lOMoARcPSD|19431042
AAH Exam 4 Study Guide
Chapters 11, 13, 67, 68
1. Shock signs and symptoms pg. 274









Shock is a clinical syndrome that results from inadequate ssue perfusion, creang an
imbalance between the delivery of oxygen and nutrients needed to support cellular funcon
Adequate blood ow to the ssues and cells requires an eecve cardiac pump, adequate
vasculature or circulatory system, and sucient blood volume.
If one of these components is impaired, perfusion to the ssues is threatened or compromised
Shock aects all body systems. It may develop rapidly or slowly, depending on the underlying
cause
The primary underlying pathophysiologic process and underlying disorder are used to classify
the shock state
Regardless of the inial cause of shock, certain physiologic responses are common to all types
of shock
 Hypoperfusion of ssues
 Hypermetabolism
 Acvaon of the inammatory state
Local regulatory mechanisms, referred to as autoregulaon, smulate vasodilaon or
vasoconstricon in response to biochemical mediators released by the cell, communicang the
need for oxygen and nutrients.
Tissue perfusion and organ perfusion depend on MAP, or the average pressure at which blood
moves through the vasculature.
MAP must exceed 65mmHg for cells to receive oxygen and nutrients needed to metabolize
energy in amounts sucient to sustain life.
2. Nursing intervenons of shock pg. 274, pg. 282
Downloaded by Mya Hauer (hauermya@gmail.com)
lOMoARcPSD|19431042







Nurses caring for paents with shock and those at risk for shock must understand the
underlying mechanisms of the various shock states (hypovolemic, cardiogenic, obstrucve,
disrupve, sepc, neurogenic, and anaphylacc shock) and recognize the subtle as well as more
obvious signs of each of these states
If shock is not eecvely treated, mulple organ dysfuncon syndrome (MODS) will result
causing death
Rapid assessment recognion and response to shock states and sepsis is essenal to the
paent’s recovery
Support of the respiratory system with supplemental oxygen and/ or mechanical venlaon
Fluid replacement to restore intravascular volume normal Saline or lactated Ringer’s
Vasoacve medicaons to restore vasomotor tone and improve cardiac funcon
 Norepinephrine, dopamine, phenylephrine vasopressin is used when uid therapy alone
does not maintain the MAP
 Connuous monitoring of VS at least every 15 minutes
Nutrional support to address the metabolic requirements that are oen dramacally increased
in shock
3. Stages of shock, signs and symptoms and nursing intervenons pg. 275















