CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS,

HIGH ACUITY AND EMERGENCY SITUATION

o Aggressive antihypertensive therapy.

COURSE OUTLINE ● ACE inhibitors alone or in combination with other
antihypertensive medications, significantly reduces its
I Nursing Care of Clients with Altered Elimination
incidence.
A Renal Failure (Acute and Chronic)
i ADPIE
II Nursing Care of Clients with Multi-Organ System CHRONIC GLOMERULONEPHRITIS
Problems ● Inflammation of the tiny(glomeruli) of the kidneys.
A Shock
B Systemic Inflammatory Response Syndrome PATHOPHYSIOLOGY
C Multi Organ Dysfunction Syndrome
i ADPIE ● Kidneys are reduced to as little as one fifth their normal
III Nursing Care of Clients with Altered Perception size. The cortex layer shrinks to 1 to 2mm in thickness or
A Traumatic Brain Injury / Alterations less. Bands of scar tissue distort the remaining cortex,
B Acute Ischemic Stroke making the surface of the kidney rough and irregular.
C Traumatic Spinal Injury Numerous glomeruli become scarred and the branches of
i ADPIE the renal artery are thickened.

CLINICAL MANIFESTATIONS
NURSING CARE OF CLIENTS WITH ALTERED
ELIMINATION ● Blood or protein in the urine (hematuria, proteinuria)
● High blood pressure
RENAL FAILURE (ACUTE AND CHRONIC) ● Swelling of ankles or face (edema)
● It is composed of the kidneys and these are directly linked ● Frequent night time urination (nocturia)
to the urinary bladder. ● Foamy urine
● This produces, stores and eliminates urine
ASSESSMENT AND DIAGNOSTIC FINDINGS
Glomeruli - cleaning unit of the kidney ● Hyperkalemia
Nephron - functional unit of the kidney ● Metabolic acidosis
● Increased serum phosphorus level
FUNCTIONS OF KIDNEY: ● Anemia secondary to decreased erythropoiesis
● Filtration ● Hypoalbuminemia
● Reabsorption ● Decreased calcium level
● Excretion ● Mental status changes

FUNCTIONS OF A NORMAL KIDNEY: MEDICAL MANAGEMENT

● Regulation of body fluid osmolality and volume. ● Antihypertensive medications
● Regulation of electrolyte balance ● Sodium & water restriction
● Regulation of acid-base balance ● Antibiotic medications to treat UTIs to prevent further
● Excretion of metabolic products and foreign substances kidney damage
● Production and secretion of erythropoietin
NEPHROTIC SYNDROME
NEPHROSCLEROSIS ● A type of kidney disease characterized by increased
● Hardening of the renal arteries. glomerular permeability and is manifested by massive
● Most often due to prolonged hypertension and diabetes. proteinuria.

PATHOPHYSIOLOGY PATHOPHYSIOLOGY
● Decreased blood flow to the kidney ● a distinct abnormal clinical and
● Patchy necrosis of the renal parenchyma biochemical entity characterized
● Fibrosis occur and glomeruli are destroyed by edema, massive proteinuria,
hypoalbuminemia and
hypoproteinemia, and
MEDICAL MANAGEMENT
hyperlipidemia and
● Treatment hypercholesterolemia.

BONOT, CAMILLE FRANCE S. | 4A - USI BSN 1

 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION

CLINICAL MANIFESTATIONS INTRARENAL AKI

● Severe swelling (edema), particularly around the eyes,
ankles and feet
● Foamy urine, a result of excess in urine
● Weight gain due to fluid retention
● Irritability
● Headache
● Malaise

POLYCYSTIC KIDNEY DISEASE

● A genetic disorder characterized by the growth of
numerous fluid-filled cysts in the kidney, which destroy the
nephrons. The cysts enlarges the affected area while
replacing much of the normal structure, resulting in
reduced kidney function and leading to kidney failure.

Two Major Inherited Forms of PKD:

1. Autosomal Dominant PKD
● Most common inherited form. Symptoms
develop between 30 & 40 years of age.
About 90% cases are autosomal dominant
PKD.
2. Autosomal Recessive PKS
FOUR CLINICAL PHASES OF ARF
● A rare inherited form 1. Onset Phase
● Earliest months of life or in utero ● From the time of the precipitating event to the beginning of
the oliguric-anuric phase.
PATHOPHYSIOLOGY
2. Oliguric-Anuric Phase
● Exact pathogenesis of AKI is not always known, but may
● Urine output less than 400ml/day, volume overload,
be associated with severe reduction in the glomerular
elevated blood urea nitrogen (BUN) and creatinine levels,
filtration rate.
electrolyte abnormalities, metabolic acidosis & uremia.
PRERENAL AKI
3. Diuretic Phase
● Extends from the time that output becomes more than
400ml/day to the time BUN stops rising and stabilizes in
normal range. Electrolyte and acid base problems begin to
normalize.

4. Convalescent Phase
● BUN stabilizes until the client returns to normal activity.
The client may take up to 2 years to regain 70% to 80% of
normal function.

ASSESSMENT
● Altered urine output
● Hypertension or hypotension
● Tachypnea
● Signs of fluid overload or extracellular fluid depletion

LABORATORY AND DIAGNOSTIC FINDINGS

● Urinalysis
POSTRENAL AKI ● Blood Analysis
o ⬆ BUN, Serum creatinine, K levels
o ⬇ Blood pH, bicarbonate, hemoglobin & hct

NURSING MANAGEMENT
● Administer prescribed medication (alkalizing agents,
phosphate-binding agents, ion exchange resins, calcium
supplements, histamine receptor antagonists &
proton-pump inhibitors)
● Promote measures to ensure normal potassium levels.
o Assess for presence of hypokalemia
o Restrict dietary potassium as necessary
o Prepare to administer insulin and glucose, which
drives potassium back into the cell
● Promote measures to maintain fluid balance

BONOT, CAMILLE FRANCE S., BUENAAGUA, MIKHAELA | 4A - BSN USI 2

 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
● Prevent GI bleeding by administering histamine receptor Decreased ● Correction
antagonists and proton pump inhibitors Metabolic Hydrogen ion of
● Promote comfort and encourage bed rest to reduce Acidosis secretion electrolyte
exertion and metabolic rate Retention of imbalance
● Provide a high-calorie and low protein diet. acid end
● Prepare the client for dialysis to correct hyperkalemia, fluid products of
overload, acidosis or severe uremia. metabolism
● Provide emotional support by giving opportunities for the
patient and family to verbalize their concerns. Inappropriate
Arrhythmias activation of the
CHRONIC KIDNEY DISEASE V renin
(END STAGE RENAL DISEASE) angiotensin
● Irreversible destruction of nephrons due to fibrosis leading system
to accumulation of waste products, toxins, fluid and Hyperkalemia;
electrolytes resulting in the uremic syndrome. Hypocalcemia

