Chapter 37 Care of Patients with Shock
Causes & types of shock by functional impairment
-Hypovolemic shock- Total body fluid decreased (in all fluid compartments) Specific Cause or risk factors- trauma, GI ulcer, surgery, inadequate clotting- hemophilia, liver disease, malnutrition, bone marrow suppression, cancer,anticoagulation therapy, diabetes insipidus, -Dehydration' hyperglycemia, vomiting, diarrhea, heavy diaphoresis, diuretic therapy, Nasogatric suction -Cardiogenic shock Direct pump failure (fluid volume not affected), specific cause or risk factor- myocardial Infarction, cardiac arrest, ventricular dysrhythmias (v fib, v tachy), cardiac amylodosis, cardiomyopathies- viral, toxic, myocardial degeneration. -Distributive shock- Fluid shifted from central vascular space (total body fluid volume normal or increased)- neural-induced, pain, anesthesia, stress, head trauma, chemical-induce- anaphylaxis, capillary leak, burns extensive- trauma, liver impairment Obstructive shock- Cardiac function decreased by non cardiac factor (indirect pump failure) total body fluid is not affected although central volume is decreased . Specific Cause or risk factors- Cardiac tamponade, arterial stenosis, pulmonary embolism, pulmonary hypertension, constructive pericarditis, thoracic tumors, tension pneumothorax.
Drug Therapy
-IV antibiotics with known activity against gram-negative bacteria are given before organisms are identified, preferably within 1 hour of sepsis diagnosis. -Septic Shock- vancomycin, aminoglycosides, systemic penicillin, or cephalosporins, macrolides & quinolones.
STAGES OF SHOCK 4
-Initial stage of shock (early stage): When the patient's baseline MAP is decreased by less than 10. A heart & respiratory rate increased from the patient's baseline level or a slight increase in diastolic BP may be the only objective manifestion of this early stage of shock -Nonprogressive Stage of Shock (Compensatory stage): occurs when MAP decreases by 10-15 from baseline. Kidney & hormonal compensatory mechanisms are activated b/c cardiovascular responses alone are not enough to maintain MAP & supply oxygen to vital organs. -Kidneys & baroreceptors sense an ongoing decrease in MAP & trigger the release of renin, antidiuretic hormone (ADH), aldosterone, epinephrine, & norepinephrine to start kidney compensation. -ADH increases water reabsorption in the kidney, further reducing urine output, & also causes blood vessel constriction in the skin & other less vital tissue areas. -Tissue hypoxia occurs in nonvital organs (skin, GI tract) & in the kidney but it's not great enough to cause permanent damage. -Changes include acidosis (low blood pH) & hyperkalemia (increased blood potassium level). Subjective changes include : thirst & anxiety, objective changes include restlessness, tachycardia, increased respiratory rate, decreased urine output, falling systolic BP, rising diastolic BP, narrowing pulse pressure, cool extremities, & a 2%-5% decrease in oxygen saturation measured by pulse ox. Can remain in stage for hours. -PROGRESSIVE STAGE OF SHOCK (Intermediate Stage): occurs when there's a sustained decrease in MAP of more than 20 from baseline. -Compensatory mechanisms are functioning but can no longer deliver sufficient oxygen, even to vital organs. -Vital organs develop hypoxia & less vital organs become anoxie (no oxygen) & ischemic (call dysfunction or death from lack of oxygen). -Some tissues have severe call damage & die. -Subjective changes include severe thirst sensation & deeper anxiety. The patient may express a sense of "something bad" (impending doom) about to happen. They may seem confused; objective changes:a rapid weak pulse; low BP; pallor to cyanosis of oral mucosa & nail beds, cool & moist skin. REFRACTORY STAGE OF SHOCK (IRREVERSIBLE STAGE)- occurs when too much cell death & tissue damage result from too little oxygen reaching the tissues. Vital organs have overwhelming damage. Body can no longer respond effectively to interventions, & shock continues. Manifestations:rapid loss of consciousness; non palpable pulse; cold dusky extremities; slow shallow respirations; & unmeasureable oxygen saturation.
catheters
-Insertion of a CVP catheter allows pressure to be monitored in the patient's right atrium or superior vena cava while providing venous access. -Intra-arterial catheters allow continuous BP monitoring & are an access for arterial blood sampling.
Nonsurgical Management
-Oxygen therapy -IV therapy: for fluid resuscitation **primary intervention** crystalloids- nonprotein- help maintain adequate fluid & electrolyte balance- NS or Ringer's lactate Colloids- large molecules (usually protein or starches)- protein containing-helps restore osmotic pressure & fluid volume Plasma- a cellular blood product containing clotting factors, is given to restore osmotic pressure when hematocrit & hemoglobin levels are within normal ranges.
Bundles for Resuscitation & Manage. Severe Sepsis
-Sepsis Resuscitation Bundle- 1. Measure serum lactate levels. 2. Obtain blood cultures BEFORE admin. antibiotics. 3. Administer broad-spectrum antibiotic therapy within 1 hour of establishing diagnosis. 4. If either hypotension or a serum lactate level greater than 4 mmol/L institue: a. Infusion of 1000 mL of crystalloids or 300-500 mL of colloids over 30 minutes. b. If hypo doesn't respond by increasing MAP, start IV vasopressor therapy.
