SHOCK

N 490
 Shock
 Definition: Complex, life-threatening syndrome characterized by
inadequate blood supply & O2 to tissues, which becomes insufficient
to support cellular activity.

 Adequate blood flow to tissues requires:

 An adequate cardiac pump
 An intact circulatory system
 Adequate blood volume
 
 If one of these components is impaired, there will be inadequate
flow of oxygen and nutrients to the cells resulting in cellular
starvation & death, organ failure, and death if not treated.
 
 Shock can develop slowly or quickly depending on the etiology but
it effects all body systems and requires ongoing assessment and
intervention if the patient is going to survive.
 Classification of Shock

 Hypovolemic Shock
 Cardiogenic Shock
 Distributive or Vasogenic Shock
 Divided into 3 types:
 Anaphylactic
 Neurogenic
 Septic shock
 Hypovolemic Shock
 The most common type of shock-characterized by
a decrease in intravascular volume.
 Occurs when volume is decreased by 15 to 25%
(approx,750-1300ml).
 May be caused by:
 external fluid loss: hemorrhage, vomiting, diarrhea
 internal fluid loss: burns, ascites
 Decreased blood volume leads to decreased
venous return  decreased stroke volume
decreased cardiac output decreased tissue
perfusion.
 Cardiogenic Shock
 Occurs when the heart’s ability to pump blood
is impaired.
 Often r/t MI, dysrhythmias, valvular damage
or cardiac tamponade.
 Decreased cardiac contractility decreased
stroke volume  pulmonary congestion &
decreased cardiac output decreased tissue
perfusion
 Distributive or Vasogenic Shock

 Is the loss of sympathetic tone  which leads to vasodilation

 There are three types:
 Neurogenic Shock– vasodilatation occurs as a result of
spinal cord injury or spinal anesthesia (r/t sympathetic
tone). Characterized by dry, warm skin and bradycardia.
 Anaphylactic Shock– antigen-antibody reaction provokes
release of histamine which causes vasodilatation
 Septic
Shock - common type of distributive shock, it is
caused by widespread of infection. The immune response
provoked by bacteria leads to a release of chemical
mediators, which lead to vasodilatation.
 Vasodilation  maldistribution of blood volume 
decreased venous return decreased stroke volume 
decreased cardiac output decreased tissue perfusion.
Initiators of shock r/t type of shock
 Chemical:
 Anesthesia neurogenic shock (vasogenic)
 PCN anaphylactic shock (vasogenic)
 Micro:
 Gram negative bacteria  septic shock (vasogenic)
 Gram positive bacteria  toxic shock syndrome septic shock (vasogenic)
 Physical:
 Trauma  hemorrhage hypovolemic shock
 Heat  burns hypovolemic shock
 Physiological:
 Heart disease Cardiogenic Shock
 Psychological:
 Dysfunctional eating patterns
 Developmental:
  organ function,  body water,  taste & thirst, CO, GFR
 These ’s make the elderly more susceptible to development of any type of
shock.
 Physiologic Effects
 Whatever cause  P & RR with  BP net effect
similar there is not enough blood & O2 supply to
tissues.
  P & RR with  BP (Hypovolemic Shock: not enough
bld.volume, Cadiogenic Shock heart ineffective pump
 volume, Distributive Shock: vasodilatation)
 Energy is created anaerobically   lactic acid
Acidosis Death if not treated.
 Restlessness/anxiety
  urinary output
 Collapsed neck veins even when supined
 Stages of Shock
 Non-progressive stage:
 cardiac output is slightly decreased b/c of the loss of actual or relative blood volume.
 the body’s compensatory mechanisms can maintain BP within a normal to low
normal level and can maintain perfusion to vital organs.
 systemic circulation and microcirculation work together in a hyperdynamic state,
which leads to an increase in lactic acid levels.
 Progressive stage.
 body begins to decompensate and the systemic circulation and microcirculation no
longer work together
 vasoconstriction continues, supply of oxygenated blood to the tissues is
reduced ,results in anaerobic metabolism and more lactic acid is produced Acidosis
and increasing PaCO2 causes microcirculation to dilate and decrease circulation of
reoxygenated blood which leads to capillary “pooling” of blood in the
microcirculation and decreased cardiac output.
 Irreversible stage.
 Occurs if the cycle of inadequate tissue perfusion is not interrupted. Shock state
becomes progressively more severe , cellular ischemia and necrosis leads to organ
failure and death.
 Clinical Manifestations
 Subjective Data
 Manifestationscan include chest pain, lethargy, somnolence, restlessness,
anxiousness, dyspnea, diaphoresis, thirst, muscle weakness, nausea, and constipation
 Objective Data
 Physical Assessment Findings
 Hypoxia, tachypnea progressing to greater than 40/min, hypocarbia.
 Skin may be pale, mottled or dusky in color, cool, diaphoretic, warm, flushed with
fever (distributive shock), and exhibit a rash (anaphylactic and septic shock).
 Angioedema (anaphylactic).
 Wheezing.
 Blood pressure may be within the expected reference range during the initial stage,
but can increase during the progressive stage and then drop to less than 50 to 60 mm
Hg.
 Tachycardia progressing to greater than 140/min.
 Pulse that is weak, thready, or bounding with distributive shock.
 Decreased cardiac output & urine output.
 Central venous pressure is decreased in hypovolemic shock.
 Central venous pressure is increased with increased systemic vascular resistance in
cardiogenic shock.
 Seizures.
 Laboratory Tests

