SHOCK

And
Management
QAMAR ZAMAN
NURSING INSTRUCTOR
SUBJECT: CCN
CLASS: 4TH YEAR

1
 Objectives
• Define shock.
• Identify physiological responses to shock
• Explain Clinical manifestations, and
general management of different stages of
shock
• Identify treatment goals of client with shock
• Describe general management strategies
for shock
• Explore different types of shock 2
 Objectives
• Explore hypovolemic shock its pathophysiology,
medical management and nursing management
• Explore Cardiogenic shock its pathophysiology,
medical management and nursing management
• Explore neurogenic shock its pathophysiology,
medical management and nursing management
• Explore anaphylactic shock its pathophysiology,
medical management and nursing management
• Explore septic shock its pathophysiology,
medical management and nursing management
• Explain MODS

3
 SHOCK
Shock is a life threatening condition that occurs
when the body is not getting enough blood flow
lack of blood flow mean the cell and organs do
not get enough O2 and nutrient to function
properly. Many organ can be damaged as a
result.
 Shock
Definition:
Clinical conditions that result in cellular
hypoperfusion are often referred to as shock
states. Which results in inadequacy to deliver
oxygen and nutrients to support vital organs and
cellular function.

5
 Pathophysiology
• Shock begins with cardiovascular system
failure
• Alterations in at least one of four
components:
– Blood volume
– Myocardial contractility
– Blood flow
– Vascular resistance

6
 Physiological responses to
shock
• Hypoperfusion → hypoxia → anaerobic
cellular respiration → lactic acidosis →
metabolic acidosis → cell death → progressive
organ dysfunction
• Hypercoagulability – increasing viscosity of
blood
• Activation of the inflammatory response –
vasoactive mediators i.e. histamine

7
 Stages of shock
Three stages of shock.

• Stage I (Compensated or Non-

progressive).
• Stage II (Decompensated or Progressive).
• Stage III (Irreversible)

8
 Stage I (compensated or Non-progressive)

With compensated shock. The body is

experiencing a state of low blood volume
but is still able to maintain blood pressure
and organ perfusion by increasing the heart
rate and constricting the blood vessels.
 Stage I (Compensated or Non-progressive)
The body activates compensatory mechanisms in an effort
to maintain circulatory volume, blood pressure, and
cardiac output.
Vasoconstriction, increased heart rate, and increased
contractility of the heart contribute to maintaining
adequate cardiac output. This results from stimulation of
the sympathetic nervous system and subsequent release of
catecholamines (epinephrine and norepinephrine).
Patients display the often-described “fight or flight”
response The body shunts blood from organs such as the
skin, kidneys, and gastrointestinal tract to the brain, heart,
and lungs to ensure adequate blood supply to these vital
organs.
10
 Medical Management in Stage
1
Medical treatment is directed toward
• Identifying the cause of the shock
• Correcting the underlying disorder
• Non specific measures such as
replacement and medication fluid
initiated can
therapy to maintain an adequate BP and tissue
perfusion

11
 Nursing Management in Stage
1
Monitoring Tissue Perfusion
• The nurse observes for changes in
– level of consciousness,
– vital signs( Report BP lower than 90 mm Hg and pulse
pressure less than 30 mm Hg)
– urinary output, skin, and laboratory values (eg, base deficit
and lactic acid levels). In the compensatory stage of shock,
serum sodium and blood glucose levels are elevated
• Administer prescribed fluids and medications,
and promote patient safety.
• Oxygen administration
• Hemodynamic monitoring( arterial line, cvp line)
• Reduce anxiety
12
 Stage II ( decompensated or
progression)
The late phase of shock in which the body
compensatory mechanism ( such as increase
heart rate and increase respiratory rate) and
unable to main perfusion to the brain and vital
organs. It occurs when the blood volume
decrease by more then 30%.
 Stage II (Decompensated or
Progressive)
Compensatory mechanisms begin to fail,
metabolic and circulatory derangements become
more pronounced, and the inflammatory and
immune responses may become fully activated.