Sepsis & Systemic Inflammatory Response Syndrome
-Sepsis is a condition in which infectious micro-organisms have entered the bloodstream. -Inflammatory responses become an enemy. -Patient has mild hypotension, a low urine output, & an increased respiratory rate. -Responses result in a hypodynamic state with decreased cardiac output -Temp of more than 100.4 or less than 96.8 -HR more than 90 -Respiratory more than 20 breaths -Abnormal WBC
Septic Shock
-Stage of sepsis & SIRS when multiple organ failure is evident & uncontrolled bleeding occurs. Etiology- Major cause of sepsis is a bacterial infection that escapes local control, fungal infections also cause sepsis -HALLMARK OF SEPSIS- an increasing serum lactate level, a normal or low total WBC count & a decreasing segmented neutrophil level with a rising band neutrophil level called left shift
Drug Therapy
-Used when the volume lost is severe & the patient doesn't respond sufficiently to fluid replacement & blood products. -Actions of drugs for shock increase venous return, improve cardiac contractility, or improve cardiac perfusion by dilating the coronary vessels. -Vasoconstricting drugs stimulate venous return by constricting blood vessels & decreasing venous pooling. Increase cardiac output, MAP, which help improve perfusion & oxygenation. dopamine (Intropin, Revimine); norepinephrine (Levophed); Nursing intervention: (dopamine) assess the patient for chest pain; monitor urine output hourly; assess BP every 15 minutes. -Inotropic drugs stimulate adrenergic receptors in the heart (beta1 receptors) & improve heart muscle cell contraction. Thus greater recoil occurs & more blood leaves the left ventricle during contraction. Dobutamine (Dobutrex)- Assess for chest pain, drug increases myocardial oxygen consumption & can cause angina or infarction. -Milrinone (Primacor)- Assess BP every 15 minutes; Hypertension is a sign of overdose. -Drugs enhancing myocardial perfusion help ensure that the heart is well perfused, esp when giving drugs to improve cardiac contraction so that aerobic metabolism is maintained in the heart cells & maximum contractility can occur. -Sodium nitroprusside (Nitropress, Nipride)- Assess BP @ least every 15 minutes. The vasodilating effect can cause systemic vasodilation & hypotension
Surgical Management
-Vascular repair, surgical hemostasis of major wounds, closure of bleeding ulcers, & chemical scarring (chemosclerosis) of varicosities.
TYPE OF SHOCKS- HYPOVOLEMIC
-occurs when too little circulating blood volume causes a MAP decrease, resulting in inadequate total body oxygenation- Reduced MAP slows blood flow resulting in decreased tissue perfusion. -Common problems leading: hemorrhage & dehydration
CHEMICAL INDUCED DISTRIBUTIVE SHOCK
3 common origins: -anaphylaxis- one result of type I allergic reactions. Result is widespread loss of blood vessel tone & decreased cardiac output. -Sepsis- widespread infection that triggers a whole body inflammatory response. Leads to distributive shock when infectious microorganisms are present in blood. -Capillary leak syndrome- The response of capillaries to the presence of biologic mediators that change blood vessel integrity & allow fluid to shift from the blood vessels into the interstitial tissues. One in tissue, fluids are stagnant & can't deliver oxygen or remove tissue waste products. -Occurs when certain body chemicals or foreign substances in the blood & vessels start widespread changes in blood vessel walls. -Problems causing fluid shift: severe burns, liver disorders, ascites, peritonitis, paralytic ileus, severe malnutrition, large wounds .
Intermediate or progressive stage The early stage of shock is demonstrated by a slightly elevated heart rate, and a normal to slightly decreased blood pressure. Refractory (also called irreversible) shock is characterized by profound tissue anoxia and cellular death. The refractory stage is manifested by severe hypotension; rapid, weak, or irregular pulse; disorientation; lethargy, or coma; pallor and cyanosis; cardiac arrest and death. The client's symptoms demonstrate intermediate shock.
A 42-year-old male presents with massive hemorrhage related to an industrial accident. His vital signs are heart rate 140, blood pressure 88/60, respirations 26 and shallow. The client's skin is cool and pale with generalized edema noted. The cardiac monitor reveals dysrhythmias. The client is awake and responds appropriately to questions. Based on this assessment data, the nurse expects the client is in which of the following stages of shock?
ANS: C The first manifestations of hypovolemic shock result from compensatory mechanisms. Signs of shock are first evident as changes in cardiovascular function. As shock progresses, changes in skin, respiration, and kidney function progress. The other questions would not identify early stages of shock.
A client brought to the emergency department after a motor vehicle accident is suspected of having internal bleeding. Which question does the nurse ask to determine whether the client is in the early stages of hypovolemic shock? a. "Are you more thirsty than normal?" b. "When was the last time you urinated?" c. "What is your normal heart rate?" d. "Is your skin usually cool and pale?"
ANS: A, C, E Septic shock manifests with decreased cardiac output, increased blood glucose, and increased serum lactate. The other parameters do not correlate with septic shock. page 823
A client has septic shock. Which hemodynamic parameters does the nurse correlate with this type of shock? (Select all that apply.) a. Decreased cardiac output b. Increased cardiac output c. Increased blood glucose d. Decreased blood glucose e. Increased serum lactate f. Decreased serum lactate
Notify the emergency room physician and prepare for an immediate needle thoracostomy and insertion of chest tube
A client involved in a motor vehicle accident is admitted to the emergency room with vital signs of heart rate 116, respirations 29, temperature 99.4 °F, and blood pressure 98/62. Upon assessment, the nurse notes obvious rib fractures to the right anterior chest, and does not detect breath sounds on the right upper lung field. The client's trachea is deviated to the side of the neck. Based on this assessment data, which of the following should be the nurse's immediate action?
ANS: A The client at risk for septic shock should be instructed to clean his or her toothbrush daily, either by running it through the dishwasher or by rinsing it in laundry bleach. Clients should be instructed to bathe daily and wash the armpits, the groin, and the rectal area. The client should refrain from cleaning pet litter boxes. Clients recovering from septic shock are not at higher risk for bleeding disorders.
A client recovering from septic shock is preparing for discharge home. What priority information does the nurse include in the teaching plan for this client? a. "Clean your toothbrush with laundry bleach daily." b. "Bathe every other day with antimicrobial soap." c. "Wash your hands after changing pet litter boxes." d. "Use an electric razor when you shave your face."
