Podcast
Questions and Answers
During the initial stages of shock, the body attempts to maintain blood flow to vital organs. Which of the following mechanisms contribute to this compensatory response?
During the initial stages of shock, the body attempts to maintain blood flow to vital organs. Which of the following mechanisms contribute to this compensatory response?
- Vasoconstriction in non-vital organs and increased release of epinephrine and norepinephrine. (correct)
- Decreased myocardial contractility, leading to reduced oxygen demand.
- Shunting blood flow to the kidneys and GI tract to preserve their function.
- Vasodilation in the heart and brain, coupled with decreased heart rate.
A patient experiencing cardiogenic shock exhibits a narrowed pulse pressure, elevated jugular venous pulsations, and adventitious lung sounds. Which of the following best explains the underlying cause of these clinical findings?
A patient experiencing cardiogenic shock exhibits a narrowed pulse pressure, elevated jugular venous pulsations, and adventitious lung sounds. Which of the following best explains the underlying cause of these clinical findings?
- Ineffective cardiac pumping resulting in systemic hypoperfusion and venous congestion. (correct)
- Increased vascular volume leading to fluid overload and pulmonary congestion.
- Peripheral vasodilation causing decreased venous return and reduced cardiac output.
- Increased sympathetic nervous system activity leading to vasoconstriction and increased afterload.
Which of the following best describes how the myocardium responds to the increased oxygen demand which is stimulated by the SNS during the initial stages of shock?
Which of the following best describes how the myocardium responds to the increased oxygen demand which is stimulated by the SNS during the initial stages of shock?
- Constricting coronary arteries to maintain blood pressure, leading to decreased myocardial O2 consumption.
- Decreasing heart rate to conserve energy, resulting in decreased myocardial O2 consumption.
- Increasing contractility and dilating coronary arteries, leading to increased myocardial O2 consumption. (correct)
- Reducing contractility to minimize workload, resulting in decreased myocardial O2 consumption.
A 62-year-old male is admitted to the emergency department with an acute myocardial infarction. His blood pressure is 80/50 mmHg, heart rate is 120 bpm, and he has pulmonary edema. Which type of shock is he most likely experiencing?
A 62-year-old male is admitted to the emergency department with an acute myocardial infarction. His blood pressure is 80/50 mmHg, heart rate is 120 bpm, and he has pulmonary edema. Which type of shock is he most likely experiencing?
An elderly patient with a history of cardiovascular disease and diabetes is admitted to the hospital with a severe infection. Which of the following factors increases this patient's risk of developing cardiogenic shock?
An elderly patient with a history of cardiovascular disease and diabetes is admitted to the hospital with a severe infection. Which of the following factors increases this patient's risk of developing cardiogenic shock?
During hypovolemic shock, what is the primary reason for decreased cardiac output and contractility at a cellular level?
During hypovolemic shock, what is the primary reason for decreased cardiac output and contractility at a cellular level?
A trauma patient has experienced significant blood loss, leading to hypovolemic shock. Which of the following physiological responses is most likely to occur as the body attempts to compensate?
A trauma patient has experienced significant blood loss, leading to hypovolemic shock. Which of the following physiological responses is most likely to occur as the body attempts to compensate?
A patient presents with a blood pressure of 70/40 mmHg, heart rate of 130 bpm, and cool, clammy skin after a severe car accident involving internal bleeding. Which of the following interventions is the highest priority?
A patient presents with a blood pressure of 70/40 mmHg, heart rate of 130 bpm, and cool, clammy skin after a severe car accident involving internal bleeding. Which of the following interventions is the highest priority?
A client is receiving both norepinephrine and dobutamine. What is the primary physiological effect the nurse should anticipate?
A client is receiving both norepinephrine and dobutamine. What is the primary physiological effect the nurse should anticipate?
A patient with a known penicillin allergy is prescribed ceftriaxone. What is the most appropriate nursing action?
A patient with a known penicillin allergy is prescribed ceftriaxone. What is the most appropriate nursing action?
A patient is prescribed furosemide. Which electrolyte imbalance should the nurse be most vigilant in monitoring?
A patient is prescribed furosemide. Which electrolyte imbalance should the nurse be most vigilant in monitoring?
Which combination of medications would cause the most concern regarding potentiation of CNS depression?
Which combination of medications would cause the most concern regarding potentiation of CNS depression?
A patient is receiving albuterol. The nurse observes the patient is also taking a beta blocker prescribed by another provider. What is the primary concern with this combination?
A patient is receiving albuterol. The nurse observes the patient is also taking a beta blocker prescribed by another provider. What is the primary concern with this combination?
A patient in shock is exhibiting signs of decreased cardiac contractility and is not responding well to vasopressors. Which underlying condition is most likely contributing to these symptoms?
A patient in shock is exhibiting signs of decreased cardiac contractility and is not responding well to vasopressors. Which underlying condition is most likely contributing to these symptoms?
Which of the following conditions would increase a client's risk for developing hypovolemic shock?
Which of the following conditions would increase a client's risk for developing hypovolemic shock?
A patient who has experienced a 30% blood loss is likely to exhibit which of the following signs and symptoms?
A patient who has experienced a 30% blood loss is likely to exhibit which of the following signs and symptoms?
A client with volume depletion is complaining of muscle cramps and thirst. Which additional assessment finding would support the diagnosis of hypovolemia?
