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Adult Health II > Shock and Multisystem Disorders > Flashcards

Shock and Multisystem Disorders Flashcards

1
Q

All Shock States

A

-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

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2
Q

Systemic Effects of Shock- Every System

A
  • 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)
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3
Q

Systemic Effects of Shock

A

-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

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4
Q

Sympathetic Nervous System Response

A
  • 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
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5
Q

Parasympathetic Nervous System Response

A

 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

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6
Q

Systemic Effects of Shock

A

-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

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7
Q

Systemic Effects of Shock

A
  • 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
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8
Q

Compensation in Shock

A

-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

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9
Q

Medical Goals in Shock

A
  • 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
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10
Q

Medical Goals in Shock Cont:

A
  • 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
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11
Q

IV Fluid Administration

A
  • 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
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12
Q

Other Meds:

A
  • 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
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13
Q

Nursing Management/ Respiratory

A
  • 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)
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14
Q

Nursing Managment/ Cardiac

A
  • 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
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15
Q

Nursing Management: Alteration in Tissue Perfusion/Decreased Cardiac Output

A
  • 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
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16
Q

Nursing Management/ Psychosocial

A
  • 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
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17
Q

Hypovolemic Shock

A

-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

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18
Q

Hypovolemic Shock: Fluid Losses

A
  • Hemorrhage- Blood Loss
  • Dehydration
  • Burns- Plasma Loss
  • Persistent vomitting/diarrhea
  • Third Spacing- plasma loss
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19
Q

Hypovolemic Shock: Clinical Findings

A
  • Hypotension
  • Tachycardia
  • Decreased Urine output
  • Central Pressures reduced
  • —-central venous pressure
  • —–Pulmonary capillary venous pressure
  • Cardiac Output reduced
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20
Q

Treatment of Hypovolemic Shock

A

-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?)

21
Q

Fluid Administration-Hypovolemic

A

-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

22
Q

Cardiogenic Shock

A
  • 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
23
Q

Cardiogenic Shock- Causes

A
  • MI
  • Heart failure (CHF)
  • Pulmonary Embolus
  • Pericardial Tamponade
  • Tension Pneumothorax
  • Cardiomyopathy (enlarged, thick, rigid muscle)
  • Ventricular rupture
  • Papillary rupture-ventricular muscle
24
Q

Cardiogenic Shock

A
  • 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
25
Q

Cardiogenic Shock

A
  • 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
26
Q

Distributive Shock (Vasogenic)

A
  • 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
27
Q

Types of Distributive Shock

A
  • 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
28
Q

Multi-organ Dysfunction Syndrome (MODS):

A
  • 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
29
Q

MODS

A
  • 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%)
30
Q

MODS

A
  • 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)
31
Q

Inflammatory Response

A
  • 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
32
Q

MODS: Organ Failure

A
  • 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)
33
Q

MODS

A
  • 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!
34
Q

Nursing Managment of MODS

A
  • 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
35
Q

Transplantation

A

-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

36
Q

From United Network for Organ Sharing (UNOS):

A 
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

37
Q

Transplantation

A
  • 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)
38
Q

What is Death?

A
  • Irreversible cessation of circulatory and respiratory functioning
    OR
  • Irreversible cessation of all functions of the entire brain, including the brain stem
39
Q

Who Gets a New Organ?

A
  • Referral for end-stage organ disease (liver, kidney, pancreas, heart, lungs)
  • Considerations
  • —Medically necessary
  • —Risk factors
  • —Surgical feasability
  • —Psychosocial feasability
  • —Immunologic status
40
Q

Listing for Tranplantation

A
  • Criteria based on urgency, height, weight, blood type
  • Donors carry a beeper
  • Hospitalized if too ill (higher priority)
  • Waiting
  • –Altered lifestyle
  • –Financial strain
  • –Helplessness
41
Q

Organ Donation

A
  • 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
42
Q

Nurses Role in Donation

A
  • 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
43
Q

Contraindications to Transplantation:

A
  • 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
44
Q

Postoperative Care

A
  • 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!
45
Q

Rejection

A
  • 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
46
Q

Signs/Symptoms of Rejection Graft VS Host

A

-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)

47
Q

Types of Transplantations

A
  • Bone, muscle, corneas
  • Pancreas
  • Pancreas-Kidney
  • Heart
  • Lung
  • Heart-Lung
  • Liver
  • Intestine
48
Q

Nursing Diagnoses

A
  • 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
49
Q

Self- Care

A
  • 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

Adult Health II (7 decks)

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