Lewis EAQ: Chapter 66

Which cardiovascular change is commonly found in patients with systemic inflammatory response syndrome (SIRS)?

Decrease in capillary refill Patients with systemic inflammatory response syndrome (SIRS) have decreased capillary refill. Other cardiovascular changes include increases rather than decreases in heart rate, central venous pressure, and pulmonary artery wedge pressure. p. 1605

A nurse is caring for a patient diagnosed with septic shock. After an infusion of 30 mL/kg of intravenous fluids, the patient is assessed and has a temperature of 101.4°F (38.6°C), a heart rate of 92 beats/minute, respiration rate of 20 breaths/minute, and a blood pressure of 80/60 mm Hg. Which nursing intervention is a priority for this patient?

Administer a vasopressor. Patients in septic shock with persistent hypotension who do not respond to fluid resuscitation should be placed on a vasopressor. The physiologic goal is to increase cardiac output and end organ perfusion. The nurse should redraw the lactic acid, obtain a 12-lead ECG, and insert an indwelling urinary catheter while caring for this patient, but these can take place following administration of a vasopressor. p. 1598

When reciting to the nursing instructor mechanisms that can trigger the systemic inflammatory response syndrome (SIRS) associated with sepsis, which listed by the student nurse requires correction?

Hypertension Hypertension is not a mechanism that triggers SIRS. SIRS is a response to a variety of mechanisms, including burns, abscess, and pancreatitis. p. 1604

What therapy is provided to a patient with acute respiratory distress syndrome (ARDS)?

Mechanical ventilation A patient with acute respiratory distress syndrome (ARDS) would be intubated and receive mechanical ventilation. Small volume nebulizer treatments would open airways; however, this intervention will not sufficiently treat ARDS. Oxygen via a Venturi mask or a non-rebreather mask would be insufficient to promote oxygenation and perfusion. p. 1605

The the nurse knows that which acid-base imbalance occurs in multiple organ dysfunction syndrome (MODS) due to impaired tissue perfusion, hypoxia, and increased lactate levels?

Metabolic acidosis Metabolic acidosis occurs due to impaired tissue perfusion, hypoxia, the shift to anaerobic metabolism which increases lactate levels, and renal dysfunction. Respiratory acidosis, respiratory alkalosis, and metabolic alkalosis have different indicators. p. 1605

A patient in shock is receiving 0.9 % NaCl (normal saline solution-NSS). Which nursing intervention is appropriate for this patient?

Monitor for the signs of circulatory overload Circulatory overload occurs due to fluid overload. Continuous infusion of 0.9% NaCl increases the fluid volume in the body and may cause circulatory overload. The patient's vital signs must be checked during transfusion of blood or blood products because they could cause an infection or an allergic reaction. Hypernatremia occurs when the patient is on 1.8%, 3%, and 5% NaCl infusions. Infusion of dextran-40 has a tendency to precipitate allergic reactions and acute renal failure. p. 1597

The nurse is caring for a patient who developed cardiogenic shock. Which medical diagnosis does the nurse suspect?

Myocardial infarction Myocardial infarction may produce necrotic areas of cardiac tissue that lead to impaired contractility and decreased cardiac output. This may lead to a cardiogenic shock state. Hemorrhage may lead to a hypovolemic shock state, tension pneumothorax may lead to an obstructive shock state, and urosepsis may lead to a septic shock state. p. 1587

Which type of shock can be treated by minimizing spinal cord trauma with stabilization?

Neurogenic shock

Which type of shock is associated with bradycardia?

Neurogenic shock Neurogenic shock is associated with bradycardia. Myocardial dysfunction and changes in body temperature are signs of septic shock. Reduction in preload, capillary refill, and stroke volume are clinical manifestations of hypovolemic shock. Chest pain is seen in anaphylactic shock. p. 1590

The nurse is caring for a patient with a tension pneumothorax. The nurse recognizes that the symptoms of tachypnea, decreased blood pressure, and decreased urine output are caused by which type of shock?

Obstructive The nurse recognizes these as signs of obstructive shock, which is a result of a physical obstruction of blood flow; can be related to tension pneumothorax, pulmonary embolism, and cardiac tamponade. Hypovolemic shock is a result of low blood volume. Septic shock is a result of a serious infection that has compromised cellular, circulatory, and metabolic function. Anaphylactic shock is a result of hypersensitivity to a sensitizing substance. pp. 1587-1593

A patient with multiple organ dysfunction syndrome (MODS) has a temperature of 102.2 o F and has copious amounts of purulent drainage and redness surrounding a diabetic wound on the right foot. Of the prescribed options, which action should be the nurse's priority action?

Obtain wound and blood cultures The immediate need when an infection is suspected in a MODS patient is to determine the cause; thus wound and blood cultures would be the first action. Antibiotics would be started after the cultures are obtained and sent for analysis. The dressing may need to be changed, but this would not be the first action of the nurse. Restricting patient visitors and requiring them to wear a mask would not be the first step the nurse would complete for suspected infection. p. 1607

The nurse is caring for a patient who is experiencing cardiogenic shock as a result of myocardial infarction. Which nursing assessment finding is most concerning?

PaO 2 60 mm Hg A PaO 2 of 60 is below the normal 80 to 100 mm Hg. The patient experiencing cardiogenic shock will exhibit hypotension and tachycardia, and therefore a blood pressure of 100/56 mm Hg and heart rate of 96 would not apply. A urine output of 260 cc/8 hrs is borderline but not reportable without a continued trending pattern. p. 1603

What is the goal in the care of a systemic inflammatory response syndrome (SIRS) patient whose bilirubin level is 3 mg/dL?

Patient will maintain adequate tissue perfusion The nurse will plan to maintain adequate tissue perfusion for a systemic inflammatory response syndrome (SIRS) patient with bilirubin level of 3 mg/dL. An elevation of the bilirubin indicates impaired liver function. Stress ulcer prophylaxis is routine and would have been initiated before SIRS occurred. Abdominal distention and increased intraabdominal pressures are associated with impaired liver function. Monitoring these conditions is essential but is of a lower priority than maintaining tissue perfusion. p. 1606

When a patient suffers from hypovolemic shock due to loss of blood, the nurse should administer large volumes of packed red blood cells (RBCs). What should be the appropriate course of action for the nurse?

Replace clotting factors based on laboratory studies When administering large volumes of packed RBCs, it is important to replace clotting factors to prevent coagulopathy. Because the pack contains only RBCs and not the clotting factors, it should be given extrinsically. Generally, the crystalloid and colloid solutions are warmed before being administered to avoid hypothermia. However, packed red blood cells should not be warmed, because high temperature can damage the red blood cells. The blood products are almost always cross typed and matched before administration. Antibiotics are not related to the administration of RBCs. p. 1597

Which drug causes arterial and venous dilation?

