Seminar on Hemorrhage and Shock

SEMINAR ON HEMORRHAGE AND
SHOCK

MODERATOR:
MRS.PARMEES KAUR
LECTURER
RPCON
PRESENTED BY :
L PREMESHWORI DEVI
M.Sc NURSING1st YEAR
RPCON
HAEMORRHAGE

INTRODUCTION
Hemorrhage is the loss of blood from blood
vessel. The blood loss is described as extra
vacated (outside the vessel).It may lie on the
surface of body, on patients clothing or on
the floor. Blood may be lost from all three
types of vessels, the arteries, the veins, the
capillaries.

1
HAEMORRHAGE
MEANING
The term hemorrhage comes from Greek
haima, blood+rhegnumai to break forth =
a free and forceful escape of blood.

2
HAEMORRHAGE
DEFINITION
The escape of blood from any part of the
vascular system.
3
SIGN AND SYMPTOMS OF
HEMORRHAGE
Early sign and symptoms
Restlessness and anxiety
Feeling faint
Coldness
Slightly increased pulse
Pallor
Patient feels thirsty
Frank bleeding.

4
SIGN AND SYMPTOMS OF
HEMORRHAGE
Sign and symptoms after severe hemorrhage
Extreme pallor
Air hunger (rapid respiration)
Rapid thread pulse
Extreme low blood pressure
Extreme thirst
Diminished urine volume
Blindness, tinnitus and coma occur prior to
death

5
TYPES OF HEMORRHAGE
(According to vessel involved)
Arterial hemorrhage
Capillary hemorrhage
Venous hemorrhage

6
TYPES OF HEMORRHAGE
ARTERIAL HEMORRHAGE
The blood loss is from artery is known as
arterial hemorrhage.
The blood is bright red and spurts with the
heart beat

7
TYPES OF HEMORRHAGE
CAPPILARY HEMORRHAGE
The blood oozes over the surface of capillary
and is darkish red in color oozing over several
hours can result in considerable blood loss.

8
TYPES OF HEMORRHAGE
VENOUS HEMORRHAGE
The blood loss from vein is known as venous
hemorrhage. The blood is dark red in color,
there is no spurting and rate of loss is much
less severe than arterial hemorrhage.

9
TYPES OF HEMORRHAGE
According to the time of wound
1.Primary hemorrhage
2.Reactionary or intermediate hemorrhage
3.Secondary Hemorrhage

10
TYPES OF HEMORRHAGE
PRIMARY HEMORRHAGE
It is immediate hemorrhage which occurs
when there is damage to any blood vessel and
bleeding occurs immediately. E.g. cut on a
finger.

11
TYPES OF HEMORRHAGE
REACTIONARY OR INTERMEDIATE
HEMORRHAGE
It occurs in first 24 hours after operation. The
more severe the operation the more likely it is
to occur specially after the patient has
recovered from circulatory collapse.

12
TYPES OF HEMORRHAGE
SECONDARY HEMORRHAGE
It is due to sloughing off the wall of blood
vessel. The commonest cause is bacterial
infection, but in absence of infection it may
cause by action of enzyme e. g. acid pepsin on
peptic ulcer.

13
TYPES OF HEMORRHAGE
According to clinical classification of the
hemorrhage
1.Revealed or external
2.Concealed or internal

14
TYPES OF HEMORRHAGE
REVEALED HEMORRHAGE
It is type when bleeding can be seen
externally.

15
TYPE OF HEMORRHAGE
CONCEALED HEMORRHAGE
It is a type when bleeding cannot be seen
externally. The bleeding occurs into one of the
body cavities such as abdomen

16
CATEGORIES OF HEMORRHAGE
ACCORDING TO BLOOD LOSS
1.Category 1 - up to 15%of total blood has
been lost
2.Category 2 -15 to 30% of blood loss
3.Category 3 -30 to 40% blood loss
4.Category 4 -more than 40% of blood loss

17
CAUSES OF HEMORRHAGE

A. Traumatic injury
Abrasion
(superficial injury where the skin or mucous
membrane is torn)
Excoriation
(superficial loss of skin due to scratching)
Hematoma(swelling containing clotted blood)
Laceration(wound with torn and ragged edge)
18
Incision (cut into soft tissue)
Contusion
(superficial injury of the tissues produced by sudden
impact in which the skin is unbroken)
Crushing injuries
(injury caused by compression of an object)
Ballistic trauma
(Gun shot wound is an injury creating an open
wound)

19
B.MEDICAL CONDITION
Intravascular changes[Hypertension]
Intramural changes[Aneurysms]
Extra vascular changes[Brain tumor]

20
DIAGNOSTIC EVALUATION OF
HEMORRHAGE
History collection
Physical examination
cyanosis
low blood pressure
Pallor
Endoscopy( examination of esophagus for GI
bleeding)
Colonoscopy (to check the condition of colon)
CT(to check the condition of brain)
21
HEMORRHAGE
Ultrasound (ovarian cyst or tubal pregnancy
bleeding)
Angiography( to evaluate arterial blood flow)
Blood test:
Cross matching
It is a test that is performed prior to blood transfussion
in order to determine if the donors is compatible
with the recipients.

22
HEMORRHAGE
Hematocrit
The Hematocrit also known as packed cell volume or
erythrocyte volume is the volume percentage of red
blood cells in blood.
Normal value: 45% for men
40% for women.
Hemoglobin
to confirm anemia.
Bleeding disorder
23
FIRST AID TREATMENT OF HEMORRHAGE

Bring the side of the wound together and press
firmly.
Press on pressure point for 10 15 minutes.
Place the causality in comfortable position and
raised the injured part and reassure him.
Apply a clean pad larger than the wound and press it
firmly with the palm until bleeding becomes less.
If bleeding continues do not take off original dressing
but add more pads.
Bandage it but not too tightly.

24
FIRST AID TREATMENT OF INTERNAL
HEMORRHAGE

Lay the casualty down with head low; raise his legs
by use of pillow.
Keep him calm and relaxed
Do not allow him to move
Keep up the body heat with thin blanket or coat
Do not give anything to eat or drink, aspiration may
occur
Do not apply hot water bottles to chest or abdomen
Take him to hospital as early as possible
Transport gently

25

NON PHARMACOLOGICAL MANAGEMENT OF
HEMORRHAGE

Pad and bandage: This is a simple method of
applying direct pressure to a bleeding wound and is
applicable to vast majority of cases. It is effective and
causes no damage.
Digital pressure: It is the pressure applied on the
point of artery supplying blood to the area of wound.
This will control hemorrhage temporally and is called
indirect pressure.
26
NON PHARMACOLOGICAL MANAGEMENT OF
HEMORRHAGE
Elevation of the limb: It will control venous
hemorrhage. This is a classical method of dealing
with a sudden hemorrhage from a ruptured varicose
vein of leg.
Application of tourniquet: This is rarely required
except for control of a torrent hemorrhage from the
limb. A temporary tourniquet may have to be
devised in sudden emergency. It should be 3 4 inch
wide. It can be a hanker chief, scarf or tie
Pack: It will temporarily control severe hemorrhage.
The method is used in operation theatre to control
temporary or sudden hemorrhage.
.

27
MEDICAL MANAGEMENT OF HEMORRHAGE
Anti Inhibitor coagulant complex
Brand name
Autoplex T
Feiba NF
Feiba VH
Anti inhibitor complex injection is used to control
bleeding surgery in patient with Hemophilia
It contain substance called coagulation factor.
These substance are used to stop bleeding of
injuries for patient with Hemophilia by helping the
blood to clot.

28
MEDICAL MANAGEMENT OF HEMORRHAGE
Aminocarpic acid
It is used for the treatment of excessive
bleeding resulting from hyperfibrinolysis.
Folic acid (Folate)
Folic acid should be given for healthy Red
blood cell production.
Vitamin B12 (Colbalamine)
It is needed to make red blood cells.
29
MEDICAL MANAGEMENT OF
HEMORRHAGE
Fluid replacement
Crystalloids : Crystalloids fluids(normal saline,
lactated Ringers solution) are the replacement fluid
of choice. They should be warmed and administered
rapidly. If a client with actual loss of blood does not
improve after 2 to 3 liters of crystalloid, then blood
should be administered. The infusion rate is 20ml/kg.
Colloids: Colloid fluids( e.g. blood, albumin)may also
be given. Blood can be administered as whole blood
or as packed red blood cells. Blood is usually warmed
and can be infused quickly. The infusion rate is
40ml/kg. bolus.
30
HEMORRHAGE
OXYGEN: Oxygen should be provided to aid
respiration.
31
SURGICALMANAGEMENT OF
HEMORRHAGE

Surgical ligature: surgical ligation can be done
to control bleeding.
Internal pressure: this may be applied by the
balloon of trilumen tube in bleeding
esophageal varies.
32
TRILUMEN TUBE

33
NURSING MANAGEMENT

Nursing staff must implement resuscitative
technique.
Oxygen therapy should be started
Vital signs checked regularly
Vomit should be assessed
NG tube should be inserted if bleeding is severe and
vomiting is continues to determine amount.
Stools should be observed for malaena.
Urine output must be monitored, as hypotension
caused by bleeding can impair renal output
34
NURSING DIAGNOSIS OF
HEMORRHAGE

Fluid and electrolyte imbalance related to large
amount of blood loss.
Nursing interventions:
Administer IV fluid
Provide blood transfusion
Maintain input and output chart.
Assess the clinical sign of dehydration.
Check the weight of the patient.

35
NURSING DIAGNOSIS OF
HEMORRHAGE
Ineffective tissue perfusion related to bleeding
Observe the sign of cyanosis and respiratory distress
Administered medication as prescribed by the
physician.
Identified changes related to systemic or peripheral
alteration in circulation.eg. Vital signs.

