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Module 7 > UNIT 2: CARE OF THE SHOCK PATIENT > Flashcards

UNIT 2: CARE OF THE SHOCK PATIENT Flashcards

1
Q

What is shock?

A

Perfusion and oxgenation issue
Inadequate tissue perfusion- widespread inadequate oxygen supply to provide nutrients for cellular function

Shock is life-threatening. Progression of shock os neither linear nor predictable

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2
Q

What are the four overlapping stages of shock?

A

Inital
1. No visible changes
2. Changes occuring at cellular level

Compensatory
1. Body compensating to restore tissue perfusion and oxygenation

Progressive
1. Compensatory mechanisms begin to fail

Refractory
1. Total body failure

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3
Q

What are the clinical manifestations of shock in the inital phase?

A
  1. Subtle or no clinical manifestations
  2. Hypoxia- production of pyruvic or lactic acid
  3. Decreased cardiac output

Class 1 shock
1. Blood loss up to 15% ( each until of blood lost drops hemagolbin by 3 point)

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4
Q

What are the clinical findings of the compensatory phase of shock?

A
  1. Confusion
  2. Hypotension
  3. Tachycardia
  4. Tachypnea
  5. Cool, clammy skin (r/t blood shunting back to core)
    • expectations: Septic shock- warm & flushed,
    • Neurogenic is usually normothermic
  6. Urinary output-decreased
  7. Resp. Alkalosis- short cycle and only in the compensatory stage

Class 2 shock
1. Blood loss 15-30% (750-1500ml)

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5
Q

What are the clinical findings of the progressive phase of shock?

A

1.Lethargic and confused- GCS 9-12
2.Severe HYPOtension
- Systolic below 90
- Diastolic below 60
- Try giving fluid bolus

  1. Tachycardiac- above 150
  2. Tachypnic, shallow, crackles
  3. Pa O2 below 80mmHg
  4. PaCO2 above 45
  5. Mottling, petechia, cap refil longer than 4 secs
  6. anuria
  7. metabolic acidosis

Class III shock
1. Blood loss 30-40% (1500-2000 ml)

With blood loss your also losing your ability to carry oxgyen

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6
Q

What are the clinical findings of the refractory (irreversible) phase of shock?

A
  1. Coma (GCS 8 or less)
  2. Hypotension requiring vasocontrictions
  3. Dysrhthmias- including possible MI
  4. Resp. Failure
    • Pulmonary edema
    • Bronchoconstriction
  5. Hepatic failure
  6. Renal failure
  7. Peripheral tissue ischemia and necrosis
  8. Anasarca
  9. Profound metabolic acidosis

Class IV shock
1. Blood loss greater than 40% (2000mL)

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7
Q

What are types of shock?

A

Pump, Pipes & Volume
1. Hypovolemic (Volume)
2. Cardiogenic (PUMP)
3. Distrubutive (PIPE)
4. Obstructive (PIPE)

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8
Q

What are the two types of hypovolemic shock?

A
  1. Absolute
  2. Relative
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9
Q

What do we need to know about Absolute & relative hypovolemic shock?

A

Hemorrhagic
1. External loss of whole blood
- Cause: Trauma surgery, AAA, GI Bleen
Non-hemorrhagic
1. Loss of other body fluids
- vomiting
- Diarrhea
- Excessive diuresis
- Diabetes insipidus

Relative
1.Fluid shift that stays internal
- Third spacing- extravascular or intracavity
- Burns, acites, peritonitis, bowel obstruction

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10
Q

What s/s will our patient with hypovolemic shock present with?

A
  1. Slow cap refill
  2. Confused
  3. Systemic vascular resistance
  4. Hypotensive
  5. Olguiria because the kidneys arent beling perfused.
  6. Normothermic
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11
Q

What is our treatment for hypovolemic shock?

