MANAGEMEN KEPERAWATAN PADA

PASIEN SHOCK

Agus K Anam,M.Kep

Definisi

Suatu sindroma dimana Suatu sindroma dimana Suatu sindroma dimana Suatu sindroma dimana PERFUSI JARINGAN TIDAK PERFUSI JARINGAN TIDAK PERFUSI JARINGAN TIDAK PERFUSI JARINGAN TIDAK

ADEKUATADEKUATADEKUATADEKUAT, akibat dari ketidak mampuan sistem , akibat dari ketidak mampuan sistem , akibat dari ketidak mampuan sistem , akibat dari ketidak mampuan sistem

sirkulasi untuk mensuplai oksigensirkulasi untuk mensuplai oksigensirkulasi untuk mensuplai oksigensirkulasi untuk mensuplai oksigensirkulasi untuk mensuplai oksigensirkulasi untuk mensuplai oksigensirkulasi untuk mensuplai oksigensirkulasi untuk mensuplai oksigen

Shock

• Perfusi jaringan tidak adekuat

• Penurunan suplai oksigen • Penurunan suplai oksigen

• Metabolisme anaerobik

• Akumulasi “metabolic waste”

apayang terjadi?Metabolisme Anaerobik

apa yang terjadi ?

Oksigenasi selOksigenasi selTidak adekwatTidak adekwat

AnaerobicAnaerobicMetabolismMetabolism

MetabolicMetabolicFailureFailure

MetabolicMetabolicAcidosisAcidosis

InadequateInadequateEnergyEnergy

ProductionProduction

Lactic AcidLactic AcidProductionProduction

Cell Death!Cell Death!

� PUMP tdk bekerja scr optimal

cardiogenic

� FLUID tidak cukup dlm sistem� FLUID tidak cukup dlm sistem

hypovolaemia

� TUBING : gangguan fungsi distribusi

distributive

Kondisi normalKondisi normalKondisi normalKondisi normal

satu komponen mengalami gangguan fungsi

komponen lain berusaha melakukan kompensasi

Pada kondisi Pada kondisi Pada kondisi Pada kondisi shockshockshockshock

satu komponen mengalami gangguan fungsi

elemen lain gagal melakukan kompensasi secara adekuat

Penyebab Shock

• Serangan jantung• Kehilangan darah yg berat atau tiba-tiba• Penurunan cairan tubuh

Core Skills Treat for Shock 8

• Penurunan cairan tubuh• Infeksi• Terpapar lama pada kondisi

panas/dingin yg ekstrem

Klasifikasi Shock

�Syok Kardiogenik

�Syok Hipovolemik�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 • Biasanya akibat kegagalan ventrikel kiri sekunder

thd infark miokardial akut infark miokardial akut infark miokardial akut infark miokardial akut & gagal jantunggagal jantunggagal jantunggagal jantung

Hypovolemic Shock

Shock akibat tubuh kehilangan darah, plasma atau cairan tubuh yg lain

Penyebab :� Perdarahan internal atau eksternal � 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• 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 theircompensatory effects.

Neurogenic ShockNeurogenic Shock

⇓⇓ Sympathetic ToneSympathetic ToneOrOr

⇑⇑ Parasympathetic ToneParasympathetic Tone

⇓⇓Vascular ToneVascular Tone

Massive VasodilationMassive Vasodilation

⇓⇓ SVR & PreloadSVR & Preload⇓⇓ Cardiac OutputCardiac Output

⇓⇓TissueTissueperfusionperfusion

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� Peningkatan permeabilitas kapiler

� Dilatasi arteriole

Venous return ↓

Septic ShockSeptic Shock

�� Shock yg terjadi akibat penyebaranatau invasi kuman

Toksin yg dilepaskan berdampak pada� Toksin yg dilepaskan berdampak padavasodilatasi

• Kompensasi normal :– Vasokonstriksi progresif

– Pe↑ aliran darah ke organ vital

RESPON TUBUH TERHADAP SYOK / KOMPENSASI

– 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• Nadi kecil dan cepat• Pernafasan cepat dan dangkal• Oliguria• Perubahan/Pe↓ tingkat kesadaran

Clinical Signs of Acute Hemorrhagic

Shock

% Blood loss Clinical Signs

< 15 Slightly increased heart rate, local swelling, bleeding

15-25 Increased heart rate, increased diastolic

Core Skills Treat for Shock 20

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

Tingkatan Shock

� Compensatory stage

Respon kompensatorik dpt menstabilkan sirkulasi

� Progressive stage� Progressive stage

Manifestasi dari sistemik hipoperfusi & kemunduran fungsi organ

� Irreversible stage

Kerusakan sel yg hebat tdk dpt dihindari yg akhirnya menujukematian

Compensatory stage assessment

• Restlessness

• oriented

• pupils normal

• heart rate increased

• Diastolic B/P normal or

slight increase

• respirations faster and

deeper

• output = or <• systolic B/P normal or

slight decrease

• 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 – 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

• Diastolic B/P falling

• respirations rapid and

shallow

• oliguria

• cold, clammy, cyanotic, • tachycardia

• pulses weak

• systolic B/P < 90

• 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

• Systolic B/P falling to unobtainable

• Diastolic B/P approaching 0

• Respirations slow and minimal response to light

• HR slow and irregular

• pulses absent (or very weak)

• Respirations slow and shallow, irregular

• output very <or absent

• cold, clammy

• absent bowel sounds

Role of the RN

• Continuing the astute assessment and

interventions begun in previous stages

• Recognizing that the patient is very likely to be

terminalterminal

• 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• 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-matchedto be cross-matched

Vasoactive medications

�Vasopressors: Intropin (dopamine), Dobutrex

(dobutamine)

� Vasodilators: Nipride (nitroprusside), Tridil� Vasodilators: Nipride (nitroprusside), Tridil

(nitroglycerine)

Other medications

• Corticosteroids

• Antibiotics

THANK’S