341 - Shock Edapt
Norepinephrine 0.4 mcg/kg/minute is ordered. The pharmacy supplies 50 mg in 250 ml D5W. Ms. Johnson weighs 176 pounds. How many ml/hour should the infusion run? (Round to the nearest whole number).
10 ml/hr 176 lbs = 80 kg 50 mg = 50,000 mcg 50,000 mcg / 250 ml = 200 mcg/ml (0.4 (rate) x 80 kg x 60 minutes) / 200 mcg/ml = 9.6 or 10 ml/hour
A nurse is triaging four clients in the emergency department (ED). Which client is most at risk for developing obstructive shock?
A client who has a pulmonary embolism Obstructive shock develops when a physical obstruction to blood flow occurs resulting in decreased cardiac output due to a non-cardiac cause. Pulmonary emboli cause an outflow obstruction as blood leaves the right ventricle through the pulmonary artery. This leads to decreased blood flow to the lungs and decreased blood return to the left atrium. Cardiac dysrhythmias can lead to cardiogenic shock. Excessive vomiting and diarrhea can lead to hypovolemic shock. Bacterial meningitis can cause septic shock, which is classified as distributive shock.
While caring for Ms. Johnson, which nursing actions are appropriate and which are contraindicated?
Appropriate: Hourly Urine Output VS Q15mins Continuous hemodynamic monitoring Contraindicated: Auscultate lung sounds Q4hrs Capillary blood glucose Q4hrs GCS Q2hrs Sepsis can quickly develop into septic shock, causing rapid client deterioration. Evaluations of treatment should be ongoing and frequent. Septic shock represents a critical situation requiring close, frequent monitoring. GCS should be completed hourly, urine output monitored hourly, vital signs every 15 minutes, hemodynamics monitored continuously, and glucose should be hourly. A GCS done every 2 hours, lung sounds every 4 hours, and blood glucose every 4 hours is too infrequent and therefore contraindicated.
The nurse is caring for a client who has a prescription for intravenous nitroprusside. Which type of shock is treated by this medication?
CARDIOGENIC Cardiogenic shock occurs when the heart fails to pump effectively due to a cardiac cause. Nitroprusside is a potent vasodilator that reduces both preload and afterload. It allows the heart to pump more effectively. In obstructive shock, the obstruction is causing the high afterload. Medications will not resolve the problem. In hypovolemic shock, fluid replacement as well as reducing fluid loss are the main goals. In distributive shock, afterload is already decreased.
The nurse shares assessment findings with the provider. Which prescriptions should the nurse anticipate? Select all that apply.
Chest x-ray Hydrocortisone 50 mg intravenous QID Bolus intravenous normal saline 30 ml/kg Urinary catheter Hemodynamic monitoring Cardiac biomarkers and an electrocardiogram (ECG) are needed in cardiogenic shock. Albuterol nebulizer treatments and diphenhydramine are needed in anaphylactic shock. Intubation and mechanical ventilation are premature based on the client's condition. Oxygen 5 - L via nasal cannula to keep SaO2 greater than 92% is prescribed. Chest x-ray is needed to assess for pulmonary edema. A urinary catheter is needed to closely monitor urine output. Fluid resuscitation is needed to replace intravascular volume. Hydrocortisone decreases inflammation and reverses capillary permeability. Hemodynamic monitoring is used to closely assess client deterioration and treatment success.
Mrs. Anderson progresses to the refractory stage of shock. Identify assessment findings consistent with this stage of shock. Select all that apply. Cold, clammy skin Unresponsive Bradycardia Anuria Profound hypotension
Refractory Stage is characterized by inadequate tissue perfusion that is irreversible. The body organs are failing due to excessive cell and organ damage. The patient experiences multiorgan dysfunction syndrome. Clinical manifestations include profound hypotension, bradycardia, anuria, respiratory failure, hypothermia, cold/clammy skin, and absent bowel sounds.
A nurse in the emergency department (ED) is caring for a client who was recently stung by a bee. Identify clinical manifestations of anaphylactic shock. Select all that apply.
FLUSHED SKIN STRIDOR RR 30 DECREASED LOC WHEEZING Anaphylactic shock causes massive vasodilation and an increase in capillary permeability, which causes fluid to leak from the vascular space into the interstitial space. Severe respiratory distress due to angioedema and circulatory failure due to vasodilation have life-threatening consequences. Tachypnea, wheezing, stridor, rhinitis, and dyspnea are signs of anaphylactic shock. The skin will be flushed with pruritus. Respiratory symptoms lead to a decreased level of consciousness as oxygenation is impaired. Tachycardia, weak pulses, and hyperactive bowel sounds (cramping, pain, nausea, vomiting, diarrhea) are signs of anaphylactic shock.
As Ms. Anderson's body attempts to compensate for hypovolemia, what physiologic change occurs related to increased angiotensin II?
Increased water reabsorption The kidneys help with vasoconstriction by releasing renin, which stimulates the release of angiotensin II, which stimulates the production of aldosterone. Aldosterone causes the kidneys to reabsorb sodium and water.
