pharm prepu 29: Drug Therapy for Shock and Hypotension
A client experiencing neurogenic shock is being treated with intravenous (IV) norepinephrine. To best educate the client and family about nursing care that is required during this treatment, the nurse will provide what information?
"Bedside cardiac monitoring is commonly ordered to monitor for cardiac arrhythmias" Explanation: For clients receiving an IV adrenergic drug to stimulate the heart or raise blood pressure, frequent cardiac monitoring is considered in order to adequately evaluate heart function. Tachycardia is an adverse reaction to the medication and should be reported to the health care provider so that dosage can be reevaluated and necessary changes made. Neither vomiting nor a rash is associated with adverse effects of adrenergic drug therapies.
Which would the nurse expect to be prescribed to a client experiencing acute bronchospasm?
Epinephrine Explanation: Epinephrine would be used to treat bronchospasm. Dopamine is indicated for the treatment of congestive heart failure. Metaraminol is used to treat shock if norepinephrine or dopamine cannot be used. Norepinephrine is used to treat shock and during cardiac arrest to promote sympathetic activity.
Which adrenergic receptor is responsible for vasodilation of peripheral vessels and bronchodilation?
β2 receptors Explanation: Vasodilation of peripheral vessels and bronchodilation are the result of stimulation of β2 receptors.
A 4-year-old is admitted to the Emergency Department in shock after a motor vehicle accident. The patient is found to be 12.5 kilograms. What would be the minimum safe dose of adrenalin if the pediatric dose is 0.005-0.01 mg/kg IV?
0.0625 mg Explanation: Epinephrine (Adrenalin, Sus-Phrine); Pediatric: 0.005-0.01 mg/kg IV, base dose on age, weight, and response; Used for treatment of shock when increased blood pressure and heart contractility are essential; to prolong effects of regional anesthetic; primary treatment for bronchospasm; as an ophthalmic agent; and to produce a local vasoconstriction that prolongs the effects of local anesthetics. Options B, C, and D are the wrong minimum dosages.
A nurse is monitoring a client receiving IV dobutamine. Which assessment finding should the nurse prioritize?
: Cardiac arrhythmias Explanation: The nurse should monitor for cardiac arrhythmias (bradycardia and tachycardia) because they are common adverse reactions observed in clients receiving dobutamine. Dobutamine does not cause urinary retention, elevated temperature, or sleeplessness. Droxidopa can cause urinary retention. Sulfonamides may cause elevated temperatures. Cholinesterase inhibitors may cause sleeplessness.
Which patient should be advised by the nurse to avoid over-the-counter cold and allergy preparations that contain phenylephrine?
A 47-year-old female with hypertension Explanation: Phenylephrine is an alpha-1 adrenergic agonist and a drug commonly used topically for relief of nasal and nasopharyngeal mucosal congestion and to produce mydriasis for ophthalmologic procedures. Phenylephrine acts as a vasopressor causing vasoconstriction of the arterioles. The vasoconstriction from phenylephrine use can increase peripheral resistance and blood pressure.
A client presents to the emergency department reporting the heart fluttering and feeling anxious. After administering isoproterenol, the nurse monitors the client for which potential result? Select all that apply. Increased use of glucose Decreased gastric motility Wakefulness
A client presents to the emergency department reporting the heart fluttering and feeling anxious. After administering isoproterenol, the nurse monitors the client for which potential result? Select all that apply. Increased use of glucose Decreased gastric motility Wakefulness Explanation: Isoproterenol will most likely cause increased (not decreased) heart rate, increased use of glucose, decreased gastric motility, dilation (not constriction) of coronary blood vessels, and wakefulness.
