For 2nd year B.Sc Nursing students

1. SHOCK
Presented By:
Mr. NANDISH.S
Associate Professor
Mandya Institute of Nursing Sciences

3. DEFINITION :
It is a state in which Oxygen and Metabolic demands of the body are
not met by the cardiac output.
It is a life threatening condition of circulatory failure, causing
inadequate oxygen delivery to meet cellular metabolic needs.
It is a clinical syndrome, which develops when there is critical
impairment of tissue perfusion due to acute circulatory failure.
It is a state in which profound and widespread reduction of effective
tissue perfusion leads to irreversible cellular injury.

4. PATHOPHYSIOLOGY :
There are three basic stages common to each type of shock.
- Compensatory stage
- Progressive stage
- Refractory stage

5. COMPENSATORY STAGE :
When arterial pressure and tissue perfusion are reduced.
Baroreceptors in carotid sinus & Aortic arch sense ↓sed blood pressure
Epinephrine & Norepinephrine are secreted to ↑se peripheral resistance &
BP
Reduced blood flow to kidney activates RAAS causing vasoconstriction
and sodium & water retention
Increased blood volume & venous return.

6. PROGRESSIVE STAGE :
This stage begins when the compensatory mechanism fails to maintain
cardiac output.
Tissue becomes hypoxic
Anaerobic metabolism, lactic acid builds up leading to metabolic acidosis
Promotes release of endothelial mediators which produce vasodilation
Venous pooling & increased capillary permeability

7. IRREVERSIBLE (REFRACTORY) STAGE :
Reduced perfusion damages cell membrane
Release of Lysosomal enzymes
Depletion of energy store in the cells
Cell Death
Circulatory & Respiratory failure

8. DIAGNOSTIC EVALUATION :
 History Collection & Physical Examination
 Complete blood count
 Serum Lactate
 Urine Routine with specific gravity
 Culture (Blood, Urine, Sputum)
 Renal Function Test
 Cardiac Enzymes
 ABG
 Chest X-Ray
 ECG
 Echocardiography

9. COMMON MANAGEMENT FOR ALL SHOCK :
- Maintain patent airway (assisting in intubation & monitoring
mechanical ventilator if patient develops respiratory distress).
- Supplemental Oxygen to increase oxygenation.
- Continuous cardiac monitoring.
- Initiating & maintaining at least Two intravenous lines (large size) for
fluid & medication administration.
- Intravenous fluids, Crystalloids, Colloids or blood products can be
started to maintain intravascular volume.

10. CLASSIFICATION :
Shock is classified based on the precipitating Factors.
1. Low blood Flow
- Cardiogenic
- Hypovolemia
2. Misdistribution of blood Flow
- Neurogenic
- Anaphylactic
- Septic

11. 1. HYPOVOLEMIC SHOCK:
 It occurs from inadequate fluid volume in the intra vascular space.
 This lack of adequate circulating volume leads to decreased tissue
perfusion.

12. ETIOLOGY / CAUSES FOR HYPOVOLEMIC SHOCK:
I. Absolute
II. Relative
Absolute :
- Loss of whole blood (Trauma, Surgery)
- Loss of Plasma (Thermal injuries)
- Loss of other body fluids (Severe Vomiting, Diarrhoea)
Relative :
- Loss of intravascular integrity (pelvic Fracture, Hemorrhagic
pancreatitis).
- Increased capillary membrane permeability.
- Decreased colloid osmotic pressure.

13. PATHOPHYSIOLOGY :
Absolute Hypovolemia Relative Hypovolemia
Decreased circulating volume
Decreased Venous Return
Decreased Cardiac Output
Decreased Oxygen supply
Decreased Tissue perfusion
Impaired cellular metabolism

14. CLINICAL MANIFESTATIONS :
System Features
Cardio Vascular Decreased preload & stroke volume
Respiratory System Tachypnea
Renal system Decreased Urine output
Skin Pallor, Cool & clammy skin
Neurological Anxiety, Agitation & Confusion
GI System Absent of bowel sounds

15. MANAGEMENT :
- Common management for all the types of shock.
- Pneumatic antishock garment applied to control both internal & external
hemorrhage by direct pressure.
- Fluids normal saline or RL Solution is started to restore filling pressure.
- Packed Red Blood cells infused to restore blood loss and improve
oxygen carrying capacity of blood.

