Multisystem Failures nursing
Acute IIR cardinal signs
Rubor = redness (due to vasodilation)
Tumor = swelling (due to release of fluid containing RBC and protein)
Callor = heat (due to increase blood flow)
Dollor = pain (swelling cause pain and pressure of the nerve endings)
Types of all shock and complications Hypovolemic, cardiogenic anaphylactic, neurogenic,
septic
Hypovolemic
Lack of circulating blood volume
Blood loss, dehydration, burn, vasodilation due to neurogenic shock or anaphylactic shock, N/V
diarrhea, NG suction.
Drop of blood pressure
Interventions: replace fluid! Monitor fluid replacement, monitor vital signs, assess S/S of fluid
overload, WBC Hemoglobin and hematocrit., positioning for comfort.
Cardiogenic
Weakened forward pumping function of the heart, right, left, ventricles or both.
MI, decreased cardiac output, irregular rate or rhythm
Example if left ventricle is affected you will see pulmonary edema, adventives lung sounds
HR > 100 bpm, weak or thready pulse, diminished heart sounds, dysrhythmia, cool moist pale
skin, chest pain
Renal failure, watch output > 30 ml a hour, 400 ml a day (less than that is oliguria, anuria is
absent of urine)
Generized edema, legs, arms face, watch weight (2 # in 24 hours or 5# a week sign of additional
cardiac and/or kidney failure)
Treatment: oxygen, mechanical intubation, diuretics, inotropic drugs (to stimulate the
contractibility of the heart such as dopamine, dobutamine, inamrinone), ECG, morphine
(improve coronary perfusion)
Anaphylactic
Occurs when an allergen such as food (shellfish, peanuts, chocolate strawberries and
tomatoes)food additive, iodine, latex, mold fungus cats or medications (penicillin) insects (bees)
, venom, enter the body causing release of histamines (widespread antibody response), which
results in capillaries dilation, and smooth muscle contracting.
Life threatening situation. Difficult to diagnose, symptoms look like PE
Comprehensive health history is important to prevent anaphylactic shock. Remember the
different of sensitivity (rash) or allergy. History of an allergy can make second time worse.
Prevent latex Washing hand with soap and water, avoid oil- based cream, prevent dust damp rag.
Make sure they have an epipen, or administer epinephrine
S/S Edema tongue airway, SOB, stridor, hypotension, anxiety.
Neurogenic shock
Absence or suppression of the sympathetic nervous system tone and is considered in the
hypovolemic shock class.
Caused by disruption of brain or hypothalamus, spinal cord injury at or above T6.
Massive peripheral vasodilation, loss of temp regulation, loss of sympathetic tone in the heart,
diminished baroreceptive responses to change blood pressure
Paralysis, warm dry skin, (You do not see decreased reflexes with neurogenic shock).
Treatment: reestablish blood volume, replace fluid! Monitoring fluid overload, medication
inotropic and vasoconstriction meds (dopamine), low dose of corticosteroids, atropine if
bradycardia, ECG, Glasgow coma scale, monitor MODS.
Interventions prevent hypovolemic shock correct hypovolemia, promote normal temp, prevent
hypoxemia, monitor ECG (dysrhytmias), identify patient at risk for neurogenic shock, patient
with DVT.
( stress is related to increased sympathetic nervous system arousal and involves a wide
physiological response)
Septic shock
Circulation and coagulation is altered
severe sepsis is associated with one or more organ dysfunction.
S/S Hypotension, blood pressure has a widened pulse, tachycardia, high temp, lactic acidosis,
oliguria, mental status changes, cellular and humoral responses. Aches and chills, decreased skin
perfusion It mimic SIRS, sign of at least one organ failure
Diagnosis, WBC, identify the source, history
Causes bowel surgery, severe malnutrition, multiple antibiotic therapy, multiple immune
suppressant therapy (patient on chemo, radiation), prolonged hospitalization, nosocomial
infection.!! Gram negative bacteria is a major cause of septic shock!!
