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41 notecards = 11 pages (4 cards per page)

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TEST 1: SHOCK

front 1

WHAT ARE THE 3 STAGES OF SHOCK

back 1

  1. COMPENSATORY
  2. PROGRESSIVE
  3. IRREVERSIBLE - IMPENDING DEATH

front 2

  1. BP STAYS W/I NORMAL LIMITS
  2. BODY SHUNTS BLOOD FROM ORGNS SUCH AS SKIN, KIDNEYS, AND GI TRACT TO THE BRAIN, HEART AND LUNGS
  3. BODY USES VASOCONSTRICTION, INCREASED HEART RATE AND INCREASED CONTRACTILITIY OF THE HEART TO MAINTAIN CARDIAC OUTPUT

back 2

COMPENSATORY

front 3

REVIEW SLIDE 12 ! NURSING MANAGEMENT IN EARLY SHOCK

back 3

REVIEW!

front 4

EARLY SIGNS OF SHOCK!

back 4

  • COLD AND CLAMMY SKIN (EXCEPT NEUROGENIC)
  • HYPOACTIVE BOWEL SOUNDS
  • DECREASED URINE OUTPUT (NORMAL IS 30ML/HR)
  • CONFUSION AND AGITATION
  • TACHYCARDIA
  • TACHYPNEA
  • RESPIRATORY ALKALOSIS (B/C THEY'RE BLOWING OFF TOO MUCH O2)
  • REMEMBER! BY THE TIME BP CHANGES, DAMAGE AS ALREADY OCCURED TO THE TISSUES

front 5

  • MECHANISMS THAT REGULATE BP CAN NO LONGER COMPENSATE
  • MAP FALLS BELOW 65
  • HYPOTENSIVE (SBP OF 100 OR LOWER OR DECREASED IN SPB OF 40 FROM BASELINE)
  • HR: > 150
  • METABOLIC ACIDOSIS (MAY HAVE SOME GI ISCHEMIA LEADING TO GI BLEEDING AND BLOODY DIARRHEA)
  • LETHARGY
  • CAP REFILL >3.5
  • MOTTLING, PETECHIAE
  • PULMONARY EDEMA - PINK FROTHY SPUTUM - COMPLETE RESPIRATORY ASSESSMENT
  • BE SURE TO REVIEW SLIDE 14!

back 5

PROGRESSIVE STAGE

front 6

MANAGEMENT OF PROGRESSIVE STAGE:

back 6

  • DEPENDS ON THE TYPE OF SHOCK, UNDERLYING CAUSE, DEGREE OF DECOMPENSATION
  • SUPPORT RESPIRATORY SYSTEM
  • OPTIMIZE INTRAVASCULAR VOLUME
  • SUPPORT PUMPING ACTION OF HEART
  • IMPROVE COMPETENCE OF VASCULAR SYSTEM
  • IV FLUIDS/VASOPRESSORS TO SUPPORT BP
  • SUPPORT RESPIRATORY SYSTEM (MAY ICLUDE MECHANICAL VENTILATION)
  • EARLY ENTERAL NUTRITIONAL SUPROT
  • H2 BLOCKERS AND PPIs FOR ULCER PREVENTION (DUE TO GI ISCHEMIA)
  • MAINTAIN GLUCOSE <180 MG/DL W/ INSULIN THERAPY
  • HEMODYNAMIC MONITORING W/ CENTRAL OR ARTERIAL LINES
  • PROMOTE REST
  • DIALYSIS
  • TRENDELENBURG POSITION TO HELP WITH BP
  • PREVENT DELIRIUM (MONITOR FOR ACUTE MENTAL CHANGES
  • PROMOTE REST AND COMFORT (CLUSTER CARE AND PROTECT FROM TEMP EXTREMES)
  • USE OF VASOPRESSORS IS THE LAST RESORT

front 7

  • STHE POINT IN SHOCK AT WHICH ORGAN DAMAGE IS SO SEVERE THAT PATIENT DOES NOT RESPOND TO TX AND CANNOT SURVIVE
  • BP REMAINS LOW, RENAL AND LIVER DYSFUNCTION IS SEVERE, AND SEVERE METABOLIC ACIDOSIS OCCURS
  • COMPLETE ORGAN FAILURE OCCURS
  • DEATH IS IMMINENT

S/S

  • JAUNDICE (LIVER FAILURE)
  • ANURIC (RENAL FAILURE)
  • IRRATIC HR
  • LOW BP
  • UNCONSCIOUS/UNRESPONSIVE
  • PROFOUND ACIDOSIS
  • MECHANICAL VENTILATION

back 7

IRREVERSIBLE STAGE

front 8

NURSING MANAGEMENT IN IRREVERSIBLE SHOCK

back 8

  • SIMILAR TO PROGRESSIVE STAGE BUT PATIENT WILL NOT RESPOND TO TX
  • MAY TRY EXPERIMENTAL THERAPIES
  • COMFORT MEASRES
  • KEEP FAMILY AND TELL THEM PROGNOSIS
  • PALLIATIVE CARE
  • END OF LIFE MEASURES

front 9

CRITICAL CONDITION WHERE THE BODY HAS DECREASED TISSUE PERFUSION EVENTUALLY LEADING TO ORGAN FAILURE AND DEATH

back 9

SHOCK

front 10

CAUSED BY WIDE SPREAD BLOODBORNE INFECTION

  • SEPSIS

back 10

SEPTIC SHOCK

front 11

SEPTIC SHOCK MANAGEMENT

back 11

INTERVENTIONS

  • IV LINES REMOVED AND REINSERTED AT ALTERNATE SITES
  • REMOVE URINARY CATHS
  • ABSCESSES ARE DRAINED
  • TEMP REGULATION

