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Haemorrahage and shock2

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Ratna Gurram <ratna_oct4@yahoo.com>

To:RATNAKUARI G

Thu, 28 Jul at 7:37 pm

[28/07, 7:18 pm] Ratnavimal: HAEMORRHAGE AND SHOCK Haemorrhage Haemorrhage is

the loss of blood from blood vessel . The blood loss is described as extra vacated ( outside
the vessel ) It may lie on the surface of body , on patient's clothing or on the floor . Blood may
be lost from all three types of vessels , the arteries , the veins or capillaries . The type of
haemorrhage is named accordingly , Bleeding which occurs as soon as vessel is divided is
known as primary haemorrhage . If the patient is collapsed the vessel may not bleed
immediately , but as recovery takes place , the blood pressure rises and bleeding occurs .
This is known as reactionary or intermediate haemorrhage . Haemorrhage can involve all the
blood vessels . Natural Arrest of Haemorrhage Adequate amount of calcium is required and
all the clotting factors are essential for the natural arrest haemorrhage . The blood in the
circulation is kept fluid by a fine balance between clotting and fibrinolysis . Tear in blood
vessel Collagen comes into contact with blood Damaged cell memvranes release
phospholipids Plasma proteins are activated Soluble fibrinogen in plasma Platelets form plug
over tear Flow Chart -5.4 Prothrombin ↓ Thrombin Insoluble librin ↓ Forms network of fibres to
cover the boar Factors Affecting Clotting Calcium Calcium helps in the clotting of blood .
Calcium can be displaced from the blood by 3.8 % solution of sodium citrate , acid citrate
dextrose solution , citrate REDMI NOTE 9e solution , ethylene diamine tetra AI QUAD
CAMERAAcid citrate dextrose and acid Biopsychosocialpathology

[28/07, 7:19 pm] Ratnavimal: . . citrate phosphate solutions are used to prevent clotting of
stored blood . Prothrombin It is formed from vitamin K , a fat soluble vitamin absorbed from
the small intestine . A patient suffering from obstructive jaundice will not absorb vitamin k and
there fore they may bleed if operated upon . For this reason vitamin k injection is given so as
to restore the pro thrombinlevel of blood . Fibrinogen is the precursor of fibrin . In absence of
fibrinogen severe bleeding may occur fibrinogen is . the substance which dissolves fibrin a
phenomenon known as fibrinolysis . The fibrinolytic activity blood may be increased : In
complicated obstetric cases associated with hemorrhage . After strenuous activity . In
presence of some malignant growth . The patient suffering from increased fibrinolysis will
show reduced evidence of clotting . They may be treated by neutralization of the fibrinolysis
by the administration of fibrinogen . Types of Haemorrhage According to the vessels
involved ) 1. Arterial haemorrhage . Capillary haemorrhage . Venous haemorrhage . Arterial
haemorrhage The blood loss is from artery is known as arterial haemorrhage . The blood is
bright red and spurts with the heartbeat The escape is from both ends of vessels not only
from nearer to the heart . Blood loss is more rapid from a vessel of corresponding size . 2.
Capillary haemorrhage The blood oozes over the surface of capillary and is darkish red in
color oozing over several hours can result in considerable blood loss . 3. Venous
haemorrhage The blood loss from vein is known as venous haemorrhage . The blood is dark
red in colour , there is no spurting and rate of loss is much less severe than arterial
haemorrhage . When there is injury to large vessels is be a serious matter . A further danger
is that air may be sucked into the damaged vein giving rise to fatal air embolism which the
blood and air form foam ( According to the time of wound ) 1. Primary haemorrhage . 2.
Reactionary or intermediate haemorrhage . 3. Secondary haemorrhage . 1 . Primary
haemorrhage It is immediate haemorrhage which occurs when there is damage to any blood
vessel and bleeding occurs immediately . E.g. cut on a finger or operative incision . 2.
Reactionary or intermediate haemorrhage It occurs in first 24 hours after operation . The more
severe the operation the more likely it is to occure specially after the patient has recovered
from circulatory collapse , operation on kidney , the thyroid and the breast as well as total
hysterectomy are particularly liable to be followed by reactionary or intermediate
haemorrhage . 3. Secondary haemorrhage It is due to sloughing off the wall of blood vessel .
The commonest cause is bacterial infection , but in the absence of infection it may cause by
action of enzyme e.g. acid pepsin on peptic ulcer . In this type the thinnest vessels burst first
and blood may be found on the dressings . This should be reported immediately because
larger vessels can also be eroded in another few days . ( According to clinical classification of
the haemorrhage ) I. Revealed or external . 2. Concealed or internal . 1. Revealed
haemorrhage It is a type when bleeding can be seen externally 2. Concealed haemorrhage It
is that type when bleeding cannot be externally . The bleeding occurs into one of body
cavities such as the abdomen , into the l of hollow organ such as intestine or into the tist It
may later become obvious e.g. by being vom or per rectum or by bruising and swelling of
surface of the body . Since it must be diagnosed on the presence of symptoms and signs alon
CO AI QUAD CAMERA

[28/07, 7:20 pm] Ratnavimal: Signs Symptoms of Haemorrhage Earts signs and symptoms
Restlessness and anxiety Feeling faint Coldness ( temp . slightly subnormal 98 degree
Fahrenheit ) . Slightly increased pulse . Pallor . Patient feels thirsty Signs and symptoms after
severe haemorrhage Extreme pallor face will be ashen white and clammy with cold sweat )
Child sensation temp . 97 degree Fahrenheit ) . Air hunger ( patient literally gasps for breaths
and respirations will be rapid ) . Rapid thready pulse . Extremely low blood pressure . Extreme
thirst . Diminished urine volume ( acute renal failure ) , Blindness , tinnitus and coma occur
prior to death Effects of Haemorrhage Cardiac cycle Cardiac cycle is the repetitive pumping
action that produces pressure changes that circulates blood throughout the body . It will get
disturbed i.e. it pumps less amount of blood to different organs . Cardiac output Normal
cardiac output is 5-6 l / min The total amount of blood separately pumped by each ventricle
per minute usually expressed in litre per minute . It can increased up to 30 / min at time of
exercise . It determined by multiplying the heart rate by volume blood ejected by each
ventricle during each beat . Control of External Haemorrhage Pressure will control all types of
external haemorrhages . and is called indirect pressure . It is particularly valuable in the neck
where other methods applicable . It will control venous Elevation of the limb haemorrhage .
This is a classical method dealing with a sudden haemorrhage from ruptured varicose vein of
leg d . Application of tourniquet This is rarely required except for control of a torrential
haemorrhage from the limb . A temporary tourniquet may have to be devised in sudden
emergency . It should be 3-4 inches wide . It be a hanker chief , scarf or a tic . The great
danger of tourniquet is that if it is left on for more than minutes then gangrene of the limb may
occur . time of application and removal of tourniquet should be recorded . The limb on which
tourniquet is applied should be kept elevated afterwards control edema which may result from
venous congestion . Surgical ligation : -It is necessary if the bleeding is persistent .
Coagulation : It can be used to coagulate blood from small blood vessels . According to its
severity there is a choice of methods . . Pack : It will temporarily control severe haemorrhage .
This method is used in operation theatre to control temporary or sudden haemorrhage . The
theatre nurse should always have a pack readily available for this emergency . h . Styptics :
These are also used to control bleeding . b . Digital pressure : - It is the pressure applied on
the point of artery supplying blood to the area of wound . This will control haemorrhage
temporarily . . a . Pad and bandage : This is the simple method of applying direct pressure to
a bleeding wound and is applicable to vast majority of cases . It is effective and causes no
damage . • and they act as astringents . Astringents such as snake venom or adrenaline may
be used locally in certain cases . Thrombin and gel foam can be used in some cases such as
in low pressure bleeding from veins capillaries . First Aid Treatment in Case of Severe
External Bleeding Bring the sides of wound together and press firmly . Press on the pressure
point for 10-15 min . Place the causality in comfortable position and raise the injured part and
reassure him . Apply a clean pad larger than the wound and it firmly with the palm until
bleeding becom If bleeding continues do not take off dressing but add more pads . Bandage ,
it but not too tightly . . . CAMERA

