Understanding shock

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Understanding shock
NS54 Collins T (2000) Understanding shock. Nursing Standard. 14, 49, 35-39.
Date of acceptance: July 4 2000.

Aims and intended learning outcomes Pathophysiology
The aim of this article is to provide an overview of Shock is an acute state in which tissue perfusion is
shock, focusing on the five different types of shock, inadequate to maintain the supply of oxygen and
treatment for each and the nursing care of a patient nutrients necessary for normal cell function. (Alexander
suffering from shock. Every nurse might potentially et al 1994), which results in widespread hypoxia. The
encounter a patient in shock, so it is important that main cause is circulatory failure, which produces a fall
nurses have an awareness of its signs and symptoms in blood pressure and cardiac output. This leads to a
and can distinguish between the different types of lack of blood perfusion of the key organs (brain, lungs in brief
shock. After reading this article you should be able to: etc), which is ultimately life threatening. There are three
■ Understand the pathophysiology of shock and how reasons tissue perfusion might become inadequate: Author
this becomes a life-threatening situation. ■ A decreased circulating blood volume. Timothy Collins RN, DipHE, is
■ Identify the five different types of shock and the ■ A failure of the heart to pump effectively. Staff Nurse, Intensive Care Unit,
differences between them. ■ A massive increase in peripheral vasodilation. Kent and Canterbury Hospital.
■ Identify the signs and symptoms of a patient suffer-
ing from shock. TIME OUT 1 Summary
■ Understand the issues in providing nursing care to a Before reading further, reflect Shock is a serious condition that
patient suffering from shock. on a patient with shock you involves many organs of the
have treated and relate the body and must be treated
stages of shock to this patient. immediately to ensure that the
Introduction Identify what actions were taken to patient recovers. Timothy Collins
Shock is a potentially life-threatening condition that stop the next stage of shock from occurring. provides a guide to shock,
Also recall what signs and symptoms were
requires immediate attention. It is a complex physio- including the different types, the
occurring and compare this to the
logical phenomenon that involves many organs of the signs and symptoms and
pathophysiology of shock.
body and it must be reversed or death might occur. As appropriate nursing care.
such, nurses should always be alert for shock in
patients and should understand the physiological Keywords
Stages of shock
processes related to shock. ■ Intensive care
The five types of shock are: hypovolaemic, cardiogenic, The patient’s symptoms will vary depending on the ■ Shock
anaphylactic, septic and neurogenic. An understanding type of shock they have.
of the differences means that aggressive treatment can Initial stages When cells are deprived of oxygen, the These key words are based
immediately be given to the patient. The management mitochondria can no longer continue to produce on the subject headings from
of the patient in shock requires skills in patient assess- adenosine triphosphate (ATP), which is essential for the British Nursing Index.
ment, monitoring of vital signs, an understanding of the generation of energy in the cells. Due to reduced This article has been subject
the pathophysiology of shock and the administration intracellular oxygen, the cell membranes become to double-blind review.
