Week 4 --Hypovolemic Shock Flashcards by Shanna Gray

Hypovolemic Shock is caused by a decrease in intravascular volume of ____________

>15% or more

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Normal cardiac output (L/min)

4-8 L/min

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Causes (2) of Hypovolemic Shock

Loss of Blood Volume
- Surgery
- Burns
- Trauma
- Diabetes Ketoacidosis
LOSS OF FLUID
- Diuresis
- Vomiting
- diarrhea

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Medical Management of Hypovolemic Shock

GOALS of TX
- Restore intravascular volume
  - ^{GOAL: MAP > 65mmHg}
- Correct underlying cause as quickly as possible
  - HEMORRHAGE?
    - find and stop the bleeding
    - replace lost blood volume
  - BURNS…?
    - treat fluid loss from burns
  - DEHYDRATION…?
    - Restore Plasma Volume
Initial TX:
- ^{IV Fluid (2 L Crystalloids)}
First Line Tx:
- ^{Blood products as indicated for blood loss or further IV crystalloid}
Second Line Tx:
- ^{Norepinephrine}
 - ^{initiates peripheral vasoconstriction}
- ^Dopamine
 - ^{Low dose- increases renal perfusion}
 - ^{High dose-vasoconstriction effects-decreases renal perfusion}
- ^Epinepherine
 - ^{Initiates peripheral Vasoconstriction}
 - ^{increased rate}
 - ^{increased contractility}

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1ST STEP IN THE TX PROCESS IS TO ADMINISTER FLUIDS

Fluids that are administered for

HYPOVOLEMIC SCHOCK

^{GOAL: TO RESTORE INTRAVASCULAR COLUME TO MAINTAIN PERFUSION}
CRYSTALLOIDS
- Isotonic —> 0.9% NSS, Lactated Ringers
- Hypertonic—>3% or 7.5% saline
BLOOD COMPONENTS
- PRBC’s, Platelets, FFP

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2ND STEP IN THE TX PROCESS IS TO ADMINISTER VASOACTIVES

GOAL of VASOACTIVE medication

to improve hemodynamic stability when fluid therapy alone cant maintain adequate MAP ^{(MAP <60 mmHg can indicate poor perfusion)}

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ACTIONS OF VASOACTIVES (4)

Increase strength of myocardial contractility (stronger contractions)
Reduce afterload
Initiates Vasconstriction to increase preload
Regulating HR to maintain Cardiac Output

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Choice of Vasoactive medication is based on (2) things

TYPE OF SHOCK
- If you are dealing with a cardiogenic shock that is impairing the hearts ability to contract….maybe you want a medication to help to strengthen contractility? Or maybe you want a medication that vasodilates to make it easier for the heart to work to keep it from becomming further damaged
DESIRED OUTCOME

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What must be completed first…prior to giving vasoactive?

must replace fluid volume first!

_**BECAUSE OTHERWISE WE ARE “CLAMPING DOWN” ON EMPTY VESSELS AND NOT BENEFITING THE PATIENT AT ALL_

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How are vasoactives typically administered?

why?

Via a central line because they tend to be “vessicants” which can cause great damage if it leaked into our tissues

_***IF YOU MUST USE A PERIPHERAL LINE FOR ADMINISTRATION THAN YOU MUST MONITOR VERY CLOSELY FOR ANY SIGNS OF INFILTRATION_

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NURSING CONSIDERATIONS

(5)

when giving Vasoactives

^{FREQUENT MONITORING OF EFFECTIVENESS}
- Regular titration may be needed based on the ever changing needs of the patient.
- Monitor….BP, MAP, HR, Urine Output, MS changes, SpO2
^{MONITORING FOR INFILTRATION IF NOT RUNNING THROUGH CENTRAL LINE}
ASSESS FOR DECREASED PERIPHERAL CIRCULATION
- Frequent assessment of pulses, bowel sounds
^{CAREFUL ADMINISTRATION AS DOSAGES ARE OFTEN IN MCG/MIN; MCG/KG/MIN, ETC}

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What do “adrenergic” medications do?

mimic the fight /flight response of SNS by activating ALPHA and BETA receptors

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Stimulation of the _________ Receptors initiates Peripheral Vasoconstriction (increasing Preload,CO, BP)

ALPHA Receptors

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Stimulation of the BETA Receptors does what?

