Shock Prevention, Assessment, and Stages

Shock Prevention and Care (Unknown Etiology)

• Early recognition and prompt fluid management are key.
• Avoid blood loss.

Assessment and Lab Findings in Shock Syndrome

• Hypotension and tachycardia are common vital sign changes.
• Decreased urine output (less than 0.5ml/kg/hr) is an important indicator.
• Increased lactic acid levels suggest tissue hypoxia.
• Electrolyte imbalances such as hyponatremia may be present.
• Elevated BUN and creatinine indicate kidney dysfunction.
• Increased PTT/PT/INR suggests impaired coagulation.

Findings in Different Stages of Shock

• Compensatory: The body attempts to restore perfusion via the sympathetic nervous system, releasing norepinephrine. A narrowed pulse pressure is an early sign.
• Progressive: Increased capillary permeability and decreased perfusion to the liver and kidneys lead to increased BUN and creatinine. DIC may occur.
• Refractory (Irreversible): Severe refractory hypoxemia, profound hypotension, and bradycardia are present. Pupils become nonreactive, deep tendon reflexes are lost, the abdomen becomes rigid with no sounds, and cyanosis and hypothermia develop.

Plan of Care for Shock of Unknown Origin

• Focus on ABCs (Airway, Breathing, Circulation).
• Ensure a patent airway and monitor oxygen saturation.
• Use vasopressors like norepinephrine or dopamine to increase blood pressure.

Nutrition and GI Prophylaxis in Shock

• Nutrition should include high protein and high-calorie meals.
• PPIs (Proton Pump Inhibitors) are used in critically ill patients; monitor for pneumonia as a side effect.
• Assess bowel function before administering PPIs to increase bowel motility.

Indicators of Effective Shock Treatment

• Increased blood pressure and a heart rate between 60-100 bpm are desirable.
• Decreased tachypnea and urine output of at least 0.5-1mL/hr/kg are positive signs.
• Lactate levels, creatinine, and BUN should normalize.

Psychosocial Support and Communication in Shock

• Create a calm, healing environment and validate patient feelings.
• Reduce unnecessary noise and provide pain management.
• Encourage hope without making false promises.

Early Enteral Feeding in Sepsis, Septic Shock, and MODS

• Start enteral feeding 24-48 hours after ICU admission if the patient is hemodynamically stable (MAP between 65-100).
• PPIs can help prevent GI bleeds.
• Elevate the head of the bed to 30-45 degrees to prevent aspiration.

Communicating Lab Findings in Shock

• Early respiratory alkalosis may progress to late metabolic acidosis.
• Increased lactate, AST/ALT, bilirubin, PTT/PT/INR levels, hyponatremia, hyperkalemia, and hypocalcemia are significant findings.
• Decreased Hgb/Hct/RBC may indicate blood loss.

Managing Septic Shock

• Airway: Intubate to prevent hypoxia.
• Breathing: Administer 100% oxygen or use mechanical ventilation.
• Circulation: Administer IV fluids to maintain a MAP goal of 65-100.

Preventing Stress Ulcers in Septic Shock/MODS

• Use PPIs to reduce gastric acid production.
• Initiate early enteral nutrition via NG tube to decompress the stomach.
• Elevate the head of the bed and monitor for GI bleeds.

Late Irreversible Stage of Shock (MODS)

• Multiple organs are unable to function properly.
  • Liver: Jaundice and elevated liver enzymes.
  • Kidneys: Stop producing urine.
  • Lungs: ARDS (Acute Respiratory Distress Syndrome) leading to hypoxia.
  • Cardiac failure: Severe hypotension and tachycardia.

Hemodynamic Monitoring and Fluid Resuscitation in Septic Shock

• Maintain a MAP of 65-100.
• Aim for a GCS (Glasgow Coma Scale) score less than 15.
• Normalize respiratory rate and lactate levels.

Findings Indicating MODS

• Tachypnea, hypoxia, severe hypotension, and tachycardia are common.
• Anuria, elevated BUN, jaundice, elevated AST/ALT, and altered mental status may be present.

