SHOCK

Types Signs and Symptoms Collaborative Management Specific to Type of ShockHypovolemia“fluid problems”

↓ Preload, ↓ stroke volume, ↓ capillary refill timeTachycardia bradypnea (late)↓ Urine Output, Pallor, Cool, Clammy skinAnxiety, Confusion, AgitationAbsent Bowel Sounds, ↓d Hct, Hgb,Increased LactateIncreased urine specific gravityChange in electrolytes

Oxygenation---Provide supplemental O2, Monitor SvO2 or ScvO2Circulation---Restore fluid volume (e.g.Blood/Blood products, crystalloids), Rapid fluid replacement using 2 large0bore(14-16 gauge) peripheral IV’s, Endpoints of fluid resuscitation: CVP 15 mm Hg, PAWP 10-12 mm HgSupportive Therapies----Correct the cause (e.g stop bleeding, GI losses, Use warmed fluids

Cardiogenic“pump problems”

↓ capillary refill time, Increased MVO2, Chest pain may or may not be present, Tachypnea, Cyanosis, Crackles, Rhonchi, Increased Na+ and H2O retention↓ renal blood flow, ↓ urine output, Pallor, cool, clammy skin↓ Cerebral perfusion, Agitation, anxiety, confusion↓ bowel sounds, N/V, Increased cardiac markersIncreased Blood glucose, Increased BUNECG (dysrhythmias), Echocardiogram (left ventricular dysfunction), CXR (pulmonary infiltrates)

Oxygenation----Provide supplemental O2 (nasal cannula, non-rebreather mask), Intubation/mechanical ventilation, if necessary, Monitor SvO2 or ScvO2Circulation---Restore blood flow with thrombolytics, angioplasty w/ stenting, emergent coronary revascularization, Reduce workload of the heart w/ circulatory assist devices: IABP, VADDrug Therapies----Nitrates (Nitroglycerin), Inotropes (Dobutamine), Diuretics (furosemide), B-Adrenergic blockers (contraindicated w/ ↓d ejection fraction)Supportive Therapies----Correct dysrhythmias

Distributive “pipe problems”

Septic

Anaphylactic

Neurogenic

↓/Increased Temp, Biventricular dilation: ↓d ejection fraction, Hyperventilation, Respiratory alkalosis respiratory acidosis, Hypoxemia, Resp Failure, ARDS, Pulmonary Hypertension, Crackles, ↓ urine output, Warm & flushed skin cool and mottled (late) skin, Alteration in mental status (confusion), Agitation, Coma (late), GI bleeding, Paralytic ileus, Increased/↓d WBC, ↓d platelets, Increased Lactate, Increased Glucose, Increased Urine specific gravity, ↓ urine Na+, Positive blood cultures

Oxygenation----Provide supplemental O2, Intubation/mechanical ventilation, if necessary, Monitor SvO2 or ScvO2Circulation---Aggressive fluid resuscitation, Endpoints of fluid resuscitation: CVP 15 mm Hg, PAWP 10-12 mmHgDrug Therapies---Antibiotics as ordered, Vasopressors (dopamine), Inotropes (Dobutamine), Anticoagulation (low-molecular weight heparin)Supportive Therapies-----Obtain cultures (blood, wound) before beginning antibiotics, Monitor temperature, Control Blood glucose, Stress Ulcer prophylaxis

Chest pain, Third spacing of fluid, Swelling of lips and tongueSOB, Edema of larynx & epiglottis, Wheezing, Rhinitis, Stridor, Flushing, Pruritus, Uritcaria, Angioedema, Anxiety, Feeling of impending doom, Confusion, ↓d LOC, Metallic taste, Cramping, Abd pain, N/V/D, Sudden onsetHistory of allergies, Exposure to contrast media

Oxygenation-----Maintain patent airway, Optimize oxygenation with supplemental O2, Intubation/mechanical ventilation, if necessaryCirculation----Aggressive fluid resuscitation with colloidsDrug Therapies----Antihistamines (diphenhydramine), Epinephrine (subcutaneous, IV, nebulized), Bronchodilators: nebulized (Albuterol), Corticosteroids (if hypotension persists)Supportive Therapies----Identify & remove offending cause, Prevention via avoidance of know allergens, Pre-medication w/ hx of prior sensitivity (contrast media)

Increased/↓d TempBradycardiaDysfunction r/t level of injuryBladder dysfunction↓ skin perfusion, cool or warm, dry skinFlaccid paralysis below the level of the lesionLoss of reflex activityBowel dysfunction

Oxygenation-----Maintain patent airway, Optimize oxygenation with supplemental O2, Intubation/mechanical ventilation, if necessaryCirculation----Cautious administration of fluidsDrug Therapies-----Vasopressors (phenylephrine), Atropine (for bradycardia)Supportive Therapies----Minimize spinal cord trauma w/ stabilization, Monitor Temperature