36
NURSING DIAGNOSIS OF HEMORRHAGE
Imbalance nutrition: less than body requirement
related to less intake
Assess the condition of the patient.
Check the weight of the patient
Provide small and frequent diet
Provide nutritious diet
37
Anxiety related to change in health status.
Assess the anxiety level of the patient
Provide psychological support of the patient
Clear the doubts of the patient
Provide medication to improve the health status of
the patient.
38
Ineffective breathing pattern related to altered
respiration.
Nursing interventions
Assess the breathing pattern of the patient.
Provide supplementary oxygen to the patient.
Encourage slow and deep respiration.
Instruct the client to use pursed lip technique.
39
SHOCK

INTRODUCTION
Shock is a complex clinical syndrome that may occur
at any time and in any place. It is a life threatening
condition often requiring team section by many
health care providers, including nurses, physician,
laboratory technicians, pharmacist and respiratory
therapist. Shock cause thousands of deaths and
unknown number of permanent injuries each year.
Shock effect all body systems .It may developed
rapidly or slowly ,depending on the underlying
cause.

40
SHOCK
DEFINITION
Shock is defined as failure of the circulatory
system to maintain adequate perfusion of
vital organs.

41
SHOCK
CLASSIFICATION
1. Hypovolemic shock
2. Cardiogenic shock
3. Distributive/Circulatory shock.

42
STAGES OF SHOCK
1.Compensatory stage
2. Progressive stage
3.Irreversible shock
STAGES OF SHOCK
COMPENSATORY STAGE
In the compensatory stage of shock, the patient blood pressure
remains within the normal limits.Vasoconstriction,increased
heart rate and increased contractility of the heart contribute
to maintaining adequate cardiac output. This result from
stimulation of sympathetic nervous system and subsequent
release of catecholamine(epinephrine and non
epinephrine)The body shunts blood from organs such as the
shin ,kidney and gastrointestinal tract to the brain and heart
to ensure adequate blood supply to these vital organs. As the
patients skin is cold and clammy, bowel sound are hypoactive
and urine output decrease in response to the release of
aldesterone and ADH.
STAGES OF SHOCK
CLINICAL MANIFESTATION OF COMPENSATORY STAGE
Normal blood pressure
Heart rate >100bpm
Respiratory rate>20 breaths/min
Skin become cold and clammy
Decreased urine output
Confusion
MEDICAL MANAGEMENT OF COMPENSATORY
STAGE
The goal are
1 identifying the cause
2 correcting the disorder
3 support the physiologic process.
Fluid replacement and medication therapy should be started
to maintain adequate blood pressure and reestablish and
maintain adequate tissue perfusion.
NURSING MANAGEMENT OF COMPENSATORY
STAGE
Monitoring tissue perfusion:
The nurse should observes for changes in level of
consciousness, vital sign(including pulse pressure), urinary
output, skin and laboratory value. In the compensatory stage
,serum sodium and blood glucose level are elevated in
response to release of aldesterone and catecholamine.
Reducing anxiety
The nurse should provide brief explanation about the
diagnostic and treatment procedure, supporting the patient
during procedure.
STAGES OF SHOCK
PROGRESSIVE STAGE
In the progressive stage of shock, the mechanism that
regulate blood pressure can no longer compensate and MAP
falls below normal limits, with an average systolic blood
pressure of less than 90 mm Hg.

CLINICAL MANIFESTATION OF PROGRESSIVE
STAGE
RESPIRATORY EFFECT
Rapid and swallow respiration
Pulmonary edema( due to pulmonary capillaries leak)
CARDIOVASCULAR EFFECT
Dysrhythmia and ischemia(lack of adequate blood supply)
Rapid heart rate exceeding 150bpm.
Chest pain
NEUROLOGICAL EFFECT
Changes in mental status(cerebral perfusion and hypoxia)

CLINICAL MANIFESTATION OF PROGRESSIVE
STAGE
RENAL EFFECT
Acute renal failure
Increased blood urea nitrogen
Increased creatinine level
Decreased urine output below 0.5/ml/kg per hour.
GASTOINTESTINAL EFFECT
Stress ulcer(gastrointestinal ischemia)
Bloody diarrhea(necrotic mucosa)

IRREVERSIBLE STAGE
In irreversible(or refractory) stage of shock organ damage is
so severe that patient does not respond to treatment and
cannot survive. Despite treatment , blood pressure remains
low and complete renal and liver failure.

CLASSIFICATION OF SHOCK
HYPOVOLEMIC: Hypovolemic shock is due to
inadequate circulating blood volume resulting from
hemorrhage with actual blood loss or dehydration
with a loss of fluid volume. It is the most common
type of shock and develop when the intravascular
volume decrease to the point where compensatory
mechanism are unable to maintain organ and tissue
perfusion.

SHOCK
Risk factor:
1.External: fluid loss
2.Internal :fluid shift

RISK FACTOR OF SHOCK
External: fluid loss
Trauma
Surgery
Vomiting
Diarrhea
Diuresis
Diabetic insipidus.

RISK FACTOR OF SHOCK
Internal: fluid shifts
Hemorrhage
Burns
Ascites(free fluid in the peritoneal cavity result from
local inflammation or obstruction)
Peritonitis
Dehydration.
CAUSES OF HYPOVOLEMIC SHOCK
Loss of blood(external or internal bleeding)
Loss of plasma(severe burns and lesions discharging fluid)
Loss of body sodium e.g. Excessive sweating ,diarrhea or
vomiting.
PATHOPHYSIOLOGY OF HYPOVOLEMIC
SHOCK
Decreased blood volume

Decreased venous return

Decreased stroke volume

Decreased cardiac output

Decreased tissue perfusion

CLINICAL MENIFESTATION OF HYPOVOLEMIC
SHOCK
Tachycardia
Diminished Blood pressure
Thirsty
Faint
Rapid breathing
Dizziness
Dry nose, mouth and mucous membrane
Loss of skin elasticity
Cold and clammy skin
Sweating
Anxiety
unconsciousness

HYPOVOLEMIC SHOCK
Medical management: Major goal of hypovolemic
shock are to
1. Restore intravascular volume to reverse the
sequence of events leading to inadequate tissue
perfusion
2. Redistribute fluid volume and
3. Correct the underlying cause of the fluid loss as
quickly as possible.

HYPOVOLEMIC SHOCK
Treatment of the underlying cause: If the patient is
hemorrhagic, efforts are made to stop the bleeding
by applying pressure to the bleeding site or surgery
to stop internal bleeding.If the cause of the
hypovolemia is diarrhoea or vommiting,medications
to treat diarrhoea and vommiting are administered
as efforts are made simultaneously to identify and
treat the cause.

HYPOVOLEMIC SHOCK
Fluid and blood replacement: At least two large gauge
intravenous lines are inserted to establish access for fluid
administration.Two intravenous line allow simultaneous
administration of fluid , medication and blood component
therapy if required
Lacted Ringers and 0.9% sodium chloride solutions are
isotonic crystalloid fluids commonly used in treating
hypovolemic shock.Large amount of fluid must be
administered to restore intravascular volume because
isotonic crystalloid solution move freely between the fluid
compartments of the body and do not remain in the vascular
system.

HYPOVOLEMIC SHOCK
Redistribution of fluid: In addition to administering
fluid to restore intravascular volume, positioning the
patient properly assist fluid redistribution. A
modified Trendelburg position is recommended in
hypovolemic shock. Elevating the legs promote the
return of venous blood.
Pharmacologic therapy: If fluid administration fail to
reverse hypovolemic shock ,then the same
medication given in the Cardiogenic shock are used
because unreversed hypovolemic shock progress to
cardiogenic shock.

HYPOVOLEMIC SHOCK
If the underlying cause of the hypovolemia is
dehydration, medication are also administered to
reverse the cause of dehydration. For example,
insulin is administered if dehydration is secondary to
hyperglycemia,desmopressin is administered for
diabetes insipidus, antidiarrheal agent for diarrhea,
and antiemetic medication for vomiting.

NURSING MANAGEMENT OF
HYPOVOLEMIC SHOCK

General nursing measures include ensuring safe
administration of prescribed fluids and medication and
documenting their administration and effects. Another
important nursing role is monitoring for signs of
complications and side effect of treatment and reporting
these sign early in treatment.
Administering blood and fluid safely: Administering blood
transfusions safely is a vital nursing role. In emergency
situations, it is important to obtain blood specimens quickly
to obtained a baseline complete blood count and type and
cross match the blood in anticipation of blood
transfussion.The patient who receives a transfusion blood
product must be monitored closely for adverse effect.

HYPOVOLEMIC SHOCK
Fluid replacement complication can occur,often when large
volumes are administered rapidly.Therefore, the nurse monitors
patient closely for cardiovascular overload and pulmonary
edema.Hemodynamic pressure, vital signs,arterial blood
gases,hemoglobin and hematocrit level,and fluid intake and
output should be monitored.The patient temperature also
should monitored closely to ensure that rapid fluid resuscitation
does not precipitate hypothermia.Intravenous fluid may need to
warmed during the administration of large volume.The nurse
need to monitor cardiac and respiratory status closely and
report changes in blood pressure,pulse pressure ,heart
rate,rhythm and lung sounds to the physician.
HYPOVOLEMIC SHOCK
Implementing other measures:Oxygen is
administered to increase the amount of
oxygen carried by available hemoglobin in the
blood.A patient who is confused may feel
apprehensive with an oxygen mask or cannula
in place, and frequent explanation about the
need for the mask may reduce some of the
patients fear and anxiety.

