CRITICAL CARE NURSING (MSN 3)

INTRODUCTION | REVIEWER | BATCH 2023

References: CRITICAL CARE UNIT

• Cheever, K. & Hinkle, J. (2018) Brunner • a room filled with client attached to
& Suddarth’s Textbook of Medical- interventional technology, equipped facility,
Surgical Nursing, 14th Edition staffed by skilled personnel to provide
• Sole, M. L., Klein, D. G., & Moseley, effective and safe care for patient with a life-
M. J. (2011). Introduction to critical threatening problem that is potentially
care nursing(6th ed.). Saunders. reversible.
• Nursing PowerPoint (FEU Version) EVOLUTION
• Lecture Notes
CRIMEAN nurses created a separate area
WAR near the nursing station for
OUTLINE (1850s) critically injured British soldiers
I. Introduction to Critical Care 1927 Dr. Walter Dandy of John
A. Definition Hopkins Hospital arranged for a
B. Evolution special area for increased
C. Professional Organization monitoring of his postoperative
II. Standards/Guidelines in Critical Care neurosurgical patients
Nurse Practice WWII shock units were created to care
A. Characteristics for the severely wounded and
B. Trainings of Nurses for Critical postoperative patients
Care 1952 Polio Epidemic- Dr. Bjorn Ibsen
C. Quality & Safety described the provision of this
III. Levels and Categories of Critical Care respiratory care.
IV. Factors that Influence an individual’s
response to illness Mechanical ventilators first
V. Ethico-Moral Practice became commercially available
I. INTRODUCTION TO in the 1960s, followed by
increasing use of automated
CRITICAL CARE monitoring of vital signs with
CRITICAL CARE NURSING alarms.
1. Critical care nursing is concerned with 1959 First modern critical care units
human responses to life-threatening opened at the University of
problems, such as trauma, major surgery, or Southern California and the
complications of illness. University of Pittsburgh, both
2. The critical care nurse's focus encompasses staffed by specially trained
both the patient's and family's responses to critical care physicians.
disease, as well as prevention and cure COMMON CHARACTERISTICS THAT
3. Careful monitoring and surveillance to
REQUIRE CRITICAL CARE:
critically ill care management adults remain
• Heart problems
vital to good patient outcomes on treatment
and monitoring protocols • Lung problems
4. Critical care is also called Intensive care unit • Multiple Organ failure
in hospital setting where patients experience • Brain trauma
severe illness or injury that needs a round h • Blood infections (sepsis)
clock care by a specially trained team • Drug- resistant infections
• Serious injury (vehicular accident, burns)

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• Any person with life threatening condition conditions that

(Airway, Breathing, Circulation, require close
Disability, Exposure) monitoring
COMMON CHARACTERISTICS OF
CRITICAL CARE UNITS ex. Whipple’s
1. A nurse-to-patient ratio of 1:1 or 1:2. procedure,
2. Critically ill patients. - deals with life Orthopedic
threatening health problems restrictions, Extensive
3. Patients with multiple diagnoses. abdominal repair.
4. Specialized equipment: Continuous
EKG, blood pressure, and oxygen This is managed by
saturation monitors. multiple IV pumps, surgeons,
arterial lines, pulmonary artery catheter, anesthesiologist
endotracheal tubes, ventilators, chest Patients with various
tubes, urinary catheters, central venous types of injuries and
lines, and nasogastric tubes and/or g- TRAUMA several diagnoses.
tubes. INTENSIVE CARE Nurses in this area
5. Isolation precautions. UNIT must be prepared in
6. Restricted visiting hours. any types of wounds
7. Bedside computers for documentation and patient care
Pediatric patients with
TYPES OF INTENSIVE CARE UNIT life threatening
TYPE DESCRIPTION conditions.
Patients specifically
with life threatening ex. severe asthma,
cardiac conditions ex. PEDIATRIC diabetic ketoacidosis,
myocardial infarction, INTENSIVE CARE traumatic neurological
CORONARY CARE UNIT (PICU) injury, surgical cases
cardiac arrest, pre-
UNIT (CCU) (if the patient has a
post heart
catheterization, chest potential rapid
pain, pre-post open deterioration or if a
heart surgery patient requires close
post cardiac bypass, monitoring
Others: post-op Cares for neonatal
CARDIOVASCULAR patients who have not
thoracic aneurysm,
INTENSIVE CARE left hospital after
repair abdominal
UNIT (CICU) birth.
aneurysm repair,
thoracotomies NEONATAL
A specialized service ex. prematurity and
INTENSIVE CARE
in large hospitals that associated
UNIT (NICU)
provides patients complications,
SURGICAL congenital disorders,
recover after
INTENSIVE CARE congenital
extremely invasive
UNIT (SICU) diaphragmatic
surgery. Often
patients may have hernia), complications
other medical

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resulting from the 3. Acquires and maintains current

birthing process knowledge and competency in patient
Patients treated for care
NEUROLOGICAL brain aneurysms, 4. Contributes to the professional
INTENSIVE CARE brain tumors, stroke, development of peers and other
UNIT (PICU) post neurologic healthcare providers
surgeries 5. Acts ethically in all areas of practice
Patients that need to 6. Uses skilled communication to
be isolated that is collaborate with the healthcare team to
ISOLATION suspected or provide care in a safe, healing, humane,
INTENSIVE CARE diagnosed with and caring environment
UNIT (NICU) contagious disease 7. Uses clinical inquiry and integrates
and need medical research findings into practice
isolation care 8. Considers factors related to safety,
An intermediate ward effectiveness, cost, and impact in
for patients who planning and delivering care
require close 9. Provides leadership in the practice
observation, setting for the profession
treatment and nursing Data from Bell, L. (2008). AACN Scope and Standards for Acute
and Critical Care Nursing Practice. Aliso Viejo, CA: American
care that cannot be
HIGH Association of Critical-Care Nurses.
provided in a general
DEPENDENCY
ward • Critical Care Nurses Association of the
UNIT
Philippines, incorporated (CCNAPI) –
Others called it step- February 1977 – a national organization of
down unit, nurses interested in the field of critical care
intermediate care nursing. This organization is accredited as a
area, or progressive Provider of Continuing Professional
care unit education by the Professional Regulation
Commission (PRC). They provide continuing
PROFESSIONAL ORGANIZATIONS educational activity which CCNAPI aims to
5. American Association of Critical Care achieve excellence and pursue ongoing
Nursing (AACN) – established in 1969 – this improvement in all its educational activity.
association promotes the health and welfare Their nursing philosophy is accomplished by
critically ill patients by advancing the art and looking after critically ill patient in an
science of critical care nursing and environment with specially trained nurses,
supporting work environments that promote appropriate equipment, adequate medical
professional nursing practice. supplies, and additional health care
The Nurse Caring for Acute and professionals.
Critically Ill Patients:
1. Systematically evaluates the quality CERTIFICATIONS FOR CRITICAL CARE
and effectiveness on nursing practice NURSE PRACTICE IN THE PHILIPPINES
2. Evaluates own practice in relation to • Registered Nurse
professional practice standards, • Intravenous training (IVT nurse)
guidelines, statutes, rules, and • BLS/ ACLS training
regulations • Critical Care course program (optional) -
highly advantage

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II. STANDARDS IN CRITICAL critically ill with the assistance of

advanced technology and
CARE NURSE PRACTICE knowledge.
Care standards for critical care nursing provide
b. Plans and initiates nursing process to
measures for determining the quality of care
its full capacity in a need-driven and
delivered, also serve as means for recognizing
proactive manner.
the competencies of nurses in the intensive care
c. Acts promptly and judiciously to
specialty.
prevent or halt deterioration when
11 STANDARDS FOR CRITICAL CARE conditions warrant.
NURSE TO PROVIDE QUALITY CARE d. Co-ordinates with other healthcare
AND EXCELLENCE providers in the provision of optimal
1. The critical care nurse functions in care to achieve the best possible
accordance with legislation, common laws, outcomes.
organizational regulations and by-laws, B. Indirect patient care – Care of the family
which affect nursing practice. a. Understands family needs and
2. The critical care nurse provides care to meet provide information to allay fears and
individual patient needs on a 24-hour basis. anxieties.
3. The critical care nurse practices current b. Assists family to cope with the life-
critical care nursing competently. threatening situation and/or patient’s
4. The critical care nurse delivers nursing care impending death.
in a way that can be ethically justified. C. Extended Roles as critical care nurses
5. The critical care nurse demonstrates – perform procedures beyond their
accountability for his/her professional professional boundary following clinical
judgment and actions. protocols
6. The critical care nurse creates and maintains Ex: Weaning patients from
an environment which promotes safety and ventilators, performing and interpreting
security of patients, visitors, and staff. ECG’s, adjusting analgesia/sedations,
7. The critical care nurse masters the use of all titrating intravenous and centra line
essential equipment, available services and medications
supplies for immediate care of patients. D. Educator
8. The critical care nurse protects the patients a. Provides health education to patient
from developing environmental induced and family to promote understanding
infection. and acceptance of the disease
9. The critical care nurse utilizes the nursing process and to facilitate recovery.
process in an explicit systematic manner to b. Participates in the training and
achieve the goals of care. coaching of novice healthcare team
10. The critical care nurse carries out health members to achieve cohesiveness in
education for promotion and maintenance of the delivery of care.
health. E. Patient Advocate
11. The critical care nurse acts to enhance the a. Acts in the best interest of the patient.
professional development of self and others. b. Monitors and safeguards the quality
of care which the patient receives.
ROLES OF CRITICAL CARE NURSES 2. Management & Leadership Role
1. Care Provider They oversee patient care, make
A. Direct patient care management and budgetary decisions, set
a. Detects and interprets indicators that work schedules, coordinate meetings, and
signify the varying conditions of the

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make decisions about personnel. The nurse 4. Neurologic assessment

manager ensuring that the work of the health 5. Respiratory assessment
care team is supported and contribute 6. Continuous renal replacement therapy
inpatient engagement. 7. Advanced pharmacology
3. Research Role 8. Advanced Intravenous therapy
A. Engage self in nursing or other health –
QUALITY AND SAFETY
related research with or under
Quality and safety are essential
supervision of an experienced
components of patient care. Patients are at risk
researcher.
for a myriad of harms, which increase morbidity,
B. Utilize guidelines in the evaluation of
mortality, length of hospital stay, and costs for
research study or report
care
C. Apply the research process in improving
NURSING PROCESS
patient care infusing concepts of quality
The American Nurses Association (ANA)
improvement and in partnership with
describes six core standards of practice a.
other team-player
1. Assessment: Collection of Data
TRAININGS OF NURSES FOR - conducting interview, review past
CRITICAL CARE UNIT medical history and records,
To continuously ensure staff completing physical examination
competencies hospitals should provide training current patient status
opportunities This will enable critical care nurse 2. Diagnosis: Analysis of data to determine
to cope on the demands of the changing needs nursing diagnosis
of critically ill patients. - this is where the nursing care plan is
1. Orientation program/Preceptorship and based. This is the clinical judgement
mentoring program regarding the patient’s response to
2. In-service training program actual or possible medical problems.
a. Unit/hospital-based training 3. Outcome Identification: Identification of
courses/workshops/seminars expected outcomes specific to the patient
b. On the job training and bedside and/or situation
supervision - Setting short- and long-term goals
3. Critical Care Nursing Program (Post- that are patient oriented and
graduate specialty program) measurable, Including assessment
a. Pot graduate course in Critical care and diagnosis details. utilizing a
nursing standardized care plan or clinical
b. Cardiac special care nursing pathway as a guideline
c. Advanced Critical Care Nursing 4. Planning: Development of a plan
(ACCN) provider course detailing interventions aimed to achieve
expected outcomes.
CCNAPI recommends that all practicing 5. Implementation: Performance of the
CCN shall ensure that they continuously update interventions noted in the plan of care.
their knowledge, skills, and behavior through - Documenting the care provided to the
active participation in related critical care nursing patient properly. performing
education. treatment in a way that minimizes
These are: complications and life-threatening
1. Advanced Cardiac Life Support issues. involving patients, families,
2. Basic Critical Care Course caregivers, and other members of the
3. Cardiac assessment health care team

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6. Evaluation: Evaluation of the patient’s almost certainly have jotted down notes during
progress toward achievement of your workday.
expected outcomes BARRIERS TO EFFECTIVE HANDOFF
- evaluating the status of the patient COMMUNICATION
and the effectiveness of the treatment a. Physical setting – background noise,
lack of privacy, interruptions
COMMUNICATION
b. Social setting – organizational hierarchy
• Effective communication is essential for
and status issues
delivering safe patient care.
c. Language – differences between people
Communication breakdowns occur
of varying racial and ethnic backgrounds
during handoff situations when patient
or geographical areas
information is being transferred or
d. Communication medium – limitations
exchanged of care.
of communications via telephone, email,
• Common handoff situations include or computerized records versus face to
nursing shift reports, transcription of face
verbal orders, and interfacility patient SBAR APPROACH
transfers. The SBAR (Situation-Background-
REPORT OR HANDOFFS Assessment-Recommendation) technique
IMPORTANCE provides a framework for communication
Report or handoff involves providing between members of the health care team about
information to the nurse who will be taking over a patient's condition.
the care of your patients. It should be given • S = Situation (a concise statement of
anytime patient care is transferred to another the problem)
nurse. This may include at the end of your shift • B = Background (pertinent and brief
or if a patient is being transferred to another unit information related to the situation)
in the hospital. • A = Assessment (analysis and
The report is necessary to educate the considerations of options — what you
incoming nurse about the patients he or she found/think)
would be caring for. If critical information is left • R = Recommendation (action
out of the report, it might have a negative impact requested/recommended — what you
on patient care and safety. The transfer of want)
information from one nurse to the next should SBAR is an easy-to-remember strategy for
include a chance for the receiving nurse to ask framing any interaction, particularly those that
questions and explain any points that are require a clinician's immediate attention and
unclear. action. It provides a simple and focused way to
PURPOSE establish expectations for what will be
The purpose of report is to provide communicated and how between team
information about the patients you cared for. members, which is critical for creating teamwork
Although the information should be in the and fostering a patient safety culture
patient’s chart, it is often more practical to
present a brief synopsis of what is going on with DOCUMENTATION
the patient. Critical care documentation requires a
It is beneficial to have your notes in front basic understanding of the nursing process and
of you when giving a report. When you first got how to utilize a care plan. All nurses learn how to
your report at the start of your shift, you should complete focus notes (FDAR, SOAPIE).
have taken some notes. In addition, you will However, some hospitals, including their critical

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care units, now use computerized c. Palliative Care - Palliative care is an

documentation. approach that improves the quality of life
1. Electronic Medical Record (EMR) of patients (adults and children) and their
An electronic (digital) collection of medical families who are facing problems
information about a person that is stored on a associated with life-threatening illness.
computer. An electronic medical record includes Palliative care is explicitly
information about a patient’s health history, such recognized under the human right to
as diagnoses, medicines, tests, allergies, health. It should be provided through
immunizations, and treatment plans. Electronic person-centered and integrated health
medical records can be seen by all healthcare services that pay special attention to the
providers who are taking care of a patient and specific needs and preferences of
can be used by them to help make individuals
recommendations about the patient’s care. A GUIDELINES FOR EFFECTIVE
blank box is offered where additional COMMUNICATION TO FACILITATE
documentation can be entered, such as details END-OF- LIFE CARE
and other items pertaining to tasks performed. • Present a clear and consistent
A nurse must remember the nursing process, message to the family. Mixed
liability, safety, and patient care when messages confuse families and
documenting. It is always necessary to “save,” or patients, as do unfamiliar medical
store. terms. The multi professional team
2. Withdrawal Medical Treatment Forms: needs to communicate and strive to
a. Do not Resuscitate (DNR) - DNR orders reach agreement on goals of care and
are only in effect if the patient does not prognosis.
have a heartbeat or has stop breathing • Allow ample time for family members
altogether. This is not applied when the to express themselves during family
person is still breathing or undergoing conferences. This increases their
treatment. This is a legal and ethical bind level of satisfaction and decreases
where written consent is a must dysfunctional bereavement patterns
A DNR order is not the same as a after the patient’s death.
"do not treat" order. Instead, it simply • Aim for all (healthcare providers,
means that CPR will not be attempted. patients, and families) to agree on the
Other treatments (such as antibiotics, plan of treatment. The plan should be
transfusions, dialysis, or the use of a based on the known or perceived
ventilator) that may prolong life are still preferences of the patient. Arriving at
available. These additional procedures such a plan through communication
are usually more likely to be successful minimizes legal actions against
than CPR, depending on the person's providers, relieves patient and family
health. Treatment that maintains the anxiety, and provides an environment
person pain-free for as long as possible. in which the patient is the focus of
concern.
b. Do not Intubate (DNI) - A DNI or “Do Not • Emphasize that the patient will not be
Intubate” order means that chest abandoned if the goals of care shift
compressions and cardiac drugs may be from aggressive therapy to “comfort”
used, but no breathing tube will be placed care (palliation) Let the patient and
through mouth into the trachea family know who is responsible for
(windpipe) to help with breathing. their care and that they can rely on

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those individuals to be present and High Alert of error and sentinel

available when needed. Medications events
• Facilitate continuity of care. If a • Medications that
transfer to an alternative level of care, carry a higher risk for
such as a hospice unit or ventilator adverse outcomes
unit, is required, ensure that all • Look-a like /sounds -a
pertinent information is conveyed to like medications
the new providers. Details of the • Policies and
history, prognosis, care requirements, procedures are
palliative interventions, and developed to address
psychosocial needs should be part of the identification,
the information transfer. location, labeling and
COLLABORATION storage of high alert
International Patient Safety Goals: (IPSG) - The medications
International Patient Safety Goals (IPSG) were • The policies and
developed in 2006 by the Joint Commission procedures are
International (JCI). Health care professionals implemented
have been challenged to reduce medical errors IPSG 4- Ensure • Uses an instantly
and promote an environment that facilitates safe Correct Site, recognized mark for
practices. Correct - surgical site,
IPSG DESCRIPTION Procedure, identification and
IPSG 1- Identify • Using 2 identifiers Correct Patient involves the patient in
Patients (Name and ID band) Surgery the marking process
Correctly • Before administering • Uses a checklist to
medications, blood, verify preoperatively
or blood products the correct site,
• Before providing correct procedure,
and correct patient
treatments and
procedures and that all
documents and
• Policies and
equipment needed
procedures support
are on hand, correct,
consistent practice in
and functional
all situations
• The full surgical team
IPSG 2- Improve • Complete verbal and
conducts and
Effective telephone order were
documents a time-out
Communication written down by the
procedure just before
receiver
starting a surgical
• Read back by the procedure
receiver of the order
• Policies and
• Confirmed by the procedures are
individual who gave developed that
the order support uniform
IPSG 3- Improve • Medications involved process to ensure the
the Safety of in a high percentage correct site, correct

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procedures, and self- contained area, with the provisions for

correct patient resources that will support critical care practice.
IPSG 5- Reduce • Follow and adapted
the Risk of hand hygiene LEVELS OF CARE
Health Care - guideline
LEVEL 1 • Should be capable of providing
Associated • Implements an immediate resuscitation for the
Infections effective hand
critically ill and short- term
hygiene program cardio-respiratory support
• Policies and because the patients are at
procedures are risk of deterioration.
developed that
• Has a major role in monitoring
support continued
and preventing complications
reduction of health in “at risk” medical and surgical
care – associated
patients
infections (HCAI)
• Must be capable of providing
IPSG 6- Reduce • Implements a mechanical ventilation and
the Risk of process for the initial simple invasive cardiovascular
Patient Harm assessment of monitoring.
resulting from patients for fall risk
• Has a formal organization of
Falls and reassessment of
medical staff and at least one
patients when
registered medical officer
indicated by a change
available to the unit at all times
in condition or
• A certain number of nurses
medications
including the nurse in-charge
• Measures are
of the unit should possess
implemented to
post- registration qualification
reduce fall risk for
in critical care or in the related
those assessed to be
clinical specialties; and has a
at risk.
nurse: patient ratio of 1:1 for all
• Measured are critically ill patients.
monitored for results,
LEVEL 2 • Should be capable of providing
both successful fall
a high standard of general
injury reduction and
critical care for patients who
any unintended
are stepping down from higher
related
levels of care or requiring
consequences.
single organ support/support
post-operatively.
III. LEVELS & CATEGORIES OF • Capable of providing
CRITICAL CARE IN THE sustainable support for
PHILIPPINES mechanical ventilation, renal
Physical set -up and supporting facilities replacement therapy, invasive
critical care units in the Philippines, the hemodynamic monitoring, and
Department of Health (DOH) Standards requires equipment for critically ill
the critical care units / intensive care unit to be a patients of various specialties
such as medicine, surgery,

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trauma, neurosurgery, progress or remain stable. Nurses must monitor

vascular surgery these patients on a regular basis since they can
• Always has a designated swiftly deteriorate. As a result, increased staffing
medical director with levels are required in high-acuity units and
appropriate intensive care facilities. Acuity scales are frequently used by
qualification and a duty nurse managers to determine how many nurses
specialist available exclusively are required for specific shifts.
to the unit
• The nurse in-charge and a
IV. FACTORS THAT INFLUENCE
significant number of nursing AN INDIVIDUAL’S RESPONSE TO
staff in the unit have critical ILLNESS
care certification; and A nurse: Many factors influence an individual’s
patient ratio is 1:1 for all response to critical illness. Stressors related to
critically ill patients. both treatment and the critical care environment
LEVEL 3 • Is a tertiary referral unit, affect patients. Many individuals suffer from
capable of managing all posttraumatic stress disorder (PTSD) after
aspects of critical care treatment in a critical care setting
medicine (This does not only Pain is a major issue for all critically ill
include the management of patients, whether conscious or not. It may be
patients requiring advanced induced directly by disease, through invasive
respiratory support but also procedures, or from routine interventions such
patients with multi-organ as suctioning, turning, and bathing
failure
PATIENT’S RECOLLECTION OF THE
• Always has a medical director
with specialist critical / CRITICAL CARE EXPERIENCE
intensive care qualification and • Difficulty communicating
a duty specialist available • Pain
exclusively to the unit and • Thirst
medical staff with an • Difficulty swallowing
appropriate level of experience • Anxiety
present in the unit. • Lack of control
• A nurse in-charge and most • Depression
nursing staff have intensive • Fear
care certification; and A nurse: • Lack of family or friends
patient ratio is at least 1:1 for • Physical restraint
all patients always. • Feelings of dread
LEVEL OF ACUITY • Inability to get comfortable • Difficulty
Acuity levels help nurse managers set sleeping
appropriate staffing levels in acute care, long- • Loneliness
term care and other treatment and rehabilitation • Thoughts of death and dying
settings., patients requiring a greater degree of DISCHARGE AND HEALTH
observation and intervention from nurses receive TEACHING PLAN
a higher acuity rating. Many critically ill patients can recover
Patients with high levels of acuity must be from their illnesses and injuries. Even though
monitored frequently to ensure that they leaving from a critical care unit signifies progress

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toward recovery, many patients are discharged • The critical care nurse demonstrates the
“quicker and sicker” either to units that care for appropriate application of knowledge in
patients in lesser acuity or long-term care nursing practice, which complies with the
hospitals or transfer to their own home. following:
Transfer or discharge from the critical o Code of professional conduct,
care unit often results in stress for both patients o Principles of autonomy,
and families. o Beneficence
Discharge planning and teaching • She / He also accepts personal responsibility
patients and their families are essential nursing for one’s own professional judgments and
interventions to improve patient and family actions as well as consequence of one’s
outcomes. One technique used to facilitate behavior.
teaching and learning is the teach-back method,
in which patients and family members are asked Competent Behavior Clusters of a
to repeat the information and instructions they Critical Care Nurse
have been given. The critical care nurse:
a. Geriatric Concerns: 1. Has respect for patient / family rights
Some elderly patients have a diminished including confidentiality
ability to adapt and cope with the major physical 2. Conducts intensive care nursing practice
and psychosocial stressors of critical illness. and makes sound independent clinical
Anxiety and fears are some concerns of the judgment in a way that can be ethically
geriatric critically ill patients, the elderly patient is justified
at greater risk of negative outcomes. 3. Aware of the importance of open
b. Family Members: discussion with others about his/her own
The family is an integral part of the healing views on ethical dilemmas
process of the critically ill patient, and critical 4. Reports all perceived unethical incidents
care nursing interventions must also focus on the to responsible person such as but not
family. limited to, responsible use of technology
The concept of treating the patient and family (clinical or administrative); use of
as an inseparable entity, realizing that the illness communication devices not related to
or injury of one family member usually impacts clinical practice
all other family members, is known as family- 5. Maintains professional decorum in
centered dealings with patient, family and co-
5 STEPS TO HELPING YOUR PATIENT’S workers.
FAMILY: ETHICAL ISSUES IN CRITICAL CARE
E valuate NURSING
P lan • Critical care nurses are often confronted
I nvolve with ethical and legal dilemmas related to
C ommunicate informed consent, withholding or
S upport withdrawing life-sustaining treatment,
organ and tissue transplantation,
V. ETHICO-MORAL PRACTICE confidentiality, and increasingly, justice in
the distribution of healthcare resources.
RESPONSIBILITIES/TASKS OF A
• Many dilemmas are by-products of
CRITICAL CARE NURSE
advanced medical technologies and
Practicing ethico-moral standards of the
therapies developed over the past
nursing profession.
several decades.

