Nursing Management of Shock States

A nurse is being orientated to the intensive care unit (ICU) and asks, "Why is so much emphasis put on helping the family when we have such sick patients?" Which responses from the nurse are appropriate?

"Empathizing with the family helps the family support the patient." "Families of critically ill patients are also experiencing a crisis. "Family members are often away from home and also need our support." "Family members can provide help to orient the patient and reduce agitation."

The patient with shock will have evidence of:

Adequate tissue perfusion Restoration of normal or baseline blood pressure Return/recovery of organ function Absence of complications from prolonged states of hypoperfusion Prevention of health care-acquired complications related to disease management and care

The nurse is caring for a patient in a shock state. The patient recently developed a temperature of 102.0° F (38.9° C), is flushed, and is reporting feeling uncomfortable. Which action by the nurse is most appropriate for this patient?

Administer ibuprofen per orders. If a patient's temperature is above 101.5° F (38.6° C) and the patient is uncomfortable, an appropriate intervention is to administer an antipyretic, such as ibuprofen, per the primary health care provider's orders.

The nurse is caring for an unconscious, intubated patient. The primary health care provider and respiratory therapist enter the patient's room and begin to discuss the patient's status. The nurse notices an increase in the patient's heart rate. What is the nurse's best action?

Ask the health care team members to continue the discussion in another room with the nurse. Asking the health care team members to continue their discussion in another room with the nurse allows the nurse to be part of the conversation while moving the stressful conversation away from the patient.

Caregiver as a Team Member

Assess the caregiver's understanding of the patient's status, treatment plan, and prognosis. The care team must promote realistic expectations and outcomes. Provide reassurance to the caregiver, as well as the patient. Invite the caregiver to meet the team. Acceptance is increased when caregivers see that the team is caring and competent, decisions are deliberate, and their input is valued. Consider including caregivers in rounds and patient care conferences. If the patient has an advance directive, the caregiver needs to ensure that the patient's wishes are followed. If the patient has a durable power of attorney for health care, this person must be involved in the patient's plan of care.

Gastrointestinal Status

Auscultate bowel sounds at least every 4 hr. Monitor for abdominal distention. If a nasogastric tube is present, measure drainage and check for occult blood. Check stools for occult blood.

Emotional Support

Caregivers often have anxiety and concerns related to the patient's condition, prognosis, and pain. Lack of information is a major source of anxiety. The nurse should educate the caregiver about the patient's condition and prognosis to help relieve this anxiety. Financial concerns can also be a source of anxiety. The nurse should put the patient's family in touch with a case manager or social worker who can provide resources, such as places to stay at decreased expense. Strategies for emotional care include active listening, reduction of anxiety, and provision of support for those who become upset or angry. Visitation that meets the needs of the caregiver assists in: Overcoming doubts about the patient's condition Reducing anxiety and fear Meeting the need to be with and support the patient Beginning the grief process if death occurs

Resources for the Caregiver

Consult with the case manager or social worker if concerns over financial issues are assessed. Consult other team members (e.g., chaplains, psychologists, patient representatives) as necessary to help caregivers cope or identify support groups for family members of a terminally or critically ill patient. If the prognosis becomes grave, support the patient's caregiver and family when difficult decisions, such as whether life support should be withdrawn, must be made and be present and supportive when a terminal diagnosis is disclosed to the patient and family. Remember, compassion is as essential as scientific and technical expertise in the total care of the patient and caregiver.

The nurse is caring for a patient in a shock state and is planning care related to decreased peripheral tissue perfusion. Which interventions should the nurse be prepared to implement?

Continuous use of a pressure-relieving mattress Turning the patient every hour according to a turning schedule Planning for bathing when the patient is most rested to decrease oxygen demand

Spiritual Needs

Do not overlook the patient's spiritual needs. Offer to call a member of the clergy rather than waiting for the patient or caregiver to express a wish for spiritual counseling. If possible, place the patient's hands and arms outside of the sheets to encourage physical contact with the patient.

Education of Caregiver

Encourage the caregiver to talk to the patient, which can increase patient orientation. Explain the purpose of any tubes and equipment attached to or surrounding the patient in simple terms. Describe the expected clinical course of shock. Inform the caregivers of what they may and may not touch. Encourage physical contact with the patient and the performance of simple care measures if the caregiver desires. Provide privacy, but explain that assistance is always readily available. Explain the use of the call bell and position it within reach of the patient or caregiver at all times.