[28/07, 7:22 pm] Ratnavimal: Control of Internal Haemorrhage The following methods can be
used to control 4 . . bleeding The organ is emptied of blood clots if possible in case of severe
bleeding from bladder , a catherer is passed and bladder is emptied . The vessels are
encouraged to contract a lot of Transfusion under increased pressure saline or sodium
bicarbonate to which a few drops of adrenaline solution have been added , is of great value in
washing the organ . This can be repeated every two hourly . The use of ergometrine after the
birth of placenta is an example of stimulating the vessel to contract . Pitosin ( Oxytocin )
intravenous may be effective in control of bleeding from esophageal varies . Packing it it can
be done with gauze soaked in adrenaline is effective . Surgical ligature , surgical ligation can
be done in case of ruptured spleen . Internal pressure this may be applied by the balloon of
triluminal tube in bleeding esophageal varies or by the balloon of Foley's catheter in the
prostatectomy cavity First Aid Treatment in Case of Internal Bleeding Lay the causality down
with head low ; raise his legs by use of pillow . Keep him calm and relaxed . Reassure him .
Do not allow him to move . Keep up the body heat with thin blankets or coat . Do not give
anything to eat or drink aspiration may occur . Do not apply ice bags or hot water bottles to
chest or abdomen . Take him to the hospital as early as possible . Transport gently .
Restoration of blood volume Bloed volume can be restored by blood transfusion . Indications
for blood transfusion 1. To counteract the effect of severe haemorrhage and replace blood
loss . 2. To prevent shock in operations where blood loss is considerable such as rectal
resection , hysterectomy and arterial surgery . 3. In severe burns to make up for blood lost by
burning but only after plasma and electrolyte have been replaced . . . . . . 4. To correct from
cancer , marrow aphasia and similar condition and from slow continuous haemorrhage . In
blood transfusion as in all intravenous injections , the tubing other portion of the delivery
apparatus must be free from air In some circumstances usually of large rapid blood foss may
be necessitate blood transfusion more quickly than possible by the simple gravity drip method
. Following methods can be used : Pressure cuff - this is an inflatable cuff placed around the
bag of blood , when it is inflated it exerts external pressure on the bag of blood thus
increasing the flow of blood into the patient . Pressure pump administration : some transfusion
giving sets permits either gravity or pressure pump administration of blood . Precautions
during blood transfusion Patient and transfusion apparatus should be kept under constant
supervision . Blood must be transfused according to the rate prescribed by the doctor .
Approx.25 drops per minute . Is the casual rate of blood transfusion which means that bag is
transfused in four hours ? Sufferers from cardiac , pulmonary diseases or severe anaemia
must be transfused at the slow rate sometimes at 12 drops per minute . Half an hourly pulse
rate and temperature should be recorded . If blood transfusion is for shock , the blood
pressure and pulse rate should be recorded after each unit of blood . All the patients should
be watched for symptoms of transfusion reaction after first few ml of blood from each unit of
blood , such as allergic reaction , pyrexia , air embolism , overloading , it is etc. thrombophleb
Haemorrhages from Special special term The occurrence from special sites is O REDMI
NOTE Sites desi • Epistaxis : it is the bleeding from nose . Haemoptysis : it is the
expectoration of from lungs . AI QUAD CAMERA Haematemesis : it is the vomiting of b CO

[28/07, 7:23 pm] Ratnavimal: Malaena : it is the passage of dark blood per rectum from a site
high in intestinal tract , Haematuria : it is the presence of blood in the urine . . Haemothorax :
it is the bleeding into the chest . Haemoperitonium : bleeding into the peritoneum Menorrhagia
: excessive menstruation at normal interval . Haemopericardium : pericardium . it is the
bleeding into the Hematomyalia : it is the bleeding into the spinal cord . SHOCK Shock is a
life threatening condition . It is characterized by inadequate tissue perfusion that if untreated
results in cell death . The supply of oxygen to tissues is essential in the maintenance of life
and this can be ensured when circulatory system is functioning normally . Historical
background : In 1923 Walter and Canner first worked for all conditions of shock .
Biopsychosocialpathology . • Toxemis Effects of drugs . 2. Deficient oxygenation of blood in
lungs Amongst many causes the following are the most important • Post Definition Shock can
be defined as a condition in which systemic blood pressure is inadequate to deliver oxygen
and nutrient to supply to vital organs and cellular functions . Shock is defined as a failure of
circulation to supply adequate oxygen to the tissues . Significance of shock : shock affects all
the body systems . It may develop slowly or rapidly depending upon the underlying causes .
During shock body struggles to survive , calling on all its haemostatic mechanism to restore
blood flow and tissue perfusion . Therefore any patient with any disease state may be at risk
of developing shock . Nursing care of patient with shock requires ongoing systemic
assessment . Many interventions required in caring for the patient with shock call for close
collaboration with other members of health care team and a physician's order . The nurse
must anticipate such orders which need to be executed with speed and accuracy . Causes of
Circulation Failure Circulation may fail from 1. Sudden malfunction of heart This may occur as
a result of Thoracic injuries particularly chest , ic pneumothiones , crushing and laceration of
lung Obstruction of pulmonary artery by an embolus • Disturbances of lung function following
surgery and anesthesia . 3. Reduction in blood volume ( oligaemia and hypovolemia ) This
may occur from loss of • Whole blood - hemorrhage ( internal or external ) . Coronary artery
occlusion with acute myocardialischemia . Trauma with structural damage to heart . ost
operative atelectasia • Plasma - this is particularly significant in burns . . Water and
electrolytes which occurs from peritonitis , intestinal obstruction , paralytic ileus . acute dilation
of the stomach , severe diarrhoeas and vomiting 4. Miscellaneous There are number of other
conditions that may lead to shock state with low blood pressure . Faintness . Acute
anaphylaxis . • Acute adrenal deficiency ( Addison's disease ) . Over dosage of drugs e.g.
analgesics like pethidine . . Following therapy with beta blocking agents . Noxious stimuli such
as pain , if severe w cause vasodilatation particularly of splene vessels with pooling of blood
in the area . T is the mechanism of primary shock . Compensatory Mechanism Whatever is
the cause of sudden collapse ; ther certain compensatory physiological mecham which
occur . . . Posture : A patient in acute circulator failu down ; he should lie flat on the or be
head down position so that cution improve towards heart . 00 NO Contraction of skin vessels
Entrac arterioles and venules of the sko Ousua conserve the blood supply to the vita