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• Although technology provides substantial binding. This includes freedom from

benefits to critically ill patients, extensive pressure from family members,
public and professional debate occurs healthcare providers, and payers.
over the appropriate use of these Persons who consent should base
technologies, especially those that are their decision on sufficient knowledge
life sustaining. • Disclosure of Information Basic
• One of the primary concerns in critical information considered necessary for
care is whether a patient’s values and decision making includes the
beliefs about treatment can be following:
overridden by the technological o A diagnosis of the patient’s
imperative, or the strong tendency to use specific health problem and
technology because it is available. condition
• Professional nurses are protectors of o The nature, duration, and
their patients’ basic rights. This obligation purpose of the proposed
requires nurses to recognize ethical treatment or procedures
dilemmas that actually or potentially o The probable outcome of any
threaten patients’ rights and to participate medical or nursing intervention
in the resolution of those dilemmas. o The benefits of medical or nursing
INFORMED CONSENT interventions
1. Consent problems arise because o The potential risks that are
patients are experiencing acute, life- generally considered common or
threatening illnesses that interfere with hazardous
their ability to make decisions about o Alternative treatments and their
treatment or participation in a clinical feasibility
research study. o Short-term and long-term
2. The doctrine of informed consent is prognoses if the proposed
based on the principle of autonomy; treatment or treatments are not
competent adults have the right to self- provided
determination or to make decisions INFORMED CONSENT: ROLES OF CRITICAL
regarding their acceptance or rejection of CARE NURSES
treatment. • Critical care nurses are asked to witness the
3. Informed consent is not a form. consent process for procedures and tests.
4. It is a process that entails the exchange • Critical care nurses should serve as
of information between the health care advocates for the patient and ensure that the
provider and the patient or patient’s informed consent process has been
proxy. completed per legal standards and
5. Elements of Informed Consent institutional policy.
• Competence (or capacity) refers to a • Critical care nurses may provide additional
person’s ability to understand patient education to support decision
information regarding a proposed making, but the process of obtaining
medical or nursing treatment. informed consent is a physician obligation.
Competence is a legal term and is DECISIONS REGARDING LIFE-
determined in court. SUSTAINING TREATMENT
• Voluntariness Consent must be 1. Care of persons who are terminally ill or in a
given voluntarily, without coercion or persistent vegetative state raises profound
fraud, for the consent to be legally questions about the constitutional rights of

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persons or surrogates to make decisions terminal weaning from mechanical

related to death or life-sustaining care, as ventilation (withdrawing).
well as the rights of the state to intervene in o Decisions are made based on
treatment decisions. consideration of all factors in the ethical
2. Technology frequently sustains life in decision-making model.
persons who would have previously died of o In all instances of withholding and
their illnesses. withdrawing life support, comfort
3. The widespread use of advanced life-support measures are maintained, including
systems and cardiopulmonary resuscitation management of pain, pulmonary
(CPR) has changed the nature and context secretions, and other symptoms as
of dying. needed.
4. A “natural death” in the traditional sense is o An ethical decision-making approach is
rare; most patients who die in healthcare used to decide on the best actions to take
facilities undergo resuscitation efforts. or not take in the situation.
CARDIOPULMONARY RESUSCITATION o The value of clearly stating in writing
DECISIONS one’s end-of-life issues before becoming
o The goals of emergency cardiovascular critically ill (advance directive) is key to
care are to preserve life, restore health, avoiding having treatment given or not
relieve suffering, limit disability, and given against one’s wishes.
reverse clinical death. PATIENT SELF-DETERMINATION ACT
o Ethical questions arise about the use of o Discussions regarding advance
CPR and emergency cardiac care directives and end-of-life wishes should
because such treatment may conflict with be made as early as possible, preferably
a patient’s desires or best interests. before death is imminent.
o The critical care nurse should be guided o The ideal time to discuss advance
by scientifically proven data, patient directives is when a person is relatively
preferences, and ethical and cultural healthy, not in the critical care or hospital
norms. setting.
o Withholding or stopping extraordinary o This allows more time for discussion,
resuscitation efforts is ethically and processing, and decision making.
legally appropriate if patients or ADVANCE DIRECTIVES
surrogates have previously made their o An advance directive is a communication
preferences known through advance that specifies a person’s preference
directives. about medical treatment should that
o It is also acceptable if the physician person become incapacitated.
determines that resuscitation is futile or o Several types of advance directives exist,
has discussed the situation with the including DNR orders, allow-a-natural-
patient, family, and/or surrogate as death orders, living wills, health care
appropriate, and there is mutual proxies, and other types of legal
agreement not to resuscitate in the event documents.
of cardiopulmonary arrest. o It is important for nurses to know whether
WITHHOLDING OR WITHDRAWING LIFE a patient has an advance directive and
SUPPORT that the directive be followed.
o Withholding life support, withdrawing life o The living will provides a mechanism by
support, or both, can range from not which individuals can authorize the
initiating hemodialysis (withholding) to

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withholding of specific treatments if they • Is the situation emotionally charged?

become incapacitated. • Has the patient’s condition changed
o When completing a living will, individuals significantly?
can add special instructions about end- • Is there confusion or conflict about the
of-life wishes. facts?
o The durable power of attorney for health • Is there increased hesitancy about the
care is more protective of patients’ right course of action?
interests regarding medical treatment • Is the proposed action a deviation from
than is the living will. customary practice?
o With a durable power of attorney for • Is there a perceived need for secrecy
health care, patients legally designate an around the proposed action?
agent whom they trust, such as a family PROCESS OF ETHICAL DECISION MAKING
member or friend, to make decisions on • This model provides a framework for
their behalf should they become evaluating the related ethical principles
incapacitated and the potential outcomes, as well as
o This person is called the health care relevant facts concerning the contextual
surrogate or proxy. factors and the patient’s physiological
DECISIONS REGARDING LIFE-SUSTAINING and personal factors.
TREATMENT
• Using this approach, the patient, family,
o Organ and tissue transplantation involve
and healthcare team members evaluate
numerous and complex ethical issues.
choices and identify the option that
o The first consideration is given to the
promotes the patient’s best interests
rights and privileges of all moral agents
involved: the donor, the recipient, the ETHICAL PRINCIPLES
family or surrogate, and all other • As reflected in the decision-making
recipients and donors. model, relevant ethical principles should
o Important ethical principles that are be considered when a moral dilemma
useful in ethical decision making exists.
regarding transplantation include respect • Principles facilitate moral decisions by
for persons and their autonomous guiding the decision-making process, but
choices, beneficence and they may conflict with each other and
nonmaleficence, justice, and fidelity. may force a choice among the competing
o Three of the most controversial issues in principles based on their relative weight
transplantation are the moral value that in the situation.
should be placed on the human body • Several ethical principles are pertinent in
part, the just distribution of a human body the critical care setting.
part, and the complex problems inherent • These principles are intended to provide
in applying the concept of brain death to respect and dignity for all persons
clinical situations. • Principlism is a widely applied ethical
ETHICAL DECISION MAKING approach based on four fundamental
Several warning signs can assist the critical care moral principles to contemporary ethical
nurse in recognizing an ethical dilemma. If these dilemmas:
warning signs occur, the critical care nurse must RESPECT FOR AUTONOMY
reassess the situation and determine whether an • The principle of autonomy states that all
ethical dilemma exists and what additional persons should be free to govern their
actions are needed. lives to the greatest degree possible.

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• The autonomy principle implies a strong and are also held directly accountable for
sense of self-determination and an their individual nursing actions.
acceptance of responsibility for one’s • Nurses who care for critically ill patients
own choices and actions. are challenged by ethical dilemmas on a
• To respect autonomy of others means to daily basis.
respect their freedom of choice and to • In their role of patient advocate, ethical
allow them to make their own decisions. decision making and open
BENEFICENCE communication must be facilitated.
• The principle of beneficence is the duty • Numerous resources are available to
to provide benefits to others when in a assist with developing the knowledge
position to do so, and to help balance and skill to do this well.
harms and benefits. • A formal decision making model assists
• In other words, the benefits of an action the nurse, but some situations may still
should outweigh the burdens. remain very ambiguous.
• A related concept is futility. • Appropriate ethical nursing responses
• Care should not be given if it is futile in are based on wanting to do the right thing
terms of improving comfort or the medical for the patients and families that you care
outcome. for and initiating the steps to advocate for
NONMALEFICENCE the patient.
• The principle of nonmaleficence is the
explicit duty not to inflict harm on others
intentionally.
JUSTICE
• The principle of justice requires that
health care resources be distributed fairly
and equitably among groups of people.
• The principle of justice is particularly
relevant to critical care because most
healthcare resources, including
technology and pharmaceuticals, are
expended in this practice setting.
VERACITY
• The principle of veracity states that
persons are obligated to tell the truth in
their communication with others.
FIDELITY
The principle of fidelity requires that one has a
moral duty to be faithful to the commitments
made to others.
“Veracity and Fidelity, along with confidentiality,
are the key to the nurse-patient relationship.
Conclusion
• Based on evolving case law, state
statutes, and state nurse practice acts,
nurses are held to a high standard of care

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References:
• Nursing PowerPoint (FEU Version) I. CORONARY ARTERY DISEASE
• Lecture Notes
OUTLINE
(CAD)
• Term given to heart problems caused by
I. Coronary Artery Disease
narrow heart (coronary) arteries that supply
II. Ischemic Heart Disease
III. Angina blood to heart muscles.
IV. Myocardial Infarction • Most prevalent type of cardiovascular disease
V. Invasive Coronary Artery and for adults.
Surgical Procedures • The nurse must be familiar with various
A. Coronary Artery Bypass Graft manifestation of coronary artery conditions as
(CABG) well as methods for assessing, preventing and
B. Percutaneous Transluminal treating.
Coronary Angioplasty (PTCA) NURSING DIAGNOSIS
VI. Congestive Heart Failure 1. Activity intolerance; Excess fluid volume;
A. Right-Sided Heart Failure 2. Decreased cardiac output
B. Left-Sided Heart Failure 3. Ineffective tissue perfusion
C. Biventricular Heart Failure 4. Ineffective airway clearance
VII. Surgical Procedures 5. Impaired gas exchange
A. Orthotopic Heart II. ISCHEMIC HEART DISEASE
Transplantation
B. Heterotopic Heart
Transplantation
C. Heart Transplantation
D. Cardiomyoplasty
E. Mechanical Assist Device
F. Total Artificial Heart
G. Ventricular Assist Device
VIII. Hypertension
A. Hypertensive Crisis
B. Hypertensive Urgency
C. Hypertensive Emergency
D. Triage Evaluation: Algorithm
E. Oral Agents for Treatment of
Hypertensive Crisis • Also known as Coronary Artery Disease (CAD)
F. Parenteral Drugs for Treatment • A disease causes lack of blood flow and
of Hypertensive Emergency oxygen to the heart muscle (myocardium).
• An imbalance between myocardial oxygen
supply and demand.
• It is caused mainly by Atherosclerosis of
CARDIOVASCULAR SYSTEM
Coronary Artery.
• It includes:
o Angina: Stable & Unstable
o Myocardial infarction
o Heart failure
o Arrhythmia
III. ANGINA
• Type of temporary chest pain or discomfort
caused by insufficient blood flow to the heart
muscle from narrowing of coronary artery.
• Pressure or squeezing in chest.
• Discomfort can also occur in shoulders, arms,
neck, jaw, or back.

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TYPES OF ANGINA RISK FACTORS

1. Stable Angina
§ Episodic clinical syndrome
§ No change in severity of attacks
2. Unstable Angina
• Deterioration within 24 hrs in
previous stable angina
• With symptoms frequently occuring
at rest
• i.e. Acute Coronary Syndrome
3. Intractable or Refractory Angina
• Severe incapacitating chest pain
4. Silent Ischemia
• Objective evidence of ischemia
• e.g. Electrocardiographic changes
with stress test
• Reports no pain
5. Varient Angina (Prinzmetal)
• Pain at rest with reversible ST-
Segment elevation
• Thought to result from coronary
artery vasospasm
PRECIPITATING FACTORS
ü Over exertion
ü Exposure to cold
ü Eating
RISK FACTORS
ü Diabetes mellitus • Age
ü Atherosclerosis • Gender
ü Hypertension • Lifestyle: Stress, Habits
ü Hormonal • Diet
PATHOPHYSIOLOGY • Chronic illness: DM, HPN
• Reduced blood flow in coronary artery (rupture PATHOPHYSIOLOGY
of an atherosclerotic plaque) • Coronary occlusion due to thrombosis,
• Clot begins to form on top of coronary lesion, embolism, or hemorrhage adjacent to
but the artery is not completely occluded. atherosclerotic plaque.
• Insufficient blood flow from cardiac,
IV. MYOCARDIAL INFARCTION hypertrophy, hemorrhage, shock, or severe
dehydration.
COMPARISON OF ASSESMENT
CHEST PAIN

• Commonly known as heart attack.

• Occurs when blood flwo decreased or stops to
a part of the heart, causing damage to the
heart muscle.

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PERCUTANEOUS TRANSLUMINAL
CORONARY ANGIOPLASTY (PTCA)
• Insertion of catheter at the femoral artery,
sometimes at the radial vein going to the
aorta, and into the coronary arteries
• Done at cardiac laboratory.
o Balloon
OTHER CLINICAL MANIFESTATION
NURSING CARE MANAGEMENT VI. HEART FAILURE
• Provide relief from pain • Known as Congestive Heart Failure (CHF).
• Rest • Heart is unable to pump sufficiently to
• Nitro-glycerine maintain blood flow.
• Lifestyle modification • It results to a condition known as Systolic
• Vital signs Dysfunctions or Diastolic Dysfunctions
• Assist with ambulation CONGESTIVE HEART FAILURE
• Provide emotional support • It is not curable.
• Health teaching • Early detection and treatment may help
• Pain differentiation improve a person’s life expectancy.
• Diagnostic test • It is a clinical syndrome in which heart is
• Diet, exercise, CABG unable to pump sufficient blood to meet the
• Reduce pain & discomfort metabolic requirements of the body, or can
• Maintain adequate circulation do so only at an elevated filling pressure.
• Decrease oxygen demand / Promote
oxygenation
• Maintain fluid & electrolyte balance/ Nutrition
• Facilitate fecal elimination
• Provide emotional support
• Promote sexual functioning
• Health teaching
EVALUATION
Expected patient outcomes:
• Relief from Angina
• Stable cardiac and respiratory status
• Maintain adequate tissue perfusion
TREATMENT GUIDELINES FOR ACUTE
MYOCARDIAL INFARCTION NURSING DIAGNOSIS
1. Rapid transit to the hospital. 1. Decreased cardiac output
2. Obtain 12-lead ECG within 10 mins. 2. Activity intolerance
3. Obtain laboratory blood specimens of cardiac 3. Excess fluid volume
biomarkers. 4. Risk for impaired gas exchange
4. Begin routine medical interventions. 5. Risk for impaired skin integrity
5. Evaluate for indications for perfusion therapy.
6. Bed rest for a minimum of 12-24 hours. CLASSIFICATION OF HEART FAILURE
7. Statin prescribed at discharge. Low-Output versus High-Output
§ Low-output metabolic demands
V. INVASIVE CORONARY ARTERY o Normal but heart is unable to meet
(1&2) AND SURGICAL PROCEDURES them.
§ High-output metabolic demands
CORONARY ARTERY BYPASS GRAFT (CABG)
o Increased and the heart is unable
• Saphenous vein, left internal mammary to meet them.
artery is grafted distal to the coronary artery Left-sided, Right-sided and Biventricular
lesion, bypassing the obstrution § Left-sided
• Performed under general anethesia o Blood is not adequately pumped
from the left ventricle
§ Right-sided

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o Blood is not pumped adequately PATHOPHYSIOLOGY

from right ventricle
§ Biventricular
o Blood is not pumped adequately
from both ventricle
LEFT-SIDED HEART FAILURE
§ Left ventricle cardiac output is less
§ Volume is received from pulmonary
circulation..
§ Blood accumulated in the left ventricle, left
atrium.
§ Pulmonary congestion forcing fluid from
pulmonary capillaries into pulmonary tissue
and alveoli causing pulmonary interstitial
edema and impaired gas exchange. Left Sided Heart Failure
RIGH-SIDED HEART FAILURE
§ Right ventricle cardiac output is less.
§ Volume received from the peripheral
venous circulation.
§ Blood accumulates in right atrium, right
ventricle.
§ Increased venous pressure lead to JVD
and increased capillary hydrostatic
pressure through the venous system.
ETIOLOGY OF HEART FAILURE
• Incidence of heart failure increases with
advancing age and coronary artery
disease.
• Diabetes Right Sided Heart Failure
• Cigarette Smoking
• Obesity
• Elevated total cholesterol
• Abnormally high or low hematocrit level
• Proteinuria
COMMON PRECIPITATING CAUSES OF HEART
FAILURE
• Anemia
• Infection
• Thyrotoxicosis
• Arrhythmias
• Bacterial Endocarditis
• Valvular dysfunction
• Pulmonary embolism
• Pulmonary disease
TYPES OF HEART FAILURE
• Pagats disease
• Nutritional deficiencies
• Hypovolemia

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BI-VENTRICULAR FAILURE • Water pills

• Left-sided “forward” failure overlaps with NURSING PROCESS
right-sided “backward” failure Assessment
• Most common cause of right-sided heart • Observe for effectiveness of therapy and
failure is left-sided heart failure, therefore, the ability of the client to understand and
both signs and symptoms are presented implement self-management strategies.
• Dullness of the lung fields to finger • Pulmonary and systemic fluid overload
percussion signs and symptoms.
• Reduced breath sounds at the bases of the Diagnosis
lung may suggest development of pleural • Activity intolerance and fatigue related to
effusion and a more common sign of decreased cardiac output
biventricular failure • Excess fluid volume related to heart failure
DIAGNOSTIC ASSESMENT syndrome
• History collection • Anxiety related to breathlessness from
• Physical examination inadequate oxygenation
• ABG analysis NURSING MANAGEMENT
• Serum chemistries • Administer medications and asssess
• Liver profile patients’ response.
• Chest x-ray • Assess fluid balance, including intake and
• 12-Leads ECG output, with goal of optimizing fluid volume.
• Nuclear imaging studies
• Cardiac catheterization VII. SURGICAL PROCEDURES
• 2D Echocardiogram Orthotopic Heart Transplantation (OHT)
• Hemodynamic Monitoring • Commonly utilized procedure for end-stage
MEDICAL MANAGEMENT heart failure parients.
• Eliminate or reduce any etiologic Heterotopic Heart Transplantation (HHT)
contributory factors (e.g. uncontrolled • It allows graft to be connected to the native
hypertension or atrial fibrillation w/ rapid heart in a parallel fashion.
ventricular response). • Its main advantage is that, it assist the
• Optimized pharmacologic and other patients’ native heart to maintain circulation
therapeutic regimens. in the cases of severe acute rejection.
• Reduce workload on heart by reducing Heart Transplantation
preload and afterload. • Also known as, cardiac transplant, is a
• Promote lifestyle conducive to cardiac surgical transplant procedure performed on
health. patients with end-stage heart failure or
• Prevent episodes of acute decompensated severe coronary artery disease.
HF. • Occurs when the heart is irreversibly
PHARMACOLOGICAL MANAGEMENT managed and no longer functions
• Digoxin adequately.
o Exerts direct beneficial effect on • Cardiac transplantation and use of artificial
myocardial contraction heart to assist or replace the failing heart
o Improved cardiac outpur enhances measures when the client is at risk of dying.
kidney perfusion, which may create POST-OPERATIVE
mild dieresis of NA and H2O • Patient is taken to the ICU to recover
• Beta blockers • When already stable, they may move to
• Inotropes special recovery unit for rehabilitation
o Agent such as dopamine, CARDIOMYOPLASTY
dobutamine and emrinone may be • A healthy muscle from another part of the
ordered for clients with very low body is wrapped around the heart to
output heart failure provide support.
o Facilitaes myocardial contractility • Latissimus dorsi muscle is used most often.
and enhance stroke volume
• A special pacemaker is implanted to make
• ARBS the skeletal muscle contract.
• ACE Inhibitors • Related to myocardium remodeling.
o Can raise potassium levels MECHANICAL ASSIST DEVICE (VAD)

