Shock nursing management depends on the accurate and timely identification of shock. This can be obtained through an accurate assessment, thorough investigations, and a proper diagnosis, following which, the right treatment and requirements can be planned and provided to the patient.
Assessment
When assessing for shock, one should keep in mind that clinical changes are initially quite subtle. Still, the following aspects must be taken into account during an initial patient assessment…
- patient history
- level of consciousness
- signs of internal or external bleeding
- skin colour and/or moisture
- respiratory rate and effort
- heart rate and rhythm
- body temperature
- blood pressure
- urine output
Investigations
Clinical tests should be carried out to confirm shock and identify the patient’s array of needs…
- CBC – a complete blood count test measures the amount of red blood cells (which carry oxygen) and white blood cells (which fight infection); this test gives a good indication of bleeding and infection.
- ABGs – an arterial blood gases test measures the acidity (pH) and the levels of oxygen and carbon dioxide in arterial blood; this test determines how well the patient’s lungs are performing gas exchange.
- Lactate Level – normal blood lactate levels are 1.3 mmol/L; an increase in lactate production is usually caused by impaired tissue oxygenation whereby the lungs switch from performing aerobic to anaerobic respiration.
- Cross Match – this is done in case the patient is found to be needing a blood transfusion.
- Electrolytes – electrolyte imbalance can be indicative of shock in the progressive phase.
- Clotting – impaired coagulation and microclots are indicative of shock in the progressive phase.
- Alcohol Levels – these are tested if the patient suffered from trauma.
- ECG – an ECG determines whether the patient is suffering from arrhythmias or is heading towards cardiac depression and failure.
- Cardiac Enzymes – cardiac enzymes a.k.a. cardiac biomarkers are released by the heart in the case of heart damage or stress caused by low oxygen; Troponin and creatinine phosphokinase (CPK) levels rise following a heart attack; elevated heart enzyme levels may also indicate acute coronary syndrome or ischaemia.
- X-rays, CT scan of the Patient’s Chest, Abdomen and Spine – determines if there is infection, injury, and fluid loss.
Diagnosis
Clinical manifestations of shock vary according to both the underlying cause and the stage it is at, varying based on the cause of shock as well as the patient’s physiological response.
Typically, a patient is considered to be in shock when the following signs are noted:
- a systolic blood pressure of <90mmHg
- tachycardia OR bradycardia
- altered mental status
Shock Nursing Management
Shock nursing management aims to:
- RESTORE ADEQUATE TISSUE PERFUSION – this can be achieved through ensuring adequate oxygen delivery to the cells in relation to gas exchange, cardiac output, and haemoglobin, as well as improving oxygen utilisation by the cells
- PREVENT SHOCK PROGRESSION INTO FURTHER STAGES
Thus, in shock nursing management, the following steps need to be tackled as needed:
- improving oxygen supply
- administering fluid therapy
- administering cardiovascular drugs
- providing nutritional support
- providing psychosocial care
1. Improving Oxygen Supply
With adequate oxygen supply we aim to:
- achieve adequate gas exchange – ensure the patient has a patent airway, and improve ventilation and oxygenation by providing supplemental oxygen and mechanical ventilation if required
- achieve adequate cardiac output – aim to control the patient’s heart rate, preload and afterload, and cardiac contractility through the administration and titration of fluids and cardiovascular drugs
2. Administering Fluid Therapy
Fluid therapy administration is necessary for all types of shock, though the type of fluid administered and the amount and speed of delivery varies with every patient.
Fluids help increase oxygenation since oxygenation is partly affected by circulation. Types of fluids administered include:
- crystalloids – electrolyte solutions such as Isotonic (eg. normal saline or RLactate), Hypertonic (eg. 10% Dextrose) or Hypotonic (eg. 0.45% NaCl – Sodium Chloride)
- colloids – types of colloids, which contain large molecules, include blood and its products such as Fresh Frozen Plasma (FFP), as well as synthetic plasma expanders such as Gelafundin (a colloidal plasma volume substitute in an isotonic balanced whole electrolyte solution that can be used for prophylaxis and therapy of hypovolaemia and shock); ADVANTAGES: colloids remain in the intravascular space, restoring fluids faster and with less volume, while blood restores Hgb; DISADVANTAGES: colloids are expensive, may cause reactions, and may also leak out of damaged capillaries, causing additional problems especially within the lungs
fluid administration Complications
Common fluid administration complications include cardiovascular overload and pulmonary oedema.
Patients with increased risk include elderly patients and patients with a history of chronic renal failure or heart failure.
To avoid fluid administration complications, the nurse should:
- monitor and document urine output and fluid intake
- monitor for changes in the patient’s vital signs
- check for lung sounds
- perform haemodynamic monitoring
3. Administering Cardiovascular Drugs
Anti-dysrhythmic agents
- anti-dysrhythmic agents such as Amiodarone prevent or treat abnormal heart rates and rhythms
Vasodilators
- vasodilators such as nitrates cause arterial dilation by decreasing the afterload following decreased resistance to blood ejection, leading to an increase of cardiac output without increased oxygen demands
- vasodilators also cause venous dilation by reducing the preload and subsequently reducing the filling pressure on the failing heart
NOTE: Vasodilators REDUCE BLOOD PRESSURE! Monitor patient at all times whilst on vasodilators!
