radiation or region

Ask the patient where the pain is and if the pain extends, radiates, or exists anywhere else.

severity

Ask the patient to rate the pain on a scale from 0 to 10 (0 being no pain and 10 being the worst pain ever experienced).

timing

Ask the patient when the problem or pain started and if the pain is constant or comes and goes.

MOI mechanism of injury is key piece of information

Traumatic injury is a very common cause of shock. Damage to vascular organs, such as the liver or spleen can contribute to significant blood loss, and a burn injury can also cause massive fluid loss. Both of these traumatic injuries can lead to hypovolemic shock.

The MOI and the location of the patient's pain should provide you with clues to what may be causing the pain.

Determine which of the following is considered a common traumatic injury.

chest injury, head injury, pelvic/leg fracture

To assess a patient's previous medical history, collect AMPLE information on a variety of medical issues and topics.

allergies - especially anaphylactic rx

medications

past medical history

last meal prior to onset of symptoms

events preceding injury - what were they doing

medications

Medications that may contribute to shock or alter a patient's response to resuscitation include cardiotonic agents, such as beta-blockers, as well as antihypertensives, diuretics, and anticoagulants.

Pertinent data worth noting related to nontraumatic shock emergences includes any of the following:

• History of vomiting and hematemesis
• bullet Diarrhea, melena, hematochezia
• bullet Vaginal bleeding
• bullet Epistaxis, hemoptysis
• bullet Polyuria, polydipsia, polyphagia
• bullet Edema
• bullet Rashes
• bullet Paraplegia or quadriplegia

melena

Passage of black, tarry stools

hematochezia

Passage of bloody stools

important info such as

asthma, renal disease, substance abuse, endocrine disorder, pulm disease, GI disease, hematological disorders, previous surgical procedures

define objective data

ABCs (Airway, Breathing, Circulation) of the primary survey and information on the patient's level of consciousness (LOC).

airway patent, HR 130, skin cool/clammy, RR 28

Pt in shock usually have ^ RR, especially d/t:

• Activation of the sympathetic nervous system results in stimulation of the beta-2 receptors which will elevate the patient's respiratory rate.
• The patient will often experience an abnormal increase in hydrogen ion concentration in the body, or acidosis, leading to an increased respiratory rate as the body attempts to exhale more CO2 and normalize pH.

breath sounds - crackles?, rhonchi?

equal chest rise or equal sounds? could be tension pneumothorax

accessory muscle use

depth of breath sounds

irreversible shock

breathing would be agonized or arrested

access circulation and organ fx

helps tell what type of shock

skin color

In the late state of shock, a patient's skin will become mottled because of the shunting of blood from the peripheral to the central circulation.

rash, petechiae, bruising

In septic shock, there is a specific rash caused by meningococcemia.

signs of bleeding, bruising, hematoma

It is important to check for signs of bleeding.

bites, stings, erythema

s/sx of anaphylactic reaction

source of infection

Sources of infection, such as an open wound or location of a feeding tube or a central venous port insertion, can cause infection.

eyes

assess if sunken and dry

peripheral pulses

skin

The absence of peripheral pulses is an indication of shock.

Determine the skin's temperature and whether the skin is cool, clammy, pale, or cyanotic. Check the patient's skin turgor by gently pinching it. If a patient is dehydrated, the patient's skin will tent.

urine

It is important to notice if the patient has urinated and if the patient's urine is dark. The urine may be concentrated or may contain blood, which would indicate a bladder or renal injury. Adults generally produce 30 to 50 cc of urine per hour while children produce 1 to 2 cc/kg of urine per hour. However, if the patient is being resuscitated with fluids, their output should be greater. If urinary tract infection is suspected, a specimen should be sent for urinalysis.

LOC

GCS

Rate each function according to how well the patient responds. If the patient's score is 3 to 8, the patient most likely has a severe injury. Coma is defined as a GCS score of 8 or less, or as no response and no eye-opening.

Takeaways:

This section discussed objective data that should be collected when assessing a patient with shock.

T

This includes information on respiration efficiency, circulatory and organ functions, and LOC. When assessing respiration, pay attention to the patient's breathing sounds such as crackles, the equality of breath sounds, the use of accessory muscles to breath, and whether or not the breathing is shallow or deep.

T

Assessing circulatory and organ function involves the use of the senses. Look for skin color abnormalities including bites, wounds, or rashes. Look at the patient's urine for the presence of blood or white blood cells. In addition, palpate the patient's peripheral pulses, and check the patient's skin and temperature.

T

The LOC is determined by observing the patient's present state of mind. Determine if the patient is awake, anxious, cooperative, unresponsive, or responsive to verbal or painful stimuli. A LOC score can be established by using the GCS.

Documenting the care of the patient with shock helps ensure quality assessment and interventions.

true

Documenting the care of the patient with shock supports maximal financial reimbursement.

true

Documenting the care of the patient with shock provides adequate legal justification for care that was or was not provided.

true

Which of the following documentation elements should be included in the patient's medical record?

• Initial assessment data
• Time of rapid interventions
• Evidence of intensive care and monitoring
• Procedures followed
• Problems encountered
• Nursing observations
• Patient responses and outcome

Which of the following documentation elements should be included in the patient's medical record both to ensure a complete and accurate record and compliance with regulatory standards?

• Communication with family
• Communication with members of the healthcare team
• Patient teaching
• Use of translators
• Refusal of care

In addition to being a requirement of most care units, documenting trauma and shock helps to ensure quality care and proper interventions. Documentation supports financial and legal matters and can even be helpful for preserving forensic evidence.

You should document information about vital signs, LOC, GCS, ABCs, present health status, past medical history, details provided by family and team members, the time of the patient's arrival, and mechanism of injury.

[Solved] Which of the following patient beliefs should the clinician - Intro To Nursing (NURS G009) - Studocu

studocu

Which of the following is not subjective data to be gathered from the patient with shock?

Present health status

Previous medical history

Presence of pain

Lung sounds

Dysfunctional heart valves can cause which type of shock?

Cardiogenic

Distributive

Hypovolemic

Neurogenic

Diagnosis of shock is the most difficult during which stage?

Compensated

Uncompensated

Irreversible

Refractory

The event that caused the shock is called:

mechanism of injury (MOI)

past medical history

sentinel event

causative agent

The P in PQRST stands for which of the following?

provocation

Which of the following is not a function of documentation?

Reputation and public relations

The components of the Glasgow Coma Scale include all of the following except:

Reflex Activity

When amending a record after emergency care has been provided, all of the following notations are needed except:

reason

ABC

AirwayBreathingCirculation

Documentation should be:

thorough, accurate, legible

A patient that is in a coma has a GCS score of:

8

Shock is a clinical manifestation of the body's inability to:

perfuse tissues