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문제

A nurse is caring for a patient in the emergency department who presents with signs of distributive shock. Which assessment finding would be the MOST critical indicator that requires immediate intervention?

The nurse must identify the most critical assessment finding in distributive shock that indicates immediate need for intervention.
해설
A central venous pressure (CVP) of 2 mmHg with warm, flushed skin indicates severe vasodilation and inadequate venous return, the most critical finding in distributive shock requiring immediate fluid resuscitation and vasopressors. Other options, like hypotension or low urine output, are concerning but do not directly indicate the same level of immediate pathophysiological derangement.
같은 주제 다음 문제A nurse is caring for a patient in the emergency department who presents with signs of dis…

심화 해설

Clinical Judgment The core of distributive shock is relative hypovolemia due to widespread vasodilation. Cardiac output may initially be normal, but extremely low vascular resistance leads to severe hypotension. Therefore, continuous monitoring of blood pressure and mean arterial pressure (MAP) is most critical. MAP directly reflects the driving pressure for organ perfusion, and a value below 65 mmHg is a warning sign of organ ischemia. While other indicators are important, a sudden drop in blood pressure can lead to a life-threatening situation requiring immediate vasopressor administration and aggressive fluid resuscitation. Memory Tip: Distributive shock is a shock where blood pressure drops because "the vessels are relaxed." Blood pressure is the first to fall and the most dangerous. Remember it as "Vessel relaxation → BP ↓." KR vs US: In Korea, you may be more familiar with non-invasive blood pressure measurement, but in NGN/US clinical settings, continuous blood pressure monitoring via an arterial line is standard for unstable patients like those with distributive shock. This is essential for capturing moment-to-moment changes and precisely titrating vasopressor effects.

임상 시나리오

Clinical Management of Distributive Shock

In distributive shock, the immediate priority is restoring intravascular volume and vascular tone to improve tissue perfusion. The critical finding of a CVP of 2 mmHg with warm, flushed skin indicates severe relative hypovolemia and vasodilation, necessitating rapid intervention.

Immediate Actions:

  • Initiate rapid fluid resuscitation with isotonic crystalloids (e.g., 30 mL/kg bolus) per sepsis guidelines, reassessing CVP and perfusion markers frequently.
  • Administer vasopressors (e.g., norepinephrine as first-line) if hypotension persists despite fluid loading, targeting a mean arterial pressure (MAP) of 65 mmHg or higher.
  • Obtain blood cultures, serum lactate, and other labs; start broad-spectrum antibiotics within 1 hour if sepsis is suspected as the cause.

Ongoing Monitoring:

  • Continuously monitor CVP, arterial blood pressure, urine output, and mental status to evaluate response to treatment.
  • Trend serum lactate levels as a marker of tissue hypoperfusion and clearance; a decrease indicates effective resuscitation.
  • Watch for transition to cold shock (cool, mottled skin) which may signal worsening cardiac output despite vasodilation.

Nursing Considerations:

  • Position the patient flat or in Trendelenburg position initially to promote venous return, unless contraindicated.
  • Ensure accurate CVP transducer placement and zeroing; a single low value should be correlated with clinical signs before acting.
  • Document all interventions and reassessments in real-time, communicating changes to the provider immediately.

핵심 개념

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