SHOCK

1. SHOCK NPN 205 Medical Surgical II

2. What Does Shock Look Like • Carla----33 year old female form the emergency room post MVC, with an apparent crush injury to the pelvis, bruising over her right upper quadrant. She is conscious, but lethargic and oriented to name only. BP is 80/46, pulse 116. She is quickly prepared for surgery. Dx: pelvic crush injury, r/o abdominal trauma, r/o liver laceration

3. Julie---86 year old female from a local nursing home with a history of variable fevers for the past week. Her appetite has decreased, mental status has deteriorated. Presently, her temperature is 104 F. • She has an indwelling Foley catheter, her urine is dark amber, foul smelling. Dx. Sepsis secondary to UTI

4. Justin---14 year old male with a history of juvenile onset diabetes mellitus. He has been admitted to the hospital because his glucose has been greater than 600 for the last 24 hours and he has a fruity odor on his breath. His serum glucose is 786. Dx: diabetic ketoacidosis.

5. What do they have in common? • Three different patients • Three different diagnoses • Three different etiologies

6. Predisposition of Shock Syndrome • Shock is a process that causes the eventual shutdown of all body systems in a systematic order • Amount of time for shock to progress varies from patient to patient • Is related to the body’s overall health and ability to compensate for it’s deficiencies • As the syndrome progresses, the process speeds up • The circulatory system fails to provide adequate blood to the tissues, resulting in cellular hypoxia and death

7. Physiology of Hypoperfusion: Shock • Inadequate tissue perfusion • Inadequate delivery of O2 and nutrients to the body tissues • Inadequate elimination of metabolic wastes

8. A & P of Perfusion • Perfusion: delivery of O2 and nutrients and the elimination of CO2 requires four things • 1. a properly beating heart • 2. adequate transport medium: blood and hemoglobin • 3. an intact functioning vessel system • 4, a functioning respiratory system

9. Physiology of Circulation in the Vessels • 600,000 miles of vessels containing 5-6 liters of blood • Vessel tone is controlled by the sympathetic and parasympathetic nervous system • Pre-capillary sphincters control blood flow through the capillaries in response to O2 demand of the tissue • Preload is dependent on the constant peripheral vascular resistance

10. Physiology of Circulation: the Blood • Container (vessels) must be full of blood at all times • Hemoglobin must be present in adequate amount and be free to carry O2, nutrients, and CO2

11. Stages of Shock • Compensated ---- body is able to compensate and maintain tissue perfusion • Progressive ---- body begins to lose its ability to compensate---inadequate perfusion begins • Irreversible---cell and tissue damage result in multi-system organ failure

12. Types of Shock • Hypovolemic • Obstructive • Cardiogenic • Distributive • Anaphylactic • Septic

13. Classifications or Types of Shock • Hypovolemic: (classic shock) • THE MOST COMMON CLASS. It is the standard used to compare other forms of shock to differentiate the diagnosis • Hemorrhagic/Blood loss • Dehydration/Fluid loss

14. Causes of Hypovolemic Shock • Hemorrhage • Severe diarrhea • Vomiting • Excessive perspiration • Third Spacing • Shift of fluid in severe burns can lead to hypovolemic shock • Peritonitis • Intestinal obstruction

15. Shock D/T Hemorrhage: Compensation • Mechanism: volume depletion due to bleeding • Body detects decrease in the cardiac output • Sympathetic nervous system is stimulated releasing epinephrine and norepinephrine to stimulate alpha and beta receptors • Alpha = vasoconstriction • Beta = bronchodilation and cardiac stimulation • Body maintains function

16. Hemorrhagic Shock: Progressive • Kidneys release antidiuretic hormone which increases vasoconstriction • Signs and symptoms: • Mental status: lethargy, sleepy, combative • Skin: clammy, pale, mottling. Cyanosis around the nose and mouth first, spreads to extremities • Blood pressure: begins to fall, capillary refill delayed • Pulse: rapid and weak • Respirations: rapid and shallow • Other: decreased urination

17. Hemorrhagic Shock: Irreversible • Signs and symptoms: • Mental status: decreased LOC, to unresponsive • Skin: gray, mottled, cyanotic, waxen, sweating stops • Blood pressure: decreases, becomes undetectable • Pulse: slows then disappears • Respiration: agonal • Other: irritable heart, bradycardia, leads to asystole

18. Interventions for Hypovolemic Shock • Stop the fluid loss – direct pressure, surgery • Replace fluids – blood and blood products, plasma expanders, crystalloid fluids (provide H2O replacement and E-lytes), Colloids (albumin, FF) • Pneumatic antishock garments • Use low dose inotropics

19. Cardiogenic Shock • Heart pump failure (40% of myocardium damaged by an MI) • Cardiac trauma • Cardiomyopathy • Congestive heart failure • Cardiac dysrhythmias

20. Cardiogenic Shock: Signs and Symptoms • Drop in cardiac output • Skin: cyanosis • Pulse: bradycardia, tachycardia, or within normal limits • Respirations: diminishing breath sounds progressing to wheezing and crackles. Patient complains of increasing dyspnea. Coughs white or pink tinged foamy sputum • Other: pulmonary edema and left heart failure • Pitting edema+ right heart failure

