Medsurg Exam 1: Shock

shock

shock

• a life-threatening condition where tissue perfusion is inadequate and cannot deliver oxygen and nutrients for cellular function

• without treatment, poor delivery of oxygen and nutrients to cells leads to cellular hypoxia, cell death, organ dysfunction, and eventually total body shutdown or death

pathophysiology of shock

1. The initial insult that caused the shocked state

2. Decrease in tissue perfusion and the start of decreased oxygenation to tissues

3. Decreases start/spur the activation of the homeostatic response

4. Sympathetic response (fight or flight) is activated to increase cardiac output (including fresh O2 and nutrients to tissues) in order to compensate; to restore tissue perfusion and oxygenation, vitals increase

5. Renin-angiotensin activation hits the kidneys to:

   • Increase reabsorption of sodium and water

   • Increase preload (due to increase fluid)

   • Decrease urinary output

6. Increase in catecholamines and cortisol:

   • Responses to help the glucose in the anaerobic metabolism

risk factors contributing to shock

• being on a disease state

• age

• Volume loss

• Myocardial damage

• Infection

• Allergic reactions

• Trauma to spinal cord

types of shock

• hypovolemic shock

• cardiogenic shock

• distributive shock

  • septic shock

  • anaphylactic shock

  • neurogenic shock

hypovolemic shock

• problem with the “tank”

• Most common type of shock

• Results from some sort of loss from the intravascular volume

  • Can be internal or external fluid loss

  • Loss 15-30% creating hypovolemic shock

• External fluid loss = trauma, vomiting, diarrhea

• Internal = internal bleeding into vasculature, burns (fluid shifted rapidly from intra to extracellular spaces and is displaced), ascites, dehydration

cardiogenic shock

• problem with the “pump”

• Shock state resulting from impairment or failure of the myocardium

• Can be coronary in nature or not coronary

  • Coronary = direct damage to heart

    • Ex. myocardial infarction/heart attack

  • Noncoronary = condition happening somewhere else in the body and is affecting the heart

    • Ex. acidosis, hypoxemia, hypoglycemia, tension pneumothorax, pulmonary embolus

distributive shock

• Problem with “pipes”

• Blood is no longer in the right place and is out of the intravascular space and is in the periphery

  • Relative hypovolemia; related to pipes having problem, not necessarily fluid loss

septic shock

• caused by overwhelming infection

• Causes chemicals to be released, triggering an inflammation response

• After inflamation, whole body dilates and fluid moves into periphery, without any pressure to move it back to the heart

anaphylactic shock

• caused by allergen exposure

• Massive antibody response causing vasodilation

• Treated with epinephrine to reverse vasodilation

• Commonly triggered by food , medication, insect stings, bites

neurogenic shock

• caused by damage to the nervous system

• Spinal cord injury, trauma

• Sympathetic stimulation causes the smooth muscle to constrict while the parasympathetic tries to vasodilate

  • This cross/disruption causes the parasympathetic to take over and vasodilate to loos volume

stages of shock

1. compensatory

2. progressive

3. irreversible

clinical manifestations of the compensatory stage of shock

The body automatically shunts blood AWAY from the nonvital organs in order to get the vital organs perfused

• normal BP

• tachycardia

• tachypnea

• cold clammy skin

• decreased urinary output

clinical manifestations of the progressive state of shock

• hypotension

• MAP <60 mmHg

• tachycardia

• rapid, shallow breathing

• pulmonary edema; fluid accumulation in lungs

  • Petechiae = dark red/purple rash due to hematological function impairment

clinical manifestations of the irreversible stage of shock

While pt. Is still being treated, the damage is not reversible

• Organs have been damaged beyond repair

• BP cannot be maintained

• Oxygenation needs constant ventilatory support

• MAP is not maintained

• MODS = multiple organ dysfunction syndrom; all organs fail

  • Organ damage is too severe to respond to any treatment

• Metabolic acidosis

• Lactic acidosis

• Complete depletion of energy stores

mean arterial blood pressure (MAP)

• MAP is the best indicator of perfusion to vital organs

• Average of arterial pressure during a single cardiac cycle

  • Normal range = 65-110 mmHg

mean arterial blood pressure equation

( 2 x diastolic pressure) + systolic pressure / 3

clinical manifestations of hypovolemic shock

• Anxiety or agitation

• Cool, clammy skin

• Confusion

• Decreased or no urine output

• Generalized weakness

• Pale skin color (pallor)

• Rapid breathing

• Sweating, moist skin

• Unconsciousness (lack of responsiveness)

clinical manifestations of cardiogenic shock

• Angina = chest pain

• Arrhythmias = abnormal heart rhythm

• Fatigue

• Feeling of doom

• EKG changes = electrical changes

• Biochemical markers

  • Increased when damage or death to heart tissue

clinical manifestations of septic shock

• Initial:

  • Hyperthermia

  • Tachycardia

  • Bounding pulse

  • Hypotension

  • Decreased urine output

  • Nausea, vomiting, decreased GI

  • Mental status changes

• Later:

  • BP drop

  • Cool clammy

  • MODS

clinical manifestations of anaphylactic shock

• occur 2-30 minutes after exposure to antigen

• mild:

  • headache

  • lightheadedness

  • nausea, vomiting

  • pruitus

  • flushing

  • dyspnea

  • bronchospasm

  • cardiac arrhythmia

  • hypotension

• severe

  • rapid hypotension

  • decreased consciousness

  • respiratory distress

  • cardiac arrest

associated priorities to treat shock

• Figuring out what is the underlying cause of the shock

• Fluid replacement

• Respiratory support through oxygenation, ventilators, or more aggressive oxygen therapy

• Nutritional support

• Maintaining BP and tissue perfusion in order to check for mean arterial pressure (MAP)

• Pain control

  • Morphine = pain control and vasodilator

usual treatments for shock

• Giving supplemental oxygen

• fluid support

• vasoactive medications

• nutritional support

• positioning

  • modified trendelenberg for hypovolemic shock

nursing considerations for shock

• monitor subtle changes in appearance, outputs, labs, EKG, etc.

• advanced directives

• older adult considerations

medications used to treat hypovolemic shock

• Normal saline (0.9% NS)

• Lactated ringers

• Albumin

• Blood

normal saline and lactated ringers

drug classification

• Crystalloid = small, freely moving molecules able to move between intracellular and intravascular spaces

general indications

• fluid replacement to get volume in but may move into third space due to small molecules

• electrolyte balance

nursing implications

• Over rescesutation

  • Extra fluid may affect other diagnoses’

• Hypothermia

  • High volumes of fluid may be at room temperature but room temperature is still too cold for the body

drug classification

general indications

nursing implications