Shock and Multiple Organ

Dysfunction Syndrome

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Shock
• Condition in which tissue perfusion is inadequate to
deliver oxygen, nutrients to support vital organs, cellular
function
• Shock Affects all body systems

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Classifications of Shock
• Hypovolemic: shock state resulting from decreased
intravascular volume due to fluid loss
• Cardiogenic: shock state resulting from impairment or
failure of myocardium
• Septic: circulatory shock state resulting from
overwhelming infection causing relative hypovolemia
• Neurogenic: shock state resulting from loss of
sympathetic tone causing relative hypovolemia
• Anaphylactic: circulatory shock state resulting from
severe allergic reaction producing overwhelming systemic
vasodilation, relative hypovolemia

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Multiple Organ Dysfunction Syndrome

• Presence of altered function of two or more organs in

acutely ill patient such that interventions are necessary
to support continued organ function

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Cellular Effects of Shock

Figure 14-1

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Compensatory Mechanisms in Shock

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Stages of Shock
• Compensatory
• Progressive
• Irreversible

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Compensatory Stage of Shock

• SNS causes vasoconstriction, increased HR, increased heart
contractility
– This maintains BP, CO
• Body shunts blood from skin, kidneys, GI tract, resulting in
cool, clammy skin, hypoactive bowel sounds, decreased urine
output
• Perfusion of tissues is inadequate
• Acidosis occurs from anaerobic metabolism
• Respiratory rate increases due to acidosis, may cause
compensatory respiratory alkalosis
• Confusion may occur

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Progressive Stage of Shock
• Mechanisms that regulate BP can no longer compensate,
BP and MAP decrease
• All organs suffer from hypoperfusion
• Vasoconstriction continues further compromising cellular
perfusion
• Mental status further deteriorates from decreased
cerebral perfusion, hypoxia

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Progressive Stage of Shock (cont’d)

• Lungs begin to fail, decreased pulmonary blood flow
causes further hypoxemia, carbon dioxide levels
increase, alveoli collapse, pulmonary edema occurs
• Inadequate perfusion of heart leads to dysrhythmias,
ischemia
• As MAP falls below 70, GFR cannot be maintained
– Acute renal failure may occur
• Liver function, GI function, hematological function all
affected
• Disseminated intravascular coagulation (DIC) may occur
as cause or complication of shock

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Irreversible Stage of Shock
• At this point, organ damage so severe that patient does
not respond to treatment and cannot survive
• BP remains low
• Renal, liver function fail
• Anaerobic metabolism worsens acidosis
• Multiple organ dysfunction progresses to complete organ
failure
• Judgment that shock is irreversible only made in
retrospect

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Question

Which stage of shock is characterized by a normal blood

pressure?
A. Initial
B. Compensatory
C. Progressive
D. Irreversible

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 Answer
B. Compensatory
Rationale: In the compensatory stage of shock, the BP
remains within normal limits. In the second stage of
shock, the mechanisms that regulate BP can no longer
compensate and the MAP falls below normal limits.
Patients are clinically hypotensive; this is defined as a
systolic BP of less than 90 mm Hg or a decrease in
systolic BP of 40 mm Hg from baseline. The irreversible
(or refractory) stage of shock represents the point along
the shock continuum at which organ damage is so severe
that the patient does not respond to treatment and
cannot survive. Despite treatment, BP remains low.

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For All Types of Shock

• Early identification, timely treatment
• Identify, treat underlying cause
• Sequence of events for different types of shock will vary
– Management, care of patient will vary

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General Management Strategies in Shock
• Fluid replacement
– Crystalloid, colloid solutions
– Complications of fluid administration
• Vasoactive medication therapy
• Nutritional support

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Pathophysiology of Hypovolemic Shock

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Hypovolemic Shock
• Medical management
– Treatment of underlying cause
– Fluid, blood replacement
– Redistribution of fluid
– Pharmacologic therapy
• Nursing management
– Administering blood, fluids safely
– Implementing other measures

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Modified Trendelenburg

Figure 14-4

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Pathophysiology of Cardiogenic Shock

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Cardiogenic Shock
• Medical management
– Correction of underlying causes
– Initiation of first-line treatment
• Oxygenation
• Pain control
• Hemodynamic monitoring
• Laboratory marker monitoring
• Fluid therapy
• Mechanical assistive devices

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Cardiogenic Shock: Pharmacologic
Therapy
• Dobutamine
• Nitroglycerin
• Dopamine
• Other vasoactive medications
• Antiarrhythmic medications

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Cardiogenic Shock: Nursing Management

• Preventing cardiogenic shock
• Monitoring hemodynamic status
• Administering medications, IV fluids
• Maintaining intra-aortic balloon counter pulsation
• Ensuring safety, comfort

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Circulatory Shock
• Septic shock
• Neurogenic shock
• Anaphylactic shock

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Pathophysiology of Circulatory Shock

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Management of All Types of Shock
• Fluid replacement to restore intravascular volume
• Vasoactive medications to restore vasomotor tone,
improve cardiac function
• Nutritional support to address metabolic requirements

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Fluid Replacement
• Crystalloids: 0.9% normal saline, lactated Ringer’s
solution, hypertonic solutions (3% hypertonic saline)
• Colloids: albumin, dextran (dextran may interfere with
platelet aggregation)
• Blood components for hypovolemic shock
• Complications of fluid replacement include fluid overload,
pulmonary edema

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 Question
Is the following statement true or false?

The most common colloid solution used to treat

hypovolemic shock is 5% albumin.

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Answer
True

Rationale: The most common colloid solution used to treat

hypovolemic shock is 5% albumin.

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 Question
Is the following statement true or false?

