Shock Flashcards
What is the definition of shock?
Syndrome characterized by hypotension and decreased tissue perfusion leading to impaired cellular metabolism
shock results in the ?
resulting in an imbalance in supply/demand for oxygen and nutrients
when a patient is in shock, the decreased tissue perfusion and hypotension leads to the body to go into an ______metabolism
anaerobic
why is being in an anaerobic metabolic state really bad?
your body will secrete lactic acid -> making your body acidosis -> cellular death
she mentions how shock in smaller terms is just what?
not enough blood and oxygen getting to the tissues/body parts that need it
for the following lecture, she wants us to use, pump, hoses, gas and bucket to help us associate things easier for shock
what’s our pump?
what’s our hoses?
whats our pump and gas?
pump - heart ( beating )
hoses - vessels
pump & gas - stroke volume
(if you run out of gas, there isn’t any for your pump to push out )
what is cardiac out?
heart rate x stroke volume
( how fast your heart is beating )
( how much of blood your ventricle pumps out )
what is blood pressure ?
cardiac output x systemaic vascular resistance
what is the 4 main categories of shock ?
cardiogenic
hypovolemic
distributie
obstructive
what are the 2 hypovolemic shocks that we are going to need to know ?
absolute ( hemorrhagic )
relative ( non-hemorrhagic )
what are the 3 distributive shocks we are going to need to know ?
neurogenic
anaphylactic
septic
to emphasize and really get the idea of it what is the 9 total types of shock we are going to talk about?
place them in their respective categories as well when talking about it outloud
cardiogenic
hypovolemic
- absolute ( hemorrhagic )
- relative (non-hemorrhagic)
distributive
- neurogenic
- anaphylactic
- septic
obstructive
in the powerpoint it shows small little details to help identify and kinda associate to why/type of shock the patient is having, describe the main 4
cardiogenic is when your ?
hypovolemic is when you?
distributive is when you ?
obstructive is when you?
pump is broken, so heart is broken
not enough gas, so not enough blood/fluid in your vessels
vessels having an issue, hose problem
( fluid is there just not working )
hose has a blockage, like your vessels has something blocking the fluid from going
what is the definition of cardiogenic shock?
- decreased contractility
- decreased filling of the heart will result in decreased stroke volume
- RESULTING in compromised to cardiac output
notes defintion
either systolic or diastolic dysfunction of the pumping action of the heart results in reduced cardiac output
what is the number one reason for why patients end up getting cardiogenic shock ?
some other precipitating causes for cardiogenic shock include
- cardiomyopathy
- blunt cardiac injury
- severe systemic or pulmonary hypertension
- cardiac tamponade
- myocardial depression from metabolic problems
myocardial infarction ( heart attack )
cardiogenic shock presentation
the following terms, I want you to say which symptom will be happening
cardiovascular
respiratory
renal
skin
neuro
gi
tachycardia, low blood pressure, slow cap refill, narrow pulse pressure
tachypnea, crackles, cyanosis
decreased urine output, sodium and water retention
pale, cool, clammy
decreased cerebral perfusion confusion, anxiety, agitation
decreased bowel sounds
how does hypovolemic shock occur?
inadequate fluid volume in the intravascular space to support adequate perfusion
what are the 2 hypovolemic shock ?
absolute hypovolemia (hemorrhagic)
relative hypovolemia(non-hemorrhagic)
what is absolute hypovolemia
(hemorrhagic)?
loss of intravascular fluid
what are some examples or causes to patients who end up having absolute hypovolemia shock ?
hemorrhage
gi loss ( vomit, diarrhea )
diabetes insipidus
hyperglycemia
diuresis
what is relative (nonhemorrhagic ) hypovolemia shock ?
shift of fluid out of vascular space into extravascular space ( third spacing )
usually due to increased capillary permeability
what are some examples of causes that can cause a patient to go into a relative hypovolemia shock ?
burns
sepsis
pulmonary edema
how does hypovolemic shock presentation itself in patients ?
cardiovascular
respiratory !! Late what?
