________________________________________________________________________ Chapter 19 Shock 13
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.1
3
DISCUSS
• Discuss the signs and symptoms that are
observed in each stage of shock in terms of
mental status, blood pressure, pulse,
respiration, urine output, skin, abdomen, and
blood glucose.
• Divide the class into three groups. Assign
each group one of the following stages of
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Describe signs
and symptoms of shock. What is the cause
of each sign or symptom?
4
DISCUSS
• Discuss the interventions used as first aid for
shock before the patient reaches a medical
facility.
• Discuss how to maintain blood flow to the
brain.
• Divide the class into small groups and have
students identify first aid treatment required
for the following shock scenarios:
• A young girl at the playground is stung
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Describe first
aid for a patient who is experiencing shock
outside of a medical facility. Assume you are
a nurse who has encountered a patient with
hypovolemic shock. What steps would you
take to provide care for that patient?
Critical Thinking Question
A patient is in the refractory stage of septic shock. What are some support and comfort
measures the nurse can implement at this point?
Discussion Guidelines: In this stage of septic shock, most physiologic changes are not
14 Chapter 19 Shock _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.1
Instructor Notes/Student Feedback
________________________________________________________________________ Chapter 19 Shock 15
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.2
Instructor Preparation
Textbook Objectives Covered
6. Explain the rationale for medical/surgical treatment of shock.
7. Assist in developing care plans for patients in each type of shock.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Guest speaker: emergency department nurse
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying the state of shock, including:
• The types of shock
• Stages of shock
• Emergency and general medical treatment for shock
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• ischemia (p. 304)
• metabolic acidosis (p. 304)
• multiple organ dysfunction
syndrome (MODS) (p. 312)
• systemic inflammatory
response syndrome (SIRS)
(p. 312)
Student Preparation
Assignments 2 hours
5
READ – Textbook (pp. 305-312)
REVIEW
• Table 19-3: Drug Therapy (p. 307)
ANSWER – Study Guide
• Part IC: 1 (p. 112)
• Part IID: 12-15, 17 (p. 113)
• Part IIIE: 4, 5, 7 (p. 114)
6
READ – Textbook (pp. 305-312)
ANSWER – Study Guide
• Part IID: 16 (p. 113)
• Part IIIE: 10 (p. 115)
7
READ – Textbook (pp. 305-312)
ANSWER – Study Guide
• Part IIIE: 3, 9 (p. 114)
16 Chapter 19 Shock _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.2
Lecture Outline 20 minutes
• Oxygen delivery such as increasing arterial oxygen saturation, hemoglobin, and cardiac
5
&
Oxygenation
• Brain cells begin to die after 4 minutes without oxygen, and oxygen consumption
increases as delivery decreases in shock: poor prognosis
Fluid Replacement
• Normal saline is usually administered initially
• Subsequent fluids may include various crystalloids and colloids depending on situation
TALKING POINTS:
• Except for cardiogenic shock, all types of shock require significant fluid volume
replacement.
• The hemorrhaging patient will require blood to replace deficient hemoglobin.
Pharmacologic Therapy
• Based on manipulation of the cardiac dynamics: contractility, preload, afterload, and heart
rate
Slide 30
Mechanical Management
• Management of shock may include the use of mechanical devices that assist in the
restoration of cellular perfusion
TALKING POINTS:
• What mechanical devices may be used to manage shock?
• MAST garment. A, Compartments allow compression of the legs and the abdomen. B,
Garment in place. Compartments are inflated with a foot pump.
7
Slide 31
Assessment
• Continuous monitoring of cardiac rate and rhythm; blood pressure; body temperature;
hemodynamic values; respiratory rate, rhythm, and depth; and arterial blood gases
• Observe skin color; palpate for warmth and moisture
________________________________________________________________________ Chapter 19 Shock 17
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.2
Assessment (cont.)
• Observe movement of the chest wall with respirations; inspect and palpate abdomen for
distention
Slide 33
Nursing Diagnosis and Nursing Interventions
• The primary nursing diagnosis for all patients in shock is Altered tissue perfusion
Slide 34
Ineffective Tissue Perfusion
• Assessment must include all body systems
• If not corrected, shock eventually results in failure of all major organs
Decreased Cardiac Output
• Administer intravenous fluids as ordered
• Assess for fluid volume deficit and excess
TALKING POINTS:
• Continuous cardiac monitoring enables the nurse to assess the effectiveness of the drugs.
• How can the nurse reduce a patient’s oxygen requirements?
Slide 36
Disturbed Thought Processes and Anxiety
• May be anxious, then confused and disoriented, and finally unconscious
• Remain calm; give simple explanations of what is being done
• Protect patient from constant, excessive noise and light
Slide 37
Deficient Fluid Volume
• Monitor for hypovolemia
• Tachycardia, hypotension, tachypnea, decreased urine output, and decreased central
venous pressure and pulmonary artery pressure
• Administer intravenous fluids cautiously while assessing urine output
TALKING POINTS:
• When should the physician be notified about a decreasing urine output?
