You are on page 1of 23

SHOCK is a life threatening condition with a variety of underlying causes.

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.

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.

 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.

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.

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 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.
a. monitoring tissue perfusion
b. reducing anxiety
c. promoting safety

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


Chances of survival depend on the patients general health before the
shocks state as well as the amount of time it takes to restore tissue
perfusion. As shocks progresses, organs systems decompensate.
a. respiratory effects
b. cardiovascular effects
c. neurologic effects
d. renal effects
e. hepatic effects
f. gastrointestinal effects
g. hematologic effects

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

a. preventing complications
b. promoting rest and comport
c. supporting family members

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.
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

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.

Overall Management Strategies in Shock

(management in all types and all phases of shocks includes the ff.)

a. fluid replacement to restore intravascular volume

b. vasoactive medications to restore vasomotor tone and improve
cardiac function
c. nutritional support to address the metabolic requirements that are
dramatically increased in shock

Is administered in all types of shocks. The type of fluids
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.


The best fluid to treat shocks remains controversial. In
emergrencies , the “best” fluid that is readily available. Both crystalloids and the
colloids, can be given to restore intravascular volume. Blood component therapy
is used most frequently in hypovolomic shock.


Close monitoring of the patients during fluid is necessary to
identify side effects and complications. The most common and serious side effect
of fluid replacement are cardiovascular overload and pulmonary edema.


Administered in all forms of shocks to improve the patients
hemodynamic stability when fluid therapy alone cannot maintain adequate MAP.
Vasoactive medications are selected for their action on receptors of the
symphatetic nervous system.when vasoactive medications are administered,
vital sign must be monitored frequently(at least every 15min until stable or more
often if indicated)

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.

>> The most common type of shocks, is characterized by a decreased
intravascular volume .

Risk Factor for Hypovolemic Shock

External: Fluid losses Internal: Fluid Shifts

Trauma hemorrhage
Surgery burns
Vomiting ascites
Diarrhea peritonitis
Diabetes insipidus dehydration

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.

Depending on the severity of shocks and the patients conditions, it is likely

that the efforts will be made to address all three goals simultaneously.

a. treatment of the underlying cause

b. fluid and blood replacement
c. redistribution of fluid
d. pharmacologic therapy
Primary prevention of shocks is an essential focus of
nursing intervention. General nursing measures include ensuring safe
administration of prescribed fluids and medications and documenting
their administration and effects

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.

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.

Patients in cardigenic shocks may experience angina
pain and develop dysrhythmias and hemodynamic instability.

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

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.


Involves the following actions:
a. supplying supplemental oxygen
b. controlling chest pain
c. providing selected fluid support
d. administering vasoactive medications
e. controlling heart rate with medications or by implementations of a
thranstoracic or intravenous pacemaker
f. implementing mechanical cardiac support (intra-aortic balloon
counterpulsation therapy, ventricular assist systems,or extracorporeal
cardiopulmonary bypass)
In the early stages of shocks, supplemental oxygen is
administered by nasal cannula at a rate 2 to 6 L/min to achieve ab
oxygen saturation exceeding 90%

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)

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.

Vasoactive medication therapy consist of multiple pharmacologic
strategies to restore and maintain adequate cardiac output.

(dobutrex) produces inotropic effects by stimulating myocardial beta
receptors, increasing the strength of myocardial activity and improving
cardiac output.

(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.

(intropine) is a symphathomimetic agent that has varying vasoactive
effects depending on the dosage.


Additional vasoactive agents that may be used in managing cardiogenic
shocks include norepinephrine(lephoped),epinephrine(adrenalin),
milrinone(primacor), amrinone( inocor) vasopressin( pitressin), and
phenylephrine (neo-synephrine)
Is also part of the medication regimen in cardiogenic shocks.

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.


a. increased stroke volume
b. improved coronary artery perfusion
c. decreased preload
d. decreased cardiac workload
e. decreased myocardial oxygen demand

Identifying patients at risk early and promoting adequate
oxygenation of the heart muscle and decreasing cardiac workload can
prevent cardiovascular shocks.


A major role of the nurse is monitoring the patients
hemodynamic and cardiac status.


The nurse has a critical role in safe and accurate administration
of intravenous fluid and medications.


The nurse plays a critical role in caring for the patient receiving
intra-aoratic balloon counterpulsation.the nurse makes ongoing timing
adjustment of the balloon pump to maximized its effectiveness by
synchronizing it with the cardiac cycle.


