Nursing Management: Shock and Multiple Organ Failure

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Nursing Management Shock and Multiple Organ
Failure

• Pamela Fowler, MS, RNC
• Assistant Professor
• Rogers State University

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What is shock?

• Shock is a clinical syndrome resulting in
  decreased blood flow to body tissues causing
  cellualr dysfunction and eventual organ failure.
• End result is inadequate supply of oxygen and
  nutrients to the tissues or IMPAIRED TISSUE
  PERFUSION
• Not simply a matter of low blood pressure

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Physiology review

• In order to maintain tissue perfusion at normal
  levels the body must have
• a working pump (heart)
• an adequate, stable amount of fluid to pump
  (blood)
• control over the size of the area the the fluid
  is being pumped through (good vascular tone,
  controls size of the vascular bed)
• Without these three elements, shock occurs

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Classifications of shock

• Distributive shock
• Hypovolemic shock
• Cardiogenic shock

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Distributive Shock

• Vasodilatation increases the size of the vascular
  space and results in altered distribution of the
  blood volume rather than actual loss of volume
• Types
• neurogenic
• septic
• anaphylatic

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Neurogenic shock

• Thought of as uncommon
• Often transitory
• Caused by massive vasodilitation as a result of
  loss of sympathetic tone
• Etiology
• spinal injury or disease
• spinal anesthesia, deep general, epidural
• vasomotor center depression

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Neurogenic shock

• Who is at risk?
• What assessment findings would indicate to the
  nurse that the client is in impending shock?
• What emergency or immediate intervention could
  be done to reverse the etiology?

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Septic shock

• Results from endotoxin activity which causes
  widespread vasodilitation
• Most commonly caused by gram-negative bacteria
• Etiology
• infection
• compromised patients

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Septic shock

• Who is at risk?
• What assessment findings would indicate to the
  nurse that the client is in impending shock?
• What emergency or immediate intervention could
  be done to reverse the etiology?

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Anaphylactic Shock

• An immediate hypersensitivity reaction
• Characterized by dilatation of arterioles and
  capillaries and increased capillary permeability
• Etiology
• allergic reaction to drugs, insect bites,
  contrast media, blood transfusions, anesthetic
  agents, foods, vaccines

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Anaphylactic shock

• Who is at risk?
• What assessment findings would indicate to the
  nurse that the client is in impending shock?
• What emergency or immediate intervention could
  be done to reverse the etiology?

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Hypovolemic Shock

• Occurs when there is actual loss of intravascular
  fluid volume
• No decrease in pumping ability of heart or
  increase in vascular space
• Can be from
• external fluid loss (actual hypovolemia)
• internal fluid shifts (relative hypovolemia)

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Hypovolemic shock

• Who is at risk?
• What assessment findings would indicate to the
  nurse that the client is in impending shock?
• What emergency or immediate intervention could
  be done to reverse the etiology?

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Cardiogenic Shock

• Occurs when the heart can no longer pump blood
  efficiently to all parts of the body
• No decrease in intravascular volume
• No increase in size of the vascular bed

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Cardiogenic shock

• Who is at risk?
• What assessment findings would indicate to the
  nurse that the client is in impending shock?
• What emergency or immediate intervention could
  be done to reverse the etiology?

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Stages

• Compensatory reversible fight-or-flight
• subtle signs may be overlooked
• Progressive Compensation is beginning to fail
  and may be detrimental
• Irreversible/Refractory compensatory mechanisms
  are ineffective or nonfunctioning

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Compensatory stage assessment

• Restlessness
• oriented
• pupils normal
• heart rate increased
• pulses bounding to thready
• systolic B/P normal or slight decrease

• Diastolic B/P normal or slight increase
• respirations faster and deeper
• output or lt
• pale, cool, may be thirsty, normal to hypoactive
  BS

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Role of the RN

• Continuous in-depth assessment of the patients
  hemodynamic status
• Prompt recognition of problems
• Accurate use of emergency orders
• Prompt and accurate reports of deviations in
  assessment to physician
• Reducing patient anxiety
• Promoting patient safety

