Week 10 THURS Flashcards
Adult shock
What type of shock is caused from an infection
septic
what diagnostic would help the nurse if she is concerned about hypoxemia/ metabolic acidosis
ABG’s
What is one common clinical manifestation of cardiogenic shock
low BP
how does shock occur
it occurs when blood flow and O2 delivery to tissues and cells are inadequate
All forms of shock have which characteristic in common?
A. Inadequate circulating fluid levels
B. Loss of sympathetic nervous system innervation
C. Tissue oxygen supply in excess of oxygen demand
D. Imbalance between tissue oxygen supply & demand
D!
Preload
filing heart( how much the heart fills w/ blood before it contracts)
Afterload
pushing against resistance ( how much resistance the heart has to overcome to pump blood out)
Cardiac output
hearts workload (amt of blood heart pumps out each minute)
stroke volume
amt of blood pumped out by the heart w/ each beat
Contractility
how forcefully the heart squeezes
The nurse is titrating vasopressin on a client for treatment of shock. The healthcare provider has just ordered that the drug be discontinued. How should the nurse comply with this order?
A. Stop the drip immediately
B. Gradually decrease the rate of flow over time
C. Increase the maintenance IV fluid rate prior to discontinuing
D. Decrease the rate over a 1 hour period and discontinue
D.
- slowly over an hour
- make sure pt doesn’t get rebound hypertension
General nursing management of shock
- monitor tissue perfusion
- monitor vs changes
- interventions to optimize oxygen delivery
- fluid resuscitation
- decrease total body work
- reduce pain/ anxiety
s/s of shock states
appearance; cold clammy skin, pallor, cyanosis
VS; hypotensive, tachycardia, tachypnea
LOC; confusion, decreased LOC
low urine output, hypoactive bowel
high serum lactate
low map
What meds goal is to maximize tissue perfusion by stimulating or blocking alpha and beta-adrenergic receptors
vasoactive drugs
T or F vasoactive meds are first line meds
FALSE
- they are not!!
What med increases BP by vasoconstriction
vasopressor agents
Vasopressor agent administration characterisitcs
- give through IV, highly cytotoxic
- onset of actions almost immediate
- titrated based on the physician orders
What med improves heart contractility, increase stroke volume and cardiac output
- increases co by mimicking the actions of the sns, activating myocardial receptors to increase myocardial contractility or increase HR
inotropes
What med is characterized as afterload reducing (vasodilating) drugs that improve cardiac output and oxygen delivery
vasodilators
Examples of vasodilators
nitroglycerin and nitroprusside
What type of shock is decreased intravascular volume
- The most common type of shock
hypovolemic shock
External and internal fluid shift examples for hypovolemic shock
- surgery, trauma, swelling, diarrhea
- internal bleeding, burns, dehydration
Patho of hypovolemic shock
- decreased intravascular volume >
- decreased venous return >
- decreased stroke volume >
- decreased cardiac output >
- decreased tissue perfusion
Clinical manifestations of hypovolemic shock
- decreased intravascular blood volume, decreased cardiac output, decreased tissue perfusion
- hypotension, tachycardia, cool/clammy skin, pallor, decreased peripheral pulses
- anxiety, altered LOC, cyanosis, arrythmais, decreased O2
Diagnosis of Hypovolemic shock
- assessment; hypoperfusion> drop in O2, low BP, ECG changes
- lab test; metabolic acidosis, hgl, hct
- imaging; x-ray and ct
Treatment for Hypovolemic shock
- stabilize blood pressure and maintain perfusion
- fluid reuscitation
- vasopressor meds
- address underlying causes first!!
Nursing management of hypovolemic shock
- restore and maintain intravasular volume
- monitor for fluid overload and complications
- monitor for improved or worsening hemodynamic stability
When caring for a patient in hypovolemic shock who is receiving large volumes of IV isotonic fluids, the nurse should monitor for symptoms of:
A. Hyperthermia
B. Pain
C. Pulmonary edema
D. Tachycardia
C!!
