CH. 21 Caring for Clients in Shock

A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first?

- Administer an epinephrine injection as ordered by the health care provider. Explanation: The key words in the question are "increasing symptoms." The first action of the nurse is to administer an epinephrine injection to abort the rapidly increasing symptoms. Next, the nurse will call 911.

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is:

- Blood pressure. Explanation: - By the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be monitored closely before the blood pressure drops.

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected?

- Brain Explanation: The body displays a "fight-or-flight" response, with the release of catecholamines. Blood will be shunted to the brain, heart, and lungs to ensure adequate blood supply. The organ that will always be protected over the others is the brain.

A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to:

- Constrict blood vessels in the cardiorespiratory system. Explanation: Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.

The acute care nurse is providing care for an adult client who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of antidiuretic hormone during hypovolemic shock?

- Decreased urinary output Explanation: During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to further retain water in an effort to raise blood volume and blood pressure. I n a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary profusion decreases as the body shunts blood away from the periphery and to the vital organs.

A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm?

- Epinephrine Explanation: Epinephrine is given for its vasoconstrictive actions, as well as for its rapid effect of reducing bronchospasm. Benadryl and Proventil (nebulized) are given to reverse the effects of histamine. Prednisone is given to reduce inflammation, if necessary.

In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances?

- Fluid volume circulating in the blood vessels decreases. Explanation: Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.

The nurse is caring for a client in intensive care unit whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. Which assessments and interventions should the nurse prioritize?

- Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration Explanation: Dopamine is a sympathomimetic agent that has varying vasoactive effects depending on the dosage. When vasoactive medications are given, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated), not "routinely." Vasoactive medications should be given through a central, not peripheral, venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. High doses can cause vasoconstriction, which increases afterload and thus increases cardiac workload. Because this effect is undesirable in clients with cardiogenic shock, dopamine doses must be carefully titrated. Reviewing medications and laboratory findings, monitoring urine output, assessing for peripheral edema, performing a focused cardiovascular assessment, and providing client education are important nursing tasks, but they are not specific to the administration of IV vasoactive drugs.

Describe MOD

- In multiple organ dysfunction syndrome (MODS), the sequence of organ dysfunction varies depending on the client's primary illness and comorbidities before experiencing shock; however, the lungs are often the first organ to show dysfunction. - The client who is at risk for MODS should be assessed for the first symptom that often accompanies this diagnosis, which is acute lung injury (ALI). Symptoms associated with ALI include shortness of breath (i.e., dyspnea) and respiratory failure. - Although the first presentation of MODS is often ALI, the client is also at risk for developing a hypermetabolic state, hepatic dysfunction, and renal dysfunction. Although the client may experience a drop in blood pressure and an increased heart rate with MODS, the heart and circulatory system are not affected first by this diagnosis. Left-sided weakness is associated with a right-sided stroke and not MODS.

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis?

- Lactated Ringer's Explanation: Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.

The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered?

- Levophed Explanation: The vasopressor agents that increase blood pressure by vasoconstriction are: - Levophed - Intropin - Neo-Synephrine - Pitressin. Other vasopressors act by reducing preload and afterload and oxygen demands of the heart, and by increasing contractility and stroke volume.

The nurse in the intensive care unit is caring for a 47-year-old, obese client who is in shock following a motor vehicle accident. What would be the main challenge in meeting this client's elevated energy requirements during prolonged rehabilitation?

- Loss of skeletal muscle Explanation: Nutritional energy requirements are met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is broken down even when the client has large stores of fat or adipose tissue. Loss of skeletal muscle greatly prolongs the client's recovery time. Loss of adipose tissue, the inability to convert adipose tissue to energy, and the inability to maintain normal body mass are not main concerns in meeting nutritional energy requirements for this client.

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. What goal of this treatment should the nurse identify?

- Maintenance of adequate mean arterial pressure Explanation: Vasoactive medications can be given in all forms of shock to improve the client's hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts.

The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include what intervention?

- Promoting communication with the client and family along with addressing end-of-life issues Explanation: Promoting communication with the client and family is a critical role of the nurse with a client in progressive shock. It is also important that the health care team address end-of-life decisions to ensure that supportive therapies are congruent with the client's wishes. Many cases of MODS result in death and the life expectancy of clients with MODS is usually measured in hours and possibly days, but not in months. Organ donation should be offered as an option on one occasion, and then allow the family time to discuss and return to the health care providers with an answer following the death of the client.

