NUR 445 - Exam 4 Study Guide
SHOCK
,Hypovolemic Shock
-Common cause
oblood loss d/t trauma, GI bleeds, surgery
ointernal bleeding
ofluid loss d/t vomiting, diarrhea, urination, burns
othird-space fluid loss
-Clinical manifestations
oEarly
Tachycardia
Restless, confused
UO decreased d/t reabsorption of sodium and water
Pale, cool, clammy skin
Pulses weak, sluggish cap refill
Hyperventilation (respiratory alkalosis)
Hypoactive bowel sounds
Hyperglycemia
oLate
Lethargy
Hypotension
Metabolic and respiratory acidosis
Anuria
Cold, cyanotic skin with weak/absent pulses
Dysrhythmias
oRefractory (ineffective treatment)
Coma
Severe hypotension
Ischemic and necrotic cold extremities
Renal and hepatic failure
-Hemodynamic parameters
oDecreased CVP, PaOP, SvO2/ScvO2, CO
oINCREASED systemic vascular resistance (SVR)
-Assess
oNeuro status
oVS
oHemodynamic readings
oUO
oSkin color and temperature
-Labs
oABGs
Initial: Respiratory alkalosis
Late: Metabolic acidosis
oSvO2/ScvO2
Decreased inadequate oxygen delivery
oH&H
Decreased if cause is bleeding
oMetabolic profile
Renal failure and liver failure INCREASED BUN & Creatinine
oLactate/base deficit
Increased lactate, negative base poor perfusion
-Nursing actions
, o100% NRB
oAnticipate and prepare for intubation
Positive-pressure mechanical ventilation needed to improve oxygenation
oLarge-bore IVs Fluid replacement
NS
LR
Blood products (PRBCs, FFP, Platelets)
-Patient Education
oInstruct patient and family on the cause of hypovolemia
oAllow family members visitation during hospital treatment
Cardiogenic shock
-Causes
oMI
oSevere valvular dysfunction
oSevere HF
-RF
oAMI
oEnd-stage CHF
oCardiomyopathy
oHTN
oDM
oCAD
oAcute vascular disease
-Clinical manifestations
oInitial
Chest pain
Diaphoresis
N/V
Decreased CO increased lactate
Hypotension
Decreased LOC
Decreased UO
Poor pulses
Pale, cool skin
Hypoactive BS
Pulmonary edema SOB, crackles, decreased SpO2
oLate
Profound hypotension and bradycardia
Coma
Cyanotic, mottled skin
Absent BS
Anuria
oAs shock progresses severe hypotension and bradycardia
-Labs
oABGs
Initial: respiratory alkalosis
Late: metabolic acidosis
oHemodynamic parameters (PA catheter)
Increased CVP and PAOP
SHOCK
,Hypovolemic Shock
-Common cause
oblood loss d/t trauma, GI bleeds, surgery
ointernal bleeding
ofluid loss d/t vomiting, diarrhea, urination, burns
othird-space fluid loss
-Clinical manifestations
oEarly
Tachycardia
Restless, confused
UO decreased d/t reabsorption of sodium and water
Pale, cool, clammy skin
Pulses weak, sluggish cap refill
Hyperventilation (respiratory alkalosis)
Hypoactive bowel sounds
Hyperglycemia
oLate
Lethargy
Hypotension
Metabolic and respiratory acidosis
Anuria
Cold, cyanotic skin with weak/absent pulses
Dysrhythmias
oRefractory (ineffective treatment)
Coma
Severe hypotension
Ischemic and necrotic cold extremities
Renal and hepatic failure
-Hemodynamic parameters
oDecreased CVP, PaOP, SvO2/ScvO2, CO
oINCREASED systemic vascular resistance (SVR)
-Assess
oNeuro status
oVS
oHemodynamic readings
oUO
oSkin color and temperature
-Labs
oABGs
Initial: Respiratory alkalosis
Late: Metabolic acidosis
oSvO2/ScvO2
Decreased inadequate oxygen delivery
oH&H
Decreased if cause is bleeding
oMetabolic profile
Renal failure and liver failure INCREASED BUN & Creatinine
oLactate/base deficit
Increased lactate, negative base poor perfusion
-Nursing actions
, o100% NRB
oAnticipate and prepare for intubation
Positive-pressure mechanical ventilation needed to improve oxygenation
oLarge-bore IVs Fluid replacement
NS
LR
Blood products (PRBCs, FFP, Platelets)
-Patient Education
oInstruct patient and family on the cause of hypovolemia
oAllow family members visitation during hospital treatment
Cardiogenic shock
-Causes
oMI
oSevere valvular dysfunction
oSevere HF
-RF
oAMI
oEnd-stage CHF
oCardiomyopathy
oHTN
oDM
oCAD
oAcute vascular disease
-Clinical manifestations
oInitial
Chest pain
Diaphoresis
N/V
Decreased CO increased lactate
Hypotension
Decreased LOC
Decreased UO
Poor pulses
Pale, cool skin
Hypoactive BS
Pulmonary edema SOB, crackles, decreased SpO2
oLate
Profound hypotension and bradycardia
Coma
Cyanotic, mottled skin
Absent BS
Anuria
oAs shock progresses severe hypotension and bradycardia
-Labs
oABGs
Initial: respiratory alkalosis
Late: metabolic acidosis
oHemodynamic parameters (PA catheter)
Increased CVP and PAOP
