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What is shock?

Why is shock
considered a

A widespread abnormal cellular
metabolism that occurs when the human
need for oxygenation and tissue
perfusion is not met to the level needed
to maintain cell function. It is the "wholebody" response that occurs when too
little oxygen is delivered to the tissues.
Because the cellular, tissue, and organ
events that occur in response to its
presence happen in a predictable


What can start the
syndrome of shock
and lead to a lifethreatening

Any problem that impairs oxygen
delivery to tissue and organs


What is shock
more often the
result of?

Cardiovascular problems and changes.


What are older
patients in long
term care at risk

Sepsis and shock related to UTI's

What occurs when
(compensation) or
are not effective
and shock

Severe hypoxia can lead to cell loss,
multiple organ dysfunction syndrome
(MODS), and dath.

How is shock
usually classified?

By the functional impairment it cuases
(hypovolemic shock, cardiogenic shock,
distributive shock, and obtrusive shock)
or by the origin of the problem
(hypovolemic, cardiogenic, vasogenic
and septic shock).




What do
oxygenation and
tissue perfusion
depend on?

How much oxygen and arterial blood
perfuses the tissue.


What is tissue and
organ perfusion
related to?

Mean arterial pressure (MAP)


Since the
system is a closed
but continuous
circuit what
factors influence

"• Total blood volume
• Cardiac output
• Size of the vascular bed"


Total blood volume and
cardiac output are
directly related to MAP
so what raises MAP?

"• Increase in Total blood volume
• Increase in Cardiac output"


How is the size of the
vascular bed related to

Any problem that impairs oxygen
delivery to tissue and organs
vasoconstriction or dialation


What is sympathetic

The state of partial blood vessel


What happens when
blood vessels dilate by
relaxing smooth muscle
in the vessel walls and
total blood volume
remains the same?

Blood pressure decreases and
blood flow is slower. Decreases in
sympathetic tone relax blood
vessel smooth muscle, dilating
blood vessels and lowering MAP.


What happens when
blood vessels constrict
and total blood volume
remains the same?

Blood pressure increases and
blood flow is faster. Incrases in
sympathetic stimulation constrict
blood vessel smooth muscle even
more than normal and raise MAP.


What parts of the body
can tolerate low levels
of oxygenation for hours
without dying or being

Some organs, such as the skin
and skeletal muscles.


What parts of the body
tolerate hypoxic
conditions poorly?

Other organs such as the heart,
brain, liver and pancreas tolerate
hypoxic conditions poorly, and
even just a few minutes with
adquated oxygen results in serious
damage and cell death.


How do we classify
Hypovolemic Shock with
relation to functional

"Total body fluid decreased in all
• Hemorrhage
• Dehydration"


How do we classify
Cardiogenic Shock by
functional impairment?

"Direct pump failure, fluid volume
not affected
• Myocardial Infarction
• Valvular problems such as
stenosis or incompetence
• Myopathies• Dysrhythmias•
Cardiac Arrest"


How do we classify
Obstructive Shock by
functional impairment?

"Cardiac function is decreased by
noncardiac factors, total fluid
volume not affected, central
volume decreased.
• Pulmonary hypertension• Tension
pneumothorax • Pericarditis•
Thoracic tumor• Tamponade"

