Dylan Naef

Introduction to Shock

Shock is decreased tissue perfusion which causes cellular O2 demands to not be met

resulting in cell death and eventual organ failure. The important thing to recognize is that there

are several different types of shock that have different processes that effect the needed

interventions. The four main classifications of shock are hypovolemic, obstructive, cardiogenic

and distributive.

Cardiogenic shock is due to either systolic or diastolic impairments causing decreased

cardiac output. Other causes of cardiogenic shock can be due to dysrhythmias and structural

factors of the heart such as valvular stenosis or a tension pneumothorax. Hypovolemic shock is

due to loss of intravascular fluid volumes from hemorrhage, vomiting or diarrhea, diabetes

insipidus, diuresis, or fluid loss from increased capillary permeability from burns (Lewis, 2017).

Distributive shock has 3 subcategories; Neurogenic shock, anaphylactic shock and septic shock.

Neurogenic shock occurs most often from a spinal cord injury which can decrease sympathetic

muscle tone decreasing venous vasodilation which decreases blood pressure and eventually

total tissue perfusion. This type of shock can begin within the first half an hour of a spinal cord

injury and last as long as 6 weeks (Lewis, 2017). Anaphylactic shock is a very dangerous allergic

reaction to a sensitive substance. This reaction causes immune responsive mediators that cause

systemic vasodilation and lead to increased capillary permeability. That capillary permeability

allows fluid volume to fill the interstitial spaces and eventually, decreased tissue perfusion.

Septic shock is due to an infection that activates either the central nervous system and/or

release of inflammatory mediators leading to decreased tissue perfusion as stated before. The

last of the 4 main categories of shock is obstructive shock which is the result of something
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blocking blood flow resulting in decreased cardiac output and decreased tissue perfusion. This

can be anything from pulmonary embolisms, compartment syndrome, to even a tension

pneumothorax physically blocking blood flow impairing cardiac output and decreasing total

tissue perfusion (Pich, 2015).

Role of the Nurse in the Shock Process

Understanding the physiological characteristics of each kind of shock can clue the care

provider and other health staff into where the initial assessments and interventions will be

focused. The next important part of shock is to understand onset and how far along the patient

is in the stages of shock. There are 4 main stages of shock that come right after the other. The

first stage being called the initial stage followed by the compensatory stage. Next the

progressive stage leading to the final stage called the refractory stage (Lewis, 2017). Each stage

there are clinically important diagnostic features, common interventions and patient important

teaching points.

The initial stage is usually difficult to see anything out of normal. Diagnostically,

increased lactic acid secretion from anaerobic metabolism is the only presenting sign of the

initial stage (Anderson, 2013). The most important interventions of shock begin with

recognizing and treating shock early for the highest chance of recovery. This stage may consist

of focused assessments for what type of shock the patient is experiencing. Emphasis on medical

history, trauma history, thorough head to toe assessments reveal any signs of oxygen

deprivation. Narrowing pulse pressures, confusion, restlessness, rapid thready pulse,

abnormally warm or cool skin, nausea or vomiting, cyanosis or heavy bleeding (Lewis, 2017).

From this stage and in every stage, will be the focus of a patent airway and maintenance of a
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verbally responsive patient. After assessments will be providing supplemental oxygen,

controlling any bleeding, stabilizing any spinal injury, and initiating IV fluids via large bore IV in

case of need for blood transfusion. During this stage will be critical to maintain a consistent

urinary assessment via Foley catheter and blood draws every 30 minutes to assess for lactate

levels and white blood cell counts. If fluid replacement, oxygen and other relative interventions

fail and the patients status worsens, then the compensatory stage begins.

The compensatory stage is a process of maintaining homeostasis due to the decreased

oxygen supply to the cells. In this stage the body is activating different compensating processes

to alleviate oxygen starvation (Lewis, 2017). In the compensatory stage, the blood pressure

drops due to the most common reason between the different types of shock being lowered

cardiac output. The body continues to attempt to compensate for the low cardiac output by

activation of the sympathetic nervous system to vasoconstrict to maintain tissue perfusion to

the heart and brain. One important diagnostic feature of this stage is that other organs like the

skin, lungs, kidneys begin to become oxygen deprived. This will show the cold or warm skin,

decreased urine output, and respiratory distress. Interventions focused on these areas of

oxygen deprivation such as increasing IV fluids, supplemental oxygen and vasoconstrictor

medications will decrease associative problems with compensatory stage symptoms and may

even help the body recover.

