| Course | NU656 AGACNP Critical Care Management |
|---|---|
| Unit | Unit 2 |
| Paper type | Shock classification paper |
| Length | About 1,080 words, 6 pages double-spaced |
| Format | APA 7 student paper |
| School | Purdue University Global |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NU656 Unit 2
Clear Lungs and a High Jugular Pulse: A Shock Classification Paper on Obstructive Shock From Massive Pulmonary Embolism in a 48-Year-Old Man With Pancreatic Cancer
[Student Name]
Purdue University Global
NU656: AGACNP Critical Care Management
Unit 2 Shock Classification Paper
[Instructor Name]
[Date]
The patient is composite; values, doses and times are bracketed.
The Case
Mr. [S.], [48], was diagnosed with locally advanced pancreatic adenocarcinoma [one] month ago and started chemotherapy through a new port [two] days ago. At [09:40] he became suddenly breathless while walking to the bathroom. On assessment: blood pressure [78/52], heart rate [128], respiratory rate [30], saturation [87] percent on [6] liters. His jugular venous pressure was about [10] cm above the sternal angle. His lungs were clear on both sides. His knees were mottled and his hands cold. Lactate [4.4] mmol/L; urine output below [20] mL an hour. Troponin [0.31] ng/mL; BNP [640] pg/mL.
Classifying the Shock
Shock is inadequate delivery of oxygen to the tissues, and it is classified by the underlying failure: too little volume, a failing pump, vessels that have lost their tone, or an obstruction to flow. Each type changes three variables in its own pattern (Vincent & De Backer, 2013).
1. Hypovolemic: low filling pressure, low cardiac output, high systemic vascular resistance. Neck veins flat.
2. Cardiogenic: high left-sided filling pressure, low output, high resistance. Neck veins raised and lungs wet.
3. Distributive: low or normal filling pressure, normal or high output, low resistance. Skin often warm early.
4. Obstructive: high right-sided filling pressure, low output, high resistance. Neck veins raised and lungs clear.
Mr. [S.] had high right-sided filling (raised jugular pressure), low output (cold, mottled skin, high lactate, low urine output) and high resistance (cold extremities). That excludes hypovolemic and distributive shock. The choice lies between cardiogenic and obstructive, and the lungs decide it. A failing left ventricle backs fluid into the lungs; an obstruction to the right ventricle's outflow leaves the lungs dry while the neck veins fill. His clear lungs point to obstruction.
Obstructive shock is the least common of the four in intensive care populations, which is one reason it is easy to miss; the causes to consider are massive pulmonary embolism, cardiac tamponade and tension pneumothorax.
Confirming the Cause
Each obstructive cause has a bedside test. Breath sounds were equal and the trachea midline, and bedside ultrasound showed lung sliding on both sides, so tension pneumothorax was unlikely. Echocardiography showed no pericardial effusion, excluding tamponade. It did show a dilated right ventricle, larger than the left, with the septum flattened into a D shape and poor movement of the right ventricular free wall, the pattern of acute right ventricular pressure overload. His lower leg ultrasound found a clot in the left popliteal vein.
With active cancer, new chemotherapy and a new central line, his risk of venous thromboembolism was high. CT pulmonary angiography, done once he was stabilized on a vasopressor, showed large clots in both main pulmonary arteries. The ESC guideline defines high-risk pulmonary embolism by hemodynamic instability, including persistent hypotension or the need for vasopressors (Konstantinides et al., 2020). He met that definition.
Treatment Follows From the State
Because the state is obstructive, treatment aims to relieve the obstruction and support the failing right ventricle while that happens.
1. Norepinephrine to restore pressure and coronary perfusion of the right ventricle, starting at [0.1] mcg/kg per minute.
2. Fluid limited to [500] mL. A right ventricle already overloaded can dilate further with more volume, pushing the septum into the left ventricle and lowering output.
