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Complex DMR > Shock > Flashcards

Shock Flashcards

1
Q

What is shock

A

Inadequate circulating oxygen to meet metabolic demands

Imbalance between cellular oxygen supply and demand

Lead to Tissue hypoxia

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2
Q

Initiation phase of shock

A

Subclinical Hypoperfusion. There is inadequate DELIVERY

of O2 to the cells

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3
Q

Compensatory stage

A

Initiation of compensatory mechanisms

to maintain blood flow to vital organs

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4
Q

Progressive stage what happens

A 
Compensatory measures begin to fail;
vasoconstriction and shunting of blood,
peripheral ischemia, lactic acidosis,
electrolyte imbalances, respiratory
acidosis
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5
Q

Refractory stage

A

Irreversible; loss of aerobic metabolism,

inefficient anaerobic metabolism, multisystem failure

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6
Q

What happens in Neural compensation

A

Baroreceptors in carotid sinus and aortic bodies sensitive to
changes in pressure
• Stimulation of SNS

• Release of catecholamines
– Increased heart rate
– Increased contractility
– Systemic vasoconstriction
     \+Increased BP  
     \+Redistribution of blood flow
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7
Q

What happens in Endocrine compensation

A

RAAS
Stimulation of anterior pituitary gland->
Adrenal cortex

• Glucocorticoids
– Increase circulating glucose levels

• Mineralocorticoid (Aldosterone)
– Increase circulating volume

►Stimulation of posterior pituitary gland
• ADH

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8
Q

What happens in Chemical compensation

A 
Chemoreceptors in carotid and aortic bodies react to low oxygen
tension
• Respiratory rate and depth increase
– Increased oxygenation
• Respiratory alkalosis occurs
– Constriction of carotid arteries
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9
Q

What happens to the body in the progressive stage

A

Compensatory mechanisms not reversing shock
• Systemic vasoconstriction/shunting of blood to vital organs
– Peripheral ischemia
• Failure of the sodium potassium pump
– Electrolyte Imbalances
• Metabolic/Respiratory acidosis

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10
Q

What happens to the body in the refractory stage

A 
►Prolonged hypoperfusion
►Loss of aerobic metabolism
►Cell death
►Multiple organ dysfunction
►Death
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11
Q

Causes of Hypovolemic shock

A 
External loss 
-Hemorrhage
– Trauma/GI bleeds
• Excessive urination
• Burns
• GI tract
– Vomiting
– Diarrhea

Internal loss
• Internal hemorrhage
– Fractures
– Ruptured aneurysms

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12
Q

Treatment for hypovolemic shock

A

Fluid resuscitation

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13
Q

Hypovolemic shock
CVP/PAOP/PAWP
CO
SVR

A

dec dec inc

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14
Q

Cardiogenic shock
CVP/PAOP/PAWP
CO
SVR

A

Inc dec inc

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15
Q

Obstructive shock causes for Impaired ventricular filling

A

Tension pneumothorax

Cardiac tamponade

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16
Q

Obstructive shock causes for Impaired ventricular emptying

A

• Increased Pulmonary Vascular Resistance (PVR)
– MASSIVE pulmonary embolism
• Increased Systemic Vascular Resistance (SVR)
– Severe valvular disease

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17
Q

Clinical manifestations of Obstructive shock

A 
Decreased cardiac output/impaired peripheral perfusion:
• Decreased level of consciousness
• Hypotension
• Tachycardia
• Tachypnea
• Decreased urine output
• Weak pulses, cold, cyanotic, and mottled skin
►Chest pain, SOB, N/V
►Muffled heart sounds
►R heart failure
• JVD
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18
Q

Obstructive shock
CVP/PAOP/PAWP
CO
SVR

A

Inc/dec
dec
inc

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19
Q

How do you treat obstructive shock

A 
O2 management 
Definitive treatment: 
• Tension pneumothorax – Needle decompression
• Cardiac tamponade - Pericardiocentesis 
MASSIVE pulmonary embolism –
– Anticoagulants/Thrombolytics-tPA
– CDT thrombolysis
– Suction thrombectomy
– Surgery- Pulmonary embolectomy
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20
Q

