Week 4 --Hypovolemic Shock

Question 1

Hypovolemic Shock is caused by a decrease in intravascular volume of ____________

Answer 1

>15% or more

Question 2

Normal cardiac output (L/min)

Answer 2

4-8 L/min

Question 3

Causes (2) of Hypovolemic Shock

Answer 3

• Loss of Blood Volume
  
  • Surgery
  • Burns
  • Trauma
  • Diabetes Ketoacidosis
• LOSS OF FLUID
  
  • Diuresis
  • Vomiting
  • diarrhea

Question 4

Medical Management of Hypovolemic Shock

Answer 4

• GOALS of TX
  
  • Restore intravascular volume
    
    • ^{GOAL: MAP > 65mmHg}
  • Correct underlying cause as quickly as possible
    
    • HEMORRHAGE?
      
      • find and stop the bleeding
      • replace lost blood volume
    • BURNS…?
      
      • treat fluid loss from burns
    • DEHYDRATION…?
      
      • Restore Plasma Volume
• Initial TX:
  
  • ^{IV Fluid (2 L Crystalloids)}
• First Line Tx:
  
  • ^{Blood products as indicated for blood loss or further IV crystalloid}
• Second Line Tx:
  
  • ^{Norepinephrine}
    
    • ^{​initiates peripheral vasoconstriction}
  • ^Dopamine
    
    • ^{<strong><em>​Low dose</em></strong>- increases renal perfusion}
    • ^{<em><strong>High dose</strong></em>-vasoconstriction effects-decreases renal perfusion}
  • ^Epinepherine
    
    • ^{​Initiates peripheral Vasoconstriction}
    • ^{increased rate}
    • ^{increased contractility}

Question 5

1ST STEP IN THE TX PROCESS IS TO ADMINISTER FLUIDS

Fluids that are administered for

HYPOVOLEMIC SCHOCK

Answer 5

• ^{<strong>GOAL: TO RESTORE INTRAVASCULAR COLUME TO MAINTAIN PERFUSION</strong>}
• CRYSTALLOIDS
  
  • Isotonic —> 0.9% NSS, Lactated Ringers
  • Hypertonic—>3% or 7.5% saline
• BLOOD COMPONENTS
  
  • PRBC’s, Platelets, FFP

Question 6

2ND STEP IN THE TX PROCESS IS TO ADMINISTER VASOACTIVES

GOAL of VASOACTIVE medication

Answer 6

• to improve hemodynamic stability when fluid therapy alone cant maintain adequate MAP ^{(MAP <60 mmHg can indicate poor perfusion)}

Question 7

ACTIONS OF VASOACTIVES (4)

Answer 7

1. Increase strength of myocardial contractility (stronger contractions)
2. Reduce afterload
3. Initiates Vasconstriction to increase preload
4. Regulating HR to maintain Cardiac Output

Question 8

Choice of Vasoactive medication is based on (2) things

Answer 8

• TYPE OF SHOCK
  
  • If you are dealing with a cardiogenic shock that is impairing the hearts ability to contract….maybe you want a medication to help to strengthen contractility? Or maybe you want a medication that vasodilates to make it easier for the heart to work to keep it from becomming further damaged
• DESIRED OUTCOME

Question 9

What must be completed first…prior to giving vasoactive?

Answer 9

must replace fluid volume first!

_**BECAUSE OTHERWISE WE ARE “CLAMPING DOWN” ON EMPTY VESSELS AND NOT BENEFITING THE PATIENT AT ALL_

Question 10

How are vasoactives typically administered?

why?

Answer 10

Via a central line because they tend to be “vessicants” which can cause great damage if it leaked into our tissues

_***IF YOU MUST USE A PERIPHERAL LINE FOR ADMINISTRATION THAN YOU MUST MONITOR VERY CLOSELY FOR ANY SIGNS OF INFILTRATION_

Question 11

NURSING CONSIDERATIONS

(5)

when giving Vasoactives

Answer 11

• ^{<strong>FREQUENT MONITORING OF EFFECTIVENESS</strong>}
  
  • Regular titration may be needed based on the ever changing needs of the patient.
  • Monitor….BP, MAP, HR, Urine Output, MS changes, SpO2
• ^{MONITORING FOR INFILTRATION IF NOT RUNNING THROUGH CENTRAL LINE}
• ASSESS FOR DECREASED PERIPHERAL CIRCULATION
  
  • ​Frequent assessment of pulses, bowel sounds
• ^{<span>CAREFUL ADMINISTRATION AS DOSAGES ARE OFTEN IN MCG/MIN; MCG/KG/MIN, ETC</span>}

Question 12

What do “adrenergic” medications do?

