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SHOCK DM/DKA
HEPATIC COMA/ENCEPHALOPATHY
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What is Shock?
Redistribution of Fluids
• Patients is positioned in trendelenburg to assist in fluid redistribution.
•Military antishock trousers (MAST) are used in extreme emergency situations when bleeding
cannot be controlled
Pharmacologic Exam
• Desmopressin
• Insulin
• Anti-emetic
• Anti-diarreal
Nursing Management
• Closely monitor px at risk for fluid deficits(younger than 1y/o or
65 years of age)
• Reduce fear and anxiety about the need for oxygen mask by
giving px explanations and frequent reasurance
Cardiogenic Shock
Cardiogenic Shock
• The ability of the heart to pump blood is impaired that
causes a decrease in cardiac output.
• Angina pain
• Hemodynamic instability
• Classic sign like low blood pressure, rapid and weak pulse.
• Dobutamine
• Dopamine
• Anti-arrythemic meds
• Nitroglycerine
• Vasoactive meds
Nursing Management
• Immunosuppression
• Extremes of age ( younger than 1y/l and older than 65y/o)
• Alcoholism
• Extensive trauma of burns
• Malnutrition
• Diabetes
• Malignancy
• Chronic illness
• Invasive procedures
Pathophysiology
• Monitor for sign of infection at intravenous lines, arterial and venous puncture
sites, surgical incisions, trauma wounds, urinary catheters and pressure ulcer
• Reduce px temp. when ordered for temp above 104.8F (40.8C) monitor
closely for shivering
• Monitor and report blood levels (antibiotics, BUN, creatinine, WBC ) and
hemodynamic status, fluid IO and nutritional status.
• Monitor daily wts. And serum albumin levels to determine daily protein
requirements
NEUROLOGIC SHOCK / SPINAL
SHOCK
– Spinal anesthesia
– Depressant meds
– Hypoglycemia
Medical Management
• Feet elevation
• Passive ROM
Anaphylactic Shock
Anaphylactic Shock
• Drug sensitivity
• Transfusion reaction
• Bee sting allergy
• Latex sensitivity
Medical Management
• Patient education
Stages of Shock
• Myocardial depression
B. Sinus Tachycardia
• Occur when the sinus node create
an impulse at a faster than normal
rate. It may be caused by acute
blood loss, anemia, shock,
hypervolemia, hypovolemia CHF,
pain, hypermetabolic states, fever,
anxiety or sympathomimetic
medication.
Characteristics:
As the heart rate increases, the diastolic falling time decreases, result in
reduced cardiac output and subsequent symptoms of syncope and low
blood pressure. If the heart cannot compensate for the decreased
ventricular falling the px may develop acute pulmonary edema
Management
C. Sinus Arrhythmias
B. Atrial Flutter
• Occur in the atrium and creates impulse at an atrial
rate between 250 and 400 time per minute.
• Chest pain
• Shortness of breath
• Low blood pressure.
Management
• The urgency of treatment depend on the ventricular response rate&
resultant symptoms
• The shorter time in diastole reduce the time available for coronary artery
perfusion, there by increasing the risk for myocardial ischemia.
• Calcium channel blocker and beta blocker are effective in controlling the ventricular
rate in atrial fibrillation
• Use Digoxin is recommended to control the ventricular rate those patient with poor
cardiac function
• The criteria for premature junction complex are the same as for PACs except
for the Pwave and the PR interval. The Pwave may be absent QRS, or may
occur before the QRS but with a PR interval of less than 0.12 second
B. Junctional Rhythm
• The wave of impulse originates from an ectopic Focus (Foci) within the
ventricles at rate faster than the next normally occurring beat.
C. Ventricular Fibrillation
D. Idioventricular Rhythm
• Is also called ventricular escape rhythm, occur when the impulse starts in
the conduction system below the AV node.
E. Ventricular Asystole
• The Clinical sign and symptoms of a heart block vary with the
resulting ventricular rate and the severity of any underlying
disease processes.
Second degree type I heart block occurs when all but one of the
atrial impulse are conducted. Through the AV node into the ventricles.
