Flashcards in Midterm Deck (112):
You’re working on a neuro unit. Which of your patients below are at risk for developing neurogenic shock? Select all that apply:*
A. A 36-year-old with a spinal cord injury at L4.
B. A 42-year-old who has spinal anesthesia.
C. A 25-year-old with a spinal cord injury above T6.
D. A 55-year-old patient who is reporting seeing green halos while taking Digoxin.
The answers are B and C. Any patient who has had a cervical or upper thoracic (above T6) spinal cord injury, receiving spinal anesthesia, or taking drugs that affect the autonomic or sympathetic nervous system is at risk for developing neurogenic shock.
True or False: The parasympathetic nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes.
Answer: FALSE….the statement should say: The sympathetic (NOT parasympathetic) nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes.
A 42-year-old male patient is admitted with a spinal cord injury. The patient is experiencing severe hypotension and bradycardia. The patient is diagnosed with neurogenic shock. Why is hypotension occurring in this patient with neurogenic shock?
A. The patient has an increased systemic vascular resistance. This increases preload and decreases afterload, which will cause severe hypotension.
B. The patient’s autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring.
C. The patient’s parasympathetic nervous system is being unopposed by the sympathetic nervous system, which leads to severe hypotension.
D. The increase in capillary permeability has depleted the fluid volume in the intravascular system, which has led to severe hypotension.
The answer is B. The sympathetic nervous system (which is a division of the autonomic nervous system) is unable to stimulate the nerves that regulate the diameter of the blood vessels (there’s a loss of vasomotor tone). So, now the vessels are relaxed and this causes massive vasodilation. Systemic vascular resistance will decrease and hypotension will occur.
You receive a patient in the ER who has sustained a cervical spinal cord injury. You know this patient is at risk for neurogenic shock. What hallmark signs and symptoms, if experienced by this patient, would indicate the patient is experiencing neurogenic shock? Select all that apply:*
A. Blood pressure 69/38
B. Heart rate 170 bpm
C. Blood pressure 250/120
D. Heart rate 29
E. Warm and dry skin
F. Cool and clammy skin
G. Temperature 104.9 ‘F
H. Temperature 95 ‘F
The answers are A, D, E, and H. Hallmark signs and symptoms of neurogenic shock are: hypotension, bradycardia, hypothermia, warm/dry skin (this is due to the vasodilation and blood pooling and will be found in the extremities).
In neurogenic shock, a patient will experience a decrease in tissue perfusion. This deprives the cells of oxygen that make up the tissues and organs. Select all the mechanisms, in regards to pathophysiology, of why this is occurring:*
A. Loss of vasomotor tone
B. Increase systemic vascular resistance
C. Decrease in cardiac preload
D. Increase in cardiac afterload
E. Decrease in venous blood return to the heart
F. Venous blood pooling in the extremities
The answers are A, C, E, and F. Massive vasodilation is occurring in the body and this is due to the loss of vasomotor tone (remember the sympathetic nervous system loses its ability to stimulate nerves that regular the diameter of vessels….so vessels are relaxed). This will DECREASE (NOT increase) systemic vascular resistance (which will decrease cardiac afterload) and the blood pressure will fall. Furthermore, there is pooling of venous blood in the extremities because there isn’t any pressure to push it back to the heart. This will cause a decrease in venous blood return to the heart. When this occurs it will decrease cardiac preload (the amount the ventricle stretch at the end of diastole). All of this together will decrease the amount of blood the heart can pump per minute….hence the cardiac output and shock will occur.
You’re providing care to a patient experiencing neurogenic shock due to an injury at T4. As the nurse, you know which of the following is a patient safety priority?*
A. Keeping the head of the bed greater than 45 degrees at all times.
B. Repositioning the patient every thirty minutes.
C. Keeping the patient’s spine immobilized.
D. Avoiding log-rolling the patient during transport.
The answer is C. It is very important when a patient has a spinal cord injury to keep the spine protected. The nurse wants to prevent further damage or perfusion issues to the spinal cord. Therefore, the patient’s spine should be immobilized. Example: usage of cervical collar, log-rolling, usage of a backboard.
