Stages of shock

Early – compensatory

1. stim. sympathetic NS (epinephrine & norepinephrine released to ↑cardiac output send ↑blood

to tissues

2. ↑glucocorticoids & mineralcorticoids cause Na & fluid retention to ↑intravascular volume

3. hypoxemia causes hyperventilation (early respiratory alkalosis)

4. decreased capillary fluid pressure causes fluid shift from interstitial space to intravascular

5. body shunts blood from the skin, kidney, & GI to brain & lungs

Signs & symptoms (early)– classic : decreased BP

1. restlessness, apprehension, feeling of fright

2. bowel sounds hypoactive

3. increased thready weak pulse >100

4. decreased UO (20-30 ml /hr.); decreased urinary Na (because Na retained to↑volume)

5. increased urinary osmolarity [urine concentration]

6. skin – cool & clammy

7. temp. = normal

Medical Management

Identify cause & try to correct

1. Are they losing blood?

2. Do they need meds?

3. Fluid replacement?

Nursing Care

Assess, monitor, evaluate

1. LOC

2. V/S.

3. 40 mmpulse pressure (systolic – diastolic) correlates with stroke volume. normal is 30-40 mm Hg. narrowing of pulse pressure is indicator of shock. report systolic 90

4. UO: 30 ml/hr (best indicator of hypoperfusion) If↓or absent, shock progressed, maintain UO

5. skin

6. with elderly check for hypertension, infections, & decreased organ perfusion. Is it a rxn to drugs?

7. lab

a. blood gases

b. ↑Na and glucose, aldosterone & catecholamines

c. capnography: CO₂ measure

d. gastric tonometry – balloon to measure CO₂ & pH of intestinal mucosa

e. central venous or mixed venous O₂ sat

Administer IV medications

promote pt safety & decrease anxiety

confusion of the 1^st things you see

explain, provide support, speak calmly, use touch, provide safety

Progressive Shock

Progressive

1. mechanisms that regulate BP no longer compensate. 90 40 mm Hg

2. myocardial depression - heart becomes dysfunctional

3.body's inability to meet O₂ requirements produces ischemia

4. autoregulatory function of microcirculation fails – results in ↑capillary permeability, so fluid

leaks from capillaries which causes interstitial edema, less fluid return to heart

5. arteriole & venous constriction further compromise cellular perfusion

6. relaxation of capillary spincters

7. inflammatory response is activated, coagulation response is activated

8. body mobilizes energy stores & increases O₂ consumption to help meet metabolic needs – need

to treat symptoms of shock. Surviving shock depends on health of individual prior to shock.

Signs & Symptoms

1. rapid, shallow respirations with crackles O₂ ↓ CO₂ ↑ due to pulmonary edema (pt can get MI, cardiac enzymes released) BNP (B-type naturetic P) lose consciousness

2. BP 80-90 mm Hg

3. HR 150

4. skin mottled, petechiae

5. UO 5-15 mL / hr (oliguria)

6. lethargy – confused due to hypoxia

7. metabolic acidosis

8. get adult respiratory edema "ARDS" or adult respiratory distress syndrome or "shock lung"

9. check cardiac enzymes: CPK, MB, tryponin I, LDH. these increase when ventricles distended

10. MAP can affect GFR, then BUN & creatinine will be high

GI

1. stress ulcers – can get necrotic / gangrene

2. bloody diarrhea

Hematologic –

1. toxins can pass into bloodstream due to ↑permeability

2. disseminated intravascular coagulation "DIC" from clotting

Nursing care

1. assess for subtle changes

   a. ABG

b. electrolytes

c. mental LOC

d. is pt on dialysis or ventilator?

