MULTISYSTEM

PROBLEMS
NCM 410 LECTURE
 Table of contents

01 02 03
SYSTEMIC MULTI-ORGAN
INFLAMMATORY DYSFUNCTION
SHOCK RESPONSES SYNDROME(MODS)
SYNDROME(SIRS)
The person experiencing shock
 01
SHOCK
Shock is a clinical syndrome characterised by a systemic imbalance between
oxygen supply and demand. This imbalance results in a state of inadequate
blood flow to body organs and tissues, causing life-threatening cellular
dysfunction. (Pearson, 2017)
Overview of cellular homeostasis and
haemodynamics
FOUR PHYSIOLOGIC COMPONENTS:

1. A sufficient cardiac output

2. An uncompromised vascular system
3. A sufficient volume of blood
4. Tissues that are able to extract and use the oxygen delivered through the
capillaries.
 baSIC HEMODYNAMICS
■ BP = CO x SVR (Systemic Vascular Resistance)

● Stroke volume (SV) is the amount of blood pumped

into the aorta with each contraction of the left ventricle.

■ Cardiac output (CO) is the amount of blood pumped per

minute into the aorta by the left ventricle.

CO = SV × HR
 baSIC HEMODYNAMICS
■ Mean arterial pressure (MAP) is the product of cardiac
output and systemic vascular resistance (SVR):
MAP = CO × SVR
MAP normal range = 70 to 110

■Sympathetic tone.
Increased sympathetic stimulation increases
vasoconstriction and SVR; decreased sympathetic
stimulation allows vasodilation which decreases SVR.
 pathophysiology

Altered Hemodynamics

Inadequate tissue perfusion

SHOCK

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME( SIRS)

MULTIPLE ORGAN DYSFUNCTION SYNDROME(MODS)

SHOCK CLASSIFICATIONS

● CARDIOGENIC shock
● Hypovolemic shock
● distributive/vasogenic
● Anaphylactic shock
● Neurogenic shock
● Septic shock
● Obstructive shock
 assessment
SHOCK MANIFESTATIONS

HYPOtension - TACHYcardia- TACHYpnea

01

Cardiogenic SHOCK
Cardiogenic shock manifestations

● Blood pressure: hypotension

● Pulse: rapid, thready; distension of veins of
hands and neck
● Respirations: increased, laboured; crackles
and wheezes; pulmonary oedema
● Skin: pale, cyanotic, cold, moist
● Mental status: restless, anxious, lethargic
progressing to comatose
● Urine output: oliguria to anuria
● Other: dependent edema; elevated central
venous pressure (CVP); elevated pulmonary
capillary wedge pressure; arrhythmias
02

hypovolemic SHOCK
is caused by a decrease in intravascular
volume of 15% or more (Huether & McCance,
2013)
 Hvs manifestations

1. INITIAL STAGE
2. COMPENSATORY
3. PRORESSIVE STAGES
4. IRREVERSIBLE/refractory STAGE
 Distributive/
vasogenic shock

- includes several types of shock that result from

widespread vasodilation and decreased peripheral
resistance.
-Because the blood volume does not change,
relative hypovolemia results.

-Examples of distributive shock include septic,

neurogenic and anaphylactic shock.
-Treatment is based on the underlying
pathogenesis.
 03

anaphylactic SHOCK

Is the result of a widespread hypersensitivity

reaction (called anaphylaxis).
Anaphylactic
shock
 04

neurogenic SHOCK
Neurogenic shock is the result of an
imbalance between parasympathetic and
sympathetic stimulation of vascular smooth
muscle.
neurogenic
shock
 05

septic SHOCK
Septic shock, the leading cause of death for
people in critical care units, is one part of a
progressive syndrome called systemic
inflammatory response syndrome (SIRS).
 Septic
shock
● Toxic Shock syndrome
● Disseminated intravascular coagulation
(DIC)
 06

obstructive SHOCK
is caused by an obstruction in the heart or
great vessels that either impedes venous
return or prevents effective cardiac pumping
action.
 obstructive
shock
● Jugular vein distension
● Pulsus paradoxus
 Diagnostic studies
● Hx and PE
● labs ● 12 leads ecg
● Continuous ecg
monitoring
● Chest x-ray, mri, ct scan
● Cont. pulse oximetry
● Invasive and
non=invasive
hemodynamic monitoring
 shock Interprofessional care