A patient in neurogenic shock is ordered intravenous fluids due to severe hypotension. During administration of the fluids the nurse will monitor the patient closely and immediately report?*
A. Increase in blood pressure
B. High central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP)
C. Urinary output of 300 mL in the past 5 hours
D. Mean arterial pressure (MAP) 85 mmHg
The answer is B. Option B would indicate the patient is in fluid volume overload. Remember that patients in neurogenic shock usually have a normal blood volume. If fluids are ordered to help increase the blood pressure, they should be used with extreme caution because fluid overload can occur. An increase in the CVP and PAWP would indicate this. These pressures show the filling pressure in the heart.
A patient with neurogenic shock is experiencing a heart rate of 30 bpm. What medication does the nurse anticipate will be ordered by the physician STAT?*
The answer is C. Atropine will quickly increase the heart rate and block the effects of the parasympathetic system on the body. Remember bradycardia occurs in neurogenic shock because the sympathetic nervous system (which increases the heart rate) loses its ability to stimulate nerves. The sympathetic and parasympathetic systems are, in a way, balancing each other out when it comes to the heart rate. The sympathetic system increases it, while the parasympathetic decreases it. If the sympathetic system isn’t working the way it should, it can NOT oppose the parasympathetic system….which will take over and lead to bradycardia.
Your patient in neurogenic shock is not responding to IV fluids. The patient is started on vasopressors. What option below, if found in your patient, would indicate the medication is working?*
A. Decreased CVP (central venous pressure)
B. Mean arterial pressure (MAP) 90 mmHg
C. Serum lactate 6 mmol/L
D. Blood pH 7.20
The answer is B. A MAP of 85-90 mmHg will help maintain tissue perfusion and indicates the vasopressor is working to maintain tissue perfusion. It does this by causing vasoconstriction. Options A, C, and D would indicate tissue perfusion is decreased.
You’re developing a nursing plan of care for a patient with neurogenic shock. As the nurse, you know that due to venous blood pooling from vasodilation a deep vein thrombosis can occur in this type of shock. A patient goal is that the patient will be free from the development of a deep vein thrombosis. Select all the nursing interventions below that can help the patient meet this goal:*
A. Perform range of motion exercises daily.
B. Place a pillow underneath the patient knees as needed.
C. Administer anticoagulants as scheduled per physician’s order.
D. Apply compression stockings daily.
The answers are A, C, and D. Option B would impede blood flow and increase the risk of a DVT. The other options would help prevent a DVT.
True or False: Hypovolemic shock occurs where there is low fluid volume in the interstitial compartment.*
FALSE Hypovolemic shock occurs where there is low fluid volume in the INTRAVASCULAR (not interstitial) system.
As the nurse you know that in order for hypovolemic shock to occur the patient would need to lose __________ of their blood volume.*
The answer is C. As the nurse you know that in order for hypovolemic shock to occur the patient would need to lose 15% or more of their blood volume.
If a patient has a blood volume of 5 Liters and loses 2 Liters, what is the percentage amount of volume loss this patient has experienced?*
The answer is B. This patient has lost 40% of blood volume. Based on this amount of fluid loss, this patient would be in class III (stage 3 of hypovolemic shock). Class III occurs when volume loss is 30-40% or 1,500-2,000 mL in an adult.
A patient who is experiencing hypovolemic shock has decreased cardiac output, which contributes to ineffective tissue perfusion. The decrease in cardiac output occurs due to?*
A. An increase in cardiac preload
B. An increase in stroke volume
C. A decrease in cardiac preload
D. A decrease in cardiac contractility
The answer is C. Because there is a major depletion of volume in the intravascular system, there will be a decrease in the amount of venous return to the heart (this is the amount of blood draining back to the heart). Hence, this will lead to a DECREASE in preload. Remember preload is the amount the ventricles stretch once their filled with blood. The ventricle won’t be stretching too much because there isn’t enough fluid to fill them. This will decrease stroke volume and in turn decrease cardiac output.
