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Characterized by inadequate tissue perfusion that ,if untreated ,results in cell death.
Systematic blood pressure is inadequate to deliver oxygen and nutrients to
support vital organs and cellular functions.
SIGNIFICANCE OF SHOCK
Shock affects all body systems. It may develop rapidly or slowly, depending on the
underlying cause. During shocks the body struggles to survive, calling on all its
homeostatic mechanism to restore blood flow and tissue perfusion. Any insult to the
body can create a cascade of events resulting in poor tissue perfusion. Therefore, almost
any patient with any disease state maybe at risk for developing shock.
CLASSIFICATION OF SHOCKS
Hypovolemic shocks occurs when there is a decrease in the
intravascular volume
Cardiogenic shocks occurs when the heart impaired pumping ability
,it maybe a coronary or non coronary origin.
Circulatory or distrivutive shocks result from a maldistribution osr
mismatch of blood flows to the cells.
STAGE OF SHOCKS
COMPENSATORY STAGE
The patients blood pressure remains with a normal limits.
Vasoconstrictions, increase heart rate and increased contractility of the heart
contribute to maintaining adequate cardiac output. This result from stimulations
of the sympathetic nervous system and subsequent release of catecholamines
(epinephrine and norepinephrine). The patient displays the often-described “fight
to fight” response.
CLINICAL MANIFESTATIONS
Despite a normal blood pressure, the patients shows numerous
clinical signs indicating inadequate organ perfusions. The result of inadequate
perfusions is anaerobic metabolism and a buildup of lactic acid, producing
metabolic acidosis.
MEDICAL MANAGEMENT
Medical treatment is directed toward identifying the cause of the
shocks, correcting the underlying disorder so that shocks does not progress, and
supporting those physiologic processes that thus far have responded
successfully to the threat.
NURSING MANAGEMENT
a. monitoring tissue perfusion
b. reducing anxiety
c. promoting safety
PROGRESSIVE STAGE
In the progressive stage of shocks, the mechanisms that regulate
blood pressure can no longer compensate and the MAP falls below
normal limits, with an average systolic blood pressure of less than 90mm
Hg.
MEDICAL MANAGEMENT
These include use of appropriate intravenous fluids and medications to
restore tissue perfusion by:
1. optimizing intravascular volume
2. supporting the pumping action of the heart
3. improving the competence of the vascular system
NURSING MANAGEMENT
a. preventing complications
b. promoting rest and comport
c. supporting family members
IRREVERSIBLE STAGE
The irreversible stage(or refractory) stage of shocks
represent the point along the shocks continuum at which organ
damage is so severe that the patients does not respond to treatment
and cannot survive.
MEDICAL MANAGEMENT
During the irreversible stage of shock is usually the same as
for the progressive stage. Although the patients conditions may have
progressed from the progressive to the irreversible stage, the
judgment that the shocks is irreversible can be made of only
retrospectively on the basis of the patients failure to respond to
treatment.
NURSING MANAGEMENT
The nurse focuses on carrying out prescribed treatments,
monitoring the patients, preventing complications, protecting the
patients from injury, and providing comport. Offering brief explanations
to the patients about what is happening is essential even if the ther is
no certainty that the patients hears or understand what is being said.
FLUID REPLACEMENT
Is administered in all types of shocks. The type of fluids
administered
And the speed of delivery vary, but fluids are given to
improve cardiac and tissue oxygenation, may include CRYSTALLOIDS
(electrolyte solutions that move freely between intravascular and
isterstitial space), COLLOIDS (large-molecule intravenous solutions) or
blood components.
NUTRITIONAL SUPPORT
Nutritional support is an important aspect of care for the patient
with shocks. Increased metabolic rates during shock increase energy
requirements. The patients in shocks requires more than 3000 calories daily. the
release of catecholamines early in the shocks continuum causes glycogen
atores to the depleted in about 8 to 10 hours.
HYPOVOLEMIC SHOCKS
>> The most common type of shocks, is characterized by a decreased
intravascular volume .
MEDICAL MANAGEMENT
Major goals in treating hypovolemic shocks are to :
1. restore intravascular volume to reverse the sequence of events
leading to inadequate tissue perfusion
2. redistribute fluid volume
3. correct the underlying cause of the fluid loss as quickly as possible.
