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410 Patho Exam 2 > Shock > Flashcards

Shock Flashcards

1
Q

What is the definition of shock?

A

Syndrome characterized by hypotension and decreased tissue perfusion leading to impaired cellular metabolism

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2
Q

shock results in the ?

A

resulting in an imbalance in supply/demand for oxygen and nutrients

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3
Q

when a patient is in shock, the decreased tissue perfusion and hypotension leads to the body to go into an ______metabolism

A

anaerobic

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4
Q

why is being in an anaerobic metabolic state really bad?

A

your body will secrete lactic acid -> making your body acidosis -> cellular death

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5
Q

she mentions how shock in smaller terms is just what?

A

not enough blood and oxygen getting to the tissues/body parts that need it

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6
Q

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?

A

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 )

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7
Q

what is cardiac out?

A

heart rate x stroke volume
( how fast your heart is beating )
( how much of blood your ventricle pumps out )

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8
Q

what is blood pressure ?

A

cardiac output x systemaic vascular resistance

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9
Q

what is the 4 main categories of shock ?

A

cardiogenic
hypovolemic
distributie
obstructive

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10
Q

what are the 2 hypovolemic shocks that we are going to need to know ?

A

absolute ( hemorrhagic )
relative ( non-hemorrhagic )

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11
Q

what are the 3 distributive shocks we are going to need to know ?

A

neurogenic
anaphylactic
septic

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12
Q

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

A

cardiogenic

hypovolemic
- absolute ( hemorrhagic )
- relative (non-hemorrhagic)

distributive
- neurogenic
- anaphylactic
- septic

obstructive

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13
Q

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?

A

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

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14
Q

what is the definition of cardiogenic shock?

A
  • 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

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15
Q

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

A

myocardial infarction ( heart attack )

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16
Q

cardiogenic shock presentation
the following terms, I want you to say which symptom will be happening

cardiovascular
respiratory
renal
skin
neuro
gi

A

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

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17
Q

how does hypovolemic shock occur?

A

inadequate fluid volume in the intravascular space to support adequate perfusion

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18
Q

what are the 2 hypovolemic shock ?

A

absolute hypovolemia (hemorrhagic)
relative hypovolemia(non-hemorrhagic)

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19
Q

what is absolute hypovolemia
(hemorrhagic)?

A

loss of intravascular fluid

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20
Q

what are some examples or causes to patients who end up having absolute hypovolemia shock ?

A

hemorrhage
gi loss ( vomit, diarrhea )
diabetes insipidus
hyperglycemia
diuresis

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21
Q

what is relative (nonhemorrhagic ) hypovolemia shock ?

A

shift of fluid out of vascular space into extravascular space ( third spacing )

usually due to increased capillary permeability

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22
Q

what are some examples of causes that can cause a patient to go into a relative hypovolemia shock ?

A

burns
sepsis
pulmonary edema

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23
Q

how does hypovolemic shock presentation itself in patients ?

cardiovascular
respiratory !! Late what?
renal
skin
neuro
gi

A

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

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24
Q

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 ____

A

30%
30%
blood products

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25
Q

what is neurogenic shock for the distributive shock section ?

A

occur within 30 minutes of a spinal cord injury or spinal anesthesia at the T5 vertebra or above and last up to 6 weeks

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26
Q

the 3 main consequences patients will experience after being in a neurogenic shock is ?

A

hypotension ( massive vasodilation )

bradycardia ( unopposed parasympathetic stimulation )

poikiothermia ( unable to keep warm or cool, the body becomes at room temp )

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27
Q

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

A

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

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28
Q

what is anaphylactic shock for distributive shock?

A

an acute and life threatening hypersensitive ( allergic ) reaction

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29
Q

what are some causes for patients to end up in an anaphylactic shock ?
dont overthink it

A

drugs
chemicals
vaccines
food
insect venom

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30
Q

what are the 3 immediate reactions that occur when patients are in an anaphylactic shock ?

A

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

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31
Q

how does anaphylactic shock presentation itself in patients ?

cardiovascular
respiratory !!
renal
skin !!
neuro
gi

A

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

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32
Q

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 ?

A

because your allergic reaction to it the next time might become even worse

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33
Q

what is septic shock for distributive shock?

A

presence of sepsis with hypotension despite adequate fluid resuscitation along with the presence of inadequate tissue perfusion

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34
Q

septic shock has 3 major pathophysiologic effects, which are ?