Each atrial impulse a take longer time for conduction than the one
before, until one impulse is fully blocked.
Characteristics:
• Ventricular and atrial rate: Depend on the underlying
rhythm
• Ventricular and atrial rhythm: The PP interval is
regular if the patient has an underlying normal sinus
rhythm; the RR interval characteristically reflect a pattern
of change .
• QRS duration: Normal may be abnormal
• P wave: In front of the QRS complex; shape depend on
underlying rhythm
• PR interval: PR interval become longer with each
succeeding ECG complex until there is a P wave not
followed by a QRS.
• P: QRS ratio 3; 2, 4:3, 5:4,
Second Degree Atrioventricular
Block Type I
Types of Conduction
Abnormalities
B.2 Second Degree Atrioventricular Block Type II
– Regularly evaluate the blood pressure, pulse rate and rhythm, rate and
depth of respiration and breath sounds to determine the hemodynamic
effects.
– Goal is to maximize the client’s controls and to make the unknown less
threatening.
• Leads can be threaded through a major veins into the right ventricles
(endocardial leads) or they can be lightly sutured onto the outside the
heart and brought the chest wall during open heart surgery.
Pacemaker Design and types
Causes:
• Cerebral arteriosclerosis
• Syphilis
• Trauma
• Hypertension
• Thrombosis
• Embolism
• Hemorrhage
• Vasospasm
Types of Stroke
1. Ischemic Stroke
• Large Artery Thrombotic Strokes- are due to atherosclerotic
plaques in the large blood vessel of the brain. Thrombus formation and
occlusion at the site of the atherosclerosis result in ischemia and
infraction and occur in older patients.
• Visual disturbance
• Some clinicians advocate the use of a properly worn sling when the
patients first becomes ambulatory to prevent upper extremity from
dangling without support.
HEMORRHAGIC STROKE
Hemorrhagic Stroke
• Primarily caused by an intracranial or subarachnoid
hemorrhage, bleeding into the brain tissue, the
ventricles, or subarachnoid space.
• Bleeding into the brain substance, common in patients with hypertension and cerebral
atherosclerosis that causes rupture of the vessel
• Brain tumor and the use of medicines( oral anticoagulants, amphetamines and illicit
drugs such as crack and cocoaine).
• Bleeding occur mostly in the cerebral lobes, basal ganglia, thalamus, brain stem
(mostly pons) and cerebellum
Subarachnoid Hemorrhage
• Avoid Valsalva maneuver, straining , forceful sneezing, pushing up to bed, acute flexion or rotation
of the head and neck.
• No enemas are permitted but stool softener and mild laxative is prescribed.
• Observed for the s/sx of deep vein thrombosis such as tenderness, swelling, warmth, discoloration
positive Homan’s sign report any abnormal findings End of the slides
BURNS
Burns
Depth of the injury depends on the temperature of the burning agent and the
duration of contact with the agent
• The epidermis and upper to uper deeper portion of the dermis are
injured. eg, scald
• The wound is painful, appears red, and exudes fluid. Capillary
refill follows tissue blanching.
• Hair follicles remain intact.
• Deep partial-thickness burns take longer to heal and are more
likely to result in hypertrophic scars.
Second Degree Burn
Classifications of Burn According
to Depth of Tissue Destruction
C. Full – Thickness Burn
(third degree burn)
B. Middle zone
• has a compromised blood supply, inflammation, and
tissue injury.
C. Outer zone
• the zone of hyperemia which sustains the least damage.
RULE OF NINE
An estimation of the TBSA involved in a burn is simplified
9 by using the rule of nines.
It is a quick way to calculate the extent of burns.
The system assigns percentage in multiples of nine to major
body surfaces.
9 18 18 9 PARKLAND FORMULA
Computation of fluids
Most commonly used in burned patient
1
• Focus on the major priorities of any trauma patient: ABC, disability, exposure, and
fluid resuscitation.
• Assess respiratory status as first priority (airway patency and breathing adequacy)
• Note any increased hoarseness, stridor, abnormal respiratory rate, and depth, or
mental changes from hypoxia.
• Fluid volume deficit r/t increased capillary permeability and evaporative fluid
loss from burn wound.