of intravenous fluids and drugs. damaged. Without oxygen, the cells start to perform

august 23/vol14/no49/2000 nursing standard 35

leading to an increase in both who have sustained trauma are extremely likely to blood pressure and heart rate (Clancy and McVicar have hypovolaemia. metabolic acidosis. peritonitis. Hypotension average man could accumulate one litre or 20 per cent is detected early by the aortic and carotid sinus baro. which causes a reduction in There will also be a narrowing of the pulse pressure. from trauma. urine output in the body recognising the blood loss and imple- is reduced and oliguria might well develop. weak and thready due to the low blood precapillary sphincters to constrict such that blood is flow in the body. As general blood flow is before symptoms occur. Due to the If blood loss continues. this burns and an excessive diuresis normally related to process also requires oxygen. which the spleen. which indicates vasoconstriction. If it takes more than two sec- onds for the colour to resume. The pulse will be notice- body’s metabolic acidosis. subsequently broken down in the liver. Eventually. however.000ml product of anaerobic metabolism. This is primarily due to delays reduced. this is the earliest sign of shock. The nurse failed and the shock can no longer be reversed. Femur 1. If the originating shock occur and it is imperative that the nurse identi- problem. the patient’s blood to the heart and brain. bowel obstruction. in trauma fractures and pyruvic acids causes the body to develop a systemic Hypovolaemia normally results from a haemorrhage. For example. As this fluid is lost. intervene in shock will eventually fail. causing the arteriolar and ably rapid. rate can also increase due to other unrelated factors. as with severe arterial bleed. In an effort to compensate for tified. this will increase the increase the cardiac output. as large blood losses occur around 1996). which immediately identifiable (Alexander et al 1994). menting the compensatory stage of shock that has Progressive stage This is where the compensatory already been discussed. an hyperventilation occurs (Adomat 1992). This is harmful to the compartments caused by severe vomiting and Thoracic injury 2. the vital organs have and fingers will be particularly affected. the hydrostatic pressure will increase and. trapped in the capillaries (Alexander et al 1994). Due Generally. or external. causing increased secretion of catecholamines (adrenaline and sludging of the microcirculation. the body tries to Hypovolaemic is the most common form of shock. has not been corrected. gastrointestinal lost with pelvic injuries (Skinner et al 1990) (Box 1). pancreatitis. heart. The five types of shock produce a variety of signs and Hypotension is normally a later sign of hypovolaemia symptoms and the treatment varies for each type. As and noradrenaline that have been released to try to anaerobic metabolism continues. such as blood loss. the kidneys are especially sensitive. tract and other organs and concentrate the blood supply In early hypovolaemic shock. fies that the patient is in shock as early as possible to the compensatory mechanisms that the body uses to optimise the patient’s outcome (Box 2). Anaerobic metabolism is far less which can be either internal. This is done by applying pressure to the occur within a few hours. sodium collects tachycardia as a result of the catecholamines adrenaline inside the cells.000ml efficient than the normal aerobic metabolism. in which the production of lactic cardiac output and results in a low perfusion state. such as bleeding from Pelvis 3. but heart to this. as the brain is more susceptible to volume can be reduced by as much as 10-15 per cent damage than the other organs. 36 nursing standard august 23/vol14/no49/2000 . It is only when the compen- mechanisms that the body has implemented to try satory mechanisms fail that the classic symptoms of and combat shock start to fail.000ml cells and needs to be removed by the blood and diarrhoea. Death will illary refill. intervene with physiological adaptations to attempt to Sometimes the cause of fluid loss can be clearly iden- overcome the shock. inappropriate diuretic therapy. which control blood pressure. kidneys. Patients cause vasoconstriction.000ml uses oxygen. blood volume is reduced. tissues (Alexander et al 1994). This stimulates tract during a paralytic ileus and this might not be the release of adrenaline and noradrenaline. lactic acid builds up as a waste Other causes include loss of fluid from extracellular Tibia 650ml Abdominal injury 2. Estimated blood loss anaerobic metabolism. while potassium leaks out. the patient has poor Classification of shock capillary refill.C O N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T Understanding shock Box 1. but sometimes the the metabolic acidosis due to anaerobic metabolism. despite an increased heart rate. that appears only after the patient has lost 30 per cent Hypovolaemic shock This occurs when circulating or more of his or her blood volume (Flavell 1994). Compensatory stage In this stage. cause of the fluid loss is not obvious. the patient will develop a decreased perfusion of the cells. for example. this will lead to such as pain or stress. The prolonged noradrenaline) due to the body concentrating the vasoconstriction will also cause the vital organs to be blood flow to the essential organs of the brain and compromised due to reduced perfusion of the organs. so the presence of a tachycardia leakage of fluid and protein into the surrounding alone is not diagnostic of shock (Flavell 1994). The skin will look cold and clammy and the feet Refractory stage At this stage. Brain should assess for vasoconstriction by testing the cap- damage and cell death have occurred. for example. combined with histamine release. patient’s fingernail and waiting for the colour to return to the nail bed. of the blood’s circulatory volume in the gastrointestinal receptors. The adrenaline and noradrenaline cause fracture sites. the Vasoconstriction also occurs because of the blood concentration and viscosity increase. three litres of blood can be vasoconstriction of the skin.

