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Classification of Shock:
1. Hypovolemic Shock
_____________ form of shock
Results from loss of circulating blood volume in the intravascular bed
Decrease circulating oxygenated blood flow to the body
Lead to inadequate tissue perfusion causes cellular hypoxia, organ failure and
death
Causes:
Hemorrhage – most common
Vomiting and diarrhea
GI bleeding
Trauma/surgery
DIC – adnormal unrelated clotting in the bloodstream throughout
the body
Thrombocytopenia
Hemophilia – bleeding disorder resulting from deficiency in
speficic coagulation proteins, f8 ( A/classic hemophilia), f9 (
B/xmas dse), x-linked recessive, male affected, female carrier
Renal losses
DM – hyperglycemic osmotic diuresis
DI
Pathophysiology:
↓ circulating blood volume - ↓ venous return to the right side of the heart
↓ cardiac filling - ↓pressure and volume
↓ preload – filling volume of the ventricle
↓ stroke volume – volume of blood that is ejected during systole
____________________ – hypotension, ↓ oxygenated blood flow to organs and
inadequate tissue perfusion
Anaerobic metabolism to produce ATP for energy – accumulation of lactic acid →
metabolic acidosis
Respiratory system compensates – increase RR to blow off CO2 and raise blood pH →
_____________________
ANS stimulation: SNS – adrenal organs (medulla)to release E and NE
Increase heart rate
Increase heart contractility to attempt to increase CO
Vasoconstriction to maintain BP for the blood flow to vital organs specially brain
and heart
Increase RR
Kidneys: Renin (angitensinogenase - RAS) – ____________________ converted in the
lungs stimulates adrenal organs (cortex) to produce aldosterone promotes renal
reabsorption of Na and water
Hypothalamus: ADH/vasopressin renal reabsoprtion of water – decrease urinary output
Compensatory mechanism fails → hypoxia and decrease tissue perfusion to organs
heart and brain → confused, restless, uncooperative/combative and condition
deteriorates, organ ischemia leading to comatose and death
Clinical Manifestations:
1. Weight loss
2. ____________________ BP / orthostatic / postural hypotension
3. Narrowed pulse pressure
4. ↑RR, PR – rapid, weak, thready pulses – weak and absent pulses
5. Hypoxia
6. Dry/ sticky mucosa
7. ↓ UO – 10 ml/hr
8. Thirst
9. Pale and cool skin
10. Delayed capillary refill
11. Changes in LOC – confusion, restless and anxiousness
12. Cardiac dysrhythmias
13. Diagnostic findings
Increased Urine Specific Gravity
Urine tests that measures the ability to concentrate urine
Normal value _________________
Increased: more concentrated urine, insufficient fluid intake, decreased renal
perfusion or increased ADH
Decreased: less concentrated urine, increased fluid intake, DI
Increased hematocrit (HCT)
Blood test used to measure the percentage of whole blood made up of RBC
Increased: DHN, Hypoxia
Decreased: Overhydration, Anemia
Increased serum osmolality (hyponatremia, fluid and electrolyte balance
measurement) ______________________________
Increased BUN
Serum test measures nitrogeneous urea: byproduct metabolism of CHON in
liver
Renal clearance of N.U. waste products
Not always an indication of renal disease
DHN, poor renal perfusion, high CHON intake, infection, stress,
corticosteroid use
N:10-20 mg/dl
Increased Creatinine
Serum tests measures amount of creatinine: end product of CHON and
muscle metabolism
Reflects glomerular filtration rate
Increase means renal disease: 50% renal function is lost
N:0.5-1.5 mg/dl
14. Hemodynamics results
Hemodynamic values for Hypovolemic Shock
Decreased CVP
= CVP: pressure which blood is return in SVC and RA
= Transducer: 0 point at the level of right atrium
= client must be supine: HOB at 45 degrees
=relaxed: coughing/straining will increase intrathoracic pressure: False high
= normal 3-8 mmHg
= increased: excessive fluid
=decreased: decrease circulating blood
Decreased PAP (10-20 mmHg)
Decreased PAWP (6-12mmHg)
Decreased Cardiac Output (4-6 L/min)
= pulmonary artery catheter ports
= inserted in radial/brachial/femoral artery then measured by transducer
Management:
Goal – ________________________________________
Oral fluids
Monitor patient intake and output
Weigh patient daily
Massive fluid resuscitation
Two large bore IC catheters
Rapid infusion device
Plasma CHON infusion: albumin
Crystalloids
- ________________ bolus initially
- Evaluate if more than _________ can cause edema
