DEPARTMENT OF MEDICAL SURGICAL NURSING

LESSON PLAN
ON
SHOCK
GENERAL OBJECTIVES: At the end of the class, the students will be able to acquire adequate knowledge regarding shock
and its management and able to develop positive attitude and apply this knowledge in their daily clinical practices.

SPECIFIC OBJECTIVES: At the end of the class, the students will be able to:

 define shock
 identify the causes
 discuss the types of shock
 describe the pathophysiology
 elaborate the stages of shock
 list down the clinical manifestation
 enumerate the diagnostic evaluation
 recognize the complication
 explain the management
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INTRODUCTION Teacher PPT
1min Introduce Shock is a life-threatening condition. It is characterized by inadequate introduces the
the topic tissue perfusion that if untreated results in cell death. The supply of topic students
oxygen to tissues is essential in the maintenance of life and this can be listen actively
ensured when circulatory system is functioning normally.
DEFINITION
Define Shock can be defined as a condition in which systemic blood pressure is Teacher define
2min shock inadequate to deliver oxygen and nutrients to supply to vital organs and the definition PPT What is
cellular functions students listen shock?
DEFINITION 2nd - Shock is defined as a failure of circulation to supply carefully and
adequate oxygen to the tissues. Shock affects all the body systems. noted
CAUSES OF SHOCK
Identify the  Severe allergic reaction Teacher
2min causes  Heart conditions identifies the
 Heavy internal or external bleeding causes of shock
students
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 Dehydration listen PPT What all
 Infection carefully are the
 Spinal injuries causes of

 Burns shock

 Persistent vomiting or diarrhoea

 Poisoning
 Drug reaction
TYPES OF SHOCK
discuss the classified by their cardiovascular characteristics.
10min types of Teacher
1, Cardiogenic Shock 6, Septic Shock
shock discuss the PPT What is
2, Hypovolemic Shock 7, Neurogenic Shock
3, Obstructive Shock types of shock the
students difference
4, Distributive Shock
5, Anaphylactic Shock contributing between
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CARDIOGENIC SHOCK Some points Cardiogenic
Shock resulting from inadequate pumping action of the heart because of and noted shock and
cardiac muscle dysfunction of mechanical obstruction of blood flow. hypovolemic
Cardiogenic shock is a state in which the heart has been damaged so shock?
much that it is unable to supply enough blood to the organs of the body
{inadequate cardiac output}
In cardiogenic shock the left ventricle has been injured in some way
leading to impaired pumping. It occurs 5 to 10 percent of patients with
acute myocardial infection {AMI}. In most cases, approximately 40
percent of the myocardium must be lost to produce cardiogenic shock. It
occurs 5 to 10 percent of patients with acute myocardial infection
{AMI}. In most cases, approximately 40 percent of the myocardium
must be lost to produce cardiogenic shock.
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Other causes of cardiogenic shock include rupture of heart valves, acute
myocarditis, end-stage heart disease, severe dysrhythmias, or traumatic
injury to the heart. This can be the end result of a heart attack or
congestive heart failure
HYPOVOLEMIC SHOCK
This is the most common type of shock and based on insufficient
circulating volume
Hypovolemic shock is an emergency condition in which severe blood and
fluid loss makes the heart unable to pump enough blood to the body. This
type of shock can cause many organs to stop working
Any severe loss of body fluid may lead to hypovolemic shock. It occurs
due to decrease in the circulating blood volume resulting from
dehydration with loss of fluid volume internal or external haemorrhage
with actual blood loss, burns with a loss of plasma protein, vomiting or
diarrhoea or loss of intravascular fluid in to the interstitial as a result of
sepsis or trauma.
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The heart rate will increase to compensate for the diminished stroke
volume and resulting poor cardiac output and blood pressure.
Eventually, if the fluid or blood loss continues, the heart rate will not be
able to compensate for the decreased stroke volume. The end result of
hypovolemic shock is inadequate tissue perfusion.
OBSTRUCTIVE SHOCK
Obstructive shock is used as another category of shock to include those
conditions that leads to a sudden obstruction of blood flow. Obstructive
shock occurs when there is a blockage of blood flow in the cardiovascular
circuit outside the heart
Several conditions may cause obstructive shock such as cardiac
tamponade, tension pneumothorax, massive pulmonary embolism, aortic
stenosis, intrathoracic tumours, and large systemic emboli.
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DISTRIBUTIVE SHOCK
Distributive shock occurs when peripheral vascular resistance is lost
because of massive vasodilatation of the peripheral circulation.
Distributive shock includes anaphylactic, septic, and neurogenic shock.
ANAPHYLACTIC SHOCK
Anaphylactic shock is a shock state resulting from severe allergic
reaction producing overwhelming systemic vasodilation and relative
hypovolemia.
Both veins and arteries vasodilate leading to decreased blood returning
to the heart. The capillaries become permeable to nearly everything,
allowing fluids, proteins, and sometimes blood to pass through in to
the interstitial space.
This causes massive interstitial oedema. The vasodilation and fluid
sequestration in the interstitial causes a relative hypovolemia
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Anaphylactic shock occurs due to the severe allergic antigen antibody reaction to
substances such as drugs {antibiotics and anaesthetics’}, contrast media, blood
products, contrast dye, insect stings or animal venom. Food products such seafood’s,
nuts peanuts, peanut butter and MSG can also cause anaphylactic shock.
SEPTIC SHOCK
Septic shock is caused by an overwhelming systemic infection and inflammation
resulting in vasodilation leading to hypotension. Most causes of sepsis are caused by
gram negative bacteria such as Escherichia coli, Proteus species, Klebsiella
pneumonia, although other bacteria and viruses may be the cause
Predisposing conditions include trauma, diabetic mellitus and corticosteroid therapy,
weaken the immune system such as AIDS and in those undergoing chemotherapy
treatments for cancer, and an indwelling Foley catheter
The immune and inflammatory response begins to try to combat the organism that is
causing an infection. The body releases multiple chemicals in to the blood stream,
including cytokines, vasodilators, complement factors, and free radicals
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In septic shock this response is not adequate to eliminate the infection and
actually causes increased damage. The organism itself also releases substances
called endotoxins or exotoxins which further harm the organs and tissues.
NEUROGENIC SHOCK
Neurogenic shock occurs when dysfunction or injury to the nervous system
causes extensive dilation of peripheral blood vessels. Without stimulation by
sympathetic nervous system the vessel walls relax uncontrollably resulting in a
sudden decrease in peripheral vascular resistance leading to vasodilation and
hypotension
In neurogenic shock there has been an insult to the nervous system so that
impulses from the sympathetic nervous system cannot maintain normal vascular
tone or stimulate vasoconstriction
It is a rarer form of shock occurring most commonly as a result of injury to the
spinal cord. Other causes include general anaesthesia, fever, metabolic
disturbances, and brain contusion and concussions
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OTHER TYPES OF SHOCK

