看護計画 領域11 安全/防御

NANDA-Nursing plan 00205 Risk for shock

Area 11 Safety/Defense
Category 2 Bodily injury Bodily harm or injury

Risk for shock 00205

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

Nursing Diagnosis: Risk for shock
Definition: A condition in which the body’s tissues are at risk of inadequate blood supply and are susceptible to life-threatening cellular dysfunction, potentially threatening health.

*In the 2021 version, the definition has changed slightly.

Definition: A potentially health-threatening condition that is likely to result in inadequate blood supply to tissues that can lead to cellular dysfunction.

1. What is shock?

Quoted from the Japanese Association for Acute Medicine → Shock Japanese Association for Acute Medicine Medical Glossary (jaam.jp)

1) Definition of shock

A life-threatening acute syndrome in which blood flow to vital organs cannot be maintained as a result of an invasion of the body or a biological response to an invasion, resulting in cell metabolism disorder and organ damage. A decrease in systolic blood pressure below 90 mmHg is often used as an index. Symptoms such as tachycardia, facial pallor, and cold sweats are typically caused by sympathetic nervous system tension. In recent years, a new classification of shock based on circulatory disturbance factors has come into use, and it can be roughly divided into the following four categories.

2) Pathophysiology and 5 signs of shock

(1) pathology

We will break down and understand the definition of shock by the Japanese Association for Acute Medicine.

“Invasion to the living body” means “infection, surgery, injury, bruise, heart disease such as acute myocardial infarction, allergens that cause anaphylaxis, and substances that stimulate nerves.”

“Results of biological reactions to invasion” are defined as “decrease in circulating blood volume in the case of hemorrhage, weakening of cardiac contractility in the case of myocardial infarction, disruption of blood distribution balance between the periphery and the center in the case of sepsis due to infection, vagal reflexes, etc. Nerve stimulation results in a decrease in cardiac output and a decrease in heart rate due to parasympathetic nerve dominance.”

“The blood flow of vital organs cannot be maintained” means “decreased perfusion pressure”. Perfusion is the flow of fluid through an organ. “Perfusion pressure” is the pressure for blood to flow into organs (tissues and cells). That pressure is “blood pressure”. Pressure has the characteristic of moving from high to low. Blood pressure is circulating blood volume x vascular resistance. Any decrease in either will decrease blood pressure. A drop in blood pressure means a drop in the pressure for perfusion to the periphery, so “blood flow to vital organs cannot be maintained.”

However, this decrease in perfusion pressure does not end as it is. When the blood flow to the tissue is reduced, the tissue becomes starved of oxygen. It promotes anaerobic metabolism. Lactic acid accumulates during anaerobic metabolism, causing the body to become acidic (acidosis). In acidosis, arterioles dilate, but venules dilate poorly. Blood is transported to the periphery by dilation of the arterioles, but because the venules cannot collect blood, stagnation of blood flow in the capillaries and extravasation occur, and central blood flow decreases. .

It states that “a decrease in systolic blood pressure of 90 mmHg or less is often used as an index,” but all four shock categories cause a decrease in blood pressure.

To summarize, it is a life-threatening acute disease in which blood pressure (circulatory blood volume x vascular resistance) cannot be maintained due to various causes, perfusion pressure in tissues decreases, and dysfunction occurs in important organs. increase.

(2) Five signs of shock (typical symptoms)

It is a sign of dysfunction in a vital organ. Famous, isn’t it?

① Pallor
② prostration
③ Cold sweat (perspiration)
④ pulselessness
⑤ Pulmonary insufficiency

3) Four categories of shock (cause)


Shock is classified into four types according to the cause.
(1) Circulatory hypovolemia
Decrease in circulating blood volume: Blood pressure↓・Heart rate↓・Cardiac output↓・Central venous pressure↓・Peripheral vascular resistance↑

(2) Cardiogenic and extracardiac restriction
Decrease in cardiac contractility: Blood pressure↓・Heart rate↓・Cardiac output↓・Central venous pressure↑・Peripheral vascular resistance↑

(3) Abnormal blood distribution
① Septic warm shock (decrease in vascular resistance due to cytokines): Blood pressure↓・Heart rate↓・Cardiac output↑・Central venous pressure↓・Peripheral vascular resistance↓

②Septic cold shock (rupture of vascular endothelial cells): Blood pressure↓・Heart rate↓・Cardiac output↓・Central venous pressure↓・Peripheral vascular resistance↓

③ Anaphylaxis (increased vascular permeability): Blood pressure↓・Heart rate↓・Cardiac output→・Central venous pressure↑・Peripheral vascular resistance↓

(4) neurogenic
Sympathetic blockade or vagal reflex: Blood pressure↓・Heart rate↑・Cardiac output→or↓・Central venous pressure↑・Peripheral vascular resistance↓

2. Indications for the “Risk for shock”

There are four categories of shock. Let’s follow the classification.

