Lewis 67 Shock Study Guide

Septic: Fluid resuscitation, antimicrobial agents, inotropic agents with vasopressors

Anaphylactic: Epinephrine, inhaled bronchodilators, colloidal fluid replacement, diphenhydramine, corticosteroids

Cardiogenic: Restore coronary artery blood flow with thrombolytic therapy, angioplasty, emergency revascularization; increase CO with inotropic agents; reduce workload by dilating coronary arteries, decreasing preload and afterload; use circulatory assist devices, such as an intraaortic balloon pump

Hypovolemic: Fluid and blood replacement, control of bleeding with pressure, surgery

What physical problems could precipitate hypovolemic shock (select all that apply)? a. Burns b. Ascites c. Vaccines d. Insect bites e. Hemorrhage f. Ruptured spleen

a, b, e, f. Hypovolemic shock occurs when there is a loss of intravascular fluid volume from fluid loss (as in hemorrhage or severe vomiting and diarrhea), fluid shift (as in burns or ascites), or internal bleeding (as with a ruptured spleen). Vaccines and insect bites would precipitate the anaphylactic type of distributive shock.

The patient is in the compensatory stage of shock. What manifestations indicate this to the nurse (select all that apply)? a. Pale and cool b. Unresponsive c. Lower BP than baseline d. Moist crackles in the lungs e. Hyperactive bowel sounds f. Tachypnea and tachycardia

a, c, f. In the compensatory stage of shock the patient's skin will be pale and cool (α-adrenergic stimulation). There may also be a change in level of consciousness but the person will be responsive, the BP will be lower than baseline, bowel sounds will be hypoactive (α-adrenergic stimulation), and tachypnea and tachycardia (β-adrenergic stimulation) will occur. Unresponsiveness and moist crackles in the lungs occur in the progressive stage of shock.

In the compensatory stage of hypovolemic shock, to what organs does blood flow decrease after the sympathetic nervous system activates the α-adrenergic stimulation (select all that apply)? a. Skin b. Brain c. Heart d. Kidneys e. Gastrointestinal tract

a, d, e. After sympathetic nervous system activation of vasoconstriction, blood flow to nonvital organs, such as skin, kidneys, and the gastrointestinal (GI) tract is diverted or shunted to the most essential organs of the heart and the brain. The patient will feel cool and clammy, the renin- angiotensin-aldosterone system will be activated, and the patient may develop a paralytic ileus.

When caring for a patient in cardiogenic shock, the nurse recognizes that the metabolic demands of turning and moving the patient exceed the oxygen supply when what change is revealed in hemodynamic monitoring? a. SvO2 from 62% to 54% b. CO from 4.2 L/min to 4.8 L/min c. Stroke volume (SV) from 52 to 68 mL/beat d. SVR from 1300 dyne/sec/cm5 to 1120 dyne/sec/cm5

a. A decreased mixed venous oxygen saturation (SvO2) indicates that the patient has used the venous oxygen reserve and is at greater risk for anaerobic metabolism. The SvO2 decreases when more oxygen is used by the cells, as in activity or hypermetabolism. All of the other values indicate an improvement in the patient's condition.

A patient with hypovolemic shock is receiving lactated Ringer's solution for fluid replacement therapy. During this therapy, which laboratory result is most important for the nurse to monitor? a. Serum pH b. Serum sodium c. Serum potassium d. Hemoglobin (Hgb) and hematocrit (Hct)

a. Lactated Ringer's solution may increase lactate levels, which a damaged liver cannot convert to bicarbonate. This may intensify the metabolic lactic acidosis that occurs in progressive shock, necessitating careful attention to the patient's acid-base balance. Sodium and potassium levels as well as hemoglobin (Hgb) and hematocrit (Hct) levels should be monitored in all patients receiving fluid replacement therapy.

A 70-year-old patient is malnourished, has a history of type 2 diabetes mellitus, and is admitted from the nursing home with pneumonia. For which kind of shock should the nurse closely monitor this patient? a. Septic shock b. Neurogenic shock c. Cardiogenic shock d. Anaphylactic shock

a. Older adults with chronic diseases and malnourished or debilitated patients are at risk of developing septic shock, especially when they have an infection (e.g., pneumonia, urinary tract infection) or indwelling lines or catheters.

