Shock
In the nonprogressive stage of hypovolemic shock, a decrease in MAP of _______ mm/Hg below baseline is detected by _________ in the aortic arch and carotid sinus. This information is transmitted to the brain; additional compensatory mechanisms are initiated.
-10-15 -baroreceptors
In the initial stage of hypovolemic shock, what are the circulatory compensations? Is it effective in this early stag?
-A slight increase in heart rate and respiratory rate may be noted (cardiovascular compensation). -A slight increase in DBP (diastolic BP) might be noted. In this early stage cardiovascular compensatory mechanisms are so effective that oxygenated blood flow to vital organs is maintained.
What are nonsurgical interventions for the client in hypovolemic shock?
-ABCs -Oxygen -IV -Consider blood products -Consider vasoconstricting drugs (in class teacher stated our body does a good job vasoconstricting already, so vasoconstricting drugs don't work as well) -Frequent vital signs and reassessment -Consider an intra-arterial catheter for continuous BP monitoring Treat the cause of the shock as soon as possible!
Despite the severity of severe sepsis, why is it often missed in patients?
-Despite the severity this is often missed!! Why? -Because cardiac function is hyperdynamic: output is increased so the SBP is high, patient feels warm and "looks good" with little or no cyanosis. Also, WBCs may no longer be elevated (because they have been used up).
What are the stages of adaptive response and events during hypovolemic shock?
-Initial Stage -Nonprogressive Stage or Compensatory Stage -Progressive Stage -Refractory Stage
What signs will the patient have in severe sepsis?
-Lower 02 Sat, increased respiratory rate, decreased or absent urine output, and decreased mental status. -At this point the downhill course leading to septic shock is rapid
What is the patient's temperament in the progressive stage of hypovolemic shock? What does he often complain of?
-Patient may be confused, possible impending doom -Complains of severe thirst
How long can a patient be in the progressive stage of hypovolemic shock?
-This is a life threatening situation that cannot be sustained for long without interventions to reverse the cause of the shock. The progressive stage of shock is a life-threatening emergency. Vital organs can tolerate this situation for only a short time before being damaged permanently. Immediate interventions are needed to reverse the effects of this stage of shock. Tolerance varies from person to person and depends on age and health. The patient's life usually can be saved if the conditions causing shock are corrected within 1 hour or less of the onset of the progressive stage.
Severe sepsis that leads to multiple organ system syndrome (MODS) (septic shock) has what occurring?
1. Cell anoxia and cell deathin more vital organs 2. Failure of nonvital organs 3. Reduced function and failure of vital organs 4. Widespread bleeding
SIRS that leads to severe sepsis has what occurring?
1. Cell anoxia, cell death 2. Organ failure 3. Release of metabolites 4. Microthrombi form, consuming platelets and clotting factors 5. Triggers more pro-inflammatory cytokines
The systemic inflammation of SIRS leads to what?
1. Hypodynamic state from vasodilation (characterized by decreased cardiac output and increased peripheral resistance) 2. Increased release of pro-inflammatory cytokines 3. Pooling of blood, cellular hypoxia 4. Vascular damage 5. Formation of microthrombi
What is the calculation our teacher taught us in class to calculate MAP?
1/3 SBP (systolic BP) + 2/3 DBP (diastolic BP) = MAP
What is the normal range for lactic acid? Why may it be abnormal in shock (does it increase or decrease)?
3-7 mg/dL 0.3-0.8 mmol/L Increased due to anaerobic metabolism with buildup of metabolites
What is the normal range for potassium? Why may it be abnormal in shock (does it increase or decrease)?
3.5-5.0 mEq/L or mmol/L Increased due to dehydration, acidosis In class, teacher istated ncreased to due RBCs breaking
What is the normal range for PaCO2? Why may it be abnormal in shock (does it increase or decrease)?
35-45 mm Hg It is increased due to anaerobic metabolism
What is the normal range for pH? Why may it be abnormal in shock (does it increase or decrease)?
7.35-7.45 It is decreased in shock due to insufficient issue oxygenation causing anaerobic metabolism and acidosis.
A MAP of below _____ is abnormal.
70mm/Hg
What is the normal range for PaO2? Why may it be abnormal in shock (does it increase or decrease)?
80-100 mm Hg It is decreased in shock due to anaerobic metabolism
What is the MAP of 120/72?
88
What is the MAP of 132/66?
88
Normal MAP is what?
90mm/Hg
Which vital sign change in a client with hypovolemic shock indicates to the nurse that the therapy is effective? A. Urine output increase from 5 mL/hr to 25 mL/hr B. Pulse pressure decrease from 35 mm Hg to 28 mm Hg C. Respiratory rate increase from 22 breaths/min to 26 breaths/min D. Core body temperature increase from 98.2° F (36.8° C) to 98.8°F (37.1° C)
A
What is capillary bed?
A capillary bed is a concentration of capillaries which supply blood to a specific organ or area of the body.
What do baroreceptors detect?
A decrease in MAP of 5 to 10 mm Hg below the patient's normal baseline value. Baroreceptors (pressure receptors) can detect instantaneous change in blood pressure-that's why young people can move from laying down and then standing up without getting dizzy (this produces a decrease in the stretch of the baroreceptors with a resultant increase in heart rate and sympathetically induced vasoconstriction that causes an increase in peripheral vascular resistance). Older people can't do this cause their baroreceptors don't work as well.
How does a local infection progress to death?
A local infection leads to a systemic infection (early sepsis), which leads to SIRS (systemic inflammatory response syndrome), which leads to organ failure (severe sepsis), which leads to multiple organ system syndrome (MODS) septic shock), which leads to death.
