Objectives
Identify
Objectives continued
Compare
Shock
Is
Shock Continued
All
problems
Infections
Patients
Types of Shock
Shock
Cardiogenic
Hypovolemic
Neurogenic
Anaphylactic
Septic
Cardiogenic Shock
Occurs
Cardiogenic Shock
Other
causes:
Myocardial ischemia
Papillary muscle dysfunction
Cardiomyopathy
Chronic or acute heart failure
Acidosis
Hypovolemic Shock
Occurs
Pathophysiology
The
Dehydration
Stages of shock
Initial
stage
Nonprogressive stage
Progressive stage
Refractory stage
Nonprogressive Stage
Continued
Renin
Nonprogressive Stage
Continued
Manifestations
include:
Subjective
Comparing these
changes with the values
and manifestations
earlier is critical to
identifying this stage of
shock.
Thirst sensation
Anxiety
Objective
Restlessness
Tachycardia
Increased respiratory rate
Decreased urine output
Falling systolic blood pressure
Rising diastolic blood pressure
Cool extremities
Narrowing pulse pressure
Decrease in oxygen saturation
Progressive Stage
Or
Manifestations
include:
Vital
Subjective:
Tissues
Objective:
This
Refractory Stage
Or
include:
Multisystem Organ
Dysfunction
Assessment and needs identification
This is the sequence of cell damage
caused by the massive release of toxic
metabolites and enzymes.
This causes more cells to die and break
open causing a vicious cycle. Small clots
occur.
Occurs first in the liver, heart, brain and
kidney.
Decreased
level of
consciousness
Respiratory depression
Diminished bowel sounds
Jaundice
Oliguria or anuria
Nursing Interventions
Oxygen therapy
Monitor vital signs
(every 15mins):
Blood pressure
Pulse pressure
Central venous
pressure
Respiratory rate
Skin and mucosal color
Oxygen saturation
Mental status
Urine output
IV
therapy: or fluid
resuscitation
(crystalloids (normal
saline and LR), protein
containing colloids
(whole blood, PRBCs,
plasma, plasma
fractions, and plasma
expanders).
Inotropics
(dobutamine,
dopamine)
Adrenergic agonists
(epinephrine,
norepinephrine,
Neo-Synephrine)
Vasopressors/
vasodilators
Pharmacologic
Management
Inotropics: Dobutamine
(Dobutrex)
Dosage:
1.0-20mcg/kg/min IV as a
continuous infusion
Purpose: directly stimulates adrenergic
receptor sites on the heart muscle and
improves heart muscle contraction
Nursing Intervention: assess for chest
pain (increases myocardial oxygen
consumption and can cause angina or
infarction).
Inotropics: Milrinone
(Primacore)
Dosage:
Adrenergic Agonists:
Epinephrine (Adrenalin)
Dosage: 0.1-0.25mg every 5-15min; may be
followed by 1-4mcg/min continuous infusion
Purpose: Rapidly stimulates alpha- and betaadrenergic receptors of autonomic nervous system
(alpha: vasoconstriction, beta: bronchodilation)
Side effects: pallor, tachycardia and palpitations,
nervousness, muscle twitching, sweating, anxiety,
insomnia, hypertension, headache and
hyperglycemia.
Nursing Intervention: Assess lung sounds,
respiratory pattern BP and HR before
administration and at peak.
Adrenergic Agonists:
norepinephrine (Levophed)
Dosage: initial: 0.5-1mcg/min IV, to
maintain systolic blood pressure between
90-100mm Hg.
Purpose: Improve blood flow by increasing
peripheral resistance, increasing venous
return to the heart and improving
myocardial contractility.
Nursing Intervention: assess blood pressure
every 15min (hypertension is a sign of an
overdose), assess the patient for headache
(is an early symptom of drug excess).
Adrenergic Agonists:
Phenylephrine (Neo-Synephrine)
Dosage:
Vasodilators: Sodium
Nitroprusside (Nitro-press)
Dosage:
0.25-10mcg/kg/min IV
Purpose: improves blood flow to the
myocardium by dilating the coronary
arteries. This effect is primary and rapid but
short.
Nursing Intervention: Protect drug container
from light (light degrades the drug quickly),
assess blood pressure at least every 15mins
(the vasodilating effect can cause systemic
vasodilation and hypotension, especially in
older adults).
Surgical Intervention
Oxygen,
Neurogenic Shock
Results
Is a type of
hypovolemic shock
causing:
Severe bradycardia
Warm, dry skin
Severe hypotension
Orthostatic
hypotension and
inability to sweat
below the level of
injury are also
symptoms.
Notify
the
physician
immediately if
these symptoms
occur, because
this problem is an
emergency!
is done symptomatically by
restoring fluids to the circulating blood
volume.
Positioning: Regardless of the level of
SCI, keep the patient in proper body
alignment to prevent further injury or
irritability.
Devices such as traction, orthoses, or
collars may be used.
Positioning
Immobilize
Positioning Continued
Instruct
Anaphylactic Shock
Anaphylaxis,
Common causes
DRUGS/FOREIGN
PROTEINS
Antibiotics
Adrenocorticotropic hormone
Insulin
Vasopressin
Protamine
Allergen extracts
Muscle relaxants
Hydrocortisone
Vaccines
Local anesthetics
Whole blood
Cryoprecipitate
Immune serum globulin
Radiocontrast media
opiates
Shellfish
Eggs
Legumes, nuts
Grains
Berries
Preservatives
Bananas
Peanuts
Hymenopetra:
bees, wasps,
hornets
Fire ants
Snake venom
This
has a rapid
onset and a
potentially fatal
outcome.
Teach the patient
with a history of
allergic reactions
to avoid allergens
whenever
possible, to wear
a medical alert
bracelet and to
alert health care
personnel about
specific allergies.
Health Promotion
Prevention is critical.
Always Be Prepared
Some
Anaphylaxis Assessment
First reaction is the patient usually reports
feelings of uneasiness, apprehension,
weakness, and impending doom.
These feelings are usually quickly
followed by generalized itching and
urticaria (hives).
Erythema and sometimes angioedema
(diffuse swelling), of the eyes, lips or
tongue occur next.
Anaphylaxis Interventions
Assess
Septic Shock
A complex type of distributive
shock that usually begins as a
bacterial or fungal infection
and progresses to a dangerous
condition over a period of
days.
Sepsis
Is
Severe Sepsis
Is
Septic Shock
Is
bacterial infection
that escapes local
control.
Fungal infections in
immunocompromised
patients.
Gram-negative
bacteria:
Escherichia coli
Pseudamonas
aeruginosa
Klebsiella pneumoniae
Gram-positive
bacteria:
Staphylococcus
streptococcus
Prevention is Key
Early
Interventions
Focus on identifying the problem as early
as possible and correcting the conditions
causing shock, and preventing
complications.
Oxygen therapy (same as with
hypovolemic)
Drug therapy (to enhance cardiac output
and restore vascular volume)
Blood replacement therapy
Psychosocial Integrity