Shock

Renee Smith
RN, DNP, EdD(c), MSN, CEN, PHN, ACNP, TCRN
Trauma Program Manager
St. Francis Medical Center
Lynwood, CA
CDU Faculty
 Shock Objectives

 Define Shock
 Describe four types of shock
 Discuss the nursing assessment of
patient in shock
 Delineate appropriate nursing
interventions in shock
 Evaluate outcomes for patient in shock
 Shock
 Shock is a syndrome resulting from
inadequate perfusion of tissues
 Decreased supply of oxygen & nutrients to
meet metabolic demands of cell
(ENA, 2001)
 Shock is systemic response to clinical insult
(illness or injury) resulting in inadequate
perfusion
(ENA, 2007)
 Shock

 Regardless of precipitating cause, shock leads

to mean arterial blood pressure inadequate to
meet the needs of the tissues
 Initially compensation mechanism to improve
perfusion
 When compensation fails cascade of cellular
abnormalities end organ dysfunction and
death
 Shock

 Early symptoms of shock often subtle &

require vigilance by health care team -
nursing to avoid them being overlooked
 Shock 3 Stages

 Compensated (Nonprogressive)
 Uncompensated (Progressive)
 Irreversible (Refractory)
 Compensated (Nonprogressive)

 Receptors sense drop in systemic

pressure
 SNS activated to restore adequate
tissue perfusion
 Vital organ function preserved: Heart &
Brain
 Cell converts from aerobic to anaerobic
respiration
 Compensated (Nonprogressive)

 Resulting lactic acidemia causes cellular

damage
 Preexisting medical history & age cause
additional stressors
 Compensated Shock Signs!

 Tachycardia, Rising DBP, reduced PP(S-D)

 Weak pulse, Cool periphery, increase CRF>2
 Low, concentrated UOP
 Increased RR
 Nausea
 Diaphoresis, Increased Blood Sugar
 Confusion, Anxiety, Restlessness
 Uncompensated (Progressive)

 Compensation mechanisms begin to fail to

maintain perfusion to vital organs
 Mechanisms initially helpful become
ineffective & cause further tissue damage
 Cellular derangement & death within all organ
systems
 Severe lactic acidemia, inflammation, immune
system activation
 Uncompensated (Progressive)

 Multisystem deterioration or failure

 Even if oxygen is sufficient, some cells
damage & not able to use it
 Irreversible (Refractory)

 Final stage of shock critical point no

treatment can reverse process
 Cellular destruction so severe death
inevitable
 Specific causes of shock
indistinguishable
 Irreversible (Refractory)

Each patients shock state can be unique,

clinical progression may be altered by
several factors:
 Cause of shock
 Patient age
 Severity
 Duration of hypoperfusion
 Presence of comorbidities
 Shock Etiologies
(ATLS, 2012)
 Hypovolemia (volume loss)
 Cardiogenic (broken pump)
 Obstructive (obstruction to flow)
 Distributive (have volume - in wrong place)
 Hypovolemic

 Etiology: hemorrhage, burns, vomiting

 Underlying pathology: whole blood loss,
plasma loss
 Most common shock state
 Classified into 4 groups
 4 Classes

 Class I: up to 15% loss

 Class II: 15-30% loss
 Class III: 30-40% loss
 Class IV: >40% loss
(ENA, 2002)
Shock Class
 Cardiogenic

 Inadequate perfusion from inadequate

contractility
 Etiology:Blunt cardiac injury,
dysrhythmias, cardiac failure, cardiac
tamponade, myocardial infarction
 Pathology: loss of cardiac contractility,
reduced cardiac output
 Cardiogenic Shock

 Left ventricular rupture

 Obstructive

 Etiology: cardiac tamponade, tension

pneumothorax, tension hemothorax
 Pathology: compression of heart with
obstruction to atrial filling, mediastinal
shift with obstruction to atrial filling,
combination of both
Cardiac tamponade CXR
 Distributive

 Etiology: neurogenic shock (SCI),

anaphylactic shock (allergic rxn), septic
shock (toxin released by bacteria)
 Pathology: venous pooling,
maldistribution of blood volume,
shunting in microcirculation, decrease
venous resistance, poor distribution of
blood flow
Distributive Shock
Nursing Assessment of Shock
 Nursing Physical Assessment

 Determine LOC
 Assess breathing effectiveness, rate
 Identify bleeding sources
 Assess skin signs (ashen, pale, blue,
temperature? moisture?)
 Observe external jugular veins (flat,
distended (*hypovolemia may not be
distended)
 Nursing Physical Assessment

 Obtain B/P (auscultate, doppler)

 Calculate pulse pressure (S-D)
 Auscultate heart: muffled sounds,
 Auscultate breath sounds: decreased,
absent,
 Auscultate bowel sounds: absent- intra
abdominal bleeding or profound shock
 Diagnostics
 Radiological studies: CXR, pelvis, femur
 Spiral CT (Rapid Pan Scan)
 Angiography (Vascular injury Aortic/Pelvic)
 Labs: type & cross, UA, ABG, CBC, chem
panel, trauma panel (acidosis, hypoxia?)
*LACTATE <2 & BASE DEFICIT+/- 2
 The nurse assures the tests are performed
and communicates with the team, if patient
unstable nurse stays with the patient !
Aortic Angiography
Pelvic Angiography
 Nursing Diagnosis

 Gas exchange, impaired r/t:

 Ineffective breathing, ineffective airway,
aspiration, altered blood flow, oxygen
carrying capacity
 Interventions: ABC’s, O2, blood,
 Outcomes: ABG (wnl), skins, LOC, resps,
bilateral breath sounds, heart sounds normal
(ENA, 2001)
 Planning & Implementation
 Administer oxygen (NRBM, AMBU,ETT,Vent)- Oxygen
is essential for shock!
 Control any bleeding (direct pressure, Quik Clot
dressing, OR, meds factor VIII, TXA)
 IV Fluids LR, NS, Plasmalyte*
 IV Voluven
 Initiate blood replacement (O-, type specific) FFP,
Cryoprecipitate, Platelets, MTP
 Give blood through filter, use only NS! (Consider
autotransfusion as appropriate)
 Prepare for OR
 Planning & Implementation

 Legs elevated
 Additional large bore IV’s needed? Or
Level I? IV Vasopressors?
 Insert NG or OG tube
 Place foley catheter
 Cardiac monitoring a must, rate, rhythm
 Pulse oximetry (good waveform must
be present)
NGT placement?
 Ongoing Assessment &
Evaluation
 ABC’s (airway still okay?)
 Monitor urinary output (end organ perfusion)
 IV resuscitation, I&O’s
 Collaborate with team members
 Monitor temperature (hypothermia can cause
resuscitation problems or failures!),
 Monitor Labs: Serum Lactate, Base Deficit,
Lytes, H&H
 Recall the Triad: Hypothermia,
Coagulopathy, Acidosis
https://www.youtube.com/watch?v
=rPqhB0ScvIo&feature=player_det
ailpage