THREE BASIC STAGES OF CKD: Gastrointe Anorexia, Uremic toxins ● Oral

1. Decreased Renal Reserve stinal nausea, and Decomposition hygiene
● Renal function is 40%-50% of normal and homeostasis is emesis of urea in the ● Hemoglobi
maintained GI tract, n and
releasing hematocrit
2. Renal Insufficiency ammonia monitoring
● Renal function is 20%-40% of normal; decreased GFR ● Diarrhea
and homeostasis is altered. Stomatitis, Uremic toxins and
Uremic Decomposition constipatio
3. End-stage Renal Disease Halitosis if the urea in n control
● Renal function is 10%-15%; all renal functions severely the oral cavity, ● Exercise
decreased releasing regimen
ammonia ● Self-care
instruction
COMMON CAUSES OF CKD V
Constipation Hypermotility
● Diabetes due to
● Chronic hypertension- too much stretching of blood electrolyte
vessels which cause scarring imbalances,
● Chronic glomerulonephritis decreased fluid
● Polycystic kidney disease intake and
decreased
Table No. 1 activity
Stages of CKD
STAGES eGFR Hematopo Anemia Decreased ● Iron
Stage 1 ≥90ml/min ietic erythropoietin supplemen
With kidney damage but normal secretion by ts
or increased GFR kidneys ● Folic Acid
Stage 2 60-89ml/min Decreased supplemen
Mild decrease in GFR RBC survival tation
Stage 3 30-59ml/min time due to ● Blood
Moderate decrease in GFR uremic toxins transfusion
Stage 4 15-29ml/min Uremic toxins ● Dialysis
Severe decrease in GFR interfering with ● Erythropoie
Stage 5 ≤15ml/min folic acid action tin
End stage renal disease injections
Alterations in Platelet
Table No. 2 Coagulation dysfunction due
Systemic Manifestations of Chronic Renal Failure and to uremic toxins
Management
SYSTEM MANIFESTA PATHOPHYSIO MANAGEMEN Increased Decreased
TIONS LOGIC BASIS T susceptibility neutrophil
Cardiovas Fluid Decreased ● Dietary phagocytosis
cular Overload; excretion of fluid
Edema water restriction Integumen Pallor Uremic Anemia ● Bath oils
● Dietary tary and lotions
Congestive Hypertension sodium Retained ● Correct
heart failure restriction Yellowness urochrome hyperphos
● Antihyperte pigment phatemia
Electrolyte Decreased nsive excreted ● Self-care
Imbalance excretion of medication through the skin instructions
Electrolytes s ● Dialysis

BONOT, CAMILLE FRANCE S., BUENAAGUA, MIKHAELA | 4A - BSN USI 3

 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
Decreased ● Erythropoie o Decreased serum protein (particularly albumin)
Dryness secretions from tin levels
all and sweat injections o Low blood pH
glands
Pruritus NURSING MANAGEMENT
Calcium or ● Provide Conservative therapy
Phosphate o Maintain strict fluid control
deposits in the o Encourage intake of high biological value protein
skin foods, such as eggs, diary products, and meats
Purpura and (causes positive nitrogen balance needed for
Ecchymosis Increased growth & healing).
capillary fragility o Encourage high calorie, low protein, low sodium,
Platelet
low potassium snacks between meals.
dysfunction
o Encourage alternating activity with rest. Encourage
Uremic frost
independence as much as possible.
Urate crystals
● Prepare the client for renal replacement therapy.
excreted thru
the skin
Neuromus Drowsiness, Uremic toxins ● Dialysis RENAL FUNCTION TESTS
cular Confusion, producing a ● Seizure ● Blood Urea Nitrogen (BUN)
Coma, and uremic precaution o It measures nitrogen (made from protein
Irritability encephalopathy s breakdown) in your blood.
Metabolic ● Safety o Normal Range: 2.5-6.4 mmol/L
acidosis Precaution
s ● Estimated GFR (eGFR)
Tremor, Electrolyte o Calculates filtration rates based on serum
Twitching, Imbalances creatinine levels, age, gender, size, and race
and Uremic toxins
Convulsions producing a ● Serum Creatinine
uremic o Looks for the buildup of creatinine, a waste product
encephalopathy from muscle tissue breakdown
o Normal Range: 53-115 mmol/L

Psychoso Decreased Uremic toxins ● Dialysis ● 24-hour urine collection

cial concentratio producing ● Psychosoci o It is done by collecting urine in a special container
n uremic al over a full 24-hour period. The container must be
encephalopathy Counseling kept cool until the urine is returned to the lab,
Metabolic ● Client and o It is often done to see how much creatinine clears
acidosis Family through the kidneys. It’s also done to measure
Cerebral Education protein, hormones, minerals, and other chemical
Edema compounds.

Respirator Pulmonary Fluid overload ● Fluid DIAGNOSTIC IMAGING

y Edema restriction
● Kidney, Ureter, and Bladder Studies (KUB)
● Dialysis
o Study of the abdomen, kidneys, ureters and bladder
Pneumonia Thick tenacious ● Cardiovasc
o Performed to delineate the size, shape and position
or oral secretions ular
Pneumonitis due to treatments of the kidneys
decreased fluid ● Pulmonary
intake hygiene ● Bladder Ultrasonography
(coughing o Measures urine volume in the bladder
and deep o The scan head is placed on the patient’s abdomen
Kussmoul’s The body tries breathing and directed toward the bladder
respiration to remove exercises, o AUtomatically calculates and displays urine volume
carbon dioxide oral care)
on acid from ● Renal Angiography
the body by o Provides an image of the renal arteries
quickly o Used to evaluate renal blood flow in suspected
breathing it out renal trauma
o Differentiates renal cysts from tumors
o Can be used preoperatively for renal
transplantation
LABORATORY AND DIAGNOSTIC FINDINGS o The femoral or axillary artery is pierced with a
● Blood analysis reveals: needle, then a catheter is threaded up through the
o Anemia femoral and iliac arteries into the aorta or renal
o Elevated BUN & serum creatinine levels artery.
o Elevated serum phosphorus level
o Decreased serum calcium level

BONOT, CAMILLE FRANCE S., BUENAAGUA, MIKHAELA | 4A - BSN USI 4

 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
● Computed Tomography and Magnetic Resonance o Daily phosphorus requirement is 800 to 1200 mg
Imaging
▪ Food lower in Phosphorus
o Provides an excellent cross-sectional views of the
anatomy of the kidney and urinary tract - Fish, chicken, breast or leg, lean meat
o An oral or IC radiopaque contrast agent is used to ▪ Food higher in Phosphorus
enhance visualization
- Crab meat, shellfish, nuts and beans, pork
spareribs, egg, small fish
RENAL REPLACEMENT THERAPY
● Dialysis
REFERENCES
o Hemodialysis
- Used for patients with AKI for short term
dialysis until kidney functions resumes and Notes from the discussion by: Mrs. Adan
for patients with ESRD who require long
term or permanent renal replacement Universidad de Sta. Isabel powerpoint presentation:
therapy.

o Peritoneal Dialysis
- Removes toxic substances and metabolic
wastes to reestablish normal fluid and NURSING CARE OF CLIENTS WITH MULTI-ORGAN
electrolyte balance SYSTEM PROBLEMS

