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25 Cards in this Set

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Initial stage of shock
This stage is present when the clients baseling MAP is decrease by less that 10 mm Hg. During this stage, compensatroy mechanisms are so effective at returning MAP to normal levels that oxygenated blood flow to all vital organs is maintained.
Increased sympathetic stimulation(Mild vasoconstriction, and increase in heart rate)
Nonprogressive Stage of shock
This stage occurs when MAP decreses 10-15 mm Hg below baseline.
A.Continued sympathetic stimulation(moderate vasocontriction, Increased heartrated, decreased pulse pressure)
B. Chemical compensation(Renin, aldosteron and antidiuretic hormone scretion AEB increased vasocontriction, decreased urine output, stimulation of the thirst reflex)
C. Some anaerobic metabolism in nonvital organs(mild acidosis, mild hyperkalemia)
Progressive Stage of shock
Decrease in MAP of >20 mm Hg from baseline
A. Anoxia of nonvital organs
B. Hypoxia of vital organs
C. Overall metabolism is anaerobic(moderate acidois, moderate hyperkalemia, tissue ischemia)
Refractory Stage of shock
A. Sever tissue hypoxia with ischemia and necrosis
b. Release of myocardial depressant factor from the pancreas
c. buildup of toxic metabolites
d. Multiple organ dysfunction syndrome
e. Death
Description of Septic Shock
Septic shock occurs when large amounts of toxins and endotoxins produced by bacteria are released into the blood, causing a whold body inflammotory reaction
any pathogenic organism
gram negative bacteria
Disseminted intravascular coagulation
Renal failure
heart failure
GI ulcers
abnormal liver function
A. Assess age, ask about recent illness, trauma, invasive procedures, or chronic conditions, that may lead to sepsis
B. Assess for drug use in the past week, some drugs may cause changes that result in septic shock such drugs as: aspirin and aspirin containing drugs antibotics, and cancer therapy drugs
Physical Assessment
Manifestations of the first phase are unique to septic shock and are often opposite from those seen with all other types of shock
Cardiovascular Changes
cardiac output increases during the first phase called hyperdynamic
also tachycardia, increased stroke volume, and normal to elevated systolic BP, and a normal CVP
Respiratory Changes
HYPERDYNAMIC STAGE: respiratory rate and depth are increased, leading to respiratory alkalosis
Acute respiratory distress may occur
Psychosocial assessment
indicator that clients may be in the beginning of septic shock os a change in affect of behavior. Compare with how they acted earlier in the day, if possible.
Skin Changes
No change
skinis cool, clammy, and pallor or cyanosis is present
Laboratory assessment
Presence of bacteria in the blood
Obtain specimens of urine, blodd, sputum and any drainage for culture per DR. order
Abnormal findings with septic shock is changes in WBS count the differential leuckocyte count may show a left shift
Changes in H&H levels are usually not present until late in SS at that point fibrinogen levels and platelet count are low also.
Activated protein C is reduced
Expected outcomes
ABG's within normal range
Maintenance of urine output of at lease 20mL/hr
Maintenance of MAP within 10mm hg of baseline
absence of multiple organ dysfunction syndrome
states measures to reduce risk for sepsis
-Ensure patent airway
-Start or KVO IV
-Administer Oxygen
-Obtain specimens of blood, urine, wound drainage, and sputum for culture
-Increase IV fluid rate
-Use aseptic technique
-Handle client gently
-Examine client for overt bleeding
-Elevate clients feet, keeping head flat or at 30 degree angle
-Take VS every 5 minutes until stable
-Administer medications as prescribed ( heparin during phase 1, clotting factor platelets and plasma during phase 2)
Drug therapy
A.Vasoconstrictors 1.Dopamine hydrochloride(Intropin, Revimine) 2. Epinephrine (Adrenalin) 3.Norepinephrine (Levophed) 4.Phenylephrine (Neo-synephrine)
B. Antibotics

Drug therapy in the first phase is aimed at preventing coagulation, and second phase is aimed increasing the blood's ability to clot

Doing experimental therapy by Giving clients antibodies
Description of Cardiogenic Shock
A condition of diminished cardiac output that severly impairs tissue perfusion, the most lethal form of shock, sometimes called pump failure.
Direct Pump Failure
specific cause or risk factors
cardiac arrest
ventricular dysrhythmias(fibrillation, tachycardia)
cardiac amyloidosis
cardiomyopathies(viral, toxic)
Myocardial degeneration
Assessment Hx
Assess for disorders such as MI or cardiomyopathy that severely decreases left ventricular function, anginal pain
Physical findings
urine output less than 20 mL/hr
pale, cold clammy skin
rapid shallow breathes
rapid thready pulse
MAP of less than 60mm Hg in adults
Juggular vein distention
severe anxiety
decreased LOC
pulmonary crackles
Intra aortic balloon pumo
Possible tube feedings or parental nutrition
bed rest
osmotic diuretics
Possible heart transplant
possible ventricular device