CARE OF CLIENTS WITH PROBLEMS OF SHOCK
By: Jerald S. Ugdoracion MN- MSN
What is SHOCK?
It is a condition of profound hemodynamic and
metabolic disturbance due to inadequate blood
flow and oxygen delivery to the capillaries and
tissues of the body
Must know in understanding SHOCK well:
• Cardiac Output : this depends on the
ability of the heart to pump
• Circulating Volume : There should be
adequate amount of blood for the heart
to pump around the body
• Peripheral Vascular Resistance : Blood
vessels must have good tone with the
ability to constrict or dilate depending
on the demands of the body
• Preload: the amount of blood that the
ventricle contains after diastolic filling
• Afterload: The amount of resistance
needed to be overcome to promote
ventricular ejection
• Mechanisms on Maintaing Circlatory
Homeostasis:
o Autonomic Response of the
Body (Interplay of
catecholamines : Epinephrine
and Norepinephrine)
o Renin-Angiotensin-
Aldosterone Mechanism
o Interplay of the Anti-diuretic
hormone
CLASSIFICATIONS OF SHOCK
1. HYPOVOLEMIC SHOCK
This results from excessive blood loss, loss of
body fluids or third spacing of fluids leading to a
sudden decrease of circulating blood volume.
Cause: Hemorrhage, Dehydration, Burns,
Trauma, Ascites
2. CARDIOGENIC SHOCK
This results from severely decreased cardiac
output
Cause: Pump Failure, Myocardial Infarction,
Cardiac Tamponade, Severe Valvular
Disease, Dysrhythmias
3. DISTRIBUTIVE (VASOGENIC SHOCK)
This results from profound and massive
vasodilatation that leads to the disproportion
between the size of vascular space and the
amount of blood contained in it.
• NEUROGENIC SHOCK or SPINAL
SHOCK
o This results from loss of
vasomotor tone that includes
generalized arteriolar and
venous dilatation
o Affects the medulla of the
Adrenal Gland and the
Sympathetic Nervous System
Cause: Head Injury, General
Anesthesia, Drug Overdose,
Opiates, Barbiturates and
Tranquilizers
• SEPTIC SHOCK or TOXIC SHOCK
o This results from a severe and
profound condition of
generalized vascular collapse
secondary to a systemic
infection
Cause: Gram (-) bacterial infection
• ANAPHYLACTIC SHOCK
o There is a profound peripheral
vascular collapse induced by
severe allergic reactions,
mediated by Inflammatory
mediators (e.g. Histamines,
Bradykinins, Leukotrienes and
Prostaglandins).
o Large quantities of fluid may
leak out of the capillaries due
 to increased capillary
permeability and
vasodilatation that occurs with
the inflammatory process, thus
leading to Hypovolemia
STAGES OF SHOCK
I. INITIAL STAGE
• This is also known as Non-progressive
Stage of Shock
• Body Compensatory Mechanisms are
activated in order to maintain
circulatory homeostasis:
o Interplay of the Sympathetic Nervous
System
 Catecholamines :  Failure
Norepinephrine and Epinephrine
causing Increased heart rate,
increased respiratory rate and
vasoconstriction to increase PVR
leading to increased BP
 Operational within
seconds to minutes
o Renin-Angiotensin-
Aldosterone Mechanism
 Causes the release of
Angiotensin II which is a potent
Vasoconstrictor and at the same
time causes the release of
Aldosterone
 Aldosterone causes
Sodium reabsorption in the
juxtaglomerular site of the
kidneys, leading to sodium
retention in the blood. Sodium in
the blood attracts water causing a
passive reabsorption of water ino
the blood increasing the blood
volume
 Activated within
20minutes
o Activation of the Anti-diuretic
Hormone
 Antidiuretic hormone
causes water reabsorption in the
distal conculuted tubules of the
kidneys increasing water in the
blood, thus increasing blood
volume.
Assessment:
 Restlessness, Confusion
 Increased Pulse rate and Respiratory
Rate
 Diaphoresis
 Normal or decreased Blood Pressure
 Decreased Pulse Pressure
 Decreased urine Output
 Thirst, Dry mucus membranes
 Respiratory Alkalosis
 Hypokalemia
II. LATE SHOCK
 This is also known as Decompensated
or Progressive Shock
 In this condition, body compensatory
mechanism fails and is unable to meet
up demands of the body
to promote circulatory
homeostasis
 Leads to Multiple Organ Damage due to
insufficient blood supply to major
organs of the body
KIDNEYS:
 This happens when the systolic
blood pressure drops to 70
mmHg
 Decreased blood to kidneys
lead to Decreased Glomerular
Filtration rate leading to
Oliguria and retention of
nitrogenous wastes leading to
Metabolic Acidosis
 Acute Tubular Necrosis
happens due to insufficient
amount of blood to the kidneys
 Complication: RENAL
FAILURE
BRAIN
 Decreased tissue Perfusion
leads to decreased Level of
Consciousness
 Complication : STROKE
HEART
 Decreased tissue pperfusion to
the heart may lead to
Myocardial Infarction and
Cardiac Dysrhythmias
GASTROINTESTINAL TRACT
 Decreased blood supply to the
GI tract causes decrease in
 peristalsis that may progress to
Paralytic Ileus 1. Administration of Fluids, Whole Blood and
 Lysis of Microorganisms may Blood products
occur due to destruction of
Kupffer cells that may have Whole Blood
resulted from decreased blood • Consists of RBC, plasma, plasma
supply to the liver. This leads proteins and approximately 60 mL
to massive release of anticoagulant/preservative solution in a
endotoxins causing Setic total volume of approximately 500 mL
Shock. • Indication : 1000 mL blood loss, when
oxygen carrying capacity of the RBC
Assessment: and volume expanding capacity of
 Shallow respirations plasma is needed
 Decreased Blood Pressure
 Increased Pulse Rate
 Oliguria/anuria Packed RBC
 Hyperkalemia • Consists primarily
 Metabolic acidosis/respiratory acidosis of RBC and small amount of plasma
 Edema and approximately 100mL anti
 Lethargy coagulant in a total amount of 300 ML
 Decreased bowel sounds • Indications include
 Cyanosis restoration or maintenance of adequate
organ oxygenation with minimal
 Dilated pupils
expansion of blood volume
PARAMETERS FOR ASSESSING STATUS • Average adult dose:
OF CLIENT IN SHOCK 2 units , pediatric dose: 5-15 mL per kg