FLUD REPLACEMENT

PHARMACOLOGIC

  • BROAD SPECTRUM ABX
  • IF IVF FAILS, THEN VASOPRESSOR AGENTS
  • VTE PROPHYLAXIS

NUTRITION

  • AGGRESSIVELY ADMINISTERED FOR 24-48 HOURS OF ICU ADMISSION
  • ENTERAL FEEDING PREFERRED

front 12

CAUSED BY SPINAL CORD INJURY THAT IS T-6 OR HIGHER

back 12

NEUROGENIC SHOCK

front 13

MAIN DIFFERENCE IN NEUROGENIC SHOCK VS ANY OTHER SHOCK!

back 13

  • DRY, WARM SKIN
  • BRADYCARDIA

front 14

NEUROGENIC SHOCK MANAGEMENT

back 14

  • TX DEPENDS ON CAUSE OF SHOCK
  • ELEVATE HOB AT LEAST 30 DEGREES, UNLESS CONTRAINDICATED
  • SUSPECTED SPINAL CORD INJURY - IMMOBILIZE
  • ASSESS FOR S/S OF VTE

front 15

CAUSED BY BLOOD LOSS FROM TRAUMA OR A GUNSHOT WOUND OR EVEN SURGERY OR BURNS

  • VOMITING, DIARRHEA, DKA, ASCITES, PERITONITIS

LOW BLOOD VOLUME

back 15

HYPOVOLEMIC SHOCK

front 16

MANAGMENT OF HYPOVOLEMIC SHOCK

back 16

  • CORRECT UNDERLYING CAUSE
  • LR OR NS
  • BLOOD
  • INFLUID FAILS = VASOPRESSIVE MEDS
  • O2
  • MODIFIED TRENDELENBRGE
  • MONITOR FOR PULMONARY EDEMA, HYPOXEMIA, RESP DISTRESS JVD (FV OVERLOAD DUE TO ADMINISTERING TOO MUCH FLUID

front 17

THE HEART FAILS TO PUMP, SIMILAR TO HEART FAILURE OR MI, WHERE HEART MUSCLES ARE WEAK AND FAIL TO PUMP

  • CAN RESULT IN ACUTE PULMONARY EDEMA
  • S/S - ANGINA, ARRHYTHMIAS, FATIGUE, FEELING OF "DOOM"

back 17

CARDIOGENIC SHOCK

front 18

MANAGMENT OF CARDIOGENIC SHOCK

back 18

  • DON'T ADMINISTER RAPID BOLUS TO THESE PATIENTS.
  • BOLUS WILL BE GIVE SLOWLY
  • TO IMPROVE CARDIAC OUTPUT, VASOPRESSORS ARE ADMINISTERED
  • ADMIN OF O2
  • PAIN MANAGEMENT - MORPHINE
  • HEMODYNAMIC MONITORING - ICU
  • FLUIDS
  • VASOPRESSORS AND ANTIARRHYTHMICS

front 19

WHAT ARE SOME LABS YOU WANT TO CHECK FOR PATIENTS W/ CARDIOGENIC SHOCK?

back 19

  • BNP
  • CARDIAC ENZYMES
  • 12-LEAD EKG
  • ECHO

front 20

SEVERE ALLERGIC REACTION

  • ACUTE ONSET
  • CV COMPROMISE

S/S

  • HEADACHE
  • LIGHTHEADEDNESS
  • N/V
  • PRURITIS
  • DYSPNEA
  • BRONCHOSPASM
  • ERYTHEMA

back 20

ANAPHYLACTIC SHOCK

front 21

MANAGEMENT OF ANAPHYLACTIC SHOCK

back 21

  • REMOVE CAUSATIVE ANTIGEN
  • FLUID MANAGEMENT
  • IM EPINEPHRINE
  • IV DIPHENHYDRAMINE
  • NEBULIZER MEDS

front 22

CAUSED BY WIDESPREAD INFECTION

MUST identify and tx source of infection

SEVERELY LOW BP

RESULTING IN ORGAN FAILURE TO LACK OF PERFUSION

COOL CLAMMY SKIN

DELAYED CAP REFILL

MENTAL STATUS CHANGE - CONFUSION AND DISORIENTATION DUE TO LOW O2 PERFUSION

HIGH WBC

TEMP - VERY HIGH OR VERY LOW (<96)

