Chapter 26 Shock, Sepsis, and Multi Organ Dysfunction Syndrome

phase 2: compensation

-alarm -muscle breakdown, catabolism, hypoglycemia

types of shock

-cardiac output -decreased SVR components (1) volume (2) contractility (3) flow (4) resistance

shock overview

-clinical condition in which tissue perfusion is inadequate & cells have a higher O2 demand and supply (ischemia) -all organ systems are affected -shock can be reversed by the body's compensation mechanisms or clinical intervention -shock can progress to MODS & death golden hour

Shock: cardiac s/s

-decreased CO -weak pulse -slow capillary refill -tachycardia (except neurogenic) -flat veins on neck and hands in dependent position *impaired tissue perfusion

poor perfusion

-hypotension & tissue hypoxia > anaerobic metabolism >metabolites build up resulting in acidosis & hyperkalemia r/t cell lysis >prolonged PR interval and widened QRS >bradycardia, heart block, vfib, or asystole

Shock: treatment

-hypotension > fluid & vasopressors -decreased LOC/inadequate perfusion > oxygen via NC, intubation & mechanical ventilation -central line may be placed to facilitate infusion of fluid, vasopressors, and to obtain frequent blood work

shock: CO factors

-hypovolemic (inadequate volume) -cardiogenic (inadequate contractility) -obstructive (flow obstruction)

Shock: Goals

-return to baseline of HR, BP, RR -return to baseline or near baseline function of organs -MAP 65 mm Hg -Urine output >30mL/hr

phase 3: resistance

-symptoms of distress disappear -pt requires assistance and support

phase 4: exhaustion/decompensation

-symptoms reappear -adaption goes below the normal level of resistance

3 OVERALL goals in treating Shock

1. Identify/Treat underlying cause 2. Restore perfusion 3. Prevent organ failure

Nursing Priorities in managing the psychosocial stress of critical illness (8)

1. Providing information on patient status 2. Explaining procedures and routines 3. Supporting the family 4. Encouraging the expression of feelings 5. Facilitating problem solving and shared decision making 6. Individualizing visitation schedules 7. Involving the family in the patient's care 8. Establishing contacts with necessary resources

4 global indicators of systemic perfusion and oxygenation, or global oxygen balance (L,BD,Bi, OS) (hint: They're also indicative of metabolic acidosis in shock patients if abnormal; Think oxygen and ABGs, but related to shock; PAO2, PCO2,FIO2, CO2 are not answers)

1. Serum lactate (increased) 2. Arterial base deficit 3. Serum Bicarbonate (decreased) 4. Central or mixed venous oxygen saturation levels Rationale: Inadequate cellular oxygenation with anaerobic metabolism and increased metabolic lactate production increase the serum lactate level. The base deficit derived from arterial blood gas (ABG) values also reflects global tissue acidosis and is useful to assess the severity of shock. Studies have demonstrated serum bicarbonate to be an equivalent alternative to arterial base deficit in predicting mortality in surgical and trauma patients. The use of mixed venous oxygen saturation (Svo2) measured by means of a pulmonary artery catheter or central venous oxygen saturation (Scvo2) measured with a central venous catheter allows assessment of the balance of oxygen delivery and oxygen consumption and the ratio of oxygen extraction.

shock: managing hemodynamics

1. fluids 2. vasopressors

shock: stages

1. initial 2. nonprogessive 3. progressive 4. refractory

nurse is working on a spinal cord injury unit and has just finished a report. Which of the following patients should be seen first? 24-year-old man who has not had a bowel movement since yesterday 28-year-old woman who is complaining of being cold 32-year-old man whose blood pressure is 84/40 mm Hg and heart rate is 60 beats/min 18-year-old woman whose dose of low-molecular-weight heparin is due

32-year-old man whose blood pressure is 84/40 mm Hg and heart rate is 60 beats/min

The patient with a mean arterial blood pressure (MAP) less than __ mm Hg or with evidence of global tissue ____perfusion is considered to be in a shock state.

