MULTISYSTEM

PROBLEMS
RHEALEEN V. VICEDO, MAN, RN
Assistant Professor IV
INTENDED LEARNING
OUTCOMES

01. 02.
Assess patients Identify Diagnostic
with multisystem studies
problems

03. 04. 05.

Determine nursing Identify Evaluate care/
diagnosis, plan and pharmacologic and management
implement care medical
interventions
SHOCK
SHOCK

• profound hemodynamic and

metabolic disturbance
• due to inadequate blood flow
and oxygen delivery to capillaries
and tissues
SHOCK
• Clinical syndrome from inadequate tissue
perfusion

• Imbalance between delivery and requirement

for oxygen and nutrients for cellular function
BASIC CONCEPTS IN THE
MAINTENANCE OF TISSUE
PERFUSION
• CARDIAC OUTPUT
• Amount of blood pumped per minute
• Ability of the heart to pump
• CIRCULATING VOLUME
• amount of blood circulating in the body
• SYSTEMIC VASCULAR RESISTANCE
• ability to constrict and dilate to maintain normal
BP
BASIC CONCEPTS IN THE
MAINTENANCE OF TISSUE
PERFUSION
• AUTONOMIC RESPONSE
• SNS / PNS
• HORMONES
• Catecholamines → vasoconstriction &
adequate pump action of the heart
• RAAS, ADH – retention of Na+ and water
STAGES OF SHOCK

• INITIAL / COMPENSATORY STAGE

• PROGRESSIVE / DECOMPENSATED

• IRREVERSIBLE / REFRACTORY
INITIAL / COMPENSATORY
STAGE
• BP remains normal
• SNS stimulation : “fight or flight response”
↓
Catecholamine release
↓
↑HR
↓
↑contractility
↓
Maintain cardiac output
INITIAL / COMPENSATORY
STAGE
• MAP= CO x PR
• Normal: > 65 mmHg (60-90mmHg)
• MAP= Mean Arterial Pressure
• CO = Cardiac Output (Stroke Volume x HR )
• PR = Peripheral Resistance (diameter of arterioles)
• MAP= SBP + 2 (DBP)
3
• SBP- systolic blood pressure
• DBP- diastolic blood pressure
INITIAL / COMPENSATORY
STAGE

• PULSE PRESSURE = Systolic BP – Diastolic BP

• Normal: 40 mmHg
INITIAL / COMPENSATORY
STAGE
• e.g. BP is 160/100 mmHg

• Compute for MAP:

MAP= 160 + 2(100) = 120
3
• Compute for Pulse Pressure
Pulse Pressure = 160 – 100
= 60
INITIAL / COMPENSATORY STAGE
↓ cardiac output

↓ renal tissue
perfusion

renin

ANGIOTENSIN Aldosterone
release

vasoconstriction Na+ and H2O K+ excretion

retention

↑ ECF volume hypokalemia

↑ BP
INITIAL / COMPENSATORY
STAGE
↓ cardiac output

↓ hydrostatic pressure in
capillaries
Fluid shift
(ICS→ECS)
↑ circulating blood
volume
INITIAL / COMPENSATORY
STAGE
hypoxemia

hyperventilation

O2 supply to Respiratory
tissues Alkalosis

↑ tissue perfusion
INITIAL / COMPENSATORY
STAGE
↓ cardiac output

SNS stimulation

Vasoconstriction in the liver

Releases 350 ml of blood to

circulation

↑ cardiac output
STAGES OF SHOCK

• INITIAL / COMPENSATORY STAGE

• PROGRESSIVE / DECOMPENSATED

• IRREVERSIBLE / REFRACTORY
PROGRESSIVE/DECOMPENSATED
STAGE
• Compensatory mechanisms fail
• MAP ↓
• BP < 90 mmHg or ↓ 40mmHg from baseline
• ↓ mental status
PROGRESSIVE/DECOMPENSATED
STAGE
• Compensatory mechanisms fail
• MAP ↓
• BP < 90 mmHg or ↓ 40mmHg from baseline
• ↓ mental status
PROGRESSIVE/DECOMPENSATED
STAGE Impaired blood flow to tissues

