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Module 7 (Critical Care) > Shock > Flashcards

Shock Flashcards

1
Q

Shock definition

A

inadequate tissue perfusion
- widespread lack of O2 supply = low nutrients for cellular function

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2
Q

Adequate blood flow to the tissues and cells requires

A

adequate cardiac pump, effective vasculature/circulatory system, and sufficient blood volume

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3
Q

MAP normal

A

> 65 for minimum perfusion
prefer >70

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4
Q

Shock affects what body systems?

A

all

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5
Q

During shock, the body struggles to survive calling on all its

A

homeostatic mechanisms to restore blood flow

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6
Q

What are the stages of shock?

A

Initial
Compensatory
Progressive
Refractory

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7
Q

Initial stage of shock

A

no visible changes
- changes occuring at cellular level

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8
Q

Compensatory stage of shock

A

body compensating to restore tissue perfusion and oxygenation

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9
Q

Progressive stage of shock

A

Compensatory mechanisms begin to fail

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10
Q

Refractory stage of shock

A

total body failure

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11
Q

Initial stage of shock s/s

A

subtle to none
hypoxia - low O2 to the cells
decreased cardiac output
- makes pyruvic and lactic acid

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12
Q

Transfuse a pt when

A

Hgb < 7

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13
Q

Even if the initial shock stage does not show s/s, could cellular damage still occur?

A

yes, invasive hemodynamic monitoring notes decreased cardiac output

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14
Q

Class 1 Shock has what percentage of blood loss

A

15%

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15
Q

For each unit of blood loss, hematocrit drops

A

3%

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16
Q

If the Hct has a 6% drop, then the patient has lost how many units of blood?

A

2 units

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17
Q

What cellular metabolism level changes from

A

aerobic to anaerobic

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18
Q

What is a high energy molecules of respirations?

A

Pyruvic acid

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19
Q

How is an anaerobic environment created while in shock?

A

process requires O2, unavailable due to decreased tissue perfusion

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20
Q

What metabolism changes occur during the initial stages of shock?

A

Pyruvic acid
Lactic acid builds up
Anaerobic environment created

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21
Q

Lactic acid builds up in the initial stage of shock and must be removed by

A

the liver

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22
Q

S/S of Compensatory stage of shock

A

confusion
low BP
high HR and RR
cool, clammy skin (exceptions)
low urine output
Respiratory alkalosis (short cycle)

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23
Q

What does the skin do in septic shock?

A

warm and flushed

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24
Q

What does the skin do in neurogenic shock?

A

normothermic

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25
Q

Respiratory alkalosis occurs only in what stage of shock

A

compensatory stage

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26
Q

Class 2 Shock has how much blood loss

A

15-30%

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27
Q

In thecompensatory stagethe body activates,

A

neural, hormonal, and biochemical compensatory mechanisms
- increasing consequences of anaerobic metabolism and to maintain homeostasis.

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28
Q

Baroreceptors in carotid and aortic bodies activate

A

SNS responds to decrease BP

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29
Q

What is the classic sign of shock?

A

decrease BP

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30
Q

Why do shock patients have low BP

A

activation of the RAAS
- increase Na and water reabsorption
- caused by decrease in CO and narrow pulse pressure

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31
Q

Increased myocardial stimulation (HR) increases

A

oxygen demands

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32
Q

In compensatory shock, blood is shunted to

A

brain and heart

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33
Q

The Shunting away from the lungs creates a

A

V/Q mismatch
- tachypnea
-confusion due to lack of O2
- decrease blood to kidneys = RAAS

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34
Q

What is the glucose production of a patient in shock?

A

increased

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35
Q

While the body is in compensatory state of shock the body can still

A

compensate for the tissue perfusion changes

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36
Q

If the cause of shock in the initial to compensatory stages is corrected, the patient will

A

recover with little to no effect

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37
Q

Progressive stage of shock s/s

A

lethargic/confused/ /COMA
- GCS 9-12
severe hypotension (<90/<60)
HR > 150
tachypneic, shallow, crackles
dysrhythmias
PaO2 < 80
PaCO2 > 45
Mottling, petechia, cap refill > 4
anuria
absent bowel sounds
Severe Metabolic acidosis
Respiratory acidosis
cold extremities
- weak or absent pulse

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38
Q

Class 3 Shock blood loss %

A

30-40%

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39
Q

In the progressive stage of shock, shunting starts to move blood away from

A

nonessential organs

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40
Q

What pump fails at the progressive stage of shock?

A

sodium/potassium pump

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41
Q

Without effective tx in the progressive stage,

A

profound hypoperfusion occurs
= worsening metabolic acidosis
= electrolyte imbalance due to failure of the Na/K pump and respiratory acidosis

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42
Q

What is one of the top assessments needing to perform in progressive stage of shock?

