nursing care & priorities for those in shock
DESCRIPTION
Nursing Care & Priorities for Those in Shock. Keith Rischer RN, MA, CEN. Todays Objectives. Compare and contrast pathophysiology & manifestations of the various shock states and the physiologic compensatory mechanisms. Identify nursing priorities with the various shock states. - PowerPoint PPT PresentationTRANSCRIPT
1
Nursing Care & Priorities for Those in ShockKeith Rischer RN, MA, CEN
2
Todays Objectives
Compare and contrast pathophysiology & manifestations of the various shock states and the physiologic compensatory mechanisms.
Identify nursing priorities with the various shock states. Compare & interpret abnormal laboratory test indicators
involved with septic, hypovolemic, and cardiogenic shock.
Analyze assessment data to determine nursing diagnoses and formulate a plan of care for clients with the various shock states.
Describe the medical management and mechanism of action, side effects and nursing interventions of pharmological management with shock states.
Compare & contrast pathophysiology, manifestations, nursing priorities seen with sepsis vs. Multiple Organ Dysfunction Syndrome (MODS).
3
Shock Defined
Any problem that impairs oxygenation delivery to tissues & organs
CV system is where it begins
Table 40-3 p.826• Hypovolemic• Cardiogenic• Distributive
Neurogenic Anaphylactic Septic-SIRS Multiple Organ Dysfunction Syndrome (MODS)
4
Processes of Shock Table 40-2 p.825
Initial stage…early shock• MAP decrease 5-10mm/Hg• Mild vasoconstriction• Tachycardic…Why???
Nonprogressive stage…compensatory stage• MAP decrease 10-15 mm/Hg• Mod. Vasoconstriction• Physiologic compensations
Renin, aldosterone, ADH Decreased u/o Mild acidosis Mild hyperkalemia
5
Processes of Shock Table 40-2 p.825
Progressive stage…intermediate stage• MAP decrease >20mm/Hg• Overall metabolism-anaerobic
Moderate acidosisModerate hyperkalemiaTissue ischemia lactic acidosis-Lactate
Refractory stage…irreversible stage
6
Hypovolemic Shock:Physical Assessment
Cardiovascular changes• Pulse• Blood pressure
Skin changes Respiratory changes
• Oxygen saturation• RR
Renal and urinary changes Central nervous system changes
7
Hypovolemic Shock:Nursing Priorities
Impaired gas exchange• Nursing interventions
Deficient fluid volume• Nursing interventions
Decreased cardiac output• Nursing interventions
Risk for ineffective tissue perfusion• Body systems impacted???• Nursing interventions
8
Sepsis
Patho Progressive
• Infection • Bacteremia• Systemic Inflammatory
Response Syndrome (SIRS)
• Sepsis• Severe sepsis• Septic shock• Multiple Organ Dysfunction
Syndrome (MODS)
9
Sepsis:Hyperdynamic (early)
Cardiovascular changes Skin changes Respiratory changes Renal and urinary changes Central nervous system changes
10
Sepsis:Hypodynamic (late)
Cardiovascular changes Skin changes Respiratory changes Renal and urinary changes Central nervous system changes
11
Shock-Laboratory Findings Chart 40-3 p.831
General ABG’s
• pH• CO2• O2• HCO3
Lactate Hct Hgb Potassium
Septic Shock Blood cultures WBC
• Neutrophils• Bands
C Reactive Protein (CRP) D-Dimer Fibrinogen INR Platelets
12
Nursing Care Priorities/Diagnosis
Impaired gas exchange r/t… Deficient fluid volume r/t… Ineffective tissue perfusion r/t… Anxiety Knowledge deficit r/t…
Ultimate Goal…
13
General Shock: Nursing Interventions Remember A,B,C,D
Reverse the shock• Administer O2• Establish IV access
Restore fluid volume• Colloid• Crystalloid
Vasoactive gtts Administer blood products as ordered Nursing assessment
• Pulse/rhythm• BP-CVP• RR-O2 sats• Urine output• Skin color• Monitor labs
14
Shock Case Study
83yr male• Admitted from ED to tele for abd pain and recent lower GI
