Shock Notes

Question 1

Shock

Answer 1

Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism.

Question 2

4 Categories for Shock

Answer 2

Cardiogenic
Hypovolemic
Distributive
Obstructive

Question 3

Cardiogenic Shock

Answer 3

systolic or diastolic dysfunction of the heart’s pumping action results in reduced CO , SV & BP.
Most common cause is MI

Question 4

Cardiogenic Shock c/m:

Answer 4

Tachycardia & hypotension - early manifestations
Decreased Cap refill, SV, CO, SVR, PAWP, CVP
Tachypneic & crackles
Decreased urine output, and increase Na+ and H2O retention
Pallor, cool and clammy skin
Anxiety, agitation & confusion
n/v, hypoactive bowel sounds

Question 5

Hypovolemic Shock

Answer 5

Inadequate volume in the intravascular space to support adequate perfusion.
Can be absolute or relative
Pts can compensate a loss of up to 15% of total volume.

Question 6

Hypovolemic Shock c/m:

Answer 6

Tachycardia, decreased preload, CO, CVP, PAWP, and Cap refill and Increased SVR. 
Tachypnea to bradypnea (late) 
Decreased urine output
Pallor, cool and clammy skin
Anxiety, agitation & confusion
Absent Bowel Sounds
Decreased Hct, Hgb & increased lactate, urine specific gravity
changes in electrolytes

Question 7

Distributive Shock

Answer 7

Neurogenic
Anaphylaxis
Septic

Question 8

Neurogenic

Answer 8

Hemodynamic phenomenon that can occur within 30 min of a spinal cord injury and lasts up to 6 wks.
Gen. associated with cervical or spinal cord injuries.

Question 9

Neurogenic c/m:

Answer 9

Bradycardia, decreased BP, CO, CVP, SVR, change in temperature
Dysfunction r/t level of injury
Bladder dysfunction
Decreased skin perfusion, cool or warm dry skin
Flaccid paralysis below the level of lesion, loss of reflex activity
Bowel dysfunction

Question 10

Anaphylactic shock

Answer 10

acute life-threatening hypersensitivity reaction to a sensitizing substance
Leads to respiratory distress due to laryngeal edema, severe bronchospasm, and circulatory failure

Question 11

Anaphylactic shock c/m:

Answer 11

Tachycardia, increased CO, decreased CVP, PAWP, CP, Third spacing of fluid
SOB, Edema of larynx & epiglottis, wheezing, stridor, and rhinitis
incontinence
flushing, pruritus, uticaria, angioedema
anxiety, feeling of impending doom, confusion, decreased LOC, metallic taste
cramping, abd pain, n/v, diarrhea
sudden onset, hx of allergies, exposure to contrast media.

Question 12

Sepsis and septic shock

Answer 12

Sepsis: life-threatening syndrome in response to an infection.
Septic shock: subset of species characterized by persistent hypotension despite fluid resuscitation and inadequate and inadequate tissue perfusion

Question 13

Sepsis and septic shock c/m:

Answer 13

tachycardia, temperature changes, myocardial dysfunction, biventricular dilation, decreased EF
hyperventilation, crackles, respiratory alkalosis or acidosis, hypoxemia, respiratory failure, ARDS, pulmonary HTN
decreased urine output
warm and flushed skin to cool and mottled skin (late)
change in mental status, agitation , coma
GI bleeding, paralytic ileus
WBC changes, decreased platelets, urine na+, increased lactate, blood glucose, procalcitonin, urine specific gravity, and positive blood cultures.

Question 14

Obstructive shock

Answer 14

develops when a physical obstruction to blood flow occurs with decreased CO.

Question 15

Obstructive shock c/m

Answer 15

Tachycardia, decreased BP, preload, CO and increased SVR, CVP, JVD and pulsus paradoxus
Tachypnea to bradypnea (late), SOB
decreased urine output
Pallor, cool and clammy skin
anxiety, agitation, confusion
Decreased to absent bowel sounds
Specific to cause of obstruction

Question 16

Stages of shock

Answer 16

Initial
Compensatory
Progressive
Refractory

Question 17

Neurologic Compensatory Stage

Answer 17

Oriented to person, place, time
Restless, apprehensive, confused
Change in level of consciousness

