This document discusses shock, including its signs, symptoms, types, and treatment. It defines shock as inadequate tissue perfusion resulting from problems with the heart, blood vessels, blood volume, or respiratory system. The main types of shock discussed are hypovolemic (e.g. from blood loss), cardiogenic (e.g. from heart failure), obstructive (e.g. from pulmonary embolism), distributive (e.g. septic or neurogenic shock), and anaphylactic shock. Treatment focuses on identifying and treating the underlying cause, maintaining adequate tissue perfusion through fluid resuscitation, and supporting vital organ function. Late stage shock can lead to multiple organ dysfunction syndrome if not

1. SHOCK
NPN 205
Medical Surgical II

2. What Does Shock Look Like
• Carla----33 year old female form the
emergency room post MVC, with an
apparent crush injury to the pelvis,
bruising over her right upper
quadrant. She is conscious, but
lethargic and oriented to name only.
BP is 80/46, pulse 116. She is quickly
prepared for surgery. Dx: pelvic crush
injury, r/o abdominal trauma, r/o liver
laceration

3. • Julie---86 year old female from a local
nursing home with a history of
variable fevers for the past week. Her
appetite has decreased, mental
status has deteriorated. Presently,
her temperature is 104 F.
• She has an indwelling Foley catheter,
her urine is dark amber, foul smelling.
Dx. Sepsis secondary to UTI

4. • Justin---14 year old male with a
history of juvenile onset diabetes
mellitus. He has been admitted to the
hospital because his glucose has
been greater than 600 for the last 24
hours and he has a fruity odor on his
breath. His serum glucose is 786.
Dx: diabetic ketoacidosis.

5. What do they have in common?
• Three different patients
• Three different diagnoses
• Three different etiologies

6. Predisposition of Shock Syndrome
• Shock is a process that causes the
eventual shutdown of all body systems in
a systematic order
• Amount of time for shock to progress
varies from patient to patient
• Is related to the body’s overall health and
ability to compensate for it’s deficiencies
• As the syndrome progresses, the process
speeds up
• The circulatory system fails to provide
adequate blood to the tissues, resulting in
cellular hypoxia and death

7. Physiology of Hypoperfusion:
Shock
• Inadequate tissue perfusion
• Inadequate delivery of O2 and
nutrients to the body tissues
• Inadequate elimination of metabolic
wastes

8. A & P of Perfusion
• Perfusion: delivery of O2 and
nutrients and the elimination of CO2
requires four things
– 1. a properly beating heart
– 2. adequate transport medium: blood
and hemoglobin
– 3. an intact functioning vessel system
– 4, a functioning respiratory system

9. Physiology of Circulation in the
Vessels
• 600,000 miles of vessels containing
5-6 liters of blood
• Vessel tone is controlled by the
sympathetic and parasympathetic
nervous system
• Pre-capillary sphincters control blood
flow through the capillaries in
response to O2 demand of the tissue
• Preload is dependent on the constant
peripheral vascular resistance

10. Physiology of Circulation: the
Blood
• Container (vessels) must be full of
blood at all times
• Hemoglobin must be present in
adequate amount and be free to carry
O2, nutrients, and CO2

11. Stages of Shock
• Compensated ---- body is able to
compensate and maintain tissue
perfusion
• Progressive ---- body begins to lose
its ability to compensate---inadequate
perfusion begins
• Irreversible---cell and tissue damage
result in multi-system organ failure

12. Types of Shock
• Hypovolemic
• Obstructive
• Cardiogenic
• Distributive
• Anaphylactic
• Septic

13. Classifications or Types of Shock
• Hypovolemic: (classic shock)
– THE MOST COMMON CLASS. It is the
standard used to compare other forms
of shock to differentiate the diagnosis
• Hemorrhagic/Blood loss
• Dehydration/Fluid loss

14. Causes of Hypovolemic Shock
• Hemorrhage
• Severe diarrhea
• Vomiting
• Excessive perspiration
• Third Spacing
– Shift of fluid in severe burns can lead to
hypovolemic shock
• Peritonitis
• Intestinal obstruction

15. Shock D/T Hemorrhage:
Compensation
• Mechanism: volume depletion due to
bleeding
• Body detects decrease in the cardiac
output
• Sympathetic nervous system is
stimulated releasing epinephrine and
norepinephrine to stimulate alpha
and beta receptors
• Alpha = vasoconstriction
• Beta = bronchodilation and cardiac
stimulation
• Body maintains function

16. Hemorrhagic Shock: Progressive
• Kidneys release antidiuretic hormone
which increases vasoconstriction
• Signs and symptoms:
– Mental status: lethargy, sleepy,
combative
– Skin: clammy, pale, mottling. Cyanosis
around the nose and mouth first,
spreads to extremities
– Blood pressure: begins to fall, capillary
refill delayed
– Pulse: rapid and weak
– Respirations: rapid and shallow
– Other: decreased urination

17. Hemorrhagic Shock: Irreversible
• Signs and symptoms:
– Mental status: decreased LOC, to
unresponsive
– Skin: gray, mottled, cyanotic, waxen,
sweating stops
– Blood pressure: decreases, becomes
undetectable
– Pulse: slows then disappears
– Respiration: agonal
– Other: irritable heart, bradycardia, leads
to asystole

18. Interventions for Hypovolemic
Shock
• Stop the fluid loss – direct pressure,
surgery
• Replace fluids – blood and blood
products, plasma expanders,
crystalloid fluids (provide H2O
replacement and E-lytes), Colloids
(albumin, FF)
• Pneumatic antishock garments
• Use low dose inotropics

19. Cardiogenic Shock
• Heart pump failure (40% of
myocardium damaged by an MI)
• Cardiac trauma
• Cardiomyopathy
• Congestive heart failure
• Cardiac dysrhythmias

