Shock

 A life-threatening condition that occurs when the body is not getting enough blood flow.
 Lack of blood flow means that the cells and organs do not get enough oxygen and nutrients
to function properly. Many organs can be damaged as a result.
 It’s requires immediate treatment and can get worse very rapidly. As many 1 in 5 people
who suffer shock will die from it.

The main types of shock include:

a. Cardiogenic shock (due to heart problems)
b. Hypovolemic shock (caused by too little blood volume)
c. Anaphylactic shock (caused by allergic reaction)
d. Septic shock (due to infections)
e. Neurogenic shock (caused by damage to the nervous system)
Cardiogenic shock
It’s when the heart has been damaged so much that it is unable to supply enough blood to the
organs of the body.

Causes
The most common causes are serious heart conditions.
Many of these occur during or after a heart attack (myocardial infarction).

These complications include:

 A large section of heart muscle that no longer moves well or does not move at all
 Breaking open (rupture) of the heart muscle due to damage from the heart attack
 Dangerous heart rhythms, such as ventricular tachycardia, ventricular fibrillation,
or supraventricular tachycardia
 Pressure on the heart due to a buildup of fluid around it (pericardial tamponade)
 Tear or rupture of the muscles or tendons that support the heart valves, especially the
mitral valve
 Tear or rupture of the wall (septum) between the left and right ventricles (lower heart
chambers)
 Very slow heart rhythm (bradycardia) or problem with the electrical system of the heart
(heart block)

Cardiogenic shock occurs when the heart is unable to pump as much blood as the body needs.
It can happen even if there has not been a heart attack if 1 of these problems occurs and your
heart function drops suddenly.

Symptoms
 Chest pain or pressure
 Coma
 Decreased urination
 Fast breathing
 Fast pulse
 Heavy sweating, moist skin
 Lightheadedness
 Loss of alertness and ability to concentrate
 Restlessness, agitation, confusion
 Shortness of breath
 Skin that feels cool to the touch
 Pale skin color or blotchy skin
 Weak (thready) pulse

Diagnose
An exam will show:
 Low blood pressure (most often less than 90 systolic)
 Blood pressure that drops more than 10 points when you stand up after lying down
(orthostatic hypotension)
 Weak (thready) pulse

To diagnose cardiogenic shock, a catheter (tube) may be placed in the lung artery (right
heart catheterization). Tests may show that blood is backing up into the lungs and the heart is
not pumping well.
Tests include:
 Cardiac catheterization
 Chest x-ray
 Coronary angiography
 Echocardiogram
 Electrocardiogram
 Nuclear scan of the heart
Other studies may be done to find out why the heart is not working properly.

Lab tests include:

 Arterial blood gas
 Blood chemistry (chem-7, chem-20, electrolytes)
 Cardiac enzymes (troponin, CKMB)
 Complete blood count (CBC)
 Thyroid stimulating hormone (TSH)

Treatment
Cardiogenic shock is a medical emergency. You will need to stay in the hospital, most often in
the Intensive Care Unit (ICU). The goal of treatment is to find and treat the cause of shock to
save your life.

You may need medicines to increase blood pressure and improve heart function, including:
 Dobutamine
 Dopamine
 Epinephrine
 Levosimendan
 Milrinone
 Norepinephrine
These medicines may help in the short-term. They are not often used for a long time.

Complications
 Brain damage
 Kidney damage
 Liver damage

Prevention
You may reduce the risk of developing cardiogenic shock by:
 Quickly treating its cause (such as heart attack or heart valve problem)
 Preventing and treating the risk factors for heart disease, such as diabetes, high blood
pressure, high cholesterol and triglycerides, or tobacco use.

Nursing Care Management

 Prevent recurrence of cardiogenic shock.
 Monitor hemodynamic status.
 Administer medications and intravenous fluids.
 Maintain intra-aortic balloon counter pulsation.
Hypovolemic shock
An emergency condition in which severe blood or fluid loss makes the heart unable to pump
enough blood to the body. This type of shock can cause many organs to stop working.

