Shock Flashcards
Shock definition
inadequate tissue perfusion
- widespread lack of O2 supply = low nutrients for cellular function
Adequate blood flow to the tissues and cells requires
adequate cardiac pump, effective vasculature/circulatory system, and sufficient blood volume
MAP normal
> 65 for minimum perfusion
prefer >70
Shock affects what body systems?
all
During shock, the body struggles to survive calling on all its
homeostatic mechanisms to restore blood flow
What are the stages of shock?
Initial
Compensatory
Progressive
Refractory
Initial stage of shock
no visible changes
- changes occuring at cellular level
Compensatory stage of shock
body compensating to restore tissue perfusion and oxygenation
Progressive stage of shock
Compensatory mechanisms begin to fail
Refractory stage of shock
total body failure
Initial stage of shock s/s
subtle to none
hypoxia - low O2 to the cells
decreased cardiac output
- makes pyruvic and lactic acid
Transfuse a pt when
Hgb < 7
Even if the initial shock stage does not show s/s, could cellular damage still occur?
yes, invasive hemodynamic monitoring notes decreased cardiac output
Class 1 Shock has what percentage of blood loss
15%
For each unit of blood loss, hematocrit drops
3%
If the Hct has a 6% drop, then the patient has lost how many units of blood?
2 units
What cellular metabolism level changes from
aerobic to anaerobic
What is a high energy molecules of respirations?
Pyruvic acid
How is an anaerobic environment created while in shock?
process requires O2, unavailable due to decreased tissue perfusion
What metabolism changes occur during the initial stages of shock?
Pyruvic acid
Lactic acid builds up
Anaerobic environment created
Lactic acid builds up in the initial stage of shock and must be removed by
the liver
S/S of Compensatory stage of shock
confusion
low BP
high HR and RR
cool, clammy skin (exceptions)
low urine output
Respiratory alkalosis (short cycle)
What does the skin do in septic shock?
warm and flushed
What does the skin do in neurogenic shock?
normothermic
Respiratory alkalosis occurs only in what stage of shock
compensatory stage
Class 2 Shock has how much blood loss
15-30%
In thecompensatory stagethe body activates,
neural, hormonal, and biochemical compensatory mechanisms
- increasing consequences of anaerobic metabolism and to maintain homeostasis.
Baroreceptors in carotid and aortic bodies activate
SNS responds to decrease BP
What is the classic sign of shock?
decrease BP
Why do shock patients have low BP
activation of the RAAS
- increase Na and water reabsorption
- caused by decrease in CO and narrow pulse pressure
Increased myocardial stimulation (HR) increases
oxygen demands
In compensatory shock, blood is shunted to
brain and heart
The Shunting away from the lungs creates a
V/Q mismatch
- tachypnea
-confusion due to lack of O2
- decrease blood to kidneys = RAAS
What is the glucose production of a patient in shock?
increased
While the body is in compensatory state of shock the body can still
compensate for the tissue perfusion changes
If the cause of shock in the initial to compensatory stages is corrected, the patient will
recover with little to no effect
Progressive stage of shock s/s
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
Class 3 Shock blood loss %
30-40%
In the progressive stage of shock, shunting starts to move blood away from
nonessential organs
What pump fails at the progressive stage of shock?
sodium/potassium pump
Without effective tx in the progressive stage,
profound hypoperfusion occurs
= worsening metabolic acidosis
= electrolyte imbalance due to failure of the Na/K pump and respiratory acidosis
What is one of the top assessments needing to perform in progressive stage of shock?
mental status or LOC
For hemorrhagic shock, class 3 progressive stage of shock is considered having a blood loss of
30-40%
- begins with compensatory mechanisms failing
- moved to ICU for advances monitoring and tx
Refractory stage of shock is
irreversible
The refractory stage is classified as
decreased perfusion from peripheral vasoconstriction and decreased CO
- exacerbates anaerobic metabolism
Refractory Stage System responses
- 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
Features of decreased cellular perfusion and altered capillary permeability
- leakage of protein into interstitial space
- increase of systemic interstitial edema
What s/s shows CO decrease
hypotension
dysrhythmias
complete loss of perfusion
Prolonged inadequate blood supply to the cells results in
cell death and multisystem organ failure
With the loss of aerobic mechanisms what accumulates?
lactic acid and other waste products
Increased capillary permeability is shown through
extreme tissue hypoxia
anasarca
fluid leakage affects organs and peripheral tissues
Anasarca
severe generalized fluid accumulating in the interstitial space
- palpable swelling throughout the entire body
- weeping out of the skin
For hemorrhagic shock refractory is considered class 4 having a blood loss of
> 40%
Refractory stage of shock s/s
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
What are the different types of shock?
