Caring for Clients Experiencing Shock

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Caring for Clients Experiencing Shock

• NR 240

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Definition of shock

• A disorder characterized by hypoperfusion coupled
  with hypo-oxygenation
• Leads to anaerobic metabolism, ischemia and cell
  death if uninterrupted also called multiple organ
  dysfunction syndrome
• Can be classified according to site of origin or
  functional impairment

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Classifications of shock functional impairment
vs site of origin
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Etiology of shock
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Stages of shock
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Pathophysiology of shock overview
Capillary leaking
Volume depletion
Decreased vascular tone
Pump failure
Renin Angiotensin Aldosterone released
Anaerobic metabolism
Acidosis Hyperkalemia Toxic metabolites Causing
endothelial damage tissue death
oliguria
MODS
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Complications of shock

• MODS (multiple organ dysfunction syndrome)
• Anoxic encephalopathy
• ARDS
• Myocardial pump failure
• myocardial depressants known as MDF which are
  released from the pancreas
• Acute tubular necrosis
• result of decreased renal perfusion
• DIC
• platelet consumption
• Rhabdomyolysis
• skeletal muscle breakdown
• Profound sepsis
• from decreased macrophage effectiveness
• Paralytic ileus
• from decreased peristalsis
• Liver failure

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Clinical manifestations of shock

• Cardiovascular Manifestations
• ? Decreased cardiac output
• ? Increased pulse rate
• ? Thready pulse
• ? Decreased blood pressure
• ? Narrowed pulse pressure
• ? Postural hypotension
• ? Low central venous pressure
• ? Flat neck and hand veins in dependent positions
• ? Slow capillary refill in nail beds
• ? Diminished peripheral pulses
• Respiratory Manifestations
• ? Increased respiratory rate
• ? Shallow depth of respirations
• ? Decreased Paco2
• ? Decreased arterial Pao2
• ? Cyanosis, especially around lips and nail beds

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Clinical manifestations of shock

• Neuromuscular Manifestations
• ? Early
• Anxiety
• Restlessness
• Increased thirst
• ? Late
• Decreased central nervous system activity
  (lethargy to coma)
• Generalized muscle weakness
• Diminished or absent deep tendon reflexes
• Sluggish pupillary response to light
• Renal Manifestations
• ? Decreased urine output
• ? Increased specific gravity
• ? Sugar and acetone present in urine

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Clinical manifestations of shock

• Integumentary Manifestations
• ? Cool to cold
• ? Pale to mottled to cyanotic
• ? Moist, clammy
• ? Mouth dry paste like coating present
• Gastrointestinal Manifestations
• ? Decreased motility
• ? Diminished or absent bowel sounds
• ? Nausea and vomiting
• ? Constipation

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Lab diagnostics for hypovolemic shock
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Hemodynamic patterns in shock
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BEST PRACTICE for The Client in Hypovolemic Shock

• Ensure a patent airway.
• Start an IV catheter or maintain an established
  catheter.
• Administer oxygen.
• Elevate the client's feet, keeping his or her
  head flat or elevated to a 30-degree angle.
• Examine the client for overt bleeding.
• If overt bleeding is present, apply direct
  pressure to the site.
• Administer medications as prescribed.
• Increase the rate of IV fluid delivery.
• Do not leave the client.

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INTERVENTION ACTIVITIES for The Client with
Hypovolemic Shock

• Shock Management Volume Promotion of adequate
  tissue perfusion for a client with severely
  compromised intravascular volume
• Monitor for signs and symptoms of persistent
  bleeding (e.g., check all secretions for frank or
  occult blood).
• Monitor the client closely for hemorrhage.
• Prevent blood volume loss (e.g., apply pressure
  to site of bleeding).
• Administer IV fluids, as appropriate.
• Note hemoglobin/hematocrit level before and after
  blood loss, as indicated.
• Administer blood products (e.g., platelets or
  fresh frozen plasma), as appropriate.
• Monitor coagulation studies, including
  prothrombin time (PT), partial thromboplastin
  time (PTT), fibrinogen, fibrin degradation/split
  products, and platelet counts, as appropriate.

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Drug therapy in Hypovolemic shock
IV agents to do replace appropriate volume and
blood product replacement. They are used as a
supportive intervention until volume depletion is
corrected
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Management of Cardiogenic chock
Cardiogenic shock guidelines
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Cardiogenic

• Pump failure results in inadequate tissue
  perfusion
• DECREASE IN CARDIAC OUTPUT CAUSES A DECREASE IN
  MEAN ARTERIAL PRESSURE
• Seen in
• MI
• Exacerbation of CHF
• restrictive pericarditis
• tamponade
• dysrhythmia
• Valvular disease

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Management of cardiogenic shock

• Reversal of underlying cause
• Arrhythmia, structural anomaly, acute coronary
  syndrome
• Supportive care
• Airway management
• Hemodynamic monitoring
• Vasoactive agents