✩ Risk of hypocirculatory shock:

・Bleeding: Traffic injury, trauma, pelvic fracture, surgery, ectopic pregnancy, gastrointestinal bleeding, malignant tumor

・Dehydration: heat stroke, vomiting, diarrhea, hyperosmotic coma

・Vascular hyperpermeability: extensive burns, ileus, malnutrition, acute pancreatitis, general peritonitis

✩ Risk of cardiogenic shock:

・Myocardial damage (myocardial infarction, dilated cardiomyopathy, myocarditis, valvular disease, heart injury)

・Arrhythmia (same deficiency syndrome, Adams-Stokes syndrome, atrioventricular block, ventricular tachycardia, supraventricular tachycardia)

✩ Risk of extracardiac obstruction/restrictive shock:

Cardiovascular occlusion (pulmonary thromboembolism, acute arterial dissection, atrial myxoma)

・ Increased intrathoracic pressure (tension pneumothorax, positive pressure ventilation)

Cardiac compression (cardiac tamponade, constrictive pericarditis)

・Vascular compression (mediastinal tumor)

✩Risk of dysdistribution shock

Neurogenic (spinal cord injury, vasovagal reflex)

・Anaphylaxis (drugs, bees, food)

・Infectious disease (sepsis), immunocompromise (immunosuppressant, anticancer drug, leukopenia)

*The most common causes of sepsis are pneumonia, urinary tract infection, gastrointestinal perforation, cholecystitis, and cholangitis.

Acute renal failure (adrenal crisis)

3. setting a goal

Goal setting by linkage (listed in the second half of the NOC)

* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).

1) Linkage achievements

Severity of shock: anaphylaxis (0417)
(Definition: severity of symptoms and signs suggestive of inadequate perfusion of tissue due to vasodilatation associated with acute onset of systemic hypersensitivity reactions and increased capillary permeability)

Severity of shock: Hypovolemia (0419)
(Definition: severity of symptoms and signs suggestive of inadequate blood status for tissue perfusion caused by severe intravascular volume depletion)

Severity of shock: neurogenic (0420)
(Definition: severity of symptoms and signs suggestive of inadequate blood status for tissue perfusion caused by persistent vasodilation due to sympathetic-parasympathetic imbalance)

Severity of shock: cardiogenic (0418)
(Definition: severity of symptoms and signs suggestive of inadequate blood flow to tissue perfusion caused by cardiac contraction and pump dysfunction)

Severity of shock: sepsis (0421)
(Definition: Severity of symptoms and signs suggestive of inadequate blood flow to tissue perfusion caused by vasodilation due to endotoxin production associated with widespread infection)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”

・If you feel any abnormalities such as dizziness, palpitations, or discomfort, consult a medical professional.
・Able to follow the treatment plan and self-manage (internal medication, etc.).

*Nurse goals include:
・Early detection of abnormalities leads to early treatment.
・ Help patients adhere to treatment plans and prevent shock from occurring.

4. nursing plan

1 >> Observation plan OP

✩✩ Observation items are divided according to the cause of the shock ✩✩
Severity of shock: Anaphylaxis》
・Presence of allergens ・History of allergies ・Possession of an epipen
・Decrease in systolic blood pressure (reference 110-120mmHg) ・Decrease in diastolic blood pressure (reference 70-80mmHg)
・Increased heart rate
·arrhythmia
・Rhinitis, wheezing (wheezing, wheezing), pharyngeal spasm, bronchial spasm
・Difficulty breathing
・Lower PaO2
・ Warm, flushed skin
・Edema of the lips, eyelids, and tongue
・Angioedema ・Edema of hands and feet ・Edema of genital area
・ paresthesia
・Pruritus
・Decreased urine volume
・Decreased level of consciousness
·panic

