SHOCK

Types Signs and Symptoms Collaborative Management Specific to Type of Shock

Hypovolemia ↓ Preload, ↓ stroke volume, ↓ capillary refill time Oxygenation---Provide supplemental O2, Monitor SvO2 or ScvO2
“fluid problems” Tachycardia  bradypnea (late) Circulation---Restore fluid volume (e.g.Blood/Blood products, crystalloids), Rapid fluid
↓ Urine Output, Pallor, Cool, Clammy skin replacement using 2 large0bore(14-16 gauge) peripheral IV’s, Endpoints of fluid
Anxiety, Confusion, Agitation resuscitation: CVP 15 mm Hg, PAWP 10-12 mm Hg
Absent Bowel Sounds, ↓d Hct, Hgb, Supportive Therapies----Correct the cause (e.g stop bleeding, GI losses, Use warmed
Increased Lactate fluids
Increased urine specific gravity
Change in electrolytes
Cardiogenic ↓ capillary refill time, Increased MVO2, Chest pain may or Oxygenation----Provide supplemental O2 (nasal cannula, non-rebreather mask),
“pump problems” may not be present, Tachypnea, Cyanosis, Crackles, Intubation/mechanical ventilation, if necessary, Monitor SvO2 or ScvO2
Rhonchi, Increased Na+ and H2O retention Circulation---Restore blood flow with thrombolytics, angioplasty w/ stenting, emergent
↓ renal blood flow, ↓ urine output, Pallor, cool, clammy skin coronary revascularization, Reduce workload of the heart w/ circulatory assist devices:
↓ Cerebral perfusion, Agitation, anxiety, confusion IABP, VAD
↓ bowel sounds, N/V, Increased cardiac markers Drug Therapies----Nitrates (Nitroglycerin), Inotropes (Dobutamine), Diuretics
Increased Blood glucose, Increased BUN (furosemide), B-Adrenergic blockers (contraindicated w/ ↓d ejection fraction)
ECG (dysrhythmias), Echocardiogram (left ventricular Supportive Therapies----Correct dysrhythmias
dysfunction), CXR (pulmonary infiltrates)
Distributive ↓/Increased Temp, Biventricular dilation: ↓d ejection Oxygenation----Provide supplemental O2, Intubation/mechanical ventilation, if
“pipe problems” fraction, Hyperventilation, Respiratory alkalosis necessary, Monitor SvO2 or ScvO2
respiratory acidosis, Hypoxemia, Resp Failure, ARDS, Circulation---Aggressive fluid resuscitation, Endpoints of fluid resuscitation: CVP 15
Septic Pulmonary Hypertension, Crackles, ↓ urine output, Warm & mm Hg, PAWP 10-12 mmHg
flushed skin cool and mottled (late) skin, Alteration in Drug Therapies---Antibiotics as ordered, Vasopressors (dopamine), Inotropes
mental status (confusion), Agitation, Coma (late), GI (Dobutamine), Anticoagulation (low-molecular weight heparin)
bleeding, Paralytic ileus, Increased/↓d WBC, ↓d platelets, Supportive Therapies-----Obtain cultures (blood, wound) before beginning antibiotics,
Increased Lactate, Increased Glucose, Increased Urine Monitor temperature, Control Blood glucose, Stress Ulcer prophylaxis
specific gravity, ↓ urine Na+, Positive blood cultures
Anaphylactic Chest pain, Third spacing of fluid, Swelling of lips and Oxygenation-----Maintain patent airway, Optimize oxygenation with supplemental O2,
tongue Intubation/mechanical ventilation, if necessary
SOB, Edema of larynx & epiglottis, Wheezing, Rhinitis, Circulation----Aggressive fluid resuscitation with colloids
Stridor, Flushing, Pruritus, Uritcaria, Angioedema, Anxiety, Drug Therapies----Antihistamines (diphenhydramine), Epinephrine (subcutaneous, IV,
Feeling of impending doom, Confusion, ↓d LOC, Metallic nebulized), Bronchodilators: nebulized (Albuterol), Corticosteroids (if hypotension
taste, Cramping, Abd pain, N/V/D, Sudden onset persists)
History of allergies, Exposure to contrast media Supportive Therapies----Identify & remove offending cause, Prevention via avoidance
of know allergens, Pre-medication w/ hx of prior sensitivity (contrast media)
Neurogenic Increased/↓d Temp Oxygenation-----Maintain patent airway, Optimize oxygenation with supplemental O2,
Bradycardia Intubation/mechanical ventilation, if necessary
Dysfunction r/t level of injury Circulation----Cautious administration of fluids
Bladder dysfunction Drug Therapies-----Vasopressors (phenylephrine), Atropine (for bradycardia)
↓ skin perfusion, cool or warm, dry skin Supportive Therapies----Minimize spinal cord trauma w/ stabilization, Monitor
Flaccid paralysis below the level of the lesion Temperature
Loss of reflex activity
Bowel dysfunction
 Nursing Interventions for All Types of Shock
System Interventions
Neurologic Be aware of s/s that may indicate neurological involvement (changes in behavior, restlessness, hyperalertness, blurred vision, confusion, & paresthesias)
Attempts should be made to alert the pt to time, place, person, and events.
