Pathophysiology and Collaborative Care for Shock Patients | Exams Nursing

Case Study Shock Multiple Cases

Huang Mei Lan is a 43 year old unmarried female who lives alone in a major West Coast city. Three years

ago she was diagnosed with breast cancer and underwent a mastectomy of the affected breast and follow

up chemotherapy. Last month, Ms. Lan experienced a recurrence of cancer in the lymph glands of the

affected side. Surgery to remove the glands was performed and chemotherapy started. Ms. Lan has a

central line, a urinary catheter, and a surgical incision. The nurse enters Ms. Lan’s room and find her

huddled in the middle of the bed shivering violently.

1. Relate Ms Lan’s current manifestations to the pathophysiology of shock to determine what type of shock

she could be experiencing.

Since she recently started chemotherapy, she could be neutropenic which could put her at

risk at risk for an infection due to her recent surgery. Also, with having a Foley catheter

she is at an increased risk for a UTI. Having a central line gives a direct line into her

vascular system so she is at an increased risk for a blood infection. Low neutrophil count

plus these invasive lines gives her an increased risk for infections. With lymph nodes

being removed on her surgical side, means she has an increased risk for infection on that

side. With the patient shivering out of control, and just having chemo and surgery, I could

most likely determine that it is septic shock that she is experiencing.

With septic shock, when bacteria enters the blood, there is an inflammatory response.

This causes vasodilation, decreased cardiac output, and cool extremities. This is due to

leukocyte lysis that causes release of histamine, serotonin, lysosomal enzymes, and

kinins. This causes the inflammatory response and fluid buildup in extremities. This

would cause her shivering.

2. Apply principles of collaborative care for Ms Lan’s form of shock to determine what the nurse’s initial

response should be and why.

You would want to call the doctor after a full set of vital signs are obtained. You would

want to get vital signs because it appears that she is having symptoms of septic shock.

You would want to inform him that she is shivering and let him know what vital signs are

obtained. You would expect a high fever, low BP, and a high respiratory rate. Also, if her

O2 sat is low and/or she is breathing rapidly, you would want to get an order for oxygen

and put that on then call respiratory to assess her. I would expect the doctor to want me to

get blood cultures, one set from the central line and the other from the arm that didn’t

have the mastectomy. I would expect an order for antibiotics and Tylenol to be given.

Huang Mei Lan Vital signs are:T 104, P 110, R 30, BP 106/66Skin- hot, dry flushed with poor turgor Alert

and oriented, restless, and anxious

3. With this additional data, do you agree with your original interpretation of the kind of shock Ms Lan is

experiencing? Why or why not?

Yes, since she is running a fever, having tachycardia, has high respiratory rate, and low

BP, but she could be in a more severe shock than we originally thought. She has poor skin

turgor and is getting restless and anxious, which are all signs of sepsis.

4. Now, based on new data, what type of shock is Ms Lan experiencing?

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Case Study Shock Multiple Cases Huang Mei Lan is a 43 year old unmarried female who lives alone in a major West Coast city. Three years ago she was diagnosed with breast cancer and underwent a mastectomy of the affected breast and follow up chemotherapy. Last month, Ms. Lan experienced a recurrence of cancer in the lymph glands of the affected side. Surgery to remove the glands was performed and chemotherapy started. Ms. Lan has a central line, a urinary catheter, and a surgical incision. The nurse enters Ms. Lan’s room and find her huddled in the middle of the bed shivering violently.

