chapter 14, shock med surg 255

Multiple organ dysfunction syndrome

-MODS; altered organ function in acutely ill patients that requires medical intervention -it is another phase in the progression of shock states -it develops with acute illness that compromise tissue perfusion. -dysfunction of organ system is associated with 20% mortality and if more than 4 organs fail 60% PATHOPHSIOLOGY -commonyl seen in patients with sepsis and inadequate tissue perfusion -frequently occurs towards the end of the continuum of septic shock when tissue perfusion cannot be effectively restored -it is not possible to predict which patients who experience shock will develop MODS -the S/S is insidious; tissue hypo-refused at microcellular and macrocellular level -organ failure usually begins in the lungs, and cardiovascular instability as well as failure of hepatic, GI, renal and immunologic and CNS follows CLINICAL MANIFESTATIONS -toosl to assess (APACHE, SAPS, PIRO, SOFA) -sequence of organ dysfunction varies depending on pt's primary illness, and comorbidities -advanced age, malnutrition, and coexisting disease increase risk -lungs are the first organ to go, patient has progressive dyspnea, and respiratory failure manifested as ALI or ARDS, requires intubation and mechanical ventilation -pt is hemodynamically stable needs increasing amounts of IV fluids, and vasoactive agents to support bP and cardiac output -hypermetabolic state: increase blood glucose,hyperlactic academia, increased Bun, metabolic rate is 1.5- 2.5 times higher than vassal metabolic rate -severe loss of skeletal muscle mass -after 7-10 days hepatic dysfunction elevated bilirubin and LFT patients are at increased risk for bleeding cardiovascular system becomes unstable and unresponsive to vasoactive agents patients becomes unresponsive or coma -goal reverse tissue hypo perfusion and hypoxemia

Nursing management sepsis or septic shock

-all invasive procedures must be carried out with aseptic technique after careful hand hygiene -IV lines, arterial lines, and venous puncture sites, surgical incisions, traumatic wounds, and urinary catheters must be monitored for signs of infection -precautions should be implemented in all patients -nurses should identify particular risk (older adults and immunosuppressed patients, those with extreme trauma, burns or diabetes) keeping in mind that high risk patients may not develop classic signs of infection and sepsis ex: confusion may be first sign of infection in the older adult - patients in ICU should be monitored using the SEPSIS-RELATED ORGAN FAILURE ASSESSMENT (SOFA) this encompasses assessment of RR, platelets, bilirubin and MAP (and use of vasopressors), serum CRCL, urine output, and glasgow coma scale score a drop of 2 points of more in the patients SOFA score from baseline is suggestive or organ dysfunction. -in a patient with infection, the presence of organ dysfunction suggest the development of sepsis -for a patient not in the ICU with infection, sepsis-3 recommends that the quick SOFA score is to screen for the development of sepsis and is an easy quick measurement tool that nurses may readily use. the presence of any two of the three parameters on this scale suggest the development of sepsis. the parameters include respiratory rate of 22 breaths or more, GCS score of less than 15 and a systolic BP of 100 mmHG or less. -the GSC score is considered positive for any score less than 15; therefore any change in the patients mental status is considered positive - any change in the patients mentation status be used when computing the qSOFA scale score -modified early warnings scale: used for sepsis patients in hospital; assess patients for changes in BP, HR, LOC, temperature, and urine output scores from zero to three are assigned to each assessment variable and MEWS score is greater than 4 suggests sepsis development -the nurse talks to the HCT to determine origin of sepsis and bacteria or organism involved. -the nurse obtains culture and sensitivity test -prescribed antibiotics are given until test comes back -elevated temperature (hyperthermia) is normal in sepsis patients and raises the patients metabolic rate and oxygen consumption -efforts to reduce temp: giving acetaminophen, applying hypothermia blanket. during this, the nurse monitors the patient for shivering, which increases oxygen consumption -efforts to increase comfort are important for a patient who has a fever, chills and shivering. -nurse administers prescribed IV fluids and mediations to restore vascular volume. -because of decreased perfusion, serum concentrations of antibiotic agents that are normally cleared by the liver and kidneys may increase and produce toxic affect. therefore, the nurse monitor blood levels (Serum levels of antibiotic agent, procalcitonin, CRP, BUN, CRCL, WBC, hemoglobin and hematocrit, platelet levels, coagulation studies. and reports changes to the primary provider

Pathophysiology progressive stage

-although all organ system suffer from hypo perfusion at this stage, several events perpetuate the shock syndrome, first the overworked heart becomes dysfunctional, the body's inability to meet increased oxygen requirements produces ischemia, and bichomecial mediators cause myocardial depression -this leads to failure of the heart, even if the underlying cause of the shock is not of cardiac origin. -second the auto regulatory function is the microcirculation fails in response to the numerous biochemical mediators released by the cells, resulting in increased capillary permeability with areas of arteriolar and venous constriction further compromising -at this stage the prognosis worsens. -the relaxation of pre capillary sphincters causes fluid to leak from the capillaries , creating interstitial edema and decreased return to the heart. - inflammatory response to injury is activated and pro-inflammatory and antiinflammatory mediators are released which activate the coagulation system in an effort to reestablish homeostasis -the body mobilizes energy stores and increases oxygen consumption to meet the increased metabolic needs of the underperfused tissues and cells -anaerobic metabolism ensures, resulting in a buildup in lactic acid and disruption of normal cell function -even if the underlying cause of the shock is reversed the sequence of compensatory responses to the decrease in tissue perfusion perpetuates the shock state, and a vicious cycle ensures. -the cellular reactions that occur during the progressive stage of shock are an active area of clinical research. -it is believed that the body's response to shock or lack of response in this stage of shock may be the primary factor determining the patients survival. -early recognition of shock signs and symptoms is essential to improving morbidity and mortality

Chart 14-1 recognizing shock in older patients

-because of the age and increased disease older adults are at greater risk for shock -increased risk for multi organ dysfunction syndrome -older adults can recover from shock if it is detected and treated early -medications such as beta blockers used to treat hypertension may mask the tachycardia (primary compensatory mechanism to increase cardiac output during hypovolemic shock - the immune system may not mount a good response (temperature greater than 101) however lack of of a febrile response (temperature less than 98.6) or in increasing trend in body temperature should be addressed. the patient may also report increasing fatigue and malaise in the absence of febrile response -the heart does not function well in hypoxemia states, the aging heart may respond to decreased myocardial oxygenation and dysrhythmias that may be misinterpreted as a normal part of aging process -there is progressive decline int he respiratory muscle strength, maximal ventilation, and response to hypoxia. older patients have decreased respiratory reserve and decompensated more quickly -changes in mentation may be inappropriately misinterpreted as dementia. older adults with sudden change in mentation should be assessed immediately for acute delirium (hypo and hyper delirium states) and treated for the presence of infection and organ hypo perfusion

Stages of shock

-can be early or late -stages of shock: 1) compensatory (stage 1) 2) progressive (stage 2) 3) irreversible (stage 3) -EBP focus on assessing the greatest population whose at risk for shock and reversing hypoxia -window of opportunity that increases the patients likelyhood to survive occurs when therapy begins within 3 hours of identifying shock especially septic shock

cardiogenic shock

-cardiogenic shock occurs when the hearts ability to pump and contract blood is impaired and the supply of oxygen is inadequate for the heart and the tissues. -the causes for cariogenic shock are either coronary or non coronary -coronary cariogenic shock is more common seen most often in patients with MI, resulting in damage to the left ventricular myocardium. -*patients who experience anterior wall MI are at greatest risk for cariogenic shock because the potentially extensive damage to the left ventricle caused by occlusion of the left anterior descending coronary artery -noncoronary cariogenic shock is related to conditions that stress the myocardium such as hypoxemia, acidosis, hypoglycemia hypocalcemia, tension pneumothorax and conditions that result in ineffective myocardial function (cardiomyopathies, valvular damage, cardiac tamponade, dysrhythmias )

anaphylactic shock

-caused by severe allergic reaction when patients who have already produced antibodies to a foregin substance develop a systemic antigen antibody reaction; specifically immunoglobulin E (IgE) -this antigen-antibody reaction provokes mast cells to release potent vasoactive substances; such as histamine or bradykinin, and activates inflammatory cytokines causing vasodilation and capillary permeability -the most common triggers are foods (peanuts) and medications and insects -three defining characteristics of anaphylactic shock 1) acute onset of symptoms 2) presence of two or more symptoms that include respiratory compromise, reduced BP, Gi distress, and skin or muscle tissue irritation 3)cardiovascular compromise from minutes to hours after exposure to antigen -signs and symptoms may be present within 30 minutes of exposure to antigen occasionally some reactions may not develop for several hours -patient may complain of headache, lightheadedness, N/Vm acute abdominal pain or discomfort, pruritus, and feeling of impending doom -assessment: erythemia, generalized flushing,difficulty breathing (laryngeal edema) bronchospasm, cardiac dysrhythmias, and hypotension -severe anaphylaxis usually include: rapid onset of hypotension, neurologic compromise, respiratory distress, and cardiac arrest.