↓ O2 supply

Anaerobic Metabolism

↓ ATP Lactic Acid

production

Na+ - K+ pump failure

Damage to cell organelles

Cell digestive enzyme Cell death Organ death

release
PROGRESSIVE/DECOMPENSATED
Impaired myocardial
STAGE function and activity
↓ blood supply to the
Acidosis heart

Dilation of arteriole end ↓ C.O.

of capillary
Constriction venule end ↓ myocardial
of capillary contractility

↑ hydrostatic pressure Myocardial depressant

↑ capillary permeability factor (MDF)
Hypoxemia of abd
Fluid shift from IVC to organs esp. by pancreas
ISC
•Oliguria /
↓ circulating blood ↓ renal blood anuria
volume supply •↑BUN, Crea
•hyperkalemia
 BP <70 mmHg

DECOMPENSATED / PROGRESSIVE
↓ glomerular filtration

Fluid and waste products retention

K
I ↓ tubular perfusion
STAGE

D
N Acute tubular necrosis
E
Y Tubular epithelial cells slough off
S
Blockage of tubules

Loss of nephron
function

Renal Failure
DECOMPENSATED / PROGRESSIVE
↓ cerebral tissue perfusion

B
STAGE

R Accumulation of
Cerebral hypoxia toxic substance Acidosis
A
I
N

Altered mental status

DECOMPENSATED / PROGRESSIVE
Hypoperfusion of the lungs

Acute Respiratory Distress Syndrome (ARDS)

L ↑ permeability of pulmo capillaries to protein and water

STAGE

U
N Non cardiac pulmonary edema
G
S Destruction of type 2 pneumocytes

↓ surfactant production
DECOMPENSATED / PROGRESSIVE

Fluid filled alveoli atelectasis

L
Ventilation-Perfusion Mismatch
STAGE

U
N
G hypoxemia ↑ work of breathing
S

Retention of CO2 ↑ platelet aggregation

Respiratory Further destruction of

Acidosis lung tissues
DECOMPENSATED / PROGRESSIVE
↓ blood supply to GIT organs

↓ peristalsis GIT mucosa Lysis of colonic

necrosis microorganisms

Paralytic ileus
STAGE

G
I
T
Release of endotoxins

Septic Shock Ulceration of gastric

mucosa

Occult bleeding Massive hemorrhage

DECOMPENSATED / PROGRESSIVE

↓ liver perfusion

↓ Metabolic function ↓ Kupferr cells destruction

L
STAGE

I
V Bacteria enters the general circulation
E
R Toxin production

Septic Shock
 DIC
• Acidosis
DECOMPENSATED / PROGRESSIVE • Blood stagnation
• Bacterial toxins
• Prostaglandins
• Procoagulation factors

Intavascular clotting

B
STAGE

L Clotting in capillaries ↓ tissue perfusion

O
↓ clotting factors in the
O general circulation
D
hemorrhage

↓ C.O.

↓ Circulation
STAGES OF SHOCK

• INITIAL / COMPENSATORY STAGE

• PROGRESSIVE / DECOMPENSATED

• IRREVERSIBLE / REFRACTORY
IRREVERSIBLE / REFRACTORY
STAGE
• Severe organ damage
• Patient does not respond to Tx

Multiple organ dysfunction

↓
complete organ failure
↓
death
STAGES OF SHOCK
All types of shock have septic component
• Lysis of colonic microorganisms
• Destruction of Kupferr cells
STAGES OF SHOCK - Manifestations
FINDINGS COMPENSATORY PROGRESSIVE IRREVERSIBLE
BP Normal SBP <90 mmHg Requires mechanical or
MAP <65 mmHg Pharmacologic support
Requires fluid resuscitation

