Surgical Nursing: Understanding Shock

Surgical Nursing: Definition of Shock

• Shock is a complex clinical syndrome resulting from inadequate tissue perfusion.
• Cells exposed to hypoxia attempt to maintain cellular integrity, using endocrine, metabolic and immunological adaptation mechanisms.
• Insufficient tissue oxygenation leads to anaerobic metabolism.
• Insufficient tissue oxygenation can seriously disrupt the balance of intracellular and extracellular fluids.
• The organism stimulates adaptation mechanisms to maintain its physiological balance and adapt to the new situation.
• Total blood volume decrease and vascular dilatation can trigger shock by decreasing mean arterial pressure (MAP).
• A decrease in mean arterial pressure (MAP) of 5-10 mmHg stimulates baroreceptors.
• The adaptation process begins with transmission of perfusion and oxygenation information to the brain to activate adaptation mechanisms of vital organs.
• If the event that caused decreased mean arterial pressure (MAP) is stopped, the organism can return to its normal homeostatic balance on its own.
• A continued decrease in mean arterial pressure (MAP) can cause anaerobic metabolism, tissue damage, lactic acid and other harmful metabolites, and acid-base imbalances.
• Arterial blood pressure results from cardiac pulse and vascular resistance through total body circulation, adequate circulation volume, cellular perfusion, cardiac pulse, and peripheral vascular resistance.
• Any damage or change in the components adversely affects perfusion, oxygenation of tissues, and it can result in shock.

Stages of Shock

• Shock is a dynamic event where the patient's condition constantly changes.
• Shock is examined in 3 stages.

Initial Phase/Compensated Stage of Shock

• The initial decrease in cardiac output and blood pressure is balanced by compensation mechanisms.
• A 10-15 mmHg decrease in blood pressure stimulates renal and compensatory mechanisms.
• Baroreceptors and kidneys are stimulated, releasing epinephrine, norepinephrine, renin, ADH, and catecholamines to prevent shock.
• Anxiety is a factor during this period.
• No organ dysfunctions occur in this phase.

Progressive Period

• Compensation mechanisms are insufficient.
• Hypoxia develops in vital organs.
• Arterial blood pressure drops more than 20mmHg.
• Patient consciousness is impaired.
• Pulse becomes fast and weak.
• Urine output reduces.
• Skin becomes sweaty and cold.

Irreversible Period

• Recycling is impossible during this period.
• Metabolic acidosis develops from severe vasoconstriction and low cardiac output.
• Toxic substances accumulate, depressing the myocardium and vascular tone.
• Treatment is ineffective in this stage.

Effect of Shock on Organs and Systems

• Brain: Cerebral perfusion failure leads to brain damage.
• Cerebral hypoxia may cause restlessness, anxiety, latergia, and coma.
• Advanced acidosis and toxic substance accumulation cause changes in cerebral functions.
• Lungs: Hypoperfusion due to vasoconstriction causes pulmonary problems and eventually ARDS.
• Hypoperfusion causes increased water and protein permeability with the development of pulmonary edema.
• Hypoxemia and hypercapnia (increased CO2 in the blood) may cause respiratory alkalosis with hyperventilation by stimulating the respiratory center.
• Hypoxia may increase CO2 levels in the blood, with accumulation of acid products and respiratory acidosis.
• Kidneys: Decreased ABP causes the release of ADH which aims to increase arterial blood pressure (ABP) through water reabsorption.
• Vasoconstriction in the renal blood flow causes the release of aldosterone and reabsorption of sodium and water.
• Systolic pressure below 70 mmHg halts glomerular filtration, thus fluid and wastes cannot be removed.
• Tubular epithelial cell damage, loss of nephron function, and acute renal failure develop.
• Liver: Decreased ABP results in vasoconstriction in the liver, leading to hepatocellular hypoxia.
• Disruption of detoxification increases toxicity risk while a decrease in phagocytosis ability results in increased infection risk.
• Gastrointestinal System: A fall in ABP results in decreased intestinal mucosa blood flow, decreased bowel sounds and also temporary paralytic ileus.
• Prolonged intestinal mucosa ischemia leads to mucosal ulceration, bleeding, and necrosis.
• Diffuse Intravascular Coagulation (DIC): Sympathetic hyperactivity and catecholamine release caused by decreased ABP results in peripheral vasoconstriction.
• It causes stagnation in the capillary area and intravascular coagulation resulting from the clumping of erythrocytes to each other cause acidosis and precoagulation agents.
• Intracerebral bleeding, petechiae on the skin, purpura, ecchymosis, diffuse bleeding in the GIS, hematuria, bleeding in invasive intervention sites can be seen when coagulation factors are consumed.

