Lecture on Nursing Interventions for Shock

Overview

This lecture covers essential nursing interventions and assessments related to various types of shock. It addresses both the early signs to recognize and the priority actions to take in different shock scenarios.

Key Questions and Answers

Hypovolemic Shock

First Intervention: Administer fluids rapidly.
Signs: Weak, thready pulse is a classic early sign.
Priority Action for Low BP: Place the patient flat with legs elevated.
Initial Action for Trauma Patient: Apply pressure to bleeding site and elevate legs.
Hemodynamic Finding: Low central venous pressure (CVP).
Initial Fluid: Normal saline.
Early Skin Appearance: Warm and flushed.

Septic Shock

Unresponsive to Fluids: Start norepinephrine infusion.
Preventing Mortality: Early detection and treatment.
Cause of Vasodilation: Infection and vasodilation.
Priority Indicator of Progressing Shock: Sudden drop in blood pressure.

Anaphylactic Shock

First-line Emergency Treatment: Administer epinephrine IM.
Immediate Priority: Maintain airway and breathing.

Neurogenic Shock

Vital Signs: Hypotension and bradycardia.
Priority Intervention: Administer vasopressors as ordered.

General Shock Management

Kidney Perfusion: Monitor for decreased urine output.
Monitor Perfusion: Monitor mental status closely.
Prevent Complications: Early identification of at-risk individuals.
Late-stage Shock Symptom: Unresponsiveness.

Assessments

Evaluating Response to Treatment: Priority vital signs.
Detecting Compensatory to Progressive Shock: Decrease in systolic blood pressure.
Lab Monitoring for Metabolic Acidosis: Serum lactate.
Priority Assessment for Post-Surgery Shock: Administer oxygen and monitor vital signs.

Additional Interventions

Vasopressor Therapy Goal: Increase perfusion to vital organs.
Improved Perfusion Indicator: Capillary refill less than 2 seconds.
Refractory Stage Intervention: Provide comfort and end-of-life care.

Instruction to UAP

Vital Signs Monitoring: Report any systolic blood pressure below 90 immediately.

This lecture emphasizes the importance of early detection, appropriate interventions, and continuous monitoring in the management of shock. It also highlights the role of proper delegation and communication in a clinical setting.

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Essential Nursing Interventions for Shock