Week 4 - SHOCK Flashcards
Med-Surge
_____________ sympathetic stimulation increases vasoconstriction and systemic vascular resistance
increased
Nutritional Support for shock patient 1) GOAL 2) interventions
GOAL: Maintain caloric requirements 1) Parenteral or enteral nutrition shoulds be started asap
Elevated Serum Lactate Level?
> 2 mmol/L
As a result of REDUCED cardiac output…a narrowing pulse pressure is often consistent with ….(2)
1) hypovolemia 2) cardiogenic shock
S/S of Stage 1 (Early / Compensated Shock)
- NEURO: Anxiety, confusion, restlessness, altered mental status
-
CARDIAC: BP* *often remains* *normal and helps to maintain adequate CO and vascular tone (hypotension typically begins in stage 2)
- VASOCONSTRICTION (narrow pulse pressure- <em>distance between systolic / diastolic)</em>
- INCREASED HR (slight tachycardia)
- INCREASED CONTRACTILITY (bounding central pulses)
-
RESPIRATORY
- SLIGHT INCREASE IN RATE
EARLY INTERVENTION AT THIS STAGE CAN PREVENT PROGRESSION TO SHOCK
Whys is nutrition a critical component when treating a SHOCK patient.
-Shock increases metabolic rates d/t catecholamine. -This leads to an INCREASED CALORIC NEED by the body -If nutrition is NOT maintained the body will break down the skeletal muscle to accomodate the increased need -Loss of skeletal muscle prolongs recovery time
Condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs and cellular function
SHOCK
S/S of Stage 3
(Irreversible Shock)
-
NEURO: Obtunded, Stuporous, Comatose or unresponsive
- Obtunded: responds slowly to external stimuli. needs repeated stimulation to maintain attention and response to the environment
- STUPOROUS:responds minimally with vigorous stimulation
- Comatose: no observable response to external stimuli
- CARDIAC: Bradycardia with arrhythmias. Severe Hypotension MAP < 60 mmHg despite therapy
- RESPIRATORY: Bradypnea w/Shallow breaths (Cheynes Stokes)
- INTEGUMENTARY: Coagulopathies with petechiae purpura, or bleeding
TRUE | FALSE The Body uses a variety of compensatory mechanisms to restore blood flow
TRUE
Stimulation of BETA 1 adrenergic receptors leads to:
*increased heart rate *increased myocardial contractility *increased rate of conduction through the AV NODE *activation of the receptors in the kidney leads to the release of renin.
Nursing Management of Stage 1 shock (Early / compensatory)
- Assess and identify the cause of shock
- Correct underlying disorder
- Initiate measures aimed at supporting the bodys compensatory mechanism
- Fluid and medication therapy
-
Monitor hemodynamic status
- Vital signs
- LOC
- Urinary output
- Skin temp/color
- peripheral pulses
- lab values
decreased systemic stimulation allows___________, which decreases systemic vascular resistance
vasodilation
Stimulation of BETA 2 adrenergic receptors leads to…
-Bronchial stimulation leads to bronchodilation *activation of receptor in uterine * activation of receptors in the liver causes a breakdown of glycogen into glucose *Skeletol muscle receptor activation, leads to muscle contraction which can lead to seizures
STROKE VOLUME
Amount of blood pumped into the aorta with each contraction of the left ventricle
Goals (6) of patient care in Stage 2
- INTERVENTIONS SHOULD DEPEND ON THE TYPE OF SHOCK AND ITS UNDERLYING CAUSE
- Optimize intravascular volume
- Support the pumping action of the heart <em>(Using medication and\or therapy)</em>
- Improve competence of the vascular system <em>(meds that assist with vasoconstriction / vasodilation) </em>
- support the respiratory system
- Continual assessment and reassessment of the bodys response to interventions
- Involve patient and family in the plan of care—end of life issues–expected outcomes
Stage where Lactic Acid moves out of the intracellular and into the intravascular places
Stage 2
Lactic acid production creates an _______________ intracellular environment which creates capillary permeability (aka: leaky cells). The increased capillary permeability causes the intracellular components to become extracellular components—leading to a metabolic state called __________ ___________
acidotic METABOLIC ACIDOSIS
One of the most important factors in decreasing the probability a patient will end up in shock?
