Unit 8 Chapter 34 Shock (Cardiogenic Shock, Septic shock, Obstructive Shock,Neurogenic shock, Hypovolemic shock, Anaphylactic Shock, Flashcards
What are the 4 stages of shock?
-Initial
-Compensatory
-Progressive
-Irreversible(REFRACTORY)
What is shock?
Basically shock is the inability of the
heart to meet the body’s demands of
oxygenated blood for different reasons
What are the types of shock
- Hypovolemic
- Cardiogenic
*Obstructive - Distributive:
-Septic
-Neurogenic
-Anaphylactic
What Mean Arterial Pressure is minimally required for perfusion of vital organs?
A. 65
B. 58
C. 40
D. 50
A. 65
In what amount of time can shock be corrected
The effects are temporary and reversible if the cause of shock is corrected within 1 to 2 hours after onset.
When shock conditions continue for longer periods without help, the resulting increased metabolites cause so much cell damage in vital organs that they are unable to perform their critical functions. When this problem, known as multiple organ dysfunction syndrome (MODS), o
What is the normal MEAN ARTERIAL PRESSURE
70-110
What occurs during the Initial stage of shock?
(NO SYMPTOMS PRESENT)
The initial stage is present when the patient’s baseline MAP is decreased by less than 10 mm Hg.
Because vital organ function is not disrupted, the indicators of shock are difficult to detect at this stage.
Slight increase in diastolic Bp.
* Increased heart rate and respirations.
* Compensatory mechanisms control blood flow to vital
organs.
* Anaerobic metabolism occurs-
Lactic acid is produced.
(Watch for acidosis)
What is the function of lactic acid
marker of muscle breakdown
What is the normal range for lactic acid
0.5-1.0
What occurs during the Compensatory stage of shock?
- Vasoconstriction, increased HR, and increased heart contractility.
- Body shunts blood from skin, kidneys, and GI tract.
*Results in cool, clammy skin, hypoactive bowel
sounds, and decreased urine output. - Perfusion of tissues is inadequate.
- Acidosis occurs as a result of anaerobic
metabolism. (lactic acid) - Respiratory rate increases due to acidosis. * Confusion may occur.
- Na and glucose levels are elevated in response to the release of aldosterone and catecholamine.
- Decrease in MAP of 10-15 mm Hg from baseline value
- Continued sympathetic stimulation * Moderate vasoconstriction
- Increased heart rate
- Decreased pulse pressure
- Chemical compensation
- Renin, aldosterone, and antidiuretic hormone secretion * Increased vasoconstriction
- Decreased urine output
- Stimulation of the thirst reflex
- Some anaerobic metabolism in nonvital organs
- Mild acidosis
- Mild hyperkalemia
What occurs during the Progressive stage of shock?
- Mechanisms that regulate BP can no longer compensate, and BP and MAP decrease.
- All organs suffer from hypoperfusion.
*Results in cool, clammy skin, hypoactive bowel - Vasoconstriction continues, further
compromising cellular perfusion.
*Mental status further deteriorates as a result of decreased cerebral perfusion and hypoxia. - Lungs begin to fail, decreased pulmonary blood flow causes further hypoxemia; carbon dioxide levels increase; alveoli collapse and pulmonary edema occurs.
- Inadequate perfusion of the heart leads to dysrhythmias and ischemia.
- As MAP falls below 70, GFR cannot be maintained.
- Liver function, GI function, and hematologic function are all affected.
Decrease in MAP of >20 mm - Anoxia of nonvital organs
- Hypoxia of vital organs
- Overall metabolism is anaerobic * Moderate acidosis
- Moderate hyperkalemia
- Tissue ischemia
INCREASE LACTIC ACID INIDATES MUSCLE BREAKDOWN
What occurs during the Refractory(IRRIVERSIBLE) stage of shock?
Organ damage is so severe that the patient does not respond to treatment and cannot survive.
* BP remains low.
* Renal and liver functions continue to fail. * Anaerobic metabolism increases acidosis. * Multiple organ dysfunction progresses to complete organ failure.
