Shock and Shock and Multisystem FailureMultisystem Failure

Shock Shock

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

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

Review of tissue perfusionReview of tissue perfusion

Processes of ShockProcesses of Shock Initial stage (early shock)Initial stage (early shock) Nonprogressive stage Nonprogressive stage

(compensatory stage)(compensatory stage) Progressive stage (intermediate Progressive stage (intermediate

stage)stage) Refractory stage (irreversible Refractory stage (irreversible

stage)stage)

Multiple Organ Multiple Organ Dysfunction SyndromeDysfunction Syndrome

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

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

Hypovolemic ShockHypovolemic Shock Occurs when low circulating blood Occurs when low circulating blood

volume causes a mean arterial volume causes a mean arterial pressure decrease; the body’s pressure decrease; the body’s oxygen need is not metoxygen need is not met

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

(Continued)(Continued)

Hypovolemic Shock Hypovolemic Shock (Continued)(Continued)

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

Cardiogenic Shock Cardiogenic Shock Actual heart muscle is unhealthy Actual heart muscle is unhealthy

and pumping is directly and pumping is directly impaired.impaired.

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

Distributive Shock Distributive Shock Caused by loss of sympathetic tone, Caused by loss of sympathetic tone,

blood vessel dilation, pooling of blood vessel dilation, pooling of blood in venous and capillary beds, blood in venous and capillary beds, and increased blood vessel and increased blood vessel permeabilitypermeability

Neural-induced distributive shockNeural-induced distributive shock Chemical-induced distributive shockChemical-induced distributive shock

(Continued(Continued))

Distributive Shock Distributive Shock (Continued)(Continued)

AnaphylaxisAnaphylaxis SepsisSepsis Capillary leak syndromeCapillary leak syndrome

Obstructive Shock Obstructive Shock Shock is caused by problems that Shock is caused by problems that

impair the ability of the normal impair the ability of the normal heart muscle to pump effectively.heart muscle to pump effectively.

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

Physical Physical Assessment/Clinical Assessment/Clinical

ManifestationsManifestations Cardiovascular changesCardiovascular changes PulsePulse Blood pressureBlood pressure Oxygen saturationOxygen saturation Skin changesSkin changes Respiratory changesRespiratory changes Renal and urinary changesRenal and urinary changes Central nervous system changesCentral nervous system changes Musculoskeletal changesMusculoskeletal changes

Interventions Interventions

Reverse the shock.Reverse the shock. Restore fluid volume.Restore fluid volume. Prevent complications through Prevent complications through

supportive and drug therapies.supportive and drug therapies. Nonsurgical management Nonsurgical management

includes oxygen therapy, fluid includes oxygen therapy, fluid replacement, and monitoring.replacement, and monitoring.

Drug TherapiesDrug Therapies Vasoconstrictors, such as Vasoconstrictors, such as

dopamine, epinephrine, dopamine, epinephrine, norepinephrine, phenylephrinenorepinephrine, phenylephrine

Agents that enhance Agents that enhance contractilitycontractility

Agents that enhance myocardial Agents that enhance myocardial perfusionperfusion

Collaborative Collaborative Management of Septic Management of Septic

ShockShock Manifestations of the first phase: Manifestations of the first phase:

unique to septic shock and often unique to septic shock and often opposite from those seen with all opposite from those seen with all other types of shockother types of shock

Cardiovascular changesCardiovascular changes Respiratory changesRespiratory changes Skin changes: in the hyperdynamic Skin changes: in the hyperdynamic

phase of septic shock, the skin is phase of septic shock, the skin is warm with no cyanosis evidentwarm with no cyanosis evident

Interventions for Septic Interventions for Septic Shock Shock

Focus on correcting conditions causing Focus on correcting conditions causing shock and preventing complications.shock and preventing complications.

Give oxygen therapy. Give oxygen therapy. Drug therapy: antibiotics and Drug therapy: antibiotics and

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

Infusion Therapy Infusion Therapy

Parenteral NutritionParenteral Nutrition Formulas: dextrose, protein, fat, Formulas: dextrose, protein, fat,

vitamins, and numerous trace vitamins, and numerous trace elements tailored to the specific elements tailored to the specific metabolic needs of the clientmetabolic needs of the client

Only used when the Only used when the gastrointestinal tract cannot be gastrointestinal tract cannot be usedused

CentralCentral PeripheralPeripheral

Blood Transfusions and Blood Transfusions and Other ComponentsOther Components

Packed red blood cellsPacked red blood cells PlateletsPlatelets Fresh frozen plasmaFresh frozen plasma AlbuminAlbumin Several specific clotting Several specific clotting factorsfactors

MedicationsMedications IV medications provide a rapid IV medications provide a rapid

therapeutic effect but can also therapeutic effect but can also lead to immediate serious lead to immediate serious reactions.reactions.

