Caring for Clients Experiencing Shock

1. Caring for Clients Experiencing Shock NR 240

2. Definition of shock • A disorder characterized by hypoperfusion coupled with hypo-oxygenation • Leads to anaerobic metabolism, ischemia and cell death if uninterrupted also called multiple organ dysfunction syndrome • Can be classified according to site of origin or functional impairment

3. Classifications of shock: functional impairment vs site of origin

4. Etiology of shock

5. Stages of shock

6. Pathophysiology of shock overview Capillary leaking Volume depletion Decreased vascular tone Pump failure Renin Angiotensin Aldosterone released Anaerobic metabolism Acidosis Hyperkalemia Toxic metabolites Causing endothelial damage & tissue death oliguria MODS

7. Complications of shock • MODS (multiple organ dysfunction syndrome) • Anoxic encephalopathy • ARDS • Myocardial pump failure • myocardial depressants known as MDF which are released from the pancreas • Acute tubular necrosis • result of decreased renal perfusion • DIC • platelet consumption • Rhabdomyolysis • skeletal muscle breakdown • Profound sepsis • from decreased macrophage effectiveness • Paralytic ileus • from decreased peristalsis • Liver failure

8. Clinical manifestations of shock • Cardiovascular Manifestations • ▪ Decreased cardiac output • ▪ Increased pulse rate • ▪ Thready pulse • ▪ Decreased blood pressure • ▪ Narrowed pulse pressure • ▪ Postural hypotension • ▪ Low central venous pressure • ▪ Flat neck and hand veins in dependent positions • ▪ Slow capillary refill in nail beds • ▪ Diminished peripheral pulses • Respiratory Manifestations • ▪ Increased respiratory rate • ▪ Shallow depth of respirations • ▪ Decreased Paco2 • ▪ Decreased arterial Pao2 • ▪ Cyanosis, especially around lips and nail beds

9. Clinical manifestations of shock • Neuromuscular Manifestations • ▪ Early • Anxiety • Restlessness • Increased thirst • ▪ Late • Decreased central nervous system activity (lethargy to coma) • Generalized muscle weakness • Diminished or absent deep tendon reflexes • Sluggish pupillary response to light • Renal Manifestations • ▪ Decreased urine output • ▪ Increased specific gravity • ▪ Sugar and acetone present in urine

10. Clinical manifestations of shock • Integumentary Manifestations • ▪ Cool to cold • ▪ Pale to mottled to cyanotic • ▪ Moist, clammy • ▪ Mouth dry; paste like coating present • Gastrointestinal Manifestations • ▪ Decreased motility • ▪ Diminished or absent bowel sounds • ▪ Nausea and vomiting • ▪ Constipation

11. Lab diagnostics for hypovolemic shock

12. Hemodynamic patterns in shock

14. BEST PRACTICE for The Client in Hypovolemic Shock • Ensure a patent airway. • Start an IV catheter or maintain an established catheter. • Administer oxygen. • Elevate the client's feet, keeping his or her head flat or elevated to a 30-degree angle. • Examine the client for overt bleeding. • If overt bleeding is present, apply direct pressure to the site. • Administer medications as prescribed. • Increase the rate of IV fluid delivery. • Do not leave the client.

15. INTERVENTION ACTIVITIES for The Client with Hypovolemic Shock Shock Management: Volume:Promotion of adequate tissue perfusion for a client with severely compromised intravascular volume • Monitor for signs and symptoms of persistent bleeding (e.g., check all secretions for frank or occult blood). • Monitor the client closely for hemorrhage. • Prevent blood volume loss (e.g., apply pressure to site of bleeding). • Administer IV fluids, as appropriate. • Note hemoglobin/hematocrit level before and after blood loss, as indicated. • Administer blood products (e.g., platelets or fresh frozen plasma), as appropriate. • Monitor coagulation studies, including prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, fibrin degradation/split products, and platelet counts, as appropriate.

16. Drug therapy in Hypovolemic shock IV agents to do replace appropriate volume and blood product replacement. They are used as a supportive intervention until volume depletion is corrected

17. Management of Cardiogenic chock Cardiogenic shock guidelines

18. Cardiogenic • Pump failure results in inadequate tissue perfusion DECREASE IN CARDIAC OUTPUT CAUSES A DECREASE IN MEAN ARTERIAL PRESSURE Seen in: • MI • Exacerbation of CHF • restrictive pericarditis • tamponade • dysrhythmia • Valvular disease

19. Management of cardiogenic shock • Reversal of underlying cause • Arrhythmia, structural anomaly, acute coronary syndrome • Supportive care • Airway management • Hemodynamic monitoring • Vasoactive agents