CARDIOGENIC SHOCK
Cardiogenic shocks occurs when the hearts ability to
contract and to pump blood is impaired and the supply of oxygen is
inadequate for the heart and tissues. The cause of cardiogenic shocks are
known as either coronary or noncoronary.
PATHOPHYSIOLOGY
In cardiogenic shocks, cardiac output, which is a function
of both stroke volume and heart rate, is compromised. when stroke volume
and heart rate decreased or become eratic, blood pressure drops and
tissue perfusion is compromised.
CLINICALY MANIPESTATIONS
Patients in cardigenic shocks may experience angina
pain and develop dysrhythmias and hemodynamic instability.
MEDICAL MANAGEMENT
The goals of medical management are to:
1. limit further myocardial damage and preserve the healthy myocardium
2. improve the cardiac function by increasing cardiac contractility
CORRECTION OF UNDERLYING
The underlying cause of cardiogenic shock must be corrected. It is
necessary first to treat the oxygenation needs of the heart muscle to ensure
its continued ability to pump blood to other organs.
PAIN CONTROL
If the patients experiences chest pain, morphine sulfate is
administered intravenously for pain relief. In addition to relieving pain,
morphine delates the blood vessels . This reduces the workload of the
heart by both decreasing the cardiac filling pressure (preload)and reducing
the preassure against which the heart muscle has to eject blood (afterload)
HEMODYNAMIC MONITORING
Is initiated to asses the patients to response to treatment .this is
performed in the intensive care unit, where an arterial line can be inserted.
The arterial line enables accurate and continuous monitoring of blood
pressure and provides a port from which to obtain frequent arterial blood
samples without having to perform repeated arterial punctures.
PHARMACOLOGIC THERAPY
Vasoactive medication therapy consist of multiple pharmacologic
strategies to restore and maintain adequate cardiac output.
DOBUTAMINE
(dobutrex) produces inotropic effects by stimulating myocardial beta
receptors, increasing the strength of myocardial activity and improving
cardiac output.
NITROGLYCERIN
(tridil) in low doses acts as a venous vasodilator and therefore produces
preload. At higher doses nitroglycerin causes arterial vasodilation and
therefore reduces afterload as well.
DOPAMINE
(intropine) is a symphathomimetic agent that has varying vasoactive
effects depending on the dosage.
FLUID THERAPY
In addition to medications appropriate fluid is necessary in
treating cardiogenic shocks. A fluid bolus should never be given quickly
because rapid fluid administration with cardiac failure may result in acute
pulmonary edema.
NURSING MANAGEMENT
PREVENTING CARDIOGENIC SHOCK
Identifying patients at risk early and promoting adequate
oxygenation of the heart muscle and decreasing cardiac workload can
prevent cardiovascular shocks.
CIRCULATORY SHOCK
Circulatory or distributive shocks occurs when the blood volume
is abnormally displaced in the vasculature.
Three type
1. septic shock
2. neurogenic shocks
3. anaphylactic shocks
SEPTIC SHOCKS
Is the common type of circulatory shock and is caused by
widespread infection.
NEUROGENIC SHOCK
In neurogenic shocks vasodilation occurs as a result of
symphathetic tone. May have a prolonged course (spinal cord injury) oa a short
one (syncope fainting)it is characterized by dry, rather than the cool , moist skin
seen in hypovolemic shocks,may have a prolonged course (spinal cord injury) or
a short one (syncope or fainting).
MEDICAL MANAGEMENT
Treatment of neurogenic shock involves restoring symphatetic tone
either trough the stabilization of a spinal cord injury or in the instance of spinal
anesthesia, by positioning the patient properly .specific treatment of neurogenic
shock depends on its cause.
NURSING MANAGEMENT
It is important to elevate and maintain the head of the bed at least
30 degrees to prevent neurogenic shock when a patient is receiving spinal or
epidural anesthesia. Elevation of the head of the bed helps to prevent the spread
of the anesthetic agent up the spinal cord.
