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Module 15- Shock!

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Title: Module 15A- Shock! Author: Catherine Cunningham Last modified by: Nation, John A Created Date: 4/7/2009 9:31:22 PM Document presentation format – PowerPoint PPT presentation

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Title: Module 15- Shock!


1
Module 15- Shock!
  • John Nation, RN, MSN
  • From the notes of Nancy Jenkins, RN, MSN

2
Shock-
  • Summary-
  • Lewis p. 1772-1798, 1738-1746
  • Types of Shock
  • Stages of Shock
  • Management of Shock
  • Nursing Interventions
  • Systemic Inflammatory Response Syndrome (SIRS)
  • Multiple Organ Dysfunction Syndrome (MODS)
  • Critical Care

3
Shock Defined
  • Shock- Clinical syndrome characterized by
    decreased tissue perfusion and impaired cellular
    metabolism resulting in an imbalance between the
    supply and demand for oxygen and nutrients
  • Put simply, not enough oxygen and not enough
    nutrients for body

4
Types of Shock-
  • Low blood flow-
  • Cardiogenic shock
  • Hypovolemic shock
  • Maldistribution of blood flow-
  • Neurogenic shock
  • Anaphylactic shock
  • Septic shock

5
Etiology and Pathophysiology
  • Cardiogenic shock-
  • Occurs when systolic or diastolic dysfunction of
    the pumping of the heart causes decreased cardiac
    output
  • Cardiac output stroke volume x heart rate

6
Cardiogenic Shock (contd)
  • Causes include
  • myocardial infarction
  • cardiomyopathy
  • blunt cardiac injury (trauma)
  • severe systemic or pulmonary hypertension
  • cardiac tamponade
  • arrhythmias
  • valvular defects
  • myocardial depression from metabolic problems.

7
Cardiogenic Shock (Contd)
  • Clinical Manifestations
  • Tachycardia
  • Hypotension
  • Narrowed pulse pressure
  • Tachypnea
  • Increased SVR, CVP, and PAWP
  • Pulmonary congestion
  • Cyanosis
  • Cool, clammy skin
  • Confusion/ agitation
  • Decreased capillary refill time

8
Cardiogenic Shock (Contd)
  • Laboratory/ Diagnostic Studies
  • Cardiac enzymes (troponin levels)
  • B-type natriuretic peptide (BNP)
  • ECG
  • Chest X-Ray
  • Echocardiogram
  • Heart Cathetarization (left, right or both)

9
Cardiogenic Shock (Contd)
  • Initially, what clinical condition does this
    sound similar to?

10
Cardiogenic Shock (Contd)
  • Treatment-
  • Restore blood flow to myocardium- early PCI!
  • Thromboyltic therapy, angioplasty, stenting,
    emergency revasularization, valve replacement
  • Hemodynamic monitoring PAWP
  • Intraaortic balloon pump (IABP) 50. IABP
  • Ventricular assist device VAD video
  • Transplant (rarely)

11
Cardiogenic Shock (Contd)
  • Treatment (Contd)
  • Medications (depends on cause)
  • Aspirin
  • heparin
  • Dopamine
  • Norepiniphrine
  • dobutamine
  • Diuretics
  • Vasodilators
  • Amiodarone

12
PAWP Monitoring
13
IABP
14
Cardiogenic Shock (Contd)
  • Mortaliaty rate of 80-90 when caused by acute MI
  • Prior MI, increasing age, and oliguria are
    associated with worsening outcomes

15
Hypovolemic Shock-
  • Loss of intravascular fluid volume
  • Volume inadequate to fill the vascular space
  • Categorized as absolute or relative hypovolemia

16
Hypvolemic Shock (Contd)
  • Absolute hypovolemia-
  • Results from fluid loss via hemorrhage,
    gastrointesinal (GI) loss (vomiting, diarrhea),
    fistula drainage, diabetes insipidus,
    hyperglycemia, or diuresis
  • Relative hypovolemia-
  • Results from fluid moving out of the vascular
    space and into the extravascular space- aka third
    spacing