• Pain r/t tissue and nerve injury and emotional impact of injury.
– Provide pain releif, and give antianxiety med if px remain highly anxious and
agitated.
Nursing Intervention
5. Monitor and Managing Potential Complications
– Acute Respiratory Failure: assess for increasing dyspnea. Stridor,
changes in respiratory patterns; monitor arterial blood gas (ABGs),
pulse oximetry to detect problematic oxygen saturation and increasing
carbon monoxide; monitor chest x-rays for cerebral hypoxia
– Distributive Shock: monitor for early signs of shock or progressive
edema. Administered fluid resuscitation as ordered in response to
physical findings; continue monitoring fluid status
– Acute Renal Failure: monitor and report abnormal urine output and
quality
– Compartment Syndrome: assess nuerovascular status of extremities
hourly; report any extremity pain, loss of peripheral pulse or sensation
– Paralytic Ileus: NGT and maintain in low intermittent suction until
bowel sound resume
– Curling’s Ulcer: assess gastric aspirate for blood and pH; assess stools
for occult blood; administerd antacids and histamine blockers (eg,
ranitidine, (zantac)) as prescribed.
Acute and Intermediate Phase
• It begins 42 to 72 hours after the burn injury. Burn wound care and pain
control are the priorities in this stage
Assessment
- Focus on hemodynamic changes
- Measure V/S frequently
- Assess peripheral pulses frequently
- Observe electrocardiogram for dysrhythmias resulting from potassium
imbalance
- Assess residual gastric volume and pH in px with NGT
- Note and report blood in gastric fluid or stool.
- Assess wound: size, color, eschar, exudate, abscess formation under the
eschar, epithelial buds, bleeding granulation tissue appearance
- Focus on pain and psychosocial response
- Assess for excessive bleeding adjacent to areas of surgical exploration
and debridement
Diagnosis
• Excessive fluid volume related to resumption of capillary integrity
• Risk for infection related to loss of skin barrier and impaired immune
response
• Impaired physical mobility r/t burn wound edema, pain, and joint
contractures
2. Preventing infection
• Provide a clean and safe environment
• Caution px to avoid touching wounds or dressings, bathed unburned areas and change
linens regularly
• Closely scrutinized wound t detect early sign of infection
6. Promoting Mobility
• Prevent complications for immobility
• Modify intervention to meets patient’s need
• Make aggressive effort to prevent contractures and hypertrophic scaring of the
wound area after wound closure for a year or more
• Initiate passive ROM
• Apply splits or functional devices to extremities for contracture control
• Document participation and self care abilities in wound care and ambulation
Prevention
• For obese patients(especially those with type 2 diabetes): weight loss is the
key to treatment and the major preventive factor for the development of
diabetes
Management
• Primary treatment of type 1 diabetes is insulin.
• Use of oral hypoglycemic agents if diet and exercise are not successful
in controlling blood glucose levels. Insulin injections may be used in
acute situations
• Reduce anxiety
(1) Hyperglycemia, due to decreased use of glucose by the cells and increased
production of glucose by the liver;
(2) Dehydration and electrolyte loss, resulting from polyuria, with a loss of up to
6.5 liters of water and up to 400 to 500 mEq each of sodium, potassium, and
chloride over 24 hours; and
(3) Acidosis, due to an excess breakdown of fatty acids and production of ketone
bodies, which are also acids. Three main causes of DKA are decreased or
missed dose of insulin, illness or infection, and initial manifestation of
undiagnosed or untreated diabetes.
Clinical Manifestations
• Polyuria, polydipsia (increased thirst)
• Acetone breath
• Kaussmauls respiration
• Teach the patient about “sick-day rules” which are strategies to help
prevent diabetic complications.
