Ch09 (1)

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Arizona Western College *

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LPN

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Medicine

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Dec 6, 2023

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44

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Copyright ©2023 F.A. Davis Company Book cover for Understanding Medical-Surgical Nursing, Seventh Edition. Chapter 9 Nursing Care of Patients in Shock
Copyright ©2023 F.A. Davis Company Learning Outcomes Explain the pathophysiology of shock and compensatory mechanisms. Identify the etiology, signs, and symptoms for each of the four categories of shock. Describe therapeutic measures for shock. List data to collect when caring for patients in shock.
Copyright ©2023 F.A. Davis Company Learning Outcomes Assist in planning nursing care for patients in shock. Prioritize care for a patient in shock. Identify findings that demonstrate a positive response to therapeutic measures for shock.
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Copyright ©2023 F.A. Davis Company Chapter Concepts Acid Base Fluid and Electrolyte Balance Infection Perfusion
Copyright ©2023 F.A. Davis Company Shock Circulatory collapse resulting in organ damage and death without immediate treatment
Copyright ©2023 F.A. Davis Company Pathophysiology of Shock Tissue perfusion • Adequate blood volume, effective cardiac pump, effective blood vessels Compensation • Change in one or both of nonfailing tissue perfusion mechanisms Shock • Failure in compensatory mechanisms
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Copyright ©2023 F.A. Davis Company Metabolic and Hemodynamic Changes in Shock Sympathetic nervous system • Tachycardia • Tachypnea • Oliguria • Cool, clammy skin with pallor Decreased blood pressure
Copyright ©2023 F.A. Davis Company Shock When cells are deprived of oxygen, their energy production moves from efficient aerobic metabolism to less efficient anaerobic metabolism. The energy needs of the cell can only be met by anaerobic metabolism for a brief time. If the oxygen deficiency is prolonged, the body’s metabolic rate and temperature fall. Anaerobic metabolism produces lactate. Lactic acid , a by- product of lactate build-up, accumulates. If the lactic acid is not cleared from the bloodstream, it causes acidosis (an acid–base imbalance). Acidosis (blood pH below 7.35) is one of the classic signs of shock
Copyright ©2023 F.A. Davis Company Prolonged Shock Inadequate blood flow results in tissue ischemia and injury throughout the body Early in shock, blood is shunted away from the kidneys to save fluid. This helps preserve blood pressure. The kidneys can tolerate reduced blood flow only for about 1 hour. Then kidney cells begin to die. Acute kidney injury can result.
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Copyright ©2023 F.A. Davis Company *Effect on Organ and Organ Systems* Tissue ischemia and organ injury Brain death if anoxic over 4 minutes
Copyright ©2023 F.A. Davis Company Complications From Shock Acute respiratory distress syndrome Disseminated intravascular coagulation Multiple organ dysfunction syndrome
Copyright ©2023 F.A. Davis Company Classification of Shock • Decreased circulating blood volume-severe blood loss Hypovolemic shock Hypovolemic shock • Cardiac failure Cardiogenic shock Cardiogenic shock • Excessive dilation of venules/arterioles Distributive shock Distributive shock • Blockage of blood flow outside heart Obstructive shock Obstructive shock
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Copyright ©2023 F.A. Davis Company Hypovolemic Shock • Dehydration, hemorrhage, burns, diarrhea, vomiting, sepsis, trauma, heat exhaustion, heat stroke Causes Apply pressure if bleeding. • Compensatory mechanism Initial symptom: Tachycardia Administer isotonic fluid therapy as ordered.
Copyright ©2023 F.A. Davis Company Cardiogenic Shock Heart fails as pump. Pulmonary edema results. Avoid IV fluid therapy. • Increases mortality as already in fluid overload • Liver – impaired clotting • Immune system – depletion of defense components
Copyright ©2023 F.A. Davis Company Distributive Shock 3 Types • Anaphylactic shock • Septic shock • Neurogenic shock Loss of peripheral vascular resistance because of massive vasodilation-no loss of fluid volume