Clinical indications for the use of adrenergic drugs stem mainly from their effects on the heart, blood vessels, and bronchi. They are often used as emergency drugs. For which of the following conditions would these drugs be used? Choose all that apply. Acute cardiovascular disorders Respiratory conditions Allergic disorders
Acute cardiovascular disorders Respiratory conditions Allergic disorders Explanation: Clinical indications for the use of adrenergic drugs stem mainly from their effects on the heart, blood vessels, and bronchi. They are often used as emergency drugs in the treatment of acute cardiovascular, respiratory, and allergic disorders.
Clinical indications for the use of adrenergic drugs stem mainly from their effects on the heart, blood vessels, and bronchi. They are often used as emergency drugs. For which of the following conditions would these drugs be used? Choose all that apply. Acute cardiovascular disorders Respiratory conditions Allergic disorders
Acute cardiovascular disorders Respiratory conditions Allergic disorders Clinical indications for the use of adrenergic drugs stem mainly from their effects on the heart, blood vessels, and bronchi. They are often used as emergency drugs in the treatment of acute cardiovascular, respiratory, and allergic disorders.
The nursing instructor has completed teaching a group of students about the adrenergic nervous system. The instructor determines the class is successful when the students correctly choose which types of receptors are utilized by this system? Select all that apply. Alpha Beta
Alpha Beta Alpha and beta receptors are the two types of adrenergic nervous system receptors. Delta receptors are involved with pain perception. Gamma interferon receptors are involved with genetic coding. There are no omega receptors.
Which condition is treated with an adrenergic agonist?
Anaphylaxis Explanation: Epinephrine, a prototype adrenergic agonist, is used to relieve the acute bronchospasm and laryngeal edema of anaphylactic shock. Since adrenergic agonists act as cardiac stimulants, some versions may be used to treat severe bradycardia or hypotension.
A client receives a beta-specific agonist. What would lead the nurse to determine that the drug is effective?
Bronchodilation Explanation: A beta-specific agonist would lead to bronchodilation. A beta-specific agonist would cause an increased heart rate. Tremor is an adverse effect of a beta-specific agonist. A beta-specific agonist would increase cardiac conductivity.
An understanding of the pathophysiologic rationale behind shock is something every nurse needs to have. Which of the following statements best describes the pathophysiology for shock?
Cells lack an adequate blood supply and are deprived of oxygen and nutrients Explanation: Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells have a lack of adequate blood supply and are deprived of oxygen and nutrients. Option A is incorrect; blood is shunted from peripheral areas of the body to the vital organs. Options C and D can be true statements, depending on the type of shock, but they are not the best answers to describe the pathophysiologic rationale for shock
A client presents to the emergency department following a traffic accident. The nurse prepares to administer an adrenergic agent after assessing for signs of shock which includes which finding?
Changes in consciousness Explanation: Symptoms of shock, such as a change in the level of consciousness, should be recorded by the nurse as part of the preadministration assessment. Cool skin, not elevated temperature, is another symptom of shock. The nurse also needs to record signs of diaphoresis and cyanosis, not reddish/pinkish or dry, dehydrated skin.
You are caring for a patient in hypovolemic shock. What is a priority nursing action for this client?
Check blood pressure and pulse. Explanation: Hypotension and abnormal heart rate are common in patients suffering from shock. Blood pressure and pulse should be monitored continuously or at least every 5 to 15 minutes during acute shock and titration of vasopressor drug therapy. Other hemodynamic indices should be checked hourly.
You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock?
Distributive Explanation: Three types of distributive shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.
Which would the nurse identify as a naturally occurring catecholamine?
Dopamine Explanation: Dopamine is a naturally occurring catecholamine. Dobutamine, ephedrine, and metaraminol are synthetic catecholamines.
An instructor is preparing a teaching plan for a group of students about adrenergic agonists. Which would the nurse include as an alpha- and beta-adrenergic agonist?
Epinephrine Explanation: Epinephrine is an alpha- and beta-adrenergic agonist. Phenylephrine is an alpha-specific adrenergic agonist. Albuterol is a beta-specific adrenergic agonist. Terbutaline is a beta-specific adrenergic agonist.