Clinical Manifestationsprogressive stage

-chances of survival depend on the patients general health before the shock state as well as the amount of time it takes to restore tissue perfusion -as shock progresses organ systems decompensate RESPIRATORY EFFECTS -the lungs, which become compromised early in shock are affected at this stage -subsqeunt decompensation of the rings increases the likelihood that the mechanical ventilation will be needed -respirations are rapid and shallow, -crakles are heard over the lung fields -decreased pulmonary blood flow causes decreased arterial oxygen and CO2 levels increase -hypoxemia and biochemical mediators cause an intense inflammatory response and pulmonary vasoconstriction, perpetuating pulmonary capillary hypo perfusion and hypoxemia -the hypo-refused alveoli stop producing surfacing and subsequently collapse -pulmonary capillaries begin to leak causing pulmonary edema, diffusion abnormalities (shunting) and additional alveolar collapse this condition is called ACUTE LUNG INJURY (ALI) -as ALI continues, interstitial inflammation and fibrosis are common consequences, leading to acute respiratory distress syndrome CARDIOVASCULAR EFFECTS - lack of blood supply leads to dysrhythmia and ischemia -the heart rate is rapid exceeding 150 BPM -the patient may complain of chest pain and even suffer MI -cardiac troponin 1 increases -myocardial depression and ventricular dilation may further impair the hearts ability to pump enough blood to the tissues to meet increasing oxygen requirements Neuologic effects -changes in mental status occur with decreased cerebral perfusion and hypoxia -initially the patient may show subtle signs in behavior change like agitation, confused or signs of delirium -subsequently lethargy increases and the patient begins to lose consciousness RENAL FUCNTIONS -when the MAP falls below 65mm Hg the globular filtration rate cannot be maintained and changes in renal function occur -Acute Kidney Injury id characterized by an increased in BUN and CrCl, fluid and electrolyte shifts, acid base balance, and loss of renal hormonal regulation of the BP -urinary output usually decreases to 0.5mL/kg/h (OR LESS THAN 30 Ml per hour) Hepatic functions -decreased blood to the liver impairs the livers ability to perform metabolic and phagocytic functions -because of this, the patient is less able to metabolize medications and metabolic waste products, such as ammonia and lactic acid -metabolic activities of the liver including glycogenesis and glycogenolysis are impaired -the patient is susceptible to infection as the liver fails to filter bacteria from the blood -liver enzymes ( aspartame aminotransferase, alanine aminotransferase, lactate dehydrogenase) and bilirubin levels are elevated leading to jaundice GI effects -GI ischemia can cause stress ulcers in the stomach putting the patient at risk for GI bleeding -small intestine: the mucosa becomes necrotic and sloughs off causing bloody diarrhea -beyond the local effects of impaired perfusion, GI ischemia leads to bacterial translocation and organ dysfunction in which bacterial toxins enter the bloodstream through the lymphatic system -in addition to causing infection, bacterial toxins can acid cardiac depression, vasodilation, increased capillary permeability, and intense inflammatory response -the result in interference with healthy cellular functioning and the ability to metabolize nutrients hematologic effects -hypotension, sluggish blood flow, metabolic acidosis, coagulation system imbalance are generalized hypoxemia can interfere with normal hemostatic mechanisms -imbalance of clothing cascade, are linked to overactivation of the inflammatory response to injury -disseminated intravascular coagulation (DIC) may occur either as a cause or as a complication of shock. -DIC: widespread clotting and bleeding may occur simultaneously, bruises and bleeding may appear in the skin -coagulation time (PT, PTT) are prolonged -clotting factors and platelets are consumed and require replacement therapy to achieve homeostasis

General management of shock; complications of fluid administration

-close monitoring during fluid administration is necessary to identify side effects and complications -the most common and serious side effects of fluid replacement are cardiovascular overload, pulmonary edema, and ACS. -the patent receiving fluid replacement must be monitored frequently for; urinary output, changes in mental status, skin perfusion, and changes in vital signs -lung sounds are auscultated frequently to determine if fluid is accumulating -adventitious sounds like crackles may indicate pulmonary edema and ALI -central venous pressure line is inserted (in subclavian or jugular vein) and is advenced until the tip of the catheter rest at the superior vena cava and the right atrium, -the CVP is used to assess preload, in the right side of the heart. -the CVP value assists in monitoring the patients response to fluids especially when used in conjunction with urine output, heart rate, BP response to fluid challenge -a normal CVP ranges from 8-12 mmHg CVP readings should be used in conjunction with other assessment that assess blood volume its not accurate if measured alone. -CVP catheters allow monitoring of intravascular measures and venous oxygenation levels -assessment of venous oxygenation (SCVO2, with a CVP line) may be helpful in evaluating intravascular volume -hemodynamic monitoring with arterial lines may be implemented to allow close monitoring of the patients BP and tissue perfusion -a pulmonary artery catheter may be inserted assist with monitoring of a patients cardiac status as well as response to therapy. -noninvasive thecnology: esophageal doppler, arterial pulse contour analysis, cardiac output devices, intrathroacic impedance monitoring provide additional hemodynamic monitoring -the nurse needs to take to the physician to determine the best place to place the lines to prevent central line associated bloodstream infection. interventions aimed at preventing this: should implemented collaboratively while the line is being placed, ongoing nursing management of the line

Clinical manifestations of compensatory shock

-despite normal BP the patient shows numerous signs of inadequate organ perfusion -the result of inadequate organ perfusion is anaerobic metabolism and a build up of lactic acid , predicting metabolic acidosis -the respiratory rate increases -the rapid respiratory rate facilitates the removal of excess CO2, but raises the blood pH and often causes a compensatory respiratory alkalosis -the patient may experience change in affect, feel anxious, or be confused if treatment -medical treatment is directed toward identifying the cause of the shock, correcting the underlying disorder so that shock correcting the underlying disorder so that shock does not progress and supporting the physiologic processes that have been thus far hard to treat. -fluid replacement and mediation therapy must be initiated to maintain adequate bp and reestablish and maintain adequate tissue perfusion

Nursing management compensatory phase

-early intervention along the continuum of shock if the key to improving the patients prognosis -the nurse must systematically assess the patient for shock risk -recognize early clinical signs of the compensatory stage before the BP drops -early interventions include identifying the cause of shock, administering IV fluids and oxygen and obtaining imbalances or infection -special considerations related to recognizing early signs of shock in the older adult

Nursing management in progressive stage

-early intervention is essential -suspecting the patient may be in shock and reporting subtle changes isimaparative -patients in prgressive stage of shock are cared for in the ICU to facilitate close monitoring (hemodynamic monitoring, EKG monitoring, arterial blood gas analysis serum electrolyte levels, physical and mental status changes) -rapid and frequent med administration, possible mechanical ventilation, dialysis and intraaortic balloon pump -working closely with Hcp the nurse documents treatment, medications and fluids that are given, recording the time, dose or volume and patient response -the nurse coordinates the scheduling of diagnostic procedures that may be carried out at the bedside -the nurse provides essential support through ongoing communication with the patient and family

Nursing management progressive phase; promoting rest and comfort and supporting family members

-efforts are mad to minimize cardiac workload by reducing the patients physical activity and treating pain and anxiety - because promoting patient rest and comfort is a priority, the nurse performs essential nursing activities in block time allowing the patient to have periods of uninterrupted rest which may prevent acute delirium -to conserve the patients energy the nurse should protect patient from temperature extremes (too hot or too cold rooms) this can cause in increase in metabolic rate and oxygen consumption and this the cardiac workload Supporting family members -becasue the person in shock receives a lot of attention from health care team the family may overwhelmed and frightened -family members may be reluctant to ask questions because their scared their getting in the way of the care for the patient -the nurse should make sure the family is comfortably situated and kept informed about the patients status -often families need encouragement from the health care team to get rest, they re more likely to get rest if they feel the patient is being taken care of well and that they will be notified of any significant change in the patents status -a visit from the hospital chaplin may be comforting and provides some attention to the family while the nurse concentrates on the patient -attending to patient and family helps meet the emotional and physiologic needs of the patient and the family

Normal cellular function

-energy metabolism occurs within the cell, where nutrients are chemically broken down and stored in the form of adenosine triphosphate (ATP) -cells use ATP to maintain normal functions like active transport, muscle contraction, and biochemical synthesis as well as specialized cellular function like conduction of electrical impulses -ATP can be synthesized aerobically (presence of oxygen) or anaerobically (without oxygen) -aerobic metabolism yields far greater amounts of ATP per mole of glucose than does anaerobic (this type of metabolism results in toxic end product lactic acid which must be removed from the cell and transported to the liver for conversion into glucose and glycogen

Chart 14-2 collaborative practice interventions to prevent central line associated bloodstream infections

