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Med Surg Chapter 66: Shock, Sepsis and Multiple Organ Dysfunction Syndrome

Terms in this set (97)

Shock
a state of inadequate tissue perfusion that impairs cellular function and can lead to organ failure
(Shock) Types of Shock
- hypovolemic
- cardiogenic
- obstructive
- distributive
(Shock) Stages of Shock
1.) initial
2.) compensatory
3.) progressive
4.) refractory
(Shock) Stage 1: Initial Stage
- usually not clinically apparent
- metabolism changes at cellular level from aerobic to anaerobic
- lactic acid waste builds up and should be cleared
- clearance requires O2, which is unavailable due to decreased tissue perfusion
(Shock) Stage 2: Compensatory Stage
- blood flow to the most essential (vital) organs, the heart and brain, is maintained
- blood flow to the nonvital organs, such as the kidneys, GI tract, skin, and lungs, is diverted or shunted
(Shock) Compensatory Stage Clinical Manifestations
- oriented
- restless
- confused
- change in LOC
- increased HR
- decreased BP
- increased rate and depth of respiration
- hypoactive bowel sounds
- urine may decrease
- normal or abnormal temperature
- cool, clammy skin (except septic patient who is warm and flushed)
(Shock) Stage 3: Progressive Stage Clinical Manifestations
- decreased responsiveness to stimuli
- delirium
- decreased cardiac output and BP
- increased HR
- hypo or hyperthermia
- cold, clammy
- ischemia of distal extremities
- ARDS
- tachypnea
- moist crackles
- GI ulcers, bleeding
- impaired absorption of nutrients
(Shock) Progressive Stage Cardiovascular Manifestations
- dysrhythmias
- MAP < 60 mmHg or 40 mmHg drop in BP from baseline
- myocardial ischemia
- possible myocardial infarction
- end result: complete deterioration of cardiovascular system
- diminished peripheral pulses, capillary refill
(Shock) Progressive Stage Respiratory Manifestations
- ARDS
- fluid moves into alveoli (alveolar edema, decreased surfactant, worsening V/Q mismatch)
- tachypnea
- moist crackles
- increased work of breathing
(Shock) Progressive Stage GI System Manifestations
- mucosal barrier ischemic
- ulcers
- GI bleeding
- risk of migration of bacteria
- decreased ability to absorb nutrients
(Shock) Progressive Stage Renal Manifestations
- hypoperfusion leads to renal tubular ischemia (may result in AKI)
- decreased urine output
- elevated BUN and serum creatinine
- metabolic acidosis
(Shock) Progressive Stage Hepatic Manifestations
- failure to metabolize drugs and waste
- jaundice
- elevated enzymes
- loss of immune function
- risk for disseminated intravascular coagulation
(Shock) Progressive Stage Endocrine Manifestations
- impaired insulin production (hyperglycemia)
- decreased digestive enzymes
(Shock) Progressive Stage Integumentary Manifestations
- edema
- decreased blood flow to the skin
The nurse is caring for a critically ill patient. The nurse suspects that the patient has progressed beyond the compensatory stage of shock if what occurs?

A. Increased blood glucose levels
B. Increased serum sodium levels
C. Increased serum calcium levels
D. Increased serum potassium levels
D
(Shock) Stage 4: Refractory Stage
- exacerbation of anaerobic metabolism
- accumulation of lactic acid, waste products
- third spacing
- failure of one organ system affects others
- poor prognosis
(Shock) Refractory Stage Manifestations
- hypotension
- hypoxemia
- tachycardia
- unresponsive
- loss of reflexes
- pupils nonreactive and dilated
- BP inadequate to perfuse vital organs
- bradycardia, irregular rhythm
- respiratory failure
- severe refractory hypoxemia
- ischemic gut
- anuria
- hypothermia
- mottled, cyanotic
(Shock) Diagnostic Studies
- blood studies
- 12-lead ECG
- continuous ECG monitoring
- chest x-ray
- hemodynamic monitoring
- ABGs
(Shock) What would a blood study show?
elevated serum lactate
(Shock) Normal Serum Lactate
0.5-1 mmol/L
(Shock) What would ABGs show?
- early: respiratory alkalosis
- later: metabolic acidosis
(Shock) General Measures
- early recognition and response
- treat the underlying cause
- at risk populations
- oxygen and ventilation
- fluid resuscitation
- fluid stewardship
- drug and nutritional therapy
(Shock) What fluids would you want to use to treat shock?
