Hypovolemic Shock Study Questions
Which stage of hypovolemic shock is indicated by a pulse oximetry value of 93%?
In the nonprogressive stage of hypovolemic shock, the pulse oximetry value ranges from 90%-95%. If the value is above 95%, it indicates the initial stage of hypovolemic shock. Any value below 70% indicates the refractory stage. In the progressive stage, the value lies between 75% and 80%. p. 755
The patient with which lab result is at risk for hemorrhagic shock?
Prolonged INR indicates that blood takes longer than normal to clot; this patient is at risk for bleeding. PTT of 12.5 and a platelet value of 170,000/mm 3 are both normal and pose no risk for bleeding. Although a hemoglobin of 8.2 g/dL is low, the patient could have severe iron deficiency or could have received medication affecting the bone marrow.
Which organ can tolerate hypoxia for 1 hour without permanent damage in a patient with hypovolemic shock? a. liver b. brain c. heart d. kidneys
d. Kidneys can tolerate hypoxia for 1 hour without permanent damage, but beyond this time the patient is at the risk of kidney failure. The liver, brain, and heart cannot tolerate hypoxia; it will lead to organ dysfunction. p. 756
What is the component of colloid solutions that is helpful in managing hypovolemic shock through the intravenous route?
Colloid solutions are mainly composed of larger molecules like starches and proteins. These molecules help to maintain the oncotic pressure of the intravascular fluid and prevent fluid loss. Salts, sugars, and minerals are components of crystalloids, not colloids. p. 759
What is associated with hypovolemic shock?
Dehydration is a symptom of hypovolemic shock. This is because in hypovolemic shock, there is a decrease in the total body fluids. Pulmonary embolus is a result of direct pump failure, which indicates cardiogenic shock. Myocardial infarction occurs due to decreased cardiac function, which causes obstructive shock. Chemical-induced sepsis is caused by fluid shift from the central vascular space. This results in distributive shock. p. 752, Table 37-1
A patient in the progressive or intermediate stage of hypovolemic shock will exhibit which manifestation?
Feeling of impending doom As shock progresses, tissue perfusion to the brain continues to be reduced, causing a sense of anxiety or that "something bad" is about to happen. Oliguria or anuria occurs in the nonprogressive stage rather than polyuria. A lack of perfusion to the skin results in cool, moist skin rather than warm skin. Due to decreased tissue perfusion, buildup of lactic or metabolic acid occurs; the arterial blood gases reflect metabolic acidosis at this time.
The nurse is caring for postoperative patients at risk for hypovolemic shock. Which condition represents an early symptom of shock?
Heart and respiratory rates increased from the patient's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal. Early in shock, the patient displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart. p. 752, Chart 37-1
Which type of shock may result if hemorrhage in a patient is not treated in time?
Hemorrhage can result in hypovolemic shock, which occurs when the mean arterial pressure decreases due to loss of blood from the vascular space resulting in inadequate total body perfusion and oxygenation. A loss of blood does result in distributive, obstructive, and cardiogenic shock; therefore, these are not associated with hemorrhage. p. 752
Why is a patient who overdosed on bumetanide at high risk for hypovolemic shock?
Hypovolemic shock results from decreased circulating blood volume; bumetanide, a potent loop diuretic, decreases blood volume. A myocardial infarction may lead to cardiogenic shock or heart failure, with resulting fluid volume excess rather than hypovolemia. Kidney failure results in increased blood volume (hypervolemia) as the failing kidney is unable to produce urine. BPH obstructs the outflow of urine into the bladder as prostatic tissue enlarges; blood volume is not reduced.
What are cardiovascular manifestations of hypovolemic shock?
In hypovolemic shock, total body fluid is reduced; therefore, the difference between systolic and diastolic pressure (pulse pressure) is decreased. Blood pressure in the body drops also causing postural hypotension. The decrease in blood volume causes a simultaneous decrease in cardiac output. There is a compensatory increase in pulse rate to restore cardiac output in shock. Peripheral pulses become weak in hypovolemic shock. p. 752, Chart 37-1
What metabolic changes occur as a result of tissue ischemia during the compensatory stage of hypovolemic shock?