Question 18

Cardiovascular Compensatory Stage

Answer 18

Sympathetic nervous system response:
• Release of epinephrine/norepinephrine (vasoconstriction)
• ↑ MVO2
• ↑ Contractility
• ↑ HR
Coronary artery dilation
Narrowed pulse pressure
↓ BP

Question 19

Respiratory Compensatory Stage

Answer 19

Blood flow to the lungs:
• ↑ Physiologic dead space
• ↑ Ventilation-perfusion mismatch
• Hyperventilation
• ↑ Minute ventilation (VE)
• Tachypnea

Question 20

GI Compensatory Stage

Answer 20

↓ Blood supply
↓ GI motility
Hypoactive bowel sounds
↑ Risk for paralytic ileus

Question 21

Renal Compensatory Stage

Answer 21

↓ Renal blood flow
↑ Renin resulting in release of angiotensin (vasoconstrictor)
↑ Aldosterone resulting in Na+ and H2O reabsorption
↑ Antidiuretic hormone resulting in H2O reabsorption

Question 22

Temperature and Skin Compensatory Stage

Answer 22

Normal or abnormal
Pale and cool
Warm and flushed

Question 23

Neurologic Progressive Stage

Answer 23

↓ Cerebral perfusion pressure
↓ Cerebral blood flow
↓ Responsiveness to stimuli
Delirium

Question 24

Cardiovascular Progressive Stage

Answer 24

↑ Capillary permeability → systemic interstitial edema
↓ CO → ↓ BP and ↑ HR
MAP <60 mm Hg (or 40 mm Hg drop in BP from baseline)
↓ Coronary perfusion → dysrhythmias, myocardial ischemia, MI
↓ Peripheral perfusion → ischemia of distal extremities, ↓ pulses, ↓ capillary refill

Question 25

Respiratory Progressive Stage

Answer 25

``` ARDS: • ↑ Capillary permeability • Pulmonary vasoconstriction • Pulmonary interstitial edema • Alveolar edema • Diffuse infiltrates • Tachypnea • ↓ Compliance • Moist crackles ```

Question 26

GI Progressive Stage

Answer 26

``` Vasoconstriction and ↓ perfusion → ischemic gut (e.g., stomach, small and large intestines, gallbladder, pancreas): • Erosive ulcers • GI bleeding • Translocation of GI bacteria • Impaired absorption of nutrients ```

