Shock is a life threatening condition defined as an acute clinical event precipitated by reduced tissue perfusion caused by reduced circulatory output, failure of the heart to pump effectively and a massive peripheral vasoconstriction .These lead to a point where the circulatory volume is insufficient to meet the oxygen and nutrient requirements of tissues .(Kneale 2003)
Quickly identifying the type of shock and ensuring correct aggressive treatment are key to patient survival.
Hypovolaemic shock is caused by an inadequate intravascular volume, which can be caused by loss of blood or other body fluids. This type of shock is usually seen after soft tissue trauma, burn injuries, vomiting, diarrhoea or bleeding. (Mower- Wade 2000) It is important for nurses to prevent Hypovolaemic shock by closely monitoring patients who are at risk and restore the fluid lost with adequate fluid replacement therapy before intravascular volume is depleted. Hypovolaemic shock begins to develop after 15% intravascular blood loss. This is known as the compensatory phase. (Muhlberg et al, 2004) This is when symptoms of Hypovolaemic shock will begin to appear. It is vital that the nurse can identify clinical presentation and respond promptly based on good understanding of the physiology of shock as in the compensatory phase, hypovolaemic shock will not manifest in adults making it harder to diagnose. (Kneale, 2003)
When nursing a patient with Hypovolaemic shock, psychological care is needed, good verbal communication and information relating to the effects of their injury are essential in providing the appropriate care in their condition as well as supporting the family also. (Kneale, 2003)
Preparation of the Emergency Department:
John Palmer, a 50 year old man sustained a stab wound to the spleen following an alleged assault in a public house. Ambulance control have advised the Emergency department (ED) that they are now transferring the patient in Hypovolaemic shock to the ED with an estimated time of arrival (ETA) of 20 minutes.
The paramedics have informed the ED that they are transferring the patient already in hypovolaemic shock. This gives a clear indication that there has been already a significant amount of blood loss. Hypovolaemic shock begins to develop after 15% intravascular blood loss, equivalent to 750mls and is known as the compensatory phase, this is when the first real symptoms occur. If the compensatory phase is not interrupted, progression of shock results in exhaustion of the compensatory mechanisms and progression to the decompensate phase. Failure to interrupt this progression eventually leads to the irreversible shock phase, leading to organ system failure and death. (Carlson, 2009)
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The nurse announced a code T over the hospital paging system, signalling the trauma team to assemble. Immediately, emergency personnel, trauma nurses, trauma physicians and anaesthetists, and other specially educated staff gathered in the resuscitation bay awaiting arrival of their patient by ambulance. (Muhlberg et al, 2004) This is where the Nurse Manager assigns jobs to the staff to prepare for the arrival of patient.
The resuscitation area should be prepared in the 20 minutes before the patient arrives with double checks on the arrest trolley, airway management sets and intravenous sets as well as a stand for the fluid and blood which will be needed to stabilise the patient as he is in hypovolaemic shock. Also, all the monitors for vital signs must be checked to be in working order as well as the respiratory monitors such as the oxygen and suctioning equipment. These should all be at hand and in working order when the patient arrives.
On arrival to the emergency department, the paramedics handed over john had already lost significant amounts of blood due to a laceration to the spleen evidenced by tachycardia, pale skin colour, weak peripheral pulses and delayed capillary refills to all extremities. This evidenced by hypovolaemic shock. (Radcliffe, 1999)
Knowing that the spleen is located in the left hypochondrial region of the abdomen and contains up to 350ml of blood which can prove to be a major source of blood loss for the patient, the nurse and physician should be prepared to treat the shock on arrival to the ED. (Ross and Wilson, 2006)
Due to the large blood loss and area of laceration, it is more than likely the patient will be hypotensive on arrival to the ED. As the shock develops the patient will also start showing clinical signs and symptoms of respiratory, cardiovascular, renal, neurological problems as well as a deterioration in skin conditions. This is the role of the nurse to assess these vital signs to identify the signs and symptoms of shock. (Edward, 1999)
It is the nurse and physician’s job to haemodynamically stable the patient before surgical intervention occurs. (Roth, 2005)
Assessment, Therapeutics and Support.
