MANAGEMEN KEPERAWATAN PADA PASIEN SHOCK
Agus K Anam,M.Kep
Definisi Suatu sindroma dimana PERFUSI JARINGAN TIDAK ADEKUAT, akibat dari ketidak mampuan sistem sirkulasi untuk mensuplai oksigen
Shock
• Perfusi jaringan tidak adekuat • Penurunan suplai oksigen • Metabolisme anaerobik • Akumulasi “metabolic waste”
Metabolisme Anaerobik apa yang terjadi ? Oksigenasi sel Tidak adekwat
Inadequate Energy Production
Metabolic Failure
Anaerobic Metabolism
Lactic Acid Production
Cell Death!
Metabolic Acidosis
PUMP tdk bekerja scr optimal cardiogenic FLUID tidak cukup dlm sistem hypovolaemia TUBING : gangguan fungsi distribusi distributive
Kondisi normal
satu komponen mengalami gangguan fungsi komponen lain berusaha melakukan kompensasi
Pada kondisi shock
satu komponen mengalami gangguan fungsi elemen lain gagal melakukan kompensasi secara adekuat
Penyebab Shock • • • • •
Core Skills
Serangan jantung Kehilangan darah yg berat atau tiba-tiba Penurunan cairan tubuh Infeksi Terpapar lama pada kondisi panas/dingin yg ekstrem
Treat for Shock
8
Klasifikasi Shock Syok Kardiogenik Syok Hipovolemik Syok Distributif Syok Obstruktif
Cardiogenic shock • Jantung kehilangan kemampuan u/ memberikan suplai darah ke seluruh bagian tubuh • Biasanya akibat kegagalan ventrikel kiri sekunder thd infark miokardial akut & gagal jantung
Hypovolemic Shock Shock akibat tubuh kehilangan darah, plasma atau cairan tubuh yg lain Penyebab : Perdarahan internal atau eksternal Trauma Dehidrasi Kehilangan plasma akibat luka bakar Terpapar panas yg berlebihan Diuresis osmotik akibat ketoasidosis diabetikum
DISTRIBUTIVE SHOCK • NEUROGENIC SHOCK • ANAPHYLAKTIC SHOCK • SEPTIC SHOCK
Neurogenic Shock • Results from injury to brain or spinal cord causing an interruption of nerve impulses to the arteries. • The arteries dilate causing relative hypovolemia. • Sympathetic impulses to the adrenal glands are lost, preventing the release of catecholamines with their compensatory effects.
Neurogenic Shock ⇓ Sympathetic Tone Or ⇑ Parasympathetic Tone
⇓Tissue perfusion
⇓ Cardiac Output
⇓Vascular Tone
Massive Vasodilation
⇓ SVR & Preload
Anaphylactic Shock • A severe immune response to a foreign substance. • Signs and symptoms most often occur within a minute, but can take up to an hour. • The most rapid reactions are in response to injected substances: – Penicillin injections. – Bees, wasps
Anaphylactic shock Reaksi antigen antibodi Pelepasan histamin Peningkatan permeabilitas kapiler Dilatasi arteriole
Venous return ↓
Septic Shock Shock yg terjadi akibat penyebaran atau invasi kuman Toksin yg dilepaskan berdampak pada vasodilatasi
RESPON TUBUH TERHADAP SYOK / KOMPENSASI
• Kompensasi normal : – – – – –
Vasokonstriksi progresif Pe↑ aliran darah ke organ vital Pe↑ cardiac output Pe↑ kecepatan dan volume pernafasan Pe↓ produksi urin
Tanda Shock Akut • • • • • • •
Pe↓ TD sistolik & diastolik secara progresif Kulit dingin, pucat, dan lembab Sianosis Nadi kecil dan cepat Pernafasan cepat dan dangkal Oliguria Perubahan/Pe↓ tingkat kesadaran
Clinical Signs of Acute Hemorrhagic Shock % Blood loss
Core Skills
Clinical Signs
< 15
Slightly increased heart rate, local swelling, bleeding
15-25
Increased heart rate, increased diastolic blood pressure, prolonged capillary refill
25-50
Above findings plus: hypotension, confusion, acidosis, decreased urine output
> 50
Refractory hypotension, refractory acidosis, death Treat for Shock
20
Tingkatan Shock Compensatory stage Respon kompensatorik dpt menstabilkan sirkulasi
Progressive stage Manifestasi dari sistemik hipoperfusi & kemunduran fungsi organ
Irreversible stage Kerusakan sel yg hebat tdk dpt dihindari yg akhirnya menuju kematian
Compensatory stage assessment • • • • •
Restlessness oriented pupils normal heart rate increased systolic B/P normal or slight decrease
• Diastolic B/P normal or slight increase • respirations faster and deeper • output = or < • pale, cool, may be thirsty
Role of the RN • Continuous in-depth assessment of the patient’s hemodynamic status – Prompt recognition of problems – Accurate use of emergency orders – Prompt and accurate reports of deviations in assessment to physician
• Reducing patient anxiety • Promoting patient safety
Progressive stage assessment • Listless, agitated, apathetic, confused • speech slowed • pupils dilated • tachycardia • pulses weak • systolic B/P < 90
• Diastolic B/P falling • respirations rapid and shallow • oliguria • cold, clammy, cyanotic, marked increase in thirst
Role of the RN • Requires expertise in assessing and understanding shock and the significance of changes in assessment data • Managing, implementing and documenting treatments, medications, fluids along with continuous assessment and collaboration
Irreversible shock assessment • Confused, disoriented or unconscious • reflexes absent • pupils dilated with minimal response to light • HR slow and irregular • pulses absent (or very weak)
• Systolic B/P falling to unobtainable • Diastolic B/P approaching 0 • Respirations slow and shallow, irregular • output very
Role of the RN • Continuing the astute assessment and interventions begun in previous stages • Recognizing that the patient is very likely to be terminal • Initiating palliative and end-of-life activities • Support and explanation to family members
Treatment of Shock Increase tissue perfusion and oxygenation status • • • •
Maintain airway Control bleeding Baseline vital signs Level of consciousness
Treatment of Shock • • • • •
Positioning ABCD approach Fluid therapy Drug therapy Keep patient at normal temperature – Prevent hypothermia – Minimize effect of shock
• On-going assessment - every 10-15 minutes
Fluid Replacement • Crystalloid replacement: NS and LR – Easily available, but can cause rebound overload, much is lost to tissues – No oxygen carrying capacity
• Colloids: plasma proteins such as albumin – Large molecules that pull fluids into tissues, but are harder to obtain, more expensive and run risk of anaphylaxis – No oxygen carrying capacity
• Blood: if the patient is in hypovolemic shock, this is the fluid of choice – Does have oxygen carrying capacity – Harder and slower to obtain, generally needs to be cross-matched
Vasoactive medications Vasopressors: Intropin (dopamine), Dobutrex (dobutamine) Vasodilators: Nipride (nitroprusside), Tridil (nitroglycerine)
Other medications • Corticosteroids • Antibiotics
THANK’S
