SHOCK
Comprehensive Nursing Notes
Nursing Education
For Nursing Students
Evidence-Based Practice
Table of Contents
1. Introduction to Shock
Shock is a life-threatening condition characterized by inadequate tissue perfusion and cellular oxygen delivery, resulting in cellular dysfunction and potential organ failure. It represents a complex pathophysiological state that requires immediate recognition and intervention by healthcare professionals.
Critical Point
Shock is not just low blood pressure! It’s a syndrome of inadequate tissue perfusion that can occur with normal, low, or even elevated blood pressure.
Key Concepts
Perfusion
The delivery of oxygen and nutrients to tissues via blood flow
Tissue Oxygenation
The process by which cells receive adequate oxygen for metabolic processes
Memory Aid: SHOCK
S – Systemic hypoperfusion
H – Hypotension (often present)
O – Organ dysfunction
C – Cellular hypoxia
K – Kinetic energy deficit (metabolism)
2. Pathophysiology
Shock Progression Cascade
Decreased Tissue Perfusion
↓ Oxygen & nutrient delivery
Cellular Hypoxia
Switch to anaerobic metabolism
Lactate Production
Metabolic acidosis develops
Organ Dysfunction
Multi-system failure
Compensatory Mechanisms
Cardiovascular
- • Increased heart rate
- • Increased contractility
- • Vasoconstriction
- • Venous return enhancement
Respiratory
- • Increased respiratory rate
- • Deeper breathing
- • Compensatory alkalosis
- • Enhanced oxygen extraction
Neurohormonal
- • Epinephrine release
- • Norepinephrine surge
- • ADH secretion
- • RAAS activation
Clinical Pearl
Early shock may present with normal vital signs due to compensatory mechanisms. Look for subtle signs like delayed capillary refill, altered mental status, and decreased urine output.
3. Types of Shock
Hypovolemic Shock
Results from inadequate circulating blood volume
Causes:
- • Hemorrhage (trauma, GI bleeding, surgery)
- • Fluid losses (vomiting, diarrhea, burns)
- • Third-spacing (ascites, edema)
- • Dehydration
Key Features:
↓ Preload, ↑ SVR, ↑ HR, ↓ CVP
Cardiogenic Shock
Results from pump failure of the heart
Causes:
- • Myocardial infarction
- • Cardiomyopathy
- • Arrhythmias
- • Valvular disorders
- • Cardiac tamponade
Key Features:
↓ CO, ↑ PCWP, ↑ SVR, Pulmonary edema
Distributive Shock
Results from abnormal distribution of blood volume
Subtypes:
- Septic: Infection-induced systemic response
- Anaphylactic: Severe allergic reaction
- Neurogenic: Spinal cord injury
Key Features:
↓ SVR, ↑ CO (initially), Vasodilation
Obstructive Shock
Results from obstruction to cardiac output
Causes:
- • Pulmonary embolism
- • Tension pneumothorax
- • Cardiac tamponade
- • Aortic stenosis (severe)
Key Features:
↑ CVP, ↓ CO, Normal/↑ SVR
Memory Aid: 4 H’s of Shock Types
Hypovolemic
Not enough volume
Heart failure
(Cardiogenic)
Huge vessels
(Distributive)
Heart blocked
(Obstructive)
4. Clinical Presentation
Early Signs
- • Restlessness, anxiety
- • Tachycardia
- • Tachypnea
- • Cool, clammy skin
- • Delayed capillary refill
- • Decreased urine output
Progressive Signs
- • Hypotension
- • Confusion, lethargy
- • Weak, thready pulse
- • Mottled skin
- • Decreased consciousness
- • Metabolic acidosis
Late Signs
- • Severe hypotension
- • Unconsciousness
- • Absent peripheral pulses
- • Cyanosis
- • Organ failure
- • Cardiovascular collapse
Shock Index Calculation
Shock Index = HR / SBP
Normal
0.5 – 0.7
Borderline
0.7 – 0.9
Abnormal
> 0.9
5. Nursing Assessment
Assessment Mnemonic: ABCDE
A – Airway
Patent, protected
B – Breathing
Rate, depth, effort
C – Circulation
HR, BP, perfusion
D – Disability
Neurologic status
E – Exposure
Environment, temp
Primary Assessment
Cardiovascular
- • Heart rate and rhythm
- • Blood pressure (all extremities)
- • Pulse quality and equality
- • Capillary refill time
- • Skin temperature and color
- • Jugular venous distention
Respiratory
- • Respiratory rate and pattern
- • Oxygen saturation
- • Breath sounds
- • Use of accessory muscles
- • Chest symmetry and expansion
Secondary Assessment
Neurological
- • Level of consciousness (GCS)
- • Pupil response
- • Motor and sensory function
- • Confusion or agitation
Renal/GI
- • Urine output (normal: 0.5-1 mL/kg/hr)
- • Bowel sounds
- • Abdominal distention
- • Nausea/vomiting
Integumentary
- • Skin color and temperature
- • Moisture level
- • Turgor and elasticity
- • Presence of edema
Time-Critical Assessment
Complete primary assessment within 2-3 minutes. Continuous monitoring of vital signs every 5-15 minutes during acute phase.