-fivve key elements of the central line bundle 1) hand hygiene 2) maximal sterile barrier precautions during line insertion 3)chlorhexidine skin antisepsis 4) optimal catheter site selection with avoidance of using the femoral vein for central venous access in adult patients 5) daily review of line necessity with prompt removal of unnecessary lines -when should hygiene be performed when patient has central line? 1) before and after palpating the catheter insertion site 2) with all dressing changes to the intravascular catheter access 3)when hands are visible soiled or contamination of hands is suspected 4) before donning and after removing gloves -what changes can be made to improve hand hygiene 1)central line procedure checklist 2)post signage stating the importanc eof hand hygiene 3)have soap and alcohol based hand preps available 4) model hand hygiene practice 5)provide patient and family education hand hygiene maximal sterile barrier precautions 1)implemented surging central line insertion 2)for primary provider it means wearing cap, mask, sterile gown, and sterile gloves the nurse should also wear a cap and mask 3)cover the patient head to toe in sterile drape, with small opening for site insertion 4) nurses should be empowered to enforce central line checklist -which antiseptic should be used to prepare the patients skin 1)cholerxidine skin antisepsis has been proven to provide better skin antisepsis such as providone-iodine solution 2)an alcohol cholorhexidine should be applied during a back and forth motion for at least 30 seconds this should not be wiped or bottled dry 3) the antiseptic solution should be allowed time to dry completely before the insertion site is punctured/accessed -nursing interventions to reduce infection 1)maintain sterile technique when changing dressing 2) hand hygiene before accessing lines 3)waring clean gloves accessing the port 4)performing 15-30 second hub scrub using chlorhexidine or alcohol and friction in a twisting motion on the access hub 5) using chlorhexidine containing dressing in patients older than 2 months 6) antiseptic port protecters when to discontinue central lines 1) assessment for line is daily for the nurse 2)time and date of central line placement should be recorded and evaluated by staff 3) need for line is reviewed on rounds

Medical management hypovolemic shock fluid and blood replacement

-fluid replacement is of primary concern besides treating the underlying cause -at least two large gauge IV lines are established to have access to fluid administration -if IV catheter cannot be quickly inserted an intraosseous catheter may be used for access in the sternum, legs (tibia) , or arms (humorous) to facilitate rapid flow movement -multiple IV lines allow simultaneous replacement, medication and blood -goal of fluid replacement is to restore intravascular volume its important to administer fluids that will rain in the intravascular compartment to avoid fluid shifts -crystalloid solutions such as lactated ringer solution or 0.9% sodium chloride are commonly used to treat hypovolemic shock -if shock is due primarily to blood loss administer 3mL of crystalloid solution for each milliliter of estimated blood loss. this is referred to as a 3:1 rule -colliod solutions may also be used -hetastrach and dextran are NOT to be used because they interfere with platelet aggregation -blood products (colloids) may be given if the shock is from hemorrhage -the desition to give blood is based not eh patents response to the crystalloid fludi, the volume lost, and the need for hemoglobin to assist with oxygen transport -patients requiring massive blood transfusions respond better when blood products are given in 1:1:1 ratio meaning units or packed RBC, plasma, and platelets -packed RBC are given tp replenish the patients oxygen carrying capacity in conjunction with other fluids that will expand volume -plasma and platelets are transfused to assist with coagulation and hemostasis -the need for transfusion is based on the patients oxygen level needs, and coagulation status which is determine by vital signs, blood gas, chemistry, coagulation laboratory values, and clinical appearance

Vasoactive medication therapy

-given in all forms of shock to improve the patients hemodynamic stability when fluid therapy alone cannot maintain adequate MAP -medications selected to help cardiac output help increase the strength of the myocardial contractibility, regulate heart rate, reduce myocardial resistance, and initiate vasoconstriction -vasoactive medications are selected for their action on receptors of the sympathetic nervous system -recepters are known as alpha-adrenergic and beta-adrenergic receptors -beta-andrenergic receptors are further classified to beta-1 and beta-2 -when alpha-adrenergic receptors are stimulated blood vessels constrict in the cardiorespiratory and GI systems, skin and kidneys -when beta-1 are stimulated, heart rate and myocardial contraction increase -when beta-2 is stimulated vasodilation occurs in the heart and skeletal muscles and the bronchioles relax -many types or vasoactive medications are used in combination to to maximize tissue perfusion by either stimulating or blocking alpha and beta receptors -when vasoactive medications are given vital signs must be monitored at least every 15 minutes until stable or more often if indicated -vasoactive medications should be given through a central venous line, because infiltration and extraversion can cause sloughing and necrosis -individual medication dose is titrated by the nurse who adjust drip rate on the basis of prescribed dose and target outcome parameter of BP and HR and th patients response -vasoactive medications must be tapered when med is no longer needed the infusion should be weaned with frequent monitoring of BP every 15 minutes -critically ill patients should be evaluated for corticosteroid insufficiency aka adrenal insufficiency and if this is present corticosteroid replacement should be present

medical management cardiogenic shock

-goal is to limit further myocardial damage and preserve the healthy myocardium and improve cardiac function -by increasing cardicc contractibility, decreaseing ventricular after load or both -these goals are achieved by increasing oxygen supply to the heart muscle while reducing oxygen demands CORRECTING UNDERLYING CAUSE -it is necessary to first treat the oxygen demands on the heart muscle to ensure its continued ability to pump blood to other organs -incase of coronary cariogenic shock (aCUTE mi, ACUTE CORONARY SYNDROMES) the patient may require thrombolytics, a percutaneous coronary intervention, coronary artery bypass graft surgery, intra-aortic balloon pump therapy, ventricular assist device or some combination of these treatments -in the case of noncornary cariogenic shock interventions focus on correcting the underlying cause like replacement of a faulty valve, correction of dysrhythmia, acidosis, electrolyte imbalance and treatment of tension pneumothorax -if shock related to cardiac arrest after resuscitation temperature control also called therapeutic hypothermia is initiated to actively lower the body temperature to a targeted core temp of 89.6 or 96.8 to preserve neurologic function

Hypovolemic shock medical management

-goals are to restore intravascular volume and to reverse the sequence of events leading to inadequate tissue perfusion, to redistribute fluid volume, and to correct the underlying cause of fluid loss ASAP TREAT THE UNDERLYIGN CAUSE -if patent is hemorrhaging, effort are made to stop the bleeding. this may involve applying pressure to the bleeding or surgical site or to stop internal bleeding -if cause of hypovolemia is diarrhea, and vomiting medications to treat them are given while efforts are make to identify and treat the cause - in older patients dehydration may be the cause

Pathophysiology of sepsis and septic shock

-gram-negative bacteria traditionally have been the most commonly implicated microorganisms in sepsis -however, there is in increased incidence of gram positive bacterial infections and fungal infections that can also cause sepsis -the site of infections identified in most cases, up to 30% of patients have no identifiable site of infection -when microorganisms invade body tissues. patients exhibit an immune response. -the immune response provokes the activation of the biochemical cytokines and mediators associated with an inflammatory response and produces a complex cascade of physiologic events that leads to poor tissue perfusion. -increased capillary permeability results in fluid seeping from the capillaries -capilalry instability and vasodilation interfere with the body ability to provide adequate perfusion, oxygen, and nutrients in the tissues and cells -the wide-spread inflammatory response that occurs is called the systemic inflammatory response syndrome (SIRS) -SIRS results from clinical insult that initiates an inflammatory response that is systemic rather than localized to the site of the insult -the insult may be significant injury (multitrauma) or an infection ( sepsis) -a patient presenting manifestations of SIRS may be exhibiting a protective inflammatory response to the initiating insult or may be exhibiting a response to infection, which leads to sepsis. -the clinical criteria used to identify SIRS, which include a temperature of >101 or <96.8, tachycardia, tachypnea, and WBC >12,000 or less than 4000 cells or >10% immature WBC have been found not to be helpful in diagnosing sepsis -SIRS- proinflamatory and anti-inflammatory cytokines released during the inflammatory response activate the coagulation system, which begins to form clots whether or not bleeding is present -this results in microvascular occlusion and and disrupts cell perfusion and inappropriate consumption of clotting factor -the imbalance of the inflammatory rresponse and the clotting and fibrinolysis cascades are considered critical elements, of the devastating physiologic progression that occurs in sepsis -sepsis is an evolving process that results in septic shock and life-threatening organ dysfunction if not recognized and treated early -in early stage of septic shock, the BP stays within normal limits, or the patient may be hypotensive but responsive to fluids the HR increases, pregressign to tachycardia hyperthermia with fever and warmed flushed skin and bounding pulses are present the respiratory rate is elevated urinary output may remain normal or decrease. GI status may be compromised, AEB N/V diarrhea or decreased gastric motility. hepatic disfunction is evidenced by increased bilirubin and worsening coagulopathies (decreased platelet count) signs go hyper metabolism include (increased serum glucose, and insulin resistance) subtle changes in mental status like confusion agitation. lactate level is elevated WBC, plasma C-reactive protein and procalcitonin levels are elevated. -as sepsis progresses tissues become less perfused and acidotic, compensation begins to fail and pt begins to show signs or organ dysfunction. cardio system begins to fail, the BP does not respond to fluid resusitation and vasoactive agents and signs of end organ damage are evident (AKI, PULMONARY DYSFUNCTION, HEPATIC DYSFUNTION, CONFUSION PROCEEDING TO NONRESPONSIVENESS) -as sepsis progresses to septic shock, the BP drops, skin becomes cool pale and mottled. temp may be normal or below, heart and respiratory rates remain rapid. urine production ceases and multiple organ dysfunction progresses to death