INCREASED FORCE and RATE OF MYOCARDIAL CONTRACTION *Increased Force (Contractility) also called INOTROPY *Increased Rate also called CHRONOTROPY

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What is a INOTROPE?

an agent that alters the force (Contractility) of cardiac muscular contractions

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What is CHRONOTROPIC?

a drug that alters the heart rate

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Stimulation of these receptors will increase the FORCE (Contractility) and RATE of the myocardial contraction

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BETA RECEPTORS

Three medications that will stimulate the ALPHA Receptors

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Phenylepherine

Norepinepherine

Epinepherine

Three (3) medications that will stimulate the BETA Receptors

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Dobutamine (INOTROPE)

Dopamine (INO, CHRONOTROP)

Epinepherine (INO, CHRONOTROP)

disadvantages of stimulating the ALPHA RECEPTORS in a patient with damaged heart?

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Increased workload and Increased O2 demands of the heart from increasing the afterload Afterload was increased when the alpha receptors were stimulated—->leading to increased PRELOAD, CO and BP

NURSING MANAGEMENT OF HYPOVOLEMIC PATIENT

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ASSESS / INTERVENE when Intravascular loss is evident
- sudden drop in CVP
- Decreased BP with S/S poor perfusion
- Identify “at Risk” patients
  - multiple injuries
  - burns
  - recently undergone surgery
  - pt on diuretics
  - Diabetes Insipidous patient
MONITOR PT’S RECEIVING VASCULAR REPLACEMENT
- Frequent VS
- Respiratory assessment
  - ^{b/c if we are giving fluids back- we place the patient at risk for fluid volume overload}
- S/S of blood reaction
  - ^{Febrile reaction}
    - ^{increase in temperature 1° Celcius above their baseline}
      - ^{Give tylenol and continue with transfusion}
  - ^{Hemolytic Reaction}
    - ^{breakdown of RBC}
      - ^{Stop transfusion immediately!}
LAB EVALUATIONS
- Hemoglobin level is best for detecting blood loss
- Loss > 2gm/dL indicates active blood loss

(5) AT RISK patients

for

Hypovolemic shock

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1) multiple injuries

2) Burns

3) recently undergone surgery

4) pt on diuretics

5) diabetes insipidous patient

Expected lab results for hypovolemic shock Serum Lactate

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> 2 mmol / L **this increase is an indicator that anaerobic metabolism is occurring in the body

Potassium level (Normal level)

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3.5 - 5

Sodium level (NORMAL)

135 - 145

Hemoglobin level (Normal) what do you anticipate it to be for hypovolemic shock patient?

Normal = 12 - 18 g/dL DECREASED with Hemorrhage INCREASED with Dehydration

Hct level (Normal for hypovolemic patient?

NORMAL = 37 % - 52% DECREASED with Hemorrhage INCREASED with Dehydration

**EXPECTED RESULTS FOR ABG'S** **PH 7.35 - 7.45 (normal) PaCo2 35 - 45 (Normal) PaO2**

* **PH** * decreased (acidosis) * **PaCo2** * Increased (Respiratory issue * **PaO2** * Decreased

**EXPECTED RESULTS FOR:** ^{BUN / CREATININE}

* **BUN** * ELEVATED *^{(normal = 10 - 20 mg/dl)}* * **CREATININE** * ELEVATED^{(normal = 0.5 - 1.5 mg / dl)}