60 Hypo (Urden, 2016, p. 521)

Organ dysfunction may be the result of direct insult (Trauma, Aspiration). Which form of MODS is this? A. Primary B. Secondary C. Tertiary

A. Primary

A patient presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur? A. Progressive B. Compensation C. Refractory D. Early

A. Progressive Rationale: The Progressive stage occurs as compensatory mechanisms fail. The client's condition spirals Into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis

Specific Renal consequence of shock

Acute Kidney Injury/Failure (Urden, 2016, box 26-1, p.521)

2 specific Pulmonary consequences of shock (One of these leads to the other; Serious respiratory issues)

Acute Lung Failure ARDS (Urden, 2016, box 26-1, p.521)

Type of distributive shock caused by severe antibody-antigen reaction

Anaphylactic

A patient complains of a sudden onset of itching and hives along with shortness of breath after initiation of an antibiotic infusion. You can hear audible wheezing. Which one of the following is the most likely explanation? Anaphylaxis Sepsis MODS Severe sepsis

Anaphylaxis

Pharmacological treatment for Bradycardia

Atropine

During hypermetabolism, changes occur in cellular anabolic and catabolic function, resulting in ______________. Hypermetabolism lasts __ to __ days.

Autocatabolism 14 to 21

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use? A. Unstable angina pectoris B. Aortic insufficiency C. Diabetes mellitus D. Hypertension

B. Aortic Insufficiency Rationale: A history of aortic insufficiency contraindicates use of the IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn't respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren't contraindications for IABP.

A patient presents to the emergency department (ED) with her husband. The patient appears in respiratory distress. The husband states "I think she ate a dessert made with peanuts; she's allergic to peanuts." The nurse should administer which of the following agents first? A. Diphenhydramine (Benadryl) IV B. Epinephrine (Adrenalin) intramuscularly (IM) C. IV infusion of normal saline D. Albuterol (Proventil) nebulizer

B. Epinephrine Rationale: All of the interventions are indicated in the treatment of anaphylactic shock. However, IM epinephrine is administered first because of its vasoconstrictive actions. Diphenhydramine (Benadryl) is administered IV to reverse the effects of histamine, thereby reducing capillary permeability. Nebulized medications, such as albuterol (Proventil), may be given to reverse histamine-induced bronchospasm. Fluid management is critical, as massive fluid shifts can occur within minutes due to increased vascular permeability. (less)

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? A. Myocardial infarction B. Head injury C. Multiple sclerosis D. Diabetes

B. Head Injury Rationale: An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries. (less)

Organ dysfunction may manifest latently as a result of widespread sustained systemic inflammation that results in dysfunction of organs not involved in direct insult. Which form of MODS is this? A. Primary B. Secondary C. Tertiary

B. Secondary

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respiration's are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? A. Neurogenic B. Septic C. Anaphylactic D. Cardiogenic

B. Septic Rationale: In the early stage of septic shock, the blood pressure may remain normal, the heart rate tachycardic, the respiratory rate increased, and fever with warm, flushed skin. The client, in the other shocks listed, usually present with different signs such as a normal body temperature, hypotension with either tachycardia or bradycardia, skin that is cool and clammy, and respiratory distress.

4 Signs and Symptoms of Neurogenic Shock

Bradycardia Hypotension Hypothermia Warm/Dry Skin

Please SELECT ALL TRUE statements regarding MODS: A. Kidneys are usually the first organ affected B. Organs always fail in progressive order C. Hypermetabolism lasts 14-21 days and leads to autocatabolism D. In addition to ARF, ARDS, and DIC, MODS may also impact GI and biliary system significantly.

C, D Rationale: GI manifestations include translocation of GI bacteria thru "leaky" gut, hypoperfusion, and colonization. Hepatobiliary manifestations include altered metabolism, hepatitis, and cholecystitis. Lungs are affected first and organs may fail all at once.

You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client? A. Hormone antagonist drugs B. Antimetabolite drugs C. Adrenergic drugs D. Anticholinergic drugs

C. Adrenergic Drugs

Most common cause of Obstructive Shock

Cardiac Tamponade

Type of shock resulting from the impaired ability of the heart to pump

Cardiogenic

4 specific Neurologic consequences of shock

Coma Sympathetic Nervous System Dysfunction Cardiac/Respiratory Depression Thermoregulatory Failure (Urden, 2016, box 26-1, p.521)

6 Signs and Symptoms of Hypovolemic Shock

Cool/clammy skin Tachycardia Tachypnea Flat neck veins Clear bilateral breath sounds Decreased urine output

Lack of adequate circulating volume leads to _________ tissue perfusion and initiation of _____ response.