★ Severity of shock: Decrease in circulating blood volume》
・Decrease in systolic blood pressure (reference 110-120 mmHg) ・Decrease in diastolic blood pressure (reference 70-80 mmHg)
* An increase in pulse pressure means that arteriosclerosis in large blood vessels is progressing.
・Average blood pressure (diastolic + pulse pressure/3)
* When the average blood pressure rises, it means that the arteriosclerosis of small blood vessels is progressing.
・Increased heart rate
·arrhythmia
・Difficulty breathing
・Lower PaO2 ・Increased PaCO2 ・Decreased urine output ・Decreased level of consciousness ・Delayed pupil response
・Prolonged capillary filling ・Increased respiratory rate ・Shallow breathing ・Pulmonary murmur ・Chest pain ・Metabolic acidosis ・Hyperkalemia

★ Severity of shock: Nervous》
・rebound pulse
(Rebound pulse is a pulse that rises slowly and disappears slowly, and is a pulse seen in aortic regurgitation, patent ductus arteriosus, hyperthyroidism, severe anemia, etc.)
・Decrease in systolic blood pressure ・Decrease in diastolic blood pressure
・Decrease in heart rate ・Increase in heart rate
·arrhythmia
・Changes in respiration ・Decrease in PaO2
・ warm, dry skin – cold, moist skin
・Body temperature drop
・Decreased urine volume
・Decrease in intestinal peristaltic sounds
・A restless state ・Anxiety ・Lesson ・Decreased level of consciousness
・Dilated pupils ・Delayed pupil response
Severity of shock: cardiogenic
・Decrease in pulse pressure ・Decrease in mean blood pressure ・Decrease in systolic blood pressure ・Decrease in diastolic blood pressure
・Prolonged capillary refill time
・Increase in central venous pressure ・Distention of the jugular vein
・Increased heart rate ・Arrhythmia ・Chest pain
・Increased respiratory rate ・Pulmonary edema
・ Pulmonary intermittent adventitious murmurs
・Decrease in PaO2 ・Increase in PaCO2
・ cyanosis – cold, moist skin – paleness
・Decreased urine volume
・Decreased level of consciousness ・Unrest ・Anxiety
・metabolic acidosis

★Severity of shock: sepsis》
* Sepsis is often caused by pneumonia, urinary tract infection, intestinal perforation, cholecystitis, and cholangitis.
・Increased heart rate
・Decrease in systolic blood pressure ・Decrease in diastolic blood pressure ・Arrhythmia
・Increase in breathing rate ・Increase in breathing depth
・Shallow breathing/dyspnea
・Respiratory symptoms such as cough and sputum
・Lower PaO2
・Temperature rise ・Chills
・ Warm, flushed skin
・Low body temperature ・Cold, damp skin ・Paleness
・Decreased urine output ・Urine properties ・Suspended matter ・Cloudiness ・Urine odor
・Decreased intestinal peristaltic sound
Abdominal pain, nausea, vomiting, diarrhea, normal stool
・Disturbance of consciousness/lethargy
・metabolic acidosis

2 >> Action plan TP

・If abnormal symptoms such as 5Ps of shock are observed, report them to the leader or doctor.
・In order to lead a recuperative life according to the treatment plan, we provide medical care assistance such as examinations and medication, as well as recuperation care such as hygiene care and environmental maintenance.
• Plan care according to symptoms. (Nursing is based on safety, comfort and independence)
・If there is a risk of anaphylaxis and you have an epipen, use it at the time of anaphylactic shock (at home). *For hospitals, staff call
・In the case of an infectious disease, take standard precautions to prevent the spread of infection. Handling of filth, hand sanitizer, PPE, etc.
・Improve the environment and arrange the routes for oxygen, drip, drain, etc.
・Manage the inserts (drain, balloon catheter, Cv catheter, tracheal catheter) cleanly.
・Persons who cannot take care of their own oral cavity should carefully perform oral care.
• Suction to prevent retention of respiratory secretions.

3 >> Education plan EP

・If you feel anything out of the ordinary, even if you can’t put it into words (feeling unwell, feeling unwell, feeling light-headed, etc.), ask the patient to call the nurse.
・Explain how to use an epi-pen.
・Explain the necessity of hand washing and gargling.
・Explain the need for oral care.
・Explain the necessity so that patients can understand care that involves invasiveness such as aspiration.

References

T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Toyoaki Yamauchi. (Date unknown). Physical Assessment Guidebook. Igaku Shoin.
Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).

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