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SHOCK & Hemodynamic Monitoring

Terms in this set (20)

Hemodynamic Monitoring
Arterial line insertion: Needed for continuous blood pressure monitoring and blood specimens for ABGs.


Pulmonary artery catheter insertion: A pulmonary artery catheter is inserted to measure central venous pressure, pulmonary artery pressures, and cardiac output. Continuous hemodynamic monitoring is important to manage fluids and dosage of inotropic medications.

Nursing Actions:
>Monitor ECG during catheter insertion
>Have resuscitation medication and equipment ready.
>Monitor hemodynamic waveforms and readings.
>Confirm catheter placement using a chest x-ray
> Allens test prior to art line

Client education: explain all procedures to the client. The client can be anxious and scared.
Define Shock
Shock is a syndrome characterized by:
- widespread inadequate/decreased tissue/organ perfusion with cellular metabolism.
-results in an imbalance between the supply of and demand for oxygen and nutrients.

Hypoperfusion results in increased demand and increased supply at the microvascular level.
Four classifications of shock
Cardiogenic shock
Hypovolemic shock
Distributive shock
Obstructive shock
Cardiogenic shock
Failure of the heart to pump effectively due to a cardiac factor.
Cardiogenic shock occurs when either systolic or diastolic dysfunction of the heart's pumping action results in reduction of cardiac output.

Causes: acute MI (RV infarct), LVF, mitral valve regurgitation, systolic dysfunction, diastolic dysfunction, dysrhythmias, and structural factors cardiomyopathy, severe systemic or pulmonary hypertension, cardiac tamponade, ventricular hypertrophy, tension pneumothorax.

Treatment (50-80% mortality): rapid revascularization (catheterization, stenting, surgery), IABP, mechanical ventilation (↓ preload/afterload), inotropic/vasoconstrictor agents, surgical repair for mechanical complications
Hypovolemic shock
A decrease in intravascular volume of at least 15% to 30%.

Relative hypovolemia fluid moves from vascular space to extravascular space "3rd spacing"

Absolute hypovolemia loss of whole blood/fluids through hemorrhage, GI bleed, fistulas, DI, or diuresis.

Excessive fluid loss from diuresis, vomiting, or diarrhea, or blood loss secondary to surgery, trauma, gynecologic/obstetric causes, burns, diabetic ketoacidosis.
Obstructive shock
Impairment of the heart to pump effectively as a result of non-cardiac factor.
Cardiac pump failure due to an indirect cardiac factor, such as blockage of great vessels, pulmonary artery stenosis, pulmonary embolism, cardiac tamponade, tension pneumothorax, and aortic dissection.
4 Stages of Shock
All types of shock progress through the same stages and produce similar effects on the body systems.

Initial: No visible changes in the client parameters; only changes at the cellular level. Not clinically apparent.
Metabolism changes at the cellular level from aerobic to anaerobic, causing lactic acid buildup.
Lactic acid is a waste produce removed by the liver but this process requires O2 which is unavailable because of decreased tissue perfusion.

Compensatory (non-progressive): Measures to increase cardiac output to restore tissue perfusion and oxygenation. Attempt to maintain homeostasis

Activation of Neural-hormonal-biochemical compensatory mechanisms
Clinical manifestations start to appear

Classic signs of shock is hypotension due to decrease cardiac output and narrowing pulse pressure
SNS stimulation - epinephrine/norepinephrine
Blood flow shunted to heart and brain, and diverted away from kidneys, lungs, GI, and skin

Progressive: Compensatory mechanisms begin to fail.

Refractory: Irreversible shock and total body failure.When compensatory mechanisms begin to fail

