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Module 2 > Shock > Flashcards

Shock Flashcards

1
Q

What is shock?

A life-threatening condition that results from __________

A

inadequate tissue perfusion.

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2
Q

Creates an imbalance between the delivery of oxygen and nutrients that are needed to support cellular function.

Shock affects ALL body systems
It can develop very rapid or very slow
It all depends on the underlying cause

-
-

A

Effective cardiac pump
Adequate vasculature / circulatory systems
Sufficient blood volume

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3
Q

-
-

A

Hypoperfusion
Hypermetabolism
Activation of the inflammatory response

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4
Q

The body calls on all homeostatic mechanisms to prevent and/or reverse shock;
however, if these compensatory mechanisms fail, the result is ____________

A

organ dysfunction and death

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5
Q

Pathophysiology of Shock

Cellular changes:
Cells lack adequate blood supply
produce energy through _________
____ intracellular environment
normal cell function ceases
_____

Vascular changes:
Regulatory mechanisms stimulate vasodilation or vasoconstriction in response to mediators released by the cell, communicating need for _____

A

anaerobic metabolism
acidotic
cell death

O2 & nutrients

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6
Q

Pathophysiology (cont.): Blood pressure regulation

-
-

All 3 must respond to maintain adequate BP

Best expressed through Mean Arterial BP (MAP):
MAP = __________

Tissue and organ perfusion depend on MAP of at least _____

If unable to calculate MAP through complicated measures, most BP measurement devices estimate a MAP

A

blood volume
cardiac pump
vasculature

Cardiac Output x Peripheral Resistance

65 mmHg

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7
Q

Pathophysiology (cont.):BP regulation & kidneys

Kidney regulate BP by
releasing: renin which converts angiotensin I to II (this acts as a ________)

This leads to the release of aldosterone
which promotes __________

_____ then
stimulates release of ____
which causes further retention of H20 to raise blood volume and Bp

This process can take ______

Important to catch early: medications, fluid bolus, blood products to treat

A

vasoconstrictor)

Na and H20 retention

Hypernatremia
ADH

hours to many days

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8
Q

The 3 stages of shock

3 stages:

Shock can be identified as early or late
it is important to understand the physiologic responses to divide it into the appropriate stage for treatment

The chance of survival greatly improves if _______

EBP states that aggressive therapy should occur within _____ for best outcome and survival

A

Stage I: Compensatory Stage
Stage II: Progressive Stage
Stage III: Irreversible Stage

diagnosed early

3 hours

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9
Q

Stage I: Compensatory stage

A

BP remains within normal limits

Increased HR and increased contractility maintain adequate cardiac output

Increased RR

SNS
release of epinephrine and norepinephrine
body shunts blood to vital organs (away from skin, kidneys, and GI tract)
cool, pale skin

Decreased urinary output (due to release of ADH and aldosterone)

Altered LOC
First sign of altered LOC- agitation, restlessness

Respiratory alkalosis <35 PCO2 (due to hyperventilation)

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10
Q

Stage I: Compensatory stageNursing mgmt

Identify ____ before progression

-

Monitor _______
Reduce _______
Promote ______

A

the cause

Fluid replacement
Vasopressors

tissue perfusion
anxiety
safety

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11
Q

Stage II: Progressive stage

Mechanisms that regulate BP can no longer compensate and the MAP falls below normal limits

BP: Systolic < ____

Neuro:

HR > ___

RR:

Acid/base: PaC02 >

Skin:

Urine output: <

Metabolic acidosis

______ is considered part of this stage (see later in ppt)

A

90 mmHg

Neuro: Declining mental status, confusion

HR > 150 bpm

RR: rapid, shallow respirations, and possibly crackles

Acid/base: PaC02 > 45 mm Hg - reflects hypoventilation

Skin: mottled, petechiae

Urine output: < 0.5 mL/kg/hr

Metabolic acidosis

MODS is considered part of this stage (see later in ppt)

