Focus on Shock Relates to Chapter 67 Nursing

Shock § Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism n Imbalance

Shock (Cont’d) § Classification of shock (table 67 -1) n Low blood flow Cardiogenic

Low Blood Flow Cardiogenic Shock § Definition n Systolic or diastolic dysfunction leads to

Low Blood Flow Cardiogenic Shock (Cont’d) § Precipitating causes n Myocardial infarction n Cardiomyopathy

Pathophysiology of Cardiogenic Shock Fig. 67 -2 Copyright © 2010, 2007, 2004, 2000, Mosby,

Low Blood Flow Cardiogenic Shock § Early manifestations n Tachycardia n Hypotension n Narrowed

Low Blood Flow Cardiogenic Shock (Cont’d) § Physical examination n Tachypnea, pulmonary congestion n

Low Blood Flow Hypovolemic Shock § Absolute hypovolemia: Loss of intravascular fluid volume n

Low Blood Flow Hypovolemic Shock (Cont’d) § Relative hypovolemia n Results when fluid volume

Pathophysiology of Hypovolemic Shock Fig. 67 -3 Copyright © 2010, 2007, 2004, 2000, Mosby,

Low Blood Flow Hypovolemic Shock (Cont’d) § Clinical manifestations n Anxiety n Tachypnea n

Maldistribution of Blood Flow Neurogenic Shock § Hemodynamic phenomenon that can occur within 30

Maldistribution of Blood Flow Neurogenic Shock (Cont’d) § Can be in response to spinal

Pathophysiology of Neurogenic Shock Fig. 67 -4 Copyright © 2010, 2007, 2004, 2000, Mosby,

Maldistribution of Blood Flow Neurogenic Shock (Cont’d) § Clinical manifestations n Hypotension n Bradycardia

Maldistribution of Blood Flow Anaphylactic Shock § Acute, life-threatening hypersensitivity reaction n Massive vasodilation

Maldistribution of Blood Flow Anaphylactic Shock (Cont’d) § Clinical manifestations n Swelling of the

Maldistribution of Blood Flow Anaphylactic Shock (Cont’d) § Clinical manifestations n Anxiety, confusion, dizziness

Maldistribution of Blood Flow Septic Shock § Sepsis: Systemic inflammatory response to documented or

Maldistribution of Blood Flow Septic Shock (Cont’d) § Septic shock = Presence of sepsis

Maldistribution of Blood Flow Septic Shock (Cont’d) § Mortality rates as high as 50%

Pathophysiology of Septic Shock Fig. 67 -5 Copyright © 2010, 2007, 2004, 2000, Mosby,

Maldistribution of Blood Flow Septic Shock § Clinical manifestations n ↑ Coagulation and inflammation

Maldistribution of Blood Flow Septic Shock (Cont’d) § Clinical manifestations n Tachypnea/hyperventilation n Temperature

Stages of Shock Initial Stage § Usually not clinically apparent § Metabolism changes from

Stages of Shock Compensatory Stage § Clinically apparent n Neural n Hormonal n Biochemical

Compensatory Stage of Shock Fig. 67 -6 Copyright © 2010, 2007, 2004, 2000, Mosby,

Stages of Shock Compensatory Stage § Baroreceptors in carotid and aortic bodies activate SNS

Stages of Shock Compensatory Stage (Cont’d) § Impaired GI motility n Risk for paralytic

Stages of Shock Compensatory Stage (Cont’d) § Shunting blood from lungs increases physiologic dead

Stages of Shock Compensatory Stage (Cont’d) § If perfusion deficit corrected, patient recovers with

Stages of Shock Progressive Stage § Begins when compensatory mechanisms fail § Aggressive interventions

Progressive Stage of Shock Fig. 67 -7 Copyright © 2010, 2007, 2004, 2000, Mosby,

Stages of Shock Progressive Stage (Cont’d) § Hallmarks of ↓ cellular perfusion and altered

Stages of Shock Progressive Stage (Cont’d) § Movement of fluid from pulmonary vasculature to