● Kidney Transplant SHOCK

- Treatment of choice for most patients with ● It is a life threatening condition in which tissue perfusion is
ESRD inadequate to deliver oxygen and nutrients to support
- An elective procedure, not emergency cellular function.
lifesaving procedure ● It affects all the body system
- Patients should be in best possible condition ● It may develop rapidly or slowly
prior to transplantation ● Any patient with any disease state may be at risk for
- During kidney transplant surgery, the donor developing shock.
kidney is placed in the lower abdomen. ● Regardless of the initial cause of shock, certain
Blood vessels of the new kidney are physiologic responses are common to all types of shock:
attached to blood vessels in the lower part of hypoperfusion of tissues, hypermetabolism, and
the abdomen. The new kidney’s ureter is activation of the inflammatory response.
connected to the bladder
CLASSIFICATIONS OF SHOCK
NUTRITION MANAGEMENT ● Hypovolemic
● Sodium o Shock state resulting from decreased
o Most renal patients are maintained on a 2000 to intravascular volume due to fluid loss.
3000 mg sodium restrictions per day o Occurs when there is a loss of fluid resulting in
o ½ to ¾ tsp. salt/day may be added in their meal inadequate tissue perfusion; caused by excessive
plan bleeding, diarrhea or vomiting, fluid loss from
- ¼ teaspoon = 500 mg sodium fistulas or burns.
o Avoid cured meat, processed and preserved foods
o Read food labels ● Cardiogenic
o Shock state resulting from impairment or failure
● Potassium of myocardium.
o Daily potassium requirement is <2000 mg o Occurs when pump failure causes inadequate
o Choose fruits and vegetables lower in potassium tissue perfusion; caused by heart failure,
o Check serving sizes of fruits and vegetables myocardial infarction, cardiac tamponade.
o In cooking tubers, double boil the vegetables to
● Septic
remove some of the potassium
o Circulatory shock state resulting from acute
▪ Foods lower in Potassium infection causing relative hypovolemia.
- Fruits: apple, grapes, papaya, pineapple, o Reaction to bacterial toxins (generally
lychee Gram-negative infections) which results in the
- Vegetables: ampalaya, cabbage, cucumber, leakage of plasma into tissues.
pechay, lettuce, sayote, upo, patola, radish
● Anaphylactic
▪ Foods higher in Potassium (TO BE AVOIDED!)
o Circulatory shock state resulting from severe
- Fruits: banana, santol, melon, lanzones, allergic reaction producing acute systemic
guyabano, buko water vasodilation, relative hypovolemia.
- Vegetables: leafy vegetables, banana heart, o Caused by an allergic reaction that causes a
langka vegetable, cauliflower, broccoli release of histamine and subsequent vasodilation.
● Calcium and Phosphorus
o Daily calcium requirement is 1000 to 1800 mg

BONOT, CAMILLE FRANCE S., BUENAAGUA, MIKHAELA | 4A - BSN USI 5

 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION

● Neurogenic ● For ALL types of Shock

o Shock state resulting from loss of sympathetic o Early Identification, timely treatment
tone causing relative hypovolemia. o Identify, treat underlying cause
o Caused by rapid vasodilation and subsequent o Sequence of events for different types of shock will
pooling of blood within the peripheral vessels; vary
caused by spinal anesthesia, emotional stress, o Management of care of patient will vary
drugs that inhibit the sympathetic nervous system.
CLINICAL FINDINGS
COMPENSATORY MECHANISM OF SHOCK ● Subjective Data
● KULANG o Apprehension
o Restlessness
STAGES OF SHOCK o Paresis of Extremities
● Compensatory Stage
o Sympathetic Nervous System causes ● Objective Data
vasoconstriction, increased HR, increased heart o Weak, rapid, thready pulse
contractility - This maintains BP, Cardiac Output o Diaphoresis; cold-clammy skin
o Body shunts blood from skin, kidneys, GI tract, o Pallor
resulting in cool, clammy skin, hypoactive bowel o Decreased urine output
sounds, decreased cardiac output. o Progressive LOC
o Perfusion of tissues is inadequate. o Decreased Mean Arterial Pressure (Normal Range:
o Acidosis occurs from anaerobic metabolism. 80 to 120 mmHg)
o Respiratory rate increases due to acidosis, may
cause compensatory respiratory alkalosis.
o Confusion may occur

● Progressive Stage
o Mechanisms that regulate BP can no longer
compensate, BP and MAP decrease.
o All organs suffer from hypoperfusion.
o Vasoconstriction continues further compromising
cellular perfusion.
o Mental status further deteriorates from decreased
cerebral perfusion, hypoxia
o Lungs begin to fail, decreased pulmonary blood
flow causes further hypoxemia, carbon dioxide
levels increase, alveoli collapse, pulmonary edema
occurs. HYPOVOLEMIC SHOCK
o Inadequate perfusion of heart leads to ● Shock state resulting from decreased intravascular
dysrhythmias, ischemia. volume due to fluid loss..
o As MAP falls below 70, GFR cannot be maintained
- Acute kidney injury may occur. PATHOPHYSIOLOGY
o Liver function, GI function, hematologic function are
all affected. ● Hypovolemic Shock
o Disseminated intravascular coagulation (DIC)
may occur as a cause or complication of shock.

● Irreversible Stage
o At this point, organ damage is so severe that the
patient does not respond to treatment and cannot
survive.
o BP remains low.
o Renal, liver function fails
o Anaerobic metabolism worsens acidosis
o Multiple organ dysfunction progresses to complete
organ failure.
o Judgment that shock is irreversible only made in
retrospect.

ASSESSMENT

BONOT, CAMILLE FRANCE S., BUENAAGUA, MIKHAELA | 4A - BSN USI 6

 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
o Fluid therapy
RISK FACTORS o Mechanical assistive devices
● External: Fluid Losses
o Trauma NURSING MANAGEMENT
o Surgery ● Monitoring hemodynamic status
o Vomiting ● Administering medications, IV fluids
o Diarrhea ● Maintaining intra-aortic balloon counter pulsation
o Diuresis ● Ensuring safety, comfort
o Diabetes Insipidus
PHARMACOLOGY (MEDICATIONS)
● Internal: Fluid Shifts ● Dobutamine
o Hemorrhage ● Nitroglycerine
o Burns ● Dopamine
o Ascites ● Other vasoactive medications
o Peritonitis ● Antiarrhythmic medications
o Dehydration
CIRCULATORY SHOCK
MEDICAL MANAGEMENT ● Septic
o Circulatory shock state resulting from acute
● Treatment of underlying cause
infection causing relative hypovolemia.
● Fluid, blood replacement
● Redistribution of fluid
● Anaphylactic
● Pharmacologic therapy
o Circulatory shock state resulting from severe
allergic reaction producing acute systemic
NURSING MANAGEMENT vasodilation, relative hypovolemia.
● Administering blood, fluids safely
● Monitor vital signs (BP, HR, O2 Saturation) ● Neurogenic
● Assess the client’s ECG for dysrhythmias o Shock state resulting from loss of sympathetic
● Assess urine output tone causing relative hypovolemia.
● Assess level of consciousness

GENERAL MANAGEMENT/STRATEGIES IN SHOCK PATHOPHYSIOLOGY

● Fluid Replacement
o Crystalloid, Colloid Solutions ● Circulatory Shock
o Complications of fluid administration
● Vasoactive medication therapy
● Nutritional support

CARDIOGENIC SHOCK
● Shock state resulting from impairment or failure of
myocardium.

PATHOPHYSIOLOGY

● Cardiogenic Shock

MEDICAL MANAGEMENT MANAGEMENT OF ALL TYPES OF SHOCK

● Correction of underlying causes ● Fluid replacement
● Initiation of first-line treatment o To restore intravascular volume
o Oxygenation o Crystalloids: 0.9% normal saline, lactated Ringer’s
o Pain Control solution, hypertonic solutions (3% hypertonic
o Hemodynamic monitoring saline)
o Laboratory marker monitoring

BONOT, CAMILLE FRANCE S., BUENAAGUA, MIKHAELA | 4A - BSN USI 7

 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
o Colloids: Albumin, dextran (dextran may interfere o Provide oxygen therapy and monitor oxygen
with platelet aggregation) saturation
o Blood Components for hypovolemic shock
o Complications: fluid overload, pulmonary edema ● Evaluation
o Reduces blood and fluid loss
● Vasoactive Medications o Restore normal circulating volume
o To restore vasomotor tone, improve cardiac o Maintains urine output of 30ml or more per hour
function o Remain oriented to time, place and person
o Used when fluid therapy alone does not o Maintain adequate cardiac output
maintain MAP (Mean Arterial Pressure)
o Support hemodynamic status; stimulate SNS MULTI-ORGAN DYSFUNCTION SYNDROME (MODS)
o Check vital signs frequently; continuous ● The presence of altered organ function in a client who is
monitoring of vital signs every 15 minutes or more acutely ill such that homeostasis cannot be maintained
often. without intervention. MODS is present when two or more
o Give through central line if possible - organs fall.
Extravasation may cause extensive tissue damage ● Dysfunction at 2 or more organ results in 54% mortality
o Dosages usually titrated to patient response. rate
● Dysfunction of 5 or more organ results in 100% mortality
rate

ETIOLOGY
● Primary
o The direct insult initially causes a localized
inflammatory response that may or may not
progress to SIRS.
o The result of direct tissue insult, which leads to
impaired perfusion or ischemia.

