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what is the definition of shock?
the lack of adequate circulation or blood supply causing inadequate oxygen delivery to vital organs causing an inability to meet cellular metabolic needs
What are the distributive shocks?
neurogenic, anaphylactic, septic
distributive shocks:
extreme vasodilation leading to decreased organ perfusion
Compensatory stage:
body attempts to compensate for damage
Which types of shocks are compensatory?
all except neurogenic
compensatory stage entails:
normal BP, normal HR, increased RR (getting more 02 in blood) due to respiratory alkalosis, cold/clammy skin, decreased urine output, confusion
Progressive shock stage:
no longer compensating, MAP falls <65
Irreversible stage:
No longer responding to treatment, focus on patient's family and education
Hypovolemic shock:
due to decreased fluid volume in vascular space
Septic Shock:
amplified responses to pathogen causes increased capillary permeability
cardiogenic shock:
heart loses ability to pump effectively
neurogenic shock:
sympathetic nervous loses ability to stimulate nerve impulses
anaphylactic shock:
hypersensitivity response leading to obstructive airway
causes of hypovolemic shock:
internal bleeding, burns, long bone fractures, surgery, vomit, DI, diarrhea, sweating, trauma
management of hypovolemic shock:
treat cause, fluid and blood replacement, modified trendelenburg promotes venous blood return, pharmacologic
Nursing management:
monitor for fluid overload (2 large bore IV, foley catheter), Warm IV fluids
Oxygen: increase O2 for available hgb
Monitor all labs = ABGs, H+H
What causes cardiogenic shock?
Acute MI, pericardial tamponade, endocarditis, dysrythmias
S/S of cardiogenic shock:
Left: pulmonary edema, dyspnea, decreased 02, increased RR, increased HR
Right: JVD, weak pulses, chest pain
Brain : confusion, agitation, and anxiety
Kidney: RAAs activation, oliguria, increased BUN/ creatinine
Skin: decreased perfusion: cool and clammy
Management of cardiogenic shock:
oxygen, morphine, Hemo monitoring, fluids
Drugs for cardiogenic shock:
diuretics, pressors, dilators
Nursing management cardiogenic shock:
Intra aortic balloon pump, check artlines, labs, breath sounds, perfusion
risk factor for septic shock:
suppressed immune system, really old or really young people, invasive procedures, surgical pts, malnutrition, chronic illness
s/s of septic shock:
Early: vasodilation, warm/flushed, decreased BP, increased HR, increased RR, fever, restless
Late: cold/clammy, HoTN, increased HR, Increased RR, decreased CO, oliguria, hypothermia
Nursing interventions for septic shock:
rapid identification, broad spectrum antibiotics, nutritional supplement, fluid resuscitation, pressors, packed RBCs, DVT prophylaxis, check MAP, platelets, bilirubin, creatinine, BUN, urine output, GCS ,HR, BP, LOC, elevated temp
Neurogenic Shock causes:
damaged cervical spine, which causes widespread blood vessel dilation
S/S of neurogenic shock:
bradycardia, hypotension, hypothermia
Interventions for neurogenic shock:
protect the spine, airway, maintain MAP
S/S of anaphylaxis shock:
dyspnea, wheezing, obstruction, swelling, HoTn, <90 SBP, increased HR, itchy
Interventions for anaphylactic shock
prevention, allergen, airway, call rapid, trendenelburg, epi, fluids, antihistamine
MODS:
altered organ function in acutely ill patients related to s/s of progressive shock
S/S of MODS:
lungs go first-> intubate, decreased BP, hyperglycemia, muscle loss, in 7-10 days the liver starts to fail
interventions for MODS
catch early and support organs, family support and early communication
When are the coronary arteries perfused?
during diastole
When is the rest of the body perfused?
