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Critical Care Nursing > Chapter 12 Shock, Sepsis, and multiple organ dysfunction syndrome > Flashcards

Chapter 12 Shock, Sepsis, and multiple organ dysfunction syndrome Flashcards

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1
Q

Shock is a clinical syndrome

A

◦ Life-threatening response to alterations in circulation
◦ Inadequate tissue perfusion
◦ Imbalance between cellular oxygen supply and demand

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2
Q

Shock Impacts all body systems

A

◦ Can lead to organ failure and death
◦ Influenced by compensatory mechanisms
◦ Influenced by successful interventions

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3
Q

Cardiovascular system
◦ Closed system:
◦ Vascular bed:

A

◦ Closed system: heart, blood, vascular bed

◦ Vascular bed: arteries, arterioles, capillaries, venules, and veins

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4
Q

Microcirculatory system

A

◦ Portion of the vascular bed between the arterioles and venules.

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5
Q

Pathophysiology

  • Shock begins with?
  • Alterations in at least one of four components:
A 
- Shock begins with cardiovascular system failure - Alterations in at least one of four components:
◦ Blood volume
◦ Myocardial contractility 
◦ Blood flow
◦ Vascular resistance
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6
Q

Stages of Shock

Stage I:

A
  • Stage I: Initiation
  • Hypoperfusion: inadequate delivery or extraction of oxygen
  • No obvious clinical signs
  • Early, reversible
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7
Q

Stages of Shock

Stage II:

A
  • Stage II: Compensatory
  • Sustained reduction in tissue perfusion Initiation of compensatory mechanisms
    ◦ Neural: baroreceptors and chemoreceptors
    ◦ Endocrine: ACTH and ADH
    ◦ Chemical
    ◦ Low oxygen tension
    ◦ Hyperventilation and respiratory alkalosis
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8
Q

Stages of Shock

- Stage III:

A
  • Stage III: Progressive
  • Failure of compensatory mechanisms
  • Profound cardiovascular effects
    ◦ Hypoperfusion
    ◦ Vasoconstriction
    ◦ Extremity ischemia
    ◦ Cellular hypoxia
    ◦ Anaerobic metabolism
    ◦ Lactic acid production (metabolic acidosis)
    ◦ Failure Na+/K+ pump
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9
Q

Stages of Shock

- Stage III: Cont

A
  • Stage III: Progressive (Cont.)
  • Increased capillary hydrostatic pressure
  • Intravascular fluid shifts
    ◦ Interstitial edema
    ◦ Decreased circulating intravascular volume
  • Decreased coronary perfusion
    ◦ Myocardial Depressant Factor (MDF) released
    ◦ Decreased myocardial contractility
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10
Q

Stages of Shock

- Stage IV:

A
  • Stage IV: Refractory
  • Prolonged inadequate tissue perfusion
    ◦ Unresponsive to therapy
    ◦ Dysrhythmias
    ◦ Pulmonary edema
    ◦ Respiratory Distress Syndrome (RDS)
    ◦ Cerebral changes
    ◦ Renal decreased GFR
    ◦ Contributes to multiple organ dysfunction and death
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11
Q

Systemic Inflammatory Response Syndrome (SIRS)

A
  • Widespread systemic inflammatory response
  • Associated with diverse disorders
    ◦ Infection
    ◦ Trauma
    ◦ Shock
    ◦ Pancreatitis
    ◦ Ischemia
  • Most frequently associated with sepsis
  • Upsets balance between proinflammatory and antiinflammatory processes
  • Normally localized process becomes systemic
  • Release of mediators
    ◦ Increased permeability of endothelial wall
    ◦ Fluid shifts into intravascular spaces
    ◦ Depletion of intravascular volume = relative hypovolemia
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12
Q

Shock Assessment for CNS

A 
Central nervous system
◦ Most sensitive to early changes
◦ Initial stage
◦ Anxiety/restlessness
◦ Late stage: Coma
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13
Q

Shock Assessment for Cardiovascular System

A 
Cardiovascular system
◦ Blood pressure
• Initial compensatory stages
◦ Slightly elevated
◦ Narrow pulse pressure
• Late stages ◦ Pulses
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14
Q

Shock Assessment for Pulmonary System

A

Pulmonary system
◦ Early stages
◦ Rapid, deep respirations
◦ Late stages: Shallow respirations, Poor gas exchange

