NURS 319- Cardiogenic and Distributive Shock

Refractory Shock - is variably defined as persistent hypotension with end-organ dysfunction despite fluid resuscitation, high dose vasopressors, oxygenation, and ventilation. If given Norepinephrine in high doses Peripheral Vasoconstriction

Refractory shock is variably defined as persistent hypotension with end-organ dysfunction despite fluid resuscitation, high-dose vasopressors, oxygenation, and ventilation.

nurse will give out the medication Atropine given IV every 5 min max dosage 3 mg

A patient is experiencing Neurogenic Shock what action will nurse take to treat bradycardia?

assessment risk factors 1. cardiogenic shock- -cardiac pump failure due to direct cardiac cause such as.... a. MI b. Heart failure c. Cardiomyopathy d. Dysrhythmias e. valvular rupture or stenosis 2.hypovolemic shock a. excessive fluid loss from diuresis b. vomiting, or diarrhea c. blood loss secondary to surgery d. trauma e. gynecologic/ obstetric causes f. burns g .diabetic ketoacidosis 3. obstructive shock -cardiac pump failure occurs due to an indirect cardiac factor (blockage of great vessels - pulmonary artery stenosis - pulmonary embolism - cardiac tamponade - tension pneumothorax -aortic dissection 4. distributive shock a. neurogenic- loss of sympathetic tone, causing massive vasodilation, head trauma, spinal cord injury, and epidural aesthesia b. septic- endotoxins and other mediators causing massive vasodilation c. anaphylactic- allergen exposure results in an antigen-antibody reaction causing massive vasodilation

Assessment Risk Factors 1. Cardiogenic Shock- Cardiac pump failure due to a direct cardiac cause, such as... a. MI (especially anterior wall infarction) b. heart failure c. cardiomyopathy d. dysrhythmias e. valvular rupture or stenosis -older adult clients are at increased risk of MI and cardiomyopathy 2. Hypovolemic Shock- a. excessive fluid loss from diuresis, b. vomiting, or diarrhea c. blood loss secondary to surgery d. trauma e. gynecologic/ obstetric causes f. burns g. diabetic ketoacidosis. -older adult clients are more prone to dehydration due to decreased fluid and protein intake and the use of medications such as diuretics. Minimal amounts of fluid loss (vomiting, diarrhea) can cause the older adult client to become dehydrated. 3. Obstructive Shock - cardiac pump failure occurs due to an indirect cardiac factor (blockage of great vessels -pulmonary artery stenosis - pulmonary embolism - cardiac tamponade - tension pneumothorax - aortic dissection 4. Distributive Shock divided into 3 types: a. Neurogenic- 1.loss of sympathetic tone, causing massive vasodilation. 2. Head trauma, spinal cord injury, and epidural anesthesia are among the causes b. septic- endotoxins and other mediators causing massive vasodilation. Most common cause is gram-negative bacteria. -urosepsis is more frequent in older adult clients due to increased use of catheters in a long term care facility and late detection of urinary tract infection. (decreased sensation of burning, urgency) c. Anaphylactic-allergen exposure results in an antigen-antibody reaction causing massive vasodilation. common causes include: 1. antibiotics 2. foods (such as peanuts 3. latex 4. bee stings

Cardiogenic Shock Treatment meds: Vasopressors such as Norepinephrine, Dopamine Inotropic Agents such as Dobutamine, Milirinone Lactate - Dobutamine acts on beta 1 receptors which increases strength of myocardial activity. It can cause vasodilation so decrease afterload. Angina Chest pain med: nitroglycerin given IV vasodilates enhances blood flow to the myocardium which improves oxygen delivery Pain Relief Med Opioid Analgesic: Morphine Sulfate

Cardiogenic Medications given to treat Cardiogenic shock include: -Dobutamine is a inotropic agent that increases cardiac contractility -Dopamine is a vasopressor which increases cardiac output by vasoconstriction -Norepinephrine is a vasopressor which increases cardiac output by vasoconstriction.

a. urine output decreases b. skin becomes cool and mottled c. mental status changes d. anxiety is obvious e. capillary refill is delayed

