NUR 405 Shock
- shock
-life threatening -results from inadequate tissue perfusion -causes life threatening cellular dysfunction, HYPOtension, and oliguria -can lead to multi-organ dysfunction and death -affects all body systems -INCREASED survival rate IF identified and treated within 3 HOURS
- three stages of shock
-compensatory -progressive -irreversible
- compensatory stage
-if caught at this stage - reversible -BP within normal limits -INCREASED HR, contractility, and vasoconstriction -fight or flight response -blood flow to brain, heart and lungs MAINTAINED -LOW blood flow to skin, kidneys, GI tract 1 / 3
-cool pale skin, HYPOactive bowel sounds, DECREASED urinary output
- compensatory stage clinical manifestations and nursing care
-INCREASED RR results in compensatory respiratory alkalosis -anxiety and confusion -identify cause and treat -oxygen -fluid replacement and medications to maintain BP -monitor LOC, UO, skin, VS, labs -report bp <100 or drop >40mmHg or MAP<65mmHg, RR>22 and altered mental status (less than 100, greater than 40, less than 65, greater than 22)
-early indicator
narrow pulse pressure (diastolic-systolic BP) should be 30-40mmHg
-maintain SvO2 of 70%
-lab values
Na and BG ELEVATED
-passive leg raises -reduce anxiety of patient and family -family presence -advanced directives -physician orders for life sustaining treatment (POLST) 2 / 3
-promote safety
- progressive stage
-compensatory mechanisms fail, MAP Below normal
-HYPOtension
sys bp less than 90mmHg or greater than 40mmHg drop from baseline and declining mental status
-myocardial depression, inflammatory response activated, lactic acid build up -chances of survival DEPEND on underlying HEALTH
-respiratory effect
-lung decompensation
rapid RR, shallow, crackles, LOW PaO2 and HIGH CO2, pulmonary edema (crackles), acute lung injury, and ARDS
-cardiovascular effects
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