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43 Cards in this Set

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Describe Shock.
Widespread, serious reduction of tissue perfusion (lack of O2 and nutrients), which, if prolonged, leads to generalized impairment of cellular functioning.
Arterial pressure is the driving force for blood through the organs.

What is it dependent on?
CO

Peripheral tone to return blood to heart

Amount of circulating blood

Marked reduction - HYPOTENSION
Who is at risk for development of shock? Clients with...
very young/very old

post-MI

severe dysrhythmia

adrenocortical dysfunction

history or recent hemorrhage or blood loss

burns

massive infection
What are the early signs of shock
agitation, restlessness with severe hypoxia
Describe Hypovolemic Shock
R/t external or internal blood loss (most common cause of shock)
Describe Cardiogenic Shock
R/t ischemia/impairment in tissue perfusion from myocardial infarction, serious arrhythmia, or CHF. All of this results in decreased CO
Describe Vasogenic Shock
R/t allergens, spinal cord injury, or peripheral neuropathy, all resulting in venous pooling and decreased blood return to the heart, which decreases CO over time
Describe Septic Shock
R/t to endotoxins released from bacteria, which cause vascular pooling, diminished venous return and CO.
HESI HINT: Cardiogenic shock
If cardiogenic shock exists with the presence of pulmonary edema (pump failure), position the client to REDUCE venous return further to the left ventricle
What are the stages of hypovolemic shock?
Stage I - Initial
Stage II - Compensatory
Stage III - Progressive
Stage IV - Irreversible
S/S of Stage I
Apprehension and restlessness (first signs of shock)

Increased HR

Cool, pale skin

Fatigue
Clinical Description of Stage I
Arteriolar constriction

Increased production of ADH

Arterial pressure is maintained

CO usually normal for healthy people

Selective reduction of BF to skin and muscle beds
S/S of Compensatory Stage
Flattened neck veins and delayed venous filling time

Increase pulse and respirations

Pallor, diaphoresis, cool skin

Decreased UO

Sunken soft eyeballs
Confusion
S/S of Progressive Stage
Edema

Increased blood viscosity

Excessively low BP

Dysrhythmia, ischemia, and MI

Weak, thready, or absent peripheral pulses
Clinical Description of Compensatory Stage
Marked reduction in CO

Arterial pressure decline (despite compensatory arterial vasoconstriction)

Massive adrenergic compensatory response resulting in: tachycardia, tachypnea, cutaneous vasoconstriction, and oliguria

Decreased cerebral perfusion
Clinical Description of Progressive Stage
Rapid circulatory deterioration

Decreased CO

Decreased tissue perfusion

Reduced blood volume
S/S of Irreversible Stage
Profound hypotension, unresponsive to vasopressor drugs

Severe hypoxemia, unresponsive to O2 administration

Anuria, renal shut down

Heart rate slows, BP falls, with consequent cardiac and respiratory arrest
Clinical Description of Irreversible Stage
Cell destruction so severe that death is inevitable

MOD Failure

IT THE NURSE'S RESPONSIBILITY TO RECOGNIZE THE S/S OF SHOCK. EVERY EFFORT SHOULD BE MADE TO PREVENT THE DEVASTATING CLINICAL COURSE THAT THE PROGRESSION OF SOCK CAN TAKE.
HESI HINT: Severe Shock
Severe shock leads to widespread cellular injury and impairs the integrity of the capillary membranes.

Fluid and osmotic proteins seep into the extravascular spaces, further reducing CO. A viscious cycle of decreased perfusion to ALL cellular level activities ensues.

All organs are damaged, and if perfusion problems persist, the damage can be permanent.
What is the goal of the medical treatment for shock?
Quick restoration of cardiac output and tissue perfusion.
How do you restore CO and tissue perfusion?
Rapid infusion with volume-expanding fluids (but if the shock is cardiogenic, then you could create pulmonary edema)

Central venous OR pulmonary artery catheters to monitor if shock is cardiogenic vs hypovolemic

Serial measuremnts of CVP, UO, HR, and mental states q 15 min

Follow immediately to improve perfusion, attention is directed towards the underlying condition

Administration of drugs is usually withheld until circulating volume has been restored

Give O2
What are volume-expanding fluids/substances?
Whole blood, plasma, plasma substitutes (colloid fluids)

Note that whole blood is acceptable volume expander, it is rarely used due to high risk transfusion reactions.
What are isotonic solutions?
They are electrolyte intravenous solutions like Lactate Ringer's and Normal Saline
If shock is cardiogenic in nature, what are things you want to do to help prevent or decrease pulmonary edema?
Resotration of cardiac function should take priority

Give cardiotonic drugs (digitalis) may increase cardiac contractility

Other drugs that enhance contractility include dopamine (Dopram)

Vasoconstricting agents like dopamine and norepinephrine (Levophed) may be used as vasoconstrictors in cardiogenic shock
Vitals of a patient in shock...
Tachycardia

Tachypnea

Blood pressure decreased (<80)
Early mental status in a patient with shock
Restless

Hyper-alert
Late mental status in a patient with shock
Decreased alertness

Lethargy

Coma
Skin changes in a patient with shock
Cool, clammy (warm with vasogenic and early septic shock)

Diaphoresis

Pale
Fluid status in a patient with shock
UO decreases or imbalance between IO

Abnormal CVP (<4 cm H2O)

Urine specific gravity >1.020 (hypovolemia)
How much urine do you want to maintain in a shock patient per hour?
30 mL

Less represents decrease renal perfusion = permanent renal damage = CALL DOCTOR
What measures can be taken to help the patient increase their level to a good level of CVP?
Bllod

Colloids

Electrolyte Solutions
The HCP may order fluids to elevate the CVP to ...
16 to 19 cm H2O to compensate for decreased CO
What are the vasopressors you give?
Epinephrine

Dopamine

Dobutamine

Norepinephrine

Isproterenol
What are the nursing interventions when you give vasopressors?
Administer through volume-controlled pump

Monitor BP q 5-15 min

Watch IV site for extravasation and tissue damage

Ask HCP for target BP (usually 80-90 systolic)
What are the vasodilators you give? Why?
Hydralazine

Nitro

Hydrochloride

They counteract vasopressors
If the drop in BP occurs and you are prescribed vasodilators and vasopressors...what do you do?
Decrease vasodilator infusion rate first

Increase vasopressors
If the rise in BP occurs and you are prescribed vasodilators and vasopressors...what do you do?
Decrease rate of vasopressors

Increase vasodilators
MAP
Mean Arterial Pressure

Pressure in the central arterial bed measured indirectly by BP measurement

Adults usually measure 100 mmHg

Measure through arterial catheter insertion
How do you calculate MAP?
CO X SVR

or

(SBP + 2DBP)/3
CO
Volume of blood ejected by the left ventricle per unit of time

Stroke Volume x HR

Normal is 4-6 L/min
SVR
systemic vascular resistance

Resistance to blood flow offered by the vessels in the peripheral vascular bed
CVP
Central Venous Pressure

Pressure within the right atrium

Normal is 4-10 cm of H2O
HESI HINT: Plasma
A common volume expanding substance is plasma and possibly whole blood