Shock

What is the expected finding for heart rate in the progressive stage of shock?

>150 bpm

How is blood pressure regulated?

A complex interaction of neural, chemical, and hormonal feedback systems affecting both cardiac output and peripheral resistance.

What type of metabolism yields more ATP?

Aerobic.

What is the expected finding for urinary output in the irreversible stage of shock?

Anuric, requires dialysis.

Describe the compensatory stage of shock.

Blood pressure is WNL. Increased heart rate. "Fight or flight" epinephrine and norepinephrine release. Body shunts blood from skin, kidneys and GI to brain and heart. Skin is cold and clammy, BS are hypoactive, and urine output decreases. (Can become metabolic acidosis with increased RR)

What are the three major components of the circulatory system?

Blood volume, the cardiac pump, and the vasculature.

A client in shock is prescribed an inotropic drug to act on alpha and beta receptors. The nurse will most likely be administering: A) Dobutamine. B) Pavulon. C) Dopamine. D) Milrinone.

C) Dopamine Dopamine has both alpha and beta receptor effects.

What is the formula for mean arterial blood pressure?

Cardiac Output x Peripheral Resistance = Mean Arterial Blood Pressure

How is peripheral resistance determined?

Diameter of the arterioles.

A client in septic shock is prescribed a medication to replace protein C. What is the name of this medication?

Drotrecogin alfa.

What are crystalloids?

Electrolyte solutions that move freely between the intravascular compartment and interstitial spaces.

What is the expected finding for heart rate in the irreversible stage of shock?

Erratic or asystole

What are the overall management strategies in shock?

Fluid replacement to restore intravascular volume, vasoactive medications to restore vasomotor tone and improve cardiac function, nutritional support to address the metabolic requirements that are dramatically increased.

Define "shock".

Inadequate tissue perfusion that, if untreated, results in cell death. (Systemic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cell function)

What are colloids?

Intravenous solutions that contain molecules that are too large to pass through capillary membranes.

What is the expected finding for skin in the irreversible stage of shock?

Jaundice

What is the expected finding for mentation in the progressive stage of shock?

Lethargy

What is the formula for estimating Mean Arterial Pressure (MAP)?

MAP = Systolic BP + 2(Diastolic BP)/3 (Round to the nearest tenth)

What are the neurologic effects of the progressive stage of shock?

Mental status deteriorates, confusion/subtle changes, lethargy increases, loss of consciousness, pupils dilate and are sluggishly reactive to light.

What are the main objectives in nursing management of the progressive stage of shock?

Preventing complications, promoting rest and comfort, and supporting family members.

Define and describe vasodilators.

Reduces preload and afterload, reducing oxygen demand on the heart. Disadvantage: causes hypotension. Types: nitroglyceride and nitroprusside.

What is the expected finding for respiratory status in the irreversible stage of shock?

Requires intubation.

What are the different typs of vasoactive agents used in treating shock?

Smpathomimetics, vasodilators, and vasoconstrictors.

How is cardiac output determined?

Stroke volume and heart rate.

What is SIRS?

Systemic Inflammatory Response Syndrome: Overwhelming inflammatory response in the absence of infection causing relative hypovolemia and decreased tissue perfusion.

What is the expected finding for blood pressure in the progressive stage of shock?

Systolic <80-90 mm Hg

How do you calculate pulse pressure?

Systolic blood pressure - diastolic blood pressure = pulse pressure.

Define and describe sympathomimetics.

Used to improve contractility, increase stroke volume, and increase cardiac output. Disadvantage: increase oxygen demands of the heart. Types: Amrinone, dobutamine, dopamine, epinephrine, and milrinone.

What are the renal effects of the progressive stage of shock?

When the MAP falls below 80 mm Hg, the GFR cannot be maintained and drastic changes in function occur. Acute renal failure develops (increase in BUN and serum creatinine, fluid and electrolyte shifts, acid-base imbalances, loss of hormonal regulation of BP). Urinary output usually decreases to below 0.5ml/kg/hr.

What is the expected finding for urinary output in the progressive stage of shock?

0.5 ml/kg/hr

What are the most common intravenous fluids used in resuscitation in hypovolemic shock?

0.9% sodium chloride and lactated ringer's solution.

What is a normal pulse pressure?

30-40 mm Hg.

What is the expected finding for heart rate in the compensatory stage of shock?

>100 bpm

What is the expected finding for respiratory status in the compensatory stage of shock?

>20 breaths/min

The nurse is caring for a client experiencing anaphylactic shock. Which of the following should be included in the plan of care for this client: (select all) A) Maintain an adequate airway. B) Decrease myocardial oxygen demand. C) Restore body fluids. D) Remove the source of infection. E) Remove the mechanical barrier to blood flow. F) Support the blood pressure.