Hypovolemic
Cardiogenic
Distributive
Obstructive
Hypovolemic Absolute
Hemorrhagic
Non-hemorrhagic
Hypovolemic Absolute hemorrhagic
external loss of whole blood
- trauma, surgery, GI bleed, ruptured aortic aneurysm
Hypovolemic Absolute non-hemorrhagic
loss of other body fluids
- V/D - dehydration
-excessive diuresis
- diabetes insipidus
- third spacing
Hypovolemic Relative
fluid shift stay internal
- 3rd spacing
3rd spacing
extravascular/intracavity
- burn, ascites, peritonitis, bowel obstructions
Hypovolemic s/s
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)
Hypovolemic fluid resuscitation calculated using the
3:1 rule
- 3 mL isotonic crystalloid for every 1 mL of estimated blood loss
SVR means
peripheral vascular resistance
- vasoconstriction causes it to increase
What is considered the volume, pump, and pipes?
Volume - hypovolemic shock (blood)
Pump - Cardiogenic shock (heart)
Pipes - distributive shock (vessels)
Cardiogenic Shock is what type of failure
pump
Decreased contractility in cardiogenic shock can result in
Acute MI
Severe heart failure exacerbation
MVC - bruising from seatbelt
Myocarditis
JVD
Pulmonary edema
Cardiogenic Shock has what type of contractility?
decreased
S/S of cardiogenic shock
Tachycardia
CO decreased
Slow cap refill
Confusion
SVR increased
Tachypnea
Hypotension
Oliguria
Normothermia
- Not inflammatory response due to inflammation so no change in temp
Cardiogenic shock overall goal
restore blood flow to myocardium by restoring balance between O2 supply and demand
Possible surgeries for a cardiogenic shock pt
Angioplasty with stenting
Emergency revascularization
Valve replacement
Hemodynamic monitoring
Drug Therapy for cardiogenic shock pts
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
Circulatory assist devices to help cardiogenic shock pts
Intra-aortic balloon pump
Ventricular assist device (VAD)- replace left ventricle
Heart transplantation
- possibly
What does the circulatory assist device do to help cardiogenic shock pts?
Decrease SVR and left ventricular workload
Distributive shock is what type of problem
pipe
What different types of distributive shock?
Anaphylactic
Neurogenic
Septic
Anaphylactic Shock can be caused by
Life-Threatening hypersensitivity (allergic) reaction
Bee sting
Peanut
Medications
Transfusion reactions
Latex allergy
Neurogenic shock
Spinal cord injury above T6
Spinal anesthesia
Septic shock
Extreme immune system response to an infection
- Pneumonia, UTI, invasive lines
End organ failure > MODS
Anaphylactic S/S
bradypnea/tachypnea
tachycardia
normothermia
flushed and warm
swollen
itchy
oliguria
urticaria
bronchoconstriction
confusion
Neurogenic S/S
dysfunction r/t inJury
low HR
POIKILOTHERMIA
flushed, warm, dry
- then poikilothermia
paralysis
Septic S/S
high RR and HR
hyperthermia/hypothermia
flushed and warm to cool and mottled
oliguria
bounding pulses then confusion
Anaphylactic shock Tx
Antihistamine
Epinephrine
Hydrocortisone
Neurogenic shock Tx
Vasopressors
Dopamine, phenylephrine, norepinephrine
Anticholinergic
Atropine – reflex bradycardia
Septic shock Tx
Vasopressors - Dopamine, phenylephrine, norepinephrine
Fluid resuscitation
Crystalloids
All distributive shock types have what s/s
low BP, CO, SVR
Obstructive shock
Obstruction in the perfusion system either the heart or the pulmonary system
Obstructive shock types
Pulmonary embolism
Pericardial tamponade
Hemopneumothorax
Tension pneumothorax
Tx for obstructive shock
Mechanical decompression
Thrombolytic therapy
Radiation, debulking, or removal of mass
Decompressive laparotomy
Nursing Mgmt for shock
- assessments
Perfusion and Oxygenation
(Signs of organ perfusion or damage)
- responsive, BP, airway
VS BASELINE
Pulse pressures
Labs
Pulse pressure =
Systolic Blood Pressure minus Diastolic Blood Pressure
Normal PP
40-60
Narrow PP
< 40
Narrow PP shows
Earlier indicator of shock than drop in systolic BP
Widened PP
> 80
Widened PP is seen in
Septic patients
Sustained intracranial pressure above 20 mmHg
What is the primary goal of nursing mgmt of shock?
correction of decreased tissue perfusion and oxygenation
How do you know if your tx of shock is working?