● Secondary
o Most often a complication of septic shock or SIRS
● Nutritional Support
(Systemic Inflammatory Response Syndrome)
o To address metabolic requirements
o MODS may be a complication of any form of shock
o Nutritional support needed to meet increased
because of inadequate tissue perfusion.
metabolic and energy requirements to prevent
further catabolism due to depletion of glycerin
RISK FACTORS
o Support with parenteral or enteral nutrition
o GI system should be used to support its integrity ● Elderly
● Shock Episode
o Administration of glutamine
● Chronic Illness and Malnutrition
o Administration of H2 blockers or proton pump
● Immunosuppression
inhibitors
CAUSES
PATIENT AND FAMILY SUPPORT
● Trauma
● Manage anxiety o Hemorrhage
● Support of coping
o Blunt trauma to organ
● Patient, family education
o Sympathetic nervous System induced
● Communication
● End-of-life issues vasoconstriction
● Grief Processes ● Infections
● Burns
● Multiple Blood Transfusions
GENERAL NURSING CARE OF CLIENTS IN SHOCK
● Surgical Complications
● Assessment ● Diseases (Eg: Acute Pancreatitis)
o History of causative and risk factors from client
o Fluid intake and urine output over the previous 24 2 PRIMARY FACTORS CAUSING MODS
hours
● SIRS (Systemic Inflammatory Response Syndrome)
o Signs of overt bleeding, weak, thready pulse,
o Characterized by overwhelming immune responses
hypotension, increased respirations and cold
that lead to free radical generation
clammy skin
o Mental Status
● Cellular Hypoperfusion
o Causing hypoxia, which releases reactive oxygen
● Planning/Implementation
and nitrogen species. These species collectively
o Keep patient warm, in modified trendelenburg
result in profound intracellular oxidative stress
position causing mitochondrial damage.
o Monitor hemodynamics status and vital signs
o Monitor urine output
o Alley client’s anxiety
o Monitor IV fluids as ordered

BONOT, CAMILLE FRANCE S., BUENAAGUA, MIKHAELA | 4A - BSN USI 8

 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION

PATHOPHYSIOLOGY ● The worst type of lung injury found in people with MODS is
acute respiratory distress syndrome (ARDS)
● Once ARDS sets in, people have difficulty maintaining
oxygen in the blood and have a higher risk of dying.

CARDIOVASCULAR (HEART)

SEVERITY OF MODS
● Respiratory System
● Cardiovascular System
● Renal System
● Endocrine System
● Hematologic System
● Neurologic System

RESPIRATORY (LUNGS)

NERVOUS (BRAIN & SPINAL CORD)

● Acute alteration in mental status can be an early signs

of MODS
● The patient may become confused and agitated,
disoriented, lethargic, or comatose.
● These changes may be due to hypoxemia, the direct effect
of inflammatory mediators or impaired perfusion.

RENAL (KIDNEYS)

● Acute Renal Failure or AKI can be caused by

hypoperfusion and also by effects of mediators.
● Decreased perfusion to the kidneys activates RAAS

BONOT, CAMILLE FRANCE S., BUENAAGUA, MIKHAELA | 4A - BSN USI 9

 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
o Decreased lymphocyte count
● The stimulation of RAAS results in systemic o Anergy
vasoconstriction and aldosterone mediated sodium and
water reabsorption TREATMENT
● MODS treatment is multifactorial and depends on the
CLINICAL MANIFESTATION inciting event and type of organ damage.
● Primary MODS o People with widespread infection and sepsis need
o Low blood pressure antibiotics.
o People who develop respiratory failure need to be
● Secondary MODS placed on a ventilator and sedated to rest the lungs.
o Pulmonary compromised - patient with lung injury o Medications called vasopressors are often required
leading to intubation to maintain blood pressure and tissue perfusion.
o Hypermetabolic phase - hyperglycemia and o People are typically treated with intravenous fluids,
hyperlacticacidemia (excess of lactic acid in the but healthcare providers need to delicately balance
blood), polyuria (excessive urine output) a person's acid-base status and electrolytes when
o Infection - skin breakdown begins using intravenous fluids.
o Auto Catabolism - severe loss of skeletal muscle o Problems with the hematologic system need to be
mass treated based on whether a person is bleeding too
much or clotting too much. Sometimes people
● Respiratory require blood or platelet transfusions.
o Dyspnea o People with severe injuries may need surgery.
o Pulmonary hypertension
o Increase RR MEDICAL MANAGEMENT
o Decrease in surfactant ● Fluid resuscitation
o Alveolar edema ● Hemodynamic support
o Hypoxemia ● Prevention and treatment of infection
● Maintenance of tissue oxygenation
● Cardiovascular ● Nutritional and metabolic support
o Myocardial depression ● Comfort and emotional support
o Hypotension ● Support for individual organ function
o Increased HR
o Increased oxygen consumption NURSING MANAGEMENT
● Controlling initiating event
● Gastrointestinal ● Promoting and monitor adequate organ perfusion
o Mucosal Ischemia ● Providing nutritional support
o GI bleeding ● Comfort and emotional support
o Mucosal ulceration ● Address end of life decisions
o Hypoperfusion due to decrease peristalsis, paralytic
ileus COLLABORATIVE MANAGEMENT
● Support Oxygen Transport
● Hematologic o Establish patent airway
o Increase in bleeding time, increase in PT and APTT o Administer oxygen therapy and IV fluids
o Decrease PLT count o Initiate mechanical ventilation
o Leukocytosis o Administer vasoactive medications, inotropic and
o Anemia antidysrhythmic
o Leukopenia o Ensure sufficient count of hemoglobin and
o Coagulopathy hematocrit

● Neurologic SEQUENTIAL ORGAN FAILURE ASSESSMENT

o Lethargy (SOFA)
o Altered level of consciousness ● It was developed in 1994 during a consensus conference
o Seizures organized by the European Society of Intensive Care and
o Fever Emergency Medicine, in an attempt to provide a means
o Hepatic encephalopathy of quantitatively and objectively describing the degree
of organ failure over time in individual patients and in
● Endocrine groups of patients with sepsis.
o Hyperglycemia ● It is a scoring system that assesses the performance of
o Increased ADH production and ACTH several organ systems in the body and assigns a score
based on the data obtained in each category.
● Renal ● The higher the SOFA score, the higher the likely
o Oliguria mortality.
o Fluid and electrolyte imbalances ● It is a mortality prediction score that is based on the
o Increased creatinine; decreased eGFR degree of dysfunction of 6 organ systems.
● Limited to 6 organ system: respiratory, coagulation,
● Immune hepatic, cardiovascular, CNS, and renal.
o Infection

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CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION

SOFA LIMITATIONS
● SOFA was designed to look at populations, and not
individual patients; it cannot accurately predict which
patients will survive when the mortality rate is high (i.e., if
mortality is 90%, which 10 patients will survive) or which
patients will die if the mortality rate is low.
● A score of 0 is given for normal function through to 4 for
most abnormal, and the worst values on each day are
recorded.

