Shock Case Studies

Full Answer Section

      Clinical manifestations of hypoxic shock:

• Tachypnea (respiratory rate 35 breaths/minute)
• Labored breathing
• Cyanosis
• Confusion
• Restlessness
• Anxiety
• Tachycardia
• Hypotension

Causes of Shock and Other Causes Causes of hypovolemic shock:

• Blood loss
• Fluid loss (e.g., dehydration, diarrhea, vomiting)
• Third-spacing of fluids (e.g., burns, pancreatitis)

Other causes of hypovolemic shock:

• Cardiogenic shock (heart failure)
• Septic shock (severe infection)
• Anaphylactic shock (severe allergic reaction)

Causes of hypoxic shock:

• Respiratory failure
• Pneumonia
• Asthma
• Pulmonary embolism
• Heart failure

Priority Nursing Responsibilities The priority nursing responsibilities for K.L. are to:

• Maintain airway, breathing, and circulation.
• Administer oxygen and fluids as prescribed.
• Monitor vital signs and fluid balance closely.
• Manage pain.
• Provide emotional support to K.L. and his family.

Ongoing Nursing Assessment Parameters The following ongoing nursing assessment parameters are essential for K.L.:

• Vital signs (every 15-30 minutes)
• Respiratory rate and effort
• Oxygen saturation
• Level of consciousness
• Skin color and temperature
• Capillary refill time
• Urine output
• Drainage from chest tube
• Wound assessment

Potential Complications The following are potential complications for K.L.:

• Respiratory failure: Hypoxic shock can lead to respiratory failure if the body is unable to get enough oxygen to the tissues.
• Multisystem organ failure (MSOF): If shock is not treated promptly, it can lead to MSOF, a life-threatening condition in which multiple organs begin to fail.
• Infection: K.L. is at risk for infection due to his open fracture and surgery.
• Deep vein thrombosis (DVT): K.L. is at risk for DVT due to his prolonged immobility and surgery.

Patient-Centered Care To provide culturally competent family-centered care for K.L. and his family, the nurse should:

• Use an interpreter to communicate with K.L.'s parents.
• Explain K.L.'s condition and treatment plan to K.L.'s parents in a way that they can understand.
• Answer K.L.'s parents' questions honestly and compassionately.
• Provide emotional support to K.L.'s parents.
• Allow K.L.'s parents to participate in K.L.'s care as much as possible.

Priority Nursing Diagnoses Based on the assessment data presented, the priority nursing diagnoses for K.L. are:

• Ineffective airway clearance
• Impaired gas exchange
• Decreased cardiac output
• Acute pain
• Anxiety

Tasks that Could be Delegated to Unlicensed Assistive Personnel (UAP) The following tasks could be delegated to a UAP:

• Monitor vital signs
• Measure urine output
• Collect drainage from chest tube
• Assist with bathing and dressing
• Provide emotional support to K.L. and his family

Evidence-Based Practice Crystalloids are used for fluid resuscitation instead of colloids because they are more effective at restoring intravascular volume. Crystalloids are also less expensive and have fewer side effects than colloids. Therapeutic Nursing Interventions Associated with End-of-Life Decision-Making The following are therapeutic nursing interventions associated with end-of-life decision-making:

• Provide emotional support to the patient and their family.
• Educate the patient and their family about the different end-of-life options.
• Help the patient and their family make decisions that are consistent with their values and wishes.
• Respect the patient's and their family's decisions.

Conclusion K.L. is a 25-year-old Korean American male who was involved in a motor vehicle crash. He is experiencing hypovolemic shock due to blood loss from his internal injuries and hypoxic shock due to the hemothorax and respiratory distress. The priority nursing  

Sample Solution

   

Types of Shock and Clinical Manifestations

K.L. is experiencing hypovolemic shock due to blood loss from his internal injuries and hypoxic shock due to the hemothorax and respiratory distress.

Clinical manifestations of hypovolemic shock:

• Hypotension (BP 80/56 mm Hg)
• Tachycardia (apical pulse 138)
• Weak peripheral pulses (no palpable radial or pedal pulses)
• Pale skin
• Cool extremities
• Thirst
• Oliguria
• Restlessness
• Anxiety
• Confusion