Cardiovascular · Topic 35 of 35
Stages of Shock
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Stages of Shock
Shock is inadequate tissue perfusion, and every type moves through the same four stages. The danger: compensation hides it, so blood pressure falls late.
Why it happens
Cells starved of oxygen switch to anaerobic metabolism and make lactic acid
The stages are shared by hypovolemic, cardiogenic, distributive (septic, anaphylactic, neurogenic) and obstructive shock; causes, specific treatment and some signs differ by type — neurogenic shock brings bradycardia with warm, dry skin, and early septic shock can bring warm, flushed skin.
The four stages
Initial → compensatory → progressive → refractory
What you'll see
Restless and fast before the pressure falls
Labs & diagnostics
Target MAP 65 mmHg or higher · urine at least 0.5 mL/kg/hr
Normal MAP is about 70–100 mmHg; in shock, an arterial line gives a more reliable MAP than a cuff.
Red flags
Prolonged hypoperfusion leads to multiple organ dysfunction syndrome (MODS); progressive-stage gut and liver injury brings GI ulceration, jaundice and rising liver enzymes.
Treatment
Secure the airway and give oxygen first
Place two large-bore IVs
Large isotonic boluses for volume loss
Cautious in cardiogenic shockTitrate to a MAP of 65 mmHg or higher
Large vein, central line preferred — extravasation causes necrosisFlat with the legs elevated
Avoid head-down TrendelenburgMore detail
Nursing priorities
Compensatory or progressive?
Is the body still holding the pressure?
| Compensatory | Progressive | |
|---|---|---|
| Blood pressure | Normal, narrowed pulse pressure | Low — MAP under 65 |
| Skin | Cool, pale | Cold, clammy, weak distal pulses |
| Mental status | Restless, anxious | Confused |
| Urine | Decreased | Under 0.5 mL/kg/hr |
| Acid-base | Lactate starting to rise | Metabolic acidosis, rising lactate |
| Lungs | Fast breathing | Crackles, pulmonary edema |
| Outlook | Reversible if the cause is treated | Organs failing — MODS risk |
Restlessness, tachycardia, tachypnea and a normal BP = compensated shock — act now. Falling BP is a late sign. Targets: MAP 65 or higher, urine at least 0.5 mL/kg/hr.
Sources · Medical-Surgical Nursing 23.1 Shock Overview (OpenStax) · Medical-Surgical Nursing 23.2 Hypovolemic Shock (OpenStax) · Shock (StatPearls) · Refractory Shock (StatPearls) · Oliguria in Critically Ill Patients (PMC) · Surviving Sepsis Campaign Guidelines 2021 (PMC) · Levophed Label (DailyMed) · Follow your facility's protocol for vasopressor titration.
Stages of Shock
Shock is inadequate tissue perfusion, and every type of shock moves through the same four stages: initial, compensatory, progressive, and refractory. In the initial stage the change is inside the cells, which switch to anaerobic metabolism and start making lactic acid while the vital signs barely move. In the compensatory stage the sympathetic nervous system, the renin-angiotensin-aldosterone system, and ADH speed the heart, constrict the vessels, and hold on to sodium and water. The earliest signs are restlessness, tachycardia, and tachypnea, with cool pale skin, thirst, decreased urine output, and a narrowed pulse pressure, while the blood pressure stays normal. That is why a falling blood pressure is a late sign. In the progressive stage the mean arterial pressure drops below 65, urine output falls under half a milliliter per kilogram per hour, lactate climbs, and organs begin to fail. Refractory shock no longer responds to fluids or vasopressors. Airway and oxygen come first, then two large-bore IVs, and the targets are a MAP of at least 65 and a urine output of at least half a milliliter per kilogram per hour.
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