Elsevier items and derived items © 2006 by Elsevier Inc. Shock and Multisystem Failure.

Elsevier items and derived items © 2006 by Elsevier Inc.

Shock and Multisystem Failure


Shock

• Can occur when any part of the cardiovascular system does not function properly for any reason

• Begins with abnormal cellular metabolism that occurs when too little oxygen is delivered to tissues

• Review of tissue perfusion

• Can occur when any part of the cardiovascular system does not function properly for any reason

• Begins with abnormal cellular metabolism that occurs when too little oxygen is delivered to tissues

• Review of tissue perfusion


Processes of Shock

• Initial stage (early shock)

• Nonprogressive stage (compensatory stage)

• Progressive stage (intermediate stage)

• Refractory stage (irreversible stage)

• Initial stage (early shock)

• Nonprogressive stage (compensatory stage)

• Progressive stage (intermediate stage)

• Refractory stage (irreversible stage)


Multiple Organ Dysfunction Syndrome

• Cell damage is caused by the massive release of toxic metabolites and enzyme.

• Metabolites trigger small clots to form that block tissue oxygenation and damage more cells, continuing the devastating cycle.

• Cell damage is caused by the massive release of toxic metabolites and enzyme.

• Metabolites trigger small clots to form that block tissue oxygenation and damage more cells, continuing the devastating cycle.


Hypovolemic Shock

• Occurs when low circulating blood volume causes a mean arterial pressure decrease; the body’s oxygen need is not met

• Caused by external hemorrhage; common after trauma and surgery or reduction in levels of clotting factors

(Continued)

• Occurs when low circulating blood volume causes a mean arterial pressure decrease; the body’s oxygen need is not met

• Caused by external hemorrhage; common after trauma and surgery or reduction in levels of clotting factors

(Continued)


Hypovolemic Shock (Continued)

• Caused by internal hemorrhage as occurs with blunt trauma, gastrointestinal ulcers, and poor control of surgical bleeding

• Caused by internal hemorrhage as occurs with blunt trauma, gastrointestinal ulcers, and poor control of surgical bleeding



Cardiogenic Shock

• Actual heart muscle is unhealthy and pumping is directly impaired.

• Cardiac output and afterload are reduced, thus reducing mean arterial pressure.

• Actual heart muscle is unhealthy and pumping is directly impaired.

• Cardiac output and afterload are reduced, thus reducing mean arterial pressure.


Distributive Shock

• Caused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, and increased blood vessel permeability

• Neural-induced distributive shock

• Chemical-induced distributive shock

(Continued)

• Caused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, and increased blood vessel permeability

• Neural-induced distributive shock

• Chemical-induced distributive shock

(Continued)


Distributive Shock (Continued)

• Anaphylaxis

• Sepsis

• Capillary leak syndrome

• Anaphylaxis

• Sepsis

• Capillary leak syndrome


Obstructive Shock

• Shock is caused by problems that impair the ability of the normal heart muscle to pump effectively.

• Heart is normal but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle.

• Shock is caused by problems that impair the ability of the normal heart muscle to pump effectively.

• Heart is normal but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle.


Physical Assessment/Clinical Manifestations

• Cardiovascular changes

• Pulse

• Blood pressure

• Oxygen saturation

• Skin changes

• Respiratory changes

• Renal and urinary changes

• Central nervous system changes

• Musculoskeletal changes


• Pulse

• Blood pressure

• Oxygen saturation

• Skin changes


• Renal and urinary changes

• Central nervous system changes

• Musculoskeletal changes


Interventions

• Reverse the shock.

• Restore fluid volume.

• Prevent complications through supportive and drug therapies.

• Nonsurgical management includes oxygen therapy, fluid replacement, and monitoring.

• Reverse the shock.

• Restore fluid volume.

• Prevent complications through supportive and drug therapies.

• Nonsurgical management includes oxygen therapy, fluid replacement, and monitoring.


Drug Therapies

• Vasoconstrictors, such as dopamine, epinephrine, norepinephrine, phenylephrine

• Agents that enhance contractility

• Agents that enhance myocardial perfusion

• Vasoconstrictors, such as dopamine, epinephrine, norepinephrine, phenylephrine

• Agents that enhance contractility

• Agents that enhance myocardial perfusion


Collaborative Management of Septic Shock

• Manifestations of the first phase: unique to septic shock and often opposite from those seen with all other types of shock



• Skin changes: in the hyperdynamic phase of septic shock, the skin is warm with no cyanosis evident

• Manifestations of the first phase: unique to septic shock and often opposite from those seen with all other types of shock



• Skin changes: in the hyperdynamic phase of septic shock, the skin is warm with no cyanosis evident


Interventions for Septic Shock

• Focus on correcting conditions causing shock and preventing complications.

• Give oxygen therapy.

• Drug therapy: antibiotics and anticoagulants, clotting factors and blood products, activated protein C, and antibodies, such as interleukin-1, interleukin-6, and tumor necrosis factor

• Focus on correcting conditions causing shock and preventing complications.

• Give oxygen therapy.

• Drug therapy: antibiotics and anticoagulants, clotting factors and blood products, activated protein C, and antibodies, such as interleukin-1, interleukin-6, and tumor necrosis factor


Infusion Therapy


Parenteral Nutrition

• Formulas: dextrose, protein, fat, vitamins, and numerous trace elements tailored to the specific metabolic needs of the client

• Only used when the gastrointestinal tract cannot be used

• Central

• Peripheral

• Formulas: dextrose, protein, fat, vitamins, and numerous trace elements tailored to the specific metabolic needs of the client

• Only used when the gastrointestinal tract cannot be used

• Central

• Peripheral


Blood Transfusions and Other Components

• Packed red blood cells

• Platelets

• Fresh frozen plasma

• Albumin

• Several specific clotting factors

• Packed red blood cells

• Platelets

• Fresh frozen plasma

• Albumin

• Several specific clotting factors


Medications

• IV medications provide a rapid therapeutic effect but can also lead to immediate serious reactions.

