A patient comes to the emergency department in the irreversible stage of shock. The best nursing intervention would be:
A) Provide opportunities for the family to spend time with the patient and help them to understand the irreversible stage of shock.
B) Inform the patient's family early that the patient will likely not survive, which allows the family time to make plans and move forward.
C) Closely monitor fluid replacement therapy and inform the family that the patient will probably survive and return to normal life.
D) Protect the patient's airway, optimize intravascular volume, and support the pumping action of the heart.
Ans: A
Feedback: The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the patient and helping them to understand the irreversible stage of shock is the best intervention. Option B is a good answer; informing the patient's family early that the patient will likely not survive does allow the family to make plans and move forward, but informing the family too early robs them of hope and interrupts the grieving process. Option C is incorrect; the chance of surviving the irreversible (or refractory) stage of shock is very small. The nurse needs to help the family cope with the reality of the situation. Option D is incorrect; with the chances of survival so small, the priorities shift from aggressive treatment and safety to addressing the end-of -life issues.
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