Introduction to Medical-Surgical Nursing, 6th ed.
19
Lesson Plans for
Shock
CHAPTER LESSON PLANS & OBJECTIVES
Lesson 19.1:
2. Describe the pathophysiology of each type of shock.
4. Explain the first aid emergency treatment of shock outside the medical facility.
Lesson 19.2:
6. Explain the rationale for medical-surgical treatment of shock.
7. Assist in developing care plans for patients in each type of shock.
CHAPTER TEACHING FOCUS
• In this chapter, students will have the opportunity to learn about the pathophysiology of shock, the
various kinds of shock, and nursing interventions for each type. The chapter includes information on
the stages of shock and the consequences of untreated shock. Furthermore, students will have the
opportunity to learn specific medical treatments for each kind of shock.
CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2013).
THEME: Oxygenation and Hemostasis
• Concept: Perfusion
• Exemplar: Shock, p. 301
THEME: Protection and Movement
• Concept: Immunity
• Exemplar: Anaphylactic Shock, p. 302
• Exemplar: Systemic Inflammatory Response Syndrome, p. 310
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Introduction to Medical-Surgical Nursing, 6th ed.
CHAPTER PRETEST
Have the students answer these questions prior to covering this chapter to understand where they stand
in relation to the content.
1) Multiple organ dysfunction syndrome is a direct consequence of __________.
a) fluid overload
b) failure of one or more organs
c) poor body alignment
d) organ donor status
2) A 12-year-old child was brought to the emergency department for difficulty breathing within 30
minutes of being stung by a wasp in the school playground. This child is likely having the signs and
symptoms of __________.
a) cardiogenic shock
b) hypovolemic shock
c) septic shock
d) anaphylactic shock
3) The most likely cause of septic shock is __________.
a) bacterial, fungal, or viral infection
b) brain or spinal cord trauma
c) pulmonary embolism
d) severe allergic drug reaction
4) Confusion typically occurs during which stage of shock?
a) Compensatory stage
b) Hypovolemic stage
c) Progressive stage
d) Distributive stage
5) The signs and symptoms of shock can vary and depend on the __________.
a) underlying cause of the shock
b) patient’s cultural background
c) patient’s history of drug allergies
d) antibiotics used to treat the underlying infection
6) MAST trousers can be used to __________.
a) treat septic shock
b) prevent hypovolemic shock from severe blood loss
c) correct acid base disturbances in renal failure
d) maximize ventilatory effort and lung compliance
7) In the irreversible or refractory stage of shock, the patient commonly exhibits __________.
a) an increased respiratory rate and depth
b) irritability and confusion
c) an increased pulse rate
d) minimal urine output
8) Which of the following is an alpha-adrenergic agonist?
a) Norepinephrine
b) Dobutamine
c) Propranolol
d) Digoxin
9) The psychosocial effects of hypoxia and cardiogenic shock can include __________.
a) anxiety
b) impaired tissue perfusion
c) altered family compliance
d) medication teaching
10) Sodium bicarbonate is administered to a patient in cardiogenic shock to correct __________.
a) potassium excess
b) heart failure
c) pulmonary distress
d) metabolic acidosis
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Introduction to Medical-Surgical Nursing, 6th ed.
Chapter Pretest Answers
CHAPTER BACKGROUND ASSESSMENT
Discuss these questions with your students prior to covering this chapter to understand where they stand
in relation to the content.
Question: What are the signs and symptoms of hypovolemic shock?
Question: In distributive shock, the problem is not blood loss but improper blood volume distribution.
How does this occur in the case of septic shock?
Answer: Pathogens such as bacteria, fungi, or viruses enter the bloodstream and release toxic substances.
4 Chapter 19 Shock _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.1
Textbook Objectives Covered
2. Describe the pathophysiology of each type of shock.
4. Explain the first aid emergency treatment of shock outside the medical facility.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Guest speaker: critical care clinical nurse specialist
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying the state of shock, including:
• The types of shock
• Assemble materials and supplies needed for each lesson as indicated below.