ANAPHYLACTIC SHOCK
Cause by a severe allergic reaction when a patient who has already
produced antibodies to a foreign substance (antigen) develops a systematic
antigen-antibody reaction.
MEDICAL MANAGEMENT
Treatment of anaphylactic shock requires removing the causative
antigen,administering medications that restore vascular tone,amd providing
emergency support of basic life functions . Epinephrine is given for its
vasoconstrictive action. Diphenhydramine(benadryl) is administered to
reverse the effect of histamine .
NURSING MANAGEMENT
The nurse has an important role in preventing anaphylactic
shock: assessing all patients for allergies or previous reactions to antigen
and communicating the existence of these allergies or reactions to other.
The must be knowledgeable about the clinical signs of anaphylaxis, must
take immediate actions if sings and symptoms occur, and must be
prepared to begin cardiopulmonary resuscitation if cardiorespiratory arrest
occurs.
Burn
The incidence of burn injuries had been declining during the past several decades.
Approximately 2 million people require medical attention for burn injury. Young children
and elderly people are at particularly high risk for burn injury. The skin in people in these
two age groups is thin and fragile; therefore, even a limited period of contact with a
source of heat can create a full thickness of burn.
Most injuries occur in the home, usually in the kitchen while cooking and in the
bathroom by means of scalds or improper use of electrical appliances around water
sources. Careless cooking is the one of the leading cause of fires in all over the world.
Classification by degree
• The most common system of classifying burns categorizes them as first-, second-, or
third-degree. Sometimes this is extended to include a fourth or even up to a sixth
degree, but most burns are first- to third-degree, with the higher-degree burns
typically being used to classify burns post-mortem. The following are brief
descriptions of these classes:[5]
• First-degree burns are usually limited to redness (erythema), a white plaque and
minor pain at the site of injury. These burns only involve the epidermis.
• Second-degree burns manifest as erythema with superficial blistering of the skin,
and can involve more or less pain depending on the level of nerve involvement.
Second-degree burns involve the superficial (papillary) dermis and may also involve
the deep (reticular) dermis layer.
• Third-degree burns occur when most of the epidermis is lost with damaged to
underlying ligaments, tendons and muscle. Burn victims will exhibit charring of the
skin, and sometimes hard eschars will be present. An eschar is a scab that has
separated from the unaffected part of the body. These types of burns are often
considered painless, because nerve endings have been destroyed in the burned area.
Hair follicles and sweat glands may also be lost due to complete destruction of the
dermis. Third degree burns result in scarring and may be fatal if the affected area is
significantly large.
• Fourth-degree burns damage bone tissue and may result in a condition called
compartment syndrome, which threatens the life of the limb.
• Fifth-degree burns are burns in which most of the hypodermis is lost, charring and
exposing the muscle underneath. Sometimes, fifth-degree burns can be fatal.
• Sixth-degree burns, the most severe form, are burn types in which almost all the
muscle tissue in the area is destroyed, leaving almost nothing but charred bone.
• Often, sixth-degree burns are deadly.
Other classifications
• A newer classification of "Superficial Thickness", "Partial Thickness" (which is
divided into superficial and deep categories) and "Full Thickness" relates more
precisely to the epidermis, dermis and subcutaneous layers of skin and is used to
guide treatment and predict outcome.
• Table 1. A description of the traditional and current classifications of burns.
• Traditional
• Nomenclature • Depth • Clinical findings
nomenclature
• Erythema, minor
• Superficial • Epidermis
• First-degree pain, lack of
thickness involvement
blisters
• Superficial
• Partial thickness — • Blisters, clear
• Second-degree (papillary)
superficial fluid, and pain
dermis
• Whiter
appearance, with
• Partial thickness — • Deep (reticular) decreased pain.
• Second-degree
deep dermis Difficult to
distinguish from
full thickness
• Dermis and
• Hard, leather-like
underlying tissue
• Third- or fourth- eschar, purple
• Full thickness and possibly
degree fluid, no sensation
fascia, bone, or
(insensate)
muscle
• Main article: Total body surface area
• Burns can also be assessed in terms of total body surface area (TBSA), which is the
percentage affected by partial thickness or full thickness burns (superficial thickness
burns are not counted). The rule of nines is used as a quick and useful way to
estimate the affected TBSA.
