Shock Management PDF

Management of Dr Salwa Alalawi Objectives  Identify Medical &Nursing management priorities in treating patients in shock due to Hypovolemic Cardiogenic Neurogenic Anaphylactic septic state. Shock  Definition:a life-threatening condition that results f...

Management of Dr Salwa Alalawi Objectives  Identify Medical &Nursing management priorities in treating patients in shock due to Hypovolemic Cardiogenic Neurogenic Anaphylactic septic state. Shock  Definition:a life-threatening condition that results from inadequate tissue perfusion.  Stages of shock: Compensatory stage Progressive stage Irreversible stage STAGES OF SHOCK: Compensatory stage  Bp remains in normal limits  Vasoconstriction, increased heart rate and increased contractility of the heart contribute to maintain adequate cardiac output  Fight or flight response in patients: the body shunts blood from organs to ensure adequate blood supply to the brain, heart & lungs Compensatory Stage  Clinical Manifestation:  Normal blood pressure (within)  Inadequate organ perfusion  Metabolic acidosis  Raising blood PH  Compensatory respiratory alkalosis  Anxious and confusion  Medical management  Directed toward identifying cause of shock  Correcting the underlying disorder so that shock does not progress  Support physiologic processes that have responded successfully to the threat  Maintain an adequate blood pressure.  Re-establish and maintain adequate tissue perfusion.  Fluid replacement  Medication therapy Nursing management  Monitor tissue perfusion:  Change in level of consciousness, Skin, Urinary output, V/S, Lab values  Reducing anxiety: Providing brief explanations:the diagnostic and treatment procedures, supporting the patient during these procedures  Promoting safety:  Impaired pt judgment  Close monitoring, frequent reorientation, hourly rounding, and implementing interventions to prevent falls  Progressive stage  Mechanisms that regulate BP can no longer compensate Systolic blood pressure less than 90 mmHg or decrease sPB of 40mmHg from baseline  Hypoperfusion:  Ischemic heart. Autoregulatory function of the circulation, Less fluid return from the heart.  Fluid leak from the capillaries.  Interstitial edema. Progressive Stage of Shock  Lungs begin to fail, decreased pulmonary blood flow causes further hypoxemia, carbon dioxide levels increase, alveoli collapse, pulmonary edema occurs  Inadequate perfusion of heart leads to dysrhythmias, ischemia  As MAP falls below 70, GFR cannot be maintained Acute kidney injury may occur  Liver function, GI function, hematologic function are all affected Clinical manifestation  Respiratory problems:  Rapid shallow respiration, crackles, hypoxemia  Acute lung injury  Cardiovascular problems:  Rapid pulse exceed 150bpm, dysrthmias, ischemia  Neurological problems:  Metal status deteriorates (agitated and confused)  Renal problems:  Acute renal failure, BUN increase Clinical manifestation  Hepatic problems:  Liver enzymes raise  Gastrointestinal problems:  stress ulceration; GI bleeding, bloody diarrhea  Hematologic problems :  Bruise (ecchymoses)  Bleeding (petechiae) Medical management  Supporting the respiratory system  Optimizing intravascular volume  Supporting pumping action of the heart  Improving the competence of the vascular system  medication: Hyperglycemia control , Antacid, histamine H2 blocker, ant peptic agent Nursing management  Intensive care setting to facilitate close monitoring, rapid and frequent administration of prescribed medications and fluids, interventions of supportive technologies such as mechanical ventilation, dialysis and intra-aortic balloon.  Preventing complication:  V/S, IV Centerlines, positioning and repositioning, reduce infection.  Promoting rest and comfort  Supporting family members Irreversible stage  severe organ damage, patient does not respond to treatment and cannot survive  Multiple organ dysfunction NURSING MANAGEMENT IRREVERSIBLE STAGE  Same as progressive state  Family must be informed of the prognosis and likely outcome  Promote with family better understanding of the purposes of management measures (no chance for recovery) to prevent misinterpretation  Provide opportunity for family to see, talk and touch the patient  Family should express their wishes concerning the use of life support system GENERAL MANAGEMENT STRATEGIES BASIC FIRST AID General Management strategies in shock  Fluid replacement.  Vasoactive medication.  Nutritional support. Crystalloid and Colloid solution Isotonic crystalloid: selected because it can given without altering the concentrations of electrolytes in the plasma. hypovolemic shock:0.9% sodium chloride solution (normal saline) and lactated Ringer’s solution Traumatic Burn injury: Hypertonic crystalloid solution 3% sodium chloride Tissue hypoperfusion: colloids (Plasma protein, which are molecules that are too large to pass through capillary membranes) Complication of fluid administration  Cardiovascular overload  urinary output, changes inmental status, skin perfusion, changes in vital signs  Pulmonary edema  adventitious lung sounds such as crackles signs of fluid accumulation  Abdominal compartment syndrome ACS  occur when large volumes of fluid are administered  Nursing care: Close monitoring V/S , Monitor Intake and output FLUID REPLACEMENT VASOACTIVE MEDICATION THERAPY  Alpha-adrenergic receptor When stimulated, blood vessels constrict in the cardiorespiratory and GI systems, skin and kidneys  Beta-adrenergic receptor Beta 1- adrenergic – when stimulated, heart rate and myocardial contraction increase Beta2 - adrenergic – when stimulated, vasodilation occurs in the heart and skeletal muscles, the bronchioles relax Central venous line using an iv pump controller Vital signs every 15 minutes until stable, or more often if indicated NUTRITIONAL SUPPORT  Increased metabolic rates increases energy requirements and caloric requirements 3000 calories daily  Nutritional requirements breaks down lean body mass even when patients has large stores of fat or adipose tissue prolonging recovery time.  