PATHOGENESIS OF SIRS/MODS

SUMMARY
● Multiple organ system dysfunction (MODS) is a severe
illness defined as dysfunction of at least two organ
systems. MODS can affect any organ, but the primary
players are the lungs, heart, kidneys, liver, brain, and
blood.
● There are many causes of MODS, but the general
categories include major trauma, severe illness, and
widespread infection. Treatment is multifaceted but
centers around treating the initial insult and working to
prevent severe injury to other organ systems.

REFERENCES

Notes from the discussion by: Mrs. Borromeo & Mrs. Adan

Universidad de Sta. Isabel powerpoint presentation:

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 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
● REFLEX CENTERS are
NURSING CARE OF CLIENTS WITH ALTERED o found in the medulla: Respiration, BP, Heart Rate,
PERCEPTION Coughing, Vomiting, Swallowing, Sneezing
● The CEREBELLUM is posterior to the midbrain and pons,
NERVOUS SYSTEM below occipital lobe
● The human nervous system is a highly specialized system o It provides integration of sensory information to
responsible for control and integration of the body’s provide smooth coordinated movements.
many activities. o It controls fine movement, balance and position
● It has 2 major parts: CNS and ANS sense or proprioception
● It functions to control motor, sensory, autonomic, ● Structures protecting the brain: Skull, meninges
cognitive and behavioral activities. ● The CEREBROSPINAL FLUID is the clear and colorless
fluid that is produced in the CHOROID PLEXUS OF THE
THE CENTRAL NERVOUS SYSTEM VENTRICLES, circulates in the surface of the brain and in
the spinal cord.
● The BRAIN is a part of the CNS. One of the important
o There are 4 ventricles: right and left lateral; 3rd and
parts of the brain is the CEREBRUM.
● The CEREBRUM is divided in L and R hemispheres 4th ventricles.
joined at the lower portion by the CORPUS CALLOSUM. o The 2 lateral ventricles open into the interventricular
● The CEREBRAL HEMISPHERES are divided into pairs of foramen (FORAMEN OF MONRO) and the 3rd and
LOBES: 4th ventricles connect to the AQUEDUCT OF
o Frontal - largest, involved in concentrations, SYLVIUS
abstract thought, memory and motor function; o The 4th ventricles drain CSF into the subarachnoid
Responsible for affect, judgment, personality and space & spinal cord and absorbed by the arachnoid
inhibitions. Broca (speech center) area involved in villi
motor control of speech o The CSF is important in immune and metabolic
o Parietal - essential in determining person’s functions of the brain
awareness of body position in space, size and o CSF is produced at a rate of 500 ml/ day
shape discrimination and right -left orientation ● CEREBRAL CIRCULATION – the brain does not store
o Temporal - contains the auditory receptive area, nutrients but requires a constant supply of oxygen.
involved in memory of sound and understanding of The brain receives 15% of the cardiac output or 750 ml
language and music. per minute of blood flow.
o Occipital - responsible for visual interpretation and o The brain has a collateral circulation through the
memory. Circle of Willis, allowing blood flow to be
● An important part of the cerebrum is the CORPUS redirected on demand.
CALLOSUM o Blood vessels in the brain have 2 layers, more
o which is responsible for the transmission of prone to rupture when weakened or under pressure
information from one side to the other. o Arteries and Veins
● The HYPOTHALAMUS plays an important role in the o Blood brain Barrier
endocrine system. ● The SPINAL CORD is continuous with the medulla and
o It regulates pituitary secretions of hormones serves as the connection between the brain and the
that influence metabolism, reproduction, stress periphery. It is approximately 18 inches long and as thick
response and urine production. It works with the as a finger. It extends from the Foramen Magnum to
pituitary to maintain fluid balance through hormonal Conus Medullaris to the Cauda Equina.
release and maintains temperature regulation by ● The VERTEBRAL COLUMN surrounds and protect the
promoting vasoconstriction or vasodilation. spinal cord, it has 7 C, 12 T & 5 L vertebrae’s
o The hypothalamus is also the site for hunger
centers and is involved in appetite control. It THE PERIPHERAL NERVOUS SYSTEM
also regulates sleep-awake cycle, blood ● The CRANIAL NERVES
pressure, aggressive and sexual behavior as
well as emotional responses.
o The hypothalamus also controls and regulates
the autonomic nervous system. Optic chasm and
mammillary bodies are also in this area.
● The BASAL GANGLIA are
o responsible for control of fine and motor
movements, including those of the hands and
lower extremities
● The BRAINSTEM: midbrain, pons and medulla oblongata,
cerebellum and cerebral hemispheres.
o The Brainstem contains the sensory and motor
pathways and serves as the center for auditory
and visual reflexes
o Cranial nerves III and IV originates in the midbrain
● The PONS is situated in front of the cerebellum and in
between medulla and midbrain
o CN V and VIII originates in the PONS, contains
motor and sensory pathways
o CN IX and XII originates in the MEDULLA

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 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION

● SPINAL NERVES COMMON CAUSES

● Falls, Motor vehicle crashes, struck by hard or metal
objects and assaults.
o Common in 0-4, 15-19 & 65 up; Higher in male

HOW TBI AFFECTS DAILY LIFE

PATHOPHYSIOLOGY

● AUTONOMIC NERVOUS SYSTEM

o Regulates the activities of the internal organs
such as the heart, lungs, blood vessels, digestive
organs and glands.
o Maintenance and restoration of internal
homeostasis

Divided into :
o Sympathetic Nervous System – fight and flight TWO FORMS OF DAMAGE IN TBI
response ● PRIMARY INJURY
o Parasympathetic Nervous System - dominant o It is the result of a direct contact to the head or
controller of most visceral functions , primary the brain in the event of an instant injury causing:
neurotransmitter is ACETYLCHOLINE.
a. Extracranial Focal Injuries
There are 3 common problems among clients with neurologic o Contusions, lacerations, external hematomas and
disorders, they are as follows: skull fractures

1. Increased intracranial pressure b. Focal Brain Injuries

● Traumatic Alterations in Consciousness o Due to sudden movement of the brain within the
(Traumatic Brain Injury) cranium: Subdural hematomas (SDH), concussion,
2. Seizures diffuse axonal injury (DAI)
● Acute Ischemic Attacks
3. Altered level of consciousness ● SECONDARY INJURY
● Traumatic Spinal Cord Injury o It presents hours and days after the initial injury. It
results from inadequate delivery of nutrients
HEAD INJURIES (TRAUMATIC BRAIN INJURY) and oxygen to the cells
Head injuries is a broad classification that encompasses any
damage to the head as a result of trauma. A head injury does a. Identification, prevention and treatment of secondary
not necessarily mean a brain injury is present. injury are the main foci of early management of
severe TBI
● It is described as an injury that is a result of an external b. Intracranial hemorrhage, cerebral edema, intracranial
force and is of sufficient magnitude to interfere with hypertension, hyperemia, seizures and vasospasm
daily life and should be subjected to treatment c. Systemic effects of hypotension, hyperthermia,
● refers to the clinical condition of transient alteration of hypoxia, hypercarbia, infection, electrolyte imbalances
consciousness as a result of traumatic injury to the brain and anemia further add to the complex biochemical,

