Critical Care - Shock, Sepsis, and MODS

B -- Signs of hypovolemia include flattened neck veins, a decreased LOC, weak and thready peripheral pulses, and a narrowed pulse pressure.

A patient has been admitted with hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support this diagnosis? a. distended neck veins b. decreased level of consciousness c. bounding radial and pedal pulses d. widening pulse pressure

A -- Increased heart rate, change in sensorium, increased temperature, and increased respiratory rate are all signs of sepsis in the presence of an existing infection.

An elderly patient is admitted with pneumonia. This morning the patient is febrile, tachycardic, tachypneic, and confused. The nurse suspects the patient may be developing what problem? a. sepsis b. delirium c. adult respiratory distress syndrome d. acute kidney injury

Septic shock

In which type of shock is there an increase in CO?

A -- Absolute hypovolemia occurs when there is a loss of fluid from the intravascular space. This can result from an external loss of fluid from the body or from internal shifting of fluid from the intravascular space to the extravascular space. Fluid shifts can result from a loss of intravascular integrity, increased capillary membrane permeability, or decreased colloidal osmotic pressure. Relative hypovolemia occurs when vasodilation produces an increase in vascular capacitance relative to circulating volume.

The nurse is caring for a patient in hypovolemic shock secondary to cirrhosis of the liver. The nurse understands that this type of shock results from shifting of fluid into the abdominal cavity. What is the resulting hypovolemia called? a. absolute hypovolemia b. distributive hypovolemia c. relative hypovolemia d. compensatory hypovolemia

C -- When systemic inflammatory response syndrome (SIRS) is the result of infection, it is referred to as sepsis.

The nurse is caring for a patient with systemic inflammatory response syndrome (SIRS) due to pneumonia. What is SIRS due to infection called? a. infectivity b. anaphylaxis c. sepsis d. ARDS

- lactate greater than 2 or lactic acid greater than 4 - base excess deficit (lower than -2) - low serum bicarb - low O2 saturation - low BP, low HR - altered mental status - decreased UO

What are classic systemic indicators of shock?

Endothelial damage, coagulation dysfunction

What are the hallmarks of sepsis?

1.) initial - decrease in CO leading to decreased tissue perfusion 2.) compensatory Begins almost immediately after initial Homeostatic mechanisms kick in, controlled by SNS - neural response: increase in HR and contractility, vasoconstriction, shunting of blood to vital organs - hormonal response: activation of RAAS, activation of anterior pituitary (increased glucose) 3.) progressive - compensatory mechanisms fail - metabolism switches from aerobic to anaerobic to produce energy —> lactic acid production - vasodilation and increased vascular permeability leading to intravascular hypovolemia and 3rd spacing (edema) - systemic release of inflammatory mediators which destroys the mitochondria (cannot use O2 anymore) - DIC, AKI, ARDS 4.) refractory - shock is unresponsive to therapy; irreversible - MODD and death

What are the stages of shock?

Systemic vasodilation, bronchoconstriction, strider, hoarseness, tachycardia, hypotension

What are the symptoms of anaphylactic shock?

A -- The syndrome encompassing severe sepsis and septic shock is a complex systemic response that is initiated when a microorganism enters the body and stimulates the inflammatory or immune system. Shed protein fragments and the release of toxins and other substances from the microorganism activate the plasma enzyme cascades (complement, kinin and kallikrein, coagulation, and fibrinolytic factors), as well as platelets, neutrophils, monocytes, and macrophages.

A nurse is caring for a patient in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock? a. bacterial toxins lead to vasodilation b. WBCs are released to fight invading bacteria c. microorganisms invade organs such as the kidneys and the heart d. decreased RBC production and fluid loss

B -- Shock is an acute, widespread process of impaired tissue perfusion that results in cellular, metabolic, and hemodynamic alterations. It is a complex pathophysiologic process that often results in multiple-organ dysfunction syndrome and death. All types of shock eventually result in ineffective tissue perfusion and the development of acute circulatory failure.