Endocrine shock
Insulin shock
Surgical shock
Deferred shock
Anaesthetic shock
It is caused by disturbance in the endocrine system. E.g., severe cases of
hypothyroidism, thyrotoxicosis and severe adrenal insufficiency
INSULIN SHOCK:
Shock resulting from an over dosage of insulin which causes too much
reduction of blood sugar characterized by sweating, trembling, dizziness,
and, if left untreated, convulsions and coma
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SURGICAL SHOCK:
A condition of shock that may occur during or after surgery,
with sign of profound hypotension, decreased urine, increased
heart rate, restlessness, and cyanosis of the extremities.
Haemoglobin for blood volume may below, or patient maybe
bleeding or have a severe infection.
DEFERRED SHOCK:
Deferred shock is a state of shock coming on at a considerable
at interval (3 to 30 hours) after the receipt of the injury
ANAESTHETIC SHOCK:
Anaesthetic shock is a type of shock produce by administration
of over dose of the anaesthetic drug.
PATHOPHYSIOLOGY OF SHOCK
Describe the
Due to risk factors or precipitating causes of shock
5min pathophysiology Teacher
describe the Write
pathophysiology PPT pathophysiology
Decreased circulatory blood volume which leads to decreased students listen of shock?
cardiac output tactfully
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Cells lack an adequate blood supply and are deprived oxygen and nutrition

It leads to decreased tissue perfusion {tissue hypoxia}

Anaerobic metabolism occurs

Metabolic Acidosis occurs and causes vasoconstriction

Because of these changes normal cell function cease causes cell membrane
dysfunction
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The cell swells and its membrane become more permeable and failure of
sodium pump

It allows electrolytes and fluids to seep out of and into the cell Toxic
substances enter circulation and damage capillary endothelial

