Shock - Quia

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MedicalMedical--Surgical Surgical Nursing CareNursing Care

Second EditionSecond Edition

Karen Burke

Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown

Copyright ©2007 by Pearson Education, Inc.

Chapter 13Chapter 13Caring for Clients Experiencing Caring for Clients Experiencing Shock, Trauma, or Critical Shock, Trauma, or Critical IllnessIllness

Priscilla LeMoneElaine Mohn-Brown

ShockShockLifeLife--threatening conditionthreatening conditionInadequate blood flow and oxygen to tissues and cellsInadequate blood flow and oxygen to tissues and cells



Stages of ShockStages of Shock

CompensatedCompensatedProgressiveProgressiveIrreversibleIrreversible



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Compensated ShockCompensated Shock

Decreased blood volume reduces cardiac output or Decreased blood volume reduces cardiac output or vasodilation occursvasodilation occursBlood pressure drops and normal tissue perfusion is Blood pressure drops and normal tissue perfusion is not maintainednot maintained



Baroreceptors stimulate the sympathetic nervous Baroreceptors stimulate the sympathetic nervous system to release epinephrine and norepinephrinesystem to release epinephrine and norepinephrine

Compensated ShockCompensated Shock

Arterial blood vessels constrict, heart rate and Arterial blood vessels constrict, heart rate and strength of heart to contract increases, venous return strength of heart to contract increases, venous return increasesincreasesReninRenin––angiotensin system is activated, increasingangiotensin system is activated, increasing



ReninRenin angiotensin system is activated, increasing angiotensin system is activated, increasing blood pressure and circulating blood volumeblood pressure and circulating blood volume

Antidiuretic hormone is released to increase blood pressureAntidiuretic hormone is released to increase blood pressure

Progressive ShockProgressive Shock

Compensatory mechanisms fail and organ functions Compensatory mechanisms fail and organ functions deteriorate deteriorate

CardiovascularCardiovascular——decreased cardiac output results in decreased cardiac output results in decreased oxygenation of cell and tissue ischemiadecreased oxygenation of cell and tissue ischemia



RespiratoryRespiratory——increased carbon dioxide results in increased carbon dioxide results in respiratory acidosisrespiratory acidosisGastrointestinal systemGastrointestinal system——ulceration of mucosa results in ulceration of mucosa results in stress ulcers and sepsis, paralytic ileusstress ulcers and sepsis, paralytic ileusLiverLiver——failure leads to hypoglycemia, bacterial infectionsfailure leads to hypoglycemia, bacterial infections

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Progressive ShockProgressive ShockNeurologicNeurologic——decreased blood flow leads to decreased level decreased blood flow leads to decreased level of consciousness, coma, cerebral edema, and brain damageof consciousness, coma, cerebral edema, and brain damageRenalRenal——reduced blood flow causes oliguria and failurereduced blood flow causes oliguria and failureSkin and temperatureSkin and temperature——vasoconstriction leads to pale skin vasoconstriction leads to pale skin and mucous membranes, activation of sweat glands and mucous membranes, activation of sweat glands



produces cool and clammy skin, body temperature produces cool and clammy skin, body temperature decreasesdecreases

Irreversible ShockIrreversible Shock

Multiple organ dysfunction syndrome (MODS)Multiple organ dysfunction syndrome (MODS)——tissue and cellular deathtissue and cellular death



BOX 13BOX 13--11 Manifestations Found in Each Stage of Shock.Manifestations Found in Each Stage of Shock.