6. Diagnostic Studies
Laboratory Studies
Immediate Labs
- • ABG: Metabolic acidosis, lactate elevation
- • CBC: Hematocrit, hemoglobin, WBC
- • BMP: Electrolytes, creatinine, BUN
- • Lactate: >2 mmol/L indicates tissue hypoperfusion
- • PT/PTT: Coagulation status
Specific Markers
- • Troponin: Cardiogenic shock
- • BNP/NT-proBNP: Heart failure
- • Procalcitonin: Sepsis
- • Cortisol: Adrenal insufficiency
- • D-dimer: Pulmonary embolism
Imaging & Monitoring
Imaging Studies
- • Chest X-ray: Pulmonary edema, pneumothorax
- • Echocardiogram: Cardiac function, tamponade
- • CT scan: Bleeding, PE, organ injury
- • Ultrasound: FAST exam, cardiac output
Hemodynamic Monitoring
- • CVP: Preload assessment
- • PCWP: Left heart filling pressure
- • Cardiac output: Pump function
- • SVR: Afterload measurement
Hemodynamic Parameters in Shock
| Parameter | Normal | Hypovolemic | Cardiogenic | Distributive | Obstructive |
|---|---|---|---|---|---|
| CVP (mmHg) | 2-8 | ↓ | ↑ | ↓ | ↑ |
| PCWP (mmHg) | 6-12 | ↓ | ↑ | ↓ | Variable |
| CO (L/min) | 4-8 | ↓ | ↓ | ↑ then ↓ | ↓ |
| SVR | 800-1200 | ↑ | ↑ | ↓ | ↑ |
7. Medical Management
Emergency Management: ABCDE + F
Airway
Secure & protect
Breathing
O2 support
Circulation
IV access, fluids
Disability
Neuro status
Exposure
Environment
Fluids/Drugs
Resuscitation
Fluid Resuscitation
Initial Fluid Therapy
- • Crystalloids: Normal saline, Lactated Ringer’s
- • Initial bolus: 20-30 mL/kg over 15-30 min
- • Goal: Restore tissue perfusion
- • Monitor: Response to fluid challenge
Blood Products
- • PRBCs: Hgb < 7-10 g/dL (context-dependent)
- • FFP: Coagulopathy, INR > 1.5
- • Platelets: Count < 50,000 with bleeding
- • Massive transfusion: 1:1:1 ratio
Vasopressor Therapy
First-Line Agents
- • Norepinephrine: 0.1-2 mcg/kg/min
- • Epinephrine: 0.1-0.5 mcg/kg/min
- • Dopamine: 5-20 mcg/kg/min
- • Dobutamine: 2.5-20 mcg/kg/min
Special Considerations
- • Vasopressin: Distributive shock
- • Milrinone: Cardiogenic shock
- • Phenylephrine: Pure vasoconstriction
- • Hydrocortisone: Refractory shock
Treatment Goals
MAP ≥ 65 mmHg, Urine output ≥ 0.5 mL/kg/hr, Lactate clearance ≥ 10% every 2 hours, ScvO2 ≥ 70%
8. Nursing Interventions
Priority Nursing Actions
Immediate (0-15 min)
- • Establish large bore IV access (2x 18G)
- • Apply oxygen via appropriate device
- • Initiate continuous monitoring
- • Obtain baseline vital signs
- • Position patient appropriately
- • Draw initial laboratory studies
Short-term (15-60 min)
- • Initiate fluid resuscitation
- • Insert urinary catheter
- • Prepare for vasopressor therapy
- • Obtain imaging studies as ordered
- • Reassess every 15 minutes
- • Document response to interventions
Ongoing (1+ hours)
- • Continuous hemodynamic monitoring
- • Titrate medications per protocol
- • Monitor for complications
- • Support family communication
- • Coordinate multidisciplinary care
- • Prepare for possible procedures
Monitoring Parameters
Cardiovascular
- • BP every 5-15 minutes (arterial line preferred)
- • HR and rhythm continuously
- • CVP if central line present
- • Capillary refill, peripheral pulses
- • Skin color, temperature, moisture
Respiratory
- • Continuous pulse oximetry
- • Respiratory rate and effort
- • ABG monitoring as indicated
- • Breath sounds every 2-4 hours
Neurological
- • LOC assessment every hour
- • GCS scoring
- • Pupil assessment
- • Motor/sensory function
Complication Prevention