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• Man-made pump that can temporarily help HYPERTENSIVE URGENCY

the pumping action of the heart. • It is an increase in systolic and diastolic
• Used to help maintain blood circulation. blood pressure associated with end-organ
DIFFERENT TYPES OF VAD damage of the CNS, heart, or kidneys.
• Intra-Aortic Ballon Pump (IABP) • An elevation of SBP (>220 mmHg) and/or
o Also known as, Intra-aortic Balloon DBP (>125 mmHg) without evidence of
Counter Pulsation (IABC) or ballon acute end-organ damage.
pump • Not necessitate admission to ICY
o It inflates and deflates at a specific • BP is gradually lowered over 24 – 48 h
rate to help the flow of blood • Treated with rapid-acting oral
through the aorta and decreases antihypertensive agents.
workload on the left ventricle ORAL DRUGS
o Helps the left side of the heart for • ACE Inhibitors (Captopril or Capo tent)
short period of time (10 days), and • Beta Blockers (Labetalol)
referred to as “acute support” • Clonidine guanabenz, Prazosin, and
o Recent heart attack Minoxidil
o Heart inflammation (acute • Loob Diuretics – generally prescribed along
myocarditis) with antihypertensive drugs
o Difficulty coming off HYPERTENSIVE EMERGENCY
cardiopulmonary bypass after • It is an acute, marked elevation in blood
open-heart surgery. pressure that is associated with signs aof
TOTAL ARTIFICIAL HEART target-organ damage (i.e. pulmonary
• A mechanical device that permanently edema, cardiac ischemia, neurologic
replace the heart that has no external tubes deficits, acute renal failure, aortic
or cable. dissection, and eclampsia).
VENTRICULAR ASSIST DEVICE (VAD) • The clinical differentiation between
• An electromechanical device for assisting hypertensive emergency and hypertensive
cardiac circulation. urgency depends on the presence of target
• Used either partially or completely replace organ damage, rather than the level of BP.
the function of failing heart. ETIOLOGY OF HYPERTENSIVE CRISIS
• Some are for short-term use, typically for • May occur in pateints with no history of the
patients recovering from myocardial condition or precipitated by noncompliance
infarction and cardiac surgery. with medical therapy or diet, or both; or by
inadequate treatment.
VIII. HYPERTENSION Common Causes:
• Known as, high blood pressure. 1. ARF
• Force that a person’s blood exerts against 2. Acute CNS events
the walls of their blood vessels. 3. Drug-induced hypertension
• It can lead to severe health complications 4. Ingestion of tyramine-containing foods or
and increase the risk of heart disease, beverages during treatment with
stroke, and sometimes death. monoamine oxidase inhibitor (MAOI)
CLASSIFICATION OF HYPERTENSION 5. Pregnancy-induced epilepsies
• Systolic blood pressure or Diastolic blood 6. Pheochromocytoma
pressure (mmHg) MANIFESTATION OF HYPERTENSIVE CRISIS
• Stage 1: 140 – 159; 90 – 99 • Can be manifested by any symptoms
Stage 2: 160 – 179; 100 – 109 depending on the end-organ involved.
Stage 3: ≥ 180; ≥ 110 • ARF, identified by sudden absence of urine
• Stage 3 hypertension is also called severe output Catecholamine excess
hypertension or accelerated hypertension
HYPERTENSIVE CRISIS
• It is a severe increase in blood pressure
leading to stroke.
• Extremely highblood pressure that ≥180
mmHg systolic pressure or ≥120 mmHg
diastolic pressure can damage blood
vessels.

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• Cardiovascular compromise, identifid by

chest pain of an acute coronary syndroem
or aortic dissection.
PHARMACOLOGIC MANAGEMENT
• Angiotensin – converting enzyme (ACE)
inhibitors
• Angiotensin receptor blockers (ARBs)
• Diuretics
• Beta-blockers
• Calcium channel blockers
NURSING MANAGEMENT
• Frequently monitoring of blood pressure
• Administer antihypertensive medications
as prescribed
• Have two large-bore Ivs
• Provide oxygen if the saturations are low
(less than 94%)
• Limit fluid intake if patient is in heart failure
• Assess ECG to ensure the patient is not
having a heart attack
TRIAGE EVALUATION: ALGORITHM

ORAL AGENTS FOR TREATMENT OF

HYPERTENSIVE CRISIS
• Captopril
• Clonidine
• Labetalol
• Prazosin
PARENTERAL DRUGS FOR TREATMENT OF
HYPERTENSIVE EMERGENCY
Parenteral Vasodilators
• Sodium nitropruside
• Nitroglycerin
• Nicardipine
• Diazoxide
• Fernoldapam mesylate
• Hydralazine
• Enalaprilat
Parenteral Adrenergic Inhibitors
• Labetalol
• Esmolol
• Phentolam

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References: • Bronchospasm, production of large amount of

• Lecture Notes thick mucus and inflammatory response
• Medical-Surgical Nursing Book contribute to respiratory obstruction
DIAGNOSTIC TEST
OUTLINE • ABG (elevated PCO2, decreased PO2 and pH)
I. Respiratory System • Vital capacity reduced
A. Types of Respiratory Diseases • Forced expiratory
II. Asthma • Volume decreased
III. Chronic Obstructive Pulmonary Disorder
• Residual Volume increased
(COPD)
MEDICAL MANAGEMENT
A. Chronic Bronchitis
• Steroids, Antibiotics, Bronchodilators,
B. Emphysema
expectorants
C. Nursing Considerations
IV. Acute Respiratory Distress Syndrome • O2, nebulization
(ARDS) NURSING MANAGEMENT
V. Pneumonia • Promote pulmonary ventilation
VI. Pneumothorax • Facilitate expectoration
VII. SARS-CoV 2: The COVID-19 Disease • Health teaching Breathing techniques
• Stress management
I. RESPIRATORY SYSTEM
is composed of the upper and lower respiratory tracts. III. CHRONIC OBSTRUCTIVE
Together, the two tracts are responsible for ventilation PULMONARY DISORDER
(movement of air in and out of the airways)
CHRONIC BRONCHITIS
TYPES OF RESPIRATORY DISEASES • increased mucus production that obstructs airway
URT LRT • chronic inflammation of the lower respiratory tract
Rhinitis/ Sinusitis Pneumonia characterized by excessive mucous secretion,
Pharyngitis Bronchitis cough, and dyspnea associated with recurring
Laryngitis Tuberculosis infections of the lower respiratory tract characterized
Rhinosinusitis by three primary symptoms: chronic cough, sputum
production, and dyspnea on exertion.
II. ASTHMA ETIOLOGY
increased responsiveness of the trachea and bronchi to • Cigarette smoking
various stimuli, with difficulty in breathing, caused by • Air pollution
narrowing of airways • Work environment
TYPES CLINICAL MANIFESTATIONS
1. Immunologic asthma occurs in childhood • Cough
2. Non-immunologic asthma occurs in adulthood • Coughing up mucus
and associated with recurrent respiratory • Wheezing
infections. Usually >35 y/o 3. • Chest discomfort
3. Mixed- combined immunologic and non-
• Bluish fingernails, lips, skin
immunologic
• Swollen Feet
Status Asthmaticus - a life-threatening asthmatic attack
in which symptoms of asthma continues and do not • Heart Failure
respond to treatment • Blue Bloater
ETIOLOGY DIAGNOSTIC TEST
• History of rhinitis, allergies, family history of • Spirometry & Pulmonary Function Testing (PFT)
asthma • Chest X-ray
CLINICAL MANIFESTATIONS • ABG Levels
• Increased tightness of chest, dyspnea • Sputum Examination
• Tachycardia, tachypnea PATHOPHYSIOLOGY
• Dry, hacking, persistent cough In chronic bronchitis exposure to an irritant over many
• (+) wheezes, crackles years causes inflammation in the lungs which leads to the
following changes:
• Pallor, cyanosis, diaphoresis, Chronic barrel
chest, elevated • Continual irritants (smoking, infection, pollution) to
PATHOPHYSIOLOGY the lungs cause the airways to become swollen and
inflamed.
• Bronchial smooth muscles constricts
o Constant irritants lead to hypertrophy
• Bronchial secretions increase
(enlargement) of the mucus-secreting glands of
• Mucosa swells and narrows airway passage the bronchial tree, an increase in the number of
• Histamine is produced in the lungs goblet cells, which results in increased mucus
secretion.

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o The smooth muscle in the airways becomes • Chemical Fumes

thicker and narrows the bronchioles. • Dust
• Extra mucus is produced to trap any irritants and CLINICAL MANIFESTATIONS
prevent them entering the lungs. • “Pink puffer”
o The cilia become unable to cope with excessive • Dyspnea, decreased exercise tolerance.
secretions and therefore the mucus blocks the • Cough may be minimal, except with respiratory
airways. This is known as Reversible Airways infection.
Obstruction. • Sputum expectoration (mild)
o The mucus goes deeper into the lungs and • Barrel chest – Increased anteroposterior
becomes harder to clear. diameter of chest due to air trapping with
• Excessive secretions are liable to infection. diaphragmatic flattening
o The walls of the bronchioles become inflamed, DIAGNOSTIC TEST
continual inflammation causes gradual • Spirometry is used to evaluate airflow
destruction of the bronchioles, resulting in obstruction
fibrosis - Irreversible Airways Obstruction. • ABG levels- decreased Pao2, pH, and
• Disease progression can also affect the pulmonary increased CO2.
blood vessels • Chest X-ray- in late stages, hyperinflation,
o If the inflammation spreads to the blood vessels flattened diaphragm, increased retrosternal
this will lead to capillary bed wall atrophy space, decreased vascular markings, possible
(wasting). This increases the pressure of the bullae
pulmonary circulation. Pulmonary arteries may
• Alpha1-antitrypsin assay useful in identifying
become distended (stretched) and blood may
genetically determined deficiency in
back track into the right side of the heart
emphysema
resulting in right sided hypertrophy
PATHOPHYSIOLOGY
(enlargement) and heart failure. This is known
as Cor Pulmonale.
PULMONARY EMPHYSEMA
• airway is obstructed due to destroyed alveolar walls
• complex lung disease characterized by destruction of
the alveoli, enlargement of distal airspaces, and a
breakdown of alveolar walls. There is a slowly
progressive deterioration of lung function for many
years before the development of illness
TWO TYPES
1. Panlobular Emphysema – destruction of
respiratory bronchiole, alveolar duct and alveolus.
- All air spaces within the lobule are
essentially enlarged, but there is little
inflammatory disease hyperinflated
(hyperexpanded) chest, marked dyspnea
on exertion, and weight loss typically occur SURGICAL MANAGEMENT
- Negative pressure is required during • Bullectomy
inspiration to move air into and out of the • Lung Volume Reduction Surgery
lungs
- Expiration becomes active and requires NURSING CONSIDERATIONS IN TAKING CARE
muscular effort OF PATIENTS WITH COPD
2. Centrilobular (Centroacinar) Emphysema – • Pulmonary rehabilitation to reduce symptoms,
pathologic changes take place mainly in the center improve quality of life, and increase physical and
of the secondary lobule, preserving the peripheral emotional participation in everyday activities
portions of the acinus • Pursed-lip breathing helps slow expiration, prevents
- There is a derangement of ventilation– collapse of small airways, and helps the patient
perfusion ratios, producing chronic control the rate and depth of respiration
hypoxemia, hypercapnia, polycythemia, • Instruct the patient to coordinate diaphragmatic
and episodes of right-sided heart failure breathing with activities such as walking, bathing,
- Leads to central cyanosis and respiratory bending, or climbing stairs
failure, and patient also develops peripheral • Provide small frequent meals and offer liquid
edema nutritional supplements to improve caloric intake and
ETIOLOGY counteract weight loss
• Smoking • Administer low flow of oxygen (1-2L/min)
• Air Pollution • Administer bronchodilator as prescribed
• Adequately hydrate the patient

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• Instruct the patient to avoid bronchial irritants NURSING MANAGEMENT

• If indicated, perform CPT in the morning and at night • Requires close monitoring in the intensive care
as prescribed unit
• Encourage alternating activity with rest periods • Assess the patient’s status frequently to
• Teach relaxation technique or provide a relaxation evaluate the effectiveness of the treatment
tape for patient • Turn the patient frequently to improve ventilation
• Enroll patient in pulmonary rehabilitation program and perfusion in the lungs and enhance
where available drainage secretions
• Monitor respiratory status, including rate and pattern • Rest is essential for patient to limit oxygen
of respirations, breath sounds, and signs and consumption and reduce oxygen needs
symptoms of acute respiratory distress • Adequate nutritional support is vital, 35 to 45
kcal/kg/day is required to meet caloric
IV. ACUTE RESPIRATORY DISTRESS requirements
SYNDROME • Identify problems with ventilation that may cause
- non- cardiogenic pulmonary infiltrations resulting in anxiety reaction to the patient
stiff and refractory hypoxemia in previously healthy
adult. It is a severe inflammatory process causing V. PNEUMONIA
diffuse alveolar damage Inflammatory process of lung parenchyma associated
ETIOLOGY with build-up of fluid or pus in the alveoli (air sac).
a. Primary – Shock, multiple trauma, infections , TWO TYPES
aspirations, inhalation of chemical toxins, drug 1. Community-acquired pneumonia (CAP)- is one of
overdose, DIC, Emboli the most common infectious diseases and is an
b. Secondary – Overaggressive fluid important cause of mortality and morbidity
administration , oxygen toxicity worldwide. Typical bacterial pathogens that cause
CLINICAL MANIFESTATIONS CAP include Streptococcus pneumoniae,
• Restlessness Haemophilus influenzae, and Moraxella catarrhalis.
• Typically develops over 4 to 48 hours However, with the advent of novel diagnostic
• severe dyspnea, severe hypoxemia technologies, viral respiratory pathogens are
increasingly being identified as frequent etiologies of
• Arterial hypoxemia that does not respond to
CAP. The most common viral pathogens recovered
supplemental oxygen
from hospitalized patients admitted with CAP include
• chest x-ray are similar to those seen with
human rhinovirus and influenza.
cardiogenic pulmonary edema
2. Ventilator-associated pneumonia (VAP)- is a lung
• increased alveolar dead space
infection that develops in a person who is on a
• Severe crackles and rhonchi heard on ventilator. A ventilator is a machine that is used to
auscultation help a patient breathe by giving oxygen through a
• Labored breathing and tachypnea tube placed in a patient’s mouth or nose, or through
PATHOPHYSIOLOGY a hole in the front of the neck. An infection may occur
1. Damage to alveolar capillary membrane if germs enter through the tube and get into the
2. Increased Vascular permeability to pulmonary patient’s lungs. (CDC, 2020)
edema ETIOLOGY
3. Impaired Gas exchange • Smoking
4. Decreased surfactant production
• Air pollution
5. Potential Atelectasis
• URTI
6. Severe hypoxia
• Altered consciousness
7. May lead to death
DIAGNOSTIC • Tracheal intubations
• CVP • Prolonged immobility
• Pulmonary Wedge Capillary Pressure • lowered immune system
• ABG • malnutrition
MEDICAL MANAGEMENT • Chronic Diseases: DM, Heart diseases, renal
• ICU disease, cancer
• strict monitoring • Inhalation toxicity/ aspiration
CLINICAL MANIFESTATION
• O2
• Chest pain
• Suction
• Bronchodilator • Irritability
• Apprehensiveness
• Antibiotics
• Restlessness
• Intubation
• Nausea
• Ventilator
• Anorexia
• History of exposure

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• Cough- productive , rusty/ yellowish/greenish • Observe and allow for spontaneous resolution
sputum, splinting of affected side, chest for less than 50% pneumothorax in otherwise
retraction (infants) healthy person.
• Sudden increased fever • Needle aspiration or chest tube drainage may be
• Nasal Flaring necessary to achieve re-expansion of collapsed
• Circumoral cyanosis lung if greater than 50% pneumothorax.
• Tachypnea • Surgical intervention by pleurodesis or
• Vomiting thoracotomy with resection of apical blebs is
PATHOPHYSIOLOGY advised for patients with recurrent spontaneous
Caused by infectious or non-infectious agents, clotting of pneumothorax
an exudate rich fibrinogen, consolidated lung tissue 2. Tension Pneumothorax
DIAGNOSTIC TESTS • Immediate decompression to prevent
• CXR cardiovascular collapse by thoracentesis or
• sputum culture chest tube insertion to let air escape
• Blood culture • Chest tube drainage with underwater-seal
• increased WBC suction to allow for full lung expansion and
• elevated sedimentation rate healing
MEDICAL MANAGEMENT 3. Open Pneumothorax
• Antibiotics • Close the chest wound immediately to restore
• Rest adequate ventilation and respiration
NURSING MANAGEMENT • Patient is instructed to inhale and exhale gently
• Encourage coughing and deep breathing after against a closed glottis (Valsalva maneuver) as
chest-physio therapy, splinting the chest if a pressure dressing (petroleum gauze secured
necessary with elastic adhesive) is applied. This maneuver
helps to expand collapsed lung
• Maintain semi-Fowler’s position
• Chest tube is inserted and water-seal drainage
• Monitor pulse oximeter
set up to permit evacuation of fluid/air and
• Promote hydration(2-3L/day) to liquefy
produce re-expansion of the lung
secretions
• Surgical intervention may be necessary to repair
• Teach effective coughing techniques to
trauma
minimize energy expenditure; plan rest periods
ETIOLOGY
• Suction if necessary
• TRAUMATIC: Trauma to the chest, broken rib,
• Instruct client to cover nose and mouth when contact sports injury to the chest, stab wound, bullet
coughing wound
• Teach the need to continue entire course of • NON-TRAUMATIC (SPONTANEOUS): COPD,
antimicrobial therapy which is usually seven to Pneumonia, PTB, Lung Cancer, Cystic Fibrosis
ten days CLINICAL MANIFESTATIONS
• Teach the patient about proper administration of • Steady ache in the chest
antibiotics and potential side effects.
• Dyspnea
• Teach that findings are expected to be less
• Tightness in the chest
within 48 to72hours of initial therapy
• Cyanosis
• Nutritionally enriched drinks or shakes maybe
• Tachycardia
helpful in maintaining nutrition
DIAGNOSTIC TESTS
VI. PNEUMOTHORAX • CX-ray
Pneumothorax occurs when air enters the space around • CT Scan
your lungs (the pleural space). Air can find its way into the • Thoracic Ultrasound
pleural space when there’s an open injury in your chest MEDICAL MANAGEMENT
wall or a tear or rupture in your lung tissue, disrupting the Treatment options may include:
pressure that keeps your lungs inflated • Observation
TERMINOLOGIES • Needle aspiration
• Simple/Spontaneous Pneumothorax • Chest tube insertion
• Traumatic Pneumothorax NURSING MANAGEMENT
• Open pneumothorax • Bed rest
• Tension Pneumothorax • Apply petroleum gauze to sucking chest wound
MANAGEMENT • Assist with emergency thoracentesis or
1. Spontaneous Pneumothorax thoracostomy
• Treatment is generally nonoperative if • Position patient upright if condition permits to
pneumothorax is not too extensive. allow greater chest expansion
• Maintain patency of chest tubes

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• Assist patient to splint chest while turning or o Hyperactivity of Pulmonary System

coughing and administer pain medications as o Pulmonary Destruction
needed MANIFESTATIONS
• Monitor oximetry and ABG levels to determine • Cough
oxygenation. • Sore Throat
• Provide oxygen as needed • Headache
PATHOPHYSIOLOGY • Diarrhea
• Whenever the alveoli/bulla/bleb raptures- air • Fever
enters into the pleural space and will continue to • Loss of Smell
flow into this space until the pressure is • Loss of Taste
equilibrated or the communication is sealed ; • Difficulty of Breathing
some air travels along the broncho vascular • Shortness of Breath
sheath to reach mediastinum • Haziness and tiny white spots in the X-ray
(pneumomediastinum)- As mediastinal pressure Result
rises, decompression occurs in cervical DIAGNOSTIC TEST
subcutaneous space(subcutaneous • SWAB TEST: rt-PCR (Real-Time Polymerase
emphysema) and retroperitoneal soft tissue Chain Reaction)
spaces. DRUGS
• The main physiologic consequence is that as the • Tocilizumab
pneumothorax enlarges, the lung collapses .
• Remdesivir
• This results in a decrease in vital capacity and a
• Baricitinib + Remdesivir
decrease in the partial pressure of oxygen
• Low dose Heparin or Enoxaparin
• The low PaO2 is due to V/P mismatch,
MANAGEMENT
anatomical shunt and sometimes alveolar
• Supportive Care
hypoventilation
• Providing fluids
• V/P mismatch occurs because the lung
collapses due to pneumothorax and the airways • Providing oxygen
are compressed but perfusion to this area is • Ventilatory support (Mechanical Ventilator) if
maintained - resulting into V/P mismatch( most indicated
important cause) GENERAL MEASURES TO PREVENT COVID-19
• Educate the general public regarding the
VII. COVID-19 disease
an infectious disease caused by the SARS-CoV 2 Virus. • Encourage people to practice healthy lifestyle
Infected patients might experience mild to severe • Vaccination
manifestations leading to death SPECIFIC MEASURES TO PREVENT COVID-19
INCUBATION PERIOD • Hand washing
• 2-14 days • Alcohol based Sanitizers
MODE OF TRANSMISSION • Avoid crowded places
• Droplet/Airborne Dx Test: Antigen, RT-PCR • Avoid travelling to high risk places
PREDISPOSING FACTORS • Avoid touching eyes, nose, and mouth
The Host (Individual) • At least 1ft away from a person with symptoms
• Age (Older Population)
• Smokers
• Immunosuppressed individuals
• Existing Comorbidities (Serious Medical
Condition)
o Heart Disease
o Diabetes
o Lung Disease
o Family Life and Culture (wild life diet
practices)
o Lack of Discipline and Education
The Environment
• Population Density (crowded)
• High level exposure to wet market with wildlife
• Animal trading
The Agent
• SARS-CoV-2
• attaching protein spikes in the lungs
• Phases of Attack
o Viral Replication

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References: • Calcium: normal or decreased