* Severe tissue hypoxia with ischemia and necrosis
* Release of myocardial depressant factor from the pancreas * Buildup of toxic metabolites
* Multiple organ dysfunction syndrome (MODS)
* Death
DEATH IS IMMINENT
Nursing intervention for Refractory stage
HOSPICE OR PALLIATIVE CONSULT
ENCOURAGE FAMILY VISITATION, family at bedside to share last moments
-there is nothing that can the team can do it is irreversible
expected O2 sat for Compensatory Stage
Oxygen saturation is assessed through pulse oximetry. Pulse oximetry values between 90% and 95% occur with the compensatory stage of shock,
Expected O2 sat for progressive Stage
values between 75% and 80% occur with the progressive stage of shock
Expected O2 sat for Refractory Stage
Any value below 70% is considered a life-threatening emergency and may signal the refractory stage of shock.
What is the method of tx for ALL TYPES OF SHOCK
Early identification and timely treatment
*Identify and treat the underlying cause
* The sequence of events for the different types of shock will vary.
Therefore, the management and care of the patient will vary.
S/S OF SHOCK
Decreased LOC
* Confusion
* Pale, mottled, cool skin.
* Poor skin turgor.
* Cool, cyanotic extremities. rate.
* Delayed capillary refill.
* Dyspnea
* Diaphoresis
* Hypothermia
* Decreased:
* Blood pressure
* Cardiac output
* Low Urine output
* Rapid, thready pulse.
* Increased respiratory
What is hypovolemic shock
The basic problem of hypovolemic shock is a loss of vascular volume, resulting in a decreased mean arterial pressure (MAP) (see Fig. 34.1) and, in some cases, a loss of circulating red blood cells (RBCs). The reduced MAP slows blood flow, decreasing tissue perfusio
What can cause hypovolemic shock
-hemmrohage
-dehyration
-vomitting
-diahrea
Careful considerations of hypovolemic shock
Dehydration is due to fluid not being in vascular space, therefore, a patient with extreme edema, can actually be dehydrated!
It is important to recognize the cause of hypovolemic shock!
If due to lack of plasma – GIVE IV fluids – Red blood cells are still there for oxygen carrying capacity
If due to loss of blood – GIVE Blood – Red blood cells are missing and they need these back
What is the best position for a client in hypovlemic shock
A. high fowlers
B.left lying
C. low fowlers
D. modified trensdelenburg
D. modified trensdelenburg
Which of the following is an early sign of shock?
A. altered level of consciousness
B. organ necrosis
C. O2 sat 70
D. BP 50/70
A. altered level of consciousness
Changes in mental status and behavior occur early in shock. Assess mental status by evaluating LOC and noting whether the patient is asleep or awake
What is the primary intervention for hypovolemic shock
IV therapy for fluid resuscitation is a primary intervention for hypovolemic shock.
Nursing Care for Hypovolemic shock
Ensure a patent airway.
* Insert an IV catheter or maintain an established catheter. A large-bore catheter is suggested.
* Administer oxygen to maintain O2 saturation at 92% to 96%; supplemental oxygen is no longer recommended if saturation is normal (Chu et al., 2018).
Elevate the patient’s feet, keeping his or her head flat or elevated to no more than a 30-degree angle.
* Examine the patient for overt bleeding.
If overt bleeding is present, apply direct pressure to the site.
* Administer drugs as prescribed.
Increase the rate of IV fluid delivery.
Do not leave the patient.
Your client has come from an abdominal resection surgery. When assessing vital signs you notice the MAP has decreased by 10 from baseline. What stage of shock do you anticipate the client experiencing
A. Initial
B. Compensatory
C. Progressive
D. Refractory
A. Initial
What is Cardiogenic Shock
the heart has a low pump, isn’t able to functionally pump the blood to other vital organs in the body
What is the cause of Cardiogenic shock?
A. the client with a history of smoking 1 pack of cigarettes a year
B. The client who has sustained multiple myocardial infarctions
C. The client who has been taking prednisone for 10 years
D. The client with a left leg amputataion
B. The client who has sustained multiple myocardial infarctions
Usually due to compromised
heart from MI or some other
“heart failure” (failure of heart
to pump effectively)
Labs for Hematocrit
37-47 F
42-52 M
Labs for Hemoglobin
12-16 F
14-18 M
What is the normal range for potassium?
3.5-5.0
S/s for Cardiogenic shock
- bradycardia
-hypotension
-cool skin
-pallor
-afib
-blood pools and clots
-weak thread pulse
-pulmonary edema
-tachycardia
Medical tx for Cardiogenic shock (DD)
Digoxin and Dobutamine increase heart contractability
* Decrease anxiety
* Increase contractility
* Decrease workload & O2 demand
Your client has been diagnosed with Cardiogenic shock. On the ecg you notice fibrillation on the monitor. What is the nurses priority action?
