Care of Patient With Shock (exam 1) Flashcards
What is the #1 nursing diagnosis for shock?
ineffective tissue perfusion
Shock is widespread ____ cellular metabolism.
abnormal
During shock ___ and ___ needs are not met.
oxygenation and tissue perfusion
Shock is also called…
Whole body response syndrome
Any problem impairing ____ delivery to ____ and ___ can start shock, leading to life threatening emergency
oxygen; tissues and organs
Stages of shock include:
initial. nonprogressive, progressive, refractory
initial stage is…
- (early shock)
2. baseline MAP decreased by
Nonprogressive stage is….
- (compensatory stage)
- MAP decreases by 10 to 15 mm Hg
- kidney and hormonal adaptive mechanisms activated (decreased UOP to compensate for fluid loss)
- tissue hypoxia in nonvital organs (skin, GI tract)
- acidosis and hyperkalemia.
* **Stopping conditions that started shock and supportive interventions can prevent shock from progressing
Progressive stage is….
- (intermediate stage)
- sustained decreased in MAP of >20mm Hg
- vital organs develop hypoxia
- life threatening emergency
* ***Conditions causing shock must be corrected with 1 hour of progressive stage onset. Afterwards body will not respond to treatment
Refractory stage is….
- (irreversible stage)
- too little oxygen reaches tissues, cell death and tissue damage result
- body cannot respond effectively to interventions; shock continues
* ***Rapid LOC, nonpalpable pulse, cold, dusky extremities; slow, shallow respirations; unmeasureable oxygen sat.
What are the types of shock?
- hypovolemic
- cardiogenic
- distributive
- obstructive
Hypovolemic shock is…
total body fluid decreased (blood loss from poor clotting with hemorrhage, dehydration)
Cardiogenic shock is…
direct pump failure, failure of blood to move forward(MI, cardiac arrest, Ventricular dysrhthmias, cardiomyopathies)
Distributive shock is…
(burn shock), fluid shift from central vascular space, maldistribution of blood volume, not where its suppose to be ( neural induced-pain, stress, head trauma, chemical induced- anaphylaxis, sepsis, burns, liver impairment)
Obstructive shock is…
(physical), cardiac function decreased by non-cardiac factor, indirect pump failure (PE, cardiac tamponade, thoracic tumors, pulmonary HTN, arterial stenosis, tension pneumothorax)
What physical assessments/ clinical manifestations should be done on these patients?
- cardiovascular
- pulse
- BP
- O2 sat.
- skin
- respiratory
- renal and urinary
- CNS
- muscloskeletal
What assessment should be done for these patents?
- psychosocial (sense of doom, anxiety)
- labs (CBC, lactic acid, ABGs, electrolytes)
- hemodynamics (BP, MAP, CO or CI, SVR, CVP, SV, SVV, PA pressures, ScVO2)
What are some nonsurgical management things that should be done for these patients?
- maintain tissue oxygenation, increase vascular volume to normal range, support compensatory mechanisms
- oxygen therapy
- IV therapy (IV access) with NS or RL
- Drug therapy (if fluids are not effective)
THE GOAL IS TO MAINTAIN PERFUSION
What kind of drugs therapy is given?
- vasopressors
- agents enhancing contractility
- agents that vasodilate
What vasopressors are given?
- dopamine
- epinephrine
- norephinephrine
- phenyleprine
- vasopressin
What agents are given that enhances contractility?
- milrinone
2. dobutamine
What agents are given to dilate?
- sodium nitroprusside
2. nitroglycerine
During hypovolemic shock, low circulating blood volume causes MAP to ____resulting in inadequate total body ____
decrease, oxygenation
Hypovolemic shock is commonly caused by ____ or____
hemorrhage (external or internal) or dehydration
Symptoms of hypovolemic shock…
increased HR
decreased BP (vasoconstriction constriction)
narrowed pulse pressure (systolic BP decreased)
postural hypotension
flat neck and hand veins independent position
slow capillary refill
diminished peripheral pulses
pale, cool, moist skin (vasoconstriction)
decreased CO/CI
Low CVP
decreased PAWP
increased SVR
increased RR (respiratory alkalosis, decreased PCO2 and PAO2,)
shallow depth of RR
During cardiogenic shock the actual heart muscle is ____, pumping is ___ impaired.
unhealthy, directly
Cradiogenic shock is failure of the blood flow to move ___.
forward
Most common cause of cardiogenic shock is ____
MI
Symptoms of cardiogenic shock…. (fluid overload)
SBP 30 mmHg tachycardia weak, theady pulse diminished heart sounds decreased LOC cool, pale moist skin decreased UOP chest pain (because of decrease in oxygen) dyrhtyhmias increased RR, tachypnea crackles (fluid backing up in lungs) decreased CO CI
During distributive shock blood volume distributed to ___ tissues where it can not circulate, deliver oxygen
interstitial
Distributive shock is caused by
loss of sympathetic tone
blood vessel dilation
pooling of blood in venous and capillary beds
capillary leak
What are the types of distributive shock
neural induced (neurogenic) and chemical induced (anaphylaxis, sepsis, capillary leak syndrome)
Symptoms of distributive shock…. (anaphylaxis)
decreased BP increased HR, tachycardia increased RR, tachypnea cough, dysphagia, hoarseness stridor, wheezing, rales, rhonchi restlessness, anxiety, apprehension pruritis, erythema, urticaria angioedema decreased CO/CI, CVP, PAWP, SVR (dilation)
Symptoms of distributive shock…. (neurogenic)
hypotension bradycardia warm, dry skin hypothermia bounding pulse decreased CO/CI, PAWP, CVP, SVR (dilation)
Symptoms of distributive shock…. (septic)
increased HR decreased BP wide pulse pressure (diastolic decreased) full, bounding pulse pink, warm, flushed skin increased RR crackles decreased LOC increased temp increased CO/CI decreased SVR, CVP, PAWP (dilation) increased SvO2 (venous blood that comes back to heart)
During obstructive shock there is an impaired ability of ____ heart muscle to pump effectively
normal
In obstructive shock there are conditions ___ heart preventing either ___ of the heart or adequate ___ of the healthy heart muscle.