A nurse is discussing the concept of shock with a new grad nurse. Which statement indicates the new grad nurse understood the information? a. Shock is a physiological state resulting in hypotension and tachycardia. b. Shock is an acute, widespread process of inadequate tissue perfusion. c. Shock is a degenerative condition leading to organ failure and death. d. Shock is a condition occurring with hypovolemia that results in hypotension.

B -- Organ dysfunction may be the direct consequence of an initial insult (primary multiple-organ dysfunction syndrome [MODS]) or can manifest latently and involve organs not directly affected in the initial insult (secondary MODS). Patients can experience both primary and secondary MODS. Primary MODS results from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself.

A nursing instructor is discussing the difference between primary and secondary multiple-organ dysfunction syndrome (MODS) with a nursing student. Which statement indicates the student understood the information? a. Primary MODS is the result of inflammation in organs not involved in the initial insult. b. Primary MODS is the result of a direct organ injury. c. Primary MODS is due to a disorganization of the inflammatory immune system response. d. Primary MODS is due to disruption of the coagulation system.

B -- The most common cause is spinal cord injury (SCI). Neurogenic shock may mistakenly be referred to as spinal shock. The latter condition refers to loss of neurologic activity below the level of SCI, but it does not necessarily involve ineffective tissue perfusion.

A patient has been admitted with a neurologic disorder. With which disorder should the nurse be the most vigilant for the development of neurogenic shock? a. ischemic stroke b. spinal cord injury c. Guillain-Barre syndrome d. Brain tumor

A -- Peripheral vasodilation results in decreased venous return. This decreases intravascular volume and the development of relative hypovolemia. Decreased venous return results in decreased SV and a fall in CO.

A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the decrease in the patient's cardiac output is the result of which mechanism? a. peripheral vasodilation b. increased venous return c. increased alveolar ventilation d. decreased myocardial contractility

C -- IgE is an antibody that is formed as part of the immune response. The first time an antigen enters the body, an antibody IgE, specific for the antigen, is formed. The antigen-specific IgE antibody is then stored by attachment to mast cells and basophils. This initial contact with the antigen is known as a primary immune response. The next time the antigen enters the body, the preformed IgE antibody reacts with it, and a secondary immune response occurs.

A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the patient is probably having an immunoglobulin E (IgE)-mediated response as a result of what physiologic mechanism? a. direct activation of mast cells and basophils b. nonimmunologic stimulation of biochemical mediators c. repeat exposure to an antigen in the presence of preformed IgE antibodies d. activation of the systemic inflammatory response

A -- Measures to facilitate the administration of volume replacement include insertion of large-bore peripheral IV; rapid administration of prescribed fluids; and positioning the patient with the legs elevated, trunk flat, and head and shoulders above the chest.

A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid? a. inserting a large-diameter peripheral IV b. positioning the patient in the Trendelenburg position c. encouraging the patient to drink at least 240 mL of fluid each hour d. administering IV fluids under pressure with a pressure bag

A -- Increased CO and decreased SVR are classic signs of septic shock.

A patient has been admitted with septic shock due to urinary sepsis. The practitioner inserts a pulmonary artery (PA) catheter. Which hemodynamic value would the nurse expect to note to support this diagnosis? a. CO of 8 L/min b. right atrial pressure (RAP) of 17 mmHg c. PaOP of 23 mmHg d. SVR of 1100

B -- Effective treatment of severe sepsis and septic shock depends on timely recognition. The diagnosis of severe sepsis is based on the identification of three conditions: known or suspected infection, two or more of the clinical indications of the systemic inflammatory response, and evidence of at least one organ dysfunction. Clinical indications of systemic inflammatory response and sepsis were included in the original American College of Chest Physicians/Society of Critical Care Medicine consensus definitions.

