SYOK

Definiton
• Shock refers to a general failure of the circulation either due to fluid loss or inefficiency of the circulatory blood flow control mechanisms, resulting in tissue damage.
• Shock is a harmful complex condition affects to somebody’s life caused by inadequate of blood flow to the tissues and body’s cell.
• Shock is generally characterized by hypotension, cold skin, and often tachycardia.
• During shock, the body activates homeostatic mechanisms to prevent damage and normalize the blood flow and tissue perfussion.
Classification
• Hypovolemic Shock
• Cardiogenic Shock
• Distributive/vasogenic Shock
• Obstructive Shock
 Hypovolemic Shock occurs when intravascular volume is decreasing
 Cardiogenic Shock occurs when there is an inadequate heart pump condition, caused by coroner or uncoroner effect
 Distributive Shock occurs when there is vasculatur’s blood flow imbalance
 Obstructive Shock caused by mechanic obstruction of blood flow through central circulation system eventhough miocard function and intravascular volume is normal.
Shock Pathophysiology
• A. Cellular Shock Effect
• When blood flow and oxygen supply for body’s cell is decreasing, they produce energy through an anaerob methabolism which consequently increase low energy level and acidic intracellular environment. The cells swollen and it’s membran becomes permeable which effect to Kalium-Natrium Pump.





Nursing Care Planning

1. Airway and Breathing
2. Circulation and Bleeding Control
3. Distribution –Neurologic Intervention
4. Exposure
5. Gastric Dilatation – Decompression
6. Urethra Cateter

a. Airway and Breathing
- Airway and breathing is main priority to get an adequate oxygenation
- Oxygen supply needed for maintaining O2 pressure between 80-100 mmHg
b. Circulation and Bleeding Control
• Priorities : control the extend bleeding, venous access, and examine tissue perfusion
• Extend bleeding controlled by wound area pressing, e.g: head, neck, and extremities
• Pelvic bleeding and inferior extremities controlled by using PSAG (gurita)
c. Disability – Neurologic Treatment
• Conscious level score, eye ball moving and pupil reaction, motoric and sensoric function.
d. Exposure
• Client suggested to take off their clothes to get a wide describe about their condition but hypotermia must be considered after all.
e. Gastric Dilatation
• Gastric dilatation sometimes happen to traumatic client, and causing hypotension
• NGT is used to prevent aspiration


Fluid Resuscitation and Organic Perfusion Evaluation
• Simptomps and signs is used to diagnose shock, and examine resuscitation
• Reverted blood pressure, blood pulse are signs whether circulation become much better eventhough they don’t indicate organic perfusion either
• Normalize skin condition refer to

INTERVENTION
• Apex auscultation, score frequency, heart pulse (documentize disritmia if telemetri’s available)
• Tachycardia often occurs (even rest-time) to compensate ventrikular contractility decreasing. Disrhytmia KAP, PAT, MAT, PVC, and AF generalize related to CHF eventhough
Evaluate blood pressure
• R/ A progressive decreasing blood pressure indicates worse condition of patient
Evaluated normal saline
• R/ Fluid therapy usually is given to a hypovolemic shock, fluid observation avoid excessed fluid intake
Skin color evaluation & cyanosis
• R/ Pale indicates perifer perfusion decreasing to heart flow inadequate, vasoconstriction and anemia
• Cool, clammy skin due to vasoconstriction and stimulation of vasoconstriction
Urine volume, consentrate and color evaluation
• R/ Decreased urine volume may occur as decreased heart flow response
Sensoric evaluation, e.g, letargi, disorientation
• Indicate cerebral perfusion inadequate caused by haert flow decreasing
Collaboration
• Give extended O2 due to indication
R/ Increasing O2 supply for body’s need
• Blood transfusion due to indication
R/ Compesating blood loss and fixing the general condition
• Digoksin (Lanoxin)
R/ Increasing myocardium contraction and blood flow
Collaboration
• ECG
R/ monitoring heart condition
Evaluation
• Signs and simptoms used to diagnose shock also to intervence result, normal lizen blood pressure, normal pulse ( vital sign is normal).
• Normalizing skin color indicate percution improve ment & normalize urine output approximately ( 30-50 cc / hour)















Management of Shock
Shock is a serious medical condition where the tissue perfusion is insufficient to meet demand for oxygen and nutrients because the body is not getting enough blood flow. This can damage multiple organs and can get worse very rapidly. This hypoperfusional state is a life-threatening medical emergency and one of the leading causes of death for critically ill people.