[28/07, 7:24 pm] Ratnavimal: Stages of shork Insensitivity : A much collapsed patient usually
2. Compensatory de There are 4 stages for shock Initial stage has little pain . Large quantities
of pain relieving 3. Progressive ( or ) ( decompensate ) drugs are unnecessary and are
ineffective 4. Refractory ( Irreversible ) because they cannot be absorbed unless given by
intravenous route . 1. Initial stage Urinary secretions . These are diminished to conserve fluid i
id in the body but it is also a sign that tissue perfusion is in adequate . Heart rate accelerates :
It occurs in most forms of circulatory failure with the important exception of faint . It is an
attempt to ensure that remaining fluid is circulated as rapidly as possible thereby providing
sufficient oxygen to tissues . Subnormal temperature : This reduces the requirements of the
tissues for the diminishing nount of oxygen available . The core temperature actually is rising .
The difference between the two is a measure of the degree of shock . All these compensatory
mechanisms are temporary in their beneficial effects and if the condition of circulation is
restored to normal without delay irreversible changes set in . Pathophysiology . The
application of heat dilates the skin vessels there by aggravating the condition and should not
be used . Lack of oxygen supply and nutrient in cells Celts produce energy through anaerobic
metabolism to produce ATP 1 Low energy yielding from nutrients and produces acidic
intracellular environment Normal cell function affected , cells swells and cell membrane
become more permeable , allowing fluid and electrolytes to move out and into the cells 1
Sodium potassium pump impaired due to this Cell structure damage 1 Ultimately death of
cells Flow Chart -5.5 During this stage + inadequain perfusion 4 Cellular hypowo +
Mitochondria becomes unable to produce ATP ↓ Due to the lack of oxygen and the cell
membranes becomes damaged . Leakage to the extracellular fluid ↓ Cell performs anaerobic
respiration + Build up of lactic and pyruvic acid + Systemic metabolic acidosis Flow Chart -5.6
The process of removing these components from the cells by the liver requires oxygen
( Which is absent ? 2. Compensatory stage This stage is characterized by the body
employing physiological mechanisms including neural hormonal and bio - chemical
mechanism in an attempt to reverse the condition in the compensatory stage of shock , the
patient's blood pressure remains with in normal limits . Vasoconstriction , increased heart rate
, and increased contractility of the heart contribute to maintaining adequate cardiac output .
This results from stimulation of the sympathetic nervous system and subsequent release of
catecholamines ( epinephrine and norepinephrine ) . The patient displays the often -
described " fight or flight " response . The body shunts blood from organs such as the skin ,
kidneys , and gastrointestinal tract to the brain and heart to ensure adequate blood supply to
these vital organs . As a result , the patient's skin is cold and clammy , bowel sounds are bypo

[28/07, 7:26 pm] Ratnavimal: Clinical manifestation . . . . active , and urine output decreases
in response to the release of aldosterone and ADH ( Anti - diuretic hormone ) Normal blood
pressure . Metabolic acidosis . Respiratory alkalosis . Deep rapid respiration . Flat neck
vein . . Changes in LOC ( Level of Consciousness ) . Irritability . Restlessness , dilated
reactive pupil . Tachycardia bounding pulse . Dry warm skin . Medical management Medical
treatment is directed toward identifying the cause of the shock correcting the underlying
disorder measures such as Fluid replacement and medication therapy . Must be initiated to
maintain the adequate BP and re establish and maintain adequate tissue perfusion . 3.
Progressive stage ( de - compensating ) . 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 . Although all organ systems suffer from hypo perfusion at this stage , two events
perpetuate the shock syndrome . First , the over worked heart becomesdys functional ; the
body's inability to meet increased oxygen requirements produces ischemia ; and biochemical
mediators cause myocardial depression This leads to failure of the cardiac pump , even if the
underlying cause of the shock is not of cardiac origin . of tess fluid the heart . Even if the
underlying cause of the shock is reversed , the becakdown of the circulatory system itself
perpetuates tshock stateate , and a vicious circle entues Clinical Manifestations . Confusion
Dilated , sluggish pupil Thirst , rapid shallow breathing . Tachycardia , cool moist skin . • Slow
capillary refill , muscle weakness Hypotension . . Management To restore the perfusion by
following Method • Optimizing intravascular volume • Supporting the pumping action of the
heart . Improving the competence of the vascular system Supporting the respiratory system .
4. Refractory ( irreversible ) At this stage the vital organs have failed and the shock can no
longer be reversed . Brain damage and cell death will occur . Death of the person will occur
immediately , Clinical Manifestations Second , the auto regulatory function of the
microcirculation fails in response to numerous biochemical mediators released by the cells
resulting in increased capillary permeability , with are as of arteriolar and venous constriction
further compromising cellular perfusion . At this stage , the patient's prognosis worsens . The
relaxation of REDMI NOTE 9phincters causes fluid to leak from CAMERA Creating interstitial
edema and return . Cyanosis . Absence of bowel sounds . Immune system collapse Anuria ,
Management Management same like progressive stage Classification of Shock Shock can be
classified according to the etiology an can be described as . . Unconsciousness , absence of
reflexes . Dilated sluggish pupil , severe thirst . Acute respiratory distress syndrome
Disseminated intravascular coagulation Bradycardia 1. Hypovolemic shock . 2. Cardiogenic
shock . 3. Circulatory shock or distributive shock a . Septic shock . b . Obstructive shock . c .
Neurogenic shock . d . Anaphylactic shock .

[28/07, 7:27 pm] Ratnavimal: 1. Hypovolemic shock This is the most common type of shock ,
due to insufficient circulatory volume . In hypovolemic shock there is decrease in circulatory
volume to level that is inadequate to meet body's need for tissue oxygenation . This occurs
when there is loss in the intravascular fluid upto 15 % to 25 % . This would represent a loss of
750 to 1300 ml of blood in a 70 kg person . Common causes of shock are : exercise , fluid
loss from circulatory system e.g. bleeding , burns , and blood loss from gastro Intestinal or
severe diarrhoea Pathophysiology Relative hypovolemia ↓ Absolute hypovolemia ↓
Decreased circulating volume Decreased venous return ✓ Decreased stroke volume
Decreased cardiac output Pathophysiology Decreased cellular oxygen supply Ineffective
tissue perfusion Impaired cellular metabolism Flow Chart -5.7 2. Cardiogenic shock It is
caused by the failure of heart to pump an adequate amount of blood to vital organs . This will
lead to reduction in cardiac output . After due damage of heart muscles , heart's ability to
contract and pump blood is impaired and the supply of oxygen is in adequate for the heart
and muscles . It can be the result of myocardial infarction . Other causes include arrhythmias ,
cardiomyopathy , congestive heart failure , and cardiac valve problems . Pronary venons
trudu pro 4 Ineffective town of tood M K Demand volume byty + Decreased cardiac pulput
camping Increased pulmonary pres + Pemenary edes + Decreased oxygener Deoaned
celular oxygen supply N ineffective tissue partusion → impaired celular metacam Flow Chart -
5.8 3. Circulatory shock or Distributive shock In this there is no blood loss but the shock is
due to the dilation of the blood vessels . This displacement of blood causes a relative
hypovolemia because not enough blood returns to heart which leads to subsequent in
adequate tissue perfusion . The varied mechanisms leading to the initial vasodilatation in
circulatory shock is subdivided into septic shock . It is the most common type of circulatory
shock and caused by wide spread infection due to sepsis called by an overwhelming infection
leading vasodilatation . E.g. Infections by bacteria . They release toxins which produce
adverse biochemical , immunological and neurological effects . The most common causative
organism of septic shock is gram negative bacteria . It is sub divided into a . Septic shock . b .
Obstructive shock . c . Neurogenic shock . d . Anaphylactic shock . a . Septic Shock Septic
shock is a serious medical condition that occurs when sepsis , which is organ injury of

