SHOCK

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SHOCK

• NPN 205
• Medical Surgical II

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What Does Shock Look Like

• Carla----33 year old female form the emergency
  room post MVC, with an apparent crush injury to
  the pelvis, bruising over her right upper
  quadrant. She is conscious, but lethargic and
  oriented to name only. BP is 80/46, pulse 116.
  She is quickly prepared for surgery. Dx pelvic
  crush injury, r/o abdominal trauma, r/o liver
  laceration

3

• Julie---86 year old female from a local nursing
  home with a history of variable fevers for the
  past week. Her appetite has decreased, mental
  status has deteriorated. Presently, her
  temperature is 104 F.
• She has an indwelling Foley catheter, her urine
  is dark amber, foul smelling. Dx. Sepsis
  secondary to UTI

4

• Justin---14 year old male with a history of
  juvenile onset diabetes mellitus. He has been
  admitted to the hospital because his glucose has
  been greater than 600 for the last 24 hours and
  he has a fruity odor on his breath. His serum
  glucose is 786.
• Dx diabetic ketoacidosis.

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What do they have in common?

• Three different patients
• Three different diagnoses
• Three different etiologies

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Predisposition of Shock Syndrome

• Shock is a process that causes the eventual
  shutdown of all body systems in a systematic
  order
• Amount of time for shock to progress varies from
  patient to patient
• Is related to the bodys overall health and
  ability to compensate for its deficiencies
• As the syndrome progresses, the process speeds up
• The circulatory system fails to provide adequate
  blood to the tissues, resulting in cellular
  hypoxia and death

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Physiology of Hypoperfusion Shock

• Inadequate tissue perfusion
• Inadequate delivery of O2 and nutrients to the
  body tissues
• Inadequate elimination of metabolic wastes

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A P of Perfusion

• Perfusion delivery of O2 and nutrients and the
  elimination of CO2 requires four things
• 1. a properly beating heart
• 2. adequate transport medium blood and
  hemoglobin
• 3. an intact functioning vessel system
• 4, a functioning respiratory system

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Physiology of Circulation in the Vessels

• 600,000 miles of vessels containing 5-6 liters of
  blood
• Vessel tone is controlled by the sympathetic and
  parasympathetic nervous system
• Pre-capillary sphincters control blood flow
  through the capillaries in response to O2 demand
  of the tissue
• Preload is dependent on the constant peripheral
  vascular resistance

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Physiology of Circulation the Blood

• Container (vessels) must be full of blood at all
  times
• Hemoglobin must be present in adequate amount and
  be free to carry O2, nutrients, and CO2

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Stages of Shock

• Compensated ---- body is able to compensate and
  maintain tissue perfusion
• Progressive ---- body begins to lose its ability
  to compensate---inadequate perfusion begins
• Irreversible---cell and tissue damage result in
  multi-system organ failure

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Types of Shock

• Hypovolemic
• Obstructive
• Cardiogenic
• Distributive
• Anaphylactic
• Septic

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Classifications or Types of Shock

• Hypovolemic (classic shock)
• THE MOST COMMON CLASS. It is the standard used to
  compare other forms of shock to differentiate the
  diagnosis
• Hemorrhagic/Blood loss
• Dehydration/Fluid loss

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Causes of Hypovolemic Shock

• Hemorrhage
• Severe diarrhea
• Vomiting
• Excessive perspiration
• Third Spacing
• Shift of fluid in severe burns can lead to
  hypovolemic shock
• Peritonitis
• Intestinal obstruction

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Shock D/T Hemorrhage Compensation

• Mechanism volume depletion due to bleeding
• Body detects decrease in the cardiac output
• Sympathetic nervous system is stimulated
  releasing epinephrine and norepinephrine to
  stimulate alpha and beta receptors
• Alpha vasoconstriction
• Beta bronchodilation and cardiac stimulation
• Body maintains function

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Hemorrhagic Shock Progressive

• Kidneys release antidiuretic hormone which
  increases vasoconstriction
• Signs and symptoms
• Mental status lethargy, sleepy, combative
• Skin clammy, pale, mottling. Cyanosis around the
  nose and mouth first, spreads to extremities
• Blood pressure begins to fall, capillary refill
  delayed
• Pulse rapid and weak
• Respirations rapid and shallow
• Other decreased urination

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Hemorrhagic Shock Irreversible

• Signs and symptoms
• Mental status decreased LOC, to unresponsive
• Skin gray, mottled, cyanotic, waxen, sweating
  stops
• Blood pressure decreases, becomes undetectable
• Pulse slows then disappears
• Respiration agonal
• Other irritable heart, bradycardia, leads to
  asystole

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Interventions for Hypovolemic Shock

• Stop the fluid loss direct pressure, surgery
• Replace fluids blood and blood products, plasma
  expanders, crystalloid fluids (provide H2O
  replacement and E-lytes), Colloids (albumin, FF)
• Pneumatic antishock garments
• Use low dose inotropics

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Cardiogenic Shock

• Heart pump failure (40 of myocardium damaged by
  an MI)
• Cardiac trauma
• Cardiomyopathy
• Congestive heart failure
• Cardiac dysrhythmias

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Cardiogenic Shock Signs and Symptoms