A) Maintain an adequate airway and F) Support blood pressure. The immediate goal of treatment of anaphylactic shock is to maintain an adequate airway and to support the blood pressure.

A client has lost a considerable amount of blood and is demonstrating signs of pending shock. Which of the following shock states is this client most likely developing? A) Transport B) Obstructive C) Hypovolemic D) Cardiogenic

A) Transport. Hemorrhage is a transport shock state.

Until the physician arrives to evaluate the status of a client in the ICU, the nurse is going to begin assessing a client for shock. Which of the following would be considered traditional methods to assess this client: (select all) A) Analyze arterial blood gas sample. B) Assess blood pressure. C) Obtain the equipment for a sublingual capnography. D) Measure urine output. E) Prepare the client for a gastric tonometry. F) Have a serum lactate level drawn.

B) Assess blood pressure and D) Measure urine output. Traditional signs to assess shock include blood pressure, heart rate, mentation and urine output.

The nurse is trying to determine the client's current stage of shock. Which of the body systems will begin the renin-angiotensin-aldosterone cycle? A) Pulmonary B) Renal C) Cardiovascular D) Endocrine

B) Renal

The nurse is caring for a client who became ill after working on a car in his garage at home. Which of the following would help diagnose the cause for this client's illness? A) Base deficit. B) Presence of pulsus paradoxus. C) Carboxyhemoglobin level. D) Presence of Beck's triad.

C) Carboxyhemoglobin level. An elevated carboxyhemoglobin level confirms carbon monoxide poisoning.

Where are the baroreceptors responsible for regulating blood pressure located?

Carotid sinus and aortic arch.

What are the cellular effects of shock?

Cellular edema, efflux of K+, increased membrane permeability, lysosomal membrane rupture, influx of Na+ and H2O, cell damage/death, and mitochondrial damage/swelling.

Define anaphylactic shock.

Circulatory shock state resulting from a severe allergic reaction producing an overwhelming systemic vasodilation and relative hypovolemia.

Define septic shock.

Circulatory shock state resulting from overwhelming infection causing relative hypovolemia.

What is the expected finding for skin in the compensatory stage of shock?

Cold, clammy.

What are the hematologic effects of the progressive stage of shock?

Combination of hypotension, sluggish blood flow, metabolic acidosis, and generalized hypoxemia interfere with hemostatic mechanisms. DIC can occur, widespread clotting and bleeding simultaneously, bruising/bleeding may appear, coag times are prolonged, clotting factors and platelets are consumed and require replacement therapy.

What are the three stages of shock?

Compensatory, progressive and irreversible.

What is the expected finding for mentation in the compensatory stage of shock?

Confusion

What are the two types of fluids administered for shock?

Crystalloids (electrolyte solutions that move freely between intravascular and interstitial spaces) and colloids (large-molecule intravenous solutions).

A client is progressing into the third stage of shock. The nurse will expect this client to demonstrate: (select all) A) Neuroendocrine responses. B) Increase in lactic acidosis. C) Intractable circulatory failure. D) Demonstrating MODS. E) Buildup of metabolic wastes. F) Profound hypotension.

D) Demonstrating MODS and E) Buildup of metabolic wastes. The third stage of shock results in major dysfunction of many organs leading to multiple organ dysfunction syndrome (MODS). The buildup of metabolic wastes leads to MODS.

A client is admitted to the ICU with a spinal cord injury from a motor vehicle accident. Which shock state is this client most at risk for developing? A) Transport B) Obstructive C) Cardiogenic D) Hypovolemic

D) Hypovolemic. Neurogenic shock is a type of hypovolemic shock.

A client has been diagnosed with sepsis. The nurse will most likely find which of the following when assessing this client: (select all) A) Severe hypotension. B) Lactic acidosis. C) Oliguria. D) Rapid, shallow respirations. E) Mental status changes. F) Elevated temperature.

D) Rapid, shallow respirations and F) Elevated temperature. Sepsis is manifested by two characteristics, such as temperature >38 degrees C, heart rate >90 bpm, resp rate >20 breaths/min.

What is the expected finding for urinary output in the compensatory stage of shock?

Decreased

What are the hepatic effects of the progressive stage of shock?

Decreased blood flow impairs liver cells' ability to function, less able to metabolize meds and waste products such as ammonia and lactic acid. More susceptible to infection. Liver enzymes and bilirubin levels are elevated. Patient appears jaundiced.

What are the gastrointestinal effects of the progressive stage of shock?