In the compensatory (nonprogressive) stage of shock, tissue hypoxia leads to acidosis because of changes in anaerobic metabolism. Hyperkalemia occurs as well from the changes in metabolism. The patient is acidotic, not alkalotic. Hypovolemic shock is associated with vasoconstriction, not vasodilation. p. 754, Table 37-2
The nurse is preparing to administer a transfusion of packed red blood cells to a patient with hemorrhagic shock. Which action is essential before initiating the transfusion?
Isotonic solutions such as Ringer's lactate or normal saline may be used as volume expanders in hypovolemic shock. Red blood cells must be given with 0.9% saline to prevent clotting during infusion. While the volume of the blood in the bag is approximately 250 mL, it may vary; however, this is not essential to validate before initiating the transfusion. The nurse monitors for dark urine when an ABO transfusion reaction is suspected. Vital signs, especially a baseline temperature, are indicated prior to transfusion; a low blood pressure during shock states is expected.
A nurse is administering dopamine to a patient who is in shock. After the therapy, the patient's mean arterial pressure is 22 mm Hg from the baseline value. Which intervention should the nurse perform to prevent severe vasoconstriction and tissue necrosis?
It is important to assess for extravasation at the IV site every 30 minutes Dopamine causes extravasation when it leaks into the tissues. The extravasation of drugs can constrict the blood vessels, which leads to severe vasoconstriction. The excess dopamine results in severe vasoconstriction; therefore, it is important to assess for extravasation at the IV site every 30 minutes. The patient should be assessed for chest pain to reduce the risk of increased myocardial oxygen consumption, because an overdose of dopamine increases myocardial oxygen consumption. Excess dopamine can lead to decreased kidney perfusion and urinary output. To prevent this condition, urine output should be monitored every hour. Hypertension is caused by dopamine overdose; therefore, to maintain the effective drug dose, blood pressure should be assessed every 15 minutes. p. 759, Chart 37-4
A patient is scheduled for thoracotomy later today. Which entry noted on the medication reconciliation record poses a risk for perioperative hemorrhagic shock and causes the nurse to contact the provider immediately?
Naproxen is a nonsteroidal anti-inflammatory agent that poses a risk for bleeding. Captopril (for hypertension), furosemide (for heart failure), or omeprazole (prevents gastroesophageal reflux disease and gastrointestinal bleeding from stomach ulcers) do not pose risks for bleeding. Anticoagulants, aspirin, and NSAIDs should be questioned.
A patient who underwent a radical colon resection for metastatic cancer has developed septic shock, is neurologically unresponsive, is unable to breathe without mechanical ventilator support, requires dialysis for renal function, is not tolerating tube feedings, and is beginning to show signs of hepatic failure. Which condition does the nurse suspect the patient has developed based on these clinical manifestations?
MODS Shock that progresses to the refractory stage causes irreversible cell death and tissue damage, releasing toxic metabolites that build up in the body. This buildup causes progressive organ failure. Once the sequence of multiple organ failure begins, the patient's condition is termed MODS. MODS involves the presence of altered organ functions in two or more organ systems. In this patient, four organs have "failed' with a fifth (the liver) imminent. Based on the clinical definition of MODS, late-stage septic shock, intracerebral hemorrhage, and adverse reaction to a medication are not clinically accurate descriptions for the patient in this scenario.
Which organ is responsible for releasing myocardial depressant factor that leads to heart damage as a result of multiple organ dysfunction syndrome (MODS)?
Myocardial depressant factor is secreted from the ischemic pancreas and is responsible for causing profound damage to the heart in MODS. The liver, brain, and kidneys, in addition to the heart, are severely damaged but they do not release myocardial depressant factors. p. 754, Table 37-2
A patient is at risk for hypovolemic shock. The nurse suspects the nonprogressive (compensatory) phase of shock is occurring when which factor is present?
Narrowing pulse pressure The nonprogressive (compensatory) stage of shock causes tachycardia, decreased systolic blood pressure, and increased diastolic blood pressure, which narrows the pulse pressure (difference between the systolic and diastolic pressures) secondary to catecholamine release. Typically, distal pulses are weak and thready as hypovolemic shock progresses.
After norepinephrine is administered to a patient with hypovolemic shock, which assessment factor is used to verify the effectiveness of the treatment?