• Drop in cardiac output
• Skin cyanosis
• Pulse bradycardia, tachycardia, or within normal
  limits
• Respirations diminishing breath sounds
  progressing to wheezing and crackles. Patient
  complains of increasing dyspnea. Coughs white or
  pink tinged foamy sputum
• Other pulmonary edema and left heart failure
• Pitting edema right heart failure

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Interventions for Cardiogenic Shock

• Hemodynamic monitoring
• IV fluids
• Intra-aortic balloon pump
• Cardiac transplant
• Inotropics/cardiotonics
• Digoxin, Amrinone, Primacor
• Vasodilators
• Diuretics
• If from obstructive may need surgical repair,
  chest tube, pacemaker, needle aspiration of fluid

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Obstructive Shock

• Can be classed as a type of cardiogenic shock
• Pulmonary embolism/Blocked pulmonary circulation
• Tension pneumothorax/Increased intrathoracic
  pressure
• Cardiac tamponade/Pressure on myocardium.
  Decreased preload

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Signs and Symptoms of Obstructive Shock

• Mental status anxiety, feeling of impending doom
• Skin pallor to cyanosis around the mouth and the
  nose
• Other chest pain, lung sounds may be clear,
  possible syncope, cardiac dysrhythmias (PVCs,
  A-Fib common) can lead to sudden cardiac arrest

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Distributive Shock

• Anaphylactic Shock
• Mechanism severe allergic reaction
• Skin hives, possible petechia. Urticaria,
  pallor, cyanosis
• Blood pressure abrupt fall in cardiac output
• Respiration rapid shallow, dyspnea with stridor,
  wheezes, crackles, leading to respiratory arrest
• Other swelling of mucus membranes/pulmonary
  edema

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Treatment of Anaphylactic Shock

• Maintain airway
• Ice to site of injection or sting
• Gastric lavage
• Isotonic IV fluids D5W, NACL, LR
• Epinephrine and theophylline
• Antihistamines (H2 blockers)
• Steroids
• Vasopressors to constrict blood vessels and raise
  BP

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Distributive Shock

• Septic shock
• Mechanism overwhelming infection
• Skin varies form flushed pink (if fever is
  present) to pale and cyanotic. Purple blotches
  possible, peeling skin, general or on palms and
  soles of feet
• Blood pressure earlycardiac output increases
  but toxins prevent increase in BP. Late --- drop
  in BP, hypotension
• Respiratory dyspnea with altered lung sounds
• Other high fever, (except in elderly and very
  young), Late sign is pulmonary edema

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Treatment for Septic Shock

• C S for infective site
• IV fluids with NS
• Medications and other treatment
• Vancomycin
• Penicillin
• Cephalosporin
• Cardiotonics and inotropics
• Vasopressors
• Heparin
• Blood products

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Distributive Shock

• Neurogenic Shock
• Mechanism vasodilation
• Skin areas of vasodilation, at first become
  warm, pink and dry. Later with pooling mottling
  of dependent areas, pallor and cyanosis to the
  upper surfaces
• Pulse highly variable depending on injury or
  action of drug/poison May be abnormally slow or
  abnormally fast, usually not normal
• Respiration severely compromised becoming slow,
  shallow, with abnormal patterns. Patient may
  loose stimulus to breath
• Other hypothermia. Pulmonary edema with drug or
  poisoning

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Treatment of Neurogenic Shock

• HOB flat with feet elevated
• IV normal saline
• Atropine for bradycardia
• Vasopressors to raise BP
• Analgesics for pain

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General Treatment of Shock

• Remember your ABCs
• Administer airway
• 100 O2 via a non- re-breather mask
• Assist ventilations if necessary
• Position patient to assist perfusion
• Keep patient warm
• Perform focused assessment
• Monitor and adjust O2, gain IV access, cardiac
  monitor, pulse oximetry
• Fluid replacement of LR or NS
• Need 3 liter of fluid to replace I liter of blood
  loss
• Apply pressure to IV or blood to facilitate
  faster infusion

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Nursing Diagnosis

• Ineffective Tissue Perfusion
• Decreased Cardiac Output
• Anxiety
• Fluid Volume Deficit
• Risk for Injury
• Risk for Infection

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Systemic Inflammatory Response Syndrome (SIRS)

• Defined as when generalized inflammation occurs
  and threatens vital organs
• Causes multiply transfusions, massive tissue
  injury, burns, and pancreatitis, severe
  infections or sepsis
• Effects endothelium is damaged and allows fluid
  to leak into the body tissues, results in poor
  perfusion of blood to organs
• Body is in a hypermetabolic state

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Systemic Inflammatory Response Syndrome (SIRS)

• Diagnosis made when 2 or more of the following
  are seen
• Temperature less than 97 or greater than 100.4
• Heart rate more than 90
• Respiratory rate more than 20 or PaCO2 less than
  32mm Hg
• WBC count less than 4000 cells or more than
  12,000
• Sepsis is used if patient has SIRS with and
  infection

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Multiply Organ Dysfunction Syndrome (MODS)

• Defined when 2 or more organ systems are failing
  at one time
• Is caused by the immune systems uncontrolled
  response to severe illness or injury
• Common cause of death of patients in the ICU,
  with mortality of 50
• Identifying and acting quickly can help survival
• Can develop quickly following surgery, trauma, or
  severe burns or slowly in the case of an infection

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Treatment for SIRS/MODS

• Critical care nursing
• Goals
• Prevent and treat infections
• Maintain tissue oxygenation
• Provide nutritional and metabolic response
• Support failing organs