Oh Nurse! Approximately how much does 1 liter of water weight? A. 1 kilogram B. 2 kilograms C. 1 pound D. 1/2 pound
A. 1 kilogram
Oh Nurse! Can more than one type of shock be present at the same time? (Picture of guy who drove himself into a tree). A. Yes B. No
A. Yes Guy in picture is suffering from an MI. He tried to drive himself to hospital, but instead drove into tree. He now has cardiogenic (MI) and hypovolemic (because of the accident-trauma) shock.
If there are different causes of shock, why are the manifestations the same?
Although the causes and initial manifestations associated with the different types of shock vary, eventually the effects of hypotension and anaerobic cellular metabolism (metabolism without oxygen) result in the common key features of shock
What happens in hypovolemic shock if the patient is on an ace inhibitor?
Angiotensin 1 can't convert to angiotensis 2, and compensatory meausures will be less effective.
What does angiotensin II do?
Angiotensin II functions in both the short- and long-term regulation of blood pressure. It is a strong vasoconstrictor, particularly of arterioles and, to a lesser extent, of veins. Constriction of the arterioles increases the peripheral vascular resistance, thereby contributing to the short-term regulation of blood pressure. Angiotensin II also reduces sodium excretion by increasing sodium reabsorption by the proximal tubules of the kidney. A second major function of angiotensin II, stimulation of aldosterone secretion from the adrenal gland, contributes to the long-term regulation of blood pressure by increasing salt and water retention by the kidney.
What happens as a result of the inflammatory response becoming the enemy?
As a result there is widespread vasodilation and blood pooling.
What integumentary assessments would you make in a patient in shock?
Assess the skin for temperature, color, and moisture. With shock, it feels cool or cold to the touch and is moist. Color changes appear first in oral mucous membranes and in the skin around the mouth. Pallor or cyanosis is best assessed in the oral mucous membranes in dark-skinned patients. Other color changes are noted first in the skin of the extremities and then in the central trunk area. The skin feels clammy or moist to the touch, not because sweating increases but because the normal fluid lost through the skin does not evaporate well on cold skin. As shock progresses, skin becomes mottled. Lighterskinned patients have an overall grayish blue color and darker-skinned patients appear darker, without an underlying reddish glow.
Yellow box
Assign a registered nurse rather than a licensed practical nurse/licensed vocational nurse (LPN/LVN) or unlicensed assistive personnel (UAP) to assess the vital signs of a patient who is at risk for or suspected of having hypovolemic shock.
Which newly admitted client does the nurse consider to be at highest risk for development of sepsis? A. 75-year-old man with hypertension and early Alzheimer's disease B. 68-year-old woman 2 days postoperative from bowel surgery C. 80-year-old community-dwelling man with no other health problems undergoing cataract surgery D. 54-year-old woman with moderate asthma and severe degenerative joint disease of the right knee
B
Yellow box
Because changes in systolic blood pressure are not always present in the initial stage of shock, use changes in pulse rate and quality as the main indicators of shock presence or progression.
_______ is an "ominous sign" in a child who is in shock.
Bradycardia Our teacher also said that decreased heart rate and decreased o2 sat is an ominous sign in children- might mean cardiac arrest
What does cardiac output equal?
CO (cardiac output)=HR (heartrate) X SV (stroke volume).
What is capillary leak syndrome? Under what kind of shock does it fall?
Capillary leak syndrome is the response of capillaries to the presence of biologic mediators that change blood vessel integrity and allow fluid to shift from the blood vessels into the interstitial tissues. Once in the interstitial tissue, these fluids are stagnant and cannot deliver oxygen or remove tissue waste products. It is a type of distributive shock.
What are specific causes or risk factors in obstructive shock?
Cardiac tamponade Arterial stenosis Pulmonary embolus Pulmonary hypertension Constrictive pericarditis Thoracic tumors Tension pneumothorax
When does cardiogenic shock occur?
Cardiogenic shock occurs when the actual heart muscle is unhealthy and pumping is directly impaired. It is shock-pump failure, fluid volume is not affected.
Why do these cardiovascular manifestations of shock occur?
Cardiovascular changes that occur with hypovolemic shock start with decreased mean arterial pressure (MAP) leading to compensatory responses. Thus the earliest clinical signs of hypovolemic shock are cardiovascular. Assess the central and peripheral pulses for rate and quality. In the initial stage of hypovolemic shock, the pulse rate increases to keep cardiac output and MAP at normal levels, even though the actual stroke volume (amount of blood pumped out from the heart) per beat is decreased. Increased heart rate is the earliest manifestation of shock. Because stroke volume is decreased, the peripheral pulses are difficult to palpate and are blocked with light pressure. As shock progresses, peripheral pulses may be absent.
Most often, shock is a result of what problem?
Cardiovascular problem
Why do these neuromuscular and central nervous system manifestations occur?
Central nervous system changes with shock first manifest as thirst. Thirst is caused by stimulation of the thirst centers in the brain in response to decreased blood volume. Assess the patient's level of consciousness (LOC) and orientation. Central nervous system changes of hypovolemic shock are caused by cerebral hypoxia. In the initial and nonprogressive stages, patients may be restless or agitated and may be anxious or have a feeling of impending doom that has no obvious cause. As hypoxia progresses, confusion and lethargy occur. Lethargy progresses to somnolence and loss of consciousness as cerebral hypoxia worsens with shock progression. Skeletal muscle changes during shock are muscle weakness and pain in response to tissue hypoxia and anaerobic metabolism, which are later manifestations. Weakness is generalized and has no specific pattern. The electrolyte changes of shock worsen muscle weakness by decreasing action potentials. Then deep tendon reflexes are decreased or absent. Assess muscle strength by having the patient squeeze your hand and by trying to keep his or her arms flexed while you attempt to straighten them. Assess deep tendon reflexes by lightly tapping the patellar tendons and Achilles tendons with a reflex hammer and observing the degree of reflexive movement.
