A B C ’ s of

Nursing

Orlando S. Samson Jr.

NPCA
 Shock
An abnormal physiologic state where an
imbalance between the amount of
circulating blood volume and the size
of the vascular bed results in
circulatory failure and oxygen and
nutrient deprivation of tissues.
 Body’s Response to Shock
1. Hyperventilation
2. Vasoconstriction
3. Tachycardia
4. Fluid shifts
5. Impaired metabolism
6. Impaired organ function
 Assessment Findings
SKIN
cool, pale, moist in hypovolemic/
cargiogenic shock
warm, dry, pink in septic and
neurogenic shock
PULSE
tachycardia
weak and thready
BLOOD PRESSURE
EARLY: NORMAL
LATE: Below normal
RESPIRATIONS
rapid and shallow
LEVEL OF CONSCIOUSNESS
restlessness, apprehension,
progressing to coma
URINARY OUTPUT
decreased
TEMPERATURE
Decreases in severe shock
(except in septic shock)

SUBJECTIVE DATA:
Apprehension; restlessness;
paresis of extremities
 TYPES of SHOCK
1. Hypovolemic Shock
- due to a decreased circulating blood
volume
Causes:
Blood Loss
Plasma Loss
Fluid Loss
2. Cardiogenic Shock
- due to the failure of the heart to pump
properly
Causes:
Myocardial Infarction
Congestive Heart Failure
Tension Pneumothorax
Pericardial Tamponade
3. Septic Shock
- similar to anaphylaxis
- maybe due to the following factors:
a. Development of drug resistance
b. Invasive procedure
c. Immunosuppression and old age
d. Trauma
e. Bacterial Infection
4. Neurogenic Shock
- due to rapid vasodilation and
subsequent pooling of blood within the
peripheral vessels
Causes:
Interruption of Sympathetic impulses:
a. Extreme pain
b. Spinal Cord injury
c. High Spinal Anesthesia
d. Head injury/ vasomotor depression
5. Anaphylactic Shock
- due to massive vasodilation
resulting from allergic reaction that
causes the release of histamine.
Causes:
Allergic Reaction to:
Insect venom or snake venom
Medications
Dyes used in radiologic studies
 Therapeutic Interventions
1. Aimed at correcting the underlying
cause
2. Fluid and blood replacement
3. Oxygen therapy, ventilator
4. Vasoconstricting drugs
5. Cardiac and hemodynamic monitoring
 Nursing Interventions
1. Maintain patent airway and adequate
ventilation.
a. Establish and maintain airway
b. Administer oxygen
c. Monitor respiratory status
d. Start resuscitative procedures
2. Promote restoration of blood volume;
administer fluid and blood replacement
as ordered.
a. Crystalloid: PNSS, Plain LR
b. Colloid: Albumin, Plasmanate
c. Blood products
3. Administer drugs as ordered.
4. Minimize factors contributing to shock.
a. Elevate lower extremities (45˚)
b. AVOID trendelenburg’s position
 c. Promote rest
d. Relieve pain by cautious use of
narcotics
e. Keep the patient warm

5. Maintain continuous assessment

of the client
6. Provide psychologic support
 Adult Respiratory Distress
Syndrome (ARDS)
- A form of pulmonary insufficiency with
no previous lung disorder that leads to
damage in the alveolar-capillary
membrane with subsequent leakage of
fluid into the interstitial spaces and
alveoli resulting in pulmonary edema
and impaired gas exchange.
Causes:
It is usually a complication of:
Trauma
Aspiration
Prolonged mechanical ventilation
Severe infection
Open-Heart surgery
Fat Embolism
Shock
 Assessment Findings
1. Dyspnea, cough, tachypnea with
intercostal/ suprasternal retraction,
scattered to diffuse rales
2. Changes in orientation, tachycardia
3. Diagnostic Tests
a. pCO2 increased/ pO2 decreased
b. Hypoxemia
c. Hgb and Hct decreased
 Nursing Interventions
1. Promote optimal ventilatory status
a. Perform ongoing assessment of
lungs with auscultation every 1-
2hours.
b. Elevate head and chest
c. Administer/ monitor mechanical
ventilation
d. Assist with chest physical therapy.
 e. Encourage coughing and
deep breathing every hour.
f. Monitor ABGs, Oxygen
saturation and report
significant changes
2. Promote rest
3. Maintain fluid and electrolyte
imbalances
4. Treat cause
 Gastroesophageal Reflux
Disease (GERD)
- it refers to backflow of gastric
contents into the esophagus gradually
breaking down esophageal mucosa.
Causes:
Inadequate Lower esophageal
spinchter (LES)
Delayed esophageal and gastric
emptying
 Hiatal Hernia
Obesity
Pregnancy
NOTE: GERD may lead to Barrett’s
Esophagus
Clinical Findings
Subjective: Heartburn, dysphagia,
burning pain after meals
 Objective: Regurgitation, hoarseness,
chronic cough, wheezing, projectile
vomiting, esophageal damage
Diagnostic Tests
Muscle Tone decreased
Esophageal pH
Fluoroscopy
Treatment:
Medications
Surgery: Nissen Fundoplication
Hill procedure
 Nursing Interventions
1. Position with head elevated 30˚-45˚
2. Give small, frequent feedings with
adequate burping
3. Provide client teaching and discharge
planning teach parents how to
position and feed the infant.