A

mental status or LOC

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43
Q

For hemorrhagic shock, class 3 progressive stage of shock is considered having a blood loss of

A

30-40%
- begins with compensatory mechanisms failing
- moved to ICU for advances monitoring and tx

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44
Q

Refractory stage of shock is

A

irreversible

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45
Q

The refractory stage is classified as

A

decreased perfusion from peripheral vasoconstriction and decreased CO
- exacerbates anaerobic metabolism

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46
Q

Refractory Stage System responses

A
  • decreased cellular perfusion and altered capillary permeability
  • CO decreases
  • lack of blood supply to the cells
  • loss of anerobic metabolism
  • extremely ineffective anaerobic metabolism available
  • increased capillary permeability
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47
Q

Features of decreased cellular perfusion and altered capillary permeability

A
  • leakage of protein into interstitial space
  • increase of systemic interstitial edema
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48
Q

What s/s shows CO decrease

A

hypotension
dysrhythmias
complete loss of perfusion

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49
Q

Prolonged inadequate blood supply to the cells results in

A

cell death and multisystem organ failure

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50
Q

With the loss of aerobic mechanisms what accumulates?

A

lactic acid and other waste products

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51
Q

Increased capillary permeability is shown through

A

extreme tissue hypoxia
anasarca
fluid leakage affects organs and peripheral tissues

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52
Q

Anasarca

A

severe generalized fluid accumulating in the interstitial space
- palpable swelling throughout the entire body
- weeping out of the skin

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53
Q

For hemorrhagic shock refractory is considered class 4 having a blood loss of

A

> 40%

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54
Q

Refractory stage of shock s/s

A

Coma (GCS < 8)
Hypotension requiring vasoconstrictors
Dysrhythmias – including possible MI
Respiratory failure
= Pulmonary edema
= bronchoconstriction
Hepatic failure
Renal failure
Peripheral tissue ischemia and necrosis
Anasarca
Profound metabolic acidosis

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55
Q

What are the different types of shock?

A

Hypovolemic
Cardiogenic
Distributive
Obstructive

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56
Q

Hypovolemic Absolute

A

Hemorrhagic
Non-hemorrhagic

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57
Q

Hypovolemic Absolute hemorrhagic

A

external loss of whole blood
- trauma, surgery, GI bleed, ruptured aortic aneurysm

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58
Q

Hypovolemic Absolute non-hemorrhagic

A

loss of other body fluids
- V/D - dehydration
-excessive diuresis
- diabetes insipidus
- third spacing

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59
Q

Hypovolemic Relative

A

fluid shift stay internal
- 3rd spacing

60
Q

3rd spacing

A

extravascular/intracavity
- burn, ascites, peritonitis, bowel obstructions

61
Q

Hypovolemic s/s

A

cold/dry/clammy extremities (shunting blood to vital organs)
Tachycardia
- low CO, cap refill, confusion, SVR increase
Tachypnea
low BP (fluid loss)
oliguria
normothermia (no inflammation)

62
Q

Hypovolemic fluid resuscitation calculated using the

A

3:1 rule
- 3 mL isotonic crystalloid for every 1 mL of estimated blood loss

63
Q

SVR means

A

peripheral vascular resistance
- vasoconstriction causes it to increase

64
Q

What is considered the volume, pump, and pipes?

A

Volume - hypovolemic shock (blood)
Pump - Cardiogenic shock (heart)
Pipes - distributive shock (vessels)

65
Q

Cardiogenic Shock is what type of failure

A

pump

66
Q

Decreased contractility in cardiogenic shock can result in

A

Acute MI
Severe heart failure exacerbation
MVC - bruising from seatbelt
Myocarditis
JVD
Pulmonary edema

67
Q

Cardiogenic Shock has what type of contractility?

A

decreased

68
Q

S/S of cardiogenic shock

A

Tachycardia
CO decreased
Slow cap refill
Confusion
SVR increased
Tachypnea
Hypotension
Oliguria
Normothermia
- Not inflammatory response due to inflammation so no change in temp

69
Q

Cardiogenic shock overall goal

A

restore blood flow to myocardium by restoring balance between O2 supply and demand

70
Q

Possible surgeries for a cardiogenic shock pt

A

Angioplasty with stenting
Emergency revascularization
Valve replacement
Hemodynamic monitoring

71
Q

Drug Therapy for cardiogenic shock pts

A

Nitrates to dilate coronary arteries
Nitroglycerin
Diuretics to reduce preload
Vasodilators to reduce afterload
Nitroprusside
β-Adrenergic blockers to reduce HR
Monitor for fluid overload – cautious with fluid

72
Q

Circulatory assist devices to help cardiogenic shock pts

A

Intra-aortic balloon pump
Ventricular assist device (VAD)- replace left ventricle
Heart transplantation
- possibly

73
Q

What does the circulatory assist device do to help cardiogenic shock pts?