and increased blood vessel permeability (capillary leak). What is neuralinduced distrbutive shock? It is a loss of MAP that occurs when sympathetic nerve impulses controlling blood vessel smooth muscle are decreased and the smooth muscles of blood vessels relax.Thready pulse • Decreased blood pressure. especially around lips and nail beds 39. What are the three common origins of chemicalinduced shock? "• Anaphylaxis • Sepsis • Capillary leak syndrome" What is the result of Anaphylaxis? Widespread loss of blood vessel tone and decreased cardiac output. Hypoproteinemia 35. 27. Diminished peripheral pulses 37. Hyperglycemia • Kidney disease. 24. 33. What can cause Distributibe Shock? A loss of sympathetic tone. 34. opioids. Ascites • Peritonitis. Paralytic ileus • Severe malnutrition. What problems cause fluid shifts? "• Severe burns • Liver disorders. and increased hydrostatic pressure in the blood. The heart itself remains normal but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle. sedatives) • Chemical-induced loss of vascular tone from sepsis. 36. Narrowed pulse pressure • Postural hypotension. 21. 31. pooling of blood in venous and capilalry beds. What are the respiratory manifestations of shock? "• Increased respiratory rate • Shallow depth of respirations • Decreased Paco2 • Decreased Pao2 • Cyanosis. When does Distributive Shock occur? When blood volume is not lost from the body but is distributed to the interstitial tissues where it cannot circulate and delivery oxygen. What is capillary leak syndrome? It is the response of capillaries to the presenc of biologic chemical (mediators) that change blood vessel integrity and allow fluid to shift from the blood in the vascular space into the interstitial tissues. What does the fluid shift in capillary leak syndrome result from? They result from increased size of capillary pores. total body fluid volume normal or increased.How do we classify Distributive Shock by functional impairment? "Fluid shifts from central central vascular space. • Neural-induced loss of vascular tone (head trauma. resulting in the body's total need for oxygen not being met. these fluids are stagnant and cannot deliver oxygen or remove tissue waste products. When does Cardogenic Shock occur? When the actual heart muscle is unhealhty and pumping is directly impaired. What are the cardiovascular manifestations of shock? "• Decreased cardiac output • Increased pulse rate. blood vessel dilation. What are the most common causes of obstructive shock? "• Pericarditis • Cardiac tamponade" 38. loss of plasma osmolarity. This blood vessel dilatin can be a normal local response to injury. What is the most common cause of direct pump failure? Myocardial Infarction What does any type of pump failure cause? Decreased cardiac output and MAP 26. Once in the interstitial tissue. • Trauma • Large wounds. 32. capillary leak" 22. What is the result of Sepsis? Sepsis is a widespread infection that triggers a whole-body inflammation response which leads to distributive shock when infectious microorganisms are present in the blood. anaphylaxis. 28. When does Hypovolemic Shock occur? It occurs when too little circulating blood volume causes a MAP decrease. What are the neuromuscular manifestations of shock? "Early= Anxiety• Restlessness• Increased thirst Late=• Decreased CSN activity (lethargy to coma)• Generalized muscle weakness• Diminished or absent deep tendon reflexes• Sluggish pupillary response to light . causing vasodilation. 30. All these can decrease MAP and may be started by nerve changes (neural induced) or the presence of chemicals (chemical induced). anesthesia. 25. 23. Low CVP • Flat neck and hand veins in dependent positions • Slow cap refill. but shock results when the vasoldilation is widespread or systemic. 29. What is obstructive shock caused by? Problems that impair the ability of the normal heart muscle to pump efectively.