A. Assess the client for signs of stroke
B. Check pupil dilation
C. increase IV fluid
D. Administer metformin
A. Assess the client for signs of stroke
when the blood pools and clots and the (Dobutamine D are administered The clot may dislodge and cause the client to experience a stroke
What are s/s of stroke
- Balance issues
- Eye drooping or blurry visison
- Facial dropping
- Arm unilateral weakness
- Slurred speech (dysarthria)
-Time call the ambulance
-Dyasthtria
-confusion
Adverse Reaction of Dobutamine that MUST BE REPORTED TO HCP
JAW PAIN OR DISCOMFORT
NECK PAIN
SOB
DIZZINESS
**ARM PAIN OR WEAKNESS*
Dobutamine can cause ST elevation, MIRROR THE SIGNS OF MI
Can dobutamine cause ST elevation
Dobutamine can cause ST elevation
Dobutamine-induced ST-segment elevation associated with a biphasic response of wall motion in patients with a recent myocardial infarction is caused by myocardial ischaemia and is abolished by revascularization of the infarct-related artery.
How do you know the tx is working?
-increase perfsion
-caapillary refill less than 3 secs
-oriented
-bp increase
-skin warmth
-30 ml urine output
Priority intervention for Cardiogenic shock
ADMINISTER MED THAT INCREASES HEART CONTRACTILITY
Patient teaching for Digoxin
- check apical pulse (1 full minute)prior to admin(HR must be 60 at minimum).
-Each foods high in potassium to avoid dig toxixcity
What is the therapeutic range for Digoxin
A. 10-20
B. 2-5
C. 0.5-2.0
D. 5-10
C. 0.5-2.0
Which lab value will warrant immediate attention for a client taking Digoxin?
A. serum Sodium 130
B. serum Potassium 2.5
C. Aptt 35 secs
D. Magnesium 3.0
B. serum Potassium 2.5
sign of dig toxity
What are the s/s of Digoxin toxixty
*Serum Digoxin level. greater than 2.2 ng/mL
* Bradycardia, cardiac dysrhythmias
* Anorexia,
nausea,
vomiting,
* diarrhea
* Blurred vision,
* yellow or green halos around objects
What is Obstructive Shock
something is blocking the flow of blood and prefusion, may be a clot or pulmonary embolism
Impedance of circulation
Interference in ventricular filling
Interference in ventricular emptying
What can cause Obstructive Shock?
Includes:
etc
Pericardial Tamponade tx: PERCARDIOCENTESIS
Tension Pneumothorax tx: CHEST TUBE
Pulmonary Emboli tx: ALTEPLASE OR HEPARIN
Pulmonary hypertension tx : DIURETIC
Thoracic tumors: SURGERY
Aortic dissection: IV FLUID PAIN MEDS
• Cardiac tamponade
• Arterial stenosis
• Pulmonary embolus.
• Pulmonary hypertension
• Constrictive pericarditis
• Thoracic tumors
• Tension pneumothorax
Medical tx for Obstructive shock
tx the cause and then everything else will be fine
Cause of Systemic Inflammatory Syndrome (SIRS)
the patient has an infection,
What Systemic Inflammatory Syndrome (SIRS)
s/sIMPORTANT
a warning sign of septic shock
we want to cath the patient ar SIRS NOT SEPTIC SHOCK
Tachypnea (>20)
* pCO2 < 32
* WBC of < 4.0 or > 12.0
* Heart rate > 90
* Temp >100.4 or < 96.8
*high glucose 120-150
*If diastolic BP decrease the damage is done and sepsis shock has occured
Systemic Inflammatory Syndrome (SIRS tx
prevent progression into septic shock
How can you tell SIRS is present? What vital signs would you see? IMPORTANT**
Exists if abnormalities occur in 2 of the following parameters:
* Body temperature
* Heart rate
* Respiratory rate
* WBC
HR GREATER THAN 90
TEMP GREATER THAN 100.4
TEMP LOWER THAN 96.4
RR GREATER THAN 20
GLUCOSE 120-130
WBC INCREASES
What is septic shock
When there is an infection IN BLOOD or an injury, cells produce cytokines – one of them is histamine
(swells body, fluid is out of vascular space)
(blood borne bacteria in blood)
What can septic shock be caused by
CAN BE CAUSED BY PNEUMONIA UTI OR KIDNEY INFECTION, NOT CHANGING TPN TUBING Q24
Priority tx for Septic Shock
IV FLUID
ANTIBIOTICS
S/S OF SEPTIC SHOCK
-severly low BP (less than 80 systolic)
-low O2
-dyspnea
-cold clammy skin
-pallor
-mottled
-delayed capillary refill
-altered level of consciousness
-disorientation
-high wbc
-oliguria
- Require vasopressor therapy to maintain a mean arterial pressure (MAP) of at least 65 mm Hg
or - Have a serum lactate level greater than 2 mmol/L (18 mg/dL),
despite adequate fluid resuscitation
Is septic shock an emergency?