What is chemical-induced distributive shock? What are the three common origins of chemical-induced distributive shock?
Chemical-induced distributive shock has three common origins: anaphylaxis (massive vasodilation), sepsis, and capillary leak syndrome. It occurs when certain body chemicals or foreign substances in the blood and vessels start widespread changes in blood vessel walls. The chemicals are usually exogenous (originate outside the body), but this type of shock also can be induced by substances normally found in the body (endogenous), such as excessive amounts of the mediator histamine.
What are common problems leading to hypovolemic shock?
Common problems leading to hypovolemic shock are hemorrhage and dehydration.
In the progressive stage of hypovolemic shock, are the compensatory mechanisms able to deliver sufficient oxygen?
Compensatory mechanisms are functioning but can no longer deliver sufficient O2, not even to vital organs Vital organs are getting hypoxic, non-vital organs ischemic
What history should you get for your patient when assessing risk factors for hypovolemic shock? Why are these important?
Consider age, history of recent surgery, recent diarrhea/vomiting, ulcers, use of diuretics, fluid intake for the past 24 hours, and urine output. Book says: Age is important because hypovolemic shock from trauma is more common in young adults and other types of shock are more common in older adults. Ask patients about recent illness, trauma, procedures, or chronic health problems that may lead to shock. These problems include GI ulcers, general surgery, hemophilia, liver disorders, and prolonged vomiting and diarrhea. Ask about the use of drugs such as aspirin, other NSAIDs, and diuretics that may cause changes leading to hypovolemic shock. Ask about fluid intake and output during the previous 24 hours. Information about urine output is especially important because urine output is reduced during the first stages of shock, even when fluid intake is normal.
Why are the manifestations of most types of shock the same regardless of what specific events or condition caused the shock to occur? A. The blood, blood vessels, and heart are directly connected to each other so that when one is affected, all three are affected. B. Because blood loss occurs with all types of shock, the most common first manifestation is hypotension. C. Every type of shock interferes with oxygenation and metabolism of all cells in the same sequence. D. The sympathetic nervous system is triggered by any type of shock and initiates the stress response.
D
Septic, neurogenic, and anaphylactic shock are what kind of shock?
Distributive shock
When does distributive shock occur?
Distributive shock occurs when blood volume is not lost from the body but is distributed to the interstitial tissues where it cannot circulate and deliver oxygen.
True or False Hypovolemic shock from most causes cannot be prevented.
False It can be prevented from most causes.
True or False Shock is a disease rather than a condition.
False It is a condition rather than a disease.
True or False Shock is limited to how the cardiovascular system responds when too little oxygen is delivered to tissues.
False It represents the "whole-body" response that occurs when too little oxygen is delivered to the tissues All body organs are affected by shock and either work harder to adapt and compensate for reduced oxygenation or fail to function because of hypoxia.
True or False Manifestations of every type of shock are the same.
False Manifestations of every type of shock are similar (but not always exactly the same) These common manifestations result from physiologic adjustments (compensatory mechanisms) in the attempt to ensure continued oxygenation of vital organs. These adjustment actions are performed by the sympathetic nervous system, triggering the stress response and activating the endocrine and cardiovascular systems. Manifestations unique to any one type of shock result from specific tissue dysfunction.
True or False Only one type of shock can be present at the same time.
False More than one type of shock can be present at the same time.
True or False In nonprogressive stage of hypovolemic shock, patients are usually calm due to blood loss.
False Restlessness and anxiety are common.
True or False Shock is classified by the functional impairment it causes.
False The shock classification gives us information about the functional impairment that results from the inadequate tissue profusion.
True or False In nonprogressive stage of hypovolemic shock, tissue damage is occurring to vital organs.
False Tissue damage is occurring in non-vital organs.
What is the normal range for hemoglobin for males and females? Why may it be abnormal in shock (does it increase or decrease)?
Females: 12-16 g/dL Males: 14-18 g/dL Increased due to fluid shift, dehydration Decreased due to hemorrhage
What is the normal range for hematocrit for males and females? Why may it be abnormal in shock (does it increase or decrease)?
Females: 37%-47% Males: 42%-52% Increased due to fluid shift, dehydration Decreased due hemorrhage
Has the fluid shifted in distributive shock? Has the total body fluid changed?
Fluid is shifted (but the total fluid volume is normal or increased.
In capillary leak syndrome, why does the fluid shift into the interstitial tissues (third spacing)? What problems cause fluid shifts?
Fluid shifts result from increased size of capillary pores, loss of plasma osmolarity, and increased hydrostatic pressure in the blood. Problems causing fluid shifts include severe burns, liver disorders, ascites, peritonitis, paralytic ileus, severe malnutrition, large wounds, hyperglycemia, kidney disease, hypoproteinemia, and trauma.
Is fluid volume affected in cardiogenic shock?
Fluid volume is not affected
What can the nurse to that is essential to a positive outcome in the patient in the nonprogressive stage of hypovolemic shock?
Frequent nursing assessment and observations of trends is essential to a positive outcome
What are risk factors for shock in the older client?
Hypovolemic Shock • Diuretic therapy • Diminished thirst reflex • Immobility • Use of aspirin-containing products • Use of complimentary therapies such as Ginkgo biloba • Anticoagulant therapy Cardiogenic Shock • Diabetes mellitus • Presence of cardiomyopathies Distributive Shock • Diminished immune response • Reduced skin integrity • Presence of cancer • Peripheral neuropathy • Strokes • Institutionalization (hospital or extended-care facility) • Malnutrition • Anemia Obstructive Shock • Pulmonary hypertension
Oh Nurse! What is the etiology of hypovolemic shock?
