Focus on Shock (Relates to Chapter 67, “Nursing Management: Shock, SIRS, and Multiple Organ Dysfunction Syndrome,” in the textbook) Copyright © 2007, 2004, 2000, Mosby, Inc.,
Download ReportTranscript Focus on Shock (Relates to Chapter 67, “Nursing Management: Shock, SIRS, and Multiple Organ Dysfunction Syndrome,” in the textbook) Copyright © 2007, 2004, 2000, Mosby, Inc.,
Focus on Shock (Relates to Chapter 67, “Nursing Management: Shock, SIRS, and Multiple Organ Dysfunction Syndrome,” in the textbook) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Shock Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism Imbalance in supply/demand for O2 and nutrients Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Shock Classification of shock Low blood flow Cardiogenic Hypovolemic Maldistribution of blood flow Septic Anaphylactic Neurogenic Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Low Blood Flow Cardiogenic Shock Definition Systolic or diastolic dysfunction Compromised cardiac output (CO) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Low Blood Flow Cardiogenic Shock Precipitating causes Myocardial infarction Cardiomyopathy Blunt cardiac injury Severe systemic or pulmonary hypertension Cardiac tamponade Myocardial depression from metabolic problems Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pathophysiology of Cardiogenic Shock Fig. 67-2 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Low Blood Flow Cardiogenic Shock Early manifestations Tachycardia Hypotension Narrowed pulse pressure ↑ Myocardial O2 consumption Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Low Blood Flow Cardiogenic Shock Physical examination Tachypnea, pulmonary congestion Pallor; cool, clammy skin Decreased capillary refill time Anxiety, confusion, agitation ↑ in pulmonary artery wedge pressure Decreased renal perfusion and UO Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Low Blood Flow Hypovolemic Shock Absolute hypovolemia: Loss of intravascular fluid volume Hemorrhage GI loss (e.g., vomiting, diarrhea) Fistula drainage Diabetes insipidus Hyperglycemia Diuresis Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Low Blood Flow Hypovolemic Shock Relative hypovolemia Results when fluid volume moves out of the vascular space into extravascular space (e.g., interstitial or intracavitary space) Termed third spacing Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pathophysiology of Hypovolemic Shock Fig. 67-3 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Low Blood Flow Hypovolemic Shock Response to acute volume loss depends on Extent of injury or insult Age General state of health Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Low Blood Flow Hypovolemic Shock Clinical manifestations Anxiety Tachypnea Increase in CO, heart rate Decrease in stroke volume, PAWP, UO If loss is >30%, blood volume is replaced Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Maldistribution of Blood Flow Neurogenic Shock Hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic (T5) vertebra or above and can last up to 6 weeks Can be in response to spinal anesthesia Results in massive vasodilation leading to pooling of blood in vessels Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pathophysiology of Neurogenic Shock Fig. 67-4 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Maldistribution of Blood Flow Neurogenic Shock Clinical manifestations Hypotension Bradycardia Temperature dysregulation (resulting in heat loss) Dry skin Poikilothermia (taking on the temperature of the environment) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Maldistribution of Blood Flow Anaphylactic Shock Acute, life-threatening hypersensitivity reaction Massive vasodilation Release of mediators ↑ Capillary permeability Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Maldistribution of Blood Flow Anaphylactic Shock Clinical manifestations Anxiety, confusion, dizziness Sense of impeding doom Chest pain Incontinence Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Maldistribution of Blood Flow Anaphylactic Shock Clinical manifestations Swelling of the lips and tongue, angioedema Wheezing, stridor Flushing, pruritus, urticaria Respiratory distress and circulatory failure Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Maldistribution of Blood Flow Septic Shock Sepsis: Systemic inflammatory response to documented or suspected infection Severe sepsis = Sepsis + Organ dysfunction Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Maldistribution of Blood Flow Septic Shock Septic shock = Presence of sepsis with hypotension despite fluid resuscitation + Presence of tissue perfusion abnormalities Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Maldistribution of Blood Flow Septic Shock Mortality rates as high as 50% Primary causative organisms Gram-negative and gram-positive bacteria Endotoxin stimulates inflammatory response Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. QuickTime™ and a YUV420 codec decompressor are needed to see this picture. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pathophysiology of Septic Shock Fig. 67-5 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Maldistribution of Blood Flow Septic Shock Clinical manifestations ↑ Coagulation and inflammation ↓ Fibrinolysis Formation of microthrombi Obstruction of microvasculature Hyperdynamic state: Increased CO and decreased SVR Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Maldistribution of Blood Flow Septic Shock Clinical manifestations Tachypnea/hyperventilation Temperature dysregulation ↓ Urine output Altered neurologic status GI dysfunction Respiratory failure is common Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Initial Stage Usually not clinically apparent Metabolism changes from aerobic to anaerobic Lactic acid accumulates and must be removed by blood and broken down by liver Process requires unavailable O2 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Compensatory