Shock

PRESENTED BY: HARVI BHAVSAR

ROLL NO: 03
WHAT IS
SHOCK ?
  INTRODUCTION
• Shock is a life threatening condition
that occur when the body is not
getting enough blood flow.
• Lack of blood flow means that the
cells and organs do not get enough
oxygen and nutrients to function
properly.
• Many organs can be damage as a
result of shock.
• Shock requires immediate treatment
  DEFINITION
• Shock can be best defined as a
clinical syndrome that results from
inadequate tissue perfusion, creating
imbalance between the delivery of
oxygen and nutrition needed to
support cellular function.
  STAGES OF
SHOCK
1.Initial
.

stage

4. 2.
Irreversibl Compensato
e stage ry stage

3.
Progressiv
e stage
  Stage 1 : Initial stage
.

- Tissue are under perfused

- Decreased Cardiac Output
- Increased anaerobic metabolism – lactic acid building

 Stage 2 : Compensatory stage

- It is reversible
- Sympathetic nervous system activated by low cardiac
output
- Attempting to compensate for the decreased cardiac
output
 Stage 3 : Progressive stage

- Falling compensatory mechanism : profound

vasoconstriction from the Sympathetic Nervous System
ischemia lactic acid production is high metabolic acidosis.

 Stage 4 : Irreversible or Refractory stage

- Cellular necrosis and multiple organ dysfunction

syndrome may occur.
  CAUSES OF SHOCK

● Severe or extensive injuries

● Heart attack
● Loss of blood
● Severe burns
● Electric shock
● Allergic reactions
● Bite of poisonous snake
● Gas poisoning
 PATHOPHYSIOLOGY
Due to any etiological causes

Decreased Tissue perfusion and

Decreased
Oxygenation

Activation of homeostatic response

 .

Increased Systemic response Increased respiratory rate to

.

(increased HR, increased BP, increase oxygen saturation and

increased cardiac contractibility) delivery
Which leads to increase cardiac
output

Increased renin angiotensin Increased Catecholamines and

activation which leads to cortisol to provide increased
Increased reabsorption of glucose for metabolism
sodium and water, which leads
to increased pre load and
decreased urine output

Restoration of tissue perfusion and oxygenation

  SIGNS AND SYMPTOMS OF
● Weakness, fainting
SHOCK
● Shallow , rapid breathing
● Nausea , Vomiting
● Blood pressure falls
● Pupils are dilated
● Pale , cold , clammy skin
● Weak , rapid pulse
 TYPES OF SHOCK
Shock

1) 2)
3) Distributive
Hypovolemic Cardiogenic
shock
shock shock

c)
a) Septic b) Neurogenic
Anaphylactic
shock shock
shock
 1) HYPOVOLEMIC SHOCK
o Most common type of shock
o It is characterized by decreased intravascular volume
o Body fluids is contained in the intracellular and
extracellular compartments
 Intracellular fluids account for about two third of
total body water.
 Extracellular body fluids is found in
1) Intravascular ( inside blood vessels )
2) Interstitial ( Surrounding tissue )
 .

o Volume of interstitial fluid is about three to

four times that of intravascular fluid.
o Hypovolemic shock occurs when there is
reduction in intravascular volume by 15% to
20% .
 Causes of Hypovolemic Shock
● Dehydration
● Bleeding
● Severe burns
● Drugs such as Diuretics
.
 Pathophysiology
Decreased intravascular volume

Decreased venous return

Decrease stroke volume

 .

Decreased cardiac output

Decreased tissue perfusion

 Sign and Symptoms

● Shallow & quick breathing

● Excessive sweating
● Low BP
● Weakness & Confusion
● Cold, clammy skin
● Low temperature
● Rapid Pulse
 Diagnostic Evaluations
● History collection
● Physical examination
● CBC
● ABG
● CT scan
● MRI
  Medical Management
● Major goals in the treatment of hypovolemic
shock are to restore intravascular fluid.
● Depending on severity of shock & patient’s
condition, three goals are addressed.
A. Treatment of underlying cause
B. Fluid & Blood replacement
C. Redistribution of fluid
A) Treatment of underlying cause:
● If the patient is hemorrhagic,
efforts are made to stop the
bleeding. It involves, apply
pressure to bleeding site &
surgical intervention to stop
internal bleeding.
● If the cause is Diarrhoea –
Antidiarrheal are given
● If the cause is vomiting –
Antiemetics are given
 B) Fluid and Blood Replacement:
● Fluid and blood replacement is very
important.
● At least two large gauge IV lines are
interested to establish access for fluid
administration.
● If IV catheter cannot be quickly inserted,
an Intraosseous catheter may be used
for access in the sternum, legs, or arms
to facilitate rapid fluid replacement.
● Multiple IV lines allow simultaneous
administration of fluid, medication &
blood component therapy if required.
C) Redistribution of Fluid:
● Administering fluids to restore
intravascular volume, positioning
the patient properly assist fluid
replacement.
● A modified Trendelenburg position
also known as passive leg raising ,
is recommended on hypovolemic
shock.
● Elevation of the legs promotes the
return of venous blood & can be
used as a dynamic assessment of
  Nursing Management:
● Hypovolemic shock can be prevented in some
instances by closely monitoring patients who are at
risk for fluid deficits and assisting with fluid
replacement before intravascular volume is depleted.
● General nursing measures include safe administration
of prescribed fluids and medications and documenting
their administration and effects.
● Volumetric IV pumps should be used to administer
vasopressure medications, if prescribed.
.

