Unit 8 Chapter 34 Shock (Cardiogenic Shock, Septic shock, Obstructive Shock,Neurogenic shock, Hypovolemic shock, Anaphylactic Shock,

Question 1

What are the 4 stages of shock?

Answer 1

-Initial
-Compensatory
-Progressive
-Irreversible(REFRACTORY)

Question 2

What is shock?

Answer 2

Basically shock is the inability of the
heart to meet the body’s demands of
oxygenated blood for different reasons

Question 3

What are the types of shock

Answer 3

• Hypovolemic
• Cardiogenic
  *Obstructive
• Distributive:
  -Septic
  -Neurogenic
  -Anaphylactic

Question 4

What Mean Arterial Pressure is minimally required for perfusion of vital organs?
A. 65
B. 58
C. 40
D. 50

Answer 4

A. 65

Question 5

In what amount of time can shock be corrected

Answer 5

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

Question 6

What is the normal MEAN ARTERIAL PRESSURE

Answer 6

70-110

Question 7

What occurs during the Initial stage of shock?

Answer 7

(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)

Question 8

What is the function of lactic acid

Answer 8

marker of muscle breakdown

Question 9

What is the normal range for lactic acid

Answer 9

0.5-1.0

Question 10

What occurs during the Compensatory stage of shock?

Answer 10

• 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

Question 11

What occurs during the Progressive stage of shock?

Answer 11

• 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

Question 12

What occurs during the Refractory(IRRIVERSIBLE) stage of shock?

Answer 12

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

Question 13

Nursing intervention for Refractory stage

Answer 13

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

Question 14

expected O2 sat for Compensatory Stage

Answer 14

Oxygen saturation is assessed through pulse oximetry. Pulse oximetry values between 90% and 95% occur with the compensatory stage of shock,

Question 15

Expected O2 sat for progressive Stage

Answer 15

values between 75% and 80% occur with the progressive stage of shock

Question 16

Expected O2 sat for Refractory Stage

Answer 16

Any value below 70% is considered a life-threatening emergency and may signal the refractory stage of shock.

Question 17

What is the method of tx for ALL TYPES OF SHOCK

Answer 17

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.

Question 18

S/S OF SHOCK

Answer 18

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

Question 19

What is hypovolemic shock

Answer 19

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

Question 20

What can cause hypovolemic shock

Answer 20

-hemmrohage
-dehyration
-vomitting
-diahrea

Question 21

Careful considerations of hypovolemic shock

Answer 21

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

Question 22

What is the best position for a client in hypovlemic shock
A. high fowlers
B.left lying
C. low fowlers
D. modified trensdelenburg

Answer 22

D. modified trensdelenburg

Question 23

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

Answer 23

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

Question 24

What is the primary intervention for hypovolemic shock

Answer 24

IV therapy for fluid resuscitation is a primary intervention for hypovolemic shock.

Question 25

Nursing Care for Hypovolemic shock

Answer 25

**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.**

Question 26

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

Answer 26

A. Initial

Question 27

What is Cardiogenic Shock

Answer 27

the heart has a low pump, isn't able to functionally pump the blood to other vital organs in the body

Question 28

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

Answer 28

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)**

Question 29

Labs for Hematocrit

Answer 29

37-47 F 42-52 M

Question 30

Labs for Hemoglobin

Answer 30

12-16 F 14-18 M

Question 31

What is the normal range for potassium?

Answer 31

3.5-5.0

Question 32

S/s for Cardiogenic shock

Answer 32

- bradycardia -hypotension -cool skin -pallor -afib -blood pools and clots -weak thread pulse -pulmonary edema -tachycardia

Question 33

Medical tx for Cardiogenic shock (DD)

Answer 33

Digoxin and Dobutamine increase heart contractability * Decrease anxiety * Increase contractility * Decrease workload & O2 demand

Question 34

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

Answer 34

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**

Question 35

What are s/s of stroke

Answer 35

- Balance issues - Eye drooping or blurry visison - Facial dropping - Arm unilateral weakness - Slurred speech (dysarthria) -Time call the ambulance -Dyasthtria -confusion

Question 36

Adverse Reaction of Dobutamine that **MUST BE REPORTED TO HCP**

Answer 36

**JAW PAIN OR DISCOMFORT** **NECK PAIN** **SOB** **DIZZINESS** **ARM PAIN OR WEAKNESS* **Dobutamine can cause ST elevation, MIRROR THE SIGNS OF MI**

Question 37

Can dobutamine cause ST elevation

Answer 37

**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.

Question 38

How do you know the tx is working?

Answer 38

-increase perfsion -caapillary refill less than 3 secs -oriented -bp increase -skin warmth -30 ml urine output

Question 39

Priority intervention for Cardiogenic shock

Answer 39

**ADMINISTER MED THAT INCREASES HEART CONTRACTILITY**

Question 40

Patient teaching for Digoxin

Answer 40

- check apical pulse (1 full minute)prior to admin(HR must be 60 at minimum). -Each foods high in potassium to avoid dig toxixcity

Question 41

What is the therapeutic range for Digoxin A. 10-20 B. 2-5 C. 0.5-2.0 D. 5-10

Answer 41

C. 0.5-2.0

Question 42

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

Answer 42

B. serum Potassium 2.5 **sign of dig toxity**

Question 43

What are the s/s of Digoxin toxixty

Answer 43

*Serum Digoxin level. greater than 2.2 ng/mL * Bradycardia, cardiac dysrhythmias * Anorexia, nausea, vomiting, * diarrhea * Blurred vision, * yellow or green halos around objects

Question 44

What is Obstructive Shock

Answer 44

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

Question 45

What can cause Obstructive Shock?