ANS: C The hypodynamic phase of septic shock is characterized by a rapid decrease in cardiac output, systolic blood pressure, and pulse pressure. The nurse must initiate drug therapy to maintain blood pressure and cardiac output. Accurate urinary output and blood cultures are important to the treatment but are not the priority when a client's pulse pressure is decreasing rapidly. The family should be updated appropriately.
A client was admitted 2 days ago with early stages of septic shock. Today the nurse notes that the client's systolic blood pressure, pulse pressure, and cardiac output are decreasing rapidly. Which intervention does the nurse do first? a. Insert a Foley catheter to monitor urine output closely. b. Ask the client's family to come to the hospital because death is near. c. Initiate the prescribed dobutamine (Dobutrex) intravenous drip. d. Obtain blood cultures before administering the next dose of antibiotics.
ANS: A When a local infection becomes systemic, the client develops a high-grade temperature, decreased urine output, and increased respiratory rate. Because of tachycardia and low blood pressure, the client may exhibit orthostatic hypotension. This is a subtle sign of systemic infection that requires further evaluation by the health care provider. The other signs are not manifestations of complications. Warmth and redness are expected with local infection.
A client who has a local infection of the right forearm is being discharged. The nurse teaches the client to seek immediate medical attention if which complication occurs? a. Dizziness on changing position b. Increased urine output c. Warmth and redness at site d. Low-grade temperature
ANS: B Ringer's lactate is an isotonic solution that acts as a volume expander. Also, the lactate acts as a buffer in the presence of acidosis. The other solutions do not contain any substance that would buffer or correct the client's acidosis.
A client who has acidosis resulting from hypovolemic shock has been prescribed intravenous fluid replacement. Which fluid does the nurse prepare to administer? a. Normal saline b. Ringer's lactate c. 5% dextrose in water d. 5% dextrose in 0.45% normal saline
ANS: A Blood cultures should be obtained before IV antibiotics are started. If hypotension occurs, fluid resuscitation is used first. CVP monitoring and vasopressor therapy are started if hypotension persists.
A client who has septic shock is admitted to the hospital. What priority intervention does the nurse implement first? a. Obtain two sets of blood cultures. b. Administer the prescribed IV vancomycin (Vancocin). c. Obtain central venous pressure (CVP) measurements. d. Administer the prescribed IV norepinephrine (Levophed).
Sepsis & Septic Shock
A complex type of distributive shock that usually begins as a bacterial or fungal infection & progresses to a dangerous condition over a period of days.
NEURAL-INDUCED DISTRIBUTIVE SHOCK
A loss of MAP that occurs when sympathetic nerve impulses controlling blood vessel smooth muscle muscle are decreased & the smooth muscles relax, causing vasodilation.
Assess lips, nailbeds, conjunctiva, and oral mucous membranes For persons of darker skin, assessment of the effects of shock on skin can be detected by assessing the client's lips, nailbeds, conjunctiva, and oral mucosa. Assessing only generalized skin color may not reveal the signs until the late stages of shock.
A new nurse to the unit is in preceptorship. The preceptor knows the new nurse understands how to determine the effects of shock on a dark skinned client in the initial stage of shock, when the nurse states she will assess which of the following?
Decreased Cardiac Output The primary problem for the client in shock is decreased cardiac output. All of the diagnoses are applicable, but decreased cardiac output is the priority.
A nurse caring for a client in shock establishes which of the following as the primary nursing diagnosis?
Immobilize of the victim's spine The primary intervention in trauma is immobilization of the client's cervical spine to avoid further trauma or paralysis. Placing the client on a spine board, and applying a cervical collar and head immobilizer is the priority, followed by airway management and treatment of hemorrhage or shock.
A nurse is part of an emergency response team arriving at the scene of a motor vehicle accident. One victim was thrown approximately 20 feet from the vehicle. The victim is unconscious, has labored respirations, and is bleeding from an open fracture of the left femur. Which of the following interventions is the nurse's first priority?
0.9% sodium chloride
A patient comes to the ED with severe injury & significant blood loss. The nurse anticipates that resuscitation will begin with which fluid?
Increased serum lactate level & rising band neutrophils
A patient has a systemic infection with a fever, increased respiratory rate, & change in mental status. Which lab values does the nurse seek out that are considered "hallmark" of sepsis?
Anaphylactic
A patient has cardiac dysrhythmias & pulmonary problems as a result of receiving an IV antibiotic. What type of shock does this represent?
Assess BP at least every 15 minutes because systemic vasodilation can cause hypotension.
A patient in hypovolemic shock is receiving sodium nitroprusside (Nitropress) to enhance myocardial perfusion. What's an important nursing implication for administering this drug?
Increase in HR Increase in respiratory rate
A patient is brought to the ED with a gunshot wound. The nurse closely monitors the patient for early signs of hypovolemic shock. What early sign does the nurse look for?
Chest pain & hypertension
A patient receives dopamine 20 mcg/kg/min IV for treatment of shock. What does the nurse assess for while administering this drug?
Distributive-neural
A patient with a head injury was treated for a cerebral hematoma. After surgery, this patient is at risk for what type of shock?
Increased pulse rate with warm, pink skin.
A patient's at risk for sepsis. Which assessment finding is most indicative of the hyper-dynamic activity that occurs in septic shock?
Decreased pH with decreased Pao2 & increased Paco2.
A patient's showing early clinical manifestations of hypovolemic shock. The physician orders an ABG. Which ABG values does the nurse expect to see in hypovolemic shock?
Progressive
A post op hospitalized patient has a decrease in MAP of greater than 20 mm Hg from baseline value; elevated, thready pulse; decreased BP; shallow respirations of 26/min; pale skin; moderate acidosis; & moderate hyperkalemia. This patient's in what phase of shock?
Apply direct pressure to the femoral artery pressure point Bright red blood indicates arterial hemorrhage and bleeding must be controlled immediately to avoid death. Applying pressure to the femoral artery pressure point helps to control upper leg bleeding. The popliteal artery pressure point controls lower leg bleeding. Elevating the legs will not prevent arterial bleeding.
