INTERACTIVE CASE STUDY

67-2

Answer Guidelines for Case Studies in Textbook

Lewis: Medical-Surgical Nursing, 7th Edition

Answer Guidelines for Case Studies in Textbook

Chapter 67: Nursing Management: Shock, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome

Shock

1. Kim was most likely experiencing hypovolemic shock, as manifested by a blood pressure of 80/56 with a narrow pulse pressure, pulse of 135 beats/min, respiratory rate of 35 breaths/min, and an inability to palpate radial and brachial pulses, with a weak carotid pulse. In addition, blood in the chest tube provides evidence of trauma-related blood loss.

2. Kims shock was caused by massive blood loss secondary to bleeding into the chest from the torn intercostal artery, damage to the spleen, and open compound fracture of the lower leg. Hypovolemic shock occurs when there is a loss of intravascular fluid volume and has many causes. The loss of intravascular volume may be an absolute hypovolemia, in which there is loss of fluid from the body such as occurs with external hemorrhage, loss of plasma (burns), or loss of other body fluids from vomiting, diarrhea, or diuresis. Relative hypovolemia occurs when there is pooling of blood or fluids in third spaces, as can occur with ascites, peritonitis, or bowel obstruction; internal bleeding, as can occur with a ruptured spleen, hemothorax, or severe pancreatitis; and massive vasodilation that creates a vascular space larger than the amount of blood available to fill it.

3. Initial nursing responsibilities include administering high-flow oxygen (100%) by non-rebreather mask, anticipating the need for rapid-sequence intubation, establishing IV access with two large-bore (14 or 16 gauge) catheters, and beginning fluid resuscitation with crystalloids and possibly blood products. The nurse should also anticipate the need for insertion of catheters for intraarterial and central venous or PA pressure monitoring, urine output, and nasogastric drainage. Blood specimens for typing and crossmatching will also be obtained.

4. Continuous assessment of vital signs, level of consciousness, cardiac rhythm, oxygen saturation, urine output, respiratory effort, quality of peripheral pulses, skin color and temperature, and effects of medications administered is necessary. If hemodynamic monitoring is instituted, continuous assessment of these trends is also indicated.

5. Kim is at high risk for complications related to systemic inflammatory response syndrome (SIRS), sepsis, and acute respiratory distress syndrome (ARDS) due to the multiple trauma and shock state he has experienced, the extensive surgical procedures he has undergone, and the extensive number of invasive lines that have been inserted.

6. Nursing diagnoses: ineffective breathing pattern, decreased cardiac output, deficient fluid volume, acute pain, ineffective tissue perfusion

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.