2. Definition Shock is a state of inadequate tissue perfusion that impairs maintenance of normal cellular metabolism. Shock is identified by its underlying cause: Shock is a state of inadequate tissue perfusion that impairs maintenance of normal cellular metabolism. Shock is identified by its underlying cause: Cardiogenic –heart failure. Cardiogenic –heart failure. Hypovolemic – decrease of 10 to 15% of blood volume. Hypovolemic – decrease of 10 to 15% of blood volume. Distributive – widespread vasodilation and increased capillary permeability. Distributive – widespread vasodilation and increased capillary permeability. Obstructive – mechanical blockage in the heart or great vessels. Obstructive – mechanical blockage in the heart or great vessels.

3. Stages of shock Initial – no S/Sx, changes on the cellular level only. Initial – no S/Sx, changes on the cellular level only. Compensatory –increase cardiac output to restore perfusion and oxygenation. Compensatory –increase cardiac output to restore perfusion and oxygenation. Progressive – compensatory mechanisms begin to fail. Progressive – compensatory mechanisms begin to fail. Refractory – irreversible shock, total body failure. Refractory – irreversible shock, total body failure. The cause, category and the stage of shock determines treatment The cause, category and the stage of shock determines treatment

4. Risk Factors for Shock Cardiogenic – MI, heart failure, cardiomyopathy, dysrhythmias, cardiac tamponade, and valvular rupture / stenosis. Cardiogenic – MI, heart failure, cardiomyopathy, dysrhythmias, cardiac tamponade, and valvular rupture / stenosis. Hypovolemic – V, D, bleeding; burns and DKA Hypovolemic – V, D, bleeding; burns and DKA Distributive is divided into three types: Distributive is divided into three types: Septic – endotoxins and other mediators causing massive vasodilation ( gram-negative bacteria ). Septic – endotoxins and other mediators causing massive vasodilation ( gram-negative bacteria ). Neurogenic – loss of sympathetic tone (vasoconstriction) causing massive vasodilation due to trauma, spinal shock, and epidural anesthesia are among the causes. Neurogenic – loss of sympathetic tone (vasoconstriction) causing massive vasodilation due to trauma, spinal shock, and epidural anesthesia are among the causes. Anaphylactic – antigen-antibody reaction causing massive vasodilation. Anaphylactic – antigen-antibody reaction causing massive vasodilation. Obstructive – blockage of great vessels, PE Obstructive – blockage of great vessels, PE

5. Diagnostic Procedures and Nursing Interventions ABGs ABGs Hemodynamic Monitoring: CO Hemodynamic Monitoring: CO Cardiogenic: ECG, echo, CT, CXR, catheterization, cardiac enzymes Cardiogenic: ECG, echo, CT, CXR, catheterization, cardiac enzymes Hypovolemic: Hgb, Hct, cross matching, determine & control bleeding CT Hypovolemic: Hgb, Hct, cross matching, determine & control bleeding CT Septic: C& S, coagulation tests: PT, INR, aPTT) Septic: C& S, coagulation tests: PT, INR, aPTT) Obstructive: echo, CT Obstructive: echo, CT

6. Assessments Clinical picture: Clinical picture: Hypoxia Hypoxia Hypotension (mean arterial pressure < 60 mm Hg) Hypotension (mean arterial pressure < 60 mm Hg) Tachycardia, weak thready pulse Tachycardia, weak thready pulse Assess/Monitor Assess/Monitor Oxygenation status (priority) Oxygenation status (priority) VS VS Urinary output Urinary output LOC LOC Cardiac rhythm (if monitored) Cardiac rhythm (if monitored) Skin color, temp., moisture, capillary refill, turgor Skin color, temp., moisture, capillary refill, turgor Symptoms indicating body system compromise: Symptoms indicating body system compromise:

7. InitialCompensatoryProgressiveRefractory HR≤ 100> 100≥ 120≥ 140 BPNormalNormal/ Increased 70-90 mm Hg < 50-60 mm Hg RRNormal20-30 30-40 > 40 UOP≥ 30 20-305-20 Negligible SkinSkin Cool, pink, dry Cold, pale, dry/ moist Cold, pale, moist Cold, mottled, cyanotic, dry Capillary refill NormalSlightly delayed DelayedNot noted

