You are on page 1of 59

Perawatan Pada Pasien Shock

Fithri kurniati

The Cardiovascular System


Made up of three key
components:
Pump (Heart)
Tubing (Blood Vessels)
Fluid (Blood)

Definition

Shock = kondisi yg mengancam nyawa akibat


dari tidak adekuatnya aliran darah ke jaringan dan
sel

Mengakibatkan: oksigen dan nutrien selular tidak


adekuat, cellular starvation, cell death, organ
failure dan kematian jika tidak segera di atasi

Butuh penatalaksanaan yang cepat dan cara


tepat

Epidemiology
Mortality

Septic shock 35-40% (1 month mortality)


Cardiogenic shock 60-90%
Hypovolemic shock variable/mechanism

Classification of Shock

Shock

Hypovolaemic

Neurogenic

Cardiogenic

Distributive

Anaphylactic

Septic

Shock
Classification

Classifications of Shock

Hypovolemic akibat kehilangan cairan tubuh >>>>


Cardiogenic - akibat dari disfungsi jantung
Anaphylactic Shock akibat dari antigen-antibody
reaction yg menyebabkan pelepasana histamin ke
sirkulasi darah
Septic Shock (systemic inflammatory response
syndrome) akibat infeksi yang luas dan invasi
mikroorganisme ke dalam tubuh
Obstructive Shock akibat sumbatan pada aliran darah
Neurogenic shock - akibat kerusakan atau disfungsi
sistem saraf simpatis (jarang)

Classifications of Shock:
Hypovolemic

Hypovolemic - gangguan perfusi jaringan akibat


kehilangan cairan tubuh/darah >>>>
Hemorrhage: kehilangan darah, plasma, atau
cairan tubuh akibat dari:
surgery
trauma
burns
severe dehydration (vomiting, diarrhea, DKA,
DI)
Internal, extravascular fluid loss: akibat odema,
ascites, ruptured spleen, pancreatitis, hemothorax
Adrenal insufficiency

Hypovolemic Shock

Hemorrhagic stage
Parameter

II

III

IV

Blood loss (ml)

<750

7501500

15002000

>2000

Blood loss (%)

<15%

1530%

3040%

>40%

Pulse rate (beats/min)

<100

>100

>120

>140

Normal

Decreased

Decreased

Decreased

Respiratory rate (bpm)

1420

2030

3040

>35

Urine output (ml/hour)

>30

2030

515

Negligible

Normal

Anxious

Confused

Lethargic

Blood pressure

CNS symptoms

Classifications of Shock
Cardiogenic

Cardiogenic - gangguan perfusi jaringan akibat disfungsi


jantung (most common cause of death from MI)
MI (usually 40% akibat kerusakan ventrikel kiri )
Myocardial ischemia (left main artery disease, multivessel
coronary artery disease)
Cardiomyopathy
Arrhythmias
Heart failure
Cardiac tamponade
Disfungsi katup akut (acute mitral regurgitation, aortic
insufficiency)
Papillary muscle rupture
Other severe forms of myocardial injury (trauma)

Classifications of Shock
Anaphylactic Shock

Anaphylactic Shock - impaired tissue perfusion resulting


from antigen-antibody reaction that releases histamine into
the blood stream Permeabilitas kapiler meningkat dan
terjadi dilatasi ateriol darah yg kembali ke jantung
menurun drastis.
Contrast media
Drug reactions
Blood transfusion reactions
Food allergies
Insect bites or stings
Snake bites

Classifications of Shock
Others

Septic Shock (systemic inflammatory response syndrome) impaired tissue perfusion caused by widespread infection
and invasion of microrganisms in the body menyebabkan
vasodilatasi
Obstructive Shock - impaired tissue perfusion resulting
form obstruction to blood flow
Pulmonary Embolus
Aortic dissection
Neurogenic shock - impaired tissue perfusion caused by
damage or dysfunction of the sympathetic nervous system
(rare)
Trauma
Anesthesia
Spinal Shock