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12
Q

Stage II: Progressive stageNursing mgmt

A

Client is typically moved into an ICU setting for this stage

Hemodynamic monitoring:
May include more invasive monitoring

ECG monitoring

ABG gases

Serum electrolyte levels

Respiratory support:
Up to mechanical ventilation

Fluid volume maintenance/replacement:
Up to dialysis

Assess for physical and mental status changes that can occur very quickly

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13
Q

Stage III: Irreversible stage

Severe organ damage past the point of survival

BP remains low, despite treatment

Renal and liver dysfunction

Respiratory dysfunction, despite O2 delivery/ interventions

Cardiac dysfunction, cannot maintain adequate MAP for perfusion

Worsening metabolic acidosis r/t __________
Leads to __________

A

lactic acidosis
(by product of anareobic resp.

multiple organ dysfunction syndrome

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14
Q

Stage iii: irreversible stage nursing mgmt.

A

Comfort measures
-Ensure all are involved & provide comfort
-Inform family about the importance of seeing, touching, and talking to client

Inform family/loved ones regarding prognosis
-Discuss living wills
-Advanced directives
-Any other written/verbal wishes
-Ethics committee, if needed, to assist in making difficult care decisions

Engaging palliative care

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15
Q

Clinical manifestations:stages of shock

Blood pressure:

A

Compensatory- Normal

Progressive- Systolic <90 mm Hg; MAP < 65 mm Hg
Requires fluids resuscitation to support blood pressure

Irreversible- Requires mechanical or pharmacologic support

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16
Q

Clinical manifestations:stages of shock

Heart rate

A

Compensatory: >100 bpm

Progressive: >150 bpm

Irreversible: Erratic

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17
Q

Clinical manifestations:stages of shock

Respiratory status

A

compensatory: >20 breaths/min
PaCO2 < 32 mm Hg

Progressive: Rapid, shallow respirations; crackles
PaO2 <80 mm Hg
PaCO2 >45 mm Hg

Irreversible: Requires intubation and mechanical ventilation and oxygenation

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18
Q

Skin

A

Copensatory: cold, clammy

Progressive: Mottled, petechiae

Irreversible:
Jaundice

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19
Q

Urinary output

A

Compensatory: decreased

Progressive: <0.5 ml/kg/hr

Irreversible: Anuric; requires dialysis
(lack of urine production.)

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20
Q

Mentation

A

Compensatory: confusion and/or agitation

Progressive: lethargy

Irreversible: Unconscious

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21
Q

Acid-base balance

A

Compensatory: Resp. alkalosis
PaCO2 <32

Progressive: Metabolic acidosis
Paco2 >45

Irreversible: Profound acidosis

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22
Q

Types of Shock

CHAIN

A

Cardiogenic
Hypovolemic
Anaphylactic
Infectious (sepsis)
Neurogenic

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23
Q

Hypovolemic shock

Most common type of shock
characterized by ____________

External _______

Internal _______

Sequence of events

A

decreased intravascular volume

External fluid losses

Internal fluid shifts

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24
Q

Risk factors for hypovolemic shock:

External:

A

External:
Trauma
Surgery
Vomiting
Diarrhea
Diuresis
Diabetes insipidus

Internal:
Hemorrhage
Burns
Ascites
Peritonitis
Dehydration
Necrotizing pancreatitis

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25
Q

Hypovolemic shock:care mgmt

______:
#1 concern

IV access:

Pharmacologic therapy:

Reverse cause of dehydration:

Monitor for s/s hypervolemic complications with frequent assessments:

A

Fluid replacement:

IV
at least 2 sites
IO (intraosseous or CVAD)

Pharmacologic therapy:
vasopressors

(nausea, vomiting, diarrhea, hyperglycemia)
Antiemetics, antidiarrheal, insulin, desmopressin)
Desmopressin- used as an antidiuretic for diabetes insipudis

Listen to lungs, JVD, difficulty breathing, electrolyte imbalance—fluid overload

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26
Q

Hypovolemic shock: fluids

A

Crystalloids:
0.9 % Sodium Chloride
Lactated Ringers

Colloids:
Albumin (5%, 25%) - Rapidly expands plasma volume

Blood Products- Plasma, packed red blood cells, and platelets

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27
Q

Hypovolemic shock: visual aid

See slide

A

Plasma loss through burns
Hemorrhage
Decreased body fluids
GI loss- bleeding, vomiting, diarrhea
Diabetes insipidus
Diuresis

