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MS3 Exam 1 > Shock > Flashcards

Shock Flashcards

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1
Q

CONCEPT

A

Perfusion

Ability of the cardiovascular and pulmonary systems to provide adequate oxygenated blood to the cells and organs of the body and the removal of metabolic waste

Inadequate perfusion will lead to changes that affect all body functioning

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2
Q

Terms to Know

Stroke Volume

A

amount of blood ejected with each ventricular contraction

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3
Q

Terms to Know

Cardiac Output

A

amount of blood pumped per minute (CO = HR x SV)

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4
Q

Terms to Know

Mean Arterial Pressure (MAP)

A

average pressure in the arterial circulation throughout the cardiac cycle

ideal 70-90

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5
Q

Terms to Know

Pulse Pressure

A

the difference between systolic and diastolic pressures

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6
Q

Types of Shock

Low Blood Flow

A

HYPOVOLEMIC

  • Severe trauma with massive tissue injury
  • Hemorrhage

CARDIOGENIC

  • Acute MI
  • Arrhythmias
  • Cardiomyopathy
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7
Q

Maldistribution of Blood Flow

A

SEPTIC

  • Pancreatitis
  • Infection →Sepsis

NEUROGENIC

  • Spinal Cord Injury
  • Narcotic Overdose

ANAPHYLACTIC

  • Multiple Transfusion
  • Severe Allergic Reaction
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8
Q

Shock

A

Characterized by decreased tissue perfusion and decreased cellular metabolism

Imbalance in supply/demand

MAP>60 ideal
MAP<50 incompatible with life

confusion, restlessness → ↓BP

normal: 25% o2 used, 1 pass through body
shock: 80% 02 used, 1 pass through body

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9
Q

Hypovolemic Shock

A

Severe blood +/or fluid loss making the heart unable to pump enough blood to the body

Emergency situation
Loss of 1/5 the normal amount of intravascular volume in the body (~750ml loss)

volume problem
most common form of shock
↓BP, ↓CO

goal: maintain intravascular (fluids, fluids, more fluids)

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10
Q

HYPOVOLEMIC SHOCK

Absolute Hypovolemia

A 
Fluid loss through: 
Hemorrhage
Gastrointestinal loss
Fistula drainage
Diabetes Insipidus
Rapid diuresis
Severe dehydration
Pregnancy &amp; Childbirth
Major Sx
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11
Q

HYPOVOLEMIC SHOCK

Relative Hypovolemia

A 
Fluid loss through:
Movement of fluid from Intravascular to Extravascular Space
Burns
Liver disease (ascites)
“Third Spacing”
Fluid shifts
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12
Q 
HYPOVOLEMIC SHOCK
(define)
A

Size of vascular compartment unchanged
Decreased venous return to heart
Decreased preload, SV and CO
Impaired cellular metabolism

Response to acute volume loss depends upon:

  • Age
  • Injury
  • Health

anaerobic & anaerobic
anaerobic - gives off heat

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13
Q

HYPOVOLEMIC SHOCK

Signs & Symptoms

A 
Anxiety, confusion
Agitation
Tachycardia
Hypotension
Pallor
Cold &amp; clammy
Decreased capillary refill / pulses
Decreased urine output (later sign)
Decreased or absent bowel sounds (earlier sign)
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14
Q

HYPOVOLEMIC SHOCK

Immediate Treatment

A 
Recognize A-B-C’s and LOC
High flow O2
2 large bore IV’s
Fluids / blood via warmer
Expose the patient (blankets to warm)
Medications as warranted
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15
Q

CARDIOGENIC SHOCK

Low Blood Flow Shock

A

Failure of the heart to act as a pump moving blood forward
Compromised CO & SV

RIGHT SIDE:
Pulmonary circulation compromised

LEFT SIDE:
Impaired ability of the ventricle to fill during diastole
Decreased Stroke Volume

clots
↓↓BP

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16
Q

CARDIOGENIC SHOCK

Causes

A 
MI (#1 cause)
Cardiomyopathy
Severe Systemic/Pulmonary HTN
Blunt Cardiac Injury (MVA. #2)
Severe Myocardial Depression from Sepsis
Cardiac Tamponade
Dysrhythmias
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17
Q 
CARDIOGENIC SHOCK
(define)
A

Decreased CO with resultant decreased MAP
Tachycardia compensation stresses the heart
Myocardial ischemia progresses to necrosis
Cardiac failure leads to shock and pulmonary failure

