Chapter 39 Shock Flashcards
Hypovolemic Shock (fxn)
total body fluid decreased (in all fluid compartments)
hemorrhage
dehydration
Cardiogenic (fxn)
direct pump failure. fluid volume not affected
myocardial infarction
valvular problems (stenosis, incompetence)
myopathies
dysrhythmias
cardiac arrest
Distributive (fxn)
fluid shifted from central vascular space. total body fluid volume normal or increased
neural induced loss of vascular tone (head trauma, anesthesia, opioids, sedatives)
chemical induced loss of vascular tone (sepsis, anaphylaxis, capillary leak)
Obstructive (fxn)
cardiac function decreased by noncardiac factors. total body fluid volume not affected. central volume decreased pulmonary HTN tension pneumothorax pericarditis thoracic tumor tampnade
Hypovolemic (site of origin)
central vascular volume decreased. total body fluid may or may not be decreased
hemorrhage
dehydration
fluid shifts (trauma, burns, anaphylaxis)
Cardiogenic (site of origin)
direct pump failure, indirect pump failure, decreased CO, total body fluid not decreased valvular problems (stenosis, incompetence) MI myopathies dysrhythmias cardiac arrest tamponade pericrditis pulm. HTN pulm. emboli
Vasogenic (site of origin)
loss of vascular tone, total body fluid not decreased.
neurogenic (head trauma, vasovagal response, drugs affecting the CNS: anesthesia, opioids, sedatives)
vessel dilation (anaphylaxis, inflammation)
Cardio manifestations of shock
Decreased CO, increased pulse
Thready pulse, decreased BP
narrowed pulse pressure, postural hypotension
Low central venous pressure, flat hand and neck veins in dependent positions
Slow cap refill, diminished peripheral pulses
Septic (site of origin)
loss of vascular tone, eventual reduced CO, seen as a more intense type of vasogenic shock
infection
Respiratory manifestations of shock
Increased RR, shallow depth
Decreased paco2
Decreased pao2
Cyanosis esp around lips and nail beds
Neuromuscular manifestations of shock
Early: anxiety, restlessness, increased thirst
Late: decreased CNS activity (lethargy to coma), generalized muscle weakness, diminished or absent deep tendon reflexes, sluggish pupillary response to light
Renal manifestations of shock
Decreased urine output
Increased specific gravity
Sugar and acetone present in urine
Integumentary manifestations of shock
Cool to cold
Pale to mottled to cyanotic
Moist, clammy
Mouth dry; paste like coating present
Gastrointestinal manifestations of shock
Decreased motility
Diminished or absent bowel sounds
Nausea and vomiting
Constipation
Causes of hypovolemic Shock
Body fluid depletion
Hemorrhage (trauma, GI ulcer, surgery, inadequate clotting: hemophilia, liver dx, malnutrition, bone marrow suppression, cancer, anti coagulation therapy)
Causes of cardiogenic shock
Direct pump failure MI cardiac arrest Ventricular dysrhythmias (fibrillation,tachycardia) Cardiac amyloidosis Cardiomyopathy (viral, toxic) Myocardial degeneration
Causes of distributive shock
Decreased vascular volume or tone: overall Neural induced (pain, anesthesia, stress, spinal cord injury, head trauma) Chemical induced (anaphylaxis, sepsis, capillary leak: burns, extensive trauma, hepatic dysfunction, hypoproteinemia)
Initial stage hypovolemic shock
Decrease in map of 5-10mmhg
Increased sympathetic stimulation (mild vasoconstriction, increase in heart rate)
Non progressive stage of shock
Decrease in map of 10-15mmhg Continued SNS stimulation (mod vasoconstriction, increased HR, decreased pulse pressure) Chemical compensation (renin, angiotensin, aldosterone, anti diuretic: increased vasoconstriction, decreased urine output, stimulation of thirst reflex) Some anaerobic Metabolism in non vital organs (mild acidosis, mild hyperkalemia)
Progressive stage of shock
Decrease in map of >20mmhg
Anoxia to nonvital organs
Hypoxia of vital organs
Overall metabolism is anaerobic (moderate acidosis, moderate hyperkalemia, tissue ischemia)
Refractory stage of shock
Severe tissue hypoxia with ischemia and necrosis
Release of myocardial depressant factor from pancreas
Buildup of toxic metabolites
Multiple organ dysfunction syndrome
Death
Detecting and Treating Impending Shock #1
monitor early responses (normal BP, narrowed pulse puressure, mild orthostatic hypotension, slight delayed capillay refill, pale/cool skin or flushe skin, slight tachypnea, nausea, vomiting, thirst, weakness.
monitor possible sources of fluid loss: hest tube, nasogastric drainage, diarrhea, vomiting, increased abdominal girl, extremity girth, hematemesis, hematochezia.
monitor circulatory status (BP, skin color, skin temp, heart sounds, HR, rhythm, presence/quality periph pulses, capillary refill.
monitor inadequate tissue oxygenation (apprehension, increased anxiety, change in mental status, agitation, oliguria, cool mottled periphery
Detecting and Treating Impending Shock #2
monitor pulse ox monitor lab values: Hgb, Hct, clotting profile, ABG, lactate level, electrolyte level, cultures, chemistry profile note bruising, petechiae, mucous membr. note color, amt, consistency, frequency of stools, vomitus, and nasogastric drainage test urine for blood, protein place pt. in supine, legs elevated administer IV or oral fluids insert and maintain large bore IV access admin O2/mech ventilation
Care of Pt. in Hypovolemic Shock
ensure patent airway start IV catheter administer O2 elevate feet, keep head flat or elevated 30* examine pt. for bleeding if overt bleeding, apply direct pressure administer drugs as prescribed increase rate of IV fluid delivery do not leave pt.