You are caring for a patient in the ICU whose condition is deteriorating. You receive orders for dopamine, which is an intravenous vasoactive drug. What would be your priority assessment and interventions specific to the administration of vasoactive medications?
Frequent vitals, monitoring the central line site, and providing accurate drug titration Explanation: When vasoactive medications are administered, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated). Vasoactive medications should be administered through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An intravenous pump should be used to ensure that the medications are delivered safely and accurately. Individual medication dosages are usually titrated by the nurse, who adjusts drip rates based on the prescribed dose and the patient's response.
A nursing instructor has finished teaching a group of nursing students the basic functions of the autonomic nervous system (ANS). The instructor determines the teaching is successful when the students correctly choose which functions as controlled by the ANS? Select all that apply. Heart rate Muscle movement Blood pressure Glandular secretions GI activity em.
Heart rate Blood pressure Glandular secretions GI activity The ANS division of the peripheral nervous system is concerned with functions essential to life and not consciously controlled, such as blood pressure, heart rate, GI activity, and glandular secretions. Muscle movement is controlled by conscious control. It is related to various substances in the central nervous system.
A client with significant burns develops shock and requires adrenergic drug therapy. The nurse interprets this as which type of shock?
Hypovolemic Explanation: Burns result in massive fluid losses, leading to hypovolemic shock. Cardiogenic-obstructive shock occurs when cardiac output is insufficient and perfusion to the vital organs cannot be maintained. Septic shock results from an overwhelming infection. Neurogenic shock occurs when there is an interference with the peripheral nervous system control of blood vessels such as with spinal cord injury.
A client presents to the ED status post-motor vehicle accident with hypotension, tachycardia, diaphoresis, pallor, and oliguria. Reports from the accident site indicate significant blood loss from the vehicle's only occupant. What type of shock does the nurse suspect is the client demonstrating?
Hypovolemic Explanation: Clinical manifestations of hypovolemic shock include hypotension, tachycardia, diaphoresis, pallor, and oliguria.
After teaching a group of nursing students about adrenergic drugs and their effects, the instructor determines that the teaching was successful when the students correctly choose which as an effect of these drugs?
Increased cardiac output Explanation: Adrenergic drugs improve hemodynamic status by improving myocardial contractility and increasing heart rate, which results in increased cardiac output. Peripheral resistance is increased by vasoconstriction. The drugs do not improve airway clearance.
A nursing instructor has led a discussion on the effects of adrenergic drugs on the body. The instructor determines the session is successful when the students correctly choose which as the effect of beta-1 receptor stimulation?
Increased force of myocardial contractions Explanation: Stimulation of beta-1 receptors leads to an increase in heart rate and an increase in the force of myocardial contraction. Peripheral vasoconstriction occurs when alpha-1 receptors are stimulated. Decreased gastrointestinal motility and secretions occur when alpha-2 receptors are stimulated. Bronchodilation occurs when beta-2 receptors are stimulated.
When preparing a plan of care for a client in hypovolemic shock, which partial nursing diagnosis might be relevant to the patient's condition?
Ineffective Tissue Perfusion Explanation: Hypovolemic shock is caused by the loss of intravascular fluids, including blood. Therefore, of the four options, the only choice relevant to hypovolemic shock is Ineffective Tissue Perfusion.
The nurse notes that a client is prescribed midodrine. Which action should the nurse take before giving the client this medication?
Measure orthostatic blood pressure. Explanation: Midodrine is an alpha-1 adrenergic agent used to treat orthostatic hypotension in clients who do not respond to traditional therapy. It causes peripheral vasoconstriction and increases vascular tone and blood pressure. Because of this, the client can develop supine hypertension. The client needs to have blood pressure monitored in the standing, sitting, and supine positions to determine if this will be a problem for the client. A cardiac monitor is not indicated for this medication. Oxygen is not indicated for this medication. The client does not need to empty the bladder before receiving a dose of this medication.
