Chapter 9 Nursing Care of Patients in Shock

Answers CHAPTER 9 NURSING CARE OF PATIENTS IN SHOCK AUDIO CASE STUDY José and Anaphylactic Shock 1. Use the thumbnail or a credit card to brush the stinger away, being careful not to pinch it and push more venom into the body. Yes, José performed it properly. 2. There may be an allergy to bees now after sensitization from the first sting. 3. The next insect sting could cause more severe anaphylactic symptoms. If symptoms occur, José can give himself an auto-injection of epinephrine. Since its effects may only work for a short time, emergency care is urgent. VOCABULARY 1. acidosis 2. anaerobic 3. anaphylaxis 4. arrhythmia 5. cardiogenic 6. cyanosis 7. tachypnea 8. oliguria 9. tachycardia 10. hypoperfusion MATCHING 1. (3) 2. (1) 3. (2) 4. (2) 5. (2) SIGNS AND SYMPTOMS OF SHOCKSTAGES Signs/Symptoms Stages Compensated Progressive Irreversible Heart rate Tachycardia Slowing Pulses Systolic blood pressure Bounding Normal Diastolic blood pressure Respirations Temperature Level of consciousness Normal Increased rate, deep Varies Anxious, restless, irritable, alert, oriented, sense of impending doom Cool, clammy, pale Tachycardia Greater than 150 beats/min Weak, thready Below 90 mm Hg In hypertensive patient, 25% below baseline Decreased Tachypnea, crackles, shallow Decreased, can rise in septic shock Confused, lethargic Skin and mucous membranes Urine output Bowel sounds Normal Normal Moist, cold, clammy, pale Decreasing to less than 20 mL/hr Decreasing Absent Below 60 mm Hg Decreasing to 0 Slowing, irregular, shallow Decreasing Unconscious, comatose Cyanosis, mottled, cold, clammy 15 mL/hr decreasing to anuria Absent 1 2 Chapter 9 Answers CRITICAL THINKING 1. Stage: Irreversible Category of Shock: Hypovolemic Initial Action: Notify health care provider (HCP), aid volume restoration by monitoring intravenous (IV) infusion 2. Stage: Compensated Category of Shock: Septic Initial Action: Notify HCP, maintain oxygen 3. Stage: Progressive Category of Shock: Cardiogenic Initial Action: Stop IV infusion, notify HCP REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (2) is correct. Decreased peripheral tissue perfusion may be seen first as slow capillary refill, except in the older patient. (1, 3, 4) do not convey peripheral tissue perfusion status. 2. (3) is correct. Tachypnea is compensatory to maintain normal oxygen levels when cardiac output decreases. (1) is incorrect. If anxiety occurs, it is not the primary cause of tachypnea. (2) is incorrect. Decreasing retention of carbon dioxide is not the primary reason for tachypnea, although it is a benefit. (4) is incorrect. 3. (2) is correct. Blood pressure is dropping, so peripheral vasoconstriction occurs to compensate, resulting in less blood flow to the extremities; sympathetic nervous system compensation causes sweating to cool the body for “fight or flight.” (1, 3) are incorrect. 4. (3) is a 25% decrease from baseline. (1, 2, 4) are incorrect. 5. (2) is correct. The goal is to increase understanding when knowledge is deficient. (1, 3, 4) are incorrect. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 6. (3) is correct. Notify the HCP immediately because the patient is hypovolemic and could need intravenous fluids. (1) is incorrect. This weight loss after dialysis is to be expected. (2) is incorrect. Resting is not the priority at this time. (4) is incorrect. The patient requires intervention now and more frequent monitoring. 7. (2) is correct. Elevated creatinine indicates possible renal damage. (1, 3, 4) are normal or near normal and not indicative of a problem. 8. (2) is correct. The pulse elevates to compensate for decreasing cardiac output in compensated shock and is therefore the earliest indication of shock from these options. (1, 3, 4) are found in progressive shock and would be seen later than tachycardia. 9. (1) is of highest concern because it is a symptom of progressive shock. (2, 3, 4) are found in compensated shock. 10. (2) is correct. Inform the registered nurse so the intravenous rate can be increased while the HCP is being notified because the patient is hypovolemic. (1, 3, 4) are incorrect because the patient needs immediate intervention. (1) provides no intervention, (3, 4) can worsen the condition. 11. (4) increases blood pressure. (1, 2, 3) are incorrect, as they do not increase blood pressure. 12. (4, 2, 5, 6, 1, 3) is correct. Use the Maslow hierarchy of human needs as a guide. Airway is considered first (4) and then oxygen (2); determining vital signs (5) will guide further treatment; intravenous fluids are needed to replace lost fluid in hypovolemic shock, so ordered intravenous fluids need to be monitored and maintained (6); and urine output monitoring will help guide treatment (1). (3) is not a priority at this time. 13. (1, 2, 5, 6) is correct. Symptoms of obstructive shock are similar to those of hypovolemic shock except that jugular veins are usually distended. Blood pressure is low, urine output is less than 20 mL per hour, and changes in level of consciousness, including confusion and lethargy, are seen. (3, 4) are incorrect because tachycardia and tachypnea would occur. 14. (1, 3, 4) are correct. Acute respiratory distress syndrome, disseminated intravascular coagulation, and multiple organ dysfunction syndrome are complications of prolonged shock. (2, 6) are genetic conditions. (5) is a bone marrow problem.