HEART RATE > 100 bpm >150 bpm Erratic / asystole

RESPIRATORY > 20 cpm Rapid, shallow breaths Requires intubation,
STATUS PaCO2 <32 mmHg Crackles mechanical ventilation
PaO2 <80 mmHg and oxygenation
PaCO2 >45 mmHg

SKIN Cold clammy Mottled Jaundice

Petichiae
URINARY OUTPUT Decreased <0.5 ml/ kg/ hr Anuric, requires dialysis

MENTATION Confused/ Agitated Lethargy Unconscious

ACID-BASE Respiratory alkalosis Metabolic Acidosis Profound acidosis
BALANCE
STAGES OF SHOCK - Manifestations
EARLY STAGE OF LATE STAGE OF SHOCK
SHOCK •Lethargy, unconscious
•↑ HR
•Restlessness, confusion
•oliguria / anuria
•↑ HR, RR •Edema
•Diaphoresis • cool clammy skin (septic, hypovolemic, cardiogenic)
•Cool clammy skin (septic) •Cool, mottled skin (neurogenic, vasogenic shock)
•Normal BP / ↓ BP •Metabolic acidosis / respiratory acidosis
•↓ Pulse pressure •Hyperkalemia
•↓ urine output •hypothermia
•Thirst, dry mucosa •DIC
• ↓ bowel sounds
•Respiratory alkalosis
•Cyanosis
•hypokalemia •Dilated pupils
CLASSIFICATIONS OF SHOCK
• HYPOVOLEMIC SHOCK
• CARDIOGENIC SHOCK
• VASOGENIC/ DISTRIBUTIVE SHOCK
• NEUROGENIC SHOCK
• SEPTIC / TOXIC SHOCK
• ANAPHYLACTIC SHOCK
HYPOVOLEMIC SHOCK
↓ circulating blood volume
• Due to:
✓ excessive blood loss
✓Loss of body fluids/ third spacing

✓E.g
✓Hemorrhage
✓Dehydration
✓Burns
✓Trauma
✓ascites
HYPOVOLEMIC SHOCK
Massive Blood / fluid
loss

↓ coronary artery
↑ Venous pooling ↓ arterial BP
filling

Metabolic acidosis ↓ tissue perfusion ↓ myocardial function

Microcirculation
↓ venous return
damage

Cellular hypoxia

Vasoactive substance
release

↑ capillary
permeability
BURNS
• Burns are caused by:
• HEAT
• CHEMICALS
• ELECTRICITY
• RADIATION
• A critical burn can be life threatening and needs
immediate medical attention.
 TYPES OF BURNS
• SUPERFICIAL - FIRST DEGREE
• Involves only the top layer of skin.
• The skin is red and dry and the burn is
usually painful.
• The area may swell.
• Most sunburns are superficial burns
• Usually heal in 5-6 days without scaring.
 TYPES OF BURNS
• PARTIAL THICKNESS - SECOND
DEGREE
• Skin is red and has blisters that may
open and seep clear fluid making the
skin appear wet.
• Usually painful and the area swollen.
• The burn heals in 3-4 weeks
• Scarring may occur.
 TYPES OF BURNS
•FULL THICKNESS -THIRD DEGREE
• Destroys all layers of skin and any or all of
the underlying structures – fat, muscle,
bones, etc.
• Look brown or black (charred) with the
tissues underneath sometimes appearing
white.
• relatively painless if the burn destroys the
nerve endings.
CRITICAL BURNS
• Burns involving trouble in breathing.
• Burns covering more than one body part.
• Burns to the head, neck, hands, feet or genitals.
• Burns (other than a very minor one) to a child or an
elderly person.
• Burns resulting from chemicals, explosions, or electricity.
RULE OF NINES
FLUID RESUSCITATION IN
BURNS

• Lactated Ringer’s in all burn resuscitation

• Burn resuscitation requires more fluid than trauma

resuscitation.
FLUID RESUSCITATION IN
BURNS

FORMULAS
• Total fluid volume to be administered for the first 24 hours
• Parkland : LR 4 mL/kg / TBSA
• Modified Brook: LR 2 mL/kg / TBSA
• ½ of the total amount should be administered on the 1st 8
hours
• The remaining ½ is divided into 2 for the succeeding 16 hours
FLUID RESUSCITATION IN
BURNS
• EXAMPLE:
A 35 year old female patient has been burned by a chemical.
Burned parts are the following: anterior left arm, whole left leg,
and the anterior chest. The weight of the patient is 75kg.

