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Flashcards in WEEK 6- SHOCK Deck (44)
1

Shock Definition

-Widespread abnormal cellular metabolism that occurs when the human need for oxygenation and tissue perfusion is not met to the level needed to maintain cell function.
-“Whole-body” response.
-Shock is a “syndrome.”
-Any problem that impairs oxygen delivery to tissues and organs can start the syndrome of shock and lead to a life-threatening emergency

2

Shock- KEY POINT

Causes and initial manifestations of each type may vary but hypotension and anaerobic cellular metabolism eventually result in the common key features of shock

3

Features of Shock

***Cardiac output is decreased
Increased pulse rate, thready
Decreased blood pressure
Increased respiratory rate, cyanosis
Decreased urinary output*
Skin cool to the touch, pale to mottled
Nausea, diminished bowel sounds

4

Types of Shock

Hypovolemic
Cardiogenic
Septic
Distributive

**may have more than one type at the same time

5

Hypovolemic Shock

--Occurs when low circulating blood volume causes a mean arterial pressure (MAP) decrease; the body’s oxygen need is not met
--Commonly caused by hemorrhage (external or internal) and dehydration

6

Cardiogenic Shock

-Actual heart muscle is unhealthy, and pumping is directly impaired
-Myocardial infarction is the most common cause of direct pump failure

7

Distributive Shock

-Blood volume is not lost but is distributed to the interstitial tissues where it cannot circulate and deliver oxygen
-Caused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, capillary leak
-Ie: anaphylaxis, sepsis

8

Complex type of distributive shock—

usually begins as a bacterial or fungal infection and progresses to a dangerous condition over a period of days

9

Sepsis—

widespread infection coupled with a more general inflammatory response, known as systemic inflammatory response syndrome (SIRS), that is triggered when an infection escapes local control

10

Stage of sepsis and SIRS when multiple organ failure

is evident and uncontrolled bleeding occurs.
Even with appropriate intervention, the death rate among patients in this stage of sepsis exceeds 60%.

11

Stages of Shock

Initial stage
Nonprogressive stage
Progressive stage
Refractory stage

12

Initial Stage of Shock

Baseline MAP decreased by less than 10 mm Hg
Heart and respiratory rate increased from the baseline or a slight increase in diastolic blood pressure
Adaptive responses of vascular constriction and increased heart rate

works at the cellular level

13

Nonprogressive Stage/ compensatory stage

MAP decreases by 10 to 15 mm Hg.
Kidney and hormonal adaptive mechanisms activated
Tissue hypoxia in non-vital organs
Acidosis and hyperkalemia (high potassium)
Stopping conditions that started shock and supportive interventions can prevent shock from progressing

14

Non-Progressive Stage S & S

Anxiety
Restlessness
Increased thirst (because of low liquids in body)
Tachycardia
Increased RR
Decrease UO
Decrease SBP/increasing DBP (narrowing PP)
Cool extremities
2-5% decrease in O2 saturation
**if stable can stay at this stage for hours

15

Progressive Stage

Further decrease in blood pressure
Sustained decrease in MAP of more than 20 mm Hg from baseline
Vital organs develop hypoxia
Life-threatening emergency
Immediate interventions are needed
Conditions causing shock need to be corrected within 1 hour of the onset of the progressive stage

COMPENSATORY MECHANISM FAIL

16

Progressive Stage S &S

**Worsening of S &S *life-threatening* Action needed within 1 hr**
Severe thirst, anxiety
Sense of impending doom
Confusion
Rapid, weak pulse
Pallor (?) to cyanosis (mucous membranes/nail beds)
Cool, moist skin
Anuria- increase urine NA and dec in K
5-20% 02 sat drop
Labs: low pH, high lactic acid, high K+