A client with volume depletion is complaining of muscle cramps and thirst. Which additional assessment finding would support the diagnosis of hypovolemia?
During anaphylactic shock, the release of chemical mediators leads to which of the following primary physiological responses?
During anaphylactic shock, the release of chemical mediators leads to which of the following primary physiological responses?
A patient with a known allergy to peanuts is exhibiting signs of anaphylaxis including urticaria, wheezing, and hypotension. What is the most important immediate intervention?
A patient with a known allergy to peanuts is exhibiting signs of anaphylaxis including urticaria, wheezing, and hypotension. What is the most important immediate intervention?
Which of the following pathophysiological processes is most directly responsible for the decreased organ perfusion seen in septic shock?
Which of the following pathophysiological processes is most directly responsible for the decreased organ perfusion seen in septic shock?
An elderly patient with a history of chronic kidney disease develops a hospital-acquired infection and progresses to septic shock. What other factor would increase this patient's risk?
An elderly patient with a history of chronic kidney disease develops a hospital-acquired infection and progresses to septic shock. What other factor would increase this patient's risk?
Which of the following assessment findings is most indicative of neurogenic shock rather than hypovolemic shock?
Which of the following assessment findings is most indicative of neurogenic shock rather than hypovolemic shock?
A patient with a spinal cord injury at the level of T4 is at risk for neurogenic shock. Which of the following mechanisms contributes to this type of shock?
A patient with a spinal cord injury at the level of T4 is at risk for neurogenic shock. Which of the following mechanisms contributes to this type of shock?
Which of the following factors is most directly implicated in the development of toxic shock syndrome?
Which of the following factors is most directly implicated in the development of toxic shock syndrome?
A patient with toxic shock syndrome is likely to exhibit which of the following clinical manifestations?
A patient with toxic shock syndrome is likely to exhibit which of the following clinical manifestations?
Obstructive shock is characterized by impaired circulation due to a blockage of blood flow. Which condition can lead to obstructive shock?
Obstructive shock is characterized by impaired circulation due to a blockage of blood flow. Which condition can lead to obstructive shock?
A patient on mechanical ventilation with high PEEP is showing signs of obstructive shock, which includes hypotension and dyspnea. How does high PEEP contribute to this condition?
A patient on mechanical ventilation with high PEEP is showing signs of obstructive shock, which includes hypotension and dyspnea. How does high PEEP contribute to this condition?
Which of the following assessment findings would be most consistent with the development of obstructive shock?
Which of the following assessment findings would be most consistent with the development of obstructive shock?
A client in shock is receiving IV fluids. Which assessment finding is MOST indicative of adequate end-organ perfusion?
A client in shock is receiving IV fluids. Which assessment finding is MOST indicative of adequate end-organ perfusion?
A client in septic shock has a prescription for IV antibiotics. According to best practice, within what timeframe should the nurse administer the antibiotics?
A client in septic shock has a prescription for IV antibiotics. According to best practice, within what timeframe should the nurse administer the antibiotics?
A nurse is caring for a client with hypovolemic shock due to hemorrhage. Which intervention is the priority?
A nurse is caring for a client with hypovolemic shock due to hemorrhage. Which intervention is the priority?
A patient with anaphylactic shock has received intramuscular epinephrine. Which of the following medications would the healthcare provider order next?
A patient with anaphylactic shock has received intramuscular epinephrine. Which of the following medications would the healthcare provider order next?
A client in cardiogenic shock is receiving norepinephrine. What is the primary goal of this medication in this situation?
A client in cardiogenic shock is receiving norepinephrine. What is the primary goal of this medication in this situation?
A nurse is caring for a client receiving vasopressors through a central venous line. Which assessment finding requires immediate intervention?
A nurse is caring for a client receiving vasopressors through a central venous line. Which assessment finding requires immediate intervention?
A client with septic shock is being resuscitated with IV fluids. What is the recommended initial fluid bolus volume?
A client with septic shock is being resuscitated with IV fluids. What is the recommended initial fluid bolus volume?
A client in shock is started on enteral nutrition (EN). What is the primary rationale for initiating EN in the early stages of shock?
A client in shock is started on enteral nutrition (EN). What is the primary rationale for initiating EN in the early stages of shock?
Which intervention is CONTRAINDICATED in the initial management of non-hemorrhagic hypovolemic shock?
Which intervention is CONTRAINDICATED in the initial management of non-hemorrhagic hypovolemic shock?
Besides vasopressors and fluid optimization, which intervention is MOST important to improve cardiac output in the treatment of cardiogenic shock?
Besides vasopressors and fluid optimization, which intervention is MOST important to improve cardiac output in the treatment of cardiogenic shock?
A client with shock is being mechanically ventilated. What is the primary goal of mechanical ventilation in this context?
A client with shock is being mechanically ventilated. What is the primary goal of mechanical ventilation in this context?
A client has been in shock for several hours. Which laboratory value would be MOST indicative of end-organ damage?
A client has been in shock for several hours. Which laboratory value would be MOST indicative of end-organ damage?
A client receiving treatment for shock is showing signs of improvement. Which assessment finding BEST indicates that the interventions are effective?
A client receiving treatment for shock is showing signs of improvement. Which assessment finding BEST indicates that the interventions are effective?
The care team is deciding on the most appropriate vasopressor for a patient in cardiogenic shock. What is the FIRST LINE treatment?