Shock progresses along a connuum and can be idened as early or late, depending on the
signs and symptoms and the overall severity of organ dysfuncon
There are 3 stages:
 Stage 1 Compensatory
 Stage 2 Progressive
 Stage 3 Irreversible
Compensatory Stage (1) S&S: BP remains Normal, Vasoconstricon, HR and contraclity of
the heart contributes to maintaining adequate cardiac output
The SNS causes paents to display the “ght-or ight” response
The body shunts from organs such as the skin, kidneys, and GI tract to the Brain, heart, and
Lungs to ensure adequate blood supply to these vital organs.
The skin may be cool and pale (capillary rell ≤3.5s)
Bowel sounds are hypoacve, and urine output  in response to the release of aldosterone and
ADH
The result of inadequate perfusion is anaerobic metabolism and buildup of lacc acid,
producing metabolic acidosis
The RR  (100bpm) due to oxygen demand to the cells and in compensaon for metabolic
The rapid RR (≥22 breaths/min) facilitates removal of excess CO2, but rises the pH and oen
cases compensatory Respiratory Alkalosis (pH, PCO2)
The paent will begin to anxious, or be confused
If Tx. begins in this stage of shock, the prognosis for the paent is beer than in later stages.
Nursing Intervenons: Early intervenon is key to improving the paent’s prognosis
Recognizing subtle clinical signs of compensatory stage before the paent’s BP drops
Early intervenons include administraon of IV uids and Oxygen, and obtaining necessary
laboratory tests to rule out and treat metabolic imbalances or infecon
 Monitoring Tissue Perfusion: RN observes subtle changes in LOC, Vital signs (including
pulse pressure), urinary output, skin capillary rell and moling), RR and laboratory
values
Downloaded by Mya Hauer (hauermya@gmail.com)
lOMoARcPSD|19431042
Serum sodium and blood glucose levels are elevated in response to the release of
aldosterone and catecholamines
 If infecon is suspected blood cultures should be obtained for proper administraon of
anbiocs
 Vital signs are indicators of hemodynamic status, and BP is an indirect measure of ssue
hypoxia
 The RN should report a systole BP of 100mmHg or lower, or a drop in systolic BP of
40mmHg from baseline or a MAP of 65mmHg or less
 Nofy the PCP promptly if the paent exhibits any two of the three following signs”
 RR ≥ 22 bpm
 Altered mentaon
 Systolic BP ≤ to 100mmHg
 INTERVENTIONS FOCUSES ON DECREASING TISSUE OXYGEN REQUIREMENTS AND
INCREASING PERFUSION TO DELIVER MORE OXYGEN TO THE TISSUES
 Reducing Anxiety: providing brief explanaon about the diagnosis and treatment
procedures, supporng the paent during these procedures, and providing informaon
about their outcomes are usually eecve in reducing stress and anxiety and thus
promong the paent’s physical and well-being.
 Clarifying advanced direcves: Nurse to ask paents on admission if they have advance
direcves, including durable power of aorney for health care or living wills, or if they
have had conversaons with anyone about their health care wishes.
 Promong Safety: close monitoring, frequent reorientaon, hourly rounding, and
implemenng intervenons to prevent falls are essenal
Progressive Stage (2) S&S: Mechanisms that Regulate the BP no longer compensate, and the
MAP falls below normal limits.
 Paent shows signs of declining mental status.
 All organs suer from hypoperfusion at this stage
 Chances of survival depend on the paent’s health and the amount of me it takes to
restore ssue perfusion
 Blood Pressure: Systolic ≤ 100mmHg; MAP ≤ 65. Requires uid resuscitaon to support
BP
 HR >150 bpm due to the lack of adequate blood supply it leads to arrhythmias and
ischemia. Paent may complain of chest pain and could suer a (MI). Levels of troponin
levels will increase
 Respiratory Status will be rapid and shallow; crackles are heard over lung elds
 ↓ pulmonary blood ow causes arterial oxygen levels to ↓ and CO2 to ↑ (PaO2
<80mmHG, PaCO2 > 45 mmHg)
 Pulmonary capillaries begin to leak, causing pulmonary edema, diusion abnormalies
(shunng), and addional alveolar collapses and could lead to ARDS
 Skin Moling, petechiae Capillary Rell ≥ 3.5s
 When the MAP falls below 65mmHg changes in the renal funcon occur. AKI occurs due
to ↑ (BUN) serum creanine levels, uid and electrolytes shi, acid-bases imbalances
 Urinary output usually decreases to less than 0.5mL/kg/h
 Changes in mental status occur with decreased cerebral perfusion and hypoxia. As blood
ow to the brain becomes impaired, mental status deteriorates.
 Paent will exhibit behaviors of agitaon, confusion, and shows signs of delirium
 Paent will be in Metabolic Acidosis (↓pH, ↓HCO3). Due to the liver not being able to
metabolize medicaons and metabolic waste products such as ammonia and lacc acid
 GI ischemia can cause stress ulcers in stomach, oung the paent at risk for GI Bleeding


Downloaded by Mya Hauer (hauermya@gmail.com)
lOMoARcPSD|19431042
Combinaon of hypotension, sluggish blood ow, metabolic acidosis, coagulaon system
imbalance and generalized hypoxemia can result if hematologic eects
 DIC may occur either as a cause or as a complicaon of shock. Ecchymoses and
petechiae may appear in the skin.
Nursing Intervenons: paents in this stage are cared for in an ICU unit with close monitoring
of ECG, ABG’s, serum electrolyte levels, physical and mental status changes.
 Rapid and frequent administraon of various prescribed medicaons and intervenons
such as with mechanical intervenon and dialysis may be needed
 Nursing intervenons that reduce the incidence of venlator-associated pneumonia
(VAP) must be implemented
 This includes frequent oral care, with a toothbrush, asepc sucon technique, turning,
elevang the HOB 30 degrees to prevent aspiraon, and implement daily interrupon of
sedaon (benzodiazepines) as prescribed to evaluate the paent’s readiness for
extubaon
 Posioning and reposioning of the paent to promote comfort and maintain skin
integrity are essenal
 Delirium should be assessed at a minimum each shi
 Eorts are made to minimize cardiac workload and reducing the paent’s physical
acvity and treang pain and anxiety. Conserve the paent’s energy.
Irreversible Stage: represents the point on which organ damage is so severe the paent does
not respond to treatment and cannot survive.
 The BP remains low despite treatment, requires mechanical and pharmacological
support
 The HR is errac
 Respiratory Status requires intubaon and mechanical venlaon
 Renal and liver dysfuncon creates an acute metabolic acidosis (Profound Acidosis)
 Death is imminent
 Skin is Jaundice, Urinary output is Anuric and requires dialysis, Mental status is
unconscious.
Nursing Intervenons: the nurse focuses on carrying out prescribed treatments, monitoring the
paent, prevenng complicaons
 Protecng the paent from injury, and providing comfort
 Oering brief explanaons to the paent about what is happening is essenal even if
there is no certainty that the paent hears or understands what is being said
 Opportunies should be provided throughout the paent’s care for the family to see,
touch, and talk to the paent.
 Distraught grieving families may interpret this as a chance for recovery when non exists,
and family members may become angry when the paent dies.
 Engaging palliave care specialists




