Care Lecture 4: Perfusion II - Shock, Hemodynamics, and DIC

enters heart through vena cava

↓

right atrium

↓

tricuspid valve

↓

right ventricle

↓

pulmonary artery

↓

lungs

↓

pulmonary vein

↓

left atrium

↓

mitral valve

↓

left ventricle

↓

aortic valve

↓

aorta

↓

cells

what is the pathway of blood through the heart?

-APTT: 30-40

-prothrombin time (PT): 10-12 seconds

-INR: 0.9-1.2

what are the normal values for APTT, prothrombin time, and INR?

-platelets: 150,000-450,000

-RBCs: 4.5-5.5

-WBCs: 4,500-11,000

what are the normal values for platelets, RBCs, and WBCs?

-stable VS & O2 sats

-pink, warm skin

-pink mucous membranes

-normal RR

-no edema

-no cyanosis

-adequate urine output (**kidney function)

-A x O x 3

-adequate capillary refill

what does a person with good/adequate tissue perfusion and circulation feel like or look like?

-inadequate urine output

-cyanosis, pale skin

-edema

-impaired mental status

-pain, unstable VS

-cold extremities

-SOB

-low O2 sats

-poor capillary refill

what are the signs and symptoms of inadequate/impaired tissue perfusion that you might see?

shock

clinical syndrome that results from decreased blood flow and oxygen to body tissues causing cellular dysfunction and eventually leads to organ failure

inadequate O2 & nutrition to cells --> impaired tissue perfusion

because there is decreased blood flow to tissues in shock states, what results?

-ARDS

-acute tubular necrosis (leads to kidney failure)

-MODS

-DIC

-death

what are some potential complications of poor perfusion?

1. initial

2. compensatory

3. progressive

4. irreversible

what are the 4 stages of shock?

4 stages of shock --> occurs on a continuum and people can move in and out of different stages

what is important to acknowledge about the stages of shock?

-inadequate O2 delivery = cellular changes

-↓ CO & tissue perfusion

-↑ anaerobic metabolism

-↑ lactic acid

what are some characteristics of the initial stage of shock?

changes from aerobic to anaerobic metabolism --> lactic acid buildup

describe cellular metabolism in the initial stage of shock

no clinical symptoms or very insidious

what is characteristic of clinical manifestations during the initial stage of shock?

↑ lactic acid = ↓ O2 delivery to tissue

because there is ↑ lactic acid in the initial stage of shock, what consequence does this have on oxygen delivery?

lactic acid levels

what is a key lab value for shock?

-compensatory mechanisms helping maintain adequate tissue perfusion to vital organs

what are some characteristics of the compensatory stage of shock?

-neuro: fight/flight response triggered

-hormonal: ↓ urine output, ACTH ↑ blood glucose

-chemical: ↑ respiratory efforts

how do the neuro, hormonal, and chemical systems in the body contribute to the compensatory stage of shock?

fever & ↑ HR as body is trying to fight back

what are some common clinical manifestations that might be seen in the compensatory stage of shock?

because of a ↓ in CO and narrowing of pulse pressure

why is low BP a classic sign of shock?

compensatory mechanisms are becoming detrimental --> symptoms progress

what is happening during the progressive stage of shock?

-sympathetic over-activity

-↑ metabolic acidosis

-cell membrane damage

-↓ CO

-progressive tissue hypoxia

what are some characteristics of the progressive stage of shock?

-listless/lethargic

-confusion

-↓ response to pain

-↑ RR

-↑ HR

-weak pulse

-ansarca

what are some clinical manifestations that might be seen in the progressive stage of shock?

ansarca

diffuse profound edema

compensatory mechanisms are nonfunctioning or totally ineffective

what is happening during the irreversible stage of shock?

-prolonged ↓ CO

-↓ BP

-cellular necrosis

-MODS

-capillary stasis & death

what are some characteristics of the irreversible stage of shock?

1. hypovolemic

2. cardiogenic

3. distributive

what are the various types of shock?

1. anaphylactic

2. septic

3. neurogenic

what types of shock fall under distributive shock?

hypovolemic shock

type of shock caused by an absolute loss of volume; can be attributed to external or internal fluid loss

1. absolute

2. relative

what are the types of hypovolemic shock?

pooling in interstitial space --> third spacing

what can be evident regarding interstitial space in hypovolemic shock?

relative hypovolemic shock

type of hypovolemic shock caused when fluid volume moves out of the vascular space into extracellular space; ex: fluid shifts, internal bleeding, massive vasodilation, and pooling of blood or fluids; fluid "shift"

absolute hypovolemic shock

type of hypovolemic shock caused by external loss of blood or loss of other body fluids; ex: vomiting, diarrhea, GI bleeding, surgery, trauma; fluid "loss"

loss of volume from our tubes, but the volume is still in the body

what is true of relative hypovolemic shock?

they will be very edematous

in someone experiencing relative hypovolemic shock, what is a hallmark sign?

burns = major risk for hypovolemia

what is one disease process that puts patients at a very increased risk of hypovolemic shock?