TYPES OF SHOCK
CARDIOGENIC SHOCK
Cardiogenic shock occurs when the hearts ability to
contract and pump blood is impaired and supply of
oxygen is inadequate for the heart and tissues. The
cause of Cardiogenic shock are known as either
coronary or non coronary

RISK FACTOR OF CARDIOGENIC SHOCK
Coronary factor:
Myocardial infarction( stoppage of the blood flow of
the heart muscle due to clot)
Non coronary factor:
1.Cardiomyopathies(heart muscle disease
associated with cardiac dysfunction)
2.Valvular damage
3.Cardiac tamponade(fluid accumulate in the
pericardium)
4.Dysrhythmias(abnormal electrical conductivity of
heart).

CAUSES OF CARDIOGENIC SHOCK
Myocarditis (inflammation of the myocardium i.e. muscle of
the heart)
Endocarditis(inflammation of the endocardium i.e. membrane
lining of the heart)
Pericardial tamponade.
Aortic stenosis
Mitral regurgitation
Cardiac dysrhythmia
PATHOPHYSIOLOGY OF CARDIOGENIC
SHOCK
Decreased cardiac contractility

Decreased stroke volume and cardiac output

Pulmonary congestion, decreased tissue
perfusion, decreased coronary artery
perfusion volume

CARDIOGENIC SHOCK
Clinical manifestation:
1.Angina pain(a tight strangling sensation or pain)
2.Dysrhythmias(abnormal rhythm)
3.Hemodynamic instability.(a state requiring
pharmacologic and mechanical support to maintain
normal blood pressure and cardiac output)

MEDICAL MANAGEMENT OF CARDIOGENIC
SHOCK
The goal of medical management are to
1.limit further myocardial damage and preserve the healthy
myocardium
2.improve the cardiac function by increasing cardiac
contractility, decreasing ventricular afterload, or both
Correction of underlying cause: 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. In the case
of coronary cardiogenic shock ,the patient may required
thrombolytic therapy ,angioplasty or coronary artery bypass
graft surgery. In case of noncoronary cardiogenic shock ,the
patient may required a cardiac valve replacement and
correction of dysrhythmia.

SHOCK
Initiation of first- line treatment: it include
1.supplying supplemental oxygen
2.controlling chest pain
3.providing selected fluid support
4.administering vasoactive medication
5.controlling heart rate with medication or by implementation of
transthoracic or intravenous pacemaker.
6.implementing mechanical cardiac support (intra aortic balloon
counterpulsation therapy,ventricular assist system or
extracorporeal cardiopulmonary bypass)

SHOCK
A.Oxygenation: In the early stage of shock, supplemental
oxygen is administered by nasal cannula at a rate of 2 to
6L/minto achieved an oxygen saturation exceeding
90%.Monitoring arterial blood gas value helps to indicate
whether the patient requires a more aggressive method of
oxygen delivery.
B.Pain control: If the patient experience chest pain,morphine
sulphate is administered intravenously for pain relief.In
addition to relieving pain,morphine dilate the blood
vessels.This reduce the workload of the heart by both
decreasing the cardiac filling pressure(preload) and reducing
the pressure against which the heart muscle has to eject
blood(afterload)

SHOCK
C.Hemodynamic monitoring: Hemodynamic
monitoring is initiated to assess the patients
response to treatment. A multilumen pulmonary
artery catheter is inserted to allow measurement of
the pulmonary artery pressure, myocardial filling
pressure, cardiac output and pulmonary and
systemic resistance.

SHOCK
Pharmacologic therapy:
a.Dobutamine: Dobutamine(Dobutrex) produces inotropic
effects by stimulating myocardial beta receptors,increasing
the strength of myocardial activity and improving cardiac
output.Myocardial alpha adrenergic receptors are also
stimulated,resulting in decresed pulmonary and systemic
vascular resistance(decreased afterload)Dobutamine
enhances the stength of cardiac contraction, improving stroke
volume ejection and overall cardiac output.
b.Nitroglycerin: Intavenous nitroglycerine (Tridil) in low doses
acts as a venous vasodilator and therefore reduce preload.At
higher dose ,nitroglycerine causes arterial vasodilation and
therefore reduce afterload as well.

SHOCK
c.Dopamine: Dopamine (Intropin)is a sympathomimetic agent
that has varying vasoactive effect depending on the dosage.It
may be used with dobutamine and nitroglycerine to improve
tissue perfussion.Low dose dopamine(0.5 to 3.0g/kg/min)
increase renal and mesentric blood flow,thereby preventing
ischemia of the organ because shock cause blood to be
shunted away from the kidneys and the mesentry.
d.Other vasoactive mediaction: Additonal vasoactive agents
that may be used in amanging cardiogenic shock include
norepinephrine(Levophed), epinephrine(Adrenalin),
milrinone(Primacor) ,amrinone(Inocor),and
vasopressin(Pitressin).Each of these medication stimulate
different receptor of thje sympathetic nervous system.

SHOCK
Antiarrhythmic medication: It is also a part of the medication
regimen in cardiogenic shock .It is required to stabilized the
heart rate .
Fluid therapy: In addition to medications appropriate fluid is
necessary in treating cardiogenic shock. Administration of
fluid must be monitored closely to detect sign of fluid
overload. A fluid bolus should never be given quickly because
rapid fluid administration in patient with cardiac failure may
result in acute pulmonary edema.

SHOCK
Mechanical assistive device: If cardiac output does not
improve despite supplemental oxygen,vasoactive medications
and fluid boluses, mechanical assistive device are used
temporarily to improve the hearts ability to pump.Intra aortic
balloon counter pulsation is one means of providing
temporary circulatory assistance. A polyurethane balloon
catheter is inserted percutaneously through the common
femoral artery and advanced into the descending thoracic
aorta.
Other means of mechanical assistance include left and
right ventricular assist device and total artificial hearts. These
device are electrical pumps driven by air. They assist or
replace the ventricular pumping action of the heart.

SHOCK
Another short term means of providing cardiac or pulmonary
support to the patient in Cardiogenic shock is through an
extra corporeal device similar to the cardiopulmonary bypass
used in open heart surgery
SHOCK
Cardiac glycosides
Digoxine :It is a cardiac glycosides derived from digitalis. It is
used for systolic HF ,atrial fibrillation and atrial flutter.Digoxin
improves the cardiac function as follow:
Increased the force of myocardial con traction
Increased cardiac output by enhancing the force of
ventricular contraction
Promote diuresis by increasing cardiac output
Tablets: 0.125,0.25,0.5 mg
Injection:0.25mg/ml

SHOCK
Brand name :
Tablet Digitran 250mcg
Tablet Digon 0.25mg
Tablet Dixin 0.25mg
Tablet Lanoxin 0.25mg

CARDIOGENIC SHOCK
Nursing role for administering Digoxin
Assess the patients clinical response to Digoxin therapy by
evaluating relief of symptoms such as
dyspnea,orthopnea,crackles ,hepatomegaly and peripheral
edema.
Assess the symptoms of electrolyte depletion,mental con
fusion,anorexia,decreased urinary output.
Berfore administering digoxin ,it is standard nursing practice
to assess the apical heart rate.When the patient rhythms is
atrial fibrillation and heart rate is less than 60, or the rhythm
become regular ,the nurse may withhold the medication and
notify the physician,because these sign indicate the
development of AV conduction block.
CARDIOGENIC SHOCK
Nursing role:
Monitor for gastro intestinal side effect: anorexia, nausea,
vomiting, abdominal pain and distention.
Monitor for neurological side effect: headache, forgetfulness,
social withdrawal, depression, confusion, hallucination,
decreased visual acuity , snowy vision.
Observed for and anticipate potential drug interaction when
other medication are added to the patients regimen.
SHOCK
Vasopressor
It is naturally occurring organic amine. It is additionally act on
dopaminergicD2 receptor in renal and mesentric blood
vessels, dilate them. on heart it has positive inotropic but
little chronotropic effective infusion raise cardiac output &
systolic BP, little effect on diastolic BP.
Dobutamine 2.5 to 10 ug/kg/min.
Cardiject inj 50mg/4ml
Dobier inj 250/5ml
SHOCK
Antiarrhythmic drugs
Membrane stabilizing agent
Disopyramide :It is a cardiac depressant and marked
anticholinergic action
100 to 600 mg 6 hourly.
SHOCK
Calcium channel blockers
Verapamil. The antihypertensive effect of verampil,stems
from a decrease in peripheral vascular resistance without an
increase in heart rate as a reflex response .it has marked
Antiarrhythmic effect particularly in supraventricular
arrthmias.it delays impulse conduction in the AV node .
Dose
oral 40- 80 mg 3 to 4 times daily
Calaptin 40mg
Vasopten 40 mg
NURSING MANAGEMENT OF CARDIOGENIC
SHOCK
1.Preventing cardiogenic shock: Identifying patient at risk
early and promoting adequate oxygenation of the heart
muscle and decreasing cardiac workload can prevent
cardiogenic shock.
2.Monitoring hemodynamic status: A major role of the nurse
is monitoring the patients hemodynamic and cardiac
status.Arterial line and electrocardiographic monitoring
equipment must be maintained and functioning properly.The
nurse anticipate the medication ,intravenous fluid and
equipment that might be used and is ready to assist in
implementing these measures.Changes in hemodynamic,
cardiac and pulmonary status are documented and reported
promptly.Additionaly ,adventitious breath sounds, changes in
cardiac rhythm and other abnormal physical assessment
finding are reported immmediately

NURSING MANAGEMENT OF CARDIOGENIC
SHOCK
3.Administering medication and intravenous fluid: The nurse
has a critical role in safe and accurate administration of
intravenous fluid and medication.The nurse document and
records medication and treatment that are administered as
well as patient response to treatment.
4. Maintaining intra aortic ballon counterpulsation: The nurse
play a critical role in caring for the patient receiving intra
aortic ballon counterpulsation.The nurse make ongoing time
adjustment of the ballon pump to minimize its effectiveness
by syncronizing it with the cardiac cycle.