A

vasodilation
maldistribution of blood flow
myocardial dysfunction
( inflammation ^ )

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35
Q

how does septic shock presentation itself in patients ?

cardiovascular
respiratory
renal
skin !!
neuro !!
gi
heme !!

A

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 )

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36
Q

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 ?

A

they might not present with a fever, so its crucial to perform will assessments on these patients

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37
Q

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.

A

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

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38
Q

what is obstructive shock ?

A

develops the physical obstruction to blood flow occurs with decreased cardiac output

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39
Q

how is obstructive shock caused by ?

A

restricted diastolic filling of right ventricle from compression

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40
Q

what is the syndrome that can cause obstructive shock?

A

abdominal compartment syndrome

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41
Q

what is abdominal compartment syndrome ?

A

abdominal pressure compresses inferior vena cava

usually surgery after an aneurysm

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42
Q

how does obstructive shock presentation itself in patients ?

cardiovascular
respiratory
renal
skin
neuro
gi

A

tachycardia
tachypnea, shortness of breath
decreased urine output
pale, cool, clammy
decreased cereal perfusion, agitation
decreased bowel sounds, absent bowel sounds

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43
Q

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 =

A

neurogenic
bradycardia
polikoemia

anaphylactic
angioedema, stridor, wheezing
hives, angioedema, itching

warm, flushed skin, fever type
DIC, clotting and bleeding at the same time

44
Q

there are 4 stages of shock, no matter the shock type, which are?

A

initial
compensatory
progressive
refractory

45
Q

what is the initial stage of shock?

A

occurs at a cellular level, usually not clinically apparent

46
Q

what is happening at in initial, cellular level of shock?

A

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

47
Q

what is the compensatory stage of shock?

A

clinically apparent and involves neural, hormonal and biochemical compensatory mechanism to try to overcome the increasing consequence of anaerobic metabolism and to maintain homestasis

48
Q

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????????

A

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

49
Q

if your patient has decreased blood flow to the gut causing peristalsis
what is an intervention we can do ? (2)

A

early/slow feeding (enteral feedings)
PPI - stress ulcer prevention

50
Q

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 ?

A

BUN and Creatinine

hourly/frequent urinary output

51
Q

what is the progressive stage of shock?

A

begins as compensatory mechanisms fail and aggressive interventions are needed to prevent the development of MODS

52
Q

what is the patho behind the progressive stage of shock ?

A

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

53
Q

what is the refractory stage?

A

honestly its just mods from what she says, so everything has failed and recovery is unlikely

54
Q

what are some diagnostic studies for shock ?

note
just know some are more specific because of the type of shock

A

blood studies
12-lead
chest x-ray
continues pulse ox
hemodynamic monitoring

55
Q

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

A
56
Q

why are we going to be giving patients who go into shock oxygen and ventilation ?

A

optimize cardiac output
transporting fluid

57
Q

patients who are experiencing, septic, hypovolemia and anaphylactic shock are going to need what ?

A

volume expansion

58
Q

how are we going to help with volume expansion ?
(3)

A

1-2 large bore iv

isotonic crystalloids ( normal saline, lactated ringers )

Rbcs for those who lost volume due to bleeding ( blood transfusions )

59
Q

how do you know if your patient is responding to fluid resusitation?
dont over think it

A

better vital signs
3 sec capillary refill
improvement in mental staus
pink and warm skin

60
Q

what are the 2 major complications of large volumes of fluid that patients may experience when receiving fluid resusitation?

A

hypotermia
coagulopathy

61
Q

why do patients end up getting hypothermia when receiving large amounts of fluids ?

and how can we fix this ?

A

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

62
Q

why do patients end up getting coagulopathy after receiving a lot of fluids with blood transfusions?

how do we fix this ?

A

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

63
Q

what Is the first line of treatment of shock ?

A

fluid resuscitation
1 or 2 bags of fluids

64
Q

what is the next step if fluid resusisctation doesn’t work ?

A

vasopressors
- increase blood pressure to help keep the fluid where it alongs and hopes to circulate the fluid better

65
Q

what are some examples of vasopressors we may give to our patients ?

A

norepinephrine, dopamine, phenyelphrine

66
Q

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 ?

A

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

67
Q

when, how, why do we start feeding patients with shock ?

A

within the firs 24 hours
with slow enteral feedings
in hopes to prevent gi bleeding,uclers, and keep their calories up

68
Q

interprofessional care are the following flashcards

A
69
Q

what is the overall goal for cardiogenic shock ?

