Unit 15 Shock Syndrome/AAA Flashcards
(43 cards)
What is shock?
Life threatening imbalance between the supply of oxygen and tissue demand/ perfusion issue.
What are types of shock?
Low blood flow:
- Hypovolemic shock
- Cardiogenic shock
Maldistribution of blood: (poor distribution/circulation)
- Neurogenic shock
- Anaphylactic shock
- Septic shock
Obstructive shock:
- Pneumothorax
- Cardiac tamponad
What are stages of shock?
Initial decreased tissue perfusion
Compensated (pre-shock)
Uncompensated (shock)
Irreversible (multiple organ dysfunction)
What initially are the problems happening in shock?
What do these metabolic changes cause a buildup of?
Hypo-perfusion
Hyper-metabolism
Activation of inflammatory response (anaerobic metabolism)
They cause a build up of Lactic Acid
Describe the compensatory stage (pre-shock).
- Flight or fight mechanism is activated
- Blood flow to vital organs are increased
- Body is reacting because of imbalance between oxygen supply and demand / decreased perfusion
If cause of decreased perfusion is correct at this stage, PT will recover with little or no effect.
What chemicals does your body release during stage 1?
Epinephrine and Norepinephrine
What are signs and symptoms of the Compensatory stage/pre-shock?
- BP normal, narrowing pulse pressure
- Elevated HR/ weak pulse
- Increased RR and depth
- Decreased peristalsis
- Restless/combative
- Cool and clammy skin (except for septic shock and neruogenic shock)
How is MAP calculated?
What is normal?
SBP + 2(DBP) / 3
Normal = 65 or >
What is the nursing care during the compensatory stage (pre-shock)?
-IV fluids to correct hypovolemia
(multiple large bore IV’s, minimum two)
- Administer O2
- Foley for fluid management
- Medications to maintain BP and tissue perfusion
- Nutritional needs
- Identify and correct underlying disorder
(ex: bleeding-stop it, infection-antibiotics, etc)
What makes older patients at risk for shock?
Medications such as beta-blockers that mask tachycardia, tachycardia keeps BP up so this will make BP drop faster in the older adult!
Dysrhythmias
Sudden change in mentation (consider infection, not just sun-downers)
During the Uncompensated shock stage (shock) what leaks out of the cells with increased permeability?
What will it cause?
Protein which will cause edema
What are signs and symptoms of Uncompensated shock (shock)?
Increased edema
Tachypnea, crackles, increased respiratory effort (symptoms of pulmonary edema, M. Vent possibly needed here)
Tachycardia
Decreased BP (~90/40) and cardiac output
Decreased LOC
What is the correct PT positioning for a PT experiencing shock?
Modified Trendelenberg
-For low BP during shock, head flat - feet up
What is nursing care during the uncompensated stage or progression of shock?
IVF and medications to restore tissue perfusion
Support respiratory system
Early intervention! PT should be in ICU
Promote rest and comfort
What happens during Irreversible (multiple organ dysfunction) last stage of shock?
Peripheral vasoconstriction
Decreased cardiac output
Accumulation of waste products
Cerebral ischemia
What is Multiple Organ Dysfunction Syndrome (MODS)?
Dysfunction of two or more organs with inability to maintain homeostasis without intervention
-can be complication of any type of shock
What are signs and symptoms of MODS?
Decreased BP and HR (needs to be maintained w/meds)
Profound hypoxemia
Increased lactic acid, BUN/Cr
Describe Hypovolemic shock.
What are the two types?
What are the s and s’s?
- Decreased blood volume leads to decreased cardiac output ultimately leading to deceased tissue perfusion.
- Most common type of shock
2 types
absolute = loss of blood volume
relative = fluids shifted to other spaces
S and S’s:
- Anxiety
- Decreased urine output
- Increased HR
- Decreased BP
What are causes of Hypovolemic Shock?
External/absolute:
- Trauma/Hemorrhage
- Vomiting/Diarrhea
- Diabetes Insipdus
Internal/relative:
- Burns
- Dehydration
- Sepsis
- Liver failure
- Pancreatitis
What are the goals in care of hypovolemic shock?
Restore and Redistribute fluid volume
Correct underlying cause of fluid loss
What are interventions to restore volume?
IV fluids w/crystaloids/colloids- volume expanders
(ex: hetastarch, dextran, albumin)
Blood products
Control bleeding
Stop vomiting and diarrhea
How would you provide redistribution in hypovolemic shock?
What can test if PT needs fluid?
-PT positioning: lower head, raise feet
-Meds: vasopressin, phenylephrine, epinephrine/norepinephrine, dopamine
(these all constrict blood vessels ^ BP)
Passive leg raising (head flat, legs up) can will show if PT needs fluid because if BP increases with manuever = PT needs fluid
What are non-pneumatic shock garments (NPSG)?
Keeps pressure on legs and abdomen to try and distribute blood to vital organs
What is the nursing management for hypovolemic shock?
- Monitor PT at risk for fluid volume deficit w/ VS, I and O’s, daily weights
- Fluid replacement before shock develops
- Treat cause
- Observe for side effects of treatment
