Care of Patients with Shock

Chapter 35Assessment of the Cardiovascular SystemThe Cardiovascular SystemAnatomy and physiologyHeartits structure and functionValves, arteriesCardiac output, cardiac index, heart rateStroke volumePreloadAfterloadContractilityVascular system Ejection fraction

2http://www.bostonscientific.com/lifebeat-online/heart-smart/how-your-heart-works.html?

Modifiable Risk FactorsCigarette smokingPhysical inactivityObesityPsychological factorsStressDepressionAngerHostilityChronic disease

3Assessment Techniques HistoryDemographic dataFamily history and genetic riskPersonal historyDiet historySocioeconomic status4Pain or Discomfort Pain or discomfort can result from ischemic heart disease, pericarditis, and aortic dissection.Chest pain can also result from noncardiac conditions such as pleurisy, pulmonary embolus, hiatal hernia, and anxiety.

Pain or Discomfort (Continued)Terms such as discomfort, heaviness, pressure, indigestion, aching, choking, strangling, tingling, squeezing, constricting, or vise-like are all used to describe pain.Women often do not experience pain in the chest but rather feelings of discomfort or indigestion.

Pain AssessmentOnsetManner of onsetDurationFrequencyPrecipitating factorsLocationRadiationQualityIntensity, which can be graded from 0 to 10, associated symptoms, aggravating factors, and relieving factors

Dyspnea Can occur as a result of both cardiac and pulmonary disease Difficult or labored breathing experienced as uncomfortable breathing or shortness of breathDyspnea on exertion (DOE)Orthopnea: dyspnea when lying flatParoxysmal nocturnal dyspnea after lying down for several hoursOther Manifestations FatiguePalpitationsWeight gainSyncope Extremity painPhysical AssessmentGeneral appearanceIntegumentary systemSkin colorSkin temperaturemoistureExtremitiesBlood pressurePulses10PrecordiumAssessment of the precordium (area over the heart) involves:InspectionPalpationPercussion AuscultationNormal heart soundsGallops and murmursPericardial friction rub11http://depts.washington.edu/physdx/heart/demo.html

Hemodynamic MonitoringInvasive system used in critical care areas to provide quantitative information about vascular capacity, blood volume, pump effectiveness, and tissue perfusionArterial linesPulmonary artery catheter

12http://www.youtube.com/watch?v=7putxZN7ij4

Invasive Monitoring EquipmentArterial linePulmonary artery cath

Chapter 39Care of Patients with Shock

14Behavioral Outcomes455.4.1 Analyze an ECG rhythm strip to identify normal sinus rhythm and common or life-threatening dysrhythmias. 455.4.2Differentiate clinical manifestations for clients exhibiting shock, pulmonary edema, cardiomyopathy, AMI, endocarditis, and peripheral arterial disease (i.e. aneurysm) 455.4.3 Interpret laboratory and diagnostic test results to determine whether the patient is at risk or has developed cardiovascular disease (i.e. AMI, angina) 455.4.3Prioritize care for patients having noninvasive and invasive cardiac diagnostics (i.e. CVP, PAP, PCWP, EKG, echocardiogram, Cardiac catheterization, stress tests) 455.4.4Identify specific dietary management for clients experiencing cardiovascular disease 455.4.5Identify specific nursing care for clients receiving medications to treat cardiovascular dysfunction, (i.e. thrombolytics, vasopressors, anticoagulants, antiplatelet agents, diuretics, antiarrythmics, antiocoagulants, antilipemics, anticholinergics)455.4.6Manage the care of clients having pacing devices 455.4.7Plan post-operative care for cardiovascular surgery clients, i.e., fem-pop, aneurysm repair, CABG, valve replacement )455.4.8Apply the teaching learning process to clients experiencing cardiovascular disease relative to exercise, sexual activity, diet, medications, pacemaker management, management of internal defibrillators, cardiac rehabilitation 455.4. 9Utilizing knowledge of pathophysiology, prioritize interventions for clients experiencing a medical emergency, i.e. cardiac tamponade, ventricular fibrillation, asystole, cardiogenic shock.

ShockWidespread abnormal cellular metabolismOxygenation and tissue perfusion needs not metWhole-body response; syndromeAny problem impairing oxygen delivery to tissues and organs can start shock, lead to life-threatening emergency

16Review of Oxygenation and Tissue PerfusionMean arterial pressure (MAP) > 60 mmHg to perfuse organsTotal blood volumeCardiac outputSize of vascular bedClassifications of ShockHypovolemicCardiogenicDistributiveObstructive