Throughout care the nurse must take an active role in safe guarding
the patient,enhancing comport and reducing anxiety.

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

Is the common type of circulatory shock and is caused by
widespread infection.

Septic shocks typically in two phases.

• reffered to as the hyperdynamic ,progressive phase
• reffered to as the hypodynamic, irreversible phase

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).

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.

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.

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.
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 .

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

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
• Erythema, minor
• Superficial • Epidermis
• First-degree pain, lack of
thickness involvement
• Superficial
• Partial thickness — • Blisters, clear
• Second-degree (papillary)
superficial fluid, and pain
• 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
• 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.

• 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.

Burn Prevention Tips

• Keep matches and lighters out of reach of the children

• Never leave unattended around fire or in bathroom/bathtub
• Install and maintain smoke detectors in the home
• Develop and practice and practice home exit fire drill
• Set the water heater temperature no higher than 120F
• Do not smoke in bed. Do not fall asleep while smoking
• Do not throw flammable liquids on to an already burning fire
• Do not use flammable liquids to start fires
• Do not remove radiator cap from a hot engine
• Watch for overhead electrical wires and underground wires when working outside
• Never store flammable liquids near a fire source, such as a pilot light
• Use caution while cooking
• Keep a working fire extinguisher in your home
Characteristics of Burn According to Depth

Burn and Skin Symptoms Wound Recuperative

causes involvement appearance course
Superficial Epidermis; Tingling Reddened; Complete
Partial possibly a Hyperesthia blanches recovery within
Thickness (1st portion of Pain that is w/pressure dry a week, no
degree burn) dermis soothed by Minimal or no scarring
cooling edema Peeling
Possible blisters
Deep Partial Epidermis; Pain Blistered; Recovery in 2
Thickness (2nd upper dermis’ Hyperesthia mottled red to 4 weeks
degree burn) portion of Sensitive to base; broken Some scarring
deeper dermis cold air epidermis; and
weeping depigmentation
surface contractures
Edema Infection my
convert it to full

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
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

• Hypovolemia is tha immediate consequence of fluid loss resulting in

decreased perfusion and oxygen delivery
• Cardiac output decrease before any significant change in blood volume is
• The greatest volume of fluid leak occurs in the first 24-36 hours after the burn,
peaking by 6-8 hours

Burn Edema

• Edema maximal after 24 hours

• It begins to resolve 1-2 days post burs and usually is completely resolved in 7-
10 days post injury
• Edema increase in circumferential burns, pressure on small blood vessels and
nerve in distal extremities cause and obstruction of blood flow and consequent

Effects on Fluids and Electrolytes and Blood Volume

• 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

• Inhalation, bronchoconstriction caused by release of histamine, serotonin

and thrombaxane a powerfull vasoconstrictor, as well as chest constriction
secondary o circumferential full thickness chest burns caused this deteoriation
• Pulmonary, upper airway injury results from direct heat or edema,
by mechanical obstruction of the upper airway
• Carbon monoxide, the pathophysiologic effects due to tissue hypoxia, a result
of carbon monoxide combining with hemoglobin to form carboxyhemoglobin,
which competes with oxygene for available hemoglobin binding sites

Other Systemic Response

• Renal fxn may be altered as a result of decreased blood volume, destruction of

red blood cells at the injury site results in free hemoglobin in the urine
• Significant impairment of the production and release of granulocytes and
macrophages from bone marrow after burn injury. The resulting immunosup
resion places the burn patient at high risk of sepsis
• Loss of skin also results in an ability to regulate body temperature. Burn
patients may therefore exhibits low body temp. in the early hours after injury
• Two potential gastrointestinal complications may occur, paralytic ileus and
Curling ulcer, gastric distention and nausea my lead to vomiting unless gastric
decompression is initiated.
Phases of Burn Care

Phase Duration Priorities

Emergent or immediate From onset of injury to • First aid
resuscitative completion of fluid • Prevention of shock
resuscitation • Prevention of
respiratory distress
• Detection and tx of
comcominant injuries
• Wound assessment and
initial care
Acute From beginning of diuresis • Wound care and closure
to near completion of • Prevention or tx of
wound care complication, including
of infection
• Nutritional support
Rehabilitation From major wound closure • Prevention of scars and
to return to individuals contractures
optimal level of physical • Physical, occupational,
and psychosial adjustment and cosmetic
• Psychosocial

