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MED SURG II - SHOCK Flashcards

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1
Q

Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism

A

Shock

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2
Q

Clinical manifestations of General Shock: Cardiac

A

Tachycardia
Hypotension
Decreased Cap Refill
Weak/Thready Pulses

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3
Q

Clinical manifestations of General Shock: Respiratory

A

Tachypnea

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4
Q

Clinical manifestations of General Shock: Renal

A

Decreased UOP

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5
Q

How does the skin look in the early stages of shock?

A

White

Ashen/Gray (darker skin tones)

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6
Q

Clinical manifestations of shock: Neurologic

A

Increased Anxiety, Agitation, and Confusion

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7
Q

Clinical manifestations of shock: GI

A

Decreased peristalsis
Decreased bowel sounds
can lead to ileus (later)

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8
Q

Shock: BUN and Creatinine

A

Increased

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9
Q

Shock: LFTs

A

Increased

Liver is not perfusing

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10
Q

Shock: Lactic Acid

A

Increased r/t metabolic acidosis

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11
Q

What is normal Lactic Acid?

A

< 2

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12
Q

Stage of Shock: Usually not clinically visible

Body is switching from aerobic to anaerobic metabolism

A

Initial

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13
Q

Stage of Shock: Body activates compensatory mechanisms to overcome increasing effects of anaerobic metabolism.

A

Compensatory

This is where we want to stop the progression of shock

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14
Q

Patient presents with: Tachycardia, Tachypnea, Slight Hypotension, Subtle MS Changes ….. what stage of shock?

A

Compensatory

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15
Q

Stage of Shock: Compensatory mechanisms fail

A

Progressive

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16
Q

Patient has marked changes in mental status and decreased peripheral perfusion…. what stage of shock?

A

Progressive

decrease in coronary, cerebral*, and peripheral perfusion

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17
Q

Stage of Shock: Profound hypotension and hypoxemia; recovery unlikely

A

Refractory

Signs of MODS

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18
Q

Primary nursing intervention for patient experiencing shock

A

OXYGEN

15L 100% non-rebreather

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19
Q

After giving Oxygen what is the next intervention?

A

Fluids

Increase Volume

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20
Q

What types of shock are fluids contraindicated in?

A

Cardiogenic and Neurogenic

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21
Q

What medications are given to a patient experiencing shock?

A

Vasopressors

Vasodilators

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22
Q

Examples of Vasopressors

A 
Levophed (norepinephrine)
Dobutamine
Pitressin
Epinephrine
Dopamine
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23
Q

After giving medications, what is the next nursing intervention for a patient experiencing shock?

A

Nutrition

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24
Q

What is the preferred route of nutrition for a patient experiencing shock?