• Lecture Notes • BUN & Crea: increased
• Medical-Surgical Nursing Book • Ammonia: possibly increased
• Glucose: hyperglycemia common
OUTLINE • Lactate: increased (hyperlactatemia)
I. Acute Gastrointestinal Bleeding 3. Hematology Profile
A. UGB • Prothrombin time, partial thromboplastin time:
B. LGB increased
II. Chronic Liver Disease 4. ABG
A. Hepatic (Liver) Cirrhosis • Respiratory Alkalosis/ Metabolic Acidosis
III. Pancreatitis 5. Gastric Aspirate for pH and Guaiac
A. Acute Pancreatitis • Possibly acidotic pH
B. Chronic Pancreatitis • Guaiac positive
IV. Diabetic Ketoacidosis LOWER GASTROINTESTINAL BLEEDING
V. Intra-Abdominal Hypertension (IAH)
CAUSES
I. ACUTE GASTROINTESTINAL • Polyps
BLEEDING • Inflammatory disease (Ulcerative colitis)
Gastrointestinal bleeding (GI bleeding), also known as • Diverticulosis
gastrointestinal hemorrhage, is all forms of bleeding in the • GI Cancer
gastrointestinal tract, from the mouth to the rectum. • Vascular ectasias
UPPER GASTROINTESTINAL BLEEDING • Hemorrhoids
CAUSES • Anal Fissures
• Duodenal Ulcer
PATHOPHYSIOLOGY
• Gastric/Peptic Ulcer
• Esophageal or Gastric varices
• Mallory-Weiss Tear
• Cancer
*Peptic ulcers may lead to bleeding, perforation, or other
emergencies.
CLINICAL SIGNS & SYMPTOMS
• Hematemesis
• Melena
• Hematochezia
• Abdominal discomfort
• Symptoms of hypovolemic shock
o Hypotension
o Tachycardia
o Cool, clammy skin
o Change in LOC PHARMACOLOGICAL MANAGEMENT
o Decreased urine output Pharmacological treatments to decrease gastric acid
o Decreased gastric motility secretion and/or reduce acid effects on gastric mucosa
Fatigue; Weakness • Histamine Blockers
LABORATORY ALERT: UGB o Cimetidine
1. CBC o Famotidine
• Hemoglobin (protein in RBC that carries 02 to the o Nizatidine
body and transport paCo2 from the body): Normal, o Ranitidine
then decreased • Proton Pump Inhibitors
• Hematocrit (amount of whole blood made of RBC): o Esomeprazole
Normal, then decreased o Omeprazole
• WBC count (fight infection and other diseases): o Pantoprazole
Increased o Lansoprazole
• Platelet count (form clots and stop or prevent • Mucosal Barrier Enhancers
bleeding): Initially increased then decreased o Sucralfate
2. Serum Electrolyte Panel o Colloidal bismuth
• Potassium: decreased then increased • Antacids
• Sodium: increased o Aluminum hydroxide

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o Calcium carbonate II. CHRONIC LIVER DISEASE

o Magnesium hydroxide Chronic liver disease (CLD) or cirrhosis of the liver is one of
o Magnesium oxide the leading causes of death in the Philippines. Hepatic failure
NURSING DIAGNOSIS also results from chronic liver disease, in which healthy liver
1. Fluid volume deficit r/t decreased circulating blood tissue is replaced by fibrotic tissue.29 This form of liver
volume. failure is called cirrhosis. Finally, liver cells can be replaced
2. Altered tissue perfusion r/t decreased circulating by fatty cells or tissue and is known as fatty liver disease
blood volume STAGES OF LIVER DISEASE
3. Risk for fluid volume excess r/t fluid overload from 1. Inflammation
treatment regimen 2. Fibrosis
PATIENT OUTCOMES 3. Cirrhosis
• Adequate circulating blood volume 4. ESLD
• Adequate tissue perfusion HEPATIC (LIVER) CIRRHOSIS
• Normal fluid/volume status chronic disease characterized by replacement of normal liver
tissue with diffuse fibrosis that disrupts the structure and
NURSING MANAGEMENT AND INTERVENTIONS function of the liver.
To promote adequate circulating blood volume THERE ARE THREE TYPES OF CIRRHOSIS OR
1. Monitor vital signs for hemodynamic instability and SCARRING OF THE LIVER:
orthostatic change • Alcoholic cirrhosis, à in which the scar tissue
2. Monitor ECG, skin, urine output, amount and characteristically surrounds the portal areas. This is
characteristics of GI secretions most frequently caused by chronic alcoholism and
3. Monitor response to blood and fluid replacement is the most common type of cirrhosis.
4. Monitor laboratory values: serial Hct, Hgb, BUN, • Post necrotic cirrhosis- in which there are broad
potassium, sodium bands of scar tissue. This is a late result of a
5. Monitor bowel sounds previous bout of acute viral hepatitis.
6. Monitor for clinical manifestations of perforation: • Biliary cirrhosis- scarring occurs in the liver
severe persistent abdominal pain; board-like around the bile ducts. This type of cirrhosis usually
abdomen results from chronic biliary obstruction and infection
7. Gastric lavage as ordered until clear (cholangitis); it is much less common than the other
8. Administer medications & parenteral fluids two types.
9. Prepare patient for endoscopy, assist as necessary &
monitor for complications PATHOPHYSIOLOGY
Alcoholic cirrhosis is characterized by episodes of
To promote adequate tissue perfusion necrosis involving the liver cells, which sometimes occur
1. Monitor vital signs every 15 minutes until stable repeatedly throughout the course of the disease. The
2. Measure RAP, PAOP, cardiac output every hour until destroyed liver cells are gradually replaced by scar tissue.
stable Eventually, the amount of scar tissue exceeds that of the
3. Monitor for tachycardia, chest pain, ST-segment functioning liver tissue. Islands of residual normal tissue and
elevation, diaphoresis, and cool/clammy extremities regenerating liver tissue may project from the constricted
4. Measure urine output every hour areas, giving the cirrhotic liver its characteristic hobnail
5. Monitor level of consciousness appearance. The disease usually has an insidious onset and
6. Assess bowel sounds a protracted course, occasionally proceeding over a period
7. Monitor for elevated bilirubin of 30 or more years.
8. Notify the physician of changes and abnormalities CLINICAL MANIFESTATIONS PRESENTATIONS
• Intermittent mild fever
To promote normal volume status • Vascular spiders
1. Monitor hemodynamic response to fluid
• Palmar erythema
administration
• Unexplained epistaxis
2. Monitor breath sounds at least every hour during fluid
administration • Ankle edema
3. Monitor for restlessness or anxiety, dyspnea, • Vague morning indigestion
tachycardia, coughing, crackles, frothy sputum, • Flatulent dyspepsia
dysrhythmias, abnormal ABG results, blood pressure, • Abdominal pain
increased RAP, jugular vein distention • Firm, enlarged liver
4. Record accurate I&O hourly • Splenomegaly
5. Document and report any abnormalities CLINICAL MANIFESTATIONS PRESENTATIONS OF
DECOMPENSATED CIRRHOSIS
• Jaundice
• Ascites

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• Weakness 4. Encourages the patient to eat. If ascites is present,

• Muscle wasting give small, frequent meals.
• Weight loss 5. Restrict sodium
• Continuous mild fever 6. Frequent change in position
• Clubbing of fingers 7. Provide skin care
• Spontaneous bruising (dt Variceal bleeding) 8. Protect the patient with cirrhosis from falls and other
• Epistaxis injuries
9. Orient the patient to time and place and explain all
• Hypotension
procedures.
DIAGNOSTIC FINDINGS
MEDICAL AND NURSING INTERVENTIONS
• Ultrasound scanning
1. The patient with liver failure is at risk for bleeding
• CT complications because of decreased synthesis of
• MRI clotting factors. Patients with a prolonged prothrombin
• Radioisotope liver scans time and partial thromboplastin time and a decreased
o give information about liver size and hepatic platelet count should be protected from injury through
blood flow and obstruction. Diagnosis is the use of padded side rails and assistance with all
confirmed by liver biopsy. activity.
• Arterial blood gas analysis may reveal a ventilation– 2. Needlesticks should be kept to a minimum.
perfusion imbalance and hypoxia 3. Blood products may be ordered in severe cases.
• Hypoalbuminemia 4. Antacids, proton pump inhibitors, or H2-blockers are
• Increase serum bilirubin, cholesterol, APT, AST, ALT ordered to prevent gastritis and bleeding from stress
• Prolonged prothrombin and partial thromboplastin ulcers.
time 5. Administration of all drugs metabolized by the liver must
MEDICAL MANAGEMENT be restricted. The administration of such drugs could
• Antacids or histamine-2 (H2) antagonists cause acute liver failure in a patient with chronic
• Vitamins and nutritional supplements disease.
• Potassium-sparing diuretics (Spironolactone) or 6. Nursing assessment of respiratory rate, breath sounds,
triamterene (Dyrenium) and pulse oximetry values is critical.
• Avoidance of alcohol 7. Frequent monitoring of abdominal girth alerts the nurse
• Immunosuppressants to fluid accumulation
• Folic acid and iron are prescribed to prevent anemia 8. Positioning the patient in a semi-Fowler’s position also
NURSING DIAGNOSIS allows for free diaphragm movement
1. Activity intolerance related to fatigue, lethargy, and 9. Frequent deep-breathing and coughing exercises and
malaise changes in position are important to facilitate full/optimal
2. Imbalanced nutrition: less than body requirements, related breathing.
to abdominal distention and anorexia 10. Ascites is medically managed through bed rest, a low
3. Impaired skin integrity related to pruritus from jaundice and sodium diet, fluid restriction, and diuretic therapy
edema 11. Close monitoring of the serum creatinine level, the BUN
4. High risk for injury related to altered clotting mechanisms level, electrolytes (Na & K) and urine output is important
and altered level of consciousness for the early detection of renal impairment.
5. Disturbed body image related to changes in appearance,
sexual dysfunction, and role function III. PANCREATITIS
6. Chronic abdominal pain related to enlarged tender liver
SYMPTOMS
and ascites
There are some general symptoms that may indicate
7. Fluid volume excess related to ascites and edema
acute/chronic pancreatitis include:
formation
8. Risk for imbalanced body temperature: hyperthermia • Severe abdominal pain after having food
related to inflammatory process of cirrhosis or hepatitis
• Upper abdominal pain that goes back
9. Ineffective breathing pattern related to ascites and
• Rapid heartbeat
restriction of thoracic excursion secondary to ascites,
abdominal distention, and fluid in the thoracic cavity • Upset stomach
NURSING MANAGEMENT • Fever
1. Promote rest • Unwanted weight loss
2. Provide oxygen therapy • Nausea and Vomiting
3. Improve client’s nutritional status (high-protein diet, if • Stinking oily stool
tolerated, supplemented by vitamins of the B • Tender and Swollen belly
complex, as well as A, C, and K) • Diarrhea
• Bleeding

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• Dehydration CLINICAL MANIFESTATIONS

LOCATION OF PANCREATITIS PAIN 1. Pain on LUQ radiating to the back – intense and
● Pain due to pancreatitis may be intermittent or chronic constant, occurring at unpredictable intervals; often
or frequently very severe lasting for several days
● People can experience frequent stabbing upper 2. Weight loss
abdominal pain that extend to back 3. Malabsorption, steatorrhea and diarrhea
● Patients with pancreatitis likely to experience upper ASSESSMENT AND DIAGNOSTIC FINDINGS
abdominal pain after food or when lying down 1. Laboratory determination
• Glucose tolerance test
ACUTE PANCREATITIS
• Increased Serum Amylase and Lipase
Acute pancreatitis is an inflammation of the pancreas.
CLINICAL MANIFESTATIONS • Fecal fat analysis (steatorrhea)
2. Imaging Studies
• Severe abdominal pain
• ERCP
• Abdominal guarding
• CT scan
• Abdominal distention
• MRI
• A rigid or board like abdomen
• Ultrasound
• Nausea and vomiting
MEDICAL MANAGEMENT
• Hypotension
1. Management of abdominal pain and discomfort is
• Fever, jaundice, mental confusion, and agitation similar to that of acute pancreatitis
• tachycardia, cyanosis, and cold, clammy skin 2. Endoscopy to remove pancreatic duct stones, correct
• Respiratory distress and hypoxia strictures, and drain cysts may be effective in selected
• Grey Turner’s Sign patients to manage pain and relieve obstruction
• Cullen’s Sign 3. Emphasize to the patient and family the importance of
ASSESSMENT AND DIAGNOSTIC FINDINGS avoiding alcohol and foods that have produced
1. Laboratory Determination abdominal pain and discomfort in the past.
• Increased Serum Amylase 4. Surgical intervention – Pancreaticojejunostomy -> a
• Increased Serum Lipase side-to-side anastomosis or joining of the pancreatic
• Urinary Amylase – increased duct to the jejunum, allowing drainage of the pancreatic
• WBC secretions into the jejunum.
• Hyperglycemia ○ A Whipple resection
• Hypocalcemia (pancreaticoduodenectomy)- to relieve
• Glycosuria the pain of chronic pancreatitis.
• Bilirubin NURSING DIAGNOSIS
2. Imaging Studies
• ERCP 1. Acute abdominal pain related to abdominal
• CT scan distention; peritoneal irritation
MEDICAL MANAGEMENT 2. Imbalanced nutrition: less than body requirements
1. Pain management – analgesia; opioids (Morphine, related to inadequate dietary intake, impaired
Fentanyl, Dilaudid) 3. pancreatic secretions, increased nutritional needs
2. Intensive care – monitored in ICU with hemodynamic secondary to acute illness,
& blood gas monitoring; correction of fluid and blood 4. Hyperthermia
loss and low albumin levels is necessary to maintain 5. Fluid and electrolyte disturbances
fluid volume and prevent renal failure. NURSING MANAGEMENT: DESIRED PATIENT
3. Respiratory care - close monitoring of arterial blood OUTCOMES
gases to use of humidified oxygen to intubation and 1. Relieving pain and discomfort
mechanical ventilation 2. Improving breathing pattern/ Adequate gas
4. Biliary drainage - Placement of biliary drains (for exchange
external drainage) and stents (indwelling tubes) in the 3. Improving nutritional status
pancreatic duct through endoscopy 4. Maintaining skin integrity
5. Surgical intervention - (diagnostic laparotomy) to PANCREATITIS: NURSING INTERVENTIONS
establish pancreatic drainage, or to resect or débride 1. Monitor and record vital signs, skin color, temperature,
a necrotic pancreas. urine output & daily weight
6. Post-acute management – antacids, low fat & low 2. Measure and record episodes of vomiting
protein diet; ERCP 3. Frequently assesses the pain and the effectiveness of
the pharmacologic (and nonpharmacologic)
CHRONIC PANCREATITIS interventions
Chronic pancreatitis is an inflammatory disorder characterized 4. Assess RR and monitor arterial blood gas levels &
by progressive destruction of the pancreas. monitor for signs of respiratory distress

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5. Position in upright or semi-Fowler’s position DIAGNOSIS EVALUATION

6. Administer O2 therapy a prescribed 1. BLOOD
7. Administer intravenous fluid and electrolytes, enteral or • Glucose elevated, bicarbonate decreased, arterial
parenteral nutrition as prescribed; monitor closely blood pH decreased, strongly positive plasma ketone,
glucose levels & administer insulin as prescribed. Electrolytes vary with state of hydration; often
8. Parenteral fluids and electrolytes are prescribed to hyperkalemic.
restore and maintain fluid balance. 2. URINE
9. Nasogastric suction may be used to relieve nausea and • Strongly positive for sugar and ketone, and moderately
vomiting positive for protein.
10. Provide frequent oral hygiene Goals: to restore normal metabolism and correct fluid and
11. Instruct and explain why oral food or fluid intake is not electrolyte deficiencies.
permitted. MANAGEMENT AND NURSING INTERVENTIONS
12. Enforce bed rest, turn the patient every 2 hours; 1. Obtain blood and urine samples immediately
13. If post-surgery, carry out wound care as prescribed and 2. Test blood for glucose, ketone, BUN, electrolytes,
take precautions to protect intact skin from contact with complete blood count, arterial pH, PO2 and
drainage; carefully assess the wound, drainage sites, and PaCO2.
skin for signs of infection, inflammation, and breakdown. 3. Obtain urine specimen at prescribed time and
14. Counsel patient to avoid excessive use of coffee and measure sugar, acetone, and volume. Catheterize
spicy foods; and eliminate alcohol only if a voided specimen cannot be obtained.
4. Set up chronological flow chart that includes vital
IV. DIABETIC KETOACIDOSIS signs, clinical manifestations, laboratory, data and
complication of uncontrolled diabetes characterized by the therapy.
presence of decreased blood pH and ketones in the blood and 5. Carry out a rapid physical examination to look for
urine. Diabetic ketoacidosis results from the absence of infection, myocardial infarction, stroke, etc.
effective insulin, which causes hyperglycemia, ketonuria, 6. Record vital signs, state of hydration, and mental
dehydration, and acidosis. status.
PATHOPHYSIOLOGY 7. Start intravenous infusion of isotonic saline solution
• Glucose no longer enters muscle cells à fat is metabolized 8. Give insulin as directed
to produce energy. 9. As the serum glucose falls, glucose is added to the
• Free fatty acids are converted to ketone bodies in the liver infusion, and the insulin dose is reduced as
à metabolic acidosis. directed.
• Relative or absolute insulin deficiency à cellular 10. Determinations of serum glucose, ketone
dehydration and volume depletion, acidosis, and protein bicarbonate, and potassium are done every6-8
catabolism. hours.
SIGNS AND SYMPTOMS 11. Monitor ECG and vital signs
12. Patient education - seek medical advice when there
•Nausea and Vomiting are symptoms of diabetic ketoacidosis.
•Fatigue
•Weight loss V. INTRA-ABDOMINAL HYPERTENSION
•Hunger
•Increased urination TERMINOLOGIES
•Drowsiness 1. Intra-Abdominal Hypertension (IAH)
•Thirst IAH is defined as intra-abdominal pressure (IAP) of at least
•Abdominal pain 12 mm Hg; it causes compression of intra-abdominal
CLINICAL MANIFESTATIONS contents and leads to renal, gut, and hepatic ischemia.
EARLY MANIFESTATIONS ● Abdominal compartment syndrome (ACS) - ACS
• Polyuria, polydipsia, fatigue, malaise, drowsiness is a serious complication that may occur when large
• Flushed, dry skin and mucous membrane volumes of fluid are administered. It may also occur
• Anorexia, headache, abdominal pains after trauma, abdominal surgery, severe
• Muscle cramps, nausea, vomiting, constipation, pancreatitis, or sepsis (Brush, 2007).
abdominal pain ● Intra-Abdominal Pressure (IAP) - is the pressure
LATER MANIFESTATIONS within the abdominal cavity.
• Kussmaul’s breathing-very deep respiratory ● Abdominal Perfusion Pressure (APP) - APP is a
movements measure of the adequacy of abdominal blood flow.
• Sweetish odor of the breath due to ketonemia APP is calculated by subtracting the IAP from the
• Hypotension and weak, thready pulse mean arterial pressure (MAP). APP in patients with
• Stupor and coma IAH or ACS should be maintained at 60 mmHg or
higher (Lee, 2012). APP = MAP-IAP

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2. Abdominal Compartment Syndrome (ACS) MANAGEMENT

• Defined as sustained pressures of >20 mmHg with or IAP can be measured directly or indirectly.
without an APP <60 mmHg associated with new organ ● Direct measurement is obtained via a needle
dysfunction or failure. Intra-abdominal pressures in this or catheter in the peritoneal space, and IAP is
range can cause rapid decline in organ function and lead measured using a fluid column or pressure
transducer system. This is the most accurate
to multiple organ failure if not treated (Lee, 2012).
method but associated with side effects such
Causes of Abdominal Compartment Syndrome
as bowel perforation and peritonitis.
- The cause of IAH or ACS are categorized into two sections, ● IAP is usually measured indirectly via the
patient's bladder. The changes in intravesical
primary and secondary conditions. Primary conditions are
pressure demonstrate an accurate reflection of
the ones that need surgical or interventional radiological
intra-abdominal pressure (IAP)
treatment. Secondary conditions are due to medical ● Patients with two or more risk factors for IAH
causes that do not require surgery or radiological should have a baseline IAP performed and if
intervention as initial therapy (Lee, 2012). elevated should have continued serial
Primary: measurements
● Trauma- blunt and penetrating abdominal ● IAP is measured 4 hourly or more frequently if
trauma, pelvic fractures, bowel perforation and IAP greater than 12mmHg or the patient is
hemorrhage hypotensive, has decreased urine output or a
● Liver transplants tense abdomen
● Ruptured abdominal aortic aneurysm ● An increased IAP reading should be
● Post-operative bleeding - *Retroperitoneal rechecked to ensure there is not a technical
hemorrhage problem e.g. a blocked catheter
● Mechanical intestinal obstruction ● If IAP greater than 12mmHg then medical
● Abdominal surgery-decreased abdominal wall management of IAH should be instituted in a
compliance secondary to post-surgical timely manner to prevent further morbidity and
abdominal packing or, tight surgical closures mortality. Renal impairment can occur with IAP
● Bleeding pelvic fractures as low as 10-15mmHg.
Secondary: ● Excessive fluid administration should be
● Massive volume replacement status-post surgery avoided as it is strongly associated with ACS.
or trauma The patient will need close clinical monitoring
● Rapid fluid resuscitation in the setting of SIRS of organ function.
(Systemic Inflammatory Response Syndrome), NURSING INTERVENTIONS
peritonitis, pancreatitis, bowel obstruction, ileus, 1. Monitor the patient's vital signs and surgical
sepsis, ruptures, abdominal aneurysm, wound closely.
abdominal tumors, cirrhosis, ascites and full 2. Report signs and symptoms of infection to the
thickness burns healthcare provider.
● Obstetrical conditions: preeclampsia, and 3. Assess the patient's pain using a valid and
pregnancy-related DIC reliable pain intensity rating scale.
● Ascites 4. Perform a gastrointestinal assessment every
● Pancreatitis shift or more frequently if needed.
● Ileus 5. Assess the patient's nutritional status and
● Sepsis ambulation status for changes from baseline.
● Major burns 6. For patients who had surgery, monitor for
● Continuous ambulatory peritoneal dialysis signs and symptoms of infection (drainage,
● Morbid obesity fever, abdominal distension and firmness,
● Severe intra-abdominal infection increased pain); monitor nutrition, ambulation,
GRADING OF ABDOMINAL and bowel sounds; and monitor intake and
COMPARTMENT SYNDROME output, particularly if the patient has wound
The WSACS (2012), states the following grading system for drainage, anorexia, or decreased fluid intake.
intra-abdominal hypertension:
PATIENT EDUCATION
Patients who've had surgery for abdominal
compartment syndrome should be taught:
1. The signs and symptoms of infection and to
notify their healthcare provider immediately if
they notice these signs and symptoms or have
pain (or worsening pain) at the operative site.
2. To report decreased appetite and fluid intake.

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3. Teach patients about their prescribed pain

medications and to notify their healthcare
provider if their pain isn't adequately controlled.
4. Encourage patients to keep follow-up
appointments with their healthcare providers.
5. By understanding abdominal compartment
syndrome and how to promptly recognize it and
intervene, you could help your patient avoid
complications and death.