True or False: A patient with acute pancreatitis is presenting with Turner and Cullen's Sign. This patient is at risk for absolute hypovolemic shock.*
The answer is FALSE: The statement should read: A patient with acute pancreatitis is presenting with Turner and Cullen’s Sign. This patient is at risk for RELATIVE (not absolute) hypovolemic shock. Relative hypovolemic shock is an INSIDE fluid shift from the intravascular system, which occurs in cases of acute pancreatitis. If a patient has Turner’s Sign (bruising on the flanks) or Cullen’s Sign (bruising around the umbilicus) this can indicate internal hemorrhage and this places the patient at risk for RELATIVE hypovolemic shock. Absolute hypovolemic shock occurs when there is an OUTSIDE fluid shift out of the body from the intravascular system.
Select all the conditions below that increases a patient's risk for absolute hypovolemic shock:*
C. Long bone fracture
The answers are: B, D, and E. Vomiting, diarrhea, and surgery can all increase the loss of fluid volume outside the body, which are absolute hypovolemic shock types. Burns, long bone fracture, and sepsis can lead to an inside fluid shift of fluid from the intravascular system and are relative hypovolemic shock types.
A patient has a 10% loss of their blood volume. Select all the signs and symptoms this patient may present with?*
A. Cool, clammy skin
B. Blood pressure within normal limits
D. Capillary refill less than 2 seconds
E. Urinary output greater than 30 mL/hr
F. Mild tachycardia
The answers are: B, D, and E. The body can compensate for a volume loss of <15% to maintain cardiac output. Therefore, the patient will be asymptomatic until blood loss is greater than 15% and you would select normal findings for this question, which are: blood pressure within normal limits, capillary refill less than 2 seconds, urinary output greater than 30 mL/hr. Anxiety, cool/clammy skin, and mild tachycardia may present when volume loss is higher.
During what stage (or class) of hypovolemic shock does the sympathetic nervous system attempt to maintain cardiac output?*
The answer is D. During stage 2 or class II of hypovolemic shock, the cardiac output is falling even more due to volume loss. This is when the patient has lost 15-30% of volume. During this time the sympathetic nervous system will take over and attempt to maintain cardiac output.
One of your patients begins to vomit large amounts of bright red blood. The patient is taking Warfarin. You call a rapid response. Which assessment findings indicate this patient is developing hypovolemic shock? Select all that apply:*
A. Temperature 104.8 'F
B. Heart rate 40 bpm
C. Heart rate 140 bpm
D. Anxiety, restlessness
E. Urinary output 15 mL/hr
F. Blood pressure 70/56
G. Pale, cool skin
H. Weak peripheral pulses
I. Blood pressure 220/106
The answers are: C, D, E, F, G, and H. Signs and symptoms of hypovolemic shock include: tachycardia, hypotension, increased respiratory rate, cool/pale/clammy skin, anxiety, decreased urinary output (normal UOP is >30 mL/hr), weak peripheral pulses
You're providing care to a patient who has experienced a 45% loss of their fluid volume and is experiencing hypovolemic shock. The patient has hemodynamic monitoring and fluid resuscitation is being attempted. Which finding indicates the patient is still in hypovolemic shock?*
A. Low central venous pressure
B. High pulmonary artery wedge pressure
C. Elevated mean arterial pressure
D. Low systemic vascular resistance
The answer is A. Central venous pressure is the measurement of the pressure in the right atrium and superior vena cava. If fluid volume is low (as in hypovolemic shock) the pressure in this area will also be low. This indicates the patient is still in hypovolemic shock.
A patient is 1 hour post-op from abdominal surgery and had lost 20% of their blood volume during surgery. The patient is experiencing signs and symptoms of hypovolemic shock. What position is best for this patient?*
A. Modified Trendelenburg
C. High Fowler's
The answer is A. Modified Trendelenburg position is where the patient is supine with their legs elevated at 45 degrees. This will help increase venous return to the heart (hence increase preload), which will help increase cardiac output.
A 35-year-old male arrives to the emergency room with multiple long bone fractures and an internal abdominal injury. The patient is anxious. Patient's vital signs are: Blood pressure 70/54, heart rate 125 bpm, respirations 30, oxygen saturation on 2 L nasal cannula 96%, temperature 99.3 'F, pain 6 on 1-10 scale. During assessment it is noted the skin is cool and clammy. The nurse will make it priority to?*
A. Collect a urine sample
B. Obtain an EKG
C. Establish 2 large-bore IV access sites
D. Place a warming blanket on the patient
The answer is C. This patient is at major risk for hypovolemic shock due to the multiple long bone fractures and an internal abdominal injury (this can lead to relative hypovolemic shock…where fluid is loss inside the body). The patient is already showing signs and symptoms of hypovolemic shock. Therefore, it should be a nursing priority to establish IV access (at least two sites should be obtained using a large-bore cannula….18 gauge or higher). Fluids and possibly blood products will need to be given to this patient along with pain medication etc.