Nursing management hypovolemic shock

-hypovolemic shock can be prevented by closely watching patients who are at risk for fluid volume deficits and assisting with fluid intake/ replacement before intravascular volume is depleted -nursing care focuses on the cause of shock and restoring intravascular volume -general nursing measures entails ensuring safe administration of prescribed fluids and medications and documenting their administration and effects. -volumetric IV pumps should be used to administer vasopressor medications -monitoring side effects and complications and reporting them promptly ADMINISTERING BLOOD AND FLUIDS SAFELY -administering blood transfusion safely is a vital nursing role - in emergency situations it is important to square blood specimens promptly to obtain a baseline CBC and to type and cross-match the blood in the anticipation of blood transfusion. a patient who receives a transfusion of blood products must be monitored closely for adverse effects -fluid replacement can occur especially when large volumes are given rapidly the nurse needs to monitor the patient for cardiovascular overload and signs of difficulty breathing a condition known as transfusion associated circulatory overload -transfusion related acute lung injury may occur S/S: pulmonary edema, hypoxemia, respiratory distress, and pulmonary infiltrates usually within hours of massive transfusion -risk of these complications is increased in the older adult, in patients with preexisting cardiac disease and with increasing number of blood products given -ACS is also possible complication of excessive fluid resuscitation and may initially present with respiratory symptoms (difficulty breathing) and decreased urine output -hemodynamic pressure, vital signs arterial blood gas analysis, serum lactate levels, hemoglobin and hematocrit levels, bladder pressure monitoring and fluid intake and output are monitored -temperature should also be monitored to make sure rapid fluid resuscitation does not cause hypothermia. IV fluids may need to be warmed when large volumes are given -physical assessment focuses on observing for JVD and monitoring jugular venous pressure. jugular venous pressure is low in hypovolemic shock it is increased significantly with fluid overload and heart failure -the nurse must monitor cardiac and respiratory status closely and report changes in BP, pulse pressure, CVP, heart rate and rhythm and lung sounds IMPLEMENTING OTHER MEASURES -oxygen is given to increase the amount of oxygen carried by available hemoglobin in the blood -a patient who is confused may feel apprehensive with an oxygen mask or cannula in place, and frequent explanations about the ned for the mask may reduce fear and anxiety

Medical management hypovolemic shock; redistribution og fluid

-in addition to giving fluids to restore intravascular volume patients should be positioned properly to assist in fluid redistribution also known as passive leg raising -passive leg raising is recommended in hypovolemic shock. elevation of the legs promotes venous return and can be used as a dynamic assessment of a patents fluid respnsiveness -a nurse assesses in the improvement of the patients vital signs, specifically a rise in BP and return of the pulse pressure to normal or near normal -a full trendelenburg position makes breathing difficult and does not increase BP or cardiac output PHARMACOLOGIC THERAPY -is fluid administration fails, then vasoactive medications that prevent cardiac failure are given -medications are aldo given to reverse the cause of the dehydration/ ex: insulin is given if dehydration is secondary to hyperglycemia, desxopressin is given for diabetes insidious, antidiarrheal agents for diarrhea and antiemetic for vomiting

Monitoring tissue perfusion in the compensatory stage

-in assessing tissue perfusion , the nurse observes the subtle changes in LOC , vital signs (including pulse pressure) -urinary output, skin, respiratory rate, laboratory values (base deficit, lactic acid levels) -serum sodium and blood glucose levels are elevated in response to release of aldosterone and catecholamines -if infection is suspected, blood cultures should be obtained prior to administration of antibiotics both these interventions should be given priority in the care of the patient -the nurse should monitor the patients hemodynamic status and promptly report deviations to the primary provider -assist and treating the identifying disorder by continuous in-depth assessment of the patient, administer prescribed medications and fluids and promote patient safety -vital signs are key indicators of hemodynamic status and BP is an indirect measure of tissue hypoxia -the nurse should report a systolic BP lower than 90 mmHg, or a drop in systolic BP of 40 mmHg from baseline or MAP less than 65 mm Hg -if patient is diagnosed with infection or thinks that infection is suspected, the nurse should notify the primary provider if the patient exhibits any two of the three signs 1) decreased blood pressure < or equal to 100 (systolic) 2) respiratory rate 22 per minute or greater 3) altered mentation -pulse pressure correlates well with stroke volume -pulse pressure is calculated by subtracting the systolic from the diastolic -normally the pulse pressure is 30-40 mmHg -Narrowing pulse pressure is an early indication of shock then a drop in systolic BP -decreased or narrowing pulse pressure is an early indicator of decreased stroke volume -elevation of the diastolic BP with release of catecholamines and attempts to increase venous return through vasoconstriction is an early compensatory mechanism in response to decreased stroke volume, BP and overall cardiac output -continuous central venous oximetry monitoring may be used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states -a central catheter is introduced into the superior vena cava and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and the pulmonary system for re-oxygenation -a normal value (SCVO2) is 70% body tissue uses approximately 25% during normal metabolism -during stressful events more oxygen is consumed and the SCVO2 saturation is lower indicating that the tissues are consuming more oxygen -interventions focus on decreasing tissue oxygen requirements and increasing tissue perfusion to deliver more oxygen to the tissues. for instance; sedating medications may be given to lower metabolic demands for oxygen -supplimental oxygen and mechanical ventilation may be required to increase the delivery of oxygen in the blood -administering IV fluids and medications supports BP and cardiac output and the transfusion of packed RBC enhances oxygen transport -monitoring oxygen consumption consumption by SCVO2 is an invasive measure to more accurately assess tissue oxygenation in the compensatory stage of shock before changes in vital signs detect altered tissue perfusion. -in the patient who has an arterial line present, arterial pulse waveform analysis or pulse contour may be used to determine the patients stroke volume and responsiveness to IV fluid replacement to meet tissue perfusion needs this may be used to estimate the patients stroke volume, thus providing information to guide patients stroke volume needs -common limitation in using the arterial pulse waveform device is that cardiac dysrhythmias, severe peripheral vascular disease, and aortic valve regurgitation decreases in accuracy -although treatments are prescribed by the provider the nurse often implements them, operates and troubleshoots equipment used in treatment and evaluates the immediate effects of treatment -the nurse also assesses the response of the family to the crisis and its treatment

Cariogenic shock pathophysiology

-in cariogenic shock, cardiac output which is a function of both stroke volume and heart rate is compromised. -when stroke volume or heart rate decrease or become erratic the BP falls, and tissue perfusion is reduced -blood supply for the tissues and organs and for the heart muscle itself is inadequte=imaired tissue perfusion -impaired perfusion weakens the heart and impair ability to pump the ventricle does not eject its volume of blood during systole properly resulting in fluids in the lungs rapidly or over a period of days Clinical manifestations -experience pain of angina -develop dyrhythmias -complain of fatigue -express feeling soft doom, and show signs of hemodynamic instability

nursing management irreversible shock

-in progressive phase of shock nurses focus on the prescribed treatments monitoring patient, preventing complications, protecting the patient from injury, and providing comfort -offering brief explanations to the patient about what is happening is essential even if the patient is not conscious or you are uncertain if the patient can hear or understand what is being said -simple comfort measures including reassuring touch, should continue despite no response to verbal stimuli -as it becomes obvious that the patient isn't likely to survive the family needs to be told about the prognosis and outcome -opportunities should be provided throughout the patients care to allow family to touch, see and talk to the patient -close family friends or spiritual advisors may be comfort to the family member in dealing with the inevitable death of their loved one, -whenever possible and appropriate the patients family should be approached regarding any living wills advanced directive, or other written or verbal wishes the patient may have shared -during this stage of shock the family may misinterpret the actions of the health care team -the family has been told nothing has been effective in reversing the shock ad that the patients survival is very unlikely, yet they find that the physicians and nurses are still continuously working on them. distraught grieving families may interpret this as a chance for recovery when none exists and family members may become angry when the patient dies -conference with all the health care team and the family promotes better understanding by the family of the patient s prognosis and the purpose for management interventions -engaging in palliative care specialists have been helpful in developing a plan o care that maximizes comfort and effective system management as well as helping the family with difficult disicions -during these family health care team conferences it is important to discuss the equipment, and treatments being provided are for patient comfort and do not suggest that the patient will recover --families should be encouraged to express their views on life support measures

pathophysiology

-in shock the cells lack adequate blood supply and are deprived of oxygen and nutrients; hence they must produce energy through anaerobic mechanisms -resulting in low energy yields from nutrients and an acidotic intracellular environment -these changes causes normal cell function to cease -the cell swells, the cell membrane become permeable allowing electrolytes and fluids to seep out of and into the cell -the sodium potassium pump becomes impaired; cell structures particularly mitochondria becomes damaged and death of the cell results -glucose is the primary substrate required fro the production of cellular energy in the form of ATP 0in stress states catecholamines, cortisol, glucagon, and inflammatory biochemical mediators are released, causing hyperglycemia and insulin resistance to mobilize glucose for cellular metabolism -activation of these substances promotes glycogenesis which is the formation of glucose from noncarbohydrate sources like proteins and fats -glycogen thats stored in the liver converts to glucose to meet metabolic needs; increasing the blood glucose concentration (hyperglycemia) this stress response depletes the glucose reserve leading to eventual organ failure -lack of nutrients and oxygen causes buildup of metabolic end products in the cells and interstitial spaces - the clotting cascade also associated with the inflammatory process becomes activated which compounds the cycle -with a lot of cell injury or death the clotting cascade is overprotective resulting in small clots lodging in microcirculation further hampering cellular perfusion -cellular metabolism is impaired and a self perpetuating negative situation ( a positive feedback loop)

