WEEK 6- SHOCK Flashcards
Shock Definition
- Widespread abnormal cellular metabolism that occurs when the human need for oxygenation and tissue perfusion is not met to the level needed to maintain cell function.
- “Whole-body” response.
- Shock is a “syndrome.”
- Any problem that impairs oxygen delivery to tissues and organs can start the syndrome of shock and lead to a life-threatening emergency
Shock- KEY POINT
Causes and initial manifestations of each type may vary but hypotension and anaerobic cellular metabolism eventually result in the common key features of shock
Features of Shock
***Cardiac output is decreased Increased pulse rate, thready Decreased blood pressure Increased respiratory rate, cyanosis Decreased urinary output* Skin cool to the touch, pale to mottled Nausea, diminished bowel sounds
Types of Shock
Hypovolemic
Cardiogenic
Septic
Distributive
**may have more than one type at the same time
Hypovolemic Shock
- -Occurs when low circulating blood volume causes a mean arterial pressure (MAP) decrease; the body’s oxygen need is not met
- -Commonly caused by hemorrhage (external or internal) and dehydration
Cardiogenic Shock
- Actual heart muscle is unhealthy, and pumping is directly impaired
- Myocardial infarction is the most common cause of direct pump failure
Distributive Shock
- Blood volume is not lost but is distributed to the interstitial tissues where it cannot circulate and deliver oxygen
- Caused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, capillary leak
- Ie: anaphylaxis, sepsis
Complex type of distributive shock—
usually begins as a bacterial or fungal infection and progresses to a dangerous condition over a period of days
Sepsis—
widespread infection coupled with a more general inflammatory response, known as systemic inflammatory response syndrome (SIRS), that is triggered when an infection escapes local control
Stage of sepsis and SIRS when multiple organ failure
is evident and uncontrolled bleeding occurs.
Even with appropriate intervention, the death rate among patients in this stage of sepsis exceeds 60%.
Stages of Shock
Initial stage
Nonprogressive stage
Progressive stage
Refractory stage
Initial Stage of Shock
Baseline MAP decreased by less than 10 mm Hg
Heart and respiratory rate increased from the baseline or a slight increase in diastolic blood pressure
Adaptive responses of vascular constriction and increased heart rate
works at the cellular level
Nonprogressive Stage/ compensatory stage
MAP decreases by 10 to 15 mm Hg.
Kidney and hormonal adaptive mechanisms activated
Tissue hypoxia in non-vital organs
Acidosis and hyperkalemia (high potassium)
Stopping conditions that started shock and supportive interventions can prevent shock from progressing
Non-Progressive Stage S & S
Anxiety
Restlessness
Increased thirst (because of low liquids in body)
Tachycardia
Increased RR
Decrease UO
Decrease SBP/increasing DBP (narrowing PP)
Cool extremities
2-5% decrease in O2 saturation
**if stable can stay at this stage for hours
Progressive Stage
Further decrease in blood pressure
Sustained decrease in MAP of more than 20 mm Hg from baseline
Vital organs develop hypoxia
Life-threatening emergency
Immediate interventions are needed
Conditions causing shock need to be corrected within 1 hour of the onset of the progressive stage
COMPENSATORY MECHANISM FAIL
Progressive Stage S &S
**Worsening of S &S *life-threatening* Action needed within 1 hr** Severe thirst, anxiety Sense of impending doom Confusion Rapid, weak pulse Pallor (?) to cyanosis (mucous membranes/nail beds) Cool, moist skin Anuria- increase urine NA and dec in K 5-20% 02 sat drop Labs: low pH, high lactic acid, high K+
Refractory Stage of Shock
Too much cell death and tissue damage resulting from too little oxygen reaching the tissues.
Body can no longer respond effectively to interventions, and shock continues.
Severe hypoxia
Multiple organ dysfunction
Death
profound hypotension
Refractory Stage S &S
Rapid loss of consciousness Non-palpable pulse cold, mottled or dusky extremities slow, shallow respirations unmeasurable 02 sat
Hypovolemic Shock
Assessment: -Patient History- - medical and surgical, recent events(upper resp tract infection, chest pai, trauma) allergies, medication, description of events leading to shock- time of onset and duration -Physical Assessment ((Cardiovascular changes Respiratory changes Renal and urinary changes Skin changes CNS changes Skeletal muscle changes)) Lewis suggests initial ABCS, followed by tissue profusion , VITALS, LOC, pulses, cap refil, skin, and urine output
- Psychosocial Assessment (is the person anxious, their feelings with anxiety, feeling of doom)
- Laboratory Assessment- LEWIS 1963
Common Nursing Diagnoses: Hypovolemic Shock
Ineffective Tissue Perfusion (general) related to hypovolemia
Deficient Fluid Volume related to active fluid volume loss
Decreased Cardiac Output related to hypovolemia
Anxiety related to potential for death
Disturbed Thought Processes related to decreased cerebral perfusion
Best Practice for Hypovolemic Shock
- Ensure a patent airway
- minimum 20 gauge IV (often 18)
- Administer oxygen
- Elevate patient’s feet, keep HOB flat or at max 30 degrees
- Examine patient for overt bleeding
- Apply pressure to overt bleeding site
- Administer drugs as prescribed
- Increase rate of IV
- Do not leave the patient
Hypovolemic Shock: Health Promotion and Maintenance
Primary Prevention
Prevent dehydration (hypovolemia)
Use safety equipment (trauma)
Be aware of hazards at home/workplace
Secondary Prevention
-just being a pt in acute care is a risk factor
Monitor pts for deydration-watch I & O….especially for pts who are:
1. cognitively impaired
2. NPO
3. have decreased mobility
Monitor for bleeding (obvious and occult) after any invasive procedure (ie: surgery, heart cath etc)
Compare:
• pulse quality and rate with baseline
• -urine output (and other output) with intake (PO and/or IV)
• -check VS for any pt with persistent thirst*
• -assess for shock with changes in: 1. mental status 2. increase in pain 3. increase in anxiety
Patient and Family Teaching after invasive procedures or ambulatory surgery:
Manifestations of shock
Stress importance of seeking immediate help for any of the following:
• Obvious heavy bleeding
• Persistent thirst
• Decreased urine output
• Light-headedness
• Sense of impending doom
Sepsis and Septic Shock quote
“Failure to recognize and intervene in early sepsis is the major contributing factor for progression to septic shock and death”
Aherns, 2007; Cheek et al., 2005 Kleinpell et al., 2006; in Ignatavicius and Workman, 2006)
Early detection is a major nursing responsibility
Local Infection vs Sepsis
Which process are these symptoms associated with?
