SHOCK INTRODUCTION

Shock is a life threatening condition with a variety of underlying causes. It is characterized by inadequate tissue perfusion that, if untreated, results in cell death. The nurse caring for the patient with shock or at risk of shock must understand the underlying mechanisms of shock & recognize the subtle as well as more obvious signs. Rapid assessment and response are essential to the patients recovery.

DEFINITION
It is a condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs and cellular function Or Shock is a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism

TYPES
1. Hypovolemic Shock Absolute hypovolemia Relative hypovolemia 2. Cardiogenic Shock 3. Vasogenic Shock/Distributive/circulatory shock Anaphylactic Neurogenic septic

HYPOVOLEMIC SHOCK
Hypovolemic shock refers to a medical or surgical condition in which rapid fluid loss results in multiple organ failure due to inadequate perfusion. In this the size of vascular compartment remains unchanged while the volume of blood or plasma decreases. The fluid loss may be absolute or relative volume loss.

Absolute hypovolemia Relative hypovolemia

Occurs when the fluid is loosed through haemorrhage, gastrointestinal loss (vomiting &diarrhoea), fistula drainage, diabetes insipidus, hyperglycemias or diueresis. Here the fluid moves out of the vascular spaces into the extravascular space (intestine or intra cavity space).this fluid shift is called third spacing e.g. confinement of fluid into the colon from a bowel obstruction, ascities, loss of blood volume into a fracture site and burns
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CAUSES
Haemorrhage-trauma, surgery, GI bleeding/internal bleeding, fracture Dehydration-Vomiting / diarrhoea/diuresis Fluid shifts-Burns/ascitis

PATHOPHYSIOLOGY
Decreased blood volume

Decreased venous return Decreased stroke volume

Decreased cardiac output Decreased tissue perfusion

Impaired cellular metabolism and cell death

MANAGEMENT

Treatment of underlying cause

If the patient is hemorrhaging, efforts are made to stop the bleeding.This may involve applying pressure to the bleeding site or surgery to stop internal bleeding. If the cause of the hypovolemia is diarrhea or vomiting, medications to treat diarrhea and vomitingare administered as efforts are made simultaneously to identify and treat the cause. Fluid and blood replacement Beyond reversing the primary cause of the decreased intravascular volume, fluid replacement (also referred to as fluid resuscitation) is of primary concern atleast two large-gauge intravenous lines are inserted to establish access for fluid administration. Two intravenous lines allow simultaneous administration of fluid, medications ,and blood component therapy if required. Lactated Ringers and 0.9% sodium chloride solutions are isotonicrystalloid fluids commonly used in treating
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hypovolemic shock. Colloids (eg, albumin, hetastarch, and dextran) may also be used. Blood products, also colloids, may need to be administered particularly when the cause of the hypovolemic shock is hemorrhage Positioning Proper positioning modified trendelenburg position for patients who show signs of shock . Elevating the legs promotes the return ofvenous blood. Positioning the patient in a full Trendelenburg positon however, makes breathing difficult and therefore is not recommended. Drug Therapy If the underlying cause of the hypovolemia is dehydration medications are also administered to reverse the cause of the dehydration For example, insulin is administered if dehydration is secondary to hyperglycemia; desmopressin (DDAVP) is administeredfor diabetes insipidus, antidiarrheal agents for diarrhea,and antiemetic medications for vomiting. NURSING MANAGEMENT Primary prevention of shock is an essential focus of nursing intervention.Hypovolemic shock can be prevented in some instance by closely monitoring patients who are at risk for fluid deficits and assisting with fluid replacement before intravascular volume is depleted . General nursing measures include ensuring safe administration of prescribed fluid and medications and documenting their administration and effects . The patient who receives a transfusion of blood products must be monitored closely for adverse effects. Fluid replacement complications can occur, often when large volumes are administered rapid. Therefore the nurse monitorsthe patient closely for cardiovascular overload and pulmonary edema.