Major classes of shock include
:
1. Hypovolemic Shock (caused by inadequate blood volume)

Hypovolemic shock is an emergency condition in which severe blood and fluid loss makes the heart unable to pump enough blood to the body. This type of shock can cause many organs to stop working.


Blood loss can be due to bleeding from cuts or other injury or internal bleeding such as gastrointestinal tract bleeding. The amount of blood in your body may drop when you lose too many other body fluids, which can happen with diarrhea, vomiting, burns, and other conditions.


Management of Shock

Symptom are :
• Anxiety, restlessness, altered mental state due to decreased cerebral perfusion and subsequent hypoxia.

• Hypotension due to decrease in circulatory volume.

• A rapid, weak, thready pulse due to decreased blood flow combined with tachycardia.

• Cool, clammy skin due to vasoconstriction and stimulation of vasoconstriction.

• Rapid and deep respirations due to sympathetic nervous system stimulation and acidosis.

• Hypothermia due to decreased perfusion and evaporation of sweat.

• Thirst and dry mouth, due to fluid depletion.

• Fatigue due to inadequate oxygenation.

• Cold and mottled skin (cutis marmorata), especially extremities, due to insufficient perfusion of the skin.

Therapy are include :
• Maintain or increase intravascular volume, In hypovolaemic shock, caused by bleeding, it is necessary to immediately control the bleeding and restore the victim's blood volume by giving infusions of balanced salt solutions. Blood transfusions are necessary for loss of large amounts of blood (e.g. greater than 20% of blood volume), but can be avoided in smaller and slower losses. Hypovolaemia due to burns, diarrhoea, vomiting, etc. is treated with infusions of electrolyte solutions that balance the nature of the fluid lost.

• Decrease any future fluid loss via I.V fluid regimen

• Give supplementary O2 therapy to commence replacement of fluids via the intravenous route.

2. Cardiogenic shock (associated with heart problems)

Cardiogenic shock is a disease state where the heart is damaged enough that it is unable to supply sufficient blood to the body. Most common causes are :

a). acute myocardial infarction

b). dilated cardiomyopathy, This is a serious disease in which the heart muscle becomes inflamed (enlarged and stretched) and doesn't work as well as it should.

c). acute myocarditis

d). arrhythmias


Symptoms are
:
similar to hypovolaemic shock but in addition:
• Distended jugular veins due to increased jugular venous pressure.

• Absent pulse due to tachyarrhythmia.

Therapy are include

The main goals of the treatment of cardiogenic shock are the re-establishment of circulation to the myocardium, minimising heart muscle damage and improving the heart's effectiveness as a pump.
• Oxygen (O2) therapy to reduces the workload of the heart by reducing tissue demands for blood flow.

• Administration of cardiac drugs

• Increase heart’s pumping action through medication such as Dopamine, dobutamine, epinephrine, norepinephrine, amrinone

3. Septic shock (associated with infections)

Septic shock is a serious condition that occurs when an overwhelming infection leads to low blood pressure and low blood flow. The brain, heart, kidneys, and liver may not work properly or may fail.


Most common of this case may it’s happened to the patients with Meningococcemia, Waterhouse-Friderichsen syndrome, DIC (disseminated intravascular coagulation), Multiple organ dysfunction syndrome (MODS), Acute Respiratory Distress Syndrome (ARDS).

Symtomps are
:
similar to hypovolaemic shock except in the first stages:
• Pyrexia and fever, or hyperthermia, due to overwhelming bacterial infection.

• Vasodilation and increased cardiac output due to sepsis.