What are the gastrointestinal manifestations of shock? "• Decreased motility • Diminished or absent bowel sounds • Nausea and vomiting • Constipation" 53. What does the reduced MAP with Hypovolemic Shock result in? Decreased tissue pefusion. Are these effects temporary and reversible? Yes. 48. and ADH secretion resulting in: • Increased vasoconstriction • Decreased urine output • Stimulation of the thirst reflex What do the adaptive or compensatory mechanisms do in hypovolemic shock? They ensure continued blood flow and oxygen delivery to vital organs while limiting blood flow to less vital areas. "A decrease in MAP of 10-15mm Hg from the patient's baseline value causes continued sympathetic stimulation. 43. What happens when the baroreceptors sense a decrease in MAP of 65 to 10 mm Hg below the baseline n hypovolemic shock? The information is transmitted to the brain centers. resulting in a decreased MAP. In the progressive stage of shock what occurs? 50. and a loss of oxygen-carrying capacity from the loss of circulating red blood cells. What are the integumentary manifestations of shock? "• Cool to cold • Pale to mottled cyanotic • Moist. mild acidosis and hyperkalemia 57. and increased metabolites cause so much cell damage in vital organs that multiple organ dysfuncton syndrome (MODS) occurs and full recovery from shock is no longer possible. "A decrease in MAP of > 20mm Hg from the patients' baseline value causes the anoxia of nonvital organs. What happens if the hypovolemic shock continues for longer periods without help? The resulting acid-base imbalance. In the nonprogressive stage of hypovolemic shock what occurs? 47. A decrease in MAP of 5 to 10 mm Hg below the patient's normal baseline value is detected by pressuresensitive nerve receptors (baroreceptors in the aortic arch and carotid sinus. The loss of RBCs decreases the ability of the blood oxygenate the tissue it does reach. 58. 44. . which stimulate adjustment (adaptive or compensatory mechanisms). ) "A decrease in baseline MAP of 510mmHg results in increased sympathetic stimulation • Mild vasoconstriction • Increase in heart rate" 56. causing secretion of renin aldosterone. What is the basic problem with hypovolemic shock? A loss of blood volume from the vascular space. 55. And chemical compensation occurs. hypoxia of vital organs and overall metabolism is anaerobic resulting in: • Moderate acidosis • Moderate hyperkalemia • Tissue ischemia" 42. What are the stages of hypovolemic shock? "• Initial Stage • Nonprogressive Stage • Progressive Stage • Refractory Stage" 45. With hypovolemic shock what occurs if the events that caused the initial decrease in MAP are halted at this point? The adaptive (compensatory) mehcanisms can return the body tissues to a normal perfused and oxygenated state.40. if the cause of shock is corrected within 1 to 2 hours after onset. clammy • Mouth dry. What are the renal manifestations of shock? "• Decreased urine output • Increased specific gravity • Sugar and acetone present in urine" 51. Some anaerobic metabolism in nonvital organs lead to: • Mild acidosis • Mild hyperkalemia" 59. 41. What do the oxygenation and tissue perfusion problems lead to ? Cellular anaerobic (without oxygen) conditions and abnormal cellular metabolism. What happens if the initiating events continue and MAP decreases further? Some tissues function under anaerboic conditions which increases lactic acid levels and other harmful metabolites which lead to electrolyte and acid-base imbalances with tissue-damaging effects and depressed heart muscle activity. Decreased pulse pressure -chemical compensation RAAS. 49. What causes the manifestations of hypovolemic shock? Moving oxygenated blood into slected areas while bypassing others causes the manifestations of shock. In the initial stage of hypovolemic shock what occurs? 46. electrolyte imbalances. pastelike coating present" 52. 54. • Moderate vasoconstriction • Increased heart rate. What is the main trigger leading to hypovolemic shock? A sustained decreased in MAP that results from decreased circulating blood volume.

