Unit 1 (sem 4) Shock
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock?
Apical heart rate 48 BPM Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.
The health care provider prescribes these actions for a patient who has possible septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the nurse implement the actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain blood and urine cultures. b. Give vancomycin (Vancocin) 1 g IV. c. Infuse vasopressin (Pitressin) 0.01 units/min. d. Administer normal saline 1000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation >95%.
ANS: E, D, C, A, B The initial action for this hypotensive and hypoxemic patient should be to improve the oxygen saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before administration of antibiotics.
A patient with neurogenic shock has just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which of the following actions should the nurse take (select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Prepare for intubation and mechanical ventilation. d. Administer large volumes of lactated Ringer's solution. e. Administer high-flow oxygen (100%) by non-rebreather mask.
ANS: A, B, C, E All of the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate.
Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? a. Use aseptic technique when caring for invasive lines or devices. b. Ambulate postoperative patients as soon as possible after surgery. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Advocate for parenteral nutrition for patients who cannot take oral feedings. e. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.
ANS: A, B, C, E Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be administered within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.
A patient who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of these prescribed interventions should the nurse implement first?
Administer oxygen at 100% per non-rebreather mask. The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions also should be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented.
A patient with cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. The PAWP is increased and cardiac output is low. The nurse will anticipate
Administration of furosemide (Lasix) IV The PAWP indicates that the patient's preload is elevated and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial oxygen demand. Normal saline infusion would increase the PAWP further. Hydrocortisone might be used for septic or anaphylactic shock.
When the nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock, which finding indicates that the medication is effective?
Skin is warm, pink, and dry Warm, pink, and dry skin indicates that perfusion to tissues is improved.
When the charge nurse is evaluating the skills of a new RN, which action by the new RN indicates a need for more education in the care of patients with shock?
Decreasing the room temperature to 68° F for a patient with neurogenic shock Patients with neurogenic shock may have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.
Cardiogenic Shock medications
Diuretics to help eliminate fluid Vasopressors ——> vasoconstriction (norepinephrine): increase preload, BP, CO, SV Dobutamine —> vasodilation, watch out for worsening hypotension Dopamine: increase contractions, SV (can cause tachycardia) Vasodilator —> decrease after load, dilates coronary arteries: nitroglycerin/nitroprusside (hypotension issue)
Septic Shock S+S
Early = warm (compensation) vasodilation: low BP & high HR, RR, temp, CO, restless, anxiety Late - cold (uncompensated) vasoconstriction: cold/clammy skin, severe hypotension, increased HR & RR, oliguria, coma, hypothermia, low CO
Septic Shock interventions
Start antibiotics within 1st hour BUT collect cultures first External Nutrition Titrate vasopressors (norepinephrine): use when fluid replacement is unsuccessful —> causes vasoconstriction & increase SVR Dobutamine: helps increase heart contraction Crystalloids Hemodynamic monitoring: CVP (filling in right side) PAWP (filling in the left side) Oxygen > 95% Prevent hyperglycemia < 180 mg/dL Monitor serum lactate levels Monitor UOP (foley insertion)
The following therapies are prescribed by the health care provider for a patient who has respiratory distress and syncope after a bee sting. Which will the nurse administer first?
Epinephrine = Epi pen Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions also are appropriate but would not be the first ones administered.
A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low. Which of these orders by the health care provider will the nurse question?
Give furosemide (Lasix) 40 mg IV. Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.
A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104° F, and blood glucose 246 mg/dL. Which of these prescribed interventions will the nurse implement first?
Give normal saline IV at 500 mL/hr. Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate and should be initiated quickly as well.
Neurogenic S+S
Hypotension Bradycardia Hypothermia Warm/dry extremities PAWP decreased
A patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which action will the nurse anticipate taking?
Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion. Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5W and nitroglycerin infusions will not directly increase SVR. Increasing the dopamine will tend to increase SVR.
A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question?
Infuse normal saline at 250 mL/hr The patient's elevated pulmonary artery wedge pressure indicates volume excess. A normal saline infusion at 250 mL/hr will exacerbate this. The other actions are appropriate for the patient.
Neurogenic shock interventions
Manage ABCS - airway, breathing, circulation, spine Protect spine - immobilize it with cervical collar, log-rolling, backboard Assess/manage airway; intubation or mech ventilation if respiratory failure present Maintain perfusion: MAP (85-90 mmHg) IV fluids —> crytalloids: use with caution (watch for fluid volume overload) Vasopressors —> vasoconstriction (Dopamine) use when fluids are not working Bradycardia —> use Atropine (increases HR) Foley Prevent DVT
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?
Monitor breath sounds frequently Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently.
To evaluate the effectiveness of the omeprazole (Prilosec) being administered to a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse make?
