NUR 445 - Exam 4 Study Guide Acute & Chronic Health Disruptions in Adults III (Arizona College of
Nursing) Complete Solutions
NUR 445 - Exam 4 Study Guide Acute & Chronic Health Disruptions in Adults III
(Arizona College of Nursing) Complete Solutions
SHOCK
NUR 445 - Exam 4 Study Guide Acute & Chronic Health Disruptions in Adults III (Arizona College of
Nursing) Complete Solutions
,NUR 445 - Exam 4 Study Guide Acute & Chronic Health Disruptions in Adults III (Arizona College of
Nursing) Complete Solutions
Hypovolemic Shock
- Common cause
o blood loss d/t trauma, GI bleeds, surgery
o internal bleeding
o fluid loss d/t vomiting, diarrhea, urination, burns
o third-space fluid loss
- Clinical manifestations
o Early
▪ Tachycardia
▪ Restless, confused
▪ UO decreased d/t reabsorption of sodium and water
▪ Pale, cool, clammy skin
▪ Pulses weak, sluggish cap refill
▪ Hyperventilation (respiratory alkalosis)
▪ Hypoactive bowel sounds
▪ Hyperglycemia
o Late
▪ Lethargy
▪ Hypotension
▪ Metabolic and respiratory acidosis
▪ Anuria
▪ Cold, cyanotic skin with weak/absent pulses
▪ Dysrhythmias
o Refractory (ineffective treatment)
▪ Coma
▪ Severe hypotension
▪ Ischemic and necrotic cold extremities
▪ Renal and hepatic failure
- Hemodynamic parameters
o Decreased CVP, PaOP, SvO2/ScvO2, CO
o INCREASED systemic vascular resistance (SVR)
- Assess
o Neuro status
o VS
o Hemodynamic readings
o UO
o Skin color and temperature
- Labs
o ABGs
▪ Initial: Respiratory alkalosis
▪ Late: Metabolic acidosis
o SvO2/ScvO2
▪ Decreased inadequate oxygen delivery
o H&H
▪ Decreased if cause is bleeding
o Metabolic profile
▪ Renal failure and liver failure INCREASED BUN & Creatinine
o Lactate/base deficit
▪ Increased lactate, negative base poor perfusion
- Nursing actions
NUR 445 - Exam 4 Study Guide Acute & Chronic Health Disruptions in Adults III (Arizona College of
Nursing) Complete Solutions
, NUR 445 - Exam 4 Study Guide Acute & Chronic Health Disruptions in Adults III (Arizona College of
Nursing) Complete Solutions
o 100% NRB
o Anticipate and prepare for intubation
▪ Positive-pressure mechanical ventilation needed to improve oxygenation
o Large-bore IVs Fluid replacement
▪ NS
▪ LR
▪ Blood products (PRBCs, FFP, Platelets)
- Patient Education
o Instruct patient and family on the cause of hypovolemia
o Allow family members visitation during hospital treatment
Cardiogenic shock
- Causes
o MI
o Severe valvular dysfunction
o Severe HF
- RF
o AMI
o End-stage CHF
o Cardiomyopathy
o HTN
o DM
o CAD
o Acute vascular disease
- Clinical manifestations
o Initial
▪ Chest pain
▪ Diaphoresis
▪ N/V
▪ Decreased CO increased lactate
▪ Hypotension
▪ Decreased LOC
▪ Decreased UO
▪ Poor pulses
▪ Pale, cool skin
▪ Hypoactive BS
▪ Pulmonary edema SOB, crackles, decreased SpO2
o Late
▪ Profound hypotension and bradycardia
▪ Coma
▪ Cyanotic, mottled skin
▪ Absent BS
▪ Anuria
o As shock progresses severe hypotension and bradycardia
- Labs
o ABGs
▪ Initial: respiratory alkalosis
▪ Late: metabolic acidosis
o Hemodynamic parameters (PA catheter)
NUR 445 - Exam 4 Study Guide Acute & Chronic Health Disruptions in Adults III (Arizona College of