A patient has been admitted with septic shock related to tissue necrosis. The nurse knows the initial goal for medical management for this patient is which intervention? a. limiting fluids to minimize the possibility of HF b. finding and eradicating the cause of infection c. discontinuing invasive monitoring as a possible cause of sepsis d. administering vasodilator substances to increase blood flow to vital organs

C -- With microcirculatory failure to the gastrointestinal tract, the gut's barrier function may be lost, which leads to bacterial translocation, sustained inflammation, endogenous endotoxemia, and multiple-organ dysfunction syndrome (MODS).

A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock? a. anorexia leads to loss of gastric enzymes b. lack of food ingestion leads to intestinal hypomotility c. hypoperfusion results in loss of gut barrier function d. low CO causes decreased hydrochloric acid

B, C, D Clinical manifestations of cardiogenic shock include heart rate greater than 100 beats/min; cool, pale, moist skin; weak, thready pulse; and increased right atrial pressure and pulmonary artery occlusion pressure.

A patient in cardiogenic shock is being treated in the critical care unit. Which findings would the nurse expect to note in the patient to support this diagnosis? (Select all that apply.) a. warm, dry skin b. heart rate greater than 100 bpm c. weak, thready pulse d. increased right atrial pressure e. decreased PaOP

B -- Disseminated intravascular coagulation (DIC) results simultaneously in microvascular clotting and hemorrhage in organ systems, leading to thrombosis and fibrinolysis in life-threatening proportions. Clotting factor derangement leads to further inflammation and further thrombosis. Microvascular damage leads to further organ injury. Cell injury and damage to the endothelium activate the intrinsic or extrinsic coagulation pathways.

A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. The nurse knows that DIC is known to occur in patients with retained placental fragments. What is the pathophysiologic consequence of DIC? a. Hypersensitivity response to an antigen b. Excessive thrombosis and fibrinolysis c. Profound vasodilatation d. Loss of intravascular volume

C -- Low platelet counts and elevated D-dimer concentrations and fibrinogen degradation products are clinical indicators of disseminated intravascular coagulation (DIC). DIC does not affect serum glucose levels.

A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expect to note to support this diagnosis? a. decreased fibrinogen degradation products b. decreased D-dimer concentrations c. decreased platelet counts d. increased serum glucose levels

C -- Mechanical circulatory assist devices are used if adequate tissue perfusion cannot be immediately restored. Options include an intraaortic balloon pump (IABP), a percutaneous ventricular assist device (VAD), or an extracorporeal membrane oxygenator. The IABP is used to decrease myocardial workload by improving myocardial supply and decreasing myocardial demand. It achieves this goal by improving coronary artery perfusion and reducing left ventricular afterload. Sodium bicarbonate, fluids, and dialysis are not indicated in this situation.

A patient is being admitted from the emergency department (ED) with cardiogenic shock secondary to unstable angina unresponsive to medications. The patient was intubated and ventilated in the ED. Which intervention should the nurse prepare to initiate when the practitioner arrives in the unit? a. administration of sodium bicarbonate b. rapid infusion of crystalloids c. insertion of an intraaortic balloon pump d. insertion of dialysis catheters for continuous renal replacement

C -- Inotropic agents are used to increase contractility and maintain adequate blood pressure and tissue perfusion. Dobutamine is the inotrope of choice. A vasopressor, preferably norepinephrine (not Epinephrine), may be necessary to maintain blood pressure when hypotension is severe. Diuretics may be used for preload reduction. Vasodilating agents (Nitroglycerine and Nitroprusside) are used for preload and afterload reduction only in specific situations in conjunction with an inotrope or when the patient is no longer in shock.

A patient is being admitted with cardiogenic shock secondary to acute heart failure. In addition to a diuretic, which medication would the nurse anticipate the practitioner ordering for the patient? a. epinephrine b. nitroprusside c. dobutamine d. nitroglycerine

A, B, C, D A key measure in the treatment of septic shock is finding and eradicating the cause of the infection. At least two blood cultures plus urine, sputum, and wound cultures should be obtained to find the location of the infection before antibiotic therapy is initiated. Antibiotic therapy should be started within 1 hour of recognition of severe sepsis without delay for cultures.

