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179 Cards in this Set

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(def)

a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism
shock
Shock results in an imbalance between what?
- supply and demand of oxygen
- supply and demand of nutrients
When a cell experiences a state of hypoperfusion, what happens to the demand/supply for oxygen and nutrients?
- demand exceeds the supply
What are 4 causes of cardiogenic shock?
1. systolic dysfunction
2. diastolic dysfunction
3. dysrhythmias
4. structural factors
What 2 classifications of shock fall under the category of low blood flow?
- cardiogenic shock
- hypovolemic shock
What 3 classifications of shock fall under the category of maldistribution of blood flow?
1. neurogenic shock
2. anaphylactic shock
3. septic shock
Hypovolemic shock is termed either ________ or ________.
absolute or relative
A loss of whole blood or loss of other body fluid (vomiting, diarrhea, diabetes insipidus) is classified as what type of shock?
- Absolute hypovolemic shock
Pooling of blood, internal bleeding, fluid shifts and massive vasodilation are classified as what type of shock?
- Relative hypovolemic shock
What are 3 causes of neurogenic shock?
- hemodynamic consequence of injury/disease to the spinal cord
- spinal anesthesia
- vasomotor center depression
(def)

A widespread and very serious allergic reaction. Symptoms include dizziness, loss of consciousness, labored breathing, swelling of the tongue and breathing tubes, blueness of the skin, low blood pressure, heart failure, and death. Immediate emergency treatment is required.
anaphylactic shock
(def)