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Drug therapy in Shock
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Caring for clients with Distributive shock

• Septic
• Neurogenic
• anaphylactic

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Management of septic shock
Surviving sepsis campaign guidelines for
management of severe sepsis and septic shock.
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Pathophysiology of septic shock
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Assessment findings in Septic shock
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BEST PRACTICE for The Client in Sepsis-Induced
Distributive Shock

• Ensure a patent airway.
• ? Start or maintain an established IV catheter.
• ? Administer oxygen.
• ? Administer antibiotics.
• ? Obtain specimens of blood, urine, wound
  drainage, and sputum for culture.
• ? Increase the rate of IV fluid delivery.
• ? Use aseptic technique for any invasive
  procedure.
• ? Handle the client gently.
• ? Examine the client for overt bleeding,
  especially of gums, injection sites, and IV
  sites.
• ? Elevate the client's feet, keeping his or her
  head flat or elevated to a 30-degree angle.
• ? Take the client's vital signs every 5 minutes
  until they are stable.
• ? Administer medications as prescribed
• Heparin during phase 1
• Clotting factors, platelets, and plasma during
  phase 2

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Management of neurogenic shock
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NEUROGENIC SHOCK

• PARASYMPATHETIC NS OVERSTIMULATION
• SYMPATHETIC NS UNDERSTIMULATION
• SUSTAINED VASODILATION RESULTS IN
• DECREASED SYSTEMIC VASCULAR RESISTANCE
• HYPOTENSION
• BRADYCARDIA
• MENTAL STATUS CHANGES
• Associated with Spinal cord injury

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Management of Neurogenic shock

• Follow shock management protocols
• Maintain spinal immobilization
• Administer vasopressors

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Management of anaphylaxis
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Anaphylaxis care

• Ensure airway
• Administer epinephrine
• Establish IV access
• Provide supportive care as required
• Intubation
• Vasopressors
• Corticosteroids
• H2 antagonists

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Drug therapy in Shock
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Can you name which shock is most likely
responsible?

• Diffuse edema to extremities, skin reddened with
  wheals noted, just started on new antibiotic
• Acute mental status change, decreased heart rate,
  skin cool and dry
• s/p radiation and chemotherapy with neutropenia
  refractory to Neupogen. rectal temp 96.5 BP
  100/60 HR 133
• PMH of MI X 4, IDDM, CHF with Harsh systolic
  murmur at 2nd intercostal space at the right
  sternal border
• S/P exploratory laparotomy POD1 with a history
  of COPD on PO steroids X 10 years whose skin is
  pale and cool. Client c/o fatigue and unable to
  participate in ADLs

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ADDITIONAL DIAGNOSES/COLLABORATIVE PROBLEMS

• PCMODS
• PC ARDS
• PCDIC
• PCPARALTYIC ILEUS
• PC HEPATIC FAILURE
• PCSEPSIS
• PCRHABDOMYOLYSIS
• RISK FOR INJURY
• PAIN
• ANXIETY VS FEAR
• PC NEGATIVE NITROGEN BALANCE
• INTERRUPTED FAMILY PROCESSES
• RISK FOR IMPAIRED VERBAL COMMUNICATION
• ACTIVITY INTOLERANCE VS FATIGUE
• INADEQUATE TISSUE PERFUSIONPERIPHERAL
• RISK FOR IMPAIRED SKIN INTEGRITY

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Monitor/Prevent potential complications of shock

• Remember risk for MODS, ARDS, DIC,
  Rhabdomyolysis, ATN, anoxia, sepsis, ileus, liver
  failure, ulcers identified as potential
  complications
• Develop assessment/monitoring strategies that are
  broad-sweeping and repeated frequently until
  stable
• Mon vital signs (VS), cardiac monitoring (CM)
  pulse oximetry, I/O, peripheral pulses,
  neurochecks
• Mon CMP, CK, CBC,PT/PTT and bleeding times, type
  and cross, total protein, albumin, LFTs
• Insert NG tube to prevent ileus
• Administer anti-ulcer therapy and antibiotic
  prophylaxis

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Shock Summary

• Disorder of impaired tissue perfusion secondary
  to decreased circulating volumes caused by
  cardiac, neurogenic, inflammatory, obstructive
  and infectious etiologies
• Manifests with AMS, agitation, thirst, Increased
  HR (except neurogenic shock) and normal to
  slightly lower BP in initial phase
• Can progress to irreversible refractory phase
• Treatment focuses on ABCs, reversal of
  underlying cause, and prevention of complications
• Evaluation of outcomes focus on tissue perfusion
  and oxygenation, cardiac pump effectiveness,
  fluid/electrolyte balance and avoidance of
  systemic complications such as MODS, ARDS, DIC,
  ATN, Rhabdomyolysis, sepsis, ileus, liver failure
  and ulcers