A
  1. 3 units of isotonic crystalloids for every 1 unit of loss. NOT to rapidly
  2. HOB elevated needs to be flat or raised to about 30 degrees.
  3. Elevate legs
  4. Give o2.
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12
Q

What should we know about cardiogenic shock (PUMP)

A
  1. PUMP failure
  2. Decreased contractility
    • Acute mi
    • Severe heart failure exacerbation
    • Myocarditis
      3.Additional signs they might have cardiogenic shock
    • JVD
    • Pulmonary edema
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13
Q

What are common causes of cardiogenic shock?

A

Typically trauma injury is the cause. Look for bruising, seat belt marks.

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14
Q

What should we monitor on a patient suspected of being in cardiogenic shock?

A
  1. Breath sounds- specifically for crackles
  2. Muffled heart sounds because of fluid surrounding heart.
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15
Q

What are our interventions for a patient in cardiogenic shock?

A
  1. Give oxygen (fish flowndering)
  2. Give beta blocker- metropolol to decrease heart rate and lower bp
  3. Give diuretics
  4. Give vasodilators (nitropressen)
  5. LIMIT fluid- dont want to overlod them and increase the workload.
  6. I&O super important
  7. Balloon pump/VAD
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16
Q

What are different types of distributive shock (PIPE)

Think NAS

A
  1. Anaphylactic
  2. Neurogenic
  3. Septic
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17
Q

What is anaphylactic shock?

A

Type of distributive shock.
It is a life-threatening hypersenstivity (allergic) reaction
1. bee, peanut, medcations
2. transfusion reactions
3. Latex allergy

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18
Q

What is neurogenic shock?

A

Type of distributive shock
1. Spina cord injury above T6
2. Spinal Anesthesia

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19
Q

What is septic shock?

A

Distrubutive shock
1. Extreme immune system response to an infection
- Pneumonia, UTI, Invasive lines
- End organ failure >MODS

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20
Q

What are our interventions for distributive shock?

A
  1. Give fluids ASAP r/t the histamine response that causes the patient to lose volume.
  2. Possible vasconstrictor/neuroepinephrine
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21
Q

How do we know that the fluid we give a septic patient is helping?

A
  1. Increase bp
  2. cap refil improves
22
Q

In anaphylactic shock what are respirations like?

A

Brady or tachy

23
Q

In anaphylactic shock what is the heart rate, blood pressure and temp like?

A

Heart rate: Tachy
Blood Pressure: Hypo
Normothermic

24
Q

In anaphylactic shock what is our cardiac output, SVR, Skin, like?

A

CO: Decreased
Systemic vascular resistence: Decreased
Skin: Flushed & Warm, swollen, itchy

25
Q

In anaphylactic shock what does our urine output look like?

A

Oilguria

26
Q

What are other signs of anaphylactic shock?

A
  1. Urticaria
  2. bronchoconstriction
  3. Confusion
27
Q

In neurogenic shock what is our resperations, HR, BP, Temp like?

A

Resp: Dysfunction related to level of injury
HR: BRADY
BP: HYPO
Temp: Poiklothermic

28
Q

In neurogenic shock what does our CO, SVR, skin and urine output look like?

A

CO: Decreased
SVR: Dcreased
SKIN: Flushed, warm, & dry initally then poikilothermic
URINE Output: No control

29
Q

What are other s/s of neurogenic shock?

A

Paralysis

30
Q

What does or RR, HR, BP, Temp look like in septic shock?

A

Resp: Tachy
HR: Tachy
BP: HYPO
Temp: Hyperthermia(initally) or hypothermia

31
Q

What is our CO, SVR, SKIN and Urine output look like in septic shock?

A

CO: Decreased
SVR:Decreased
SKIN: Flushed & warm initally, then cool and molted
Urine Output: oliguria

32
Q

What are other s/s of septic shock?

A

bounding pulses initally confusion

33
Q

What are types of obstructive shock?

A
  1. PE
  2. Pericardial tamponate
  3. Hemopnumothorax
  4. Tension Pneumothorax
34
Q

How do we manage obstructive shock?

A

Manage the obstruction- get rid of whatever the cause is.