Death of cell occur {shock}

elaborate STAGES OF SHOCK
10min the stages
of shock  INITIAL STAGE
Teacher
 COMPENSATORY STAGE
elaborate
 PROGRESSIVE STAGE the stages PPT Name the
of shock stages of
 IRREVERSIBLE STAGE. students shock?
listen and
noted
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INITIAL STAGE
During this stage, the hypoperfusional state causes hypoxia, leading to the
mitochondria being unable to produce adenosine triphosphate (ATP). Due
to this oxygen, the sell member an is become damaged, they become leaky
to extra –cellular fluid and the sells perform anaerobic respiration.
This cause build- up of lactic and pyruvic as a which result in systemic
metabolic acidosis. The process removing these compounds from the sells
by the liver recurred oxygen, which is absent
COMPENSATORY STAGE
During the phase the body employs several mechanisms in an attempt to
correct the metabolic upset of shock. When arterial pressure and tissue
perfution brain. Hyperventilation will create a respiratory alkalosis in an
attempt to neutralize the metabolic acidosis of shock returning the body to a
normal pH hydrogen ion concentration.
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PROGRESSIVE STAGE
The progressive stage of shock begins as compensatory mechanisms fail to
maintain cardiac output. Tissues become hypoxic because of poor
perfusion. Due to the decreased perfusion of the cells, sodium ions build up
within while potassium ions leak out.
As anaerobic metabolism continues; increasing the body’s metabolic
acidosis, the arteriolar smooth muscle and precapillary sphincters relax such
that blood remains in the capillaries. This acidosis state depresses
myocardial function.
Tissue hypoxia also promotes the release of endothelial mediators, which
produce vasodilation and endothelial abnormalities leading to venous
pooling and increased capillary permeability.
As this fluid is lost, the blood concentration and viscosity increase, causing
sludging of the micro circulation. The prolonged vasoconstriction will also
cause the vital organs compromised due to reduced perfusion.
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IRREVERSIBLE STAGE
At the stage the vital organs have failed and the shock can no longer be
reversed.as the shock progresses, organ damage occur as compensatory
mechanisms can no longer maintain cardiac output.
Reduced perfusion damages a cell membrane, liposomal enzymes are released
and energy stores are depleted, possibly leading to cell death.
Perfusion to coronary arteries reduced, causing myocardial depression and a
further reduction in cardiac output. Eventually, circulatory and respiratory
failures occur. Brain damage and cell death have occurred. Death will occur
imminently.
COMPENSATORY MECHANISM FOR THE RESTORATION OF
CIRCULATORY BLOOD VOLUME IN SHOCK
• Precipitating cause of shock
• Decreased circulating blood volume
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• Decreased cardiac output
• Hypotension and decreased tissue perfusion
• Baroreceptors stimulated
• Increased sympathetic stimulation and cardio vascular system
• Increased heart rate and contractility, Arteriolar constriction,
Venous constriction
• Increased cardiac output, Increased blood pressure, Increased
venous return
CLINICAL MANIFESTATION
5min list down the ▪ Low blood pressure
clinical ▪ Rapid, shallow breathing Teacher list
manifestation down the PPT What all
▪ Rapid, weak pulse clinical are the
▪ Cold, clammy skin manifestation symptoms
of shock present in
▪ Dizziness or fainting students shock?
listen
carefully
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▪ Oliguria
▪ Weakness
▪ Changes in level of consciousness
CLINICAL MANIFESTATIONS OF SPECIFIC TYPE OF SHOCK
CARDIOGENIC SHOCK
 Decreased cardiac output
 Pulmonary oedema
 Increased central venous pressure
 Chest pain or pressure
 Distended jugular veins due to increased jugular venous pressure
 Weak or absent pulse
 Arrhythmia, often tachycardia
 Profuse sweating, moist skin
 Shortness of breath
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 Pale skin colour and feels cool to the touch
HYPOVOLEMIC SHOCK
✓ Decreased cardiac output
✓ Hypotension
✓ Altered tissue perfusion
✓ Cool and clammy skin
✓ Cyanosis or pale skin colour
✓ A rapid, weak, thread pulse
✓ Thirst and dry mouth, due to fluid depletion
✓ Fatigue due to inadequate oxygenation
✓ Anxiety, restlessness, altered mental state
✓ Distracted look in the eyes or staring in to space, often with pupils dilated
OBSTRUCTIVE SHOCK
o Tachycardia
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o Tachypnea
o Hypotension