Minimize noise & light to control sensory input.
A day-night cycle of activity & rest should be maintained as much as possible.
Sensory overload and disruption of the pts diurnal cycle may contribute to delirium
Cardiovascular If pt has an unstable HR, BP, central venous pressure, and PA pressures including continuous cardiac output (if available) should be assess q 15 minutes.
Monitor trends in hemodynamic parameters yields more important information than individual numbers. Integration of hemodynamic data w/ physical
assessment data is essential in planning strategies to manage the pt with shock.
Place the pt in the Trendelenburg position judiciously to help tx hypotensive crisis.
Monitor ECG; Assess Heart sounds for the presence of an S3 or S4 or new murmurs. The presence of S3 in adults usually indicate heart failure.
Assess the pts response to fluid resuscitation q 10-15 minutes (make adjustments as needed).
Administer medications as ordered to correct the dysfunctions of the cardio system.
Once the pt stabilizes the frequency of monitoring is ↓d and the pt is slowly weaned off meds to support BP and tissue perfusion
Respiratory Resp status needs to be assessed q 15 -30 minutes. Increased rate & depth provide info regarding the pts attempts to correct metabolic acidosis.
Monitor Pulse Ox continuously; Monitor ABG’s a PaO2 below 60 mm Hg (in the absence of chronic lung disease) indicated the presence of hypoxemia & the
need for the administration of higher O2 concentrations or for a different mode of administration. Low PaCO2 in the presence of a low pH & low bicarb level
may indicate that the pt is attempting to compensate for a metabolic acidosis. A rising PaCO2 in the presence of a persistently low pH & PaO2 may indicate
the need for intubation and mechanical ventilation. Most pts in shock will be intubated and on mechanical ventilation.
Renal Hourly measurements of urinary output are essential in assessment of the adequacy of renal perfusion.
An in-dwelling bladder catheter is inserted to facilitate measurements. Urine output less than 0.5ml/kg/hr may indicate inadequate kidney perfusion. BUN and
creatinine are also monitored. Serum creatinine is a better indicator of renal function b/c BUN levels can be influenced by the catabolic state of the pt.
Integumentary If pts temp is elevated it needs to be assessed q hr, if normal temp should be monitored q 4 hrs. Keep the pt warm by using light covers and controlling the
temp in the pts room. If the pts temp rises above 101.5 & the pt becomes uncomfortable or experiences cardio compromise, the fever maybe managed with
non-steroidal anti-inflammatory drugs (Motrin, Tylenol), or by removing some of the pts covers.
Monitor the pts skin for temp, pallor, flushing, cyanosis, diaphoresis, and piloerection. Assess capillary refill
Gastrointestinal Bowel sounds should be assess at least q 4 hrs & abdominal distention should be assessed. If a NG tube is inserted drainage should be measures and
checked for occult blood. Check stools for occult blood.
Personal Hygiene Hygiene is especially important b/c impaired tissue perfusion predisposes a pt to skin breakdown. The nurse must be careful when bathing a pt in shock is
experiencing resp problems. The nurse must use a clinical judgment in determining priorities of care in order to limit the demand for O2 consumption.
Oral care is important b/c mucous membranes become dry and fragile.
Intubated pts usually have difficulty swallowing resulting in the pooling of secretions.
A water soluble lubricant may be applied to the lips to prevent cracking. A swab moistened with saline water maybe used to provide moisture to the mouth.
Lemon glycerin swabs should not be used b/c the may further irritate the mucosa.
Passive ROM should be performed 3-4 x’s daily to maintain joint mobility. Turn pt q 1-2 hrs to prevent skin breakdown.
Monitor O2 during all nursing interventions to monitor pts tolerance to activity.
Emotional Anxiety, fear, & pain may aggravate resp distress & increase the release of cathcholamines. When providing care the nurse should monitor the pts pain, &
anxiety level. Continous infusion of a benzodiazepine (Ativan), and opioid or anesthetic (Morphine, Diprivan), & occasionally a neuromuscular blocking agent
(Nimbex) are extremely helpful in decreasing anxiety, pain, and O2 demand.
The nurse should encourage the pt to talk to the pt, even if the pt appears comatose b/c hearing is often the last sense to go.
If the pts is intubated & able to write provide them with a piece of paper to write their needs on.
Give pt simple explanations; Don’t overlook spiritual beliefs. Provide a priest, rabbi, or minister. Family can have a significant effect on the pt. To perform this
role, they need to be supportive and comforting. Family (1) links the pt to the outside world (2) facilitates decision making & advise to the pt (3) assist with
ADL’s (4) act as liaisons to advise the health care team of the pts wishes for care, (5) provide safe, caring, familiar relationships for the pts; If possible the
same nurses should provide care to the pt to ↓ anxiety, limit contradictory information and increase trust.