EARLY DETECTION **we must be able to recognize subtle as well as obvious signs
what is “Stroke Volume” ?
amount of blood pumped into the aorta with each contraction of the left ventricle.
To maintain cellular metabolism- the cells of all body organs and tissues require a regular and consistent supply of__________and removal of ___________
oxygen metabolic wastes
Patient with good perfusion uses _________ metabolism to create energy
aerobic
NORMAL PT (Pro Thrombin)
10-15 seconds
NORMAL INR Lav values
1 - 1.2 seconds
S/S of Stage 2
(Intermediate / Progressive-Uncompensated)
-
NEURO
- Decreasing LOC
-
CARDIOVASCULAR
- Obvious Tachycardia >100 bpm
-
DECREASED BLOOD PRESSURE (hypotension)
- <strong></strong>d/t epinepherine / norepinepherine starting to wear out
- Weak Thready Pulses (difficult to palpate)
- Cool, Clammy, cyanotic skin <em>(d/t peripheral vasoconstriction)</em>
-
RESPIRATORY
- Rapid, shallow breaths<em> (body attempting to blow off CO2 and balance out the high lactic acid level)</em>
-
LABS
- Elevated Lactate Levels >2 mmol/L
- (this increase is indicative of anerobic metabolism occurring in the body)
Progression into STAGE 3 (refractory / irreversible shock)
- Happens when tissue perfusion cannot be restored
- Organ damage from anoxia and cellular death can become so severe that the patient cannot survive despite all treatments provided
With regard to the vascular system.,,,the vessels in the body need to have good “tone”. What is tone?
Tone is the ability to constrict or dilate to maintain normal pressure
difference between systolic and diastolic blood pressure
pulse pressure
Progression of SHOCK in “5” steps:
1) Poor delivery of O2 and nutrients to cells 2) Cellular starvation 3) Cell death 4) Organ dysfunction 5) Organ failure and death
(true | false) Bodies do NOT function well in a acidotic state
TRUE
Adequate Tissue Perfusion requires (3)
1) Adequate Cardiac Pump 2) Effective vasculature & circulatory system 3) Sufficient blood volume **IF ONE OF THESE IS IMPAIRED, TISSUE PERFUSION IS THREATENED AND\OR COMPROMISED
SYMPATHETIC NERVOUS SYSTEM (SNS) maintains the smooth muscle surrounding the arteries and arterioles in a state of partial contraction called ____________
sympathetic tone
In the absence of sufficient O2, cells revert to using ___________ metabolism to create energy
anaerobic
Three (3) Stages of shock
1) Early, reversible & compensatory 2)Intermediate or Progressive (Uncompensated) 3) Refractory or Irreversible
This process indicates that anaerobic metabolism is occurring in the body
Elevated Serum Lactate
Define “Cardiac Output” What is the FORMULA?
the amount of blood (L/min) pumped per minute into the aorta by the left ventricle. Cardiac Output = Stroke Volume x Heart Rate
Respiratory support for Shock
GOAL: increase the amount of O2 carried by the hemoglobin in the blood 1) continuous pulse-ox monitouring 2) frequent respiratory assessments 3) Mechanical ventilation if respiratory failure occurs
Mean Arterial Pressure (MAP)
Average Pressure in the arterial circulation throughout the cardiac cycle. *it is the product of CARDIAC OUTPUT and Systemic Vascular Resistance (SVR) **CO, SVR, or total blood volume rises conversely so does your MAP and tissue perfusion **CO, SVR or total blood volume falls– then MAP and tissue perfusion also decrease
Three factors that make up “Stroke Volume”
1) Preload 2) Afterload 3) Contractility
Anaerobic metabolism leads to the production of ________
Lactic acid
(9) Nursing Management of Stage 2 shock (Intermediate / Progressive-Uncompensated)
-
Pt needs to be closely monitored in ICU
- Invasive hemodynamic monitoring (CVP)
- Telemetry monitoring (Continuous ECG)
- ABG’s (watching their PH and acidotic state)
- ELECTROLYTES (b/c they become altered in an acidotic state)
- PHYSICAL and MS changes (improving or worsening mental status?)
