Which of the following initial assessment findings suggests the patient may be experiencing obstructive shock?

B) Delayed capillary refill time

A) Clear breath sounds bilaterally

B) Delayed capillary refill time

C) Normal heart sounds without murmurs

D) Alert and oriented to person, place, and time

Based on the initial assessment findings, which nursing action is the priority for managing the patient’s condition?

C) Monitor the patient’s vital signs and reassess for changes in status.

A) Administer supplemental oxygen to increase oxygen saturation.

B) Prepare the patient for emergency surgery to relieve obstructive shock.

C) Monitor the patient’s vital signs and reassess for changes in status.

D) Provide patient education on managing anxiety related to breathing difficulties.

Which of the following interventions is most appropriate for a nurse to implement when caring for a patient who has been diagnosed with a pulmonary embolism?

C) Monitor the patient for signs of bleeding due to anticoagulation therapy.

A) Encourage the patient to perform deep breathing exercises.

B) Ambulate the patient frequently to prevent further clot formation.

C) Monitor the patient for signs of bleeding due to anticoagulation therapy.

D) Restrict the patient’s fluid intake to reduce pulmonary congestion.

Which of the following is the primary nursing responsibility when administering low molecular weight heparin (LMWH) to a patient with a pulmonary embolism?

B) Assess for signs of bleeding and bruising

A) Monitor blood pressure and heart rate closely

B) Assess for signs of bleeding and bruising

C) Encourage increased fluid intake

D) Position the patient in semi-Fowler's position

What is the most appropriate initial nursing action when a patient reports new onset of mild chest discomfort while on anticoagulation therapy?

C) Reassess the patient's vital signs and symptoms

A) Administer prescribed pain medication

B) Notify the healthcare provider immediately

C) Reassess the patient's vital signs and symptoms

D) Increase the patient's oxygen flow rate

Which immediate nursing intervention is most appropriate for addressing the patient's new onset of mild chest discomfort?

B) Reposition the patient for comfort

D) Provide a dose of nitroglycerin

Which nursing intervention is most appropriate for a patient with slightly elevated D-dimer levels and respiratory alkalosis?

A) Encourage deep breathing exercises

D) Limit the patient's mobility

What is the primary reason for encouraging mobility in patients who are recovering from a condition involving elevated D-dimer levels?

C) To reduce the risk of thromboembolic events

A) To improve cardiovascular fitness

B) To enhance respiratory function

C) To reduce the risk of thromboembolic events

What is the most appropriate initial nursing intervention for a patient experiencing mild dizziness due to orthostatic changes?

B) Encourage slow position changes

D) Increase the patient's diuretic dosage

What is the primary reason for performing orthostatic blood pressure measurements in this patient?

A) To assess for potential dehydration

B) To evaluate the patient's respiratory function

C) To check for signs of infection

Obstructive Shock - Nursing Case Study

Pathophysiology

• Primary mechanism: Obstructive shock occurs when a physical blockage prevents blood from effectively circulating through the heart or large blood vessels, reducing cardiac output. This can be due to conditions like pulmonary embolism or cardiac tamponade, leading to inadequate oxygen delivery to tissues.

• Secondary mechanism: The heart struggles to fill or pump properly due to increased pressure from the obstruction, causing a backlog of blood and further decreasing oxygen supply to the body. This can trigger compensatory mechanisms, like increased heart rate, which are often insufficient.

• Key complication: If unaddressed, obstructive shock can lead to organ failure due to prolonged lack of oxygen and nutrients, emphasizing the need for rapid identification and intervention to remove the obstruction and restore circulation.

Patient Profile

Demographics:

45-year-old female, office administrator

History:

• Key past medical history: Hypertension, managed with lifestyle changes

• Current medications: None

• Allergies: None

Current Presentation:

• Chief complaint: Mild shortness of breath

• Key symptoms: Slight chest discomfort, lightheadedness

• Vital signs: Blood pressure 118/78 mmHg, heart rate 92 bpm, respiratory rate 18 breaths/min, temperature 98.6°F, SpO2 96% on room air

Section 1

Initial Assessment Findings:

Upon arrival in the emergency department, the nursing team conducts a thorough initial assessment of the patient. The nurse observes that the patient appears mildly anxious and is using accessory muscles slightly when breathing. Capillary refill time is delayed at 3 seconds, indicating potential peripheral perfusion issues. Auscultation of the lungs reveals clear breath sounds bilaterally, but the nurse notes a mild wheeze upon deeper inspiration. The patient's skin is warm and slightly diaphoretic, consistent with the body's compensatory response to maintain adequate circulation and oxygenation.

Further assessment includes a focused cardiac examination, which reveals normal heart sounds without any murmurs, rubs, or gallops. Jugular venous distention is noted, suggesting increased central venous pressure, a common finding in obstructive shock. The nurse also performs a brief neurological assessment, finding the patient alert and oriented to person, place, and time, though slightly lightheaded. The patient rates her chest discomfort as a 3 on a scale of 10, which is consistent with her initial presentation of mild symptoms. Vital signs remain stable, with blood pressure at 116/76 mmHg, heart rate at 94 bpm, respiratory rate at 20 breaths/min, and SpO2 at 95% on room air.

These findings guide the healthcare team in their next steps, prompting the need for further diagnostic testing to identify the cause of the obstructive shock, such as imaging studies to evaluate for potential pulmonary embolism or echocardiography to assess cardiac function and rule out tamponade. The stable vital signs and mild symptoms offer a window of opportunity for early intervention, emphasizing the importance of prompt and accurate diagnosis to prevent deterioration.