A young male sustains injuries related to a motorcycle accident. A nurse driving to work stops and assists the victim at the site of the accident. The victim is bleeding bright red blood profusely from his right upper leg. An observer at the scene has already activated the EMS system and the anticipated arrival time is less than 5 minutes. Which of the following actions is the most appropriate for the nurse to perform at this time?
Pulse rate
A young trauma patient is at risk for hypovolemic shock related to occult hemorrhage. What baseline indicator allows the nurse to recognize the early signs of shock?
Assessment
Age is important- Hypovolemic shock from trauma is more common in young adults & other types of shock- more common in older adults. -Information about urine output is especially important because urine output is reduced during the first stages of shock even when fluid intake is normal.
impaled object in the abdomen.
All of the following are indications for the use of PASG EXCEPT:
dilation of the blood vessels.
All of the following can result in hypoperfusion EXCEPT:
Anaphylaxis
Allergic reactions that result in widespread loss of blood vessel tone & decreased cardiac output
Key features:Shock
Cardiovascular manifestations: decreased cardiac output, increased pulse rate, thready pulse, decreased BP, narrowed pulse pressure, postural hypotension ¥, low central venous pressure, flat neck & hand veins in dependent positions, alow capillary refill nailbeds Respiratory - increased respiratory rate, shallow depth of respirations, increased paco2, increased paco2, cyanosis (lips & nail beds) Neuromuscular- anxiety, restlessness, increased thirst LATE- Decreased CNS activity (lethargy to coma); Generalized muscle weakness, diminished or absent deep tendon reflexes, sluggish pupillary response to light. KIDNEY- decreased urine output; increased specific gravity; sugar & acetone present in urine INTEGUMENTARY- Cool to cold; pale to mottled to cyanotic; moist, clammy; mouth dry; pastelike coating presenting GASTROINTESTINAL- Decreased motility; diminished or absent bowel sounds; nausea & vomiting; constipation.
Physical Assessment
Cardiovascular- differ in different stages. Cardiac output & BP are lower (hypodynamic) in early sepsis & septic shock. In severe septic; cardiac output is higher & HR & BP (hyperdynamic); Increased CO reflected by tachycardia, increased SV, normal systolic BP, & normal CVP. Respiratory- as tissue hypoxia becomes more profound & metabolic acidosis is present, the depth of respiration increases; ARDs- acute respiratory distress syndome- Skin Changes- hypodynamic stage- blood is shunted away from skin, & pallor, cyanosis or mottling may be present. Hyperdynamic- skin is warm & no cyanosis evident. Cool & clammy with pallow, mottling or cyanosis. Kidney/Urinary- low urine output compared with fluid intake indicates shock
OBSTRUCTIVE SHOCK
Caused by problems that impair the ability of the normal heart muscle to pump effectively. The heart itself remains normal, but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle. -Most common causes: pericarditis & cardiac tamponade
Ischemic
Cell dysfunction or death from lack of oxygen
Vasocontriction
Decrease in diameter by contracting the muscle
Cardiogenic
Direct pump failure
Crystalloid
Fluid replacement Doesn't cause allergic reactions -Normal saline, Ringer's Lactate
Distributive
Fluid shifted from central vascular space
Colloid solution
Hemorrhagic shock Restore osmotic pressure Carries oxygen to peripheral tissues Substitute for blood Hetastarch, Packed red cells, fresh frozen plasma (FFP)
Etiology
Hypovolemic shock occurs when too little circulating blood volume causes a MAP decrease that prevents total body oxygenation. -Problems: hemorrhage (external or internal) & dehydrration
Risk Factors for Shock (older adult)
Hypovolemic- diuretic therapy, diminished thirst reflex, immobility, use of aspirin-containing products, use of therapies (Ginkgo biloba); anticoagulant therapy Cardiogenic- Diabetes mellitus; presence of cardiomyopathies Distributive: Diminished immune response; reduced skin integrity; presence of cancer; peripheral neuropathy; strokes; institutionalization (hospital or extended care); malnutrition; anemia Obstructive- Pulmonary hypertension; presence of cancer
Adaptive Responses & Events During Hypovolemic
INITIAL STAGE- Decrease in baseline MAP of 5-10. Increased sympathetic stimulation- mild vasoconstriction; increased HR. NONPROGRESSIVE STAGE- Decrease in MAP of 10-15 from patient's baseline value. Continued sympathetic stimulation- moderate vasoconstriction; increased HR; decreased pulse pressure; Chemical compensation- renin aldosterone & antidiuretic hormone secretion, increased vasoconstriction; decreased urine output; stimulation of third reflex; some anaerobic metabolism in nonvital organs- mild acidosis & mild hyperkalemia PROGRESSIVE STAGE-Decrease in MAP >20 from patients baseline value; anoxia of nonvital organs; overall metabolism is anaerobic-moderate acidosis, moderate hyperkalemia, tissue, ischemia REFRACTORY STAGE- severe tissue hypoxia, with ischemia & necrosis; release of myocardial depressant factor from pancreas; build up of toxic metabolites. Death.
Dilation
Increase in diameter of vessel walls by relaxing the smooth muscle.
decreased blood pressure.