A patient in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which patient finding requires immediate nursing action?*
A. Patient heart rate is 115 bpm
B. Patient experiences dyspnea and crackles in lung fields
C. Patient is anxious
D. Patient's urinary output is 35 mL/hr
The answer is B. When crystalloid fluids are given there is a risk for fluid volume overload even though the patient is hypovolemic, especially with rapid infusions. Therefore, the nurse should monitor the patient for this. If a patient develops difficulty breathing (dyspnea) and has crackles in the lung fields (this represents edema in the lungs), fluid is backing up in the lungs. This requires immediate nursing action. Option A and C are expected finding in hypovolemic shock, and option D is a normal finding…urinary output should be >30 mL/hr.
A patient has lost 750 mL of blood volume. The MD orders Normal Saline infusion. Using the 3:1 rule, how much crystalloid solution should be prescribed by the doctor?*
A. 2,250 mL of Normal Saline
B. 250 mL of Normal Saline
C. 375 mL of Normal Saline
C. 1,225 mL of Normal Saline
The answer is A. For crystalloid solutions (this includes normal saline and lactated ringer’s), a 3:1 rule is used. This rule states for every 1 mL of approximate blood loss 3 mL of crystalloid solution is given. Therefore, if the patient loses 750 mL of blood, the patient would receive 2,250 mL of saline. 750 x 3 = 2,250
You're providing an in-service to new nurse graduates on the fluid treatment for hypovolemic shock. You ask the participants to list the types of crystalloid solutions used in hypovolemic shock. Which responses are INCORRECT? Select all that apply:*
B. Lactated Ringer's
C. Normal Saline
The answers are A and D. Albumin and Hetastarch are COLLOID solutions…not crystalloid. Lactated Ringer’s and Normal Saline are considered crystalloid solutions and are used in the treatment of hypovolemic shock.
Select all the fluid types below that are considered colloids?*
A. Fresh Frozen Plasma
C. Normal Saline
D. Lactated Ringer's
The answers are B and E. These are colloid solutions. Options C and D are considered crystalloid solutions, and options A and F are blood products.
Which statement is true about colloid solutions? Select all that apply:*
A. These solutions are made up of large molecules that cannot diffuse through the capillary wall, so more fluid stays in the intravascular space longer when compared with the action of a crystalloid solution.
B. These solutions can diffuse through the capillary wall so less fluid stays in the intravascular system when compared to the action of a crystalloid solution.
C. The nurse should monitor for an anaphylactic reaction when these products are administered.
D. These fluids are considered hypertonic solutions.
The answers are A and C. These are true statements about colloid solutions. Options B and D are incorrect.
A patient is receiving large amounts of fluids for aggressive treatment of hypovolemic shock. The nurse makes it PRIORITY to?*
A. Rapidly infuse the fluids
B. Warm the fluids
C. Change tubing in between bags
D. Keep the patient supine
The answer is B. It is very important when giving large amount of fluids that the nurse ensures the fluids are warm. WHY? To prevent the patient from developing hypothermia. If this develops, clotting enzymes can become altered along with leukopenia and thrombocytopenia. Keep the patient warm, but not too hot.
The patient with hypovolemic shock is in need of clotting factors. Which type of fluid would best benefit this patient?*
C. Fresh Frozen Plasma
D. Packed Red Blood Cells
The answer is C. A patient who needs clotting factors would benefit from fresh frozen plasma (FFP).
Why does the brain need ICP?
It allows the brain to expand if need be, since the skull is not flexible
Brain is made up of what?
12% Intravascular blood
78% Brain tissue
If the brain swells, what goes up?
How does the brain help offset swelling?
