SHOCKS

What is the definition for shocks?

§  Decreased tissue perfusion leading to no O2 or nutrients being delivered

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easier way to understand

·      Inadequate tissue perfusion that impairs cellular function and can lead to organ failure

·      Lack of oxygen getting to the tissues in the body. The body is getting deprived of oxygen.

what are the different types of shocks?

§  Systemic Inflammatory Response (SIRS)

§  Sepsis

§  Multiple Organ Dysfunction Syndrome (MODS)

what is MODS?

·      Failure of 2 or more organ systems

·      Results from SIRS

what are the stages of shock?

Initial stage

compensatory stage (non-progressive)

progressive stage (decompensatory)

irreversible refractory stage

what is the initial stage of shocks?

§  Metabolism changes from aerobic to anaerobic

·      There will be no S/S

what is the compensatory stage of shocks?

\-non-progressive

§  There is NO decrease in BP

§  Increased HR

§  Vasoconstriction

§  Cool and clammy skin

§  Endocrine - Releases renin & ADH (ADH makes the body hold onto fluid)

§  This is the ideal stage to treat a shock but usually gets missed

why do you see vasoconstriction in the compensatory stage of shocks?

because the Body will compensate enough to not lower BP

(Vessels tighten)

what is the progressive stage of shocks?

§  decompensatory

§  Low BP

§  Overall decreased condition

§  Hypoxic injury

§  Decreased perfusion / O2

§  Increased cap. Permeability

§  Brain – low CPP (Decreased LOC, altered mental status)

§  Heart – Muscle cell death

§  Kidneys – Tubular Necrosis

§  Gut – Decreased peristalsis (No bowel sounds)

§  Liver – acute hepatic failure (Cannot metabolize)

§  Lungs – ARDS

§  Vessels – DIC

§  Intervene ASAP

what is the irreversible refractory stage of shocks?

§  Irreversible physiologic changes

§  MODS

§  Unable to tell when pt transitions to stage 3

§  Still try to increase BP and treat it

§  All system shut down (Irreversible damage, hard to tell when this occurs)

§  Treat before getting to this point (Pt will die)

what is occurring in hypovolemic shock?

there is not enough volume (fluid) in the body

• Low intravascular volume

• poor cardiac output

what are the causes of hypovolemic shock?

·      Dehydration

·      Hemorrhaging

·      3rd spacing – burns

why do you see low volume in hypovolemic shock?

because there is a decrease in

\-preload

\-stroke volume

\-cardiac output

why is there decreases preload in hypovolemic shock?

§  Low CVP and PAWP (0-1 is low, 2-6 is normal)

·      If the CVP is less than 2 – pt needs more volume

§  Preload is the pressure coming into the heart

§  Ex. CVP is 1 (low), pt is tachycardic, low bp, and they were bleeding = hypovolemic shock

What will you assess for in a pt with hypovolemic shock?

poor perfusion

cool and clammy skin

decreased renal function

hypotension

tachycardia

low hgb if the pt is bleeding

what are the goals for hypovolemic shock?

• reperfusion

• find the cause of volume loss

  • bleeding → administer blood

  • dehydration → give fluids

  • Burns

  • Diabetes insipidus (DRY INSIDE)

  • V/D

What are the interventions for hypovolemia?

\-fluid resuscitation (Blood or IVF) - replace what is being lost

\-Obtain vascular access - 1 or 2 large bore (14-16 gauge) IV catheters

\-intraosseous (IO) access device

\-central venous cath

\-strick I/O’s

how will you know your pt has improved from a hypovolemic shock?

BP will increase

increased UOP

improved neuro function

peripheral pulses present

what medications will you give for hypovolemic shock?

\-Isotonic solution - 0.9% NS or LR (most common)

\-Hypertonic solutions - 1.8%, 3%, 5% NaCl

\-Blood or blood products - PRBC’s, fresh frozen plasma, platelets

\-colloids - Human serum albumin (5% or 25%)

why would you administer hypertonic solution for hypovolemic shock?

§  Volume expansion

·      Pulls fluid from tissue into the blood vessels

why would you administer blood or blood products for hypovolemic shock?

§  Replaces blood loss

§  Increases O2 carrying capability

why would you administer colloids for hypovolemic shock?

§  Can increase plasma colloid osmotic pressure

§  Rapid volume expansion

·      Albumin holds water in the pt

what is distributive shock?

§  Vascular permeability and/or dilation leading to decreased cardiac output

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easier words:

§  Vessels are big and the vessels are not being perfused fully b/c we have the same amount of fluid. No blood into the organs

what are the different types of shocks in distributive shock?

\-septic shock (immune response)

\-anaphylaxis shock (d/t histamine release)

\-neurogenic shock (No SNS)

what is septic shock in distributive shock?

·      Endotoxins and other mediators leading to __massive vasodilation__

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easier words:

·      Massive infection in the body - Immune system makes an inflammatory response and the vessels open up

what is anaphylaxis shock in distributive shock?

