Elsevier items and derived items © 2006 by Elsevier Inc. Shock and Multisystem Failure

Elsevier items and derived items © 2006 by Elsevier Inc. Shock Can occur when any part of the cardiovascular system does not function properly for any reason Begins with abnormal cellular metabolism that occurs when too little oxygen is delivered to tissues Review of tissue perfusion Can occur when any part of the cardiovascular system does not function properly for any reason Begins with abnormal cellular metabolism that occurs when too little oxygen is delivered to tissues Review of tissue perfusion

Elsevier items and derived items © 2006 by Elsevier Inc. Processes of Shock Initial stage (early shock) Nonprogressive stage (compensatory stage) Progressive stage (intermediate stage) Refractory stage (irreversible stage) Initial stage (early shock) Nonprogressive stage (compensatory stage) Progressive stage (intermediate stage) Refractory stage (irreversible stage)

Elsevier items and derived items © 2006 by Elsevier Inc. Multiple Organ Dysfunction Syndrome Cell damage is caused by the massive release of toxic metabolites and enzyme. Metabolites trigger small clots to form that block tissue oxygenation and damage more cells, continuing the devastating cycle. Cell damage is caused by the massive release of toxic metabolites and enzyme. Metabolites trigger small clots to form that block tissue oxygenation and damage more cells, continuing the devastating cycle.

Elsevier items and derived items © 2006 by Elsevier Inc. Hypovolemic Shock Occurs when low circulating blood volume causes a mean arterial pressure decrease; the body’s oxygen need is not met Caused by external hemorrhage; common after trauma and surgery or reduction in levels of clotting factors (Continued) Occurs when low circulating blood volume causes a mean arterial pressure decrease; the body’s oxygen need is not met Caused by external hemorrhage; common after trauma and surgery or reduction in levels of clotting factors (Continued)

Elsevier items and derived items © 2006 by Elsevier Inc. Hypovolemic Shock (Continued) Caused by internal hemorrhage as occurs with blunt trauma, gastrointestinal ulcers, and poor control of surgical bleeding

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Cardiogenic Shock Actual heart muscle is unhealthy and pumping is directly impaired. Cardiac output and afterload are reduced, thus reducing mean arterial pressure. Actual heart muscle is unhealthy and pumping is directly impaired. Cardiac output and afterload are reduced, thus reducing mean arterial pressure.

Elsevier items and derived items © 2006 by Elsevier Inc. Distributive Shock Caused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, and increased blood vessel permeability Neural-induced distributive shock Chemical-induced distributive shock (Continued) Caused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, and increased blood vessel permeability Neural-induced distributive shock Chemical-induced distributive shock (Continued)

Elsevier items and derived items © 2006 by Elsevier Inc. Distributive Shock (Continued) Anaphylaxis Sepsis Capillary leak syndrome Anaphylaxis Sepsis Capillary leak syndrome

Elsevier items and derived items © 2006 by Elsevier Inc. Obstructive Shock Shock is caused by problems that impair the ability of the normal heart muscle to pump effectively. Heart is normal but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle. Shock is caused by problems that impair the ability of the normal heart muscle to pump effectively. Heart is normal but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle.

Elsevier items and derived items © 2006 by Elsevier Inc. Physical Assessment/Clinical Manifestations Cardiovascular changes Pulse Blood pressure Oxygen saturation Skin changes Respiratory changes Renal and urinary changes Central nervous system changes Musculoskeletal changes Cardiovascular changes Pulse Blood pressure Oxygen saturation Skin changes Respiratory changes Renal and urinary changes Central nervous system changes Musculoskeletal changes

Elsevier items and derived items © 2006 by Elsevier Inc. Interventions Reverse the shock. Restore fluid volume. Prevent complications through supportive and drug therapies. Nonsurgical management includes oxygen therapy, fluid replacement, and monitoring. Reverse the shock. Restore fluid volume. Prevent complications through supportive and drug therapies. Nonsurgical management includes oxygen therapy, fluid replacement, and monitoring.