CARDIOGENIC SHOCK
5.Enhancing safety and comfort: The nurse must take an
active role in safeguarding the patient ,enhancing comfort
and reducing anxiety .These include administering medication
to relieve chest pain ,preventing infection at the multiple
arterial and venous line insertion sites, protecting the skin
and monitoring respiratory function.

DISTRIBUTIVE OR CIRCULATORY SHOCK
Distributive or Circulatory shock occurs when blood volume is
abnormally displaced in the vasculature- for example,when
blood volume pools in peripheral blood vessels.The
displacement of blood volume causes a relative hypovolemia
because not enough blood return to the heart,which lead to
subsequent in adequate in tissue perfusssion.

In this there is no blood loss but the shock is due to dilation of
the blood vessels.This displacement of blood causes a relative
hypovolemia because not enough blood returns to heart
which leads to subsequent inadequate tissue perfusion.

TYPES OF DISTRIBUTIVE SHOCK
Septic shock.
Neurogenic shock.
Anaphylactic shock.

PATHOPHYSIOLOGY OF DISTRIBUTIVE SHOCK
Vasodilatation

Mal distribution of blood volume

Decreased venous return

Decreased stroke volume

Decreased cardiac output

Decreased tissue perfusion

SEPTIC SHOCK
Septic shock is the most common type of circulatory shocks
and is caused by widespread infection.
Risk factor
1.Immunosuppression
2.Extremes of age
3.Malnourishment
4.Chronic illness
5.Invasive procedure.
Causes
Gram negative bacterial infection

SEPTIC SHOCK
Pathophysiology
Gram negative bacteria

release of endotoxin

Phagocytic activity of microphages system

vascular permeability

Capillary damage
Leakage of plasma- fluid volume loss
hypotension
CLINICAL MANIFESTATION OF SEPTIC SHOCK
Flushed skin
Tachypnoea
Tachycardia
Nausea ,vomiting
Hyperthermia
Confusion
Hypotension
Decrease urine output
MEDICAL MANAGEMENT OF SEPTIC SHOCK
Medical management includes identifying and eliminating the
cause of infection.Specimen of blood,sputum ,urine,wound
drainage and invasive cathetertips are collected for culture
using aseptic technique.
Fluid replacement instituted to correct hypovolemia that
result from the incopetence vasculature and inflammatory
response.Crystalloid, colloids and blood products may be
administered to increase intravascular volume.

76
MEDICAL MANAGEMENT OF SEPTIC SHOCK
Pharmacologic therapy: Broad spectrum antibiotic agent
started until culture and sensitivity reports are received if the
infection organism is unknown. A third generation
cephalosporin plus an aminoglycoside may be prescribed
initially.
Nutritional therapy: Aggressive nutritional supplementation is
critical in the management of specific shock because
malnutrition further impairs the patient resistance of
infection. Nutritional supplement should be initiated within
24 hours of the onset of shock.Enteral feeding are preferred
to the parentral route because of the increased risk of
iatrogenic infection associated with intravenous catheter.

NURSING MANAGEMENT OF SEPTIC SHOCK
The nurse caring for any patient in any setting must kept in
mind the risk of sepsis and high mortality rate associated with
septic shock.All invasive procedure must be carried out with
aseptic technique after careful hand hygeine.Additionally
,intravenous lines,arterial and venous puncyure site,surgical
incision, traumatic wound urinary catheter and ulcer pressure
are monitored for sign of infection in all patients.
NEUROGENIC SHOCK
This is very uncommon type of shock. It is most often seen in
patients who have had an extensive spinal cord injuries. The
loss of autonomic and motor reflex below level of injury result
in loss of sympathetic control. This lead to relaxation of
vessels and peripheral dilatation and hypotension. This is
characterized by warmth and dry skin bradycardia rather than
other type of shock.

CAUSES OF NEUROGENIC SHOCK
Severe brain and spinal cord damage
CLINICAL MANIFESTATION OF NEUROGENIC SHOCK
Low BP
Dry skin
Weak pulse
Rapid breathing
Unconsciousness
Weakness
Thirst
Dry mouth
Fatique.
MANAGEMENT OF NEUROGENIC SHOCK
Medical management:
It involve restoring sympathetic tone either through the
stabilazation of a spinal cord injury or in the instsance of
spinal anesthesia by positioning the patient properly.
Nursing management:
The nurse should elevate and maintain the head of the bed at
least 30 degree to prevent neurogenic shock when the
patient is receiving spinal or epidural anesthesia.

ANAPHYLACTIC SHOCK

Anaphylactic shock is caused by the severe reaction to an
allergen, antigen, drug or foreign protein. When a patient
who has already produced antibodies to a foreign substance
develops a systemic antigen antibody reaction. Antigen
antibody provides mast cells to release vasoactive substance
such as histamine or bradykinin that cause vasodilatation.

ANAPHYLACTIC SHOCK
SYMPTOMS
Confusion
Weakness
Pale color
Unconsciousness
SOB
MEDICAL MANAGEMENT OF ANAPHYLACTIC
SHOCK

Treatment of anaphylactic shock requires removing the
causative antigen,administering medication that restore
vascular tone and providing emergency support of basic life
functions.Epiniphrine is given for its vasoconstructive
action.Diphenhydramine is administered to reverse the
effects of histamine,thereby reducing capillary
permeability.These medications are given
intravenously.Nebulized medication such as albuterol, may be
given to reverse histamine induced bronchospasm.

Nursing management of anaphylactic shock
The nurse has an an important role in preventing anaphylactic
shock: assessing all patients for allergies or previous reactions
to antigens(eg. Medication, blood product)and
communicating the existence of these allergies or reaction to
others.When new allergies are identified, the nurse advises
the patient to wear or cary identification that names the
specific allergen or antigen.
When administering any new medication the nurse observe
the patient for an allergic reaction.This is especially important
in intravenous medications.Allergy to penicillin is one of the
most common cause of anaphylactic shock.

NURSING MANAGEMENT OF ANAPHYLACTIC
SHOCK
The nurse has an an important role in preventing anaphylactic
shock: assessing all patients for allergies or previous reactions
to antigens(eg. Medication, blood product)and
communicating the existence of these allergies or reaction to
others.When new allergies are identified, the nurse advises
the patient to wear or cary identification that names the
specific allergen or antigen.
When administering any new medication the nurse observe
the patient for an allergic reaction.This is especially important
in intravenous medications.Allergy to penicillin is one of the
most common cause of anaphylactic shock.

NURSING MANAGEMENT OF ANAPHYLACTIC
SHOCK
In the hospital and outpatient diagnostic testing sites,the
nurse must identified patient at risk for anaphylactic reaction
to contrast agent(radiopaque )used for diagnostic test.
The nurse must be knowledgeable about the clinical signs of
anaphylaxis, must take immediate action if sign and
symptoms are present and must be prepared to begin
cardiopulmonary resuscitation if cardiorespiratory arrest
occur.

NURSING DIAGNOSIS OF SHOCK
Fluid volume deficit related to hemorrhage
Nursing intervention:
Monitor the sign and symptoms of internal bleeding
Check for blood pressure.
Give comfortable position.
Keep the patient warm and monitor temperature hourly.
Administer intravenous fluid as ordered.
Monitor urine output.
Administer oxygen as ordered.

Decreased cardiac output related to ineffective cardiac
function.
Administer IV fluids.
Monitor urine output.
Monitor blood pressure and pulse rate
Administer inotropic agent to correct ventricular function.

Risk for infection related to interruption of skin integrity
from invasive procedures.
Take precaution to prevent nosocromial infections.
Wash hand frequently.
Use aseptic technique
Monitor site for insertion for sign of infection.
Change the intravenous.
Change the intravenous catheter every three days.
Provide indwelling catheter care frequently.

Altered nutrition less than body requirement related to
decrease oral intake.
Monitor daily weight and identify weight loss
Consult nutritionist for recommendations about diet.
Check for gastric residuals every 4 hourly; notify the physician
if it is greater than 100ml.
Monitor for hematocrit ,hemoglobin to assess the adequacy
of nutritional replacement

Altered peripheral tissue perfusion related to edema from
stasis of blood in the capillaries and vasoconstriction.
Monitor the extend of fluid retention.
Monitor daily weight of the patient.
Determine the severity of edema.
Watch for elevation in central venous pressure.
Check signs and symptoms of fluid overload.

MULTIPLE ORGAN DYSFUNCTION SYNDROME
Multiple organ dysfunction syndrome is altered organ
function in acutely ill patient that requires medical
intervention to support continued organ function. It is
another phase in progression of shock states.
INCIDENCE
It is estimated that MODS has an associated mortality rate as
high 75%
TYPES OF MODS
PRIMARY MODS:
It is the result of direct tissue insult, which then lead to
impaired perfusion or ischemia
SECONDARY MODS
It is most often a complication of septic shock or Systemic
inflammatory response syndrome.
RISK FACTOR OF MODS

Chronic illness
Malnutrition
Immunosuppression
Surgical or traumatic wound.
CAUSES OF MODS
Dead tissue
Injured tissue
Infection
Perfusion deficit
Persistent source of inflammation
CLINICAL MANIFESTATION OF MODS
Low blood pressure
Fever
Hyperglycemia
Hyperlacticademia(excess of lactic acid in the blood).
Polyuria
Skin breakdown
Severe loss of skeletal muscle mass.
Hyperbilirubinemia(liver failure)
Oliguria progressing to anuria(renal failure)
MEDICAL MANAGEMENT OF MODS
Early detection and documentation of initial sign of infection
are essential.
MEDICATION
1.Vasopressor therapy
Dopamine, epinephrine, norepinephrine, phenylephrine
To maintain circulation and tissue perfusion after volume
resuscitation has been accomplished
2.H
2
receptor antagonist
Ranitidine (Zantac), cimetidine (Tagamet), famotidine
(Pepcid), nizatidine (Axid)
Blocks gastric secretion
Broad spectrum antibiotics

NURSING MANAGEMENT OF MODS
Primary nursing intervention are aimed at supporting the
patient and monitoring organ perfusion
Providing information and support to the family members
Encourage frequent and open communication about
treatment modalities
Informed about the goal of rehabilitation because the
massive loss of skeletal muscle makes rehabilitation long
,slow process
Early detection and documentation of initial sign of infection
are essential

ALTERATION IN BODY TEMPERATURE
INTRODUCTION
Body temperature reflects the balance
between the heats produced and heat loss
from the body. Abnormal body temperature
can be slight such as low grade fever or life
threatening as in severe case of hypothermia
or hyperthermia.
The normal Body temperature is 37degree c

BODY TEMPERATURE
DEFINITION
The body temperature is the difference between the
amount of heat produced by the body process and
amount of heat loss to the external environment.
Body temperature =
Heat produced Heat lost

BODY TEMPERATURE
TYPES
Core temperature
Surface temperature
CORE TEMPERATURE
It is the temperature of the interior body tissue
below the skin and subcutaneous tissue.
SURFACE TEMPERATURE
It refers to body temperature at the surface that is
of skin and subcutaneous tissue.