Nursing) Complete Solutions
Nursing) Complete Solutions
NUR 445 - Exam 4 Study Guide Acute & Chronic Health Disruptions in Adults III
(Arizona College of Nursing) Complete Solutions
SHOCK
NUR 445 - Exam 4 Study Guide Acute & Chronic Health Disruptions in Adults III (Arizona College of
Nursing) Complete Solutions
,NUR 445 - Exam 4 Study Guide Acute & Chronic Health Disruptions in Adults III (Arizona College of
Nursing) Complete Solutions
Hypovolemic Shock
- Common cause
o blood loss d/t trauma, GI bleeds, surgery
o internal bleeding
o fluid loss d/t vomiting, diarrhea, urination, burns
o third-space fluid loss
- Clinical manifestations
o Early
▪ Tachycardia
▪ Restless, confused
▪ UO decreased d/t reabsorption of sodium and water
▪ Pale, cool, clammy skin
▪ Pulses weak, sluggish cap refill
▪ Hyperventilation (respiratory alkalosis)
▪ Hypoactive bowel sounds
▪ Hyperglycemia
o Late
▪ Lethargy
▪ Hypotension
▪ Metabolic and respiratory acidosis
▪ Anuria
▪ Cold, cyanotic skin with weak/absent pulses
▪ Dysrhythmias
o Refractory (ineffective treatment)
▪ Coma
▪ Severe hypotension
▪ Ischemic and necrotic cold extremities
▪ Renal and hepatic failure
- Hemodynamic parameters
o Decreased CVP, PaOP, SvO2/ScvO2, CO
o INCREASED systemic vascular resistance (SVR)
- Assess
o Neuro status
o VS
o Hemodynamic readings
o UO
o Skin color and temperature
- Labs
o ABGs
▪ Initial: Respiratory alkalosis
▪ Late: Metabolic acidosis
o SvO2/ScvO2
▪ Decreased inadequate oxygen delivery
o H&H
▪ Decreased if cause is bleeding
o Metabolic profile
▪ Renal failure and liver failure INCREASED BUN & Creatinine
o Lactate/base deficit
▪ Increased lactate, negative base poor perfusion
- Nursing actions
NUR 445 - Exam 4 Study Guide Acute & Chronic Health Disruptions in Adults III (Arizona College of
Nursing) Complete Solutions
, NUR 445 - Exam 4 Study Guide Acute & Chronic Health Disruptions in Adults III (Arizona College of
Nursing) Complete Solutions
o 100% NRB
o Anticipate and prepare for intubation
▪ Positive-pressure mechanical ventilation needed to improve oxygenation
o Large-bore IVs Fluid replacement
▪ NS
▪ LR
▪ Blood products (PRBCs, FFP, Platelets)
- Patient Education
o Instruct patient and family on the cause of hypovolemia
o Allow family members visitation during hospital treatment
Cardiogenic shock
- Causes
o MI
o Severe valvular dysfunction
o Severe HF
- RF
o AMI
o End-stage CHF
o Cardiomyopathy
o HTN
o DM
o CAD
o Acute vascular disease
- Clinical manifestations
o Initial
▪ Chest pain
▪ Diaphoresis
▪ N/V
▪ Decreased CO increased lactate
▪ Hypotension
▪ Decreased LOC
▪ Decreased UO
▪ Poor pulses
▪ Pale, cool skin
▪ Hypoactive BS
▪ Pulmonary edema SOB, crackles, decreased SpO2
o Late
▪ Profound hypotension and bradycardia
▪ Coma
▪ Cyanotic, mottled skin
▪ Absent BS
▪ Anuria
o As shock progresses severe hypotension and bradycardia
- Labs
o ABGs
▪ Initial: respiratory alkalosis
▪ Late: metabolic acidosis
o Hemodynamic parameters (PA catheter)
NUR 445 - Exam 4 Study Guide Acute & Chronic Health Disruptions in Adults III (Arizona College of
Nursing) Complete Solutions
