An abnormal physiologic state where an imbalance between the amount of circulating blood volume and the size of the

vascular bed results in circulatory failure and oxygen and nutrient deprivation of tissues

 Hyperventilation leads to respiratory alkalosis Vasoconstriction Tachycardia Fluid shifts intracellular to extracellular to maintain circulating blood volume

 Impaired metabolism tissue anoxia leads to anaerobic metabolism causing lactic acid buildup, resulting in metabolic acidosis Impaired organ function
Kidney: decreased perfusion can result in renal failure Lung: shock lung (ARDS)

1. Compensatory 2. Progressive 3. Irreversible

Initial insult leading to shock state

Decreased tissue perfusion and low oxygenation

Activation of homeostatic response

Activation of homeostatic response

Increased sympathetic response Increased renin-angiotensin activation Increase Decrese catecholamines respiratory and rate cortisol increase to -increase HR, BP, cardiac contractility -increase reabsorption of sodium and to water provide more oxygen glucose saturation for metabolism and delivery Leads toto increase in cardiac output - Leads increase in preload and decrease urine output

Restoration of tissue perfusion and oxygenation

 In the second stage of shock, the mechanisms that regulate BP can no longer compensate, and the MAP falls below normal limits. Patients are clinically hypotensive; -systolic BP of less than 90 mm Hg - or a decrease in systolic BP of 40 mm Hg from baseline

 The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive.

 Hypovolemic Cardiogenic Septic Neurogenic Anaphylactic

 Characteristic
Decreased circulating blood volume

Causes
Blood loss Plasma loss (e.g. burns) Fluid loss (e.g. excessive vomiting or diarrhea)

 Characteristic
Failure of the heart to pump properly

Causes
Myocardial Infarction Congestive Heart Failure Cardiac arrhythmias Pericardial tamponade Tension pneumothorax

 Factors favoring septic shock

Development of antibiotic-resistant organisms Invasive procedures such as urinary tract instrumentation Immunosuppression and old age Trauma: presence of blood in peritoneal cavity greatly increases likelihood of peritonitis

 Cause
Release of bacterial toxins that act directly on the blood vessels producing massive vasodilation and pooling of blood; results most frequently from gram-negative septicemia

 Characteristic
Failure of arteriolar resistance, leading to massive vasodilation and pooling of blood

Cause: Interruption of sympathetic impulses fromanesthesia High spinal

Exposure to unpleasant circumstances Vasomotor depression Extreme pain Head injury Spinal cord injury

 Characteristic
Massive vasodilation resulting from allergic reaction causing release of histamine and related substances

Cause: Allergic reaction to

Insect venom medications Dyes used in radiologic studies

a. Skin
1. Cool, pale, moist in hypovolemic and cardiogenic shock 2. Warm, dry, pink in septic and neurogenic shock

b. Pulse
1. Tachycardia, due to increased sympathetic stimulation 2. Weak and thready

c. Blood pressure
1. Early stage: may be normal due to compensatory mechanisms 2. Later stage: systolic and diastolic BP drops

d. Respiration
- rapid and shallow due to tissue anoxia and excessive amounts of CO2

e. Level of consciousness
- Restlessness and apprehension, progressing to coma

f. Urinary output
- decreases due to impaired renal perfusion

g. Temperature:
- decreases in severe shock (except in septic shock)

A. Maintain patent airways and adequate ventilation B. Promote restoration of blood volume; administer fluid and blood replacement as ordered C. Administer drugs as ordered D. Minimize factors contributing to shock
-positioning, promote rest, relieve

E. Maintain continuous assessment of the client

cvp, ecg, lab)

(vs, i&o,

F. Provide psychologic support: reassure client to relieve apprehension and keep family advised

Medication Inotropic Agents Dobutamine (Dobutrex) Dopamine (Intropin) Epinephrine (Adrenalin) Milrinone (Primacor) Vasodilators Nitroglycerin (Tridil) Nitroprusside (Nipride)

Desired Action in Shock Improve contractility, increase stroke volume, increase cardiac output

Disadvantages Increase oxygen demand of the heart

Reduce preload and afterload, reduce oxygen demand of heart

Cause hypotension

Vasopressor Agents Increase blood pressure Norepinephrine (Levophed) by vasoconstriction Dopamine (Intropin) Phenylephrine (NeoSynephrine) Vasopressin (Pitressin)

Increase afterload, thereby increasing cardiac workload; compromise perfusion to skin, kidneys, lungs, gastrointestinal tract

Textbook of Medical-Surgical Nursing, Smeltzer, et.al.