 ABGs – decreased tissue oxygenation (decreased pH,

decreased PaO2, increased PaCO2)
 Serum lactic acid – increases due to anaerobic metabolism
 Serum glucose and electrolytes – serum glucose can increase
during shock
 Cardiogenic shock
 Cardiac enzymes – creatine phosphokinase, troponin
 Hypovolemic shock
 Hgb and Hct – decreased with hemorrhage, increased with
dehydration
 Septic shock
 Cultures – blood, urine, wound
 Coagulation tests – PT, INR, aPTT
 Outcome Management
 Treatment should be instituted when 2 of the 3
following indicators are present :
 Systolic BP of 80mm Hg or less.
 Pulse pressure of 20 mm Hg or less.
 Pulse rate of 120 beats/min or more.
 Emphasis is placed on maintaining adequate
circulating volume, using body positions that
do not interfere with pulmonary ventilation,
and use of medications.
 Outcome Management
 Correct the causative factor
 Improve oxygenation
 Restore and maintain adequate perfusion
 Assist circulation
 Replace fluid volume
 Multiple organ dysfunction syndrome (MODS)

 MODS develops from severe hypotension &

reperfusion of ischemic cells causing further
tissue injury.
 MODS is present when two or more organs fail.
 Primary MODS-Primary site of insult
 Secondary MODS - dysfunction of organs not
involved in the original insult
 Clinical Manifestations
 There is usually a precipitating event to MODS
such as aspiration, septic shock, ruptured
aneurysm with resultant hypotension.
 Client is resuscitated, appears well for several
days and then develops SIRS.
 Systemic Inflammatory Response Syndrome
(SIRS) is an inflammatory state affecting the
whole body
 Within a few days MODS develops.
 (see box 81-3,p.2185)
 Multiple organ dysfunction syndrome (MODS)

 MODS remains the leading cause of death in

ICU’s with mortality rates from 50-90%.
 For those that survive, the average LOS in the
ICU is 21 days.
 The rehab, which is directed at muscle mass
and neuromuscular function takes another 10
months.
 Pharmacological Agents

Inotropic agents – Milrinone lactate (Primacor)

