The document discusses shock syndrome and its definitions, pathophysiology, signs and symptoms, assessment, diagnosis, and nursing management. It defines shock syndrome as an inadequate systemic response to tissue perfusion. The main points are:
1. Shock occurs when oxygen uptake is less than oxygen demand at the tissue level, leading to anaerobic metabolism and lactic acid buildup.
2. Sepsis-induced shock is discussed in detail, including criteria for severe sepsis and septic shock. Early goal-directed therapy within 6 hours focuses on fluid resuscitation, vasopressors, inotropes, and other interventions.
3. Nursing management of shock includes identifying risk early, preventing complications,
The document discusses shock syndrome and its definitions, pathophysiology, signs and symptoms, assessment, diagnosis, and nursing management. It defines shock syndrome as an inadequate systemic response to tissue perfusion. The main points are:
1. Shock occurs when oxygen uptake is less than oxygen demand at the tissue level, leading to anaerobic metabolism and lactic acid buildup.
2. Sepsis-induced shock is discussed in detail, including criteria for severe sepsis and septic shock. Early goal-directed therapy within 6 hours focuses on fluid resuscitation, vasopressors, inotropes, and other interventions.
3. Nursing management of shock includes identifying risk early, preventing complications,
The document discusses shock syndrome and its definitions, pathophysiology, signs and symptoms, assessment, diagnosis, and nursing management. It defines shock syndrome as an inadequate systemic response to tissue perfusion. The main points are:
1. Shock occurs when oxygen uptake is less than oxygen demand at the tissue level, leading to anaerobic metabolism and lactic acid buildup.
2. Sepsis-induced shock is discussed in detail, including criteria for severe sepsis and septic shock. Early goal-directed therapy within 6 hours focuses on fluid resuscitation, vasopressors, inotropes, and other interventions.
3. Nursing management of shock includes identifying risk early, preventing complications,
Sri Setiyarini, S.Kp., M.Kes. sri_setiyarini@ugm.ac.id
Keperawatan Kritis & kegawatdaruratan PSIK-FK UGM
DEFINISI SHOCK SYNDROME adalah respon sistemik terhadap tidak adehuatnya perfusi Jaringan The pathway to shock follows a common metabolic pattern. Shock
VO 2 MRO 2 = Normal Metabolism
VO 2 < MRO 2 =
VO 2 = Oxygen Uptake = Q X 13.4 X Hb X (SpO 2 -SvO 2 ) MRO 2 = The metabolic demand for oxygen at the tissue level. The rate at which oxygen is utilized in the conversion of glucose to energy and water through glycolysis and Krebs cycle.
Process for energy production in cell when O2 in adequate
Anaerobic Metabolism Net energy production of 2 ATP Back-up energy plan in case of hypoxia Waste products Lactic acid Difficult to get rid of by The body PATHOPHYSIOLOGY OF SHOCK SYNDROME
Cells switch from aerobic to anaerobic metabolism
lactic acid production
Cell function ceases & swells
membrane becomes more permeable
electrolytes & fluids seep in & out of cell
Na+/K+ pump impaired
mitochondria damage
cell death
Tanda &Gejala Organ System Failure (komplikasi shock) Indikasi awal shock:
