SHOCK - Earlier interventions = greater chance

 Life-threatening condition, results of survival

from inadequate tissue perfusion - Window or opportunity-patient survival
occurs when aggressive therapy begins
 Imbalance between the delivery of within 3 hours of identifying a shock
oxygen and nutrients needed to support state, especially septic shock
cellular function
 Adequate blood flow to the tissue and Compensatory Stage
cell requires:  Vasoconstriction, increased HR, and
o effective cardiac pump increased contractility of the heart
o adequate vasculature contribute to maintaining adequate
o sufficient blood volume CO.-BP WITHIN NORMAL LIMITS
 Primary underlying pathophysiologic  "Fight-or-flight" response.
process and underlying disorder - used  The body shunts blood from organs such
to classify shock as the skin, kidneys, and
 Failure of compensatory mechanisms  gastrointestinal (GI) tract to the
brain, heart, and lungs to ensure
end-organ dysfunction and DEATH ☹ adequate blood supply to these vital
PATHOPHYSIOLOGY organs.
 Anaerobic metabolic low-energy yields - Cool and clammy skin
from nutrients and an acidotic - Less UO
intracellular environment - Hypoactive bowel sounds 
- Because of lactic acid production paralytic ileus
 acidic state
Clinical Manifestations
 Na-K pump becomes impaired; cell
structures, primarily the mitochondria  Metabolic acidosis
are damaged, and death of the cell  Increased in RR. (compensation)
results  May experience a change in affect,
 Glucose is the primary substrate feel anxious, or be confused.
required for the production of  Prognosis for the patient is better
cellular energy in the form of ATP than in later stages
 In stress states, catecholamines, Medical Management
cortisol, glucagon, and inflammatory
biochemical mediators (i.e.,  Directed toward identifying and
cytokines) are released, causing to correcting the underlying cause so
mobilized glucose for cellular that shock does not progress, and
metabolism. hyperglycemia and insulin supporting physiologic responses
resistance will happen  Fluid replacement and medication
 Clotting cascade is over productive. therapy must be initiated to maintain
- Because of over stress an adequate BP and reestablish and
- Body thinks there is hemorrhage maintain adequate tissue perfusion
- MICROVASCULAR CLOTTING  VISCIOUS Nursing Management
CYCLE  Assess pt at risk for shock, recognize
BLOOD PRESSURE REGULATION subtle clinical signs before BP drops.
 Three major components of the  Observe for subtle changes in LOC, VS,
circulatory system - blood volume, the UO, skin, RR, and lab values
cardiac pump, and the vasculature -  Serum Na and blood glucose levels are
must respond effectively to complex elevated in response to the release of
neural, chemical and hormonal feedback aldosterone and catecholamines.
systems to maintain an adequate blood  Blood cultures should be obtained
pressure (BP) and perfuse body tissue prior to administration of prescribed
- Mean Arterial BP = Cardiac output x antibiotics
Peripheral resistance  Should report a systolic BP lower than
- tissue perfusion and organ perfusion 90 mm Hg or a drop in systolic BP of
depend on mean arterial pressure (MAP) 40 mm Hg from baseline or a MAP less
- MAP must exceed 65mmHg for cells to than 65 mm Hg
receive the oxygen and nutrients
needed to metabolize energy in amounts
sufficient to sustain life
- BP is regulated by baroreceptors
(pressure receptors) located in the
carotid sinus and aortic arch.
- BP is regulated by baroreceptors
located in the carotid sinus and
aortic arch.
- Chemoreceptors – regulate BP and
respiratory rate depending on oxygen
and CARBON DIOXIDE blood
concentrations.
 RAAS Mechanism is activated

