Shock Hypvolemic Cardiogenic Distributive

Shock
Shock - life threatening condition involving almost every organ system. - a problem of inadequate tissue perfusion due to inadequate blood flow to tissues. Therefore no oxygen going to cells. Types of Shock - Hypovolemic - Cardiogenic - Distributive

Shock
HYPOVOLEMIC SHOCK Decreased blood flow and tissue perfusion are due to intravascular volume depletion. Causes : Hemorrhage internal or external Pooling of fluids in the interstitial space eg. thermal injuries bacterial toxins Pooling of fluid in third spaces eg. fluid in peritoneal cavity

**MOST COMMON CAUSE = LOSS OF WHOLE BLOOD

Shock
HYPOVOLEMIC SHOCK - Assess fluid status - Intake and output - Daily weights - Insensible losses - Surgical dressings - Mark the outline from drains or hematomas - Chest tube drainage Bleeding: pressure to site notify housestaff rapid replacement of fluids (IV)

Shock
CARDIOGENIC SHOCK Shock caused by impaired pumping ability of the heart. The most common form is left ventricular failure.

TWO TYPES OF CARDIOGENIC SHOCK : - Coronary cardiogenic shock - Non-coronary cardiogenic shcok

Shock
Coronary Cardiogenic Shock Obstruction of coronary artery by atherosclerotic plaque interrupts blood flow to the heart muscle Non-coronary Cardiogenic Shock Poor cardiac function in the absence of coronary artery disease. Cardiomyopathies-disease of the heart muscle cell that impair contraction. Valvular heart disease-stenosis, regurgitation Tamponade-condition in which blood rapidly fills the pericaprdial sac causing the ventricles to be compressed resulting in inadequate filling.

Shock
CARDIOGENIC SHOCK - Attempt to minimize further infarction size of MI - Use calm attitude to alleviate pts fears thus decreasing O2 needs to the heart - Pain relief immediately - Administer O2 - Limit activity

Shock
DISTRIBUTIVE SHOCK - Characterized by massive vasodilitation (alteration in blood vessel size) with poor flow to tissues despite a normal or even increased cardiac output. - Neurogenic shock (loss of sympathetic tone) - Anaphlactic shcok (increased capillary permeability) - Septic shock (MOST COMMON from overwhelming infection)

Shock
PATIENTS AT RISK FOR SHOCK Hypovolemic Shock Trauma Post operative Severe diarhea and vomiting Athersclerotic disease e.g. acute myocardial infractions with loss of >40% left ventricular mass Extremes of age Malnutrition Chronic Illness Pregnancy

Cardiogenic Shock

Septic Shock

Shock
NEUROGENIC SHOCK - careful immobilization of spinal cord injuries ASAP - increase head of bed 15-20o post spinal anaesthetic

ANAPHALACTIC SHOCK - know patients allergies - administer IV drugs carefully - thorough checking when administering blood products

Shock
SEPTIC SHOCK - protect patient from invading pathogens by using asceptic technique during procedures - handwashing between patients - line care asceptic - monitor temperature - monitor WBC

Shock
PROGRESSION OF SHOCK - Initial stage - Compensatory stage - Progressive stage - Refractory stage Initial Stage Cardiac output and tissue perfusion are decreased Decrease in O2 begins to alter cellular function Aerobic metabolism decreases Anerobic metabolism increases causing excess lactic acid

Shock
COMPENSATORY STAGE As cardiac output and blood pressure decrease compensatory mechanisms try to restore cardiac output and tissue perfusion to vital organs Increased heart rate (activation of sympathetic nervous system) fight or flight Fluid retention kidneys try to retain Na and H2O by decreased urine output and salt excretion. (ADH and adosterone) Vasoconstriction adrenal medulla secretes epinephrine and norepinephrine

Shock
COMPENSATORY STAGE cont d Anterior pituitary gland secretes ACTH causing glycogenolysis therefore increasing blood sugar CLINICAL MANIFESTATIONS OF COMPENSATORY STAGE - Decreased BP and increased NR (>100) - Skin is cool and moist - Peripheral pulses are weak and rapid - Urine output decreased <30/hr - Bowel sounds hypoactive contd

Shock
CLINICAL MANIFESTATIONS OF COMPENSATORY STAGE cont d - Slight alteration in level of consciousness (restless, confusion but still able to respond appropriately to commands) - Increased RR > 20/min (poor gas excahnge) - Lab Increased glucose Decreased pO2 Decreased pCO2 Increased pH

