Definition Shock is a physiologic state characterized by systemic

reduction in tissue perfusion, resulting in decreased tissue oxygen

delivery. 3

4. Other Ways * It’s a condition, in which circulation fails to meet the

metabolic need of the tissue & at the same time fails to remove the
metabolic waste products. • Inadequate tissue perfusion to meet tissue
demands • Usually result of inadequate blood flow and/or oxygen delivery
• Inadequate peripheral perfusion leading to failure of tissue
oxygenation • Lead to anaerobic metabolism 4

5. 5 Demand Supply

6. 6 Demand Supply Shock

7. Pathophysiology of Shock

8. Cells switch from aerobic to anaerobic metabolism lactic acid

production Cell function ceases & swells membrane becomes more permeable
electrolytes & fluids seep in & out of cell Na+/K+ pump impaired
mitochondria damage cell death
9. Shock – Effects on Organ Heart – ↓ CO / hypotension / myocardial
depressants Lung - ↓gas exchange / tachypnoea / pulmonary edema
Endocrine – ADH → ↑ reabsorption of water CNS – perfusion ↓ –
drowsy Blood - Coagulation abnormalities – DIC Renal - ↓ GFR - ↓
urine output GIT – mucosal ischaemia – bleeding & hepatic - ↑ enzyme
levels

10. 11

11. HYPOVOLAEMIC ETIOLOGY Blood loss. haemorrhage Plasma / body

water loss. Electrolytes imbalance. Vomiting. Diarrhea.
Dehydration.

12. Valvular heart disease Myocardial infarction. Cardiac

arrhythmias. Cardiomyopathy CARDIOGENIC ETIOLOGY

13. OBSTRUCTIVE ETIOLOGY Cardiac Tamponade Pulmonary Embolism

Tension Pneumothorax Air embolism

14. NEUROGENIC ETIOLOGY Paraplegia. Quadriplegia. Trauma to spinal

cord. Spinal anesthesia.

15. ANAPHYLACTIC ETIOLOGY Injections - Penicillins. Anaesthetics

Stings. Shelfish.

16. Gram + Gram - Fungi / Virus Protozoa SEPTIC ETIOLOGY

17. ENDOCRINE ETIOLOGY Hypo & Hyperthyroidism. Adrenal insufficiency.

18. Clinical Features Features of shock depend on the degree of loss

of volume & on duration of shock. Types Mild shock. Moderate shock.
Severe shock.

19. Mild Shock Features Collapse of subcutaneous veins of extremities

esp. the feet, which become pale and cool Sweat on forehead, hand and
feet Urine output normal. Pulse rate normal. Blood pressure normal.
Patient feels thirsty and cold.

20. Moderate Shock Features Mild shock features + drowsy & confused
Oliguria Pulse rate increased usually less then 100/min. Blood
pressure normal initially then falls in later stage.

21. Severe Shock Features Unconscious. Gasping respiration.

Anuria. Rapid pulse. Profound hypotension.

22. Stages of shock Initial : The cells become leaky and switch to
anaerobic metabolism. Non-progressive:(compensated stage) Attempt to
correct the metabolic upset of shock. Progressive: (decompensated
stage ) Eventually the compensation will begin to fail. Refractory :
Organs fail and the shock can no longer be reversed.

23. 24

24. SHOCK [ Management ]

25. Monitoring Blood pressure Heart rate Respiratory rate Urine

output Blood CBC Pulse- oximetry ECG U/S , CT , X-ray

26. Special Monitoring CARDIO – VASCULAR - Central venous pressure

Normal ; 5-10cmH2O, If CVP<5cmH2O Inadequacy of blood volume
CVP>12cmH2O Cardiac dysfunction - Cardiac output Pulmonary catheter
Doppler ultrasound Pulse waveform analysis

27. Special Monitoring SYSTEMIC & ORGAN PERFUSION Clinical : urine

output & LOC Sr. Lactate estimation & Base defecit Blood gas analysis
PO2 / PCO2 / ph Mixed venous O2 saturation – N – 50-70% Newer
methods Muscle tissue O2 probes Near –infrared spectroscopy
Sublingual capnometry

28. Guidelines Treat the cause Improve Cardiac function Improve

Tissue perfusion

29. Goals of Resuscitation Overall goal: increase O2 delivery

decrease demand Treatment O2 content Cardiac output Blood pressure
Sedation/analgesia

30. Principles of Resuscitation A: Airway patent upper airway B:

Breathing adequate ventilation and oxygenation C: Circulation
placement of adequate IV access cardiac function oxygenation

31. Fluid Therapy in Shock Crystalloid Solutions Normal saline

Ringers Lactate solution Hartmann’s solution Colloid Solutions
Blood transfusion

32. Oxygen Carrying Capacity Only RBC contribute to oxygen carrying

capacity (hemoglobin) Replacement with all other solutions will
support volume Improve end organ perfusion Will Not provide
additional oxygen carrying capacity

33. Dynamic Fluid Response Infusing 250-500ml of Fluid rapidly in 5

- 10 mts. Responders – Improvement Transient responders – revert
back Non – responders

34. Vasopressors / Inotropic Drugs Vasopressors – Phenylephrine / NA

Distributive shock states Septic shock / Neurogenic Inotropics -
Dobutamine Cardiogenic shock / Severe septic shock To increase the
cardiac output

35. Other Treatments Correction of Acid – base balance Steriods -

Hydrocortisone Antibiotics Catheterisation Nasal O2 / Ventilatory
support CVP Line Control of Pain ICU – Critical care management

36. End Points of Resuscitation Classic / Traditional Restoration of

blood pressure Normalization of heart rate and urine output
Appropriate mental status Improved / Global All of the above plus
Normalization of serum lactate levels Resolution of base deficit
Adequate - MVS Goal directed approach Urine output > 0.5 mL/kg/hr
CVP 5 -10 cm H2o MAP 65 to 90 mmHg Central venous oxygen concentration >
70%

is clouding or opacity of crystalline lens the impairs vision.