What type of shock occurs when the hearts ability to contract and to pump blood is impaired and the supply of O2 is inadequate for the heart and tissues
cardiogenic shock
Pathophysiology of cardiogenic shock
- decreased cardiac contractility >
- decreased stroke volume and cardiac output >
- which leads to pulmonary congestion, decreased systemic tissue perfusion, or decreased coronary artery perfusion >
- which then goes back to decreased cardiac contractility
Clinical manifestations of cardiogenic shock
- angina - faint pulses
- fatigue - hypotension
- arrythmias
- cyanosis
- clammy, cold, cyanotic
- JVD
Diagnosis of cardiogenic shock
- cardiac biomarkers; BNP, cardiac enzymes, serum lactate
- ECG and ST segment changes
Treatment of cardiogenic shock
- Goal: limit further myocardial damage & preserve healthy myocardium, improve cardiac function by increasing cardiac contractility, decreasing ventricular afterload
- Treat underlying cause
- First line: focused on adequate oxygenation, pain control, hemodynamic stability
Nursing management of cardiogenic shock
- prevention
- monitor hemodynamics
- administer medications and fluids
What type of shock occurs when the intravascular volume pools in peripheral blood vessels > causes relative hypovolemia because not enough blood returns to the heart, which leads to inadequate tissue perfusion
- systemic vasodilation and decreased blood flow to vital organs such as the brain, heart, and kidneys. It can also cause fluid to leak from the capillaries into the surrounding tissues as a result.
Distributive shock
3 subtypes of distributive shock
- Septic
- anaphylactic
- neurogenic
Patho of distributive shock
- precipitating event (injury/assault)
- causes vasodilation
- then activates the inflammatory response
- then maldistribution of Intravasular volume
- then decreased venous return
- which causes decreased cardiac output
- and then causes deceased tissue perfusion
- Most common type of distributive shock
- life-threatening organ dysfunction caused by dysregulated host response to infection
Septic shock
RF for septic shock
- immunosupression
- malnourishment
- chronic illness
- invasive procedures
- surgeries
infection confirmed or suspected and systemic inflammatory response syndrome criteria
sepsis
Clinical manifestations of septic shock
- inital; hyperthermia, tachycardia, bounding pulses, n/v/ decreased GI motility
- later; severe hypotension, cool, mottled skin, organ dysfunction
Diagnosis of septic shock
- blood, sputum, urine cultures
- wound drainage cultures
- invasive catheters sent for culture
Treatment of septic shock
- Identify & initiate treatment for patients in early sepsis within 1 hour to optimize patient outcomes
- Remove IV lines and reinsert into alternative site
- if possible remove urinary catheters and reinserted
- fluid replacement
- pharmacologic therapy> pain/ antibiotics/ vasopressors
Nursing management of septic shock
- monitor all lines, tubes, and drains
- obtain cultures
- monitor for effectiveness of medication
- monitor blood levels
- daily wts, I &O
- assess for changes in VS
Loss of vascular sympathetic tone and subsequent unopposed parasympathetic response
- Most common cause: blunt injury to spinal cord above T6
Neurogenic shock
Clinical manifestations of Neurogenic shock
- dry, warm skin
- hypotension w/ bradycardia
- sensory and motor deficits distal to affected spinal cord levels
- hypothermia
treatment of neurogenic shock
- ABCDE assessment> stabilize ABC
- stabilize spinal cord
- restore sympathetic tone
- surgical stabilization
Nursing management of Neurogenic shock
- support cardiovascular and neuro function
- high risk of VTE> passive ROM, antithrombotic agents, monitor s/s infections
- usually want MAP 85-90 to perfuse spinal cord
Severe allergic reaction when patients have already produced antibodies to an antigen develop a systemic antigen (IgE) antibody reaction> provokes mast cells to release potent vasoactive substances (histamine & bradykinin) and activates inflammation> causes widespread vasodilation and capillary permeability
- mild and severe types
Anaphylactic Shock
Mild Anaphylactic Shock clinical manifestations
headache, lightheadedness, nausea, vomiting, pruritus, generalized flushing, dyspnea, bronchospasm, cardiac arrhythmias, hypotension
Severe anaphylactic shock
clinical manifestations
Rapid hypotension, decreased LOC, respiratory distress, cardiac arrest
Medial management of anaphylactic shock
- remove causative agent
- administer meds to restore vascular tone; epi, benedryl, nebs
- provide emergency support
- fluid managment
Nursing management of anaphylactic shock
- prevention and early recognitiion
- ask about all allergies and reactions
- observe for reactions when administering new meds
T or F sirs comes first before mods
True!
