N3 Exam 1 (copy)

Hypovolemic shock

• Life-threatening condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function

•  Affects all body systems

   May develop rapidly or slowly

Who is most at risk for hypovolemic shock

Any patient with any disease state may be at risk for developing shock

Regardless of the initial cause of shock, certain physiologic responses are common to all types of shock

hypoperfusion of tissues, hypermetabolism, and activation of the inflammatory response

PATHOPHYSIOLOGY OF SHOCK: Vascular responses

 Proinflammatory biochemical mediators

 Anti-inflammatory biochemical mediators

PATHOPHYSIOLOGY OF SHOCK: BP regulation

 Mean arterial BP

 Baroreceptors

 Chemoreceptors

 Renin–angiostien–aldosterone

 Figure 11-2 in the book

P h y s i o l o g y / P a t h o p h y s i o l o g y

1. initial insult leading to shock state

2. decreased tissue perfussion and oxygen

3. activation of homeostatic response

4. decreased sympathetic response, HR, BP, cardiac contractility, which leads to decreased cardiac output;

5. increased respiratory rate to oxygen saturation and delivery

6. increased Renin-angiotensin activation, which leads to increased reabsorption of sodium and water, which leads to increased preload and decreased urine output

7. increased Catecholamines and cortisol to provide increased glucose for metabolism

8. R e s t o r a t i o n of t i s s u e p e r f u s i o n a n d o x y g e n a t i o n

TYPES OF SHOCK

Cardiogenic shock (due to heart problems)

Hypovolemic shock

Anaphylactic shock (caused by allergic reaction)

Septic shock (due to infections)

Neurogenic shock (caused by damage to the

nervous system)

A nurse is planning the care of a client who is being treated for shock.

What statement best describes the pathophysiology of this client's

health problem?

A. Blood is shunted from vital organs to peripheral areas of the body.

B. Cells lack an adequate blood supply and are deprived of oxygen and

nutrients

C. Circulating blood volume is decreased with a resulting change in the

osmotic pressure gradient.

D. Hemorrhage occurs as a result of trauma, depriving vital organs of

adequate perfusion.

B

STAGES OF SHOCK

1. Compensatory stage

2. Progressive stage

3. The irreversible (or refractory) stage

slide 9 figure

COMPENSATORY STAGE OF SHOCK

 BP within normal limits

 Adequate cardiac output

 “Fight-or-flight” response

Clinical manifestations of COMPENSATORY STAGE OF SHOCK

 Clinical manifestations

 Inadequate perfusion

 Increased respirations

 Anxiety

 Confusion

 Table 11-1 In the book

MEDICAL AND NURSING MANAGEMENT OF

THE COMPENSATORY STAGE OF SHOCK

 Treat underlying cause

 Fluid replacement

 Supplementation oxygen, decrease patient anxiety

 Maintain BP and tissue perfusion

 Frequent assessment (subtle changes)

 LOC, I&O, respiratory and heart rate, BP (MAP of 65 mm Hg or less, narrowing or decreased pulse pressure)

 Promote safety (advanced directives)

 Gerontologic considerations, Chart 11-1

PROGRESSIVE STAGE OF SHOCK

BP no longer compensated (patient hypotensive)!!!

 MAP below normal limits

 Decreased mental status

PROGRESSIVE STAGE OF SHOCK Pathophysio

 Heart failure

 Decreased cellular perfusion

 Interstitial edema

 Anaerobic metabolism

 Hyperactive clotting cascade

CLINICAL MANIFESTATIONS OF THEPROGRESSIVE STAGE OF SHOCK

 Rapid and shallow respirations

 Chest pain (increased cardia biomarkers)

 Changes in mental status

 Acute kidney injury (decreased GFR)

 Liver failure

 GI bleeding

 Abnormal bruising and petechiae with prolonged clotting times

MEDICAL AND NURSING MANAGEMENT OF THE PROGRESSIVE STAGE OF SHOCK

 Treat underlying cause

 Restore tissue perfusion with fluid management

 Respiratory support

 Nutritional support for energy

 Assessment (subtle changes) including ABGs, hemodynamic monitoring, ECG

monitoring, mental status changes, and serum electrolytes

 Oral care if on ventilator to prevent VAP

 Promote rest and comfort to reduce stress, decreased chance of postintensive

care syndrome

IRREVERSIBLE STAGE OF SHOCK

 Severe organ damage

 Unable to maintain BP with treatment

 Unable to oxygenate with ventilatory support

 Unable to maintain MAP

 Multiple organ dysfunction MODS

 Complete organ failure

IRREVERSIBLE STAGE OF SHOCK:Complete organ failure

 Organ damage too severe to respond to treatment

 Acute metabolic acidosis

 Lactic acidosis

 Depleted energy stores

CLINICAL MANIFESTATIONS OF THE

IRREVERSIBLE STAGE OF SHOCK

 Patient unable to respond to treatment

 Ventilator dependent

 Severe hypotension

 Complete decline in mental status

• organ failure

MEDICAL AND NURSING MANAGEMENT OF THE IRREVERSIBLE STAGE OF SHOCK

 Treat underlying cause

 Respiratory support

 Circulatory support

 Nutritional support

 Experimental treatments

 Simple comfort measures (palliative care)