On arrival to the emergency department, the paramedics handed over john had already lost significant amounts of blood due to a laceration to the spleen evidenced by tachycardia, pale skin colour, weak peripheral pulses and delayed capillary refills to all extremities. This evidenced by hypovolaemic shock. (Radcliffe, 1999)
When being assessed within the emergency department, John was connected to a cardiac monitor and pulse oximetry to closely monitor his condition. These assessments must be carried out by the ED nurse upon arrival to the ED. (Muhlberg et al, 2004)
Johns vital signs are heart 146, BP: 87/59, respiration rate was 22 per minute and shallow, Spo2: 89% on room air, and temperature 34 degree Celsius. The cardiac monitor showed sinus tachycardia.
Warmed blankets were placed on John and he was immediately placed on 15 litre o2 via non re-breather mask. His Spo2 increases to 98%. The blood pressure cuff was place on opposite arm of the pulse oximetry to avoid vasoconstriction as if it was on the same arm it can give inaccurate pulse oximetry readings. (Mower- Wade et al, 2000)
Respiratory Assessment and Intervention
The initial intervention was aimed at optimizing oxygen delivery to all organs. As John was able to talk to the nurse and answer simple questions about him, this established his airway was patent. 15 litre oxygen therapy was administered through a non-rebreathable mask as prescribed, a mask or nasal cannula could also be used, to optimize ventilation in order to combat insufficient oxygen distribution to the tissues of the body. (Jones.1996). Over use of oxygen therapy can damage the bronchial mucosa and cilia. Humidification of the oxygen was undertaken to prevent secondary problems, such as pneumonia as well as promoting the expectoration of secretions. (Pikingston, 2004) Due to this, the patient will need regular mouth care to keep the mouth moist as the patient will be nil by mouth in case of surgical intervention.(Collins, 2000).Peripheral oxygen saturation was closely monitored using pulse oximetry and the nurse was aware of changes that could indicate hypoxia. Although, this cannot be solely relied on as the patient may have inadequate tissue perfusion and pulse oximetry would not pick up on this. An arterial blood gas was taken, providing information on adequacy of ventilation, oxygen delivery to the tissues and acid base balance. (Bench, 2004)
Respiratory rate was closely monitored and recorded by evaluating the depth and pattern. When the rate is increasing, it is a reliant indicator of shock. This is because there will be a build up of lactic acid in the body due to the production of ATP, caused by inadequate delivery of oxygen to the cells. Respiratory rate increases to rid the body of these toxins and also to try increase tissue oxygenation. (Hand, 2001)
The respiratory rate, rhythm and depth were monitored, which indicate air hunger, accessory muscle use and tachypnoea. (Newberry, 2002)
Cardiovascular Assessment and Intervention.
Heart rate was closely monitored as it would increase responding to falling blood pressure. A slight increase in heart rate leading to tachycardia is designed to compensate for initial reductions of blood volume but as the shock progresses heart rate will drop. (Kneale, 2003). The fight or flight response increases the rate and force of the hearts contractions and vasoconstriction. The compensatory mechanism will maintain blood pressure with as much as 1,500 mls of blood or fluid lost. John’s blood pressure was closely monitored although the nurse was aware that it is not a reliable indicator of his condition. Central Venous pressures are required. (Sheppard & Wright, 2000)
The management of circulation is focused on increasing circulating volume and cardiac output through IV crystalloids, colloids or blood transfusion. Bench (2004:716) states “As the aetiology of hypovolaemic shock is related to fluid loss, fluid replacement is clearly the most appropriate form of treatment to instigate”
Fluids must be prescribed by a physician. It is important the nurse knows the implications of different types of fluids. They also must be competent in administering such fluids and evaluating their effectiveness.
In initial fluid resuscitation, two large bore peripheral cannulas were inserted allowing for rapid infusions of blood, drug and fluid. IV cannula care was undertaken as per hospital policy. (Bench, 2004) Pressure bags may also be used for rapid infusion of IV fluids. John was positioned with his legs elevated, trunk flat and his head and shoulders above his chest to optimize effectiveness.