- PNSS
- Avoid dextran - ↓platelet adhesiveness
Monitor urinary output
Monitor vital signs
Blood Transfusion: ___________________, Hbg of 7-8 g/dl, Hct 21 – 24%
Fresh frozen plasma, platelets, packed RBC
Administer vasopressors as ordered to maintain BP and increase cardiac contractility
Dopamine _____________ and Norepinephrine _______________
Monitor ABG results - Oxygen therapy to ensure tissue perfusion
100% oxygen : __________________________
Position the patient:
mild – HOB elevated 30-60 to maintain pulmonary ventilation
severe – supine/flat/ legs elevated not higher than a pillow
avoid t-burg position – mediastinal pressure of abdominal contents against
diaphragm leading to decrease pulmonary compliance
Compensatory Stage
- Fluid loss of __________ / 750-1500ml
- SNS stimulation: release of epinephrine/norepinephrine
- Normal to decrease blood pressure, narrowed pulse pressure,
tachycardia, tachypnea (respiratory alkalosis), hypoxia, decrease U.O.,
thirst, pale and cool skin, delayed capillary refill, changes in LOC
(confusion, restlessness, anxiousness)
Progressive Stage
- Fluid loss of _______________ / 1500 – 2000ml
- Increase CR, cardiac dysrhythmias (irregular heart beat) lead to
myocardial ischemia (lack of blood flow to the heart), hemodynamics
decrease, Systemic Vascular Resistance increase due to peripheral
vasoconstriction (SVR- blood flow, viscosity and lining of the blood
vessel), lead to decrease capillary blood flow to tissues leading to
increase capillary hydrostatic pressure lead to third space fluid shifting-
edema (pulmonary) hypoxemia respiratory/metabolic acidosis,
hypotensive, narrowed pulse pressure, kidneys decrease function –
oliguria, BUN and creatinine increase, LOC deterioration – decrease
cerebral perfusion, lethargic, confused, comatose, Multi-organ
dysfunction syndrome (MODS)
Refractory or Irreversible Stage
- Fluid loss greater than __________ / > 2000ml
- Organ failure, imminent death
- Bradycardia, CP arrest
2. Cardiogenic Shock
Failure of the heart to pump adequately
Results from decrease cardiac output and compromising tissue perfusion
40% of the left ventricle necrosis: occlusion of major coronary vessels
Decreased blood flow to coronary arteries leading to cardiac hypoxia
Causes:
- Most common: dysrhythmias: Heart attack/Myocardial infarction
- CHF
- cardiac tamponade
accumulation of fluid in the pericardium
pericarditis
pericardial effusion
restrict ventricular filling – decrease cardiac output
muffled heart sounds
pericardiocentesis
Assessment:
Hypotension: ___________________________- lower than the client’s
baseline
U.O. < 30 ml/hr
Cold clammy skin
Poor peripheral pulses : weak and thready
Tachycardia
Tachypnea
Pulmonary congestion: blood backs up the pulmonary system, fluid leaks
out the pulmonary capillaries into lung tissue and alveoli causes
pulmonary edema: Crackles
Altered LOC: disorientation, restlessness and confusion
Chest discomfort: pain and tightness
Changes in ECG: ST depression, T inversion, ST elevation, PVC
Decrease capillary refill
Interventions:
Adm _____________________
- Opioid analgesics: suppress pain but can suppress respiration and
coughing reflex
- decrease pulmonary congestion and relieve pain
- avoid for gall bladder surgery: spasm of sphincter of the oddi: mascular
valve that controls flow of digestive juices (bile and pancreatic juices
- Avoid for respiratory disorders, head injuries, increased ICP, seizures
Adm O2 as prescribed
Prepare for intubation and mechanical ventilation
Administer vasopressors and positive inotropics to maintain organ
perfusion
Vasopressors: Dopamine (Intropin) and Norepinephrine (Levophed)
Positive Inotropics: Dobutamine, Digoxin (cardiac glycoside): stimulate
myocardial contractility – increase cardiac output – improve blood flow to
kidneys and peripherys – increase organ perfusion
Monitor apical pulse: 60 b/m withheld the medication
Monitor K level: causes hypokalemia: Toxicity: therapeutic digoxin range:
0.5-2 ng/ml
Nitroglycerin: dilate coronary artery to decrease angina pain
Na nitroprusside (Nipride): ________________________________
Preload: filling volume of the ventricle at the end of the diastole
Afterload: amount of resistance against which the left ventricle pumps:
influenced by blood viscosity, flow patterns: Increase resistance more
myocardium has to work to overcome the resistance. Determine by the
blood pressure.
