The nurse, a member of the health care team in the ED, is caring for a patient who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention?
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 immediately that the patient will likely not survive to allow 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 initiate the early rehabilitation process.
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. 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 will rob the family of hope and interrupt the grieving process. The chance of surviving the irreversible (or refractory) stage of shock is very small, and the nurse needs to help the family cope with the reality of the situation. 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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