1. 1 Todays Objectives  Compare and contrast pathophysiology & manifestations of the various shock states and the physiologic compensatory mechanisms.  Identify nursing priorities with the various shock states.  Compare & interpret abnormal laboratory test indicators involved with septic, hypovolemic, and cardiogenic shock.  Analyze assessment data to determine nursing diagnoses and formulate a plan of care for clients with the various shock states.  Describe the medical management and mechanism of action, side effects and nursing interventions of pharmological management with shock states.  Compare & contrast pathophysiology, manifestations, nursing priorities seen with sepsis vs. Multiple Organ Dysfunction Syndrome (MODS).

2. 2 Shock Defined  Any problem that impairs oxygenation delivery to tissues & organs CV system is where it begins Table 40-3 p.826 Hypovolemic Cardiogenic Distributive Neurogenic Anaphylactic Septic-SIRS Multiple Organ Dysfunction Syndrome (MODS)

3. 3 Processes of Shock Table 40-2 p.825  Initial stage…early shock MAP decrease 5-10mm/Hg Mild vasoconstriction Tachycardic…Why???  Nonprogressive stage…compensatory stage MAP decrease 10-15 mm/Hg Mod. Vasoconstriction Physiologic compensations Renin, aldosterone, ADH Decreased u/o Mild acidosis Mild hyperkalemia

4. 4 Processes of Shock Table 40-2 p.825  Progressive stage…intermediate stage MAP decrease >20mm/Hg Overall metabolism-anaerobic Moderate acidosis Moderate hyperkalemia Tissue ischemia lactic acidosis-Lactate  Refractory stage…irreversible stage

5. 5 Hypovolemic Shock:Physical Assessment  Cardiovascular changes Pulse Blood pressure  Skin changes  Respiratory changes Oxygen saturation RR  Renal and urinary changes  Central nervous system changes

6. 6 Hypovolemic Shock:Nursing Priorities  Impaired gas exchange Nursing interventions  Deficient fluid volume Nursing interventions  Decreased cardiac output Nursing interventions  Risk for ineffective tissue perfusion Body systems impacted??? Nursing interventions

7. 7 Sepsis  Patho  Progressive Infection Bacteremia Systemic Inflammatory Response Syndrome (SIRS) Sepsis Severe sepsis Septic shock Multiple Organ Dysfunction Syndrome (MODS)

8. 8 Sepsis:Hyperdynamic (early)  Cardiovascular changes  Skin changes  Respiratory changes  Renal and urinary changes  Central nervous system changes

9. 9 Sepsis:Hypodynamic (late)  Cardiovascular changes  Skin changes  Respiratory changes  Renal and urinary changes  Central nervous system changes

10. 10 Shock-Laboratory Findings Chart 40-3 p.831 General  ABG’s pH CO2 O2 HCO3  Lactate  Hct  Hgb  Potassium Septic Shock  Blood cultures  WBC Neutrophils Bands  C Reactive Protein (CRP)  D-Dimer  Fibrinogen  INR  Platelets

11. 11 Nursing Care Priorities/Diagnosis  Impaired gas exchange r/t…  Deficient fluid volume r/t…  Ineffective tissue perfusion r/t…  Anxiety  Knowledge deficit r/t… Ultimate Goal…

12. 12 General Shock: Nursing Interventions Remember A,B,C,D  Reverse the shock Administer O2 Establish IV access  Restore fluid volume Colloid Crystalloid  Vasoactive gtts  Administer blood products as ordered  Nursing assessment Pulse/rhythm BP-CVP RR-O2 sats Urine output Skin color Monitor labs

13. 13 Shock Case Study  Nursing priorities…  Rapid Response paged  SBAR to primary MD  Medical/Nursing management: 2 large bore IV’s NS 1000cc FF Prepare for transfer to ICU Stat Hgb Obtain 2u PRBC from blood bank

14. 14 15” later…  VS: P-100 R-20 BP-92/46 sats 98% 6l n/c  Hgb 8.2  First unit of blood initiated  Prepare for transfer to ICU…unable to take at this time  Foley catheter placed  VS just before transfer: P-88 R-18 BP- 102/64 sats 100% 4l n/c

15. 15 Septic Shock: Nursing Interventions All the same as previous slide and…  Obtain blood, urine cultures as ordered  Administer IV abx  Administer anti-arrythmics  Aggressive IV fluid resuscitation  Assess closely for signs of bleeding…DIC  Strict aseptic technique  Fever reduction as needed  Client-family education

16. 16 Vasoactive Gtts chart 40-6 p.833  Dopamine Renal Beta effect Alpha effect  Levophed (norepinephrine)  Phenylephrine (neo-synephrine)

17. 17 Multiple Organ Dysfunction Syndrome  Patho Uncontrolled inflammation Progressive dysfunction of 2 or more systems Risk factors Causes Trauma Pancreatitis ARDS Major surgery

18. 18 Multiple Organ Dysfunction Syndrome  Four major organ systems involvement Pulmonary Renal Cardiovascular Coagulation

19. 19 Physical Assessment  Pulmonary  CV  Renal  GI  Neuro  Coagulation

20. 20 Therapeutic Management  Support tissue oxygenation  Fluid resuscitation  Blood and blood products  Dialysis or CRRT  Nutritional support  Antibiotic therapy Priority Nursing Diagnoses…

21. 21 Nursing Priorities-Interventions  Assess resp. status  Continuous cardiac monitoring Assess perfusion  Provide hydration and nutritional support  Assess for coagulation dysfunction  Emotional support/comfort measures Evaluation….