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Nursing Care & Priorities for Those in ShockKeith Rischer RN, MA, CEN

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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).

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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)

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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

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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

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Hypovolemic Shock:Physical Assessment

Cardiovascular changes• Pulse• Blood pressure

Skin changes Respiratory changes

• Oxygen saturation• RR

Renal and urinary changes Central nervous system changes

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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

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Sepsis

Patho Progressive

• Infection • Bacteremia• Systemic Inflammatory

Response Syndrome (SIRS)

• Sepsis• Severe sepsis• Septic shock• Multiple Organ Dysfunction

Syndrome (MODS)

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Sepsis:Hyperdynamic (early)

Cardiovascular changes Skin changes Respiratory changes Renal and urinary changes Central nervous system changes

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Sepsis:Hypodynamic (late)

Cardiovascular changes Skin changes Respiratory changes Renal and urinary changes Central nervous system changes

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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

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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…

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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

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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

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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

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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

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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

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Mechanism of Action: Abx

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Vasoactive Gtts chart 40-6 p.833

Dopamine• Renal• Beta effect• Alpha effect

Levophed (norepinephrine) Phenylephrine (neo-synephrine)

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Multiple Organ Dysfunction Syndrome

Patho• Uncontrolled inflammation• Progressive dysfunction of 2 or more systems• Risk factors• Causes

TraumaPancreatitisARDSMajor surgery

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Multiple Organ Dysfunction Syndrome

Four major organ systems involvement• Pulmonary• Renal• Cardiovascular• Coagulation

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Physical Assessment

Pulmonary CV Renal GI Neuro Coagulation

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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

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Therapeutic Management

Support tissue oxygenation Fluid resuscitation Blood and blood products Dialysis or CRRT Nutritional support Antibiotic therapy

Priority Nursing Diagnoses…

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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….

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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

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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

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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

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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…

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Case Study #2…

90yr male• PMH: anemia, hypothermia due to thalamus disorder,

pneumonia, COPD, HTN, renal insufficiency, mild dementia. Lives in assisted living

• HPI: Son visited today and noted to be incr. confused-brought to ED for eval.

• VS: T-90.9 P-41 (Junctional) R-16 BP 99/45 sats 97% 2l per n/c

• Assessment: Neuro-confused-responds to voice Resp-clear-neg. assessment

– CXR: left basilar infiltrate CV-No edema, S1S2, pulses strong x4

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Labs

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Case Study #2…

Order received to give 2u PRBC After second unit VS:

• T-95.5 P-38 R-36 BP-113/49 sats 88% 6l n/c• c/o SOB-breath sounds course bilat• u/o 100cc last 4 hours

SBAR…• Order for Lasix 40mg IV…80cc u/o last hour• SBAR

Additional Lasix 80 mg IV and assess

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Case Study #2…

Status 1 hour later…• RR 36-44 w/sats 84-88% on oxymizer 15l• Breath sounds remain course• u/o 30cc since Lasix 80mg 1 hour ago• SBAR

Bipap started per RTSats increased to 94%, RR 20-24, appears more

comfortable

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AM Labs

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4 Days Later…Summary

Sepsis…ARF necessitated need for dialysis due to resultant hyperkalemia, fluid overload.

Multisystem failure of kidneys, heart, and lungs Kaofeed placed and started on TF VS:

• T-98.1 P-80 (SR) R-16 BP-159/75 sats 100% (5l oxymizer)

• I-1700 /O-2480

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Case Study #2

Assessment• Neuro-follows commands-more responsive• Resp-dimin bilat w/scatt. Crackles-non-labored• CV-NSR, tr. Edema LE• GU-Incr. u/o, Foley

Medical-Nursing priorities• Pneumonia

Leukocytosis (Solumedrol?) IV abx

• Hyperkalemia D50, insulin IV, NaBicarb IV, Calcium Gluconate Unable to take Kayexalate po or rectally

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Medical-Nursing Priorities

Resp. failure• Bipap…oxymizer to keep sats >90%

Acute renal failure• ATN…sepsis• ACE held• u/o improving

Sepsis Encephalopathy

• Ativan, Haldol prn Nutrition

• TF

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Labs