**MAP & urine output

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18
Q

CARDIOGENIC SHOCK

Signs & Symptoms

A 
Tachycardia, thready pulse, JVD
Hypotension
Narrowed pulse pressure
Increased SVR
Increased myocardial O2 consumption (Angina)
Pale, cold, moist skin
Cyanosis
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19
Q

CARDIOGENIC SHOCK

S&S of Peripheral Hypoperfusion

Study These Flashcards
A
  • Renal Blood Flow
  • Decreased Urine Output
  • Impaired Cerebral Blood Flow

lethargy→coma

20
Q

CARDIOGENIC SHOCK

Treatments

Study These Flashcards
A 
Cautious use of fluids
High flow O2
Medications as indicated
Vazoactives (CO &amp; contractility)
Beta 1 medications

Starling’s Law: overstretch cardiac muscle to the point it cannot constrict

21
Q 
DISTRIBUTIVE SHOCK
(define)

vasogenic shock

Study These Flashcards
A

An increase in the size of the vascular bed due to massive vasodilatation or peripheral pooling of blood

Normal blood volume that can not adequately fill the increased size of the capillary bed

Types:
NEUROGENIC
SEPTIC
ANAPHYLACTIC

blood vessel problem
massive vasodilation

22
Q 
NEUROGENIC SHOCK
(define)
Study These Flashcards
A

Occurs after spinal cord injury at T5 or above

Results in massive vasodilatation leading to pooling of blood in vessels
Loss or suppression of -sympathetic tone- (↓ sympathetic motor function)

The rarest of all shocks

23
Q

NEUROGENIC SHOCK

Signs & Symptoms

Study These Flashcards
A

Hypotension
Bradycardia
–Dry, warm skin initially–
With hypothalamic dysfunction there is temperature dysregulation
Respiratory dysfunction based on level of cord injury

Can begin 30 minutes after injury & last days to weeks

bradycardia→atropine

24
Q

NEUROGENIC SHOCK

Treatment

Study These Flashcards
A

Treat the injury
Corticosteroids (anti-inflammatory)
Vasoactive agents (cerebral perfusion pressure = MAP-ICP)
Reduce parasympathetic stimulation