Ms. Johnson is admitted to the intensive care unit (ICU) with a diagnosis of sepsis. She is at risk for developing septic shock. Select the priority assessments that should be conducted. Select all that apply. HINT: There are 6 priority assessments
Mental status Bowel sounds Lung sounds Time & amount of last insulin dose Urine output Capillary blood glucose level Priority assessment include bowel sounds, lung sounds, blood cultures, mental status, blood glucose level, time/amount of last insulin dose, and urine output. In septic shock, mental status declines due to decreased oxygenation. Decreasing cardiac output due to fluid shifts from the intravascular to interstitial space can result in decreased kidney perfusion. Increased capillary permeability can cause pulmonary edema. Septic shock causes hyperglycemia due to gluconeogenesis and insulin resistance and is one of the first signs of sepsis in a diabetic client. Congratulations! You have analyzed cues and correctly identified essential assessments needed for this client.
One hour after receiving a fluid bolus, Ms. Johnson's blood pressure continues to trend downward and her central venous pressure (CVP) reading is 6 mm Hg. The nurse prepares to administer three medications. Match the medication to the corresponding rationale for administration.
Norepinephrine It causes vasoconstriction and is used for hypotension that is unresponsive to fluid resuscitation. Pantoprazole Proton pump inhibitor is used to prevent stress ulcers. Enoxaparin Anticoagulant is used to prevent venous thrombosis formation.
As hypovolemia progresses, the body attempts to compensate for intravascular volume loss. Select the early signs of hypovolemic shock due to compensatory efforts. Select all that apply.
Restlessness Anxiety Pallor BP 130/75 mm Hg Delayed capillary refill In the compensatory stage of shock, the patient may exhibit normal blood pressure (BP) (due to compensatory vasoconstriction), narrowed pulse pressure, tachycardia, tachypnea, slightly decreased urine output, thirst, pallor, hypoactive bowel sounds, and delayed capillary refill. Decreasing oxygenation results in restlessness, apprehension, and anxiety. If the underlying cause is not corrected, compensatory mechanisms begin to fail as the patient moves into the progressive stage of shock.
Which assessment findings reflect the compensatory stage of septic shock? Select all that apply.
Restlessness Skin warm and flushed Hypoactive bowel sounds Hypotension In the compensatory stage, the body is attempting to increase cardiac output to restore tissue perfusion and oxygenation. The patient exhibits a narrowed pulse pressure, hypotension, tachycardia, tachypnea, restlessness, and apprehension as acidosis develops. The client will also experience hypoactive bowel sounds due to the blood shunting to vital organs. The skin is warm and flushed due to hyperthermia. The kidneys increase renin, aldosterone, and antidiuretic hormone while maintaining urine output (depending on overall fluid intake). In the progressive stage of shock, moist crackles are a sign of increased capillary permeability and significant fluid shifts resulting in pulmonary edema. Decreased urine output is a result of acute tubular necrosis due to the failure of the body to compensate.
The nurse initiates an infusion of Lactated Ringer's solution for fluid resuscitation. Which laboratory result is most critical for the nurse to monitor during this therapy?
Serum pH Lactated Ringer's solution can increase lactate levels, damaging the liver and leading to a buildup of bicarbonate in the blood. This may lead to metabolic acidosis in progressive shock. Close monitoring of the client's acid-base balance is essential. Serum sodium and potassium as well as hematocrit should be monitored in all clients receiving fluid resuscitation.
Ms. Anderson is experiencing hypovolemic shock caused by internal bleeding and obstructive shock caused by tension pneumothorax. Three priority nursing diagnoses include ineffective breathing pattern, decreased cardiac output , and acute pain.
The client has signs of hypovolemic shock, such as hypotension, tachycardia, tachypnea, absent peripheral pulses, weak carotid pulse, and low hemoglobin and hematocrit (H&H) due to internal abdominal bleeding (likely ruptured spleen). The client is also experiencing obstructive shock as evidenced by asymmetric chest movement, absent left side lung sounds, and tracheal deviation due to tension pneumothorax. Three priority nursing actions are breathing (ineffective breathing pattern), circulation (decreased cardiac output), and acute pain.
The client is likely experiencing SEPTIC shock related to IMMUNOSUPRESSION . Patient outcome depends on EARLY IDENTIFICATION and ANTIBIOTIC THERAPY. .
The timing of the patient's last dose of chemotherapy elevates her risk for immunosuppression, which reduces the ability to fight any infection placing her at high risk for sepsis. She is exhibiting early signs of sepsis including hypotension, tachypnea, tachycardia, decreased oxygenation, and hyperthermia. Great job! You have recognized cues for sepsis and the risk for septic shock.
The anticipated central venous pressure (CVP) measurement for Ms. Johnson after fluid resuscitation will INCREASE . The goal for urine is 0.5 ml/kg. Supplemental oxygen delivery is necessary to maintain SaO2 greater than 90%. Serum glucose should be maintained less than 180 mg/dL.
While the normal CVP range is between 2 and 8, the goal of fluid resuscitation in septic shock is to achieve a target CVP of 8-12 mm Hg. Supplemental oxygen or mechanical ventilation is needed to maintain arterial oxygen saturation 90% or greater (PaO2 greater than 60 mm Hg) to avoid hypoxemia. Urine output below 0.5 ml/kg indicates inadequate kidney perfusion. Glucose should be maintained below 180 mg/dL.
