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1 Shock2 Shock3 Definition of Shock

Shock is a term used to refer to a group of signs & symptoms that can be caused by a variety of problems.

Shock is an abnormal physiologic state in which there is a disproportion between the circulating blood volume and the size of the vascular bed resulting in circulatory failure and anoxia.

4 Types of ShockHypovolemic.

Cold shock because the extremities become cold.Cardiogenic Shock.Neurogenic Shock.Vasogenic Shock.

Warm Shock because the extremities remain warm.Vasogenic Shock can also be classified as either Septic or anaphylactic.

5 Hypovolemic ShockHypovolemic shock is loss of blood the point where the metabolic needs of the body cannot be met.An individual who loses approx. 1/3 or 1000 ml of their normal blood volume will probably go into shock.Hypovolemia can also be caused by burns.

Referred to as: BURN SHOCK.Can also be caused by movement of fluid into another body space.

6 Hypovolemic ShockSigns and SymptomsSigns and Symptoms

C/O < 5C/O < 5Increased heart rateIncreased heart rateNarrow pulse pressureNarrow pulse pressureSystolic pressure < 90Systolic pressure < 90Decreased urine outputDecreased urine output

7 Hypovolemic ShockTreatmentTreatment

Stop blood or plasma lossStop blood or plasma lossFluid replacement is primary concernFluid replacement is primary concern

Ringers lactate, 0.9% Ringers lactate, 0.9% NaClNaClAlbumin, Albumin, hetastarchhetastarch, blood products, blood products

Position in modified Position in modified trendelenburgtrendelenburg

8 Cardiogenic Shock

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Failure of the cardiac muscle to act as a pump The heart can no longer perform adequately and is unable to pump sufficient blood to the organs MI’s are the most common cause

9 Cardiogenic ShockTreatmentTreatment

O2 at 3 O2 at 3 -- 5 L/min5 L/minControl chest pain with morphineControl chest pain with morphineVasoactive Vasoactive drugsdrugs

Dopamine 0.5 Dopamine 0.5 -- 3.0 mcg/min3.0 mcg/minIV Nitro IV Nitro

Fluid supportFluid support

10 Cardiogenic ShockTreatment/Nursing ManagementTreatment/Nursing Management

Safety and comfortSafety and comfortReduce anxietyReduce anxietyDecrease chest painDecrease chest painPrevent infection from various linesPrevent infection from various linesPosition to increase effective ventilationPosition to increase effective ventilation

11 Distributive ShockCaused by an increase in the size of the vascular bed due to massive vasodilation or.Peripheral pooling of blood.Still have a normal blood volume, but even the normal amt. of blood cannot adequately fill the increased size of the capillary bed.Neurogenic, septic, or anaphylactic.

12 NeurogenicNeurogenic Shock is caused by dilation of blood vessels secondary to nervous factors such as:

Brain damage.Deep spinal anesthesia.

It results in vasomotor collapse & venous pooling.Signs and Symptoms.

Decreased B/P.Bradycardia.Decrease in venous return.Decrease in cardiac output which results in inadequate tissue perfusion and anoxia.

13 Neurogenic ShockTreatment/Nursing ManagementTreatment/Nursing Management

Positioning during anesthesiaPositioning during anesthesia

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Elastic stockings, elevating foot of bedElastic stockings, elevating foot of bedPassive range of motion to immobile extremities Passive range of motion to immobile extremities All the above serve as ways to decrease potential for All the above serve as ways to decrease potential for neurogenic neurogenic shockshock

14 Septic ShockCaused by bacterial infection, Caused by bacterial infection, immunosuppressionimmunosuppressionSigns and SymptomsSigns and Symptoms

InfectionInfectionWarm phaseWarm phaseCold phaseCold phase

Treatment/Nursing ManagementTreatment/Nursing ManagementAntibioticsAntibioticsEliminate source of infectionEliminate source of infectionFluid replacementFluid replacement

15 Septic ShockTreatment/Nursing Management.Treatment/Nursing Management.Use of aseptic technique.Use of aseptic technique.Monitor for signs of infection.Monitor for signs of infection.Reduce temps over 104 with aspirin, hypothermia blankets.Reduce temps over 104 with aspirin, hypothermia blankets.Monitor therapeutic blood levels of meds.Monitor therapeutic blood levels of meds.IV fluids and meds.IV fluids and meds.

16 Anaphylactic ShockA massive allergic reaction

Adrenaline/ Epi is given many times to combat itEpi can be given through ET tube

Observe for bronchoconstrictionTreatment/Nursing Management

Screen for allergiesCPRAdminister meds, fluidsDocuments

17 Stages of Shock - 1 St and 2nd Stages1 st Stage = Initial Phase.

The CO is insufficient to meet the metabolic needs of the body but not low enough to produce symptoms.Patient is anxious & alert, altered mental status, increased respirations.

2 nd Stage = Compensatory Stage.Due to catacholamines being released you will see during the compensatory stage:An Increase in HR.Increase in CO.Vasoconstriction.B/P WNL (Due to compensation) or decrease of 10-15 mm. Hg.