a systemic inflammatory response to a documented or suspected infection resulting in hypotension despite fluid resuscitation along with the presence of tissue perfusion abnormalities
Septic shock
What types of patients are at a higher risk for septic shock?
- older adults
- patients with chronic diseases
- patients receiving immunosuppressive therapy
- malnourished or debilitated
___________ shock occurs where either systolic or diastolic dysfunction of the pumping action of the heart results in compromised cardiac output.
Cardiogenic
The heart's inability to pump the blood forward is classified as _______ dysfunction.
systolic
Systolic dysfunction primarily affects what part of the heart?
left ventricle b/c systolic pressure and tension are greater on the left side of the heart
What is compromised if systolic dysfunction affects the right side of the heart?
pulmonary circulation
__________ dysfunction is an impaired ability of the right or left ventricle to fill during diastole.
Diastolic
Relative hypovolemia is also known as what?
third spacing
In nearly all cases of shock, an increased HR is seen. What is the one exception?
Neurogenic shock
What effect does shock have on pulse pressure?
decreases pulse pressure
What effect does shock have on BP?
decreases
Hypovolemic shock result in a ______ (increase or decrease) in preload.
decrease
Hypovolemic shock result in a ______ (increase or decrease) in stroke volume.
decrease
Hypovolemic shock result in a ______ (increase or decrease) in capillary refill time.
decrease
Is tachypnea or bradypnea seen in early hypovolemic shock? What about late hypovolemic shock?
tachypnea in early stage, bradypnea in later stage
There is a(n) _________ (increase or decrease) in urine output with hypovolemic shock.
decrease
What changes in skin do you expect to see with hypovolemia?
decreased skin perfusion
cool or warm
dry
Describe bowel sound findings with hypovolemic shock.
Absent bowel sounds
Hypovolemic shock results in a cascade of events that lead to what 2 things (known as the hallmarks of shock)?
- decrease tissue perfusion
- impaired cellular metabolism
In hypovolemic shock, a patient may compensate for a loss of up to ___% of total blood volume.
15% (approximately 750mL)
Loss of blood volume between 15 and 30% will result in what response?
sympathetic nervous system mediated response
What changes occur in the body when the SNS mediated response is triggered? (3)
- increased heart rate
- increased cardiac output
- increased respiratory rate and depth
What are 6 causes of absolute hypovolemia?
1. hemorrhage
2. GI loss (vomiting or diarrhea)
3. fistula drainage
4. diabetes insipidus
5. hyperglycemia
6. diuresis
How can sepsis lead to relative hypovolemia?
massive vasodilation due to sepsis results in fluid leaking from the vascular space to the interstitial space
Why are stroke volume and pulmonary arterial wedge pressure decreased in hypovolemic shock?
b/c there is a decrease in circulating blood volume
What neurological changes are seen with hypovolemic shock?
- anxiety
- confusion
- agitation
Why is there an increase in lactic acid with hypovolemic shock?
b/c of the lack of oxygen at the cellular level resulting in anaerobic metabolism; this occurs once significant hypoperfusion has occured
What type of fluid replacement would likely reverse tissue dysfunction caused by a loss of 15-30% of fluid?
crystalloid fluid replacement
If volume loss is greater than ____%, compensatory mechanisms may begin to fail.
30%
What type of fluid replacement should be initiated for a fluid loss greater than 30%?
blood or blood products
Irreversible tissue destruction occurs with a loss of more than ___% of total blood volume.
40%
Respiratory alkalosis is considered a(n) _______ (early or late) sign of shock? why?
Early - due to hyperventilation
Metabolic acidosis is considered a(n) ________ (early or late) sign of shock? why?
Late - due to the accumulation of acids as a byproduct of anaerobic metabolism
Increased Urine Specific Gravity is a(n) ________ (early or late) sign of shock? why?
Early - occurs b/c of the action of ADH
Urine specific gravity fixed at 1.010 is a(n) ________ (early or late) sign of shock? why?
Late - this occurs in renal failure
Increased potassium levels are a(n) _______ (early or late) sign of shock? why?
late - related to cellular death, renal failure, and in the presence of acidosis
Decreased potassium levels are a(n) ________ (early or late) sign of shock? why?
early- increased secretion of aldosterone causes renal excretion of potassium
Increased sodium levels are a(n) _______ (early or late) sign of shock? why?
early- due to renal retention of sodium b/c of the increased secretion of aldosterone
Decreased sodium levels are a(n) _______ (early or late) sign of shock? why?
late - ONLY IF hypotonic fluids are administered
Increased glucose levels are a(n) _______ (early or late) sign of shock? why?
early - b/c the liver releases it in a response to stress and cortisol release
Decreased glucose levels are a(n) (early or late) sign of shock? why?
Late - depletion of storage and possible hepatocellular dysfunction
BUN is _______ (increased or decreased) in shock?
increased
___mL/kg/hour is the desired rate of urinary output.
0.5mL/kg/hour
The human body contains approximately ___ to ___ liters of blood.
5 to 6
What are the clinical guidelines for a patient to be classified as hypotensive?
SBP less than 90 or a reduction in SBP greater than 40 AND in which the BP is not adequate for normal perfusion
What are the 4 stages of shock?
1. initial
2. compensatory
3. progressive
4. refractory
Which Stage of Shock?

occurs at the cellular level and is not usually clinically apparent
initial stage
During the initial stage of shock, what is occurring at the cellular level? What is the result of this?
metabolism is converting from aerobic to anaerobic due to a lack of oxygen at the cellular level; results in lactic acid buildup
Which Stage of Shock?

body activates neural, hormonal, and biochemical compensatory mechanisms
Compensatory Stage
One of the first clinical signs of shock may be what?
a fall in bloop pressure (due to decreased CO and a narrowing of pulse pressure)
During the compensatory stage, baroreceptors located in the carotid and aortic bodies respond to decreased CO how?
by activating the SNS to stimulate the release of norepinephrine and epinephrine (potent vasoconstrictors)
Preferential perfusion to vital organs occurs during which stage of shock?
compensatory stage
During the compensatory stage, decreased blood flow to the kidneys activates what system?
the renin-angiotensin system
What are the 2 primary functions of Angiotensin II?
- potent vasoconstrictor (arterial and venous)
- stimulates the adrenal cortex to release aldosterone
What is the function of aldosterone?
- stimulates the kidneys to retain sodium and water and to excrete potassium
The posterior pituitary releases what hormone in the presence of increased serum osmolality?
ADH
What is the function of ADH?
- stimulates the kidneys to reabsorb water
Decreased blood flow to the GI during the compensatory stage of shock predisposes the patient to what possible complication?
paralytic ileus
Decreased blood flow to the skin during the compensatory stage of shock results in what symptom?
cool and clammy skin
The progressive stage of shock begins when?
when compensatory mechanisms fail
In the progressive stage of shock, aggressive interventions are necessary to prevent the development of what?
MODS (Multiple Organ Dysfunction Syndrome)
What are the 2 distinguishable features of the progressive stage of shock?
1. continued decrease in cellular perfusion
2. altered capillary permeability (results in fluid/proteins leaking out of the vascular space into the interstitial space)
Which Stage of Shock?

