SHOCK

I. Define shock A condition in which systemic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cellular functions.In shock cells lack adequate blood supply & are deprived of oxygen & nutrients, therefore they must produce energy through anaerobic metabolism. This results in low energy yields from nutrients & an acidotic intracellular environment. Normal cell function ceases. The cell swells & the cell membrane becomes more permeable, allowing electrolytes & fluids to seep out of & into the cell. The Na/K+ pump becomes impaired; cell structures are damaged and death of the cell results.

II. Causes of shock A. inadequate cardiac pumpB. inadequate blood volume- wont circulate where needs to goC. inadequate vascular tone

*when one component is impaired, blood flow is threatened or compromised*without treatment the results are poor delivery of oxygen and nutrients to the cells, cellular starvation, cell death, organ dysfunction progressing to organ failure, and eventually death

III. The three stages of shock A. Compensatory- fight or flight

i. Clinical manifestationsa. BP is normal

b. HRc. Skin is cold & clammy due to shunting of bloodd. Possible restlessness or confusion

e. urinary outputf. RR

ii. Nursing actions & assessmentsa. VS- loc

b. Cardiac output , so Bp (bradycardia)c. Skin- cold & clammy

d. Lab values- H&H, O2*report any deviations from normal

B. Progressivei. the overworked heart becomes dysfunctional; the bodys inability to meet

increased O2 requirements produces ischemia; the body cant compensate & bp begins to fall

ii. clinical manifestations

a. Bp b. HR (>150)c. chest paind. rapid, shallow R, cracklese. skin is mottled, petechaie

f. mental deterioration b/c urinary output causing toxins in blood & to brain

iii. nursing actions & assessmentsa. assess frequently

b. promote rest & comfort

a. pt in bed to energy useb. may be cold/clammy but dont want to warm too fast

c. dont forget about the familya. notify if change or getting worseb. encourage counseling or visit from chaplin

C. Irreversiblei. cant be reversed

a. Bp - nothing can be done to bring , so will go into multiple organ failure

ii. client death inevitableiii. tissue damage repair impossible

iv. cardiac output v. reduced venous return- blood cooling in capillaries (edema, pulmonary

congestionvi. nursing actions

a. continue to monitor vsb. protect client from injuryc. provide comfortd. allow family time with client

IV. Complications of shock A. cardiogenic shock

i. Caused by miii. Pump itself fails

iii. Heart is unable to pump blood & supply of O2 is inadequate for heart & tissues

iv. cardiac contractility- heart not pumping effectivelyv. cardiac output

vi. tissue perfusiona. pulmonary congestion

b. coronary perfusion- blood poolingvii. clinical manifestations

a. difficulty breathingb. cracklesc. chest paind. shallow Re. dysnea on exertion

viii. treatmenta. supply O2

a. not getting enoughb. so give at 2-6 l/min per nasal cannulac. want O2 sat at 92%

b. control pain with morphine (dilates blood vessels, pain)c. IV fluids- NS or LRd. vasoactive medication

a. helps heart beat faster/stronger

b. pre and afterloadc. stabilize heart beat (p307)

d. dobutamine ( cardiac output), nitro (dilate bv), dopamine ( tissue perfusion)

e. control HRf. possible pacemaker

B. hypovolemic shocki. decrease in blood volume problem

ii. most common type iii. caused by extreme fluid losses

a. traumab. dehydrationc. N/V/Dd. Burns

iv. begins with in intravascular volumev. decrease co

vi. heart beating faster b/c blood- trying to oxygenate quicklya. HRb. co

vii. stroke volume leading to tissue perfusion b/c less blood cells & will dieviii. treatment

a. restore fluid lossa. LRb. 0.9 % NaCl (NS)

b. redistribute fluid volume

a. reposition of client (trendelenburg- head feet )c. correct cause of fluid loss

ix. preventiona. assess pt

a. when come back from surgery look at bandage (circle drainage)

b. make sure have IV fluidsc. might have to move pt to assess

b. monitor pta. for N/V/Db. offer fluidsc. adequate hydrationd. I&Oe. ambulation

C. circulatory shocki. problem with blood vessels not distributing blood throughout the body (blood

volume pools in the peripheral blood vessels)ii. types

a. septic shock- most commona. caused by widespread infectionb. hypodynamic irreversible phase caused by vasodilation of bvc. check lines b/c can become infectedd. risk factors