17

Refractory Stage of Shock

Too much cell death and tissue damage resulting from too little oxygen reaching the tissues.
Body can no longer respond effectively to interventions, and shock continues.
Severe hypoxia
Multiple organ dysfunction
Death

profound hypotension

18

Refractory Stage S &S

Rapid loss of consciousness
Non-palpable pulse
cold, mottled or dusky extremities
slow, shallow respirations
unmeasurable 02 sat

19

Hypovolemic Shock

Assessment:
-Patient History- - medical and surgical, recent events(upper resp tract infection, chest pai, trauma) allergies, medication, description of events leading to shock- time of onset and duration
-Physical Assessment
((Cardiovascular changes
Respiratory changes
Renal and urinary changes
Skin changes
CNS changes
Skeletal muscle changes))
Lewis suggests initial ABCS, followed by tissue profusion , VITALS, LOC, pulses, cap refil, skin, and urine output

-Psychosocial Assessment (is the person anxious, their feelings with anxiety, feeling of doom)
-Laboratory Assessment- LEWIS 1963

20

Common Nursing Diagnoses: Hypovolemic Shock

Ineffective Tissue Perfusion (general) related to hypovolemia
Deficient Fluid Volume related to active fluid volume loss
Decreased Cardiac Output related to hypovolemia
Anxiety related to potential for death
Disturbed Thought Processes related to decreased cerebral perfusion

21

Best Practice for Hypovolemic Shock

1. Ensure a patent airway
2. minimum 20 gauge IV (often 18)
3. Administer oxygen
4. Elevate patient’s feet, keep HOB flat or at max 30 degrees
5. Examine patient for overt bleeding
6. Apply pressure to overt bleeding site
7. Administer drugs as prescribed
8. Increase rate of IV
9. Do not leave the patient

22

Hypovolemic Shock: Health Promotion and Maintenance

Primary Prevention
Prevent dehydration (hypovolemia)
Use safety equipment (trauma)
Be aware of hazards at home/workplace
Secondary Prevention
-just being a pt in acute care is a risk factor
Monitor pts for deydration-watch I & O….especially for pts who are:
1. cognitively impaired
2. NPO
3. have decreased mobility
Monitor for bleeding (obvious and occult) after any invasive procedure (ie: surgery, heart cath etc)
Compare:
• pulse quality and rate with baseline
• -urine output (and other output) with intake (PO and/or IV)
• -check VS for any pt with persistent thirst*
• -assess for shock with changes in: 1. mental status 2. increase in pain 3. increase in anxiety
Patient and Family Teaching after invasive procedures or ambulatory surgery:
Manifestations of shock
Stress importance of seeking immediate help for any of the following:
• Obvious heavy bleeding
• Persistent thirst
• Decreased urine output
• Light-headedness
• Sense of impending doom

23

Sepsis and Septic Shock quote

“Failure to recognize and intervene in early sepsis is the major contributing factor for progression to septic shock and death”

Aherns, 2007; Cheek et al., 2005 Kleinpell et al., 2006; in Ignatavicius and Workman, 2006)


**Early detection is a major nursing responsibility**

24

Local Infection vs Sepsis

Which process are these symptoms associated with?

Fever- a high one could be sepsis or local
Tachycardia- sepsis
Decreased oxygen saturation –sepsis
Reduced Urine Output –sepsis



25

Early Manifestations of Sepsis

Temp may be high OR low
WBC is usually high
U/O decreases
RR increases
BP decreases
Microthrombi start to form

**these early manifestations are subtle, of short duration and may be missed**

26

Severe Sepsis

 Amplified inflammatory response
 All tissues involved, all have some degree of hypoxia
 Some cell death occurring

 Disseminated Intravascular Coagulation (DIC)
Microthrombi formation widespread
you only see it in extreme cases
**this uses up available platelets and clotting factors**

-Leaky capillaries
-Anaerobic metabolism
-Poor cellular oxygen uptake
-Hyperglycemia

Why does this stage often get missed initially??

27

Because….