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References: Prerenal Causes of Acute Kidney Injury

• Nursing PowerPoint (FEU Version) Prerenal: • Problems affecting the flow of blood
• Lecture Notes (functional) before it reaches the kidneys.
OUTLINE • The kidneys do not receive enough
I. Acute Renal Failure blood to filter.
II. Chronic Kidney Disease Renal: • Problems with the kidney itself that
III. End Stage Renal Disease Intrinsic prevent proper filtration of blood or
(structural) production of urine.
ALTERED ELIMINATION • Renal causes of acute kidney failure
Kidney Failure include those affecting the filtering
function of the kidney, those affecting
ARF A sudden loss of
the blood supply within the kidney,
kidney function
and those affecting the kidney tissue
caused by an illness,
that handles salt and water
an injury, or a toxin
processing.
that stresses the
kidneys (kidney Postrenal: • Problems affecting the movement of
function may urine out of the kidneys.
recover). • It sometimes referred to as
CKD A long and usually obstructive renal failure, since it is
slow process where often caused by something blocking
the kidneys lose their elimination of urine produced by the
ability to function. kidneys.
ESRD When the kidneys
have completely and
permanently shut
down.
I. ACUTE RENAL FAILURE (ARF)
• Abrupt or rapid decline in renal filtration function
due to damage in the kidney.
o Rapid onset of oliguria (<400 ml/day).
o Severe rise in BUN and Creatinine
o Azotemia – accumulation of nitrogen in
the blood.
• Inability of the kidney to maintain hemostasis
leading to build-up of nitrogenous wastes.
• Rapid decline in renal function with azotemia
fluid and electrolyte imbalances.
• High mortality rate but is related to clients being
seriously ill and aged.
Etiology: The etiology of AKI is classified as either
prerenal, postrenal, or intrarenal. Classification
depends on where the precipitating factor exerts its
pathophysiological effect on the kidney.

RISK FACTORS
• Major surgery or trauma
• Infection
• Hemorrhage
• Severe heart failure, liver disease
• Lower urinary tract obstruction

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• Use of nephrotoxic contrast media and • Emergency management of hyperkalemia;

medications. insulin and dextrose; Kayexalate.
TREATMENT GOALS • HD/PD (Hemodialysis/Peritoneal Dialysis)
• Identify and correct underlying cause DIAGNOSTIC TESTS
• Prevent additional renal damage 1. URINALYSIS
• Restore urine output and kidney function a. Fixed specific gravity 1.010 (low)
• Compensate for impaired renal function: b. Proteinuria, if glomerular damage
maintain fluid and electrolyte balance. c. Presence of red blood cells
SIGNS AND SYMPTOMS (glomerular dysfunction), white
• Hyperkalemia blood cells (inflammation), renal
• Nausea and Vomiting – Metabolic Acidosis tubule epithelial cells (ATN).
• HTN – water retention/increase water d. Cell casts (protein and cellular
volume → increase BP. debris molded in shape of tubular
• Pulmonary edema – increase water lumen); brown color may indicate
retention that can lead to respiratory arrest hemoglobinuria or myoglobinuria.
(decreases lung expansion leading to 2. SERUM BUN AND CREATININE
difficulty of breathing). a. Creatinine rises rapidly (24 – 48
hours) and peaks in 5 – 10 days;
• Ascites – increased water retention
rise is slower if output maintained.
• Asterixis – jerking movements
b. Halt in rise of BUN and Creatinine
• Encephalopathy – increase signals onset of recovery.
ammonia/toxins 3. SERUM ELECTROLYTES
STAGES OF ARF a. Monitored to determine whether to
1. ONSET – 1 to 3 days with increased BUN initiate dialysis.
and creatinine and possible decreased b. Moderate rise in potassium
urine output. c. Hyponatremia related to water
2. OLIGURIC – urine output of <400/day, excess.
increased (BUN, creatinine, phosphate, 4. CBC
potassium), that may last up to 14 days. - showed moderate anemia and low
3. DIURETIC – increased urine output to as hematocrit (Iron and folate may be low
much as 4000 mL/day but now waste and add to anemia).
products, at end of this stage may begin to 5. RENAL ULTRASOUND
see improvement. - used to identify any obstruction, identify
4. RECOVERY – things go back to normal or acute from chronic renal failure.
may remain insufficient and become 6. CT SCAN
chronic. - identify obstruction and kidney size
ARF àCKD àESRF 7. IVP, RETROGRADE PYELOGRAPHY,
STAGE 1: kidney damage normal function (90%+) OR ANTEGRADE PYELOGRAPHY.
STAGE 2: kidney damage mild loss of function (89- a. Assess renal structure and function
60%) b. Retrograde and antegrade testing
STAGE 3: moderate to severe loss of function (59- less toxicity from contrast media.
30%) c. Renal biopsy: determine cause,
STAGE 4: severe loss of function (29-15%) differentiate acute from chronic.
STAGE 5: kidney failure, need treatment to live (- MEDICATIONS AND TREATMENTS
15%)
• Intravenous fluids and blood volume
NOTE:
expanders to restore renal perfusion.
Hyperkalemia – most dangerous complication that
• Low dose Dopamine (Intropin) intravenous
may lead to cardiac arrest if rise in K+ is too fast.
infusion to increase renal blood flow and
improve cardiac output.
NURSING CARE
• Diuretic: Furosemide (Lasix) or osmotic
• Eliminating the underlying cause
diuretic such as mannitol along with
• Daily weight
intravenous fluids; “washes out” nephrons;
• CVP monitoring prevents oliguria reducing azotemia and
• Low Protein (CHON), Potassium (K+), electrolyte imbalance.
Sodium (Na+), and high carbohydrate diet.

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• Antihypertensive medications including II. CHRONIC RENAL FAILURE (CKD)

ACE inhibitors to limit renal injury. and ESRD
• Medications to prevent possible • is a progressive, irreversible deterioration of
complications. renal function in which the body’s ability to
• Prevention of gastrointestinal bleeding (at maintain metabolic and fluid & electrolyte
risk due to stress, impaired platelet balance fails, resulting in uremia or Azotemia
function). (retention or urea and other nitrogenous wastes
• Antacids in the blood).
• H2 receptor antagonists • Incidence is more common with older adults
• Proton-pump inhibitors • Treatments focus on symptomatic approach
• Hyperkalemia: serum K > 6.5 mEq/L puts
client at risk for cardiac arrest. CAUSES
• Calcium chlorides • DM (uncontrollable sugar; common cause
• Bicarbonate of CRF).
• Insulin and glucose • Hypertension
• Sodium polystyrene sulfonate (Kayexalete) • Chronic Glomerulonephritis
• Hemodialysis and Peritoneal dialysis • Pyelonephritis
1. Removes potassium from body • Obstruction of Urinary tract (less common)
primarily in large intestine. • Vascular disorder
2. If given orally, is combined with sorbitol • Infections (pyelonephritis)
3. May be given as retention enema with • Medication or toxic agents
tap water enema to follow after 30 – 60
minutes. STAGES OF CKD
4. Aluminum hydroxide (AlternaGEL,
STAGE 1 – ● characterized by a 40% to 75%
Amphojel, Nephrox) – binds with
Reduced loss of nephron function.
phosphates in GI tract and is eliminated
renal ● No symptoms.
from bowel.
reserve ● GFR >90
FLUID MANAGEMENT
• Once vascular volume and renal perfusion
restored, fluids are restricted.
STAGE 2 – ● occurs when 75% to 90% of
• Often intake is calculated by adding output
Renal nephron function is loss. At this
from previous 24 hours and 500 ml for
Insufficienc point, the serum creatinine and
insensible losses.
y blood urea nitrogen rise, the
• Fluid balance monitored by daily weights kidney loses its ability to
and serum Na level. concentrate urine and anemia
DIETARY MANAGEMENT develops.
• Renal insufficiency and underlying disease ● The patient will report
creates increased rate of catabolism POLYURIA and NOCTURIA.
(breakdown of body proteins) and ● GFR >60
decreased rate of anabolism (tissue repair).
STAGE 3A – ● the final stage of chronic renal
• Client needs adequate nutrition and End Stage failure occurs when there is less
calories to prevent catabolism but protein Renal than 10% nephron function
intake needs to be limited to minimize Disease remaining. All of the normal
azotemia. (ESRD) regulatory, excretory, and
• Protein limited to 6g/kg body weight per hormonal functions of the
day; protein should be of high biologic kidney are severely impaired.
value (contains essential amino acids). ● ESRD is evidence by elevated
• Carbohydrate intake is increased for creatinine and blood urea
adequate calories and protein-sparing nitrogen levels as well as
effect. electrolyte imbalance.
● GFR 30 to 59

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D. Disorientation
E. Tremors, seizures (caused by
cerebral edema)
F. Behavior changes
● INTEGUMENTARY
A. Dry, flaky skin (increase toxin in
blood).
B. Gray-bronze skin discoloration
C. Pruritus (makati)
D. Ecchymosis
E. Brittle nails
F. Thinning of hair
● CARDIOVASCULAR
A. Hypertension
Stage 3: Hypertensive and edema B. Pitting edema
• Less fats in diet C. Engorged neck veins
• Decreased active lifestyle D. Pericarditis
Stage 4: I&O must be monitored closely (no less E. Hyperkalemia
than 30 ml per hr). F. Hyperlipidemia
• Oliguric ● PULMONARY
• Increase BUN, Crea, Potassium, A. Crackles (accumulation of fluids)
Phosphorus, Edema, back pain, Diff B. Thick tenacious sputum
urinating, Increase BP, Anemia. (productive cough).
• Should have regular check up with C. Depressed cough reflex
nephrologist and dietitian. D. Pleuritic pain
• Referred to dialysis/Renal transplant E. Shortness of breath
• Explain the use of dialysis F. Tachypnea (to blow off carbonic
acid by hyperventilating)
• GFR 15 to 29
G. Kussmaul’s respiration (fast, deep
Stage 5: Severely damage, End stage renal
breathing).
disease
● GASTROINTESTINAL
• Anuria
A. Metallic taste (toxins that
• Appear very sick accumulate).
• frequent nausea and vomiting B. Anorexia (leads to loss of appetite)
• anorexia; decrease in appetite C. N/V
• diff of sleeping D. Constipation or diarrhea (too much
• 3 times a week dialysis fluid to the abd. track).
• GFR <15 E. Bleeding from GI tract
ASSESSMENT AND DIAGNOSTIC TEST ● MUSCULOSKELETAL
• Decrease GFR A. Muscle cramps
• Increase Creatinine & BUN B. Loss of muscle strength
• Sodium and water retention C. Bone pain
• Metabolic Acidosis D. Joint pains
• Decrease erythropoietin E. Bone fracture
• Decrease RBC (carries oxygen, causes F. Foot drop (caused by edema)
hypoxemia). ● REPRODUCTIVE
• Reciprocal relationship of Calcium and A. Amenorrhea
Phosphorus imbalance. B. Infertility & decrease libido
> Affects parathyroid hormone
> Leads to hypercalcemia NURSING DIAGNOSIS
CLINICAL MANIFESTATIONS • Fluid volume excess r/t decreased urine
● NEUROLOGIC output; water & sodium retention.
A. Weakness • Imbalanced Nutrition: less than body
B. Fatigue requirements r/t anorexia, n/v, dietary
C. Confusion, inability to concentrate restrictions.

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• Activity intolerance r/t fatigue; muscle • Position pt in a manner that carefully places
weakness. the part of the abdomen that is to be rayed
GOAL OF CARE: (PATIENT OUTCOMES) between the X-ray machine and a cassette
• To maintain kidney function & homeostasis containing the X-ray film or digital media (pt
for as long as possible. may be standing/lying flat or side lying
• To maintain fluid and electrolyte balance depending Dr's request)
• To maintain adequate nutritional intake • Instruct pt to remain completely still while
• To prevent complications the exposure is made, as any movement
MEDICAL MANAGEMENT may distort the image and even require
• Antihypertensive drugs another X-ray to be done
• Erythropoietin drugs (EPOGEN) After the procedure
• Iron supplement • Generally there is no special type of care
• Phosphate binding agents following a KUB X-ray. However, the doctor
• Calcium supplements, Vit. D may give additional or alternate instructions
after the procedure, depending on patient’s
• Antacids
particular situation.
• Anti-seizure drugs (VALIUM,DILANTIN)
• High carbs, low protein INTRAVENOUS PYELOGRAM
• Fluid restriction • An IVP is an imaging test used to look at
• DIALYSIS (hemodialysis or peritoneal the kidneys and ureters.
dialysis). • During the test, the radiologist injects a
• KIDNEY TRANSPLANT contrast dye into one of the veins. The Dr.
NURSING MANAGEMENT uses X -ray images to watch the contrast
• Regulate protein, fluid & sodium intake dye as it moves from the kidney into the
• Restriction of potassium ureter and then to the bladder
• Assess for s/sx of fluid & electrolyte • An IVP can show the healthcare provider
imbalances. the size, shape, and structure of pt's
• Promote emotional support kidneys, ureters, and bladder
• Encourage self-care & greater
independence
DIAGNOSTIC & LAB PROCEDURES
Kidney, Ureter, and Bladder X-ray (KUB)
• is a non-invasive diagnostic tool that uses
x-ray imaging to view the kidneys, ureters,
and bladder
• KUB radiography is typically used to
evaluate the condition of these organs, and
potential urinary health conditions
Before the procedure
• The doctor will explain the procedure
• No prior preparation, such as fasting, or
sedation is required
• Notify the radiologic technologist if pt is
pregnant or suspect pregnancy 24-HOUR URINE COLLECTION
• Notify if pt has taken a medication that • A simple lab test that measures what’s in
contains bismuth, such as Pepto- Bismol the pt’s urine
for the past four days (medications that • To check kidney function
contain bismuth may interfere with testing • Done by collecting the urine in a special
procedure) container over a full 24-hour period
During the procedure • Container must be kept cool until the urine
• Remove pt clothing jewelry, or other is returned to the lab
objects that can interfere with the What happens during 24-Hour Urine Collection
procedure 1. Pt will be given 1 or more containers for
• Wear patient's gown collecting and storing urine. A special pan
that fits in the toilet or a urinal may be used

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to collect the urine. Transfer the urine from

the collecting container to the storage
container. You will need to keep it cold.
2. The 24-hour collection may start at any
time during the day after you urinate. It is
common to start the collection the first thing
in the morning. It is important to collect all
urine in the following 24-hour period.
3. Instruct not to save the urine from first time
urinating. Flush this first specimen but note
the time. This is the start time of the 24-hour
collection.
4. All urine, after the first flushed specimen,
must be saved, stored, and kept cold. This
means keeping it either on ice or in a
refrigerator for the next 24 hours.
5. Once the urine collection has been
completed, the urine containers need to be
taken to the lab as soon as possible

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References: • When did the injury occur?

• Cheever, K. & Hinkle, J. (2018) Brunner & • What caused the injury? An striking the head? A
Suddarth’s Textbook of Medical-Surgical fall?
Nursing, 14th Edition • What was the direction and force of the blow?
• Nursing PowerPoint (FEU Version) DIAGNOSIS
• Lecture Notes • Ineffective airway clearance and impaired gas
OUTLINE exchange related to brain injury.
I. Head Injury • Ineffective cerebral tissue perfusion related to
II. Transient Ischemic Attack increased ICP, decreased CCP and possible
III. Hemorrhagic Stroke seizures.
IV. Intracranial Pressure PLANNING
V. Spinal Cord Injury • Maintenance of Patent airway, adequate CPP,
fluid and electrolyte balance, adequate
I. HEAD INJURY nutritional status.
• It is a broad classification that includes injury to the • Prevention of secondary injury
scalp, skull, or brain. • Maintenance of body temperature, maintenance
• A head injury may lead to conditions ranging from of skin Integrity.
mild concussion to coma and death the most serious INTERVENTION
form is known as a traumatic brain injury. • Monitoring Neurologic Function
INCIDENCE • Level of Consciousness
• It occurs in about seven million Americans every
• Vital Sign
year.
• Motor Function
• More that 500,000 are hospitals
• Stablish and Maintain an Adequate Airway
• 100,000 experience chronic disable
• Monitor Fluid and Electrolyte Balance
• 2000 left on a persistent vegetables state
• Promoting Adequate Nutrition.
CLINICAL MANIFESTATIONS
• Preventing Injury
• RHINORRHEA – thin, mostly clear nasal
discharge. • Maintaining Skin Integrity
• Improving Cognitive Functioning
• SKULL FRACTURE
• Preventing Sleep Pattern Disturbance.
• OTORRHEA – drainage of liquid in the ear
• RACCOON Sign – unilateral or bilateral • Supporting Family Coping
progressive periorbital ecchymosis associated • Monitoring and Managing Potential
with edema. Complications.
EVALUATION
• BATTLE SIGN – bruising over the mastoid
Expected patient outcome may include the following:
process.
NURSING DIAGNOSIS • Attains or maintains effective airway clearance,
ventilation, and brain oxygenation.
• Decreased Intracranial Adaptive Capacity r/t
increased intracranial pressure. • Achieve satisfactory fluid and Electrolyte
balance.
• Risk for Seizures
• Attains adequate nutritional status
• Acute Confusion r/t increased intracranial
pressure. • Avoid Injury
• Deficient Knowledge r/t lack of experience with • Demonstrate intact skin integrity
head injury.
MANAGEMENT OF BRAIN INJURIES II. TRANSIENT ISCHEMIC ATTACK
• CT Scan • disease (stroke) or “brain attack,” is a sudden loss of
• MRI Scan function resulting from disruption of the blood supply
• PET Scan to a part of the brain. High-risk groups include people
MEDICAL THERAPEUTICS older than 55 years.
• Oxygen • Early treatment with thrombolytic therapy for
• Hyperventilation ischemic stroke results in fewer stroke symptoms
and less loss of function.
• Mannitol
MODIFIABLE RISK FACTORS
• Indwelling urinary catheter
• Ischemic Stroke
• Sedations
• Asymptomatic carotid stenosis
• High dose
• Atrial fibrillation
• barbiturate coma Propofol (Diprivan)
• Diabetes (associated with accelerated
NURSING ASSESSMENT
atherogenesis).
ASSESSMENT • Dyslipidemia
The nurse may elicit information from the patient, from • Excessive alcohol consumption
family or from witnesses or emergency rescue personnel.

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• Hypercoagulable states Hypertension

(controlling hypertension, the major risk factor,
is the key to preventing stroke).
TYPES OF STROKE
• Ischemic
• Hemorrhagic
• Left Hemispheric Stroke
• Right Hemispheric Stroke
NURSING DIAGNOSIS
• Impaired Physical Mobility related to
hemiparesis, loss of balance and coordination,
spasticity and brain injury.
• Ineffective Coping. Self-Care Deficit (bathing,
hygiene, toileting…) related to stroke sequelae.
• Impaired urinary elimination related to flaccid
bladder, detrusor instability confusion or
difficulty in communicating.
LEVEL OF CONSCIOUSNESS
PATHOPHYSIOLOGY
• OBTUNDATION – the patient is difficult to
• In an ischemic brain attack, there is disruption of
arouse and needs constant stimulation to follow
the cerebral blood flow due to obstruction of a
commands. He may respond with a few words
blood vessel. This disruption in blood flow
but will drift back to sleep when the stimulus is
initiates a complex series of cellular metabolic
removed.
events referred to as the ischemic cascade.
• STUPOR – the patient becomes unconscious
• Ischemic cascade begins when cerebral blood
spontaneously and is very hard to awaken.
flow decreases to less than 25 mL per 100 g of
blood/minute affecting aerobic respiration. • SEMI COMA – the patient is not awake but will
o Mitochondria switched to anaerobic respond purposefully to deep pain.
respiration, which generates large • COMA – the patient is completely unresponsive.
amounts of lactic acid, causing a ALTERED LEVEL OF CONSCIOUSNESS
change in the pH (acidosis). • Coma – clinical state of unconsciousness in
o The membrane pumps that maintain which patient is unaware of self and
electrolyte balances begin to fail, and environment for prolonged periods.
the cells cease to function – infarction • Akinetic Mutism – state of unresponsiveness to
(cell death). the environment in which the patient makes no
CLINICAL MANIFESTATIONS movement or sound but sometimes opens the
• Numbness or weakness of the face, arm, or leg, eye.
especially on one side of the body. • Persistent vegetative state – patient is wakeful
• Confusion or change in mental status, trouble but devoid conscious content without cognitive
speaking or understanding speech. or affective mental function.
• Visual disturbances FURTHER DIAGNOSTIC WORK UP
• Difficulty walking, dizziness, or loss of balance • 12-lead electrocardiogram (ECG) and a carotid
or coordination. ultrasound are standard tests
• Sudden severe headache Other studies may include:
• Motor, sensory, cranial nerve, cognitive, and • CT angiography or CT perfusion
other functions may be disrupted. • Magnetic resonance imaging (MRI) and
ASSESSMENT AND DIAGNOSTIC FINDINGS magnetic resonance angiography of the brain
• Initial assessment focuses on airway patency, and neck vessels; CT scan.
which may be compromised by loss of gag or NEUROLOGIC DEFICIT
cough reflexes and altered respiratory pattern; • Visual Field Deficits
cardiovascular status (including blood pressure, • Homonymous hemianopsia (loss of half of the
cardiac rhythm and rate, carotid bruit); and gross visual field).
neurologic deficits. • loss of peripheral vision Diplopia
• TIA is manifested by a sudden loss of motor, • Motor Deficits
sensory or visual function (the result of • HEMIPARESIS – mild or partial weakness or
temporary ischemia). loss of strength on one side of the body.
• HEMIPLEGIA – severe or complete loss of
strength or paralysis on one side of the body.
• ATAXIA – poor muscle control that causes
clumsy voluntary movements.