renal
skin
neuro
gi
tachycardia, decreased cardiac output, slow cap refill
tachypnea with late bradypnea
decreased urine output
pale, cool, clammy
decreased cerebral perfusion, confusion, anxiety, agitation
decreased or absent bowel sounds
for patients who have hypovolemic shock, the body is able to replace the blood volume at ___loss
however, greater than ___%loss we must give them ____
30%
30%
blood products
what is neurogenic shock for the distributive shock section ?
occur within 30 minutes of a spinal cord injury or spinal anesthesia at the T5 vertebra or above and last up to 6 weeks
the 3 main consequences patients will experience after being in a neurogenic shock is ?
hypotension ( massive vasodilation )
bradycardia ( unopposed parasympathetic stimulation )
poikiothermia ( unable to keep warm or cool, the body becomes at room temp )
how does neurogenic shock presentation itself in patients ?
when you see !! its bolded in the powerpoint and you need to know it
cardiovascular !!
respiratory
renal
skin !!!
neuro
gi
bradycardia, hypotension
related to level of injury, depending if they have a higher spinal cord injury they need intubation, lower, they dont need it
bladder dysfunction
poikilothermia
flaccid paralysis below the level of injury
bowel dysfunction
what is anaphylactic shock for distributive shock?
an acute and life threatening hypersensitive ( allergic ) reaction
what are some causes for patients to end up in an anaphylactic shock ?
dont overthink it
drugs
chemicals
vaccines
food
insect venom
what are the 3 immediate reactions that occur when patients are in an anaphylactic shock ?
massive vasodilation (hypotension)
release of vasoactive mediators
(try to fight it off)
increase in capillary permeability, resulting in fluids leaks from the vascular space into the interstitial space
how does anaphylactic shock presentation itself in patients ?
cardiovascular
respiratory !!
renal
skin !!
neuro
gi
tachycardia, chest pain, increase cardiac output
wheezing, stridor, angioedema, increase work of breathing
incontience possible
flushing, itching, angioedema, urticaria
( edema around the throat ), hives
anxiety, confusion, feeling of impending doom
cramping, abdominal pain, n/v/d
its important to inform patients that once you’re allergic to something, you should try to stay away from it as much as possible as to why ?
because your allergic reaction to it the next time might become even worse
what is septic shock for distributive shock?
presence of sepsis with hypotension despite adequate fluid resuscitation along with the presence of inadequate tissue perfusion
septic shock has 3 major pathophysiologic effects, which are ?
vasodilation
maldistribution of blood flow
myocardial dysfunction
( inflammation ^ )
how does septic shock presentation itself in patients ?
cardiovascular
respiratory
renal
skin !!
neuro !!
gi
heme !!
tachycardia, myocardial dysfunction
tachypnea, pulmonary edema, crackles, ards
decreased urine output
warm, flushed early, cool and mottled late
agitations confusion, decreased loc, coma late
decreased bowel sounds, gi bleed, paralytic ileum
increased coagulation, decreased fibrinolysis (DIC)
( clotting and bleeding at the same time )
dr.brooks mentions a good point to how patients who have septic shock will develop a fever, remember these patients are having an infection that has now become systemic and the inflammatory process is trying to fight it off
but think about the patients who are immunosuppressed, elderly, what is going to happen to them ?
they might not present with a fever, so its crucial to perform will assessments on these patients
another thing dr.brooks mentioned about septic shock, these patients are going to have severe hypotension, however they aren’t losing fluid? why is this ?
how do we treat this?
remember this is only shock that does this.
because of the severe hypotension
normally treat it with fluid resuscitation, even though its just going to be leaking out because of the massive vasodilation
- so we have to do other interventions
what is obstructive shock ?
develops the physical obstruction to blood flow occurs with decreased cardiac output
how is obstructive shock caused by ?
restricted diastolic filling of right ventricle from compression
what is the syndrome that can cause obstructive shock?
abdominal compartment syndrome
what is abdominal compartment syndrome ?
abdominal pressure compresses inferior vena cava
usually surgery after an aneurysm
how does obstructive shock presentation itself in patients ?
