Nursing Care & Priorities for
Those in Shock
Keith Rischer RN, MA, CEN
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Todays Objectives
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Compare and contrast pathophysiology &
manifestations of the various shock states and the
physiologic compensatory mechanisms.
Identify nursing priorities with the various shock states.
Compare & interpret abnormal laboratory test indicators
involved with septic, hypovolemic, and cardiogenic
shock.
Analyze assessment data to determine nursing
diagnoses and formulate a plan of care for clients with
the various shock states.
Describe the medical management and mechanism of
action, side effects and nursing interventions of
pharmological management with shock states.
Compare & contrast pathophysiology, manifestations,
nursing priorities seen with sepsis vs. Multiple Organ 2
Dysfunction Syndrome (MODS).
Shock Defined
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Any problem that impairs oxygenation delivery to
tissues & organs
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CV system is where it begins
Table 40-3 p.826
• Hypovolemic
• Cardiogenic
• Distributive
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Neurogenic
Anaphylactic
Septic-SIRS
Multiple Organ Dysfunction Syndrome (MODS)
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Processes of Shock
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Initial stage…early shock
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Table 40-2 p.825
MAP decrease 5-10mm/Hg
Mild vasoconstriction
Tachycardic…Why???
Nonprogressive stage…compensatory stage
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MAP decrease 10-15 mm/Hg
Mod. Vasoconstriction
Physiologic compensations
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Renin, aldosterone, ADH
Decreased u/o
Mild acidosis
Mild hyperkalemia
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Processes of Shock
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Table 40-2 p.825
Progressive stage…intermediate stage
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MAP decrease >20mm/Hg
Overall metabolism-anaerobic
 Moderate
acidosis
 Moderate hyperkalemia
 Tissue ischemia
 lactic acidosis-Lactate
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Refractory stage…irreversible stage
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Hypovolemic Shock:Physical Assessment
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Cardiovascular changes
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Pulse
Blood pressure
Skin changes
 Respiratory changes
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Oxygen saturation
RR
Renal and urinary changes
 Central nervous system changes
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Hypovolemic Shock:Nursing Priorities
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Impaired gas exchange
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Deficient fluid volume
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Nursing interventions
Decreased cardiac output
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Nursing interventions
Nursing interventions
Risk for ineffective tissue perfusion
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Body systems impacted???
Nursing interventions
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Sepsis
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Patho
Progressive
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Infection
Bacteremia
Systemic Inflammatory
Response Syndrome
(SIRS)
Sepsis
Severe sepsis
Septic shock
Multiple Organ Dysfunction
Syndrome (MODS)
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Sepsis:Hyperdynamic (early)
Cardiovascular changes
 Skin changes
 Respiratory changes
 Renal and urinary changes
 Central nervous system changes
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Sepsis:Hypodynamic (late)
Cardiovascular changes
 Skin changes
 Respiratory changes
 Renal and urinary changes
 Central nervous system changes
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Shock-Laboratory Findings
Chart 40-3 p.831
General
 ABG’s
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pH
CO2
O2
HCO3
Lactate
Hct
Hgb
Potassium
Septic Shock
 Blood cultures
 WBC
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Neutrophils
Bands
C Reactive Protein
(CRP)
D-Dimer
Fibrinogen
INR
Platelets
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Nursing Care Priorities/Diagnosis
Impaired gas exchange r/t…
 Deficient fluid volume r/t…
 Ineffective tissue perfusion r/t…
 Anxiety
 Knowledge deficit r/t…
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Ultimate Goal…
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General Shock: Nursing Interventions
Remember A,B,C,D
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Reverse the shock
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Restore fluid volume
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Administer O2
Establish IV access
Colloid
Crystalloid
Vasoactive gtts
Administer blood products as ordered
Nursing assessment
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Pulse/rhythm
BP-CVP
RR-O2 sats
Urine output
Skin color
Monitor labs
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Shock Case Study
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83yr male
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Admitted from ED to tele for abd pain and recent lower GI
bleeding. Colonoscopy later in day.
