Shock is defined as:

A physiologic state in which there is inadequate

blood flow to tissues and cells of the body Brunner & Suddarth, 2004 A condition in which systemic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cellular functions Mikhail, 1999

SIGNIFICANCE OF SHOCK:
Shock affect all body systems. It may develop

rapidly or slowly, depending on the underlying cause. Nursing care of the patient in shock requires ongoing systemic assessment.

STAGES OF SHOCK
1. COMPENSATORY STAGE 2. PROGRESSIVE STAGE 3. IRREVERSIBLE STAGE

COMPENSATORY STAGE

PROGRESSIVE STAGE

IRREVERSIBLE STAGE

1. COMPENSATORY STAGE
In this compensatory stage of shock, the patients

blood pressure remains within normal limits. This results from stimulation of the sympathetic nervous system. The patient displays signs of fight-or-flight response There is blood shunting

COMPENSATORY STAGE CLINICAL MANIFESTATIONS

Blood pressure
normal

Heart rate
>100 bpm

Respiratory status
>20 breaths/minute

Skin
cold and clammy

Urinary output (UO)

decreased

Mentation
confusion

Acid-base balance
Respiratory alkalosis

Compensatory stage
MEDICAL MANAGEMENT Directed toward
identifying the cause of the shock; correcting the underlying disorder so that shock does not progress; and supporting those physiologic processes that thus far have responded successfully to the threat

Compensatory stage
NURSING MANAGEMENT Monitoring tissue perfusion
Changes in LOC V/S UO Skin Lab values Hemodynamic status Administer IVF and meds

Reducing anxiety Promoting safety

2. PROGRESSIVE STAGE
In the progressive stage of shock, the mechanisms

that regulate blood pressure can no longer compensate and the mean arterial pressure (MAP) falls below normal limits, with an average systolic blood pressure of less than 90 mm/Hg.

PROGRESSIVE STAGE: PATHOPHYSIOLOGY

Although

all organ system suffer from hypoperfusion at this stage, two events perpetuate the shock syndrome:
(1)Cardiac dysfunction and; (2) Failure of the autoregulatory function of the microcirculation Even if the underlying cause of the shock is reversed, the breakdown of the circulatory system itself perpetuates the shock state, and a visual cycle ensues.

PROGRESSIVE STAGE: ASSESSMENT AND DIAGNOSTIC FINDINGS

As shock progresses, organs systems decompensate RESPIRATORY EFFECTS
Rapid and shallow respirations Crackles Decreased O levels and increased CO levels Alveolar collapse Pulmonary edema Interstitial inflammation and fibrosis ARDS

PROGRESSIVE STAGE: ASSESSMENT AND DIAGNOSTIC FINDINGS contd..

CARDIOVASCULAR EFFECTS Dysrhythmias and ischemia Rapid heart rate Chest pain Rise in cardiac enzyme levels Further impairment of the hearts pumping capacity

PROGRESSIVE STAGE: ASSESSMENT AND DIAGNOSTIC FINDINGS contd..

NEUROLOGIC EFFECTS Confusion Subtle change in behaviour Lethargy Sluggish pupillary reactions

PROGRESSIVE STAGE: ASSESSMENT AND DIAGNOSTIC FINDINGS contd..

RENAL EFFECTS Acute Renal Failure (ARF)
Increase in BUN Increase in serum creatinine Fluid and electrolyte shifts Acid-base imbalances Decrease in urinary output

PROGRESSIVE STAGE: ASSESSMENT AND DIAGNOSTIC FINDINGS contd..

HEPATIC EFFECTS Increased liver enzymes Decreased metabolic and phagocytic actions Elevated bilirubin levels

PROGRESSIVE STAGE: ASSESSMENT AND DIAGNOSTIC FINDINGS contd..

GASTROINTESTINAL EFFECTS Gastric stress ulcers Bloody diarrhea Increased risk of bleeding and infection

PROGRESSIVE STAGE: ASSESSMENT AND DIAGNOSTIC FINDINGS contd..

HEMATOLOGIC EFFECTS Disseminated intravascular coagulation (DIC) Bruises Bleeding Prolonged coagulation times

PROGRESSIVE STAGE: MEDICAL MANAGEMENT

Depends on the kind of shock and its underlying

cause IV fluids and medications Early enteral nutritional support and use of drugs to prevent GI ulcers and bleeding

PROGRESSIVE STAGE: NURSING MANAGEMENT

Patient in the progressive stage are often cared for in the

ICU.