CARDIOGENIC SHOCK
Cardiogenic shock is characterized by a decreased pumping ability of the heart causing a shock-like state with inadequate perfusion to the tissues. It occurs most commonly in association with, and as a direct result of, acute ischemic damage to the myocardium CAUSES Systolic dysfunction-inability of heart to pump forward
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 Myocardial infarction/cardiomyopathy Diastolic dysfunction-inability of the heart to fill during diastole Pericardial tamponade Dysrhythmias Brady/tachydysrhythmias Structural factors Valvular stenosis/regurgitation, ventricular septal rupture PATHOPHYSIOLOGY Decreased cardiac contractility

Decreased stroke volume and cardiac output

Pulmonary congestion

Decreased systemic Tissue perfusion

Decreased coronary artery perfusion

CLINICAL MANIFESTATIONS Patients in cardiogenic shock may experience angina pain, develop dysrhythmias and hemodynamic instability MANAGEMENT The goals of medical management are to (1) limit further myocardial damage and preserve the heal myocardium and (2) improve the cardiac function by increasing cardiac contractility,decreasing ventricular afterload, or both . In general, these goals are achieved by increasing oxygen supply tothe heart muscle while reducing oxygen demands. 1. Correction of underlying causes 2. Initiation of first line treatment Supplying supplemental oxygen In the early stages of shock, supplemental oxygen isadministered by nasal cannula at a rate of 2 to 6 L/min to achieve an oxygen saturation exceeding 90%.

 Controlling chest pain If the patient experiences chest pain, morphine sulfate is administered intravenously for pain relief. In addition to relieving pain, morphine dilates the blood vessels Providing selected fluid support Administering vasoactive medications Vasoactive medication therapy consists of multiple pharmacologic strategies to restore and maintain adequate cardiac output. Dobutamine- Dobutamine (Dobutrex) produces inotropic effects by stimulating myocardial beta receptors, increasing the strength of myocardial activity and improving cardiac output Nitroglycerine- Intravenous nitroglycerin (Tridil) in low doses acts as a venous vasodilator and therefore reduces preload Dopamine- Dopamine (Intropin) is a sympathomimetic agent that has varying vasoactive effects depending on the dosage. It may be used with dobutamine and nitroglycerine to improve tissue perfusion Other vasoactive medications- Additional vasoactive agents that may be used in managing cardiogenic shock include norepinephrine(Levophed), epinephrine (Adrenalin), milrinone (Primacor), amrinone (Inocor), vasopressin (Pitressin), and phenylephrine Antiarrhythmic medication is also part of the medication regimen in cardiogenic shock. Multiple factors, such as hypoxemia, electrolyte imbalances, and acidbase imbalances, contribute to serious cardiac dysrhythmias in all patients with shock. Fluid Therapy In addition to medications, appropriate fluid is necessary in treating cardiogenic shock. Administration of fluids must be monitored closely to detect signs of fluid overload. Incremental intravenous fluid boluses are cautiously administered to determine optimal filling pressures for improving cardiac output. Implementing mechanical cardiac support( intra- aortic balloon counter pulsation therapy, ventricular assist systems)If cardiac output does not improve despite supplemental oxygen, vasoactive medications, and fluid boluses, mechanical assistive devices are used temporarily to improve the hearts ability to pump. Intra-aortic balloon counter pulsation is one means of providing temporary circulatory assistance
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NURSING MANAGEMENT Preventing Cardiogenic Shock In some circumstances, identifying patients at risk early and promoting adequate oxygenation of the heart muscle and decreasing cardiac workload can prevent cardiogenic shock Monitoring Hemodynamic Status A major role of the nurse is monitoring the patients hemodynamic and cardiac status. Arterial lines and electrocardiographic monitoring equipment must be maintained and functioning properly. Administering medications and intravenous fluids The nurse has a critical role in safe and accurate administration of intravenous fluids and medications. Fluid overload and pulmonary edema are risks because of ineffective cardiac function and accumulation of blood and fluid in the pulmonary tissues. The nurse documents and records medications and treatments that are administered as well as the patients response to treatment . The nurse needs to be knowledgeable about the desired effects as well as the side effects of medications. For example, it is important to monitor the patient for decreased blood pressure after administering morphine or nitroglycerin. The patient receiving thrombolytic therapy must be monitored for bleeding. Arterial and venous puncture sites must be observed for bleeding and pressure must be applied at the sites if bleeding occurs. Intravenous infusions must be observed closely because tissue necrosis and sloughing may occur if vasopressor medications infiltrate the tissues. Urine output, BUN, and serum creatinine levels are monitored to detect increased renal function secondary to the effects of cardiogenic shock or its treatment. Maintaining intra aortic balloon pulsation The nurse plays a critical role in caring for the patient receiving intra-aortic balloon counter pulsation . The nurse makes ongoing timing adjustments of the balloon pump to maximize its effectiveness by synchronizing it with the cardiac cycle. The patient is at great risk for circulatory compromise to the leg on the side where the catheter for the balloon has been placed; therefore, the nurse must frequently check the neurovascular status of the lower extremities. Enhancing safety and comfort Throughout care, the nurse must take an active role in safeguarding the patient, enhancing comfort, and reducing anxiety.This includes administering medication to
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relieve chest pain, preventing infection at the multiple arterial and venous line insertion sites, protecting the skin, and monitoring respiratory function. Brief explanations about procedures that are being performed and the use of comforting touch often provide reassurance to the patient and family.