Stages of Shock Progressive Stage (Cont’d) § Fluid moves into alveoli Edema n Decreased

Stages of Shock Progressive Stage (Cont’d) § CO begins to fall Decreased peripheral perfusion

Stages of Shock Progressive Stage (Cont’d) § Myocardial dysfunction results in Dysrhythmias n Ischemia

Stages of Shock Progressive Stage (Cont’d) § Mucosal barrier of GI system becomes ischemic

Stages of Shock Progressive Stage (Cont’d) § Liver fails to metabolize drugs and wastes

Stages of Shock Progressive Stage (Cont’d) § Acute tubular necrosis/acute renal failure Copyright ©

$Stages of Shock Refractory Stage § Exacerbation of anaerobic metabolism § Accumulation of lactic$

$Refractory Stage of Shock Fig. 67 -8$

$Stages of Shock Refractory Stage § Profound hypotension and hypoxemia § Tachycardia worsens §$

$Stages of Shock Refractory Stage (Cont’d) § Failure of one organ system affects others$

Diagnostic Studies § Thorough history and physical examination § No single study to determine

Collaborative Care § Successful management includes n Identification of patients at risk for shock

Collaborative Care (Cont’d) § Successful management includes n Interventions to control or eliminate the

Collaborative Care (Cont’d) § General management strategies n Ensure patent airway n Maximize oxygen

Collaborative Care (Cont’d) § Cornerstone of therapy for septic, hypovolemic, and anaphylactic shock =

Collaborative Care (Cont’d) § Volume expansion n If the patient does not respond to

Collaborative Care (Cont’d) § Primary goal of drug therapy = correction of decreased tissue

Collaborative Care (Cont’d) § Nutrition is vital to decreasing morbidity from shock n Initiate

Collaborative Cardiogenic Shock § Restore blood flow to the myocardium by restoring the balance

Collaborative Cardiogenic Shock (Cont’d) § Hemodynamic monitoring § Drug therapy (e. g. , diuretics

Collaborative Care Hypovolemic Shock § Management focuses on stopping the loss of fluid and

Collaborative Care Septic Shock § Fluid replacement (e. g. , 6 to 10 L

Collaborative Care Septic Shock (Cont’d) § Intravenous corticosteroids for patients who require vasopressor therapy,

Collaborative Care Septic Shock (Cont’d) § Antibiotics after obtaining cultures (e. g. , blood,

Collaborative Care Septic Shock (Cont’d) § Glucose levels <150 mg/dl § Stress ulcer prophylaxis

Collaborative Care Neurogenic Shock § In spinal cord injury: Spinal stability n Treatment of

Collaborative Care Anaphylactic Shock § Prevent! n n n Assess for allergies/adverse reactions Family

Collaborative Care Anaphylactic Shock (Cont’d) § Aggressive fluid replacement § Intravenous corticosteroids if significant

Nursing Assessment § ABCs: Airway, breathing, and circulation Copyright © 2010, 2007, 2004, 2000,

Nursing Assessment (Cont’d) § Focused assessment of tissue perfusion n Vital signs n Peripheral

Nursing Assessment (Cont’d) § Brief history n Events leading to shock n Onset and

Nursing Diagnoses § Ineffective tissue perfusion: Renal, cerebral, cardiopulmonary, gastrointestinal, hepatic, and peripheral §

Planning § Goals for patient n Adequate tissue perfusion n Restoration of normal or

Nursing Implementation § Health Promotion n Identify patients at risk (e. g. , elderly

Nursing Implementation (Cont’d) § Health Promotion n Planning to prevent shock (e. g. ,

Nursing Implementation (Cont’d) § Acute Interventions n Monitor the patient’s ongoing physical and emotional

Nursing Implementation (Cont’d) § Acute Interventions n Evaluate the patient’s response to therapy n

Nursing Implementation (Cont’d) § Neurologic status: Orientation and level of consciousness § Cardiac status

Nursing Implementation (Cont’d) § Respiratory status n Respiratory rate and rhythm n Breath sounds

