Adult Complex: Exam 2

Indications: mechanical ventilation

• Acute respiratory failure

• Apnea

• Inability to breathe/protect the airway

• Severe hypoxemia and/or hypercarbia

• Respiratory muscle fatigue

• Hemorrhage

• Trauma

• Neuromuscular problems

• Drug overdose

• Burns

• Shock

Invasive v. noninvasive ventilation

• Invasive

  • Process by which a ventilator is used to deliver oxygen to the lungs; is a means of supporting patients until they recover the ability to breathe independently

  • Can serve as a bridge to long-term ventilation or until a decision is made to stop ventilatory support

  • Is not a curative process

• Noninvasive

  • Uses a mask instead of an endotracheal tube to help oxygen + ventilate patients

  • Is ideal for those who need a higher level of ventilatory support, but their condition isn’t bad enough to warrant mechanical ventilation

  • Types

    • CPAP

    • BiPAP

Nursing care: mechanical ventilation

• Maintain correct tube placement

  • Continuously monitor intubated patients for proper tube placement

  • Note exit point from mouth/nare

  • Assess integrity of tape/securement device

  • Observe for symmetric chest wall movement

  • Auscultate to confirm bilateral breath sounds

  • If tubes move/become dislodged, they can migrate upwards in the pharynx or enter the R/L mainstem bronchus (ventilating one lung)

    • Airway emergency

    • Stay with patient + try to maintain airway

    • Support ventilation with a BVM + 100% oxygen

    • Call for help to assess/reposition tube

• Maintain proper cuff inflation

  • Maintain cuff pressure at 20-30 cm H₂O to ensure adequate tracheal perfusion

  • Measure + record cuff pressure after intubation + on a routine basis (q8h) with minimally occluding volume technique

    • Place a stethoscope over the trachea + inflate the cuff by adding air until no air at PIP (end of ventilator inspiration)

    • For spontaneously breathing patients, inflate until no sound is heard after a deep breath or after inhalation with a BVM

  • Use a manometer to confirm cuff pressure is between 20-30 cm H₂O

  • Document cuff pressure

  • If adequate pressure can’t be maintained or larger volumes of air are needed to maintain inflation, a leak or tracheal dilation at the cuff site may be present

    • Notify providers in such cases

• Maintain tube patency

  • Suctioning indications

    • Visible secretions in endotracheal tube

    • Increase in respiratory rate/frequent coughing

    • Sudden decrease in O₂ sats

    • Suspected secretion aspiration

    • Increased peak airway pressure

    • Auscultating adventitious breath sounds over the trachea/bronchi

  • Assess need for suctioning hourly

    • Visible coughing

    • Coarse crackles/wheezes over large airways

    • Moist cough

    • Increase in PIP

    • Restlessness/agitation

  • Neuro patients may not show any signs of the need for suctioning; suctioning every shift is recommended

  • Do not suction routinely

  • Note color, character, consistency, and amount of sputum suctioned

  • Closely assess patients before, during, and after suctioning

    • If patients don’t tolerate suctioning, stop immediately; continue reassessments until patients hemodynamically stabilize, recover and/or situations resolve before retrying

  • Maintain adequate hydration when indicated

  • Provide supplemental humidification of inspired gases through the ventilator to help thin secretions

  • Turning q2 + early ambulation helps move secretions into larger airways

• Maintain alarm systems

  • Ensure all ventilator alarms are always on

  • High pressure alarms

    • Increased airway secretions

    • Wheezing/bronchospasm

    • Endotracheal tube is displaced

    • Ventilator tube is obstructed from water or kink in the tubing

    • Patient coughs, gags, or bites on oral endotracheal tube

    • Patient is anxious or fights the ventilator

  • Low pressure alarms

    • Disconnection or leak in ventilator or in patient’s airway cuff

    • Patient stops spontaneous breathing

• Oral care

  • Moisten lips, tongue, and gums with saline/water swabs to prevent drying

  • Using chlorhexidine at least 3 times/day can help decrease oral contamination and ventilator-associated pneumonia

• Skin integrity

  • Reposition + replace endotracheal tubes per agency policy to prevent skin breakdown

    • Two staff members should always perform repositioning to maintain correct positioning + prevent accidental dislodgement

    • Monitor patients for any signs of respiratory distress during procedure

    • For orally intubated patients, remove bite block + old tape, provide oral care, and reposition tube to opposite side of the mouth; replace bite block, reconfirm cuff inflation + tube placement, and resecure tube per policy

Complications: mechanical ventilation

• Adverse hemodynamic effects (hypotension)

  • Increased intrathoracic pressure compresses thoracic vessels

  • Compression decreases venous return to the heart, preload, SBP, MAP, and cardiac output

• Ventilator-assisted pneumonia

  • Pneumonia that occurs 48+ hours after intubation

  • Risk factors

    • Contaminated respiratory equipment

    • Inadequate hand hygiene

    • Adverse environment

    • Decreased patient ability to cough + clear secretions

    • Poor nutrition

    • Immobility

    • Underlying disease processes

  • Manifestations

    • Fever

    • High WBC counts

    • Change in color and/or amount of sputum

    • Crackles/wheezes on auscultation

    • New lung infiltrates on chest x-ray

  • Prevention guidelines

    • Minimizing sedation, including daily spontaneous awakening + breathing trials

    • Early ambulation + frequent turning (q2h)

    • Use of endotracheal tubes with subglottic secretion drainage ports

    • Elevating head of bed a minimum of 30-45 degrees unless contraindicated

    • Oral care with chlorhexidine

    • No routine changes of ventilator circuit tubing

    • Hand hygiene before + after suctioning whenever ventilator equipment is touched

    • After contact with any respiratory secretions

    • Always wear gloves when in contact with patient + change gloves between activities

• Aspiration

  • Suction patient’s mouths often via Yankauer or sterile single-use catheter

  • Risk factors

    • Improper cuff inflation

    • Patient positioning

    • Decreased gastric mobility + bowel function, if patient is getting enteral nutrition

  • Even when cuffs are properly inflated, take precautions to prevent vomiting

  • Unless contraindicated, keep head of the bed elevated at least 30 degrees for all intubated patients getting enteral nutrition

• Barotrauma

  • Results when increased airway pressure distends the lungs + possibly ruptures fragile alveoli/blebs

  • Risk increases as lung inflation pressures increases

  • Patients with noncompliant lungs are at greatest risk (patients with acute respiratory distress syndrome)

  • Increasing inflation pressure places patient at risk for pneumothorax, which can quickly develop to a tension pneumothorax

• Volutrauma

  • Can occur if too large a volume of air (tidal volume) is used to ventilate noncompliant lungs

  • Causes alveolar rupture + movement of fluids and protein into alveolar spaces

  • Minimized by using low-volume ventilation in patients with stiff, noncompliant lungs

Nursing care: noninvasive ventilation

• Assess LOC, hemodynamic stability, and work of breathing

  • Patients with a decreased LOC can’t protect their airway or clear secretions; intubation + mechanical ventilation may be needed

  • Any degree of hemodynamic instability warrants immediate reevaluation of noninvasive ventilation

• Provide mouth, nare, and eye care

• Provide measures to protect the skin from breakdown/ulceration

  • Any degree of redness = S1 pressure injury

  • Attempts of alleviate pressure for tight-fitting masks (alternative length of time the mask is on) is essential

  • Using masks of different sizes can help; consult RTs for additional info

• Patients must be able to remove masks independently due to vomiting risk; elevate heads of bed 30-45 degrees

Clinical manifestations: asthma exacerbation

• Wheezing

  • Unreliable sign to gauge attack severity; doesn’t always occur

• Cough

  • Can sometimes be the only symptom (cough variant asthma)

  • Can be productive/nonproductive

• Dyspnea

  • Accessory muscle use

  • Tripoding

• Tachypnea

• Anxiety

• Agitation

• Chest tightness

• Prolonged expiration

• Peak expiratory flow rate <50% PB

• Patient report of usual treatments failing

• Decreased/absent breath sounds

  • Silent chest (severely decreased breath sounds; ominous), indicative of severe airway obstruction + impeding acute respiratory failure

Interprofessional care: asthma exacerbation

• Drug therapy

  • Corticosteroids

    • First line agents to treat acute asthma attacks + first step in acute asthma management

    • Reduce bronchial hyperresponsiveness, block late-phase asthma response, and inhibit the migration of inflammatory cells

    • Side effects

      • Easy bruising

      • Decreased bone mineral density

      • Oropharyngeal candidiasis

      • Hoarseness

      • Dry cough

    • Side effects are managed with metered dose inhalers and by gargling with water or mouthwash after each use

  • Beta agonists

    • Can be short or long acting

      • Short acting can help with acute bronchospasms, but are not first-line therapies

      • Short acting shouldn’t be used along for recurrent, repeated asthma attacks or for long-term control

      • Long acting shouldn’t be used alone as primary treatment; they can be used as treatment adjuncts

      • Long acting should be used only if patients don’t respond to medium dose inhaled corticosteroids

      • Teach patients that long acting drugs shouldn’t be used to treat acute symptoms or to obtain quick relief from bronchospasm

      • Tell patients that long acting drugs are used once every 12 hours

    • Too frequent use indicates poor asthma control, can mask severity of condition, and lead to reduced drug effectiveness

Nursing care: asthma exacerbation

• In severe attacks, continually monitor vitals and work of breathing

  • Patients can be tachycardic/pneic and solely focus on breathing

  • Respirations can be >30 rpm, and accessory muscles can be in use

  • Patients can be agitated, restless, or confused from hypoxemia

  • Patients often sit forward to maximize diaphragmatic movement

• Serial peak expiratory flow rates, oximetry, and ABGs give info about the severity of attacks and the response to therapy

