Shock
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SHOCK I.
Define shock
A condition in which systemic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cellular functions. In shock cells lack adequate blood supply & are deprived of oxygen & nutrients, therefore they must produce energy through anaerobic metabolism. This results in low energy yields from nutrients & an acidotic intracellular environment. Normal cell function ceases. The cell swells & the cell membrane becomes more permeable, allowing electrolytes & fluids to seep out of & into the cell. The Na/K+ pump becomes impaired; cell structures are damaged and death of the cell results.
II.
Causes of shock A. inadequate cardiac pump B. inadequate blood volume- won’t circulate where needs to go C. inadequate vascular tone
*when one component is impaired, blood flow is threatened or compromised *without treatment the results are poor delivery of oxygen and nutrients to the cells, cellular starvation, cell death, organ dysfunction progressing to organ failure, and eventually death
III.
The three stages of shock A. Compensatory- “fight or flight” i. Clinical manifestations a. BP is normal
b. c. d.
↑ HR Skin is cold & clammy due to shunting of blood Possible restlessness or confusion
e. f.
↓ urinary output
b.
Cardiac output ↓, so Bp ↓ (bradycardia) Skin- cold & clammy
↑ RR ii. Nursing actions & assessments a. VS- loc c.
d.
Lab values- ↓H&H, ↓O2 *report any deviations from normal B. Progressive i. the overworked heart becomes dysfunctional; the body’s inability to meet increased O2 requirements produces ischemia; the body can’t compensate & bp begins to fall ii. clinical manifestations
a. b. c. d. e.
f.
Bp ↓ ↑ HR (>150) chest pain rapid, shallow R, crackles skin is mottled, petechaie
mental deterioration b/c ↓ urinary output causing toxins in blood & to brain iii. nursing actions & assessments a. assess frequently
b.
promote rest & comfort
a.
c.
pt in bed to ↓ energy use b. may be cold/clammy but don’t want to warm too fast don’t forget about the family a. notify if change or getting worse b. encourage counseling or visit from chaplin
C. Irreversible i. can’t be reversed
a.
Bp ↓- nothing can be done to bring ↑, so will go into multiple organ failure ii. client death inevitable iii. tissue damage repair impossible
iv.
cardiac output ↓ v. reduced venous return- blood cooling in capillaries (edema, pulmonary congestion vi. nursing actions a. continue to monitor vs b. protect client from injury c. provide comfort d. allow family time with client
IV.
Complications of shock A. cardiogenic shock i. Caused by mi ii. Pump itself fails iii. Heart is unable to pump blood & supply of O2 is inadequate for heart & tissues
iv. v. vi.
↓ cardiac contractility- heart not pumping effectively ↓ cardiac output ↓ tissue perfusion a. pulmonary congestion
b.
↓ coronary perfusion- blood pooling vii. clinical manifestations a. difficulty breathing b. crackles c. chest pain d. shallow R e. dysnea on exertion viii. treatment a. supply O2 a. not getting enough b. so give at 2-6 l/min per nasal cannula c. want O2 sat at 92%
b. c. d.
control pain with morphine (dilates blood vessels, ↓ pain) IV fluids- NS or LR vasoactive medication a. helps heart beat faster/stronger
b. c.
↓ pre and afterload stabilize heart beat (p307)
d.
dobutamine (↑ cardiac output), nitro (dilate bv), dopamine (↑ tissue perfusion) e. control HR f. possible pacemaker B. hypovolemic shock i. decrease in blood volume problem ii. most common type iii. caused by extreme fluid losses a. trauma b. dehydration c. N/V/D d. Burns
iv.
begins with ↓ in intravascular volume v. decrease co
vi.
heart beating faster b/c ↓ blood- trying to oxygenate quickly
a. b.
↓HR ↓co
vii.
↓ stroke volume leading to ↓ tissue perfusion b/c less blood cells & will die viii. treatment a. restore fluid loss a. LR b. 0.9 % NaCl (NS) b. redistribute fluid volume
a.
reposition of client (trendelenburg- head ↓ feet ↓) c. correct cause of fluid loss ix. prevention a. assess pt a. when come back from surgery look at bandage (circle drainage) b. make sure have IV fluids c. might have to move pt to assess b. monitor pt a. for N/V/D b. offer fluids c. adequate hydration d. I&O e. ambulation C. circulatory shock i. problem with blood vessels not distributing blood throughout the body (blood volume pools in the peripheral blood vessels) ii. types a. septic shock- most common a. caused by widespread infection b. hypodynamic irreversible phase caused by vasodilation of bv c. check lines b/c can become infected d. risk factors i. immunosuppression
ii.