Pathophysiology of Shock

A mean arterial pressure (MAP) of 80 to 120

mmHg diperlukan sel untuk memperoleh oxygen and


nutrients yg dibutuhkan untuk metabolisme guna
menghasilkan energi yg cukup untuk mempertahankan
hidup

Tubuh memiliki mekanisme kompensasi untuk


mempertahankan MAP akibat dari perubahan
kemampuan pompa jantung, volume darah/cairan tubuh,
dan perubahan pada sistem vaskular

Selama mekanisme tersebut efektif tubuh dapat


tetap bertahan hidup , namun jika gagal perfusi
jaringan tidak adekuat dan shock mulai terjadi

Compensatory
Mechanisms
Baroreceptors (pressure receptors) - terletak pada
sinus karotid dan arkus aortikus
Penurunan MAP menyebabkan menurunnya regangan
pada baroreceptors ( terjadi kehilangan efek inhibisi
baroreseptor terhadap pusat pusat vasomotor)
Aktivitas simpatetis eferen terstimulasi otak
mengirim impuls ke kelenjar adrenal untuk melepas
katekolamin (epinephrine & norepinephrine)
Catecholamines menyebabkan peningkatan denyut
jantung dan vasokonstriksi
Aktivitas parasimpatis menurun pada saat yg
bersamaan

Compensatory
Mechanisms
Chemoreceptors - berada pada arkus aortikus dan arteri
karotis
Berespon/sensitif terhadap prubahan oksigen dalam darah
Meregulasi blood pressure and heart rate

Kidneys melepas renin yang menyebabkan konversi


angiotensin I to angiotensin II vasocontrictor kuat
Terjadi pelepasan aldosterone dari korteks adrenal
menyebabkan retention of sodium and water
Peningkatan retensi sodium mencetuskan pelepasan ADH
(antidiuretic hormone)
ADH menyebabkan ginjal menahan cairan dalam tubuh
untuk meningkatan jumlah volume darah/sirkulasi dan
blood pressure

Chain of Events= rantai kejadian


Penurunan perfusi jaringan menurunkan jumlah oksigen, nutrien
cell, begitu pula degnan energi
Metabolisme intraseluler menghasilkan ATP sebagai sumber
energi dan sebagian disimpan untuk cadangan energi
Jika ketersediaan oksigen rendah maka metabolisme akan
berlangsung secara anaerob yg menghasilkan limbah berupa
asam laktat
Peningkatan keasaman menyebabkan fungsi seluler menurun
Disfungsi seluler pada awalnya bersifat reversibel namun dpt
menyebabkan kerusakan organ jika tdk segera ditangani

Chain of Events contd


harapannya, adanya penurunan pada tekanan darah dan
penurunan kadar oksigen dalam darah maka baroreceptors
and chemoreceptors mampu untuk melakukan kompensasi
Apabila mekanisme kompensasi tersebut gagal untuk
mengembalikan perfusi jaringan the syndrome of

shock begins
Cell mengalami odema, membrane sel menjadi lebih
permeabel yg mengakibatkan cairan dan eletrolit berpindah
dari dan ke dalam sel mitokondria dan lisosom rusak dan
mati

Chain of Events contd


Platelets and white blood cells clump together and
obstruct the microvasculature
Major organs mulai mengalami malfunction akibat
hypoxemia & metabolic acidosis

Respiratory failure, renal failure, cerebral perfusion


menurun, and disseminated intravascular coagulation
(DIC) may also be seen
Semakin dini medical management and nursing
interventions dilakukan prognosis >>>>

Stages of Shock - Compensatory


If treated, prognosis is good
blood pressure masih DBN
vasoconstriction, increased heart rate and increased
contractility, betujuan untuk mempertahankan cardiac
output yg adekut
Darah di organ nonessential (skin, lungs, kidneys, GI
tract) dikurangi
Assessment data:
Kulit Teraba dingin, lembab dan berkeringat
Bising usus menurun
UOP menurun
confusion, combativeness (result of compensatory
respiratory alkalosis)