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Copyright ©2023 F.A. Davis Company Anaphylactic Shock – Most Severe Extreme hypersensitivity reaction to antigen Education: Allergy avoidance methods Most common cause: Food allergies Carry epinephrine auto-injector. Carry medical alert information. Seek medical care immediately.
Copyright ©2023 F.A. Davis Company Septic Shock • Goal: To reduce mortality • Identify sepsis quickly to treat promptly. Surviving sepsis campaign: www.survivingsepsis.org • Tachycardia; hypotension; fever; shivering; shortness of breath; clammy, sweating skin; confusion; pain Symptoms
Copyright ©2023 F.A. Davis Company *Categories of Shock* Hypovolemic-serious loss of body fluid Cardiogenic-endocarditis, arrhythmias, valvular disease Obstructive-block to cardiovascular flow- pericardial tamponade, tension pneumo, pulmonary embolus
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Copyright ©2023 F.A. Davis Company *Categories of Shock* Distributive Shock -Any condition causing massive vasodilation • Anaphylaxis -reaction to allergen-urticaria, laryngeal edema, bronchospasms • Septic shock -Loss of vascular autoregulatory control and loss of fluid into the interstitium caused by massive release of chemical mediators and endotoxins from pathogens • Neurogenic shock -Dysfunction or injury to the nervous system from spinal cord injury, general anesthesia, fever, metabolic disturbance, brain injury
Copyright ©2023 F.A. Davis Company Activity: Cue Recognition 9.1 You are collecting data on a 77-year-old resident who has a right heel wound. The wound now has purulent drainage with reddened surrounding skin. Vital signs are HR 106, BP 96/78, RR 22, T 100.8°F (38.2°C). The resident is shivering, confused to place and time, moaning, and reporting severe right foot pain. What do you do?
Copyright ©2023 F.A. Davis Company Cue Recognition 9.1: Answer Complete Complete • Complete head-to-toe data collection, provide warm blankets for comfort, and notify the health-care provider (HCP) immediately. Continue Continue • Continue monitoring the resident. Anticipate Anticipate • Anticipate transfer to an acute care facility.
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Copyright ©2023 F.A. Davis Company Cue Recognition 9.1: Answer Rationale The resident is exhibiting symptoms of sepsis likely due to the foot wound. Since time is critical for this life-threatening condition, the HCP must be notified urgently so treatment can be started. I-SBAR-R = Identify self and patient, situation, background, assessment, recommendation, & readback
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Copyright ©2023 F.A. Davis Company Activity: ISBARR Communication You are preparing to communicate with the resident’s HCP. Think about the information you should include in the communication. Now turn to your neighbor and communicate using ISBARR. Afterwards, review suggested ISBARR communication on next slide.
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Copyright ©2023 F.A. Davis Company
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Copyright ©2023 F.A. Davis Company ISBARR Communication: Suggested Answers I dentify: This is Amy LVN. I am calling as Mr. Town, 77, in room 110 has had a condition change. S ituation: He has HR 106, BP 96/78, RR 22, T 100.8°F, new onset confusion, is shivering, moaning, and reports severe right foot pain. B ackground: He has a right heel wound. A ssessment of Situation: Wound infection R ecommendation: I am wondering if he is developing sepsis. What would you like to do? R ead back: Orders from HCP.
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Copyright ©2023 F.A. Davis Company
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Copyright ©2023 F.A. Davis Company Neurogenic Shock Rare Extensive dilation of peripheral blood vessels
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Copyright ©2023 F.A. Davis Company Obstructive Shock Decreased cardiac output: Shock Rare Causes • Pericardial tamponade • Tension pneumothorax • Acute pulmonary hypertension Jugular vein distension
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Copyright ©2023 F.A. Davis Company Therapeutic Measures for Shock Maintain airway/respiratory support. Maintain Provide cardiovascular support. Provide Maintain circulatory volume. BP monitoring-narrowing pulse pressure before drop in systolic pressure Maintain Control bleeding. Bleeding Monitor neurologic status. Monitor Treat injuries. Treat Treat cause. Treat ABCD