A

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

restore cardiac function

70
Q

what are the definitive measure we are going to need to do for patients who are in cardiogenic shock ? (3)

A

angioplasty with stenting
emergency revasculzaization
valve replacement

71
Q

cardiogenic shock interprofressional care involves what types of drug therapy ?

A

beta blockers reduce hr
vasodilators - hypotensive
diuretics - remove fluids
nitrates to help dilate

72
Q

we may need to give patients who are in cardiogenic shock what type of circulatory assiated devices?

A

intraaortic balloon pump
( helps you push blood )
ventricular assist device
( works everything for you pretty much )

73
Q

lastly if the drug therapy, the circulatory assisted device dont help patients with cardiogenic shock. what is the last resort?

A

heart transplant

74
Q

what is the main goal or focus of hypovolemic shock?

A

cousins on stopping loss of fluid and restoring the circulating volume

75
Q

fluid resuscitation is calculated using what to help hypovolemic shock?

A

3:1 rule
( 3ml of isotonic crystalloid for every 1 mL of estimated blood loss )

76
Q

what is the best way to figure out how much fluid or blood a patient has lost?

A

weigh the pads of fluids or blood and follow the 3:1 rule after that

77
Q

what are the interprofessional care for septic shock ? (5)

A

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

78
Q

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?

A

corticosteroids

79
Q

when a patient is septic, we understand their is an infection causing this, however before we give an antibiotics, what must we get first?

A

blood culture

80
Q

why do we get a blood culture first?

A

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

81
Q

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?

A

broad spectrum antibiotics
then go to a
narrow spectrum antibiotics

82
Q

what is the interprofressional care for neurogenic shock ?

A

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

83
Q

while keeping the spine stable, we must treat their massive hypotension and bradycardia for neurogenic patients, with what 2 medications ?

A

vasopressors
atropine ( increases heart rate )

84
Q

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?

A

hypothermia because they can not control their body temp due to the spinal cord injury

85
Q

what is the interprofessional care for anaphylactic shock?
(3)

A

epinephrine - allergy reaction
diphenhydramine ( benedrayl ) - blocking histamines
h2 ( histamine 2) blockers - famotadine

86
Q

why are we giving diphenhydramine ( bendrayl ) and h2 blockers to patients who are in anaphylactic shock ?

A

because both these medications are helping get rid of all the histamines being activated in the body

87
Q

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?

A

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

88
Q

primary strategy is early recognition and treatment to relieve obstruction for obstructive shock, what might we give a patient to help with this ?

A

mechanical decompression
thrombolytic therapy
radiation
decompresive laparotomy

89
Q

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

A
90
Q

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

A
91
Q

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

A
92
Q

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

A
93
Q

how are we going to assess a patients neurologic status for those in shock?

A

orientation
level of consciousness
reducing noise and light levels
keep a day and night cycle

93
Q

the following flashcards are how we are going to assess a patient for each system

A
94
Q

how are we going to assess a patients cardiovascular status for those in shock?

A

continues EKG, BP, CVP, CO,
dysrhythmias
heart sounds
prescribed fluid and drug therapy

95
Q

VERY IMPORTANT TO NOTE
DO NOT TREAT HYPOTENSION WITH WHAT ?

A

Trendelenburg position

96
Q

how are we going to assess a patients respiratory status for those in shock?

A

respiratory rate
breath sounds
continuous pulse oximetry
arterial blood gases
mechanical ventilation

97
Q

how are we going to assess a patients renal status for those in shock?

A

urine output
I and o
serum creatinine

98
Q

how are we going to assess a patients skin status for those in shock?

A

temperature
pallor ?
flushing?
cyanosis ?
diaphoresis ?

99
Q

how are we going to assess a patients gi status for those in shock?

A

occult blood
asucualte bowel sounds

100
Q

how are we going to assess a patients personal hygiene status for those in shock?

A

perform bathing
turning every 1-2 hours
passive and active range of motion
oral care

101
Q

how are we going to assess a patients emotional status for those in shock?

A

drugs as needed for anxiety
talk to the patient
privacy
call light within reach

102
Q

if a patient recovers from shock, what do we usually recommend them ?

A

rehab and prevention from it happening again

103
Q

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

A
104
Q

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.

A

D. variations in cardiac output and decreased systemic vascular resistance in septic shock.

105
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?

A. Decreased blood glucose levels
B. Increased serum sodium levels
C. Increased serum calcium levels
D. Increased serum potassium levels

A

D. Increased serum potassium levels

106
Q

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.

A

D. Decreased systemic vascular resistance..

410 Patho Exam 2 (7 decks)

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