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Types of ShockTypes of Shock

HypovolemicHypovolemicAnaphylacticAnaphylacticCardiogenicCardiogenicSepticSeptic



SepticSepticNeurogenicNeurogenic

Causes of Hypovolemic ShockCauses of Hypovolemic Shock

Decrease in circulating blood volume due to:Decrease in circulating blood volume due to:Hemorrhage due to traumaHemorrhage due to traumaSurgerySurgeryGI bleedingGI bleeding



HemophiliaHemophiliaPostpartum hemorrhagePostpartum hemorrhage


Internal fluid shifts due to:Internal fluid shifts due to:Cirrhosis with ascitesCirrhosis with ascitesPleural effusionPleural effusionPancreatitisPancreatitis



Intestinal obstructionIntestinal obstruction

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Loss of body fluids due to:Loss of body fluids due to:VomitingVomitingDiarrheaDiarrheaNasogastric suctioningNasogastric suctioning



DiureticsDiureticsDiabetes insipidusDiabetes insipidus

Loss of fluids through skin due to diaphoresis or Loss of fluids through skin due to diaphoresis or burnsburns

Causes of Anaphylactic ShockCauses of Anaphylactic Shock

Immunologic reaction from antigens due to:Immunologic reaction from antigens due to:Food allergiesFood allergiesStings and bites from insectsStings and bites from insectsSnake venomSnake venom



Substances used to diagnose and treat diseaseSubstances used to diagnose and treat diseaseLatex, pollen, molds, food additivesLatex, pollen, molds, food additives

Causes of Cardiogenic ShockCauses of Cardiogenic Shock

Failure of heart’s pumping action or other cardiac Failure of heart’s pumping action or other cardiac disordersdisorders

Myocardial infarctionMyocardial infarction



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Causes of Septic ShockCauses of Septic Shock

Overwhelming infection produced by toxins due to:Overwhelming infection produced by toxins due to:Age, <1 year, >65 yearsAge, <1 year, >65 yearsDebilitating disease processesDebilitating disease processesSurgery, invasive lines or tubesSurgery, invasive lines or tubes



Drug therapyDrug therapy

Causes of Neurogenic ShockCauses of Neurogenic Shock

Changes in sympathetic tone of blood vessels due to:Changes in sympathetic tone of blood vessels due to:Spinal cord injury above T6 levelSpinal cord injury above T6 levelHead injuryHead injurySpinal anesthesiaSpinal anesthesia



Opiate drug overdoseOpiate drug overdoseInsulin reactionInsulin reaction

Pathophysiology of ShockPathophysiology of Shock

Alteration in one or more factor:Alteration in one or more factor:Adequate blood flowAdequate blood flowCorrect heart pumping actionCorrect heart pumping actionNormal blood vessel diameter to maintain tissue perfusionNormal blood vessel diameter to maintain tissue perfusion



Disruption of normal cell functionDisruption of normal cell functionInadequate tissue perfusion to sustain normal cellular Inadequate tissue perfusion to sustain normal cellular metabolismmetabolismProlonged shock results in hypoxia and cell death, then Prolonged shock results in hypoxia and cell death, then organ failure and deathorgan failure and death

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Manifestations of Hypovolemic Manifestations of Hypovolemic ShockShock



Pathophysiology and Pathophysiology and Manifestations of Anaphylactic Manifestations of Anaphylactic

ShockShockAntigenAntigen––antibody reaction stimulates mast cells to antibody reaction stimulates mast cells to release histamine and other mediators, causing:release histamine and other mediators, causing:

VasodilationVasodilation



HypotensionHypotensionHypovolemiaHypovolemia

Inflammation, bronchoconstriction, and cutaneous Inflammation, bronchoconstriction, and cutaneous reactions occur, causing a lifereactions occur, causing a life--threatening eventthreatening event

BOX 13BOX 13--33 Manifestations of Anaphylactic Shock.Manifestations of Anaphylactic Shock.



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Pathophysiology and Pathophysiology and Manifestations of Cardiogenic Manifestations of Cardiogenic

ShockShockVentricles fail to pump blood into the circulatory Ventricles fail to pump blood into the circulatory systemsystem

Decreased stroke volumeDecreased stroke volume



Blood backs up in lungs causing:Blood backs up in lungs causing:Pulmonary edemaPulmonary edemaHypotensionHypotensionCardiac failureCardiac failure

BOX 13BOX 13--44 Manifestations of Cardiogenic Shock.Manifestations of Cardiogenic Shock.



