Shock & MODS Chapter 11 PDF

Sepsis, Shock & MODS CHAPTER 11 Objectives 1. Describe age related differences that influence the care of patients with shock, SIRS, sepsis & multiple organ dysfunction syndrome. 2. Describe and evaluate signs and symptoms for patients with shock, SIRS, sepsis & multiple organ dysfunc...

Sepsis, Shock & MODS CHAPTER 11 Objectives 1. Describe age related differences that influence the care of patients with shock, SIRS, sepsis & multiple organ dysfunction syndrome. 2. Describe and evaluate signs and symptoms for patients with shock, SIRS, sepsis & multiple organ dysfunction syndrome. 3. Design a nursing care plan for the patient with shock, SIRS, sepsis & multiple organ dysfunction syndrome. 4. Identify and apple laboratory data and diagnostic data, in conjunction with clinical manifestations to support the diagnosis and effectiveness of the therapy for patients with shock, SIRS, sepsis & multiple organ dysfunction syndrome. 5. Apply nursing care priorities and teaching points for patients with shock, SIRS, sepsis & multiple organ dysfunction syndrome. 6. Identify special considerations for the patient with hematological disorders. SIRS - Systemic Inflammatory Response Syndrome Syndrome resulting from an insult that causes a systemic inflammatory response Causes: burns, trauma, surgery, infection, inflammation, ischemia Includes 2 or more criteria: Tachycardia Tachypnea (RR > 20bpm) High or Low temperature (> 38 or 12), leukopenia (WBC 10%) Management for SIRS NPO until stable Blood sugar control insulin or glucose Bedrest until hemodynamically stable Stool softeners Patient IV VTE prophylaxis IV fluids Heparin subQ Vasopressors if not fluid responsive PPI prophylaxis Pain management Famotidine Morphine sulfate Possible corticosteroids Supplemental O2 Surgical removal of infectious Broad spectrum antibiotics organism if it is causing agent (ie: abcess) Nursing Care for SIRS Assess and treat pain Apply SCDs or TEDs Closely monitor for decompensation or Assist with ambulation, turns, ROM complications Monitor continuous V/S Provide emotional support Monitor I/O Nutrition Monitor blood labs Ensure patent IV Monitor mental status and LOC * Monitor heart and lung sounds Monitor for diagnostic/imaging results Educate patient regarding diagnosis & treatment General Shock Overview Life-threatening! Causes: infection, volume deficit, allergic reaction, cardiac failure, neurologic trauma/complication Due to inadequate tissue perfusion tissue hypoperfusion  cell dysfunction  cell death Systemic Acute or slow onset Anyone is at risk for development Basic Pathophysiology of Shock  Depends on the TYPE and STAGE Clinical Treatment: treat the cause + ABCs Manifestatio ns, Treatment Early identification and intervention is key! and Nursing Care for Earliest sign of shock – change in Shock mental status GOAL: reestablish and maintain adequate tissue perfusion General Nursing Care for Shock Maintain airway Prevent complications Supplemental O2 Closely monitor for decompensation or complications Patient IV Provide enteral or parenteral Maintain hemodynamic devices nutrition Monitor V/S continuously Apply SCDs or TEDs Monitor blood labs Assist with ambulation, turns, ROM Monitor diagnostic and imaging Provide emotional support results Educate patient regarding diagnosis Administer medications & treatment General Patient Education for Shock Diagnosis, Hand hygiene Safety diagnostic practices practices testing, treatment When to seek Supportive Medications medical care attention  Norepinephr Vasopressor via affecting smooth muscle  vasoconstriction ine AE: bradycardia, severe HTN, arrhythmias, peripheral ischemia Vasopressor affecting CNS  positive inotropic effects Epinephrine AE: tachycardia, hypokalemia, hypoglycemia, acidosis, arrhythmias, peripheral ischemia Phenylephri Vasopressor, vasoconstriction ne AE: tachycardia, bradycardia, arrhythmias, peripheral ischemia Cardiac Medications Vasopressin Anti-diuretic hormone that causes vasoconstriction AE: tachycardia, decreased