Monitor stools for occult blood Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the omeprazole administration.
During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which finding is most important for the nurse to report to the health care provider?
New onset of confusion and agitation The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.
After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of
Norepinephrine (Levophed) When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Drotrecogin alpha may decrease inappropriate inflammation and help prevent systemic inflammatory response syndrome, but it will not directly improve blood pressure. Nitroprusside is an arterial vasodilator and would further decrease SVR.
Which assessment is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective?
Oxygen saturation Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments also will be expected with effective treatment of anaphylactic shock.
When the nurse is caring for a patient in cardiogenic shock who is receiving dobutamine (Dobutrex) and nitroglycerin (Tridil) infusions, the best evidence that the medications are effective is that the
PAWP drops to normal range. Rationale: Because PAWP is increased in cardiogenic shock as a result of the increase in volume and pressure in the left ventricle, normalization of PAWP is the best indicator of patient improvement. The changes in BP and heart rate could occur with dobutamine infusion even if patient tissue perfusion was not improved. Troponin and creatine kinase (CK) levels are indicators of cardiac cellular death and are not used as indicators of improved tissue perfusion.
After change-of-shift report in the progressive care unit, who should the nurse care for first?
Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics Antibiotics should be administered within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome (SIRS) and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not require immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually require atropine in patients who have a spinal cord injury. The findings for the patient admitted with anaphylaxis indicate resolution of bronchospasm and hypotension.
A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)?
Place the patient in a private room. Rationale: The patient who has received chemotherapy is immune compromised, and placing the patient in a private room will decrease the exposure to other patients and reduce infection/sepsis risk. Administration of medications through the central line increases the risk for infection and sepsis. There is no indication that the patient is neutropenic, and restricting the patient to cooked and processed foods is likely to decrease oral intake further and cause further malnutrition, a risk factor for sepsis and shock. Insertion of an NG tube is invasive and will not decrease the patient's nausea and vomiting.
After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider?
Platelet count and presence of petechiae The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome (MODS) is developing. The other information will also be discussed with the health care provider but does not indicate that the patient's condition is deteriorating or that a change in therapy is needed immediately.
When caring for a patient who has septic shock, which assessment finding is most important for the nurse to report to the health care provider?
Skin cool & clammy Since patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing.
A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory stage of shock?
The cardiac output is elevated. Rationale: In the early stages of septic shock, the cardiac output is high. The other hemodynamic changes would indicate that the patient had developed progressive or refractory septic shock.
The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy?
The patient has a temperature of 94.1° F. Rationale: Hypothermia is an indication that the patient is in the progressive stage of shock. The other data are consistent with compensated shock.
When caring for a patient with cardiogenic shock and possible MODS, which information obtained by the nurse will help confirm the diagnosis of MODS?
The patient has an elevated ammonia level and confusion. Rationale: The elevated ammonia level and confusion suggest liver failure in addition to the cardiac failure. The crackles, chest pain, and cool extremities are all consistent with cardiogenic shock and do not indicate that there are failures in other major organ systems.
Which information about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the heath care provider?
The patient is complaining of chest pain. Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient's diagnosis and should be reported to the health care provider but does not indicate a need for a change in therapy.
The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a left forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action?
The patient's IV infusion site is cool and pale.
Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient information indicates that the nurse should consult with the health care provider before administration of the norepinephrine?
The patient's central venous pressure is 3 mm Hg. Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.
Which information obtained by the nurse when caring for a patient who has cardiogenic shock indicates that the patient may be developing multiple organ dysfunction syndrome (MODS)?
The patient's serum creatinine level is elevated.
The emergency department (ED) receives notification that a patient who has just been in an automobile accident is being transported to your facility with anticipated arrival in 1 minute. In preparation for the patient's arrival, the nurse will obtain
Two 14-gauge IV catheters A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Although colloids may sometimes be used for volume expansion, crystalloids should be used as the initial therapy for fluid resuscitation. Vasopressor infusion is not used as the initial therapy for hypovolemic shock.
When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse?
Urine output 15 ml for 2 hours The best data for assessing the adequacy of cardiac output are those that provide information about end-organ perfusion such as urine output by the kidneys. The low urine output is an indicator that renal tissue perfusion is inadequate and the patient is in the progressive stage of shock. The low BP, increase in pulse, and low-normal O2 saturation are more typical of compensated septic shock.
Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful?
Urine output is 60 ml over the last hour Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful.
While assessing a patient in shock who has an arterial line in place, the nurse notes a drop in the systolic BP from 92 mm Hg to 76 mm Hg when the head of the patient's bed is elevated to 75 degrees. This finding indicates a need for
additional fluid replacement. Rationale: A postural drop in BP is an indication of volume depletion and suggests the need for additional fluid infusions. There are no data to suggest that antibiotics, sympathomimetics, or additional oxygen are needed.