Drugs for Hypovolemic Shock: #1 Vasoconstrictors
Dopamine
Norepinephrine (Levophed)
Phenylephrine HCl
improve blood flow by increasing peripheral resistance, increasing venous return and improving myocardial contractility.
assess chest pain, urine output hourly (decreases), BPq15min, h/a, q30min for extravasation, color and perfusion.
HTN = overdose
h/a = drug excess
vasoconstriction r/t extravasation =necrosis
Drugs for Hypovolemic Shock: #2 Inotropic Agents
Dobutamine (Dobutrex)
Milrinone (Primacor)
stimulates adrenergic receptor sites on heart muscle and improved cell contraction
assess chest pain and BP q15min
increases myocardial O2 consumption causing angina or infarction, HTN = overdose
Drugs for Hypovolemic Shock: #3 Agents Enhancing Myocardial Perfusion
Sodium Nitroprusside (Nitropress, Nipride)
improved blood flow to myocardium by dilating coronoary arteries, effect is rapid but short
Protect drug container from light, assess BPq15min
light degrades drug
vasodilating effect causes systemic dilation and hypotension esp. older adults
Conditions Predisposing to Sepsis and Septic Shock
malnutrition, immunosupression
large open wounds, mucous membrane fissures in prolonged contact with bloody or drainage soaked packing
GI ischemia, exposure to invasive proced.
malignancy, older than 80
infection with resistant microorganisms, cancer chemotherapy
alcoholism, DM
chronic kidney disease, transplantation recipient
Hepatitis, AIDS
Risk Factors for Hypovolemic Shock
Diuretic therapy diminished thirst reflex immobility use of ASA containing products use of integrative therapies such as Ginkgo biloba anticoagulant therapy
Risk Factors for Cardiogenic Shock
DM
presence of cardiomyopathies
Risk Factors for Distributive Shock
diminished immune response reduced skin integrity presence of cancer peripheral neuropathy strokes institutionalization malnutrition anemia
Risk Factors for Obstructive Shock
Pulmonary HTN
presence of cancer
SIRS Systemic Inflammatory Response Syndrome Criteria
Temp. >100.4F (38C) or 90 RR>20 or PaCO2 12,000 or 10% bands Sepsis considered present if two or more SIRS criteria are present along with any known infection and one or more: hypotension U/O < expected positive fluid balance decreased capillary refill hyperglycemia (>120mg/dL) unexplained change in mental status
Sepsis Resuscitation Bundle
serum lactate levels
obtain blood cultures before administering antibiotics
broad spectrum antibiotic therapy within 1-3hrs of diagnosis
If hyotension or serum lactate level >4mmol/L institute:
IV delivery 20mL/kg of crystalloid fluids. If hypotension does not respond by increasing MAP to 65, start IV vasopressor therapy
if hypotension persists, & still >4mmol/L maintain:
CVP of at least 8mm Hg
central venous oxygen saturation of 70% or mixed venous oxygen saturation of at least 65%
Sepsis Management Bundle
When septic shock present, administer low dose steroids (20-300 mg hydrocortisone IV daily in divided doses) in accordance with ICU protocol
admin. drotrecogin alfa for pts meeting ICU and drotrecogin criteria
admin. insulin maintain blood glucose<150
use mech. vent. to maintain inspiratory plateau pressures less than 30cm H2O
Pt. at risk for Sepsis: Home Care Assessment
Assess for infection: temp. pulse, RR, BP, color of skin and mucous membranes, mouth and perianal area for fissures or lesions, nonintact skin for exudates, redness, increased warmth, swelling, pain, tenderness, discomfort, cough, cold or flu, urine dark or cloudy, odorous, pain or burning.
assess adherence and understanding of infection prevention
assess home: cleanliness, kitchen and bathroom facilities, availability and type of soap, presence of pets, cats, rodents, reptiles
Infection Precautions #1: Home Care
avoid crowds, do not share eating utensils or personal toilet articles
bathe daily, wash armpits, groin, genitals, rectal area at least 2Xs/day with antimicrobial soap. clean toothbrush daily by running it though dishwasher or rinsing it in liquid laundry bleach
wash hands with antimicrobial soap before eating, drinking, after touching pet, shaking hands, as soon s you come home and after toileting
wash dishes with hot sudsy water or dishwasher, do not drink water standing >15min, do not reuse cups and glasses without washing them
Infection Precautions #2: Home Care
do not change pet litter boxes,take temp qday. Refrigerate and prepare food appropriately, NO raw or undercooked meat, fish, poultry or eggs
report S&S to PCP: >100F, persistent cough w/ or w/o sputum, pus or foul smelling drainage from open skin or normal body opening, presence of boil or abscess, urine cloudy or foul smelling or causes burning on urination.
do not dig in garden or work with houseplants, use antibacterial cleansers to clean kitchen and bathroom surfaces twice each week. wear rubber or vinyl work gloves when cleaning.
use condom, take all drugs
