Shock • S/S:

• a life-threatening condition that occurs when the • ↑ blood to heart & brain
body is not getting enough blood flow. “choc” –
• ↑ HR, ↑ vasoconstriction, ↑ cardiac output = ↑
unknown origin
perfusion
• a critical condition brought on by the sudden drop in
• ↓ blood lungs, kidneys & other body parts
blood flow through the body.
• release of epinephrine & norepinephrine
• l/t to organ failure & eventually death
• ↓ GI function (Risk for paralytic ileus)
Types of shock
• ↓ lung perfusion (Hyperventilate)
1. Hypovolemic – low fluid volume in the blood
• ↓skin (Pale skin, Diaphoresis – d/t epinephrine
• Hemorrhage & dehydration
release)
2. Cardiogenic – heart cannot pump enough blood to
•↓ blood to kidneys (Activate the Renin-
meet the perfusion needs of the body
AngiotensinAldosterone System (RAAS)
• AMI, CHF, Tension pneumothorax, cardiac
• Activation of angiotensin 2 (Vasoconstriction)
tamponade, dysrhythmias, endocarditis
• Aldosterone (Sodium and water retention)
3. Septic – d/t sepsis or infection
•ADH (Water retention ↑BP and blood flow to the
• Gram positive or negative infections
heart)
4. Anaphylactic – d/t allergy or any allergic reactions
3. Progressive stage
• Sting bee, Snake bite
Body is failing, can’t compensate anymore
5. Neurogenic – d/t damage to the nervous system
• S/S:
• Spinal cord injury
• drop in cardiac output ↓ O2 to the cell, Low BP,
4 stages of Shock Oliguria

1. Initial stage • increase capillary permeability (Fluid shift from

intravascular to interstitial) Massive edema, Cold
• Cardiac output starts to become low extremities
• Switch away from aerobic respiration to anaerobic • central nervous system changes
respiration
• slow speech, confused, agitated, ↓ reaction
• Lactic acid builds up l/t metabolic acidosis
• ↑ RR, ↓ O2, respiratory failure
• N: <2 mmol/L Abnormal: >4 mmol/L
• Heart muscle dies, dysrhythmias
• S/S:
• renal failure ↑ BUN, ↑ creatinine, metabolic
• not yet perceive acidosis
• Others may experience • loses protective mechanism against HCl, GI bleeding,
Increase HR, Low BP ulcers,

2. Compensatory stage • ↓ liver function, ↓ clotting factor, ↓ anti microbes,

↑ ammonia, ↑ bilirubin
• Body senses the ↓ in BP & cardiac output
4. Refractory stage
• Body systems compensate to reverse lactic acidosis
• Unmanageable/cannot be reverse
• vasoconstriction
• All organs shut down
• Condition is worst • Ineffective tissue perfusion

• Multiple system organ failure l/t death • Impaired tissue integrity

S/SX • Acute pain

• Hypotension • Deficient Fluid Volume

• Tachycardia • Anxiety

• Tachypnea Management of Hypovolemic Shock

• Cold, clammy extremities • Goals: Replace fluid in the intravascular system &
correct underlying causes
• Obtundation, abnormal mental status
• IV access: at least 2 IV sites
• Mottled skin
• Oxygenation & mechanical ventilation
• Oliguria
• Assess for bleeding!
• Metabolic acidosis
• Assess for signs of adequate tissue perfusion
• Hyperlactatemia
• Hypotension
Complications
• Tachypnea
• Acute respiratory distress syndrome
• Tachycardia
• Acute renal failure
• Cold clammy skin, poor mental status
• Multiple organ dysfunction syndrome
• Urinary output low
S/S
• Attach Foley catheter to monitor urine output
↓ renal perfusion, ↓ serum albumin & pre-albumin,
↓ GI motility, acute neurologic changes, myocardial • Hemodynamic monitoring to ensure optimal tissue
dysfunction, disseminated intravascular coagulation perfusion & oxygen delivery
(DIC), changes in glucose metabolism.
• Modified Trendelenburg to ↑ venous return
• ComaDeath
• Monitor laboratory values Hgb, Hct, ABG,
Diagnostic Assessments electrolytes, CBC, BUN, Creatinine, lactate level

• History & physical examination • Give IV Fluids

• Telemetry monitoring & ECG • Crystalloid solution - NSS or LR IV fluids

• CBC & differential • Watch out for fluid volume overload Crackles in the
lungs, elevated CVP
• Renal & liver function tests
• Colloid solution – Albumin, Hetastarch Watch out
• Serum lactate level
for fluid volume overload
• Cardiac biomarkers
• Blood & blood products Packed RBC, platelets or
• D-dimer test N: less than 0.50 fresh frozen plasma. For bleeding pts./severe
hypovolemic shock
• Coagulation profile
• If pt. doesn’t respond to crystalloid fluids, Monitor
• Blood & urine cultures for transfusion reaction!
• ABG Management of Cardiogenic Shock
Nursing diagnosis • Goals: Reperfusion, ↑ Cardiac Output (CO),
• Decreased cardiac output ventilation, diuretics
• Maintain hemodynamics monitoring, Mechanical 5. Vasodilators
ventilation, Central line placement thru Swan Ganz
• Nitroglycerine- Dilates coronary arteries
catheter
• ↑ perfusion to heart muscle
• Monitor S/S of adequate tissue perfusion BP, skin
color, capillary refill, mental status • Watch out for hypotension
• Lab: cardiac markers ↑troponin, ↑ BNP, CXR to Management of Septic Shock
assess pulmonary edema, Serum lactate- assess for
anaerobic metabolism • Goal: ↑ perfusion &oxygenation

