1 Shock

2 Shock
3 Definition of Shock
„ Shock is a term used to refer to a group of signs & symptoms that can be caused by a variety of
problems.

„ Shock is an abnormal physiologic state in which there is a disproportion between the circulating blood
volume and the size of the vascular bed resulting in circulatory failure and anoxia.

4 Types of Shock
„ Hypovolemic.
‹ Cold shock because the extremities become cold.

„ Cardiogenic Shock.
„ Neurogenic Shock.
„ Vasogenic Shock.
‹ Warm Shock because the extremities remain warm.

‹ Vasogenic Shock can also be classified as either Septic or anaphylactic.

5 Hypovolemic Shock
„ Hypovolemic shock is loss of blood the point where the metabolic needs of the body cannot be met.
„ An individual who loses approx. 1/3 or 1000 ml of their normal blood volume will probably go into
shock.
„ Hypovolemia can also be caused by burns.
‹ Referred to as: BURN SHOCK.

„ Can also be caused by movement of fluid into another body space.

6 Hypovolemic Shock
„ Signs and Symptoms
‹ C/O < 5
‹ Increased heart rate

‹ Narrow pulse pressure

‹ Systolic pressure < 90

‹ Decreased urine output

7 Hypovolemic Shock
„ Treatment
‹ Stop blood or plasma loss
‹ Fluid replacement is primary concern

 Ringers lactate, 0.9% NaCl

 Albumin, hetastarch,
hetastarch, blood products
‹ Position in modified trendelenburg

8 Cardiogenic Shock

1
 „ Failureof the cardiac muscle to act as a pump
„ The heart can no longer perform adequately and is unable to pump sufficient blood to the
organs
„ MI’s are the most common cause

9 Cardiogenic Shock
„ Treatment
‹ O2 at 3 - 5 L/min
‹ Control chest pain with morphine

‹ Vasoactive drugs

 Dopamine 0.5 - 3.0 mcg/min

 IV Nitro

‹ Fluid support

10 Cardiogenic Shock
„ Treatment/Nursing Management
‹ Safety and comfort
 Reduce anxiety

 Decrease chest pain

 Prevent infection from various lines

 Position to increase effective ventilation

11 Distributive Shock
„ Caused by an increase in the size of the vascular bed due to massive vasodilation or.
„ Peripheral pooling of blood.
„ Still have a normal blood volume, but even the normal amt. of blood cannot adequately fill
the increased size of the capillary bed.
„ Neurogenic, septic, or anaphylactic.

12 Neurogenic
„ Neurogenic Shock is caused by dilation of blood vessels secondary to nervous factors such as:
‹ Brain damage.

‹ Deep spinal anesthesia.

„ It results in vasomotor collapse & venous pooling.

„ Signs and Symptoms.
‹ Decreased B/P.

‹ Bradycardia.

‹ Decrease in venous return.

‹ Decrease in cardiac output which results in inadequate tissue perfusion and anoxia.

13 Neurogenic Shock
„ Treatment/Nursing Management
‹ Positioning during anesthesia

2
 ‹ Elastic stockings, elevating foot of bed
‹ Passive range of motion to immobile extremities

‹ All the above serve as ways to decrease potential for neurogenic shock

14 Septic Shock
„ Caused by bacterial infection, immunosuppression
„ Signs and Symptoms
‹ Infection

‹ Warm phase

‹ Cold phase

„ Treatment/Nursing Management
‹ Antibiotics

‹ Eliminate source of infection

‹ Fluid replacement

15 Septic Shock
„ Treatment/Nursing Management.
„ Use of aseptic technique.
„ Monitor for signs of infection.
„ Reduce temps over 104 with aspirin, hypothermia blankets.
„ Monitor therapeutic blood levels of meds.
„ IV fluids and meds.

16 Anaphylactic Shock
„ A massive allergic reaction
‹ Adrenaline/ Epi is given many times to combat it

 Epi can be given through ET tube

‹ Observe for bronchoconstriction

„ Treatment/Nursing Management
‹ Screen for allergies

‹ CPR

‹ Administer meds, fluids

‹ Documents

17 Stages of Shock - 1 St and 2nd Stages

„ 1 st Stage = Initial Phase.
‹ The CO is insufficient to meet the metabolic needs of the body but not low enough to produce symptoms.

‹ Patient is anxious & alert, altered mental status, increased respirations.

„ 2 nd Stage = Compensatory Stage.

‹ Due to catacholamines being released you will see during the compensatory stage:

‹ An Increase in HR.

‹ Increase in CO.

‹ Vasoconstriction.

‹ B/P WNL (Due to compensation) or decrease of 10-15 mm. Hg.

3
18 Stages of Shock - 1 St and 2nd Stages
„ Also observe for.
‹ Metabolic acidosis in compensatory stage.

„ Treatment/Nursing Management.
‹ Correct underlying cause of shock.

‹ Fluid replacement.

