Ch. 66 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome

When caring for a pt in cardiogenic shock, the nurse recognizes that the metabolic demands of turning and moving the pt exceed the O2 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. SV from 52 to 68 mL/beat d. SVR from 1300 dyne/sec/cm5 to 1120 dyne/sec/cm5

a. SvO2 from 62% to 54%

What physical problems could precipitate hypovolemic shock (select all) a. burns b. ascites c. vaccines d. insect bites e. hemorrhage f. ruptured spleen

a. burns b. ascites e. hemorrhage f. ruptured spleen

What types of injuries cause a mechanical tissue trauma that can trigger SIRS (select all) a. burns b. fungi c. viruses d. crush injuries e. surgical procedures

a. burns d. crush injuries e. surgical procedures

A nurse has administered corticosteroids to a patient with multiple organ dysfunction syndrome (MODS). In what order should the results of this medication occur in this situation. a. Renal excretion of potassium b. Increased intravascular volume c. Improved capillary permeability d. Enhanced renal artery perfusion

C, B, D, A (Corticosteroids are administered to patients who have MODS to suppress the inflammatory response. If the patient responds positively to the corticosteroids, capillary permeability should improve, stopping leakage of intravascular fluid and helping restore intravascular blood volume. Improved intravascular volume should help improve the blood pressure, and if compensatory sympathetic discharge is halted, renal blood flow increases. Increased renal blood flow should increase the glomerular filtration rate and renal excretion of potassium.)

A pt w/ acute pancreatitis is experiencing hypovolemic shock. which initial orders for the pt will the nurse implement first? a. start 1000 mL of NS 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 w/ a non-rebreather mask

d. administer high-flow oxygen w/ a non-rebreather mask

When caring for a patient in acute septic shock, what should the nurse anticipate? a. Infusing large amounts of IV fluids b. Administering osmotic and/or loop diuretics c. Administering IV diphenhydramine (Benadryl) d. Assisting with insertion of a ventricular assist device (VAD)

a. Infusing large amounts of 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. VADs are useful for cardiogenic shock not septic shock. Diphenhydramine may be used for anaphylactic shock but would not be helpful with septic shock.)

Which intervention may prevent GI bacterial and endotoxin translocation in a critically ill pt w/ SIRS? a. early enteral feedings b. surgical removal of necrotic tissue c. aggressive multiple antibiotic therapy d. strict aseptic technique in all procedures

a. early enteral feedings

The pt is in compensatory stage of shock, what manifestations indicate this to the nurse (select all) 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

a. pale and cool c. lower BP than baseline f. tachypnea and tachycardia

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

d. decreased perfusion occurs, leading to dysrhythmias, decreased CO, and decreased oxygen delivery to cells

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

d. decreased tissue perfusion

A 70 year old pt is malnourished, has a history of type 2 diabetes mellitus, and is admitted from the nursing home w/ pneumonia. For which kind of shock should the nurse closely monitor this pt? a. septic shock b. neurogenic shock c. cardiogenic shock d. anaphylactic shock

a. septic shock

The nurse suspects sepsis as a cause of shock when the laboratory test results indicate a. hypokalemia b. thrombocytopenia c. decreased hemoglobin d. increased blood urea nitrogen (BUN)

b. thrombocytopenia

Which interventions should be used for anaphylactic shock (select all) a. antibiotics b. vasodilator c. antihistamine d. oxygen supplementation e. colloid volume expansion f. crystalloid volume expansion

c. antihistamine d. oxygen supplementation e. colloid volume expansion f. crystalloid volume expansion

What is the key factor in describing any type of shock a. hypoxemia b. hypotension c. vascular collapse d. inadequate tissue perfusion

d. inadequate tissue perfusion

The nurse would recognize which clinical manifestation as suggestive of sepsis? a. Sudden diuresis unrelated to drug therapy b. Hyperglycemia in the absence of diabetes c. Respiratory rate of seven breaths per minute d. Bradycardia with sudden increase in blood pressure

b. 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.)