 Support and education for the friends and family

 Be honest regarding prognosis

Which stage of shock is characterized by a normal blood

pressure?

A. Initial

B. Compensatory.

C. Progressive

D. Irreversible

B

HYPOVOLEMIC SHOCK: External fluid flossess

• most common type of shock

•  Trauma

   Surgery

   Diarrhea

Hypovolemic shock: Internal fluid losses

 Occurs with15% to 30% reduction in intravascular volume

 Hemorrhage

 Burns

CLINICAL MANIFESTATIONS

OF HYPOVOLEMIC SHOCK

Decreased blood volume

Decreased cardiac output

Decreased tissue perfusion

MEDICAL AND NURSING MANAGEMENT OF

HYPOVOLEMIC SHOCK

 Restore and redistribute intravascular volume with fluid, blood

replacement

 Treat underlying cause

 Vasoactive medications

 Focus on prevention

 Ongoing monitoring of those at risk for hypovolemia

 Safe administration of fluids and medications

 Supplemental oxygen

 Comfort measures

When caring for a patient in hypovolemic shock who is

receiving large volumes of IV isotonic fluids, the nurse should

monitor for symptoms of:

A. Hyperthermia

B. Pain

C. Pulmonary edema.

D. Tachycardia

IVF ISOTONIC Solution types

• D5W

• Normal NS

• LR

• 
  

  	• 0.9% saline (NS)
  	• So/odextrose in vvater (5%DvV)
  	• 5% dextrose in 0.225 dosaline (5 o D/1/4NS)
  	Lactated ringer's solution

D5W Function

• Is an isotonic carbohydrate (sugar) solution that contains glucose (sugar) as the solute.

• When this is absorbed, the glucose is usually quickly taken up by cells and utilized for energy, leaving only water, which is then a hypotonic solution.

D5W Purpose

• Provides 170 cal/L

• Prevents ketosis associated with starvation

• Often used for diabetic patients who are NPO

D5W Risks

• avoided in patients with renal failure, cardiac compromise, or those who are at risk for increased intercranial pressure.

• it can sometimes lead to fluid overload in cardiac and renal patients, and cerebral edema those with intercranial pressure issues

Normal NS function

 More NaCl than ECF

 Expands IV volume

What is normal Saline preferred for

• Preferred fluid for immediate response

• only IV that can be given with blood transfusion

• fluid of choice for resuscitation efforts

• one of the most common IVF: it works for most hydration needs due to vomiting, diarrhea, hemorrhage, or even shock

• only fluid used in conjunction with blood administration.

NS risks

• Risk for fluid overload higher

• sometimes used with caution or even avoided in patients with cardiac or renal compromise because of the sodium causing fluid retention that may put extra stress on the heart or kidneys

LR Function

 Similar in composition to plasma

except contains no magnesium

 Expands ECF—treat burns and GI losses

 No free water or calories

LR Purpose

• Especially great for burn victims or those with hypovolemia due to fluid shifts.

• Used in operating room frequently

LR risks and contradictions

• It is avoided in patients with liver disease because the liver may not be able to efficiently process the lactate

• Contraindicated with hyperkalemia and lactic acidosis

Hypertonic solutions

• D51/2

• D10W

D5 ½ NS

 Common maintenance fluid

 Replaces fluid loss

 KCl added for maintenance or replacement

D10W

•Provides 340 kcal/L

•Provides free water but no electrolytes

•Limit of dextrose concentration may be infused peripherally

True or False: Hypovolemic shock occurs where there is low

fluid volume in the interstitial system

a. True

b. False

B.

A patient who is experiencing hypovolemic shock has

decreased cardiac output, which contributes to ineffective

tissue perfusion. The decrease in cardiac output occurs due to?

A. An increase in cardiac preload

B. An increase in stroke volume

C. A decrease in cardiac preload

D. A decrease in cardiac contractility

C

P r e l o a d

Pressure from volume of blood in ventricles at end of diastole

(end diastolic pressure)

Preload increased in

Hypervolemia

Regurgitation of cardiac valves

Heart Failure

Afterload

Resistance left ventricle must overcome to circulate blood

Afterload increased in

Increased in:

Hypertension

Vasoconstriction

1Afterload =

T Cardiac workload

Central venous access

• Who can insert these

lines?