The respiratory system is often the first system to display signs of critical dysfunction
Patient centered care: nursing care
Monitor the following:
>Oxygenation status (priority)
>Vital signs
>Cardiac rhythm with continuous cardiac monitoring
>Urine output: hourly, report if less than 20 mL/hr
>Level of consciousness
>Skin color, temperature, moisture, capillary refill, turgor
Explain procedures and findings to the client and family while providing reassurance.
>Place the client on high-flow oxygen, such as a 100% nonrebreather face mask. If the client has COPD, insert a 2 L/min nasal cannula and increase the oxygen flow as needed.
>Be prepared to intubate the client. Have emergency resuscitation equipment ready.
>maintain patent IV access
>For hypotension, place the client flat with is legs elevated to increase venous return.
>If change in status occurs, notify the rapid response team and provider of the findings.
>Prepare for and maintain client care during transfer to the ICU, surgery, other speciality unit, or diagnostic area.
>Prepare for and perform hemodynamic monitoring.
>Monitor central venous pressure, pulmonary artery pressures, cardiac output, and pulse pressure.
>Titrate continuous IV drips to maintain hemodynamic parameters as prescribed.
Distributive shock
Divided into three types:

Neurogenic: Loss of sympathetic tone causing massive vasodilation. Hypotension & bradycardia hallmark symptoms. Spinal cord injury, and epidural anesthesia are among the causes. Vasodilation occurs as a result of a loss of balance between parasympathetic and sympathetic stimulation.

Septic: Endotoxins and other mediators causing massive vasodilation. +Most common cause is gram-negative bacteria.
Urosepsis is more frequent in older adults due to increased use of catheters in long-term care facilities and late detection of urinary tract infection (decreased sensation of burning, urgency).

Anaphylactic: Allergen exposure results in an antigen-antibody reaction causing massive vasodilation. Common causes include antibiotics, food (e.g. peanuts, latex, and bee stings).
Expected findings in GENERAL
-Cardiogenic/Obstructive/Hypovolemic: weak pulse, hypotensive, cold/clammy, prolonged capillary refill, central venous pressure decreased cyanosis
- Septic shock: warm, febrile, bounding pulses
-Anaphylactic shock: wheezing, angioedema
Inotropic Agents
Dobutamine

Actions: Strengthens cardiac contraction and increases cardiac output.

Nursing considerations:
>Administer by continuous IV infusion with constant hemodynamic monitoring, assess for tachydysrhythmias.
>Can titrate agent to maintain prescribed hemodynamic parameters.
>Agents are often administered in combination with a vasopressor
Vasopressors
Dopamine hydrochloride, Norepinephrine

Action:
>Strengthens cardiac contraction, and increases cardiac output
>Increases kidney perfusion at low doses
>Decreases kidney perfusion at high doses

Nursing considerations:
>Limited for patients who do not respond to fluid resuscitation
>Administer by continuous IV infusion with constant hemodynamic monitoring (goal is a MAP of 65 or higher)
>Can titrate vasopressor to maintain prescribed hemodynamic parameters,assess for tachydysrhythmias.
>Monitor urine output
>Administer through a central line to prevent extravasation. Rapid onset occurs in 5 minutes, and short duration occurs in 10 minutes.
Vasopressin (ADH)
Actions: Causes vasoconstriction, increases systemic vascular resistance, increases blood pressure.

Nursing Considerations:
> Given along with norepinephrine
>Administer by continuous IV infusion low does with constant hemodynamic monitoring
>Monitor urine output
>Administer through a central line to prevent extravasation. Rapid onset occurs in 5 minutes, and short duration occurs in 10 minutes.
Normal Lactate reference range
The normal blood lactate concentration in unstressed patients is
0.5-1 mmol/L.

Lactate builds up as metabolism at the cellular level changes from aerobic to anaerobic.

Patients with critical illness can be considered to have normal lactate concentrations of less than 2 mmol/L
IV therapy
The cornerstone of therapy for Septic, Hypovolemic, and Anaphylactic shock is volume expansion with IV therapy.

Complications: hypothermia, coagulopathy, fluid volume overload.
Pre-load
volume of blood in ventricles at end of diastole
Mean Arterial Pressure (MAP)
++used to monitor tissue perfusion++

Normal range 75-105 mm/Hg

Must be over 65 mm/Hg for cells to receive the oxygen and nutrients needed to sustain life
Pulmonary Artery Wedge Pressure (PAWP)
10mm-20mm Hg
Measures Left Ventricular Pre-Load
Central Venous Pressure (CVP)
2-8 mmHg
Measures the Right Ventricular Pre-Load
Systemic Vascular Resistance (SVR)
the pressure in the peripheral blood vessels that the heart must overcome to pump blood into the system
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