Patient at risk for septic shock

Example: A patient with a kidney infection who has urosepsis from an indwelling catheter is at risk for the development of septic shock. The goal is to treat the sepsis and remove the causative agent, in this case, the indwelling catheter. Identify early signs of infection and carefully monitor for the development of infection. Perform interventions to prevent infection, including:Minimizing use of catheters by following established guidelines, such as Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals, 2014.Use of aseptic technique during invasive procedures Strict adherence to handwashing Changing, cleaning, and discarding equipment according to agency policy

Patient at risk for hypovolemic shock

Example: A patient with a traumatic leg injury is at risk for hypovolemic shock due to blood loss. The goals are to stop bleeding and replace fluids. Careful monitoring of fluid balance Intake and output Daily weight Trending information such as intake and output, daily weight, vital signs, and laboratory values

Patient at risk for anaphylactic shock

Example: A patient with asthma and a history of cephalosporin allergy is at risk for anaphylactic shock if treated with penicillin G intravenously for a Streptococcus pneumoniae meningitis infection. The goal is to prevent anaphylaxis by identifying the cross-sensitivity between cephalosporins and penicillin and prevent administration of penicillin G. Carefully question patients about allergies.Confirm allergies before giving drugs or starting diagnostic procedures.Premedicate patients who need a drug that is likely to cause an allergic reaction.Encourage patients with allergies to obtain and wear a medical alert device and report their allergies to their health care providers.Educate patients about the availability of kits that contain treatment for acute allergic reactions.

Patient at risk for cardiogenic shock

Example: In a patient at risk for cardiogenic shock after a myocardial infarction, the goal is to limit the infarct size by restoring coronary blood flow and reducing myocardial demand. Spacing out care and testing can help to decrease oxygen (O2) demand.

The nurse is caring for an intubated patient who is experiencing alternating levels of consciousness. How should the nurse approach caring for this patient?

Explain all care to the patient in simple terms. Ensure that the plan of care is communicated when the patient is most alert. Keep paper and pencil in the room for the patient to use when he or she is awake.

Caregivers play an important role in the patient's care. In addition to linking the patient to the outside world, caregivers also

Facilitate decision making Advise the patient Assist with activities of daily living Act as liaisons to inform the health care team of the patient's wishes Provide safe, caring, familiar relationships for the patient The presence of a caregiver may help orient the patient and reduce agitation. Therefore the nurse should work closely with caregivers to ensure the needs of critically ill patients are thoroughly met.

Perform Oral Care

Frequent oral care is necessary because of dry and fragile membranes in patients with hypovolemia and pooling of secretions in the mouth of intubated patients. Apply water-soluble lubricant to the lips. Brush teeth or gums with a soft brush every 12 hr. Swab lips and oral mucosa with moisturizing solutions every 2-4 hr.

The nurse is caring for a patient in a shock state. After reviewing the daily orders for the patient, the nurse notes that electrolyte levels have not been ordered. For which critical electrolyte imbalance should the nurse closely monitor this patient?

Hypokalemia as a result of the body compensating for renal hypoperfusion by initiating release of aldosterone

The nurse is caring for an older adult patient in an intensive care unit (ICU) who is in a shock state. The patient has many caring family members who want to understand and assist in providing care to the patient. Which nursing intervention should the nurse take to best facilitate this family's desire?

Identify one spokesperson and coordinator for the family.

Body Temperature and Skin Changes

If patient has a normal temperature, monitor every 4 hr. If patient has an abnormal temperature, take a core reading hourly. Keep patient comfortably warm. If temperature is above 101.5° F (38.6° C) and the patient is uncomfortable or having cardiovascular problems, administer antipyretic and remove some covers, but be careful to prevent shivering, which can increase heat production. If fever persists, consider using a cooling device. Monitor skin for inadequate perfusion, which can manifest through: Changes in temperature Pallor Flushing Cyanosis Diaphoresis Piloerection

Cardiovascular Status

If the patient is unstable, continuously assess heart rate and rhythm, blood pressure, central venous pressure, and pulmonary artery pressure, cardiac output, systemic vascular resistance, stroke volume, and stroke volume variation (if available) for trends and integrate with physical assessment data. Monitor (using electrocardiography) for dysrhythmias from cardiovascular or metabolic abnormalities from shock. Assess for new murmurs or third or fourth heart sounds. Assess response to fluid and drug administration as often as every 10 minutes and titrate as needed. Decrease monitoring as tissue perfusion is restored and patient's condition is stabilized. If patient is hypotensive, avoid Trendelenburg position because it can decrease pulmonary function and increase intracranial pressure.

Renal Status

Initially, measure urine every 1-2 hr as an indicator of renal perfusion. An indwelling catheter facilitates precise measurements. Urine output <0.5 mL/kg/hr may indicate inadequate kidney perfusion. Monitor serum creatinine levels to assess renal functioning.