Hypovolemic shock occurs when too little circulating blood volume causes a MAP decrease that prevents total body oxygenation. Common problems leading to hypovolemic shock are hemorrhage (external or internal) and dehydration. Hypovolemic shock from external hemorrhage is common after trauma and surgery. Hypovolemic shock from internal hemorrhage occurs with blunt trauma, GI ulcers, and poor control of surgical bleeding. Hemorrhage also can be caused by any problem that reduces the levels of clotting factors. Hypovolemia as a result of dehydration can be caused by any problem that decreases fluid intake or increases fluid loss.
When does hypovolemic shock occur?
Hypovolemic shock occurs when too little circulating blood volume causes a MAP decrease, resulting in inadequate total body oxygenation. It is total body fluid decreased in all fluid compartments.
What are the different types of shock?
Hypovolemic shock, cardiogenic shock, distributive shock (which includes septic shock, neurogenic shock, and anaphylactic shock), and obstructive shock.
What are specific causes or risk factors in chemical-induced distributive shock?
I. Anaphylaxis II. Sepsis III. Capillary leak i. Burns ii. Extensive trauma iii. Liver impairment iv. Hypoproteinemia
What are specific causes or risk factors in cardiogenic shock?
I. Myocardial infarction II. Cardiac arrest III. Ventricular dysrhythmias i. Atrial Fibrillation/Atrial Flutter ii. Tachycardia IV. Cardiac amyloidosis V. Cardiomyopathies i. Viral ii. Toxic VI. Myocardial degeneration
What are specific causes or risk factors in hypovolemic shock (hemorrhage)?
I. Trauma II. GI ulcer III. Surgery IV. Inadequate clotting i. Hemophilia ii. Liver disease iii. Malnutrition iv. Bone marrow suppression v. Cancer vi. Anticoagulation therapy
What happens when MAP falls below 70mm/Hg?
If it falls below this number for an appreciable time, vital organs will not get enough oxygen perfusion, and will become hypoxic.
In hypovolemic shock, if after compensatory measures the MAP continues to decrease, what happens? Is it reversible? What if it continues?
If the initiating events continue and MAP decreases further, some tissues function under anaerobic conditions. This condition increases lactic acid levels. This causes electrolyte and acid-base imbalances with tissue-damaging effects and depressed heart muscle activity. These effects are temporary and reversible if the cause of shock is corrected within 1 to 2 hours after onset. When shock conditions continue for longer periods without help, the resulting acid-base imbalance, electrolyte imbalances, and increased metabolites cause so much cell damage in vital organs that multiple organ dysfunction syndrome (MODS) occurs and recovery from shock is no longer possible.
Increase in plasma osmolality (dehydration) or decrease in circulating fluid volume (trauma) can cause what?
Increase in plasma osmolality (dehydration) or decrease in circulating fluid volume (trauma) can trigger this cascade: Dehydration or loss of blood causes increased thirst, leading to increased fluid intake, secretion of antidiuretic hormone, which leads to a decrease in fluid output (decreased urine production) and an increase in water retention, which leads to an increase in circulating fluid volume, and decrease in plasma osmolarity (solutes in solution), which then leads to a decrease in thirst and a decrease in ADH.
What are intra-arterial catheters? What's the pressure bag for?
Intra-arterial catheters allow continuous blood pressure monitoring and are an access for arterial blood sampling. They are inserted into an artery (radial, brachial, femoral, or dorsalis pedis). The catheter is attached to pressure tubing and a transducer, which converts arterial pressure into an electrical signal seen as a waveform on an oscilloscope and as a digital numeric value. The pressure bag provides pressure so that the blood doesn't shoot out of the artery.
What causes distributive shock?
It can be caused by a loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, and increased capillary leak. All these factors can decrease mean arterial pressure (MAP) and may be started by nerve changes (neural-induced) or the presence of some chemicals (chemical-induced).
In nonprogressive stage of hypovolemic shock, what compensatory mechanisms are activated?
Kidney and hormonal compensatory mechanisms are activated because cardiovascular responses (initial stage) alone are not enough to maintain MAP and supply oxygen to vital organs.
Why do these kidney manifestations of shock occur?
Kidney and urinary changes occur with shock to compensate for decreased MAP by saving body water through decreased filtration and increased water reabsorption. Assess urine for volume, color, specific gravity, and the presence of blood or protein. Decreased urine output is a sensitive indicator of early shock. Measure urine output at least every hour. In severe shock, urine output may be absent. Of the four vital organs (heart, brain, liver, and kidney), only the kidney can tolerate hypoxia and anoxia for up to 1 hour without permanent damage. When hypoxia or anoxia persists beyond this time, patients are at risk for acute kidney injury (AKI) and kidney failure. Increased specific gravity (more waste products), more sugar in urine and bloodstream (fight or flight response kidney tells liver to release sugar since we're in fight or flight).
Why does an increase of cardiac output cause an increase in the MAP?
MAP is the pressure needed for the heart to pump blood out (cardiac output) against the vascular resistance (SVR), so when the cardiac output increases, the MAP increases as well.
How may the patient present in the refractory stage? What are signs and symptoms?
Manifestations are a rapid loss of consciousness; nonpalpable pulse; cold, dusky extremities; slow, shallow respirations; and unmeasurable oxygen saturation.
What is MAP?
Mean Arterial Pressure is the average arterial BP
Yellow box
Monitor the patient closely because drugs that dilate coronary blood vessels, such as nitroprusside, can cause systemic vasodilation and increase shock if the patient is volume depleted.
What is the most common cause of cardiogenic shock?
Myocardial infarction is the most common cause of direct pump failure
What is neural-induced distributive shock?
