A patient exhibits pallor, mild diaphoresis, and dizziness upon standing. Her blood pressure is 105/68 mmHg, and her heart rate is 95 bpm. What is the most likely nursing diagnosis for this patient?

D) Ineffective Breathing Pattern

Based on the patient's response to interventions, which of the following findings suggests an improvement in the patient's condition?

C) Capillary refill time of 2 seconds

A) Blood pressure of 110/72 mmHg

B) Respiratory rate of 18 breaths per minute

C) Capillary refill time of 2 seconds

D) Oxygen saturation of 98% on room air

What is the most likely reason for the initial nursing intervention of increasing oral fluid intake for this patient?

C) To improve the patient's hydration status

A) To decrease the patient's blood pressure

B) To reduce the patient's heart rate

C) To improve the patient's hydration status

D) To increase the patient's respiratory rate

Which finding in the patient's lab results suggests the need for increased fluid intake?

B) Elevated blood urea nitrogen (BUN)

A patient with mild abdominal discomfort and decreased urine output has slightly elevated BUN and creatinine levels. Which nursing intervention is most appropriate to address the potential renal implications?

A) Encourage the patient to increase fluid intake.

B) Restrict the patient's fluid intake.

C) Administer a diuretic as prescribed.

D) Prepare the patient for dialysis.

A patient in the hospital shows mild pallor with stable vital signs and normal lab results except for a slight decrease in BUN and creatinine levels. What is the most appropriate next step for the nurse to take?

A) Increase the patient's fluid intake.

C) Administer supplemental oxygen.

D) Start a high-protein diet immediately.

Shock - Nursing Case Study

Pathophysiology

• Primary mechanism: Shock occurs when there is inadequate blood flow to tissues, leading to insufficient oxygen and nutrient delivery. This can result from low blood volume, heart failure, or widespread blood vessel dilation.

• Secondary mechanism: The body's compensatory responses include increased heart rate and vasoconstriction to maintain blood pressure. However, prolonged compensation can lead to tissue damage and organ dysfunction.

• Key complication: Without timely intervention, shock can progress to multiple organ failure, as organs are deprived of necessary oxygen and nutrients, emphasizing the need for rapid recognition and treatment.

Patient Profile

Demographics:

28-year-old female, office manager

History:

• Key past medical history: Mild asthma

• Current medications: Albuterol inhaler as needed

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Dizziness and lightheadedness

• Key symptoms: Mild fatigue, slight nausea

• Vital signs: Blood pressure 110/70 mmHg, heart rate 90 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F, oxygen saturation 98% on room air

Section 1

Initial Assessment Findings:

Upon further assessment, the nurse notes that the patient, while alert and oriented, exhibits some pallor and mild diaphoresis. The patient reports that her dizziness worsens when she stands up quickly, suggesting possible orthostatic changes. A repeat set of vital signs shows a slight decrease in blood pressure to 105/68 mmHg, while her heart rate has increased to 95 bpm. Her respiratory rate remains stable at 18 breaths per minute, and her oxygen saturation is unchanged at 98% on room air.

The nurse conducts a focused cardiovascular and respiratory assessment. Heart sounds are regular with no abnormal rhythms detected, and lung sounds are clear bilaterally. The patient denies any chest pain, shortness of breath, or cough. Peripheral pulses are palpable but slightly weaker in the extremities, and capillary refill is slightly delayed at approximately 3 seconds. These findings are consistent with early compensatory mechanisms in response to decreased perfusion.

The nurse documents these findings and considers potential causes of the patient's symptoms, such as hypovolemia or vasodilation. Based on the assessment, the nurse initiates basic interventions to support the patient's condition, such as encouraging oral fluid intake to potentially address fluid volume status and assessing for any additional triggers or factors that may have contributed to the current state. The nurse plans to monitor the patient's vital signs and symptoms closely, providing updates to the healthcare team for any changes that may require further diagnostic testing or intervention.

Section 2

Response to Interventions

Several hours after the initial assessment, the nurse returns to evaluate the patient's response to the interventions. The patient has adhered to the recommendation to increase oral fluid intake, consuming approximately 500 mL of water over the past few hours. A repeat set of vital signs shows that the patient's blood pressure has stabilized slightly at 110/72 mmHg, and her heart rate has decreased to 88 bpm. The patient reports feeling less dizzy, particularly when rising from a seated position, suggesting an improvement in her orthostatic symptoms. Her respiratory rate remains at 18 breaths per minute, and oxygen saturation is still 98% on room air.

The nurse conducts another focused assessment and notes that the patient's skin color has improved, and there is a slight reduction in diaphoresis. Peripheral pulses are more palpable, and capillary refill time has decreased to 2 seconds, indicating enhanced peripheral perfusion. The patient is alert and oriented, maintaining clear conversation and displaying no signs of confusion or distress. These positive changes suggest that the initial interventions have been effective in addressing the early signs of shock, likely related to mild hypovolemia.

