MED SURG II - SHOCK Flashcards
Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism
Shock
Clinical manifestations of General Shock: Cardiac
Tachycardia
Hypotension
Decreased Cap Refill
Weak/Thready Pulses
Clinical manifestations of General Shock: Respiratory
Tachypnea
Clinical manifestations of General Shock: Renal
Decreased UOP
How does the skin look in the early stages of shock?
White
Ashen/Gray (darker skin tones)
Clinical manifestations of shock: Neurologic
Increased Anxiety, Agitation, and Confusion
Clinical manifestations of shock: GI
Decreased peristalsis
Decreased bowel sounds
can lead to ileus (later)
Shock: BUN and Creatinine
Increased
Shock: LFTs
Increased
Liver is not perfusing
Shock: Lactic Acid
Increased r/t metabolic acidosis
What is normal Lactic Acid?
< 2
Stage of Shock: Usually not clinically visible
Body is switching from aerobic to anaerobic metabolism
Initial
Stage of Shock: Body activates compensatory mechanisms to overcome increasing effects of anaerobic metabolism.
Compensatory
This is where we want to stop the progression of shock
Patient presents with: Tachycardia, Tachypnea, Slight Hypotension, Subtle MS Changes ….. what stage of shock?
Compensatory
Stage of Shock: Compensatory mechanisms fail
Progressive
Patient has marked changes in mental status and decreased peripheral perfusion…. what stage of shock?
Progressive
decrease in coronary, cerebral*, and peripheral perfusion
Stage of Shock: Profound hypotension and hypoxemia; recovery unlikely
Refractory
Signs of MODS
Primary nursing intervention for patient experiencing shock
OXYGEN
15L 100% non-rebreather
After giving Oxygen what is the next intervention?
Fluids
Increase Volume
What types of shock are fluids contraindicated in?
Cardiogenic and Neurogenic
What medications are given to a patient experiencing shock?
Vasopressors
Vasodilators
Examples of Vasopressors
Levophed (norepinephrine) Dobutamine Pitressin Epinephrine Dopamine
After giving medications, what is the next nursing intervention for a patient experiencing shock?
Nutrition
What is the preferred route of nutrition for a patient experiencing shock?
Enteral
Ex: Tube feeding
What type of shock:
Systolic or diastolic dysfunction resulting in reduced CO and SV
Cardiogenic
What is CO? What is normal?
Volume in liters pumped by the heart in 1 minute
4-8L
What is SV? What is normal?
Volume in mL ejected per beat
60-120mL
Causes of Cardiogenic Shock
*MI* HF Cardiomyopathy Dysrhythmias Valve Disorders Ventricular Hypertrophy
What is unique about a patient in Cardiogenic shock? (Cardiac)
Narrowed Pulse Pressure
Chest Pain
Dysrhythmias
Extra Heart Sounds (S3 S4)
What is unique about a patient in Cardiogenic shock? (Respiratory)
crackles d/t pulmonary congestion
What kind of patient does a Cardiogenic shock pt resemble?
Heart Failure Patient
After oxygenation, what is the next intervention for a patient experiencing Cardiogenic Shock?
Correct the underlying problem by restoring blood flow and reducing the workload of the heart
What are ways to reduce the workload of the heart?
Beta Blockers, CCBs, Digoxin, Morphine
What are way to restore blood flow?
Thrombolytics, Angioplasty, Stents, CABG
What labs need to be monitored for a patient experiencing Cardiogenic shock?
Troponin
CKMB
BNP
What DX tests should be ran for a patient experiencing cariogenic shock?
EKG
ECHO
Chest XR
Dobutamine
Dopamine
Improves SV, CO
Improves contractility
How must Dobutamine and Dopamine be given?
In a central line
Titrated drip, weight based
What is a possible side effect of Dobutamine and Dopamine?
Dysrhythmia
Nitroglycerin
Systemic Vasodilation
Reduces preload and after load to decrease the hearts O2 demands
What are side effects of Nitroglycerin?
