OSTE: Shock
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Objective Structured Team Exercise (OSTE)
Patient Experiencing Shock
Introduction
Patient Profile: Steve, a 25 year old graduate student, was an unrestrained driver
involved in a motor vehicle crash. He was found face down 15 feet from his car. There were no
passengers. The windshield was broken and his car was found up against a tree. Steve was found
conscious and moaning. He was taken to the emergency department (ED).
Subjective Data: Steve states “I can’t breathe” and cries out when his abdomen is
palpated.
Objective Data:
Cardiovascular: BP 84/70; apical pulse 120 but no radial or brachial pulses palpable;
carotid pulse present but weak.
Lungs: Respiratory rate 35/minute; laboured breathing with severe respiratory distress;
asymmetric chest wall movement; absence of breath sounds on left side.
Abdomen: Slightly distended and painful to palpation.
What is Shock?
Shock is a life-threatening condition that occurs when the body is not getting enough
blood flow. This can damage multiple organs. Shock requires immediate medical treatment and
can get worse very rapidly.
What is Hypovolemic Shock?
Hypovolemic shock is an emergency condition in which severe blood and fluid loss
makes the heart unable to pump enough blood to the body. This type of shock can cause many
organs to stop working.
Risk Factors for Hypovolemic Shock
External: Fluid Losses
Trauma-bleeding
Surgery-blood loss
Vomiting-fluid loss
Diarrhea-fluid loss
Diabetes insipidus-severely diluted urine
Diuresis- d/t polyuria
Internal: Fluid Shifts
Hemorrhage- internal bleeding
Burns-edema and fluid shift
Ascites-fluid in abdomen (cirrhosis)
Peritonitis-inflammation of
peritoneum -fluid shift
Dehydration
Hemorrhage and hypovolemic shock are the leading immediate causes of death following trauma
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Why is Steve experiencing shock?
1) torn thoracic artery
2) hemopneumothorax
3) torn spleen
Torn thoracic artery:
- The internal thoracic arteries (also known as mammary arteries) arise from the subclavian
arteries and supply blood to most of the anterior thorax wall.
- Due to trauma and/or the broken ribs our patient suffered, his thoracic artery was torn.
- Rupture of such a large vessel will cause someone to have a severe hemorrhage and a
massive hemothorax (large amounts of blood in the pleural space).
- Rupture of the thoracic artery may cause the patient to have blood loss into the
hemithorax (one side of chest) of 500- 1000ml/hr
- Patient has 50-75% mortality rate, upon arrival in the ED
Treatment: surgery to repair torn artery- remove blood from pleural space
Hemopneumothorax:
- hemopneumothorax results when blood and air enter the pleural space
- when ribs were broken they pierced the left lung, air entered the pleural space; torn artery
also caused blood to enter pleural space…causing a decrease in the negative pressure
necessary for ventilation. (Remember-the pleurae cling strongly to the thorax wall and
lungs and secrete lubrication which allows the lungs to glide easily during breathing and
help maintain intrapleural pressure)
- we know our patient has absence of breath sounds on left side, asymmetric chest wall
movement, it is therefore likely his is experiencing a hemopneumothorax
- Result = collapsed lung, difficulty breathing & loss of blood= shock
Treatment: insertion of chest tube to drain blood (suction), which helps return the lung to a state
of neg. pressure
Spleen:
What do we know about the spleen?
- Filters blood, provides storage for blood cells, and manufactures antibodies; the spleen in
a highly vascular organ
What’s going to happen if the spleen is torn? – massive hemorrhage
- the spleen is the most commonly injured organ in blunt trauma, especially with damage
in upper left quadrant
- a torn spleen will often occur when the eighth, ninth and tenth ribs are fractured on the
left side
- the patient with splenic injury will complain of left upper quadrant pain (remember our
patient cried out when his abdomen was palpated!)
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Ballance’s sign: dullness on percussion of abdomen and increased girth due to blood
accumulation in abdominal cavity
- Kehr’s sign: pain referred to left shoulder due to damage to spleen
- Torn spleen= hemorrhage-=hypovolemic shock
Treatment: splenectomy
-
Signs and Symptoms of Hypovolemic Shock
 There are different signs and symptoms for early shock and late shock. Common sense
would say that the signs and symptoms become more severe as the shock progresses. In
this case the signs and symptoms do become more severe but it is hard to recognize the
severity of the signs. For example, in the early stages of shock you have cool clammy
skin and in the late stage of shock your skin becomes more pale, slightly cyanotic and
colder. These are very fine changes that occur that would be very hard to see with the
naked eye.
The early signs of shock
 an altered level of consciousness, sometimes manifested in agitation and restlessness, or a
central nervous system depression, cool, clammy skin, orthostatic hypotension, mild
tachycardia, and vasoconstriction.
 At this time, the body is able to sustain blood pressure and tissue perfusion by employing
compensatory mechanisms that primarily promote vasoconstriction to support an increase
in intravascular volume.
The late signs of shock
 Worsening changes in mental status which could include coma, hypotension, and marked
tachycardia. The signs and symptoms from early shock seem to worsen as the shock
progresses.
