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Case Study A
! Client A is a 76 year old female brought in by EMS to

http://www.lovelivehealth.com/how-to-improve-your-blood-circulation/

Shock

RAJANI

GEORGE, BSN, RN

the ER from a skilled nursing facility with C/O

abdominal pain X 2 days, shortness of breath (SOB),
bilateral lower extremity edema, lethargy, and
diaphoresis.
! In the ER
! What

assessments will the nurse perform?

other assessment data does the nurse need to care for this
patient?
! What medications can the nurse anticipate to administer?
! What

abdominal pain? you can not give pain meds bc they will mask
symptoms.

Case Study A

! Allergic

to PCN and shellfish.

! PMH: DM2, CRF, CVA with left hemiparesis, MI X 2, HTN,
Hyperlipidemia,
! Diagnostic tests in ER
X-Ray, Echocardiogram
" Labs: CBCP, CMP, Coags, BNP, Blood culture X2, UA and UC

Learning Objectives
! Describe shock and its underlying pathophysiology.
! Describe stages of shock.
! Describe Hypovolemic, Cardiogenic, Circulatory shock.
! Discuss the role of nurse in care of patients in shock.

" Chest

! Admitted

to telemetry unit with diagnosis of CHF and UTI

! What should be the nurses priorities for this patient care ?

inadequate tissue perfusion! its going to cause impaired

cellular metabolism. if not fixed the cells are going to die.
(Hinkle & Cheever, 2014, pp. 285-309)

make sure shes on tele

Shock
! Definition: A life threatening condition that results from

inadequate tissue perfusion causing impaired cellular

metabolism and cell death.
! Tissue perfusion requires
! Sufficient

blood flow
circulatory system
! Effective cardiac pump
! Adequate

tissue problems: tank, pump, pipe

you need sufficient blood flow (tank) (4-8L)
heart- adequate circulatory system (pump)
effective cardiac pump

who is at risk for shock? (so you can monitor)

older adults, younger children, heart failure, MI (anything
effecting the pump), clots, perforations,
immunocompromised pt, burn pts.
Tissues are hypo perfused- HYPERmetatabolism of cells

Pathophysiology Review
! Normal Cellular Function
! Aerobic and Anaerobic metabolism
! Cellular Changes
! Figure 14.1 in Hinkle and Cheever, p. 287
! Vascular Responses
! Vasodilation or Vasoconstriction
! Blood pressure Regulation
! Cardiac Output (co), Mean arterial pressure (MAP)
(Hinkle & Cheever, 2014, pp. 286-287)

normal cellular function: ATP (energy is needed to active

transport)- aerobic (needs oxygen = more ATP) if you
make anaerobic you also have lactic acid and produce less
ATP.
cellular changes: sodium water pump - sodium goes into
cell so does water! but theres no oxygen is it is impaired.
so cells swell and burst = sodium goes into blood system!
vascular: if your body is constricting it has problems with
heart, pump. If dilates its something else.

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Nursing Diagnosis
! Acute pain
! Altered mental status
! Anxiety

Stages of Shock
! Compensatory stage early stage of shock
! Body attempts to maintain adequate cardiac output and tissue perfusion
! Blood is shunted to vital organs
" Away

! Decreased cardiac output

! Deficient fluid volume
! Ineffective breathing pattern
! Ineffective tissue perfusion
! Risk for Infection

You have volume going into your heart. the blood is

going to heart, lungs, brain, kidneys, GI, skin!

from skin, gastrointestinal (GI)

brain, heart, lungs, kidneys, liver

" Towards

! Early intervention
! Identify cause of shock, administer intravenous (IV) fluids, oxygen,
medications, transfusion, laboratory tests, and diagnostic tests

compensatory stage: bp is normal = pt is beginning to

show some signs of hypo-perfusion = tachycardia to
compensate to keep blood flowing to vital organs. skin
will be cold, clammy, pale.
Urinary output.
(Hinkle & Cheever, 2014, pp. 288-290)

During shock: blood will go to brain, heart, lungs,

kidneys, but is going to shunt blood away from skin
and GI bc its less important.

Nursing Interventions
! Hemodynamic
!

status

Report systolic BP < 90 mm Hg, decreased or narrowing of pulse

pressure

! Oxygenation
! Supplemental oxygen
! Clinical findings
! Change in affect, agitation, anxiety, confusion, fatigue, malaise,
tachycardia, tachypnea, cold clammy skin, decreased urine output,

need to get oxygen, retake B/P,

Stages of shock
! Progressive Stage
Body starts to loose its ability to regulate BP
Cardiac pump failure
! Capillary permeability increases and fluid leaks out of cells
! Inflammatory response to injury is activated
!
!

