Chapter 54 - Shock
What are the two early warning signs of MODS?
Subtle mentation changes and a gradual rise in temperature
Treatment of PE
Thrombolytics, surgical embolectomy, mechanical ventilation if severe
True or False? Chewing aspirin allows for a more rapid absorption rate than does swallowing it whole
True
What type of patient is at an increased risk for tension pneumothorax?
Vent patient
Treatment for pneumothorax
chest tube, needle decompression
What are the three types of distributive shock?
neurogenic, anaphylactic, septic
Pulse pressure equation
systolic pressure - diastolic pressure
How is MAP calculated?
(SBP + 2DBP)/3
What are some psychological responses for a patient experiencing nonprogressive shock?
Anxiety; feelings of doom; confusion
In cardiogenic shock, ______ is compromised and BP ______
CO; falls
What might be the first sign of infection and sepsis in the elderly ?
Confusion
Causes of MODS?
Dead or injured tissue, infection, perfusion deficits
In older adults, changes in mentation (such as sudden confusion) may be misinterpreted as ________. ALWAYS ASSESS FOR INFECTION/ORGAN HYPOPERFUSION
Dementia
The release of catecholamines causes the __________ of glycogen stores in the early shock continuum
Depletion
Current treatment of septic shock involves
Eliminating cause of infection and aggressive cardiopulmonary support
Treatment of anaphylactic shock
Epinephrine and Benadryl; oxygen, vent support, chest compressions if cardiac arrest occurs
Signs and symptoms of anaphylactic shock
Erythema, hypotension, angioedema, hypovolemia, tissue edema, bronchospasm, abdominal and pelvic cramps, hives, itching, swelling of tongue, wheezing, stridor, GI upset
Epinephrine is given for anaphylactic shock because it
Has a vasoconstrictive effect and reduces bronchospasm
Treatment for neurogenic shock
IV fluid, vasopressors, restoring sympathetic tone, proper positioning/immobilization of the patient
What medication is most commonly given for chest pain and why?
IV morphine sulfate; relieves chest pain and dilates blood vessels to reduce workload on heart; decreases both preload and afterload
Septic shock is caused by widespread _________
Infection
The patient with progressive shock will be _________ due to a change in LOC
Lethargic
What is the purpose of monitoring the MAP?
MAP reflects end-organ perfusion
In progressive shock, the skin will be _________
Mottled
Signs and symptoms of cardiac tamponade
Narrowing pulse pressure (systolic-diastolic), chest pain, muffled heart sounds, JVD, hypotension, tachycardia
A type of gram-positive bacteria that commonly causes nosocomial infections
MRSA
Aggressive nutritional therapy is critical in the management of septic shock because _______ further impairs compensatory mechanisms
Malnutrition
Causes of anaphylactic shock
Meds, contrast media, blood products Food Latex allergy Insect bites
Patients in irreversible shock will experience overwhelming ___________ __________
Metabolic acidosis
During shock, there are increased __________ rates and therefore increased _________ requirements
Metabolic; caloric
Urinary output will be _________ _________ in the first stage of shock (compensated)
Mildly decreased
Loss of skeletal _________ greatly prolongs the patient's recovery time
Muscle
Cardiogenic shock is seen most often in patients with __________ _________
Myocardial infarction
The first stage of shock is known as ____________ or ______________
Nonprogressive or compensated
____________ infections occur in the hospital in patients that are critically ill. These infections originate in the lungs, urinary, and GI tract
Nosocomial
If not treated, shock can lead to ________ failure and _________.
Organ; death
In nonprogressive shock, the HR is _________ 100 BPM and the RR is _______ than 20 breaths/min
Over; fewer
General interventions for cardiogenic shock include supplemental _________, controlling ______ pain, fluid support, _________ meds, controlling heart rate, and using mechanical assist devices if needed
Oxygen; chest; vasoactive
A clot that gets lodged in the pulmonary vasculature and causes ischemia and decreased pulmonary blood flow
PE
The patient with neurogenic shock experiences a predominant __________ stimulation that causes vasodilation lasting for an extended period
Parasympathetic
Nurses titrate the vasoactive drips based on what two factors?
