🫀 शारीरिक अनुकूलन (Physiological Adaptation) · 10 मध्ये पाठ 8 · 7 min

Shock का चार प्रकार र Sepsis को पहिलो घण्टा

Four Kinds of Shock and the First Hour of Sepsis

🩸 Hypovolemic shock लाई fluid चाहिन्छ। Cardiogenic shock त्यसमै डुब्छ। दुवैमा blood pressure कम हुन्छ। परीक्षाले कुन bag झुण्ड्याउने भनी सोध्छ, र गलत उत्तर एकदमै सम्भावित देखिन्छ।

🩸 Hypovolemic shock wants fluid. Cardiogenic shock drowns in it. Both have low blood pressure. The exam asks which bag you hang, and the wrong answer is a very plausible one.

💡 मुख्य कुरा

Compensation ले सामान्य blood pressure पछाडि shock लुकाउँछ: heart rate, pulse pressure, छाला र पिसाब हेर्नुहोस्। Hypovolemic र septic मा fluids; cardiogenic मा होइन। Neurogenic shock ढिलो र तातो खालको हो।

Compensation hides shock behind a normal blood pressure: watch heart rate, pulse pressure, skin and urine. Fluids for hypovolemic and septic; not for cardiogenic. Neurogenic shock is the slow, warm one.

🧠 यो किन महत्त्वपूर्ण छ

Shock भनेको तन्तुमा अपर्याप्त perfusion हो। COMPENSATORY चरण: tachycardia, pulse pressure साँघुरिनु, चिसो चिप्लो छाला, चिन्ता, पिसाब घट्नु; blood pressure अझै सामान्य देखिन सक्छ। PROGRESSIVE र REFRACTORY चरण: hypotension (MAP 65 भन्दा कम), भ्रम, oliguria, बढ्दो lactate सहित metabolic acidosis, र अङ्ग फेल। HYPOVOLEMIC (hemorrhage, burns, dehydration): isotonic fluids र रगत, क्षति रोक्नुहोस्। CARDIOGENIC (ठूलो MI, heart failure): पम्प फेल हुन्छ, त्यसैले fluids ले pulmonary congestion बिगार्छ; inotropes, diuretics र कहिलेकाहीँ mechanical support। DISTRIBUTIVE shock का तीन प्रकार हुन्छन्। SEPTIC: संदिग्ध infection सहित hypotension र अङ्ग dysfunction; पहिलो घण्टाको bundle मा blood cultures, एक घण्टाभित्र broad-spectrum antibiotics, hypotension वा 4 वा बढी lactate का लागि 30 mL/kg crystalloid, lactate मापन, र fluids पछि MAP 65 भन्दा तल रहे vasopressors (पहिले norepinephrine) हुन्छन्। ANAPHYLACTIC: पहिले intramuscular epinephrine, त्यसपछि fluids र airway सहयोग। NEUROGENIC (T6 वा माथिको spinal cord injury): यो एक मात्र shock हो जसमा BRADYCARDIA र तातो सुख्खा छाला हुन्छ, sympathetic tone हराएका कारण; fluids, vasopressors र atropine ले उपचार गर्नुहोस्। सबैका लागि नर्सिङ हेरचाह: oxygen, दुई ठूला-bore IVs, कम्तीमा 0.5 mL/kg/hr (वयस्कमा करिब 30 mL/hr) को प्रति घण्टा पिसाब, निरन्तर निगरानी, र बिरामीलाई न्यानो राख्नु।

Shock is inadequate tissue perfusion. COMPENSATORY stage: tachycardia, narrowing pulse pressure, cool clammy skin, anxiety, decreased urine output; the blood pressure can still look normal. PROGRESSIVE and REFRACTORY stages: hypotension (MAP below 65), confusion, oliguria, metabolic acidosis with rising lactate, and organ failure. HYPOVOLEMIC (hemorrhage, burns, dehydration): isotonic fluids and blood, stop the loss. CARDIOGENIC (massive MI, heart failure): the pump fails, so fluids worsen pulmonary congestion; inotropes, diuretics and sometimes mechanical support. DISTRIBUTIVE shock has three types. SEPTIC: suspected infection with hypotension and organ dysfunction; the first hour bundle is blood cultures, broad-spectrum antibiotics within one hour, 30 mL/kg of crystalloid for hypotension or a lactate of 4 or more, lactate measurement, and vasopressors (norepinephrine first) if MAP stays below 65 after fluids. ANAPHYLACTIC: intramuscular epinephrine first, then fluids and airway support. NEUROGENIC (spinal cord injury at or above T6): the only shock with BRADYCARDIA and warm dry skin, from lost sympathetic tone; treat with fluids, vasopressors and atropine. Universal nursing care: oxygen, two large-bore IVs, hourly urine output of at least 0.5 mL/kg/hr (about 30 mL/hr in adults), continuous monitoring, and keeping the client warm.

🏥 वास्तविक जीवनमा

🧊 सर्जरी पछि रक्तस्राव भइरहेको बिरामीको blood pressure 118/88 र heart rate 126 छ, छाला चिसो छ र पछिल्लो एक घण्टामा 15 mL पिसाब आएको छ। नयाँ नर्सले pressure ठीकै ठान्छे। अनुभवी नर्सले 30 को pulse pressure, tachycardia र oliguria लाई compensated hemorrhagic shock को रूपमा पढ्छे, र pressure खस्किनुअघि नै बिरामी फेरि operating room मा जान्छ। Blood pressure सबैभन्दा पछि सर्ने अंक हो।

🧊 A client bleeding after surgery has a blood pressure of 118/88 and a heart rate of 126, with cool skin and 15 mL of urine in the last hour. A new nurse reads the pressure as fine. The experienced nurse reads a pulse pressure of 30, tachycardia and oliguria as compensated hemorrhagic shock, and the client goes back to the operating room before the pressure ever falls. The blood pressure is the last number to move.