MEASUREMENTS SITES OF BODY
TEMPERATURE
CORE
Rectal
Tympanic membrane
Esophageal
Pulmonary artery
Urinary bladder
SURFACE
Skin
Axiliary
Oral
ASSESSMENT OF BODY TEMPERATURE

Sites: There are several sites for measuring core and
surface body temperature.The core temperature of
the pulmonary artery ,esophagus and urinary
bladder are often used in intensive care
settings.These measurement require the use of
continuous invasive device placed in body cavities
and organs.The temperature device obtain accurate
reading quickly and continually display reading on an
electronic monitor
TYPES OF THERMOMETRE
Glass thermometer
Electronic thermometer
Disposible thermometer
Each device measures temperature in
centigrade or Fahrenheit scales. Electronic
thermometer allow the nurse to convert
scales by activating a switch. When it is
necessary to convert temperature reading the
following formulas can be used:

FORMULA FOR CONVERTING CENTRIGRADE TO
FAHRENHEIT
To convert Fahrenheit to Centrigade,subtract 32
degree from the Fahrenheit reading and multiply the
result by 5/9.
(F 32 degree) x 5/9 = C
Example: (104 degreeF 32 degree F) X 5/9 = 40
degree C.
2.To convert Centrigade to Farenheit, multiply the
Centrigade reading by 9/5 and add 32 degree to the
sproduct.
(9/5 X C) +32 degree = F
Example: (9/5 x40 degree C)+32 degree = 104
degree F

THERMOMETRE TYPE
Glass thermometre: The mercury in glass thermometre is the
most fimiliiar.It is a glass tube sealed at one end with a
mercury-filled bulb at the other.Exposure of the bulb to heat
cause the mercury to expand and rise in the enclosed
tube.The length of the thermometre is marked with Farenheit
or Centrigade caliberation.The farthest point reached by the
mercury in the tube is the temperature reading.The mercury
will not fkuctuate or fall unless the thermometre is shaken
vigorously.
The nurse read the mercury thermometre by holding it
with the fingertips horizontally at eye level, with the bulp
pointed to the left.By rotating the thermometre slowly, the
column of silver mercury appear.

THERMOMETRE TYPE
The type of glass thermometer are
The oral
The rectal
Electronic thermometre: The electronic thermometre consists
of a rechargeable battery powered display unit, a thin wire
cord , and a temperature processing prove covered by a
disposable plastic sheath. One form of electric thermometre
uses a pencil like probe. Separate non breakable probes are
available for oral and rectal use. The probe can also be used
for axillary temperature measurement. Within 20 to 50
second of insertion, a reading appears on the display unit.A
sound signal when the peak temperature reading has been
measured.

THERMOMETRE TYPE
Another form of electronic thermometer is used exclusively
for tympanic temperature. An otoscope like speculum with an
infrared sensor tip detect heat detected from the tympanic
membrane. Within 2 to 5 seconds of placement in the
auditory canal ,a reading appear on the display unit. A sound
signal when the peak the peak temperature has been
measured.
Disposable thermometer: Disposable, single use thermometer
are thin strips of plastic with chemically impregnated paper.
They are used for oral and axillary temperature, particularly
with childreen.They are inserted the same way as an oral
thermometre and used only once. Chemical dots on the
thermometre change color to reflect the temperature
reading.only 45 seconds are needed to record the
temperature

ADVANTAGE AND DISADVANTAGE OF SELECT
TEMPERATURE MESUREMENT SITES AND METHODS:

Tympanic membrane sensor:
Advantage:
Easily accessible site
Minimal client positioning required.
Provide accurate core reading.
Very rapid measurement.
Can be obtained without disturbing or walking client.
Disadvantage:
Hearing aids must be removed before measurement
Should not be used with client who have had surgery of the
ear or tympanic membrane.
Required disposible probe cover
Expensive

Contd..
Electronic thermometer
Advantage:
Plastic sheath unbreakable; ideal for children
Quick readings
Disadvantage
May be less accurate by Axiliary route

Contd..
Rectal
Advantage
Argued to be more reliable when oral temperature cannot be
obtained.
Disadvantage:
Should not be used who have had rectal surgery, rectal
disorder ,bleeding tendencies
Required positioning and may be source of client
embarrassment and anxiety
Required lubrication

Contd..
Oral
Advantage :
Accessible requires no position change.
Comfortable for client
Provide accurate surface temperature reading.
Indicate rapid change in core temperature.
Disadvantage:
Affected by ingestion of fluids or foods, smoke and oxygen
delivery
Should not be used with client who have had oral surgery,
trauma, history of epilepsy or shaking chills
Should not used with infants, small children, or confused,
unconscious or uncooperative clients

Contd..
Axilla
Advantage
Safe and non invasive
Can be used in newborn
Disadvantage:
Long measurement time
Required continuous positioning by nurse
Required exposure of thorax

Contd..
Skin
Advantage
Inexpensive
Provide continuous reading
Safe and noninvasive
Disadvantage
Diaphoresis or sweat can impair adhesion.

BODY TEMPERATURE REGULATION
Body temperature is regulated by physiological and
behavioral mechanisms .For the body temperature to stay
constant, and within the normal range, the relationship
between heat production and heat loss must be maintained.
This relationship is regulated by neurological and
cardiovascular mechanisms to promote temperature
regulation.
Neural and vascular control: The hypothalamus located
between the cerebral hemispheres, controls body
temperature. A comfortable temperature is the set point at
which a heating system operates. The hypothalamus senses
minor changes in body temperature. The anterior
hypothalamus control heat loss and posterior hypothalamus
controls heat production.

When the nerve cells in the hypothalamus become heated
beyond the set point, impulses are sent out to reduce body
temperature. Mechanisms of heat loss include sweating,
vasodilatation and inhibition of heat production. If the
hypothalamus senses the bodys temperature lower than set
point, signal are sent out to increase heat production by
muscle shivering or heat conservation by vasoconstriction of
surface blood vessels

Heat production: Thermoregulation requires the normal
function of heat production processes. Heat is produced as a
by- product of metabolism. Cellular chemical reaction
requires energy in the form of ATP. The amount of energy
used for metabolism is the metabolic rate. As metabolism
increase, additional heat is produced. When metabolism
decrease, less heat is produced. Heat production occurs
during rest, voluntary movements, involuntary shivering and
non shivering thermogenesis

Heat loss: Heat loss and heat production occur
simultaneously. The skins structure and exposure to the
environment result in constant, normal heat loss through
radiation, conduction convection and evaporation.
Radiation is the transfer of heat between two objects by
electromagnetic wave.
Conduction is transfer of heat from one object to another
with direct contact.
Convection is the transfer of heat away by air movement.
Evaporation is the transfer of heat energy when a liquid is
change to gas.

Behavioral control: Humans voluntary act to maintain
comfortable body temperature when exposed to
temperature extremes. When the environmental
temperature falls, a person can add clothing, move to a
warmer place, increase muscular activity by running in place,
or sit with arms and legs tightly wrapped together. In contrast
, when the temperature become hot , a person can remove
clothing, stop activity, seek a cooler place or take a cool
shower.

FACTORS AFFECTING BODY TEMPERATURE

Age
Exercise
Hormone influence
Daily variation
Stress
Environment
Ingestion of hot/cold liquids
Smoking.
AGE: The older adult has a narrower range of body
temperature than a younger adult.
EXERCISE: Any form of exercise can increase body
temperature.

FACTORS AFFECTING BODY TEMPERATURE
HORMONAL INFLUENCE: In female, hormone changes during
ovulation and menstruation cause body temperature
fluctuations
DAILY VARIATION: Body temperature normally changes 0.5
degree to 1 degree C.
STRESS: Physical or emotional stress such as anxiety, can raise
body temperature.
ENVIRONMENT: Environmental temperature extremes can
raise or lower body temperature.
INGESTION OF HOT/COLD LIQUIDS: Drinking hot or cold liquid
can cause slight variation in actual oral temperature reading.
SMOKING: Smoking cigarettes can increase body temperature
measurement..

DISPOSIBLE THERMOMETRE
TYMPANIC THERMOMTRE
RECTAL THERMOMETRE

DIGITAL ORAL THERMOMETRE

AXILLARY THERMOMETRE

ALTERATION IN BODY TEMPERATURE

Hyperthermia/Pyrexia
Hypothermia

PYREXIA
Hyperthermia or fever occur because heat loss mechanisms
are unable to keep pace with excess heat production,
resulting in abnormal rise in body temperature. A fever is
usually not harmful if it stay below 39 degree C.
A true fever result from an alteration in hypothalamic set
point. Pyogens such as bacteria cause a rise in body
temperature. When they enter the body , Pyogens act as
antigens, triggering the immune system. Hormone like
substance are released to promote the bodys defence
against infection.
Fever also serve a diagnostic purpose. The duration and
degree of fever depend on the pyogens strength and the
ability to the individual respond. The term fever of unknown
origin(FUO) refers to a fever whose etiology cannot be
determined.