If obstructive shock is suspected, how would you assess

A 
►Neurological status
►Vital signs/Respiratory status
• SpO2/ABGs
►Hemodynamic parameters
• CO/Filling pressures/ScvO2
/SvO2
►Urine output
►Skin color and temperature
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21
Q

If obstructive shock what are your nursing actions

A

►Apply a 100% non-rebreather oxygen mask
►Prepare for intubation and mechanical ventilation
►Administer medications as ordered
• Vasoactive medications
• Anticoagulation via heparin administration
• Thrombolytic therapy
prep for definitive treatment

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22
Q

Distributive shock definition

A

A physiological problem that causes massive
vasodilation and poor vascular tone (decreased SVR,
increased vascular capacity, venous pooling) that creates a
RELATIVE hypovolemia.

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23
Q

Types of distributive shock

A

Neurogenic shock
anaphylactic shock
septic shock

24
Q

sepsis cause

A

A life-threatening organ dysfunction caused by a dysregulated host
response to infection

a life-threatening condition that arises when
the body’s response to an infection injures its own tissues and organs

25
Q

neurogenic shock definition/cause

A

Disruption of sympathetic nervous system resulting in poor vascular
tone/relative hypovolemia/unopposed parasympathetic stimulation

Upper spinal cord injury
– at or above T5
• Spinal anesthesia
• Neurological/brain injury

26
Q

Anaphylaxis (general) cause

A

Histamine release

27
Q

Clinical manifestation of Neurogenic shock

A 
VASODILATION
• Hypotension
• Decreased cardiac output
• Warm, dry skin
• Often accompanied by BRADYCARDIA
28
Q

Neurogenic shock

CVP, PAOP/PAWP CO SVR

A

Dec, dec, dec

29
Q

Anaphylactic shock cause (specific)

A

Severe systemic hypersensitivity reaction
Allergic reaction/antigen antibody reaction with a release of histamine resulting in:
Venous dilation
Increased capillary permeability
Smooth muscle contraction

30
Q

Anaphylactic shock symptoms

A

Hypotension, edema, respiratory distress.

there is rapid airway compromise/circulatory collapse

31
Q

Anaphylactic shock CVP, PAOP/PAWP CO SVR

A

Dec, dec, dec

32
Q

Anaphylactic Medical management

A

Epinephrine 0.3-0.5 mg IM - Promotes bronchodilation/vasoconstriction
Epinephrine .05 - 0.1mg slow IV push

Support airway & ventilation – 100% non-rebreather

Support circulation - IV Fluids

33
Q

Other medications for Anaphylactic shock

A

Methylprednisolone (Solu-Medrol)

Antihistamines - Diphenhydramine 25-50mg (Benadryl) IV or PO

Histamine blockers - Ranitidine (Zantac) or other H2 blockers

Racemic Epinephrine Inhaled for stridor

Bronchodilators - Albuterol

34
Q

Nursing assessments for anaphylactic shock

A

►Respiratory assessment
►Vital signs
►Skin assessment

35
Q

What should you do as the nurse if pt has anaphylactic shock

A

►Remove trigger immediately
►Epinephrine IM
►Apply oxygen via a 100% non-rebreather mask
►Insert an IV and administer IV fluid as ordered
►Administer medications as ordered

36
Q

Most common type of sepsis

A

Bacterial

37
Q

What happens during Septic shock (patho)

A

Response no longer localized Pro-inflammatory cytokines outnumber anti-inflammatory cytokines Overwhelming inflammation, profound vasodilation, increased capillary permeability, enhanced coagulation (microemboli)

Relative hypovolemia, hypotension, clotting

38
Q

SOFA & Value

A

Organ dysfunction identified via the Sequential Organ Failure
Assessment (SOFA): A higher SOFA score (>2) is associated with an
increased probability of mortality

39
Q

Sepsis manifestations

A

Persistent hypotension requiring vasopressors to maintain MAP ≥65
mm Hg and
Serum lactate level >2 mmol/L
Despite adequate volume resuscitation