It is important to recognize and treat shock early. A late sign of shock is:
Capillary Leak Syndrome
Mediators change blood vessel integrity & allow fluid to shift from the vascular space to the interstitial tissues
Physical Assessment/ Clinical Manifestation
Most manifestations of hypovolemic shock are caused by the changes resulting from compensatory efforts. -Compensatory mechanisms : are physiologic responses that try to keep an adequate blood flow to vital organs. -Cardiovascular changes- start with decreased MAP, leading to compensatory responses. Earliest sign!!! Pulse rate increases to keep cardiac output & MAP at normal levels, even though the actual stroke volume per beat is decreased. Increased HR- earliest manifestation of shock! Peripheral pulses difficult to palpate & are blocked with light pressure. -Systolic pressure decreases as shock progresses & cardiac output decreases. -Pulse ox- 90-95%- nonprogressive stage of shock; 75-80% - progressive stage of shock. -Respiratory rate increases during hypovolemic- to ensure that oxygen intake is increased so that it can be delivered to critical tissues. -Kidney & urinary changes occur with shock to compensate for decreased MAP by saving body water through decreased filtration & increased water reabsorption. Decreased urine output is a sensitive indicator of early shock! -Skin changes- reduced skin perfusion. This allows more blood to circulate to the vital organs which can't tolerate low oxygen levels. -Central Nervous System Changes- 1st manifestation as thirst. Thirst is caused by stimulation of the thirst centers in the brain in response to decreased blood volume. -Skeletal Muscle Changes- Muscle weakness & pain in response to tissue hypoxia & anaerobic metabolism.
Anoxic
No oxygen
DISTRIBUTIVE SHOCK
Occurs when blood volume is not lost from the body but is distributed to the interstitial tissues where it can't circulate & deliver oxygen. Can be caused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous & capillary beds, & increased capillary leak.
CARDIOGENIC SHOCK
Occurs when the actual heart muscle is unhealthy & pumping & is directly impaired. Myocardial infarction- most common cause of direct pump failure.
Distributive-neurogenic
Older adult who has a spinal cord reunion
Distributive-septic
Older adult with UTI Patient with pneumonia Older adult with sacral pressure ulcers Patient with MRSA infection
Exogenous
Originate outside the body
Review of oxygenation & tissue perfusion
Oxygenation & perfusion depend on how much oxygen from arterial blood perfuses the tissue. Tissue & organ perfusion is related to mean arterial pressure (MAP)
Patient in Hypovolemic Shock!
Patent Airway IV catheter, or maintain an established one Administer oxygen Elevate patient's feet, keeping head flat or elevated to no more than 30 degree angle Examine for overt bleeding If overt bleeding, apply direct pressure Drugs are prescribed Increase rate of IV fluid delivery DO NOT LEAVE PATIENT
Cardiogenic
Patient who had a myocardial infarction
Hypovolemic
Patient who had a ruptured aortic aneurysm. Patient with ruptured spleen resulting from trauma Patient with dehydration Patient with diabetes insipidus Patient receiving excessive diuretic therapy Patient who has cancer of the head & neck, with a nasogastric tube Patient receiving heparin therapy
Distributive-Chemical
Patient who had an allergic reaction to a medication Patient with insect bites
Obstructive
Patient with cardiac tamponade Patient with tension pneumothorax
Multiple organ dysfunction Syndrome
Sequence of cell damage caused by the massive release of toxic metabolites & enzymes. Once the damage has stsrted, the sequence becomes a vicious cycle as more dead cells break open & release harmful metabolites. These trigger small clots (microthrombi) to form, which block tissue oxygenation & damage more cells, -Liver, heart, brain, & kidney function are lost first. -Most profound change is damage to the heart muscle. One cause of this damage is the release of myocardial depressant factor (MDF) from the ischemic pancreas.
Sympathetic tone
State of partial blood vessel constriction
Endogenous
Substances normally found in the body
Heparin
The ICU nurse is caring for a patient with septic shock. Which IV infusion order for this patient does the nurse question?
Disseminated intravascular coagulation (DIC)
The ICU nurse observes petechiae, ecchymoses, & blood oozing from gums & other mucous membranes of a patient with septic shock. How does the nurse interpret this finding?
Endotoxins
The clinical manifestations in the first phase of sepsis-induced distributive shock results from the body's reaction to which factor?
ANS: B Hypovolemic shock can be caused by dehydration. A client who has bulimia is at highest risk for dehydration owing to excessive vomiting. Basketball, smoking, and traveling do not put the client at risk for hypovolemic shock.
The emergency department nurse is triaging clients. Which client does the nurse assess most carefully for hypovolemic shock? a. 15-year-old adolescent who plays high school basketball b. 24-year-old computer specialist who has bulimia c. 48-year-old truck driver who has a 40-pack-year history of smoking d. 62-year-old business executive who travels frequently
During progressive shock, blood that normally perfuses the kidneys is shunted to the heart and brain, resulting in renal hypoperfusion.
The family of a 44-year-old male, suffering hemorrhagic shock as a result of a motor vehicle accident, states that they do not understand why the client is now on dialysis when he did not sustain injury to the kidneys in the accident. The nurse's most appropriate response is based on which of the following?
ANS: D During severe sepsis, interventions should focus on decreasing hypoxia, maintaining acid-base balance, keeping blood glucose levels as normal as possible, maintaining organ perfusion, minimizing adrenal insufficiency, and decreasing microemboli. Treatment should include administration of low-dose corticosteroids, insulin drip with blood glucose checks every 1 to 2 hours, hourly intake and output monitoring, and an increase in ventilator rate and tidal volume.
The intensive care nurse is caring for an intubated client who has severe sepsis that led to acute respiratory distress. Which nursing intervention is most appropriate during this stage of sepsis? a. Check blood glucose levels every 4 hours. b. Monitor intake and urinary output twice each shift. c. Decrease ventilator rate and tidal volume. d. Administer prescribed low-dose corticosteroids.
ANS: A Any problem that impairs oxygen delivery to tissues and organs can start the syndrome of shock and lead to a life-threatening emergency. Shock represents the "whole-body response," affecting all organs in a predictable sequence. Compensation mechanisms attempt to maintain homeostasis and deliver necessary oxygen to organs but eventually will fail without reversal of the cause of shock, resulting in death. page 809
The intensive care nurse is educating the spouse of a client who is being treated for shock. The spouse states, "The doctor said she has shock. What is that?" What is the nurse's best response? a. "Shock occurs when oxygen to the body's tissues and organs is impaired." b. "Shock is a serious condition, but it is not a life-threatening emergency." c. "Shock progresses slowly and can be stopped by the body's normal compensation." d. "Shock is a condition that affects only specific body organs like the kidneys."
hemorrhage. Severe bleeding, or hemorrhage, is the major cause of shock (hypoperfusion).
