Nursing Management: Shock and Multiple Organ Failure

1. Spring, 2003 NURS1228 Nursing Management: Shock and Multiple Organ Failure Pamela Fowler, MS, RNC Assistant Professor Rogers State University

2. What is shock? Shock is a clinical syndrome resulting in decreased blood flow to body tissues causing cellualr dysfunction and eventual organ failure. End result is inadequate supply of oxygen and nutrients to the tissues or IMPAIRED TISSUE PERFUSION Not simply a matter of low blood pressure

3. Physiology review In order to maintain tissue perfusion at normal levels the body must have a working pump (heart) an adequate, stable amount of fluid to pump (blood) control over the size of the area the the fluid is being pumped through (good vascular tone, controls size of the vascular bed) Without these three elements, shock occurs

4. Classifications of shock Distributive shock Hypovolemic shock Cardiogenic shock

5. Distributive Shock Vasodilatation increases the size of the vascular space and results in altered distribution of the blood volume rather than actual loss of volume Types neurogenic septic anaphylatic

6. Neurogenic shock Thought of as uncommon Often transitory Caused by massive vasodilitation as a result of loss of sympathetic tone Etiology spinal injury or disease spinal anesthesia, deep general, epidural vasomotor center depression

7. Neurogenic shock Who is at risk? What assessment findings would indicate to the nurse that the client is in impending shock? What emergency or immediate intervention could be done to reverse the etiology?

8. Septic shock Results from endotoxin activity which causes widespread vasodilitation Most commonly caused by gram-negative bacteria Etiology infection compromised patients

9. Septic shock Who is at risk? What assessment findings would indicate to the nurse that the client is in impending shock? What emergency or immediate intervention could be done to reverse the etiology?

10. Anaphylactic Shock An immediate hypersensitivity reaction Characterized by dilatation of arterioles and capillaries and increased capillary permeability Etiology allergic reaction to drugs, insect bites, contrast media, blood transfusions, anesthetic agents, foods, vaccines

11. Anaphylactic shock Who is at risk? What assessment findings would indicate to the nurse that the client is in impending shock? What emergency or immediate intervention could be done to reverse the etiology?

12. Hypovolemic Shock Occurs when there is actual loss of intravascular fluid volume No decrease in pumping ability of heart or increase in vascular space Can be from external fluid loss (actual hypovolemia) internal fluid shifts (relative hypovolemia)

13. Hypovolemic shock Who is at risk? What assessment findings would indicate to the nurse that the client is in impending shock? What emergency or immediate intervention could be done to reverse the etiology?

14. Cardiogenic Shock Occurs when the heart can no longer pump blood efficiently to all parts of the body No decrease in intravascular volume No increase in size of the vascular bed

15. Cardiogenic shock Who is at risk? What assessment findings would indicate to the nurse that the client is in impending shock? What emergency or immediate intervention could be done to reverse the etiology?

16. Stages Compensatory: reversible; fight-or-flight subtle signs may be overlooked Progressive: Compensation is beginning to fail and may be detrimental Irreversible/Refractory: compensatory mechanisms are ineffective or nonfunctioning

17. Compensatory stage assessment Restlessness oriented pupils normal heart rate increased pulses bounding to thready systolic B/P normal or slight decrease Diastolic B/P normal or slight increase respirations faster and deeper output = or < pale, cool, may be thirsty, normal to hypoactive BS

18. Role of the RN Continuous in-depth assessment of the patient�s hemodynamic status Prompt recognition of problems Accurate use of emergency orders Prompt and accurate reports of deviations in assessment to physician Reducing patient anxiety Promoting patient safety

19. Progressive stage assessment Listless, agitated, apathetic, confused speech slowed pupils dilated tachycardia pulses weak, thready systolic B/P < 90 Diastolic B/P falling respirations rapid and shallow oliguria cold, clammy, cyanotic, marked increase in thirst BS < or absent

20. Role of the RN Requires expertise in assessing and understanding shock and the significance of changes in assessment data Managing, implementing and documenting treatments, medications, fluids along with continuous assessment and collaboration

21. Irreversible shock assessment Confused, disoriented or unconscious reflexes absent pupils dilated with minimal response to light HR slow and irregular pulses absent (or very weak) Systolic B/P falling to unobtainable Diastolic B/P approaching 0 Respirations slow and shallow, irregular output very <or absent cold, clammy, mottled absent bowel sounds

22. Role of the RN Continuing the astute assessment and interventions begun in previous stages Recognizing that the patient is very likely to be terminal Initiating palliative and end-of-life activities Support and explanation to family members

23. Overall Therapeutic Management Most critical factor is early recognition Interventions ID patient at high risk for shock (extremes of age, chronic, debilitating illnesses, surgery, trauma, decreased immunity, hospitalization) Watch for assessment findings of shock Control or alleviate the primary cause Implement measures to correct pathologic changes and enhance tissue perfusion

24. Some things to expect ABC�s positioning oxygen ventilatory support Fluid replacement: if not cardiogenic shock Acid-base imbalance Cardiac dysrhythmias Vasoactive medication administration

25. Fluid Replacement Crystalloid replacement: NS and LR Easily available, but can cause rebound overload, much is lost to tissues No oxygen carrying capacity Colloids: plasma proteins such as albumin Large molecules that pull fluids into tissues, but are harder to obtain, more expensive and run risk of anaphylaxis No oxygen carrying capacity

26. Blood: if the patient is in hypovolemic shock, this is the fluid of choice Does have oxygen carrying capacity Harder and slower to obtain, generally needs to be cross-matched

27. Vasoactive medications Vasopressors: Intropin (dopamine), Dobutrex (dobutamine) Vasodilators: Nipride (nitroprusside), Tridil (nitroglycerine)

28. Other medications Corticosteroids Antibiotics

29. Goals of therapy Adequate tissue perfusion No complications related to shock

30. Acute interventions LOOK FOR SHOCK LOOK FOR SHOCK LOOK FOR SHOCK LOOK FOR SHOCK LOOK FOR SHOCK LOOK FOR SHOCK LOOK FOR SHOCK

31. Once shock is suspected Frequent neuro checks (every 1 hour) Frequent VS (up to q 5-15 minutes) monitor ECG monitor peripheral pulses if these are weak is your patient getting benefit from peripheral IV sites????) assess respiratory efforts, chest sounds, pulse ox or ABG�s

32. Monitor output hourly think about what meds pt is getting Monitor body temp keep pt comfortably warm watch skin color, goose-bumps, diaphoresis monitor capillary refill times Auscultate BS every 8 hours at least patient may need to be kept NPO or other feedings watch for abdominal distention, NG output

33. Attend to patient�s personal hygiene, especially oral care and skin integrity measures Use compassionate understanding in dealing with family and patient Talk to the patient (even if comatose) Remember to provide privacy Provide spiritual support as desired Facilitate family visits and interaction with the patient as possible.