• Prescription for infusion therapy is necessary.

• IV medications provide a rapid therapeutic effect but can also lead to immediate serious reactions.

• Prescription for infusion therapy is necessary.


Vascular Access Device (VAD)

• Short peripheral catheters

– Superficial veins of the hand and forearm

– Dwell for 72 to 96 hours and then require removal and insertion into another venous site

• Complaints of tingling, feeling of “pins and needles” in the extremity, or numbness during the venipuncture can indicate nerve puncture.

• Short peripheral catheters

– Superficial veins of the hand and forearm

– Dwell for 72 to 96 hours and then require removal and insertion into another venous site

• Complaints of tingling, feeling of “pins and needles” in the extremity, or numbness during the venipuncture can indicate nerve puncture.



Midline Catheter

• Catheter that is 6 to 8 inches long, inserted through veins of the antecubital fossa

• Used for therapies lasting from 1 to 4 weeks

• Should not be used for infusion of vesicant medications, which can cause tissue damage if they escape into the subcutaneous tissue (extravasation)

• Catheter that is 6 to 8 inches long, inserted through veins of the antecubital fossa

• Used for therapies lasting from 1 to 4 weeks

• Should not be used for infusion of vesicant medications, which can cause tissue damage if they escape into the subcutaneous tissue (extravasation)


Peripherally Inserted Central Catheter (PICC)

• Length ranges from 40 to 65 cm.

• Basilic vein is the preferred site for insertion; cephalic vein can be used.

• Placement is confirmed by chest x-ray examination.

• No information is available on optimal dwell time.

• Teach clients to perform normal ADLs, avoiding excessive physical activity.

• Length ranges from 40 to 65 cm.

• Basilic vein is the preferred site for insertion; cephalic vein can be used.

• Placement is confirmed by chest x-ray examination.

• No information is available on optimal dwell time.

• Teach clients to perform normal ADLs, avoiding excessive physical activity.



Nontunneled Percutaneous Central Catheter

• Inserted through subclavian vein in the upper chest or jugular veins in the neck

• Usually 15 to 20 cm long

• Tip resides in the superior vena cava

• Placement confirmed by chest x-ray examination

• No recommendations for optimal dwell time

• Inserted through subclavian vein in the upper chest or jugular veins in the neck

• Usually 15 to 20 cm long

• Tip resides in the superior vena cava

• Placement confirmed by chest x-ray examination

• No recommendations for optimal dwell time


Tunneled Central Catheter

• A portion of the catheter lying in a subcutaneous tunnel separates the points at which the catheter enters the vein from where it exits the skin.

• Tunneled central catheter is used for infusion therapy that is frequent and long-term.

• A portion of the catheter lying in a subcutaneous tunnel separates the points at which the catheter enters the vein from where it exits the skin.

• Tunneled central catheter is used for infusion therapy that is frequent and long-term.


Implanted Port

• Implanted ports consist of a portal body, a dense septum over a reservoir, and a catheter.

• A subcutaneous pocket is surgically created to house the port body.

• Port is usually placed in the upper chest or the upper extremity

• Port needs to be flushed after each use and at least once a month between courses of therapy.

• Implanted ports consist of a portal body, a dense septum over a reservoir, and a catheter.

• A subcutaneous pocket is surgically created to house the port body.

• Port is usually placed in the upper chest or the upper extremity

• Port needs to be flushed after each use and at least once a month between courses of therapy.



Dialysis Catheter

• Lumens are very large to accommodate the hemodialysis procedure or a pheresis procedure that harvests specific blood cells.

• This catheter should not be used for administration of other fluids or medications, except in an emergency.

• Lumens are very large to accommodate the hemodialysis procedure or a pheresis procedure that harvests specific blood cells.

• This catheter should not be used for administration of other fluids or medications, except in an emergency.


Infusion System

• Containers

• Administration sets

• Add-on systems

• Needleless connection devices

• Rate controlling devices:

– Controller

– Pumps

• Syringe pumps

• Ambulatory pumps

• Containers

• Administration sets

• Add-on systems

• Needleless connection devices

• Rate controlling devices:

– Controller

– Pumps

• Syringe pumps

• Ambulatory pumps


Catheter Care and Maintenance

• Educating the client

• Confirming tip location

• Performing the nursing assessment

• Securing and dressing the catheter

• Changing administration sets and needleless connectors

• Controlling infusion pressure(Continued)

• Educating the client

• Confirming tip location

• Performing the nursing assessment

• Securing and dressing the catheter

• Changing administration sets and needleless connectors

• Controlling infusion pressure(Continued)


Catheter Care and Maintenance (Continued)

• Flushing the catheter

• Obtaining blood samples from the catheter

• Removing the catheter

• Flushing the catheter

• Obtaining blood samples from the catheter

• Removing the catheter


Considerations for Older Adults

• Skin care precautions

• Vein and catheter selection

• Cardiac and renal changes

• Skin care precautions

• Vein and catheter selection

• Cardiac and renal changes


Alternative Sites for Infusion

• Arterial therapy

• Intraperitoneal infusion

• Subcutaneous infusion

• Intraspinal infusion

• Intraosseous therapy

• Arterial therapy

• Intraperitoneal infusion

• Subcutaneous infusion

• Intraspinal infusion

• Intraosseous therapy

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Elsevier items and derived items © 2006 by Elsevier Inc. Shock and Multisystem Failure.

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