Development of anasarca may occur b/c of altered capillary permeability
Progressive Stage
Which Stage of Shock?

Blood flow to the lungs is decreased
Compensatory Stage
Which Stage of Shock?

tachypnea, crackles, and overall increased work in breathing
progressive stage
During the progressive stage, sustained hypoperfusion results in what?
weak peripheral pulses and ischemia to distal extremities
During the progressive stage, myocardial dysfunction from decreased perfusion results in what? (3)
- dysrhythmias
- myocardial ischemia
- possible MI
The effect of prolonged hypoperfusion on the kidneys is what?
renal tubular ischemia
What clinical findings related to renal function are seen during the progressive stage of shock? (3)
- decreased output
- increased BUN
- increased creatinine
In regards to the renal system, why does metabolic acidosis occur during the progressive stage of shock?
b/c the impaired kidneys cannot excrete acids or reabsorb bicarbonate
Which Stage of Shock?

- Oriented to person, place, time
or
- Restless, apprehensive, confused
or
- Change in LOC
Compensatory Stage
Which Stage of Shock?

- Decreased cerebral perfusion
- Decreased cerebral blood flow
- Listless or agitated
- Decreased response to stimuli
Progressive Stage
Which Stage of Shock?

- Unresponsive
- Areflexia
- pupils unreactive and dilated
Refractory Stage
Which Stage of Shock?

- SNS releases epinephrine/norepinephrine
- increased contractility and HR
- Coronary artery dilation
Compensatory Stage
Which Stage of Shock?

- Narrowed pulse pressure
- BP adequate to perfuse vital organs
Compensatory Stage
Which Stage of Shock?

- increase capillary permeability results in anasarca
- decreased CO results in decreased BP and increased HR
Progressive stage
Which Stage of Shock?

- Decrease in coronary perfusion leads to dysrhythmias, myocardial ischemia, and/or myocardial infarction
Progressive stage
Which Stage of Shock?

- decreased peripheral perfusion results in ischemia of distal extremities and diminished pulses
- decreased capillary refill
Progressive stage
Which Stage of Shock?

Decreased BP is inadequate to perfuse vital organs
Refractory Stage
Which Stage of Shock?

- decreased blood flow to the lungs leads to physiologic dead space in the lungs
- hyperventilation occurs
Compensatory stage
Which Stage of Shock?

Acute Respiratory distress syndrome
Progressive stage
Which Stage of Shock?

- Increased capillary permeability results in pulmonary and alveolar edema
- increase in respirations
- decrease in lung compliance
Progressive Stage
Which Stage of Shock?

Severe refractory hypoxemia
Refractory stage
Which Stage of Shock?

Respiratory failure
Refractory Stage
Which Stage of Shock?

- decreased blood flow to the GI with hypoactive bowel sounds
Compensatory Stage
Which Stage of Shock?

ischemic gut (results in erosive ulcers, bleeding, translocation of bacteria, and impaired absorption of nutrients)
Progressive and Refractory Stage
Which Stage of Shock?

Decreased renal blood flow resulting in Renin release
Compensatory Stage
Which Stage of Shock?

Renal tubules become ischemic which may lead to acute tubular necrosis
Progressive Stage
Which Stage of Shock?

Anuria
Refractory Stage
Which Stage of Shock?