STAGES OF SHOCK
- Compensatory (stage 1), progressive
(stage 2), and irreversible (stage 3)
 Narrowing or decreased pulse pressure decreases to less than 0.5 ml/kg
is an earlier indicator of shock than per hour.
a drop in systolic BP  Cardiovascular effects
 Continuous central venous oximetry o A lack of adequate blood supply
(Scv-02) monitoring may be used to leads to dysrhythmias and ischemia
evaluate mixed venous blood oxygen  Pt may complain of chest pain
saturation and severity of tissue and even suffer an MI
hypoperfusion states. A normal Scv-02  Hepatic effects
value is 70% o Decreased blood flow to the liver
 Supplemental 02, IV fluids, inotropic impairs the ability of liver cells
supports, and mech vent are some of to perform metabolic and
the interventions done. phagocytic functions.
 Reduce anxiety and promote safety o Less able to metabolize
medications and metabolic waste
products
o Patient becomes more susceptible
to infection as the liver fails to
filter bacteria from the blood
o Liver enzymes are elevated, and
the patient develops jaundice.
 Gl effects
o Small intestine the mucosa can
become necrotic and slough off,
causing bloody diarrhea. Gl
ischemia leads to bacterial
translocation and organ
dysfunction
 Hematologic effects-
o The combination of hypotension,
sluggish blood flow, metabolic
2nd Progressive Stage acidosis, coagulation system
imbalance, and generalized
 Mechanisms that regulate BP can no hypoxemia can interfere with
longer compensate, and the MAP falls normal hemostatic mechanisms.
below normal limits.  Disseminated intravascular
 Pt is now clinically hypotensive- coagulation (DIC) may occur
defined as a systolic BP of <90 mmHg either as a cause or as a
or a decrease in systolic BP of 40 complication of shock.
mmHg from baseline. The patient shows
signs of declining mental status Medical Management
 (1) overworked heart becomes  Include the use of appropriate IV
dysfunctional, (2) autoregulatory fluids and medications may include
function of the microcirculation early enteral nutritional support,
fails, (3) Anaerobic metabolism ensues targeted hyperglycemic control with IV
insulin and use of antacids,
Clinical Manifestations histamine-2 (H2) blockers, or
 Respiratory effects- antipeptic medications to reduce the
o Lung decompensation will risk of GI ulceration and bleeding.
necessitate mech vent. RR rapid  Tight glycemic control (serum glucose
and shallow. Crackles present. of 80 to 100 mg/dL) is no longer
Decreased pulmonary blood flow recommended
causes decreased 02 and increased  Current evidence suggests that
CO2. Hypoperfusion of alveoli maintaining serum glucose less than
causes collapse 180 mg/dl with insulin therapy and
o Pulmonary capillaries begin to close monitoring is indicated in the
leak, causing pulmonary edema, management of the critically ill
diffusion abnormalities patient
(shunting), and additional
alveolar collapse. This condition Nursing Management
is called acute lung injury (ALI);  Hemodynamic monitoring, preventing
as ALI continues, interstitial infections, neurovascular status if
inflammation and fibrosis. are arterial lines are inserted.
common consequences, leading to - FOR EXAMPLE, FEMORAL ARTERY
acute respiratory distress ACCESS- check for the right leg
syndrome (ARDS) circulation, capillary refill of
 Neuro effects toe nails, circumference of leg
o Mental status deteriorates.  VAP bundles of care are instituted
Changes in mental status occur  Assess for acute delirium,
with decreased cerebral perfusion characterized by an acute change in
and hypoxia. mental status, inattention,
 Renal effects disorganized thinking, and altered LOC
o When the MAP falls below 65 mm Hg,  Promote rest and comfort
the GFR of the kidneys cannot be  Supporting family members
maintained, and drastic changes in
renal function occur. AKI can 3rd irreversible stage
occur. Urinary output usually
Organ damage is so severe that the patient
does not respond to treatment and cannot
survive
Despite treatment, BP remains low
Reserves of ATP are almost totally
depleted, and mechanisms for storing new
supplies of energy have been destroyed
RESPIRATORY SYSTEM dysfunction prevents
adequate oxygenation and ventilation
despite mechanical and ventilatory support
CARDIOVASCULAR SYSTEM is ineffective in
maintaining an adequate MAP for tissue
perfusion
MULTIPLE ORGAN DYSFUNCTION progressing to
complete organ failure has occurred, and
death is imminent

NURSING MANAGEMENT
Similar to intervention and treatments
used in the progressive stage
End of life nursing care – living wills
Ethics committees may assist families and
health care teams in making difficult
decisions
False hopes should not be given to family
members

GENERAL MANAGEMENT STRATEGIES IN SHOCK

Fluid replacement, respiratory support,
vasoactive meds and nutritional support
are the main interventions
1. FLUID REPLACEMENT
2. Crystalloid and colloid solutions
– in emergencies, the “best”
fluids is often the fluid that is
readily available
3. Isotonic crytalloid solutions
4. Commonly used for resuscitation in
hypovolemic shock include normal
saline and lactated Ringer’s
solution
5. Lactate ion will be converted to
bicarbonate
Disadvantage of using isotonic
crystalloid solutions is that some
of the volume given is lost to the
interstitial compartment and some
remains in the intravascular
compartment  more fluid may need
to be given than the amount lost
to support tissue perfusion