A

Enteral

Ex: Tube feeding

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25
What type of shock: | Systolic or diastolic dysfunction resulting in reduced CO and SV
Cardiogenic
26
What is CO? What is normal?
Volume in liters pumped by the heart in 1 minute | 4-8L
27
What is SV? What is normal?
Volume in mL ejected per beat | 60-120mL
28
Causes of Cardiogenic Shock
``` *MI* HF Cardiomyopathy Dysrhythmias Valve Disorders Ventricular Hypertrophy ```
29
What is unique about a patient in Cardiogenic shock? (Cardiac)
Narrowed Pulse Pressure Chest Pain Dysrhythmias Extra Heart Sounds (S3 S4)
30
What is unique about a patient in Cardiogenic shock? (Respiratory)
crackles d/t pulmonary congestion
31
What kind of patient does a Cardiogenic shock pt resemble?
Heart Failure Patient
32
After oxygenation, what is the next intervention for a patient experiencing Cardiogenic Shock?
Correct the underlying problem by restoring blood flow and reducing the workload of the heart
33
What are ways to reduce the workload of the heart?
Beta Blockers, CCBs, Digoxin, Morphine
34
What are way to restore blood flow?
Thrombolytics, Angioplasty, Stents, CABG
35
What labs need to be monitored for a patient experiencing Cardiogenic shock?
Troponin CKMB BNP
36
What DX tests should be ran for a patient experiencing cariogenic shock?
EKG ECHO Chest XR
37
Dobutamine | Dopamine
Improves SV, CO | Improves contractility
38
How must Dobutamine and Dopamine be given?
In a central line | Titrated drip, weight based
39
What is a possible side effect of Dobutamine and Dopamine?
Dysrhythmia
40
Nitroglycerin
Systemic Vasodilation | Reduces preload and after load to decrease the hearts O2 demands
41
What are side effects of Nitroglycerin?
Flushed, warm skin | Headaches (indicate good perfusion)
42
Examples of Circulatory Assist Devices
IABP (decrease workload, decrease SVR) | VAD (heart transplant)
43
Nursing Management for a patient experiencing Cardiogenic Shock
1. Oxygen 2. Hemodynamic monitoring 3. Vitals, cardiac monitor 4. PIV, labs, EKG, Chest XR, Echo 5. Administer meds 6. Prep for procedure 7. Enhance safety and comfort
44
What type of shock: Decreased intravascular volume
Hypovolemic
45
Absolute Hypovolemia
Fluid comes up and out | Loss of intravascular fluid volume
46
Causes of Absolute Hypovolemia?
``` N/V Hemmorhage Diarrhea Diuresis Diabetes Mellitus - Polyuria Diabetes Insipidus - Lack of ADH ```
47
Relative Hypovolemia
Fluid volume moves from intravascular space to extravascular space *third spacing*
48
Causes of Relative Hypovolemia?
Burns Ascites Internal Bleeding Massive Vasodilation (sepsis)
49
What % of total blood volume must be lost before s/s of shock appear?
15% | ~ 750mL
50
Will patients with chronic illness show s/s of shock sooner or later than a healthy patient?
Sooner
51
Will Elderly patients and Children show s/s of shock sooner or later?
Sooner
52
What's unique about a patient experiencing Hypovolemic shock? (skin)
``` Third Spacing (ascites) Trauma ```
53
What's unique about a patient experiencing Hypovolemic shock? (GI)
Vomiting, Diarrhea | Bloody stools, Emesis
54
Primary nursing intervention for a patient experiencing Hypovolemic shock?
OXYGEN
55
What do you do after giving a patient experiencing hypovolemic shock oxygen?
Treat the underlying cause | Stop the loss of fluid
56
What do you use to replace the fluid lost during hypovolemic shock?
``` isotonic fluids (NS, LR) volume expanders (albumin, dextrans) ```
57
How many mL of fluid replacement is needed for every 1mL of blood loss
3mL
58
If a patient is experiencing hypovolemic shock d/t blood loss what labs need to be monitored?
H and H less than or equal to 7 = think about transfusion High H and H = fluid loss (not bleeding)
59
If a patient is experiencing hypovolemic shock d/t vomiting and/or diarrhea what labs should be monitored?
electrolytes (esp Na+ and K+)
60
Nursing Management of a patient experiencing Hypovolemic Shock?
``` Hold Pressure, Elevate Place on Oxygen Take BP, HR PIV access, large bore Administer blood and fluids safely ```
61
What type of shock: | An insult or injury causes massive vasodilation without compensation because f the loss of SNS constriction
Neurogenic
62
Predisposing factors to Neurogenic Shock
Spinal Cord Injury (As quick as 30min post) Spinal anesthesia Opioids, benzos (depression of the vasomotor center)
63
What's unique about a patient experiencing Neurogenic shock? (Cardiovascular)
Bradycardia and Hypotension caused by massive vasodilation and loss of SNS
64
What's unique about a patient experiencing Neurogenic shock? (Pulmonary)
Depends on the level of the injury
65
What's unique about a patient experiencing Neurogenic Shock? (Renal)
Bladder dysfunction
66
What's unique about a patient experiencing Neurogenic shock? (Skin)
Massive dilation causes warm, dry skin -- may progress to take on temp of environment (poikilothermia)
67
The skin takes on the temperature of the environment
poikilothermia
68
What's unique about a patient experiencing Neurogenic shock? (GI)
Bowel Dysfunction
69
Medications for patients experiencing Neurogenic Shock
Vasopressors | Atropine for bradycardia