John was prescribed by the physician crystalloid fluids, using the normal 3:1 ratio for fluid resuscitation, 200ml of crystalloid for every 100ml of fluid loss. (Graham CA, 2005) A common crystalloid fluid is Ringers lactate or Hartmann’s. These fluids are made up of water and electrolytes and work to expand blood volume in presence of blood loss and contain lactate which is a buffer in the presence of metabolic acidosis. Every millilitre of blood lost may require 3ml of crystalloid solution and therefore large amounts of fluid would be needed. Crystalloid replacement therapy is of limited value as it does not have oxygen carrying capabilities, leaving john susceptible to hypoxia, red blood cells would be required. Crystalloids have the advantage of being inexpensive and widely available in the clinical setting with isotonic crystalloid solutions being the mainstay of fluid resuscitation. However, nurses need to be aware of signs of overload such as peripheral and pulmonary oedema. (Gupta & Nolan, 1994)
The fluid should be warmed to prevent hypothermia, which could lead to metabolic acidosis. John’s peripheral temperature went up to 35 degrees Celsius. Core and peripheral temperature observations are required as the loss of blood leads to a lower temperature from reduced circulator heat, with potential for severe blood loss to lead to hypothermia. This is why warmed blankets were placed on john on arrival to the ED. Rapid re-warming is avoided as this risks peripheral vasodilatation, affecting the physiological compensatory mechanism. Instead gradual re-warming and the use of warmed IV fluids when large volumes of fluid replacement are required can reduce further heat loss (Kneale 2003). It was important that John’s body temperature was maintained within normal limits to prevent increasing metabolic demands that his body may have been unable to meet (Smeltzer et al, 2008).
Sheppard & Wright 2000 suggest that fluid loss up to 1500mls, Hartmann’s should be used, after that blood should be added, as mentioned before it does not have the oxygen carrying capacity.
Blood provides the necessary haemoglobin to carry oxygen to the tissues. John bloods were taken to be typed and cross matched. In this situation however, immediate transfusions of blood group 0 negative was given as it is a universal donor group while waiting on the blood results. A Blood transfusion was prescribed for John as a full blood count was taken and showed his haemoglobin level to be as low as 8. John was explained to by the ED nurse regarding the risks associated with the transfusion and was made aware of the known adverse side-effects such as infection and allergic reactions. (Hand.2001). If such clinical symptoms became evident the blood transfusion would have been stopped.
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When administering blood it is important the nurse confirms that the blood was prescribed by a physician. Checks must be carried out of the patient’s name, date of birth, hospital reference number and the expiry of the blood product with the cross-match form and the prescription chart (Royal Marsden, 2006). This must be checked by two people either another nurse or a physician.
John’s observations were assessed every 15minutes, he was monitored for signs of associated reactions such as itching, increased heart rate and pyrexia. (Oldham J et al, 2009) Normal saline was infused also to increase John’s fluid intake.
The nurse accurately recorded fluid replacement, which is essential regardless of type of fluid. The nurse constantly observed John’s blood pressure, pulse and respirations for signs of improvement to indicate the fluid resuscitation was working effectively and also observed for fluid induced complications as previously mentioned.
Neurological and Pain assessment and Intervention.
A neurological assessment was carried out; John scored 11 out of 15 on the Glasgow Coma Scale, which measures level of consciousness. It was observed that John was anxious, restless and agitated. If John became more hypoxic and cerebral perfusion decreased he would become increasingly confused, drowsy, disorientated and eventually unresponsive. The nurse focused on John’s safety and constantly reassured and re-orientated him. His level of consciousness using the Glasgow coma scale was constantly assessed.
Although fluid replacement therapy is the main treatment in managing circulation, pharmacological methods may be prescribed to increase cardiac output and myocardial contractibility. Such medications include the administration of dopamine or dobutamine. These must also be prescribed by a physician and the nurse must keep in mind of the 5 R’s when administering such medication.