Causes
Losing about a fifth or more of the normal amount of blood in your body causes hypovolemic
shock.
Blood loss can be due to:
 Bleeding from cuts
 Bleeding from other injuries
 Internal bleeding, such as in the gastrointestinal tract

The amount of circulating blood in your body may drop when you lose too many other body
fluids.
This can be due to:
 Burns
 Diarrhea
 Excessive perspiration
 Vomiting

Symptoms
 Anxiety or agitation
 Cool, clammy skin
 Confusion
 Decreased or no urine output
 General weakness
 Pale skin color (pallor)
 Rapid breathing
 Sweating, moist skin
 Unconsciousness
The greater and more rapid the blood loss, the more severe the symptoms of shock.

Diagnose
A physical exam will show signs of shock, including:
 Low blood pressure
 Low body temperature
 Rapid pulse, often weak and thread

Tests that may be done include:

 Blood chemistry, including kidney function tests and those tests looking for evidence of heart
muscle damage
 Complete blood count (CBC)
 CT scan, ultrasound, or x-ray of suspected areas
 Echocardiogram: sound wave test of heart structure and function
 Endoscopy: tube placed in the mouth to the stomach (upper endoscopy) or colonoscopy
(tube placed through the anus to the large bowel)
 Right heart (Swan-Ganz) catheterization
 Urinary catheterization (tube placed into the bladder to measure urine output)

In some cases, other tests may be done as well.

Treatment
Get medical help right away. In the meantime, follow these steps:

 Keep the person comfortable and warm (to avoid hypothermia).

 Have the person lie flat with the feet lifted about 12 inches (30 centimeters) to increase
circulation. However, if the person has a head, neck, back, or leg injury, do not change the
person's position unless they are in immediate danger
 Do not give fluids by mouth.
 If person is having an allergic reaction, treat the allergic reaction, if you know how.
 If the person must be carried, try to keep them flat, with the head down and feet lifted.
Stabilize the head and neck before moving a person with a suspected spinal injury.

The goal of hospital treatment is to replace blood and fluids. An intravenous (IV) line will be put
into the person's arm to allow blood or blood products to be given.

Medication
 Dopamine
 Dobutamine
 Epinephrine
 Norepinephrine
may be needed to increase blood pressure and the amount of blood pumped out of the heart
(cardiac output).

Complications
 Kidney damage
 Brain damage
 Gangrene of arms or legs, sometimes leading to amputation
 Heart attack
 Other organ damage
 Death

Prevention
Preventing shock is easier than trying to treat it once it happens. Quickly treating the cause will
reduce the risk of developing severe shock. Early first aid can help control shock.

Nursing Management
Nursing Assessment
 History. The history is vital in determining the possible causes and in determining the
work-up.
 Vital signs. Vital signs, prior to arrival at the emergency department, should also be
noted.
 Trauma. In patients with trauma, determine the mechanism of injury and any
information that may heighten suspicion of certain injuries.
Nursing Goals
The major goals for the patient are:
 Maintain fluid volume at a functional level.
 Report understanding of the causative factors of fluid volume deficit.
 Maintain normal blood pressure, temperature, and pulse.
 Maintain elastic skin turgor, most tongue and mucous membranes, and orientation to
person, place, and time.
Anaphylaxis Shock
Is a life-threatening type of allergic reaction.

Causes
Anaphylaxis is a severe, whole-body allergic reaction to a chemical that has become
an allergen.

An allergen is a substance that can cause an allergic reaction.

After being exposed to a substance such as bee sting venom, the person's immune system
becomes sensitized to it. When the person is exposed to that allergen again, an allergic reaction
may occur.

Anaphylaxis happens quickly after the exposure.

The condition is severe and involves the whole body.

Tissues in different parts of the body release histamine and other substances. This causes the
airways to tighten and leads to other symptoms.

Some drugs (morphine, x-ray dye, aspirin, and others) may cause an anaphylactic-like reaction
(anaphylactoid reaction) when people are first exposed to them. These reactions are not the
same as the immune system response that occurs with true anaphylaxis. But, the symptoms,
risk of complications, and treatment are the same for both types of reactions.