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 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
metabolic and inflammatory changes further o FOUR Score (Full Outline of Unresponsiveness
compromise the injured brain. Score)
o Mental Status
● Scalp Injury o Cranial Nerve Testing
o A minor injury o Cerebellar Testing
o Bleeds profusely when injured, poor BV constriction o Sensory and Motor assessment
o Trauma may result in an Abrasion, Contusion, o Reflexes
Laceration and Hematoma ● Radiographic Studies: CT Scan: to diagnose a skull
o Large avulsion maybe life threatening fracture;
o Dx: PE, Inspection/Palpation o MRI: for a better and clear view of the brain injury
o PET Scan (Positron Emission Tomography); it is an
● Skull Fracture imaging of the brain to detect disease or injury thru
o A break in the continuity of the skull due to a forced injection of radioactive substances to act as tracer.
trauma o Cerebral Angiography
o May occur without damage to the brain o Spinal Tap
o Skull fractures are classified as: Linear, o Cerebral Perfusion
Comminuted or Depressed o Intracranial Pressure Monitoring
o Location Fractures: frontal, temporal, basal skull ● Gerontologic Considerations:
o Etiology of the injury- falls, motor vehicle crashes
o Higher mortality
THE MONRO-KELLIE DOCTRINE also known as the o Longer hospital stay
MONRO-KELLIE hypothesis states that:
o Poor functional outcomes
o Neurologic assessment is challenging; hearing and
● The cranial vault contains the 3 main components: Brain,
Blood & CSF visuals deficits may present as well as cognitive
● The cranial vault is a closed- system; when one of the and dementia issues.
components increases in volume, the other components
should decrease in volume to maintain equilibrium MEDICAL MANAGEMENT
● Any bleeding or swelling increases intracranial pressure ● Non depressed skull fractures; no surgery needed but
● When ICP is severe, it can displace the brain through and close monitoring required.
against the rigid cranium. o Home management instruction needed
o Blood flow to the brain is decreased, oxygen flow o Watch out for signs and symptoms of concussion
and waste removal is disrupted ● Depressed Skull Fracture requires surgery with
o Cells of the brain becomes anoxic & cannot elevation of skull and debridement within 24 hours of
metabolize properly injury
o This leads to ischemia, infarction, irreversible brain o Skull fractures may be a combination of open,
damage to brain death. compound, closed or simple
o Associated injuries include concurrent scalp
CLINICAL MANIFESTATIONS lacerations, dural tears and brain injury directly
Symptoms other than local, depends on the severity and below the fracture due to compression of the tissue
distribution of brain injury below the injury and from lacerations due to bony
fragments
● Persistent localized pain; suggests fracture
● Fractures to the cranium may or may not suggest BRAIN INJURY
swelling ● One of the most important considerations in any form of
● Fractures at the base of the skull: hemorrhage from head injury is whether the BRAIN is injured because even
nose, pharynx, ears, and under the conjunctiva a minor injury can have a significant effect and can result
● Battles’ sign (ecchymosis over the mastoid ) in brain damage.
● CSF drain from ears ( otorrhea) and nose ( rhinorrhea ) ; ● With brain damage, obstruction can occur causing
basal skull fracture decreased blood flow to the brain tissues and this can
be fatal because the brain cannot hold oxygen to a certain
● Bloody spinal fluid; brain laceration or contusion degree. Since the brain cells cannot survive without blood
● Altered LOC, pupillary abnormalities, altered / absent gag supply, damage is irreversible. If the blood supply is
reflex, neurological deficits, change in VS, interrupted even for a few minutes
hyper/hypothermia, sensory-vision-hearing impairment
● Signs of post-concussion syndrome: headache, dizziness, TYPES OF BRAIN INJURY
anxiety, irritability, lethargy
● Acute/ subacute subdural hematoma, changes in LOC, CONCUSSION
pupillary signs, hemiparesis, coma, hypertension, ● also known as Mild TBI results from a head injury with a
bradycardia, slowing RR: signs of expanding mass or temporary loss of neurologic function but no apparent
ICP. structural damage to the brain.
● Mechanism of injury is usually through a blunt injury from
ASSESSMENT AND DIAGNOSTIC FINDINGS an acceleration-deceleration force, a direct blow or blast
● Physical Exams and Neurologic Status: injury.
o Assess Level of Consciousness; GLASGOW Coma ● Loss of consciousness for a few seconds or a minute;
Scale slight jarring of the brain causes dizziness and spots

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 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
before the eyes or it can be severe enough to cause o Relieving intracranial pressure
complete loss of consciousness.
● Frontal lobe affection: bizarre, irrational behavior SUBDURAL HEMATOMA
● Temporal Lobe affection: temporary amnesia or ● A collection of blood between the dura and the brain,
disorientation normally between dura and the space normally occupied
by a thin cushion of fluid. Results from trauma but maybe
The duration of mental status abnormalities is an indicator of also as a result of coagulopathies or aneurysm.
the grade of concussion. o Venous in origin; caused by rupture of the small
● Once discharged from the hospital, observe & monitor the vessels that bridge the subdural space
patient for decrease of LOC, worsening headache, o SDH maybe acute or chronic- depends on the
dizziness, seizures, abnormal pupillary response, amount of bleeding (CT Scan)
vomiting, irritability, slurred speech and numbness and
weakness of arms and legs (Brunner & Suddarth , 14th a. Acute SDH
ed. 2018). These symptoms are indicators for need to o It is associated with major head injuries : contusion
intervene. or laceration and develops rapidly.
● Repeated concussive incidents can lead to a syndrome
called Traumatic Encephalopathy. SIGNS AND SYMPTOMS
● Changes in LOC , pupillary signs and hemiparesis. Coma,
CONTUSION
BP, heart rate , slowing RR : signs of rapidly expanding
● a more severe cerebral injury. The brain is bruised with
mass.
possible surface injury.
● Patient is unconscious, faint pulse, shallow breathing,
● cool pale skin, subnormal BP and temperature and SURGICAL MANAGEMENT
● incontinent bowel and bladder ● Craniotomy; removal of blood clot
● Patient arousal is possible with effort but falls back to
unconsciousness easily. b. Chronic SDH
● In general, patients with widespread injury who have o It develops from minor injuries that are forgotten,
abnormal motor function, abnormal eye movements and usually in the elderly due to atrophy and the aging
elevated ICP have a poor outcome (brain damage, process.
disability or death. Those that recover consciousness o Chronic SDH can be mistaken for a stroke, less
completely, may pass into a stage of cerebral irritability profuse bleeding but compression of intracranial
(conscious but easily disturbed by any form of stimulation contents is prominent.
such as noise and light) and may become hyperactive. o Blood within the brain changes in character within
Recovery is delayed and residual headache and vertigo 2-4 days; becomes thicker & darker. In 2 weeks the
are common, impaired mentality or seizures occur. clot breaks down in the consistency of a motor oil.

INTRACRANIAL HEMORRHAGE SIGNS AND SYMPTOMS

● Hematomas developing within the cranial vault are the ● Severe headaches that come and go, alternating focal
most serious results of brain injury neurologic signs (partial or complete paralysis, muscle
● Hematomas can be epidural, subdural, or intracerebral, it weakness, partial or complete loss of sensation, seizures,
depends on the location. poor cognitive abilities, difficulty in reading and writing,
● Fairly large hematomas can cause distortion, increased personality changes, mental deterioration and focal
ICP and brain herniation. seizures. (Bauman & McCourt,2014)
EPIDURAL HEMATOMA SURGICAL MANAGEMENT
● Blood collected between the space of the skull and dura
mater; results from skull fracture and rupture or laceration ● Multiple Burr Holes or Craniotomy; when the subdural
of the middle meningeal artery. mass cannot be suctioned or drained through burr holes.

