Week 10 Flashcards
What is shock?
Shock is a syndrome characterised by tissue ischaemic from decreased perfusion and impaired cellular metabolism.
It is generalised as a state of hypo-perfusion.
What are the signs and symptoms of shock?
- increased pulse rate (this may be the only early sign)
- pallor/sweat
- reduced urine output (<30ml/hr)
- reduced conscious level
What is hypovolaemic shock and what can it be caused by?
- it is when there is a decrease in intravascular blood resulting in inadequate tissue perfusion. = low blood volume
- can be caused by:
- bleeding= internal/external
- diarrhoea/vomitting
- dehyration
Differentiate among the clinical findings during the 3 stages of shock and identify how the management strategies change.
- Compensatory stage- pt displays “fight or flight response”. Treatment is aimed at identifying cause of shock, preventing it’s progression and initiating fluid and pharmacological interventions.
- Progressive stage - BP can no longer compensate, the Mean Arterial Pressure (MAP) falls below normal limits. All organ systems start to suffer from hypoperfusion and ischaemia begins. Treatment is dependant on pt health prior to shock and amount of time it takes to restore perfusion.
- Irreversible stage- reached a point which the organ damage is so severe the pt cant survive and doesn’t respond to treatment. Treatment is to initiate comfort measures and try experimental strategies. Inform the family
Why does shock affect all body systems?
During shock the body struggles to survive, calling on all its homeostatic mechanisms to restore blood flow and tissue perfusion.
Systemic BP is inadequate to deliver oxygen and nutrients to support vital organs and cellular function.
what are the symptoms of hypovolaemic shock?
- increased pulse rate - sometimes the only early indication sign
- tachycardia
- low BP
- anxiety
- altered in LOC
- tachypnoea
- sweat/pallor
- decreased urinary output
- shallow respirations
- hypotension (usually the last thing to drop)
List the nursing management for Hypovolemic shock.
- pt assessment = ABCDE (need to stablise these 1st)
- vital signs
- maybe pt position - trendelenburg = assist with haemodynamic
- provide reassurance/comfort
- oxygen support = non-rebreather (15L), venturi
- provide IV access
- fluid support (to restore intravascular volume) = crystalloids (NS), colloids (plasma proteins), bloods
- provide nutritional support = (parentral, enteral) = TPN, ensure, administer glutamine (trauma pt’s).
How do you locate the bleeding?
- physical examination = (look for external factors 1st)
- CXR
what is the most common and serious side effects of fluid replacement?
- cardiovascular overload
- pulmonary oedema
describe the clinical manifestations of a person suffering from severe hypovolaemic shock
Consider a non-responder
- BVL=>40% ->2000mL
- confused and lethargic
- RR - >35bpm
- BP - barely recordable if at all
- HR - >140bpm
- urine negligible
describe the clinical manifestations of a person suffering from moderate hypovolaemic shock
considered transient
- BVL = 30-40% - 1500-2000mL
- confused, anxious
- HR - >120bpm
- BP - decreases
- urine - 5-15ml/hr
- RR- 30-40 bpm
describe the clinical manifestations of a person suffering from mild hypovolaemic shock
considered responder
- BVL = 15-30% - 750mL
- slightly anxious
- HR - <100bpm
- urine- 30mL/hr
- RR- 14-20bpm
- BP- normal
