Chapter 9: nursing care of patients in shock Flashcards
shock
circulatory collapse resulting in organ damage and death w/out immediate treatment
pathophysiology of shock: tissue perfusion
adequate blood volume, effective cardiac pump, effective blood vessels
pathophysiology of shock: compensation
change in one or both of nonfailing tissue perfusion mechanisms
pathophysiology of shock: shock
failure in compensation
metabolic and hemodynamic changes in shock: sympathetic nervous system
tachycardia
tachypnea
oliguria
cool, clammy skin w/ pallor
- decreased blood pressure
effect on organ and organ systems
tissue ischemia and organ injury
brain death if anoxic over 4 minutes*
complications from shock
- acute respiratory distress syndrome (ARDS) —> covid, massive blood transfusions, pancreatitis, harmful chemicals inhaled, fire
- disseminated intravascular coagulation (DIC) —>losing ability to clot so bleeding everywhere. can give platelets, plasma, blood products. at this point, they may be beyond help at this point.
- multiple organ dysfunction syndrome (MODS)
classification of shock
hypovolemic shock
cardiogenic shock
obstructive shock
distributive shock
hypovolemic shock
decreased circulating blood volume
cardiogenic shock
cardiac failure
obstructive shock
blockage of blood flow outside heart
distributive shock
excessive dilation of venules/arterioles
- septic, anaphylactic, neurogenic
hypovolemic shock
- apply pressure if bleeding
- initial symptom: tachycardia
- administer isotonic fluid therapy as ordered
cardiogenic shock
- heart fails as pump
- pulmonary edema results
- avoid fluid therapy!! increases mortality as already in fluid overload
obstructive shock
- decreased cardiac output: shock
- causes: pericardial tamponade, tension pneumothorax, acute pulmonary hypertension
- jugular vein distension
distributive shock: types
anaphylactic
septic
neurogenic
anaphylactic shock
- extreme hypersensitivity reaction to antigen
- teach allergy avoidance methods
- most common: food allergies
- carry epinephrine autoinjetor
- carry medical alert information
septic shock
- goal: to reduce mortality
- implement interventions PROMPTLY: have admission and triage information ready. 2/5 vitals have to be off, blood pressure has to be off parameters, temp greater than 101, 02 sat low, etc etc. initiate sepsis alert.
neurogenic shock
- rare
- extensive dilation of peripheral blood vessels
therapeutic measures for shock
- maintain airway/respiratory support
- provide cardiovascular support
- maintain circulatory volume
- control bleeding
- treat cause/identify source of infection
nursing care for shock
- maintain airway, oxygenation
- monitor vital signs
- monitor I+Os
- provide fluids as ordered
- provide warmth
- relieve pain
- monitor for pressure injury (vasopressor use)