What mechanism that can trigger SIRS is r/t myocardial infarction or pancreatitis? a. endotoxin release b. abscess formation c. global perfusion deficits d. ischemic or necrotic tissue

d. ischemic or necrotic tissue

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.

a. dobutamine to increase myocardial contractility. c. circulatory assist devices such as an intraaortic balloon pump. (Dobutamine (Dobutrex) is used in patients in cardiogenic shock with severe systolic dysfunction. Dobutamine increases myocardial contractility, decreases ventricular filling pressures, decreases systemic vascular resistance and pulmonary artery wedge pressure, and increases cardiac output, stroke volume, and central venous pressure. Dobutamine may increase or decrease the heart rate. The workload of the heart in cardiogenic shock may be reduced with the use of circulatory assist devices such as an intraaortic balloon pump or ventricular assist device.)

A pt w/ hypovolemic shock is receiving LR solution for fluid replacement therapy. During this therapy, which laboratory result is the most important for the nurse to monitor? a. serum pH b. serum sodium c. serum potassium d. Hgb and Hct

a. serum pH

Which indicators of tissue perfusion should be monitored in critically ill patients by the nurse? SATA a. skin b. urine output c. level of consciousness d. ADLs e. vital signs, including pulse oximetry f. peripheral pulses w/ cap refil

a. skin b. urine output c. level of consciousness e. vital signs, including pulse oximetry f. peripheral pulses w/ cap refil

In the compensatory stage of hypovolemic shock, to what organs does blood flow decrease after the sympathetic nervous system activates the alpha-adrenergic stimulation (select all) a. skin b. brain c. heart d. kidneys e. gastrointestinal tract

a. skin d. kidneys e. gastrointestinal tract

A 50-yr-old woman with a suspected brain tumor is scheduled for a CT scan with contrast media. The nurse notifies the physician that the patient reported an allergy to shellfish. Which response by the physician should the nurse question? a. Infuse IV diphenhydramine before the procedure. b. Administer lorazepam (Ativan) before the procedure. c. Complete the CT scan without the use of contrast media. d. Premedicate with hydrocortisone sodium succinate (Solu-Cortef).

b. Administer lorazepam (Ativan) before the procedure. (An individual with an allergy to shellfish is at an increased risk to develop anaphylactic shock if contrast media is injected for a CT scan. To prevent anaphylactic shock, the nurse should always confirm the patient's allergies before diagnostic procedures (e.g., CT scan with contrast media). Appropriate interventions may include cancelling the procedure, completing the procedure without contrast media, or premedication with diphenhydramine or hydrocortisone. IV fluids may be given to promote renal clearance of the contrast media and prevent renal toxicity and acute kidney injury. The use of an antianxiety agent such as lorazepam would not be effective in preventing an allergic reaction to the contrast media.)

The nurse determines that a large amount of crystalloid fluids administered to a pt on 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. HR of 106

b. CVP of 15 mm Hg

When caring for a critically ill patient who is being mechanically ventilated, the nurse will monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? a. Increased serum albumin b. Decreased respiratory compliance c. Increased gastrointestinal (GI) motility d. Decreased blood urea nitrogen (BUN)/creatinine ratio

b. Decreased respiratory compliance (Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism.)

A 64-yr-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure of 78/58 mm Hg, pulse of 124 beats/min, respirations of 28 breaths/min, and temperature of 97.2°F (36.2°C). Which physician order should the nurse complete first? a. Obtain a 12-lead ECG and arterial blood gases. b. Rapidly administer 1000 mL normal saline solution IV. c. Administer norepinephrine (Levophed) by continuous IV infusion. d. Carefully insert a nasogastric tube and an indwelling bladder catheter.

b. Rapidly administer 1000 mL normal saline solution IV. (Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be initiated after fluid resuscitation is initiated.)

A patient w/ a gunshot wound to the abdomen is being treated for hypovolemic and septic shock. To monitor the pt for early organ damage associated w/ MODS, what is the most important for the nurse to assess? a. urine output b. breath sounds c. peripheral circulation d. central venous pressure

b. breath sounds

Which pt manifestations confirm the development of MODS? a. upper GI bleed, GSC score of 7, and Hct of 25% b. elevated serum bilirubin, serum creatinine of 3.8 mg/dL, and platelet count of 15,000 c. urine output of 30 mL/hr, BUN of 45 mg/dL, white blood cell (WBC) count of 1120 d. respiratory rate of 45, PaO2 of 60 mm Hg, and chest x-ray w/ bilateral diffuse patchy infiltrates

b. elevated serum bilirubin, serum creatinine of 3.8 mg/dL, and platelet count of 15,000

