SHOCK Mr. Brown 25 years old ,was an unrestrained driver involved in a motor vehicle crash .

he was found face down is feet from his car there were no passengers. The windshield was broken and the car was found up againts a tree . mr. Brown was found conscious and moaning . he was taken to the emergency departement . Subjective data States that he cannot breathe Complains of abdominal pain Objective data Physical examination 1. Cardiovascular BP 84/70 , apical pilse 120 but no radial or brachial pilse palpable , carotid pulse present but weak 2. Lungs : respiratory rate 35x/min ,labored breathing with severe respiratory distrees asymmetric chest wall movement , absensce of breath sounds on left side 3. Abdomen : slightly distended and painful to palpation

Diagnostic studies 1. Chest X ray : hemopneumothorax and rib fractures on left side 2. Hematocrit : 28% Collaborative care 1. In the ED,placement of chest tube ,which drained bright red blood Surgical procedure 1. Splenectomy 2. Repair of torn thoracic artery

Critical thingking questions

1. What type of shock was present in MR. Brown ? what clinical manifestation did he display ? syok hipovolemik Manifestasi klinika : hypotension TD 84/70 , tachycardia and tachypnea ,weak thready pulses ,hemotocrit 28% , respiratory rate 35Xmin. 2. What were the causes of Mr .brown shock ? what are other causes of this type of shock ? karna adanya trauma hemopneumothorax . pnyebab lainya rib fractures on left side . 3. What are the initial nursing responsibilities for Mr. Brown ? 1. Pertahankan posisi pasien semi fowler 2. Berikan cairan infus 1-2 ltr . ringer laktat 3. Transfusi darah 4. Berikan nasal kanul 5. Perawatan tube 6. Monitor tanda-tanda vital 7. Cek elektrolit 8. Terapi obat-obatan vasoaktif (cacolamines yang menstimulusi reseptor alfa menyebabkan vasokontriksi dan stimulus reseptor beta menyebabkan vasodilatasi ) 4. What continual nursing assessment parameters are essential for this patient ? 1. Monitor urin 2. Mempertahankan posisi semi fowler 3. Mempertahankan tanda-tanda vital dalam batas normal 4. Pertahankan kepatenan infus 5. Based on the assessment data presented , write on or more nursing diagnoses . are there any collaborative problems ? 1. Gangguan pola nafas b.d penurunan expansi paru 2. Perubahan perfusi jaringan b.d penurunan suplai darah k jaringan 3. Nyeri b.d trauma hebat 4. Kurangnya pengetahuan b.d kuranganya informasi mengenai pengobatan

Permasalahan yang membutuhkan kolaborasi : 1. Pemasangan pen / gib pada thorak sebelah kiri akibat fraktur 2. Farmako tentang antibiotik

Nursing research issues 1. What is the patients ability to understand what is being said and happening as the shock state worsens ? 2. Compare the cognitive status of patients in different stages of shock ? 3. What nursing measures can be implemented to conserve oxygen and decrease oxygen utilization in patients with shock ? 4. What patient position improve oxygenation and circulating status ? 5. Compare the accuracy of blood preassure monitoring devices to detect the blood preassures change in shock ; invasive arterial monitoring compared with non invasive devices .

SEPSIS Mr michael is an 81 year old man who has brought to the emergency department via an ambulance from a local nursing home . he was found by the nurses on their 6 AM Rounds to be very confused ,restless , and hypotensive . Past health history Mr michael is a type 1 diabectic with a history of prostate cancer and congestive heart failure . he has been a resident of the nursing home for 3 years . he has had an indwelling urinary catheter in place for 5 days because of difficulty voiding . until today , Mr michael has been very oriented and cooperative . his current medications are digoxin , hydrochlorothiazide ( hydrodiuril), isosorbide ( isordil) and insulin . Subjective data 1. Denies any pain or discomfort

Objective data 1. Neurologic : lethargic,confused,easily aroused ,does not follow commands : moves all extermities in response to stimuli 2. Cardiovascular : B/P 80/60 , HR 112 and regular , T 1040 F(400 C) rectal ; heart sounds normal without murmur or S3 ,S4 ; peripheral pulse weak and thready 3. Skin ; warm , dry , flushed 4. Respiratory : RR 34 and shallow ; breath sounds audible in all lobes with creackles bilaterally in the bases 5. GI/GU : abdomen soft with hypoactive bowel sounds : urinary catheter in place draining scant ,purulent urine

In the ED , two 16-gauge Ivs were inserted and 700ml of normal saline was given over the first hour .the patient was place on 40% oxygen via facemask . the urinary catheter was removed and cultured and blood cultures were drawn at three intervals . a new catheter was inserted . the patient was started on IV antibiotics and was transferred to the ICU with the diagnosis of sepsis due to gram negative sepsis

In the ICU ,a pulmonary catheter was inserted in additional to an arterial line .