Elsevier items and derived items © 2006 by Elsevier Inc. Drug Therapies Vasoconstrictors, such as dopamine, epinephrine, norepinephrine, phenylephrine Agents that enhance contractility Agents that enhance myocardial perfusion Vasoconstrictors, such as dopamine, epinephrine, norepinephrine, phenylephrine Agents that enhance contractility Agents that enhance myocardial perfusion

Elsevier items and derived items © 2006 by Elsevier Inc. Collaborative Management of Septic Shock Manifestations of the first phase: unique to septic shock and often opposite from those seen with all other types of shock Cardiovascular changes Respiratory changes Skin changes: in the hyperdynamic phase of septic shock, the skin is warm with no cyanosis evident Manifestations of the first phase: unique to septic shock and often opposite from those seen with all other types of shock Cardiovascular changes Respiratory changes Skin changes: in the hyperdynamic phase of septic shock, the skin is warm with no cyanosis evident

Elsevier items and derived items © 2006 by Elsevier Inc. Interventions for Septic Shock Focus on correcting conditions causing shock and preventing complications. Give oxygen therapy. Drug therapy: antibiotics and anticoagulants, clotting factors and blood products, activated protein C, and antibodies, such as interleukin-1, interleukin-6, and tumor necrosis factor Focus on correcting conditions causing shock and preventing complications. Give oxygen therapy. Drug therapy: antibiotics and anticoagulants, clotting factors and blood products, activated protein C, and antibodies, such as interleukin-1, interleukin-6, and tumor necrosis factor

Elsevier items and derived items © 2006 by Elsevier Inc. Infusion Therapy

Elsevier items and derived items © 2006 by Elsevier Inc. Parenteral Nutrition Formulas: dextrose, protein, fat, vitamins, and numerous trace elements tailored to the specific metabolic needs of the client Only used when the gastrointestinal tract cannot be used Central Peripheral Formulas: dextrose, protein, fat, vitamins, and numerous trace elements tailored to the specific metabolic needs of the client Only used when the gastrointestinal tract cannot be used Central Peripheral

Elsevier items and derived items © 2006 by Elsevier Inc. Blood Transfusions and Other Components Packed red blood cells Platelets Fresh frozen plasma Albumin Several specific clotting factors Packed red blood cells Platelets Fresh frozen plasma Albumin Several specific clotting factors

Elsevier items and derived items © 2006 by Elsevier Inc. Medications IV medications provide a rapid therapeutic effect but can also lead to immediate serious reactions. Prescription for infusion therapy is necessary. IV medications provide a rapid therapeutic effect but can also lead to immediate serious reactions. Prescription for infusion therapy is necessary.

Elsevier items and derived items © 2006 by Elsevier Inc. Vascular Access Device (VAD) Short peripheral catheters –Superficial veins of the hand and forearm –Dwell for 72 to 96 hours and then require removal and insertion into another venous site Complaints of tingling, feeling of “pins and needles” in the extremity, or numbness during the venipuncture can indicate nerve puncture. Short peripheral catheters –Superficial veins of the hand and forearm –Dwell for 72 to 96 hours and then require removal and insertion into another venous site Complaints of tingling, feeling of “pins and needles” in the extremity, or numbness during the venipuncture can indicate nerve puncture.

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Midline Catheter Catheter that is 6 to 8 inches long, inserted through veins of the antecubital fossa Used for therapies lasting from 1 to 4 weeks Should not be used for infusion of vesicant medications, which can cause tissue damage if they escape into the subcutaneous tissue (extravasation) Catheter that is 6 to 8 inches long, inserted through veins of the antecubital fossa Used for therapies lasting from 1 to 4 weeks Should not be used for infusion of vesicant medications, which can cause tissue damage if they escape into the subcutaneous tissue (extravasation)

Elsevier items and derived items © 2006 by Elsevier Inc. Peripherally Inserted Central Catheter (PICC) Length ranges from 40 to 65 cm. Basilic vein is the preferred site for insertion; cephalic vein can be used. Placement is confirmed by chest x-ray examination. No information is available on optimal dwell time. Teach clients to perform normal ADLs, avoiding excessive physical activity. Length ranges from 40 to 65 cm. Basilic vein is the preferred site for insertion; cephalic vein can be used. Placement is confirmed by chest x-ray examination. No information is available on optimal dwell time. Teach clients to perform normal ADLs, avoiding excessive physical activity.

