All About Shock: Med/surg 2 Exam 2

Front 1

definition of shock

Back 1

widespread, serious reduction of tissue perfusion (lack of O2 and nutrients) which, if prolonged, leads to generalized impairment of cellular functioning

Front 2

What is arterial pressure?

Back 2

the driving force of blood flow thru all organs

Front 3

What is arterial pressure dependent on?

Back 3

1) on cardiac output to perfuse the body
2) on peripheral vasomotor tone to return blood and other fluids to the heart

Front 4

What two things result in system hypotension?

Back 4

marked reduction in either
1) cardiac output
2) or peripheral vasomotor tone
without a compensatory elevation in the other

Front 5

Shock risk factors

Back 5

-very young and very old
-post MI pts
-pts with severe dysrhythmia
-pts with adrenocortical dysfunction
-pts with a hx of recent hemorrhage or blood loss
-pts with burns
-pts with massive or overwhelming infection

Front 6

*What are early signs of shock?

Back 6

agitation and restlessness, which result from cerebral hypoxia

Front 7

What are the 4 types of shock?

Back 7

hypovolemic shock, cardiogenic shock, vasogenic shock, septic shock

Front 8

What is hypovolemic shock?

Back 8

r/t external or internal blood or fluid loss; the most common cause of shock

Front 9

What is cardiogenic shock?

Back 9

r/t ischemia or impairment in tissue perfusion resulting from MI, serious arrhythmia, or HF. All of these cause decreased cardiac output

Front 10

What is vasogenic shock?

Back 10

r/t to allergens (anaphylaxis), spinal cord injury, or peripheral neuropathies, all resulting in venous pooling and decreased blood return to the heart, which decreases cardiac output over time

Front 11

What is septic shock?

Back 11

r/t endotoxins released by bacteria, which cause vascular pooling, diminished venous return, and reduced cardiac output

Front 12

*What position should you place pts in if they have cardiogenic shock in the presence of pulmonary edema?

Back 12

Position pts to reduce venous return (high Fowler position with legs down) in order to decrease further venous return to the left ventricle

Front 13

What is a main medical tx for most shock?

Back 13

Rapid infusion of volume-expanding fluids:
1) whole blood, plasma, plasma substitutes, but all rarely used b/c of risk of transfusion rxns
2) isotonic, electrolyte IV solutions such as Ringer lactate soln and NS

Front 14

Medical tx for cardiogenic shock:

Back 14

Not the infusion of volume-expanding fluids, as they may result in pulmonary edema. Instead:
1) restoration of cardiac function should take priority
2) administration of cardiotonic drugs (such as Dig) may increase cardiac contractility
3) Other drugs that enhance contractility include dopamine (Dopram)
4) Vasoconstricting agents such as dopamine (Dopram) and norepinephrine (Levophed) may be used

Front 15

Central venous pulmonary artery catheters as medical tx for shock?

Back 15

Central venous pulmonary artery catheters are inserting in the OR to monitor cardiogenic vs hypovolemic shock

Front 16

What to monitor during shock and how often?

Back 16

Serial measurements of central venous pressure (CVP), urine output, heart rate, and the clinical and mental state of the pt are taken every 5-15 minutes

Front 17

When should you treat the cause of shock?

Back 17

Following immediate attention to improvement of perfusion, attention is directed toward treating the underlying cause of the condition

Front 18

Do you give drugs during shock?

Back 18

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

Front 19

What should be administered during shock?

Back 19

Oxygen

Front 20

What VS are expected with shock?

Back 20

-Tachycardia (pulse > 100)
-Tachypnea (respirations > 24)
-BP decreases (systolic <80)

Front 21

Mental status in shock

Back 21

1) Early shock: restless, hyper alert
2) Late shock: decreased alertness, lethargy, coma

Front 22

Skin changes in shock?

Back 22

-cool, clammy skin (warm skin in vasogenic and early septic shock)
-diaphoresis
-paleness

Front 23

Fluid status in shock?

Back 23

Acute renal tubular necrosis can happen quickly in shock
1) urine output decreases or an inbalanace b/w intake and output occurs
2) CVP is abnormal (<4 cm of H20)
3) a urine specific gravity of >1.020 indicates hypovolemia

Front 24

Analysis (Nsg Dx) in shock?

