METHODICAL INSTRUCTION FOR STUDENTS
OF THE BSN 4yr. PROGRAM 4 COURSE
Nursing Faculty
LESSON № 24 (PRACTICAL – 6 HOURS)
Theme: Shock. Interventions for clients with shock
Aim: students must be able to provide interventions for clients with shock
Professional orientation of students: Heart disease and stroke are major killers of individuals in the United States, and minority cultural groups have disproportionately high losses. American Indians and Alaskaatives have a cardiac disease mortality rate twice than rate of general population. African Americans have a higher mortality and morbidity rate from coronary artery disease and stroke than the general population.
Methodology of Practical Class (9:00-12:00)
Algorithm of students’ communication with patients with pathology in subject (communication skills) (for clinical department):
During examination of the patient students have to use such communicative algorithm:
Complaints and anamnesis taking in patients
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Take complaints and anamnesis in a patient.
5. Explain to the patient results of his/her lab tests correctly and accessibly.
6. Explain to the patient your actions concerning him/her (the necessity of hospitalization, certain examinations and manipulations), which are planned in future.
7. Conversation accomplishment.
Objective examination:
Physical methods of examination of patients with internal diseases
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a patient, what examinations will be carried out and get his/her informed consent.
5. Find a contact with the patient and make an attempt to gain his/her trust.
6. Inform about the possibility of appearing of unpleasant feelings during the examination.
7. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope, etc.).
8. Examination (demonstration of clinical skill).
9. Explain to the patient results of his/her lab tests correctly and accessibly.
10. Conversation accomplishment.
Estimation of laboratory and instrumental investigations
Informing about the results of examination of patients with internal diseases
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a patient results of his/her lab tests correctly and clearly.
5. Involve the patient into the conversation (compare present examination results with previous ones, clarify whether your explanations are clearly understood).
Planning and prognosis the results of the conservative treatment
Friendly facial expression and smile.
1. Gentle tone of speech.
2. Greeting and introducing.
3. Correct and clear explanation of necessary treatment directions.
4. Discuss with a patient the peculiarities of taking medicines, duration of their usage, possible side effects; find out whether your explanations are clear for him/her or not.
5. Conversation accomplishment.
Work 1. Interventions For Clients With Peripheral Vascular Problems
Individual Students Program
After completing this theme, you should be able to:
1. Prioritize nursing care for the client experiencing the nonprogressive stage of hypovolemic shock.
2. Compare and contrast the pathophysiology and clinical manifestations of the hyperdynamic and hypodynamic phases of septic shock.
3. Identify clients at risk for septic shock.
4. Develop an educational plan for prevention for the client at risk for septic shock who lives at home.
Program of self training:
1. Describe the clinical manifestations associated with the compensatory mechanisms for shock.
2. Identify clients at risk for hypovolemic shock.
3. Use laboratory data and clinical manifestations to determine the effectiveness of therapy for shock.
4. Explain the basis for crystalloid versus colloid intravenous therapy for shock.
5. Explain the expected client responses to the drugs used in the treatment of shock.
Seminar discussion of theoretical issues (12:30-14:00)
Student’s Individual Work (14:15-15:00)
Students who have passed Moodle tests the day before class are free from test control during the class
Test evaluation and situational tasks
1. The client’s urinary output is normal, whereas respiratory rate and heart rate are slightly elevated from baseline. Which of the following should the nurse suspect?
a. Early stage of shock
b. Compensatory stage of shock
c. Intermediate stage of shock
d. Refractory stage of shock
2. A client has been admitted with a gastrointestinal ulcer. The client is NPO and has a nasogastric tube in place connected to low suction. What form of shock should the nurse monitor this client for?