Central Venous Catheter

• Provides IV access for medication infusion.
• Monitors Central Venous Pressure (CVP).

Central Venous Catheter Types, Assessment, and Care

• Types: PICC (Peripherally Inserted Central Catheter), tunneled venous catheter, and central line.
• Assessment includes site inspection, catheter patency, and monitoring for complications like infection, thrombosis, occlusion, and air embolism.
• Notify the healthcare provider if there are signs of complications.

Management and Assessment of Hypovolemic Shock

• Insert two large bore IV catheters.
• Administer isotonic fluids (NS 0.9% or Lactated Ringers) as the first line treatment.
• Consider vasopressors (norepinephrine or dopamine).
• Monitor vital signs and provide nutritional support.

Key Communication for Hypovolemic Shock

• Report low urine output, bleeding, tachycardia, hypotension, arrhythmias, and mental status changes to the healthcare provider.

Assessment and Lab Findings in Hypovolemic Shock

• Early stage: Respiratory alkalosis.
• Late stage: Metabolic acidosis.
• Elevated lactate levels, BUN, and creatinine.
• Electrolyte imbalances such as hyperkalemia and hyponatremia.

Plan of Care for Hypovolemic Shock of Unknown Origin

• Monitor vital signs, perform hemodynamic monitoring, and track urine output.
• Use appropriate positioning and pain management.
• Administer vasopressors and blood transfusions as needed.

Fluid vs. Blood Transfusions in Hypovolemic Shock

• Fluids are used for fluid loss without significant blood loss, early-stage hemorrhagic shock, or dehydration.
• Blood transfusions are used for hemorrhagic shock or severe anemia.
• Both fluids and blood transfusions are used for severe hemorrhagic shock or massive transfusion protocol.

Indicators of Effective Hypovolemic Shock Treatment

• Normal blood pressure, heart rate, and respiratory rate.
• Afebrile status, normal urine output, and normal capillary refill.
• CVP of 15 mmHg.

Vasopressin

• Use: Septic shock.
• Implement: Refractory shock.
• Titrate: According to MAP goals.
• Question: Hypovolemic or cardiogenic shock.
• Side effects: Hyponatremia, hypertension, and decreased urine output.

Norepinephrine

• Use: Septic shock and cardiogenic shock.
• Implement: Patients with sepsis/septic shock or hypotension.
• Titrate: Based on MAP or blood pressure.
• Question: Signs of hypovolemia.
• Side effects: Arrhythmias and renal perfusion issues.

Dobutamine

• Use: Cardiogenic shock to increase cardiac output.
• Implement: Low cardiac output.
• Titrate: To optimize cardiac output.
• Question: Arrhythmias.
• Side effects: Tachycardia and hypotension.

Methylprednisolone/Hydrocortisone

• Use: Septic shock when vasopressors are ineffective.
• Implement: Refractory shock.
• Titrate: Monitor for improvement in BP and MAP.
• Question: Fungal infections.
• Side effects: Hyperglycemia, GI bleeds, and infection.

Sodium Nitroprusside

• Use: Manage hypertensive crisis or cardiogenic shock.
• Implement: Hypertension or cardiogenic shock.
• Titrate: Based on BP and MAP.
• Question: Hypotension.
• Side effects: Cyanide toxicity and hypotension.

Nitroglycerin

• Use: Acute coronary syndrome, pulmonary edema, cardiogenic shock.
• Implement: Acute heart failure.
• Titrate: To achieve target blood pressure.
• Question: Hypotensive patients or right ventricular infarction.
• Side effects: Hypotension and headache.

Dopamine

• Use: Hypovolemic or cardiogenic shock.
• Implement: Hypotension.
• Titrate: Based on blood pressure and urine output.
• Question: Tachyarrhythmias or significant arrhythmias.
• Side effects: Arrhythmias and tachycardia.