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• ischemia (p. 304)
• systemic inflammatory
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.1
Student Preparation
Assignments 2 hours
1
READ – Textbook (pp. 301-303)
ANSWER – Text
• Review Questions for the NCLEX Examination: 1, 2 (p. 313)
ANSWER – Study Guide
2
READ – Textbook (pp. 301-303)
REVIEW
• Figure 19-1: Intraaortic balloon pump (p. 306)
• Table 19-1: Obstructive Shock (p. 302)
• Table 19-2: Compensatory Mechanisms in Shock (p. 304)
ANSWER – Text
• Review Questions for the NCLEX Examination: 3, 4 (p. 313)
ANSWER – Study Guide
• Part IA: 1-6 (p. 111)
• Part IID: 1, 6-8 (pp. 112-113)
3
READ – Textbook (pp. 303-305)
ANSWER – Text
• Review Questions for the NCLEX Examination: 5, 6, 8–10 (pp. 313-314)
ANSWER – Study Guide
4
READ – Textbook (p. 305)
REVIEW
• Box 19-1: Assessment in First Aid for the Patient in Shock (p. 305)
ANSWER – Text
• Review Questions for the NCLEX Examination: 7 (p. 314)
ANSWER – Study Guide
• Part IIIE: 1 (p. 114)
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.1
50-Minute Lesson Plan
Lecture Outline 20 minutes
Slide 1
Chapter 19
Shock
1
&
2
Slide 2
Definition of Shock
• Inadequate tissue perfusion resulting in impaired cellular metabolism
• Deprives cells of essential oxygen and nutrients, forcing cells to rely on anaerobic
(without oxygen) metabolism
• Less energy is produced
• Lactic acid causes tissue acidosis and subsequent organ dysfunction
TALKING POINTS:
Slide 3
Types of Shock
• Hypovolemic
• Cardiogenic
• Obstructive
• Distributive
Slide 4
Hypovolemic Shock
• Inadequate blood volume to maintain the supply of oxygen and nutrients to body tissues
• Intravascular or circulating volume deficits can occur from external or internal losses
TALKING POINTS:
• Point out common activities that can lead to volume depletion (i.e., dehydration, exercise,
extreme temperatures, trauma, etc.)
Slide 5
Cardiogenic Shock
• Occurs when heart fails as a pump
• Decreased myocardial contractility causes decreased cardiac output and impaired tissue
perfusion
• Difficult to treat and usually results when diseased coronary arteries cannot meet the
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.1
Slide 6
Obstructive Shock
• Physical impairment of adequate circulating blood flow
• Obstruction of the heart or great vessels either blocks venous return to the right side of
the heart or prevents effective pumping action
• Causes
• Tension pneumothorax
• Pericardial tamponade
TALKING POINTS:
• Conditions that lead to obstructive shock impede blood flow from the heart.
Slide 7
• Complicated by increased capillary permeability; plasma leaks into interstitial
compartment, decreasing intravascular blood volume
Distributive Shock
• The problem is not loss of blood but excessive dilation of blood vessels or decreased
vascular resistance, causing the blood to be improperly distributed
Slide 8
Distributive Shock (cont.)
• Anaphylactic shock
• A severe allergic reaction that results in the release of chemicals that dilate blood
vessels and increase capillary permeability
• Fluid leaks out of capillaries into the tissues
TALKING POINTS:
• What are some substances that people can be allergic to?
• The onset of anaphylaxis is typically sudden and dramatic following exposure to a
substance to which the patient has developed antibodies.
Slide 9
Distributive Shock (cont.)
• Septic shock
• Hypotension unresponsive to fluid resuscitation along with metabolic acidosis, acute
encephalopathy, oliguria, and/or coagulation disorders
• Pathogenic organisms (bacteria, fungi, viruses, rickettsiae) release toxic substances
TALKING POINTS:
• Sepsis is a systemic inflammatory response to a documented or suspected infection;
sepsis can progress to septic shock.
8 Chapter 19 Shock _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.1
Slide 10
Distributive Shock (cont.)
• Neurogenic shock
• Disruption in the nervous system affects the vasomotor center in the medulla
• Disrupted sympathetic nerve impulses result in vasodilation or loss of vascular
resistance
• Signs and symptoms: pooling of blood in peripheral tissues with subsequent
decreased venous return and cardiac output; bradycardia with hypotension
• Causes
TALKING POINTS:
• In neurogenic shock, what is the result of disturbances that disrupt sympathetic nerve
impulses?