• Acidosis: pH level ↓ than 7.35 • Keep O2 saturation at >95%

• IV fluid: Normal Saline. Not given with pt. w/ fluid • Risk for Acute respiratory distress syndrome (ARDS)
overload (Pulmonary edema) • Pts. need intubation w/ mechanical ventilation
• Diuretics: ↓ blood volume • Fight microorganisms
• Furosemide IV- ↓ workload of the heart • Specimen culture needed before antibiotic!
• Watch for K+ level • Don’t delay antibiotic therapy
• 3.5 – 5.0 mEq/L • Collect before starting antibiotics
• Watch for risk of hypotension • Beta-lactam – for gram positive bacteria
• Watch fluid status • Titrate vasopressors (e.g. norepinephrine)- Used if
• Check Urinary function fluid replacement is unsuccessful. Causes
vasoconstriction & increase SVR
• Check U/O
• Crystalloids or colloid solutions- 1st initial
1. Vasopressors treatment! If not working vasopressors is added as Tx.
• Epinephrine, Norepinephrine, Dopamine • Successful if ↑ systolic BP > 90 & CVP w/in N: range
8-12 mmHg
Constriction of blood vessels
• Unsuccessful if persistent hypotension & CVP > than
Positive inotropic effects
8 mmHg
• ↑ strengths of hearts contraction, ↑ preload, ↑ BP,
• Inotropic (Dobutamine)- Can be added if there is low
↑ CO, ↑ Stroke volume
tissue perfusion
2. Norepinephrine
• ↑ the strength of the heart’s contractions
• ↑ Tissue perfusion ↑ BP
• Nutrition

• Early stage- Helps GI integrity for healing & immune

3. Dobutamine health

• ↑ contraction, ↑ stroke volume Famotidine- ordered to prevent ulcer

• Watch worsening hypotension d/t vasodilation • Protein Activated C Drug (Drotrecogin Alpha)
effect
-Most effective if started w/in 24-48h
• Give norepinephrine or dopamine instead if observe
-Has anti-inflammatory & thrombotic effects.
• Watch out for cardiac dysrhythmias Watch for bleeding!

4. Dopamine • ↓ inflammation

• ↑ Contraction, ↑ BP, ↑ Stroke volume -Steroids (corticosteroids – low dose)

• Watch out for tachycardia, Report chest heaviness

• if not responding to vasopressors, ↓ inflammation 6. Call 911 or emergency service
by the immune system
Management for Neurogenic Shock
• Hemodynamic monitoring- With central
• Goal: manage pt.’s airway, breathing, circulation &
venous/arterial catheter to help assess tissue
spine
perfusion
• Protect the spine, keep spine immobilized E.g.
• Control blood glucose
cervical collar, log rolling patient, using backboard etc.
• <180 mg/dL
• Assess & manage airway May need intubation &
• It affects immune system & healing Started on mechanical Ventilation if resp. failure is present
insulin drop
• Maintain tissue perfusion. Mean arterial pressure =
• Monitor serum lactate level – sign of anaerobic 85-90 mmHg to maintain perfusion to organs

respiration N: 1 mmol/L • IV fluids (Crystalloids) -Used w/ caution for fluid

overload. Watch for dyspnea, crackles, edema, high
• Monitor Urine output: > 30 ml/hr. Sign of renal
CVP etc.
failure if <30 ml/hr.
• Vasopressors- If fluids not working. Causes
Management for Anaphylactic Shock
vasoconstriction ↑, BP, Cardiac output (CO)
Anaphylactic Shock
• Dopamine: Positive inotropes, Vasoconstriction & ↑
• Goals: recognize S/S HR

• ACT FAST • If Bradycardia is present, Atropine – sounds like

“top” ↑ HR, blocks parasympathetic effects of the
• Allergen- remove it heart w/c cause slow HR
• Airway- promote high flow of O2 • If there is hypothermia- Warming devices
• Call Rapid Response • Foley catheter placement
• Trendelenburg Position- ↑ venous return to heart • Prevention of DVT- Range of motion (ROM) daily,
• First line drug is Epinephrine- Vasoconstriction - ↓ apply compression stockings, anticoagulants
swelling, Bronchodilation l/t ↓ wheezing • Avoid crossing legs or placing pillow under knees
• Administer per MD order, IV fluids, Albuterol • Compromised circulation
(nebulizer), Antihistamines (Diphenhydramine (H1)
Ranitidine (H2)), Corticosteroids

• Stay & monitor the pt. Prone for biphasic

anaphylaxis

• Teach

• How to avoid allergens

• Wear medical alert bracelet

• Carry EpiPen Always

1. Replace when expired

2. Know how to prepare & administer

3. Can inject through clothes, if needed

4. Inject & hold in place for 3 secs then remove

5. Massage injection site for 10 seconds