Back 24

1) Fluid volume defecit r/t..
2) Decreased cardiac output r/t
3) Disturbed thought processes r/t..
4) Anxiety (family and individual) r/t..

Front 25

Arterial pressure: What is mean arterial pressure (MAP)?

Back 25

1) level of pressure in the central arterial bed measured indirectly by BP
2) in adults, usually approaches 100 mmHg
3) can be measured directly thru arterial catheter insertion

Front 26

Arterial pressure: What is cardiac output (CO)?

Back 26

Volume of blood ejected by the left ventricle per unit of time

Front 27

Arterial pressure: What is peripheral resistance (PR)?

Back 27

resistance to blood flow offered by the vessels in the peripheral vascular bed

Front 28

Arterial pressure: What is central venous pressure (CVP)?

Back 28

pressure within the right atrium
-normal is 4-10 cm H20
-in shock often <4 cm of H20

Front 29

Shock Interventions: monitor and understand..

Back 29

arterial pressure by understanding the concepts r/t arterial pressure (MAP, CO, PR, CVP)

Front 30

Shock interventions: What do you monitor several times an hour?

Back 30

Monitor BP, pulse, respirations, and arrhythmias every 15 minutes or more often, depending on stability of pt

Front 31

What to monitor during shock and how often?

Back 31

Serial measurements of central venous pressure (CVP), urine output, heart rate, and the clinical and mental state of the pt are taken every 5-15 minutes

Front 32

When should you treat the cause of shock?

Back 32

Following immediate attention to improvement of perfusion, attention is directed toward treating the underlying cause of the condition

Front 33

Do you give drugs during shock?

Back 33

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

Front 34

What should be administered during shock?

Back 34

Oxygen

Front 35

What VS are expected with shock?

Back 35

-Tachycardia (pulse > 100)
-Tachypnea (respirations > 24)
-BP decreases (systolic <80)

Front 36

Shock interventions: when should you assess urine output

Back 36

Assess urine output every hour to maintain at least 30 mL/hr
-Notify HCP if urine output drops <30 mL/hr (reflects decreased renal perfusion and may result in permanent renal damage)

Front 37

Shock interventions: administer fluids

Back 37

Administer fluids as prescribed by HCP: blood, colloids, or electrolyte solns until designated CVP is reached (in shock situations, the HCP often orders fluids so as to elevate CVP to 16-19 cm of H20 as compensation for decreased CO)

Front 38

Shock interventions: posn for most shock pts

Back 38

Place client in modified Trendelenburg posn (feet up 45 degrees, head falt)

Front 39

Shock interventions: how should you administer meds?

Back 39

Administer meds IV (not IM or SQ) until perfusion improves in muscles and SQ tissue

Front 40

Do you keep pt warm or cool?

Back 40

Keep pt warm; increase heat in room or put warm blankets on client (not too hot)

Front 41

Shock interventions: siderails?

Back 41

Keep siderails up during all procedures; pts in shock experience mental confusion and may easily be injured by falls

Front 42

Shock intervention: lab work?

Back 42

Obtain blood for lab work as prescribed: complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), creatinine (renal damage), and blood gasses (oxygenation)

Front 43

Shock interventions: When administering vasopressors (constricters) or adrenergic stimulants..

Back 43

When administering vasopressors or adrenergic stimulants such as epinephrine, dopamine (dopram), dobutamine (dobutrex), norepinephrine (levophed) or isoproterenol (Isuprel):
1) administer thru volume controlled pump
2) monitor BP every 5-15 min
3) watch IV site carefully for extravasation and tissue damage
4) ask HCP for target mean systolic BP (usually 80-90 mmHg)

Front 44

Shock interventions: When administering vasodilators to counteract effects of vasopressors:

Back 44

When administering vasodilators, such as hydralazine (Apresoline), nitroprusside (Nipride), or labetalol hydrochloride (Normodyne, Trandate) to counteract effects of vasopressors:
1) Wait for precipitous decrease or increase in BP if prescribed together
2) if drop in BP occurs, decrease vasodilator infusion rate first, then increase vasopressor
3) if BP increases precipitously, decrease vasopressor first, then increase rate of vasodilator
4) obtain blood work as prescribed: CBC, electrolytes, BUN, creatinine (renal damage), and blood gasses (oxygenation)

Front 45

*What do all vasopressors and vasodilators drugs require?

