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SHOCK, hiv/aids, HYPERSENSITIVITY, RENAL FAILURE

Terms in this set (69)

early signs and symptoms of shock
vasoconstriction
increased heart rate
increased respiratory rate
anxiety or confusion
cold, clammy skin
decreased urinary output
respiratory alkalosis
hypoactive bowel sounds
Who is at risk for shock?
any patient with any disease state may be at risk
what happens during the compensatory stage of shock?
During this stage of shock, vasoconstriction occurs and heart rate and contractility maintain adequate cardiac output
stimulation of the sympathetic nervous system and release of catecholamines (epinephrine and norepinephrine)
blood shunting (fight or flight response)
What happens during the progressive stage of shock?
During this stage of shock, all organs suffer from hypoperfusion
heart becomes dysfunctional, which can lead to heart failure
increased permeability and areas if arteriolar and venous constriction
precapillary sphincters relax causing fluid leakage leading to interstitial edema and decreased return to the heart
inflammatory response= coagulation
anaerobic metabolism=build up of lactic acid and disruption of normal cell function
Symptoms during progressive stage of shock
BP decreases
HR > severe tachycardia >150
decreased urine (<0.5 mL/kg)
lethargy
metabolic acidosis
mottled skin
respirations become rapid and shallow
What occurs during the irreversible stage of shock?
organ damage is so severe that patient doesn't respond to treatments and cannot survive
symptoms during irreversible stage of shock
low BP
renal and liver dysfunction=acute metabolic acidosis
ATP reserves depleted
inadequate oxygenation despite ventilator support
cardiovascular system unable to maintain an adequate MAP for tissue perfusion
Three different types of shock
hypovolemic, cardiogenic, distributive (neurogenic)
hypovolemic shock
decreased intravascular volume by 15 to 30% (apprx. 750 to 1500 mL of blood in 154lb person)

decreased fluid=decreased venous return=decreased ventricular filling=decreased stroke volume=decreased cardiac output=decreased tissue perfusion
what are some general causes of hypovolemic shock?
traumatic injury/blood loss
internal fluid shifts: dehydration, severe edema, ascites, third spacing
what occurs during cariogenic shock?
the hearts inability to pump and contract blood is impaired and the oxygen supply is inadequate for the heart and lungs
causes of cardiogenic shock
• Myocardial infarction
• Irregular rate/rhythm
• Cardiomyopathy

either coronary or non-coronary
coronary: most commonly due to pt's with recent MI resulting in damage to left ventricle
Who are the patients at greatest risk for cardiogenic shock?
Patients who experience an anterior wall MI
Non-coronary shock causes:
conditions that stress the myocardium: sex, hypoxemia, acidosis, hypoglycemia, hypocalcemia, tension pneumothorax
ineffective myocardial function due to cardiomyopathies, valvular damage, cardiac tamponade, dysrrhythmias
What occurs during neurogenic/distributive shock?
intravascular volume pools in peripheral blood vessels causing hypovolemia
loss of balance between parasympathetic and sympathetic stimulation
blood volume is adequate but is displaced due to dilated vasculature causing hypotensive state
What are the major causes of neurogenic/distributive shock?
spinal cord injuries, spinal anesthesia, other nervous system damage
signs and symptoms of neurogenic shock?
dry, warm skin (instead of cool), moist skin, bradycardia
What are the medical interventions for a patient experiencing neurogenic shock?
Medical interventions include: restore sympathetic tone; stabilize spinal cord injury, proper positioning
What are the nursing interventions for a patient with neurogenic shock?
elevate HOB at least 30 degrees with epidural
support cardio and neuro function
assess daily for VTE and DVT
Passive range of motion, pneumatic compression device
monitor for signs of internal bleeding
Medical interventions for hypovolemic shock include:
restoring intravascular volume and treating the underlying cause
redistribution of fluid through modified Trendelenburg positioning and using vasoactive meds to prevent cardiac failure
What are some nursing interventions for a patient in hypovolemic shock?
safely administer blood and fluid and documenting their administration and effects
monitor for complications and side effects of treatment and report (cardiovascular overload and s/sx of difficulty breathing)
administer oxygen as needed/ordered
What are the medical interventions for a patient experiencing cardiogenic shock?
limit further myocardial damage and preserve/improve cardiac function (increase contractility, decrease afterload and increase oxygen supply to heart while reducing oxygen demand)
signs and symptoms of cariogenic shock
angina, dysrhythmias, fatigue, hemodynamic instability
What is the first line of treatment for a patient experiencing cardiogenic shock?
oxygen administration, pain control, hemodynamic monitoring, labs, fluid therapy, medication therapy
what drug is used to increase cardiac output?
dobutamin
What drugs increase perfusion?
nitroglycerin and dopamine
Nursing interventions for a patient in cariogenic shock?
monitor hemodynamic status and cardiac status
administer meds and fluids
maintain intra-aortic balloon counterpulsation
enhance safety and comfort
Risk factors of acute and chronic kidney disease
CV disease, diabetes (primary cause), HTN (second greatest cause), obesity
How is chronic kidney disease diagnosed?
Kidney damage or decreased GFR for > 3 months
How many stages of chronic kidney disease are there?
Five stages
What would a GFR be for end-stage/stage 5 kidney disease?
<15
What are the manifestations of kidney disease?
elevated creatinine (normal creatinine is 0.6-1.2)
anemia (decreased erythropoietin production)
metabolic acidosis
calcium and phosphorus abnormalities
fluid retention (edema and CHF)
Electrolyte abnormalities
difficulty controlling HTN, HF worsens
What are some causes of Acute Kidney Injury (AKI)?
prolonged hospitalization, trauma, medications, HTN, cancer, obstruction, hemorrhage, excessive fluid loss (conditions that reduce the flow of blood to the kidneys such as hypovolemia, hypotension, decreased cardiac output)
signs and symptoms of acute kidney injury
fluid and electrolyte imbalances
fatigue
insufficient urine production or retention
SOB
swelling
dry skin and mucous membranes (dehydration)
CNS: drowsiness, headache, muscle twitching, and seizures
Treatment for acute kidney injury
eliminate underlying cause
maintain fluid balance
provide renal replacement therapy
pharmacologic therapy
provide nutritional support
Treatment for chronic kidney disease
treatment of underlying cause
regular clinical and lab assessments (keep BP under 130/80)
renal replacement therapies
prevention of complications by controlling CV risks factors, treatment of hyperglycemia, managing anemia, smoking cessation, decrease weight, decrease salt and alcohol intake, exercise
Lab values related to acute kidney disease
urine osmolality
urinalysis
BUN and creatinine
lab values related to chronic kidney disease
GFR
blood tests such as RBC, serum albumin, electrolytes, and BUN
What is a normal BUN?
10-20 mg/dL
What is the normal GFR?
120-130 mL/min
WHAT IS A NORMAL CREATININE?
0.6-1.2
If a GFR is below 60, what does that indicate?
50 % or more loss of kidney function
What are some nursing interventions that should be done to prevent complications of shock?
support the respiratory system with supplemental oxygen and/or mechanical ventilation
fluid replacement to restore intravascular volume (typically start with an isotonic crystalloid like 0.9 NS and LR)
monitor urine output, changes in mental status, change in vital signs, skin perfusion, and lung sounds
provide nutritional support- > 3000 cal/day as catecholamines in early shock cause rapid depletion of glycogen stores
safe nursing practices for patients undergoing hemodialysis, peritoneal dialysis, and renal transplant
ensure meds are given at appropriate times taking into account effects of/on dialysis
teach proper nutrition: decrease protein, sodium, potassium, phosphorus, and fluid
meet psychosocial needs
Nutritional teaching for patients on dialysis
caloric requirements are met with high-carbohydrate meals-protein is spared
foods/fluids containing potassium or phosphorus (bananas, citrus, coffee) are restricted
after the diuretic phase, eat high-protein, high-calorie diet and resume activities gradually
Basic pathophysiology of acute kidney injury
reduction of blood flow to kidney caused by hypovolemia, hypotension, decreased cardiac output, heart failure, obstruction of kidney or lower UTI, bilateral obstruction of renal arteries or veins
AKI catergories
prerenal failure, intrarenal failure, and postrenal failure
What causes prerenal failure?
volume depletion, impaired cardiac efficiency and vasodilation
What causes infrarenal failure?
prolonged renal ischemia, nephrotoxic agents (NSAIDS), infectious process
What cause postrenal failure?
obstruction of flow (kidney stone, scarring, bph/prostate CA)

