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Med Surg Unit 4 > Shock > Flashcards

Shock Flashcards

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1
Q

Pathophysiology of Hypovolemic Shock

A

NOT ENOUGH FLUID IN MY BUCKET

  1. Body loses too much fluid through bleeding, vomiting, diarrhea, burns, polyuria, third spacing
  2. Not enough circulating volume to carry oxygen to the organs
  3. Result = decreased venous return to the heart, which leads to decreased cardiac output and hypo perfusion
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2
Q

Pathophysiology of Cardiogenic Shock

A
  • MY PUMP AS FAILED*
    1. Damage to the heart that decreased blood flow to the body
    2. Causes: Massive MI, heart valve problems, cardiac arrest, ventricular dysrhythmias, cardiomyopathy and most common = HEART FAILURE
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3
Q

Pathophysiology of Distributive Shock

A
  • MY BUCKET IS TOO BIG*
    1. Blood volume is not lost from the body, but shifted (distributed) to the interstitial tissues- organs are not perfused
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4
Q

Pathophysiology of Obstructive Shock

A
  • MY PUMP HAS A MECHANICAL PROBLEM*
  1. Blood can’t get where it needs to be because heart cannot pump effectively; heart itself is normal but conditions outside prevent either adequate filling or adequate contraction of healthy heart muscle
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5
Q

Sub-Categories of Distributive Shock

A
  1. Septic Shock
  2. Neurogenic Shock
  3. Anaphylactic Shock
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6
Q

Pathophysiology of Anaphylactic Shock

A
  1. Severe allergic reaction
  2. Loss of blood vessel tone
  3. Decreased BP, decreased Cardiac output
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7
Q

Pathophysiology of Septic Shock

A
  1. Higher risk of death than sepsis and is associated with:
    > SIRS (Systemic Inflammatory Response Syndrome
    > MODS ( Multiple Organ Dysfunction Syndrome)
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8
Q

Pathophysiology of Neurogenic Shock

A
  1. Damage to CNS (spinal cord injury, especially C3-C5
  2. Blood vessel dilation
  3. Body cannot regulate its own BP, HR, Temp
  4. Keep O2 from reaching organs
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9
Q

Pathophysiology of Sepsis

A
  1. Extreme response to an infection that can cause:
    > Tissue Damage
    > Organ Failure
    > Death
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10
Q

Risk Factors for Hypovolemic Shock

A

Specific Causes:
1. Hemorrhage
2. Trauma
3. GI ulcer
4. Surgery
5. Inadequate clotting
6. Hemophilia
7. Liver Disease
8. Cancer Therapy
9. Anticoagulation Therapy
10. Dehydration
11. Vomiting
12. Diarrhea
13. Heavy Diaphoresis
14. Diuretic Therapy
15. Nasogastric Suction
16. Diabetes Insipidus

Overall:
1. Total body fluid decreased (in all fluid compartments)

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11
Q

Risk Factors for Cardiogenic Shock

A

Specific Causes:
1. MI
2. Cardiac Arrest
3. Ventricular Dysrhythmias
4. Cardiomyopathies
5. Myocardial Degeneration
6. Cardiac Tamponade

Overall:
1. Direct pump failure (fluid volume no affected)

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12
Q

Risk Factors for Distributive Shock

A

Specific Causes:
1. Neural Induced
2. Pain
3. Anesthesia
4. Stress
5. Spinal Cord Injury
6. Head Trauma
7. Chemical Induced
8. Anaphylaxis
9. Sepsis
10. Capillary Leak
11. Burns
12. Extensive Trauma
13. Liver Impairment
14. Hypoproteinemia

Overall:
1. Fluid shift from central vascular space (total body volume normal or increased)

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13
Q

Risk Factors for Obstructive Shock

A

Specific Causes:
1. Cardiac Tamponade
2. Arterial Stenosis
3. Pulmonary Embolus
4. Pulmonary Hypertension
5. Constrictive Pericarditis
6. Thoracic Tumor
7. Tension Pneumothorax

Overall:
1. Cardiac function decreased by non cardiac factor (indirect pump failure); total body fluid not affected, although central volume is decreased

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14
Q

Risk Factor for Anaphylactic Shock

A

Specific Causes:
1. Food
2. Latex
3. Insect Venom
4. Medications

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15
Q

Risk Factor for Neurogenic Shock

A

Specific Causes
1. Spinal Cord Injury C3-C5 (affect airway!)

