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NPN 205
Medical Surgical II

What Does Shock Look Like

Carla----33 year old female form the
emergency room post MVC, with an
apparent crush injury to the pelvis,
bruising over her right upper
quadrant. She is conscious, but
lethargic and oriented to name only.
BP is 80/46, pulse 116. She is quickly
prepared for surgery. Dx: pelvic
crush injury, r/o abdominal trauma,
r/o liver laceration

Julie---86 year old female from a local

nursing home with a history of
variable fevers for the past week. Her
appetite has decreased, mental
status has deteriorated. Presently,
her temperature is 104 F.
She has an indwelling Foley catheter,
her urine is dark amber, foul
smelling. Dx. Sepsis secondary to

Justin---14 year old male with a

history of juvenile onset diabetes
mellitus. He has been admitted to the
hospital because his glucose has
been greater than 600 for the last 24
hours and he has a fruity odor on his
breath. His serum glucose is 786.
Dx: diabetic ketoacidosis.

What do they have in common?

Three different patients
Three different diagnoses
Three different etiologies

Predisposition of Shock Syndrome

Shock is a process that causes the
eventual shutdown of all body systems in
a systematic order
Amount of time for shock to progress
varies from patient to patient
Is related to the bodys overall health and
ability to compensate for its deficiencies
As the syndrome progresses, the process
speeds up
The circulatory system fails to provide
adequate blood to the tissues, resulting in
cellular hypoxia and death

Physiology of Hypoperfusion:
Inadequate tissue perfusion
Inadequate delivery of O2 and
nutrients to the body tissues
Inadequate elimination of metabolic

A & P of Perfusion
Perfusion: delivery of O2 and
nutrients and the elimination of CO2
requires four things
1. a properly beating heart
2. adequate transport medium: blood
and hemoglobin
3. an intact functioning vessel system
4, a functioning respiratory system

Physiology of Circulation in the

600,000 miles of vessels containing
5-6 liters of blood
Vessel tone is controlled by the
sympathetic and parasympathetic
nervous system
Pre-capillary sphincters control blood
flow through the capillaries in
response to O2 demand of the tissue
Preload is dependent on the constant
peripheral vascular resistance

Physiology of Circulation: the

Container (vessels) must be full of
blood at all times
Hemoglobin must be present in
adequate amount and be free to carry
O2, nutrients, and CO2

Stages of Shock
Compensated ---- body is able to
compensate and maintain tissue
Progressive ---- body begins to lose
its ability to compensate---inadequate
perfusion begins
Irreversible---cell and tissue damage
result in multi-system organ failure

Types of Shock


Classifications or Types of Shock

Hypovolemic: (classic shock)
standard used to compare other forms
of shock to differentiate the diagnosis
Hemorrhagic/Blood loss
Dehydration/Fluid loss

Causes of Hypovolemic Shock

Severe diarrhea
Excessive perspiration
Third Spacing
Shift of fluid in severe burns can lead to
hypovolemic shock

Intestinal obstruction

Shock D/T Hemorrhage:

Mechanism: volume depletion due to
Body detects decrease in the cardiac
Sympathetic nervous system is
stimulated releasing epinephrine and
norepinephrine to stimulate alpha
and beta receptors
Alpha = vasoconstriction
Beta = bronchodilation and cardiac
Body maintains function

Hemorrhagic Shock: Progressive

Kidneys release antidiuretic hormone
which increases vasoconstriction
Signs and symptoms:
Mental status: lethargy, sleepy,
Skin: clammy, pale, mottling. Cyanosis
around the nose and mouth first,
spreads to extremities
Blood pressure: begins to fall, capillary
refill delayed
Pulse: rapid and weak
Respirations: rapid and shallow
Other: decreased urination

Hemorrhagic Shock: Irreversible

Signs and symptoms:
Mental status: decreased LOC, to
Skin: gray, mottled, cyanotic, waxen,
sweating stops
Blood pressure: decreases, becomes
Pulse: slows then disappears
Respiration: agonal
Other: irritable heart, bradycardia, leads
to asystole

Interventions for Hypovolemic

Stop the fluid loss direct pressure,
Replace fluids blood and blood
products, plasma expanders,
crystalloid fluids (provide H2O
replacement and E-lytes), Colloids
(albumin, FF)
Pneumatic antishock garments
Use low dose inotropics

Cardiogenic Shock
Heart pump failure (40% of
myocardium damaged by an MI)
Cardiac trauma
Congestive heart failure
Cardiac dysrhythmias

Cardiogenic Shock: Signs and

Drop in cardiac output
Skin: cyanosis
Pulse: bradycardia, tachycardia, or
within normal limits
Respirations: diminishing breath
sounds progressing to wheezing and
crackles. Patient complains of
increasing dyspnea. Coughs white or
pink tinged foamy sputum
Other: pulmonary edema and left heart
Pitting edema+ right heart failure