[28/07, 7:29 pm] Ratnavimal: damage in response to infection , leads to dangerously low
blood pressure and abnormalities in cellular metabolism . The primary infection is most
commonly by bacteria , but can also be by fungi , viruses , or parasites , and can be located in
any part of the body , but most commonly in the lungs , brain , urinary tract , skin , or
abdominal organs . It can cause multiple organ dysfunction syndrome ( formerly known as
multiple organ failure ) and death . Pathophysiology Infectious toxins Unregulated immune
system activation Profound CV pulmonary and hemostatic changes + BP + Tissue perfusion
Vessel endothelial & platelet damage Release of kinins , serotonin and histamine Capillary
permeability and vasodilation Absolute ( 3rd spacing ) and relative hypovolemia Flow Chart -
5.9 Pathophysiology b . Obstructive Shock Obstruction of blood flow results from cardiac
arrest . E.g. Cardiac tamponade , pneumothorax , pulmonary embolism , and aortic stenosis .
Spinal trauma or anaesthesia Inhibit the sympathetic nerve stimulation + Psychic trauma +
Fainting + Spinal cord injury c . Neurogenic Shock This is a very uncommon type of shock . It
is most often seen in patients who have had and extensive spinal cord injuries . The loss of
autonomic and motor reflexes below level of injury results in loss of sympathetic control . This
leads to relaxation of vessels and peripheral dilation and hypotension . This is characterized
by warm and dry skin , bradycardia , rather than other type of shock . + Loss of function below
the level of injury Venous vasodilation Decrease venous return Decreased stroke volume
Decreased cellular oxygen supply Impaired cellular metabolism Flow Chart -5.10 d .
Anaphylactic Shock Anaphylactic shock is caused by severe reaction to an allergen , antigen ,
drug or foreign protein . When a patient who has already produced antibodies to a foreign
substance develops a systemic antigen antibody reaction , antigen antibody provides mast
cells to release vasoactive substance such as histamine or bradykin that cause vasodilatation
. Pathophysiology Due to antibody responses Release of histamine Vasodilatation ↓
Increased capillary permeability + Severe broncho constriction Decreased oxygen supply and
utilization Inadequate tissue perfusion . Flow Chart -5.11

[28/07, 7:32 pm] Ratnavimal: Risk Factors Immunosuppressants , invasive procedures and
psychological trauma . Diagnosis of Shock Diagnosis of shock is essential for proper
treatment and management . An accurate history and assessment of patient symptoms must
be done before commencing treatment . . * . . . . . First Aid in Shock Conducts head to toe
examination for signs of shock . Assess neurological status of the person by assessing the
level of consciousness . Assess the cardiovascular status . Blood pressure varies with the
stages of shock . Assess for renal status . Anuria and renal failure can occur . Assess for
integumentary status . Check for skin colour , cold and clammy skin , cyanosis . Assess
gastro intestinal status . Hypo active bowel sounds . Assess for the metabolic status .
Metabolic acidosis will be there . Diagnostic Studies Blood studies reveal overly acidic blood
PH with low circulatory carbon dioxide , blood pressure monitoring . First Aid in Case of
Shock Principles Involved In First Aid 1. Remove the cause of accident from near the
causality . If possible remove the causality from danger such as burning house , room with
poisonous gases . 2. Handling the patient with due care and attention to reduce pain and to
prevent worsening of the condition . 3. Constant observation should be provided to the
causality to identify failure of breathing , bleeding and then to take appropriate measures to
treat problems . 4. Using material available at hand . 5. Clear the crowd around the causality .
6. Take the help of the by standers to give first aid . 7. Reassure the causality . 8. Transport
the causality to the doctor as early as possible . . Lay him down on his back comfortably with
head low and turned to one side except in case of head injury . Loosen the clothing around
the neck , chest and waist . Reassure the causality . 2 . consciousness . Transport the
causality to the hospital immediately . Treatment of Shock Pharmacological interventions : 1.
Hypovolemic shock . Volume expanders Keep the causality warm . Give him sips of water if
he is thirsty . Never give any alcoholic drinks . Never use hot water bag or massage the
limbs . Arrest hemorrhage by adequate measures . Check pulse , respiration and level of 5 .
Desmopression ( in case of diabetes ) Antidiarrhocal agents for diarrhoea Carcinogenic shock
Volume expanders Positive cardiac ionotropics Vasodilators Vasoactive and antiarrythmia
medication 3. Distributive shock Volume expanders Positive cardiac ionotropic agents
Vasoconstrictors 4. Obstructive shock • Volume expanders Septic shock • Broad spectrum
antibiotics 6. Neurogenic shock • Hypoglycemia - glucose is rapidly Administration of
intravenous fluids , Mo bepfl administered . Management of Shock products , and
medication . They a treating shock . These include Crystalloids : These are used for
intravensis replacement in early stages of shock og ma solution and normal saline most
commonly

[28/07, 7:33 pm] Ratnavimal: . . . . lonotropic agents : Like dopamine , dobutamine 2.

Decreased cardiac output related to and epinephrine to improve myocardial contractility ,
adequate cardiac output and improve Norsine ineffective cardiac function . Interventions
tissue perfusion . Administer IV fluide Monitor urine output Vasodilators : Nitroglycerine ,
sodium nitroprusside used to dilate the coronary arteries . Diuretics : These are used to treat
oliguria and Monitor blood pressure and pulue natu Nursing Diagnosis in Case of Shock 1.
Fluid volume deficit related to haemorrhage . Nursing interventions : Monitor the signs and
symptoms of internal bleeding . increase urine output . Antibiotics : Used to treat septic shock
because they are bactericidal . Antihistamines . Epinephrine used in an aphylactic shock .
Steroids : Used to decrease fluid shifts out of vasculature by stabilizing capillary walls ,
Sodium bicarbonate : It is used to treat metabolic acidosis that occurs as shock progress .
Bronchodilators : Like atropine , aminophyline , used to relieve bronco constriction in case of
an aphylactic shock . Check for blood pressure . Give comfortable position . Keep the patient
warm and monitor temperature hourly . Administer intravenous fluids as ordered . Monitor
urine output . een as ordered . . NOTE 9 Nursing Management in Case of Shock Maintain
ABC of the patient . Provide supplemental oxygen therapy to the patient . 4 . Do not deliver
more than 2 It . of oxygen per minute if person has history of chronic pulmonary diseases .
Monitor for ABG value to assess the patient response to oxygen therapy . Continuous
monitoring of vital signs should be done . Check for urine output of the client . Maintain
nutritional status of the patient . Administer prescribed medication to the patient . 5. Altered
peripheral tissue perfusion related Give psychological support to the patient and the relatives .
to edema from stasis of blood in the capillaries and vasoconstriction . Nursing interventions : •
3. Risk for infection related to interruption of skin integrity from invasive procedures . Nursing
interventions Administer ionotropic agents to correct ventricular function . . Take precautions
to prevent nosocomial infections . a . Wash hands frequently . b . Use aseptic techniques . c .
Monitor sites of insertion for signs of infection . d . Change the intravenous catheter every
throc days . e . Provide indwelling catheter care frequently . f . Monitor for white blood cell
count for elevation greater than 10,000 cells per mm3 . Altered nutrition less than body
requirement related to decrease oral intake . Nursing interventions : Monitor daily weight and
identify weight loss . Consult nutritionist for recommendations about dict . Check for gastric
residuals every 4 hourly ; notify the physician if it is greater than 100 ml . Monitor for
hematocrit , hemoglobin to assess the adequacy of nutritional replacement . Monitor the
extent of fluid retention . Monitor daily weight of the patient . Determine the severity of
edema . Watch for elevation in central venous pressure . Check signs and symptoms of fluid
overload . hosocialpathology Prevention of Shock Preoperative Measures Circulatory collapse
should be assessed by strenuous measures if at all possible . Preoperatively the patient .
should be as fit as possible and from the point of view from circulatory system .

[28/07, 7:35 pm] Ratnavimal: . . . . His blood should be adequate and Saba V quantity and
volume . His tissues should be adequately hydrated . He should be mobile so that there
should be no stagnation in the circulatory system . Patient should be kept warm on his
journey from ward to theatre . Post operatively Fluid and electrolyte replacement should be
done with normal saline , dextrose 5 % , plasma and rest and relief from the pain continues .
Gentle handling by nursing staff will help in prevention of shock . Diuretics like mannitol an
osmotic diuretic which is neither absorbed in the renal tubules nor metabolized . If oliguria
 persists frusemide can be given . Dopamine can be given to improve blood pressure . NOTE
9 Complications a . ARDS- ( acute respiratory distress syndrome ) In case of septic shock
patient may go for ARDS or DIC - disseminated intravascular coagulation due to in effective
perfusion and decrease venous return b . Multiple Organ Failure Due to inadequate tissue
perfusion and decreased venous return multiple organ failure occurs .