 It is important to know that healthy adults with impending hemorrhagic hypovolemic
shock may not become hypotensive until as much as 30% of their circulating blood
volume is lost.
Sympathetic Nervous System
 Assessing the early and late signs and symptoms of shock we can see that the
sympathetic nervous system kicks into action.
 Some sympathetic effects that occur when a person is in shock are: dilated pupils,
increased heart rate with vasoconstriction, dilated bronchi for increased respiratory rate,
decrease GI motility and secretions, decrease urinary output, and increased blood
clotting.
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Blood Pressure
 Another sign of hypovolemic shock that Mr. S is showing is an extremely low blood
pressure. When the sympathetic nervous system starts the fight or flight response there is
an increase in heart rate and vasoconstriction which should increase the blood pressure.
 When a person is in hypovolemic shock there is a decrease in venous return to the heart,
resulting in decreased cardiac output. With all of this occurring in the body the blood
volume is increased in three ways: interstitial fluid volume shifts into the vasculature, the
liver and spleen release stored red blood cells and plasma, and the rennin-angiotensinaldosterone system activates which allows the body to retain sodium and water and
increase mean arterial blood pressure.
Lab Values
 Three main lab values the health care professionals should be looking at are hemoglobin,
hematocrit, and ABG levels.
 Hemoglobin and hematocrit levels will decrease due to hemorrhaging and Arterial blood
gas (ABG) analysis may reveal metabolic acidosis.
 The metabolic acidosis occurs because with hypovolemic shock the body shunts blood
from non-vital organs to vital organs such as the brain, lungs, and heart. The shunting of
blood leads to acidosis, decreased bowel peristalsis, and other cellular complications.
Nursing Care for Steve
Initial nursing responsibilities for management of hypovolemic shock
 Monitor vital signs, O2 values, cardiac rhythm/rate and temperature
 Position patient with lower extremities elevated at 20 degree angle, knees straight, trunk
horizontal and head slightly elevated (see picture pg. 312 med/surgery text)
 Apply warm blankets
 Administer oxygen 15 L/min via non-breather mask
 Infuse an IV of 1L of 0.9% sodium chloride solution
 If BP drops and heart rate increases infuse 2 units of packed RBC’s
 Insert a indwelling urinary catheter and monitor urine output
Nursing management on unit
 Administer prescribed medications and fluids
 Monitor blood levels; observe invasive vascular lines for infection and keep free from
infection
 Monitor vital signs
 Maintain skin integrity by repositioning patient
 Provide safety, comfort and rest
 Ensure family is informed about patient’s status and questions are answered
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Care for chest tube
 Visible blood drainage will appear immediate post-op and should become serous.
Drainage usually decreases progressively in first 24 hours.
 If patient is bleeding 100mL every 15 minutes check it every few minutes
 Ensure incision is kept clean and for pain around the insertion site a topical transdermal
analgesic can be applied. Watch for signs of infection
 Observe for leaks or bubbling in the tubing which may be the result of a tension
pneumothorax (Pg. 635-636 in Med/Surgery text – caring for the chest tube)
Post-op care for splenectomy
 Shower as usual; avoid baths until incision has completely healed. Replace wet dressings
with clean dry ones
 Take only non-aspirin containing medications for minor pain
 Avoid vigorous activity
 Call your doctor if you experience any redness, swelling, increased pain, excessive
bleeding or discharge from the incision site, cough, SOB, chest pain, nausea/vomiting
Goals for post-op thoracic surgery
 Improved gas exchange (positioning, breathing techniques with incentive spirometry)
 Improved airway clearance (encourage coughing and support incision, chest percussion
helps to loosen and mobilize secretions so patient can cough or have them suctioned up)
 Relieve pain and discomfort (topical transdermal analgesics, opioid analgesics)
 Promote mobility and shoulder exercises(Restores movement and preventing stiffening)
 Monitor for potential complications (Resp. Distress, dysrhythmias, pneumothorax etc.)
 Pg. 643 Med/Surgery Text for Care plan for a thoracotomy
Nursing Diagnoses for Hypovolemic Shock
 Deficient fluid volume r/t trauma, loss of fluid from body
 Ineffective tissue perfusion: cardiopulmonary; peripheral r/t arterial/venous blood flow
exchange problems
 Risk for injury: prolonged shock resulting in multiple organ failure or death
 Fear r/t serious threat to health status
Treatment for Steve
Oxygen Therapy
In hypovolemic shock, reduced intravascular blood volume causes circulatory
dysfunction and inadequate tissue perfusion. Any patient who is at risk for decreased oxygen is
at risk for the development of shock, therefore, the initial assessment should be geared towards
the ABCs because:
 A- airway
 B- breathing
 C- circulation
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Why Oxygen is applied Steve?
 Steve states “I can’t breathe” in addition he has a collapsed lung two factors that affect
his breathing and make him feel short of breath.
 His hematocrit is 28% the normal value for men is 40%-54% meaning the percentage of
RBC is low compared with the total blood volume. Therefore, if his RBCs are low, his
hemoglobin is low causing a decrease in the amount of oxygen being distributed to his
organs.