Pathophysiology and Pathophysiology and Manifestations of Septic ShockManifestations of Septic ShockAs bacteria are destroyed, endotoxins are releasedAs bacteria are destroyed, endotoxins are released

Damage tissuesDamage tissuesStarve cells of oxygen and nutrientsStarve cells of oxygen and nutrients

Histamine and other chemicals are releasedHistamine and other chemicals are released



VasodilationVasodilationIncreased capillary permeabilityIncreased capillary permeabilityHypovolemia occursHypovolemia occurs

Microemboli form in capillaries causing cell damage Microemboli form in capillaries causing cell damage and deathand death

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BOX 13BOX 13--55 Manifestations of Septic Shock.Manifestations of Septic Shock.



Pathophysiology and Pathophysiology and Manifestations of Neurogenic Manifestations of Neurogenic

ShockShockBlood vessels dilateBlood vessels dilate

Peripheral vasodilationPeripheral vasodilation

Blood poolsBlood pools



Inadequate tissue perfusionInadequate tissue perfusion

Thermoregulation is impairedThermoregulation is impairedOrgan failure and death occurOrgan failure and death occur

BOX 13BOX 13--66 Manifestations of Neurogenic Shock.Manifestations of Neurogenic Shock.



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Complications of ShockComplications of Shock

Acute respiratory distress syndrome (ARDS)Acute respiratory distress syndrome (ARDS)Disseminated intravascular coagulation (DIC)Disseminated intravascular coagulation (DIC)



Diagnostic Tests to Identify Type Diagnostic Tests to Identify Type of Shockof Shock

CBC, especially hemoglobin and hematocritCBC, especially hemoglobin and hematocritArterial blood gasesArterial blood gasesElectrolytes, especially serum sodium and potassiumElectrolytes, especially serum sodium and potassiumBlood glucose levelsBlood glucose levels



Blood glucose levelsBlood glucose levelsBlood urea nitrogen and creatinineBlood urea nitrogen and creatinine


Blood culturesBlood culturesWhite blood cell countWhite blood cell countSerum cardiac markersSerum cardiac markers

Creatine kinaseCreatine kinase



Creatine kinaseCreatine kinaseCKCK--MBMBTroponinsTroponins

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XX--raysraysComputerized tomography (CT) scansComputerized tomography (CT) scansMagnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)Peritoneal lavagePeritoneal lavage



Peritoneal lavagePeritoneal lavage

Oxygen Therapy in ShockOxygen Therapy in Shock

Maintain patient airwayMaintain patient airwayAdminister oxygen via nonbreather mask at 12 to 15 Administer oxygen via nonbreather mask at 12 to 15 L/minL/minMaintain PaOMaintain PaO22 > 90 mm Hg> 90 mm Hg



Maintain PaOMaintain PaO22 90 mm Hg 90 mm HgMonitor for respiratory distressMonitor for respiratory distressAnticipate endotracheal intubation and mechanical Anticipate endotracheal intubation and mechanical ventilationventilation

Nursing Management of Client Nursing Management of Client with Hypovolemic Shockwith Hypovolemic Shock

Initiate intravenous fluidsInitiate intravenous fluidsApply pneumatic antishock garments (PASG)Apply pneumatic antishock garments (PASG)

To raise blood pressure and stabilize pelvic and femoral To raise blood pressure and stabilize pelvic and femoral fracturesfractures



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Nursing Management of Client Nursing Management of Client with Anaphylactic Shockwith Anaphylactic Shock

Maintain patient airway and administer oxygenMaintain patient airway and administer oxygenAdminister epinephrine subcutaneously or Administer epinephrine subcutaneously or intravenouslyintravenouslyAdminister antihistaminesAdminister antihistamines



Administer antihistaminesAdminister antihistaminesAdminister corticosteroidsAdminister corticosteroidsIf respiratory distress continues, administer If respiratory distress continues, administer aminophylline or nebulized albuterolaminophylline or nebulized albuterol

