NUR 445
Exam 3
Module 6 - Shock & Sepsis
What is Shock:
- Life-threatening syndrome where the circulatory system fails to supply adequate oxygenation
- Tissue hypoxia = organ failure and death if untreated
- Hypoxic condition + inadequate perfusion = priority with shock
SIS DIk *ONnock>M0D
CK T CRITICAL CARIE
HEMODYINRMICS
NURRSING
i (COE D)
fiflflfifi G{ §'\(; VOlumeoF blood pumped by tre
heart in one mioutre (in L)
Suiput adjusted for e
pzz\mn body surface area (BA)
Innar- level=zlactic auid, ¥ Volume ¢jected with each heartbeat
Stroke volme index
Stroke Volume adjusted For BSA
%%\,anacrobiC mrabdlim
; }2"'}1'%]0;
Systemic vascwar resistance I mon, vascular resistance
resistarce o ruumhs resistarnce o re
to the 1eft ventricle 10 the rignt ventricle
mmmu l
.,)queSSIVe - comocma)mw ma
f’:\\:m
in 'szmncn [ - pressure the neark must
end €yect blood odainsi during
Systole (o ion)
= qulmfl& recoven unlitety, Wfl“ Outpat wsive. Prussura, Monideving
;“fi s
uabons hmbw mypotension, resp. Failure,
DISTRIBUTIVE : ~va0+\1/ C\ - [Controctivey] [Abrerioad] Peaswemns; Spmic: s
{3
s Mean ortaria) gessure
B
WIDESPREAD VASODILATION
'——_——;‘g
Has G foovmesYoy fore Sl
di acteiar
|Arteria) Pressure-Bosed Cardiac Output (APCO)|
t(‘n r*!%"”( \hm :
%NNL%LNLM : \ndu} tions© t0 assess a. patients avility 10 respond10 Fluids
= smubcdrr.st # | couse - M}
hmu T by ncreasing stroke volume
WV HR, Tx notfiuids o - Peasurements : continuous cardiac owrput (<0), Siroke wol.,
\r\abu requlate 4tmp, @ vids -
‘Mi e
Confinkous Cardiac Index (CCT ¢ SV
CoNiraindicasons - children and hoseon IABP
ama.c ety (flP Ttfl" Uvo,smcvam) filmonam Aflerq Flow- D\rma Ca.t\nem]
’l [( ¢ EDIne Gy “(‘V ,Mls TOMINe : [Venous Oz Seturation | ) Snock, M\
P ,‘\‘ -f'ufik\ e > pivretics _\l‘\f‘if{ 4 Sehwation in venous bised " severe’ Cneonic HF ,bdxofpnmm
-u\\c19|CYcQMOn sis 3t ming i
Lvophed : MAP X Hypovolemic Shece: (5c40p), e venous 0, (50y) Peosuvements: PAD pressure + PAWP
15610,
=10 sup
o Sv0e¥ 0 (957
demed
Teo s Venous or Right Aial Pressure (CVP) |
AITWO! r - -o.”'
Twor Hron netdes u-»,
oo -
- re ments - R-gw ventncular
Inkerpeetation: ONP = Rventicular faiure
preoad
i —dr—
} 2 NI r( ¢ \“
\Z
=
s;'f.*f,’;q’."l“,’,fl“ “"\Pm“gg
nes N E 1S
hm\ SN0y or s‘o‘(w-imo
= balanced
Op Supphy+ demend
Ne— OF volume Overioad
4 CvP = ypovolemia
AAA
@
% Storic_shock: [, T
Bemeve - arial contracten
4 50 v S0 (<L07) Conue - rieuiba buige %
s o+ ¥ Sal, 4 CO, TO demond e R oo &
or bind = carai VA - abrial fillioy « ¢
MOST Cammon, Zgonemmia. feom & o..fly:“.