SIGNS AND SYMPTOMS INTRACEREBRAL HEMORRHAGE

● It is bleeding into the parenchyma of the brain.
● Brief loss of consciousness followed by a lucid interval ● Commonly seen in head injuries when force is exerted to
(this is due to rapid absorption of CSF and decreased the head over a small area
intravascular volume as a compensatory mechanism. ● It also results from systemic hypertension, rupture of
● Once the mechanism can no longer compensate, even a aneurysm, vascular anomalies, intracranial tumors,
small increase in the volume of the blood clot produces bleeding disorders (leukemia,hemophilia, aplastic anemia
marked elevation of ICP. & thrombocytopenia) as well as complications of
● With increased ICP: patient becomes restless, agitated, anticoagulant therapy.
and confused and may progress to COMA. ● Onset is insidious, begins with development of
● EPIDURAL HEMATOMAS ARE EXTREME neurological deficits then headache
EMERGENCIES. Respiratory Arrest or marked neurologic
deficit may present.
NURSING MANAGEMENT
SURGICAL MANAGEMENT ● Supportive care
● Control of ICP
● Craniotomy, to open the skull, remove clot and control ● Fluids and electrolyte fluid
bleeding. ● Management & antihypertensive drugs
● Drain inserted, prevents re-accumulation of blood
o Removing blood clots
o Draining a brain abscess

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 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION

SURGICAL MANAGEMENT ● Risk for injury related to seizures, disorientation,

● Removal of blood clots thru CRANIOTOMY or restlessness or brain damage
CRANIECTOMY and control of hemorrhage. ● Risk for imbalanced temperature- regulating mechanisms
in the brain
MEDICAL MANAGEMENT ● Risk for impaired skin integrity related to bed rest,
hemiparesis, hemiphlegia, immobility or restlessness
● Assessment and diagnosis of the extent of injury are ● Ineffective coping related to brain injury
followed through from a ● Disturbed sleep pattern related to Brain Injury and
● series of initial physical and neurologic examinations. frequent neurologic checks
● CT scan and MRI are the main imaging neurodiagnostic ● Risk for dysfunctional family processes related to
tools and are useful unresponsiveness of the patient, unpredictability of
● PET ( Positron Emission Tomography ) is important for outcome, prolonged recovery period, patient’s residual
assessing brain function. physical disability and emotional deficit.
● To transport a patient with head injury, it should be on a ● Deficient knowledge about brain injury, recovery and
board with head and neck support aligned with the axis of rehabilitation process.
the body. A cervical collar is placed and maintained until
cervical spine x-rays are done and SCI (Spinal Cord COLLABORATIVE PROBLEMS /
Injury) is documented because most patients with head
injuries are presumed to have cervical spine injury.
POTENTIAL COMPLICATIONS
● Decreased cerebral perfusion
● Treat Increased intracranial pressure ● Cerebral edema and herniation
o Surgery to evacuate blood clots, debridement and ● Impaired oxygenation and ventilation
elevation of depressed skull fractures and suture of ● Impaired fluid, electrolyte and nutritional balance
severe scalp lacerations. ● Risk of post traumatic seizures
o ICP is monitored closely, a drain may be inserted.
Patient is placed in the ICU and management GOAL OF CARE
includes maintaining adequate oxygenation, ● Maintain a patent airway
elevating head of the bed, maintaining normal blood ● Adequate Cerebral Perfusion Pressure ( CPP)
volume. ● Maintain fluid and electrolyte balance
● Supportive management ● Adequate nutritional status
o Ventilator support pain and management ● Prevention of secondary injury
o Seizure prevention ● Maintenance of body temperature within normal limits
o Fluid and electrolyte maintenance ● Maintenance of skin integrity
o Nutritional support ● Improvement of coping
● Prevention of sleep deprivation
CASE: The Patient with Traumatic Brain Injury ● Effective family coping
● Increased knowledge about rehabilitation process
● Absence of complications
ASSESSMENT
● Health History: NURSING INTERVENTIONS
o When did the injury occur?
o What caused the injury? ● Maintaining the airway
● Monitoring neurologic functioN
o What was the direction and force of the blow?
● Promoting adequate nutrition
● Preventing injury
Take NOTE: ● Maintaining body temperature
● History of unconsciousness or amnesia after head injury ● Maintaining skin integrity
indicates significant degree of brain damage ● Improving coping
o Any change in the next several minutes to an hour ● Preventing sleep pattern disturbance
after initial injury can reflect recovery or a ● Supporting family coping
secondary damage. ● Monitoring and managing potential complications
o Determine if there was loss of consciousness, ● Promoting home, community based and transitional care.
duration of the unconscious period and whether the
patient can be aroused. EVALUATION
● Determine the level of consciousness (LOC)
o Glasgow Coma Scale ● Attains or maintenance of effective airway clearance,
ventilation and brain
● Monitor increased intracranial pressure
● oxygenation
● Achieves satisfactory fluid and electrolyte balance
NURSING DIAGNOSES ● Attains adequate nutritional status
● Ineffective airway clearance and impaired gas exchange ● Avoids injury
related to brain injury ● Maintains body temperature within normal limits
● Risk for ineffective cerebral tissue perfusion related to ● Demonstrates intact skin integrity
increased ICP, decreased CPP and possible seizures ● Shows improvement in copin
● Deficient fluid volume related to decreased LOC and ● Demonstrates usual sleep-wake cycle
hormonal dysfunction ● Family demonstrates adaptive family processes
● Imbalanced nutrition less than body requirements related ● Demonstrates absence of complications
to increased metabolic demands, fluid restriction and ● Experiences no post traumatic seizures
inadequate intake

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 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
● Participates in the rehabilitation process as indicated for
patient and family members ● Respiratory Problems
o Respiratory dysfunction is related to the level of
SPINAL CORD INJURY injury
● It is an injury to the spinal cord, vertebral column, o The muscles contributing to respiration are the
supporting soft tissue, or intervertebral discs caused by diaphragm (C4), intercostal (T1-T6), Abdominal
TRAUMA. (T6-T12)
● Predominant risks to younger population, male, alcohol o Injuries at C4 and above will result paralysis of the
and drug use. diaphragm (will require ventilator support, acute
● Major causes of death are pneumonia, pulmonary respiratory failure is the leading cause of death in
embolism, and sepsis high cervical cord damage)
● Paraplegia (lower body paralysis) and Tetraplegia ( upper
and lower limb paralysis) are common injuries EFFECTS OF SPINAL CORD INJURY
PATHOPHYSIOLOGY ● Central Cord Syndrome

Characteristics:
o Sensory / motor deficits in
upper extremities
o Bowel and bladder dysfunction
(cause: injury or edema of the
central cord
o Hyperextension injuries

● Anterior Cord Syndrome

CLINICAL MANIFESTATIONS
Spinal Injuries can either be Complete or Incomplete, the Characteristics:
injuries are classified according to the area of spinal cord o Loss of pain, temperature and
damage: central, lateral, anterior or peripheral motor function below the level
of lesion: light touch, position
● Complete Spinal Cord Lesion and vibration sensation remains
o Paraplegia and Tetraplegia; due to loss of sensory intact.
and voluntary motor communication from brain to o Caused by acute disc herniation
the periphery to hyperflexion injuries
associated with fracture or
● Incomplete Spinal Cord Lesion dislocation of vertebra.
o Sensory and motor fibers are preserved below the
lesion, spinal cord can still relay messages to the ● Lateral Cord Syndrome
brain (Brown-Sequard Syndrome)

