SHOCK

Introduction
Shock can refer to a range of related medical conditions in which the victim's heart, lungs and
blood cannot deliver oxygen to the body properly. Shock is not a diagnosis or condition, it is
always a symptom of a larger problem, and is a medical emergency that requires immediate
attention. One should never confuse true shock with a feeling of extreme surprise - one does not
lead to the other.

Definition
mate interventions before shock ensues. Shock is defined as failure of the circulatory system to
maintain adequate perfusion of vital organs. Disorders lading to inadequate tissue perfusion
result in decreased oxyenation at the cellular level. Inadequate oxygen results in anaerobic
cellular metabolism and accumulated waste products in cells. If this condition is untreated, cell
and organ death occur.
classification
Hypovolemic
due to inadequate circulating blood volume resulting from haemorrhage with actual blood loss,
burns with a loss of plasma proteins and fluid shifts, or dehydration with a loss of fluid volume.
It is the most common type of shock and develops when the intravascular volume decreases to
the point where com peasantry mechanisms are unable to maintain organ and tissue perfusion.
Cardiogenic shock
that early Cardiogenic shock is due to inadequate pummping, of the heart because of primary
cardiac muscle dysfunction or mechanical obstruction of blood flow caused by myocardial
infarction (MI), valvular insufficiency caused by disease or trauma, cardiac dysrhythmias, or all
obstructive condition, such as pericardial tamponade or pulmonary embolus.

incidence
Etiology of shock was more distributed with 26.9% of patients in cardiogenic shock, 16.8%
distributive, and 10.7% classified as mixed.

Distributive shock
(also called 1rasogenic shock) is due to changes in blood vessel tone that increase the size of the
vascular space without an increase in the circulating blood volume. The result is a relative
hypovolemia (total fluid volume remains the same but is redistributed). Distributive shock is
further divided into three types:.
Anaphylactic shock. A severe hypersensitivity reaction resulting in massive systemic
vasodilation.
Neurogenic shock interference with nervous sys tem control of the blood vessels, such as with
spinal cord injury ( cervical spine injury , spinal anaesthesia, or severe vasovagal reactions
caused by pain or psychic trauma.
Septic shock, caused by a release of vasoactive sub stances

1.Hypovolemic shock

due to inadequate circulating blood volume resulting from haemorrhage with actual blood loss,
burns with a loss of plasma proteins and fluid shifts, or dehydration with a loss of fluid volume.
It is the most common type of shock and develops when the intravascular volume decreases to
the point where com peasantry mechanisms are unable to maintain organ and tissue perfusion.

Hypovolemic shock is a life-threatening condition that results when you lose more (1_25 20)
percent (500_1500) of your body’s blood or fluid supply. This severe fluid loss makes it
impossible for the heart to pump a sufficient amount of blood to your body. Hypovolemic shock
can lead to organ failure.

Etiology

Hypovolemic shock results from significant and sudden blood or fluid losses within your body.
Blood loss of this magnitude can occur because of:

bleeding from serious cuts or wounds

bleeding from blunt traumatic injuries due to accidents

internal bleeding from abdominal organs

bleeding from the digestive tract

Endometriosis

Dehydration (excessive or prolonged diarrhea,vomiting,excessive sweating, increase urine out

put. Longed fluid deficit

severe burns. Shifted plasma from vascular to interstitial spaces

Mild symptoms can include:

 headache

 fatigue

Severe symptoms

Early symptoms of hypovolemia include

headache

fatigue

Weakness

Thirst

Dizziness.

The more severe signs and symptoms are often associated with hypovolemic shock. These
include
oliguria
cyanosis
abdominal and chest pain
hypotension
tachycardia, cold hands
and feet
progressively altering mental status.
2.Cardiogenic shock
that early Cardiogenic shock is due to inadequate pummping, of the heart because of primary
cardiac muscle dysfunction or mechanical obstruction of blood flow caused by myocardial
infarction (MI), valvular insufficiency caused by disease or trauma, cardiac dysrhythmias, or all
obstructive condition, such as pericardial tamponade or pulmonary embolus.
Pathophysiology
Cardiogenic shock is characterized by inadequate tissue perfusion due to cardiac dysfunction,
and it is often caused by acute myocardial infarction.The pathophysiology of cardiogenic shock
involves a vicious spiral circle: ischemia causes myocardial dysfunction, which in turn
aggravates myocardial ischemia. Myocardial stunning and/or hibernating myocardium can
enhance myocardial dysfunction, thus, worsening the cardiogenic shock. Low perfusion
pressures with global ischemia leads to muthliorgan dysfunction.