The care team is deciding on the most appropriate vasopressor for a patient in cardiogenic shock. What is the FIRST LINE treatment?
A client is assessed to be going into shock. After notifying the provider, charge nurse, and rapid response team, what is another initial step the nurse should take?
A client is assessed to be going into shock. After notifying the provider, charge nurse, and rapid response team, what is another initial step the nurse should take?
Which of the following is a critical safety consideration when using invasive hemodynamic monitoring?
Which of the following is a critical safety consideration when using invasive hemodynamic monitoring?
Following the placement of an arterial line, a nurse observes significant bleeding from the insertion site. What is the MOST immediate action?
Following the placement of an arterial line, a nurse observes significant bleeding from the insertion site. What is the MOST immediate action?
A client in the ICU is unable to participate in their education due to their critical condition. How should the nurse proceed with providing essential information?
A client in the ICU is unable to participate in their education due to their critical condition. How should the nurse proceed with providing essential information?
A client who is experiencing shock has a systolic blood pressure consistently below 90 mm Hg and a MAP under 65 mm Hg. Which action should the nurse prioritize?
A client who is experiencing shock has a systolic blood pressure consistently below 90 mm Hg and a MAP under 65 mm Hg. Which action should the nurse prioritize?
A nurse is caring for a client with shock who has a urinary output of 10 mL/hour. What intervention should the nurse anticipate?
A nurse is caring for a client with shock who has a urinary output of 10 mL/hour. What intervention should the nurse anticipate?
A nurse is assessing a client in shock and notes that their extremities are cold and clammy. What does this finding indicate?
A nurse is assessing a client in shock and notes that their extremities are cold and clammy. What does this finding indicate?
What is the MOST important reason for educating the family of a critically ill client in the ICU?
What is the MOST important reason for educating the family of a critically ill client in the ICU?
A nurse is caring for a client in shock and notes a declining trend in blood pressure despite fluid resuscitation. What intervention should the nurse anticipate?
A nurse is caring for a client in shock and notes a declining trend in blood pressure despite fluid resuscitation. What intervention should the nurse anticipate?
Which of the following laboratory values is included in the MEWS-SRS (Sepsis Recognition Score) but not in the standard MEWS?
Which of the following laboratory values is included in the MEWS-SRS (Sepsis Recognition Score) but not in the standard MEWS?
A nurse observes that a client in shock has increasing tachycardia and tachypnea. What is the MOST likely cause of these manifestations?
A nurse observes that a client in shock has increasing tachycardia and tachypnea. What is the MOST likely cause of these manifestations?
Which of the following actions is MOST important for the nurse to take to prevent complications associated with an arterial line?
Which of the following actions is MOST important for the nurse to take to prevent complications associated with an arterial line?
Which complication is MOST directly associated with the placement of an arterial line?
Which complication is MOST directly associated with the placement of an arterial line?
A client in shock requires both fluid resuscitation and vasopressor medications. What is the rationale for these combined interventions?
A client in shock requires both fluid resuscitation and vasopressor medications. What is the rationale for these combined interventions?
A nurse is preparing to assist with the insertion of a central line in a client experiencing shock. What supplies should the nurse ensure are readily available?
A nurse is preparing to assist with the insertion of a central line in a client experiencing shock. What supplies should the nurse ensure are readily available?
A trauma client showing early signs of shock has a slightly decreased blood pressure compared to their baseline. What is the MOST appropriate nursing action?
A trauma client showing early signs of shock has a slightly decreased blood pressure compared to their baseline. What is the MOST appropriate nursing action?
A patient in cardiogenic shock requires mechanical circulatory support (MCS). Which of the following is an appropriate MCS intervention?
A patient in cardiogenic shock requires mechanical circulatory support (MCS). Which of the following is an appropriate MCS intervention?
A patient presents with hypovolemic shock due to a confirmed internal hemorrhage. What is the MOST appropriate initial intervention?
A patient presents with hypovolemic shock due to a confirmed internal hemorrhage. What is the MOST appropriate initial intervention?
What is the primary treatment goal for a patient experiencing obstructive shock?
What is the primary treatment goal for a patient experiencing obstructive shock?
A patient is in septic shock and requires vasopressor therapy. Which vasopressor is typically the FIRST-line choice for maintaining adequate MAP?
A patient is in septic shock and requires vasopressor therapy. Which vasopressor is typically the FIRST-line choice for maintaining adequate MAP?
A patient is receiving fluid resuscitation for septic shock. According to the Surviving Sepsis Campaign, what is the MINIMUM recommended amount of crystalloid fluid to administer in the first 3 hours?
A patient is receiving fluid resuscitation for septic shock. According to the Surviving Sepsis Campaign, what is the MINIMUM recommended amount of crystalloid fluid to administer in the first 3 hours?
Which laboratory finding would a nurse expect to see in a patient experiencing hypovolemic shock?
Which laboratory finding would a nurse expect to see in a patient experiencing hypovolemic shock?
A patient with anaphylactic shock has already received IM epinephrine. What is another important nursing intervention that is needed?
A patient with anaphylactic shock has already received IM epinephrine. What is another important nursing intervention that is needed?
A patient in shock has a decreased cardiac output and low blood pressure. The provider prescribes an inotrope. What is the expected outcome of this medication?
A patient in shock has a decreased cardiac output and low blood pressure. The provider prescribes an inotrope. What is the expected outcome of this medication?
