00205 Shock Risk

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00205
Nanda label: shock risk
Diagnostic focus: shock
Approved 2008 • Revised 2013, 2017, 2020 • Evidence level 3.2

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « shock risk ” is defined as: susceptible to an inappropriate blood supply to body tissues that can lead to cellular dysfunction, which can compromise health. P>

Risk factors

  • bleeding
  • Factors identified by a standardized and validated assessment scale
  • Hyperthermia
  • Hypothermia
  • hypoxemia
  • Hypoxia
  • Inappropriate knowledge of bleeding management strategies
  • Inappropriate knowledge of infection management strategies
  • Insufficient knowledge of modifiable factors
  • INEFICA MANAGEMENT OF MEDICATION
  • Insufficient liquid volume
  • Loss of non -hemorrhagic liquids
  • smoking
  • Unstable blood pressure

Risk population

  • People entered into emergency units
  • People with extreme ages
  • People with a history of myocardial infarction

Associated problems

  • Artificial breathing
  • Burns
  • Chemotherapy
  • Diabetes mellitus
  • Embolism
  • heart disease
  • Hypersensitivity
  • Immunosuppression
  • Infections
  • Lactate levels> 2 mmol/l
  • Hepatic diseases
  • Medical devices
  • Neoplasms
  • Nervous system diseases
  • Pancreatitis
  • Radiation therapy
  • sepsis
  • Score of the sequential assessment of organic failure (SOFA)> 3
  • Acute physiological simplified score (SAPS) III> 70
  • Spinal cord injuries
  • Surgical procedures
  • Systemic inflammatory response syndrome (Sris)
  • Trauma

Suggestions of use

The risk factors for this diagnosis represent collaboration problems, for which the main independent nursing actions are surveillance and prevention. For example, if the risk factor is hypotension, the activities will focus on monitoring blood pressure. Instead of establishing a diagnosis as a risk of shock related to hypotension, it is preferable to write down a collaboration problem (for example, possible complication of hypotension: shock).

NOC Results

  • The main result to measure the real presence of shock is tissue perfusion: cell phone. Other results should be selected depending on the risk factors of each patient.
  • Risk Control: Personal actions to prevent, eliminate or reduce health threats that can be modified
  • Risk detection: personal actions carried out to identify threats to the health of the individual
  • Circulation status: Unidirectional blood flow without obstacles, with adequate pressure, through the large vessels of systemic and pulmonary circuits
  • Gravity of infection: Intensity of infection and associated symptoms
  • Service of blood loss: intensity of bleeding or internal or external bleeding
  • Tissue perfusion: cell phone: sufficiency of the blood flow of the vasculature to maintain the function at the cellular level
  • Reaction to blood transfusion: severity of the complications of the reaction to a blood transfusion
  • Vital signs: degree in which temperature, pulse, breathing and blood pressure are within normal limits

Evaluation objectives and criteria

  • The patient does not experience shock, as evidenced by an adequate tissue perfusion: cell phone and normal vital signs.
  • demonstrates tissue perfusion: normal cell phone, as manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, mild or within the normal parameters):
    • blood pressure (systolic and diastolic)
    • Capillary filling
    • Oxygen saturation
    • Creatinine elimination
  • Other examples

    • Vital signs within normal parameters for the patient (as a standard, blood pressure of at least 90 mmHg, heart rate between 60 and 100 bpm with normal rhythm, and respiratory rate of 12 to 20 breaths per minute)
    • Normal urine production (0.5 ml/kg/hr)
    • Balance of intake and liquid elimination
    • Warm and dry skin c

    NIC Interventions

    • NIC interventions that focus on monitoring and avoiding shock, without taking into account risk factors, are risk identification, shock prevention and vital signs surveillance. The choice of other interventions will depend on the risk factors of each patient
    • Blood component administration: blood administration or blood components, and patient response surveillance
    • Hemorrhage control: reduction or suppression of rapid and excessive blood losses
    • Infection control: decrease in the acquisition and transmission of infectious agents
    • Circulatory care: Arterial insufficiency: surveillance of arterial circulation
    • Circulatory care: venous insufficiency: Venous circulation surveillance
    • Embolism care: pulmonary: limitation of complications for the patient who suffers, or is at risk of suffering, an occlusion of pulmonary circulation
    • Risk identification: Analysis of possible risk factors, determination of health risks and prioritization of risk reduction strategies for a person or group
    • Hypolemia management: expansion of the volume of intravascular fluids in a patient with poor volume
    • Oxygen therapy: Oxygen administration and control of its effectiveness
    • Shock prevention: detection and treatment of a patient at imminent risk of shock
    • Hemorrhage prevention: reduction of stimuli that can cause bleeding or bleeding in patients at risk
    • Infection protection: Prevention and early detection of infections in a patient at risk
    • Bleed reduction: limitation of blood volume loss during an episode of bleeding
    • Bleeding reduction: gastrointestinal: limitation of the loss of blood volume of the uterus occupied during the third trimester of pregnancy
    • Bleed reduction: Wound: Limitation of the loss of blood volume of a wound that can be the result of trauma, incisions or the placement of a probe or catheter
    • Bleed reduction: nasal: limitation of the loss of blood volume of the nasal cavity
    • Bleed reduction: postpartum: limitation of the loss of blood volume of the uterus after delivery
    • Bleed reduction: uterus prior to childbirth: Limitation of the loss of blood volume of the uterus occupied during the third trimester of pregnancy
    • Surveillance: Collection, interpretation and synthesis of patient data, continuously and with an end, to make clinical decisions
    • Surveillance of vital signs: Collection and analysis of cardiovascular and respiratory data, as well as body temperature, to determine and prevent complications
    • Respiratory surveillance: Collection and analysis of patient data to guarantee the permeability of the respiratory tract and the appropriate gas exchange

    Nursing Activities

    Nursing activities for this potential problem focus on the surveillance and prevention of real shock, as well as the assessment of risk factors. Preventive measures should be taken to resolve patient risk factors (for example, hypovolemia, infection)

    Valuations

    • Monitor the presence of conditions that may cause hypovolemia (for example, surgery, anticoagulant therapy, diarrhea and prolonged vomiting, abundant bleeding)
    • Monitor heart conditions (myocardial infarction, ventricular arrhythmias, cardiac arrest, evil hypertension, severe congestive heart failure)
    • Evaluate circulatory conditions (for example, pulmonary embolism, tension pneumotorax, aortic stenosis)
    • Monitor income and expenses, including wounds, drains, vomiting and diarrhea
    • Monitor the vital signs (RTP and TA)
    • Monitor the color and humidity of the skin

    Patient and family education

    • Instruct the patient and the family about the prevention of infections (for example, skin care and wounds, hands hygiene, avoid agglomerations in case of immunosuppression)
    • Instruct the signs and symptoms of shock (for example, excessive hemorrhage, loss of liquids, chest pain); indicate that these symptoms must be reported

    Collaboration activities

    • Monitor invasive hemodynamic parameters, if available (for example, central venous pressure, cardiac output and average blood pressure)
    • Administer prescribed medications to treat risk factors (for example, vasoactive, antimicrobial, cardiac glucóside)
    • Administer oxygen if the symptoms indicate a progression towards a real shock, or as required to maintain the treatment of a risk factor
    • Channel with a nutritionist if a special diet is required to reinforce the health of the immune system or healing

    Others

    • Be prepared to manage liquids, electrolytes, colloids, blood or blood components, to solve problems of circulatory volume
    • Use strict aseptic methods to prevent infections (for example, hands hygiene when attending to each patient, aseptic wound care, isolation precautions)
    • Provide oral, enteral or parenteral nutrition