Exam 2, CH 9 SHOCK
Classification of shock
Hypovolemic: Decreased circulating blood volume Cardiogenic: cardiac failure Obstructive: blockage of blood flow outside heart Distributive: excessive dilation of the veins and arteries
Compensated stage of shock
*Able to MAINTAIN blood pressure and tissue perfusion TACHYCARDIA BOUNDING PULSE NORMAL BLOOD PRESSURE INCREASED RESPIRATIONS TEMP. VARIES ANXIOUS, RESTLESS, IRRITABLE, ALERT, ORIENTED, SENSE OF DOOM COOL, CLAMMY, PALE NORMAL URINE AND BOWELS
Irreversible signs of shock
*No response to treatment, DEATH is imminent SLOWING HEARTBEAT PULSE ABSENT BP SYSTOLIC BELOW 60 RESPIRATIONS SLOW IRREGULAR SHALLOW TEMP DECREASING UNCONSCIOUS, COMATOSE CYANOTIC, MOTTLED, COLD, CLAMMY URINE 15ML TO ANURIA BOWLS ABSENT
Progressive signs of shock
*compensatory mechanisms start to FAIL TACHYCARDIA MORE THAN 150BPM WEAK THREADY PULSE LOW BLOOD PRESSURE; SYSTOLIC BELOW 90 TACHYPNEA, CRACKLES, SHALLOW TEMP DECREASED, CAN RISE IN SEPTIC SHOCK CONFUSED, LETHARGY MOIST, COLD, CLAMMY, PALE URINE DECREASED TO LESS THAN 20ML/HR BOWELS DECREASED
Types of Distributive shock
- Anaphylactic shock: extreme sensitivity reaction to an antigen, causing vasodilation and inflammation- death can occur in minutes - Septic shock: caused by SYSTEMIC infection and inflammation, release of chemicals causes vasodilation and loss of fluid into interstitial space - Neurogenic Shock: injury or dysfinction usually to spinal cord, causing extensive vasodilation. Most rare kind of shock, which either stimulate the parasympathetic NS or block the sympathetic NS
three critical conditions from prolonged shock
-Acute respiratory distress syndrome -disseminated intravascular coagulation (widespread vessel clotting) -multiple organ dysfunction syndrome
Hypovolemic shock
-Severe loss of body fluid: dehydration, internal or external hemorrhage, fluid loss from burns, vomiting or diarrhea, loss of intravascular fluid into the interstitial space from sepsis or trauma *tachycardia may be the only symptom s/s: tachycardia, tachypnea, hypotension, cyanosis, oliguria, flat and nondistended peripheral veins, decreased jugular veins, altered mental status -body can compensate for 15% or 750 ml through an increase in HR
the nurse is providing care to a patient experiencing shock and should be vigilant for signs of which of the following complications that are related to prolonged shock
-acute respiratory distress syndrome -disseminated intravascular coagulation -multiple organ dysfunction syndrome
complications from shock
-acute respiratory distress syndrome (ARDS): respiratory failure despite high levels of O2 and mechanical ventilation -disseminated intravascular coagulation (DIC): Results from ischemic damage to blood vessels, formation of tiny thrombi and depletion of clotting factors. -Multisystem organ dysfunction syndrome (MODS)
obstructive shock
-blockage of blood to the heart: pericardial tamponade: when pericardial sac fills with blood or fluid, compresses heart and limits its filling capacity. tension pneumothorax: abnormal collection of air in the pleural space acute pulmonary hypertension: abnormal elevated pressure in the pulmonary artery. pulmonary embolism or tumor blocking blood flow can also lead to shock. s/s: similar to hypovolemic shock, except that jugular veins are distended as hypo is decreased.
Causes of shock include
-inadequate cardiac output, caused by heart failure, hemorrhage, or a sudden decrease in peripheral vascular resistance due to anaphylaxis (life threatening allergic reaction), sepsis (a life threatening condition caused by the body's response to an infection resulting in an organ dysfunction) or neurologic alterations.
nursing diagnoses in shock
-ineffective tissue perfusion R/T hypovolemia or inadequate cardiac output AEB altered LOC, tachycardia, reduced BP, decreased urine output -decreased cardiac output R/T reduced circulating blood volume or decreased cardiac contractility AEB abnormal vital signs and cardiac arrythmia -Fear R/T severity of conditon and unknown outcome AEB verbalization of fear (am i going to die?)