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Progressive stage assessment

• Listless, agitated, apathetic, confused
• speech slowed
• pupils dilated
• tachycardia
• pulses weak, thready
• systolic B/P lt 90

• Diastolic B/P falling
• respirations rapid and shallow
• oliguria
• cold, clammy, cyanotic, marked increase in thirst
• BS lt or absent

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Role of the RN

• Requires expertise in assessing and understanding
  shock and the significance of changes in
  assessment data
• Managing, implementing and documenting
  treatments, medications, fluids along with
  continuous assessment and collaboration

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Irreversible shock assessment

• Confused, disoriented or unconscious
• reflexes absent
• pupils dilated with minimal response to light
• HR slow and irregular
• pulses absent (or very weak)

• Systolic B/P falling to unobtainable
• Diastolic B/P approaching 0
• Respirations slow and shallow, irregular
• output very ltor absent
• cold, clammy, mottled
• absent bowel sounds

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Role of the RN

• Continuing the astute assessment and
  interventions begun in previous stages
• Recognizing that the patient is very likely to be
  terminal
• Initiating palliative and end-of-life activities
• Support and explanation to family members

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Overall Therapeutic Management

• Most critical factor is early recognition
• Interventions
• ID patient at high risk for shock (extremes of
  age, chronic, debilitating illnesses, surgery,
  trauma, decreased immunity, hospitalization)
• Watch for assessment findings of shock
• Control or alleviate the primary cause
• Implement measures to correct pathologic changes
  and enhance tissue perfusion

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Some things to expect

• ABCs
• positioning
• oxygen
• ventilatory support
• Fluid replacement if not cardiogenic shock
• Acid-base imbalance
• Cardiac dysrhythmias
• Vasoactive medication administration

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Fluid Replacement

• Crystalloid replacement NS and LR
• Easily available, but can cause rebound overload,
  much is lost to tissues
• No oxygen carrying capacity
• Colloids plasma proteins such as albumin
• Large molecules that pull fluids into tissues,
  but are harder to obtain, more expensive and run
  risk of anaphylaxis
• No oxygen carrying capacity

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• Blood if the patient is in hypovolemic shock,
  this is the fluid of choice
• Does have oxygen carrying capacity
• Harder and slower to obtain, generally needs to
  be cross-matched

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Vasoactive medications

• Vasopressors Intropin (dopamine), Dobutrex
  (dobutamine)
• Vasodilators Nipride (nitroprusside), Tridil
  (nitroglycerine)

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Other medications

• Corticosteroids
• Antibiotics

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Goals of therapy

• Adequate tissue perfusion
• No complications related to shock

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Acute interventions

• LOOK FOR SHOCK
• LOOK FOR SHOCK
• LOOK FOR SHOCK
• LOOK FOR SHOCK
• LOOK FOR SHOCK
• LOOK FOR SHOCK
• LOOK FOR SHOCK

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Once shock is suspected

• Frequent neuro checks (every 1 hour)
• Frequent VS (up to q 5-15 minutes)
• monitor ECG
• monitor peripheral pulses
• if these are weak is your patient getting benefit
  from peripheral IV sites????)
• assess respiratory efforts, chest sounds, pulse
  ox or ABGs

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• Monitor output hourly
• think about what meds pt is getting
• Monitor body temp
• keep pt comfortably warm
• watch skin color, goose-bumps, diaphoresis
• monitor capillary refill times
• Auscultate BS every 8 hours at least
• patient may need to be kept NPO or other feedings
• watch for abdominal distention, NG output

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• Attend to patients personal hygiene, especially
  oral care and skin integrity measures
• Use compassionate understanding in dealing with
  family and patient
• Talk to the patient (even if comatose)
• Remember to provide privacy
• Provide spiritual support as desired
• Facilitate family visits and interaction with the
  patient as possible.