2
Slide 11
Effects of Shock on Body Systems and Functions
• Respiratory system
• Tissue hypoxia and anoxia, respiratory failure, acute respiratory distress syndrome
(ARDS)
• Acid-base balance
• Metabolic acidosis
• Cardiovascular system
Effects of Shock on Body Systems and Functions (cont.)
• Neuroendocrine system
• Release of catecholamines (epinephrine and norepinephrine), mineralocorticoids
Effects of Shock on Body Systems and Functions (cont.)
• Gastrointestinal system
• Decreased peristalsis, ischemia of intestinal submucosa, impaired liver function
3
Slide 14
Early, Reversible, and Compensatory Stages
• Continued reduction in cardiac output triggers set of neural, endocrine, and chemical
compensatory mechanisms in an effort to overcome the consequences of anaerobic
metabolism and maintain blood flow to vital organs
• During this stage the following may occur
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.1
Slide 15
Early, Reversible, and Compensatory Stages (cont.)
• Events
• Decreased renal blood flow triggers the release of renin and a sequence of events
that produces angiotensin II
• Adrenal cortex secretes aldosterone, which promotes sodium retention by the kidneys
Slide 16
Early, Reversible, and Compensatory Stages (cont.)
• Symptoms
• Mental status
• Irritability, restlessness
• Blood pressure
• Normal or slightly decreased, decreasing pulse pressure, orthostatic hypotension
• Pulse
Slide 17
Early, Reversible, and Compensatory Stages (cont.)
• Urine output
• Decreased
• Skin
• Cool and pale
• Exception: warm and dry with septic shock
• Abdomen
TALKING POINTS:
• Shock should be assessed, identified, and treated during this stage to have the best
outcome. Delayed recognition can lead to increased complications.
10 Chapter 19 Shock _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.1
Slide 18
Progressive Stage
• Cause of shock is not corrected or if compensatory mechanisms continue without
reversing the shock
• Neural, endocrine, chemical compensatory mechanisms begin to function independently
and in opposition
Slide 19
Progressive Stage (cont.)
• Symptoms
• Mental status
• Listlessness, confusion
Slide 20
Progressive Stage (cont.)
• Temperature
• Subnormal, except with septic shock
• Urine output
weakness
TALKING POINTS:
• What is MODS?
• Shock must be identified during this stage, if it has not been identified yet. Otherwise it will
shock.
Refractory Stage
• Irreversible changes in vital organs as compensatory mechanisms fail
• Tissue perfusion deteriorates, as blood remains pooled in the capillary bed where
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.1
Slide 22
Refractory Stage (cont.)
• Symptoms
• Mental status
• Loss of consciousness
• Blood pressure
• Systolic continues to fall; diastolic approaches zero
Diagnosis
• Based on history and physical examination
• Tests and procedures that help establish type of shock, stage, and the cause
4
Slide 24
First Aid for Shock Outside the Medical Facility
• Treatment provided before medical care is available can have a significant effect on the
chances of survival
• Healthy People 2020 objectives (2000): the necessity for increasing public awareness of
TALKING POINTS:
• What first aid interventions should be performed for the patient in shock?
Slide 25
Question 1
• The type of shock that is caused by physical impairment is __________.
A. Hypovolemic
B. Cardiogenic
C. Obstructive
D. Septic
TALKING POINTS:
12 Chapter 19 Shock _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.1
Slide 26
Question 2
• Which of the following is a true statement about the effects of shock on body systems and
functions?
A. Metabolic alkalosis
B. Increased glomerular filtration
C. Absorption of catecholamines and mineralocorticoids
D. Decreased peristalsis
Activities
Classroom Choose from below to make 30 minutes
Online
1
ASSESS BASELINE
• Have the class complete the Pretest. Collect
their work and use the results to guide how
you teach the class.
DISCUSS
• Discuss the various kinds of shock and
possible complications if shock is allowed to
progress.
• Invite a critical care clinical nurse specialist to
address the class and present current
ASSESS BASELINE
• Post the Pretest and the Background
Assessment online and have your class
complete them. Use the results to guide how
you teach the class.
2
DISCUSS
• Discuss the causes of the various types of
shock.
• Discuss what occurs in the body systems
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Describe the
effects of shock on the body. How can the
nurse work to identify changes in the body