Decreased Shock

Specific Hematologic/Coagulation consequence of Shock (Most dangerous in shock)

Disseminated Intravascular Coagulation (DIC) (Urden, 2016, box 26-1, p.521)

Type of shock resulting from maldistribution of circulating blood volume

Distributive

A nurse is consulting with a multidisciplinary team regarding renal impairment from sepsis. Which of the following statements regarding renal dysfunction is true? An increased creatinine level is the earliest sign of renal impairment. Elevated peak levels of antibiotics can lead to renal impairment. Hypotensive episodes do not affect renal function. Increased production of erythropoietin may result in renal impairment.

Elevated peak levels of antibiotics can lead to renal impairment.

First line treatment of choice for Anaphylaxis

Epinephrine

The nurse notes that the patient's arterial blood gases reflect hypoxia, respiratory alkalosis, scattered crackles, and distended jugular veins. Heart tones are distant, but an S3 and S4 are noted despite scant amounts of concentrated urine output. The nurse anticipates the administration of which of the following intravenous pharmacologic or parenteral therapies? Isotonic saline Amiodarone Furosemide Sodium bicarbonate

Furosemide

3 specific Gastrointestinal/Endocrine consequences of Shock (3 failures)

GI Tract Failure Liver Failure Pancreatic Failure (Urden, 2016, box 26-1, p.521)

Because shock is a dynamic physiologic phenomenon, ___________ may occur late in the process and even normalize when tissue perfusion is still inadequate. (hint: If you've had a shock patient with this, eventually they've been given Levophed)

Hypotension (Urden, 2016, p. 521)

6 Signs and Symptoms of Septic Shock

Hypotension Tachycardia Increased Respiratory Rate Fever Warm flushed skin/Erythema Slight Confusion

Most common type of Shock

Hypovolemic

Type of shock resulting from loss of circulating or intravascular volume; May result from burns and hemorrhage.

Hypovolemic

fluids

IV fluids (normal saline & lactate ringers) volume expanders (albumin, plasma, blood)

What is the major and immediate focus of shock treatment? (Because all types of shock lead to a certain impairment, whats our focus? Think hypoxia and hypotension)

Improvement and preservation of tissue perfusion Rationale: Eventually we will want to find and treat the underlying cause of the shock, but this can take time. In the immediate period once its identified as shock, we want to restore perfusion and keep the tissues alive. (Urden, 2016, p. 521)

3 stages of Shock Syndrome (C,P,R)

Initial/Compensatory Progressive Refractory

In this stage of shock, cardiac output is decreased, tissue perfusion is threatened, prompting compensatory mechanisms mediated by SNS (vasoconstriction, etc) to begin

Initial/Compensatory Phase

Why is Lactated Ringer's Solution most commonly used in treatment of shock over standard isotonic solution?

Lactated Ringers compensation more closely resembles blood plasma

Septic Shock isn't generally picked up on quick, as it is based on presence of symptoms that may not appear right away. What quick lab test could one measure to be a possible predictor?

Lactic Acid

What occurs during Absolute Hypovolemia?

Loss of fluid from the intravascular space to the extravascular space (Third Spacing)

7 Signs and Symptoms of Cardiogenic Shock

Low mean arterial pressure Narrow pulse pressure Crackles S3 heart sound Dyspnea JVD Chest Pain

Adequate tissue perfusion depends on an adequate supply of oxygen and the cells ability to use it. Name 4 collaborative therapies that will support oxygen delivery to the tissues in Shock (hint: First you'll wanna get an airway, but how? After you got oxygen flowing, somethings gotta carry it to the tissues right? Not if the vessels are too dilated. The oxygen needs something to bind to as well. What if that decreases?)