1. HEMODYNAMIC MONITORING Nursing Considerations:

a. Blood Pressure 1. Infuse at prescribed rate. A unit can be
b. Pulse infused to an adult in 90to 120 minutes
c. Central Nervous System and 2 – 5 mL/kg on pediatric doses
d. PAP, PCWP 2. Transfuse blood within 4 hours after
e. Cardiac Output leavin the blood bank
2. RESPIRATORY MONITORING
a. Respiratory rate, depth, rhythm Platelet Concentrates
and effort • Consist of platelets suspended
b. Blood gases (pH, pCO2, pO2) in plasma. Each unit platelet is consist
3. FLUID-ELECTROLYTE of 5.5 x 1010 platelets and the volume of
MONITORING plasma is 50-400 mL
a. Urine Specific Gravity • Indications include prevention
b. Serum Electrolytes or resolution of hemorrhage
c. Blood Lactate levels • Dosage: 1 unit per 10 kg body
d. Weight weight
e. BUN and Creatinine • Infused in 20-60 minutes
4. NEUROLOGIC MONITORING
a. Alertness, Orientation and Plasma
Confusion • Consist of water (91%), plasma proteins
5. HEMATOLOGIC MONITORING including essential clotting factors (7%)
a. RBC and carbohydrates (2%), approximately
b. Hematocrit, hgb levels 200-250 mL
c. WBC • May be stored in liquid or frozen state
d. Platelets within 6 hours after collection
e. PT, PTT time • Indications include blood loss, loss of
blood clotting factors , over
MEDICAL MANAGEMENT
 anticoagulation with warfarin,
congenital blood clotting factor
deficiencies
• Infused within 15-30 minutes
Cryoprecipitate
• Consists of certain blood clotting
factors suspended in 20mL plasma.
Each unit consists of 80-120 units of
Blood Factor VIII, 250 mg fibrinogen
and 20% to 30% of the factor XIII
present in FWB
• Indications include deficiencies in
Blood clotting factor VIII (Hemophilia,
DIC, Von Wllebrand’s disease)
• Adult dosage is usually 10 units which
is repeated every 8 to 12 hours until
deficiency is corrected
• Infused within 3 to 15 minutes
Fractionated Plasma products
• Composed of highly concentrated blood
plasma proteins that makes up a colloid
solution to provide blood volume
expansion
Nursing Considerations:
2. Observe closely for the most common
acute complications associated with
Blood Transfusion – circulatory
overload, crackles, dyspnea, distended
neck veins
3. Confirm ABO and Rh compatibility of
recipient and blood. Compare the bag
label, bag tag, transfusion form and
medical order
4. Obtain a record of vital signs
5. Obtain blood from blood bank, inspect
for abnormal color, cloudiness, clots
and excess air. Check expiration date
6. Verify Patient identification
7. Start infusion slowly (2mL per minute)
approximately 30 drops per minute
8. Remain at bedside for 30minutes and
watch for side effects like difficulty in
breathing and presence of rashes,
9. Monitor Vital signs every hour
10. Record the following on client’s chart
a. Time and Names of Persons
starting and ending the
transfusion
b. Names of individuals verifying
patient ID
c. Product and Volume infused
d. Immediate responses of the
client
Blood Type Considerations
Note:
• The Blood Type indicates the antigen
that they are carrying (e.g. Blood Type
A blood contains an Antigen A, and
should not be given against people with
Blood Types that contains Antibodies
for Antigen A)
• Only Blood Type O is the blood type
that contains no antigen for A and B
making it the universal donor
• Blood Type AB contains does not
contain antibodies for A and B making
it the universal recipient for Blood
• the "anti-A" and "anti-B" antibodies
from the O donor, after diluted in the
recipient's blood, do not mount a
sufficient immune response to cause a
concern in most cases
BLOODTYPE
COMPONENT A B AB O
ANTIGEN A B AB --
ANTIBODY B A -- AB
Note: This is only applicable in transfusing RBCs. If FWB
is transfused, only specific blood types are allowed to be used
as donors. Example only Blood Type A is given for patients
with Blood Type A
Plasma Expanders (e.g. Dextran, Hetastarch,
Mannitol)
• these substances increases blood
volume by increasing colloin oncotic
pressure allowing osmosis to occur.
Crystalloid Solutions
• Hypotonic Solutions: 45% NSS, 5%
dextrose in Water
• Isotonic Solutions : 90% NSS, Lactated
Ringers Solution
2. MAST (MEDICAL ANTI-SHOCK
TROUSERS)
 I. Vasoconstrictors
a. Norepenephrine (Levarterenol)
b. Metaraminol (Amarine)
c. Epinephrine
d. Dopamine
e. Dobutamine
Medical antishock trousers (MAST) Given to promote peripheral
have been used to increase venous return to the vasoconstriction increasing peripheral vascular
heart until definitive care could be given. This, resistance and Blood Presure
combined with compression of blood vessels, is
believed to cause the movement of blood from
the lower body to the brain, heart and lungs.
II. Vasodilators
a. Nitroprusside (Nipride)
3. IABP (INTRA-AORTIC BALOON b. Nitroglycerine Isosorbide
PUMP) c. Phentolamine (Regitine)
d. Prazosin ( Minipress)
e. Hydralazine (Apresoline)