A

Decrease SVR and left ventricular workload

74
Q

Distributive shock is what type of problem

A

pipe

75
Q

What different types of distributive shock?

A

Anaphylactic
Neurogenic
Septic

76
Q

Anaphylactic Shock can be caused by

A

Life-Threatening hypersensitivity (allergic) reaction
Bee sting
Peanut
Medications
Transfusion reactions
Latex allergy

77
Q

Neurogenic shock

A

Spinal cord injury above T6
Spinal anesthesia

78
Q

Septic shock

A

Extreme immune system response to an infection
- Pneumonia, UTI, invasive lines
End organ failure > MODS

79
Q

Anaphylactic S/S

A

bradypnea/tachypnea
tachycardia
normothermia
flushed and warm
swollen
itchy
oliguria
urticaria
bronchoconstriction
confusion

80
Q

Neurogenic S/S

A

dysfunction r/t inJury
low HR
POIKILOTHERMIA
flushed, warm, dry
- then poikilothermia
paralysis

81
Q

Septic S/S

A

high RR and HR
hyperthermia/hypothermia
flushed and warm to cool and mottled
oliguria
bounding pulses then confusion

82
Q

Anaphylactic shock Tx

A

Antihistamine
Epinephrine
Hydrocortisone

83
Q

Neurogenic shock Tx

A

Vasopressors
Dopamine, phenylephrine, norepinephrine
Anticholinergic
Atropine – reflex bradycardia

84
Q

Septic shock Tx

A

Vasopressors - Dopamine, phenylephrine, norepinephrine
Fluid resuscitation
Crystalloids

85
Q

All distributive shock types have what s/s

A

low BP, CO, SVR

86
Q

Obstructive shock

A

Obstruction in the perfusion system either the heart or the pulmonary system

87
Q

Obstructive shock types

A

Pulmonary embolism
Pericardial tamponade
Hemopneumothorax
Tension pneumothorax

88
Q

Tx for obstructive shock

A

Mechanical decompression
Thrombolytic therapy
Radiation, debulking, or removal of mass
Decompressive laparotomy

89
Q

Nursing Mgmt for shock
- assessments

A

Perfusion and Oxygenation
(Signs of organ perfusion or damage)
- responsive, BP, airway
VS BASELINE
Pulse pressures
Labs

90
Q

Pulse pressure =

A

Systolic Blood Pressure minus Diastolic Blood Pressure

91
Q

Normal PP

A

40-60

92
Q

Narrow PP

A

< 40

93
Q

Narrow PP shows

A

Earlier indicator of shock than drop in systolic BP

94
Q

Widened PP

A

> 80

95
Q

Widened PP is seen in

A

Septic patients
Sustained intracranial pressure above 20 mmHg

96
Q

What is the primary goal of nursing mgmt of shock?

A

correction of decreased tissue perfusion and oxygenation

97
Q

How do you know if your tx of shock is working?

A

Interventions to control or eliminate cause of decreased perfusion
Protection of target and distal organs from dysfunction
Provision of multisystem supportive care

98
Q

Decreased tissue perfusion in shock leads to

A

an increased lactate with a base deficit

99
Q

Labs reflecting anaerobic metabolism

A

ABG – Respiratory alkalosis then metabolic acidosis
Creatinine – increased
Impaired kidney function caused by hypoperfusion because of severe vasoconstriction
DIC screen – Acute DIC can develop within hours to days
Lactic Acid
CBC

100
Q

Central venous pressure monitors the

A

Direct pressure measure right atrium and SVC (vena cava)
- Measures systemic vascular resistance
- Assess perfusion
- Assess systemic fluid status

101
Q

Normal CVP

A

2-6

102
Q

Shock pts CVP require

A

8-12

103
Q

On a Central line with multiple lumens, the transducer will be connected to

A

distal port

104
Q

A PICC line need to transducer on what lumen?

A

any

105
Q

The central line and PICC is located in the heart at the

A

lower 3rd of the superior vena cava

106
Q

The CVP reflects the amount of blood returning to the heart via

A

venous system and the ability of the heart to pump the blood into the arterial system.

107
Q

Central venous pressure monitoring is used to assess

A

right ventricular function and systemic fluid status.

108
Q

What is the first nursing action for a shock pt?

A
  • assess airway
  • 100% oxygen via non-rebreather
  • plan care around avoid disrupting O2 supply and demand
    (let them rest)
109
Q

The nurse is caring for a patient in septic shock. Which hemodynamic change would the nurse expect?
- Increased ejection fraction.
- Increased mean arterial pressure.
- Decreased central venous pressure.
- Decreased systemic vascular resistance.

