Cardiogenic – lemone 274 (learn the chart with manifestations)

Cardiogenic – lemone 274 (learn the chart with manifestations)

Heart's pumping ability is compromised to the point that it cannot maintain cardiac output & adequate tissue perfusion, cyanosis more prevalent,↑CVP, edema, fluid overload. * MI is primary cause

anterior wall of heart affected

cardiogenic shock leads to:

1. decreased cardiac contractility which leads to ↓l

2. decreased stroke volume & cardiac output which leads to ↓l

3. pulmonary congestion which leads to ↓l

4. decreased coronary artery perfusion which leads to ↓l

5. decreased cardiac contractility (creates cycle)

*treatment:

1. give O₂,

2. control chest pain (morphine a. dilates blood vessels, b. ↓preload, c.↓afterload, d.↓anxiety)

morphine is a vasoactive drug

Distributive

1. vasodilation &↓peripheral resistance (ability of vessels to contract & relax)

2. relative hypovolemia – body not really have low volume, but body thinks so due to vasodilation.

3. when you faint, this is distributive shock

4. precipitating event (infection etc)

5. vasodilation

6. activation of inflammatory response (↑capillary permeability – fluid seeps into tissue. if not treated, then pt really does lose fluid)

7. maldistribution of blood volume which leads to ↓

8. decreased venous return which leads to↓

9. decreased cardiac output which leads to ↓

10. decreased tissue perfusion

Septic – caused by widespread infection, most common type of distributive shock

1. leading cause of death in ICU

2. gram neg. bacteria. ie. E. coli; also some gram +

3. look for susceptible people: transplant pt, chemotherapy, elderly, very young, chronic illnesses, malnourished, invasive procedures

4. skin warm due to vasodilation ↑temp; later skin will be cold

5. blood clotting in capillaries will use up clotting factor, pt will get "DIC" - prone to bleeding

6. use APC – human activated protein will↓mortality in septic shock, anti-inflammatory, stimulates fibrinolysis, balances hemostasis between coagulation & anti-coagulation

7. nutrition needed also

Vasodilators

Vasodilators

1. Nitroglycerine (Tridil) & Nitroprusside (Nipride)

2. reduce preload (pressure when blood into heart- ↓ pressure) & afterload (heart has to pump against aorta), ↓O₂ demand of the heart

3. disadvantage: cause hypotension

4. given with cardiogenic shock

5. given with dopamine or dobutrex helps maintain BP

Vasoconstrictors (not used much) short-term, problem maintaining BP, will ↑BP

1. Norepinephrine (Levophed), Phenylephrine (Neo-Synephyrine), Vasopressin (Pitressin)

2. increase BP by vasocontriction

3. disadvantage: ↑afterload, thereby ↑workload of heart, compromise perfusion to skin, kidneys,

lungs, GI tract.

Other meds Lemone 277

1. diuretics ↑UO only when fluid replacement adequate

2. sodium bicarb – buffer

3. calcium

4. antiarrhythmics

5. broad-spectrum antibiotics – all invasive procedures

6. cardiogenic glycosides

7. corticosteroids

8. morphine

9. oxygen by mask, canula

10. Oxygen for 4-6 hrs then oxygen P0₂ 80 (best 90) perfusion 85. on ventilator if too low

Nutritional Support – need 3000 cal / day, will burn muscle in shock, helps GI to have food run thru it

1. Parenteral

2. Enteral – if in shock long time

   glutamine – ess. amino acid in stress – immunologic function in GI tract. fuel for lymphocytes

3. Stress ulcers – must be on something

a. H₂ inhibitors – pepcid, zantac

b. proton pump inhibitors - prevacid

Hypovolemic – lemone 273

1. caused by a ↓in circulating volume of 15% or greater (for 154 lbs pt, loss of 750-1300 ml / blood) this is 3 units of loss

2. external fluid loss – trauma, surgery, vomiting, diarrhea, diuresis, diabetes insipidus

3. internal fluid loss – hemorrhage, burns, ascites, peritonitis, dehydration, third space

4. progression: treatment is *prevention, correct underlying cause. ie with nausea give antiemetics

monitor blood glucose

Hypovolemic Shock leads to:

1. decreased blood volume which leads to↓

2. decreased venous return which leads to ↓

3. decreased stroke volume which leads to ↓

4. decreased cardiac output which leads to ↓

5. decreased kidney perfusion

*try to give packed red cells, give lactated ringers sol'n and .9 normal saline, elevate feet to↑BP

(this is called "shock position" or modified trendelenberg)

Management of Shock: interdisciplinary approach

Management of Shock: interdisciplinary approach, be timely, recognize & treat, notify Dr.