A nurse is monitoring a patient receiving IV fluids for hypovolemic shock. Which assessment finding indicates a potential complication of intravenous therapy and fluid overload?
A nurse is monitoring a patient receiving IV fluids for hypovolemic shock. Which assessment finding indicates a potential complication of intravenous therapy and fluid overload?
A patient with septic shock is unresponsive to initial norepinephrine infusion. What is the MOST appropriate next step in vasopressor therapy?
A patient with septic shock is unresponsive to initial norepinephrine infusion. What is the MOST appropriate next step in vasopressor therapy?
A nurse is caring for a patient at risk for hypovolemic shock. What is the MINIMUM acceptable urine output the nurse should expect to see?
A nurse is caring for a patient at risk for hypovolemic shock. What is the MINIMUM acceptable urine output the nurse should expect to see?
A patient is receiving vasopressors for shock. What physiological response should the nurse expect to see as a result of this medication?
A patient is receiving vasopressors for shock. What physiological response should the nurse expect to see as a result of this medication?
A patient with a severe allergy is experiencing anaphylactic shock. After administering epinephrine, which of the following medications might also be administered?
A patient with a severe allergy is experiencing anaphylactic shock. After administering epinephrine, which of the following medications might also be administered?
A patient in shock is being monitored for fluid status. Which vital sign change is MOST indicative of hypovolemia?
A patient in shock is being monitored for fluid status. Which vital sign change is MOST indicative of hypovolemia?
A patient is diagnosed with non-hemorrhagic hypovolemic shock. The medical provider orders a rapid infusion of crystalloids. How much crystalloid fluid should you administer?
A patient is diagnosed with non-hemorrhagic hypovolemic shock. The medical provider orders a rapid infusion of crystalloids. How much crystalloid fluid should you administer?
A client experiencing obstructive shock due to pericardial tamponade is likely to exhibit which set of clinical signs, also known as Beck's triad?
A client experiencing obstructive shock due to pericardial tamponade is likely to exhibit which set of clinical signs, also known as Beck's triad?
During the compensatory stage of shock, the body activates several mechanisms to maintain blood pressure and oxygen delivery. Which physiological response is NOT characteristic of this stage?
During the compensatory stage of shock, the body activates several mechanisms to maintain blood pressure and oxygen delivery. Which physiological response is NOT characteristic of this stage?
In the progressive stage of shock, a client's condition deteriorates significantly. Which of the following clinical findings indicates progression from the compensatory to the progressive stage?
In the progressive stage of shock, a client's condition deteriorates significantly. Which of the following clinical findings indicates progression from the compensatory to the progressive stage?
A client with a suspected infection is exhibiting signs of Systemic Inflammatory Response Syndrome (SIRS). Which laboratory finding would be most indicative of the inflammatory imbalance seen in SIRS?
A client with a suspected infection is exhibiting signs of Systemic Inflammatory Response Syndrome (SIRS). Which laboratory finding would be most indicative of the inflammatory imbalance seen in SIRS?
A client in septic shock remains hypotensive despite aggressive fluid resuscitation. This hemodynamic instability signifies progression to which stage of sepsis?
A client in septic shock remains hypotensive despite aggressive fluid resuscitation. This hemodynamic instability signifies progression to which stage of sepsis?
In the care of elderly clients, why is the recognition of shock potentially more challenging compared to younger clients?
In the care of elderly clients, why is the recognition of shock potentially more challenging compared to younger clients?
The Modified Early Warning Score (MEWS) is used to identify clients at risk of clinical deterioration. Which of the following vital signs is NOT typically included in the MEWS calculation?
The Modified Early Warning Score (MEWS) is used to identify clients at risk of clinical deterioration. Which of the following vital signs is NOT typically included in the MEWS calculation?
A client is suspected of experiencing a tension pneumothorax as a complication of obstructive shock. Which assessment finding would be MOST indicative of this condition?
A client is suspected of experiencing a tension pneumothorax as a complication of obstructive shock. Which assessment finding would be MOST indicative of this condition?
Which of the following is a key difference between sepsis and severe sepsis?
Which of the following is a key difference between sepsis and severe sepsis?
Aortic dissection can lead to obstructive shock. What assessment finding is most indicative of aortic dissection?
Aortic dissection can lead to obstructive shock. What assessment finding is most indicative of aortic dissection?
What is the underlying cause of the systemic inflammatory response syndrome (SIRS)?
What is the underlying cause of the systemic inflammatory response syndrome (SIRS)?
Tissue and cellular hypoxia can cause cellular death and vital organ dysfunction in shock. What further exacerbates this tissue hypoxia?
Tissue and cellular hypoxia can cause cellular death and vital organ dysfunction in shock. What further exacerbates this tissue hypoxia?
In the initial stage of shock, the body switches from aerobic to anaerobic metabolism due to a lack of oxygen in the blood. What is a key indicator of this metabolic shift?
In the initial stage of shock, the body switches from aerobic to anaerobic metabolism due to a lack of oxygen in the blood. What is a key indicator of this metabolic shift?
What is the primary goal of critical care nurses in managing clients at risk of or experiencing shock?
What is the primary goal of critical care nurses in managing clients at risk of or experiencing shock?
A client experiencing pulmonary embolism as a cause of obstructive shock may also experience which of the following?