A. no
B. yes
B. yes
CALL A RAPID RESPONSE OR CODE
Which of the following is an indication of sepsis shock?
A. WBC 5,000
B. Capillary refill 2 seconds
C. Lactic Acid 4.0
D. BP 110/60
C. Lactic Acid 4.0
can sepsis cause ards
yes
ARDS in a patient with septic shock has a high mortality rate.
Core measures for SESPSIS VERY IMPORTANT
Within 1 hour:
1. Measure lactate level.
- Obtain blood cultures before administering antibiotics.
- Administer broad-spectrum antibiotics.(PENICILLIN OR CEPHALOSPORIN)
- Begin rapid administration of 30 mL/kg crystalloid(0.9 NS) for hypotension or lactate ≥4 mmol/L.
- Apply vasopressors(EPI, NOREPI, DOBUTAMINE) if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥65 mm Hg.
What is the normal lactic level
0.5-1
Does IV fluid decrease the high lactic level?
A.yes
B.no
A.yes
Nursing MGNT FOR SHOCK
- Continuous patient assessment.
- Monitor oxygenation.
- Monitor perfusion.
- Control pain and anxiety.
- Cardiac monitoring.
What is neuronegic shock
shock that occurs after spinal cord injury
s/s neurogenic shock
- Paralysis
- Hypotension
- Bradycardia
warm, dry, pink skin - Hypothermia
- Respiratory Failure—if cervical or upper thoracic
- Bladder/bowel distention
- No perspiration below level of injury—*Temperature impairment
What is a complication of neurogenic shock
Autonomic Dysreflexia
Nursing mnmt Autonomic Dysreflexia
-relieve pressure
-sit patient up
-straight cath
-stool softer
-no wrinkle on sheets
-loose clothing
What is Anaphylactic shock
SEVERE ALLERGIC REACTION
S/S OF Anaphylactic shock
HIVES
** DYSPNEA**
**HYPOTENSION*
-angioedema;swollen tongue
-itchiness
-stridor
-hypoxia
-cyanosis
WHEEZING
-hypotension
BRONCHOCONSTRICTION
TX for Anaphylactic Shock
EPINEPHRINE PEN IMMEDIATELY Q5 OR Q15 UNTIL SYMPTOMS RESOLVE
What causes death in pt with anaphlactic shock
The major factor in fatal outcomes for anaphylaxis is a delay in the administration of epinephrine
What should a client avoid if they have allergies
Teach the patient with a history of allergic reactions to avoid known allergens whenever possible, to wear a medical alert bracelet, and to alert health care personnel about specific allergies.
What can cause ANAPHYLACTIC SHOCK
-Bee sting
-food allergy
-medications
Emergency Care of the Patient With Anaphylaxis
- Immediately assess the respiratory status, airway, and oxygen saturation of patients who show any symptom of an allergic reaction.
- Call the Rapid Response Team.
- Ensure that intubation and tracheotomy equipment is ready.
- Apply oxygen using a high-flow, nonrebreather mask at 90% to 100%.
- Immediately discontinue the IV drug or infusing solution of a patient having an anaphylactic reaction to that drug or solution. Do not discontinue the IV, but change the IV tubing and hang normal saline.
- If the patient does not have an IV, start one immediately and infuse normal saline.
- Be prepared to administer epinephrine IM.
Repeat drug as needed every 5 to 15 minutes until the patient responds. - Keep the head of the bed elevated about 10 degrees if hypotension is present; if blood pressure is normal, elevate the head of the bed to 45 degrees or higher to improve ventilation.
- Raise the feet and legs.
- Stay with the patient.
- Reassure the patient that the appropriate interventions are being instituted.
