Shock

Dr. Manal Ismail

Professor of Critical Care and Emergency Nursing
 Outline

1. Define Shock

2. Stages of shock

3. Types of shock

4. Prevention of Shock

5. Nursing Care of patients with shock

 Shock Definition

Shock is a condition in which tissue perfusion is inadequate to

deliver oxygen and nutrients to support vital organ and cellular
function
What happens in shock?
Factors That Affecting The
Hemodynamic Conditions
 STAGES OF SHOCK

a) INITIAL STAGE: the cardiac output is insufficient to supply the

normal nutritional needs of tissues but not low enough to cause
serious symptoms

b) 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.
 Cont.,

C) PROGRESSIVE STAGE: The unfavorable change become more

and more apparent falling BP , increased vasoconstriction,
increased heart rate and oliguria .If compensatory mechanism
are unable to cope with the reduce output shock becomes
progressively more severe and passed onto .

d) IRREVERSIBLE STAGE: In this stage of shock no type of

therapy can save the patients life , BP decreases, blood volume
can be normal in this stage. Fluid transfusion may restore BP
only temporary, BP decline until DEATH occurs.
 TYPES OF SHOCK

Hypovolemic Cardiogenic Distributive

shock shock shock

Neurogenic Septic shock Anaphylactic

shock shock
 HYPOVOLEMIC SHOCK
• It occurs when a significant amount of fluid is lost from the
intravascular space, fluid may be blood, plasma or
electrolytes solution .It is the most common type of shock.
• CAUSES;
a) Severe bleeding e.g., severe polytrauma, hematemesis.
b) Severe persistent vomiting e.g. ; minor and major disorder
in pregnancy
c) Severe diarrhea e.g. ; cholera
d) Severe edemas or ascites ,peritonitis , pancreatitis
e)Diuresis f)Severe burns g)Inadequate fluid
 Cont.,
• CLINICAL FEATURE;
• BP decrease
• Skin cold and clammy
• Pallor
• Tachycardia ,
Tachypnea
• Restlessness , Anxiety
, Weakness
• Altered sensorium
• Oliguria
 progressive
• Metabolic acidosis ;PaCO2 and HCO3 decreased
• Nausea and vomiting , thirst
• Pulse rapid , weak and thready
• Irritability
• Dilated pupils with decrease response to light
• Respiration rate rapid >20b/min, shallow
Progressive:
• Cyanosis ;
• Increased serum electrolyte ,blood glucose , serum creatinine ,
sodium, potassium
• Unconsciousness and unresponsive to pain Anuria , renal failure
 CARDIOGENIC SHOCK

Cardiogenic shock occurs

when the heart’s ability to
pump blood is impaired.

This is a condition that

results from inadequate
perfusion of body tissue with
oxygenated blood that is
insufficient to sustain life
,cardiac output is decreased.
 Causes

1. Acute myocardial infraction resulting in massive damage to

myocardium.
2.CHF ,Pulmonary embolism
3. Cardiac tamponade
4. Septicemia
Clinical features
1. shock
2. Dysrythmias,chest pain
3. Left and/or Right ventricular failure
 Distributive shock

Shock caused by a reduction in systemic vascular resistance

(SVR), differs in its presentation as the patient is unable to mount
a normal compensatory response.
Whether this is due to
• systemic infection,
• anaphylaxis
• spinal nerve damage,
the defining feature is that the patient will feel peripherally
warm due to vasodilation rather than cool as in the other type
 A. NEUROGENIC SHOCK

• Neurogenic shock results from

generalized vasodilation and loss
of vasomotor tone leading to:
a. Massive increase in vascular
capacity
b. Pooling of blood in periphery
c. Decreased venous return to
Heart.
 Causes

1. Brain traumatic injury, vasomotor depression

2. Spinal cord injury
3. Deep spinal anesthesia
4. During Lumper puncture
5. Severe pain, emotional stress
Clinical features:
1. Shock
2. Skin warm Drugs causing vasomotor center depression
 B. ANAPHYLACTIC SHOCK
Anaphylaxis is a life-threatening systemic
hypersensitivity reaction due to contact with an
allergen.
Causes
1. Drugs: penicillin , radio contrast, anesthetic
drugs, iron injectable . . etc.
2. Blood transfusion
3. Stings and snake bite
Clinical features
1. Shock
2. Cough, wheezing, laryngeal edema,
bronchospasm 3. Urticaria, angioedema , pruritus
 C. SEPTIC SHOCK
It is the most common type of
shock and caused by widespread
infection.
Causes
1. UTI , abortion
2. Improper wound care and
management
Clinical features
1. Shock
2. 2. Hyperthermia
NURSING MANAGEMENT
 Prevention of Shock
• Hypovolemic shock can be prevented in some instances by
closely monitoring patients who is at risk for fluid deficit and
assisting with fluid replacement before Intravascular volume is
depleted.
• Safe administration of prescribed fluids and medication and
proper documentation, monitoring sign of complication and side
effects and early reporting
• Safe blood administration Blood sample should be obtained
for CBC, cross match grouping. Patient receiving BT must be
closely monitored for adverse effect.
 Cont.,

• Proper care of wound and using aseptic technique in any

invasive procedures.

• Proper pain management.

• Skin test should be done before giving antibiotics as

anaphylaxis reaction may occur.

• Early detection and management of cardiac diseases.

 NURSING ASSESSMENT
CABs: Circulation, Airway, breathing, and Focused assessment of
tissue perfusion;
• Vital signs
• Peripheral pulses
• Level of consciousness
• Capillary refill
•Skin (e.g., temperature, color, moisture)
•Urine output
•Brief history Taking
•Events leading to shock
•Onset and duration of symptoms , Allergies
 NURSING CARE OF SHOCK

• Turn the person on his or her side to prevent choking if the

person vomits or bleeds from the mouth.

• Keep the person warm and comfortable and cover the person
with a blanket.

• NPO: Even if the person complains of thirst, give nothing by

mouth. If the person wants water, moisten the lips.
 Cont.,

• Reassure the person. Make him or her as comfortable as you

can.
• Fluid and blood replacement: Open IV line on both hands with
two wide bore cannula and start fluid rapidly as advised.
• Administer oxygen via face mask.
• Identify the cause and treat accordingly.
• Vasoactive medications to improve cardiac contractility, i.e.
Dopamine, Dobutamine, Noradrenaline.
• Other care are same as the care of unconscious patient.
 References

Tintinalli J. Tintinalli's Emergency Medicine: A •

Comprehensive Study Guide. 7th edition. McGraw-Hill
Professional. 2010.
Holmesa C L. and Walle K R. Vasoactive drugs for •
vasodilatory shock in ICU. Lippincott Williams & Wilkins.
2009.
Morton PG, Fontain DK, HudakGM, Gallo BM. Critical care •
nursing: A holistic approach. Lippincott Williams & Wilkins.
2005