Shock, SIRS, MODS, & DIC

NUR 433; Adult Health II; Mrs. Cooper; MCUSON

what is decreased tissue perfusion and impaired cellular metabolism

shock

shock is an imbalance between supply of and demand for _____ and nutrients

O2

how many classifications of shock are there

4

what are the 4 classifications of shock

1. cardiogenic

2. hypovolemic

3. distributive

4. obstructive

what are the two subcategories of hypovolemic shock

• absolute

• relative

what are the three subcategories of distributive shock

• neurogenic

• anaphylactic

• septic

cardiogenic shock is when the heart is failing as the _____

pump

cardiogenic shock is when the heart cannot move enough _____ forward to maintain adequate cardiac output and tissue perfusion

blood

_____ _____ is the heart’s inability to pump the blood forward

systolic dysfunction

the most common cause of systolic/diastolic dysfunction is _____

MI (myocardial infarction)

decreased filling of the heart will result in _____ stroke volume

decreased

cardiogenic shock results in low cardiac _____ and cardiac _____

output; index

list 6 common causes of cardiogenic shock

• myocardial infarction (MI)

• cardiomyopathy

• blunt cardiac injury

• severe systemic or pulmonary hypertension

• cardiac tamponade

• myocardial depression from metabolic problems

***cardiogenic shock is a result from impaired heart function

cardiogenic shock results in _____ stroke volume

decreased

cardiogenic shock results in _____ cardiac output

decreased

cardiogenic shock results in _____ oxygen delivery

decreased

cardiogenic shock results in _____ tissue perfusion

decreased

***cardiogenic shock is also a result of impaired cellular metabolism

in cardiogenic shock, with poor left-sided function, pressure can also back up into the lungs causing pulmonary _____

congestion

list some s/s of cardiogenic shock

• tachycardia

• hypotension

• narrow pulse pressure

• increased SVR

• tachypnea

• pulmonary congestion

• pallor

• cool, clammy skin

• delayed capillary refill

• anxiety

• confusion

• agitation

• increased PAWP

• decreased renal perfusion

• decreased urine output

the goal of cardiogenic shock is to improve cardiac _____ while decreasing cardiac _____ and restoring myocardial _____ supply

output; workload; oxygen

list some nursing interventions for a patient experiencing cardiogenic shock

·         Support airway and oxygenation

·         Hemodynamic monitoring

·         Nitrates

·         Diuretics to reduce preload

·         Vasodilators to reduce afterload

·         β-blockers as prescribed

·         Angioplasty/stenting

·         Emergency revascularization

·         Valve replacement when indicated

·         Circulatory assist devices:

list 3 circulatory assist devices to help treat cardiogenic shock

• IABP

• VAD

• Heart transplantation

_____ _____ occurs when there is not enough circulating intravascular volume to adequately fill the heart

hypovolemic shock

_____ _____ is loss of intravascular fluid volume

absolute hypovolemia

what are some common causes of absolute hypovolemia

o   Hemorrhage

o   GI loss (e.g., vomiting, diarrhea)

o   Fistula drainage

o   Diabetes insipidus

o   Diuresis

_____ _____ results when fluid volume moves out of the vascular space into extravascular space (e.g., intracavitary space) and third spacing

relative hypovolemia

***hypovolemic shock results from decreased circulating volume

in hypovolemic shock, venous return is _____

decreased

in hypovolemic shock, preload is _____

decreased

in hypovolemic shock, stroke volume is _____

decreased

in hypovolemic shock, cardiac output is _____

decreased

in hypovolemic shock, oxygen delivery is _____

decreased

in hypovolemic shock, tissue perfusion is _____

decreased

a patient experiencing hypovolemic shock may compensate for about _____ volume loss

15%

a patient experiencing hypovolemic shock with a volume loss of approximately ___-___% triggers a stronger sympathetic response

15%-30%

list some s/s of hypovolemic shock

·         Anxiety

·         Tachypnea

·         Tachycardia

·         Increased respiratory rate and depth

·         decreased stroke volume

·         decreased CVP

·         decreased PAWP

·         decreased urine output

***With worsening shock, hypotension and poor peripheral perfusion will be evident

list the two major goals for hypovolemic shock

1. stop the loss

2. replace the volume

list some nursing interventions for hypovolemic shock

·         Control the source of fluid/blood loss

·         Establish IV access

·         Isotonic crystalloid replacement

·         Blood replacement when blood loss is significant

·         Monitor response:

o    VS

o    Capillary refill

o    Mental status

o    Skin temperature

o    Urine output

what kind of shock occurs when the patient loses sympathetic nervous system tone

neurogenic shock

in neurogenic shock, without normal _____, the blood vessels dilate and blood pools in the peripheral circulation

vasoconstriction

what are the two common causes of neurogenic shock

• spinal cord injury, especially T5 or above

• spinal anesthesia

in neurogenic shock, there is a loss of _____ tone

sympathetic

in neurogenic shock, massive _____ occurs

vasodilation

in neurogenic shock, _____ pools

in neurogenic shock, there is _____ venous return

decreased

in neurogenic shock, there is _____ stroke volume

decreased

in neurogenic shock, there is _____ cardiac output

decreased

in neurogenic shock, there is _____ tissue perfusion

decreased

in neurogenic shock, parasympathetic influence can also result in _____

bradycardia

list some s/s of neurogenic shock

• hypotension

• bradycardia

• inability to regulate body temperature (resulting in heat loss)

