Shock Types

Question 1

What is shock.

Answer 1

​Shock is a widespread abnormal cellular metabolism that occurs when the human need for oxygenation and tissue perfusion is not met to the level needed to maintain cell function.

Question 2

Hypovolemic shock

Answer 2

1. Hypovolemic – occurs when too little circulating blood volume causes a sustained MAP decrease, resulting in the body’s total need for O2 not being met

Question 3

Causes of hypovolemic shock

Answer 3

Hemorrhage – trauma, GI ulcers, surgery, clotting disorders
• Dehydration – vomiting, diarrhea, diaphoresis, diuretics, NG suction, diabetes insipidus (kidneys unable to conserve water), Hyperglycemia

Question 4

Cardiogenic shock

Answer 4

2. Cardiogenic – Direct pump failure (heart itself is compromised) fluid volume not affected
   • MI (most common), valvular problems (stenosis, incompetence), cardiomyopathy, dysrhythmias, cardiac arrest

Question 5

Distributive shock

Answer 5

Distributive – blood volume is not lost but is distributed to the interstitial tissues where it cannot circulate and deliver O2

Question 6

Causes of distributive shock

Answer 6

• neural-induced loss of vascular tone
• Pain, anesthesia, stress, spinal cord injury, head trauma
• chemical-induced loss of vascular tone
• Sepsis, anaphylaxis, capillary leak (burns, trauma, liver disease)

Question 7

Obstructive shock

Answer 7

Obstructive – Indirect pump failure (conditions outside the heart prevent either adequate filling or adequate contraction of the muscle)

• pericarditis, cardiac tamponade, pulmonary hypertension / embolism
• some of these listed above cause compression of the heart

Question 8

First stage of shock

Answer 8

Initial (early) stage – decrease in MAP of 5-10 mm Hg
• increased sympathetic stimulation
o ↑ RR, ↑ HR, ↑ diastolic BP (from vasoconstriction)
o anxiety or restlessness THESE ARE RED FLAGS & KEY INDICATORS
o Difficult to detect because vital organ function is not disrupted

Question 9

Second stage of shock

Answer 9

2. Nonprogressive (compensatory) stage – decrease in MAP of 10-15 mm Hg from baseline
   • Kidney & hormonal mechanisms are activated to aid cardiovascular system to maintain MAP
   • acid-base & electrolyte changes occur (↓ pH, ↑ K+)
   • continued sympathetic stimulation
   o moderate vasoconstriction, ↑ HR, ↓ Pulse pressure (difference between systolic & diastolic), falling systolic, rising diastolic
   o ↓ urine production, slow cap refill, cool skin
   o ↑ thirst and anxiety

Question 10

Third stage of shock

Answer 10

3. Progressive stage – decrease in MAP of > 20 mm Hg from baseline
   • systems starting to fail
   • anoxia of nonvital organs
   • hypoxia of vital organs
   • pale / mottled / cyanotic skin, decreased LOC, little urine output, low central venous pressure

Question 11

Fourth stage of shock

Answer 11

4. Refractory (irreversible) stage – organs are failing (MODS – multiple organ dysfunction syndrome) Lots of tissue death and organ damage
   • cyanotic, cold skin, diminished / absent pulses, unconsciousness, no urine output, significant hypotension
   • Death soon follows

Question 12

Neuro status change in shock

Answer 12

​A.​neurological status
• EARLY: Anxiety, Restlessness, Increased thirst
• LATE: ↓ central nervous system activity (lethargy to coma), generalized muscle weakness, diminished / absent DTR’s, Sluggish papillary response to light

Question 13

Cardio change in shock

Answer 13

​B.​cardiovascular status
• ↓ cardiac output, BP
• ↑ Pulse rate (thread)
• postural hypotension, low central venous pressure
• slow cap. refill, diminished peripheral pulses

Question 14

Respiratory changes in shock

Answer 14

​C.​respiratory status
• ↑ RR (shallow)
• ↓ Paco2 and Pao2
• cyanosis (especially around lips and nail beds)

Question 15

Renal status

Answer 15

​D.​renal status

• ↓ urine output, ↑ specific gravity, sugar & acetone present in urine

Question 16

General status during shock

Answer 16

​E.​general status (skin, temperature, and thirst)
• skin is cool to cold; pale to mottled to cyanotic; moist, clammy
• dry mouth, pastelike
• ↓ GI motility
• diminished or absent bowel sounds
• nausea, vomiting, constipation

Question 17

​Progression of events leading to Septic shock:

Answer 17

​Local shock → Systemic infection (early sepsis) → SIRS (systemic inflammatory response syndrome) → organ failure (severe sepsis) → multiple organ system failure (MODS) (septic shock) → DEATH

Question 18

Discuss nursing interventions indicated in hypovolemic and septic shock.

Answer 18

• Monitor for early compensatory shock responses (normal BP, narrowed pulse pressure, mild orthostatic hypotension, slight delayed cap. refill, pale/cool skin or flushed skin, slight tachypnea, N & V, increased thirst, weakness)
• Monitor sources of fluid loss
• Monitor for signs of inadequate tissue oxygenation (apprehension, increased anxiety, changes in mental status, agitation, oliguria, cool & mottled extremities)
• Monitor O2 sats
• O2 administration, Administer IV fluids and/or blood products, monitor vitals and note changes, assess pain levels frequently
• Use of aseptic technique during invasive procedures, removing indwelling caths and IV ASAP when no longer needed.
• Review lab values for changes in serum lactate levels, total WBC count, and in the differential.