the nurse is contributing to the plan of care for an older patient at risk for cardiogenic shock. which of these interventions would the nurse include for the nursing diagnosis of deficient knowledge to aid the learning of this older patient about this condition
-involve family/caregivers in teaching -provide materials in large print -speak slowly and clearly
Nursing process for patient in shock
-maintain airway and provide oxygen -monitor vital signs -monitor intake and output -provide adequate fluid intake -maintain body temperature with warmed IV fluids, room temperature, blankets -provide quiet/restful environment -monitor for pain, provide pain relief measures. Geriatric: -change positions slowly Nursing diagnosis: decreased cardiac output. -monitor heart rate and cardiac rhythm with ECG -monitor skin/nailbed color, capillary refill, peripheral pulses. -give cardiovascular medications and oxygen as ordered -monitor skin for pressure injuries and implement prevention interventions when vasopressors used. -provide comfort measures to alleviate pain and anxiety and maintain normal body temperature geriatric: -monitor perfusion by methods other than capillary refill, such as skin temperature Nursing diagnosis: deficient knowledge -identify patients ability to learn and barriers to learning -provide patient centered information on shock and treatment -allow time for questions and clarification Geriatric: -involve family/caregivers in teaching -speak slowly and clearly in a low/tone pitch -provide materials in large print.
therapeutic interventions for shock
-maintain airway/respiratory support -provide cardiovascular support -maintain circulatory volume: 0.9NS IVF -control bleeding -treatment of life-threatening conditions -determination and treatment of causes of shock, including medications -provide warmth and pain medication -Review lab tests: CBC, BMP, PT, PTT, blood type and crossmatch, ABGs, urinalysis
cardiogenic shock
-results when heart fails to pump -immediate tx to prevent death -will see PULMONARY EDEMA -main cause is ACUTE MYOCARDIAL INFARCTION -occurs in 5-10% of patients with AMI (acute myocardial infarction) -40% of the myocardium must be lost to produce this type of shock -similar s/s to hypovolemic shock, except has distended jugular and peripheral veins and pulmonary edema -other causes are rupture of heart valves, acute myocarditis, end stage heart disease, severe arrythmias, traumatic injury to heart -will hear "crackles"
Metabolic and Hemodynamic Changes in Shock
-sympathetic nervous system: *epinephrine and norepinephrine are released from the adrenal medulla *increase CO by causing heart to beat faster and stronger (tachycardia) *respiratory rate increases to deliver more oxygen to the tissues (tachypnea) *blood flow is reduced to kidneys to conserve fluid (oliguria) *peripheral vasoconstriction occurs to shunt blood to the vital organs (pallor) *decreased blood flow to skin/ release of moisture to cool the body in preparation for fight or flight(cool, clammy skin)
shock effect on organs
-tissue ischemia and organ injury -kidneys injured FIRST -GI have injury to mucosa and paralytic ileus -liver injury -immune system is weakened -heart injury -brain death if anoxic over four minutes
Pathophysiology of Shock
-tissue perfusion and BP: adequate blood volume, an effective cardiac pump, and effective blood vessels are the three mechanisms which maintain this. compensation: change in one or both of non-failing tissue perfusion mechanisms shock: failure in compensation, leading to inadequate tissue perfusion.
best ways to manage sepsis and septic shock (evidence base practice)
-use screening tools on high risk patients -obtain all ordered cultures (two sets of blood culture) -administer IV antimicrobials within 1 hour -administer IV fluids (30ml crystalloid fluid w/n first 3 hours for hypotension) -administer ordered vasopressors (norepinephrine first choice) -report ordered lab results (such as lactate level) -use ordered prone positioning for mechanically ventilated patients with ARDS -maintain glycemic control -provide enteral nutrition -assist with planning of care and the use of palliative care as appropriate
therapeutic measures for shock
1. Airway management: oxygen, O2 over 95%, venous lactic acid less than 2.2 mmol/L 2. Breathing and respiratory support^ 3. Cardiovascular support: vasopressor medication, if fluid resuscitation not effective. Revascularization of heart in cardiogenic shock via angioplasty, with or without stent or fibrinolytic therapy. Antiaarhythmics positive inotropes 4.Maintenance of circulatory volume: Crystalloid fluids 30ml within 3 hours for septic shock blood products urine output greater than 30ml/hr hemoglobin greater than 10g/dl 5.Control of bleeding if present: pressure dressings, surgical intervention 6. assessment of neurologic status 7. treatment of life-threatening injuries: surgical intervention, medications 8. medications for types of shock: sepsis/septic shock= broad spectrum antimicrobials within 1 hour of diagnosis. cardiogenic shock: diuretics, nitrates, inotropics, vasopressors anaphylactic shock: epinephrine, diphenhydramine (benadryl), methylprednisolone (solu-medrol)
classic signs of shock
1. Tachycardia (rapid heart rate) is caused by decreased cardiac output and reduced tissue oxygenation. its purpose is to increase cardiac output and oxygen delivery with more heartbeats that pump blood out of the heart 2. Tachypnea (rapid breathing) caused by decreased tissue oxygenation. Its purpose is to increase respirations so that more oxygen is available for delivery to tissues. 3. Oliguria (producing small amounts of urine), is caused by a reduced blood flow to the kidneys. Its purpose as a compensatory mechanism is to serve as much fluid as possible to help maintain normal blood pressure. 4. Pallor is caused by reduced blood volume or flow. Peripheral vasoconstriction shunts blood from the skin to the vital organs 5. Cool, clammy skin is the result of decreased blood flow to the skin and the release of moisture (sweat) from the skin. Sweating cools the body in anticipation of the fight or flight response, which generates body heat when it occurs.
