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Todays Objectives

Todays Objectives. Compare and contrast pathophysiology & manifestations of the various shock states and the physiologic compensatory mechanisms. Identify nursing priorities with the various shock states.

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Todays Objectives

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  1. Todays Objectives • Compare and contrast pathophysiology & manifestations of the various shock states and the physiologic compensatory mechanisms. • Identify nursing priorities with the various shock states. • Compare & interpret abnormal laboratory test indicators involved with septic, hypovolemic, and cardiogenic shock. • Analyze assessment data to determine nursing diagnoses and formulate a plan of care for clients with the various shock states. • Describe the medical management and mechanism of action, side effects and nursing interventions of pharmological management with shock states. • Compare & contrast pathophysiology, manifestations, nursing priorities seen with sepsis vs. Multiple Organ Dysfunction Syndrome (MODS).

  2. Shock Defined Any problem that impairs oxygenation delivery to tissues & organs CV system is where it begins Table 40-3 p.826 Hypovolemic Cardiogenic Distributive Neurogenic Anaphylactic Septic-SIRS Multiple Organ Dysfunction Syndrome (MODS)

  3. Processes of Shock Table 40-2 p.825 Initial stage…early shock MAP decrease 5-10mm/Hg Mild vasoconstriction Tachycardic…Why??? Nonprogressive stage…compensatory stage MAP decrease 10-15 mm/Hg Mod. Vasoconstriction Physiologic compensations Renin, aldosterone, ADH Decreased u/o Mild acidosis Mild hyperkalemia

  4. Processes of Shock Table 40-2 p.825 Progressive stage…intermediate stage MAP decrease >20mm/Hg Overall metabolism-anaerobic Moderate acidosis Moderate hyperkalemia Tissue ischemia lactic acidosis-Lactate Refractory stage…irreversible stage

  5. Hypovolemic Shock:Physical Assessment Cardiovascular changes Pulse Blood pressure Skin changes Respiratory changes Oxygen saturation RR Renal and urinary changes Central nervous system changes

  6. Hypovolemic Shock:Nursing Priorities • Impaired gas exchange • Nursing interventions • Deficient fluid volume • Nursing interventions • Decreased cardiac output • Nursing interventions • Risk for ineffective tissue perfusion • Body systems impacted??? • Nursing interventions

  7. Sepsis • Patho • Progressive • Infection • Bacteremia • Systemic Inflammatory Response Syndrome (SIRS) • Sepsis • Severe sepsis • Septic shock • Multiple Organ Dysfunction Syndrome (MODS)

  8. Sepsis:Hyperdynamic (early) Cardiovascular changes Skin changes Respiratory changes Renal and urinary changes Central nervous system changes

  9. Sepsis:Hypodynamic (late) Cardiovascular changes Skin changes Respiratory changes Renal and urinary changes Central nervous system changes

  10. Shock-Laboratory FindingsChart 40-3 p.831 General ABG’s pH CO2 O2 HCO3 Lactate Hct Hgb Potassium Septic Shock Blood cultures WBC Neutrophils Bands C Reactive Protein (CRP) D-Dimer Fibrinogen INR Platelets

  11. Nursing Care Priorities/Diagnosis Impaired gas exchange r/t… Deficient fluid volume r/t… Ineffective tissue perfusion r/t… Anxiety Knowledge deficit r/t… Ultimate Goal…

  12. General Shock: Nursing Interventions Remember A,B,C,D Reverse the shock Administer O2 Establish IV access Restore fluid volume Colloid Crystalloid Vasoactive gtts Administer blood products as ordered Nursing assessment Pulse/rhythm BP-CVP RR-O2 sats Urine output Skin color Monitor labs

  13. Shock Case Study • Nursing priorities… • Rapid Response paged • SBAR to primary MD • Medical/Nursing management: • 2 large bore IV’s • NS 1000cc FF • Prepare for transfer to ICU • Stat Hgb • Obtain 2u PRBC from blood bank

  14. 15” later… • VS: P-100 R-20 BP-92/46 sats 98% 6l n/c • Hgb 8.2 • First unit of blood initiated • Prepare for transfer to ICU…unable to take at this time • Foley catheter placed • VS just before transfer: P-88 R-18 BP-102/64 sats 100% 4l n/c

  15. Septic Shock: Nursing Interventions All the same as previous slide and… Obtain blood, urine cultures as ordered Administer IV abx Administer anti-arrythmics Aggressive IV fluid resuscitation Assess closely for signs of bleeding…DIC Strict aseptic technique Fever reduction as needed Client-family education

  16. Vasoactive Gtts chart 40-6 p.833 Dopamine Renal Beta effect Alpha effect Levophed (norepinephrine) Phenylephrine (neo-synephrine)

  17. Multiple Organ Dysfunction Syndrome • Patho • Uncontrolled inflammation • Progressive dysfunction of 2 or more systems • Risk factors • Causes • Trauma • Pancreatitis • ARDS • Major surgery

  18. Multiple Organ Dysfunction Syndrome • Four major organ systems involvement • Pulmonary • Renal • Cardiovascular • Coagulation

  19. Physical Assessment Pulmonary CV Renal GI Neuro Coagulation

  20. Therapeutic Management Support tissue oxygenation Fluid resuscitation Blood and blood products Dialysis or CRRT Nutritional support Antibiotic therapy Priority Nursing Diagnoses…

  21. Nursing Priorities-Interventions Assess resp. status Continuous cardiac monitoring Assess perfusion Provide hydration and nutritional support Assess for coagulation dysfunction Emotional support/comfort measures Evaluation….

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