CO, bradycardia, MI, peripheral ischemia for Shock Vasopressor affecting CNS  positive inotropic effect  increased CO Dopamine AE: arrhythmias, bradycardia, palpitations Positive inotrope to increase CO for short term decompensation  increases Dobutamine myocardial contractility AE: chest pain, hypotension, hypertension, SOB Positive inotrope; primarily for acute HF Milrinone AE: arrhythmias, tachycardiac, hypotension, palpitations Use for 48-hours or less, proven not affective after 48 hours  Continuous EKG monitoring Continuous V/S monitoring Nursing Monitor I/O Consideratio Monitor LOC and MS ns for all Cardiac Monitor for AE Medications Titrate continuous infusions accordingly Ensure patent IV access Ensure emergency medications are near by  Hypovolemic Due to deficient blood volume Cardiogenic Due to failure or impairment of myocardium Obstructive Due to an obstruction in the great vessels of heart leading decrease CO and poor perfusion Types of Distributive Results in displacement of intravascular volume resulting in hypovolemia Shock and inadequate delivery of O2 to cells Consists of any type of shock that results in hypovolemia: septic, neurogenic, anaphylactic Septic Due to dysregulated host response to an infection resulting in hypovolemia Neurogenic Due to loss of sympathetic tone causing hypovolemia Anaphylactic Severe allergic reaction causing systemic vasodilation and hypovolemia Hypovolemic Shock Due to decreased intravascular volume Causes: dehydration, hemorrhage, GI bleed, burns, ascites, V, D, diuresis, DI, DKA, trauma, surgery, internal fluid shifts Reduction of vascular volume by 15- 30% Loss of 750-1500mLs or more Clinical Manifestations of Hypovolemic Shock Restless, Altered mental Hypotensive Tachycardic Dyspnea anxious status Cool, clammy Pale Decreased UO Poor perfusion Fatigue Visible body Lightheaded/ Thirsty fluid loss weak (D,V,GI bleed) Hypovolemic Shock Diagnostic findings: Increased lactate BUN and Cr increase Possible decrease in Hb/HCT Elevated K and Na Increased urine specific gravity (>1.020) Medical Treatment: Treat underlying cause Restore hemodynamic stability Fluid or blood repletion Vasoactive medications Goal: restore intravascular volume to improve poor tissue perfusion and correct fluid loss Nursing care for Hypovolemic Shock ABCs + stabilization Monitor blood work Maintain airway Obtain type and screen / cross matching Apply supplemental O2 Monitor mechanical ventilator & advanced airway ABGs, CBC, CMP, Coags, lactate, CRP, LDH Ensure at least 2x patent PIV or CAD Administer medications Administer fluid resuscitation Insulin – if d/t hyperglycemia Colloids Desmopressin – if d/t DI Crystalloids Antidiarrheal agents Blood Products Administer medications to maintain cardiovascular Antiemetic agents stability GI ulcer prophylaxis Norepinephrine DVT prophylaxis Dopamine Electrolytes Vasopressin Epinephrine Monitor strict I/O & daily weight Phenylephrine Foley catheter Monitor V/S continuously Enteral feeding once shock is resolved Invasive hemodynamic monitoring Arterial line Maintain normothermia CVP Monitor for complications Cardiogenic Shock Heart is unable to contract adequately Poor CO Inadequate tissue perfusion Causes: acute MI, tamponade, arrhythmias, valve damage, cardiomyopathies, tension pneumothorax, hypoglycemia, hypocalcemia, acidosis, severe hypoxemia Can occur acutely or over periods of days Goal: prevention! Clinical Manifestations of Cardiogenic Shock Feeling of Hemodyna Arrhythmia Angina Fatigue impending mic s doom instability Pulmonary Poor Dyspnea Palpitations Anxiety congestion perfusion Change in Peripheral Diaphoresis Oliguria JVD LOC Edema Diagnostic Tests for Cardiogenic Shock Blood Cardiac Hemodyna EKG TTE Chest X-ray values Cath mic devices Lactate Shows MI Shows Rules out Can reveal Swan- ABG/mixed tamponad other conditions Ganz venous e, valve types of that can Catheter  Cardiac issues, shock lead to PAP biomarker myopathie cardiogeni greater s s, EF, c shock than 25 CK blood flow, (ie: cardiac Troponin structural tamponad