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Critical Care Nursing
A Holistic Approach
Part 12
Shock, SIRS, and
Multiple Organ Dysfunction
Chapter 54
Topics Covered
• Pathophysiology of Shock
– Tissue Oxygenation and Perfusion
– Compensatory Mechanisms
– Stages of Shock
• Classifications of Shock
– 1-Hypovolemic shock
– 2-Cardiogenic shock
– 3-Anaphylactic shock
– 4-Neurogenic shock
– 5-Septic shock
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
SHOCK
• A serious life threatening condition where there is a
decrease in overall tissue circulatory perfusion. To a point
where the body cannot meet circulatory metabolic
demand.
• More demand and less perfusion
• Hypoperfused state at the cellular level
• Eventually can become systemic leading to multi organ
failure
• Electrolyte Disturbances
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Signs and symptoms of shock
• Hypotension
• Tachycardia
• Altered Mental Status
• Later stage =Decreased Urine Output
• Metabolic Acidosis
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Pathophysiology of Shock
• 1-Tissue oxygenation & Perfusion
• 2-Compensatory mechanisms
• 3. Stages of shock
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Pathophysiology of Shock:
Cellular Perfusion & Tissue Oxygenation.
KEY!!
• Has to do with Oxygen supply & demand.
• In a shock state the body is stressed, there is an
increased metabolic need leading to an increased
demand of O2 on cells.
• In theory…… In a shock state, cells which make up our
organs need more O2 because of the increased metabolic
demands.
– Not enough O2, cell death-----organ death– multi
system failure!
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Pathophysiology of Shock
Compensatory Mechanisms
• What do you think some can be???
• Do we want “vasoconstriction” or “vasodilation”
throughout system?
• What are some of the drugs we use in shock?
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Recap of Compensatory Mechanisms
• 1-SNS response
– Epi, norepi,=vasoconstriction
• 2-Endocrine response
– Secrete ADH, more fluid, preload
• 3-Renin-angiotensin system =aldosterone, more NA and
vasoconstriction
• Diagram 54-2, pp.1211
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Your Compensatory Mechanism’s geared
towards;
• 1-Maintaining CV function
– Vasoconstriction
• SNS response
• 2-Maintaining Blood Volume
– Hold onto H2O
• Secreting ADH and Activating Renin-Angiotensin
system = aldosterone
• (Volume & Pressure)
• Diagram 54-1 pp. 1210.
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Shock Stages: A Progressive Downward
Spiral
Vital signs
Cerebral
perfusion
Reversible
STAGE I
Nonprogressive
stage
Relatively normal
Intact
Yes
STAGE II
Progressive stage
Noticeable
changes;
tachycardia and
tachypnea
Change in LOC
Yes, if recognized
and treated
appropriately
STAGE III
Irreversible
Temp down
Pulse down
Respirations down
Hypotensive
Profound decrease
in cerebral
perfusion
No
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Classification of Shock
• Classified according to “causative” factor.
• Shock is always secondary to something.
• All end up in hypoperfused state
– 1-Hypovolemic shock
– 2-Cardiogenic shock
– 3-Anaphylactic shock
– 4-Neurogenic shock
– 5-Septic shock
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Classifications of Shock
• Hypovolemic Decreased venous return from acute fluid loss
– Dehydration
– Hemorrhage
– Diarrhea
• Cardiogenic Loss of LV Function
– Pump failure
• Distributive Decreased venous return from vasodilation
– Anaphylaxis
– Spinal cord injury/neurogenic
– Sepsis
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
1-Hypovolemic shock
• Fluid loss from hemorrhage, trauma, diarrhea,
dehydration or burns.
• SS- Hypotension, Altered MS, increased HR (SNS),
initially increased deep & rapid respirations which
become shallow as pt. deteriorates, decreased UO with
dark urine, weak thready pulses, skin cool and pale.
• Treatment: restore volume loss!
– Ie Isotonic fluids, Blood, Albumin
• Untreated leaves the body under perfused=hypovolemic,
acid/base abnormalities then ultimately multi-organ
dysfunction
• Nice diagram 54-2, pp.1216. Magic number 500ml.
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Hypovolemic Shock
ASSESSMENT DATA
LAB DATA
• Change in LOC
• CBC, Chem 12
• Tachypnea (initially)
• ABGs
• Cool clammy skin
• Hemoglobin and hematocrit
• Tachycardia
• Coagulation profiles
• Hypotension (with appx
500ml of fluid loss)
• Decreased urinary output
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Nursing Management During Fluid
Resuscitation
• Deliver warmed fluids through large-bore IVs
• Monitor for pulmonary edema, which can occur if fluids are
given too quickly
• Elevate lower extremities
• Monitoring
– Vital signs
– Oxygen saturation
– Mentation (LOC)
– Urinary output and labs
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Question 1
• A trauma patient had significant blood loss in the operating room. The
nurse suspects that the patient is in hypovolemic shock. Which
assessment finding is consistent with hypovolemia?