·      Allergen exposure resulting in antigen-antibody reaction leading to __massive vasodilation__

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easier words:

·      histamine makes vessels dilate leaking fluid and causing hives

what is the patho of anaphylaxis shock in distributive shock?

o   Hypersensitivity Reaction (allergic)

o   Allergic reaction > histamine released > causes massive vasodilation > capillary leakage > decreased intravascular volume & third spacing occurs (edema)

what are the causes of anaphylaxis shock in distributive shock?

§  ABX

§  Foods – peanuts

§  Latex

§  Bee stings

what is the background of anaphylaxis shock in distributive shock?

§  Massive vasodilation

§  Release of vasoactive mediators

§  An increase in capillary permeability

what are the assessment findings of anaphylaxis shock in distributive shock?

§  Feeling of impending doom

§  Swelling of the lips and tongue

§  Itchy throat

§  hives

§  Wheezing

§  Stridor - Airway!!!

§  Tachycardia

§  Dizziness

§  Chest pain

§  Incontinence

what are the interventions for anaphylaxis shock in distributive shock?

§  #1 priority - AIRWAY → Epinephrine, norepi, dopamine (vasopressors) - Closes the blood vessels - vasoconstrict

§  Benadryl

§  Steroids for inflammation

what is the education for anaphylaxis shock in distributive shock?

§  Medical identification wristband

§  Avoid allergens

§  Have epi pen available at all times

what is the drug of choice for an anaphylactic shock?

Epinephrine IV or IM

·      Orange to the thigh, blue to the sky

·      Can be given through clothing

what is the MOA of Epinephrine for an anaphylactic shock?

§  Causes peripheral vasoconstriction and bronchodilation

§  Opposite effect of histamine

what is neurogenic shock in distributive shock?

·      Loss of sympathetic tone (after spinal injury) leading to __massive vasodilation__

·      no fight or flight

·      expect hypotension and bradycardia

what is the cause of neurogenic shock in distributive shock?

spinal injury

\-occurs in 30 min after injury

what is the background of neurogenic shock in distributive shock?

§  Loss of sympathetic nervous system with T6 or higher injury

§  NO SNS – no fight or flight

what assessment findings will you find on a pt with of neurogenic shock in distributive shock?

§  Vasodilation - Hypotension

§  bradycardia d/t no SNS

§  paralysis

what are the interventions of neurogenic shock in distributive shock?

§  For vasodilation - Give vasopressors (Norepi, Dopamine)

§  For bradycardia - Atropine

§  For spinal cord -Promote spinal stability, C-Collar, Log rolling

What medication will you give for neurogenic shock?

o   Norepinephrine and Dopamine

\-titratable drip

what is the MOA of norepi and dopamine for neurogenic shock?

§  Vasoconstriction – raises BP

·      You are giving the pt an artificial SNS (fight or flight)

what is the USE of norepi and dopamine for neurogenic shock?

§  Persistent Hypotension after IVF resuscitation

can be given for Neurogenic & Septic shock

how will you know that norepi and/or dopamine that was given for neurogenic shock worked?

you will see Increased perfusion to the organs

you will see a MAP of greater than 65 mm Hg.

what is a contraindication of norepi and dopamine for neurogenic shock?

§  Cardiogenic shock b/c increases workload of heart

what is an obstructive shock?

§  Blockage of blood flow to the heart or lungs

§  Increased intrathoracic pressure leading to decreased cardiac output, poor perfusion, and hypoxemia

what are the causes of obstructive shock?

§  Pulmonary embolism – hypoxemia

§  Cardiac tamponade - Can be classified as obstructive or cardiogenic -Fix by draining fluid around the heart

§  Pneumothorax - Fix with needle decompression

what assessment findings will you see on a pt with an obstructive shock?

§  Hypotension - d/t blockage

§  Poor perfusion

what diagnostics and labs will you do for a pt with an obstructive shock?

§  Echo

§  Chest xray

§  D-dimer

§  CT chest

what interventions will be done for a pt with an obstructive shock?

§  Fix underlying issue - fixing the issue fixes the blockage

§  Must identify cause FAST! Cardiac arrest can occur

§  Thrombectomy

§  Chest tube

§  Pericardiocentesis

what is a cardiogenic shock?

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\-pump action is not maintaining cardiac output

\-extreme vasoconstriction

\-left heart failure S/S

what is cardiogenic shock in easier words?

AKA bad pump

§  Pump action is not maintaining cardiac output

§  Poor cardiac output causes hypotension & tachycardia

§  SNS activates

·      Leads to extreme vasoconstriction

what are the causes of a cardiogenic shock?

§  MI

§  HF

§  Cardiomyopathy

§  Dysrhythmias

what diagnostics and labs will be done for a pt with cardiogenic shock?

§  Chest xray

§  EKG

§  Echo

§  BNP

what assessment findings will present on a pt with cardiogenic shock?

it will look like CHF with poor perfusion

fluid overload

crackles

increases PAWP

hypotension

poor perfusion

weak pulse

cool and clammy

renal impairment

what are the goals for a pt with cardiogenic shock?