3. Unfractionated heparin bolus and infusion.
4. Systemic thrombolysis, which the ESC guideline recommends for high-risk pulmonary embolism unless contraindicated (Konstantinides et al., 2020). His cancer had no brain metastases and he had no recent major surgery or bleeding; the port placement two days earlier was discussed and judged a minor procedure. Alteplase [100 mg] over [two] hours was given at [11:30]. The bleeding risk is real: in a large trial of thrombolysis for intermediate-risk embolism, extracranial bleeding occurred in 6.3 percent of treated patients against 1.2 percent with placebo (Meyer et al., 2014). That trial excluded patients in shock; for a patient already failing, as Mr. [S.] was, the balance favors lysis.
5. Intubation avoided if possible, because positive pressure and induction drugs can collapse a failing right ventricle.
Where Classification Can Go Wrong
Three pitfalls deserve mention, because each would have misclassified Mr. [S.]. The first is relying on blood pressure alone. All four types of shock lower pressure, so the pressure tells the team that shock is present but nothing about its kind. The second is reading the troponin and BNP as proof of a primary heart problem. Both rise when the right ventricle is strained by an embolism, and here they measured the size of the obstruction's effect rather than its cause. The third is mixed shock. A patient with cancer and a new port could also have been septic, and sepsis with a large embolism would combine distributive and obstructive patterns. His warm-shock features were absent, his temperature was normal and his skin was cold, but the team drew blood cultures before thrombolysis so that a second process would not be missed.
The bedside findings that settled the classification, jugular venous pressure, lung sounds and skin temperature, took less than two minutes to gather. The echocardiogram then confirmed what the examination had already suggested. Classification does not require a pulmonary artery catheter in most patients; it requires looking at the three variables in the right order and asking which pattern they make together.
Why Classification Mattered
Had he been treated for cardiogenic shock, the likely orders would have been a diuretic and an inotrope, removing volume from a ventricle that needed filling. Had he been treated for hypovolemic shock, liters of fluid would have dilated the right ventricle further. Each treatment is correct for its own state and harmful for his. His lactate was [2.1] and his pressure [104/66] off norepinephrine by [16:00]. He was discharged on apixaban on [Day 8], with a plan to continue anticoagulation while his cancer is active. His oncology team was told about the embolism on the same day, and his chemotherapy resumed [two] weeks later without further clots. The lesson the team drew was that the lungs were the finding that decided everything, and that they had been examined in the first minute of the assessment, before any test had been ordered or any drug chosen.
References
Konstantinides, S. V., Meyer, G., Becattini, C., Bueno, H., Geersing, G.-J., Harjola, V.-P., Huisman, M. V., Humbert, M., Jennings, C. S., Jiménez, D., Kucher, N., Lang, I. M., Lankeit, M., Lorusso, R., Mazzolai, L., Meneveau, N., Ní Áinle, F., Prandoni, P., Pruszczyk, P., . . . Zamorano, J. L. (2020). 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). European Heart Journal, 41(4), 543-603. https://doi.org/10.1093/eurheartj/ehz405
Meyer, G., Vicaut, E., Danays, T., Agnelli, G., Becattini, C., Beyer-Westendorf, J., Bluhmki, E., Bouvaist, H., Brenner, B., Couturaud, F., Dellas, C., Empen, K., Franca, A., Galiè, N., Geibel, A., Goldhaber, S. Z., Jimenez, D., Kozak, M., Kupatt, C., . . . Konstantinides, S. V. (2014). Fibrinolysis for patients with intermediate-risk pulmonary embolism. New England Journal of Medicine, 370(15), 1402-1411. https://doi.org/10.1056/NEJMoa1302097
Vincent, J.-L., & De Backer, D. (2013). Circulatory shock. New England Journal of Medicine, 369(18), 1726-1734. https://doi.org/10.1056/NEJMra1208943
NU656 Unit 2 instructions, in plain terms
The Unit 2 assignment gives you a patient in shock and asks you to classify the shock state before you treat it. Most prompts want the four categories defined, the patient's findings placed against them, the cause confirmed and a treatment plan that follows logically from the classification. Expect four to six pages in APA 7 with current sources, usually a critical care review for the framework and a guideline for the specific cause. Some versions add a table of expected hemodynamic patterns. The purpose is to show that the category chosen changes the orders written, so a paper that jumps to drugs before naming the state misses what the unit is teaching. Explain what would have happened under the wrong label.