A. Increased urine output
B. Flushed appearance
C. Cool and clammy skin
D. Bradycardia
• Answer C: Cool and clammy skin is a sign that is consistent with
hypovolemia. Hypovolemia stimulates the sympathetic nervous
system that causes the release of catecholamines such as epinephrine
and norepinephrine. The result is vasoconstriction of arterioles in
nonessential tissue beds such as the skin, to shunt blood to vital
organs. Heart rate increases in response to catecholamines. Reduced
blood flow to the kidneys stimulates release of renin, angiotensin, and
aldosterone. Angiotensin causes vasoconstriction to increase blood
pressure. Aldosterone causes sodium and water retention; thus, urine
output decreases.
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
2-Cardiogenic shock
• Secondary to an extensive MI. Book definition: “Is
actually extreme heart failure and therefore results from
loss of critical contractile function of the heart” (Morton
2013).
– Most common cause L ventricular MI
– No Pump… No L ventricle.
– Left Ventricle is more than 40% failed!!!!!
– Remember shock is a late result!!
– No systemic perfusion, multi-system failure.
– Ejection fraction less than 35%.
• Figure 54-5 pp. 1218
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Signs/Symptoms of Cardiogenic Shock
ASSESSMENTS
• Identify who is at high risk
LABS/DIAGNOSTICS
–
MI
• Elevated cardiac enzymes
(troponin, CPK-MB)
–
Ejection fraction <35%
• BNP
–
Diabetes mellitus
• ECG changes
–
Elderly
• Echocardiography
• Chest pain
• Pulmonary artery pressures
• Thready rapid pulses
• Distended neck veins
• Pulmonary congestion
(crackles, rales& gurgles,)
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Treatment and Nursing Care
• Judicious fluids with diuretics and nitrates
• Monitor and replace electrolytes, especially K+,
• Narcotic analgesics, but watch the SaO2 and Hypotension
• Treat rhythm disturbances
• Possible cardioversion or pacing
• Left ventricular assistive devices: IABP
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Medications
• Medication administration
• Vasoconstrictors- dopamine, dobutamine, neo, epi etc.
• Vasodilators-nitroglycerin
Dopamine
Dobutamine
Milrinone
Ntg
HR
/\
/\
/\
/\
SVR
(afterload)
/\
\/
\/
\/
Contractio
n
/\/\
/\/\
/\/\
Neosynephrine
/\/\
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Question 2
• A patient in cardiogenic shock has an increased heart rate. This
compensatory mechanism initially results in which of the following?
A. Increased urine output
B. Vasodilation of blood vessels
C. Decreased stroke volume
D. Increased cardiac output
• Answer D: In cardiogenic shock, compensatory mechanisms initially
result in increased cardiac output because shock triggers the
sympathetic nervous system. The catecholamines are released. These
stimulate an increase in heart rate, the first response in shock to
increase cardiac output (stroke volume times heart rate equals
cardiac output) and therefore oxygen delivery to vital organs.
Stimulation of renin–angiotensin–aldosterone response causes
vasoconstriction to increase blood pressure and sodium and water
retention thereby reducing urine output.
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
3-Anaphylactic shock
• Results from body being exposed to a specific allergen.
• Allergic reaction-Mast cells, H1 and H2.
• There is loss in blood vessel tone, systemic vasodilation,
bronchoconstriction and uticaria.
– Can happen in minutes.
• Treatment:
– ABC’s
– What else????
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Signs/Symptoms and Nursing Care
• SIGNS/SYMPTOMS
• NURSING CARE
–
Urticaria and pruritus
–
Identify offending allergen
–
Anxiety and restlessness
–
–
Dyspnea, wheezing; can
lead to stridor
Oxygen and possible
intubation if not reversed
–
–
Severe respiratory distress
from laryngeal edema
Antihistamine such as
benadryl
–
Possible epinephrine
–
Hypotension and
circulatory collapse
–
Rapid infusion of NS if
hypotensive
–
Circulatory support with
vasoconstrictors prn
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
4-Neurogenic shock
• Results from loss in sympathetic nerve tone causing
peripheral vasodilation
• Then subsequently decreased tissue perfusion leading to
potential cell death-organ-multisystem dysfunction.