Norepinephrine is a vasoconstrictor drug used in hypovolemic shock to increase perfusion and oxygenation. These drugs constrict the blood vessels and increase venous return. Urine production will not increase until blood pressure rises and perfuses the kidneys. Norepinephrine does not have any effect on a patient's level of consciousness or blood glucose levels. p. 759, Chart 37-4
A patient in hypovolemic shock presents with a normal hematocrit and hemoglobin. What type of fluid should the nurse anticipate the health care provider will prescribe to restore oncotic pressure?
Plasma The ideal intervention for restoring osmotic pressure in a patient with normal hematocrit and hemoglobin is plasma. Plasma protein fractions and synthetic plasma expanders are used to increase fluid volume. Whole blood is suitable for replacing large blood losses in patients with a decrease in hemoglobin and hematocrit levels. Ringer's lactate does not restore oncotic pressure; it is a crystalloid that restores fluid volume and is used in instances where the patient needs volume expansion and correction of acidosis. Packed red cells are chosen for moderate blood losses when the patient needs red blood cells without added fluid volume. p. 759
When caring for a patient with septic shock who has disseminated intravascular coagulation (DIC), the nurse anticipates which finding?
Plasma d-dimer levels rise during DIC as multiple fibrin clots break down. A reduction in red blood cells, hemoglobin, and hematocrit, rather than an increase (polycythemia), occur in DIC. Thrombocytopenia (a reduction of platelets) rather than thrombocytosis (an increased number of platelets) occurs along with reduced fibrinogen levels as these components are incorporated into the multiple small clots that develop in DIC.
How does the nurse recognize that a positive outcome has occurred when administering plasma protein fraction (Plasmanate)?
Plasmanate expands the blood volume and helps maintain MAP greater than 65 mm Hg, which is a desired outcome in shock. Urine output should be 0.5 mL/kg/hr or greater than 30 mL/hr. Albumin levels reflect nutritional status, which may be poor in shock states due to an increased need for calories. Plasmanate expands blood volume by exerting increasing colloid osmotic pressure in the bloodstream, pulling fluid into the vascular space; this does not improve an abnormal hemoglobin.
Mean arterial pressure of a patient with hypovolemic shock is 8 mm Hg below the normal baseline. Which condition would the nurse assess for?
Production of lactic acid A mean arterial pressure of 8 mm Hg below baseline is associated with the initial stage of hypovolemia. In this stage, the production of lactic acid occurs in some tissues, but the overall metabolism remains aerobic. Oxygen perfusion to the vital organs will be maintained because of the effectiveness of the compensatory mechanisms. The secretion of renin, aldosterone, and antidiuretic hormones will not occur. These hormones are secreted when there is a further decrease in the mean arterial pressure of 10-15 mm Hg below the normal baseline.
What are the actions of renin in the maintenance of blood pressure?
Renin is produced in the body as a response to low blood pressure. This enzyme helps in maintaining blood pressure by decreasing urine output and constricting peripheral blood vessels. Renin also increases sodium reabsorption in the kidney which causes further retention of water. Renin does not directly affect cardiac function or potassium levels. p. 754, Table 37-2
Which assessment findings are consistent with the nonprogressive (compensatory) phase of shock?
Restlessness, anxiety, cool skin, and increased respiratory rate (tachypnea) along with oliguria, tachycardia, and narrowing pulse pressure, appear in the nonprogressive (compensatory) stage of shock. Organ damage manifested by increased liver enzymes or kidney function occurs in the progressive or intermediate phase of shock. Tachycardia, rather than bradycardia, occurs in shock states secondary to catecholamines released as compensatory mechanisms. p. 755
The nurse is administering continuous intravenous infusion of norepinephrine to a patient in shock. Which finding causes the nurse to decrease the rate of infusion?
Signs of excess vasoconstricting drugs include headache, hypertension, and decreased renal perfusion manifested by oliguria. While vasoconstricting medications and the shock state may cause tachycardia (heart rate greater than 100 beats/min), this patient's heart rate is within normal range. Vasoconstricting drugs do not affect the respiratory rate; shock itself causes an increased respiratory rate in an effort to deliver more oxygen to the tissues.
Which vasodilator drug is often helpful in managing hypovolemic shock?
Sodium nitroprusside dilates the coronary arteries, enhancing myocardial perfusion and improving hypovolemic shock. Milrinone and dobutamine are both inotropic agents that act by increasing the force of heart muscle contractions. Phenylephrine is a vasoconstrictor, not a vasodilator. p. 759, Chart 37-4
What are risk factors for hypovolemic shock?