Which hemodynamic monitoring description of the identified shock is accurate? a. tachycardia w/ HTN is characteristic of neurogenic shock b. in cardiogenic shock the pt will have increased pulmonary artery wedge pressure and a decreased cardiac output c. anaphylactic shock is characterized by increased systemic vascular resistance, decreased cardiac output, and decreased PAWP d. in septic shock, bacterial endotoxins cause vascular changes that result in increased systemic vascular resistance and decreased CO

b. in cardiogenic shock the pt will have increased pulmonary artery wedge pressure and a decreased cardiac output

What abnormal finding should the nurse expect to find in early compensatory shock? a. metabolic acidosis b. increased serum sodium c. decreased BG d. increased serum potassum

b. increased serum sodium

When shock occurs in a pt w/ pulmonary embolism or abdominal compartment syndrome, what type of shock would that be? a. disruptive shock b. obstructive shock c. cardiogenic shock d. hypovolemic shock

b. obstructive shock

A 78-yr-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; heart rate 110; respiratory rate 42 and shallow; CO 8 L/minute; and PAWP 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.

b. septic shock. (Septic shock is the presence of sepsis with hypotension despite fluid resuscitation along with the presence of inadequate tissue perfusion. To meet the diagnostic criteria for sepsis, the patient's temp must be higher than 100.9° F (38.3° C), or the core temp must be lower than 97.0° F (36° C). Hemodynamic parameters for septic shock include elevated heart rate; decreased pulse pressure, blood pressure, systemic vascular resistance, central venous pressure, and pulmonary artery wedge pressure; normal or elevated pulmonary vascular resistance; and decreased, normal, or increased pulmonary artery pressure, cardiac output, and mixed venous O2 saturation.)

The nurse is caring for a 29-yr-old man who was admitted 1 week ago with multiple rib fractures, pulmonary contusions, and a left femur fracture from a motor vehicle crash. The attending physician states the patient has developed sepsis, and the family members have many questions. Which information should the nurse include when explaining the early stage of sepsis? a. Antibiotics are not useful when an infection has progressed to sepsis. b. Weaning the patient away from the ventilator is the top priority in sepsis. c. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. d. The patient has recovered from sepsis if he has warm skin and ruddy cheeks.

c. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. (Patients with sepsis may be normovolemic, but because of acute vasodilation, relative hypovolemia and hypotension occur. Patients in septic shock require large amounts of fluid replacement and may require frequent fluid boluses to maintain circulation. Antibiotics are an important component of therapy for patients with septic shock. They should be started after cultures (e.g., blood, urine) are obtained and within the first hour of septic shock. Oxygenating the tissues is the top priority in sepsis, so efforts to wean septic patients from mechanical ventilation halt until sepsis is resolving. Additional respiratory support may be needed during sepsis. Although cool and clammy skin is present in other early shock states, the patient in early septic shock may feel warm and flushed because of a hyperdynamic state.)

A patient's localized infection has become systemic and septic shock is suspected. What medication is expected to treat septic shock refractory to fluids? a. Insulin infusion b. Furosemide (Lasix) IV push c. Norepinephrine administered by titration d. Administration of nitrates and β-adrenergic blockers

c. Norepinephrine administered by titration (If fluid resuscitation using crystalloids is not effective, vasopressor medications such as norepinephrine (Levophed) & dopamine are indicated to restore mean arterial pressure (MAP). Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Furosemide (Lasix) is indicated for patients with fluid volume overload. Insulin infusion may be administered to normalize blood sugar and improve overall outcomes, but it is not considered a medication used to treat shock.)

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.

d. level of consciousness, urine output, and skin color and temperature. (Adequate tissue perfusion in a patient with multiple-organ dysfunction syndrome is assessed by the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity skin temperature, and peripheral pulses.)

The nurse is caring for a 72-yr-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be most concerning? a. Restlessness, heart rate of 124 beats/min, and hypoactive bowel sounds b. Mean arterial pressure of 54 mm Hg; increased jaundice; and cold, clammy skin c. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding d. Agitation, respiratory rate of 32 breaths/min, and serum creatinine of 2.6 mg/dL

c. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding (Severe hypoxemia, lactic acidosis, and bleeding are clinical manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are clinical manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold and clammy skin, agitation, tachypnea, and increased serum creatinine are clinical manifestations of the progressive stage of shock.)

