Shock
- Life threatening- results in death if untreated
- Caused by inadequate tissue perfusion
Pt. presents in shock with hypotension. What would you expect
the body to do in attempt to maintain homeostasis? Select all
1. Decrease heart rate
- Increase heart rate
- Decrease resp. rate
- Increase resp. rate
2 & 4
Adequate Tissue Perfusion (B4)
Requires:
When 1 component is impaired,
1.Adequate cardiac pump (heart)
2.Intact circulatory system
3.Sufficient blood volume
inadequate blood flow to tissues result
in impaired O2 & nutrient delivery to cells
Cellular ischemia leads to cellular death and organ failure
Who is at increased risk of shock?
- Older adults
- Patients with chronic illness ex: diabetes, CKD, HF
- Patients who are receiving immunosuppressive therapy
- Malnourished patients
- Debilitated individuals
- Malnourished patients
- Debilitated individuals
Classification of Shock
*1. Maldistribution of blood flow ( 3)
- Low blood flow (3)
Classification of Shock (B4)
* Maldistribution of blood flow
–Septic
–Anaphylactic
–Neurogenic
- Low blood flow
–Cardiogenic
–Hypovolemic
–Obstructive
Maldistribution of blood flow-
loss of blood vessel tone. Leads to
massive pooling in venous and capillary beds and decreases
venous return.
____________ fluid moves out of vascular space
and is unavailable to maintain blood flow
relative fluid loss
Obstructive shock
physical obstruction restricting the filling of the
heart
shock is basically
VASODILATION OF VESSEL
Septic Shock
DEFINE:
- Myocardial depression =
NURSING INTERVENTIONS
- Vasodilation
*May be normovolemic
*Acute hypotension
*Inflammatory response-capillary dilatation and permeability,
platelet aggregation (exaggerated effect)
*Inflammatory response-capillary dilatation and permeability,
platelet aggregation (exaggerated effect)
* Maldistribution of blood flow
* Myocardial depression
*Decreased E/F
*Respiratory Failure, organ shutdown
culture ( broad -spectrum antibiotics ) WE GOTTA START SOMEWHERE.
Cardiogenic Shock
NURSING interventionS
–Severe heart failure seen with massive damage to left ventricle with
an MI
Angioplasty /stents/bypass/medication ( b2/calcium)/ valve replacement
Hypovolemic Shock = define
Absolute hypovolemia-
vs
Relative hypovolemia-
Decreased intravascular volume due to external fluid loss or
internal fluid shift
Absolute hypovolemia-fluid loss from body (blood or other body fluid)
Hemorrhage, Diarrhea, Vomiting, Excessive sweating,
GI bleed, Excessive diuresis
Relative hypovolemia- fluid loss from the vascular space
Ascites, Anasarca, Internal bleeding, vasodilation
The patient suffers a massive MI. Which type of shock should the
nurse be aware of?
1. Hypovolemic
2. Neurogenic
3. Cardiogenic
4. Septic
3
Tissue & organ perfusion depend upon mean arterial pressure (MAP). MAP should exceed _______ mm Hg for cellular oxygenation and ATP
metabolism ( state equation)
70-100 mm
MAP= SBP plus 2(DBP)
3
Cardiac Output equation
SV * HR
4 Stages of Shock (B7)
- Initial
- Compensatory
- Progressive
- Refractory (Irreversible)
Initial stage of Shock
approx. ____blood loss (750 ml)
______ Liter
Initial stage S&S
–VS WNL
–approx. 10-15% blood loss (750 ml)
–5-6 Liter= normal blood volume
–very subtle changes
–urinary output WNL
–skin pink in color
–normal cap refill
Compensatory Stage
* Fight or Flight response-
- ________ blood loss, ________ ml
SNS stimulated to produce epinephrine and
norepinephrine, HR increases, vasoconstriction occurs so BP is
maintained, then decreasing.
