Chapter 39: Pts With Shock

Question 0

Hypovolemic shock

Answer 0

Total body fluid decreased
Hemorrhage
Dehydration
Fluid shifts: trauma, burns, anaphylaxis

˜Low circulating blood volume causes mean arterial pressure (MAP) decrease; inadequate total body oxygenation due to loss of RBCs
˜Commonly caused by hemorrhage (external or internal), dehydration (suction, diabetes insipidus, hyperglycemia), inadequate clotting, trauma, surgery, GI ulcer

Question 1

Shock definition

Answer 1

˜Widespread abnormal cellular metabolism
˜Oxygenation and tissue perfusion needs not met
˜“Whole-body” response; “syndrome”
˜Any problem impairing oxygen delivery to tissues and organs can start shock, lead to life-threatening emergency

Question 2

Cardiogenic shock

Answer 2

˜Actual heart muscle is unhealthy; pumping is directly impaired
˜Myocardial infarction most common cause, valve problems, myopathies, ventricular dysrhythmias, cardiac arrest, myocardial degeneration
Fluid volume not affected
Direct pump failure
Decreased CO and MAP

Question 3

Distributive shock

Answer 3

˜Blood volume distributed to interstitial tissues where it cannot circulate, deliver oxygen (fluid shifted from central vascular)
Total volume normal or increased
˜Caused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, capillary leak > decreased MAP
˜Neural-induced distributive shock: head trauma, anesthesia, opioids, sedatives > decreased MAP
˜Chemical-induced distributive shock: sepsis, anaphylaxis, capillary leak,

Question 4

Obstructive shock

Answer 4

˜Impaired ability of normal heart muscle to pump effectively
˜Conditions outside heart prevent either adequate filling of heart or adequate contraction of healthy heart muscle (cardiac function decreased by noncardiac factors)
Cause is indirect pump failure.
Central volume decreased: ˜Pericarditis most common cause and
˜ Cardiac tamponade. pulm HTN, tension pneumothorax, thoracic
tumor,
Total fluid not affected

Question 5

Stages of shock

Answer 5

˜Initial
˜Nonprogressive
˜Progressive
˜Refractory

Question 6

Initial stage

Answer 6

˜Baseline MAP decreased by <10 mm Hg
˜Increased SNS stimulation
Heart and respiratory rate increased from baseline, or slight increase in diastolic blood pressure may be the on,y objective manifestation of this early stage of shock
˜Adaptive responses of vascular constriction, increased heart rate
O2 90-95%

Question 7

Nonprogressive stage

Answer 7

˜MAP decreases by 10 to 15 mm Hg
Continued SNS stimulation
Chemical compensation: ˜Kidney and hormonal adaptive mechanisms activated renin, aldosterone, ADH, epi, norepinephrine > vasoconstrict, decreased urine, stimulation of thirst
˜Tissue hypoxia in nonvital organs, skin GI
˜Acidosis and hyperkalemia
˜Stopping conditions that started shock and supportive interventions can prevent shock from progressing. Cellular effects are reversible.

Thirst and anxiety. Objective: Restlessness, tachycardia, increase respirations, decreased urine, falling systolic, rising diastolic, narrow pulse pressure, cool extremities, 2 to 5% decrease in oxygen.

Question 8

Progressive stage

Answer 8

˜Sustained decrease in MAP of >20 mm Hg from baseline
Anoxia of vital organs
˜Vital organs develop hypoxia
Moderate acidosis, hyperkalemia, tissue ischemia
˜Life-threatening emergency
˜Conditions causing shock must be corrected within 1 hour of progressive stage onset

Subjective include severe thirst and deeper anxiety. They have a feeling of something bad to happen. Immediate confusion. Objective includes a rapid week pulse, low blood pressure, pallor to cyanosis, cool moist skin, anuria, 5 to 20% decrease in oxygen, low Ph O2 75-80%

Question 9

Refractory stage/irreversible stage

Answer 9

˜Too little oxygen reaches tissues; cell death and tissue damage result
˜Body cannot respond effectively to interventions; shock continues
˜Rapid loss of consciousness, nonpalpable pulse, cold, dusky extremities; slow, shallow respirations; unmeasurable oxygen saturation

Severe tissue hypoxia with ischemia and the process. Release of myocardial depressant factor from the pancreas. Buildup of toxic metabolites. Multiple organ dysfunction syndrome. Death.

Therapy is not effective in saving the patient’s life, even if the cause of shock is corrected and MAP temporarily returns to normal. So much damage has occurred in vital organs. Manifestations include rapid loss of consciousness, nonpalpable pulse, cold mottled dusky extremities, slow shallow respiration, unmeasurable o2 sat.

