Shock & Sepsis
This type of shock results from severe blood or fluid loss.
What is hypovolemic shock?
Rationale:
Hypovolemic shock occurs when circulating blood volume decreases, leading to reduced preload, cardiac output, and tissue perfusion. Rapid fluid replacement is the priority intervention.
This rhythm has no organized electrical activity and requires immediate CPR and defibrillation.
What is ventricular fibrillation?
Rationale:
Ventricular fibrillation produces no cardiac output and is treated with immediate CPR and defibrillation.
After cardiac catheterization, this assessment should be performed frequently to detect impaired circulation.
What are distal pulse assessments?
Rationale:
Assessing peripheral pulses identifies arterial occlusion or impaired perfusion at the catheter insertion site.
This syndrome is defined as progressive dysfunction of two or more organ systems.
What is multiple organ dysfunction syndrome (MODS)?
Rationale:
MODS commonly develops after severe sepsis, trauma, or shock due to persistent tissue hypoperfusion.
A patient with septic shock has a blood pressure of 78/42 mmHg despite receiving IV fluids. The priority intervention is to administer this prescribed therapy.
What are vasopressors?
Rationale:
When hypotension persists after adequate fluid resuscitation, vasopressors are required to maintain MAP ≥65 mmHg and preserve organ perfusion.
This laboratory value is the best indicator of tissue hypoperfusion during sepsis.
What is serum lactate?
Rationale:
Elevated lactate reflects anaerobic metabolism caused by inadequate oxygen delivery to tissues and is used to assess the severity of shock and response to treatment.
This rhythm is treated first with atropine if the patient is symptomatic.
What is symptomatic bradycardia?
Rationale:
Atropine increases heart rate by blocking vagal stimulation of the heart.
This is the priority complication to assess for immediately after removal of a femoral arterial sheath.
What is bleeding or hematoma formation?
Rationale: Uncontrolled bleeding can rapidly lead to hypovolemic shock.
This organ system is commonly the first affected during MODS, resulting in acute respiratory distress syndrome (ARDS).
What are the lungs?
Rationale:
The lungs are particularly susceptible to inflammatory injury, making ARDS a common early manifestation.
A patient receiving morphine suddenly has a respiratory rate of 8 breaths/minute. What is the nurse's priority action?
What is assess the airway and administer naloxone if indicated?
Rationale:
Airway and breathing are the highest priorities. Naloxone reverses opioid-induced respiratory depression.
Within the first hour of recognizing sepsis, this medication should be administered after obtaining blood cultures.
What are broad-spectrum antibiotics?
Rationale:
Early antibiotic administration is associated with improved survival and is a cornerstone of the Surviving Sepsis Campaign guidelines.
This medication is commonly administered to terminate stable supraventricular tachycardia (SVT).
What is adenosine?
Rationale:
Adenosine briefly blocks AV nodal conduction, interrupting reentry pathways responsible for many SVTs.
Following coronary artery bypass graft (CABG) surgery, this intervention helps prevent postoperative pulmonary complications.
What is early ambulation and incentive spirometry?
Rationale:
These interventions reduce atelectasis, improve ventilation, and decrease the risk of pneumonia.
This hourly assessment provides one of the best indicators of renal perfusion.
What is urine output?
Rationale:
Urine output of at least 30 mL/hr generally indicates adequate renal perfusion.
A telemetry monitor displays ventricular fibrillation. What is the nurse's first action?
What is initiate CPR and prepare for immediate defibrillation?
Rationale:
Ventricular fibrillation is a pulseless, shockable rhythm requiring immediate CPR and defibrillation to restore circulation.
Persistent hypotension despite adequate fluid resuscitation requiring vasopressors defines this condition.
What is septic shock?
Rationale:
Septic shock is characterized by profound circulatory and metabolic abnormalities that require vasopressor support to maintain adequate perfusion.
This dysrhythmia significantly increases the patient's risk for ischemic stroke.
What is atrial fibrillation?
Rationale:
Blood stasis in the atria promotes clot formation, increasing the risk of embolic stroke.
Patients with an implantable cardioverter-defibrillator (ICD) should avoid prolonged exposure to this.
What are strong magnetic fields?
Rationale:
Strong magnetic fields may interfere with ICD function.
This acid-base disturbance commonly develops when tissues are inadequately perfused.
What is metabolic acidosis?
Rationale:
Poor oxygen delivery leads to anaerobic metabolism and lactic acid accumulation.
A patient one day after cardiac catheterization reports sudden coolness and numbness in the affected leg. What should the nurse do first?
What is assess distal pulses and notify the provider immediately?
Rationale:
These findings may indicate arterial occlusion. Rapid assessment and intervention are necessary to preserve limb perfusion.
This hemodynamic goal indicates adequate organ perfusion in patients with septic shock.
What is a mean arterial pressure (MAP) of at least 65 mmHg?
Rationale:
Maintaining MAP ≥65 mmHg helps ensure adequate blood flow to vital organs.
This pulseless rhythm is treated with CPR and epinephrine but is not defibrillated.
What is pulseless electrical activity (PEA)?
Rationale:
PEA has organized electrical activity without mechanical contraction. Defibrillation is ineffective because there is no shockable rhythm.
Following PCI, recurrence of this symptom requires immediate evaluation for possible restenosis or reinfarction.
What is chest pain?
Rationale:
New chest pain after PCI may indicate coronary artery occlusion requiring urgent intervention.
This nursing intervention helps reduce ventilator-associated pneumonia in critically ill patients.
What is elevating the head of the bed 30–45 degrees?
Rationale:
Head-of-bed elevation decreases aspiration risk and is part of evidence-based ventilator care bundles.
A patient with sepsis becomes increasingly confused, has decreased urine output, and a rising lactate level. What is the nurse's priority concern?
What is worsening tissue hypoperfusion progressing toward multiple organ dysfunction syndrome (MODS)?
Rationale:
Altered mental status, oliguria, and elevated lactate are signs of worsening organ perfusion and impending organ failure, requiring immediate reassessment and escalation of care.