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Caring for Clients Experiencing Shock

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Definition of shock

A disorder characterized by hypoperfusion coupled with hypo-oxygenation

Leads to anaerobic metabolism, ischemia and cell death if uninterrupted also called multiple organ dysfunction syndrome

Can be classified according to site of origin or functional impairment

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Classifications of shock: functional impairment vs site of origin

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Etiology of shock

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Stages of shock

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Pathophysiology of shock overview

Decreased vasculartone

Capillary leaking Volume depletion

Pump failure

Renin AngiotensinAldosterone released

oliguria

Anaerobic metabolism

AcidosisHyperkalemia

Toxic metabolitesCausing endothelial damage

& tissue death

MODS

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Complications of shock MODS (multiple organ dysfunction syndrome) Anoxic encephalopathy ARDS Myocardial pump failure

myocardial depressants known as MDF which are released from the pancreas

Acute tubular necrosis result of decreased renal perfusion

DIC platelet consumption

Rhabdomyolysis skeletal muscle breakdown

Profound sepsis from decreased macrophage effectiveness

Paralytic ileus from decreased peristalsis

Liver failure

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Clinical manifestations of shock

Cardiovascular Manifestations ▪ Decreased cardiac output ▪ Increased pulse rate ▪ Thready pulse ▪ Decreased blood pressure ▪ Narrowed pulse pressure ▪ Postural hypotension ▪ Low central venous pressure ▪ Flat neck and hand veins in dependent positions ▪ Slow capillary refill in nail beds ▪ Diminished peripheral pulses

Respiratory Manifestations ▪ Increased respiratory rate ▪ Shallow depth of respirations ▪ Decreased Paco2 ▪ Decreased arterial Pao2 ▪ Cyanosis, especially around lips and nail beds

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Clinical manifestations of shock

Neuromuscular Manifestations ▪ Early Anxiety Restlessness Increased thirst ▪ Late Decreased central nervous system activity (lethargy to

coma) Generalized muscle weakness Diminished or absent deep tendon reflexes Sluggish pupillary response to light

Renal Manifestations ▪ Decreased urine output ▪ Increased specific gravity ▪ Sugar and acetone present in urine

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Clinical manifestations of shock

Integumentary Manifestations ▪ Cool to cold ▪ Pale to mottled to cyanotic ▪ Moist, clammy ▪ Mouth dry; paste like coating present

Gastrointestinal Manifestations ▪ Decreased motility ▪ Diminished or absent bowel sounds ▪ Nausea and vomiting ▪ Constipation

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Lab diagnostics for hypovolemic shock

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Hemodynamic patterns in shock

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BEST PRACTICE for The Client in Hypovolemic Shock

Ensure a patent airway. Start an IV catheter or maintain an established

catheter. Administer oxygen. Elevate the client's feet, keeping his or her head

flat or elevated to a 30-degree angle. Examine the client for overt bleeding. If overt bleeding is present, apply direct pressure

to the site. Administer medications as prescribed. Increase the rate of IV fluid delivery. Do not leave the client.

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INTERVENTION ACTIVITIES for The Client with Hypovolemic Shock

Shock Management: Volume: Promotion of adequate tissue perfusion for a client with severely compromised intravascular volume

Monitor for signs and symptoms of persistent bleeding (e.g., check all secretions for frank or occult blood).

Monitor the client closely for hemorrhage. Prevent blood volume loss (e.g., apply pressure to site of

bleeding). Administer IV fluids, as appropriate. Note hemoglobin/hematocrit level before and after blood loss, as

indicated. Administer blood products (e.g., platelets or fresh frozen plasma),

as appropriate. Monitor coagulation studies, including prothrombin time (PT),

partial thromboplastin time (PTT), fibrinogen, fibrin degradation/split products, and platelet counts, as appropriate.

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Drug therapy in Hypovolemic shock

IV agents to do replace appropriate volume and blood product replacement. They are used as a supportive intervention until volume depletion is corrected

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Management of Cardiogenic chock

Cardiogenic shock guidelines

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Cardiogenic

Pump failure results in inadequate tissue perfusion

DECREASE IN CARDIAC OUTPUT CAUSES A DECREASE IN MEAN ARTERIAL PRESSURE

Seen in: MI Exacerbation of CHF restrictive pericarditis tamponade dysrhythmia Valvular disease

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Management of cardiogenic shock

Reversal of underlying cause Arrhythmia, structural anomaly, acute

coronary syndrome Supportive care

Airway management Hemodynamic monitoring Vasoactive agents

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Drug therapy in Shock

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Caring for clients with Distributive shock

Septic Neurogenic anaphylactic

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Management of septic shock

Surviving sepsis campaign guidelines for management of severe sepsis and septic shock.