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15
Q

Shock Assessment for Renal System

A 
Renal system
◦ Decreased glomerular filtration
◦ Activated renin- angiotensin-aldosterone system
◦ Sodium retention
◦ Water reabsorption 
◦ Oliguria
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16
Q

Shock Assessment for GI System

A

Gastrointestinal (GI) system
◦ Slowing intestinal activity
◦ Decreased bowel sounds, distension, nausea, and constipation

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17
Q

Shock Assessment for Hepatic

A

Hepatic
◦ Altered liver enzymes
◦ Clotting disorders
◦ Increased susceptibility to infection

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18
Q

Shock Assessment for Hematological System

A 
Hematological
◦ Consumptive coagulopathy (DIC)
◦ Enhanced clotting/inhibited fibrinolysis
◦ Depletion of clotting factors
◦ Clotting in the microcirculation
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19
Q

Shock Assessment for Integumentary System

A

Integumentary
◦ Skin color, temperature, texture, and turgor
◦ Cyanosis-late/unreliable sign
◦ Skin turgor evaluation

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20
Q

Laboratory Values

  • Various laboratory studies
  • Serum lactate level
A 
- Various laboratory studies 
◦ Hemogram
◦ Serum chemistry
◦ Coagulation studies
- Serum lactate level
◦ Measure of overall state of shock
◦ Indicator of decreased oxygen to cells 
◦ Indicator of adequacy of resuscitation
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21
Q

Management of Shock Domains

General management of shock

A 
- Treat underlying cause
  ◦ Reverse altered circulatory component
  ◦ Maintain circulatory volume and organ perfusion 
- Domains-Combination treatment/therapy
  ◦ Fluids
  ◦ Oxygenation
  ◦ Pharmacotherapy
  ◦ Temperature
  ◦ Nutrition
  ◦ Skin integrity
  ◦ Psychological support 
  ◦ Mechanical therapy
  ◦ Minimize oxygen consumption
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22
Q

IV Access and Fluid Challenge

  • Rapid infusion of a?
  • Hemodilution of?
  • Blood products
  • Complications
A
  • Two Peripheral IV catheter sites 14 or 16 Gauge OR Central Line
  • Rapid infusion of a crystalloid solution
    ◦ Lactated Ringer’s or normal saline
    ◦ 250 mL up to 2 liters
  • Hemodilution of plasma protein
  • Blood products
    ◦ IV access of a 20-gauge and higher
    ◦ Infuse with only normal saline
    ◦ Transfusion reaction; keep vein open with normal saline solution
  • Complications
    ◦ Pulmonary edema
    ◦ Transfusion reaction
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23
Q

Oxygenation for shock/sepsis

A
  • Maintain airway
  • Oxygenation
  • Mechanical ventilation
    ◦ Sedation
    ◦ Neuromuscular blockade
24
Q

Pharmacological Support for shock/sepsis

  • Based on
  • Central venous access
A
  • Based on
    • Cardiac output
    • Heart rate
    • Preload, afterload, and contractility
  • Central venous access
    • Administration
    • Hemodynamic monitoring
25
Q

Pharmacological Management for Cardiac output

A
  • Chronotropic drugs
  • Dysrhythmia agents
  • Bradycardia in neurogenic shock may require atropine
26
Q

Pharmacological Management for Preload

A
  • Hypovolemic and distributive shock — IV fluid challenge - Cardiogenic shock — venous vasodilators
27
Q

Pharmacological Management for Afterload

A
  • Distributive shock — vasoconstriction

- Cardiogenic shock — arterial vasodilators

28
Q

Pharmacological Management for Contractility

A
  • Cardiogenic shock — dobutamine

- Beta blockers

29
Q

Pharmacological Management (Cont.)