Flushed, warm skin
Headaches (indicate good perfusion)
Examples of Circulatory Assist Devices
IABP (decrease workload, decrease SVR)
VAD (heart transplant)
Nursing Management for a patient experiencing Cardiogenic Shock
- Oxygen
- Hemodynamic monitoring
- Vitals, cardiac monitor
- PIV, labs, EKG, Chest XR, Echo
- Administer meds
- Prep for procedure
- Enhance safety and comfort
What type of shock: Decreased intravascular volume
Hypovolemic
Absolute Hypovolemia
Fluid comes up and out
Loss of intravascular fluid volume
Causes of Absolute Hypovolemia?
N/V Hemmorhage Diarrhea Diuresis Diabetes Mellitus - Polyuria Diabetes Insipidus - Lack of ADH
Relative Hypovolemia
Fluid volume moves from intravascular space to extravascular space
third spacing
Causes of Relative Hypovolemia?
Burns
Ascites
Internal Bleeding
Massive Vasodilation (sepsis)
What % of total blood volume must be lost before s/s of shock appear?
15%
~ 750mL
Will patients with chronic illness show s/s of shock sooner or later than a healthy patient?
Sooner
Will Elderly patients and Children show s/s of shock sooner or later?
Sooner
What’s unique about a patient experiencing Hypovolemic shock? (skin)
Third Spacing (ascites) Trauma
What’s unique about a patient experiencing Hypovolemic shock? (GI)
Vomiting, Diarrhea
Bloody stools, Emesis
Primary nursing intervention for a patient experiencing Hypovolemic shock?
OXYGEN
What do you do after giving a patient experiencing hypovolemic shock oxygen?
Treat the underlying cause
Stop the loss of fluid
What do you use to replace the fluid lost during hypovolemic shock?
isotonic fluids (NS, LR) volume expanders (albumin, dextrans)
How many mL of fluid replacement is needed for every 1mL of blood loss
3mL
If a patient is experiencing hypovolemic shock d/t blood loss what labs need to be monitored?
H and H
less than or equal to 7 = think about transfusion
High H and H = fluid loss (not bleeding)
If a patient is experiencing hypovolemic shock d/t vomiting and/or diarrhea what labs should be monitored?
electrolytes (esp Na+ and K+)
Nursing Management of a patient experiencing Hypovolemic Shock?
Hold Pressure, Elevate Place on Oxygen Take BP, HR PIV access, large bore Administer blood and fluids safely
What type of shock:
An insult or injury causes massive vasodilation without compensation because f the loss of SNS constriction
Neurogenic
Predisposing factors to Neurogenic Shock
Spinal Cord Injury (As quick as 30min post)
Spinal anesthesia
Opioids, benzos (depression of the vasomotor center)
What’s unique about a patient experiencing Neurogenic shock? (Cardiovascular)
Bradycardia and Hypotension caused by massive vasodilation and loss of SNS
What’s unique about a patient experiencing Neurogenic shock? (Pulmonary)
Depends on the level of the injury
What’s unique about a patient experiencing Neurogenic Shock? (Renal)
Bladder dysfunction
What’s unique about a patient experiencing Neurogenic shock? (Skin)
Massive dilation causes warm, dry skin – may progress to take on temp of environment (poikilothermia)
The skin takes on the temperature of the environment
poikilothermia
What’s unique about a patient experiencing Neurogenic shock? (GI)
Bowel Dysfunction
Medications for patients experiencing Neurogenic Shock
Vasopressors
Atropine for bradycardia
Nursing Management of Patient Experiencing Neurogenic Shock
- Maintain Spinal Alignment
- Provide O2
- Place on monitor
- PIV
- Meds
- Safety and Comfort
Cardiovascular support for patient experiencing Neurogenic Shock
DVT prophylaxis
Neurologic Support for a patient experiencing Neurogenic Shock
Monitor for s/s of internal injury
Neurologic status, orientation, LOC, behavioral problems, report any changes
What type of shock:
hypersensitivity (allergic) reaction to a sensitizing substance causes quick massive vasodilation
Anaphylactic
Predisposing factors for Anaphylactic Shock
Exposure to allergen Contrast dye Drugs Chemicals Vaccines Food Insects Venom Latex Anesthesia
What’s unique about Anaphylactic Shock?