• dry skin

• poikilothermia

what term means taking on temperature of the environment that occurs in neurogenic shock

poikilothermia

what is a nursing intervention for neurogenic shock resulting form a spinal cord injury

spinal stability

what is a nursing intervention for hypotension and bradycardia resulting from neurogenic shock

• vasopressors

• atropine

fluids are infused _____ as hypotension generally is not related to fluid loss

cautiously

monitor for _____ caused by hypothalamic dysfunction in neurogenic shock

hypothermia

what kind of shock occurs in acute, life-threatening hypersensitivity (allergic) reaction

anaphylactic shock

massive _____ occurs in anaphylactic shock

vasodilation

there is a release of _____ mediators in anaphylactic shock

vasoactive

there is an increase in _____ permeability in anaphylactic shock

capillary

there is a potential _____ compromise in anaphylactic shock

airway

what is a common cause of anaphylactic shock

a severe hypersensitivity/allergic reaction to an allergen

in anaphylactic shock _____ leaves vascular space

fluid

in anaphylactic shock, there is a _____ in circulating volume/perfusion

decrease

***in anaphylactic shock, laryngeal edema and bronchospasm leads to airway/oxygenation compromise

list some s/s of anaphylactic shock

·         Anxiety

·         Confusion/dizziness

·         Sense of impending doom

·         Swelling of lips/tongue

·         Angioedema

·         Wheezing

·         Stridor

·         Flushing

·         Pruritus

·         Urticaria

·         Respiratory distress

·         Circulatory failure

what is the first nursing intervention for anaphylactic shock

epinephrine and airway!!!

list some next nursing interventions for anaphylactic shock

o   Maintain patent airway

o   Nebulized bronchodilators

o   Diphenhydramine

o   Histamine receptor blockers

o   Aggressive crystalloid fluid resuscitation

o   Corticosteroids when indicated

o   Endotracheal intubation or emergency airway may be required

what kind of shock occurs when there is a physical obstruction to blood flow

obstructive shock

in obstructive shock, the heart may be capable of pumping, but _____ cannot adequately enter or leave the heart

blood

list some common causes of obstructive shock

• develops when physical obstruction to blood flow occurs with decreased CO

• abdominal compartment syndrome - abdominal pressure compresses inferior vena cava

• other mechanical causes that restrict filling or outflow

***obstructive shock occurs when there is a physical obstruction

in obstruction shock, there is a _____ venous return and/or outflow

decreased

in obstruction shock, there is a _____ stroke volume

decreased

in obstructive shock, there is a _____ cardiac output

decreased

in obstructive shock, there is a _____ cellular oxygen supply

decreased

in obstructive shock, there is a _____ tissue perfusion

decreased

in obstructive shock, there is impaired cellular _____

metabolism

list some s/s of obstructive shock

o   Decreased CO

o   Increased afterload

o   Variable left ventricular filling pressure

o   Hypotension/poor perfusion as the obstruction worsens

o   Finding related to the specific source of obstruction

list some nursing interventions from obstructive shock

·         Rapid assessment and immediate treatment are important

·         The priority is not simply raising the BP

o   Primary strategy is early recognition and treatment to relieve obstruction

§  Mechanical decompression

§  Thrombolytic therapy

§  Radiation, debulking, or removal of mass

§  Decompressive laparotomy

what shock occurs when an infection produces a systemic inflammatory response that causes abnormal circulation and inadequate tissue perfusion

septic shock

what is the common cause of septic shock

documented or suspected infection

list the 3 major effects of septic shock

1. vasodilation

2. maldistribution of blood flow

3. myocardial dysfunction

• decreased ejection fraction

• ventricular dilation

with septic shock, there is inflammation and _____ coagulation

increased

with septic shock, there is _____ fibrinolysis

decreased

***with septic shock, microthrombi occurs

***with septic shock, there is an obstruction of microcirculation

with septic shock, there is _____ tissue oxygenation/perfusion

decreased

with septic shock, early septic shock may show:

_____ cardiac output

_____ SVR

_____/_____ skin may occur

increased

decreased

warm/flushed

list some additional findings of septic shock

·         Early septic shock may show:

o   ↑ cardiac output

o   ↓ SVR

o   Warm/flushed skin may occur

·         Additional findings:

o   ↓ urine output

o   Tachypnea/hyperventilation

o   Respiratory alkalosis early

o   Altered neurologic status

o   GI dysfunction

o   GI bleeding

o   Paralytic ileus

o   Progressive respiratory failure

list some nursing interventions for septic shock

INFECTION + PERFUSION + ORGAN SUPPORT

·         Obtain cultures

·         Begin broad-spectrum antibiotics

·         Fluid replacement with isotonic crystalloids

·         Hemodynamic monitoring

·         Vasopressors if BP remains inadequate

·         Vasopressin may be used

·         Corticosteroids may be considered when BP cannot be maintained despite fluids and vasopressors

·         Maintain glucose control

·         Stress-ulcer prophylaxis

·         VTE prophylaxis

list the 4 overlapping stages of shock

1. initial

2. compensatory

3. progressive

4. refractory