Blood vessels constrict to make room for swelling. Downside - Causes less blood flow to the brain which means less O2 and less glucose to the brain
Also, the body will reabsorb CSF fluid so there is less in the brain, making more room
How much glucose does the brain need?
25% of cardiac output
How much O2 does the brain need?
20% of cardiac output
What are s/s of a head injury?
Headache, confusion, blurry vision (caused by pressure on cranial nerve III), changes in LOC, vomiting (projectile), sweating, vertigo (balance issues), posturing, decreased respirations
BIGGEST thing to look for - Changes in behavior (Does pt usually act this way?)
Why do we check PERRLA?
Eyes are windows to the brain. When checking pupils, you're looking to see if cranial nerve is intact. Pupil will be affected on the same side as the injury.
We should always check _____ on a head injury pt?
Brain can tolerate a MAP as low as ____
It's not good, but it's tolerable
MAP ranges for a head injury pt?
CPP less than 50 causes what?
CPP less than 30 causes what?
MAP - ICP =
Bleeding in brain
Body has autoregulation - Vasoconstriction and reabsorbs CSF
Autoregulation is starting to fail - not working
Autoregulation is not working
Start of Cushing's Triad
Blood pressure - Increase in systolic b/p with widening pulse pressure - diastolic not affected too much
No order for q15min b/p checks? Call MD
Heart rate - Bradycardia with full and bounding pulse
No order for med (atropine) to bump up HR? Call MD
Respirations - Altered respirations
If you see any changes, what should you do?
Why do we need to watch for cushings triad
It is a medical emergency. Can/will cause brain herniation
If you see all three symptoms of cushings at the same time, it’s too late for interventions. Interventions should have been implemented long before to manage patient.
Brain can/will herniate
Herniation = Brain dead
What is mannitol?
Osmotic diuretic - Will draw fluid from the brain and allow it to be reabsorbed into the intravascular space, causing b/p to go up, causing MAP to increase = Good for the patient
Why can't we give the pt a bolus of mannitol ot 3% NS?
Will cause brain to lose too much fluid at once and will cause it to shrivel
“Pitch (brain) of the TENT falls down”
Brain herniates to left or right
Brain herniates down and lateral (left or right)
towards the CORE
Away from the core
Spinal shock causes:
Loss of sensation
Flaccid paralysis below level of injury
Neurogenic shock causes:
Loss of vasomotor tone
Hypotension and bradycardia
- Usually associated with T6 injury or higher
Keeps the diaphragm alive
With spinal cord injury, if the cord is completely involved pt will experience what?
Total loss of sensory and motor function below the level
A patient with an incomplete or partial cord involvement will experience:
Mixed loss of voluntary motor activity and sensation
If a patient has an injury at C4 and ABOVE, how is the respiratory system affected?
Total loss of respiratory muscle function, requiring mechanical ventilation.
If a patient has an injury at C4 and BELOW, how is the respiratory system affected?
Diaphragmatic breathing and hypoventilation if phrenic nerve is functioning
Cervical and thoracic injuries cause paralysis of which muscles, related to the respiratory system?
Abdominal and intercostal muscles
Patient will not be able to cough effectively and can lead to atelectasis or pneumonia.
Any cord injury above level T6 greatly _______ the effects of SNS
S/S of a T6 injury
Peripheral vasodilation resulting in hypotension
* Cardiac monitoring is necessary
Clinical manifestations involving GU
Urinary retention is common
Bladder can become atonic and overdistended
Bladder can become hyperirritable - Reflex emptying
- Could require an indwelling catheter
What is a reflexic bladder?
What is an areflexic bladder?
Bladder doesn't receive a signal to empty when its full
- Will require an in and out cath
Risk with indwelling catheter
Increased risk of infection
- shouldn't be used longer than a month
At what part of the spine is the bladder affected?
At what part of the spine is the upper GI affected?
Cord injury at T5 S/S:
- Hypomotility (T5 and above), causing paralytic ileus and gastric distention
- Stress ulcers
- Risk for intra abdominal bleeding
Pt with cord injury affecting T5 and above should have what?
- Pt is at increased risk for aspiration
- NG tube will help decrease acid
At what part of the spine is the lower GI affected?
Pt with cord injury at T12 is a risk for what?
Pt at increased risk for constipation!