1. fluid replacement to restore intravascular volume

2. vasoactive meds. to restore vasomotor tone & improve cardiac function

3. nutritional support to address metabolic requirements

Fluid Replacement: give it early to maximize intravascular volume

1. controversial

2. crystalloids

   a. 0.9% NaCl (isotonic)

   b. D5 lactated ringers (isotonic) – has some electrolytes, glucose, & lactate ion which changes

   to bicarb which buffers metabolic acidosis

   c. 3% NaCl (*hypernatremia can develop from hypertonic sol'n & cause fluid to move into

intravascular compartment from interstitial

3. colloids – volume expanders

a. albumin – blood product

b. hetastarch – synthetic, less expensive, can prolong clotting time

c. dextran – synthetic, less expensive, prolong platelet aggregation,

d. plasma protein fraction

Complications of Fluid Administration

1. CVP – central venous pressure – line in rt. atria measure pressure (normal is 4-12)

a. hypovolemic shock – down to -2 ("0" has to be at heart level with manometer)*

b. hypervolemic – up to 20

2. Cardiovascular overload & pulmonary edema – from too much fluid

a. UO – perfusion of kidneys & shock progession

b. mental status – confused – too much fluid get brain edema

c. skin perfusion – cold clammy

d. V/S changes BP ↓(late) pulse increased

e. lung sounds – listen for edema

Medications – Vasoactive agents

1. must be on IV pump

2. monitor every 15 minutes

3. titrate (↓or↑ ) to maintain MAP level

4. shows good perfusion, want MAP 65

Vasoactive agents

Sympathomimetics – adrenergic drugs

Amrinone (Inocor), Dobutamine (Dobutrex), Dopamine (Inotropin), Epinephrine (adrenalin), Milrinone (primacor)

1. ↑contractility, ↑stroke volume, ↑cardiac output

2. disadvantages: causes ↑oxygen demand of heart

vasopressive & vasoconstrictive affect

1. α adrenergic drugs constrict blood vessels, ↑BP
   

   a. inotropic drugs ↑stroke volume, improve cardiac contractility, ↑cardiac output

   dopamine, dobutamine, isopril (can cause rapid HR), cause↑O₂ demand of heart,

usually give a mixture. ie. dopamine & vasodilator so heart can get enough O₂

2. β₁ adrenergic drugs –↑HR & myocardial contractions

1. β₂ adrenergic drugs – vasodilation of heart & skeletal muscles & bronchioles relax

2. 
   

Deep Vein Thrombosis

Deep Vein Thrombosis - can get from lower abdominal surgery

1. cause

2. signs & symptoms

3. management

4. pulmonary embolism

Respiratory Complications – cigarette smokers, chest surgery, abdominal surgery pts,

1. Aelectasis – primarily, temp > 100

2. bronchitis (is a form of COPD, as is asthma), can produce muco-pus

3. bronchopneumonia - 2^nd most common complication. productive cough, ↑T, ↑pulse, ↑resp.