cardiovascular
respiratory
renal
skin
neuro
gi
tachycardia
tachypnea, shortness of breath
decreased urine output
pale, cool, clammy
decreased cereal perfusion, agitation
decreased bowel sounds, absent bowel sounds
I am going to want to recap the difference between each shock
lets talk about each one that has a big difference compared to other shocks that you need to know
this are the big ones that have differences with that need to be pointed out
neurogenic shock
heart rate =
skin =
anaphylactic shock
respiratory =
skin =
septic shock
skin =
heme =
neurogenic
bradycardia
polikoemia
anaphylactic
angioedema, stridor, wheezing
hives, angioedema, itching
warm, flushed skin, fever type
DIC, clotting and bleeding at the same time
there are 4 stages of shock, no matter the shock type, which are?
initial
compensatory
progressive
refractory
what is the initial stage of shock?
occurs at a cellular level, usually not clinically apparent
what is happening at in initial, cellular level of shock?
metabolism changes at cellular level from aerobic to anaerobic
- lactic acid builds up and must be removed by the liver
- process requires oxygen however is unavailable due to decreased tissue perfusion
what is the compensatory stage of shock?
clinically apparent and involves neural, hormonal and biochemical compensatory mechanism to try to overcome the increasing consequence of anaerobic metabolism and to maintain homestasis
what is the patho that is happening behind the compensatory stage of shock? (4)
dont over think it
the cool, clammy skin is for everything BUT????????
vasoconstriction to pump blood in lungs, heart, brain
decreased renal perfusion = RAAS system = increase blood pressure
decreased blood flow to the gut causes peristalsis - increase risk for gi bleed
cool, clammy skin
septic shock, patient is warm and flushed
if your patient has decreased blood flow to the gut causing peristalsis
what is an intervention we can do ? (2)
early/slow feeding (enteral feedings)
PPI - stress ulcer prevention
if a patient has decreased renal perfusion, what lab are we looking at?
test question
what is better, lab for renal or hourly urinary output ?
BUN and Creatinine
hourly/frequent urinary output
what is the progressive stage of shock?
begins as compensatory mechanisms fail and aggressive interventions are needed to prevent the development of MODS
what is the patho behind the progressive stage of shock ?
honestly in short, everything is 100x worse compared to the compensatory, working even harder to breathe, gi bleeding is more at risk
decreased cellular perfusion and altered capillary permeability lead to leaky
- more edema
- losing fluid
cardiac output decrease - bp drops, pulses get weaker
dysrhythmias, ekg changes, ischemia
gi bleeding, tachypnea, crackles
acute kidney injury issues, hypo perfusion, we can’t filter things like we should, peeing too much or not at all
liver fails, jaundice, elevated enzymes, DIC- clotting and bleeding everywhere
what is the refractory stage?
honestly its just mods from what she says, so everything has failed and recovery is unlikely
what are some diagnostic studies for shock ?
note
just know some are more specific because of the type of shock
blood studies
12-lead
chest x-ray
continues pulse ox
hemodynamic monitoring
notes
successful management
- identification of patients at risk for developing shock
- interventions to control or eliminate cause of decreased perfusion
- protection of target and distal organs from dysfunction
- provision of multi system supportive care
general management
- ensure patent is response
- ensure a patent airway
- maximize oxygen delivery
why are we going to be giving patients who go into shock oxygen and ventilation ?
optimize cardiac output
transporting fluid
patients who are experiencing, septic, hypovolemia and anaphylactic shock are going to need what ?
volume expansion
how are we going to help with volume expansion ?
(3)
1-2 large bore iv
isotonic crystalloids ( normal saline, lactated ringers )
Rbcs for those who lost volume due to bleeding ( blood transfusions )
how do you know if your patient is responding to fluid resusitation?
dont over think it
better vital signs
3 sec capillary refill
improvement in mental staus
pink and warm skin
what are the 2 major complications of large volumes of fluid that patients may experience when receiving fluid resusitation?
hypotermia
coagulopathy
why do patients end up getting hypothermia when receiving large amounts of fluids ?
and how can we fix this ?