 Steve is hemorrhaging causing a decrease in his red blood cells therefore, his hemoglobin
drops, his body’s main means of delivering oxygen to the body. It is essential to apply
oxygen to Steve to distribute oxygen throughout his body.
It is vital to maintain tissue perfusion to Steve’s vital organs, especially the brain and heart
because without tissue perfusion to Steve’s vital organs it can lead to:
 Irreversible cerebral damage
 Cardiac arrest
 Death
IV Therapy
The first choice of fluid you want to start Steve on are crystalloid fluids such as Normal
Saline and Ringers Lactate.
The key factor to crystalloid solution:
These solutions have [Na+] which is the biggest electrolyte found in blood. Therefore,
Steve who is losing blood needs crystalloid fluids to replace the [Na+] that is being lost in order
for his body to maintain homeostasis.
Why Crystalloid Solutions are more effective
 Used for volume expansion.
 They are safe and effective for recovery of patients in hypovolemic shock.
 These solutions have small molecules that flow easily from the bloodstream into cells and
tissues.
 A loss of blood volume of approximately 1000ml can be replaced with a 3000-4000ml
infusion of crystalloid fluid without any adverse effects.
 They contain about the same concentration of particles as extracellular fluid. Therefore,
fluid does not shift between the extracellular and intracellular areas.
 0.9% Normal Saline is the only solution that may be administered with blood products.
 These fluids are very convenient in emergency cases such as Steve’s because no special
compatibility testing is required. In this case, Steve who is losing blood needs a blood
transfusion so we know it is safe to mix this solution with blood products and begin
transfusion immediately.
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Colloids
Are also used for volume expansion
 Colloids contain undissolved particles, such as protein, sugar, and starch molecules,
which are too big to pass through capillary walls.
 They have a longer duration of action because the larger molecules stay in the
intravascular compartment longer.
 Examples of colloids:
o Albumin
o Dextran
Precautions of administering Colloids
 Colloids are used if the patient’s blood volume does not improve with crystalloids.
 Due to their large particles they must be administered slowly and with extreme caution
because they may cause dangerous intravascular volume overload, for this reason they
must be given in smaller volumes.
Steve is also losing blood; therefore, packed red blood cell transfusion is necessary which we
could administer with the crystalloid solution because they are compatible.
Packed RBC
 RBC transfusions revive oxygen- starved tissues. While the crystalloid solution is
infusing, the blood bank has time to type and cross-match the patient for transfusion of
type-specific blood.
 If there is no time to do a cross-match and one must begin transfusion immediately. The
universal donor type O-Rh-positive PRBCs or O-Rh-negative PRBCs for females with
childbearing potential is transfused.
 Type-specific blood is ABO and Rh compatible is available within less than 15 minutes.
 Each unit of packed RBCs is typically infused over 1 to 2 hours, but always within 4
hours.
Steve is losing blood due to trauma leading to a decrease in oxygen levels; therefore,
starting a blood transfusion can be used to treat Steve’s low oxygen and blood volume levels.
Precautions for administration of blood
1. Check patient’s first and last name
2. Check date of birth
3. Check hospital identification number
4. Check Physician
5. Check blood type and Rh of patient
6. Check blood type and Rh of donor unit
7. Check blood bag number
8. Check blood recipient ID band number
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9. Asses for symptoms of possible reaction such as:
a. Anaphylaxis
b. Hypotension, tachycardia
c. Fever (an elevation of 1.5 degrees C)
d. Bleeding
e. Back pain
f. Chest tightness, pain discomfort
g. Chills
h. Nausea/vomiting
i. Restlessness/anxiety
10. If transfusion reaction occurs stop infusion immediately and keep line open with 0.9%
NaCl
11. Inform the patient’s physician
Patients needing fluid resuscitation Monitoring for Complications are unstable and need
to be monitored closely.
 Crystalloid solutions can lead to volume overload, electrolyte disturbances, heart failure,
pulmonary edema, interstitial edema, and acute respiratory distress syndrome.
 Colloids and blood products can trigger allergic reactions, including anaphylactic shock.
 Massive infusions of cool or room temperature solutions can cause hypothermia. Warm
fluids before administering.
Different Types of Shock
 Anaphylactic Shock
o Is a severe, whole-body allergic reaction. After being exposed to a substance like
bee sting venom, the person's immune system becomes sensitized to that allergen.
On a later exposure, an allergic reaction may occur. This reaction is sudden,
severe, and involves the whole body.
 Cardiogenic Shock
o Is a state in which the heart has been damaged so much that it is unable to supply
enough blood to the organs of the body.
 Neurogenic shock (caused by damage to the nervous system)
o Is caused by sudden loss of signals from the sympathetic nervous system that
maintains the normal muscle tone in blood vessel walls. The blood vessels relax
and become dilated, resulting in pooling of the blood in the venous system and an
overall decrease in blood pressure. Can be a complication of injury to the brain or
spinal cord.
 Septic Shock
o Is a serious condition that occurs when an overwhelming infection leads to lifethreatening low blood pressure.
OSTE: Shock
References
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