CIRCULATORY SHOCK
Circulatory or distributive shock occurs when blood volume is abnormally displaced in the vasculaturefor example, when blood volume pools in peripheral blood vessels. It can be cause d by a loss of sympathetic tone or by release of biochemical mediators from cells

The varied mechanisms leading to the initial vasodilation incirculatory shock further subdivide this classification of shockinto three types: (1) septic shock, (2) neurogenic shock, and (3) anaphylactic shock. PATHOPHYSIOLOGY Vasodilation

Maldistribution of blood volume

Decreased venous return

Decreased stroke volume

Decreased cardiac output

Decreased tissue perfusion

SEPTIC SHOCK
Septic shock is the most common type of circulatory shock and is caused by widespread infection It is the most common cause of death in non coronary intensive care units in the United States and the 13th leading cause of death in the U.S. population
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. Elderly patients are at particular risk for sepsis because of decreased physiologic reserves and an aging immune system RISK FACTORS Nosocomial infections in critically ill patients Patients with bacteremia and pneumonia Intra abdominal infections,Wound infections Bacteremia associated with indwelling catheters Immunosupression Malnourishment Chronic illness Invasive procedures The most common causative microorganisms of septic shock are the gramnegative bacteria; however, there is also an increased incidence of gram-positive bacterial infections. MEDICAL MANAGEMENT Treatment of septic shock involves identifying and eliminating the cause of infection Specimens of blood, sputum, urine,wound drainage, and invasive catheter tips are collected for culture using aseptic technique. Antibiotic-coated intravenous central lines may be placed to decrease the risk of invasive line-related bacteremia in high-risk patients, such as the elderly Abscesses are drained and necrotic areas are debrided Pharmacologic therapy If the infecting organism is unknown, broad-spectrum antibiotic agents are started until culture and sensitivity reports are received A third generation cephalosporin plus an aminoglycoside may be prescribed initially. This combination works against most gram-negative and some grampositive organisms. Recombinant human activated protein C (APC), or drotrecogin alfa (Xigris), has recently been demonstrated to reduce mortality in patients with severe sepsis Nutritional therapy Aggressive nutritional supplementation is critical in the management of septic shock because malnutrition further impairs the patientsresistance to infection. Nutritional supplementation shouldbe initiated within the first 24 hours of the onset of shock