17
Hypovolemic Shock (Contd)
  • Causes
  • Bleeding
  • Vomiting
  • Diarrhea
  • Diabetes insipidus
  • Diuresis
  • Third spacing

18
Hypovolemic Shock (Contd)
  • Clinical Manifestations-
  • Depend on extent of injury, age, general health
    status
  • Decrease in venous return, preload, stroke
    volume, and cardiac output
  • Increase in heart rate, increase in respiratory
    rate

19
Hypovolemic Shock
  • Clinical Manifestations (Contd)
  • Decrease in stroke volume, pulmonary artery wedge
    pressure, and central venous pressure
  • Decrease in urine output, absent bowel sounds,
    cool, clammy skin
  • Anxiety, confusion, agitation

20
Hypovolemic Shock (Contd)
  • Lab/ Diagnostic Tests
  • Find the source of blood loss
  • CT, ultrasound, surgery
  • CBC, electrolytes, blood gases, lactate level
  • SpO2
  • Hourly urine output monitoring

21
Hypovolemic Shock (Contd)
  • Treatment-
  • Stop source of fluid loss
  • Restore circulating volume

22
Hypovolemic Shock
  1. What is often the priority in the treatment of
    hypovolemic shock?
  2. How might you recognize the development of
    hypovolemic shock?
  3. What would you do about it?

23
Neurogenic Shock-
  • Hemodynamic phenomenon occuring after spinal
    injury at T5 or above
  • Usually within 30 minutes of injury, can last up
    to 6 weeks
  • Causes massive vasodilation without compensation
    secondary to the loss of sympathetic nervous
    system vasoconstrictor tone
  • Can also be caused by spinal anesthesia

24
Neurogenic Shock (Contd)
  • Clinical manifestations-
  • Bradycardia (from unopposed parasympathetic
    stimulation)
  • Hypotension (from massive vasodilation)
  • Hypothermia (due to heat loss)
  • Initially, skin may be warm due to vasodilation
  • Later, skin may be cool, depending on ambient
    temperature

25
Neurogenic Shock (Contd)
  • Clinical Manifestations (Contd)
  • Bladder dysfunction
  • Paralysis below level of lesion
  • Bowel dysfunction

26
Neurogenic Shock (Contd)
  • Early Signs-
  • Blood pools in venous and capillary beds
  • Skin warm and pink
  • Pulse slow and bounding
  • Decreased BP
  • Decreased MAP

27
Neurogenic (Contd)
  • Late Signs-
  • Skin pale and cool

28
Neurogenic Shock (Contd)
  • Treatment-
  • Depends on the cause
  • If spinal cord injury, promote spinal stability
  • Vasopressors and atropine for hypotension and
    bradycardia (respectively)
  • Fluids administered cautiously
  • Monitor for hypothermia

29
Anaphylactic Shock
  • Acute and life-threatening allergic reaction
    (hypersensitivity) reaction
  • Can be caused by drugs, chemicals, vaccines, food
    insect venom
  • Causes massive vasodilation, release of
    vasoactive mediators, and an increase in
    capillary permeability

30
Anaphylactic Shock (Contd)
  • Fluid shift from the vascular space to the
    interstitial space
  • Respiratory distress secondary to laryngeal
    edema, severe bronchospasm, or circulatory
    failure from vasodilation

31
Anaphylactic Shock (Contd)
  • Clinical Manifestations-
  • Anxiety, confusion
  • Dizziness
  • Chest pain
  • Incontinence
  • Swelling of lip and tongue
  • Wheezing, stridor, shortness of breath
  • Flushing, pruritus, and uticaria (hives)
  • angioedema

32
Anaphylactic Shock (Contd)
  • Treatment-
  • Epinephrine is the drug of choice
  • Diphenhydramine used to block massive release of
    histamine
  • Maintain patent airway
  • Nebulized bronchodilators (albuterol)
  • Intubation or cricothyroidotomy (video) be needed
  • Fluid replacement, primarily with colloids
  • corticosteroids

33
  • From Seton. Educational use only.