- 20-30% blood loss, 1500ml or 1.5L
Compensatory Stage (B7)
- ________ not a good indicator; may be WNL
- Changes in LOC and narrowing pulse pressure (<_____) is an earlier
indicator of shock than BP - Increased _______
- ___________ skin
- Decreased ____________ sounds
- ____________ increase
- BP- not a good indicator; may be WNL
- Changes in LOC and narrowing pulse pressure (<30) is an earlier
indicator of shock than BP - Orthostatic hypotension
- Blood shunted from GI tract, kidneys, skin to heart and brain
- Increased thirst
- Cold clammy skin
**except early sepsis - Decreased bowel sounds
- Respirations increase
- Urine output decreased d/t ADH (retention aids in increase in fluid
volume) foley & hrly output - Confused, restlessness, anxious, agitated, combative, do not sedate
(masks deterioration) - Prognosis good if detected now
- Must look for S&S other than BP as indicator of early shock
Progressive Stage (B8)
- Mechanisms that regulate BP can no longer compensate- system
exhausted - Noticeable clinical deterioration
- MAP<60
- Hypotensive- systolic below 90mmHg or a decrease in systolic of 40
mmHg - Unable to get BP, need automatic cuff or arterial line with con’t BP
monitoring - Unable to get BP, need automatic cuff or arterial line with con’t BP
monitoring - Pulse pressure<20
- 40% blood loss; 2000ml or 2L
Progressive Stage (B8) - Decreased cardiac output- leads to anaerobic metabolism- lactic acid
builds up- metabolic acidosis occurs - HR> 150, chest pain, MI, arrhythmias, EKG changes, elevated
cardiac enzymes - Rapid shallow respirations, crackles, alveoli collapse, CO2 retention
- Decreased perfusion to brain- leads to confusion- lethargy or listless
and agitated, dec responsiveness to stimuli
Progressive Stage (B8) - Output 5-15ml/hr, increased BUN, serum creatinine, AKI
- Decreased liver perfusion leads to decreased ability to metabolize
meds and waste. Lactic acid, ammonia, bilirubin and liver enzymes
increase, bacteria not filtered from blood
Progressive Stage (B8) - Dry Mucus membranes
- Skin mottled, cold, petechiae, ecchymosis, jaundiced
- Capillary refill >2 sec
- GI ischemia leads to stress ulcers, GI bleeding, gut bacteria may
enter blood stream - Bowel sounds hypoactive or decreased
- Disseminated Intravascular coagulation (DIC)
Refractory (Irreversible) Stage (B9)
- Vasoconstriction cuts off blood supply long enough that ischemia
turns to infarction, multiple organ dysfunction or failure. The more
organs involved the worse the prognosis.
–Pulse pressure 0-10
–BP is very low and needs pharmacological support
–>40% blood loss, 2000 or 2L
–Unconscious
–Dilated pupils with minimal or absent response to light
–Sepsis
–Cap refill > 3 sec
Refractory (Irreversible) Stage
- Intubation & mechanical ventilation
- Renal failure- dialysis
- DIC
- Organ Failure
- Death
Treatment of Shock
- Treat underlying cause- stop the bleeding, vomiting, diarrhea etc
- Restore intravascular volume/Fluid Resuscitation
* Administer Normal Saline (change in packet)
- Administer blood or blood products
Treatment of Shock (B9) - Whole Blood- restores blood volume and O2 carrying capacity of
blood - Whole Blood- restores blood volume and O2 carrying capacity of
blood - Packed RBC- contains RBC and 20% plasma, no clotting factors,
restore O2 carrying ability, decreased risk of fluid volume overload - Fresh frozen plasma- liquid part of blood separated from cells.
Expands circulating volume
Administer blood or blood products/ Treatment of Shock
- Whole Blood- restores blood volume and O2 carrying capacity of
blood - Whole Blood- restores blood volume and O2 carrying capacity of
blood - Packed RBC- contains RBC and 20% plasma, no clotting factors,
restore O2 carrying ability, decreased risk of fluid volume overload - Fresh frozen plasma- liquid part of blood separated from cells.
Expands circulating volume
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parenteral medications53
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precaution41
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pain38
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Chest58
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post partum79
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pp complications40
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post partum breastfeedinf17
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Family Planning23
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normal newborn68
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high risk6
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anterpartal86
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L &D83
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IV therapy40
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Diabetes30
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IV medication5
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Shock28
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Preop77
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Grief and Loss5
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Preoperative Nutrition70
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Preoperative19
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STI58
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Womens Health107
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Eye n Ear68