Sodium nitroprusside Sodium nitroprusside acts by dilating both the arteries and veins. It is used in the treatment of cardiogenic shock. Dopamine has inotropic activity. It increases the force of the heartbeat and is used in the treatment of cardiogenic shock. Vasopressin is a vasoconstrictor used mainly in the treatment of septic shock. Phenylephrine acts by constricting the peripheral nerves and is used in the treatment of neurogenic shock. p. 1599

An instructor working with nursing students in the critical care unit is assessing their knowledge of multiple organ dysfunction syndrome (MODS). Which statement indicates correct understanding of the concept?

"We would generally see dyspnea, changes in pulmonary artery wedge pressure (PAWP), tachypnea, and a decreasing PaO 2/FIO ratio as early signs." The respiratory system is generally the first to show signs of dysfunction in MODS, which means dyspnea, tachypnea, changes in PAWP and a decreasing PaO 2/FIO ratio may be early indicators. Liver dysfunction often begins long before clinical evidence of the dysfunction is apparent. Prognosis once MODS develops is poor, with a 70%-80% mortality rate. Metabolic changes are not self limiting, as they can trigger a hypermetabolic response and last for several days. p. 1605

While planning the management of oxygen delivery in a patient with shock, what appropriate measures should the nurse undertake?

-Administer supplemental oxygen as prescribed -Space activities that increase oxygen consumption -Monitor continuously by using a central venous catheter To optimize oxygen supply and ventilation in a patient suffering from shock, the activities that increase oxygen consumption should be evenly spaced. Mixed venous oxygen saturation should be monitored through a central venous catheter. The patient should not exert energy by excessive moving around because it increases oxygen demand. p. 1596

The nurse is reviewing orders for laboratory work for a patient who is experiencing shock. Which of the following tests would the nurse expect to be ordered?

-Creatinine -Arterial blood gases -Complete blood count Creatinine is a blood test to check kidney function, which is crucial for a patient with shock. Arterial blood gases would be ordered to assess acid-base balance and oxygenation status. A complete blood count would also be ordered to assess red and white blood cell function. Prostate surface antigen (PSA) is done as a screening for prostate cancer and would not be ordered for a patient experiencing shock. Although a glucose level would need to be checked on a patient in shock, a glycosated hemoglobin assessment, which examines blood glucose control over 12 weeks, would not be ordered for a patient in shock. p. 1590

When examining a patient with cardiogenic shock, which signs of peripheral hypoperfusion does the nurse expect?

-Cyanosis -Cold skin -Weak pulse Cyanosis, cold skin, and a weak pulse are the signs of peripheral hypoperfusion in cardiogenic shock. Bradycardia and hypertension are not seen in cardiogenic shock; instead, tachycardia and low blood pressure are noted. p. 1591

Which findings in a patient with systemic inflammatory response syndrome (SIRS) help the nurse identify cardiovascular system dysfunction?

-Decrease in blood pressure -Decrease in mean arterial pressure -Decrease in systemic vascular resistance A patient with SIRS may have cardiovascular system dysfunction manifested as a decrease in blood pressure, mean arterial pressure, and systemic vascular resistance. Heart rate, stroke volume, and cardiac output tend to increase in such patients. p. 1605

Vasopressin has been prescribed for a patient in septic shock. What nursing interventions are important for this patient?

-Do not titrate -Infuse at low doses -Use in vasopressor-refractory patients Vasopressin should be infused in low doses without titrating it, because titration can cause dose-related adverse effects. Vasopressin is usually used for patients who are vasopressor-refractory, for replacing the stores of physiologic vasopressin that are often depleted in septic shock. Inotropic agents can be added with vasopressin to increase tissue perfusion. Vasopressin can be given to patients suffering from coronary artery diseases, but it should be used with caution. p. 1601

A nurse is caring for a patient who is in a state of cardiogenic shock caused by myocardial infarction. The nurse uses pulse oximetry to monitor the oxygen saturation levels. Where should the nurse attach the pulse oximetry probe to get an accurate reading?

-Ear -Nose -Forehead Pulse oximetry is used to monitor oxygen saturation. The patient in a state of shock has poor peripheral circulation, and a peripheral reading may not be accurate. Therefore the probe should be attached to the ear, nose, or forehead for a reliable measurement. Pulse oximetry readings obtained through the toes and fingers may not be accurate due to compromised peripheral circulation. p. 1603

A patient has been brought to the emergency department (ED) in a semiconscious state. The history collected from family members indicates that the patient consumed shellfish after which he experienced itching, difficulty breathing, and confusion. What treatment should the nurse anticipate for this patient?

-Famotidine -Epinephrine -Diphenhydramine Epinephrine is the drug of choice to treat anaphylactic shock. It causes peripheral vasoconstriction and bronchodilation and opposes the effect of histamine. Famotidine is administered to prevent gastrointestinal ulcers and bleeding. IV diphenhydramine is given to block the excessive release of histamine due to an allergic reaction. Dobutamine is given in cases of cardiogenic shock. Low-molecular-weight heparin is usually given in cases of septic shock as a prophylaxis against venous thromboembolism. p. 1600

What are the immediate effects of the inflammatory response that precedes multiple organ dysfunction syndrome (MODS)?

-Hypermetabolism -Increased vascular permeability -Direct damage of the endothelium Inflammatory cascade causes direct damage of the endothelium, increased vascular permeability, and hypermetabolism quickly. Vascular permeability allows mediators and proteins to leak from the endothelium further on in the cascade; microvascular clots are a late effect of inflammation which will eventually lead to impaired perfusion, and finally organ damage which precipitates MODS. p. 1605

Patients in septic shock require large amounts of fluid replacement. The nurse would expect the healthcare practitioner to order an amount of fluids in which range to achieve adequate fluid resuscitation?

30-50 mL/kg Patients in septic shock require volume resuscitation of 30-50 mL/kg with isotonic crystalloids to achieve adequate fluid resuscitation. A volume of 20-40 mL/kg is too little. A volume of 40-50 mL/kg does not express the full expected range. A volume of 60 mL/kg is too high an upper limit. p. 1601

The nurse reviews the medical record of a patient with pneumonia and notes that the patient has hypotension, hypothermia, leukocytosis, and hypoxemia. What should the nurse infer from these findings?

The patient has septic shock Septic shock is most commonly found in the patient having gram-negative bacterial infections, such as pneumonia. Because it is characterized by hypotension, hypothermia, leukocytosis, and hypoxemia in patients with infections, the nurse concludes that the patient has septic shock. Neurogenic shock is most commonly seen in the patient who has an injury. Cardiogenic shock is caused by cardiovascular disorders, such as a myocardial infarction and cardiomyopathy. Hypovolemic shock is caused by hemorrhage or trauma. p. 1591

For a patient to be diagnosed with multiple organ dysfunction syndrome (MODS), how many organ systems must be simultaneously failing?