Answer 12

• mimic the fight /flight response of SNS by activating ALPHA and BETA receptors

Question 13

Stimulation of the _________ Receptors initiates Peripheral Vasoconstriction (increasing Preload,CO, BP)

Answer 13

ALPHA Receptors

Question 14

Stimulation of the BETA Receptors does what?

Answer 14

INCREASED FORCE and RATE OF MYOCARDIAL CONTRACTION *Increased Force (Contractility) also called INOTROPY *Increased Rate also called CHRONOTROPY

Question 15

What is a INOTROPE?

Answer 15

an agent that alters the force (Contractility) of cardiac muscular contractions

Question 16

What is CHRONOTROPIC?

Answer 16

a drug that alters the heart rate

Question 17

Stimulation of these receptors will increase the FORCE (Contractility) and RATE of the myocardial contraction

Answer 17

BETA RECEPTORS

Question 18

Three medications that will stimulate the ALPHA Receptors

Answer 18

Phenylepherine

Norepinepherine

Epinepherine

Question 19

Three (3) medications that will stimulate the BETA Receptors

Answer 19

Dobutamine (INOTROPE)

Dopamine (INO, CHRONOTROP)

Epinepherine (INO, CHRONOTROP)

Question 20

disadvantages of stimulating the ALPHA RECEPTORS in a patient with damaged heart?

Answer 20

Increased workload and Increased O2 demands of the heart from increasing the afterload Afterload was increased when the alpha receptors were stimulated—->leading to increased PRELOAD, CO and BP

Question 21

NURSING MANAGEMENT OF HYPOVOLEMIC PATIENT

Answer 21

• ASSESS / INTERVENE when Intravascular loss is evident
  
  • sudden drop in CVP
  • Decreased BP with S/S poor perfusion
  • Identify “at Risk” patients
    
    • multiple injuries
    • burns
    • recently undergone surgery
    • pt on diuretics
    • Diabetes Insipidous patient
• MONITOR PT’S RECEIVING VASCULAR REPLACEMENT
  
  • Frequent VS
  • Respiratory assessment
    
    • ^{b/c if we are giving fluids back- we place the patient at risk for fluid volume overload}
  • S/S of blood reaction
    
    • ^{Febrile reaction}
      
      • ^{increase in temperature 1° Celcius above their baseline}
        
        • ^{Give tylenol and continue with transfusion}
    • ^{Hemolytic Reaction}
      
      • ^{​breakdown of RBC}
        
        • ^{​Stop transfusion immediately!}
• LAB EVALUATIONS
  
  • ​Hemoglobin level is best for detecting blood loss
  • Loss > 2gm/dL indicates active blood loss

Question 22

(5) AT RISK patients

for

Hypovolemic shock

Answer 22

1) multiple injuries

2) Burns

3) recently undergone surgery

4) pt on diuretics

5) diabetes insipidous patient

Question 23

Expected lab results for hypovolemic shock Serum Lactate

Answer 23

> 2 mmol / L **this increase is an indicator that anaerobic metabolism is occurring in the body

Question 24

Potassium level (Normal level)

Answer 24

3.5 - 5

Question 25

Sodium level (NORMAL)

Answer 25

135 - 145

Question 26

Hemoglobin level (Normal) what do you anticipate it to be for hypovolemic shock patient?

Answer 26

Normal = 12 - 18 g/dL DECREASED with Hemorrhage INCREASED with Dehydration

Question 27

Hct level (Normal for hypovolemic patient?

Answer 27

NORMAL = 37 % - 52% DECREASED with Hemorrhage INCREASED with Dehydration

Question 28

EXPECTED RESULTS FOR ABG’S

PH 7.35 - 7.45 (normal) PaCo2 35 - 45 (Normal) PaO2

Answer 28

• PH
  
  • decreased (acidosis)
• PaCo2
  
  • Increased (Respiratory issue
• PaO2
  
  • Decreased

Question 29

EXPECTED RESULTS FOR:

^{<strong>BUN / CREATININE</strong>}

Answer 29

• BUN
  
  • ELEVATED ^{(normal = 10 - 20 mg/dl)}
• CREATININE
  
  • ELEVATED^{<em> (normal = 0.5 - 1.5 mg / dl)</em>}

Question 30

Normal Central Venous Pressure

(CVP)

Answer 30

2 - 8 cm H₂0

_{<em>(OR)</em>}

2 - 6 mm Hg

Question 31

Measurement of blood pressure in the

thoracic vena cava, near the right atrium

Answer 31

Central Venous Pressure (CVP)