i. immunosuppression

ii. extremes of age 65iii. malnourishmentiv. chronic illnessesv. invasive procedures

e. nursing measuresi. aseptic technique

ii. hand washingiii. sterile dressing changesiv. monitor vs, I&O

f. treatmenti. identify & eliminate cause of infection

ii. fluid replacement to correct hypovolemia caused by inflammatory response

iii. blood products to increase intravascular volumeb. neurogenic shock

a. vasodilation which occur as a result of sympathetic toneb. caused by a spinal cord injury or nervous system damagec. may have a prolonged coursed. can be

i. short term- faintingii. long term- spinal cord injury, spinal cord anesthesia

e. risk factorsi. spinal cord injury

ii. spinal anesthesiaiii. depressant action of medicationsiv. glucose deficiency

f. clinical manifestationsi. warm, dry skin

ii. bradycardia- bp, hriii. vasodilation of bviv. pooling of blood in capillaries

g. nursing actions is in preventioni. elevate & maintain HOB elevated in pt with epidural

or spinal anesthesiaii. in suspected spinal cord injury immobilize client to

prevent further damageiii. apply elastic compression stockings- may have to

give lovenoxiv. check homans sign- if + call dr (pain, redness,

warmth, edema)c. anaphylactic shock

a. caused by severe allergic reactionb. an antigen-antibody reaction causes widespread vasodilation

& capillary permeabilityc. occurs rapidlyd. life threateninge. often can be prevented

i. wear breaceletii. stay away from

iii. epipen availablef. risk factors

i. penicillin sensitivityii. transfusion reaction

iii. bee sting allergyiv. latex sensitivity

g. clinical manifestationsi. widespread vasodilation

ii. uticaraiii. itching

iv. flushingv. n/v/d

vi. fluid transfer to subq tissuevii. bronchospasm & facial edema

h. treatmenti. immediate attention & life support

1. epinephrine for vasoconstrictive action2. diphenhydramine (benadryl)- to reverse

effect of histamine, reduces capillary permeability

3. proventil (albuterol) inhaleri. prevention

i. assess all clients for allergiesii. education of client & family

j. nursing actionsi. client & med hx- what happens when client does take

ii. assessiii. observe client when administering a new mediv. contrast agents- diagnostic tests for allergyv. speak on client terms (shellfish)

vi. education about further exposure1. client & family2. on contact with substance

V. Clinical findings in shock A. anxiety- due to decreased O2

B. BP- cardiac output & blood volumeC. P- compensationD. urinary output & concentration of urine

i. blood flow to kidneysii. fluid retention

iii. BUN & creatinineE. cold, clammy skin

i. metabolismii. peripheral vasoconstriction

F. cyanosis

i. O2 in bloodii. CO2 in blood

G. pallor- peripheral vasoconstriction

VI. Drugs used A. antiarrhythmicB. Ca+ channel blockers- increase force of contraction, increasing flow of blood

C. B- adrenergic blocker- HRD. Na+ bicarbonate- metabolic acidosisE. antibiotics- fight infectionF. bronchodilators- dilate bronchioles

G. anticholinergic- HRH. anticoagulant- prevent blood from clotting

I. anticonvulsants- high T & toxins in blood so need to prevent convulsionsJ. diuretics- keep fluid from building up in tissue and need to get rid ofK. corticosteroids- reduce inflammation in anaphylactic L. antihistamines- histamine reactionM. narcotics- pain in cardiogenic (morphine)N. colloids- large-molecule IV solution used as blood & fluid volume expandersO. crystalloids- electrolyte solution that moves freely between intravascular and interstitial

spaces, used as blood & fluid volume expander

P. vasopressors- BP so drugs wont poolVII. Factors that affect progress of shock

A. degree of complication- stage inB. existing conditions

i. chronicii. malnutrition

iii. surgeryiv. diarrheav. infection

C. agei. elderly

ii. debilitatediii. young

D. managementi. assessment

ii. monitoringiii. dont overhydrate in cardiogeniciv. sooner treated the betterv.

VIII. Complications of shock A. myocardial depression

i. O2ii. cardiac outputiii. pulmonary edema

B. ARDS- gas exchange in the lungC. renal failure- especially hypovolemicD. DIC

i. clotting to excessii. can be treated with crystalloids

E. GI ulcersF. long-term HTNG. MODS- multiple organ dysfunction syndrome is an altered organ function in an acutely

ill patient that requires medical intervention to support continued organ functionH. hepatic insufficient