Cardiogenic Shock description: -occurs when the hearts abillity to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. - when stroke volume ad heart rate decrease or become erratic, BP falls and systemic tissue perfusion is compromised Tissue Perfusion Compromised seen in... a. urine output decreases b. skin becomes cool and mottled c. mental status changes d. anxiety is obvious e. capillary refill is delayed Diastolic Dysfunction increases left atrial pressure which leads to pulmonary congestion and hypoxemia. The capillary wedge pressure is greater than 18 mmHg

Clinical Manifestations neurogenic shock

Clinical Manifestations of Neurogenic Shock include -dry warm skin -hypotension with bradycardia

MODS (multiple organ dysfunction syndrome)

Complications: MODS Mulitple Organ Dysfunction Syndrome- MODS can occur from the release of toxic metabolites and destructive enzymes in response to inadequate oxygenation. MODS develops from inadequate tissue perfusion (severe hypotension) and reperfusion of ischemic cells, causing further tissue injury. organ failure usually first occurs in the lungs (adult respiratory distress syndrome) but can occur in the kidney, heart (decreased coronary artery perfusion, decreased cardiac contractility) and decreased cardiac contractility -GI tract (necrosis) risk factors- -include malnutrition, coexisting disease, and advanced age.

DIC (disseminated intravascular coagulation)

DIC is a complication of septic shock that is when thousands of small clots form, creating hypoxia and anaerobic metabolism. As a result of massive, multiple clot formation, platelets, and other clotting factors such as fibrinogen are depleted and client is at risk for hemorrhage and blood can leak from membraned and puncture sites. -assess client preferences related to transfuision of blood products, Some clients might notbaccept this treatment for various reasons ( religion, fear of ontamination) -administer client preference related to transfusion of blood products, some clients might not accept this treatment for various reasons. -monitor results of lab tests (PT, PTT, blood fibrongen, fibrin, degradation products) -assess for further indications of bleeding from mucus membranes, venipuncture sites, gums, and around IV catheters

1. Arterial Lining Insertion: Used to draw up blood specimens and ABGS and other tests. Plus this lining is needed for continuous blood pressure monitoring. 2. Pulmonary Artery Catheter Insertion: this catheter is inserted to measure central venous pressure, pulmonary artery pressure, and cardiac output. -continuous hemodynamic monitoring to manage fluids and dosage of inotropic meds. Nursing Actions: - Monitor ECG during catheter insertion - Have resuscitation meds and equipment ready - monitor hemodynamic waveforms and readings - confirm catheter placement using a chest x-ray

Diagnostic Procedures: 1. hemodynamic monitoring a. arterial lining insertion: needed for continuous blood pressure monitoring and blood specimens for ABGs and other tests. b. Pulmonary artery catheter insertion: a pulmonary artery catheter is inserted to measure central venous pressure, pulmonary artery pressure, and cardiac output. -continuous hemodynamic monitoring is important to manage fluids and dosage of inotropic meds.

Health Promotion and Disease Prevention Hemodynamic Shock

Health Promotion: 1. Cardiogenic- -educate the client about ways to reduce the risk of a myocardial infarction (MI) such as exercise, diet, stress, reduction, and smoking cessation. 2. Hypovolemic Shock- -advise the client to drink plenty of fluids when exercising or when in hot weather -advise the client to obtain early medical attention with illness or trauma and with any evidence of dehydration or bleeding. 3. Obstructive/ Neurogenic/ Hypovolemic Shock - educate the client to obtain early medical attention with evidence of an infection (localized redness, swelling, drainage, fever, urinary frequency, and burning) -advise the client to complete the entire course of antibiotics as directed. 4. Septic Shock - advise the client to obtain early medical attention with evidence of an infection (localized redness, swelling, drainage, fever, urinary frequency, and burning) - Advise the client to complete the entire course of antibiotics as directed. 5. Anaphylactic Shock - advise the client to wear a medical identification wristband, avoid allergens, and have to have an epinephrine pen available at all times. - teach the client and family how to use the epinephrine pen and to be alert to early manifestations of an allergic reaction.