A nurse is caring for a client after an acute myocardial infarction. Which sign or symptom should the nurse prioritize for immediate treatment if noted on assessment? Select all that apply. Hypertension Oliguria Hypoxia Tachypnea Bradycardia
Oliguria Hypoxia Tachypnea Explanation: Signs and symptoms of shock include cold and clammy skin, sweating, hypotension (not hypertension), tachycardia (not bradycardia), hypoxia, tachypnea, and decreased urinary output.
The nurse is reviewing the medical record of a client who is receiving adrenergic drug therapy to treat hypovolemic shock. Which nursing diagnosis would the nurse be least likely to note?
Risk for Allergy Response Explanation: Risk for Allergy Response would be appropriate for a client experiencing an allergic reaction or anaphylactic shock, not hypovolemic shock. Hypovolemic shock can have decreased cardiac output due to low volume, ineffective tissue perfusion due to the body shunting what volume it has to major organs, and a disturbed sleep pattern due to confusion and altered mental state.
The nurse anticipates that the immunosuppressed patient is at greatest risk for which type of shock?
Septic Explanation: Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures. Neurogenic shock is associated with spinal cord injury and anesthesia. Cardiogenic shock is associated with disease of the heart. Anaphylactic shock is associated with hypersensitivity reactions.
A nurse is monitoring the vital signs of a client who has received epinephrine. The nurse would report which assessment findings?
Systolic blood pressure below 100 mm Hg Explanation: The nurse must immediately report a fall in systolic blood pressure below 100 mm Hg. Epinephrine should raise the blood pressure, so a continued low systolic pressure indicates the medication has not been effective. A diastolic blood pressure of 75 mm Hg, a pulse rate of 60 beats/min, and a temperature reading of 97.6°F are normal and need not be reported immediately.
A nurse is monitoring the vital signs of a patient who has been administered epinephrine. Which of the readings should nurse report immediately to the primary health care provider?
Systolic blood pressure below 100 mm Hg Explanation: The nurse must immediately report to the health care provider a fall in systolic blood pressure below 100 mm Hg. Epinephrine should raise the blood pressure, so a continued low systolic pressure indicates the medication has not been effective. A diastolic blood pressure of 75 mm Hg, a pulse rate of 60 beats per minute, and a temperature reading of 97.6°F are normal and need not be reported immediately.
You are caring for an 88-year-old client who was admitted to the ICU. The patient is suspected of being in cardiogenic shock. Which of the following observations could indicate that the patient is in shock?
Systolic blood pressure of 80 mm Hg Explanation: When monitoring patients for signs of shock, the nurse should check blood pressure, skin temperature, urine output, heart rate, orientation, and respiration. Patients in shock may exhibit a significant decrease in blood pressure (e.g., systolic blood pressure < 90 mm Hg), tachycardia, decreased respiratory rate and urine output (e.g., < 30 mL/hr), disorientation, and cold, clammy skin.
A client is being treated for septic shock. Which assessment result best indicates that adequate tissue perfusion has been restored?
The arterial blood pressure is 90 mm Hg. Explanation: In the case of shock, various strategies are implemented to improve and maintain tissue perfusion of the vital organs. The usual goal is to maintain tissue perfusion evidenced by an arterial pressure of at least 80 to 100 mm Hg. The other assessment values are reliant upon effective tissue perfusion
When caring for a client in shock, one of the major nursing goals is to reduce the risk that the client will develop complications. What does this require the nurse to do?
Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment and response Explanation: Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the patient with the best chance for recovery. An accurate diagnosis is not as important as understanding the underlying mechanisms of shock. Keeping the health care provider updated with the most accurate information is important, but the nurse is in the best position to provide rapid assessment and response, which gives the client the best chance for survival. Monitoring for significant changes is critical, and evaluating client outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs such as blood pressure and skin temperature.
