Types of shock
cardiogenic
hypovolemic
distributive
obstructive
septic
Cardiogenic shock, aka
pump failure
In systolic cardiogenic shock, there is a problem with
blood moving forward
Systolic cardiogenic shock may be due to
MI
What is the definition of stroke volume?
volume of blood pumped out of the heart every time the heart contracts (~70 mL)
What is the definition of cardiac output?
volume of blood pumped by heart in a minute
Causes of cardiogenic shock
MI
cardiomyopathy
blunt cardiac injury
Early manifestations of cardiogenic shock
tachycardia
hypotension
narrowed pulse pressure
increased myocardial oxygen consumption
*
look like acute decompensated HF
*
How would the patient in cardiogenic shock appear?
tachypnea, pulmonary congestion
pallor, cool, clammy skin
decreased capillary refill time
anxiety, confusion, agitation
decreased renal perfusion and UOP
What labs/diagnostic studies would the nurse look at to determine if the patient has cardiogenic shock?
BNP
echo's
Xrays
Interventions: cardiogenic shock
-restore blood flow
-thrombolytic therapy
-angioplasty with stenting (cath lab)
-emergency revascularization
-valve replacement (would be much later)
-hemodynamic monitoring
-drug therapy (diuretics, vasodilators, beta blockers, dobutamine)
What is the overall end result of any type of shock?
decreased tissue perfusion
impaired cellular metabolism
What can cause hypovolemic shock?
hemorrhage
GI loss (V/D)
fistula drainage
diabetes insipidus & mellitus
hyperglycemia
diuresis
What is relative hypovolemia?
third spacing
fluid volume moves out of vascular space into extravascular space (interstitial or intracavitary space)
Clinical manifestations of hypovolemic shock
anxiety, confusion, agitation (1st SIGN)
tachypnea
increase in CO, HR
pallor
cool, clammy skin (from shunting of blood to vital organs)
prolonged cap refill
decrease of SV, UOP, PAWP
How is fluid replacement calculated for a patient with hypovolemic shock?
3mL isotonic crystalloid for every 1 mL of estimated blood loss
What kind of solutions are used for fluid replacement in the patient with hypovolemic shock?
warm lactated ringers, blood, plasma expanders (albumin, heta starch)
Neurogenic shock usually occurs when?
usually 30 min of a spinal cord injury
In neurogenic shock, what is lost?
sympathetic tone
Clinical manifestations of neurogenic shock
hypotension
*
bradycardia
*
temperature dysregulation
Neurogenic shock: nursing intervensions
in spinal cord injury: spinal stability
treatment of hypotension and bradycardia with vasopressors (dopamine) and atropine
fluids used cautiously as THIS hypotension generally not related to fluid loss
monitor for hypothermia
Anaphylactic shock
acute, life-threatening hypersensitivity rxn after contact, inhalation, ingestion, or injection with an antigen (allergen) to which the person have previously been sensitized
What does anaphylactic shock result in?
severe respiratory distress- swelling of bronchioles
circulatory collapse
Clinical manifestations of anaphylactic shock
anxiety, confusion, dizziness
swelling of lips, tongue, angioedema
wheezing, stridor
flushing, pruritus, urticaria
chest pain
incontinence
Clinical manifestations of obstructive shock
decreased CO
increased afterload (resistance)
JVD
Stages of shock
1. initial
2. compensatory
3. progressive
4. irreversible
Initial stage of shock
usually not clinically apparent
metabolism changes from aerobic to anaerobic (lactic acidosis)
T/F: initial stage of shock has clinical manifestations of tachycardia, hypertension, and cool/clammy skin
false
initial stage of shock usually not clinically apparent
What occurs during the compensatory stage of shock?
vasoconstriction while blood to vital organs (brain, heart)
decreased blood to kidneys- activates RAAS
impaired GI motility
cool, clammy skin from shunting of blood
respiratory distress- increased dead space in lungs (not available for air exchange)
In which stage of shock can the patient recover without consequences?
compensatory stage
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 level
d. increased serum potassium levels
when cell death occurs- potassium liberated from cells; acidosis also contributes to hyperkalemia
In the progressive stage of shock, what happens to the compensatory mechanisms?
they fail!
Hallmarks of decreased cellular perfusion and altered capillary permeability
leakage of protein into interstitial space
increased systemic interstitial edema
How is the progressive stage of shock broken down?
movement of fluid from pulmonary vasculature to interstitium
fluid moves into alveoli
CO begins to fall
Irreversible stage of shock
exacerbation of anaerobic metabolism
accumulation of lactic acid
Vital signs indicating systemic inflammatory response syndrome (SIRS)
Temp: <36 or >38.3
HR: >90
RR: >20
PCO2: <32
WBC: <4K or > 12K or bands > 10%
A patient is said to be SEPTIC if they have ____ and _____
SIRS and an infection (urosepsis? from foley?)
What is severe sepsis?
sepsis and organ dysfunction
HYPOTENSION RESPONDS TO FLUID
What is septic shock?
severe sepsis and hypotension (does not respond to fluid)
What is the progression of septic shock from SIRS?
SIRS -> sepsis -> severe sepsis -> septic shock
What is the most likely organ system to fail?
respiratory
pts become hypoxic, tachypnea
The nurse is caring for a patient in septic shock. Which hemodynamic change would the nurse expect?
a. increased ejection fraction
b. increased mean arterial pressure
c. decreased central venous pressure
d. decreased systemic vascular resistance
d. decreased systemic vascular resistance
What is the first choice vasopressor for hypotension in septic shock (not responsive to fluids)
norepinephrine
What is the normal lactate level?
1.0-2.0
If lactate levels are > 4, evidence shows urgent intervention is required. Complete tissue hypoxia, and will lead to ______ dysfunction
organ dysfunction
How soon should the nurse administer an antibiotic for a patient newly diagnosed with septic shock?
within 1 hour!
When assessing a patient in shock, the nurse recognizes that the hemodynamics of shock include:
a. normal cardiac output in cardiogenic shock
b. increase in central venous pressure in hypovolemic shock
c. increase in systemic vascular pressure in all type
d. variations in cardiac output and decreased systemic vascular resistance in different types of shock
Systemic vascular resistance is increased/decreased for the following:
a. cardiogenic
b. neurogenic
c. hypovolemic
d. septic
cardiogenic- increased
neurogenic- decreased
hypovolemic- increased
septic- decreased
Nursing assessment for a patient possibly going into shock would focus on?
assessment of tissue perfusion!
VS
peripheral pulses
level of consciousness
capillary refill
skin
UOP