Given to promote vasodialtion on the

is microvasculature in major organs to promote
a blood flow

III. Sodium Bicarbonate

Given to counteract metabolic acidosis
that occurs with shock and lactic acid deposition

mechanical device that is used to decrease IV. Antibiotics

myocardial oxygen demand while at the same Given to treat underlying causes of
time increasing cardiac output. By increasing Septic shock
cardiac output it also increases coronary blood
flow and therefore myocardial oxygen delivery. V. Steroids
It consists of a cylindrical polyethylene balloon Given to decrease the inflammatory
that sits in the aorta, approximately 2 cm from reaction in the body leading to decreased
the left subclavian artery and counterpulsates. vasodilaton, decreased capillary permeability and
That is, it actively deflates in systole increasing leaking of intravascular fluid to the interstitial
forward blood flow by reducing afterload thus, spaces
and actively inflates in diastoleincreasing blood
flow to the coronary arteries. These actions have
VI. Glucagon
the combined result of decreasing myocardial
Given to increase colloid oncotic
oxygen demand and increasing myocardial
pressure allowing ososis tooccur thus increasing
oxygen supply
blood volume
Please refer to this internet website for
additional information: VII. Anti-ulcer Medications
http://www.youtube.com/watch?
v=o11fhdVOYWA a. Cimetidine
Given to decrease the possibility of ulcer
formation associated with shock

VIII. Diphenhydramine
PHARMACOLOGIC THERAPY (Benadryl)
 Given to decrease anaphylaxis mediated
by inflammatory mediators to decrease
inflammation and ots effects that may aggravate
shock

IX. Cardiotonic Medications

a. To treat dysrhytmias
i. Lidocaine
ii. Bretylium
iii. Quinidine
iv. Procainamide
b. To treat Bradycardia
i. Isoproterenol
ii. Atropine SO4

NURSING MANAGEMENT

PROMOTING FLUID BALANCE AND

CARDIAC OUTPUT, RESPIRATORY,
RENAL, GI SUPPORT and PROMOTING
SAFETY
1. Administer blood components and
fluids as ordered
2. Position the client in Modified
Trendelenburg Position
• Supine, head supported with
pillow, legs extended and elevated
at 20 to 30 degree angle, pelvis
slightly higher than torso
3. Administer Oxygen therapy as ordered
4. Encourage client to perform deep
breathing and coughing exercises
5. Suction client as necessary
6. Monitor hourly urine output, BUN and
Creatinine
7. NGT to Suction
8. Antacids may be given to decrease
gastric acidity
9. Soft restraints may be used if restless
and attempts to remove life saving
equipments
10. Prevent complications of immobility
11. protect client from chills, especially in
septic shock, which causes sludging of
blood in microcirculation

Prepared by:
Mr. Jerald S. Ugdoracion, RN, MN-MSN
(please do not reproduce without permission)