– Do not eliminate insulin doses when nausea and vomiting occur
– Take usual insulin dose or previously prescribed sick-day doses and attempt to
consume frequent small portions of carbohydrates
– Drink fluids every hour to avoid dehydrations
– Check blood glucose level every 3-4 hours
End of the slides
Hepatic Encephalopathy
• CBC – pancytopenia
• PTT – prolonged
• Monitor serum ammonia level daily; monitor electrolyte status and correct if abnormal
• Hypertension
• Chronic glomerulonephritis
• Pyelonephritis
• Vascular disorder
• Infections
Uremia develops
• Integumentary: ecchymosis, purpura, thin brittle nails, coarse thinning hair, gray-bronze
skin color, dry flaky skin
• Pulmonary: crackles, thick tenacious sputum, depressed cough reflex, shortness of breath,
tachypnea, kussmaul type of respiration, uremic pneumonitis
• Musculoskeletal: muscle craps, loss of muscle strength, renal osteodystrophy, bone pain,
fracture, foot drop
• Hematologic: anemia,thrombocytopenia
Assessment and Diagnostic
Findings
1. Glomerular filtration rate
• 24ᵒ urinalysis for creatinine clearance = decrease GFR
• Increase BUN level
• Serum creatinine (most sensitive indicator of renal function
3. Anemia
• Inadequate erythropoietin production
• Producing fatigue, angina and shortness of breath
• Antacids
• Hyperphosphatemia and hypocalemia are treated with aluminium based antacid
• Magnesium based antacid should be avoided to prevent magnesium toxicit
Medical Management
2. Diet therapy
• Vitamin supplementation
• CHON restriction
• Potassium restriction
3. Dialysis
• Used to remove fluid and uremic waste products from the body when the kidney cannot do so.
• Used to treat px with edema that does not respond to tx, hepatic coma, hyperkalemiam
hypercalcemiam HPN and uremia
Types of Dialysis
Medical Management
• Methods of Therapy
Complication includes:
1. Hemodialysis
• Commonly used method of • Hypertriglyceridemia
dialysis • Heart failure
• Used for acutely ill and require • Coronary heart disease
short term dialysis (days to weeks)• Angina pain
• Used for ESRD who require long • Stoke
term or permanent therapy to • Peripheral vascular insufficiency
prevent death • Hypotension
• Uses dialyzer (synthetic • Painful muscle cramping
semipermeable membrane • Exsanguinations
replacing the renal glomeruli and
tubules as the filter for the • Dysrhythmias
impaired kidneys) • Air embolism
Dialysis disequilibrium • Dialysis disequilibrium
Hemodialysis
Nursing Diagnosis
• Excess fluid volume r/t decreased urine output, dietary excesses and
retention of Na and H2O
• Report the health care provider the s/sx of decreased renal fxn
– Worsening s/sx of renal failure (N/v, change in usual output, ammonia odor or
breath
– s/sx of hyperkalemia
– s/sx of access problem (clotted fistula or graft and infection)
CAUSES:
• Hypovolemia
• Sudden increased in intravascular pressure in the
lung
• Inadequate liver function
Pathophysiology
pulmonary edema most commonly occurs as a result of increased
microvascular pressure from abnormal cardiac function
– Patient hands become cold and moist the nailbeds are cyanotic
• Crackles are due to the movement of air through the alveolar fluid
• Tachycardia, the pulse oximetry values begins to fall and arterial blood
gads analyzing demonstrates increased hypoxemia
Medical management
• Monitor I and O
• Massive pulmonary embolism is life threatening and can cause death within
the first 1 to 2 hours after the embolic event.
• Symptoms depend on the size of the thrombus and the area of the
pulmonary artery occlusion.
• Dyspnea is the most common symptom. Tachypnea is the most frequent sign
• Chest pain is common, usually sudden in onset and pleuritic in nature; it can
be substernal and may mimic angina pectoris
Thrombolytic Therapy
• Thrombolytic therapy may include urokinase alteplase, anistreplase and
streptokinase (tissue plasminogen activator). It is reserved for pulmonary
embolism affecting a significant area and causing hemodynamic instability
• Bleeding is a significant side effect; nonessential invasive procedures are voided
Surgical Management
• Embolectomy by means of thoracotomy with cardiopulmonary bypass technique
• Transvenous catheter embolectomy with or without insertion of an inferior vena
caval filter (eg. Greenfield)
Nursing Interventions
• Providing general care.. Encourage deep-brathing exercises
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