Answer 45

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

Question 46

Medical tx for Obstructive shock

Answer 46

tx the cause and then everything else will be fine

Question 47

Cause of Systemic Inflammatory Syndrome (SIRS)

Answer 47

the patient has an infection,

Question 48

What Systemic Inflammatory Syndrome (SIRS) s/s**IMPORTANT**

Answer 48

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

Question 49

Systemic Inflammatory Syndrome (SIRS tx

Answer 49

prevent progression into septic shock

Question 50

**How can you tell SIRS is present? What vital signs would you see?** IMPORTANT**

Answer 50

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

Question 51

What is septic shock

Answer 51

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)

Question 52

What can septic shock be caused by

Answer 52

**CAN BE CAUSED BY PNEUMONIA UTI OR KIDNEY INFECTION, NOT CHANGING TPN TUBING Q24**

Question 53

Priority tx for Septic Shock

Answer 53

**IV FLUID** **ANTIBIOTICS**

Question 54

S/S OF SEPTIC SHOCK

Answer 54

-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

Question 55

Is septic shock an emergency? A. no B. yes

Answer 55

B. yes **CALL A RAPID RESPONSE OR CODE**

Question 56

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

Answer 56

C. Lactic Acid 4.0

Question 57

can sepsis cause ards

Answer 57

yes ARDS in a patient with septic shock has a high mortality rate.

Question 58

Core measures for SESPSIS **VERY IMPORTANT**

Answer 58

Within 1 hour: 1. Measure lactate level. 2. Obtain blood cultures before administering antibiotics. 3. Administer broad-spectrum antibiotics.(PENICILLIN OR CEPHALOSPORIN) 4. Begin rapid administration of 30 mL/kg crystalloid(0.9 NS) for hypotension or lactate ≥4 mmol/L. 5. Apply vasopressors(EPI, NOREPI, DOBUTAMINE) if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥65 mm Hg.

Question 59

What is the normal lactic level

Answer 59

0.5-1

Question 60

Does IV fluid decrease the high lactic level? A.yes B.no

Answer 60

A.yes

Question 61

Nursing MGNT FOR SHOCK

Answer 61

* Continuous patient assessment. * Monitor oxygenation. * Monitor perfusion. * Control pain and anxiety. * Cardiac monitoring.

Question 62

What is neuronegic shock

Answer 62

shock that occurs after spinal cord injury

Question 63

s/s neurogenic shock

Answer 63

* 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

Question 64

What is a complication of neurogenic shock

Answer 64

Autonomic Dysreflexia

Question 65

Nursing mnmt Autonomic Dysreflexia

Answer 65

-relieve pressure -**sit patient up** -straight cath -stool softer -no wrinkle on sheets -loose clothing

Question 66

What is Anaphylactic shock

Answer 66

**SEVERE ALLERGIC REACTION**

Question 67

S/S OF Anaphylactic shock

Answer 67

**HIVES** ** DYSPNEA** **HYPOTENSION* -angioedema;swollen tongue -itchiness -stridor -hypoxia -cyanosis **WHEEZING** -hypotension **BRONCHOCONSTRICTION**

Question 68

TX for Anaphylactic Shock

Answer 68

**EPINEPHRINE PEN IMMEDIATELY Q5 OR Q15 UNTIL SYMPTOMS RESOLVE**

Question 69

What causes death in pt with anaphlactic shock

Answer 69

The major factor in fatal outcomes for anaphylaxis is a delay in the administration of epinephrine

Question 70

What should a client avoid if they have allergies

Answer 70

**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.

Question 71

What can cause ANAPHYLACTIC SHOCK

Answer 71

-Bee sting -food allergy -medications

Question 72

Emergency Care of the Patient With Anaphylaxis

Answer 72

* 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.

Question 73

Care and Use of Automatic Epinephrine Injectors

Answer 73

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

Question 74

will clients have high lactic acid with sepsis OR ANY TYPE OF SHOCK

Answer 74

yes, 2,3,4 levels

Question 75

After administering Epi what is next

Answer 75

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.

Question 76

if stridor is present what is the interdisciplinary team's next action

Answer 76

Ensure that intubation and tracheotomy equipment is ready.

Question 77

Side effects of EPI AND PT TEACHING

Answer 77

-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.**

Question 78

Vasoactive meds

Answer 78

* 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. ## Footnote CLIENTS THAT ARE ON THESE MEDICATIONS ARE IN THE ICU

Question 79

adverse reaction of dobutamin

Answer 79

jaw pain, s/s of MI

Question 80

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

Answer 80

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.

Question 81

Nutritional therapy

Answer 81

* 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(**

Question 82

Psychological Support of Patients and

Answer 82

* 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=

Question 83

Multiple Organ Dysfunction Syndrome: MOD

Answer 83

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%

Question 84

S/S OF MODS

Answer 84

* Increased HR * Increased cardiac contractility and output. * Increased oxygen consumption. * Increased release of catecholamines, cortisol, antidiuretic hormone, and glucagons.

Question 85

TX OF MODS

Answer 85

* Individual organ support. * Mechanical ventilation. * Dialysis * Blood product transfusions. * Pharmacological support. * Avoid additional complications

Question 86

GOAL OF MOD

Answer 86

* Avoid additional complications=PREVENT REFRACTORY STAGE

Question 87

Distributive Shock causes

Answer 87

• Neural induced • Pain • Anesthesia • Stress. • Spinal cord injury • Head trauma • Chemical induced - • Anaphylaxis • Sepsis • Capillary leak < • Burns • Extensive trauma • Liver impairment • Hypoproteinemia