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25 Cards in this Set
- Front
- Back
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Hemodynamic monitoring
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decreased cardiac output; pressures within various chambers
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Diagnostic procedures: cardiogenic (6)
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ECG
Echocardiogram CT Cath Chest X-ray Cardiac enzymes |
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Cardiac enzymes
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creatine phosphokinase (CPK)
troponin |
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Hypovolemic diagnostic proceedures (3)
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H & H
type and cross match for possible blood transfusion Investigate sources of bleeding |
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Hypovolemic shock: sources of bleeding
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Blood in nasogastric drainage
Blood in stools Esophogastroduodenoscopy CT scan of ABD |
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Diagnostics for septic shock
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Cultures: blood, urine, wound
Coagulation tests: PT, INR, aPTT |
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Diagnostics for obstructive shock
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echocardiogram
CT scan |
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Hypovolemic shock due to hemmorage; H & H will be...
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decreased
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Hypovolemic shock due to dehydration; H & H will be...
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increased
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Signs and symptoms of shock
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hypoxia
hypotension (mean arterial pressure < 60) tachycardia; weak thready pulse |
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Stages of shock
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initial
compensatory progressive refractory |
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Vitals for Initial shock
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HR: ≤ 100
Sys BP: Normal RR: Normal Urine output: ≥ 30 Skin: cool, pink, dry Cap refill: Normal |
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Vitals for Compensatory shock
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HR: >100
Sys BP: Normal/Increased RR: 20-30 Urine output: 20- 30 Skin: cold, pale, dry/moist Cap refill: slightly delayed |
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Vitals for Progressive shock
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HR: ≥ 120
Sys BP: 70-90 RR: 30-40 Urine output: 5-20 Skin: cold, pale, moist Cap refill: delyed |
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Vitals for Refractory shock
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40
Sys BP: < 50-60 RR: > 40 Urine output: neglible Skin: cold, mottled, cyanotic, dry Cap refill: not noted |
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Assess/Monitor...
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O2
Vitals Urinary output LOC Cardiac rhythm Skin: color, temp, moisture, cap refill, turgor Body system compromise: chest pain, changes in heart tones, lung sounds, bowel sounds, neurological status. |
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Nursing interventions: If shock is suspected...
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Obtain vital signs
Lab & diagnostics calculate urine output & monitor hourly output; report <30ml/hr Perform complete assessment |
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Nursing interventions for hypotension
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place client flat w/legs elevated or in trendelenburg position to increase venous return
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Nursing interventions for shock
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1. Identify client risk factors
2. "if shock suspected steps" 3. Place on high-flow O2: non-rebreather mask; if COPD 2L nasal canula 4. Assure IV access 5. positioning for hypotension 6. Notify provider 7. Initiate orders to intervene: ICU., surgery, etc. 8. Explain procedures and findings to family & client |
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ICU interventions
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hemodynamic monitoring
meds IV access is patent place on continuous cardiac monitoring |
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Complications: organ dysfuntion
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MI; ARDS, renal failure, liver failure,
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Treatment
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Based on type of shock & symptoms
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Complications: DIC
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Disseminated intravascular coagulation:
complication of septic shock: thousands of small clots form in organs-->hypoxia and anaerobic metabolism. |
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DIC symptoms
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petechiae, ecchymosis, skin is pale, cyanotic, blood oozes from membranes and puncture sites
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Considerations for elderly
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may not be able to compensate (stage) for long; may not be able to increase C/O; decreased baroreceptors = problems with vasoconstriction and BP;
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