Interventions to control or eliminate cause of decreased perfusion
Protection of target and distal organs from dysfunction
Provision of multisystem supportive care
Decreased tissue perfusion in shock leads to
an increased lactate with a base deficit
Labs reflecting anaerobic metabolism
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
Central venous pressure monitors the
Direct pressure measure right atrium and SVC (vena cava)
- Measures systemic vascular resistance
- Assess perfusion
- Assess systemic fluid status
Normal CVP
2-6
Shock pts CVP require
8-12
On a Central line with multiple lumens, the transducer will be connected to
distal port
A PICC line need to transducer on what lumen?
any
The central line and PICC is located in the heart at the
lower 3rd of the superior vena cava
The CVP reflects the amount of blood returning to the heart via
venous system and the ability of the heart to pump the blood into the arterial system.
Central venous pressure monitoring is used to assess
right ventricular function and systemic fluid status.
What is the first nursing action for a shock pt?
- assess airway
- 100% oxygen via non-rebreather
- plan care around avoid disrupting O2 supply and demand
(let them rest)
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.
- 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.
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
- 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.
Pharmacology for Shock Pts
Volume expanders (IV Fluids)
- not in cardiogenic and neurogenic
Volume expansion is reserved for what shock pts?
septic, hemorrhagic hypovolemic
- anaphylactic
Volume expansion cautioned with
cardiogenic and neurogenic shocks
Volume expanders include
Crystalloids (ex: normal saline, lactated ringers, 5% dextrose)
Colloids (ex: albumin, red blood cells)
Crystalloids
(ex: normal saline, lactated ringers, 5% dextrose)
Colloids
(ex: albumin, red blood cells)
Two major complications of large volumes
hypothermia
coagulopathy
How to avoid hypothermia from large volumes of IV fluids?
Warm up crystalloid or colloid solutions, if possible
How to avoid Coagulopathy in large volumes of fluids
RBCs do not contain clotting factors
Replace clotting factors
- platelets and cryo
What can be added if the pt has persistent hypotension after adequate fluids?
vasopressor
Fluid responsiveness is determined by what assessments
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
The goal for fluid resuscitation is
restoration of tissue perfusion
Assessment of end-organ perfusion
urine output, neurologic function, peripheral pulses
Hemodynamic parameters CO tx
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.
Vasopressor drugs
norepinephrine – first line
Vasopressin
- Antidiuretic > Retain fluid
dopamine
phenylephrine
Vasopressin does what
- Antidiuretic > Retain fluid
Vasopressors are reserved for
patients unresponsive to fluid resuscitation OR cardiogenic or neurogenic
Vasopressors increase
Increase SVR and BP
Vasopressors MAP
> 65
Vasopressors adverse reactions
Decreased perfusion to vital organs
- Monitor end organ perfusion
Extravasation
Vasodilators reserved for
cardiogenic shock
Vasodilator types
nitroglycerin
nitroprusside (aka sodium nitroprusside)
Vasodilators do what
Decrease afterload
Relaxes smooth muscle in arteries and veins
Vasodilators MAP
greater than 65 mm Hg
Vasodilators adverse reactions
Tachycardia
Palpitations
Headache
Fatigue
Angina
Glucocorticoids used for
Septic, Anaphylactic and possibly Cardiogenic
Glucocorticoid types
prednisone, methylprednisolone, dexamethasone
Glucocorticoid purpose
Septic, Anaphylactic and possibly Cardiogenic
Glucocorticoid expected actions
increase risk of infection and blood glucose
insomnia and jittery
Glucocorticoid adverse reactions
Diuretics types
Furosemide, spironolactone, bumetanide
Diuretics purpose
Diuretics expected actions
Diuretics adverse reactions
pantoprazole is a
PPI
pantoprazole does what
Stress ulcer prophylaxis with proton pump inhibitors
- know it works if it
VTE prophylaxis
heparin, enoxaparin
Unless contraindicated