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• DYSARTHRIA – speech disorder caused by o Positioning the Hand and Fingers -

muscle weakness; causes slurred or slow hand is placed in slight supination.
speech that can be difficult to understand. • Changing position
• DYSPHAGIA – difficulty in swallowing o Established exercise program
• Sensory Deficits Paresthesia (occurs on the side o Assisting with nutrition
opposite the lesion). o Attaining bladder and bowel control
• Verbal Deficits o Improving thought process
• Expressive Aphasia Receptive Aphasia Global o Improving communication
(mixed) aphasia. PREVENTION
MEDICAL MANAGEMENT • A healthy lifestyle including not smoking,
• Patients who have experienced a TIA or stroke engaging in physical activity (at least 40 minutes
should have medical management for a day, 3 to 4 days a week), maintaining a healthy
secondary prevention. weight, and following a healthy diet (including
• Anticoagulant (e.g., warfarin) modest alcohol consumption), can reduce the
• If anticoagulant is contraindicated, antiplatelet risk of having a stroke.
will do (e.g., aspirin). Specific Diet Recommended by the Dietary
• Statin (e.g., simvastatin) Approaches to Stop Hypertension (DASH)
• Thrombolytic Therapy – used to treat ischemic • High in fruits and vegetables, moderate in low
stroke by dissolving the blood clot that is fat dairy products, and low in animal protein).
blocking blood flow to the brain. It works by
binding to fibrin and converting plasminogen to III. HAEMORRHAGIC STROKE (HS)
plasmin, which stimulates fibrinolysis of the clot. is a bleeding into the brain tissue, the ventricles, or the
o Example: t-PA (tissue plasminogen subarachnoid space.
activator). CAUSES
• Enhancing Prompt Diagnosis – immediate ● Primary intracerebral haemorrhage from a
referral to Neuro team once arrived at the spontaneous rupture of small vessels accounts
hospital. for approximately 80% of haemorrhagic strokes
o If with increased ICP due to and is caused chiefly by uncontrolled
hemorrhagic TIA, osmotic diuretic hypertension.
(e.g., mannitol) could be prescribed. ● Subarachnoid haemorrhage results from a
Other treatment measures: ruptured intracranial aneurysm.
• Providing supplemental oxygen if oxygen ● May result to increased ICP
saturation is below 95%. NURSING DIAGNOSIS
• Elevation of the head of the bed to 30 degrees ● Urinary retention related to effects of spinal cord
to assist the patient in handling oral secretions injury
NURSING INTERVENTIONS
and decrease ICP.
● Place the client in a sitting position to help lower
• Possible hemicraniectomy for increased ICP
the bladder pressure.
from brain edema in a very large stroke.
● Catheterize the client to prevent bladder
• Intubation with an endotracheal tube to establish
distention.
a patent airway if necessary.
ASSESSMENT (ACUTE SPINAL INJURY)
• Continuous hemodynamic monitoring ● Altered level of consciousness
• Frequent neurologic assessments ● Sluggish pupillary reaction
NURSING MANAGEMENT ● Motor and sensory dysfunction
• Monitor neurologic functions: ● Cranial nerve deficits (Extraocular eye
o change in level of consciousness or movements, facial droop, presence of ptosis).
responsiveness as evidenced by ● Speech difficulties and visual disturbance
movement, resistance to changes of ● Headache and nuchal rigidity and other
position, and response to stimulation; neurologic deficits.
orientation to time, place, and person. NURSING DIAGNOSIS
o Ability to speak Volume of fluids ● Ineffective tissue perfusion (cerebral) related to
ingested or given; volume of urine bleeding or vasospasm.
excreted each 24 hours. ● Disturbed sensory perception related to
o Presence of bleeding Maintenance of medically imposed restrictions (aneurysm
blood pressure within the desired precautions).
parameters Monitoring of continuous ● Anxiety related to illness and/or medically
oxygen saturation imposed restrictions (aneurysm precautions).
• Improve mobility and prevent joint deformities PLANNING
though appropriate positioning. ● Improved cerebral tissue perfusion
o Preventing Shoulder Adduction – place
a pillow in the axilla while on bed.

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● Relief of sensory and perceptual deprivation, HOW ICP IS CALCULATED

relief of anxiety and the absence of ● Subtract the ICP from the mean arterial pressure
complications. (MAP).
POTENTIAL COMPLICATIONS ● Example, if the MAP is 100 mmHg and the ICP
● Vasospasm is 15 mm Hg, then the CPP is 85 mmHg. The
● Seizures normal CPP is 70 to 100 mmHg.
● Hydrocephalus ● Patients with a CPP of less than 50 mmHg
● Rebleeding experience irreversible neurologic damage.
● Hyponatremia Therefore, the CPP must be maintained at 70 to
NURSING MANAGEMENT 80 mmHg to ensure adequate blood flow to the
● Optimizing cerebral tissue prefusion brain.
● Aneurysm precaution CAUSES OF ICP
● Relieving sensory deprivation and anxiety ● Aneurysm rapture and subarachnoid
● Monitoring and managing potential hemorrhage.
complication. ● Brain tumor
EVALUATION ● Encephalitis
● Demonstrate intact neurologic status and ● Hydrocephalus (increased fluid around the
normal vital signs and respiratory pattern. brain).
● Demonstrate normal sensory perception ● Hypertensive brain hemorrhage
● Exhibit reduce anxiety level ● Intraventricular hemorrhage
● Free of complication ● Meningitis
● Severe head injury
IV. INTRACRANIAL PRESSURE ● Subdural hematoma
● Is pressure is a rise in the pressure inside the ● Status epilepticus
skull that can result from or cause brain injury. ● Stroke
● The rigid cranial vault contains brain tissue CLINICAL MANIFESTATIONS OF ICP
(1400 g), blood (75 mL), and CSF (75 mL). The ● The earliest sign of increasing ICP is a change
volume and pressure of these three components in LOC. Agitation, slowing of speech, and delay
are usually in a state of equilibrium. in response to verbal suggestions may be early
A. Monro–Kellie hypothesis indicators.
B. Cushing triad ● As ICP increases, the patient becomes
TOOL TO MONITOR INCREASE ICP stuporous, reacting only to loud or painful
● Widening pulse pressure (rising systolic, stimuli.
declining diastolic). ● As neurologic function deteriorates further, the
● Irregular respirations (Biot’s breathing) patient becomes comatose and exhibits
● Bradycardia abnormal motor responses in the form of
PATHOPHYSIOLOGY decortication (abnormal flexion of the upper
● Increased ICP affects many patients with acute extremities and extension of the lower
neurologic conditions because pathologic extremities), decerebration (extreme extension
conditions alter the relationship between of the upper and lower extremities), or flaccidity.
intracranial volume and ICP. DIAGNOSTIC TEST
● Increased ICP from any cause decreases ● MRI or CT scan of the head can often determine
cerebral perfusion, stimulates further swelling the cause and confirm the diagnosis.
(edema), and may shift brain tissue, resulting in ● Doppler studies provide information about
herniation—a dire and frequently fatal event. cerebral blood flow.
● Decrease blood flow resulting to ischemia which MEDICAL MANAGEMENT
manifests slow bounding pulse and respiratory ● Decrease cerebral edema, lowering the volume
irregularities. of CSF, or decreasing cerebral blood volume
● Cerebral edema while maintaining cerebral perfusion.
CEREBRAL RESPONSE TO INCREASED ● Accomplished by administering osmotic
INTRACRANIAL PRESSURE diuretics, restricting fluids, draining CSF,
● As ICP rises, compensatory mechanisms in the controlling fever, maintaining systemic blood
brain work to maintain blood flow and prevent pressure and oxygenation, and reducing cellular
tissue damage. metabolic demands.
● The brain can maintain a steady perfusion ● Monitored ICP with the use of an intraventricular
pressure if the arterial systolic blood pressure is catheter (ventriculostomy), a subarachnoid bolt,
50 to 150 mmHg and the ICP is less than 40 an epidural or subdural catheter, or a fiberoptic
mmHg. transducer-tipped catheter placed in the
● Changes in ICP are closely linked with cerebral subdural space or in the ventricle.
perfusion pressure (CPP).

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ALTERED PERCEPTION | REVIEWER | BATCH 2023

NURSING MANAGEMENT ● C4 to C5 – Tetraplegia with impairment, poor

● Maintain patent airway; suctioning should be pulmonary capacity, complete dependency for
done cautiously. It could further increase the ADLs.
ICP. ● C6 to C7 – Tetraplegia with some arm/hand
● Monitor breathing pattern movement allowing some independence in
● Increased pressure on the frontal lobes or deep ADLs.
midline structures may result in Cheyne–Stokes ● C7 to T1 – Tetraplegia with limited use of Thumb
respirations. increasing independence.
● Pressure in the midbrain can cause ● T2 to L1 – Tetraplegia with the intact arm
hyperventilation. function and varying function of intercostals and
● If the lower portion of the brainstem (the pons abdominal muscles.
and medulla) is involved, respirations become ● L1 to L2 – Mixed motor-sensory loss, bowel
irregular and eventually cease (Biot’s bladder dysfunctions.
respiration). TETRAPLEGIA
● Positioning – head should be maintained at ● The simplest Tetraplegia definition is that it is a
midline position. Head of the bed be elevated at form of paralysis that affects both arms and both
30-45 degrees. legs.
● Avoid Valsalva maneuver ● Quadriplegia is another term for tetraplegia—
● Prevent infection they are the same condition. However, most
doctors use the term tetraplegia in official
V. SPINAL CORD INJURY documentation. A person with tetraplegia is
● Occurs predominantly in men as result of motor referred to as a tetraplegic.
vehicular accidents, falls, gunshot wounds, and ● Depending on the severity of the tetraplegia-
sports-related injuries. causing injury, the tetraplegic might need to use
● Most commonly occurs in cervical and lower assistive breathing devices, like a respirator
thoracic upper lumbar vertebrae. PARAPLEGIA
INCIDENCE ● The definition of paraplegia is that it is a form of
● SCI is highest among persons age 16-30, in paralysis that affects both legs. If only one leg
whom 53.1 percent of injuries. were paralyzed, then it would be referred to as
● Males represent 81.2 percent of all reported monoplegia of the leg.
SCIs and 89.8 percent of all sports-related SCIs. ● A person with paraplegia is referred to as a
● Among both genders, auto accidents, falls and paraplegic
gunshots are the three leading causes of SCI. TETRAPLEGIA AND QUADRIPLEGIA VS.
● Sports and recreation-related SCI injuries PARAPLEGIA
primarily affect people under age 29. ● When comparing tetraplegia/quadriplegia vs
ANATOMY & PHYSIOLOGY paraplegia, tetraplegia is considered the more
● Originates in the brainstem, passes through the severe condition. Where a paraplegic will retain
foramen magnum, and continues through to the the use of their arms, a tetraplegic will be unable
conus medullaris near the L2 before terminating to control their arms or legs.
in filum terminable. ● Paraplegics can maintain more independence
● Contains cerebrospinal fluid. than quadriplegics because of their ability to use
● 45 cm (18 in) in men ,43 cm (17 in) long in their arms. This makes participating in activities
women. like exercise, cooking, and self-care easier.
● 13 mm (1⁄2 in) in the cervical and lumbar regions COMPLICATIONS
to 6.4 mm (1⁄4 in) in the thoracic area. ● Spinal – the spinal shock associated with SCI
● 31 pairs of spinal Nerve.(C1–C8),(T1– T12), reflects a sudden depression of reflex activity in
(L1–L5), (S1–S5) and Co1. the spinal cord (arflexia) below the level of injury.
● Spinal meninges: Dura, Arachnoid. And Pia ● Neurologic Shock – neurologic Shock
matter. developed as a result of the loss of autonomic
● External surface: Conus medularis (L1- L2) nervous system function below the level of the
cauda equina (L3-L5). lesion.
● Spinal Tissue: Gray Matter(neuronal cell bodies, ● Deep Vein Thrombosis – is a potential
dendrites, axons and glial cells) complication of immobility and is common in
● White Matter (Myelinated Axon) patients with SCI.
● Dorsal Root (afferent sensory root) NURSING DIAGNOSIS
● Ventral Root (Efferent motor root) ● Ineffective breathing pattern related to
LEVELS OF INJURY weakness or paralysis of abdominal and
● C1 to C3 – Tetraplegia with total loss of intercostal muscles and inability to clear
muscular/respiratory function. secretions.
● Ineffective airway clearance related to
weakness of intercostal muscles.

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PLANNING ● Immediate transportation with the capacity to

● Improved breathing patterns and airway manage neurologic trauma.
clearance. ● Autonomic Hyperreflexia
● Improved mobility and sensory and perceptual ● An exaggerated sympathetic response to
awareness. noxious stimulus (considered as a medical
● Maintenance of skin integrity emergency).
● Relief of urinary retention ● Occurs in clients with injury above T6
● Improved bowel function promotion of comfort ● Stimuli
and absence of complication. ● Distended bladder or other visceral organs
NURSING INTERVENTION: ● Stimulation of the skin (pressure ulcer, tactile,
● Promoting adequate breathing and airway pain and thermal stimuli).
clearance.
● Improving mobility
● Promoting adaptation to sensory and perceptual
alterations.
● Maintaining skin integrity
● Maintaining urinary elimination
● Improving bowel function
● Providing comfort measure
● Monitoring and managing potential
complications.
EVALUATION:
● Demonstrate improvement in gas exchange and
clearance of secretions.
● Moves within limits of the dysfunction and
demonstrates completion of exercise within
functional limitation.
● Demonstrates adaptation to sensory and
perceptual alteration.
● Demonstrate optimal integrity
● Regains urinary bladder functions
● Regain bowel functions
● Report absence of pain and discomfort
● Pre of complication
CLINICAL MANIFESTATIONS:
● Incomplete spinal cord lesions (the sensory or
motor fiber, or both are preserved below the
lesion) are classified according to the area of
spinal cord injury; central, lateral, anterior or
peripheral.
● Complete spinal cord lesion (total loss of
sensation and voluntary muscles control below
the lesion can result in paraplegia and
tetraplegia)
DIAGNOSTIC TESTS:
● Complete blood count (e.g. Hb, RBC, WBC)
● Arterial blood gas level PaO2:85-95 mmHg
PaCO2:35-45 mmHg.
● Computerized tomography scan
● Magnetic resonance imaging (mri)
● Myelography
● Surgical management
● Emergency management
INITIAL CARE MUST INCLUDE RAPID
ASSESSMENT:
● Immobilization
● Extrication
● Stabilization or control of life-threatening
injuries.
● Transportation to the most appropriate medical
facility.

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o Myocardial infarction
References: o Cardiomyopathy
• Nursing PowerPoint (FEU Version) o Blunt cardiac injury
• Lecture Notes o Severe systemic or pulmonary
• Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & hypertension.
Cheever, K.H. (2010). Brunner & Suddarth’s o Cardiac tamponade (Obstructive)
textbook of Medical-Surgical Nursing (12th o Myocardial depression from
ed.). Lippincott Williams & Wilkins metabolic problems.
• Sole, M.L., Klein, D.G., & Moseley, M.J. • Early manifestations
(2013). Introduction to Critical Care Nursing. o Tachycardia
Mo: Elsevier/Saunders o Hypotension
OUTLINE o Narrowed pulse pressure
I. Classification o ↑ Myocardial O2 consumption
II. Cardiogenic Shock • Physical examination
III. Hypovolemic Shock o Tachypnea, pulmonary congestion
IV. Neurogenic Shock o Pallor; cool, clammy skin
V. Anaphylactic Shock o Decreased capillary refill time
VI. Septic Shock o Anxiety, confusion, agitation
VII. Stages of Shock o ↑ in pulmonary artery wedge
A. Initial Stage pressure.
B. Compensatory Stage o Decreased renal perfusion and UO
C. Progressive Stage
D. Refractory Stage III. HYPOVOLEMIC SHOCK
VIII. Diagnostic Studies • Absolute hypovolemia: Loss of
IX. Collaborative Care intravascular fluid volume.
A. Cardiogenic Shock o Hemorrhage
B. Hypovolemic Shock o GI loss (e.g., vomiting, diarrhea)
C. Neurogenic Shock o Fistula drainage
D. Anaphylactic Shock o Diabetes insipidus
E. Septic Shock o Hyperglycemia
X. Nursing Assessment o Diuresis
XI. Nursing Diagnoses • Relative hypovolemia
XII. Planning o Results when fluid volume moves
XIII. Nursing Implementation out of the vascular space into
XIV. Evaluation extravascular space (e.g.,
interstitial or intracavitary space).
SHOCK o Termed third spacing
● Syndrome characterized by decreased • Response to acute volume loss depends on
tissue perfusion and impaired cellular o Extent of injury or insult
metabolism. o Age
o Imbalance in supply/demand for o General state of health
O2 and nutrients. • Clinical manifestations
o Anxiety
I. CLASSIFICATION o Tachypnea
● Low blood flow
o Increase in CO, heart rate
o Cardiogenic
o Decrease in stroke volume, PAWP,
o Hypovolemic
UO
o Obstructive
NOTE: If loss is >30%, blood volume is replaced.
• Maldistribution of blood flow
o Septic IV. NEUROGENIC SHOCK
o Anaphylactic • Hemodynamic phenomenon that can
o Neurogenic occur within 30 minutes of a spinal cord
II. CARDIOGENIC SHOCK injury at the fifth thoracic (T5) vertebra or
• Definition above and can last up to 6 weeks.
o Systolic or diastolic dysfunction • Results in massive vasodilation leading
o Compromised cardiac output (CO) to pooling of blood in vessels.
• Precipitating causes • Clinical manifestations
o Hypotension

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o Bradycardia VII. STAGES OF SHOCK
o Temperature dysregulation
(resulting in heat loss). INITIAL STAGE
o Dry skin • Usually not clinically apparent
o Poikilothermia (taking on the • Metabolism changes from aerobic to
temperature of the environment). anaerobic.
o Lactic acid accumulates and must
V. ANAPHYLACTIC SHOCK be removed by blood and broken
• Acute, life-threatening hypersensitivity down by liver.
reaction. o Process requires unavailable O2
o Massive vasodilation COMPENSATORY STAGE
o Release of mediators (NONPROGRESSIVE)
o ↑ Capillary permeability • Clinically apparent
• Clinical manifestations o Neural
o Anxiety, confusion, dizziness o Hormonal
o Tachycardia, tachypnea, o Biochemical compensatory
hypotension. mechanisms.
o Wheezing, stridor • Attempts are aimed at overcoming
o Sense of impending doom consequences of anaerobic metabolism
o Chest pain and maintaining homeostasis.
o Swelling of the lips and tongue,
• Baroreceptors in carotid and aortic bodies
angioedema.
activate SNS in response to ↓ BP.
o Wheezing, stridor
o Vasoconstriction while blood to
o Flushing, pruritus, urticaria
vital organs maintained.
o Respiratory distress and
• ↓ Blood to kidneys activates renin–
circulatory failure.
angiotensin system
VI. SEPTIC SHOCK o ↑ Venous return to heart, CO, BP
• Sepsis: Systemic inflammatory response to • If perfusion deficit corrected, patient
documented or suspected infection. recovers with no residual sequelae.
• Severe sepsis = Sepsis + Organ • If deficit not corrected, patient enters
dysfunction progressive stage.
• Septic shock = Presence of sepsis with PROGRESSIVE STAGE (INTERMEDIATE)
hypotension despite fluid resuscitation + • Begins when compensatory mechanisms
Presence of tissue perfusion abnormalities. fail
• Mortality rates as high as 50% • Aggressive interventions to prevent
• Primary causative organisms multiple organ dysfunction syndrome.
o Gram-negative and gram-positive • Progressive (intermediate)Stage of Shock
bacteria. • Hallmarks of ↓ cellular perfusion and
o Endotoxin stimulates inflammatory altered capillary permeability:
response. o Leakage of protein into interstitial
• Clinical manifestations space.
o ↑ Coagulation and inflammation o ↑ Systemic interstitial edema
o ↓ Fibrinolysis • Anasarca (severe generalized edema)
§ Formation of o Fluid leakage affects solid organs
microthrombi. and peripheral tissues.
§ Obstruction of o ↓ Blood flow to pulmonary
microvasculature. capillaries.
o Hyperdynamic state: Increased CO • Movement of fluid from pulmonary
and decreased SVR. vasculature to interstitium.
o Tachypnea/hyperventilation o Pulmonary edema
o Temperature dysregulation o Bronchoconstriction
o ↓ Urine output o ↓ Residual capacity
o Altered neurologic status • Fluid moves into alveoli
o GI dysfunction o Edema
o Respiratory failure is common o Decreased surfactant
o Worsening V/Q mismatch
o Tachypnea

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o Crackles perfusion.
o Increased work of breathing o Protection of target and distal
• CO begins to fall organs from dysfunction.
o Decreased peripheral perfusion o Provision of multisystem
o Hypotension supportive care.
o Weak peripheral pulses • General management strategies
o Ischemia of distal extremities o Ensure patent airway
• Myocardial dysfunction results in o Maximize oxygen delivery
o Dysrhythmias • Cornerstone of therapy for septic,
o Ischemia hypovolemic, and anaphylactic shock =
o Myocardial infarction volume expansion.
o End result: Complete deterioration o Isotonic crystalloids (e.g., normal
of cardiovascular system. saline) for initial resuscitation of
• Mucosal barrier of GI system becomes shock.
ischemic. • Volume expansion
o Ulcers o If the patient does not respond to 2
o Bleeding to 3 L of crystalloids, blood
o Risk of translocation of bacteria administration and central venous
o Decreased ability to absorb monitoring may be instituted.
nutrients o Complications of fluid resuscitation
• Liver fails to metabolize drugs and wastes o
o Jaundice § Hypothermia
o Elevated enzymes § Coagulopathy
o Loss of immune function o Primary goal of drug therapy =
o Risk for DIC and significant correction of decreased tissue
bleeding. perfusion.
• Acute tubular necrosis/acute renal failure § Vasopressor drugs (e.g.,
epinephrine) – o
REFRACTORY STAGE (IRREVERSIBLE) Achieve/maintain MAP
• Exacerbation of anaerobic metabolism >60 to 65 mmHg;
• Accumulation of lactic acid Reserved for patients
• ↑ Capillary permeability unresponsive to other
• Profound hypotension and hypoxemia therapies.
• Tachycardia worsens § Vasodilator therapy (e.g.,
• Decreased coronary blood flow nitroglycerin [cardiogenic
• Cerebral ischemia shock], nitroprusside
• Failure of one organ system affects others [noncardiogenic shock]) –
• Recovery unlikely Achieve/maintain MAP
>60 to 65 mmHg.
VIII. DIAGNOSTIC STUDIES § Nutrition is vital to
• Thorough history and physical examination decreasing morbidity from
• No single study to determine shock shock – Initiate enteral
o Blood studies nutrition within the first 24
§ Elevation of lactate hours.
§ Base deficit § Nutrition is vital to
o 12-lead ECG decreasing morbidity from
o Chest x-ray shock – Initiate parenteral
o Hemodynamic monitoring nutrition if enteral feedings
contraindicated or fail to
IX. COLLABORATIVE CARE meet at least 80% of the
• Successful management includes caloric requirements;
o Identification of patients at risk for Monitor protein, nitrogen
shock. balance, BUN, glucose,
o Integration of the patient’s history, electrolytes.
physical examination, and clinical
findings to establish a diagnosis.
o Interventions to control or eliminate
the cause of the decreased

