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Perawatan Pada Pasien Shock
Fithri kurniati
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The ardiovascular System
Pump (Heart)
Tubing (Blood Vessels)
Fluid (Blood)
Made up of three key
components:
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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
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Epidemiology
Mortality
Septic shock 35-40% (1 month mortality)
Cardiogenic shock 60-90%
Hypovolemic shock variable/mechanism
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5
Shock
CardiogenicHypovolaemic
Anaphylactic Septic
Distributive
Neurogenic
Classification of Shock
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Shock
Classification
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Classifications of Shock
Hypovolemicakibat kehilangan cairan tubuh >>>>
Cardiogenic - akibat dari disfungsi jantung
Anaphylactic Shockakibat dari antigen-antibodyreaction yg menyebabkan pelepasana histamin ke
sirkulasi darah
Septic Shock (systemic inflammatory response
syndrome)akibat infeksi yang luas dan invasi
mikroorganisme ke dalam tubuh Obstructive Shockakibat sumbatan pada aliran darah
Neurogenic shock - akibat kerusakan atau disfungsi
sistem saraf simpatis (jarang)
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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
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Hypovolemic Shock
Hemorrhagic stage
Parameter I II III IV
Blood loss (ml) 2000
Blood loss (%) 40%
Pulse rate (beats/min) 100 >120 >140
Blood pressure Normal Decreased Decreased Decreased
Respiratory rate (bpm) 1420 2030 3040 >35
Urine output (ml/hour) >30 2030 515 Negligible
CNS symptoms Normal Anxious Confused Lethargic
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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, multivesselcoronary 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)
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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 jantungmenurun drastis.
Contrast media
Drug reactions
Blood transfusion reactions
Food allergies
Insect bites or stings
Snake bites
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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 bydamage or dysfunction of the sympathetic nervous system
(rare)
Trauma
Anesthesia
Spinal Shock
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Pathophysiology of Shock
A mean arterial pressure (MAP) of 80 to 120
mmHg diperlukan sel untuk memperoleh oxygen andnutrients yg dibutuhkan untuk metabolisme guna
menghasilkan energi yg cukup untuk mempertahankanhidup
Tubuh memiliki mekanisme kompensasi untukmempertahankan MAP akibat dari perubahan
kemampuan pompa jantung, volume darah/cairan tubuh,dan perubahan pada sistem vaskular
Selama mekanisme tersebut efekt i f tubuh dapat
tetap bertahan hidup , namun j ika gagal perfus i
jar ingan tidak adekuat dan shock mulai ter jad i
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Compensatory
Mechanisms
Baroreceptors (pressure receptors) - terletak pada
sinus karotid dan arkus aortikus
Penurunan MAP menyebabkan menurunnya regangan
pada baroreceptors ( terjadi kehilangan efek inhibisibaroreseptor terhadap pusat pusat vasomotor)
Aktivitas simpatetis eferen terstimulasi otakmengirim impuls ke kelenjar adrenal untuk melepas
katekolamin (epinephrine & norepinephrine) Catecholamines menyebabkan peningkatan denyut
jantung dan vasokonstriksi
Aktivitasparasimpatis menurun pada saat ygbersamaan
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Chemoreceptors - berada pada arkus aortikus dan arteri
karotis
Berespon/sensitif terhadap prubahan oksigen dalam darah
Meregulasi blood pressure and heart rate
Kidneysmelepas renin yang menyebabkan konversi
angiotensin I to angiotensin II vasocontrictor kuat
Terjadi pelepasan aldosterone dari korteks adrenalmenyebabkan retention of sodium and water
Peningkatan retensi sodium mencetuskan pelepasan ADH(antidiuretic hormone)
ADH menyebabkan ginjal menahan cairan dalam tubuhuntuk meningkatan jumlah volume darah/sirkulasi dan
blood pressure
Compensatory
Mechanisms
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Chain of Events= rantai kejadian
Penurunan perfusi jaringan menurunkan jumlah oksigen, nutrien
cell, begitu pula degnan energi
Metabolisme intraseluler menghasilkan ATP sebagai sumberenergi 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
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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
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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 >>>>
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Stages of Shock - Compensatory
If treated, prognosis is good
blood pressure masih DBN
vasoconstriction, increased heart rate and increased
contractility, betujuan untuk mempertahankan cardiacoutput 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 compensatoryrespiratory alkalosis)
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Compensatory Shock contd
Treatmentfokus 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 meningkatsebagai respon terhadap pelepasan ADH and
catecholamines)
Berikan cairan dan obat2an sesuai instruksi
Segera laporkan setiap adanya perubahan
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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 mengalamikegagalan
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, elevatedcardiac enzymes
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Progressive Shock Contd
Brainperubahan 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 racunberkurang (ammonia and lactic acid), lebih beresiko terhadap
infeksi, SGOT (AST), SCPT (ALT) and LDH meningkat, ikterik
GI- stress ulcers, GI Bleed, mucosa dpt mengalami nekrosisdan iritasi mengakibatkan bloody diarrhea; toxins
dilepaskan ke aliran darah menyebabkan depresi jantung
dan vasodilatasi
Hematologic System - DIC, platelets and clotting factorsmeningkat, PT/PTT memanjang
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Progressive Shock contd
Treatmenttergantung tipe shock dan penyebab yang
mendasari.
