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1 Nursing Care & Priorities for Those in Shock Keith Rischer RN, MA, CEN.

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Presentation on theme: "1 Nursing Care & Priorities for Those in Shock Keith Rischer RN, MA, CEN."— Presentation transcript:

1 1 Nursing Care & Priorities for Those in Shock Keith Rischer RN, MA, CEN

2 2 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).

3 3 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)

4 4 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

5 5 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

6 6 Hypovolemic Shock:Physical Assessment  Cardiovascular changes Pulse Blood pressure  Skin changes  Respiratory changes Oxygen saturation RR  Renal and urinary changes  Central nervous system changes

7 7 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

8 8 Sepsis  Patho  Progressive Infection Bacteremia Systemic Inflammatory Response Syndrome (SIRS) Sepsis Severe sepsis Septic shock Multiple Organ Dysfunction Syndrome (MODS)

9 9 Sepsis:Hyperdynamic (early)  Cardiovascular changes  Skin changes  Respiratory changes  Renal and urinary changes  Central nervous system changes

10 10 Sepsis:Hypodynamic (late)  Cardiovascular changes  Skin changes  Respiratory changes  Renal and urinary changes  Central nervous system changes

11 11 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

12 12 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…

13 13 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

14 14 Shock Case Study  83yr male Admitted from ED to tele for abd pain and recent lower GI bleeding. Colonoscopy later in day. PMH: AFib-on Coumadin daily, HTN Hgb 11.2, INR 2.8, creat.90 ED VS: T-98.8 P-76 R-16 BP-108/64 sats 98% 2l n/c  Enter room to perform initial assessment: Pale-diaphoretic, lethargic. Can answer simple questions and oriented x3 Smell suspicious ?GI bleeding Note large pool of dark, red blood on pad VS: P-110 R-24 BP-78/34 sats 90% 2l n/c

15 15 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

16 16 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

17 17 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

18 18 Mechanism of Action: Abx

19 19 Vasoactive Gtts chart 40-6 p.833  Dopamine Renal Beta effect Alpha effect  Levophed (norepinephrine)  Phenylephrine (neo-synephrine)

20 20 Multiple Organ Dysfunction Syndrome  Patho Uncontrolled inflammation Progressive dysfunction of 2 or more systems Risk factors Causes Trauma Pancreatitis ARDS Major surgery

21 21 Multiple Organ Dysfunction Syndrome  Four major organ systems involvement Pulmonary Renal Cardiovascular Coagulation

22 22 Physical Assessment  Pulmonary  CV  Renal  GI  Neuro  Coagulation

23 23 Diagnostic-Lab Findings  ABG pH CO2 O2 HCO3 O2 sats  WBC  Platelets  Fibrinogen  PT-INR  Hgb  Creatinine  K+  GFR  Troponin  BNP  Liver Enzymes ALT-AST Alk Phos Total bili Ammonia albumin

24 24 Therapeutic Management  Support tissue oxygenation  Fluid resuscitation  Blood and blood products  Dialysis or CRRT  Nutritional support  Antibiotic therapy Priority Nursing Diagnoses…

25 25 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….

26 26 Sepsis/MODS Case Study  40 yr male w/seizure disorder  Chief complaint Altered mental status Vague abd pain Weakness Hypotension  Physical assessment Epigastric-LUQ tender  VS T-101.2/P-110/R-24/BP 92/42/sats 95% RA  Admission Labs WBC-11,000 Hgb-12.2 Platelets-64,000 Creatinine-2.7 ALT-502 AST-219 Ammonia-68 Lipase-1947 Glucose-322 CT-encephalopathy Abd CT-inflamm. pancreas

27 27 Case Study:Later… Day of Admission  Increasing lethargy, resp. distress  ABG pH- 7.28 CO2- 59 O2- 52 HCO3- 23 O2 sats- 84 FiO2-100% vent…AC12, PEEP +5 CT-abd. Ileus-hepatic infarcts

28 28 Case Study:Day 1  CVP-21  VS-101.2-118-24-82/40  NG placed  Labs WBC-12.7 Platelets-56 Creatinine-.7 ALT-243 AST-219 Lipase 523 ABG pH-7.25 CO2-52 O2-76 O2 sats-92% FiO2-100% PEEP now +10  Weight up 8 kg  Non icteric  IV Infusions Insulin gtt Lasix gtt TPN-Lipids Fentanyl gtt Versed gtt Levophed gtt Neosynephrine gtt Vasopressin gtt Heparin gtt

29 29 Case Study:Day 2  CVP-16 –weight up another 7.5 kg…poor u/o  VS-100.5-110-24-84/44  Labs WBC-21.5 Hgb-12.5 Platelets-77 Creatinine-0.9 ALT-143 AST-41 Ammonia-30 Lipase 114 CXR-white out ABG pH-7.11 CO2-78 O2-58 HCO3-24 O2 sats-75% Vent-FiO2-100%, +15  Treatment Plan CRRT IV abx-Cipro/Flagyl Hold Lasix gtt NG LCS Lactulose Wean vasoactive gtts as able Continue all previous gtts Pan cultures  Physical assessment Distended abd-hypoactive NG bile output Coarse crackles bilat Cool to touch Nursing Priorities…

30 30 Case Study #2…  90yr male PMH: anemia, hypothermia due to thalamus disorder, pneumonia, COPD, HTN, renal insufficiency, mild dementia. Lives in assisted living HPI: Son visited today and noted to be incr. confused- brought to ED for eval. VS: T-90.9 P-41 (Junctional) R-16 BP 99/45 sats 97% 2l per n/c Assessment: Neuro-confused-responds to voice Resp-clear-neg. assessment –CXR: left basilar infiltrate CV-No edema, S1S2, pulses strong x4

31 31 Labs

32 32 Case Study #2…  Order received to give 2u PRBC  After second unit VS: T-95.5 P-38 R-36 BP-113/49 sats 88% 6l n/c c/o SOB-breath sounds course bilat u/o 100cc last 4 hours  SBAR… Order for Lasix 40mg IV…80cc u/o last hour SBAR Additional Lasix 80 mg IV and assess

33 33 Case Study #2…  Status 1 hour later… RR 36-44 w/sats 84-88% on oxymizer 15l Breath sounds remain course u/o 30cc since Lasix 80mg 1 hour ago SBAR Bipap started per RT Sats increased to 94%, RR 20-24, appears more comfortable

34 34 AM Labs

35 35 4 Days Later…Summary  Sepsis…ARF necessitated need for dialysis due to resultant hyperkalemia, fluid overload.  Multisystem failure of kidneys, heart, and lungs  Kaofeed placed and started on TF  VS: T-98.1 P-80 (SR) R-16 BP-159/75 sats 100% (5l oxymizer) I-1700 /O-2480

36 36 Case Study #2  Assessment Neuro-follows commands-more responsive Resp-dimin bilat w/scatt. Crackles-non-labored CV-NSR, tr. Edema LE GU-Incr. u/o, Foley  Medical-Nursing priorities Pneumonia Leukocytosis (Solumedrol?) IV abx Hyperkalemia D50, insulin IV, NaBicarb IV, Calcium Gluconate Unable to take Kayexalate po or rectally

37 37 Medical-Nursing Priorities  Resp. failure Bipap…oxymizer to keep sats >90%  Acute renal failure ATN…sepsis ACE held u/o improving  Sepsis  Encephalopathy Ativan, Haldol prn  Nutrition TF

38 38 Labs

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