Shock

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What is shock?
syndrome characterized by decreased tissue perfusion and impaired cellular metabolism; imbalance between supply of and demand of oxygen and nutrients
What are the four classifications of shock?
hypovolemic, distributive, obstructive, and cardiogenic shock
What are the four general signs of shock?
hypotension, tachycardia, altered LOC, decreased UO
What are the four stages of shock?
initial, compensatory, progressive, refractory
In a word, what is generally occurring with the initial stage of shock?
hypoperfusion
What are signs and symptoms of initial shock?
lactic acid buildup, mild tachycardia, mild tachypnea, slightly cool hands/feet, anxiety
What is occurring in compensatory shock?
there's a huge drop in BP because of the decreased CO and narrowed pulse pressure so the body begins to attempt to "fix" the situation by increasing BP and achieving homeostasis
What happens to the blood flow in compensatory shock?
blood flow is shunted towards vital organs (brain, heart) and away from other organs
When blood flow is increased to the heart, how do the heart respond in compensatory shock?
increases HR, contractility, and SVR
When blood flow is decreased to the lungs, how do the lungs respond in compensatory shock?
increase in rate and depth of respirations
When blood flow is decreased to the skin, how does the skin respond in compensatory shock?
will become cool and clammy
When blood flow is decreased to the kidneys, how do the kidneys respond in compensatory shock?
RAAS is activated to increase BP and CO which causes decreased UO and increased serum osmolality and Na
When blood flow is decreased to the GI system in compensatory shock, how does it respond?
there's decreased peristalsis to lower oxygen demands in the gut and the liver is unable to remove lactic acid efficiently causing hypoactive bowel sounds and high lactate levels
What is happening in progressive shock?
the body is wearing down and cannot compensate anymore and there is a huge decrease in coronary artery, cerebral, and peripheral perfusion
What happens to the CO in progressive shock?
it begins to fall d/t lack of compensation resulting in further decreased BP and decreased cellular perfusion
What cardiovascular symptoms will you see in progressive shock?
tachycardia, severe hypotension (MAP <60), decreased CO/stroke volume, and decreased capillary refill
With decreased cellular perfusion in progressive shock, what happens to the capillary permeability?
it allows leakage of fluid and proteins into surrounding interstitial spaces causing diffuse edema, decreased blood volume, weak peripheral pulses, and ischemia of distal extremities
With increased capillary permeability in progressive shock, what happens to the lungs?
fluid leaks into interstitial spaces causing edema, bronchoconstriction, and decreased residual capacity
What respiratory symptoms will you see in progressive shock?
tachypnea, crackles, increased work of breathing
With prolonged hypoperfusion in progressive shock, what happens to the GI system?
starts to become ischemic, will start bleeding, and decreases ability to absorb nutrients
With prolonged hypoperfusion in progressive shock, what happens to the kidneys?
Acute Tubular Necrosis that could lead to AKI, kidneys cannot excrete wastes
What urinary symptoms will you see in progressive shock?
decreased UO, metabolic acidosis, increased BUN/creat, decreased urine osmolality
With prolonged hypoperfusion in progressive shock, what happens to the liver?
liver failure leads to buildup of bilirubin which causes jaundice
What symptoms of progressive shock will you see on the skin?
cool/clammy, ischemic distal extremities, edema, jaundice
What is happening in refractory shock?
tissue perfusion is SEVERELY compromised and organs ultimately fail
What does the increased accumulation of lactic acid do to the capillary permeability in refractory shock?
it further increases it and allows more fluid to leave the vascular space causing worsened hypotension and tachycardia
Can vasopressors and O2 supplementation help in refractory shock?
NO because the hypotension and hypoxemia is too profound
What are cardiovascular symptoms in refractory shock?
severe hypotension, decreased CO, tachycardia (or bradycardia)
What are pulmonary symptoms in refractory shock?
severe refractory hypoxemia, ARF
What are renal symptoms in refractory shock?
anuria, metabolic acidosis, highly elevated BUN/creat and lactate
What are symptoms in the skin in refractory shock?
mottled, cyanotic, cold
What are neurological symptoms in refractory shock?
unresponisve, areflexia, pupils are nonreactive/dilated
What are GI symptoms in refractory shock?
ischemic gut, no bowel sounds
What is hypovolemic shock?
massive fluid loss
What are causes of hypovolemic shock?
