Class notes
NUR 411 Nursing Management; Shock Lecture Notes
- Course
- Nursing 411
- Institution
- Borough Of Manhattan Community College
This is a comprehensive and detailed note on Nursing Management; Shock for Nur 411.
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1Nursing Management Shock
• Focus your attention on airway management, breathing and circulation.
• Next focus on tissue perfusion to include vital signs assessment and evaluation of conscious
level, peripheral pulses, capillary refill and urine output
• As shock progresses skin will become mottled and cooler, urine output decrease peripheral
pulses decrease, neurological status will decline.
Cardiogenic shock
Occurs when the heart muscle is unhealthy and the pumping of the heart is affected- myocardial infarct,
cardiac arrest, myocardial degeneration, heart valve damage
Systolic dysfunction is an inability of the heart to pump forward – MI, cardiac injury, severe systemic or
pulmonary hypertension.
Diastolic dysfunction is inability of the heart to fill during diastole -Tamponade, ventricular
hypertrophy.
Other cause –Dysrhythmias and Structural factors – valvular stenosis
This leads to decreased tissue perfusion and a shock like state.
Patient Presentation Appearance, signs and symptoms
• Pale, cool and clammy skin
• Pulmonary congestion and hypoxemia worsen as the ventricles fail to eject adequate volume and
the blood backs up into the lung.
• Tissue hypoperfusion continues because the oxygen does not meet the metabolic needs.
Restlessness and agitation progressing to unresponsiveness
• Chest pain
• Dysrhythmias
• Orthopnea
• Crackles heard in lungs
• Cough with increased secretions
Vital signs
• Weak thready pulses Rhythm may be irregular
• HR: >100 beats/min
• BP: <80 mm Hg
• RR: > 20 breaths/min
Nursing interventions
The early stages of shock may only be slight changes in blood pressure and pulse with a drop in mean
arterial pressure.
JAS Shock BMCC 02/25/2022
, 2
Nursing Outcome Criteria
• Patient alert and oriented
• Pao2 80 to 100 mm Hg
• pH 7.35 to 7.45
• Paco2 35 to 45 mm Hg
• O2 sat ?95 %
• RR 12 to 20 breaths/min, eupnea Lungs clear to auscultation
Nursing Intervention
• .Continuously monitor oxygenation status with pulse oximetry.
• Monitor for desaturation in response to nursing intervention.
• Monitor ECG for dysrhythmias caused by hypoxemia, electrolyte imbalances, or ventricular
dysfunction.
• Monitor fluid volume status.
• Obtain HR, RR, and BP every 15 minutes to evaluate the patient’s response to therapy and detect
cardiopulmonary deterioration.
• Assess the patient’s respiratory status. The use of accessory muscles and inability to speak
suggest worsening pulmonary congestion.
• Assess for excess fluid volume, which can further compromise myocardial function.
• Review ABGs for decreasing trend in Pao2 (hypoxemia) or pH (acidosis). These conditions can
adversely affect myocardial contractility.
• Review serial chest radiographs to evaluate the patient’s progress or a worsening lung condition.
Patient Management
• Provide supplemental oxygen as ordered. If the patient develops respiratory distress, be prepared
for intubation and mechanical ventilation.
• Administer low-dose morphine sulfate as ordered to reduce preload in an attempt to decrease
pulmonary congestion.
• Minimize oxygen demand by maintaining bed rest and decreasing anxiety, fever, and pain.
• Position the patient for maximum chest excursion and comfort.
• Administer diuretics and /or vasodilators as ordered to reduce circulating volume and decrease
preload.
Neurogenic shock
Neurogenic shock is manifested by the triad of hypotension, bradycardia, and hypothermia. shock tends
to occur more commonly in injuries above t6, secondary to the disruption of the sympathetic outflow
from t1-l2 and to unopposed vagal tone, leading to decrease in vascular resistance with associated
vascular dilatation.
Damage to either the brain or spinal cord (Above T6) inhibits transmission of neural stimuli to the
arteries and arterioles, which reduce vasomotor tone.
The decrease peripheral resistance result in vasodilatation and hypotension.
JAS Shock BMCC 02/25/2022
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