Patient response and prescribed dose
In distributive shock, blood volume pools in the ___________ blood vessels. This causes a relative ____________ because not enough blood returns to the heart
Peripheral; hypovolemia
Signs and symptoms of PE
Pleuritic chest pain, SOB, tachycardia, hypoxia
IV nitroglycerin acts as a venous vasodilator and reduces _________
Preload
What reduces the incidence of septic shock?
Proper aseptic technique Properly cleaning equipment Hand hygiene
What is a critical nurse role for a patient experiencing MODS?
Providing information and support to family members
The patient in nonprogressive shock will have what sort of acid-base balance?
Respiratory alkalosis
In a pneumothorax, air or blood in the pleural space causes a _________ in lung expansion; pressure builds and then compresses vessels of the heart
Restriction
What interventions help prevent thrombus formation in patients with neurogenic shock?
SCDs and lovenox (heparin)
Systemic Inflammatory Response Syndrome (SIRS) presents clinically like _______
Sepsis
Due to compromised blood flow to the GI tract, ________ _______ can occur in patients experiencing shock
Stress ulcers
What two factors determine cardiac output?
Stroke volume and heart rate
In the final stage of shock, end-organ damage is so severe that the patient does not respond to treatment and cannot ____________
Survive
Distributive shock is caused by a loss of _______________ _____________ or by a release of biochemical ____________ from cells
Sympathetic tone; mediators
What is inserted into a patient experiencing progressive shock to prepare for fluid administration ?
TWO LARGE BORE PERIPHERAL IVS (16 GUAGE)
Other signs and symptoms of progressive shock ?
Tachycardia, dyspnea, restlessness, diaphoresis, prolonged capillary refill, metabolic acidosis
Vasoactive medications should be _______ when possible
Tapered
Why is some form of ENTERAL nutrition always given when treating patients experiencing shock?
The integrity of the GI system depends on direct exposure to nutrients
Why are clinical signs more obvious during the second stage of shock?
The patient loses the ability to compensate for the insult, infection, or injury
Epinephrine is usually given IM in the _______ in a dose of __________ mg/kg. This can be repeated every 5-30 minutes
Thigh; 0.01
In the case of cardiogenic shock due to ischemia or infarction, the patient may require
Thrombolytic therapy Angioplasty CABG Ventricular assist device (VAD) Intra-aortic balloon pump
If someone is experiencing shock that does not improve, where will the body begin shunting blood?
To the brain and heart (instead of the skin, GI tract, kidneys)
True or False? As in other stages of shock, the nurse still carries out prescribed treatments, monitors the patient, protects patient safety, and provides comfort in the last stage
True
The overwhelming inflammatory and immune response in SIRS/sepsis is thought to be caused by ___________ ___________ _________
Tumor necrosis factor (TNF)
Distributive shock occurs when the body's ability to adjust ____________ tone is impaired, thus blood volume is abnormally displaced in the vasculature
Vascular
Medications used for shock that restore vasomotor tone and improve cardiac function
Vasoactive meds
In neurogenic shock, _________ occurs as a result of a loss of balance between the parasympathetic and sympathetic systems
Vasodilation
In anaphylaxis, mast cells and basophils release vasoactive substances (histamine, bradykinin). This leads to widespread _________ and potentially vascular __________
Vasodilation; collapse
Therapy with __________ is given in septic shock if a MAP of 65 or more is not achieved by fluid therapy alone
Vasopressors
Neurogenic shock is characterized by dry, ________ skin, hypotension, and _________
Warm; BRADYCARDIA
What is cardiac tamponade?
compression of the heart by an accumulation of fluid in the pericardial sac
Common causes of obstructive shock?
pulmonary embolism, cardiac tamponade, and tension pneumothorax
Neurogenic shock can be caused by
spinal cord injury spinal anesthesia depressant action of medications glucose deficiency
Goals of management of cardiogenic shock are
(1) limit further damage to heart (2) to improve the cardiac function by increasing cardiac contractility and decreasing ventricular afterload
What is a normal CVP?
2-8 mm Hg
The hypodynamic (cold) phase of sepsis is characterized by:
BP drops, skin cool/pale, temp normal or below normal, HR & RR still rapid, decreased UO, MODS
What 3 things are monitored during cardiogenic shock to assess kidney function?
BUN, creatinine, and urine output
Why is important to assess and monitor the patient at risk for shock before the BP falls?
