Week 4 - SHOCK

Question 1

_____________ sympathetic stimulation increases vasoconstriction and systemic vascular resistance

Answer 1

increased

Question 2

Nutritional Support for shock patient 1) GOAL 2) interventions

Answer 2

GOAL: Maintain caloric requirements 1) Parenteral or enteral nutrition shoulds be started asap

Question 3

Elevated Serum Lactate Level?

Answer 3

> 2 mmol/L

Question 4

As a result of REDUCED cardiac output…a narrowing pulse pressure is often consistent with ….(2)

Answer 4

1) hypovolemia 2) cardiogenic shock

Question 5

S/S of Stage 1 (Early / Compensated Shock)

Answer 5

• NEURO: Anxiety, confusion, restlessness, altered mental status
• CARDIAC: BP* *often remains* *normal and helps to maintain adequate CO and vascular tone ^{_{(hypotension typically begins in stage 2)}}
  
  • ​VASOCONSTRICTION ^{(narrow pulse pressure- <em>distance between systolic / diastolic)</em>}
  • INCREASED HR ^{(slight tachycardia)}
  • INCREASED CONTRACTILITY ^{(bounding central pulses)}
• RESPIRATORY
  
  • SLIGHT INCREASE IN RATE

EARLY INTERVENTION AT THIS STAGE CAN PREVENT PROGRESSION TO SHOCK

Question 6

Whys is nutrition a critical component when treating a SHOCK patient.

Answer 6

-Shock increases metabolic rates d/t catecholamine. -This leads to an INCREASED CALORIC NEED by the body -If nutrition is NOT maintained the body will break down the skeletal muscle to accomodate the increased need -Loss of skeletal muscle prolongs recovery time

Question 7

Condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs and cellular function

Answer 7

SHOCK

Question 8

S/S of Stage 3

(Irreversible Shock)

Answer 8

• NEURO: Obtunded, Stuporous, Comatose or unresponsive
  
  • Obtunded: responds slowly to external stimuli. needs repeated stimulation to maintain attention and response to the environment
  • STUPOROUS:responds minimally with vigorous stimulation
  • Comatose: no observable response to external stimuli
• CARDIAC: Bradycardia with arrhythmias. Severe Hypotension MAP < 60 mmHg despite therapy
• RESPIRATORY: Bradypnea w/Shallow breaths ^{(Cheynes Stokes)}
• INTEGUMENTARY: Coagulopathies with petechiae purpura, or bleeding

Question 9

TRUE | FALSE The Body uses a variety of compensatory mechanisms to restore blood flow

Answer 9

TRUE

Question 10

Stimulation of BETA 1 adrenergic receptors leads to:

Answer 10

*increased heart rate *increased myocardial contractility *increased rate of conduction through the AV NODE *activation of the receptors in the kidney leads to the release of renin.

Question 11

Nursing Management of Stage 1 shock (Early / compensatory)

Answer 11

1. Assess and identify the cause of shock
2. Correct underlying disorder
3. Initiate measures aimed at supporting the bodys compensatory mechanism
4. Fluid and medication therapy
5. Monitor hemodynamic status
   
   1. Vital signs
   2. LOC
   3. Urinary output
   4. Skin temp/color
   5. peripheral pulses
   6. lab values

Question 12

decreased systemic stimulation allows___________, which decreases systemic vascular resistance

Answer 12

vasodilation

Question 13

Stimulation of BETA 2 adrenergic receptors leads to…

Answer 13

-Bronchial stimulation leads to bronchodilation *activation of receptor in uterine * activation of receptors in the liver causes a breakdown of glycogen into glucose *Skeletol muscle receptor activation, leads to muscle contraction which can lead to seizures

Question 14

STROKE VOLUME

Answer 14

Amount of blood pumped into the aorta with each contraction of the left ventricle

Question 15

Goals (6) of patient care in Stage 2

Answer 15

• INTERVENTIONS SHOULD DEPEND ON THE TYPE OF SHOCK AND ITS UNDERLYING CAUSE
• Optimize intravascular volume
• Support the pumping action of the heart ^{<em>(Using medication and\or therapy)</em>}
• Improve competence of the vascular system ^{<em>(meds that assist with vasoconstriction / vasodilation) </em>}
• support the respiratory system
• Continual assessment and reassessment of the bodys response to interventions
• Involve patient and family in the plan of care—end of life issues–expected outcomes

Question 16

Stage where Lactic Acid moves out of the intracellular and into the intravascular places

Answer 16

Stage 2

Question 17

Lactic acid production creates an _______________ intracellular environment which creates capillary permeability (aka: leaky cells). The increased capillary permeability causes the intracellular components to become extracellular components—leading to a metabolic state called __________ ___________

Answer 17

acidotic METABOLIC ACIDOSIS

Question 18

One of the most important factors in decreasing the probability a patient will end up in shock?

Answer 18

EARLY DETECTION **we must be able to recognize subtle as well as obvious signs

Question 19

what is “Stroke Volume” ?