Actions Strengthens cardiac contraction and increases cardiac
output
Nursing Administer by continuous IV infusion with constant
Considerations hemodynamic monitoring.
Can titrate agent to maintain prescribed
hemodynamic parameters.
Agent can cause vasodilation in some clients.
Agents are often administered in combination with a
vasopressor.
 Pharmacological Agents

Vasopressors – Dobutamine (Dobutrex), Dopamine hydrochloride

(Intropin),
Norepinephrine (Levophed)
Actions Strengthens cardiac contraction and increases cardiac
output
Increases kidney perfusion at low doses
Decreases kidney perfusion at high doses
Nursing Administer by continuous IV infusion with constant
Considerations hemodynamic monitoring.
Can titrate vasopressor to maintain prescribed
hemodynamic parameters.
Monitor urine output.
Administer through a central line to prevent
extravasation. Rapid onset occurs in 5 min, and short
duration occurs in 10 min.
 Pharmacological Agents

Pituitary Hormone – Vasopressin (Pitressin Synthetic)

Actions Strengthens cardiac contraction
Causes vasoconstriction, increases systemic vascular
resistance blood pressure, and
increases cardiac output
Nursing Administer by continuous IV infusion with constant
Considerations hemodynamic monitoring.
Can titrate vasopressor to maintain prescribed
hemodynamic parameters.
Monitor urine output.
Administer through a central line to prevent
extravasation. Rapid onset occurs in 5 min, and short
duration occurs in 10 min.
 Medications: Pharmacological Agents
Sympathomimetics – Epinephrine (Adrenaline)
Actions Rapid-acting bronchodilator
Increases heart rate and cardiac output
Nursing Monitor blood pressure, pulse, and cardiac output.
Considerations Epinephrine can cause sloughing if infiltrates tissue.

Proton-pump inhibitors – Pantoprazole (Protonix)

Actions Protects against stress ulcer development

Nursing Do not mix with other medications.

Considerations
 Medications: Pharmacological Agents
Opioid analgesics – Morphine sulfate, Fentanyl (Sublimaze))
Actions Pain management
Nursing Monitor respirations of clients who are nonventilated.
Considerations Monitor blood pressure, heart rate, and SaO2.
Monitor ABGs.
Use opioid analgesics cautiously in conjunction with
hypnotic sedatives.
Assess and document the client’s pain level and
response to medication.
Use cautiously due to risk of increased vasodilation
and hypotension.
Have naloxone (Narcan) and resuscitation equipment
available for severe respiratory depression in a client
who is nonventilated.
 Pharmacological Agents

Anticoagulant – Low-molecular weight heparin, enoxaparin sodium

(Lovenox)
Actions Deep vein thrombosis prophylaxis

Nursing Administer subcutaneously, usually in abdomen.

Considerations Do not rub injection site.

Isotonic crystalloids or colloids (including blood products) – 0.9%

sodium
chloride or lactated Ringer’s solution
Actions Hypovolemic shock – volume replacement

Nursing ALERT – During hypovolemic shock, replace volume

Considerations first.
Use vasopressors only if blood pressure remains low
after volume is replaced.
 Pharmacological Agents

Antihistamines – Diphenhydramine (Benadryl)

Actions Used to treat anaphylactic shock
Blocks histamine at receptor sites
Nursing Can cause drowsiness, hypotension, and tachycardia.
Considerations

Vasodilator – Sodium nitroprusside (Nipride)

Actions Used to treat cardiogenic shock

Reduces afterload and preload
Causes vasodilation
Decreases cardiac output and afterload
Nursing Assess blood pressure every 15 min.
Considerations Administer with caution because it is a potent
vasodilator.
Protect the solution from light.
 Pharmacological Agents

Antibiotics sensitive to cultured organism(s) – Vancomycin

(Vancocin)
Actions Used to treat septic shock
Inhibits cell growth or reproduction of undesired
organism
Nursing Monitor for hypersensitivity reaction.
Considerations Administer IV vancomycin slowly.
Culture infected area prior to administration of the
first dose of vancomycin.
Monitor the IV site for infiltration.
Do not administer vancomycin with other
medications.
Monitor coagulopathy and renal function.
 Pharmacological Agents