Respiratory Status

Initially, monitor respiratory rate, depth, and rhythm every 15-30 min.Increased rate and depth may occur as the body attempts to correct metabolic acidosis. Assess lung sounds every 1-2 hr and as needed for:Fluid overloadSecretions Utilize continuous pulse oximetryUse ear, nose, or forehead because of poor peripheral perfusion Monitor arterial blood gases.Partial arterial oxygen tension (PaO2) <60 mm Hg indicates hypoxemia and need for increased O2 delivery.Low partial pressure of carbon dioxide in arterial blood (PaCO2), pH, and bicarbonate levels can indicate an attempt to compensate for metabolic acidosis from elevated lactate levels. Rising PaCO2 with persistently low pH and PaO2 requires advanced pulmonary management such as intubation and mechanical ventilation.

Provide Access to Patient

Limiting visitation does not protect the patient from adverse physiologic consequences. The American Association of Critical-Care Nurses (AACN) strongly recommends less restrictive, individualized visiting policies, which can be established by assessing the patient's and caregiver's needs and preferences and incorporating these into the plan of care. It is important to prepare caregivers for the experience at first visitation.Briefly describe the patient's appearance and physical environment (e.g., equipment, noise).Join caregivers as they enter the room. Observe the responses of the patient and caregivers.

The nurse is performing an assessment on a patient in a shock state. Which information should the nurse use to monitor cerebral blood flow?

Mild agitation Restlessness Level of consciousness

Minimize O2 Demand

Monitor O2 consumption during nursing interventions. Space out nursing care to promote rest.

The nurse is caring for a patient who was in a motor vehicle accident and is hemorrhaging. Which assessments are necessary to monitor this patient for the development of shock?

Monitor intake and output. Compare all assessment findings to the previous findings.

The nurse is preparing a care plan for a patient in a shock state. What actions should be included for this patient?

Monitor intake, output, and daily weight. Reduce noise and light in the patient's room. Adhere strictly to handwashing and minimize invasive procedures. Auscultate bowel sounds and assess for abdominal distention at least every 4 hours

Medications for Stress Reduction

Monitor the patient's mental state and level of pain using valid assessment tools. Provide medications to decrease anxiety and pain as appropriate. Continuous infusions of a benzodiazepine and an opioid or sedative are extremely helpful in decreasing anxiety and pain.

The nurse's role in caring for a patient in or at risk for shock involves:

Monitoring the patient's ongoing physical and emotional status Identifying trends to detect changes in the patient's condition Planning and implementing nursing interventions and therapies Evaluating the patient's response to therapy Providing emotional support to the patient, family, and caregivers Collaborating with other members of the interprofessional team to coordinate care

Communication with Caregiver

Most important, caregivers wish to be kept informed of the patient's condition. Make sure to provide periodic updates to the family, especially during periods of rapid or acute care. Identify a spokesperson for the family to help coordinate information exchange between the team and family. If possible, the same nurse should care for the patient to decrease anxiety, limit conflicting information, and increase trust. Encourage caregivers to express concerns, ask questions, and state their needs. Structure the patient's environment in a way that decreases anxiety. Example: Encourage caregivers to bring in photographs and personal items.

Neurologic Status

Neurologic status is the best indicator of cerebral blood flow. Assess:Orientation and level of consciousness ≥1-2 hrChanges in behaviorRestlessnessHyperalertnessBlurred visionConfusionParesthesiasChanges in mental status (mild agitation) Orient the person on a regular basis.Orientation to intensive care unit (ICU) environments is vital. Keep a day-night cycle of activity and have patient rest as much as possible.Changes in sleep-wake patterns can contribute to delirium. Reduce noise and light levels to control sensory input. Sensory overload can contribute to delirium.

Patients at risk for shock include those who are:

Older Immunocompromised Malnourished Experiencing effects of chronic illnesses Recovering from surgery or trauma Suffering from excessive blood loss Recovering from hemorrhage, spinal cord injury, or sepsis (conditions that can precipitate shock)

Prevent Skin Breakdown and Infection

Perform bathing and nursing interventions carefully because of problems with O2 delivery to tissues. Provide care that relieves pressure on the tissues and allows for increased tissue perfusion. Turn patient at least every 1-2 hr and maintain body alignment to help prevent pressure ulcers. Use specialty bed and mattresses to reduce pressure.

Range of Motion

Perform passive range of motion 3-4 times per day. Maintains joint mobility

The nurse is initially meeting the partner of a critically ill patient in the intensive care unit (ICU). The patient was just admitted to the ICU for acute hypovolemic shock after surgery. Which interventions should the nurse perform for the partner?

Plan on accompanying the partner to the patient's room. Monitor the response of the partner when he or she sees the patient. Describe the ICU environment and appearance of the patient before taking the partner to the room.