The third stage of shock is the progressive stage. In this stage all of the previous

compensating systems for the decreased tissue perfusion and lowered cardiac output begin to

fail. The critical assessment here is signs of decreased tissue perfusion to the brain resulting in

decreased cognitive functioning. Another result and defining feature of the progressive stage is
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the high grade edema called anasarca. This body-wide edema further inhibits tissue profusion

and eventually leads to total cardiac failure. This stage the patient is in serious need to be

admitted to an intensive care unit for aggressive treatments to correct the poor tissue

perfusion and oxygen deprivation to the organs. Without all of the previously stated

interventions the patient is at serious risk for multiple organ failure (MODS) leading to the

refractory stage.

The refractory stage is the final stage of shock. This stage shows all of the previous

symptoms of hypoxemia and profound hypotension. The build up from anaerobic metabolism

of lactic acid and other waste products lead to even further capillary permeability and edema.

At this stage of shock, the chance for a patient to recover is very unlikely.

Patient Teaching Needed for the Patient and Family

Education is one key feature for nurses to provide and in shock it not only helps comfort

the patient and family that are experiencing shock, but also assists in the application and

intervention of shock. Teaching the patient about shock and what is happening to them can

help the patient understand to help in the assessment stages of shock. The knowledge of

understanding what is happening will also slightly to moderately calm and relax the patient

reducing oxygen demands which assists in recovery from shock. The most important education

to be provide to patient and family is the importance of understanding causation of shock from

thorough medical, trauma and medication history. If the patient is unable to assist in sharing all

of the possible precipitating factors to shock then the family will be critical in gaining that

information.
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Goals and Outcomes Before and After Shock

In general, earlier the prognosis and time of interventions means the better the

outcome for the patient. The farther along the patient goes into the stages of shock the more

significant the impairments and higher the mortality rate become. For example, cardiogenic

shock has an extremely high mortality rate even when there is aggressive treatments and

medical interventions in a hospital at 39 percent (Xiushui, 2017). There are several important

goals that should be met before and after someone goes into shock. First goal is to identify risk

factors for development of shock. Understanding each kind of shock and why it is happening

can direct the interventionist and care team to further obtain the correct health history,

assessment findings and lead to proper diagnostic procedures. At this point is to engage the

correct interventions as quickly as possible so that the consequences of decreased tissue

perfusion are not overwhelming and permanent. While providing interventions another

important goal is to protect the organs that are effected most from the decreased tissue

perfusion and those that are next anatomically from dysfunction. The last goal is to provide

comfort and knowledge to the patient and family so that they may gain comfort that they are

being taken care of, and that they may initiate preventative ways to avoid the causes of shock

in the future (such as avoidance of allergic substances in anaphylactic shock or proper hand

washing and wound cleansing techniques to avoid septic shock).

Shock can be a life-threatening process and has higher mortality rates the farther along

a patient goes without interventions. Therefore, it is so important to understand the

pathophysiology and common reasons for the different kinds of shock. Then understanding the
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possible common interventions for decreased tissue perfusion can be initiate and patient

outcomes increase.

References

Lewis, S., Dirksen, S. R., Heitkemper, M., Bucher, L., Harding, M. M., Jeff. (2017). Medical-

Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume,

10th Edition. [Evolve Select Online]. Retrieved

from https://evolveebooks.elsevier.com/#/books/9780323328524/

Pich, H., & Heller, A. R. (2015, May). [Obstructive shock]. Retrieved June 04, 2017, from

https://www.ncbi.nlm.nih.gov/pubmed/25994928

Andersen, L. W., Mackenhauer, J., Roberts, J. C., Berg, K. M., Cocchi, M. N., & Donnino, M. W.

(2013, October). Etiology and therapeutic approach to elevated lactate. Retrieved June

04, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975915/

Xiushui, M. (2017, January 11). Cardiogenic Shock. Retrieved June 04, 2017, from

http://emedicine.medscape.com/article/152191-overview#a7