defects e, PE, BNP venous pooling) Medical Treatment for Cardiogenic Shock Treat the cause Supplemental O2 Judicious IV fluid replacement Pain control Vasoactive medications Dobutamine, Nitroglycerin, Dopamine, Antiarrhythmics, vasopressors Invasive hemodynamic monitoring CVP, Arterial line, SWAN-Ganz Catheter Invasive mechanical assistive devices IABP, VAD GOAL: limit further myocardial damage, improve cardiac function by increasing cardiac contractility, decreasing afterload  done by increasing O2 supply to heart muscle while reducing O2 demands Nursing care for Cardiogenic Shock ABCs + stabilization Monitor blood work Maintain airway ABGs, CBC, CMP, Coags, lactate, CRP, LDH Apply supplemental O2 Administer medications Monitor mechanical ventilator & advanced airway Aspirin Ensure at least 2x patent PIV or CAD Diuretics Administer medications to maintain Fibrinolytic therapy (tPa) if PCI is not possible cardiovascular stability GI ulcer prophylaxis Norepinephrine DVT prophylaxis Dopamine Dobutamine Electrolytes Milrinone Monitor strict I/O & daily weight Nitroglycerin Foley catheter Amiodarone Enteral feeding once shock is resolved Monitor V/S continuously Maintain normothermia Maintain bed rest until stable Monitor for complications Assess heart/lung sounds & LOC for changes Prepare for possible interventions Pain management IABP, Cath Lab/PCI, LVAD, ECMO, surgery (ie: CABG) Septic Shock Due to a widespread infection Every hour sepsis is unidentified or untreated, the chance of survival decreases by 7.6% #1 cause of hospital admissions 1.6 Million people are diagnosed with sepsis each year 270,000 die from sepsis each year #1 cost of hospitalizations $24 billion dollars annually Goal: EARLY identification and EARLY intervention! Pathophysiology of Septic Shock 1. Insult – infection 2. Immune response is activated 3. Cytokines and medicators are released 4. Leads to poor tissue perfusion 5. Increased capillary permeability 6. Fluid leaks, hypovolemia occurs 7. Vasodilation occurs 8. Coagulation cascade is impaired  Inadequate tissue perfusion Stages of Shock Sepsis Severe Septic SIRS Sepsis Stages Sepsis Shock SIRS is defined as 2 or more of the following: Fever >38◦C or < 36◦C Heart rate >90 beats per minute Respiratory rate >20 breaths per minute or PaCO2 12,000/mm3 or 10% bands) SEPSIS: If + SIRS criteria plus suspected NEW/worsening infection Must have an identified source of infection. Sepsis Severe Septic Stages SIRS Sepsis Sepsis Shock SEVERE SEPSIS: Sepsis + Acute Organ Dysfunction Mottled skin Capillary refill >3 seconds Decreased urinary output Lactate >2 Abrupt change in mental status Thrombocytopenia or DIC Cardiac dysfunction SEPTIC SHOCK: MAP of less than 60 after fluid resuscitation Lactate >4 despite adequate fluid resuscitation Need for vasoactive medications in order to maintain MAP >60  Clinical Manifestations of Septic Shock Early stages: Late sages: Confused, agitated Lethargic, obtunded Hypotensive but responsive to fluids Hypotensive but not responsive to fluids Hyperthermic Hyperthermic or hypothermic Warm, flushed Cool, pale, mottled Bounding pulses Weak pulses, edema Tachypneic Tachypneic UO normal or slight decrease Anuric GI compromise GI compromise Hepatic dysfunction Abnormal coags Worsening hepatic dysfunction Elevated bili levels Platelets decrease Hypermetabolism Increase PTT/INR Hyperglycemia Jaundice Insulin resistance Worsening hypermetabolism Elevated lactate, CRP Hypo/hyperglycemic Worsening acidosis Diagnostic Tests for Shock  Blood labs CBC Lactate CRP ABG  Cultures Sputum Blood Urine  X-rays  CT  MRI Medical Interventions for Septic Shock Tx cause: Antibiotic therapy Hyperglycemic control Broad spectrum antibiotics: Zosyn & Nutritional support – enteral or Vancomycin parenteral Fluid repletion Steroids Isotonic fluids Antipyretics Maintain airway Electrolyte repletion Supplemental O2 Surgical removal of infectious source if Cardiovascular support possible (Ie: foreign object, foley, MAP > 65 to maintain tissue perfusion central