‘ * 00&pcufi( SIS
Do al 129
TSRe v
Stages of Shock:
- Initial
o Hypoxia: not getting oxygen to the cells (e MAger ot Yuoek
. . Initial stage Compensatory stage Progressive stage Refractory stage
" Change in HR, Decreased cardiac » Body switches from | » Sympathetic nervous » Electrolyte imbalance » Irreversible cellular
aerobic to anaerobic system stimulated ic acidosi and organ damage
OUtpUt metabolism 1 catecholamine release ' Metaf;ohc aCId_OS'S.
» Impending death
= Alterationin LOC » Elevated lactic acid T cardiac contractility - Fespleatony agicons
level Y » Peripheral oedema
- Compensatory » Subtle changes in » Neurohormonal response: » Irregular
. . . . . clinical signs vasoconstriction and blood tachyarrhythmias
o Everything is making up for what is going shunted to vital organs » Hipoliniion
|
on » Aldosterone released : z::;n i ooy il
. {4 urine output (<30ml/hr)
= tachycardia, tachypnea y b Altered fevel of
» Decreased urine output > 1 Heart rate e
. Y
= Hyperglycemia b 1 Glucose levels
= Weak pulse | (Springhouse 2004)
= Decreased bowel sounds
= Cool, moist skin
- Progressive
o Things are failing
, o Shunting blood away from organs
= Respiratory acidosis
= Metabolic acidosis
* Hypotension
= Aerobic metabolism
= Anuria (no urine)
= Dysrhythmias
- Refractory
o Extreme tissue hypoxia
o MODS
= Coma
= Severe hypotension
= Respiratory acidosis
= Hepatic/renal failure
= Necrosis
Hypovolemic Shock:
- Rapid fluid loss = lack of circulation volume
- Risk: blood loss 2 trauma, Gl Bleed, Burns, Severe Vomiting/diarrhea
- Hemodynamics:
o Acute loss of circulating fluid volume = decreased venous return
to the right heart
o Decreased stroke volume/CO = decreased tissue perfusion
athophysiolo ). e,
o Decreased CVP = low O2 stat Oy &
. YW blood or u valume from excessive
fidvoume loss. (@) 0. b |
@] I nC I’ea Sed SVR = COm pe nsatOI’y meCha n | SmS through diarrhea, vomiting, or fluid shifts as in burn patients
s f;om bleeding (hemorrhag;)ér[obrr tr(;auma like a gunshot or HYPOvolemic shock
- . . . nife injury, or even surgery eed.
- Clinical Manifestations: LOW biood volume
o Restlessness Sl
n Hypovolemic shock - As mentioned before - ; "‘:‘p':":f D
u ri n e
o Pale, cool, clammy skin B e
o Dec reased . this is often seen in the progressive stage & is % ‘:;‘;m"‘;'::""‘:‘”‘“ ““““
* Cold and clammy
skin immediately & get some IV normal saline " o
o Wea k pu lses PRIORITY NCLEXTIP started quickly! -e_',’ v =
o Delayed capillary refill [ kapan | f
. - Which vital sign would alert the nurse ( " ‘!‘
o Hyperventilation 1 ot hemorhae i =
f * HR110 & m
o Hypoactive bowel sounds
. [ interventions } .
o Hyperglycemia :
B @ &,
- Management: = 8 |
R . . PRIORITY = Hemodynamic stability & CRITICAL! DO NGT delay s e
O Malelze Oxygenatlon (PRIORITY) % :2:[:::“0;”@' bag of norepinephrine NCLEX TIP
NEVER place the HOB in = MAP (mean arterial pressure) = SpO2 = the sensor should be
L] 1 OO% N o n re b reath e r M a s k High Fowler's position Over 65 mmHg placed on the forehead instead
2. IV Normal Saline = CVP (central venous pressure) of extremities
= Anticipate and prep for intubation Dcutmaebasiingy| Deiiel
o Fluid Resuscitation | o - .