An immunocompromised 65-year-old client has developed a urinary tract infection, and the care team recognizes the need to prevent an exacerbation of the client's infection that could result in urosepsis and septic shock. Which action should the nurse perform to reduce the client's risk of septic shock?

- Remove invasive devices as soon as they are no longer needed Explanation: - Early removal of invasive devices can reduce the incidence of infections. Broad application of antibiotic ointments is not performed. TPN may be needed, but this does not directly reduce the risk of further infection. Range-of-motion exercises are not a relevant intervention.

The nurse in the intensive care unit is admitting a 57-year-old client with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to which preliminary conclusion?

- The client is in the compensatory stage of shock. Explanation: Compensatory stage of shock: - blood pressure remains within normal limits - Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output - Clients display "fight or flight" response. - The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. Progressive shock: - blood pressure drops Septic shock (client's chance of survival is low) will certainly not be released within 24 hours Irreversible stage of shock: - his blood pressure would be very low - organs would be failing.

Describe the 3 things that go on in the Decompensation stage of Shock

Failure of compensatory mechanisms!!! 1. Cellular hypoxia: - decreased oxygen in cells - cellular damage and destruction 2. Coagulation defects: - inflammatory response - formation of microemboli 3. Cardiovascular changes: - impaired myocardial cells - insufficient heart rate and force of contraction

A client is somewhat disoriented, with blood pressure lower than earlier assessment and pale skin. What stage of shock is characterized these physiologic changes? A) Irreversible stage B) Compensation stage C) Decompensation stage D) Primary stage

C) Decompensation stage

DISTRIBUTIVE/NORMOVOLEMIC SHOCK - Causes - List the 3 types

Causes: 1. Amount of fluid in circulatory system not reduced yet ineffective tissue perfusion 2. Vasodilation 3. Reduced central blood flow Types: 1. Neurogenic 2. Septic 3. Anaphylactic

CARDIOGENIC SHOCK - Patho - 2 Causes - Gerontologic Considerations

Patho: Ineffective heart contraction - Reduction in cardiac output Cause: 1. myocardial infarction (MI) 2. HF Gerontologic considerations - Increased risk: * history of cardiac disease * decreased percentage of body water * decreased immune response

What should your primary Shock assessment consist of? 7 assessments

- Primary assessment; compromised blood volume or circulation 1. Vital signs: Hypotension 2. Peripheral Pulses: - Narrow - Rate: initial tachycardia then bradycardia - Volume: weak and thready - Rhythm: irregular 3. Changes in mentation - Anxiety - Restlessness - Agitation - Confusion - Progresses to loss of consciousness 4. Skin - cold/clammy - pale - mottled - increased capillary refill (longer to refill) - cyanosis 5. urine output - oliguria - renal damage 6. Temperature - increase heat loss - subnormal 7. Respirations: - shallow - grunting - air hungry - SaO2 rate decreases

The nurse assesses a BP reading of 80/50 mm Hg from a patient in shock. What stage of shock does the nurse recognize the patient is in?

- Progressive Explanation: In the second stage of shock, the mechanisms that regulate BP can no longer compensate, and the MAP falls below normal limits. Patients are clinically hypotensive; this is defined as a systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline.

A triage nurse in the emergency department (ED) is on shift when a 4-year-old is carried into the ED by their grandparent. The child is not breathing, and the grandparent states the child was stung by a bee in a nearby park while they were waiting for the child's parent to get off work. Rapid onset of which condition would lead the nurse to suspect that the child is experiencing anaphylactic shock?

- Respiratory distress Explanation: Characteristics of severe anaphylaxis usually include: - rapid onset of hypotension - neurologic compromise - respiratory distress. Cardiac arrest can occur if prompt treatment is not provided

The nursing instructor is talking with a group of senior nursing students about shock. When caring for a patient at risk for shock what assessment finding would the nurse consider a potential sign of shock?

- Shallow, rapid respirations Explanation: A symptom of shock is: - shallow, rapid respirations - Systolic blood pressure drops in shock - mean arterial pressure is less than 65 mm Hg Bradycardia occurs in neurogenic shock, but other states of shock are normally accompanied by tachycardia.

What is the major clinical use of dobutamine?

- increase cardiac output. Explanation: Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.

The nurse would observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment of the client

- with an overwhelming bacterial infection. Explanation: Unlike other forms of shock, clients with septic shock have an elevated leukocyte count and initially manifest fever accompanied by warm, flushed skin and a rapid, bounding pulse. Therefore, the client with an overwhelming bacterial infection is most likely to exhibit these symptoms. Extreme loss of blood causes hypovolemic shock overdose of opioids causes neurogenic shock severe allergic reaction causes anaphylactic shock.

