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Nursing Plans and Interventions A. B. Monitor arterial pressure by understanding the con- cepts related to arterial pressure (Table 3-3). Monitor BP, pulse, respirations, and arrhythmias every 15 minutes or more often, depending on stability of client. Assess urine output every hour to maintain at least 30 mL/hr. . Notify health care provider if urine output drops below 30 mL/hr (reflects decreased renal perfusion and may result in acute renal failure). Administer fluids as prescribed by provider to improve preload: blood, colloids, or electrolyte solutions until designated CVP is reached (Table 3-4). Remember client’s bed position is dependent on cause of shock. . Administer medications IV (not intramuscular [IM] or subcutaneous) until perfusion improves in muscles and subcutaneous tissue. . Keep client warm; increase heat in room or put warm blankets (not too hot) on client. Keep side rails up during all procedures; clients in shock experience mental confusion and may easily be injured by falls. Obtain blood for lab work as prescribed: complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), creatinine (renal damage), lactate (sepsis), and blood gases (oxygenation and ventilation). TABLE 3-3 Arterial Pressure Concept Definition Mean arterial pressure | * Level of pressure in the central (MAP) arterial bed measured indirectly by BP measurement * MAP = cardiac output X total peripheral resistance = systolic BP + 2 (diastolic BP)/3 * In adults, usually approaches 100 mm Hg * Can be measured directly through arterial catheter insertion Cardiac output (CO) * Volume of blood ejected by the left ventricle per unit of time * Stroke volume (amount of blood ejected per beat) X heart rate (normal: 4 to 6 L/min) Peripheral resistance * Resistance to blood flow offered (PR) by the vessels in the peripheral vascular bed Central venous * Pressure within the right atrium; pressure (CVP) normal CVP/RAP ranges from 2 to 6 mm Hg K. When administering vasopressors or adrenergic stim- ulants, such as epinephrine (Bronkaid), dopamine (Intropin), dobutamine (Dobutrex), norepinephrine (Levophed), or isoproterenol (Isuprel): 1. Administer through volume-controlled pump. 2. Monitor hemodynamic status every 5 to 15 minutes. 3. Watch intravenous site carefully for extravasation and tissue damage. 4. Ask health care provider for target mean systolic BP (usually 80 to 90 mm Hg). L. When administering vasodilators, such as hydralazine (Apresoline), nitroprusside (Nipride), or labetalol hydrochloride (Normodyne, Trandate) to counteract effects of vasopressors: 1. Wait for precipitous decrease or increase in BP if prescribed together. 2. If drop in BP occurs, decrease vasodilator infusion rate first; then increase vasopressor. 3. If BP increases precipitously, decrease vasopressor rate first; then increase rate of vasodilator. 4. Obtain blood work as prescribed: CBC, electrolytes, BUN, creatinine (renal damage), and blood gases (oxygenation). 5. Glucose levels should be maintained at 140 to 180 mg/dL. HESI Hint » All vasopressor and vasodilator drugs are potent and dangerous and require that the client be titrated prudently. M. Provide family support: 1. Notify appropriate support persons for families waiting during crisis—call spiritual advisor, other family members, or anyone the family thinks will be supportive. 2. At intervals, notify family of actions and progress or lack of progress in realistic terms. 3. Collaborate with health care provider before notify- ing family of medical interventions. Disseminated Intravascular Coagulation (DIC) oooooooooooooooooooooooooooooooooooooooooooooooooooo Description: Coagulation disorder with paradoxical throm- bosis and hemorrhage A. DIC is an acute complication of conditions such as hypotension and septicemia. It is suspected when there is blood oozing from two or more unexpected sites. B. The first phase involves abnormal clotting in the micro- circulation, which uses up clotting factors and results in the inability to form clots, so hemorrhage occurs. C. The diagnosis is based on laboratory findings. 1. Prothrombin time (PT): prolonged - N a1 1 1 1