Chapter 26

A nurse is discussing the concept of shock with a new graduate nurse. Which statement indicates the new graduate nurse understood the information?

A. Shock is a physiologic state resulting in hypotension and tachycardia.

B. Shock is an acute wide spread process of inadequate tissue perfusion.

C. Shock is a degenerative condition leading to organ failure and death.

D. Shock is a condition occurring with hypovolemia that results in hypotension.

B. Shock is an acute wide spread process of inadequate tissue perfusion.

Shock is a complex pathophysiologic process that often results in MODs and death. All types of shock eventually result in ineffective tissue perfusion and the development of acute circulatory failure.

The nurse is caring for a patient in hypovolemic shock secondary to cirrhosis of the liver. The nurse understands that this type of shock results from shifting of fluid into the abdominal cavity. What is the resulting hypovolemia called?

A. Absolute hypovolemia

B. Distributive hypovolemia

C. Relative hypovolemia

D. Compensatory hypovolemia

A. Absolute hypovolemia

Absolute Hypovolemia:

A loss of fluid from the intravascular space

Relative Hypovolemia: Vasodilation occurs to increase vascular capacity

Distributive Hypovolemia:

Maldistribution of circulating blood volume. Three types

1. Septic: microorganisms entering the body

2. Anaphylactic: severe antibody-antigen reaction

3. Neurogenic: loss of sympathetic tone

A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid?

A. Inserting a large-diameter peripheral intravenous catheter.

B. Positioning the patient in the Trendelenburg position.

C. Encouraging the patient to drink at least 240mL of fluid each hour.

D. Administering intravenous fluid under pressure with a pressure bag.

A. Inserting a large-diameter peripheral intravenous catheter.

To initiate volume replacement. to minimize fluid loss.

Measures to facilitate the administration of volume replacement include insertion of large-bore peripheral intravenous catheters; rapid administration of prescribed fluids; and positioning the patient with the legs elevated, trunk flat, and head + shoulders above chest.

The nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient's signs and symptoms are the result of what problem?

A. Inability of the heart to pump blood forward.

B. Loss of circulating volume and subsequent decreased venous return.

C. Disruption of the conduction system when reentry phenomenon occurs.

D. Suppression of the sympathetic nervous system.

A. Inability of the heart to pump blood forward.

Heart Failure -> ineffectively pumping blood -> low cardiac output -> low tissue perfusion and circulatory failure

Cardiogenic shock is the result of failure of the heart to effectively pump blood forward. It can occur with dysfunction of the right or the left ventricle or both. The lack of adequate pumping function leads to decreased tissue perfusion and circulatory failure.

The nurse is caring for a patient in cardiogenic shock. Which hemodynamic parameters would the nurse expect to find to support this diagnosis?

A. Increased right atrial pressure.

B. Decreased pulmonary artery wedge pressure.

C. Increase cardiac output

D. Decreased Cardiac Index

D. Decreased cardiac index

Cardiac index is a hemodynamic parameter that relates to the cardiac output from the left ventricle in 1 minute to body surface area.

Assessment of the hemodynamic parameter of patients in cardiogenic shock reveals a decreased cardiac output and cardiac index less than 2.2 L/min/m2

A patient has been admitted in anaphylactic shock due to an unknown allergen. The nurse understand that the patient is probably having an immunoglobulin E mediated response as a result of what physiologic mechanism?

A. Direct activation of mast cells and basophils

B. Nonimmunologic stimulation of biochemical mediators.

C. Repeat exposure to an antigen in the presence of preformed IgE antibodies.

D. Activation of the systemic inflammatory response.

C. Repeat exposure to an antigen in the presence of preformed IgE antibodies.

Nonimmunologic stimulation of biochemical mediators. Hypersensitivity Reaction

Nonimmunologic activation of mast cells and basophils. Biochemical mediators: Histamine, protaglasdins, cytokines, etc.

A patient has been admitted in anaphylactic shock due to an unknown allergen. The nurse understand that the decrease in the patient's cardiac output is the result of which mechanism?

A. Peripheral vasodilation

B. Increased venous return

C. Increased alveolar ventilation

D. Decreased myocardial contractility

A. Peripheral vasodilation

Peripheral vasodilation results in decreased venous return. This decreases intravascular volume and the development of relative hypovolemia. Decreased venous return results in decreased volume and a fall in cardiac output.

A patient with known penicillin allergy develops anaphylactic shock after a dose of ampicillin was given in error. Which medication would the nurse administer first?

A. Methylprednisolone

B. Gentamicin

C. Atropine

D. Epinephrine

D. Epinephrine

Epinephrine is given in anaphylactic shock to promote bronchodilation and vasoconstriction and inhibit further release of biochemical mediators.

Epinephrine is the first-line treatment of choice for anaphylaxis and should be administered when initial signs and symptoms occur.

A patient has been admitted with a neurologic disorder. With which disorder should the nurse be the most vigilant for the development of neurogenic shock?