*balloon in heart can increase cardiac effectiveness "balloon pump"

2. coordinate everything

3. prevent infection

4. promote rest & comfort (get pt warm, but not too warm) – BP will ↓

5. provide support to family

Irreversible – later: not survive

noncompensatory – organ damage severe, continue to treat, but start to make end of life decision

1. decreased blood flow to heart

2. anaerobic metabolism (acidosis)

3. arteriolar dilation

4. decreased blood flow to kidney – aneuric (retention) failure of N-K pump, Na enters cell, shifts to hypovolemia from intravascular to interstitial

5. multiple organ failure

Progresses

1.BP decreases

2.Urinary volume decreases

3.metabolic acidosis

4.signs & symptoms of failure of most organs

Signs & Symptoms

1. BP requires mechanical or pharmacologic support

2. HR erratic or asystole

3. respiratory requires intubation

4. jaundice – liver failure

5. aneuric – requires dialysis

6. unconscious

7. profound acidosis

Stages of general anesthesia

Stages of general anesthesia

A. Stage I (induction) begins with the administration of intravenous agents or with inhalation of a

combination of anesthetic gases and oxygen

Endotracheal intubation is performed or newer devices are used ie. laryngeal mask airway,

esophageal tracheal combitube, or lighted stylet or wand to see vocal cords

B. Stage 2 (maintenance) during this phase the client is positioned, skin prepped, surgery performed

1. once it is safe for any of these activities to begin, then maintenance phase is begun

2. during this phase the appropriate levels of anesthesia are maintained. The depth of anesthesia

can be increased as needed

C. Stage III (emergence phase) this period begins when the anesthesiologist dereases the anesthetic

agents & pt begins to awaken

1. extubation usually occurs during this period

2. complications can occur such as laryngospasm, vomiting, slow spontaneous respirations, &

uncontrolled reflex movement

IV. Factors which place the intraoperative pt at risk;

A. advanced age can decrease tolerance of general anesthesia, physiologic changes in aging can

affect blood, fluid loss & replacement, hypothermia, pain, tolerance of surgical

procedure / position

B. respiratory disorders: respiration depression from general anesthesia & acid / base imbalances

can occur

C. renal & liver dysfunction: may poorly tolerate general anesthesia & can have fluid / electrolye

& acid / base imbalances, decreased metabolism & excretion of drugs

D. alcoholism can increase the amount of anesthesia required

E. medications: anticoagulants (including aspirin) can cause intraoperative hemorrhage

1. diuretics – esp. thiazides can cause fluid & electrolyte imbalances. some are K⁺ sparing,

some are not. can produce altered cardio / vasc response & respiratory depression

2. antihypertensives (esp. phenothiazines) can increase hypotensive affects of anesthesia

3. antidepressants (esp. monoamine oxidase inhibitors) can increase hypotensive affects

4. antibiotics (esp. "mycin") may cause apnea and resp. paralysis

5. herbal supplements – can prolong anesthesia affects. esp. ones with sedative affects,

ie. St. John's wort (can increase bleeding risk, increase BP)

V. Potential Intraoperative Complications

A. Nausea & vomiting: if gagging occurs, turn pt to side & head of bed lowered to prevent aspiration

anesthesiologist can give antiemetics

B. hypoxia & respiratory complications: inadequate ventilation, occlusion of airway, inadvertently

put in esophagus instead of trachea

peripheral perfusion is checked frequently and oxygen sat monitored

C. Hypothermia: body temp below normal 98.0

1. glucose if metabolism is reduced. as a result can have metabolic acidosis?

2. warm solutions can be given, blankets, change any wet gowns, remove wet drapes

read pg 63 about malignant hypertension box 4-1

Types of agents used for general anesthesia

Types of agents used for general anesthesia

A. IV induction agents or total intravenous anesthesia "TIVA" has rapid onset & last only few mins.

This allows time for endo-tracheal tube to be inserted & inhalation agent to be started

1. Clients with a history of malignant hyperthermia should avoid inhalation agents because

they trigger MH (malignant hyperthermia)

2. Examples of IV agents:

Barbituates: pentothal & brevital

Non-barbituates: amidate & diprivan

B. Inhalation agents – may be volatile liquids – room temp = gas

1. Volatile liquids are administered through a specially designed vaporizer after being mixed

with O₂ as a carrier gas

2. enters body through alveoli

3. administered through a mask, endotracheal tube, laryngeal mask airway or tracheostomy