Compensatory Shock contd

Treatment fokus pada identifikasi dan koreksi


penyebab, serta mengoptimalkan mekanisme
kompensasi (resusitasi cairan and vasoactive
drugs)
Nursing Responsibilities:
Monitor perubahan LOC, skin, UOP and VS
monitor labwork (Na and Glucose meningkat
sebagai respon terhadap pelepasan ADH and
catecholamines)
Berikan cairan dan obat2an sesuai instruksi
Segera laporkan setiap adanya perubahan

Progressive Shock/
Dekompensasi
BP drops (< 80-90 mmHg). Prognosis worsens.
Meskpun shock teratasi, the patient may not recover.

Jantung yg Overworked mengalami ischemic dan


mengakibatkan kemampuan pompa jantung mengalami
kegagalan
Permeabilitas membran seluler meningkat terjadi
kebocoran plasma ke ruang intersitisiel dan jumlah
aliran balik ke jantung menurun
Sistem organ mengalami dekompensasi:
Lungs - ARDS develops leading to respiratory failure
Heart - dysrhythmias, HR > 150, chest pain, MI, elevated
cardiac enzymes

Progressive Shock Contd


Brain perubahan tingkat kesadaran , pupil mungkin dilatasi,
reflek cahaya menurun
Kidneys - gagal ginjal akut dpt terjadi. BUN and Cr
meningkat , UOP usually < 20 cc/hr
Liver - kemampuan utk metabolisme obat dan racun
berkurang (ammonia and lactic acid), lebih beresiko terhadap
infeksi, SGOT (AST), SCPT (ALT) and LDH meningkat, ikterik
GI - stress ulcers, GI Bleed, mucosa dpt mengalami nekrosis
dan iritasi mengakibatkan bloody diarrhea; toxins
dilepaskan ke aliran darah menyebabkan depresi jantung
dan vasodilatasi
Hematologic System - DIC, platelets and clotting factors
meningkat, PT/PTT memanjang

Progressive Shock contd


Treatment tergantung tipe shock dan penyebab yang
mendasari.

Tujuannya adalah menggunakan cairan dan


obat-obatan untuk mengembalikan perfusi
jaringan :
Mengoptimalkan volume intravascular
Meningkatkan kemampuan pompa jantung
Memperbaiki fungsi sistem vaskular
Kebutuhan nutrisi tetap haus dipenuhi
untukmelindungi GI tract

Progressive Shock contd

Nursing Responsibilities - requires good


assessment skills and an understanding of
shock.
Must be able to identify significant changes in
assessment data.
Patient will require hemodynamic monitoring and
EKG monitoring
May require mechanical ventilation or IABP therapy
(intra-aortic balloon pump)
Requires close monitoring of changes in ABG
results, electrolyte levels and mental & physical
status

Progressive Shock contd


Beban kerja jantung harus diminimalisir
reduce physical activity
reduce fear and anxiety
Rencana keperawatan jagan sampai mengganggu
waktu istirihat pasien
Hindari pasien dari perubahan suhu yg ekstrem
(menggigil meningkatkan beban kerja jantung,
hangat/panas menyebabkan vasodilatasi)

Lakukan tindakan untuk mencegah komplikasi


dan injury, serta memberi kenyamanan.

Irreversible Stage
Organ damage is so severe that the patient pasien
tidak berespon terhadap tindakan dan tdk dpt
bertahan hidup

BP tetap rendah
Complete renal and liver failure, releasing toxins
metabolic acidosis >>>
Anaerobic metabolism is creating more lactic acid also
contributing to metabolic acidosis
ATP reserves are used up
The cells can no longer store ATP related to cell
destruction
Patient develops multi-organ failure

Irreversible Shock contd

Treatment lanjutkan seperti pada Progressive


Shock (only determined to be irreversible when the
patient dies)
Nursing Responsibilities
Lanjutkan treatment yg diinstruksikan, monitor
the patient, prevent complications, protect from
injury and provide comfort
Komunikasikan kepada klien dan beri dukungan
pasien untuk menjalani proses grieving
PENTING!

