In simple terms, name the tx for the types of shock:

a.  Hypovolemic

b.  Cardiogenic

c.  Distributive

a.  Replace the fluids that are lost, blood or plasma

b.  Therapies that improve overall cardiac function

c.  Either loosen-up constricted vessels or tighten-up dilated vessels.

In simple terms, describe what the problem is in:

a.  Cardiogenic shock

b.  Distributive shock

c.  Hypovolemic shock

a.  Pump failure

b.  Tubing malfunction

c.  Fluid loss

Describe the physiology of shock:

a.  Shock is due to inadequate _______.

b.  Low BP is due to inadequate__________.

c.  Low CO is caused by a problem with _____.

a.  BP

b.  CO or low peripheral resistance

c.  HR or SV

Describe the physiologies of shock:

a.  What are the two HR abnormalities?

b.  What are the 3 stroke volume abnormalities?

c.  Low peripheral vascular resistance is due to what?

a.  Tachycardia or bradycardia

b.  Failure to receive, failure to eject, or inadequate blood volume

c.  Inappropriate vasodilation

Define:

a.  Stroke Volume (SV)

b.  Cardiac Output (CO)

c.  Mean Arterial Pressure (MAP)

a.  Amount of blood pumped into aorta by contraction of left ventricle

b.  Amount of blood pumped into aorta by contraction of left ventricle in one minute

c.  Product of cardiac output and systemic vascular resistance

a.  What is the common denominator of all types of shock?

a.  Inadequate cellular oxygenation

b.  Tissue hypoxia shifts the metabolism from __________ to ___________ pathways.

b.  aerobic to anaerobic

c.  When a stimulus leads to alteration in hemodynamics within the body, how does the body respond?

c.  Maintains perfusion to vital organs, heart and brain

In early reversible and compensatory shock:

a.  Mean arterial pressure drops how much?

b.  Decrease in circulating blood vol. by how much?

c.  Which nervous system is stimulated?

d.  What is released?

e.  What does the body do to try to maintain BP?

f.  What do we do?

a.  10-15%

b.  25-35% (1000 mL)

c.  Sympathetic

d.  Catecholamine

e.  Increase HR and contractility, increase in peripheral vasoconstriction

f.  Treat underlying cause

In intermediate or progressive shock:

a.  Mean arterial pressure does what?

b.  Fluid loss does what?

c.  Vasoconstriction leads to what?

d.  Body switches to anaerobic metabolism and forms _____________ as a waste product.

e.  What do HR and vessels do?

f.  How do heart and brain respond?

g.  What acid-base imbalance develops?

a.  Drops further (20%)

b.  Increase in vascular loss

c.  Oxygen deficiency

d.  Lactic acid

e.  HR and vasoconstriction increase

f.  They become hypoxic

g.  Acidosis with hyperkalemia

Describe the cardiovascular response to shock:

a.  Initially, what do HR and BP do?

b.  How do they progress?

.  Slight tachycardia, normal BP

b.  Progresses to weak, rapid pulse with dysrhythmias.  Then progressive decrease in systolic and diastolic BP with narrowing of pulse pressure; BP becomes inaudible.

In refractory or irreversible shock:

a.  Tissues are ________, cellular death widespread.

b.  What is the body’s response to restoration of BP and fluid volume?

c.  Cellular death leads to what?

a.  anoxic

b.  There is too much damage to restore homeostasis of tissues.

c.  Tissue death, vital organs fail and death occurs.

Describe the respiratory response to shock:

a.  Initially, what does respiratory rate do?

b.  Initially, what happens with gas exchange?

c.  What complication can develop as a result of decreased lung perfusion?

a.  Increases

b.  Gas exchange is impaired, which leads to anaerobic metabolism and development of acidosis

c.  Acute Respiratory Distress Syndrome (ARDS)

Describe the GI & Hepatic response to shock::

a.  When GI organs become ischemic, what does blood circulation do?

b.  What happens when GI mucosa becomes ischemic?

c.  Describe paralytic ileus.

d.  Describe how liver metabolism is altered.

a.  Circulation is shunted to heart and brain.

b.  It is prone to rapid ulceration (stress ulcers)

c.  Decreased gastrointestinal mobility with decreased blood flow

d.  Initially, glucose is made available, but then hypoglycemia develops, and fat breakdown leads to ketones and metabolic acidosis.