If the patient is hemorrhaging efforts are made to stop bleeding. This may involve applying pressure to the site or procedure to stop internal bleeding

Hypovolemic Shock Nursing Goals (1) restore intravascular volume (2) reverse events leading to inadequate tissue perfusion (3) correct underlying loss of fluid loss If the patient is hemorrhaging efforts are made to stop bleeding. This may involve applying pressure to the site or procedure to stop internal bleeding. Monitor for complications: 1. Fluid overload: Jugular vein distention 2. Hypothermia: IV fluids may be needed to warm and don't give rapid infusion

(1) sudden fluid loss (2) Hemorrhage (3) Gradual deficit by dehydration

Hypovolemic Shock is the most common type of shock and is characterized by a decrease intravascular volume the fluid inside the blood vessels. Hypovolemic shock can be caused by... (1) sudden fluid loss (2) Hemorrhage (3) Gradual deficit by dehydration

1. Hypovolemic Shock 2. Septic Shock

Hypovolemic Shock symptoms: -Decreased central venous pressure seen in two types of shocks.

neurogenic shock

In neurogenic shock their is a loss of balance between parasympathetic and sympathetic stimulation. The sympathetic nervous system is not able to respond to body stressors.

LABS RUNS

LAB RUNS: A. Cardiogenic Shock 1. Cardiac enzymes: elevation can indicate cardiac ischemia or infarction. 2. B type- natriuretic Peptide: elevated in response to increased left ventricular pressure B. Hypovolemic Shock 1. HgB and Hct: decreased with hemorrhage, increased with dehydration C. Septic Shock Cultures: blood, urine, wound Coagulation tests: PT, INR, aPTT

medications- sympathomimetics

Medications -Sympathomimetics is a vasopressor and inotrope. -Epinephrine is a rapid acting bronchodilator - increase heart rate and cardiac output nursing actions- -monitor blood pressure, pulse, and cardiac output -epinephrine can cause sloughing if it infiltrate tissue

Milrinone and dobutamine are inotropic agents which strengthens cardiac contractions and increases cardiac output. -dobutamine -milrinone lactate nursing actions -administer by continuous IV infusion with constant hemodynamic monitoring -can titrate to maintain prescribed

Medications- Inotropic Agents -Milrinone Lactate -Dobutamine

meds -vasopressors -norepinephrine -vasopressin -dobutamine

Medications- Vasopressors - norepinephrine is 1st drug of choice -vasopressin is 2nd line drug of choice -dobutamine help to induce vasoconstriction and increase MAP mean arterial pressure nursing actions- - administer by continuous IV infusion with constant hemodynamic monitoring. - can titrate to maintain prescribed hemodynamic parameters - monitor urine output -administer through a central line to prevent extravasation

Neurogenic Shock Medical Management:

Neurogenic Shock Medical Management: Treatment of neurogenic shock involves IV fluid or plasma expanders, vasopressors, and restoring sympathetic tone, either through stabilization of a spinal cord injury or, in the instance of spinal anesthesia, by positioning the patient properly. -if hypoglycemia is the cause glucose is rapidly administered.

Nursing Management For Neurogenic Shock

Nursing Management for Neurogenic Shock- -Nurse is aware that orthostatic hypotension caused by loss of vasomotor tone below the level of spinal cord lesion can occur with position changes. - even slightly raising head of bed for a new tetraplegic patient can result in a drastic hypotension -apply sequential compression devices since pooled blood increases risk of thrombus formation. -Nurse must check patient daily for any lower extremity pain, redness, tenderness, unilateral edema, and warmth of edema. - administration of heparin or Lovenox may prevent thrombus formation. - Passive range of motion also helps to promote circulation

a. blockage of great vessels b. pulmonary artery stenosis c. pulmonary embolism d. cardiac tamponade e. tension pneumothorax f. aortic dissection Obstructive shock caused by indirect cardiac factors such as pulmonary embolism. A sign of pulmonary embolism is chest pain.

