what are some postoperative complications?
fluid and electrolyte imbalances-deficit nausea and vomiting shock ineffective breathing pattern urinary retention constipation acute pain risk for infection risk for peripheral neurovvascular dysfunction
which two organs are the first to show signs of dysfunction during shock?
heart
kidneys
A urine output of less than 30 mL/hr is indicative of
renal hypoperfusion and or hypovolemia
clinical findings in pre-shock
Near normal BP > 100bmp HR >20 RR cold, clammy skin mildly decrease urinary output confusion respiratory alkalosis
clinical findings in shock
systolic <80 to 90 100 to 150 HR RR-rapid, shallow, crackles skin-mottled, petechiae severely decreased urinary output lethargy metabolic acidosis
clinical findings in End-organ dysfunction
requires mechanical or pharmacologic support HR-Erratic or asystole RR-requires ventilation Skin-Jaudice Anuric, requires dialysis Unresponsive Profound acidosis
Syndrome characterized by decrease tissue perfusion and impaired cellular metabolism. Imbalance in supply/demand for O2 and nutrients?
Shock
Management of shock in all types and phases.
fluid replacement to restore intravascular volume
vasoactive medications to restore vasomotor tone and improve cardiac function.
nutritional support.
what happens when alpha adrenergic receptors are stimulated?
blood vessels constrict in cardiorespiratory
GI systems
skin
kidneys
Medications commonly used to treat cardiogenic shock
dobutamine
dopamine
nitroglycerin
How is supplemental O2 administered in the early stages of shock?
nasal cannula
saturation exceeding 90%
Monitoring of ABG values
pulse oximetry values
if a patient is experiences chest pain, what IV analgesic should be administered for pain relief?
morphine sulfate
morphine dilates the blood vessels.
Monitor for decreased BP
what are the primary pathophysiology outcome in shock?
Hypoperfusion
tissue hypoxia
acidosis
end organ dysfunction
Medications to be given when shock is due to septic.
Antibiotics- if the organism is unknown, empiric broad-spectrum are started.
blood, urine, sputum and drainage of any kind should be sent for culture.
medications to vasoconstrict and improve myocardial contractility
dopamine norepinephrine phenylephrine dobutamine milrione
medication to maintain adequate urine output in a shock patient.
Lasix
medication to restore blood pressure in shock patients
adrenergics
sympathomimetics -Dopamine (Intropin)
when administering Dopamine (Intropin), what is an early symptom of drug excess?
Headache
what are some side effects of Diphenhydramine HCl (Benadryl)?
Drowsiness confusion insomnia headache vertigo photosensitivity
How should the RN administer Dobutamine hydrocholoride (Dubutrex)?
Through central venous catheter or large peripheral vein with and infusion pump.
Don’t infuse through line with other meds.
what type of solution should be infused with Norepinephrine?
dextrose solution
some side effects of Dopamine (Intropin)
Increased ocular pressure Ectopic beats nausea Tachycardia chest pain dysrhythmias
Tx: monitor BP, pulses, urinary output. Use infusion pump
Side effects of Epinephrine (Adrenalin)
Nervousness
Restlessness
Dizziness
local necrosis of skin
Tx: adequate hydration, carefully aspirate syringe before IM and SC doses.
effects of shock on the heart?
decreased coronary artery perfusion: decreased function of the heart muscle as a pump.
decreased SV, CO and BP.
Effects of shock on the brain.
decrease O2 and nutrient supply: decreased brain function; confusion, unconsciousness.
Effect of shock on the lungs
decrease blood volume=decreased O2.
decrease gas exchange at the capillary level.
Effects of shock on the liver
Glycogen stores are depleted by an excess of circulating epinephrin - metabolic acids that are normally detoxified in the liver cause ACIDOSIS.
inability of the heart to pump blood forward?
systolic dysfunction
Inability of the heart to fill during diastole?
diastolic dysfunction
Eg. pericardial tamponade
External loss of whole blood?
Absolute hypovolemia shock
Eg. hemorrhage, GI bleeding, surgery
loss of other body fluids (vomiting, diarrhea, excessive diuresis, diabetes insipidus, diabetes mellitus (DM)
Relative hypovolemia
pooling of blood or fluids (bowel obstruction). fluid shifts (burn injuries, ascites). internal bleeding (fracture of long bones, ruptured spleen, severe pancreatitis, hemothorax). massive vasodilation (sepsis).
Effects of shock on the kidneys
A drop in cardiac output causes a decrease in blood flow through the kidneys.
decrease urinary output
renal failure
BP systolic below 90
what are the two types of low blood flow shock?
cardiogenic shock
hypovolemic shock
name the three types of maldistribution of blood flow shock
septic
anaphylactic
neurogenic
No change in blood volume
blood not in the right place
Early manifestations of cardiogenic shock
Tachycardia hypotension narrowed pulse pressure increase myocardial O2 consumption systolic dysfunction diastolic dysfunction compromised cardiac output (CO)
During physical examination what are some of the findings of a patient in a cardiogenic shock?