A client experiencing pulmonary embolism as a cause of obstructive shock may also experience which of the following?
Flashcards
What is Shock?
What is Shock?
A state of cellular hypoperfusion, leading to similar physiological responses regardless of the initial cause.
Classic Shock Sign?
Classic Shock Sign?
Often indicated by a drop in blood pressure due to decreased cardiac output and narrowed pulse pressure.
Initial Body Response?
Initial Body Response?
Baroreceptors trigger the sympathetic nervous system (SNS) for vasoconstriction and release of epinephrine/norepinephrine.
Blood Flow Shunting?
Blood Flow Shunting?
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Heart's Response
Heart's Response
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Cardiogenic Shock
Cardiogenic Shock
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Cardiogenic Shock Response
Cardiogenic Shock Response
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Hemorrhagic shock
Hemorrhagic shock
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Enteral Nutrition
Enteral Nutrition
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Lactic Acidosis in Shock
Lactic Acidosis in Shock
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Hypovolemic Shock Risk Factors
Hypovolemic Shock Risk Factors
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Parenteral Nutrition
Parenteral Nutrition
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Hemorrhagic Shock Stages
Hemorrhagic Shock Stages
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Ceftriaxone (Rocephin)
Ceftriaxone (Rocephin)
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Norepinephrine (Levophed)
Norepinephrine (Levophed)
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Volume Depletion Symptoms
Volume Depletion Symptoms
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Anaphylactic Shock
Anaphylactic Shock
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Dobutamine (Dobutrex)
Dobutamine (Dobutrex)
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Anaphylactic Shock Risk Factors
Anaphylactic Shock Risk Factors
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Anaphylactic Shock Symptoms
Anaphylactic Shock Symptoms
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Septic Shock Mechanism
Septic Shock Mechanism
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Septic Shock Risk Factors
Septic Shock Risk Factors
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Septic Shock Infection Signs
Septic Shock Infection Signs
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Neurogenic Shock Cause
Neurogenic Shock Cause
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Neurogenic Shock Risk Factors
Neurogenic Shock Risk Factors
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Neurogenic Shock Symptoms
Neurogenic Shock Symptoms
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Toxic Shock
Toxic Shock
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Obstructive Shock
Obstructive Shock
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Tension Pneumothorax Signs
Tension Pneumothorax Signs
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Beck's Triad
Beck's Triad
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Hemoptysis
Hemoptysis
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Pulsus Paradoxus
Pulsus Paradoxus
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Pulse deficit
Pulse deficit
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Shock
Shock
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Geriatric Considerations in Shock
Geriatric Considerations in Shock
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Stages of Shock
Stages of Shock
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Initial Stage of Shock
Initial Stage of Shock
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Compensatory Stage of Shock
Compensatory Stage of Shock
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Progressive Stage of Shock
Progressive Stage of Shock
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Refractory Stage of Shock
Refractory Stage of Shock
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SIRS
SIRS
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Early Warning Scores
Early Warning Scores
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MEWS-SRS
MEWS-SRS
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Invasive Hemodynamic Monitoring Risk
Invasive Hemodynamic Monitoring Risk
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Arterial Line Complications
Arterial Line Complications
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ICU Client/Family Education
ICU Client/Family Education
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ICU Education Topics
ICU Education Topics
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Key Information for Client/Family
Key Information for Client/Family
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Shock Manifestations
Shock Manifestations
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Frequent Shock Assessments
Frequent Shock Assessments
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Cues for Shock Analysis
Cues for Shock Analysis
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Potential Needs in Shock
Potential Needs in Shock
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Primary Survey Priorities
Primary Survey Priorities
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Early Shock Manifestations
Early Shock Manifestations
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Initial Shock Interventions
Initial Shock Interventions
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Lines Placement in Shock
Lines Placement in Shock
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Arterial Line Monitoring
Arterial Line Monitoring
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Crash Cart Availability
Crash Cart Availability
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Large-Bore IV Access
Large-Bore IV Access
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Optimize Oxygen Delivery
Optimize Oxygen Delivery
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Fluid Resuscitation Goal
Fluid Resuscitation Goal
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Drug Therapy Goal
Drug Therapy Goal
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Importance of Nutrition
Importance of Nutrition
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Fluid Resuscitation Volume
Fluid Resuscitation Volume
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Antibiotics in Septic Shock
Antibiotics in Septic Shock
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Anaphylactic Shock Treatment
Anaphylactic Shock Treatment
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Hypovolemic Shock Treatment