FEVER OF UNKNOWN ORIGIN
The term fever of unknown origin refers to a fever
whose etiology is unknown.
PYREXIA
DEFINITION
Fever or pyrexia is defined as a rise in the body temperature
above 99degree F(37.7 degree C)
A body temperature above the normal is called pyrexia,
hyperthermia or fever.

PYREXIA
CAUSES
1.Infection
2.Disease of the nervous system
3.Certain malignant neoplasm
4.disease such as leukemia, embolism and thrombosis
5.Allergic reaction to foreign pyrogens

CLINICAL FEATURES OF PYREXIA

1.Respiratory system: Shallow and rapid breathing
2.Circulatory system: Increased pulse rate and palpitation
3.Alimentary system: Dry mouth,coatred tongue, loss of
appetite,indigestion,nausea,vomitting constipation or
diarrhea.
4.Urinary system: Diminished urinary output, burning
micturition,high colored urine.
5.Nervous system: Headache, restlessness, irritability
,insomnia,convulsions,delirium
6.Musculo skeletal system: Malaise, fatigue, body pain, joint
pain
7.Integumentary system: Heavy sweating,hot flushes, goose
flesh, shivering or rigors

TYPES OF FEVER
1.Onset or invasion: Onset or invasion of fever is the period
when the body temperature is rising and it may be a sudden
or gradual process.E.g Dengue fever
2.Fastigium or stadium: It is period when the body
temperature has reached its maximum and remain fairly
constant at a high level.eg Pneumonia
3.Defervescence or decline: It is the period when elevated
temperature is returning to normal. The fever may be subside
suddenly or gradually.E.g Scarlet fever
4.Crisis:It is a sudden return to normal temperature from very
high temperature within a very few hours or days.Eg Yellow
fever E.g. Yellow fever(a hemorrhagic fever caused by
Flavivirus)

TYPES OF FEVER
5.True crisis: The temperature falls suddenly within few hours
and touches normal ,accompanied by a marked improvement
in the clients condition.
6.False crisis: A sudden fall in temperature but not
accompanied by an improvement in the general condition is
called false crisis. It may be a danger signal and not a sign of
improvement.
7. Lysis: The temperature fall in a zig zag manner for 2 or 3
days or a week before reaching normal, during which time the
others symptoms also gradually disappear.

TYPES OF FEVER
8. Constant fever or Continuous fever :It is one in which the
temperature varies not more than two degree between
morning and evening and it does not reach normal for a
period of days or week.E.g Typhoid
9.Remittent fever: It is a fever characterized by variation of
more than two degree between morning and evening but
does not reach normal.Eg Ineffective Endocarditis
10.Intermittent or quotidian fever: The temperature rise from
normal or subnormal to high fever and back at regular
intervals. The interval may varies from few hours to 3 days.
e.g. Malaria

TYPES OF FEVER
11. Inverse fever: In this type the highest range of
temperature is recorded in the morning hours and lowest in
the evening which is contrary to that found in the normal
course of fever.
12.Hectic or swinging fever: When the difference between
the high and low points is very great, the fever is called hectic
or swinging fever.e.g. Lung abscess
13.Relapsing fever: Relapsing fever is one in which there are
brief febrile periods followed by one or more days of normal
temperature.e.g. malaria

TYPES OF FEVER
14.Irregualr fever: When the fever is entirely irregular in its
course, it cannot be classified under any one of the fever.e.g.
Acute rheumatic fever
15.Rigor: Rigor is a sudden severe attack of shivering inn
which the body temperature rises rapidly to a stage of
hyperpyrexia .e.g. Pyelonephritis
16.Low pyrexia: In low pyrexia the fever does not rise above
99 to 100 degree F or between 32.2 nadn37.8 degree C.
17.Moderate pyrexia: The body temperature remain between
100 to 103 degree F .e.g.Gastroentritis
18. High pyrexia: The temperature remains between 103 and
105 degree F.

TYPES OF FEVER
19. Hyperpyrexia: The temperature goes above 105 dehgree
F.
20. Subnormal temperature: When the body temperature
falls below normal. It is called subnormal temperature. The
temperature may vary between 95 and 98 degree F.
21.Hyperthermia: When the body temperature is raised to
105 degree F or above it is called hyperthermia.

RELAPSING FEVER

CONTINUES FEVER
INTERMITTENT AND REMITTENT FEVER
REMMITENT FEVER

MEDICAL MANAGEMENT OF FEVER
The main aim is
to reduce body temperature
Improve the heath status
Provide antipyretics
Medications
Paracetamol (Acetaminophen)miscellaneous analgesic
Anacin (aspirin) analgesic
IBU (ibuprofen) non steroidal anti inflammatory agent
NURSING MANAGEMENT OF FEVER
1.Regulation of the body temperature: When the client
temperature is moderately elevated , various method of
reducing the temperature may be started. The room should
be maintained at comfortable temperature. The room should
be well ventilated. The blankets and excess clothing should be
removed but prevent the client from getting draughts.
The various method used for cooling the body are:
1.Exposure to cool by an electric fan.
2.Administration of cold drinks.
3.Application of cold compress and ice bags

5.Cold bath
6. use of hypothermic blanket or mattres

HYPERTHERMIC BLANKET
HYPOTHERMIA BLANKET
NURSING MANAGEMENT OF FEVER
Administered medication to reduce body temperature.
Provide IV fluids to maintain normal fluid balance
NURSING DIAGNOSIS OF FEVER
Hyperthermia related to infection.
Assess the patient body temperature.
Check the vital sign
Provide cold compress
Administer medication
Imbalance nutritional patter less than body requirement
related to loss of appetite.
Assess the patient nutritional status
Provide IV fluid
Provide small and frequent diet
Provide calorie rich diet.
Check the weight of the patient

NURSING DIAGNOSIS
Fluid volume deficit related to sweating.
Nursing intervention
Assess the patient condition
Identify the underlying cause
Administered medication
Provide intra venous fluid.
Activity intorelence related to weakness.
Assess the activity level of the patient
Support while doing normal daily activities
Provide proper medication to improve the health status
Encourage passive exercise.
Sleeping pattern disturbance related to muscle ache.
Assess the patient sleeping hour
Provide cool and calm environment
Restrict the visitors while sleeping
Provide divertional therapy.
Administered medication.
HYPOTHERMIA
A core body temperature below the lower limit of normal is
called hypothermia
Hypothermia is a condition in which the body's core
temperature drops below that required for normal
metabolism and body functions
If a person is exposed to cold, and their internal mechanisms
cannot replenish the heat that is being lost, the body's core
temperature falls, and characteristic symptoms occur such as
shivering and mental confusion
CLASSIFICATION OF HYPOTHERMIA
Mild
Moderate
Severe
Profound
F
91.5 98.6
degree
86.1 91.4
degree
80.6 86.0
degree
<80.6 degree
C
33.1 - 36
degree
30.1 33
degree
27 30
degree
<27 degree
CAUSES OF HYPOTHERMIA IN NEWBORN

Thermogenesis: A newborn baby is more prone to develop
hypothermia because of large surface area per unit of body
weight. A low birth weight baby has decreased thermal
insulation due to reduced subcutaneous and brown fat.
Brown fat is the site of heat production. it is located around
the adrenal gland,kidneys,nape of neck,interscapular and
axillary regions. Metabolism of brown fat result in heat
production. Blood flowing through the brown fat result in
heat productin.blood flowing through the brown fat becomes
worm and through circulation transfer heat to other part of
the body. This mechanism of heat production is known as non
shivering Thermogenesis.
New born loses heat by evaporation( particularly soon
after birth due to evaporation of amniotic fluid from skin
surface)
CAUSES OF HYPOTHERMIA IN NEONATE
Conduction (by coming in contact with cold objects cloths,
tray etc)convection (by air current in which cold air replaces
warm air around baby open windows, fans) and radiation(to
colder solid object in vicinity such as walls)
Measurement: for routine monitoring, only axillary
temperature measurement should be undertaken. In order to
produce accurate results, the neonate arm should be
abducted with the thermometre bulb deep in the axilla.The
thermometre should be kept in full 3 minutes to obtained
replicable equilibrium of temperature. Axillary temperature
has been shown to reflect rectal temperature if properly.
Axillary determinations of temperature are less hazardous
than are rectal
CAUSES OF HYPOTHERMIA IN NEONATE
Warm chain: Baby must kept warm at the place of birth(home
or hospital)during transportation for special care from home
to hospital or within the hospital. Satisfactory control
demand both prevention of heat loss and prevention heat
gain. The warm chain is a set of term interlinked procedure
carried out at birth and later which will minimize the
likelihood of hypothermia in all newborns
Warm chain: Baby must kept warm at the place of birth(home
or hospital)during transportation for special care from home
to hospital or within the hospital. Satisfactory control
demand both prevention of heat loss and prevention heat
gain. The warm chain is a set of term interlinked procedure
carried out at birth and later which will minimize the
likelihood of hypothermia in all newborns
CAUSES OF HYPOTHERMIA
The most common cause is exposure to cold.
Decreased heat production:
Nutritional depletion: malnutrition, hypoglycemia, extremes
of age (the very young and the very old)
Endocrine disorders: hypothyroidism
Neuromuscular dysfunction: impaired shivering, immobility

CAUSES OF HYPOTHERMIA
Increased heat loss:
Environmental exposure
Drug intoxication: alcohol, toxins, sedative/hypnotics,
narcotics, barbiturates
Skin disorders: burn
Impaired thermoregulation:
spinal cord injury

CLINICAL MANIFESTATION OF HYPOTHERMIA
Decreased body temperature
Bradycardia
Brachypnea
Hypotension
Frostbite
Decreased urine output
Lack of muscle coordination
Disorientation
Drowsiness

SIGN AND SYMPTOMS OF HYPOTHERMIA
PERIPHERAL VASOCONSTRICTION
Acrocynosis( bluish and purple color of extremities)
Cool extremities
Decreased peripheral perfusion
CNS DEPRESSION
Lethargy
Bradycardia
Apnea
Poor feeding
INCREASED METABOLISM
Hypoglycemia
Hypoxia
SIGN AND SYMPTOMS OF HYPOTHERMIA
Metabolic acidosis
Increased in pulmonary pressure
Respiratory distress
Tachyponea
Chronic signs
Weight loss
FROSTBITE
Frostbite is the medical condition where localized damage is
caused to skin and other tissues due to freezing.
Frostbite is most likely to happen in body parts farthest from
the heart and those with large exposed areas.
The initial stages of frostbite are sometimes called frostnip.