Nursing Management of Client Nursing Management of Client with Cardiogenic Shockwith Cardiogenic Shock

Administer oxygenAdminister oxygenAdminister vasopressor drugs and positive inotropic Administer vasopressor drugs and positive inotropic drugsdrugsAdminister diuretic drugsAdminister diuretic drugs



Administer diuretic drugsAdminister diuretic drugsAdminister antidysrhythmic drugsAdminister antidysrhythmic drugsMonitor mechanical devicesMonitor mechanical devices

IntraIntra--aortic balloon pump (IABP)aortic balloon pump (IABP)Ventricular assist device (VAD)Ventricular assist device (VAD)

Nursing Management of Client Nursing Management of Client with Septic Shockwith Septic Shock

Obtain blood, urine, wound, sputum culturesObtain blood, urine, wound, sputum culturesAdminister intravenous fluidsAdminister intravenous fluidsAdminister antibiotic drugsAdminister antibiotic drugs



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Nursing Management of Client Nursing Management of Client with Neurogenic Shockwith Neurogenic Shock

Administer intravenous fluidsAdminister intravenous fluidsAdminister analgesic drugsAdminister analgesic drugs



Client and Family Support in Client and Family Support in ShockShock

Client and Family Support in ShockClient and Family Support in ShockAcknowledge anxiety and fearAcknowledge anxiety and fearProvide comfort measuresProvide comfort measuresProvide time, space, and privacyProvide time, space, and privacy



Provide anticipatory guidanceProvide anticipatory guidanceKeep family informedKeep family informed

Discharge TeachingDischarge TeachingAvoid known allergensAvoid known allergensNotify health care professionals of allergensNotify health care professionals of allergensAvoid wearing bright colors, perfumes, and scented hair Avoid wearing bright colors, perfumes, and scented hair sprays if allergic to insect stingssprays if allergic to insect stingsRead package labels if allergic to foodsRead package labels if allergic to foods



Read package labels if allergic to foodsRead package labels if allergic to foodsWear MedicWear Medic--Alert bracelet or necklaceAlert bracelet or necklaceAdvise to carry an emergency kit for anaphylaxisAdvise to carry an emergency kit for anaphylaxisReview manifestations of anaphylaxisReview manifestations of anaphylaxisSeek medical attention immediately when symptoms Seek medical attention immediately when symptoms occuroccur

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IV Fluids Administered in ShockIV Fluids Administered in Shock

Replace fluids in a 3:1 ratio (300 mL for every 100 Replace fluids in a 3:1 ratio (300 mL for every 100 mL fluid loss)mL fluid loss)Crystalloid solutionsCrystalloid solutionsColloid solutionsColloid solutions



Colloid solutionsColloid solutionsBlood and blood productsBlood and blood products

AutotransfusionAutotransfusion

Causes of TraumaCauses of Trauma

Injury caused by physical forceInjury caused by physical forceMotor vehicle crashesMotor vehicle crashesFallsFallsDrowningDrowning



DrowningDrowningGunshotsGunshotsBurnsBurnsStabbingStabbingPhysical assaults, contact sportsPhysical assaults, contact sports

Common Traumatic InjuriesCommon Traumatic Injuries

Minor traumaMinor traumaFractures to collarboneFractures to collarboneSmall secondSmall second--degree burndegree burnCut requiring stitchesCut requiring stitches



Major or multiple traumaMajor or multiple traumaAmputationAmputationMultipleMultiple--system injuriessystem injuries

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Common Traumatic InjuriesCommon Traumatic Injuries

Blunt traumaBlunt traumaInternal damage that does not break skinInternal damage that does not break skin

Penetrating traumaPenetrating traumaForeign object that pierces bodyForeign object that pierces body



g j p yg j p yExternal appearance of wound does not determine internal External appearance of wound does not determine internal damagedamage

