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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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