Nursing Key Conditions & Interventions: Cardiac, Respiratory, Neurological

Mèniére's Disease

Expected finding: Vertigo - severe dizziness, nausea, vomiting.

Hypovolemic Shock from Blood Loss

Tachycardia, tachypnea, oliguria, orthostatic hypotension → indicates 20-40% blood loss (~24%). Less than 20% loss = anxiety/restlessness.

Obstructive Shock

Cause: Blockage of blood flow. Example: Cardiac tamponade.

AAA Risk Factors

Risk factors: Family history of aneurysm, smoking cigarettes.

Pulsus Paradoxus

Definition: ↓ Systolic BP > 10 mmHg during inspiration. Seen in pericardial effusion.

Impending Cardiac Arrest

Key sign: signs of shock, profound fatigue.

Distributive Shock

Cause: Systemic vasodilation → ↓ SVR → ↓ blood to vital organs.

Inner Ear Fluids

Protective fluid: Endolymph (also perilymph).

AMD Risk Factor

Light blue eyes → ↑ risk.

Retinal Detachment

Assessment signs: includes Bright flashes, floaters after trauma.

Prostate Cancer Manifestations

Blood in urine/semen.

Colorectal Cancer Surgery Post-Op Concerns

Absent bowel sounds → possible obstruction.

Shock Definition

Hypovolemic shock - occurs with 25-30% volume loss.

SIRS

Cause: Deregulated cytokine storm → ↑ inflammation. Main organ at risk: Liver.

Valve Replacement

Most common: Aortic, mitral valves.

Anaphylaxis Care Priorities

First: Prepare crash cart for intubation (airway priority). Then give epinephrine.

Bacterial Meningitis Lumbar Puncture Delay

One Reason: Elevated ICP → risk of herniation.

Skin Infection Culture Rationale

Best answer: To determine if infection is bacterial and which antibiotic to use.

Isolation Patients Care

Mask - prevents droplet transmission.

SLE (lupus) Signs

Signs: Butterfly rash, fatigue, hair loss, memory issues.

Opportunistic Infections Risks

Highest: Client with HIV (low CD4 count).

Hydroxychloroquine Risk

Potential complication: Eye problems (retinal damage).

Anaphylaxis Mortality Risk

Risk factor: Taking beta blockers → reduces epinephrine effect.

Peritoneal Dialysis Peritonitis Risk

Ulcerative colitis increases risk.

Vaccine Immunity

Produces antibodies.

Coup

Primary injury at impact.

Contrecoup

Opposite side injury.

Worsening signs of Increased ICP

↓ GCS, pupil changes, optic nerve swelling.

Care for Increased ICP

HOB 30-45°, neck midline, correct ventriculostomy level, sedation as needed, limit suctioning.

Severe TBI Assessment

Assess posturing, Cushing's Triad, cough reflex, ability to follow commands.

Cushing's Triad

Widened pulse pressure, bradycardia, shallow breathing, apnea.

Fall risk medications

BP meds, antipsychotics, sedatives, antidepressants.

Common TBI causes

Sports injuries, violence, falls.

Maintain SBP for Subarachnoid Hemorrhage

Maintain SBP < 160 mmHg.

ICP medication

Mannitol.

Potential Unfavorable Outcome of Hyperoxia

Hyperoxia (excessive oxygen) can worsen outcomes in brain injury due to increased oxidative stress.

Safe findings for Hemoglobin

Hemoglobin 16 g/dL - Within normal range: Female: 12-16 g/dL, Male: 14-18 g/dL.

Safe findings for Platelets

Platelets 250,000/mm³ - Normal range: 150,000-400,000/mm³.

Safe findings for Glasgow Coma Scale (GCS)

GCS 16 - Indicates normal neuro function; not an unfavorable outcome.

Possible Treatment for Brain Herniation

Hyperventilation.

How Hyperventilation helps

Lowers PCO₂ → causes cerebral vasoconstriction → decreases ICP.

Avoid lowering room temperature excessively

Temperature fluctuations ↑ ICP.

Avoid lowering blood pressure too much

↓ cerebral perfusion → ischemia.

Avoid decreasing sedation unnecessarily

Sedation reduces agitation & ICP.

Signs of Cushing's Triad

Widened pulse pressure, bradycardia, irregular breathing.

Purpose of Cushing's Triad

Compensatory mechanism to maintain brain perfusion and prevent brainstem ischemia.

Purpose of CT Angiography

Detects vasospasm by showing decreased blood flow in cerebral arteries (uses contrast dye).

First Action after Traumatic Fall

Prepare for STAT non-contrast head CT.

Why prepare for non-contrast head CT

Identifies acute bleeding, hematomas, contusions, and fractures—critical for immediate intervention.