Which of the following nursing interventions helps minimize the risk for hypothermia in a patient in shock?

- Direct warming lights to the patient's body Explanation: Directing warming lights to the client's body and keeping the patient's head covered with a turban reduces heat loss. This helps minimize the risk of hypothermia related to hemorrhage. Administering antipyretics or a tepid sponge bath further reduces the body temperature and may cause complications. Adrenergic and bronchodilating drugs improve the potential for gas exchange but do not reduce the body temperature.

A critical care nurse is aware of similarities and differences between the treatments for different types of shock. What intervention is used in all types of shock?

- Early provision of nutritional support Explanation: Nutritional support is necessary for all clients who are experiencing shock. Hyperglycemic (not hypoglycemic) control is needed for many clients. Hypertonic IV fluids are not normally utilized and antibiotics are necessary only in clients with septic shock.

HYPOVOLEMIC SHOCK - Patho - Causes - Symptoms evident at how many mL's? - At how many mL's is it life threatening>

** Most common type Patho: - Extracellular fluid is significantly diminished. Causes 1. Blood or plasma loss (surgery, trauma, birth) 5. Fluid loss (burns, large draining wounds, suctioning) Symptoms evident at fluid loss of: - 750 to 1500 mL Life threatening: - 2000 mL

The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?

- 5% albumin Explanation: Typically, if colloids are used to treat tissue hypoperfusion, albumin is the agent prescribed. Albumin is a plasma protein; an albumin solution is prepared from human plasma and is heated during production to reduce its potential to transmit disease. The disadvantage of albumin is its high cost compared to crystalloid solutions. Hetastarch and dextran solutions are not indicated for fluid administration because these agents interfere with platelet aggregation. Blood products are not indicated in this situation.

A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is:

- A myocardial infarction. Explanation: Cardiogenic shock is seen most frequently as a result of a myocardial infarction.

Which colloid is expensive but rapidly expands plasma volume?

- Albumin Explanation: Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.

List the 3 Diagnostic Findings of Shock

1. ABG measurement—PaO2, CO2, SpO2 2. Central venous pressure (pressure on right atrium) - Hypovolemic : lower than normal - Cardiogenic: above normal 3. Pulmonary artery pressure (pressure on left side of heart) - PAP, PCWP: lower than normal

List the 3 stages of Shock

1. Compensation 2. Decompensation 3. Irreversible (Multisystem failure; kidneys, heart, lungs, liver, & brain)

What are the 3 Causes of Shock?

1. Decreased blood volume 2. Heart fails as effective pump 3. Peripheral blood vessels massively dilate

List the 4 Categories of Shock

1. Hypovolemic 2. Distributive 3. Obstructive 4. Cardiogenic

List the 3 Shock Medical Management

1. IV fluids: - crystalloid solution - colloid (albumin) - packed RBC 2. Drug therapy Vasopressor: (raises BP) - Dopamine - Norepinephrine - Vasopressin Inotropic agents - digoxin - dobutamine - milrinone 3. Mechanical - Intra-aortic balloon pump (IABP) - Ventricular assist device (VAD) - Pneumatic antishock garment (PASG)

List the 7 Life Threatening Complications

1. Kidney failure 2. Neurologic deficits 3. Bleeding disorders 4. Acute respiratory distress syndrome 5. Stress ulcers 6. Sepsis 7. Multiple organ dysfunction

The nurse is concerned that a client is developing multiple organ dysfunction syndrome (MODS). Place the signs/symptoms in the classic sequence in which this syndrome develops.

1. Lung dysfunction 2. Fluid balance 3. Hypermetabolism 4. Liver dysfunction 5. Kidney dysfunction 6. Bleeding disorder 7. Cardiovascular instability 8. Neurologic deterioration

When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently?

Close monitoring of the patient during fluid replacement is necessary to identify side effects and complications. The most common and serious side effects of fluid replacement are cardiovascular overload and pulmonary edema. The patient receiving fluid replacement must be monitored frequently for: - adequate urinary output - changes in mental status - skin perfusion - changes in vital signs. Lung sounds are auscultated frequently to detect signs of fluid accumulation. Adventitious lung sounds, such as crackles, may indicate pulmonary edema.

