Nursing Care of Patients in Shock PDF

10/22/2024 Nursing Care of Patients in Shock Chapter 9 Niomi Quinteros BSN, RN Circulatory collapse resulting in organ Shock damage and death without immediate treatment Shock...

10/22/2024 Nursing Care of Patients in Shock Chapter 9 Niomi Quinteros BSN, RN Circulatory collapse resulting in organ Shock damage and death without immediate treatment Shock 1  10/22/2024 Tissue perfusion and B/P are maintained by: Adequate blood volume Effective cardiac pump Effective blood vessels Pathophysiology of Shock Compensation (Compensatory Mechanism) Once system fails and changes are made in one or both of nonfailing systems Shock occurs when Inadequate tissue compensatory mechanism fails perfusion Sympathetic nervous system Metabolic and Tachycardia Hemodynamic Changes Tachypnea in Shock Oliguria Cool, clammy skin with pallor Decreased blood pressure 2  10/22/2024 Effect on Organ and Organ Systems Tissue ischemia and organ injury Brain death if anoxic over 4 minutes Acute respiratory distress syndrome (A R D S) Complications from Shock Disseminated intravascular coagulation (D I C) Multiple organ dysfunction syndrome (M O D S) 3  10/22/2024 Classification of Shock Hypovolemic shock Decreased circulating blood volume Cardiogenic shock Cardiac failure Obstructive shock Blockage of blood flow outside heart Distributive shock Excessive dilation of venules/arterioles Characteristics of all shock is decreased blood pressure - below level to maintain adequate blood flow to tissues. Hypovolemic Shock Decreased circulating volume Any severe loss of body fluid including dehydration Causes Dehydration, hemorrhage Loss of fluid from burns, vomiting, diarrhea, or intravascular into interstitial space Signs and Symptoms Restlessness, altered mental status Pale, cool, clammy skin Tachycardia, tachypnea Nondistended peripheral veins, decrease jugular vein circumference Decrease urine output 4  10/22/2024 Cardiogenic Shock Cardiac failure, heart fails to adequately pump blood to the body Causes Acute myocardial infarction Rupture of heart valve Acute myocarditis/cardiomyopathy End stage heart disease Severe dysrhythmias (A-fib) Traumatic injury to the heart Signs and Symptoms Similar to hypovolemic – plus- Distended jugular and peripheral vein Pulmonary edema, extreme shortness of breath, wheezing and gasping for breath, coughing white frosty sputum Obstructive Shock Blocked blood flow outside heart Causes Pericardial tamponade- Pericardial sac fills with blood Tension pneumothorax- compression of heart with air in pleural spaces Acute pulmonary hypertension- increase pressure in pulmonary artery Signs and Symptoms Similar to hypovolemic Distended jugular 5  10/22/2024 Peripheral vascular is loss due to excessive dilation of venules/arterioles Distributive Shock Types Anaphylactic shock Septic shock Neurogenic shock Anaphylactic Shock Extreme hypersensitivity reaction to antigen, death in minutes Causes Insect stings, antibiotics, peanuts, anesthetics, dye, blood Signs and symptoms Similar to hypovolemic shock Allergic reactions, rash, urticaria, laryngeal edema, severe bronchospasm, wheezing Conscious: SOB, metallic taste Administer Epinephrine (Adrenaline) and O2 First action is to maintain airway patency, Highest priority Monitor lung sounds and SpO2 6  10/22/2024 Septic Shock Systemic infection and inflammation Causes Gram negative bacteria Multidrug resistant bacteria and fungi Predisposing conditions Trauma Diabetes Corticosteroid therapy HIV Chemotherapy Burns Malnutrition Invasive catheters Septic Shock Signs and Symptoms Early Phase Warm/flushed skin Fever, elevated WBC’s Decreased B/P, tachycardia tachypnea Second Phase Decreased B/P, tachycardia, nondistended jugular and peripheral veins, cold clammy skin Tachypnea Oliguria Temperature decreases to normal or subnormal Altered mental status Leading cause of death in critically ill clients 7  10/22/2024 Neurogenic Shock Dysfunction or injury of the nervous system, dilation of peripheral blood vessels Causes General anesthesia Fever Metabolic disturbances Brain contusions/concussions Signs and Symptoms Decreased B/P, altered mental status Early s/s: bradycardia, warm dry skin Late s/s: tachycardia, cool clammy skin Classic Signs of Shock Tachycardia Tachypnea Oliguria Pallor, and cool clammy skin 8  10/22/2024 Therapeutic Measures for Shock Maintain airway/respiratory support. Provide cardiovascular support. Maintain circulatory volume. Control bleeding. Treat cause/identify source of infection. Nursing Care Maintain airway, oxygenation. Monitor vital signs. Monitor intake and output. Provide fluids as ordered. Provide warmth. Relieve pain. Monitor for pressure injury (vasopressor use). 9  10/22/2024 Review Question The nurse is reinforcing teaching to the family of a patient experiencing hypovolemic shock. Which of these would the nurse correctly state causes hypovolemic shock? 1. “Circulating blood volume is decreased.” 2. “The heart fails to pump blood.” 3. “There is a blockage of blood flow outside the heart.” 4. “Excessive dilation of blood vessels occurs.” Review Question Which action would be appropriate for the nurse to take for a patient with cardiogenic shock? 1. Administer epinephrine as ordered. 2. Give ordered antimicrobials within 1 hour. 3. Question I V fluid orders. 4. Provide ordered nutrition. 10  10/22/2024 Review Question The nurse reinforces teaching to a patient with allergies that includes which of these? 1. Sleep with head of bed elevated. 2. Carry epinephrine autoinjector. 3. Do ankle exercises hourly. 4. Change positions slowly. Review Question Which of these would the nurse implement as the priority action for the patient with newly diagnosed septic shock? 1. Obtain blood cultures before antibiotics. 2. Give broad-spectrum antibiotics within 1 hour of septic shock diagnosis. 3. Monitor ordered I V fluids. 4. Provide ordered enteral nutrition. 11  10/22/2024 Review Question Which of these interventions would the nurse implement for the patient experiencing shock? Select all that apply. 1. Maintain airway, oxygenation. 2. Monitor vital signs. 3. Monitor intake and output. 4. Ambulate patient bid. 5. Relieve pain. 6. Check capillary refill in older adult. 12