34
Anaphylactic Shock
  • What are you worried about with a medication
    reaction?
  • What are you watching for?

35
Septic Shock
  • Septic shock- Presence of sepsis with
    hypotension, despite fluid resuscitation, with
    decreased tissue perfusion
  • Sepsis- systemic inflammatory response to an
    infection
  • Over 750,000 clients diagnosed with severe sepsis
    annually and 28 to 50 die

36
Septic Shock (Contd)
  • Course-
  • Septicemia (initially bacteremia) causes
    inflammatory cascade
  • Commonly caused by gram negative bacteria
  • If gram positive infection (Staphylococcus and
    streptococcus), up to 50 mortality rate

37
Septic Shock
  • Patho
  • Invading microorganisms result in massive
    inflammatory response
  • Causes endothelial damage, microemboli,
    vasodilation, increased capillary permeability,
    platelet aggregation, myocardial depression

38
Septic Shock (Contd)
  • Clinical Manifestations-
  • Increased or decreased temperature
  • Biventricular dilations causing decreased
    ejection fraction
  • Hyperventilation, respiratory alkalosis,
    respiratory acidosis, crackles, ARDS
  • Decreased urine output
  • Skin warm and flushed, then cool and clammy
  • Altered LOC
  • Paralytic ileus, GI bleeding
  • ? ? WBC, ? platelets, ? lactate, ? glucose, ?
    urine specific gravity, ? urine Na, positive
    blood cultures

39
Septic Shock (Contd)
  • Treatment-
  • Large amounts of fluid replacement
  • Vasopressor drug therapy
  • Corticosteroids
  • Antibiotics
  • Drotrecogin alpha (Xigris)- no longer used
  • Glucose less than 150
  • Stress ulcer prophylaxis with H2- receptor
    blockers and DVT prophylaxis

40
  • From Seton. Educational use only.

41
Obstructive Shock
  • Physical obstruction to blood flow
  • Causes
  • Cardiac tamponade, tension pneumothorax, PE, left
    ventricular thrombi
  • Decreased cardiac output, increased afterload
  • Fix the underlying problem is primary treatment

42
Common Diagnostic Tests
  • CBC
  • BMP
  • Arterial blood gases
  • Blood cultures
  • Cardiac enzymes (cardiogenic shock)
  • Glucose

43
Common Diagnostic Tests (Contd)
  • DIC (Disseminated Intravascular Coagulation)
    screen FSP, fibrogen level, platelet count, PTT
    and PT/INR, and D-dimer
  • Lactic Acid
  • Liver enzymes- ALT, AST, GGT

44
Diagnostic Tests (Contd)
  • Electrolytes-
  • Sodium level increased early, decreased later if
    hypotonic fluid administered
  • Potassium decreased in early shock, then
    increased later with cellular breakdown and renal
    failure

45
Common Nursing Diagnoses
  • Decreased cardiac output
  • Altered tissue perfusion
  • Fluid volume deficit
  • Anxiety
  • Fear

46
  • LVAD implantation (23 minutes into clip)

47
Stages of Shock
  • Compensatory Shock-
  • ? Mean Arterial Pressure (MAP)
  • ? blood pressure (but adequate to perfuse vital
    organs)
  • ? cardiac output
  • Sympathetic nervous system (SNS) stimulation
    causes vasoconstriction. Blood flow to heart and
    brain maintained, while blood flow to the
    kidneys, GI tract, skin, and lungs is diverted
  • Decreased blood flow to kidneys causes activation
    of renin-angiotensin system, leading to sodium
    retention and potassium excretion
  • In this stage the body is able to compensate for
    changes in tissue perfusion

48
Progressive Shock
  • Altered capillary permeability (3rd spacing)
  • Alveolar and pulmonary edema, ARDS, ? PA
    pressures
  • ? cardiac output, ? coronary perfusion, can cause
    arrhythmias and MI
  • Acute tubular necrosis
  • Jaundice, ? ALT,AST GGT
  • DIC
  • Cold, clammy skin

