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 1
Dysfunction Syndrome (MODS).
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)
2
Processes of Shock

Initial stage…early shock
•
•
•

Table 40-2 p.825
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
3
Processes of Shock

Table 40-2 p.825
Progressive stage…intermediate stage
•
•
MAP decrease >20mm/Hg
Overall metabolism-anaerobic
 Moderate
acidosis
 Moderate hyperkalemia
 Tissue ischemia
 lactic acidosis-Lactate

Refractory stage…irreversible stage
4
Hypovolemic Shock:Physical Assessment

Cardiovascular changes
•
•
Pulse
Blood pressure
Skin changes
 Respiratory changes

•
•
Oxygen saturation
RR
Renal and urinary changes
 Central nervous system changes

5
Hypovolemic Shock:Nursing Priorities

Impaired gas exchange
•

Deficient fluid volume
•

Nursing interventions
Decreased cardiac output
•

Nursing interventions
Nursing interventions
Risk for ineffective tissue perfusion
•
•
Body systems impacted???
Nursing interventions
6
Sepsis


Patho
Progressive
•
•
•
•
•
•
•
Infection
Bacteremia
Systemic Inflammatory
Response Syndrome
(SIRS)
Sepsis
Severe sepsis
Septic shock
Multiple Organ Dysfunction
Syndrome (MODS)
7
Sepsis:Hyperdynamic (early)
Cardiovascular changes
 Skin changes
 Respiratory changes
 Renal and urinary changes
 Central nervous system changes

8
Sepsis:Hypodynamic (late)
Cardiovascular changes
 Skin changes
 Respiratory changes
 Renal and urinary changes
 Central nervous system changes

9
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
10
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…
11
General Shock: Nursing Interventions
Remember A,B,C,D

Reverse the shock
•
•

Restore fluid volume
•
•



Administer O2
Establish IV access
Colloid
Crystalloid
Vasoactive gtts
Administer blood products as ordered
Nursing assessment
•
•
•
•
•
•
Pulse/rhythm
BP-CVP
RR-O2 sats
Urine output
Skin color
Monitor labs
12
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
13
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 BP102/64 sats 100% 4l n/c

14
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
15
Vasoactive Gtts

chart 40-6 p.833
Dopamine
•
•
•
Renal
Beta effect
Alpha effect
Levophed (norepinephrine)
 Phenylephrine (neo-synephrine)

16
Multiple Organ Dysfunction Syndrome

Patho
•
•
•
•
Uncontrolled inflammation
Progressive dysfunction of 2 or more systems
Risk factors
Causes
 Trauma
 Pancreatitis
 ARDS
 Major
surgery
17
Multiple Organ Dysfunction Syndrome

Four major organ systems involvement
•
•
•
•
Pulmonary
Renal
Cardiovascular
Coagulation
18
Physical Assessment
Pulmonary
 CV
 Renal
 GI
 Neuro
 Coagulation

19
Therapeutic Management
Support tissue oxygenation
 Fluid resuscitation
 Blood and blood products
 Dialysis or CRRT
 Nutritional support
 Antibiotic therapy

Priority Nursing Diagnoses…
20
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….
21