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dopamine (Intropin)

Classfication: Adrenergic agonist

Mechanism of action: acts on (alpha) receptors causing vasocontriction of blood vessels, and to a lesser degree beta receptors (inotropic effects) which increase cardiac output

Use: shock, hypotension, to increase perfusion to VS

Side/adverse effects: HA, tachycaardia, dysrhythmias, N/V/diarrhea, dyspnea

Nursing Implications: need continuous ECG monitoring, BP monitoring, I/O, monitor for fluid volume excess (CHF) should have CVP or PWP during injection


epinephrine (Adrenalin)

Classification: non-selective adrenergic agonist

Mechanism of action: beta agonist (B1 and B2) leading bronchodilation, cardiac, and CNS stimulation

Use: shock, cardiac arrest, anaphylaxis, allergic reactions, acute asthma attacks

Side/Adverse effects: tremor, anxiety, insomnia, cerebral hemorrhage, tachycardia, dysrhythmias, hypertension, anorexia, N/V, dyspnea

Nursing Implications:

Continuous ECG monitoring during administration with CVP, PCWP if possible arterial BP monitoring recommended. Can give VIA ET tube


***Risk for Shock


What is shock?

A syndrome characterized by hypo-perfusion of body tissues that leads to diffuse tissue hypoxia, abnormal cellular metabolism and ultimately cell death


What are factors that contribute to normal regulation of blood flow?

  1. Adequate blood volume
  2. Ability of the heart to effectively pump
  3. Vascular tone

Shock develops when cells do not receive adequate blood flow/O2 thus altering metabolism

  • Supply/demand problem

Shock cannot be defined as a specific disease, but manifests within many disease processes



What is the impact of shock on society?

  1. Increasing incidence
  2. Critical care environment
  3. Increased incidence of sepsis
  4. Brings high mortality rate
  5. Financial burden


What are risk factors for developing shock?

  1. Age extremes
  2. Poor general health
  3. Immunosuppression
  4. Trauma
  5. Multiple medical/surgical therapies
  6. Long term medical instrumentation


What is the general pathophysiology of shock?

Shock is a syndrome that occurs when the body attempts to achieve homeostasis in response to perfusion/oxygen problem.


What are the causes of hypovolemic shock?

  1. Hemorrhage
  2. Burns
  3. Loss of other body fluids (vomiting, diarrhea, DI)
  4. Pooling of blood from ascites, peritonitis
  5. Internal bleeding from ruptured spleen


What is actual hypovolemia?

Loss of whole blood or plasma


What is relative hypovolemia?

Internal shift of fluids from intravascular space to extravascular space


What is hypovolemic shock?

Decreased circulating blood volume (size of the vascular compartment remains the same, while the blood volume decreases)


What is cardiogenic shock?

Defect in ability of heart to pump and move blood forward



What are the causes of cardiogenic shock?

  1. Previous acute MI
  2. Large MI
  3. LVEF 35% or less
  4. Elderly

Most commonly ventricular ischemia particularly related to acute MI. Other causes are dysrhythmias and structural defects which interfere with the heart's ability to effectively pump blood


What is distributive shock (neurogenic, anaphylactic, septic)?

Defect in vascular smooth muscle tone: size of the vascular compartment enlarges but blood volume remains the same (vasodilation). Same mechanism for neurogenic, anaphylactic and septic shock


What is neurogenic shock?

  1. Hemodynamic result of SCI at T5 or above
  2. Spinal anesthesia
  3. Vasomotor center depression


What is anaphylactic shock?

Massive vasodilation from histamine, leukotriene, mast cells. Massive systemic allergic reaction


What is septic shock?

Systemic infection. Endotoxin from microorganism causes vasodilation


How do all types of shock alter hemodynamics in the same way?

Decreased Perfusion


Decreased CO


Decrease in mean arterial pressure (MAP)


Continued decresased perfusion


Compensatory mechanisms


Increase in SV, Increase HR, Increase CO, Increase SVR, Increase MAP


Further continued decreased perfusion


Decreased CO


Decreased MAP


What are the stages of shock?

Shock progresses through four stages. The progression from one to the next can be halted/stopped with treatment/intervention.

  1. Inital
  2. Compensatory
  3. Progressive
  4. Refractory


What happens in the initial stage of shock?

First stage. No signs or symptoms. Changes are cellular. Shock is reversible.


What happens in the compensatory stage of shock?

Second stage. Compensatory mechanisms kick in to return cells to pre-shock state

  1. Most metabolic need of body continues to be met because of the effects of the SNS/RAAS
  2. Decreased MAP activates SNS leading to selective peripheral vasoconstriction and blood shunts to brain and heart.
  3. SNS also causes increase in HR and contractility leading to increased CO increasing O2 to myocardium
  4. Decreased blood flow to kidneys activites RAAS causing vasoconstriction and increased BP. Also ADH released causing H20 reabsorption, increasing blood volume
  5. Fluid shift from intracellular to intravascular spaces due to decreased hydrostatic pressure and osmotic gradient also increased blood volume

All lead to increased preload, increased HR, contractility, CO, BP


What happens in the progressive (uncompensated) stage of shock?

  1. Compensatory mechanisms fail and irreversible cellular damage occurs
  2. Tissue hypoxia/cell death
  3. Metabolic acidosis


What are the signs and symptoms of progressive stage of shock?