Cardiac Function is hyperdynamic:
HR increases
CO increases
Extremities warm
Little or no cyanosis
WBC no longer elevated
Patient ‘looks’ better

28

WBC drops

as bone marrow unable to keep producing new mature neutrophils and other WBCs
Immunocompromised pts may have very low WBC

29

Severe Sepsis: Major Clinical Manifestations

Lower oxygen saturation
Rapid respiratory rate
Decreased to absent U/O
Change in patient’s cognition and affect

**Sepsis needs appropriate and aggressive intervention to prevent septic shock**

30

Septic Shock

Multiple organ failure
Uncontrolled bleeding

***even with appropriate intervention, death rate exceeds 60%***
Severe hypovolemic shock also present
Inability to clot
Leaking capillaries
Clinical manifestations look like late stage hypovolemic shock….which are?

31

Questions

Is your patient at risk for infection/sepsis/septic shock?
-List risk factors

Does your patient exhibit any S & S?
-Identify key assessments and findings

What needs to be done? By Whom?
-List appropriate interventions for both prevention and treatment


32

Sepsis and Septic Shock Assessment:

-Patient History
-Physical Assessment
Respiratory changes
Cardiovascular changes
Renal and urinary changes
Skin changes
CNS changes
-Psychosocial Assessment
-Laboratory Assessment

33

***Nursing Responsibilities***

--Assessments as noted previously!!
--Monitor for early detection
VS at least 2 x per shift (compare to baseline)
Elevated serum lactate
Normal or low WBC
segmented neutrophils decrease
Band neutrophils increase

--Use aseptic technique!!!
Remove urinary catheters and IVs as soon as no longer needed

34

Health Promotion and Maintenance

Prevention is the best strategy
Complete a risk assessment

Who is at risk for sepsis? (see Table 39-4, p. 840)


35

Patient Teaching

Teach manifestations of:
-Local Infection
(Pain, redness, swelling , purulent drainage, loss of function_

-Early Sepsis
(Fever, U/O less than intake, lightheadedness)

Monitor temp
Complete entire course of prescribed abx
Notify HCP of S &S

36


Anaphylaxis defined:

A life-threatening allergic reaction

37

RXNS TO ANAPHYLAXIS

--Most likely reactions to:
medication, latex or food
Note hx of asthma, eczema, seasonal allergies
**When giving meds:
((ask about allergies-even if they already have an allergy band on**
Explain medications!!))
Reaction may not occur immediately
Drugs previously tolerated may cause anaphylaxis

38

Anaphylaxis S & S

Monitor for:
 HR & RR increase, BP drops
 Swelling of eyes, lips, face
 Difficulty breathing, talking, swallowing (laryngeal edema)
 Wheezing or cough
 Pruritis, hives
 Feeling of impending doom
 Nausea, diarrhea, abd pain
 Decreased LOC

39

Anaphylaxis: Act FAST

FACE
AIRWAY
STOMACH
TOTAL BODY

40

Management

Stop offending medication immediately
(If IV, change to NS and change tubing)

Check VS

O2, IV, Drugs

Epinephrine is drug of choice
(May also give benadryl, corticosteroids)

41

Community-Based Care

Patient Teaching to reduce risk of:
*** Anaphylaxis
 Foods, drugs, insect venom, latex
 Focus on prevention
 Act FAST *see poster
 Self-injectable epinephrine (ie: epipen)
 Medic alert bracelet or necklace

42

Re-cap: Management of Shock

*Goals of shock management are to:
 maintain tissue oxygenation
 increase vascular volume to normal range
 support compensatory mechanisms
*Oxygen therapy
*IV therapy
*Drug therapy
 Vasoconstrictors
 Drugs to enhance contractility
 Drugs to enhance myocardial perfusion
 Septic Shock
 also requires antibiotics, corticosteroids, insulin, activated protein C, blood replacement

43

A relative hypovolemia

fluid moves from the vascular space into the extravascular space (“third spacing”)

44

MAP`

110/70.. ACTUALLY LOOK IT UP IDK WHAT IT MEANS