Specific risk factors for hypovolemic shock include hemophilia, malnutrition, and diuretic therapy. Hypovolemia can be caused by impaired clotting in patients with hemophilia and malnourishment. Excessive diuresis due to diuretic therapy can also cause reduction in blood volume. Patients with spinal cord injury have distributive shock in which the total blood volume is not reduced but fluid shifts from the central vascular space. In patients with myocardial infarction, cardiac function is impaired which causes cardiogenic shock. p. 752, Table 37-1
Where are the baroreceptors that are responsible for detection of pressure changes within the arterial system located?
The baroreceptors responsible for detecting pressure changes in the arterial system are located in aortic arch and carotid sinus. There are no baroreceptors located in radial sinus, brachial arch, and femoral sinus. p. 754
Which clinical manifestation may be evident in the initial stage of hypovolemic shock?
The initial stage of hypovolemia can be detected only by an increase in heart and respiratory rates. Reduction in urine output is a manifestation of the nonprogressive stage. Antidiuretic hormone increases water reabsorption in the kidneys which results in decreased urine output. In the initial stage of hypovolemia, the compensatory mechanisms are efficient in maintaining cardiac output, so there is no overall decrease in cardiac output. A 2%-5% decrease in oxygen saturation indicates the nonprogressive stage of hypovolemia. p. 752, Chart 37-1
What points does the nurse consider during the psychosocial assessment of a patient who is suspected to have hypovolemia?
The nurse should assess whether the response of a patient with suspected hypovolemia answers the question asked. It is also important to check if the patient becomes irritated or upset when questions are asked again and again. If the patient gets upset or irritated, it shows that the patient is not able to handle mental stress. The patient's concentration level is important in determining if the patient has a limited attention span. Questions should be repeated so that the patient can understand the question completely and give a correct response. In psychometric assessment, the questions should not be phrased in a "yes" or "no" format, because the mental level of the patient cannot be judged when only required to give one-word answers.
A patient's laboratory report shows a hematocrit of 29%. What does this value indicate?
The patient is hemorrhaging In hemorrhage, the hematocrit value decreases from the normal adult level of 42% to 52% for males and 37% to 47% for females. Edema results from fluid shift, which causes hematocrit levels to increase. Dehydration also results in an elevated hematocrit value. p. 758
Which stage of hypovolemic shock is a medical emergency and requires immediate intervention?
The progressive stage of shock is a medical emergency that requires immediate intervention because compensatory mechanisms may be unable to deliver an adequate amount of oxygen to the vital organs. If this condition is left untreated even for an hour, it will lead to multiple organ dysfunction syndrome and even death. At the initial stage, the compensatory mechanisms are efficient enough to maintain normal oxygenation and perfusion rates of the vital organs; thus, immediate interventions are not required. The refractory stage involves excessive cell damage and tissue death, because tissue perfusion is blocked at this stage due to an excessive decrease in mean arterial pressure. The nonprogressive stage is not a medical emergency. If supportive interventions are performed, a patient can remain in the nonprogressive stage for hours without any damage to the vital organs. p. 755
A patient admitted with a bleeding duodenal ulcer is NPO and has a nasogastric tube in place connected to low continuous suction. What assessment finding does the nurse report to the provider as a possible indicator of nonprogressive stage of shock?
When shock progresses from the initial stage to the nonprogressive stage, symptoms are subtle but present. Once the patient enters the progressive and refractory stage of shock, manifestations are more obvious and may not be responsive to therapy. Recognizing early manifestations of shock are important to patient outcomes. The nonprogressive stage of shock is present when the MAP decreases by 10-15 mm Hg from baseline, urine output decreases, and heart rate and respiratory rate increase. Confusion and moderate hyperkalemia is observed in the progressive stage of shock. The patient's urine output is still within normal limits as may be seen in the initial stage of shock, but urine output will continue to decrease as the shock stages progress.
Which shock results in a decrease of total body fluids? a. hypovolemic shock b. cardiogenic shock c. distributive shock d. obstructive shock
a. Hypovolemic shock results in a decrease of total body fluids. Cardiogenic shock is indicated by direct pump failure. In distributive shock, the fluid shifts from the central vascular space. In obstructive shock, cardiac function is decreased due to indirect pump failure. pp. 752-753