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28
Q

Cardiogenic shock

Impaired ability for the heart to contract and pump blood…which causes inadequate O2 for heart and tissue

Two types:

A

Coronary-
Anterior wall Mis put at greater risk for b/c more damage to left ventricle

Non-coronary
hypocalcemia, hypoxemia, cardiomyopathy, tamponade, dysrhythmias

29
Q

Cardiogenic shock:

Risk factors:

S&S:

A

Older age
Heart failure
Previous heart attack (higher for women)
Coronary artery disease
high blood pressure
Diabetes

Angina
Fatigue
Feelings of doom
Dsrythymias
Increased RR, tachycardia, low BP
Pale skin
Weak pulse
SOB

30
Q

Cardiogenic shock: care mgmt

Limit myocardial damage and preserve healthy myocardium

Improve cardiac function by increasing ________ and decreasing ______ (or both!)

Correct underlying cause…
Coronary:
Non-coronary:

If cause of cardiogenic shock is from cardiac arrest, ______ and _____

A

cardiac contractility
ventricular afterload

resuscitate client and keep cool (therapeutic hypothermia); WHY?

31
Q

Cardiogenic shock: pharm therapy

A

Dobutamine:

Nitroglycerin:

Dopamine:

Norepinephrine, Epinephrine, Milrinone, Vasopressin, and Phenylephrine

Antiarrhythmics

32
Q

Increases the strength of myocardial activity and improving cardiac output

Decreases pulmonary and systemic vascular resistance (decreased afterload)

A

Dobutamine:

33
Q

Venous vasodilator, reduces preload

Higher doses can cause arterial vasodilation

Frequently used in combo with dobutamine

A

Nitroglycerin:

34
Q

May be used with dobutamine and nitroglycerin to improve tissue perfusion

Doses greater than 8 mcg/kg/min can cause vasoconstriction

Can also increase HR past therapeutic levels

A

Dopamine:

35
Q

Distributive shock

Occurs when:

this displacement leads to
relative hypovolemia due to blood not returning to the heart
Which leads to inadequate tissue perfusion

A

intravascular blood pools in peripheral blood vessels

36
Q

3 types of distributive shock:

A

Anaphylactic
Neurogenic
Septic Shock

37
Q

Distributive shock:Anaphylactic shock

Severe allergic reaction to: antibodies the body has already produced (for example: ________)

Antigen-antibody reaction
-causes mast cells release vasoactive substances (histamine and bradykinin)
-activates inflammatory cytokines
-vasodilation and capillary permeability

____ onset of symptoms

Signs/symptoms…what would you expect?

A

blood transfusion reactions

Acute

38
Q

Anaphylactic shock clinical assessment:

Severe-

A

Generalized flushing
Diffuse erythema
Difficulty breathing (laryngeal edema)
Bronchospasms
Hypotension
Dysrhythmias

Severe – respiratory distress, rapid onset hypotension, neurologic compromise, cardiac arrest

39
Q

Distributive shock:Anaphylactic shock Care mgmt

A

Remove causative agent (for example, discontinuing an antibiotic)

Establish adequate IV access

Fluid replacement

Vasopressors

Diphenhydramine (Benadryl)

Nebulized medications:
Albuterol (Proventil)

Maintain/establish airway

40
Q

Distributive shock:Neurogenic shock

Vasodilation occurs as a result of a loss of balance between _______ and _______ stimulation.

What effect does SNS and PNS stimulation have on smooth muscle?