Hypovolemic Shock Treatment
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Cardiogenic Shock treatment
Cardiogenic Shock treatment
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Nutrition in Shock
Nutrition in Shock
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Fluid Resuscitation Access
Fluid Resuscitation Access
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Drug Therapy Goal in Shock
Drug Therapy Goal in Shock
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Cardiogenic Shock treatmet Goal
Cardiogenic Shock treatmet Goal
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Vasopressors and Inotropes
Vasopressors and Inotropes
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Inotrope Action
Inotrope Action
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Major Vasopressors
Major Vasopressors
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Common Inotropes
Common Inotropes
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Crystalloid Examples
Crystalloid Examples
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Colloid Examples
Colloid Examples
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Preferred Vasopressor
Preferred Vasopressor
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Mechanical Circulatory Support (MCS)
Mechanical Circulatory Support (MCS)
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Hemorrhagic Shock Treatment
Hemorrhagic Shock Treatment
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Non-Hemorrhagic Hypovolemic Shock Treatment
Non-Hemorrhagic Hypovolemic Shock Treatment
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First-line Anaphylactic Shock Treatment
First-line Anaphylactic Shock Treatment
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Septic Shock Treatment Components
Septic Shock Treatment Components
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Obstructive Shock Treatment
Obstructive Shock Treatment
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Study Notes
- Shock is categorized into cardiogenic, hypovolemic, distributive, and obstructive types
- Despite differing causes, initial presentations, and management approaches, the cellular responses to hypoperfusion are similar across all shock types
General Signs and Body Response to Shock
- A key sign of shock is a drop in blood pressure, resulting from decreased cardiac output and narrowed pulse pressure
- Baroreceptors in the carotid and aortic bodies activate the sympathetic nervous system (SNS) in response to decreased blood pressure
- The SNS stimulates vasoconstriction and releases epinephrine and norepinephrine
- Blood flow is maintained to the heart and brain, but diverted away from non-vital organs such as the kidneys, GI tract, skin, and lungs
- Myocardium responds to SNS stimulation by increasing heart rate and contractility, leading to increased myocardial oxygen consumption, while coronary arteries dilate to meet these demands
Cardiogenic Shock
- It results from cardiac dysfunction, leading to circulatory failure and hypoperfusion, which causes myocardial ischemia
- Decreased myocardial contractility leads to decreased cardiac output and systemic hypoperfusion
- The body's compensatory mechanisms activate (sympathetic NS), causing vasoconstriction and tachycardia
Risk Factors for Cardiogenic Shock
- Risk factors include being 75 years or older, Asian American, Pacific Islander, or assigned female at birth
- Preexisting conditions like cardiovascular disease, diabetes mellitus, sepsis, and obesity also increase risk
Clinical Findings of Cardiogenic Shock
- Clinical findings may include chest pain, significant arrhythmias, narrowed pulse pressure, elevated jugular venous pulsations, and adventitious lung sounds
- Other signs include rhonchi and distended jugular veins with elevated pulsations
Hypovolemic Shock
- Occurs when intravascular volume is decreased by 25% to 30%, resulting in poor cardiac output
- Hemorrhagic shock results from insufficient blood and oxygen perfusion of body tissues
Hypovolemic Shock Effects
- Low cardiac output and decreased contractility occur as cells switch to anaerobic metabolism
- Lactic acidosis results from the cells metabolic switch, leading to decreased heart contractility and reduced response to vasopressors
Risk Factors for Hypovolemic Shock
- Recent trauma, abdominal aortic aneurysms, peptic ulcer disease, and hemorrhagic disorders in maternal clients
Hemorrhagic Shock Stages (Blood Loss)
- Initial stages (< 20% blood loss) show anxiety and restlessness
- At 20% to 40% blood loss, manifestations include tachycardia, tachypnea, oliguria, and orthostatic hypotension, with possible internal hemorrhage signs like hematemesis, bloody stool, and abdominal distention
- Blood loss greater than 40% results in hypotension, severe tachycardia, and deteriorating mental status
Additional Manifestations of Volume Depletion
- Symptoms such as orthostatic hypotension, muscle cramps, thirst, abdominal or chest pain, lethargy, agitation, or confusion
- Other findings include decreased skin turgor, dry mucous membranes, tachycardia, flattened neck veins, cyanosis, and hypotension
Anaphylactic Shock
- It is a severe hypersensitivity (allergic) reaction mediated by IgE
- Chemical mediators released include histamines, prostaglandins, leukotrienes, and platelet-activating factors
- Mediator release increases vascular permeability, decreases systemic vascular resistance (SVR), causes vasodilation, decreases perfusion to vital organs, and causes bronchoconstriction
- Clients are likely to have a history of exposure to an allergen such as medication, food, or insect sting
Risk Factors for Anaphylactic Shock
- The presence of previous anaphylaxis, family history of anaphylaxis, asthma, or allergies
Clinical Presentation of Anaphylactic Shock
- Flushing, edema (face and mouth), urticaria, hypotension, hoarseness, facial and oral edema, tachypnea, wheezing, or stridor
Septic Shock
- Occurs due to the release of inflammatory cytokines in the presence of sepsis
- Cytokines damage blood vessel linings and initiate clotting, producing microemboli
- Proinflammatory mediators (histamines, serotonin, bradykinin) increase cardiac output (CO) initially
- Blood flow bypasses capillaries, decreasing perfusion to organs, and later CO may decrease
Risk Factors for Septic Shock
- Chronic kidney disease, hospital-acquired infections, invasive tubes or lines, immunosuppression, pancreatitis, recent major surgery, traumatic injury (including burns), advanced age, and cancer
Clinical Manifestations of Septic Shock
- Related to the source of infection, such as cellulitis or necrotizing infections of soft tissues
Neurogenic Shock
- It stems from autonomic dysregulation due to spinal cord injury above T6, often from trauma to the cervical or thoracic vertebrae