• Oxygen therapy is given to achieve a PaO2 of at least 60 mmHg or O2 sats >90%

  • Should be continuous + pulse ox

• If patients can swallow, oral corticosteroids will be part of the treatment plan; if not, IV steroid are given

• Auscultate lung sounds; wheezing may be heard, being louder in airways that are responding to therapy as airflow increases

• If silent chest is observed, notify provider; acute respiratory failure is imminent

Clinical manifestations: status asthmaticus

• Hypoxia

• Hypercapnia

• Acute respiratory failure

• Chest tightness

• Severely marked increase of shortness of breath

• Inability to speak

• Hypotension

• Bradycardia

• Cardiac arrest

Interprofessional care: status asthmaticus

• Treated with IV magnesium sulfate

  • Admin shouldn’t delay the need for intubation

• Immediate mechanical venilation + hemodynamic monitoring is essential

  • Continuous analgesic infusions + sedation with drugs help decrease work of breathing and promote synchrony with ventilators

  • Neuromuscular blockers can be used

  • Inhaled anesthetics can be used for those not responding to conventional treatment

Etiology + patho: acute respiratory failure

• Hypoxemic (oxygenation failure)

  • Arterial oxygen <60 mmHg on room air + at sea level with normal/slightly subnormal CO₂ levels

    • Low arterial oxygen can exist despite supplemental oxygen

  • The main issue is the inadequate exchange of oxygen between the alveoli + pulmonary capillaries

  • Physiologic mechanisms

    • V/Q mismatch

      • Not 1:1 = mismatch

      • Causes

        • Increased secretions in the airways/alveoli

        • Bronchospasms

        • Pain

        • Atelectasis

        • Pulmonary emboli

      • Treated by treating underlying cause

        • Oxygen therapy is a first step to reverse hypoxemia

        • Frequent ABG analysis, pulse oximetry, respiratory rate + rhythm, and response to oxygen therapy are important

    • Shunt

      • Extreme V/Q mismatch

      • Occurs when blood exits the heart without having its gas exchanged

      • Oxygen therapy may not be effective

    • Diffusion impairment

      • Occurs when gas exchange across the alveolar-capillary membrane is compromised by a process that damages/destroys the alveolar membrane or affects blood flow through the pulmonary capillaries

      • Caused by conditions that thicken the alveolar-capillary membrane (fibrotic) slow gas transport

        • Ex: pulmonary fibrosis, interstitial lung disease, and ARDS

      • Classic sign is hypoxemia that worsens with exercise but not at rest

    • Alveolar hypoventilation

      • Decrease in ventilation that increases arterial CO2

      • Common causes

        • CNS problems

        • Chest wall dysfunction

        • Acute asthma

        • Restrictive lung disease

      • Mainly a mechanism of hypercapnic respiratory failure, but contributes to hypoxemia

• Hypercapnic (ventilatory failure)

  • Arterial CO₂ >50 mmHg, which can be accompanies by hypoxemia and/or acidemia (blood pH <7.35)

  • Main issue is insufficient CO₂ removal

  • Causes

    • CNS problems

      • Overdoses of respiratory depressing meds

      • Brainstem infarction

        • Can interfere with the medullary respiratory center; medulla fails to sense changes in arterial oxygen → no increase in respiratory rate occurs

      • TBIs

        • When occurring with a decreased LOC, patient ability to protect airway, breathe, or manage secretions is hindered

    • Neuromuscular problems

      • Diseases that cause muscle weakness/paralysis lead to patient inability to clear CO2 and maintain arterial oxygen levels

      • Toxin exposure can interfere with the nerve supply to muscles + lung ventilation

      • Respiratory muscle weakness can occur from muscle wasting during critical illness or peripheral nerve damage

    • Chest wall abnormalities

      • With severe obesity, the weight of the chest + abdominal contents limit lung expansion

      • In patients with flail chest, fractures prevent the ribs from expanding normally

      • With kyphosis, changes in spinal configuration compresses the lungs + prevents normal chest wall expansion

    • Problems with airways/alveoli

      • Patients with COPD, asthma, and cystic fibrosis are at higher risk because of the underlying patho of such conditions results in airflow obstruction + air trapping

      • Respiratory muscle fatigue + ventilatory failure occur from added work of breathing needed to inspire against increased airway resistance + air trapped in alveoli

Clinical manifestations: hypoxemic acute respiratory failure

• Specific

  • Accessory muscle use

  • Dyspnea (early)

    • Observing patient position helps assess the effort associated with work of breathing

    • Patients with mild respiratory distress may be able to lie down, while those in moderate distress may prefer to sit

    • Patients in severe distress may be unable to breathe unless sitting upright

  • Intercostal muscle retraction

  • Nasal flaring

  • Paradoxical chest/abdominal wall movement (late + severe)

  • Prolonged expiration

  • Decreased O2 sats

  • Tachypnea

  • Cyanosis (late)

• Nonspecific

  • BP changes (increased early; decreased late)

  • Dysrhythmias (late)

  • Tachycardia (early)

  • Cool, pale, clammy, diaphoretic skin (early)

  • Altered mental status (agitation, confusion, disorientation, restlessness, combativeness)

    • One of the first to appear; the brain is sensitive to changes in oxygenation + acid-base levels)

  • Decreased LOC

  • Coma (late)

  • Fatigue

  • Inability to talk in complete sentences without stopping to breathe

Clinical manifestations: hypercapnic acute respiratory failure

• Specific

  • Dyspnea

  • Limited chest wall movement

  • Pursed-lip breathing

  • Tripoding

    • Helps decreased work of breathing in patients with moderate to severe COPD and acute respiratory failure

  • Bradypnea or tachypnea with shallow respirations

    • Increased respiratory rates require a substantial amount of work + can lead to muscle fatigue

  • Decreased tidal volume

  • Decreased minute ventilation

• Nonspecific

  • Hypertension

  • Dysrhythmias

  • Tachycardia

  • Altered mental status

  • Morning headache

  • Progressive somnolence

  • Increased intracranial pressure

  • Coma (late)

  • Decreased DTRs

  • Muscle weakness

  • Tremors/seizures (late)

Diagnostic studies: acute respiratory failure

• Chest x-rays, if ID possible causes

• ABGs, to evaluate oxygenation + ventilation and acid-base balance

• Pulse oximetry

• CBC

• Electrolytes

• Urinalysis

• ECG

• Blood + sputum cultures

• CT scan or V/Q lung scan, if pulmonary emboli are suspected

• End-tidal CO₂, for patients in severe respiratory failure who need mechanical ventilation

Interprofessional care: acute respiratory failure

• Drug therapy

  • Reduce airway inflammation + bronchospasm

    • In acute bronchospasm, short-acting bronchodilators can be given at 15-30 minute intervals until a response occurs

      • Give via handheld nebulizers/metered-dose inhalers with spacers

      • Prolonged use can increase risk for dysrhythmias and cardiac ischemia

      • Monitor vitals + ECG for changes

    • Corticosteroids can be used in combo with other meds; it can take several hours to see their effects

      • Inhaled corticosteroids can take 4-5 days for optimal therapeutic effects

      • Monitor potassium levels

      • Prolonged used causes adrenal insufficiency

      • Hyperglycemia is a common side effects

  • Relieve pulmonary congestion

    • Diuretics can be given to decrease pulmonary congestion caused by heart failure

    • Changes in HR + rhythm and significant BP changes are common; give meds cautiously

  • Treat infection

    • IV antibiotics are given for treatment

    • Chest x-rays can show location + extent of infections

    • Sputum cultures can help ID organisms causing the infection and their sensitivity to antibiotics

  • Reduce anxiety, pain, and restlessness

    • For non-intubated patients, anxiety, pain, and restlessness can cause tachypnea and ineffective ventilation

    • For intubated patents, they can cause ventilator dyssynchrony and increase the risk for unplanned extubation

    • Turn + reposition patients frequently

    • Provide reassurance + emotional support to patients + caregivers

    • IV benzos + opioids can help

      • Start at the lowest dose possible

    • Assess for treatable causes of restlessness (hypoxemia, pain, delirium) + manage as needed

    • Restlessness + mental status changes are the first signs of hypoxemia or patient-ventilator dyssynchrony

      • Address underlying causes + avoid only depending on analgesics and sedatives

• Chest physiotherapy

  • Indicated for all patients producing sputum or have severe atelectasis or pulmonary infiltrates on chest x-ray

  • Postural drainage, percussion, and vibration to the affected lung segments help move secretions to the larger airways, for removal via suctioning/coughing

  • Contraindications

    • TBI

    • Increased ICP

    • Unstable orthopedic injuries

    • Recent hemoptysis

Nursing care: acute respiratory failure

• Acute care

  • Primary goal is to ID and treat the underlying cause

  • Monitor patients continuously for therapeutic response, ABG trends, and signs of clinical improvement

• Respiratory therapy

  • Oxygen therapy

    • Main goal is to correct hypoxemia

    • Never withhold oxygen from patients

    • Always administer at the lower possible FIO₂ (oxygen concentration) needed to keep the arterial, pulse, and saturation of oxygen within patient-specific goals

    • Observe patient response to oxygen therapy

    • Closely monitor for mental status changes, respiratory rates, and ABGs

    • Oxygen delivery device choices depend on patient condition, degree of respiratory failure, ability to maintain a patent airway, amount of FIO₂ delivered, and patient ability to breath spontaneously

      • The selected device must help maintain arterial oxygen at >60 mmHg and saturation at >90%

      • Face masks can cause anxiety; if patients try to remove them, explore other device options

    • Risks of prolonged oxygen delivery

      • Oxygen toxicity

        • Exposure to FIO₂ (>60%) for longer than 48 hours

      • Absorption atelectasis

        • Oxygen replaces nitrogen and other gases usually present in alveoli

      • Increased pulmonary capillary permeability

      • Decreased surfactant production

      • Surfactant inactivation

      • Fibrotic changes in the alveoli

  • Mobilize secretions

    • Positioning

      • Position patients upright, with heads of the bed elevates at least 30 degrees, or with a reclining chair/chair bed

