1. Interventions for Clients in Shock

2. Shock Can occur when any part of the cardiovascular system does not function properly for any reason 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 Begins with abnormal cellular metabolism that occurs when too little oxygen is delivered to tissues

3. Review of tissue perfusion Organ perfusion is related to mean arterial pressure (MAP). Because the cardiovascular system is a closed but continuous circuit, the factors that influence MAP include the following: Organ perfusion is related to mean arterial pressure (MAP). Because the cardiovascular system is a closed but continuous circuit, the factors that influence MAP include the following: –Total blood volume –Cardiac output –Size of the vascular bed Total blood volume and cardiac output are directly related to MAP — increases in either total blood volume or cardiac output usually raise MAP. Decreases in either total blood volume or cardiac output eventually lower MAP. Total blood volume and cardiac output are directly related to MAP — increases in either total blood volume or cardiac output usually raise MAP. Decreases in either total blood volume or cardiac output eventually lower MAP. The size of the vascular bed is inversely (negatively) related to MAP — increases in the size of the vascular bed lower MAP, and decreases raise MAP The size of the vascular bed is inversely (negatively) related to MAP — increases in the size of the vascular bed lower MAP, and decreases raise MAP

5. Processes of Shock Initial stage (early shock) Initial stage (early shock) Nonprogressive stage (compensatory stage) Nonprogressive stage (compensatory stage) Progressive stage (intermediate stage) Progressive stage (intermediate stage) Refractory stage (irreversible stage) Refractory stage (irreversible stage)

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

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

9. Hypovolemic Shock (Continued) Caused by internal hemorrhage as occurs with blunt trauma, gastrointestinal ulcers, and poor control of surgical bleeding Caused by internal hemorrhage as occurs with blunt trauma, gastrointestinal ulcers, and poor control of surgical bleeding

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

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

12. Distributive Shock (Continued) Anaphylaxis Anaphylaxis Sepsis Sepsis Capillary leak syndrome Capillary leak syndrome

13. Obstructive Shock Shock is caused by problems that impair the ability of the normal heart muscle to pump effectively. 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. Heart is normal but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle.

14. Physical Assessment/Clinical Manifestations Cardiovascular changes Cardiovascular changes Pulse Pulse Blood pressure Blood pressure Oxygen saturation Oxygen saturation Skin changes Skin changes Respiratory changes Respiratory changes Renal and urinary changes Renal and urinary changes Central nervous system changes Central nervous system changes Musculoskeletal changes Musculoskeletal changes

15. Interventions Reverse the shock. Reverse the shock. Restore fluid volume. Restore fluid volume. Prevent complications through supportive and drug therapies. Prevent complications through supportive and drug therapies. Nonsurgical management includes oxygen therapy, fluid replacement, and monitoring. Nonsurgical management includes oxygen therapy, fluid replacement, and monitoring.

16. Drug Therapies Vasoconstrictors, such as dopamine, epinephrine, norepinephrine, phenylephrine Vasoconstrictors, such as dopamine, epinephrine, norepinephrine, phenylephrine Agents that enhance contractility Agents that enhance contractility Agents that enhance myocardial perfusion Agents that enhance myocardial perfusion

18. 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 Manifestations of the first phase: unique to septic shock and often opposite from those seen with all other types of shock Cardiovascular changes Cardiovascular changes Respiratory changes Respiratory changes Skin changes: in the hyperdynamic phase of septic shock, the skin is warm with no cyanosis evident Skin changes: in the hyperdynamic phase of septic shock, the skin is warm with no cyanosis evident

21. Interventions for Septic Shock Focus on correcting conditions causing shock and preventing complications. Focus on correcting conditions causing shock and preventing complications. Give oxygen therapy. 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 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