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Shock MedSurg
Shock
| Question | Answer |
|---|---|
| What is Mean Arterial Pressure? | is the cardiac output times peripheral resistance. This tells how well the body is being perfused: adequate tissue and organ perfusion need a MAP over 65-70 mmHg. |
| How is Mean Arterial Pressure determined? | systolic pressure + (2 X diastolic pressure) divided by 3. |
| What is Cardiac Index? | like CO but individualized by height and weight of the client. More accurate than CO! Normal values are 2.5-4 L/min/m^2 |
| What is Cardiac Output? | amount of blood that is pumped out by the ventricles in one minute. SV X HR. Normal is 4-8 L/min |
| Central Venous Pressure (aka Right Atrial Pressure) is determined how? | using a water manomemeter. It is placed at the fourth intercostal space, midaxillary. The trend shows the FV status and a direct view of the R atrium pressure. Normal values: 4-10 cm of water or 2-6 mmHg |
| What is systemic vascular resistance? | the amount of pressure that the heart must push against to et blood out to the rest of the body. Normal values: 900-1400 dynes per sec per cm^-5 |
| What is pulmonary vascular resistance? | The force against which the right ventricle must push against to get blood to the pulmonary vascular to get oxygenated. Normal values: 37-250 dynes per sec per cm^-5 |
| what is preload? | Ability of the heart to change its force of contraction and therefore its SV in response to changes in venous return (Frank Starling Mechanism) The amount of stretch left in the ventricle at the end of diastole |
| Things that impact preload: | Venous return; total blood volume; stiffness of muscular wall. Nipride decreases preload. |
| What is afterload? | the amount of resistance to ejection of blood from the ventricles. |
| Things that impact afterload: | Systemic and pulmonary vascular resistance. Nipride decreases afterload. |
| What is stroke volume: | the amount of blood pumped out of the heart with each beat. |
| What is Shock? | A condition in which systemic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cellular function. Life-threatening condition. It is evidenced by inadequate circulation with poor tissue perfusion and oxygenation. |
| What happens in the cells with shock? | Anaerobic metabolism is utilized causing the release of lactic acid which causes the cell to swell and the membrane to become more permeable to fluid and electrolytes. |
| What is hypovolemic shock? | internal or external depletion of body fluids. (blood, plasma, or fluids) |
| What is cardiogenic shock? | ineffective pump. Can be from MI, dysrhythmias, valvular insufficiency, or cardiac contusion |
| what is circulatory/distributive shock? | any changes in the vascular bed (constriction or dilation) |
| Pathophysiology of hypovolemic shock: | decrease in: blood volume, venous return, SV, CO, B/P, tissue perfusion. |
| Once the blood pressure drops what has occured | changes at the cellular level; damage has already been done. |
| Hypovolemic shock occurs when a client loses how much intravascular volume? | 15-25% or 750 ml to 1300 ml of blood in a 70 kg (154lb) person. |
| What clinical manifestations should you expect with a client suffering from hypovolemic shock? | Irritable/anxious, decreased LOC, decreased capillary refill, skin may be pale/gray, neck veins may collapse, UO decreased or absent, HR will be increased, hypotensive, tachypnic. |
| Hemodynamics expected with hypovolemic shock: | Increased PVR and SVR Decreased: CVP, CO, PAP, wedge pressure. |
| What is cardiogenic shock? | ineffective pump! The change occurs in the heart, not the fluid or vasculature. |
| What are coronary causes for cardiogenic shock? | Myocardial infarction (right and left ventricles) |
| What are non-coronary causes for cardiogenic shock? | severe hypoxemia, acidosis, severe hypoglycemia, hypocalcemia, arrhythmias |
| what is the pathophysiology for cardiogenic shock? | decreased: cardiac contractility, SV, CO.. this leads to pulmonary congestion and decreased systemic tissue perfusion and decreased coronary artery perfusion. This is a cycling problem. |