Classification of Shock

• Classification depends on the effects of the basic components involved.
• Shock can be classified based on the cause.
• Shock types include hypovolemic, cardiogenic (develops with decreased blood flow), distributive, and obstructive.

Hypovolemic Shock

• Hypovolemic shock is a systemic disorder in which the heart cannot deliver enough blood and oxygen to organs due to decreased intravascular volume.
• Metabolic waste products cannot be removed from tissues, resulting in an immunological chaos picture.
• Hypovolemic shock is an emergency medical syndrome from various surgical and medical illnesses.
• Early diagnosis and treatment are very important in terms of preventing cell damage and death.
• Decreased tissue blood and oxygen supply changes cell energy metabolism.
• Oxidative metabolism transitions to the anaerobic metabolic pathway.
• The resulting energy demand disrupts energy-based cellular functions, and sodium-potassium pump functions of the cells.
• Intracellular calcium, CO2 and H+ concentrations increase.
• Extracellular sodium and intracellular potassium levels cannot be maintained.
• Intracellular edema and extracellular dehydration occurs.
• Acute extracellular fluid loss, includes vomiting, diarrhea, massive diuresis, diabetes mellitus/insipidus, and the polyuric phase of acute renal failure.
• Acute plasma loss often includes extensive burns, pancreatitis or peritonitis.

Symptoms/Findings of Hypovolemic Shock

• Systolic blood pressure of 100 / min
• Decrease in pulse pressure and filiform pulse
• Minute Respiratory Rate above 20
• Oliguria or anuria
• Cold, pale, moist skin with cyanosis, reduced tone and turgor elongation of capillary filling time
• Respiratory alkalosis, lactic acidosis
• Manifestation of CNS symptoms, such as restlessness, confusion, coma, organ destruction and response primary to the underlying disease

Treatment and Nursing Care for Hypovolemic Shock

• Focus on treatment and care of the patient and prevention of intravascular space loss.
• Control the loss and replace fluids based on the quality and quantity of volume lost.
• Immobilize the patient to help control bleeding and to ensure vascular access.
• Transfuse crystalloid fluids, solutions, blood, and blood products.
• Monitor the patient closely for hypothermia and coagulopathy during blood replacement.
• Applied fluids, blood and blood products should be at room temperature and the environment temperate.
• Give 1 unit of plasma when 10 units of blood are transfused, especially patients requiring blood transfusion, to support coagulation factors from bank blood.

Cardiogenic Shock

• Characterized as organ dysfunction resulting from decreased cardiac output and insufficient tissue perfusion despite sufficient intravascular volume.

Etiology of Cardiogenic Shock

• Acute Myocardial Infarction (AMI) (acute mitral regurgitation, ventricular septum and free wall rupture, right MI)
• Cardiomyopathies (dilated or hypertrophic ones)
• Myocarditis
• Myocardial depression (severe hypoxia, acidosis, anesthetic agents, beta-blockers, calcium channel blockers, sepsis)
• Ventricular Septal Defect causes Sol ventrikülden sağ ventriküle anormal kan akesinin olması
• ventricular aneurysm.
• acute mitral regurgitation results in mitra kapağının ani yehmezliği and Sol atrium ve akciger damarlarern basına anter
• pericardial tamponade, the Kale etrafinde sıvı birikmesi Kalp yeteri kader Pompalayamaz.
• Bradyarrhythmias and Tachyarrhythmias and A-V blocks.

Symptoms/Findings of Cardiogenic Shock

• Pulmonary Artery Capillary Wedge Increase in Pressure (PAWB)
• Increase in Central Venous Pressure (CVP)
• Decrease in pulse pressure
• Increase in cardiac blood values (Troponin T, which is kalp krizi sınrasında kale dokusenden Kane Kanışan Proteindir), the Değer yüksek çıkarsa Onceden kalp krizi geçirildiği anlaşılara.
• Tachypnea, Cyanosis, Cold, clammy skin, Nausea, vomiting, Decrease in urine, Anxiety, delirium

Nursing Care for Cardiogenic Shock

• Close monitoring and evaluation of hemodynamic parameters.
• Opening of 2 separate vascular routes.
• Controlled fluid replacement in accordance with the directive.
• Avoiding fluid overload.
• Oxygen application in accordance with the directive.
• Pain control and sedation.
• Monitor urine output, arterial blood pressure, CVP, PAWB, heart rate.
• Inform the patient and family about their condition.