Shock
PROGRESSIVE STAGE Compensatory mechanisms are unsuccessful in maintaining perfusion to vital organs. Organs become ischemic causing multiple organ system failure. Capillaries lose their ability to regulate flow Fluid moves into interstitial compartment-edema Microemoli cause further damage to tissue Dysrhythmias and MI cause further decrease in blood flow

Shock
CLINICAL MANIFESTATIONS OF PROGRESSIVE SHOCK - Decreased BP <80mm Hg and heart rate (irregular) - Peripheral pulses thready or even absent - Ischemia of fingers and toes - Skin cold and cyanotic - No longer responds to verbal commands - Renal tubules become ischemic (ATN) - urine output <20/hr - increased urea and creatinine in blood contd

Shock
CLINICAL MANIFESTATIONS OF PROGRESSIVE SHOCK cont d - Ischemia of stomach and intestines may cause loss of bowel sounds and GI bleeding - Jaundince from liver failure - bilirubin, liver enzymes (AST<ALT), ammonia and lactic acid accumulate in blood - Patient fatigues and hypoventilates with ensuring respiratory failure (shock lung or ARDS) from decreased pulmonary capillary blood flow and increased capillary permeability pO2 decreased and pC02 increased

Shock
REFRACTORY STAGE Final stage of shock Not responsive to treatment Death is inevitable NURSING MANAGEMEMT Monitor those at risk by: thorough nursing history thorough assessment careful and repeated observation

Burns
CLASSIFACTION OF BURN SEVERITY Burn depth (partial thickness or full thickness) Partial = 1st and 2nd degree burns Full = 3rd and 4th degree burns Burn size (percent of injured skin excluding 1st degree burns) Determined most commonly by Rule of Nines Rule of nines is a quick way to estimate burn size. (the body is divided into anatomic sections each of which represents 9% multiples of 9% of the total body area. contd

or surface

Burns
CLASSIFACTION OF BURN SEVERITY cont d Burn location (Determines what potential complications may be) Age of burn victim (higher risk of death for children under 4 years and adults older than 65 years) General health of burn victim (affect response to injury and treatment) Mechanism of injury (depending what caused burn will determine treatments) ie. Special consideration will be given to someone with an inhilation burn)

Burns
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Burns
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Burns
NURSING CARE OF CLIENTS WITH BURNS Categories: 1. Thermal (exposure to flame or hot liquids) 2. Chemical Burns (exposure to strong acids or organic compounds) 3. Electrical (caused by heat that is generated by electrical energy) 4. Radiation (exposure to radioactive source) (nuclear and sun)

Burns
NURSING CARE OF CLIENTS WITH BURNS cont d Nursing Care: 1. Evaluation of ABCs 2. Initiation of fluid ressucitation (IV therapy) Large bore needle with suture. Central line. 3. Insertion of Foley catheter (hourly output) 4. Nasogastric tube insertion (pt NPO and develop intestinal ileus) contd

Burns
NURSING CARE OF CLIENTS WITH BURNS cont d 5. Vital signs and lab values BUN CR, Electrolytes, CBC, ABGs Chest X-ray, EKG 6. Pain and wound care (IV Narcotics NOT IM or SC) (sterile technique) 7. Psychological support (assist to deal with anxiety of both client and family) Debridement involves removal of the eschar - done to promote wound healing and prevent bacterial infections (Mechanical, Enzymatic and Surgical)

Burns
DRESSINGS 1. Topical antimicrobial agents are applied in both types of dressings. 2. Open Dressing cream is applied - advantage of visualization of wound - greater mobility of joints - simpler wound care

contd

Burns
DRESSINGS cont d 3. Closed Dressing cream applied - gauze dsg from distal to proxiamal - advantage is there is less evaporation of fluid and heat loss - disadvantage is that movement is restricted - less access to wound visualization

contd

Burns
NUTRITIONAL SUPPORT 1. Tube feeding to promote wound healing. 2. Total parenteral nutrition via central line. (watch for glucose levels with burn pts) WOUND CLOSURE 1. Autographs (use of clients own unburned skin) 2. Cultured Epithelial Autografts (limited success) (Need to watch for bleeding, positioning of client and signs of infection post grafting)