‹ Monitor for changes in mental status, decreased urine output, vital

vital signs.
‹ Reduce anxiety.

‹ Promote safety.

19 Stages of Shock - Progressive Stage

„ 3 rd stage = Progressive stage.
‹ Unfavorable signs & symptoms become more apparent to you. You will see:

 Falling B/P.

 Increased heart rate.

 Oliguria.

 System dysfunction begins.

„ In other words, the compensatory mechanisms are not able to compensate.

„ Keep patient warm and comfortable to decrease 02 demand.
„ Shock to be reversed at this time, otherwise death results.

20 Stages of Shock - Progressive Stage

„ Treatment/Nursing Management
‹ Intensive assessment monitoring
‹ Medications and fluids
‹ Aseptic technique

‹ Positioning

‹ Promote rest and comfort

‹ Family support

21 Stages of Shock - Irreversible Stage

„ During this stage, no matter what is done the outcome is death
‹ There is myocardial depression

‹ There is massive capillary dilation

‹ Blood remains pooled in the extremities

‹ Patient succumbs (Dies)

„ Treatment/Nursing management
‹ Much family support in addition to physical care

22 Physiologic Effects of Shock

„ The Neuro Endocrine response
‹ Initially, but very briefly, there will be a decreased B/P
„ Also important in the Neuro Endocrine response is the regulation of Water & Sodium
„ Fluid shifts that occur with shock
‹ Early in shock, blood is squeezed from the capillaries back into the vascular system & the result is two fold:

4
 ‹ 1. It tends to dilute the blood
‹ 2. It causes tissue dehydration

23 Systemic and Microcirculation During Shock

„ At the onset of shock & during the compensatory stage, the systemic & microcirculatory system work
together & their activities tend to remain coordinated
„ With the systemic system, there is
‹ Increased HR

‹ vasoconstriction

„ In the microcirculation, there is

‹ Vasoconstriction

24 As Shock Progresses
„ The systemic circulation remains vasoconstricted to get blood back to the heart. At this
point, the cells are becoming anoxic because there has been a decreased amt. of blood
given to them because the systemic circulation has been constricted.
„ As a result, the microcirculation ( down near the cells) dilates in order to get blood to the tissue.
„ Decreased CO, falling B/P begin to appear.
25 Intestinal Changes During Shock
„ Because the intestines really aren't vital to life, they are the 1st organs in the body to lose their supply
of blood.

„ As a result the bowel becomes anoxic.

„ Tissue necrosis results & bacteria are released into the abdominal cavity.
26 Kidney’s During Shock
„ The kidneys can compensate fairly well for a time

„ When the B/P begins to fall oliguria sets

„ Oliguria results in kidneys losing their ability to regulate electrolytes & acid base balance
‹ Changes in the acid base balance

27 Respiratory Function During Shock

„ VERY IMPORTANT IN COMPENSATION

„ Ventilation is going to be a priority because most patients develop tissue hypoxia

„ The cells become 02 starved

‹ Tissue began to metabolize anaerobically

‹ Body begins to hyperventilate & to blow up excess C02

 Results in respiratory alkalosis

28 Mortality Rates of Shock

„ Hypovolemic shock is most common type of shock.
‹ Better survival rate.

„ Cardiogenic Shock has a mortality rate of close to 80%.

„ Vasogenic Shock can occur very rapidly, in a matter of minutes.

5
 ‹ patient can be dead in a matter of minutes.

„ Septic Shock has a mortality rate of about 90%.

29 General Signs and Symptoms of Shock

„ Decrease in B/P.

„ Increase in HR.

„ Rapid, thready pulse.

„ Cold & Clammy.

„ When shock is assessed at this point, it's way ahead of you.

30 When to Anticipate Shock
„ Surgery
„ Trauma
„ Metabolic disorders
„ Infections
„ Old age
31 Interventions for Hemorrhaging
„ Infuse whole blood.
„ Dextran (Volume expander), Albumin, Hespan, Volex.
„ Keep in mind when dealing with hemorrhagic shock you're not just pumping in blood, but you're
stopping the reason for the shock.
„ Position in a modified Trendelenburg. The legs are raised at a 20 to 45 degree angle & the head is
either flat or slightly raised.
32 Drugs During Shock
„ Vasodilators
‹ To combat the massive vasoconstriction (Nipride)

„ Vasopressors
‹ Dopamine

„ Diuretics
33 General Nursing Management of Shock
„ Maintenance of patient airway.
„ Patient positioning.
„ Maintenance of body temperature.
„ Maintenance of skin integrity.
„ Psychological support.

34 Other Considerations During Shock

„ Don't be so concerned with the tubes, etc. that you forget about the patient.

6
„ Keep patient as calm as possible because the more agitated & excited they get, the faster they breathe &
the more 02 compromised they become.
„ Pain deepens shock.
„ Give explanations to decrease anxiety levels.
„ Cover lightly.