Shock Case Studies
Scenario #1
K.L., a 25-yr-old Korean American, was not wearing his seat belt when he was the driver involved in a motor vehicle crash. The windshield was broken and K.L. was found 10 ft from his car. He was face down, conscious, and moaning. His wife and daughter were found in the car with their seat belts on. They sustained minor injuries and were very frightened and upset. All passengers were taken to the emergency department (ED). The following information pertains to K.L.
Subjective Data
States, “I can't breathe”
Cries out when abdomen is palpated
Objective Data
Physical Examination:
Cardiovascular: BP 80/56 mm Hg; apical pulse 138 but no palpable radial or pedal pulses; carotid pulse present but weak
Respiratory: respiratory rate 35 breaths/minute; labored breathing with shallow respirations; asymmetric chestwall movement; absence of breath sounds on left side
Trachea deviated slightly to the right
Abdomen: slightly distended and left upper quadrant painful on palpation
Musculoskeletal: open compound fracture of the lower left leg
Diagnostic Studies
Chest x-ray: Hemothorax and six rib fractures on left side
Hematocrit: 28%
Interprofessional Care in the ED
Intraosseous access in right proximal tibia placed prehospital
Left chest tube placed, draining bright red blood
Fluid resuscitation started with crystalloids
High-flow O2via non-rebreather mask
Emergency Surgical Procedures
Splenectomy
Repair of torn intercostal artery
Repair of compound fracture
Discussion Questions
What types of shock is K.L. experiencing? What clinical manifestations did he display that support your answer?
What were the causes of K.L.'s shock states? What are other causes of these types of shock?
Priority Decision: What are the priority nursing responsibilities for K.L.?
Priority Decision: What ongoing nursing assessment parameters are essential for this patient?
What are his potential complications?
Patient-Centered Care: K.L.'s parents arrive. English is their second language. They are very anxious and asking about their son. What can you do to provide culturally competent family-centered care?
Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses?
Teamwork and Collaboration: Identify the tasks that could be delegated to unlicensed assistive personnel (UAP).
Evidence-Based Practice: You are orienting a new graduate RN. He asks you why crystalloids are used instead of colloids for fluid resuscitation. What is your response?
Examine therapeutic nursing interventions associated end-of-life decision-making.
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
Full Answer Section
Clinical manifestations of hypoxic shock:- Tachypnea (respiratory rate 35 breaths/minute)
- Labored breathing
- Cyanosis
- Confusion
- Restlessness
- Anxiety
- Tachycardia
- Hypotension
- Blood loss
- Fluid loss (e.g., dehydration, diarrhea, vomiting)
- Third-spacing of fluids (e.g., burns, pancreatitis)
- Cardiogenic shock (heart failure)
- Septic shock (severe infection)
- Anaphylactic shock (severe allergic reaction)
- Respiratory failure
- Pneumonia
- Asthma
- Pulmonary embolism
- Heart failure
- 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.
- 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
- 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.
- 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.
- Ineffective airway clearance
- Impaired gas exchange
- Decreased cardiac output
- Acute pain
- Anxiety
- 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
- 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.