shock

hypovolemic-decreased body fluid (hemorrhage, dehydration)

cardiovascular-direct pump failure (MI)

distributive- Fluid shift from central vascular space; increase in fluid (pain, anesthesia, sepsis)

Obstructive-indirect pump failure; cardiac function decreased (pulmonary embolus)

• decreased cardiac output
• increased pulse; thready
• decreased BP
• slow cap. refill
• diminshed peripheral pulse

• Icreased resp. rate; shallow depth
• Cyanosis, around lips and nail beds
• increased Paco2
• decreased Pao2

• Eearly:
• anxiety
• restlessness
• increased thirst

• Late:
• lethargy
• muscle weakness
• absent deep tendo reflex
• sluggish pupillary response to light

• decreased urine output
• increased specific gravity
• sugar present in urine

• cool/cold
• pale, mottled to cyanotic
• moist, clammy
• mouth dry

• decreased motility
• diminished bowel sounds
• n/v
• constipation

• Diuretic therapy
• Diminished thirst reflex
• immobility
• use of aspirin
• use of compilmentary therapies
• anticoagulant therapy

• Total blood volume
• Cardiac Output
• Size of vascular bed

*these are related to oxygenation and tissue perfusion

*Increases in total blood volume or cardiac  output raise MAP. Decreases lower MAP.

*Increase in bed size lower MAP and decreases raise MAP

*allergic reaction, happens in seconds to minutes

*loss of blood vessel tone; decreased cardiac output

*widespread infection that triggers a whole body inflammatory response (distributive shock); infection in blood

• response of capillaries that change blood vessel intergrity and allow fluid to shift from te blood vessels into interstitial tissue. Once in tissue can no longer supply O2 or remove waste
• (burns, peritonitis, large wounds, malnutrition)

loss of blood volume from vascular space, resulting in decreased MAP, and a loss of O2 carrying capacity from the loss of curculating RBC's

• intitial
• nonprogressive
• progressive
• reactory

*patients baseline MAP is 5-10mm Hg less

*compensatory mechanisms are so effective at returning systolic pressure to  normal that O2 blood flow to vital organs is maintained

*may notice an increase in pt's heart and RR from baseline or slight increase in diastolic bp

*MAP decreases 10-15mm Hg

*this activates kidney and hormonal compensatory mechanisms b/c cardiovascular are no longer to maitain supply of O2 to organs on own

*kidneys release renin (ADH) which maintains fluid volume by fluid constriction; ie decreased urine output and blood vessel constriction in skin

*pt will be thirsty and anxious, restless, tachycardia, increased RR, decreased urine output, decreased systolic, increased dystolic, 2-5% decrease in O2, pt cold 

*sustained decrease in MAP of more than 20 mm Hg

*O2 not being delivered to vital organs, severe cell damage and death

*pt feels impending doom, confused, rapid weak pulse, low bp, cyanosis, anuria, rising latic acid and postassium level

*this needs to be corrected in less than 1 hour for pt to survive

*too much cell deat has occurred, therapy no longer effective

Multiple Organ Dysfunction Syndrome- one organ dies and contiues to the next

• age
• GI ulcers
• surgery
• hemophilia
• liver diorders
• vomiting and diarrhea
• asparin, diuretics and NSAIDS

PH < 7.35 = decreased tissue O2

Latic acid > 7= decreased tissue O2, buildup metabolites

• Hematocrit > 47% (F), 52% (M)=
•                     Dehydration
•                  < 37% (F), 42% (M)=
•                     Hemorrhage
•  
• Hemoglobin > 16 (F), 18(M)= dehydration
•                   < 12 (F), 14(M)= hemorrhage

Potassium> 5= dehydration

*fluid replacement, increase plasma volume

*cotains sodium, chlorde, calcium, potassium, and lactate dissolved in water-expands vlume, and buffers acidosis

• ensure airway
• start IV
• administer O2
• Elevate feet, head flat <30 degrees
• examinefor overt bleedng (apply pressure if necessary)
• administer drugs
• icrease iv flow
• do not leave pt

pulse, BP, Pulse pressure, Central Venous pressure (monitors rt atrium), RR, skin and mucosal color, O2 saturation, mental status, urine output

*every 15 minutes

• dopamine
• norepinephrine

• dobutamine
• milrinone

sodium nitroprusside

• maintain tissue perfusion
• replace loss fluid
• control fluid loss
• treat cause of hypovolemia
• support compensatory mechaisms