The lens is a delicate structure & any insult on it causes absorption of

water, resulting in the lens becoming opaque.

According oWHO, cataract is the leading cause of blindness in theworld

(2002).

CauseFrom birth (congenital).

Age (senile).Eye injury (traumatic).Secondary to existing eye disease

(e.g. uveitis).Drug like corticosteroids.Cataract associated with
systemic disease (DM, Hyperparathyroidism).UV light exposure.

€High dose of radiation therapy.Degree of CataractImmature cataract

² part of the lens is opaque.Mature cataract

² the whole lens is opaque & may be swollen.

Congenital CataractCauseyAbnormal development of the eye.yMetabolic

disturbance.

Rubella or malnutrition in first trimester of pregnancy.

C/

y
Unable to see.

white pupil (Unilateral or bilateral).

Rx: -

Removing the cataract

132

Senile Cataract

Occur in patients over the age of 6

years.

They result from sclerosis of the lens due to a degenerativeprocess.

Usually bilateral.

It is either;

Nuclear:-

affects the central lens & takes on a brown color.

The patient sees better in dim light when pupil is dilated.

Cortical:-

Affects the periphery of the lens & looks white.

€

Vision is usually better in bright light when the pupil is constricts.

133

eneral C/

radual, progressive, and painless loss of vision.

Double vision/blurred vision/

Reduced light transmission.

Rainbow/haloes/

revious dark pupil appear milky or white.

Dx

Hx.

/E.

Ophtalmoscopic exam.

S
lit lamp examination.

13

Slit lamp examination.

135

gx

Surgery;

surgical removal of the lens usually done under local anesthesia.

IO

(intraocular lens) are usually implanted at the time of cataract

extraction.

Nursing intervention

Preparing the pt for surgery.

Orient pt and explain the procedure and plan of care todecrease anxiety.

Instruct the pt not to touch to decrease contamination.

Administer preoperative eye drops.

136

Postoperative care;

Administer medication as prescribed.

Teach the pt to report sudden pain and restlessness withincreased pulse.

Caution pt against coughing, sneezing, rapid movement, bending.

Encourage pt to wear shield at night to protect operated eyefro injury

while sleeping.

137

lunt contusionIt is bruising of the periorbital soft tissue.

C/M

swelling and discoloration of the tissue.Bleeding in to the tissue and

structure of the eye.Pain.

MgxReducing swelling and pain by applying cold and warmcompress.Refer for

ophthalmologist ass·t.

HyphemaIt is the presence of blood in the anterior chamber.C/MPain.

Blood in the anterior chamber.Increase IOP

MgxUsually spontaneously recovers.If sever bed rest, and eye shield

application.

Orbital fractureIt is fracture and dislocation of the wall of the

orbit,orbital margin or both.Cause:-Injury on the cranial area.C/M

Rhinorrhea.Contusion.Diplopia.

MgxMay heal by itself, if no displacement or infringement onthe other

structure.

Surgery:-repair of the orbital floor.

Foreign bodyIt is the presence of foreign material on the cornea
orconjunctiva.C/MSevere pain with lacrimation.Foreign body sensation.

Photophobia.Redness.Swelling.

MgxConsider a medical emergency.Removal of foreign body through

irrigation, cotton tippedapplicator.Surgical removal.

Laceration/Perforation.It is cutting or penetration of soft tissue.

C/MPainBleedingLacrimation Photophobia

MxConsider as medical emergency.Surgical repair-method of repair depends

on the severityof injury.Antibiotics.

Ruptured globeIt is concussive injury to globe with tears in the ocular

coat, usually the globe.

C/

Pain

ltered I

Limitation of gaze in field of rupture

yphema

hemorrhage

gx
Consider as medical emergency.

Surgical repair

ntibiotics

Steroids

Enucleation

156

Burn of the eye

It is the destruction of the eye tissue by chemical, thermal,

andultraviolet ray.

A.

urn of chemical agent that is caused by alkali or acids.

C/

Pain

Burning

Lacrimation
Photophobia

gx

Consider as medical emergency.

Copious irrigation until

H is 7.

eratoplasty for severe scaring.

Antibiotics.

157

Burns of thermal sourcesC/

ain

urned skin

listers

M
gx

First aid-apply sterile dressing.

ain control.

eave fluid blebs intact.

uture eyelid together to protect eye if perforation is possible.

kin grafting with severe second and third degree burns.

Burn of UV sourceC/

ain

Foreign body sensation

acrimation

hotophobia
M

gx

ain relief.

ilateral patching with antibiotic ointment and cycloplegics.

159