Medical Management of Shock

Fluid replacement untuk menggantikan


intravascular volume (Crystalloids, Colloids,
Blood components)

Obat2an Vasoactive untuk mengembalikan tonus


vasomotor dan meningkatkan cardiac function

Nutritional support to address increased


metabolic requirements

Fluid Replacement
Crystalloids - electrolyte solutions = dapat berpindah
dgn mudah antara intravascular compartment and
interstitial spaces
Selalu berikan isotonic solutions - same
concentration of electrolytes as the extracellular fluid
(avoids wide changes in plasma electrolytes)
Paling sering diberikan : Lactated Ringers and
Normal Saline
Diperlukan dalam jumlah banyak - 1/3 bagian akan
mengisi interstitial spaces
If a hypertonic solution is used (3% Saline), fluid
moves from interstitial spaces to vascular system

Fluid Replacement contd


Colloids - contain molecules too large to pass
through capillary membranes.
Pull fluid into intravascular space by means of
oncotic pressure (like hypertonic solutions)
Takes less volume and acts longer
Most common used are 5% Albumin, 6%
Hetastarch (Hespan) and 6% Dextran solution
Caution must be used with Dextran because it
interferes with platelet aggregation
Anaphylactic reactions can occur with colloids

Fluid Replacement

Complications of fluid therapy Cardiovascular overload


Pulmonary edema

Monitor patient for adequate UOP, changes in mental


status, skin perfusion and vital signs.
Assess breath sounds frequently during fluid
administration
Patients may have arterial lines, CVP or Swan-Ganz
catheter
If CVP being monitored, should be between 4 and 12

Vasoactive Drugs

Digunakan apabila pemberian cairan tidak dapat


mempertahankan MAP
Drug yg dipilih tergantung koreksi apa yg diperlukan untuk
meningkatkan CO:
Meningkatkan kontraktilitas
Menyebabkan vasokonstriksi
regulate the heart rate
Bekerja pada reseptor sistem saraf simpatis
Alpha - Vasoconstriction of Cardiorespiratory and GI
systems, skin and kidneys
Beta1 - increase heart rate and contractility
Beta2 - vasodilatation of heart and skeletal muscles,
relaxation of bronchioles

Vasoactive Drugs contd

Nursing Responsibilities
Monitor vital signs tiap15 min selama
vasoactive drugs diberikan
Berikan melalui central line
Use an IV Pump
Titrate drip rate according to patient
parameters (ordered by the physician)
Jangan hentikan drips secara tiba2 - wean
slowly while monitoring vital signs q15 min

Nutritional Support

Patients yg mengalami shock memerlukan lebih


dari 3000 calories per hari
Pelepasan catecholamines menyebabkan
penggunaan cadangan glycogen - can occur in 810 hours. This causes skeletal muscle to be
broken down for energy.
Start parenteral (HAF) or enteral (NGT, PEG, JTube, Duodenal tube, Dobb-Hoff) within 3-4 days
Biasanya diberikan H2 blockers (cimetidine,
ranitidine) untuk mencegah stress ulcers akibat
penurunan perfusi GI tract

Management of Specific Shock


Conditions
Hypovolemic paling sering, terjadi apabila terjadi
penurunan intravascular volume hingga 15 - 25% (7501300 ml for a 70 Kg person)
Can occur by fluid loss or fluid shifting
Penurunan volume intravaskular venous return to
heart and ventricular filling menurun SV and CO
menurun BP menurun and inadequate tissue perfusion
Tujuan: (1) mengembalikan intravascular volume, (2)
redistribute fluid volume, and (3) correct underlying
cause of loss
Shock hipovolume yang tidak dpt diperbaiki dpt
berkembang menjadi cardiogenic shock