      • If there’s a chance for aspiration, position patients in side-lying position

      • Patients with a unilateral lung problem can be placed in a lateral/side-lying position (good lung down)

        • Allows for improved V/Q matching in the affected lung

    • Coughing

      • Augmented coughing can help some patients

        • To help, place 1/both hands at the anterolateral base of the patient’s lungs

        • As deep inspirations end + expirations start, move hands forcefully upward

        • Increases abdominal pressure + helps patient cough

      • Huffing is a series of coughs performed while saying the word “huff”

        • Prevents the glottis from closing, forcing air + mucous out of the airways

        • Patients take a deep breath, hold if for 2-3 seconds, and forcefully exhale

      • Staged coughing

        • With patients sitting, have them breath in/out 3-4 times through the mouth, then cough while bending forward and pressing a pillow inward against the diaphragm

    • Suctioning

      • May be needed if patients are unable to expectorate secretions

      • Perform cautiously, as stimulating the gag reflex can induce vomiting

      • Suctioning through artificial airways are done as needed

    • Humidification

      • Adjunct to secretion management

      • Be aware that aerosol therapy can cause bronchospasm + severe coughing, causing a decrease in arterial oxygen

      • Frequent assessment of patient tolerance to therapy is critical

    • Hydration

      • Unless contraindicated, adequate fluid intake (2-3 L/day) keeps secretions thin + easier to remove

        • May not be possible in patients with respiratory failure

      • Patients who can’t take in enough fluids PO need IV hydration

      • Assess cardiac + renal status to determine if patients can tolerate IV fluid volume and avoid heart failure and pulmonary edema

      • Regularly assess for signs of fluid overload

    • Early ambulation

Etiology + patho: ARDS

• Phases

  • Injury (exudative)

    • Usually occurs 24-72 hours after the initial insult (direct/indirect)

    • Generally lasts 7-10 days

    • Engorgement of peribronchial and perivascular interstitial space → interstitial edema

    • V/Q mismatch and shunt develop because the alveoli fill with fluid

  • Reparative (proliferative)

    • Starts 1-2 weeks after the initial lung injury

  • Fibrotic (fibroproliferative)

    • Can start as early as 24 hours after initial lung injury

    • Not all patients enter the fibrotic stage; those who do have a poorer prognosis

• Causes

  • Direct

    • Aspiration

    • Pneumonia

    • Sepsis

    • Chest trauma

    • Embolism

    • Inhalation of toxic substances

    • Near-drowning

    • O₂ toxicity

    • Radiation pneumonitis

  • Indirect

    • Massive trauma

    • Sepsis/septic shock

    • Severe TBI

    • Shock (hypovolemic, cardiogenic)

    • Acute pancreatitis

    • Cardiopulmonary bypass

    • DIC

    • Opioid overdose

    • Transfusion-related acute lung injury

    • Urosepsis

Clinical manifestations: ARDS

• Initial injury + 24-72 hours after

  • Mild dyspnea

  • Tachypnea

  • Cough

  • Restlessness

  • Lung auscultation can be normal or reveal fine, scattered crackles

• With progression

  • Increased work of breathing → respiratory distress

  • Tachypnea + retractions

  • Tachycardia

  • Diaphorsis

  • Altered mental status

  • Cyanosis

  • Pallor

  • Lung auscultation can reveal scattered/diffuse crackles and course crackles on expiration

Complications: ARDS

• Can develop from the disease itself/its treatment

• Abnormal lung function

  • Most patients will recover within a year, and many will have normal/near-normal lung function, but not this isn’t true for all patients

  • Contributing factors

    • The severity of scarring + changes within the lungs

    • Mechanical ventilation

    • Duration of time ventilated

    • Use of extracorporeal life support

  • Patients may report fatigue, chest pain, shortness of breath after minimal activity, and persistent dyspnea post-ARDS

• Ventilator-associated pneumonia

  • Risk factors

    • Immunocompromised patients

    • Invasive monitoring devices

    • Aspiration

    • Prolonged mechanical ventilation

• Barotrauma

  • Occurs when fragile alveoli are overdistended with excess pressure during mechanical ventilation

  • High peak airway pressures needed to ventilate lungs predispose patients to barotrauma

  • Results in alveolar air escaping from ruptured alveoli

  • Can lead to

    • Pulmonary interstitial emphysema

    • Pneumothorax

    • Subcutaneous emphysema

    • Pneumopericardium

    • Tension pneumothorax

  • Providing ventilation with a smaller tidal volume and varying amounts of PEEP minimizes the risk

• GI ulcers

  • Due to blood diversion from the GI to the respiratory system to help meet oxygen demands

  • Management strategies include correcting predisposing conditions (hypotension, shock, acidosis)

  • Prophylactic management

    • Antiulcer drugs (PPIs)

    • Mucosal-protecting drugs (sucralfate)

  • Early enteral nutrition helps prevent mucosal damage

• VTE

  • Complication of immobility + venous stasis

  • Prophylaxis

    • SCD/TED hoses

    • Anticoagulation

    • Early ambulation

• AKI

  • Can occur from decreased renal perfusion + subsequent decreased oxygen delivery to the kidneys

  • Most often occurs due to hypotension in septic shock

  • Can result from hypoxemia or nephrotoxic drugs used to treat ARDS-related infections

  • Monitor I/O, daily weights, and daily BUN + creatinine levels

  • Patients often receive continuous renal replacement therapy; they’re often hemodynamically unstable and need vasopressors and/or inotropes to maintain HR + BP

    • They can’t tolerate large volumes of fluid that traditional hemodialysis would remove

    • Patients can receive therapy 24 hours/day

• Psychological issues

  • Survivors of ARDS can have anxiety, issues with memory/attention, inability to focus, nightmares, depression, and sometimes, varying degrees of PTSD

Nursing + interprofessional care: ARDS

• Mechanical ventilation

  • Required for patients with moderate/severe ARDS

  • Pressure-control ventilation helps keep inspiratory + plateau pressures form getting too high

  • Prevents alveolar overdistention + rupture

• Drug therapy

  • Antibiotics to treat underlying infection

  • Corticosteroids to decrease inflammatory response

partial-thickness burns

• Superficial (1st degree)

  • Epidermis affected

  • Blanchable erythema

  • Pain

  • Mild swelling

  • Blistering/peeling skin after 24 hrs

• Deep (2nd degree)

  • Epidermis + dermis affected

  • Red, shiny, wet, fluid-filled vesicles

  • Several pain

  • Mild/moderate edema

full-thickness burns

• 3rd/4th degree burns

  • Dry, waxy, white, brown/charred, leathery, hard skin

  • Visible thrombosed vessels

  • Insensitive to pain due to nerve destruction

  • Possible muscle, tendon, and bone involvement

Rule of Nines

Lund-Browder chart

Best used for kids because it considers patient age in proportion to relative body-area size

Patho: emergent burn phase

• Usually lasts 72 hours after initial injury

• Fluid + electrolyte shifts

  • burn shock - Combo of distributive + hypovolemic shock; significant threat to major burn patients

  • Patients vitals will begin to change as third spacing occurs

  • Mass edema + significant wound drainage may be seen

  • Loss of intravascular fluid can cause burn shock

    • Monitor for hypotension, tachycardia, and tachypnea

    • Report changes in vitals to providers

    • AKI + death can develop if not resuscitated sufficiently

  • Hemolysis of RBCs from circulating factors released at the time of injury from burned tissue affects perfusion

    • Monitor for high hematocrits from hemoconcentration from fluid loss

      • Levels will return to normal after burn shock resolves

  • Major electrolyte shifts of sodium + potassium can occur during this phase

    • Potassium shifts develop first when injured cells + hemolyzed RBCs release potassium into circulation (hyperkalemia)

    • Sodium rapidly moves to interstitial spaces (hyponatremia)

  • Ends once capillary membrane permeability is restored after successful fluid resuscitation

• Inflammation + healing

  • Burns cause coagulation necrosis

  • Neutrophils + monocytes accumulate at injury sites

  • Fibroblasts + newly formed collagen fibrils appear + begin wound repaid within the first 6-12 hours after injury

• Immunologic changes

  • Burns challenge immune systems by altering the skin’s barrier to invading organisms

  • Bone marrow depression occurs + circulating levels of immunoglobulins decrease

  • Defects occur in WBC function

  • Inflammatory cytokine cascade impairs the function of lymphocytes, monocytes, and neutrophils → high infection risk

Clinical manifestations: emergent burn phase

• Patients are normally alert + able to answer questions during admission or until intubated, if there’s respiratory compromise

  • Monitor cognition + report changes

• Unconsciousness/altered mental status

  • Causes

    • Hypoxia, from inhalation injury

    • Head trauma

    • Substance use

    • Side effects of sedation/pain meds

• Anxiety

  • Give patients simple explanations of what to expect

• Heat loss

  • Provide warm blankets, increase room temp, or use heat lamps

• Hypovolemia → shock

• Pain

• Blisters

• Paralytic ileus

• Shivering

Complications: emergent burn phase

• Respiratory

  • Types of inhalation injuries

    • Injuries form toxic gas exposure

    • Supraglottic injury from direct heat or chemicals causing severe mucosal edema

    • Subglottic injury from airway inflammation + edema → atelectasis + pneumonia

  • Severity can be mild to severe; rapid initial + ongoing assessment is critical

  • Airway compromise + pulmonary edema can develop within hours of injury

  • Patients may need a fiberoptic bronchoscopy + carboxyhemoglobin blood levels to confirm suspicions