! Medical management
Support the respiratory system
Optimize intravascular volume
! Support cardiac pump action
! Improve vascular system function
!
!

(Hinkle & Cheever, 2014, pp. 290-292)

body is running a marathon. Lose ability to regulate B/P.

cardiac pump failure heart is getting tired. inflammatory
response. Support respiratory etc.

Nursing Interventions
! Collaboration with other health care team
! Patients monitored in intensive care unit (ICU)
! Preventing complications
! Respiratory effects
! Cardiovascular effects
! Neurological effects
! Renal effects
! Gastrointestinal effects
! Hematological effects

Stages of shock
! Irreversible (refractory) Stage
! Organ damage is so severe that the body does not respond to
treatment to survive
! Medical management strategies depends on the bodys response to
treatment

(Hinkle & Cheever, 2014, pp. 292-293)

! Supporting family

to prevent further resp you need oxygen (way more than

2L) she may need cpap/intubation. crackles in lungs is
progressive stage = fluid backup. increased carbon
dioxide. hypo perfused aveoli = no surfactant so your
aveoli collaspes = dead space = ards.
MAP = where heart is going to shunt blood. map>65.
cardiac biomakers: cmp etc.
renal: when map is less than 65=kidney injury
serum creatinine: decreases
electrolyte imbalances.

liver: metabolism is impaired. jaundice = bilirubin ^

GI: blood is not going to be shunt there. There is
ischemic bc no perfusion = blood diarrhea. bacterica in
GI is compromised other bacteria take over and take
over lymphatic system.
hemo: DIC- could cause shock or be a side effect of
shock. eccmosys and bruising, petechia. platelets may
be consumed by the body = you need more platelets.
Once organs are damaged its irreversible.

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Nursing Interventions

Classification of Shock

probs with the tank

! Preventing complications

! Hypovolemic- reduction in effective circulating volume

! Supporting family

! Cardiogenic- failure of cardiac pump

! Engaging with palliative care specialists

! Circulatory (distributive) - vasodilation and peripheral

pooling
! Septic
! Anaphylactic
! Neurogenic

Hypovolemic Shock
! Most common
! Decreased intravascular volume by 15% to 30%
! External fluid losses
! Trauma, surgery, vomiting, diarrhea, diuresis, diabetes insipidus
! Internal fluid shifts
! Hemorrhage, burns, ascites, peritonitis, dehydration, severe
edema

Hypovolemic shock
! Medical Management
! Treat underlying cause
" Hemorrhaging" Diarrhea

Fluid and blood replacement

" IV/IO

access
(LR or 0.9% sodium chloride)
" Colloids ( albumin, packed red blood cells)
" Crystalloids

!
(Hinkle & Cheever, 2014, pp. 295-298)

vomiting, diarrhea, trauma, burns, bleeding.

Redistribution of fluid
" Positioning

intraosseous:IV access to bone, when you cant get

peripheral access.
crystlloids: usually normal saline or LR.
colliods: albumin-pulls fluids from extravascular space
to intravascular space.
get foley cath bc of all the fluids you give
elevate legs up: bc you get a pooling of fluids on feet
so you wanna bring it back to your hearrt

Hypovolemic Shock
! Clinical Findings
! Anxiety
neuro system:
! Decreased level of consciousness
! Poor capillary refill
decrease blood flow
! Pale, gray skin
! Tachycardia
! Hypotension bc youre working with less
! Tachypnea
! Collapsed neck vein no fluid!
! Decreased urine output or oliguria

interventions to stop bleeding

or vomiting- medications

Nursing Interventions
! Identify at risk patients
! Administer volume replacement fluids
! Monitor for complications of treatment
! Fluid

overload, difficulty breathing, pulmonary edema,

decreased urine output, hypothermia

fluids

elderly= esp in extreme weather

still havent produced urine even with fluid = fluid is not
working!!! do something else.

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Cardiogenic shock
! Hearts ability to contract and pump blood is impaired

and the supply of oxygen is inadequate for heart and

tissues

! Coronary causes
! Acute

MI (anterior wall)
! Non-coronary causes
! Severe hypoxemia, acidosis, hypoglycemia, hypocalcemia,
tension pneumothorax,
! Ineffective myocardial function (cardiomyopathies, valvular
damage, cardiac tamponade, dysrhythmias

cardiac tamponade: pleura around heart is filled with

fluid so heart cannot pump.