A. Ischemic stroke

B. Spinal cord injury

C. Guillain-Barre syndrome

D. Brain Tumor

B. Spinal cord injury

Spinal Cord Injury most common cause of neurogenic shock.

Neurogenic shock may mistakenly be referred to as spinal shock. The latter condition refers to loss of neurologic activity below the level of SCI, but it does not necessarily involve ineffective tissue perfusion.

A patient has been admitted in septic shock due to urinary sepsis. The practitioner inserts a pulmonary artery (PA) catheter. Which hemodynamic value would the nurse expect to find to support this diagnosis?

A. Increased Cardiac Output (CO)

B. Increased Right Arterial Pressure (RAP)

C. Increased Pulmonary artery occlusion pressure (PAOP)

D. Increased systemic vascular resistance (SVR)

A. Increased Cardiac Output (CO)

Increased cardiac output and decreased systemic vascular are classic signs of septic shock.

Clinical Manifestations of Septic Shock

increased cardiac output/cardiac index

increase Svo2

decreased RAP, PAOP, SVR

A nurse is caring for a patient in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock?

A. bacterial toxins lead to vasodilation

B. which blood cells are released to fight invading bacteria

C. Microorganisms invade organs such as the kidneys and heart.

D. Decreased red blood cell production and fluid loss.

A. bacterial toxins lead to vasodilation

Severe Sepsis/Septic Shock: systemic inflammatory response due to microorganisms. Predominant cause of sepsis: Gram + bacteria. most common infection side: respiratory system.

A patient has been admitted in septic shock related to tissue necrosis. The nurse knows the initial goal for medical management for this patient is which intervention?

A. Limiting fluids to minimize the possibility of heart failure

B. Finding and eradicating the cause of infection

C. Discontinuing invasive monitoring as a possible cause of sepsis

D. Administering vasodilator substances to increase blood flow to vital organs.

B. Finding and eradicating the cause of infection

Effective treatment of severe sepsis and septic shock depends on timely recognition. The diagnosis of severe sepsis is based on the identification of three conditions: known or suspected infection, two or more of the clinical indication of the systemic inflammatory response, and evidence of at lease one organ dysfunction.

Lungs and CV systems: most common organs with dysfunction. Pulmonary vasodilation and microemboli -> V/Q mismatching

A patient has been admitted in hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support this diagnosis?

A. Distended neck veins

B. Decreased level of consciousness

C. Bounding radial and pedal pulses

D. Narrowed pulse pressure

D. Narrowed pulse pressure

Signs of under perfusion include flattened neck veins, a decreased level of consciousness, weak and thready peripheral pulses, and a narrowed pulse pressure

A patient is being admitted from the emergency department in cardiogenic shock secondary to unstable angina unresponsive to medications. The patient was intubated and ventilated in the ED. Which intervention should the nurse prepare to initiate when the practitioner arrives in the unit?

A. Administration of sodium bicarbonate

B. Rapid infusion of crystalloids

C. Insertion of an intra-aortic ballon pump (IABP)

D. Insertion of dialysis catheters for continuous renal replacement therapy (CRRT)

C. Insertion of an intra-aortic balloon pump (IABP)

Mechanical circulatory assist devices are used if adequate tissue perfusion cannot be immediately restored. Options include an Intraaortic ballon pump (IABP), Percutaneous ventricular assist device (VAD), or Extracorporeal membranes oxygenator.

A patient is being admitted in cardiogenic shock secondary to acute heart failure. In addition to a diuretic, which medication would the nurse anticipate the practitioner ordering for the patient?

A. Epinephrine

B. Nitroprusside

C. Dobutamine

D. Nitroglycerine

C. Dobutamine

Used to treat cardiogenic shock as a result of inadequate tissue perfusion. Treats heart failure by strengthening your heart muscles.

Epinephrine-should be norepinephrine

Nitrorusside- lowers bp

Nitroglycerine- vasodilator

The nurse is caring for a patient who was just admitted in septic shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order?

A. Administering fresh-frozen plasma

B. Obtain a serum lactate level.

C. Administer epinephrine

D. Measure central venous pressure

B. Obtain a serum lactate level

Global indicators of low systemic perfusion and oxygenation:

High Serum Lactate, High Arterial base deficit, Low Serum bicarbonate, low O2 saturation.

Surviving Sepsis Campaign Bundles

A. Measure lactate level

2. Obtain blood cultures prior to administration of antibiotics

3. Administer broad spectrum antibiotics

4. Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L

The nurse is caring for a patient with systemic inflammatory response syndrome (SIRS) due to pneumonia. What is SIRS due to infection called?

A. infectivity

B. Anaphylaxis

C. Sepsis

D. Acute respiratory distress syndrome (ARDS)

C. Sepsis

A nursing instructor is discussing the difference between primary and secondary multiple organ dysfunction syndrome (MODS) with a nursing student. Which statement indicates the student understood the information?

