1/3/2008. Karen Burke Priscilla LeMone Elaine Mohn-Brown. Medical-Surgical Nursing Care, 2e Karen Burke, Priscilla LeMone, and Elaine Mohn-Brown

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1 Medical-Surgical Nursing Care Second Edition Karen Burke Priscilla LeMone Elaine Mohn-Brown Chapter 13 Caring for Clients Experiencing Shock, Trauma, or Critical Illness Shock Life-threatening condition Inadequate blood flow and oxygen to tissues and cells Compensated Progressive Irreversible Stages of Shock 1

2 Compensated Shock Decreased blood volume reduces cardiac output or vasodilation occurs Blood pressure drops and normal tissue perfusion is not maintained Baroreceptors stimulate the sympathetic nervous system to release epinephrine and norepinephrine Compensated Shock Arterial blood vessels constrict, heart rate and strength of heart to contract increases, venous return increases Renin angiotensin system is activated, increasing blood pressure and circulating blood volume Antidiuretic hormone is released to increase blood pressure Progressive Shock Compensatory mechanisms fail and organ functions deteriorate Cardiovascular decreased decreased cardiac output results in decreased oxygenation of cell and tissue ischemia Respiratory increased increased carbon dioxide results in respiratory acidosis Gastrointestinal system ulceration of mucosa results in stress ulcers and sepsis, paralytic ileus Liver failure leads to hypoglycemia, bacterial infections 2

3 Progressive Shock Neurologic decreased blood flow leads to decreased level of consciousness, coma, cerebral edema, and brain damage Renal reduced blood flow causes oliguria and failure Skin and temperature vasoconstriction leads to pale skin and mucous membranes, activation of sweat glands produces cool and clammy skin, body temperature decreases Irreversible Shock Multiple organ dysfunction syndrome (MODS) tissue and cellular death BOX 13-1 Manifestations Found in Each Stage of Shock. 3

4 Types of Shock Hypovolemic Anaphylactic Cardiogenic Septic Neurogenic Causes of Hypovolemic Shock Decrease in circulating blood volume due to: Hemorrhage due to trauma Surgery GI bleeding Hemophilia Postpartum hemorrhage Causes of Hypovolemic Shock Internal fluid shifts due to: Cirrhosis with ascites Pleural effusion Pancreatitis Intestinal obstruction 4

5 Causes of Hypovolemic Shock Loss of body fluids due to: Vomiting Diarrhea Nasogastric suctioning Diuretics Diabetes insipidus Loss of fluids through skin due to diaphoresis or burns Causes of Anaphylactic Shock Immunologic reaction from antigens due to: Food allergies Stings and bites from insects Snake venom Substances used to diagnose and treat disease Latex, pollen, molds, food additives Causes of Cardiogenic Shock Failure of heart s pumping action or other cardiac disorders Myocardial infarction 5

6 Causes of Septic Shock Overwhelming infection produced by toxins due to: Age, <1 year, >65 years Debilitating disease processes Surgery, invasive lines or tubes Drug therapy Causes of Neurogenic Shock Changes in sympathetic tone of blood vessels due to: Spinal cord injury above T6 level Head injury Spinal anesthesia Opiate drug overdose Insulin reaction Pathophysiology of Shock Alteration in one or more factor: Adequate blood flow Correct heart pumping action Normal blood vessel diameter to maintain tissue perfusion Disruption of normal cell function Inadequate tissue perfusion to sustain normal cellular metabolism Prolonged shock results in hypoxia and cell death, then organ failure and death 6

7 Manifestations of Hypovolemic Shock Pathophysiology and Manifestations of Anaphylactic Shock Antigen antibody reaction stimulates mast cells to release histamine and other mediators, causing: Vasodilation Hypotension Hypovolemia Inflammation, bronchoconstriction, and cutaneous reactions occur, causing a life-threatening event BOX 13-3 Manifestations of Anaphylactic Shock. 7

8 Pathophysiology and Manifestations of Cardiogenic Shock Ventricles fail to pump blood into the circulatory system Decreased stroke volume Blood backs up in lungs causing: Pulmonary edema Hypotension Cardiac failure BOX 13-4 Manifestations of Cardiogenic Shock. Pathophysiology and Manifestations of Septic Shock As bacteria are destroyed, endotoxins are released Damage tissues Starve cells of oxygen and nutrients Histamine and other chemicals are released Vasodilation Increased capillary permeability Hypovolemia occurs Microemboli form in capillaries causing cell damage and death 8

9 BOX 13-5 Manifestations of Septic Shock. Pathophysiology and Manifestations of Neurogenic Shock Blood vessels dilate Peripheral vasodilation Blood pools Inadequate tissue perfusion Thermoregulation is impaired Organ failure and death occur BOX 13-6 Manifestations of Neurogenic Shock. 9

10 Complications of Shock Acute respiratory distress syndrome (ARDS) Disseminated intravascular coagulation (DIC) Diagnostic Tests to Identify Type of Shock CBC, especially hemoglobin and hematocrit Arterial blood gases Electrolytes, especially serum sodium and potassium Blood glucose levels Blood urea nitrogen and creatinine Diagnostic Tests to Identify Type of Shock Blood cultures White blood cell count Serum cardiac markers Creatine kinase CK-MB Troponins 10

11 Diagnostic Tests to Identify Type of Shock X-rays Computerized tomography (CT) scans Magnetic resonance imaging (MRI) Peritoneal lavage Oxygen Therapy in Shock Maintain patient airway Administer oxygen via nonbreather mask at 12 to 15 L/min Maintain PaO 2 > 90 mm Hg Monitor for respiratory distress Anticipate endotracheal intubation and mechanical ventilation Nursing Management of Client with Hypovolemic Shock Initiate intravenous fluids Apply pneumatic antishock garments (PASG) To raise blood pressure and stabilize pelvic and femoral fractures 11