    • Patients exposed to carbon monoxide will have elevate carboxyhemoglobin levels

  • Examine sputum for carbon particles

  • Watch for signs of respiratory distress (increased agitation, anxiety, restlessness, or changes in rate/character of breathing); symptoms may not be present at first

  • Patients with preexisting lung diseases are more likely to develop respiratory infections

• Cardiovascular

  • Deep circumferential burns + subsequent edema formation can impair peripheral perfusion

    • If untreated, ischemia, paresthesia, and necrosis can occur

    • Escharotomies restore circulation to compromised extremities or improve chest expansion

  • Patients are at risk for VTE, especially if other risk factors are present

    • Risk factors

      • Advanced age

      • Obesity

      • Extensive/lower extremity burns

      • Concomitant lower extremity trauma

      • Prolonged immobility

    • It’s recommended for patients to receive low-molecular-weight heparin or low-dose unfractioned heparin, if there are no contraindications

    • Apply SCDs if patients are immobile

• Renal

  • AKI are the most common renal complication

  • If hypovolemia is left untreated, renal ischemia can occur → AKI development

  • Monitor the adequacy of fluid replacement, proper admin can prevent the myoglobin + hemoglobin from blocking renal tubules

Nursing + interprofessional care: emergent burn phase

• Airway management

  • Place patients in high-Fowler’s unless contraindicated (spinal injury)

  • Treatment for inhalation injuries include

    • 100% O₂ via nonrebreather

    • Aerosolized heparin

    • N-acetylcysteine

    • Albuterol

  • Reposition patients q1-2h

  • Suction prn

  • Encourage deep breathing + coughing hourly

  • Monitor ABGs to assess adequacy of gas exchange

  • Keep patients on tele

    • Monitor pulse oximetry + capnography

  • Evaluate patient response to interventions + report adverse reactions/deterioration to providers

  • Generally, patients with significant face/neck burns need intubation within 1-2 hours after injury

    • Early intubation prevents the need for emergency cricothyrotomy

  • Other patients need intubation if symptoms of severe respiratory distress develop

  • Extubation can occur at the end of the emergent phase when airway edema resolves

    • Usually 3-5 days after initial injury

    • Others may be intubated for longer, due to extensive lung damage

• Fluid therapy

  • Insert at least 2 large-bore IVs when burns are >15% TBSA

    • Central lines can be used for burns >20% TBSA

  • Calculate TBSA of burns to calculate initial IV fluid needs

    • Use ABA or Parkland formula to calculate fluid needs for the first 24 hours after injury

    • Formulas provide estimates; titrate based on patient response

  • A-lines are best for measuring MAP + BP; manual BP measurements are often invalid due to edema + vasoconstriction

  • Crystalloids + sometimes colloids (albumin) are used for resuscitation

  • Insert Foleys in patients with >20% TBSA burns

  • Monitor patients for early signs of fluid overload, especially older ones or those with chronic heart, lung, or kidney diseases

  • Assess for the adequacy of fluid resuscitation hourly via urine output + cardiac parameters

    • Output should be 0.5-1 mL/kg/hr for adults; 1-1.5 mL/kg/hr for kids

    • Cardiac parameters

      • MAP >65

      • SBP >90 mmHg

      • HR <120

    • Patients with electrical burns have greater fluid needs to prevent AKI

      • They often need osmotic diuretics to increase urine output + overcome hemoglobinuria or myoglobinuria

      • Higher hourly outputs of 75-100 mL/hr are best

• Wound care

  • On admission to burn units, patients will shower or receive a trolley bath

  • Use mild cleansers + washcloths, and perform cleansing and gentle wound debridement

  • Debridements

    • Surgical

      • Done in ORs

      • Necrotic skin is removed

    • Open

      • Burns are covered with topical antimicrobials + left open toair

      • Usually limited to facial burns

  • When bathing is complete, skin + burns are dried, the total burn percentage is re-estimated

  • Providers will prescribe topical dressings/agents based on burn depth, bacterial count, and cost

  • Dressing changes continue once/twice a day, depending on burn severity + dressing types

  • Check patients for sulfa allergies; many burn antimicrobials contain it

  • Always wear PPE when patient burn wounds are exposed

  • Wear nonsterile disposable gloves when removing contaminated dressings + when washing wounds

  • Facial

    • Keep ears free from pressure due to poor vascularization + infection tendency

      • Do not use pillows for patients with ear burns; cartilage pressure can cause chondritis

        • Ears may stick to the pillowcase → pain + bleeding

      • Raise patient heads with a rolled towel under the shoulder to avoid pressure necrosis

        • Also used for neck burns to hyperextend the neck + prevent contracture

  • Extremities

    • Extend burned hands + arms and raise them on pillows/foam wedges to reduce edema

    • Remove splints often + inspect the skin + bony prominences to avoid areas of pressure from inappropriate/prolonged application

  • Perineum

    • Keep perineum clean + dry after voiding/bowel movements

    • Remove Foleys from fluid resuscitation asap

    • If patients have frequent, loose stools, consider using a fecal diversion device

• Drug therapy

  • Analgesics + sedatives

    • Early in the post-burn period, give IV pain meds

    • Evaluate pain management plans often, as needs can change + tolerances can develop, especially in the acute phase

    • Patient pain level may not directly correlate with the depth + extent of the burn

    • Consider multimodal approaches to pain control

      • Sedative/hypnotics + antidepressants with analgesics help with anxiety, insomnia, and depression

  • Tetanus immunization

    • Patients routinely get tetanus toxoid due to the exposure risk to clostridium tetani

    • Tetanus immunoglobulin would be considered if the patient hasn’t received an active immunization in within 10 years before the burn

• Nutrition therapy

  • Hypermetabolic states proportional to wound size occurs after major burns

    • Resting metabolic expediture can increased 50-100% above normal

    • Core temps increase

    • Catecholamine release → catabolism stimulation

  • When fluid replacements needs are addressed, nutrition takes prioirty

  • Early + aggressive nutritional supports starts in hours of injury

    • Decreases complications + mortality

    • Optimizes wound healing

    • Minimizes negative effects of hypermetabolism + catabolism

Patho: acute burn phase

• Starts with the mobilization of interstitial fluid + subsequent diuresis and continues until wound are nearly healed

  • Ends when partial-thickness wound heal or full-thickness burns are covered by skin grafts

• Can take weeks/months depending on the burn severity + patient response to treatment

• Oxygenation problems can resolve, but inhalation injuries won’t for days/weeks/months

• Vitals are more stable

• Would healing starts as WBCs surround the burn wound + phagocytosis occurs

• Necrotic tissues starts to slough

• Patients become more aware of the enormity of their situation

Clinical manifestations: acute burn phase

• Partial thickness wounds start healing at the wound margins

• Epithelial buds from hair follicles/glands in the dermal bed eventually close the wound

• Healing is spontaneous + usually occurs in 10-21 days

• Patients often have more pain due to repeated dressing changes, therapy exercises, opioid tolerance, fatigue, and reduced coping ability

Complications: acute burn phase

• Infection

  • Normal skin flora will quickly colonize burn wounds

  • Manifestations

    • Hypo/hyperthermia

    • Tachycardia

    • Tachypnea

    • Hypotension

    • Oliguria

    • Elevated WBC count

  • Fungal infections can develop in mucous membranes due to systemic antibiotic therapy + low resistance

    • Give antifungals (nystatin + fluconazole) as ordered

• Neuro

  • Can result from severe hypoxia from respiratory injuries or as a complication from electrical injuries

  • Other causes

    • Electrolyte imbalances

    • Stress

    • Cerebral edema

    • Sepsis

    • Sleep problems

    • Analgesic/antianxiety meds

  • Patients can be disoriented, withdraw, be combative, hallucinate, or have frequent nightmare-like episodes

  • Delirium is more acute at night + occurs more often in older patients

    • Use screening tools to diagnose; start interventions to prevent

  • Orient + reassure patients who are confused/agitated

• Musculoskeletal

  • ROM can be affected by less supple + compliant skin

  • Skin + joint contractures can occur

    • Patients may prefer flexed positions for comfort

    • Have patients stretch + move burned parts as much as possible

  • Consult with PT/OT about proper positioning + splinting to prevent/reduce contractures

• GI

  • Diarrhea can result form enteral nutrition or antibiotic use

  • Constipation can occur from opioid use, decreased mobility, and low-fiber diets

  • Curling ulcers can occur (diffuse superficial lesions, including mucosal erosion)

    • Prevent by feeding patients asap after burns

    • Antacids, histamine receptor blockers, and PPIs are used prophylactically to neutralize stomach acids + inhibit histamine + secretion of hydrochloric acid

    • Patients with major burns can have occult blood in stools + need close monitoring for bleeding

  • Stress response can decrease GI blood flow

• Endocrine

  • Watch for transient increase in glucose levels due to stress-mediated cortisol + catecholamine release

  • Insulin’s effectiveness decreases because of relative insulin insensitivity → high glucose levels

  • Increased caloric intake to address metabolic needs can increase

  • When hyperglycemia occurs, check glucose levels + give insulin as ordered

  • Monitor glucose lab results

• Electrolyte imbalances

  • Hyponatremia can develop from excess GI suction + diarrhea

    • Manifestations

      • Headache

      • Irritability

      • Confusion

      • Vomiting

      • Seizures

      • Coma

    • Patients can develop dilutional hyponatremia from excess water intake

      • To avoid, offer patients fluids besides water

  • Hypernatremia can occur after successful fluid resuscitation, if large amounts of hypertonic solutions were given

    • Manifestations

      • Altered mental status

        • Drowsiness

        • Restlessness

        • Confusions

        • Lethargy

      • Seizures

      • Coma

    • Sodium restrictions, in IV fluids and enteral nutrition, can reduce levels

  • Hyperkalemia can occur if patients have renal failure, adrenocortical insufficiency, or massive deep muscle injury (electrical burns)

