Nursing Care & Priorities for Those in Shock

1. Nursing Care & Priorities for Those in Shock Keith Rischer RN, MA, CEN

2. 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).

3. 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)

4. 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

5. 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

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

7. 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

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

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

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

11. 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

12. 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…

13. 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

14. Shock Case Study • 83yr male • Admitted from ED to tele for abd pain and recent lower GI bleeding. Colonoscopy later in day. • PMH: AFib-on Coumadin daily, HTN • Hgb 11.2, INR 2.8, creat .90 • ED VS: T-98.8 P-76 R-16 BP-108/64 sats 98% 2l n/c • Enter room to perform initial assessment: • Pale-diaphoretic, lethargic. Can answer simple questions and oriented x3 • Smell suspicious ?GI bleeding • Note large pool of dark, red blood on pad • VS: P-110 R-24 BP-78/34 sats 90% 2l n/c

15. 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

16. 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

17. 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

18. Mechanism of Action: Abx

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

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

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

22. Physical Assessment Pulmonary CV Renal GI Neuro Coagulation

23. Diagnostic-Lab Findings Creatinine K+ GFR Troponin BNP Liver Enzymes ALT-AST Alk Phos Total bili Ammonia albumin • ABG • pH • CO2 • O2 • HCO3 • O2 sats • WBC • Platelets • Fibrinogen • PT-INR • Hgb

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

25. 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….

26. Sepsis/MODS Case Study 40 yr male w/seizure disorder Chief complaint Altered mental status Vague abd pain Weakness Hypotension Physical assessment Epigastric-LUQ tender VS T-101.2/P-110/R-24/BP 92/42/sats 95% RA Admission Labs WBC-11,000 Hgb-12.2 Platelets-64,000 Creatinine-2.7 ALT-502 AST-219 Ammonia-68 Lipase-1947 Glucose-322 CT-encephalopathy Abd CT-inflamm. pancreas

27. Case Study:Later… Day of Admission Increasing lethargy, resp. distress ABG pH- 7.28 CO2- 59 O2- 52 HCO3- 23 O2 sats- 84 FiO2-100% vent…AC12, PEEP +5 CT-abd. Ileus-hepatic infarcts

28. Case Study:Day 1 CVP-21 VS-101.2-118-24-82/40 NG placed Labs WBC-12.7 Platelets-56 Creatinine-.7 ALT-243 AST-219 Lipase 523 ABG pH-7.25 CO2-52 O2-76 O2 sats-92% FiO2-100% PEEP now +10 Weight up 8 kg Non icteric IV Infusions Insulin gtt Lasix gtt TPN-Lipids Fentanyl gtt Versed gtt Levophed gtt Neosynephrine gtt Vasopressin gtt Heparin gtt

29. Case Study:Day 2 CVP-16 –weight up another 7.5 kg…poor u/o VS-100.5-110-24-84/44 Labs WBC-21.5 Hgb-12.5 Platelets-77 Creatinine-0.9 ALT-143 AST-41 Ammonia-30 Lipase 114 CXR-white out ABG pH-7.11 CO2-78 O2-58 HCO3-24 O2 sats-75% Vent-FiO2-100%, +15 Treatment Plan CRRT IV abx-Cipro/Flagyl Hold Lasix gtt NG LCS Lactulose Wean vasoactive gtts as able Continue all previous gtts Pan cultures Physical assessment Distended abd-hypoactive NG bile output Coarse crackles bilat Cool to touch Nursing Priorities…

30. Case Study #2… • 90yr male • PMH: anemia, hypothermia due to thalamus disorder, pneumonia, COPD, HTN, renal insufficiency, mild dementia. Lives in assisted living • HPI: Son visited today and noted to be incr. confused-brought to ED for eval. • VS: T-90.9 P-41 (Junctional) R-16 BP 99/45 sats 97% 2l per n/c • Assessment: • Neuro-confused-responds to voice • Resp-clear-neg. assessment • CXR: left basilar infiltrate • CV-No edema, S1S2, pulses strong x4

31. Labs

32. Case Study #2… • Order received to give 2u PRBC • After second unit VS: • T-95.5 P-38 R-36 BP-113/49 sats 88% 6l n/c • c/o SOB-breath sounds course bilat • u/o 100cc last 4 hours • SBAR… • Order for Lasix 40mg IV…80cc u/o last hour • SBAR • Additional Lasix 80 mg IV and assess

33. Case Study #2… • Status 1 hour later… • RR 36-44 w/sats 84-88% on oxymizer 15l • Breath sounds remain course • u/o 30cc since Lasix 80mg 1 hour ago • SBAR • Bipap started per RT • Sats increased to 94%, RR 20-24, appears more comfortable

34. AM Labs

35. 4 Days Later…Summary • Sepsis…ARF necessitated need for dialysis due to resultant hyperkalemia, fluid overload. • Multisystem failure of kidneys, heart, and lungs • Kaofeed placed and started on TF • VS: • T-98.1 P-80 (SR) R-16 BP-159/75 sats 100% (5l oxymizer) • I-1700 /O-2480

36. Case Study #2 • Assessment • Neuro-follows commands-more responsive • Resp-dimin bilat w/scatt. Crackles-non-labored • CV-NSR, tr. Edema LE • GU-Incr. u/o, Foley • Medical-Nursing priorities • Pneumonia • Leukocytosis (Solumedrol?) • IV abx • Hyperkalemia • D50, insulin IV, NaBicarb IV, Calcium Gluconate • Unable to take Kayexalate po or rectally

37. Medical-Nursing Priorities • Resp. failure • Bipap…oxymizer to keep sats >90% • Acute renal failure • ATN…sepsis • ACE held • u/o improving • Sepsis • Encephalopathy • Ativan, Haldol prn • Nutrition • TF

38. Labs