The major cause of shock is:
Laceration A contusion is a superficial tissue injury resulting from blunt trauma, which causes the breakage of small blood vessels and bleeding into the surrounding tissues. An abrasion is a partial-thickness denudation of an area of integument, generally resulting from falls or scrapes. A puncture wound occurs when sharp or blunt objects penetrate the integument. Lacerations are open wounds resulting from sharp cutting or tearing.
The nurse documenting trauma injuries for a client with open wounds resulting from a lawnmower blade cut will document this integumentary injury as which of the following?
-Elevate the feet with the head flat or elevated 30 degrees. -Monitor vital signs every 5 minutes until they are stable -Provide oxygen therapy -Ensure IV access -Notify the Rapid Response Team
The nurse identifies signs & symptoms of internal hemorrhage in a post op patient. What's included in the care of this patient in hypovolemic shock?
ANS: B The client receiving sodium nitroprusside should have his or her blood pressure assessed every 15 minutes. Higher doses can cause systemic vasodilation and can increase shock. The nurse should monitor the client's pain, urinary output, and extremities, but these assessments do not directly relate to the nitroprusside infusion.
The nurse is administering prescribed sodium nitroprusside (Nipride) intravenously to a client who has shock. Which nursing intervention is a priority when administering this medication? a. Ask if the client has chest pain every 30 minutes. b. Assess the client's blood pressure every 15 minutes. c. Monitor the client's urinary output every hour. d. Observe the client's extremities every 4 hours.
ANS: B Administration of oxygen for any type of shock is appropriate to help reduce potential damage from tissue hypoxia. The other interventions should be completed after oxygen is administered.
The nurse is assessing a client at risk for shock. The client's systolic blood pressure is 20 mm Hg lower than baseline. Which intervention does the nurse perform first? a. Increase the IV fluid rate. b. Administer oxygen. c. Notify the health care provider. d. Place the client in high Fowler's position.
ANS: B The syndrome of hypovolemic shock results in inadequate tissue perfusion and oxygenation; thus some cells are metabolizing anaerobically. Such metabolism increases the production of lactic acid, resulting in an increase in hydrogen ion production and acidosis. Other laboratory values associated with acidosis include increased creatinine (impaired renal function) and increased partial pressure of arterial carbon dioxide. Urine specific gravity is not associated with acidosis. page 812
The nurse is assessing a client who has hypovolemic shock. Which laboratory value indicates that the client is at risk for acidosis? a. Decreased serum creatinine b. Increased serum lactic acid c. Increased urine specific gravity d. Decreased partial pressure of arterial carbon dioxide
ANS: A An increase in heart and respiratory rates (heart rate first) from the client's baseline and a slight increase in diastolic blood pressure may be the only objective manifestations of early shock. These findings do not correlate with other stages of shock.
The nurse is assessing a client who has septic shock. The following assessment data were collected: Baseline Data Today's Data Heart rate 75 beats/min 98 beats/min Blood pressure 125/65 mm Hg 128/75 mm Hg Respiratory rate 12 breaths/min 18 breaths/min Urinary output 40 mL/hr 40 mL/hr The nurse correlates these findings with which stage of shock? a. Early b. Compensatory c. Intermediate d. Refractory
ANS: A, B, D Heart and respiratory rates increased from the client's baseline level and a slight increase in diastolic blood pressure may be the only objective manifestations of this early stage of shock. pg 813
The nurse is assessing a client who is in early stages of hypovolemic shock. Which manifestations does the nurse expect? (Select all that apply.) a. Elevated heart rate b. Elevated diastolic blood pressure c. Decreased body temperature d. Elevated respiratory rate e. Decreased pulse rate
ANS: D The late phase of sepsis-induced distributive shock is characterized by most of the same cardiovascular manifestations as any other type of shock. The distinguishing feature is lack of ability to clot blood, causing the client to bleed from areas of minor trauma and to bleed spontaneously. The other manifestations are associated with all types of shock.
The nurse is assessing a client who was admitted for treatment of shock. Which manifestation indicates that the client's shock is caused by sepsis? a. Hypotension b. Pale clammy skin c. Anxiety and confusion d. Oozing of blood at the IV site
ANS: C Certain conditions or treatments that cause immune suppression, such as having cancer and being treated with chemotherapeutic agents, aspirin, and certain antibiotics, can predispose a person to septic shock. The other client situations do not increase the client's risk for septic shock.
The nurse is assessing clients in the emergency department. Which client is at highest risk for developing septic shock? a. 25-year-old man who has irritable bowel syndrome b. 37-year-old woman who is 20% above ideal body weight c. 68-year-old woman who is being treated with chemotherapy d. 82-year-old man taking beta blockers for hypertension
ANS: A During the hyperdynamic phase of septic shock, because of alterations in the clotting cascade, clients begin to form numerous small clots. Heparin is administered to limit clotting and prevent consumption of clotting factors. The other medications would not be prescribed during the hyperdynamic phase of septic shock.
The nurse is caring for a client in the hyperdynamic phase of septic shock. Which medication does the nurse expect to be prescribed? a. Heparin sodium b. Vitamin K c. Corticosteroids d. Hetastarch (Hespan)
ANS: D Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals. This results in massive blood vessel dilation and increased capillary leak, which manifests as swelling. The other clinical manifestations do not relate to anaphylaxis or distributive shock.
The nurse is caring for a client who has had an anaphylactic event. Which priority question does the nurse ask to determine whether the client is experiencing distributive shock? a. "Is your blood pressure higher than usual?" b. "Are you having pain in your throat?" c. "Have you been vomiting?" d. "Are you usually this swollen?"
