NURSING

MANAGEMENT OF
SHOCK
SHOCK
• Condition in which widespread perfusion to the
cells is inadequate to deliver oxygen and nutrients
to support vital organs and cellular function.
(VonRueden, Bolton & Vary, 2008)

• A complex, life threatening condition or

syndrome characterized by inadequate blood flow
to the tissues and cells of the body.
WHAT HAPPENS IN SHOCK?
WHAT HAPPENS IN SHOCK?
INITIAL STAGE
• The cardiac output is insufficient to supply the
normal nutritional needs of tissues but not low
enough to cause serious symptoms
COMPENSATORY STAGE
• The cardiac output is reduced further but due to
compensatory vasoconstriction, the BP tends to
remain within the normal range.

• Blood flow to the skin and kidney decrease while

blood flow to CNS and myocardium is maintained.
PROGRESSIVE STAGE
• The unfavorable change become more and more
apparent – falling BP, increase vasoconstriction,
increased heart rate and oliguria.

• If compensatory mechanisms are unable to cope with

the reduced output, shock becomes progressively
more severe and passed onto the next stage.
IRREVERSIBLE STAGE
• In this stage of shock, no type of therapy can
save the patient’s life – BP decreases, blood
volume can be normal in this stage.

• Fluid transfusion may restore BP only

temporarily.

• BP still declines until eventually DEATH

occurs.
CLINICAL FINDINGS
IN SHOCK
MANIFESTATIONS AMONG ELDERLY
HYPOVOLEMIC SHOCK
• Caused by reduction of
fluid 15% to 30% of blood
(750- 1500ml of blood in
70kg person).

 Loss of blood externally by

blooding or shifts of
internal fluids by
dehydration AND severe
edema
 C AUSES OF
HYPOVOLEMIC SHOCK
• SEVERE BLEEDING
• SEVERE PERSISTENT VOMITING
• SEVERE DIARRHEA
• SEVERE EDEMA or ASCITES
• DIURESIS
• SEVERE BURNS
• INADEQUATE FLUID
PATHOPHYSIOLOGY OF
HYPOVOLEMIC SHOCK
CLINICAL MANIFESTATIONS OF
HYPOVOLEMIC SHOCK
• Hypotension
• Cold clammy skin
• Pallor
• Tachycardia
• Tachypnea
• Restlessness
• Anxiety
• Weakness
• Altered sensorium
• Oliguria <20 ml/hr – possibly in progressive stages
CLINICAL MANIFESTATIONS OF
HYPOVOLEMIC SHOCK
• Metabolic acidosis
• Nausea, vomiting thirst
• Irritability
• Shallow respirations
• Increased serum electrolyte, blood glucose,
serum creatinine, sodium, potassium
• Unconsciousness and unresponsive to pain
MANAGEMENT OF
HYPOVOLEMIC SHOCK
• Treatment of underlying cause (stop bleeding by
pressure of surgery for internal organs), medication to
treat diarrhea.

• Fluid and blood replacement: use large vein and two IV

lines, use CRYSTALLOID solutions or albumin, blood
products (PRBCs for hemoglobin to carry O2 to tissues).

• Modified Trendelendburg position

• Pharmacologic therapy: vasopressors, antimotility,

antiemetic
MANAGEMENT OF
HYPOVOLEMIC SHOCK
MANAGEMENT OF
HYPOVOLEMIC SHOCK
• Administering blood and
fluids safely
• Oxygenation delivery
• Comfort and rest provided
to patient
CARDIOGENIC SHOCK
• occurs when the heart’s ability to pump
blood is impaired.

• Results from inadequate perfusion of

body tissue with oxygenated blood that is
insufficient to sustain life.

• CARDIAC OUTPUT is decreased.