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ALTERED MULTI-ORGAN SYSTEM | REVIEWER | BATCH 2023
COLLABORATIVE CARE – CARDIOGENIC o Endotracheal intubation or
SHOCK cricothyroidotomy may be
• Restore blood flow to the myocardium by necessary.
restoring the balance between O2 supply • Aggressive fluid replacement
and demand. • Intravenous corticosteroids if significant
• Thrombolytic therapy hypotension persists after 1 to 2 hours of
• Angioplasty with stenting aggressive therapy.
• Emergency revascularization COLLABORATIVE CARE –
• Valve replacement HYPOVOLEMIC SHOCK
• Hemodynamic monitoring • Management focuses on stopping the loss
• Drug therapy (e.g., diuretics to reduce of fluid and restoring the circulating volume
preload). • Fluid replacement is calculated using 3:1
• Circulatory assist devices (e.g., intra-aortic rule (3mL of isotonic crystalloid for every
balloon pump, ventricular assist device). 1mL of estimated blood loss
• Management focuses on stopping the loss
of fluid and restoring the circulating volume.
X. NURSING ASSESSMENT
• ABCs: Airway, Breathing, and Circulation
• Fluid replacement is calculated using a 3:1
• Focused Assessment of Tissue Perfusion
rule (3 ml of isotonic crystalloid for every 1
ml of estimated blood loss). o Vital signs
o Peripheral pulses
COLLABORATIVE CARE – SEPTIC SHOCK o Level of consciousness
• Fluid replacement (e.g., 6 to 10 L of isotonic o Capillary refill
crystalloids and 2 to 4 L of colloids) to o Skin
restore perfusion. o Urine output
o Hemodynamic monitoring
• Brief History
• Vasopressor drug therapy; vasopressin for o Events Leading to shock
patients’ refractory to vasopressor therapy. o Onset and duration of symptoms
• Intravenous corticosteroids for patients • Details of care received before
who require vasopressor therapy, despite hospitalization
fluid resuscitation, to maintain adequate
• Allergies
BP.
• Vaccinations
• Antibiotics after obtaining cultures (e.g.,
blood, wound exudate, urine, stool, XI. NURSING DIAGNOSES
sputum) • Ineffective Tissue Perfusion: renal,
• Drotrecogin alfa (Xigris) cerebral, cardiopulmonary,
o Major side effect: Bleeding
gastrointestinal, hepatic, and
• Glucose levels <150 mg/dl
peripheral
• Stress ulcer prophylaxis with histamine
(H2)-receptor blockers. • Fear
• Deep vein thrombosis prophylaxis with low- • Potential Complication: Organ
dose unfractionated heparin or low- Ischemia/dysfunction
molecular-weight heparin.
XII. PLANNING
COLLABORATIVE CARE – NEUROGENIC
• Goals for the patient:
SHOCK o Assurance of adequate tissue
• In spinal cord injury: Spinal stability perfusion
o Treatment of the hypotension and o Restoration of normal or baseline
bradycardia with vasopressors and BP
atropine. o Return/recovery of organ function
o Fluids used cautiously as o Avoidance of complications from
hypotension is generally not prolonged states of hypoperfusion
related to fluid loss.
o Monitor for hypothermia XIII. NURSING IMPLEMENTATION
COLLABORATIVE CARE – 1. Health Promotion
ANAPHYLACTIC SHOCK a. Identify patients at risk (e.g. elderly
• Epinephrine, diphenhydramine patients, those with debilitating
• Maintaining a patent airway illnesses who are
o Nebulized bronchodilators immunocompromised, surgical or

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accidental trauma patients) XIV. EVALUATION
b. Planning to prevent shock (e.g. • Normal or baseline ECG, BP, CVP, and
monitoring fluid balance to prevent PAWP
hypovolemic shock, maintenance • Normal Temperature
of handwashing to prevent spread • Warm, dry skin
of infection)
• Urinary output > 0.5 mL/kg/hr
2. Acute Interventions
• Normal RR and SaO2 > 90%
a. Evaluate the patient’s response to
therapy • Verbalization of fears, anxiety
b. Provide emotional support to the
patient and family
c. Collaborate with other members of
the health team when warranted
3. Neurologic Status
a. Orientation and Level of
consciousness
4. Cardiac Status
a. Continuous ECG
b. VS, capillary refill
c. Hemodynamic parameters: central
venous pressure, PA pressures,
CO, PAWP
d. Heart Sounds: Murmurs, S3, S4
5. Respiratory Status
a. RR and Rhythm
b. Breath sounds
c. Continuous pulse oximetry
d. ABG
e. Most patients will be intubated and
mechanically ventilated
6. Urine Output
7. Tympanic or pulmonary arterial
temperature
8. Skin
a. Temperature
b. Pallor
c. Flushing
d. Cyanosis
e. Diaphoresis
f. Piloerection
9. Bowel Sounds
10. Nasogastric drainage/ stools for occult
blood
11. I&O, fluid and electrolyte balance
12. Oral care/ hygiene based on O2
requirements
13. Passive/ active Range of Motion
14. Assess level of anxiety and fear
a. Medication PRN
b. Talk to patient
c. Visit from clergy
d. Family involvement
e. Comfort measures
f. Privacy
g. Call light within reach

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MODS | REVIEWER | BATCH 2023

REFERENCES: • Perfusion deficits

• Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & • Persistent sources of inflammation such as
Cheever, K. H. (2010). Brunner and Suddarth’s pancreatitis or pneumonitis
textbook of medical-surgical nursing (12th ed.). B. HIGH RISK FOR DEVELOPING MODS
Philadephia: Lippincott Williams & Wilkins. • Impaired immune responses such as older
• Sole, M. L., Klein, D. G., & Mosley, M. J. adults
(2013). Introduction to critical care nursing. St. • With chronic illnesses
Louis, Mo: Elsevier/Saunders. • With malnutrition
OUTLINE • With cancer
I. Introduction to ABC: Multi Organ • With prolonged or exaggerated inflammatory
Dysfunction Syndrome (MODS) responses are at risk, including: victims of
II. Determination & Management: severe trauma or with sepsis
Etiology and Risk Factors C. MULTI ORGAN FAILURE: CLASSIFICATION
A. Causes of MODS 1. PRIMARY MULTI-ORGAN DYSFUNCTION
B. High Risk for Developing MODS SYNDROME
C. Multi Organ Failure: Classification • Results directly from a “well-defined insult”
i. Primary MODS where the organ dysfunction occurs early and
ii. Secondary MODS is directly attributed to the insult itself.
D. Multi Organ Failure: Clinical • Direct insult initially causes localized
Manifestations inflammatory response that may or may not
E. Multi Organ Failure: Prognosis progress to SIRS.
F. Multi Organ Failure: Medical • Small percentage of clients develop primary
Management MODS.
G. Multi Organ Failure: Nursing
• Example: Primary pulmonary injury, such as
Management aspiration.
III. Life Saving Intervention 2. SECONDARY MULTI-ORGAN DYSFUNCTION
A. First Aid Measures SYNDROME
B. Basic Life Support (BLS)
• A consequence of widespread systemic
C. Advanced Cardiac Life Support
inflammation, which develops after a variety of
(ACLS)
insults, and results in dysfunction of organs not
IV. Life Maintaining Intervention
involved in the initial result.
V. Cardiac Output
• Hypermetabolic state lasts for 14 to 21 days
VI. Hemodynamic Instability
VII. Prioritization Of Clients With Multi- • During hypermetabolic state, the body engages
Organ Failure in autocatabolism, which causes changes in
VIII. Nursing Management the body’s metabolic processes; The process
IX. Expected Outcome can be stopped, the outcome for the death.
X. Health Teaching • It occurs with conditions: Septic shock and
ARDS
D. MULTI ORGAN FAILURE: CLINICAL
I. INTRODUCTION ABC: MULTI ORGAN MANIFESTATIONS
DYSFUNCTION SYNDROME (MODS) • Usually there is a precipitation event to MODS:
• A progressive dysfunction of more than one organ o Aspiration
in critically ill or injured patients o Ruptured aneurysm
• Interchangeably referred to as Systemic o Septic shock (associated with resultant
Inflammatory Response Syndrome (SIRS) and hypotension)
Multisystem Organ Failure (MSOF) • Client is resuscitated; the cause is treated; and
• Leading cause of death in Intensive Care Units appears to do well for a few days.
• Its initial insult that stimulates MODS may result • The following possible sequence of events often
from a variety of causes, including but not limited to: develops.
o Extensive burns • Client experiences SIRS before MODS within a few
o Trauma days.
o Cardiorespiratory failure • There is an insidious onset grade fever, tachycardia,
o Multiple blood transfusions increased numbers and segmented neutrophils on
o Systemic infection (most common) the different count (left shift)
II. DETERMINATION & MANAGEMENT: • Client has dyspnea with diffuse patchy infiltrates on
ETIOLOGY AND RISK FACTORS the chest x-ray.
• Some often has deterioration in mental reasonably
A. CAUSES OF MODS normal renal and hepatic laboratory results.
• Dead tissue • Dyspnea progresses, and intubation and mechanical
• Injured tissue ventilation are required.
• Infection

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• Coagulopathy or Disseminated intravascular F. MULTI ORGAN FAILURE: MEDICAL

coagulation (DIC) is usually present MANAGEMENT
• Client is usually stable hemodynamically and has • Restrain the Activators:
relative polyuria, an increased in cardiac index o Manifestations of potential infection
(greater than 4.5 L/min). must be quickly treated to restrain the
• Systemic vascular resistance of less than 600 dynes activators of MODS.
cm-5. o Antibiotics should be administered if
• Increased blood glucose level in the absence of the agent is known.
diabetes is usual. o Broad-spectrum antibiotics should be
• Between 7 and 10 days: given if the organisms is not known.
o Bilirubin level increases and o Drotrecogin alfa (Xigris) is administered
continuously increases, followed by if the severity of sepsis is identified in
serum creatinine order to prevent progression of
o Blood glucose and Lactate level MODS.
continue to increase because of o Aggressive pulmonary care is needed
hypermetabolic state when there is a progression in clients
o Other progressive changes include: who are at risk of MODS because
Nitrogen and protein combined with lungs are often the first organs to fail.
decreased level of serum albumin, o Coughing and deep breathing or
prealbumin, and retinol ambulation are the simple
o Bacteremia with enteric organism is interventions.
common and infection from candida o Oxygen saturation must be monitored.
viruses such as herpes and o Malnutrition develops from
cytomegalovirus are common. hypermetabolism and the GI tract
o Surgical wound fail to heal, and often seeds other areas with bacteria,
pressure ulcer may develop. some clinicians require enteral
o Increased amounts of fluids and feeding.
inotropic medications are needed to o Feeding enhances perfusion and
keep blood volume and cardiac decreases the bacterial load and the
preload near normal and to replace effects of endotoxins.
fluid loss through polyuria G. MULTI ORGAN FAILURE: NURSING
• Between 14 and 21 days: MANAGEMENT
o Client is unstable and appears close to • Effective client and family coping is the overall
death nursing goal:
o May lose consciousness o Must remain sensitive to the needs of
o Renal failure worsens to the point the family.
dialysis is needed o Caring for the family of critically ill client
o Edema may be present due to low is a challenge in that understanding,
serum protein levels predicting, and intervening with
o Mixed venous oxygen level may families in crisis is less exact than the
increase because of problems with calculation of oxygen needs.
tissue uptake of oxygen caused by o There’s no easy formula to use to
mitochondrial dysfunction provide hope, courage, coping, and
o Lactic acidosis worsens, liver enzymes caring.
continuously increases, and o Must remain alert to the needs of the
coagulation disorders become client and family during this stressful
impossible to correct. time.
E. MULTI ORGAN FAILURE: PROGNOSIS III. LIFE SAVING AND INTERVENTION
• If MODS process is not reversed by Day 21, the
1. FIRST AID MEASURES
client will die.
• An immediate care given to a person who have
• Death usually occurs between days 21 and 28 after
been injured or suddenly taken ill.
the injury or precipitation event.
• Includes self help and home care when medical
• Not all clients with MODS die; however, MODS
assistance is delayed or not available.
remains the leading cause of death in the ICU with
• Roles of First Aid:
mortality rates from 50% to 90% despite antibiotics
o Bridge that fills the gap between the
development, better resuscitation, and more
victim and physician.
sophisticated organ support.
o Not intended to compete with or take
• 21 days is the average duration of ICU stay for the
the place of the services of the
clients who survived.
physician.
• Rehabilitation lasts for 10 months is directed to o Ends when medical assistance
recovery of muscle mass and neuromuscular begins.
function.

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2. BASIC LIFE SUPPORT (BLS) • Check humidifier fluid level.

• An emergency procedure that consists of • Records intake & output and daily weight.
recognizing respiratory arrest and cardiac Positive pressure may cause water balance
arrest or both and the proper application of due to humidification of inspired air.
CPR to maintain life or until the victim recovers
or advance life support is available. • Suspend ventilator tubing from an IV hook or
• A-B-C Steps: support it on a pillow to reduce traction on the
o Airway opened ET tube.
o Breathing restored • Change ventilator tubing every 24 hours.
o Circulation restored • Check vital signs and auscultate lungs every
• Use of supplementary techniques hour.
3. ADVANCE CARDIAC LIFE SUPPORT Rationale: Positive pressure ventilation may
• A set of clinical interventions for the urgent decrease venous return and cardiac output.
treatment of cardiac arrest and other life • Observe and listen for possible cuff leaks
threatening medical emergencies, as well as around tracheostomy or endotracheal tube.
the knowledge and skills to deploy those • Empty accumulated water on ventilator tubing.
interventions. Disconnect tubing and stretch it to release
• Extensive medical knowledge and rigorous water trapped into corrugated areas and
hands-on training and practice required to drained to water basin. Do not drain water back
master ACLS. to humidifier.
• Only qualified health care providers (e.g. • Provide method of communication such as
physicians, paramedics, nurses, respiratory magic slate.
therapists, clinical pharmacists, physician • Test nasogastric drainage pH every hour and
assistants, nurse practitioners) and other administer antacid to maintain pH above 5.
specially trained health care providers can • Test nasogastric drainage and fecal matter
provide ACLS, as it requires the ability to: daily for occult blood.
o Manage the patient’s airway • Assess lungs compliance.
o Initiate IV access • Implement methods of stress reduction.
o Read and interpret electrocardiograms • Keep ventilator alarms on.
o Understand emergency MEDICAL MANAGEMENT OF THE CLIENT
pharmacology. RECEIVING PARENTERAL NUTRITION
IV. LIFE MAINTAINING INTERVENTION • Parenteral nutrition is indicated to maintain
1. Airway Management status and prevent malnutrition when the client
2. Care of Patient with Ventilator has inadequate intestinal function or cannot be
3. Parenteral fluid Administration fed orally or by tube.
4. Intervention of Cardiac Output Problems and • PN prescription is guided by the nutritional
Pharmacologic Intervention for Hemodynamic assessment and the definition of nutrient goals
Instability for calories and protein.
5. Continuous Hemodynamic Monitoring • PN solution contains carbohydrates, such as
6. Fluid and Electrolyte Problems glucose, fats, triglyceride, and protein as amino
7. Nutrition acid levels designed to meet the caloric and
8. Perioperative Problems protein needs of client.
AIRWAY MANAGEMENT INTERVENTIONS
• Most important responsibility of the health team • Administer parenteral nutrition
is management of the patient’s airway. • Nurses are responsible for safely administering
• Maintenance and ventilation and monitoring the infusion of PN solution.
• Intubation and extubation • Check every solution for its:
MANAGING PATIENTS ON VENTILATORS o Expiration date
Preparation: o Correct ingredients (glucose, fat,
• Double check the ventilator settings according protein, electrolytes)
to the physician’s order. o Leaks or tears in the bag, and the
• Plug the machine and turn it on. appearance of the solution (separating
• Familiarize with location of alarm system. or cracking of the solution)
• Connect the ventilator tubing to patient’s • PN must be delivered using peristaltic pump to
endotracheal tube or tracheostomy tube. accurately control the infusion rate and prevent
Procedure: the possibility of a bolus.
• Monitor patient’s vital signs every 5 minutes • In the acute care setting, PN solutions are
until stable. typically infused over 24 hours.
• Obtain ABG 15 minutes after ventilation is • In the home, PN solutions are given while the
established. client is sleeping.
• Monitor ventilation setting. • Monitor the folllowing:

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o Blood glucose level o Sense of heaviness or weakness int

o Allergy for PN components eh arms or legs
o Maintain vascular assess o Skin feels stiff or taut
o Prevent infection o Any redness, changes in the skin
o Provides dressing changes temperature or pain in swollen areas
V. CARDIAC OUTPUT can be a sign of infection and should
• The amount of blood ejected by the left immediately reported
ventricle in one minute. 2. ELECTROLYTE IMBALANCE
• Left ventricle seems to get the lion’s share of • It can caused by:
attention, perhaps because the body’s blood o Vomiting
flow and pulse are provided by the left o Diarrhea
ventricle. o Sweating
• For an adult, an average cardiac output is o High fevers
about 5-8 liters of ejected blood per minute. o Kidney disease
• Adult’s cardiac output can increase to 25 L/min o Medications unrelated to cancer
with strenuous activities in order to satisfy the therapy
body’s demands for oxygen and nutrients. o Certain chemotherapy drugs such as
Cisplatin and targeted therapies such
VI. HEMODYNAMIC INSTABILITY as Erbitux.
• A state requiring pharmacologic or mechanical • Electrolytes regulate activity of nerves and
support to maintain a normal blood pressure or muscle, their imbalance could lead to
adequate cardiac output. malfunctions in multiple organ systems. It could
• General indications for pulmonary artery cause:
pressure monitoring include: o Muscle spasms
o Assessment of cardiovascular function o Weakness and twitching
(complicated MI, cardiogenic shock, o Irregular heartbeat and blood pressure
papillary muscle rupture) changes
o Peri-operative monitoring of surgical o Lethargy
patients with major systems o Confusion
dysfunction. Shock of all type (septic, o Neurological problems
hypovolemic, any shock that is • Severe electrolyte imbalance can result in
prolonged or origin is unknown) death. Monitoring for electrolyte imbalance is a
o Assessment of pulmonary status, fluid simple process and is accomplished through
status (dehydration, hemorrhage, GI routine laboratory work.
bleeding, burns)
o Therapeutic indications (aspiration of
VII. PRIORITIZATION OF CLIENTS WITH
air emboli, cardiac pacing) MULTI-ORGAN FAILURE
o Diagnostic indications (aspiration of • Prevention is the top priority
arterial blood, pulmonary • Early detection and documentation of initial
hypertension) signs of infection
FLUID AND ELECTROLYTE PROBLEMS • At present, there’s no agent that can reverse
1. WATER RETENTION the established organ failure
• Build-up of excess fluid in tissues • Therapy is limited to supportive care
• Swelling of the feet, ankles, and hands are
generally the first sign Treatment Measures are Aimed at:
• It can also affect other parts of the body such • Controlling the initiating event
as the abdomen, chest cavity, face and neck o Restrain the activators
• Possible causes include: o Antibiotic management
o Certain medications (some • Safeguarding hemodynamics and respiration
chemotherapy drugs) • Maintaining adequate tissue oxygenation
o Heart, liver, or kidney disease (principal target)]
o Blockage of veins or lymph system • Providing nutritional support
• Symptoms to look for and report to physician: o Starting enteral nutrition within 36
o Feelings of tightness in the arms or hours of administration to an ICU has
legs reduced infectious complications
o Difficulty fitting into clothing • Human recombinant activated protein C
o Rings, wristwatch or shoes fit tighter (activated Drotrecogin alfa)
than usual o Can reduce 28-day mortality among
o Pitting of the lower legs and arms, patients with MODS according to a
when pressing the skin with finger, randomized control trial
there is an indentation that remains for
a few seconds.

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VIII. NURSING MANAGEMENT

1. Supporting the patient and monitoring organ
perfusion until primary organ insults are halted
2. Provide information and support to family
members
3. Address end-life decisions to ensure supportive
therapies congruent with patient wishes
IX. EXPECTED OUTCOME
• Normal aerobic cellular metabolism
Indicators:
1. Arterial blood gases (pH, PaO2, and PaCO2)
within normal range
2. Maintenance of urine output of at least 20
mL/hr
3. Maintenance of mean arterial blood pressure
within 10 mmHg of baseline
4. Absence of MODS
5. States measures to reduce risk for sepsis
X. HEALTH TEACHING
• Protecting vulnerable clients from infection and
sepsis at home –Important nursing function:
o Instruct importance of self-care
strategies
§ Good hygiene, handwashing,
balanced diet, rest, exercise,
skin care, mouth care
o Teach family members how to take
temperature and read thermometer
o Instruct to notify health care provider
immediately, if signs of infection
appear
o Instruct infection precaution

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REFERENCE: 4. To treat a wide variety of illnesses or injury

• Hinkle, Janice and Cheever, Kerry H. 2018 situations, ranging from sore throat to heart
Brunner and Suddart’s Medical Surgical Nursing attack.
14th Edition. Walters Kluwer. PRINCIPLE OF EMERGENCY MANAGEMENT AND
• FEU-IN ABC Teams PowerPoint EMERGENCY MEDICAL SERVICES
• https://www.slideshare.net/sanilmlore/emergen 1. Early detection
cy-nursing-29438911 Links to an external site. 2. Early reporting
• https://www.webmd.com/lung/what-to-know- 3. Early response
about-airway obstruction 4. Good on scene care
OUTLINE 5. Care during transportation
I. Principles of Emergency Nursing 6. Transport to definitive care
A. Scope of Emergency Nursing II. GENERAL PRINCIPLE OF EMERGENCY
B. Principle of Emergency
MEDICAL CARE
Management & Emergency
1. Triage
Medical Services
a. assess and decide which patient will be
II. General Principle of Emergency seen first and in which order
Medical Care
b. Take vital signs and complete focused
A. Three Categories
assessments
III. Triage Nurse as an Advanced Skill
c. Administer medications
A. Questions Appropriate to Triage
d. Emergent life-saving measures like
Decisions
assisting with rapid sequence (intubations,
B. Objective Information
CPR, etc)
C. ABCD Approach
e. Provide medical Treatment
D. AVPU Mnemonic
f. Charting- take full Hx of patients so you
E. EFGHI Approach can diagnose them easier & accurately
F. AMPLE Approach
g. Educate patients and family members- help
IV. Emergency Disability
them understand the importance of not
A. Airway, Breathing, And Circulation
following them
Emergency
h. Communicate with the healthcare
B. Upper Airway Obstruction
providers and patients
C. Lower Airway Obstruction
i. Transfer- getting patient safely admitted to
D. Other Causes of ABC Emergency a nursing unit for further care & evaluation
E. Stroke and Head Injury
The word triage comes from the French word “Trier”
V. Environmental Emergency
meaning to sort. Used to sort the patients into groups
A. Poisoning
based on the severity of their health problems and
B. Burns
immediacy which these problems must be treated
3 CATEGORIES:
EMERGENCY MANAGEMENT 1. EMERGENT - emergent patients had the
Emergency Nursing – The term emergency is used for highest priority
those patients who require immediate action to prevent 2. URGENT - urgent patients had serious
further deteriorations or stabilizing the condition till the problems but not immediately life-threatening
availability of services close to the patients. ones
I. PRINCIPLE OF EMERGENCY 3. NONURGENT - nonurgent patients had
NURSING episodic
1. Establish a patent airway and provide adequate. illnesses
2. Control hemorrhage, prevent and manage
shock.
3. Maintain and restore effective circulation
4. Evaluate the neurological status of the client
5. Carry out a rapid and ongoing physical
assessment
6. Start cardiac monitoring (monitor arrhythmias)
7. Protect and clean wounds
8. Identify significant medical history and allergies
9. Document the findings in medical records.
SCOPE OF EMERGENCY NURSING
1. To provide immediate action to treat the patient
2. For crisis intervention
3. To treat emergency condition irrespective of age
group

