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AHIV - ch 34
| Question | Answer |
|---|---|
| Shock sequence | Local infection -> Systemic infection (early sepsis) -> SIRS (systemic inflammatory response) -> Organ failure (severe sepsis) -> MODS (Multiple organ system failure) -> Death |
| Shock | Widespread abnormal cellular metabolism that occurs when gas exchange with oxygenation & tissue perfusion needs are not met sufficiently to maintain cell function |
| What can start the syndrome of shock? | Any problem that impairs perfusion (the cardiovascular system delivers oxygen to all tissues) & gas exchange (the lungs bring oxygen into the body) to tissues & organs can start the syndrome of shock & lead to a life-threatening emergency |
| Hypovolemic shock | Occurs when too little circulating blood volume decreases MAP, resulting in inadequate total body perfusion & gas exchange |
| Hypovolemic shock causes/risk factors | Hemorrhage, trauma, GI ulcer, surgery, clotting, hemophilia, liver disease, cancer therapy, anticoagulation therapy, dehydration, vomiting, diarrhea, heavy diaphoresis, diuretic therapy, nasogastric suction, & diabetes insipidus |
| Cardiogenic shock | Direct pump failure (fluid volume not affected) |
| Cardiogenic shock causes/risk factors | Myocardial infarction, cardiac arrest, ventricular dysrhythmias, cardiomyopathies, myocardial degeneration, & cardiac tamponade |
| Distributive shock | When blood volume is not lost from the body but is distributed to the interstitial tissues where it cannot perfuse organs; includes septic shock, neurogenic shock, & anaphylactic shock |
| Distributive shock causes/risks | Neural induced, pain, anesthesia, stress, spinal cord injury, head trauma, chemical induced, anaphylaxis, sepsis, capillary leak, burns, extensive trauma, liver impairment, & hypoproteinemia |
| Obstructive shock | Cardiac function decreased by noncardiac factor (indirect pump failure); total body fluid not affected, although central volume is decreased |
| Obstructive shock causes/risk factors | Cardiac tamponade, arterial stenosis, pulmonary embolus, pulmonary hypertension, constrictive pericarditis, thoracic tumors, & tension pneumothorax |
| S/S of shock | Symptoms result from physiologic adjustments (compensatory mechanisms) that the body makes in the attempt to ensure continued perfusion of vital organs; see chart on pg. 733 |
| Mean arterial pressure (MAP) | Perfusion is related to this; factors that influence: total blood volume, cardiac output, & size & integrity of the vascular bed; total blood volume & cardiac output are directly related (increase in both = increase in MAP, same with decrease); norm: > 65 |
| Stages of shock | 1) Initial stage 2) Compensatory stage 3) Progressive stage 4) Refractory stage |
| Initial stage | Baseline MAP decreased by < 10; increase in HR (from adaptive responses of vascular constriction), RR, & slightly in diastolic BP (may be your only signs of shock in this stage) |
| Compensatory stage | MAP decreases by 10 - 15; kidney & hormonal adaptive mechanisms are activated (decreased urine output), tissue hypoxia in nonvital organs, acidosis & hyperkalemia, O2 90 - 95%, & increased anxiety; reversible stage |
| Progressive stage | MAP decrease > 20; compensatory mechanisms functioning, but can no longer deliver sufficient oxygen, even to vital organs, impending doom; altered mental status, rapid, weak pulse, low BP, cyanosis, cool, anuria, increased thirst, O2 75 - 80% |
| Refractory stage | Slow shallow respirations, dusky extremities, nonpalpable pulse; can’t be saved |
| Multiple organ dysfunction syndrome (MODS) | The sequence of cell damage caused by the massive release of toxic metabolites & enzymes |
| First sign of shock | Increased heart rate (to keep cardiac output & MAP at normal levels, even though the actual stroke volume per beat is decreased) |
| Assessment in shock | Cardiac: increased HR & BP Resp: increased RR, shallow resp, decreased PaCO2 & O2 stat Renal: decreased urine -> anuria, risk for AKI & kidney failure Skin: Cyanosis & clammy CNS: thirsty, change in LOC Skeletal: weak & in pain |
| Labs during shock | Decreased pH (acidosis) Decreased PaO2 Increased PaCO2 Increased Lactic acid (norm: 3 - 7 mg/dL) Decreased H&H (anemic) Increased potassium |
| Initial & compensatory stage interventions | Blood transfusion, O2, & fluids |
| Nonsurgical management of shock | Oxygen, IV therapy (fluids; 18 - 20g), drug therapy (see chart on pg. 740), monitoring vital signs & LOC, & hemodynamic monitoring |
| Surgical management of shock | Vascular repair, surgical hemostasis of major wounds, closure of bleeding ulcers, & chemical scarring (chemosclerosis) of varicosities |
| Sepsis | An extreme response to infection that can cause tissue damage, organ failure, & death if not treated promptly & appropriately; infection in bloodstream |
| Septic shock | Subset of sepsis that is associated with a much higher risk of death than is sepsis alone; associated with both systemic inflammatory response syndrome (SIRS) & sepsis with multiple organ dysfunction syndrome (MODS); uncontrolled bleeding occurs (DIC) |
| Septic shock can be identified in patients who… | - Require vasopressor therapy to maintain a MAP of at least 65 - Have a lactate level greater than 18 mg/dL |
| Sepsis/septic shock health promotion & maintenance | - Prevention - Evaluate risk - Aseptic technique - Early detection of sepsis |
| Conditions predisposing to sepsis & septic shock | See table 34.4 on pg. 743 |
| Sepsis/septic shock assessment | Cardio: cardiac output & BP are low; inadequate clotting -> DIC Resp: ARDS Skin: cool & clammy with pallor, mottling, or cyanosis; petechiae from DIC Kidney: low urine output Psych: impending doom; LOC Labs: C&S (draw lactate while waiting) |
| Interventions for sepsis & septic shock | Focus on identifying the problem as early as possible, correcting the conditions causing it, & preventing complications |
| Hour-1 bundle for management of sepsis | - Measure lactate level - Blood cultures before administering antibiotics - Administer broad-spectrum antibiotics - Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate > 4 - Apply vasopressors if hypotensive |
| Specific interventions for sepsis/septic shock | O2, drug therapy to enhance cardiac output & restore vascular volume, antibiotics, adrenal support via corticosteroids, insulin to maintain blood glucose, heparin, & blood replacement therapy |
| Sepsis S/S | Increased WBCs (shift to the left), vasodilation (increased HR, decreased BP), decreased urine output, increased temp, impaired clotting, decreased capillary refill time, hypoxia, hyperglycemia, cool & clammy. Late signs: petechiae & decreased HR |
| Sepsis labs | C&S, H&H, lactic acid, D-dimer, & platelets (150 - 400) |
| Lactic acid | Chemical your body produces when your cells break down carbohydrates for energy; it assists in cell respiration, glucose production, & molecule signaling |
Created by:
tatianalopez03
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