Module 2 > Shock > Flashcards

Shock Flashcards

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1
Q

What is shock?

A life-threatening condition that results from __________

A

inadequate tissue perfusion.

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2
Q

Creates an imbalance between the delivery of oxygen and nutrients that are needed to support cellular function.

Shock affects ALL body systems
It can develop very rapid or very slow
It all depends on the underlying cause

-
-

A

Effective cardiac pump
Adequate vasculature / circulatory systems
Sufficient blood volume

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3
Q

-
-

A

Hypoperfusion
Hypermetabolism
Activation of the inflammatory response

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4
Q

The body calls on all homeostatic mechanisms to prevent and/or reverse shock;
however, if these compensatory mechanisms fail, the result is ____________

A

organ dysfunction and death

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5
Q

Pathophysiology of Shock

Cellular changes:
Cells lack adequate blood supply
produce energy through _________
____ intracellular environment
normal cell function ceases
_____

Vascular changes:
Regulatory mechanisms stimulate vasodilation or vasoconstriction in response to mediators released by the cell, communicating need for _____

A

anaerobic metabolism
acidotic
cell death

O2 & nutrients

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6
Q

Pathophysiology (cont.): Blood pressure regulation

-
-

All 3 must respond to maintain adequate BP

Best expressed through Mean Arterial BP (MAP):
MAP = __________

Tissue and organ perfusion depend on MAP of at least _____

If unable to calculate MAP through complicated measures, most BP measurement devices estimate a MAP

A

blood volume
cardiac pump
vasculature

Cardiac Output x Peripheral Resistance

65 mmHg

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7
Q

Pathophysiology (cont.):BP regulation & kidneys

Kidney regulate BP by
releasing: renin which converts angiotensin I to II (this acts as a ________)

This leads to the release of aldosterone
which promotes __________

_____ then
stimulates release of ____
which causes further retention of H20 to raise blood volume and Bp

This process can take ______

Important to catch early: medications, fluid bolus, blood products to treat

A

vasoconstrictor)

Na and H20 retention

Hypernatremia
ADH

hours to many days

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8
Q

The 3 stages of shock

3 stages:

Shock can be identified as early or late
it is important to understand the physiologic responses to divide it into the appropriate stage for treatment

The chance of survival greatly improves if _______

EBP states that aggressive therapy should occur within _____ for best outcome and survival

A

Stage I: Compensatory Stage
Stage II: Progressive Stage
Stage III: Irreversible Stage

diagnosed early

3 hours

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9
Q

Stage I: Compensatory stage

A

BP remains within normal limits

Increased HR and increased contractility maintain adequate cardiac output

Increased RR

SNS
release of epinephrine and norepinephrine
body shunts blood to vital organs (away from skin, kidneys, and GI tract)
cool, pale skin

Decreased urinary output (due to release of ADH and aldosterone)

Altered LOC
First sign of altered LOC- agitation, restlessness

Respiratory alkalosis <35 PCO2 (due to hyperventilation)

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10
Q

Stage I: Compensatory stageNursing mgmt

Identify ____ before progression

-

Monitor _______
Reduce _______
Promote ______

A

the cause

Fluid replacement
Vasopressors

tissue perfusion
anxiety
safety

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11
Q

Stage II: Progressive stage

Mechanisms that regulate BP can no longer compensate and the MAP falls below normal limits

BP: Systolic < ____

Neuro:

HR > ___

RR:

Acid/base: PaC02 >

Skin:

Urine output: <

Metabolic acidosis

______ is considered part of this stage (see later in ppt)

A

90 mmHg

Neuro: Declining mental status, confusion

HR > 150 bpm

RR: rapid, shallow respirations, and possibly crackles

Acid/base: PaC02 > 45 mm Hg - reflects hypoventilation

Skin: mottled, petechiae

Urine output: < 0.5 mL/kg/hr

Metabolic acidosis

MODS is considered part of this stage (see later in ppt)

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12
Q

Stage II: Progressive stageNursing mgmt

A

Client is typically moved into an ICU setting for this stage

Hemodynamic monitoring:
May include more invasive monitoring

ECG monitoring

ABG gases

Serum electrolyte levels

Respiratory support:
Up to mechanical ventilation

Fluid volume maintenance/replacement:
Up to dialysis

Assess for physical and mental status changes that can occur very quickly

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13
Q

Stage III: Irreversible stage

Severe organ damage past the point of survival

BP remains low, despite treatment

Renal and liver dysfunction

Respiratory dysfunction, despite O2 delivery/ interventions

Cardiac dysfunction, cannot maintain adequate MAP for perfusion

Worsening metabolic acidosis r/t __________
Leads to __________

A

lactic acidosis
(by product of anareobic resp.

multiple organ dysfunction syndrome

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14
Q

Stage iii: irreversible stage nursing mgmt.

