LECTURER: IDOL L. BONDOC,M.D.,R.N.

DOC IDOL

 Life-threatening

condition in which systemic BP is inadequate to deliver oxygen and nutrients to support vital organs and cellular function.
tissue perfusion that, if untreated, results in cellular starvation, cell death, organ dysfunction progressing to organ failure, and eventual death.

Inadequate

1. 2.

Adequate cardiac pump

Effective vasculature circulatory system Sufficient blood volume or

3.

 Almost

any patient with any disease state may be at risk of developing shock
requires assessment ongoing systematic

Nurse

Close

collaboration with other members of the health care team and a physicians orders orders that need to be executed with speed and accuracy

Anticipate

ANO KA BA?

1.HYPOVOLEMIC SHOCK decrease in intravascular volume 2.CARDIOGENIC SHOCK heart has an impaired pumping ability, coronary or noncoronary origin
3. CIRCULATORY OR DISTRIBUTIVE SHOCK maldistribution or mismatch of blood flow to the cells

4. OBSTRUCTIVE SHOCK mechanical obstruction of blood flow through the central circulatory system despite normal myocardial function and intravascular volume.
example: Pulmonary embolism Cardiac tamponade Dissecting aortic aneurysm Tension pneumothorax

Cellular edema
Mitochondrial damage/swelling

Increased membrane permeability

Lysosomal membrane rupture

Efflux of K
Influx of Na and water

Cell damage and death

MAP = SBP + 2 (DBP) 3 Example: patients BP = 125/75 mm HG

MAP = 125 + (2 x 75) 3 MAP = 92 (rounded to nearest 1/10)

PHYSIOLOGY/PATHOPHYSIOLOGY
Precipitating cause of shock
Decrease circulating blood volume

Decrease cardiac output Hypotension and decrease tissue perfusion

Baroreceptors stimulated Increase sympathetic stimulation and CV system

Increase HR; contractility Arteriolar constriction Venous constriction Increase CO Increase BP Increase return

IDOL L. BONDOC,M.D.,R.N.

CLINICAL FINDINGS IN STAGES OF SHOCK

FINDINGS COMPENSATORY PROGRESSIVE IRREVERSIBLE/ REFRACTORY

Blood pressure

Systolic <80-90 mm Hg

Requires mechanical or pharmacologic support

Heart rate

>100 bpm

>150 bpm

Erratic or asystolic

Respiratory status

>20 breaths/min

Rapid, shallow respirations; crackles

Requires intubation

CLINICAL FINDINGS IN STAGES OF SHOCK

FINDINGS COMPENSATORY PROGRESSIVE IRREVERSIBLE/ REFRACTORY

Skin

Cold, clammy

Mottled Petechiae

Jaundice

Urinary output

Decreased

0.5 ml/kg/hr

Anuric Requires dialysis

Unconscious

Mentation

Confusion

Lethargy

Acid-base balance

Metabolic acidosis, initially Respiratory alkalosis, compensatory

Metabolic acidosis

Profound acidosis

CLINICAL FINDINGS IN STAGES OF SHOCK

FINDINGS COMPENSATORY PROGRESSIVE IRREVERSIBLE/ REFRACTORY

Prognosis

Good

Worse

Nil

Carry out Nursing Monitor tissue Preventing prescribed Management perfusion complications treatments (hemodynamic) Promoting rest Preventing Reducing and comfort complications anxiety Supporting Protecting Promoting family from injury safety members
Providing comfort

HELLO!!!

 Level
Vital

of consciousness

signs PP = SBP DBP

Normal PP = 30 to 40 mm Hg Narrowing PP is an earlier indicator of shock than a drop of SBP

Urinary

output
values increase Na, K and

Laboratory

glucose

RESPIRATORY EFFECTS

Rapid and shallow Crackles Increase C02 Decrease 02 Pulmonary damage progression

ARDS Acute lung injury (ALI) Shock lung Noncardiogenic edema

CARDIOVASCULAR EFFECTS

Dysrhythmias and ischemia

HR >150
Chest pain to MI Increase cardiac enzymes LDH, CPK-MB, cTn-I Myocardial depression and ventricular dilation

NEUROLOGIC EFFECTS Dilated pupils

Confusion Lethargy

RENAL EFFECTS
ARF

Increase BUN and serum creatinine Fluid and electrolytes shift

Loss of the renal-hormonal regulation of BP

Decrease UO below 0.5/ml/kg per hour or below 30 ml per hour

Accumulation

HEPATIC EFFECTS

and lactic acid

of ammonia

Elevated

liver enzymes AST/SGOT, ALT/SGPT, LD bilirubin

Elevated

GASTROINTESTINAL EFFECTS Stress ulcers

Bloody

diarrhea
toxin translocation

Bacterial

HEMATOLOGIC EFFECTS
DIC

widespread clotting and bleeding

Ecchymoses bruises Petechiae bleeding Prolonged PTT and PT Decreased clotting factors and platelet counts

 Decreased
ECF

IV volume

= IV + interstitial (3-4x of IV)

Reduction

in IV volume of 15% to 25% or loss of 750 to 1300 ml of blood in a 70-kg (154-lb) person

HATAW YOKABABS!