Focus (COP) Interventions (MOxFEm)

Treating the underlying Cause Medications
Increasing arterial Oxygenation Oxygen therapy
Improving tissue Perfusion Fluid Replacement
Emergency care measures
 shock medications
adrenergics vasodilators
vasoconstrictors
inotropes Nitroglycerine
Adrenaline Dopamine, (Glycerol trinitrate)
Noradrenaline Dobutamine,
Aramine Isoprenaline Nitroprusside(Nipride)
Sodium
diuretics
bicarbonate
Oxygen therapy
 Fluid resuscitation

● Crystalloid Solutions (Isotonic or Hypotonic)

● Colloid Solutions (Plasma Expanders)
● Blood and Blood Products
Nursing assessment
ABC’s:
Airway
Breathing
Circulation
Tissue perfusion
 Nursing diagnosis
Includes:
● Decreased cardiac output
● Ineffective tissue perfusion
● Anxiety
 nursing interventions
Decreased cardiac
output
Assess and monitor cardiac anxiety
function Assess cause of anxiety
Measure and record I&O Administer pain meds
Monitor bowel sounds Increase comfort and
Maintain bed rest and calm envi. reduce restlessness
Provide support
Ineffective tissue
perfusion
Monitor skin color, temp,
turgor, moisture
Assess LOC
Monitor body
temperature
 02
Systemic
Inflammatory response
syndrome
Generalized inflammation in organs remote
from the initial insult characterizes SIRS.
Many different mechanisms can trigger SIRS.
These include:
• Mechanical tissue trauma: burns, crush injuries, surgical
procedures
• Ischemic or necrotic tissue: pancreatitis, vascular disease, MI
• Microbial invasion: bacteria, viruses, fungi, parasites
• Endotoxin release: gram-negative and gram-positive
bacteria
• Global perfusion deficits: post cardiac resuscitation, shock
states
• Abscess formation: intraabdominal, extremities
• Regional perfusion deficits: distal perfusion deficits
 03
Multiple organ
Dysfunction syndrome
(mods)
is the failure of 2 or more organ systems in an
acutely ill patient such that homeostasis cannot
be maintained without intervention.
 Clinical
manifestations
OF SIRS AND MODS
CLINICAL MANIFESTATIONS
of
SIRS AND MODS
RESPIRatory CNS
● Acute changes to
Neurological status
● Development of
(confusion,
ARDS
disorientation,
delirium, fever, etc.)

cardiovascular endocrine

● Biventricular Failure ● hyperglycemia->hypoglycemia

CLINICAL MANIFESTATIONS
of
SIRS AND MODS
REnal system Hepatic
● Prerenal -Renal
hypoperfusion
● Intrarenal -acute ● Bilirubin > 2 mg/dl,
tubular necrosis jaundice

Gi system hematologic
● GI bleeding, mucous ● Bleeding times, PT, PTT
ischemia ● Platelet count
Sequential organ failure assessment
(sofa)

● can be used to ● is a mortality prediction ● It is believed to

determine level of score that is based on the provide a better
organ dysfunction degree of dysfunction of six stratification of the
and mortality risk in
organ systems mortality risk in ICU
ICU patients
patients
ABC’s:
Nursing interventions
Airway (optimize O2 delivery, minimize consumption, MV)
Blood (volume management to increase preload,
vasopressors, optimize cerebral blood flow, monitor bleeding)
Continuous ECG monitoring, Calcium channel blockers
Decrease cerebral O2 requirements
Enteral nutrition, stress ulcer prophylaxis, dietician consult
Factors being lost, replace(platelets)
Elaborate class discussion
 lesson highlights

shock Sirs
early sign of shock is
Characterized by
a change in the level
generalized
of consciousness, with
inflammation in
restlessness being a
organs remote from
common symptom of
the initial insult
cerebral hypoxia.
types Mods
Cardiogenic the failure of 2 or
Hypovolemic more organ systems
Anaphylactic in an acutely ill patient
Neurogenic
Septic
Obstructive
 “
“I attribute my success to this, I never gave nor took
any excuse.”

—florence nightingale
 “I attribute my success to this, I
never gave nor took any excuse.”
—florence nightingale
Thanks!
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