-
RAPID & FREQUENT ADMIN OF MEDS & FLUIDS
- Usually require vasopressors with titration
-
SUPPORTIVE THERAPIES (IF OUR ORGANS BEGIN TO FAIL)
- Mechanical Ventilation (respiratory failure)
- DIalysis (renal failure)
- NURSE NEEDS EXPERTISE IN ASSESSING AND UNDERSTANDING THE SIGNIFICANCE OF CHANGES IN DATA
Widening pulse pressure is consistent with ________ Narrow pulse pressure is consistent with _________ and ______________
Septic shock hypovolemia, cardiogenic shock
Nursing Management of Stage 3 shock
(Irreversible Shock)
- SAME TX AS FOR THE SECOND STAGE
- Monitoring patient
- Preventing complications
- Protection from injury
- Providing comfort / dignity
- Communication with family about outcome ***explain about what is happening **Offer opportunities to see, touch, talk **Spiritual advisors visitation
Stimulation of ALPHA 1 adrenergic receptors is responsible for ….?
Stimulation of this receptor site causes vasoconstriction of: Arterioles of skin viscera | mucous membranes
NORMAL aPTT (lab value)
< 35 seconds
PROGRESSION INTO STAGE 2
- Body loses the ability to compensate
- Clinical signs become more obvious (pt becomes symtomatic)
- Inflammatory response activated (can lead to ARDS)
- Decreased perfusion leads to extracellular acidotic state (metabolic acidosis)
- Coagulation become impaired
- AGGRESSIVE TX IS ESSENTIAL TO SURVIVAL OF THE PATIENT
- Sustained decrease in MAP of 20 mmHg or more below normal level
- Fluid loss of 35% - 50%
l
EARLY INTERVENTION AT THIS STAGE CAN PREVENT PROGRESSION TO SHOCK
EARLY / COMPENSATED SHOCK
TRUE / FALSE ANY CONDITION THAT COMPROMISES OXYGEN DELIVERY TO ORGANS AND TISSUES CAN LEAD TO SHOCK
TRUE
Explain process of anaerobic metabolism (5)
1) Absence of sufficient O2–>cells revert to anaerobic metabolism 2) Anaerobic metabolism leads to the production of lactic acid 3) This creates an acidotic intracellular environment 4) This increases capillary permeability 5) This permeability causes LEAKAGE of intracellular components which leads to increased extracellular acidosis.
PRELOAD vs AFTERLOAD
-
PRELOAD
- vOLUME OF BLOOD IN VENTRICLE JUST BEFORE IT CONTRACTS
-
AFTERLOAD
- THE PRESSURE THE HEART HAS TO OVERCOME IN ORDER TO GET BLOOD OUT (vasculature)
When our Systemic Vascular Resistance is very high–(meaning that we are very clamped down and vasoconstricted) then our afterload is very ____________
HIGH
PRELOAD is INCREASED in what types of situations?
*hypervolemia
*regurgitation of cardiac valves
*Heart failure
AFTERLOAD is INCREASED in what types of situations?
*Hypertension
*Vasoconstriction
INCREASED AFTERLOAD = INCREASED CARDIAC WORKLOAD
In the early stages of shock the body is doing things to BOOST cardiac output and the body releases excessive amounts of EPINEPHERINE and NOREPINEPHERINE. These are natural VASOPRESSORS that assist in boosting HR and CO. What are the neurological S/S that the patient will begin to demonstrate?
ANXIETY
CONFUSION
RESTLESSNESS
what is the PULSE PRESSURE OF 120 / 80
Pulse Pressure = 40
__________________ suggests significant blood loss and if often one of the 1st signs of SHOCK. Often the results of increasing diastolic pressure from compensatory cetecholamine release
100/66 100/74 100/84
Narrowing Pulse Pressure
one of the ways that the body attempts to fix
ACIDOSIS is to…
increase the rate of breathing and blow that CO2 off
CARDIAC OUTPUT (CO)
AMOUNT OF BLOOD PUMPRED PER MINUTE INTO THE AORTA BY THE LEFT VENTRICLE
CO = SV * HR
Mean Arterial Pressure (MAP)
Average pressure in the arterial circulation throughout the cardiac cycle
MAP = CO * SVR
Pulse Pressure
Difference between SYSTOLIC and DIASTOLIC
**Narrowing Pulse pressure is often an early indicator of SHOCK
Shock is triggered by a SUSTAINED drop in _______
Mean Arterial Pressure (MAP)