 CAUSES OF
CARDIOGENIC SHOCK
• Acute myocardial infarction
• Congestive heart failure
• Pulmonary embolism
• Cardiac tamponade
• Cardiomyopathy
CLINICAL MANIFESTATIONS OF
CARDIOGENIC SHOCK
• Same with hypovolemic shock
• DYSRHYTHMIA
• Chest pain
• Respiratory distress
• Ventricular failure
• Mechanical complication during
ventricular septal rupture
MANAGEMENT OF
CARDIOGENIC SHOCK
• Oxygen delivery
• Thrombolytic therapy
• Correction of acidosis
• Antidysrhythmic agents
• Pain management
• Hemodynamic monitoring
• ECG monitoring
• IV fluid administration
• Reduce anxiety and ensure comfort
SEPTIC SHOCK
• Most common type of
circulatory shock
caused by widespread
infection
• Despite the increased
sophistication of
antibiotic therapy, the
incidence of septic
shock has continued to
rise during the past 60
years.
CAUSES OF
SEPTIC SHOCK
• Invasive procedures
• Older population
and resistance to
antibiotics
• Virus, fungi, gram
negative bacteria
• Chronic diseases:
DM, AIDS
• Improper wound
care and
management
• Severe burns
• UTI, abortion
CLINICAL MANIFESTATIONS
OF SEPSIS
CLINICAL MANIFESTATIONS
OF SEPSIS
EARLY TREATMENT OF
SEPSIS PATIENTS
CLINICAL MANIFESTATIONS
SEPTIC SHOCK
• HYPERTHERMIA
• Severe headache
• Anuria
• Respiratory distress
• Decreased cardiac output
• Hypotension
• Skin cold and pale
• Multiple organ failure
MANAGEMENT OF
PATIENTS IN SEPTIC SHOCK
• Fluid replacement therapy
• Nutrition therapy (enteral nutrition possibly)
• Use aseptic technique
• Monitor injection sites for infection
• Assess culture and sensitivity from any sites
• Administer antibiotic therapy
• Assess clinical manifestations of infection
 NEUROGENIC SHOCK
• Inability of nervous system to control
dilation of blood vessels.
• Neurogenic shock results from
generalized vasodilation and loss of
vasomotor tone due to
• Massive increase in vascular capacity
• Pooling of blood in periphery
• Decreased venous return to heart
 PATHOLOGY OF
NEUROGENIC SHOCK
• Vasodilation occurs when loss of balance
between parasympathetic and sympathetic
stimulation
• Sympathetic stimulation causes
vasoconstriction
• BLOOD VOLUME is normal but
parasympathetic stimulation causes
vasodilation and fluid shifts occur
CAUSES OF NEUROGENIC SHOCK
• Brain traumatic injury
• Brain damage
• Spinal cord injury
• Deep spinal anesthesia
• During lumbar puncture
• Severe pain, hypoglycemia,
emotional stress
• Drugs causing vasomotor
center depression
• Anti snake venom
CLINICAL MANIFESTATIONS OF
NEUROGENIC SHOCK
• Nervousness
• LOC changes
• Confusion
• Skin warm but dry
• Respiratory depression
• hypotension
 MANAGEMENT OF
NEUROGENIC SHOCK
• Control spinal cord injury clinical manifestations

• Position patient carefully in spinal anesthesia

• Elevate HOB when using spinal anesthesia to prevent

agent from spreading to the brain

• Monitor patient closely for signs of internal bleeding that

could lead to hypovolemic shock

• Apply anti-embolic stocking and check for lower

extremity pain and tenderness/redness
ANAPHYLACTIC SHOCK
• Occurs rapidly as a result
of antigen exposure or
severe allergic reaction.
• It is life threatening.
ANAPHYLACTIC SHOCK
ANAPHYLACTIC SHOCK
ANAPHYLACTIC SHOCK
MANAGEMENT OF
ANAPHYLACTIC SHOCK
• Stop antibiotic/remove the cause
• Give epinephrine, antihistamine STAT
• Nebulize patient
• Infuse IV fluids
• Close monitoring for allergens
• Assess previous reaction and response
• END of LECTURE