A patient is being admitted with septic shock. The nurse appreciates that the key to treatment is finding the cause of the infection. Which cultures would the nurse obtain before initiating antibiotic therapy? (Select all that apply.) a. blood cultures x2 b. wound cultures c. urine cultures d. sputum cultures e. CBC with differential

D -- Epinephrine is given in anaphylactic shock to promote bronchodilation and vasoconstriction and inhibit further release of biochemical mediators.

A patient with a known penicillin allergy develops anaphylactic shock after a dose of ampicillin was given in error. Which medication would the nurse administer first? a. Methylprednisolone b. Gentamicin c. Atropine d. Epinephrine

A

A patient with an allergy to bee stings was just stung by a bee. After administering oxygen, removing the stinger, and administering epinephrine, the nurse notices the patient has a blood pressure of 86/48mmHg. What should be the nurse's next action? a. administer IV diphenhydramine b. initiate a nitroprusside infusion and titrate c. prepare for placement of an advanced airway d. place the patient in the recumbent position and elevate the legs

A -- Cardiogenic shock is the result of failure of the heart to effectively pump blood forward. It can occur with dysfunction of the right or the left ventricle or both. The lack of adequate pumping function leads to decreased tissue perfusion and circulatory failure.

The nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient's signs and symptoms are the result of what problem? a. inability of the heart to pump blood forward b. loss of circulating volume and subsequent decreased venous return c. disruption of the conduction system when re-entry phenomenon occurs d. suppression of the SNS

D -- Assessment of the hemodynamic parameter of patients in cardiogenic shock reveals a decreased cardiac output and a cardiac index less than 2.2 L/min/m2.

The nurse is caring for a patient in cardiogenic shock. Which hemodynamic parameters would the nurse expect to note to support this diagnosis? a. increased right atrial pressure b. decreased pulmonary artery wedge pressure c. increased cardiac output d. decreased cardiac index

A, C, D There is no evidence to support the use of low-dose dopamine to maintain urine output. An adrenocorticotropic hormone (ACTH) stimulation test should not be used to identify patients who need hydrocortisone.

The nurse is caring for a patient in septic shock due secondary to pneumonia. The nurse knows that evidence-based guidelines for the treatment of septic shock include which interventions? (Select all that apply.) a. Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg. b. Administer low-dose dopamine to maintain urine output greater than 30 mL/h. c. Start enteral nutrition within the first 48 hours after diagnosis of septic shock. d. Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L. e. Perform an adrenocorticotropic hormone (ACTH) stimulation test to identify patients who need hydrocortisone

B -- Sodium bicarbonate is not recommended in the treatment of shock-related lactic acidosis. Glucose control to a target level of 140 to 180 mg/dL is recommended for all critically ill patients. Vasoconstrictor agents are used to increase afterload by increasing the systemic vascular resistance and improving the patient's blood pressure level. Crystalloids are balanced electrolyte solutions that may be hypotonic, isotonic, or hypertonic. Examples of crystalloid solutions used in shock situations are normal saline and lactated Ringer solution.

The nurse is caring for a patient in shock with an elevated lactate level. Which order should the nurse question in the management of this patient? a. start an insulin drop for blood sugar greater than 180 mg/dL b. administer sodium bicarbonate to keep arterial pH greater than 7.20 c. start a NE drip to keep MAP greater than 65 d. administer crystalloid fluids

B -- According to the Surviving Sepsis Campaign Bundles, the following interventions should be completed within 3 hours of time of presentation 1. Measure lactate level. 2. Obtain blood cultures prior to administration of antibiotics. 3. Administer broad spectrum antibiotics. 4. Administer 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L.