A

Comfort measures
-Ensure all are involved & provide comfort
-Inform family about the importance of seeing, touching, and talking to client

Inform family/loved ones regarding prognosis
-Discuss living wills
-Advanced directives
-Any other written/verbal wishes
-Ethics committee, if needed, to assist in making difficult care decisions

Engaging palliative care

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15
Q

Clinical manifestations:stages of shock

Blood pressure:

A

Compensatory- Normal

Progressive- Systolic <90 mm Hg; MAP < 65 mm Hg
Requires fluids resuscitation to support blood pressure

Irreversible- Requires mechanical or pharmacologic support

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16
Q

Clinical manifestations:stages of shock

Heart rate

A

Compensatory: >100 bpm

Progressive: >150 bpm

Irreversible: Erratic

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17
Q

Clinical manifestations:stages of shock

Respiratory status

A

compensatory: >20 breaths/min
PaCO2 < 32 mm Hg

Progressive: Rapid, shallow respirations; crackles
PaO2 <80 mm Hg
PaCO2 >45 mm Hg

Irreversible: Requires intubation and mechanical ventilation and oxygenation

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18
Q

Skin

A

Copensatory: cold, clammy

Progressive: Mottled, petechiae

Irreversible:
Jaundice

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19
Q

Urinary output

A

Compensatory: decreased

Progressive: <0.5 ml/kg/hr

Irreversible: Anuric; requires dialysis
(lack of urine production.)

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20
Q

Mentation

A

Compensatory: confusion and/or agitation

Progressive: lethargy

Irreversible: Unconscious

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21
Q

Acid-base balance

A

Compensatory: Resp. alkalosis
PaCO2 <32

Progressive: Metabolic acidosis
Paco2 >45

Irreversible: Profound acidosis

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22
Q

Types of Shock

CHAIN

A

Cardiogenic
Hypovolemic
Anaphylactic
Infectious (sepsis)
Neurogenic

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23
Q

Hypovolemic shock

Most common type of shock
characterized by ____________

External _______

Internal _______

Sequence of events

A

decreased intravascular volume

External fluid losses

Internal fluid shifts

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24
Q

Risk factors for hypovolemic shock:

External:

A

External:
Trauma
Surgery
Vomiting
Diarrhea
Diuresis
Diabetes insipidus

Internal:
Hemorrhage
Burns
Ascites
Peritonitis
Dehydration
Necrotizing pancreatitis