Sudden Onset
Nursing priorities for a patient experiencing Anaphylactic Shock
Airway and Epinephrine
What’s unique about a patient experiencing Anaphylactic shock? (Pulmonary)
SOB *laryngeal edema* bronchospasm wheezing stridor may need artificial airway
What’s unique about a patient experiencing Anaphylactic shock? (Renal)
Incontinence
What’s unique about a patient experiencing Anaphylactic shock? (Skin)
Flushing
Pruritus
Urticaria
Angioedema (commonly caused by Ace Inhibitors)
What’s unique about a patient experiencing Anaphylactic shock? (Neurological)
Feeling of impending doom
What’s unique about a patient experiencing Anaphylactic shock? (GI)
Cramping
Abdominal Pain
N/V/D
Medical Management of a patient experiencing Anaphylactic Shock
Remove causative antigen
Fluids - aggressive
Medication (Epinephrine IM, Benadryl IV) – both oppose histamine
Nursing Management of a patient experiencing Anaphylactic Shock
- Remove Antigen
- Epi IM (vastus lateralis)
- HOB up if airway issue, supine if not
- Airway - O2 or Intubation
- PIV x 2, IV fluids (aggressive isotonic)
- Meds
What medications are given to a patient experiencing Anaphylactic shock?
Albuterol/aerolized epi - reduce laryngeal edema
Benadryl
H2 Blockers - Zantac
Steroids - antiinflammatories
What is Sepsis?
constellation (group) of symptoms in response to an infection
What type of shock: in the presence of sepsis with hypotension despite adequate fluid resuscitation; inadequate tissue perfusion with tissue hypoxia.
Septic Shock
What’s unique about a patient experiencing Anaphylactic shock? (Cardiovascular)
normal/low-normal BP that responds to fluids (early) low BP that does not respond to fluids (late) give meds (vasopressors)
What’s unique about a patient experiencing Anaphylactic Shock? (Pulmonary)
Hypoxia (early) Respiratory Distress (late)
If septic shock is not managed early it can progress to ….
ARDS
What’s unique about a patient experiencing Anaphylactic shock? (Skin)
warm and flushed – cool and mottled (late)
What’s unique about patient experiencing Anaphylactic shock? (Neurological)
Hyperthermia (infection)
Hypothermia (late)
FSBS of a patient experiencing Septic Shock
elevated b/c liver can’t keep up
What is important to collect with a patient experiencing septic shock? (labs)
blood cultures
suspected source of infection
lactate level
Fluid Challenge
administer 30mL/kg isotonic crystalloid fluids for hypotension or lactate >4mmol/L
Q30min
remeasure lactate
What do you give for persistent hypotension that does not respond to fluids
Vasopressors
norepinephrine
Medical Management of a patient experiencing Septic Shock
Antibiotics: broad spectrum within the 1st hour (get blood cultures first) GI prophylaxis (PPIs)
Blood sugar - goal <180
Nursing Management of patient experiencing Septic Shock
- HOB, up if resp. issue, flat if possible
- Oxygen – ear, forehead, bridge of the nose = better perfusion
- Vitals, rectal temp is best (more accurate, better perfusion)
- PIV
- Blood cultures and other labs
- Fluids
- Antibiotics - starting within first hour decreases mortality rate
- Fever treatment (Tylenol, cooling blanket, decrease room temperature, remove covers) – decrease the temperature gradually
¥ Hemodynamic status - central lines
¥ Reassess temp after Tylenol
¥ Collaborate to find source of infection
¥
Be aware of risks for all patients o Pt w/ multiple invasive lines ¥ Assess fluid/kidney status ¥ I & O ¥ Daily weights ¥ Nutritional status ¥ FSBS
Sepsis six
oxygen blood cultures antibiotics fluid challenge lactate urine output
What type of shock: Physical obstruction of blood flow to or from the heart, causes decreased CO
Obstructive
Complication of any form of shock due to inadequate tissue perfusion
Failure of two or more organ systems
MODS
Medical Management of MODS
Prevention Early detection Control initiating event Promote adequate organ perfusion Provide nutritional support
Nursing management similar to septic shock
Causes of Obstructive Shock
Cardiac Tamponade
Tension Pneumo
Superior Vena Cava Syndrome
Abdominal Compartment Syndrome
Presentation of Obstructive Shock
Similar to HF JVD Cough Muffled Heart Sounds Edema