Unit 15 Shock Syndrome/AAA Flashcards
What is shock?
Life threatening imbalance between the supply of oxygen and tissue demand/ perfusion issue.
What are types of shock?
Low blood flow:
- Hypovolemic shock
- Cardiogenic shock
Maldistribution of blood: (poor distribution/circulation)
- Neurogenic shock
- Anaphylactic shock
- Septic shock
Obstructive shock:
- Pneumothorax
- Cardiac tamponad
What are stages of shock?
Initial decreased tissue perfusion
Compensated (pre-shock)
Uncompensated (shock)
Irreversible (multiple organ dysfunction)
What initially are the problems happening in shock?
What do these metabolic changes cause a buildup of?
Hypo-perfusion
Hyper-metabolism
Activation of inflammatory response (anaerobic metabolism)
They cause a build up of Lactic Acid
Describe the compensatory stage (pre-shock).
- Flight or fight mechanism is activated
- Blood flow to vital organs are increased
- Body is reacting because of imbalance between oxygen supply and demand / decreased perfusion
If cause of decreased perfusion is correct at this stage, PT will recover with little or no effect.
What chemicals does your body release during stage 1?
Epinephrine and Norepinephrine
What are signs and symptoms of the Compensatory stage/pre-shock?
- BP normal, narrowing pulse pressure
- Elevated HR/ weak pulse
- Increased RR and depth
- Decreased peristalsis
- Restless/combative
- Cool and clammy skin (except for septic shock and neruogenic shock)
How is MAP calculated?
What is normal?
SBP + 2(DBP) / 3
Normal = 65 or >
What is the nursing care during the compensatory stage (pre-shock)?
-IV fluids to correct hypovolemia
(multiple large bore IV’s, minimum two)
- Administer O2
- Foley for fluid management
- Medications to maintain BP and tissue perfusion
- Nutritional needs
- Identify and correct underlying disorder
(ex: bleeding-stop it, infection-antibiotics, etc)
What makes older patients at risk for shock?
Medications such as beta-blockers that mask tachycardia, tachycardia keeps BP up so this will make BP drop faster in the older adult!
Dysrhythmias
Sudden change in mentation (consider infection, not just sun-downers)
During the Uncompensated shock stage (shock) what leaks out of the cells with increased permeability?
What will it cause?
Protein which will cause edema
What are signs and symptoms of Uncompensated shock (shock)?
Increased edema
Tachypnea, crackles, increased respiratory effort (symptoms of pulmonary edema, M. Vent possibly needed here)
Tachycardia
Decreased BP (~90/40) and cardiac output
Decreased LOC
What is the correct PT positioning for a PT experiencing shock?
Modified Trendelenberg
-For low BP during shock, head flat - feet up
What is nursing care during the uncompensated stage or progression of shock?
IVF and medications to restore tissue perfusion
Support respiratory system
Early intervention! PT should be in ICU
Promote rest and comfort
What happens during Irreversible (multiple organ dysfunction) last stage of shock?
Peripheral vasoconstriction
Decreased cardiac output
Accumulation of waste products
Cerebral ischemia
What is Multiple Organ Dysfunction Syndrome (MODS)?
Dysfunction of two or more organs with inability to maintain homeostasis without intervention
-can be complication of any type of shock
What are signs and symptoms of MODS?
Decreased BP and HR (needs to be maintained w/meds)
Profound hypoxemia
Increased lactic acid, BUN/Cr
Describe Hypovolemic shock.
What are the two types?
What are the s and s’s?
- Decreased blood volume leads to decreased cardiac output ultimately leading to deceased tissue perfusion.
- Most common type of shock
2 types
absolute = loss of blood volume
relative = fluids shifted to other spaces
S and S’s:
- Anxiety
- Decreased urine output
- Increased HR
- Decreased BP
What are causes of Hypovolemic Shock?
External/absolute:
- Trauma/Hemorrhage
- Vomiting/Diarrhea
- Diabetes Insipdus
Internal/relative:
- Burns
- Dehydration
- Sepsis
- Liver failure
- Pancreatitis
What are the goals in care of hypovolemic shock?
Restore and Redistribute fluid volume
Correct underlying cause of fluid loss
What are interventions to restore volume?
IV fluids w/crystaloids/colloids- volume expanders
(ex: hetastarch, dextran, albumin)
Blood products
Control bleeding
Stop vomiting and diarrhea
How would you provide redistribution in hypovolemic shock?