Therapy are include :
• Restore intravascular volume via I.V fluid

• Give supplemental O2 therapy

• Identify and control source of infection

• Administer antibiotic

• Remove risk factor for infection

4. Neurogenic shock (caused by damage to the nervous system)
Neurogenic shock is shock caused by the sudden loss of the sympathetic nervous system signals to the smooth muscle in vessel walls. This can result from severe central nervous system (brain and spinal cord) damage. With the sudden loss of background sympathetic stimulation, the vessels suddenly relax resulting in a sudden decrease in peripheral vascular resistance and decrease blood pressure
.

Signsandsymptoms:
similar to hypovolaemic shock except in the skin's characteristics. In neurogenic shock, the skin is warm and dry.


Therapy are include :
• Large volumes of fluid may be needed to restore normal hemodynamics

• Vasopressors (Norepinephrine)

• Atropine (speeds up heart rate and Cardiac Output)

5. Anaphylactic Shock (caused by allergic reaction)

Anaphylaxis is an severe, whole-body allergic reaction. After an initial exposure to a substance like bee sting toxin, the person's immune system becomes sensitized to that allergen. On a subsequent exposure, an allergic reaction occurs. This reaction is sudden, severe, and involves the whole body.


Common causes include insect bites/stings, horse serum (used in some vaccines), food allergies, and drug allergies.


Symptoms of anaphylaxis are related to the action of Immunoglobulin E and other anaphylatoxins, which act to release histamine and other mediator substances from mast cells (degranulation). In addition to other effects, histamine induces vasodilation of arterioles and constriction of bronchioles in the lungs, also known as bronchospasm (constriction of the airways).

Symptoms can include the following
:
Polyuria, respiratory distress, hypotension (low blood pressure), encephalitis, fainting, unconsciousness, urticaria (hives), flushed appearance, angioedema (swelling of the lips, face, neck and throat), tears (due to angioedema and stress), vomiting, itching, diarrhea, abdominal pain, anxiety, impending sense of doom.


Therapy are include :
• Identify and remove causative antigen
• Administer counter-mediators such as anti-histamine
• Oxygen therapy and I.V fluid replacemen



















Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium
Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestinal (GI) tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment are paramount to prevent potentially life-threatening hypovolemic shock. Elderly patients are more likely to develop fluid imbalances.
Defining Characteristics:
• Decreased urine output
• Concentrated urine
• Output greater than intake
• Sudden weight loss
• Decreased venous filling
• Hemoconcentration
• Increased serum sodium
• Hypotension
• Thirst
• Increased pulse rate
• Decreased skin turgor
• Dry mucous membranes
• Weakness
• Possible weight gain
• Changes in mental status
Related Factors:
• Inadequate fluid intake
• Active fluid loss (diuresis, abnormal drainage or bleeding, diarrhea)
• Failure of regulatory mechanisms
• Electrolyte and acid-base imbalances
• Increased metabolic rate (fever, infection)
• Fluid shifts (edema or effusions)
Expected Outcomes
• Patient experiences adequate fluid volume and electrolyte balance as evidenced by urine output greater than 30 ml/hr, normotensive blood pressure (BP), heart rate (HR) 100 beats/min, consistency of weight, and normal skin turgor.