● Another important nursing role is monitoring for

complications and side effects of treatment and
reporting them promptly.

Volumetric IV pump
  Nursing Diagnosis:
1) Decreased cardiac output related to
inadequate circulating volume as evidenced
by low BP.
2) Ineffective tissue perfusion related to
decreased blood volume as evidenced by
hypotension.
3) Risk for impaired gas exchange related to
oxygen delivery to tissue is compromised.
4) Risk for deficient fluid volume related to fluid
loss.
 2) CARDIOGENIC SHOCK
● Cardiogenic shock is based upon an
inadequate circulation of blood due to
primary failure of ventricles of heart to
function effectively.
● Cardiogenic shock occurs when there is
insufficient perfusion of tissues of heart to
meet required demand for oxygen and
nutrients.
 Risk Factors:

● Old age
● Having history of Heart Failure
● Coronary Artery Disease
● Diabetes or HTN
● Existing cardiac disease
  Causes of Cardiogenic Shock:
- Myocardial Infarction - Myocarditis

- Cardiomyopathy - Cardiac Tamponade

 .

●Valvular Diseases
●Dysrhythmias
●Severe Hypoxia
●Acidosis
●Hypoglycemia
●Hypocalcemia
●Tension Pneumothorax
  Classification:

Cardiogenic Shock

Coronary Non coronary

cardiogenic shock cardiogenic shock
1) Coronary Cardiogenic Shock:
• More common than non coronary cardiogenic
shock
• Most often seen in patients with acute MI.

2)Non coronary Cardiogenic

Shock:
• Related to conditions that stress the
myocardium as well as condition that result in
an ineffective myocardial function.
Examples:

● Severe hypoxia
● Acidosis
● Hypogycemia
● Tension Pneumothorax
● Cardiomyopathies
● Cardiac Tamponade
● Dysrhythmias
  Pathophysiology:
Decreased cardiac
contractibility

Decreased stroke
volume

Decreased
Decreased
Pulmonary coronary
Tissue
Congestion artery
Perfusion
perfusion
 Sign and symptoms:

● Cool, clammy skin

● Hypotension
● Tachycardia
● Tachypnea
● Oliguria
● Cynosis
● Mental confusion
 Diagnostic Evaluation:

● History collection
● Physical examination
● ECG
● Echocardiography
● Angiogram
  Medical Management:
● The goal of medical management in
cardiogenic shock are to limit further
myocardial damage & preserve the healthy
myocardium & to improve cardiac function.
● The goals are:
1. Correction of underlying cause
2. Initiation of first line treatment
3. Pharmacologic therapy
1) Correction of underlying cause:
● As with all forms of shock, the
underlying cause of cardiogenic shock
must be corrected.
● In case of coronary cardiogenic shock
the patient may require:
 Thrombolytic therapy
 Percutaneous coronary intervention
 CABG
 Ventricular assistive devices
 .

● In the case of non coronary cardiogenic shock

intervention focuses on correcting underlying
cause, such as:
 Replacement of faulty valve
 Correction of dysrhythmias
 Correction of acidosis & electrolyte
disturbances
 Treatment of tension pneumothorax
2) Initiation of first line treatment:
● Oxygenation: In early stages of
shock, oxygen given by nasal
canula at rate of 2 to 6 L/min.
● Pain control: IV morphine is given
to control chest pain.
● Fluid therapy: Appropriate fluid
therapy is also important. Closely
monitor for fluid overload.
3) Pharmacological therapy:
● Vasodilators – Nitrates
● Betablockers –
Propranolol
( 20 to 40 mg )
● Calcium channel
blockers : Nifedipine

Verapamil
  Nursing Management:
1)Preventing cardiogenic shock:
• Identifying at-risk patients early, promoting adequate
oxygenation of heart muscle and decreasing cardiac
workload can prevent cardiogenic shock.
• This can be accomplished by conserving patient’s energy,
promptly relieving angina, and administering supplemental
oxygen.
2) Monitoring Hemodynamic Status:

• A major role of the nurse is monitoring the patient’s

hemodynamic and cardiac status.
.