hemorrhage, dehydration, burns, surgery, GI bleeding, vomiting, diarrhea, excessive diuresis, DI, DM
What are cardiovascular symptoms of hypovolemic shock?
decreased capillary refill, tachycardia, hypotension
What are pulmonary symptoms of hypovolemic shock?
tachypnea but will be bradypnea in the late stages
What are renal symptoms of hypovolemic shock?
decreased UO, increased urine specific gravity and lactate, metabolic acidosis
What are skin symptoms of hypovolemic shock?
pallor, cool/clammy
What are neurological symptoms of hypovolemic shock?
anxiety, confusion, agitation
What are GI symptoms of hypovolemic shock?
absent bowel sounds
What are diagnostic findings of hypovolemic shock?
increased Hgb/Hct, increased serum Na
decreased MAP, CVP, PAWP
What is some nursing care for hypovolemic shock?
monitor fluid resuscitation parameters, watch for respiratory compromise and pulmonary congestion with fluid overload, monitor for renal/cerebral complications
How do you treat hypovolemic shock?
identify/control source of loss, use large bore IV to replace fluids
Why would NS or LR be given for a hypovolemic shock patient?
to replace intravascular volume
Why would 3% or 5% NS be given for a hypovolemic shock patient?
to replace intravascular volume by pulling from intracellular space
Why would blood products be given for a hypovolemic shock patient?
replaces intravascular volume and blood loss or replaces coagulation factors to control bleeding
Why would albumin 5% be given for a hypovolemic shock patient?
to increase plasma colloid osmotic pressure for rapid volume expansion
Which type of patient would receive NS or LR in hypovolemic shock? What do you monitor for with these fluids?
general fluid loss such as diuresis, DI, dehydration, or blood loss; monitor for circulatory overload
Which type of patient would receive 3% or 5% NS in hypovolemic shock? What do you monitor for with these fluids?
hypovolemia with electrolyte imbalances; monitor for hypernatremia
Which type of patient would receive blood products in hypovolemic shock? What do you monitor for with these fluids?
hemorrhage, surgery, excessive bleeding; blood administration precautions
Which type of patient would receive 5% albumin in hypovolemic shock? What do you monitor for with these fluids?
major hemorrhage; monitor for circulatory overload
What is the rule for fluid resuscitation in hypovolemic shock?
3:1 Rule- give 3ml of fluid for every 1ml of blood loss
When monitoring for improvement during hypovolemic shock treatment, what should you expect to see?
HR improvement after 300ml, BP improvement after 500ml, and urine output improvement after 1L
What happens in cardiogenic shock?
the heart fails to efficiently pump enough blood to supply the body
What causes cardiogenic shock?
MI, cardiomyopathy, valve dysfunction, papillary muscle rupture, HF, hypoperfusion, pulmonary congestion
What are cardiovascular symptoms of cardiogenic shock?
tachycardia, hypotension, cap refill >3 seconds, possible CP, JVD, distant heart sounds, decreased CO
What are pulmonary symptoms of cardiogenic shock?
tachypnea, crackles, dypnea, cyanosis, rhonchi
What are renal symptoms of cardiogenic shock?
decreased UO, increased BUN, increased lactate
What are skin symptoms of cardiogenic shock?
pallor, cool/clammy, peripheral edema
What are neurological symptoms of cardiogenic shock?
anxiety, confusion, agitation
What are GI symptoms of cardiogenic shock?
hypoactive bowel sounds, N/V
What are diagnostic findings of cardiogenic shock?
Increased: cardiac markers, BNP, blood glucose, BUN, CVP, PAWP, SVR, lactate
What is some nursing care for cardiogenic shock?
frequent VS and lung sound assessment, administer/titrate meds, watch for pulmonary congestion, airway management
How do you treat cardiogenic shock?
fluids, dobutamine, Levophed, pain/anxiety relief, Lasix, IABP, PCI, nitrates, BB
What is obstructive shock?
a mechanical barrier blocks blood flow
What causes obstructive shock?
massive PE, tension pneumothorax, cardiac tamponade
What are cardiovascular symptoms of obstructive shock?
pulsus paradoxus, distant heart sounds, hypotension, decreased preload and MAP
What are pulmonary symptoms of obstructive shock?
tachypnea, dyspnea, pleuritic pain, hemoptysis, cough, SOB
What are renal symptoms of obstructive shock?