Heart rate Hipotensi (sistolik <90 mm Hg selama min. 30 mnt) PENGKAJIAN & PENEGAKAN DIAGNOSIS TANDA/ TAHAPAN. KOMPENSASI DEKOMPENS ASI IRREVERSIBEL HR 120-lebih 140-lebih lambat RR Sedikit berubah meningkat Agonal KESADARAN gelisah bingung koma KULIT Pucat, dingin, keringat di perifer Sangat Pucat, dingin, keringat Mottled/bercak2,dingi n,tidak ada keringat, waxen/membesar TEKANAN DAAH Sedikit berubah menurun Tidak berubah Uji diagnostik darah: electrolytes, BUN, and creatinine, CBC and coagulation profile Arterial blood gases (ABGs) or pulse oximetry Cardiac output studies cardiac index (CI), cardiac output, preload, right atrial pressure (RAP), afterload, and systemic vascular resistance Serum lactate Urinalysis: specific gravity, osmolarity, and urine electrolytes Electrocardiogram (ECG) PRINSIP PENATALAKSANAAN - Semua tipe shock terapi emergency - MAnajemen Umum utk semua shock - Manajemen khusus sesuai etiologi shock - RESUSITASI DAN INVESTIGASI harus berjalan PARALLEL dan bukan serial. Management Shock- UMUM NURSING 1. Memahami patofisiologi 2. IDENTIFIKASI DINI resiko (akan memfasilitasi diagnosis & terapi). 3. Mencegah komplikasi 4. Kontrol Infeksi 5. Support Pasien & Keluarga 6. Menyediakan rujukan & sumber & Kolaborasi TE Oh, 2009 Management Shock- UMUM MEDIS 1. Terapi O2 & Ventilasi mekanik 2. Terapi cairan 3. Support inotropik 4. Diuretik
TE Oh, 2009
Manajemen Keperawatan & Kolaborasi unt masing-masing Shock SEPSIS BERAT SHOCK SEPSIS Management tergantung pd tingkat keparahan sepsis dengan atau tanpa disertai shock Definisi-definisi SEPSIS = adanya (kemungkinan atau terdokumentasi ) infeksi bersama dengan manifestasi sistemik infeksi. SEPSIS BERAT = sepsis yang menginduksi hipoperfusi jaringan atau disfungsi organ (beberapa mengikuti infeksi) SEPSIS YANG MENGINDUKSI HIPOTENSI (Sepsis Induced Hypotenstion) = Sistolik < 90 mm Hg / MAP < 70 mm Hg / sistolik menurun > 40 mm Hg / < 2 SD dibawah Normal untuk usianya pada keadaan tidak ada penyebab lain dari hipotensi Definisi2 SEPTIC SHOCK= sepsis yg menginduksi hipotensi yang menetap walau telah diberi resusitasi cairan yg adekuat. SEPSIS YG MENGINDUKSI HIPOPERFUSI JARINGAN (Sepsis Induced Tissue Hypoperfusion) = infeksi yg menginduksi hipotensi, peningkataan kadar lactate, atau oliguria
SEPSIS BERAT & SHOCK SEPSIS Pengambilan sampel darah (identifikasi mikroorganisme penyebab). sampel darah minimal 2 set (botol aerobic and anaerobic) dan diambil dng 2 cara yi: langsung tusuk/percutaneous dan lewat peralatan IV (setelah 48 jam pemasangan alat) Sampel urin, secresi pernafasan, luka, cairan tubuh lainnya (grade 1C). KRITERIA Sepsis Berat o Sepsis-menginduksi hipotensi o Kadar Laktat diatas nilai normal o Urine output < 0.5 mL/kg/jam untuk > 2 j walau reusisitasi adekuat o Acute lung injury dng Pao2/Fio2 < 250 tanpa infeksi pneumonia sbg pyebab o Acute lung injury dng Pao2/Fio2 < 200 tanpa infeksi pneumonia sbg pyebab o Creatinine > 2.0 mg/dL (176.8 mol/L) o Bilirubin > 2 mg/dL (34.2 mol/L) o Platelet count < 100,000 L o Coagulopati (international normalized ratio > 1.5) Adapted from Levy MM, Fink MP, Marshall JC, et al: 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31: 12501256. Surviving Sepsis Campaign care bundles Dalam waktu 3 jam terjadi SEPSIS BERAT 1. Ukur kadar LAKTAT 2. Lakukan KULTUR DARAH SEBELUM PEMBERIAN ANTIBIOTIK 3. Beri Terapi ANTIBIOTIK SPEKTRUM LUAS 4. Beri 30 mL/kg kristaloid untuk hipotensi atau kadar lactate 4 mmol/L (tidak dianjurkan pemberian HAES Dalam waktu 6 jam terdapat tanda gejala septic shock: 5. Terapi dng vasopressors ( untuk hipotensi yang tidak berespon terhadap resusitasi cairan untuk mempertahankan MAP 65 mm Hg) 6. Pada kondisi terjadi hipotensi menetap walaupun telah diresusitasi cairan (septic shock) atau kadar laktat awal 4 mmol/L (36 mg/dL), maka lakukan: Pengukuran CVP PENGUKURAN saturasi oksigen vena sentral 7. Ukur kembali kadar laktat jika kadar laktat awal meningkat 8. Indikasi diberi Albumin jika resusitasi cairan membutuhkan banyak 9. Fluid challenges, untuk mengkaji respon penggantian cairan 10. Jika tidak tjd peningkatan hemodinamik walau penggantian cairan telah cukup maka hentikan penambahan cairan dan beri vasopressors, 11. Tambahan terapi jika saturasi oxygen vena < 70% atau menetap < 65% persists selama 6 jam resus cairan yg adekuat: Infus dobutamin (max. 20 g/kg per mnt) atau Transfusi PRC untuk mencapai min. hematocrit 30% untuk mencapai tujuan saturasi oksigen