4. Mulple Organ Dysfuncon Syndrome (MODS) pg. 297
 It develops with acute illness that compromises ssue perfusion
 Presence of altered funcon of two or more organs
 Commonly seen in paents with sepsis as a result of inadequate ssue perfusion
 High mortality rate: 75%
 The clinical presentaon of MODS is insidious; ssues become hypoperfused eventually causing
organ dysfuncon that requires mechanical and pharmacologic intervenon to support organ
funcon
Downloaded by Mya Hauer (hauermya@gmail.com)
lOMoARcPSD|19431042








Organ failure begins in the lungs, and cardiovascular instability, as well as failure of the hepac,
GI, Renal, immunologic, and CNS.
The sequence of organ dysfuncon varies depending on the paent’s primary illness and
comorbidies before experiencing shock
Paents experience progressive dyspnea, and respiratory failure manifested as ALI and ARDS
The paent usually remains hemodynamically stable but may require increasing amounts of IV
uids and vasoacve agents to support BP and cardiac output
Signs of hypermetabolic state, characterized by hyperglycemia
Severe loss of skeletal muscle mass
The goal of all shock stages is to reverse the ssue hypoperfusion and hypoxia
The more organs fail the worse the outcome.
5. Cardiogenic shock pg. 287













Occurs when the heart’s ability to contract and pump blood is impaired and the supply of
oxygen is inadequate for the heart and ssues
The causes are known as coronary and noncoronary. Coronary is seen in most paents with MI
resulng in damage to a signicant poron of the le ventricle myocardium
Noncoronary causes are related to condions that stress the myocardium (severe hypoxemia,
acidosis, hypoglycemia, hypocalcemia, tension pneumothorax)
Cardiac output, which is a funcon of both stroke volume and heart rate, is compromised
 ↓cardiac contraclity
 ↓ stroke volume & cardiac output the BP will also ↓ and ssue perfusion is reduced
 Because impaired ssue perfusion weakens the heart and impairs its ability to pump, the
ventricle does not fully eject its volume of blood during systole
 As a result, uid accumulates in the lungs causing ↑ pulmonary congeson
Manifestaons: may experience the pain of angina, develop arrhythmias, complain of fague,
express feelings of doom, and show signs of hemodynamic instability
Correcon of underlying causes: the paent may require thrombolyc therapy, coronary
intervenon, CABG, IABP therapy, ventricular assist device, or some combinaon of these
treatments.
If oxygen falls below 90%, supplemental oxygen therapy is given of 2 to 6 L/min. (monitor ABG’,
pulse oximeter, and venlatory eorts)
Hemodynamic monitoring
Administraon of uids must be monitored closely to detect signs of uid overload
Pharmacological Therapy: Vasoacve medicaon therapy consists of mulple pharmacological
strategies to restore and maintain adequate cardiac output.
Inotropic Medicaons such as Dobutamine increases the cardiac output by mimicking the
acon of the SNS, acvang myocardial receptors (beta-receptors) to increase myocardial
contraclity.
Vasodilators, are used primarily to decrease the aerload, reducing the workload of the heart
and oxygen demand
 such as Nitroglycerin given in higher doses, causes arterial vasodilaon and therefore
reduces aerload.
 These acons with Dobutamine, increased cardiac output while decreasing cardiac
workload
Dopamine also has vasoacve eects depending on the dosage. It may be used with
Dobutamine and nitroglycerin to improve ssue perfusion. (it improves contraclity)
Downloaded by Mya Hauer (hauermya@gmail.com)
lOMoARcPSD|19431042