decreased UO
What are skin symptoms of obstructive shock?
pallor, cool/clammy
What are neurological symptoms of obstructive shock?
anxiety, confusion, agitation
What are GI symptoms of obstructive shock?
hypoactive or absent bowel sounds
What are diagnostic findings of obstructive shock?
specific to cause; Increased: CVP, PAWP, SVR
What is some nursing care for obstructive shock?
prep equipment for emergency procedures, frequent VS, give thrombolytics
How do you treat obstructive shock caused by cardiac tamponade?
pericardiocentesis
How do you treat obstructive shock caused by tension pneumothorax?
needle decompression or chest tube
How do you treat obstructive shock caused by a PE?
thrombolytics or embolectomy
What is distributive shock?
massive vasodilation with redistribution of blood volume
What are the three types of distributive shock?
neurogenic shock, septic shock, and anaphylactic shock
What is neurogenic shock?
a loss of sympathetic innervation due to spinal cord injuries T6 and up
What are cardiovascular manifestations of neurogenic shock?
massive vasodilation, decreased venous return, bradycardia, decreased CVP/PAWP and decreased CO
What are pulmonary manifestations of neurogenic shock?
dysfunction below level of injury
What are renal manifestations of neurogenic shock?
bladder dysfunction
What are skin manifestations of neurogenic shock?
cool/warm, dry, decreased perfusion
What are neurological manifestations of neurogenic shock?
flaccid paralysis below injury, loss of reflex activity
What are GI manifestations of neurogenic shock?
bowel dysfunction
How do you treat neurogenic shock?
maintain spinal stability, optimize O2 delivery, IV fluids, and vasopressors
What is septic shock?
a systemic response to infection that involves massive vasodilation
What are cardiovascular manifestations of septic shock?
T >38C, decreased EF, tachycardia, myocardial depression
What are pulmonary manifestations of septic shock?
tachypnea, crackles, respiratory alkalosis, hypoxemia, ARF/ARDS, pulmonary HTN
What are renal manifestations of septic shock?
decreased UO
What are skin manifestations of septic shock?
warm and flushed (cool and mottled will be a late sign)
What are neurological manifestations of septic shock?
confusion, agitation, and coma (late)
What are GI manifestations of septic shock?
bleeding, paralytic ileus
What are some diagnostic findings for septic shock?
abnormal WBC, positive blood cultures, SIRS
Increased: lactate, blood glucose, urine specific gravity, PaCO2 >32,
Decreased: platelets, urine Na, SVR, CVP
What is the initial treatment for septic shock?
fluids, vasopressors, A-line, IV corticosteriods
For patients that need substantial volumes while in septic shock, what should you add to the fluids?
albumin 0.5-1 g/kg/dose
What is the general treatment for septic shock?
antibiotics within first hour
What is the goal of treatment for septic shock?
normal CVP, MAP >65, normal UO, Hgb >7, blood glucose <150
What is anaphylactic shock?
massive vasodilation in response to severe allergic reaction
What are cardiovascular manifestations of anaphylactic shock?
hypotension, tachycardia, chest tightness
What are pulmonary manifestations of anaphylactic shock?
SOB, throat swelling, wheezing
What are renal manifestations of anaphylactic shock?
incontinence
What are skin manifestations of anaphylactic shock?
flushing, itching, hives
What are neurological manifestations of anaphylactic shock?
anxiety, impending doom, confusion, decreased LOC, metallic taste
What are GI manifestations of anaphylactic shock?
cramping, abd pain, NVD
What is nursing care for anaphylactic shock?
monitor airway and respiratory drive, intubation, give epi ASAP, frequent VS
How do you treat anaphylactic shock?
maintain airway (bronchodilators, epi, intubate), fluids, vasopressors, epi, IV corticosteriods, antihistamines, steroids
What is SIRS?
systemic inflammatory response to a variety of insults (sepsis, ischemia, infarction, injury)
What is MODS?
failure of two or more organ systems in acutely ill patient and homeostasis cannot be maintained (caused by SIRS)
What are clinical manifestations of SIRS?
abnormal temperature, tachycardia, tachypnea, PCO2 <32, abnormal WBC
How do you treat SIRS or MODS?
aggressive infection control, remove necrotic tissue, strict asepsis, sedation with mechanical ventilation, O2 therapy, glycemic control; prevent SIRS from developing into MODS!!
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