Question 10

Health promotion and maintenance

Answer 10

˜Can usually be prevented
˜Avoid trauma and hemorrhage
ØProper safety equipment
ØSeat belts
ØAwareness of hazards in home/workplace
˜Secondary prevention
ØAssess for early manifestations
˜Patient teaching
Drink adequate fluids
Assess for shock in a patient who develops a change in mental status, increasing pain, or an increase in anxiety. Teach manifestations of shock.

Question 11

Cardiovascular manifestations

Answer 11

Decreased cardiac output/ MAP
˜Increased pulse, thready pulse
˜Decreased blood pressure
˜Narrowed pulse pressure
Postural hypotension
Low central venous pressure
Flat neck and hand veins in dependent positions
Slow capillary refill
Diminished peripheral pulses
Increased heart rate is the earliest manifestation
Systolic is not always decreased. When vasoconstriction is present, diastolic increases but systolic remains the same.

Question 12

Respiratory manifestations

Answer 12

˜Increased respiratory rate
˜Shallow depth of respirations
˜Decreased Paco2
˜Decreased Pao2
Cyanosis, especially around lips and nail beds
The depth increases when lactic acidosis is present

Question 13

Multiple organ dysfunction syndrome

MODS

Answer 13

˜Sequence of cell damage caused by massive release of toxic metabolites and enzymes
˜Microthrombi form
˜Occurs first in liver, heart, brain, kidney
˜Myocardial depressant factor from ischemic pancreas.

Once the damage has started, the sequence becomes a vicious cycle as more dead cells break open and release harmful metabolites.

Question 14

Neuromuscular manifestations

CNS changes

Answer 14

Early: anxiety, restless, increasedthirst
Late: decreased CNS lethargy-coma, general muscle weakness, diminished or absent muscle reflexes, sluggish pupils

Question 15

Renal manifestations

Answer 15

Decreased urine output is early sign
Increased specific gravity
Sugar and acetone present in urine
Can tolerate hypoxia in anorexia for up to one hour without permanent damage. Afterwards they are at risk for acute tubular necrosis and kidney failure

Question 16

Integumentary manifestations

Answer 16

Cool
Pale
Mottled-cyanotic
Moist and clammy (normal fluid does not evaporate)
Mouth dry, pastry

Dark skin assess pallor in the mucous membranes. Patients will appear darker with an underlying reddish glow. With lite skin it is first noticed in the extremities and the central trunk area. They will progress to an overall grayish blue color

Question 17

GI manifestations

Answer 17

Decreased motility
Diminished or absent bowel sounds
N&V
constipation

Question 18

Nonsurgical management

Answer 18

˜Maintain tissue oxygenation, increase vascular volume to normal range, support compensatory mechanisms
˜Oxygen therapy
˜IV therapy
ØNS or RL. Crystalloids
NS expands plasma volumes
RL (Na, cl,ca,k,lactate which buffers acidosis)
Colloids: whole blood, PRBCs, improve H&H, plasma(restores pressure with normal H&H), albumin, platelets. Restore osmotic pressure
˜Drug therapy: increase venous return, improve contractility, dilate coronary arteries

Ensure a patent airway. Start IV catheter. Administer oxygen, elevate the patients feet keeping his or her head flat or elevated to 30°, examine for overt bleeding, apply pressure if needed, administer meds, increased rate of fluids, do not leave the patient

Assess pulse, blood pressure, pulse pressure, central venous pressure, respiratory rate, skin and mucosal color, oxygen saturation, mental status, and urine output every 15 minutes until patient is improved.

Question 19

Drug therapy

Answer 19

˜Vasoconstrictors
ØDopamine: ^CO
ØEpinephrine
ØNorepinephrine(levophed):
ØPhenylephrine
˜Agents enhancing contractility: inotropic agents, dobutamine
˜Agents enhancing myocardial perfusion: sodium nitroprusside/nitropress. Monitor vitals q 15 min, vasodilation, careful if volume depleted.

Question 20

Septic shock

Answer 20

˜Complex type of distributive shock—bacterial/fungal infection progresses to dangerous condition within days
˜Sepsis—widespread infection coupled with general inflammatory response (SIRS systemic inflammatory response syndrome); triggered when infection escapes local control. Leads to extensive vascular and tissue changes that impair oxygenation. Widespread dilation and blood pooling. Acute respiratory distress syndrome may occur.

Mild hypotension, decreased urine, increased RR, temp varies, thrombi leads to hypoxia leads to reduced organ function.

Possible bacteremia. H&H normal until late septic. Fibrinogen levels and platelet counts are low from DIC. There might take is above normal when there’s acidosis. Activated protein C will be low. Plasmid D dimer levels rise.