Back 45

All vasopressor and vasodilator drugs are potent and dangerous and require that the client be weaned on and off them. Do not change both infusion rates simultaneously

Front 46

Shock interventions: provide family support..

Back 46

1) notify appropriate support persons for families waiting during crisis, i.e. call spiritual advisor, other family members, or anyone the family thinks will be supportive
2) at intervals, notify family of actions and progress or lack of progress in realistic terms
3) collaborate with HCP before notifying family of medical interventions

Front 47

*Pt has shock after bee sting. What is the first priority?

Back 47

1) Maintaining an open airway (the allergic rxn damages the lining of the airways, causing edema).
2) Keep the client warm and free of constricting clothing
3) Keep pt's legs elevated (but not in the Trendelenburg posn b/c the wt of the lower orgams restricts breathing)
4) Epinephrine: SQ for mild and IV for severe
5) Volume-expanding fluids are usually given to pts in shock, unless shock is cardiogenic

Front 48

*Volume-expanding fluids in cardiogenic shock?

Back 48

Not in cardiogenic shock, as pulmonary edema may result. Drugs of choice instead are:
1) Digitalis preparations: they increase the contractility of the heart muscle
2) vasoconstrictors (Levophed, Dopamine). Generalized vasoconstriction provides more blood to the heart to help maintain CO

Front 49

What are the 4 stages of hypovolemic shock?

Back 49

Stage I: Initial Stage
Stage 2: Compensatory Stage
Stage 3: Progressive Stage
Stage 4: Irreversible Stage

Front 50

Hypovolemic shock: Stage I

Back 50

Stage I - Initial Stage
-blood loss of <10%
-compensatory mechanisms triggered

S/Sx:
-apprehension and restlessness (first signs of shock)
-increased HR
-cool pale skin
-fatigue

Front 51

Hypovolemic shock: Stage II

Back 51

Stage II - Compensastory Stage
-blood volume reduced by 15-25%
-decompensation begins

S/Sx:
-flattened neck veins and delayed venous filling time
-increased pulse and respirations
-pallor, diaphoresis, and cool skin
-decreased urinary output
-sunken soft eyeballs
-confusion

Front 52

Hypovolemic shock: Stage III

Back 52

Stage III - Progressive Stage
S/Sx:
-edema
-increased blood viscosity
-excessively low BP
-dysrhythmia, ischemia, and myocardial infarction
-weak thready or absent peripheral pulses

Front 53

Hypovolemic shock: Stage IV

Back 53

Stage IV - Irreversible Stage
S/Sx:
-profound hypotension, unresponsiveness to vasopressor drugs
-severe hypoxemia, unresponsiveness to O2 administration
-anuria, renal shutdown
-HR slows, BP falls, with consequent cardiac and respiratory arrest

Front 54

Hypovolemic shock: Stage I Clinical Description

Back 54

-arteriolar constriction
-increased production of ADH
-arterial pressure maintained
-CO usually normal for healthy ppl
-Selective reduction in blood flow to skin and muscle beds

Front 55

Hypovolemic shock: Stage II Clinical Description

Back 55

-marked reduction in CO
-arterial pressure decline (despite compensatory arteriolar vasoconstriction)
-massive adrenergic compensatory response, resulting in: tachycardia, tachypnea, cutaneous vasoconstriction, and oliguria
-decreased cerebral perfusion

Front 56

Hypovolemic shock: Stage II clinical description

Back 56

-rapid circulatory deterioration
-decreased CO
-decreaed tissue perfusion
-reduced blood volume

Front 57

Hypovolemic Shock: Stage IV clinical description

Back 57

-cell destruction so severe that death is inevitable
-multiple organ system failure
-it is the nurse;s responsibility to recognize teh s/sx of shock. Every effort should be made to prevent the devastating clinical course that the progression of shock can take

Front 58

*Vicious cycle of severe shock

Back 58

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 vicious circle of decreased perfusion to all cellular level activities ensues. All organs are damaged, and if perfusion problems persist, the damage can be permanent