Tachypnea pulmonary congestion pallor, cool, clammy skin decreased capillary refill time (>3sec) anxiety confusion agitation decreased renal perfusion and urinary output
result when fluid volume moves out of the vascular space into extravascular space (third spacing)
Relative hypovolemia
Some clinical manifestations of hypovolemic shock
Anxiety, confusion, agitation Tachypnea decreased Preload, SV and CO decreased urinary output pallor, cool clammy skin
Tx: identify the cause of the problem
volume replacement, adequate oxygenation
Compensatory stage of shock
cardiac output is further reduced, but due to compensatory vasoconstriction blood pressure tends to remain within a normal range.
blood flow to skin and kidneys decrease.
blood flow to CNS and myocardium tends to be maintained.
decrease occurs in blood reservoirs.
pt. may compensate for 15% total blood volume (750mL).
further loss of 15-30% activates SNS (increase HR, CO, RR).
if lose is >30% blood volume is replaced.
Name the three types of distributive (Vasogenic) shock
inadequate vascular tone.
Neurogenic
Anaphylactic
Septic
Anaphylactic Shock
life-threatening hypersensitivity reaction
massive vasodilation
capillary permeability
release of mediators (histamine or bradykinin)
clinical manifestations of anaphylactic shock
Anxiety, confusion, dizziness sense of impeding doom chest pain incontinence swelling of the lips and tongue, angioedema wheezing, stridor, SOB flushing, pruritus, urticaria respiratory distress and circulatory failure
Angioedema
The rapid swelling of the dermis, subcutaneous tissue, mucosa and submucosal tissues.
occurs in anaphylactic shock
Tx: Epinephrine
Medical management of Anaphylactic shock
Epinephrine (vasoconstrictive action and reducing bronchospasm)
Diphenhydramine (to reverse the effects of histamine, reducing cap permeability).
Albuterol (Proventil) reverse histamine induced bronchospasm.
Patients who have a penicillin allergy may also develop and allergy to similar medications such as?
Cefazolin sodium (Ancef)
Clinical manifestations of septic shock
Tachypnea/hyperventilation
temperature dysregulation (fever, warm flushed skin)
decrease urine output
altered neurologic status (confusion or agitation)
GI dysfunction (nausea, vomiting, diarrhea, decrease bowel sounds)
respiratory failure is common
Initial stage of shock
not always clinically apparent
recognize who is at greater risk (actively bleeding, internal bleeding)
monitor for SNS stimulation
Compensatory stage of shock
SNS activated
vasoconstriction
increase diastolic and systolic pressure
decreasing pulse pressure is a positive sign of?
vasoconstriction
underlying hypovolemia
what happens to the pulse pressure when diastolic pressure increases?
pulse pressure decrease
Progressive stage of shock
end organ failure
medications that mimic the SNS should be given
Refractory stage of shock
irreversible profound hypotension and hypoxemia tachycardia worsens decreased coronary blood flow renal shutdown circulatory failure cerebral ischemia (brain tissue death) multiple organ failure
Epinephrine (Adrenalin)
Mimics SNS
peripheral vasoconstriction (jeopardizes tissue perfusion)
increase work of heart, HR and CO.
Side effects of Epinephrine (Adrenalin)
monitor HR >110 BPM monitor dyspnea (pulmonary edema) chest pain dysrhythmias, increase myocardial O2 use renal failure (ischemia)
Norepinephrine (Levophed) use
hypotension (unresponsive to fluid) cardiogenic shock after MI septic shock (increase vascular tone) cardiac stimulation to increase BP mimics SNS peripheral vasoconstriction renal vasoconstriction increase systemic vascular resistance
Side effects of Norepinephrine (Levophed)
dysrhythmias
hypertension
side effects of Antihistamine (Benadryl)
drowsiness
blurred vision
dry mouth (anticholinergic)
Tx: DO NO TAKE WITH MAO
monitor BP
Antihistamine (Benadryl) uses
anaphylactic shock
blocks massive release of histamine
to prevent and treat nausea, vomiting and dizziness
Patients at risk for septic shock
immunosuppression extremes of age (young, old) malnourishment chronic illness invasive procedures
patients at risk for neurogenic shock
spinal cord injury
spinal anesthesia
depressant action of medications
glucose deficiency
Risk factors for anaphylactic shock
penicillin sensitivity transfusion reaction bee sting allergy latex sensitivity severe allergy to some foods or medications
Risk factors for hypovolemic shock
trauma, surgery vomiting, diarrhea diuresis diabetes insipidus NPO status hemorrhage burns ascites peritonitis dehydration