because the blood inside you is like at 98F but the fluid you’re gonna get is like 75F room temp, so its a huge difference in temp and thats why patients get cold
we can fix this by warming up the fluids prior to giving them
why do patients end up getting coagulopathy after receiving a lot of fluids with blood transfusions?
how do we fix this ?
they dont have clotting factors because the fluid doesn’t help with clotting
so we need to monitor their clotting factors, so then they are at risk for DIC
what Is the first line of treatment of shock ?
fluid resuscitation
1 or 2 bags of fluids
what is the next step if fluid resusisctation doesn’t work ?
vasopressors
- increase blood pressure to help keep the fluid where it alongs and hopes to circulate the fluid better
what are some examples of vasopressors we may give to our patients ?
norepinephrine, dopamine, phenyelphrine
we place a patient on a vasopressor as a 2nd form of treatment in case the fluid resuscitation doesn’t work.
however we may need to add vasodilator therapy to patients which shock for what reason ?
because vasopressor is working its hardest to try to maintain the blood pressure up however, the heart is also having to work very very hard to push that blood around,
so we put them on a vasodilator in hopes for the heart not to work too hard while being on a vasopressor
when, how, why do we start feeding patients with shock ?
within the firs 24 hours
with slow enteral feedings
in hopes to prevent gi bleeding,uclers, and keep their calories up
interprofessional care are the following flashcards
what is the overall goal for cardiogenic shock ?
restore blood flow to myocardium by restoring balance between oxygen supply and demand
restore cardiac function
what are the definitive measure we are going to need to do for patients who are in cardiogenic shock ? (3)
angioplasty with stenting
emergency revasculzaization
valve replacement
cardiogenic shock interprofressional care involves what types of drug therapy ?
beta blockers reduce hr
vasodilators - hypotensive
diuretics - remove fluids
nitrates to help dilate
we may need to give patients who are in cardiogenic shock what type of circulatory assiated devices?
intraaortic balloon pump
( helps you push blood )
ventricular assist device
( works everything for you pretty much )
lastly if the drug therapy, the circulatory assisted device dont help patients with cardiogenic shock. what is the last resort?
heart transplant
what is the main goal or focus of hypovolemic shock?
cousins on stopping loss of fluid and restoring the circulating volume
fluid resuscitation is calculated using what to help hypovolemic shock?
3:1 rule
( 3ml of isotonic crystalloid for every 1 mL of estimated blood loss )
what is the best way to figure out how much fluid or blood a patient has lost?
weigh the pads of fluids or blood and follow the 3:1 rule after that
what are the interprofessional care for septic shock ? (5)
fluid replacement
vasopressors
- if that doesn’t help keep the blood pressure up we then go to corticosteroids
antibiotics
keep glucose level less than 180
if a patient in on a vasopressor for their septic shock, and it is not helping keeping their blood pressure up, what else would we add to help this patient?
corticosteroids
when a patient is septic, we understand their is an infection causing this, however before we give an antibiotics, what must we get first?
blood culture
why do we get a blood culture first?
to help figure out what type of bacteria it is and properly kill it
and plus we want to avoid creating antibiotics resistance for this bacterias
so when we start the antibiotic therapy within the first hour for patients with septic shock, what medication type do we give first, then what do we give after the blood culture comes back?
broad spectrum antibiotics
then go to a
narrow spectrum antibiotics
what is the interprofressional care for neurogenic shock ?
remember fluid is not the problem, its the massive vasodilator because of the SNS because of the spinal cord injury
so we must really need to take care of their spine and keep it stable
while keeping the spine stable, we must treat their massive hypotension and bradycardia for neurogenic patients, with what 2 medications ?
vasopressors
atropine ( increases heart rate )
while we can give neurogenic shock patients fluids, remember it isn’t the biggest issue here, they are hypotensive but not because the loss of fluid but due to the spinal cord injury causing dilation
so what do we need to watch out if we do give them fluid and why?
hypothermia because they can not control their body temp due to the spinal cord injury
what is the interprofessional care for anaphylactic shock?
