1. Acute Biologic Crisis: prevention. TYPES OF ASSESSMENT SHOCK FINDINGS 1.

Cardio Patient in genic cardiogenic Shock shock may experience angina pain and develop dysrhythmias and hemodynamic instability.

Different types of Shock, assessment findings, medical and nursing management, prognosis and MEDICAL MANAGEMENT The goals of medical management are to (1) limit further myocardial damage and preserve the healthy myocardium and (2) improve the cardiac function by increasing cardiac contractility, decreasing ventricular afterload, or both. Correction of underlying Causes Coronary cardiogenic: Thrombolytic therapy, angioplasty, or coronary artery bypass graft surgery. Noncoronary cardiogenic shock: cardiac valve replacement or correction of a dysrhythmia Initiation of First-Line Treatment Supplying supplemental oxygen Controlling chest pain Providing selected fluid support Administering vasoactive medications Controlling heart rate with medication or by implementation of a transthoracic or intravenous pacemaker Implementing mechanical NURSING MANAGEMENT Preventing Cardiogenic Shock Identify patients at risk and promote adequate oxygenation of the heart muscle and decrease its workload. Conserve patients energy. Promptly relieve angina Administer supplemental oxygen If shock cannot be prevented, work with other members of the health care team to prevent shock from progressing and to restore adequate cardiac function and tissue perfusion. PROGNOSIS Poor, only 1/3 patient actually treated survive initial episode and many of the survival have continuing angina, ccf, and decreased exercise tolerance. Approximately with a surgically correctable lesion leave hospital PREVENTION The best in prevent cardiogenic shock is to preavent a heart attack from happen these lifestyle changes include: -control hig blood pressure Dont smoke Maintain healthy weight Exercise regularly

Monitoring Hemodynamic Status Monitor the patients hemodynamic and cardiac status. Maintain arterial lines and monitor electrocardiographic equipment. Anticipate medications, intravenous fluids, and equipment that might be used. Be ready to assist in implementing measures. Document and report promptly any changes in hemodynamic, cardiac, and pulmonary status.

cardiac support (intra-aortic balloon counterpulsation therapy, ventricular assist systems, or extracorporeal cardiopulmonary bypass Pharmacologic Therapy Dobutamine (Dobutrex) increases/improves cardiac output Nitroglycerin (Tridil) venous vasodilator thus reduces preload Dopamine (Intropin) low dose increases renal and mesenteric blood flow medium-dose improves contractility, and slightly increases heart rate high-dose vasoconstriction, increases cardiac workload (undesirable) Other Vasoactive Medications: norepinephrine (Levophed), epinephrine (Adrenalin), milrinone (Primacor), amrinone (Inocor), vasopressin (Pitressin), and phenylephrine (NeoSynephrine) Antiarrhythmic Medications stabilizes heart rate

Report immediately changes in cardiac rhythm, presence of adventitious breath sounds, and other abnormal physical assessment findings. Aministering Medications and Intravenous Fluids Document and record medications and treatments that are administered as well as the patients response to treatment. Know the desired effects as well as the side effects of medications. Maintaining Inta-Aortic Balloon Counterpulsation Check the neurovascular status of the lower extremities frequently. Enhancing Safety and Comfort Administer medication to relieve chest pain Prevent infection at the multiple arterial and venous line insertion sites Protect the skin Monitor respiratory function Position the patient properly to promote effective breathing without decreasing blood pressure and to increase the patients comfort while reducing anxiety.

2. Hypovo Thirst lemic Increased Shock heart rate Cool and clammy skin Decreased arterial blood pressure Decreased urine output Changes in mentation

Medical goals in treating hypovolemic shock are to (1) restore intravascular volume to reverse the sequence of events leading to inadequate tissue perfusion, (2) redistribute fluid volume, and (3) correct underlying cause of fluid loss as quickly as possible. Treatment of the Underlying Cause: Hemorrhage: apply pressure to the bleeding site or surgery to stop internal bleeding Diarrhea/Vomiting: administer medications to treat diarrhea and vomiting Dehydration: fluid replacement Fluid and Blood Replacement Insert at least two largegauge intravenous lines to establish access for fluid administration Fluids commonly used: Lactated Ringers and 0.9% sodium chloride solutions Colloids (eg, albumin, hetastarch, and dextran) Dextran is not indicated in hemorrhaging patient