ANS: C IV therapy for fluid resuscitation is the primary intervention for hypovolemic shock. A dopamine hydrochloride drip is a secondary treatment if the client does not respond to fluids. Aminoglycosides and heparin are given to clients with septic shock.
The nurse is caring for a client who has hypovolemic shock. After administering oxygen, what is the priority intervention for this client? a. Administer an aminoglycoside. b. Initiate a dopamine hydrochloride (Intropin) drip. c. Administer crystalloid fluids. d. Initiate an intravenous heparin drip.
Decreasing urine output Increasing HR
The nurse is caring for a patient at risk for hypovolemic shock. Which indicators of shock does the nurse monitor for?
Localized infected area
The nurse is caring for a patient at risk for septic shock from a wound infection. In order to prevent systemic inflammatory response syndrome, the nurse's priority is to monitor which factor?
Metabolic acidosis
The nurse is caring for a patient in septic shock. The nurse notes that the rate & depth of respirations is markedly increased. The nurse interprets this as a possible manifestation of the respiratory system compensating for which condition?
Determine & treat the cause of the shock
The nurse is caring for a patient with cardiogenic shock. What's the priority for managing this patient?
Drop in BP
The nurse is caring for a patient with sepsis. What's a late clinical manifestation of shock?
Antibiotics
The nurse is caring for a patient with septic shock. Which therapy specific to the management of shock for this patient does the nurse anticipate will be used?
A rapid, weak, & thready pulse
The nurse is caring for a post op patient who had major abdominal surgery. Which assessment finding is consistent with hypovolemic shock?
Restlessness
The nurse is caring for an older adult patient at risk for shock. What's an early sign of shock in this patient?
ANS: A Distributive shock is the type of shock that occurs when blood volume is not lost from the body but is distributed to the interstitial tissues, where it cannot circulate and deliver oxygen. Neurally-induced distributive shock may be caused by pain, anesthesia, stress, spinal cord injury, or head trauma. The other clients are at risk for hypovolemic and cardiogenic shock. pg 812
The nurse is caring for multiple clients in the emergency department. The client with which condition is at highest risk for distributive shock? a. Severe head injury from a motor vehicle accident b. Diabetes insipidus from polycystic kidney disease c. Ischemic cardiomyopathy from severe coronary artery disease d. Vomiting of blood from a gastrointestinal ulcer
Increased urinary output
The nurse is evaluating the care & treatment for a patient in shock. Which finding indicates that the patient is having an appropriate response to the treatment?
Hematocrit at 34% Maintaining a hematocrit at 30% to 35% and a hemoglobin level between 12.5 and 14.5 g/100 mL is the goal of blood administration. Frequent monitoring of hemoglobin and hematocrit is essential to evaluate therapy of blood transfusions.
The nurse is evaluating the effectiveness of blood transfusions to a client with hypovolemic shock, secondary to hemorrhage. Which of the following indicates to the nurse that a therapeutic effect of the administration of blood has been achieved?
ANS: C Dopamine hydrochloride causes vasoconstriction that in turn increases cardiac output and mean arterial pressure, thereby improving tissue perfusion and oxygenation. Tachycardia is not a desired response but often occurs as a side effect. pg 818
The nurse is monitoring a client in hypovolemic shock who has been placed on a dopamine hydrochloride (Intropin) drip. Which manifestation is a desired response to this medication? a. Decrease in blood pressure b. Increase in heart rate c. Increase in cardiac output d. Decrease in mean arterial pressure
ANS: A Therapy during the second (late) phase of septic shock is aimed at enhancing the blood's ability to clot. Enoxaparin would increase the client's risk of bleeding and therefore should not be administered during the last phase of septic shock. Administering clotting factors, plasma, platelets, and other blood products will assist the client's blood to clot. Intravenous insulin to control hyperglycemia and antibiotic therapy would continue in the late phases of septic shock.
The nurse is planning care for a client with late-phase septic shock. All of the following treatments have been prescribed. Which prescription does the nurse question? a. Enoxaparin (Lovenox) 40 mg subcutaneous twice daily b. Transfusion of 2 units of fresh frozen plasma c. Regular insulin intravenous drip per protocol d. Cefazolin (Ancef) 1 g IV every 6 hours
ANS: A A decrease in urine output is a sensitive indicator of early shock. In severe shock, urine output is decreased (compared with fluid intake) or even absent. Alterations in temperature, irregular rhythms, and changes in bowel movements are not early signs of shock.
The nurse is planning discharge education for a client who had an exploratory laparotomy. Which nursing statement is appropriate when teaching the client to monitor for early signs of shock? a. "Monitor how much urine you void and report a decrease in the amount." b. "Take your temperature daily and report any below-normal body temperatures." c. "Assess your radial pulse every day and report an irregular rhythm." d. "Monitor your bowel movements and report ongoing constipation or diarrhea."
ANS: C Sodium nitroprusside (Nipride) must be protected from light to prevent degradation of the drug. It should be delivered via pump. This medication does not have any effect on respiratory rate. Hypertension is a sign of milrinone (Primacor) overdose.
The nurse is preparing to administer sodium nitroprusside (Nipride) to a client. Which important action related to the administration of this drug does the nurse implement? a. Assess the client's respiratory rate. b. Administer the medication with gravity tubing. c. Protect the medication from light with an opaque bag. d. Monitor for hypertensive crisis.
ANS: C Teach everyone to prevent dehydration by having adequate fluid intake during exercise or when in a hot and dry environment. Insensitive water loss increases in this type of environment. Heat causes vasodilation as well, also contributing to water loss. The other statements are not accurate.
The nurse is providing community education for clients at risk for dehydration. One client states, "We are not at risk because we live in a hot and dry climate." What is the nurse's best response? a. "You are still at risk but not as high a risk as those who live in hot and humid climates." b. "Any type of heat can cause peripheral vasoconstriction, which causes the body to lose water." c. "In a hot and dry environment, the body can lose an increased amount of water without your knowledge." d. "Even though you are not at risk, you should drink adequate fluids when you exercise."