Nursing Implementation (Cont’d) § Urine output § Tympanic or pulmonary arterial temperature § Skin:

Nursing Implementation (Cont’d) § Nasogastric drainage/stools for occult blood § I&O, fluid and electrolyte

Nursing Implementation (Cont’d) § Assess level of anxiety and fear n Medication PRN n

Evaluation § Normal or baseline, ECG, BP, CVP, and PAWP § Normal temperature §

Case Study Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Case Study § 26 -year-old male arrives via paramedics to ED with multiple gun

Case Study (Cont’d) § Three units type O packed RBC given for profuse blood

Case Study (Cont’d) § Surgery successful in removing bullets and repairing blood vessels §

Discussion Questions 1. What complications will you anticipate with this amount of blood loss?

Discussion Questions (Cont’d) 3. What medications will likely be ordered? 4. What should you

Slides: 87

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Focus on Shock (Relates to Chapter 67, “Nursing Management: Shock, SIRS, and Multiple Organ Dysfunction Syndrome, ” in the textbook) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Shock § Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism n Imbalance in supply/demand for O 2 and nutrients Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Shock (Cont’d) § Classification of shock (table 67 -1) n Low blood flow Cardiogenic n Hypovolemic n n Maldistribution of blood flow Septic n Anaphylactic n Neurogenic n Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Low Blood Flow Cardiogenic Shock § Definition n Systolic or diastolic dysfunction leads to compromised cardiac output Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Low Blood Flow Cardiogenic Shock (Cont’d) § Precipitating causes n Myocardial infarction n Cardiomyopathy n Blunt cardiac injury n Severe systemic or pulmonary hypertension n Cardiac tamponade n Myocardial depression from metabolic problems Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Low Blood Flow Cardiogenic Shock § Early manifestations n Tachycardia n Hypotension n Narrowed pulse pressure n ↑ Myocardial O 2 consumption Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Low Blood Flow Cardiogenic Shock (Cont’d) § Physical examination n Tachypnea, pulmonary congestion n Pallor; cool, clammy skin n Decreased capillary refill time n Anxiety, confusion, agitation § ↑ in pulmonary artery wedge pressure § Decreased renal perfusion and UO Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Low Blood Flow Hypovolemic Shock § Absolute hypovolemia: Loss of intravascular fluid volume n Hemorrhage n GI loss (e. g. , vomiting, diarrhea) n Fistula drainage n Diabetes insipidus n Hyperglycemia n Diuresis Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Low Blood Flow Hypovolemic Shock (Cont’d) § Relative hypovolemia n Results when fluid volume moves out of the vascular space into extravascular space (e. g. , interstitial or intracavitary space) n Termed third spacing Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Low Blood Flow Hypovolemic Shock (Cont’d) § Clinical manifestations n Anxiety n Tachypnea n Increase in CO, heart rate n Decrease in stroke volume, PAWP, UO § If loss is >30%, blood volume is replaced Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Maldistribution of Blood Flow Neurogenic Shock § Hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic (T 5) vertebra or above and can last up to 6 weeks Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Maldistribution of Blood Flow Neurogenic Shock (Cont’d) § Can be in response to spinal anesthesia § Results in massive vasodilation leading to pooling of blood in vessels n Compensation is lost due to the loss of SNS vasoconstrictor tone Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Maldistribution of Blood Flow Neurogenic Shock (Cont’d) § Clinical manifestations n Hypotension n Bradycardia n Temperature dysregulation (resulting in heat loss) n Dry skin n Poikilothermia (taking on the temperature of the environment) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Maldistribution of Blood Flow Anaphylactic Shock § Acute, life-threatening hypersensitivity reaction n Massive vasodilation n Release of inflammatory mediators n ↑ Capillary permeability Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Maldistribution of Blood Flow Anaphylactic Shock (Cont’d) § Clinical manifestations n Swelling of the lips and tongue, angioedema n Wheezing, stridor n Flushing, pruritus, urticaria n Respiratory distress and circulatory failure Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Maldistribution of Blood Flow Anaphylactic Shock (Cont’d) § Clinical manifestations n Anxiety, confusion, dizziness n Sense of impending doom n Chest pain