Hypovolemic Shock:

a.  Decrease in intravascular volume by

what percent?

b.  What are the common causes?

c.  What is ascites?

d.  What is the treatment?

a.  >15%

b.  Hemorrhage, burns, severe dehydration, third spacing, diarrhea, vomiting

c.  Loss of usable fluid to the system

d.  Hypertonic IV solution; colloids

a.  Describe the s/s of the neurologic response to shock (when cerbral hypoxia develops).

b.  Describe the renal response to shock.

c.  Describe the responses of

skin, temperature, and thirst to shock.

a.  Restlessness initially, then altered LOC, lethargy, coma

b.  Oliguria (urine output < 20 ml./hr)

c.  Skin:  cool, pale, hypothermic;

Thirsty from dehydration

Cardiogenic Shock:

a.  Occurs commonly in victims of what?

b.  What percentage of the left ventricle must be necrotic for cardiogenic shock to occur?

c.  What is the effect of the decreased contractility?

a.  MI (occurs in 10%)

b.  40%

c.  Leads to lower BP and low tissue perfusion from the poor CO.

Cardiogenic Shock:

a.  What mechanism is the problem?

b.  What are the common causes?

c.  What can be the result?

d.  What is the treatment?

a.  Pumping ability of the heart is compromised to a degree that it cannot maintain CO and adequate tissue perfusion.

b.  MI, cardiac arrest, cardiomyopathy

c.  Left and right sided heart failure

d.  Tx is in reducing workload of heart:

• Give O2
• Lasix to control volumes
• Pressor to maintain BP

**Give lowest doses possible!!

Septic Shock:

a.  Describe the s/s of the Warm Phase.

b.  What is happening in the warm phase with CO, peripheral vessels, output, and HR?

c.  Describe the s/s of the Cold Phase.

d.  What is happening in the cold phase with volume and HR?

a.  Skin flushed, warm due to vasodilation

b.  Increased CO, peripheral dilation, decreased output, rapid bounding pulse

c.  Skin cool due to fluid deficit with shock, altered LOC

d.  Hypovolemia (vol. shifted to interstitial space), tachycardia (thready

Septic Shock:

a.  Leading cause of death where?

b.  What are common stimuli?

c.  Who is at increased risk?

d.  What mechanism is the issue?

.  In intensive care units

b.  Gram negative bacterial infections (pseudomonas, E. Coli); Gram positive bacterial infections (staphylococcus and streptococcus)

c.  Clients with chronic illness, poor nutritional status, Foleys or central lines

d.  Good pump, good volume, BAD vessels

Neurogenic Shock:

a.  Describe the body’s response to the imbalance between parasympathetic and sympathetic stimulation of vascular smooth muscle.

b. What are the common causes, and what happens?

c.  How will the skin look?

d.  Can you set this pt up in bed?

a.   Sustained vasodilation

b.  Head injury, spinal cord trauma, insulin reactions, aesthesia, because of sudden loss of neurotransmission to heart and lungs

c.  Cyanotic

d.  No!

