Jenna Cohen Exam 2 Study Guide Cardiovascular Dysfunction Part 2 The Nursing Care of the Child in Shock Shock Failure to maintain adequate perfusion to vital organs shock means poor perfusion Physiology Shock different types Cardiogenic decrease cardiac output impaired pumping Rare in Peds pump is not moving adequately to properly get through only in ped patient after cardiac surgery toxicities that may impair the hearts function some congenital defects that would cause a weak impaired pumping heart congenital defects may lead to cardiogenic shock due to the stress on the heart have the fluid but the pump itself isn t functioning correctly Hypovolemic large reduction in circulating blood volume fluid shift or loss of fluid volume dehydration vomiting diarrhea fluid not in the right spot common in kids could be due to a big trauma causing bleeding Distributive Vasogenic Shock widespread vasodilation and increased capillary permeability Types of Distributive allowing fluid to get out of the vessels fluid leaving the vessels not where it needs to be o Anaphylactic Shock severe allergic reaction o Neurogenic Shock vasodilation result of loss of sympathetic tone by spinal cord or nervous system damage sns is not functioning properly due to damage o Septic Shock wide spread infection probably the most saddle in developing and can often be caught by surprised didn t know they had a widespread infection Shock Compensation if big bad acute injury this will happen very quickly minutes hours a slow bleed or a heart slowly using function can take much longer important we look more than one VS back to see trends Compensated organs maintained by compensatory mechanism s blood flow is uneven epinephrine norepinephrine dopamine o HR increased RR increased or normal narrow pulse pressure difference in systolic and diastolic they re closer and closer together which impacts perfusion which is r t shock irritability BP WNL for age decreased urine output unless monitoring very closely for another purpose not likely this will be picked up pallor peripheral perfusion decreased leads to pallor Uncompensated CV system failing compensatory mechanisms failing only have so much epi in our system naturally o HR increase RR increased BP decreased confusion moderate metabolic acidosis poor capillary refill oliguria going down and even more decreased urine output more signs of peripheral perfusion Severely Uncompensated Irreversible this is hard to predict outcome very difficult to predict situation can turn back to normal functioning but also cannot return back or have significant brain damage organ damage so great that death may occur even if able to return BP HR and saturations s to normal bc of deprivation of blood flow and oxygen o Periodic breathing or apnea decreased BP decreased HR thready pulse anuria stupor coma HR was going up now it s bottoming out no urine being created bc not getting what they need Assessing shock level degree of tachycardia bradycardia usually a last sign LOC BP Lab Procedures All types of Shock o CBC with diff want to think of the anemia that may be resulting or may be the cause would clue us in to sepsis if WBC count increased o BUN Creatinine o Electrolytes cardiogenic whether we have an electrolyte important to the heart o Pt Ptt INR platelets clotting studies can use up many of these substances from that is imbalanced being in shock o Urinalysis o ABGs Cardiogenic Shock Rare in Peds o Cardiac enzymes Hypovolemic Shock if R T blood loss o Type and Crossmatch Septic Shock Cardiogenic Shock o ECG o Cardiac echocardiogram o Computerized tomography CT o Cardiac catheterization o Chest X ray Hypovolemic o Blood urine and wound cultures Diagnostic Tests expected in ICU Severe level situations culture everything before initiating abx good look at the heart electricity problem or pumping o CVP central venous pressure tells us the hydration pressure through the central veins ICU situation as well as the cardiogenic shock in a quick manner Analysis of Assessments Key Nursing Diagnoses Concepts Impaired Gas Exchange Oxygenation priority Ineffective tissue perfusion R T Decreased cardiac Output Perfusion Fluid Volume Deficient Anxiety pending death severity of condition Oxygenation Gas exchange Fluid Electrolyte Balance Coping Addressing oxygenation problems is key to make it through the rest of these issues any shock situation would result in decreased cardiac output fluid volume deficient due to hypovolemia or due to distributive where the fluid is not where it needs to be in priority interventions work on the most sensitive organ system address the respiratory system will they need intubation for long term restoring blood volume using boluses 10 20cc kg dose of either ns or lactated ringers also can use colloid products like plasmanate will go into blood vessels and wont get leaked and lost when we have a fluid shift if we need blood products themselves give the fluid in those dosings then blood product components position changing not that effective priority for everyone put oxygen on perfusion All Types of Shock O2 Deprivation problem for everyone Hypovolemic Shock o Fluids before o Vasopressors Neurogenic Shock o Fluids o Preferred perfusor Norepinephrine Septic Shock top priority after oxygen o Antibiotics o Preferred perfusor Norepinephrine o Possible fluids Heparin Clotting factors Platelets Plasma depending on extent and impact the shock is having on the patient Anaphylactic Shock o Epinephrine if we have an IV we give it IV if we don t we give it IM Antihstamine diphenhydramine o Possible corticosteroid decrease inflammation and swelling leading to complications from swelling Cardiogenic Shock o Decreased afterload Inotropic Drugs RARE so the heart doesn t have to work as hard fluids aren t here bc we have sufficient fluid First Priority Nursing Interventions Administer Prescribed Meds normal saline or lactated ringers 10 20cc kg dose FLUIDS FIRST Vasopressor Dopamine look at PME for both drugs to see how they work improved bp improved perfusion to get us through emergency situations Sympathomimetic Epinephrine First Priority Nursing Interventions Administer Prescribed Medications All types of Shock o Proton pump inhibitors prevent stress ulcers Prilosec Nexium in PME Hypovolemic Prilosec nexium o Volume replacement with 0 9 NS or Ringers Lactate o Blood products if needed dosed according to weight o Vasopressors replace fluid first Cardiogenic o Rare in children