Sepsis/Shock/MODS Flashcards
What two things determine blood pressure?
Systemic vascular resistance
Cardiac output
How is cardiac output determined?
Heart rate x stroke volume
what factors affect stroke volume?
heart size
fitness level
gender
contractility
preload and afterload
what factors affect heart rate?
hormones
fitness level
age
Shock begins when…
the cardiovascular system fails to function properly
and alteration of AT LEAST ONE of four circulatory components
What are the 4 circulatory components?
Blood volume
Myocardial contractility
blood flow
vascular resistance
Types of shock
cardiogenic
distributive
hypovolemic
obstructive
What physiological alteration causes cardiogenic shock and example?
inadequate myocardial contractility
Heart attack
What physiological alteration causes distributive shock? Examples
inadequate vascular tone
Sepsis
anaphylaxis
What is physiological alteration causes hypovolemic shock?
inadequate intravascular volume
Shock: Stage I Initiation
Explain.
Decreases perfusion
inadequate delivery of oxygen
No obvious signs
Decreased CO can occur
Shock Stage II: Compensatory
Explain.
Body tries to compensate for reduction of perfusion
Shock Stage II Compensatory: Neural compensation
baroreceptors and chemoreceptors send signals to sympathetic nervous system
VASOCONSTRICTION > INCREASE HR
REDISTRIBUTES BLOOD TO VITAL ORGANS
BRONCHODILATION > RESP RATE GOES UP
Shock Stage II Compensatory:
Endocrine compensation
Renin-angiotensin-aldosterone-system is ACTIVTED
renal reabsorption of sodium and water
Blood glucose levels increase
Shock stage II compensatory clinical presentation
Increased HR
Thirst
Cool, moist skin
oliguria
diminished bowel sounds
restlessness
hyperglycemia
rapid and deep respirations
decreased creatinine
Shock Stage III Progressive
Explain
Hypoperfusion not corrected and compensatory mechanisms have failed
ischemia in extremities
Cells > anaerobic metabolism > lactic acid > metabolic acidosis
Failure of sodium-potassium pump > cell swelling
Shock stage III progressive: Clinical signs
Decrease BP
Dysrhythmias
Tachypnea
cold clammy skin
decreased capillary refill
mottling
Anuria
absent bowel sounds
lethargy
Shock stage III: progressive
What can you expect labs to look like?
High BUN, Creatinine Potassium
Respiratory and metabolic acidosis
Shock Stage IV: Refractory
Explain
Severe tissue hypoxia with ischemia and necrosis
worse acidosis
SIRS
MODS
Shock stage IV Refractory
Clinical presentation
Severe dysrhythmias and hypotension
respiratory and metabolic acidosis
acute respiratory failure
DIC
ARDS
hepatic dysfunction or failure
AKI
heart failure
brain ischemia
What is SIRS?
Systemic inflammatory response syndrome
balance between proinflammatory and anti-inflammatory processes are disrupted
CNS assessment for shock
Early signs are anxiety and restlessness
Late signs are confusion and lethargy/coma
Cardiovascular assessment for shock
Blood pressure will be increased INITIALLY
HR is increased
check capillary refill
Assess for JVD
Check pulse rate and quality
Respiratory assessment for shock
Early : rapid and deep breathing
late: shallow
ABGs
pulse ox
Renal Assessment for shock
Decreased GFR
oliguria (< 0.5 mL/kg/hr)
GI assessment for shock
slowed intestinal activity
decreased bowel sounds
N/V
constipation
Hepatic Assessment for shock
Altered liver enzymes
DIC
liver can’t detoxify
Hematological assessment for shock
decreased platelet
messed up clotting factors
Skin assessment for shock
skin mottling around knees
may see cyanosis
What does fluid challenge mean?
performed to assess patient’s response to fluids
rapid infusion of 250 mL of a crystalloid solution (NS or LR)
What are some complications of fluid challenging?