bleeding. Colonoscopy later in day.• PMH: AFib-on Coumadin daily, HTN• Hgb 11.2, INR 2.8, creat .90• ED VS: T-98.8 P-76 R-16 BP-108/64 sats 98% 2l n/c
Enter room to perform initial assessment:• Pale-diaphoretic, lethargic. Can answer simple questions
and oriented x3• Smell suspicious ?GI bleeding
Note large pool of dark, red blood on pad VS: P-110 R-24 BP-78/34 sats 90% 2l n/c
15
Shock Case Study
Nursing priorities… Rapid Response paged SBAR to primary MD Medical/Nursing management:
• 2 large bore IV’s• NS 1000cc FF• Prepare for transfer to ICU• Stat Hgb• Obtain 2u PRBC from blood bank
16
15” later…
VS: P-100 R-20 BP-92/46 sats 98% 6l n/c Hgb 8.2 First unit of blood initiated Prepare for transfer to ICU…unable to
take at this time Foley catheter placed VS just before transfer: P-88 R-18 BP-
102/64 sats 100% 4l n/c
17
Septic Shock: Nursing Interventions
All the same as previous slide and… Obtain blood, urine cultures as ordered Administer IV abx Administer anti-arrythmics Aggressive IV fluid resuscitation Assess closely for signs of bleeding…DIC Strict aseptic technique Fever reduction as needed Client-family education
18
Mechanism of Action: Abx
19
Vasoactive Gtts chart 40-6 p.833
Dopamine• Renal• Beta effect• Alpha effect
Levophed (norepinephrine) Phenylephrine (neo-synephrine)
20
Multiple Organ Dysfunction Syndrome
Patho• Uncontrolled inflammation• Progressive dysfunction of 2 or more systems• Risk factors• Causes
TraumaPancreatitisARDSMajor surgery
21
Multiple Organ Dysfunction Syndrome
Four major organ systems involvement• Pulmonary• Renal• Cardiovascular• Coagulation
22
Physical Assessment
Pulmonary CV Renal GI Neuro Coagulation
23
Diagnostic-Lab Findings
ABG• pH• CO2• O2• HCO3• O2 sats
WBC Platelets Fibrinogen PT-INR Hgb
Creatinine K+ GFR Troponin BNP Liver Enzymes
• ALT-AST• Alk Phos• Total bili• Ammonia• albumin
24
Therapeutic Management
Support tissue oxygenation Fluid resuscitation Blood and blood products Dialysis or CRRT Nutritional support Antibiotic therapy
Priority Nursing Diagnoses…
25
Nursing Priorities-Interventions
Assess resp. status Continuous cardiac monitoring Assess
perfusion Provide hydration and nutritional support Assess for coagulation dysfunction Emotional support/comfort measures
Evaluation….
26
Sepsis/MODS Case Study
40 yr male w/seizure disorder
Chief complaint• Altered mental status• Vague abd pain• Weakness• Hypotension
Physical assessment• Epigastric-LUQ tender
VS• T-101.2/P-110/R-24/BP
92/42/sats 95% RA
Admission Labs• WBC-11,000• Hgb-12.2• Platelets-64,000• Creatinine-2.7• ALT-502• AST-219• Ammonia-68• Lipase-1947• Glucose-322• CT-encephalopathy• Abd CT-inflamm. pancreas
27
Case Study:Later… Day of Admission
Increasing lethargy, resp. distress ABG
• pH- 7.28• CO2- 59• O2- 52• HCO3- 23• O2 sats- 84• FiO2-100% vent…AC12, PEEP +5• CT-abd. Ileus-hepatic infarcts
28
Case Study:Day 1
CVP-21 VS-101.2-118-24-82/40 NG placed Labs
• WBC-12.7• Platelets-56• Creatinine-.7• ALT-243• AST-219• Lipase 523• ABG
pH-7.25 CO2-52 O2-76 O2 sats-92% FiO2-100% PEEP now +10
Weight up 8 kg Non icteric IV Infusions
• Insulin gtt• Lasix gtt• TPN-Lipids• Fentanyl gtt• Versed gtt• Levophed gtt• Neosynephrine gtt• Vasopressin gtt• Heparin gtt
29
Case Study:Day 2 CVP-16 –weight up another 7.5
kg…poor u/o VS-100.5-110-24-84/44 Labs
• WBC-21.5• Hgb-12.5• Platelets-77• Creatinine-0.9• ALT-143• AST-41• Ammonia-30• Lipase 114• CXR-white out• ABG
pH-7.11 CO2-78 O2-58 HCO3-24 O2 sats-75% Vent-FiO2-100%, +15
Treatment Plan• CRRT• IV abx-Cipro/Flagyl• Hold Lasix gtt• NG LCS• Lactulose• Wean vasoactive gtts as able• Continue all previous gtts• Pan cultures
Physical assessment• Distended abd-hypoactive
NG bile output• Coarse crackles bilat• Cool to touch
Nursing Priorities…