16. CARDIOGENIC SHOCK :
 It occurs due to failure of Heart to pump blood effectively.
 It can occur with dysfunction of either right or left ventricle or both.
 The lack of adequate pumping leads to decreased cardiac output and
decreased tissue perfusion.

18. ETIOLOGY :
Acute MI
Cardiopulmonary Arrest
Septal Rupture
Ventricular Aneurysm
Cardiomyopathy (Hypertrophic & Restrictive)
Intracardiac Tumor
Pulmonary Emboli
Valvular Dysfunction
Acute Myocarditis
Cardiac Tamponade
Dysrhythmias

19. CLINICAL MANIFESTATIONS :
Hypotension
Weak, thready pulse
Diminished heart sound
Change in sensorium
Cool, pale & moist skin
Chest pain
Tachypnoea
Crackles
Decreased cardiac output
Increased Intra Atrial pressure

20. MANAGEMENT :
 Inotropic drugs : Dopamine, Dobutamine, Amiodarone & Epinephrine
to increase contractility of heart.
 Vasodilators : Nitroglycerine or Nitroprusside given to reduce
workload of Left ventricle.
 Diuretics : Lasix given to reduce fluid volume overload.
 Intra – Aortic Balloon pump therapy: decreases systemic vascular
resistance.
 Thrombolytic Therapy or coronary artery Revascularization : it
restores coronary artery blood flow.
 Ventricular Assist Device : it reforms pumping action of heart.

21. ANAPHYLACTIC SHOCK
 It results of an immediate hypersensitivity reaction.
 It is a life threatening condition require immediate and prompt
interventions.

23. ETIOLOGY / CAUSES :
 Foods : Egg, Milk, Chocolate, Fish & Fish oil, Nuts & seeds.
 Food Additives : food coloring, preservatives.
 Diagnostic agents : Iodinated contrast dye, Sulfobromophthalein,
Iopanoic acid.
 Biologic Agents : blood & blood components, Insulin, Vaccines,
Antitoxins.
 Drugs : Antibiotics, Aspirin, Narcotics, Local Anaesthesia
 Venoms : Bees & Wasp, Snakes, Jelly fish, spiders.

24. System Features
Cardio Vascular Hypertension, Tachycardia
Respiratory System Dysphagia, Hoarseness, Stridor, wheezing
Skin Pruritis, Erythema, Angioedema
Neurological Anxiety, Restlessness, Decreased level of
consciousness
GI System Nausea, Vomiting, Diarrhoea.
CLINICAL MANIFESTATIONS :

25. MANAGEMENT :
- Preservation & support of airway and ventilation
- Bronchodilators
- Ventillatory support

26. NEUROGENIC SHOCK :
 It is a type of distributive shock.
 It is the result of loss or suppression of sympathetic tone.
 Onset occurs within minutes and it may last for days, weeks or months
depending on the cause.

27. ETIOLOGY / CAUSES :
 Spinal cord injury above the level of T6.
 Spinal Anaesthesia.
 Emotional stress.
 Central Nervous system dysfunction.

28. PATHOPHYSIOLOGY :
Disruption of sympathetic nervous system
Loss of sympathetic tone
Venous & arterial vasodilation
Decreased venous return
Decreased stroke volume
Decreased cellular oxygen supply
Impaired tissue perfusion
Impaired cellular metabolism

29. CLINICAL MANIFESTATIONS :
- Hypotension
- Bradycardia
- Hypothermia
- Warm & Dry skin
- Decreased Heart rate
- Flaccid & Paralysis
- Loss of Reflex activity
- Bowel Dysfunction

30. MANAGEMENT :
 Common management.
 Fluid replacement to maintain blood pressure & cardiac output.
 Vasopressor drugs to increase blood pressure.

31. SEPTIC SHOCK :
 It is a form of distributive shock.
 It occurs when micro organisms invade the body.
 The micro organisms include gram positive & gram negative bacteria,
fungi, viruses.

32. PRECIPITATING FACTORS :
Intrinsic Factors :
- Age
- Coexisting diseases like Diabetes, Burns, AIDS, etc
- Malnutrition
Extrinsic Factors :
- Invasive Devices
- Surgical & traumatic wounds
- Invasive diagnostic procedures
- Immuno suppressive therapy

33. MANAGEMENT :
- Common management
- Antibiotic therapy
- Inotropic & vasopressor drugs (Dopamine, Dobutaminie)
- Endotoxins and Interleukins to counteract mediators of sepsis.
* Nursing Management depends on type of shock.