**usually reverses itself when obstruction is cleared
AKI phases
Initiation
Oliguria
Diuresis
Recovery
initiation phase of AKI
reduced perfusion, kidney injury is evolving, prevention is possible
Oliguria phase of AKI
decreased urine output

increased serum levels:
-urea
-creatinine
-uric acid
-organic acids
-potassium
-magnesium

minimum amount of urine needed to rid body of normal waste (400 mL) is not present

uremic symptoms first appear

conditions such as hyperkalemia (life-threatening)
Diuresis phase of AKI
gradual increase in urine output
-signals that glomerular filtration has started to recover
lab values stabilize & decrease
renal function may still be impaired

DEHYDRATION IS A RISK
Recovery phase of AKI
improvement in renal function
may take 3-12 months
Pathophysiology of chronic kidney disease
Prolonged acute inflammation that is not organ-specific thus subtle systemic manifestations
What is the leading cause of mortality and morbidity in patients with chronic kidney disease?
increased risk of CV disease
What can slow the progression of chronic kidney disease?
treatment of HTN, anemia, hyperglycemia, and detection of proteinuria
What is the most common and serious complication of peritoneal dialysis?
peritonitis
signs and symptoms of peritonitis
cloudy dialysate drainage, severe abdominal pain, and rebound tenderness
treatment of peritonitis
intraperitoneal antibiotics
other complications of peritoneal dialysis
1. leakage of dialysate through cath immediately after insertion (avoid abdominal exercises and straining during BMs, can be avoided if start with small amount of dialysate (500 mL) and gradually increase

2. bleeding
-usually stops within 1-2 days

3. hypertriglyceridemia
-common in pt undergoing long-term therapy

4. abdominal hernias

5. lower back pain

6. anorexia
How do you prevent renal disease?
control BS
healthy BP
low salt, low fat diet
exercise at least 30 min most days of week
maintain/achieve healthy weight
don't smoke/use tobacco
limit alcohol intake
How do you prolong kidney function?
follow a health/medication plan
restrict protein and fluid as directed
What are some things nurses should anticipate, intervene, or evaluate in patients with CKD on dialysis for fluid and electrolyte disturbances?
Assess for hyperkalemia, hypermagnesemia, an hypernatremia
Symptoms of hyperkalemia include?
tired, weak, numbness/tingling, nausea, vomiting, trouble breathing, chest pain, palpitations
What should a patient with hyperkalemia be educated on?
decreasing dietary potassium
avoid NSAIDS
take loop diuretics
monitor serum potassium levels (normal levels 3.5-5)
What symptoms does hypermagnesemia cause?
nausea/vomiting, muscle weakness, decreased respirations, low BP, slow HR, cardiac arrest (normal level is 1.7-2.2)
what symptoms are associated with hypernatremia?
thirst, altered LOC, dry mouth, increased HR, dehydration, fatigue (normal serum sodium is 135-145)
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