stages of shock Flashcards
What are the stages of shock?
Initial insult
Compensatory
Progressive
irreversible/ refractory
how do you treat the initial stage of shock
fluid, oxygen, surgery once case is known
When must initial insult be treated for best outcomes?
Within 3 hours of identifying shock
What are the signs and symptoms of compensatory shock?
Normal BP
Vasoconstriction
Increased HR
Blood shunts from vital organs:
cool and pale skin
hypoactive bowel sounds
decreased urine output
Metabolic acidosis
Respiratory alkalosis
Anxious and confused
What does the nurse monitor for a patient for compensatory shock and why?
Vitals
Key indicators of hemodynamic status
What does BP indicate in a patient with compensatory shock?
Indirect measure of hypoxia
When should you notify the MD regarding vital sign changes?
If a patient has two or more of these while also having an infection/ suspected infection
RR more than 22
Altered mental status
Systolic BP less than 100 mmHg/ drop of 40 mmHg from baseline/ MAP less than 65
How do you measure pulse pressure?
SBP-DBP
What is a normal pulse pressure?
40 mmHg
What is the correlation between pulse pressure and stroke volume?
Narrowing pulse pressure indicates decreased stroke volume
How is continuous central venous oximetry (SvcO2) obtained?
Central catheter in the superior vena cava
What is a normal SvcO2?
70%
What is the relationship between shock and ScvO2?
In shock more oxygen is consumed →lowered ScvO2
What are the nursing interventions for compensatory shock?
Identifying the cause of shock
IV fluids
Oxygenation
Obtaining lab tests
Pain control
Sedating agents when needed
Reducing anxiety
Promoting safety
What is the BP of someone with progressive shock?
BP is not compensating
Systolic less than 100 mmHg or a decrease of systolic BP of 40 mmHg from baseline
What are the cardiovascular effects in the progressive state?
HR >150 BPM
Failure of cardiac pump
Possible MI
Levels of cardiac biomarkers increase
What are the respiratory effects in the progressive state?
Rapid, shallow breathing
Crackles
Decreased pulmonary flow causes arterial oxygen to decrease and CO2 to increase
Hypoperfused alveoli stop making surfactant and collapse
Leakage of pulmonary capillaries leading to pulmonary edema, diffusion abnormalities (shunting), and additional alveolar collapse (acute lung injury)
ARDS
what are the neurological effects of progressive shock?
Subtle changes in behavior → Agitation → Confusion →Delirium → lethargy → loss of concentration
What are the renal effects in the progressive state?
AKI from not enough perfusion to kidneys
What are the liver effects of the progressive state of shock?
Not able to metabolize meds, ammonia, or lactic acid (metabolic waste products)
Increase infection (liver can’t filter blood bacteria
Jaundice due to elevated liver enzymes and bilirubin
What are the GI effects in the progressive state?
Stress ulcers → risk for GI bleeds
Bacterial translocation (from GI ischemia)
What are the hematological effects in the progressive state?
DIC: inflammatory cytokines activate the clotting cascade–widespread clotting and bleeding simultaneously
How do we manage the progressive stage of shock?
IV fluids and meds
Respiratory support (mechanical ventilation)
Optimize intravascular volume
Support pumping action of heart (intra-aortic balloon pump)
Improve competence of vascular system
Early enteral feeding
Glycemic control, medications to reduce risk of GI ulceration and bleeding
How do we prevent complications in progressive shock?
Monitor S/S of infection
Aseptic technique when suctioning and providing care
Oral care
Q2 turns
HOB at least 30 degrees
How do we promote rest and comfort for a patient in progressive shock?
Priority!
Conserve energy
Prevent temperature extremes (excessive cold → shivering → loss of energy)
Can’t warm too quickly → vasodilation leads to drop in BP
How do we prevent delirium in shock?
Assess once a shift
Frequent orientation activities
Assessing and treating pain
Promoting sleep
Providing early mobilization activities
Limiting sedation (especially with benzos like lorazepam/ativan)
What is the irreversible (refractory) stage of shock
Organ damage is so severe that treatment is futile
BP remains low
Renal and liver failure
- Release of necrotic tissue toxins
- Develop metabolic acidosis
What is the intervention of irreversible (refractory) stage of shock?
Offer brief explanations to the patient about what is happening
Essential even if we’re not certain they can hear or understand us
What are general management strategies of shock?
Respiratory support with supplemental oxygen and/or mechanical ventilation
Fluid replacement to restore intravascular volume
Vasoactive medications to restore vasomotor tone and improve cardiac function
Nutritional support to address the metabolic requirements that are so increased in shock
What is provided in all types of shock?
Fluid replacement/ resuscitation
Vasoactive medication
What happens if we give too little fluid in fluid resuscitation?
Higher incidence of morbidity and mortality from lack of tissue perfusion
What happens if we give excessive fluid in fluid resuscitation?
pulmonary edema
- Progressive and sudden → ARDS
Systemic
- Abdominal compartment syndrome → too much pressure in the abdomen and the abdominal wall cannot expand anymore
When should fluid resuscitation be initiated in shock?
Early!
What are examples crystalloid solutions for shock?
Electrolyte solutions
Commonly 0.9 sodium chloride (NS) or LR
Isotonic solution
Hypertonic solution
What are the disadvantages of isotonic solutions?
Diffuses into interstitial space
Doesn’t stay in vasculature for long
What is hypertonic solution for shock?
3% NaCl
For TBI patients to bring down ICP
What are colloid solutions?
Large molecule IV solutions
Too large to pass through the capillary membranes, pulls blood back into the vasculature
What is an example of a colloid IV solution?
Albumin (expensive)
What are examples of inotropic medications?
Dobutamine
Dopamine
Epinephrine
Milrinone
What are the pros and cons of inotropic medications
Pros: Increased contractility
Cons: Increased oxygen demand of the heart
What are examples of vasodilator medications?
Nitroglycerine
Nitroprusside
What are examples of vasopressors?
Norepinephrine
Dopamine
Epinephrine
Vasopressin
What are the pros and cons of vasopressors?
Pros: Increases blood pressure
Cons: Increases cardiac workload
What must the nurse do after the administration of vasoactive medications?
Monitor vital signs every 15 minutes until stable
Sometimes more often than 15
Where can vasoactive medications be given and why?
Through a central line
If not, causes tissue necrosis and sloughing
How do we stop giving vasoactive medications?
We taper and ween them slowly, titrate the dose! Don’t stop quickly
How many calories does someone with irreversible/refractory state of shock need?
More than 3000 calories a day
What type of muscle mass is broken down first in irreversible state of shock?
Skeletal
Hypermetabolic state
How and when should we initiate feedings in irreversible shock?
Early
Enteral feeding