- Trauma disrupts descending sympathetic tracts, resulting in direct damage to axons, grey matter, and the anterior root
- There is a loss of sympathetic tone and an unopposed parasympathetic response directed by the vagus nerve
- The secondary injury causes electrolyte shifts, edema, and a vascular insult leading to necrosis of the grey matter
Risk Factors for Neurogenic Shock
- Include spinal cord injury, Guillain-Barré syndrome, and spinal anesthesia
Clinical Manifestations of Neurogenic Shock
- Hypotension, flushed and warm skin, autonomic dysreflexia, temperature dysregulation, orthostatic hypotension, and bradyarrhythmias
Toxic Shock
- Infection from Staphylococcus aureus and endotoxins from group A streptococcus
- Often results from nasal or vaginal tampons but can occur from burns, soft tissue or post-surgical infections, and dialysis catheters
- Excessive inflammatory cell activation leads to hypotension, rash resembling a sunburn, fever, and organ failure
Obstructive Shock
- Blood flow is blocked, disrupting circulation to major organs
- Causes include pulmonary disorders (pulmonary embolism, tension pneumothorax), mechanical ventilation (high PEEP), and cardiac conditions (aortic dissection, pericardial tamponade/effusion, mass within the heart)
Risk Factors for Obstructive Shock
- Severe atherosclerotic disease, uncontrolled hypertension, coagulopathies, cancer, AIDS, pulmonary hypertension, respiratory diseases/surgeries with mechanical ventilation, and thoracic trauma
Clinical Findings in Obstructive Shock
- Vary widely with cause, but may include dyspnea, pale skin, impaired mental status, oliguria, shivering, and hypotension
- Manifestations of tension pneumothorax (diminished/absent breath sounds, tracheal deviation, neck vein distention) or pericardial tamponade (Beck’s triad: muffled heart sounds, hypotension, increased JVP)
Additional Manifestations in Obstructive Shock
- Tension pneumothorax: Jugular venous distention (JVD), cyanosis, asymmetrical breathing pattern, absent breath sounds, subcutaneous emphysema
- Pulmonary embolism: Hemoptysis, pulsus paradoxus
- Pericarditis/tamponade: Pulsus paradoxus
- Aortic dissection: Pulse deficit
General Considerations for All Types of Shock
- A life-threatening circulatory failure affecting all body systems
- Tissue and cellular hypoxia cause cellular death and vital organ dysfunction, leading to acidosis and decreased blood flow
- Reversible in early stages, but delays in diagnosis/treatment may lead to irreversible changes (multiorgan failure, death)
- Critical care stays are more problematic for older clients (65+) due to reduced physiological reserve, comorbidities, and geriatric-specific syndromes
Stages of Shock
- Initial Stage: Subtle clinical manifestations, such as pale skin and feelings of unwellness or anxiety; aerobic turns to anerobic metabolism and lactic acid increases
- Compensatory Stage: Activation of the SNS leading to tachycardia, tachypnea, decreased peripheral pulses, fluctuating blood pressure, and prolonged capillary refill time; Aldosterone release, vasoconstriction, increased HR, and release of catecholamines
- Progressive Stage: Client’s condition deteriorates with altered LOC, weak pulses, pale or ashen skin, prolonged capillary refill time, and oliguria or anuria; electrolyte imbalance and hypotension
- Refractory Stage: Death is imminent with a comatose state, hypotension unresponsive to treatment, renal failure (anuria), and respiratory failure; irreversible cellular and organ failure
Systemic Inflammatory Response Syndrome (SIRS) and Sepsis
- SIRS is caused by tissue injury or infection
- Sepsis occurs when SIRS is triggered by infection
- Cytokines released into circulation disrupt homeostasis, activating the inflammatory cascade
SIRS
- Exaggerated defense response to stressors, potentially life-threatening
- Inflammation triggered by infectious or noninfectious stimuli
- Deregulated cytokine storm may cause reversible or irreversible organ dysfunction or death
- Liver dysfunction can cause cerebral edema, blood clotting issues, and renal failure
- Sepsis=SIRS + suspected infection. When clients have sepsis with one or more organ failures it is termed severe sepsis. Septic shock includes hemodynamic instability after intravascular volume replenishment
Safety Considerations
- Critical care nurses must recognize trends and changes in client condition
- Early warning scores (Modified Early Warning Score (MEWS) and MEWS-SRS) identify high-risk clients
- Invasive monitoring poses infection risks
- After arterial line placement, securement is essential due to risk of bleeding
Client Teaching
- Provide education and information to reduce stress
- Inform client/family about ICU routines, environment, care partners, and transition
Nursing Assessments
- New onset of hypotension (less than 90 mm Hg systolic or MAP under 65 mm Hg
- Declining trends in blood pressure
- Oliguria/anuria
- Changes in level of consciousness
- Tachycardia or other cardiac dysrhythmias
- Tachypnea
- Alterations in oxygen saturation
- Extremities that are cold, mottled, or clammy
Actions
- Frequent physical assessments
- Assessment of hemodynamics
- Lab values
- Assessment of invasive tubes and lines such as central lines, arterial pressure lines, and urinary collection devices
Client Needs Analysis
- Further administration of IV fluids
- The addition or adjustment of vasopressor to inotropic medications
- Client may also exhibit signs of needing respiratory or cardiac interventions
Priority Nursing Actions
- Assessing the airway, breathing, and circulation (ABC priority framework)
- Establishing hemodynamic monitoring and intravenous access
Interprofessional Collaboration
- Collaborate with other disciplines and team members to develop an optimal plan of care
- Adjust and reprioritize the plan of care as the client’s condition changes
Likely Initial Interventions
- Fluid resuscitation
- Continuous cardiac monitoring
- Stabilization of the client’s airway and oxygen status
- Have supplies available for arterial and central line insertion
- Ensure a crash cart is available
Dependent Nursing Actions
- Assisting with the insertion and maintenance of invasive central venous access devices (CVAD), arterial lines, and other hemodynamic monitoring modalities
- Administering IV fluids, packed red blood cells (PRBCs), and/or blood products
- Monitoring and analyzing hemodynamic values and trends
- Administering and titrating IV medication drips such as vasopressors and inotropes
- Administering enteral or parenteral nutrition
- Administering antibiotics as prescribed
Evaluation
- Assess the clients response to the treatments
- Ask yourself: Did the client Improve, Worsen, or Stay the same?