| What clinical manifestations would you see with cardiogenic shock? | Obtunded(cannot arouse), confused, restless, cyanotic, shallow/rapid RR (Cheynes Stokes), hypotension, Neck vein distension (if R ventricular MI), narrow pulse pressure, oliguria, cold clammy extremities, decrease temp, crackles, rales, pink frothy sputum |
| Hemodynamics with Cardiogenic shock: | Increased: CVP, SVR, Wedge (PAOP) Decreased: CO and CI |
| What is circulatory (distributive) shock? | It occurs due problems in the vascular tone. It causes massive dilation and a relative hypovolemia. Blood volume is the same but the container is larger thus appearing to be hypovolemic |
| what are the 3 types of circulatory shock? | Neurogenic shock, anaphylatic shock, septic shock |
| What is the pathophysiology of circulatory shock? | vasodilation-> maldistribution of blood volume-> causing decrease: venous return, SV, CO, and tissue perfusion. |
| What is neurogenic shock? | the loss of inervation to the blood vessels resulting in loss of sympathetic tone which causes a decreased B/P. HR will not compensate!! |
| what are the causes of neurogenic shock? | spinal cord injury, spinal anesthesia, nervous system damage, lack of glucose |
| What are the clinical manifestations expected for neurogenic shock? | restless, confused, warm/dry skin, bradycardia, will not sweat, apnea, tachypnea, profound hypotension, decreased UO |
| What nursing care should be given with neurogenic shock? | trendelenburg position, may use positioning with a brace or collar. Do not use fluid replacement but will use vasoconstrictors (norepi, phenylepi, vasopressin). If epidural-keep HOB 30 to prevent medication from crawling up. |
| What is anaphylactic shock? | Very severe allergic reaction. This reaction causes mast cells to release potent vasoactive substances. Causes wide spread vasodilation. In addition to this, there is a lot of capillary permeability.. things are moving where they shouldn't. |
| What are the clinical manifestations expected for anaphylactic shock? | Altered mental status, stridor, tachynpea, wheezing, severe headache, hives, itching flush/warm skin, bronchospasms, possible seizures. When you listen, you will hear upper airway stridor/wheezing. |
| what nursing care should be given with anaphylactic shock? | monitor for allergic reaction when giving a new med. Assess for allergies before giving medications. Educate client and family about their allergy. May need to carry ID and/or epi-pen. |
| How is anaphylactic shock treated? | Epi-pen, benadryl, IV steroids. Nebs: duonebs, xopenex, albuterol |
| What is septic shock? | Most common type of circulatory shock; due to massive sepsis. Gram neg bacteria is the most common cause. The source of infection is a great indicator of clinical outcomes. |
| How is septic shock treated? | antibiotics. Xigris is designed to treat sepsis. Cost thousands of dollars. S/E: bleeding. |
| DIC (disseminated intravascular coagulation) is a complication of septic shock. What is DIC? | proteins in the blood become hyperactive and clots form within the blood stream and travel to the organ capillary beds; they cease to function. Clients become hypoxic. Overwhelming anaerobic metabolism occurs. Petechiea, ooze blood from every orific |
| How is DIC treated? | Heparin is given to break up clots. Give platelets, plasma, and clotting factors that are missing. |
| What are the 2 phases of septic shock? | Hyperdynamic (WARM) phase and Hypodynamic (COLD) phase. |
| What are the signs of hyperdynamic phase (WARM)? | Progressive phase: Increased CO/HR/RR, systemic vasodilation, febrile, bounding pulses, B/P is usually normal, UO and BS may be decreased. May see N/V/D. Hypermetabolic state. Increase glucose and insulin resistance. Subtle changes in LOC |
| What are the signs of hypodynamic phase (COLD)? | Irreversible phase: decreased CO/BP, systemic vasoconstriction (increased HR/RR), BP will not respond to vasoactive meds. Skin will be cool, pale, mottled. Anuric. Multiple organ failure. |
| Signs of compensatory stage of shock: | B/P: normal. HR >100, RR >20. Skin: cold/clammy. UO: decreased. Confusion. Respiratory alkalosis. Narrowing of pulse pressure is a better detector of shock tan a decreased B/P |