Relate Ms Lan’s current manifestations to the pathophysiology of shock to determine what type of shock she could be experiencing.  Since she recently started chemotherapy, she could be neutropenic which could put her at risk at risk for an infection due to her recent surgery. Also, with having a Foley catheter she is at an increased risk for a UTI. Having a central line gives a direct line into her vascular system so she is at an increased risk for a blood infection. Low neutrophil count plus these invasive lines gives her an increased risk for infections. With lymph nodes being removed on her surgical side, means she has an increased risk for infection on that side. With the patient shivering out of control, and just having chemo and surgery, I could most likely determine that it is septic shock that she is experiencing.  With septic shock, when bacteria enters the blood, there is an inflammatory response. This causes vasodilation, decreased cardiac output, and cool extremities. This is due to leukocyte lysis that causes release of histamine, serotonin, lysosomal enzymes, and kinins. This causes the inflammatory response and fluid buildup in extremities. This would cause her shivering.
Apply principles of collaborative care for Ms Lan’s form of shock to determine what the nurse’s initial response should be and why.  You would want to call the doctor after a full set of vital signs are obtained. You would want to get vital signs because it appears that she is having symptoms of septic shock. You would want to inform him that she is shivering and let him know what vital signs are obtained. You would expect a high fever, low BP, and a high respiratory rate. Also, if her O2 sat is low and/or she is breathing rapidly, you would want to get an order for oxygen and put that on then call respiratory to assess her. I would expect the doctor to want me to get blood cultures, one set from the central line and the other from the arm that didn’t have the mastectomy. I would expect an order for antibiotics and Tylenol to be given. Huang Mei Lan Vital signs are:T 104, P 110, R 30, BP 106/66Skin- hot, dry flushed with poor turgor Alert and oriented, restless, and anxious
With this additional data, do you agree with your original interpretation of the kind of shock Ms Lan is experiencing? Why or why not?  Yes, since she is running a fever, having tachycardia, has high respiratory rate, and low BP, but she could be in a more severe shock than we originally thought. She has poor skin turgor and is getting restless and anxious, which are all signs of sepsis.
Now, based on new data, what type of shock is Ms Lan experiencing?

 She is experiencing sepsis.

What stage of shock is Ms Lan experiencing?  Severe sepsis
What would be the expected laboratory tests for Ms Lan?  Blood cultures from the central line and one from non-surgical side arm. Also, a CBC with platelets, which would include her white count with differentials. They also might want to do a CMP to look at her kidney function. I may see a DIC Panel, activated protein C, lactic acid level, and ABGs done.
Apply principles of collaborative care for clients experiencing shock to determine what are, in general and specific to Ms Lan, the expected medical/pharmaceutical treatment/interventions?  I would expect the doctor to order IV fluids, oxygen, and antibiotics. I would see vasoconstrictor and inotropic agents and possible steroid therapy through her IV for inflammation management. I would expect more frequent vital signs to be taken and maybe have her moved to the ICU so she can have 1 on 1 care. Insulin may be prescribed to maintain normoglycemia. The appropriate medical/pharmaceutical interventions have been implemented for Ms Lan.
Discuss nursing implication for treatment and medications prescribed for Ms Lan’s type of shock.  Oxygen to maintain oxygen levels and help with her rapid breathing. Oxygen demands increase with sepsis.  IV fluids to maintain good BP, make sure she does not become hypovolemic, and prevent kidney failure. We want to make sure that we aren’t overloading the patient with fluids by watching for edema and crackles in the lungs.  Vasoconstrictors to help increase BP. Antiobiotcs to help treat the infection. Insulin to maintain a normal glucose level. We want to make sure the BP doesn’t get too high.  Steriods to decrease inflammation. We want to monitor blood sugars in the patient.
Utilize the data in the preceding question to develop and prioritize a list of nursing diagnoses with 3 nursing interventions and one outcome criteria for Ms Lan.  Risk for hyperthermia o Measure and record vital signs every hour o Work with the doctor to help determine the cause of the temperature increase o Recognize that hyperthermia is a rise in body temperature above 40º C o OUTCOME: Maintain body temperature below 40º C

 Cardiogenic shock

What stage of shock is Mr. Tanner experiencing?  He is in the compensatory stage of cardiogenic shock, but is getting worse and could lead to the progressive stage.
What would be the expected laboratory tests for Mr. Tanner?  ABGs, cardiac enzymes, coagulation study, CMP and CBC
Apply principles of collaborative care for clients experiencing shock to determinewhat are, in general and specific to Mr. Tanner, the expected medical/pharmaceutical treatment/interventions?  I would expect him to be put on vasodilators, Sympathomimetic amines, aspirin, morphine, and possibly a diuretic. I would expect the patient to the tele monitor as well as having a EKG. I would expect that a cardiologist would be called right away and the patient would be taken to the cardiac cath lab to see if he has any major blockage in his heart. We would want him to be on oxygen. The appropriate medical/pharmaceutical interventions have been implemented for Mr. Tanner.
Discuss nursing implication for treatment and medications prescribed for Mr. Tanner.  EKG to determine his rhythm and rate, and to see if there is any changes to determine if he has had a MI.  Tele monitor to continuously watch his HR and rhthym.  Vasodilators (nitroglycerin) to increase perfusion to his body and increase cardiac output. We want to monitor to make sure the patient’s BP doesn’t get too low. Sympathomimetic amines to improve heart contractility and improve cardiac output and renal perfusion. Monitor to make sure the patient’s BP doesn’t get too low. Morphine to manage pain. We want to monitor that his respirations do not get too low. Diuretic to reduce venous return. We want to make sure that cause fluid deficit in this patient. Aspirin to help with blood flow through the vessels by thinning blood. We want to monitor for adverse effects like GI bleeding.  Oxygen to help with tissue perfusion.
Utilize the data in the preceding question to develop and prioritize a list of nursing diagnoses with 3 nursing interventions and one outcome criteria for Mr. Tanner.  Altered tissue perfusion R/T inadequate cardiac output  Monitor VS including O2 sats  Check capillary refills with assessments