8. NANDA Nursing Diagnoses Decreased cardiac output Decreased cardiac output Impaired gas exchange Impaired gas exchange Ineffective tissue perfusion Ineffective tissue perfusion Deficient fluid volume Deficient fluid volume Anxiety Anxiety

9. Interventions Identify clients at risk for developing shock. Identify clients at risk for developing shock. If shock process is suspected: If shock process is suspected: Obtain VS & pulse oximetry. Obtain VS & pulse oximetry. Obtain any laboratory or diagnostic test Obtain any laboratory or diagnostic test Assess UOP. Report if  3o ml/h Assess UOP. Report if  3o ml/h Perform a complete assessment. Perform a complete assessment. Administer ahigh-flow oxygen (100% nonrebreather face mask). Administer ahigh-flow oxygen (100% nonrebreather face mask). Be sure patent IV access is available. Be sure patent IV access is available. For hypotension, place the client flat, flat with legs elevated, or in Trendelenburg For hypotension, place the client flat, flat with legs elevated, or in Trendelenburg position to increase venous return. position to increase venous return.

10. Interventions Initiate orders to intervene with shock ( ICU, OR or diagnostic area. Initiate orders to intervene with shock ( ICU, OR or diagnostic area. Explain procedures and findings to the client and family and reassure the client and family. Explain procedures and findings to the client and family and reassure the client and family. If in the intensive care unit: If in the intensive care unit: Prepare for and carry out hemodynamic monitoring. Prepare for and carry out hemodynamic monitoring. Administer medications as ordered. Administer medications as ordered. Be sure IV access is patent. Be sure IV access is patent. Place the client on continuous cardiac monitoring. Place the client on continuous cardiac monitoring.

11. Interventions Hypovolemic Hypovolemic Fluid replacement:, Vasopressors to increase blood pressure. ALERT: In hypovolemic shock, replace volume first to enhance blood pressure before using vasopressors. Fluid replacement:, Vasopressors to increase blood pressure. ALERT: In hypovolemic shock, replace volume first to enhance blood pressure before using vasopressors. Cardiogenic Cardiogenic Afterload reducers, Inotropic agents Vasopressors Afterload reducers, Inotropic agents Vasopressors Anaphylactic Anaphylactic Antihistamines, Epinephrine Antihistamines, Epinephrine Septic Septic Antibiotics, Norepinephrine, Heparin initially and then clotting factors, platelets, and plasma Antibiotics, Norepinephrine, Heparin initially and then clotting factors, platelets, and plasma Neurogenic Neurogenic Volume replacement, Norepinephrine Volume replacement, Norepinephrine

12. Interventions All types of shock All types of shock Proton pump inhibitors (PPIs) possible for all clients in shock to protect against stress ulcer development Proton pump inhibitors (PPIs) possible for all clients in shock to protect against stress ulcer development Deep vein thrombosis (DVT) prophylaxis (heparin, low-molecular weight heparin) possible with all shock clients Deep vein thrombosis (DVT) prophylaxis (heparin, low-molecular weight heparin) possible with all shock clients Prevention Prevention Educate the client about risk factors for accidents, MI, DM, UTI, etc. Educate the client about risk factors for accidents, MI, DM, UTI, etc. Educate the client about interventions to avoid dehydration with gastrointestinal illness, genitourinary infections, etc. Educate the client about interventions to avoid dehydration with gastrointestinal illness, genitourinary infections, etc.

13. Complications and Nursing Implications Organ Dysfunction, MI, ARDS, RF, and liver failure due to ischemia ( Assess organ function and take interventions to compensate for dysfunction Organ Dysfunction, MI, ARDS, RF, and liver failure due to ischemia ( Assess organ function and take interventions to compensate for dysfunction Disseminated intravascular coagulation (DIC). Thousands of small clots form within organ capillaries (liver, kidney, heart, brain) creating hypoxia and anaerobic metabolism. As a result of massive clot formation, fibrinogen resources are taxed and the client is at increased risk for hemorrhage. Disseminated intravascular coagulation (DIC). Thousands of small clots form within organ capillaries (liver, kidney, heart, brain) creating hypoxia and anaerobic metabolism. As a result of massive clot formation, fibrinogen resources are taxed and the client is at increased risk for hemorrhage.