n Incontinence Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Maldistribution of Blood Flow Septic Shock § Sepsis: Systemic inflammatory response to documented or suspected infection § Severe sepsis = Sepsis + Organ dysfunction Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Maldistribution of Blood Flow Septic Shock (Cont’d) § Septic shock = Presence of sepsis with hypotension despite fluid resuscitation + Presence of tissue perfusion abnormalities Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Maldistribution of Blood Flow Septic Shock (Cont’d) § Mortality rates as high as 50% § Primary causative organisms n Gram-negative and gram-positive bacteria n Endotoxin stimulates inflammatory response Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Maldistribution of Blood Flow Septic Shock § Clinical manifestations n ↑ Coagulation and inflammation n ↓ Fibrinolysis Formation of microthrombi n Obstruction of microvasculature n n Hyperdynamic state: Increased CO and decreased SVR Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Maldistribution of Blood Flow Septic Shock (Cont’d) § Clinical manifestations n Tachypnea/hyperventilation n Temperature dysregulation n ↓ Urine output n Altered neurologic status n GI dysfunction n Respiratory failure is common Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Shock Initial Stage § Usually not clinically apparent § Metabolism changes from aerobic to anaerobic n Lactic acid accumulates and must be removed by blood and broken down by liver n Process requires unavailable O 2 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Shock Compensatory Stage § Clinically apparent n Neural n Hormonal n Biochemical compensatory mechanisms § Attempts are aimed at overcoming consequences of anaerobic metabolism and maintaining homeostasis Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Shock Compensatory Stage § Baroreceptors in carotid and aortic bodies activate SNS in response to ↓ BP n Vasoconstriction while blood to vital organs maintained § ↓ Blood to kidneys activates renin– angiotensin system n ↑ Venous return to heart, CO, BP Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Shock Compensatory Stage (Cont’d) § Impaired GI motility n Risk for paralytic ileus § Cool, clammy skin from blood n Except septic patient who is warm and flushed Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Shock Compensatory Stage (Cont’d) § Shunting blood from lungs increases physiologic dead space ↓ Arterial O 2 levels n Increase in rate/depth of respirations n V/Q mismatch n § SNS stimulation increases myocardium O 2 demands Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Shock Compensatory Stage (Cont’d) § If perfusion deficit corrected, patient recovers with no residual sequelae § If deficit not corrected, patient enters progressive stage Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Shock Progressive Stage § Begins when compensatory mechanisms fail § Aggressive interventions to prevent multiple organ dysfunction syndrome Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Shock Progressive Stage (Cont’d) § Hallmarks of ↓ cellular perfusion and altered capillary permeability: Leakage of protein into interstitial space n ↑ Systemic interstitial edema n Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Shock Progressive Stage (Cont’d) § Movement of fluid from pulmonary vasculature to interstitium Pulmonary edema n Bronchoconstriction n ↓ Residual capacity n Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Shock Progressive Stage (Cont’d) § Fluid moves into alveoli Edema n Decreased surfactant n Worsening V/Q mismatch n Tachypnea n Crackles n Increased work of breathing n Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Shock Progressive Stage (Cont’d) § CO begins to fall Decreased peripheral perfusion n Hypotension n Weak peripheral pulses n Ischemia of distal extremities n Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Shock Progressive Stage (Cont’d) § Myocardial dysfunction results in Dysrhythmias n Ischemia n Myocardial infarction n End result: Complete deterioration of cardiovascular system n Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Shock Progressive Stage (Cont’d) § Mucosal barrier of GI system becomes ischemic Ulcers n Bleeding n Risk of translocation of bacteria n Decreased ability to absorb nutrients n Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Shock Progressive Stage (Cont’d) § Liver fails to metabolize drugs and wastes Jaundice n Elevated enzymes n Loss of immune function n Risk for DIC and significant bleeding n Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

$Stages of Shock Refractory Stage § Exacerbation of anaerobic metabolism § Accumulation of lactic$

