1. Timby/Smith: Introductory Medical-Surgical Nursing, 10/e 01/29 Pg 199
Chapter 17 Caring for Clients in Shock By: P.K. Williams, RN

2. 25 Words to Know /29 Pg 199
Adrenocorticotropic hormone Anaerobic Metabolism
Anaphylactic shock Ischemia Antidiurectic hormone
Cardiac output Cathecholamines Cardiogenic shock
Compensation stage Irreversible shock
Corticosteroid hormones Oliguria
Decompensation stage Neurogenic shock
Distributive shock Obstructive shock
Endotoxins Hypoxia
Hypovolemic shock Septic shock Shock
Multiple organ dysfunction syndrome Positive inotropic agents
Systemic inflammatory response syndrome
Vasopressors

3. On completion of this chapter, you will be able to:
11 Objectives /00 Pg 199
On completion of this chapter, you will be able to:
Define shock.
Name four general categories of shock.
Identify the subcategories of distributive shock.
List pathophysiologic consequences of shock.
Name the three stages of shock.
Identify three physiologic mechanisms that attempt to compensate for shock.
Discuss signs and symptoms manifested by clients in shock.
Name three diagnostic measurements used when monitoring clients in shock.
Give three medical approaches for treating shock.
List complications of shock.
Discuss the nursing management of clients with shock.

4. Shock*** /29 Pg 199
Life-threatening condition: Insufficient arterial blood flow; Insufficient cell, tissue oxygenation
Causes
Decreased blood volume
Heart failure
Massive dilation of peripheral blood vessels
Compensatory mechanisms attempt to counteract effects
Hypovolemic; Distributive; Obstructive; Cardiogenic

5. Types of Shock*** 05/29 Pg 199 Hypovolemic Shock: Most common
Extracellular fluid volume significantly diminished
Causes: Significant fluid loss; diabetes insipidus
Symptomatic upon 15%-30% volume loss
Distributive Shock***
Normovolemic Shock: Decreased central blood flow from vasodilation
Neurogenic; Septic; Anaphylactic

6. Question 06/29 Pg 199 Is the following statement true or false?
Hypovolemic shock is the deadliest form of shock.

7. Answer /29 Pg 199
False.
Hypovolemic shock is the most common form of shock.

8. Types of Shock*** 08/29 Pg 201 Distributive Shock (Cont’d)
Neurogenic Shock: Rarest***
Damage: Brain’s vasomotor center; Peripheral nerves
Causes: Spinal cord, head injury; Overdose (opioids, sedatives, etc.)
Resulting: Decreased arterial vascular resistance; Vasodilation; Hypotension
Consequences: Anaerobic metabolism; metabolic acidosis

9. Types of Shock*** 09/29 Pg 2201 Distributive Shock (Cont’d)
Septic Shock (AKA toxic shock): Highest mortality***
40%-60% die despite aggressive treatment
Cause: Overwhelming bacterial infections; Endotoxin release
Predecessor: Systemic inflammatory response syndrome
May progress to multiple organ dysfunction syndrome

10. Question 10/29 Pg 201 Is the following statement true or false?
Septic shock is the deadliest form of shock.

11. Answer /29 Pg 201
True.
Septic shock is the deadliest form of shock. Forty to sixty percent of those who develop septic shock will die from its complications.

12. Types of Shock 12/29 Pg 201 Distributive Shock (Cont’d)
Anaphylactic Shock***
Severe allergic reaction
Common allergic substances: Bee venom, latex, fish, nuts, and penicillin
Immune response: Histamine, chemical release
Vasodilation; Increased capillary permeability; Airway edema; Hypotension; Hives or itchy rash

13. Types of Shock 13/29 Pg 201 Obstructive Shock***
Cardiac blood circulation is compromised due to compression
Cardiac tamponade; Tension pneumothorax; Ascites; Hepatomegaly

14. Types of Shock 14/29 Pg 201 Cardiogenic Shock***
Ineffective cardiac contraction
Reduces cardiac output
MI with subsequent heart failure

15. Shock Stages*** /29 Pg 202

16. Shock Stages*** 16/29 Pg 202 Compensation: Stabilization Attempt
First stage
Catecholamine release
Neurotransmitters to trigger sympathetic nervous system responses
Renin-Angiotensin-Aldosterone system
Restores BP in decreased circulating volume
ADH, ACTH secretion
Sodium, water balance

17. Shock Stages*** /29 Pg 203
Decompensation: Compensatory Mechanisms Fail
Cellular Hypoxia
Anaerobic metabolism; Metabolic acidosis; Cell damage
Coagulation Defects
Inflammatory response; Microemboli predisposition; RBC oxygenation compromised
Cardiovascular Changes
Blood vessel dilation; Cardiac output decrease; Hypotension

18. Cellular effects of shock
Shock Stages*** /29 Pg 203
Cellular effects of shock

19. Shock Stages*** 19/29 Pg 204 Irreversible Stage: Imminent Death
Significant cells and organs damaged
“Point of no return”
Multiple system failure

20. Critical Assessments for Shock*** 20/29 Pg 204
Vital Signs
Baseline BP
Peripheral Pulse Characteristics
Rate, Volume, Rhythm
Mentation Changes
Changes in Skin Characteristics
Urine Output
Arterial BP

21. Question 21/29 Pg 204 Is the following statement true or false?
In assessing clients for shock, it is of utmost importance to have access to their baseline heart rate.

22. Answer*** /29 Pg 204
False.
In assessing clients for shock, it is of utmost importance to have access to their baseline blood pressure for comparison.

23. Assessment Findings 23/29 Pg 199
Diagnostic Findings
Arterial blood gas (ABG) measurements
Direct arterial puncture, indwelling arterial catheter
PaO2: In shock, <60 mmHg
SpO2 >90%, assume PaO2 ≥ 60mmHg
PaCO2: Normal or decreased

24. Assessment Findings*** 24/29 Pg 199
Diagnostic Findings (Cont’d)
Central venous pressure (CVP): BP in the right atrium, vena cava
Normal CVP: 4-10 cm H2O
Hypovolemic shock: CVP < normal
Cardiogenic shock: CVP > normal
Pulmonary artery pressure (PAP): BP in left side of heart
WNL PAP: mmHg (systolic); 8-12 mmHg (diastolic)
In shock: PAP low

25. Shock Diagnostics*** 25/29 Pg 206
Example of a pulmonary artery (PA) pressure monitoring system

26. Medical Management of Shock*** 26/29 Pg 205
Aggressive Treatment to Prevent
If Shock Develops***
Treatment dependent upon type, level of shock
Includes
Intravenous fluid therapy: Restore intravascular volume
Drug therapy: Adrenergics (vasopressors)
Mechanical devices: Improve cardiac output; Redistribute blood

27. Shock Prognosis and Complications*** 27/29 Pg 208
Recovery: Usual with adequate, prompt treatment
Secondary Complications: Tissue hypoxia; Organ ischemia; Reduced oxygenation
Life-threatening Complications
Kidney failure; Neurologic deficits
Bleeding disorders: Disseminated intravascular coagulation (DIC)
Acute respiratory distress syndrome (ARDS)
Stress ulcers
Sepsis

28. The Client in Shock: Assessment*** 04/29 Pg 199
Early signs of shock; Vital signs; BP; Skin color, temperature; Radial and peripheral pulses; Urine output
Signs of dyspnea; Bleeding; LOC; Lung and heart sounds
Analyze lab test results: RBC, WBC, ABG, and SpO2
Monitor coagulation test results: Platelet, PT, and PTT

29. End of Presentation NOW ENCLEX
By: P.K. Williams, RN /29 Pg 211