-burns

-hemorrhage (internal & external)

-diuretics

-vomiting/diarrhea

-trauma

-diabetes insipidus

-DKA

-ascites

-bowel obstruction

what are some potential causes of hypovolemic shock?

-↑ HR

-↑ CO

-↑ RR and depth

-↓ CVP

-altered mental status

-↓ stroke volume

-anxiety

-↓ urine output

what are some clinical manifestations of hypovolemic shock?

-prompt recognition of s/s

-further volume loss prevented

-underlying cause treated

-adequate BP and perfusion maintained

what are some desired outcomes associated with hypovolemic shock?

-control bleeding (tourniquet)

-surgery (if indicated)

-volume replacement

-blood transfusion (replace volume)

-I&Os

-uterine massage

-STOP thrombolytics & anticoagulants

what are some specific care management strategies related to hypovolemic shock?

discontinue these since they are helping with blood loss

why should someone in hypovolemic shock stop taking any thrombolytics & anticoagulants?

need to replace the loss of blood to improve CO & prevent tissue ischemia

why might a patient in hypovolemic shock receive a blood transfusion?

cardiogenic shock

a type of shock that involves failure of the "pump" of the heart; dysfunction of the heart's pumping action results in reduced cardiac output (CO), stroke volume (SV), and BP

1. coronary

2. noncoronary (obstructive)

what are the 2 types of cardiogenic shock?

-MI

-cardiomyopathy

-dysrhythmias

-HF

-tamponade

-valvular dysfunction

-PE

-tension pneumo

what are some potential causes of cardiogenic shock?

supporting the heart and oxygenation

assessments and interventions for cardiogenic shock revolve around what goal?

be careful with our fluids!!!

**why? --> if we have fluids running, the pump will overload since the heart can't handle this much volume

with cardiogenic shock, what is one of the key things we do differently regarding treatment compared to the other types of shock?

-peripheral edema

-confusion

-progressive SOB

-↑ HR

-↓ BP

-tachypnea

-↑ SVR

-crackles

-cyanosis, pallor, diaphoresis

-cool & clammy skin

-↓ urine output

what are some clinical manifestations of cardiogenic shock?

-prompt recognition of s/s

-↓ O2 demand

-↓ workload of heart

-pain relief

-maintain BP and HR

what are some desired outcomes associated with cardiogenic shock?

distributive shock

type of shock caused by defects in vascular tone; can be attributed to relative hypovolemia that occurs when vasodilation increases the side of vascular space

helps left ventricle (main pumping chamber of heart) pump blood to rest of the body

what is the purpose of an LVAD?

-inotropics (help heart work smarter, not harder)

-vasodilators (↓ afterload)

-diuretics (↓ preload)

-correct dysrhythmias

-hemodynamic monitoring

-heart transplant

-IABP or LVAD

-thrombolytics

-nitroglycerin

what are some specific care management strategies related to cardiogenic shock?

alters distribution of blood volume

how does distributive shock states affect blood volume?

-massive vasodilation

-defect in vascular tone

-myocardial depression

what are some potential causes of distributive shock?

neurogenic shock

type of distributive shock characterized by a massive vasodilation without compensation because of the loss of sympathetic nervous system vasoconstrictor tone; leads to a pooling of blood in the blood vessels, tissue hypoperfusion, and impaired cellular metabolism

disruption in SNS

↓

loss of sympathetic tone

↓

vasodilation

↓

BP, venous return, SV, CO decreases

↓

cellular O2 decreases

↓

impaired tissue perfusion

what is the pathophysiology of neurogenic shock?

SNS & PNS cannot communicate

↓

body SHOULD vasoconstrict during fight or flight --> doesn't happen in neurogenic shock

↓

SNS cannot correct massive vasodilation

↓

blood gets distributed incorrectly

what is true of the relationship between the SNS, PNS, and neurogenic shock?

-injury or disease of spinal cord

-spinal anesthesia

-vasomotor center depression (from drugs such as BZDs, opioids)

what are some potential causes of neurogenic shock?

-poikilothermia (taking on temperature of the environment

-↓ HR

-↓ BP

-dry skin

what are the classic manifestations of neurogenic shock?

-airway & spinal stability

-hypothermia prevented

-BP and HR return to normal

what are the desired outcomes associated with neurogenic shock?

-fluid replacement (monitor to avoid volume overload)

-sympathomimetics and vasopressors to ↑ BP & HR

**treatment varies depending on cause

what are some specific care management strategies related to neurogenic shock?

-vasopressors = maintain BP & perfusion

-atropine = treat bradycardia

-IV fluids

-phenylephrine

what are some medications that can be given to someone in neurogenic shock?

anaphylactic shock

type of distributive shock that is an acute & life-threatening hypersensitivity reaction to a sensitizing substance

-medications

-insect bites/stings

-blood transfusions

-food

-dye (iodine)

what are some potential causes of anaphylactic shock?

sensitizing substance

↓

massive vasodilation

↓

release of vasoactive mediators

↓

increase in capillary permeability

↓

fluid leaks from vascular space into interstitial space

describe the pathophysiology of anaphylactic shock

-resp. failure

-↑ HR w/ rapid, weak pulse

-↓ BP

-↑/normal CO

-itching & edema at site (early signs)

-dilated pupils

-dyspnea

-cyanosis, flushing

-angioedema

-bronchial edema

-impending doom

what are some clinical manifestations associated with anaphylactic shock?

sign that sympathetic nervous system is kicking in

when a patient's BP is down and their HR is up, what does this indicate?