ANS: B, E, F Daily temperatures, washing dishes in hot sudsy water or a dishwasher, and rinsing toothbrushes in liquid bleach or in the dishwasher are infection precautions for the immune compromised client. Clients at increased risk because of immune suppression need to wear a facemask when in large crowds or around ill people. Water need not be bottled but should not be used if it has been standing for longer than 15 minutes. This population is not restricted from pets but is only advised not to change pet litter boxes.
The nurse is providing health education to a client on immunosuppressant therapy. Which instructions does the nurse include in this client's teaching? (Select all that apply.) a. "Wear a facemask at all times." b. "Take your temperature once a day." c. "Drink only bottled water." d. "Avoid any contact with pets." e. "Wash dishes with hot sudsy water." f. "Rinse your toothbrush in liquid laundry bleach."
Provide pain relief
The nurse, establishing a plan of care for a client with cardiogenic shock, includes which of the following in the plan of care?
Decreased urine output Increased HR
The patient has decreased oxygenation & impaired tissue perfusion. Which clinical manifestations are evidence of one of the non-progressive or compensatory stages of shock?
Severe Sepsis
The progression of sepsis with an amplified inflammatory response. -All tissues are involved & are hypoxic to some degree. -Some organs are experiencing cell death & dysfunction -Clinical manifestation: Lower oxygen saturation, rapid respiratory rate, decreased to absent urine output, & a change in the patient's cognition & affect
compensated shock. When the body is able to maintain blood pressure and perfusion in spite of failure of the cardiovascular system, it is called compensated shock. Compensating mechanisms include increased pulse and breathing, and constriction of peripheral blood vessels.
The severity of shock is classified into three categories. When the body is able to maintain blood pressure and perfusion, it is called:
all of the above. All causes of shock can be categorized into three major types. Hypovolemic shock is from blood and fluid loss. Cardiogenic shock is from failure of the heart to pump efficiently. Neurogenic shock is caused by uncontrolled dilation of the blood vessels.
The three major types of shock include: cardiogenic or pump failure. hypovolemice or fluid failure. neurogenic or container failure. all of the above.
Hypovolemic
Total body fluid decreased (in all fluid compartments)
Obstructive
Total body fluid volume not affected
avoid covering the patient as not to overheat. The emergency care steps for shock include: maintain an open airway and assess the respiratory rate. If the patient is breathing adequately, apply high-concentration oxygen by nonrebreather mask. Assist ventilations or perform CPR if necessary; control any external bleeding; apply and inflate the pneumatic anti-shock garment (PASG) if approved or ordered by your local medical direction; if there is no possibility of spine injury, elevate the legs 8 to 12 inches; splint any suspected bone injuries or joint injuries; prevent loss of body heat by covering the patient with a blanket; transport the patient immediately; and if the patient is conscious, speak calmly and reassuringly throughout assessment, care, and transport.
Treatment for hypoperfusion includes all of the following EXCEPT:
Reduced skin integrity
What factor increases an older adult's risk for distributive (septic) shock?
Extravasation
When administering norepinephrine (Levophed) what does the nurse monitor for in the patient?
Packed red cells
Which IV therapy results in the greatest increase in oxygen-carrying capacity for a patient with hypovolemic shock?
Pallor or cyanosis in the mucous membranes
Which change in the skin is an early indication of hypovolemic shock?
-Renin -Antidiuretic hormone (ADH) -Epinephrine -Aldosterone
Which hormones are released in response to decreased mean arterial pressure (MAP)?
Patient with severe vomiting & large watery diarrheal stools.
Which patient is most likely to show elevated hemoglobin & hematocrit during shock?
Patient with a recent MI Patient with a history of CHF
Which patients are at risk for cardiogenic shock?
Severely malnourished patient Patient with paralytic ileus Patient with kidney disease Patient with large wounds
Which patients are at risk for shock related to fluid shifts?
-Shock is a whole body response to body tissues not receiving enough oxygen. -Shock is widespread abnormal cellular metabolism. -Shock may occur in older adults in response to UTIs
Which statements about shock are true?
pelvic fracture. Use of the PASG is contraindicated in eviscerations, chest injuries, and late stage pregnancy due to increased pressure and altered blood supply.
While the use of the PASG is controversial, all of the following are contraindications to using the device EXCEPT:
Shock
Widespread abnormal cellular metabolism that occurs when oxygenated & tissue perfusion needs are not met to the level necessary to maintain cell function. -Whole body response that occurs when too little oxygen is delivered to the tissues. -Any problem that impairs oxygen delivery to tissues & organs can start the syndrome of shock & lead to a life-threatening emergency.
Sepsis
Widespread infection that triggers a whole-body inflammatory response
Perfusion Perfusion is the supply of oxygen to and removal of wastes from the cells and tissues of the body as a result of the flow of blood through the capillaries.
______________ is the supply of oxygen to and removal of wastes from the cells and tissues of the body as a result of the flow of blood through the capillaries.
LAB- Hypovolemic Shock
pH (arterial)- 7.35-7.45- Decreased: insufficient tissue oxygenation causing anaerobic metabolism & acidosis. Pao2- 80-100 mm Hg- Decreased: anaerobic metabolism Paco2- 35-45 mm Hg- Increased; anaerobic metabolism Lactic Acid (arterial) 3-7 mg/dL (0.3-0.8 mmol/L) Increased: anaerobic metabolism with build up of metabolites Hematocrit- Females- 37%-47%- Males- 12-52%- Increased: fluid shift; dehydration; Decreased: hemorrhage Hemoglobin- Female- 12-16 g/dL- Male- 14-18 g/dL- Increased fluid shift; dehydration; Decreased: hemorrhage Potassium- 3.5-5.0 mEq/L- Increased: dehydration; acidosis