14
 Clinical Manifestations of Stage II
• Respiratory Effects
– Respirations are rapid and shallow.
– Crackles are heard over the lung fields.
– Acute respiratory distress syndrome
• Cardiovascular Effects
– Dysrhythmias and ischemia.
– Heart rate is rapid, sometimes exceeding 150 bpm.
– chest pain
– Week pulse
– Low BP
• Neurologic Effects
– changes in behavior or agitation and confusion.
– Subsequently, lethargy increases, and the patient begins to lose
consciousness
– Dizziness, hedaec 14
 Clinical Manifestations of Stage II
• Renal Effects
– ARF, increased BUN and Creatinine
– Low urine output
– Acid base and electrolyte imbalance
• Gastrointestinal Effects
– Stress ulcers in the stomach, putting the patient at risk for GI
bleeding
• Hematologic Effects
– Disseminated intravascular coagulation (DIC)
– Ecchymoses, petechiae
• General
– Anxiety or agitation/restlessness
– Bluish lips and fingernails
– Dizziness, lightheadedness, or faintness
– Pale, cool, clammy skin
– Profuse sweating, moist skin 16
 Medical Management in Stage II
• Depends on the type of shock
• Supporting the respiratory system
• Optimizing intravascular volume
• Supporting the pumping action of the heart
• Enteral nutritional support, aggressive hyperglycemic
control with IV insulin
• Histamine-2 (H2) blockers, or antipeptic agents to
reduce the risk of GI ulceration and bleeding.
• The patient should not be warmed too quickly, and
warming blankets should not be applied, because they
can cause vasodilation and a subsequent drop in BP.

17
 Medical Management in Stage
II
• Preventing Complications
• Promoting Rest and Comfort
• Supporting Family Members

18
 Stage III (Irreversible)
In the final, irreversible stage, cellular and tissue
injury are so severe that the patient’s life is not
sustainable even if metabolic, circulatory, and
inflammatory derangements are corrected.
At this point, full-blown multisystem organ
dysfunction syndrome (MODS) may
evident. become

19
 Stage IV: Refractory
• Prolonged inadequate tissue perfusion
– Unresponsive to therapy
– Dysrhythmias
– Pulmonary edema
– Respiratory Distress Syndrome (RDS)
– Cerebral changes
– Renal decreased GFR
– Contributes to multiple organ dysfunction and
death
20
 Systemic Inflammatory Response
Syndrome (SIRS)
• Widespread systemic inflammatory
response
• Associated with diverse disorders
– Infection
– Trauma
– Shock
– Pancreatitis
– Ischemia
• Most frequently associated with
sepsis
21
 Types of shocks
• Hypovolemic shock
– Hemorrhagic shock
• Cardiogenic shock
• Distributive shock
i. Neurogenic shock
ii. Anaphylactic
shock
iii. Septic shock
-Obstructive Shock
22
 Hypovolemic shock
Hypovolemic shock is a result of inadequate
circulating blood volume, The extracellular body
fluid is found in one of two compartments:
intravascular (inside blood vessels) or interstitial
(surrounding tissues). Hypovolemic shock
occurs when there is a reduction in intravascular
volume by 15% to 30%, which represents a loss
of 750 to 1500 mL of blood in a 70-kg person

23
Etiology

24
25
 Assessment
• History or active bleeding
• ABG’s
• Lactate Levels
• CBC (Hb, HCT)
• Coagulation profile

26
 Medical Management
• Treatment of the Underlying Cause
– Hemorrhaging, efforts are made to stop the bleeding.
This may involve applying pressure to the bleeding site
or surgical interventions.
– If the cause of the hypovolemia is diarrhea or vomiting,
medications to treat diarrhea and vomiting

27
 Medical Management
• Fluid and Blood Replacement
– Large bore IV access or central Venous access
– Fluid replacement
• Sodium chloride 0.9% infusion
• Ringer lactate infusions
– Plasma Expanders
– Blood transfusion
– Antibiotic therapy
• Pharmacologic Therapy
9/21/20 –17 Vasoactive meCdopiyrcigihtn©e20s17,byaTnanzteieleUml Raehmtainc's,
 Cardiogenic Shock
• Definition:
Cardiogenic shock, which results from loss of
contractility of the heart, is an extreme form of
heart failure.

