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NCLEX Review: The 3 Stages of Shock You Should Know as a Nurse

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Shock is a condition when the body is not getting enough blood flow. This condition is life-threatening, so the best option is immediate treatment.

Types of Shock

  • Septic shock: is caused by infection
  • Hypovolemic shock: due to low blood volume
  • Neurogenic shock: caused by a trauma in the nervous system
  • Cardiogenic shock: caused by problems of the heart
  • Anaphylactic shock: caused by allergic reactions

General Signs and Symptoms of Shock

  • Hypotension
  • Tachycardia
  • Tachypnea
  • Obtundation or abnormal mental status
  • Colds
  • Clammy extremities
  • Mottled skin
  • Oliguria
  • Metabolic acidosis
  • Hyperlactatemia
  • In hypovolemic shock, there’s also orthostatic hypotension, pallor, and flattened jugular venous pulsations; this may result in a sequelae of chronic liver diseases
  • In septic shock, symptoms suggesting infection and infective endocarditis is evident in skin
  • Anaphylactic shock includes
  • Hypotension
  • Flushing
  • Urticaria
  • Tachypnea
  • Hoarseness of voice
  • Oral and facial edema
  • Hives
  • Wheezing
  • Inspiratory stridor

Stages of Shock

Initial Stage

  • The low cardiac output leads the cells to undergo hypoxia. This may result in a decrease in tissue perfusion, then lead to an inability to support the oxygen demands from the cells.
  • Low oxygen causes the cells to perform anaerobic respiration.

Signs and symptoms

  • Signs and symptoms from this stage are not immediately obvious as compared to the later stage.

Compensatory Stage

  • The body system is trying to compensate using neural, hormonal, and biochemical mechanisms.
  • If treated, this stage is reversible.
  • Baroreceptors sense the drop in blood pressure. This stimulates the sympathetic nervous system to release epinephrine and norepinephrine, resulting in vasoconstriction, increased blood pressure and heart rate.

Signs and Symptoms

  • Cold and clammy skin
  • In septic shock, the skin is hot and flushed
  • Hyperventilation

Progressive Stage

  • The body compensation failed.
  • This progresses to many organ dysfunction syndromes.
  • The blood stays in the capillaries which can cause fluid and protein leakage in the tissues.
  • Depleted blood volume.

Signs and Symptoms

  • Slowed speech
  • Restlessness
  • Agitated
  • Anxious
  • Does not respond to stimulation
  • Fluid in the lungs (crackles)
  • Increased respiratory rate
  • Decreased oxygen level
  • Cardiac dysrhythmia
  • Bleeding
  • Refractory stage
  • The vital organs failed and shock is no longer reversible
  • Brain damage and cell death
  • Irreversible organ dysfunction

Diagnostic tests

The doctor will assess for the signs and symptoms of shock and will perform laboratory tests. For undifferentiated shock, the laboratory tests include:

  • CBC and differential
  • Renal and liver function tests
  • Serum lactate level
  • Cardiac biomarkers
  • D-dimer level
  • Coagulation profile
  • Blood and urine cultures
  • Blood gas analysis
  • Chest X-rays: determine the source of infection
  • CT scan: to know the etiology of shock
  • Point of care ultrasonography

Treatment

  • The first approach of care is to stabilize the airways and breathing, done through oxygen administration then followed by mechanical ventilation, if necessary
  • Peripheral IV or intraosseous infusion (IO)
  • Immediate treatment with intravenous (IV) fluid, followed by vasopressor therapy for difficulty in securing peripheral venous access
  • There are also specific therapies/treatments needed for specific types of shock:

Septic shock

    • Fluid resuscitation with IV isotonic crystalloids 30 mL/kg within 3 hours
    • Empiric antibiotic therapy within 1 hour
    • Vasopressors: Norepinephrine and Vassopresin if refractory
    • Hypovolemic shock
    • Two large-bore IVs or central line
    • Place the patient in Trendelenburg position
    • IV fluid resuscitation: 2 to 4 L of isotonic crystalloids
    • PRBS transfusion if there’s bleeding

Neurogenic shock

    • First-line treatment: intravenous fluid resuscitation
    • Second-line treatment: Vasopressors and inotropes if hypotension persists
    • Epinephrine: used in refractory cases of hypotension
    • Surgical intervention for decompression of the spine

Cardiogenic shock

    • Start ACLS protocol and cardioversion for unstable tachyarrhythmias or bradyarrhythmias
    • IV Fluids
    • Inotropes and aortic balloon pumps should be considered if there’s refractory shock
    • Anaphylactic shock
    • IV fluid resuscitation: 4 to 6 L of IV crystalloids
    • Intramuscular epinephrine
    • Antihistamine
    • Corticosteroids
    • Nebulize with Albuterol

Nursing Management

  • Assess mental status
  • Monitor input and output of the patient
  • Administer medications as ordered by the physician
  • Check laboratories such as BUN and creatinine for kidney status
  • Provide nutrition as recommended by the dietician
  • Make sure that the patient is rested and does not feel pain
  • Check serum glucose levels if the patient is diabetic
  • Check skin color, pulses, and warmth for peripheral perfusion; take note and inform the physician if there are changes.
  • Ensure DVT and stress ulcer prophylaxis