Inotropes and Vasoconstrictors
- inotropes and vasoconstrictors increase myocardial contractility leading to an increase in cardiac output
- inotropes stimulate adrenergic receptors, causing similar effects to the fight or flight reaction; types of sympathomimetic agents include naturally occurring catecholamines eg. adrenaline, noradrenaline and dopamine; synthetic cathecolamines eg. dobutamine
NOTE: Vasoconstrictors INCREASE BLOOD PRESSURE!
ADRENALINE (EPINEPHRINE)
- binds to beta 1 and beta 2 receptors
- cause an increase in heart rate, cardiac contractility, vasodilation, and cardiac output
- with an increasing rate of infusion also comes an increase in alpha receptors, which result in increased blood pressure and vascular resistance through vasoconstriction
- the heart now needs to work harder and so, its oxygen demand increases too
NORADRENALINE
- binds to beta 1 receptors only
- does not cause an increase in heart rate
- a low dose of noradrenaline increases cardiac contractility, leading to an increase in cardiac output
- higher doses tend to limit effect due to alpha stimulation which causes massive vasoconstriction
- whilst this causes an increase in blood pressure, it compromises peripheral circulation and increases the workload of the heart
DOPAMINE
- dopamine is the chemical precursor of noradrenaline
- a low dose of dopamine stimulates dopaminergic receptors, causing renal and mesentric vasodilation, leading to a good urine output
- a moderate dose of dopamine stimulates beta 1 receptors, causing an increase in cardiac contractility and cardiac output
- a high dose of dopamine stimulates alpha receptors, causing massive vasoconstriction, an increase in blood pressure, and an increase in the workload of the heart
DOBUTAMINE
- dobutamine causes no dopaminergic effects
- dobutamine mainly stimulates beta 1 receptors, causing an increase in cardiac contractility and cardiac output; dobutamine may also stimulate beta 2 receptors, causing mild vasodilation, causing a reduction the the preload, afterload, and stress on the heart
- dobutamine is helpful in treating heart failure, especially in hypotensive patients who are unable to tolerate vasodilators
- dobutamine may also be used as an adjunct therapy to adrenaline or noradrenaline and dopamine to reduce vasoconstriction effect
ADMINISTRATION OF INOTROPES:
- correct dilution of inotropes is of utmost importance
- inotropes are administrated as infusions through electronic pumps so that consistent administration is ensured
- administration of inotropes is done through a central line
- careful haemodynamic monitoring is very important especially since it help in the titrating process of inotropes dosage as needed
- inotropes should NOT replace fluid and electrolyte balance
- inotropes should be weaned off slowly
EFFECTS OF ADRENERGIC RECEPTORS
| RECEPTOR | LOCATION | RESPONSE |
| ALPHA | skin, muscles, kidneys, and intestines | constrict peripheral arterioles |
| BETA 1 | cardiac tissue | increase heart rate and cardiac contractility |
| BETA 2 | vascular and bronchial smooth muscle | dilates peripheral arterioles; increases heart rate; causes bronchodilation |
4. Providing Nutritional Support
Shock causes increased metabolic rates, which in return increase the patient’s energy requirements. Catecholamines (adrenaline and noradrenaline) deplete glycogen stores in 8-10 hours, after which the body starts breaking down skeletal muscle for energy. This prolongs recovery period unless it is prevented.
Typically, a patient in shock may require >3000kcal daily, however, the patient is usually unable to eat due to intubation, sedation, and anxiety. For this reason, enteral or parenteral nutrition should be initiated within 48 hours, and increased to full nutrition by day 3-7, if the patient is haemodynamically stable (excessive nutrient intake should be avoided in the early phase of critical illness).
NOTE: patients diagnosed with shock are also prone to develop pressure ulcers.
5. Providing Psychosocial Care
Psychological care should be provided throughout the whole course of hospitalisation, especially within the critical care environment. Liaise with other healthcare professionals as needed.
Whilst adopting an empathic approach, provide information and reassurance to both the patient (if conscious; if unconscious still talk to your patient as if he/she is listening, making him/her aware of what is going on in relation to care) and relatives, as this reduces anxiety. Communicate with the patient’s relatives about the patient’s condition as well as procedures being performed.
Shock Nursing Management Additional Interventions
- ensure good vascular access for fluid administration, central venous pressure (CVP) monitoring, and to draw blood for investigations
- insert a NGT (or OGT if patient has facial trauma) so that emesis (vomiting) and aspiration are prevented
- insert a urinary catheter to monitor urine output and fluid balance accordingly
- monitor the patient’s temperature and ensure maintenance of normal body temperature
- reposition patient frequently to prevent pressure ulcer formation
- provide frequent mouth and eye care
- assess for pain and administer analgesics as needed
- ensure continuous monitoring and documentation
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