Two MODS is the failure of two or more organ systems in an acutely ill patient such that homeostasis cannot be maintained without intervention. Three, four, or five organ systems failing are more than necessary for a MODS diagnosis. p. 1605

The nurse recalls that cardiogenic shock is differentiated from other forms of shock because the patient with cardiogenic shock typically experiences what?

Volume excess In cardiogenic shock the heart fails as a pump. This usually results in fluid retention and poor perfusion of organs, including the kidneys, which adds to the fluid volume excess. As cardiogenic shock progresses, hypotension will develop, but it is not the cause of cardiogenic shock. Dysrhythmias may or may not be present with cardiogenic shock. Volume depletion is not generally seen with cardiogenic shock. It is, however, seen more with hypovolemic or distributive forms of shock. p. 1591

When working in an acute medical setting, which patients should a nurse consider to be prone to a risk of developing septic shock?

-A 55-year-old with diabetes -A 45-year-old with heart failure -A 70-year-old with malnourishment -An 80-year-old with a compromised immune system Patients who are at risk of developing septic shock include older adults who have a compromised immune system. Patients with diabetes and heart failure due to a dysfunctional immune response are also at risk of developing septic shock. Malnourished patients are at risk, owing to their inadequate immune body components. Patients who are prone to cold and headache and have no other health-related illnesses do not have any risk of developing septic shock. pp. 1592-1593

A patient is brought to the emergency department (ED) after multiple bee stings. On assessment, the nurse finds that the patient has edema on the lips and tongue as well as chest pain, dizziness, wheezing, and stridor. What type of shock should the nurse document this as?

Anaphylactic shock Anaphylactic shock is an acute, life-threatening hypersensitivity reaction to a sensitizing substance that, in this case, is insect venom. The reaction quickly causes massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. As capillary permeability increases, fluid leaks from the vascular space into the interstitial space. The consequences of these pathophysiologic processes include edema on the lips and tongue, chest pain, wheezing, and stridor. Sepsis is a systemic inflammatory response to a documented or suspected infection. Neurogenic shock is a hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic (T5) vertebra or above. Obstructive shock develops when a physical obstruction to blood flow occurs with decreased cardiac output. pp. 1590-1591

Which form of shock is associated with pruritus?

Anaphylactic shock Pruritus is a clinical manifestation of anaphylactic shock. Septic shock is initially associated with warm and flushed skin with later changes that include cool and mottled skin. Warm or cool and dry skin is a sign of neurogenic shock. Pale, cool, and clammy skin is a sign of obstructive shock. p. 1591

Which type of organism most commonly causes sepsis?

Bacteria The most common organisms that cause sepsis are gram-negative and gram-positive bacteria. Fungi, viruses, and parasites can also cause sepsis but not as frequently. p. 1592

A patient admitted to the hospital after a motor vehicle accident (MVA) is in hypovolemic shock. On examination, the nurse finds that the patient is becoming anxious, and the urine output is decreasing. What appropriate action should the nurse perform?

Begin crystalloid fluid replacement When the volume of blood loss is less than 30 percent, crystalloid fluid replacements are performed to reverse tissue dysfunction. Blood products are administered when the blood volume loss is more than 30 percent. The nurse should not wait for deterioration to occur to start the fluid replacement therapy. This is because the body can typically compensate naturally for a blood volume loss up to 15 percent. p. 1601

Which type of shock is associated with hyperglycemia, presence of pulmonary infiltrates in chest x-ray and increased levels of blood urea nitrogen (BUN)?

Cardiogenic Increased blood levels of glucose, nitrogen, and cardiac markers and presence of pulmonary infiltrates are seen in cardiogenic shock. Increased blood levels of lactate, glucose, and positive blood cultures are signs of septic shock. Manifestations of obstructive shock are specific to the area or organ of obstruction. Electrolyte imbalances and decreased hemoglobin and hematocrit are seen in hypovolemic shock. p. 1591

A patient presents to the emergency department (ED) in a state of shock. On assessment, the nurse finds that the patient is cyanotic and has crackles on auscultation of the lungs. As which type of shock will the nurse classify this?

Cardiogenic shock A patient with cardiogenic shock shows peripheral hypoperfusion presenting as cyanosis and has crackles on auscultation of the lungs due to pulmonary congestion. In neurogenic shock, the patient demonstrates symptoms related to the injury such as hypotension and bradycardia. The patient in hypovolemic shock may experience tachycardia as a late sign. In anaphylactic shock, the patient may experience wheezing and stridor. p. 1591

A patient experiences a myocardial infarction (MI). The nurse closely monitors the patient for complications and recognizes that hypotension is a warning sign of which condition?

Cardiogenic shock One of the initial cardinal signs of cardiogenic shock after a myocardial infarction (MI) is a slow, steady drop in blood pressure. Hypotension after an MI may be an indirect sign of a secondary MI or a fatal dysrhythmia. Depending on the origin of pulmonary edema, patients may experience hypotension or hypertension. p. 1587

A patient is showing signs of anaphylactic shock from an insect sting. Which primary health care provider's prescription does the nurse implement first?

Epinephrine 1:1000, 0.5 mg subcutaneous (SQ) The patient in anaphylaxis experiences bronchial spasm and constriction. The administration of epinephrine is necessary to reverse this process and facilitate an open airway. Although administering normal saline, diphenhydramine, and oxygen are appropriate, they must be done after an airway has been established. p. 1601

What laboratory finding correlates with a medical diagnosis of cardiogenic shock?

Increased blood urea nitrogen (BUN) and serum creatinine levels

A patient in neurogenic shock is receiving phenylephrine. Which nursing actions are appropriate when caring for this patient?

Monitoring for signs of reflex bradycardia and restlessness Phenylephrine is β-adrenergic agonist and may cause bradycardia and restlessness due to central nervous system stimulation. β-adrenergic agonists such as epinephrine cause dyspnea and pulmonary edema. Phenylephrine does not increase the elimination of potassium levels or blood glucose levels. Therefore the patient does not have risk of hypokalemia and hyperglycemia. Phenylephrine does not impair thyroid and adrenal gland functioning. Therefore the nurse will not monitor for the signs of hypothyroidism and Addison's disease. p. 1599

Following coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery to repair the leak. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient assessment is the most important for planning nursing care?

Pulmonary artery pressure (PAP) 28/14 mm Hg Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be caused by the MI. The CI, CVP, and MAP readings are normal. p. 1603

A nurse is caring for a patient diagnosed with septic shock. The patient develops dyspnea, tachycardia, and bilateral lung crackles. The nurse suspects the patient has developed acute respiratory distress syndrome (ARDS). Which intervention is the nurse's priority?