4. lobar pneumonia – lobe of the lung, chill, ↑TPR, flushed cheeks, little or no cough, give antibiotics, expectorant, fluids

5. hypostatic pulmonary congestion – old, weak, poor ambulation, secretions pool in lungs, crackles in lungs, dullness in lower lung, semi-Fowlers

6. pleurisy – inflammation, knife-like pain in chest on inspiration, slight T, resp. rapid, ↓O₂ ,

restless, apprehension, give pain meds & antibiotics, ambulate, inspirometer

know pulmonary embolism S&S postop

Urinary Complications

1. urinary retention – caused by spasms of bladder sphincter (assess bladder) can use ultrasound

2. urinary incontinence - elderly

GI Complications

1. nausea – postop prevent aspiration

2. constipation

3. paralytic ileus (no bowel sounds). bowel sounds should be back within 24 hrs. in 36 hrs if not present, it is paralytic ileus

4. intestinal obstruction – twist or scar tissue blockage

   a. hyperactive bowel sounds above obstruction

   b. hypoactive bowel sounds below obstruction

Postop Psychosis

1. physiological

   a. cerebral anoxia

   b. meds

   c. * electrolyte imbalance

   d. thromboembolism to brain

2. psychological

   a. fear & anxiety (to prevent: inform pt, orient, be positive, talk about familiar things)

   b. pain

   c. depression

   d. obscured vision, confinement (ICU pts)

severe: need mental health expert, use same nurse each day, well-lit room, restraint if necessary

Neurogenic

Neurogenic

1. result of an imbalance between P & S stimulation of vascular smooth muscle.

   a. parasymp. (activates vasodilation) &

   b. sympath. (activates vasoconstriction)

2. If parasymp. overstimulation or sympath. understimulation persists, sustained vasodilation occurs, which leads to ↓

3. blood pools in the venous & capillary beds

4. seen in

   a. spinal cord injury

   b. insulin shock

   c. syncopy (fainting)

   d. is short-lived

   e. skin is warm & dry

   f. hypotension & bradycardia (slow heart rate)

Disseminated Intravascular Coagulation "DIC" *seen with infections (pg 1146 lemone)

1. characterized by widespread intravascular clotting & bleeding

2. low platelet & fibrinogen levels

3. prolonged PT, PTT, & thrombin time

4. elevated fibrin degradation products (FDPs) or fibrin split products (FSPs)

5. D-dimers

6. *seen with infections ie. fetus dies in utero, abrutio placenta

7. symptoms due to↑fibrinolysis

   a. oozing at IV site

   b. bleeding when brushing teeth

Interventions – treat the cause

1. correct secondary effects of tissue ischemia

   a. give O₂

   b. fluids

   c. correct electrolyte imbalances

   d. administer vasopressors

   e. no RBCs because plasma has clotting factors

2. fresh frozen plasma & platelet concentrate

3. Heparin – interferes with clotting cascade

Blood Types – lemone 262-263, Taylor 1716-1717

A type A agglutinogen agglutinin B (antibodies will clot with addition of B)

B type B agglutinogen agglutinin A (antibodies will clot with addition of A)

AB type A&B agglutinogen neither (universal recipient)

O Neither A or B both A & B (universal donor)

autologous donation – pt donates own blood for use after own surgery

Blood & Blood Components

1. whole bloodstream

2. packed RBC PRBC

3. platelets

4. plasma

5. cryoprecipitate

6. clotting factors

7. prothrombin

8. albumin

Risks

1. Circulatory overload

2. electrolyte imbalances

3. infectious diseases

4. reactions

   a. febrile (primary reaction – withing 15 min)

   b. hypersensitivity: if get reaction, *stop transfusion & give Benadryl if needed

   c. hemolytic reactions – rarest reactions – wrong blood (will clump) ✰check urine for blood

   d. can get transfusion reaction in pt with frequent transfusions, get pre-medication to prevent

✽precautions✽

1. nurse must check blood type & date and sign form

2. write start & end time of transfusion

3. hang saline drip to rinse line before doing drip.

4. sit with pt & check V/S every 5 minutes for 1^st 15 minutes

   Hemorrhage – (pg 74) treatment – shock position, stop bleeding, get order for IV blood,

1. primary: time of operation

2. intermediary: 1^st 24 hrs past surgery

3. secondary: later from erosion / infection

4. capillary: slow ooze

5. venous: bubble dark

6. arterial: spurt with every beat, bright,

7. evident

8. concealed✴symptoms: apprehensive, thirsty, pale cold, rapid pulse, weak,↓temp, rapid - deep respirations, cardiac output ↓, BP↓, cyanosis, spots before eyes