The nurse documents these findings and communicates the patient's progress to the healthcare team. In collaboration with the team, the nurse decides to continue monitoring the patient closely, ensuring continued fluid intake and evaluating for any new symptoms. The patient's stability allows for consideration of discharge planning, with instructions for maintaining adequate hydration and recognizing signs of worsening symptoms. The nurse also plans to educate the patient on lifestyle modifications that may prevent future episodes, fostering a proactive approach to her health management.

Section 3

As the patient's condition remains stable and shows signs of improvement, the nurse continues to monitor vital signs and assess for any new complications that may arise. A few hours later, the patient reports experiencing mild abdominal discomfort and has noticed a slight decrease in urine output. Recognizing these as potential indicators of dehydration or kidney involvement, the nurse performs a focused abdominal assessment and checks the patient's last recorded intake and output. The abdomen is soft and non-tender, with normal bowel sounds, but the urine output is noted to be less than 30 mL per hour over the past three hours.

To further evaluate the patient's renal function and hydration status, the healthcare team orders basic lab tests, including a complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), and creatinine levels. The results reveal slightly elevated BUN and creatinine levels, suggesting that the kidneys might be responding to the earlier hypovolemic state. Electrolytes are within normal limits, indicating no immediate imbalances. The nurse discusses these findings with the patient, explaining the importance of maintaining adequate fluid intake to support kidney function and prevent further complications.

In response to these new findings, the nurse collaborates with the healthcare team to adjust the care plan, emphasizing continued hydration and monitoring of renal function. The patient is encouraged to drink additional fluids, and a follow-up urine output measurement is planned to assess for improvements. The nurse also takes this opportunity to educate the patient on recognizing signs of dehydration and the importance of early intervention. With these adjustments, the care team remains optimistic about the patient's recovery and potential discharge, while ensuring ongoing vigilance for any new developments.

Section 4

As the patient continues to receive increased oral fluids, the nurse closely monitors for any changes in the patient's condition. A few hours after the care plan adjustment, the nurse notes a positive response to the hydration efforts. The patient's urine output has increased, with the most recent measurement showing 35 mL per hour over the past two hours, indicating a gradual improvement in renal function. The patient's vital signs remain stable, with a heart rate of 76 beats per minute, blood pressure at 118/76 mmHg, respiratory rate of 18 breaths per minute, and an oxygen saturation of 98% on room air.

In addition to monitoring urine output and vital signs, the nurse conducts a follow-up abdominal assessment, finding that the abdomen remains soft and non-tender, with active bowel sounds present. The patient reports that the mild abdominal discomfort has subsided, and they express feeling more comfortable overall. Encouraged by these findings, the nurse continues to emphasize the importance of maintaining adequate hydration and reminds the patient to report any new symptoms immediately.

With the patient's condition showing signs of improvement and stabilization, the healthcare team discusses the possibility of discharge planning. They consider scheduling a follow-up appointment with the patient's primary care provider to reassess renal function and overall recovery. The nurse provides the patient with educational materials on hydration, signs of dehydration, and when to seek medical attention. As the patient demonstrates understanding and adherence to the care recommendations, the nurse feels confident in the patient's ability to continue the recovery process at home, while remaining prepared for any potential new developments.

Section 5

As the day progresses, the patient remains under close observation to ensure continued improvement and early detection of any potential complications. In the afternoon, the lab results from the patient's earlier blood tests return. The results show that the patient's blood urea nitrogen (BUN) and creatinine levels have decreased slightly, reflecting an improvement in renal function, with BUN at 18 mg/dL and creatinine at 1.2 mg/dL. Electrolyte levels are within normal limits, with sodium at 138 mmol/L and potassium at 4.0 mmol/L, indicating that the oral hydration efforts are effectively addressing the patient's fluid needs. These findings provide further reassurance that the patient's condition is stabilizing.

However, despite the positive lab results, the nurse notices a slight change in the patient's skin assessment. The patient's skin, while still warm and dry, shows mild pallor that was not previously noted. The nurse decides to reassess the patient's hemoglobin and hematocrit levels to rule out any underlying anemia or blood loss that might contribute to this observation. The patient denies feeling dizzy or fatigued, and their energy level remains good, but the nurse remains vigilant in monitoring for any signs that could suggest a need for further intervention.

The healthcare team discusses these findings, considering the potential causes of the pallor and planning to adjust the care plan if necessary. They decide to recheck the patient's complete blood count (CBC) and ensure that any new symptoms are promptly addressed. Meanwhile, the nurse continues to educate the patient on the importance of monitoring for signs of anemia and encourages them to maintain a balanced diet to support recovery. As the team prepares for the possibility of discharge, they plan to review the results of the repeat CBC and adjust the care plan accordingly, ensuring the patient remains on the path to full recovery.