NURSING MANAGEMENT The nurse caring for any patient in any setting must keep in mind the risks of sepsis and the high mortality rate associated with septic shock. All invasive procedures must be carried out with aseptic technique after careful hand hygiene Intravenous lines, arterial and venous puncture sites, surgical incisions,traumaticwounds, urinary catheters, and pressure ulcers are monitored for signs of infection in all patients. When caring for the patient with septic shock, the nurse collaborates with other members of the health care team to identify the site and source of sepsis and the specific organisms involved .Appropriate specimens for culture and sensitivity are often obtained by the nurse. Elevated body temperature (hyperthermia) is common with sepsis and raises the patients metabolic rate and oxygen consumption.Thus, an elevated temperature may not be treated unless it reaches dangerous levels (more than 40C[104F]) or unless the patient is uncomfortable. Efforts may be made to reduce the temperature by administering acetaminophen or applying hypothermia blankets. During these therapies, the nurse monitors the patient closely for shivering, which increases oxygen consumption. The nurse administers prescribed intravenous fluids and medications,including antibiotic agents and vasoactive medicationsto restore vascular volume. As with other types of shock, the nurse monitors the patients hemodynamic status, fluid intake and output, and nutritional status.Daily weights and close monitoring of serum albumin levelshelp determine the patient s protein requirements.

NEUROGENIC SHOCK
In neurogenic shock, vasodilation occurs as a result of a loss of sympathetic tone. This can be caused by spinal cord injury, spinal anesthesia, or nervous system damage. It can also result from the depressant action of medications or lack of glucose (eg, insulin reaction or shock). Neurogenic shock may have a prolonged course (spinal cord injury) or a short one (syncope or fainting). It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is bradycardia, rather than the tachycardia that characterizes other forms of shock.

MEDICAL MANAGEMENT Treatment of neurogenic shock involves restoring sympathetic tone either through the stabilization of a spinal cord injury or, inthe instance of spinal anesthesia, by positioning the patient properly.Specific treatment of neurogenic shock depends on its cause

NURSING MANAGEMENT It is important to elevate and maintain the head of the bed at least 30 degrees to prevent neurogenic shock when a patient is receiving spinal or epidural anaesthesia Nursing interventions are directed toward supporting cardiovascularand neurologic function until the usually transient episode of neurogenic shock resolves. Applying elastic compression stocking and elevating the foot of the bed may minimize pooling of blood in the legs. Pooled blood increases the risk for thrombus formation. Therefore, the nurse needs to check the patient daily for any redness, tenderness, warmth of the calves, and positive Homans sign (calf pain on dorsiflexion of the foot). Administering heparin or low-molecular-weight heparin(Lovenox) as prescribed, applying elastic compression stockings,or initiating pneumatic compression of the legs may prevent thrombus formation. Patients who have experienced a spinal cord injury may notreport pain caused by internal injuries. Therefore, in the immediatepostinjury period, the nurse must monitor the patientclosely for signs of internal bleeding that could lead to hypovolemic shock.

ANAPHYLACTIC SHOCK
Anaphylactic shock is caused by a severe allergic reaction when apatient who has already produced antibodies to a foreign substance (antigen) develops a systemic antigenantibody reaction. An antigenantibody reaction provokes mastcells to release potent vasoactive substances, such as histamine or bradykinin, that cause widespread vasodilation and capillary permeability Anaphylactic shock occurs rapidly and is life-threatening.Because anaphylactic shock occurs in patients already exposed to an antigen who have developed antibodies to it, it can often be prevented.

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MEDICAL MANAGEMENT Treatment of anaphylactic shock requires removing the causative antigen (eg, discontinuing an antibiotic agent) Administering medications that restore vascular tone, and providing emergency support of basic life functions. Epinephrine is given for its vasoconstrictive action. Diphenhydramine (Benadryl) is administered to reverse the effects of histamine, thereby reducing capillary permeability If cardiac arrest and respiratory arrest are imminent or have occurred, cardiopulmonary resuscitation is performed

NURSING MANAGEMENT The nurse has an important role in preventing anaphylactic shock: assessing all patients for allergies or previous reactions to antigens (eg, medications, blood products, foods, contrast agents,latex) and communicating the existence of these allergies or reactions to others. When administering any new medication, the nurse observesthe patient for an allergic reaction. This is especially important with intravenous medications. Allergy to penicillin is one of themost common causes of anaphylactic shock In the hospital and outpatient diagnostic testing sites, the nurse must identify patients at risk for anaphylactic reactions to contrast agents (radiopaque, dye-like substances that may contain iodine) used for diagnostic tests

The nurse must be knowledgeable about the clinical signs of anaphylaxis, must take immediate action if signs and symptoms occur, and must be prepared to begin cardiopulmonary resuscitation if cardiorespiratory arrest occurs .