1. Find the TBSA burned in %

2. Compute for the fluids to be administered in the first 8 hours
using parkland formula
FLUID RESUSCITATION IN
BURNS
1. Find the TBSA burned in %
Using the Rule of 9:
Anterior L arm = 4.5 %
L leg = 18%
Anterior Chest = 18%
TBSA = 40.5%
FLUID RESUSCITATION IN
BURNS
2. Compute for the fluids to be administered in the first 8 hours
using parkland formula
(TVF = 4ml x weight in kg x TBSA )
= 4ml x 75kg x 40.5
= 12,150 ml (amount of fluid needed for 24hrs)

FLUID NEEDED FOR THE 1st 8 hours

= 12,150 / 2
= 6,075 ml of PLR within the first 8 hours
**the remaining 6,075ml to be infused in the following 16 hours
CARE FOR BURNS
• Cool The Burn
• Use large amounts of cool water.
• DO NOT USE ice or ice water
• Use whatever sources are available

• Cover the Burn

• Use dry, sterile dressings or clean cloth.
• Loosely bandage in place.
• Prevents infection.
DO’S & DON’TS OF BURN
CARE
• DO s • DON’T s
• Cool a burn by flushing • Apply ice directly to any
with water burn unless very minor.
• Cover with dry, clean • Touch a burn with
covering. anything except a clean
• Do keep he victim covering.
comfortable • Remove pieces of cloth
• DOC: Silver Sulfadiazine that stick to a burn.
• Don’t break blisters.
CLASSIFICATIONS OF SHOCK
• HYPOVOLEMIC SHOCK
• CARDIOGENIC SHOCK
• VASOGENIC/ DISTRIBUTIVE SHOCK
• NEUROGENIC SHOCK
• SEPTIC / TOXIC SHOCK
• ANAPHYLACTIC SHOCK
CARDIOGENIC SHOCK
• Impaired or compromised cardiac output
• Due to:
✓ pump failure
✓ decreased venous return
• E.g
✓Myocardial Infarction
✓dysrhythmias
✓Restrictive pericarditis
✓Valvular diseases
✓Cardiac tamponade
CARDIOGENIC SHOCK
CARDIOGENIC SHOCK
CLASSIFICATIONS OF SHOCK
• HYPOVOLEMIC SHOCK
• CARDIOGENIC SHOCK
• VASOGENIC/ DISTRIBUTIVE SHOCK
• NEUROGENIC SHOCK
• SEPTIC / TOXIC SHOCK
• ANAPHYLACTIC SHOCK
VASOGENIC/DISTRIBUTIVE
SHOCK
• “circulatory shock”
• Results from profound and massive vasodilation
• Intravascular volume pools in peripheral blood
vessels
• Not enough blood returns to the heart
VASOGENIC/DISTRIBUTIVE
SHOCK
• NEUROGENIC SHOCK
• Loss of vasomotor tone (both arterial and venous)
• loss of balance between SNS-PNS

E.g.
• Head injury
• Spinal cord injury
• General anesthesia
• Drug overdose (opiates, barbiturates, tranquilizers)
• Fainting / syncope
VASOGENIC/DISTRIBUTIVE
SHOCK
• SEPTIC / TOXIC SHOCK
• Wide spread infection
• Generalized vascular collapse from systemic infection
• Usually caused by gram-negative organisms
• Endotoxins → massive vasodilation

E.g.
• Bacteremia
SYSTEMIC INFLAMMATORY
RESPONSE SYNDROME (SIRS)
• Similar to sepsis but there is no identifiable
source of infection
• Stimulates an overwhelming inflammatory
immunologic and humoral response
SYSTEMIC INFLAMMATORY
RESPONSE SYNDROME (SIRS)

