BSN Notes: Common Signs And Symptoms: Shock- Stages,Overall Pathophysiology,Clinical featuresk


·         Shock is a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism.
·         This results in an imbalance between the supply of and demand for oxygen and nutrients to support the vital organs and cellular functions
Stages of shock
1.       Initial stage
2.       Non Progressive/Compensatory stage
3.       Progressive/ Intermediate stage
4.       Irreversible/ Refractory stage

1.       Initial phase:
·         ↓in mean arterial pressure (Mean arterial pressure is calculated by the formula- MAP= (systolic blood pressure +2diastolic pressure )/3
·         Compensatory mechanism effective in this stage.
·         Decreased cellular metabolism
·         Overall cellular metabolism is aerobic
·         The only objective sign of this stage is - tachycardia
2.       Non progressive/ Compensatory Stage
            Results from stimulation of the sympathetic nervous system and subsequent release of catecholamine's
            The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs.
Overall Pathophysiology:-
Decrease in MAP (10-15 mmHg From baseline)
Kidney and chemical compensatory mechanism activate
Kidney and baroreceptor sense an ongoing decrease in MAP & activates RAAS, NE, epinephrine release
Tissue hypoxia in Non-vital organs  i.e. GI
Some metabolism is anaerobic
Acid - Base and electrolytes balance change
Acidosis and ↑ in K ion in blood (hyperkalaemia )

Neuronal compensation:
Decreased BP
Detection of decreased BP by baroreceptor and chemotherapy and impulses  are relayed to VMC in MO
Sympathetic stimulation (ANS)
Release of epinephrine and nor-epinephrine from adrenal cored

Endocrine Compensation
Decreased BP
Stimulation of anterior and posterior pituitary → release ADH → retention of water and salt
Release GIucocorticoid and mineralocorticoid
Increase blood GIucose
Na and water retention
Stimulation of renin angiotensin
Causes vasoconstriction
Increased BP

Chemical Compensation
Decreased cardiac output
Decreased  pulmonary blood blow
Ventilation perfusion imbalance
Stimulation of chemoreceptors for O2 concentration
Increased rate and depth of respiration

Clinical features:
Compensatory features
Blood pressure
Heart rate
> 100 bpm
Respiratory status
> 20 breaths/min
Cold, clammy
Urinary output
Acid- base balance
Respiratory alkalosis

Medical Management
Identify the cause of the shock and correct the underlying disorder so that shock does not Progress.
Fluid replacement and medication therapy must be initiated to maintain an adequate blood pressure and re-establish and maintain adequate tissue perfusion.

3.       Progressive stage:-
In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate and the MAP falls below normal limits, with an average systolic blood pressure of less than 90 mm Hg.
Sustained  ↓ in MAP ( > 20 mmHg)
Compensation functioning but unable to deliver sufficient oxygen to even vital organs that produces ischemia.
Biochemical mediators cause myocardial depression
Life threatening emergency
Very sensitive tissues start to die
Clinical features
Blood pressure

Systolic < 80-90 mm Hg
Heart rate

> 150 beats per minute
Respiratory status

Rapid, shallow respirations; crackles


Mottled, petechiae

Urinary output

0.5 ml/kg/hour


Acid-base balance
Metabolic acidosis

Medical Management
Appropriate intravenous fluids and medications to restore tissue perfusion by:
·         Optimizing intravascular volume,
·         Supporting the pumping action of the heart,
·         Improving the competence of the vascular system.

4.       Irreversible/ Refractory stage
·         Patient does not respond to treatment
·         Blood pressure remains low.   
·         Renal and liver failure and vital organs continues to deteriorate in function.
Too little O2 reaching to tissue→ too  much cell death → tissue damage→ overwhelming changes in vital organ→ irreversible changes in tissues→ cell deterioration and → cellular death
Medical Management
Medical management during the irreversible stage of shock is usually the same as for the progressive stage.
Nursing Management
·         Carrying out prescribed treatments, monitoring the patient
·         Preventing complications
·         Protecting the patient from injury  
·         Providing comfort.



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item BSN Notes: Common Signs And Symptoms: Shock- Stages,Overall Pathophysiology,Clinical featuresk
BSN Notes: Common Signs And Symptoms: Shock- Stages,Overall Pathophysiology,Clinical featuresk
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