Optimizing Oxygen Delivery
- Increase supply and decrease demand
- Optimize CO with fluids or drugs
- Increase hemoglobin
- Increase arterial oxygen saturation with supplemental O2 and mechanical ventilation
Fluid Resuscitation
- Cornerstone of therapy for septic, hypovolemic, and anaphylactic shock
- Begin with 1-2 large-bore IV catheters, IO access device, or central venous catheter
- Goal is to restore tissue perfusion by watching for urine output, neurologic function, peripheral pulses
Drug Therapy for Shock
- Goal is to correct decreased tissue perfusion-vasoconstrictors properties
- Drugs are given IV via infusion pump and central venous line
Nutrition
- Common to see protein-calorie malnutrition due to hypermetabolism
- Enteral nutrition (EN) should be started within the first 24 hours
General Treatment
- Supportive care
- Administration of IV fluids
- Mechanical ventilation and hemodynamic monitoring
Specific Shock Treatments by Class
- Fluid resuscitation at least 30 mL/kg during the first 3 hours
- Begin IV antibiotics within 1 hour of recognizing the signs of septic shock
- Treatment of non-hemorrhagic hypovolemic shock is the rapid infusion of isotonic of crystalloids for a total of 30 mL/kg.
- First line of treatment for anaphylactic shock is IM epinephrine. Further treatment includes fluids with IV crystalloids, steroids, antihistamines and nebulized albuterol
- Find and stop the source of bleeding with hemorrhagic hypovolemic shock
- Vasopressors not recommended for hypovolemic shock because it can worsen tissue perfusion.
Nutrition
- Must be individualized for the client’s preexisting conditions, current condition, and nutrient needs for optimal healing
- Focuses on vasopressors, inotropes, optimization of fluid status, and treatment of the underlying cause or mechanical support. Norepinephrine is first line treatment
Mechanical Circulatory Support (MCS)
- Intra-aortic balloon pump (IABP
- Left ventricular assist devices (LVAD)
- Extracorporeal membrane oxygenation (ECMO)
- Cardiac transplantation
Anaphylactic Shock Treatment
- Administer IM epinephrine as first line
- Remove the culprit for the allergic reaction
- Further treatment includes fluid resuscitation, with IV crystalloids, driven by the client’s hemodynamic status
Septic Shock Treatment
- Administer crystalloid IV fluids
- Antibiotic therapy should begin within 1 hour of recognition
- Fluid resuscitation of at least 30 mL/kg during the first 3 hours of resuscitation
- Norepinephrine is the first drug of choice for vasopressor therapy
- Vasopressin should be added to the treatment regimen
Obstructive Shock Treatment
- Removing the cause
- Additional treatment consists of IV fluid administration and administration of vasopressors if needed
Vasopressors and Inotropes
- Vasopressors act to increase CO by increasing contractility/HR and SVR by causing vasoconstriction. Increasing the SVR leads to increased mean arterial pressure (MAP) and increased perfusion to organs
- Examples include phenylephrine, norepinephrine, epinephrine, and vasopressin. Dopamine is a vasopressor with inotrope properties that is dose-dependent
- Inotropes increase cardiac contractility, improving aid cardiac output (CO), which aids in maintaining MAP and perfusion to the body
- Examples include Dobutamine and milrinone
Rapid Infusion of IV Fluids
- Increases CO and tissue perfusion
- Crystalloids (Lactated Ringer’s, 0.9% sodium chloride)
- Colloid solutions include albumin and blood products
Assessments
- Fluid should be individualized per client
- Monitor laboratory values for electrolyte alterations and volume overload
Laboratory Findings to Evaluate Fluid Management
- BUN/Creatinine: May be elevated due to a decrease in renal perfusion from hypovolemia indicating a renal injury
- Transaminases: An elevated ALT and AST may indicate hypoxia of liver tissues
- Hemoconcentration: The hematocrit may be elevated due to an increase in the concentration of red blood cells in hypovolemia
Enteral and Parenteral Nutrition
- Enteral and parenteral nutrition may be used separately or in combination with each depending on the client’s needs and condition
- Nutrition for critically ill clients must be individually tailored for the client’s preexisting conditions, current condition, and nutrient needs for optimal healing.
Pharmaceutical Information
- Ceftriaxone (Rocephin): Anti-infective
- Norepinephrine (Levophed): Vasopressors
- Dobutamine (Dobutrex): Inotropes
- Albuterol (Proventil, Ventolin): Bronchodilators
- Hydrocortisone (Solu-cortef): Corticosteroid
- Diphenhydramine (Benadryl): Antihistamine
- Furosemide (Lasix): Loop diuretic
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