Neural-induced distributive shock is a loss of MAP that occurs when sympathetic nerve impulses controlling blood vessel smooth muscle are decreased and the smooth muscles relax, causing vasodilation. This blood vessel dilation can be a normal local response to injury, but shock results when vasodilation is widespread.
Would lifting the legs help those in cardiogenic shock?
No
In the elderly, is decreased skin turgor a reliable sign of hypovolemic shock?
No, since decreased skin turgor can be a normal sign in older adults.
Yellow box
Notify the health care provider or the Rapid Response Team for any patient who has vital signs or other conditions that meet the sepsis with SIRS criteria.
What causes obstructive shock?
Obstructive shock is caused by problems that impair the ability of the normal heart muscle to pump effectively. The heart itself remains normal, but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle. Basically, cardiac function is decreased due to some non-cardiac cause (indirect pump failure).
What is our goal as nurses when it comes to our patients and sepsis?
Our goal as nurses is to recognize sepsis and intervene early.
Why is it a good idea to sit patients up if they have cardiogenic shock? Is output higher or lower than normal? Will they have pulmonary edema? What is a good drug for cardiogenic shock? (This is what our teacher said in class. Not on the PPT).
Our teacher said in class that: In cardiogenic shock: patient's have so much fluid if they lay down they'll drown. Output lower than normal-heart is failing in cardiogenic shock. Pulmonary edema intertwined. Size of vascular bed engorged. So much fluid, see foam coming out of endotracheal tube. Morphine good drug since it causes periperhal vasodilation. Their breathing slows down, but we can breathe for them-keeps it from pooling.
What are O2 sat changes in the patient in shock?
Oxygen saturation is assessed through pulse oximetry. Pulse oximetry values between 90% and 95% occur with the nonprogressive stage of shock, and values between 75% and 80% occur with the progressive stage of shock. Any value below 70% is considered a life-threatening emergency and may signal the refractory stage of shock.
_________ and ________ depend on how much oxygen from arterial blood perfuses the tissue.
Oxygenation perfusion
Is the patient hypokalemic in the nonprogressive stage of hypovolemic shock? Why or why not?
Patient may be hyperkalemic due to the breaking of RBCs.
What are baroreceptors? Where are they located?
Pressure-sensitive nerve receptors (baroreceptors) in the aortic arch and carotid sinus.
Should you give the patient in hypovolemic shock fluids? If no, why? If yes, how much?
Professor in class said: Yes, give them some IV fluids, but not too much. 1 maybe 2 liters of fluid if pt has blood loss, because more fluid we give them, the more we dilute their clotting factors, so they can't clot the blood, especially on the insdie-a lot of fluid impedes body's clotting ability by diluting clotting factors.
MODS leads to death when?
Prolonged organ failure Extensive, irreversible damage Recovery not possible
In the progressive stage of hypovolemic shock, describe the pulse, blood pressure, skin color, and pH.
Pulse is rapid and weak, BP low, skin pale, pH decreasing
Why do these respiratory manifestations of shock occur?
Respiratory changes with shock are an adaptive or compensatory response to help maintain oxygenation when tissue perfusion is decreased. Assess the rate, depth, and ease of respiration. Respiratory rate increases during hypovolemic shock to ensure that oxygen intake is increased so that it can be delivered to critical tissues. When shock progresses to the stage at which lactic acidosis is present, the respiratory depth also increases.
What happens to the potassium and lactic acid levels in the progressive stage of hypovolemic shock?
Rising K+ and rising lactic acid levels
Organisms in the blood multiply and _____ is triggered.
SIRS (systemic inflammatory response syndrome)
What are some secondary prevention measures that a nurse can implement to prevent hypovolemic shock?
Secondary prevention of hypovolemic shock is a major nursing responsibility. Keep in mind that just being a patient in the acute care setting is a risk factor. Identify patients at risk for dehydration, and assess for early manifestations. This is especially important for those who have reduced cognition or reduced mobility or who are on NPO status. Assess all patients who have invasive procedures or trauma for obvious or occult bleeding. Compare pulse quality and rate with baseline. Compare urine output with fluid intake. Check vital signs for patients who have persistent thirst. Assess for shock in any patient who develops a change in mental status, an increase in pain, or an increase in anxiety. When patients have invasive procedures or ambulatory surgery and then go home, teach them and their families the manifestations of shock. Stress the importance of seeking immediate help for obvious heavy bleeding, persistent thirst, decreased urine output, light-headedness, or a sense of impending doom (a feeling that something bad is happening or going to happen).
What type of shock is sepsis and septic shock?
Sepsis and septic shock is a complex type of distributive shock that usually begins as a bacterial or fungal infection and progresses to a dangerous condition over a period of days.
What is sepsis? What is SIRS?
Sepsis is a condition in which infectious microorganisms have entered the bloodstream. As the numbers of organisms increase, an inflammatory response, known as systemic inflammatory response syndrome (SIRS)
What is sepsis?
Sepsis is a widespread infection that triggers a whole-body inflammatory response.
When does sepsis lead to distributive shock? What is septic shock?
Sepsis leads to distributive shock when infectious microorganisms are present in the blood. This form of shock is most commonly called septic shock.
What is septic shock?
Septic Shock is the stage of SIRS when multiple organ failure is evident and uncontrolled bleeding occurs. -Death rate exceeds 50% -Severe hypovolemic shock due to bleeding -Decreased cardiac function due to cardiac cellular ischemia -Clinical manifestations resemble the late (refractory) stage of hypovolemic shock.
Severe sepsis comes after SIRS. What happens in severe sepsis?
Severe sepsis is the progression of sepsis with an amplified inflammatory response -All tissues are hypoxic to some degree -Some organs are experiencing cell death -Microthrombi formation is widespread, using much of the available platelets and clotting factors, a condition known as DIC (disseminated intravascular coagulation) -This continued stress response triggers the release of glucose from the liver resulting in hyperglycemia. The more severe the response the higher the blood glucose
Why is shock considered a syndrome? The syndrome is started when what is impaired?