GI ischemia causes stress ulcers in the stomach, patient at risk for GI bleed, mucosa in small intestine can become necrotic and slough off causing bloody diarrhea, bacterial toxins can enter the bloodstream through the lymph system, inability to metabolize nutrients.

What are the 3 main classifications of shock?

Hypovolemic shock, cardiogenic shock, and distributive shock. (4th category - obstructive shock)

Define and describe vasoconstrictors.

Increases blood pressure by vasoconstriction. Disadvantages: increases afterload, therby increasing cardiac workload, compromising perfusion to skin, kidneys, lungs and GI tract. Types: norepinephrine, phenylephrine, and vasopressin.

What is the role of the kidneys in regulating blood pressure?

Kidneys regulate blood pressure by releasing renin, an enzyme needed for the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor --> release of aldosterone from the adrenal cortex --> promotes retention of sodium and water.

What are the cardiovascular effects during the progressive stage of shock?

Lack of blood supply leads to dysrythmias and ischemia, rapid heart rate (sometimes over 150 bpm), c/o chest pain and possible MI, cardiac enzyme levels rise, myocardial depression and ventricular dilation increase.

How do you manage the irreversible stage of shock?

Medically: Usually the same as progressive, but experimental meds/therapies may be used to reduce/reverse the severity of shock. Nursing: Carrying out prescribed treatments, monitoring, preventing complications, protecting patient from injury, and providing comfort.

How is the compensatory stage managed?

Medically: correct underlying disorder, fluid replacement, meds. Nursing: assess systemically those at risk to recognize early shock.

How is the progressive stage of shock managed?

Medically: treat underlying cause, IV fluids and meds, enteral nutritional support, antacids, histamine-2 blockers, antipeptic agents to reduce GI ulcers and bleeding. Nursing: assessment/changes, ECG monitoring, ABGs, electrolyte levels, physical/mental status changes, administration of meds and fluids, possible ventilation/dialysis/balloon pump.

What are biochemical mediators?

Messenger substances that may be released by a cell to create an action at that site or be carried by the bloodstream to a distant site before being activated; also called cytokines.

What is the expected finding for acid-base balance in the progressive stage of shock?

Metabolic acidosis.

What are the main objectives in nursing management of the compensatory stage of shock?

Monitoring tissue perfusion, reducing anxiety, and promoting safety.

What is the expected finding for skin in the progressive stage of shock?

Mottled, petechiae

What is the expected finding for blood pressure in the compensatory stage of shock?

Normal

How can the nurse best assess tissue perfusion?

Observe for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and lab values. (Elevated sodium and glucose)

What is the expected finding for acid-base balance in the irreversible stage of shock?

Profound acidosis.

What is the expected finding for respiratory status in the progressive stage of shock?

Rapid, shallow respirations; crackles

What is the expected finding for blood pressure in the irreversible stage of shock?

Requires mechanical or pharmacologic support.

What are the respiratory effects during the progressive stage of shock?

Respirations are rapid and shallow, crackles are heard over the lung fields, decreased pulmonary blood flow causes arterial oxygen levels to decrease and carbon dioxide levels to increase, hypoxemia and biochemical mediators cause an inflammatory response and pulmonary vasoconstriction, alveoli stop producing surfactant and collapse, pulmonary capillaries leak contents causing pulmonary edema, shunting begins, acute respiratory distress syndrome begins.

What is the expected finding for acid-base balance in the compensatory stage of shock?

Respiratory alkalosis.

Define hypovolemic shock.

Shock state resulting from decreased intravascular volume due to fluid loss.

Define circulatory shock.

Shock state resulting from displacement of blood volume creating a relative hypovolemia and inadequate delivery of oxygen to the cells; also called distributive shock.

Define cardiogenic shock.

Shock state resulting from impairment or failure of the myocardium.

Define neurogenic shock.

Shock state resulting from loss of sympathetic tone causing relative hypovolemia.

What is the pathophysiology of the progressive stage of shock?

The overworked heart becomes dysfunctional; the body's inability to meet increased oxygen requirements produces ischemia; biochemical mediators cause myocardial depression. The autoregulatory function of the microcirculation fails; fluid leaks from capillaries creating edema; less fluid returns to the heart.

What occurs during the irreversible stage of shock?

The point at which damage is so severe the patient does not respond to treatment and cannot survive. Blood pressures remain low. Complete renal and liver failure. Necrotic tissue toxins. Overwhelming metabolic acidosis. ATP reserves are depleted. Multiple organ failure --> complete organ failure --> death.

What is the expected finding for mentation in the irreversible stage of shock?

Unconcious