Shock exam 1

The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient?

Disseminated intravascular coagulation (DIC) may occur either as a cause or as a complication of shock. In this condition, widespread clotting and bleeding occur simultaneously. Bruises (ecchymoses) and bleeding (petechiae) may appear in the skin.

Arterial blood pressure

In shock both systolic and diastolic arterial BPs fall because cardiac output decreases. A systolic BP of 90-100 indicates impending shock, 80 or lower indicates shock.

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed?

Narrowed pulse pressure. Pulse pressure correlates well with stroke volume. Pulse pressure is calculated by subtracting the diastolic from the systolic measurement, the difference is the pulse pressure. The pulse pressure is normally 30-40 mm Hg. Narrowing of the numbers indicates shock.

Obstructive shock

Occurs when there is interference with the circulation of blood into and out of the heart, compromising the volume of blood that enters and leaves the heart en route to the lungs and tissue.

Septic shock

(toxic shock), has the highest mortality rate of the various types of shock. Up to 60% of those who develop septic shock die despite aggressive treatment (Kalil, 2015). It is associated with overwhelming bacterial infections

Discuss the nursing management of clients with shock

-Assess for early signs of shock and report, —Check vital signs on initial contact and frequently thereafter to closely monitor the client's condition -Observe skin color and temperature and assess the rate and quality of radial and peripheral pulses -Monitor urine output and determine respiratory rate and effort to detect evidence of dyspnea or airway obstruction resulting from edema, which accompanies anaphylactic shock -Inspect for bleeding or other causes that may explain the developing symptoms of shock. -Determine level of consciousness and orientation status regularly to detect changes -auscultate the chest for abnormal lung and heart sounds -Check laboratory test results for evidence of low RBCs and hemoglobin, findings that correlate with hypovolemic shock. An elevated WBC count supports septic shock. -Implement measures to control bleeding, other fluid losses, or fluid maldistribution and to promote blood circulation to the brain and vital organs. -Support breathing to ensure adequate blood oxygenation. Use measures to maintain normal body temperature and implement medical therapy as directed.

Define shock

A life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Shock develops as a consequence of one of three events: (1) blood volume decreases, (2) the heart fails as an effective pump, or (3) peripheral blood vessels massively dilate.

Anaphylactic shock

A severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive

APACHE scoring system

Acute, Physiology, Age, and Chronic Health Evaluation to arrive at a number that reflects the severity of the clients status and predicts the potential lengthy of stay in a critical care setting.

distributive shock

Also called normovolemic shock because the amount of fluid in the circulatory system is not reduced, yet the fluid circulation does not permit effective tissue perfusion. Vasodilatation, a prominent characteristic of distributive shock, increases the space in the vascular bed. Also includes other types of shock

Name three diagnostic measurements used when monitoring clients in shock.

Arterial blood gas, central venous pressure, and pulmonary artery pressure measurements. CVP (central venous pressure): pressure of the blood in the right atrium in shock CVP is lower than normal (2-7) Pulmonary artery pressure: Shows information about the left ventricular function. 2, 3, or 4 lumen catch is inserted into the vena cava and advanced through the right atrium and right ventricle into pulmonary artery. Normal ranges are 20-30mm Hg systolic and 8-12 mm Hg diastolic.

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is:

Blood pressure

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected?

Brain

Compensation stage

First stage of shock, several physiologic mechanisms attempt to stabilize the spiraling consequences. Release of catecholamines, activation of the renin-angiotensin-aldosterone system.

Cardiogenic shock

Heart contraction is ineffective, which reduces cardiac output

Give three medical approaches for treating shock

Intravenous (IV) fluid therapy:restore intravascular volume. The total volume, type of solution(s), and rate of administration vary according to the etiology of shock. Usually, a ratio of 3:1 is followed; that is, 3 L of fluid is administered for every 1 L of fluid lost. This amount stabilizes the client, replaces the deficit, and provides a reserve to prevent shock from recurring. Vasopressor drug therapy: Drugs with alpha-adrenergic activity, increase peripheral vascular resistance and raise BP. Examples include dopamine (Intropin), norepinephrine (Levophed), and metaraminol (Aramine). They are best administered after fluid therapy increases the intravascular fluid volume; otherwise, the vasoconstrictive qualities further impair cellular circulation, which already is compromised by the effects of angiotensin mechanical devices that restore blood circulation to cells: intra-aortic balloon pump (IABP) and ventricular assist device (VAD), pneumatic antishock garment (PASG),

The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered?

Levophed. The vasopressor agents that increase blood pressure by vasoconstriction are Levophed, Intropin, Neo-Synephrine, and Pitressin

Subtypes of distributive shock

Neurogenic, septic, and anaphylactic shock

Irreversible stage of shock

Occurs when significant cells and organs become damaged. Clients condition reaches a "point of no return", despite treatment efforts. The client no longer responds to medical interventions. Multiple systems begin to fail. When the kidneys, lungs, heart, liver and brain cease to function, death is imminent.

Multiple organ dysfunction syndrome (MODS)

Once septic shock, which is accompanied by hypotension, develops, the client may deteriorate to the point of multiple organ dysfunction syndrome, a complication of overwhelming inflammation that results in massive cellular, tissue, and organ injury.

neurogenic shock

Rarest type of shock, results from injury that affects the vasomotor center in the medulla of the brain or to the peripheral nerves that extend from the spinal cord to the blood vessels. Injury to the spinal cord or head or overdoses of opioids, tranquilizers, or general anesthetics can cause neurogenic shock

Which nursing interventions would be appropriate for a client in impending shock with decreased cardiac output? Select all that apply.

Restrict activity to total rest, Establish at least one IV site with a large-gauge catheter. Administer IV fluids or blood products at the prescribed rate.

Identify three physiologic mechanisms that attempt to compensate for shock

Stages of shock: Compensation stage, decompensation stage, Irreversible stage.

The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to what preliminary conclusion?

The client is in the compensatory stage of shock

Name four general categories of shock

The four main categories of shock are hypovolemic, distributive, obstructive, and cardiogenic, depending on the cause

Which colloid is expensive but rapidly expands plasma volume

albumin

A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock

neurogenic shock

Decompensation stage

stage in shock that occurs as compensatory mechanisms fail and the client's condition spirals downward into cellular hypoxia, coagulation defects, and cardiovascular changes. Although shock can develop quickly, early signs and symptoms are evident during the decompensation stage. Critical assessments include vital signs, changes in mentation, skin, and urine output.

Hypovolemic shock

the most common type of shock, the volume of extracellular fluid is significantly diminished, primarily because of lost or reduced blood or plasma. Significant bleeding, such as during surgery, after trauma, or after delivery of an infant. It also may result from significant fluid loss, as with burns, large draining wounds, reduced fluid intake, prolonged gastrointestinal (GI) suctioning, or disorders in which fluid losses exceed fluid intake, such as diabetes insipidus