Mrs. Bagent 1-9 BWAKANANG SHET

Mrs. Bagent was admitted to the medical unit of the hospital 3 days...
Mrs. Bagent was admitted to the medical unit of the hospital 3 days ago with
pneumonia and heart failure. Upon admission, the client was having difficulty
breathing and had an elevated temperature and white blood cell count (WBC).
Claforan IV was ordered to treat pneumonia. Her weight had increased by 6 pounds
in the 5 days preceding admission and she had significant swelling in her lower
extremities. Mrs. Bagent was receiving IV furosemide (Lasix) twice a day. She
became very short of breath while ambulating to the bathroom. To promote rest, an
indwelling urinary catheter was inserted. During the last 24 hours her condition
deteriorated and she was transferred to the intensive care unit (ICU).
1. Define shock. Discuss the potential causes of septic shock; and state at least 3
risk factors for developing septic shock
 Shock can best be defined as a condition in which wide-spread perfusion to the cells
is inadequate to deliver oxygen and nutrients to support vital organs and cellular
function (VonRueden, Bolton & Vary, 2008). Adequate blood flow to the tissues and
cells requires an adequate cardiac pump, effective vasculature or circulatory system,
and sufficient blood volume. If one of these components is impaired, perfusion to the
tissues is threatened or compromised. Without treatment, inadequate blood flow to
the cells results in poor delivery of oxygen and nutrients, cellular hypoxia, and cell
death that progresses to organ dysfunction and eventually death.
 3 risk factors for developing septic shock
o Heart conditions (heart attack, heart failure)
o Heavy internal or external bleeding, such as from a serious injury or rupture
of a blood vessel
o infection
2. Shock affects all body systems. Discuss the signs and symptoms shock produces
in the following systems:
 respiratory
o compensatory stage:
 >20 breaths per minute
 PaCO2: <32 mmHg
o Progressive stage
 rapid, shallow respirations, crackles
 PaO2: <80mmHg
 PaCO2: >45 mmHg
o Irreversible stage
 Required intubation and mechanical ventilation and oxygenation
 cardiovascular
 HR: >100 bpm
 BP: Normal
o Progressive stage
 HR: >150 bpm
 BP: Systole: <80-90 mmHg (Requires fluid resuscitation to support
blood pressure
 Erratic or asystole
 BP: requires mechanical or pharmacologic support
 neurological
 confusion
o Progressive stage
 lethargy
 Unconscious
 hematological
o Progressive stage
 imbalance of the clotting cascade
Elaborate on the specific considerations for Mrs. Bagent in regard to each system
 respiratory: Subsequent decompensation of the lungs increases the likelihood that

mechanical ventilation will be needed
 cardiovascular: New laboratory markers can be used to assess the function of the
heart. B-type natriuretic peptide (BNP) is one of these markers. BNP is increased
when the ventricle is overdistended; therefore, elevations in BNP can be used to
assess ventricular function of patients in shock states
 neurological: Initially, the patient may exhibit subtle changes in behavior or agitation
and confusion. Subsequently, lethargy increases, and the patient begins to lose
consciousness. Assess frequently the Level of consciousness of the patient
 hematological: watch out for bruises, petechiae and prothrombin time or activated
partial thromboplastin time because Disseminated intravascular coagulation (DIC)
may occur either as a cause or as a complication of shock.

3. The physician evaluating Mrs. Bagent asks the nurse what her pulse pressure is.
What is pulse pressure and why is it of concern?
 Pulse pressure correlates well with stroke volume. Pulse pressure is calculated by
subtracting the diastolic measurement from the systolic measurement; the difference
is the pulse pressure (Cottingham, 2006). Normally, the pulse pressure is 30 to 40
mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than
a drop in systolic BP. Decreased or narrowing pulse pressure, an early indication of
decreased stroke volume, is illustrated in the following example:
Systolic BP - Diastolic BP= Pulse pressure

Normal pulse pressure:
120 mg Hg -80 mm Hg=40 mm Hg

Narrowing of pulse pressure:
90 mm Hg-70 mm Hg=20 mm Hg
4. Discuss the cellular changes that occur when a patient is in shock.

In shock, the cells lack an adequate blood supply and are deprived of oxygen and nutrients;
therefore, they must produce energy through anaerobic metabolism. This results in low
energy yields from nutrients and an acidotic intracellular environment. Because of these
changes, normal cell function ceases. he cell swells and the cell membrane becomes more
permeable, allowing electrolytes and fluids to seep out of and into the cell. The sodium-
potassium pump becomes impaired; cell structures, primarily the mitochondria, are
damaged; and death of the cell results.

Glucose is the primary substrate required for the production of cellular energy in the form of
ATP. In stress states, catecholamines, cortisol, glucagons, and inflammatory cytokines and
mediators are released, causing hyperglycemia and insulin resistance to mobilize glucose
for cellular metabolism. Activation of these substances promotes gluconeogenesis, which is
the formation of glucose from noncarbohydrate sources such as proteins and fats. Glycogen
that has been stored in the liver is converted to glucose through glycogenolysis to meet
metabolic needs, increasing the blood glucose concentration (ie, hyperglycemia).

Continued activation of the stress response by shock states causes a depletion of glycogen
stores, resulting in increased proteolysis and eventual organ failure (Vincent, 2007). The
inability of the body to have enough nutrients and oxygen for normal cellular metabolism
causes a buildup of metabolic end products in the cells and interstitial spaces. Cellular
metabolism is impaired, and a negative feedback loop is initiated.