Medical Management
! Goal limit further myocardial damage, preserve the

healthy myocardium, improve cardiac function

!

Increase oxygen supply to the heart muscle while reducing

oxygen demand

! Correct the underlying causes

! Coronary
" Thrombolytic/fibrinolytic

therapy, PCI, CABG, intra-aortic balloon

pump
!

Non-coronary
" Valve

replacement, dysrhythmia correction,

(Hinkle & Cheever, 2014, pp. 298-300)

Cardiogenic Shock
! Clinical Findings
! Hypotension
! Confused, restless
! Shallow, rapid respirations
! Distended neck veins fluid backup!
! Oliguria
! Cold clammy extremities
! Low temperature
! Crackles fluid backup
! Heart sounds distant in tamponade

vasocontriction: bc its shunting blood to vital organs

Pharmacological Therapy
! Goal- improve cardiac contractility, decrease preload and

afterload, and stabilize heart rate and rhythm.

! Inotropic Agents
!

Dobutamine, Dopamine, Epinephrine, Milrinone

! Vasodilators
! Nitroglycerin, Nitroprusside
! Vasopressor Agents
! Norepinephrine, Dopamine, Phenylephrine, Vasopressin
! Antiarrhythmic
! Amiodarone, Metoprolol, Labetalol, Diltiazem
! Mechanical assistive devices

Medical Management
! First-Line Treatment
! Oxygenation
" Oxygen

saturation >90%

Pain control

vasodialation also! give after you get stable BP

" Morphine

Hemodynamic monitoring

Laboratory monitoring

Fluid Therapy Cautiously! initially keep bp to keep pt

" Assess

" BNP,

response to treatment, continuous ECG and ST

TELE

CKMB, TROP I

alive. Cpap

(Hinkle & Cheever, 2014, pp. 299)

Nursing Interventions
! Collaborating with other healthcare team
! Identify and monitor at-risk patients
! Monitor hemodynamic status
! Administer medications and IVFs
! Maintaining function of devices
! Safety and comfort

(Hinkle & Cheever, 2014, pp. 296, 299-300)

dobutamine: to try to keep bp up and hypotension will happen

though.
dopamine: in low amount helps with your kidneys.
nitro:

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Circulatory Shock
! Distributive Shock- intravascular volume pools in

Anaphylactic Shock
! Impaired tissue perfusion from antigen-antibody

peripheral blood vessels.

reaction that releases histamine into blood stream.

! Septic

! History

Shock
! Anaphylactic Shock
! Neurogenic Shock

PIPES
anything
thing that affects your circulatory system can put you
(Hinkle & Cheever, 2014, pp. 300-308)
into shock.

of medication sensitivity, transfusion reaction, reaction

to insect bites/stings, Latex sensitivity, Food/Nuts allergy

! Clinical findings
! Altered mental status, headache
! Stridor, tachypnea, wheezing
! Tachycardia, hypotension
! Hives, itching, flushed, warm skin
! Abdominal cramping, nausea, vomiting, diarrhea, chills

its vasodilatation! bc its distributive. its going everywhere.

blood going back to your heart is limited. less volume coming
back you have decreased cardio output. Less fluid coming back.
if you hear stridor call everyone! resp!

Neurogenic Shock
! Impaired tissue perfusion caused by damage to or

dysfunction of the sympathetic nervous system.

! Spinal

cord injury, Spinal anesthesia, depressant action of

medications, trauma

! Clinical findings
! Restlessness, confusion, paralysis, nausea, vomiting
! Warm, dry skin, no sweating ( altered temperature-regulating
center)
! Hypotension, bradycardia, decreased urinary output
! Apnea, tachypnea, diaphragmatic breathing

Review Question
A patient is receiving treatment for hypovolemic shock
due to severe diarrhea and vomiting. The nurse expects
what type of fluid to be administered? Select all that
apply.
A. Albumin
B. Fresh frozen plasma
C. Lactated Ringers (LR)
D. 0.9% Normal Saline
E. Packed Red Cells
c&d

Review Question
A nurse is following the progress of a client being
treated for cardiogenic shock. Which findings
indicate that the treatment has been inadequate?
Select all that apply.
A. Crackles
B. Decreased cardiac output
C. Blood pressure and HR is within normal limits
D. Oliguria