- isotonic and/or hypertonic fluids
- blood or blood products
- colloids
Hypovolemic Shock
- blood volume problem
- 2 types
(Hypovolemic Shock) Types
- absolute
- relative
(Hypovolemic Shock) Absolute
loss of blood, body fluids
(Hypovolemic Shock) What can cause absolute shock?
- hemorrhage
- GI bleed
- vomiting
- diarrhea
- diabetes insipidus
(Hypovolemic Shock) Relative
- pooling of blood/fluids
- fluid shift
- internal spacing (third spacing)
(Hypovolemic Shock) What can cause relative shock?
- bowel obstruction
- burn injury
- ascites
(Hypovolemic Shock) Clinical Manifestations
- anxiety
- confusion
- tachypnea
- decrease in BP, stroke volume, urinary output
- pallor, cool, clammy
- absent bowel sounds
- decreased cardiac output
(Hypovolemic Shock) Labs
- bleeding: decreased hemoglobin, hematocrit, electrolytes
- dehydration: increased hemoglobin, hematocrit, electrolytes
- increased urine specific gravity
- increased lactate
(Hypovolemic Shock) Treatment
- stop the loss
- replenish volume
- volume expansion
- 3:1 rule: 3 mL of isotonic crystalloid for every 1 mL of estimated blood loss
- large-bore IV catheters, intraosseous access device, central venous catheter
- isotonic crystalloids and colloids
(Hypovolemic Shock) Intraosseous Infusion (IO)
the process of injecting fluids, blood, and or medications directly into the marrow of a bone
(Hypovolemic Shock) Nursing Assessment
- monitor for fluid overload
- do not use LR in patients with liver failure
- hypertonic solutions: watch for hypernatremia
- allergic reactions
(Hypovolemic Shock) Fluid Responsiveness
- vital signs
- capillary refill
- skin temperature
- urine output
(Hypovolemic Shock) What are the 2 major complications of large fluid admin?
- hypothermia
- coagulopathy
(Hypovolemic Shock) What does adequate fluids cause?
persistent hypotension
(Hypovolemic Shock) What can treat this?
vasopressors
As the nurse you know that for hypovolemic shock to occur, the patient would need to lose _____ of their blood volume.

A. > 50%
B. > 20%
C. 15%
D. 10%
B
Cardiogenic Shock
- blood pump problem
- systolic or diastolic dysfunction
- compromised cardiac output (CO)
(Cardiogenic Shock) Causes
- myocardial infarction
- cardiomyopathy
- blunt cardiac injury
- severe systemic or pulmonary hypertension
- cardiac tamponade
(Cardiogenic Shock) Early Clinical Manifestations
- tachycardia
- hypotension
- tachypnea (crackles)
- chest pain
- cyanosis
- pallor
- anxiety
- confusion
- agitation
- narrowed pulse pressure
- increased myocardial O2 consumption
(Cardiogenic Shock) Labs
- elevated troponin
- elevated creatinine kinase
- ECG dysrhythmias
(Cardiogenic Shock) Interprofessional Care
- overall goal: restore blood flow to myocardium by restoring balance between O2 supply and demand
- hemodynamic monitoring
- drug therapy
- angioplasty with stenting
- IABP
- emergency revascularization
- valve replacement
(Cardiogenic Shock) Drug Therapy
- nitrates to dilate coronary arteries
- diuretics to reduce preload
- vasodilators to reduce afterload
- beta blockers to reduce HR
(Cardiogenic Shock) Medications
- dobutamine
- dopamine
- epinephrine
- norepinephrine
(Cardiogenic Shock) Dobutamine
- preferred in cardiogenic shock
- inotrope that causes vasodilation
(Cardiogenic Shock) Dopamine
- low doses: renal and mesenteric vasodilation
- high doses: vasoconstriction (> SVR)
(Cardiogenic Shock) Epinephrine
- preferred in anaphylaxis
- high doses: vasoconstrictor, chronotrope, ionotrope, bronchial smooth muscle relaxation
(Cardiogenic Shock) Norepinephrine
- preferred in septic shock
- increased contractility (BP)
- increased HR
- vasoconstriction (afterload)
Distributive/Vasogenic Shock
- blood vessel problem
- 3 types
- vasculature dilated
- difficult for heart to move blood and fluid
(Distributive/Vasogenic Shock) Types
- neurogenic
- anaphylactic
- septic
(Distributive/Vasogenic Shock) Neurogenic Shock
- primary injury: sudden loss of sympathetic tone (leaving parasympathetic system unopposed)
- secondary injury: hours to days; vascular, electrolyte shifts, edema
- regulation of HR, BP, and temperature is compromised
(Distributive/Vasogenic Shock: Neurogenic) Causes
spinal cord injury
(Distributive/Vasogenic Shock: Neurogenic) Clinical Manifestations
- hypotension
- bradyarrythmias
- flushed warm skin
- poikilothermism
- dry skin
- flaccid paralysis below the spinal cord level
- bladder/bowel dysfunction
(Distributive/Vasogenic Shock: Neurogenic) Interprofessional Care
- medications