line) Norepinephrine, vasopressin, epinephrine, GOAL: prevention, early identification, phenylephrine, dobutamine early treatment, stabilize, reperfusion, IV access remove the cause Nursing care for Septic Shock ABCs + stabilization Monitor blood work Maintain airway ABGs, CBC, CMP, Coags, lactate, CRP, LDH, Apply supplemental O2 cultures Monitor mechanical ventilator & advanced airway Administer medications Ensure at least 2x patent PIV or CAD Antipyretics Administer IV Fluids Analgesics Administer medications to maintain Antibiotics * within 60 minutes of dx * cardiovascular stability Steroids Norepinephrine, vasopressin, epinephrine, GI ulcer prophylaxis phenylephrine, dobutamine DVT prophylaxis Monitor V/S continuously Electrolytes Maintain bed rest until stable Sodium Bicarbonate Assess heart/lung sounds & LOC for changes Insulin/Dextrose Pain management Maintain normothermia Monitor strict I/O & daily weight Foley catheter Maintain euglycemia Enteral feeding once shock is resolved Monitor for complications Provide emotional support Sepsis Bundle Within 1 hour  obtain lactate  obtain blood cultures (x2)  administer broad spectrum antibiotics  aggressive fluid resuscitation administer vasopressors if needed to maintain MAP > 65 Neurogenic Shock Due to a loss of control/homeostasis between parasympathetic and sympathetic nervous system Sympathetic  causes vasoconstriction Parasympathetic  causes vasodilation Causes: spinal cord injury (commonly T6 and above), spinal anesthesia, other nervous system damage, or medications Pathophysiology: systemic vasodilation, leads to hypotension, bradycardia = insufficient perfusion; sympathetic system is not able to respond and compensate Clinical Manifestations of Neurogenic Shock Warm, dry Diaphoresis Hypotension Bradycardia skin above injury Flaccid Loss of Loss of Loss of DTR paralysis sensation temperature below level below level below level control of injury of injury of injury Possible paralytic ileus Dx Test and Medical Tx for Neurogenic Shock Diagnostic Tests Medical Treatment Stabilize ABCs Clinical presentation and history – SCI or trauma DVT prophylaxis CT NPO Bedrest until stable MRI IV fluids Vasoactive agents Pain management Morphine Pregabalin for neuropathic pain Atropine Surgery to alleviate trauma Nursing care for Neurogenic Shock ABCs + stabilization Monitor strict I/O & daily weight Maintain airway Foley catheter Apply supplemental O2 Enteral feeding once shock is resolved Monitor mechanical ventilator & advanced airway Monitor blood work Ensure at least 2x patent PIV or CAD ABGs, CBC, CMP, Coags Administer IV Fluids Administer medications Administer medications to maintain Antipyretics cardiovascular stability Norepinephrine, vasopressin, epinephrine, Analgesics phenylephrine, dopamine GI ulcer prophylaxis – if intubated Atropine DVT prophylaxis Monitor V/S continuously Electrolytes Maintain bed rest until stable – spine Insulin/Dextrose immobilization* Maintain normothermia & euglycemia Assess heart/lung sounds Monitor for complications Assess neuro – GCS, LOC, PERRLA Provide emotional support Pain management Anaphylactic Shock Due to severe systemic allergic reaction with immunoglobulin E (IgE) Acute onset of symptoms (2-30 minutes) Delayed reaction up to 8-10 hours Causes: foods, medications, inset stings and bites, latex, blood products, contrast Pathophysiology: antigen-antibody reaction causing mast cells to release histamine or bradykinin, activating cytokines  massive widespread vasodilation and increased capillary permeability 3 Key Clinical Characteristics: Acute 2 or more symptoms (respiratory compromise, hypotension, Gi distress or skin irritation) Cardiovascular compromise within minutes to hours after exposure to antigen Clinical Manifestations of Anaphylactic Shock N, V, acute Feeling of Generalized Dizzy/ Pruritus, Headache abdominal impending erythema and lightheaded Urticaria pain doom flushing Dyspnea d/t Wheezes, Feeling of Bronchospasm Cardiac laryngeal Angioedema Stridor, SOB, lump in throat s arrhythmias edema Cough