The client has an elevated leukocyte count and initially manifests a fever accompanied by warm, flushed skin, and a rapid, bounding pulse. What type of shock is this client most likely experiencing? A) Neurogenic shock B) Anaphylactic shock C) Obstructive shock D) Septic shock

D) Septic Shock

A client who experienced shock remains unstable. Which medication classes would the nurse anticipate to be ordered to prevent or minimize stress ulcers?

Stress ulcers occur frequently in acutely ill patients because of the compromised blood supply to the gastrointestinal tract. Therefore: - antacids - H2 blockers like famotidine (Pepcid) - proton pump inhibitors like lansoprazole (Prevacid), & esomeprazole magnesium (Nexium) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. Proteases and peptidases split proteins into small peptides and amino acids and help with digestion. A promotility agent such as metoclopramide is used to decrease nausea, vomiting, heartburn, a feeling of fullness after meals, and loss of appetite.

What is the function of the mineralocorticoids secreted by the adrenal glands during the compensation stage of shock? Select all that apply.

The function of mineral corticoids, which are corticosteroid hormones, is to: - conserve sodium - promote potassium excretion - control sodium and water balance. Both ADH and corticosteroid hormones promote fluid reabsorption and retention.

What happens if Shock goes untreated?

- Organ damage or death

A client who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse's care planning during the administration of a vasoactive drug?

- The drug dose should be tapered down once vital signs improve. Explanation: When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state. Subjective assessment data are secondary to objective data. Arterial blood gases should be carefully monitored, but draws every10-minutes are not the norm.

The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient?

- The patient has developed a stress ulcer that is bleeding. Explanation: GI ischemia can cause stress ulcers in the stomach during the progressive stage of shock, putting the patient at risk for GI bleeding. The patient would not be on vasoconstrictors but vasodilators, to improve perfusion, and such a reaction would be unlikely. There is no indication that the patient has a tumor or varices in the esophagus.

The intensive care unit nurse is caring for a client in distributive shock who is experiencing pooling of blood in the periphery. The nurse should assess for signs and symptoms of:

- decreased venous return. Explanation: Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the demands of the body.

What is the APACHE scoring system

- higher the score = higher risk for death Acute Physiology Age Chronic Health Evaluation

The test results for a client in the early stages of shock indicate low RBCs and hemoglobin. These findings correlate with:

- hypovolemic shock. Explanation: Evidence of low RBCs and hemoglobin are findings that correlate with hypovolemic shock. An elevated white blood cell count supports septic shock. Evidence of dyspnea or airway obstruction resulting from edema accompanies anaphylactic shock. Auscultate the chest for abnormal lung and heart sounds when you suspect cardiogenic shock.

Describe the 4 things that go on in the Irreversible stage of Shock

1. Significant cells and organ damage 2. No response to medical interventions 3. Multiple system fail; kidney, lungs, liver, and brain 4. Death is imminent

Which of the types of shock is caused by severe allergic reaction or spinal cord injuries? A) Cardiogenic shock B) Obstructive shock C) Distributive shock D) Hypovolemic shock

C) Distributive shock

Neurogenic Shock - List 8 causes - List 4 Symptoms

Causes: 1. spinal cord injury 2. opioid overdose 3. tranquilizers 4. general anesthetic Symptoms: 1. Decreased arterial vascular resistance 2. vasodilation 3. hypotension 4. reduced cardiac output

OBSTRUCTIVE SHOCK - Patho - 3 Causes

Patho: Interference of circulation of blood in/out of the heart - Compromised blood volume to lungs and tissue Causes 1. Cardiac tamponade 2. Tension pneumothorax 3. Ascites or enlarged liver

Which type of shock occurs from an antigen-antibody response?

- Anaphylactic Explanation: During anaphylactic shock, an antigen-antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, causing widespread vasodilation and capillary permeability. Septic shock is a circulatory state resulting from overwhelming infection causing relative hypovolemia. Neurogenic shock results from loss of sympathetic tone causing relative hypovolemia. Cardiogenic shock results from impairment or failure of the myocardium.

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed?

- Narrowed pulse pressure Explanation: Pulse pressure correlates well with stroke volume. Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP. Decreased or narrowing pulse pressure is an early indication of decreased stroke volume.

A nurse in the intensive care unit (ICU) receives report from the nurse in the emergency department (ED) about a new patient being admitted with a spinal cord injury received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that the patient is probably experiencing?

- Neurogenic shock Explanation: Neurogenic shock can be caused by spinal cord injury. In this case, it resulted by diving into waters of unknown depth. The patient will present with a low blood pressure, bradycardia, and warm dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.