Acute IIR cardinal signs
Rubor = redness (due to vasodilation)
Tumor = swelling (due to release of fluid containing RBC and protein)
Callor = heat (due to increase blood flow)
Dollor = pain (swelling cause pain and pressure of the nerve endings)
Types of all shock and complications Hypovolemic, cardiogenic anaphylactic, neurogenic,
septic
Hypovolemic
Lack of circulating blood volume
Blood loss, dehydration, burn, vasodilation due to neurogenic shock or anaphylactic shock, N/V
diarrhea, NG suction.
Drop of blood pressure
Interventions: replace fluid! Monitor fluid replacement, monitor vital signs, assess S/S of fluid
overload, WBC Hemoglobin and hematocrit., positioning for comfort.
Cardiogenic
Weakened forward pumping function of the heart, right, left, ventricles or both.
MI, decreased cardiac output, irregular rate or rhythm
Example if left ventricle is affected you will see pulmonary edema, adventives lung sounds
HR > 100 bpm, weak or thready pulse, diminished heart sounds, dysrhythmia, cool moist pale
skin, chest pain
Renal failure, watch output > 30 ml a hour, 400 ml a day (less than that is oliguria, anuria is
absent of urine)
Generized edema, legs, arms face, watch weight (2 # in 24 hours or 5# a week sign of additional
cardiac and/or kidney failure)
Treatment: oxygen, mechanical intubation, diuretics, inotropic drugs (to stimulate the
contractibility of the heart such as dopamine, dobutamine, inamrinone), ECG, morphine
(improve coronary perfusion)
Anaphylactic
Occurs when an allergen such as food (shellfish, peanuts, chocolate strawberries and
tomatoes)food additive, iodine, latex, mold fungus cats or medications (penicillin) insects (bees)
, venom, enter the body causing release of histamines (widespread antibody response), which
results in capillaries dilation, and smooth muscle contracting.
Life threatening situation. Difficult to diagnose, symptoms look like PE
Comprehensive health history is important to prevent anaphylactic shock. Remember the
different of sensitivity (rash) or allergy. History of an allergy can make second time worse.
Prevent latex Washing hand with soap and water, avoid oil- based cream, prevent dust damp rag.
Make sure they have an epipen, or administer epinephrine
S/S Edema tongue airway, SOB, stridor, hypotension, anxiety.
Neurogenic shock
Absence or suppression of the sympathetic nervous system tone and is considered in the
hypovolemic shock class.
Caused by disruption of brain or hypothalamus, spinal cord injury at or above T6.
Massive peripheral vasodilation, loss of temp regulation, loss of sympathetic tone in the heart,
diminished baroreceptive responses to change blood pressure
Paralysis, warm dry skin, (You do not see decreased reflexes with neurogenic shock).
Treatment: reestablish blood volume, replace fluid! Monitoring fluid overload, medication
inotropic and vasoconstriction meds (dopamine), low dose of corticosteroids, atropine if
bradycardia, ECG, Glasgow coma scale, monitor MODS.
Interventions prevent hypovolemic shock correct hypovolemia, promote normal temp, prevent
hypoxemia, monitor ECG (dysrhytmias), identify patient at risk for neurogenic shock, patient
with DVT.
( stress is related to increased sympathetic nervous system arousal and involves a wide
physiological response)
Septic shock
Circulation and coagulation is altered
severe sepsis is associated with one or more organ dysfunction.
S/S Hypotension, blood pressure has a widened pulse, tachycardia, high temp, lactic acidosis,
oliguria, mental status changes, cellular and humoral responses. Aches and chills, decreased skin
perfusion It mimic SIRS, sign of at least one organ failure
Diagnosis, WBC, identify the source, history
Causes bowel surgery, severe malnutrition, multiple antibiotic therapy, multiple immune
suppressant therapy (patient on chemo, radiation), prolonged hospitalization, nosocomial
infection.!! Gram negative bacteria is a major cause of septic shock!!