What is the priority nursing responsibility in the prevention of shock? a. frequently monitoring all pts vital signs b. using aseptic technique for all invasive procedures c. being aware of the potential for shock in all pts at risk d. teaching pts health promotion activities to prevent shock

c. being aware of the potential for shock in all pts at risk

When administering any vasoactive drug during the treatment of shock, the nurse should know that what is the goal of therapy? a. increasing urine output to 50 mL/day b. constriction of vessels to maintain BP c. maintaining a MAP of at least 65 mm Hg d. dilating vessels to improve tissue perfusion

c. maintaining a MAP of at least 65 mm Hg

A pt in the progressive stage of shock has rapid, deep respirations. The nurse documents that the patient's hyperventilation is compensating for metabolic acidosis when the patient's ABG results include what? a. pH 7.42, PaO2 80 mm Hg b. pH 7.48, PaO2 69 mmHg c. pH 7.38, PaO2 30 mmHg d. pH 7.32, PaO2 48 mm Hg

c. pH 7.38, PaO2 30 mmHg

The nurse is assisting in the care of several patients in the critical care unit. Which patient is most at risk for developing multiple organ dysfunction syndrome (MODS)? a. A 22-yr-old patient with systemic lupus erythematosus admitted with a pelvic fracture b. A 48-yr-old patient with lung cancer admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia c. A 65-yr-old patient with coronary artery disease, dyslipidemia, and primary hypertension admitted for unstable angina d. A 82-yr-old patient with type 2 diabetes mellitus and chronic kidney disease admitted for peritonitis related to a peritoneal dialysis catheter infection

d. A 82-yr-old patient with type 2 diabetes mellitus and chronic kidney disease admitted for peritonitis related to a peritoneal dialysis catheter infection (A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Individuals at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.)

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 r/t the increased angiotensin II? a. vasodilation b. decreased BP and CO c. aldosterone release results in sodium and water excretion d. ADH release increases water reabsorption

d. ADH release increases water reabsorption

What laboratory finding is consistent with a medical diagnosis of cardiogenic shock? a. Decreased liver enzymes b. Increased white blood cells c. Decreased red blood cells, hemoglobin, and hematocrit d. Increased blood urea nitrogen (BUN) and serum creatinine (Cr) levels

d. Increased blood urea nitrogen (BUN) and serum creatinine (Cr) levels (The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, but white blood cell levels do not typically increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia.)

A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? a. Acute pain b. Impaired skin integrity c. Decreased cardiac output d. Ineffective tissue perfusion

d. Ineffective tissue perfusion (The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses.)

After coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery for repair. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient parameter is the most important for planning nursing care? a. Cardiac index (CI) of 5 L/min/m2 b. Central venous pressure of 8 mm Hg c. Mean arterial pressure (MAP) of 86 mm Hg d. Pulmonary artery pressure (PAP) of 28/14 mm Hg

d. Pulmonary artery pressure (PAP) of 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 a result of the MI. The CI, CVP, and MAP readings are normal.)

what statements describing systemic inflammatory response syndrome (SIRS) and/or multiple organ dysfunction syndrome (MODS) is accurate? a. MODS may occur independently from SIRS b. all pts w/ 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

d. a common initial mediator that causes endothelial damage leading to SIRS and MODS is endotoxin

In late refractory shock in a pt w/ massive thermal burns, what should the nurse expect the pt's laboratory results to reveal? a. respiratory alkalosis b. decreased potassium c. increased BG d. increased ammonia (NH3) levels

d. increased ammonia (NH3) levels

A pt in shock has a nursing diagnosis of fear r/t 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 pt? a. administer antianxeity agents b. allow caregivers to visit as much as possible c. call a member of the clergy to visit the pt d. inform the pt of the current plan of care and its rationale

d. inform the pt of the current plan of care and its rationale

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.

d. neurogenic shock from massive vasodilation. (Neurogenic shock results in massive vasodilation without compensation as a result of the loss of sympathetic nervous system vasoconstrictor tone. Massive vasodilation leads to a pooling of blood in the blood vessels, tissue hypoperfusion, and, ultimately, impaired cellular metabolism. Clinical manifestations of neurogenic shock are hypotension (from the massive vasodilation) and bradycardia (from unopposed parasympathetic stimulation).)