 Record I/O’s every shift  OUTCOME: Patient will demonstrate adequate tissue perfusion  Decreased cardiac output  Monitor and report presence of shortness of breath  Monitor pulse oximetry every shift  Monitor for decreased cardiac output E/B edema  OUTCOME: Patient will demonstrate adequate cardiac output AEB BP, pulse and rhythm in normal parameters of patient  Acute pain  Assess pain level with vital signs  Manage pain with medications as prescribed  Ask patient to report side effects from pain meds such as nausea or itching  OUTCOME: Patient will verbalize that pain is being managed Client 3 Jane House, 20 years old, was admitted to the ED following an MVA (motor vehicle accident) earlier in the day. She was unrestrained passenger in an automobile that was T- boned by another motor vehicle on her side of the car. She was pinned in the wreckage for 30 minutes and an emergency transport helicopter brought her to the ED. She suffered a partially severed leg, chest contusion, possible fractured pelvis, open head wound, and fractured jaw. She has lost several units of blood. She has been in post- anesthesia care unit (PACU) for the past hour following surgery to reattach her leg and close her head wound. Her vital sign have been stable. The nurse enters the room to find Jane’s NG draining copious amounts of sanguineous fluid.

Relate Ms House’s current manifestations to the pathophysiology of shock to determine what type of shock she could be experiencing.  Hypovolemic shock due to blood loss
Apply principles of collaborative care for Ms. House’s type of shock to determine what the nurse’s initial response should be and why?

 We would use vasoconstrictors to help increase the BP. We want to monitor for signs of excessive vasoconstrictors. We want the inotropic drugs to improve heart muscle contraction and we want to monitor for CP and excessive tachycardia.

Utilize the data in the preceding question to develop and prioritize a list of nursing diagnoses with 3 nursing interventions and one outcome criteria for Ms House.  Deficit fluid volume 1. Monitor pulse, respirations, and BP 2. Check capillary refill 3. Administer IV fluids and blood products as ordered. OUTCOME: Patient will maintain a normal BP, pulse, and temperature.  Risk for electrolyte imbalance 1. Monitor cardiac rate and rhythm 2. Review lab data and report abnormals to provider 3. Administer IV fluids as ordered and monitor their effects OUTCOME: Patient will maintain normal electrolyte balance.  Risk for ineffective peripheral tissue perfusion 1. Check brachial, radial, dorsal pedis, posterior tibial, and popliteal pulse bilaterally. 2. Assess skin color and temperature of skin. 3. Check capillary refill. OUTCOME: Patient will demonstrate adequate tissue perfusion.
Suppose you are the emergency department nurse in charge of the care for Ms. House. Ms. House’s parents arrive in the emergency department insisting they need to see their daughter while you are implementing care for her shock. They are in control but upset. What would you do? Why?  I would let them know that we are administering care to her and let them know she is in satisfactory condition but needs emergent care immediately. I would ask them to please let the staff administer this care and as soon as the care is implemented we will get them in to see her as soon as possible. Client 4 Timothy Murphy, 30 years old, was admitted to ICU earlier today from ED following a diving injury. He

and his friends were swinging from a rope into a creek below when his head struck the bottom of the creek resulting in a cervical fracture and paralysis from his neck down. He has been alert and oriented, but his vital signs have been labile. He was placed on a ventilator on CMV at 12 BPM. His neck is immobilized in a cervical collar. The nurse enters the room because the ventilator alarms are going off.