- fluids (caution due to hypotension not related to fluid loss)
- temperature (monitor for hypothermia)
(Distributive/Vasogenic Shock: Neurogenic) Medications
- atropine
- vasopressors
(Distributive/Vasogenic Shock) Anaphylactic Shock
- acute, life-threatening hypersensitivity (allergic) reaction
- massive vasodilation
- release of vasoactive mediators
- increased capillary permeability
(Distributive/Vasogenic Shock: Anaphylactic) Causes
- latex
- contrast media
- blood or blood products
- drugs
- anesthetic agents
- vaccines
- environmental agents
(Distributive/Vasogenic Shock: Anaphylactic) Clinical Manifestations
- sudden onset
- swelling of lips and tongue
- angioedema
- anxiety, confusion, dizziness
- sense of impending doom
- chest pain
- incontinence
- flushing
- pruritus
- urticaria
- respiratory distress
- circulatory failure
(Distributive/Vasogenic Shock: Anaphylactic) Emergency Management
- recognize signs and symptoms
- maintain patent airway
- intubate
- high flow oxygen
- IV access
- corticosteroids: methylprednisone (Solu-Medrol) IV
- treat shock
(Distributive/Vasogenic Shock: Anaphylactic) What drugs are given?
- epinephrine 0.3-0.5 mg IM (mid outer thigh) every 5-15 minutes
- nebulized albuterol (Proventil) for bronchospasm resistant to epi
- diphenhydramine (Benadryl) IV (uticaria/itching)
(Distributive/Vasogenic Shock: Anaphylactic) Interprofessional Care
- maintain a patent airway (nebulized bronchodilators, aerosolized epinephrine, endotracheal intubation or cricothyroidotomy may be necessary)
- aggressive fluid replacement (crystalloids)
- IV corticosteroids if significant hypotension persists after 1-2 hours of aggressive therapy
(Distributive/Vasogenic Shock) Septic Shock
- 270,000 dead/year USA
- 8,000,000 dead/year globally
- #1 leading cause of hospital deaths
- 39% of USA believe its contagious
- 12% can identify signs and symptoms
- 1/3 of sepsis survivors are readmitted within 3 months
(Distributive/Vasogenic Shock: Septic Shock) Stages of Sepsis
1.) SIRS
2.) sepsis
3.) septic shock
4.) MODS
(Distributive/Vasogenic Shock: Septic Shock) SIRS
2 or more:
- temp > 38 (100.7) or < 36 (96.7)
- HR > 90 bpm
- RR > 20 breath/min or PaO2 < 32 mmHg
- WBC > 12,000 or < 4,000 or > 10% bands
(Distributive/Vasogenic Shock: Septic Shock) Sepsis
SIRS + a confirmed infection
(Distributive/Vasogenic Shock: Septic Shock) Septic Shock
sepsis + persistent hypotension or elevated lactate
(Distributive/Vasogenic Shock: Septic Shock) Multiple Organ Dysfunction Syndrome (MODS)
- failure of 2 or more organ systems in acutely ill patients such that homeostasis cannot be maintained without intervention
- mortality increased with each system that goes down
- poor prognosis (progressive, refractory)
(Distributive/Vasogenic Shock: Septic Shock) Early Recognition
S - shivering, fever or very cold
E - extreme pain/general discomfort
P - pale or discolored skin
S - sleepy, difficult to arouse
I - "I feel like I might die"
S - short of breath
(Distributive/Vasogenic Shock: Septic Shock) qSOFA (Quick Sequential Organ Failure Assessment Score)
- GCS < 15
- SBP < 100 mmHg
- RR > 22
(Distributive/Vasogenic Shock: Septic Shock) Surviving Sepsis Treatment Bundle (time zero)
- measure lactate
- obtain blood cultures
- administer BS, anti-B
- crystalloid at 30 mL/kg
- vasopressors
(Distributive/Vasogenic Shock: Septic Shock) Sepsis Six Treatment Bundle
- administer high flow oxygen
- take blood culture and consider source
- administer IV antibiotics
- IVF
- hemoglobin and lactate
- hourly UOP
(Distributive/Vasogenic Shock: Septic Shock) Blood Culture Collection
- 2 types of bacteria
- collection sites
- skin prep
- volume needed
(Distributive/Vasogenic Shock: Septic Shock) Lactate
- marker for anaerobic and hypoxemia
- indictor for sepsis and septic shock
- venous or arterial
- normal: 0.5-1 mmol/L
(Distributive/Vasogenic Shock: Septic Shock) Hyperlactemia
2-4 mmol/L
(Distributive/Vasogenic Shock: Septic Shock) Lactic Acidosis
pH < 7.35
(Distributive/Vasogenic Shock: Septic Shock) Monitoring Sepsis
- MAP
- ABG
- renal function studies
- cultures
- CVP
- svcO2 > 70%, (>65% with pulmonary arterial catheter)
- C-reactive protein, procalcitonin
- erythrocyte sedimentation rate
(Distributive/Vasogenic Shock: Septic Shock) Goals
- evidence of adequate tissue perfusion
- restoration of normal or baseline BP
- recovery of organ function
- avoidance of complications from prolonged states of hypoperfusion
(Distributive/Vasogenic Shock: Septic Shock) What individuals are at high risk?
