Nursing Diagnosis Risk for Shock - NIC NOC
Shock is a life-threatening condition that occurs when the body is not getting enough blood flow. This can damage multiple organs. Shock requires immediate medical treatment and can get worse very rapidly.
A person in shock has extremely low blood pressure. Depending on the specific cause and type of shock, symptoms will include one or more of the following:
- Anxiety or agitation/restlessness
- Bluish lips and fingernails
- Chest pain
- Dizziness, lightheadedness, or faintness
- Pale, cool, clammy skin
- Low or no urine output
- Profuse sweating, moist skin
- Rapid but weak pulse
- Shallow breathing
NIC: Shock Management
- Monitor vital signs, orthostatic blood pressure, mental status, and urine output.
- Monitor laboratory values as evidence of tissue perfusion inadekuat (eg increased levels of lactic acid, decreased arterial pH).
- Give crystalloid IV fluids as needed (NaCl 0.9%, RL; D5% W)
- Give vasoactive medications.
- Provide oxygen therapy and mechanical ventilation
- Monitor hemodynamic trend.
- Monitor fetal heart rate (bradycardia if HR <110 beats / min) or (tachycardia when HR> 160 beats per minute) lasting longer than 10 minutes.
- Take blood samples for blood gas analysis and the examination of tissue oxygenation monitor.
Get patency of venous access.
- Give fluids to maintain blood pressure or cardiac output.
- Monitor critical oxygen delivery to the tissues (SaPO2, hemoglobin level, cardiac output).
Record in the event of bradycardia or decreased blood pressure, or abnormal low systemic arterial pressure as pale, cyanosis or diaphoresis.
- Monitor signs and symptoms of respiratory failure (low PaO2, PCO2 increased, paralysis of respiratory muscles)
- Monitor blood glucose levels and handle if any abnormality.
- Monitor coagulation and complete blood count with WBC differential.
- Monitor fluid status include intake and output.
- Monitor renal function.
- Do a urinary catheter.
- Perform installation of NGT and monitor gastric residual.
- Position the patient to optimize perfusion.
- Provide emotional support to the family.
- Provide a realistic hope to the family.
- Auscultation of lung sounds to determine the presence of breath sounds crackles and other extras.
- Note the signs and symptoms of decreased cardiac output.
- Monitor symptoms of inadequate coronary artery perfusion (eg ST wave changes on EKG or angina).
- Monitor the value of coagulation (PT, PTT, fibrinogen, platelets).
- Pertahanakan fluid balance by providing fluid and diuretic.
- Give positive inotropic drugs or contractility.
- Increase preload optimal by improving contractility while minimizing heart failure (giving nitroglycerin).
- Increase afterload reduction (giving vasodilators or intraaortic balloon pumping).
- Increase coronary artery perfusion (to maintain MAP> 60 mmHg and controls tachycardia).
NIC: Shock Management: Vasogenic
- Perform wound care to prevent infection and promote healing.
- Give antibiotics as scheduled.
- Give antihistamines as instructed.
- Give epinephrine in an emergency in the event of anaphylaxis.
- Provide anti-inflammatory medications as instructed.
- Eliminate neurogenic stimulus that causes a reaction.
- Treat hyperthermia with antipyretic drugs, air mattress or sponge bath.
- Prevent and control shivering with drug delivery and cover extremities.
NIC: Shock Management: Volume
- Monitor signs and symptoms of persistent bleeding.
- Record the value of Hb and HT before and after blood loss.
- Give blood products according to instructions (platelets or fresh frozen plasma).
- Prevent blood loss by holding the bleeding.
NIC: Shock Prevention
- Note the bruising, petechiae and conditions of the mucous membrane.
- Note color, amount, and frequency of defecation, vomiting and gastric residue.
- Urine test to determine the presence of glucose, blood or protein.
- Monitor presence of abdominal pain and girth.
- Monitor signs and symptoms of ascites.
- Monitor initial response to fluid loss: increased HR, decreased blood pressure, orthostatic hypotension, decreased urine output, narrow pulse pressure, decreased capillary refill, skin pale and cold, and diaphoresis.
- Monitor early signs of shock cardiogenik: the amount of urine output and cardiac output were decreased, increased SVR and PCWP, pulmonary crackles, S3 and S4 heart sounds, tachycardia.
- Monitor early signs of an allergic reaction: wheezing, hoarseness (coarse breath sounds and panting), dyspnea, rash, angioedema, feeling unwell on the gastrointestinal tract, anxiety and restlessness.
- Monitor early signs of septic shock: skin warm, dry, shiny, increased cardiac output and temperature.
- Maintain airway patency.
- Give antiarrhythmic agent.
- Give diuretics as instructed.
- Give bronchodilator as needed.