Anxiety Objective changes include: • Restlessness. GI tract and kidney during the nonprogressive stage of hypovolemic shock? 70. What worsens the problem? The fact that the adaptive mechanisms require large amounts of oxygen in some tissues (e. Falling systolic blood pressure. Decreased urine output. further reducing urine output. In the nonprogressive stage of hypovolemic shock what oocurs when renin is secreted from the kidney? Renin starts the reactions to decrease urine ouptut.. Narrowing pulse pressure. 75. In the nonprogressive stage of hypovolemic shock what occurs when the baroreceptors in the kidney sense an ongoing decrease in MAP? The kidneys begin to compensate by releasing of renin. and also causes blood vessel constriction in the skin and other less vital tissue areas. Changes include acidosis (low blood pH) and hyperkalemia (increased blood potassium level). 71. 63. Cool extremities. increase sodium reabosorption and cause widespread blood vessel constriction. What is the cellular change during the initial stage of hypovolemic shock. AdH.Tachycardia. 69. What occurs during the nonprogressive state of hypovolemic shock when the MAP decreases by 10 to 15 mm Hg from baseline? Kidney and hormonal adaptive (compensatory) mechanisms are activated because cardiovascular adjustments alone are not enough to maintain MAP and supply needed oxygen to the vital organs. 67. What occurse in the progressive stage of hypovolemic shock? Adaptive or compensatory mechanisms are functioning but can no longer deliver sufficent oxygen.g. What are the manifestations of the nonprogressive stage of hypvolemic shock resulting from decreased tissue perfusion? "Subjective changes include: • Thirst sensation. 64. although overall cellular metabolism is still aerobic. 73. What can prevent hypovolemic shock from progressing beyond the nonprogressive stage? 74. 66. ADH incereases wter reabsorption in the kidney. Tissue hypoxia occurs. even to the vital organs. Why is shock so difficult to detect in the initial stage of hypovolemic shock? Because vital organ function is not disrupted. The change is increased anaerobic metabolism with production of lactic acid. A heart and respiratory rate increase from the patient's baseline level or a slight increase in diastolic blood pressure . Increased respiratory rate. What may be the only manifestations of the initial stage of hypovolemic shock. How long can a person remain in the nonprogressive stage of hypovolemic shock? They can remain in ths nonprogressive stage for hours without having permanent damage. 65. 62. In the initial stage of hypovolemic shock what do the compensatory mechanisms do? They are very effective at returning MAP to normal lvels that oxygenated blood flow to all vital organs is maintained. epinephrine. In the refractory stage of shock what occurs? "• Severe tissue hypoxia and ischemia and necrosis • Release of myocardial depressant factor from the pancreas • Buildup of toxic metabolites • Multiple organ dysfunction syndrome (MODS) • Death" 68. 2% to 5% decrease in oxygen saturation" 72. 61. aldosterone. What occurs in the skin.60. What occurs due to anaerobic metabolism during the nonprogressive stage of hypovolemic shock? Acid-base and electolyte changes occur in response to the buildup of metabolites. In the nonprogressive state of hypovolemic shock what occurs when ADH is secreted by the posterior pituitary gland. 76. Rising diastolic blood pressure. Stopping the conditons that started the shock at this stage and providing supportive interventions can prevent it from progressing. but it is not great enough to cause permanent damage. . and both cardiac output and MAP are maintained within the normal range. When does the progressive stage of shock occur? When there is a sustained decrease in MAP of more than 20mm HG from baseline. The adaptive responses of vascular cconstriction and increased heart rate are effective. the heart). norepinephrine is triggered.

What happens to vital organs during the progressive stage of hypovolemic shock? They develop hypoxia. and central nervous systems becom evident. mottled or dusky extremities Slow.. What skeletal muscle changes occur in hypovolemic shock? Cahnge inlcude muscle weakness and pain response to tissue hypoxia and anaerobic metabolism (later manifestations). 99. Is therapy effective during the refractory stage of hypovolemic shock? Therapy is not effective in saving the patient's life. 96. weak pulse. What is the most profound change with MODS? It is damdage to the heart muscle. integumentary. Rapid loss of consciousness Nonpalpable pulse Cold. 91. What do the microthrombi do? They block tissue oxygenation and damage more cells. 81. What is multiple organ dysfunction syndrome? The sequence of cell damdage caused by the massive release of tox metabolites and enzymes. What oxygen saturation level is considered a life-threatening emergency? Any value below 70% and may signal the reftractory stage of shock. Anuria • 5% to 20% decrease in oxygen saturation" What may lab values show during the progressive stage of hypovolemic shock? "• Low pH • Rising lactic acid level • Rising potassium level. Vital organs have overwhelming damage. What are the two types of fluids used to increase fluid volume? Crystaolloids and colloids . 84. What changes do we see as shock progresses? Changes in the renal. What do nursing interventions for hypovolemic shock focus on? They focus on reversing the shock. heart. Where does MODS occur first? First in the liver. 94. and kidney. So much tissue damage has ocurred with widespread release of toxic metabolites and detructive enzymes that cell damage to vital organs continues despite agrressive interventions. 87. respiratory. 97. What happens when anoxia or hypoxia persists beyond one hour? Patients are at risk for acute tubular necrosis and kidney failure. What do the metabolites trigger? They trigger small clots (microthrombi) to form 88. the sequence bcomes a vicious cycle as more dead cells break open and release harmful metabolites. Low blood pressure • Pallor to Cyanosis of oral mucous membranes and nail beds • Cool and moist skin. What do the manifestations of the progressive stage of hypovolemic shock include? "It includes a worsening of subjective changes: • Severe thirst sensation. When does the refractory stage of hypovolemic shock occur? When too much cell death and tissue damage result from too little oxygen reaching the tissues. brain." How long can vital organs tolerate the progressive stage of hypovolemic shock? Only a short time before they are damaged permanently. shallow respirations Unmeasurable oxygen saturation 85. even if the cause of shock is corrected and MAP temporarily returns to normal. 80. 92. and preventing complications through supportive and drug therapies. As the result of poor oxygenation and a buildup of toxic metabolites some tissue have severe cell damage and die. 86. 78. 82. 90. Severe anxiety • A sense of impending doom Worsening objective changes include: • Rapid. The patient's life usually can be saved if the conditions causing shock are corrected within 1 hour or less of onset of the progressive stage. restoring fluid volume to the normal range. What occurrs with MODS? Once the damage has started. Why is this stage of hypovolemic shock termed refractory? Because the body can no longer respond effectively to interventions and shock continues. The remaining cells metabolize anaerobically. What type of shock is more common in younger adults? Hypovolemic shock from trauma 93. What is one cause of this damage to the the heart muscle? The release of myocardial depressant factor (MdF) form the ischemic pancreas. Weakness is generalized and has no specific pattern. 79. What re the manifestations of the refractory stage of hypovolemic shock? • • • • • 77. 83. musculoskeletal. 95. 89. and less vital organs become anoxic (no oxygen) and ischemic (cell dysfunction or death from lack of oxygen. Where are signs of shock first evident? Changes in the cardiovascular function. 98. thus continuing the devastating cycle.

