Caring for Clients Experiencing Shock NR 240 Definition of shock A disorder characterized by hypoperfusion coupled with hypooxygenation Leads to anaerobic metabolism, ischemia and cell death.
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Caring for Clients Experiencing Shock NR 240 1 Definition of shock A disorder characterized by hypoperfusion coupled with hypooxygenation Leads to anaerobic metabolism, ischemia and cell death if uninterrupted also called multiple organ dysfunction syndrome Can be classified according to site of origin or functional impairment 2 Classifications of shock: functional impairment vs site of origin 3 Etiology of shock 4 Stages of shock 5 Pathophysiology of shock overview Capillary leaking Volume depletion Decreased vascular tone Anaerobic metabolism Acidosis Hyperkalemia Toxic metabolites Causing endothelial damage & tissue death Pump failure Renin Angiotensin Aldosterone released oliguria MODS 6 Complications of shock MODS (multiple organ dysfunction syndrome) Anoxic encephalopathy ARDS Myocardial pump failure myocardial depressants known as MDF which are released from the pancreas Acute tubular necrosis result of decreased renal perfusion platelet consumption DIC Rhabdomyolysis Profound sepsis from decreased macrophage effectiveness Paralytic ileus skeletal muscle breakdown from decreased peristalsis Liver failure 7 Clinical manifestations of shock Cardiovascular Manifestations ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Decreased cardiac output Increased pulse rate Thready pulse Decreased blood pressure Narrowed pulse pressure Postural hypotension Low central venous pressure Flat neck and hand veins in dependent positions Slow capillary refill in nail beds Diminished peripheral pulses ▪ ▪ ▪ ▪ ▪ Increased respiratory rate Shallow depth of respirations Decreased Paco2 Decreased arterial Pao2 Cyanosis, especially around lips and nail beds Respiratory Manifestations 8 Clinical manifestations of shock Neuromuscular Manifestations ▪ Early Anxiety Restlessness Increased thirst ▪ Late Decreased central nervous system activity (lethargy to coma) Generalized muscle weakness Diminished or absent deep tendon reflexes Sluggish pupillary response to light Renal Manifestations ▪ Decreased urine output ▪ Increased specific gravity ▪ Sugar and acetone present in urine 9 Clinical manifestations of shock Integumentary Manifestations ▪ ▪ ▪ ▪ Cool to cold Pale to mottled to cyanotic Moist, clammy Mouth dry; paste like coating present Gastrointestinal Manifestations ▪ ▪ ▪ ▪ Decreased motility Diminished or absent bowel sounds Nausea and vomiting Constipation 10 Lab diagnostics for hypovolemic shock 11 Hemodynamic patterns in shock 12 13 BEST PRACTICE for The Client in Hypovolemic Shock Ensure a patent airway. Start an IV catheter or maintain an established catheter. Administer oxygen. Elevate the client's feet, keeping his or her head flat or elevated to a 30-degree angle. Examine the client for overt bleeding. If overt bleeding is present, apply direct pressure to the site. Administer medications as prescribed. Increase the rate of IV fluid delivery. Do not leave the client. 14 INTERVENTION ACTIVITIES for The Client with Hypovolemic Shock Shock Management: Volume: Promotion of adequate tissue perfusion for a client with severely compromised intravascular volume Monitor for signs and symptoms of persistent bleeding (e.g., check all secretions for frank or occult blood). Monitor the client closely for hemorrhage. Prevent blood volume loss (e.g., apply pressure to site of bleeding). Administer IV fluids, as appropriate. Note hemoglobin/hematocrit level before and after blood loss, as indicated. Administer blood products (e.g., platelets or fresh frozen plasma), as appropriate. Monitor coagulation studies, including prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, fibrin degradation/split products, and platelet counts, as appropriate. 