for the patient in hypovolemic order priority
1. ensure patent airway 2. apply oxygen 3. obtain vital signs 4.monitor prescribed intravenous fluids 5. record hourly urine output 6. provide restful environment
Tissue perfusion and blood pressure are maintained by three mechanisms.
1.) adequate blood volume. 2.) an effective cardiac pump 3.) effective blood vessels. The body is able to compensate for a problem in one mechanism, Shock occurs when the compensatory mechanisms fail to maintain the blood pressure, leading to poor tissue perfusion.
the nurse is caring for a hypertensive patient whose blood pressure is usually 156/86 mm Hg. which of the following blood pressures is considered a progressive shock blood pressure finding for this patient
114/64 mm Hg
the nurse is caring for a patient who is experiencing progressive shock. place in correct order of occurrence the systolic blood pressure findings that the nurse obtained for this patient who progressed through the three stages of shock and is now in irreversible shock, begin with compensated shock and use all options
116mm Hg 86mm Hg 56mm Hg
ABCD for shock
AIRWAY: HEAD TILT CHIN LIFT METHOD BREATHING: RATE, DEPTH, SYMMETRY. LUNG SOUNDS, CRACKLES (CARDIOGENIC). CIRCULATION: BLOOD PRESSURE, DROP IN SYSTOLIC, TACHYCARDIA, PULSE WEAK AND THREADY DISABILITY: PATIENTS LEVEL OF CONCIOUSNESS INDICATES DISABILITY CAN RANGE FROM LETHARGY TO COMA.
`nurse caring for patient with gastrointestinal bleeding who has IV infusion of 0.9% normal saline at 50ml/hr the patient has large red bloody stool and reports dizziness the nurse assists patient to bed and obstains v/s: bp 90/52, pulse 118, respiration 22
inform the registered nurse now
nursing assessment in shock
Assessment carried out quickly for shock, and always start with ABCD -airway is assessed for patency, opened as needed -breathing is assessed for rate, depth, symmetry of chest movement, use of accessory muscles, lung sounds -circulation is assessed with BP, pulse, skin color and temp, cap refill, presence of cyanosis -Disability is assessed by determining LOC, CSM in all four limbs
antihistamine
Diphenhydramine (Benadryl) inhibits histamine release. monitor vital signs, may cause drowsiness
Why does prolonged shock cause extensive damage to organs?
It does so because inadequate blood flow results in tissue ischemia and injury throughout the body. Early in shock, blood shunts away from KIDNEYS to save fluid. this helps preserve blood pressure to provide oxygen to vital organs. kidneys can tolerate reduced blood flow for 1 hour. then kidney cells begin to die. Acute kidney injury can occur. then the MYOCARDIUM receives inadequate oxygen pumping cells decrease cardiac output. Acidosis toxins release into bloodstream from ischemic tissues, or ischemia induced arrhythmias (abnormal HB) further reduce the pumping ability of the heart. brain deprived of blood flow for more than 4 minutes brain cells die, brain death can result from prolonged shock. organs of GI, intestines without oxygen injures the mucosa. Paralytic ileus (intestine paralysis) can occur. if gastrointestinal bacteria or endotoxins move from the bowel into the circulation, toxemia can result. Liver can be damaged by ischemia, elevated serum levels of ammonia, bilirubin, and liver enzymes and decreased production of plasma proteins occur. Immune system weakened leaving body vulnerable to infection.
