Critical Care E3 - Chapter 11

SHOCK Stage IV is called? And has what type of clinical signs? Is it reversible?

Refractory Stage This stage of shock is unresponsive to therapy; ultimately, organs begin to fail, increasing patient mortality.

SHOCK Cardiogenic Shock Management

*No Fluid replacement* Decrease preload -Diuretics, venous vasodilators Increase cardiac output Decrease afterload -Arterial vasodilators

SHOCK Normal Serum Lactate Level

>2.2 mEq/L ↑ Hypoxia leading to anaerobic metabolism and production of lactic acid

SHOCK Fresh frozen plasma (FFP) is administered to replace: A. clotting factors. B. erythrocytes. C. leukocytes. D. platelets

A: clotting factors Fresh frozen plasma is administered to replace all clotting factors except platelets. Platelets are given rapidly to help control bleeding caused by low platelet counts.

SHOCK While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority? a. Central nervous system b. Gastrointestinal system c. Renal system d. Respiratory system

ANS: A The central nervous system experiences decreased perfusion first. The patient will have central nervous system changes early during the course of shock, such as changes in the level of consciousness. Although the gastrointestinal, renal, and respiratory systems also experience changes during shock, changes in the central nervous system provide the earliest indication of decreased perfusion.

SHOCK The nurse is caring for an 18-year-old athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? a. The patient is developing neurogenic shock. b. The patient is experiencing an allergic reaction. c. The patient most likely has an elevated temperature. d. The vital signs are normal for this patient.

ANS: A The most profound feature of neurogenic shock is bradycardia with hypotension from the decreased sympathetic activity. There is no evidence to support an allergic reaction in this scenario. Hypothermia, not an elevated temperature, can develop from uncontrolled heat loss associated with vasodilation in neurogenic shock. Vital signs are not normal given the clinical situation.

SHOCK The nurse is caring for a young adult patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) a. Blood pressure b. Heart rate c. Level of consciousness d. Pupil response e. Respirations f. Urine output

ANS: A, C, F The level of consciousness assesses cerebral perfusion, urine output assesses renal perfusion, and blood pressure is a general indicator of systemic perfusion. Heart rate is not an indicator of perfusion. Pupillary response does not assess perfusion. Respirations do not assess perfusion

SHOCK The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? a. Creatinine 1.0 mg/dL b. Lactate 6 mmol/L c. Potassium 3.8 mEq/L d. Sodium 140 mEq/L

ANS: B Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation in shock, and as an outcome predictor. All other listed values are within normal limits and do not require additional follow-up.

SHOCK The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 96.8° F. Which intervention is most important for the nurse to include in the patient's plan of care? a. Administration of atropine sulfate (Atropine) b. Application of 100% oxygen via facemask c. Application of slow rewarming measures d. Infusion of IV phenylephrine (Neo-Synephrine)

ANS: C Hypothermia can develop in neurogenic shock from uncontrolled heat loss; therefore, a patient should be rewarmed slowly to avoid further vasodilation. In shock, a drop in systolic blood pressure to less than 90 mm Hg is considered hypotensive. Atropine is used for symptomatic bradycardia. The patient's oxygen saturation is 95% on room air with an adequate respiratory rate. The application of 100% oxygen via facemask is not indicated. The patient's heart rate is adequate to support a normal blood pressure. *In Spinal shock...the body cannot compensate so values are normal (brady w/hypotension & hypothermia w/hypotension)

SHOCK A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention? a. Human albumin infusion b. Hypotonic saline solution c. Lactated Ringer's bolus d. Packed red blood cells

ANS: C The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated Ringer's solutions, are the priority intervention. Albumin and plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused when the volume loss is caused by a loss of plasma rather than blood, such as in burns, peritonitis, and bowel obstruction. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema and are not used for fluid resuscitation. There is no evidence to support a transfusion in the given scenario.

SHOCK During the initial stages of shock, what are the physiological effects of decreased cardiac output? a. Arterial vasodilation b. High urine output c. Increased parasympathetic stimulation d. Increased sympathetic stimulation

ANS: D A reduction in blood pressure leads to an increase in catecholamine release, resulting in an increase in heart rate and contractility to improve cardiac output. Decreased cardiac output leads to arterial vasoconstriction in an effort to increase blood pressure. Low urine output results, as decreased cardiac output reduces blood flow to the kidneys. There is an increase in sympathetic stimulation in response to a decrease in cardiac output.

SHOCK The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a. Breath sounds and capillary refill b. Blood pressure and oral temperature c. Oral temperature and capillary refill d. Right atrial pressure and urine output

ANS: D Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy effectiveness can be adequately assessed.

SHOCK The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy? a. Normal body temperature b. Balanced intake and output c. Adequate pain management d. Urine output of 0.5 mL/kg/hr

Adequate urine output of at least 0.5 mL/ kg/hr indicates adequate perfusion to the kidneys following administration of fluid to enhance circulating blood volume. Normal body temperature and adequate pain management are not assessment findings indicating an adequate response to fluid therapy. During fluid resuscitation in severe sepsis, intake and output will not be balanced as circulating fluid volume deficit is restored.