Pulmonary management with mechanical ventilation Patients with ARDS need aggressive pulmonary management with mechanical ventilation. Repeat chest radiograph may be done after initiation of mechanical ventilation. Arterial blood gas measures respiratory alkalosis in early stages of septic shock and metabolic acidosis in late stages of septic shock. Broad spectrum antibiotics are important in the early component of therapy and should be started within the first hour of severe sepsis or septic shock, but once breathing is compromised, that becomes the priority. p. 1603

Which manifestation in a patient with systemic inflammatory response syndrome (SIRS) suggests respiratory system dysfunction?

Refractory hypoxemia In a patient with SIRS, refractory hypoxemia suggests respiratory system dysfunction. Other manifestations of respiratory system dysfunction include pulmonary hypertension, decreased compliance, and increased minute ventilation. p. 1605

In a patient diagnosed with septic shock, which manifestations are initial compensatory mechanisms of the respiratory system?

-Tachypnea -Hyperventilation In septic shock, hyperventilation and tachypnea are initial compensatory manifestations of the respiratory system. Severe hypoxemia is a refractory manifestation. Pulmonary vasoconstriction and pulmonary interstitial edema are progressive manifestations. p. 1595

The health care provider prescribes a dose of dobutamine for a patient in cardiogenic shock due to myocardial infarction. What appropriate actions should the nurse perform for safely administering the medication?

-Administer through a central line -Monitor heart rate and blood pressure -Stop infusion if tachydysrhythmias develop When using dobutamine, the patient's heart rate and blood pressure should be continuously monitored, as it may worsen hypotension, requiring the addition of a vasopressor. The infusion should be stopped if tachydysrhythmias develop. The administration through a central line is recommended, because infiltration leads to tissue sloughing. The drug should not be administered with sodium bicarbonate, because it can get deactivated. Because dobutamine is not adsorbed in plastic containers, it is not necessary to administer the drug in glass bottles. p. 1599

The nurse is taking care of a patient with cardiogenic shock due to a myocardial infarction. The health care provider prescribes dopamine to be administered. What nursing intervention should the nurse perform for administering dopamine?

-Administer via a central line -Monitor for tachydysrhythmias -Monitor for peripheral vasoconstriction Dopamine is a positive inotropic agent used in cardiogenic shock. The drug may cause tissue sloughing, if infiltrated. Therefore it is administered through a central line and not via a peripheral line. The patient should be monitored for tachydysrhythmias caused by enhanced inotropic effects. There is also a risk of peripheral vasoconstriction, so the nurse should be observant for symptoms such as paresthesia and coldness of the extremities. The drug may get deactivated by an alkaline solution; therefore it should not be administered along with sodium bicarbonate. Because dopamine is not known to have an adrenergic action, it will not cause dyspnea and pulmonary edema. p. 1599

When planning for home care of a patient who has just recovered from shock, what appropriate measures should the nurse follow?

-Admit to rehabilitation center -Arrange for transitional care units -Refer to home health care agencies Patients recovering from shock often require diverse services after discharge. Such services aim at maintaining continuity of care and monitoring the patient for indications of complications. These can include admission to transitional care units, rehabilitation centers, or home health care agencies. The patient may not be able to resume work, because recovery takes time. Self-care is not sufficient, because specialized monitoring and care may be needed. p. 1604

The nurse is caring for a patient who has hypovolemic shock from hemorrhage. The nurse expects to find which clinical manifestation(s)?

-Anxiety -Tachycardia -Hypotension -Decreased capillary refill In a patient with hypovolemic shock due to hemorrhage, assessment findings will be related to intravascular fluid loss that include cool skin, decreased capillary refill, hypotension, orthostatic changes, tachycardia, anxiety, and decreased urine output. Hypothermia is associated with spinal cord injury.

Which nursing interventions are appropriate to manage hematologic dysfunctions in a patient with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?

-Avoiding multiple venipunctures -Minimizing intramuscular injections Platelet count is decreased in patients with SIRS and MODS with hematologic dysfunction. This decrease increases the risk of bleeding. Therefore multiple venipunctures should be avoided and intramuscular injections should be minimized in order to minimize traumatic interventions. Continuous infusion of insulin and glucose may be needed to maintain blood glucose levels in cases in which there is endocrine dysfunction rather than hematologic dysfunction. Continuous echocardiographic monitoring helps to manage cardiovascular dysfunctions rather than hematologic dysfunctions. Positive end-expiratory pressure ventilation helps to manage respiratory dysfunction associated with SIRS and MODS. p. 1606

The nurse is administering oxygen therapy to a patient in septic shock. What are the possible factors that directly affect oxygen delivery in the patient and should be monitored?

-Cardiac output -Available hemoglobin -Arterial oxygen saturation Oxygen delivery depends on cardiac output, available hemoglobin, and arterial oxygen saturation (SaO 2). The amount of blood that the heart pumps to the body may decide the amount of oxygen delivered to the tissues. Hemoglobin, the protein content in red blood cells, is responsible for carrying oxygen molecules. Low hemoglobin means a low oxygen supply to the tissues. Arterial oxygen saturation indicates the total oxygen carried by the blood in the arteries and implies the level of tissue oxygenation. The urine output and white blood cells are also important parameters to be monitored in a patient who suffers from a shock. However, these do not impact the oxygen delivery directly. p. 1603

A patient is admitted to the hospital with a suspected diagnosis of obstructive shock. What could be the possible causes of this type of shock?

-Cardiac tamponade -Tension pneumothorax -Superior vena cava syndrome Obstructive shock develops when a physical obstruction to blood flow occurs resulting in decreased cardiac output. This can be caused by restricted diastolic filling of the right ventricle from compression caused by cardiac tamponade, tension pneumothorax, or superior vena cava syndrome. Hypersensitivity to antibiotics may cause anaphylactic shock. Spinal cord injury may lead to neurogenic shock. p. 1593

A nurse is monitoring a patient for signs and symptoms related to septic shock. Which are late signs of this emergency condition?

-Cool and mottled skin -Myocardial dysfunction Late signs of septic shock are cool and mottled skin and myocardial dysfunction. The release of platelet-activating factors increases coagulation, resulting in the formation of microthrombi and decreased blood flow in the microcirculation. The patient in early stages of septic shock may have warm and flushed skin, respiratory alkalosis, altered mental status, and decreased urine output. p. 1591

A patient is suspected to have septic shock due to untreated cellulitis in the lower extremity. What findings would the nurse expect to observe when assessing this patient?