a. Distributive shock
b. Obstructive shock
c. Cardiogenic shock
d. Hypovolemic shock
3. What is the pathophysiologic basis for the acidosis associated with hypovolemic shock?
a. Poor respiratory effort secondary to skeletal muscle weakness caused by the hydrogen ion excess
b. Lactic acid production resulting from decreased oxygen delivery to the tissues and increased anaerobic metabolism
c. Failure of the kidneys to excrete hydrogen ions and reabsorb bicarbonate ions as a result of renal hypertension
d. Increased sensitivity of the central chemoreceptors, enhancing the rate and depth of ventilation
4. A client brought to the emergency room after a motor vehicle accident is suspected of having internal bleeding. What initial clinical manifestation of hypovolemic shock would the nurse expect to find in this client?
a. Increased respiratory rate
b. Decreased urinary output
c. Increased heart rate
d. Cool, pale skin
5. A client admitted to the inpatient unit has been ordered to receive packed red blood cells to correct a moderate surgical blood loss. The client asks how this treatment will assist in his recovery. What would be the nurse’s best response?
a. “It will help to restore adequate electrolyte balance.”
b. “Surgical procedures often require blood replacement.”
c. “It will improve the ability of your blood to carry oxygen.”
d. “It will help to restore the oncotic pressure in your blood cells.”
6. A client in hypovolemic shock has been placed on a dopamine hydrochloride drip. Which parameter would indicate a desired client response to this drug?
a. Hypotension
b. Tachycardia
c. Increased cardiac output
d. Decreased mean arterial pressure
7. A nurse is monitoring a client who is receiving a dopamine hydrochloride drip for the treatment of shock. What symptom would indicate a possible overdose of this medication?
a. Pallor
b. Hypertension
c. Palmar erythema
d. Increased pulse deficit
8. What assessment is most appropriate for the client receiving sodium nitroprusside?
a. Assess for chest pain.
b. Assess blood pressure every 15 minutes.
c. Monitor urinary output every 30 minutes.
d. Observe the client’s extremities for color and perfusion.
9. Which client is most at risk for an adverse event when receiving atropine sulfate?
a. The client with bronchogenic carcinoma
b. The client with gastroesophageal reflux
c. The client with glaucoma
d. The client with asthma
10. Which manifestations should the nurse expect when caring for the client with distributive shock resulting from an anaphylactic event?
a. Increased heart rate and blood pressure
b. Increased blood pressure and cardiac output
c. Decreased blood pressure and respiratory rate
d. Decreased blood pressure and edema
Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions.
(the instructor has tests & situational tasks)
Basic level:
Student must know:
I. Overview
1. Physiology review
2. Pathophysiology
A) Initial stage of shock (early stage)
B) Nonprogressive stage of shock (compensatory stage)
C) Progressive stage of shock (intermediate stage)
D) Refractory stage of shock (irreversible stage)
E) Multiple organ dysfunction syndrome
3. Etiology
A) Hypovolemic shock
B) Cardiogenic shock
C) Distributive shock
1) Neural-induced distributive shock.
2) Chemical-induced distributive shock.
(i) Anaphylaxis.
(ii) Sepsis.
(iii)Capillary leak syndrome.
D) Obstructive shock
4. Incidence/prevalence
II. Collaborative management: Hypovolemic shock
1. Assessment
A) History
B) Physical assessment/clinical manifestations
1) Cardiovascular manifestations.
2) Integumentary manifestations.
3) Respiratory manifestations.
4) Kidney/urinary manifestations.
5) Central nervous system manifestations.
6) Musculoskeletal manifestations
C) Psychosocial assessment
D) Laboratory assessment
2. Interventions
A) Nonsurgical management.
1) Oxygen therapy.
2) Intravenous therapy.
a) Colloid fluid replacement.
b) Crystalloid fluid replacement.
3) Drug therapy.
a) Vasoconstricting agents
b) Agents enhancing myocardial contractility.
c) Agents enhancing myocardial perfusion.
4) Monitoring
B) Surgical management.
III. Collaborative management: Sepsis-induced distributive shock (septic shock)
1. Assessment
A) History
B) Physical assessment/clinical manifestations
1) Cardiovascular manifestations.
2) Respiratory manifestations.
