Shock

• Shock

  1. Energy Production affected

  2. Moves from efficient Aerobic metabolism to less efficient Anaerobic metabolism

  3. Anaerobic metabolism produces lactate

  4. Lactic acid accumulates

  5. Causes acidosis

  6. Acidosis (pH below 7.35) – classic signs of shock
• Shock Stages

  1. Compensated

  2. Decompensation

  3. Irreversible
• Metabolic and Hemodynamic Changes in Shock


  1. Classic signs & symptoms of shock

  2. Tachycardia

  3. Tachypnea

  4. Oliguria

  5. Restlessness, anxiety

  6. Cool, clammy skin with pallor

  7. Subnormal body temp (exception- septic shock)

  8. Decreased blood pressure
• Types of Shock

  1. Hypovolemic shock

  2. Distributive shock

  3. Obstructive shock

  4. Cardiogenic shock
• Hypovolemic Shock

  1. Causes: Dehydration; internal or external hemorrhage; fluid loss from burns, vomiting, or diarrhea; loss of intravascular fluid into the interstitial space from sepsis or trauma

  2. Signs & Symptoms: Restlessness; pale, cool, clammy skin; tachycardia; tachypnea; decreased urine output; altered mental status

  3. Apply pressure if bleeding

  4. Administer fluid therapy as ordered
• Distributive Shock

  1. Types: Neurogenic shock

  2. Septic shock

  3. Anaphylactic shock
• Neurogenic Shock

  1. Rare

  2. Extensive dilation of peripheral blood vessels
• Septic Shock

  1. Surviving sepsis campaign

  2. Goal: To reduce mortality

  3. Fever, elevated leukocyte count, flushed skin, rapid/bounding pulse

  4. Implement interventions promptly
• Anaphylactic Shock

  1. Extreme hypersensitivity reaction to antigen

  2. Teach allergy avoidance methods

  3. Most common: Food allergies

  4. Carry epinephrine autoinjector

  5. Carry medical alert information
• Obstructive Shock

  1. Blockage of blood flow inside or outside of the heart

  2. Causes: Pericardial tamponade; Tension pneumothorax; Acute pulmonary hypertension; Pulmonary embolism

  3. Decreases cardiac output, leading to shock

  4. Jugular vein distension
• Cardiogenic Shock

  1. Causes: Heart fails as pump and decreases cardiac output

  2. Main Cause is myocardial infarction

  3. Other causes: traumatic injury to heart; myocarditis; cardiomyopathy; heart valve defects; endocarditis; or arrhythmias

  4. Requires immediate treatment to prevent death

  5. S/S are like those of Hypovolemic Shock

  6. Pulmonary edema may occur

  7. Avoid fluid therapy

  8. Increases mortality as already in fluid overload
• Medical Management for Shock

  1. Treat cause/identify type of shock

  2. Maintain airway/respiratory support

  3. Maintain circulatory volume

  4. IV Fluids!!!

  5. Provide cardiovascular support

  6. Vasopressors

  7. Positive inotropic agents
• Complications from Shock

  1. Acute respiratory distress syndrome (ARDS)

  2. Disseminated intravascular coagulation (DIC)

  3. Multiple organ dysfunction syndrome (MODS)
• Nursing Diagnoses

  1. Altered Tissue Perfusion

  2. Decreased Cardiac Output

  3. Deficient Knowledge
• Nursing Care

  1. Maintain airway, oxygenation

  2. Monitor vital signs

  3. Monitor intake and output

  4. Provide fluids as ordered

  5. Provide warmth

  6. Relieve pain
• Tissue perfusion

  Requires adequate blood volume, effective cardiac pump, and effective blood vessels
• Types of shock

  • Hypovolemic
  • Distributive
  • Obstructive
  • Cardiogenic
• Therapeutic measures for shock