17Hypovolemic ShockLow circulating blood volume causes mean arterial pressure (MAP) decrease; inadequate total body oxygenationCommonly caused by hemorrhage (external or internal), dehydration18Cardiogenic Shock Actual heart muscle is unhealthy; pumping is directly impairedMyocardial infarction most common cause19Distributive Shock Blood volume distributed to interstitial tissues where it cannot circulate, deliver oxygenCaused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, capillary leakTypes:Neural-induced distributive shockChemical-induced distributive shock20Chemical-Induced Distributive ShockAnaphylaxisSepsisCapillary leak syndrome21Obstructive Shock Impaired ability of normal heart muscle to pump effectivelyConditions outside heart prevent either adequate filling of heart or adequate contraction of healthy heart musclePericarditis most common causeCardiac tamponade22Health Promotion and MaintenanceCan usually be preventedAvoid trauma and hemorrhageProper safety equipmentSeat beltsAwareness of hazards in home/workplaceSecondary preventionAssess for early manifestationsPatient teaching.23Stages of ShockInitial stage (early shock)Nonprogressive (compensatory) stageProgressive (intermediate) stageRefractory (irreversible) stagehttp://www.youtube.com/watch?v=9a7N9AU1GiQ

24Initial StageBaseline MAP decreased by 20 mm Hg from baselineVital organs develop hypoxiaModerate acidosis and hyperkalemiaLife-threatening emergencyConditions causing shock must be corrected within 1 hour of progressive stage onset27Refractory StageToo little oxygen reaches tissues; cell death and tissue damage resultBody cannot respond effectively to interventions; shock continuesRapid loss of consciousness, nonpalpable pulse, cold, dusky extremities; slow, shallow respirations; unmeasurable oxygen saturation28Multiple Organ Dysfunction Syndrome (MODS)Sequence of cell damage caused by massive release of toxic metabolites and enzymesMicrothrombi formOccurs first in liver, heart, brain, kidneyMyocardial depressant factor (MDF) from ischemic pancreas29Clinical ManifestationsCardiovascularRespiratorySkinRenal and urinaryPsychosocial assessmentLaboratory tests30Cardiovascular ManifestationsDecreased cardiac outputIncreased pulseDecreased blood pressureNarrowed pulse pressurePostural hypotension

Low central venous pressureFlat neck and hand veins in dependent positionsSlow capillary refillDiminished peripheral pulses31Respiratory ManifestationsIncreased respiratory rateShallow depth of respirationsDecreased Paco2Decreased Pao2Cyanosis, especially around lips and nail beds32Neuromuscular ManifestationsEarlyAnxietyRestlessnessIncreased ThirstLateDecreased CNS activity (lethargy to coma) Generalized Muscle weakness Diminished or absent tendon reflexes Sluggish pupillary response to light33Renal ManifestationsDecreased urine outputIncreased specific gravityGlucose and acetone present (urine)34Integumentary ManifestationsSkin is Cool to cold Pale to mottled to cyanoticMoist, clammyMouth dry with paste-like coating35Gastrointestinal Manifestations Decreased motilityDiminished or absent bowel soundsNausea and vomitingConstipation36Physical Assessment/Clinical Manifestations CardiovascularPulseBlood pressureOxygen saturationSkinRespiratoryRenal and urinaryCNSMusculoskeletalPsychosocial37DiagnosisMonitoringCVP, PAP, PCWP (Cardiac output)Laboratory testsH & HElectrolytes38Nonsurgical ManagementMaintain tissue oxygenation, increase vascular volume to normal range, support compensatory mechanismsOxygen therapyIV therapyCrystalloids (NS or LR)Colloids (pRBCs, Albumin, Plasmanate, Hetastarch, Hespan)39Drug TherapiesVasoconstrictorsDopamineEpinephrineNorepinephrinePhenylephrineAgents enhancing contractilityDobutamineMilrinone (Primacor)Agents enhancing myocardial perfusionNitroprusside (Nipride)40Management of CareMonitoring vital signs and level of consciousness is a major nursing action to determine the patient's condition and the effectiveness of therapy. Monitor these vital signs:PulseBlood pressurePulse pressureCentral venous pressure (CVP)Respiratory rateSkin and mucosal color41Sepsis and Septic Shock Complex type of distributive shockbacterial/fungal infection progresses to dangerous condition within daysSepsiswidespread infection coupled with general inflammatory response (SIRS); triggered when infection escapes local control

42Septic ShockStage of sepsis and SIRSmultiple organ failure evident; uncontrolled bleeding occursDeath rate for patients in this stage exceeds 60%Severe sepsisProgression of sepsis with amplified inflammatory response

43Septic ShockEtiology and genetic riskIncidence/prevalenceHealth promotion and maintenance44Clinical ManifestationsCardiovascularRespiratorySkinRenal and urinaryPsychosocial assessmentLaboratory /Diagnostic testsBlood culturesLactic acid levelCardiac output/Stroke volumeCBC with differentialSerum glucoseD-dimerC-reactive Protein45InterventionsOxygen therapyDrug therapyAntibioticsSteroidsInsulinAnticoagulantsBlood replacement (FFP, Plasma)Fluid replacement therapyPositioningGeneral hygiene46Community-Based CareHome care managementTeaching for self-management47