Stage Clinically apparent Neural Hormonal Biochemical compensatory mechanisms Attempts are aimed at overcoming consequences of anaerobic metabolism and maintaining homeostasis Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Compensatory Stage of Shock Fig. 67-6 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Compensatory Stage Baroreceptors in carotid and aortic bodies activate SNS in response to ↓ BP Vasoconstriction while blood to vital organs maintained ↓ Blood to kidneys activates renin– angiotensin system ↑ Venous return to heart, CO, BP Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Compensatory Stage Impaired Risk for paralytic ileus Cool, GI motility clammy skin from blood Except septic patient who is warm and flushed Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Compensatory Stage Shunting blood from lungs increases physiologic dead space ↓ Arterial O2 levels Increase in rate/depth of respirations V/Q mismatch SNS stimulation increases myocardium O2 demands Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Compensatory Stage If perfusion deficit corrected, patient recovers with no residual sequelae If deficit not corrected, patient enters progressive stage Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Progressive Stage Begins when compensatory mechanisms fail Aggressive interventions to prevent multiple organ dysfunction syndrome Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Progressive Stage of Shock Fig. 67-7 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Progressive Stage Hallmarks of ↓ cellular perfusion and altered capillary permeability: Leakage of protein into interstitial space ↑ Systemic interstitial edema Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Progressive Stage Anasarca Fluid leakage affects solid organs and peripheral tissues ↓ Blood flow to pulmonary capillaries Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Progressive Stage Movement of fluid from pulmonary vasculature to interstitium Pulmonary edema Bronchoconstriction ↓ Residual capacity Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Progressive Stage Fluid moves into alveoli Edema Decreased surfactant Worsening V/Q mismatch Tachypnea Crackles Increased work of breathing Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Progressive Stage CO begins to fall Decreased peripheral perfusion Hypotension Weak peripheral pulses Ischemia of distal extremities Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Progressive Stage Myocardial dysfunction results in Dysrhythmias Ischemia Myocardial infarction End result: Complete deterioration of cardiovascular system Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Progressive Stage Mucosal barrier of GI system becomes ischemic Ulcers Bleeding Risk of translocation of bacteria Decreased ability to absorb nutrients Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Progressive Stage Liver fails to metabolize drugs and wastes Jaundice Elevated enzymes Loss of immune function Risk for DIC and significant bleeding Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Progressive Stage Acute tubular necrosis/acute renal failure Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Refractory Stage Exacerbation of anaerobic metabolism Accumulation of lactic acid ↑ Capillary permeability Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Refractory Stage of Shock Fig. 67-8 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Refractory Stage Profound hypotension and hypoxemia Tachycardia worsens Decreased coronary blood flow Cerebral ischemia Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stages of Shock Refractory Stage Failure of one organ system affects others Recovery unlikely Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies Thorough history and physical examination No single study to determine shock Blood studies Elevation of lactate Base deficit 12-lead ECG Chest x-ray Hemodynamic monitoring Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Tests cont. Blood Type and cross BAL- 20-50% of trauma have alcohol involved Urine drug screen CBC Electrolytes Bun, Creat, specific gravity Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Successful management includes Identification of patients at risk for shock Integration of the patient’s history, physical examination, and clinical findings to establish a diagnosis Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Successful management includes Interventions to control or eliminate the cause of the decreased perfusion Protection of target and distal organs from dysfunction Provision of multisystem supportive care Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care General management strategies Ensure patent airway Maximize oxygen delivery Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Cornerstone of therapy for septic, hypovolemic, and anaphylactic shock = volume expansion Isotonic crystalloids (e.g., normal saline) for initial resuscitation of shock Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. QuickTime™ and a YUV420 codec decompressor are needed to see this picture. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Volume expansion If the patient does not respond to 2 to 3 L of crystalloids, blood administration and central venous monitoring may be instituted Complications of fluid resuscitation Hypothermia Coagulopathy Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Primary goal of drug therapy = correction of decreased tissue perfusion Vasopressor drugs (e.g., epinephrine) Achieve/maintain MAP >60 to 65 mm Hg Reserved for patients unresponsive to other therapies Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Primary goal of drug therapy = correction of decreased tissue perfusion Vasodilator therapy (e.g., nitroglycerin [cardiogenic shock], nitroprusside [noncardiogenic shock]) Achieve/maintain MAP >60 to 65 mm Hg Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Nutrition is vital to decreasing morbidity from shock Initiate enteral nutrition within the first 24 hours Initiate parenteral nutrition if enteral feedings contraindicated or fail to meet at least 80% of the caloric requirements Monitor protein, nitrogen balance, BUN, glucose, electrolytes Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Cardiogenic Shock Restore blood flow to the myocardium by restoring the balance between O2 supply and demand Thrombolytic therapy Angioplasty with stenting Emergency revascularization Valve replacement Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Cardiogenic Shock Hemodynamic monitoring Drug therapy (e.g., diuretics to reduce preload) Circulatory assist devices (e.g., intraaortic balloon pump, ventricular assist device) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Hypovolemic Shock Management focuses on stopping the loss of fluid and restoring the circulating volume Fluid replacement is calculated using a 3:1 rule (3 ml of isotonic crystalloid for every 1 ml of estimated blood loss) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Septic Shock Fluid replacement (e.g., 6 to 10 L of isotonic crystalloids and 2 to 4 L of colloids) to restore perfusion Hemodynamic monitoring Vasopressor drug therapy; vasopressin for patients refractory to vasopressor therapy Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Septic Shock Intravenous corticosteroids for patients who require vasopressor therapy, despite fluid resuscitation, to maintain adequate BP Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Septic Shock Antibiotics after obtaining cultures (e.g., blood, wound exudate, urine, stool, sputum) Drotrecogin alfa (Xigris) Major side effect: Bleeding Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Septic Shock Glucose levels <150 mg/dl Stress ulcer prophylaxis with histamine (H2)-receptor blockers Deep vein thrombosis prophylaxis with low-dose unfractionated heparin or low-molecular-weight heparin Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Neurogenic Shock In spinal cord injury: Spinal stability Treatment of the hypotension and bradycardia with vasopressors and atropine Fluids used cautiously as hypotension is generally not related to fluid loss Monitor for hypothermia Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Anaphylactic Shock Epinephrine, diphenhydramine Maintaining a patent airway Nebulized bronchodilators Endotracheal intubation or cricothyroidotomy may be necessary Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Anaphylactic Shock Aggressive fluid replacement Intravenous corticosteroids if significant hypotension persists after 1 to 2 hours of aggressive therapy Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment ABCs: Airway, breathing, and circulation Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment Focused assessment of tissue perfusion Vital signs Peripheral pulses Level of consciousness Capillary refill Skin (e.g., temperature, color, moisture) Urine output Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment Brief history Events leading to shock Onset and duration of symptoms Details of care received before hospitalization Allergies Vaccinations Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Diagnoses Ineffective tissue perfusion: Renal, cerebral, cardiopulmonary, gastrointestinal, hepatic, and peripheral Fear Potential complication: Organ ischemia/dysfunction Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Planning Goals for patient Assurance of adequate tissue perfusion Restoration of normal or baseline BP Return/recovery of organ function Avoidance of complications from prolonged states of hypoperfusion Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Health Promotion Identify patients at risk (e.g., elderly patients, those with debilitating illnesses or who are immunocompromised, surgical or accidental trauma patients) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Health Promotion Planning to prevent shock (e.g., monitoring fluid balance to prevent hypovolemic shock, maintenance of handwashing to prevent spread of infection) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Acute Interventions Monitor the patient’s ongoing physical and emotional status to detect subtle changes in the patient’s condition Plan and implement nursing interventions and therapy Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Acute Interventions Evaluate the patient’s response to therapy Provide emotional support to the patient and family Collaborate with other members of the health team when warranted Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Neurologic status: Orientation and level of consciousness Cardiac status Continuous ECG VS, capillary refill Hemodynamic parameters: central venous pressure, PA pressures, CO, PAWP Heart sounds: Murmurs, S3, S4 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Respiratory status Respiratory rate and rhythm Breath sounds Continuous pulse oximetry Arterial blood gases Most patients will be intubated and mechanically ventilated Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Urine output Tympanic or pulmonary arterial temperature Skin: Temperature, pallor, flushing, cyanosis, diaphoresis, piloerection Bowel sounds Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Nasogastric drainage/stools for occult blood I&O, fluid and electrolyte balance Oral care/hygiene based on O2 requirements Passive/active range of motion Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Assess level of anxiety and fear Medication PRN Talk to patient Visit from clergy Family involvement Comfort measures Privacy Call light within reach Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Evaluation Normal or baseline, ECG, BP, CVP, and PAWP Normal temperature Warm, dry skin Urinary output >0.5 ml/kg/hr Normal RR and SaO2 ≥90% Verbalization of fears, anxiety Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.