RISK FACTORS
EXTERNAL: FLUID LOSSES Trauma Surgery Vomiting Diarrhea Diuresis Diabetes insipidus INTERNAL: FLUID SHIFTS Hemorrhage Burns Ascites Peritonitis Dehydration

PATHOPHYSIOLOGIC SEQUENCE OF EVENTS

Decreased blood volume

Decreased venous return Decreased stroke volume Decreased cardiac output/BP Decreased tissue perfusion

READ ALOUD!!!

MAJOR GOALS IN THE MANAGEMENT

1.

TREATMENT CAUSE

OF

THE

UNDERLYING

2.

FLUID AND BLOOD REPLACEMENT/ RESUSCITATION

REDISTRIBUTION OF FLUID
a.

3.

Modified Trendelenberg's position

4.

PHARMACOLOGY
a.

Insulin if DHN is secondary to hyperglycemia Desmopressin (DDAVP) DI Anti-diarrheal diarrhea Antiemetic vomiting

b. c. d.

5.

IMPLEMENTING OTHER MEASURES

a. b.

O2 administration Direct efforts to the safety and comfort of the patient

GRRRRR!!!

Impaired

hearts ability to contract and to pump blood oxygen for the heart and tissues

Inadequate

RISK FACTORS
CORONARY FACTORS NON-CORONARY FACTORS

Myocardial infarction

Cardiomyopathies
Valvular damage Cardiac tamponade Dysrhythmias

PATHOPHYSIOLOGIC SEQUENCE OF EVENTS

Decreased cardiac contractility

Decreased stroke volume and cardiac output

Pulmonary congestion

Decreased systemic tissue perfusion

Decreased coronary artery perfusion

NURSING MANAGEMENT:
1.

PREVENTING CARDIOGENIC SHOCK

a.
b. c.

Conserving the patients energy

Promptly relieving angina 02 supplement

2.

MONITORING STATUS

HEMODYNAMIC

3.

ADMINISTERING MEDICATIONS AND INTRAVENOUS FLUIDS MAINTAINING INTRA-AORTIC BALLOON COUNTERPULSATION ENHANCING COMFORT SAFETY AND

4.

5.

Blood

volume is abnormally displaced in the vasculature

a relative hypovolemia because not enough blood returns to the heart, which lead to subsequent inadequate tissue perfusion

Causes

RISK FACTORS
SEPTIC SHOCK NEUROGENIC SHOCK
ANAPHYLACTIC SHOCK

Immunosuppression Spinal cord injury Penicillin

Extreme of age (< 1 yr and >65 yr) Malnourishment Chronic illness Invasive procedures

Spinal anesthesia

sensitivity

Transfusion Depressant action reaction of medications Bee sting allergy Glucose deficiency Latex sensitivity

PATHOPHYSIOLOGIC SEQUENCE OF EVENTS

Vasodilation
Maldistribution of blood volume Decreased venous return

Decreased stroke volume

Decreased cardiac output Decreased tissue perfusion

REACTION BOYS???

NURSING MANAGEMENT FOR SEPTIC SHOCK

1.

All invasive procedures must be carried out with aseptic technique after careful hand hygiene
Collaborate with other members of the health care team to identify the site and source of sepsis and the specific organisms involved

2.

3.

Efforts to increase comfort if the patient experiences fever, chills, or shivering

Administer prescribed IVF and medications Monitor hemodynamic status, fluid I&O, nutritional status, daily weights

4.

5.

NURSING MANAGEMENT OF NEUROGENIC SHOCK 1. Elevate and maintain the head of the bed at least 30 degrees spinal or epidural anesthesia
2. 3.

Immobilization spinal cord injury If no spinal cord injury, mobilize or do passive exercises to prevent DVT (positive Homans sign)

4.

In the immediate post-injury period, monitor for signs of internal bleeding that could lead to hypovolemic shock. Supporting cardiovascular neurologic function.
a.

5.

and

Applying elastic compression stockings administer heparin as ordered

Elevating the foot of the bed

b.

NURSING MANAGEMENT of ANAPHYLACTIC SHOCK

1.

Assess all allergies reactions to antigens Communicate the reactions or allergies

or

previous of

2.

existence

3.

Advise the patient to wear or carry ID that names the specific allergen or antigen

4.

Be aware of drug interaction if antibiotics is administered Identify patients at risk for anaphylactic reaction to contrast agents Explain the events to patient and family

5.

6.