SHOCK
Definition: Shock is characterized by inadequate tissue perfusion leading to tissue hypoxia and altered cellular metabolism.
Causes: Occurs in association with haemorrhage, trauma, burns, infection, heart disease. Results from a failure of 3 aspects of circulation- heart pump, peripheral resistance and blood volume.
Pathophysiology
Injury/Stress
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Sympathetic nervous system.
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Generalized vasoconstriction [shunts blood to heart and brain (vital organs) and decrease blood flow to skin and G.I. and renal system]
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Decrease O2 availability
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Increased tissue hypoxia
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Changes in permeability of cell membrane [Fluid shifts into the blood vessels and increases blood volume compensatory action.
Reduction in renal perfusion
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Alteration in the rennin-angiotensin mechanism.,
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Increase systemic blood pressure and aldosterone release (from adrenal cortex)
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Sensation of thirst
Hypoxia
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Anaerobic metabolism instead of aerobic metabolism
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Decreased production of ATP (adenosine triphosphate)
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Cellular swelling oedema
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Deterioration of cell function
Classification of Shock
1. Hypovolaemic shock- occurs due to loss of intravascular fluid volume.
2. Cardiogenic shock occurs as a result of poor cardiac friction often associated with AMI
3. Distributive shock
a. Septic shock: It is caused by severe infection
Pathogenic organisms
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Toxins
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Dilate capillary and damage capillary walls
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Plasma leaks out of circulation
b. Neurogenic shock occurs as a result of failure of arterial resistance (caused by spinal anaesthesia, quadriplegia, spinal cord injury).
c. Anaphylactic shock: Results from an Ag-Ap. reaction.
Clinical Manifestation
1. Classic signs pallor, cool, moist skin, rapid breathing, ischaemia of eyelids, lips, gums and tongue, rapid, weak, thready pulse, low BP, decreased urine output.
2. Other signs - Altered mental status: decreased gastric mortality
Diagnosis Lab tests
1. Complete blood count, haemoglobin, haematocrit, WBC count, platelets.
2. Biochemistry serum electrolytes, BUN, creatinine, lactase, glucose.
3. Blood cultures.
4. ECG
5. Arterial blood gas measurements
6. Haemodynamic monitoring central venous pressure (CVP) - 0.7 mm Hg/6-12 cm H:O-N); Pulmonary Artery Pressure (PAP)
7. Pulmonary artery wedge pressure (PAWP) determines whether shock is of cardiac or non-cardiac origin.
Immediate Nursing Interventions
1. Stay with patient.
2 Assess LOC
3. Ensure adequate airway.
4. Apply pressure to bleeding sites.
5. Place patient with leg's elevated above the heart level. 1
6. Assess vital signs pulse, respiration, BP
7. Inform physician of unusual findings.
8. Prepare for fluid resuscitation
9. Administer oxygen
Nursing Management
1. Monitor (circulatory status) pulse and BP every 15 mins. Report if systolic pressure <100 mmHg.
2. Check for cold, clammy skin and keep the patient warm.
3. Administer IV fluids as prescribed and maintain an I/O chart.
4. Apply direct pressure over wound-controls external haemorrhage.
5. Report urine output <30 ml/hr.
6. Note effectiveness of drug action. Familiarize self with action and side effects of digitalis, ẞ-blockers, calcium channel blockers, vasodilators, diuretics.
7. Assess for infiltration.
8. Provide sufficient rest periods for the patient.
9. Provide nursing care without tiring the patient.
10. Provide explanations to patient and family to minimize anxiety.
11. Turn and reposition the patient every 2 hours to prevent bedsores. Encourage deep breathing and coughing every 1-2 hour to avoid the risk of developing atelectasis or pneumonia in any patient who is immobile.
12. Assess for signs of altered level of consciousness assess the patient for responsiveness; orientation to person, place and time.
13. Note increasing restlessness, agitation, anxiety and confusion.
14. Provide reassurance and support to patient and family.
15. Use padding to protect patient from injury from bed rails.
16. Ensure patent airway.
17. Administer O₂ as prescribed
18. Provide hygiene measures.
19. Provide skin care measures- check for reddened areas over pressure points and use pressure-relieving devices.
20. Encourage patient to assist in activities that can be tolerated.
21. Explain interventions to patient and family prior to implementing.
22. Allow family participation in patient care.
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