29
 Causes of Cardiogenic
• Shock
Either coronary or non coronary.
• Left ventricular damage from myocardial
infarction
• Papillary muscle rupture
• Ventricular septal rupture
• Cardiomyopathy
• Cardiac tamponade
• Acute myocarditis
• Valvular disease
• Dysrrhythmias
30
Cardiogenic Shock Pathophysiology

31
9/21/2017 40
 Medical Management of
Cardiogenic Shock
• Correction of Underlying Causes
• Initiation of First-Line Treatment
– Oxygenation
– Pain Control
– Hemodynamic Monitoring
– Laboratory Marker Monitoring
– Fluid Therapy
• A fluid bolus should never be given rapidly, because rapid
fluid administration in patients with cardiac failure may
result in acute pulmonary edema.

33
 Distributive shock or Circulatory
shock
• The mechanism underlying all distributive
shock states is vasodilation that causes pools
in peripheral blood vessels.
i. Neurogenic shock:- Vasodilation results
from a loss of sympathetic innervation to the
blood vessels.
ii. Anaphylactic shock and septic shock,
vasodilation results from the presence of
vasodilating substances in the blood.

34
35
36
 Neurogenic Shock
• Neurogenic shock results from loss or
disruption of sympathetic tone, most often due
to severe cervical or upper thoracic spinal cord
injury.

37
 Clinical manifestations
• hypotension with bradycardia, rather than
the tachycardia
• dry, warm skin rather than the cool, moist skin
seen in hypovolemic shock.

38
 Anaphylactic shock
• Anaphylaxis is an allergic reaction to a specific
allergen that evokes a life-threatening
hypersensitivity response. Anaphylaxis may be
either immunoglobulin E (IgE)– or non–IgE
mediated.

39
 Pathophysio of
Anaphylaxis
• The antibody–antigen reaction causes the white
blood cells (WBCs) to secrete chemical mediators
that cause
• Systemic vasodilation
• rapid onset of hypotension
• Increased capillary permeability
• Bronchoconstriction
• Coronary vasoconstriction
• Urticaria (hives).
• cardiac

40
9/21/2017 56
 Medical Management
• Removing the causative antigen
• IV access
• Telemetry continuously
• Oxygen therapy if indicated
• Corticosteroids ( Solucortif = hydrocortisone)
• Antihistamines (Avil = Phenarimine injection)
• Intubation or mechanical ventilation
• Inotropes

57
 Nursing Management
• Monitor the patient’s response to the treatment.
• Providing care to relieve
dermatological manifestations.
• Evaluated for allergies and future risk
for anaphylaxis.

43
 Septic Shock
• Septic shock, the most common type of
circulatory shock, is caused by
widespread infection

44
 Obstructive Shock
• Physical impairment to adequate
circulatory blood flow
• Causes
• Clinical manifestations
– Chest pain
– Dyspnea
– Jugular venous distension
– Hypoxia
– Cause-dependent findings

45
Management of Obstructive Shock
• Treat the cause
– Cardiac tamponade (pericardiocentesis)
– Tension pneumothorax (thoracentesis)

46
 Multiple Organ Dysfunction
Syndrome (MODS)
• Multiple organ dysfunction syndrome
(MODS) is altered organ function in acutely
ill patients that requires medical intervention to
support continued organ function. It is another
phase in the progression of shock states.

47
 Multiple Organ Dysfunction
Syndrome (MODS)
• Pulmonary dysfunction.
• Renal dysfunction
• Liver dysfunction
• Cardiovascular dysfunction
• Hematologic dysfunction.
• Neurologic dysfunction

48
 Multiple Organ Dysfunction
Syndrome (Cont.)
• Clinical manifestations
– Tachypnea/hypoxemia
– Petechiae/bleeding
– Jaundice
– Abdominal distension
– Oliguria  anuria
– Tachycardia
– Hypotension
– Change in level of consciousness

49
 Multiple Organ Dysfunction
Syndrome
(Cont.)
• Management
– Control infection
• Antibiotics
– Provide adequate tissue oxygenation
• Maintain 88% to 92% arterial oxygen saturation
• Maintain hemoglobin above 7 to 9 g/dL
– Restore intravascular volume
• Aggressive fluid resuscitation
• Isotonic crystalloids
– Support organ function
50
 Shock, Sepsis, and MODS
• Patient outcomes
– Improved tissue perfusion
• Alert, oriented
• Normotensive
• Warm, dry skin
• Adequate urine output
• Normal hemodynamics
• Lab values within normal limits
• Absence of infection
• Intact skin

51