Briefly explain each procedure being performed. Use comforting touch to provide reassurance to the patient and family. Primary Prevention: Hypovolemic Monitor closely patients who shock are at risk for fluid deficits and recognized early assist with fluid replacement and treated promptly is Ensure safe administration of associated with prescribed fluids and a good outcome. medication and document their However, administration and effects advanced Monitor for signs of stages of HS w/ complications and side effects a fluid loss of of treatment and report these more than 25% signs early in treatment of total body fluid are Administering Blood and considered Fluids Safely irreversible Administer blood transfusions shock and are safely usually Obtain blood specimens quickly associated w/ a to obtain a baseline complete poor outcome or blood count and to type and death. cross-match the blood in anticipation of blood transfusions Monitor closely for adverse effects Monitor the patient closely for cardiovascular overload and pulmonary edema Monitor hemodynamic pressure, vital signs, arterial blood gases, hemoglobin and hematocrit levels, and fluid and intake and output Monitor temperature to ensure

Hypovolemic shock can be prevented in some instances by closely monitoring patient who are at risk for fluid deficits and assisting with fluid replacement before intravascular volume is depleted.

because it interferes with platelet aggregation. Transfuse packed red blood cells Redistribution of Fluid Place the patient in a modified Trendelenburg position Elevate legs to promote venous return Pharmacologic Therapy Dehydration secondary to hyperglycemia: administer insulin Diabetes Insipidus: administer desmopressin (DDAVP) Diarrhea: antidiarrheal agents Vomiting: antiemetic medications 3. Anaphy lactic Shock Anaphylactic shock is primarily an allergic reaction. To identify anaphylactic shock, first look for symptoms of allergy: Itching Red, raised, blotchy skin (hives) Treatment of anaphylactic shock requires removing the causative agent (eg, discontinuing an antibiotic agent), administering medications that restore vascular tone, and providing emergency support of basic life functions. Epinephrine is given for its vasoconstrictive action Administer Diphenhydramine (Benadryl) to reverse the effects of histamine, thereby reducing capillary

that rapid fluid resuscitation does not precipitate hypothermia Observe for jugular veins for distention and monitor jugular venous pressure Monitor cardiac and respiratory status closely and report changes in blood pressure, pulse pressure, heart rate, rhythm, and lung sounds to physician Implementing Other Measures Administer oxygen to increase the amount of oxygen carried by available hemoglobin in the blood Explain about the need for oxygen mask to reduce fear and anxiety Direct efforts to the safety and comfort of the patient Assess all patients for allergies or previous reactions to antigens (eg, medications, blood products, foods, contrast agents, latex) and communicate the existence of these allergies or reactions to others. Assess the patients understanding of previous reactions and steps taken by the patient and family to prevent further exposure to antigens Advise the patient to wear or

Anaphylaxis is a severe disorder with a guarded prognosis. Symptoms usually resolve with prompt treatment. However, among individuals with severe anaphylactic shock, brain

Prevent anaphylaxis by avoiding the allergens that trigger your symptoms. People with a history of anaphylaxis should wear a medical identification to alert others in the event or another

Wheezin g

Anaphylactic shock happens when the victim shows signs of low blood pressure: Confusio n Weaknes s Pale color Unconsci ousness

permeability. Give nebulized medications such as albuterol (Proventil) to reverse histamine-induced bronchospasm Perform cardiopulmonary resuscitation if cardiac and respiratory arrest are imminent or have occurred Endotracheal intubation or tracheostomy may be necessary to establish an airway. Intravenous lines are inserted to provide access for administering fluids and medications.

Anaphylaxis or anaphylactic shock often have symptoms of shortness of breath: Unable to speak more than one or two words Sitting straight up or with hands on knees Gasping for breath Pursing lips to breathe

carry identification that names the specific allergen or antigen Observe for allergic reaction when administering new medication In the hospital and outpatient diagnostic testing sites, identify patients at risk for anaphylactic reactions to condtrast antigen (radiopaque, dye-like substances that may contain iodine) used of diagnostic tests. Know the clinical signs of anaphylaxis, take immediate action if signs and symptoms occur, and prepare to begin cardiopulmonary resuscitation if cardiorespiratory arrest occurs. Assists with intubation if needed Monitor hemodynamic status Ensure intravenous access for administration of medications Administer prescribed medication and fluids Document treatments and their effects.

damage or death may occur frequently, even with treatment.

reaction.

