1. Care of Patients with Shock
Chapter 39
Care of Patients with Shock

2. Shock
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.
“Whole-body” response.
Shock is a “syndrome.”
Any problem that impairs oxygen delivery to tissues and organs can start the syndrome of shock and lead to a life-threatening emergency.

3. Classification of Shock by Functional Impairment
Hypovolemic shock
Cardiogenic shock
Distributive shock
Obstructive shock

4. Classification of Shock by Origin of the Problem
Hypovolemic
Cardiogenic
Basogenic
Septic

5. Processes of Shock Initial stage (early shock)
Nonprogressive stage (compensatory stage)
Progressive stage (intermediate stage)
Refractory stage (irreversible stage)

6. Review of Oxygenation and Tissue Perfusion
Total blood volume
Cardiac output
Size of the vascular bed

7. Hypovolemic Shock
Occurs when low circulating blood volume causes a mean arterial pressure decrease; the body’s oxygen need is not met
Commonly caused by hemorrhage (external or internal) and dehydration
S&P

8. Cardiogenic Shock
Actual heart muscle is unhealthy, and pumping is directly impaired.
Myocardial infarction is the most common cause of direct pump failure.

9. Distributive Shock
Blood volume is not lost but is distributed to the interstitial tissues where it cannot circulate and deliver oxygen
Caused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, capillary leak
Neural-induced distributive shock
Chemical-induced distributive shock

10. Chemical-Induced Distributive Shock
Anaphylaxis
Sepsis
Capillary leak syndrome

11. Obstructive Shock
Caused by problems that impair the ability of the normal heart muscle to pump effectively
Heart is normal, but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle
Pericarditis
Cardiac tamponade

12. Stages of Shock Initial stage Nonprogressive stage Progressive stage
Refractory stage

13. Initial Stage of Shock Baseline MAP decreased by less than 10 mm Hg
Heart and respiratory rate increased from the baseline or a slight increase in diastolic blood pressure
Adaptive responses of vascular constriction and increased heart rate

14. Nonprogressive Stage MAP decreases by 10 to 15 mm Hg.
Kidney and hormonal adaptive mechanisms activated.
Tissue hypoxia in nonvital organs.
Acidosis and hyperkalemia.
Stopping conditions that started shock and supportive interventions can prevent shock from progressing.

15. Progressive Stage of Shock
Sustained decrease in MAP of more than 20 mm Hg from baseline.
Vital organs develop hypoxia.
Life-threatening emergency.
Immediate interventions are needed.
Conditions causing shock need to be corrected within 1 hour of the onset of the progressive stage.

16. Refractory Stage of Shock
Too much cell death and tissue damage result from too little oxygen reaching the tissues.
Body can no longer respond effectively to interventions, and shock continues.

17. Multiple Organ Dysfunction Syndrome
Sequence of cell damage caused by the massive release of toxic metabolites and enzymes.
Metabolites released from dead cells.
Microthrombi form.
MODS occurs first in the liver, heart, brain, and kidney.
Myocardial depressant factor from the ischemic pancreas.

18. Health Promotion and Maintenance
Primary prevention of hypovolemic shock
Secondary prevention of hypovolemic shock

19. Physical Assessment/Clinical Manifestations
Cardiovascular changes
Pulse
Blood pressure
Oxygen saturation
Skin changes
Respiratory changes
Renal and urinary changes
Central nervous system changes
Musculoskeletal changes

20. Assessment
Psychosocial assessment
Laboratory tests

21. Nonsurgical Management
Goals of shock management are to maintain tissue oxygenation, increase vascular volume to normal range, and support compensatory mechanisms
Oxygen therapy
IV therapy
Drug therapy

22. Drug Therapies
Vasoconstrictors, such as dopamine, epinephrine, norepinephrine, phenylephrine
Agents that enhance contractility
Agents that enhance myocardial perfusion

23. Sepsis and Septic Shock
Complex type of distributive shock—usually begins as a bacterial or fungal infection and progresses to a dangerous condition over a period of days
Sepsis—widespread infection coupled with a more general inflammatory response, known as systemic inflammatory response syndrome (SIRS), that is triggered when an infection escapes local control

24. Severe Sepsis
Progression of sepsis with an amplified inflammatory response

25. Septic Shock
Stage of sepsis and SIRS when multiple organ failure is evident and uncontrolled bleeding occurs.
Even with appropriate intervention, the death rate among patients in this stage of sepsis exceeds 60%.

26. Septic Shock (Cont’d) Etiology and genetic risk Incidence/prevalence
Health promotion and maintenance

27. Septic Shock: Clinical Manifestations
Cardiovascular changes
Respiratory changes
Skin changes
Renal urinary changes
Psychosocial assessment
Laboratory tests

28. Septic Shock: Interventions
Oxygen therapy
Drug therapy
Blood replacement therapy

29. Community-Based Care
Home care management
Health teaching