By the time the BP drops, damage has already been occuring at the cellular and tissue levels
____________ shock occurs when the hearts ability to contract and pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues
Cardiogenic
What are two complications that can arise from fluid administration?
Cardiovascular overload and hypothermia
In nonprogressive shock, how will the patient's skin feel?
Cold/clammy
In cardiogenic shock, systemic tissue perfusion is ___________, resulting in
Compromised; decreased UO, mottled and cool skin, delayed cap refill, changes in mentation, and anxiety
Why is it okay to not treat a fever in sepsis until it gets higher than 104 F or the patient becomes uncomfortable?
Fever is one of the body's natural mechanisms for fighting infection
Signs of sepsis include:
Fever or hypothermia Tachycardia Tachypnea Hypocapnia Leukocytosis or leukopenia or left shift (all reflective of WBCs)
Keeping the patient ______ during anaphylaxis is suggested because it improves venous return to the heart
Flat
______ replacement is a major goal in hypovolemic shock
Fluid
_________ replacement is a standard part of shock treatment
Fluid
________ is defined as severe organ dysfunction of ____ or more organ systems lasting at least 24-48 hours in the setting of sepsis, trauma, burns, or severe inflammatory conditions
MODS; 2
The second stage of shock is known as _________ or ___________
Progressive; uncompensated
A pulmonary embolism can cause blood to back up into the ______ side of the heart and cause heart failure
Right
Other causes of cardiogenic shock include:
Severe hypoxemia, acidosis, hypoglycemia, hypocalcemia, cardiomyopathy, arrhythmias
A condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs and cellular function
Shock
The patient in end-stage shock is ______
Unresponsive
Treatment for cardiac tamponade
pericardiocentesis
Report a pulse pressure that is lower than ______ mm Hg
25
What is a normal cardiac output ?
4-6 L/min
In the progressive stage of shock, systolic BP will be below _________ mm Hg and MAP will be less than _______ mm Hg
80-90; 65
Obstructive shock is caused by
A physical obstruction to blood flow
Excess lactic acid limits the amount of _______ produced and normal cellular function cannot be maintained
ATP
It is important to remember that in neurogenic shock, the blood volume is ________, but the vasculature is dilated causing it to be displaced and BP to be ____________
Adequate; hypotensive
What can increase the risk of MODS?
Advanced age, malnutrition, coexisting diseases
What is one of the most common causes of anaphylactic shock?
Allergy to penicillin
What is the difference between SIRS and sepsis?
An identifiable causative infectious agent is established with sepsis
In shock, cells must produce energy through ____________ metabolism
Anaerobic
What type of shock is caused by a severe allergic reaction when patients who have already produced antibodies to a foreign substance (antigen) develop a systemic antigen-antibody reaction
Anaphylactic shock
Medications to prevent stress ulcers?
Antacids (carafate) H2 blockers (famotidine) PPIs (lansoprazole)
In sepsis, _________ therapy is initiated after cultures are obtained unless obtaining cultures is delayed. In this situation, antimicrobials should be administered in ______ _______ after identification of septic shock
Antibiotic; 1 hour
What is a reportable urine output?
Anything less than 30 mL/hr or 0.5 mL/kg/hr
Afterload is related closely to _______ _______
Aortic pressure
________ should be given in the case of a patient with acute MI. This helps prevent worsening thrombosis in the coronary arteries
Aspirin
The first step in generalized shock treatment is to
Assess oxygenation
The patient in the final stage of shock may require _____________ ventilation
Assisted
Important labs to look at for cardiogenic shock ?
BNP and cardiac enzymes (troponin)
Lactated Ringer's contains the lactate ion. The liver converts this to __________ to help treat acidosis
Bicarb
In all types of shock, cells lack an adequate _________ _________ and are inadequately oxygenated
Blood supply
Tissue perfusion is determined by what two factors?