Appropriate treatment modalities for the management of cariogenic shock include (select all that apply): a. dobutamine to increase myocardial contractility b. vasopressors to increase systemic vascular resistance c. circulatory assist devices such as an intraortic balloon pump d. corticosteroids to stabilize the cell wall in the infarcted myocardium e. trendelenburg position to facilitate venous return and increased preload

a. dobutamine to increase myocardial contractility c. circulatory assist devices such as an intraortic balloon pump

A patient with severe trauma has been treated for hypovolemic shock. The nurse recognizes that the patient is in the irreversible stage of shock when what is included in assessment findings? a. A lactic acidosis with a pH of 7.32 b. Marked hypotension and refractory hypoxemia c. Unresponsiveness that responds only to painful stimuli d. Profound vasoconstriction with absent peripheral pulses

b. During both the compensatory and the progressive stages of shock, the sympathetic nervous system is activated in an attempt to maintain CO and SVR. In the irreversible stage of shock, the sympathetic nervous system can no longer compensate to maintain homeostasis and a loss of vasomotor tone leading to profound hypotension affects perfusion to all vital organs, causing increasing cellular hypoxia, metabolic acidosis, and cellular death.

Which hemodynamic monitoring description of the identified shock is accurate? a. Tachycardia with hypertension is characteristic of neurogenic shock. b. In cardiogenic shock the patient will have an increased pulmonary artery wedge pressure (PAWP) and a decreased cardiac output (CO). c. Anaphylactic shock is characterized by increased systemic vascular resistance (SVR), decreased CO, and decreased PAWP. d. In septic shock, bacterial endotoxins cause vascular changes that result in increased SVR and decreased CO.

b. Hemodynamic monitoring in cardiogenic shock will reveal increased pulmonary artery wedge pressure (PAWP) and decreased CO. The characteristic signs of neurogenic shock are bradycardia and hypotension. Septic shock manifests with decreased systemic vascular resistance (SVR) and increased CO. Hypovolemic shock is characterized by increased SVR, decreased CO, and decreased PAWP.

What abnormal finding should the nurse expect to find in early compensatory shock? a. Metabolic acidosis b. Increased serum sodium c. Decreased blood glucose d. Increased serum potassium

b. In early compensatory shock, activation of the renin- angiotensin-aldosterone system stimulates the release of aldosterone, which causes sodium reabsorption and potassium excretion by the kidney, elevating serum sodium levels and decreasing serum potassium levels. Blood glucose levels are elevated during the compensatory stage of shock in response to catecholamine stimulation of the liver, which releases its glycogen stores in the form of glucose. Metabolic acidosis does not occur until the progressive stage of shock. At this stage compensatory mechanisms become ineffective and anaerobic cellular metabolism causes lactic acid production.

When shock occurs in a patient with pulmonary embolism or abdominal compartment syndrome, what type of shock would that be? a. Distributive shock b. Obstructive shock c. Cardiogenic shock d. Hypovolemic shock

b. Obstructive shock occurs when a physical obstruction impedes the filling or outflow of blood, resulting in reduced cardiac output (CO).

The nurse determines that a large amount of crystalloid fluids administered to a patient in septic shock is effective when hemodynamic monitoring reveals what? a. CO of 2.6 L/min b. CVP of 15 mm Hg c. PAWP of 4 mm Hg d. Heart rate (HR) of 106 bpm

b. The endpoint of fluid resuscitation in septic and hypovolemic shock is a central venous pressure (CVP) of 15 mm Hg or a PAWP of 10-12mmHg. The CO is too low and the heart rate is too high to indicate adequate fluid replacement.

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

b. Thrombocytopenia can occur. When sepsis is the cause of shock, endotoxin stimulates a cascade of inflammatory responses that start with the release of tumor necrosis factor (TNF) and interleukin-1 (IL-1), which stimulate other inflammatory mediators. The release of platelet- activating factor causes formation of microthrombi and vessel obstruction. There is vasodilation, increased capillary permeability, and neutrophil and platelet aggregation and adhesion to the endothelium. The process does not occur in other types of shock until late stages of shock.

78 y.o man has confusion and temperature of 104. He's diabetic with purulent drainage from his right heel. After infusion of 3L of NS, his assessment findings are BP 84/40, HR 110, Res 42 and shallow, CO 8L/min and PAWP 4mm. Patient is most likely in: a. sepsis b. septic shock c. multiple organ dysfunction syndrome d. SIRS

b. septic shock

Priority Decision: What is the priority nursing responsibility in the prevention of shock? a. Frequently monitoring all patients' vital signs b. Using aseptic technique for all invasive procedures c. Being aware of the potential for shock in all patients at risk d. Teaching patients health promotion activities to prevent shock

c. Prevention of shock necessitates identification of persons who are at risk and a thorough baseline nursing assessment with frequent ongoing assessments to monitor and detect changes in patients at risk. Frequent monitoring of all patients' vital signs is not necessary. Aseptic technique for all invasive procedures should always be implemented but will not prevent all types of shock. Health promotion activities that reduce the risk for precipitating conditions, such as coronary artery disease or anaphylaxis, may help to prevent shock in some cases.