MANIFESTATIONS:
• Fever of more than 38°C (100.4°F)
• HR > 90
• RR > 20 ; PaCO2 < 32 mm Hg
• WBC >12,000/µL or <4,000/µL or >10%
immature [band] forms
VASOGENIC / DISTRIBUTIVE
SHOCK
• ANAPHYLACTIC SHOCK
• Severe allergic reactions
• Patients already produced antibodies (IgE) to foreign
bodies → systemic antigen-antibody reaction
• Large quantities of fluid may leak out of the capillaries
causing severe hypovolemia
VASOGENIC / DISTRIBUTIVE
SHOCK
• Trigger → mast cells
activated → release of
histamine, bradykinin,
cytokines, leukotrines,
prostaglandins →
widespread
vasodilation → airway
obstruction → death
VASOGENIC / DISTRIBUTIVE
SHOCK
Precipitating event

vasodilation

Activation of inflammatory
response

↓ venous return

↓ C.O.

↓ tissue perfusion
PARAMETERS FOR ASSESSING
STATUS OF CLIENT IN SHOCK
• HEMODYNAMIC MONITORING
• BP
• Pulse
• Central venous System
• pulmonary artery pressure, pulmonary capillary
wedge pressure
• Cardiac output
• ECG
 PARAMETERS FOR ASSESSING
STATUS OF CLIENT IN SHOCK
• HEMODYNAMIC MONITORING
PULMONARY CAPILLARY WEDGE
PRESSURE (PCWP)
• Measured by inserting balloon-tipped,
multi-lumen catheter (Swan-Ganz
Catheter) into a peripheral vein
• Normal: 2-15mmHg
• Most accurate reflection pf left atrial
pressure, left ventricular end-diastolic
pressure (LVEDP), or preload
PARAMETERS FOR ASSESSING
STATUS OF CLIENT IN SHOCK
• NEUROLOGIC MONITORING
• alertness
• orientation
• confusion

• HEMATOLOGIC MONITORING
• RBC
• HCT, HGB Levels
• WBC
• Platelets
• PT, PTT clotting time
COLLABORATIVE MANAGEMENT
• PROMOTING FLUID BALANCE
• whole blood and blood products
• Colloid solutions (plasma expanders)
• Crystalloid solutions
• eg. d5%, PNSS, PLR’s
COLLABORATIVE MANAGEMENT
• ASSISTING WITH CARDIAC SUPPORT
• Modified Trendelenburg position
• Supine, head supported with pillow
• Legs extended and elevated at 20-30°
• Pelvis higher than torso
• Intra-aortic balloon pump
COLLABORATIVE MANAGEMENT
• ASSISTING WITH RESPIRATORY SUPPORT
• Oxygen therapy
• mechanical ventilation
• Deep breathing, coughing exercises
• Suction prn
COLLABORATIVE MANAGEMENT
• ASSISTING WITH RENAL SUPPORT
• monitor urine output q1
• Monitor BUN, Crea
• Diuretics: furosemide, mannitol

• ASSISTING WITH G.I. SUPPORT

• prevent stress ulcer
• NGT to suction
• Histamine Blockers
• Antacids
COLLABORATIVE MANAGEMENT
•PROMOTING SAFETY
• soft restraints if restless
• Practice strict asepsis
• prevent complications of immobility
DRUG THERAPY
• VASODILATORS
• nitroglycerine, isosorbide
• Hydralazine

• Na+ Bicarbonate
• Antibiotics
• Heparin
• Steroids
• Antacids/ proton pump inhibitors
DRUG THERAPY
• Glucose 50% to meet energy demands
• Naloxone (Narcan) to block endorphin-mediated
hypotension
• Dyphenhydramine (Benadryl)
• Narcotics with great care
• Cardiogenic Meds:
• For dysrhythmias e.g. Lidocaine
• For bradycardia e.g. Atropine
“