• What are nursing considerations when providing care for patients with these access?

Intravenous (IV) Therapy

Goal of IV therapy

• Maintain fluid balance

• Prevent fluid and electrolyte imbalances

• Administer parenteral medications

• Replenish blood volume

• Assist in pain management

Thinking Nurse: What are patient conditions

that require IV therapy?

Principles for Practice

• Successful IV therapy depends on patient preparation,

site selection, catheter selection, and catheter insertion

• A____ plays key role in decision making for IV

therapy

• Follow rights of medication administration:

• WHAT ARE THE 8 PATIENTRIGHTS?

Intravenous Catheters- Angiocatheter

• An Angiocatheter = venous access device (VAD) is inserted into a

vein

•Can be peripheral or central venous access devices, depending on where the final tip resides

Choosing the right Catheter***When selecting the appropriate

VAD, consider:

• a patient’s prescribed therapy

• length of treatment

• duration the device remains

in place

• vascular characteristics

• patient’s age, co-morbidities,

history of infusion therapy,

preference for VAD location,

and pt’s a________

Saline Lock (S.L.)

• When continuous infusion of solutions or medications is not necessary, a short-peripheral IV can be locked with preservative-free 0.9% sodium chloride (NS).

• The “old” term is HepLock

WHY?

Thinking Nurse: What gauge is the PIV on the photo?

Intravenous solution categories

1. isotonic

2. hypotonic

3. hypertonic

   • Hypotonic: can exacerbate a

   hypotensive state

   • H

   ______: irritating to the vein; can

   cause increased risk of heart

   failure and pulmonary edema

Isotonic

Have same osmolality

as body fluids; can cause

increased risk for fluid overload

Hypotonic Purpose

0.45% NS (1/2 NS)

fluid is designed to treat cellular dehydration, caused by such conditions as hypernatremia or diabetic ketoacidosis

Hypotonic avoided in

• always avoided in patients with burns, trauma, or liver disease because of its tendency to deplete intravascular fluid levels.-

• Infusing half normal saline, causes water to shift from the extracellular fluid compartment to the ICF compartment

Hypotonic can be harmful:

• Sudden shift of fluid from blood vessels to the cells – cardiovascular collapse

• Hypotonic solutions - potential to cause cellular swelling

• Monitor for changes in mentation →indicate cerebral edema

Examples- Hypotonic IV solutions

D5NS.45 (5% dextrose in ½ normal saline)

5% Dextrose and water (D5W)- Provides calories and water

Hypertonic solution types

• D5 ½ NS

• D10W

D5 ½ NS

• Common maintenance fluid

• Replaces fluid loss

• KCl added for maintenance or replacement

D10W

•Provides 340 kcal/L

•Provides free water but no electrolytes

•Limit of dextrose concentration may be infused peripherally

IV Solution Additives- Potassium

• Potassium chloride (KCl) – common additive to IV fluids

• Measured in milliequivalents (mEq)

• order usually written to indicate the amount of milliequivalents per liter

• IV solutions are often available with Potassium premixed in them`

Evidence-Based Practice

• Implementation of quality indicators and benchmarks to prevent CLABSIs develops a culture of accountability

• Remove VADs appropriately

• Use disinfection caps that contain a sponge saturated with 70% alcohol

• Primary and secondary continuous administration sets used to administer solutions other than lipid, blood, or blood products should be changed no more often than every 96 hours

Safety Guidelines: IV Therapy

• Prior to initiating IV therapy, assess the patency and functioning of the VAD.

• Maintain sterility at all time

• Assess S/S of IV complications

• Ensuring correct IVF as ordered

• Know which IV can be given via PIV VS Central access

• Trace the line!!!!

Thinking Nurse: How do you assess IV patency?

What are possible IV complications?

IV complications: To prevent infusion-related complications

solutions and medications with an osmolarity greater than 900 mOsm/L are infused through a C___ C____

IV complications: Short-peripheral catheters

should not be used for vesicant therapy, parenteral nutrition, or infusates with an osmolarity greater than 900mOsm/L

Solutions or medications with low or high pH have the potential to cause

infusion-related complications such as phlebitis when administered with a short-peripheral or midline catheter.

Thinking Nurse: What is the common low pH IV solution?

Phlebitis

inflammation of vein caused by mechanical, bacterial, or chemical irritation

Signs/symptoms of Phlebitis?

Pain, ↑ skin temp, redness

Treatment for Phlebitis?