  1. Maintaining airway/respiratory support

  2. Circulatory volume

  3. Providing cardiovascular support
• Treatment for shock

  1. Maintaining airway/respiratory support

  2. Circulatory volume

  3. Providing cardiovascular support
• Data to collect when caring for patients in shock

  • Monitor vital signs
  • Intake and output
  • Provide fluids as ordered
• Plan nursing care for patients in shock

  1. Maintaining airway

  2. Oxygenation

  3. Monitoring vital signs

  4. Relieving pain
• Prioritize care for a patient in shock

  1. Maintaining airway

  2. Oxygenation

  3. Monitoring vital signs

  4. Relieving pain
• Inadequate tissue perfusion leads to oxygen deficit, tissue hypoxia, and organ damage
• Circulatory collapse is a condition where the body's circulatory system fails to deliver enough blood to meet the body's needs, leading to organ failure
• Hypoperfusion is a condition where there is inadequate blood flow to an organ or tissue, leading to reduced oxygen and nutrient delivery. It can result in tissue damage and organ dysfunction
• 30ml/kg within the first 3 hours
• Pathophysiology of shock

  1. Tissue perfusion requires adequate blood volume, effective cardiac pump, and effective blood vessels

  2. Compensation mechanisms change in one or both nonfailing tissue perfusion mechanisms

  3. A shift from aerobic to anaerobic metabolism occurs due to oxygen deficit

  4. Aerobic Metabolism: the process of producing energy in the presence of oxygen

  5. Anaerobic Metabolism: occurs in the absence of oxygen, producing energy through glycolysis and fermentation

  6. Lactic acid accumulation causes acidosis, a classic sign of shock
• The normal range for lactic acid levels in blood typically falls between 0.5 to 2.2 millimoles per liter (mmol/L) or 4.5 to 19.8 milligrams per deciliter (mg/dL)
• In the context of shock, elevated lactic acid levels are commonly observed and can serve as an important indicator of tissue hypoperfusion and anaerobic metabolism
• Shock Stages

  1. Compensated Shock

  2. Decompensated Shock

  3. Irreversible Shock
• Classic signs & symptoms of shock
• What is the cause and compensatory purpose of these classic signs of shock: tachycardia, tachypnea, oliguria, pallor, and cool, clammy skin?
• Compensatory mechanisms in shock

  1. Tachycardia: Increases heart rate to maintain cardiac output

  2. Tachypnea: Increases respiratory rate to enhance oxygen delivery to tissues

  3. Oliguria: Decreased urine output due to decreased renal perfusion

  4. Pallor: Vasoconstriction to redirect blood flow

  5. Cool, clammy skin: Peripheral vasoconstriction to conserve body heat
• Compensatory responses aim to maintain perfusion to vital organs and tissues in the face of reduced blood volume or impaired cardiac function
• If shock is not promptly treated, compensatory mechanisms can become overwhelmed, leading to worsening tissue hypoperfusion and organ dysfunction
• Types of Shock

  • Hypovolemic shock
• Hypovolemic shock is characterized by a significant decrease in circulating blood volume, leading to inadequate tissue perfusion and oxygen delivery
• Causes of Hypovolemic Shock

  • Hemorrhage: Traumatic injury, gastrointestinal bleeding, obstetric hemorrhage
  • Dehydration: Excessive fluid loss, inadequate fluid intake
  • Excessive fluid loss: Diuretic use, burns, third-spacing
• Pathophysiology of Hypovolemic Shock

  1. Decreased circulating blood volume: Loss of intravascular fluid, reduction in preload and stroke volume

  2. Compensatory mechanisms: Activation of sympathetic nervous system, renin-angiotensin-aldosterone system

  3. Decreased tissue perfusion and oxygen delivery: Impaired oxygen transport, cellular hypoxia and metabolic acidosis
• Clinical Presentation of Hypovolemic Shock

  1. Signs and symptoms: Tachycardia, hypotension, cold clammy skin, altered mental status, weak peripheral pulses, oliguria

  2. Severity classification: Class I to IV based on symptoms