1. ABG result were pH 7,25 ; PaO2 60 mmhg ; Pa CO2 28 mmhg ;HCO3 12mEq/L;SaO2 82% 2. Hemodynamic pressures taken were right atrial pressure (CVP) ,PAP,PAWP,cardiac output and SVR 3. Lab results were WBC 21,000/uI,Na 133mEq/L .Cl 96 mEq/L ,glucose 230 mg/dl ,creatinine 1.7 mg/dl ,Hb 12 g/dl ,Hct 36% Mr .michaels blood pressure countinued to drop despite several liters of crystalloids . dopamine was started and titrated up as needed to try to maintain the patients blood pressure ,in addition to more fluid administration .depsite all efforts ,including intubation and mechanical ventilation ,Mr michael died on sixth hospital day .the cause was multiple organ dysfunction syndrome due to gram negative sepsis .

Critical thinking question

1. What risk factors for sepsis were present in Mr.michael ? a. Neorologic nya : lethargic, confused/bingung,easy arouse(sensitive), does not follow command/tak mau ikut perintah b. Cardiovascular : B/P 80/60, HR 112, T 40c, nadi peripheral lemah dan tak teraba c. Skin : hangat, kering dan memerah d. Respiratory : 34x/mnt dangkal, ada suara crackle/ berderak pada bagian lobus sebelah bawah e. GI/GU : Perut teraba lunak, dengan bunyi bising usung yang hypoaktif dan urinya ada pus berwarna pekat

2. What preventive measures could have been taken by the nursing home satff in regard to Mr. Michael ? a. memasang catheter karna kesulitan berkemih b. memberikan pengobatan yaitu Digoxin,Hydrochlorothiazide (Hydro Diuril), Isosorbide (Isordil) dan insulin

3. What are the major pathopysiologic changes assosiated with sepsis ? Terjadinya sepsis dapat melalui dua cara yaitu aktivasi lintasan humoral dan aktivasi cytokines. Lipopolisakarida (LPS) yang terdapat pada dinding bakteri gram negatif dan endotoksinnya serta komponen dinding sel bakteri gram positif dapat mengaktifkan: Sistim komplemen Membentunk kompleks LPS dan protein yang menempel pada sel monosit Faktor XII (Hageman faktor)

Sistim komplemen yang sudah diaktifkan akan merangsang netrofil untuk saling mengikat dan dapat menempel ke endotel vaskuler, akhirnya dilepaskan derivat asam arakhidonat, enzim lisosom superoksida radikal, sehingga memberikan efek vasoaktif lokal pada mikrovaskuler yang mengakibatkan terjadi kebocoran vaskuler. Disamping itu sistim komplemen yang sudah aktif dapat secara langsung menimbulkan meningkatnya efek kemotaksis, superoksida radikal, ensim lisosom. LBP-LPS monosit kompleks dapat mengaktifkan cytokines, kemudian cytokines akan merangsang neutrofil atau sel endotel, sel endotel akan mengaktifkan faktor jaringan PARASIT-INH-1. Sehingga dapat mengakibatkan vasodilatasi pembuluh darah dan DIC. Cytokines dapat secara langsung menimbulkan demam, perobahan-perobahan metabolik dan

perobahan hormonal.

Faktor XII (Hageman factor) akan diaktivasi oleh peptidoglikan dan asam teikot yang terdapat pada dinding bakteri gram positif. Faktor XII yang sudah aktif akan meningkatkan pemakaian faktor koagulasi sehingga terjadi disseminated intravascular coagulation (DIC). Faktor XII yang sudah aktif akan merobah prekallikrein menjadi kalikrein, kalikrein merobah kininogen sehingga terjadi pelepasan hipotensive agent yang potensial bradikinin, bradikinin akan menyebabkan vasodiltasi pembuluh darah.

