NCLEX® Review for Shock

What is Shock in Nursing?

Shock is a life-threatening condition where the body’s tissues do not receive enough oxygen due to inadequate blood flow. This results in cellular damage, organ failure, and, if untreated, death. Understanding shock is critical for nursing students, especially for NCLEX prep, where shock-related questions frequently appear.

During shock, the body initially compensates by increasing heart rate and constricting blood vessels to maintain perfusion. However, as shock progresses, these compensatory mechanisms fail, leading to hypotension, metabolic acidosis, and multi-organ dysfunction. Recognizing the types, stages, signs, and nursing interventions for shock is essential for both nursing school and clinical practice.

Types of Shock in Nursing

There are several types of shock, each with distinct causes and pathophysiology. Nurses must identify the type of shock quickly to administer the appropriate treatment.

1. Hypovolemic Shock

Cause: Severe blood or fluid loss leads to inadequate tissue perfusion.

• Examples: Hemorrhage (trauma, surgery, GI bleeding), dehydration (vomiting, diarrhea, burns).
• Key Nursing Interventions: Rapid IV fluid replacement, oxygen therapy, monitor vitals, and treat underlying cause.

2. Cardiogenic Shock

Cause: The heart fails to pump sufficient blood to the body.

• Examples: Myocardial infarction (heart attack), arrhythmias, severe heart failure.
• Key Nursing Interventions: Oxygen, vasopressors, inotropes (e.g., dobutamine, dopamine), and monitoring for worsening symptoms.

3. Obstructive Shock

Cause: Physical obstruction of blood flow prevents adequate circulation.

• Examples: Pulmonary embolism, cardiac tamponade, tension pneumothorax.
• Key Nursing Interventions: Remove obstruction (e.g., pericardiocentesis for tamponade), oxygen therapy, and hemodynamic support.

4. Distributive Shock

Distributive shock occurs when there is widespread vasodilation, leading to inadequate blood return to the heart.

a. Septic Shock

• Cause: Severe infection causing systemic inflammatory response and hypotension.
• Treatment: IV fluids, broad-spectrum antibiotics, vasopressors (e.g., norepinephrine).

b. Anaphylactic Shock

• Cause: Severe allergic reaction causing airway swelling and hypotension.
• Treatment: Epinephrine, antihistamines, steroids, IV fluids, oxygen.

c. Neurogenic Shock

• Cause: Spinal cord injury leading to loss of vascular tone and hypotension.
• Treatment: IV fluids, vasopressors, atropine for bradycardia.

Stages of Shock in Nursing

Recognizing stages of shock helps nurses intervene before irreversible damage occurs.

1. Initial Stage: Mild signs (tachycardia, slightly decreased perfusion).
2. Compensatory Stage: Body tries to maintain perfusion (increased heart rate, cool skin, restlessness).
3. Progressive Stage: Organ dysfunction begins (hypotension, metabolic acidosis, confusion, weak pulses).
4. Refractory Stage: Irreversible damage (multiple organ failure, unconsciousness, death).

Signs and Symptoms of Shock

The signs and symptoms of shock become progressively more noticeable as the condition worsen, making detection of early signs important for early intervention.

Early Signs

• Elevated heart rate
• Minimal drop in mean arterial pressure (MAP) ~ 10mmHg

Compensatory Signs

• Further drop in MAP ~ 10 – 15mmHg
• Increased elevated heart rate
• Weak and rapid pulse
• Restlessness
• Fatigue
• Cool, clammy skin

Progressive Signs

• MAP drops ~ 20mmHg from baseline
• Reduced urine output
• Extreme fatigue
• Pale skin
• Bluish discoloration of the nail beds and lips
• Dizziness
• Altered mental status

Refractory Signs

• Unconsciousness
• Cell and organ damage

Clinical Manifestations

The clinical manifestations of shock include a range of signs, symptoms, and tests that can be observed or performed to help identify the condition. Examples of these manifestations include the following.

Physical manifestations

• Reduced alertness
• Heart rate > 100 beats per min
• Respiratory rate > 22 breaths per min
• Systolic Blood pressure <90mmHg, or a ≥30mmHg drop from baseline
• Urine output < 0.5mL/kg/hour

Laboratory manifestations

• Lactate > 3mmol/L, or 27 mg/dL
• PaCO2 < 32mmHg
• Base deficit < −4 mEq/L

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Treatment

Pharmacology of Shock

Treatment of shock generally consists of three categories; Supportive care, IV fluids, and additional treatment needed depending on the specific type of shock.

Supportive care

Supportive care begins by turning the client’s head to the side to avoid aspiration of any vomit that may occur. Warm blankets are placed and oxygen is supplied either a face mask, or intubation if necessary. Catheters are placed to allow access to venous system. Additional monitoring tools are placed in order to monitor blood pressure, heart rate, oxygen saturation, urine output, and more. These tools help the medical team to assess and monitor the condition of the client, allowing them to make more educated decisions on treatment strategy.

Vasopressors (phenylephrine, norepinephrine, epinephrine, and vasopressin, and dopamine) and inotropes (dobutamine and milrinone) are drugs that can be used to rapidly increase blood pressure by way of vasoconstriction. Doses of these drugs may be required during the initial treatment phases of shock. It should be noted that these medications are not a cure, they only allow for a temporarily increase in blood pressure to buy the client time. The ultimate goal when treating shock is to treat the cause and allow the body to restore and maintain blood pressure and tissue perfusion on its own.

IV Fluids

Another hallmark treatment for shock is the administration of IV fluids which are used to restore vascular volume. The typical initial treatment approach is 1L of normal saline infused over a period of 15 minutes. If parameters do not return to normal, additional fluid may be administered.

Additional Treatments

Supportive care and IV fluids are the mainstays of shock treatment, but additional measures may need to be taken depending on the specific type of shock being treated. These additional treatments typically deal with dealing with the source of the shock which varies between types. Perhaps the most obvious example of a necessary additional treatment is in the case of hemorrhagic shock, which results from severe blood loss. In this case, the bleeding event would also need to be promptly addressed alongside the other two measures in order for the shock to be treated. In the case of septic shock caused by widespread infection, broad spectrum antibiotics would also be administered to begin infection treatment.

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Nursing Interventions

Nursing interventions play a critical role in the success or failure of treating clients with shock. In fact, nurses are often the one who initially identify the condition due to their close client contact. It is for this reason that nurses must remain vigilant and well trained to recognize the early signs of shock.

Additionally, many of the methods used to treat shock fall directly to the responsibility of nurses, including fluid administration, monitoring vital signs, catheter placement, oxygen administration, and providing supportive care.

Conclusion

“Shock” is an umbrella term which can be broken down into a number of different subtypes. While each of these subtypes arises from different causes, they share important similarities such as hypotension and inadequate tissue perfusion. Likewise, the treatment of these subtypes also possesses many similarities in addition to a few differences. Whichever type of shock is being treated, however, nurses will undoubtedly be on the front lines.

References

Quick and dirty guide to shock. Medic Tests.
https://legacy.medictests.com/quick-dirty-guide-shock/.

Shock. Merck Manuals. https://www.merckmanuals.com/professional/critical-care-medicine/shock-and-fluid-resuscitation/shock.

Shock. Better Health. https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/shock.

Inotropes and Vasopressors. NCBI. https://www.ncbi.nlm.nih.gov/books/NBK482411/.