the nurse is assigned to the nursing care team caring for the following patients. which patient would be the priority for the nurse to see first
a patient who is 1 day post-op with blood pressure 88/58 mm Hg, pulse 152 bpm, respirations 24
blood vessels shock
anaphylactic shock septic shock neurogenic shock
Anaerobic Metabolism IMPORTANT in shock
is the source of nutrition and energy for the cell that prevents cellular death when oxygen is not available. It is a SHORT TERM compensatory mechanism to help save the cell until oxygen becomes available again.
medications for shock
autonomic SYMPATHETIC nervous system medications: -Alpha adrenergic catecholamines: strengthen cardiac muscle contractions, increases blood pressure, and ^cardiac output: epinephrine, dopamine, and norepinephrine -Beta adrenergic agents: ^ cardiac output in cardiogenic shock: Dobutamine -antihistamine: inhibits histamine release during an allergic reaction. Benadryl; causes drowsiness, dry mouth -anti-inflammatory corticosteroids: control of severe allergic reactions. solumedrol, solu-cortef, dexamathasone side effects: usually only present with long-term use, but always monitor for infection
late signs and symptoms of septic shock
late (cold) phase: tachycardia, tachypnea; hypotension; oliguria; delayed capillary refill; cool, clammy skin, normal or subnormal temperature; altered mental status
the nurse is caring for a patient following splenectomy.. which of the following symptoms is of highest priority for the nurse to report
blood pressure 86/52 mm Hg
symptoms of obstructive shock
blood pressure 88/56 low urine output 100 ml over 6 hours jugular vein distention confusion and lethargy
Trendelenburg position NOT good for shock
body is supine and feet up, was used to try to increase cardiac output in hypovolemic shock, research shows that is not helpful in improving cardiac output for patients in shock and can have profound effects.
septic shock
loss of vascular autoregulatory control and loss of fluid into the interstitium caused by massive release of chemical mediators and endotoxins from pathogens.
heart shock
cardiogenic shock
the nurse would recognize which of these conditions as the cause for decreased level of consciousness, which is commonly found in patients experiencing shock
cerebral hypoxia
which of the following actions would the nurse take to collect data to determine status of peripheral tissue perfusion in 48 year old patient in shock
check capillary refill
the nurse is reinforcing teaching to the family of a patient experiencing hypovolemic shock. which of these would the nurse correctly state causes hypovolemic shock
circulating blood volume is decreased
a 47 year old patient is admitted with hypovolemic shock from trauma injuries resulting from an automobile accident. the patient remains oliguric 2 days later which assessment of the patient indicates to nurse that the patient is experiencing a complication of shock during follow up appt
creatinine 2.2 mg/dl (normal= 0.6 to 1.3 mg/dl)
which of these findings during data collection would the nurse specifically anticipate in a patient experiencing anaphylactic shock
wheezing urticaria bronchospasm
shock
defined as inadequate tissue perfusion, means there is not enough oxygen being delivered to meet the METABOLIC needs of the tissues.
Beta- adrenergic agent
dobutamine increases cardiac output in CARDIOGENIC SHOCK monitor VS and I/O
neurogenic shock
dysfunction or injury to the nervous system from spinal cord injury, general anesthesia, fever, metabolic disturbance, brain injury. causes extensive dilation of peripheral blood vessels. causes include spinal cord injury, general anesthesia, fever, metabolic disturbances, and brain contusions and concussions. Signs include hypotension and altered mental status and, during the early phases, bradycardia and warm, dry skin. As shock progresses, however, tachycardia and cool, clammy skin develops
early signs and symptoms of septic shock
early (warm) phase: tachycardia; blood pressure, urine output, and capillary refill can be normal; skin WARM and flushed; fever usually present; although temperature can be subnormal, fever may be absent in older or immunosuppressed people
epinephrine
first drug given in anaphylactic shock to bronchodilate
early phase of neurogenic shock
hypotension; altered mental status; bradycardia; warm, dry skin
Fluid volume shock
hypovolemic shock
the nurse is monitoring a patient experiencing shock who is being given crystalloid intravenous fluids. which of these findings would indicate to the nurse that the treatment is effective
increased blood pressure
shock effect on organs and organ systems
lungs: -acute respiratory failure -acute respiratory distress syndrome (ARDS) renal system: -renal insufficiency -acute kidney injury heart: -arrhythmias -myocardial infarction -myocardial ischemia liver: -decreased production of plasma proteins -impaired clotting -elevated serum levels of ammonia, bilirubin, and liver enzymes immune system: depletion of defense components gastrointestinal system: -absorption of endotoxins and bacteria -mucosal injury -pancreatitis -paralytic ileus central nervous system: -ischemic damage -necrosis -brain death
anti-inflammatory
methylprednisolone(solu-medrol) hydrocortisone (solu-cortef) dexamethasone (decadron) controls severe allergic reactions; monitor patient for signs and symptoms of infection
which medications would the nurse anticipate the health care provider may order to increase blood pressure for a patient with septic shock
norepinephrine
which of the following does the nurse understand is the primary reason that respiration increases in compensated shock
normal oxygen levels are maintained
which of these would the nurse implement as the PRIORITY action for the patient with newly diagnosed septic shock?