-Crackles -Hyperventilation -Decreased urine output In septic shock, the combined effects of the inflammatory mediators result in damage to the endothelium, vasodilation, increased capillary permeability, and neutrophil and platelet aggregation and adhesion to the endothelium. The patient with septic shock may develop crackles due to increased vasodilation and respiratory failure. Initially, the patient may hyperventilate to compensate, resulting in respiratory alkalosis. Symptoms such as decreased urine output are related to renal hypoperfusion. Rhonchi and cyanosis are symptoms of cardiogenic shock. p. 1591

What are the results of hypermetabolic response in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?

-Hypoglycemia -Hyperglycemia -Glycogenolysis -Gluconeogenesis In systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS), there is rapid conversion of glucose from glycogen stores and amino acids due to hypermetabolic response. In the progressive stage, despite increases in glycogenolysis and gluconeogenesis, the liver is unable to maintain an adequate glucose level and the patient develops hypoglycemia. Acute adrenal insufficiency in SIRS and MODS also results in a hypoglycemic state. At the initial stage, there is a release of catecholamines and glucocorticoids, which leads to hyperglycemia and insulin resistance. Due to the hypermetabolic response, glycogenolysis occurs and glycogen stores are rapidly converted to glucose. Once glycogen is depleted, amino acids are converted to glucose through a process called gluconeogenesis. In SIRS and MODS, there is gluconeogenesis, or conversion of amino acids to glucose, rather than glycolysis, or breakdown of glucose. There is glycogenolysis or conversion of glycogen to glucose rather than glycogenesis, or formation of glycogen. p. 1605

A pregnant patient is hospitalized with severe hemorrhage. The nurse expects what laboratory results?

-Increased lactate levels -Decreased hematocrit levels Severe hemorrhage results in blood loss and hypovolemic shock in the patient. Due to the loss of blood, the patient has increased lactate levels and decreased hematocrit levels. Loss of blood does not result in sodium retention and does not increase serum sodium levels. Loss of blood will not increase insulin levels and does not decrease blood glucose levels in the patient. Hypovolemia will not stimulate cardiac myocytes and will not increase the production of natriuretic peptide levels. Therefore the patient will probably not have increased sodium levels, decreased blood glucose levels, or increased natriuretic peptide levels. p. 1591

When examining a patient in the progressive stage of shock, which factors related to the gastrointestinal (GI) system should the nurse consider?

-Increased risk of GI bleeding -Increased likelihood of GI ulcers -Increased risk of bacterial migration from the GI tract to the bloodstream

A nurse has received the laboratory work of a patient who is suspected to have hypovolemic shock. What would be the laboratory findings if the patient is in the early stages of hypovolemic shock?

-Increased sodium levels -Increased glucose levels -Decreased potassium levels The patient may have increased glucose levels, increased sodium levels, and decreased potassium levels in the early stages of shock. Glucose levels increase due to the release of liver glycogen stores in response to sympathetic nervous system stimulation and cortisol. Sodium levels increase due to the increased secretion of aldosterone, causing renal retention of sodium. Potassium levels decrease because of the increased secretion of aldosterone, causing the renal excretion of potassium. Metabolic acidosis is a manifestation of late shock; respiratory alkalosis is seen in early shock due to hyperventilation. Increased liver enzymes indicate liver cell destruction in the progressive stage of shock. p. 1590

A nurse is taking care of a patient with hypovolemic shock from a motor vehicle accident (MVA). The health care provider prescribes human serum albumin for fluid replacement. What should the nurse do to safely administer this medication?

-Monitor for circulatory overload -Use 5% solution of serum albumin -Monitor for chills, fever, and urticaria Human serum albumin is used for increasing plasma colloid osmotic pressure and for rapid volume expansion. The patient should be monitored for circulatory overload. Because the patient is hypovolemic, a 5% solution of serum albumin should be used. Also, note that a 25% solution is used in patients with fluid and sodium restrictions. The infusion can cause mild side effects like chills, fever, and urticaria. Because the infusion is not reactive to light, protection from sunlight is not required, and it does not increase the risk of bleeding. p. 1597

When considering the use of nitroglycerin for treating a patient with shock, what actions should the nurse perform?

-Monitor the heart rate -Monitor the blood pressure -Use a glass bottle for infusion Nitroglycerin is a vasodilator used in the treatment of cardiogenic shock. During medication with nitroglycerin, the patient's heart rate and blood pressure should be continuously monitored in order to prevent any chances of reflex tachycardia. Because plastics tend to adsorb nitroglycerin, glass bottles should be used for infusion to avoid adsorption. The drug can be administered through a peripheral line; a central line is not required. Because it is not photosensitive, the drug does not need to be protected from sunlight. p. 1599

When using an isotonic fluid replacement for a patient who is in shock, what are important interventions that a nurse should perform?

-Monitor the patient closely for circulatory overload -Avoid using lactated Ringer's solution in patients with liver failure Isotonic fluids primarily remain in the intravascular space and increase the intravascular volume. Therefore the patient should be closely monitored for circulatory overload. Use of lactated Ringer's solution should be avoided in patients with liver failure, because it results in the accumulation of lactate. The isotonic fluids do not cause hypernatremia or hypersensitivity reactions. These solutions do not damage the peripheral veins and can be safely administered through peripheral lines. A central line is not required. p. 1597

The nurse is monitoring a patient with neurogenic shock caused by a spinal cord injury. The nurse finds that the PaO 2 is below 60 mm Hg. How should the nurse interpret this finding?

-Need for higher oxygen concentrations -Need for intubation and mechanical ventilation -Need for a different mode of oxygen administration Arterial blood gases (ABGs) provide definitive information on ventilation and oxygenation status and acid-base balance. A PaO 2 below 60 mm Hg indicates hypoxemia and the need for higher oxygen concentrations or for a different mode of oxygen administration. A rising PaCO 2 with a persistently low pH and PaO 2 indicate the need for advanced pulmonary management. Most patients in shock are intubated and on mechanical ventilation. Low PaO 2 implies the need for ventilation and not fluid resuscitation. p. 1603

Which should the nurse evaluate when performing an assessment of end organ function on a patient who received fluid volume resuscitation for septic shock?

-Urine output -Peripheral pulses -Neurologic function The goal for fluid resuscitation is restoration of tissue and end organ perfusion. An assessment of end organ perfusion includes urine output, peripheral pulses, and neurologic function. Visual acuity, oral mucosa, and bowel sounds do not provide relevant data for the nurse to evaluate end organ function. p. 1591

A nurse caring for a patient with multiple organ dysfunction syndrome understands that the patient may be at increased risk of bleeding. What nursing interventions should the nurse perform to manage this patient?