Generalized management strategies in shock crystalloid and colloid solutions

-in the emergencies the "best" fluid is often the fluid that is readily available -fluid recussitation should be initiated early in shock to maximize intravascular volume. -isotonic crystalloid solutions are often selected because they contain the same concentration of electrolytes as the extracellular fluid and therefore can be given without altering the concentrations of electrolytes in the plasma -IV crystalloid solution commonly used in hypovolemic shock include 0.9% sodium Chloride, lactated ringer -Ringers lactate is an electrolyte solution that contained lactate ion which should not be confused with lactic acid. the lactate ion is converted to bicarbonate which he's buffer the overall acidosis that occurs in shock -a disadvantage of using isotonic crystalloid solution is that some of the volume given is lost in the interstitial compartment and some remains in the intravascular compartment. this occurs as a consequence of cellular permeability that occurs during shock -diffusion of crystalloids into the interstitial space means that more fluid may need to be given than the amount lost to a support tissue perfusion -care must be tank when rapidly administering isotonic crystalloids to avoid underresuscitating and over resuscitation -insufficent fluid replacement is associated with higher incidence of morbidity and mortality from lack of tissue perfusion whereas over resuscitation can cause systemic and pulmonary edema that progresses to ALI, intrabdominal hypertension and abdominal compartment syndrome (ACS) and multiple organ dysfunction syndrome (MODS) -ACS is a serious complication that may occur when large volumes of fluids are given can also occur after abdominal surgery, trauma, sepsis, and pancrititis -ACS fluid leaks into the intra abdominal cavity , increasing pressure that is displaced onto the surrounding vessels and organs -venous return, preload and cardiac output are compromised. the pressure also elevates the diaphragam . making it difficult to breath -the renal and GI systems also begin to slow signs of dysfunction (decreased urine output, absent bowel sounds, intolerance of tube feeding) -abdominal compartment pressure can be measured normally it is 0-5 mmHg and a pressure of 12 mmHg is considered to be indicative of IAH -if ACS is present, interventions that usually include surgical decompression are necessary to relieve the pressure -hypertonic crystalloid solution often 3% sodium chloride mat bw given in patients with shock and traumatic brain injury =these solutions exert a large osmotic force that pulls fluid from the intracellular space to the extracellular space to achieve a fluid balance -this osmotic effects results in fewer fluids being given to restore eintravascular volume which is important in patients with head injury and cerebral swelling -complications associated with the use of hypotonic solutions include; excessive serum osmolality which can cause rapid fluid shifts, overwhelming the heart and leading to hypernatremia -generally IV colloidal solutions are similar to plasma proteins in that contain molecules that are too large to pass through the papillary membrane. -colloids expand intravascular volume by exerting oncotic pressure thereby pulling fluids into the intravascular space, increasing intravascular volume -colloids have a longer duration of action than crystalloids because the molecules remain in the intravascular space longer -if colloids are used to treat tissue hypo perfusion albumin is the agent prescribed. albumin is a plasma protein' albumin is a solution prepared from human plasma and is heated during production to reduce its potential to transmit disease -the disadvantage of albumin is its high cost compared to crystalloid solutions -resuscitation with colloid solutions has not reduced the risk of morbidity and mortality compared to resuscitation with crystalloid solutions

Progressive stage

-in the second stage of shock, the mechanisms that regulate the BP can no longer compensate, and the MAP falls below normal limits -patients are clinically hypotensive -this is defined as a systolic BP of less than 90 mmHg or a decrease in systolic BP of 40 mmHg from baseline -the patient shows signs of declining mental status

compensatory state

-in this compensatory stage of shock the BP remains the same or within normal limits -vasocontriction, increased HR and increased contractibility of the heart contribute to maintaining adequate cardiac output. (sympathetic response) - sympathetic NS releases catecholamines (epinephrine and norepinephrine) -patient displays the fight or flight response -the body shunts blood from the organs like the skin, kidneys, and GI tract and sends blood to the brain, heart, and lungs to ensure adequate blood supply -as a result the skin looks cool and pale, bowel sounds are hypoactive, and urine output decreases and urine output decreases in response to ADH and aldosterone

Nutritional support

-increased metabolic rates during shock increase energy needs -patients in shock may require more than 3000 calories daily, =the release of catecholamines early in shock continuum causes rapid depletion of glycogen stores, -nutritional body requirements are met by breaking down lean mass. -in this catabolic process skeletal muscle is browken down even when the patient has large stores of fat or adipose tissue. -loss of skeletal muscle greatly prolongs the patients recovery time -parenteral or enteral nutritional support should be initiated immediately -enteral nutrition is preferred promoting GI function through direct exposure to nutrients and limiting infectious complications associated with parenteral feedings -implementing early enteral feeding is been proven to help gut- mediated immunity, reduce metabolic response to stress, and improve overall patient morbidity -stress ulcers occur frequently in patient who are critically ill because compromised blood supply to GI. therefore, antacids, h2 blockers (famotidine, proton pump inhibitors) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH

General management strategies in shock

-managemnt in all types and all phases of shock include the following 1) support of the respiratory system with supplemental oxygen ad or mechanical ventilation to provide optimal oxygenation 2) fluid replacement to restore intravascular volume 3) vasoactive medications to restore vasomotor tone and improve cardiac function 4)nutritional support to address the metabolic requirements that are often dramatically increased in shock Fluid replacement -fluid replacement also referred to as fluid resuscitation is given to all types of shock -the types of fluid given and the speed of delivery vary however fluids are given to improve cardiac and tissue oxygenation -the fluids given may be crystalloid (electrolyte solutions that move freely between intravascular compartment and interstitial space) and colloids (large molecules IV solutions) and blood components (packed RBC fresh frozen plasma and platelets)

Nursing management progressive phase; preventing complications

-monitor for early signs of complications this includes 1)evaluating blood levels of medications 2) observing invasive vascular lines for signs of infection 3)checking neurovascualr status of arterial lines are inserted, especially in the lower extremities -the nurse promotes patient safety and comfort by ensuring that all procedures and arterial and venous punctures are carried out using correct aseptic technique and that these sights are maintained to prevent infection -nursing interventions can reduce the incidence of ventricular associated pneumonia and must be implemented this includes oral care, suctioning, turning, elevating the head of the bed at least 30 degrees to prevent aspiration and implementing daily interruption of sedation as prescribed to evaluate readiness of extubation - positioning and repositioning can promote comfort and maintain skin integrity -assess for acute delirium characterized by acute change in mental status, inattention, disorganized thinking, and altered LOC. -critically ill patients with delirium have longer mechanical ventilation needs, experience higher functional decline, and higher rates of morbidity and mortality than those without delirium also at risk for developing Gpost-intesive care syndrome which manifests as new or worsening impairments in the patients physical, cognitive, or mental status after a critical illness has resolved and that persists beyond the acute hospitalization -delirium should be assessed at the minimum every shift using a standard delirium assessment tool such as the Confusion Assessement Method (CAM)-ICU -the CAM-ICU is specifically designed for patients who are critically ill -nursing interventions that can prevent delirium include: engaging patient in frequent reorientation activities (date, time, place) assessing and treating pain, promoting sleep, providing early mobilization, and limiting sedations especially sedation with benzodiazepines

Neurogenic shock

-neurogenic shock vasodilation occurs from loss of balance between parasympathetic and sympathetic stimulation - sympathetic stimulation causes vascular smooth muscle to contrict and parasympathetic causes vascular muscle to relax -the patent experiences a predominant parasympathetic stimulation causing vasodilation lasting for a while leading to a hypovolemic state, -blood volume is adequate because vasculature is dilated. the blood volume is displaced causing a low bp -the parasympathetic response causes decrease in systemic vasulature resistance and bradycardia. inadequate BP is inadequate tissue perfusion -caused by spinal cord injury, spinal anesthesia, and nervous system damage also from depressant action of medication or lack of glucose -neurogenic shock may have a prolonged course (spinal cord injury) or a short course ( syncope or fainting) -normally sympathetic NS causes in crease in BP and HR but in neurogenic shock, the sympathetic system isn't able to respond to body stressors -S/S: dry, warm skin, hypotension and bradycardia rather than tachycardia