20. Cardiogenic Shock: Signs and
Symptoms
• Drop in cardiac output
– Skin: cyanosis
– Pulse: bradycardia, tachycardia, or
within normal limits
– Respirations: diminishing breath
sounds progressing to wheezing and
crackles. Patient complains of
increasing dyspnea. Coughs white or
pink tinged foamy sputum
– Other: pulmonary edema and left heart
failure
– Pitting edema+ right heart failure

21. Interventions for Cardiogenic
Shock
• Hemodynamic monitoring
• IV fluids
• Intra-aortic balloon pump
• Cardiac transplant
• Inotropics/cardiotonics
– Digoxin, Amrinone, Primacor
• Vasodilators
• Diuretics
• If from obstructive may need surgical
repair, chest tube, pacemaker, needle
aspiration of fluid

22. Obstructive Shock
• Can be classed as a type of
cardiogenic shock
– Pulmonary embolism/Blocked
pulmonary circulation
– Tension pneumothorax/Increased
intrathoracic pressure
– Cardiac tamponade/Pressure on
myocardium. Decreased preload

23. Signs and Symptoms of
Obstructive Shock
• Mental status: anxiety, feeling of
impending doom
• Skin: pallor to cyanosis around the
mouth and the nose
• Other: chest pain, lung sounds may
be clear, possible syncope, cardiac
dysrhythmias (PVC’s, A-Fib common)
can lead to sudden cardiac arrest

24. Distributive Shock
• Anaphylactic Shock
– Mechanism: severe allergic reaction
– Skin: hives, possible petechia. Urticaria,
pallor, cyanosis
– Blood pressure: abrupt fall in cardiac
output
– Respiration: rapid shallow, dyspnea with
stridor, wheezes, crackles, leading to
respiratory arrest
– Other: swelling of mucus
membranes/pulmonary edema

25. Treatment of Anaphylactic Shock
• Maintain airway
• Ice to site of injection or sting
• Gastric lavage
• Isotonic IV fluids – D5W, NACL, LR
• Epinephrine and theophylline
• Antihistamines (H2 blockers)
• Steroids
• Vasopressors to constrict blood
vessels and raise BP

26. Distributive Shock
• Septic shock
– Mechanism: overwhelming infection
– Skin: varies form flushed pink (if fever is
present) to pale and cyanotic. Purple blotches
possible, peeling skin, general or on palms and
soles of feet
– Blood pressure: early—cardiac output
increases but toxins prevent increase in BP.
Late --- drop in BP, hypotension
– Respiratory: dyspnea with altered lung sounds
– Other: high fever, (except in elderly and very
young), Late sign is pulmonary edema

27. Treatment for Septic Shock
• C & S for infective site
• IV fluids with NS
• Medications and other treatment
– Vancomycin
– Penicillin
– Cephalosporin
– Cardiotonics and inotropics
– Vasopressors
– Heparin
– Blood products

28. Distributive Shock
• Neurogenic Shock
– Mechanism: vasodilation
– Skin: areas of vasodilation, at first become
warm, pink and dry. Later with pooling:
mottling of dependent areas, pallor and
cyanosis to the upper surfaces
– Pulse: highly variable depending on injury or
action of drug/poison: May be abnormally slow
or abnormally fast, usually not normal
– Respiration: severely compromised: becoming
slow, shallow, with abnormal patterns. Patient
may loose stimulus to breath
– Other: hypothermia. Pulmonary edema with
drug or poisoning

29. Treatment of Neurogenic Shock
• HOB flat with feet elevated
• IV normal saline
• Atropine for bradycardia
• Vasopressors to raise BP
• Analgesics for pain

30. General Treatment of Shock
– Remember your ABC’s
– Administer airway
– 100% O2 via a non- re-breather mask
– Assist ventilations if necessary
– Position patient to assist perfusion
– Keep patient warm
– Perform focused assessment
– Monitor and adjust O2, gain IV access, cardiac
monitor, pulse oximetry
– Fluid replacement of LR or NS
– Need 3 liter of fluid to replace I liter of blood
loss
– Apply pressure to IV or blood to facilitate faster
infusion

31. Nursing Diagnosis
• Ineffective Tissue Perfusion
• Decreased Cardiac Output
• Anxiety
• Fluid Volume Deficit
• Risk for Injury
• Risk for Infection

32. Systemic Inflammatory Response
Syndrome (SIRS)
• Defined as when generalized
inflammation occurs and threatens
vital organs
• Causes: multiply transfusions,
massive tissue injury, burns, and
pancreatitis, severe infections or
sepsis
• Effects: endothelium is damaged and
allows fluid to leak into the body
tissues, results in poor perfusion of
blood to organs
• Body is in a hypermetabolic state

33. Systemic Inflammatory Response
Syndrome (SIRS)
• Diagnosis made when 2 or more of
the following are seen:
– Temperature less than 97 or greater than
100.4
– Heart rate more than 90
– Respiratory rate more than 20 or PaCO2
less than 32mm Hg
– WBC count less than 4000 cells or more
than 12,000
– Sepsis is used if patient has SIRS with
and infection

34. Multiply Organ Dysfunction
Syndrome (MODS)
• Defined: when 2 or more organ
systems are failing at one time
• Is caused by the immune system’s
uncontrolled response to severe
illness or injury
• Common cause of death of patients
in the ICU, with mortality of 50%
• Identifying and acting quickly can
help survival
• Can develop quickly following
surgery, trauma, or severe burns or
slowly in the case of an infection

35. Treatment for SIRS/MODS
• Critical care nursing
• Goals
– Prevent and treat infections
– Maintain tissue oxygenation
– Provide nutritional and metabolic
response
– Support failing organs