Stages of Shock Refractory Stage § Exacerbation of anaerobic metabolism § Accumulation of lactic acid § ↑ Capillary permeability Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

$Refractory Stage of Shock Fig. 67 -8$

Refractory Stage of Shock Fig. 67 -8

$Stages of Shock Refractory Stage § Profound hypotension and hypoxemia § Tachycardia worsens §$

Stages of Shock Refractory Stage § Profound hypotension and hypoxemia § Tachycardia worsens § Decreased coronary blood flow § Cerebral ischemia Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

$Stages of Shock Refractory Stage (Cont’d) § Failure of one organ system affects others$

Stages of Shock Refractory Stage (Cont’d) § Failure of one organ system affects others § Recovery unlikely Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Diagnostic Studies § Thorough history and physical examination § No single study to determine shock n Blood studies Elevation of lactate n Base deficit n n 12 -lead ECG n Chest x-ray n Hemodynamic monitoring Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care § Successful management includes n Identification of patients at risk for shock n Integration of the patient’s history, physical examination, and clinical findings to establish a diagnosis Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care (Cont’d) § Successful management includes n Interventions to control or eliminate the cause of the decreased perfusion n Protection of target and distal organs from dysfunction n Provision of multisystem supportive care Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care (Cont’d) § General management strategies n Ensure patent airway n Maximize oxygen delivery Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care (Cont’d) § Cornerstone of therapy for septic, hypovolemic, and anaphylactic shock = volume expansion n Isotonic crystalloids (e. g. , normal saline) for initial resuscitation of shock Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care (Cont’d) § Volume expansion n If the patient does not respond to 2 to 3 L of crystalloids, blood administration and central venous monitoring may be instituted n Complications of fluid resuscitation § Hypothermia § Coagulopathy Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care (Cont’d) § Primary goal of drug therapy = correction of decreased tissue perfusion n Vasopressor drugs (e. g. , epinephrine, dopamine) Achieve/maintain MAP >60 to 65 mm Hg n Reserved for patients unresponsive to otherapies n Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care (Cont’d) § Primary goal of drug therapy = correction of decreased tissue perfusion n Vasodilator therapy (e. g. , nitroglycerin [cardiogenic shock], n Achieve/maintain MAP >60 to 65 mm Hg Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care (Cont’d) § Nutrition is vital to decreasing morbidity from shock n Initiate enteral nutrition within the first 24 hours Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care (Cont’d) § Nutrition is vital to decreasing morbidity from shock n Initiate parenteral nutrition if enteral feedings contraindicated or fail to meet at least 80% of the caloric requirements n Monitor protein, nitrogen balance, BUN, glucose, electrolytes Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Cardiogenic Shock § Restore blood flow to the myocardium by restoring the balance between O 2 supply and demand § Thrombolytic therapy § Angioplasty with stenting § Emergency revascularization § Valve replacement Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Cardiogenic Shock (Cont’d) § Hemodynamic monitoring § Drug therapy (e. g. , diuretics to reduce preload) § Circulatory assist devices (e. g. , intraaortic balloon pump, ventricular assist device) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care Hypovolemic Shock § Management focuses on stopping the loss of fluid and restoring the circulating volume § Fluid replacement Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care Septic Shock § Fluid replacement (e. g. , 6 to 10 L of isotonic crystalloids and 2 to 4 L of colloids) to restore perfusion n Hemodynamic monitoring § Vasopressor drug therapy if unresponsive to fluids Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care Septic Shock (Cont’d) § Intravenous corticosteroids for patients who require vasopressor therapy, despite fluid resuscitation, to maintain adequate BP Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care Septic Shock (Cont’d) § Antibiotics after obtaining cultures (e. g. , blood, wound exudate, urine, stool, sputum) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care Septic Shock (Cont’d) § Glucose levels <150 mg/dl § Stress ulcer prophylaxis with histamine (H 2)-receptor blockers § Deep vein thrombosis prophylaxis with low-dose heparin or lowmolecular-weight heparin Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care Neurogenic Shock § In spinal cord injury: Spinal stability n Treatment of the hypotension and bradycardia with vasopressors and atropine