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The nurse is transferring a patient who is in the progressive stage of shock into ICU from the medical unit. The medical nurse is aware that shock affects many organ systems and that nursing management of the patient will focus on what intervention?
- A. Reviewing the cause of shock and prioritizing the patients psychosocial needs
- B. Assessing and understanding shock and the significant changes in assessment data to guide the plan of care
- C. Giving the prescribed treatment, but shifting focus to providing family time as the patient is unlikely to survive
- D. Promoting the patients coping skills in an effort to better deal with the physiologic changes accompanying shock
Correct Answer: B
Rationale: Nursing care of patients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. Early interventions are essential to the survival of patients in shock; thus, suspecting that a patient may be in shock and reporting subtle changes in assessment are imperative. Psychosocial needs, such as coping, are important considerations, but they are not prioritized over physiologic health.
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A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of circulatory shock should the nurses identify? Select all that apply.
- A. Anaphylactic
- B. Hypovolemic
- C. Cardiogenic
- D. Septic
- E. Neurogenic
Correct Answer: A,D,E
Rationale: The varied mechanisms leading to the initial vasodilation in circulatory shock provide the basis for the further subclassification of shock into three types: septic shock, neurogenic shock, and anaphylactic shock. Hypovolemic and cardiogenic shock are not subclassifications of circulatory shock.
A patient is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the patients care?
- A. Communicate clearly and frequently with the patients family.
- B. Taper down interventions slowly when the prognosis worsens.
- C. Transfer the patient to a subacute unit when recovery appears unlikely.
- D. Ask the patients family how they would prefer treatment to proceed.
Correct Answer: A
Rationale: As it becomes obvious that the patient is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided, throughout the patients care, for the family to see, touch, and talk to the patient. The onus should not be placed on the family to guide care, however. Interventions are not normally reduced gradually when they are deemed ineffective; instead, they are discontinued when they appear futile. The patient would not be transferred to a subacute unit.
The nurse, a member of the health care team in the ED, is caring for a patient who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention?
- A. Provide opportunities for the family to spend time with the patient, and help them to understand the irreversible stage of shock.
- B. Inform the patients family immediately that the patient will likely not survive to allow the family time to make plans and move forward.
- C. Closely monitor fluid replacement therapy, and inform the family that the patient will probably survive and return to normal life.
- D. Protect the patients airway, optimize intravascular volume, and initiate the early rehabilitation process.
Correct Answer: A
Rationale: The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the patient and helping them to understand the irreversible stage of shock is the best intervention. Informing the patients family early that the patient will likely not survive does allow the family to make plans and move forward, but informing the family too early will rob the family of hope and interrupt the grieving process. The chance of surviving the irreversible (or refractory) stage of shock is very small, and the nurse needs to help the family cope with the reality of the situation. With the chances of survival so small, the priorities shift from aggressive treatment and safety to addressing the end-of-life issues.
A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the patient? Select all that apply.
- A. Hypovolemia
- B. Difficulty breathing
- C. Cardiovascular overload
- D. Pulmonary edema
- E. Hypoglycemia
Correct Answer: B,C,D
Rationale: Fluid replacement complications can occur, often when large volumes are administered rapidly. Therefore, the nurse monitors the patient closely for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. Hypovolemia is what necessitates fluid replacement, and hypoglycemia is not a central concern with fluid replacement.
A critical care nurse is aware of similarities and differences between the treatments for different types of shock. Which of the following interventions is used in all types of shock?
- A. Aggressive hypoglycemic control
- B. Administration of hypertonic IV fluids
- C. Early provision of nutritional support
- D. Aggressive antibiotic therapy
Correct Answer: C
Rationale: Nutritional support is necessary for all patients who are experiencing shock. Hyperglycemic (not hypoglycemic) control is needed for many patients. Hypertonic IV fluids are not normally utilized and antibiotics are necessary only in patients with septic shock.