ORAL VIVA ACUTE NURSING

Respiratory distress

Inflammation/fluid accumulating in the alveoli, impairing gas exchange, leading to hypoxemia.

Pathophysiology of Respiratory Distress

Inflammation within the alveoli, impairing gas exchange and reducing oxygen delivery to tissues.

Nursing Intervention for Respiratory Distress

Administer oxygen as per protocol (2-4L NP).

Opioid Overdose

Suppresses the respiratory center in the brainstem causing respiratory depression and hypoventilation.

Pathophysiology of Opioid Overdose

Fentanyl suppresses the respiratory center within the brainstem, causing respiratory depression and reducing oxygenation.

Nursing Intervention for Opioid Overdose

Administer oxygen and cease PCA.

Sepsis

Inflammatory response leading to vasodilation and capillary leak, resulting in hypotension, poor tissue perfusion, and organ dysfunction.

Pathophysiology of Sepsis

Sepsis causes systemic vasodilation and capillary leak, leading to poor tissue perfusion and organ dysfunction.

Nursing Intervention for Sepsis

Initiate the sepsis pathway which includes oxygen therapy.

Acute Coronary Syndrome (Chest Pain)

Coronary artery occlusion reduces blood flow to the myocardium, leading to myocardial ischemia and reduced cardiac output.

Pathophysiology of Acute Coronary Syndrome

Coronary artery occlusion reduces blood flow to the myocardium, causing myocardial ischemia and impaired cardiac output.

Nursing Intervention for Acute Coronary Syndrome

Semi-Fowler position and prepare for ECG.

Stroke

Reduced cerebral blood flow deprives brain tissue of oxygen and glucose, causing neurological deficits.

Pathophysiology of Stroke

Reduced cerebral blood flow causing neurological dysfunction.

Nursing Intervention for Stroke

Elevate head at 30 degrees in semi-Fowler and perform neuro observations.

Brain Bleed/Head Trauma

Increase in intracranial pressure, reducing cerebral perfusion.

Pathophysiology of Brain Bleed

Intracranial bleeding increases intracranial pressure, reducing cerebral perfusion.

Nursing Intervention for Brain Bleed

Elevate head to 30 degrees in semi-Fowler and prepare patient for CT.

Evaluation Criteria for Respiratory Distress

SPO2 improves, decreased RR, patient reports easier breathing.

Evaluation Criteria for Opioid Overdose

RR increases to normal rate (12-20).

Evaluation Criteria for Sepsis

Vital improvement (BP, HR), confusion resolves, urine output improves, improved perfusion.

Evaluation Criteria for Acute Coronary Syndrome

Chest pain improves, BP and HR stabilize.

Evaluation Criteria for Stroke

Neurological status improves or remains stable with no worsening of numbness and weakness.

Evaluation Criteria for Brain Bleed/Head Trauma

GCS stabilizes/improves, no further neurological changes.