Shock Nursing Management
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Direct answer
Shock is a state of inadequate tissue perfusion so that cells are starved of oxygen, whatever the blood pressure reads; untreated it advances through compensated, decompensated and refractory stages ending in multi-organ failure. The main types are hypovolaemic, cardiogenic, obstructive (tension pneumothorax, tamponade, massive pulmonary embolism) and distributive (septic, anaphylactic, neurogenic). Nursing management is early recognition — tachycardia, cool clammy skin, falling urine output and anxiety while blood pressure is still normal — followed by oxygen, large-bore IV access, fluids or blood as prescribed, treating the cause, and minute-to-minute monitoring.
What you must remember
- Compensated (early) shock: tachycardia, tachypnoea, cold clammy pale skin, weak thready pulse, anxiety and restlessness, urine falling below 0.5 mL/kg/hour — with a NORMAL blood pressure; hypotension is a late sign.
- Progressive (decompensated) shock: hypotension, oliguria, confusion, metabolic acidosis with rising lactate; refractory shock means multiple organ failure despite treatment.
- Type recognition: hypovolaemic follows bleeding, vomiting, diarrhoea or burns; cardiogenic accompanies infarction or arrhythmia with raised jugular veins; obstructive shows distended neck veins with clear lungs (tension pneumothorax, tamponade, massive PE); distributive shock gives warm flushed extremities early (sepsis, anaphylaxis) except neurogenic, which combines hypotension with bradycardia.
- Immediate nursing actions: call for help, high-flow oxygen, keep the patient supine and warm, secure two large-bore (16-18 G) cannulae, send blood group and crossmatch with cultures before antibiotics when sepsis is suspected, and hang fluids or blood as prescribed.
- Sepsis care bundle: measure lactate, draw blood cultures before antibiotics, give broad-spectrum antibiotics within one hour, give 30 mL/kg crystalloid for hypoperfusion, and start vasopressors (noradrenaline is usual) through a central line to hold MAP at 65 mmHg or above.
- Anaphylactic shock: intramuscular adrenaline 0.5 mg (0.5 mL of 1:1000) into the mid-outer thigh without delay, repeated every few minutes as needed, alongside oxygen, supine positioning and IV fluids.
- Monitor continuously: vital signs every 5-15 minutes, hourly urine output (target at least 0.5 mL/kg/hour), level of consciousness, skin perfusion, lactate trend and accurate intake-output.
Common confusion
Students anchor on blood pressure and miss the golden hour of compensation: a tachycardic, anxious, clammy patient with normal pressure is already in shock and most salvageable. Warm skin is another trap — it suggests distributive (septic or neurogenic) rather than improving perfusion. Finally, neurogenic shock reverses the classic pattern with bradycardia instead of tachycardia, because sympathetic outflow to the heart is lost.
Exam-focused takeaway
Prioritisation questions dominate: what first in a bleeding or septic patient — oxygen, call for help, large-bore access, fluids per protocol. MCQs test the stages and their signs, the four types with discriminating features, the one-hour sepsis rules and adrenaline dose and route in anaphylaxis. Long answers want the classification, stages and nursing management of shock.
Frequently asked questions
Why can blood pressure be normal in early shock?
Sympathetic compensation — vasoconstriction and tachycardia — maintains pressure while tissue perfusion is already failing. Rising pulse, cool skin, oliguria and restlessness are the earlier signs.
What are the four main types of shock?
Hypovolaemic from volume loss, cardiogenic from pump failure, obstructive from mechanical blockade (tension pneumothorax, tamponade, massive embolism) and distributive from vasodilation (septic, anaphylactic, neurogenic).
How is septic shock treated within the first hour?
Lactate measurement, blood cultures before antibiotics, broad-spectrum antibiotics within one hour, 30 mL per kilogram crystalloid for hypoperfusion, and noradrenaline to keep MAP at 65 mmHg or above.
How is anaphylactic shock managed?
Adrenaline 0.5 mg of a 1:1000 solution intramuscularly into the mid-outer thigh immediately, repeated every five minutes as required, with oxygen, supine positioning, the trigger stopped and IV fluids. Antihistamines and steroids are adjuncts only.