extremes of age <1 or >65 iii. malnourishment iv. chronic illnesses v. invasive procedures
e.
b.
nursing measures i. aseptic technique ii. hand washing iii. sterile dressing changes iv. monitor vs, I&O f. treatment i. identify & eliminate cause of infection ii. fluid replacement to correct hypovolemia caused by inflammatory response iii. blood products to increase intravascular volume neurogenic shock a. vasodilation which occur as a result of sympathetic tone b. caused by a spinal cord injury or nervous system damage c. may have a prolonged course d. can be i. short term- fainting ii. long term- spinal cord injury, spinal cord anesthesia e. risk factors i. spinal cord injury ii. spinal anesthesia iii. depressant action of medications iv. glucose deficiency f. clinical manifestations i. warm, dry skin
ii.
c.
bradycardia- ↓bp, ↓hr iii. vasodilation of bv iv. pooling of blood in capillaries g. nursing actions is in prevention i. elevate & maintain HOB elevated in pt with epidural or spinal anesthesia ii. in suspected spinal cord injury immobilize client to prevent further damage iii. apply elastic compression stockings- may have to give lovenox iv. check homan’s sign- if + call dr (pain, redness, warmth, edema) anaphylactic shock a. caused by severe allergic reaction b. an antigen-antibody reaction causes widespread vasodilation & capillary permeability c. occurs rapidly d. life threatening e. often can be prevented i. wear breacelet ii. stay away from iii. epipen available f. risk factors i. penicillin sensitivity ii. transfusion reaction iii. bee sting allergy iv. latex sensitivity g. clinical manifestations i. widespread vasodilation ii. uticara iii. itching
h.
i. j.
V.
iv. flushing v. n/v/d vi. fluid transfer to subq tissue vii. bronchospasm & facial edema treatment i. immediate attention & life support 1. epinephrine for vasoconstrictive action 2. diphenhydramine (benadryl)- to reverse effect of histamine, reduces capillary permeability 3. proventil (albuterol) inhaler prevention i. assess all clients for allergies ii. education of client & family nursing actions i. client & med hx- what happens when client does take ii. assess iii. observe client when administering a new med iv. contrast agents- diagnostic tests for allergy v. speak on client terms (shellfish) vi. education about further exposure 1. client & family 2. on contact with substance
Clinical findings in shock A. anxiety- due to decreased O2
B. ↓BP- ↓cardiac output & blood volume C. ↑ P- compensation D. ↓urinary output & concentration of urine i. ↓blood flow to kidneys ii. ↑ fluid retention iii. ↑ BUN & creatinine E. cold, clammy skin
i.
↓ metabolism ii. peripheral vasoconstriction F. cyanosis
i. ii.
↓ O2 in blood
↓ CO2 in blood G. pallor- peripheral vasoconstriction
VI.
Drugs used A. antiarrhythmic B. Ca+ channel blockers- increase force of contraction, increasing flow of blood
C. B- adrenergic blocker- ↓HR D. Na+ bicarbonate- metabolic acidosis E. antibiotics- fight infection F. bronchodilators- dilate bronchioles
G. anticholinergic- ↑HR H. anticoagulant- prevent blood from clotting
I.
VII.
J. K. L. M. N. O.
anticonvulsants- high T & ↑ toxins in blood so need to prevent convulsions diuretics- keep fluid from building up in tissue and need to get rid of corticosteroids- reduce inflammation in anaphylactic antihistamines- histamine reaction narcotics- pain in cardiogenic (morphine) colloids- large-molecule IV solution used as blood & fluid volume expanders crystalloids- electrolyte solution that moves freely between intravascular and interstitial spaces, used as blood & fluid volume expander
P.
vasopressors- ↑BP so drugs won’t pool
Factors that affect progress of shock A. degree of complication- stage in B. existing conditions i. chronic ii. malnutrition iii. surgery iv. diarrhea v. infection C. age i. elderly ii. debilitated iii. young D. management i. assessment ii. monitoring iii. don’t overhydrate in cardiogenic iv. sooner treated the better v.
VIII. Complications of shock A. myocardial depression
i. ii.
