Unit six: oxygenation/perfusion (shock)
a septic client experiences what
fever: acetaminophen Hypothermia: give warm blanket IVF: room temp
obstructive shock
physical obstruction related to tamponade, emboli, compartment syndrome that impedes the filling or outflow of blood resulting in reduced cardiac output.
Liver role
product body proteins: album Filtered blood
A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position? Modified Trendelenburg Supine Semi-Fowler's Trendelenburg
Modified Trendelenburg promotes the return of venous blood. The other positions may make breathing difficult and may not increase blood pressure or cardiac output.
The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed?
Narrowed pulse pressure Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP
A nurse in the intensive care unit (ICU) receives report from the nurse in the emergency department (ED) about a new patient being admitted with a spinal cord injury received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that the patient is probably experiencing? 1. hypovolemic shock 2. cardiogenic shock 3. neurogenic shock
Neurogenic shock can be caused by spinal cord injury. In this case, it resulted by diving into waters of unknown depth. The patient will present with a low blood pressure, bradycardia, and warm dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.
Cardiogrnic shock
Occurs when the heart's pumping ability is compromised to the point in cannot maintain cardiac output. patho: decrease cardiac contractibility--> decrease volume/ CO--> pulmonary congestion, decrease systemic tissue perfusion, decreased coronary artery perfusion
A client has a pulse rate of 142 beats per minute and a blood pressure of 70/30. To promote venous return, the nurse
Raises the foot of the client's bed
When a client is in the compensatory stage of shock, which symptom occurs? Tachycardia Urine output of 45 cc/hour Bradycardia Respiratory acidosis (hypoventilation)
Tachycardia The compensatory stage of shock encompasses a normal blood pressure, tachycardia, decreased urinary output, confusion, and respiratory alkalosis (hyperventilating: see early stage of asthma)
Neurogenic shock causes and management, S:S
causes: vasodilation loss of balance between sympathetic and parasympathetic, spinal injury or nervous system damage S:S vascular resistance and bradycardia, hypotension dry, warm skin rather than cool, moist skin Management: -stable spinal injury: Carefully immobilizing to prevent damage. -important to elevate and maintain the head of the bed at least 30 degree to prevent neurogenic shock when patient receive spinal or epidural anesthesia. -must check daily pain, redness or warmth: high risk for VTE ( early ambulation, antithrombotic agents) -
Septic shock causes
circulatory shock occure by widespread infection or sepsis. ex: blood stream bacteria, pneumonia, UTI, Intra-abdominal infections or wound infection.
what is septic S:S and tx?
hypotension Fever>38 (100.4F) WBC>12,000 or <4,000 RR>20, PaCO2 <32 Lactic acidosis oliguria Altered level of consciousness Altered renal function MODS Metabolic acidosis TX: antibiotic
What is the major clinical use of dobutamine?
increase cardiac ouput
how you can tell patient improve shock?
increase urine >30 ml/hr BP >90 MAP>65 oxygen>90
Cardiogenic shock treatment
morphine : help decrease anxiety, decrease preload and afterload. IVF
neurogenic shock
overriding parasympathetic stimulation resulting in bradycardia and decrease systemic
What is the nurse expecting finding cardiogenic shock?
sever hypoxemia acidosis hypoglycemia hypocalcemia tension pneumothorax Acute MI S:S pain on chest, develop dysthymias, complained of fatigue, express feeling of doom, show hemodynamic instability
Vasoactive Medications -norephedrine
-given when the fluid therapy not maintain MAP, BP -check BP Q 15 min, continues BP monitoring -give through central line due to extravasation cause tissue damage -dosages usually titrated to patient response.
what position to put patient on while suspect shock?
a modified Trendelenburg
Septic shock treatment
antibiotics
why need insert central venous pressure line into subclavian or jugular vein?
measure right atrial pressure, monitoring of intravascular pressure and venous oxygen levels Normal pressure: 4-12 mmHg or cm H2O
when administering vasoactive medicaiton to shock patient?
vasoactive med can give to all form of shock to improve the pt. hemodynamic stability when fluid therapy alone cannot maintain adequate. Med: help increase the strength of myocardial contractibility, regulate the heart rate, reduce myocardial resistance, initiated vasocontraction -nurse must monitor VS Q 15 min until stable -administer Central venous line -Monitor: BP, HR, pt. response to med, check MAP>65 to ensure adequate tissue perfusion
Preventing complications of shock, nurse intervention:
-Frequent oral care -aseptic suctions Tanique turning and elevated the head of bed at least 30 degree -review medicaiton, monitor BP -review 1 hours bundle handle of septic -Promote rest, comfort (excessive warm, cold, shivering increase metabolic rate and oxygen need -support family member
distributive shock
-Widespread vasodilation -shock state resulting from displacement of intravascular volume creating a relative hypovolemia and inadequate delivery of oxygen to the cells
Nutritional Therapy
-increased metabolic energy requirements to prevent further catabolism due to depletion of glycogen -support with parenteral or enteral nutrition -GI systems should be used to support its integrity -administering of glutamine, H2 blockers or proton pump inhibitors - pt. may need 3000 calories daily
How to correct cardiogenic shock ?