Corticosteroids – Hydrocortisone (Solu‑Cortef), Methylprednisolone

(Solu‑Medrol)
Actions Reduces WBC migration and decreases inflammation
Nursing Hydrocortisone can cause hypertension.
Considerations Discontinue medication gradually.
Administer hydrocortisone with an antiulcer
medication to prevent peptic ulcer formation.
Monitor weight and blood pressure.
Monitor glucose and electrolytes.
 Question
The nurse obtains vital signs for a client who has been
admitted with a myocardial infarction: BP 86/56, sinus
tachycardia rate 122, respirations 32, CVP 28 (normal = 2 to
12 mm Hg). Which of the following physician orders
should the nurse question?

A. Infuse nitroglycerin (Tridil) at 5 mcg/min.

B. Administer 100% O2 per non-rebreather mask.
C. Infuse normal saline at 200 mL/hr.
D. Give furosemide (Lasix) 40 mg IV.
 The nurse obtains vital signs for a client who has been admitted
with a myocardial infarction: BP 86/56, sinus tachycardia rate
122, respirations 32, CVP 28 (normal = 2 to 12 mm Hg). Which
of the following physician orders should the nurse question?

A. Infuse nitroglycerin (Tridil) at 5 mcg/min.

B. Administer 100% O2 per non-rebreather mask.
C. Infuse normal saline at 200 mL/hr.
D. Give furosemide (Lasix) 40 mg IV.

The low blood pressure (BP) and increased central venous pressure
(CVP) indicate that the client has cardiogenic shock and fluid overload.
Administration of large volume of fluid is contraindicated at this time,
because this would further decrease cardiac output. The other orders are
appropriate.
 Question
An RN who has just completed the intensive care unit
orientation is caring for a client with a myocardial
infarction and cardiogenic shock. Which action by the
RN indicates the need for more education?

A. The RN elevates the client’s legs.

B. The RN gives morphine 2 mg IV.
C. The RN gives 100% oxygen to the client per
rebreathing mask.
D. The RN adjusts the thermostat to increase the room
temperature.
 An RN who has just completed the intensive care unit
orientation is caring for a client with a myocardial
infarction and cardiogenic shock. Which action by the
RN indicates the need for more education?

A. The RN elevates the client’s legs.

B. The RN gives morphine 2 mg IV.
C. The RN gives 100% oxygen to the client per rebreathing mask.
D. The RN adjusts the thermostat to increase the room
temperature.

Elevation of the client's legs will increase venous return and worsen
the congestion that is associated with cardiogenic shock. The other
actions are appropriate.
 Question
A client with distributive shock after spinal
anesthesia has received normal saline 1500 mL
over an hour, but continues to have a mean arterial
pressure (MAP) of 55 mm Hg and heart rate of 52.
The nurse anticipates administration of:
A. furosemide (Lasix).
B. amiodarone (Cordarone).
C. norepinephrine (Levophed).
D. methylprednisolone (Solu-Medrol).
A client with distributive shock after spinal anesthesia has received
normal saline 1500 mL over an hour, but continues to have a mean arterial
pressure (MAP) of 55 mm Hg and heart rate of 52. The nurse anticipates
administration of:

A. furosemide (Lasix).
B. amiodarone (Cordarone).
C. norepinephrine (Levophed).
D. methylprednisolone (Solu-Medrol).

Ifadministration of fluids is ineffective in increasing perfusion for clients

with distributive shock, vasoconstrictive medications such as
norepinephrine are given to decrease the size of the vascular system and
increase blood pressure.
Furosemide would cause fluid loss and further decrease blood pressure.
Amiodarone is given if tachydysrhythmias are causing cardiogenic shock.
Steroids such as methylprednisolone are used in spinal cord injury to
decrease edema around the injured cord.