Chapter 14

Shock and Multiple Organ

Dysfunction Syndrome
Shock

 Life-threatening condition in which tissue perfusion is

inadequate to deliver oxygen and nutrients to support
cellular function
 Affects all body systems
 May develop rapidly or slowly
 Any patient with any disease state may be at risk for
developing shock
 Regardless of the initial cause of shock, certain
physiologic responses are common to all types of shock:
hypoperfusion of tissues, hypermetabolism, and
activation of the inflammatory response

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Classifications of Shock #1

 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 acute
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 acute systemic
vasodilation, relative hypovolemia

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Classifications of Shock #2

 Hypovolemic
 Cardiogenic
 Obstructive
 Distributive (neurogenic, anaphylactic, septic)

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Compensatory Mechanisms in Shock

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Stages of Shock

 Compensatory
 Progressive
 Irreversible

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Compensatory Stage of Shock

 SNS causes vasoconstriction, increased HR, increased heart

contractility
o 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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Progressive Stage of Shock #1

 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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Progressive Stage of Shock #2

 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
o Acute kidney injury may occur
 Liver function, GI function, hematologic function are all
affected
 Disseminated intravascular coagulation (DIC) may occur
as cause or complication of shock

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Irreversible Stage of Shock

 At this point, organ damage is so severe that the 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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question #1

Which stage of shock is characterized by a normal blood

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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Answer to Question #1

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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

For All Types of Shock

 Early identification, timely treatment

 Identify, treat underlying cause
 Sequence of events for different types of shock will vary
o Management, care of patient will vary

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Pathophysiology of Hypovolemic Shock

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Hypovolemic Shock

 Medical management
o Treatment of underlying cause
o Fluid, blood replacement
o Redistribution of fluid
o Pharmacologic therapy
 Nursing management
o Administering blood, fluids safely
o Implementing other measures

Copyright © 2018 Wolters Kluwer · All Rights Reserved

General Management Strategies in Shock

 Fluid replacement
o Crystalloid, colloid solutions
o Complications of fluid administration
 Vasoactive medication therapy
 Nutritional support

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Pathophysiology of Cardiogenic Shock

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Cardiogenic Shock

 Medical management
o Correction of underlying causes
o Initiation of first-line treatment
 Oxygenation
 Pain control
 Hemodynamic monitoring
 Laboratory marker monitoring
 Fluid therapy
 Mechanical assistive devices

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Cardiogenic Shock: Pharmacologic
Therapy

 Dobutamine
 Nitroglycerin
 Dopamine
 Other vasoactive medications
 Antiarrhythmic medications

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Cardiogenic Shock: Nursing Management

 Preventing cardiogenic shock

 Monitoring hemodynamic status
 Administering medications, IV fluids
 Maintaining intra-aortic balloon counter pulsation
 Ensuring safety, comfort

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Circulatory Shock

 Septic shock
 Neurogenic shock
 Anaphylactic shock

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Pathophysiology of Circulatory Shock

Copyright © 2018 Wolters Kluwer · All Rights Reserved

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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question #2

Is the following statement true or false?

The most common colloid solution used to treat
hypovolemic shock is 5% albumin

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Answer to Question #2

True
Rationale: The most common colloid solution used to treat
hypovolemic shock is 5% albumin

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question #3

Is the following statement true or false?

The primary goal in treating cardiogenic shock is to limit
further myocardial damage

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Answer to Question #3

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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question #4

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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Answer to Question #4

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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

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
o Extravasation may cause extensive tissue damage
 Dosages usually titrated to patient response

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nutritional Therapy

 Nutritional support needed to meet increased metabolic

and energy requirements to 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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Psychological Support of Patients and
Families

 Anxiety
 Support of coping
 Patient, family education
 Communication
 End-of-life issues
 Grief processes

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Multiple Organ Dysfunction Syndrome

 Presence of altered function of two or more organs in an

acutely ill patient such that interventions are necessary to
support continued organ function
 Primary or secondary
 High mortality rate; 75%
 Treatment
o Controlling initiating event
o Promoting adequate organ perfusion
o Providing nutritional support
 Promoting communication

Copyright © 2018 Wolters Kluwer · All Rights Reserved