Chapter 39 Shock

Question 1

Hypovolemic Shock (fxn)

Answer 1

total body fluid decreased (in all fluid compartments)
hemorrhage
dehydration

Question 2

Cardiogenic (fxn)

Answer 2

direct pump failure. fluid volume not affected
myocardial infarction
valvular problems (stenosis, incompetence)
myopathies
dysrhythmias
cardiac arrest

Question 3

Distributive (fxn)

Answer 3

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)

Question 4

Obstructive (fxn)

Answer 4

cardiac function decreased by noncardiac factors. total body fluid volume not affected. central volume decreased
pulmonary HTN
tension pneumothorax
pericarditis
thoracic tumor
tampnade

Question 5

Hypovolemic (site of origin)

Answer 5

central vascular volume decreased. total body fluid may or may not be decreased
hemorrhage
dehydration
fluid shifts (trauma, burns, anaphylaxis)

Question 6

Cardiogenic (site of origin)

Answer 6

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

Question 7

Vasogenic (site of origin)

Answer 7

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)

Question 8

Cardio manifestations of shock

Answer 8

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

Question 9

Septic (site of origin)

Answer 9

loss of vascular tone, eventual reduced CO, seen as a more intense type of vasogenic shock
infection

Question 10

Respiratory manifestations of shock

Answer 10

Increased RR, shallow depth
Decreased paco2
Decreased pao2
Cyanosis esp around lips and nail beds

Question 11

Neuromuscular manifestations of shock

Answer 11

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

Question 12

Renal manifestations of shock

Answer 12

Decreased urine output
Increased specific gravity
Sugar and acetone present in urine

Question 13

Integumentary manifestations of shock

Answer 13

Cool to cold
Pale to mottled to cyanotic
Moist, clammy
Mouth dry; paste like coating present

Question 14

Gastrointestinal manifestations of shock

Answer 14

Decreased motility
Diminished or absent bowel sounds
Nausea and vomiting
Constipation

Question 15

Causes of hypovolemic Shock

Answer 15

Body fluid depletion
Hemorrhage (trauma, GI ulcer, surgery, inadequate clotting: hemophilia, liver dx, malnutrition, bone marrow suppression, cancer, anti coagulation therapy)

Question 16

Causes of cardiogenic shock

Answer 16

Direct pump failure
MI
cardiac arrest
Ventricular dysrhythmias (fibrillation,tachycardia)
Cardiac amyloidosis
Cardiomyopathy (viral, toxic)
Myocardial degeneration

Question 17

Causes of distributive shock

Answer 17

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)

Question 18

Initial stage hypovolemic shock

Answer 18

Decrease in map of 5-10mmhg

Increased sympathetic stimulation (mild vasoconstriction, increase in heart rate)

Question 19

Non progressive stage of shock

Answer 19

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)

Question 20

Progressive stage of shock

Answer 20

Decrease in map of >20mmhg
Anoxia to nonvital organs
Hypoxia of vital organs
Overall metabolism is anaerobic (moderate acidosis, moderate hyperkalemia, tissue ischemia)

Question 21

Refractory stage of shock

Answer 21

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

Question 22

Detecting and Treating Impending Shock #1

Answer 22

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

Question 23

Detecting and Treating Impending Shock #2

Answer 23

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

Question 24

Care of Pt. in Hypovolemic Shock

Answer 24

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.

Question 25

Drugs for Hypovolemic Shock: #1 Vasoconstrictors

Answer 25

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

Question 26

Drugs for Hypovolemic Shock: #2 Inotropic Agents

Answer 26

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

Question 27

Drugs for Hypovolemic Shock: #3 Agents Enhancing Myocardial Perfusion

Answer 27

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

Question 28

Conditions Predisposing to Sepsis and Septic Shock

Answer 28

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

Question 29

Risk Factors for Hypovolemic Shock

Answer 29

Diuretic therapy
diminished thirst reflex
immobility
use of ASA containing products
use of integrative therapies such as Ginkgo biloba
anticoagulant therapy

Question 30

Risk Factors for Cardiogenic Shock

Answer 30

DM

presence of cardiomyopathies

Question 31

Risk Factors for Distributive Shock

Answer 31

diminished immune response
reduced skin integrity
presence of cancer
peripheral neuropathy
strokes
institutionalization
malnutrition
anemia

Question 32

Risk Factors for Obstructive Shock

Answer 32

Pulmonary HTN

presence of cancer

Question 33

SIRS Systemic Inflammatory Response Syndrome Criteria

Answer 33

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

Question 34

Sepsis Resuscitation Bundle

Answer 34

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%

Question 35

Sepsis Management Bundle

Answer 35

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

Question 36

Pt. at risk for Sepsis: Home Care Assessment

Answer 36

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

Question 37

Infection Precautions #1: Home Care

Answer 37

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

Question 38

Infection Precautions #2: Home Care

Answer 38

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