Case Study A
! Client A is transferred to ICU.
! What

assessments should be the nurses priority to care for this

patient?
! What diagnostic tests will the nurse anticipate to provide care?
! What multi-team collaboration is needed to care for this
patient?

abd

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SIRS and Sepsis

Surviving Sepsis Campaign

https://www.acep.org/sepsis/

http://www.acphospitalist.org/archives/2011/01/sepsis.htm

Learning Outcomes
! Describe Sepsis, Severe sepsis, and Septic shock
! Describe Systemic inflammatory response syndrome

(SIRS)
! Discuss the role of the nurse in the care of patient with
Sepsis

Systemic Inflammatory Response Syndrome (SIRS)

! A syndrome resulting from a severe clinical insult that

initiates an overwhelming inflammatory response by the

body in the absence of infection. Two or more of the
following condition
! Clinical signs and symptoms include
"Temperature

below 36C(96.8F) or above 38C(100.4F)

Rate above 90 beats/minute
"Respiratory Rate above 20 breaths/minute; or partial pressure
of arterial carbon dioxide (PaCO2) below 32 mmHg
"WBC below 4000 cells/mm, or above 12,000 cells/mm; or
the presence of more than 10% immature WBC (bands)
"Heart

(Hinkle & Cheever, 2014, pp. 301-306)

need two of these to meet the criteria for sepsis

SEPSIS

Severe Sepsis

! Associated with bodys overwhelming and life-

! Sepsis and signs of end organ damage, hypotension

threatening response to infection of the blood

! Leads to tissue damage, organ failure, and death
! 2 SIRS and confirmed/suspected infection
! Central Line-associated Bloodstream Infection
(CLABSI), urosepsis, infected wounds, burns, surgery
! The leading cause of death in ICU.

! Clinical findings
! Chills, tachypnea, unexplained alteration in mental status,
tachycardia, altered WBC, decreased urine output, skin mottling,
poor capillary refill, hypoglycemia, thrombocytopenia,
coagulation disorders, altered hepatic function

(SBP < 90), Lactate > 4 mmol

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Septic Shock
! Severe sepsis with persistent hypotension, signs of

end organ damage, Lactate > 4 mmol

! Clinical Findings
Cardiac-severe hypotension not responding to fluids, tachycardia,
hyperthermia, fever, warm, flushed skin, bounding pulses
! Neurologic- confusion, agitation
! Respiratory- tachypnea
! Renal- oliguria
! GI-decreased gastric motility, nausea, vomiting, diarrhea
!

take lactate levels

Surviving Sepsis Guidelines

! Early Goal Directed Therapy (EGDT)
! Hinkle & Cheever, 2014, pp. 303, chart 14-6
! Nursing Implications
! Rapid identification of infectious source-blood, urine, sputum,
wound, catheter tips for culture and sensitivity
! Administer IV fluids, antibiotics, blood transfusions, vasopressor
and inotropic agents within time frame
! Nutritional therapy- 24 to 48 hours
! Collaborate with other healthcare team
! Hyperthermia- monitor, management, and treatment

Multi Organ Dysfunction Syndrome(MODS)

! Definition: the presence of altered organ function in

acutely ill patients such that homeostasis cannot be

maintained without interventions.
! 15%

of all patients admitted to ICU

to 47% patients with multiple trauma
! 80% of all ICU deaths
! Mortality rates increases as the number of organs involved
increase
! Sequence of organ failure depends on the reserve of each
organ system.
! 20%

https://jhupbooks.press.jhu.edu/content/more-hot

Clinical Findings

Assessment

! Pulmonary- hypoxemia, hypercarbia, adventitious breath

! Physical Assessment- depend on organ system involved

sounds
! Hepatobiliary- elevated liver function tests,
hyperbilirubinemia, decreased albumin
! Gastrointestinal- bleeding, paralytic ileus, intolerance to
tube feeding
! Renal- increased creatinine levels, oliguria
! Neurology- altered level of consciousness
! Coagulation and Hematologic- thrombocytopenia
! Cardiovascular- hypotension, hypo-perfusion, tachycardia

! Inspection
! Restlessness, confusion, tachypnea, tachycardia, interstitial edema
! Palpation
! Rapid, weak, thready peripheral pulses, distended abdomen,
enlarged liver
! Percussion
! Dullness over areas of consolidation, pleural effusion
! Auscultation
! Crackles, absent bowel sounds, labile BP, reduced lung expansion