A
  • Decreased systemic vascular resistance.

Rationale: Patients in septic shock will have a decreased systemic vascular resistance, decreased ejection fraction, and decreased mean arterial pressure. Decreased central venous pressure (preload) is expected in hypovolemic or obstructive shock.

110
Q

The nurse is caring for a critically ill patient. The nurse suspects that the patient has progressed beyond the compensatory stage of shock if what occurs?
- Decreased blood glucose levels
- Increased serum sodium levels
- Increased serum calcium levels
- Increased serum potassium levels

A
  • Increased serum potassium levels

Rationale: Hyperkalemia occurs in the progressive phase of shock when cellular death liberates intracellular potassium. Hyperkalemia will also occur in acute kidney injury and in the presence of acidosis.

111
Q

Pharmacology for Shock Pts

A

Volume expanders (IV Fluids)
- not in cardiogenic and neurogenic

112
Q

Volume expansion is reserved for what shock pts?

A

septic, hemorrhagic hypovolemic
- anaphylactic

113
Q

Volume expansion cautioned with

A

cardiogenic and neurogenic shocks

114
Q

Volume expanders include

A

Crystalloids (ex: normal saline, lactated ringers, 5% dextrose)
Colloids (ex: albumin, red blood cells)

115
Q

Crystalloids

A

(ex: normal saline, lactated ringers, 5% dextrose)

116
Q

Colloids

A

(ex: albumin, red blood cells)

117
Q

Two major complications of large volumes

A

hypothermia
coagulopathy

118
Q

How to avoid hypothermia from large volumes of IV fluids?

A

Warm up crystalloid or colloid solutions, if possible

119
Q

How to avoid Coagulopathy in large volumes of fluids

A

RBCs do not contain clotting factors
Replace clotting factors
- platelets and cryo

120
Q

What can be added if the pt has persistent hypotension after adequate fluids?

A

vasopressor

121
Q

Fluid responsiveness is determined by what assessments

A

Vital signs
- Increase BP
- Monitor PP (narrow or wide)
Cerebral and abdominal pressures
Capillary refill < 3
Skin temperature WNL
Urine output > 0.5 mg/kg/hr

122
Q

The goal for fluid resuscitation is

A

restoration of tissue perfusion

123
Q

Assessment of end-organ perfusion

A

urine output, neurologic function, peripheral pulses

124
Q

Hemodynamic parameters CO tx

A

Monitor trends in BP with an automatic BP cuff or an arterial catheter to assess the patient’s response.
Use an indwelling bladder catheter to monitor urine output during resuscitation.

125
Q

Vasopressor drugs

A

norepinephrine – first line
Vasopressin
- Antidiuretic > Retain fluid
dopamine
phenylephrine

126
Q

Vasopressin does what

A
  • Antidiuretic > Retain fluid
127
Q

Vasopressors are reserved for

A

patients unresponsive to fluid resuscitation OR cardiogenic or neurogenic

128
Q

Vasopressors increase

A

Increase SVR and BP

129
Q

Vasopressors MAP

A

> 65

130
Q

Vasopressors adverse reactions

A

Decreased perfusion to vital organs
- Monitor end organ perfusion
Extravasation

131
Q

Vasodilators reserved for

A

cardiogenic shock

132
Q

Vasodilator types

A

nitroglycerin
nitroprusside (aka sodium nitroprusside)

133
Q

Vasodilators do what

A

Decrease afterload
Relaxes smooth muscle in arteries and veins

134
Q

Vasodilators MAP

A

greater than 65 mm Hg

135
Q

Vasodilators adverse reactions

A

Tachycardia
Palpitations
Headache
Fatigue
Angina

136
Q

Glucocorticoids used for

A

Septic, Anaphylactic and possibly Cardiogenic

137
Q

Glucocorticoid types

A

prednisone, methylprednisolone, dexamethasone

138
Q

Glucocorticoid purpose

A

Septic, Anaphylactic and possibly Cardiogenic

139
Q

Glucocorticoid expected actions

A

increase risk of infection and blood glucose
insomnia and jittery

140
Q

Glucocorticoid adverse reactions

A
141
Q

Diuretics types

A

Furosemide, spironolactone, bumetanide

142
Q

Diuretics purpose

A
143
Q

Diuretics expected actions

A
144
Q

Diuretics adverse reactions

A
145
Q

pantoprazole is a

A

PPI

146
Q

pantoprazole does what

A

Stress ulcer prophylaxis with proton pump inhibitors
- know it works if it

147
Q

VTE prophylaxis

A

heparin, enoxaparin
Unless contraindicated

Module 7 (Critical Care) (22 decks)

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