Distributive Shock

• Type of shock caused by changes in the volume distribution of the intravascular and interstitial areas.
• Characterized by excessive dilation with loss of systemic vascular resistance, in absence of external fluid or blood loss.
• Divided into Neurogenic Shock, Anaphylactic Shock, and Septic Shock.

Physiopathology of Neurogenic Shock

• Disruption of sympathetic nervous system → Loss of sympathetic tone → Venous and arterial vasodilation → Decreased Venous return → Decreased Stroke volume → Decreased Cardiac output → Decreased Cellular oxygen supply → Decreased Tissue perfusion →Impaired cellular metabolism

Symptoms/Findings of Neurogenic Shock

• Decrease or increase in body temperature (deterioration in regulation)
• Respiratory function failure due to the level of injury
• Cold or dry skin as a result of skin perfusion failure
• Mild paralysis in the lower part of the lesion site
• Decrease in reflexes and loss of rectal and bladder sphincter
• Losses in bowel and bladder functions

Nursing Care for Neurogenic Shock

• Provide an open airway and maintain effective breathing and circulation.
• Protection from hypothermia and meeting hygienic requirements form the basis of nursing care.

Anaphylactic Shock

• Rapid onset, life-threatening, systemic hypersensitivity which develops in response to substances like drugs, chemicals, vaccines, food, beverages, insect bites.
• Caused by the sudden release of mediators from mast cells and basophils, of various clinical and severity.
• Characterized by widespread vasodilation, release of vasoactive mediators, and increased capillary permeability. Leakage of fluid from the intravascular space into the interstitial space causes a loss of volume.

Symptoms/Findings of Anaphylactic Shock

• Smooth muscle contraction.
• Superficial and Systemic vasodilation.
• Increased vascular permeability.
• Gastrointestinal spasms
• Bronchoconstriction/bronchospasm with Wheezing, dyspnea, and hypoxia
• Flushing with superficial kızarık cilt.
• Abdominal Cramping, vomiting, and diarrhea
• Circulatory collapse leading to Hypotension
• Fluid leaks into superficial dermis causing Urticaria cilt blisters
• Lesions fluid leaks into deep dermis and subcutaneous tissues causing Angioedema which is localized Swelling
• Kobarik citt Treatment should focus on providing an open airway, ensuring effective breathing, and maintaining circulatory support.

Nursing Care for Anaphylactic Shock

• Ensure airway patency and effective breathing.
• Maintain circulatory support.
• Administer requested treatments like antihistamines.
• Cricotomy preparation should be done due to the risk of airway obstruction.

Septic Shock

• Type of shock in which systemic inflammatory response develops against a possible infection.
• Systemic inflammatory response in septic shock develops as a result of the toxins of infectious microorganisms, immunosuppression or inadequate immune response to severe infections.
• It is caused by Gram (-) bacteria, yeast, fungi and viruses

Sepsis Symptoms

• Organ dysfunction life treating and caused by a dysregulated host response to infections.

Symtoms of Septic Shock

• Require vasopressors to increase average means arterial pressure.
• Increase in Lactate of average than 2 mmol/s Symptoms involve alteration in fever. Leukocytosis also affects fever, and tachycardia includes hypotension.

Symptoms and Nursing Care for Septic Shock

• Airway is important additionally as an serious infection.
• Application of high therapy supports breathing and circulation as well as fluid replacement.

Obstructive Shock

• Shock caused by the suppression of the vessels feeding the myocardium, aorta, and or by obstructing the circulation volume as a result of a mechanical obstruction. Inability of the left ventricle to drain adequately.
• Obstruction of pulmonary arterial flow due to venous
• Pericardioal tamponade
• Tension of pneumothorax .
• Uterine obstruction in women's health.

Treatment and Nursing Care

• To focus on maintaining Open Heart and ensuring appropriate circulation

• To measure comfort for patient and to make their lives easier to support Electrolysis.

• Includes Maintaining for the patient.

• Support patient

• Ensure for Comfort

• Maintain Fluid and Electrolyte levels

• Rapid early diagnosis and determination phase and treatment are the priority.

• Maintain electrolytes, and blood levels

• Provide fluids, monitor apical pulse and all abnormalities/complications

• Monitor for blood pressure changes.

Ensure Personal hygiene Ensured Skincare with positions every second