A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to
administer oxygen The initial actions of the nurse are focused on the ABCs—airway, breathing, circulation—and administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration.
When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the nurse will anticipate administration of large volumes of crystalloids when the
cardiac output is increased and the central venous pressure (CVP) is low. Rationale: A high cardiac output and low CVP suggest septic shock, and massive fluid replacement is indicated. Increased PAWP indicates that the patient has excessive fluid volume (and suggests cardiogenic shock), and diuresis is indicated. Bradycardia and a low systemic vascular resistance (SVR) suggest neurogenic shock, and fluids should be infused cautiously.
An assessment finding indicating to the nurse that a 70-kg patient in septic shock is progressing to MODS includes
fixed urine specific gravity at 1.010. Rationale: A fixed urine specific gravity points to an inability of the kidney to concentrate urine caused by acute tubular necrosis. With MODS, the patient's respiratory rate would initially increase. The MAP of 55 shows continued shock, but not necessarily progression to MODS. A 360-ml urine output over 8 hours indicates adequate renal perfusion.
To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for the nurse to make are
lung sounds and oxygenation status Rationale: The respiratory system is usually the system to show the signs of MODS because of the direct effect of inflammatory mediators on the pulmonary system. The other assessment data are also important to collect, but they will not indicate the development of MODS as early.
Norepinephrine (Levophed) has been ordered for the patient in hypovolemic shock. Before administering the drug, the nurse ensures that the
patient has received adequate fluid replacement. Rationale: If vasoconstrictors are given in a hypovolemic patient, the peripheral vasoconstriction will further decrease tissue perfusion. A patient with hypovolemia is likely to have a heart rate greater than 100 and a low urine output, so these values are not contraindications to vasoconstrictor therapy. Patients may receive other sympathomimetic drugs concurrently with Levophed.
The best nursing intervention for a patient in shock who has a nursing diagnosis of fear related to perceived threat of death is to
place the patient's call bell where it can be easily reached. Rationale: The patient who is fearful should feel that the nurse is immediately available if needed. Pastoral care staff should be asked to visit only after checking with the patient to determine whether this is desired. Providing time for family to spend with the patient is appropriate, but patients and family should not feel that the nurse is unavailable. Sedative administration is helpful but does not as directly address the patient's anxiety about dying.
A diabetic patient who has had vomiting and diarrhea for the past 3 days is admitted to the hospital with a blood glucose of 748 mg/ml (41.5 mmol/L) and a urinary output of 120 ml in the first hour. The vital signs are blood pressure (BP) 72/62; pulse 128, irregular and thready; respirations 38; and temperature 97° F (36.1° C). The patient is disoriented and lethargic with cold, clammy skin and cyanosis in the hands and feet. The nurse recognizes that the patient is experiencing the
progressive stage of hypovolemic shock. Rationale: The patient's history of hyperglycemia (and the associated polyuria), vomiting, and diarrhea is consistent with hypovolemia, and the symptoms are most consistent with the progressive stage of shock. The patient's temperature of 97° F is inconsistent with septic shock. The history is inconsistent with a diagnosis of cardiogenic shock, and the patient's neurologic status is not consistent with refractory shock.
A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is
release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. Rationale: The release of aldosterone and ADH lead to the decrease in urine output by increasing the reabsorption of sodium and water in the renal tubules. SNS stimulation leads to renal artery vasoconstriction. β-Receptor stimulation does increase cardiac output, but this would improve urine output. During shock, fluid leaks from the intravascular space into the interstitial space.
While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding
restlessness and apprehension. Restlessness and apprehension are typical during the compensatory stage of shock. Cold, mottled extremities, cool and clammy skin, and a systolic BP less than 90 are associated with the progressive and refractory stages.
Rationale: The patient who is fearful should feel that the nurse is immediately available if needed. Pastoral care staff should be asked to visit only after checking with the patient to determine whether this is desired. Providing time for family to spend with the patient is appropriate, but patients and family should not feel that the nurse is unavailable. Sedative administration is helpful but does not as directly address the patient's anxiety about dying.
urine output of 0.5 ml/kg/hr. Rationale: A urine output of 0.5 ml/kg/hr indicates adequate renal perfusion, which is a good indicator of cardiac output. The patient may continue to have peripheral edema because fluid infusions may be needed despite third-spacing of fluids in relative hypovolemia. Decreased central venous pressure (CVP) for a patient with relative hypovolemia indicates that additional fluid infusion is necessary. An oxygen saturation of 90% will not necessarily indicate that cardiac output has improved.