Cannot control ICP, use MAP to counteract ICP
Dopamine, Levafed(?), Epinephrine

25
ANAPHYLACTIC SHOCK | Pathophysiology
Acute, Life-Threatening Hypersensitivity Reaction Massive Vasodilatation Release of Mediators (Histamine, Serotonin, etc.) Increased Capillary Permeability (capillary leakage) Loss of Intravascular Volume Impaired Tissue Perfusion
26
ANAPHYLACTIC SHOCK | Causes
AntigensFoodsFood AdditivesDiagnostic AgentsBiologic AgentsEnvironmental AgentsDrugsVenoms / Insects Blood reactionsIgE-mediated or non-IgE-mediated
27
ANAPHYLACTIC SHOCK | Degree of Reaction
Sudden onset of S&S CUTANEOUS MANIFESTATIONS Urticaria, rash, erythema, angioedema, puritis, flushing RESPIRATORY COMPROMISE Swelling of lips & tongue, SOB, wheezing, stridor, chest pain NEUROLOGICAL COMPROMISE Anxiety, confusion, impending doom, ↓ LOC
28
ANAPHYLACTIC SHOCK | Treatments
Epinephrine Corticosteroids High flow O2 Artificial airways
29
``` SEPTIC SHOCK (define) ```
Systemic inflammatory response to infection Presence of sepsis with hypotension despite fluid resuscitation with abnormal tissue perfusion Leading cause of death in non-coronary ICU’s PRIMARY CAUSATIVE ORGANISMS: Gram-negative & Gram-positive bacteria [↓ outcome gram-neg] Endotoxins stimulate inflammatory responses body temperature heart rate respiration rate leukocyte count
30
SEPTIC SHOCK | Signs & Symptoms
Early Manifestation ↓LOC Cutaneous Manifestations Warm, dry, flushed skin Cardiovascular Manifestations Hypotension, hyperthermia, ↓SVR, compensatory CO, ↑coagulation, ↓fibrinolysis, ↓urine output Tachypnea Fluid resuscitation does NOT work
31
SEPTIC SHOCK | "Warm" vs "Cool"
``` “WARM” stage Hypotension Tachycardia Warm, flushed skin Increased core temperature Chills Anxiousness N/V/D ``` ``` “COLD” stage Hypotension Tachycardia and dysrhythmias Cool, pale edematous skin Lethargy or Coma Oliguria / Anuria Decreased core temperature ``` longer in cold stage → harder to reverse
32
SEPTIC SHOCK | Treatments
Antibiotics and IV fluids Possible ventilator support Support vital functions Cultures to identify organism skin starts weeping d/t fluid overload
33
STAGES OF SHOCK Initial Stage [pt 1]
May not be clinically apparent May be restless or anxious Metabolism changes from aerobic to anaerobic (leads to lactic acid accumulation) Lactic Acid accumulates (sodium bicarb tx) Must be removed by blood & broken down by the liver This requires unavailable O2
34
STAGES OF SHOCK Initial Stage [pt 2]
Baroreceptors detect a sustained decrease in the MAP (<10 mmHg) Decreased circulating blood flow Natural physiologic responses are activated Vasoconstriction Increased cardiac contractions & HR Reversible at this point
35
STAGES OF SHOCK Compensatory Stage [pt 2]
Attempted homeostasis MAP < 10-15 mmHg & 25-35% volume loss Renin-Angiotensin system activated Impaired GI motility Cool, clammy skin Except septic shock where skin is warm & flushed "fight or flight" activity still reversible
36
STAGES OF SHOCK Compensatory Stage [pt 2]
Shunting blood from lungs = physiologic dead space SNS stimulation increases myocardial O2 demand Decreased blood to kidneys Reabsorb Na+/H2O, ↓K+ If the deficit is not corrected, the patient enters the PROGRESSIVE STAGE
37
STAGES OF SHOCK Progressive Stage [pt 1]
MAP < 20 mmHg Begins when compensatory mechanisms fail Lactic acid accumulation Requires aggressive interventions to prevent multi-organ dysfunction syndrome (MODS) and death
38
STAGES OF SHOCK Progressive Stage [pt 2]
Decreased cellular perfusion and altered capillary permeability Movement of fluid from intravasculature to interstitium Hyperkalemia due to cellular destruction
39
STAGES OF SHOCK Progressive Stage [pt 3]
Fluid movement into alveoli CO begins to fall Myocardial Dysfunction GI system becomes ischemic Liver fails to metabolize drugs & wastes Failure of one organ system affects others cardiac muscle affected by lactic acid
40
STAGES OF SHOCK | Refractory Stage
``` Exacerbation of anaerobic metabolism Accumulation of lactic acid (sodium bicarb drips tx) Increased capillary permeability Hypotension & tachycardia worsen Decreased coronary blood flow Cerebral ischemia Hypoxemia ``` RECOVERY UNLIKELY
41
COMPARISON OF SHOCK STATES
SHOCKSTATE CVP PWP CO SVR BP Hypovolemic ↓↓↓↓ ↓↓↓↓ ↓↓↓↓ ↑↑↑↑ ↓↓↓↓ Cardiogenic ↓↓↓↓ ↑↑↑↑ ↓↓↓↓ ↑↑↑↑ ↓↓↓↓ Septic ↓↓↓↓ ↓↓↓↓ ↓↓↓↓ ↓↓↓↓ ↓↓↓↓
42
MEDICAL MANAGEMENT
SUPPORTIVE CARE Ventilation & Oxygenation ADEQUATE INTRAVASCULAR VOLUME Positioning Volume Replacement CIRCULATORY SUPPORT Vasopressors & Positive Inotropes Vasodilators Circulatory Assist Devices **NO Ringer's Lactate**
43
NURSING DIAGNOSES
``` DECREASED CARDIAC OUTPUT IMPAIRED GAS EXCHANGE FLUID VOLUME DEFICIT ALTERED TISSUE PERFUSION: Cerebral, Renal, GI, Peripheral HYPERTHERMIA / HYPOTHERMIA FEAR / ANXIETY KNOWLEDGE DEFICIT: Patient / Family ``` [pulse pressure & urinary output - best indicator of tissue perfusion]
44
COMPLICATIONS
Multiple Organ Dysfunction Syndrome (MODS) Myocardial Failure ARDS Disseminated Intravascular Coagulation (DIC) GI Bleeding Hepatic Failure Death
45
In which shock state is the client warm, flushed, bradycardia and hypotension? 1. Cardiogenic shock 2. Septic shock 3. Hypovolemic shock 4. Neurogenic shock
4

MS3 Exam 1 (6 decks)

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