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16
Q

Cardiovascular Symptoms of Shock

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A
  1. Decreased cardiac output
  2. Increased pulse rate
  3. Thready pulse
  4. Decreased BP
  5. Narrowed pulse pressure
  6. Postural Hypotension
  7. Low Central Venous Pressure
  8. Flat neck and hand vein dependent position
  9. Slow capillary refill
  10. Diminished peripheral pulses
17
Q

Respiratory Symptoms of Shock

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A
  1. Increased RR
  2. Shallow depths of respirations
  3. Decreased PaCO2 initially then progressing to increased PaCO2
  4. Decreased PaO2
  5. Cyanosis especially around the lips and nail beds
18
Q

Gastrointestinal Symptoms of Shock

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A
  1. Decreased motility
  2. Diminished or absent bowel sounds
  3. Nausea and vomiting
  4. Constipation
19
Q

Neuromuscular Symptoms of Shock

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A

Early:
1. Anxiety
2. Restlessness
3. Increased Thirst

Late:
1. Decreased CNS activity (lethargy)
2. Generalized muscle weakness
3. Diminished or absent deep tendon reflexes
4. Sluggish pupillary response to light

20
Q

Kidney Symptoms of Shock

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A
  1. Decreased urine output
  2. Increased specific gravity
  3. Sugar and acetone present in urine
21
Q

Integumentary Symptoms of Shock

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A
  1. Cool to cold
  2. Pale to mottled to cyanotic
  3. Moist, clammy
  4. Mouth dry, paste like coating present
  5. Decreased capillary refill
22
Q

General Treatment for Shock

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A
  1. Treatment for all shock states is generally the same, with a few differences related to the type of shock it is
  2. GOAL: stabilize the patient as much as you can with broad-baed treatment and then target your therapies based on what is specifically happening with the patient
  3. Optimize oxygen delivery
    > Provide oxygen via mask or high-flow NC: the sicker the patient, the more likely they’ll be intubated
    > Restore volume: administer IV fluids and/or PRBCs (FILL UP THE BUCKET)
    > Administer medication (will depend on type of shock the patient is experiencing)
  4. Reduced oxygen consumption
    > Decrease work of breathing-intubate give oxygen
    > Treat pain and anxiety
    > Keep patient normothermic (shivering increases oxygen demands as does fever)
    > Decreased oxygen demands with mechanical ventilation, sedation or even neuromuscular blocking agents
23
Q

Hypovolemic Shock Assessment

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A
  1. Decreased cardiac output
  2. Increased systemic vascular resistance (SVR) – the resistance in the circulatory system that is used to create blood pressure, the flow of blood and is also a component of cardiac function.
  3. Decreased central venous pressure (CVP) - pressure in the thoracic vena cava near the right atrium.; important factor because it can be used to estimate a patient’s fluid volume status, assess cardiac function, and gauge how well the right ventricle of the heart is functioning
  4. Cool skin, delayed cap refill
  5. Low BP, low urine output
  6. Tachycardia
  7. No single laboratory confirms or rules out shock
    Changes in lab data that can support the diagnosis of hypovolemic shock (Laboratory Profile: Hypovolemic Shock box in IGGY)
    > Decreased pH, PaO2
    > Increased PaCO2, Lactic acid
    > Increased or decreased
    > Hemoglobin & Hematocrit
    > Increased potassium
24
Q