Oxygen saturations maintain cellular homeostasis. which produces a Blood loss Observations production provides a direct measure of blood flow and low cardiac output state. including the patient’s anxiety and pain. Initially. the mortality 40 per cent patient’s life crystalloid fluids will increase the circulating volume. also begin to fail. but this compensatory mechanisms are unable to prevent. frequency and be palpated it is safe to assume that the patient has a depth of respirations. may be confused as a result of poor cerebral perfusion. This type of shock can also (Up to 15 clinical signs artery in shock causes the blood to be directed away from occur following heart failure. nulated or a central line may be inserted. For example. The resultant hypoxia (30-40 per deterioration and blood gases need to be monitored for both oxy. cent blood in all volume) observations genation and for metabolic acidosis. the tachycardia can also be detrimental to the heart. COPD patients should be closely monitored put and blood pressure cause poor perfusion of blood for reduced respirations and O2 saturations. Two large bore cannulae pulmonary circulation and the right side of the heart should be inserted for the rapid administration of fluids. His or her skin will be cold. Normally the anti-cubital fossa veins pulse and a systolic blood pressure below 90mmHg. heart rhythm and temper- blood pressure of at least 80mmHg (Buckley 1992). Regular to the tissues and eventually the cells are unable to Class 3: A dramatic blood gases should also be taken. Ideally. the respira. because hypovolaemia does predispose given 100 per cent oxygen via face maskand frequent to hypothermia. clammy and cyanotic. How do you think class 2 hypovolaemic shock and nursing care might differ for each? has lost 15-30 per cent blood volume following a trauma. including august 23/vol14/no49/2000 nursing standard 37 . All greater oxygen supply to the heart muscle that is except for patients in the acute phase of shock should be given already ischaemiac due to the shock. reaction occurs. the respiratory pressure. damage to the heart muscle. weak required obtain IV access. if the patient is bleeding. The Other options may be an IV cut down. tachycardia and will not always be possible. Think Anaphylactic shock This type of shock is a severe about the ways you might prevent any further allergic reaction in which an antigen-antibody blood loss. as colloid and dynamic monitoring and drug therapy. This pump failure. C O N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T Understanding shock which is the difference between the systolic and diastolic Cardiogenic shock This is characterised as left Box 2. This is due to decreased cardiac stroke ventricular failure of the heart itself. blood pressure. which remains 100 per cent oxygen via non-rebreathe masks. with 80 per cent of patients dying blood Drastic action cannot transport oxygen and dilute the blood further. from cardiogenic shock (Alexander et al 1994). volume) and surgery When patients are in shock it can be difficult to A patient in cardiogenic shock will have a fast. hormones that cause 1994). pulse. Cavenagh 1992) and any deterioration in consciousness should be reported immediately. including blood blood pressure reading. thready cerebral perfusion and oxygenation and the patient cause vasoconstriction within the body. there is a reduction in arterial blood volume) are activated to cope with hypoxia. It might not be possible to obtain a observation of vital signs is necessary. Due to the low cardiac blood mechanisms tory rate and depth increases in response to the cellular output state. ature. TIME OUT 3 Compare hypovolaemic and TIME OUT 2 cardiogenic shock and make a Refer to Box 2. oxygen resulting in a further drop in blood pressure that the Severe saturation should be greater than 95 per cent. or myocarditis (De Jong 1997). bleeding. Imagine that list of the differences in you have a patient who has treatment. Treatment involves supporting the heart and reducing Vital signs should be monitored regularly. which might require emergency surgery. the falling cardiac out- stable However. Diamorphine is given for pain and the patient The patient’s level of consciousness should be regularly might require inotropic support to increase the contrac- assessed using the Glasgow Coma score (Ellis and tility of the heart. thus increasing its cardiac output. This Confusion cause. (American College of Surgeons 1993) in the arms