    • Manifestations

      • Dysrhythmias

      • Confusion

      • Tetnay

      • Muscle crmpas

      • Paresthesia

      • Weakness

  • Hypokalemia occurs with V/D, prolonged GI suction, IV therapy, and through wounds without supplementation

    • Manifestations

      • Dysrhythmias

      • Weakness

      • Paresthesia

      • Decreased GI motility

      • Decreased reflexes

Nursing + interprofessional care: acute burn phase

• Wound care

  • Consists of ongoing observation, assessment, cleansing, debridement, and dressing changes

  • Dressing changes, topical antimicrobial therapy, graft are, and donor site care is done as often as prn, depending on topical cream/dressing

    • Collagenase is used for enzymatic debridement; promotes removal of nonviable tissue from health wound beds

  • Gently cleanse wounds to remove old antimicrobials + any loose necrotic tissue, scabs, or dried blood

  • After cleansing, cover wound with topical antimicrobial creams or silver-impregnated dressings

    • Avoid silver sulfadiazine if patients are allergic/sensitive to sulfa

• Excision + grafting

  • excision - Devitalized tissue (eschar) is surgically removed down to SQ tissue/fascia

  • Dermatomes are used to remove donor skin for grafting

    • Abdomen + thighs are common donor sites

  • Grafts are placed on clean, viable tissue to achieve good adherence, and stapled/sutured in place

  • Wound vac dressings are often placed on top of skin grafts to optimize adherence to the excised wound bed

  • Nursing care of donor site is specific to the dressing used

• Pain management

  • Burn patients experience two types of pain

    • Continuous background pain

    • Treatment-induced pain

  • First line of treatment is medication

    • For background pain, frequent IV admin of an opioid provides a steady, therapeutic level

    • If tolerating foods, slow-release, twice-daily opioids can be used

    • Anxiolytics + adjuvant analgesics can enhance opioid effectiveness

    • Breakthrough doses of analgesia must be available

  • For treatment-induced pain, pre-medicate with analgesics IV/PO

  • Complementary pain therapies can also work

• PT/OT

  • Continuous therapy is critical if patients are to regain + maintain muscle strength + optimal joint function

  • Exercise during dressing changes, when bulky dressings are removed + patients medicated, can be effective

  • Passive + active ROM should be performed on all joints

  • Maintain the schedule for wearing splints

    • Check skin to ensure splints aren’t causing excess pressure

• Nutrition therapy

  • Goal is to provide adequate calories + protein to promote healing; when wounds are still open, patients are in a hypermetabolic + catabolic state

  • Patients can benefit from antioxidant protocols

    • Selenium

    • Vitamin E

    • Acetylcysteine

    • Ascorbic acid

    • Zinc

    • Multivitamins

  • Meeting daily calorie needs is essential + should start in 1-2 days post-burn

    • Dieticians regularly calculate daily calorie needs + adjust as conditions change

  • Monitor labs (albumin, prealbumin, total protein, transferring) regularly

  • Encourage patients to eat high protein + carb foods to meet calorie goals

    • Ask caregivers/family to bring favorite foods from home

  • Reinforce steps being taken to achieve adequate intake

    • Ideally, weight loss shouldn’t be >10% of pre-burn weight

  • Record daily caloric intake using calorie- count sheets + review with dieticians

  • Weigh patients weekly to evaluate progress

Patho: rehab burn phase

• Starts when wounds have nearly healed, and patients are engaging in some level of self care

• Can happen as soon as 2 weeks or as long as 7-8 months after major burns

• Wounds health either by spontaneous re-epithelialization or skin grafting

• New skin appears flat + pink; in ~4-6 weeks, area becomes raised + hyperemic

• If adequate ROM isn’t continued, the new tissue will shorten → contracture

• Mature healing is achieved in ~12 months when suppleness has returned, and pink/red color has faded to a slightly lighter hue than the surrounding unburned tissue

• Factors influencing recovery

  • Age

  • Chronic illness

  • Physical disabilities

  • Substace absue

Clinical manifestations: rehab burn phase

• Scarring characteristics

  • Discoloration

    • Fades over time

    • Tell patients with darker skin that it’ll take longer to regain tone due to altered melanocytes

    • Provide teaching + emotional support to help patients with grief over body changes

    • Cosmetic camo/pigment implantation can help even out unequal skin tones + improve overall appearance + self-image

  • Contour

    • Gentle pressure is maintained on health burns with custom-fitted pressure garments + clear, thermoplastic face masks

    • Pressure garments + masks should never be worn over unhealed wounds

    • Pressure garments are worn up to 23 hours/day for as long as 12-18 months

  • Patients may report discomfort from itching where healing is occurring

    • Teach patients that water-based moisturizers + short-term use of oral antihistamines can help reduce itching

  • Have patients protect healed burn areas from direct sunlight for ~3 months to prevent hyperpigmentation + sunburns

  • Tell patients to wear sunscreen when exposing healed skin to the sun

Complications: rehab burn phase

• Skin + joint contractures

  • Joint contractures can develop from the shortening of scar tissue in the flexor tissues of a joint

  • Susceptible areas

    • Anterior/lateral neck areas

    • Axillae

    • Antecubital fossae

    • Fingers

    • Groin areas

    • Popliteal fossae

    • Knees

    • Ankles

• Hypertrophic scarring

• Carefully monitor patients for complications

  • Encourage proper positioning, splinting, and exercise

  • Tell patients to continue with prevention strategies until skin matures ~1 year post healing

• Burned legs can be wrapped with elastic bandages to assist with circulation of leg-graft + donor sites before ambulation

• Burned arms can be wrapped with a layer of tubular elastic gauze; prevents blister formation, promotes venous return, and decreases pain + itchiness

Nursing + interprofessional care: rehab burn phase

• Ask patients about thoughts + feelings about discharge

• Encourage patients + caregivers to participate in care

  • Provide wound care instructions, if needed

    • Tell patients to shower to wash wounds

    • Have patients and/or caregivers perform dressing chaanges

  • Provide advice on scar management, moisturizing, and sun protection

  • Suggest using water-based creams that penetrate the dermis on healed areas to keep skin supple + moisturized

• Ensure patients know when to contact burn team + stress need to keep outpatient visits

• If needed, collab with social work/case management to arrange home care servies

• Assess pain management + nutrition needs during each visit

• Encourage patients to perform PT/OT exercises

• Reassure patients to maintain morale, especially when they realize that healing takes time

Emotional + psych needs: burns

• Assess circumstances of the burn, family relationships, and prior ways of coping with stress

• Open + frequent communication among patients, caregivers, close friends, and burn team members is essential

  • Be sensitive to the patient’s emotions + concerns

  • Encourage patients to discuss fears about loss of lifestyle/function, temporary/permanent deformity + disfigurement, return to work + home life, and financial burdens from long hospital stays + rehab

• Encourage independence + eventual return to pre-burn activities

  • Peer counseling + informal interactions with other burn survivors can bring comfort during adjustment periods + help restore confidence

  • Reassure patients that their feelings during the adjustment period are normal; frustration + impatience are expected as a new life is established

  • Help patients in adapting to a realistic, yet positive appraisal of their specific situation, emphasizing when they can/can’t do

• Continued support from trusted + familiar burn team members is essential for caregivers

  • Help them assist with aspects of patient care to help them reconnect with with their loved one + ease the transition back home

  • Acknowledge the reality + normalcy of their emotions

• Address spiritual + cultural needs

  • Pastoral care can help

  • ID what’s important to patients + caregivers and communicate such info in plans of care

  • Encourage burn teams to be culturally aware of + sensitive to the patient + caregiver’s cultural needs

• Address concerns about sexuality with honesty

  • Immature scar tissue can make touch unpleasant or can dull sensations

  • Assure patients + partners that it’s normal and to heed anticipatory guidance from the burn team to avoid undue emotional strain

• Early psych interventions are essential if patients have psychiatric illnesses or if the injury was a suicide attempt

  • Histories of mental health issues can influence the length of hospitalization + time needed to prep for discharge

  • Psychological support starts in the hospital, but links to community resources are needed to ensure continuity of care

• Caregiver + patient emotional support groups can be beneficial in meeting patient + caregiver emotional needs at any phase of the recovery process

Parkland formula

4 mL x body weight (kg) x percentage of TBSA burned

Emergency Severity Index

• 5-level triage system that incorporates concepts of illness severity + resource use to determine who is treated first

• Includes a triage algorithm that directs users to assign a level to patients coming to the ED

  • ESI-1

    • Unstable ABCs

    • Obvious life/organ threat

    • Death risk high

    • High resource intensity with staff at bedside continuously

  • ESI-2

    • Threatened ABCs

    • High-risk patients should be seen in 10 mins

    • High resource intensity with multiple, often complex, diagnostics

  • ESI-3

    • Stable ABCs

    • Patients should be seen in an hour

    • Medium/high resource intensity with multiple diagnostics

  • ESI-4

    • Stable ABCs

    • Can wait to be seen

    • Simple diagnostics/procedures; low resource intensity

  • ESI-5

    • Stable ABCs

    • Can wait to be seen

    • Simple physical exam can suffice

primary survey

• Focuses on ABCs, disability, exposure, full set of vitals + family presence, and getting other monitoring devices

• If there’s uncontrolled external bleeding, ABCs can be modified to CABCs (catastrophic hemorrhage, airway, breathing, circulation)

  • If present, the bleeding must be controlled first; apply direct pressure with a sterile dressing → pressure dressing to any obvious bleeding sites

• Aims to ID life-threatening problems so that appropriate interventions can be started

• Components

  • Alertness + airway

    • Signs of a compromised airway

      • Dyspnea

      • Inability to speak

      • Gasping (agonal) breaths

      • Foreign bodies in the airway

      • Face/neck trauma

    • Patient alertness level is a crucial factor for choosing correct airway interventions