↓ O2
↓ cardiac output iii. pulmonary edema
B. ARDS- ↓gas exchange in the lung C. renal failure- especially hypovolemic D. DIC i. clotting to excess ii. can be treated with crystalloids E. GI ulcers F. long-term HTN G. MODS- multiple organ dysfunction syndrome – is an altered organ function in an acutely ill patient that requires medical intervention to support continued organ function H. hepatic insufficient
Define shock
A condition in which systemic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cellular functions. In shock cells lack adequate blood supply & are deprived of oxygen & nutrients, therefore they must produce energy through anaerobic metabolism. This results in low energy yields from nutrients & an acidotic intracellular environment. Normal cell function ceases. The cell swells & the cell membrane becomes more permeable, allowing electrolytes & fluids to seep out of & into the cell. The Na/K+ pump becomes impaired; cell structures are damaged and death of the cell results.
II.
Causes of shock A. inadequate cardiac pump B. inadequate blood volume- won’t circulate where needs to go C. inadequate vascular tone
*when one component is impaired, blood flow is threatened or compromised *without treatment the results are poor delivery of oxygen and nutrients to the cells, cellular starvation, cell death, organ dysfunction progressing to organ failure, and eventually death
III.
The three stages of shock A. Compensatory- “fight or flight” i. Clinical manifestations a. BP is normal
b. c. d.
↑ HR Skin is cold & clammy due to shunting of blood Possible restlessness or confusion
e. f.
↓ urinary output
b.
Cardiac output ↓, so Bp ↓ (bradycardia) Skin- cold & clammy
↑ RR ii. Nursing actions & assessments a. VS- loc c.
d.
Lab values- ↓H&H, ↓O2 *report any deviations from normal B. Progressive i. the overworked heart becomes dysfunctional; the body’s inability to meet increased O2 requirements produces ischemia; the body can’t compensate & bp begins to fall ii. clinical manifestations
a. b. c. d. e.
f.
Bp ↓ ↑ HR (>150) chest pain rapid, shallow R, crackles skin is mottled, petechaie
mental deterioration b/c ↓ urinary output causing toxins in blood & to brain iii. nursing actions & assessments a. assess frequently
b.
promote rest & comfort
a.
c.
pt in bed to ↓ energy use b. may be cold/clammy but don’t want to warm too fast don’t forget about the family a. notify if change or getting worse b. encourage counseling or visit from chaplin
C. Irreversible i. can’t be reversed
a.
Bp ↓- nothing can be done to bring ↑, so will go into multiple organ failure ii. client death inevitable iii. tissue damage repair impossible
iv.
cardiac output ↓ v. reduced venous return- blood cooling in capillaries (edema, pulmonary congestion vi. nursing actions a. continue to monitor vs b. protect client from injury c. provide comfort d. allow family time with client
IV.
Complications of shock A. cardiogenic shock i. Caused by mi ii. Pump itself fails iii. Heart is unable to pump blood & supply of O2 is inadequate for heart & tissues
iv. v. vi.
↓ cardiac contractility- heart not pumping effectively ↓ cardiac output ↓ tissue perfusion a. pulmonary congestion
b.
↓ coronary perfusion- blood pooling vii. clinical manifestations a. difficulty breathing b. crackles c. chest pain d. shallow R e. dysnea on exertion viii. treatment a. supply O2 a. not getting enough b. so give at 2-6 l/min per nasal cannula c. want O2 sat at 92%
b. c. d.
control pain with morphine (dilates blood vessels, ↓ pain) IV fluids- NS or LR vasoactive medication a. helps heart beat faster/stronger
b. c.
↓ pre and afterload stabilize heart beat (p307)
d.
dobutamine (↑ cardiac output), nitro (dilate bv), dopamine (↑ tissue perfusion) e. control HR f. possible pacemaker B. hypovolemic shock i. decrease in blood volume problem ii. most common type iii. caused by extreme fluid losses a. trauma b. dehydration c. N/V/D d. Burns
iv.
begins with ↓ in intravascular volume v. decrease co
vi.
heart beating faster b/c ↓ blood- trying to oxygenate quickly
a. b.
↓HR ↓co
vii.
↓ stroke volume leading to ↓ tissue perfusion b/c less blood cells & will die viii. treatment a. restore fluid loss a. LR b. 0.9 % NaCl (NS) b. redistribute fluid volume
a.
reposition of client (trendelenburg- head ↓ feet ↓) c. correct cause of fluid loss ix. prevention a. assess pt a. when come back from surgery look at bandage (circle drainage) b. make sure have IV fluids c. might have to move pt to assess b. monitor pt a. for N/V/D b. offer fluids c. adequate hydration d. I&O e. ambulation C. circulatory shock i. problem with blood vessels not distributing blood throughout the body (blood volume pools in the peripheral blood vessels) ii. types a. septic shock- most common a. caused by widespread infection b. hypodynamic irreversible phase caused by vasodilation of bv c. check lines b/c can become infected d. risk factors i. immunosuppression
ii.