Obstructive Shock cardiac pump failure due to indirect cardiac factors like... a. blockage of great vessels b. pulmonary artery stenosis c. pulmonary embolism d. cardiac tamponade e. tension pneumothorax f. aortic dissection

Obstructive Shock

Obstructive shock is a form of shock caused by a physical obstruction to blood flow, either in the heart or major blood vessels. This causes a decrease in CO and thus a decrease in tissue perfusion. 1. Tension Pneumothorax- air or blood has entered the pleural space and causes a restriction in the lungs expansions, if enough air is trapped then eventually pressure builds up and compresses vessels and myocardium. 2. cardiac tamponade results from excessive fluid in the pericardium the sac that surrounds the heart. 3. PE- is a clot that gets lodged in the pulmonary vasculature and causes ischemia to capillary beds.' -if the patient is experiencing obstructive shock, then these procedures, are done at bedside. to diagnose pneumothorax would need- a. chest radiograph b. computed tomography (CT ) Scans - a chest radiograph is often used to diagnose a pneumothorax. A chest tube or needle decompression is the primary procedure to relieve tension pneumothorax. Cardiac tamponade is diagnosed similarly with: a. echocardiography b. pericardiocentesis PE Diagnosed using a. CT angiogram

meds

Opioid Analgesic: Morphine Sulfate Actions: Pain Management Nursing Actions: -monitor respirations of clients who are nonventilated -monitor blood pressure, heart rate, and SaO2 -Moniotr ABGS Proton Pump Inhibitor: Pantoprazole action-protect against stress ulcer development Anticoagulants: -Low molecular weight heparin -Enoxaparin Sodium actions- deep vein thrombosis, prophylaxis, Isotonic crystalloids or colloids -0.9% sodium chloride and or lactated ringers action- hypovolemic shock fluid replacement replace fluid first vasodilator; sodium nitroprusside -used to treat cardiogenic shock -reduce afterload and preload -causes vasodilation decreases cardiac output and afterload

Patient Centered Care

Patient Centered Care: Nursing Care- -oxygenation status (priority) -vital signs -cardiac rhythm with continuous cardiac monitoring -urine output, report if less than 20 mL/hr -LOC -skin color, temperature, moisture, capillary refill, turgor -place the client on high flow oxygen such as 100% non-rebreather face mask. -if person has COPD insert a 2 liter per min nasal cannula and increase the oxygen flow as needed. - be prepared to intubate the client, have emergency resuscitation equipment ready - maintain patent airway - for hypotension, place the client flat with both legs elevated to increase venous return. -monitor central venous pressure, pulmonary artery pressure, cardiac output, and pulse pressure -titrate continous IV fluid

1. administer epinephrine intramuscularly 2. administer oxygen via face mask as applied 3. provide diphenhydramine

Patient experiencing respiratory distress after eating an item of known allergy. What intervention will nurse implement to provide emergency care to this patient?

SEPSIS CRITERIA PLUS CONFIRMED BACTERIA INFECTION

Sepsis is defined as presence of at least two of the four signs of the systemic inflammatory response syndrome... 1. Fever (above 38 C) OR Hypothermia (below 36 C) 2. Tachycardia (more than 90 beats/min) 3. Tachypnea (more than 20 breaths/min) OR PaCo2 less than 32 mmHg Hypocapnia 4. Leukocytosis ( more than 12,000 cells) or Leukopenia (less than 4,000) 5. WBC Immature bands > 10% bands

blood culture coagulation tests: aPTT, INR, PT

Septic Shock diagnosis tests

Shock is a state of inadequate tissue perfusion that impairs cellular function and can lead to organ failure.

Shock is a state of inadequate tissue perfusion that impairs cellular function and can lead to organ failure. Any condition that compromises oxygen delivery to organs and tissues can lead to shock. -Shock is a rapidly-progressing, life threatening process. Early detection with rapid response is necessary to improve client outcome. - Older adult clients have reduced compensatory mechanisms and rapidly progress through the stages of shock. - Catecholamine secretions might not improve contractility or cause vasoconstriction as in younger adults due to decreased baroreceptor response. Decreased abillity to compensate can cause sustained low cardiac output and blood pressure.