Monitor arterial blood gas level and prepare to treat imbalances
Monitor urinary output
Prepare client for insertion of Intraaortic Balloon Pump: improve coronary
artery perfusion and improve cardiac output
Diastole: Inflate to increase blood flow to the coronary arteries to increase
Oxygen delivery to heart muscle
Systole: deflate to reduce afterload to decrease the workload of the heart
Assist insertion of pulmonary artery catherter (Swan-Ganz) to assess
degree of heart failure
Monitor distal pulses and CVP
Assessment:
o Flaccid paralysis
o Loss of reflex activity below the level of the lesion
o Bradycardia
o Hypotension
o Decreased cardiac output
o Decreased hemodynamics
o Hypothermic
o Paralytic ileus
Interventions:
Monitor signs of shock following an injury
Assess for reflex activity and bowel sounds
Administer IV fluids for volume replacement
Administer ____________as ordered to control the BP to promote tissue
perfusion and manage cardiovascular instability
Administer ____________________________________________ that will
increase the patient’s heart rate to improve tissue perfusion
Provide rewarming measures such as covering patient with warm blankets
Place the patient on continues pulse oximeter for respiratory assessment
___________________ the airway, if necessary
Pulse Oximetry
= non-invasive that registers oxygen saturation of the client’s hemoglobin
= Sa02= 95 to 100%
= sensor place on finger, toe, earlobe
= maintain transducer at heart level
= do not select extremity with an impending blood flow
= < 91% necessitates immediate treatment
= < 85% oxygenation to body tissues is compromised
= < 70% life threatening: Endotracheal tube to maintain patent airway
Septic/Toxic Shock
____________________ present in the blood
Results from severe infection commonly caused by gram-negative
organism
Endotoxins release in the bloodstream causes massive vaodilation
Hemophilus, escherechia, pseudomonas, klebsiella, neisseria
Risk: very young children, older adults, immunocompromised individuals,
chronically ill patients, patients with malignancies
Interventions:
Maintaning patent airway – respiratory failure – intubation
Initial intervention oxygen delivery 5-6L/min
SF – lung expansion
Pulse oximetry and ABG monitoring
Administartion of IV fluids as prescribed
Monitor V/S
Monitor hemodynamics status
Administer inotropic agents/ vasoactive agents
Monitor UO for adequacy of renal perfusion
Adm antipyretic as prescribed
Obtain cultures
Administer appropriate antibiotic therapy
Anaphylactic Shock
Results from _________________________
Systemic serious and immediate hypersensitivity reaction
Mediated release of histamine, bradykinin, leukotrienes, prostaglandin
Deposition in vessels and tissue walls – inflammation of affected organ
Immune mediated: anaphylactic, Chemically mediated – anaphylactoid
Causes:
Antigen-antibody reaction usually result from allergies
Allergen
Foods, environmental agents (pollens, molds, animal danders)
Medication
Blood products
Venoms
Responses: self – limiting (5-10 minutes) but could be fatal if not promptly treated.
Primary Immune Response: IgE – formation of antibody from allergen, antibody
accumulate and attach themselves in the plasma with large amounts of
histamine/basophils
Secondary Immune Response – rupture of cells – degranulation, release of histamine,
leukotrines, platelet activating factors, prostaglandins - increased capilliary permeability
Assessment:
Hypotension, tachycardia, arrhythmias cardiac arrest
Chest and on the face - Pruritus, erythema, urticaria, redness, warm and swelling
Headache, dizziness, paresthesia
Angioedema – swelling in the face, oral cavity and lower pharynx and larynx
Hoarseness, coughing, narrowed airway, chest tightness/wheezing/stridor, dysnea,
dysphagia bronchoconstriction / pulmonary edema - respiratory arrest
Restless, dizziness, anxious and apprehensive with complaint of sense of impending
doom
Smooth muscle constriction – vomiting, abdominal cramping, urinary incontinence
Decreased hemodynamics
Interventions:
o Establish patent airway
o Remove the client from the causative agent/ source
o 1st step: Hallmark management for anaphylaxis: Prepare for administration of
epinephrine (adrenalin) cardiac stimulation and bronchodilation, inhibits the release of
secondary immune response, SQ .3-.5ml every 5-10 mins or IV 3 ml of via ET tube 3-
5ml.
o 2nd step: ABC - Provide Oxygen
o Consider ET intubation in severe cases with mechanical ventilation
o 3rd Step: Administer antihistamines as prescribed. Diphenhydramine (Benadryl) -
anticholinergic or corticosteroids – anti-inflammation
o Provide measures to control shock
o Provide emotional support