CLASSIFICATION OF FROSTBITE
Frostnip is a superficial cooling of tissues without cellular
destruction.
Chilblains are superficial ulcers of the skin that occur when a
predisposed individual is repeatedly exposed to cold
Frostbite involves tissue destruction.

CLINICAL MANIFESTATION OF FROST BITE
First degree
This is called frostnip and only affects the surface of the skin,
which is frozen. There is itching and pain, and then the skin
develops white, red, and yellow patches and becomes numb.
Second degree
If freezing continues, the skin may freeze and harden, but the
deep tissues are not affected and remain soft and normal.
Second-degree injury usually blisters 12 days after becoming
frozen.
Third and fourth degree
If the area freezes further, deep frostbite occurs. The
muscles, tendons, blood vessels, and nerves all freeze.

Frostbite

Frostbite

TREATMENT OF FROST BITE
Passive rewarming
It involves using body heat and room temperature to aid the
person's body in rewarming itself
This includes wrapping in blankets or moving to a warmer
environment
Active rewarming
It is the direct addition of heat to a person.
NURSING MANAGEMENT OF HYPOTHERMIA
Monitor vital sign
Assess body temperature
Assess skin color
Provide adequate nutrition and diet
Maintain intake and output chart
Reduce physical activity
Provide dry clothing and bed linen
Provide prescribed drugs
Recording and reporting.

MANAGEMENT OF HYPOTHERMIA
For newborn
In delivery room
Conduct delivery in warm room
Immediately dry newborn with a clean soft preferably warm
towel
Use another warm towel to wrap the baby
Place the baby skin to skin on mother abdomen
Cover the head well
Kangaroo mother care should be provided to promote the
health and wellbeing of the babies.
Careful bathing of the baby by using warm water in warm
room should be done.
HYPOTHERMIA MANAGEMENT OF NEWBORN
Bath quickly and gently
Dry quickly and thoroughly from head to toe.
Wrap in a warm ,dry towel
Dress and wrap infant, use a cap on head
Place infant close to mother
Temperature maintenance during transport
Stabilized the temperature of the baby before transport
Record temperature before transport
Carry the baby close to chest of mother
Covered head, legs and hands. Avoid undressing the baby
unnecessary
Thermocol box with prewarmed linen may be used during
transport

HYPOTHERMIA MANAGEMENT OF NEWBORN
Moderate hypothermia: Skin to skin contact should be in
warm room and warm bed. Warmer/Incubator may be used,
if available. Continue rewarming till temperature reach
normal.
Radiant warmer: The use of radiant warmer facilitate the care
of the neonate, particularly the care of critically ill neonate .It
should be used in servo control mode with the abdominal skin
temperature maintained at 36.2 degree C.
Severe hypothermia: Use air heated incubator (air temp 37
38 degree C) or manually operated radiant warmer or
thematically controlled heated mattress.
NURSING DIAGNOSIS OF HYPOTHERMIA
Ineffective thermoregulation related to decrease body
temperature
Assess the patient body temperature.
Provide hot drinks
Provide woolen clothes
Maintain the room temperature warm.

Acute pain related to diminished circulation with tissue
necrosis.
Advice the patient to avoid exposure to cold
Provide active and passive warming.
Provide hot drinks.
Administered medication.

Activity intolerance related to decrease body temperature.
Assess the patient while doing daily activities.
Advice the patient not to exposed in cold temperature
Provide hot water for bathing
Assist the patient while doing normal activities

Impaired skin integrity related to frostbite.
Assess the patient skin condition
Advice the patient not to massage over the affected area.
Instruct the patient to maintain passive rewarming.
Advice the patient not to wear wet cloths

UNCONSCIOUSNESS
INTRODUCTION
Unconscious includes all memories that one is unable to bring
to conscious awareness.
An altered level of consciousness (LOC) is apparent in the
patient who is not oriented and does not follow commands
Coma is a clinical state of unconsciousness in which the
patient is unaware of self or the environment for prolonged
periods(days to months or even year)
UNCONSCIOUSNESS
In physiology:
Unconsciousness is the lack of consciousness or
responsiveness to people and other environmental stimuli
In psychology:
In Freuds psychoanalytic theory of personality, unconscious
mind is a reservoir of feelings, thoughts and memories that
outside of our consciousness.

UNCONSCIOUNESS
DEFINITION: Unconsciousness is an abnormal state resulting
from disturbance of sensory perception to the extent that the
patient is not aware of what is happening around him.
DEGREE OR LEVEL OF UNCONSCIOUSNESS
Excitatory unconsciousness(excitatory path to consciousness)
Somnolent(a state of near to sleep)
Stupor(lack of critical cognitive function and LOC is almost
entirely unresponsive and only responds to base stimuli such
as pain)

STAGES OF UNCONSCIOUSNESS
Drowsy: There is reduced awareness or wakefulness and
presence of hyperexcitability with irritability.
Confusion : There is inability to think clearly with presence of
disorientation for time , place and person
Delirium: The patient is out of contact with the environment
and having disorientation.
Obtundation : There is increased sleep
Stupor or semicoma : The patient is unresponsive but
arousable by repeated stimuli again goes back to
unresponsiveness when the stimuli is withdrawn
Coma: Unresponsive and unarousable by any stimulus.

CAUSES OF UNCONSCIOUSNESS
Infection: Meningitis, encephalitis, brain abscess, cerebral
malaria.
Metabolic disorder : Hypoglycemia
Drug and poisons: Sedative, snake bites, insect stings, lead
poisoning.
Miscellaneous: Head injury, intracranial hemorrhage, brain
tumor, hydrocephalus, hypoxia, shock.

CLINICAL MANIFESTATION OF
UNCONSCIOUSNESS
Changes in
pupillary response
eye opening response
verbal response
motor response
Behavioral changes such as
Restlessness
Increased anxiety
Lack of consciousness
Lack of awareness

CLINICAL MANIFESTATION OF
UNCONSCIOUSNESS
Inability to speak
Palpitation
confusion

ASSESSMENT AND DIAGNOSTIC FINDINGS
A complete assessment is performed with particular attention
to the neurological system .It includes evaluation of
Mental status
Cranial nerve function
Cerebellar function(balance and co ordination)
Reflexes
Motor and sensory function

.GLASGOW COMA SCALE

ASSESSMENT OF CRANIAL NERVE FUNCTION
CRANIAL NERVE CLINICAL EXAMINATION

I (olfactory) - With eyes closed, the patient identifies familiar
odors ( coffee, tobacco). Each nostril is tested
separately.

II (optic) - Snellen eye chart; visual fields; ophthalmoscope
examination

III (oculomotor) - For cranial nerves III, IV and VI: test for ocular
IV (trochlear) rotations, conjugate movements nystagmus.
VI(abducens) Test for pupillary reflexes, and inspect eyelids for
ptosis.
V(trigeminal) - Have patient close the eye. Touch cotton to
forehead, cheeks and jaw. Sensitivity to
superficial pain is tested by using the sharp
and dull end. Patient report sharp or dull
with each movement. If responses are
incorrect, test for temperature sensation. Test
tubes of cold and hot water are used
alternately.
While the patient looks up, lightly
touch a wisp of cotton against the temporal
surface of each cornea. A blink and tearing
are normal responses .
Have the patient clench and move the jaw
from side to side.

VII (facial) - Observe for symmetry while the patient
performs facial movements; smiles, whistles,
elevates eyebrows, frowns, tightly closes
eyelids against resistance ( examiner attempts
to open them). Observe face for flaccid
paralysis (shallow nasolabial folds).
VIII (acoustic) - Whisper or watch-tick test
Test for lateralization (Weber)
Test for air and bone conduction (Rinne)
IX (glassopharyngeal) -
Assess patient`s ability to discriminate between
sugar and salt on posterior third of the tongue.

X( vagus) - Depress a tongue blade on posterior tongue, or
stimulate posterior pharynx to elicit gag reflex
Note any hoarseness in voice.
have patient say ah. Observe for symmetric
rise if uvula and soft palate.
XI ( spinal accessory) -
Palpate and note strength of trapezius muscles
while patient shrugs shoulders against resistance.
Plapate and note strength of each
sternocleidomastoid muscle as patient turn head
against opposing pressure of the examiner`s hand.
XII (hypoglossal)
While the patient protrudes the tongue, and
deviation or tremors are noted. The strength of the
tongue is tested by having the patient move the
protruded tongue from side to side against a
tongue depressor.