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Pathophysiology of septic shock

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Assessment findings in Septic shock

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BEST PRACTICE for The Client in Sepsis-Induced Distributive Shock

Ensure a patent airway.▪ Start or maintain an established IV catheter.▪ Administer oxygen.▪ Administer antibiotics.▪ Obtain specimens of blood, urine, wound drainage, and sputum for

culture.▪ Increase the rate of IV fluid delivery.▪ Use aseptic technique for any invasive procedure.▪ Handle the client gently.▪ Examine the client for overt bleeding, especially of gums, injection

sites, and IV sites.▪ Elevate the client's feet, keeping his or her head flat or elevated to

a 30-degree angle.▪ Take the client's vital signs every 5 minutes until they are stable.▪ Administer medications as prescribed: Heparin during phase 1 Clotting factors, platelets, and plasma during phase 2

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Management of neurogenic shock

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NEUROGENIC SHOCK

PARASYMPATHETIC NS OVERSTIMULATION

SYMPATHETIC NS UNDERSTIMULATION SUSTAINED VASODILATION RESULTS IN

DECREASED SYSTEMIC VASCULAR RESISTANCE

HYPOTENSION BRADYCARDIA MENTAL STATUS CHANGES

Associated with Spinal cord injury

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Management of Neurogenic shock

Follow shock management protocols Maintain spinal immobilization Administer vasopressors

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Management of anaphylaxis

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Anaphylaxis care

Ensure airway Administer epinephrine Establish IV access Provide supportive care as required

Intubation Vasopressors Corticosteroids H2 antagonists

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Drug therapy in Shock

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Can you name which shock is most likely responsible?

Diffuse edema to extremities, skin reddened with wheals noted, just started on new antibiotic

Acute mental status change, decreased heart rate, skin cool and dry

s/p radiation and chemotherapy with neutropenia refractory to Neupogen. rectal temp 96.5 BP 100/60 HR 133

PMH of MI X 4, IDDM, CHF with Harsh systolic murmur at 2nd intercostal space at the right sternal border

S/P exploratory laparotomy POD#1 with a history of COPD on PO steroids X 10 years whose skin is pale and cool. Client c/o fatigue and unable to participate in ADLs

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ADDITIONAL DIAGNOSES/COLLABORATIVE PROBLEMS PC:MODS PC: ARDS PC:DIC PC;PARALTYIC ILEUS PC: HEPATIC FAILURE PC:SEPSIS PC:RHABDOMYOLYSIS RISK FOR INJURY PAIN ANXIETY VS FEAR PC: NEGATIVE NITROGEN BALANCE INTERRUPTED FAMILY PROCESSES RISK FOR IMPAIRED VERBAL COMMUNICATION ACTIVITY INTOLERANCE VS FATIGUE INADEQUATE TISSUE PERFUSION:PERIPHERAL RISK FOR IMPAIRED SKIN INTEGRITY

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Monitor/Prevent potential complications of shock

Remember risk for MODS, ARDS, DIC, Rhabdomyolysis, ATN, anoxia, sepsis, ileus, liver failure, ulcers identified as potential complications

Develop assessment/monitoring strategies that are broad-sweeping and repeated frequently until stable Mon vital signs (VS), cardiac monitoring (CM) pulse

oximetry, I/O, peripheral pulses, neurochecks Mon CMP, CK, CBC,PT/PTT and bleeding times, type and

cross, total protein, albumin, LFTs Insert NG tube to prevent ileus Administer anti-ulcer therapy and antibiotic

prophylaxis

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Shock Summary

Disorder of impaired tissue perfusion secondary to decreased circulating volumes caused by cardiac, neurogenic, inflammatory, obstructive and infectious etiologies

Manifests with AMS, agitation, thirst, Increased HR (except neurogenic shock) and normal to slightly lower BP in initial phase

Can progress to irreversible refractory phase Treatment focuses on ABC’s, reversal of underlying cause,

and prevention of complications Evaluation of outcomes focus on tissue perfusion and

oxygenation, cardiac pump effectiveness, fluid/electrolyte balance and avoidance of systemic complications such as MODS, ARDS, DIC, ATN, Rhabdomyolysis, sepsis, ileus, liver failure and ulcers