-Observe bleeding sites -Minimize traumatic interventions -Administer platelets and clotting factors The patient with multiple organ dysfunction syndrome is at a risk of bleeding due to increased bleeding time, thrombocytopenia, and dysfunctional clotting process. The nursing interventions should be aimed at preventing potential bleeding and replacing factors being lost. The patient should be observed for frank or occult bleeding from potential sites. The factors like platelets and clotting factors should be replaced if deficient. Traumatic interventions such as intramuscular injections or multiple venipunctures should be avoided. Decreasing the fluid intake and providing enteral feedings will not help in minimizing hematologic complications. p. 1606

Which types of shock are associated with decreased cerebral perfusion?

-Obstructive shock -Cardiogenic shock -Hypovolemic shock Manifestations of cardiogenic shock include decreased cerebral perfusion causing anxiety, confusion and agitation. Decreased cerebral perfusion associated with obstructive shock causes anxiety, confusion, and agitation. Decreased cerebral perfusion associated with hypovolemic shock causes anxiety, confusion and agitation. Septic shock causes mental changes like confusion, agitation, and coma in the late stages. Loss of reflex activity and flaccid paralysis are seen with neurogenic shock. Anxiety, metallic taste, confusion, and impending doom are signs of hypovolemic shock. p. 1591

When examining a patient with septic shock, what symptoms would the nurse expect to find?

-Paralytic ileus -Decreased urinary output -Gastrointestinal (GI) bleeding Patients suffering from septic shock may experience decreased tissue perfusion, which may result in a paralytic ileus, GI bleeding, and decreased urinary output. Pulsus paradoxus and jugular vein distension are found in obstructive shock and are mainly the result of compromised hemodynamics. p. 1591

A nurse is caring for a 52-year-old patient receiving chemotherapy for lung cancer. Which strategies should the nurse take to reduce the risk for opportunistic infections thereby reducing the risk of sepsis?

-Pay strict attention to thorough handwashing -Use aseptic technique during invasive procedures -Thoroughly clean or discard equipment between patients Patients who are immunocompromised are at a high risk for opportunistic infection. Strategies to decrease the risk of infection include paying attention to strict handwashing, using aseptic technique during invasive procedures, and thoroughly cleaning or discarding equipment between patients. Changing the IV site daily increases the risk of infection. Antibiotics are not administered prophylactically. p. 1602

A patient in cardiogenic shock is prescribed a dose of sodium nitroprusside. What appropriate actions should the nurse perform to safely administer sodium nitroprusside?

-Protect solution from light -Wrap infusion bottle with opaque covering -Monitor the serum cyanide levels and signs of cyanide toxicity

A nurse is examining a patient with anaphylactic shock due to an insect bite. What types of skin manifestations would the nurse expect to find?

-Pruritus -Flushing -Urticaria Insect bites may cause allergic reactions and anaphylactic shock. The skin manifestations may include pruritus, flushing, and urticaria caused by massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. Pallor and cold, clammy skin changes are usually seen in cardiogenic, hypovolemic, and obstructive shock caused by decreased circulatory volume and tissue perfusion. p. 1591

A nurse is assessing a patient who is suspected of having hypovolemic shock. What are the conditions that can cause hypovolemic shock?

-Ruptured spleen -Bowel obstruction -Diabetes insipidus Hypovolemic shock may be caused due to bowel obstruction, a ruptured spleen, or diabetes insipidus. Bowel obstruction causes relative hypovolemia by preventing fluid absorption for the bowel. A ruptured spleen may cause massive internal bleeding, leading to hypovolemia. Diabetes insipidus causes a marked increase in fluid loss through the kidneys, leading to hypovolemia. A tension pneumothorax and valvular stenosis may lead to cardiogenic shock. p. 1589

Vasopressor agents are prescribed for which types of shock?

-Septic shock -Neurogenic shock Septic shock occurs in response to an infection. It is associated with the release of cytokines and other inflammatory mediators, resulting in vasodilatation, increased capillary permeability, and platelet aggregation. Vasopressors will constrict the blood vessels and relieve hypotension. Neurogenic shock is caused by a severe injury to the CNS causing a loss of sympathetic stimulation of blood vessels resulting in vasodilatation. A fall in blood pressure can be restored by administering vasopressor agents that act by constricting the blood vessels. Obstructive shock is caused by an obstruction in the vessels of the heart or the heart itself. Restoring the circulation by treating the cause of obstruction will be beneficial for a patient with obstructive shock. Systolic or diastolic dysfunction of the heart results in cardiogenic shock. Treatment involves use of nitrates, inotropes, diuretics, and beta-blockers. A loss in the intravascular fluid volume causes hypovolemic shock. Treatment of hypovolemic shock includes restoring the fluid volume by infusion of blood or blood products and crystalloids. p. 1600

Which types of shock may cause reduced urinary output in a patient?

-Septic shock -Obstructive shock -Cardiogenic shock -Hypovolemic shock Decreased urine output is a clinical manifestation of septic, hypovolemic, and cardiogenic shock. Neurogenic shock is associated with bladder dysfunction. Anaphylactic shock is associated with urinary incontinence. p. 1591

When managing a patient with shock, which appropriate actions should the nurse take as part of nutritional therapy?

-Start enteral nutrition within the first 24 hours -Start parenteral nutrition if enteral feedings are contraindicated -Start a slow continuous drip of small amounts of enteral feedings Enteral nutrition should ideally begin within the first 24 hours. It is important because it enhances the perfusion of the (gastrointestinal) GI tract and helps to maintain the integrity of the gastrointestinal mucosa. Enteral feeding should be started with a slow continuous drip of small amounts of enteral feedings. If enteral feedings are contraindicated, parenteral feedings can be started. Enteral feeding should be planned to meet at least 80 percent of the total calorie requirements, but if it is not feasible, parenteral feeding should be started. Nutritional therapy should start as early as possible. The nurse should not wait for the patient to recover before starting nutritional therapy. p. 1598

A patient is receiving 5% human serum albumin. The nurse should monitor for which complications associated with the infusion?

-Urticaria -Fluid overload Colloidal solutions such as 5% human serum albumin may cause fluid and sodium retention, resulting in fluid overload. Therefore to prevent the risk of fluid overload in the patient, the nurse should check for signs of fluid overload, or hypervolemia. Colloidal solutions can cause chills, fever, and urticaria. Therefore the nurse should assess the patient for symptoms of urticaria in order to provide appropriate treatment. Unlike dextrose, human serum albumin does not increase the risk of bleeding in the patient. Human serum albumin causes sodium retention, so the nurse should check for the symptom of hypernatremia, not hyponatremia. Human serum albumin does not cause a decrease in plasma bicarbonate concentration and does not result in hyperchloremic acidosis. p. 1597

When using dextran as a fluid therapy for a patient who is in a state of shock, which factors should the nurse consider?