Infection Prevention
- • Strict aseptic technique for all procedures
- • Hand hygiene compliance
- • Daily line assessment
- • Urinary catheter care
- • Oral care every 2-4 hours
Pressure Injury Prevention
- • Skin assessment every shift
- • Repositioning every 2 hours if stable
- • Pressure-relieving surfaces
- • Heel protectors and padding
DVT Prevention
- • Sequential compression devices
- • Range of motion exercises
- • Early mobilization when stable
- • Pharmacological prophylaxis as ordered
Family-Centered Care
Communication
- • Provide frequent updates on condition
- • Explain procedures and interventions
- • Use interpreters when needed
- • Address questions and concerns promptly
Support
- • Allow presence during appropriate times
- • Provide emotional support resources
- • Facilitate spiritual care if desired
- • Prepare for potential outcomes
9. Complications
Immediate Complications
Cardiovascular
- • Cardiac arrest
- • Arrhythmias
- • Myocardial infarction
- • Pulmonary edema
Respiratory
- • Acute respiratory failure
- • ARDS
- • Pulmonary embolism
- • Aspiration pneumonia
Long-term Complications
Organ System Failure
- • Acute kidney injury
- • Liver failure
- • Gastrointestinal bleeding
- • Neurological sequelae
Other Complications
- • DIC (Disseminated Intravascular Coagulation)
- • SIRS (Systemic Inflammatory Response)
- • Secondary infections
- • Pressure injuries
MODS Mnemonic: MARBLES
Multiple Organ Dysfunction Syndrome affects:
M – Mental
Neurologic
A – Airways
Respiratory
R – Renal
Kidneys
B – Blood
Hematologic
L – Liver
Hepatic
E – Endocrine
Metabolic
S – Stomach
GI System
10. Patient & Family Education
Understanding Shock
What is Shock?
Shock is a serious condition where the body’s organs don’t get enough blood and oxygen to work properly. It’s a medical emergency that requires immediate treatment.
- • Not just being “shocked” emotionally
- • Different from low blood pressure alone
- • Can affect any organ system
- • Requires intensive medical care
Recovery Process
- • Recovery time varies by individual
- • Some effects may be temporary
- • Follow-up care is essential
- • Gradual return to normal activities
- • Monitor for late complications
Home Care Instructions
Warning Signs to Report
- • Dizziness or fainting
- • Chest pain or shortness of breath
- • Rapid heart rate
- • Confusion or memory problems
- • Decreased urine output
- • Unusual fatigue or weakness
Lifestyle Modifications
- • Stay hydrated (unless fluid restricted)
- • Take medications as prescribed
- • Attend all follow-up appointments
- • Gradually increase activity level
- • Maintain good nutrition
- • Get adequate rest
When to Call 112
Call emergency services immediately if you experience: severe difficulty breathing, chest pain, loss of consciousness, signs of severe bleeding, or if you feel like “something is very wrong.”
Don’t hesitate – it’s better to be safe than sorry!
Important Contact Information
Emergency
112
Hospital
________________
(Fill in your hospital’s number)
Primary Care
________________
(Fill in your doctor’s number)
Key Nursing Takeaways
Early Recognition
Shock can present with normal BP. Look for subtle signs and trust your clinical judgment.
Time is Critical
Rapid assessment and intervention can prevent progression to irreversible shock.
Team Approach
Coordinate with the multidisciplinary team for optimal patient outcomes.