The nurse is caring for a patient who what just admitted with septic shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order? a. administer fresh frozen plasma b. obtain a serum lactate level c. administer epinephrine d. measure central venous presssure

B -- Hypermetabolism in systemic inflammatory response syndrome (SIRS) or multiple-organ dysfunction syndrome (MODS) results in profound weight loss, cachexia, and loss of organ function. The goal of nutritional support is the preservation of organ structure and function. Although nutritional support may not definitely alter the course of organ dysfunction, it prevents generalized nutritional deficiencies and preserves gut integrity. Enteral nutrition may exert a physiologic effect that downregulates the systemic immune response and reduces oxidate stress.

The nurse is caring for a patient with multiple-organ dysfunction syndrome (MODS). The nurse understands that earlier nutritional support is critical for the patient to prevent profound weight loss. Why does this occur in patient MODS? a. patient experiences hypometabolism b. patient experiences hypermetabolism c. patient experiences anorexia d. patient has gut dysfunction

D -- An individual with latex allergies should carry an injectable epinephrine pen. The proteins in latex are similar to the proteins in certain foods and may cause an allergic reaction in people who are allergic to latex. Foods to avoid include banana, avocado, chestnut, kiwi, tomato, water chestnuts, guava, hazelnuts, potatoes, peaches, grapes, and apricots. Vinyl gloves are not latex and are safe to use. Individuals with latex allergies need to share this information with all health care providers and wear a medical alert bracelet.

The nurse is providing discharge teaching to a 24 y/o female patient who has a latex allergy about preventing and treating allergic reactions. Which statement, if made by the patient, indicates a need for further teaching? a. "My dentist should be told about my latex allergy." b. "I should avoid foods such as bananas, avocados, and kiwi." c. "I will use vinyl gloves for activities such as cleaning." d. "Because my reactions are not severe, I will not need an EpiPen."

SBP less than 90 and/or acute drop in SBP greater than 30, tachycardia, weak thready pulse, diminished heart sounds, chest pain, rhythm changes, tachypnea, crackles, increased preload

What are signs and symptoms of cardiogenic shock?

Altered mental status, low BP, prolonged capillary refill, decreased urine output, tired, pale skin

What are signs of decreased CO?

Signs of decreased CO, prolonged capillary refill, cool extremities, orthostatic hypotension, tachycardia, tachypnea

What are the signs and symptoms of hypovolemia shock?

- bradycardia, hypotension - warm, dry, flushed skin

What are the signs and symptoms of neurogenic shock?

anaphalactic shock, neurogenic shock, septic shock

What are the types of distributive shock?

TIME T: temp increase or decrease I: infection s/s M: mental decline (confused, difficult to arouse) E: extremely ill (severe pain, SOB, discomfort)

What are you looking for when monitoring for sepsis?

Septicemia

What is a major risk factor for DIC?

Procalcitonin is a new measure that has been put in place. It might be more sensitive than lactate. Procalcitonin over 2: elevated Over 10: severely elevated

What is new evidence-based practice of shock when looking at lab values?

Any 2 = workup for sepsis 1.) alteration in mental status (GCS less than 15) 2.) systolic BP less than or equal to 100 3.) RR greater than or equal to 22

What is the criteria for qSOFA?

MI

What is the most common cause of cardiogenic shock?

Hypovolemic shock

What is the most common type of shock?

1.) measure lactate or lactic acid 2.) get blood cultures x 2 before antibiotics 3.) administer broad-spectrum antibiotics 4.) crystalloid IVF 30 mL/kg for hypotension or lactate greater than 4 5.) vasopressor therapy (ME) if hypotensive to keep MAP greater than 65

What is the sepsis first hour bundle?

Epi IM 0.2 - 0.5 mg Epi IV 0.05 - 0.1 mg High-dose diphenhydramine, Famotidine, corticosteroids

What is the treatment for anaphylactic shock?

Anterior wall MI

What type of MI typically causes cardiogenic shock?

Newborns, elderly, pregnant women, people with comorbidities, lower immune system, wounds or injuries, invasive devices

Who is most at risk for shock?