Common Environmental InjuriesCommon Environmental Injuries

HyperthermiaHyperthermiaHeat exhaustionHeat exhaustionHeat strokeHeat stroke

HypothermiaHypothermia



ypypPoisoningsPoisonings

Effects of Traumatic InjuryEffects of Traumatic Injury

Airway obstructionAirway obstructionPneumothoraxPneumothoraxHemorrhageHemorrhageHypovolemic shockHypovolemic shock

Musculoskeletal injuriesMusculoskeletal injuriesIntegumentary injuriesIntegumentary injuriesPsychologic effects on Psychologic effects on clientclient



Hypovolemic shockHypovolemic shockNeurologic injuriesNeurologic injuriesGastrointestinal and Gastrointestinal and genitourinary injuriesgenitourinary injuries

clientclientPsychosocial effects on Psychosocial effects on familyfamily

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Emergency Treatment of Emergency Treatment of Traumatic InjuryTraumatic Injury

Assess to identify extent of injuriesAssess to identify extent of injuriesProvide life supportProvide life supportImmobilizeImmobilizeAdminister oxygenAdminister oxygen



Administer oxygenAdminister oxygenControl bleedingControl bleedingStart IV fluidsStart IV fluidsTransportTransportEmergency surgeryEmergency surgery

Diagnostic Tests for Traumatic Diagnostic Tests for Traumatic InjuriesInjuries

Tests to rule out shockTests to rule out shockBlood alcohol levelsBlood alcohol levelsUrine drug screenUrine drug screenPregnancy testPregnancy test



Pregnancy testPregnancy testDiagnostic peritoneal lavageDiagnostic peritoneal lavageComputerized tomography (CT scan)Computerized tomography (CT scan)Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)

Legal Investigation of Injuries Legal Investigation of Injuries Related to Criminal ActivityRelated to Criminal Activity

Identify, store, and properly transfer potential evidenceIdentify, store, and properly transfer potential evidenceDo not cut through clothing containing blood stains or Do not cut through clothing containing blood stains or bullet holesbullet holesPlace clothing in individual breathable containers and Place clothing in individual breathable containers and l b ll b l



labellabelLabel bullets or knivesLabel bullets or knivesRecord entrance and exit wounds in chartRecord entrance and exit wounds in chartPhotograph woundsPhotograph woundsPlace paper bag over hands if presence of evidence in Place paper bag over hands if presence of evidence in suspectedsuspected

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AssessmentAssessmentPerform headPerform head--toto--toe assessmenttoe assessmentObtain brief history, allergies, past medical historyObtain brief history, allergies, past medical historyAssess vital signs every 5Assess vital signs every 5––10 minutes to hourly, to 10 minutes to hourly, to every 2every 2––4 hours4 hoursAssess for early signs of shockAssess for early signs of shock



RestlessnessRestlessnessTachycardiaTachycardiaSlight anxietySlight anxiety

Assess late signs of shockAssess late signs of shockHypotensionHypotension

Assess urine outputAssess urine output

InterventionsInterventions

Insert nasogastric tube if risk of aspirationInsert nasogastric tube if risk of aspirationApply cardiac monitor to assess cardiac statusApply cardiac monitor to assess cardiac statusInsert intravenous lines and administer medications as Insert intravenous lines and administer medications as indicatedindicated



indicatedindicatedMonitor for hypothermiaMonitor for hypothermiaAdminister tetanus prophylaxis if penetrating woundAdminister tetanus prophylaxis if penetrating woundMaintain strict aseptic techniqueMaintain strict aseptic technique

EvaluationEvaluation

Absence of infectionAbsence of infectionPreventing complications from immobilityPreventing complications from immobilityDocument healing of injuriesDocument healing of injuries



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Discharge TeachingDischarge Teaching

Determine potential home modificationsDetermine potential home modificationsReview medication administrationReview medication administrationGive information about dietsGive information about dietsDiscuss rehabilitation planDiscuss rehabilitation plan