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Nontunneled Percutaneous Central Catheter Inserted through subclavian vein in the upper chest or jugular veins in the neck Usually 15 to 20 cm long Tip resides in the superior vena cava Placement confirmed by chest x-ray examination No recommendations for optimal dwell time Inserted through subclavian vein in the upper chest or jugular veins in the neck Usually 15 to 20 cm long Tip resides in the superior vena cava Placement confirmed by chest x-ray examination No recommendations for optimal dwell time

Elsevier items and derived items © 2006 by Elsevier Inc. Tunneled Central Catheter A portion of the catheter lying in a subcutaneous tunnel separates the points at which the catheter enters the vein from where it exits the skin. Tunneled central catheter is used for infusion therapy that is frequent and long-term. A portion of the catheter lying in a subcutaneous tunnel separates the points at which the catheter enters the vein from where it exits the skin. Tunneled central catheter is used for infusion therapy that is frequent and long-term.

Elsevier items and derived items © 2006 by Elsevier Inc. Implanted Port Implanted ports consist of a portal body, a dense septum over a reservoir, and a catheter. A subcutaneous pocket is surgically created to house the port body. Port is usually placed in the upper chest or the upper extremity Port needs to be flushed after each use and at least once a month between courses of therapy. Implanted ports consist of a portal body, a dense septum over a reservoir, and a catheter. A subcutaneous pocket is surgically created to house the port body. Port is usually placed in the upper chest or the upper extremity Port needs to be flushed after each use and at least once a month between courses of therapy.

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Dialysis Catheter Lumens are very large to accommodate the hemodialysis procedure or a pheresis procedure that harvests specific blood cells. This catheter should not be used for administration of other fluids or medications, except in an emergency. Lumens are very large to accommodate the hemodialysis procedure or a pheresis procedure that harvests specific blood cells. This catheter should not be used for administration of other fluids or medications, except in an emergency.

Elsevier items and derived items © 2006 by Elsevier Inc. Infusion System Containers Administration sets Add-on systems Needleless connection devices Rate controlling devices: –Controller –Pumps Syringe pumps Ambulatory pumps Containers Administration sets Add-on systems Needleless connection devices Rate controlling devices: –Controller –Pumps Syringe pumps Ambulatory pumps

Elsevier items and derived items © 2006 by Elsevier Inc. Catheter Care and Maintenance Educating the client Confirming tip location Performing the nursing assessment Securing and dressing the catheter Changing administration sets and needleless connectors Controlling infusion pressure (Continued) Educating the client Confirming tip location Performing the nursing assessment Securing and dressing the catheter Changing administration sets and needleless connectors Controlling infusion pressure (Continued)

Elsevier items and derived items © 2006 by Elsevier Inc. Catheter Care and Maintenance (Continued) Flushing the catheter Obtaining blood samples from the catheter Removing the catheter Flushing the catheter Obtaining blood samples from the catheter Removing the catheter

Elsevier items and derived items © 2006 by Elsevier Inc. Considerations for Older Adults Skin care precautions Vein and catheter selection Cardiac and renal changes Skin care precautions Vein and catheter selection Cardiac and renal changes

Elsevier items and derived items © 2006 by Elsevier Inc. Alternative Sites for Infusion Arterial therapy Intraperitoneal infusion Subcutaneous infusion Intraspinal infusion Intraosseous therapy Arterial therapy Intraperitoneal infusion Subcutaneous infusion Intraspinal infusion Intraosseous therapy