• Changes in hemodynamic, cardiac and pulmonary status and

laboratory values are documented and reported promptly.

3) Administering medications and IV

fluids:
• The nurse play a critical role in safe and accurate
administration of IV fluids and medications.
• Fluid overload and pulmonary oedema are risks because of
ineffective cardiac function and accumulation of blood and
fluid in pulmonary tissues.
4) Enhancing safety and comfort:
• The nurse must take an active role in safeguarding the
patient, enhancing comfort and reduce anxiety.
• This includes administering medication to relieve chest pain,
preventing infection at multiple arterial and venous line
insertion sites, protecting the skin and monitoring respiratory
and renal functions.
  Nursing Diagnosis:
1) Impaired gas exchange related to decreased
blood flow as evidenced by breathlessness.
2) Acute pain related to patient’s conditions
verbalized by patient.
3) Decreased cardiac output related to
impaired myocardial function as evidenced
by hypotension.
4) Ineffective tissue perfusion related to
decreased cardiac output as evidenced by
cold, clammy skin.
 3)Distributive shock
● Distributive shock occurs when intravascular
volume pools in peripheral blood vessels.
● The abnormal displacement of intra vascular
volume causes a relative hypovolemia
because not enough blood returns to heart,
which lead to inadequate tissue perfusion.
● Three sub classification of distributive shock.
  Classification:

Distributive
shock

Neurogenic Anaphylactic
Septic shock
shock shock
A) Septic Shock:
● Septic shock is the most common type of
distributive shock, is caused by widespread
infection or sepsis.
● SEPSIS: “Life threatening organ dysfunction
caused by a dysregulated host response to
infection.”
● SEPTIC SHOCK: “A subset of sepsis in which
underlying circulatory & cellular metabolism
abnormalities are profound enough to
substantially increase mortality.”
 Risk factors:

● Aging
● Drug resistant bacteria
● Immunodeficiency
● Invasive procedures
● Emergent / multiple surgeries
 Pathophysiology:
Infection

Microbial Toxins

Host defence mechanism gets

activated
 .

Inflammatory
response

Inadequat
Adequate Excessive e

Survival
 .

Tissue Injury

Multiorgan
Failure

Death
 Sign & Symptoms:

● Tachycardia
● Difficulty in breathing
● Fever, chills, rigors
● Fatigue, Malaise
● Nausea & vomiting
 Diagnostic Evaluation:
● History collection
● Physical examination
● Culture test
● CBC
● RFT, LFT
● ECG
● Chest X-ray
● USG
● ABG
● Clotting profile
  Medical Management:
●It includes:
1) Correction of underlying causes
2) Fluid replacement therapy
3) Pharmacological therapy
4) Nutritional therapy
 1) Correction of underlying cause:
● Current treatment of sepsis & septic shock
involves rapid identification & elimination of
the cause of infection’
● Current goals are to identify & treat patients in
early sepsis within 3 hrs to optimize patient
outcome.
● The effort to continue to reduce death from
sepsis, CMS has launched Core Measure for
Sepsis ,requiring that hospitals demonstrate
adherence to 3 hrs & 6 hrs timed
interventions.
● Collect sample for culture & then starts anti-
2) Fluid replacement therapy:
● Fluid replacement must be
instituted to correct tissue
hypoperfusion that results from
incomplete vasculate & the
inflammatory response.
● Reestablishing tissue perfusion
through aggrieve fluid
resuscitation is key to the
management of sepsis & septic
shock.
3) Pharmacologic therapy:
● If the infecting organism is
unknown, broad sprectrum
antibiotic agents are started until
culture & sensitivity reports are
received.
● If fluid therapy alone does not
effectively improve tissue
perfusion, vasopressor agents,
specially norepinephrine of
dopamine may be initiated.
4) Nutritional therapy:
● Aggressive nutritional supplementation
should be initiated within 24 to 48 hrs of ICU
admission the hypermetabolic state present
with septic shock.
● Malnutrition further impair the patient’s
resistance to infection.
  Nursing Management:
● All invasive procedures must be carried out with
aseptic technique after careful hand hygiene.
● In addition, IV lines, arterial and venous puncture sites,
surgical incision, traumatic wounds and urinary
catheter must be monitored for sings of infection.
● Nurses should identify patients who are at risk for
sepsis and septic shock (i.e., older adults,
immunosuppressive patients and those with extensive
trauma, burns and diabetes.), keeping in mind that
these high risk patients may not develop typical or
classic signs of infection and sepsis.
  Nursing Diagnosis:
● Impaired cardiopulmonary tissue perfusion
related to wide spread of infection as
evidenced by difficulty in breathing.
● Impaired fluid electrolyte imbalance related
to capillary leakages evidenced by nausea,
vomiting.
● Altered body temperature related to wide
spread of infection as evidenced by patient’s
body temp.
● Risk for impaired skin integrity related to
B) Neurogenic Shock:

● In neurogenic shock, vasodilation occurs as a

result of a loss of balance between
parasympathetic & sympathetic stimulation.
● Sympathetic stimulation causes vascular
smooth muscle to constrict &
parasympathetic stimulation causes vascular
smooth muscle to relax or dilate.
 .