3) Integumentary manifestations.
4) Psychosocial assessment
C) Laboratory assessment
2. Planning and implementation
A) Planning: expected outcomes.
B) Interventions.
1) Oxygen therapy.
2) Drug therapy.
3) Antibiotics
4) Antibodies.
5) Anticoagulants.
6) Clotting factors and blood products.
7) Providing a safe environment
IV. Community-based care
1. Health teaching
2. Home care management
V. Evaluation: outcomes
Answers
1. A
An increase in heart and respiratory rates (heart rate first) from the client’s baseline or a slight increase in diastolic blood pressure may be the only objective manifestations of early shock.
2. D
This client is at risk for hypovolemic shock caused by bleeding from gastrointestinal ulcers, leading to fluid volume loss, and from nasogastric suction that can compound the situation if the client is not sufficiently hydrated with IV fluids.
3. B
The syndrome of hypovolemic shock results in inadequate tissue perfusion and oxygenation; thus, some cells are metabolizing anaerobically. Such metabolism increases the synthesis of lactic acid, resulting in an increase in hydrogen ion production and acidosis.
4. C
The first manifestations of hypovolemic shock result from compensatory mechanisms. Signs of shock are first evident as changes in cardiovascular function. As shock progresses, changes in skin, respiration, and kidney function progress.
5. C
Packed red blood cells are considered colloid fluids. They are most often used to restore red blood cell loss and thereby increase the oxygen-carrying capacity of the blood without adding excess fluid volume.
6. C
Dopamine hydrochloride causes vasoconstriction that, in turn, increases cardiac output and mean arterial pressure, thereby improving tissue perfusion and oxygenation.
7. B
An overdose of dopamine hydrochloride is manifested by hypertension.
8. B
The client receiving sodium nitroprusside should have his or her blood pressure assessed every 15 minutes. Higher doses can cause systemic vasodilation and increase shock.
9. C
Atropine sulfate should be given cautiously to clients with glaucoma because it might precipitate an episode of acute angle-closure glaucoma.
10. D
Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals, which results in massive blood vessel dilation and increased capillary leak.
References:
А–Basic:
Required Textbooks:
1. Ignatavicius, D.D. (2012). Clinical Decision-making Study Guide for Medical-Surgical Nursing, (7th ed.) St. Louis: Elsevier
2. Ignatavicius, D.D. & Workman, M.L. (2012). Medical-surgical nursing: Patient centered collaborative care. (7th ed.) St. Louis: Elsevier
3. Potter, P.A. & Perry, A. G. (2013). Fundamentals of nursing, 8th ed.) St. Louis: Mosby/Elsevier.
4. Ackley, B.J. & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care, (9th ed.) St. Louis: Mosby/Elsevier.
5. Deglin, J. H., Vallerand, A. H., & Sandoski, C.A. (2013). Davis’s Drug Guide for Nurses, (13th ed.) Philadelphia: F. A. Davis.
Internet Resources:
1. http://intranet.tdmu.edu.ua/education.php
В – Additional:
Other Textbooks:
1. Ignatavicius, D.D. et.al. (2013). Clinical Companion for Medical-Surgical Nursing: for- Patient-Centered Collaborative Care. (7th ed) St. Louis: Elsevier.
2. Mosby’s Dictionary of Medicine, Nursing, and Health Professions, (2009). (8th ed.) St. Louis: Elsevier
3. Potter, P. A. et al. (2013). Fundamentals of nursing: Study guide, (8th ed.) St. Louis: Elsevier.
4. Pickar, G. & Abemethy, A.P. (2008). Dosage Calculations, (8ft.ed.). Clifton Park, NY: Thomson Delmar.
5. Venes, D. editor (2009) Taber’s Cyclopedia Medical Dictionary (21*ed.). Philadelphia: F A. Davis.
Methodical instruction has been worked out by: B. Lokay, MD, PhD, BSN
Methodical instruction was discussed and adapted at the Department sitting
June 12, 2013. Minute № 13