Causes of burns
• Burns may be caused by a wide variety of substances and external sources such as
exposure to chemicals, friction, electricity, radiation, and extreme temperatures, both
hot and cold.
• Most chemicals (but not all) that can cause moderate to severe chemical burns are
strong acids or bases.[6] Chemical burns are usually caused by caustic chemical
compounds, such as sodium hydroxide, silver nitrate, and more serious compounds
(such as sulfuric acid and Nitric acid).[7] Hydrofluoric acid can cause damage down to
the bone and its burns are sometimes not immediately evident.[8]
• Electrical burns are generally caused by an exogenous electric shock, such as being
struck by lightning or defibrillated or cardioverted without a conductive gel. The
internal injuries sustained may be disproportionate to the size of the burns seen, and
the extent of the damage is not always obvious. Such injuries may lead to cardiac
arrhythmias, cardiac arrest, and unexpected falls with resultant fractures.[9]
• Radiation burns may be caused by protracted and overexposure to UV light (as
from the sun), tanning booths, radiation therapy (as patients who are undergoing
cancer therapy), sunlamps, and X-rays. By far the most common burn associated with
radiation is sun exposure, specifically two wavelengths of light UVA, and UVB, the
latter being the more dangerous of the two. Tanning booths also emit these
wavelengths and may cause similar damage to the skin such as irritation, redness,
swelling, and inflammation. More severe cases of sun burn result in what is known as
sun poisoning.
• [edit] Scalding
•
•
• Two day-old scald caused by boiling radiator fluid.
• Scalding is a specific type of burning that is caused by hot fluids or gases. They most
commonly occur in the home from exposure to high temperature tap water.[10] Steam
is a common gas that causes scalds. The injury is usually regional and usually does
not cause death. More damage can be caused if hot liquids enter an orifice. However,
deaths have occurred in more unusual circumstances, such as when people have
accidentally broken a steam pipe. The demographics that are of the highest risk to
suffering from scalding are young children, with their delicate skin, and the elderly
over 65 years of age.
• Cold burn
•
•
• Frostbitten hands
• A cold burn (see frostbite) is a kind of burn which arises when the skin is in contact
with a low-temperature body. They can be caused by prolonged contact with
moderately cold bodies (snow and cold air for instance) or brief contact with very
cold bodies such as dry ice, liquid helium, liquid nitrogen, or canned air. In such a
case, the heat transfers from the skin and organs to the external cold body. The effects
are very similar to that of a burn caused by extreme heat. The remedy is also the
same. For a minor cold burn, it is advisable to keep the injured organ under a flow of
water of comfortable temperature. This will allow heat to transfer slowly from the
water to the organs.
Management
• A local anesthetic is usually sufficient in managing pain of minor first-degree and
second-degree burns. However, systemic anti-inflammatory drugs such as naproxen
may be effective in mitigating pain and swelling. Additionally, topical antibiotics
such as Mycitracin are useful in preventing infection to the damaged area.[11]
Lidocaine can be administered to the spot of injury and will generally negate most of
the pain. Regardless of the cause, the first step in managing a person with a burn is to
stop the burning process at the source. For instance, with dry powder burns, the
powder should be brushed off first. With other burns, such as those caused by
exposure to chemicals, the affected area should be rinsed throughly with a large
amount of clean water to remove the caustic agent and any foreign bodies. Cold
water should not be applied to a person with extensive burns, however, as it may
compromise the burn victim's temperature status.
• If the patient was involved in a fire accident, then it must be assumed that he or she
has sustained inhalation injury until proven otherwise, and treatment should be
managed accordingly. At this stage of management, it is also critical to assess the
airway status. Any hint of burn injury to the lungs (e.g. through smoke inhalation) is
considered a medical emergency. Survival and outcome of severe burn injuries is
remarkably improved if the patient is treated in a specialized burn center/unit rather
than a hospital. Serious burns, especially if they cover large areas of the body, can
result in death.