49
Refractory Stage
  • Anaerobic metabolism- lactic acid build-up
  • Increased capillary blood leak
  • Profound hypotension, inadequate to perfuse vital
    organs
  • Respiratory failure
  • Unresponsive
  • Anuria
  • DIC
  • hypothermia

50
Collaborative Care
  • Successful management involves
  • Identifying at risk clients
  • Integration of clients medical history,
    assessment findings to establish diagnosis
  • Interventions to address cause of decreased
    perfusion
  • Protection of organs
  • Multisystem supportive care

51
Collaborative Management (Contd)
  • Start with ABCs! Ensure patent airway and oxygen
    delivery
  • Volume expansion and fluid administration
    cornerstone of treatment of septic, hypovolemic,
    and anaphylactic shock
  • Primary goal of therapy is correction of
    decreased tissue perfusion
  • Hemodynamic monitoring, drug therapy, circulatory
    assist

52
Nursing Implementation
  • Health Promotion-
  • Identify at risk clients
  • Prevent shock (monitoring fluid balance, good
    hand washing to prevent infection, community
    education and health promotion)

53
Interventions (Acute)
  • Assess neurologic status- check LOC every hour or
    more often
  • Monitor heart rate/ rhythm, BP, central venous
    pressure, pulmonary artery pressure, cardiac
    output
  • Trendelenburg position not supported by research
    and may compromise pulmonary function and
    increase ICP
  • Monitor EKG for dysrhythmias, S3 or S4 heart
    sounds

54
Interventions
  • Assessment (Respiratory)-
  • Respiratory rate and effort
  • Pulse oximetry
  • ABGs for acid/base balance
  • Intubation/ ventilation

55
  • Assessment-
  • Hourly urine output
  • If less than 0.5 ml/kg/hour, may indicate
    inadequate kidney perfusion
  • BUN and creatinine
  • Temperature
  • Capillary refill
  • Monitor skin for pallor, flushing, cyanosis,
    diaphoresis, piloerection

56
  • Assessment (Contd)-
  • Check bowel sounds
  • If NG tube present, check drainage for blood
  • Passive ROM and oral care
  • Talk with client, even if sedated or intubated

57
Systemic Inflammatory Response Syndrome (SIRS)
  • Systemic Inflammatory Response Syndrome (SIRS)- a
    systemic inflammatory response to a variety of
    insults, including infection, ischemia,
    infarction, and injury
  • Characterized by generalized inflammation of
    organs
  • Two or more of the following conditions
    temperature gt38.5C (101.3 F) or lt35.0C (95.0
    F) heart rate of gt90 beats/min respiratory rate
    of gt20 breaths/min or PaCO2 of lt32 mm Hg and WBC
    count of gt12,000 cells/mL, lt4000 cells/mL, or gt10
    percent immature (band) forms

58
Multiple Organ Dysfunction Syndrome (MODS)
  • Results from SIRS
  • Characterized by failure of two or more organ
    systems such that homeostasis can not be obtained
    without intervention
  • Often culminates in ARDS
  • Can cause massive vasodilation and myocardial
    depression
  • Commonly manifests as changes in LOC
  • Acute renal failure common

59
  • GI tract highly vulnerable to ischemic injury
    secondary to shunting in early stages
  • At risk for ulceration and GI bleeding
  • Potential for bacterial translocation from GI
    tract to cirulation
  • Causes hypermetabolic state
  • Failure of coagulation system manifests as DIC
  • Electrolyte changes and fluid shifts

60
Critical Care
  • Care of the critically ill patient
  • Invasive monitoring capabilities
  • Bedside procedures possible
  • 2 to 1 patient to nurse ratio
  • Intensivists or pulmonary/ critical care
    physicians and advanced practice nurses

61
Critical Care
  • Post-surgical pathways often include going to ICU
  • Certain medications, devices, and frequency of
    testing require placement in ICU
  • Medications must be reconciled with any move to
    or from critical care to other level of care
  • Notify family members

62
The End!
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