n Fluids used cautiously as hypotension is generally not related to fluid loss n Monitor for hypothermia Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care Anaphylactic Shock § Prevent! n n n Assess for allergies/adverse reactions Family education Epinephrine Knowledge about signs/symptoms Be prepared for emergency measures § Epinephrine, diphenhydramine § Maintaining a patent airway Nebulized bronchodilators n Endotracheal intubation or cricothyroidotomy may be necessary n Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care Anaphylactic Shock (Cont’d) § Aggressive fluid replacement § Intravenous corticosteroids if significant hypotension persists after 1 to 2 hours of aggressive therapy Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Assessment (Cont’d) § Focused assessment of tissue perfusion n Vital signs n Peripheral pulses n Level of consciousness n Capillary refill n Skin (e. g. , temperature, color, moisture) n Urine output Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Assessment (Cont’d) § Brief history n Events leading to shock n Onset and duration of symptoms § Details of care received before hospitalization § Allergies Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Diagnoses § Ineffective tissue perfusion: Renal, cerebral, cardiopulmonary, gastrointestinal, hepatic, and peripheral § Fear § Potential complication: Organ ischemia/dysfunction Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Planning § Goals for patient n Adequate tissue perfusion n Restoration of normal or baseline BP n Return/recovery of organ function n Avoidance of complications from prolonged states of hypoperfusion Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Implementation § Health Promotion n Identify patients at risk (e. g. , elderly patients, those with debilitating illnesses or who are immunocompromised, surgical or accidental trauma patients) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Implementation (Cont’d) § Health Promotion n Planning to prevent shock (e. g. , monitoring fluid balance to prevent hypovolemic shock, maintenance of handwashing to prevent spread of infection) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Implementation (Cont’d) § Acute Interventions n Monitor the patient’s ongoing physical and emotional status to detect subtle changes in the patient’s condition n Plan and implement nursing interventions and therapy Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Implementation (Cont’d) § Acute Interventions n Evaluate the patient’s response to therapy n Provide emotional support to the patient and family n Collaborate with other members of the health team when warranted Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Implementation (Cont’d) § Neurologic status: Orientation and level of consciousness § Cardiac status n Continuous ECG n VS, capillary refill n Hemodynamic parameters: central venous pressure, PA pressures, CO, PAWP n Ongoing assessment of CO Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Implementation (Cont’d) § Respiratory status n Respiratory rate and rhythm n Breath sounds n Continuous pulse oximetry n Arterial blood gases n Many patients will be intubated and mechanically ventilated Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Implementation (Cont’d) § Urine output § Tympanic or pulmonary arterial temperature § Skin: Temperature, pallor, flushing, cyanosis, diaphoresis, piloerection § Bowel sounds Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Implementation (Cont’d) § Nasogastric drainage/stools for occult blood § I&O, fluid and electrolyte balance § Oral care/hygiene based on O 2 requirements § Passive/active range of motion Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Implementation (Cont’d) § Assess level of anxiety and fear n Medication PRN n Talk to patient n Visit from clergy n Family involvement n Comfort measures n Privacy n Call light within reach Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Evaluation § Normal or baseline, ECG, BP, CVP, and PAWP § Normal temperature § Warm, dry skin § Urinary output >0. 5 ml/kg/hr § Normal RR and Sa. O 2 ≥ 90% § Verbalization of fears, anxiety Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Case Study § 26 -year-old male arrives via paramedics to ED with multiple gun shot wounds to abdomen § Unresponsive, BP 58/30, HR 146 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Case Study (Cont’d) § Surgery successful in removing bullets and repairing blood vessels § Surgeon estimated he lost at least 2 L of blood prior to surgery § He is admitted to ICU Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Discussion Questions 1. What complications will you anticipate with this amount of blood loss? 2. What fluids can you expect to administer? Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Discussion Questions (Cont’d) 3. What medications will likely be ordered? 4. What should you monitor hourly or every 2 hr? Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.