15 Drug therapy in Hypovolemic shock IV agents to do replace appropriate volume and blood product replacement. They are used as a supportive intervention until volume depletion is corrected 16 Management of Cardiogenic chock Cardiogenic shock guidelines 17 Cardiogenic Pump failure results in inadequate tissue perfusion DECREASE IN CARDIAC OUTPUT CAUSES A DECREASE IN MEAN ARTERIAL PRESSURE Seen in: MI Exacerbation of CHF restrictive pericarditis tamponade dysrhythmia Valvular disease 18 Management of cardiogenic shock Reversal of underlying cause Arrhythmia, structural anomaly, acute coronary syndrome Supportive care Airway management Hemodynamic monitoring Vasoactive agents 19 Drug therapy in Shock 20 Caring for clients with Distributive shock Septic Neurogenic anaphylactic 21 Management of septic shock Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. 22 Pathophysiology of septic shock 23 Assessment findings in Septic shock 24 BEST PRACTICE for The Client in Sepsis-Induced Distributive Shock ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Ensure a patent airway. Start or maintain an established IV catheter. Administer oxygen. Administer antibiotics. Obtain specimens of blood, urine, wound drainage, and sputum for culture. Increase the rate of IV fluid delivery. Use aseptic technique for any invasive procedure. Handle the client gently. Examine the client for overt bleeding, especially of gums, injection sites, and IV sites. Elevate the client's feet, keeping his or her head flat or elevated to a 30-degree angle. Take the client's vital signs every 5 minutes until they are stable. Administer medications as prescribed: Heparin during phase 1 Clotting factors, platelets, and plasma during phase 2 25 Management of neurogenic shock 26 NEUROGENIC SHOCK PARASYMPATHETIC NS OVERSTIMULATION SYMPATHETIC NS UNDERSTIMULATION SUSTAINED VASODILATION RESULTS IN DECREASED SYSTEMIC VASCULAR RESISTANCE HYPOTENSION BRADYCARDIA MENTAL STATUS CHANGES Associated with Spinal cord injury 27 Management of Neurogenic shock Follow shock management protocols Maintain spinal immobilization Administer vasopressors 28 Management of anaphylaxis 29 Anaphylaxis care Ensure airway Administer epinephrine Establish IV access Provide supportive care as required Intubation Vasopressors Corticosteroids H2 antagonists 30 Drug therapy in Shock 31 Can you name which shock is most likely responsible? Diffuse edema to extremities, skin reddened with wheals noted, just started on new antibiotic Acute mental status change, decreased heart rate, skin cool and dry s/p radiation and chemotherapy with neutropenia refractory to Neupogen. rectal temp 96.5 BP 100/60 HR 133 PMH of MI X 4, IDDM, CHF with Harsh systolic murmur at 2nd intercostal space at the right sternal border S/P exploratory laparotomy POD#1 with a history of COPD on PO steroids X 10 years whose skin is pale and cool. Client c/o fatigue and unable to participate in ADLs 32 ADDITIONAL DIAGNOSES/COLLABORATIVE PROBLEMS PC:MODS PC: ARDS PC:DIC PC;PARALTYIC ILEUS PC: HEPATIC FAILURE PC:SEPSIS PC:RHABDOMYOLYSIS RISK FOR INJURY PAIN ANXIETY VS FEAR PC: NEGATIVE NITROGEN BALANCE INTERRUPTED FAMILY PROCESSES RISK FOR IMPAIRED VERBAL COMMUNICATION ACTIVITY INTOLERANCE VS FATIGUE INADEQUATE TISSUE PERFUSION:PERIPHERAL RISK FOR IMPAIRED SKIN INTEGRITY 33 Monitor/Prevent potential complications of shock Remember risk for MODS, ARDS, DIC, Rhabdomyolysis, ATN, anoxia, sepsis, ileus, liver failure, ulcers identified as potential complications Develop assessment/monitoring strategies that are broad-sweeping and repeated frequently until stable Mon vital signs (VS), cardiac monitoring (CM) pulse oximetry, I/O, peripheral pulses, neurochecks Mon CMP, CK, CBC,PT/PTT and bleeding times, type and cross, total protein, albumin, LFTs Insert NG tube to prevent ileus Administer anti-ulcer therapy and antibiotic 34 prophylaxis Shock Summary Disorder of impaired tissue perfusion secondary to decreased circulating volumes caused by cardiac, neurogenic, inflammatory, obstructive and infectious etiologies Manifests with AMS, agitation, thirst, Increased HR (except neurogenic shock) and normal to slightly lower BP in initial phase Can progress to irreversible refractory phase Treatment focuses on ABC’s, reversal of underlying cause, and prevention of complications Evaluation of outcomes focus on tissue perfusion and oxygenation, cardiac pump effectiveness, fluid/electrolyte balance and avoidance of systemic complications such as MODS, ARDS, DIC, ATN, Rhabdomyolysis, sepsis, ileus, liver failure and 35 ulcers