21. Interventions for Cardiogenic Shock • Hemodynamic monitoring • IV fluids • Intra-aortic balloon pump • Cardiac transplant • Inotropics/cardiotonics • Digoxin, Amrinone, Primacor • Vasodilators • Diuretics • If from obstructive may need surgical repair, chest tube, pacemaker, needle aspiration of fluid

22. Obstructive Shock • Can be classed as a type of cardiogenic shock • Pulmonary embolism/Blocked pulmonary circulation • Tension pneumothorax/Increased intrathoracic pressure • Cardiac tamponade/Pressure on myocardium. Decreased preload

23. Signs and Symptoms of Obstructive Shock • Mental status: anxiety, feeling of impending doom • Skin: pallor to cyanosis around the mouth and the nose • Other: chest pain, lung sounds may be clear, possible syncope, cardiac dysrhythmias (PVC’s, A-Fib common) can lead to sudden cardiac arrest

24. Distributive Shock • Anaphylactic Shock • Mechanism: severe allergic reaction • Skin: hives, possible petechia. Urticaria, pallor, cyanosis • Blood pressure: abrupt fall in cardiac output • Respiration: rapid shallow, dyspnea with stridor, wheezes, crackles, leading to respiratory arrest • Other: swelling of mucus membranes/pulmonary edema

25. Treatment of Anaphylactic Shock • Maintain airway • Ice to site of injection or sting • Gastric lavage • Isotonic IV fluids – D5W, NACL, LR • Epinephrine and theophylline • Antihistamines (H2 blockers) • Steroids • Vasopressors to constrict blood vessels and raise BP

26. Distributive Shock • Septic shock • Mechanism: overwhelming infection • Skin: varies form flushed pink (if fever is present) to pale and cyanotic. Purple blotches possible, peeling skin, general or on palms and soles of feet • Blood pressure: early—cardiac output increases but toxins prevent increase in BP. Late --- drop in BP, hypotension • Respiratory: dyspnea with altered lung sounds • Other: high fever, (except in elderly and very young), Late sign is pulmonary edema

27. Treatment for Septic Shock • C & S for infective site • IV fluids with NS • Medications and other treatment • Vancomycin • Penicillin • Cephalosporin • Cardiotonics and inotropics • Vasopressors • Heparin • Blood products

28. Distributive Shock • Neurogenic Shock • Mechanism: vasodilation • Skin: areas of vasodilation, at first become warm, pink and dry. Later with pooling: mottling of dependent areas, pallor and cyanosis to the upper surfaces • Pulse: highly variable depending on injury or action of drug/poison: May be abnormally slow or abnormally fast, usually not normal • Respiration: severely compromised: becoming slow, shallow, with abnormal patterns. Patient may loose stimulus to breath • Other: hypothermia. Pulmonary edema with drug or poisoning

29. Treatment of Neurogenic Shock • HOB flat with feet elevated • IV normal saline • Atropine for bradycardia • Vasopressors to raise BP • Analgesics for pain

30. General Treatment of Shock • Remember your ABC’s • Administer airway • 100% O2 via a non- re-breather mask • Assist ventilations if necessary • Position patient to assist perfusion • Keep patient warm • Perform focused assessment • Monitor and adjust O2, gain IV access, cardiac monitor, pulse oximetry • Fluid replacement of LR or NS • Need 3 liter of fluid to replace I liter of blood loss • Apply pressure to IV or blood to facilitate faster infusion

31. Nursing Diagnosis • Ineffective Tissue Perfusion • Decreased Cardiac Output • Anxiety • Fluid Volume Deficit • Risk for Injury • Risk for Infection

32. Systemic Inflammatory Response Syndrome (SIRS) • Defined as when generalized inflammation occurs and threatens vital organs • Causes: multiply transfusions, massive tissue injury, burns, and pancreatitis, severe infections or sepsis • Effects: endothelium is damaged and allows fluid to leak into the body tissues, results in poor perfusion of blood to organs • Body is in a hypermetabolic state

33. Systemic Inflammatory Response Syndrome (SIRS) • Diagnosis made when 2 or more of the following are seen: • Temperature less than 97 or greater than 100.4 • Heart rate more than 90 • Respiratory rate more than 20 or PaCO2 less than 32mm Hg • WBC count less than 4000 cells or more than 12,000 • Sepsis is used if patient has SIRS with and infection

34. Multiply Organ Dysfunction Syndrome (MODS) • Defined: when 2 or more organ systems are failing at one time • Is caused by the immune system’s uncontrolled response to severe illness or injury • Common cause of death of patients in the ICU, with mortality of 50% • Identifying and acting quickly can help survival • Can develop quickly following surgery, trauma, or severe burns or slowly in the case of an infection

35. Treatment for SIRS/MODS • Critical care nursing • Goals • Prevent and treat infections • Maintain tissue oxygenation • Provide nutritional and metabolic response • Support failing organs