Shock and Multisystem Disorders Flashcards
All Shock States
-Shock defined
Failure of the circulatory system to maintain adequate perfusion of vital organs
-HYPOVOLEMIC- blood volume issue
-CARDIOGENIC- heart not functioning
-DISTRIBUTIVE- vascular tone issue
-Tone is the degree of constriction of smooth muscles in the arterioles
Systemic Effects of Shock- Every System
- Respiratory failure 1st system affected
- Respiratory Acid-Base Imbalance
- –Respiratory alkalosis- early stages, ↑ resp rate
- –Respiratory acidosis- as lungs fail, ATP produced anaerobically causing lactic acid buildup
- –Metabolic acidosis- as more systems involved
- Cellular destruction by lysosomal enzymes- released from dead/dying cells
- DIC-disseminated intravascular coagulation (widespread intravascular micro clotting)
Systemic Effects of Shock
-Hypotension begins the vascular process
massive vasodilation from distributive or cardic shock
or fluid losses from hypovolemic shock
-Vasoconstriction-increased afterload, compensatory response
-Catecholamines-increased sympathetic response ( HR, anxiety, irritability, tremors)
-Histamine-vasodilation
-Endocrine Response-stress response, ↑ aldosterone, causing sodium & fluid retention to compensate for hypotension
Sympathetic Nervous System Response
- B/P and HR increase
- Respiratory efficiency increases
- Bronchi dilate and respiratory rate increases
- Pupils dilate
- Piloerection
- Blood diverted from GI and other organs
- Increased glucose levels
- Increased TSH levels, increased metabolism
- Sweating
- ALL help provide energy needed for fight or flight
Parasympathetic Nervous System Response
GI motility and nutrient absorption
HR to rest the heart
Constriction of bronchi, secretions
Relaxed GI and urinary sphincters- evacuation of waste
Pupil constriction, decreasing retinal stimulation
Systemic Effects of Shock
-Metabolic Response-catabolism, high
nutritional demands, but can we feed them?
-Neurologic Response-confusion, coma, late response-brain is last to fail
-Immune System-more susceptible to infection, impaired immune response if instigating problem not resolved
-GI Response-perfusion is impaired, can cause ISCHEMIA, very important concept
Systemic Effects of Shock
- Renal System-after lungs, kidneys are next to go
- Require high, oxygenated blood flow
- Which labs do we monitor for?
- BUN, Creatinine
- Normal BUN= 7-20 mg/dL
- Normal Creatinine= 0.6-1.2 mg/dL
Compensation in Shock
-Stimulation of the sympathetic system- stress response
-ADH is released
-Renin-angiotension system is initiated
-Role of ADH and aldosterone
-This is all done to restore oxygenation by:
Augmenting cardiac output
Redistributing blood flow
Restoring blood volume
Medical Goals in Shock
- Correct the Cause (trauma, allergic reaction, PE, MI?)