Drastic decrease in _____ and ____

Inadequate BP results in insufficient perfusion of tissues and cells

A

parasympathetic and sympathetic

Parasympathetic wins- more vasodilation

SVR and bradycardia

41
Q

Distributive shock:Neurogenic shock causes & s/s

Causes:

S/S:

A

Spinal cord injury
Spinal anesthesia
Other related diseases that cause nervous system damage
Short courses of neurogenic shock: syncope

Similar to parasympathetic stimulation
Dry, warm skin
Hypotension
Bradycardia***

42
Q

Distributive shock:Neurogenic shock care mgmt

Goal of treatment is restore ________ (could be a surgical procedure, proper positioning)

Keep HOB _____ (especially when anesthetic agent has been given-this will prevent it from spreading up the cord)

In spinal cord injury, great caution with _____ the client

Support CV and Neuro function

Higher incidence of _________ may be implemented

Monitor for s/s of ______ which could lead to hypovolemic shock

A

sympathetic tone

> 30 degrees

moving/mobilizing

VTE; DVT prophylaxis

internal bleeding

43
Q

Distributive shock: septic shock

Defined as: “a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality.”

Most common type of Distributive Shock*****

Caused by widespread infection or Sepsis

A
44
Q

Distributive shock: septic shock

-
-
Most common bacteria: _______

Sepsis is defined as: “life threatening organ dysfunction caused by __________

Both sepsis and septic shock incidences have continued to rise despite all the aggressive treatments / therapies

A

Bloodstream (bacteremia), most commonly CVAD’s
Lungs (pneumonia)
Urinary tract (urosepsis); most commonly urinary catheters

gram negative

a dysregulated host response to infection”.

45
Q

Distributive Shock:Septic Shock risk factors

A

Invasive lines and procedures

Indwelling medical devices

Increased number of antibiotic-resistant microorganisms

Increasing number of older population

46
Q

Septic shock: S&S

Early stages of sepsis:

Progression to septic shock:

A

BP – may remain WNL or respond to fluid therapy
Tachycardia
Hyperthermia
Fever
Warm flushed skin with bounding pulses
Elevated RR
Subtle changes in mental status
Decreased urine output

Hypotension – not responding to fluids
Skin is cool , pale, and mottled
Tachycardia
Tachypnea
Oliguria
nonresponsive

47
Q

Distributive Shock:Septic Shock reduction/prevention

A

Strict infection control practices:
Hand hygiene
CLABSI prevention
Early removal of indwelling/invasive devices
Protocols to reduce VAP
Wound debridment
Early ambulation with pneumonia

48
Q

Distributive shock:sepsis/septic shock labs

A

Labs:
Lactic acid (lactate): derived from muscle cells and erythrocytes; common marker used for sepsis

C-reactive protein (CRP): present during inflammatory process

Procalcitonin: substance produced in response to bacterial infections and tissue injury. Sepsis marker that is MOST studied.

49
Q

Distributive shock:sepsis/Septic shock treatment

A

Fluid replacement therapy:
Implemented to correct tissue hypoperfusion

Pharmacolgic therapy
-Broad-spectrum antibiotics
-Vasopressors
-Inotropic agents
-PRBC’s
-Neuro-muscular blockade and sedation aganets
-DVT and PUD prophylaxis

Nutritional therapy
Should be initiated 24-48 hours of admission

50
Q

SIRS Criteria and stages of sepsis: visual aid

SIRS = systemic inflammatory response syndrome

SIRS= Temp>100.4, HR >90, RR>20 or PaCO2 <32
WBC’s >12,000 or <4,000

Sepsis= SIRS + Infection

Severe Sepsis= Sepsis + End organ damage

Septic Shock = Severe Sepsis + Hypotension

A
51
Q

Sepsis bundle:
Surviving Sepsis Campaign Bundle & CMS Core measure monitoring metrics

A

Complete within 1 hr of patient presentation/symptoms:
-measure lactate level (remeasure if initial is >2 mmol/L
-Obtain blood cultures

-Administer broad spectrum antibx

-Begin rapid admin. Of 30 mL/kg crystalloid for hypotension or lactate >/= 4 mmol/L (within 30 min)

-Admin. Vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP ./= 65 mmHg

52
Q

Sepsis bundle cont:

Complete within 3 hr of patient presentation/symptoms

A

Obtain serum lactate level

Obtain blood cultures prior to admin. Antibx

Admin. Rx broad spectrum antibx

Initiate aggressive fluid resuscitation in patients with hypotension or elevated serum lactate (>/= 4 mmol/L)