o Cyanosis
o Oliguria
o Altered mental status
o Jugular veins maybe distended
o Pulses paradoxes in case of tamponade
SEPTIC SHOCK
➢ Pyrexia due to increased level of cytokines
➢ Systemic vasodilation resulting in hypotension
➢ Warm and sweaty skin due to vasodilation
➢ Systemic leukocyte adhesion to endothelial tissue
➢ Reduced contractility of the heart
➢ Activation of the coagulation pathways, resulting in DIC
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➢ Increased levels of neutrophils
➢ Low or absent urine output
➢ Skin rash or discolouration
NEUROGENIC SHOCK
 Hypotension
 Altered mental status
 Bradycardia
 Skin that is warm and dry
 Tachycardia and Tachypnea
 Cool and clammy skin
 Priapism due to peripheral nervous system stimulation
ANAPHYLACTIC SHOCK
 Skin eruptions and large bumps
 Localized oedema, especially around the face
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 Laryngeal oedema
 Weak and rapid pulse
 Breathlessness and cough
 Tachycardia and Tachypnea
 Hypotension
 Cyanosis
 Urticaria and pruritus
 Severe bronchospasm
 Extremely apprehensive
 Complain of a metallic taste
DIAGNOSTIC EVALUATION Teacher
enumerate
 Chest x-ray
enumerate the PPT Write the
the  CVP measurement diagnostic different
3min diagnostic evaluation diagnostic
 Haemoglobin level measurement
evaluation of shock measures for
 Arterial blood gases analysis shock?
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 Urinalysis
 Complete blood count
 Blood, urine and sputum culture
 Blood chemistry including kidney function tests
 Cardiac catheterization and Coronary angiography
 Echocardiogram and Electrocardiogram
 Cardiac enzymes [troponin, CKMB] test
 Computed tomography
MANAGEMENT OF SHOCK
 Crystalloids
Teacher What all are
explain the  Inotropic agents explains the PPT the
5min management management management
 Vasodilators
of shock given for
 Diuretics students shock
listen patients?
 Antibiotics
tactfully
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 Antihistamines
 Steroids
 Sodium bicarbonate
 Bronchodilators
NURSING MANAGEMENT
 Maintain ABC of the patient.
 Provide supplemental oxygen therapy to the patient
 Do not deliver more than 2li. Of oxygen per minute if person has history of
chronic pulmonary diseases
 Monitor for ABG value to assess the patient response to oxygen therapy.
Continuous monitoring of vital signs should be done.
 Check for urine output of the client.
 Maintain nutritional status of the patient. Administer prescribed medication
to the patient
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NURSING DIAGNOSIS
 Fluid volume deficit related to haemorrhage
 Decreased cardiac output related to ineffective cardiac function.
 Risk for infection related to interruption of skin integrity from
invasive procedures.
 Imbalanced nutrition less than body requirement related to
decrease oral intake.
 Altered peripheral tissue perfusion related to oedema from stasis
of blood in the capillaries and vasoconstriction. Teacher
recognize
COMPLICATIONS
the
recognize  ARDS complication PPT What all are
2min the students the
 Multiple Organ Failure
complication listen complication?
carefully
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CONCLUSION
Shock is extremely dangerous and one of the more complicated conditions to
1min
understand. The one thing to remember is that the body has to have a minimum
amount of blood pressure to get oxygen and nutrients to the brain and other vital
organs. Anything that gets in the way of maintaining that minimum blood
pressure is a serious medical emergency.
SUMMARY
3min
In this session we have discussed regarding shock: definition, causes, types,
pathophysiology, stages of shock, clinical manifestation, diagnostic evaluation,
management, nursing management, complications
RECAPITULATION
 Define shock?
5min
 Enumerate the causes?
Explain the stages of shock?
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Describe the pathophysiology?
Enlist the clinical manifestation?
List down the diagnostic evaluation?
Elaborate the management of shock?
Identify the complication?
Recognize the complications?
BOOK REFERENCES
 Chinthamani, Lewis medical surgical nursing, Elsevier
1min
publication, 1st edition
 Suzanne Smeltzer, Brenda Bare, Text book of medical surgical
nursing, Lippincott publication, 10th edition
 Joyce M. Black, Jane Hokanson Hawks, medical surgical nursing,
Elsevier publication, 7th edition, volume-2
NET REFERENCE
• https://www.healthline.com/health/shock
• https://www.ncbi.nlm.nih.gov/books/NBK531492/
• https://my.clevelandclinic.org/health/treatments/24055-shock-first-
aid-treatment