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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.