●The blood volume is displaced

producing hypotensive state.
●Inadequate BP results in the
insufficient perfusion of tissue & cells
that is common to all shock states.
 Causes:
● Spinal cord injury
● Spinal anesthesia
● Lack of glucose
● Other nervous system damage
 Sign & Symptoms:
● Hypotension
● Bradycardia
● Warm, Dry extremities
● Poikilothermia - (Inability to maintain
a constant core temp.)
 Diagnostic Evaluation:
● History collection
● Physical Examination
● Vital signs Assessment
● CT scan
● MRI
  Medical Management:
● Treatment of neurogenic shock involves restoring
sympathetic tone, either through the stabilization
of a spinal cord injury or spinal anesthesia.
● High dose of steroid is given to reduce
inflammation.
● IV fluids administration is done to stabilize blood
pressure.
● Inotropic agents such as dopamine may be
infused for fluid resuscitation.
● Atropine is given intravenously to manage severe
bradycardia
  Nursing Management:
● It is important to elevate and maintain the head of the
bed at least 30 degree to prevent neurogenic shock.
● In suspected spinal cord injury, neurogenic shock may
be prevented by carefully immobilizing the patient to
prevent further damage to spinal cord.
● Nursing interventions are directed toward supporting
cardiovascular and neurogenic function until the
usually transient episode of neurogenic shock
resolves.
  Nursing Diagnosis:
1) Acute pain related to nerve damage as evidenced by
patient’s oral report.

2) Ineffective tissue perfusion related to disruption in

autonomic pathways as evidenced by low blood pressure.

3) Risk for injury relate to altered level of consciousness,

weakness.

4) Risk for impaired skin integrity related to compromised

circulation and prolonged immobility.
C) ANAPHYLACTIC SHOCK:
● Anaphylactic shock is caused by a severe allergic
reaction when patients who have already produced
antibodies to a foreign substance develop systemic
antigen- antibody reaction, specially an IgE mediate
response.
● This antigen antibody reaction provokes mast cells to
release potent vasoactive substances such as
histamine or bradykinin and cytokines causing
widespread vasodilation.
● Common triggers are: Foods
Medications
Insects
.

● Three main characteristics of anaphylaxis:

1) Acute onset of symptoms.
2) Two or more response include
respiratory compromise, reduced BP, skin
or mucosal tissue irritation,
3) Cardiovascular compromise from min
to hours after exposure to antigen.
 Signs and Symptoms:
● Headache
● Nausea , vomiting
● Pruritus
● Abdominal pain or discomfort
● Bronchospasm
● Cardiac dysrhythmias
● Hypotension
 Diagnostic Evaluation:
● History collection
● Physical Examination
● Allergy testing
● CBC ( WBC count)
  Medical Management:
● Treatment of anaphylactic shock requires removing the
causative antigen.
● Administer medication that restores vascular tone &
providing emergency basic life function.
● IM epinephrine is given for vasoconstrictive action.
● Diphenhydramine is given Intravenously to reverse
effects of histamine.
● Nebulized medication , such as albuterol may be given
to reverse histamine induced bronchospasm.
  Nursing Management:
● The nurse must assess all patients for allergies or
previous reactions to antigens (e.g., medications,
blood products, foods, latex) and communicate the
existence of these allergies.
● When administering any new medication, the nurse
observes all patients for allergic reactions.
● This is especially important with antibiotics, beta-
blockers, angiotensin inhibitors, aspirin and NSAIDs.
● If the patient reports an allergy to a medication, the
nurse must be aware of the risks involved in the
administration of similar medications.
.

● At hospital and outpatient diagnostic testing sites, the

nurse must identify patients who are at risk for
anaphylactic reactions to contrast agent ( radiopaque,
dye-like substance that may contain iodine) used for
diagnostic tests.
● The nurse must be knowledgeable about the clinical
signs if anaphylaxis, must take immediate action if
sign and symptoms occur and must be prepare to
begin CPR if cardiorespiratory arrest occurs.
  Nursing Diagnosis:
1) Ineffective breathing pattern related to
bronchospasm as evidenced by use of accessory
muscles.
2) Altered tissue perfusion related to decreased cardiac
output as evidenced by altered mental status, pale
and cold extremities,
3) Risk for injury related to dizziness and hypotension.
4) Knowledge deficient related to lack of information
about anaphylaxis as evidenced by asking frequent
questions