. What helps restore osmotic pressure and fluid volume? Protein containing colloids such as blood and blood products when shock is caused by blood loss. minerals. To help maintain an adequate fluid and electrolyte balance. 121. 117. What do changes in CVP reflect? Hypovolemic shock. 111. it can also be given with blood What do inotropic drugs directly stimulate? Adrenergic receptor sites on the heart muscle and improve heart muscle cell contraction resuling in greater recolil and more blood leving the left ventricle during contraction. What does Ringer's contain? "• Sodium • Chloride • Calcium • Potassium • Lactate All dissolved in water What do the drugs enhancing myocardial perfusion ensure? That the heart is well perfused. Why should you not hang Ringer's with blood? The calcium induces clotting of the infusing blood 107. What do whole blood and prbc's do? They increase hematocrit and hemoglobing along with fluid volume. What surgical interventions may be need to correct the cause of shock after a cause has been established? "• Vascular repair or revision • Surgical hemostasis of major wounds • Closure of bleeding ulcers. Why are PRBC's used? They are given for moderate blood loss because they resotre the red blood cell deficit and improve oxygen carrying capacity without adding excessive fluid colume.100. 120. salts. 109. 106. 124. What are the actions for drugs for shock? They increase venous return. ususually starches. especially when giving drugs to impprove cardiac contraction. 123. 115. Why are crystalloid fluids given? 103. What do crystalloids contain? Nonprotein substances (e. What vasoconstricting drugs are used? Dopamine and norepinephrine What are two common crystalloids? Normal saline and Ringer's lactate. What drugs are used to enhance myocardial perfusion? Drugs that dilate coronary blood vessels while minimally dilating systemic vessels such as sodium nitroprusside. 116. 112. How often should you assess vital signs in a patient with shock? Every 15 minutes until the shock is controlled and the patient's conditon improves. 122. 110. Why might drug therapy be used? If the volume deficit is sever and the patient does not respond sufficiently to the replacement of fluid volume and blood products. Why is whole blood used? To replace large columes of blood loss because it increase colume and imporves the oxygen-carrying capacity of the blood. What do plasma protein factors and synthetic plasma do? They increase plasma volume and are used as early treatment for hypovolemic shock before a cause can be established. How do vasoconstricing drugs stimulate venous return? By constricing the blood vessels and decreasing venous pooling of blood thereby increasing cardiac output and MAP. which help improve tissue perfusion and oxygenation. 104. 108. and chemical scarring (chemosclerosis) of varicosities 125.. or improve cardiac perfusion by dilating the coronary vessels.g. 113. What inotropic drugs are used? Dobutamine and milrinone 119. 118. It is widespread and couple with a more general inflammatory response known as systemic inflammatory response syndrome. Why must care be taken when we administer drugs that enchance myocardial perfusion? Because they can cause systemic vasodilation and increase shock if the patient is volume depleted. Why is plasma given? To restore osmotic pressure when hematocrit and hemoglobin levels are within normal ranges. 102. so that aerobic metabolisms is maintained in the heart cells and maximum contractility occurs. 105. 114. sugars) 101. What is sepsis or septic shock? It is a complex type of distrbutive shock that usually begins as a bacterial or fungal infection and progresses to a dangerous condition over a period of days. What do colloid solutions contain? Large molecules. What is the fluid replacement solution of choice to increase plasma volume? Normal saline. improve cardiac contractility.