= Normal Saline “ L= ¥ = 100\
= Large-Bore IV
= Blood Products + MAP monitoring (keep at 50)
= Do not give TOO MUCH Crystalloids = can worsen hemorrhage
o Identify and Tx Cause
- Nursing Assessments:
o Neuro assessments
o Vitalsigns
o Hemodynamics
= SVO2is decreased because they are NOT getting oxygen
o Urine Output
Exam 3
Module 6 - Shock & Sepsis
What is Shock:
- Life-threatening syndrome where the circulatory system fails to supply adequate oxygenation
- Tissue hypoxia = organ failure and death if untreated
- Hypoxic condition + inadequate perfusion = priority with shock
SIS DIk *ONnock>M0D
CK T CRITICAL CARIE
HEMODYINRMICS
NURRSING
i (COE D)
fiflflfifi G{ §'\(; VOlumeoF blood pumped by tre
heart in one mioutre (in L)
Suiput adjusted for e
pzz\mn body surface area (BA)
Innar- level=zlactic auid, ¥ Volume ¢jected with each heartbeat
Stroke volme index
Stroke Volume adjusted For BSA
%%\,anacrobiC mrabdlim
; }2"'}1'%]0;
Systemic vascwar resistance I mon, vascular resistance
resistarce o ruumhs resistarnce o re
to the 1eft ventricle 10 the rignt ventricle
mmmu l
.,)queSSIVe - comocma)mw ma
f’:\\:m
in 'szmncn [ - pressure the neark must
end €yect blood odainsi during
Systole (o ion)
= qulmfl& recoven unlitety, Wfl“ Outpat wsive. Prussura, Monideving
;“fi s
uabons hmbw mypotension, resp. Failure,
DISTRIBUTIVE : ~va0+\1/ C\ - [Controctivey] [Abrerioad] Peaswemns; Spmic: s
{3
s Mean ortaria) gessure
B
WIDESPREAD VASODILATION
'——_——;‘g
Has G foovmesYoy fore Sl
di acteiar
|Arteria) Pressure-Bosed Cardiac Output (APCO)|
t(‘n r*!%"”( \hm :
%NNL%LNLM : \ndu} tions© t0 assess a. patients avility 10 respond10 Fluids
= smubcdrr.st # | couse - M}
hmu T by ncreasing stroke volume
WV HR, Tx notfiuids o - Peasurements : continuous cardiac owrput (<0), Siroke wol.,
\r\abu requlate 4tmp, @ vids -
‘Mi e
Confinkous Cardiac Index (CCT ¢ SV
CoNiraindicasons - children and hoseon IABP
ama.c ety (flP Ttfl" Uvo,smcvam) filmonam Aflerq Flow- D\rma Ca.t\nem]
’l [( ¢ EDIne Gy “(‘V ,Mls TOMINe : [Venous Oz Seturation | ) Snock, M\
P ,‘\‘ -f'ufik\ e > pivretics _\l‘\f‘if{ 4 Sehwation in venous bised " severe’ Cneonic HF ,bdxofpnmm
-u\\c19|CYcQMOn sis 3t ming i
Lvophed : MAP X Hypovolemic Shece: (5c40p), e venous 0, (50y) Peosuvements: PAD pressure + PAWP
15610,
=10 sup
o Sv0e¥ 0 (957
demed
Teo s Venous or Right Aial Pressure (CVP) |
AITWO! r - -o.”'
Twor Hron netdes u-»,
oo -
- re ments - R-gw ventncular
Inkerpeetation: ONP = Rventicular faiure
preoad
i —dr—
} 2 NI r( ¢ \“
\Z
=
s;'f.*f,’;q’."l“,’,fl“ “"\Pm“gg
nes N E 1S
hm\ SN0y or s‘o‘(w-imo
= balanced
Op Supphy+ demend
Ne— OF volume Overioad
4 CvP = ypovolemia
AAA
@
% Storic_shock: [, T
Bemeve - arial contracten
4 50 v S0 (<L07) Conue - rieuiba buige %
s o+ ¥ Sal, 4 CO, TO demond e R oo &
or bind = carai VA - abrial fillioy « ¢
MOST Cammon, Zgonemmia. feom & o..fly:“.