Shock is a "syndrome" because the cellular, tissue, and organ events occur in a predictable sequence. Any problem that impairs oxygen delivery to tissues and organs can start the syndrome of shock and lead to a life-threatening emergency
What is shock?
Shock is defined as inadequate tissue perfusion. Our book defines it as "widespread abnormal cellular metabolism that occurs when oxygenation and tissue perfusion needs are not met to the level necessary to maintain cell function."
What does MAP equal?
Since MAP is a product of Cardiac Output (CO) and Systemic Vascular Resistance (SVR) [MAP = CO x SVR]
Why do these integumentary manifestations of shock occur?
Skin changes occur because of reduced blood flow in the skin. An early compensatory mechanism is skin blood vessel constriction, which reduces skin perfusion. This allows more blood to circulate to the vital organs, which cannot tolerate low oxygen levels.
Does the patient have a temperature in SIRS?
Some patients have a low-grade fever and others have a high fever. Still others may have a below-normal body temperature. Fever and hypotension result directly from SIRS.
In hypovolemic shock, what decrease in MAP is the progressive stage?
Sustained decrease in MAP of more than 20 mm/Hg
Treating shock: Face is pale, lift the ______. Face is red, lift the ______.
Tail Head
What are some primary prevention measures that a nurse can implement to prevent hypovolemic shock?
Teach all people to prevent dehydration by having an adequate fluid intake during exercise and when in hot, dry environments. Urge people to prevent trauma and hemorrhage by using proper safety equipment and seat belts and being aware of hazards in the home or workplace.
Why does the heart beat faster in compensatoy measures in hypovolemic shock?
Teacher stated in class: So the heart doesn't take initiative to go faster, it needs instructions to say : go faster. The reninangiotensin-aldosterone system and vasopressin (ADH) have the effect of directly stimulating an increase in heart rate, cardiac contractility, and vascular tone. The kidneys and baroreceptors sense an ongoing decrease in MAP and trigger the release of renin, antidiuretic hormone (ADH), aldosterone, epinephrine, and norepinephrine to start kidney compensation. Renin, secreted by the kidney, causes decreased urine output, increased sodium reabsorption, and widespread blood vessel constriction. Renin converts to angiotensinogen, then to angiotensin I, and then to angiotensin II. ADH increases water reabsorption in the kidney, further reducing urine output, and also causes blood vessel constriction in the skin and other less vital tissue areas. Aldosterone holds onto potassium. This all leads to increased stroke volume. Together these actions compensate for shock by maintaining the fluid volume within the central blood vessels.
What are arterial chemoreceptors? Where are they located? What do they have to do with hypovolemic shock?
The arterial chemoreceptors are chemosensitive cells that monitor the oxygen, carbon dioxide, and hydrogen ion content of the blood. They are located in the carotid bodies (taken from Porth-it's what our teacher talked about in class briefly). Our teacher said that: Carotid body can detect slight change in pH-so since lactic acid is building up, the carotid body is recognizing pH change. Because of this, they induce widespread vasoconstriction.
In hypovolemic shock, does the loss of blood volume from the vascular space result in an increase or decrease in mean arterial pressure? What else does the loss of RBCs result in?
The basic problem of hypovolemic shock is a loss of blood volume from the vascular space, resulting in a decreased mean arterial pressure (MAP) and a loss of oxygen-carrying capacity from the loss of circulating red blood cells (RBCs).
How does sepsis and SIRS differ? What triggers SIRS?
The client has sepsis when the infectious organisms have entered the bloodstream. SIRS is the systemic inflammatory response when the infectious organisms increase. SIRS is triggered as a result of infection escaping local control
The client was delivered to the hospital by a friend. The client has a gunshot wound to the head. Would the first CBC lab result be normal or abnormal? What if he was taken to the hospital by an ambulance?
The initial CBC would be normal because the concentration of particles in blood is normal even if he was in hypovolemic shock; if an ambulance gave him a liter of fluid on the way, CBC would be low since it is diluted by the liter of fluid.
What is the refractory stage also known as?
The irreversible stage
If sepsis is stopped at the creation of microthrombi due to SIRS, is organ damage reversible? What happens if it isn't stopped? What happens because of these thrombi?
The microthrombi begin to form in some organ capillaries, causing hypoxia and reducing organ function -If sepsis is stopped now the organ damage is reversible -If sepsis is not stopped, microthrombi continue to develop. These thrombi increase organ hypoxia and generate more toxic metabolites, a vicious downward cycle; SIRS gets worse
What are the most common causes of obstructive shock?
The most common causes of obstructive shock are pericarditis and cardiac tamponade
As a result of the widespread vasodilation and blood pooling, what happens to the patient?
The patient has mild hypotension, a low urine output, and an increased respiratory rate. These responses are compensatory mechanisms in response to impaired oxygenation however they result in decreased cardiac output.
When does the refractory stage occur?
The refractory stage or irreversible stage of shock occurs when too much cell death and tissue damage result from too little oxygen reaching the tissues. Vital organs have overwhelming damage. The body can no longer respond effectively to interventions, and shock continues.
In regards to the capillary bed and MAP, what if the size of capillary bed increases, but it has the same blood volume. What is the result?
The result is a decreased mean arterial pressure (MAP) and a decreased blood flow.
In regards to the capillary bed and MAP, what if the size of capillary bed is normal, but has decreased blood volume?
The result is a decreased mean arterial pressure (MAP) and a decreased rate of blood flow.
In regards to the capillary bed and MAP, what if the size of capillary bed is increased, and has decreased blood volume?