When administering any vasoactive drug during the treatment of shock, the nurse should know that what is the goal of the therapy? a. Increasing urine output to 50 mL/hr b. Constriction of vessels to maintain BP c. Maintaining a MAP of at least 60 mm Hg d. Dilating vessels to improve tissue perfusion

c. Vasoactive drugs are those that can either dilate or constrict blood vessels and are used in various stages of shock treatment. When using either vasodilators or vasoconstrictors, it is important to maintain a mean arterial pressure (MAP) of at least 60 mm Hg so that adequate perfusion is maintained. The other goals would be appropriate only with either vasodilators or vasoconstrictors, not with all vasoactive drugs.

What is the key factor in describing any type of shock? a. Hypoxemia b. Hypotension c. Vascular collapse d. Inadequate tissue perfusion

d. Although all of the factors may be present, regardless of the cause, the end result is inadequate supply of oxygen and nutrients to body cells from inadequate tissue perfusion.

As the body continues to try to compensate for hypovolemic shock, there is increased angiotensin II from the activation of the renin-angiotensin-aldosterone system. What physiologic change occurs related to the increased angiotensin II? a. Vasodilation b. Decreased blood pressure (BP) and CO c. Aldosterone release results in sodium and water excretion d. Antidiuretic hormone (ADH) release increases water reabsorpton

d. Angiotensin II vasoconstricts both arteries and veins, which increases blood pressure (BP). It stimulates aldosterone release from the adrenal cortex, which results in sodium and water reabsorption and potassium excretion by the kidneys. The increased sodium raises serum osmolality and stimulates the pituitary gland to release antidiuretic hormone (ADH), which increases water reabsorption, which further increases blood volume, leading to an increase in BP and CO.

During administration of IV norepinephrine (Levophed), what should the nurse assess the patient for? a. Hypotension b. Marked diuresis c. Metabolic alkalosis d. Decreased tissue perfusion

d. As a vasopressor, norepinephrine may cause severe vasoconstriction, which would further decrease tissue perfusion, especially if fluid replacement is inadequate. Vasopressors generally cause hypertension, reflex bradycardia, and decreased urine output because of decreased renal blood flow. They do not directly affect acid-base balance.

Progressive tissue hypoxia leading to anaerobic metabolism and metabolic acidosis is characteristic of the progressive stage of shock. What changes in the heart contribute to this increasing tissue hypoxia? a. Arterial constriction causes decreased perfusion. b. Vasoconstriction decreases blood flow to pulmonary capillaries. c. Increased capillary permeability and profound vasoconstriction cause increased hydrostatic pressure. d. Decreased perfusion occurs, leading to dysrhythmias, decreased CO, and decreased oxygen delivery to cells.

d. Decreased myocardial perfusion leads to dysrhythmias and myocardial ischemia, further decreasing CO and oxygen delivery to cells. The kidney's renin-angiotensin- aldosterone system activation causes arteriolar constriction that decreases perfusion. In the lung, vasoconstriction of arterioles decreases blood flow and a ventilation-perfusion mismatch occurs. Areas of the lung that are oxygenated are not perfused because of the decreased blood flow, resulting in hypoxemia and decreased oxygen for cells. Increased capillary permeability and vasoconstriction cause increased hydrostatic pressure that contributes to the fluid shifting to interstitial spaces.

Priority Decision: A patient with acute pancreatitis is experiencing hypovolemic shock. Which initial orders for the patient will the nurse implement first? a. Start 1000 mL of normal saline at 500 mL/hr. b. Obtain blood cultures before starting IV antibiotics. c. Draw blood for hematology and coagulation factors. d. Administer high-flow oxygen (100%) with a non-rebreather mask.

d. In every type of shock there is a deficiency of oxygen to the cells and high-flow oxygen therapy is indicated. Fluids would be started next, blood cultures would be done before any antibiotic therapy, and laboratory specimens then could be drawn

In late irreversible shock in a patient with massive thermal burns, what should the nurse expect the patient's laboratory results to reveal? a. Respiratory alkalosis b. Decreased potassium c. Increased blood glucose d. Increased ammonia (NH3) levels

d. In late irreversible shock, progressive cellular destruction causes changes in laboratory findings that indicate organ damage. Increasing ammonia levels indicate impaired liver function. Metabolic acidosis is usually severe as cells continue anaerobic metabolism and the respiratory alkalosis that may occur in the compensatory stage has failed to compensate for the acidosis. Potassium levels increase and blood glucose decreases.

Patient has a SCI at T4, vital signs include falling BP with bradycardia. Nurse recognizes the patient is experiencing: a. relative hypovolemia b. absolute hypovolemia c. neurogenic shock from low blood flow d. neurogenic shock from massive vasodilation

d. neurogenic shock from massive vasodilation