What does the continued anaerobic metabolism result in? Poor oxygen uptake and the continued stress response triggers the continued release of glucose form the liver and the patient also has hyperglycemia. low-grade or high) • Reduced urine output • Elevated WBC's 137. Whem is SIRS triggered? When an infection escapes local control. Microthrombi formation is widespread using much of the available platelets and clotting factors (DIC) 131. 140. Even with intervention what is the death rate of patients in this stage of sepsis? 60^ 129. Why is the sepsis often missed in the second stage? Because cardiac function is hyperdynamic in this phase. urine output is decreased or absent and there is a change in the patient's cognition and affect. What occurs at the tissue level with sepsis? The WBCs are producing many proinflammatory cytokines and as a result. 135. What symptoms are a result of the adaptive mechanisms? "• Reduced urine output • Increased respiratory rate What causes cell hypoxia and reduced organ function with sepsis? Microthrombi begin to form within the capillaries of some organs. 142. and cardiac output is increasee with a more rapid heart rare and an elevated systolic blood pressure. By this time what changes are occuring at the cellular level? WBC count may no longer be elevated. which results in the generation of more toxic metabolites. What does damage to the endothelial cells do? It reduces anticlotting actions and triggers the formation of even more small clots. These cause more cell damage and increase the production of proinflammatory cytokines. 141. although some organs are experienceing cell death and dysfunction at this time. 128. 139. injured cells. In additon what does the amplified sirys and cytokine release result in? Capillary leakiness. respiratory rate is rapid. The pooling of blood and the widespread capillary leaking stimulatse the heart. What do the microthrombi do? They increase the number of cells that are operating under anaerobic conditions. 136. • Temperature can vary (low. Is the damage at this point reversible? Yes. What symptoms result directly from SIRS? Fever and hypotension 130. What is severe sepsis? It is the progression of sepsis with an amplified inflammatory response. leading to an intensifying or amplification of the SIRS and a vicious repeating cycle of poor oxygenation and tissue perfusion. 127. What are some of the signs of sepsis? • Mild hypotension • Increased respiratory rate • These actions result in a hypodynamic state with decreased cardiac output. and increased metabolism. if if it is stopped at this point but it is very hard to detect. Oxygen sats are lower. The organisms and the toxins or endotoxins in the bloodstream enter other body areas and the inflammatory response becomes an enemy leading to extensive tissue and vascular changes that furtehr impair oxygenaton and tissue perfusion.126. 134. What may the patient's extremities feel like at this time? They may feel warm and there is little or no cyanosis. What is septic shock? It is the stage of sepsis and SIRS when multiple organ failure is evident and uncontrolled bleeding occurs. there is a widespread vasodilation and pooling of blood in some tissues. 133. All tissues are involved and all have some degree of hypoxia. The more severe the response the higher the blood sugar. 138. 132. .