Chapter 37 Care of the Client withInfectious and Inflammatory Cardiac Disease48Infective EndocarditisMicrobial infection involving the endocardiumOccurs primarily with IV drug abuse, valvular replacements, systemic infections, or structural cardiac defectsPossible ports of entry: mouth, skin rash, lesion, abscess, infections, surgery, or invasive procedures including IV line placement

49Manifestations MurmurHeart failureArterial embolizationSplenic infarctionNeurologic changesPetechiae (pinpoint red spots)Splinter hemorrhages

50http://www.youtube.com/watch?v=HtDzHWNYKQM

51DiagnosisPositive blood culturesMurmurEchocardiogramTransesophageal echocardiography

52http://www.youtube.com/watch?v=zLB_mY57B8MInterventions AntimicrobialsSupportive therapy for heart failureAnticoagulantsRest, balanced with activityToothbrushFlossingDental carePatient education

53ManagementSurgical management Valve replacement or repairRepairing congenital shuntsDraining abscess

54Pericarditis Inflammation or alteration of the pericardiumInfective organismsTypes:Dresslers syndromePost-pericardiotomy syndromeAcute exacerbations of systemic connective tissue disease

55Assessment Substernal precordial pain radiating to left side of the neck, shoulder, or backGrating, oppressive pain, aggravated by breathing, coughing, swallowingPain worsened by the supine position; relieved when the client sits up and leans forwardFeverPericardial friction rub

56http://www.youtube.com/watch?v=fI4XXFRotNEDiagnosisEchocardiogramThickeningEffusionCT ScanCBCElevated WBCECG ST-T spikingAtrial fibrillation

57Interventions Hospitalization for diagnostic evaluation, observation for complications, and symptom reliefNonsteroidal anti-inflammatory drugsCorticosteroid therapyComfortable position, usually sitting upright or leaning forwardPericardial drainage

58Pericardiocentesis

Click on on the photohttp://www.youtube.com/watch?v=y0-K2RcThi059Emergency Care of Cardiac TamponadeCardiac tamponadean extreme emergencyIncreased fluid volumeHemodynamic monitoringPericardiocentesisPericardial windowPericardiectomy

60Subacute or chronic disease of cardiac muscleTypes:Dilated cardiomyopathy Hypertrophic cardiomyopathyRestrictive cardiomyopathyArrhythmogenic right ventricular cardiomyopathyCardiomyopathy

61Dilated CardiomyopathyMost common typeDamage to myofibrils and myocardial metabolismNormal wall thickness with dilated ventricles impaired systolic functionEtiology:ETOH abuse, chemotherapy, infection, inflammation, poor nutritionClinical manifestations:DOE, Decreased exercise capacity, fatigue and palpitations, left sided heart failure (S&S), Right sided HF develops (late in disease with poor prognosis)

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Hypertrophic CardiomyopathyAsymmetric ventricular hypertrophy and disarray of myocardial fibers stiff left ventricle diastolic filling abnormalities left ventricular outflow obstructionEtiology:Autosomal dominant trait (single gene)Clinical Manifestations:Sudden death (die without showing symptoms usually cause of death for athletes who dies suddenly), DOE, angina (atypical, occurs at rest, prolonged, no relation to exertion, and not relieved by nitrates), syncope, dizziness, palpitations

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Restrictive CardiomyopathyRareStiff ventricles restrict filling during diastoleEtiology:Endocardial or myocardial disease (Sarcoidosis, Amyloidosis)Clinical ManifestationsLeft or Right sided heart failure

66Restrictive Cardiomyopathy

Arrhythmogenic (RV) CardiomyopathyReplacement of myocardial tissue with fibrous and fatty tissueEtiology:Familial association, most often affects young adultsClinical Manifestations:Most often right sided clinical manifestations 1/3 of clients have left ventricular involvementPalpitations, light-headedness, syncope, SOB, peripheral edema, abdominal distention long-term effect develop heart failure

68DiagnosisChest x-rayEchocardiogramRadionucleotide Imaging (MUGA Scan)Cardiac catheterization (Angiography)

69Varies with type of cardiomyopathyDrug therapyDiureticsVasodilating agentsCardiac glycosidesAntidysrhythmicsOthers: Beta-adrenergic blockers, Calcium channel blockersImplantable cardiac defibrillatorsToxin exposure avoidanceAlcohol avoidance***Vasodilators, diuretics, nitrates and cardiac glycosides are contraindicated in obstructive HCMNonsurgical Management

70Depends on cardiomyopathy typeMost common:VentriculomyomectomyPercutaneous alcohol septal ablationHeart transplantationSurgical Management

http://www.youtube.com/watch?v=bdIZkasIDas

71Health Promotion and MaintenanceSmoking & Alcohol CessationManaging other conditions (HTN, CAD)Mild to moderate exerciseDietary management balanced (low salt, fat)Medication (administration, side effects)Signs of heart failureComplications

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