PMH: AFib-on Coumadin daily, HTN
Hgb 11.2, INR 2.8, creat .90
ED VS: T-98.8 P-76 R-16 BP-108/64 sats 98% 2l n/c
Enter room to perform initial assessment:
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Pale-diaphoretic, lethargic. Can answer simple questions
and oriented x3
Smell suspicious ?GI bleeding
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Note large pool of dark, red blood on pad
VS: P-110 R-24 BP-78/34 sats 90% 2l n/c
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Shock Case Study
Nursing priorities…
 Rapid Response paged
 SBAR to primary MD
 Medical/Nursing management:
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2 large bore IV’s
NS 1000cc FF
Prepare for transfer to ICU
Stat Hgb
Obtain 2u PRBC from blood bank
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15” later…
VS: P-100 R-20 BP-92/46 sats 98% 6l n/c
 Hgb 8.2
 First unit of blood initiated
 Prepare for transfer to ICU…unable to
take at this time
 Foley catheter placed
 VS just before transfer: P-88 R-18 BP102/64 sats 100% 4l n/c
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Septic Shock: Nursing Interventions
All the same as previous slide and…
 Obtain blood, urine cultures as ordered
 Administer IV abx
 Administer anti-arrythmics
 Aggressive IV fluid resuscitation
 Assess closely for signs of bleeding…DIC
 Strict aseptic technique
 Fever reduction as needed
 Client-family education
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Mechanism of Action: Abx
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Vasoactive Gtts
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chart 40-6 p.833
Dopamine
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Renal
Beta effect
Alpha effect
Levophed (norepinephrine)
 Phenylephrine (neo-synephrine)
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Multiple Organ Dysfunction Syndrome
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Patho
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Uncontrolled inflammation
Progressive dysfunction of 2 or more systems
Risk factors
Causes
 Trauma
 Pancreatitis
 ARDS
 Major
surgery
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Multiple Organ Dysfunction Syndrome
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Four major organ systems involvement
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Pulmonary
Renal
Cardiovascular
Coagulation
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Physical Assessment
Pulmonary
 CV
 Renal
 GI
 Neuro
 Coagulation
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Diagnostic-Lab Findings
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ABG
• pH
• CO2
• O2
• HCO3
• O2 sats
WBC
Platelets
Fibrinogen
PT-INR
Hgb
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Creatinine
K+
GFR
Troponin
BNP
Liver Enzymes
• ALT-AST
• Alk Phos
• Total bili
• Ammonia
• albumin
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Therapeutic Management
Support tissue oxygenation
 Fluid resuscitation
 Blood and blood products
 Dialysis or CRRT
 Nutritional support
 Antibiotic therapy
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Priority Nursing Diagnoses…
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Nursing Priorities-Interventions
Assess resp. status
 Continuous cardiac monitoring Assess
perfusion
 Provide hydration and nutritional support
 Assess for coagulation dysfunction
 Emotional support/comfort measures
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Evaluation….
