SNAPSU: Exam II Shock, SIRS, MODS

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_______ is a syndrome characterized by decreased tissue perfusion, impaired cellular metabolism which results in imbalance between supple and demand of O2 and nutrients.

Shock

This type of shock occurs when there is a decreased venous return to the heart, decreased preload, decreased SV and decreased CO as a result of loss in intravascular fluid volume.

Hypovolemic Shock

There are two types of hypovolemic shock, which one is being described: fluid moves out of the vascular space into the extravascular space. This shift is also known as third spacing as seen in patients with sepsis and burns.

Relative Hypovolemia

There are two types of hypovolemic shock, which one is being described: fluid is lost through hemorrhage, GI loss, fistula drainage, diabetes insipidus or duiresis.

Absolute Hypovolemia

This type of shock results from an acute and life-threatening hypersensitivity reaction to a sensitizing substance.

Anaphylactic Shock

This type of shock is a systemic inflammatory response to a documented or suspected infection.

Septic Shock

This type of shock is a hemodynamic phenomenon that can occur within 30 mins of a spinal cord injury at the T5 or above and last up to 6 weeks.

Neurogenic shock

This type of shock occurs when either systolic or diastolic dysfunction of the pumping action of the heart results in reduced cardiac output.

Cardiogenic shock

What are the two different classifications of shock?

*Low blood-Flow (cardiogenic and hypovolemic)
*Maldistribution (neurogenic, spetic, and anaphylactic)

What are the four stages of shock?

1. Initial
2. Compensatory
3. Progressive
4. Irreversible

Which stage of shock is being described: the cardiovascular system is profoundly affect resulting in dec. CO, dec BP, and dec coronary artery, cerebral and peripheral perfufion.Other ssx include anasarca, weak peripheral pulses, ischemia, tachypnea, crackles, inc BUN/Creatinine, Jaundice. Patient is at risk for DIC.

Progressive stage- the compensatory mech has failed.

Which stage of shock is being described: no clinical manifestation are yet seen, shock is at the cellular level, metabolism changes from aerobic to anaerobic causing lactic acid to build-up.

Initial stage

Which stage of shock is being described: decrease CO and decrease perfusion exacerbate anaerobic metabolism, worsening of hypotension and tachycardia, profound hypoxemia. Failure of liver, lungs, and kidneys will result in accumulation of waste products (lactate, urea, ammonia, CO2). Recovery is unlikely.

Irreversible stage.

Which stage of shock is being described: Body activites neural, hormonal and biochemical mechanisms all of which will result in inc HR, contractility, inc CO, BP and blood volume.

Compensatory stage

The patient presents to the ER with HR 105, BP 88/60, Resp 24, dec cap refil, dec urinary output. Patient is cyanotic and his lung sounds reveal crackles. Patient's skin appears pallor, cool and clammy. He has decreased bowel sounds and is very anxious and confused.Patient's CO is <4L/min. What type of shock can be suspected here?

Cardiogenic Shock (Low Blood Flow)

What diagnostic findings will be seen in a patient with cardiogenic shock?

--Inc. Cardiac enzymes --Inc BNP --Inc blood glucose --inc BUN --ECG (dysrythmias) --Echo (left ventricular dysfunction) --Chest x-ray (pulmonary infiltrates) --Inc PAWP and PRV

What is the overall goal for a patient in cardiogenic shock?

Restore blood flow to the myocardium by restoring balance between O2 supply and demand.

What drugs can be used to decrease workload, reduced preload, reduce after load, reduce HR and contractility for a patient with cardiogenic shock?

--- Nitrates to decrease workload
--- diuretic to decrease preload
--- vasodilators to decrease afterload
--- beta blocker to decrease HR and contractility
---O2

What other measures can be take for a patient with cardiogenic shock?

--- thrombolic therapy ---stenting --- emergency revascularization ---valve replacement --- VAD/ IABP ---Transplant

Patient presents to the ER with a gunshot to the chest. Patient's is hypotensive, tachycardiac, has dec cap refil, has cool, clammy, mottled, dec U/O, dec BS, dry mucous membrane, and highly anxious. His lab work shows a dec in hematocrit and hemoglobin. What type of shock is the patient likely to be at risk for?

Hypovolemic Shock

Due to the reduction of intravascular volume in Hypovolemic shock, what changes can be seen in the cardiovascular system?

--Dec Preload -- Dec Stroke Volume --decrease CO

What type of care can the nurse anticipate to provide for a patient in hypovolemic shock?