Tujuannya adalah menggunakan cairan danobat-obatan un tuk mengembal ikan perfusi
jar ingan :
Mengoptimalkan volume intravascular
Meningkatkan kemampuan pompa jantung
Memperbaiki fungsi sistem vaskular
Kebutuhan nutrisi tetap haus dipenuhi
untukmelindungi GI tract
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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 andEKG monitoring
May require mechanical ventilation or IABP therapy(intra-aortic balloon pump)
Requires close monitoring of changes in ABGresults, electrolyte levels and mental & physical
status
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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 komplikasidan injury, serta memberi kenyamanan.
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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
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Irreversible Shock contd
Treatmentlanjutkan seperti pada Progressive
Shock (only determined to be irreversible when the
patient dies)
Nursing Responsibilities
Lanjutkan treatment yg diinstruksikan, monitorthe patient, prevent complications, protect from
injury and provide comfort
Komunikasikan kepada klien dan beri dukungan
pasien untuk menjalani proses grievingPENTING!
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Medical Management of Shock
Fluid replacement untuk menggantikan
intravascular volume (Crystal loids , Col loids,
Blood components)
Obat2an Vasoactiveuntuk mengembalikan tonus
vasomotor dan meningkatkan cardiac function
Nutr i t ional suppo rt to address increased
metabolic requirements
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Fluid Replacement
Crystalloids - electrolyte solutions = dapat berpindah
dgn mudah antara intravascular compartment and
interstitial spaces
Selalu berikan isotonic solutions - sameconcentration 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
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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
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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-Ganzcatheter
If CVP being monitored, should be between 4 and 12
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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
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Vasoactive Drugs contd
Nursing Responsibilities
Monitor vital signs tiap15 min selama
vasoactive drugs diberikanBerikan 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
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Nutritional Support
Patients yg mengalami shock memerlukan lebih
dari 3000 calories per hari
Pelepasan catecholamines menyebabkan
penggunaan cadangan glycogen - can occur in 8-
10 hours. This causes skeletal muscle to be
broken down for energy.
Start parenteral (HAF) or enteral (NGT, PEG, J-
Tube, Duodenal tube, Dobb-Hoff) within 3-4 days
Biasanya diberikan H2 blockers (cimetidine,
ranitidine) untuk mencegah stress ulcers akibat
penurunan perfusi GI tract
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Hypovolemic Shock contd
Nursing Responsibilities
Sedapat mungkin harus dicegah melaluimonitoring ketat pasien2 yg beresiko
Berikan terapi cairan dan obatAN secara amandan hati2 and document effect
Monitor for complications and side effects andreport early
Safely administer blood/blood products.Monitor for adverse effects
Administer oxygen and monitor effectiveness
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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 shockditandai dgn chest pain and dysrhythmias
tujuan: (1) batasi kerusakan lebih lanjut ,(2) jaga kesehatan
jantung, (3) perbaiki kemampuan pompa jantung
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Cardiogenic Shock contd
Treatment:
Oxygen - monitor O2 sat and ABGs
Morphine for chest painuntuk 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 renaland mesenteric perfusion, medium-dose(4-8
mcg/kg/min) for improving contractility and heart
rate,high-dose
causes vasoconstriction
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Cardiogenic Shock contd
Nursing Responsibilities:
Lakukan tindakan pencegahan - identify patients at risk.
Berikan oksigenasi secara adekuat. Kurangi beban kerja
jantung. Beri bantuan untuk mengembalikan fungsijantung dan perfusi jaringan.
Antisipasi kebutuhan terhadap obat2an, cairan,
hemodynamic monitoring and assist with
implementation
Dokumentasikan perubahan hemodinamik dan statuscardiac laporkan segera
Monitor komplikasi dan side effects - BP and HR
changes, bleeding, tissue necrosis and sloughing, UOP,
BUN, Cr, circulatory compromise with IABP
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Distributive Shock
Category for Neurogenic, Anaphylactic and Septic Shock
terjadi vasodilatasi arterial and venous menyebabkan
re lat ive hypovo lemia
Vasodilation disebabkan oleh hilangnya tonussimpatetis 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
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Neurogenic Shock
Terjadi akibat akibat loss of sympathetic tone - spinal
cord injury, spinal anesthesia, nervous system damage,
depressant action of medications, lack of g lucose
(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 danimobilisasi
Support cardiovascular and neurologic functions
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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!!
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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 combatingendotoxins - monoclonal antibodies (enhances
immune function)
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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 ofsepsis
Reduce temperature in hyperthermic patients, butmonitor closely for chills, shivering and increased O2
consumption
Administer fluids, meds, vasoactive drugs to restorevascular volume.
Monitor antibiotic levels, BUN, Cr, WBC
Monitor hemodynamic status, I&O, nutritional status(daily wts, albumin).
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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 andkidneys
2 patterns of presentation:
Initial episode of hypotens ionwhich is treated and
patient seemingly responds If patient presents with a pu lmonaryinsult and has
respiratory failure, can rapidly develop MOF and
pat ient on ly su rvives 2 to 4 days
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Multiple Organ Failure contd
Other pattern occurs most often with septicshock:
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
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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 failurebiasnya memerlukan dialysis
Hemodynamic patient unstable
Mortality rate increases to 40-60% during earlystage of MOF and 90-100% in later stage - Patient
usually dies in about 28 days
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Multiple Organ Failure contd
Treatment:
Control initiating event
Promote adequate organ perfusionProvide nutritional support
Nursing Responsibilities:
essentially the same as septic shock
For those who survive, recovery andrehabilitation is a long, slow process
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