Symptoms
Cardiogenic shock signs and symptoms include:

 Rapid breathing
 Severe shortness of breath

 Sudden, rapid heartbeat (tachycardia)

 Loss of consciousness

 Weak pulse

 Low blood pressure (hypotension)

 Sweating

 Pale skin

 Cold hands or feet

 Urinating less than normal or not at all

 Septic Shock
Causes

 abdominal or digestive system infections

 lung infections like pneumonia

  urinary tract infection

 reproductive system infection

Pathophysiology
Sepsis is the systemic response to infection. The process begins with the growth of
microorganisms at the site of infection, organisms may invade the bloodstream directly or may
remain in one area. organisms release various substances into the blood stream such as
endotoxins and elements synthesized them called exotoxins. Once these substances are released
into the body they activate the
Neurogenic Shock
Pathophysiology
With injury to he cervical spine, the autonomic nervous system is afected, Below the level of
injury, there is blocking of sympathetic nervous stimulation and the parasympathetic system goes
unopposed. This unopposed stimulation causes vasodilation, decreased venousreturn], decrease
cardiac output, and decreased tissue perfusion), Teaching clients safety measures may help
prevent spinal Cord in jury and neurogenic shock. Health maintenance actions are to protect the
client 's spine, maintain the client' s airway and breathing, pro vide circulatory support, and
provide for thermoregulation tion). Health restoration involves rehabilitation when the client is
stable,
complement cascade and a complex shock occurs.
forms of result, The massive distributive shock has several major causes. Acute Allergic
Reaction (
Anaphylactic Shock
Anaphy - begin lactic shock occurs as a result of an acute allergic reintion from exposure to a
substance to which the client has alemd been sensitized. Common sensitizing agents are peni
berries, peanuts, snake venom, iodine - based coritrast for X - ray studies, foods, and
nonsteroidal anti - inflammatory drugs (NSAIDs). Re - exposure to the foreign substance results
in the offending antigen binding to previously made in immunoglobulins (i, e, lgE) located on
the mast cell. This binding causes the release of several chemical mediators from the cell, such
as histamine, platelet - activating factor leukotrienes, and prostaglandins (see Chapter 78)
Manifestations include massive vasodilation, Urticaria (hives), laryngeal derma, and bronchial
construction, Without prompt treatment, a person with anaphylactic shock will die of
cardiovascular collapse and respiratory failure
Symptoms
  fever

 low body temperature (hypothermia)

 fast heart rate

 rapid breathing, or more than 20 breaths per minute

 confusion

 dizziness

 Tachypnea

 Cyanosis

 Dry flushed skin

 Pale cold clammy skin

 Systemic effect of shock

Hormonal Effects
 Glucagon (contributes to hyperglycaemia) - ACTH (stimulates cortisol release and
glucose production)
 Hypothalamus Effects
 decreased blood flow to hypothalamus - release of ADH from post pituitary results in
retention of salt, water and peripheral vasoconstriction
 Renal Effects
 decreased renal blood flow - renin released from kidney - initiation of RAAS results in
peripheral vasoconstriction, reabsorption of Na + and H2O
 Respiratory Effects
 Tachypnoea is one of the first signs that reflect reduced blood flow and oxygen transport,
Cardiovascular and Respiratory systems work together. If blood flow around the body is
compromised in any way, oxygen delivery to tissues is reduced. To compensate for this,
ventilation will increase to attempt to increase oxygen uptake in the lungs. So how does
this happen? The Baroreceptors not only stimulate the cardiovascular control centre but
also the respiratory centre in the medulla, increasing the respiratory rate 19
 Peripheral Effects
 arteriolar constriction - increased peripheral resistance - shunting of blood to main core
organs (causing cold clammy skin)
 Cardiac Effects - increased force of contractions - increased rate (tachycardia) - increased
cardiac output
Diagnostic test

 Electrocardiogram (ECG).
 Chest X-ray
 Cardiac catheterization (angiogram).

Blood test

Blood count
WBC
Body fluid study
ABG
RFT
Electrolyte test
Treatment
Hypovolemic shock treatment
blood loss

Stop external bleeding With direct pressure dressing tomiquet (as last resort) .
Reduce intra - abdominal or retroperitoneal bleeding by applying Mas garment of prepare
for emergency Surgery lesion, tubes Administer lactated Ringer 's solution of normal
saline Transfuse with fresh whole blood ,packed Cells, fresh frozen Plasma platelets, or
other Clotting factors,
if significant improvement does riot occur with crystalloid administration.

Use non - blood plasma expanders (albumnin, hetastarch dextran blood is available
Conduct autotransfusion if appropriate
Plasma loss
Administer low dose Cardiotonics (dopamine dobutamine)
Administer lactated Ringer 's solution of normal saline Administer albumnin. fresh frozen
plasma, hetastarch, or dextran if cardiac output is still low
Crystalloid loss
Administer isotonic or hypotonic saline with electrolytes as needed tomaintain normal
circulating volume and electrolyte balance.