  1. Diminished LOC
  2. Increased HR
  3. Increased myocardial contractility
  4. Possible dysrhythmias
  5. Decreasing BP and MAP
  6. Low PaO2
  7. Metabolic acidosis, low pH
  8. Aggressive management needed to reverse shock state


What happens in the refractory (irreversible) stage of shock?

Fourth stage. Progressive end organ dysfunction becomes irreversible and unresponsive to therpeutic interventions

  1. Tissue hypoxia worsens
  2. Anaerobic metabolism takes over
  3. Metabolic lactic acidosis alters pH
  4. Stasis of blood in capillaries
  5. Increased capillary pressure (anasarca)
  6. Fluid now shifts to extravascular spaces
  7. Decreasing venous return to heart
  8. Decreasing CO
  9. Peripheral vasoconstriction (SNS)


What are the signs and symptoms of refractory stage of shock?

  1. Depressed LOC (decreased cerebral blood flow)
  2. Hypotension (decreased CO)
  3. Tachycardia (SNS)
  4. Myocardial depression/bradycardia
  5. Cerbral ischemia (brain death)
  6. Central failure of SNS and loss of BP = Respiratory failure and cardiac arrest


What is disseminated intravascular coagulation (DIC)?

Disorder in which bleeding and clotting occur abnormally and simultaneously. Always caused by an underlying condition. Goal is aggressive treatment of underlying cause.


What is systemic inflammatory response syndrome (SIRS)?

Systemic activation of the inflammatory-immune response. Inflammation occurs in many organs and/or organ systems at once.


What is multiple organ dysfunction syndrome (MODS)?

When more than one organ system fails, usually respiratory first (ARDS), followed by others, infection, inflammation, ischemia. Carries 90% mortality rate.


What are the neurologic symptoms in compensated, progressive, refractory stages of shock?

Compensated: restless, irritable, apprehensive, oriented, verbal, subtle change in LOC

Progressive: confused, notable change in LOC, decreased response to stimuli

Refractory: unresponsive, severely decreased LOC, dilated non reactive pupils


What are the cardiovascular symptoms in compensated, progressive, refractory stages of shock?

Compensated: BP maintained at greater than 90 systolic, HR increases to compensate in all types of shock except neurogenic shock where HR decreases

Progressive: BP below 90 systolic, Tachycardia greater than 100, irregular, dysrhythmias, peripheral pulses weak, thready, prolonged capillary refill

Refractory: BP is falling to unobtainable, bradycardia


What are the respiratory symptoms in compensated, progressive, and refractory stages of shock?

Compensated: RR normal or slightly increased

Progressive: Tachypnea with shallow breathing, pulmonary edema

Refractory: Slow, irregular cheyne stoking or respiratory failure


What are the GI symptoms in compensated, progressive and refractory stages of shock?

Compensated: WNL or slight N/V/D

Progressive: hypoactive BS, GI bleeding, decreased absorption of nutrients

Refractory: absent BS, ischemic gut


What are the renal symptoms in compensated, progressive, and refractory stages of shock?

Compensated: urine output WNL or slight decreased UO

Progessive: Oliguria, increased BUN/Cr, metabolic acidosis

Refractory: Anuria


What are the body temperature changes/symptoms during compensated, progressive, refractory stages of shock?

Compensated: no change

Progressive: hypothermia, will see hyperthermia in septic shock

Refractory: severe hypothermia


What are the skin changes/symptoms in the compensated, progressive, and refractory stages of shock?

Compensated: cool, pale, except in septic shock: warm and flushed

Progressive: Cold, clammy, cyanotic

Refractory: cyanotic, mottled, ashen


What is the prevention of shock?

  1. Prevent infection
  2. Early recognition
  3. Early interventions


What are the early interventions for shock?

  1. Fluids
    1. Crystalloid - maintain intravascular fluid volume
    2. Colloid - expand fluid volume
  2. Medications
    1. Dopamine - inotropic effects, sympathetic effects
    2. Epinephrine - sympathetic effects of increased HR, increased CO
  3. Nutrition
    1. Shock is a hypermetabolic/catabolic state. Begin TPN early for improved outcomes.


What is the emergency management of shock?

  1. LOC
  2. VS, O2 sat, peripheral pulses and capillary refill time
  3. Cardiac rhythm
  4. Urine output
  5. Electrolytes
  6. ABGs


What are the nursing interventions for shock?

  1. Airway
  2. Oxygen
  3. IV access
  4. Fluid restriction
  5. Control bleeding
  6. Glycemic control
  7. Administer and monitor effects of vasopressor therapy
  8. Prevent complication
    1. Mechanical ventilation
    2. Foley catheter
    3. Central IV access
    4. Parenteral/enteral feedings


What is a ventricular assistive device?

  • Inserted into path of flowing blood to augment or replace action of the ventricle
  • Temporary device which can partially or totally support circulation until heart recovers or donor heart can be obtained


What is intraaortic balloon pump?

  • Balloon inserted percutaneously into the descending aorta
  • ECG triggers inflation and deflation
  • Inflation of balloon occurs at beginning of diastole (improves filling)
  • Deflates of balloon and beginning of systole (reduces afterload and work of heart)
  • Numerous potential complications

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