Study topic
Shock and sepsis
NCLEX shock chapter: early hypovolemic and septic cues, fluid then pressor escalation, ARDS hypoxemia, and anaphylaxis with epinephrine first.
Shock questions ask whether you can name the perfusion problem, catch it early, and put the right first drug or fluid move in front of comfort care. Sepsis, classic shock types, ARDS, and anaphylaxis share that same urgency.
What shock looks like early
Blood pressure can lag. Restlessness, anxiety, thirst, tachycardia, and tachypnea are often the first usable warnings. Cool, clammy skin fits hypovolemic and many cardiogenic pictures. Warm flushed skin can appear in early septic (distributive) shock. Bradycardia with warm dry skin after spinal injury is a different map entirely.
| Type | Driver | Exam fingerprint |
|---|---|---|
| Hypovolemic | Volume loss (bleed, fluid loss) | Tachycardia, cool clammy skin, flat picture of volume; stop loss + replace volume |
| Cardiogenic | Pump failure | Shock with pulmonary congestion / weak pump signs; fluids are not the blunt answer |
| Distributive: septic | Infection + vasodilation | Infection source, fever/hypothermia, confusion, lactate up, often warm early |
| Distributive: anaphylactic | IgE-mediated massive release | Minutes after allergen: airway swelling, wheeze, hives, hypotension |
| Distributive: neurogenic | Loss of sympathetic tone | Hypotension + **bradycardia** + warm dry skin after spinal injury |
| Obstructive | Block to flow (PE, tamponade, tension pneumo) | Shock plus the specific obstruction cues; fix the obstruction |
If there is no contraindication, a common supportive position in hypotensive shock is legs elevated to help venous return. Do not force Trendelenburg positions that worsen breathing or head injury protocols.
Sepsis and septic shock
Suspect sepsis when infection collides with systemic instability: high or low temperature, fast heart and respiratory rates, new confusion, and often elevated lactate. Hypotension that persists after adequate fluids is septic shock territory.
- Recognize and escalate early. New confusion plus infection vitals is not “wait and see.”
- Obtain cultures when they will not delay the first antibiotic dose.
- Start broad antibiotics promptly per order once the pathway is triggered.
- Give the ordered crystalloid bolus (commonly framed as about 30 mL/kg in septic shock protocols; follow the order/protocol in front of you).
- If MAP remains critically low after adequate volume, anticipate a vasopressor (norepinephrine is a common first-line).
- Reassess: mentation, MAP, urine output, lactate trend, and skin perfusion tell you if the client is improving.
Safety
Do not withhold the first antibiotic solely to chase a perfect culture set if the client is crashing. Get what you can without delaying the dose, then keep hunting the source.
ARDS in the shock lane
ARDS shows up as refractory hypoxemia: SpO2 stays dangerously low despite high inspired oxygen, with bilateral infiltrates and severe work of breathing. This is critical-care oxygenation failure. Report and escalate; nasal cannula tweaks alone will not rewrite the picture.
Anaphylaxis and allergy safety
Minutes after a drug, food, latex, or sting: lip/tongue swelling, wheezing, hives, and falling blood pressure means anaphylaxis. Stop the infusion or remove the trigger. Intramuscular epinephrine is the first medication expectation. Airway support and IV access follow. Antihistamines and steroids are adjuncts, not the opening move when the airway and pressure are failing.
- Hives and itching after a new medicine: stop the drug, assess airway and vitals, notify. Do not “finish the bag slowly.”
- Charted penicillin allergy with a penicillin-class order: hold and clarify before giving.
- Severe food allergy teaching: carry epinephrine, avoid the allergen, teach when to use the auto-injector. “Just take an antihistamine if exposed” is the wrong primary plan.
- Latex allergy: screen for cross-reactive foods such as banana, avocado, kiwi, and chestnut when the history fits.
- Diphenhydramine teaching: expect sedation; plan for safety with driving and fall risk.
Priority map
| Picture | First move |
|---|---|
| Trauma bleed + cool clammy + low BP | Stop loss / volume / oxygen / escalate |
| Infection + confusion + lactate up + hypotension | Sepsis pathway: cultures-as-able, antibiotics, fluids, then pressor if MAP stays low |
| Spinal injury + low BP + HR 50s + warm dry | Neurogenic shock map; support BP per protocol, protect spine |
| Wheeze + lip swelling + hypotension after drug/sting | Stop trigger; IM epinephrine |
| SpO2 stuck low on high O2 + bilateral whiteout | ARDS pathway; critical oxygenation support |
Must know
- 1Shock = inadequate tissue perfusion. Early cues often beat a low BP: restlessness, anxiety, tachycardia, tachypnea, cool clammy skin (except some distributive states).
- 2Hypovolemic shock from bleeding: stop the loss you can, large-bore IV access, volume replacement, oxygen, escalate. Position with legs elevated if no contraindication.
- 3Sepsis suspicion: infection plus fever or hypothermia, tachycardia, tachypnea, new confusion, and often rising lactate. Do not wait for every culture result to start the pathway.
- 4Septic shock after adequate fluid boluses with MAP still low: expect a vasopressor, commonly norepinephrine, per protocol.
- 5Cultures before antibiotics when it will not delay the first dose. Fluids and source control still matter.
- 6Neurogenic shock: hypotension with bradycardia and warm, dry skin after spinal injury. That is not classic hypovolemic “cool and clammy.”
- 7ARDS: severe dyspnea with SpO2 that stays low despite high oxygen, and bilateral infiltrates. Treat as a critical oxygenation failure.
- 8Anaphylaxis: lip/tongue swelling, wheezing, hives, hypotension → stop the trigger, give IM epinephrine first, support airway, then antihistamine/steroid adjuncts as ordered.
- 9Documented penicillin allergy + penicillin-class order: hold and clarify. New hives after a drug: stop the infusion and assess.
- 10Latex allergy: ask about cross-reactive foods (banana, avocado, kiwi, chestnut are classic associations).
Memory hooks
Epi before Benadryl
Airway swelling and shock from anaphylaxis get intramuscular epinephrine first. Antihistamines help hives; they do not replace epinephrine.
Warm dry slow = neurogenic
After spinal cord injury, low BP with a slow heart rate and warm dry skin points to neurogenic shock, not blood loss alone.
Fluids then squeeze
In septic shock, give the ordered fluid challenge first. If MAP stays critically low after adequate volume, add a vasopressor.
How it's tested
Stems pair infection with lactate and hypotension, trauma bleeding with cool clammy skin, spinal injury with bradycardia, or a new drug with wheezing and lip swelling. Distractors give antihistamine before epinephrine, withhold antibiotics until every culture returns, or treat neurogenic shock like simple volume loss only.