• D/ CIV line, apply moist, warm compress, monitor IV site q hr for redness/ tenderness to prevent

• solution should be administered in another site

0-4 grading scale for Phlebitis?

A: Erythema, pain, edema, red streak along vein, palpable venous cord, purulent drainage

What is Infiltration?

• Leakage of intravenous solution or medication (non-vesicant) into the extravascular tissue

• Happens when the needle or catheter in which the product is entering the blood vessel (vein) is dislodged from the vein

Signs/symptoms of Infiltration?

Edema, pallor, ↓ skin temp around the site, and pain

Treatment for Infiltration?

D/C IV line, elevate extremity, warm compress to absorb fluid

Product should be administered at another site

0-4 grading scale for Infiltration?

Skin blanched, tight/leaking, bruised, swollen, edema, pitting, circulation, pain

What is Extravasation?

IV catheter becomes dislodged and medication infuses into the tissues (vesicant)

The accidental administration of IV drugs into the surrounding tissue, because the needle has punctured the vein and the infusion goes directly into the arm tissue. The leakage of high osmolarity solutions or chemotherapy agents can result in significant tissue destruction

Signs/symptoms of Extravasation?

Pain, stinging, burning, swelling, redness at site

Treatment for Extravasation?

D/C IV line, apply cool compress, admin antidote if one exists formed

0-4 grading scale for Extravasation?

Skin blanched, tight/leaking, bruised, swollen, edema, pitting, circulation, pain

VIP Score 0?

IV site appears healthy — No sign of phlebitis — Observe cannula

VIP Score 1?

One of: slight pain near IV site OR slight redness near IV site — Possible first sign of phlebitis — Observe cannula

VIP Score 2?

Two of: pale near IV site, erythema, swelling — Early stage of phlebitis — Resite cannula

VIP Score 3?

All of: pain along path of cannula, erythema, induration — Medium stage of phlebitis — Resite cannula, consider treatment

VIP Score 4?

All of (evident & extensive): pain along path of cannula, erythema, induration, palpable venous cord — Advanced stage of phlebitis/start of thrombophlebitis — Resite cannula, consider treatment

VIP Score 5?

All of (evident & extensive): pain along path of cannula, erythema, induration, palpable venous cord, pyrexia — Advanced stage of thrombophlebitis — Initiate treatment, resite cannula

IV-Site Infection

Does not produce much (if any) pus or inflammation at the IV site. This is the most common cannula-related infection, may be the most difficult to identify

Cellulites

Warm, red and often tender skin surrounding the site of cannula insertion; pus is rarely detectable

Thrombolism / thrombophlebitis

occur when a small clot becomes detached from the sheath of the cannula or the vessel wall - prevention is the greatest form of defence. Flush cannula regularly and consider re-siting the cannula if in prolonged

Bruising

commonly results from failed IV placement - particularly in the elderly and those on anticoagulant therapy

Air embolism

occurs when air enters the infusion line, although this is very rare it is best if we consider the preventive measures - Make sure all lines are well primed prior to use and connections are secure

Insertion of a Short-Peripheral Intravenous Device

You will learn this

in Nursing 5

• Intravenous devices provide

access to the venous system for

fluid delivery

• Various catheters available

• BEVEL UP!!!

PIV Sites

• Hands and arms

• Antecubital fossa (AC space)

Cannulation

• What are the signs of a good vein ?

• Bouncy

• Soft

• Above previous sites

• Refills when depressed

• Visible

• Has a large lumen

• Well supported

• Straight

• Easily palpable

Gerontologica: Agerelated considerations

• Veins of the older population are very fragile; they have less subcutaneous support tissue, and their skin is thinning. Avoid sites that are easily moved or bumped.

• If possible, avoid the back of the older adult’s hand or the dominant arm for venipuncture because use of these sites interferes with the individual’s independence.

• As older adults lose subcutaneous tissue, the veins lose stability and roll away from

the needle. To stabilize the vein, pull the skin taut and toward you with your nondominant hand and anchor the vein with your thumb.

• Reduce the angle of insertion (e.g., 5 to 15 degrees on insertion) to accommodate more superficial veins.

Regulating Intravenous Flow Rate

• Proper regulation reduces

complications

• Regulate infusion rates

• Manual flow-control

devices

Regulation of IV drip rate manually

1. Tubing for these sets contain a roller camp

2. Can open or close & regulate rate manually

3. Use a watch with a second hand to count number of drops per minute in the chamber

Thinking Nurse: When would you need to give IV without a pump?

Changing Intravenous Solutions

• Change a container when

• An order for a new solution is received

• It is time to add a sequential container to avoid

exceeding

hang time

• The patient’s condition indicates the need

• The IVF is expired