Nursing Interventions for All Types of Shock

System InterventionsNeurologic Be aware of s/s that may indicate neurological involvement (changes in behavior, restlessness, hyperalertness, blurred vision, confusion, & paresthesias)

Attempts should be made to alert the pt to time, place, person, and events.Minimize noise & light to control sensory input.A day-night cycle of activity & rest should be maintained as much as possible.Sensory overload and disruption of the pts diurnal cycle may contribute to delirium

Cardiovascular If pt has an unstable HR, BP, central venous pressure, and PA pressures including continuous cardiac output (if available) should be assess q 15 minutes.Monitor trends in hemodynamic parameters yields more important information than individual numbers. Integration of hemodynamic data w/ physical assessment data is essential in planning strategies to manage the pt with shock. Place the pt in the Trendelenburg position judiciously to help tx hypotensive crisis.Monitor ECG; Assess Heart sounds for the presence of an S3 or S4 or new murmurs. The presence of S3 in adults usually indicate heart failure.Assess the pts response to fluid resuscitation q 10-15 minutes (make adjustments as needed).Administer medications as ordered to correct the dysfunctions of the cardio system.Once the pt stabilizes the frequency of monitoring is ↓d and the pt is slowly weaned off meds to support BP and tissue perfusion

Respiratory Resp status needs to be assessed q 15 -30 minutes. Increased rate & depth provide info regarding the pts attempts to correct metabolic acidosis. Monitor Pulse Ox continuously; Monitor ABG’s a PaO2 below 60 mm Hg (in the absence of chronic lung disease) indicated the presence of hypoxemia & the need for the administration of higher O2 concentrations or for a different mode of administration. Low PaCO2 in the presence of a low pH & low bicarb level may indicate that the pt is attempting to compensate for a metabolic acidosis. A rising PaCO2 in the presence of a persistently low pH & PaO2 may indicate the need for intubation and mechanical ventilation. Most pts in shock will be intubated and on mechanical ventilation.

Renal Hourly measurements of urinary output are essential in assessment of the adequacy of renal perfusion.An in-dwelling bladder catheter is inserted to facilitate measurements. Urine output less than 0.5ml/kg/hr may indicate inadequate kidney perfusion. BUN and creatinine are also monitored. Serum creatinine is a better indicator of renal function b/c BUN levels can be influenced by the catabolic state of the pt.

Integumentary If pts temp is elevated it needs to be assessed q hr, if normal temp should be monitored q 4 hrs. Keep the pt warm by using light covers and controlling the temp in the pts room. If the pts temp rises above 101.5 & the pt becomes uncomfortable or experiences cardio compromise, the fever maybe managed with non-steroidal anti-inflammatory drugs (Motrin, Tylenol), or by removing some of the pts covers.Monitor the pts skin for temp, pallor, flushing, cyanosis, diaphoresis, and piloerection. Assess capillary refill

Gastrointestinal Bowel sounds should be assess at least q 4 hrs & abdominal distention should be assessed. If a NG tube is inserted drainage should be measures and checked for occult blood. Check stools for occult blood.

Personal Hygiene Hygiene is especially important b/c impaired tissue perfusion predisposes a pt to skin breakdown. The nurse must be careful when bathing a pt in shock is experiencing resp problems. The nurse must use a clinical judgment in determining priorities of care in order to limit the demand for O2 consumption.Oral care is important b/c mucous membranes become dry and fragile.Intubated pts usually have difficulty swallowing resulting in the pooling of secretions.A water soluble lubricant may be applied to the lips to prevent cracking. A swab moistened with saline water maybe used to provide moisture to the mouth. Lemon glycerin swabs should not be used b/c the may further irritate the mucosa.Passive ROM should be performed 3-4 x’s daily to maintain joint mobility. Turn pt q 1-2 hrs to prevent skin breakdown.Monitor O2 during all nursing interventions to monitor pts tolerance to activity.

Emotional Anxiety, fear, & pain may aggravate resp distress & increase the release of cathcholamines. When providing care the nurse should monitor the pts pain, & anxiety level. Continous infusion of a benzodiazepine (Ativan), and opioid or anesthetic (Morphine, Diprivan), & occasionally a neuromuscular blocking agent (Nimbex) are extremely helpful in decreasing anxiety, pain, and O2 demand.The nurse should encourage the pt to talk to the pt, even if the pt appears comatose b/c hearing is often the last sense to go.If the pts is intubated & able to write provide them with a piece of paper to write their needs on.Give pt simple explanations; Don’t overlook spiritual beliefs. Provide a priest, rabbi, or minister. Family can have a significant effect on the pt. To perform this role, they need to be supportive and comforting. Family (1) links the pt to the outside world (2) facilitates decision making & advise to the pt (3) assist with ADL’s (4) act as liaisons to advise the health care team of the pts wishes for care, (5) provide safe, caring, familiar relationships for the pts; If possible the same nurses should provide care to the pt to ↓ anxiety, limit contradictory information and increase trust.