Fever- a high one could be sepsis or local
Tachycardia- sepsis
Decreased oxygen saturation –sepsis
Reduced Urine Output –sepsis
Early Manifestations of Sepsis
Temp may be high OR low WBC is usually high U/O decreases RR increases BP decreases Microthrombi start to form
these early manifestations are subtle, of short duration and may be missed
Severe Sepsis
Amplified inflammatory response
All tissues involved, all have some degree of hypoxia
Some cell death occurring
Disseminated Intravascular Coagulation (DIC)
Microthrombi formation widespread
you only see it in extreme cases
this uses up available platelets and clotting factors
- Leaky capillaries
- Anaerobic metabolism
- Poor cellular oxygen uptake
- Hyperglycemia
Why does this stage often get missed initially??
Because….
Cardiac Function is hyperdynamic: HR increases CO increases Extremities warm Little or no cyanosis WBC no longer elevated Patient ‘looks’ better
WBC drops
as bone marrow unable to keep producing new mature neutrophils and other WBCs
Immunocompromised pts may have very low WBC
Severe Sepsis: Major Clinical Manifestations
Lower oxygen saturation
Rapid respiratory rate
Decreased to absent U/O
Change in patient’s cognition and affect
Sepsis needs appropriate and aggressive intervention to prevent septic shock
Septic Shock
Multiple organ failure
Uncontrolled bleeding
even with appropriate intervention, death rate exceeds 60%
Severe hypovolemic shock also present
Inability to clot
Leaking capillaries
Clinical manifestations look like late stage hypovolemic shock….which are?
Questions
Is your patient at risk for infection/sepsis/septic shock?
-List risk factors
Does your patient exhibit any S & S?
-Identify key assessments and findings
What needs to be done? By Whom?
-List appropriate interventions for both prevention and treatment
Sepsis and Septic Shock Assessment:
-Patient History
-Physical Assessment
Respiratory changes
Cardiovascular changes
Renal and urinary changes
Skin changes
CNS changes
-Psychosocial Assessment
-Laboratory Assessment
Nursing Responsibilities
–Assessments as noted previously!!
–Monitor for early detection
VS at least 2 x per shift (compare to baseline)
Elevated serum lactate
Normal or low WBC
segmented neutrophils decrease
Band neutrophils increase
–Use aseptic technique!!!
Remove urinary catheters and IVs as soon as no longer needed
Health Promotion and Maintenance
Prevention is the best strategy
Complete a risk assessment
Who is at risk for sepsis? (see Table 39-4, p. 840)
Patient Teaching
Teach manifestations of:
-Local Infection
(Pain, redness, swelling , purulent drainage, loss of function_
-Early Sepsis
(Fever, U/O less than intake, lightheadedness)
Monitor temp
Complete entire course of prescribed abx
Notify HCP of S &S
Anaphylaxis defined:
A life-threatening allergic reaction
RXNS TO ANAPHYLAXIS
–Most likely reactions to:
medication, latex or food
Note hx of asthma, eczema, seasonal allergies
When giving meds:
((ask about allergies-even if they already have an allergy band on
Explain medications!!))
Reaction may not occur immediately
Drugs previously tolerated may cause anaphylaxis
Anaphylaxis S & S
Monitor for: HR & RR increase, BP drops Swelling of eyes, lips, face Difficulty breathing, talking, swallowing (laryngeal edema) Wheezing or cough Pruritis, hives Feeling of impending doom Nausea, diarrhea, abd pain Decreased LOC
Anaphylaxis: Act FAST
FACE
AIRWAY
STOMACH
TOTAL BODY
Management
Stop offending medication immediately
(If IV, change to NS and change tubing)
Check VS
O2, IV, Drugs
Epinephrine is drug of choice
(May also give benadryl, corticosteroids)
Community-Based Care
Patient Teaching to reduce risk of: *** Anaphylaxis Foods, drugs, insect venom, latex Focus on prevention Act FAST *see poster Self-injectable epinephrine (ie: epipen) Medic alert bracelet or necklace
Re-cap: Management of Shock
*Goals of shock management are to: maintain tissue oxygenation increase vascular volume to normal range support compensatory mechanisms *Oxygen therapy *IV therapy *Drug therapy Vasoconstrictors Drugs to enhance contractility Drugs to enhance myocardial perfusion Septic Shock also requires antibiotics, corticosteroids, insulin, activated protein C, blood replacement
A relative hypovolemia
fluid moves from the vascular space into the extravascular space (“third spacing”)
MAP`
110/70.. ACTUALLY LOOK IT UP IDK WHAT IT MEANS