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Copyright ©2023 F.A. Davis Company Therapeutic Measures for Shock Tachycardia, tachypnea, hypotension, cyanosis, mental status altered, oliguria S/S Cardiac isoenzymes, Sepsis: C-reactive protein, endotoxins, procalcitonin Lab Tests Chest x-ray Imaging Arterial pressure, ECG, hemodynamic monitoring Monitor
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Copyright ©2023 F.A. Davis Company Therapeutic Measure Bronchodilators Epinephrine - 1 st drug of choice Cardiovascular support • Vasopressors Antihistamines Benadryl Septic shock • Antimicrobial WN 1 hr Cardiogenic shock • Diurectics, inotropics, nitrates, vasopressors Anti-inflammatory Solu-Medrol Decadron
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Copyright ©2023 F.A. Davis Company Nursing Diagnoses Decreased Cardiac Output Risk for Ineffective Peripheral Tissue Perfusion
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Copyright ©2023 F.A. Davis Company Nursing Care Begin with ABCD. Begin Maintain airway, oxygenation. Maintain Monitor vital signs. Monitor Monitor intake and output. Monitor Provide fluids as ordered. Provide Provide warmth. Provide Relieve pain. Change positions slowly Relieve
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Copyright ©2023 F.A. Davis Company Practice Analysis Tip: Linking NCLEX-PN® to Practice The licensed practical nurse/licensed vocational nurse will Check and monitor client vital signs. Recognize and report change in client condition.
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Copyright ©2023 F.A. Davis Company Review Question #1 The nurse is reinforcing teaching to the family of a patient experiencing hypovolemic shock. Which of these would the nurse correctly state causes hypovolemic shock? 1. Circulating blood volume is decreased. 2. The heart fails to pump blood. 3. There is a blockage of blood flow outside the heart. 4. Excessive dilation of blood vessels occurs.
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Copyright ©2023 F.A. Davis Company Review Question #1 Answer Correct Answer: 1
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Copyright ©2023 F.A. Davis Company Review Question #2 Which action would be appropriate for the nurse to take for a patient with cardiogenic shock? Select all that apply. 1. Administer epinephrine as ordered. 2. Give ordered antimicrobials within 1 hour. 3. Question IV fluid orders. 4. Provide ordered nutrition. 5. Elevate patient legs. 6. Apply oxygen as ordered.
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Copyright ©2023 F.A. Davis Company Review Question #2 Answer Correct Answer: 3, 6
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Copyright ©2023 F.A. Davis Company Review Question #3 The nurse reinforces teaching to a patient with allergies that includes which of these? Select all that apply. 1. Implement allergen avoidance methods. 2. Carry epinephrine auto-injector. 3. Do deep breathing exercises hourly. 4. Change positions slowly. 5. Carry medical alert information. 6. Sleep with head of bed elevated.
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Copyright ©2023 F.A. Davis Company Review Question #3 Answer Correct Answer: 1, 2, 5
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Copyright ©2023 F.A. Davis Company Review Question #4 Which of these would the nurse implement as the priority action for the patient with newly diagnosed septic shock? 1. Obtain blood cultures before antibiotics. 2. Give broad-spectrum antibiotics within 1 hour of septic shock diagnosis. 3. Monitor ordered IV fluids. 4. Provide ordered enteral nutrition.
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Copyright ©2023 F.A. Davis Company Review Question #4 Answer Correct Answer: 1
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Copyright ©2023 F.A. Davis Company Review Question #5 Which of these interventions would the nurse implement for the patient experiencing shock? Select all that apply. 1. Ambulate patient bid. 2. Check capillary refill in older adult. 3. Maintain airway, oxygenation. 4. Monitor vital signs. 5. Monitor intake and output. 6. Relieve pain.
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Copyright ©2023 F.A. Davis Company Review Question #5 Answer Correct Answer: 3, 4, 5, 6
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