Question 27

Renal Progressive Stage

Answer 27

``` Renal tubules become ischemic → acute tubular necrosis ↓ Urine output ↑ BUN-to-creatinine ratio ↑ Urine sodium ↓ Urine osmolality and specific gravity ↓ Urine potassium Metabolic acidosis ```

Question 28

Hepatic Progressive Stage

Answer 28

Failure to metabolize drugs and waste products Cell death (↑ liver enzymes) Jaundice (↓ clearance of bilirubin) ↑ NH3 (ammonia) and lactate

Question 29

Hematologic Progressive Stage

Answer 29

DIC: • Thrombin clots in microcirculation • Consumption of platelets and clotting factors

Question 30

Temperature and Skin Progressive

Answer 30

Hypothermia or hyperthermia | Cold and clammy

Question 31

Neurologic Refractory Stage

Answer 31

Unresponsive Areflexia (loss of reflexes) Pupils nonreactive and dilated

Question 32

Cardiovascular Refractory Stage

Answer 32

Profound hypotension ↓ CO Bradycardia, irregular rhythm ↓ BP inadequate to perfuse vital organs

Question 33

Respiratory Refractory Stage

Answer 33

Severe refractory hypoxemia | Respiratory failure

Question 34

GI Refractory Stage

Answer 34

Ischemic gut

Question 35

Renal Refractory Stage

Answer 35

Anuria

Question 36

Hepatic Refractory Stage

Answer 36

Metabolic changes from accumulation of waste products (e.g., NH3, lactate, CO2)

Question 37

Hematologic Refractory Stage

Answer 37

DIC progresses

Question 38

Emergency Management of Shock

Answer 38

Initial: • If unresponsive, assess circulation, airway, and breathing (CAB). • If responsive, monitor airway, breathing, and circulation (ABC). • Stabilize cervical spine as appropriate. • Control any external bleeding with direct pressure or pressure dressing. • Give high-flow O2 (100%) by nonrebreather mask or bag-valve-mask. • Anticipate need for intubation and mechanical ventilation. • Establish IV access with 2 large-bore catheters (14- to 16-gauge) or an intraosseous access device; aid with central line insertion. • Begin fluid resuscitation with crystalloids (e.g., 30 mL/kg repeated until hemodynamic improvement is seen). • Draw blood for laboratory studies (e.g., blood cultures, lactate, WBC). • Assess for life-threatening injuries (e.g., cardiac tamponade, liver laceration, tension pneumothorax). • Consider vasopressor therapy if hypotension persists after fluid resuscitation. • Insert an indwelling urinary catheter and nasogastric tube. • Start antibiotic therapy after blood cultures if sepsis is suspected. • Obtain 12-lead ECG and treat dysrhythmias. Ongoing Monitoring: • ABCs • Level of consciousness • Vital signs, including pulse oximetry; peripheral pulses, capillary refill, skin color and temperature • Respiratory status • Heart rate and rhythm • Urine output

Question 39

Fluid Therapy

Answer 39

Isotonic Crystalloids Hypertonic Crystalloids Blood Products Colloids

Question 40

Isotonic Crystalloids: Mechanism of Action & Indication

Answer 40

0.9% NaCl, normal saline solution (NSS) or Lactated Ringer’s (LR) solution Fluid primarily stays in the intravascular space, ↑ intravascular volume. Used for initial volume replacement in most types of shock.

Question 41

Isotonic Crystalloids: Nursing Implications

Answer 41

Monitor patient closely for circulatory overload. Do not use LR in patients with liver failure.LR may be used if hyperchloremic acidosis develops from use of NSS in fluid resuscitation.

Question 42

Hypertonic Crystalloids: Mechanism of Action & Indication

Answer 42

1.8%, 3%, 5% NaCl Fluid stays in the intravascular space, increases serum osmolarity, shifts fluid volume from intracellular space to extracellular space to intravascular space. May be used for initial volume expansion in hypovolemic shock.

Question 43

Hypertonic Crystalloids: Nursing Implications

Answer 43

Monitor patient closely for signs of hypernatremia (e.g., disorientation, seizures). Central line preferred for infusing saline solutions ≥3%, since these may damage veins.

Question 44

Blood Products: Mechanism of Action & Indication

Answer 44

Packed red blood cells Fresh frozen plasma Platelets Replaces blood loss, increases O2-carrying capability. Replaces coagulation factors. Helps control bleeding caused by thrombocytopenia All types.

Question 45

Blood Products: Nursing Implications

Answer 45

Same precautions as any blood administration

Question 46

Human serum albumin (5% or 25%): Mechanism of Action & Indication

Answer 46

Colloids Can increase plasma colloid osmotic pressure. Rapid volume expansion. All types except cardiogenic and neurogenic shock

Question 47

Human serum albumin (5% or 25%): Nursing Implications

Answer 47

Use 5% solution in hypovolemic patients. Use 25% solution in patients with fluid and sodium restrictions. Monitor for circulatory overload. Mild side effects of chills, fever, and urticaria may develop. More expensive than crystalloids.

Question 48