Treatment of cardiogenic shock

 myocardial infraction or injury
 Give up to 300 ml of normal saline solution ofringer lactate o rule out hypovolemia,
Unless heart failure Of pulmonary edema is present Insert CVP OI pulmonary artery.
Catheter to monitor cardiac and pulmonary artery pressure and PCWP
administer fluids to maintain left ventricular filling pressure of 15 - 20 mm Hg
Administer entropic (dopamine or dobutamine)
Vasodilators (sodium nitroprusside, nitroglycerin ,calcium - Channel blockers morphine)
Diuretics (mannitol or furosemide)
Cardiotonics (digitalis) Beta - blockers (propranolol)
Glucocorticosteroidst
Intra - aortic balloon pump or external counterpulsation device if un responsive to other
therapies Same as above if rapid response does not occur.
 External pressure on the heart interferes with heart filing or emptying
 relive tamponade With ECG - assisted Dericardiocentesis: repair surgically if it recurs
Thrombolytic (streptokinase of anticoagulant (heparin) therapy
 Cardiac dysrhythmias

 Relieve fluid accumulation with parenthesis Reduce inspiratory pressure Treat

dysrhythmias
 be prepared to initiate CPR cardiac pacing
Distributive
1. neurogenic shock
  Normal saline to restore volume
 Treat bradycardia with atropine Vasopressors ( norepinephrine, metaraminol bitartrate,
high dosage dopamine and phenylephrine) may be given Place client in modified
Trendelenburg position
 Place client in a head down or recumbent position Give atropine if bradycardia and
profound hypotension eliminate pain

2.Treatment of Septic shock

 identify origin of sepsis; culture all suspected sources Vigorous

 IV fluid resuscitation with normal saline Empirical antibiotic therapy until sensitivities
are reported.
 If suspected organism is gram - positive, Vancomycin.
 If suspected organism is gram - negative, give expanded spectrum penicillin or a
cephalosporin and aminoglycoside.
 Administer Cardiotonics agents ( Dopamine or dobutamine norepinephrine
isoproterenol, digitalis, calcium)
 Naloxone (narcoticagon Prostaglandins Monoclonal antibodies Temperature control
(both hypothermia and hyperthermia are noted)
 Heparin clotting factors, blood products if DIC develops

3. Treatment Anaphylatic shock

 Prepare for surgical management of the airway

 Decrease further absorption of antigen ( stop Iv tourniquet between injection of sting site
and heart
 Epinephrine (1: 100) 2 inhalations every 3 hours or
 Epinephrine (1: 1000) 0. 2 - 0 5 ml every 5 - 15 min given subcutaneously, at rate of 1
mg / min
 IV fluid resuscitation with isotonic solution Diphenhydramine HCl or H receptor
antagonist IV Theophylline IV drip for bronchospasm Steroids IV | Vasopressors
(norepinephrine metaraminol bitartrate dosage dopamine).
 Gastric lavage for ingested antigen Ice pack to injection site Meat tenderizer paste to
sting site.
Surgical management

 surgery for removal of clot or air accumulation with needle thoracotomy or chest tube in
insertion.
 prepare for prompt cardiac surgery.
 Underlying causes (injury..GIT bleeding...)

Nursing care of patient on SHOCK

Give Rescue Breaths or CPR as needed.

Lay the person flat, face - up, but do not move him or her if you suspect a head, back, or neck
injury. . Raise the person's feet about 2 inches. Use a box, etc. If raising the legs will cause
pain or further injury, keep him or her flat. Keep the person still.

Do not raise the feet or move the legs if hip or leg bones are broken. Keep the person lying flat.

Fluid and blood replacement: Open MV line on both hands with two wide bore Cannula and start
fluid rapidly as advised

Administer oxygen via face mask.

Identify the cause and treat accordingly.

Vasoactive medications to improve cardiac contractility, i. e. Dopamine, Dobutamine,

Noradrenaline.

Other care are same as the care of unconscious patient.

Check for signs of circulation. If absent, begin FDD

Turn the person on his or her side to prevent choking if the person vomits or bleeds from the
mouth. Keep the person warm and comfortable.

Loosen belt (s) and tight clothing and cover the person with a blanket
: Even if the person complains of thirst, give nothing by mouth. If the person wants water,
moisten the lips.

Decreased Cardiac Output: Inadequate blood pumped by the heart to meet metabolic demands
of the body.

May be related to

 Alterations in heart rate and rhythm.

 Decreased ventricular filling (preload).
 Fluid volume loss of 30% or more.
 Late uncompensated hypovolemic shock.

Possibly evidenced by

 Abnormal arterial blood gasses (ABGs); hypoxemia and acidosis.

