SHOCK/TYPES OF SHOCK AND ITS MANAGEMENT.pdf

3/15/2024 © R R INSTITUTIONS , BANGALORE 1
SUBJECT – MEDICAL AND SURGICAL NURSING
TOPIC – SHOCK
PREPARED BY DOLISHA WARBI

3/15/2024 © R R INSTITUTIONS , BANGALORE
2
DEFINITION:
Shock is defined as a syndrome characterized by, "Inadequate tissue perfusion".
This inadequate tissue perfusion is the result of failure of one or more of the following:
1. Heart pump failure.
2. Massive hemorrhage.
3. Resistance to arterial blood flow.
4. Decreased capacity of the venous beds.
It is a life-threatening condition associated with generalized circulatory inadequacy.

STAGE OF SHOCK:
Stage I: Compensatory, or Non-progressive Stage;
ØPatient's blood pressure remains within normal limits.
ØNormal circulatory compensatory mechanisms
eventually cause full recovery without help from
outside therapy.
Stage II: Decompensated or Progressive stage;
ØWithout therapy, the shock becomes steadily worse until
death.
Stage III: Irreversible stage;
ØShock has progressed to such an extent that all forms of
known therapy are inadequate to save the person’s life,
even though, for the moment, the person is still alive.

TYPES
CARDIOGENIC
SHOCK
HYPOVOLEMIC
SHOCK OR
HEMORRHAGIC
SHOCK
ANAPHYLACTIC
SHOCK
SEPTIC SHOCK
NEUROGENIC
SHOCK

CARDIOGENIC SHOCK:
Cardiogenic shock is a condition of diminished cardiac output that severely impairs cardiac perfusion.
Sometimes. Cardiogenic shock is also known as pump failure or low blood flow shock
CAUSES OF CARDIOGENIC SHOCK :
ü Mi
ü Valvular regurgitation
ü Acute myocarditis
ü Cardiomyopathy
ü Cardiac tamponade
ü Pulmonary embolism
ü Acute valvular dysfunction
ü Cardiac dysrhythmia
ü Rupture ventricular aneurysm
ü Beta-blocker overdose
ü Ca-channel blocker overdose
RISK FACTORS:
ü Older age
ü Diabetes mellitus
ü In large infarcts, early use of beta blockers.
ü History of hypertension.
ü Prior myocardial infarction
ü Prior angina
ü ST elevation
ü Coronary heart disease
ü High blood pressure
ü Heart failure
ü Cardiovascular stress with previous myocardial damage

PATHOPHYSIOLOGY:
Can progress to irreversible organ damage and death
Lead to dysfunction of multiple organs, including the kidneys, liver, and brain
Inadequate perfusion of tissues leads to tissue hypoxia and metabolic acidosis
Ventricular failure can lead to pulmonary congestion and edema, impairing gas
exchange in the lung
Vasoconstriction throughout the body increases
Compensatory mechanisms (neurohormonal mechanisms) reacted and increase
heart rate, vasoconstriction, and fluid retention
Reduced contractility leads to decreased stroke and cardiac output
Severe impairment in cardiac function

CLINICAL MANIFESTATION:
qAngina Pectoris, squeezing pain in centre of chest.
qDysrhythmias
qDiminished heart sounds
qAcute drop in blood pressure > 30 mm Hg
qDecreased cardiac output
qTachypnoea, shortness of breath
qWeak, thready pulse
qSweating, cold hand & feet
qUrine output < 30 mL/hr
qCool, pale, moist skin

DIAGNOSTIC EVALUATION:
Physical examination
Vital signs.
Electrocardiogram (ECG)
Echocardiography
Chest x-ray
Coronary angiography
Blood test
Arterial pressure monitoring
MANAGEMENT:
Oxygen administration
Fluid and medication like vasoactive – dobutamine, nitro-glycerine, morphine(IV) and dopamine (reduce chest
pain).
In case of hypotension administer Norepinephrine
Echocardiography
Coronary angiography

NURSING MANAGEMENT:
• Monitor patient vital signs
• Controlling high blood pressure
• Maintain optimal weight and limit the salt intake
• Limiting alcohol consumption can also help to control high blood pressure.
• Reducing salt intake may reduce the risk of heart attack.
• Educate the patient for regular exercise.
• Performed ECG daily
• Medication and fluid administration as per orders
• Ensuring patient's safety and comfort.
COMPLICATION:
1. Renal failure
2. Dysrhythmias
3. Stroke
4. Cardiopulmonary arrest
5. Multi system organ failure
6. Death