    • Determine LOC by assessing patient response to verbal and/or painful stimuli

      • Use AVPU to help determine LOC

        • Alert

        • Responsive to voice

        • Responsive to pain

        • Unresponsive

    • Airway maintenance should progress rapidly from least → most invasive method

    • Treatment includes opening airway via:

      • Jaw-thrust maneuver, avoiding neck hyperextension

      • Suctioning and/or foreign body removal

      • Inserting naso/oropharyngeal airway (unconscious patients only)

      • Endotracheal intubation

    • If intubation is impossible due to airway obstruction, emergency cricothyroidotomy/tracheotomy is done

      • Ventilate patients with 100% oxygen via BVM before intubation/cricothyroidotomy

    • Rapid-sequence intubation is the preferred procedure for securing an unprotected airway in the ED

      • Involves sedative + paralytic use to aid in intubation + reduce risk of aspiration and airway trauma

    • If patients have a suspected spinal cord injury and isn’t already immobilized, c-spines must be stabilized at the same as the airway assessment

      • Keep beds flat + continue monitoring airway patency and breathing effectiveness

  • Breathing

    • Every critically injured/ill patient has increased metabolic + oxygen demand; they should receive supplemental oxygen

    • Give high-flow oxygen via nonrebreather masks + monitor patient response

    • Interventions for life-threatening issues:

      • BVM ventilation with 100% oxygen

      • Needle decompression

      • Intubation

      • Treatment of underlying cause

  • Circulation + control of hemorrhage

    • Uncontrolled internal/external bleeding places patients at risk for hemorrhagic shock

    • Check for femoral/carotid pulses

      • Peripheral pulses may be absent due to direct injury or vasoconstriction

    • Assess quality + rate oof pulses

    • Assess skin for color, temp, and moisture

    • Altered mental status + delayed cap refill care common signs of shock

      • When assessing cap refill in cold temps, the coldness delays refill

    • Establish IV access in upper extremities unless contraindicated (open fracture or injury that affects limb circulation)

      • Insert 2 large-bore catheters

      • Start aggressive fluid resuscitation via normal saline or lactated Ringer’s

    • Consider intraosseous or central venous access if peripheral access cannot be rapidly established

    • In emergency (life-threatening) situations, give blood that’s not cross-matched (O-) if immediate transfusions are needed

  • Disability

    • Conduct brief neuro assessments

    • LOC is a measure of the degree of disability

    • Use GCS scores to determine LOC; allows for consistent communication among interprofessional care team

      • Is not accurate for intubated or aphasic patients

    • Assess pupils for PERRLA

  • Exposure + environmental control

    • Remove patient clothing to perform thorough assessments

    • Try not to cute through areas that can be forensic evidence (bullet holes)

    • Don’t remove impaled objects; can cause bleeding + further injury

    • When patient is exposed, use warming blankets, overhead warmers, and warmed IV fluids to limit heat loss, prevent hypothermia, and maintain privacy

  • Full set of vitals + family presence

    • Obtain full set of vitals after patient is exposed

      • If patients have sustained/suspected of having sustained chest trauma, or if BP is abnormally high/low, obtain BP in both arms

    • Assign a care team members to explain the care being given + answer questions if a caregiver is present during resuscitation/invasive procedures

  • Get monitoring devices + give comfort

    • Start adjunct measures for monitoring patient condition if not already done

    • Use the LMNOP acronym to remember resuscitation aids

secondary survey

• Brief, systematic process that aims to ID all injuries

• Helpful for discovering unknown problems in patients with a poor/confusing history

• Components

  • History + head-to-toe

    • Obtain a history + mechanism of the injury/illness

    • Use MIST to help obtain a prehospital report of the incident/illness

      • Mechanism of injjry

      • Injuries sustained

      • Signs/symptoms before arrival

      • Treatment before arrival

    • Details of the incident are important because the mechanism of injury + injury patterns can predict specific injuries

    • Use SAMPLE to ask about patient history

      • Symptoms from the injury/illness

      • Allergies

      • Medication history

      • Past history

      • Last meal/oral intake

      • Events/environmental factors leading to the illness/injury

    • Head, neck, and face

      • Check eyes for extraocular movements

      • Disconjugate gaze is a sign of neuro damage

      • Battle’s sing can indicate basilar skull fractures

      • Raccoon eyes (periorbital bruising) usually occurs from fractures of the base of the frontal part of the skull

      • Check ears for blood + CSF

      • Do not block clear drainage from the ear or nose

    • Chest

      • Inspection + palpation of the chest can help detect heart + lung injuries

    • Abdomen + flanks

      • Stabilize, don’t remove, any impaled objects

      • If patients have blunt abdominal trauma, or if there’s suspected intraabdominal hemorrhage, perform a focused abdominal sonography for trams (FAST)

        • Can ID blood in the peritoneal space + assess cardiac function

        • Noninvasive + done quickly at bedside

        • Can’t rule out a retroperitoneal bleed; if suspected, CT scans are needed

    • Pelvis + perineum

      • Inspect + gently palpate the pelvis

        • Do not rock the pelvis

        • Pain can indicate a pelvic fracture + need for imaging

      • Assess for bladder distention, hematuria, dysuria, or inability to void

    • Extremities

      • Assess upper + lower extremities for point tenderness, crepitus, and deformities

      • If not done prehospital, splint injured extremities above + below injury to decrease further soft tissue injury + pain

      • Check pulses before + after movement/splinting

        • Pulseless extremities are time-sensitive emergencies

      • Immobilize + elevate injured extremities + apply ice packs

      • Antibiotics are given for open fractures to prevent infection

      • Assess extremities for compartments syndrome

        • Pain

        • Pallor

        • Pulselessness

        • Paresthesia

        • Paralysis

  • Inspect posterior surfaces

    • Logroll trauma patients while protecting the c-spine

  • Just keep reevaluating

    • After secondary survey is complete, document findings

    • Ongoing monitoring + evals are critical

    • Provide appropriate care and assess patient response

    • Use VIPP for reevaluation process

      • Vitals

      • Injuries sustained + interventions

      • Primary survey

      • Pain level

    • Evals of airway patency + effectiveness of breathing are always the highest priorities

      • Monitor respiratory rate + rhythm, O2 sats, and ABGs, if ordered

      • Portable chest x-rays confirm tube placements

    • Give tetanus prophylaxis based on vaccination history + condition of any wounds

    • Closely monitor LOC + vitals

    • Note quality of peripheral pulses + skin temp, color, and moisture for any info about circulation and perfusion

    • When indicated, insert Foleys to decompress the bladder, monitor urine output, and check for hematuria

    • Notify providers of any changes that can occur to patients during ongoing assessments

Etiology + patho: increased ICP

• Results from an increase of brain tissue, blood, or CSF in the skull

• Clinically significant because it decreases cerebral perfusion pressure and increases risks for brain ischemia and infarction

• Common causes

  • Mass

  • Cerebral edema

• Contributing factors

  • Arterial pressure

  • Venous pressure

  • Intraabdominal + intrathoracic pressure

  • Posture

  • Temp

  • ABGs (CO₂)

• Cerebral insults increase formation + spread of cerebral edema → hypercapnia, cerebral acidosis, impaired autoregulation, and systemic hypertensio

  • Edema distorts brain tissue, further increases ICP + leads to more tissue hypoxia and acidosis

• Maintain cerebral blood flow to preserve tissue + minimize secondary injury

• Sustained increases in ICP result in brainstem compression + brain herniation

  • Herniation occurs as brain tissue is forcibly shifted from a compartment of greater pressure to a compartment of less pressure

Clinical manifestations: increased ICP

• Altered LOC

• Changes in vitals

  • Cushing’s triad

    • Systolic hypertension + widened pulse pressure

    • Bradycardia + full, bounding pulse

    • Irregular respirations

  • Often don’t occur until ICP increase is prolonged or is suddenly + markedly increased

  • Medical emergency; is a sign of brainstem compression + impending death

• Ocular signs

  • Compression of cranial nerve III

    • Ipsilateral pupil dilation (dilation on affected side)

    • Pupils may be sluggish/unresponsive to light

    • Inability to move eye upward + adduct

    • Ptosis

  • Effects from other cranial nerves

    • Blurred vision

    • Diplopia

    • Changes in extraocular eye movements

• Decreased motor function

  • Contralateral hemiparesis/hemiplegia, depending on location of the source of increased ICP

  • Decorticate/decerebrate posturing, from noxious stimuli

    • Decerebrate posturing can indicate more serious damage

• Headache

  • Nocturnal and/or morning headaches are causes for concern

  • Straining, agitation or movement can worsen pain

• Vomiting

  • When unpreceded by nausea = unexpected

  • Nonspecific sign of increased ICP that’s related to pressure changes in the cranium

Diagnostic studies: increased ICP

• CT + MRI can discover many conditions that can cause increased ICP and assess effects of treatment

• EEG

• Cerebral angiography

• ICP measurement

• Brain tissue oxygenation measurement via LICOX catheter

• PET scns

• Transcranial Doppler studies

• Evoked potential studies

• Lumbar punctures are contraindicated; cerebral herniation can occur from sudden release of pressure

Nursing care: increased ICP

• Assessment

  • LOC

  • Body functions

  • Vitals

  • GCS scoring

    • 15 = fully alert

    • <8 = coma

    • Plot scores on graphs for comparisons + determination of stability, improvement, or deterioration

    • Allows different healthcare pros to come to the same conclusion about patient status

  • Neuro assessment

    • Compare pupils for size, shape, movement, and reactivity

    • If cranial nerve II is compressed, ipsilateral pupil dilation will be seen, and get larger until fully dilated

      • If ICP continues increasing, both pupils dilate

    • Testing the corneal reflex gives info about cranial nerve V + VII; if absent, start routine eye care to prevent corneal abrasion