Community health and home care nurses whose role includes administering medications, including antibiotic agents, in thepatients home or other settings must be prepared to administerepinephrine subcutaneously or intramuscularly in the event of ananaphylactic reaction.

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STAGES OF SHOCK Compensatory stage Progressive stage Irreversible/refractory stage

CLINICAL FINDINGS IN STAGES OF SHOCK

Finding Blood pressure Heart rate Respiratory status Skin Urinary output Mentation Acidbase balance Compensatory Normal >100 bpm >20 bpm Cold and clammy Decreased Confusion Progressive Irreversible stage

Systolic BP<80-90 mmHg Requires support >150 bpm Asystole Rapid shallow Requires intubation Mottled petechiae Jaundice 0.5 ml/kg/hr Anuric Lethargy Unconscious

COMPENSATORY STAGE
In compensatory stage of shock the patients blood pressure remains within the normal units. Vasoconstriction, increased heart rate and increased contracti;lity of the heart continue to maintain adequate cardiac output. This resuts from stimulation of sympathetic nervous system and subsequent release of catecholamines. The body shunts blood from organs such as skin, kidneys and gastrointestinal tract to the brain and heart to ensure to ensure adequate blood supply to these organs. As a result the patients skin is cold and clammy, bowel sounds are hypoactive and urine output decreases. MEDICAL MANAGEMENT Identifying the cause of shock and correct the underlying disorder
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 As compensation cannot be maintained effectively, measures such as fluid replacement and medication therapy must be initiated NURSING MANAGEMENT The nurse needs to assess systematically those patients at risk for shock Monitoring tissue perfusion- assess for change in the level of consciousness, vital signs, urinary output, skin and laboratory values The role of nurse at the compensatory stage of shock is to monitor the patients hemodynamic status and promptly report the deviations to physicians Reducing anxiety Promoting safety- monitoring potential threats to patients safety

PROGRESSIVE STAGE
In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate and the MAP fallsbelow normal limits, with an average systolic blood pressure ofless than 90 mm Hg. Although all organ systems suffer from hypoperfusion at this stage, two events perpetuate the shock syndrome. First, the overworked heart becomes dysfunctional; the bodys inability to meet increased oxygen requirements produces ischemia; and biochemical mediators cause myocardial depression This leadsto failure of the cardiac pump, even if the underlying cause of the shock is not of cardiac origin. Second, the autoregulatory function of the microcirculation fails in response to numerous biochemical mediators released by the cells, resulting in increased capillary permeability, with areas of arteriolar and venous constriction further compromising cellular perfusion. At this stage,the patients prognosis worsens. The relaxation of precapillarysphincters causes fluid to leak from the capillaries, creating interstitial edema and return of less fluid to the heart MEDICAL MANAGEMENT Specific medical management in the progressive stage of shockdepends on the type of shock and its underlying cause. It is alsobased on the degree of decompensation in the organ systemssome medical interventions are common to all types. These include use of appropriate intravenous fluids and medications to restore tissue perfusion by (1)optimizing intravascular volume, (2) supportingthe pumping action of the heart, and (3) improving the competenceof the vascular system.

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NURSING MANAGEMENT Nursing care of the patient in the progressive stage of shock requiresexpertise in assessing and understanding shock and the significanceof changes in assessment data. The patient in theprogressive stage of shock is often cared for in the intensive care setting to facilitate close monitoring Preventing Complications If supportive technologies are used, the nurse helps reduce the risk of related complications and monitors the patient for early signs of complications Simultaneously, the nurse promotes the patients safety and comfort by ensuring that all procedures, including invasive procedures and arterial and venouspunctures, are carried out using correct aseptic techniques. Promoting Rest and Comfort Efforts are made to minimize the cardiac workload by reducingthe patients physical activity and fear or anxiety. Promoting restand comfort is a priority in the patients care. To ensure that thepatient gets as much uninterrupted rest as possible, the nurse performsonly essential nursing activities. Supporting Family Members Because the patient in shock is the object of intense attention bythe health care team, the family members may feel neglected; The nurse should make sure that thefamily is comfortably situated and kept informed about the patients status