back 22

SEPTIC SHOCK

front 23

WHAT DIFFERENTIATES NEUROGENIC SHOCK FROM THE REST OF THE DIFFERENT TYPES OF SHOCKS

back 23

  • T-6 OR HIGHER INJURY
  • BRADYCARDIA : DUE TO PNS BEING DOMINANT, AND SNS IS DEPRESSED
  • SKIN IS WARM, PINK, AND DRY - DUE TO VASODILATION

front 24

INTERVENTIONS FOR NEUROGENIC SHOCK

back 24

  • IV NORMAL SALINE (PRIORITY TO INCREASE AND STABILIZE BP)
  • LAXATIVES
  • FOLEY
  • LOSE CLOTHING

front 25

MOST IMPORTANT COMPLICATION OF NEUROGENIC SHOCK

back 25

AUTONOMIC DYSREFLEXIA CAUSED BY ANYTHING W/ THAT CAUSES CONSTRICTION:

  • TRIGGER BY FULL BLADDER
  • CONSTIPATION OR TIGHT-FITTING CLOTHING

S/S: HYPERTENSION

front 26

PRIORITY S/S FOR HYPOVOLEMIC SHOCK

back 26

COLD/CLAMMY SKIN

front 27

WHAT IS THE MOST COMMONLY USED ISOTONIC IV FLUID USED FOR SHOCK?

back 27

LR IS MOST COMMONLY USED; NS IS USED AS WELL

LR ACTS AS A VOLUME EXPANDER FOR BETTER PERFUSION

front 28

WHAT MUST A PATIENT HAVE ON FILE WHEN THEY HAVE SHOCK?

back 28

ADVANCED DIRECTIVES

front 29

AVERAGE PRESSURE AT WHICH BLOOD MOVES THROUGH THE VASCULATURE

back 29

MEAN ARTERIAL PRESSURE

front 30

WHAT IS A NORMAL MAP?

back 30

65 OR BETTER

front 31

RESULT OF INADEQUATE PERFSION IS ANAEROBIC METABOLISM AND BUILD UP OF THIS?

  • A SUBSTANCE THE BODY PRODUCES MAINLY BY THE BREAKDOWN OF GLUCOSE UNDER ANAEROBIC CONDITIONS

back 31

LACTIC ACID

front 32

WHAT IS THE CRITERIA FOR LACTIC ACID TO BE FOR A PERSON TO BE CONSIDERED "IN SHOCK?"

back 32

GREATER THAN 2

front 33

WHAT IS THE INITIAL NURSING ACTION BEFORE ADMINISTERING BROAD SPECTRUM ABX?

back 33

GET A CULTURE

front 34

REVIEW SLIDE 22

back 34

REVIEW

front 35

IMPROVE CONTRACTILITY OF HEART, INCREASED STROKE VOLUME, AND INCREASE CARDIAC OUTPUT

  • MAY CAUSE INCREASED BP, HR, AND ARRHYTHMIAS

back 35

INOTROPIC AGENTS

  • DOPAMINE
  • DOBUTAMINE
  • MILIRINON

front 36

REDUCE PRELOAD AND AFTERLOAD OF CARDIAC SYSTEM AND REDUCE O2 DEMAND OF HEART

  • MAY CAUSE HYPOTENSION AND HEADACHES

back 36

VASODILATORS

  • NITROGLYCERIN

front 37

INCREASE BP BY VASOCONSTRICTION

  • MAY COMPROMISE PERFUSION TO PERIPHERAL AREAS, SKIN, GI TRACT

back 37

VASOPRESSOR AGENTS

  • NOREPINEPHRINE
  • DOPAMINE
  • VASOPRESSIN
  • ALWAYS ADMINISTERED THROUGH CV LINE (PICC LINE AS WELL) B/C IT IS A VESICANT

front 38

RULES FOR VASOPRESSORS

back 38

  • USED FOR A SHORT PERIOD OF TIME B/C THEY CAN ALTER PERFUSION! MUST WEAN PATIENT OFF
  • MUST MONITOR MAP AND BP WHEN STARTING TO WEAN
  • START WEANING PATIENT OFF WHEN MAP IS GREATER THAN 65
  • CHECK BP EVERY 15 MINUTES WHEN WEANING PATIENT OFF USING ARTERIAL LINES
  • REVIEW SLIDE 25

front 39

WHAT IS THE DAILY CALORIES NEEDED FOR PATIENTS W/ SHOCK?

back 39

AT LEAST 3000 CALOIRIES DAILY DU ETO INCREASED METABOLIC RATES

  • SHOULD BE INTIATED IMMEDIATELY BY PARENTAL OR ENTERAL ROUTE
  • ENTERAL IS PREFERRED

front 40

STRESS ULCER PREVENTION DURING PROGRESSIVE STAGE

back 40

H2 BLOCKERS, ANTACIDS, PPIs

front 41

VASOPRESSORS ARE USED TO KEEP THE MAP ABOVE WHAT?

back 41

65