Answer 19

amount of blood pumped into the aorta with each contraction of the left ventricle.

Question 20

To maintain cellular metabolism- the cells of all body organs and tissues require a regular and consistent supply of__________and removal of ___________

Answer 20

oxygen metabolic wastes

Question 21

Patient with good perfusion uses _________ metabolism to create energy

Answer 21

aerobic

Question 22

NORMAL PT (Pro Thrombin)

Answer 22

10-15 seconds

Question 23

NORMAL INR Lav values

Answer 23

1 - 1.2 seconds

Question 24

S/S of Stage 2

(Intermediate / Progressive-Uncompensated)

Answer 24

• NEURO
  
  • Decreasing LOC
• CARDIOVASCULAR
  
  • Obvious Tachycardia >100 bpm
  • DECREASED BLOOD PRESSURE ^{(hypotension)}
    
    • ^{<strong>​</strong>d/t epinepherine / norepinepherine starting to wear out}
  • Weak Thready Pulses ^{(difficult to palpate)}
  • Cool, Clammy, cyanotic skin ^{<em>(d/t peripheral vasoconstriction)</em>}
• RESPIRATORY
  
  • Rapid, shallow breaths^{<em> (body attempting to blow off CO2 and balance out the high lactic acid level)</em>}
• LABS
  
  • Elevated Lactate Levels >2 mmol/L
  • ^{(this increase is indicative of anerobic metabolism occurring in the body)}

Question 25

Progression into STAGE 3 (refractory / irreversible shock)

Answer 25

• Happens when tissue perfusion cannot be restored
• Organ damage from anoxia and cellular death can become so severe that the patient cannot survive despite all treatments provided

Question 26

With regard to the vascular system.,,,the vessels in the body need to have good “tone”. What is tone?

Answer 26

Tone is the ability to constrict or dilate to maintain normal pressure

Question 27

difference between systolic and diastolic blood pressure

Answer 27

pulse pressure

Question 28

Progression of SHOCK in “5” steps:

Answer 28

1) Poor delivery of O2 and nutrients to cells 2) Cellular starvation 3) Cell death 4) Organ dysfunction 5) Organ failure and death

Question 29

(true | false) Bodies do NOT function well in a acidotic state

Answer 29

TRUE

Question 30

Adequate Tissue Perfusion requires (3)

Answer 30

1) Adequate Cardiac Pump 2) Effective vasculature & circulatory system 3) Sufficient blood volume **IF ONE OF THESE IS IMPAIRED, TISSUE PERFUSION IS THREATENED AND\OR COMPROMISED

Question 31

SYMPATHETIC NERVOUS SYSTEM (SNS) maintains the smooth muscle surrounding the arteries and arterioles in a state of partial contraction called ____________

Answer 31

sympathetic tone

Question 32

In the absence of sufficient O2, cells revert to using ___________ metabolism to create energy

Answer 32

anaerobic

Question 33

Three (3) Stages of shock

Answer 33

1) Early, reversible & compensatory 2)Intermediate or Progressive (Uncompensated) 3) Refractory or Irreversible

Question 34

This process indicates that anaerobic metabolism is occurring in the body

Answer 34

Elevated Serum Lactate

Question 35

Define “Cardiac Output” What is the FORMULA?

Answer 35

the amount of blood (L/min) pumped per minute into the aorta by the left ventricle. Cardiac Output = Stroke Volume x Heart Rate

Question 36

Respiratory support for Shock

Answer 36

GOAL: increase the amount of O2 carried by the hemoglobin in the blood 1) continuous pulse-ox monitouring 2) frequent respiratory assessments 3) Mechanical ventilation if respiratory failure occurs

Question 37

Mean Arterial Pressure (MAP)

Answer 37

Average Pressure in the arterial circulation throughout the cardiac cycle. *it is the product of CARDIAC OUTPUT and Systemic Vascular Resistance (SVR) **CO, SVR, or total blood volume rises conversely so does your MAP and tissue perfusion **CO, SVR or total blood volume falls– then MAP and tissue perfusion also decrease

Question 38

Three factors that make up “Stroke Volume”

Answer 38

1) Preload 2) Afterload 3) Contractility

Question 39

Anaerobic metabolism leads to the production of ________

Answer 39

Lactic acid

Question 40

(9) Nursing Management of Stage 2 shock (Intermediate / Progressive-Uncompensated)

Answer 40

• Pt needs to be closely monitored in ICU
  
  • Invasive hemodynamic monitoring ^(CVP)
  • Telemetry monitoring ^{(Continuous ECG)}
  • ABG’s ^{(watching their PH and acidotic state)}
  • ELECTROLYTES ^{(b/c they become altered in an acidotic state)}
  • PHYSICAL and MS changes ^{(improving or worsening mental status?)}
• RAPID & FREQUENT ADMIN OF MEDS & FLUIDS
  
  • ​Usually require vasopressors with titration
• SUPPORTIVE THERAPIES ^{(IF OUR ORGANS BEGIN TO FAIL)}
  