4. Ease of administration & rapid excretion by ventilation make them desirable agenst

5. Non-desirable effect is the irritating effect on respiratory tract

6. Complications that can arise are coughing, laryngospasm, bronchospasm, ↑secretions,

and respiratory depression

7. Examples of volatile liquids: fluothane, ethrane, & forane

8. gaseous agents: nitrous oxide

C. Adjuncts to general anesthesia – drugs that are added to an inhalation anesthetic other than IV

induction agent is an adjunct

1. Opioids are used preoperatively for sedation & analgesia, intraoperatively for induction &

maintenance of anesthesia, & postop for pain management.

a. They alter response to pain stimuli

b. If given close to the end of surgery, the residual analgesia often carries over in the PACU

This allows pt to awaken pain-free.

c. Examples: fentanyl, morphine-sulfate, & demerol

d. increase risk of respiratory depression – closely observe pt respiration & O₂ sat

e. Narcan is the drug used to reverse respiratory depression from opiates & it will reverse all

analgesic effects

2. Benzodiazepines are widely used for pre-medication before surgery for their amnestic effects, as

agents for the induction & maintenance of anesthesia, for conscious sedation, as supplemental

IV sedation during local & regional anesthesia, & for postop anxiety & agitation

a. Versed is the most commonly used benzo due to its shorter duration of aciton, amnestic

property, & absence of pain on injection

b. can be given IM or IV

c. can get respiratory depression with benzos

d. Flumazenil (romazicon) is the antagonist that may be used to reverse effects of benzos

(used as an antidote like narcan)

3. Neuromuscular blocking agents (muscle relaxants) are used as adjuncts to general anesthesia

to facilitate endotracheal intubations & to optimize the surgical working conditions by providing

relaxation & paralysis of skeletal muscles

a. neuromuscular blocking agents interrupt the trans. of nerve impulses at neuromuscular. jxn.

b. disadvantages of use of muscle relaxants is that the duration of their action may be longer

than the surgical procedure or reversal agents may not be completely effective & eliminated -

residual effects

Pt must be carefully observed so that their respiratory muscle movements & air patency good

Are they getting enough oxygen?

4. Antiemetics are used preoperatively, intraop, & postop. can be given with anesthesia

examples:

a. Zofran

b. phenergen

c. reglan

d. anapsin

Intraoperative Period

Intraoperative Period

I. Two main types of anesthesia: Anesthesia is classified according to the effect it has on the pt's CNS

& pain perception

A. Regional anesthesia: loss of sensation to a region of the body without loss of consciousness

when a specific nerve or group is blocked with administration of a local anesthetic

1. The pt may be given medication(s) to produce mild sedation or to relieve anxiety.

2. The nurse must avoid careless conversation, unnecessary noise, and unpleasant smells

which can be noticed by pt & cause OR experience to be negative

3. An example of regional: a. spinal., b. epidural., & c. peripheral nerve block

B. General anesthesia is the loss of sensation with loss of consciousness, skeletal muscle

relaxation, analgesia, and elimination of the somatic, autonomic & endocrine responses

including coughing, gagging, vomiting, & sympathetic NS responsiveness

1. General anesthesia is usually the technique of choice for pts having surgical procedures

a. that require significant skeletal muscle relaxation

b. last for long period of time

c. require awkward positions because of location of incision site

d. or require control of respiration

e. The client is extremely anxious & unable to have local or regional due to

contraindications or refuse

f. or if client is unable to remain immobile for long period of time. ie. head injury,

or intoxication

2. General anesthesia is most commonly administered by inhalation & to lesser extent by IV

3. An advantage to general anesthesia is the rapid excretion of the anesthetic agent &

prompt reversal of its effects when desired. It can be used with all age groups & any

type of surgery

4. Disadvantages of general anesthesia include risks associated with circulatory, respiratory,

hepatic, & renal side effects

a. If pt has a history of CHF or emphysema = greater risk for complications

b. Pts with hepatic & renal disorders can't excrete – liver not metabolize well