18 Chapter 19 Shock _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.2
Slide 38
Risk for Injury
• Related to changes in consciousness
• Related to therapeutic measures
• Antidysrhythmics can depress cardiac activity
• Anticoagulants can permit excessive bleeding
TALKING POINTS:
• Closely monitor the patient for both therapeutic and adverse effects of drugs used to treat
the patient in shock.
• What measures should be instituted to prevent pressure ulcers?
Slide 39
Risk for Infection
• IV lines, indwelling urinary catheters, chest tubes, airways, ventricular assist devices, and
other equipment provide avenues for infection in patient in shock
• Wash your hands thoroughly between patients
• Follow agency guidelines for care of IV and urinary catheters
TALKING POINTS:
• Which patients have the greatest risk for infection?
• What are the signs of infection?
Ineffective Family Coping
Slide 41
Systemic Inflammatory Response Syndrome (SIRS)
• Generalized inflammation that threatens vital organs
• Conditions that can lead to SIRS are shock, multiple transfusions, massive tissue injury,
burns, and pancreatitis
• Effects are damage to the endothelium of blood vessels and a hypermetabolic state
Diagnosis
• Diagnosis of SIRS is made when a patient manifests two or more of the following:
• Temperature less than 97° F (36° C) or more than 100.4° F (38° C)
________________________________________________________________________ Chapter 19 Shock 19
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.2
Slide 43
SIRS Manifestations
• Range from mild to severe
• Sepsis
• A patient has SIRS with a confirmed infection
• Advanced SIRS and failure of more than one organ
• Deterioration of cardiac, pulmonary, renal, and central nervous systems, liver,
Medical Treatment and Nursing Interventions
• Prevent and treat infection
• Monitor potential sites; assess for signs and symptoms
Slide 45
Medical Treatment and Nursing Interventions (cont.)
• Maintain tissue oxygenation
• Administer sedatives and analgesics as ordered to reduce oxygen requirements
• Monitor the patient on mechanical ventilation
Slide 46
Medical Treatment and Nursing Interventions (cont.)
• Support failing organs
• Mechanical ventilation for respiratory distress syndrome
• Replacement therapy for renal failure
Activities
Classroom Choose from below to make 30 minutes
Online
5
DISCUSS
• Discuss how to achieve adequate
oxygenation of the patient in shock.
• Divide the class into small groups and have
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Compare and
contrast interventions for patients in each
20 Chapter 19 Shock _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.2
6
DISCUSS
• Discuss general principles for the positioning
of the patient in shock and why positioning is
important.
• Discuss why fluid replacement is important
in the treatment of most types of shock.
• Invite an emergency department nurse to
and surgical interventions.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Discuss why
oxygenation to improve blood flow is so
important in the treatment of shock.
7
DISCUSS
• Discuss the various types of shock, listing
their characteristics and the common
interventions used for each including drug
therapy.
• Discuss mechanical devices used for
treating shock.
• Discuss the possible complications of shock.
• Discuss four signs that are used to diagnose
SIRS. How many of these are needed to
diagnose SIRS?
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Discuss
factors to consider when monitoring patients
for therapeutic, as well as adverse effects,
associated with drugs used to treat shock.
Critical Thinking Question
A nurse has been hiking with some friends in a national park. The group encounters a young
adult who is disoriented to time and is complaining of difficulty breathing and fatigue. He
says that he has been hiking for a long time and has run out of water. His skin is cool and
diaphoretic. The nurse checks his pulse and finds that it is weak and rapid and suspects
that he may be experiencing signs and symptoms of shock. What should the nurse do next?
________________________________________________________________________ Chapter 19 Shock 21
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 19.2
Instructor Notes/Student Feedback
22 Chapter 19 Shock _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
19
Assessments for
Shock
CHAPTER 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.
Assessments by Lesson & Objective
Lesson 19.1
1
Study Guide
• Part IID: 2-5 (p. 112)
• Part IIIE: 2 (p. 114)
Evolve Instructor Resources
• Test Bank: 1, 14, 25
Evolve Student Resources
• NCLEX Review: 4-6
2
Study Guide
• Part IA: 1-6 (p. 111)
Evolve Instructor Resources
• Test Bank: 2, 5, 8, 13, 15, 25, 26
3
Study Guide
• Part IB: 1-4 (pp. 111-112)
Evolve Instructor Resources
• Test Bank: 3, 4, 9, 20
Evolve Student Resources
• NCLEX Review: 1, 3
4
Study Guide
• Part IIIE: 1 (p. 114)
Evolve Instructor Resources
• Test Bank: 10
________________________________________________________________________ Chapter 19 Shock 23
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
Lesson 19.2
5
Study Guide
• Part IC: 1 (p. 112)
Evolve Instructor Resources
• Test Bank: 16, 17, 19
Evolve Student Resources
• NCLEX Review: 7, 9
• Prioritization: 1-3
6
Study Guide
• Part IID: 16 (p. 113)
• Part IIIE: 10 (p. 115)
Evolve Instructor Resources
Evolve Student Resources
• NCLEX Review: 2
7
Study Guide
• Part IIIE: 3, 9 (p. 114)
Evolve Instructor Resources
• Test Bank: 6, 12, 24, 27
Instructor’s Notes/Student Feedback