IRREVERSIBLE STAGE
The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Despite treatment, blood pressure remains low. Complete renal and liver failure, compounded by the release of necrotictissue toxins, creates an overwhelming metabolic acidosis. Anaerobic metabolism contributes to a worsening lactic acidosis. Reserves of ATP are almost totally depleted, and mechanisms forstoring new supplies of energy have been destroyed.. Multiple organ dysfunction progressing to complete organ failure has occurred,and death is imminent. MEDICAL MANAGEMENT Medical management during the irreversible stage of shock is usually the same as for the progressive stage

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NURSING MANAGEMENT As in the progressive stage of shock, the nurse focuses on carrying out prescribed treatments, monitoring the patient, preventing complications, protecting the patient from injury, and providing comfort. As it becomes obvious that the patient is unlikely to survive, the family needs to be informed about the prognosis and likely outcomes. During this stage of shock, families may misinterpret the actions of the health care team Conference swith all members of the health care team and the familywill promote better understanding by the family of the patientsprognosis and the purpose for the measures being taken

MANAGEMENT OF SHOCK

Aims

Identification of patients at risk Integration of patients history, physical examination, and clinical findings Intervention to control/eliminate cause of decreased perfusion Protection of target organs from dysfunction Provision of multisystem supportive care General measures Ensure a patent airway Supplemental oxygen and mechanical ventilation SaO2 >90% Fluid resuscitation
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 Insert 2 large bore IV cannulas Use crystalloids, colloids and blood components Crystalloids Isotonic-0.9%Nacl or RL Hypertonic-1.8%,3%,5% NaCl blood/blood products Whole blood/packed RBC, fresh frozen plasma Colloids Hetastarch, albumin, dextran Drugs and Nutritional Therapy Sympathomimetics Amrinone, dobutamine, dopamine, epinephrine Vasodilators Nitroglycerine, nitropruside Vasoconstrictors Nor epinephrine, vasopressin Antacids,H2 blockers, PPI Nutrition->3000 calories/day, Enteral/parentral feeding used

RESEARCH ABSTRACT
Septic Shock - A Review Article
Abstract Septic shock still remains one of the leading causes of death in hospital patients. Greater awareness, understanding of the condition .and the knowledge of most
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effective treatment measures available can decrease the rate of mortality. Making an early, accurate diagnosis of septic shock is the key to increasing survival rates. Excessive inflammation, excessive coagulation and suppression of fibrinolysis are the hallmarks of Sepsis. Infection control, haemodynamic stabilization, and modulation of the septic response are the cornerstones of treatment. The management is influenced more by appropriate treatment with antibiotics and fluids than by specific intensive care. Septic response can be modulated by the use of Steroids and Activated Protein C and with tight glucose control. Low Tidal Volume ventilation and high volume Haemofilteration are other beneficial strategies in Sepsis. As septic shock worsens and fails to respond to all therapy, one must be prepared to limit and withdraw treatment.

CONCLUSION
Shock affects all body systems. It may develop rapidly or slowly,depending on the underlying cause. During shock, the body struggles to survive, calling on all its homeostatic mechanisms to restore blood flow and tissue perfusion. Any insult to the body can create a cascade of events resulting in poor tissue perfusion. Therefore, almost any patient with any disease state may be at risk for developing shock

BIBLIOGRAPHY
Medical Surgical Nursing,10 th edition, 2004, Lippincott Williams and Wilkins,Pg 295-312

1.Suzanne C.Smeltzer ,Bare G Brenda , Textbook of

2.Joyce M Black, Jane Hokanson Hawks, Medical Surgical Nursing, 8 th edition, Vol.2, Elsevier publications, Pg 2154- 2168

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