Med Surg- Shock Lecture PDF

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Summary

Lecture notes on Shock for Medical Surgical Nursing. Could also be helpful for students prepping for the NCLEX....

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SHOCK = a life threatening condition of circulatory failure OR pause in normal act of death  ORGANS SHUTTING DOWN Preload Afterload Contractility Either an issue w/ pump, pipes or the volume Tissue Perfusion: CO= HR x SV SV= function of preload, afterload, contractility CVP= preload SVR= afterload; pressure that left vesicle has to pump against (BP; MAP) *don’t need to know specific formulas (important equation slide) MAP below 65= problem Most important organs: 1. Heart 2. Brain 3. Kidneys

Results:  Hypo-perfusion  Metabolic acidosis o because of lactic acidosis Alpha & Beta Receptors:  B1- heart o Beta 1 agonist- increase contractility & HR (use it a lot for shock?)  B2- lungs o Don’t use this as often  Alpha 1- vasoconstriction; phenylephrine (pressure already low so don’t usually want to give unless pt is being operated on) Responses to decreased system oxygen delivery  Cellular edema  Increased membrane permeability  Hydrolysis of cellular membrane 1

Adrenal Glands:  Cortisol  Epinephrine o Flight or flight response RAAS:  Promotes inflammation in the kidney o Kidneys will become damaged much quicker Stages of Shock: (PE)  Non-progressive stages compensated stage or pre-shock o “feeling of impending doom” o Respiratory alkalosis  Progressive stage  uncompensated stage or shock o Systolic BP 38 or less than 36  HR >90  RR >20  Pa02 12,000 or 10% bands  How to assess for organ damage: (septic shock) o Less than 30mL for hour for kidneys o Lactic acid: above 2 (then septic shock) Septic Shock:  Initial Resusitation (early goal directed therapy o CVP 8-12 o MAP > or greater than 65 o Urine Output > or equal to 0.5 o CVP or mixed CVP 70% o In pt w/ elecvated lactate levels targeting resuscitation to normalized lactate  Antibiotics o Vancomycin (gram positive) o Zosin (gram negative- but depends on the hospital/where you are located)  Infection o Send for loss stools o Meticulous mouth care- brush at least 2x/day o NGT tube/meticulous oral care o Foley care o Pressure ulcers (turning every 2hr/move 15 degrees)  Hypotension o Increased vessel wall & capillary permeability  Leaking out into 3rd spacing Septic Shock Treatment:  Glucose Control o Keep at 180 o Hyperglycemia probably helpful  IV Bicarb therapy until pH reaches 7.15 o Can increase lactic acid production (this is the problem) Toxic Shock Syndrome:  Able to menstruate?  Usually either streptococcus pyogens or staphylococcus aureus  **have to take out tampon**  If no tampon then look for necrotasis fashinitis  Tx: IV immunoglobins (IVIG)  Clindamycin (DOG: risk of CDiff)  S/s

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Cardiogenic Shock:  Risk factor- MI  Assess: BP down; narrow pulse pressure  Intra-aortic balloon pump  Tx: o Dobutamine (4+ beta)  Like dopamine but w/o tachy CASE:  Type: Neuogenic shock (spinal cord injuries above T6 then it takes out sympathetic nervous system; brady)  Treatment:  Clinically: o Skin is warm & dry** SHOCK= BP DOWN, HR UP Obstructive Shock: Photo- tension pneumo (first picture) Pneumo-pericardium & pneumo thorax (second picture) Multi-Organ Dysfunction Syndrome (MODS)  Diagnosis o Cardiac dysfunction  EKG  Troponin  Echocardiogram  CXR o Lungs  CXR  02 stat  ABGs o Liver  ALT  AST (cirrohosis- would be normal)  Alkphoshate  INR; PT o Pancreas  Lipase  Amalase  CT  MRI o Kidneys 5

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 Urine output (first)  BUN/Cr  Ultrasound  CT Scan Brain  CT scan to head  Neurotest GI tract  Bowel sounds (if no bowel sounds- worried) Skin  Peticciaie Endocrine  Adrenal- cortisol  Thyroid- PTH; T3/T4

P/F Ratio:  Difference= 02 delivery  PA02: P/F Ratio  PA02/FIO2 (as a number)  Normal: >300  200-300 mild hypoxia  100-200 moderate hypoxia ...