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Review Question
The ER nurse identifies the patient at risk for sepsis as,
select all that apply
A. An infant 3 months old with diarrhea and
vomiting
B. A 67 year old female undergoing chemotherapy
for breast cancer c/o chest pain
C. A 45 year old female hx of MVA and
quadriplegia, with stage III
decubitus
D. A 13 year old with mild allergic reaction to
peanut butter

Review Question
Hyperthermia is common in sepsis and raises the patients
metabolic rate and oxygen consumption. What statement by
the nurse is indicative of understanding the management of
fever in a septic patient. Select all that apply.
A. Fever is one of bodys natural mechanism for fighting
infections.
B. Treatment with acetaminophen will be initiated if
Temperature is above 40C(104F) or by using
hypothermia blanket.
C. Shivering does not influence treatment.
D. Monitor core temperature hourly.

Chest Trauma

Learning Outcomes
! Discuss types of chest trauma
! Describe flail chest
! Describe the role of nurse in the care of patient with

flail chest

http://alexisartscience.blogspot.com/2011/01/blunt-trauma-tochest.html

Chest Trauma
! Thoracic Injuries
! Trauma

to chest and lungs affects

" Inspiration
" Gas

Blunt trauma
! Common Causes
! Automobile

crashes (steering wheel, seat belt), bicycle

crashes, falls, assaults, explosions

exchange

" Expiration

! Treatment

and management depends on the type and extent of

injury
! Approximately 16,000 deaths in U.S. alone
! Improved prehospital and peri-operative care in trauma centers

! Types of blunt chest trauma

! Chest

wall fractures, rib fractures, dislocations, barotrauma,

pleura, lungs, digestive tracts, heart, arteries, veins, and
lymphatic system

(Hinkle & Cheever, 2014, p. 610-612)

(Hinkle & Cheever, 2014, p. 610-611)

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Diagnostics tests

Assessments
! Physical Assessment
! Inspection,

auscultation, palpation, vital signs

! Primary Assessment
! Airway

obstruction, tension pneumothorax, hemothorax,

flail chest, cardiac tamponade

! Secondary Assessment
! Pneumothorax,

! Chest X-Ray
! CT Scan
! Laboratory
!

CBC, Coagulation studies, TAS, ABG, CMP,

! ECG

hemothorax, pulmonary contusion, traumatic

aortic rupture

Flail Chest
! Complication of blunt chest trauma from a steering wheel

injury
! Multiple contiguous ribs (three or more adjacent rib
fracture)

Management
! Supportive
! Adequate ventilation- high flow O2, intubation
! Administration of humidified O2
! Fluid resuscitation-in absence of hypotension
! Pain management
" IV

opioids, epidural

! Clearing

secretions from lungs

http://www.mdct.com.au/joomla/chest/case-of-the-week-15/5/2008

! Chest wall loses stability causing respiratory distress

Penetrating trauma

Conclusion

! Common Causes
! Automobile

crashes, assaults, explosions, bullets, knives,

industrial accidents

! Types of injury
! Traumatic

Pneumothorax

"Open

Pneumothorax
"Tension Pneumothorax
! Cardiac

Tamponade
http://www.independent.com/news/2012/sep/13/defeating-deadlyinfections/

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References
! Blood circulation image. Retrieved from http://www.lovelivehealth.com/how-to-improve-your-

blood-circulation/
! Chest Trauma image. Retrieved from http://alexisartscience.blogspot.com/2011/01/blunt-trauma-

to-chest.html
! Defeating deadly infections cartoon image. Retrieved from
!
!
!
!
!
!
!

http://www.independent.com/news/2012/sep/13/defeating-deadly-infections/
Flail Chest image. Retrieved from http://www.mdct.com.au/joomla/chest/case-of-the-week15/5/2008
Flail Chest Video. Retrieved from https://www.youtube.com/watch?v=mJ_FYwUqzsM
Hinkle, J.L. & Cheever, K.H. (2014). Brunner and Suddarths Textbook of Medical Surgical
Nursing (13th ed.). Philadelphia: Lippincott Williams & Wilkins.
More than Hot Retrieved from https://jhupbooks.press.jhu.edu/content/more-hot
Sepsis image. Retrieved from http://www.acphospitalist.org/archives/2011/01/sepsis.htm
Surviving Sepsis Guideleines. Retrieved from
http://www.survivingsepsis.org/Guidelines/Pages/default.aspx
Surviving Sepsis Campaign image. Retrieved from https://www.acep.org/sepsis/

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