NURSING ASSESSMENT OF UNCONSCIOUS
PATIENT
1 Examination
Level of responsiveness or consciousness
Clinical assessment
Eye opening ; verbal and motor response; pupils(size ,reaction
to light)
Clinical significant
Obeying command is a favorable command
2 Examination
Pattern of respiration
Clinical assessment
Hyperventilation

CONTD..
Clinical significance
Disturbance in respiratory centre of brain may result in
various respiratory pattern
3 Examination
Pupils
Clinical assessment
Progressive dilatation, reaction to light
Clinical significance
Indicate increasing ICP

Contd..
4 Eye movement Normally eye should move from side to side-
functional and structural integrity of brain stem is assessed
by inspection of extraocular movement
5 Corneal reflex when cornea is touched with wisp of clean
cotton, blink response indicate normal test cranial nerve V
and VI.
6 Facial symmetry asymmetry (decrease in wrinkle) sign of
paralysis
7 Swallowing reflex Drolling versus spontaneous swallowing
absent in coma, paralysis of cranial nerve X and XII
8 Neck stiff neck, absent of spontaneous neck movement
subarchanoid hemorrhage, fracture or dislocation of spine
Contd..
9 Response of extremity to noxious stimuli firm pressure on
the upper and lower extremity asymmetric response in
paralysis.
10 Deep tendon reflex tap patellar and biceps tendons
absent in deep coma
11 Pathologic reflex firm pressure on the sole of foot with
blunt object flexion of the toes specially the great toe is
normal except in newborn. helps in determining location of
lesion in brain.
12 Abnormal posture observation for posturing(spontaneous
or inresponse to noxious stimuli) deep extensive brain
lesion
UNCONSCIOUSNESS
Procedure used to identify the cause of unconsciousness
includes
Tomography (computed tomography, magnetic imaging
tomography, positron emission tomography)
Electroencephalography
Laboratory test includes analysis of
Blood glucose
Electrolyte
Serum ammonia
Blood urea nitrogen level
Arterial blood gas level

COMPLICATION OF UNCONSCIOUSNESS

Respiratory failure
Pneumonia
Pressure ulcers
Aspiration

UNCONSCIOUSNESS
The first priority of treatment for the patient with altered LOC
is to obtain and maintain patent airway
The patient may be orally or nasally intubated or a
tracheostomy may be performed
Mechanical ventilator is used to maintain adequate
oxygenation until the patients ability to breath on his/her
own
Monitor the circulatory status (blood pressure , heart rate) to
ensure adequate perfusion to the body and brain.
An intravenous catheter is inserted to provide access for fluid
and intravenous medication
Nutritional support using either a feeding tube or
gastrostomy tube is initiated as soon as possible

UNCONSCIOUSNESS
Assessment
The nurse should determine the patients orientation to time
person and place assesses verbal response. the patient is
asked to identify the day, the day date or season of the year
and to identify where h or she is or to identify the clinicians,
family members or visitors present.
Motor response include spontaneous, purposeful movement,
movement only in noxious stimuli ( e g pressure/pain)
In addition to LOC the nurse monitor parameters such as
respiratory status, eye signs, and reflexes on an ongoing basis
summarize the assessment and the clinical significance of the
findings .Body functions (circulation , respiration , elimination
,fluid and electrolyte balance) are examined in systematic and
ongoing manner.

UNCONSCIOUSNESS
MAINTAINING THE AIRWAY
The most important consideration in managing the patient
with altered LOC is to established an airway and ensure
ventilation. Obstruction of airway is a risk because the
epiglottis and tongue may relax ,occluding the oropharynx or
the patient may aspirate vomitus and nasopharyngeal
secretion
Elevate the head of the bedat 30 degree helps prevent
aspiration. Positioning the patient in lateral and semilateral
position will also help as it permits the jaw and tongue to fall
forward, thus promoting drainage of secretion
The patient also require suctioning and oral hygiene
Chest physiotherapy and postural drainage should be
performed to initiate pulmonary hygiene.
MURSIMG MANAGEMENT OF UNCONSCIOUS
PATIENT
PROTECTING THE PATIENT
For the protection of the patient , padded siderails are
provided and raised at all times. Care should be taken to
prevent injury from invasive lines and equipment and other
potential source of injury should be identified (e.g. restraints,
tight dressings, environmental irritants, dressings ,tubes and
drains)
UNCONSCIOUSNESS
MAINTAINING FLUID BALANCE AND MANAGING
NUTRITIONAL NEEDS
Hydration status is assessed by examining tissue turgor and
mucous membrane ,assessing input and output trends and
analyzing laboratory data. The required fluid should be
provided intravenously
If the patient does not recover quickly and sufficiently enough
to take adequate fluids and calorie by mouth , feeding tube
will be inserted to for fluid administration and enteral
feeding.
NURSING MANAGEMENT OF UNCONSCIOUS
PATIENT
PROVIDING MOUTH CARE
The mouth is inspected for dryness ,inflammation and
crusting. The unconscious patient required regular oral care
because there is risk of parotitis if the mouth is not keep
clean. The mouth is cleansed and rinsed carefully to remove
secretion and crusts and to keep the mucous membrane
moist.
PATIENT
MAINTAINING SKIN AND JOINT INTIGRITY
Special attention is given to unconscious patient because
they cannot respond to external stimuli. Assessment includes
a regular schedule of turning to avoid pressure ,which can
cause breakdown and necrosis of the skin. Dragging the
patient up in bed must be avoided, because this creates a
shearing force and friction on the skin surface.
The use of splints or foam boots aids in the prevention of
footdrop and eliminates the pressure of bedding on the toes.
Trochanter rolls supporting the hip joints keep the legs in
proper alignment.
PRESERVING CORNEAL INTEGRITY
Some unconscious patient have their eyes open and have
inadequate or absent corneal reflexes. The cornea is likely to
become irritated or scratched, leading to keratitis and corneal
ulcers. T he eyes may be cleansed with cotton balls moistened
with sterile normal saline to remove debris and discharge.
UNCONSCIOUSNESS
ACHIEVING THERMOREGULATION
High fever in the unconscious patient may be caused by
infection of the respiratory or urinary tract, drug reaction or
damage to the hypothalamic temperature regulating centre.
A slight elevation of temperature may be caused by
dehydration. The environment can be adjusted depending on
the patients condition , to promote normal body
temperature. The room may be cooled to 18.3 degree C(65
degree F)
MANAGEMENT OF UNCONSCIOUSNESS
PREVENTING URINARY RETENTION
The patient with an altered LOC is often incontinent or has
urinary retention. The bladder is palpated or scanned at
intervals to determine whether urinary retention is present,
because a full bladder may be an overlooked cause of
overflow incontinence
If there are signs of urinary retention, initially an indwelling
urinary catheter attached to a closed drainage system is
inserted.
PROMOTING BOWEL FUNCTION
The abdomen is assessed for distention by listening for bowel
sound and measuring the girth of the abdomen .There is a risk
of diarrhea from infection, antibiotics and hyperosmolar
fluids.
Immobility and lack of dietary fiber may cause constipation.
The nurse monitor the number and consistency of bowel
movement and perform a rectal examination for sign of fecal
impaction .Stool softeners may be prescribed and glycerin
suppositories can be used. The patient may require an enema
every other day to empty the bowel.
PROVIDING SENSORY STIMULATION
Communication is extremely important and includes
touching the patient and spending enough time with the
patient to become sensitive to his needs. It is also important
to avoid making any negative comments about the patient
status.
The nurse orient the patient to time and place at least once
every 8 hours.
NURSING DIAGNOSIS
Ineffective airway clearance due to upper airway obstruction
Positioning with extended head or head turned to one side to
drain respiratory secretion and tongue falling back.
Intermittent oropharyngeal suctioning to remove secretion
Inserting airway tube
Provided oxygen therapy by mask

NURSING DIAGNOSIS
Risk for fluid volume deficit due to inability to take oral
feeding
Administering fluid therapy
Monitoring hydration and electrolyte status
Monitor intake and output.

NURSING DIAGNOSIS
Risk for impaired skin integrity related to
immobility
Regular changing to position
Provide passive exercise
Use pressure reliving mattress
Provide care of pressure point.

NURSING DIAGNOSIS
Altered nutritional status less than body requirement related
to inability of food intake.
Provide NG tube feeding.
Maintain intake and output chart.
Administered IV fluid.

NURSING DIAGNOSIS
Risk for suffocation related to cognitive impairment and loss
of protective reflex
Assess the neurological status and note factors that nerve
potential to compromise airway or affect ability to swallow
Provide proper suctioning to maintain airway
Monitor medication regimen
Monitor the patient frequently.
NURSING DIAGNOSIS
Total self care deficit related to cognitive impairment
Identified the degree of individual impairment
Assess the intellectual functioning
Determine the individual strength and skill of the client
Administered medication

SUMMARY
Hemorrhage
Causes , symptoms & treatment of hemorrhage
Types of shock with causes ,sign and treatment
MODS, its type , causes ,symptoms and treatment
Fever , types, causes, treatment
Frostbite ,cause, symptoms and treatment
Unconsciousness , causes, management

BIBLIOGRAPHY
BRUNNER & SUDDARTS,TEXT BOOK OF MEDICAL SURGICAL
NURSING,10
TH
EDITION,PUBLISHED BY LIPPINCOT,PAGE NO
303- 321
JOYCE M BLACK,MEDICAL SURGICAL NURSING,8
TH

EDITION,VOLUME 2,PUBLISHED BY ELSEVIER,PAGE NO.1243
1251
O.P. GHAI,ESSENTIAL PEDIATRICS,6
TH
EDITION,CBS PUBLISHER
AND DISTRIBUTER,PAGE NO.153-154
S .MALIK.N.ANAND,TEXT BOOK OF PSYCHIATRIC,1
ST

EDITION,LOTUS PUBLISHER,PAGE NO 28 30
K.D TRIPATHY,MEDICAL PHARMACOLOGY,3
RD
EDITION,JAYPEE
PUBLISHERS,PAGE NO 39,43,51
POTTER PERRY,BASIC NURSING THEORY & PRACTICE,3
RD

EDITION,PAGE NO 453- 461.

Seminar on Hemorrhage and Shock

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