Causes
Anaphylaxis can occur in response to any allergen. Common causes include:
 Drug allergies
 Food allergies
 Insect bites/stings

Pollen and other inhaled allergens rarely cause anaphylaxis. Some people have an anaphylactic
reaction with no known cause.

Anaphylaxis is life-threatening and can occur at any time. Risks include a history of any type of
allergic reaction.

Symptoms
Symptoms develop quickly, often within seconds or minutes.

They may include any of the following:

 Abdominal pain
 Feeling anxious
 Chest discomfort or tightness
 Diarrhea
 Difficulty breathing, coughing, wheezing, or high-pitched breathing sounds
 Difficulty swallowing
 Dizziness or lightheadedness
 Hives, itchiness, redness of the skin
 Nasal congestion
  Nausea or vomiting
 Palpitations
 Slurred speech
 Swelling of the face, eyes, or tongue
 Unconsciousness

Diagnose
The health care provider will examine the person and ask about what might have caused the
condition.

Tests for the allergen that caused anaphylaxis (if the cause is not obvious) may be done after
treatment.

Treatment
Anaphylaxis is an emergency condition that needs medical attention right away. Call 911
immediately.

Check the person's airway, breathing, and circulation, which are known as the ABC's of Basic
Life Support. A warning sign of dangerous throat swelling is a very hoarse or whispered voice,
or coarse sounds when the person is breathing in air. If necessary, begin rescue breathing
and CPR.

1. Call 911.
2. Calm and reassure the person.
3. If the allergic reaction is from a bee sting, scrape the stinger off the skin with something
firm (such as a fingernail or plastic credit card). Do not use tweezers. Squeezing the
stinger will release more venom.
4. If the person has emergency allergy medicine on hand, help the person take or inject it. Do
not give medicine through the mouth if the person is having difficulty breathing.
5. Take steps to prevent shock. Have the person lie flat, raise the person's feet about 12
inches (30 centimeters), and cover the person with a coat or blanket. Do not place the
person in this position if a head, neck, back, or leg injury is suspected, or if it causes
discomfort.

DO NOT:
 Do not assume that any allergy shots the person has already received will provide
complete protection.
 Do not place a pillow under the person's head if they are having trouble breathing. This
can block the airways.
 Do not give the person anything by mouth if they are having trouble breathing.
Paramedics or other providers may place a tube through the nose or mouth into the airways. Or
emergency surgery will be done to place a tube directly into the trachea.

The person may receive medicines to further reduce symptoms.

Complications
Without prompt treatment, anaphylaxis may result in:
 Blocked airway
 Cardiac arrest (no effective heartbeat)
 Respiratory arrest (no breathing)
 Shock
Prevention
To prevent allergic reactions and anaphylaxis:
 Avoid triggers such as foods and medicines that have caused an allergic reaction in the
past. Ask detailed questions about ingredients when you are eating away from home. Also
carefully examine ingredient labels.
 If you have a child who is allergic to certain foods, introduce one new food at a time in small
amounts so you can recognize an allergic reaction.
 People who know that they have had serious allergic reactions should wear a medical ID
tag.
 If you have a history of serious allergic reactions, carry emergency medicines (such as a
chewable antihistamine and injectable epinephrine or a bee sting kit) according to your
provider's instructions.
 Do not use your injectable epinephrine on anyone else. They may have a condition (such as
a heart problem) that could be worsened by this drug.

Nursing Management

Nursing Assessment
Communication is an essential part of assessment.
 Assess any kind of allergy. The nurse must assess all patients for allergies or
previous reactions to antigens.
 Assess patient’s knowledge. The nurse must also assess the patient’s
understanding of previous reactions and steps taken by the patient and the family to
prevent further exposure to antigens.
 New allergies. When new allergies are identified, the nurse advises the patient to
wear or carry identification that names the specific allergen or antigen.