-Use of dextran as a fluid therapy increases the risk of bleeding -Use dextran in limited quantities for shock therapy because it has side effects -Check whether the patient is monitored for allergic reactions and acute renal failur

The health care provider prescribes 5% sodium chloride solution for the initial fluid replacement in a patient with hypovolemic shock. Which factors should the nurse consider when administering this solution to the patient?

-nfuse the solution through a central line -Monitor the patient closely for signs of hypernatremia A 5% sodium chloride solution is a hypertonic solution that is used for initial volume expansion in patients with hypovolemic shock. The patient should be monitored for signs of hypernatremia, such as disorientation and convulsions. The infusion should be administered through a central line, because it can damage the peripheral veins. The solution does not increase the risk of bleeding and is not photosensitive. Also, it does not increase the risk of renal failure. p. 1597

If the patient in shock is to receive 1000 mL of normal saline in two hours, at what rate should the infusion pump be set? Record your answer using a whole number ___________ mL/hour

500 mL/hr For the 1000 mL of normal saline to be infused in two hours, the infusion pump should be set at 500 mL per hour (1000 mL divided by two hours). pp. 1597-1598

A nurse is reviewing the chart of a 68-year-old patient admitted with pneumonia. The nurse knows that the patient has the potential to develop sepsis based on which risk factors?

Age Sepsis is a constellation of symptoms or syndrome in response to an infection. Advanced age, recent surgery, a history of chronic disease, and immunosuppressive therapy like chemotherapy puts a patient at a greater risk for infection. Hearing loss and daily intake of multivitamins do not increase a patient's risk of infection. p. 1592

A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient?

Aggressive IV crystalloid fluid resuscitation Patients in septic shock require large amounts of crystalloid fluid replacement. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be). Nitrates and β-adrenergic blockers are used most often in the treatment of patients in cardiogenic shock. pp. 1597-1598

What action should the nurse take when caring for a patient with multiple organ dysfunction syndrome (MODS)?

Aim for glycemic control at 140 to 180 mg/dL When caring for a patient with multiple organ dysfunction syndrome (MODS), the nurse should pay attention to the glycemic control with a goal of 140 to 180 mg/dL. The aim of proper nutritional support is to preserve organ function. Sedation may be given to patients with MODS because it helps to decrease the oxygen demand. Patients should not be put on bed rest for several weeks. Early ambulation helps to reduce infections. The enteral mode is the preferred mode of nutrition. However, if it is not possible or it does not meet the caloric needs of the patient, parenteral nutrition should be initiated or added. p. 1607

A patient has neurologic dysfunction related to sepsis. Which assessment finding is specific to this dysfunction?

Altered mental status Neurologic dysfunction commonly presents as mental status changes with systemic inflammatory response syndrome. These acute changes can be an early sign of sepsis. Shivering is the body's response to temperature regulation. Hypotension is a result of decreased cardiac output. Decreased urine output is a result of impaired renal function. p. 1605

A nurse is caring for multiple patients. Which patient does the nurse monitor most closely for possible development of sepsis?

An 86-year-old patient with a fever and history of chronic urinary tract infections Advanced age, recent surgery, history of chronic disease, and immunosuppressive therapy put a patient at risk of infection. Due to these factors, the 86-year-old patient with a fever and chronic infections has the highest risk for developing sepsis. The 62-year-old patient has risk factors of advanced age and chronic disease, but the lack of fever puts this patient at a lower risk. The 7-year-old patient only exhibits one risk factor, and the 54-year-old patient does not exhibit any risk factors. p. 1602

A patient involved in a motor vehicle accident was admitted to the intensive care unit with a closed-head injury. Which clinical manifestation warns the nurse that the patient's condition is progressing to multiple organ dysfunction syndrome (MODS)?

Decreased PaO 2 with an increase in FiO 2 Decreased PaO 2 with an increase in FiO 2 (refractory hypoxemia) is the correct answer, because the lungs are the first organ to show signs of dysfunction and are the main organ affected in multiple organ dysfunction syndrome. Hypotension and dysrhythmias can occur with hypovolemia and hypoxia without progressing to multiple organ dysfunction syndrome. Urine output less than 400 mL/day develops later in the course of multiple organ dysfunction syndrome, when the kidneys become involved. Alteration in level of consciousness is probably already present with the closed head injury, and also can occur with hypoperfusion, microvascular coagulopathy, or cerebral ischemia, and will not necessarily progress to multiple organ dysfunction syndrome. p. 1605-1606

What causes gut bacteria to move into circulation in patients with systemic inflammatory response syndrome (SIRS)?

Decreased perfusion of gut mucosa Decreased perfusion in the gastrointestinal (GI) tract leads to a breakdown of the normally protective mucosal barrier, which causes the bacterial movement from the GI tract into circulation. In order to control these bacteria, antibiotics are administered. Antibiotics are nephrotoxic medicines that can cause acute kidney injury. The breakdown of the mucosal barrier is the direct effect of hypoperfusion rather than the inflammatory mediators. In critical illnesses, GI motility is often decreased causing abdominal distension and paralytic ileus. p. 1605

A nurse is caring for a patient diagnosed with septic shock. For which sign of peripheral hypoperfusion does the nurse assess the patient?

Diaphoresis One sigh of peripheral hypoperfusion is diaphoresis. Because the patient will sweat, warm, dry skin does not indicate peripheral hypoperfusion. Rather than red skin, the patient will exhibit pallor and cyanosis with peripheral hypoperfusion. Strong peripheral pulses are not present with peripheral hypoperfusion. p. 1592

A nurse is caring for a patient with multiple organ dysfunction syndrome (MODS) caused by sepsis. Which is the most appropriate communication with the caregiver when further treatment is futile?

Discuss realistic goals and likely outcomes When further treatment is futile, the nurse should have a conversation with the patient's caregiver about realistic goals and likely outcomes for a patient with MODS. The nurse should not give the caregiver false hope. Discussing options is appropriate communication with the caregiver, but encouraging the caregiver to withdraw life support does not empower the caregiver's autonomy. Asking the caregiver if he or she want to see the clergy is not the most appropriate response at this time. This is more appropriate to offer after discussion of goals and likely outcomes. p. 1607

The nurse is mentoring a graduate nurse and is explaining the use of fluids in a patient who is experiencing hypovolemic shock. Which of the following fluids increases osmotic pressure to provide rapid volume expansion?

Human serum albumin Human serum albumin is a colloidal fluid that increases osmotic pressure and will provide rapid volume expansion. Lactated Ringer's and 3% sodium chloride are used for initial volume replacement in shock, but they do not provide rapid volume expansion. Fresh frozen plasma is used to replace blood loss and replace coagulation factors. p. 1597

The nurse would recognize which clinical manifestation as suggestive of sepsis?