Ongoing Assessment
• Obtain patient history to ascertain the probable cause of the fluid disturbance. This can help to guide interventions. Causes may include acute trauma and bleeding, reduced fluid intake from changes in cognition, large amount of drainage post-surgery, or persistent diarrhea.
• Assess or instruct patient to monitor weight daily and consistently, with same scale, and preferably at the same time of day. This facilitates accurate measurement and follows trends.
• Evaluate fluid status in relation to dietary intake. Determine if patient has been on a fluid restriction. Most fluid enters the body through drinking, water in foods, and water formed by oxidation of foods.
• Monitor and document vital signs. Sinus tachycardia may occur with hypovolemia to maintain an effective cardiac output. Usually the pulse is weak, and may be irregular if electrolyte imbalance also occurs. Hypotension is evident in hypovolemia.
• Monitor blood pressure for orthostatic changes (from patient lying supine to high-Fowler’s). Note the following orthostatic hypotension significance:
o Greater than 10 mm Hg drop: circulating blood volume is decreased by 20%.
o Greater than 20 to 30 mm Hg drop: circulating blood volume is decreased by 40%.
• Assess skin turgor and mucous membranes for signs of dehydration. The skin in elderly patients loses its elasticity; therefore skin turgor should be assessed over the sternum or on the inner thighs. Longitudinal furrows may be noted along the tongue.
• Assess color and amount of urine. Report urine output less than 30 ml/hr for 2 consecutive hours. Concentrated urine denotes fluid deficit.
• Monitor temperature. Febrile states decrease body fluids through perspiration and increased respiration.
• Monitor active fluid loss from wound drainage, tubes, diarrhea, bleeding, and vomiting; maintain accurate input and output.
• Monitor serum electrolytes and urine osmolality and report abnormal values. Elevated hemoglobin and elevated blood urea nitrogen (BUN) suggest fluid deficit. Urine-specific gravity is likewise increased.
• Document baseline mental status and record during each nursing shift. Dehydration can alter mental status.
• Evaluate whether patient has any related heart problem before initiating parenteral therapy. Cardiac and elderly patients often have precarious fluid balances and are prone to develop pulmonary edema.
• Determine patient’s fluid preferences: type, temperature (hot or cold).
• During treatment, monitor closely for signs of circulatory overload (headache, flushed skin, tachycardia, venous distention, elevated central venous pressure [CVP], shortness of breath, increased BP, tachypnea, cough). This prevents complications associated with therapy.
• If hospitalized, monitor hemodynamic status including CVP, pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP) if available. This direct measurement serves as optimal guide for therapy.
Therapeutic Interventions
• Encourage patient to drink prescribed fluid amounts.
o If oral fluids are tolerated, provide oral fluids patient prefers. Place at bedside within easy reach. Provide fresh water and a straw. Be creative in selecting fluid sources (e.g., flavored gelatin, frozen juice bars, sports drink).
Oral fluid replacement is indicated for mild fluid deficit. Elderly patients have a decreased sense of thirst and may need ongoing reminders to drink.
• Assist patient if unable to feed self and encourage caregiver to assist with feedings as appropriate.
• Plan daily activities. Planning prevents patient from being too tired at mealtimes.
• Provide oral hygiene. This promotes interest in drinking.
For more severe hypovolemia:
• Obtain and maintain a large-bore intravenous (IV) catheter. Parenteral fluid replacement is indicated to prevent shock.
• Administer parenteral fluids as ordered. Anticipate the need for an IV fluid challenge with immediate infusion of fluids for patients with abnormal vital signs.
• Administer blood products as prescribed. These may be required for active GI bleeding.
• Assist the physician with insertion of a central venous line and arterial line as indicated. This allows more effective fluid administration and monitoring.
• Maintain IV flow rate.
o Should signs of fluid overload occur, stop infusion and sit patient up or dangle. These decrease venous return and optimize breathing.
Elderly patients are especially susceptible to fluid overload.
• Institute measures to control excessive electrolyte loss (e.g., resting the GI tract, administering antipyretics as ordered).
• Once ongoing fluid losses have stopped, begin to advance the diet in volume and composition.
• For hypovolemia due to severe diarrhea or vomiting, administer antidiarrheal or antiemetic medications as prescribed, in addition to IV fluids.
Education/Continuity of Care
• Describe or teach causes of fluid losses or decreased fluid intake.
• Explain or reinforce rationale and intended effect of treatment program.
• Explain importance of maintaining proper nutrition and hydration.
• Teach interventions to prevent future episodes of inadequate intake. Patients need to understand the importance of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid deficits.
• Inform patient or caregiver of importance of maintaining prescribed fluid intake and special diet considerations involved.
• If patients are to receive IV fluids at home, instruct caregiver in managing IV equipment. Allow sufficient time for return demonstration. Responsibility for maintaining venous access sites and IV supplies may be overwhelming for caregiver. In addition, elderly caregivers may not have the cognitive ability and manual dexterity required for this therapy.
• Refer to home health nurse as appropriate.