What can test if PT needs fluid?
-PT positioning: lower head, raise feet
-Meds: vasopressin, phenylephrine, epinephrine/norepinephrine, dopamine
(these all constrict blood vessels ^ BP)
Passive leg raising (head flat, legs up) can will show if PT needs fluid because if BP increases with manuever = PT needs fluid
What are non-pneumatic shock garments (NPSG)?
Keeps pressure on legs and abdomen to try and distribute blood to vital organs
What is the nursing management for hypovolemic shock?
- Monitor PT at risk for fluid volume deficit w/ VS, I and O’s, daily weights
- Fluid replacement before shock develops
- Treat cause
- Observe for side effects of treatment
What is the side effect of hypovolemic shock treatment?
What patients are at high risk for this complication?
Circulatory overload:
-When large volumes are administered rapidly
-High risk PT’s those with HF, Renal failure
At what angle is JVD tested?
45 degrees sitting up
What should you first do with fluids and blood before given?
Warm them
Describe Cardiogenic shock.
What are some causes?
What are S and S’s?
- Heart suddenly can’t pump enough blood to meet body’s needs. (Pumping issue)
- Decreased cardiac output leading to decreased perfusion
Causes: MI, Cardiomyopathy, etc
S and S’s: Those of HF
- Pulmonary congestion
- Tachycardia
- JVD
- S3
- Increased wedge pressure
- Cool clammy skin
What are surgical treatments for Cardiogenic shock?
What do they all help do?
Correct underlying problem:
- Acute MI - emergency procedure ex: angioplasty,etc
- Treat dysrhythmias
Circulatory assist with mechanical devices ex:
- Intra Aortic Balloon Pump (catheter thru groin, intermittent pumping, helps heart pump efficiently)
- LVAD
They increase preload and decrease afterload
What are the pharmacological interventions for cardiogenic shock?
Diuretics
Volume expanders: IVF
Vasodilators: nitroprusside, nitroglycerin
Vasopressors: norepinephrine, epi, dopamine
Positive inotropes: dobutamine, dopamine, digoxin
(Medication selected for whatever the cause)
What is a complication of medication administration to prevent cardiogenic shock?
What is the treatment?
Extravasation-Tissue sloughing:
-accidental infiltration of a vesicant or drug into the surrounding IV site.
(better to administer in central line)
Tx: phentolamine
What are findings that indicate abdominal aortic aneurysm?
What are signs of impending rupture?
- Abdominal bruit
- Complaint of heart beat in abdomen
- Feeling of abdominal mass/throbbing
- Cyanosis
Intense back pain
Decreased BP
Decreased Hct
What is an aneurysm?
What can they form from?
What are the other kinds of aortic aneurysms?
Abnormal bulge that occurs in major blood vessels
Can form from fats and other substances that cause atherosclerosis
Thoracic aortic aneurysms and dissecting aortic aneurysm
What are risk factors of aortic aneurysms?
Age
Smoker
HTN
Male
and Family hx
What are signs and symptoms of thoracic aortic aneurysms?
Dyspnea
Cough/stridor
Cyanosis
Chest pain
What diagnostic testing can be done for aortic aneurysms?
Abdominal Ultrasound
Aortagram w/contrast
CT
X-ray
Pulsating mass in abdomen
Systolic bruit over mass
What is an aortic dissection?
Inner layer of aorta tears, then blood escapes through tear causing layers to separate (dissect)
Describe the process of surgical repair of abdominal aortic aneurysm.
What is the nurses role in witnessing consent?
- General anesthesia
- Cut out affected part, synthetic graft put in place.
Observe PT signs and writes date and time
What is percutaneous treatment for aortic aneurysms?
What is the advantage to this procedure over sx repair?
What is the risk?
Endovascular grafts are inserted into thoracic aorta via femoral artery.
Advantage: recovery time is shorter than Sx repair
Increased risk for need of another intervention
What are signs and symptoms of aorta dissection?
- Intense lower back pain
- Tachycardia
- Hypotension
- Cool clammy skin
- Restlessness/agitation
What are the nurses priorities during an aortic dissection?
Large bore IV’s
Rush to OR
Rapid response
VS
Regardless of the type of aortic aneurysm what are the treatments?
Sx repair with synthetic graft
or
Percutaneous intervention w/ graft through femoral artery
Describe uncompensatory shock (shock).
Further decrease in circulating volume and organ perfusion
BP dropping
Impaired gas exchange