- Restore perfusion of organs, blood flow
- Vent support for oxygenation
- Administer Vasoactive Medications
- Vasoconstrictors (Dopamine, Epinehprine)
- Vasodilators (Nipride, Nitroglycerin)
- Maximize Circulation
- Mast pants, IABP, MODIFIED TRENDELENBERG- trunk flat, legs elevated
- IABP-Intra aortic balloon pump- inflates during dyastole and deflates during systole to increase coronary blood flow, reducing afterload, allowing heart to empty and increase Cardiac Output
Medical Goals in Shock Cont:
- Replace fluids-stay tuned
- Prevent GI Bleeding
- Maintain circulation, feeding if possible, protect the mucosa
- NG feeding
- H2 blockers, antacids
- Antibiotics
- Cultures
- Are not given empirically anymore
IV Fluid Administration
- Cystalloids-isotonic- (0.9 NACL)
- Colloids-proteins like albumin, pulls fluid into the vascular space
- Blood transfusion-volume AND osmotic pressure
- Autotransfusion
- Evaluate Fluid Replacement-monitor I/O, lung sounds, VS, central pressures
- If kidney failure- extreme care with fluid replacement
Other Meds:
- Low-molecular weight anticoagulants (heparin, lovenox, fragmin)
- Steroids- edema in spinal cord, watch for GI bleeding, blood sugars
- H2 blockers (like Zantac, Pepcid)
- Opioids- can cause vasodilation (only Morphine)
- Narcan (Nalaxone)- endorphin effect on capillary vasodilation (hypotension)
- Heart Meds (Digoxin, antiarrhythmics) to regulate heart rate and decrease cardiac irritability
Nursing Management/ Respiratory
- Impaired Gas Exchange/Ineffective Airway Clearance
- Improve/maintain oxygenation
- Ventilation
- ABGs, oxygen saturation
- Lung sounds
- Positioning- trendelenburg
- Pain management
- Chest x-rays
- Goal: oxygenation maintained aeb: normal ABGs, normal SaO2, lungs clear, Resp. rate 12-20 (may be on ventilator)
Nursing Managment/ Cardiac
- Alteration in tissue Perfusion/Decreased Cardiac Output
- Maintain tissue perfusion/cardiac output
- Monitor VS
- Monitor UO (>30 ml/hr)
- Assess peripheral perfusion
- Temperature
- Opioids with caution for pain if hypotensive- cause vasodilation
Nursing Management: Alteration in Tissue Perfusion/Decreased Cardiac Output
- Fluids- titrate carefully
- Vasoconstrictors/vasodilators
- Cardiac monitoring
- Hemodynamic monitoring (cardiac output, CVP, Blood pressure)
- Monitor H/H
- Goal: Perfusion maintained aeb UO wnl, vs wnl, labs wnl, cardiac parameters wnl, peripheral pulses palpable
Nursing Management/ Psychosocial
- Interrupted Family Processes
- Allow family visitation
- Emotional support of patient/family
- Don’t let technology get in the way
- Allow family to bring in pictures, personal items
- Encourage family to speak with loved one
- Describe technology
- Be a patient/family advocate
- Goal: Improved family processes aeb: family is trusting, cooperative, asks questions appropriately
Hypovolemic Shock
-Vascular space has increased in proportion to fluid volume
-Decreased
stroke volume (blood from one ventricle)
cardiac output (stroke volume X heart
rate)
BP
renal blood flow
organ perfusion
Hypovolemic Shock: Fluid Losses
- Hemorrhage- Blood Loss
- Dehydration
- Burns- Plasma Loss
- Persistent vomitting/diarrhea
- Third Spacing- plasma loss
Hypovolemic Shock: Clinical Findings
- Hypotension
- Tachycardia
- Decreased Urine output
- Central Pressures reduced
- —-central venous pressure
- —–Pulmonary capillary venous pressure
- Cardiac Output reduced
Treatment of Hypovolemic Shock
-Optimize oxygen Delivery/Reduce Fluid losses
-Oxygen administration
-Fluid resuscitation
-Positive inotropes
—–Dobutamine, Dopamine
-Vasopressors- constrictors
——Epinephrine, Neosynephrine,Levophed
Vasodilators
——Nipride, Nitroglycerin
Positioning (Modified trendelenberg?)
MAINTAIN PRELOAD (what is that again?)