extremes of age <1 or >65 iii. malnourishment iv. chronic illnesses v. invasive procedures
e.
b.
nursing measures i. aseptic technique ii. hand washing iii. sterile dressing changes iv. monitor vs, I&O f. treatment i. identify & eliminate cause of infection ii. fluid replacement to correct hypovolemia caused by inflammatory response iii. blood products to increase intravascular volume neurogenic shock a. vasodilation which occur as a result of sympathetic tone b. caused by a spinal cord injury or nervous system damage c. may have a prolonged course d. can be i. short term- fainting ii. long term- spinal cord injury, spinal cord anesthesia e. risk factors i. spinal cord injury ii. spinal anesthesia iii. depressant action of medications iv. glucose deficiency f. clinical manifestations i. warm, dry skin
ii.
c.
bradycardia- ↓bp, ↓hr iii. vasodilation of bv iv. pooling of blood in capillaries g. nursing actions is in prevention i. elevate & maintain HOB elevated in pt with epidural or spinal anesthesia ii. in suspected spinal cord injury immobilize client to prevent further damage iii. apply elastic compression stockings- may have to give lovenox iv. check homan’s sign- if + call dr (pain, redness, warmth, edema) anaphylactic shock a. caused by severe allergic reaction b. an antigen-antibody reaction causes widespread vasodilation & capillary permeability c. occurs rapidly d. life threatening e. often can be prevented i. wear breacelet ii. stay away from iii. epipen available f. risk factors i. penicillin sensitivity ii. transfusion reaction iii. bee sting allergy iv. latex sensitivity g. clinical manifestations i. widespread vasodilation ii. uticara iii. itching
h.
i. j.
V.
iv. flushing v. n/v/d vi. fluid transfer to subq tissue vii. bronchospasm & facial edema treatment i. immediate attention & life support 1. epinephrine for vasoconstrictive action 2. diphenhydramine (benadryl)- to reverse effect of histamine, reduces capillary permeability 3. proventil (albuterol) inhaler prevention i. assess all clients for allergies ii. education of client & family nursing actions i. client & med hx- what happens when client does take ii. assess iii. observe client when administering a new med iv. contrast agents- diagnostic tests for allergy v. speak on client terms (shellfish) vi. education about further exposure 1. client & family 2. on contact with substance
Clinical findings in shock A. anxiety- due to decreased O2
B. ↓BP- ↓cardiac output & blood volume C. ↑ P- compensation D. ↓urinary output & concentration of urine i. ↓blood flow to kidneys ii. ↑ fluid retention iii. ↑ BUN & creatinine E. cold, clammy skin
i.
↓ metabolism ii. peripheral vasoconstriction F. cyanosis
i. ii.
↓ O2 in blood
↓ CO2 in blood G. pallor- peripheral vasoconstriction
VI.
Drugs used A. antiarrhythmic B. Ca+ channel blockers- increase force of contraction, increasing flow of blood
C. B- adrenergic blocker- ↓HR D. Na+ bicarbonate- metabolic acidosis E. antibiotics- fight infection F. bronchodilators- dilate bronchioles
G. anticholinergic- ↑HR H. anticoagulant- prevent blood from clotting
I.
VII.
J. K. L. M. N. O.
anticonvulsants- high T & ↑ toxins in blood so need to prevent convulsions diuretics- keep fluid from building up in tissue and need to get rid of corticosteroids- reduce inflammation in anaphylactic antihistamines- histamine reaction narcotics- pain in cardiogenic (morphine) colloids- large-molecule IV solution used as blood & fluid volume expanders crystalloids- electrolyte solution that moves freely between intravascular and interstitial spaces, used as blood & fluid volume expander
P.
vasopressors- ↑BP so drugs won’t pool
Factors that affect progress of shock A. degree of complication- stage in B. existing conditions i. chronic ii. malnutrition iii. surgery iv. diarrhea v. infection C. age i. elderly ii. debilitated iii. young D. management i. assessment ii. monitoring iii. don’t overhydrate in cardiogenic iv. sooner treated the better v.
VIII. Complications of shock A. myocardial depression
i. ii.
↓ O2
↓ cardiac output iii. pulmonary edema
B. ARDS- ↓gas exchange in the lung C. renal failure- especially hypovolemic D. DIC i. clotting to excess ii. can be treated with crystalloids E. GI ulcers F. long-term HTN G. MODS- multiple organ dysfunction syndrome – is an altered organ function in an acutely ill patient that requires medical intervention to support continued organ function H. hepatic insufficient