A. Primary MODS is the result of inflammation in organs not involved in the initial insult.

B. Primary MODS is the result of a direct organ injury.

C. Primary MODS is due to a disorganization of the inflammatory immune system response.

D. Primary MODS is due to disruption of the coagulation system.

B. Primary MODS is the result of a direct organ injury.

Primary MODS: from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself. (direct organ injury)

Secondary MODS: the consequence of systemic inflammation that results in dysfunction of organs not involved in the initial insult.

A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock?

A. Anorexia leads to loss of gastric enzymes

B. Lack of food ingestion leads to intestinal hypomotility

C. Hypoperfusion results in loss of gut barrier function.

D. Low cardiac output causes decreased hydrochloric acid secretions

C. Hypoperfusion results in loss of gut barrier function.

Normal gut flora and gut environment are altered, healthy probiotics decrease, and pathogenic organisms profilirate.

With microcirculatory failure to the gastrointestinal tract, the guts barrier function may be lost, which leads to bacterial translocation, sustained inflammation, endogenous endotoxemia, and MODs.

Clinical manifestations:

Abdominal distention/ascites

Intolerance to enteral feedings

Paralytic ileus

Uppor/Lower GI bleeding

Diarrhea

Ischemic colitis

Mucosal ulceration

Decreased bowel sounds

Bacterial overgrowth in stool

A patient has developed septic shock. The nurse knows that the clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult. Which finding would the nurse expect to find to support this diagnosis?

A. Elevated serum creatinine

B. Decreased bilirubin

C. Jaundice

D. Decreased serum transaminase

C. Jaundice

Clinical Manifestations:

Jaundice

Hepatomegaly

Hyperbilirubinemia

High liver enzymes

High serum ammonia

Low serum albumin

Low serum transferring

RUQ pain

Abdominal distention

Unexplained fever

Low bowel sounds

A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. The nurse knows that DIC is known to occur in patients with retained placental fragments. What is the pathophysiologic consequence of DIC?

A. Hypersensitivity response to an antigen

B. Excessive thrombosis and fibrinolysis

C. Profound vasodilation

D. Loss of intravascular volume

B. Excessive thrombosis and fibrinolysis

Coagulation dysfunction manifesting as disseminated intravascular coagulation, low platelet counts and elevated D-dimer concentrations of fibrinogen degradation.

A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expected to find to support this diagnosis?

A. Decreased fibrinogen degradation products

B. Decreased D-dimer concentrations

C. Decreased platelet counts

D. Increased serum glucose levels

C. Decreased platelet counts

A. Decreased fibrinogen degradation products-will increase

B. Decreased D-dimer concentrations-will increase

The nurse is caring for a patient in shock with an elevated lactate level. Which order should the nurse question in the management of this patient?

A. Start an insulin drip for blood sugar greater than 180 mg/dL

B. Administer sodium bicarbonate to keep artrial pH greater than 7.20

C. Start a norepinephrine drip to keep MAP greater than 65 mm Hg

D. Administer crystalloids fluids

B. Administer sodium bicarbonate to keep arterial pH greater than 7.20

Sodium Bicarbonate is not recommended in the Tx of shock related lactic acidosis.

Medical Management:

Tissue perfusion: Major focus

Pulmonary gas exchange

Cardiac Output/Hemoglobin levels

Fluid administration (to increase preload): crystalloid or colloid solution

Blood transfusion for low Hgb

Vasoconstrictor agents (to increase BP by increasing afterload)

Nutritional supplementation (within 24-48 hrs)

Glucose control (140 to 180): to lower infection, renal failure, sepsis, and death.

A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for signs and neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process?

A. Loss of sympathetic nervous system innervation

B. Parasympathetic nervous system stimulation

C. Injury to the hypothalamus

D. Focal injury to cerebral hemispheres

A. Loss of sympathetic nervous system innervation.

Findings

Massive peripheral vasodilation, inhibition of the baroreceptor response, and impaired thermoregulation (poikilothermia), Sympathetic tone loss, and baroreceptor response inhibition.

A patient in cardiogenic shock is being treated in the critical care unit. Which findings would the nurse expect to note in the patient to support this diagnosis? SATA

A. Warm, dry skin

B. Heart rate greater than 100 beats per minute

C. Weak, thready pulse

D. Increased right atrial pressure

E. Decreased pulmonary artery occlusion pressure

B. Heart rate greater than 100 beats per minute

C. Weak, thready pulse

D. Increased right atrial pressure

A. Warm, dry skin- Neurogenic shock

E. Decreased pulmonary artery occlusion pressure (high PAOP w/ Cardiogenic shock)

Cardiogenic Shock Assessment

Decline in CO, Chest pain, Tachycardia, Respiratory Alkalosis (Initially), Pulmonary edema (crackles, rhonchi), Hypoxemia, Renal Failure, Cerebral hypoperfusion, Hemodynamic parameters: low CI (<2.2), low EF, high preload, high RAP, high PAOP (>15 mmHg), high Afterload, high SVR