Nursing Care of the Adult and Geriatric Client with Systems Failure PDF

Nursing Care of the Adult and Geriatric Client with Systems Failure N004 Reading and SLO See lecture outline See lecture outline Lewis 11th ed. SLO Lecture Content: Nursing care of the client with systems failure o Shock o Systemic inflammatory response syndrome o Multiple organ dysfunction syndrom...

Nursing Care of the Adult and Geriatric Client with Systems Failure N004 Reading and SLO See lecture outline See lecture outline Lewis 11th ed. SLO Lecture Content: Nursing care of the client with systems failure o Shock o Systemic inflammatory response syndrome o Multiple organ dysfunction syndrome o Application of the nursing process Student Learning Outcomes    1. Differentiate the two major classifications of shock: Low blood flow and maldistribution of blood flow. 2. Describe the pathophysiology and clinical manifestations of shock. 3. Compare and contrast the effects of systemic inflammatory response syndrome, shock, and multiple organ dysfunction syndrome on the major body systems. SLO’s cont.    4. Compare the collaborative care, drug therapy and nursing management of clients with different types of shock. 5. Describe the nursing management of a client experiencing multiple organ dysfunction syndrome. 6. Apply the nursing process for a client with multi-systems failure. Review Structures and Functions of the Cardiovascular System  Heart    Structure Blood Flow Through the Heart Blood Supply to the Myocardium Structures and Functions of the Cardiovascular System  Heart (cont.)   Conduction System Mechanical System Normal Sinus Rhythm Mechanical System  Cardiac cycle  Systole  Diastole Structures and Functions of the Cardiovascular System (cont.)  Regulation of the Cardiovascular System    Autonomic Nervous System Baroreceptors Chemoreceptors Cardiac Physiology  Neurotransmitters & Humoral Mechanisms  Autonomic nervous system involved in maintaining short term regulation of b/p   Change d/t CNS ischemia, mood or emotion Hormones also contribute to the regulation of b/p (Rennin, Angiotensin I, Angiotensin II) Cardiac Physiology  Cardiac output    Quantity of the blood forced out of the left ventricle = stroke volume > CO = increased b/p < CO = decreased b/p Hemodynamic Monitoring Review  Hemodynamic terminology      Cardiac output and cardiac index Preload Afterload Vascular resistance Contractility Hemodynamic Monitoring (cont’d)  Types of invasive pressure monitoring  Arterial blood pressure   Measurements Complications Fig. 66-3 Fig. 66-6 Hemodynamic Monitoring (cont’d)  Types of invasive pressure monitoring (cont’d)  Pulmonary artery flow-directed catheter    Pulmonary artery catheter insertion Pulmonary artery pressure measurements Central venous or right atrial pressure measurement Fig. 66-7 Fig. 66-8 SHOCK Shock:Classifications: low blood flow or Maldistribution  4 Main Categories of shock:  Cardiogenic shock  Hypovolemic shock   – Absolute/Relative Obstructive Shock Distribution Shock:  Neurogenic shock  Anaphylactic shock  Septic shock Low Blood Flow Shock  Cardiogenic Shock     Systolic dysfunction Diastolic dysfunction Dysrhythmia Structural Hypovolemic Absolute: External loss of whole blood Loss of other body fluids Relative: Polling of fluids Fluid shifts Internal bleeding Massive vasodilatation Fig. 672 Fig. 673 Maldistribution of blood flow shock   Neurogenic Anaphylactic Septic Fig. 674 Fig. 675 Obstructive Shock  Develops when physical obstruction to blood flow occurs with decreased CO   From restriction to diastolic filling of the right ventricle due to compression Abdominal compartment syndrome Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Obstructive Shock  Patient will experience     Decreased CO Increased afterload Variable left ventricular filling pressures Rapid assessment and immediate treatment are important. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Shock (cont’d)   Stages of shock  Compensatory stage  Progressive stage  Irreversible stage Diagnostic studies Compensatory Stage of Shock Fig. 67-7. Compensatory stage: reversible stage during which compensatory mechanisms are effective and homeostasis is maintained. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 33 Progressive Stage of Shock Fig. 67-8. Progressive stage: compensatory mechanisms are becoming ineffective and fail to maintain perfusion to vital organs. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 34 Irreversible Stage of Shock Fig. 67-9. Irreversible or refractory stage: compensatory mechanisms are not functioning or are totally ineffective, leading to multiple organ dysfunction syndrome. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 35 Shock (cont’d)  Collaborative care: General measures    Oxygen and ventilation Fluid resuscitation Drug therapy    Sympathomimetic drugs Vasodilator drugs Nutritional therapy Shock (cont’d)  Collaborative care: Specific measures       Cardiogenic shock Hypovolemic shock Septic shock Neurogenic shock Anaphylactic shock Obstructive Nursing Management Shock  Nursing assessment    Nursing diagnoses Planning Nursing implementation  Health promotion Nursing Management Shock (cont’d)  Nursing implementation (cont’d)  Acute intervention  Neurologic status  Cardiovascular status  Respiratory status  Renal status  Body temperature and skin changes  Gastrointestinal status  Personal hygiene  Emotional support and comfort Systemic Inflammatory Response Syndrome and Multiple Organ Dysfunction Syndrome  SIRS  MODS SIRS   Systemic inflammatory response syndrome (SIRS) is a systemic inflammatory response to a variety of insults Generalized inflammation in organs remote from the initial insult SIRS  Triggers    Mechanical tissue trauma: burns, crush injuries, surgical procedures Abscess formation: intra-abdominal, extremities Ischemic or necrotic tissue: pancreatitis, vascular