Chapter 42, Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Systemic Inflammatory Response Syndrome and Multiple Organ Dysfunction Syndrome

Which definition of systemic inflammatory response syndrome (SIRS) is accurate?

-A systemic response to a variety of insults

(R) SIRS is an inflammatory response syndrome that results from varies insults including infection, ischemia, infarction, and injury.

Which assessment finding is an early indicator of systemic inflammatory response syndrome (SIRS) or multiple organ dysfunction syndrome (MODS)?

-Lethargy

(R) Neurologic dysfunction can be an early indicator of SIRS or MODS and often presents as mental status changes and is related to hypoxemia and the effects of inflammatory mediators.

When caring for a patient with systemic inflammatory response syndrome (SIRS), the nurse would maintain a blood glucose level of mg/dL with a continuous insulin and glucose infusion.

-140-180

(R) Hypermetabolism processes trigger a cascade of events that can cause hyperglycemia and insulin resistance. The nurse should provide continuous medication to maintain an adequate range of blood glucose at 140-180 mg/dL (7.77-10.0 mmol/L).

For which reason would the nurse strive to provide optimal nutrition support when caring for a patient with systemic inflammatory response syndrome (SIRS)?

-Decreases morbidity

(R) Nutrition support should be initiated within 24 to 48 hours to preserve organ function. Providing early and optimal nutrition decreases both morbidity and mortality rates.

Which action would the nurse take first when admitting a patient with multiple organ dysfunction syndrome (MODS) who is in acute respiratory distress syndrome (ARDS)?

-Prepare for mechanical ventilation.

(R) The patient in ARDS requires aggressive oxygen therapy and mechanical ventilation. This is the priority intervention because the patient may suddenly lose their ability to breathe.

Which strategy would the nurse implement to decrease the risk for health care-associated infections (HAIs)?

-Follow infection control practices.

(R) Aggressive infection control strategies are essential for HAI risk reduction efforts. These efforts include pulmonary management, strict asepsis, and daily line necessity assessment.

Which information obtained by the nurse would suggest that a patient with cardiogenic shock is developing multiple organ dysfunction syndrome (MODS)?

-Serum creatinine level is elevated.

(R) A patient who may be developing MODS will present with renal impairment. This is manifested by an elevated serum creatinine.

Which organ system would the nurse expect to be among those affected first in a patient admitted with septic shock and multiple organ dysfunction syndrome (MODS)?

-Renal

-Respiratory

-Cardiovascular

Which intervention would the nurse anticipate when caring for a patient with systemic inflammatory response syndrome (SIRS) that is progressing to multiple organ dysfunction syndrome (MODS)?

-Enteral feedings

(R) Enteral feedings are important and should be anticipated by the nurse to provide the essential nutrients and calories being used and metabolized by the body of the patient experiencing SIRS.

-Infusion of glucose and insulin

(R) The nurse should anticipate the infusion of glucose and insulin when the patient is experiencing SIRS to maintain an adequate blood glucose level when the endocrine system is not able to adequately respond to the body's metabolic demands.

-Administration of loop diuretics

(R) The nurse should anticipate the need to administer loop diuretics to assist the kidneys in functioning and maintaining urine output when the patient is experiencing SIRS.

-Continuous electrocardiogram (ECG) monitoring

(R) Continuous ECG monitoring should be anticipated by the nurse and provided for the patient experiencing SIRS to monitor the condition of the heart. Invasive hemodynamic monitoring is also done to determine whether heart failure is occurring.

Which order would the nurse expect to assess early signs of a systemic infection when caring for a patient with an indwelling urinary catheter?

-Obtaining a urine culture

(R) A culture is ordered based on the potential etiology of the systemic infection. The patient has an indwelling urinary catheter, which is a potential source of infection. A urine culture should be ordered to determine whether the catheter is the cause of the infection.

-Drawing a blood culture

(R) The patient is suspected of having a systemic infection, which indicates that a blood infection is present. The blood will need to be cultured to determine whether a systemic infection is present, so this order should be anticipated by the nurse.

-Administering a broad-spectrum antibiotic

(R) A broad-spectrum antibiotic is ordered initially to treat a systemic infection and help to prevent sepsis from progressing to systemic inflammatory response syndrome or multiple organ dysfunction syndrome. The nurse should anticipate an order for a broad-spectrum antibiotic.

Which finding indicates a progression to severe renal dysfunction in a patient with shock that has progressed to systemic inflammatory response syndrome (SIRS)?

-Urine specific gravity of 1.032

(R) A urine specific gravity greater than 1.020 indicates renal hypoperfusion and a potential progression from SIRS to multiple organ dysfunction syndrome (MODS) because the kidneys are not able to concentrate the urine.

-Urine sodium level of 18 mEq/L

(R) A urine sodium level below 20 mEq/L indicates renal hypoperfusion and a potential progression from SIRS to MODS.

-Urine osmolality of 980 mOsm/kg

(R) Increased urine osmolality indicates renal hypoperfusion and a potential progression from SIRS to MODS.

Which concern would the nurse have when a patient in the intensive care unit (ICU) exhibits hypotension, tachycardia, tachypnea, hyperthermia, confusion, and drowsiness?

-Septic shock

(R) The low blood pressure, high heart rate, elevated respiratory rate, and elevated temperature along with the lack of orientation and drowsiness are consistent with the general clinical signs and hemodynamic variables associated with sepsis progressing to septic shock. Additional testing and assessment are indicated to determine the etiology of the infection.