The ASIA (American Spinal Injury Association) provides Characteristics:

classification of SCI according to the degree of sensory and o Ipsilateral paralysis or paresis(weakness) is noted
motor function present (refer to attached ASIA worksheet). together with ipsilateral loss of touch, pressure and
vibration and contralateral loss of pain and
ASIA describes a person’s functional impairment as a result of temperature
SCI. This scale indicates how much sensation a person feels o Caused by a transverse hemisection of the cord;
after light touch and a pin prick at multiple points on the body results from knife or missile injury,
and tests key motions on both sides of the body. fracture/dislocation of the unilateral articular
process, or a ruptured disc
ASSESSMENT
● Neurologic Level ASSESSMENT AND DIAGNOSTIC FINDINGS
o This refers to the lowest level at which sensory and ● Neurologic Exams
motor functions are normal. ● X-ray of the lateral cervical spine
● CT Scan
Signs and Symptoms: ● MRI - is ordered when ligamentous injury is suspected.
o Total sensory and motor paralysis below the o If MRI is contraindicated, MYELOGRAM is done
neurologic level o ECG monitoring if SCI is suspected. ECG will
o Loss of bladder and bowel control reveal bradycardia and asystole ( cardiac
o Loss of sweating and vasomotor tone below the standstill). They are common in patients with acute
neurologic level spinal cord injuries
o Marked reduction of BP from loss of peripheral
vascular resistance EMERGENCY MANAGEMENT
o If conscious, patient reports acute pain in back or ● All victims of motorcycle crash vehicles, diving or contact
neck; may speak of fear that the neck or back is sports, injury, a fall, or any direct trauma to the head and
broken. neck must be considered to have SCI until it is ruled out.
Initial care must be provided and includes rapid

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 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
assessment, immobilization, extrication and stabilization or ● Impaired bed and physical mobility related to motor and
control of life threatening injuries and transportation to the sensory impairments
most appropriate facility. ● Risk for injury related to motor and sensory impairments
● Risk for impaired skin integrity related to immobility and
MEDICAL MANAGEMENT sensory loss
● Acute Phase ● Impaired urinary elimination related to inability to void
spontaneously
Goals: ● Constipation related to presence of atonic bowel as a
● To prevent secondary injury result of autonomic disruption
● To observe for symptoms of progressive neurologic ● Acute pain related to treatment and prolonged immobility
deficits ● Autonomic dysreflexia related to uninhibited sympathetic
● To prevent complications response of the nervous system following SCI
● Complications: VTE ; Orthostatic hypotension
The patient is resuscitated as necessary and oxygenation and
cardiovascular stability is maintained. PLANNING AND GOAL SETTING
● To improve breathing pattern and airway clearance
● Pharmacologic Therapy: includes administration of high ● Improved mobility
dose corticosteroids in the 1st 24 hours. ● Prevention of injury due to sensory impairment
● Respiratory Therapy : Oxygen is given to maintain a high ● Maintenance of skin integrity
partial pressure of arterial oxygen (PaO2) ; to prevent ● Relief of urinary retention
hypoxemia ( creates or worsens neurologic deficits of the ● Improved bowel function
spinal cord) ● Decreasing pain
● If endotracheal intubation is necessary, extreme care is ● Early recognition of autonomic dysreflexia
important to observe to avoid flexing or extending the ● Absence of complications
patient’s neck resulting a cervical injury
● Diaphragmatic Pacing ( electrical stimulation of the NURSING INTERVENTIONS
phrenic nerve) attempts to stimulate the diaphragm to help ● Promoting adequate breathing and airway clearance
patients breathe. ● Improving mobility
● Skeletal Fracture Reduction and Traction: Use of ● Preventing injury due to sensory and perceptual
Skeletal traction and head tongs (Halo Traction) alterations
● Maintaining skin integrity
SURGICAL MANAGEMENT ● Maintaining urinary elimination
● To preserve neurologic function by removing pressure ● Improving bowel function
from the spinal cord and providing stability. ● Providing comfort measures: the patient in traction, Tongs
● It is indicated when in the following situations: or Halo vest
o Compression of the cord is evident ● Recognizing Autonomic dysreflexia
o The injury results in a fragmented or unstable ● Monitoring and managing potential complications
vertebral body ● Promoting home, community and transitional care
o Injury involves a wound that penetrates the cord
o Body fragments are in the spinal canal EVALUATION
o The patient’s neurologic status is deteriorating ● Demonstrate improvement in gas exchange and clearance
of secretions as evidenced by normal breath sounds on
COMPLICATIONS auscultation
● Spinal and Neurogenic Shock ● Moves within limits of the dysfunction and demonstrates
● Venous Thromboembolism completion of exercises within functional limitations
● Respiratory Failure and Pneumonia ● Avoids injury due to sensory, motor and perceptual
● Autonomic dysreflexia alterations
● Pressure ulcers ● Demonstrates optimal skin integrity
● Infections ● Regains urinary bladder function
● Reports absence of pain and discomfort
THE PATIENT WITH SPINAL CORD INJURY ● Recognizes manifestations of autonomic dysreflexia if they
occur
● Is free from complications
ASSESSMENT
● Assess breathing pattern THE PATIENT WITH TETRAPLEGIA OR PARAPLEGIA
● Assess for Cough
● Monitor changes in motor and sensory functions ASSESSMENT
● Assess for spinal shock
● Assess for signs of urinary retention and bladder ● Assessment focuses on the patient’s general condition,
distention complications and how the patient is managing at that
● Temperature monitoring is needed particular point in time.
● A head-to-Toe assessment and review of systems should
be a part of the data base.
NURSING DIAGNOSIS
o Thorough inspection of the skin integrity
● Ineffective breathing pattern related to weakness or o Establish bowel and urinary pattern
paralysis of the diaphragm, abdominal and intercostal
● Responses and behavior of family towards the condition of
spaces
the patient
● Ineffective airway clearance related to muscle weakness
and inability to clear secretions

BONOT, CAMILLE FRANCE S., BUENAAGUA, MIKHAELA | 4A - BSN USI 18

 CARE OF THE CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION

NURSING DIAGNOSIS
● Impaired bed and physical mobility related to loss of motor
function
● Risk for disuse syndrome
● Risk for impaired skin integrity related to permanent
sensory loss and immobility
● Impaired urinary elimination related to level of injury
● Constipation related to effects of spinal cord disruption
● Sexual dysfunction related to neurologic dysfunction
● Ineffective coping related to impact of disability on daily
living
● Deficient knowledge about requirements for long-term
management

PLANNING AND GOALS

● Attain forms of mobility
● Maintain healthy, intact skin
● Achievement of bladder management without infection
● Achievement of bowel control
● Achievement of sexual expression
● Strengthening coping mechanisms
● Knowledge of long term management
● Prevention of complications

NURSING INTERVENTIONS
● Increasing mobility thru exercise programs and
mobilization
● Prevent disuse syndrome
● Promote skin integrity
● Improve bladder management
● Establish bowel control
● Counseling on sexual expression
● Enhancing coping mechanisms
● Monitoring and managing potential complications:
Spasticity, infection and sepsis
● Promote home, community and transitional care

EVALUATION
● Attains maximum form of mobility
● Contractures do not develop
● Maintains healthy and intact skin
● Achieve bladder control, absence of UTI
● Achieves bowel control
● Reports sexual satisfaction
● Shows improvement adaptation to environment
● Exhibits reduction in spasticity
● Describes long term management required
● Exhibits absence of complications

REFERENCES

Notes from the discussion by: Mrs.San Andres

Universidad de Sta. Isabel powerpoint presentation:

BONOT, CAMILLE FRANCE S., BUENAAGUA, MIKHAELA | 4A - BSN USI 19