are the easiest to cannulate in shock. Despite recent advances in haemo. Due to the (15-30 per pulse. blood pressure. causes widespread vasodilation due to lactic acidosis. O2 saturations. A decrease in urine output will occur: urine (De Jong 1997). cardiomyopathy. cool skin might appear confused. where the skin patient will have a urine output below 30ml/hour and is surgically cut to expose the vein and then it is can. but as the shock progresses. restless or unresponsive. The baroreceptors then release both blood loss rate decreases and metabolic acidosis increases (Flavell noradrenaline and adrenaline. The patient should be temperature. trauma per cent Compensatory the kidneys to the heart and brain. normally follows a Class 1: Usually few perfusion to the kidneys. Class 4: Immediate (More than threat to the ideal replacement fluid is blood. Four classes of blood pressures. but if a peripheral pulse can gases. A change in mental status indicates decreased an increase in the contractility of the heart and also Class 2: Rapid. but rate remains high. the increase in heart rate cent blood Urine output volume) reduced Treatment for the shock consists of treating the will probably do little to increase cardiac output. as it Change in all cause must be found and treatment given to stop the is being placed under more pressure and requires a observations. as vasoconstriction of the renal myocardial infarction. particularly for patients Pulmonary oedema will eventually occur when the hypotension with hypovolaemic shock. As with hypovolaemic shock. There are many causes. which results in hypovolaemic shock volume and increased peripheral resistance (Alexander reduced tissue perfusion and impaired cellular activity et al 1994).

emotional immune response. such as by failure to produce adequate streptococci. however. can also be responsible (Adam and Osborne cardiac output? List the ways to 1997). which might cause a reduction of the frequency depends on the patient’s condition. Oxygen therapy will be shock. but this is not always possible. pyrexia. Gram-positive organisms. This causes a maldistribution of blood flow. and even food additives. Neurogenic shock This type of shock is related to the bronchi and gastro-intestinal mucosa. medical condition. diagnostic machinery. as signs and symptoms differ for toxins can cause the patient to be flushed and warm. fluid therapy to increase the circulatory volume. such as consider to be most at risk preservatives. The mast cells nervous system homeostasis. However. a drug or traumatic injury (Acdam and develop laryngeal oedema. renal failure and oliguria. pulse. the aim is to return the patient to normal include restlessness and anxiety. as a weak and thready pulse is indicative of and the invading endotoxins. McVicar 1996). caused by a loss of sympathetic nervous activity and what type of shock This results in the release of histamine and prote- results? Write a list of the main causes of loss olytic enzymes. The treatment for anaphylaxis is prompt admin. as well as the strength of the with fluids and antibiotics to try to reduce the infection pulse. tachycardia and homeostatic levels. which can then develop to obstruct the air. The loss of sympathetic impulses itchy urticaria skin rashes. causing damage improve cardiac output. leading to vasodilation and increased of sympathetic nervous activity. causes massive vasodilation of the arterioles and This is a medical emergency. thirst and respiratory failure. The bacteria that most TIME OUT 5 commonly cause septic shock are Gram-negative What type of shock is caused bacteria. Hydrocortisone and chlorphenara. of the vital organs and to prevent the shock from culation (Clancy and McVicar 1996). Regular monitoring therapy and circulatory support. What is or even death to the cell (Adam and Osborne 1997). such as antibiotics. as physical observation can be 38 nursing standard august 23/vol14/no49/2000 . oxygen mine are given. This type of shock can be caused by disease effects and it inhibits the mediators released by the or injury of the brain stem or spinal cord. capillary permeability (Adomat 1992). The patient might well disease. and O2 saturations should take place. The bacteria invade phagocytes. bronchospasm. cardiac rate and rhythm. Septic shock This can arise from a variety of over- whelming bacterial toxins. The aim of the care is to re-establish perfusion as the body allows more blood to the peripheral cir. resulting in a istration of