Hyperglycemia in the absence of diabetes Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis, along with tachypnea and tachycardia, not bradypnea and bradycardia. p. 1606

What electrolyte change is likely in patients with systemic inflammatory response syndrome (SIRS) and multiorgan dysfunction syndrome (MODS)?

Hypophosphatemia In patients with SIRS and MODS, hypophosphatemia is common. The release of aldosterone increases urinary potassium loss, and catecholamines cause potassium to move into the cells. As a result, hypokalemia rather than hyperkalemia occurs. The release of antidiuretic hormone and aldosterone results in sodium and water retention. Hence, hyponatremia does not occur. Other changes include hypocalcemia rather than hypercalcemia. p. 1605

Which type of shock causes an absence of bowel sounds?

Hypovolemic shock Absence of bowel sounds is associated with hypovolemic shock. Decreased bowel sounds are seen with cardiogenic shock. Bowel dysfunction is associated with neurogenic shock. Abdominal pain, nausea, and vomiting are seen with anaphylactic shock. p. 1591

A patient in septic shock is receiving fluid resuscitation. How will the nurse most accurately measure urine output?

Indwelling urinary catheter The nurse will insert an indwelling urinary catheter to measure adequate urine output. Strict input and output and daily weights are not exact enough for measuring urine output. A nasogastric tube is not related to measuring urine output. p. 1603

A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis?

Ineffective tissue perfusion The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. Ineffective tissue perfusion supersedes acute pain, impaired tissue integrity, and decreased cardiac output, because circulation is a priority. Acute pain may occur, but is not a priority at this time. Tissue integrity is not impaired. p. 1589

When caring for a patient in acute septic shock, what should the nurse anticipate?

Infusing large amounts of intravenous (IV) fluids Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. Diphenhydramine may be used for anaphylactic shock, but would not be helpful with septic shock. VADs are useful for cardiogenic shock, not septic shock. p. 1601

A nurse is caring for a patient with sepsis. Which laboratory value will the nurse monitor to measure the byproduct of anaerobic metabolism caused by significant hypoperfusion and impaired oxygen utilization at the cellular level?

Lactic acid Lactic acid is the measurement of the byproduct of anaerobic metabolism caused by significant hypoperfusion and impaired oxygen utilization at the cellular level in sepsis patients. Base deficit indicates acid production secondary to hypoxia. Blood cultures are used to determine the organism causing infection. Arterial blood gas measures respiratory alkalosis in early stages of septic shock and metabolic acidosis in late stages of septic shock. p. 1590

A patient diagnosed with sepsis fails to respond to fluid resuscitation. The healthcare provider orders the patient to be started on a vasopressor. The nurse evaluates which response to determine the effectiveness of the vasopressor?

Mean arterial pressure greater than 65 mm Hg The goal of vasopressor therapy is to maintain a mean arterial pressure greater than 65 mm Hg. Fluids can be increased or vasopressor therapy can be decreased if the patient develops hypotension. Vasopressors do not have an effect on lactic acid results or SpO 2. p. 1598

Which system of the body is often the first to show signs of dysfunction in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?

Respiratory system Systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) occur due to a systemic inflammatory response. Inflammatory mediators have a direct effect on the pulmonary vasculature. Thus the respiratory system is often the first system to show signs of dysfunction. Signs of nervous system dysfunction, such as mental changes, can be early signs of SIRS and MODS. However, the nervous system is not the first system to show signs of SIRS and MODS. When the respiratory system is affected, ventilation-perfusion mismatch becomes worse. Tissue oxygen demands increase, leading to cardiovascular changes. Hence, cardiovascular changes occur after changes in the respiratory system. In the early stages of SIRS and MODS, there is shunting away of blood from the gastrointestinal tract, making it vulnerable to ischemic injury. However, such changes show signs of dysfunction later than does the respiratory system. p. 1605

Which system shows initial signs of dysfunction in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?

Respiratory system The pulmonary vasculature is directly affected by inflammatory mediators. Hence the initial signs of dysfunction in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) are seen in the respiratory system. Cardiovascular changes are detected later when there is myocardial depression. Effects on the gastrointestinal system are seen when the motility gets decreased. Neurologic dysfunctions are seen when the patient's mental status begins to show signs of change. p. 1605

Which term is used to describe a constellation of symptoms or a syndrome in response to an infection characterized by a dysregulated patient response along with new organ dysfunction?

Sepsis Sepsis is a constellation of symptoms or syndrome in response to an infection. It is characterized by a dysregulated patient response. Shock is a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism. Inflammation is the body's response to a microorganism entering the body. Organ dysfunction refers to the failure of an organ system in an acutely ill patient in whom homeostasis cannot be maintained without intervention. p. 1592

What is the most commonly reported cause for death in patients with multiple organ dysfunction syndrome (MODS)?

Sepsis The mortality rate of patients with multiple organ dysfunction syndrome (MODS) is 70 percent to 80 percent. The most common cause of death reported is sepsis. Although decreased perfusion increases the risk for ulceration in the gastrointestinal (GI) system, this condition does not usually lead to death. Renal failure requires the use of dialysis until functionality returns or a transplant occurs; this condition does not result in death. Electrolyte imbalances are due to fluid and electrolyte imbalances that affect mental status; this condition does not usually cause death. p. 1606

The primary health care provider prescribes antibiotics and vasopressors for a patient. Which type of shock does the nurse expect to be treating?

Septic shock Septic shock occurs in response to infection. Therefore antibiotics are prescribed for a patient with septic shock. Cardiogenic shock occurs when systolic or diastolic function of the heart is impaired. Sympathomimetic drugs are used for the treatment of cardiogenic shock. Injury to the spinal cord at the fifth thoracic vertebra or above causes neurogenic shock. Vasconstricting medications are prescribed to prevent vasodilation for a patient in septic shock. Anaphylactic shock is a life-threatening allergic reaction to a sensitizing substance. Antihistamines, bronchodilators, and corticosteroids are used in the treatment of anaphylactic shock. p. 1600

Which laboratory value may indicate, by its decrease, hepatic dysfunction in a patient with systemic inflammatory response syndrome (SIRS)?

Serum transferrin In patients with systemic inflammatory response syndrome (SIRS), hepatic dysfunction impairs protein synthesis, leading to a decrease in serum transferrin. Elimination of waste products is hampered, causing an increase in ammonia. When liver cell damage occurs, there is an elevation of liver enzymes, such as serum γ-glutamyl transferase and serum aspartate aminotransferase. p. 1606

The nurse is caring for a patient who has hypovolemic shock. Which medical diagnosis does the nurse suspect?

Severe burns Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. Insect bites may lead to an anaphylactic shock state. Pulmonary embolism may lead to an obstructive shock state, and myocardial infarction may lead to a cardiogenic shock state. p. 1589