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Flashcards in Week 4 --Hypovolemic Shock Deck (41)
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1

 

Hypovolemic Shock is caused by a decrease in intravascular volume of ____________

 

>15% or more

2

Normal cardiac output (L/min)

4-8 L/min

3

Causes (2) of Hypovolemic Shock

  • Loss of Blood Volume
    • Surgery
    • Burns
    • Trauma
    • Diabetes Ketoacidosis
  • LOSS OF FLUID
    • Diuresis
    • Vomiting
    • diarrhea

4

 

Medical Management of Hypovolemic Shock

  • GOALS of TX
    • Restore intravascular volume 
      • GOAL:  MAP > 65mmHg
    • Correct underlying cause as quickly as possible
      • HEMORRHAGE?
        • find and stop the bleeding
        • replace lost blood volume
      •   BURNS...?
        • treat fluid loss from burns
      • DEHYDRATION...?
        • Restore Plasma Volume
  • Initial TX:   
    • IV Fluid (2 L Crystalloids)
  • First Line Tx:
    • Blood products as indicated for blood loss or further IV crystalloid
  • Second Line Tx:
    • Norepinephrine
      • ​initiates peripheral vasoconstriction
    • Dopamine 
      • ​Low dose- increases renal perfusion
      • High dose-vasoconstriction effects-decreases renal perfusion
    • Epinepherine
      • ​Initiates peripheral Vasoconstriction
      • increased rate
      • increased contractility

5

1ST STEP IN THE TX PROCESS IS TO ADMINISTER FLUIDS

Fluids that are administered for

HYPOVOLEMIC SCHOCK

  • GOAL:  TO RESTORE INTRAVASCULAR COLUME TO MAINTAIN PERFUSION
  • CRYSTALLOIDS
    • Isotonic —> 0.9% NSS, Lactated Ringers
    • Hypertonic—>3% or 7.5% saline
  • BLOOD COMPONENTS
    • PRBC's, Platelets, FFP

6

2ND STEP IN THE TX PROCESS IS TO ADMINISTER VASOACTIVES

GOAL of VASOACTIVE medication

 

  • to improve hemodynamic stability when fluid therapy alone cant maintain adequate MAP (MAP <60 mmHg can indicate poor perfusion)

7

 

ACTIONS OF VASOACTIVES (4)

  1. Increase strength of myocardial contractility (stronger contractions)
  2. Reduce afterload
  3. Initiates Vasconstriction to increase preload
  4. Regulating HR to maintain Cardiac Output

8

 

Choice of Vasoactive medication is based on (2) things

  • TYPE OF SHOCK
    • If you are dealing with a cardiogenic shock that is impairing the hearts ability to contract....maybe you want a medication to help to strengthen contractility? Or maybe you want a medication that vasodilates to make it easier for the heart to work to keep it from becomming further damaged
  • DESIRED OUTCOME

9

 

What must be completed first...prior to giving vasoactive?

 

must replace fluid volume first!

 

**BECAUSE OTHERWISE WE ARE "CLAMPING DOWN" ON EMPTY VESSELS AND NOT BENEFITING THE PATIENT AT ALL

10

How are vasoactives typically administered?

why?

Via a central line because they tend to be "vessicants" which can cause great damage if it leaked into our tissues

 

***IF YOU MUST USE A PERIPHERAL LINE FOR ADMINISTRATION THAN YOU MUST MONITOR VERY CLOSELY FOR ANY SIGNS OF INFILTRATION

11

 

NURSING CONSIDERATIONS

(5)

when giving Vasoactives

  • FREQUENT MONITORING OF EFFECTIVENESS
    •  Regular titration may be needed based on the ever changing needs of the patient.
    • Monitor....BP, MAP, HR, Urine Output, MS changes, SpO2
  • MONITORING FOR INFILTRATION IF NOT RUNNING THROUGH CENTRAL LINE
  • ASSESS FOR DECREASED PERIPHERAL CIRCULATION
    • Frequent assessment of pulses, bowel sounds
  • CAREFUL ADMINISTRATION AS DOSAGES ARE OFTEN IN MCG/MIN; MCG/KG/MIN, ETC

12

 

What do "adrenergic" medications do?