Enteral nutrition is preferred, promoting GI function through direct exposure of nutrients and limiting complications in parenteral feeding. Glutamine can also be administered to promote GI immunity.  Antacids, h2 blockers and proton pump inhibitors are prescribed to prevent ulcer formation. Classification of shock  Hypovolemic shock  Cardiogenic shock  Distributive or vasogenic shock:  Neurogenic  Septic  Anaphyactic Conditions Precipitating shock  Hypovolemic shock:  Decrease in the intravascular volume  Cardiogenic shock:  Heart has impaired pumping ability  Distributive shock:  Misdistribution or mismatch of blood flow to the cell  Risk factors for hypovolumic shock  External: fluid losses  Internal: fluid shifts  Trauma  Hemorrhage  Surgery  Burns  Vomiting  Ascites  Diarrhea  Peritonitis  Diuresis  Diabetes insipidus  Medical management  Restore intravascular volume:2 large IV lines, blood products.  lactated Ringer’s solution or 0.9% sodium chloride solution are commonly used to treat hypovolemic shock  Redistribute fluid volume: modified Trendelenburg  Pharma: vasoactive  Correct the underlying cause of the fluid loss as quickly as possible  insulin, desmopressin (DDAVP), antidiarrheal and antiemetic Redistribute fluid volume Nursing role  Monitor V/S  Safe Administer fluid and blood replacement  Oxygen supply Cardiogenic shock Risk factors:  Coronary factors:  Myocardial infraction  Noncoronary factors:  Cardiomyopathies  Valvular damage  Cardiac tamponade  Dysthythmias  Angina Pain  Dysrhythmias  complain of fatigue, express feelings of doom  signs of hemodynamic instability Medical management  Limit myocardial damage  Improve the cardiac function: Increase cardiac contractility Decreasing ventricular after load Correction of underlying causes  Coronary cardiogenic shock Thrombolytic therapy Angioplasty therapy Coronary artery bypass surgery  Non- coronary cardiogenic shock Cardiac valve replacement First-line treatment  Supplying supplement oxygen (2-6 L/M)  Controlling chest pain (morphine sulphate)  Administering vasoactive medication  Providing selective fluid support  Implementing mechanical cardiac support Pharmacology  Dobutamine  Nitroglycerin  Dopamine  Other vasoactive medication  Anti-arrhythmic medication Nursing management  Preventing cardiogenic shock  Monitoring hemodynamic status  Administering medication and IV  Maintain IABC  Enhancing safety and comfort Distributive shock  Septic shock  Neurogenic shock  Anaphylactic shock Septic shock  Causes: Infection (nosocomial infection)  Gram-negative Bacteria Prevention:  Hand washing  Aseptic technique Septic shock  Medical management Fluid replacement & fluid challenge test (IV infusion of at least 30 mL/kg of crystalloids over 30 minutes) Broad spectrum antibiotic & Inotropic agents Nutritional therapy:  Enteral feeding Nursing Management:  Hand hygiene  Maintain aseptic:IV lines, arterial and venous puncture sites, surgical incisions, traumatic wounds, and urinary catheters must be monitored for signs of infection  obtains appropriate specimens for culture and sensitivity  control temperature: administering acetaminophen or applying a hypothermia blanket Neurogenic shock  Loss of sympathetic tone  Causes of neurogenic shock  Spinal cord injury  Spinal anesthesia  Nervous system damage Clinical Manifestation  Short course Fainting Different than the other shocks Dry, warn skin Braydicardia  Long course Spinal cord injury Medical management  Stabilization of spinal cord  Elevated the bed during spinal anesthesia up to 30 degree  pneumatic compression devices often combined with antithrombotic agents (e.g., low–molecular-weight heparin(Dvt)  anti-embolism stockings  Support cardiovascular and neurologic function Anaphylactic shock  Allergic reaction when the body produce antibody to a foreign substance Anaphylactic shock Anaphylactic shock  Clinical manifestation Anaphylactic shock Anaphylactic shock  Removing causative antigen  Fluid management  CPR as needed and general system support Endotracheal intubation, IV lines  Epinephrine  Diphenhydramine  Aminophylline  ALBUTEROL (PROVENTIL) -bronchospasm NURSING MANAGEMENT  Assessing for allergies or previous reactions to antigens  Communicate existence of allergies  Identification of new allergies  Administering medications subcutaneously or intramascularly  Allergy diagnostic testing  Cardiopulmonary resuscitation (CPR)  Orientation of exposure, recognizing symptoms and administering emergency treatment Thank You