Nursing care for a patient in shock.

Set of activities performed by the nurse aimed at recovering the patient’s vital functions.

Objectives:

– Maintain the patient’s life support. – Decrease the anxiety of the family.

Equipment:

– Crash cart. – Equipment necessary for bladder catheterization. – Equipment necessary for Electrocardiogram. – Sphygmomanometer. – Stethoscope.

Material:

– Non-sterile gloves. – Specific medication. – Physiological saline solution. – Necessary material for oxygen therapy. – Necessary material for bladder catheterization. – Necessary material for fluid therapy. – Necessary material for the Electrocardiogram. – Material necessary for Peripheral Catheter Insertion Technique. – Material necessary for Venous Blood Sampling. – Nursing records.

Procedure:

– Assess patient’s condition: heart rate, blood pressure, sweating, temperature, pallor, anxiety, agitation, state of consciousness. – Call for help and notify the physician. – Preserve the patient’s privacy. – Move the crash cart with the patient. – Put on disposable gloves. – Administer sufficient oxygen therapy to reduce hypoxemia. – Cannulate 1-2 large venous lines and maintain them with saline. – Draw venous blood for coagulation, hematology, crossmatching and biochemistry, according to medical indication. – Administer fluids and drugs prescribed by the physician. – Monitor vital signs. – Elevate lower limbs if the patient’s condition permits, Trendelenburg position. In cardiogenic shock (patient with dyspnea) place the patient in the Fowler position with the lower limbs in decline. – Perform bladder catheterization. – Perform water balance. – If cardio-respiratory arrest occurs, start resuscitation maneuvers. – Prepare everything necessary for transfer to ICU, if necessary. – Collect the material used and clean it. – Remove gloves. – Record in the nursing documentation: start time and duration, medication administered, procedures performed, time of transfer to ICU, incidents, constants.