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III. TRIAGE NURSE IS AN INSPECT inspect for hidden injuries-log

ADVANCED SKILL roll patient to inspect posterior
aspect.
ASKING QUESTIONS IS THE KEY TO APPROPRIATE • Complete Health History
TRIAGE DECISIONS
1. What were the circumstances, precipitating the
• Head to toe assessment
events, location, time of the injury or illnesses? • Diagnostic and Laboratory testing
2. When the symptoms appear? • Insertion or application of monitoring device (eg.
3. Was that the patient unconscious after the injury ECG, UB)
or onset of illness? • Splinting of suspected fracture
4. How did the patient get to the ED? • Cleansing, closure, and dressing of wounds
5. What was the health status of the patient before • Performance of necessary intervention based
the injury or illness? on the patient’s
6. Is there a history of medical illness, or previous SECONDARY SURVEY USING
surgeries, a history of admission to the hospital? AMPLE APPROACH
7. Is the patient is currently taking any medication,
• Allergy
especially hormones, insulin, digitalis, or
anticoagulants • Medical history
8. And other significant questions • Past health history
OBJECTIVE INFORMATION OBTAINED DURING THE • Last meal
RAPID TRIAGE ASSESSMENT • Events/Environment preceding illness or injury
1. AIRWAY- patent or impaired
2. BREATHING- Unlabored or labored IV. ABC EMERGENCY DISABILITY
3. CIRCULATION- Skin color and moisture; pulse A An airway obstruction happens when you can't move
rate and rhythm; obvious bleeding air in or out of your lungs. It could be because you inhaled
4. DISABILITY- LOC including GCS, AVPU scale; something that's blocking your airway. Or it could be
muscle strength in upper and lower extremities caused by disease, allergic reaction, or trauma. Airway
5. EXPOSURE- Hyperthermic or hypothermic obstructions may block part of your airway or the whole
PRIMARY SURVEY USING ABCD APPROACH thing.
- Airway, Breathing, Circulation, and Disability Acute upper obstruction is a life threatening medical
ASSESS AND INTERVENE condition.
1. Establish a patent CAUSES
2. Provide adequate ventilation 1. Trauma
3. Evaluate and restore cardiac output by a. Foreign Bodies
controlling hemorrhage, preventing and treating b. Inflammation
shock and maintain effective c. Hematomas
4. Determine neurologic disability by assessing 2. CNS Disease- secretions
neurologic function using the Glasgow Coma 3. Drug overdose
A QUICK NEUROLOGIC ASSESSMENT USING THE 4. Infections- glottis
AVPU MNEMONIC: 5. Obstructive Sleep Apnea
ALERT Is the patient is alert and PARTIALLY OCCLUDED UPPER AIRWAY
responsive? CAN LEAD TO:
VERBAL Does the patient response to 1. Progressive hypoxia
verbal stimuli. 2. Hypercarbia
PAIN Does the patient respond only to 3. Respiratory and cardiac
painful stimuli. COMPLETE OBSTRUCTION CAN LEAD TO:
UNRESPONSIVE Unresponsive. Is the patient is 1. Permanent brain injury
2. Death will occur between 3-5 minutes secondary
unresponsive to all stimuli,
to hypoxia
including pain?
WHAT CAN CAUSE AN
SECONDARY SURVEY USING UPPER AIRWAY OBSTRUCTION?
EFGHI APPROACH 1. FOREIGN OBJECTS
EXPOSE THE Inhaling an object that blocks the airway is the fourth
PATIENT leading cause of unintentional death. This is more likely
FULL SET OF five interventions: cardiac to happen in children, who have smaller airways, and
VITAL SIGNS monitor pulse oximetry, urinary people who have problems with their nerves and
catheter, NG if not muscles.
contraindicated, lab studies The objects most likely to cause choking deaths in
GIVING COMFORT pain control, reassurance to children include:
MEASURES patient and family 1. Hot dogs
HISTORY Head to toe assessment 2. Candy
3. Nuts

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4. Grapes b. Avoid endoscopy because of risk of

5. Balloons rupture. If packet intact, may observe
In adults, the objects most likely to cause choking and use whole bowel irrigation with
deaths include: polyethylene glycol to hasten passage
1. Meat of packets through gastrointestinal
2. Fish tract.
3. Sausage c. Otherwise surgery to remove packets.
4. Bread products THINGS TO OBSERVE
5. Fruits 1. Anxiety, pain (neck retrosternal epigastric)
6. Vegetables 2. Choking
SPECIAL TYPES OF SWALLOWED FOREIGN 3. Vomiting
BODIES 4. Dysphagia
1. FOOD IMPACTION 5. Inability to swallow
a. Avoid proteolytic enzymes because f 6. Drooling
risk of esophageal perforation. 7. Air hunger and Dyspnea- generally less
b. Avoid gas forming agents if perforation common
is suspected OBJECTIVES
c. Barium swallow after treatment to 1. Recognize the clinical scenario, signs, and
confirm clearance of the impaction and symptoms of swallowed foreign bodies.
to rule out esophageal pathology 2. Learn the diagnostic and therapeutic approach
d. Expectant management if handling to the various types of swallowed foreign bodies.
secretions and impacted <12 hours or CONSIDERATIONS
then, endoscopy 1. Patients with swallowed foreign bodies may be
2. COIN (Often Asymptomatic) asymptomatic or may present in extremis.
a. X-ray to confirm location (esophageal Although most objects will pass through the
coins lie with flat side showing on gastrointestinal tract without problems, it is
anteroposterior x-ray) important to recognize which patients require
b. Endoscopy preferred if at the level of observation and which will need intervention
the cricopharyngeal muscle 2. ANAPHYLAXIS
c. Alternative: Foley Catheter removal Allergies can lead to a severe, life-threatening reaction.
under fluoroscopy if lodged <24h It's almost always unexpected and can lead to death.
(pushing object into stomach) Anaphylaxis causes the airways to swell and stop you
d. Expectant Management may be from breathing if not treated right away.
considered if impacted <24h The most common causes of anaphylaxis include:
3. BUTTON BATTERY 1. Peanuts
a. High risk of mucosal burns and 2. Tree nuts
esophageal perforation if lodged in 3. Seeds
esophagus. 4. Milk
b. X-ray to confirm location. 5. Medicines
c. Surgical consult for endoscopy if in & 6. Insect venom
esophagus and has not passed CLINICAL CRITERIA FOR DIAGNOSIS OF
through the pylorus or patient ANAPHYLAXIS
symptomatic. 1. Acute onset (minutes to hours) with reaction of
d. Expectant management if past the the skin and/or mucosal tissue in addition to
esophagus and no symptoms. Repeat respiratory symptoms or hypotension.
radiographs until battery cleared. o Skin symptoms - itchiness, Redness,
4. SHARP OR POINTED OBJECTS hives, generalized urticaria, and
a. X-ray to confirm location. If foreign mucosal edema,
body proximal to or in duodenum, o Respiratory manifestations-
endoscopic removal recommended laryngeal stridor, bronchospasm,
given risk of intestinal perforation. bronchorrhea, and hypoxia.
b. If symptomatic, impacted, or foreign Hypotension results from extravasation
body past duodenum, surgical consult of fluid from the vasculature and loss of
for endoscopy or laparotomy. vasomotor tone.
c. Expectant management with serial 2. Two or more of the following occurring rapidly
radiographs. (minutes to hours) after exposure to likely
5. BODY PACKING INGESTION OF PACKETS allergen involvement of the skin mucosal tissue,
OF DRUGS respiratory symptoms, hypotension, or
a. Rupture of packet may be fatal gastrointestinal symptoms (Include abdominal
(especially with cocaine). May cause pain, cramping, and diarrhea.
symptoms because of drug effect or 3. Hypotension occurring rapidly (minutes to
gastrointestinal obstruction. hours) after exposure to known allergen for that

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patient. Hypotension may present as faintness can be triggered by many different factors,
or altered mental status. including:
TREATMENT 1. Changes in the weather
1. Epinephrine 2. Allergens
2. Diphenhydramine 3. Infections
3. Hydrocortisone 4. Exercise
4. IVF PNSS or PLR (1-2L Bolus) 2. BRONCHIOLITIS
5. Methylprednisolone Bronchiolitis most often affects young children and is
6. Prednisolone usually caused by a virus. It makes your airways swell,
7. Ipratropium Bromide (nebulization-single dose) blocking airflow. Symptoms of bronchiolitis can include:
8. H1 and H2 blockers 1. Trouble breathing
2. Coughing
3. SMOKE INHALATION 3. Runny nose
leading cause of death due to fires. It produces injury 4. Fever
through several mechanisms, including thermal injury to 5. Wheezing
the upper airway, irritation or chemical injury to the 6. Young babies may stop breathing periodically
airways from soot, asphyxiation, and toxicity from carbon 3. CHRONIC OBSTRUCTIVE PULMONARY
monoxide (CO) and other gases such as cyanide (CN). DISEASE (COPD)
SIGNS AND SYMPTOMS • That’s an inflammatory lung disease that blocks
1. Facial burns the airflow into the lungs. COPD can cause
2. Blistering o edema of the oropharynx inflammation of the lining of the tubes that carry
3. Hoarseness air to the sacs in the lungs.
4. Stridor • This is called chronic bronchitis. Emphysema
5. Upper Airway obstruction also contributes to COPD by destroying the air
6. Carbonaceous Sputum sacs at the end of the smallest air passages.
4. BURNS • Symptoms of COPD include:
When the air temperature gets hot enough, such as in a 1. Wheezing
fire, it can injure your upper airway. These injuries cause 2. Tightness in your chest
swelling to your epiglottis, which is a flap of cartilage at 3. Chronic cough
the root of the tongue, and the mucous membranes 4. Shortness of breath
around the larynx. This swelling can block your airway. 5. Swelling in legs, ankles, or feet
5. INFECTIONS 6. Frequent respiratory infections
The most common cause of infectious airway obstruction OTHER CAUSES OF AIRWAY, BREATHING, AND
in children is croup, which is caused by a virus. Infections CIRCULATION EMERGENCY:
caused by bacteria can also lead to airway obstruction,
though it's not as common. 1. CARDIAC ARREST
These include: • In cardiac arrest, the heart is unable to pump
1. Epiglottitis and circulate the blood to the body’s organ and
2. Bacterial tracheitis, an infection of your trachea tissues. It is often caused by a dysrhythmia such
3. Diphtheria as ventricular fibrillation , progressive
4. Retropharyngeal abscess bradycardia, and asystole.
5. Peritonsillar abscess • Cardiac arrest can also occur when the electrical
activity is present on ECG but cardiac
WHAT CAN CAUSE A LOWER AIRWAY contractions are ineffective, a condition called
OBSTRUCTION? Pulseless Electrical Activity.
Lower airway obstructions can be caused by a variety of • Pulseless Electrical Activity may be caused by
different conditions. variety of problems such as profound
SIGNS & SYMPTOMS hypovolemia (eg. Hemorrhage).
1. Tachypnea • Diagnosis that associated with cardiac arrest
2. Dyspnea include MI, massive pulmonary emboli,
3. Cough hyperkalemia, hypothermia, severe hypoxia,
4. Decreased Breath Sounds and medication overdose.
5. Wheezing MANIFESTATION:
6. Rales 1. Loss of consciousness
7. Rhonchi 2. Loss of pulse
1. ASTHMA 3. Loss of blood pressure
• Asthma is a lifelong disease that affects airflow. 4. Breathing usually ceases but ineffective
Symptoms include airway swelling, respiratory gasping may
hyperreactivity, and making more mucus. MANAGEMENT:
• They can cause coughing, wheezing, shortness 1. Cardio Pulmonary Resuscitation
of breath, and tightness in your chest. Asthma

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2. EXTERNAL HEMORRHAGE 3. STROKE & HEAD INJURY

Hemorrhage - stopping bleeding is essential to the care
STROKE
and survival of the patient in an emergency or disaster
situation. Hemorrhage that results in the reduction of • is a brain attack. It is much like a heart attack, only it
circulating blood volume is a main cause of shock. occurs in the brain. Like a heart attack, stroke is a
OBSERVATION AND INDICATING IMPAIRMENT: medical emergency. When the blood supply to a part
1. Weak and thready pulse of the brain is cut off or greatly decreased, a stroke
2. HR > 120 beats per minute occurs.
3. Pallor • If the blood supply is cut off for several hours or more,
4. Systolic BP < 90 mm HG the brain cells, without enough blood supply die.
5. Decrease level of consciousness Depending upon the amount of blood involved and
MANAGEMENT location of the stroke area in the brain, a person
1. FLUID REPLACEMENT - fluid replacement is having a stroke can show many signs and
imperative to maintain circulation. Isotonic symptoms.
electrolytes solutions that includes (eg. Lactated • These can range from barely noticeable difficulties
Ringer’s , normal saline), colloids, and blood moving or speaking to paralysis or death.
component
2. CONTROL EXTERNAL HEMORRHAGE - ISCHEMIC STROKES
1. Rapid physical assessment- (clothing • occur when a blood vessel gets so narrow or clogged
is cut away) to identify the area of that not enough blood can get through to keep the
hemorrhage. brain cells alive.
2. Direct, firm pressure is applied over the HEMORRHAGIC STROKES
bleeding • occur when the wall of a blood vessel becomes weak
3. Direct, firm pressure at involved artery and blood leaks out into the brain. Of the 2 main
at the site that is proximal to the types of stroke, the ischemic stroke occurs 80-85%
4. A firm pressure dressing is applied, of the time. With an ischemic stroke, a blood vessel
and the injured part is elevated to stop in the brain becomes clogged. With a hemorrhagic
venous and capillary stroke, a blood vessel in the brain actually bursts or
5. If the extremity is involved, extremity is leaks.
immobilized to control blood • Hemorrhagic strokes tend to be more serious than
WHAT ARE SYMPTOMS OF AN AIRWAY ischemic strokes. Death occurs in 30-50% of people
OBSTRUCTION? with this type of stroke.
Symptoms of an airway obstruction can vary depending SYMPTOMS:
on how severe the blockage is, including: • Weakness in the arm or leg or both on the same
1. Violent coughing side
2. Struggling to breathe • Weakness in the muscles of the face
3. Turning blue • Difficulty speaking
4. Choking
5. Gagging
• Coordination problems
6. Vomiting • Dizziness
7. Wheezing • Vision problems
• Sudden headache
HOW IS AN AIRWAY OBSTRUCTION TREATED?
• The treatment for an airway obstruction depends
• Loss of consciousness
TREATMENT:
on the cause and severity.
• An inhaled object is a medical emergency and • The initial treatment for stroke is supportive
needs treatment right away. If an inhaled object • You usually will be given fluids through an IV
causes choking, you should call 911 and because if you're having a stroke, you may often
perform first aid. be dehydrated
• The five-and-five method recommended by the • Oxygen may be given to be sure that your brain
American Red Cross consists of five black blows is getting the maximal amount
followed by five abdominal thrusts, which is the • If you have any difficulty breathing, this will be
Heimlich maneuver. Alternate between the two assessed and treated. Unlike people with chest
until the object is coughed up. pain, people having a stroke are not given an
• Other treatment options may include: aspirin immediately
1. Oxygen • You are requested not to eat or drink until your
2. Intravenous (IV) fluids ability to swallow is assessed
3. Antibiotics • Blood pressure control: It is important not to
4. Other medicines lower the blood pressure too much so that the
5. Endotracheal tube brain will get enough blood pressure
6. Breathing machine
7. Airway surgery

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EMERGENCY NURSING | REVIEWER | BATCH 2023

Prevention: • Never leave a poisonous product unattended

• Strokes are preventable! Have your blood around children, even for a moment. Many
pressure checked and monitored by a doctor. poisonings occur when an adult who is using a
Even moderately high blood pressure over years poisonous product becomes distracted by the
can lead to a stroke doorbell, a telephone, or some other
• Treat high cholesterol with diet and exercise and interruption.
then medication to reduce the risk of stroke. • Be aware of common substances that are
High levels of blood cholesterol known as LDL poisonous, such as houseplants and cosmetics.
(low-density lipoprotein) increase risk for stroke • Keep products in their original containers.
and may cause the formation of artery- • Never store poisonous products in food
narrowing plaque containers. Never leave alcohol within sight or
• For the general population, aspirin has not been reach of a child.
shown to reduce stroke risk. It may be useful if • Read product labels for caution statements, how
prescribed by a doctor for people who have an to use the product correctly, and first aid
increased risk of stroke instructions.
• Control diabetes • Consult the doctor about including activated
• Stop smoking or never smoke charcoal in your first aid supplies at home.
• Know the symptoms of stroke. Act quickly when Activated charcoal reduces the toxic effect of
someone exhibits the signs of a stroke. Stroke is some poisons.
a medical emergency HOUSEHOLD POISONS
V. ENVIRONMENTAL EMERGENCY • Do not keep poisons such as drain cleaner, oven
cleaner, or plant food under your kitchen sink.
POISONING (CHEMICALS, DRUGS, FOOD) Keep them out of the sight and reach of children.
• A poison is a substance that has toxic effects Dishwasher detergent is especially dangerous
and may injure you or make you sick if you are • Have your home tested for levels of lead if any
exposed to it. Poisons can be found everywhere, older leaded paints may still be present
from simple household cleaners to cosmetics to • Some house or garden plants and the chemicals
houseplants to industrial chemicals. used to care for them (such as fertilizers) can be
• Even medicines that are taken in the wrong poisonous if ingested. Be sure to teach your
dose, at the wrong time, or by the wrong person children not to play with them
can cause a toxic effect. MEDICINES
• Poisonous substances can hurt you if they are • Put all medicines and vitamins out of the sight
swallowed, inhaled, spilled on your skin, or and reach of children. Acetaminophen, such as
splashed in your eyes. Tylenol, is a common source of childhood
• Generally, any product that gives off fumes or is poisoning
an aerosol that can be inhaled should be • Never call medicines "candy."
considered a possible poison. More than 90% of • Keep medicines in their original labelled
poisonings occur in the home. containers
SYMPTOMS: • Buy non-prescription medicines in child-
• Nausea and vomiting resistant packages
• Cramps • Try to take medicines out of the sight of children
• Throat pain • Do not regularly use medicines to sleep, lose
• Drooling weight, or relax. Try to find nondrug solutions
• Sudden sleepiness, confusion, or decreased • Check the label on the bottle each time you take
• Anxiousness, nervousness, irritability, or a medicine to make sure you're taking the
• Substance residue or burn around the mouth, correct one
teeth, eyes, or on the • Check the expiration dates on medicines. If your
• Difficulty breathing medicines are expired or no longer needed
EXTENSIVE BURNS
• Headache A burn is the partial or complete destruction of skin
• Loss of consciousness caused by some form of energy, usually thermal energy.
• Extreme anxiousness, nervousness, irritability, Burn severity is dictated by:
or tremors • Percent total body surface area (TBSA)
• Seizure involvement
• Chest discomfort or pain with symptoms of a • Burns >20-25% TBSA require IV fluid
heart attack resuscitation
• Signs of shock • Burns >30-40% TBSA may be fatal without
PREVENTION: treatment

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• In adults: "Rule of Nines" is used as a rough • Tracheostomies not needed during resuscitation
indicator of % TBSA period
Rule of Nines for Establishing Extent of Body Surface • Remember: Intubation can lead to
Burned complications, so do not intubate if not needed
ANATOMIC SURFACE % OF TOTAL BODY Breathing
SURFACE • Hypoxia
Head & Neck 9% o Fire consumes oxygen so people may
Anterior Trunk 18% suffer from hypoxia as a result of flame
Posterior Trunk 18% injuries
Arms, Including Hands 9% each • Carbon monoxide (CO)
Legs, Including Feet 18% each o Byproduct of incomplete combustion
Genitalia 1% o Binds hemoglobin with 200 times the affinity
of oxygen
Depth of burn injury (deeper burns are more severe) o Leads to inadequate oxygenation
Deep burns (deep second-degree to fourth-degree burns) o Diagnosis of CO poisoning
• Patient color ("cherry red" with poisoning)
Deep second-degree burns (deep partial-thickness) Treatment
• Damage to deeper dermis • Remove source
• Less moist, less blanching, less pain • 100% oxygen until CO levels are <10%
• Heal by scar deposition, contraction and limited • Smoke inhalation injury
re-epithelialization • Pathophysiology
Third-degree burns (full-thickness) o Smoke particles settle in distal
bronchioles
• Entire thickness of skin destroyed (into fat)
o Mucosal cells are die
• Any color (white, black, red, brown), dry, less o Sloughing and distal atelectasis
painful (dermal plexus of nerves destroyed) o Increase risk for pneumonia
• Heal by contraction and scar deposition (no • Treatment
epithelium left in middle of wound) o Supportive pulmonary management
Fourth-degree burns o Aggressive respiratory therapy
• Burn into muscle, tendon, bone Circulation
• Need specialized care (grafts will not work) 1. Obtain IV access anywhere possible
• Deep burns usually need skin grafts to optimize o Unburned areas preferred
results and lead to hypertrophic (raised) scars if o Burned areas acceptable
not grafted o Central access more reliable if
TREATMENT proficient
The ABCs (airway, breathing, circulation) of trauma take o Cut-downs are last resort
precedent over caring for the burn 2. Resuscitation in burn shock (first 24 hours)
Airway o Massive capillary leak occurs after
• Extensive burns may lead to massive edema major burns
• Obstruction may result from upper airway o Fluids shift from intravascular space to
interstitial space
swelling
o Fluid requirements increase with
• Risk of upper airway obstruction increases with greater severity of burn (larger %
Massive burns TBSA, increase depth, inhalation
• All patients with deep burns >35-40% TBSA injury, associate injuries)
should be endotracheally intubated o Fluid requirements decrease with less
o Burns to the head severe burn (may be less than
o Burns inside the mouth calculated rate)
• Intubate early if massive burn or signs of o IV fluid rate dependent on physiologic
obstruction response
o Intubate if patients require prolonged § Place Foley catheter to
transport and any concern with potential for monitor urine output
obstruction § Goal for adults: urine output of
o If any concerns about the airway, it is safer 0.5 ml/kg/hour
to intubate earlier than when the patient is § Goal for children: urine output
decompensating of 1 ml/kg/hour
• Signs of airway obstruction § If urine output below these
o Hoarseness or change in voice levels, increase fluid rate
o Use of accessory respiratory muscles o Preferred fluid: Lactated Ringer's
o High anxiety Solution
o Isotonic

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