When a client is in the compensatory stage of shock, which symptom occurs?

- Tachycardia Explanation: The compensatory stage of shock encompasses: - normal blood pressure - tachycardia - decreased urinary output - confusion - respiratory alkalosis

Septic Shock - 5 causes - 5 Symptoms - What is progression?

Causes: 1. bacterial infections 2. Escherichia coli 3. Pseudomonas 4. Staphylococcus aureus 5. Endotoxins: harmful chemicals Symptoms: 1. Elevated WBC 2. fever, warm, flushed skin 3. Rapid, bounding pulse 4. progresses to cold, pale skin 5. hypotensive Progression: - systemic inflammatory response syndrome (SIRS) - multiple organ dysfunction syndrome

Anaphylactic Shock - List 6 causes - List 6 Symptoms

Causes: 1. severe allergic reaction 2. bee venom 3. latex 4. fish 5. nuts 6. PCN Symptoms: 1. Vasodilation 2. increased capillary permeability 3. tissue and airway swelling 4. hypotension 5. hives 6. itchy rash

Describe the 3 things that go on in the Compensation stage of Shock

Physiologic mechanisms for homeostatic stability!!! 1. Catecholamines: - stimulate sympathetic nervous system - increase heart rate - myocardial contractility - increase venous return - bronchial dilatation 2. Renin-angiotensin-aldosterone system: - restores blood pressure - increase blood volume 3. Antidiuretic and corticosteroid hormones: - ADH and ACTH; control sodium and water balance

The nurse provides care for a client who is critically ill due to a diagnosis of pneumonia and is at risk for developing shock. Assessment data reveals a white blood cell (WBC) count of 15 × 103 cells/mm3 (15 × 109/l) (normal: 4.5 to 10.5 × 103 cells/mm3 (4.5 to 10.5 × 109/l), a temperature of 102.2°F (39°C), and warm, flushed skin.

Shock is a life-threatening physiologic condition in which there is inadequate blood flow to tissues and cells of the body. Different types of shock states exist, with septic shock having the highest mortality due to the likelihood of multiple organ system dysfunction. A client who is critically ill with pneumonia is at risk for septic shock. Septic shock is a subset of sepsis in which underlying circulatory and cellular metabolic abnormalities are profound enough to substantially increase mortality. Septic shock is evidenced by the following: - respiratory rate greater than or equal to 22 breaths/min - altered mentation - systolic blood pressure (BP) less than or equal to 100 mm Hg. The nurse should notify the client's health care provider (HCP) when these symptoms occur with infection because they are indicative of septic shock. Based on the clinical presentation: - increased leukocyte count; fever; and warm, flushed skin indicating increased perfusion, this client who is critically ill with pneumonia is at risk for sepsis and, therefore, septic shock, not hypovolemic or cardiogenic shock. Clients who experience a loss of blood volume are at risk for hypovolemic shock whereas those who experience an acute myocardial infarction (MI) are at risk for cardiogenic shock. A clinical manifestation indicative of cardiogenic shock is angina (i.e., chest pain), which is not seen in septic shock. Because the client is presenting with warm, flushed skin, the nurse would not expect to see decreased urine output at this time.

Define Shock

- Inadequate oxygen and arterial blood flow to tissues/cells; life-threatening condition

The nurse is caring for a client admitted with cardiogenic shock. The client is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this client?

- It dilates the blood vessels. Explanation: For clients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the client's anxiety.

A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock?

- neurogenic shock Explanation: Injury to the spinal cord or head or overdoses of opioids, opiates, tranquilizers, or general anesthetics can cause neurogenic shock. Septic shock is a subcategory of distributive shock, but it is associated with overwhelming bacterial infections. Anaphylactic shock is a subcategory of distributive shock, but it is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive, such as bee venom, latex, fish, nuts, and penicillin. Hypovolemic shock occurs when the volume of extracellular fluid is significantly diminished, primarily because of lost or reduced blood or plasma.

What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis?

Early intervention along the continuum of shock is the key to improving the client's prognosis. The nurse must systematically assess the client at risk for shock, recognizing subtle clinical signs of the compensatory stage before the client's BP drops. Early interventions include: - identifying cause of shock - administering intravenous (IV) fluids and oxygen - obtaining necessary laboratory tests to rule out and treat metabolic imbalances or infection. - In assessing tissue perfusion, the nurse observes for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and laboratory values (e.g., base deficit and lactic acid levels) Administering vasoconstrictive medications or prophylactic packed red blood cells is not necessary as an early intervention.