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What is Shock?A condition in which systemic BP is adequate to deliver oxygen and nutrients to support vital organs and cellular functions. Maintenance of tissue perfusion depends on adequate cardiac pump, effective vasculature or circulating system and sufficient blood volume. Widespread serious reduction of tissue perfusion ( lack of O2 )

Classification of shockA. HYPOVOLEMIC SHOCKLoss of circulating volume due to excessive blood loss, loss of body fluids and third spacing of fluids. Most common type of shock. Characterized by decreased intravascular volume of 15-25%. 15-


Predisposing factors:External:FluidLosstrauma surgery vomiting diarrhea diuresis diabetes insipidus

Internal:FluidShifta. hemorrhage b. burns c. ascite d. peritonitis e. dehydration

Medical ManagementGOALS: restore intravascular volume redistribute fluid volume correct the underlying cause Fluid and Blood replacement: Lactated Ringer s solution, colloid, and 0.9% NaCl (normal saline) to restore intravascular volume. Blood replacement for extensive and rapid blood loss; auto-transfusion methods may be considered for closed cavity hemorrhage.

Redistribution of Fluids Patients is positioned in trendelenburg to assist in fluid redistribution. Military antishock trousers (MAST) are used in extreme emergency situations when bleeding cannot be controlled

Pharmacologic ExamDesmopressin Insulin AntiAnti-emetic AntiAnti-diarreal

Nursing ManagementClosely monitor px at risk for fluid deficits(younger than 1y/o or 65 years of age) Assist with fluid replacement Ensure safe administration of of prescribe fluids and medications, and document effects Monitors and report signs of complications and effect of treatment. Monitor for cardiovascular overload and pulmonary edema: hemodynamic pressure, VS, ABG, and fluid IO. Reduce fear and anxiety about the need for oxygen mask by giving px explanations and frequent reasurance

Cardiogenic Shock

Cardiogenic ShockThe ability of the heart to pump blood is impaired that causes a decrease in cardiac output. Causes of cardiogenic shock are either coronary or noncoronary Coronary cardiogenic shock is more common and seen most often in px with myocardial infarction. Noncoronary causes include tension pneumothorax, sever metabolic problem, cardiac tamponade, cardiomyopathy, valvular damage and dysrhythmias.

Pathophysio of Cardiogenic Shock

Clinical Manifestation:Dysrhythmias are common and result from a decrease in oxygen to the myocardium. Angina pain Hemodynamic instability Classic sign like low blood pressure, rapid and weak pulse. Cerebral hypoxia and manifested by confusion and agitation. Deceased urinary output and cold clammy skin.

Medical Managementcorrection of underlying cause initiation of first line treatment supplemental oxygen controlling chest pain selected fluids support vasoactive medications controlling heart rate mechanical cardiac support e.g intra-aortic balloon counterpulsation, ventricular intraassist sysytem.

Coronary cardiogenic shock is treated with thrombolytic theraphy, angioplasty, or CABG Noncoronary cardiogenic shock is treated with cardiac valve replacement or correction of dysrhythmias.

PharmacologicDobutamine Dopamine AntiAnti-arrythemic meds Nitroglycerine Vasoactive meds

Nursing ManagementPreventing cardiogenic shock Administering meds and IV fluids Maintaining mechanical devices Enhancing safety and comfort

Distributive Shock / Vasogenic Shock ( Circulatory Shock )

Result from profound vasodilation Three classification of distributive shock: Septic shock, Anaphylactic shock and Neurologic shock

Septic Shock

Septic ShockThe most common type of distributive shock, is caused by widespread infection. GramGram-negative bacteria are the most common pathogens. GramGram-positive bacteria and viruses and fungi, can also cause septic shock

Risk factors:Immunosuppression Extremes of age ( younger than 1y/l and older than 65y/o) Alcoholism Extensive trauma of burns Malnutrition Diabetes Malignancy Chronic illness Invasive procedures

PathophysiologyMicroorganism invasion causes immune response that activates biochemical mediators associated with inflammatory response and produces a variety of effects leading to shock. There is an increase in the capillary permeability, with fluid loss from the capillaries and vasodilatation, result in inadequate perfusion of oxygen and nutrients to the tissue and cell.