- Liver fails to metabolize drugs and waste products
- jaundice
- increase in NH3 and lactate
Progressive Stage
Which Stage of Shock?

Metabolic changes occur from the accumulation of waste products due to liver failure
Refractory Stage
Which Stage of Shock?

Disseminated intravascular coagulation occurs
Progressive Stage (possible) and Refractory Stage
Which Stage of Shock?

Temperature can be normal or abnormal
Compensatory
Which Stage of Shock?

Hypothermia
Progressive and Refractory
Which Stage of Shock?

Skin is Pale and Cool
Compensatory Stage
Which Stage of Shock?

Skin is cold and clammy
Progressive Stage
Which Stage of Shock?

Skin is mottled and cyanotic
Refractory Stage
During the Progressive stage of shock, the liver loses its ability to function as an immune organ and bacteria may escape the GI. As a result, ______ may occur.
bacteremia (kupffer cells that would normally scavenge the escaped bacteria are not functioning due to liver failure)
DIC (disseminated intravascular coagulation) results in what?
clinically significant bleeding form many orifices (GI, lungs, puncture sites, etc.)
Which Stage of Shock?

decreased perfusion from peripheral vasoconstriction and decreased CO exacerbate anaerobic metaboslism
Refractory Stage
Which Stage of Shock?

patient exhibits profound hypotension and hypoxemia
Refractory Stage
True/False:

Recovery from the refractory stage of shock is unlikely.
True
Which Stage of Shock?

Disoriented, lethargic, comatose
Refractory
True/False:

ABGs are the only test needed to diagnose shock.
False- there is no single test to determine whether a person is in shock
The process of establishing a diagnosis of shock begins with what?
- a thorough history and physical examination
What are examples of diagnostic studies used to diagnose shock? (7)
- ABGs
- 12- lead ECG
- chest x-ray
- pulse oximetry
- hemodynamic monitoring
- blood studies
- electrolyte levels

**see table 67-3, pg. 1775 for additional tests and descriptions of each**
Maloactic fermentation converts what?
Tart malic acid into softer lactic acid and a small amount of CO2, a secondary fermentation in the barrel
Oxygen deliver is dependent on what 3 physiological things?
- cardiac output
- available hemoglobin
- arterial oxygen saturation
What are 3 methods used to increase the available supply of oxygen in the body?
1. optimize CO with drug therapy or fluid replacement
2. increase hemoglobin with blood or packed RBCs
3. increase arterial O2 sat with supplemental oxygen and mechanical ventilation
What are 2 types of monitoring that can be used to evaluate the body's balance between oxygen supply and demand.
- Central venous catheter (measures central venous oxygenation)
- PA catheter (measures mixed venous oxygenation)
What values are often looked at to evaluate a patient's response to oxygen treatments or their response to oxygen wasting activities?
- arterial O2 saturation
- CO
- Hemoglobin
- oxygen consumption
The cornerstone of therapy for septic, hypovolemic, and anaphylactic shock is what?
volume expansion
Although both crystalloids and colloids have a role in fluid resuscitation, the choice of which to use for resuscitation remains controversial. Currently it is accepted that which be used for initial resuscitation?
Isotonic crystalloids (ex. normal saline)
True/False:

Lactated Ringer's are the ideal choice for fluid resuscitation in cases of shock.
False- these should be used with extreme caution b/c the liver cannot convert the lactate to bicarbonate, thus increasing serum lactate levels
If a client does not respond to 2-3 liters of crystalloids, the next action is what?
the administration of blood and central venous or PA monitoring
What are the 2 major complications of large fluid volume resuscitation?
- hypothermia
- coagulopathy
The patient can be protected from hypothermia during massive fluid resuscitation how?
by warming both crystalloid and colloid solution before infusion
True/False:

Packed RBCs do not contain clotting factors
True
How can coagulopathy be prevented in a patient receiving packed RBCs?
by using blood studies to replace clotting factors that aren't given with the packed RBCs
True/False:

Vasopressor drugs are the primary and first choice for restoration of BP.
False- these are potent vasoconstrictors, and therefore reserved when all other methods have failed. Remember, the goal for fluid resuscitation is the restoration of tissue perfusion. Vasopressors will further jeopardize tissue perfusion.
The goal of vasopressor therapy is to achieve and maintain arterial pressure of ___ to ___ mm HG.
60 to 65
In the emergency management of shock, it is imperative that the nurse continually monitor what 8 things?
- LOC
- vital signs
- pulse oximetry
- peripheral pulses
- capillary refill
- respiratory status
- cardiac rhythm
- urine output
Would a vasodilating drug ever be used in a patient in shock?
only if the patient shows evidence of excessive vasoconstriction and poor tissue perfusion in spite of fluid replacement
Patients receiving Isotonic crystalloids for volume replacement should be monitored closely for what?
signs of circulatory overload
What is one of the primary manifestations of hypermetabolism in shock?
protein-calorie malnutrition
How soon should enteral nutrition begin after a person in shock has been stabilized?
within 24 hours
Enteral nutrition is the preferred delivery method of nutrition, however parenteral nutrition will be implemented in what 2 situations?
- if the patient cannot tolerate enteral nutrition for various reasons
- if enteral nutrition is failing to meet at least 80% of the patient's nutritional needs
What are common methods used to assess the nutritional and fluid status of patient's recovering from shock?
- daily weights (indicates fluid status)
- Serum protein, nitrogen balance, BUN, serum glucose, and serum electrolytes
If a patient is being treated for shock with a hypertonic solution, the nurse should particularly monitor the patient for what?
signs of hypernatremia (disorientation, convulsions)
The role of the nurse is vital in caring for patients who are at risk for developing shock. The initial assessment should be geared towards what?
ABCs (Airway, breathing, and circulation)

**always prioritize assessments, ABCs are ALWAYS priority before other assessments**
It is essential to get a brief history to properly diagnose a shock condition. What type of information should the nurse obtain when gathering information?
- description of event leading to shock condition
- time of onset and duration of symptoms
- health history (meds, allergies)
- details re: any previous care
What are the 4 overall goals for a patient in shock?
1. assurance of adequate tissue perfusion
2. restoration of normal or baseline BP
3. return/recovery of organ function
4. avoidance of complications from prolonged states of hypoperfusion
Although there are many possible nursing diagnoses related to shock, 2 commonly seen ones are what?
- Ineffective tissue perfusion: (list systems affected)
- Fear
List 5 classes of patients who are at an increased risk for shock.
1. older patients
2. patients with debilitating illnesses
3. immunocompromised patients
4. trauma patients (surgical or accidental)
5. any patient at risk for decreased O2 delivery or tissue hypoxia
Proper planning on part of the nurse is key to preventing shock. What actions by the nurse may prevent shock?
- careful, ongoing monitoring of intake and output and daily weights
- proper handwashing
The role of the nurse in caring for a patient in shock consists of what 5 things?
1. monitoring the patient's ongoing physical and emotional status to detect subtle changes
2. plan and implement nursing interventions
3. evaluation of patient's response to therapy
4. providing emotional support to the patient and family
5. collaborating with other members of the health team to coordinate care
How often should the neurological status of a patient in shock be assessed?
at least every hour (or more often)
What is the best indicator of cerebral blood flow?
neurological status
The nurse should be aware of clinical manifestations that may indicate neurologic involvement. What are examples of such manifestations? (6)
- change in behavior
- restlessness
- hyperalertness
- blurred vision
- confusion
- paresthesias
Most shock therapy is based on information about the patient's __________ status.
cardiovascular
If a patient is unstable, what should be assessed every 15 minutes in regards to the cardiovascular system? (5)
- Heart Rate, heart sounds
- Capillary Refill
- BP
- Central venous pressure
- PA pressures, including continuous cardiac output
How often should PAWP (Pulmonary artery wedge pressure) be assessed in an unstable patient?
- every 1 to 2 hours
The patient's ______ should be continuously monitored to detect dysrhythmias that may result from cardiovascular and metabolic problems.
ECG
The presence of an S3 sound in an adult usually indicates what?
heart failure
In the beginning of shock treatment, the patient's respond to fluid and medication administration is assessed how often?
every 15 minutes
What should be monitored when assessing the respiratory status of a patient in shock?
- rate, depth, and rhythm of respirations
- breath sounds
- pulse oximetry
- ABGs
True/False:

