfusion.
24. A patient in the progressive stage of shock has rapid, deep respirations. The nurse determines that the patient's hyperventilation is compensating for a metabolic acidosis when the patient's arterial blood gas (ABG) results include which results? a. pH 7.42, PaO2 80 mm Hg b. pH 7.48, PaO2 69 mm Hg c. pH 7.38, PaCO2 30 mm Hg d. pH 7.32, PaCO2 48 mm Hg
24. c. If the metabolic acidosis is compensated, the pH will be within the normal range. If the patient is hyperventilating to blow off carbon dioxide to reduce the acid load of the blood, PaCO2 will be decreased.
25. Which interventions should be used for anaphylactic shock (select all that apply)? a. Antibiotics b. Vasodilator c. Antihistamine d. Oxygen supplementation e. Colloid volume expansion f. Crystalloid volume expansion
25. c, d, e. Antihistamines, oxygen supplementation, and colloid volume expansion are used to treat anaphylactic shock. Epinephrine, a vasopressor, is also frequently used. Only septic shock is treated with antibiotics. Vasodilators and inotropes are only used for cardiogenic shock. Volume expansion fluids vary with each type of shock.
26. A patient in shock has a nursing diagnosis of fear related to severity of condition and perceived threat of death as manifested by verbalization of anxiety about condition and fear of death. What is an appropriate nursing intervention for the patient? a. Administer antianxiety agents. b. Allow caregivers to visit as much as possible. c. Call a member of the clergy to visit the patient. d. Inform the patient of the current plan of care and its rationale.
26. d. Although some patients in shock may be treated with antianxiety and sedative drugs to control anxiety and apprehension, the nurse should always acknowledge the patient's feelings, explain procedures before they are carried out, and inform the patient of the plan of care and its rationale. Members of the clergy should be called only if the patient requests or agrees to a visit. Visits by family may have a therapeutic effect for some patients and may increase stress in others.
27. Which statement describing systemic inflammatory response syndrome (SIRS) and/or multiple organ dysfunction syndrome (MODS) is accurate? a. MODS may occur independently from SIRS. b. All patients with septic shock develop MODS. c. The GI system is often the first to show evidence of dysfunction in SIRS and MODS. d. A common initial mediator that causes endothelial damage leading to SIRS and MODS is endotoxin.
27. d. A common initial mediator that causes endothelial damage leading to systemic inflammatory response syndrome (SIRS) and/or multiple organ dysfunction syndrome (MODS) is endotoxin. MODS results from SIRS. Not all patients with septic shock develop MODS, although they do have SIRS. The respiratory system is frequently the first to show evidence of SIRS and MODS.
28. What mechanism that can trigger SIRS is related to myocardial infarction or pancreatitis? a. Endotoxin release b. Abscess formation c. Global perfusion deficits d. Ischemic or necrotic tissue
28. d. The ischemic or necrotic tissue mechanism triggers SIRS with myocardial infarction, pancreatitis, and vascular disease. Endotoxin release is seen with gram-negative and gram-positive bacteria. The abscess formation mechanism occurs with intraabdominal and extremitiy abscesses. Global perfusion deficits are seen post-cardiac resuscitation and in shock states.
29. What types of injuries cause a mechanical tissue trauma that can trigger SIRS (select all that apply)? a. Burns b. Fungi c. Viruses d. Crush injuries e. Surgical procedures
29. a, d, e. Mechanical tissue trauma triggering of SIRS occurs with burns, surgical procedures, and crush injuries. Fungi, viruses, bacteria, and parasites cause microbial invasion.
3. What physical problems could precipitate hypovolemic shock (select all that apply)? a. Burns b. Ascites c. Vaccines d. Insect bites e. Hemorrhage f. Ruptured spleen
3. a, b, e, f. Hypovolemic shock occurs when there is a loss of intravascular fluid volume from fluid loss (as in hemorrhage or severe vomiting and diarrhea), fluid shift (as in burns or ascites), or internal bleeding (as with a ruptured spleen). Vaccines and insect bites would precipitate the anaphylactic type of distributive shock.