• Measures:
  
  • ​Amount of blood returning to the heart
  • ability of the heart to pump the blood into the arterial system
  • Hemodynamics
    
    • ^​PRELOAD
    • ^{VOLUME OVERLOAD}
    • ^{CARDIAC OVERLOAD}
    • ^SEPSIS
  • Normal values for CVP
    
    • ^{​2 - 8 cm H20} (or)
    • ^{<strong>2 - 6 mm Hg</strong>}

Question 32

what does CVP measure

Answer 32

–Indicated mean right atrial pressure –frequently used as an estimate of right ventricular preload __does NOT measure blood volume-only estimates it

Question 33

what lab is best for detecting blood loss?

Answer 33

• HEMOGLOBIN
  
  • Loss >2 gm/dL ^{indicates active blood loss}

Question 34

HYPOVOLEMIC SHOCK FLUID….???

^{Initial FluidTreatment:}

^{First-Line Agent(s):…..}

^{Second-Line Agent(s)….}.

Answer 34

• INITIAL FLUID TX:
  
  • IV FLUID-2L of Crystalloid
• 1st LINE AGENT
  
  • blood products for blood loss (or)
  • further IV crystalloids
• 2nd LINE AGENT
  
  • Norepinephrine ^{<em>(Levophed)</em>}
  • Dopamine ^{<em>(Intropin)</em>}
  • Epinephrine

Question 35

Stimulation of ALPHA RECEPTORS does what?

Answer 35

INITITATES PERIPHERAL VASOCONSTRICTION

*increased PRELOAD

*increased CARDIAC OUTPUT

*increased BP

Question 36

Disadvantages of taking meds that

stimulate the ALPHA receptors (2)

Answer 36

1) increased workload of heart

2) increased O2 demands of heart

^{<em>**r/t increased afterload –not good for damaged heart</em>}

Question 37

Disadvantages of taking meds that

stimulate the BETA receptors (2)

Answer 37

1) increased workload of heart

2) increased O2 demands of heart

*^{**r/t increasing HR and contractility}*

Question 38

Central Venous Pressure (CVP)

Answer 38

• Measure blood pressure in the thoracic vena cava (near the right atrium)
  
  • hint: ^{this is where all the returning blood from the body goes through and it is measuring pressures in the right side of the heart. Anything that would decrease pressure in the right side of the heart is going to result in low CVP}.
  • ^{most common reason for decreased pressure—>is decreased volume}
• Measures:
  
  • Amount of blood returning to the heart
  • Ability of the heart to pump the blood into the arterial system
  • Hemodynamics
    
    • ^{<em>PRELOAD</em>}
    • ^{<em>VOLUME OVERLOAD</em>}
    • ^{<em>CARDIAC FAILURE</em>}
    • ^{<em>SEPSIS</em>}
• NORMAL VALUES: 2-8 cm H₂Oor2-6 mm Hg

Question 39

^{<em><u><strong>STIMULATION OF THE ALPHA RECEPTORS:</strong></u></em>}

Advantages

^{►Results in _________which increases______…which increases CO & BP}

_*Disadvantages*:_

►^{Increased______and_______ demands of heart by increasing afterload}

^Medications:

►____________, ___________ & _____________

Answer 39

• ^{<strong>Advantages:</strong>}
  
  • peripheral vasoconstriction
  • Preload
• ^{<strong>Disadvantages:</strong>}
  
  • increases workload
  • O₂
• ^{<strong>Medications:</strong>}
  
  • Phenylephrine
  • Norepinepherine
  • Epinepherine

Question 40

^{STIMULATION OF THE <strong><em><u>BETA</u></em></strong> RECEPTORS:}

^{<strong><u>Advantages</u></strong>}

^{►Results in _________and / or______ of mycardial contraction}

^{<u><strong>Disadvantages:</strong></u>}

^{►Increases______and_______ demands of heart by increasing rate and contractility}

^{<strong><u>Medications:</u></strong>}

^{►____________,___________ & _____________}

Answer 40

^{<strong><u>Advantages:</u></strong>}

• ^{increased force}*
• ^rate*

^{<strong><u>Disadvantages:</u></strong>}

• ^workload*
• ^O2*

^Medications:

• Dobutamine ^{(<strong>inotrope)</strong>}*
• Dopamine ^{(<strong>ino and chronortrope</strong>)}*
• Epinepherine ^{<strong>(Ino and Chronotrope)</strong>}*

Question 41

Best position for patient in hypovolemic shock

Answer 41

Trendelenburg