Minimum initial fluid bolus of 30 mL/kg with crystalloid solutions

53
Q

Complete ASAP or within the first 6 hr of patient presentation/symptoms

A

Begin vasopressor agents if hypotension is not improved after initial fluid bolus (MAP 70%)
-Bedside cardiovascular US
-Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

54
Q

Distributive Shock: risk factors
Septic Shock:

Neurogenic Shock:

Anaphylactic shock:

A

Septic shock:
Immunosuppression
Extremes of age <1 and >65
Malnourishment
Chronic illness
Invasive procedures
Emergent and/or multiple surgeries

Neurogenic shock:
-Spinal cord injury
-Spinal anesthesia
-Depressant action of medications

Anaphylactic shock:
-Hx medication sensitivity
-Transfusion reaction
-hx reaction to insect bites/stings
-Food allergies
-Latex sensitivity

55
Q

Vasoactive agents

A

Inotropic agents

Vasodilators

Vasopressor agents

56
Q

Inotropic agents:

Improve contractility, increase stroke volume, increase cardiac output

A

Dobutamine
Dopamine
Epinephrine
Milrinone

57
Q

Vasodilators

A

Nitroglycerin
Nitroprusside

58
Q

Vassopressor agents

A

Norepinephrine
Dopamine
Phenylephrine
Vasopressin
Epinephrine

59
Q

Quick Review of shock:

Cardiogenic =

Obstructive =

Hypovolemic =

Distributive =

A

Cardiogenic = heart fails to pump out blood
MI, Arrythmia, aortic stenosis, mitral regurgitation

Obstructive = cardiac pump failure due to an indirect cardiac factor: outflow is obstructed
PE, tension pneumothorax, tamponade, aortic dissection

Hypovolemic = heart pumps well, but not enough blood volume to pump
Hemorrhage, fluid loss (burns, vomiting, diarrhea)

Distributive = heart pumps well, but there is peripheral vasodilation
Pancreatitis, burns, multi-trauma via activation of the inflammatory response

60
Q

Multiple organ dysfunction syndrome(MODS)

Altered organ function

Falls into _______ Phase of Shock

Dysfunction and mortality:
One organ system dysfunction=20% mortality
>4 organ systems dysfunction=60% mortality

MODS can be a complication of all forms of shock; however, is most common in ____

A

Stage II: Progressive

sepsis

61
Q

Risk factors and s&S of Mods:

Lungs
Liver
Neuro
Renal

A

Advanced age
Malnutrition
Coexisting diseases / chronic illness
Immunosuppression
Surgical or traumatic wounds

Lungs
Progressive dyspnea
Respiratory failure

Liver
Elevated bilirubin and liver function tests

Neuro
Unresponsive or coma

Renal
Decreased urine output

62
Q

MODS: Care mgmt

Goal is to prevent; however, if unable to, goal then becomes to reverse MODS

Frequent monitoring of diagnostics (labs, ecg monitoring…more invasive testing if needed)

A
  1. Controlling the initial event
  2. Promoting adequate organ perfusion
  3. Providing nutritional support
  4. Maximizing patient comfort
63
Q

Stages of shock:

When do you start fluid replacement and vasopressors?

Since the body may not be able to maintain this state for long:

A

Compensatory

64
Q

Most common type of Distributive Shock*****

A

Sepsis

65
Q

Pulse pressure
- norm?
how to calculate?

A

Normal is 40 mmHg
- Systolic – diastolic = pulse pressure
- Eg: 120/80 = 40 mmHg
- Eg: 90/70 = 20 mmHg

66
Q

Hypovolemic shock occurs when there is a reduction of

A

intravascular volume by 15-30% (750-1500 mL)

67
Q

Hypovolemic shock

proper positioning

A
  • Modified Trendelenburg (passive leg raise) head flat legs raised
  • This helps promote venous blood return to the heart
68
Q

Neurogenic shock

Can be caused by depressant actions of medications

Or from prolonged lack of glucose (an insulin reaction)

A

Module 2 (6 decks)

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