Hypovolemic Shock Pyschosocial Assessment

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A
  • Changes in mental status and behavior occur early in shock!
  1. Assess mental status by evaluating LOC and noting if patient is awake or sleeping
  2. If sleeping, attempt to wake the patient up and document how easily aroused they are
  3. If awake, determine if patient is alert and oriented to person, place and time
  4. Avoid yes or no questions
25
Hypovolemic Shock Interventions
1. PRIORITY PROBLEM: Inadequate perfusion d/t active fluid volume loss and hypotension 2. Interventions focus on reversing shock, restoring fluid volume, and preventing complications 3. Nonsurgical management: > Oxygen therapy: maintain O2 saturation 94%-96% > IV therapy: fluid resuscitation! Use crystalloids (NS or LR) or colloids (packed red blood cells, plasma) > Drug therapy: Vasoconstrictors, inotropic agents, agents that enhance myocardial perfusion 4. Monitoring of vital signs and level of consciousness – could include intra-arterial monitoring, pulmonary artery monitoring 5. Surgical management: > Repairing the cause: vascular repair, surgical hemostasis of major wounds, closure of bleeding ulcers, and chemical scarring of varicosities
26
Cardiogenic Shock Assessment
1. Left-sided heart failure – with a malfunctioning pump, fluid is backing up into the lungs! > Pulmonary congestion > Dyspnea > Coarse lung sounds > Distant heart sounds > Elevated pulmonary artery pressure > Low cardiac output 2. Right-sided heart failure – with a malfunctioning pump, fluid is backing up into the vascular system! > Systemic venous congestion > Peripheral edema > Elevated central venous pressure > Jugular venous distention > Normal or low pulmonary artery pressure
27
Cardiogenic Shock Interventions
1. Reduce myocardial oxygen demand while improving oxygen supply 2. IV fluids unless patient is in FVO 3. Inotropes to improve cardiac output > Dobutamine or dopamine > Milrinone to also decrease afterload (has vasodilatory effects) 4. Possibly give diuretics to remove excess fluid 5. Vasopressors to increase BP via vasoconstriction 6. Very sick patients may need an intra-aortic balloon pump - a device that helps your heart pump more blood 7. In the cases of myocardial infarction, patient needs revascularization
28
Obstructive Shock Assessment
1. Clinical manifestations will vary based on the cause of the obstruction 2. Signs of pulmonary embolism > SOB > Increased work of breathing > Tachypnea > Falling O2 sats > Feeling of impending doom > Chest pain > Cough with or without hemoptysis > Pulsus paradoxus (SBP increases on expiration, drops on inspiration by 10mmHg or more) 3. Signs of tension pneumothorax > Drop in BP due to decreased venous return > Increased SOB > Increased work of breathing > Drop in O2 sats > Displaced trachea (worse case scenario) > Decreased or absent lung sounds on the side of the pneumothorax 4. Signs of cardiac tamponade > Beck’s triad: elevated CVP, decreased BP, muffled heart tones > PEA (pulseless electrical activity) – YIKES! > Pulsus paradoxus
29
Obstructive Shock Interventions
1. GOAL = remove whatever is causing the obstruction! 2. Tension pneumothorax – needle decompression or chest tube 3. Cardiac tamponade – pericardiocentesis 4. Pulmonary embolism – heparin, thrombolytic therapy, IVC (inferior vena cava) filter
30
Anaphylactic Shock Signs and Symptoms
1. Wheezing/stridor 2. CP, hypotension, tachycardia 3. Swelling of lips/tongue 4. Angioedema 5. Hives, uticaria, itching, cutaneous flushing
31
Anaphylactic Shock Treatment
1.Airway management 2. Epinephrine, Histamine blockers (Pepcid, Tagamet, Benadryl), Bronchodilators, Steroids 3.Fluids for BP support 4. BLS/ACLS protocol
32
Neurogenic Shock Signs and Symptoms
1.Hypotension, bradycardia 2. Flushed warm skin 3. Cyanotic lips and fingernails 4. Lack of full consciousness
33
Neurogenic Shock Treatment
1.Immobilization – stabilize that spine! 2. IV fluids 3. Vasopressors 4. Anticholinergic (atropine)

Med Surg Unit 4 (8 decks)

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