-pt. required thrombolytic/fibrinolytic therapy -CABG surgery -correct acidosis -tx tension pneumothorax -mange temperature, hypothermia -Oxygenation O2>90% -pain control medicaiton: IV morphine reduce pain, preload, afterload and anxiety. Hemodynamic monitoring: ICU atrial line can be insert to continue monitoring BP, provide port for blood sample -Lab: BNP, ECG, CRP -Fluid therapy: not give rapidly risk HF, acute pulmonary edema -Vasoactive ( inotropic action: norepinephrine, epinephrine): increase CO, HR -Vasodilation ( dobutamine, nitroglycerin, dopamine) : reduce workload of heart -Furosmide :reduce workload of heart _ Nurse must monitor: U/O, BUN/Cr
neurogenic, septic, anaphylactic
-shock state resulting from loss of sympathetic tone causing relative hypovolemia -distributive shock type or circulation shock occure when massive arterial and venous dilation promote intravascular volume pools in peripheral blood vessel.
Colloid solutions
0.5 %Albumin id plasma protein (higher cost) expands intravascular volume by exerting oncotic pressure: pulling fluid into intravascular space
stage of shocks
1-compensated: BP remain WNL, vasocontraction (increase heart rate>100 bpm RR>20 bpm, PaCO2 <32 mmHg, skin cold, clammy, urine output <30, mentation: confusion, agitation, Acid base: respiratory alkalosis 2-progressive: BP<90, MAP<65 (required fluid resuscitation to support BP) HR >150 bpm RR: rapid shallow, respiration crackle, PaO2<80, PaCO2>45 Skin: mottled, petechiae Urine output <0.5 ml/kg Mentation: lethargy Acid bases: Metabolic acidosis 3-irreversible: refraction stage, at this point patient can not services, multiples organs damages BP: required mechanical or pharmacologic support HR: Erratic or asystole (no pulse) RR: required incubation and mechanical ventilation & oxygenation Skin: bilirubin elevated see Jaundice: liver failure Urine output: anuria, required dialysis Mentation: unconsciones Acid base: profound acidosis: anaerobic metabolism continues to worsening lactic acidosis.
Hypovemic shock treatment
1. if pt. bleeding: stop bleeding 2. if diarrhea, N/V: antidiarrhea 3. Dehydration: give fluid: crystalloids ( 0.9% NS, lactated Ringer's) required IV line infusion, can cause hypernatremia, pulmonary edema, abdominal compart syndrome colloid: albumin (5%, 25%) rapid expand plasma volume, required human donors -Recommend administer 3 ml of crystalloid solution for each mL of estimated blood loos 3:1 2. insulin is administer if dehydration is secondary to hyperglycemia
what is the general management strategies in shock ?
1.support of the respiratory system: oxygen supplement, mechanical ventilation to provide optimal oxygenation. 2. Fluid replacement: crystalloid ( Normal saline and lactased ring's solution) electrolyte that move freely between intravascular compartment and interstitial spaces, colloids (large molecule IV solution and blood components (packed red blood cells, fresh frozen plasma and platelets) 3. Vasoactive medication to restore as motor tone and improve cardiac function 4. Nutrional support to address the metabolic requirement. Enteral tub feeding, 3000 caloric need
A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is: Cardiomyopathies. Arrhythmias. A myocardial infarction. Valvular damage.
A myocardial infarction.
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? kidney lung Brian
Brain Blood will be shunted to the brain, heart, and lungs to ensure adequate blood supply. The organ that will always be protected over the others is the brain.
When caring for a patient in hypovolemic shock who is receiving large volumes of IV isotonic fluids, the nurse should monitor for symptoms of: A.Hyperthermia B.Pain C.Pulmonary edema D.Tachycardia
C.Pulmonary edema
Older adults with impaired cardiac function are more likely to develop which type of shock? Septic shock Anaphylactic shock Neurogenic shock Cardiogenic shock
Cardiogenic shock Older adults, particularly those with decreased cardiac function, are prone to cardiogenic shock. Typically, underlying causes of septic shock is circulatory in nature and caused by infection, neurogenic shock occurs as a result of a loss of balance between parasympathetic and sympathetic stimulation, and anaphylactic shock is caused by a severe allergic reaction.
what is the complication of fluid administration? nurse should watch for ?
Cardiovascular overload Pulmonary edema Nurse: must monitor u/o, mental status change, Vital sign, lung sounds auscultated
Hypvolemic shock
Cause: acute blood loos, resulting from decreased intravascular volume due to fluid loss Early sign: tachycardia, vasoconstriction, slightly increase or decrease in BP, thirst. Late sing: acidosis/hypoxia, deep, rapid respiration, weak, threats pulse, oliguria, change AMS, Tx: if loos blood replace blood or fluid.
Anaphylactic shock causes/S:S/management
Causes: sever allergic reaction, activated inflammatory cytokines--> vasodilation S:S: wheezing, light headache, feeling doom, flushing, SOB, difficult breathing, bronchospasm Management: -remove agent -intramuscular epinephrine ( vasoconstrictive action) -bronchodilation -Diphenhydramine (benadryl) -CPR if cardiac arrest
hypovolemic shock tx
Crystalloid: Normal saline
what can you replace fluid hypovemolic ?
Crystalloid: Normal saline and lactated 's ringer Colloid: 5% albumin Red blood cell
nutrition support for progressive's stage of shock
Enteral nutrition Proton pump inhibitor: to promote GI tract, reduce stomach acid
A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess Skin perfusion Bowel sounds Mental status Lung sounds
Lung sounds