Fluid Administration-Hypovolemic
-Fluid Volume Deficit
-Colloids
-PRBCs
-Blood products: FFP, platelets, cryoprecipitate
-Warmed solutions
- Monitor preload through CVP, PCWP
CVP=central venous pressure (0-5 mmHg)- measures volume (preload)
I-f too high need to reduce fluid infusions
PCWP=pulmonary capillary wedge pressure (8-12 mmHg)- measures pressure (afterload)
-Monitor fluid balance: UO, I/O, weight, lytes
Goal=patient is normovolemic aeb VSS, I/0 balanced, UO wnl, weight wnl, e-lytes wnl
Cardiogenic Shock
- Inability of the heart muscle to function to provide adequate blood flow to the systemic circuit (rest of the body)
- Usually from cardiac muscle damage
- —–Gunshot wound
- ——MI- dead heart muscle
- ——Infection
Cardiogenic Shock- Causes
- MI
- Heart failure (CHF)
- Pulmonary Embolus
- Pericardial Tamponade
- Tension Pneumothorax
- Cardiomyopathy (enlarged, thick, rigid muscle)
- Ventricular rupture
- Papillary rupture-ventricular muscle
Cardiogenic Shock
- Fluid overload is a problem (elevated CVP, PCWP)
- Cardiac Output is low (normal 4-8 L/min)
- Afterload is a problem (even with low blood pressure) because pump has failed
- Pulmonary congestion as fluid backs up from the heart to the lungs
- Organ perfusion is decreased
- Alteration in LOC- ↓ blood flow to brain
- Decreased urine output due to decreased kidney perfusion
Cardiogenic Shock
- Goal: improve myocardial oxygen demand, reduce myocardial workload
- Optimize oxygen delivery- Monitor oxygenation
- Hemodynamic monitoring
- Inotropes esp. Dobutamine
- Vasoconstrictors/vasopressors
- Diuretics
- Medical intervention (CABG, Thrombolytic agents)
- Intra-aortic balloon pump
- AFTERLOAD REDUCTION
Distributive Shock (Vasogenic)
- Changes in blood vessel tone that increase the size of the vascular space without an increase in the circulating volume
- RELATIVE HYPOVOLEMIA
- Fluid volume is the same with redistribution
Types of Distributive Shock
- Neurogenic Shock-nervous system control of blood vessels is lost due to spinal injury (esp. cervical), vasovagal reactions, spinal anesthesia
- —–Parasympathetic is unopposed-vasodilation, hypotension
- Septic Shock- massive vasodilation due to toxins from bacteria
- Anaphylactic Shock- hypersensitivity reaction (antigen-antibody) causing massive vasodilation
Multi-organ Dysfunction Syndrome (MODS):
- 2 or more organs fail
- “Presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without interventions.”
- American College of Chest Physicians and Society of Critical Care Medicine
MODS
- Two or more organ systems are affected
- Less than 50% have patients have a positive blood culture
- Primary MODS-initial insult (trauma, inadequate resuscitation, aspiration)
- Secondary MODS-secondary complications (MI, sepsis, shock, ARDS)
- Mortality rate is high (90%)
MODS
- Massive systemic inflammation
- —-Mediated by complement, histamine, tumor necrosis factor, etc.
- —-Cause systemic flooding of cells- neutrophils, lymphocytes, etc
- Tissue hypoxia
- Cellular death (apoptosis)
- Microvascular coagulopathy (DIC)
Inflammatory Response
- Tissue injury causes activation of Hageman factor (factor XII):
- Kinin- causes local vasodilation bring blood and leukocytes to the site, stimulates local nerve endings alerting body of injury
- Histamine- cell membrane injury caused release, causing vasodilation, more cells, alters capillary permeability to bring neutrophils in
- Chemotaxis- ability to attract neutrophils
MODS: Organ Failure
- Mortality rate increases 15-20% with each failed organ
- ARDS- Lungs are first organ affected
- —Sepsis, pancreatitis, hypertransfusion, aspiration, abdominal trauma and multiple fractures
- Renal failure (MR 10%)
- Liver Failure (MR 90-100%)
- CNS Failure (brain microabscesses, cerebral edema)
- Cardiac Failure (last system to go)
MODS
- Gastrointestinal system
- —Gut ischemia allows translocation of bacteria, chemical mediators and endotoxins to enter peritoneal cavity and portal circulation and exacerbates MODS
- ENTERAL FEEDING prevents this!
