Shock: NCLEX Review

Shock – What is it?

Shock is a generalized systemic response to inadequate tissue perfusion. The major types are hypovolemic (absolute and relative), cardiogenic, distributive (neurogenic, anaphylactic, and septic), and obstructive shock. While they all generally have the same end result if not treated, the signs, symptoms, and interventions can be different for each type.

Shock is a complex process that can be explained down the the cellular level. We could get into cytokines and neutrophil entrapment, but this post is going to focus on nursing interventions rather than detailed pathophysiology.

As usual, I will be using my favorite textbooks/resources to write this post! Clicking on the links below will take you to an affiliate website where you can purchase them for yourself or browse around for other books.

Phases of Shock

Initial: Decreased cardiac output, decreased perfusion, anaerobic metabolism, lactic acidosis. You want to catch any signs and symptoms before it progresses any further.

Compensatory: The body is responding to the problem by increasing cardiac output and increasing oxygen delivery to tissues. (Sympathetic nervous system is in action here!)

Progressive: Compensation is not working and cells are starting to die off because anaerobic metabolism is not enough. (Systemic Inflammatory Response System)

Refractory: Shock is unresponsive to treatment and death is the probable outcome. (Multiple Organ Dysfunction Syndrome)

Hypovolemic Shock

This is the most common type of shock. It is caused by either a loss of volume (hemorrhage) or a displacement of volume (burn patients).

Signs/Symptoms/Assessment

  • Weak and rapid pulse
  • Hypotension
  • Restlessness/Altered mental status
  • Tachypnea
  • Cool, clammy skin
  • Oliguria
  • Sluggish capillary refill
  • Absent bowel sounds
  • Poor peripheral pulses

Interventions

  • Treat the cause!
  • If hemorrhage, hold pressure, replace fluids/blood
  • Insert 2 large bore IVs
  • Notify the HCP/rapid response team
  • Administer oxygen (high flow if necessary)
  • Maintain patent airway
  • Monitor vital signs
  • Monitor I/O
  • Assess skin color, temperature, turgor, moisture
  • Assess lung sounds
  • Elevate the legs (contraindicated if patient has spinal anesthesia)

Cardiogenic Shock

This is defined by a failure of the heart to pump adequately, which reduces cardiac output. This means that tissues are not being adequately oxygenated just as in hypovolemic shock. Some causes are myocardial infarction, valvular problems, and ventricular failure (reduced ejection fraction).

Treatment goals are to support cardiac output and improve coronary artery blood flow.

Signs/Symptoms/Assessment

  • Same as above
  • Pulmonary congestion
  • Chest discomfort

Interventions

  • Administer oxygen
  • Administer morphine
  • Administer vasodilators
  • Maintain patent airway
  • Administer vasopressors and positive inotropic medications
  • Treat problem–prepare for cath lab, IABP, CABG
  • Monitor I/O
  • Assist with insertion of Swan-Ganz
  • Monitor CVP, PAWP, and MAP
  • Monitor circulation (cap refill, pulses, mucous membranes)

Review Cardiac Medications Here!

Anaphylaxis

This type of shock is different from hypovolemic and cardiogenic shock. You will see that the assessment data, signs and symptoms, and interventions are also different. Anaphylaxis, or anaphylactic shock, is a sudden, severe cascade response (hypersensitivity) to an allergen. Antibodies combine with antigens and set off mast cells and histamines and cause massive vasodilation.

Signs/Symptoms/Assessment

  • Pruritus, angioedema, erythema, urticaria
  • Headache, dizziness, paresthesia, feeling of impending doom
  • Hoarseness, coughing, wheezing, stridor, dyspnea, tachypnea, sensation of narrowed airway, respiratory arrest
  • Hypotension, dysrhythmias, tachycardia, cardiac arrest
  • GI cramping, abdominal pain, N/V/D

Interventions

  • Remove the suspected allergen (stop blood transfusion, stop iodine contrast, etc.)
  • Assess respiratory status, maintain patent airway
  • notify HCP and/or rapid response team
  • administer oxygen
  • infuse normal saline (try for 2 large bore IV’s)
  • Medications: epinephrine, antihistamines (benadryl), steroids (hydrocortisone), beta-agonist
Image credit: Lonnie Millsap (lonniemillsap.com)

Neurogenic Shock

This is another type of distributive shock that impairs perfusion from vasodilation. It is most common in patients with recent injuries above T6. This can lead to pooling of blood in blood vessels.

Signs/Symptoms/Assessment

  • Hypotension
  • Bradycardia
  • Decreased cardiac output
  • Inability to sweat below the level of the injury (skin is warm and dry)

Interventions

  • Monitor vital signs
  • Notify HCP/rapid response team
  • IV fluids
  • Administer vasopressors
  • Administer atropine for bradycardia
Image source: Wikipedia

Septic Shock

Septic shock is the most extreme reaction to an infection; it is a subset of sepsis in which there is profound circulatory, cellular, and metabolic abnormalities. It is vasodilation caused by endotoxins from microorganisms.

Signs/Symptoms/Assessment

  • Tachypnea > 22 breaths/minute
  • Altered mental status – GCS < 15
  • Systolic blood pressure < 100
  • Lactic acid > 2 mmol/L
  • Unresponsive to fluid resuscitation
  • symptoms of infection – fever >100.2 F or <96.8 F

Interventions

  • Assist with placing central line
  • Monitor CVP
  • Fluid resuscitation
  • Vasopressors
  • Monitor urine output
  • Ensure cultures have been sent
  • IV antibiotics

Knowing the signs and how to manage different types of shock is essential for any nurse! I hope this review helps spark your memory for the NCLEX! Check out some of my other NCLEX review posts below:


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