| Signs of progressive stage of shock: | BP: sys 80-90 mmHg. HR > 150, Resp: rapid, shallow resp. Crackles. Skin: mottled, petechiea. UO: 0.5ml/kg/h. Lethargic. Metabolic acidosis- kidneys are starting to fail |
| Signs or irreversible stage of shock: | requires mechanical/pharmy support. Numerous vasoactive drips running. Erratic HR or asystole. Need intubation. Jaundice. Anuric. Unconscious. Profound acidosis |
| What type of IV line will a client in progressive stage of shock have? | a central venous line. |
| What type of IV line will clients in intial stage of shock have | All clients should have at least 2 IVs (18-20 gauge) |
| What are the two types of crystalloids used with shock? | Isotonic (NS, LR) or hypertonic (3% NaCl) |
| what do isotonic solutions do and what are the risks? | LR: contain lactate ions to buffer acidosis. Stay in vascular space but 3 parts of solution are lost to interstitial spaces for every 1 part in intravascular space. Risk of pulmonary edema. |
| What do hypertonic crystalloid solutions do and what are the risks? | large osmotic force that pulls fluid from the intracellular space to extracellular space to maintain fluid balance. allows less fluid to be admins. Risk: hypernatremia, excessive serum osmolality, hypokalemia, altered thermoregulation. |
| What are the three types of colloids used with shock? | Albumin, Hetastarch, Dextran |
| What are albumins advantages and disadvantages? | It is a rapid expander. Disadvantages: expensive, human donation, limited quantities, can cause heart failure. |
| What are hetastarch advantages and disadvantages? | it is a synthetic expander, cheaper than albumin, last 36 hours. Disadvantages: prolongs bleeding and clotting time |
| What are dextran advantages and disadvantages? | synthetic expander. Disadvantages: interfere with platelet aggregation. Do not use with hemorrhage induced shock or with a patient with coagulation disorder. |
| What do sympathomimetics do? What are the disadvantages? | they increase cardiac output by mimicking action of the sympathetic NS..causing vasoconstriction. Increases preload, HR, and myocardial contractility. Desired action: improved contractility and CO. Disadvantages: increase O2 demand of heart |
| What are the five kinds of sympathomimetics? | Amrinone, Dobutamine, Dopamine, Epinephrine, Milrinone |
| What do vasodilators do and what are the disadvantages? | They reduce preload and afterload and decrease the O2 demands of the heart. Disadvantage: hypotension |
| What are the 2 types of vasodilators? | nitroglycerin and nitroprusside |
| What do vasoconstrictors do and what are the disadvantages? | increase b/p by vasoconstriction. Disadvantages: increase afterload, causing increase in cardiac workload. Compromise perfusion to skin, kidneys, lungs, GI tract. Monitor UO and BS to access perfusion |
| What are the 3 types of vasoconstrictors? | Norepinephrine, phenylephrine, vasopression |
| What are important nursing care for vasoactive drugs? | Monitor B/P every 5 mins after admin and then q15 mins. Medications should be administered via CVL; never in a PAC line. Clients will be weaned off these drugs. |
| What positions are needed for hypovolemic shock? Cardiogenic? Neurogenic? | Hypovolemia: trendelenburg Cardiogenic: want to 45 degrees or higher Neurogenic: HOB at 30 degrees, keep correct body alignment and immobile. |
| What is the normal RAP/CVP? | 2-6 mmHg. |
| What is the normal PAOP (wedge pressure)? | 4-12 mmHg. |
| What is the normal cardiac output? | 4-8 L/min |
| What is the normal cardiac index? | 2.5-4 L/min |
| What risk do clients with a PAC have? | high tendency of going into Vtach |
| What are MAST stocking used for? Contraindications? | used to increase venous return (like a large TED hose). Contraindicated: pregnancy, burn injuries, or abd injuries. |
| When is a balloon pump used? How does it work? | Cardiogenic. It is fed through femoral vessel and into descending aorta. Inflated during diastole and deflated during systole. It increases SV and coronary artery perfusion; decreases workload. This is just a bridge to open heart surgery or transplant. |
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