5 A Dopamine drip has been ordered.
Part A: Discuss what this medication is for, and side effects that the nurse must monitor
for.
 Dopamine is given to improve the patient's hemodynamic stability when fluid therapy
alone cannot maintain adequate Mean Arterial Pressure (MAP). It helps to increase
the strength of myocardial contractility, regulate the heart rate, reduce myocardial
resistance, and initiate vasoconstriction. Vital signs must be monitored frequently (at
least every 15 minutes until stable, or more often if indicated). Dopamine should be
administered through a central venous line, because infiltration and extravasation of
some vasoactive medications can cause tissue necrosis and sloughing. An IV pump
or controller should be used to ensure that the medications are delivered safely and
accurately. Dosages of vasoactive medications should be tapered, and the patient
should be weaned from medication with frequent monitoring of BP (every 15
minutes).
Part B: The physician orders Dopamine 8 mcg/ kg/minute. The pharmacy brings the nurse
a bag of Dopamine 800 mg in 500 mL of 0.9% NaCl. Mrs. Bagent's weight is 135 pounds. At
what rate should the nurse program the IV pump to run (mL/hr)?
(See explanation)

6. Mrs. Bagent's urine output is being monitored every hour. Her last hourly urine
output (UO) was 18 mL. What is a goal UO? Discuss why her UO is low.
 The normal Urine Output (UO) is 30-60mL/ hr. and the goal is that UO will not be
less than 30mL/hr. When the MAP falls below 70 mm Hg, the glomerular filtration
rate of the kidneys cannot be maintained, and drastic changes in renal function
occur. Acute renal failure (ARF) may develop. ARF is characterized by an increase
in blood urea nitrogen (BUN) and serum creatinine levels, fluid and electrolyte shifts,
acid-base imbalances, and a loss of the renal-hormonal regulation of BP. Urinary
output usually decreases to less than 0.5 mL/kg/h (or less than 30 mL/h) but may
vary depending on the phase of ARF.
7. List five priority nursing diagnoses for Mrs. Bagent.
1. Impaired Gas Exchange related to Impaired ventilation-perfusion.

2. Decreased Cardiac Output related to Increased or decreased preload or after load.
3. Ineffective Tissue Perfusion related to Reduction/cessation of blood flow.
4. Excess Fluid Volume related to Decrease in renal organ perfusion.
5. Anxiety related to Change in health status.
8. Nutritional support is very important for Mrs. Bagent. Discuss why a dietician
consult is a priority and why nutritional support should occur as soon as possible
 Nutritional support is an important aspect of care for patients with shock. Increased
metabolic rates during shock increase energy requirements and therefore caloric
requirements. Patients in shock may require more than 3000 calories daily. The
release of catecholamines early in the shock continuum causes depletion of
glycogen stores in about 8 to 10 hours. Nutritional energy requirements are then met
by breaking down lean body mass. In this catabolic process, skeletal muscle mass is
broken down even when the patient has large stores of fat or adipose tissue. Loss of
skeletal muscle greatly prolongs the patient's recovery time.
 Parenteral or enteral nutritional support should be initiated as soon as possible.
Enteral nutrition is preferred, promoting GI function through direct exposure to
nutrients and limiting infectious complications associated with parenteral feeding
(Vincent, 2007). In addition, glutamine (an essential amino acid during stress), which
may be administered in enteral formulas, is important in the immunologic function of
the GI tract, providing a fuel source for lymphocytes and macrophages (Stapleton, et
al., 2007).
9. Multiple Organ Dysfunction Syndrome (MODS) can occur in septic shock if

perfusion to tissues cannot be restored. Discuss the signs and symptoms of MODS
and treatment options.
 Multiple organ dysfunction syndrome (MODS) is altered organ function in acutely ill

patients that requires medical intervention to support continued organ function. It is
another phase in the progression of shock states.
 The clinical presentation of MODS is insidious.
o hemodynamically
o Signs of a hypermetabolic state characterized by:
 hyperglycemia (elevated blood glucose level)
 hyperlactic acidemia (excess lactic acid in the blood)
 increased BUN
 The metabolic rate may be 1.5 to 2 times the basal metabolic rate. At
this time
o severe loss of skeletal muscle mass (autocatabolism) to meet the high energy
demands of the body.
o After approximately 7 to 10 days:
 signs of hepatic dysunction
 elevated bilirubin and liver function tests
 renal dysfunction
 elevated creatinine
 anuria
 As the lack of tissue perfusion continues, the hematologic system
becomes dysfunctional, with worsening immunocompromise and
increasing risk of bleeding
 The cardiovascular system becomes unstable and unresponsive to
vasoactive agents
 Patient's neurologic response progresses to a state of
unresponsiveness or coma
 The goal of all shock states is to reverse the tissue hypoperfusion and hypoxia. If
effective tissue perfusion is restored before organs become dysfunctional, the
patient's condition stabilizes. Along the septic shock continuum, the onset of organ
dysfunction is an ominous prognostic sign; the more organs that fail, the worse the
outcome. Prevention remains the top priority in managing MODS. If preventive
measures fail, treatment measures to reverse MODS are aimed at
o controlling the initiating event
o promoting adequate organ perfusion
o providing nutritional support
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What are the signs and symptoms of shock in different body systems?

What is pulse pressure and why is it important for Mrs. Bagent?

Mrs. Bagent was admitted to the medical unit of the hospital 3 days...

 respiratory: Subsequent decompensation of the lungs increases the likelihood that

Systolic BP - Diastolic BP= Pulse pressure

7. List five priority nursing diagnoses for Mrs. Bagent.

1. Impaired Gas Exchange related to Impaired ventilation-perfusion.

9. Multiple Organ Dysfunction Syndrome (MODS) can occur in septic shock if

 Multiple organ dysfunction syndrome (MODS) is altered organ function in acutely ill

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