Download Shock and Multisystem Failure

Shock and Multisystem Failure
Elsevier items and derived items © 2006 by Elsevier Inc.
Shock
• Can occur when any part of the cardiovascular
system does not function properly for any reason
• Begins with abnormal cellular metabolism that
occurs when too little oxygen is delivered to
tissues
• Review of tissue perfusion
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Processes of Shock
• Initial stage (early shock)
• Nonprogressive stage (compensatory stage)
• Progressive stage (intermediate stage)
• Refractory stage (irreversible stage)
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Multiple Organ Dysfunction Syndrome
• Cell damage is caused by the massive release
of toxic metabolites and enzyme.
• Metabolites trigger small clots to form that block
tissue oxygenation and damage more cells,
continuing the devastating cycle.
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Hypovolemic Shock
• Occurs when low circulating blood volume
causes a mean arterial pressure decrease; the
body’s oxygen need is not met
• Caused by external hemorrhage; common after
trauma and surgery or reduction in levels of
clotting factors
(Continued)
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Hypovolemic Shock (Continued)
• Caused by internal hemorrhage as occurs with
blunt trauma, gastrointestinal ulcers, and poor
control of surgical bleeding
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Cardiogenic Shock
• Actual heart muscle is unhealthy and pumping is
directly impaired.
• Cardiac output and afterload are reduced, thus
reducing mean arterial pressure.
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Distributive Shock
• Caused by loss of sympathetic tone, blood
vessel dilation, pooling of blood in venous and
capillary beds, and increased blood vessel
permeability
• Neural-induced distributive shock
• Chemical-induced distributive shock
(Continued)
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Distributive Shock (Continued)
• Anaphylaxis
• Sepsis
• Capillary leak syndrome
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Obstructive Shock
• Shock is caused by problems that impair the
ability of the normal heart muscle to pump
effectively.
• Heart is normal but conditions outside the heart
prevent either adequate filling of the heart or
adequate contraction of the healthy heart
muscle.
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Physical Assessment/Clinical Manifestations
• Cardiovascular changes
• Pulse
• Blood pressure
• Oxygen saturation
• Skin changes
• Respiratory changes
• Renal and urinary changes
• Central nervous system changes
• Musculoskeletal changes
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Interventions
• Reverse the shock.
• Restore fluid volume.
• Prevent complications through supportive and
drug therapies.
• Nonsurgical management includes oxygen
therapy, fluid replacement, and monitoring.
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Drug Therapies
• Vasoconstrictors, such as dopamine,
epinephrine, norepinephrine, phenylephrine
• Agents that enhance contractility
• Agents that enhance myocardial perfusion
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Collaborative Management of Septic Shock
• Manifestations of the first phase: unique to
septic shock and often opposite from those seen
with all other types of shock
• Cardiovascular changes
• Respiratory changes
• Skin changes: in the hyperdynamic phase of
septic shock, the skin is warm with no cyanosis
evident
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Interventions for Septic Shock
• Focus on correcting conditions causing shock
and preventing complications.
• Give oxygen therapy.
• Drug therapy: antibiotics and anticoagulants,
clotting factors and blood products, activated
protein C, and antibodies, such as interleukin-1,
interleukin-6, and tumor necrosis factor
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Infusion Therapy
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Parenteral Nutrition
• Formulas: dextrose, protein, fat, vitamins, and
numerous trace elements tailored to the specific
metabolic needs of the client
• Only used when the gastrointestinal tract cannot
be used
• Central
• Peripheral
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Blood Transfusions and Other Components
• Packed red blood cells
• Platelets
• Fresh frozen plasma
• Albumin
• Several specific clotting factors
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Medications
• IV medications provide a rapid therapeutic effect
but can also lead to immediate serious
reactions.
• Prescription for infusion therapy is necessary.
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Vascular Access Device (VAD)
• Short peripheral catheters
– Superficial veins of the hand and forearm
– Dwell for 72 to 96 hours and then require
removal and insertion into another venous site
• Complaints of tingling, feeling of “pins and
needles” in the extremity, or numbness during the
venipuncture can indicate nerve puncture.
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Midline Catheter
• Catheter that is 6 to 8 inches long, inserted
through veins of the antecubital fossa
• Used for therapies lasting from 1 to 4 weeks
• Should not be used for infusion of vesicant
medications, which can cause tissue damage if
they escape into the subcutaneous tissue
(extravasation)
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Peripherally Inserted Central Catheter (PICC)
• Length ranges from 40 to 65 cm.
• Basilic vein is the preferred site for insertion;
cephalic vein can be used.
• Placement is confirmed by chest x-ray
examination.
• No information is available on optimal dwell time.
• Teach clients to perform normal ADLs, avoiding
excessive physical activity.
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Nontunneled Percutaneous Central Catheter
• Inserted through subclavian vein in the upper
chest or jugular veins in the neck
• Usually 15 to 20 cm long
• Tip resides in the superior vena cava
• Placement confirmed by chest x-ray examination
• No recommendations for optimal dwell time
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Tunneled Central Catheter
• A portion of the catheter lying in a subcutaneous
tunnel separates the points at which the catheter
enters the vein from where it exits the skin.
• Tunneled central catheter is used for infusion
therapy that is frequent and long-term.
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Implanted Port
• Implanted ports consist of a portal body, a dense
septum over a reservoir, and a catheter.
• A subcutaneous pocket is surgically created to
house the port body.
• Port is usually placed in the upper chest or the
upper extremity
• Port needs to be flushed after each use and at
least once a month between courses of therapy.
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Dialysis Catheter
• Lumens are very large to accommodate the
hemodialysis procedure or a pheresis procedure
that harvests specific blood cells.
• This catheter should not be used for
administration of other fluids or medications,
except in an emergency.
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Infusion System
• Containers
• Administration sets
• Add-on systems
• Needleless connection devices
• Rate controlling devices:
– Controller
– Pumps
• Syringe pumps
• Ambulatory pumps
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Catheter Care and Maintenance
• Educating the client
• Confirming tip location
• Performing the nursing assessment
• Securing and dressing the catheter
• Changing administration sets and needleless
connectors
• Controlling infusion pressure
(Continued)
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Catheter Care and Maintenance (Continued)
• Flushing the catheter
• Obtaining blood samples from the catheter
• Removing the catheter
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Considerations for Older Adults
• Skin care precautions
• Vein and catheter selection
• Cardiac and renal changes
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Alternative Sites for Infusion
• Arterial therapy
• Intraperitoneal infusion
• Subcutaneous infusion
• Intraspinal infusion
• Intraosseous therapy
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