Care and Use of Automatic Epinephrine Injectors
Practice assembly of injection device with a non–drug-containing training device provided through the injection device manufacturer.
Keep the device with you at all times.
* When needed, inject the drug into the top of your thigh, slightly to the outside, holding the device so the needle enters straight down 10 secs.
* You can inject the drug right through your pants; just avoid seams and pockets where the fabric is thicker.
*Use the device when any symptom of anaphylaxis is present and before you call 911 (Hayden, 2019).
It is better to use the drug when it is not needed than to not use it when it is needed!!!
Whenever you need to use the device, get to the nearest hospital for monitoring for at least the next 4 to 6 hours.
- Have at least two drug-filled devices on hand in case more than one dose is needed.
Protect the device from light and avoid temperature extremes. - Carry the device in the case provided by the manufacturer.
- Keep safety cap in place until you are ready to use the device.
- Check the device for:
Expiration date—If the date is close to expiring or has expired, obtain a replacement device.
Drug clarity—If the drug is discolored, obtain a replacement device.
Security of cap—If the cap is loose or comes off accidently, obtain a replacement device.
-avoid storing in freezer or car
will clients have high lactic acid with sepsis OR ANY TYPE OF SHOCK
yes, 2,3,4 levels
After administering Epi what is next
call rapid response, call 911
Closely monitor any patient receiving a drug that is associated with anaphylaxis to recognize symptoms early. If you suspect anaphylaxis, respond by immediately notifying the Rapid Response Team because most anaphylaxis deaths occur from dysrhythmias, shock, and cardiopulmonary arrest that are related to treatment delay.
if stridor is present what is the interdisciplinary team’s next action
Ensure that intubation and tracheotomy equipment is ready.
Side effects of EPI AND PT TEACHING
-tahycardia
-dizziness
-palpitations
Whenever you need to use the device, get to the nearest hospital for monitoring for at least the next 4 to 6 hours.
Vasoactive meds
- Used when fluid therapy alone does not
maintain MAP.
o Nitroprusside (Nipride) o Dobutamine (Dobutrex) o Norepinephrine (Levophed)
*Give through central line. - Dosages are titrated to patient response.
CLIENTS THAT ARE ON THESE MEDICATIONS ARE IN THE ICU
adverse reaction of dobutamin
jaw pain, s/s of MI
Your client who is diagnosed with cardiogenic shock has been prescribed dobutamine. The treatment has increased peripheral blood pressure and now her skin is warm but now has tachycardia 110 . What is the nurse’s next action
A. stop the infusion
B. titrate the infusion up
C. titrate the infusion down
D. Administer furosomide
C. titrate the infusion down
vasoactive drugs
o Nitroprusside (Nipride)
o Dobutamine (Dobutrex)
o Norepinephrine (Levophed
Vasoactive medications should NEVER be stopped abruptly as this could cause severe hemodynamic instability and perpetuate the shock state.
Nutritional therapy
- Nutritional support is needed to meet increased metabolic and
energy requirements.
-prevent constipation - Support with parenteral or enteral nutrition.
- GI system should be used, if possible, to support its integrity.
- Administration of H2 blockers or proton pump inhibitors(famotodine or pantaprozole to prevent stress ulcers(
Psychological Support of Patients and
- Anxiety
- Support for coping
- Patient and family education refractory stage multiple organs have died and there is nothing else we can do
- Communication
- End-of-life issues = invite family to bedside for last good byes
- Grief processes=
Multiple Organ Dysfunction Syndrome: MOD
A progression of shock.
Altered organ function that requires medical intervention to support continued organ function.
MULTI ORGAN SUPPORT VIA DIALYSIS ETC
* High mortality rate; 75–100%
S/S OF MODS
- Increased HR
- Increased cardiac
contractility and
output. - Increased oxygen
consumption. - Increased release of
catecholamines,
cortisol, antidiuretic
hormone, and
glucagons.
TX OF MODS
- Individual organ support.
- Mechanical ventilation.
- Dialysis
- Blood product transfusions.
- Pharmacological support.
- Avoid additional complications
GOAL OF MOD
- Avoid additional complications=PREVENT REFRACTORY STAGE
Distributive Shock causes
• Neural induced
• Pain
• Anesthesia
• Stress.
• Spinal cord injury
• Head trauma
• Chemical induced -
• Anaphylaxis
• Sepsis
• Capillary leak <
• Burns
• Extensive trauma
• Liver impairment
• Hypoproteinemia