12 Nursing Management of Client with Anaphylactic Shock Maintain patient airway and administer oxygen Administer epinephrine subcutaneously or intravenously Administer antihistamines Administer corticosteroids If respiratory distress continues, administer aminophylline or nebulized albuterol Nursing Management of Client with Cardiogenic Shock Administer oxygen Administer vasopressor drugs and positive inotropic drugs Administer diuretic drugs Administer antidysrhythmic drugs Monitor mechanical devices Intra-aortic aortic balloon pump (IABP) Ventricular assist device (VAD) Nursing Management of Client with Septic Shock Obtain blood, urine, wound, sputum cultures Administer intravenous fluids Administer antibiotic drugs 12

13 Nursing Management of Client with Neurogenic Shock Administer intravenous fluids Administer analgesic drugs Client and Family Support in Shock Client and Family Support in Shock Acknowledge anxiety and fear Provide comfort measures Provide time, space, and privacy Provide anticipatory guidance Keep family informed Discharge Teaching Avoid known allergens Notify health care professionals of allergens Avoid wearing bright colors, perfumes, and scented hair sprays if allergic to insect stings Read package labels if allergic to foods Wear Medic-Alert bracelet or necklace Advise to carry an emergency kit for anaphylaxis Review manifestations of anaphylaxis Seek medical attention immediately when symptoms occur 13

14 IV Fluids Administered in Shock Replace fluids in a 3:1 ratio (300 ml for every 100 ml fluid loss) Crystalloid solutions Colloid solutions Blood and blood products Autotransfusion Causes of Trauma Injury caused by physical force Motor vehicle crashes Falls Drowning Gunshots Burns Stabbing Physical assaults, contact sports Common Traumatic Injuries Minor trauma Fractures to collarbone Small second-degree degree burn Cut requiring stitches Major or multiple trauma Amputation Multiple-system injuries 14

15 Common Traumatic Injuries Blunt trauma Internal damage that does not break skin Penetrating trauma Foreign object that pierces body External appearance of wound does not determine internal damage Common Environmental Injuries Hyperthermia Heat exhaustion Heat stroke Hypothermia Poisonings Effects of Traumatic Injury Airway obstruction Pneumothorax Hemorrhage Hypovolemic shock Neurologic injuries Gastrointestinal and genitourinary injuries Musculoskeletal injuries Integumentary injuries Psychologic effects on client Psychosocial effects on family 15

16 Emergency Treatment of Traumatic Injury Assess to identify extent of injuries Provide life support Immobilize Administer oxygen Control bleeding Start IV fluids Transport Emergency surgery Diagnostic Tests for Traumatic Injuries Tests to rule out shock Blood alcohol levels Urine drug screen Pregnancy test Diagnostic peritoneal lavage Computerized tomography (CT scan) Magnetic resonance imaging (MRI) Legal Investigation of Injuries Related to Criminal Activity Identify, store, and properly transfer potential evidence Do not cut through clothing containing blood stains or bullet holes Place clothing in individual breathable containers and label lbl Label bullets or knives Record entrance and exit wounds in chart Photograph wounds Place paper bag over hands if presence of evidence in suspected 16

17 Assessment Perform head-to to-toe toe assessment Obtain brief history, allergies, past medical history Assess vital signs every 5 10 minutes to hourly, to every 2 4 hours Assess for early signs of shock Restlessness Tachycardia Slight anxiety Assess late signs of shock Hypotension Assess urine output Interventions Insert nasogastric tube if risk of aspiration Apply cardiac monitor to assess cardiac status Insert intravenous lines and administer medications as indicated Monitor for hypothermia Administer tetanus prophylaxis if penetrating wound Maintain strict aseptic technique Evaluation Absence of infection Preventing complications from immobility Document healing of injuries 17

18 Discharge Teaching Determine potential home modifications Review medication administration Give information about diets Discuss rehabilitation plan Emphasize need for follow-up care Discuss emotional changes Provide referrals as needed Provide preventative education Interventions for Environmental Injuries Hyperthermia Move to cool place Loosen clothing Apply cool, wet towels Apply cooling blanket and oxygen for heat stroke Monitor for renal failure and seizures Interventions for Environmental Injuries Hypothermia Move to warm place Remove wet clothing Apply warm blankets, radiant heat lamp, warming blanket Administer warm intravenous fluids and warm peritoneal lavage Administer warm, humidified oxygen Observe for cardiac arrest 18

19 Interventions for Environmental Trauma Poisonings Identify the poison Call the local poison control center Assess airway, breathing, and circulation Assist with administration of antidote or elimination method Administer oxygen for inhaled poisons Cleanse contaminated skin with water Teaching for poisoning ICU Psychosis Acute confusion after 2 to 3 days in ICU Manifestations: Altered attention span Memory loss Confusion Visual and auditory hallucinations ICU Psychosis Treatment: Administer sedative or psychotropic drugs Decrease client s sensoriperceptual problems Decrease client s sleep deprivation 19

20 ICU Effects on Family Fear of death of loved one Anxious about equipment Anxious about client s potential for pain Worry about finances and changes in family roles Interventions with Family Give status reports Get involved in client s care Assess for signs of exhaustion Obtain resources and referrals as needed Organ Donation Consent may be given by client, spouse, adult child, parent, adult sibling, guardian Organs that can be donated: kidneys, y, heart, lungs, g,p pancreas, intestines, liver, corneas, bones, bone marrow, skin Encourage client and family to ask questions and express feelings 20

21 Organ Donation Provide support by a grief counselor or clergy Signature must be obtained for organ donation Client must be brain dead Notify Organ Procurement Organization with decision to proceed BOX Brain Death Criteria. 21