 Capillary refill greater than 3 seconds.
 Cardiac dysrhythmias.
 Change in level of consciousness.
 Cold, clammy skin.
 Decreased urinary output (less than 30 ml per hour).
 Decreased peripheral pulses.
 Decreased pulse pressure.
 Decreased blood pressure.
 Tachycardia.

Desired Outcomes

 Client will maintain adequate cardiac output, as evidenced by strong peripheral pulses,
systolic BP within 20 mm Hg of baseline, HR 60 to 100 beats per minute with regular
rhythm, urinary output 30 ml/hr or greater, warm and dry skin, and normal level of
consciousness.
Deficient Fluid Volume

Deficient Fluid Volume: Decreased intravascular, interstitial, and intracellular fluid.

May be related to

 Active fluid volume loss (abnormal bleeding, diarrhea, diuresis or abnormal drainage).
 Internal fluid shifts.
 Inadequate fluid intake and/or severe dehydration.
 Regulatory mechanism failure.
 Trauma.

Possibly evidenced by

 Capillary refill greater than 3 seconds.

 Changes in the level of consciousness.
 Cool, clammy skin.
 Decreased skin turgor.
 Dizziness.
 Dry mucous membranes.
 Increased thirst.
 Narrowing of pulse pressure.
 Orthostatic hypotension.
 Tachycardia.
 Urine output may be normal (>30ml/hr) or as low as 20 ml/hr.

Desired Outcomes

 Client will be normovolemic as evidenced by HR 60 to 100 beats per minute, systolic

BP greater than or equal to 90 mm Hg, absence of orthostasis, urinary output greater
than 30ml/hr, and normal skin turgor.
Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the
tissues at the capillary level.

May be related to

 Decreased stroke volume.

 Decreased preload.
 Diminished venous return.
 Severe blood loss.

Possibly evidenced by

 Altered mental status.

 Cool, clammy skin, pale colour.
 Cyanosis.
 Delayed capillary refill.
 Dizziness.
 Shallow respirations.
 Weak, thready pulse.

Desired Outcomes

 Client will maintain maximum tissue perfusion to vital organs, as evidenced by warm
and dry skin, present and strong peripheral pulses, vitals within patient’s normal
range, balanced I&O, absence edema, normal ABGs, alert LOC, and absence of
chest pain.


Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.

May be related to
  Change in health status.
 Fear of death.
 Unfamiliar environment.

Possibly evidenced by

 Agitation.
 Apprehensive.
 Difficulty in concentrating.
 Increased awareness.
 Increased questioning.
 Sympathetic stimulation.
 Verbalized anxiety.

Desired Outcomes

 Client will describe a reduction in level of anxiety experienced.

 Client will use effective coping mechanisms.

Complication
 Cardiopulmonary arrest.
 Dysrhythmia.
 Renal failure.
 Multisystem organ failure.
 Ventricular aneurysm.
 Thromboembolic squealed.
 Stroke
 DIC
 Death.

Health Education
Teaching clients safety measures may help prevent spinal Cord in jury and neurogenic shock.
Encraging clients to treat infections immediately and completely may help reduce the incidence
of septic shock , older and immune compromised clientits should be closely monitored closely
For infection and treatment should begin immediately when infection is diagnosed. Shock is a
serious development, Identify high - risk clients and implement measures to prevent shock
whenever possible.
To help prevent the onset of anaphylactic shock clients to avoid precipitators and to use
epinephrine injection (e.. EpiPen). Encouraging clients to wearmedical alert bracelets and to
seek allergy desensitizah also decreases their potential for anaphylactic shock for receives

Prevention of cardiogenic shock related to MI begins with health promotion activities directed at
client education for decreasing the risk factors associated with coronary artery disease (
increasing exercise modifying dietary intake) Supportive oxygenation and administrate tion of
inotropic agents and vasodilators are health maintenance activities

Conclusion

shock is a life-threatening condition, necessitating prompt diagnosis and therapy to prevent

MOF and death. Despite new insights into pathophysiology and new horizons for treatment, the
main principles of management remain the rapid and complete repletion of circulating blood
volume and treatment of the underlying cause.

Treatment should generally be instituted for shock whenever at least two of the following three
conditions occur: systolic BP of 80 mm Hg or less, pulse pressure of 20 mm Hg or less, and
pulse rate of 120 or more.

REFRENCES
1. Medical surgical Nursing
EIGHTH EDITION
Joyce Black
PHD, RN, CPSN, CWSN, Associate professor
College of nursing University of Nebraska Medical Centre OMAHA Nebraska
2. Medical and surgical Textbook
Edited by,
WILMA J. PHIPPS. PhD, RN,FAAN
Professor Emeritus of Medical-Surgical Nursing
3. Internet references.
4. Medical and surgical Nursing
7th edition
Joyce M. Black & Jane Hokanson Hawks
Volume-1
Saunders publisher
5. Medical surgical Nursing
2 edition
BT Basavanthappa
Japee publisher