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18 Stages of Shock - 1 St and 2nd StagesAlso observe for.Also observe for.

Metabolic acidosis in compensatory stage.Metabolic acidosis in compensatory stage.Treatment/Nursing Management.Treatment/Nursing Management.

Correct underlying cause of shock.Correct underlying cause of shock.Fluid replacement.Fluid replacement.Monitor for changes in mental status, decreased urine output, viMonitor for changes in mental status, decreased urine output, vital signs.tal signs.Reduce anxiety.Reduce anxiety.Promote safety.Promote safety.

19 Stages of Shock - Progressive Stage3 rd stage = Progressive stage.

Unfavorable signs & symptoms become more apparent to you. You will see:Falling B/P.Increased heart rate.Oliguria.System dysfunction begins.

In other words, the compensatory mechanisms are not able to compensate.Keep patient warm and comfortable to decrease 02 demand.Shock to be reversed at this time, otherwise death results.

20 Stages of Shock - Progressive StageTreatment/Nursing ManagementTreatment/Nursing Management

Intensive assessment monitoringIntensive assessment monitoringMedications and fluidsMedications and fluidsAseptic techniqueAseptic techniquePositioning Positioning Promote rest and comfortPromote rest and comfortFamily supportFamily support

21 Stages of Shock - Irreversible StageDuring this stage, no matter what is done the outcome is death

There is myocardial depressionThere is massive capillary dilationBlood remains pooled in the extremities

Patient succumbs (Dies)Treatment/Nursing managementTreatment/Nursing management

Much family support in addition to physical careMuch family support in addition to physical care

22 Physiologic Effects of ShockThe Neuro Endocrine response

Initially, but very briefly, there will be a decreased B/PAlso important in the Neuro Endocrine response is the regulation of Water & SodiumFluid shifts that occur with shock

Early in shock, blood is squeezed from the capillaries back into the vascular system & the result is two fold:

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1. It tends to dilute the blood2. It causes tissue dehydration

23 Systemic and Microcirculation During ShockAt the onset of shock & during the compensatory stage, the systemic & microcirculatory system work together & their activities tend to remain coordinatedWith the systemic system, there is

Increased HRvasoconstriction

In the microcirculation, there isVasoconstriction

24 As Shock ProgressesThe systemic circulation remains vasoconstricted to get blood back to the heart. At this point, the cells are becoming anoxic because there has been a decreased amt. of blood given to them because the systemic circulation has been constricted.As a result, the microcirculation ( down near the cells) dilates in order to get blood to the tissue.Decreased CO, falling B/P begin to appear.

25 Intestinal Changes During ShockBecause the intestines really aren't vital to life, they are the 1st organs in the body to lose their supply

of blood.

As a result the bowel becomes anoxic.

Tissue necrosis results & bacteria are released into the abdominal cavity.

26 Kidney’s During ShockThe kidneys can compensate fairly well for a time

When the B/P begins to fall oliguria sets

Oliguria results in kidneys losing their ability to regulate electrolytes & acid base balanceChanges in the acid base balance

27 Respiratory Function During ShockVERY IMPORTANT IN COMPENSATION

Ventilation is going to be a priority because most patients develop tissue hypoxia

The cells become 02 starvedTissue began to metabolize anaerobically

Body begins to hyperventilate & to blow up excess C02Results in respiratory alkalosis

28 Mortality Rates of ShockHypovolemic shock is most common type of shock.

Better survival rate.Cardiogenic Shock has a mortality rate of close to 80%.Vasogenic Shock can occur very rapidly, in a matter of minutes.

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patient can be dead in a matter of minutes.Septic Shock has a mortality rate of about 90%.

29 General Signs and Symptoms of ShockDecrease in B/P.

Increase in HR.

Rapid, thready pulse.

Cold & Clammy.

When shock is assessed at this point, it's way ahead of you.

30 When to Anticipate ShockSurgeryTraumaMetabolic disordersInfections

Old age31 Interventions for Hemorrhaging

Infuse whole blood. Dextran (Volume expander), Albumin, Hespan, Volex.

Keep in mind when dealing with hemorrhagic shock you're not just pumping in blood, but you're stopping the reason for the shock.Position in a modified Trendelenburg. The legs are raised at a 20 to 45 degree angle & the head is

either flat or slightly raised.

32 Drugs During ShockVasodilators

To combat the massive vasoconstriction (Nipride)

VasopressorsDopamine

Diuretics

33 General Nursing Management of ShockMaintenance of patient airway.Maintenance of patient airway.Patient positioning.Patient positioning.Maintenance of body temperature.Maintenance of body temperature.Maintenance of skin integrity.Maintenance of skin integrity.Psychological support.Psychological support.

34 Other Considerations During ShockDon't be so concerned with the tubes, etc. that you forget about the patient.

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Keep patient as calm as possible because the more agitated & excited they get, the faster they breathe & the more 02 compromised they become.Pain deepens shock.Give explanations to decrease anxiety levels.Cover lightly.