    • Test all extremities for strength + note any asymmetry in strength or movement

    • Assess motor response of unconscious/cooperative patient by observing spontaneous movement

      • If not possible, apply pain stimulus + note response

      • Do not include hand grasps as part of assessment; it’s a reflex action and can misrepresent patient status

      • Record vitals

• Acute care

  • Respiratory function

    • Maintain patent airway

    • Remove secretions via suctioning PRN

    • Patients with GCS scores <8 or altered LOC who aren’t able to maintain patent airways or ventilate effectively need intubation and mechanical ventilation

    • Monitor ABGs + act to maintain levels in prescribed/acceptable parameters

    • Prevent hypoxia and hypercapnia to minimize secondary injury

      • Suctioning + coughing cause transient decreases in arterial oxygen + increase ICP

      • Keep suctions to a minimum and <10 seconds

      • Give 100% oxygen before/after to prevent decreases in arterial oxygen

      • Limit suctioning to passes/suction procedure if possible

    • Avoid abdominal distention; it can interfere with respiratory function

      • NG tube insertion to aspirate stomach contents can prevent distention, vomiting, and aspiration

  • Sedation

    • Pain, anxiety, and fear related to primary injury, therapeutic procedures, or noxious stimuli can increase ICP + BP

    • Admin of sedatives, paralytics, and analgesics can alter neuro states, masking true changes

      • Drug therapy may need to be temporarily stopped to appropriately assess neuro status

    • Choice, dose, and combo of drugs can vary depending on patient history, neuro state, and overall clinical presentation

    • Opioids have minimal effects on cerebral blood flow or oxygen metabolism

    • Be aware of the side effects of alpha adrenergic agonists (dexmedetomidine), especially hypotension, which can lower cerebral perfusion pressure

    • Nondepolarizing neuromuscular blocking agents can help achieve complete ventilatory control in the treatment of refractory intracranial hypertension

      • Must be used in combo with sedatives, analgesics, or benzos

    • Benzos are usually avoided due to hypotensive effects + long half-lives

    • Patients should be kept in quiet, calm environments with minimal noise + interruptions

      • Observe patients for agitation, irritation, or frustration

      • Teach families + caregivers about decreasing stimulation

      • Coordinate with care teams to minimize procedures that can cause agitation

  • Fluid + electrolyte balance

    • Closely monitor IV fluids via infusion pumps

    • Assess I/O, including insensible losses, and obtain daily weights

    • Monitor electrolytes, especially glucose, sodium, potassium, magnesium, and osmolality

    • Monitor urine output to detect problems related to diabetes insipidus + SIADH

  • Monitoring ICP

    • Used with other parameters to guide patient care + assess response to treatment

    • Be alert to factors that increase ICP + try to minimize them

    • Increased intrathoracic pressure can increased ICP by impeding venous return

      • Patients should avoid coughing, straining, sneezing, and the Valsalva maneuver

  • Body position

    • Maintain patients in head-up position; keep heads midline, avoiding extreme neck flexion

      • Flexion can cause venous obstruction + contribute to increased ICP

    • Adjust body position to decrease ICP + improve cerebral perfusion pressure

    • Elevating heads of beds to 30 degrees promotes head drainage + decreases vascular congestion that can produce cerebral edema

      • Elevation >30 degrees can decrease cerebral perfusion pressure by lowering systemic BP

      • Carefully evaluate effects of elevation on both ICP + cerebral perfusion pressure

      • Position beds so that they lower ICP while optimizing cerebral perfusion pressure + other indices of cerebral oxygenation

    • Turn patients with slow + gentle movements; rapid changes can increase ICP

    • Prevent discomfort when turning + repositioning; pain/agitation increases ICP

    • Avoid extreme hip flexion to decrease risk for raising intraabdominal pressure, which increases ICP

    • Provide physical care to minimize complications of immobility; turn q2h

  • Protection from injury

    • Use restraints carefully in agitated patients

      • If they’re needed, they should be secure enough to be effective

      • Observe the skin underneath restraints regularly for signs of irritation/breakdown

    • Agitation can increase from restraint use, indicating the need for other measures (sedation, family company)

    • Place patients with/at risk for seizures on seizure precautions

      • Padded side rails

      • Ambu bags at bedside

      • Readily available suction

      • Accurate + timely admin of antiseizure meds

      • Close observation

    • Antiseizure prophylaxis against early seizures (within first 7-10 days) is recommended in severe brain injury

    • Keep patients in quiet, nonstimulant environments; use calm and reassuring approaches when interacting

  • Psych considerations

    • Be aware of the psychologic wellbeing of patients + families

    • Keep explanations short + simple

    • Allow patients + caregivers to acquire the amount of info they want

    • Assess family members’ desires to help with providing care for patients + allow their participation as appropriate

    • Encourage interprofessional management involving the patient + family in decision making as much as possible

Interprofessional care: increased ICP

• Maintenance of adequate oxygenation to support brain function + prevent secondary injury is essential

• Endotracheal tubes or tracheostomies may be needed to maintain adequate ventilation

• ABGs guide oxygen therapy

• If increased ICP is caused by a mass, surgical removal is the best treatment

• Drug therapy

  • Mannitol

    • Osmotic diuretic given IV to decrease ICP via plasma expansion and osmosis

    • Reduces hematocrit + blood viscosity → increases cerebral blood flow + oxygenation

    • Creates a vascular osmotic gradient; decrease in total brain fluid content causes fluid movement from tissues to blood vessels → reducing ICP

    • Monitor fluid + electrolyte balance

    • Contraindicated with renal disease + increased serum osmolality

  • Hypertonic saline solutions

    • Produce massive movement of water out of edematous swollen brain cells and into blood vessels, reducing swelling + improving cerebral blood flow

    • During (slow) infusion, monitor BP + serum sodium levels, as intravascular fluid volume excess can occur

  • Corticosteroids

    • Treat vasogenic edema around tumors + abscesses

    • Not recommended for TBIs

    • Stabilize cell membranes + inhibit prostaglandin synthesis, preventing the formation of proinflammatory mediators

    • Improve neuronal function by improving cerebral blood flow + restoring autoregulation

    • Complications

      • Hyperglycemia

        • Perform glucose checks q6h

      • Infections

      • GI bleeds

        • Patients should be on histamine receptor blockers or PPIs

  • Normal saline

    • Preferred solution for giving secondary meds

    • Hypotonic solutions can decrease serum osmolality + increase cerebral edema

  • Acetaminophen

    • Used to maintain temps between 96.8 - 98.6 F

    • Metabolic demands (fever, agitation, shivering, pai, seizures) can increase ICP

    • If shivering occurs, patients may need sedation or a different cooling method

  • Barbiturates

    • High doses are used in patients with increased ICP refractory to other treatments

    • They decrease cerebral metabolism → decreasing ICP + reducing cerebral edema

    • Dosing is based on analysis of bedside EEG tracing + ICP

Types + clinical manifestations of skull fractures

• Basilar

  • CSF/brain otorrhea

  • Tympanic membrane bulging, from blood/CSF

  • Battle sign

  • Tinnitus/difficulty hearing

  • Rhinorrhea

  • Facial paralysis

  • Conjugate deviation of gaze

  • Vertigo

• Frontal

  • Exposure of brain to contamiants via frontal sinus

  • Possible associate with air in forehead tissue

  • CSF rhinorrhea

  • Facial paralysis

  • Loss of taste

  • Battle sign

• Orbital

  • Raccoon eyes

  • Optic nerve injury

• Parietal

  • Deafness

  • CSF/brain otorrhea

  • Tympanic membrane bulging

  • Facial paralysis

  • Loss of taste

  • Battle sign

• Posterior fossa

  • Occiptal bruising → cortical blindness

  • Visual field defects

  • Ataxia/other cerebellar signs (rare)

• Temporal

  • Boggy temporal muscle, from blood extravasation

  • Battle sign

  • CSF otorrhea

  • Middle meningeal artery disruption

  • Epidural hematoma

Nursing care: cranial surgery

• Acute care

  • Is similar to that of patients with increased ICP

  • Preop teaching is important in reducing fears in patients, families, and caregivers

  • Provide general info about surgery type + postop expectations

  • Explain that some hair may be shaved to allow for better exposure + prevent contamination

  • Inform patients that they’ll be in the ICU/IMC postop

  • Main goal of postop care is preventing increased ICP

    • Frequent neuro assessments are essential in the first 48 hours

    • Closely monitor fluid + electrolyte levels and serum osmolality to detect changes in sodium regulation, onset of diabetes insipidus, or severe hypovolemia

    • Manage problems associated with increased ICP

  • Monitor patients for pain + nausea; give antiemetics as ordered

    • Do not give promethazine; it can increase somnolence + change the accuracy of a neuro assessment

  • Control pain with short-acting opioids + monitor neuro status

  • When the incision over the skull is in the anterior (middle) fossa, elevate the head of the bed at least 30 degrees

    • If the surgical approach is in the posterior fossa, or a Burr hole is present, keep patients flat or at a slight elevation (10-15 degrees)

  • Turning + repositioning depends on the site of the operations

    • If a bone flap was removed, don’t position patients on the operative side

    • Place sigs at the head of the bed alerting all of the craniectomy site + position of surgical site

  • Observe dressing for color, odor, and drainage amount

  • Check drains for placement

  • Assess area around the dressing

  • Scalp care should include meticulous incision care to prevent infection

    • Cleanse area + treat per agency protocol/provider orders

  • When dressings are removed, use antiseptic soaps for washing the scalp

  • Psych impacts of hair removal can be lessened via wigs, turbans, scarves, or hats

  • For patients on radiation, teach them to use sunblock and head coverings if any sun exposure is expected

