Shock

Rahayu Setyowati
Bachelor of Nursing, PADJADJARAN UNIVERSITY INDONESIA
Outline
 Definition
 Phatophysiology
 Stages
 Classes of Shock
 Clinical Presentation
 Management
 Nursing care Plan
 DEFINITION
 A physiologic state characterized by
 Inadequate tissue perfusion

 Clinically manifested by
 Hemodynamic disturbances
 Organ dysfunction
 PATHOPHYSIOLOGY

 Imbalance in oxygen supply and demand

 Conversion from aerobic to anaerobic
metabolism
 Appropriate and inappropriate metabolic and
physiologic responses
Cont ..Pathophysiology
 Cellular changes
 Cell lack an adequate blood supply  must
produce energy through anaerobic metabolic.
 Swell and membran more permeable 
sodium potassium pump impaired  damage
cell  death of the cell
 Vascular respon
 Local regulatory mechanisms  stimulate
vasodilation or vasocontriction
Cont ..Pathophysiology
 Blood Pressure regulation
tissue and organ perfusion depend Mean
Arterial Pressure (MAP), MAP must exceed
65 mmHg.

MAP = DP + 1/3 (SP – DP)

or pulse pressure (indicated stroke volume)

PP = SP – DP (normal 30-40 mmHg)
 STAGES OF SHOCK

 Characterized by three stages

 Compensated stage
 Progressive stage
 Irreversible stage
Cont ..stage

Compensated shock
 tachycardia, vasoconstriction, normal BP, skin
cool and clamy, bowel sound hypoactive, urine
output decrease, confusion, respiratory
alkalosis
Progressive shock
MAP falls, BP low, tachycardia > 150bpm, rapid
respiration, lethargy, urine output < 0,5ml/kg/h,
metabolic acidosis
Cont ..stage
Irreversible stage
shock with organ damage and cannot
survive. Clinical manifestation : asystole,
require intubation and ventilator, BP requires
pharmacologic support, anuria, unconscious,
acidosis.
 CLASSIFICATION
 Schemes are designed to simplify complex
physiology
 Major classes of shock
 Hypovolemic
 Cardiogenic
 Distributive (septic , anaphylactic and
neurologic)
Hypovolemic Shock

 Results from decreased intravascular volume

 Etiologic classes
 Hemorrhage - e.g. trauma, GI bleed, ruptured
aneurysm
 Fluid loss - e.g. diarrhea, vomiting, burns
Hypovolemic Shock
 Hemorrhagic Shock
Parameter I II III IV

Blood loss (ml) <750 750–1500 1500–2000 >2000

Blood loss (%) <15% 15–30% 30–40% >40%

Pulse rate (beats/min) <100 >100 >120 >140

Blood pressure Normal Decreased Decreased Decreased

Respiratory rate (bpm) 14–20 20–30 30–40 >35

Urine output (ml/hour) >30 20–30 5–15 Negligible

CNS symptoms Normal Anxious Confused Lethargic

Crit Care. 2004; 8(5): 373–381.

Cardiogenic Shock

 Results from pump failure (inability to

contract and pump blood)
 Decreased systolic function
 Resultant decreased cardiac output
 Etiologic categories
 Myopathic
 Arrhythmic
 Mechanical
 Extracardiac (obstructive)
Distributive Shock : septic shock

 Caused by widespread infection

 => shock associated with sepsis,
characterized by symptom of sepsis plus
hypotension and hypoperfusion
 Risk factor
 immunosuppression
 Extreme of age (<1yr / > 65yr)
 Chronic illness
 Invasive procedure
Distributive Shock
 Septic Shock

SIRS 2 or more of the following:

Temp >38 or <36
HR > 90
RR > 20
WBC > 20K
>10% bands

Sepsis SIRS in the presence of suspected or documented infection

Severe Sepsis Sepsis with hypotension, hypoperfusion, or organ dysfunction

Septic Shock Sepsis with hyotension unresponsive to volume resuscitation,

and evidence of hypoperfusion or organ dysfunction

MODS Dysfunction of more than one organ

Distributive Shock : Anaphylactic

 Rapidly and life threatening

 Occure in patient already exposed to an
antigen and who have developed antibodies to
it, it can often be prevented.
 Becaused by a severe allergic reaction when
patien who have already produced antibodies
to a foreign subtance (antigen) develop a
systemic antigen-antibody reaction.
 Antibody-antigen reaction  vasoactive
substance (histamin, bradikinin)  widespread
vasodilatation and capillary permeability.