How is increased cardaic output reflected? "• Tachycardia • Stroke Volume increased • Normal to elevated systolic BP • Normal CVP • Skin color appears normal with pink mucous membranes • Skin may be warm to touch" 153. As sepsis progresses what may occur? DIC with the formation of thousands of small clots in the tiny capillaries of the liver. • The cause of sepsis is often less obvious than for other types of shock. fungal infections can also lead to sepsis. Bood may ooze from the gums. What is present in this stage of septic shock? Hypovolemic shock is present with hypodynamic cardiac function.Increased • Stroke volume . other mucous membranse.143.< 85% 160. although inimmunocompromised patients.120 • Oxygen saturation . The lungs are susceptible to damage and the life thrreatening lung complication of ARDS may occur in septic shock.decreased • Stroke Volume . (left shift) 156. reducing oxygenation in those organs.normal to slightly increased • Blood glucose . 154. What happens to the skin with septic shock? Circulation is severely compromised and the skin is cool and clammy.2-4 mmol/L • Blood glucose .greatly decreased • Stroke volume . Urine output that is less than expected. What are some common organisms that cause sepsis? Escherichia coli and Klebsiella pneumoniae as well as Staph and Strep. 145.greatly decreased • Serum lactate .120 mg/dL • Oxygen Saturation . and heart.< 110 • Oxygen saturation .60 to 80 mL • Serum lactate . What happens to the skin in the hypodynamic stage of sepsis? 157. as well as around IV catheters. the depth of the respiration also increases. Blood is shunted away from the skin by vasoconstriction and pallor.Increased • Serum lactate . 148. or cyanosis is present. This resembles the late stages of hypovolemic shock. What respiratory changes may occur in septic shock? As tissue hypoxia becomes more profound and metabolic acidosis is present.3 to 5 L/min • Stroke volume . The skin is warm and no cyanosis is evident. 147. What are the parameters for early sepsis? "• Cardiac Output .< 80% What renal urinary change indicates any type of sepsis or shock problem? 161. 150. 149. What is the hallmark of sepsis? An increasing serum lactate level. 152.< 95% 159. capillary laek continus as a resulf ofo the presense of pro-inflammatory cyotkines and cardiat contractility is poor from cellurlar ischemia and the presence of myocardial depressant factor.decreased • Serum lactate . What are the normal levels in the healthy patient? "• Cardiac output . brain.95%-100% What happens to the skin in the hyperdynamic stage of sepsis? 158. What is the major cuase of sepsis? Bacterial infection that escapes local control.> 4 mmol/L • Blood glucose . What are the parameters for Septic Shock? "• Cardiac output . This is the result of an inability of the blood to clot because the platelets and clotting factors were consumed eariler. or mottling may be present. mottling.110 . 155. and venipuncture sites.> 150 • Oxygen saturation . What is the indicator that patients may be in the beginning of severe sepsis? Often a change in affect or behavior.< 2 mmol/L • Blood glucose . and a decreasing segmented neuthrophil level with a rising band neutrophil level. . kidney. spleen. 144. When does hemorrhage occur with sepsis? In the septic shock stage. What are the parameters for late sepsis? "• Cardiac output . 151. cyanosis . How does sepsis and septic shock differ form other tpes of shock? • Then entire syndrome may occur over many hours to days • Manifestations usually are less obvious • The chance for recover is good when sepsis is caught early and appropriate interventions are started. What happens with patients in DIC? Petechiae and ecchymoses can occur anywhere.110. a normal or low total WBC count. and pallor. 146.

4 or less than 96. May need to suppor with low-dose corticosteroids (hydrocortisone or fludrocortisone) 169. What is the Systemic Inflammatory Response Syndrome (SIRS) Criteria? "• Temp > than 100. Decreased cap refill • Hyperglycemia > than 120mg/dL in the absence of diabetes • Unexplained change in mental status 166. What are some other biologic indicators of sepsis and septic shock? Plasma D-dimer levels rise during sepsis as the fibrin in clots is broken down. What is an indicator of sepsis and septic shock? A low blood level of activated protein C.162. What can the stress of severe sepsis cause? Adrenal insufficiency in many patients. 164. What are the most common agents for septic shock? Gram. What does the current therapy for clotting? Activated protein C to stop the inflammatory response. Urine output less than expected • Positive fluid balance. .negative bacteria.8 • Heart rate > 90 bpm • Repspiratory rate of > 20 breaths or a Paco2 level < than 32 mm Hg • Abnormal WBC count 165. 163. When is sepsis considered to be present? "When two or more SIRS criteria are present along with any now infection and one or more of these clinical manifestations: • Hypotension. What is a common collaborative problem for patients with septic shock? MODS 167. 168.