Nursing management anaphylaxis

-nurse must assess all patients for allergies or previous reactions to antigens (medications, blood products, foods contrast agents, latex) and communicate the existence of allergies and reactions to health care members -the nurse assesses the patients understanding of reactions and steps taken by patient and family to prevent further exposure to antigens -when new allergies are identified, the nurse advises the patient to wear or carry identification that names specific allergen or antigen -when giving new medication the nurse observes the patient for a reaction. this is especially important with antibiotics, beta blockers, angiotensin inhibitors (angiotensin converting enzyme inhibitors, angiotensin receptor blockers) aspirin and non steroidal anti-inflammatory drugs -previosu adverse reactions to a drug indicated greater risk for developing reaction to a new drug -patient may be at risk for having allergic reaction in medications they've already had a reaction to in a similar group of drugs -in diagnostic outpatient testing sites or hospital nurse needs to know it pt is allergic contrast agent (radiopaque, dye-like substances that may contain iodine)

promoting safety nurse management compensatory

-nurse must be vigilant to potential threats to the patients safety -high anxiety levels, and altered mentation stuff impair judgement -in this stage of shock (compensatory), patients who were peviously cooperative and followed instructions may now disrupt IV lines, and catheters and complicate their condition -close monitoring, frequent reorientation, hourly rounding, and implementing interventions to prevent falls (bed alarm) are essential

Distributive shock

-occurs when intravascular volume pools in peripheral blood vessels -ths causes hypovolemic because not enough blood return to the heart leading to inadequate tissue perfusion -caused by loss of sympathetic tone or release of biochemical mediators from cells that causes vasodilation -three types of shock 1) septic shock 2)neurogenic shock 3) anaphylactic shock -in all these types of shock massive arterial and venous dilation promotes peripheral pooling of the blood, -arterial dilation reduced systemic vascular resistance -initially cardiac output can be high both from the reduction in the after load and from the hearts muscles increased effort to maintain perfusion despite the incompetent vasulature -pooling of the blood in the periphery results in decreased cardiac output venous return, stroke volume cardiac output, BP and altered tissue perfusion.

Relieving anxiety in compensatory phase nursing management

-patients and their families often become apprehensive and anxious -providing brief explanations about the diagnosis, and treatment procedures, supporting the patient during procedures, and providing information about their outcomes are usually effective in reducing stress and anxiety and thus promoting the patients physical and mental well being -speaking in a calm, reassuring voice and using gentle touch also help ease the patients concerns -these actions may provide comfort for the critically ill, frightened patients -family members have certain needs during crisis such as the need for honest, consistent, and thorough communication with health care providers physical an emotional closeness to the patient sensing that health care providers are about their patients, seeing the patient frequently, and knowing exactly what has to be done for the patient -the nurse should advocate that the family member be present during procedures and while patient care is provided -the presence of family provides necessary connection and support for the patient during a time of crisis -sharing decision making with the patient and the family enhances communication with he health care team,reduces patent anxiety, and improves overall satisfaction with care

Medical management MODS

-prevention is top priority -older patients at risk because immune compromise, natural degenerative process -early documentation and recognition of signs of infection is essential in managing MODS in older patients -subtle chang einmentation and gradual rise in temp are early warnings -risk patients: critically ill, malnutrition, immunosuppression, surgical or traumatic wounds -if preventative measures fail treatment involves 1)controlling the initiative event 2)promoting adequate organ perfusion 3) providing nutritional support 4)maximizing patient comfort

Medical mangement of neurogenic shock

-restoring sympathetic tone through stabilization of the spinal cord, or in the instance of anesthesia properly positioning the patient

Nursing management MODS

-same goals as for patient with shock -support the patient and monitor organ perfusion -provide information and support family PROMOTING COMMUNICATION -nurse encourages open and frequent communication about treatment modalities and to ensure patients wishes regarding medical management are met. -patients with mods must be informed about goals of rehabilitation and expectations of progress -because massive loss of skeletal muscle mass occurs rehabilitation is long and slow the nurse must communicate and encourage the patient during the phase of recovery

irreversible shock medical management

-similar treatment and management as the progressive stage -the judgement that the shock can be reversed is made only retrospectively on the basis of the patients failure to respond to treatment -experimental strategies (investigational medications, like immunomodulation therapy) may be tried to reduced or reverse severity of shock

Irreversible stage of shock

-the irreversible or refractory stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment, and cannot survive -despite treatment BP remains low, renal and liver dysfunction compounded by the release of biochemical mediators creates an acute metabolic acidosis -anaerobic metabolism contributes to worsening lactic acidosis -reserves of ATP are almost totally depleted and mechanisms for restoring new supplies of energy have been completely destroyed -respiratory system dysfunction prevents adequate oxygenation and ventilation despite mechanical ventalitory support -cardiovascular system is ineffective in maintaining adequate MAP for tissue perfusion -multiple organ dysfunction pregressing to complete organ failure has occurred and death is imminent

Sepsis and septic shock

-the most common type of disruptive shock is caused by widespread infection or sepsis -sepsis "life threatening organ dysfunction caused by dysregulated host response to infection -septic shock is a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to increase mortality -leading cause of death in the non coronary ICU patients -30 million people suffer or die from sepsis each year worldwide -the number of hospital admission for sepsis had increased three fold in the last decade -finding and aggresively treating the source of infection and quickly restoring perfusion are important interventions -hospital aquired conditions which may include hospital associated infections (infections not present at the time of admission) in critically ill patients that may progress to septic shock most frequently originate in the bloodstream (bacteremia) and lungs (pneumonia) and urinary tract (urosepsis) -other infections of increasing concern are bacteremia associated with intravascular catheters and indwelling urinary catheters -additional risks factors that contribute to the growing incidence of sepsis are the increased use of invasive procedures and indwelling medical devices, the increased number of antibiotic-resistant microorganism and the increasingly older population -older adults are at increased risk for sepsis due to physiologic reserve an aging immune system, comorbid conditions and often nonspecific presentation of infection -other risks are those undergoing surgical and other invasive procedures especially patients who have undergone emergency surgery those with malnutrition or immunosuppression and those with chronic illness such as diabetes, hepatitis, chronic kidney disease, and immunodifecency disorders -sepsis can be reduced or prevented by using strict infection control practices, beginning with thorough hand hygiene. other interventions include include implementing programs to prevent central line infection ensuring early removal of invasive devices that are no longer necessary (indwelling urinary catheters) implementing programs that prevent ventricular associated events and pneumonia; promoting early ambulation; timely debridement of wounds to remove necrotic tissue, caring out standard precautions and adhering to infection prevention/control practices. including the use of meticulous aseptic technique and properly cleaning equipment and the patient environment

Hypovolemic shock

-the most common type of shock characterized by decreased intravascular volume -hypovolemic shock occurs when their is a reduction in intravascular fluid volume by 15-30% which represents a loss of 750-1500 mL Pathophysiology -can be caused by external fluid loses, like traumatic blood loss, or by internal fluid shift like severe dehydration, severe edema or ascites -intravascular fluid volume can be reduced by both fluid loss and fluid shifting between intravascular and interstitial compartments -hypovolemic shock begins with decrease in intravascular volume resulting in decreased venous return of blood to the heart and subsequent decreased ventricular filling -decreased ventricular filling results in decreased stroke volume and decreased cardiac output when output drops, bP drops, and tissue cannot be perfused adequately

blood pressure regulation

-three major components of the circulatory system 1) blood volume 2)cardiac pump 3) and the vasculature -they all must respond effectively to complex neural, hormonal and chemical systems to maintain adequate blood pressure -these systems affect cardiac output and peripheral resistance - cardiac output: product of stroke volume (amount of blood ejected from the left ventricle during systole) and heart rate -Tissue perfusion depend on mean arterial pressure or the average pressure at which the blood moves through the vasculature -MAP must exceed 65mm Hg fro cells to receive oxygen and nutrients needed to metabolize energy to be able to sustain life -BP is regulated by baroreceptors located in the carotid sinus and aortic arch they are responsible fro monitoring volume and regulating neuronal and endocrine activites -when BP drops catecholamines (epinephrine and norepinephrine) are released from adrenal medulla; increasing heart rate and cause vasoconstriction restoring BP -chemoreceptors also located in the aortic arch and carotid arteries regulate BP and respiratory rate -these mechanisms can respond to changes in BP on a moment to moment basis -the kidneys regulate BP by releasing renin an enzyme needed fro conversion of angiotensin1- to angiotensin2 a potent vasoconstrictor -this indirectly leads to release of aldosterone from the adrenal cortex which promotes retention of sodium and water. (hypernatremia) -hypernatremia: stimulates release of ADH by pituitary gland and causes the kidneys to retain water further in an effort to raise blood volume and BP -secondary mechanisms may take hours or days to respond to changes in BP

medical management progressive stage

-treatment depends on the type of shock; its underlying cause, and the degree of decompensation n the organ system - in all forms of shock IV fluids, and medications to restore tissue perfusion by the following methods 1)supporting the respiratory system 2)optimizing intravascular volume 3) supporting the pumping action of the heart -other management include: enteral feedings, targeted hyperglycemic control with IV insulin and antacids, histamine 2 blockers or antiseptic medications to reduce the risk of ulcers in the GI and bleeding -maintaining serum glucose of less than 180 mg/dl with insulin therapy and close monitoring is indicated in the management of the critically ill patient

medical management anaphylactic shock

-treatment: remove the causative agent, discontinue antibiotic, administering medications that restore vascular tone and providing emergency support of basic life functions -fluid management is critical, massive fluid shifts occur within minutes due to increased vascular permeability -intramuscular epinephrine is given for vasoconstrictive action -diphenhydramine is given IV to reverse effects of histamine this reduces capillary permeability -nebulized medications, such as albuterol may be given to reduce histamine induced bronchospasm -if cardiac arrest or respiratory arrest are imminent or occurred, CPR is performed -endotracheal intubation may b necessary -IV line are accessed to give medications and fluids

