WHAT ARE THE 3 STAGES OF SHOCK

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

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

COMPENSATORY

REVIEW SLIDE 12 ! NURSING MANAGEMENT IN EARLY SHOCK

REVIEW!

EARLY SIGNS OF SHOCK!

• 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

• 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!

PROGRESSIVE STAGE

MANAGEMENT OF PROGRESSIVE STAGE:

• 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

• 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

IRREVERSIBLE STAGE

NURSING MANAGEMENT IN IRREVERSIBLE SHOCK

• 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

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

SHOCK

CAUSED BY WIDE SPREAD BLOODBORNE INFECTION

• SEPSIS

SEPTIC SHOCK

SEPTIC SHOCK MANAGEMENT

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

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

NEUROGENIC SHOCK

MAIN DIFFERENCE IN NEUROGENIC SHOCK VS ANY OTHER SHOCK!

• DRY, WARM SKIN
• BRADYCARDIA

NEUROGENIC SHOCK MANAGEMENT

• 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

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

• VOMITING, DIARRHEA, DKA, ASCITES, PERITONITIS

LOW BLOOD VOLUME

HYPOVOLEMIC SHOCK

MANAGMENT OF HYPOVOLEMIC SHOCK

• 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

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"

CARDIOGENIC SHOCK

MANAGMENT OF CARDIOGENIC SHOCK

• 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

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

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

SEVERE ALLERGIC REACTION

• ACUTE ONSET
• CV COMPROMISE

S/S

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

ANAPHYLACTIC SHOCK

MANAGEMENT OF ANAPHYLACTIC SHOCK

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

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)

SEPTIC SHOCK

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

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

INTERVENTIONS FOR NEUROGENIC SHOCK

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

MOST IMPORTANT COMPLICATION OF NEUROGENIC SHOCK

AUTONOMIC DYSREFLEXIA CAUSED BY ANYTHING W/ THAT CAUSES CONSTRICTION:

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

S/S: HYPERTENSION

PRIORITY S/S FOR HYPOVOLEMIC SHOCK

COLD/CLAMMY SKIN

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

LR IS MOST COMMONLY USED; NS IS USED AS WELL

LR ACTS AS A VOLUME EXPANDER FOR BETTER PERFUSION

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

ADVANCED DIRECTIVES

AVERAGE PRESSURE AT WHICH BLOOD MOVES THROUGH THE VASCULATURE

MEAN ARTERIAL PRESSURE

WHAT IS A NORMAL MAP?

65 OR BETTER

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

LACTIC ACID

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

GREATER THAN 2

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

GET A CULTURE

REVIEW SLIDE 22

REVIEW

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

• MAY CAUSE INCREASED BP, HR, AND ARRHYTHMIAS

INOTROPIC AGENTS

• DOPAMINE
• DOBUTAMINE
• MILIRINON

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

• MAY CAUSE HYPOTENSION AND HEADACHES

VASODILATORS

• NITROGLYCERIN

INCREASE BP BY VASOCONSTRICTION

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

VASOPRESSOR AGENTS

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

RULES FOR VASOPRESSORS

• 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

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

AT LEAST 3000 CALOIRIES DAILY DU ETO INCREASED METABOLIC RATES

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

STRESS ULCER PREVENTION DURING PROGRESSIVE STAGE

H2 BLOCKERS, ANTACIDS, PPIs

VASOPRESSORS ARE USED TO KEEP THE MAP ABOVE WHAT?

65