Dopamine should be carefully trated because eects could be undesirable in paents with
cardiogenic shock
Anarrhythmic Medicaons are required to stabilize the Heart Rate.
 Due to factors such as hypoxemia, electrolyte imbalance, and acid-base imbalances,
contribute to serious cardiac arrhythmias
Nursing Management: revolves around prevenng serious complicaons, monitoring
hemodynamics, administering medicaons, and uids, promong safety and comfort
 Prevenng cardiogenic shock
 Monitoring hemodynamic Status: ECG monitoring, medicaons, IV uids, a
 Administering Medicaons and Intravenous Fluids: uid overload and pulmonary edema
are at risk because of the accumulaon of blood and uid in the pulmonary ssues.
o The nurse must also monitor urine output, serum electrolytes, BUN, Creanine
levels to detect decreased renal funcon
6. Signs and symptoms of approaching death pg. 376, pg. 377 chart 13-4









Paents approaching the end-of-life experience many symptoms, regardless of their underlying
disease process
Symptoms in terminal illness may be caused by the disease, either directly (dyspnea due to
chronic obstrucve lung disease) or indirectly (N&V related to pressure in the gastric area), by
the treatment of the disease, or by coexisng disorder that is unrelated to the disease
Symptoms should be carefully assessed and managed. With pharmacologic and nonpharmacologic
Pharmacologic symptom management are the use of the smallest dose of the medicaon to
achieve the desired eect, avoidance pf polypharmacy, and management of adverse eects
Pain: is a common symptom for illnesses such as COP, Cancer and renal diseases
 The primary goal is to ensure that pain is assessed, prevented where possible, and
managed
Dyspnea: am uncomfortable awareness of breathing, is one of the most prevalent symptoms at
the end-of-life
 Visible signs of distress such as tachypnea, diaphoresis, or cyanosis
Impaired Secreons at the End-of-life: may be manifested by noisy, gurgling breathing or
moaning
 In most cases, the sounds of breathing are related to oropharyngeal relaxaon with the
inability to clear secreons through cough and swallowing due to somnolence
Anorexia and Cachexia are common of seriously ill paents
 Is characterized by the disturbance in carbohydrate, protein, and fat metabolism
“wasng away” endocrine funcon, anemia. The syndrome results in severe asthenia
(loss of energy)
 Cachexia is associated with anabolic and catabolic changes in metabolism that relate to
acvity in profound protein loss desire for food and uid may diminish
 People may no longer be able to use, eliminate, or store nutrients and uids adequately
Anxiety and depression paents experience at the end-of-life.
 Anxiety may be exacerbated by other symptoms such as pain or dyspnea.
Downloaded by Mya Hauer (hauermya@gmail.com)
lOMoARcPSD|19431042
Clinical depression should neither be accepted as an inevitable consequence of dying
nor confused with sadness and ancipatory grieving, which are normal reacons with
impending death
Delirium: Delirium refers to concurrent disturbances in the level of consciousness, aenon,
awareness, and cognive capability that develop over a short me
 Many paents remain alert, arousable, and able to communicate unl very close to
death.
 Others sleep for long intervals and awaken only intermiently, with eventual
somnolence unl death
 Delirium may be related to metabolic changes, infecon, and organ failure
 Sleep depravaons and hallucinaons may occur
Many paents experience fague, the suer from conspaon as a side eect of medicaons,
such as opioids, and sedentary naon. They will also suer from inconnence
Nausea and voming may be common
Skin breakdown occurs as the organs including the skin begin to fail, decreased temperature
control
Impaired vision, hearing,






7. Bronchodilators and corcosteroids pg. 379



Treatment for Dyspnea (it is aimed at modifying lung physiology and improving performance as
well as altering the percepon of the symptom)
Are used to treat underlying obstrucve pathology, thereby improving overall lung funcon
Is used as a palliave nursing intervenon for Dyspnea to treat the underlying cause
8. Palliave care pg. 368



Interdisciplinary model of care that focuses on symptom management and
psychosocial/spiritual support for those with serious life-liming illness
It is appropriate at any age and at any stage in a serous illness, even while pursuing diseasedirected or curave therapies
Interdisciplinary collaboraon is an essenal component which is rooted in communicaon and
collaboraon among the various disciplines to address the needs of paent and family
9. Hospice pg. 368, 372





Is a type of palliave care, focusing on comfort at the end-of-life
Paents that enroll in hospice have made the decision to forgo disease-directed therapies ad
focus solely on the relief of symptoms associated with their illness and the dying process
All hospice care is palliave care but not all palliave care is hospice
The dierence is that hospice is delivered at the end-of-life care
It focuses on the quality of life, and by necessity, it includes realisc emoonal, social, spiritual,
and nancial preparaon of death
10. Altered LOC signs and symptoms pg. 2186

During emergency Nursing, determine the neurologic disability by assessing neurologic funcon
using the Glasgow Coma Scale and a Motor and Sensory evaluaon of the spine
Downloaded by Mya Hauer (hauermya@gmail.com)