Hypovolemic Shock contd

Nursing Responsibilities
Sedapat mungkin harus dicegah melalui
monitoring ketat pasien2 yg beresiko
Berikan terapi cairan dan obatAN secara aman
dan hati2 and document effect
Monitor for complications and side effects and
report early
Safely administer blood/blood products.
Monitor for adverse effects
Administer oxygen and monitor effectiveness

Cardiogenic
Shock
Occurs when the hearts ability to pump is impaired. Dapat
berupa gangguan pada coronary or non-coronary.
Seringkali terjadi pda pasien MIs and extensive ventricular
damage.
Apabila SV or HR menurun, blood pressure drops and tissue
perfusion terganggu
Juga, apabila SV menurun, ventricle tidak memompa keluar
darah seluruhnya tekanan balik ke sistem pulmoner
kongesti/odema pulmoner Patients in cardiogenic shock
ditandai dgn chest pain and dysrhythmias
tujuan: (1) batasi kerusakan lebih lanjut ,(2) jaga kesehatan
jantung, (3) perbaiki kemampuan pompa jantung

Cardiogenic Shock contd


Treatment:
Oxygen - monitor O2 sat and ABGs
Morphine for chest pain untuk menurunkan beban
kerja jantung melalui penuruan preload and afterload
EKG and cardiac enzymes - to assess damage
Hemodynamic monitoring - arterial line, pulmonary
artery catheter
Vasoactive therapy (Sympathomimetics, Vasodilators)
Dopamine - low-dose (0.5 - 3 mcg/kg/min) for renal
and mesenteric perfusion, medium-dose (4-8
mcg/kg/min) for improving contractility and heart
rate, high-dose causes vasoconstriction

Cardiogenic Shock contd

Nitroglycerin - Vasodilator. Preload menurun. Meningkatkan


aliran darah ke otot jantung itu sendiri, sehingga oksigenasi
adekuat. Pada dosis tinggi, dpt menyebabkan arterial
vasodilation and menurunkan afterload
Others - dobutamine, norepinephrine, epinephrine,
isoproterenol, amrinone
Lasix
Antiarrhythmics
Sodium Bicarbonate
Crystalloids and/or Colloids - give cautiously
Intra-aortic balloon pump - counterpulsation. Balloon
mengembang selama diastole, mengempes sebelum fase
sistolik

Cardiogenic Shock contd


Nursing Responsibilities:
Lakukan tindakan pencegahan - identify patients at risk.
Berikan oksigenasi secara adekuat. Kurangi beban kerja
jantung. Beri bantuan untuk mengembalikan fungsi
jantung dan perfusi jaringan.
Antisipasi kebutuhan terhadap obat2an, cairan,
hemodynamic monitoring and assist with
implementation
Dokumentasikan perubahan hemodinamik dan status
cardiac laporkan segera
Monitor komplikasi dan side effects - BP and HR
changes, bleeding, tissue necrosis and sloughing, UOP,
BUN, Cr, circulatory compromise with IABP

Distributive Shock
Category for Neurogenic, Anaphylactic and Septic Shock
terjadi vasodilatasi arterial and venous menyebabkan
relative hypovolemia
Vasodilation disebabkan oleh hilangnya tonus
simpatetis dan pelepasan mediator kimia oleh sel
Dapat segera terlihat melalui peningkatan CO
berhubungan dengan penurunan systemic vascular
resistance (SVR) and upaya jantung utk
mengkompensasi
Pooling of blood decreased venous return
decreased SV and CO decreased BP decreased
tissue perfusion

Neurogenic Shock

Terjadi akibat akibat loss of sympathetic tone - spinal


cord injury, spinal anesthesia, nervous system damage,
depressant action of medications, lack of glucose
(insulin shock). Usually transient.
Patient teraba hangat, kulit kering (opposed to cool,
clammy skin)
Usually bradycardic as opposed to tachycardic
Atasi penyebab
Nursing Responsibilities:
Bantu utk pencegahan dengan mengatur posisi dan
imobilisasi
Support cardiovascular and neurologic functions