dextran (dextran 40): Mechanism of Action & Indication

Answer 48

Colloids Hyperosmotic glucose polymer. Limited use because of side effects, including reducing platelet adhesion, diluting clotting factors.

Question 49

dextran (dextran 40): Nursing Implications

Answer 49

Increases risk for bleeding. | Monitor patient for allergic reactions and AKI. Has maximum volume recommendations per manufacturer.

Question 50

Cardiogenic Shock & Septic Shock: Oxygenation Interprofessional Care

Answer 50

Provide supplemental O2 (e.g., nasal cannula, nonrebreather mask) Intubation and mechanical ventilation, if needed Monitor ScvO2 or SvO2

Question 51

Hypovolemic Shock: | Oxygenation Interprofessional Care

Answer 51

* Provide supplemental O2 | * Monitor ScvO2 or ScvO2

Question 52

Neurogenic, Anaphylactic & Obstructive Shock: Oxygenation Interprofessional Care

Answer 52

* Maintain patent airway * Provide supplemental O2 * Intubation and mechanical ventilation (if needed)

Question 53

Cardiogenic Shock: Circulation Interprofessional Care

Answer 53

Restore blood flow with angioplasty with stenting, emergent coronary revascularization • Reduce workload of heart with circulatory assist devices: IABP, VAD

Question 54

Hypovolemic Shock: Circulation Interprofessional Care

Answer 54

* Rapid fluid replacement using 2 large-bore (14–16 gauge) peripheral IV lines, an intraosseous access device, or central venous catheter * Restore fluid volume (e.g., blood or blood products, crystalloids) * End points of fluid resuscitation: * CVP 15 mm Hg * PAWP 10–12 mm Hg

Question 55

Septic Shock: Circulation Interprofessional Care

Answer 55

* Aggressive fluid resuscitation (e.g., 30 mL/kg of crystalloids repeated if hemodynamic improvement is noted) * End points of fluid resuscitation are based on: * Focused physical examination including vital signs, cardiopulmonary assessment, capillary refill, peripheral pulses, and skin or any 2 of the following: * ScvO2 >70 or SvO2 >65 * CVP 8–12 mm Hg * Cardiovascular ultrasound * Assessment of fluid responsiveness with passive leg raise or fluid challenge

Question 56

Neurogenic Shock: Circulation Interprofessional Care

Answer 56

Cautious administration of fluids

Question 57

Anaphylactic Shock: Circulation Interprofessional Care

Answer 57

Aggressive fluid resuscitation with colloids

Question 58

Obstructive Shock: Circulation Interprofessional Care

Answer 58

* Restore circulation by treating cause of obstruction | * Fluid resuscitation may provide temporary improvement in CO and BP

Question 59

Cardiogenic Shock: Drug Therapy

Answer 59

* Nitrates (e.g., nitroglycerin) * Inotropes (e.g., dobutamine) * Diuretics (e.g., furosemide) * β-Adrenergic blockers (contraindicated with ↓ ejection fraction)

Question 60

Septic Shock: Drug Therapy

Answer 60

* Antibiotics as ordered * Vasopressors (e.g., norepinephrine) * Inotropes (e.g., dobutamine) * Anticoagulants (e.g., low-molecular-weight heparin)

Question 61

Neurogenic Shock: Drug Therapy

Answer 61

* Vasopressors (e.g., phenylephrine) | * Atropine (for bradycardia)

Question 62

Anaphylactic Shock: Drug Therapy

Answer 62

* Epinephrine (IM or IV) * Antihistamines (e.g., diphenhydramine) * Histamine (H2)-receptor blockers (e.g., ranitidine [Zantac]) * Bronchodilators: nebulized (e.g., albuterol) * Corticosteroids (if hypotension persists

Question 63

Cardiogenic Shock: Supportive Therapy

Answer 63

Treat dysrhythmias

Question 64

Hypovolemic Shock: Supportive Therapy

Answer 64

* Correct the cause (e.g., stop bleeding, GI losses) | * Use warmed IV fluids, including blood products (if appropriate)

Question 65

Septic Shock: Supportive Therapy

Answer 65

* Obtain cultures (e.g., blood, wound) before beginning antibiotics * Monitor temperature * Control blood glucose * Stress ulcer prophylaxis

Question 66

Neurogenic Shock: Supportive Therapy

Answer 66

* Minimize spinal cord trauma with stabilization | * Monitor temperature

Question 67

Anaphylactic Shock: Supportive Therapy

Answer 67

* Identify and remove offending cause * Prevent via avoidance of known allergens * Premedicate with history of prior sensitivity (e.g., contrast media)

Question 68

Obstructive Shock: Supportive Therapy

Answer 68

• Treat cause of obstruction (e.g., pericardiocentesis for cardiac tamponade, needle decompression or chest tube insertion for tension pneumothorax, embolectomy for pulmonary embolism)

Question 69

Phenylephrine: Mechanism of Action and Indications

Answer 69

α-Adrenergic agonist (peripheral vasoconstriction) Renal, mesenteric, splanchnic, cutaneous, and pulmonary blood vessel constriction ↑ HR, BP, SVR ↑/↓ CO Neurogenic shock

Question 70

Phenylephrine: Nursing Implication

Answer 70

Monitor for reflex bradycardia, headache, restlessness. Monitor for renal failure from ↓ renal blood flow. Give via central line (infiltration leads to tissue sloughing).