Free Flow
Sudden shortness of breath, chest pain, and tachycardia in a client with a DVT suggest this complication.
pulmonary embolism (PE)
This nursing action is required before obtaining accurate readings from an invasive hemodynamic monitoring system.
leveling and zeroing the transducer
This 2 vital sign combination is commonly associated with shock and decreased tissue perfusion.
hypotension and tachycardia
Increasing creatinine and decreasing urine output indicate declining perfusion to this organ.
kidneys
When a client develops acute pulmonary edema from heart failure, this basic nursing intervention helps reduce the work of breathing.
positioning the client in High Fowler's position
This neurological change is often an early indicator of decreased cerebral perfusion.
new-onset confusion or altered mental status
This invasive monitoring device provides continuous, beat-to-beat blood pressure measurements and allows frequent arterial blood sampling.
arterial line
Warm, flushed skin in the early stages is most commonly associated with this type of distributive shock.
septic shock
Confusion + headache + unilateral weakness forms this neurological pattern.
possible ischemic stroke
Applying compression devices to a postoperative client reduces the risk of this complication.
deep vein thrombosis (DVT)
A client’s hemoglobin decreases from 13 g/dL to 9 g/dL after surgery. This trend indicates this.
ongoing blood loss
An elevated level of this laboratory test may indicate recent clot formation and breakdown.
D-dimer
Low cardiac output, elevated SVR, cool extremities, and hypotension are consistent with this type of shock.
cardiogenic shock
A client with elevated CVP, crackles, jugular venous distention, and peripheral edema is most likely experiencing this hemodynamic problem.
fluid volume overload (or heart failure)
For a client with hypotension due to dehydration, this intervention is expected to improve circulating volume.
administering isotonic IV fluids
This assessment finding, when occurring with cool skin and delayed capillary refill, strengthens the conclusion that perfusion is declining.
decreasing urine output
This lab value is used to monitor unfractionated heparin therapy.
aPTT (activated partial thromboplastin time)
Persistent hypotension despite compensation is characteristic of this stage of shock.
progressive stage
A client reports increasing chest pain while troponin levels continue to rise. This pattern suggests this condition is worsening.
myocardial ischemia or infarction
This nursing intervention reduces the risk of air entering a central venous catheter during tubing changes.
clamping the catheter (if appropriate) and ensuring all connections are secure
The nurse should report this combination of findings immediately: MAP 60 mm Hg, urine output 15 mL/hr, and this laboratory trend.
increasing serum lactate level
This imaging study is commonly used to diagnose a pulmonary embolism.
CT pulmonary angiogram (CTPA)
Tachycardia, increased respiratory rate, and cool skin are common findings during this stage of shock.
compensatory stage
This complication is suspected when the client's hand becomes pale, cool, and has diminished pulses after arterial line insertion.
arterial occlusion or limb ischemia
Administering vitamin K to a client on warfarin will have this effect on coagulation.
increased clotting ability (reduced INR)