Anaphylactic Shock
Results from an allergic reaction. Mast cells release potent
vasodilators (histamine, bradykinin)
Occurs rapidly and is life-threatening
Treatment:
Remove causative antigen
Kembalikan tonus vascular - Epinephrine
Anti-histamines - Benadryl
Bronchodilator (Aminophylline) if patient has
histamine induced bronchospasms
Nursing Responsibilities - Prevention!!, Recognition!!
(sudden onset flushing, warmth, anxiety, itching, nasal
congestion, laryngeal edema, bronchospasm, SOB,
wheezing) Fast Action!!

Septic Shock
Most common - caused by widespread infection
Mortality rate 40 - 90%
Most common causative organisms are gram-negative
bacteria. However, can also be caused by gram-positive
and viruses
2 Phases:
Hyperdynamic - high CO with vasodilation, hyperthermic
with warm, flush skin, elevated HR and RR, UOP normal or
increased, may have nausea, vomiting or diarrhea
Hypodynamic - low CO with vasoconstriction in response to
hypovolemia from capillary leaking, BP drops, skin cool and
pale, temp normal or below, HR and RR elevated, no UOP,
multiple organ failure

Septic Shock contd

Treatment - Identify and eliminate cause of infection


Obtain cultures
Start antibiotics (cephalosporin and aminoglycoside
initially)
Remove potential routes of infection
Drain abscesses, debride wounds
Crystalloid and/or colloids
Aggressive nutritional support (if the gut works,
use it)
Treatment beginning to shift toward combating
endotoxins - monoclonal antibodies (enhances
immune function)

Septic Shock contd

Nursing Responsibilities
Prevention - use aseptic technique with all procedures,
monitor patient for signs of infection
Collaborate with health care team to identify source of
sepsis
Reduce temperature in hyperthermic patients, but
monitor closely for chills, shivering and increased O2
consumption
Administer fluids, meds, vasoactive drugs to restore
vascular volume.
Monitor antibiotic levels, BUN, Cr, WBC
Monitor hemodynamic status, I&O, nutritional status
(daily wts, albumin).

Multiple Organ Failure

Dpt terjadi sebagai komplikasi dari semua jenis shock


The exact mechanism that triggers it is unknown
Cant predict who will develop it
Biasanya dimulai dari paru2 dan diikuti oleh liver and
kidneys
2 patterns of presentation:
Initial episode of hypotension which is treated and
patient seemingly responds
If patient presents with a pulmonary insult and has
respiratory failure, can rapidly develop MOF and

patient only survives 2 to 4 days

Multiple Organ Failure contd


Other pattern occurs most often with septic
shock:
Progressive development over a month
Patient experiences respiratory failure and
often requires ventilator
Despite apparent hemodynamic stability,
patient exhibits a hypermetabolic state
(hyperglycemia, hyperlactatemia, polyuria) - if
can be reversed, mortality rate is 25-40%
Infection is usually present and skin
breakdown begins to occur

Multiple Organ Failure contd


severe loss of muscle mass (auto- catabolism)
occurs
Apabila fase hypermetabolic tidak dpt diperbaiki,
MOF akan berkembang
patient menjadi jaundiced, hyperbilirubinemia and
renal failure biasnya memerlukan dialysis
Hemodynamic patient unstable
Mortality rate increases to 40-60% during early
stage of MOF and 90-100% in later stage - Patient
usually dies in about 28 days

Multiple Organ Failure contd

Treatment:
Control initiating event
Promote adequate organ perfusion
Provide nutritional support
Nursing Responsibilities:
essentially the same as septic shock
For those who survive, recovery and
rehabilitation is a long, slow process

Terima
Kasih