obtain blood cultures before antibiotics
A patient is found lying in a pool of blood from a leg incision that has opened, and she is restless and confused. The nurse calls for help and takes vital signs. Which of the following treatments for shock would the nurse anticipate being ordered first?
oxygen
a patient who is hemorrhaging from a leg incision is restless and confused the nurse applies pressure to the incision and calls for help. which of the following treatments for shock would the nurse anticipate being ordered first
oxygen
which patient would be a priority for the nurse to see?
patient who is one day post-op with BP 88/58, pulse 152, R 24 (shock)
with which of the following stages of shock would the nurse anticipate the skin to be cold and moist during data collection
progressive
the nurse is caring for a patient with a bowel obstruction which of the following is the earliest indication that the patient is developing symptoms of shock
pulse 110 bpm
anaphylactic shock
reaction to an allergen, such as an insect, sting, medication, peanuts, antibiotic, anesthetic, contrast dye, or blood product. category: distributive shock s/s: tachycardia, tachypnea, wheezing, hypotension, cyanosis, oliguria, altered mental status -can have urticaria, pruritis, angioedema, laryngeal edema, severe bronchospasm *if conscious, can be extremely apprehensive
the nurse is contributing to the plan of care for a patient experiencing shock. Which of the following nursing diagnoses is most appropriate to include in this plan of care
risk for ineffective tissue perfusion (cerebral, peripheral)
factors that increase sepsis risk include
sepsis: life threatening organ dysfunction caused by dysregulated host response to infection being over 65, having a chronic illness, having a weakened immune system, having burns, or being critically ill. Infections of the GI, lungs, skin and urinary tract are most common. E-coli, staph a, and strept most common bacteria causing.
SHOCK SUMMARY
signs and symptoms: tachycardia, tachypnea, hypotension, oliguria, altered mental state, cyanosis. diagnostic: increased lactic acid, decreased pH (metabolic acidosis), decreased hemoglobin with hemorrhage, increased white blood cell count in SEPSIS Therapeutic measures: oxygen, intravenous fluids, vasopressor medications, treatment of underlying cause complications: acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), Multiple organ dysfunction syndrome (MODS) priority nursing diagnoses: risk for ineffective tissue perfusion (cerebral, peripheral) decreased cardiac output
which of the following outcomes for the nursing diagnosis deficient knowledge is appropriate for the patient recovering from shock
states understanding of shock
Which of the following mechanisms does the body use to compensate for shock?
sympathetic nervous system stimulation
the nurse is collecting data on a patient experiencing shock in the emergency department. the nurse would recognize signs of compensation for shock as resulting from which of these mechanisms
sympathetic nervous system stimulation
which of the following findings would indicate that therapeutic measures are effective in shock?
systolic BP 118Hg
which of these objective data collection findings would indicate to the nurse that the therapeutic measures for a patient experiencing shock have been effective
systolic blood pressure 118 mm Hg
late phase of neurogenic shock
tachycardia, tachypnea, cool, clammy skin
what is the cause and compensatory purpose of each of the classic signs of shock:
tachycardia: tachypnea: oliguria: pallor: cool, clammy skin:
An oxygen deficit leads to
tissue hypoxia and hypoperfusion of vital organs and cell death.
Autonomic nervous system agents and Alpha and beta adrenergic agents
to strengthen MYOCARDIAL contraction, INCREASE systolic blood pressure, and INCREASE cardiac output. epinephrine (adrenalin) dopamine (Intropin) norepinephrine (Levophed) phenylephrine hydrochloride (Neo-synephrine) indicator: correct hypovolemia before giving medications. Monitor VS often; vasopressor use should include arterial blood pressure monitoring; monitor intake and output
which of the following findings would the nurse recognize as specifically occurring in anaphylactic shock?
wheezing hypotension tachycardia urticara bronchospasm
lack of oxygen during shock
when cells deprive from oxygen their energy production is affected. moves from areobic to anaerobic metabolism. anaerobic metabolism produces lactate. Lactic acid a byproduct of lactate buildup, accumulates. If the lactic acid is not cleared from the bloodstream, it causes ACIDOSIS. Acidosis is one of the classic signs of shock.
