Nursing Management of shocked patient
Shock is a life-threatening condition with a variety of underlying causes. It is characterized by inadequate tissue perfusion that, if untreated, results in cell death. Early intervention along the continuum of shock is the key to improving the patient’s prognosis. Therefore, the nurse needs to assess systematically those patients at risk for shock to recognize the subtle clinical signs of the compensatory stage before the patient’s blood pressure drops.
MONITORING TISSUE PERFUSION
In assessing tissue perfusion, the nurse observes for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and laboratory values. In the compensatory stage of shock, serum sodium and blood glucose levels are elevated in response to the release of aldosterone and catecholamines. The role of the nurse at the compensatory stage of shock is to monitor the patient’s hemodynamic status and promptly report deviations to the physician, assist in identifying and treating the underlying disorder by continuous in-depth assessment of the patient, administer prescribed fluids and medications, and promote patient safety. Vital signs are key indicators of the patient’s hemodynamic status; however, blood pressure is an indirect method of monitoring tissue hypoxia. Pulse pressure correlates well to stroke volume, the amount of blood ejected from the heart with systole. Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg
(Mikhail, 1999). Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic blood pressure. Decreased or narrowing pulse pressure, an early indication of decreased stroke volume.
Nursing Management of progressive shock
Nursing care of the patient in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. The patient in the progressive stage of shock is often cared for in the intensive care setting to facilitate close monitoring (hemodynamic monitoring, electrocardiographic monitoring, arterial blood gases, serum electrolyte levels, physical and mental status changes), rapid and frequent administration of various prescribed medications and fluids, and possibly intervention with supportive technologies, such as mechanical ventilation, dialysis, and intra-aortic balloon pump. Working closely with other members of the health care team, the nurse carefully documents treatments, medications, and fluids that are administered by members of the team, recording the time, dosage or volume, and the patient’s response. Additionally, the nurse coordinates both the scheduling of diagnostic procedures that may be carried out at the bedside and the flow of health care personnel involved in the patient’s care.
If supportive technologies are used, the nurse helps reduce the risk of related complications and monitors the patient for early signs of complications. Monitoring includes evaluating blood levels of medications, observing invasive vascular lines for signs of infection, and checking neurovascular status if arterial lines are inserted, especially in the lower extremities. Simultaneously, the nurse promotes the patient’s safety and comfort by ensuring that all procedures, including invasive procedures and arterial and venous punctures, are carried out using correct aseptic techniques and that venous and arterial puncture and infusion sites are maintained with the goal of preventing infection. Positioning and repositioning the patient to promote comfort, prevent pulmonary complications, and maintain skin integrity are integral to caring for the patient in shock.
PROMOTING REST AND COMFORT
Efforts are made to minimize the cardiac workload by reducing the patient’s physical activity and fear or anxiety. Promoting rest and comfort is a priority in the patient’s care. To ensure that the patient gets as much uninterrupted rest as possible, the nurse performs only essential nursing activities. To conserve the patient’s energy, the nurse protects the patient from temperature extremes (excessive warmth or shivering cold), which can increase the metabolic rate and subsequently the cardiac workload. The patient should not be warmed too quickly, and warming blankets should not be applied because they can cause vasodilation and a subsequent drop in blood pressure.
SUPPORTING FAMILY MEMBERS
Because the patient in shock is the object of intense attention by the health care team, the family members may feel neglected; however, they may be reluctant to ask questions or seek information for fear that they will be in the way or will interfere with the attention given to the patient. The nurse should make sure that the family is comfortably situated and kept informed about the patient’s status. Often, family members need advice from the health care team to get some rest; they are more likely to take this advice if they feel that the patient is being well cared for and that they will be notified of any significant changes in the patient’s status. A visit from the hospital chaplain may be comforting to the family and provides some attention to the family while the nurse concentrates on the patient.
The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Despite treatment, blood pressure remains low. Complete renal and liver failure, compounded by the release of necrotic tissue toxins, creates an overwhelming metabolic acidosis. Anaerobic metabolism contributes to a worsening lactic acidosis. Reserves of ATP are almost totally depleted, and mechanisms for storing new supplies of energy have been destroyed. Multiple organ dysfunction progressing to complete organ failure has occurred, and death is imminent. Multiple organ dysfunction can occur as a progression along the shock continuum or as a syndrome unto itself.
As in the progressive stage of shock, the nurse focuses on carrying out prescribed treatments, monitoring the patient, preventing complications, protecting the patient from injury, and providing comfort. Offering brief explanations to the patient about what is happening is essential even if there is no certainty that the patient hears or understands what is being said. As it becomes obvious that the patient is unlikely to survive, the family needs to be informed about the prognosis and likely outcomes. Opportunities should be provided, throughout the patient’s care, for the family to see, touch, and talk to the patient. A close family friend or spiritual advisor may be of comfort to the family in dealing with the inevitable death of the patient. Whenever possible and appropriate, the family should be approached regarding any living will, advance directive, or other written or verbal wishes the patient may have shared in the event that he or she cannot participate in end-of-life decisions. In some cases, ethics committees may assist the family and health care team in making difficult decisions.
During this stage of shock, families may misinterpret the actions of the health care team. They have been told that nothing has been effective in reversing the shock and that the patient’s survival is very unlikely, yet the health care team continues to work feverishly on the patient. A distraught, grieving family may interpret this as a chance for recovery when none exists. As a result, family members may become angry when the patient dies. Conferences with all members of the health care team and the family will promote better understanding by the family of the patient’s prognosis and the purpose for the measures being taken. During these conferences, it is essential to explain that the equipment and treatments being provided are for the patient’s comfort and do not suggest that the patient will recover. Families should be encouraged to express their wishes concerning the use of life-support measures.
Overall Management Strategies in Shock
As described previously and in the discussion of types of shock to follow, management in all types and all phases of shock includes the following:
• Fluid replacement to restore intravascular volume
• Vasoactive medications to restore vasomotor tone and improve cardiac function
• Nutritional support to address the metabolic requirements that are often dramatically increased in shock
Therapies described in this section require collaboration among all members of the health care team to ensure that the manifestations of shock are quickly identified and that adequate and timely treatment is instituted to achieve the best outcome possible.