Initial: No visible changes in client parameters; only changes on the cellular level. Compensatory (Non Progressive): Measures to increase cardiac output to restore tissue perfusion and oxygenation. Progressive: Compensatory mechanisms to fail Refractory: Irreversible shock and total body failure

Stages of the Shock All types of shock progress through the same stages and produce similar effects on body systems. Initial: No visible changes in client parameters; only changes on the cellular level. Compensatory (Non Progressive): Measures to increase cardiac output to restore tissue perfusion and oxygenation. Progressive: Compensatory mechanisms to fail Refractory: Irreversible shock and total body failure

a. bronchodilation , less wheezing an expected action of epinephrine is bronchodilation as evidenced by less wheezing epinephrine is a sympathomimetics agent will see a. increase in heart rate b. increase in BP c. relaxes the muscles on the airways bronchodilation

The action of epinephrine has been in a patient with anaphylactic shock effective when... Epinephrine is given MED FOR ANAPHYLATIC SHOCK

1. Cardiogenic Shock 2. Hypovolemia Shock 3. Obstructive Shock 4. Distributive Shock

Types of Shock: 1. Cardiogenic Shock: failure of the heart to pump effectively due to a cardiac factor. 2. Hypovolemia Shock: a decrease in intravascular volume of at least 15% to 30%. 3. Obstructive Shock: impairment of the heart to pump effectively as a result of a noncardiac factor. 4. Distributive Shock: Widespread vasodilation and increased capillary permeability, including neurogenic, septic, and anaphylactic shock.

Hgb and Hct and would see an increase with dehydration

Which of following would you diagnose someone with hypovolemic shock?

1. Warm, dry, skin - The patient experiences parasympathetic stimulation that causes vasodilation lasting for an extended period. 2. Bradycardia -Overriding parasympathetic stimulation will cause a drop in heart rate . Lab values for hemodynamic Monitoring: SVR will be decreased stroke volume resistance as seen with vasodilation

Which of the following is a sign of neurogenic shock? answer: 1. warm, dry, skin 2. bradycardia 3. hypotension Labs/ Hemodynamic Monitoring -SVR stroke volume resistance will be decreased

1. cardiac enzymes 2. B-type natriuretic peptide

Which of the following labs would be use to diagnose someone with cardiogenic shock?

Anaphyatic shock

anaphylactic shock occurs rapidly and is life threatening. Because anaphylactic shock occurs in patients already exposed to an antigen and who have developed antibodies to it, it sometimes can be prevented. -the nurse observes for generalized hives, pruitus, or flushing, angioedema, swelling of tongue, dyspnea, wheezing, stridor, hypoxemia, and reduced blood pressure. Treatment of anaphylactic shock requires removing causative antigen and administer meds that restore vascular tone, In addition the healthcare team will need to provide emergency airway support, position the patient in supine, administer oxygen, provide ventilation support. (endotracheal intubation or tracheostomy may be needed to establish airway) early administration of epinephrine given intramuscularly which is repeated every 5 to 30 mins if response is inadequate. IV Lines are administered to provide access for administering fluids and. Aggression IV fluid resuscitation is expected with hypotension. The patients cardiac status is monitored for and the ECG is assessed because anaphylaxis and treatments can be associated with arrhythmia and cardiac ischemia.

Medication: Antibiotics

septic shock is most commonly caused by gram negative bacteria so administer antibiotics within 1 hour of septic shock diagnosis. Vancomycin- antibiotics sensitive to culture organism such as vancomycin

therapeutic procedures hemodynamic shock

therapeutic procedures 1. intubation and mechanical ventilation -an artificial airway is inserted and the clients respirations are controlled by mechanical ventilation. 2. PEEP positive end expiratory pressure is applied to the end of expiration to keep alveoli open to promote gas exchange. -PEEP is added to the ventilator setting to increase oxygenation and improve lung expansion. Client ed- wont be able to talk with the endotracheal tube in place