Emergency Procedure at the Burn scene

• Extinguish the flames

• Cool the burn
• Remove restricted objects
• Cover the wound
• Irrigate chemical burns
Emergency Medical Management

• Transport to the nearest emergency department

• Priorities the airway, breathing, and circulation
• Administer humidification, bronchodilator, mucolytic agents
• Continuous + airway pressure and mechanical ventilation may also be required to
achieve adequate oxygenation
• Asses for cervical spinal injuries
• Asses for burn and wound
• Insert IVP and NGT, and suction the pt. to prevent vomiting
• Practice aseptic technique to prevent infection
• Asses for TBSA
• Fluid replacement
• Asses for Acute Respiratory and Renal Failure
• Transfer to a burn center
• Management of fluid loss and shock

Acute or Intermediate Phase of Burn Care

Infection prevention

• Phase occur 48-72 hours after burn injury

• Asses for electrolytes imbalance, and gastrointestinal fxn
• Infection prevention wound cleaning, topical antibacterial therapy, wound dressing,
wound debridement, and wound grafting
• Pain management and nutritional support
• Asses for airway obstruction caused by upper airway edema
• Asses for capillaries integrity
• Monitor fever for the signs of infection
• Monitor for infection like staphylococcus, proteus, pseudomonas,
Escherichia coli, kliebsuella, candida albicans,

Wound Cleaning
• Hydrotherapy
• Use tap water
• Tub baths
Topical Antibacterial Therapy

• Silver sulfadiazine (silvadene)

• Mafenide acetate (sulfamylon)
• Silver nitrate
• Acticoat

Wound Dressing

• 1st topical agent is applied then covered by a several layers of dressing

• A light dressing is also applied areas for which a splint has been designed to
conform to the body contour the proper positioning

Dressing Change

• Dressings are changed in the pt. units hydrotherapy room, or tx approximately 20

min after and analgesics agent administered
• They may also changed in the OR after the pt. administered anesthesia

Wound Debridement

• To remove tissue contaminated by bacteria and foreign bodies, thereby protecting

the pt. from invasion of bacteria
• To remove devitalized tissue or burn eschar in preparation for grafting and wound
• Natural debridement
• Mechanical debridement
• Surgical debridement

Angina Pectoris

 Chest pain resulting from myocardial ischemia caused by inadequate myocardial

blood and oxygen supply
 Caused by imbalanced between oxygen supply demand
 Caused include obstruction of coronary blood flow because of atherosclerosis,
coronary artery spasm and conditions increasing myocardial oxygen consumption
 The goal of treatment is to provide relief of an acute attack, correct imbalance
between the myocardial oxygen supply and demand, and prevent progression of
the disease and further attack to reduce the disk of MI.

Precipitating Factors
 Physical exertion
 Exposure to cold
 Eating a heavy meal
 Stress or any emotion provoking situation

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

2. Unstable Angina/Preinfraction Angina

 Occurs with an unpredictable degree of exertion or emotion and
increases in occurrence, duration and severity overtime
 May not be relieved with rest and nitroglycerine

3. Variant/ Prinzmetal’s/ Vasospastic Angina

 Result from coronary spasm
 Similar to classic angina but last longer
 May occur at rest
 ECG- ST segment elevation

4. Intractable or refractory Angina

 Severe incapacitating chest pain

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
 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

 Mark distal pulses

 Inform the client that a warm flushing sensation may be felt as the
contrast medium is injected
 Inform the client that he may feel fluttery feeling as the catheter passes
through the heart
 Prepare insertion site by shaving or cleaning

 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
 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

Following Acute Episode

a. Instruct the client regarding the purpose of the diagnostic medical surgical
procedure and post procedure expectation.
b. Assist the client to identify angina precipitating event
c. Instruct the client to stop activity and the rest if the chest pain occurs and to take
nitroglycerine as prescribe
d. Instruct the client to seek medical attention if pain persist
e. Instruct the client regarding the prescribe medication
f. Provide diet instruction to the client, stressing the dietary changes re not
temporary and must be maintain for life
g. Assist the client to identify risk factor that can be modified
h. Assist the client to set goals that will promote changes in lifestyle to reduce
impact of risk factor
i. Assist the client identify barriers to compliance with therapeutic plan to identify
methods to become barriers
j. Provide community resources to the client regarding exercise reduction and stress