Hypotension, Neurological Chest pain Palpitations Itchy eyes Tachycardia compromise Diagnostic Tests for Anaphylactic Shock Clinical presentation and history ABG Histamine levels NO time for CT/MRI Medical Treatment for Anaphylactic Shock Remove the cause Diphenhydramine IV Maintain airway Reverse histamine effects Advanced airway – trach if needed Steroids Mechanical ventilation Fluid resuscitation Supplemental O2 Cardiovascular support Nebulizer treatments IV fluids Albuterol Vasoactive agents – dopamine All resuscitation efforts – Epinephrine IM BLS/CPR/ACLS For vasoconstriction NPO SE: tachycardia Requires cardiac monitoring DVT prophylaxis Nursing care for Anaphylactic Shock ABCs + stabilization Monitor strict I/O & daily weight Maintain airway Foley catheter Apply supplemental O2 Enteral feeding once shock is resolved Monitor mechanical ventilator & advanced airway Monitor blood work Ensure at least 2x patent PIV or CAD ABGs, CBC, CMP Administer IV Fluids Administer medications Administer medications to maintain Epinephrine cardiovascular stability Albuterol Vasopressors Steroids IV fluids Antihistamines Monitor V/S continuously Antipyretics Maintain bed rest until stable Analgesics Assess heart/lung sounds GI ulcer prophylaxis – if intubated Monitor for complications DVT prophylaxis Provide emotional support Electrolytes Assess edema and neuro status Insulin/Dextrose Distributive Shock Results in impaired vascular tone (vasodilation), resulting in hypovolemia Subdivided into: Septic shock Neurogenic shock Anaphylactic shock Shock Cheat Sheet MODS – Multiple Organ Dysfunction Syndrome Two or more organs are malfunctioning due to inadequate tissue perfusion and cellular dysfunction that they require interventions for support Results from any type of shock (mostly sepsis) Poor prognosis – mortality rate is 60% Requires early identification and treatment Clinical Manifestations of MODS Cardiovascu Narrow Respiratory Renal lar Pulse compromise failure instability Pressure Immunologi Hepatic CNS GI failure c failure dysfunction impairment Fever Pain Medical Treatment for MODS Respiratory: Hepatic Mechanical Ventilation Laxative Sedation/paralytic Blood products Cardiovascular: Albumin Vasoactive medications Endocrine: IV fluids vs Diuresis Insulin vs Dextrose Blood products ECMO GI Enteral or parenteral nutrition Renal: Electrolyte repletion Hematological: CVVHD Anti-coagulants Remove excess fluid Remove toxins Medications Fix acidosis Dialyses Palliative Care Nursing care for MODS ABCs + stabilization Monitor strict I/O & daily weight Maintain airway Foley catheter Apply supplemental O2 Enteral or parenteral feeding Monitor mechanical ventilator & advanced airway Monitor blood work Ensure at least 2x patent PIV or CAD Everything Administer IV Fluids Administer medications Administer medications to maintain Pain management cardiovascular stability Vasopressors Provide comfort and supportive IV fluids measures Pastoral care Monitor V/S continuously Case management Hemodynamic devices Maintain bed rest until stable Assess heart/lung sounds Monitor for complications Provide emotional support NCLEX - NextGen 2. True or False: Septic shock causes system wide vasodilation which leads to an increase in systemic vascular resistance. In addition, septic shock causes increased capillary permeability and clot formation in the microcirculation throughout the body. NCLEX - NextGen 4. Which of the following are classic signs of systemic inflammatory response syndrome (SIRS)? A. Hypothermia, hypotension, and bradypnea B. Fever, tachycardia, and hypotension C. Fever, tachycardia, and tachypnea D. Hypothermia, bradycardia, and leucopenia NCLEX - NextGen 5. The nurse is educating the nursing student regarding the clinical findings and pathophysiology of neurogenic shock. Which of the follow would explain the clinical findings of neurogenic shock? A. Loss of sympathetic nervous system innervation B. Parasympathetic nervous system stimulation C. Injury to the hypothalamus D. Focal injury to cerebral hemispheres