adrenaline. reduction in venous return to the heart. IV colloid for the loss of sympathetic nerve activity (Clancy and therapy is started to increase circulatory volume. leading to interrupted. nutritional status etc? collapse because of degranulation of the mast cells. eggs or Identify which patients you fruits. blood pressure and pulse ical ventilation and cardiac support with inotropes is oximetry. This then leads to a way. which are found within the loose connective tissues. Symptoms of septic shock Ideally. The body then goes into circulatory such as age. peripheral vascular resistance. but at glomerular filtration rate. resulting in a significant decrease in oedema. The hypotension. and/or Osborne 1997). The patient should ideally be monitored for required and admission to intensive care for mechan. the use of vasoconstrictor inotropes that compensate rations. frequency and depth of respi. One of these factors causes the body to from developing septic shock. It also causes the smooth muscle to trauma. the hypotension. which might involve of blood pressure. Neurogenic shock then release large amounts of histamine and occurs as the result of the loss of sympathetic nerve bradykinin that have a massive vasodilatory effect on activity from the brain’s vasomotor centre due to the body (Henderson 1998). This causes progressing. leading to a mismatch between the supply of and demand for oxygen with- Nursing care of a patient in shock in the microvasculature. which has been greatly increased due to massive vasodilation (Alexander et al Assessment and treatment of the patient will depend 1994). or the effects of depressive drugs (usually relax. leading to brochodilation of the airways anaesthetic agents). be hypersensitive to the antigen that the body is Are there any predisposing factors. foods such as nuts. Adrenaline causes an increase decrease in cardiac output. each. the nurse should not rely solely on often necessary. with hypotension rapidly in blood pressure by producing vasoconstriction following. allergic to. insect bites. possibly resulting in acute a bare minimum they should be recorded half hourly. nurse should check for any fall in blood pressure and Treatment focuses on increasing the circulatory volume changes in heart rate. transfusion of incorrectly TIME OUT 4 cross-matched blood. as anaphylaxis causes a venules as the vasoconstrictor tone has been sudden increase in vascular permeability. Regular observations are essential. Treatment involves intravenous (Henderson 1998). This initial vasodilation induced by bacterial on the type of shock. as well as oxygen.C O N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T Understanding shock drugs.

failure of the body to maintain cellular homeostasis. American Journal of Nursing. 19-25. the situation and it is imperative that the patient is neurosurgical assessment using the All patients should be given nil by mouth in case reassured and is allowed to ask questions regarding Glasgow Coma Scale. so pulse notes accompany the patient on transfer to the inten. The nurse must be patient. The patient’s and submit a profile are outlined on page 41. Regular assessment and accurate monitor- to transfusion. as this will reduce the incidence of ing of patients most at risk of shock is crucial and the hypothermia. Any patient in shock requires a minimum of two wide august 23/vol14/no49/2000 nursing standard 39 . 41. Anxiety. progress. haemoglobin and haematocrit levels need to be taken to assess the degree of blood loss (Skinner et al 1990). London. Alexander M et al (1994) Nursing with any deterioration reported immediately. aspirating stomach contents. Standard. might require mechanical ventilation. used in conjunction with the Glasgow coma score. 3. Now that you have completed blood has been cross-matched and intravenous fluids the article.5ml/kg/hour should be reported to indicate hypo-perfusion of the kidneys. to use a humidifying circuit to moisten the oxygen with It is essential when nursing a patient in shock to De Jong MJ (1997) Clinical snapshot: sterile water. cardiogenic shock. If oxygen informed of the patient’s progress and should be the key concept to physiological control. Coning The patient should lie flat in the acute stage of Practice. 124-128. Drugs should be given intravenously to Adam S. 97. 2. The patient’s respiratory rate should be measured. oximetry and blood gases are taken to provide an sive care unit. The volume profile. 