How this NU656 Unit 2 example is built
The case paragraph reads like a rapid response note: blood pressure 78/52, heart rate 128, saturation 87 percent on six liters, a jugular venous pressure of about 10 cm and clear lungs on both sides. Classification follows as a numbered list of the four states with their filling pressure, output and resistance patterns, drawn from Vincent and De Backer. His findings are then matched to it, and the highlighted sentence explains why dry lungs separate an obstruction from a failing left ventricle. Bedside ultrasound, echocardiography and CT angiography confirm the cause in order. The treatment section runs from norepinephrine to alteplase, each step tied to the obstructive state, and a pitfalls section explains three ways the classification could have gone wrong.
Where the points sit in the NU656 Unit 2 rubric
Rubrics for this paper tend to weigh the classification itself most heavily, then the confirmation of cause, the treatment reasoning, the use of evidence and APA mechanics. Full points for classification come from placing the patient's actual findings against each category, not from defining the categories in the abstract. Confirmation is scored on whether each alternative cause is excluded with a named test. Treatment reasoning earns credit when each order is explained by the state, for example why fluid is limited in right ventricular failure. The evidence row looks for a current guideline behind the specific therapy chosen. Graders also notice when a paper admits its limits, such as the bleeding risk of thrombolysis, and weigh it honestly.
NU656 Unit 2 help: mistakes that cost points
A common error is reading a raised troponin and BNP as proof of a primary heart problem, when both rise with right ventricular strain from an embolism. Another is giving several liters of fluid to a hypotensive patient whose right ventricle is already dilated, which can push the septum into the left ventricle and lower output further. Some papers classify by blood pressure alone, which tells you shock is present but not its type. Others skip the bedside exclusion of tamponade and tension pneumothorax and go straight to CT. Intubating early without a plan for induction can collapse a failing right ventricle. And a treatment list without reasons loses most of the reasoning points, however correct it is.
Get an NU656 Unit 2 example written to your instructions
Whatever hemodynamic data the NU656 Unit 2 case lists, the typing is built from them; include your rubric and any classification table the section prefers. Free on a first request and back within 24-48h, the paper sorts the patient into one of four shock states using pressures, pump output and vascular resistance, and only then turns to drugs. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.
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NU656 Unit 2 questions, answered
What if the case gives no cardiac output number?
Most bedside cases do not. The sample estimates output from skin temperature, capillary refill, urine output, lactate and pulse pressure, and says plainly that it is estimating. A narrow pulse pressure with cold extremities suggests low output; warm skin with a wide pulse pressure suggests the opposite. If your case supplies echo or catheter data, the table uses them directly.
Can a patient have more than one shock state at once?
Yes, and mixed states are common in intensive care: a septic patient with a weakened heart, or a bleeding patient who is also vasodilated. The sample names a single dominant state because this case supports one, and it states what would suggest a second, such as falling resistance after reperfusion. A prompt with a mixed picture would get a table showing both.
Where can I find a free NU656 Unit 2 sample paper?
The full NU656 Unit 2 shock classification paper is on this page, with the case, the four-state list, the confirmation of pulmonary embolism, the treatment plan and three references. A custom paper for your own shock case can be requested through the form.
Why is thrombolysis given in the NU656 Unit 2 paper?
The patient has high-risk pulmonary embolism, defined by the ESC guideline as embolism with hemodynamic instability, and the guideline recommends systemic thrombolysis for that group unless it is contraindicated. The paper reviews his bleeding risk before alteplase is given.
How does the NU656 Unit 2 paper tell obstructive from cardiogenic shock?
Both raise the jugular pressure and lower the output, so the lungs decide it. A failing left ventricle backs fluid into the lungs, while an obstruction to right ventricular outflow leaves them clear. Echocardiography then shows a dilated right ventricle and a flattened septum.