Shock occurs when? (list at least 2 causes)
- inability to meet metabolic demands of the tissue
- hypoperfusion results in cellular dysfunction
- there is a homeostatic imbalance between nutrient supply and demand
- adaptive responses can no longer accommodate circulatory changes
Shock can be classified into 3 main umbrella(types) of categories. List them.
- Hypovolaemic
- Cardiogenic
- Distributive shock
why do we assess for acidaemia and what are we assessing for?
We assess acidaemia to see if compensatory mechanisms are being used.
When assessing for acidaemia you are assessing for:
-Ph
-serum lactate
-BE (base excess)
what can increased lactate levels indicate?
it can be a warning sign of organ failure
List at least 4 early indications of shock?
- tachycardia
- altered consciousness
- cold diaphoretic skin
- tchypnoea
- shallow resps
- decreased urine output (<30mls/hr)
What can tachypnoea indicate in a person with shock?
Acidosis may be occurring
If a pt who is suffering from shock has shallow respirations, what could this indicate?
Alkolosis
In general terms what are the main things we should be doing if we suspect a pt may be suffering from shock?
we should be:
- conducting a rapid assessment
- so we can make a dx
- to initiate and improve intervention
List at least 2 causes of hypovolaemic shock.
Hypovolaemic shock can be a low volume of any fluid. This can be caused by: -bleeding-internal/external -diarrhoea/vomiting -dehydration -burns
what is cardiogenic shock?
When an obstruction causes a blockage of circulation. This can also include PE, cardiac temponade.
What is the main management of hypovolaemic shock
Fluid resuscitation.
Fluid infused reflect fluid lost:
-burns =plasma
-massive haemorrhage = blood
List at least 4 clinical manifestations of cardiogenic shock.
- low CO
- hypotension
- severe pulmonary congestion
- high CVP
- oliguria
- peripheral perfusion
- anxiety
- dyspnoea/tachypnoea
- resp alkalosis/acidosis
- distended neck veins
what is another term used for Systemic Inflammatory Response Syndrome (SIRS)?
Septic shock
Clinical manifestations of septic shock can be? (list 3)
- infectious agents in blood causing haemodynamic compromise
- ineffective tissue oxygen delivery
- inappropriate vasodilation
- normal or increased CO
- hypovolaemic due to vasodilation
what is anaphylaxis?
a severe allergic reaction
Neurogenic shock can also be known as?
spinal shock
List the aims of nursing care of a shocked patient.
- rapid A-E assessment
- support of pt (physical, emotional, psychological)
- holistic care (family)
- maintain communication (pt, family, staff)
- interventions = fluids, obs, meds, transfer, scribe
what does “on the floor and four more” mean?
blood on the floor and four more is chest , abdomen, pelvis and long bones.
list the nursing practice for anaphylaxis?
- assessment = accurate hx, allergies, time of onset
- ABC
- remove causative agent
- secure airway
- IM injection
- early intubation (hear stridor intubate)
- med administration = antihistamine & corticosteroids
what is the nursing practice for sepsis?
similar to hypovolaemia
- assessment
- correct physiological deterioration
- fluid management (don’t overload pt)
- address underlying infection
- administer Inotrope = vasopressin
what is the nursing practice for Neurogenic shock?
- ABC
- stabilise neck/torso
- consider fluids
- resp assessment and monitor
- maintain core temp
- initiate NBM
- pressure area care
what would you be doing in a primary survey of shock?
A-E assessment
- don’t forget c-spine control
- temp control
what would you be doing on a secondary survey of shock?
- top to toe assessment
- assessing pt for any other injuries/symptoms
- continue A-E, obs
- further assessments = cardio, neuro, resp
- documentation
- medications
- fluid management
List the early indications of shock. (List at least 4)
- tachycardia
- altered consciousness
- cold diaphoretic skin
- tachypnoea
- shallow resps
- decreased urine output
- hypotension
- lactate and acid base disturbances