- Pt should have order for Colace, fiber, enemas
- Keep pt hydrated!
T12 and below bowel becomes _________.
- There's a decrease in sphincter tone
How is the skin affected with spinal cord injuries?
- Pt's who are immobile are at increased risk
- Pt's who are immobile are at increased risk
Issues with thermoregulation
- Poikilothermism: Body adjusts to the temperature of the room, rather than regulating on its own
Autonomic dysreflexia is a syndrome in which there is a sudden onset of excessively high blood pressure. It is more common in people with spinal cord injuries that involve the thoracic nerves of the spine or above (T6 or above).
S/S of autonomic dysreflexia
- A pounding headache.
- A flushed face and/or red blotches on the skin above the level of spinal injury.
- Sweating above the level of spinal injury.
- Nasal stuffiness.
- A slow heart rate (bradycardia).
- Goose bumps below the level of spinal injury.
- Cold, clammy skin below the level of spinal injury.
What causes autonomic dysreflexia?
Autonomic dysreflexia occurs when something happens to your body below the level of your injury. This can be a pain or irritant (such as tight clothing or something pinching your skin) or a normal function that your body may not notice (such as having a full bladder and needing to urinate).
Reversing autonomic dysreflexia
The only way to return things to normal is to change the situation—for example, by removing tight clothing or emptying the bladder
What medication is given to increase heart rate?
What class of medication is given for low BP?
What is the only type of shock where you see BRADYCARDIA initially? Why?
Why? Because SNS is blocked and it causes heart rate to decrease
Why do you see HYPOtension in neurogenic shock?
With neurogenic shock there is major vasodilation in the vessels, without an increased fluids in the vessel
Anyone with a cord injury at T6 and above are at risk for which two types of shock?
Spinal and Neurogenic
T6 and below pt is only at risk for ______ shock
Characteristics of spinal shock
-loss of sensation
-flaccid paralysis below level of injury
What is neurogenic shock usually associated with?
cervical or upper thoracic injury (C6 or higher)
Non-modifiable risk factors for stroke
-ethnicity or race
Modifiable risk factors for stroke
-excessive alcohol consumption
-lack of exercise
Characteristics of transient ischemic attack (TIA):
-temporary loss of vision in one eye
-numbness or loss of sensation
-sudden inability to speak
Characteristics of transient ischemic attack (TIA):
-darkened or blurred vision
-unilateral or bilateral numbness or weakness
-results from injury to blood vessel and blood clot formation
-warning: TIA (30-50% of cases)
-onset: often during or after sleep
-S/S develop slowly, usually some improvement, recurrence in 20-25% of survivors
-occurs when an embolus lodges and occludes a cerebral artery
-warning: TIA (uncommon)
-onset: lack of relationship to activity, sudden onset!
-single event, D&S develop quickly, usually some improvement, recurrence common without aggressive tx of underlying disease
-bleeding within the brain caused by a rupture of a vessel (most important cause-HTN)
-warning: headache (25% of cases)
-onset: activity (often)
-progression over 24 hour
-poor prognosis, fatality more likely with presence of coma
-intracranial bleeding into CSF-filled space between arachnoid and pia mater
-warning: headache (common)
-onset: activity (often), sudden onset, most commonly related to head trauma
-usually single event, fatality more likely with presence of coma
Clinical manifestations for pt who have had a stroke
Motor function impairment:
-swallowing and speech
-paralyzed left side: hemiplagia
-tends to deny or minimize problems
-rapid performance, short attention span
-impulsive, safety problems
-impaired time concepts
-paralyzed right side: hemiplagia
-impaired speech/language aphasia
-impaired right/left discrimination
-slow performance, cautious
-aware of deficits: depression, anxiety
-impaired comprehension related to language, math
Drug tx for pts with ischemic strokes
thrombolytic (fibrinolytic) therapy
-TPA within 3-4.5 hours of onset of stroke
Surgical tx for pts with ischemic strokes
-stent retrievers-way to open blocked arteries
-mechanical embolus removal in cerebral ischemia (MERCI) retriever
Drug tx for pts with hemorrhagic stroke
-drugs to manage HTN
(oral and IV agents to keep BP in normal limits)
-seizure prophylaxis in acute period after (situation specific)