 Risk factor
- antibiotic sensitivity
- tranfusion reaction
- bee sting alergy
- severe alergy to some food or medication
Distributive Shock : neurologic
 Occurs as a result of a loss parasympatic
stimulation, that cause vasodilation lasting
and extended period

 Risk Factor
- spinal cord injury
- spinal anesthesia
- depressant action of medication
- glucose deficiency
 OVERALL MANAGEMENT
STRATEGIES IN SHOCK

 Oxygen
 Fluid replacement to restore intravascular volume
 Vasoactive medications to restore vasomotor
tone and improve cardiac function
 Nutritional support to address the metabolic
requirements that are often dramatically
increased in shock
 Maintenance body temperature
Oxygen

 Airway maintenance is priority

 Oxygen is administered
Fluid replacement
 Crystalloid, colloid solution or blood
components
 The most common side effects 
cardiovascular overload and pulmonary edema
 Must be monitored : urinary output, change in
mental status, skin perfusion, change in vital
sign, lung sounds (ex: crackles pulmonary
edema).
 monitoring haemodinamic  CVP
Vasoactive medications
 To improve the patient hemodinamic when
fluid therapy alone cannot maintain adequate
MAP
 Help to increase the strength of myocardial
contractility, regulate the heart rate, initiate
vasoconstiction
 Include : alpha adrenergic receptor and beta
adrenergic receptor = ephineprin,
norephineprin, dopamin, dobutamin
Nutritional support
 Increases metabolic rates  increase energy
and calorie requirement.
 Break down lean body mass
 Perenteral or enteral nutritional support
 Blood supplay decreases, stress ulcer can
occur  antacid, histamin -2 blocker
(ranitidine) to prefent ulcer formation by
inhibiting gastric acid secretion or increasing
gastric pH
Body temperature

 Hypotermia depresses cardiac contractility

and impairs cardiac output
 Temperature is must be monitored
 Infused rapidly  hypotermia
 Patient should be kept warm and comfortable
(Hypovolemic Shock)
 Control severe external bleeding
 Fluid crystalloid (RL or NS 0,9%), colloid
(Albumin) and blood replacement 
monitor (edema pulmonary, IO chart, vital
sign)
 Elevate lower extremities
 Trendelenburg position
 Monitoring fluid replacement complication
 Oxygen is administered
 Vasoactive medication
(Cardiogenic Shock)
 Supine, or head and shoulders slightly
elevated
 Do NOT elevate lower extremities
 O2
 Controlling chest pain (nitroglicerin or
morphine)
 Providing selected fluid support
 Administering vasoactive medications
 Controlling heart rate
(Cardiogenic Shock)
 Treat the underlying cause if possible
 Treat rate, then rhythm, then BP
 Correct bradycardia or tachycardia
 Correct irregular rhythms
 Treat BP
 Cardiac contractility

 Dobutamine, Dopamine
 Peripheral resistance
 Dopamine, Norepinephrine
 Septic
Airway  ETT may be necessary
Breathing  high flow O2
Circulation  intravascular fluid (RL)
Hypotension  dopamin
Antibiotic therapy
Severe acidosis  Sodium Bicarbonat
Maintain body temperature
 Anaphylaxis
Airway  anticipate intubation
Breathing  O2
Circulation  intravascular fluid
Epinephrine if severe respiratory distress or
laryngel edema
Suppress inflammatory response
 Antihistamines (diphenhydramine)

 Corticosteroids (bronchospasm & vasodilation)

Key Issues In Shock
 Falling BP = LATE sign of shock
 BP is NOT same thing as perfusion
 Pallor, tachycardia, slow capillary refill =
Shock, until proven otherwise
NURSING CARE PLAN FOR THE PATIENT IN
SHOCK

NURSING DIAGNOSIS :

Altered tissue perfusion releated to decrease

blood volume (hypovolemia shock), decrease
myocardial contractility (cardiogenic shock),
widespread vasodilation (septic and
anaphylactic shock)
Cont ..NCP

 PATIENT OUTCOMES
- alert
- skin warm and dry with good turgor
- capillary refill less than 2 seconds
- jugular neck vein normal
- normal vital sign
- pulse regular
- balance intake and output
- urine output 30 – 50 ml/ hrs
- absence of complication
Cont ..NCP

 INTERVENTION
- maintain patent airway
- monitor Oxygenation
- establish intravenous access, use large bore
catheters
- CVP if possible
- control bleeding
- administer fluid
- consider warming fluids before infusion
Cont ..intervention

- replace blood if needed

- evaluate patient response : vital sign, level of
consciousness, serum and urine laboratory values
- monitor of fluid overload
- monitor cardiopulmonary status
- monitor level of consciousness
- monitor fluid balance : I&O
- administer madications as prescribed
- provide adequate nutritional support
 REFERENCES
 Lou sole, Mary., Klein, Deborah. (2009).
Critical Care Nursing. 5th ed. Saunders : USA
 John, MA., Cline, David M. (2004).
Emergency Medicine. The McGraw-Hill : USA
 Smeltzer, Suzanne. (2004). Medical Surgical
Nursing. 10th ed. Lippincott : Philadelphia