## Footnote **Normal Central Venous Pressure** **(CVP)**

**2 - 8 cm H₂0** _(OR) **2 - 6 mm Hg**

## Footnote **Measurement of blood pressure in the** **thoracic vena cava, near the right atrium**

**_Central Venous Pressure (CVP)_** * **_Measures:_** * **Amount of blood returning to the heart** * **ability of the heart to pump the blood into the arterial system** * **Hemodynamics** * *^PRELOAD* * *^{VOLUME OVERLOAD}* * *^{CARDIAC OVERLOAD}* * *^SEPSIS* * **Normal values for CVP** * **^{2 - 8 cm H20} *(or)*** * ^{2 - 6 mm Hg}

**what does CVP measure**

--Indicated mean right atrial pressure --frequently used as an estimate of right ventricular preload \_\_does NOT measure blood volume-only estimates it

**what lab is best for detecting blood loss?**

* HEMOGLOBIN * Loss \>2 gm/dL ^{indicates active blood loss}

**HYPOVOLEMIC SHOCK FLUID....???** ^{Initial FluidTreatment:} ^{First-Line Agent(s):.....} ^{Second-Line Agent(s)....}.

* **_INITIAL FLUID TX_:** * IV FLUID-2L of Crystalloid * **_1st LINE AGENT_** * blood products for blood loss (or) * further IV crystalloids * **_2nd LINE AGENT_** * Norepinephrine **^(Levophed)** * Dopamine **^(Intropin)** * Epinephrine

## Footnote **Stimulation of ALPHA RECEPTORS does what?**

**INITITATES PERIPHERAL VASOCONSTRICTION** \*increased PRELOAD \*increased CARDIAC OUTPUT \*increased BP

**Disadvantages of taking meds that** **stimulate the ALPHA receptors (2)**

**1) increased workload of heart** **2) increased O2 demands of heart** ^{**r/t increased afterload --not good for damaged heart}

**Disadvantages of taking meds that** **stimulate the BETA receptors (2)**

**1) increased workload of heart** **2) increased O2 demands of heart** *^{**r/t increasing HR and contractility}*

## Footnote **Central Venous Pressure *(CVP)***

* **Measure blood pressure in the thoracic vena cava (near the right atrium)** * ***hint:*** ^{this is where all the returning blood from the body goes through and it is measuring pressures in the right side of the heart. Anything that would decrease pressure in the right side of the heart is going to result in low CVP}. * ^{most common reason for decreased pressure—>is decreased volume} * **Measures:** * **Amount of blood returning to the heart** * **Ability of the heart to pump the blood into the arterial system** * **Hemodynamics** * ^PRELOAD * ^{VOLUME OVERLOAD} * ^{CARDIAC FAILURE} * ^SEPSIS * **NORMAL VALUES**: *2-8 cm H₂O****or****2-6 mm Hg*

^{STIMULATION OF THE ALPHA RECEPTORS:} ***_Advantages_*** ^{►Results in _________which increases______...which increases CO & BP} _***Disadvantages*:**_ ►^{Increased______and_______ demands of heart by increasing afterload} ***_^Medications:_*** ►\_\_\_\_\_\_\_\_\_\_\_\_, ___________ & \_\_\_\_\_\_\_\_\_\_\_\_\_

* ^Advantages: * peripheral vasoconstriction * Preload * ^{Disadvantages:} * increases workload * O₂ * ^Medications: * Phenylephrine * Norepinepherine * Epinepherine

^{STIMULATION OF THE BETA RECEPTORS:} ^Advantages ^{►Results in _________and / or______ of mycardial contraction} ^{Disadvantages:} ^{►Increases______and_______ demands of heart by increasing rate and contractility} ^Medications: ^{►____________,___________ & _____________}

^Advantages: * ^{increased force}* * ^rate* ^{Disadvantages:} * ^workload* * ^O2* **_^Medications:_** * Dobutamine ^(inotrope)* * Dopamine^{(ino and chronortrope)}* * Epinepherine^{(Ino and Chronotrope)}*

Best position for patient in hypovolemic shock

Trendelenburg

Week 4 --Hypovolemic Shock Flashcards

(41 cards)