3. Appropriate treatment modalities for the management of cardiogenic shock include (select all that apply) a. dobutamine to increase myocardial contractility. b. vasopressors to increase systemic vascular resistance. c. circulatory assist devices such as an intraaortic balloon pump. d. corticosteroids to stabilize the cell wall in the infarcted myocardium. e. Trendelenburg positioning to facilitate venous return and increase preload.
3. a, c
30. Which intervention may prevent GI bacterial and endotoxin translocation in a critically ill patient with SIRS? a. Early enteral feedings b. Surgical removal of necrotic tissue c. Aggressive multiple antibiotic therapy d. Strict aseptic technique in all procedures
30. a. Early enteral feedings in the patient in shock increase the blood supply to the GI tract and help to prevent translocation of GI bacteria and endotoxins into the blood, preventing initial or additional infection. Surgical removal of necrotic tissue, especially from burns, eliminates a source of infection in critically ill patients, as does the use of strict aseptic technique in all patient procedures. Known infections are treated with specific agents and broad-spectrum agents are used only until organisms are identified.
31. Priority Decision: A patient with a gunshot wound to the abdomen is being treated for hypovolemic and septic shock. To monitor the patient for early organ damage associated with MODS, what is most important for the nurse to assess? a. Urine output b. Breath sounds c. Peripheral circulation d. Central venous pressure
31. b. Generally, the first body system affected by mediator induced injury in MODS is the respiratory system. Adventitious sounds and areas with absent breath sounds will be present. Other organ damage occurs but lungs are usually first.
32. Which patient manifestations confirm the development of MODS? a. Upper GI bleeding, Glasgow Coma Scale (GCS) score of 7, and Hct of 25% b. Elevated serum bilirubin, serum creatinine of 3.8 mg/dL, and platelet count of 15,000/μL c. Urine output of 30 mL/hr, BUN of 45 mg/dL, and white blood cell (WBC) count of 1120/μL d. Respiratory rate of 45, PaCO2 of 60 mm Hg, and chest x-ray with bilateral diffuse patchy infiltrates
32. b. The presence of MODS is confirmed when there is defined clinical evidence of failure of two or more organs. Elevated serum bilirubin indicates liver dysfunction, a serum creatinine of 3.8 mg/dL indicates kidney injury, and a platelet count of 15,000/μL indicates hematologic failure. Other criteria include urine output less than 0.5 mL/kg/hr, blood urea nitrogen (BUN) ≥100 mg/dL, white blood cell (WBC) count >10000/μL, upper or lower GI bleeding, Glasgow Coma Scale (GCS) score ≤6, and Hct ≤20%. A respiratory rate of 45, PaCO2 of 60 mm Hg, and chest x-ray with bilateral diffuse patchy infiltrates indicate respiratory failure but not other organ damage
4. A 70-year-old patient is malnourished, has a history of type 2 diabetes mellitus, and is admitted from the nursing home with pneumonia. For which kind of shock should the nurse closely monitor this patient? a. Septic shock b. Neurogenic shock c. Cardiogenic shock d. Anaphylactic shock
4. a. Older adults with chronic diseases and malnourished or debilitated patients are at risk of developing septic shock, especially when they have an infection (e.g., pneumonia, urinary tract infection) or indwelling lines or catheters.
4. The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations. b. breath sounds, blood pressure, and body temperature. c. pulse pressure, level of consciousness, and pupillary response. d. level of consciousness, urine output, and skin color and temperature.
4. d
5. Which hemodynamic monitoring description of the identified shock is accurate? a. Tachycardia with hypertension is characteristic of neurogenic shock. b. In cardiogenic shock the patient will have an increased pulmonary artery wedge pressure (PAWP) and a decreased cardiac output (CO). c. Anaphylactic shock is characterized by increased systemic vascular resistance (SVR), decreased CO, and decreased PAWP. d. In septic shock, bacterial endotoxins cause vascular changes that result in increased SVR and decreased CO.
5. b. Hemodynamic monitoring in cardiogenic shock will reveal increased pulmonary artery wedge pressure (PAWP) and decreased CO. The characteristic signs of neurogenic shock are bradycardia and hypotension. Septic shock manifests with decreased systemic vascular resistance (SVR) and increased CO. Hypovolemic shock is characterized by increased SVR, decreased CO, and decreased PAWP.