Prescription for infusion therapy Prescription for infusion therapy is necessary.is necessary.

Vascular Access Device Vascular Access Device (VAD)(VAD)

Short peripheral cathetersShort peripheral catheters– Superficial veins of the hand and Superficial veins of the hand and

forearmforearm– Dwell for 72 to 96 hours and then Dwell for 72 to 96 hours and then

require removal and insertion into require removal and insertion into another venous siteanother venous site

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

Midline CatheterMidline Catheter Catheter that is 6 to 8 inches long, Catheter that is 6 to 8 inches long,

inserted through veins of the inserted through veins of the antecubital fossaantecubital fossa

Used for therapies lasting from 1 to 4 Used for therapies lasting from 1 to 4 weeksweeks

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

Peripherally Inserted Peripherally Inserted Central Catheter (PICC)Central Catheter (PICC)

Length ranges from 40 to 65 cm.Length ranges from 40 to 65 cm. Basilic vein is the preferred site for Basilic vein is the preferred site for

insertion; cephalic vein can be used.insertion; cephalic vein can be used. Placement is confirmed by chest x-Placement is confirmed by chest x-

ray examination.ray examination. No information is available on No information is available on

optimal dwell time.optimal dwell time. Teach clients to perform normal Teach clients to perform normal

ADLs, avoiding excessive physical ADLs, avoiding excessive physical activity.activity.

Nontunneled Percutaneous Nontunneled Percutaneous Central CatheterCentral Catheter

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

Usually 15 to 20 cm longUsually 15 to 20 cm long Tip resides in the superior vena cavaTip resides in the superior vena cava Placement confirmed by chest x-ray Placement confirmed by chest x-ray

examinationexamination No recommendations No recommendations for optimal dwell timefor optimal dwell time

Tunneled Central CatheterTunneled Central Catheter A portion of the catheter lying in A portion of the catheter lying in

a subcutaneous tunnel separates a subcutaneous tunnel separates the points at which the catheter the points at which the catheter enters the vein from where it enters the vein from where it exits the skin.exits the skin.

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

Implanted Implanted PortPort

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

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

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

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

Dialysis CatheterDialysis Catheter Lumens are very large to Lumens are very large to

accommodate the hemodialysis accommodate the hemodialysis procedure or a pheresis procedure procedure or a pheresis procedure that harvests specific blood cells.that harvests specific blood cells.

This catheter should not be used This catheter should not be used for administration of other fluids for administration of other fluids

or medications, except in an or medications, except in an emergency.emergency.

Infusion SystemInfusion System ContainersContainers Administration setsAdministration sets Add-on systemsAdd-on systems Needleless connection devicesNeedleless connection devices Rate controlling devices:Rate controlling devices:

– ControllerController– PumpsPumps

Syringe pumpsSyringe pumps Ambulatory pumpsAmbulatory pumps

Catheter Care and Catheter Care and MaintenanceMaintenance

Educating the clientEducating the client Confirming tip locationConfirming tip location Performing the nursing assessmentPerforming the nursing assessment Securing and dressing the catheterSecuring and dressing the catheter Changing administration sets and Changing administration sets and

needleless connectorsneedleless connectors Controlling infusion pressureControlling infusion pressure

(Continued)(Continued)

Catheter Care and Catheter Care and MaintenanceMaintenance (Continued)(Continued)

Flushing the catheterFlushing the catheter Obtaining blood samples from Obtaining blood samples from

the catheterthe catheter Removing the catheterRemoving the catheter

Considerations for Older Considerations for Older AdultsAdults

Skin care precautionsSkin care precautions Vein and catheter selectionVein and catheter selection Cardiac and renal changesCardiac and renal changes

Alternative Sites for Alternative Sites for InfusionInfusion

Arterial therapyArterial therapy Intraperitoneal infusionIntraperitoneal infusion Subcutaneous infusionSubcutaneous infusion Intraspinal infusionIntraspinal infusion Intraosseous therapyIntraosseous therapy