Table 14-1 clinical findings in stages of shock

Compensatory: Blood pressure: normal, HR: >100BPM, Respiratory status: >20 breaths per minute PaCO2 <32 mmHg Skin: cold clammy, urinary output; decreased, mentation confused and or agitated acid based balance; respiratory alkalosis Progressive: blood pressure: systolic: 90 mmHg of MAP <65 mmHg requires fluids resuscitation to support blood pressure HR: >150 bpm, respiratory rate: rapid shallow respirations with crackles PaO2 <80 mm Hg, PaCo2 >45mmHg sKIN: MOTTLED, PETECHIAE (brown spots on skin from bleeding and clots) urinary output: <0.5mL/kg/h,, mentation; lethargy acid based balance: metabolic acidosis irreversible: blood pressure: requires mechanical ventilation or pharmacologic support, HR: erratic respiratory status: requires intubation and mechanical ventilation and oxygenation, skin jaundice, urinary output; anuric requires dialysis, mentation; unconscious acid based balance: profound acidosis

cariogenic shock; initiation of first line treatment

OXYGENATION -in early stage of shock, supplemental oxygen is given by cannula at a rate 2-6L per minute to achieve an oxygen saturation of over 95% - monitoring arterial blood gas, pulse ox, and ventilary efforts determine if the patient requires a more aggressive method of oxygen delivery PAIN CONTROL -if pt has chest pain, IV morphine is given for pain relief -in addition to relieving pain, morphine dilutes the blood vessels thus reducing workload of the heart by decreasing the cardiac filling pressure and reducing the pressure against the heart muscle to eject blood (after load) -morphien may also reduce a patients anxiety Hemodynamic monitoring -it assess the patients response to treatment -performed in ICU where arterial line can be inserted -arterial line allows monitoring for BP an allow blood samples to be drawn -multilumen central venous and pulmonary catheter may be inserted to measure the myocardial filling pressures, pulmonary artery pressures, cardiac output, and pulmonary and systemic resistance LABRATORY MARKER MONITORING -markers for ventricular dysfunction: cardiac enzyme levels and biomarkers (cTn-1) and serum lactate are measured, a trans thoracic echocardiography may be performed at the bedside and a 12-lead ECG is obtained to assess myocardial damage -continuous ECG and ST monitoring is for seeing if patient has ischemia FLUID therapy -incremental IV fluid boluses are cautiously given to determine optimal filling pressures for improving cardiac output

TABLE 14-6 sepsis campaign bundle

complete within 3 hours of patient presentation aymptoms -obtain serum lactate level, blood culture prior to administration of antibiotics -administered broad spectrum antibiotics (As prescribed) -initiate fluid resuscitation in patients with hypotension or elevated serum lactate (>4mmol/l) -minimum initial fluid bolus of 30mL/kg using crystalloid solution Complete as soon as possible or within the first 6 hours of patient presentation symptoms -begin vasopressor if hypotension has not improved (<65 MAP) after initial fluids -if hypotension persists after initial fluid resuscitation (<65MAP) or elevated serum lactate (>4mmol/l) reassess intravascular volume and tissue perfusion using two of the following assessment parameters 1) measure CVP (goal 8-12 mmHg) 2) measure scvo2 (goal greater than 70%) 3) bedside cardiovascular ultrasound 4)dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge additional interventions and targets for therapy in the early management of sepsis -support blood pressure to achieve urine output >0.5 ml/kg/h -administer vasopressor agents if fluid resuscitation isn't working to restore BO and cardiac output -norepineehprine is initially given (vasopressor of choice)*** do not give anything else - obtain blood, sputum, wound drainage and urine cultures and give broad spectrum antibiotics -antibiotic administration should occur within 3 hours of admission to emergency department or within 1 hour of inpatient admission -support respiratory system with supplemental oxygen and ventilation -transfuse packed RBC when hemoglobin is <7 g/dL to achieve target level between 7-9g/dL in adults -provide IV sedation and analgesia avoid use of neuromuscular blockade when possible -control serum glucose <180 mg/dl with IV insulin therapy -implement interventions and give meds to prevent DVT and stress ulcer prophylaxis -discuss advanced care planning with patients and family -the nurse monitors I&O, daily weights, nutritional status monitoring albumin and pre albumin monitors patients nutritional state

Nursing management for neurogenic shock

elevate and maintain head of the bed at least 30 degrees, when patient receives spinal or epidural anesthesia. elevation helps prevent the spread os anestheia to the spinal cord -in suspected spinal cord injury neurogenic shock an due prevented by immobilizing the patient to prevent further damage -interventiosn focus on supporting cardiovascular and neurologic function until the shock resolves -at higher risk for VTE because of increased pooling of blood from the vascular dilation; greater risk is in patient with spinal cord injury -nurse checks daily for lower extremity pain, redness, tenderness, and warmth -is pt has pain and objective assessment of the calf is suspected, the patient should be evaluted for DVT -passive ROM of immobile extremities helps promote ciruclation -early intervention to prevent VTE: compression devices combined with antithrombolitic agents (LMWH) -the patient with a spinal cord injury may not report pain from the internal injury, the nurse must watch closely for S/S of internal bleeding that could lead to hypovolemic shock

chart 14-3 risk factors for hypovolemic shock

external fluid loses -diarrhea -vomiting -trauma -surgery -diuresis -diabetes insidious internal: fluid shift -hemorrhage -burns -ascites -peritonitis -dehydration -necrotizing pancreatitis

Chart 14-2 vasoactive medications for shock

inotropic agents: improve contractility, increase stroke volume, increase cardiac output. disadvantage: increase O2 demand on heart 1) dobutamine 2)dopamine 3)epinephrine 4)milrinone Vasodilators: reduce preload and after load, reduce oxygen demand of heart Disadvantage: hypotension 1) Nitroglycerin 2)Nitroprusside Vassopressor agents; increase blood pressure by vasoconstriction. disadvantages: increase afterloadm increasing cardiac workload, compromise perfusion to the skin, kidneys, lungs, GI tract 1)norepinephrine 2)dopamine 3)phenylephrine 4)vasopressin 5)epinephrine

Vascular response

local regulatory mechanisms referred to as auto regulation, stimulate vasodilation or vasoconstriction in response to biochemical mediators released by the cell communicating the need for oxygen and nutrients -a biochemical mediator is a substance released by an immune cell such as macrophages ; the substance triggers and action at the cell site or travels to the bloodstream ti a distant site where it triggers action