outside; filling; contraction
The most common cause of obstructive shock is…
***pericarditis
other causes are cardiac tamponade and PE
Symptoms of obstructive shock…. (PE)
decreased BP tachycardia distended neck veins tachypnea restlessness, anxiety impending sense of doom crackles pleural friction rub cool, moist skin increased PA pressures (directly related to problem) decreased CO/CI
Generalized systemic inflammation in organs remote from the initial injury is….
SIRS (system inflammatory response syndrome)
SIRS occurs in ___% of patients in critical care
50
SIRS etiology:
- due to infection
2. due to noninfectious source (thromboembolism, autoimmune disorder, pancreatitis)
SIRS can be diagnosed when ___ clinical manifestations are present.
2 or more
Manifestations of SIRS include:
- temp >38 or 90
3. **RR >20 or PaCO2 12,000 or
Uncontrolled inflammation or infection, persistent hypoperfusion, flow dependent oxygen consumption (VO2), and/or persence of necrotic tissue.
MODS (multiple organ dysfunction syndrome)
MODS is a ___ of cell damage caused by massive release of toxic metabolites and enzymes.
sequence
MODS is ____ depressant factor from ischemic pancreas
myocardial
MODS can result from ___
SIRS
MODS is ____ form
microthrombi
MODS is progressive failure of ____ interdependent organ systems
2 or more
MODS had a ___ mortality rate
high
A systemic response to an infection is called?
sepsis
Sources of sepsis include:
- gram negative bacteria (almost half the cases)
- gram positive bacteria (rising in number)
- fungi
- viruses
Prevention of sepsis include:
- hand hygiene
- assessing
- looking for source on infection
- assessing central lines, catheters, IV lines
Symptoms of sepsis include:
- temp >38 or 90
- RR >20
- altered mental status
- fluid balance >20 mL/kg in 24 hrs
- glucose >140 (glucose increases with inflammation)
- WBC >12,000 or 10% bands
- elevated c reactive protein (inflammatory marker
- elevated plasma procalcitonin (inflammatory marker)
- SBP 40
- MAP 70%
- CI >3.5
- serum lactate >1
- Pao2/Fio2 0.5 (because kidneys aren’t working)
- INR >1.5 or aPPT >60 sec
- absent bowel sounds
- PLT 4
Sepsis include shock with hypotension despite adequate fluid resuscitation (death rate for this patient exceeds 40%)
septic shock
During septic shock there is a presence of perfusion abnormalities which may include:
- lactic acidosis (metabolic acidosis)
- oliguria
- mental status alteration
Cardiovascular changes during septic shock include:
- peripheral vasodilation
- relative hypovolemia
- increased capillary permability, loss of intravascular volume, preload reduced, CO increased
- decreased tissue perfusion
- inadequate oxygen delivery to the cells
Neuo and endocrine changes during septic shock include:
- SNS stimulated—ACTH
- release or epinephrine, norepinephrine, glucocorticoids, aldosterone, glucagon, renin
- hypermetabolic state
- relative insulin resistance (increased glucose)
- mitochondrial dysfunction (can’t receive oxygen)
Complications of septic shock include:
- Cardiac failure
- ARDS
- ATN (renal)
- DIC
- shock liver, ischemic injury to GI tract
What is the treat for DIC?
- give clotting factors (platelets)
- fluids
- heparin
intervemtions for DIC include:
- prevention (hand hygiene, take out lines, no sick visitors)
- early recognition (assess vitals)
- fluid therapy
- oxygen therapy
- drug therapy
- watch for signs of bruising easily, blood in stool, small petechiae spots, small occlusion in peripheral, bleeding gums, oozing blood from sites
What does the SOFA (quickSOFA) score include?
- 3 items measured, one point each (respiratory >=22, altered mental status, SBP= 2 associated with poor outcomes
Treatment includes:
- initial fluid resuscitation foe severe sepsis (>1 liter crystalliod,
30mL/kg of NS in the first 4-6 hours, incremental fluid bolus depending on patent responsiveness - norepinephrine IV gtt (1st choice vasopressor)
- corticosteroid therapy (hydrocortisone) only if fluid and vasopressor therapy not effective
What should be done within 3 hours?
- measure lactate level
- obtain blood cultures prior to administrating antibiotics
- administer 30mL/kg of crystalloid for hypotension or lactate >4
What should be done within 6 hours?
- apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a MAP >= 65
- reassess volume status and tissue perfusion
- remeasure lactate if initial lactate elevated