-recognition of early s/s

-airway maintained

-BP & HR return to normal

-identification & removal of allergen

what are the desired outcomes associated with anaphylactic shock?

-maintain open airway

-epinephrine

-antihistamines (benadryl)

-aminophylline (bronchodilator)

-vasopressors

-start large bore IVs

-fluid administration

-steroid use (correct inflammation)

what are some specific care management strategies related to anaphylactic shock?

-lung sounds

-urine output

-edema

-cap refill

when administering fluids to someone in shock, what are some important assessments for the nurse to complete?

epinephrine

what is the first drug of choice to treat anaphylactic shock?

better for rapid administration of fluids & medications

why would we use large bore IVs for treatment of someone in anaphylactic shock?

to bring BP back up

why would we give vasopressors for treatment of someone in anaphylactic shock?

septic shock

type of distributive shock caused by a systemic inflammatory response to infectious agent

gram negative bacteria

septic shock is mostly caused by what?

-persistent hypotension despite fluid resuscitation

-inadequate tissue perfusion that = tissue hypoxia

what is septic shock characterized by?

microorganism enters body

↓

exaggerated response to microorganism

↓

pro-inflammatory response activated

↓

damage to endothelium, vasodilation, ↑ capillary permeability

explain the pathophysiology of septic shock

1. vasodilation

2. maldistribution of blood flow

3. myocardial depression

what are the 3 major pathophysiologic effects of septic shock?

usually subtle

what is true of the signs and symptoms of septic shock?

-↓ BP, but skin still warm & dry

-↑ HR, RR

-WBC > 12,000

-fever

-edema

-polyuria

-respiratory alkalosis (d/t compensatory hyperventilation)

what are some clinical manifestations of EARLY septic shock?

-severe ↓ BP

-↑ HR, RR

-oliguria

-respiratory acidosis

-altered mental status

-GI dysfunction

-respiratory failure, ARDS

-hyperglycemia

what are some clinical manifestations of SEVERE septic shock?

SIRS (systemic inflammatory response syndrome) = related to septic shock

what is a related syndrome of septic shock that occurs when there is no identifiable source of infection?

-identify and treat cause

-BP and HR return to normal

what are the desired outcomes associated with septic shock?

-cultures

-antibiotics

-vasopressors

-large bore IVs

-fluid administration

-blood sugar maintenance

-PREVENTION IS KEY

what are some specific care management strategies related to septic shock?

-CBC

-DIC screen

-chem profile

-lactate

-ABGs

-blood cultures

-liver enzymes

-ECG

-CXR

-echocardiogram

what are some diagnostic tests often used to detect sepsis?

-RBCs

-WBCs

-platelets

-Hct

-Hgb

what are the main components included in a CBC?

volume expansion with administration of the appropriate fluid

what is the cornerstone of therapy for septic, hypovolemic, and anaphylactic shock?

patient w/ persistent hypotension after fluid resuscitation = vasopressor can be given

for patients in shock, who might receive vasopressors?

vasodilators can ↓ afterload

because patients in cardiogenic shock have decreased myocardial contractility, what med can be given to decrease afterload?

restore heart function & balance between O2 supply/demand in myocardium

for a patient in cardiogenic shock, what is the overall goal of treatment?

-stopping loss of fluid

-restoring circulating volume

the underlying principles of managing patients with hypovolemic shock focus on what?

broad-spectrum antibiotics

what are an important and early part of treatment for septic shock?

within first hour of diagnosis

when should antibiotics be started for septic shock?

aseptic technique

in what manner should blood cultures be collected?

obtain cultures (blood, wound, urine, stool, sputum) BEFORE antibiotics are started

what is important for a nurse to know regarding administration of antibiotics for septic shock and drawing cultures?

-blood

-lines

-central lines

-ventilators

-etc.

*anything that could carry infection risk

what should be cultured in someone with septic shock?

prevention = first step

what is the first strategy in managing patients at risk for anaphylactic shock?

-provide warmth

-reduce activity

-manage pain

in order to reduce energy demands in a patient with shock, what are some strategies that nurses can utilize?

-elevate FOB

-large bore IV access (14-18g)

-urinary catheter

in order to promote and maintain fluid balance and perfusion in a patient with shock, what can be done?

intraaortic balloon pump (IABP)

intervention that provides temporary circulatory assistance to the sick heart by reducing afterload and cardiac work to improve organ perfusion; provides assistance by augmenting aortic diastolic pressure

O2 delivery = ↑ O2 supply & ↓ O2 demand to better perfuse tissues

why might a patient in shock be given supplemental oxygen?