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Nursing Care for Clients with
Shock and Hemodynamic
Monitoring
Types of Shock
Hypovolemic Shock
Hypovolemic shock is a condition where the heart is unable to supply enough blood to the body because of blood loss or inadequate blood volume. Some expected findings in a client with hypovolemic shock include:
Hypotension Tachycardia Decreased urinary output Cool, moist skin Narrowed pulse pressure
The nurse should anticipate administering packed red blood cells (PRBCs) to restore blood volume and replace hematocrit and hemoglobin levels in a client with hypovolemic shock.
Compensatory Stage of Shock
In the compensatory stage of shock, the body tries to maintain blood pressure and perfusion to vital organs. Expected findings include:
Tachycardia (heart rate 100-150 bpm) Respiratory alkalosis Cold, diaphoretic skin Decreased urinary output Confusion
Findings that would not be expected in the compensatory stage include mottled skin, hypotension, and metabolic acidosis.
Anaphylactic Shock
Anaphylactic shock is a severe, whole-body allergic reaction. The nurse should administer epinephrine first to reverse the most severe manifestations of anaphylactic shock. Other medications like corticosteroids and diuretics are not the treatment of choice.
Disseminated Intravascular Coagulation (DIC)
DIC is an abnormal coagulation process involving fibrinogen formation and decreased platelet counts, leading to bleeding. It is not a genetic disorder
involving vitamin K deficiency, nor is it controlled with lifelong heparin usage.
Pulmonary Artery Wedge Pressure (PAWP)
An elevated PAWP of 15 mmHg may indicate conditions like hypervolemia, left ventricular failure, mitral regurgitation, or an intracardiac shunt. It does not indicate a fluid volume deficit, right ventricular failure, or afterload reduction.
Dopamine Administration
When initiating a dopamine IV infusion for a hypotensive client, the nurse should monitor the client's urine output hourly as part of the plan of care. Assessing bilateral breath sounds, performing neurological assessments, and observing pulmonary capillary wedge pressure are not the most important nursing interventions.
Central Venous Pressure (CVP) Measurement
The most important consideration in measuring CVP is that the zero point on the manometer must be leveled with the right atrium. Blood samples should not be drawn through the subclavian catheter if it is being used for CVP, the client does not need to cough during the measurement, and the client does not need to be lying flat in bed.
Calculating Dopamine Dosage
To calculate the dopamine dosage in micrograms per kilogram per minute (mcg/kg/min) for a client receiving 400 mg of dopamine hydrochloride in 250 mL D5W at an infusion rate of 23 mL/hr and weighing 79.5 kg, the calculation would be:
(400 mg / 250 mL) x (23 mL/hr) / 79.5 kg = 7.71 mcg/kg/min
Reducing Myocardial Oxygen Consumption
The best way to reduce myocardial oxygen consumption is by decreasing afterload, which reduces the amount of stretch in the cardiac muscle just before contraction. Reducing preload, increasing contractility, and increasing preload are not the most effective ways to reduce myocardial oxygen consumption.
Oliguria and Bradypnea in Hypovolemic
Shock
Oliguria
Oliguria, or decreased urine output, is present in hypovolemic shock as a result of decreased blood flow to the kidneys. This reduction in renal
Acute Renal Failure (ARF)
When teaching a client with acute renal failure (ARF) about the oliguric phase, the appropriate information to include is that BUN and serum creatinine levels begin to decrease during the diuresis phase, not the oliguric phase. The oliguric phase is characterized by decreased urine output, not the reestablishment of normal renal tubular function, which is associated with the recovery phase of ARF.
Fluid Output and Acute Renal Failure
Fluid Output Less Than 400 ml per 24 Hours
Inadequate urinary output is associated with the oliguric phase of acute renal failure (ARF).
Fluid Output Greater Than 1000 ml per 24 Hours
Increased urinary output is associated with the diuretic phase of ARF.
Therapeutic Effects of Dopamine
Systolic Blood Pressure Increases
When dopamine has a therapeutic effect, it causes vasoconstriction peripherally and increases systolic blood pressure.
QRS Width Increases
A wide QRS complex indicates a dysrhythmia, which is an adverse effect, not a therapeutic effect, of dopamine.
Apical Heart Rate Increases
Tachycardia is an adverse effect, not a therapeutic effect, of dopamine.
Pulmonary Capillary Wedge Pressure (PCWP) Increases
This is not a therapeutic effect of dopamine.
Management of Sucking Chest Wound
Do Not Remove the Dressing
A dressing should not be removed from a sucking chest wound until immediately prior to chest tube insertion. Removal of the dressing will cause an increase in size of the pneumothorax and increased respiratory difficulty.
Administer Oxygen via Nasal Cannula
The client has an increased respiratory rate and heart rate, indicating respiratory difficulty. Administering oxygen will increase the oxygen exchange in the lungs and the oxygen available to the tissues.
Interpretation of Arterial Blood Gases (ABGs)
Respiratory Acidosis
The normal pH is 7.35 to 7.45. The pH of 7.22 indicates that this client is acidotic, and the correct interpretation of the results is that the client is in respiratory acidosis.
Risk for Fluid Volume Deficit
Client with Gastroenteritis and Fever
This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration.
Peritonitis
Six hours after surgery of a ruptured appendix, a client has a WBC of 17, abdominal tenderness, and abdominal rigidity, indicating the client is exhibiting symptoms of peritonitis.
Hemodynamic Support for Left Ventricular
Failure
Fluids to Keep the CVP Elevated
The client has left ventricular failure and a high pulmonary capillary wedge pressure (PCWP), indicating the need for fluids to keep the central venous pressure (CVP) elevated.
Signs and Symptoms of Air Embolus
Loss of Central Venous Pressure Waveform and Inability to
Aspirate Blood from the Line
These are the most indicative signs and symptoms of an air embolus in a client with a central venous catheter.
Priority Action for Low Central Venous
Pressure (CVP) After Abdominal Aortic
Aneurysm Surgery
Increase the IV Fluid Infusion per Protocol
A low CVP indicates hypovolemia and a need for an increase in the infusion rate.
Monitoring Parameter for Effectiveness of
Treatment in Pulmonary Hypertension
Pulmonary Vascular Resistance (PVR)
PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving.
Effective Teaching About Arterial Pressure
Monitoring
Position the Zero-Reference Stopcock Line Level with the
Phlebostatic Axis
For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis.
Questioning an Order for a Client with Septic
Shock
Giving PRN Furosemide (Lasix) 40 mg IV
With a low urine output, low CVP, and low pulmonary artery wedge pressure, the nurse should question an order to give a diuretic, as this would further decrease the client's fluid volume.
Shock Management
Hydrocortisone Administration
The healthcare provider has ordered the administration of hydrocortisone (Solu-Cortef) 100 mg IV to the patient.
Norepinephrine Titration
The healthcare provider has also ordered the titration of norepinephrine (Levophed) to keep the patient's systolic blood pressure (BP) above 90 mm Hg.
Questioning the Saline Infusion
The nurse should question the order to infuse normal saline at 250 mL/hr. The patient's elevated pulmonary artery wedge pressure indicates volume excess, and a saline infusion at this rate would exacerbate the volume excess.
Appropriate Interventions
The other interventions ordered by the healthcare provider are appropriate for the patient's condition: - Keeping the head of the bed elevated to 30 degrees - Titrating dobutamine (Dobutrex) to keep the systolic BP above 90 mm Hg
These interventions aim to manage the patient's hemodynamic status and support their cardiovascular function.
