Chapter 67 Nursing Management: Shock, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome

1. a normal cardiac output in cardiogenic shock. 1. When assessing a patient in shock, the nurse recognizes that the hemodynamics of shock include 1. a normal cardiac output in cardiogenic shock. 2. an increase in central venous pressure in hypovolemic shock. 3. an increase in systemic vascular resistance in all types of shock. 4. variations in cardiac output and decreased systemic vascular resistance in septic shock. Answer: 4 Rationale: Septic shock has three major pathophysiologic effects: vasodilation, maldistribution of blood flow, and myocardial depression. Patients may be normovolemic, but because of acute vasodilation, relative hypovolemia and hypotension may occur. The ejection fraction is decreased for the first few days after the initial insult. Because of a decreased ejection fraction, the ventricles will dilate to maintain stroke volume. The ejection fraction typically improves and ventricular dilation resolves over 7 to 10 days. Persistence of a high CO and a low SVR beyond 24 hours is an ominous finding and is often associated with increased development of hypotension and MODS. Systemic vascular resistance (SVR) increases in cardiogenic and hypovolemic shock; SVR decreases in neurogenic, anaphylactic, and septic shock. Cardiac output decreases in cardiogenic shock. Central venous pressure decreases in hypovolemic shock.

1. increased blood glucose levels. 2. increased serum sodium levels. 2. The nurse determines that the patient in shock has progressed beyond the compensated stage when laboratory tests reveal 1. increased blood glucose levels. 2. increased serum sodium levels. 3. increased serum potassium levels. 4. increased serum calcium levels. Answer: 3 Rationale: Hyperkalemia occurs in the progressive phase of shock when cellular death liberates intracellular potassium. Hyperkalemia will also occur in acute renal failure and in the presence of acidosis.

1. Insert an indwelling urinary catheter. 3. A patient admitted to the hospital from a long-term care facility appears to be in the late stage of shock with systemic inflammatory response syndrome (SIRS). Which of the following orders implemented by the nurse has the highest priority? 1. Insert an indwelling urinary catheter. 2. Insert two large-bore intravenous catheters. 3. Administer 0.9% normal saline at 100 ml/hr. 4. Administer 100% oxygen by non-rebreather mask. Answer: 4 Rationale: A patient in the irreversible stage of shock (late stage) will demonstrate profound hypotension and hypoxemia. If the condition progresses to systemic inflammatory response syndrome, the patient may experience profound hypoxemia. Oxygenation is a priority and should be initiated first with a 100% oxygen delivery method such as a non-rebreather mask.

4. decreasing blood pressure. 4. A patient with a history of alcoholism is admitted to the intensive care unit (ICU) with hemorrhage from esophageal varices. Admission vital signs are blood pressure 84/58 mm Hg, pulse 105 beats/min, and respiratory rate 32 breaths/min. The nurse recognizes the onset of systemic inflammatory response syndrome (SIRS) upon finding 1. pulmonary edema. 2. cardiac dysrhythmias. 3. absent bowel sounds. 4. decreasing blood pressure. Answer: 1 Rationale: The respiratory system is often the first system to show signs of dysfunction in systemic inflammatory response syndrome. Increases in capillary permeability facilitate movement of fluid from the pulmonary vasculature into the pulmonary interstitial spaces. The fluid then moves to the alveoli, causing alveolar edema and pulmonary edema.