SHOCK is a life threatening condition with a variety of underlying causes.

Characterized

by

inadequate tissue perfusion that ,if untreated ,results in cell death. Systematic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cellular functions.

SIGNIFICANCE OF SHOCK
Shock affects all body systems. It may develop rapidly or slowly, depending on the underlying cause. During shocks the body struggles to survive, calling on all its homeostatic mechanism to restore blood flow and tissue perfusion. Any insult to the body can create a cascade of events resulting in poor tissue perfusion. Therefore, almost any patient with any disease state maybe at risk for developing shock.

CLASSIFICATION OF SHOCKS
Hypovolemic shocks occurs when there is a decrease in the intravascular volume Cardiogenic shocks occurs when the heart impaired pumping ability ,it maybe a coronary or non coronary origin. Circulatory or distrivutive shocks result from a maldistribution osr mismatch of blood flows to the cells.

HYPOVOLEMIC SHOCKS
>> The most common type of shocks, is characterized by a decreased intravascular volume .

Risk Factor for Hypovolemic Shock External: Fluid losses Trauma Surgery Vomiting Diarrhea Diabetes insipidus Internal: Fluid Shifts hemorrhage burns ascites peritonitis dehydration

MEDICAL MANAGEMENT

Major goals in treating hypovolemic shocks are to : 1. restore intravascular volume to reverse the sequence of events leading to inadequate tissue perfusion 2. redistribute fluid volume 3. correct the underlying cause of the fluid loss as quickly as possible.

Depending on the severity of shocks and the patients conditions, it is likely that the efforts will be made to address all three goals simultaneously. a. b. c. d. treatment of the underlying cause fluid and blood replacement redistribution of fluid pharmacologic therapy

NURSING MANAGEMENT

Primary prevention of shocks is an essential focus of nursing intervention. General nursing measures include ensuring safe administration of prescribed fluids and medications and documenting their administration and effects

CARDIOGENIC SHOCK
Cardiogenic shocks occurs when the hearts ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. The cause of cardiogenic shocks are known as either coronary or noncoronary.
PATHOPHYSIOLOGY

In cardiogenic shocks, cardiac output, which is a function of both stroke volume and heart rate, is compromised. when stroke volume and heart rate decreased or become eratic, blood pressure drops and tissue perfusion is compromised.
CLINICALY MANIPESTATIONS

Patients in cardigenic shocks may experience angina pain and develop dysrhythmias and hemodynamic instability.
MEDICAL MANAGEMENT

The goals of medical management are to: 1. limit further myocardial damage and preserve the healthy myocardium 2. improve the cardiac function by increasing cardiac contractility
CORRECTION OF UNDERLYING

The underlying cause of cardiogenic shock must be corrected. It is necessary first to treat the oxygenation needs of the heart muscle to ensure its continued ability to pump blood to other organs.
INITIATION OF FIRST LINE TREATMENT

Involves the following actions: a. supplying supplemental oxygen b. controlling chest pain c. providing selected fluid support

d. administering vasoactive medications e. controlling heart rate with medications or by implementations of a thranstoracic or intravenous pacemaker f. implementing mechanical cardiac support (intra-aortic balloon counterpulsation therapy, ventricular assist systems,or extracorporeal cardiopulmonary bypass)
OXYGENATION

In the early stages of shocks, supplemental oxygen is administered by nasal cannula at a rate 2 to 6 L/min to achieve ab oxygen saturation exceeding 90%

PAIN CONTROL

If the patients experiences chest pain, morphine sulfate is administered intravenously for pain relief. In addition to relieving pain, morphine delates the blood vessels . This reduces the workload of the heart by both decreasing the cardiac filling pressure (preload)and reducing the preassure against which the heart muscle has to eject blood (afterload)
HEMODYNAMIC MONITORING

Is initiated to asses the patients to response to treatment .this is performed in the intensive care unit, where an arterial line can be inserted. The arterial line enables accurate and continuous monitoring of blood pressure and provides a port from which to obtain frequent arterial blood samples without having to perform repeated arterial punctures.
PHARMACOLOGIC THERAPY

Vasoactive medication therapy consist of multiple pharmacologic strategies to restore and maintain adequate cardiac output.
DOBUTAMINE

(dobutrex) produces inotropic effects by stimulating myocardial beta receptors, increasing the strength of myocardial activity and improving cardiac output.
NITROGLYCERIN

(tridil) in low doses acts as a venous vasodilator and therefore produces preload. At higher doses nitroglycerin causes arterial vasodilation and therefore reduces afterload as well.
DOPAMINE

(intropine) is a symphathomimetic depending on the dosage.