Question 21

Oxygenation and tissue perfusion

Answer 21

Related to MAP. It is effected by total blood volume, cardiac output, size of the vascular bed.
^total blood volume ^CO raise MAP
Increase in size vascular bed(dilation of vessels), decrease in MAP

Increases in sympathetic stimulation cause constriction. Decreases cause dilation.

The effects of hypotension and anaerobic cellular metabolism result in the features of shock.

Question 22

Risk for sepsis

Answer 22

Malnutrition, immunosuppression, large open wounds, mucous membrane fissures in contact with bloody dressings, GI ischemia, invasive procedures, malignancy, >80 yo, infection with resistance microorganisms, chemo, alcoholism, DM, chronic kidney disease, transplant, hepatitis, HIV/aids.

Bacterial infection that escapes local control. Possible fungal infection. There is a genetic risk because of differences in immune systems.

Question 23

Severe sepsis

Answer 23

All tissues hypoxic, some organs are dysfunctioning, thrombi formation widespread used all the platelets>DIC, liver releases glucose>hyperglycemia, CO increased rapid HR increased systolic BP, no cyanosis, WBCs no longer elevated, it may even be low.

Low O2, rapid RR, decreased or absent urine, change in cognition

• low o2 sat, increased RR, decreased or absent urine, change in cognition and affect,

Question 24

Anaphylaxis

Answer 24

Type 1 allergic reaction that begins within seconds to minutes after exposure. There is a widespread loss of blood vessel tone and decreased cardiac output.

Question 25

Sepsis

Answer 25

Widespread infection that triggers a whole body inflammatory response. It leads to distributive shock when infectious microorganisms are present in the blood. This is usually called septic shock.

Question 26

Capillary leak syndrome

Answer 26

Responsive capillaries to the presence of biologic chemicals/mediators that change blood vessel integrity and allow fluid to shift from the blood in the vascular space into the interstitial tissues. Problems causing this include burns, liver disorders, ascites, peritonitis, paralytic ileus, severe malnutrition, large wounds, hyperglycemia, kidney disease, hypoproteinemia, and trauma

Question 27

Delegation of shock

Answer 27

When a patient is at risk or is suspected of having hypovolemic shock the registered nurse should perform assessment and vital signs rather than an LPN or an unlicensed assistive personnel.

Question 28

Nursing diagnoses for hypovolemic shock

Answer 28

Ineffective tissue perfusion, deficient fluid volume, decreased cardiac output, anxiety, disturbed thought processes

Question 29

Lab values for hypovolemic shock

Answer 29

They do not confirm or rule out but they may support the diagnosis of shock.

pH 7.35-7.45. Will decrease
PaO2 80-100. Will decrease
PaCO2 35-45 will increase
Lactic acid. 0.3-0.8  will increase
Hematocrit 37-52% increase = fluid shift and dehydration
        Decreased: hemorrhage
Hemoglobin 12-18.  Same as hematocrit
Potassium 3.5-5. Increased dehydration and acidosis.

Question 30

Septic shock

Answer 30

Stage of sepsis and SIRS when multiple organ failure is evident and uncontrolled bleeding occurs. Even with appropriate intervention, death rate is about 60%. Severe hypovolemic shock is present with hyperdynamic cardiac function. Inability of the blood to clot. Capillary leak. Poor contractility. Manifestations resemble late stage of hypovolemic shock

Homework sign is increasing serum lactate level, normal or low WBC, decreasing segmented neutrophil level with a rising band level indicating a left shift

Question 31

Systemic inflammatory response syndrome/SIRS

Answer 31

Temperature above 100.4 or less than 96.8
Heart rate greater than 90
Heart rate greater than 20 or CO2 less than 32
WBC greater than 12,000 or less than 4000 or greater than 10% bands
It is septic if there is presence of two or more listed above and any one or more of these clinical manifestations: hypotension, decreased urine output, positive fluid balance, decreased capillary refill, hyperglycemia greater than 120, and unexplained change in mental status

Question 32

Sepsis Resuscitation bundle

Answer 32

1. Measure serum lactate levels
2. Obtain blood cultures before antibiotics
3. antibiotics within 1 to 3 hours of diagnosis
4. If hypotension or lactate greater than four MMOL is present give IV crystalloid fluids of 20 mL per kilogram. If that does not respond by increasing MAP to 65, start IV vasopressor therapy
5. If that does not help, monitor CVP and keep it at least eight. Central venous oxygen saturation of at least 70% or mixed venous oxygen saturation of at least 65%

Question 33

Sepsis management bundle

Answer 33

1. When shock is present administer low-dose steroids usually 200 to 300 mg of hydrocortisone IV daily. This is for adrenal insufficiency
2. Admin drotrecogin Alfa for Pts meeting criteria (this med is no longer available)
3. Administer insulin to maintain blood glucose lower than 150
4. Use mechanical ventilation to maintain inspiratory plateau pressures less than 30 cm H2O