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Ratna Gurram <ratna_oct4@yahoo.com>

To:RATNAKUARI G

Thu, 28 Jul at 7:37 pm

[28/07, 7:18 pm] Ratnavimal: HAEMORRHAGE AND SHOCK Haemorrhage Haemorrhage is

the loss of blood from blood vessel . The blood loss is described as extra vacated ( outside
the vessel ) It may lie on the surface of body , on patient's clothing or on the floor . Blood may
be lost from all three types of vessels , the arteries , the veins or capillaries . The type of
haemorrhage is named accordingly , Bleeding which occurs as soon as vessel is divided is
known as primary haemorrhage . If the patient is collapsed the vessel may not bleed
immediately , but as recovery takes place , the blood pressure rises and bleeding occurs .
This is known as reactionary or intermediate haemorrhage . Haemorrhage can involve all the
blood vessels . Natural Arrest of Haemorrhage Adequate amount of calcium is required and
all the clotting factors are essential for the natural arrest haemorrhage . The blood in the
circulation is kept fluid by a fine balance between clotting and fibrinolysis . Tear in blood
vessel Collagen comes into contact with blood Damaged cell memvranes release
phospholipids Plasma proteins are activated Soluble fibrinogen in plasma Platelets form plug
over tear Flow Chart -5.4 Prothrombin ↓ Thrombin Insoluble librin ↓ Forms network of fibres to
cover the boar Factors Affecting Clotting Calcium Calcium helps in the clotting of blood .
Calcium can be displaced from the blood by 3.8 % solution of sodium citrate , acid citrate
dextrose solution , citrate REDMI NOTE 9e solution , ethylene diamine tetra AI QUAD
CAMERAAcid citrate dextrose and acid Biopsychosocialpathology

[28/07, 7:19 pm] Ratnavimal: . . citrate phosphate solutions are used to prevent clotting of
stored blood . Prothrombin It is formed from vitamin K , a fat soluble vitamin absorbed from
the small intestine . A patient suffering from obstructive jaundice will not absorb vitamin k and
there fore they may bleed if operated upon . For this reason vitamin k injection is given so as
to restore the pro thrombinlevel of blood . Fibrinogen is the precursor of fibrin . In absence of
fibrinogen severe bleeding may occur fibrinogen is . the substance which dissolves fibrin a
phenomenon known as fibrinolysis . The fibrinolytic activity blood may be increased : In
complicated obstetric cases associated with hemorrhage . After strenuous activity . In
presence of some malignant growth . The patient suffering from increased fibrinolysis will
show reduced evidence of clotting . They may be treated by neutralization of the fibrinolysis
by the administration of fibrinogen . Types of Haemorrhage According to the vessels
involved ) 1. Arterial haemorrhage . Capillary haemorrhage . Venous haemorrhage . Arterial
haemorrhage The blood loss is from artery is known as arterial haemorrhage . The blood is
bright red and spurts with the heartbeat The escape is from both ends of vessels not only
from nearer to the heart . Blood loss is more rapid from a vessel of corresponding size . 2.
Capillary haemorrhage The blood oozes over the surface of capillary and is darkish red in
color oozing over several hours can result in considerable blood loss . 3. Venous
haemorrhage The blood loss from vein is known as venous haemorrhage . The blood is dark
red in colour , there is no spurting and rate of loss is much less severe than arterial
haemorrhage . When there is injury to large vessels is be a serious matter . A further danger
is that air may be sucked into the damaged vein giving rise to fatal air embolism which the
blood and air form foam ( According to the time of wound ) 1. Primary haemorrhage . 2.
Reactionary or intermediate haemorrhage . 3. Secondary haemorrhage . 1 . Primary
haemorrhage It is immediate haemorrhage which occurs when there is damage to any blood
vessel and bleeding occurs immediately . E.g. cut on a finger or operative incision . 2.
Reactionary or intermediate haemorrhage It occurs in first 24 hours after operation . The more
severe the operation the more likely it is to occure specially after the patient has recovered
from circulatory collapse , operation on kidney , the thyroid and the breast as well as total
hysterectomy are particularly liable to be followed by reactionary or intermediate
haemorrhage . 3. Secondary haemorrhage It is due to sloughing off the wall of blood vessel .
The commonest cause is bacterial infection , but in the absence of infection it may cause by
action of enzyme e.g. acid pepsin on peptic ulcer . In this type the thinnest vessels burst first
and blood may be found on the dressings . This should be reported immediately because
larger vessels can also be eroded in another few days . ( According to clinical classification of
the haemorrhage ) I. Revealed or external . 2. Concealed or internal . 1. Revealed
haemorrhage It is a type when bleeding can be seen externally 2. Concealed haemorrhage It
is that type when bleeding cannot be externally . The bleeding occurs into one of body
cavities such as the abdomen , into the l of hollow organ such as intestine or into the tist It
may later become obvious e.g. by being vom or per rectum or by bruising and swelling of
surface of the body . Since it must be diagnosed on the presence of symptoms and signs alon
CO AI QUAD CAMERA

[28/07, 7:20 pm] Ratnavimal: Signs Symptoms of Haemorrhage Earts signs and symptoms
Restlessness and anxiety Feeling faint Coldness ( temp . slightly subnormal 98 degree
Fahrenheit ) . Slightly increased pulse . Pallor . Patient feels thirsty Signs and symptoms after
severe haemorrhage Extreme pallor face will be ashen white and clammy with cold sweat )
Child sensation temp . 97 degree Fahrenheit ) . Air hunger ( patient literally gasps for breaths
and respirations will be rapid ) . Rapid thready pulse . Extremely low blood pressure . Extreme
thirst . Diminished urine volume ( acute renal failure ) , Blindness , tinnitus and coma occur
prior to death Effects of Haemorrhage Cardiac cycle Cardiac cycle is the repetitive pumping
action that produces pressure changes that circulates blood throughout the body . It will get
disturbed i.e. it pumps less amount of blood to different organs . Cardiac output Normal
cardiac output is 5-6 l / min The total amount of blood separately pumped by each ventricle
per minute usually expressed in litre per minute . It can increased up to 30 / min at time of
exercise . It determined by multiplying the heart rate by volume blood ejected by each
ventricle during each beat . Control of External Haemorrhage Pressure will control all types of
external haemorrhages . and is called indirect pressure . It is particularly valuable in the neck
where other methods applicable . It will control venous Elevation of the limb haemorrhage .
This is a classical method dealing with a sudden haemorrhage from ruptured varicose vein of
leg d . Application of tourniquet This is rarely required except for control of a torrential
haemorrhage from the limb . A temporary tourniquet may have to be devised in sudden
emergency . It should be 3-4 inches wide . It be a hanker chief , scarf or a tic . The great
danger of tourniquet is that if it is left on for more than minutes then gangrene of the limb may
occur . time of application and removal of tourniquet should be recorded . The limb on which
tourniquet is applied should be kept elevated afterwards control edema which may result from
venous congestion . Surgical ligation : -It is necessary if the bleeding is persistent .
Coagulation : It can be used to coagulate blood from small blood vessels . According to its
severity there is a choice of methods . . Pack : It will temporarily control severe haemorrhage .
This method is used in operation theatre to control temporary or sudden haemorrhage . The
theatre nurse should always have a pack readily available for this emergency . h . Styptics :
These are also used to control bleeding . b . Digital pressure : - It is the pressure applied on
the point of artery supplying blood to the area of wound . This will control haemorrhage
temporarily . . a . Pad and bandage : This is the simple method of applying direct pressure to
a bleeding wound and is applicable to vast majority of cases . It is effective and causes no
damage . • and they act as astringents . Astringents such as snake venom or adrenaline may
be used locally in certain cases . Thrombin and gel foam can be used in some cases such as
in low pressure bleeding from veins capillaries . First Aid Treatment in Case of Severe
External Bleeding Bring the sides of wound together and press firmly . Press on the pressure
point for 10-15 min . Place the causality in comfortable position and raise the injured part and
reassure him . Apply a clean pad larger than the wound and it firmly with the palm until
bleeding becom If bleeding continues do not take off dressing but add more pads . Bandage ,
it but not too tightly . . . CAMERA