--- OXYGEN --Restore volume (remember the 3:1 rule, 3mL of isotonic crystolloid for every 1mL of estimated blood loss) -- correct the cause --Use warm fluids

A 22 year old college student was rescued from a pool by his friends after diving head first into the shallow end. He is unconscious on arrival to the ED. His VS are: HR 42, RR 10, BP 60/40. His skin is pale and cool. What type of shock is he at risk for?

Neurogenic shock: (MASSIVE VASODILATION WITHOUT COMPENSATION DUE TO THE LOSS OF SNS VASOCONSTRICTOR TONE)

In neurogenic shock, the patient's skin will initially be warm due to massive dilaation. Later, the patient's skin may be cool or warm depending on the ambient temperature (taking on the temperature of the environment). What is this known as?

Poikilothermia

What type of interventions should the nurse perform for the patient with neurogenic shock?

--OXYGEN --intubation if necessary --minimize spinal cord trauma with stablization --CAUTIOUS administration of fluids because hypotension is not related to fluid loss -- Atropine (bradycardia) --Vasopressor --Monitor temperature

A 93 year old woman admitted to the med-surg floor from the nursing home. She has a history of dementia and previous MI. She has an indwelling urinary catheter, which was placed a few days ago in the nursing home. 100 mls cloudy, dark urine is noted in the bag. Her VS are: Temp 100.0, HR 98 and irregular, RR 28 and deep with crackles bilaterally, BP 100/65. She is awake to verbal stimuli, but confused and agitated. Her CBC reveals a WBC of 17,000 and a blood glucose of 250 mg/dl. What type of shock is she at risk for?

Septic Shock

What diagnostic findings would indicate that the patient may be going through a septic shock?

--Inc WBC but dec in elderly --dec platelets --inc lactate --inc blood glucose --inc urine specific gravity --positive blood cultures

What is the initial drugs of choice for patient in septic shock?

Norepinephrine and dopamine

Patients in septic shock require large amounts of fluid replacement. What types and amounts of fluids are needed within the first 6 hours?

possible 6-10 L of isotonic crystalloids and 2-4L of colloids

What are some other drug therapies indicated for patients in septic shock?

--Antibiotics (obtain blood culture before) --Vasopressors (dopamine) --Inotropes (Dobutamine) --Anticoagulants --DROTRECOGEN ALFA (XIGRIS) for patient with high risk of death

What type of shock are these the clinical manifestations of: SOB, edema of larynx, wheezing, stridor, chest pain, third spacing, flushing, pruritus, urticaria, swelling of lips and tongue, and metallic taste.

Anaphylactic Shock

Anaphylactic shock is a (cytotoxic, immediate,immunocomplex, OR cell mediated) that causes massive vasodilation, release of vasoactive mediators and increase in cap permeability. (pick one)

immediate reaction

What is the drug of choice for a patient in anaphylactic shock?

Epinephrine

What are some other drugs that can be used for a patient in anaphylactic shock?

-- Antihistamines (Benadryl) -- Bronchodilators --Corticosteroids

Proper oxygen delivery is dependent on what three things? how can each of these be optimized?

--- CO (fluid replacement)
--- Hemoglobin (transfusion of blood or RBC)
---SaO2 (supplement or mechanical ventilation)

Goal of Vasopressors are to keep MAP greater than what?

65 mm Hg

What should the nurse be mindful of when it comes to nutrition therapy for a patient in shock?

---Early Enteral feedings enhance perfusion to the GI tract and help maintain the integrity of the gut mucosa

That is the nurse's role in prevention and treatment of Shock?

• Early recognition of the patient at risk for shock is key!!
• Maintain airway, optimize oxygen delivery, plan activities to minimize oxygen demands
• Large bore IV insertion for septic, hypovolemic and anyphylactic shock
• MAP should be maintained at 60-65 mm Hg; end organ perfusion (urine output, SVO2, lactate levels) should also be monitored to ensure perfusion
• Protect integrity of gastric mucosa with early enteral feedings
• Monitor response to interventions
• Monitor for signs of SIRS & MODS

________ is a generalized inflammatory response in organs remote from the area of initial insult including infection such as sepsis, ischemia, infarction, and injury.

SIRS (systemic inflammatory response syndrome)

_____ is the progressive dysfunction of two or more organ systems.

MODS (Multiple organ dysfunction syndrome)

What are the most common cause of MODS?

Sepsis and septic shock are most common cause

what is the pathophysiology of MODS?

Organ perfusion is compromised d/t hypotension, decreased perfusion, microemboli, and shunting of blood.

what are some of the nursing care that should be implemented for a patient with MODS?

• As with shock, prevention & early intervention are essential!
• Avoid infection
• Maintain oxygenation
• Maintain nutrition/metabolic needs
• Support failing organs
• Relationship of Shock, SIRS & MODS

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