6. In the compensatory stage of hypovolemic shock, to what organs does blood flow decrease after the sympathetic nervous system activates the α-adrenergic stimulation (select all that apply)? a. Skin b. Brain c. Heart d. Kidneys e. Gastrointestinal tract
6. a, d, e. After sympathetic nervous system activation of vasoconstriction, blood flow to nonvital organs, such as skin, kidneys, and the gastrointestinal (GI) tract is diverted or shunted to the most essential organs of the heart and the brain. The patient will feel cool and clammy, the reninangiotensin- aldosterone system will be activated, and the patient may develop a paralytic ileus.
7. As the body continues to try to compensate for hypovolemic shock, there is increased angiotensin II from the activation of the renin-angiotensin-aldosterone system. What physiologic change occurs related to the increased angiotensin II? a. Vasodilation b. Decreased blood pressure (BP) and CO c. Aldosterone release results in sodium and water excretion d. Antidiuretic hormone (ADH) release increases water reabsorpton
7. d. Angiotensin II vasoconstricts both arteries and veins, which increases blood pressure (BP). It stimulates aldosterone release from the adrenal cortex, which results in sodium and water reabsorption and potassium excretion by the kidneys. The increased sodium raises serum osmolality and stimulates the pituitary gland to release antidiuretic hormone (ADH), which increases water reabsorption, which further increases blood volume, leading to an increase in BP and CO.
8. The patient is in the compensatory stage of shock. What manifestations indicate this to the nurse (select all that apply)? a. Pale and cool b. Unresponsive c. Lower BP than baseline d. Moist crackles in the lungs e. Hyperactive bowel sounds f. Tachypnea and tachycardia
8. a, c, f. In the compensatory stage of shock the patient's skin will be pale and cool (α-adrenergic stimulation). There may also be a change in level of consciousness but the person will be responsive, the BP will be lower than baseline, bowel sounds will be hypoactive (α-adrenergic stimulation), and tachypnea and tachycardia (β-adrenergic stimulation) will occur. Unresponsiveness and moist crackles in the lungs occur in the progressive stage of shock.
9. The nurse suspects sepsis as a cause of shock when the laboratory test results indicate a. hypokalemia. c. decreased hemoglobin. b. thrombocytopenia. d. increased blood urea nitrogen (BUN).
9. b. Thrombocytopenia can occur. When sepsis is the cause of shock, endotoxin stimulates a cascade of inflammatory responses that start with the release of tumor necrosis factor (TNF) and interleukin-1 (IL-1), which stimulate other inflammatory mediators. The release of platelet activating factor causes formation of micro thrombi and vessel obstruction. There is vasodilation, increased capillary permeability, and neutrophil and platelet aggregation and adhesion to the endothelium. The process does not occur in other types of shock until late stages of shock
Drug Diuretics (e.g., furosemide [Lasix])
Action Decrease the workload of the heart by decreasing fluid volume and reducing preload.
Drug Nitroprusside (Nipride)
Action Acts as a potent vasodilator of veins and arteries and may increase or decrease CO, depending on the extent of preload and afterload reduction.
Drug Phosphodiesterase inhibitors (e.g., Milrinone [Primacor])
Action Increase cardiac contractility and output and decrease preload and afterload by directly relaxing vascular smooth muscles.
Anaphylactic Shock
Medical Therapies: Epinephrine, inhaled bronchodilators, colloidal fluid replacement, diphenhydramine, corticosteroids
Hypovolemic Shock
Medical Therapies: Fluid and blood replacement, control of bleeding with pressure, surgery
Septic Shock
Medical Therapies: Fluid resuscitation, antimicrobial agents, inotropic agents with vasopressors
Cardiogenic Shock
Medical Therapies: Restore coronary artery blood flow with thrombolytic therapy, angioplasty, emergency revascularization; increase CO with inotropic agents; reduce workload by dilating coronary arteries, decreasing preload and afterload; use circulatory assist devices, such as an intraaortic balloon pump
2 x Na + BUN/2.8 + Glucose/18
Serum Osmolality