disease, myocardial infarction SIRS  Triggers     Microbial invasion: Bacteria, viruses, fungi Endotoxin release: Gram-negative bacteria Global perfusion deficits: Post–cardiac resuscitation, shock states Regional perfusion deficits: Distal perfusion deficits MODS  Multiple organ dysfunction syndrome (MODS) is the failure of two or more organ systems   Homeostasis cannot be maintained without intervention Results from SIRS MODS   SIRS and MODS represent the ends of a continuum Transition from SIRS to MODS does not occur in a clear-cut manner SIRS and MODS  Consequences of inflammatory response       Release of mediators Direct damage to the endothelium Hypermetabolism Vasodilation leading to decreased SVR Increase in vascular permeability Activation of coagulation cascade SIRS and MODS Pathophysiology  Organ and metabolic dysfunction  Hypotension  Decreased perfusion  Formation of microemboli  Redistribution or shunting of blood SIRS and MODS Pathophysiology  Respiratory system      Alveolar edema Decrease in surfactant Increase in shunt V/Q mismatch End result: ARDS SIRS and MODS Pathophysiology  Cardiovascular system  Myocardial depression and massive vasodilation SIRS and MODS Pathophysiology  Neurologic system  Mental status changes due to hypoxemia, inflammatory mediators, or impaired perfusion  Often early sign of MODS SIRS and MODS Pathophysiology  Renal system  Acute renal failure  Hypoperfusion  Release of mediators  Activation of renin–angiotensin– aldosterone system  Nephrotoxic drugs, especially antibiotics SIRS and MODS Pathophysiology  GI system    Motility decreased: Abdominal distention and paralytic ileus Decreased perfusion: Risk for ulceration and GI bleeding Potential for bacterial translocation SIRS and MODS Pathophysiology  Hypermetabolic state      Hyperglycemia–hypoglycemia Insulin resistance Catabolic state Liver dysfunction Lactic acidosis SIRS and MODS Collaborative Care    Prognosis for MODS is poor Goal: Prevent the progression of SIRS to MODS Vigilant assessment and ongoing monitoring to detect early signs of deterioration or organ dysfunction is critical SIRS and MODS Collaborative Care  Prevention and treatment of infection  Aggressive infection control strategies to decrease risk for nosocomial infections  Once an infection is suspected, institute interventions to control the source SIRS and MODS Collaborative Care  Maintenance of tissue oxygenation  Decrease O2 demand Sedation  Mechanical ventilation  Paralysis  Analgesia  SIRS and MODS Collaborative Care  Maintenance of tissue oxygenation  Optimize O delivery 2   Maintain normal hemoglobin level Maintain normal PaO2  Individualize tidal volumes with PEEP SIRS and MODS Collaborative Care  Maintenance of tissue oxygenation  Enhance CO Increase preload or myocardial contractility  Reduce afterload  SIRS and MODS Collaborative Care  Nutritional and metabolic needs   Goal of nutritional support: Preserve organ function Total energy expenditure is often increased 1.5 to 2.0 times SIRS and MODS Collaborative Care  Nutritional and metabolic needs  Use of the enteral route is preferred to parenteral nutrition  Monitor plasma transferrin and prealbumin levels to assess hepatic protein synthesis SIRS and MODS Collaborative Care  Support of failing organs    ARDS: Aggressive O2 therapy and mechanical ventilation DIC: Appropriate blood products Renal failure: Continuous renal replacement therapy or dialysis Relationship of Shock, SIRS, and MODS Fig. 67-1 ?    Mr. Kim presented with hypovolemic shock. The Doctor ordered: Dopamine 2mcg/kg/min. The solution available is 400mg in 250ml D5W. The client weighs 150 lbs. How many mcg/min would you administer? Determine the flow rate setting for a volumetric pump. Patient Profile  A 25 y.o.male, was not wearing his seat belt when he was the driver involved in a M.V.A. The windshield was broken and he was found 15ft from his car. He was face down, conscious, and moaning. His wife and child were wearing seat belts and sustained no serious injuries. All passengers were taken to the ED.  Subjective data: “I can’t breath” Patient Profile  Objective data: BP 80/56, apical pulse 138 but no palpable radial or pedal pulses. Carotid pulse present but weak. Tele: ST  Lungs: RR 38, labored breathing with shallow respirations, asymmetric chest wall movement, absence of breath sounds on left side. Trachea deviated to the right.  Abdomen: slightly distended and left upper quadrant painful on palpation  Musculoskeletal: open compound fracture of the lower left leg.  Diagnostic studies: Chest x-ray- Hemothorax, six rib fractures on left side.  H&H: 9 & 18 Patient Profile  Collaborative Care (in the ED)  Left chest tube placed, draining bright red blood  IV Access obtained via one peripheral line and right subclavin  Surgical Procedure: Splenectomy, Repair of torn intercostal artery, Repair of compound fracture. Discussion Questions  What typed of shock is K.L. experiencing? What clinical manifestation did he display that support your answer?  What were the causes of K.L. shock states? What are other causes of these types of shock?  What are the priority nursing responsibilities for K.L?  What on going nursing assessments parameters are essential for this patient?  What are his potential complications to each system?  Cardiac  Respiratory  Renal  GI  Neuro  Hepatic References        Adams, M.& Urban, C. (2013) Pharamcology connections to Nursing Practice (2nd ed.) Boston:Pearson Evolve.Elsevier.com Lewis, S.M., Heitkemper, M.N., & Dirksen, S.R. (2019). Medical Surgical Nursing: Assessment and Management of Clinical Problems, 10th ed. Mosby. McKenry, et all (2006) Mosby’s Pharmacology in Nursing, Elsevier. O’Brien, P. (2004). Study Guide for Medical Surgical Nursing, 6th ed. Mosby. Perry, A, Potter P. (2009) Fundamental of Nursing, 7th ed. Mosby. http://www.anaesthetist.com/icu/organs/heart/ecg/