Medical management of sepsis and septic shock

nurses must be able to identify and manage patients with sepsis including the following 1) as the leading cause of death from infections sepsis must be recognized promptly 2) sepsis is different from infection in that in sepsis there is a dysregulated host response with organ dysfunction an infection may cause specific organ dysfunction without a dysregulated host response. 3) sepsis is caused by an interplay between infectious pathogens and a myriad of patient specific risks including genetics, age and the presence of other diseases and disorders. 4)the organ dysfunction that occurs with sepsis may not be readily apparent; on the contrary, a new onset of organ dysfunction may be caused by an unrecognized infectious process. CORRECTION OF UNDERLYING CAUSES -current treatment of sepsis and septic shock involves rapid identification and elimination of the cause of infection. -goals: identify and treat patients in early sepsis within 3 hours to optimize patient outcome. -specimens of blood, urine, sputum and wound drainage and tips of invasive catheters are collected for culture using aseptic techniques -IV lines are removed and reinserted at a different site, urinary catheters are removed and changed -abscesses are drained and necrotic areas are debrided -all cultures obtained before antibiotic administration. antibiotics should be inititated within the first hour of treatment of a patient who has sepsis FLUID REPLACEMENT THERAPY -must be initiated to correct tissue hypo perfusion that results from incompetent vasculature and inflammatory response -reestablishing tissue perfusion through aggressive fluid resuscitation is key to management of sepsis and septic shock -initial fluid challenge includes IV infusion of at least 30mL/kg of crystalloids over 30 minutes may be required to treat sepsis induced tissue hypoperfusion -monitoring BP, CVP, fluid responsiveness with passive leg raises, urine output, and serum lactate are monitored PHARMACOLOGIC THERAPY -if infection is unknown broad spectrum antibiotics are started until culture and sensitivity reports are received -if fluid therapy does improve tissue perfusion then vasopressor agents may also be given to provide pharmacologic support to the myocardium -packed RBC may be ordered to support oxygen delivery and transport to tissues - neuromuscular blockade agents and sedation agents may be required to reduce metabolic demands and provide comfort to the patient -DVT prophylaxis with low dose unfractionalized heparin or low molecular weight heparin in combination with mechanical prophylaxis (compression devices) should be initiated and medications for stress ulcer prophylaxis ( H2 blocking agents, proton pump inhibitors) NUTRITIONAL THERAPY -agressive nutritional therapy should be initiated within 24-48 hours of ICU admission to dress hypermotabolic state -malnutrition further impaires the patients resistance to infection -enteral feedings are preferred because increased risk for iatrogenic infections associated with IV catheters -HOWEVER, enteral feedings may not be possible if decreased perfusion to the GI tract reduces peristalsis and impaired absorption

medical management cont. cariogenic shock

pharmacologic therapies - vasoactive medication is targeted to maintain cardiac output within normal limits -in coronary cariogenic shock goals are to: improve cardiac contractibility, decrease preload and after load, and stabilize HR and rhythm -types of medication given in combination: inotropic medications to increase cardiac output by mimicking SNS. activating myocardial receptors to increase myocardial contractibility (inotropic action) or increase the heart rate (chronotropic action) these agents may enhance vascular tone increasing preload -vasodilators: used primarily to decreased after load, reducing the workload of the heart and oxygen demand -medications commonly combined to treat cariogenic shock include: dobutamine, nitroglycerin and dopamine DOBUTAMINE -inotropic effects by stimulating myocardial beta receptors, increasing the strength of myocardial activity and helping cardiac output -myocardial alpha receptors are stimulated resulting in decreased pulmonary and systemic vascular resistance (decrease after load) NITROGLYCERIN -IV nitroglycerin in low dosages acts as a venous vasodilator and reduced preload. -in higher doses it reduces arterial vasodilation and therefore reduces after load as well. -these actions in combination with dobutamine increased cardiac output while minimizing cardiac workload -vasodilation enhances oxygen delivery to the weakened heart muscle DOPAMINE -sympathomimetic agent that has varying vasoactive effects depending on the dosage -can be used with dobutamine and nitroglycerin to improve tissue perfusion -doses 2-8 ug improve contractibility (inotropic action) slightly increase the heart rate (chronotropic action) and may increase cardiac output -doses higher than 8ug predominately cause vasoconstriction , which increases afterlaod and thus increases cardiac workload . because this effect isn't desired for patients in cariogenic shock doses must be titrated -in severe metabolic acidosis which is later in shock stages, the metabolic acidosis must be corrected to ensure maximum ffectiveness of vasoactive medications OTHER VASOACTIVE MEDICATIONS -norephinephrine milrinone, vasopressin, and phenylephrine and epinephrine -they each stimulate different receptors in the sympathetic nervous system - combination these medications may be prescribed -diuretics such as furosemide may be given to reduce the workload of the heart by reducing fluid accumulation antiarythmatic medications - hypoxemia, electrolyte imbalances, and acid base balance contribute to serious cardiac dysrhythmias 0as a response to decreased cardiac output and BP the heart rate increases beyond normal limits. this impedes cardiac output by shortening diastole and thereby decreasing the time for ventricular filling - anti arrhythmic medications are given to stabilize HR MECHANICAL assistive devices -if cardiac output does not improve despite supplemental oxygen vasoactive medications, fluid boluses and mechanical ventilation are used temporarily to improves hearts ability to pump -intra-aortic balloon counter pulsation provides temporary circulatory assistance -other mechanical assistance include left and right ventricular assistive devices and total temporary artificial hearts

Nursing management cariogenic shock

preventing cariogenic shock -identifying risk early -adequate oxygenation of the heart muscle and decreasing cardiac workload can prevent cariogenic shock -this can be accomplished by conserving the patients energy promptly relieving angina and administering supplemental oxygen -often however, cariogenic shock cannot be prevented MONITORING HEMODYNAMIC STATUS -a major role of the nurse is monitoring the patients hemodynamic and cardiac status -arterial blood lines and ECG monitoring equipment must be well maintained and functioning properly -nurse anticipates the medications, IV fluids, and equipment that might be used and is ready to assist in implementing theses measures -changes in hemodynamic status and lab values are documented and reported promptly -adventitious sounds, changes in cardiac rhythm and other abnormal physical assessment findings are reported immediately ADMINISTERING MEDICATIONS AND IV fluids -nurse plays in critical role in the safe and accurate adminsitration of IV fluids and medications -fluid overload and pulmonary edema are risks because of ineffective cardiac function and accumulation of the blood and fluid in the pulmonary tissue -the nurse needs to know the desired effects and side effects of medications -nurse monitors the patients for decreased BP if they're given morphine or nitroglycerine -arterial and venous sites puncture should be observed for bleeding -IV infusions need to be observed for necrosis and sloughing occur if vasopressor medications infiltrate the tissue -vasoactive medications should be given using a central IV line to reduce infection -monitor urine output, serum electrolytes, BUN, and CRCL, to detect decreased renal function MAINTAINING INTRAAORTIC BALLOON COUNTERPULSATION -the nurse makes ongoing timing adjustments of the balloon pump to help it sink with cardiac cycle -the patient is at risk for circulatory compromise in the leg that the catheter has been placed. therefore the nurse must check the neuromuscular status of lower extremities frequently -in emergencies and procedures patients prefer if family is there patients should chose who gets to be there and HCP should talk to patient about who should be there before the life threatening emergency occurs ENHANCING PATIENT SAFETY AND COMFORT -administer medication to relieve chest pain, preventing infection and multiple arterial and venous line insertion sites, protecting the skin, and monitoring respiratory and renal function -proper positioning of the patient promotes effective breathing without decreasing bp and increases comfort while reducing anxiety -breif explanations about the procedure being performed and comforting touch is often to reassure the patient and family -yhr family is anxious and benefits from opportunities to talk and see the patient

table 14-4 sepsis related organ failure SOFA

respiration PaO2 : score 1 <400 score 2 <300 score 3 <200 score 4 <100 (with respiratory support coagulation platelets; score 1: <150 score 2 <100, score 3 <50 score 4 <20 Liver bilirubin: score 1: 1.2-1.9 score 2: 2.0-5.9 score 3 6.0-11.9 score 4 >12.0 cardiovascular hypotension: score 1: MAP <70 mmhg, score 2; dopamine less than or equal to 5, score 3 dopamine >5 or epinephrine < 0.1 or norepinephrine <0.1 score 4: dopamine >15 or epinephrine or norepinephrine >0.1 CNS: glasgow coma scale; score 1: 13-14, score 2: 10-12 score 3: 6-9 score 4: <6

Chart 14-5 risk factors for distributive shock

septic shock -immunosupression -extremes of age <1 year >65 -malnurishment -chronic illness -invasive procedures -emergent or multiple surgeries Neurogenic shock -spinal cord injury -spinal anesthesia -depressant action of medications Anaphylactic shock -history of medication sensitivity -transfusion reactions -history of reaction insect bites -food allergies -latex sensitivity

Shock overview

shock: a life threatening condition that results from inadequate tissue perfusion -results from inadequate tissue perfusion, creating imbalance between the delivery of oxygen and nutrients needed to support cellular function -adequate blood flow to the tissues and cells requires an effective cardiac pump, adequate vasculature or circulatory system and sufficient blood supply if one of these components is impaired, perfusion to the tissues is threatened or compromised. -without adequate treatment, inadequate blood flow to the cells results in poor delivery of oxygen and nutrients. cellular hypoxia, and cell death that progresses to organ dysfunction and eventually death -shock effects all body systems -it may develop rapidly or slowly -during shock the body struggles to survive and calls on the homeostasis mechanisms to restore blood flow -any insult to the body can create a cascade of events resulting in poor tissue perfusion -any patient with any disease state may be at risk for developing shock -types of shock 1)hypovolemic shock 2)cariogenic shock 3)neurogenic shock 4)anaphylactic shock -common symptoms in all shock: hypo perfusion of tissues, hyper metabolism, and activation of the inflammatory response -the body responds to shock by activating the sympathetic nervous system and mounting a hypermetobolic and inflammatory response -failure to compensatory mechanisms to effectively restore physiologic balance is the final pathway of all shock states and results in end organ dysfunction and death -nursing care requires ongoing assessment to care for a patient with chock involves close collaboration with team members -nurses are key in identifying shock