• Usually spinal cord injury above T6.
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
5-Septic shock
• Severe potentially fatal illness caused by infection into
bloodstream. High mortality rate.
– Initiated by infection
– There is a decreased vascular tone
– Release of Cytokines causing vasodilation and increased
capillary permeability.
– Neutrophils and phagocytes stick to vessel walls causing
further vasculature damage.
– 3rd spacing…… pt needs fluids and?
– Initial infection comes from different sources.
– SS
• Increased HR, decreased BP, fever….
• Table 54-6 pp.1392
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
SIRS
• Systemic Inflammatory Response System
– “Precursor” to sepsis
2 or more criteria…evaluate your patient!
-Temp >38C, <36C (>100.4F, <96.8F)
-HR >90 beats per minute
-RR >20 or PCO2 <32
-WBC >12,000, <4,000, or >10% bands
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Findings and Treatment in Septic shock
• PHYSICAL FINDINGS
–
Changes in LOC
–
Tachypnea
–
Fever
–
Decreased urinary output
–
Diminished peripheral
pulses
–
3rd spacing
• TREATMENT
– Antibiotics (“shotgun”
approach until causative
organism identified)
– Restoring volume with
crystalloid/colloids
– Monitoring for fluid
overload with PA
catheter
– Dopamine/Levophed/
Dobutamine
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Casy Study
• A 25 year old woman with no prior history presents to
the ED complaining of a cough productive of tenacious
greenish yellow mucous. Vital signs are temperature
101.8F (38.8C), heart rate 129/min, respiratory rate
27/min, and blood pressure 112/68 mmHg.
• -What information is needed to determine if this patient
has shock?
• -What initial interventions are needed to stabilize this
patient?
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Question 3
• The patient with severe sepsis has a decrease in blood pressure. Early
in sepsis, this is most likely due to which of the following?
A. Hypovolemia
B. Heart failure
C. Vasodilation
D.Allergic reaction
• Answer C: Proinflammatory cytokines are released in response to
systemic inflammatory repost and sepsis. These stimulate release of
nitric oxide, a potent vasodilator. Vasodilation causes a reduction in
blood pressure. Eventually, the patient can develop a “relative
hypovolemia” because the vascular compartment has expanded.
Myocardial dysfunction can develop later in septic shock due to
release of myocardial depressant factors.
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Question 4
• Early goal-directed therapy is initiated in a patient with severe sepsis.
The goals are to improve organ perfusion and prevent septic shock
from developing. Which of the following is not consistent with these
objectives?
A. Vasodilator administration
B. Administration of IV fluid boluses
C. Vasopressor administration
D. Administration of antibiotics within 1 hour of recognition
• Answer A: Infection and sepsis are caused by microorganisms. Early
antibiotic administration is fundamental to ameliorate the infection. In
sepsis, vasodilation reduces blood flow to vital organs. Maintaining
blood pressure and blood flow to vital organs is essential. A
vasopressor can increase blood pressure through vasoconstrictor
effects, and IV fluid administration increases blood volume. These are
three initial therapies in early goal-directed therapy for sepsis.
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Multi Organ Dysfunction Syndrome (MODS)
• Usually from septic shock
• Failure of 1 organ, leading to failure of a 2nd, and so on
• Lungs are the primary affected organ, followed by kidney
and heart
• Can be primary or secondary
– From Direct injury or indirect injury
– Example: ARDS from blunt force chest trauma
(direct) or ARDS from a wound that became infected
leading to septic shock leading to ARDS)
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Question 5
• Which of the following patients meets the criteria to have multiple organ
dysfunction syndrome (MODS)?
A. A 65-year-old man with chronic obstructive pulmonary disease
(COPD) who requires mechanical ventilation and enteral tube feedings
B. A 42-year-old woman with end-stage renal disease who requires
hemodialysis every day
C. A 28-year-old man with septic shock who requires continuous renal
replacement therapy and mechanical ventilation
D. A 70-year-old man with diabetes who recently had coronary artery
bypass surgery
• Answer C: A 28-year-old man who has septic shock and who requires
continuous renal replacement therapy and mechanical ventilation is at risk
for MODS, which is the progressive failure of two or more organ systems
in acutely ill patients. It can follow an acute threat to systemic
homeostasis such that organ function cannot be maintained without
intervention. A patient with septic shock has sustained an insult related to
the inflammatory response. The resulting respiratory failure requiring
mechanical ventilation and acute renal dysfunction necessitating renal
replacement therapy (dialysis) to serve the function of the kidneys that
have failed meet the criteria for MODS.
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.