12. Vasopressors. Ditujukan unt mempertahankan perfusi jar krn hipotensi yg mengancam nyawa belum terselesaikan mencapai target MAP 65 mm hg (grade 1C) Norepinephrine direkomendasikan sbg pilihan utama (grade 1B). 13.Inotropic Therapy Dobutamin infus dicoba s/d dosis 20 g/kg/min (digunakan sbg tambahan pemberian vassopresor jk terdapat Disfungsi miolard, CO rendah, tanda2 hipoperfusi, (grade 1C). Penggunaan dobutamine sbg pilihan utama pd kondisi dicurigai CO rendah 14. Mengurangi pemberian produk darah terutama PRC kecuali Hb < 7gr/dl 15. Ventilator pd ps sepsis yg menginduksi in Respiratory Distress Syndrome Beri TV 6 mL/kg (grade 1A). Pertahankan plateau pressures 30 cm h2O / kurang (grade 1B) Beri PEEP (grade 1B) 16. Minimalkan sedasi, hindari obat blok neuromuskular 17. Kontrol gula darah (insulin diberikan jk GD> 180 mg/dL. 18. Profilaksis stress ulcers 19. Nutrisi Tujuan resusitasi dini pada 6 jam sepsis-induced hypoperfusion(grade 1C): (a) CVP 812 mm hg (b) MAP 65 mm hg (c) Urine output 0.5 mL/kg/jam (d) Central venous (superior vena cava) oxygen saturation 70% or mixed venous oxygen saturation 65%. Pencegahan INFEKSI Cuci tangan, barrier precautions, perawatan kateter Posisi kepala ditinggikan Oral care dng subglottic suctioning, Dekontaminasi oral dan digestif untuk mengurangi VAP (grade 2B). Dekontaminasi oropharyngeal dng oral chlorhexidine gluconate untuk mengurangi risiko VAP pd sepsis berat (grade 2B) Selama sepsis dan shock, Monitoring.. status hemodinamik. jaga CVP 812 mm Hg. RR status. AGD, catat: pH, PaO2, PaCO2. kadar glucose darah (control pd 80110 mg/dL) sesuaikan teteran infus insulin status neurologic Cegah INOS, VAP, pertahankan tehnik aseptic secara ketat
Minimum PEEP tidal volume & end- inspiratory plateau pressure adekuat. Terapi IV : colloids and crystalloids, and fluid challenge Kaji keseimbangan Cairan & Elektrolit. Platelets jik kadar <5,000/mm3. Drotrecogin alfa (Xigris): obat anticoagulant, profibrinolytic, anti-inflamasi Posisi optimal unt pertukaran gas (HOB 45). Reposisi tiap 2 jam. Perawatan kulit sesuai prosedur Terapi jika demam DIAGNOS KEPERAWATAN UTAMA RISIKO SHOCK b/d sepsis, SIRS OUTCOMES. status Imun Terapi perilaku: kesakitan atau cedera INTERVENTION kontrol infeksi penatalaksanaan Medikasi Management lingkungan Surveillance Management Nutrisi
cl as s Blood loss (ml) % Pulse rate Pulse press Syst BP Rec refil RR Menta l state U/O I < 750 15% N N N N N alert >30 ml/hr II 750- 1500 15-30 % > 100 reduce N prolon ged
20-30 anxiou s 2030 ml/hr III 1500- 2000 30-40 %
> 120 Very reduce reduce Very prolon ge 30-40 confus ed 520 ml/hr IV > 2000 > 40 %
>140 but variable in terminal stages of shock Very reduce d/ absent Very reduced
absent >45 or slow sighing respirat ion Comato sed/ uncons cious < 5 ml/hr HIPOVOLEMIK SHOCK DIAGNOSA KEPERAWATAN UTAMA Defisit volume cairan b/d kehilangan volume cairan secara aktif OUTCOMES. Fluid balance Electrolit and acid/base balance Hydration INTERVENTIONS mengurangi perdarahan resuscitasi cairan, transfusi produk darah Circulatory care Shock management Monitoring asam basa HIPOVOLEMIK SHOCK Kolaborasi Tindakan awal: ABC Terapi definitif (operasi, dll) untuk mengontrol sumber kehilangan Resusitasi cairan pd waktu yang tepat IV kateter ukuran besar. Jk mungkin hangatkan dahulu cairannya risiko hipotermi.