Discuss rehabilitation planDiscuss rehabilitation planEmphasize need for followEmphasize need for follow--up careup careDiscuss emotional changesDiscuss emotional changesProvide referrals as neededProvide referrals as neededProvide preventative educationProvide preventative education

Interventions for Environmental Interventions for Environmental InjuriesInjuries

HyperthermiaHyperthermiaMove to cool placeMove to cool placeLoosen clothingLoosen clothingApply cool, wet towelsApply cool, wet towels



Apply cooling blanket and oxygen for heat strokeApply cooling blanket and oxygen for heat strokeMonitor for renal failure and seizuresMonitor for renal failure and seizures

Interventions for Environmental Interventions for Environmental InjuriesInjuries

HypothermiaHypothermiaMove to warm placeMove to warm placeRemove wet clothingRemove wet clothingApply warm blankets, radiant heat lamp, warming blanketApply warm blankets, radiant heat lamp, warming blanket



Administer warm intravenous fluids and warm peritoneal Administer warm intravenous fluids and warm peritoneal lavagelavageAdminister warm, humidified oxygenAdminister warm, humidified oxygenObserve for cardiac arrestObserve for cardiac arrest

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Interventions for Environmental Interventions for Environmental TraumaTrauma

PoisoningsPoisoningsIdentify the poisonIdentify the poisonCall the local poison control centerCall the local poison control centerAssess airway, breathing, and circulationAssess airway, breathing, and circulation



Assist with administration of antidote or elimination Assist with administration of antidote or elimination methodmethodAdminister oxygen for inhaled poisonsAdminister oxygen for inhaled poisonsCleanse contaminated skin with waterCleanse contaminated skin with waterTeaching for poisoningTeaching for poisoning

ICU PsychosisICU Psychosis

Acute confusion after 2 to 3 days in ICUAcute confusion after 2 to 3 days in ICUManifestations:Manifestations:

Altered attention spanAltered attention spanMemory lossMemory loss



yyConfusionConfusionVisual and auditory hallucinationsVisual and auditory hallucinations

ICU PsychosisICU Psychosis

Treatment:Treatment:Administer sedative or psychotropic drugsAdminister sedative or psychotropic drugsDecrease client’s sensoriperceptual problemsDecrease client’s sensoriperceptual problemsDecrease client’s sleep deprivationDecrease client’s sleep deprivation



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ICU Effects on FamilyICU Effects on Family

Fear of death of loved oneFear of death of loved oneAnxious about equipmentAnxious about equipmentAnxious about client’s potential for painAnxious about client’s potential for painWorry about finances and changes in family rolesWorry about finances and changes in family roles



Worry about finances and changes in family rolesWorry about finances and changes in family roles

Interventions with Family Interventions with Family

Give status reportsGive status reportsGet involved in client’s careGet involved in client’s careAssess for signs of exhaustionAssess for signs of exhaustionObtain resources and referrals as neededObtain resources and referrals as needed



Obtain resources and referrals as neededObtain resources and referrals as needed

Organ DonationOrgan Donation

Consent may be given by client, spouse, adult child, Consent may be given by client, spouse, adult child, parent, adult sibling, guardianparent, adult sibling, guardianOrgans that can be donated: Organs that can be donated:

kidneys, heart, lungs, pancreas, intestines, liver, corneas, kidneys, heart, lungs, pancreas, intestines, liver, corneas,



y , , g , p , , , ,y , , g , p , , , ,bones, bone marrow, skinbones, bone marrow, skin

Encourage client and family to ask questions and Encourage client and family to ask questions and express feelingsexpress feelings

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Organ DonationOrgan Donation

Provide support by a grief counselor or clergyProvide support by a grief counselor or clergySignature must be obtained for organ donationSignature must be obtained for organ donationClient must be brain deadClient must be brain deadNotify Organ Procurement Organization withNotify Organ Procurement Organization with



Notify Organ Procurement Organization with Notify Organ Procurement Organization with decision to proceeddecision to proceed

BOX 13BOX 13--1111 Brain Death Criteria.Brain Death Criteria.



Shock - Quia

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