Pulmonary edema
transfusion reaction
Medications used for shock
Norepinephrine
Vasopressin
Dobutamine
Epinephrine
What does norepinephrine do?
causes vasoconstriction
Purpose of vasopressin
to restore vascular tone in distributive shock
What does dobutamine do?
increase cardiac contractility and HR
causes vasodilation in low cardiac output states
What are some examples of supportive care for patients with shock?
Warm blankets
nutrition-enteral feedings
Turning every 2 hours
barrier creams
elevate heels of the bed
What is Hypovolemic shock? Give examples
Inadequate fluid volume
EX: bleeding, trauma, diarrhea/vomiting
Manifestations of hypovolemic shock
Increased HR
decreased BP
Tachypnea
cool, pale skin
oliguria
flat neck veins
What is the management/treatment for hypovolemic shock?
Give isotonic crystalloids (NS or LR) or blood
What is Cardiogenic shock? Give examples
Heart fails to pump efficiently
Heart attack, dysrhythmias, severe heart failure
Management/ treatment for cardiogenic shock
decrease preload and afterload
increase cardiac output
Manifestations of cardiogenic shock
Increased HR
dysrhythmias
decreased BP
chest pain
tachypnea
decreased mentation
Clinical manifestations of distributive shock- Neurogenic
PROFOUND bradycardia with hypotension
Hypothermia
warm dry flushed skin
Septic shock v sepsis
septic shock is a life threatening complication of sepsis
Sepsis is life threatening organ dysfunction caused by response to infection
What is the diagnostic criteria for sepsis?
2 or more indicators of systemic inflammation
Temp >38.3 or <36
HR > 90
RR > 20
WBC >12 or < 4
Diagnosis criteria for septic shock
Urine output < 0.05 mL/kg/hr
Creatinine > 0.5
Lactate > 4 or > 2
What are the steps in the sepsis bundle
obtain blood culture
give broad spectrum antibiotics
rapidly give 30 ml/kg of fluids
give vasopressors if patient is hypotensive
What is MODS?
Multiple organ dysfunction syndrome
dysfunction of 2 or more organ systems from uncontrolled inflammatory response
What is Primary MODS?
direct injury to organ from shock, trauma, or burn
What is secondary MODS?
consequence of widespread systemic inflammation
Clinical manifestations of MODS
tachypnea/hypoxemia
Petechiae/bleeding
jaundice
abdominal distention
oliguria or anuria
tachycardia
hypotension
LOC change
What is DIC?
Disseminated Intravascular coagulation
exaggerated microvascular coagulation, depletion of clotting factors and bleeding
What is the most common cause of DIC?
sepsis
DIC Assessment findings
overt bleeding
occult bleeding
PLT deficiency
decreased organ perfusion
Expected lab findings for DIC
Low PLTs
Low fibrinogen
low coag factors
low hgb and hct
HIGH D-dimer
How do you know if patient is tolerating fluid replacement?
MAP is between 65-70
Urine output is > 0.5 mg/kg/hr
What is neurogenic shock?
Shock from spinal cord injuries
Management for Neurogenic shock
Immobilization
IV fluids for hypotension
slow rewarming to prevent further vasodilation
Clinical manifestations of anaphylactic
Angioedema
High HR and BP
integumentary
tightened airway
wheezing
Management of anaphylactic shock
epinephrine
protect airway
remove offending agent
What organs are the first to fail in MODS?
Kidneys
What is the management of MODS?
antibiotics
provide adequate tissue perfusion
maintain 88%-92% O2 sat
Maintain Hgb 7-9
What are some positive outcomes of shock, sepsis, and MODS?
Improved tissue perfusion
normotensive
warm, dry skin
adequate urine output
intact skin
What can cause DIC?
Infection
trauma
obstetric conditions
blood disorders
septic shock
ARDS
Nursing management for DIC
Assess and prevent
blood products
relieve pain
analyze lab values