Interventions for Cardiogenic

Hemodynamic monitoring
IV fluids
Intra-aortic balloon pump
Cardiac transplant
Digoxin, Amrinone, Primacor

If from obstructive may need surgical
repair, chest tube, pacemaker, needle
aspiration of fluid

Obstructive Shock
Can be classed as a type of
cardiogenic shock
Pulmonary embolism/Blocked
pulmonary circulation
Tension pneumothorax/Increased
intrathoracic pressure
Cardiac tamponade/Pressure on
myocardium. Decreased preload

Signs and Symptoms of

Obstructive Shock
Mental status: anxiety, feeling of
impending doom
Skin: pallor to cyanosis around the
mouth and the nose
Other: chest pain, lung sounds may
be clear, possible syncope, cardiac
dysrhythmias (PVCs, A-Fib common)
can lead to sudden cardiac arrest

Distributive Shock
Anaphylactic Shock
Mechanism: severe allergic reaction
Skin: hives, possible petechia. Urticaria,
pallor, cyanosis
Blood pressure: abrupt fall in cardiac
Respiration: rapid shallow, dyspnea with
stridor, wheezes, crackles, leading to
respiratory arrest
Other: swelling of mucus
membranes/pulmonary edema

Treatment of Anaphylactic Shock

Maintain airway
Ice to site of injection or sting
Gastric lavage
Isotonic IV fluids D5W, NACL, LR
Epinephrine and theophylline
Antihistamines (H2 blockers)
Vasopressors to constrict blood
vessels and raise BP

Distributive Shock
Septic shock
Mechanism: overwhelming infection
Skin: varies form flushed pink (if fever is
present) to pale and cyanotic. Purple blotches
possible, peeling skin, general or on palms and
soles of feet
Blood pressure: earlycardiac output
increases but toxins prevent increase in BP.
Late --- drop in BP, hypotension
Respiratory: dyspnea with altered lung sounds
Other: high fever, (except in elderly and very
young), Late sign is pulmonary edema

Treatment for Septic Shock

C & S for infective site
IV fluids with NS
Medications and other treatment
Cardiotonics and inotropics
Blood products

Distributive Shock
Neurogenic Shock
Mechanism: vasodilation
Skin: areas of vasodilation, at first become
warm, pink and dry. Later with pooling:
mottling of dependent areas, pallor and
cyanosis to the upper surfaces
Pulse: highly variable depending on injury or
action of drug/poison: May be abnormally slow
or abnormally fast, usually not normal
Respiration: severely compromised: becoming
slow, shallow, with abnormal patterns. Patient
may loose stimulus to breath
Other: hypothermia. Pulmonary edema with
drug or poisoning

Treatment of Neurogenic Shock

HOB flat with feet elevated

IV normal saline
Atropine for bradycardia
Vasopressors to raise BP
Analgesics for pain

General Treatment of Shock

Remember your ABCs
Administer airway
100% O2 via a non- re-breather mask
Assist ventilations if necessary
Position patient to assist perfusion
Keep patient warm
Perform focused assessment
Monitor and adjust O2, gain IV access, cardiac
monitor, pulse oximetry
Fluid replacement of LR or NS
Need 3 liter of fluid to replace I liter of blood
Apply pressure to IV or blood to facilitate faster

Nursing Diagnosis

Ineffective Tissue Perfusion

Decreased Cardiac Output
Fluid Volume Deficit
Risk for Injury
Risk for Infection

Systemic Inflammatory Response

Syndrome (SIRS)
Defined as when generalized
inflammation occurs and threatens
vital organs
Causes: multiply transfusions,
massive tissue injury, burns, and
pancreatitis, severe infections or
Effects: endothelium is damaged and
allows fluid to leak into the body
tissues, results in poor perfusion of
blood to organs
Body is in a hypermetabolic state

Systemic Inflammatory Response

Syndrome (SIRS)
Diagnosis made when 2 or more of
the following are seen:
Temperature less than 97 or greater than
Heart rate more than 90
Respiratory rate more than 20 or PaCO2
less than 32mm Hg
WBC count less than 4000 cells or more
than 12,000
Sepsis is used if patient has SIRS with
and infection

Multiply Organ Dysfunction

Syndrome (MODS)
Defined: when 2 or more organ
systems are failing at one time
Is caused by the immune systems
uncontrolled response to severe
illness or injury
Common cause of death of patients
in the ICU, with mortality of 50%
Identifying and acting quickly can
help survival
Can develop quickly following
surgery, trauma, or severe burns or
slowly in the case of an infection

Treatment for SIRS/MODS

Critical care nursing
Prevent and treat infections
Maintain tissue oxygenation
Provide nutritional and metabolic
Support failing organs