70
Nursing Management of Patient Experiencing Neurogenic Shock
1. Maintain Spinal Alignment 2. Provide O2 3. Place on monitor 4. PIV 5. Meds 6. Safety and Comfort
71
Cardiovascular support for patient experiencing Neurogenic Shock
DVT prophylaxis
72
Neurologic Support for a patient experiencing Neurogenic Shock
Monitor for s/s of internal injury | Neurologic status, orientation, LOC, behavioral problems, report any changes
73
What type of shock: | hypersensitivity (allergic) reaction to a sensitizing substance causes quick massive vasodilation
Anaphylactic
74
Predisposing factors for Anaphylactic Shock
``` Exposure to allergen Contrast dye Drugs Chemicals Vaccines Food Insects Venom Latex Anesthesia ```
75
What's unique about Anaphylactic Shock?
*Sudden Onset*
76
Nursing priorities for a patient experiencing Anaphylactic Shock
Airway and Epinephrine
77
What's unique about a patient experiencing Anaphylactic shock? (Pulmonary)
``` SOB *laryngeal edema* bronchospasm wheezing stridor may need artificial airway ```
78
What's unique about a patient experiencing Anaphylactic shock? (Renal)
Incontinence
79
What's unique about a patient experiencing Anaphylactic shock? (Skin)
Flushing Pruritus Urticaria Angioedema (commonly caused by Ace Inhibitors)
80
What's unique about a patient experiencing Anaphylactic shock? (Neurological)
Feeling of impending doom
81
What's unique about a patient experiencing Anaphylactic shock? (GI)
Cramping Abdominal Pain N/V/D
82
Medical Management of a patient experiencing Anaphylactic Shock
Remove causative antigen Fluids - aggressive Medication (Epinephrine IM, Benadryl IV) -- both oppose histamine
83
Nursing Management of a patient experiencing Anaphylactic Shock
1. Remove Antigen 2. Epi IM (vastus lateralis) 2. HOB up if airway issue, supine if not 2. Airway - O2 or Intubation 3. PIV x 2, IV fluids (aggressive isotonic) 4. Meds
84
What medications are given to a patient experiencing Anaphylactic shock?
Albuterol/aerolized epi - reduce laryngeal edema Benadryl H2 Blockers - Zantac Steroids - antiinflammatories
85
What is Sepsis?
constellation (group) of symptoms in response to an infection
86
What type of shock: in the presence of sepsis with hypotension despite adequate fluid resuscitation; inadequate tissue perfusion with tissue hypoxia.
Septic Shock
87
What's unique about a patient experiencing Anaphylactic shock? (Cardiovascular)
``` normal/low-normal BP that responds to fluids (early) low BP that does not respond to fluids (late) give meds (vasopressors) ```
88
What's unique about a patient experiencing Anaphylactic Shock? (Pulmonary)
``` Hypoxia (early) Respiratory Distress (late) ```
89
If septic shock is not managed early it can progress to ....
ARDS
90
What's unique about a patient experiencing Anaphylactic shock? (Skin)
warm and flushed -- cool and mottled (late)
91
What's unique about patient experiencing Anaphylactic shock? (Neurological)
Hyperthermia (infection) | Hypothermia (late)
92
FSBS of a patient experiencing Septic Shock
elevated b/c liver can't keep up
93
What is important to collect with a patient experiencing septic shock? (labs)
blood cultures suspected source of infection lactate level
94
Fluid Challenge
administer 30mL/kg isotonic crystalloid fluids for hypotension or lactate >4mmol/L Q30min remeasure lactate
95
What do you give for persistent hypotension that does not respond to fluids
Vasopressors | *norepinephrine*
96
Medical Management of a patient experiencing Septic Shock
``` Antibiotics: broad spectrum within the 1st hour (get blood cultures first) GI prophylaxis (PPIs) ``` Blood sugar - goal <180
97
Nursing Management of patient experiencing Septic Shock
1. HOB, up if resp. issue, flat if possible 2. Oxygen – ear, forehead, bridge of the nose = better perfusion 3. Vitals, rectal temp is best (more accurate, better perfusion) 4. PIV 5. Blood cultures and other labs 6. Fluids 7. Antibiotics - starting within first hour decreases mortality rate 8. Fever treatment (Tylenol, cooling blanket, decrease room temperature, remove covers) – decrease the temperature gradually ¥ Hemodynamic status - central lines ¥ Reassess temp after Tylenol ¥ Collaborate to find source of infection ¥ ``` Be aware of risks for all patients o Pt w/ multiple invasive lines ¥ Assess fluid/kidney status ¥ I & O ¥ Daily weights ¥ Nutritional status ¥ FSBS ```
98
Sepsis six
``` oxygen blood cultures antibiotics fluid challenge lactate urine output ```
99
What type of shock: Physical obstruction of blood flow to or from the heart, causes decreased CO
Obstructive
100
Complication of any form of shock due to inadequate tissue perfusion Failure of two or more organ systems
MODS
101
Medical Management of MODS
``` Prevention Early detection Control initiating event Promote adequate organ perfusion Provide nutritional support ``` Nursing management similar to septic shock
102
Causes of Obstructive Shock
Cardiac Tamponade Tension Pneumo Superior Vena Cava Syndrome Abdominal Compartment Syndrome
103
Presentation of Obstructive Shock
``` Similar to HF JVD Cough Muffled Heart Sounds Edema ```

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