Cardiac output and systemic vascular resistance
In progressive shock, the myocardium tries to continue to increase the CO in order to maintain BP. Unfortunately, the body cannot go on like this forever. Without treatment, the _____ _____ will fail
Cardiac pump
Vasoactive medications should be administered through a _____ ______ because infiltration and extravasation of these meds can cause tissue necrosis and sloughing
Central line
When fluids are being given to treat shock, a central line is placed to monitor _______ _______ ______
Central venous pressure (CVP)
Distributive shock is also called ____________ shock
Circulatory
In septic shock, inflammatory cytokines activate the ___________ system and this leads to clot formation in unnecessary areas
Coagulation
Nursing management of patients with obstructive shock includes tasks such as
Collecting and setting up equipment Helping gain informed consent Chest drainage system set up
Sympathetic stimulation causes vascular smooth muscle to ________; parasympathetic stimulation causes it to __________
Constrict; dilate
Vasoactive medications increase myocardial _________, regulate ________ ________, reduce myocardial resistance, and initiate _____________
Contractility, heart rate, vasoconstriction
If the patient with septic shock has not responded to vasopressor support, ________ may be considered
Corticosteroids
In sepsis, intravascular volume is replaced through the administration of
Crystalloids, colloids, and blood products
Specimens of blood, sputum, urine, and wound drainage are collected for _________ when sepsis is suspected
Culture
Why are the elderly at an increased risk for sepsis?
Decreased physiologic reserves and an aging immune system
Vasoactive medications commonly used to treat cardiogenic shock include
Dobutamine, dopamine, and nitroglycerin
Crystalloid fluids consist of __________ that move freely between intravascular and interstitial spaces. What are som examples of crystalloid fluids given to patients in shock?
Electrolytes; Saline, Lactated Ringer's
When a patient is being weaned from vasoactive meds, how often should you check BP?
Every 15 minutes
When vasoactive medications are administered, the nurse must monitor vital signs at least how often?
Every 15 minutes
True or False? The patient in the final stage of shock has a mild decrease in urinary output
False; the patient will be anuric
True or False? If your patient's BP is improving, you can abruptly stop their vasoactive medications
False; vasoactive meds should be titrated and NEVER just stopped abruptly
Treatments for nonprogressive shock include:
Fluids, medication therapy, and close monitoring
What is CVP?
Helps monitor the patient's response to fluid resuscitation; represents the volume in the right atrium
Blood products may need to be given if the primary cause of hypovolemic shock is _________
Hemorrhage
The hyperdynamic (warm) phase of sepsis is characterized by:
High CO, BP in normal limits or low, tachycardia, fever, warm/flushed skin, bounding pulse, elevated RR, increased glucose, GI symptoms (n/v, diarrhea, decreased bowel sounds)
Shock can cause the release of catcholemines, cortisol, glucagon, and cytokines, causing ______________
Hyperglycemia
DONT give LR to patients with _________
Hyperkalemia
In the second stage of shock, there is a severely decreased urine output. Why?
Hypoperfusion to the kidneys
Norepinephrine may be considered as a first-line agent for __________ in patients with cardiogenic shock because it causes vasoconstriction
Hypotension
Dobutamine acts on beta-1 receptors to increase myocardial activity and _______ _______
Improve CO
In cardiogenic shock, diastolic dysfunction __________ left atrial pressure, which leads to pulmonary congestion and hypoxemia
Increases
How are the goals of cardiogenic shock management achieved?
Increasing oxygen supply to the heart and decreasing oxygen demands
As it becomes obvious that the patient will not survive the last stage of shock, what is most important?
Informing the family and using clear, honest communication
hypovolemic shock occurs when there is a reduction in _________ volume. Examples include hemorrhage and dehydration.
Intravascular
The nurse must be able to identify patients at risk for anaphylaxis including patients who are allergic to contrast, __________, and ___________
Iodine and fish
The last stage of shock is the _________ stage (end-organ dysfunction)
Irreversible
Increased oxygen requirements in progressive shock can cause ___________
Ischemia
Describe what happens to the BP in nonprogressive shock
It normally stays within normal limits
Signs of obstructive shock caused by pneumothorax
JVD, crepitus, dyspnea, chest pain, tachycardia, tachypnea, trach shifts away from affected side, decreased breath sounds on affected side
With anaerobic cellular metabolism, the _________ ________ levels rise in the blood.
Lactic acid
Colloids are _____ molecule IV solutions given to restore intravascular volume. What is an example of a colloid?
Large; albumin
Elevating the patient's _______ slightly will help improve cerebral blood flow and promote venous return
Legs