Nursing Managment of MODS
- Restore and maintain oxygenation
- Metabolic support (feeding within 48-96 hours of critical illness/insult)
- Source Control (stabilize fractures, treat infection, control hemorrhage, etc)
- EARLY RECOGNITION AND TREATMENT
Transplantation
-Historical perspective
-Blood transfusions 17th century
-Tooth transplant 18th century
1954-1st kidney transplant
1963-1st lung transplantation
1963-1st liver transplant
1967-1st human heart transplant
From United Network for Organ Sharing (UNOS):
Transplants Jan 1988 – Jan 2011 509,448 Transplants nationally Jan 11-Jan 12= 2,263 Transplants in Ohio 2011 = 95 Transplants in Michigan 2011= 66
Waiting list candidates
113,822 as of 4/16/12
Transplantation
- Regulated by UNOS (United Network of Organ Sharing)
- Cost- hundreds of thousands of dollars
- Shortage of Donors
- Ethical considerations
- —-Definition of death, buying and selling organs, prisoners as donors, cadaveric transplantation, xenotransplantation (animal to human)
What is Death?
- Irreversible cessation of circulatory and respiratory functioning
OR - Irreversible cessation of all functions of the entire brain, including the brain stem
Who Gets a New Organ?
- Referral for end-stage organ disease (liver, kidney, pancreas, heart, lungs)
- Considerations
- —Medically necessary
- —Risk factors
- —Surgical feasability
- —Psychosocial feasability
- —Immunologic status
Listing for Tranplantation
- Criteria based on urgency, height, weight, blood type
- Donors carry a beeper
- Hospitalized if too ill (higher priority)
- Waiting
- –Altered lifestyle
- –Financial strain
- –Helplessness
Organ Donation
- Living donors
- Confidentiality
- Many regulating organizations
- –Uniform Anatomical Gift Act, 1968
- ——Driver’s license designation as donor
- –National Transplant Act, 1984
- ——Registry, illegal to buy and sell organs
- –United Network of Organ Sharing
- ——Under guidance of US Dept of Health & Human Services
Nurses Role in Donation
- Early identification of donors (in ICU)
- Is the patient a suitable donor (infection, patient wishes, family wishes)
- Determining brain death
- Careful medical management of potential donors to maintain organ efficiency
Contraindications to Transplantation:
- Active infection
- HIV/AIDS
- Malignant disease- some exceptions
- Active substance abuse
- MODS
- Severe psychiatric disease
- Previous non-compliance
- Lack of social supports
- Lack of sufficient financial resources
Postoperative Care
- Normal post-op complications including pneumonia, DVT, wound infection
- Immunosuppression for the rest of their lives (trade one disease process for another)
- Risk of rejection!
Rejection
- Acute Rejection-occurs within the first 3 months
- Chronic Rejection-occurs 3 months after transplantation, results in progressive loss of graft function
- —–Infection-leading cause of morbidity and mortality
- —–Malignancy
- ————–Basal cell and squamous cell skin cancers
- ————-Cancer of vulva, perineum, lungs – highly lymphatic
Signs/Symptoms of Rejection Graft VS Host
-Fever
-Fatigue
-SOB
-Graft tenderness
–Labs
Kidney (increased creatinine)
Liver (increased serum bilirubin, liver enzymes)
Pancreas (increased urine amylase)
Heart (Two p waves, high resting heart rate)
Types of Transplantations
- Bone, muscle, corneas
- Pancreas
- Pancreas-Kidney
- Heart
- Lung
- Heart-Lung
- Liver
- Intestine
Nursing Diagnoses
- Risk for Infection #1
- Risk for Injury (rejection)
- Knowledge Deficit (meds, dialysis, treatments)
- Ineffective Coping
- Risk for Imbalanced Nutrition r/t side effects of steroids, increased metabolic needs
Self- Care
- Meds-many and complex regime
- Follow-up
- Post-transplantation biopsies
- Know the signs/symptoms of rejection
- Home health care needs
- Maintain health with dentist, pap smears, routine screenings (PSA)
- Psychosocial issues
- Quality of life