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25
Hypovolemic shock:care mgmt ______: #1 concern IV access: Pharmacologic therapy: Reverse cause of dehydration: Monitor for s/s hypervolemic complications with frequent assessments:
Fluid replacement: IV at least 2 sites IO (intraosseous or CVAD) Pharmacologic therapy: vasopressors (nausea, vomiting, diarrhea, hyperglycemia) Antiemetics, antidiarrheal, insulin, desmopressin) Desmopressin- used as an antidiuretic for diabetes insipudis Listen to lungs, JVD, difficulty breathing, electrolyte imbalance---fluid overload
26
Hypovolemic shock: fluids
Crystalloids: 0.9 % Sodium Chloride Lactated Ringers Colloids: Albumin (5%, 25%) - Rapidly expands plasma volume Blood Products- Plasma, packed red blood cells, and platelets
27
Hypovolemic shock: visual aid See slide
Plasma loss through burns Hemorrhage Decreased body fluids GI loss- bleeding, vomiting, diarrhea Diabetes insipidus Diuresis
28
Cardiogenic shock Impaired ability for the heart to contract and pump blood...which causes inadequate O2 for heart and tissue Two types:
Coronary- Anterior wall Mis put at greater risk for b/c more damage to left ventricle Non-coronary hypocalcemia, hypoxemia, cardiomyopathy, tamponade, dysrhythmias
29
Cardiogenic shock: Risk factors: S&S:
Older age Heart failure Previous heart attack (higher for women) Coronary artery disease high blood pressure Diabetes Angina Fatigue Feelings of doom Dsrythymias Increased RR, tachycardia, low BP Pale skin Weak pulse SOB
30
Cardiogenic shock: care mgmt Limit myocardial damage and preserve healthy myocardium Improve cardiac function by increasing ________ and decreasing ______ (or both!) Correct underlying cause… Coronary: Non-coronary: If cause of cardiogenic shock is from cardiac arrest, ______ and _____
cardiac contractility ventricular afterload resuscitate client and keep cool (therapeutic hypothermia); WHY?
31
Cardiogenic shock: pharm therapy
Dobutamine: Nitroglycerin: Dopamine: Norepinephrine, Epinephrine, Milrinone, Vasopressin, and Phenylephrine Antiarrhythmics
32
Increases the strength of myocardial activity and improving cardiac output Decreases pulmonary and systemic vascular resistance (decreased afterload)
Dobutamine:
33
Venous vasodilator, reduces preload Higher doses can cause arterial vasodilation Frequently used in combo with dobutamine
Nitroglycerin:
34
May be used with dobutamine and nitroglycerin to improve tissue perfusion Doses greater than 8 mcg/kg/min can cause vasoconstriction Can also increase HR past therapeutic levels
Dopamine:
35
Distributive shock Occurs when: this displacement leads to relative hypovolemia due to blood not returning to the heart Which leads to inadequate tissue perfusion
intravascular blood pools in peripheral blood vessels
36
3 types of distributive shock:
Anaphylactic Neurogenic Septic Shock
37
Distributive shock:Anaphylactic shock Severe allergic reaction to: antibodies the body has already produced (for example: ________) Antigen-antibody reaction -causes mast cells release vasoactive substances (histamine and bradykinin) -activates inflammatory cytokines -vasodilation and capillary permeability ____ onset of symptoms Signs/symptoms…what would you expect?
blood transfusion reactions Acute
38
Anaphylactic shock clinical assessment: Severe-
Generalized flushing Diffuse erythema Difficulty breathing (laryngeal edema) Bronchospasms Hypotension Dysrhythmias Severe – respiratory distress, rapid onset hypotension, neurologic compromise, cardiac arrest
39
Distributive shock:Anaphylactic shock Care mgmt
Remove causative agent (for example, discontinuing an antibiotic) Establish adequate IV access Fluid replacement Vasopressors Diphenhydramine (Benadryl) Nebulized medications: Albuterol (Proventil) Maintain/establish airway
40
Distributive shock:Neurogenic shock Vasodilation occurs as a result of a loss of balance between _______ and _______ stimulation. What effect does SNS and PNS stimulation have on smooth muscle? Drastic decrease in _____ and ____ Inadequate BP results in insufficient perfusion of tissues and cells
parasympathetic and sympathetic Parasympathetic wins- more vasodilation SVR and bradycardia
41
Distributive shock:Neurogenic shock causes & s/s Causes: S/S:
Spinal cord injury Spinal anesthesia Other related diseases that cause nervous system damage Short courses of neurogenic shock: syncope Similar to parasympathetic stimulation Dry, warm skin Hypotension Bradycardia***
42
Distributive shock:Neurogenic shock care mgmt Goal of treatment is restore ________ (could be a surgical procedure, proper positioning) Keep HOB _____ (especially when anesthetic agent has been given-this will prevent it from spreading up the cord) In spinal cord injury, great caution with _____ the client Support CV and Neuro function Higher incidence of _________ may be implemented Monitor for s/s of ______ which could lead to hypovolemic shock
sympathetic tone >30 degrees moving/mobilizing VTE; DVT prophylaxis internal bleeding
43
Distributive shock: septic shock Defined as: “a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality.” Most common type of Distributive Shock***** Caused by widespread infection or Sepsis
44
Distributive shock: septic shock Most common areas of origin: - - - Most common bacteria: _______ Sepsis is defined as: “life threatening organ dysfunction caused by __________ Both sepsis and septic shock incidences have continued to rise despite all the aggressive treatments / therapies
Bloodstream (bacteremia), most commonly CVAD’s Lungs (pneumonia) Urinary tract (urosepsis); most commonly urinary catheters gram negative a dysregulated host response to infection”.
45
Distributive Shock:Septic Shock risk factors
Invasive lines and procedures Indwelling medical devices Increased number of antibiotic-resistant microorganisms Increasing number of older population