20. Drug therapy in Shock

21. Caring for clients with Distributive shock • Septic • Neurogenic • anaphylactic

22. Management of septic shock Surviving sepsis campaign guidelines for management of severe sepsis and septic shock.

23. Pathophysiology of septic shock

24. Assessment findings in Septic shock

25. BEST PRACTICE for The Client in Sepsis-Induced Distributive Shock • Ensure a patent airway. ▪ Start or maintain an established IV catheter. ▪ Administer oxygen. ▪ Administer antibiotics. ▪ Obtain specimens of blood, urine, wound drainage, and sputum for culture. ▪ Increase the rate of IV fluid delivery. ▪ Use aseptic technique for any invasive procedure. ▪ Handle the client gently. ▪ Examine the client for overt bleeding, especially of gums, injection sites, and IV sites. ▪ Elevate the client's feet, keeping his or her head flat or elevated to a 30-degree angle. ▪ Take the client's vital signs every 5 minutes until they are stable. ▪ Administer medications as prescribed: • Heparin during phase 1 • Clotting factors, platelets, and plasma during phase 2

26. Management of neurogenic shock

27. NEUROGENIC SHOCK • PARASYMPATHETIC NS OVERSTIMULATION • SYMPATHETIC NS UNDERSTIMULATION • SUSTAINED VASODILATION RESULTS IN • DECREASED SYSTEMIC VASCULAR RESISTANCE • HYPOTENSION • BRADYCARDIA • MENTAL STATUS CHANGES • Associated with Spinal cord injury

28. Management of Neurogenic shock • Follow shock management protocols • Maintain spinal immobilization • Administer vasopressors

29. Management of anaphylaxis

30. Anaphylaxis care • Ensure airway • Administer epinephrine • Establish IV access • Provide supportive care as required • Intubation • Vasopressors • Corticosteroids • H2 antagonists

31. Drug therapy in Shock

32. Can you name which shock is most likely responsible? • Diffuse edema to extremities, skin reddened with wheals noted, just started on new antibiotic • Acute mental status change, decreased heart rate, skin cool and dry • s/p radiation and chemotherapy with neutropenia refractory to Neupogen. rectal temp 96.5 BP 100/60 HR 133 • PMH of MI X 4, IDDM, CHF with Harsh systolic murmur at 2nd intercostal space at the right sternal border • S/P exploratory laparotomy POD#1 with a history of COPD on PO steroids X 10 years whose skin is pale and cool. Client c/o fatigue and unable to participate in ADLs

33. ADDITIONAL DIAGNOSES/COLLABORATIVE PROBLEMS • PC:MODS • PC: ARDS • PC:DIC • PC;PARALTYIC ILEUS • PC: HEPATIC FAILURE • PC:SEPSIS • PC:RHABDOMYOLYSIS • RISK FOR INJURY • PAIN • ANXIETY VS FEAR • PC: NEGATIVE NITROGEN BALANCE • INTERRUPTED FAMILY PROCESSES • RISK FOR IMPAIRED VERBAL COMMUNICATION • ACTIVITY INTOLERANCE VS FATIGUE • INADEQUATE TISSUE PERFUSION:PERIPHERAL • RISK FOR IMPAIRED SKIN INTEGRITY

34. Monitor/Prevent potential complications of shock • Remember risk for MODS, ARDS, DIC, Rhabdomyolysis, ATN, anoxia, sepsis, ileus, liver failure, ulcers identified as potential complications • Develop assessment/monitoring strategies that are broad-sweeping and repeated frequently until stable • Mon vital signs (VS), cardiac monitoring (CM) pulse oximetry, I/O, peripheral pulses, neurochecks • Mon CMP, CK, CBC,PT/PTT and bleeding times, type and cross, total protein, albumin, LFTs • Insert NG tube to prevent ileus • Administer anti-ulcer therapy and antibiotic prophylaxis

35. Shock Summary • Disorder of impaired tissue perfusion secondary to decreased circulating volumes caused by cardiac, neurogenic, inflammatory, obstructive and infectious etiologies • Manifests with AMS, agitation, thirst, Increased HR (except neurogenic shock) and normal to slightly lower BP in initial phase • Can progress to irreversible refractory phase • Treatment focuses on ABC’s, reversal of underlying cause, and prevention of complications • Evaluation of outcomes focus on tissue perfusion and oxygenation, cardiac pump effectiveness, fluid/electrolyte balance and avoidance of systemic complications such as MODS, ARDS, DIC, ATN, Rhabdomyolysis, sepsis, ileus, liver failure and ulcers