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Sepsis/MODS Case Study
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40 yr male w/seizure
disorder
Chief complaint
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Physical assessment
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Altered mental status
Vague abd pain
Weakness
Hypotension
Epigastric-LUQ tender
VS
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T-101.2/P-110/R-24/BP
92/42/sats 95% RA
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Admission Labs
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WBC-11,000
Hgb-12.2
Platelets-64,000
Creatinine-2.7
ALT-502
AST-219
Ammonia-68
Lipase-1947
Glucose-322
CT-encephalopathy
Abd CT-inflamm. pancreas
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Case Study:Later… Day of Admission
Increasing lethargy, resp. distress
 ABG
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pH- 7.28
CO2- 59
O2- 52
HCO3- 23
O2 sats- 84
FiO2-100% vent…AC12, PEEP +5
CT-abd. Ileus-hepatic infarcts
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Case Study:Day 1
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CVP-21
VS-101.2-118-24-82/40
NG placed
Labs
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WBC-12.7
Platelets-56
Creatinine-.7
ALT-243
AST-219
Lipase 523
ABG
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pH-7.25
CO2-52
O2-76
O2 sats-92%
FiO2-100%
PEEP now +10
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Weight up 8 kg
Non icteric
IV Infusions
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Insulin gtt
Lasix gtt
TPN-Lipids
Fentanyl gtt
Versed gtt
Levophed gtt
Neosynephrine gtt
Vasopressin gtt
Heparin gtt
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Case Study:Day 2
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CVP-16 –weight up another 7.5
kg…poor u/o
VS-100.5-110-24-84/44
Labs
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WBC-21.5
Hgb-12.5
Platelets-77
Creatinine-0.9
ALT-143
AST-41
Ammonia-30
Lipase 114
CXR-white out
ABG
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pH-7.11
CO2-78
O2-58
HCO3-24
O2 sats-75%
Vent-FiO2-100%, +15
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Treatment Plan
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CRRT
IV abx-Cipro/Flagyl
Hold Lasix gtt
NG LCS
Lactulose
Wean vasoactive gtts as able
Continue all previous gtts
Pan cultures
Physical assessment
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Distended abd-hypoactive
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NG bile output
Coarse crackles bilat
Cool to touch
Nursing Priorities…
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Case Study #2…
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90yr male
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PMH: anemia, hypothermia due to thalamus disorder,
pneumonia, COPD, HTN, renal insufficiency, mild
dementia. Lives in assisted living
HPI: Son visited today and noted to be incr. confusedbrought to ED for eval.
VS: T-90.9 P-41 (Junctional) R-16 BP 99/45 sats 97%
2l per n/c
Assessment:
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Neuro-confused-responds to voice
Resp-clear-neg. assessment
– CXR: left basilar infiltrate
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CV-No edema, S1S2, pulses strong x4
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Labs
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Case Study #2…
Order received to give 2u PRBC
 After second unit VS:
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T-95.5 P-38 R-36 BP-113/49 sats 88% 6l n/c
c/o SOB-breath sounds course bilat
u/o 100cc last 4 hours
SBAR…
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Order for Lasix 40mg IV…80cc u/o last hour
SBAR
 Additional
Lasix 80 mg IV and assess
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Case Study #2…
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Status 1 hour later…
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RR 36-44 w/sats 84-88% on oxymizer 15l
Breath sounds remain course
u/o 30cc since Lasix 80mg 1 hour ago
SBAR
 Bipap
started per RT
 Sats increased to 94%, RR 20-24, appears more
comfortable
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AM Labs
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4 Days Later…Summary
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Sepsis…ARF necessitated need for dialysis due
to resultant hyperkalemia, fluid overload.
Multisystem failure of kidneys, heart, and lungs
Kaofeed placed and started on TF
VS:
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T-98.1 P-80 (SR) R-16 BP-159/75 sats 100% (5l
oxymizer)
I-1700 /O-2480
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Case Study #2
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Assessment
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Neuro-follows commands-more responsive
Resp-dimin bilat w/scatt. Crackles-non-labored
CV-NSR, tr. Edema LE
GU-Incr. u/o, Foley
Medical-Nursing priorities
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Pneumonia
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Leukocytosis (Solumedrol?)
IV abx
Hyperkalemia
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D50, insulin IV, NaBicarb IV, Calcium Gluconate
Unable to take Kayexalate po or rectally
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Medical-Nursing Priorities
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Resp. failure
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Acute renal failure
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ATN…sepsis
ACE held
u/o improving
Sepsis
Encephalopathy
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Bipap…oxymizer to keep sats >90%
Ativan, Haldol prn
Nutrition
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TF
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Labs
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