49-53. as this will prevent damage to the explain all the procedures to the patient and relatives. Nursing should be given to any patient in shock. Intensive and Critical Care Nursing. patients are likely to die from cardiac to monitor pressure areas and to prevent fluid from American College of Surgeons (1993) Advanced Trauma Life Support arrest or respiratory failure before this would occur. However. Relatives should always be kept Clancy J. personnel and patient Buckley R (1992) The management of hypovolaemic shock. administered intramuscularly. 40-41. you might like to are being administered as quickly as possible. 8. 6. admitted to intensive care. High flow oxygen that the appropriate equipment. they should be warmed prior untreated. 6. 12. 94-99. McVicar A (1996) Homeostasis: assessment of the patient’s respiratory status. 6. Many patients in shock are Program for Physicians. RN. patient’s conscious level and assessment should be anaphylactic shock. 6. as these indicate that the patient needs of the patient who has Trauma. Oxford Medical. Standard. Nurses should observe for tachypnoea and psychological and spiritual Skinner D et al (1990) ABC of Major respiratory tiredness. however. Osborne S (1997) Critical Care Nursing. and identify shock in its early stages so that the tained at all times to prevent infection. 57. Think about the effects on the patient’s family and/or carers and how they should be recorded to ensure there is no loss of periph- might respond to these needs. The nurse should regularly assess the be absorbed quickly. accumulating in the lungs. patient’s outcome is optimised. experienced or is experiencing The patient’s core and peripheral temperatures shock. Guidelines to help you write of blood lost should ideally be replaced. A urinary catheter should be inserted nurse must ensure these skills are incorporated into and hourly urine measurements recorded: volumes of his or her daily practice no less than 0. British Journal of Theatre therapy is to continue for a long period. Chicago IL. Bath. especially when oxygen therapy is in Consider the emotional. can be observed. especially think about writing a practice if the patient is bleeding excessively externally. Flavell CM (1994) Combating consciousness which might put the patient at risk of hemorrhagic shock. Strict asepsis must be main. bronchial mucosa and cilia and help to promote Time should be taken to keep relatives informed of Ellis A. Nursing. If large amounts of fluids will all eventually cause circulatory collapse if left are to be administered. The CVP line should be measured emergency and it is essential that nurses are able to hourly to monitor the circulating fluid level of the identify and treat patients in shock. 12. 1. Patients in shock should be kept warm. so the nurse must ensure ACS. eral circulation and an assessment of the patient’s capillary refill is essential. Nursing care is essential. mouth TIME OUT 6 26-30. this is not the case for Adomat R (1992) Understanding shock. it is essential allowed time to express their fears and anxieties. Singapore. Levels will be low in hypovolaemic shock and able to distinguish between the five types of shock in cardiogenic shock. they inputs need to be recorded. and the depth and pattern noted. C O N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T Understanding shock important in identifying the state of the patient in bore cannulas for rapid intravenous fluid and drug REFERENCES shock. Because of this. as Conclusion this will cause peripheral vasodilation and could cause hypotension. when adrenaline should be British Journal of Nursing. 25-28. BMJ Publishing. A central venous catheter (CVP) should Shock is a life-threatening condition arising from a be inserted to measure the fluid status of the patient. confusion and pain are all indicators that administration. this can also be used for administrating large volumes resulting in cardiovascular collapse. Cavenagh SJ (1992) Aspects of expectoration of secretions. any further surgery is needed or there is any loss of his or her care. is a rare complication in which brainstem herniation shock and regular positional changes should be given Churchill Livingstone. occurs. 47. Henderson N (1998) Anaphylaxis. The Adult. The nurse TIME OUT 7 must ensure that if the patient is actively bleeding. The symptoms vary Strict fluid balance is essential and any losses and between the different types of shock. Shock is a medical of fluids and drugs. but should not be warmed too quickly. However.