Angelite Nurses

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. See Table 4.8 for classification of shock.

Body's Response to Shock

1. Hyperventilation leading to respiratory alkalosis
2. Vasoconstriction: shunts blood to heart and brain
3. Tachycardia
4. Fluid shifts: intracellular to extracellular shift to maintain circulating blood volume
5. Impaired metabolism: tissue anoxia leads to anaerobic metabolism causing lactic acid buildup, resulting in metabolic acidosis
6. Impaired organ function
1. Kidney: decreased perfusion can result in renal failure.
2. Lung: shock lung (adult respiratory distress syndrome [ARDS])

Table 4.8 Classifications of Shock

Assessment Findings

1. Skin
1. Cool, pale, moist in hypovolemic and cardiogenic shock
2. Warm, dry, pink in septic and neurogenic shock
2. Pulse
1. Tachycardia, due to increased sympathetic stimulation
2. Weak and thready
3. Blood pressure
1. Early stages: may be normal due to compensatory mechanisms
2. Later stages: systolic and diastolic blood pressure drops.
4. Respirations: rapid and shallow, due to tissue anoxia and excessive amounts of CO₂ (from metabolic acidosis)
5. Level of consciousness: restlessness and apprehension, progressing to coma
6. Urinary output: decreases due to impaired renal perfusion
7. Temperature: decreases in severe shock (except septic shock).

Nursing Interventions

1. Maintain patent airway and adequate ventilation.
1. Establish and maintain airway.
2. Administer oxygen as ordered.
3. Monitor respiratory status, blood gases.
4. Start resuscitative procedures as necessary.
2. Promote restoration of blood volume; administer fluid and blood replacement as ordered
1. Crystalloid solutions: Ringer's lactate, normal saline
2. Colloid solutions: albumin, plasmanate, dextran
3. Blood products: whole blood, packed red blood cells, fresh frozen plasma
3. Administer drugs as ordered (see Table 4.9).
4. Minimize factors contributing to shock.
1. Elevate lower extremities to 45° to promote venous return to heart, thereby improving cardiac output.
2. Avoid Trendelenburg's position: increases respiratory impairment.
3. Promote rest by using energy-conservation measures and maintaining as quiet an environment as possible.
4. Relieve pain by cautious use of narcotics.
1. Since narcotics interfere with vasoconstriction, give only if absolutely necessary, IV and in small doses.
2. If given IM or subcutaneously, vasoconstriction may cause incomplete absorption; when circulation improves, client may get overdose.
5. Keep client warm.
5. Maintain continuous assessment of the client.
1. Check vital signs frequently.
2. Monitor urine output: report urine output of less than 30 ml/hour.
3. Observe color and temperature of skin.
4. Monitor CVP.
5. Monitor ECG.
6. Check lab studies: CBC, electrolytes, BUN, creatinine, blood gases.
7. Monitor other parameters such as arterial blood pressures, cardiac output, pulmonary artery pressures, pulmonary artery wedge pressures.
6. Provide psychologic support: reassure client to relieve apprehension, and keep family advised.

Table 4.9 Drugs Used to Treat Shock