• Once the burning process has been stopped, the patient should be volume resuscitated
according to the Parkland formula, since such injuries can disturb a person's osmotic
balance. This formula dictates the amount of Lactated Ringer's solution to deliver in
the first twenty four hours after time of injury. This formula
• excludes first and most second degree burns. Half of the fluid should be given in the
first eight hours post injury and the rest in the subsequent sixteen hours. The formula
is a guide only and infusions must be tailored to urine output and central venous
pressure. Inadequate fluid resuscitation causes renal failure and death.
Full Thickness Epidermis; Pain free Dry; pale white Eschar sloughs
(3rd degree entire dermis, Shock leathery, or Grafting
burn) and sometimes Hematuria charred Scarring and
subcutaneous (blood in the Broken skin loss of contour
tissue; may urine)and with fat and fxn;
involve possibly exposed contractures
connective hemolysis Edema Loss of digits
tissue, muscle, (blood cell or extremity
and bone destruction) possible
Possibly
entrance and
exit wounds
(electrical burn)
Local and Systemic Response to Burns
• Burns that do not exceed 25% TBSA produce a primarily local response
• Burns that exceed 25% TBSA may produce both a local and systemic
response and are considered major burn injuries
Cardiovascular Response
Burn Edema
• Evaporative fluid loss through the burn wound may reach 3 to 5 L or more
over a 24 hour period until the burn surfaces are covered
• Hyponatremia is most common during the first week of the acute phase, as
water shifts from the interstitial to the vascular space
• Immediately after burn injury, hyperkalemia (excessive potassium) results
from massive cell destruction. Hypokelamia (potassium depletion) may occur
later with fluid shifts from the interstitial to the vascular space
Pulmonary Response
Infection prevention
Wound Cleaning
• Hydrotherapy
• Use tap water
• Tub baths
Topical Antibacterial Therapy
Wound Dressing
Dressing Change
Wound Debridement
Angina Pectoris
Precipitating Factors
Physical exertion
Exposure to cold
Eating a heavy meal
Stress or any emotion provoking situation
TYPES
1. Stable Angina
Predictable and consistent pain that occurs on exertion and
relieved by rest or nitroglycerine
Stable pattern of onset, duration, severity and relieving factors
CLINICAL MANIFESTATIONS
1. Chest Pain
Varying severity from indigestion to choking or heavy/tightness sensation
Range from discomfort to agonizing pain
Substernal or retrosternal
Poorly localized
May radiate to the neck, jaw, shoulder, and inner aspects of the upper
arms
Feeling of numbness in the arm wrist or hands
DM patient may not experience pain
Elderly may not exhibit typical pain profile
-may present with dyspnea
2. Associated symptoms
Dyspnea
Pallor
Sweating
Palpitation and tachycardia
Dizziness and faintness
Hypertension
Diagnostic Studies
1) ECG: normal during rest
ST depression or elevation and T wave inversion during episode of pain
2) Stress test: Chest pain or changes in the ECG or vital signs during testing
indicating ischemia
3) Cardiac enzymes: normal
4) Cardiac Catheterization
Provide definitive diagnosis by providing information of the patency of the
coronary artery
Medical Management
Objective: decrease O2 demand and increase O2 supply
1) Pharmacologic therapy
a. Nitrates: Nitroglycerine
Mainstay of the treatment of the angina
MOA: dilates the coronary artery
Decrease preload and afterload
Routes: SL, topical, IV
Nursing Interventions:
Pre-procedure
Obtain consent
Assess for allergies to seafood’s, iodine and radioapaque dyes
Withhold meals before the procedure
Document baseline vital signs
Have the client void
Administer sedatives as order
Post-procedure
Monitor VS and cardiac rhythm for dysrhythmias
Assess for the chest pain and notify the physician
Monitor peripheral pulses color, warmth and sensation distal to insertion
sites
Monitor bleeding and hematoma
Extremity extended for 4-6 hours
Strict bed rest for 6-12 hours
Encourage fluids
Monitor for the signs of hypersensitivity
Immediate management
a. Assess pain
b. Provide bed rest
c. Administer O2 at 3L nasal cannula as prescribed to dilate coronary arteries,
reduced the O2 requirements of the myocardium, and relieve the chest pain
d. Obtain a 12 lead ECG
e. Provide continuous cardiac monitoring