[28/07, 7:22 pm] Ratnavimal: Control of Internal Haemorrhage The following methods can be
used to control 4 . . bleeding The organ is emptied of blood clots if possible in case of severe
bleeding from bladder , a catherer is passed and bladder is emptied . The vessels are
encouraged to contract a lot of Transfusion under increased pressure saline or sodium
bicarbonate to which a few drops of adrenaline solution have been added , is of great value in
washing the organ . This can be repeated every two hourly . The use of ergometrine after the
birth of placenta is an example of stimulating the vessel to contract . Pitosin ( Oxytocin )
intravenous may be effective in control of bleeding from esophageal varies . Packing it it can
be done with gauze soaked in adrenaline is effective . Surgical ligature , surgical ligation can
be done in case of ruptured spleen . Internal pressure this may be applied by the balloon of
triluminal tube in bleeding esophageal varies or by the balloon of Foley's catheter in the
prostatectomy cavity First Aid Treatment in Case of Internal Bleeding Lay the causality down
with head low ; raise his legs by use of pillow . Keep him calm and relaxed . Reassure him .
Do not allow him to move . Keep up the body heat with thin blankets or coat . Do not give
anything to eat or drink aspiration may occur . Do not apply ice bags or hot water bottles to
chest or abdomen . Take him to the hospital as early as possible . Transport gently .
Restoration of blood volume Bloed volume can be restored by blood transfusion . Indications
for blood transfusion 1. To counteract the effect of severe haemorrhage and replace blood
loss . 2. To prevent shock in operations where blood loss is considerable such as rectal
resection , hysterectomy and arterial surgery . 3. In severe burns to make up for blood lost by
burning but only after plasma and electrolyte have been replaced . . . . . . 4. To correct from
cancer , marrow aphasia and similar condition and from slow continuous haemorrhage . In
blood transfusion as in all intravenous injections , the tubing other portion of the delivery
apparatus must be free from air In some circumstances usually of large rapid blood foss may
be necessitate blood transfusion more quickly than possible by the simple gravity drip method
. Following methods can be used : Pressure cuff - this is an inflatable cuff placed around the
bag of blood , when it is inflated it exerts external pressure on the bag of blood thus
increasing the flow of blood into the patient . Pressure pump administration : some transfusion
giving sets permits either gravity or pressure pump administration of blood . Precautions
during blood transfusion Patient and transfusion apparatus should be kept under constant
supervision . Blood must be transfused according to the rate prescribed by the doctor .
Approx.25 drops per minute . Is the casual rate of blood transfusion which means that bag is
transfused in four hours ? Sufferers from cardiac , pulmonary diseases or severe anaemia
must be transfused at the slow rate sometimes at 12 drops per minute . Half an hourly pulse
rate and temperature should be recorded . If blood transfusion is for shock , the blood
pressure and pulse rate should be recorded after each unit of blood . All the patients should
be watched for symptoms of transfusion reaction after first few ml of blood from each unit of
blood , such as allergic reaction , pyrexia , air embolism , overloading , it is etc. thrombophleb
Haemorrhages from Special special term The occurrence from special sites is O REDMI
NOTE Sites desi • Epistaxis : it is the bleeding from nose . Haemoptysis : it is the
expectoration of from lungs . AI QUAD CAMERA Haematemesis : it is the vomiting of b CO

[28/07, 7:23 pm] Ratnavimal: Malaena : it is the passage of dark blood per rectum from a site
high in intestinal tract , Haematuria : it is the presence of blood in the urine . . Haemothorax :
it is the bleeding into the chest . Haemoperitonium : bleeding into the peritoneum Menorrhagia
: excessive menstruation at normal interval . Haemopericardium : pericardium . it is the
bleeding into the Hematomyalia : it is the bleeding into the spinal cord . SHOCK Shock is a
life threatening condition . It is characterized by inadequate tissue perfusion that if untreated
results in cell death . The supply of oxygen to tissues is essential in the maintenance of life
and this can be ensured when circulatory system is functioning normally . Historical
background : In 1923 Walter and Canner first worked for all conditions of shock .
Biopsychosocialpathology . • Toxemis Effects of drugs . 2. Deficient oxygenation of blood in
lungs Amongst many causes the following are the most important • Post Definition Shock can
be defined as a condition in which systemic blood pressure is inadequate to deliver oxygen
and nutrient to supply to vital organs and cellular functions . Shock is defined as a failure of
circulation to supply adequate oxygen to the tissues . Significance of shock : shock affects all
the body systems . It may develop slowly or rapidly depending upon the underlying causes .
During shock body struggles to survive , calling on all its haemostatic mechanism to restore
blood flow and tissue perfusion . Therefore any patient with any disease state may be at risk
of developing shock . Nursing care of patient with shock requires ongoing systemic
assessment . Many interventions required in caring for the patient with shock call for close
collaboration with other members of health care team and a physician's order . The nurse
must anticipate such orders which need to be executed with speed and accuracy . Causes of
Circulation Failure Circulation may fail from 1. Sudden malfunction of heart This may occur as
a result of Thoracic injuries particularly chest , ic pneumothiones , crushing and laceration of
lung Obstruction of pulmonary artery by an embolus • Disturbances of lung function following
surgery and anesthesia . 3. Reduction in blood volume ( oligaemia and hypovolemia ) This
may occur from loss of • Whole blood - hemorrhage ( internal or external ) . Coronary artery
occlusion with acute myocardialischemia . Trauma with structural damage to heart . ost
operative atelectasia • Plasma - this is particularly significant in burns . . Water and
electrolytes which occurs from peritonitis , intestinal obstruction , paralytic ileus . acute dilation
of the stomach , severe diarrhoeas and vomiting 4. Miscellaneous There are number of other
conditions that may lead to shock state with low blood pressure . Faintness . Acute
anaphylaxis . • Acute adrenal deficiency ( Addison's disease ) . Over dosage of drugs e.g.
analgesics like pethidine . . Following therapy with beta blocking agents . Noxious stimuli such
as pain , if severe w cause vasodilatation particularly of splene vessels with pooling of blood
in the area . T is the mechanism of primary shock . Compensatory Mechanism Whatever is
the cause of sudden collapse ; ther certain compensatory physiological mecham which
occur . . . Posture : A patient in acute circulator failu down ; he should lie flat on the or be
head down position so that cution improve towards heart . 00 NO Contraction of skin vessels
Entrac arterioles and venules of the sko Ousua conserve the blood supply to the vita