Proper documentation Preventing complications

Monitoring Maintaining aseptic technique Positioning and repositioning Preventing pulmonary and integumentary complications

Promoting rest and comfort

Efforts are made to minimize cardiac workload by reducing patients physical activity and fear or anxiety. Protection from excessive warmth or cold

Supporting family members

The nurse should make sure that the family is comfortably situated and kept informed about the patients status.

PROGRESSIVE STAGE: SUMMARY OF CLINICAL FINDINGS Blood pressure Heart rate

Systolic <80-90 mmHg >150 bpm

Respiratory status Skin

Rapid, shallow respirations; crackles
Mottled, petechiae 0.5 mL/kg/hr Lethargy

Urinary output

Mentation

Acid-base balance
Metabolic acidosis

3. IRREVERSIBLE STAGE
Represents the point along the shock continuum

at which organ damage is so severe that the patient does not respond to treatment and cannot survive Blood pressure remains low despite treatment Presence of an overwhelming metabolic acidosis Multiple organ dysfunction has occured and death is imminent

IRREVERSIBLE STAGE: MEDICAL MANAGEMENT

Usually the same as for the progressive stage Experimental strategies may also be employed Antibiotic agents

IRREVERSIBLE STAGE: NURSING MANAGEMENT

Also same as for the progressive stage
Carrying out prescribed treatments Monitoring the patient Preventing complications Protecting patient from injury Providing comfort Offering brief explanations to the patient

Keeping the family informed

Provide opportunities for family-client contact Approach the family regarding any living will, advanced directives, or other written or verbal wishes of the client Facilitate a conference for the health care team and the family members

IRREVERSIBLE STAGE: SUMMARY OF CLINICAL FINDINGS Blood pressure Heart rate

Requires mechanical or pharmacological support Erratic or asystole

Respiratory status Skin

Jaundice

Requires intubation

Urinary output

Mentation

Anuric, requires dialysis Unconscious

Acid-base balance
Profound acidosis

1. FLUID REPLACEMENT 2. VASOACTIVE MEDICATIONS 3. NUTRITIONAL SUPPORT

1. FLUID REPLACEMENT
Are given to improve cardiac and tissue

oxygenation Includes:
Colloids Crystalloids Blood products

2. VASOACTIVE MEDICATION THERAPY

Vasoactive medications are administered in all

forms of shock to improve the patients hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. These medications help to:
Increase myocardial contractility Regulate the heart rate Reduce myocardial resistance Initiate vasoconstriction

VASOACTIVE AGENTS USED IN TREATING SHOCK

Vasodilators
Nitroglycerine (Tridil) Nitroprusside (Nipride)

Vasoconstrictors
Norepinephrine (levophed) Phenylepinephrine (Neo-Synephrine) Vasopressin (Pitressin)

Antibiotics Heparin Steroids Histamine H2 Receptor Antagonist

3. NUTRITIONAL SUPPORT
Nutritional support is an important aspect of care

for the patient with shock. Increased metabolic rates during shock increase energy requirements and therefore caloric requirements. Parenteral or enteral nutritional support should be initiated as soon as possible Medications are also prescribed to prevent or treat stress ulcers

1. HYPOVOLEMIC SHOCK
Characterized by a decrease in intravascular

volume Occurs when there is a reduction in intravascular volume of 15% to 25% Can be caused by:
External fluid losses Internal fluid losses

MEDICAL MANAGEMENT
Major goals
Restore intravascular volume Redistribute fluid volume Reverse the underlying cause

Treatment of the underlying cause

Hemorrhage Diarrhea/vomiting

Fluid and blood replacement

Insert two large-gauge IV line Administration of isotonic crystalloids Administration of blood and blood products

Redistribution of fluid Pharmacologic therapy

Drugs used in cardiogenic shock Also depends on the cause of hypovolemia

NURSING MANAGEMENT
Primary focus: prevention of shock, if possible Otherwise, nursing interventions focus on assisting

with treatment targeted at treating its cause and restoring intravascular volume.
Administering blood and fluids safely
Obtain blood specimens Monitor for potential complications Hemodynamic monitoring, vital signs, ABG, Hgb&Hct, temp., physical assessment

Implementing other measures

O administration

CARDIOGENIC SHOCK
Occurs when the hearts ability to contract and

pump blood is impaired and the supply of oxygen is inadequate Causes:

Coronary
Myocardial Infarction

Decreased cardiac contractility Decreased stroke volume and cardiac output Decreased systemic tissue perfusion Decreased coronary artery tissue perfusion

Pulmonary congestion

CLINICAL MANIFESTATIONS
Angina pain Dysrhythmias Hemodynamic stability

MEDICAL MANAGEMENT
Goals: 1. Limit further myocardial damage and preserve the healthy myocardium 2. Improve the cardiac function