Section 2

New Diagnostic Results:

Following the initial assessment, the healthcare team proceeds with further diagnostic testing to identify the underlying cause of the obstructive shock. A CT angiogram of the chest is performed, revealing a small pulmonary embolism in the right lower lobe. This finding aligns with the patient's mild respiratory symptoms and slightly increased use of accessory muscles, suggesting that the embolism is impacting pulmonary circulation but not severely compromising respiratory function at this stage. An echocardiogram is also conducted and shows no evidence of pericardial effusion or cardiac tamponade, ruling out another potential cause of obstructive shock.

Laboratory results provide additional insights into the patient’s condition. The D-dimer level is elevated, supporting the presence of a thrombotic event, while complete blood count and basic metabolic panel are within normal limits, indicating no significant hematologic or electrolyte abnormalities. The patient's arterial blood gas analysis shows a mild respiratory alkalosis, with a pH of 7.47 and PaCO2 of 33 mmHg, reflecting her slightly increased respiratory rate and effort. These findings confirm the presence of a pulmonary embolism as the cause of the obstructive shock, guiding the medical team towards initiating appropriate anticoagulation therapy to address the clot and prevent further complications.

With the diagnosis established, the healthcare team discusses the plan of care with the patient, explaining the need for anticoagulation treatment to dissolve the clot and reduce the risk of additional embolic events. The patient is started on low molecular weight heparin, given subcutaneously, with a plan to transition to oral anticoagulants once stable. The nursing team monitors the patient closely for any signs of bleeding or adverse reactions to the medication, while continuing to assess her respiratory status and provide reassurance to alleviate her anxiety. The prompt identification and treatment initiation provide a positive outlook for the patient's recovery, emphasizing the importance of early detection and intervention in managing obstructive shock.

Section 3

Change in Patient Status

After 24 hours on anticoagulation therapy, the patient's condition remains stable, but the nursing team observes some changes in her vital signs and overall status that warrant attention. Her respiratory rate has decreased slightly to 18 breaths per minute, and she appears less reliant on accessory muscles, indicating an improvement in her respiratory effort. Oxygen saturation remains stable at 96% on room air, suggesting effective oxygenation. However, the patient reports a new onset of mild chest discomfort, described as a dull ache, which prompts further evaluation.

The nursing team conducts a thorough assessment and notes that the patient's heart rate has increased to 105 beats per minute, and her blood pressure is slightly elevated at 138/85 mmHg. These changes, along with the report of chest discomfort, raise concerns about the possibility of increased pulmonary pressures or additional embolic events. A repeat ECG shows sinus tachycardia but no signs of ischemic changes, ruling out acute cardiac complications. The nursing team communicates these findings to the healthcare provider, who considers the potential need for additional imaging if symptoms persist.

In response to these developments, the nursing team focuses on optimizing the patient's comfort and monitoring her closely for any progression of symptoms. They ensure that the patient is positioned comfortably, encourage deep breathing exercises to improve ventilation, and continue to educate her about the importance of medication adherence and symptom reporting. The team also reassures the patient, addressing her anxiety and emphasizing that these changes are being closely managed. The plan of care is adjusted to include more frequent monitoring and reassessment, ensuring any further changes are promptly detected and addressed.

Section 4

The nursing team continues to monitor the patient closely, emphasizing the importance of frequent assessments to detect any changes in her condition. During a routine check, they note that the patient's heart rate has decreased slightly to 98 beats per minute, which is a reassuring sign. Her blood pressure remains elevated at 140/88 mmHg, but no further increase is observed. The patient reports that her chest discomfort has reduced to a mild level, now describing it as intermittent and less intense. This improvement suggests a positive response to the current management plan, yet vigilance remains crucial.

A repeat set of laboratory tests is ordered, including a D-dimer and arterial blood gases (ABG). The D-dimer levels are slightly elevated, which is consistent with her recent diagnosis and ongoing treatment, while the ABG results show a slight respiratory alkalosis with a pH of 7.47, PaCO2 of 32 mmHg, and PaO2 of 85 mmHg. These findings align with her current respiratory status and provide further reassurance that she is maintaining adequate oxygenation.

The nursing team uses these assessment findings to guide their ongoing care. They continue to prioritize patient education, reinforcing the importance of reporting any new or worsening symptoms immediately. The patient is encouraged to remain mobile as tolerated, which helps reduce the risk of further complications. The team also continues to provide emotional support, acknowledging the patient's concerns and offering reassurance about the carefully coordinated efforts to manage her condition. This approach not only addresses the current clinical picture but also lays the groundwork for a gradual transition towards recovery, with a focus on preventing potential complications.

Section 5

As the nursing team continues their vigilant monitoring, they notice a subtle change in the patient's respiratory status during the next assessment. The patient's respiratory rate has decreased slightly to 18 breaths per minute, which is within normal limits, and she reports feeling more comfortable with her breathing. Her oxygen saturation remains stable at 96% on room air, indicating that her current respiratory function is well-maintained. However, the patient mentions experiencing mild dizziness when transitioning from lying down to sitting, prompting the nursing team to consider orthostatic changes as a potential concern.

In light of these observations, the team decides to perform orthostatic blood pressure measurements. The results indicate a slight drop in blood pressure from 140/88 mmHg when lying down to 130/80 mmHg when sitting, with no significant change in heart rate. These findings suggest the need to monitor her hydration status and ensure adequate fluid intake, as dehydration could contribute to her symptoms. The nursing team discusses the importance of slow position changes with the patient to minimize dizziness and prevent falls.

To address these new findings, the nursing plan includes increased fluid intake and continued encouragement of mobility, balanced with periods of rest. The patient is reassured that these interventions are part of the proactive approach to prevent any further complications. The nursing team remains attentive to any evolving symptoms, ready to adjust the care plan as needed to support the patient's gradual recovery and maintain her overall stability.