HYPOVOLEMIC SHOCK OR HEMORRHAGIC SHOCK:
• Hypovolemic shock is a life-threatening emergency in which severe blood or other fluid loss makes the heart
unable to pump enough blood to the body.
• This type of shock can cause many organs to stop working.
DEFINITION
• It is defined as a decreased in the intravascular blood volume to such an extent that effective tissue perfusion
cannot be maintained.
NORMAL
HYPOVOLEMIC SHOCK

ETIOLOGY:
ü Cuts on a person’s neck and head
ü Dehydration
ü Ulcers or other issues related to the digestive tract
ü Diarrhea
ü Heavy bleeding that takes place while a woman is in labor or delivering a baby
ü Excessive sweating
ü Ectopic pregnancy
ü High fever
ü Ruptured ovarian cyst
ü Kidney disease
ü The organs in an individual’s belly getting damaged
ü A tear in a major blood vessel or in the heart
ü Surgery.

PATHOPHYSIOLOGY:
Decrease tissue perfusion
Decrease cardiac output
Decrease stroke volume
Decrease venous return
Decrease blood volume ( intravascular volume)

• Weakness
• Feeling tired
• Drop in blood pressure
• Skin being cold and clammy
• Rapid heartbeat
• Breathing that’s shallow and quick
• Feeling confused
• Either peeing little or not at all
• Low temperature
• Anxiety
• Blood test
• X-ray
• Echocardiogram
• CT scan
• Urine test
• Electrocardiogram

MEDICAL MANAGEMENT:
1. Vasoactive drugs, e.g. norepinephrine, dopamine: Prevents cardiac failure.
2. If dehydration is secondary to hyperglycemia, insulin is administered.
3. Antiemetics, such as dimenhydrinate: To prevent vomiting
4. Antidiarrheal drugs such as loperamide, bismuth subsalicylate: These are prescribed to prevent diarrhea
5. In case of massive hemorrhage, efforts are made to stop bleeding
NURSING MANAGEMENT:
üMonitor the complete medical history of the patient
üPerform the physical examination of patient.
üMonitor the vital signs.
üMonitor the patient closely to prevent complication.
üMonitor weight of the patient daily,
üAdminister oxygen to increase the amount of oxygen.
üAdminister medications as ordered.
üPut pressure incase of external bleeding.

ANAPHYLACTIC SHOCK:
Anaphylactic shock is defined as. "A severe, sometimes fatal, reaction to a substance to
which a person has an extreme sensitivity, often involving respiratory difficulty and
circulation failure”

CAUSES:
Insect stings.
Food such as shellfish, milk, eggs, latex and peanuts.
Exercise and aerobic activity can trigger anaphylactic shock.
Certain medications such as antibiotics; aspirin and other over the counter pain relievers can cause medication
allergies
RISK FACTORS:
1. History of anaphylactic reaction
2. Allergies
3. Family history of anaphylaxis
4. Heart disease

PATHOPHYSIOLOGY:
Complication of many organs function.
Serve allergies formation can affects many systems
Tissue edema formation can leads to partial and complete obstruction
Inflammatory response to tissue and cell
Allergen enters into the body

1. Difficulty in breathing or wheezing
2. Low blood pressure
3. Swelling of lips, mouth, tongue or throat.
4. Choking sensation.
5. Itching
6. Flushed or pale skin.
7. Tachycardia
8. Anxiety
9. Dizziness leads to fainting.
10. Loss of bowel or bladder function.
11. Chest pain
12. Oliguria to anuria.
Ø Medical History
Ø Physical examination
Ø Blood tests
Ø Plasma histamine or urinary histamine metabolites:
These are helpful in confirming the diagnosis of
anaphylactic shock
Ø Food allergen specific skin test

MEDICAL MANAGEMENT:
Epinephrine (Adrenaline): Reduce body's allergic response.
Oxygen
Intravenous (IV) antihistamines and cortisone
Beta-agonist, such as albuterol.
Diphenhydramine: It is administered to reverse the effects of histamine.
NURSING MANAGEMENT:
Assess patient for allergies or previous reactions to antigens
Assess the level of anxiety.
Monitor the vital signs
Monitor the oxygenation status of patient
Assess the patient's knowledge about anaphylactic shock
Encourage adequate rest to patient.
Monitor urine output.

SEPTIC SHOCK:
Septic shock is caused by systemic infection and inflammatory extensive release of chemical mediators and
endotoxins causes dilation of blood vessels and loss of fluid into the interstitial space.

