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Definition
Epidemiology
Mortality
Classification of Shock
Shock
Hypovolaemic
Neurogenic
Cardiogenic
Distributive
Anaphylactic
Septic
Shock
Classification
Classifications of Shock
Classifications of Shock:
Hypovolemic
Hypovolemic Shock
Hemorrhagic stage
Parameter
II
III
IV
<750
7501500
15002000
>2000
<15%
1530%
3040%
>40%
<100
>100
>120
>140
Normal
Decreased
Decreased
Decreased
1420
2030
3040
>35
>30
2030
515
Negligible
Normal
Anxious
Confused
Lethargic
Blood pressure
CNS symptoms
Classifications of Shock
Cardiogenic
Classifications of Shock
Anaphylactic Shock
Classifications of Shock
Others
Septic Shock (systemic inflammatory response syndrome) impaired tissue perfusion caused by widespread infection
and invasion of microrganisms in the body menyebabkan
vasodilatasi
Obstructive Shock - impaired tissue perfusion resulting
form obstruction to blood flow
Pulmonary Embolus
Aortic dissection
Neurogenic shock - impaired tissue perfusion caused by
damage or dysfunction of the sympathetic nervous system
(rare)
Trauma
Anesthesia
Spinal Shock
Pathophysiology of Shock
Compensatory
Mechanisms
Baroreceptors (pressure receptors) - terletak pada
sinus karotid dan arkus aortikus
Penurunan MAP menyebabkan menurunnya regangan
pada baroreceptors ( terjadi kehilangan efek inhibisi
baroreseptor terhadap pusat pusat vasomotor)
Aktivitas simpatetis eferen terstimulasi otak
mengirim impuls ke kelenjar adrenal untuk melepas
katekolamin (epinephrine & norepinephrine)
Catecholamines menyebabkan peningkatan denyut
jantung dan vasokonstriksi
Aktivitas parasimpatis menurun pada saat yg
bersamaan
Compensatory
Mechanisms
Chemoreceptors - berada pada arkus aortikus dan arteri
karotis
Berespon/sensitif terhadap prubahan oksigen dalam darah
Meregulasi blood pressure and heart rate
shock begins
Cell mengalami odema, membrane sel menjadi lebih
permeabel yg mengakibatkan cairan dan eletrolit berpindah
dari dan ke dalam sel mitokondria dan lisosom rusak dan
mati
Progressive Shock/
Dekompensasi
BP drops (< 80-90 mmHg). Prognosis worsens.
Meskpun shock teratasi, the patient may not recover.
Irreversible Stage
Organ damage is so severe that the patient pasien
tidak berespon terhadap tindakan dan tdk dpt
bertahan hidup
BP tetap rendah
Complete renal and liver failure, releasing toxins
metabolic acidosis >>>
Anaerobic metabolism is creating more lactic acid also
contributing to metabolic acidosis
ATP reserves are used up
The cells can no longer store ATP related to cell
destruction
Patient develops multi-organ failure
Fluid Replacement
Crystalloids - electrolyte solutions = dapat berpindah
dgn mudah antara intravascular compartment and
interstitial spaces
Selalu berikan isotonic solutions - same
concentration of electrolytes as the extracellular fluid
(avoids wide changes in plasma electrolytes)
Paling sering diberikan : Lactated Ringers and
Normal Saline
Diperlukan dalam jumlah banyak - 1/3 bagian akan
mengisi interstitial spaces
If a hypertonic solution is used (3% Saline), fluid
moves from interstitial spaces to vascular system
Fluid Replacement
Vasoactive Drugs
Nursing Responsibilities
Monitor vital signs tiap15 min selama
vasoactive drugs diberikan
Berikan melalui central line
Use an IV Pump
Titrate drip rate according to patient
parameters (ordered by the physician)
Jangan hentikan drips secara tiba2 - wean
slowly while monitoring vital signs q15 min
Nutritional Support
Nursing Responsibilities
Sedapat mungkin harus dicegah melalui
monitoring ketat pasien2 yg beresiko
Berikan terapi cairan dan obatAN secara aman
dan hati2 and document effect
Monitor for complications and side effects and
report early
Safely administer blood/blood products.
Monitor for adverse effects
Administer oxygen and monitor effectiveness
Cardiogenic
Shock
Occurs when the hearts ability to pump is impaired. Dapat
berupa gangguan pada coronary or non-coronary.
Seringkali terjadi pda pasien MIs and extensive ventricular
damage.
Apabila SV or HR menurun, blood pressure drops and tissue
perfusion terganggu
Juga, apabila SV menurun, ventricle tidak memompa keluar
darah seluruhnya tekanan balik ke sistem pulmoner
kongesti/odema pulmoner Patients in cardiogenic shock
ditandai dgn chest pain and dysrhythmias
tujuan: (1) batasi kerusakan lebih lanjut ,(2) jaga kesehatan
jantung, (3) perbaiki kemampuan pompa jantung
Distributive Shock
Category for Neurogenic, Anaphylactic and Septic Shock
terjadi vasodilatasi arterial and venous menyebabkan
relative hypovolemia
Vasodilation disebabkan oleh hilangnya tonus
simpatetis dan pelepasan mediator kimia oleh sel
Dapat segera terlihat melalui peningkatan CO
berhubungan dengan penurunan systemic vascular
resistance (SVR) and upaya jantung utk
mengkompensasi
Pooling of blood decreased venous return
decreased SV and CO decreased BP decreased
tissue perfusion
Neurogenic Shock
Anaphylactic Shock
Results from an allergic reaction. Mast cells release potent
vasodilators (histamine, bradykinin)
Occurs rapidly and is life-threatening
Treatment:
Remove causative antigen
Kembalikan tonus vascular - Epinephrine
Anti-histamines - Benadryl
Bronchodilator (Aminophylline) if patient has
histamine induced bronchospasms
Nursing Responsibilities - Prevention!!, Recognition!!
(sudden onset flushing, warmth, anxiety, itching, nasal
congestion, laryngeal edema, bronchospasm, SOB,
wheezing) Fast Action!!
Septic Shock
Most common - caused by widespread infection
Mortality rate 40 - 90%
Most common causative organisms are gram-negative
bacteria. However, can also be caused by gram-positive
and viruses
2 Phases:
Hyperdynamic - high CO with vasodilation, hyperthermic
with warm, flush skin, elevated HR and RR, UOP normal or
increased, may have nausea, vomiting or diarrhea
Hypodynamic - low CO with vasoconstriction in response to
hypovolemia from capillary leaking, BP drops, skin cool and
pale, temp normal or below, HR and RR elevated, no UOP,
multiple organ failure
Nursing Responsibilities
Prevention - use aseptic technique with all procedures,
monitor patient for signs of infection
Collaborate with health care team to identify source of
sepsis
Reduce temperature in hyperthermic patients, but
monitor closely for chills, shivering and increased O2
consumption
Administer fluids, meds, vasoactive drugs to restore
vascular volume.
Monitor antibiotic levels, BUN, Cr, WBC
Monitor hemodynamic status, I&O, nutritional status
(daily wts, albumin).
Treatment:
Control initiating event
Promote adequate organ perfusion
Provide nutritional support
Nursing Responsibilities:
essentially the same as septic shock
For those who survive, recovery and
rehabilitation is a long, slow process
Terima
Kasih