Mechanical Ventilation (Get an airway) Vasoactive Drugs (Constrict the vessels/Get the hear pumping) Fluid Administration (Fill up the tank/vessels) Blood transfusion (If hemoglobin tanks)

Translocation of bacteria from a "leaky gut" perpetuates an inflammatory focus in critically ill patients with systemic inflammatory response syndrome (SIRS)/multiple organ dysfunction syndrome (MODS). What is the primary mechanism of bacterial translocation? Colonization of the oropharynx Mesenteric lymphatic transfer Proliferation of Bifidobacterium and Lactobacillus Gastrointestinal lesions

Mesenteric lymphatic transfer

What are the level and duration of Hyperlactatemia predictive of in shock patients?

Morbidity and Mortality Rationale: The level and duration of this hyperlactatemia are predictive of morbidity and mortality, and management guided by lactate levels has been effective in improving outcomes. (Urden, 2016, p. 521)

Results from progressive physiologic failure of two or more separate organ systems in an acutely ill patient

Multiple Organ Dysfunction Syndrome

2 most common causes of Cardiogenic Shock

Myocardial Infarction Congestive Heart Failure

Type of distributive shock that results in loss of sympathetic tone, thus impaired sympathetic nervous system innervation

Neurogenic

Type of shock associated with physical obstruction of the great vessels or the heart itself; Cardiac Tamponade; Tension pneumothorax

Obstructive

Why is hypotension an unreliable indicator in hemorrhagic shock?

Patients can lose 25% of volume before hypotension occurs.

A patient is in shock and is hypotensive. A vasoconstrictor is recommended to increase afterload and systemic vascular resistance (SVR). Which of the following medications is most appropriate? Nitroprusside (Nipride) Phenylephrine (Neo-Synephrine) Dobutamine (Dobutrex) Labetalol (Trandate)

Phenylephrine (Neo-Synephrine)

In this stage of shock, compensatory mechanisms BEGIN to fail in meeting the patients metabolic needs, progressing to complications such as SIRS, lactic acidosis, DIC, ARDS, etc

Progressive Phase

In this stage of shock, shock becomes unresponsive to therapy and is considered irreversible, MODS is a certainty, and death is the final outcome

Refractory Phase

Class II hypovolemia is considered a 15% to 30% fluid volume loss. Falling cardiac output activates what compensatory response? Widened pulse pressure Increase urine sodium level Decreased urine osmolality and specific gravity Respiratory alkalosis

Respiratory alkalosis

Type of Distributive Shock caused by of microorganisms invading the body

Septic

MODS may be a complication of any shock, but which shock is it more commonly seen in?

Septic Shock (Hinkle and Cheever, 2013, p. 306)

Which of the following states includes hypotension despite adequate fluid resuscitation along with perfusion abnormalities such as lactic acidosis and oliguria? Bacteremia Systemic inflammatory response syndrome Multiple organ dysfunction syndrome Septic shock

Septic shock

Which laboratory value provides information regarding the severity of impaired perfusion and helps determine the adequacy of therapies in the patient with septic shock and multiple organ dysfunction syndrome (MODS)? Serum glucose Serum lactate Serum albumin Serum creatinine

Serum lactate

Complex pathophysiologic syndrome that often progresses to multi organ dysfunction syndrome

Shock Syndrome

Administration of what alkali is NOT recommended for the treatment of shock-related lactic acidosis, as it can causes excessive sodium retention?

Sodium Bicarbonate (Urden, 2016, p. 522)

Toxic epidermal necrolysis occurring in less than 10% of the body caused by a hypersensitivity reaction to drugs like Bactrim, Sulfa drugs, and Dilantin

Steven-Johnson Syndrome (Porth, 2011, p. 1184)

6 Signs and Symptoms of Anaphylactic Shock

Sudden Hypotension Bronchospasm Tightness in chest Dyspnea Wheezing/Stridor Pruritus (severe itching)

Knowing that Secondary MODS is a consequence of widespread sustained systemic inflammation, what is the common initiating event that causes secondary MODS? (hint: The answer is in the question)

Systemic Inflammatory Response Syndrome (SIRS)

Which of the following sets of clinical assessment and laboratory findings would indicate that your patients has SIRS (systemic inflammatory response syndrome)? Temperature of 37.4° C; heart rate of 110 beats/min; and respiratory rate of 18 breaths/min Temperature of 36.2° C; heart rate of 88beats/min; and WBC count of 15,000 Temperature of 35.8° C; heart rate of 98 beats/min; and respiratory rate of 24 breaths/min Temperature of 38.6° C; PaCO2 of 34; and WBC count of 11,500

Temperature of 36.2° C; heart rate of 88beats/min; and WBC count of 15,000

All types of shock eventually result in what impairment?