OTHER VASOACTIVE MEDICATIONS

agent that has varying vasoactive effects

Additional vasoactive agents that may be used in managing cardiogenic shocks include norepinephrine(lephoped),epinephrine(adrenalin), milrinone(primacor), amrinone( inocor) vasopressin( pitressin), and phenylephrine (neo-synephrine)

ANTIARRHYTHMIC MEDICATIONS

Is also part of the medication regimen in cardiogenic shocks.

FLUID THERAPY

In addition to medications appropriate fluid is necessary in treating cardiogenic shocks. A fluid bolus should never be given quickly because rapid fluid administration with cardiac failure may result in acute pulmonary edema.
MECHANICAL ASSISTIVE DEVICES

a. b. c. d. e.

increased stroke volume improved coronary artery perfusion decreased preload decreased cardiac workload decreased myocardial oxygen demand

NURSING MANAGEMENT
PREVENTING CARDIOGENIC SHOCK

Identifying patients at risk early and promoting adequate oxygenation of the heart muscle and decreasing cardiac workload can prevent cardiovascular shocks.
MONITORING HEMODYNAMIC STATUS

A major role of the nurse is monitoring the patients hemodynamic and cardiac status.
ADMINISTERING MEDICATIONS AND INTRAVENOUS FLUIDS

The nurse has a critical role in safe and accurate administration of intravenous fluid and medications.
MAINTAINING INTRA-AORATIC BALLOON COUNTERPULSATION

The nurse plays a critical role in caring for the patient receiving intraaoratic balloon counterpulsation.the nurse makes ongoing timing adjustment of the balloon pump to maximized its effectiveness by synchronizing it with the cardiac cycle.
ENHANCING SAFETY AND COMPORT

Throughout care the nurse must take an active role in safe guarding the patient,enhancing comport and reducing anxiety.

 CIRCULATORY SHOCK
Circulatory or distributive shocks occurs when the blood volume is abnormally displaced in the vasculature.
Three type

1. septic shock 2. neurogenic shocks 3. anaphylactic shocks

SEPTIC SHOCKS
Is the common type of circulatory shock and is caused by widespread infection. Septic shocks typically in two phases. reffered to as the hyperdynamic ,progressive phase reffered to as the hypodynamic, irreversible phase

NEUROGENIC SHOCK
In neurogenic shocks vasodilation occurs as a result of symphathetic tone. May have a prolonged course (spinal cord injury) oa a short one (syncope fainting)it is characterized by dry, rather than the cool , moist skin seen in hypovolemic shocks,may have a prolonged course (spinal cord injury) or a short one (syncope or fainting).

MEDICAL MANAGEMENT

Treatment of neurogenic shock involves restoring symphatetic tone either trough the stabilization of a spinal cord injury or in the instance of spinal anesthesia, by positioning the patient properly .specific treatment of neurogenic shock depends on its cause.

NURSING MANAGEMENT

It is important to elevate and maintain the head of the bed at least 30 degrees to prevent neurogenic shock when a patient is receiving spinal or epidural anesthesia. Elevation of the head of the bed helps to prevent the spread of the anesthetic agent up the spinal cord.

ANAPHYLACTIC SHOCK
Cause by a severe allergic reaction when a patient who has already produced antibodies to a foreign substance (antigen) develops a systematic antigenantibody reaction.

MEDICAL MANAGEMENT

Treatment of anaphylactic shock requires removing the causative antigen,administering medications that restore vascular tone,amd providing emergency support of basic life functions . Epinephrine is given for its vasoconstrictive action. Diphenhydramine(benadryl) is administered to reverse the effect of histamine .
NURSING MANAGEMENT

The nurse has an important role in preventing anaphylactic shock: assessing all patients for allergies or previous reactions to antigen and communicating the existence of these allergies or reactions to other. The must be knowledgeable about the clinical signs of anaphylaxis, must take immediate actions if sings and symptoms occur, and must be prepared to begin cardiopulmonary resuscitation if cardiorespiratory arrest occurs.

Wesleyan University- Philippines Cabanatuan City

Maria Cheska Tolentino

BSN3-4 GRP IV

Jackie Lou Ocampo