 

 

  • mimic the fight /flight response of SNS by activating ALPHA and BETA receptors

13

 

Stimulation of the _________ Receptors initiates Peripheral Vasoconstriction (increasing Preload,CO, BP)

ALPHA Receptors

14

Stimulation of the BETA Receptors does what?

INCREASED FORCE and RATE OF MYOCARDIAL CONTRACTION *Increased Force (Contractility) also called INOTROPY *Increased Rate also called CHRONOTROPY

15

 

What is a INOTROPE?

an agent that alters the force (Contractility) of cardiac muscular contractions

16

 

What is CHRONOTROPIC?

a drug that alters the heart rate

17

 

Stimulation of these receptors will increase the FORCE (Contractility) and RATE of the myocardial contraction

 

 

BETA RECEPTORS

18

Three medications that will stimulate the ALPHA Receptors

Phenylepherine

Norepinepherine

Epinepherine

19

 

Three (3) medications that will stimulate the BETA Receptors

Dobutamine (INOTROPE)

Dopamine (INO, CHRONOTROP)

Epinepherine (INO, CHRONOTROP)

20

 

disadvantages of stimulating the ALPHA RECEPTORS in a patient with damaged heart?

 

 

Increased workload and Increased O2 demands of the heart from increasing the afterload Afterload was increased when the alpha receptors were stimulated---->leading to increased PRELOAD, CO and BP

21

NURSING MANAGEMENT OF HYPOVOLEMIC PATIENT

  • ASSESS / INTERVENE when Intravascular loss is evident
    • sudden drop in CVP
    • Decreased BP with S/S poor perfusion
    • Identify "at Risk" patients
      • multiple injuries
      • burns 
      • recently undergone surgery
      • pt on diuretics
      • Diabetes Insipidous patient
  • MONITOR PT'S RECEIVING VASCULAR REPLACEMENT
    • Frequent VS
    • Respiratory assessment
      • b/c if we are giving fluids back- we place the patient at risk for fluid volume overload
    • S/S of blood reaction
      • Febrile reaction 
        • increase in temperature 1° Celcius above their baseline
          • Give tylenol and continue with transfusion
      • Hemolytic Reaction
        • ​breakdown of RBC
          • ​Stop transfusion immediately!
  • LAB EVALUATIONS
    • ​Hemoglobin level is best for detecting blood loss
    • Loss > 2gm/dL indicates active blood loss

22

 

(5) AT RISK patients

for

Hypovolemic shock

1) multiple injuries

2) Burns

3) recently undergone surgery

4) pt on diuretics

5) diabetes insipidous patient

23

Expected lab results for hypovolemic shock Serum Lactate

> 2 mmol / L **this increase is an indicator that anaerobic metabolism is occurring in the body

24

Potassium level (Normal level)

3.5 - 5

25

Sodium level (NORMAL)

135 - 145

26

Hemoglobin level (Normal) what do you anticipate it to be for hypovolemic shock patient?

Normal = 12 - 18 g/dL DECREASED with Hemorrhage INCREASED with Dehydration

27

Hct level (Normal for hypovolemic patient?

NORMAL = 37 % - 52% DECREASED with Hemorrhage INCREASED with Dehydration

28

EXPECTED RESULTS FOR ABG'S

PH 7.35 - 7.45 (normal) PaCo2 35 - 45 (Normal) PaO2

  • PH
    • decreased (acidosis)
  • PaCo2
    • Increased (Respiratory issue
  • PaO2
    • Decreased

29

EXPECTED RESULTS FOR:

BUN /  CREATININE

 

  • BUN
    • ELEVATED (normal = 10 - 20 mg/dl)
  • CREATININE
    • ELEVATED (normal = 0.5 - 1.5 mg / dl)

30

 

Normal Central Venous Pressure

(CVP)

2 - 8 cm H20

(OR)

2 - 6 mm Hg