The primary goal in treating cardiogenic shock is to limit

further myocardial damage.

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Answer
False

Rationale: The primary goal in treating cardiogenic shock is

not to limit further myocardial damage. The primary goal
in treating cardiogenic shock is to treat the oxygenation
needs of the heart muscle.

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 Question
When caring for a patient in hypovolemic shock who is
receiving large volumes of IV isotonic fluids, the nurse
should monitor for symptoms of:
A. Hyperthermia
B. Pain
C. Pulmonary edema
D. Tachycardia

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Answer
C. Pulmonary edema

Rationale: The nurse should monitor for circulatory

overload and pulmonary edema when large volumes of
fluids are administered intravenously. Hypothermia may
occur with large volumes of fluid that are not warmed.
Pain would not be seen in hypovolemic shock but may
occur with cardiogenic shock. Tachycardia would be
expected in hypovolemic shock.

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Vasoactive Medications
• Used when fluid therapy alone does not maintain MAP
• Support hemodynamic status; stimulate SNS
• Check vital signs frequently; continuous monitoring of
vital signs every 15 minutes or more often
• Give through central line if possible
– Extravasation may cause extensive tissue damage
• Dosages usually titrated to patient response

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Nutritional Therapy
• Nutritional support needed to meet increased metabolic,
energy requirements prevent further catabolism, due to
depletion of glycogen
• Support with parenteral or enteral nutrition
• GI system should be used to support its integrity
• Administration of glutamine
• Administration of H2 blockers or proton-pump inhibitors

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Psychological Support of Patients and
Families
• Anxiety
• Support of coping
• Patient, family education
• Communication
• End-of-life issues
• Grief processes

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Multiple Organ Dysfunction Syndrome

• Presence of altered function of two or more organs in an
acutely ill patient such that interventions necessary to
support continued organ function
• Primary or secondary
• High mortality rate; 75%
• Treatment
– Controlling initiating event
– Promoting adequate organ perfusion
– Providing nutritional support
• Promoting communication
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• Decreased tissue perfusion
• Decreased cardiac output
• Fluid volume deficit
• Anxiety

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• A client’s nursing diagnosis is Fluid Volume

Deficit Related to Excessive Fluid Loss.
Which action related to fluid management
should be delegated to a nursing
assistant?
a. Administer IV fluids as prescribed by the
physician.
b. Provide straws and offer fluids between meals.
c. Develop plan for added fluid intake over 24
hours.
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d. Teach family members to assist client with fluid

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• The client also has the nursing diagnosis
Decreased Cardiac Output related to
decreased plasma volume. Which finding
on assessment supports this diagnosis?
a. Flattened neck veins when client is in supine
position.
b. Full and bounding pedal and post-tibial pulses.
c. Pitting edema located in feet, ankles, and
calves.
d. ShallowCopyright
respirations with
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auscultation.

• Which of these clients in the neurologic

ICU will be best to assign to an RN who
has floated from the medical unit?
a. A 26-yr-old client with a basilar skull fracture
who has clear drainage coming out of the nose.
b. A 42-yr-old client admitted several hours ago
with a headache and diagnosed with a ruptured
berry aneurysm.
c. A 46-yr-old client who was admitted 48 hours
ago with bacterial meningitis and has an
antibiotic dose due.
d. A 65-yr-old client with an astrocytoma who has
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just returned to the unit after having a

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• You are monitoring blood administration to
a trauma victim in shock. Which of the
following assessments indicate a
dangerous transfusion reaction?
a. Red raised areas on the skin that itch
b. An increase in body temp by 3 degrees
c. Decreasing BP and dyspnea
d. Increasing BP and pulse

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• A 17 yr old male presents to the Emergency

Department via EMS. He was riding his dirt
bike on a cross country trail when he struck
a tree. He has bruising over his right upper
quadrant and is complaining of severe pain
with palpation. VS are 86/50, HR 122, RR
24 T 96.5 and his O2 sat is 94% on room
air. The patient is cool and sweaty and
appears confused.

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Hypovolemic Shock

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• A listless 2 year old is rushed into the
Emergency Department in his mother’s arms.
She relates he was eating a peanut butter cookie
when he began crying and rubbing his mouth.
Within seconds his lips and eyes became swollen
and he developed a raised rash over his trunk
and extremities. His breathing became labored
and audible wheezing could be heard. His
mother states he has never eaten nuts before.
VS are BP 86/33 P185 R52 T 97.6 axillary and
O2 Sat 88% on room air

Distributive - Anaphylaxis
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• A 72 year old male is brought to the

Emergency Department via EMS. He
sustained a 10 foot fall from a ladder
onto his back. He is awake and alert. BP
is 80/50 P 55 R 26 T 96.6 O2 sat 91% on
room air The patient complains of mid
low back pain and decreased ability to
move his legs. His legs are pink, warm
and dry but you notice above his
waistline that he is pale, cool and
clammy.

DistributiveCopyright
- Neurogenic
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• A 55 yr old diabetic female presents to the Emergency
Department complaining of bilateral flank pain, foul
smelling urine, vomiting and chills for 3 days. She is
lethargic and her skin is pale and cool. VS are BP
90/60 P 112 T 96.6 R22 O2 sat 93% room air

Septic Shock

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• A 68 yr old male presents to the Emergency

Department complaining of severe
midsternal chest pain that radiates to his
left arm and jaw. He reports shortness of
breath, nausea and dizziness. He is
lethargic, pale and diaphoretic with mottled
extremities. Rales are heard bilaterally
upon auscultation of his lung sounds. VS
are 72/50 P 118 T 96.8 R 22 O2 sat 89%
on room air
Cardiogenic Shock
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