The result is a large drop in mean arterial pressure (MAP) and a very sluggish blood flow.
In regards to the capillary bed and MAP, what if the size of capillary bed decreases, but has the same blood volume?
The result is an increased mean arterial pressure (MAP) and an increased rate of blood flow.
What is the result of anaphylaxis on blood vessel tone and cardiac output?
The result is widespread loss of blood vessel tone and decreased cardiac output.
What is multiple organ dysfunction syndrome (MODS)?
The sequence of cell damage caused by the massive release of toxic metabolites and enzymes is termed multiple organ dysfunction syndrome (MODS). Once the damage has started, the sequence becomes a vicious cycle as more dead cells break open and release harmful metabolites. These trigger small clots (microthrombi) to form, which block tissue oxygenation and damage more cells, thus continuing the devastating cycle. Liver, heart, brain, and kidney functions are lost first. The most profound change is damage to the heart muscle. One cause of this damage is the release of myocardial depressant factor (MDF) from the ischemic pancreas.
How do the small arteries and veins increase or decrease in diameter? When does blood pressure increase or decrease?
The small arteries and veins connected to capillaries can increase in diameter by relaxing the smooth muscle in vessel walls (dilation) or decrease in diameter by contracting the muscle (vasoconstriction). When blood vessels dilate and total blood volume remains the same, blood pressure decreases and blood flow is slower. When blood vessels constrict and total blood volume remains the same, blood pressure increases and blood flow is faster.
What is the treatment for anaphylaxis. What did our teacher say was the dose?
The treatment is epinephrine. The dose for the child above 60 lbs is 0.3 mg sub q (adult dose), but epipen is often IM. Hold for count of 10-go in through clothing. Not a disaster for getting adult dose to child under 60 lbs-just have a fast heartrate for a while.
What happens if the cause of shock is corrected and the MAP returns to normal in the refractory stage of hypovolemic shock?
Therapy is not effective in saving the patient's life, even if the cause of shock is corrected and MAP temporarily returns to normal.
Is there a decrease in RBCs in a patient with dehydration?
There is a loss of the serum part of blood, resulting in a decrease of blood volume from the vascular space.
What can cause hypovolemic shock (that could be prevented)?
These are what we talked about in class: NPO can cause, hiking in desert can cause (dehydration), alcohol can cause, lack of seat belts and and child safety seat can cause if get in an accident No shoes, no clothes: risk for head injury, hit by a car, road rash. Children can get second degree burns on feet because parents forgot tar is hot if they walk barefoot.
The oxygenation and perfusion problems of hypovolemic shock lead to what cellular conditions and what cellular metabolism?
These oxygenation and perfusion problems lead to cellular anaerobic (without oxygen) conditions and abnormal cellular metabolism.
In a client that comes in for trauma, why is it important to look under them?
They may have extensive blood loss evident underneath them.
What are compensatory measures in hypovolemic shock? When do they occur?
They occur when there is a decrease in MAP of 10-15 mm Hg from the patient's baseline value. 1. Continued sympathetic stimulation i. Moderate vasoconstriction a. Because of the arterial chemoreceptors sensing low pH levels due to increased lactic acid. ii. Increased heart rate a. ADH and the reninangiotensin-aldosterone system cause this iii. Decreased pulse pressure 2. Chemical compensation i. Renin, aldosterone, and antidiuretic hormone secretion a. Increased vasoconstriction b. Decreased urine output c. Stimulation of the thirst reflex 3. Some anaerobic metabolism in nonvital organs i. Mild acidosis ii. Mild hyperkalemia
What do anaerobic conditions causes an increase in what? What do these substances do?
This condition increases lactic acid levels and other harmful metabolites (e.g., protein-destroying enzymes, oxygen free radicals). These substances cause electrolyte and acid-base imbalances with tissue-damaging effects and depressed heart muscle activity.
In hypovolemic shock, baroreceptors sense a decrease in MAP. What are the compensatory measures that take place because of this? If the events that caused the initial decrease in MAP are halted now, would the compensatory measures be enough? If the MAP would decrease further, what would happen?
This information (decrease in MAP) is transmitted to brain centers, which stimulate adjustments (compensatory mechanisms) that help ensure continued blood flow and oxygen delivery to vital organs while limiting blood flow to less vital areas. The movement of oxygenated blood into selected areas while bypassing others ("shunting") results in some shock manifestations. If the events that caused the initial decrease in MAP are halted now, compensatory mechanisms provide adequate oxygenation and perfusion without outside intervention.
Is total body fluid affected in obstructive shock?
Total body fluid is not affected.
True or False Any type of pump failure decreases cardiac output and MAP.
True
True or False Capillary leak syndrome leads to sepsis
True
True or False In nonprogressive stage of hypovolemic shock, stopping the condition that caused shock may prevent the problem from progressing.
True
True or False In nonprogressive stage of hypovolemic shock, the patient will often complain of thirst.
True
True or False Loss of RBCs and/or serum decreases the ability of the blood to oxygenate the tissue that it does reach; anaerobic conditions may result.
True
True or False Most often, shock is a result of cardiovascular problems.
True
True or False The skin and skeletal muscles can tolerate low levels of oxygen for hours without dying or being damaged.
True
In the MAP calculation provided to us by our teacher (MAP=1/3 SBP + 2/3 DPB), where do the numbers 1/3 and 2/3 come from?
Two thirds of the cardiac cycle are spent in diastole, and 1/3 in systole.
Why are the early signs of sepsis/SIRS missed? What happens if the problem is caught early?
Unfortunately the early symptoms are subtle and have a relatively short duration so they are often missed or misdiagnosed If the problem is caught early and treated aggressively the progression can be stopped.
Yellow box
Use only normal saline for infusion with blood or blood products because the calcium in Ringer's lactate induces clotting of the infusing blood.