§  decreasing cardiac workload (afterload)

§  increasing cardiac output (perfusion)

how will the nurse decrease the cardiac workload (afterload) for a pt with cardiogenic shock?

by administering a vasodilator - sodium nitroprusside

how will the nurse increase perfusion (cardiac output) for a pt with cardiogenic shock?

by administering a positive inotrope - dobutamine

what is the USE of sodium nitroprusside for a pt with cardiogenic shock?

for cardiogenic shock

what is the MOA of sodium nitroprusside for a pt with cardiogenic shock?

§  Vasodilation

·      Decreases afterload (cardiac workload)

·      Makes it easier for the heart to pump by opening up the vessels (dilation)

what is the goal of sodium nitroprusside for a pt with cardiogenic shock?

increased perfusion

how will you know that sodium nitroprusside for a pt with cardiogenic shock worked?

Improved perfusion and circulation

what are the nursing considerations of sodium nitroprusside for a pt with cardiogenic shock?

·      BP every 10-15 mins

·      Inactivated by light - Keep in dark place or in foil

what is the USE of dobutamine for a pt with cardiogenic shock?

Decreased cardiac output related to pump failure

what is the MOA of dobutamine for a pt with cardiogenic shock?

§  Increase cardiac contraction & output

·      Makes heart pump harder

what is the goal of dobutamine for a pt with cardiogenic shock?

Increase stroke volume and cardiac output

how will you know that dobutamine worked for a pt with cardiogenic shock ?

·      Decreased pulmonary edema

·      increased perfusions: peripheral color return

·      improved UOP

what are the nursing considerations of dobutamine for a pt with cardiogenic shock?

·      BP every 10-15 min

·      Must be in central line

what is SIRS/Sepsis/Septic shock caused by?

bacteria

• it is a Super response from the immune system

• Release of Inflammatory cytokines and tumor necrosis factor (TNF)

easier words:

Infection in bloodstream and the body has an inflammatory response to try and fight the infection

what does sepsis mean?

we proven an infection is present 

what is SIRS?

a systemic inflammation

what is the cause of SIRS/Sepsis/Septic Shock?

o   Increased cap. Permeability

o   Vasodilation

o   Edema

o   Myocardial depression - Low CO leading to hypoxia

o   Toxic Shock Syndrome (Rash)

What is MODS?

§  End organ damage from hypoxia

§  Multiple body system

what are the nursing interventions for septic shock/ MODS / Sepsis?

§  Aggressive fluid replacement to restore the intravascular volume and organ perfusion

§  ABX

§  30 mL/ kg of isotonic crystalloid solution

§  If still hypotensive vasopressors may be added after. - Drug of choice norepinephrine

§  Measure response to fluids / drugs by measuring - CO through hemodynamic monitoring

what is the specific order of interventions for sepsis?

§  Fluid resuscitation (it is an ABC – Circulation)

·      30 mL/kg - isotonic bolus (LR or NS)

§  Blood cultures

·      To see what type of infection it is

·      __Changes in WBC, temp is sign of infection__

§  Administer ABX

what are the S/S of the heart for Septic Shock, Sepsis, MODS?

·      Elevated BP

·      Decrease in preload

·      Decrease in cardiac output

what are the interventions for the S/S of the heart for Septic Shock, Sepsis, MODS?

·      Hemodynamic & cardiac monitoring

·      initiate vasopressors, and titration,

·      arterial line

what are the S/S of the lungs for Septic Shock, Sepsis, MODS?

·      Inflammatory Mediators

o   ARDS

o   Crackles

o   Infiltrates

o   Tachypnea

what are the interventions for the S/S of the lungs for Septic Shock, Sepsis, MODS?

·      Maintain airway and MV

·      Decrease anxiety

what are the S/S of the renal system for Septic Shock, Sepsis, MODS?

·      Decreased UOP

what are the interventions for the S/S of the renal system for Septic Shock, Sepsis, MODS?

·      I/O’s

·      Daily weights

what are the S/S of the skin for Septic Shock, Sepsis, MODS?

·      Pallor

·      Cool and clammy

what are the interventions for the S/S of the skin for Septic Shock, Sepsis, MODS?

·      Turn every 2 hrs

·      Assess circulation

what are the S/S of the neurologic system for Septic Shock, Sepsis, MODS?

·      Decreased CPP

·      Anxiety

·      Confusion agitation

what are the interventions for the S/S of the neurologic system for Septic Shock, Sepsis, MODS?

·      Safety

what are the S/S of the GI system for Septic Shock, Sepsis, MODS?

·      Decreased or absent bowel sounds

·      Liver -Increased LFT’s (Bleeding d/t release of clotting factors during cell death)

what are the interventions for the S/S of the GI system for Septic Shock, Sepsis, MODS?

·      Bowel rest

·      TPN