MEDICAL MANAGEMENT
Correction of underlying causes Coronary cardiogenic shock: thrombolytic therapy, angioplasty, CABG Noncoronary: cardiac valve replacement, or correction of a dysrhythmia Initiation of first-line treatment Supplying supplemental O Controlling chest pain Providing selected fluid support Administering vasoactive medications
Dobutamine, dopamine,

Controlling heart rate with medication or by implantation of a transthoracic or intravenous pacemaker Implementing mechanical cardiac support

MEDICAL MANAGEMENT: FIRST-LINE TREATMENTS

Pain control: MORPHINE Hemodynamic monitoring
Measures:
Pulmonary artery pressures Cardiac output Pulmonary and systemic resistance

Pharmacologic therapy
Dobutamine
Increases strength of myocardial contraction Decreases pulmonary and systemic resistance

Nitroglycerin
Venous dilator Arterial dilator

Dopamine
Low-dose Medium-dose High-dose

Other Vasoactive medications

MEDICAL MANAGEMENT: FIRST-LINE TREATMENTS contd..

Fluid therapy Mechanical assistive devices Intra-aortic balloon counterpulasation Left and right ventricular assist devices

NURSING MANAGEMENT
Preventing cardiogenic shock Monitoring hemodynamic status Administering medications and IV fluids Maintaining Intra-aortic balloon counterpulsation Enhancing safety and comfort

CIRCULATORY SHOCK
Occurs when blood volume is abnormally displaced in

the vasculature for example, when blood volume pools in peripheral blood vessels. The displacement causes a relative hypovolemia Causes:
Loss of sympathetic tone Release of biochemical mediators by cells

Three types:
1. Septic shock 2. Neurogenic shock 3. Anaphylactic shock

CIRCULATORY SHOCK:

1. SEPTIC SHOCK
Most common type; caused by widespread infection The greatest risk of sepsis occurs in patients with

bacteremia and pneumonia Risk factors in the increased incidence of septic shock:
Increased number of immunocompromised patients Increased incidence of invasive procedures Increased number of resistant microorganisms Increase in the older population

SEPTIC SHOCK: MEDICAL MANAGEMENT

Pharmacologic therapy Third generation cephalosphorin plus an aminoglycoside Recombinant human activated protein C (APC) / drotrecogin alfa (Xigris) Nutritional therapy Enteral rather than parenteral route

SEPTIC SHOCK: NURSING MANAGEMENT

Use strict septic technique in all procedures Monitor for signs of infection Obtain appropriate specimens for C&S Address an elevated body temperature
Administer acetaminophen as prescribed Provide hypothermia blankets Monitor for shivering Provide comfort

Adminidtration of prescribed IV fluids and medications Monitor blood levels of medications, BUN, creatinine, WBC Monitor other values
Hemodynamic status I&O Nutritional status

CIRCULATORY SHOCK

2. NEUROGENIC SHOCK
A shock state resulting from loss of sympathetic tone

causing relative hypovolemia Causes:

Spinal cord injury Spinal anesthesia Nervous system damage Medications Lack of glucose

Distinctly characterized by:

Dry, warm skin Bradycardia

MEDICAL MANAGEMENT:
Specific treatment depend on its cause Restoring sympathetic tone

NURSING MANAGEMENT:
Prevention is the key!
Elevate HOB upon administration of spinal anesthesia Immobilize patients head suspected with spinal cord injury

Support cardiovascular and neurologic function

Apply elastic compression stockings Monitor for and prevent complications associated with immobilty

CIRCULATORY SHOCK

ANAPHYLACTIC SHOCK:
A circulatory shock state resulting from a severe

allergic reaction producing an overwhelming systemic vasodilation and reactive hypovolemia There is widespread vasodilation and capillary permeability Can be prevented

MEDICAL MANAGEMENT
Removing the causative antigen Administering medication Epinephrine Diphenhydramine (Benadryl) Albuterol (Proventil) CPR if cardiorespiratory arrest is imminent ET tube insertion and tracheotomy

NURSING MANAGEMENT
Assess all patients for allergies Observe patient for allergic reaction when

administering new medications Identify patients at risk for anaphylaxis in diagnostic testing sites Be adept with the clinical signs of anaphylaxis, CPR and other emergency measures Teaching the client and the family about preventing future anaphylacticc episodes and administering emergency medications to treat anaphylaxis

Brunner and Suddarths Textbook of MedicalSurgical Nursing, 10th Edition Focus on Nursing Pharmacology, Amy M. Karch, 3rd Edition