5. Nursing interventions
   1. help client with ADL (activities of daily living)
   2. partial bed rest
   3. reassure client
   4. assist with turning, deep breathing and coughing exercises
   5. relieve chest pain by oxygen and medication as ordered
   6. during angina attacks, monitor bp, heart rate, pain, meds, symptoms; get electrocardiogram
   7. keep nitroglycerin available for immediate use
   8. client and family teaching
      1. risks
         • teach the risk factors for CAD (coronary artery disease)
         • encourage client to lose excess weight; review low-fat, low-cholesterol diet
         • teach smoking cessation
         • teach side effects of drugs for CAD
         • stress - teach stress reduction techniques
      2. avoid
         • activities known to cause angina
         • physical activities for two hours after meals
         • very cold and very hot weather
         • alcohol and caffeine drinks
         • diet pills, nasal decongestants, or any remedy that can raise heart rate or blood pressure
      3. use
         • nitroglycerin tablets; carry at all times
         • if necessary nitroglycerin patch
      4. report
         • angina
         • angina >15 minutes, go to clinic or hospital

3. Shock
   1. Definition - body cells need more oxygen than blood is supplying. cells and then organs fail. shock has many different causes. It is a medical emergency.
   2. Five types of shock:
      1. cardiogenic
      2. septic
      3. neurogenic
      4. anaphylactic
      5. hypovolemic
         
   3. Findings: progression of shock
      1. initial stage:
         1. decreased cardiac output and perfusion
         2. cellular function interrupted
         3. anaerobic metabolism increases
         4. no clinical symptoms at this stage
      2. compensatory stage: neural, chemical, and hormonal mechanisms act to restore perfusion.
         1. neural compensation: pressoreceptors in aorta activate sympathetic nervous system (NS), which contracts blood vessels so that skin cools; sympathetic NS stimulates heart, so tachycardiasets in; it cuts blood flow to kidneys and gastrointestinal system, and dilates pupils.
         2. Hormonal compensation: decreased blood flow to kidneys releases angiotensin, which constricts vessels and increases BP; Angiotensin stimulates the secretion of aldosterone. Aldosteronemakes kidneys retain sodium, which increases serum osmolality, which in turn stimulates antidiuretic hormone; ADH causes water retention.
            • increased sodium and water retention results in increased BP, decreased urine volume and increased urine specific gravity.
            • anterior pituitaryis stimulated to secrete Adrenocorticotropic hormone, and ACTH acts on adrenal cortexto increase secretion of glucocorticoids, which increase serum glucose.
              
   3. chemical compensation: decreased pulmonary blood flow causes hypoxemia; hypoxemia is sensed by chemoreceptors that increase rate and depth of respirations, which results in respiratory alkalosis
   4. findings of compensatory stage of shock
      • altered L.O.C.
      • tachypnea
      • anxiety, restlessness
      • skin cool and clammy
      • diaphoresis
      • thirst
      • pupils dilated
      • tachycardia
      • weak peripheral pulses
      • decreased bowel sounds
      • decreased urine output
      • concentrated urine
        
   3. progressive stage of shock - compensatory mechanisms can no longer maintain perfusion.
      1. severe hypoperfusion
      2. massive cell death
      3. organs begin to fail
      4. findings of progressive stage of shock
         • consciousness - L.O.C. severely depressed
         • lungs -hypoventilation, moist crackles
         • cardiovascular - decreased BP: systolic below 90 mm mg, narrowing pulse pressure, tachycardia, irregular pulse, peripheral pulses weak, thready
         • elimination - urine volume below 20 cc/hour, urine osmolality dilute, absent bowel sounds
   4. refractory stage: shock irreversible: death from multi-system organ failure is evident
      1. findings of refractory stage of shock
         • cardiac failure
         • respiratory failure
         • renal shutdown
         • liver dysfunction
         • loss of consciousness
           
   2. diagnostics 
   3. management - objective: to correct underlying cause and prevent progression
      • cardiogenic shock
        • pharmacologic treatments 

§  positive inotropic agents: increase myocardial contractility and improve systolic ejection: dobutamine (Dobutrex), amrinone lactate (Inocor)

§  vasodilators: improve heart's pumping action by reducing its workload: nitroglycerin (Corobid), nitroprusside sodium (Nipride), (Usually limited to clients with failing ventricular function)

§  vasopressors: increase peripheral vascular resistance and elevate blood pressure: norepinephrine (Levophed), dopamine hydrochloride (Intropin)

§  oxygen therapy

• surgical treatments

§  intra-aortic balloon counterpulsation

§  left and right ventricular assist pumping

§  heart transplant

• hypovolemic shock: rapid fluid replacement therapy to replace lost volume
• anaphylactic shock:
  • epinephrine (adrenalin)
  • antihistamines
  • aminophylline (truphylline)
• neurogenic: depends on causative agent
• septic: antibiotic therapy
  
4. nursing interventions for shock: the cardio-care six except
• do not elevate or lower head: maintain complete bed rest in flat position or with legs slightly raised to increase venous return
• do not move client; no commode
• keep client warm
• administer parenteral therapy, drugs, and O₂ as ordered
• monitor mean hemodynamic indicators as ordered
• blood plasma expanders or packed cells