- older patients
- immunocompromised
- chronic illness
- surgery or trauma
(Distributive/Vasogenic Shock: Septic Shock) Prevention
- monitor fluid balance to prevent hypovolemic shock
- maintain hand washing to prevent spread of infection
(Distributive/Vasogenic Shock: Septic Shock) Nursing Assessment
- ABCs
- focused assessment of tissue perfusion
- vital signs
- peripheral pulses
- LOC
- capillary refill
- skin (temperature, color, moisture)
- urine output
(Distributive/Vasogenic Shock: Septic Shock) Nutrition
- nutrition is vital to increasing morbidity from shock
- start enteral nutrition within first 24 hours
- parental nutrition used only if enteral feedings contraindicated
- start feeding = slow drip of small amounts of enteral nutrition (10 mL/hr)
- weigh patient daily
- monitor serum protein, total albumin, prealbumin, BUN, glucose, electrolytes
(Distributive/Vasogenic Shock: Septic Shock) Neurologic Status
- assess orientation and LOC, clinical manifestations
- orient to person, place, time, events
- reduce noise and light levels in ICU
- keep a day-night cycle
(Distributive/Vasogenic Shock: Septic Shock) Cardiovascular Status
- continuous ECG, BP, CVP pressures
- monitor for dysrhythmias
- do not treat hypotension with Trendelenburg position
- heart sounds: murmurs, S3, S4
(Distributive/Vasogenic Shock: Septic Shock) Respiratory Status
- respiratory rate, depth, and rhythm
- breath sounds
- continuous pulse oximetry
- arterial blood gases
- many patients will be intubated and on mechanical ventilation
(Distributive/Vasogenic Shock: Septic Shock) Renal System
- urine output
- serum creatinine
(Distributive/Vasogenic Shock: Septic Shock) Integumentary System
- body temperature and skin changes
- core temperature
- skin: temperature, pallor, flushing, cyanosis, diaphoresis, piloerection
(Distributive/Vasogenic Shock: Septic Shock) GI System
- auscultate bowel sounds
- NG drainage/stools for occult blood
(Distributive/Vasogenic Shock: Septic Shock) Personal Hygiene
- perform bathing, nursing measures carefully
- turn every 1-2 hours
- passive/active range of motion
(Distributive/Vasogenic Shock: Septic Shock) Emotional Support and Comfort
- assess level of anxiety, fear, pain
- drugs PRN
- talk to patient
- give simple explanations of all procedures
- visit from clergy
- caregiver involvement
- privacy
- call light within reach
(Distributive/Vasogenic Shock: Septic Shock) Nursing Management: Evaluation
- adequate tissue perfusion with restoration of normal or baseline BP
- normal organ function with no complications from hypoperfusion
- decreased fear and anxiety and increased physiologic comfort
Obstructive Shock
- blood flow problem
- develops when physical obstruction to blood flow into or out of the heart occurs
- pump is impaired due to a noncardiac factor
(Obstructive Shock) Causes
- pulmonary embolism
- tension pneumothorax
- cardiac tamponade
- aortic stenosis
- coarctation of the aorta
(Obstructive Shock) Clinical Manifestations
- confusion
- loss of consciousness
- chest pain
- lightheadedness
- sudden increase in HR
- faint pulse
- short of breath
- shallow, fast breathing
- cold feet, clammy skin
(Obstructive Shock) Interprofessional Care
- mechanical decompression
- thrombolytic therapy
- radiation, debulking, or removal of mass
- decompressive laparotomy
(Obstructive Shock) What is the primary strategy for treatment?
early recognition and treatment to relieve obstruction
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