35
Q

What should our assessment of a shock patient include?

A
  1. Physical- perfusion an oxygenation- cap refil, MAP, vitals,
    • Look for signs of organ perfusion or damage
  2. Hemodynamic monitoring vital signs baseline
    • Pulse pressure= systolic blood pressure - diastolic blood pressure
    • Normal Pulse pressure (PP)- 40-60 mmhg
    • Narrow less than 40- early indicator of shock than drop in systolic bp
    • Widened more than 80 mmHg- Septic patients, sustained intracranial pressure above 20 mmhg
36
Q

What diagnostic studies should we review for shock patients

A
  1. ABGs
  2. Lactic acid
  3. CMP (H&H, WBC)
37
Q

What do we need to know about central venous pressure monitoring?

A
  1. Direct pressure measure right atrium and SVC
    • Measures systmic vascular resistence
    • Assess perfusion
    • Assess systemic fluid status
  2. Normal CVP 2-6mmHg
  3. Shock patients require 8-13 mmhg
38
Q

What should we know about oxygen and ventilation therapy in shock patients

A

1st nursing action is to place 100% oxygen via non rebreather
1. Maintain patent airway
2. Increase supply- optimize CO with fluid replacement and drugs, increased hemogbolin by transfusion, increased arterial oxygen with supplmental oxygen and mechanical ventilation
3. Plan care to avoid disrupting o2 supply and demand– cluster care

39
Q

What should we know about volume expansion pharmacology for the tx of shock patients?

A
  1. Reserved for SEPTIC, HEMORRHAGIC HYPOVOLEMIC
  2. Fluid resuscitation caution with cardiogenic and neurogenic shock
  3. Crystalloids (normal saline, LR, 5% dextrose)
  4. Colloids (Albumin, RBC)
40
Q

What are two major complications of large volumes of fluid when tx shock pts.

A
  1. Hypothermia
    • Iv hanging are generally room temp
    • Warm up crystalloid or colloid solution if possible
  2. Coagulopathy
    • RBCs do not contain clotting factors
    • Replace clotting factors
    • The more blood you give the greater the risk.
41
Q

What should we do is hypotension persists after adequate fluids in the tx of shock?

A
  1. Vasopressor may be added
42
Q

What do we assess to know if our patient was resposive to the fluids given?

A
  1. Vital signs
  2. Cerebral and abdominal pressures
  3. Cap refil
  4. Skin temp
  5. Urine output
43
Q

What should we know about vasopressors in the tx of shock?

A
  1. Norepinephrine- 1st line
  2. Vasopression
    • Antidiuretic > retain fluid
    • Dopamine (increases HR… heart hard)
    • Phenylephrine (Suddafed)
  3. Increase SVR and BP
  4. Achieve/maintain MAP greater than 65 mmhg
44
Q

When are vasopressors typically used in the treatment of shock?

A

Reserved for patinets unresponsive to fluid resuscitation OR cardiogenic or neurogenic shock

45
Q

what are adverse reactions to vasopressors?

A
  1. Decreased perfusion to vital organs
    • Monitor end organ perfusion
  2. Extravasation
46
Q

What should we know about vasodilator drugs in the tx of shock?

A
  1. Decreases afterload
    • relaxes smooth muscle in arteries and veins
  2. Helps achieve/maintain map greater than 65mmHg
47
Q

What shock patients do we see vasodilators used in?

A

Resevered for cardiogenic shock
1. Nitroglycerin
2. Nitroprusside (sodium nitroprusside)

48
Q

What are adverse reactions to vasodilators?

A
  1. Tachycardia
  2. palpitations
  3. headache
  4. fatigue
  5. angina
49
Q

What shock patients might get a glucocorticoid?

A
  1. Septic, anaphylactic and possibly cardiogenic shock

Examples: Prednisone (PO), methylprednisone, dexamethosane (IV)- increases bS, decrease sleep may need to increase sedative

50
Q
A

Module 7 (22 decks)

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