Anaphylactic Shock:

a.  Result of widespread ______________.

b.  Vasodilation leads to what?

c.  What happened in the past that has led to this?

d.  Large amounts of ____________ released.

e.  These levels lead to what?

f.  What develops?

a.  Hypersensitivity (anaphylaxis)

b.  Hypovolemia and altered cellular metabolism

c.  Sensitized in past; re-contact with the allergen

d.  Histamine

e.  Increased permeability and massive vasodilation

f.  Respiratory distress with bronchospasm and laryngospasm

Crystalloid solutions:  Hypotonic

a.  What is the concentration r/t extracellular fluid (ECF)?

b.  When is it useful?

c.  Give 2 examples of hypotonic solutions

a.  Less than the concentration of ECF

b.  Only used to deliver piggyback meds.

c.  5DW and 5D1/2NS

Crystalloid solutions:  Isotonic

a.  What is the concentration r/t extracellular fluid (ECF)?

b.  When is it useful?

c.  Give 2 examples of isotonic solutions.

a.  The same

b.  Useful in increasing the blood volume without altering the electrolyte concentration of plasma.

c.  LR ad NS are used with hemorrhage and shock until blood specific for that pt is ready to be transfused.

Crystalloid solutions:  Hypertonic

a.  What is the concentration, r/t extracellular fluid (ECF)?

b.  When is it useful?

c.  Give 2 exampls of hypertonic solutions.

a.  Concentration is greater than ECF.

b.  Used to pull fluids back into intravascular space.

c.  Mannitol and 5%NS

Colloids:

a.  Are they easily diffused through capillary walls?

b.  What do fluids do, and so what does pressure do?

c.  Examples:  albumin, hetastarch, plasma protein fraction, dextran (no answer for this

a.  No

b.  Fluids stay in vascular compartment; increase osmotic pressure

a.  Describe what occurs with ABO incompatibility.

b.  What are the s/s?

c.  How long must a nurse directly observe a pt getting a transfusion?

d.  What are nursing interventions is incompatibility is suspected?

a.  RBCs clump and block capillaries, decreasing blood flow to vital organs; hemoglobin is released which blocks renal tubules and can cause renal failure.

b.  Lumbar, abd and/or chest pain, fever, chills, urticaria, n/v

c.  15 minutes

d.  Stop infusion immediately and do not transfuse the blood in the tubing; infuse fluids; notify MD; follow protocol.

a.  Describe what a unit of Packed Cells contains.

b.  How many points will each unit raise HCT?

c.  How does this affect oxygenation?

a.  Contains the same hemoglobin level as whole blood but in less volume.

b.  3-4 points

c.  Greatly increases carrying ability of blood.

a.  What is MODS?

b.  What are initial changes of MODS?

c.  What clinical conditions lead to MODS?

a.  Multiple Organ Dysfunction Syndrome

b.  Localized inflammation, which can lead to widespread inflammation

c.  Clinical conditions:

• Infection
• Pancreatitis
• Ischemai
• Multi-trauma
• Hemorrhagic shock
• Aspiration of gastric contents
• Massive transfusion

a.  Define valve stenosis.

b.  How does it affect CO?

a.  Stenosis is when the valve leaflets fuse together and cannot fully open or close; the valve narrows and becomes rigid.

b.  The forward flow of blood is impeded, which decreases CO b/c of impaired ventricular filling or ejection and SV.

a.  What is the characteristic manifestation of valvular disease?

b.  In pts with valvular disorders, atrial distention often causes what dysrhythmia?

c.  What does digitalis do for a pt with valvular disease?

a.  Murmur caused by the turbulent flow across the valve

b.  Atrial fibrillation

c.  Increases the force of myocardial contraction to maintain CO

a.  Define valve regurgitation.

b.  How does it affect CO?

a.  Regurgitation is the backflow of blood through the valve into the aorta it just left, due to regurgitant valves (or insufficient or incompetent) that do not close completely.

b.  Eventually, CO falls as compensatory mechanisms become less effective.

a.  In pts with valvular disease, what 3 classes of meds might be given to reduce preload and afterload?

b.  Why might anticoagulants be given?

c.  Why might antibiotics be given?

a.  Diuretics, ACE inhibitors, vasodilators

b.  to prevent clot and embolus formation, which can be a complication of fibrillation; also required following insertion of a mechanical heart valve

c.  Prophylactically prior to any dental work or invasive procedures, due to increased risk for infective endocarditis as altered blood flow allows bacterial colonization.