A nurse is preparing to administer an adrenergic agent for shock. Which nursing assessment should be completed with priority?
Vital signs Explanation: When a client is to receive an adrenergic agent for shock, obtain the blood pressure, pulse rate and quality, and respiratory rate and rhythm. Urinary output, pain, and the physical assessment are not a priority in shock.
An 80-year-old patient in the emergency department is receiving dopamine for treatment of shock. Which of the following adverse effects could the patient experience?
arrhythmia Explanation: Serious arrhythmias (e.g., tachyarrhythmia) may occur with any of the vasoactive agents used for treatment of shock and hypotension. Other adverse effects of dopamine include tachycardia, hypotension, and angina.
Epinephrine is the drug of choice for treatment of anaphylactic shock. Epinephrine acts by stimulating
beta receptors. Explanation: At low doses, epinephrine stimulates beta receptors, which results in bronchodilation and increased cardiac output. At higher doses, the drug stimulates alpha receptors, which increases blood pressure.
Epinephrine typically demonstrates the potential to promote relaxation of muscles in what structure?
bronchiole Explanation: Epinephrine is the adrenergic drug of choice for relieving the acute bronchospasm and laryngeal edema of anaphylactic shock. The medication has no effect on the muscles suggested by the other options.
An 80-year-old client has been brought to the emergency department in shock. The client is receiving dopamine. The nurse should prioritize the assessment for what potentially serious adverse effect?
cardiac arrhythmia Explanation: Dopamine therapy can result in cardiac arrhythmias, which can be life threatening. Older clients are more likely to experience the adverse effects associated with adrenergic agonists and should be started on lower doses and monitored closely for arrhythmias and blood pressure changes. Blood dyscrasias, hepatic toxicity, and renal insufficiency are not commonly associated with dopamine use. In fact, at lower doses, dopamine increases renal perfusion.
The client admitted to the emergency department with shock has been prescribed norepinephrine. The client consumed multiple high-energy beverages prior to the onset of symptoms. What finding should the nurse be most alert for?
exaggerated increase in heart rate and blood pressure Explanation: Caffeine-containing substances cause an increased heart rate and blood pressure when combined with norepinephrine. Caffeine intake does not preclude the use of norepinephrine, however, and does not create an increased risk for vascular collapse.
You are assessing your patient. When prioritizing the patient's care, you recognize that your patient is at risk for hypovolemic shock when
fluid 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.
A client has been admitted to the emergency department with signs and symptoms of shock and the client's hypotension has not responded adequately to fluid volume replacement. The nurse will prepare to administer:
norepinephrine. Explanation: Norepinephrine is used to treat severe hypotension and shock that persists after adequate fluid volume replacement. The other listed medications are normally administered to treat heart failure.
The nurse is reviewing information collected from the parent of a pediatric client who uses the adrenergic drug albuterol inhaler as prescribed for asthma. Which information would the nurse suspect caused the client to have the extreme reaction to the adrenergic drug?
received an over-the-counter (OTC) cold remedy Explanation: Children are at risk for complications associated with the use of adrenergic agonists, including tachycardia, hypertension, tachypnea, and gastrointestinal (GI) complications. Because phenylephrine is often found in over-the-counter (OTC) allergy and cold preparations, parents need to be instructed to be careful with the use of these drugs. Parents should check the labels for ingredients, monitor the recommended dose, and avoid combining drugs that contain similar ingredients. The client's symptoms are not caused by the acetaminophen, participating in physical education class, or using the albuterol inhaler in the morning. Vomiting, a fast heartbeat, deep respirations, and muscle cramps are all adverse effects of an adrenergic drug.
Your 69-year-old patient is started on IV dopamine for management of hypotension following open-heart surgery. As you care for the patient, you monitor him for adverse effects of the drug, including
tachycardia. Explanation: Potential adverse effects of dopamine include tachycardia, arrhythmia, and angina.