[28/07, 7:24 pm] Ratnavimal: Stages of shork Insensitivity : A much collapsed patient usually
2. Compensatory de There are 4 stages for shock Initial stage has little pain . Large quantities
of pain relieving 3. Progressive ( or ) ( decompensate ) drugs are unnecessary and are
ineffective 4. Refractory ( Irreversible ) because they cannot be absorbed unless given by
intravenous route . 1. Initial stage Urinary secretions . These are diminished to conserve fluid i
id in the body but it is also a sign that tissue perfusion is in adequate . Heart rate accelerates :
It occurs in most forms of circulatory failure with the important exception of faint . It is an
attempt to ensure that remaining fluid is circulated as rapidly as possible thereby providing
sufficient oxygen to tissues . Subnormal temperature : This reduces the requirements of the
tissues for the diminishing nount of oxygen available . The core temperature actually is rising .
The difference between the two is a measure of the degree of shock . All these compensatory
mechanisms are temporary in their beneficial effects and if the condition of circulation is
restored to normal without delay irreversible changes set in . Pathophysiology . The
application of heat dilates the skin vessels there by aggravating the condition and should not
be used . Lack of oxygen supply and nutrient in cells Celts produce energy through anaerobic
metabolism to produce ATP 1 Low energy yielding from nutrients and produces acidic
intracellular environment Normal cell function affected , cells swells and cell membrane
become more permeable , allowing fluid and electrolytes to move out and into the cells 1
Sodium potassium pump impaired due to this Cell structure damage 1 Ultimately death of
cells Flow Chart -5.5 During this stage + inadequain perfusion 4 Cellular hypowo +
Mitochondria becomes unable to produce ATP ↓ Due to the lack of oxygen and the cell
membranes becomes damaged . Leakage to the extracellular fluid ↓ Cell performs anaerobic
respiration + Build up of lactic and pyruvic acid + Systemic metabolic acidosis Flow Chart -5.6
The process of removing these components from the cells by the liver requires oxygen
( Which is absent ? 2. Compensatory stage This stage is characterized by the body
employing physiological mechanisms including neural hormonal and bio - chemical
mechanism in an attempt to reverse the condition in the compensatory stage of shock , the
patient's blood pressure remains with in normal limits . Vasoconstriction , increased heart rate
, and increased contractility of the heart contribute to maintaining adequate cardiac output .
This results from stimulation of the sympathetic nervous system and subsequent release of
catecholamines ( epinephrine and norepinephrine ) . The patient displays the often -
described " fight or flight " response . The body shunts blood from organs such as the skin ,
kidneys , and gastrointestinal tract to the brain and heart to ensure adequate blood supply to
these vital organs . As a result , the patient's skin is cold and clammy , bowel sounds are bypo
[28/07, 7:26 pm] Ratnavimal: Clinical manifestation . . . . active , and urine output decreases
in response to the release of aldosterone and ADH ( Anti - diuretic hormone ) Normal blood
pressure . Metabolic acidosis . Respiratory alkalosis . Deep rapid respiration . Flat neck
vein . . Changes in LOC ( Level of Consciousness ) . Irritability . Restlessness , dilated
reactive pupil . Tachycardia bounding pulse . Dry warm skin . Medical management Medical
treatment is directed toward identifying the cause of the shock correcting the underlying
disorder measures such as Fluid replacement and medication therapy . Must be initiated to
maintain the adequate BP and re establish and maintain adequate tissue perfusion . 3.
Progressive stage ( de - compensating ) . 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 . Although all organ systems suffer from hypo perfusion at this stage , two events
perpetuate the shock syndrome . First , the over worked heart becomesdys functional ; the
body's inability to meet increased oxygen requirements produces ischemia ; and biochemical
mediators cause myocardial depression This leads to failure of the cardiac pump , even if the
underlying cause of the shock is not of cardiac origin . of tess fluid the heart . Even if the
underlying cause of the shock is reversed , the becakdown of the circulatory system itself
perpetuates tshock stateate , and a vicious circle entues Clinical Manifestations . Confusion
Dilated , sluggish pupil Thirst , rapid shallow breathing . Tachycardia , cool moist skin . • Slow
capillary refill , muscle weakness Hypotension . . Management To restore the perfusion by
following Method • Optimizing intravascular volume • Supporting the pumping action of the
heart . Improving the competence of the vascular system Supporting the respiratory system .
4. Refractory ( irreversible ) At this stage the vital organs have failed and the shock can no
longer be reversed . Brain damage and cell death will occur . Death of the person will occur
immediately , Clinical Manifestations Second , the auto regulatory function of the
microcirculation fails in response to numerous biochemical mediators released by the cells
resulting in increased capillary permeability , with are as of arteriolar and venous constriction
further compromising cellular perfusion . At this stage , the patient's prognosis worsens . The
relaxation of REDMI NOTE 9phincters causes fluid to leak from CAMERA Creating interstitial
edema and return . Cyanosis . Absence of bowel sounds . Immune system collapse Anuria ,
Management Management same like progressive stage Classification of Shock Shock can be
classified according to the etiology an can be described as . . Unconsciousness , absence of
reflexes . Dilated sluggish pupil , severe thirst . Acute respiratory distress syndrome
Disseminated intravascular coagulation Bradycardia 1. Hypovolemic shock . 2. Cardiogenic
shock . 3. Circulatory shock or distributive shock a . Septic shock . b . Obstructive shock . c .
Neurogenic shock . d . Anaphylactic shock .

[28/07, 7:27 pm] Ratnavimal: 1. Hypovolemic shock This is the most common type of shock ,
due to insufficient circulatory volume . In hypovolemic shock there is decrease in circulatory
volume to level that is inadequate to meet body's need for tissue oxygenation . This occurs
when there is loss in the intravascular fluid upto 15 % to 25 % . This would represent a loss of
750 to 1300 ml of blood in a 70 kg person . Common causes of shock are : exercise , fluid
loss from circulatory system e.g. bleeding , burns , and blood loss from gastro Intestinal or
severe diarrhoea Pathophysiology Relative hypovolemia ↓ Absolute hypovolemia ↓
Decreased circulating volume Decreased venous return ✓ Decreased stroke volume
Decreased cardiac output Pathophysiology Decreased cellular oxygen supply Ineffective
tissue perfusion Impaired cellular metabolism Flow Chart -5.7 2. Cardiogenic shock It is
caused by the failure of heart to pump an adequate amount of blood to vital organs . This will
lead to reduction in cardiac output . After due damage of heart muscles , heart's ability to
contract and pump blood is impaired and the supply of oxygen is in adequate for the heart
and muscles . It can be the result of myocardial infarction . Other causes include arrhythmias ,
cardiomyopathy , congestive heart failure , and cardiac valve problems . Pronary venons
trudu pro 4 Ineffective town of tood M K Demand volume byty + Decreased cardiac pulput
camping Increased pulmonary pres + Pemenary edes + Decreased oxygener Deoaned
celular oxygen supply N ineffective tissue partusion → impaired celular metacam Flow Chart -
5.8 3. Circulatory shock or Distributive shock In this there is no blood loss but the shock is
due to the dilation of the blood vessels . This displacement of blood causes a relative
hypovolemia because not enough blood returns to heart which leads to subsequent in
adequate tissue perfusion . The varied mechanisms leading to the initial vasodilatation in
circulatory shock is subdivided into septic shock . It is the most common type of circulatory
shock and caused by wide spread infection due to sepsis called by an overwhelming infection
leading vasodilatation . E.g. Infections by bacteria . They release toxins which produce
adverse biochemical , immunological and neurological effects . The most common causative
organism of septic shock is gram negative bacteria . It is sub divided into a . Septic shock . b .
Obstructive shock . c . Neurogenic shock . d . Anaphylactic shock . a . Septic Shock Septic
shock is a serious medical condition that occurs when sepsis , which is organ injury of