Clinical ManifestationFirst phase: Hyperdynamic or Progressive phaseHigh cardiac output with vasodilation Hyperthermia (febrile) with warm, flushed skin, bounding pulses Heart and respiratory rate elevated Blood pressure may remain within normal limits, or subtle changes in mental status. Decreased urinary output or normal Gastrointestinal status compromised (eg, decreased bowel sounds, n/v or diarrhea)

Late phase: Hypodynamic or Irreversible phaseLow cardiac output with vasoconstriction Decreased blood pressure Skin cool and pale Temperature normal or below normal Rapid respiratory and heart rate Anuria and multiple organ dysfunction

Septic Shock

Medical ManagementUrine, blood, sputum, and wound drainage specimens are collected to identify and eliminate the causes of infection. Begins immediately a broad-spectrum antibiotic broadtherapy Fluid replacement and aggressive nutritional supplement (high protein) is provided. Enteral feedings are preferred.

Nursing ManagementIdentify px at risk for sepsis and septic shock Monitor for sign of infection at intravenous lines, arterial and venous puncture sites, surgical incisions, trauma wounds, urinary catheters and pressure ulcer Reduce px temp. when ordered for temp above 104.8F (40.8C) monitor closely for shivering Administered prescribed intravenous fluids and medications Monitor and report blood levels (antibiotics, BUN, creatinine, WBC ) and hemodynamic status, fluid IO and nutritional status. Monitor daily wts. And serum albumin levels to determine daily protein requirements

NEUROLOGIC SHOCK / SPINAL SHOCKThere is loss of vasomotor tone that includes arteriolar and venous dilatation .

Predisposing factors:Spinal cord injury Spinal anesthesia Depressant meds Hypoglycemia

Medical ManagementRestoring sympathetic tone

Nursing ManagementElevate the head of the bed 30 degrees ( in spinal / epidural anesthesia ) Immobilize the patient ( in spinal cord injury ) Elastic compression stockings Feet elevation Heparin / low molecular weight heparin Pneumatic compression of the legs Passive ROM

Anaphylactic Shock

Anaphylactic ShockAn antigen-antibody reaction brought about by antigensevere allergenic reaction provokes mast cell to release chemical mediators like histamine and bradykinin widespread vasodilatation and capillary permeability.

Predisposing factors:Drug sensitivity Transfusion reaction Bee sting allergy Latex sensitivity

Medical ManagementRremoval of causative agent Restore vascular tone ( epinephrine ) Antihistamines and bronchodilators

Nursing ManagementAssess for previous hypersensitivity reactions Prevention of future exposure to antigens Identification of new antigens Patient education


BP is maintained within normal limits due to the effect of normally functioning regulatory mechanisms Blood loss less than 10%

Signs and SymptomsApprehension and restlessness ( 1st sign of shock ) Increase heart rate Cool, pain skin Metabolic acidosis Fatigue Tachypnea Mental status change

Medical ManagementIdentify the cause of shock Correction of shock Support of the regulatory mechanisms

Nursing ManagementMonitoring tissue perfusion

LOC V/S Urine output Skin Laboratory values

Reducing anxiety Promoting safety

Progressive Stage / Decompensated

Exhaustion of the compensatory mechanism Myocardial depression Increased capillary permeability

Signs and SymptomsA. Respiratory effects

hypoxemia and hypercarbia intense inflammatory response decreased surfactant production acute respiratory distress syndrome ( acute lung injury, shock lungs, non cardiogenic pulmonary edema )B. Cardiovascular effects

dyshrythmias myocardial infraction cardiac depression

C. Neurologic effects

decreased cerebral perfusion mental status change behavioral change papillary dilation

Signs and SymptomsD. Renal effects MAP