Resusitasi cairan Umumnya mendahului sebelum tindakan lain Rekomendasi The American College of Surgeons: o Crystalloid: RL / NaCl : shock tahap I, II o crystalloids + produk darah: shock tahap III and IV. o 3 ml crystalloid - every 1 mL of blood loss. o RBCs (> disukai) / WB jika resusitasi kristaloid tidak berhasil. vasopressors, TIDAK mulai diberikan jika cairan dalam intravascular masih tidak cukup atau underperfused Posisi Trendelenburgs fasilitasi venous return dan mencegah perpindahan visera abdominal dan diafragma. Ps Sadar, beri penjelasan akan prosedur yg diberikan.
CARDIOGENIC SHOCK DIAGNOS KEPERAWATAN UTAMA Penurunan Cardiac Output b/d perubahan kontraktilitas miokard/preload/afterload/stroke volume/ OUTCOMES. Circulation status Cardiac pump effectiveness Tissue perfusion: abdominal organs, Cardiac, Peripheral; Vital sign INTERVENTION Tujuan utama: membatasi konsumsi O2 miocard CO perfuasi jaringan dan oksigenasi (PaO2 >70 mm Hg). MANAGEMENT Batasi aktivitas Bedrest. Jelaskan prosedur anxiety Keluarga menunggui ( jk dpt stress). Lingkungan: tenang, nyaman Obat-obatan: diberikan dg berbagai cara Hemodinamik stabil: diuretics + nitrates (preload) Hpotensi berat: vasoactive dan mungkin jg Vasopressors MEDICAL MANAGEMENT Percutaneous Coronary Intervention (Pci), Thrombolysis, Coronary Artery Bypass Grafting Intra-aortic Balloon Pump Obstructive Shock PULMONARY EMBOLUS - Heparin CARDIAC TAMPONADE Surgical or percutaneous drainage of pericardial fluid
TERAPI: ABCDE Resusitasi cairan-kristaloind PA catheter helpful in preventing overhydration. Look for other causes of hypotension Consider vasopressor support with dopamine or dobutamine Transfer patient to regional spine center Anaphylactic Shock Shock karena hipersensitivitas luas Bentuk dari shock distributif. Killer Bee Penyebab Drugs: Penicillin and related antibiotics Aspirin Trimethoprim- sulfamethoxazole (Bactrim, Septra) Vancomycin NSAIDs Other: Hymenoptera stings Insect parts and molds X-Ray contrast media (ionic) Foods and Additives: Shellfish Soy beans Nuts Wheat Milk Eggs Monosodium glutamate Nitrates and nitrites Tartrazine dyes (food colors)
TERAPI: Airway (have low threshold for early intubation) Oxygenation and ventilation Epinephrine (IV, IM, SC IV Fluids (crystalloids) Antihistamines Steroids Beta agonists Aminophylline Pressor support (dopamine, dobutamine / epinephrine) Diagnosis Keperawatan umum pada semua shock DIAGNOSA: Intoleransi aktivitas ketidakseimbangan suplai dan kebutuhan oksigen OUTCOME toleran thd aktivitas Konservasi energi Melaksanakan aktivitas fisik tanpa kelelahan INTERVENTION Manajemen energi Cardiac care INTERVENTIAON: Manajemen Nutrisi Terapi oksigen Promosi/memenuhi kebutuhan tidur Perawatan Diri : Bantu ADL Monitor tanda vital Exercise therapy: gerakan persendian
REFERENSI UTAMA Dellinger, R.P., et al. and and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. 2013. Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Critical Care MedicineFebruary 2013. Volume 4. Number 2 Kleinpell R., Aitken L and Schorr C.A.2013. Implications of the New International Sepsis Guidelines for Nursing. Am J Crit Care 2013;22:212-222 doi: 10.4037/ajcc2013158 Bulecheck, G.M., Butcher H.K., Dochterman J.McC. 2008. Nursing intervention Classification (NIC), 5 th ed. Elseviers health science, Philladelphia. Jonshon M., et al. And Center for Nursing Classification & Clinical effectiveness. 2006. NANDA, NOC and NIC Linkages. 2 nd ed.Mosby Elsevier. Missouri. NANDA International. 2012. Nursing Diagnoses Definition and Classification 2012-2014. Wiley-Blackwell , Iowa TE Oh, et al.2009. Internsive Care. Maturnuwun..