Page 580 - ACCCN's Critical Care Nursing

Management of Shock 557

Paralytic ileus is a concern in the acute phase of injuries feature a complex interaction of generic compensatory
above T5, where disruption of integrative innervation mechanisms which attempt to sustain perfusion and
132
pathways leads to unmodulated colonic functioning particularly oxygen delivery to the vital organ systems
and peristaltic hypomotility. Ileus may lead to respiratory of the body. These protective responses are particularly
compromise and should be managed. The patient should strong in supporting cerebral perfusion and combine
remain ‘nil by mouth’ and treatment includes gastric responses from the SNS, endocrine and adrenal/renal
decompression, adequate IV hydration and electrolyte systems. As shock develops cellular dysfunction occurs
balance. Drug therapy with prokinetics, probiotics, aperi- in response to the release of a large collection of
ents and IV neostigmine or lignocaine has been reported systemic and local inflammatory mediators which
to be useful. in evitably overwhelm cell function and lead to diffuse
organ injury if shock continues unabated. The clas-
Pressure care is attended every second hour and where
Jordan frames are used, slats are removed between use. sification system described here differentiates shock
The patient is susceptible to deep venous thrombosis into categories including hypovolaemic, cardiogenic
(DVT), so sequential calf compression devices and other and distributive; classification is dependent on aetio-
prophylaxis are initiated early with D-dimers monitored logy. Clear assessment is required to distinguish the
regularly. type of shock aids in appropriate treatment decisions,
targeting the cause and managing associated symptoms.
SUMMARY Critical care nurses are in a position to provide clear
assessment and first-line emergency management of
Shock is a generic term describing a syndrome and the various shock states. Collaborative integrated care
pervasive set of potentially life-threatening symptoms. is important to provide the patient with the best pos-
The pathophysiological changes associated with shock sible outcome.

Case study

Locally and internationally, there are many reports that demon- The ED was very busy and no further observations were recorded
strate systematic hospital challenges for in-patients that develop until 0100h when her blood pressure was noted to be 82/60. The
shock. Identified issues include failure to recognise or respond to ED workflow was interrupted by the arrival of multiple patients
deteriorating patients, inadequate or delayed treatment, unstable from a nearby traffic accident that diverted nursing and medical
patient transfers and a lack of clinical supervision. This has led to staff to the resuscitation bays.
the implementation of track and trigger systems and development Only two further sets of observations were documented over the
of various standards and performance indicators aimed at improv- next four hours and recorded as 82/60 and then SBP 60. A further
ing patient care. The following case study highlights some of these fluid bolus of 500 mL of normal saline was administered. The
issues.
medical registrar was notified at 0540h by the team leader. After
examination, antibiotics were prescribed and an indwelling
An independent 80-year-old female, Ellen, presented to the emer- catheter inserted. There was no residual volume. Ellen was
gency department (ED) at 2200 h. The ED was very busy and short- then seen by the ICU registrar at 0620h. Central and arterial lines
staffed. Ellen was prescribed antibiotics for a urinary tract infection were inserted and it was recommended that the patient be trans-
(UTI) 10 days ago but stopped taking them 6 days ago because of ferred to ICU.
thrush. She started to feel very sick this evening and called an
ambulance. Relevant medical history includes hypertension and a Unfortunately, prior to transfer, Ellen died. The case was investigated
recent diagnosis of chronic renal failure which is currently being through a root cause analysis process as it was allocated the
investigated. On arrival, the triage nurse recorded Ellen’s blood highest severity code. Recommended system improvements
pressure at 104/37. An initial fluid bolus of 500 mL of normal saline included processes to improve early recognition of deterioration
was administered by the receiving ED nurse as per the local policy. and sepsis.

Research vignette

Harrison GA, Jacques T, McLaws ML, Kilborn G. Combinations of criteria could be wasteful of resources. This study searched a large
early signs of critical illness predict in-hospital death- the SOCCER database to explore the association of combinations of recordings
study (signs of critical conditions and emergency responses). of early signs (ES), or early with late signs (LS) with in-hospital
Resuscitation 2006; 71(3): 327–34. death.
Abstract Methods
Background A cross-sectional survey was undertaken of 3046 non-do not
Medical emergency team (MET) call criteria are late signs of a dete- attempt resuscitation adult admissions in 5 hospitals without MET
riorating clinical condition. Some early signs predict in-hospital over 14 days. The medical records were reviewed for recordings of
death but have a high prevalence so their use as single sign call 26 ES and 21 LS and in-hospital death. Combinations of ES with or