A
  • Sedatives
  • Analgesics
  • Insulin (two consecutive glucose readings are above 180 mg/dL)
  • Corticosteroids
  • Antibiotics
  • Low–molecular-weight heparin to prevent DVTs
  • H2-receptor antagonist or protein pump inhibitor to prevent gastric stress ulceration
30
Q

Body Temperature Regulation

A
  • Rapid administration of IV fluids may reduce temperature
  • Hypothermia
    • Depresses cardiac contractility
    • Impairs cardiac output
    • Impairs oxygenation
  • Fluid warmer
  • Warm blankets
31
Q

Nutritional Support

  • Enteral nutrition
  • Parenteral nutrition
A
  • Enteral nutrition
    ◦ Within 24 to 48 hours of admission
    ◦ Preferred route of nutritional support
    ◦ Hindered by paralytic ileus
  • Parenteral nutrition
    ◦ Given if enteral nutrition is not tolerated
32
Q

Skin Integrity

- Skin care

A 
◦ Turn every 2 hours
◦ Protective barrier cream
◦ Pressure-relieving devices
◦ Elevate heels off the surface of the bed 
◦ Foley catheter if indicated
33
Q

Psychological Support

A
  • Provide information to patient and family

- Advance directive discussions

34
Q

Classifications of Shock

A
  • Hypovolemic shock
    ◦ Inadequate intravascular blood volume
  • Cardiogenic shock
    ◦ Heart fails to act as an effective pump
  • Obstructive shock
    ◦ Physical impairment to adequate circulating blood flow
  • Distributive shock
    ◦ Widespread vasodilation and decreased vascular tone resulting in a relative hypovolemia
    ◦ Neurogenic
    ◦ Anaphylactic
    ◦ Septic
35
Q

The nurse admits a 35-year-old patient to the emergency department following a 3-day history of nausea and vomiting. Vital signs assessed by the nurse include a BP of 70/50 mm Hg, HR 145 beats/min, RR 36 breaths/min, and SpO2 of 92% on room air. The nurse recognizes which classification of shock?

A

D. Hypovolemic

36
Q
  • Inadequate circulating volume

- Causes

A 
- Inadequate circulating volume
◦ Internal or external losses of blood or fluid
- Causes
◦ History
◦ External or internal loss of fluid 
- Clinical manifestations
37
Q

Hypovolemic Shock Management

  • Identify underlying cause
  • Restore circulating volume
  • Appropriate fluid replacement
A 
- Identify underlying cause
  ◦ Eliminate underlying cause
- Restore circulating volume
  ◦ Appropriate fluid selection
  ◦ Blood
  ◦ Isotonic crystalloids
  ◦ Fluid challenge (3-for-1 rule, 300-mL replacement for   100-mL blood loss)
- Appropriate fluid replacement
  ◦ Blood pressure (MAP 65-70 mm Hg) 
  ◦ Hemodynamic values
  ◦ Urine output
  ◦ Laboratory results
38
Q

Cardiogenic Shock

A
  • Heart fails to act as an effective pump
    ◦ Decreased cardiac output; impaired perfusion
  • Causes
    ◦ Left ventricular myocardial infarction
  • Clinical manifestations
    ◦ Left ventricular failure
    ◦ Right ventricular failure
39
Q

Cardiogenic Shock Management

  • Pharmacological
  • Increase cardiac output
  • Decrease afterload
  • Mechanical
A 
- Pharmacological
  ◦ Decrease preload
  ◦ Diuretics, venous vasodilators
- Increase cardiac output 
  ◦ Positive inotropes
- Decrease afterload
  ◦ Arterial vasodilators
- Mechanical 
  * IABD
  * VAD
40
Q

The nurse is caring for a patient being treated with an intraaortic balloon pump. Which intervention is most important to include in the patient’s plan of care?

A. Turning side to side every 2 hours
B. Assessing peripheral pulses
C. Padding bony prominences
D. Applying splint to affected limb

A

B. Assessing peripheral pulses

41
Q

Obstructive Shock

  • Physical impairment to adequate circulatory blood flow
  • Causes
  • Clinical manifestations
A 
- Clinical manifestations 
  ◦ Chest pain
  ◦ Dyspnea
  ◦ Jugular venous distension 
  ◦ Hypoxia
  ◦ Cause-dependent findings
42
Q

Management of Obstructive Shock

Treat the cause

A

Treat the cause
◦ Cardiac tamponade (pericardiocentesis)
◦ Tension pneumothorax (thoracentesis)

43
Q

Distributive Shock

A 
Widespread vasodilation and decreased systemic vascular resistance
◦ Relative hypovolemia 
- Types
◦ Neurogenic 
◦ Anaphylactic 
◦ Septic
44
Q

Distributive Shock— Neurogenic
Interruption of?
Causes

A
  • Interruption of sympathetic nervous system impulse transmission
  • Causes
    ◦ Upper spinal cord injury
    ◦ Spinal anesthesia
    ◦ Nervous system damage
    ◦ Vasomotor depression
45
Q

