Multiple Organ Dysfunction Syndrome
The initial assessment is geared toward the ABCs: airway, breathing, and circulation.
Further assessment focuses on the assessment of tissue perfusion and includes evaluation
of vital signs, peripheral pulses, level of consciousness, capillary refill, skin (e.g.,
temperature, color, moisture), and urine output.
The overall goals for a patient in shock include (1) assurance of adequate tissue
perfusion, (2) restoration of normal BP, (3) return/recovery of organ function, and (4)
avoidance of complications from prolonged states of hypoperfusion.
o To prevent shock, the nurse needs to identify patients at risk (e.g., patients who are
older, those with debilitating illnesses, those who are immunocompromised, surgical
or accidental trauma patients).
o Planning is essential to help prevent shock after a susceptible individual has been
identified (e.g., monitoring fluid balance to prevent hypovolemic shock, maintenance
of hand washing to prevent spread of infection).
o The role of the nurse in shock involves (1) monitoring the patient’s ongoing physical
and emotional status to detect subtle changes in the patient’s condition; (2) planning
and implementing nursing interventions and therapy; (3) evaluating the patient’s
response to therapy; (4) providing emotional support to the patient and family; and
(5) collaborating with other members of the health team when warranted by the
o Neurologic status, including orientation and level of consciousness, should be
assessed every hour or more often.
o Heart rate/rhythm, BP, central venous pressure, and PA pressures including
continuous cardiac output (if available) should be assessed at least every 15 minutes
and PAWP every 1 to 2 hours.
Trends in these parameters yield more important information than individual
Trendelenburg (head down) position during hypotensive crisis is not
supported by research and may compromise pulmonary function and increase
The patient’s ECG should be continuously monitored to detect dysrhythmias
that may result from the cardiovascular and metabolic derangements
associated with shock. Heart sounds should be assessed for the presence of an
S3or S 4ound or new murmurs. The presence of an S sou3d in an adult
usually indicates heart failure. The frequency of this monitoring is decreased
as the patient’s condition improves. o The respiratory status of the patient in shock must be frequently assessed to ensure
adequate oxygenation, detect complications early, and provide data regarding the
patient’s acid-base status.
Pulse oximetry is used to continuously monitor oxygen saturation.
Arterial blood gases (ABGs) provide definitive information on ventilation and
oxygenation status, and acid-base balance.
Most patients in shock will be intubated and on mechanical ventilation.
o Hourly urine output measurements assess the adequacy of renal perfusion and a urine
output of less than 0.5 ml/kg/hour may indicate inadequate kidney perfusion.
BUN and serum creatinine values are also used to assess renal function.
o Tympanic or pulmonary arterial temperatures should be obtained hourly if
temperature is elevated or subnormal, otherwise every 4 hours.
o Capillary refill should be assessed and skin monitored for temperature, pallor,
flushing, cyanosis, diaphoresis, or piloerection.
o Bowel sounds should be auscultated at least every 4 hours, and abdominal distention
should be assessed.
If a nasogastric tube is inserted, drainage should be checked for occult blood
as should stools.
o Oral care for the patient in shock is essential and passive range of motion should be
performed three or four times per day.
o Anxiety, fear, and pain may aggravate respiratory distress and increase the release of
The nurse should talk to the patient, even if the patient is intubated, sedated, and paralyzed or
appears comatose. If the intubated patient is capable of writing, a “magic slate” or a pencil and
paper should be provided.
Family and significant others (1) link the patient to the outside world; (2)
facilitate decision-making and advise the patient; (3) assist with activities of
daily living; (4) act as liaisons to advise the health care team of the patient’s
wishes for care; and (5) provide safe, caring, familiar relationships for the
patient. Family time with the patient should be facilitated, provided this time
is perceived as comforting by the patient.