  • ^​Mechanical Ventilation ^{(respiratory failure)}
  • DIalysis ^{(renal failure)}
• NURSE NEEDS EXPERTISE IN ASSESSING AND UNDERSTANDING THE SIGNIFICANCE OF CHANGES IN DATA

Question 41

Widening pulse pressure is consistent with ________ Narrow pulse pressure is consistent with _________ and ______________

Answer 41

Septic shock hypovolemia, cardiogenic shock

Question 42

Nursing Management of Stage 3 shock

(Irreversible Shock)

Answer 42

• SAME TX AS FOR THE SECOND STAGE
• Monitoring patient
• Preventing complications
• Protection from injury
• Providing comfort / dignity
• Communication with family about outcome ***explain about what is happening **Offer opportunities to see, touch, talk **Spiritual advisors visitation

Question 43

Stimulation of ALPHA 1 adrenergic receptors is responsible for ….?

Answer 43

Stimulation of this receptor site causes vasoconstriction of: Arterioles of skin viscera | mucous membranes

Question 44

NORMAL aPTT (lab value)

Answer 44

< 35 seconds

Question 45

PROGRESSION INTO STAGE 2

Answer 45

1. Body loses the ability to compensate
2. Clinical signs become more obvious ^{(pt becomes symtomatic)}
3. Inflammatory response activated ^{(can lead to ARDS)}
4. Decreased perfusion leads to extracellular acidotic state ^{(metabolic acidosis)}
5. Coagulation become impaired
6. AGGRESSIVE TX IS ESSENTIAL TO SURVIVAL OF THE PATIENT
7. Sustained decrease in MAP of 20 mmHg or more below normal level
8. Fluid loss of 35% - 50%

l

Question 46

EARLY INTERVENTION AT THIS STAGE CAN PREVENT PROGRESSION TO SHOCK

Answer 46

EARLY / COMPENSATED SHOCK

Question 47

TRUE / FALSE ANY CONDITION THAT COMPROMISES OXYGEN DELIVERY TO ORGANS AND TISSUES CAN LEAD TO SHOCK

Answer 47

TRUE

Question 48

Explain process of anaerobic metabolism (5)

Answer 48

1) Absence of sufficient O2–>cells revert to anaerobic metabolism 2) Anaerobic metabolism leads to the production of lactic acid 3) This creates an acidotic intracellular environment 4) This increases capillary permeability 5) This permeability causes LEAKAGE of intracellular components which leads to increased extracellular acidosis.

Question 49

PRELOAD vs AFTERLOAD

Answer 49

• PRELOAD
  
  • vOLUME OF BLOOD IN VENTRICLE JUST BEFORE IT CONTRACTS
• AFTERLOAD
  
  • THE PRESSURE THE HEART HAS TO OVERCOME IN ORDER TO GET BLOOD OUT (vasculature)

Question 50

When our Systemic Vascular Resistance is very high–(meaning that we are very clamped down and vasoconstricted) then our afterload is very ____________

Answer 50

HIGH

Question 51

PRELOAD is INCREASED in what types of situations?

Answer 51

*hypervolemia

*regurgitation of cardiac valves

*Heart failure

Question 52

AFTERLOAD is INCREASED in what types of situations?

Answer 52

*Hypertension

*Vasoconstriction

INCREASED AFTERLOAD = INCREASED CARDIAC WORKLOAD

Question 54

In the early stages of shock the body is doing things to BOOST cardiac output and the body releases excessive amounts of EPINEPHERINE and NOREPINEPHERINE. These are natural VASOPRESSORS that assist in boosting HR and CO. What are the neurological S/S that the patient will begin to demonstrate?

Answer 54

ANXIETY

CONFUSION

RESTLESSNESS

Question 55

what is the PULSE PRESSURE OF 120 / 80

Answer 55

Pulse Pressure = 40

Question 56

__________________ suggests significant blood loss and if often one of the 1st signs of SHOCK. Often the results of increasing diastolic pressure from compensatory cetecholamine release

100/66 100/74 100/84

Answer 56

Narrowing Pulse Pressure

Question 58

one of the ways that the body attempts to fix
ACIDOSIS is to…

Answer 58

increase the rate of breathing and blow that CO2 off

Question 59

CARDIAC OUTPUT (CO)

Answer 59

AMOUNT OF BLOOD PUMPRED PER MINUTE INTO THE AORTA BY THE LEFT VENTRICLE

CO = SV * HR

Question 60

Mean Arterial Pressure (MAP)

Answer 60

Average pressure in the arterial circulation throughout the cardiac cycle

MAP = CO * SVR

Question 61

Pulse Pressure

Answer 61

Difference between SYSTOLIC and DIASTOLIC

**Narrowing Pulse pressure is often an early indicator of SHOCK

Question 62

Shock is triggered by a SUSTAINED drop in _______

Answer 62

Mean Arterial Pressure (MAP)