Nursing Care Planning and Goals

The major goals for a patient with anaphylactic shock are:
 Client will maintain an effective breathing pattern, as evidenced by relaxed breathing
at normal rate and depth and absence of adventitious breath sounds.
 Client will demonstrate improved ventilation as evidenced by an absence of
shortness of breath and respiratory distress.
 Client will display hemodynamic stability, as evidenced by strong peripheral pulses;
HR 60 to 100 beats/min with regular rhythm; systolic BP within 20 mm Hg of
baseline; urine output greater than 30 ml/hr; warm, dry skin; and alert, responsive
mentation.
 Client and significant others will verbalize understanding of allergic reaction, its
prevention, and management.
 Client and significant others will verbalize understanding of need to carry emergency
components for intervention, need to inform health care providers of allergies, need
to wear medical alert bracelet/necklace, and the importance of seeking emergency
care.

Discharge and Home Care Guidelines
Upon discharge, the patient and family need to learn about the following:
 Emergency medications. The nurse should provide information about emergency
medications and plans that should be considered should a crisis reoccur.
 Precipitating factors. The nurse must assist the client and/or family in identifying
factors that precipitate and/or exacerbate crises.
Septic shock
Septic shock is a serious condition that occurs when a body-wide infection leads to dangerously
low blood pressure.

Causes
Septic shock occurs most often in the very old and the very young. It may also occur in people
with weakened immune systems.

Any type of bacteria can cause septic shock. Fungi and (rarely) viruses may also cause the
condition. Toxins released by the bacteria or fungi may cause tissue damage. This may lead to
low blood pressure and poor organ function. Some researchers think that blood clots in small
arteries cause the lack of blood flow and poor organ function.

The body has a strong inflammatory response to the toxins that may contribute to organ
damage.

Risk factors
 Diabetes
 Diseases of the genitourinary system, biliary system, or intestinal system
 Diseases that weaken the immune system, such as AIDS
 Indwelling catheters (those that remain in place for extended periods, especially intravenous
lines and urinary catheters, and plastic and metal stents used for drainage)
 Leukemia
 Long-term use of antibiotics
 Lymphoma
 Recent infection
 Recent surgery or medical procedure
 Recent use of steroid medicines
 Solid organ or bone marrow transplantation

Symptoms
Septic shock can affect any part of the body, including the heart, brain, kidneys, liver, and
intestines.
 Cool, pale arms and legs
 High or very low temperature, chills
 Light headedness
 Little or no urine
 Low blood pressure, especially when standing
 Palpitations
 Rapid heart rate
 Restlessness, agitation, lethargy, or confusion
 Shortness of breath
 Skin rash or discoloration
 Decreased mental status

Diagnose
Blood tests may be done to check for:
 Infection around the body
 Complete blood count (CBC) and blood chemistry
 Presence of bacteria or other organisms
  Low blood oxygen level
 Disturbances in the body's acid-base balance
 Poor organ function or organ failure

Other tests may include:

 A chest x-ray to look for pneumonia or fluid in the lungs (pulmonary edema)
 A urine sample to look for infection
Additional studies, such as blood cultures, may not become positive for several days after the
blood has been taken, or for several days after the shock has developed.

Treatment
Septic shock is a medical emergency. In most cases, people are admitted to the intensive care
unit of the hospital.

Treatment may include:

 Breathing machine (mechanical ventilation)
 Dialysis
 Drugs to treat low blood pressure, infection, or blood clotting
 Fluids given directly into a vein (intravenously)
 Oxygen
 Sedatives
 Surgery to drain infected areas, if needed
 Antibiotics
The pressure in the heart and lungs may be checked. This is called hemodynamic monitoring.
This can only be done with special equipment and intensive care nursing.

Complications
Respiratory failure, cardiac failure, or any other organ failure can occur. Gangrene may occur,
possibly leading to amputation.

Prevention
Prompt treatment of bacterial infections is helpful. However, many cases of septic shock cannot
be prevented.

