What is shock? - ANSWER-inadequate tissue perfusion
What is the patho of shock? - ANSWER-cellular changes, vascular
response, and changes in BP
What is the sequence of regulatory mechanisms in shock? -
ANSWER-FIGURE 11-2 in textbook
What are the three stages of shock? - ANSWER-Compensatory
Progressive
Irreversible
What is occurring in the compensatory stage of shock? - ANSWER--
Inadequate perfusion
-Increased respirations
-Anxiety
-Confusion
Clinical manifestations of compensatory stage of shock? - ANSWER-
*Fight of Flight Response*
-Normal BP
-HR >100, adequate CO
-RR > or equal to 22
,-Skin will be cold, clammy, shorter than 3.5 second cap refill
-decreased UOP
-agitated and confused
-respiratory alkalosis
What is the medical management for compensatory stage of shock? -
ANSWER--treat underlying cause
-replace fluids
-supplemental O2, decrease pt anxiety
-maintain BP and tissue perfusion
*early intervention is key to improving pt prognosis*
Nursing interventions for compensatory stage of shock? -
ANSWERComplete frequent assessments of your pt (risk for shock,
recognize subtle clinical signs of this stage prior to BP dropping)
-Monitor tissue perfusion (LOC, vitals, UOP, skin- cap refill & mottling,
RR, lab values)
*nurse should notify provider promptly if the pt exhibits any two of the
three signs- 1) RR greater than or equal to 22 2) altered mentation 3)
SBP less than or equal to 100 or drop of SBP of 40 or more from
baseline or MAP of 65 or less*
-reduce anxiety/ promote safety= pts who were previously cooperative
may now disrupt IV lines/ foleys, close monitoring/ hourly rounding/
frequent reorientation/ implementing fall prevention interventions -
advanced directives clarification
,What is occurring in the progressive stage of shock? - ANSWER--BP
no longer compensated (pt is clinically hypotensive)
-MAP below normal limits
-declining mental status
Clinical manifestations of progressive stage of shock? - ANSWER--
Rapid and shallow respirations, crackles
-Chest pain (increased cardia biomarkers)
-Changes in mental status, lethargy
-Acute kidney injury (decreased GFR), UOP greater than 0.5 mL/kg/hr
-Liver failure
-GI bleeding
-Abnormal bruising and petechiae with prolonged clotting times
-SBP less than or equal to 100
-HR greater than 150
-mottling, petechiae
-metabolic acidosis
What is the medical management for progressive stage of shock? -
ANSWER--treat underlying condition
-Restore tissue perfusion with fluid management (support resp
system, optimize intravascular volume, support pumping action of the
heart, improving competence of the vascular system)
-nutritional support for energy
-targeted hyperglycemic control via IV insulin and antacids, H2
blockers, antipeptic meds to reduce GI ulceration/ bleeding risk
Glycemic control is linked to outcomes in the pt in shock. Although
, tight glycemic control is not indicated, evidence shows serum
glucose less than BLANK is linked to best outcome? - ANSWER-180
Nursing interventions for progressive stage of shock? -
ANSWERassessment will have subtle changes (ABGs, hemodynamic
monitoring, ECG monitoring, mental status changes, serum
electrolytes)
-observe invasive vascular lines/ caths for signs of infection
-VAP= frequent oral care, aseptic suction technique, turning, elevating
HOB at least 30 degrees to prevent aspiration, sedation vacays
-positioning and repositioning pt to promote skin integrity
-promote rest and comfort to reduce stress, decreased chance of post
intensive care syndrome
What is occurring in the irreversible stage of shock? - ANSWER--
Severe organ damage
-Unable to maintain BP with treatment
-Unable to oxygenate with ventilatory support
-Unable to maintain MAP
-Multiple organ dysfunction
-Complete organ failure
Clinical manifestations of irreversible stage of shock? - ANSWER--BP
requires mechanical or pharm support; severe hypotension
-HR is erratic
-intubation and mech vent is required
-jaundice
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