The nurse is caring for a newly admitted patient who is unconscious and in a shock state. When walking by the patient's room, the nurse notes that a visiting family member looks very uncomfortable. What can the nurse do to increase the comfort of the family member?

Show the family member where the call light is and how to obtain help if any is needed. Provide a simple explanation of what the different equipment is for and what should not be touched or moved. Discuss opportunities and ways to touch and talk to the patient and how those actions might affect the patient. Give the family member the option of bringing in some items from home to make the room more familiar to and calming for the patient and family.

Communication

Talk to the patient; even someone who cannot respond, who is intubated or sedated, or who appears comatose may be able to hear. Allow the intubated patient to write or use an alphabet board or signboard. Carefully consider conversations, especially when they concern the patient. Conversations held in the presence of, but without participation from, the patient can be particularly stressful to the patient.Find alternative places to have discussions.Whenever possible, include the patient in the discussion. Give the patient simple explanations of procedures before performing them and provide information about the plan of care. Provide simple and honest answers to questions.

Empathize with Caregiver

The experience of having a friend or relative in the ICU is physically and emotionally demanding, often to the point of exhaustion. Ultimately, caregivers of the critically ill are in crisis, and family-centered care is essential. Caregivers often disrupt their daily routines to support the patient. They may be far from their home, friends, and relatives. Encourage the caregiver to take time for self-care, including regular meals and sleep, to prevent physical and psychologic stress. Recognize caregivers' feelings, listen to caregivers openly and without being judgmental, and acknowledge their decisions

Summary

The nurse cares for patients experiencing a variety of shock states by identifying those at risk and intervening to prevent the development of shock and closely monitoring those patients experiencing shock. The nurse intervenes to minimize the effects of the shock state and works to prevent progression to SIRS or MODS. The patient experiencing shock requires holistic care that includes general interventions, interventions specific to the type of shock experienced, interventions specific to the body systems affected, and interventions to assist the family. The family of the patient experiencing shock requires a high degree of support from the nurse because the experience of having a family member in an ICU is stressful. The nurse must take measures to include the family in the plan of care, as appropriate, while providing the family with the information and resources they need. When the nurse takes a holistic approach to the care of the patient experiencing shock, the potential for improved outcomes is increased.

Introduction

The nurse plays a vital role in caring for the patient who is at risk for developing shock or who is currently in a state of shock. The nurse performs careful assessments, understands and integrates the complex assessment findings, plans care, and implements a variety of nursing interventions. The nurse must try to prevent shock in at-risk patients through close monitoring of fluid status and the development of infection. When a patient is in shock, the nurse implements acute nursing interventions to support and monitor each body system as well as support the caregivers and family of the critically ill patient. The nurse also plays a vital role in assessment and ongoing monitoring to help detect early signs of deterioration or organ dysfunction.

Monitor for and Treat Electrolyte Imbalances

The release of antidiuretic hormone and aldosterone results in sodium and water retention; aldosterone increases urinary potassium loss and catecholamines cause potassium to move into the cells, resulting in hypokalemia. Hypocalcemia, hypomagnesemia, and hypophosphatemia are common. Metabolic acidosis results from impaired tissue perfusion, hypoxia, a shift to anaerobic metabolism, and progressive renal dysfunction. Imbalances exacerbate mental status changes, neuromuscular dysfunction, and dysrhythmias.

The patient experiencing shock requires a variety of nursing interventions. Some interventions are

general and apply to all patients experiencing shock, and other interventions are more specific to the type of shock.

Early recognition and treatment are critical to

managing shock. Prompt intervention in the early stages may prevent the decline to the progressive or irreversible stage. The nurse sets goals and performs both general and specific nursing interventions to care for the patient experiencing shock.

After identifying patients at high risk for developing shock, the nurse should take active steps to

minimize the risk in these patients. Many different nursing interventions can minimize the risk of shock, and some common interventions are discussed.

When someone becomes critically ill, care extends beyond the patient to the

patient's caregivers. The primary needs of a caregiver of a patient experiencing shock include compassion, support, resources, and access to the patient.

The nurse must understand the importance of providing emotional support and comfort to a patient in a

shock state. Fear, anxiety, and pain may exacerbate respiratory distress and increase the release of catecholamines. Do not underestimate the effects of fear and anxiety when a patient is faced with a critical, life-threatening situation. The nurse should take holistic measures to minimize these effects on the patient's condition.

The caregiver can be a

vital resource for the patient and the health care team. The nurse should ensure that the caregiver can spend time with the patient, provided that the patient perceives this time as comforting. Information on specific education and communication and reasons to include the caregiver as part of the health care team are provided in the table.