40
Q 
Early Sepsis (WARM) Hint: HR
RR
BP
CO
SVR
Filling Pressures 
SvO2
Pulses
Skin appearance
Temp
UO
PACO2
WBC
A 
►HR> 100
►RR > 20
►BP normal or low
►Increased CO
►Decreased SVR
►Decreased filling
pressures
►Increased SvO2
►Bounding pulses
►Flushed
►Temp up
►Change in mental status
►Oliguria
►PaCO2 < 32 mmHg
►WBC > 12,000
41
Q 
Late Sepsis (Cold) Hint: HR
RR
BP
CO
SVR
Filling Pressures 
SvO2
Pulses
Skin appearance
Temp
UO
PACO2
WBC
A 
►HR>100
►RR up or down
►Hypotension
►Decreased CO
►SVR variable
►Filling pressures variable
►Decreased SvO2
►Weak pulses
►Cool, pale
►Temp down
►Decreased LOC
►Anuria
►Metabolic acidosis
►Decreased WB
42
Q

Preventing septic shock

A 
Management—Prevention
• Hand hygiene
• Aseptic technique
• Identification of patients at risk (e.g., mechanically ventilated
patients mouth care)
43
Q

Important after recognition of septic shock

A

Prompt recognition of infection
• Source control
• Antibiotic therapy based on culture results

44
Q

What must be done within one hour of septic shock recognition

A
  1. Measure lactate level
  2. Obtain blood cultures prior to administration of antibiotics
  3. Administer broad spectrum antibiotics
  4. Administer 30 ml/kg crystalloid for hypotension or lactate > 4mmol/L
  5. Apply vasopressors if hypotension continues during or after fluid
    resuscitation
45
Q

Lab values to check in septic shock

A 
Laboratory values
– SvO2
, ScvO2
– ABGs
– Metabolic profile
– Lactate/base deficit
46
Q

Nursing assessments in Septic shock

A
  • Neurological status
  • Vital signs/respiratory status
  • Hemodynamic readings
  • Hourly Urine output
  • Skin color and temperature
  • Bleeding
47
Q

Actions of nurse w/ septic patient

A

► Administer oxygen as ordered/Anticipate and prepare for intubation
► Administer fluid replacement as ordered
► Administer vasoactive drips such as norepinephrine as ordered
► Obtain two blood cultures from two different sites: urine, sputum, and wound
cultures
► Administer antibiotics as ordered after cultures are obtained
► Meticulous hand washing and aseptic technique with all procedures
► Mouth Care every 4 hours

48
Q

Early DIC

A

► Enhanced coagulation/thousands of small clots in capillaries leads to:
• Poor tissue perfusion
• Consumption of clotting factors

49
Q

Late DIC

A 
Late
► Excessive clot formation leads to:
• Stimulation of fibrinolysis – release of fibrin degradation products – potent
anticoagulants which leads to:
BLEEDING
50
Q

DIC lab values

A

►Platelets, protein C, antithrombin 3, fibrinogen – decreased
►Fibrin degradation products increased
►PT, PTT prolonged

51
Q

Medical management of DIC

A 
Volume replacement
• Crystalloids
• Blood products
►Supportive Care
• Maximize oxygenation
• Maintain BP
52
Q

DIC Nursing actions

A 
►Monitor vital signs
►Assess for bleeding/Avoid activities that may cause bleeding
►Monitor laboratory values
►Administer blood products as ordered
►Supportive care
53
Q

What happens in the body during MODS

A 
ARDS = 40% Mortality
AKI/CKD
Liver failure
CNS dysfunction
Heart failure
54
Q

Supportive care DIC

A 
►Supportive
• Maximize Oxygenation/Mechanical Ventilation
• Control Infection/Antibiotics
• Fluids/Blood Products
• Vasoactive Drips
55
Q

DIC Nursing management

A 
►Assessment!
• Respiratory
• Cardiovascular
• Neurological
• Renal
►Actions
• Provide care as ordered
• Supportive Care

Complex DMR (12 decks)

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