Most patients in shock will be intubated and on mechanical ventilation
True
Initial interpretation of ABGs is often who's responsibility?
the nurses
A PaO2 below 60mmHg (in the absence of chronic lung disease) indicates what? What is the next action to correct this?
the presence of hypoxemia - Administration of higher concentration of oxygen or a different mode of oxygen delivery
How often should the rate, rhythm, and depth of respirations be assessed for a patient in shock?
every 15-30 minutes
What alteration in the use of pulse oximetry might be made for a patient in shock?
the finger or toe might not be accurate due to poor peripheral circulation; the probe may need to be attached to the nose, ear, or forehead to increase accuracy
A urine output of less than __ml/kg/hr may indicate inadequate perfusion to the kidneys.
0.5ml/kg/hr
In the presence of an abnormal or elevated temperature, the tympanic or pulmonary arterial temperature should be assessed how often? What if the temperature is normal?
every hour for abnormal/elevated, every 4 hours for normal
When assessing the skin, the nurse should pay close attention if the patient exhibits what? (6)
- abnormal temperature
- pallor
- flushing
- cyanosis
- diaphoresis
- piloerection
For the patient in shock, what types of assessments are made in reference to the GI system?
- Bowel sounds every 4 hours
- abdomen examination for signs of ascites
What special nursing assessments are made if a NG tube is in place?
- drainage is measured and checked for signs of occult blood
The stools of a patient in shock should be assessed for what?
occult blood
The client in shock is prone to skin breakdown and infection. Bathing and other hygiene/care measures are prevention against this, however this is not always done for a patient in shock. Why?
b/c these activities drain available oxygen and these patients are already experiencing problems with oxygen delivery; the nurse must use clinical judgment in these cases
True/False:

Lemon glycerin swabs should be used to clean the oral cavity of a patient in shock.
False- Normal saline or diluted mouthwash should be used; lemon swabs further dry the mucosa
How often should passive ROM be done to maintain joint flexibility for a person in shock?
Every 3-4 hours
How often should a person in shock be repositioned? What other measures might be in place to reduce pressure?
Every 1-2 hours; additionally, a pressure-relieving mattress or specialty bed may be used
What medication groups are often administered to reduce anxiety and fear in the patient with shock? (3)
- benzodiazepines
- opioids/anesthetics
- neuromuscular blocking agents
What is often the last sense to be diminished in a critical patient?
hearing- you should always talk with your patient even if they are non-responsive b/c they still may be able to hear you
What are some measures that can be taken to reduce fear and anxiety in shock patients? (7)
- talk with them (even if they seem unresponsive)
- Give them a method of communication (ex. slate) if they are intubated
- Give simple explanations of procedures before performing them
- Offer to contact a member of the clergy for spiritual counseling
- Involve family in care and support
- Provide Privacy
- Keep call light in reach at all times
(def)

the failure of two or more organ systems in an acutely ill patient such that homeostasis cannot be maintained w/o intervention
MODS (Multiple organ dysfunction syndrome)
(def)

a systemic inflammatory response to a variety of insults, including infection, ischemia, infarction, and injury
SIRS (Systemic inflammatory response system)
What is usually the first body system to show signs of dysfunction in SIRS and MODS?
The respiratory system
What are 6 expected outcomes for a patient in shock?
1. Normal or baseline ECG and BP
2. Normal temperature
3. Warm, dry skin
4. Urinary output >0.5mL/kg/hr
5. Normal respiratory rate and rhythm and O2 saturation >90%
6. Verbilization of fears and anxiety