46
Septic shock: S&S Early stages of sepsis: Progression to septic shock:
BP – may remain WNL or respond to fluid therapy Tachycardia Hyperthermia Fever Warm flushed skin with bounding pulses Elevated RR Subtle changes in mental status Decreased urine output Hypotension – not responding to fluids Skin is cool , pale, and mottled Tachycardia Tachypnea Oliguria nonresponsive
47
Distributive Shock:Septic Shock reduction/prevention
Strict infection control practices: Hand hygiene CLABSI prevention Early removal of indwelling/invasive devices Protocols to reduce VAP Wound debridment Early ambulation with pneumonia
48
Distributive shock:sepsis/septic shock labs
Labs: Lactic acid (lactate): derived from muscle cells and erythrocytes; common marker used for sepsis C-reactive protein (CRP): present during inflammatory process Procalcitonin: substance produced in response to bacterial infections and tissue injury. Sepsis marker that is MOST studied.
49
Distributive shock:sepsis/Septic shock treatment
Fluid replacement therapy: Implemented to correct tissue hypoperfusion Pharmacolgic therapy -Broad-spectrum antibiotics -Vasopressors -Inotropic agents -PRBC's -Neuro-muscular blockade and sedation aganets -DVT and PUD prophylaxis Nutritional therapy Should be initiated 24-48 hours of admission
50
SIRS Criteria and stages of sepsis: visual aid SIRS = systemic inflammatory response syndrome SIRS= Temp>100.4, HR >90, RR>20 or PaCO2 <32 WBC's >12,000 or <4,000 Sepsis= SIRS + Infection Severe Sepsis= Sepsis + End organ damage Septic Shock = Severe Sepsis + Hypotension
51
Sepsis bundle: Surviving Sepsis Campaign Bundle & CMS Core measure monitoring metrics
Complete within 1 hr of patient presentation/symptoms: -measure lactate level (remeasure if initial is >2 mmol/L -Obtain blood cultures -Administer broad spectrum antibx -Begin rapid admin. Of 30 mL/kg crystalloid for hypotension or lactate >/= 4 mmol/L (within 30 min) -Admin. Vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP ./= 65 mmHg
52
Sepsis bundle cont: Complete within 3 hr of patient presentation/symptoms
Obtain serum lactate level Obtain blood cultures prior to admin. Antibx Admin. Rx broad spectrum antibx Initiate aggressive fluid resuscitation in patients with hypotension or elevated serum lactate (>/= 4 mmol/L) Minimum initial fluid bolus of 30 mL/kg with crystalloid solutions
53
Complete ASAP or within the first 6 hr of patient presentation/symptoms
Begin vasopressor agents if hypotension is not improved after initial fluid bolus (MAP 70%) -Bedside cardiovascular US -Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge
54
Distributive Shock: risk factors Septic Shock: Neurogenic Shock: Anaphylactic shock:
Septic shock: Immunosuppression Extremes of age <1 and >65 Malnourishment Chronic illness Invasive procedures Emergent and/or multiple surgeries Neurogenic shock: -Spinal cord injury -Spinal anesthesia -Depressant action of medications Anaphylactic shock: -Hx medication sensitivity -Transfusion reaction -hx reaction to insect bites/stings -Food allergies -Latex sensitivity
55
Vasoactive agents
Inotropic agents Vasodilators Vasopressor agents
56
Inotropic agents: Improve contractility, increase stroke volume, increase cardiac output
Dobutamine Dopamine Epinephrine Milrinone
57
Vasodilators
Nitroglycerin Nitroprusside
58
Vassopressor agents
Norepinephrine Dopamine Phenylephrine Vasopressin Epinephrine
59
Quick Review of shock: Cardiogenic = Obstructive = Hypovolemic = Distributive =
Cardiogenic = heart fails to pump out blood MI, Arrythmia, aortic stenosis, mitral regurgitation Obstructive = cardiac pump failure due to an indirect cardiac factor: outflow is obstructed PE, tension pneumothorax, tamponade, aortic dissection Hypovolemic = heart pumps well, but not enough blood volume to pump Hemorrhage, fluid loss (burns, vomiting, diarrhea) Distributive = heart pumps well, but there is peripheral vasodilation Pancreatitis, burns, multi-trauma via activation of the inflammatory response
60
Multiple organ dysfunction syndrome(MODS) Altered organ function Falls into _______ Phase of Shock Dysfunction and mortality: One organ system dysfunction=20% mortality >4 organ systems dysfunction=60% mortality MODS can be a complication of all forms of shock; however, is most common in ____
Stage II: Progressive sepsis
61
Risk factors and s&S of Mods: Lungs Liver Neuro Renal
Advanced age Malnutrition Coexisting diseases / chronic illness Immunosuppression Surgical or traumatic wounds Lungs Progressive dyspnea Respiratory failure Liver Elevated bilirubin and liver function tests Neuro Unresponsive or coma Renal Decreased urine output
62
MODS: Care mgmt Goal is to prevent; however, if unable to, goal then becomes to reverse MODS Frequent monitoring of diagnostics (labs, ecg monitoring...more invasive testing if needed)
1. Controlling the initial event 2. Promoting adequate organ perfusion 3. Providing nutritional support 4. Maximizing patient comfort
63
Stages of shock: When do you start fluid replacement and vasopressors? Since the body may not be able to maintain this state for long:
Compensatory
64
Most common type of Distributive Shock*****
Sepsis
65
Pulse pressure - norm? how to calculate?
Normal is 40 mmHg - Systolic – diastolic = pulse pressure - Eg: 120/80 = 40 mmHg - Eg: 90/70 = 20 mmHg
66
Hypovolemic shock occurs when there is a reduction of
intravascular volume by 15-30% (750-1500 mL)
67
Hypovolemic shock proper positioning
- Modified Trendelenburg (passive leg raise) head flat legs raised - This helps promote venous blood return to the heart
68
Neurogenic shock Can be caused by depressant actions of medications Or from prolonged lack of glucose (an insulin reaction)
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