Tissue Perfusion/Circulatory failure

True or False: SIRS is present when two or more of the following clinical manifestations are present: RR high, WBC high or low, heart rate>90, and temp high or low. The manifestations are a deviation from baseline and not related to treatment such as chemo.

True

True or False: In Class I Hypovolemic Shock, the patient may not exhibit any symptoms.

True Rationale: Please recall that in Class I shock there may be no obvious signs of hypovolemic shock (Urden, 2016, p. 523)

shock: decreased SVR

VASODILATION -neurogenic -anaphylactic -septic

What occurs during Relative Hypovolemia?

Vasodilation produces an increase in vascular capacitance, but not enough circulating volume

2 specific Cardiovascular consequences of shock

Ventricular failure Microvascular thrombosis (Urden, 2016, box 26-1, p.521)

The most common cause of cardiogenic shock is: cardiopulmonary arrest. acute myocardial infarction. acute myocarditis. prolonged septic shock.

acute myocardial infarction.

Collaborative management for the patient with multiple organ dysfunction syndrome includes decreasing oxygen demand with administration of: vasoactive and positive inotropic medications. diuretics and antidysrhythmic medications. crystalloids and antibiotics. antipyretics and sedation.

antipyretics and sedation.

Severe sepsis and septic shock management guidelines include: low-dose dopamine for renal protection. blood glucose maintenance around 150 mg/dL. erythropoietin administration for anemia. antithrombin therapy for deep vein thrombosis protection.

blood glucose maintenance around 150 mg/dL.

initial stage

body can compensate -baseline decrease MAP 5-10mm Hg -pt not feeling well -typically at home

The nurse is developing a care plan for the patient in cardiogenic shock, and the goals for therapy include: increasing preload. decreasing afterload. increasing myocardial workload. increasing systemic vascular resistance (SVR).

decreasing afterload.

A major consequence of hematologic dysfunction during shock includes: disseminated intravascular coagulation (DIC). acute lung injury (ALI). microvascular thrombosis. thermoregulatory failure.

disseminated intravascular coagulation (DIC).

progressive stage

emergency treatment within 1st hr -baseline MAP decrease >20 -failure to rescue if no tx within 1hr

The priority nursing diagnosis for the patient in shock regardless of the phase or type is: deficient fluid volume. ineffective breathing pattern. ineffective tissue perfusion. imbalanced nutrition: less than body requirements.

ineffective tissue perfusion.

refractory stage

irreversible organ damage -tissue ischemia, necrosis, MODS, death -emergency treatment is too late

A patient is admitted secondary to a near-drowning in an ice-covered lake. The nurse knows that a primary risk for this patient includes: severe sepsis. septic shock. disseminated intravascular coagulation. multiple organ dysfunction syndrome (MODS).

multiple organ dysfunction syndrome (MODS).

vasopressors

norepineprhine epinephrine phenylephrine high dose dopamine vasopressin dobutamine

phase 1

normal level of resistance

Selye's General Adaptation Syndrome

phase 1 phase 2 phase 3 phase 4

A postoperative patient has a heart rate of 110 beats/min and blood pressure (BP) of 110/80 mm Hg (previously 130/60 mm Hg). Urine output has been 20 mL/hr for the past 3 hours, capillary filling time is 5 seconds, the skin is cool, the neck veins are flattened, and the patient is complaining of thirst. The nurse suspects: the patient is experiencing hypovolemic shock. the patient has a cardiac tamponade. the patient is in cardiogenic shock. the patient is having an allergic reaction.

the patient is experiencing hypovolemic shock.

nonprogressive stage

treatment can stop shock from progressing -baseline MAP decrease 10-15mm Hg -treatment is CRITICAL to prevent shock

components of circulation

volume contractility flow resistance