Phenylephrine

• Use: Hypotensive shock.
• Implement: Hypovolemic shock.
• Titrate: To maintain MAP > 65 mmHg, prevent extreme hypertension.
• Question: Significant blood loss.
• Side effects: Hypertension and bradycardia.

Types of Burns

• Thermal, chemical, smoke and inhalation, electrical, and cold thermal.

Burn Prevention Measures

• Turn pot handles inwards, install smoke alarms, have a fire escape plan.
• Avoid overloading power strips and use 30 SPF sunscreen.

Levels of Burns and Assessment Findings

• First-Degree (Superficial Partial-Thickness): Red, dry, mild pain, no blisters. Heals in 3-6 days without scars (e.g., sunburn).
• Second-Degree (Deep Partial-Thickness): Red/white, blisters, severe pain, moist or dry. Heals in 2-6 weeks, may scar (e.g., hot liquid burns).
• Third-Degree (Full-Thickness): White/brown, leathery, no blisters, no pain (nerves destroyed). Requires skin grafts, takes months (e.g., fire burns).
• Fourth-Degree (Severe Full-Thickness): Blackened, charred, dry, no pain (deep nerve damage). Requires surgery or amputation (e.g., electrical burns).

Circumferential Burn

• Burn that goes all the way around a body part.
• Can cause nerve damage, impaired circulation, and compartment syndrome.

Emergency Management of Different Types of Burns

• Inhalation: Secure airway, oxygen therapy, and bronchodilators.
• Electrical: Turn off power source, cardiac monitoring, and fluid resuscitation.
• Chemical: Flush the chemical off with water or saline, assess airway and breathing, and pain management.
• Thermal: Remove from the source of the burn, cool the burn with water, and provide pain management.

Pathophysiology of Burns

• Skin damage leads to fluid loss, pain, inflammation, and infection risk.

Capillary Leak Syndrome, Paralytic Ileus, and Altered Vitamin D

• Capillary leak syndrome: Blood vessels become leaky, causing edema.
• Paralytic ileus: Intestines stop moving, causing a blockage.
• Altered skin impacts the soaking up of Vitamin D.

Plan of Care for Burn Clients

• Focus on ABCs, positioning, opioids, PPIs, and monitoring fluid balance.

Phases of Burn Management

• Emergent (0-72 hours): Focus on ABCs, fluid resuscitation (Lactated Ringers), and infection prevention.
• Acute (72 hours- several weeks): Management of wounds, and nutritional support (high protein and carbs).
• Rehabilitation (months to years): Long-term recovery including PT and education on self-care.

Fluid Maintenance in the Emergent Phase

• 4 mL x kg body weight x % Total Body Surface Area (TBSA) burned.
• Administer 50% in the first 8 hours, then 25% in the next 8, and 25% in the last 8.
• Lactated Ringers is the preferred fluid.

Assessment Indicating Effective Fluid and Electrolyte Replacement (24-72 Hours)

• Stable vitals, urine output of 0.5-1ml/kg/hr, and regular lab results.

Best Method for Monitoring Weight in Burn Clients

• Daily weights on the same scale each day.

Nutritional Needs of Burn Clients

• High protein and high-calorie meals, up to 5,000 calories a day.

Nutrition Replacement Plan Based on Degree of Burns

• Superficial partial thickness (first degree): no change in diet needed.
• Second, third, and fourth-degree: high calorie and high protein, NG tube inserted for parental nutrition.

Potential Complications of Burns

• Hypovolemic shock: Low blood pressure, high heart rate.
• Sepsis: Drastic drop or increase in WBC, increased redness, swelling, and foul odor.
• Compartment syndrome: Pain unrelieved by opioids, pale, cool extremities, and decreased pulse (late sign).
• AKI: No urine or low urine output.

Preventive Measures and Treatments for Burn Complications

• Hypovolemic shock: Fluid resuscitation, monitor BP.
• Sepsis: Tetanus prophylaxis, wound care, high protein/calorie diet.
• Airway compromise: Airway assessment, elevate bed, and humidified oxygen.
• Compartment syndrome: Frequent neuro checks.
• AKI: Adequate fluids.