Distributive Shock—Neurogenic

Clinical manifestations

A

◦ Bradycardia with hypotension
◦ Warm, dry, and flushed skin
◦ Hypothermia due to impaired thermoregulation

46
Q

Distributive Shock—Neurogenic

Management

A

Management
◦ Immobilization of spinal injuries
◦ Positioning of spinal- blocked patients
◦ IV fluids for hypotension
◦ Vasopressors (only after
volume is replaced)
◦ Slow rewarming to prevent further vasodilation

47
Q

Distributive Shock—Anaphylactic
Introduction of an?
Causes

A 
Introduction of an antigen into a sensitive individual, initiating an antigen-antibody response
◦ Release of vasoactive mediators 
◦ Histamine
Causes
◦ Severe allergic reaction
48
Q

Distributive Shock—Anaphylactic

Clinical manifestations

A 
Clinical manifestations 
◦ Airway
◦ Upper
◦ Lower
◦ Angioedema
◦ Cardiovascular 
◦ Integumentary
49
Q

Distributive Shock—Anaphylactic

Management

A 
Management
◦ Removal of offending agent 
◦ Airway
◦ Pharmacology
◦ Medications
◦ Fluid replacement
50
Q

Distributive Shock—Septic
Follows invasion of a?
Causes
Clinical manifestations

A 
- Follows invasion of a host by a microorganism
◦ Progressive 
- Causes
◦ Immunosuppression
◦ Significant bacteremia
- Clinical manifestations
◦ Metabolic acidosis
◦ Acute encephalopathy
◦ Oliguria
◦ Hypoxemia
◦ Coagulation disorders
◦ Hypotension
◦ Decreased skin perfusion/mottling
◦ Petechiae
51
Q

Distributive Shock—Septic

Management – Prevention

A

Management – Prevention
◦ Hand hygiene
◦ Aseptic technique
◦ Identification of infection risk

52
Q

Distributive Shock—Septic

Management – Treatment

A 
Management – Treatment
◦ Antibiotic therapy
◦ Early goal-directed therapy
◦ First 6 hours
◦ ACTH
◦ Glycemic control
◦ Temperature control
53
Q 
Multiple Organ Dysfunction Syndrome (MODS)
Progressive dysfunction of?
- Most common causes
- Can occur after any?
- Mortality rates
A
  • Progressive dysfunction of two or more organ systems
  • Most common causes
    ◦ Sepsis
    ◦ Septic shock
  • Can occur after any severe injury or illness
  • Mortality rates
    ◦ 45% to 55% with failure of two organ systems
    ◦ 80% with three or more
    ◦ 100% with three or more for more than 4 days
54
Q

Multiple Organ Dysfunction Syndrome

  • Maldistribution of?
  • Organs severely affected
A 
- Maldistribution of blood flow to various organs 
◦ Impaired tissue perfusion
◦ Decreased oxygen supply to cells
- Organs severely affected 
◦ Lungs
◦ Splanchnic bed 
◦ Liver
◦ Kidneys
55
Q

Multiple Organ Dysfunction Syndrome

- Clinical manifestations

A 
- Clinical manifestations
◦ Tachypnea/hypoxemia
◦ Petechiae/bleeding
◦ Jaundice
◦ Abdominal distension
◦ Oliguria>anuria
◦ Tachycardia
◦ Hypotension
◦ Change in level of consciousness
56
Q

Multiple Organ Dysfunction Syndrome

Management

A 
- Management
◦ Control infection
◦ Antibiotics
◦ Provide adequate tissue oxygenation
◦ Maintain 88% to 92% arterial oxygen saturation
◦ Maintain hemoglobin above 7 to 9 g/dL 
◦ Restore intravascular volume
◦ Aggressive fluid resuscitation
◦ Isotonic crystalloids
◦ Support organ function
57
Q

Shock, Sepsis, and MODS

- Patient outcomes

A 
- Patient outcomes
◦ Improved tissue perfusion
◦ Alert, oriented
◦ Normotensive
◦ Warm, dry skin
◦ Adequate urine output
◦ Normal hemodynamics
◦ Lab values within normal limits 
◦ Absence of infection
◦ Intact skin

Critical Care Nursing (15 decks)

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