📌 सम्झनुहोस्

सुरुवाती shock: tachycardia, साँघुरो pulse pressure, चिसो छाला, कम पिसाब, सामान्य BPEarly shock: tachycardia, narrow pulse pressure, cool skin, low urine, normal BP
Sepsis को पहिलो घण्टा: cultures, antibiotics, 30 mL/kg fluids, lactate, MAP 65 भन्दा कम भए norepinephrineSepsis hour one: cultures, antibiotics, 30 mL/kg fluids, lactate, norepinephrine if MAP under 65
Cardiogenic shock मा inotropes र diuretics दिइन्छ, fluid boluses होइन; neurogenic मा bradycardia हुन्छCardiogenic shock gets inotropes and diuretics, not fluid boluses; neurogenic is bradycardic

📖 यस पाठका शब्दहरू

Cardiogenic shock: मुटुको पम्प असफल हुँदा हुने shock हो, जसलाई ठूला fluid bolus भन्दा inotropes ले उपचार गरिन्छ।

Septic shock: तरल दिएपछि पनि कम रहिरहने रक्तचाप भएको sepsis हो; पहिलो घण्टामा lactate, cultures, antibiotics, 30 mL/kg तरल र आवश्यक परे vasopressors दिइन्छ।

Minimum urine output: वयस्कले कम्तीमा 30 mL/hr (0.5 mL/kg/hr) र बालबालिकाले कम्तीमा 1 mL/kg/hr पिसाब बनाउनुपर्छ; दुई घण्टा यसभन्दा कम भए shock, डिहाइड्रेसन वा magnesium toxicity जस्तो मिर्गौलामा रगत प्रवाह कम भएको देखाउँछ, र creatinine बढ्नुअघि नै रिपोर्ट गरिन्छ।

Epinephrine: Anaphylaxis को पहिलो औषधि हो, बाहिरी तिघ्रामा 0.3 देखि 0.5 mg IM (1 mg/mL), र cardiac arrest मा प्रत्येक 3 देखि 5 मिनेटमा 1 mg IV; tachycardia र उच्च रक्तचाप अपेक्षा गर्नुहोस्, र दुई पटक सान्द्रता जाँच्नुहोस् किनकि दुई शक्तिमा दश गुणा फरक हुन्छ।

✅ आफूलाई जाँच्नुहोस्

कुन बिरामी लक्षणहरूले hypovolemic shock को compensatory चरण जनाउँछन्?Which client findings indicate the compensatory stage of hypovolemic shock?

Blood pressure 80/40, heart rate 140, भ्रम र पिसाब बिल्कुलै नआउनुBlood pressure 80/40, heart rate 140, confusion and no urine output
Heart rate 124, blood pressure 112/88, चिसो छाला, पिसाब 20 mL/hrHeart rate 124, blood pressure 112/88, cool skin, urine 20 mL/hr
Heart rate 56, तातो सुख्खा छाला, blood pressure 90/60Heart rate 56, warm dry skin, blood pressure 90/60
ज्वरो, रातो छाला, bounding pulses, heart rate 110, blood pressure 96/50Fever, flushed skin, bounding pulses, heart rate 110, blood pressure 96/50

उत्तर: B · Heart rate 124, blood pressure 112/88, चिसो छाला, पिसाब 20 mL/hr

लगभग सामान्य pressure सहित tachycardia, साँघुरो pulse pressure, चिसो छाला र घटेको पिसाब compensation हो; पहिलो सेट ढिलो shock हो, तेस्रो neurogenic हो।

Tachycardia, narrowed pulse pressure, cool skin and reduced urine output with a near-normal pressure are compensation; the first set is late shock, the third is neurogenic.

Septic shock भएको बिरामीले 30 mL/kg crystalloid पाएपछि MAP 58 छ। नर्सले अर्को कुन हस्तक्षेप अपेक्षा गर्छे?A client with septic shock has a MAP of 58 after receiving 30 mL/kg of crystalloid. Which intervention does the nurse anticipate next?

Cultures आएपछि मुखद्वारा antibioticsOral antibiotics once cultures return
Fluid overload रोक्न diureticsDiuretics to prevent fluid overload
Norepinephrine infusionA norepinephrine infusion
अर्को 30 mL/kg bolus मात्रAnother 30 mL/kg bolus only

उत्तर: C · Norepinephrine infusion

पर्याप्त fluids पछि पनि hypotension रहिरहे vasopressors चाहिन्छ, र norepinephrine पहिलो रोजाइ हो।

Persistent hypotension after adequate fluids calls for vasopressors, with norepinephrine as the first choice.

Cardiogenic shock मा ठूला fluid boluses किन टारिन्छ?Why are large fluid boluses avoided in cardiogenic shock?

थप volume ले pulmonary edema बिगार्छExtra volume worsens pulmonary edema
बिरामीलाई hypotension हुँदैनThe client is not hypotensive
Fluids ले hyperkalemia गराउँछFluids cause hyperkalemia
Fluids ले inotropic औषधिमा बाधा पुर्‍याउँछFluids interfere with inotropic medications

उत्तर: A · थप volume ले pulmonary edema बिगार्छ

Cardiogenic shock मा समस्या पम्पको हो, volume को होइन; थपिएको fluid फोक्सोतिर फर्कन्छ।

In cardiogenic shock the problem is the pump, not volume; added fluid backs up into the lungs.

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