Shock and Multisystem Failure

1. Shock and Multisystem Failure

2. 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

3. Processes of Shock • Initial stage (early shock) • Nonprogressive stage (compensatory stage) • Progressive stage (intermediate stage) • Refractory stage (irreversible stage)

4. 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.

5. 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)

6. Hypovolemic Shock (Continued) • Caused by internal hemorrhage as occurs with blunt trauma, gastrointestinal ulcers, and poor control of surgical bleeding

8. Cardiogenic Shock • Actual heart muscle is unhealthy and pumping is directly impaired. • Cardiac output and afterload are reduced, thus reducing mean arterial pressure.

10. 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)

12. Distributive Shock (Continued) • Anaphylaxis • Sepsis • Capillary leak syndrome

13. 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.

15. 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

16. Interventions • Reverse the shock. • Restore fluid volume. • Prevent complications through supportive and drug therapies. • Nonsurgical management includes oxygen therapy, fluid replacement, and monitoring.

17. Drug Therapies • Vasoconstrictors, such as dopamine, epinephrine, norepinephrine, phenylephrine • Agents that enhance contractility • Agents that enhance myocardial perfusion

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

19. 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

20. Infusion Therapy

21. 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

22. Blood Transfusions and Other Components • Packed red blood cells • Platelets • Fresh frozen plasma • Albumin • Several specific clotting factors

23. Medications • IV medications provide a rapid therapeutic effect but can also lead to immediate serious reactions. • Prescription for infusion therapy is necessary.

24. 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.

26. 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)

27. 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.

29. 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

30. 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.

31. 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.

33. 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.

34. Infusion System • Containers • Administration sets • Add-on systems • Needleless connection devices • Rate controlling devices: • Controller • Pumps • Syringe pumps • Ambulatory pumps

35. 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)

36. Catheter Care and Maintenance(Continued) • Flushing the catheter • Obtaining blood samples from the catheter • Removing the catheter

37. Considerations for Older Adults • Skin care precautions • Vein and catheter selection • Cardiac and renal changes

38. Alternative Sites for Infusion • Arterial therapy • Intraperitoneal infusion • Subcutaneous infusion • Intraspinal infusion • Intraosseous therapy