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43 Cards in this Set
- Front
- Back
Describe Shock. |
Widespread, serious reduction of tissue perfusion (lack of O2 and nutrients), which, if prolonged, leads to generalized impairment of cellular functioning.
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Arterial pressure is the driving force for blood through the organs.
What is it dependent on? |
CO
Peripheral tone to return blood to heart Amount of circulating blood Marked reduction - HYPOTENSION |
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Who is at risk for development of shock? Clients with...
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very young/very old
post-MI severe dysrhythmia adrenocortical dysfunction history or recent hemorrhage or blood loss burns massive infection |
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What are the early signs of shock
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agitation, restlessness with severe hypoxia
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Describe Hypovolemic Shock
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R/t external or internal blood loss (most common cause of shock)
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Describe Cardiogenic Shock
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R/t ischemia/impairment in tissue perfusion from myocardial infarction, serious arrhythmia, or CHF. All of this results in decreased CO
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Describe Vasogenic Shock
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R/t allergens, spinal cord injury, or peripheral neuropathy, all resulting in venous pooling and decreased blood return to the heart, which decreases CO over time
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Describe Septic Shock
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R/t to endotoxins released from bacteria, which cause vascular pooling, diminished venous return and CO.
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HESI HINT: Cardiogenic shock
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If cardiogenic shock exists with the presence of pulmonary edema (pump failure), position the client to REDUCE venous return further to the left ventricle
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What are the stages of hypovolemic shock?
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Stage I - Initial
Stage II - Compensatory Stage III - Progressive Stage IV - Irreversible |
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S/S of Stage I
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Apprehension and restlessness (first signs of shock)
Increased HR Cool, pale skin Fatigue |
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Clinical Description of Stage I
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Arteriolar constriction
Increased production of ADH Arterial pressure is maintained CO usually normal for healthy people Selective reduction of BF to skin and muscle beds |
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S/S of Compensatory Stage
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Flattened neck veins and delayed venous filling time
Increase pulse and respirations Pallor, diaphoresis, cool skin Decreased UO Sunken soft eyeballs Confusion |
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S/S of Progressive Stage
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Edema
Increased blood viscosity Excessively low BP Dysrhythmia, ischemia, and MI Weak, thready, or absent peripheral pulses |
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Clinical Description of Compensatory Stage
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Marked reduction in CO
Arterial pressure decline (despite compensatory arterial vasoconstriction) Massive adrenergic compensatory response resulting in: tachycardia, tachypnea, cutaneous vasoconstriction, and oliguria Decreased cerebral perfusion |
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Clinical Description of Progressive Stage
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Rapid circulatory deterioration
Decreased CO Decreased tissue perfusion Reduced blood volume |
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S/S of Irreversible Stage
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Profound hypotension, unresponsive to vasopressor drugs
Severe hypoxemia, unresponsive to O2 administration Anuria, renal shut down Heart rate slows, BP falls, with consequent cardiac and respiratory arrest |
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Clinical Description of Irreversible Stage
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Cell destruction so severe that death is inevitable
MOD Failure IT THE NURSE'S RESPONSIBILITY TO RECOGNIZE THE S/S OF SHOCK. EVERY EFFORT SHOULD BE MADE TO PREVENT THE DEVASTATING CLINICAL COURSE THAT THE PROGRESSION OF SOCK CAN TAKE. |
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HESI HINT: Severe Shock
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Severe shock leads to widespread cellular injury and impairs the integrity of the capillary membranes.
Fluid and osmotic proteins seep into the extravascular spaces, further reducing CO. A viscious cycle of decreased perfusion to ALL cellular level activities ensues. All organs are damaged, and if perfusion problems persist, the damage can be permanent. |
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What is the goal of the medical treatment for shock?
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Quick restoration of cardiac output and tissue perfusion.
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How do you restore CO and tissue perfusion?
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Rapid infusion with volume-expanding fluids (but if the shock is cardiogenic, then you could create pulmonary edema)
Central venous OR pulmonary artery catheters to monitor if shock is cardiogenic vs hypovolemic Serial measuremnts of CVP, UO, HR, and mental states q 15 min Follow immediately to improve perfusion, attention is directed towards the underlying condition Administration of drugs is usually withheld until circulating volume has been restored Give O2 |
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What are volume-expanding fluids/substances?
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Whole blood, plasma, plasma substitutes (colloid fluids)
Note that whole blood is acceptable volume expander, it is rarely used due to high risk transfusion reactions. |
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What are isotonic solutions?
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They are electrolyte intravenous solutions like Lactate Ringer's and Normal Saline
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If shock is cardiogenic in nature, what are things you want to do to help prevent or decrease pulmonary edema?
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Resotration of cardiac function should take priority
Give cardiotonic drugs (digitalis) may increase cardiac contractility Other drugs that enhance contractility include dopamine (Dopram) Vasoconstricting agents like dopamine and norepinephrine (Levophed) may be used as vasoconstrictors in cardiogenic shock |
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Vitals of a patient in shock...
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Tachycardia
Tachypnea Blood pressure decreased (<80) |
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Early mental status in a patient with shock
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Restless
Hyper-alert |
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Late mental status in a patient with shock
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Decreased alertness
Lethargy Coma |
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Skin changes in a patient with shock
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Cool, clammy (warm with vasogenic and early septic shock)
Diaphoresis Pale |
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Fluid status in a patient with shock
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UO decreases or imbalance between IO
Abnormal CVP (<4 cm H2O) Urine specific gravity >1.020 (hypovolemia) |
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How much urine do you want to maintain in a shock patient per hour?
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30 mL
Less represents decrease renal perfusion = permanent renal damage = CALL DOCTOR |
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What measures can be taken to help the patient increase their level to a good level of CVP?
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Bllod
Colloids Electrolyte Solutions |
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The HCP may order fluids to elevate the CVP to ...
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16 to 19 cm H2O to compensate for decreased CO
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What are the vasopressors you give?
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Epinephrine
Dopamine Dobutamine Norepinephrine Isproterenol |
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What are the nursing interventions when you give vasopressors?
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Administer through volume-controlled pump
Monitor BP q 5-15 min Watch IV site for extravasation and tissue damage Ask HCP for target BP (usually 80-90 systolic) |
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What are the vasodilators you give? Why?
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Hydralazine
Nitro Hydrochloride They counteract vasopressors |
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If the drop in BP occurs and you are prescribed vasodilators and vasopressors...what do you do?
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Decrease vasodilator infusion rate first
Increase vasopressors |
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If the rise in BP occurs and you are prescribed vasodilators and vasopressors...what do you do?
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Decrease rate of vasopressors
Increase vasodilators |
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MAP
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Mean Arterial Pressure
Pressure in the central arterial bed measured indirectly by BP measurement Adults usually measure 100 mmHg Measure through arterial catheter insertion |
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How do you calculate MAP?
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CO X SVR
or (SBP + 2DBP)/3 |
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CO
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Volume of blood ejected by the left ventricle per unit of time
Stroke Volume x HR Normal is 4-6 L/min |
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SVR
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systemic vascular resistance
Resistance to blood flow offered by the vessels in the peripheral vascular bed |
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CVP
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Central Venous Pressure
Pressure within the right atrium Normal is 4-10 cm of H2O |
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HESI HINT: Plasma
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A common volume expanding substance is plasma and possibly whole blood
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