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Todays Objectives

Compare and contrast pathophysiology & manifestations of the various shock states and the physiologic compensatory mechanisms.

Identify nursing priorities with the various shock states. Compare & interpret abnormal laboratory test indicators

involved with septic, hypovolemic, and cardiogenic shock.

Analyze assessment data to determine nursing diagnoses and formulate a plan of care for clients with the various shock states.

Describe the medical management and mechanism of action, side effects and nursing interventions of pharmological management with shock states.

Compare & contrast pathophysiology, manifestations, nursing priorities seen with sepsis vs. Multiple Organ Dysfunction Syndrome (MODS).

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Shock Defined

Any problem that impairs oxygenation delivery to tissues & organs

CV system is where it begins

Table 40-3 p.826• Hypovolemic• Cardiogenic• Distributive

Neurogenic Anaphylactic Septic-SIRS Multiple Organ Dysfunction Syndrome (MODS)

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Processes of Shock Table 40-2 p.825

Initial stage…early shock• MAP decrease 5-10mm/Hg• Mild vasoconstriction• Tachycardic…Why???

Nonprogressive stage…compensatory stage• MAP decrease 10-15 mm/Hg• Mod. Vasoconstriction• Physiologic compensations

Renin, aldosterone, ADH Decreased u/o Mild acidosis Mild hyperkalemia

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Processes of Shock Table 40-2 p.825

Progressive stage…intermediate stage• MAP decrease >20mm/Hg• Overall metabolism-anaerobic

Moderate acidosisModerate hyperkalemiaTissue ischemia lactic acidosis-Lactate

Refractory stage…irreversible stage

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Hypovolemic Shock:Physical Assessment

Cardiovascular changes• Pulse• Blood pressure

Skin changes Respiratory changes

• Oxygen saturation• RR

Renal and urinary changes Central nervous system changes

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Hypovolemic Shock:Nursing Priorities

Impaired gas exchange• Nursing interventions

Deficient fluid volume• Nursing interventions

Decreased cardiac output• Nursing interventions

Risk for ineffective tissue perfusion• Body systems impacted???• Nursing interventions

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Sepsis

Patho Progressive

• Infection • Bacteremia• Systemic Inflammatory

Response Syndrome (SIRS)

• Sepsis• Severe sepsis• Septic shock• Multiple Organ Dysfunction

Syndrome (MODS)

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Sepsis:Hyperdynamic (early)

Cardiovascular changes Skin changes Respiratory changes Renal and urinary changes Central nervous system changes

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Sepsis:Hypodynamic (late)

Cardiovascular changes Skin changes Respiratory changes Renal and urinary changes Central nervous system changes

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Shock-Laboratory Findings Chart 40-3 p.831

General ABG’s

• pH• CO2• O2• HCO3

Lactate Hct Hgb Potassium

Septic Shock Blood cultures WBC

• Neutrophils• Bands

C Reactive Protein (CRP) D-Dimer Fibrinogen INR Platelets

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Nursing Care Priorities/Diagnosis

Impaired gas exchange r/t… Deficient fluid volume r/t… Ineffective tissue perfusion r/t… Anxiety Knowledge deficit r/t…

Ultimate Goal…

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General Shock: Nursing Interventions Remember A,B,C,D

Reverse the shock• Administer O2• Establish IV access

Restore fluid volume• Colloid• Crystalloid

Vasoactive gtts Administer blood products as ordered Nursing assessment

• Pulse/rhythm• BP-CVP• RR-O2 sats• Urine output• Skin color• Monitor labs

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Shock Case Study

Nursing priorities… Rapid Response paged SBAR to primary MD Medical/Nursing management:

• 2 large bore IV’s• NS 1000cc FF• Prepare for transfer to ICU• Stat Hgb• Obtain 2u PRBC from blood bank

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15” later…

VS: P-100 R-20 BP-92/46 sats 98% 6l n/c Hgb 8.2 First unit of blood initiated Prepare for transfer to ICU…unable to

take at this time Foley catheter placed VS just before transfer: P-88 R-18 BP-

102/64 sats 100% 4l n/c

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Septic Shock: Nursing Interventions

All the same as previous slide and… Obtain blood, urine cultures as ordered Administer IV abx Administer anti-arrythmics Aggressive IV fluid resuscitation Assess closely for signs of bleeding…DIC Strict aseptic technique Fever reduction as needed Client-family education

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Vasoactive Gtts chart 40-6 p.833

Dopamine• Renal• Beta effect• Alpha effect

Levophed (norepinephrine) Phenylephrine (neo-synephrine)

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Multiple Organ Dysfunction Syndrome

Patho• Uncontrolled inflammation• Progressive dysfunction of 2 or more systems• Risk factors• Causes

TraumaPancreatitisARDSMajor surgery

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Multiple Organ Dysfunction Syndrome

Four major organ systems involvement• Pulmonary• Renal• Cardiovascular• Coagulation

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Physical Assessment

Pulmonary CV Renal GI Neuro Coagulation

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Therapeutic Management

Support tissue oxygenation Fluid resuscitation Blood and blood products Dialysis or CRRT Nutritional support Antibiotic therapy

Priority Nursing Diagnoses…

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Nursing Priorities-Interventions

Assess resp. status Continuous cardiac monitoring Assess

perfusion Provide hydration and nutritional support Assess for coagulation dysfunction Emotional support/comfort measures

Evaluation….