‘ * 00&pcufi( SIS
Do al 129
TSRe v
Stages of Shock:
- Initial
o Hypoxia: not getting oxygen to the cells (e MAger ot Yuoek
. . Initial stage Compensatory stage Progressive stage Refractory stage
" Change in HR, Decreased cardiac » Body switches from | » Sympathetic nervous » Electrolyte imbalance » Irreversible cellular
aerobic to anaerobic system stimulated ic acidosi and organ damage
OUtpUt metabolism 1 catecholamine release ' Metaf;ohc aCId_OS'S.
» Impending death
= Alterationin LOC » Elevated lactic acid T cardiac contractility - Fespleatony agicons
level Y » Peripheral oedema
- Compensatory » Subtle changes in » Neurohormonal response: » Irregular
. . . . . clinical signs vasoconstriction and blood tachyarrhythmias
o Everything is making up for what is going shunted to vital organs » Hipoliniion
|
on » Aldosterone released : z::;n i ooy il
. {4 urine output (<30ml/hr)
= tachycardia, tachypnea y b Altered fevel of
» Decreased urine output > 1 Heart rate e
. Y
= Hyperglycemia b 1 Glucose levels
= Weak pulse | (Springhouse 2004)
= Decreased bowel sounds
= Cool, moist skin
- Progressive
o Things are failing
, o Shunting blood away from organs
= Respiratory acidosis
= Metabolic acidosis
* Hypotension
= Aerobic metabolism
= Anuria (no urine)
= Dysrhythmias
- Refractory
o Extreme tissue hypoxia
o MODS
= Coma
= Severe hypotension
= Respiratory acidosis
= Hepatic/renal failure
= Necrosis
Hypovolemic Shock:
- Rapid fluid loss = lack of circulation volume
- Risk: blood loss 2 trauma, Gl Bleed, Burns, Severe Vomiting/diarrhea
- Hemodynamics:
o Acute loss of circulating fluid volume = decreased venous return
to the right heart
o Decreased stroke volume/CO = decreased tissue perfusion
athophysiolo ). e,
o Decreased CVP = low O2 stat Oy &
. YW blood or u valume from excessive
fidvoume loss. (@) 0. b |
@] I nC I’ea Sed SVR = COm pe nsatOI’y meCha n | SmS through diarrhea, vomiting, or fluid shifts as in burn patients
s f;om bleeding (hemorrhag;)ér[obrr tr(;auma like a gunshot or HYPOvolemic shock
- . . . nife injury, or even surgery eed.
- Clinical Manifestations: LOW biood volume
o Restlessness Sl
n Hypovolemic shock - As mentioned before - ; "‘:‘p':":f D
u ri n e
o Pale, cool, clammy skin B e
o Dec reased . this is often seen in the progressive stage & is % ‘:;‘;m"‘;'::""‘:‘”‘“ ““““
* Cold and clammy
skin immediately & get some IV normal saline " o
o Wea k pu lses PRIORITY NCLEXTIP started quickly! -e_',’ v =
o Delayed capillary refill [ kapan | f
. - Which vital sign would alert the nurse ( " ‘!‘
o Hyperventilation 1 ot hemorhae i =
f * HR110 & m
o Hypoactive bowel sounds
. [ interventions } .
o Hyperglycemia :
B @ &,
- Management: = 8 |
R . . PRIORITY = Hemodynamic stability & CRITICAL! DO NGT delay s e
O Malelze Oxygenatlon (PRIORITY) % :2:[:::“0;”@' bag of norepinephrine NCLEX TIP
NEVER place the HOB in = MAP (mean arterial pressure) = SpO2 = the sensor should be
L] 1 OO% N o n re b reath e r M a s k High Fowler's position Over 65 mmHg placed on the forehead instead
2. IV Normal Saline = CVP (central venous pressure) of extremities
= Anticipate and prep for intubation Dcutmaebasiingy| Deiiel
o Fluid Resuscitation | o - .
= Normal Saline “ L= ¥ = 100\
= Large-Bore IV
= Blood Products + MAP monitoring (keep at 50)
= Do not give TOO MUCH Crystalloids = can worsen hemorrhage
o Identify and Tx Cause
- Nursing Assessments:
o Neuro assessments
o Vitalsigns
o Hemodynamics
= SVO2is decreased because they are NOT getting oxygen
o Urine Output