Relate Mr. Murphy’s current manifestations to the pathophysiology of shock to determine what type of shock he could be experiencing.  He is experiencing neurogenic shock.
Apply principles of collaborative care for Mr. Murphy’s type of shock to determine what the nurse’s initial response should be and why?  Since he is already in the ICU and a respirator therapist is usually on hand right away, I would get the respirator therapist to assess the ventilator alarms. Timothy Murphy: His vital signs are: T 99. P 60 and boundingR 28, he is bucking the ventilator BP 82/60Skin- warm and dry
With this additional data, do you agree with your original interpretation of the kind of shock Mr. Murphy is experiencing? Why or why not?  Yes, he is having neurogenic shock. He is having difficulty breathing and his pulse is lower.
Now, based on new data, what type of shock is Mr. Murphy experiencing?  Neurogenic shock
What stage of shock is Mr. Murphy experiencing?  The initial stages of neurogenic shock
What would be the expected laboratory tests for Mr. Murphy?  We would want to do routine blood work of a CBC and a chemistry as well as ABGs
Apply principles of collaborative care for clients experiencing shock to determinewhat are, in general and specific to Mr. Murphy, the expected medical/pharmaceutical treatment/interventions?  restoring sympathetic tone, either through the stabilization of a spinal cord injury or, in the instance of spinal anesthesia, by positioning the patient properly  I would expect the doctor to order a CAT scan, MRI of his spine, I would expect a urinary catheter to be put in place since he is paralyzed from the neck down and may not be able to urinate on his own.

Encourage the client a self-help or therapy group OUTCOME: Patient will state accurate self-appraisal Client 5 Steve Cron is a 76 year old same day surgery patient admitted to the unit a few minutes ago from PACU following left hip hemi-arthroplasty. The nurse started his second dose of Ancef IV five minutes ago. He calls the nurse’s station and complains of itching and shortness of breath. The nurse arrives in his room and finds him extremely restless, anxious, and gasping.
Relate the Mr. Cron’s current manifestations to the pathophysiology of shock to determine what type of shock the client could be experiencing.  Anaphylactic shock
Apply principles of collaborative care for Mr. Cron’s type of shock to determine what the nurse’s initial response should be and why?  I would call a code and put oxygen on him. If he stops breathing I would start to perform CPR. Steve Cron His vital signs are: T 100. P 130 and irregularR 40, dyspneic, stridor, wheezing BP 60 with a dopplerSkin- warm, generalized edema Anxious and extremely restless
With this additional data, do you agree with your original interpretation of the kind of shock Mr. Cron is experiencing? Why or why not?  Yes, he is in anaphylactic shock because he is having stridor and wheezing, his BP is dropping rapidly, his pulse is high and he is extremely anxious because he can’t breathe.
Now, based on new data, what type of shock is Mr. Cron experiencing?  Anaphylactic shock
What stage of shock is Mr. Cron experiencing?  He is in severe anaphylactic shock
What would be the expected laboratory tests for Mr. Cron each client?  After the patient has a patent airway, I would expect the doctor to order ABGs, routine blood work, and specific allergy testing could be done.
Apply principles of collaborative care for clients experiencing shock to determine what are, in general and specific to Mr. Cron, the expected medical/pharmaceutical treatment/interventions?

 Fluid management is critical, as massive fluid shifts can occur within minutes due to increased vascular permeability. Intramuscular epinephrine is given for its vasoconstrictive action. Diphenhydramine (Benadryl) is given intravenously to reverse the effects of histamine, thereby reducing capillary permeability. Nebulized medications, such as albuterol (Proventil), may be given to reverse histamine-induced bronchospasm. The appropriate medical/pharmaceutical interventions have been implemented for Mr. Cron.

Discuss nursing implication for treatment and medications prescribed for Mr. Cron.  We would want to put an allergy bracelet on this patient that states he is also allergic to Ancef after he is stabalized. We would want to monitor his BP so that we aren’t over vasoconstricting the patient. We want to continuously monitor his oxygen levels until he is no longer having respiratory distress. If his respiratory distress isn’t resolved quickly he may need to be intubated and brought to the ICU. If this happened, I would need to make sure that the family is notified by the physician.
Utilize the data in the preceding question to develop and prioritize a list of nursing diagnoses with 3 nursing interventions and one outcome criteria for Mr. Cron.  Ineffective airway clearance 1 1. Auscultate breath sounds 1 2. Administer oxygen as ordered 1 3. Monitor respiratory pattern, rate, depth, and effort OUTCOME: Patient will maintain a patent airway at all times  Impaired gas exchange 1 1. watch for signs of distress including axiety and agitation 2 2. monitor O2 sats and ABGs 3 3. Administer oxygen as ordered 4 OUTCOME: Patient will maintain clear lung fields  Fear 1. Stay with the patient and let them know what we are doing to help him 2. Discuss the situation with the client 3. When the patient is able to have him express his feelings OUTCOME: Patient will report and demonstrate reduced fear

Pathophysiology and Collaborative Care for Shock Patients, Exams of Nursing

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