ETIOLOGY:
1. Abdominal or digestive system infections.
2. Pneumonia
3. Urinary tract infection
4. Reproductive system infection
5. Patient with immunosuppression has greater chance of
acquiring septic shock
6. Elderly people and infants are more prone to septic
shock
7. Malnourishment
8. Chronic illness
Causative microorganisms implicated in septic shock
G+ve
BACTERIA
G-ve
BACTERIA FUNGI
§ Staphylococ
cus aureus
§ Staphylococ
cus
epidermidis
§ Streptococcu
s pneumonia
§ Escherichia
coli
§ Enterobacter
spp
§ Klebsiella
pneumoniae
§ Hemophilus
influenzae
§ Bacteroides
§ Protozoa
§ Rickettsia
§ Virus

RISK FACTORS:
1. Poor nutrition
2. Wounds, injuries such as burn
3. Hematoma
4. Anemia
5. Major surgeries
PATHOPHYSIOLOGY:
Septic shock involves a widespread inflammatory response which produces a hypermetabolic effect.
Microorganisms invade the body tissues which in turn, exhibit an immune response. Immune response provokes the
activation of biochemical cytokines
Sepsis can cause derangements or failure in every organ system.
Pro-inflammatory or anti-inflammatory cytokines are released.
Dysregulated host response to infection.

1. Change in mental status
2. Palpitations
3. Rapid heart rate
4. Shortness of breath
5. Pair arms and legs.
6. Skin.
• Initially Warm and flushed.
• Later: Cool, pale and edematous
7. Skin rash or discoloration
8. Hypotension occur because of vasodilation
9. Decrease urine output.
Decrease urine output
Cool, pale

§ Liver function test
§ Blood culture test.
§ Urine test.
§ Chest X-ray.
MEDICAL MANAGEMENT:
qAntibiotics such as ceftriaxone, azithromycin. ciprofloxacin and vancomycin are administered intravenously.
qFluid replacement therapy: Performed to correct the tissue hypoperfusion
qDrotrecogin alfa is used which act as antithrombotic anti-inflammatory and profibrinolytic agent.
qVasopressors: These are used to maintain adequate blood pressure (Norepinephrine, phenylephrine,
dopamine, epinephrine, and vasopressin).

NURSING MANAGEMENT:
• Assess the presence of hypotension, tachypnea, and tachycardia, decreased urine output, clotting disorder.
• Monitor patient closely for shivering.
• Administer prescribed IV fluids and medications.
• Assess the patient’s intake and output and nutritional status.
• Instruct patient and family about septic shock.
• Communicate with patient and family members
• Encourage patient and family to talk about their concern.
COMPLICATION:
1. Kidney failure
2. Heart failure
3. Abnormal blood clotting
4. Respiratory failure
5. Stroke
6. Liver failure
Abnormal blood clotting

NEUROGENIC SHOCK:
Neurogenic shock is a life-threatening condition caused by the disruption of autonomic nervous system regulation
of vascular tone. This disruption leads to widespread vasodilation and subsequent hypotension, often accompanied
by bradycardia (slow heart rate).
Neurogenic shock typically occurs as a result of severe injury or trauma to the spinal cord, brain, or nerves
controlling the blood vessels.

CAUSES:
Ø Spinal cord injury
Ø Gunshot wounds to the spine.
Ø Brain injury
Ø Nerve damage
Ø Autonomic nervous system toxins
Ø Guillain-Barré syndrome
Ø Spinal anaesthesia
Ø Transverse myelitis
Ø Depression action of medications and lack of glucose can cause neurogenic shock.
RISK FACTORS:
1. Spinal anesthesia
2. Spinal cord injury
3. Deficiency of glucose.
4. Depressant action of medications

PATHOPHYSIOLOGY:
Impaired cellular metabolism
Decreased tissue perfusion
Decreased cellular oxygen supply
Cardiac output decreased
Bp decreased
Loss of the sympathetic tone
Disruption of sympathetic nervous system

1. Difficulty in breathing
2. Chest pain
3. Cyanosis
4. Нуроthermia
5. Peripheral vascular dilatation.
6. Absence of jugular vein distention.
• History collection
• Physical examination
• Blood culture & sensitivity test
• CT Scan.
• MIRI scan.
• X-rays

MEDICAL MANAGEMENT:
• Inotropic agents, such as dopamine( to help increased heart rate).
• Vasopressor-Constrict (tighten) blood vessels and raise blood pressure.( Norepinephrine (Levophed) · Dopamine
(Intropin) · Dobutamine · Epinephrine (Adrenalin).
• IV atropine: It is given to manage severe bradycardia
• IV steroids, such as methyl prednisolone
• Heparin.
• Immobilization - if needed traction to stabilize the spine, to bring the spine into proper alignment or both.
NURSING MANAGEMENT:
ü Assess patient's neurologic status.
ü Monitor vital signs
ü Assess patients past medical history
ü Assess the level of pain, its location, severity and duration
ü Administered medication to the patient.
ü Avoid crossing patient leg and putting pillow under knees
ü Administered appropriate oxygen.
ü Maintain proper alignment of spine

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