during systole
Diastole:
relaxation and filling of the heart muscle
systole:
Contraction of the heart
endocardium:
epithelial tissue that lines the inside of the heart
myocardium:
muscle fibers responsible for pumping
epicardium:
exterior layer of the heart
cardiac output:
total amount of blood ejected by the ventricles per minute
stroke volume:
amount of blood ejected from ventricle per beat
baroreceptors:
located in aorta and carotid arteries that detect changes in blood pressures
preload:
stretch of the ventricles at the end of diastole
afterload:
resistance to the ejection of blood from the ventricles
contractility:
force generated from the myocardium
P wave represents
atrial depolarization
PR interval represents
atrial depolarization
QRS complex represents
ventricular depolarization
T wave represents
ventricular repolarization
Modifiable factors
weight, diet, exercise
CAD
coronary artery deposits is lipid deposits and fibrous tissue in the lining of the blood vessel walls
s/s of CAD:
ischemia, angina, radiating jaw&arm pain, SOB, sweating
risk factors for CAD:
Family hx, age, gender, race,
modifiable risk factors for CAD:
HTN, smoking, diabetes, metabolic syndrome, obesity, inactivity, hyperlipidemia
prevention for CAD:
control cholesterol, stop smoking, manage HTN, manage diabetes, physical activity (150 min/week)
Angina pectoris:
any pain or pressure in the anterior chest r/t CAD
stable angina:
caused by physical activity, predictable pain, relieved by nitro
unstable angina:
occurs randomly, unpredictable, not relieved by nitro
variant angina:
sometimes triggered by physical activity making it unpredictable, worsens with time, not relieved with rest
myocardial infarction s/s
chest pain, HVD, increased BP, EKG changes, SOB, dyspnea, tachypnea, restless, cool/clammy
diagnosis for MI
ST elevation, Q wave abnormality, T wave inversion
ECHO: to determine EF
Labs: Troponin
treatment for MI
EKG within 10 minutes, door to balloon in 90 minutes, bed rest for 24 hours, oxygen, aspirin, nitro, morphine
PCI (cardiac cath)
balloon/stent placement, contraindication, can start bleeding (hold pressure and contact HCP immediately)
Mitral regurgitation
backflow of blood from the left ventricle into the left atrium
s/s of mitral regurgitation:
asymptomatic, dyspnea, fatigue, SOB on excertion
assess/Dx for mitral regurgitation:
murmurs, ECHO
Tx for mitral regurgitation:
treat like LHF, reduce cardiac afterload, ACE inhibitors, ARBs, Beta Blockers
Mitral Stenosis:
backflow of blood from left atrium to the lungs due to obstruction from LA to LV
S/S of mitral stenosis:
asymptomatic, dyspnea, SOB, dry/wheezing cough, hemoptysis, paroxysmal nocturnal dyspnea
ass/dx for mitral stenosis:
weak pulse, low pitched rumbling diastolic murmur, ECHO, stress test, EKG, cardiac cath
Tx for mitral stenosis:
anticoagulants due to pooling in left atrium
aortic stenosis
narrowing of the aorta
risk factors for aortic stenosis:
age, diabetes, hypercholesterolemia, HTN, smoking
s/s of aortic stenosis:
dyspnea, angina, increased pulmonary pressure, dizzy
assess/dx of aortic stenosis:
systolic murmur heard over aortic area, vibration, s4 sounds, ECHO every 5 years, EKG, MRI every 6-12 months
pericarditis
inflammation of the pericardium
causes of pericarditis
infection, surgery, rheumatid fever, lupus, immune/medication rxn, radiation
treatment for pericarditis:
NSAIDS, pericardiocentesis, lean forward, antibiotics, analgesics
Heart failure:
a chronic condition in which the heart is unable to pump out all of the blood that it receives
classes of HF:
systole: weakened heart muscle=decreased ability to pump
diastole: stiff heart muscle=decreased ability to fill
causes of HF:
CAD, HTN, valve disorder, MI
s/s of HF:
Left: pulmonary congestion, crackles, low 02, dyspnea, SOB, ventricular gallop, cough, orthopnea,
Right: JVD, edema, hepatomegaly, ascites, anorexia, decreased CO2
assess/dx of HF:
ECHO, EKG, chest x-ray, Labs, stress test
complications of HF:
thromboembolism and pulomary embolism= clot concern=anticoagulants
ACE inhibitors for HF:
decrease workload, decrease preload, decrease afterload
ARBS for HF:
decrease workload, decrease preload, decrease afterload
Hydralazine/Isosorbide for HF:
vasodilates and decreases preload
Beta Blockers for HF:
decreases BP, decrease afterload, decrease cardiac workload
diuretics for HF:
remove excess fluid volume
digoxin for HF:
decreases HR, increases contractility
how to calculate Pulse Pressure:
SBP-DBP
How to calculate SV:
EDV-ESV
How to calculate CO
HR x SV
How to calculate EF
SV/EDV x 100
How to calculate MAP
2xdiastolic + systolic all divided by 3
Gero considerations for Peripheral circulation:
Vessels stiffen-> increased resistance-> impair blood flow -> increased left ventricle workload -> hypertrophy -> LV ischemia
assessment for peripheral circulation:
Health hx, physical (cap refill, blood pooling, pulses, hair, ulcers, color), palpitation (peripheral pulses, weeping, redness, edema)
diagnostics for peripheral circulation
doppler, exercise testing, duplex ultrasounds, angiography
PAD
peripheral artery disease