Key Priority Frameworks

ABCs & Neuro: Always assess and stabilize airway, breathing, and circulation before diagnostics.

ICP Management Principles

Avoid hyperoxia & hypercapnia, maintain adequate cerebral perfusion, control temperature, minimize stimulation and agitation.

Mild TBI Manifestations

Headache, confusion.

Moderate/Severe TBI Manifestations

Seizures, extremity weakness, loss of vision, depression, persistent headache, aggression.

Risk-Increasing Activities for CTE

Football, military service, physical abuse.

Not Associated Activities for CTE

Basketball, office work, swimming, golfing.

Cerebral Perfusion Regulation

Maintained via constriction/dilation of cerebral blood vessels (autoregulation)

Penetrating Brain Injuries

Damage depends on size, route, and speed of penetrating object

Coup/contrecoup injuries

Occur with closed head injuries

Subarachnoid Hemorrhage (SAH) Risk Factors

Marfan's syndrome, hypertension, smoking, alcohol use disorder

Subarachnoid Hemorrhage High Mortality Risk

Rebleeding

TBI Risk Factors

Falls are a leading cause

Basilar Skull Fracture Sign

Battle's sign (bruising over mastoid process)

Atrial Fibrillation

Irregular rhythm, no identifiable P waves, cannot measure PR interval

Normal Sinus Rhythm

Regular rhythm, normal PQRST sequence

Coronary Artery Disease Pathophysiology

Plaque buildup → narrowed arteries → decreased O₂ & nutrient delivery → angina/MI

Pericarditis Risk Factor

Recent viral illness

Pericarditis Medications

Colchicine + NSAIDs for inflammation and pain

Pericarditis Labs

↑ ESR, ↑ CRP, ↑ troponin I

Peripheral Vascular Disease Interventions

Leg elevation, compression stockings, calf pump exercises, ambulation

Pericardial Effusion with Hypotension Procedure

Anticipated Procedure: Pericardiocentesis

Cardiac Resynchronization Therapy (CRT)

For ventricular dyssynchrony

Synchronized Cardioversion

For symptomatic atrial fibrillation

Asthma Bronchospasm Causes

Inflammation, edema, excess mucus → narrowed airways

Open Pneumothorax

Air moves in/out of chest wound; "sucking" sound

Tension Pneumothorax

Air trapped, pressure increases → ↓ venous return

COPD Risks

Pneumonia, weight loss, muscle dysfunction, poor nutrition

Obstructive Sleep Apnea Signs

Loud snoring, breathing cessation ≥10 seconds, snort awakening, daytime sleepiness, chronic fatigue

Pulmonary Edema Manifestations

SOB, tachypnea, hypoxia, agitation, excessive sweating, JVD, cyanosis, pedal edema in chronic HF

ARDS Hallmark

Decreased lung compliance due to stiffness of poorly aerated lungs

VQ Mismatch Example

Congestive heart failure

Battle's Sign Alert

Possible basilar skull fracture

Hypotension + Muffled Heart Sounds Alert

Anticipate pericardiocentesis

Irregular ECG Alert

Think atrial fibrillation

Loud Snoring + Daytime Sleepiness Alert

Suspect obstructive sleep apnea

Fall History Alert

Possible TBI risk

Ischemic Stroke Medication

Alteplase (tPA) dissolves clots → administer within 3 hrs of symptom onset

tPA Contraindications

Active bleeding, recent surgery, hemorrhagic stroke

tPA Complication

Intracranial bleeding → stop infusion, report immediately

Priority Neuro Assessment

LOC (earliest sign of deterioration)

Signs of ↑ICP

Headache, ↓LOC, vomiting, pupil changes, widened pulse pressure

Post-head injury orders

Elevate HOB 30°, keep head midline, avoid coughing/straining, seizure precautions.

Absence seizure

Brief blank stare, eyelid fluttering, no postictal confusion.

Generalized tonic-clonic seizure

LOC, stiffening (tonic), jerking (clonic), postictal confusion.

Seizure precautions

Pad bed rails, suction ready, O₂ ready, bed low, call light within reach.

During seizure

Turn to side, loosen clothing, don't restrain, don't put objects in mouth.

Post-seizure

Reorient, assess injury, document onset/duration.

Neurogenic shock

Hypotension, bradycardia, warm/dry skin → loss of sympathetic tone.

Autonomic dysreflexia

Severe HTN, bradycardia, flushing/sweating above injury → check bladder/bowel first.

Halo device care

Pin site cleaning, wrench at bedside, no pulling/pressure on device.

Ventilator high-pressure alarm

Caused by secretions, biting tube, coughing, kinks.