Terjadinya kebocoran kapiler, akumulasi netrofil dan perobahan-perobahan metabolik, perobahan hormonal, vasodilatasi, DIC akan menimbulkan

sindroma sepsis. Hipotensi respiratory distress syndrome, multiple organ failure akhirnya kematian (Japardi, 2002).

4. Discuss the mechanism for hypotension in the patient with sepsis ? Sepsis merupakan respons sistemik terhadap infeksi dimana pathogen atau toksin dilepaskan ke dalam sirkulasi darah sehingga terjadi aktivitas proses inflamasi. (infeksi dan inflamasi)Terminologi dan Definisi Sepsis 1SIRS (Systemic Inflammatory Response Syndrome)

Respons tubuh terhadap inflamasi sistemik mencakup 2 hal atau lebih keadaan berikut: 1. suhu >38C atau <36C

2. frekuensi jantung >90x.menit

3. frekuensi napas >20x/menit atau PaCO2 <32 mmHg

4.

leukosit

darah

>12000/mm3,

<4000/mm3

atau

batang

>10%

Sepsis

Keadaan klinis

berkaitan dengan infeksi

dengan manifestasi

SIRS

Sepsis beratSepsis yang disertai dengan disfungsi organ, hipoperfusi atau hipotensi termasuk asidosis laktat, oligouria dan penurunan kesadaran Sepsis dengan hipotensiSepsis dengan tekanan darah sistolik <90 mmHg atau penurunan tekanan darah sistolik >40 mmHg dan tidak ditemukan penyebab hipotensi lainnya.

Renjatan septik Sepsis dengan hipotensi meskipun telah diberikan resusitasi cairan secara adekuat atau memerlukan vasopresor untuk mempertahankan tekanan darah dan perfusi organ

5. Explain the physiologic reason for the following assessment parameters found this patient Penurunan kesadaran karena infeksi yang disebabkan oleh adanya bakteri gram negatif sehingga menyebabkan sepsis jika Tidak tertangani dengan baik akan terjadi penurunan kesadaran. Sirkulasi ke jaringan otak menjadi semakin buruk. Bisa menyebabkan Gelisah, agitasi dan kebingungan. Warm ,dry,and flushed skin Sistem imun pada kulit dimana sel darah putih melawan jaringan tubuh / protein ekstraselular . sistem imun tubuh terdiri dari sel-sel darah puih ,antibodi dan substansi lainya yang berfungsi untuk melawan infeksi ataupun protein asing lainya . Tavhycardia Tachypnea Fever Decreased SVR Increacsed CO Oliguria Hyperglicemia

6. Why was pulmonary artery catheter indicated for Mr.michael ?

1. Karna adanya curah jantung yang rendah dengan vasokontriksi yang mencerminkan upaya tubuh untuk mengompensasi hivolemia yang disebabkan oleh kehilangan volume intravaskuler melalui kapiler . 2. Untuk mengukur curah jantung pasien 3. Untuk mendapatkan sampel darah vena dan pacu atrium kanan dan ventrikel kanan .

7. Analyze the result the arterial blood gases ? pH : 7,25 <pH turun asidosis > PCO2 : 28 mmhg < turun basa > HCO3 : 12 mEq/L <turun asam > PO2 : 60 mmHg < turun >

SaO2 : 82% <turun > Asidosis metabolik terkompensasi sebagian Tidaak memerlukan rebrathing mask 8. Describe the changes in the hemodynamic pressure that would be expected in Mr. Michael 9. Explain the rational for fluid therapy and the use of dopamine ? Karna sepsis mengalami Hipovolemia dan harus segera diatasi dengan cairan kristaloid (NaCl 0.9% atau ringer laktat) maupun koloid. Pada dopamine di berikan dengan alasan pada mr micheal mengalami penyakit kardiovaskuler serta penyakit sistem saraf pusat. 10. Based on the assesment data provided ,write one or more nursing diagnosis .what collaborative problems are present ? Pola nafas tidak efektif berhubungan dengan kelelahan otot pernafasan. Kolaborasi - Berikan oksigen tambahan - Berikan humidifikasi tambahan misalnya : nebulizer

Tugas CMSN sepsis

kelompok shock dan

Di buat oleh : 1. Athi Nuriandari 2. Hermanus bambang 3. Zulfiwati

Sekolah tinggi ilmu kesehatan Binawan 2013/2014