Effective Outcomes Related to Body Image in Burn Clients

• Verbalizing acceptance, decreased anxiety and depression, and positive self-talk.

Types of Burn Wound Care

• Superficial Partial-Thickness (First-Degree): Cool compress, moisturizer, aloe vera.
• Deep Partial-Thickness (Second-Degree): Antimicrobial ointment, non-adherent dressing, avoid tight bandages.
• Full-Thickness (Third/Fourth-Degree): Debridement, skin grafting, pain management, antimicrobial ointment.
• Inhalation Burns: Oxygen therapy, bronchodilators.
• Electrical Burns: Cardiac monitoring.
• Chemical Burns: Irrigate thoroughly.

Pain Management in Burn Clients

• Opioids, relaxation techniques, sedatives, and positioning.

Debridement

• Cleaning of a wound by removing dead tissue.
• Administer analgesic prior and provide emotional support.

Escharotomy

• Releasing pressure caused by burned tissue to allow proper circulation and respiration.
• Assess vitals, give pain meds, prepare the site, and explain the procedure.

Types of Dressings in Burn Wound Care

• Gauze Dressings: Absorbs exudate, requires frequent changes.
• Silver-impregnated Dressings: Antimicrobial, used for deep partial/full-thickness burns.
• Hydrocolloid Dressings: Maintains moisture balance in partial-thickness wounds, can stay in place for several days.
• Biological Dressings: Temporary coverage for full-thickness burns before grafting, reduces infection risk.

Maintaining Mobility in Burn Clients

• Positioning: Prevent contractures, maintain joint mobility, avoid flexion, promote extension, and use splints.
• Exercise: Maintain muscle strength and joint range of motion, begin as soon as possible.
• Physical Therapy: Structured rehabilitation tailored to the patient's progress.
• Pain Management: Minimize pain with analgesics before exercises and therapy.

Mannitol in Burn Care

• Indications: Prevent acute renal failure, maintain urine output, reduce intracranial pressure.
• Side Effects: Electrolyte imbalances (hypokalemia), dehydration, hypotension, headache, nausea, dizziness, pulmonary edema.
• Client Teaching: Report dehydration signs and follow-up for lab tests.

Hydromorphone in Burn Care

• Indications: Pain management, particularly in severe pain.
• Side Effects: Drowsiness, dizziness, nausea, vomiting, constipation, respiratory depression, hypotension, risk of dependence.
• Client Teaching: Take only as prescribed and avoid alcohol.

Lorazepam in Burn Care

• Indications: Manage anxiety, agitation, and as a sedative.
• Side Effects: Drowsiness, dizziness, confusion, respiratory depression, risk of dependency, memory impairment.
• Client Teaching: Take as prescribed, avoid alcohol and other sedatives.

Silver Sulfadiazine in Burn Care

• Indications: Prevent and treat infections in burn wounds.
• Side Effects: Skin discoloration, itching, burning sensation at application site, allergic reactions, leukopenia.
• Client Teaching: Apply as directed, avoid large body areas unless instructed, and notify healthcare provider of rash or infection.

Mafenide Acetate in Burn Care

• Indications: Prevent infection, especially in deep partial and full-thickness burns.
• Side Effects: Local irritation, burning sensation, itching at application site, metabolic acidosis.
• Client Teaching: Apply as prescribed, avoid contact with eyes, report unusual side effects such as rapid breathing or symptoms of acidosis.

Tetanus Toxoid in Burn Care

• Indications: Prevent tetanus infection after a burn injury.
• Side Effects: Redness, swelling, tenderness at the injection site, fever, headache, allergic reactions (rash, difficulty breathing).
• Client Teaching: Expect mild pain or swelling at the injection site; if a severe allergic reaction occurs, use an EpiPen.

Understand shock prevention through early recognition and fluid management. Learn to assess shock with lab findings. Explore the compensatory, progressive, and refractory stages of shock.