What is systemic vascular resistance (SVR)?
Vascular resistance refers to the resistance that must be overcome to push blood through the circulatory system and create flow. The resistance offered by the peripheral circulation is known as the systemic vascular resistance (SVR).
What increases and decreases SVR (systemic vascular resistance)?
Vasoconstriction (i.e., decrease in blood vessel diameter) increases SVR, whereas vasodilation (increase in diameter) decreases SVR.
What is a normal immune system's response to an infection?
When the immune system is normal and infection is confined to a local area, invasion by the organism initiates a local response designed to keep the organism from spreading. Part of this normal response includes capillary leakage which allows plasma to leak into the tissues. This causes localized swelling and dilutes any toxins that have entered the area. One benefit of this response is that it limits the organisms to a local area. Fever, tachycardia, and decreased urine are not part of this response.
Why does an increase of the capillary bed (vasodilation) cause a decrease of the MAP?
When the vessels dilate, there is less resistance for the blood pushing out of the heart to overcome, so the MAP (MAP=CO X SVR) decreases.
When does the systemic inflammation of SIRS become an enemy to the patient?
With the organisms and their toxins in the bloodstream at this point and entering other body areas, the inflammatory responses become an enemy, leading to extensive hormonal, tissue, and vascular changes and oxidative stress that further impair oxygenation and tissue perfusion.
What does anaerobic mean?
Without oxygen
In the initial stage of hypovolemic shock, are the compensatory measures all cardiovascular?
Yes
Is there an increase in WBCs with SIRS?
Yes, usually. The book says usually in this stage, the patient has the elevated WBC count expected with a systemic infection.
Should you put oxygen on a patient in shock even if their O2 sats are in the normal range?
Yes. Always give oxygen when patient is in shock.
Oh Nurse! Are these ladies at risk for shock? (Picture of elderly women at a long-term care facility).
Yes. Our Iggy book says: "For example, older patients in long-term care settings are at risk for sepsis and shock related to urinary tract infections." Our teacher stated, they may be dehydrated-facility not providing beverage of choice, can't go to bathroom, so they might be in hypovolemic shock due to dehydration. Might have UTI- you see confusion in the elderly with UTI-urosepsis may occur. Thirst receptors decrease as we get older.
In shock, _______ heart rate is an early sign. _______ blood pressure is a late sign.
increased Decreased
The size of the vascular bed is inversely (negatively) related to MAP. This means that increases in the size of the vascular bed ______ MAP and decreases ______ MAP.
lower raise
In nonprogressive stage of hypovolemic shock, why does the pH decrease?
pH may decrease due to anaerobic metabolism. This causes an increase in respiration.
Total blood volume and cardiac output are directly related to MAP, so increases in either total blood volume or cardiac output _____ MAP. Decreases in either total blood volume or cardiac output _____ MAP.
raise lower
In ______ the offending organisms have entered the blood stream.
sepsis
The reduced MAP ______ blood flow, resulting in _______ tissue perfusion. The loss of RBCs _______ the ability of the blood to oxygenate the tissue it does reach.
slows decreased decreases (This ↓ in MAP slows blood flow and decreases profusion).
What are some early neuromuscular manifestations of shock?
• Anxiety • Restlessness • Increased thirst
What are some integumentary manifestations of shock?
• Cool to cold • Pale to mottled to cyanotic • Moist, clammy • Mouth dry; pastelike coating present
In the initial stage, is there a decrease or increase of mean arterial pressure (MAP)? By how much? Is there increased or decreased sympathetic stimulation? Is there vasoconstriction or vasodilation? What happens to the heart rate?
• Decrease in baseline mean arterial pressure (MAP) of 5-10 mm Hg • Increased sympathetic stimulation • Mild vasoconstriction • Increased heart rate
What are some cardiovascular manifestations of shock?
• Decreased cardiac output • Increased pulse rate • Thready pulse • Decreased blood pressure • Narrowed pulse pressure • Postural hypotension • Low central venous pressure • Flat neck and hand veins in dependent positions • Slow capillary refill in nail beds • Diminished peripheral pulses
What are some late neuromuscular manifestations of shock?
• Decreased central nervous system activity (lethargy to coma) • Generalized muscle weakness • Diminished or absent deep tendon reflexes • Sluggish pupillary response to light
What are some gastrointestinal manifestations of shock?
• Decreased motility • Diminished or absent bowel sounds • Nausea and vomiting • Constipation
What are some kidney manifestations of shock?
• Decreased urine output • Increased specific gravity • Sugar and acetone present in urine
What are some respiratory manifestations of shock?
• Increased respiratory rate • Shallow depth of respirations • Increased PaCO2 • Decreased PaO2 • Cyanosis, especially around lips and nail beds
What are conditions predisposing to septic shock and sepsis?
• Malnutrition • Immunosuppression • Large, open wounds • Mucous membrane fissures in prolonged contact with bloody or drainage-soaked packing • GI ischemia • Exposure to invasive procedures • Malignancy • Older than 80 years • Infection with resistant microorganisms • Receiving cancer chemotherapy • Alcoholism • Diabetes mellitus • Chronic kidney disease • Transplantation recipient • Hepatitis • HIV/AIDS
What are specific causes or risk factors in neural-induced distributive shock?
• Pain • Anesthesia • Stress • Spinal cord injury • Head trauma
Because the cardiovascular system is a closed but continuous circuit, the main factors that influence MAP are what?
• Total blood volume • Cardiac output • Size of the vascular bed
What are specific causes or risk factors in hypovolemic shock (dehydration)?
• Vomiting • Diarrhea • NPO • Heavy diaphoresis • Diuretic therapy • Nasogastric suction • Diabetes insipidus • Hyperglycemia