[28/07, 7:29 pm] Ratnavimal: damage in response to infection , leads to dangerously low
blood pressure and abnormalities in cellular metabolism . The primary infection is most
commonly by bacteria , but can also be by fungi , viruses , or parasites , and can be located in
any part of the body , but most commonly in the lungs , brain , urinary tract , skin , or
abdominal organs . It can cause multiple organ dysfunction syndrome ( formerly known as
multiple organ failure ) and death . Pathophysiology Infectious toxins Unregulated immune
system activation Profound CV pulmonary and hemostatic changes + BP + Tissue perfusion
Vessel endothelial & platelet damage Release of kinins , serotonin and histamine Capillary
permeability and vasodilation Absolute ( 3rd spacing ) and relative hypovolemia Flow Chart -
5.9 Pathophysiology b . Obstructive Shock Obstruction of blood flow results from cardiac
arrest . E.g. Cardiac tamponade , pneumothorax , pulmonary embolism , and aortic stenosis .
Spinal trauma or anaesthesia Inhibit the sympathetic nerve stimulation + Psychic trauma +
Fainting + Spinal cord injury c . Neurogenic Shock This is a very uncommon type of shock . It
is most often seen in patients who have had and extensive spinal cord injuries . The loss of
autonomic and motor reflexes below level of injury results in loss of sympathetic control . This
leads to relaxation of vessels and peripheral dilation and hypotension . This is characterized
by warm and dry skin , bradycardia , rather than other type of shock . + Loss of function below
the level of injury Venous vasodilation Decrease venous return Decreased stroke volume
Decreased cellular oxygen supply Impaired cellular metabolism Flow Chart -5.10 d .
Anaphylactic Shock Anaphylactic shock is caused by severe reaction to an allergen , antigen ,
drug or foreign protein . When a patient who has already produced antibodies to a foreign
substance develops a systemic antigen antibody reaction , antigen antibody provides mast
cells to release vasoactive substance such as histamine or bradykin that cause vasodilatation
. Pathophysiology Due to antibody responses Release of histamine Vasodilatation ↓
Increased capillary permeability + Severe broncho constriction Decreased oxygen supply and
utilization Inadequate tissue perfusion . Flow Chart -5.11

[28/07, 7:32 pm] Ratnavimal: Risk Factors Immunosuppressants , invasive procedures and
psychological trauma . Diagnosis of Shock Diagnosis of shock is essential for proper
treatment and management . An accurate history and assessment of patient symptoms must
be done before commencing treatment . . * . . . . . First Aid in Shock Conducts head to toe
examination for signs of shock . Assess neurological status of the person by assessing the
level of consciousness . Assess the cardiovascular status . Blood pressure varies with the
stages of shock . Assess for renal status . Anuria and renal failure can occur . Assess for
integumentary status . Check for skin colour , cold and clammy skin , cyanosis . Assess
gastro intestinal status . Hypo active bowel sounds . Assess for the metabolic status .
Metabolic acidosis will be there . Diagnostic Studies Blood studies reveal overly acidic blood
PH with low circulatory carbon dioxide , blood pressure monitoring . First Aid in Case of
Shock Principles Involved In First Aid 1. Remove the cause of accident from near the
causality . If possible remove the causality from danger such as burning house , room with
poisonous gases . 2. Handling the patient with due care and attention to reduce pain and to
prevent worsening of the condition . 3. Constant observation should be provided to the
causality to identify failure of breathing , bleeding and then to take appropriate measures to
treat problems . 4. Using material available at hand . 5. Clear the crowd around the causality .
6. Take the help of the by standers to give first aid . 7. Reassure the causality . 8. Transport
the causality to the doctor as early as possible . . Lay him down on his back comfortably with
head low and turned to one side except in case of head injury . Loosen the clothing around
the neck , chest and waist . Reassure the causality . 2 . consciousness . Transport the
causality to the hospital immediately . Treatment of Shock Pharmacological interventions : 1.
Hypovolemic shock . Volume expanders Keep the causality warm . Give him sips of water if
he is thirsty . Never give any alcoholic drinks . Never use hot water bag or massage the
limbs . Arrest hemorrhage by adequate measures . Check pulse , respiration and level of 5 .
Desmopression ( in case of diabetes ) Antidiarrhocal agents for diarrhoea Carcinogenic shock
Volume expanders Positive cardiac ionotropics Vasodilators Vasoactive and antiarrythmia
medication 3. Distributive shock Volume expanders Positive cardiac ionotropic agents
Vasoconstrictors 4. Obstructive shock • Volume expanders Septic shock • Broad spectrum
antibiotics 6. Neurogenic shock • Hypoglycemia - glucose is rapidly Administration of
intravenous fluids , Mo bepfl administered . Management of Shock products , and
medication . They a treating shock . These include Crystalloids : These are used for
intravensis replacement in early stages of shock og ma solution and normal saline most
commonly

[28/07, 7:33 pm] Ratnavimal: . . . . lonotropic agents : Like dopamine , dobutamine 2.

Decreased cardiac output related to and epinephrine to improve myocardial contractility ,
adequate cardiac output and improve Norsine ineffective cardiac function . Interventions
tissue perfusion . Administer IV fluide Monitor urine output Vasodilators : Nitroglycerine ,
sodium nitroprusside used to dilate the coronary arteries . Diuretics : These are used to treat
oliguria and Monitor blood pressure and pulue natu Nursing Diagnosis in Case of Shock 1.
Fluid volume deficit related to haemorrhage . Nursing interventions : Monitor the signs and
symptoms of internal bleeding . increase urine output . Antibiotics : Used to treat septic shock
because they are bactericidal . Antihistamines . Epinephrine used in an aphylactic shock .
Steroids : Used to decrease fluid shifts out of vasculature by stabilizing capillary walls ,
Sodium bicarbonate : It is used to treat metabolic acidosis that occurs as shock progress .
Bronchodilators : Like atropine , aminophyline , used to relieve bronco constriction in case of
an aphylactic shock . Check for blood pressure . Give comfortable position . Keep the patient
warm and monitor temperature hourly . Administer intravenous fluids as ordered . Monitor
urine output . een as ordered . . NOTE 9 Nursing Management in Case of Shock Maintain
ABC of the patient . Provide supplemental oxygen therapy to the patient . 4 . Do not deliver
more than 2 It . of oxygen per minute if person has history of chronic pulmonary diseases .
Monitor for ABG value to assess the patient response to oxygen therapy . Continuous
monitoring of vital signs should be done . Check for urine output of the client . Maintain
nutritional status of the patient . Administer prescribed medication to the patient . 5. Altered
peripheral tissue perfusion related Give psychological support to the patient and the relatives .
to edema from stasis of blood in the capillaries and vasoconstriction . Nursing interventions : •
3. Risk for infection related to interruption of skin integrity from invasive procedures . Nursing
interventions Administer ionotropic agents to correct ventricular function . . Take precautions
to prevent nosocomial infections . a . Wash hands frequently . b . Use aseptic techniques . c .
Monitor sites of insertion for signs of infection . d . Change the intravenous catheter every
throc days . e . Provide indwelling catheter care frequently . f . Monitor for white blood cell
count for elevation greater than 10,000 cells per mm3 . Altered nutrition less than body
requirement related to decrease oral intake . Nursing interventions : Monitor daily weight and
identify weight loss . Consult nutritionist for recommendations about dict . Check for gastric
residuals every 4 hourly ; notify the physician if it is greater than 100 ml . Monitor for
hematocrit , hemoglobin to assess the adequacy of nutritional replacement . Monitor the
extent of fluid retention . Monitor daily weight of the patient . Determine the severity of
edema . Watch for elevation in central venous pressure . Check signs and symptoms of fluid
overload . hosocialpathology Prevention of Shock Preoperative Measures Circulatory collapse
should be assessed by strenuous measures if at all possible . Preoperatively the patient .
should be as fit as possible and from the point of view from circulatory system .

[28/07, 7:35 pm] Ratnavimal: . . . . His blood should be adequate and Saba V quantity and
volume . His tissues should be adequately hydrated . He should be mobile so that there
should be no stagnation in the circulatory system . Patient should be kept warm on his
journey from ward to theatre . Post operatively Fluid and electrolyte replacement should be
done with normal saline , dextrose 5 % , plasma and rest and relief from the pain continues .
Gentle handling by nursing staff will help in prevention of shock . Diuretics like mannitol an
osmotic diuretic which is neither absorbed in the renal tubules nor metabolized . If oliguria
persists frusemide can be given . Dopamine can be given to improve blood pressure . NOTE
9 Complications a . ARDS- ( acute respiratory distress syndrome ) In case of septic shock
patient may go for ARDS or DIC - disseminated intravascular coagulation due to in effective
perfusion and decrease venous return b . Multiple Organ Failure Due to inadequate tissue
perfusion and decreased venous return multiple organ failure occurs .