SHOCK Stage II is called? And has what type of clinical signs? Is it reversible?

Compensatory Stage Hyperventilation occurs. Compensatory mechanisms are activated in an attempt to maintain blood flow to the tissues *reversible

SHOCK In distributive shock, the major physiological problem causing the shock is: A. blood loss and actual hypovolemia. B. decreased cardiac output. C. third spacing of fluids into peritoneal space. D. vasodilation and relative hypovolemia.

D: vasodilation and relative hypovolemia Distributive shock presents with widespread vasodilation and decreased systemic vascular resistance that results in a relative hypovolemia. Blood loss is associated with hypovolemic shock. Decreased cardiac output is a primary cause of cardiogenic shock. Primary internal sequestration of fluids that causes internal fluid loss is associated with hypovolemic shock.

SHOCK The nurse is admitting to the ICU a patient in early sepsis. What is the nurse's best understanding of the patient's nutritional requirements? A. Total parenteral nutrition is preferred. B. Enteral nutrition initiated within the first 24 to 48 hours is critical. C. The caloric needs of the patient in sepsis are significantly lower. D. Early enteral feeding may lead to diarrhea, delaying wound healing.

Early enteral nutrition within 24 to 48 hours of admission to an intensive care unit is supported by evidence and recommended in patients with severe sepsis, septic shock, or both. Enteral nutrition is the preferred route of administration, as this method assists the intestinal mucosa in maintaining its barrier function. The caloric needs of a patient in sepsis are high and require increased caloric intake. Early enteral feeding decreases diarrhea.

SHOCK The drug of choice for treating anaphylactic reactions is...

Epinephrine- an adrenergic agent that promotes bronchodilation and vasoconstriction. Histamine blocking agents such as ranitidine and benadryl are appropriate medications but are used as secondary agents. Corticosteroids may be used to reduce inflammation.

SHOCK Cardiogenic shock

Heart fails to act as an effective pump ex: MI, severe HF

SHOCK Stage I is called? And has what type of clinical signs? Is it reversible?

Initiation Stage Hypoperfusion: inadequate delivery or extraction of oxygen. There are no obvious clinical signs noted. *reversible.

SHOCK Serum lactate level is an...

Is an overall measure of the state of shock, regardless of the cause. Increased lactate levels indicate a decrease in oxygen delivery to the tissue and the shift to anaerobic metabolism

SHOCK Systemic Inflammatory Response Syndrome (SIRS)

Most frequently associated with sepsis Widespread systemic inflammatory response(leaks into 3rd space) -pulmonary edema/HTN

SHOCK Obstructive shock

Physical impairment to adequate circulating blood flow ex: cardiac tamponade, tension pneumothorax, pulmonary embolism

SHOCK The nurse admits a patient to the coronary care unit in cardiogenic shock. The nurse anticipates administering which medication in an effort to improve cardiac output? A. Dopamine (Intropin) B. Phenylephrine (Neo-Synephrine) C. Dobutamine (Dobutrex) D. Nitroprusside (Nipride)

Positive inotropic agents such as dobutamine (Dobutrex) are given to increase the contractile force of the heart in cardiogenic shock. Dopamine (Intropin) is used primarily in low cardiac output states to restore vasculare tone and increase blood pressure

SHOCK Stage III is called? And has what type of clinical signs? Is it reversible?

Progressive Stage Increased capillary hydrostatic pressure Intravascular fluid shifts This phase of shock responds poorly to fluid volume replacement. MDF released. *reversible

SHOCK Distributive shock

Widespread vasodilation and decreased vascular tone resulting in a relative hypovolemia. Neurogenic- epidural block, cervical spine, anesthesia Anaphylactic-drug reactions, allergies, bee sting Septic-infection

SHOCK Shock begins when alteration occurs to what four essential circulatory components:

blood volume myocardial contractility blood flow vascular tone or resistance

SHOCK Clinical manifestations of Distributive Shock-Neurogenic

include bradycardia with hypotension; warm, flushed, dry skin due to vasodilation; and hypothermia due to impaired thermoregulation and loss of heat through vasodilation. Because of spinal injury...cannot compensate

SHOCK ADH increases absorption of...

water only

SHOCK Which statement correctly represents hemodynamic values associated with the initial stages of septic shock state? A. Low heart rate; high blood pressure B. High heart rate; low right atrial pressure C. High PAOP; low cardiac output D. High SVR; normal blood pressure

In septic shock, inflammatory mediators damage the endothelial cells that line blood vessels, producing *profound vasodilation* and increased capillary permeability. Initially this results in a* high heart rate, hypotension*, and low SVR, and subsequently in low right atrial pressure.

SHOCK Hypovolemic Shock Management

Identify underlying cause -Eliminate underlying cause Restore circulating volume -Appropriate fluid selection --Blood --Isotonic crystalloids

SHOCK Hypovolemic shock

Inadequate intravascular blood volume ex: Surgery, Trauma, diarrhea, burns

SHOCK Multiple Organ Dysfunction Syndrome (MODS)

Progressive dysfunction of two or more organ systems Most common causes -Sepsis -Septic shock