sirs triggers the immune system overproduction of inflammatory cytokines and mediators
the Overproduction of inflammatory cytokines is often referred to as “cytokine storm”, and in combination with prolonged hypotension, it can lead to hypoperfusion of multiple organs, hypoxic damage, and progressive organ dysfunction.
systemic inflammatory response syndrome (sirs)
Sirs diagnosis
At least 2 criteria must be met;
WBCs below 4000 (leukopenia)
WBC above 12000 (leukocystosis)
Body temperature: hypo or hypertension
HR >90 (tachycardia)
RR>30 (tachypnea)
Clinical manifestations of SIRS
Vital signs: temperature, HR, respiratory rate)
Leukocyte count
Decreased UO
Altered LOC
Continuum of mild to severe
Severe SIRS can progress to MODS
- Altered organ function in acutely ill patients that requires medical intervention to support continued organ function
- Progressive dysfunction of 2+ organ systems that persists >24 hours
Multiple organ dysfunction syndrome (mods)
Primary MODS pathway
- Develops early (within first 72 hours of admission)
- Direct consequence of well-defined initiating event, such as injury, hemorrhage, or hypoxemia
- Inadequate oxygen delivery to cells
- Failure of microcirculation to remove metabolic end-products
Secondary MODS pathway
- Host response to toxins that occurs within context of S I R S rather than as direct response to initiating insult
- Onset later in patient’s course, often weeks after initial acute insult
MODS pathophysiologic considerations
Pathologic Changes;
- Uncontrolled systemic inflammation
- Tissue hypoxia
- Unregulated apoptosis
- Microvascular coagulopathy
Risk Factors;
- Primary M O D S: increased severity of injury, shock, and S I R S
- Secondary M O D S: infection, transfusion, multiple surgical operations
What organ system tend to fail first?
Lungs(respiratory)!
Sequential organ injury w/ MODS and shock
- pulmonary dysfunction
- cardiovascular dysfucntion
- hypermetabolic
- Acute kidney dysfucntion
- neurolgic dysfucntion
- Liver and GI dysfunction
- hematologic dysfunction
Management of shock and MODS
- prevent SIRS and sepsis
- detect early SIRS, sepsis, and MODS
- implement treatment plan
Primary goal of management of MODS
hemodynamic management and monitoring to maintain adequate tissue perfusion
The nurse is caring for a 68 year old client with extensive cardiovascular disease. Which type of shock is the client most likely to develop?
Cardiogenic shock
Neurogenic shock
Septic shock
Anaphylactic shock
Cardiogenic shock
The nurse is caring for a client who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. Which is priority for the nurse to monitor related to this treatment?
Hyperthermia
Presence of S3 & S4 gallops
Crackles
Jugular vein distension
Crackles> fluid overload s/s
The nurse is providing care for a client who is in shock after massive blood loss from a workplace injury. Which compensatory mechanism to increase cardiac output during hypovolemic states is identified by the nurse? Select all that apply
third spacing of fluid
Dysrhythmias
Tachycardia
Gastric hypermotility
Slight elevation in BP
Tachycardia and Slight elevation of BP
- Tachycardia and a slight increase in blood pressure is a primary compensatory mechanism to increase cardiac output during hypovolemic states
The nurse is caring for a client whose infection places them at high risk for shock. Which assessment findings would the nurse consider a potential sign of shock?
Lethargy
Elevated MAP
Shallow, rapid respirations
Bradycardia
Hypotension
- Lethargy
- shallow, rapid respirations
- hypotension
A client experiencing shock will have shallow, rapid respirations and be lethargic. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg. Bradycardia occurs in neurogenic shock, but other states of shock have tachycardia as a symptom.
