SHOCK

Nursing & Midwifery Science — Lecture Notes

1. Definition of Shock

Shock is a life-threatening medical emergency characterised by inadequate tissue perfusion and oxygen delivery
to cells and vital organs. If not promptly identified and treated, shock leads to progressive organ dysfunction,
multi-organ failure, and death.

2. Types of Shock

Hypovolemic Shock
Caused by significant loss of blood or body fluids.
• Haemorrhagic — e.g., postpartum haemorrhage (PPH), trauma, surgery
• Non-haemorrhagic — e.g., severe diarrhoea, vomiting, burns, dehydration

Cardiogenic Shock
Caused by failure of the heart to pump blood adequately.
• Myocardial infarction (most common cause)
• Severe cardiac arrhythmias
• Acute heart failure

Distributive Shock
Caused by abnormal distribution of blood flow in the circulatory system.
• Septic shock — systemic response to severe infection
• Anaphylactic shock — severe allergic reaction (e.g., to drugs, insect stings)
• Neurogenic shock — loss of vasomotor tone from spinal cord injury

Obstructive Shock
Caused by physical obstruction to blood flow.
• Pulmonary embolism
• Cardiac tamponade
• Tension pneumothorax

3. Causes of Shock

• Severe bleeding — internal or external (e.g., PPH, road traffic accident)

• Severe systemic infection leading to sepsis
 • Severe allergic reaction (anaphylaxis) — e.g., penicillin, food, latex
• Acute myocardial infarction or cardiac failure
• Severe dehydration from diarrhoea, vomiting, or burns
• Spinal cord injury disrupting vasomotor control
• Major surgery or obstetric complications

4. Pathophysiology of Shock

The underlying mechanism of shock follows a progressive pathway:

Step 1 Triggering event occurs (e.g., haemorrhage, infection, cardiac failure)

Step 2 Cardiac output falls or blood is maldistributed

Step 3 Compensatory mechanisms activate: tachycardia, vasoconstriction, ADH release

Step 4 If unresolved, blood pressure drops (decompensation)

Step 5 Tissue hypoxia develops — cells switch to anaerobic metabolism

Step 6 Lactic acid accumulates — metabolic acidosis

Step 7 Progressive organ dysfunction → Multi-Organ Dysfunction Syndrome (MODS)

Step 8 Irreversible shock → death if untreated

5. Clinical Manifestations (Signs & Symptoms)

Early / Compensated Shock

• Restlessness, anxiety, confusion
• Tachycardia (pulse > 100 bpm) — rapid, bounding
• Blood pressure normal or slightly reduced
• Cool, pale skin
• Increased respiratory rate
• Urine output slightly decreased

Late / Decompensated Shock

• Hypotension — systolic BP < 90 mmHg
• Rapid, weak, thready pulse
• Cold, clammy, mottled skin
• Confusion, altered consciousness, drowsiness
• Oliguria — urine output < 30 ml/hour
• Cyanosis — bluish lips and fingernails
• Shallow, rapid, laboured breathing
Irreversible Shock
• Loss of consciousness (coma)
• Absent or very weak pulse
• Multi-organ failure (kidneys, liver, brain, lungs)
• Death if intervention is not immediate

6. Diagnostic Investigations

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Blood Pressure Monitoring Detect hypotension — key indicator of shock

Full Blood Count (FBC) Assess haemoglobin, haematocrit, white cells

Serum Lactate Elevated > 2 mmol/L indicates anaerobic metabolism

Arterial Blood Gas (ABG) Assess oxygenation, ventilation, acid-base balance

Serum Electrolytes Detect sodium, potassium, and fluid imbalances

Blood Glucose Hypoglycaemia may complicate shock

Urine Output (catheter) Hourly monitoring — target ≥ 30 ml/hour

ECG Identify cardiac cause (MI, arrhythmia)

Blood Cultures Identify organism in suspected septic shock

Chest X-Ray Assess cardiac size, pulmonary oedema, pneumothorax

Echocardiogram Evaluate cardiac function in cardiogenic shock

7. Management of Shock

A. Immediate Emergency Management — ABCDE Approach

A — Airway: Ensure airway is clear and patent; suction if needed
B — Breathing: Administer high-flow oxygen 10–15 L/min via face mask
 C — Circulation: Establish two large-bore IV cannulas; rapid IV fluid infusion
D — Disability: Assess level of consciousness using AVPU or GCS scale
E — Exposure: Fully expose the patient; identify source of shock; keep warm

B. Fluid Resuscitation
• Normal saline (0.9% NaCl) or Ringer's Lactate — 1–2 litres rapidly IV
• Blood transfusion — indicated in haemorrhagic shock
• Colloids (e.g., albumin) may be used in severe cases
• Caution: Avoid aggressive fluid loading in cardiogenic shock

C. Management by Shock Type

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Hypovolemic Control bleeding; rapid IV fluids; blood transfusion

Cardiogenic Inotropes (e.g., dopamine, dobutamine); treat MI; oxygen

Septic IV broad-spectrum antibiotics; IV fluids; vasopressors

Anaphylactic Adrenaline (epinephrine) 0.5 mg IM; antihistamines; IV steroids

Neurogenic IV fluids; vasopressors (noradrenaline); immobilise spine

Obstructive Treat cause: thrombolytics for PE; pericardiocentesis for tamponade

D. Pharmacological Management
• Vasopressors: Noradrenaline, dopamine — to raise blood pressure
• Adrenaline (Epinephrine): First-line drug for anaphylactic shock (0.5 mg IM)
• Broad-spectrum antibiotics: For septic shock (e.g., piperacillin-tazobactam)
• Corticosteroids: Hydrocortisone in refractory septic shock
• Inotropes: Dobutamine, dopamine — in cardiogenic shock
 • Antihistamines & Hydrocortisone: Adjuncts in anaphylaxis

8. Nursing & Midwifery Care of a Patient in Shock

• Monitor vital signs every 5–15 minutes (BP, pulse, respiration, temperature, SpO2)
• Position patient flat (supine); elevate legs 15–30° in hypovolemic shock to improve venous return
• Insert urinary catheter and monitor urine output hourly (target ≥ 30 ml/hr)
• Administer prescribed IV fluids and medications promptly
• Maintain a patent IV line; check cannula site regularly
• Provide oxygen therapy as prescribed; monitor oxygen saturation
• Keep patient warm — prevent hypothermia which worsens shock
• Record all observations, fluid intake, and output accurately
• Provide psychological support — reassure the patient and relatives
• Assist with diagnostic procedures (blood samples, ECG, catheterisation)
• Prepare patient for transfer to ICU or theatre if indicated
• Report any deterioration in condition immediately to the medical team

9. Complications of Untreated Shock

• Acute Kidney Injury (AKI) — due to renal hypoperfusion

• Acute Respiratory Distress Syndrome (ARDS) — lung failure
• Disseminated Intravascular Coagulation (DIC) — clotting disorder
• Hepatic failure — liver damage from ischaemia
• Bowel ischaemia — gut necrosis
• Multi-Organ Dysfunction Syndrome (MODS)
• Brain damage — from prolonged cerebral hypoxia
• Death

10. Prevention of Shock

• Early identification and management of risk factors (e.g., PPH prophylaxis with oxytocin)
• Prompt treatment of infections before progression to sepsis
• Careful administration of drugs with allergy documentation to prevent anaphylaxis
• Adequate blood volume maintenance in surgical and obstetric patients
• Active management of the third stage of labour (AMTSL) to prevent PPH
• Continuous monitoring of high-risk patients in labour and postoperatively

Nursing & Midwifery Science | Shock — Lecture Notes