The nurse should always check they have the Right patient, Right time and frequency, Right dose, Right route, and Right drug when administering medication. The nurse monitored John for symptoms of overdose by assessing him for headaches, drowsiness and hypertension. (Muhlberg et al, 2004)
Controlling pain was hugely important to help relieve John’s pain and anxiety. John was prescribed morphine via an intravenous line for direct access to blood stream. The nurse monitored for a decrease in respiratory function as well as nausea and vomiting. John was charted and given an anti-emetic to prevent him from losing more fluid. (Bench, 2004). John was assessed and monitored frequently for a response to the analgesic.
Renal Assessment and Intervention.
While fluid resuscitation was under way, the physician inserted urinary catheter, to assess for other injuries. The nurse continued to monitor vital signs, urine output, Spo2 values, cardiac rhythm and rate and temperature.
John’s urinary output is a major indicator of the stage of shock and signs of improvement. Early in shock, the kidneys are affected, renal blood flow is reduced early and so renal perfusion is affected. The glomerular filtration rate is reduced which leads to a reduction in urinary output. The body also retains water to increase circulation.
John was catheterised to ensure correct monitoring of urinary output as it is essential in adequately treating shock (Kent, 2001). The management and care of the catheter was carried out as per hospital policy. If shock is in progression, the urinary output would be less than 30ml/hr. This may signify acute renal failure. (Buckley, 1992) The nurse adequately monitored and recorded John’s urine output for signs of reduced output.
Skin Integrity
The nurse considered the maintenance of John’s skin integrity as it put at risk by poor tissue perfusion, inadequate nutritional intake and immobility. (Bench, 2004) The nurses should change the patient’s position regularly to assess pressure areas. The stab wound should be treated to prevent infection. Normal saline is the solution of choice used to cleanse and remove any dirt from the wound. (Smeltzer and Bare, 2004)
Psychological Support
The patient’s fears and anxieties should be addressed by the nursing staff regardless of the aggression he shows due to the large consumption of alcohol,
Smeltzer & Bare 2003 explains the holistic approach as caring for the patient’s body and mind together as one. John needed appropriate psychological support. Most importantly the nurse spoke to John throughout every procedure and gauged how he was feeling. The nurse gave him information on each procedure so he feels a little more in control.
It was also ensured that the family was contacted when John arrived to the ED. His sister was kept informed and supported throughout this ordeal. They were encouraged to express their feelings, concerns and worries, They were also involved where possible in decision making and patients care where appropriate.(Buckley,1992)
As shock is a life threatening condition, the nurse expected John to feel extremely anxious as there is a link between anxiety and the effects of shock on the neurological status. Medications such as lorazepam were given as prescribed for John’s anxiety and his response was assessed and monitored. He was also prescribed librium due to his large consumption of alcohol at the time of altercation. Librium is an anti-anxiety drug which helps with withdrawal symptoms from alcohol. This will be given when John’s alcohol levels are negative within his blood.
Due to the seriousness of the altercation, surgery was inevitable for John to control bleeding. This was explained to John and family, information on the surgery and the preparation details was given briefly by the physician and then re-enforced by the ED nurse. While the Physician organised the surgery and ordered an abdominal ultrasound to assess the laceration, the ED nurse allowed John and his sister to ask questions and express their concerns of same.
Reassurance was given by the ED nurse and preparation was underway.
Conclusion
Shock is defined by critical tissue hypo perfusion. It must be rapidly reversed before organ damage is sustained and irreversible.
To provide the best treatment, nurses need to recognize its clinical presentation. The nurse needs to respond appropriately and promptly. It is important to remember that if the management of shock is not addressed, the patient will progress to the irreversible shock phase and eventually death.
The nurse must have a good understanding of the physiology of hypovolaemic shock. Airway, breathing and circulation must be stabilized initially and the nurse needs to be competent in recognizing indicators of shock complications
Oxygen therapy, fluid resuscitation and pharmacology are key to the patient’s optimized recovery; the nurse must be competent in the administration of same. The nurse must also be aware of complications associated with the above treatment and be able to competently monitor and record said complications. (Hand, 2001)
Effective communication with the patient, relatives and the rest of the multidisciplinary team is vital to ensure that collaborative practice maximises the quality of patient care delivered. (Bench, 2004)
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