Nursing Management

Nursing Assessment
Assessment is one of the nurse’s primary responsibilities, and this must be done precisely and
diligently.
 Signs and symptoms. Assess if the patient has positive blood culture, currently
receiving antibiotics, had an examination or chest x-ray, or has a suspected infected
wound.
 Signs of acute organ dysfunction. Assess for presence of hypotension, tachypnea,
tachycardia, decreased urine output, clotting disorder, and hepatic abnormalities.
Planning & Goals
Healthcare team members should be prepared with a care plan for the patient for a more
systematic and detailed achievement of the goals.
 Patient will display hemodynamic stability.
 Patient will verbalize understanding of the disease process.
 Patient will achieve timely wound healing.
Discharge and Home Care Guidelines
Even after discharge, the patient must still be taught how to establish home and community care
regimen.
 Prevent shock episodes. The nurse should instruct the patient and the
family strategies to prevent shock episodes through identifying the factors
implicated in the initial episodes.
 Instructions on assessment. The patient and the family should be taught about
assessments needed to identify the complications that may occur after discharge.
 Treatment modalities. The nurse must teach the patient and the family about
treatment modalities such as emergency administration of medications, IV therapy,
parenteral or enteral nutrition, skin care, exercise, and ambulation.
Neurogenic Shock
Vasodilation occurs as a result of a loss of balance between parasympathetic and sympathetic
stimulation.

It is a type of shock (a life-threatening medical condition in which there is insufficient blood flow
throughout the body) that is caused by the sudden loss of signals from the sympathetic nervous
system that maintain the normal muscle tone in blood vessel walls.

Causes
 Spinal cord injury. Spinal cord injury (SCI) is recognised to cause hypotension and
bradycardia (neurogenic shock).
 Spinal anesthesia. Spinal anesthesia—injection of an anesthetic into the space
surrounding the spinal cord—or severance of the spinal cord results in a fall in blood
pressure because of dilation of the blood vessels in the lower portion of the body and a
resultant diminution of venous return to the heart.
 Depressant action of medications. Depressant action of medications and lack
of glucose could also cause neurogenic shock.

Signs and Symptoms

 Dry, warm skin. Instead of cool, moist skin, the patient experiences dry, warm skin due to
vasodilation and inability to vasoconstrict.
 Hypotension. Hypotension occurs due to sudden, massive dilation.
 Bradycardia. Instead of getting tachycardic, the patient experience bradycardia.
 Diaphragmatic breathing. If the injury is below the 5th cervical vertebra, the patient will
exhibit diaphragmatic breathing due to loss of nervous control of the intercostal
muscles (which are required for thoracic breathing).
 Respiratory arrest. If the injury is above the 3rd cervical vertebra, the patient will go into
respiratory arrest immediately following the injury, due to loss of nervous control of
the diaphragm.

Diagnose
 Computerized tomography (CT) scan. A CT scan may provide a better look at
abnormalities seen on an X-ray.
 Xrays. Medical personnel typically order these tests on people who are suspected of
having a spinal cord injury after trauma.
 Magnetic resonance imaging (MRI). MRI uses a strong magnetic field and radio waves
to produce computer-generated images.

Medication
 Inotropic agents. Inotropic agents such as dopamine may be infused for fluid
resuscitation.
 Atropine. Atropine is given intravenously to manage severe bradycardia.
 Steroids. Patient with obvious neurological deficit can be given I.V. steroids, such
as methylprednisolone in high dose, within 8 hours of commencement of neurogenic
shock.
 Heparin. Administration of heparin or low molecular-weight heparin as prescribed may
prevent thrombus formation.

Nursing Management
Nursing Assessment
Assessment of a patient with neurogenic shock should involve:
 ABC assessment. The prehospital provider should follow the
basic airway, breathing, circulation approach to the trauma patient while protecting
the spine from any extra movement.
 Neurologic assessment. Neurologic deficits and a general level at which
abnormalities began should be identified.

Nursing Care Planning & Goals

The major goals for the patient include:
 Maintain adequate ventilation as evidenced by absence of respiratory distress and
ABGs within acceptable limits
 Demonstrate appropriate behaviors to support the respiratory effort.
 Maintain proper alignment of spine without further spinal cord damage.
 Maintain position of function as evidenced by absence of contractures, foot drop.
 Increase strength of unaffected/compensatory body parts.
 Demonstrate techniques/behaviors that enable resumption of activity.
 Recognize sensory impairments.
 Identify behaviors to compensate for deficits.
 Verbalize awareness of sensory needs and potential for deprivation/overload.