Using neck muscles to take breaths

4. Neurog enic Shock

Dry, warm skin Bradycardia

Position the patient properly If hypoglycemia is the cause, administer glucose Specific treatment depends on the cause of shock

Elevate and maintain the head

of bed at least 30 degrees to prevent shock when patient is receiving spinal or epidural anesthesia Carefully immobilize the patient to prevent further damage to the spinal cord Apply elastic compression stockings and elevate the foot of the bed to minimize pooling of blood in the legs. Check the patient daily for any redness, tenderness, warmth of calves, and positive Homans sign (calf pain on dorsiflexion of the foot). Administer heparin or lowmolecular-weight heparin (Lovenox) as prescribed, apply elastic compression stockings, and initiate pneumatic compression of the legs to prevent thrombus formation. Perform passive range of motion of the immobile extremities to promote circulation Monitor the patient closely for

neurogenic shock are readily treatable and respond well to medical therapy.

However, it can be a potentially devastating complication, leading to organ dysfunction and death if not promptly recognized and treated.

There is no way to prevent neurogenic shock from occurring other than to avoid any severe injuries that may cause damage to the nervous system. Falls, accidents, and other traumas can be difficult to prevent, however. Use safety precautions whenever possible.

signs of internal bleeding that could lead to hypovolemic shock. 5. Septic Shock First Phase (hyperdynamic, progressive): Increased heart rate (tachycardia) Hyperthermia, with warm, flushed skin and bounding pulses. Elevated respiratory rate Normal or decreased urinary output Nausea, vomiting, diarrhea, decreased bowel sounds Subtle changes in mental status, such as confusion or agitation Later Phase (hypodynamic, irreversible): Low cardiac output with vasoconstrictio Pharmacologic therapy If infecting organism is unknown, broad-spectrum antibiotic agents are started. Third-generation cephalosporin plus an aminoglycoside may be prescribed initially Antibiotic agent may be changed to one that is more specific to the infecting organism and less toxic to the patient when culture and sensitivity reports are available. Nutritional Therapy Nutritional supplementation should be initiated within the first 24 hours of the onset of shock. Enteral feedings are preferred to the parenteral route because of the increased risk of iatrogenic infection associated with intravenous catheters However, enteral feedings may not be possible if decreased perfusion to the gastrointestinal tract reduces peristalsis and impairs absorption. Keep in mind the risks of sepsis and the high mortality tae associated with septic shock All invasive procedures must be carried out with aseptic technique after careful hand hygiene. Monitor intravenous lines, arterial and venous puncture sites, surgical incisions, traumatic wounds, urinary catheters, and pressure ulcers for signs of infection in all patients. Identify patients that are at particular risk for sepsis and septic shock (ie, elderly and immunosuppressed patients or patients with extensive trauma or burns or diabetes) Obtain appropriate specimens for culture and sensitivity to identify the site and source of sepsis and the specific organisms involved. Administer acetaminophen or apply hypothermia blankets to reduce temperature Monitor the patient closely for shivering, which increases oxygen consumption. Administer prescribed intravenous fluids and medications, including Septic shock has poor prognosis when it is associated with organ dysfunction, persistent low blood pressure, and evidence of inadequate circulation to the tissue. Can be prevented by choosing immediate treatment for wounds, bacterial infections or burns. Prevention include: Prompt treatment of sepsis Prompt treatment of septicemia

n Decreased blood pressure Cool and pale skin Temperature may be normal or below normal Rapid heart and respiratory rates Oliguria

antibiotic agents and vasoactive medications to restore vascular volume. Monitor blood levels (antibiotic agent, BUN, creatinine, white blood count) and report increased levels to physician. Monitor hemodynamic status, fluid intake and output, and nutritional status. Weigh the patient daily. Monitor serum albumin level to determine the patients protein requirements.

FIGURE 27-2. ECG electrode placement. The standard left precordial leads are V14th intercostal space, right sternal border; V24th intercostal space, left sternal border; V3diagonally between V2 and V4; V45th intercostal space, left midclavicular line; V5same level as V4, anterior axillary line; V6 (not illustrated)same level as V4 and V5, midaxillary line. The right precordial leads, placed across the right side of the chest, are the mirror opposite of the left leads. RA, right arm; LA, left arm; RL, right leg; LL, left leg. Adapted from Molle, E. A., Kronenberger, J., West-Stack, C., & Durham, L. S. (2005). Lippincott Williams & Wilkins's pocket guide to medical assisting (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.