Discuss Collaborative Interventions for the Person Experiencing Shock, Including Medications, Blood Transfusion and Intravenous Fluids

Week 13 revision: Shock and trauma

Learning Outcomes

1. Discuss collaborative interventions for the person experiencing shock, including medications, blood transfusion and intravenous fluids.
2. Describe the risk factors, aetiologies and pathophysiology of the different types of shock.
3. Identify the classifications of shock.
4. Discuss the four (4) stages and clinical manifestations of shock.
5. Describe the components and types of trauma.
6. Discuss causes, effects and initial management of trauma.
7. Discuss diagnostic tests used in assessing the person experiencing trauma and shock.

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1. Discuss collaborative interventions for the person experiencing shock, including medications, blood transfusion and intravenous fluids.

Interventions

Nursing care for a Pt experiencing shock focuses on assessing and monitoring overall tissue perfusion and on meeting the physiological needs of the Pt. Decreased cardiac output is a primary issue for a person in shock. Assess and monitor the following:

• BP, HR and rhythm, heart sounds
• RR, WOB, SpO2, lung sounds
• Peripheral pulses
• Temp

A baseline assessment in required to establish which stage of shock the person is in.

• Measure and record fluid input/output. (A ↓ in circulating blood volume ċ hypotention + the effect of the compensatory mechanisms associated ċ shock can cause renal failure. Urinary output < 0.5mL/kg/hr in an acutly sick pt indicates ↓ renal blood flow)
• Monitor bowl sounds, abdo distention and abdo pain. (↓ splenic blood flow reduces peristalsis)
• Monitor skin colour, temp, turgor and moisture. (↓ tissue perfusion is evidenced by the skin becoming pale, cool and moist; as haemoglobin concentration ↓ cyanosis occurs).
• Monitor body temp. (An ↑ in body temp will ↑ metabolic demand, therefore ↑ myocardial O2 demand and may place the Pt ċ previous cardiac problems at greater risk of hypoperfusion)
• Assess mental status and level of consciousness. (Restlessness + anxiety are common early in shock, in the later stages the Pt may become lethargic + progress to a comatose state. Altered levels of consciousness are the result of both cerebral hypoxia and acidosis)

Maintain bed rest. Place the Pt in the supine position ċ legs elevated to about 20 degrees, trunk flat, head and shoulders should be elevated above the chest (use a pillow). A little rhyme I was taught is ‘if they are pale raise the tail, if they are red raise the head’. Limiting activity and ensuring rest ↓ the workload of the heart. The supine position ċ legs elevated ↑ venous return; however this should not be used for Pts in cardiogenic shock.

Medications

When fluid replacement is not enough to reverse shock vasoactive and inotropic drugs may be administered. When used to treat shock these types of drugs increase venous return through vasoconstriction of the peripheral vessels, ↑ the contractility of the heart and dilate coronary arteries to ↑ perfusion to the myocardium.

Vasoconstrictors: adrenaline, noradrenaline

Inotropes: Dopamine, dobutamine, isoprenaline

These drugs (sympathomimetics) mimic the fight-or-flight response of the sympathetic nervous system, selectively stimulating alpha-adrenergic and beta-adrenergic receptors.

The physiological effect of these drugs includes improved perfusion and oxygenation to the heart, ċ ↑ stroke volume and HR and ↑ cardiac output. Increased cardiac output in turn ↑ tissue perfusion and oxygenation. The main disadvantage is that increases in stroke volume and HR also increase O2 requirements of the myocardium.

Vasodilators: GTN

Act directly on smooth muscle (arteries and veins). ↓ cardiac output as a result of vasodilation. These effects ↓ the O2 demand of the heart and ↓ pulmonary congestion. These drugs are used to treat cardiogenic shock and may be combined ċ vasoconstrictors and inotropes.

Other medications that may be given to a Pt in shock include:

• Diuretics (to ↑ urine output after fluid replacement has begun)
• Sodium bicarbonate (to treat acidosis)
• Calcium (to replace calcium lost as a result of blood transfusions)
• Antiarrhythmic agents (to stabilise heart rhythm)
• Broad spectrum antibiotics (septic shock)
• Cardiotonic glycoside (for heart failure)
• Corticosteroids (anaphylactic shock)
• Morphine (dilate veins and ↓ anxiety)

 Blood transfusion

Blood and blood products may be used to treat hypovolemic shock due to haemorrhage. Whole blood, fresh-frozen plasma, packed RBCs, platelet concentration or cryprecipitate may be given. Packed RBCs are given to provide haemoglobin concentration and are supplemented ċ crystalloids to maintain adequate circulatory volume. Whole blood or blood products ↑ O2 carrying capacity of the blood, thus ↑ O2 to the cells.

IV fluids