(3)
epinephrine - allergy reaction
diphenhydramine ( benedrayl ) - blocking histamines
h2 ( histamine 2) blockers - famotadine
why are we giving diphenhydramine ( bendrayl ) and h2 blockers to patients who are in anaphylactic shock ?
because both these medications are helping get rid of all the histamines being activated in the body
common sense things for anaphylactic shock, we need to monitor breathing, keep a patent airway, using fluids and cortisociteroids if hypotension is still happening, just overall what is the big picture of anaphylactic shock?
allergic reaction, so monitor for airway closing up and giving proper medications to prevent it from happening
remember silent chest is worse than hearing wheezing
primary strategy is early recognition and treatment to relieve obstruction for obstructive shock, what might we give a patient to help with this ?
mechanical decompression
thrombolytic therapy
radiation
decompresive laparotomy
notes
nursing assessment
- airway
- breathing
- circulation
focused assessment of tissue perfusion
- vital signs
- peripheral pulses
- level of ocnsciousness
- capillary refill
- skin
- urine output
brief history
- events leading to shock
- onset and duration of symptoms
health history
- medications
- allergies
- vaccinations, recent travel
notes
clinical problems
- impaired cardiac function
- impaired respiratory function
- alerted blood pressure
care goals
- evidence of adequate tissue perfusion
- restore normal or baseline bp
- recovery of organ function
- avoid complications from prolonged states of hypo perfusion
notes
health promotion
identify patients at risk
- older patient
- those who are immunocompromised
- those with chronic illness
- surgery or trauma patients
planning to prevent shock
- monitor fluid balance to prevent hypovolemic shock
- good hand hygiene to prevent spread of infection
notes
acute care
- monitor patients ongoing physical and emotional status
- identify trends to fetch changes in patients condition
- plan and implement nursing interventions and therapy
- evaluate patients response to therapy
- provide emotional support to patient and caregiver
- collaborate with other members of interprofessional team to coordinate care
how are we going to assess a patients neurologic status for those in shock?
orientation
level of consciousness
reducing noise and light levels
keep a day and night cycle
the following flashcards are how we are going to assess a patient for each system
how are we going to assess a patients cardiovascular status for those in shock?
continues EKG, BP, CVP, CO,
dysrhythmias
heart sounds
prescribed fluid and drug therapy
VERY IMPORTANT TO NOTE
DO NOT TREAT HYPOTENSION WITH WHAT ?
Trendelenburg position
how are we going to assess a patients respiratory status for those in shock?
respiratory rate
breath sounds
continuous pulse oximetry
arterial blood gases
mechanical ventilation
how are we going to assess a patients renal status for those in shock?
urine output
I and o
serum creatinine
how are we going to assess a patients skin status for those in shock?
temperature
pallor ?
flushing?
cyanosis ?
diaphoresis ?
how are we going to assess a patients gi status for those in shock?
occult blood
asucualte bowel sounds
how are we going to assess a patients personal hygiene status for those in shock?
perform bathing
turning every 1-2 hours
passive and active range of motion
oral care
how are we going to assess a patients emotional status for those in shock?
drugs as needed for anxiety
talk to the patient
privacy
call light within reach
if a patient recovers from shock, what do we usually recommend them ?
rehab and prevention from it happening again
lastly evaluation
- adequate tissue perfusion with restoration of normal or baseline bp
- normal organ function with no complications from hypoperfusion
- decreased fear and anxiety and increased psychologic comfort
When assessing a patient in shock, the nurse recognizes that the hemodynamics of shock include:
A. normal cardiac output in cardiogenic shock.
B. increase in central venous pressure in hypovolemic shock.
C. increase in systemic vascular resistance in all types of shock.
D. variations in cardiac output and decreased systemic vascular resistance in septic shock.
D. variations in cardiac output and decreased systemic vascular resistance in septic 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?
A. Decreased blood glucose levels
B. Increased serum sodium levels
C. Increased serum calcium levels
D. Increased serum potassium levels
D. Increased serum potassium levels
The nurse is caring for a patient in septic shock. Which hemodynamic change would the nurse expect?
A. Increased ejection fraction.
B. Increased mean arterial pressure.
C. Decreased central venous pressure.
D. Decreased systemic vascular resistance.
D. Decreased systemic vascular resistance..