• Ambulatory care

  • Base care on a realistic appraisal of factors for patient rehab potential

    • Surgery indication

    • Postop course

    • General health

  • Specific rehab potential can’t be determined util cerebral edema + increased ICP subside postop

  • Take care to maintain as much function as possible through measures such as

    • Careful positioning

    • Meticulous skin + mouth care

    • Regular ROM exercises

    • Bowel + bladder care

    • Adequate nutrition

  • Address needs + problems of each patient individually because many variables affect care plans

  • Collab with other care team members

    • PTs can give exercise plans

    • Speech therapists can help with communication + swallowing skills

    • Social workers can help patient + family adapt to changes in home life, work, and financial circumstances

Etiology + patho: ischemic strokes

• Results from inadequate blood low to the brain from partial/complete arterial occlusion

• Classes

  • Thrombotic

    • Occurs from injury to a blood vessel wall + formation of blood clot

    • Develops readily where atherosclerotic plaques have already narrowed blood vessels

    • Most common stroke cause

      • More common in older adults, especially those with

        • High cholesterol

        • Atherosclerosis

        • Diabetes

    • Extent depends on

      • Onset speed

      • Size of damaged area

      • Prescence of collateral circulation

    • Most patients don’t have a decreased LOC in the first 24 hours, unless due to a brainstem stroke or other condition (seizure, increased ICP, hemorrhage)

    • Manifestations can progress in the first 2 hours as infarction and cerebral edema increase

  • Embolic

    • Occurs when an embolus lodges in + occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel

    • Second most common cause of stroke

    • Most emboli originate in the endocardial layer of the heart when a plaque breaks off the endocardium and enters the circulation

    • Causative conditions

      • A-fib

      • MI

      • Infective endocarditis

      • Valvular heart prostheses

      • Patent foramen ovale

      • Atrial septal defects

      • Emboli from air or fat from long bone fractures (rare)

    • Can affect any age group

      • Rheumatic heart disease is a cause of embolic stroke in young/middle-aged adults

    • Patients have severe manifestations that occur suddenly

      • Patient are usually conscious with a headache

    • Effects are initially characterized by severe neuro deficits, which can be temporary if the clot breaks up and allows blood to flow

      • Smaller emboli then continue to obstruct smaller vessels, which then involve smaller portions of the brain with fewer deficits noted

Etiology + patho: hemorrhagic strokes

• Result from bleeding into brain tissue or the subarachnoid space/ventricles

• Types

  • Intracerebral

    • Bleeding within the brain caused by a rupture of a vessel (usually in the basal ganglia)

    • Poor prognosis; half of deaths occur in the first 48 hours

    • Causes

      • Hypertension (most common)

      • Vascular malformations

      • Coagulation disorders

      • Anticoagulant/thrombolytic drugs

      • Trauma

      • Brain tumors

      • Ruptured aneurysms

    • Often occurs during periods of activity

    • There’s often a sudden onset of symptoms, with progression over minutes/hours due to ongoing bleeding

    • Manifestations

      • Neuro deficits

      • Headache

      • N/V

      • Decreased LOC

      • Hypertension

    • Symptom extent depend on the amount, location, and duration of bleeding

    • Blood clots in the closed skull can result in masses that cause pressure on/displace brain tissue and decrease cerebral blood flow, leading to ischemia and infarction

    • Common locations:

      • Cerebral lobes

      • Cerebellum

        • Characterized by:

          • Severe headache

          • Vomiting

          • Loss of ability to walk

          • Dysphagia

          • Dysarthria

          • Eye movement changes

      • Pons

        • Is the most serious bleed location; basic life functions are affected

        • Characterized by:

          • Hemiplegia leading to:

            • Complete paralysis

            • Coma

            • Abnormal body posturing

            • Fixed pupils

            • Hyperthermia

            • Death

      • Thalamus

        • Results in hemiplegia with more sensory than motor loss

        • Bleeding in subthalamic areas lead to vision + eye movement

      • Subcortical white matter

      • Internal capsule

      • Putamen (part of basal ganglia)

    • Manifestations of putaminal/internal capsule bleeding:

      • Weakness of one side, including the face, arm, and leg

      • Slurred speech

      • Deviation of the eyes

    • Progressions of symptoms related to a severe hemorrhage:

      • Hemiplegia

      • Fixed + dilated pupils

      • Abnormal body posturing

      • Coma

  • Subarachnoid

    • Occurs when there’s intracranial bleeding into the CSF-filled space between the arachnoid and pia mater membranes on the brain’s surface

    • Causes

      • Cerebral aneurysm rupture

      • Trauma

      • Illicit drug (coke) use

    • Patient can present with warning signs if the ballooning artery applies pressure to brain tissue

      • Minor warning symptoms can result from leaking of an aneurysm before major rupture

    • Manifestations

      • LOC may/may not occur

        • LOC ranges from alert → comatose, depending of bleeding severity

      • Focal neuro deficits (including cranial nerve deficits)

      • N/V

      • Seizures

      • Stiff neck

    • Complications

      • Rebleeding before surgery/other therapies start

      • Cerebral vasospasm, which can result in infarction

        • Patients with subarachnoid hemorrhage who’re are at risk for vasospasm are often in the ICU for up to 14 days or until the threat of vasospasm is reduced

        • Peak time is 6-10 days after the initial bleed

Clinical manifestations: strokes

• Related to stroke location

• Motor function

  • Most obvious effects of stroke

  • Deficits include:

    • Mobility

    • Respiratory function

    • Swallowing + speech

    • Gag reflex

    • Self-care activities

  • Symptoms are caused by the destruction of motor neurons in the pyramidal pathway (nerve fibers from the brain that pass through the spinal cord to motor cells)

  • Characteristic motor deficits

    • Loss of skilled voluntary movement (akinesia)

    • Impaired integration of movements

    • Changes in muscle tone

    • Altered reflexes

      • Hyporeflexia → hyperreflexia for most patients

  • Deficits follow certain specific patterns; a lesion of one side of the brain affects motor function on the opposite side of the body

• Communication

  • Left hemisphere is dominant for language skills in right-handed patients and in most left-handed patients

  • Aphasia may be present

    • Types

      • Receptive - Loss of comprehension

      • Expressive - Inability to produce language

      • Global - Total inability to communicate

    • Occurs when a stroke damages the dominant hemisphere of the brain

    • Patterns may differ, since strokes affect different portions of the brain

    • Described as:

      • Nonfluent - Minimal speech activity with slow speech that requires obvious effort

      • Fluent - Speech is present, but has little meaningful communication

    • Dysarthria (problem with muscular speech control) can occur

      • Impairment can involve pronunciation, articulation, and phonation

      • Affects the mechanics of speech

• Affect

  • Emotional responses can be exaggerated/unpredictable

• Intellectual function

  • Left-brain strokes are more likely to result in memory problems related to language

    • Patients with left-brain strokes are cautious in making judgements

  • Patients with right-brain strokes tend to be more impulsive and move quickly

  • Patients with either type of stroke find it hard to make generalizations, interfering with their ability to learn

• Spatial-perceptual problems

  • More common in patients after right-brain strokes, but can occur in patients after left-brain strokes

  • Categories

    • Incorrect perception of self + illness

    • Spatial neglect

    • Agnosia - Inability to ID objects via sight, touch, or hearing

    • Apraxia - Inability to carry out learned, sequetial movemnts on command

• Elimination

  • Most urinary/bowel problems are temporary

  • When strokes affect 1 hemisphere, prognosis for normal bladder function is excellent

  • Though motor control of the bowel usually isn’t a problem, patients are often constipated

    • Constipation is associated with:

      • Immobility

      • Weak abdominal muscles

      • Dehydration

      • Decreased response to the defecation reflex

  • Incontinence can occur if patients can’t communicate their needs to eliminate or have difficulty managing clothing

  • Scheduled toileting + easily removable clothing encourages independence

Diagnostic studies: strokes

• Performed to:

  • Confirm stroke occurrence

  • ID likely cause

  • Guide therapy decisions

• Key assessment is to determine symptom onset time

• Noncontrast CTs/MRIs

  • Rapidly distinguish between ischemic/hemorrhagic stroke

  • Determine size + location of stroke and treatment options

• MRIs are more effective in IDing ischemic strokes than CTs

• CTs are rapid diagnostic tools to rule out hemorrhage

• CT angiography provides visualization of cerebral blood vessels

  • Can be done at the same time as noncontrast CTs

  • Give an estimate of perfusion and detect filling defects in cerebral arteries

• Magnetic resonance angiography detects vascular lesions/blockages

• Cardiac imaging is recommended because many strokes are caused by blood clots from the heart

• Blood tests can help ID conditions contributing to stroke and guide treatment

• Angiography can:

  • ID cervical and cerebrovascular occlusion

  • Atherosclerotic plaques

  • Malformation of vessels

  • Cerebral angiographies can find subarachnoid hemorrhages

  • Angiography risks

    • Dislodging emboli

    • Causing vasospasm

    • Inducing further hemorrhage

    • Provoking an allergic reaction to contrast media

• Intraarterial digital subtraction angiography allows for visualization of blood vessels in the neck and large vessels in the circle of Willis

  • Reduces contrast dose, uses smaller catheters, and shortens procedure length compared to normal angiography

  • Considered safer than cerebral angiography due to less vascular manipulation

• Transcranial doppler ultrasonography measures velocity of blood flow in major cerebral arteries

  • Effective in detecting microemboli and vasospasm

  • Ideal for patients suspected of subarachnoid hemorrhage

• Carotid duplex scans detect the cause of the stroke and stratify patients for either medical management/carotid intervention if they’ve carotid stenosis

• Lumbar punctures can determine if blood is in the CSF if subarachnoid hemorrhage and CT scans don’t prove it

  • Avoided in patients if they’re suspected of having obstructed foramen magnums or other signs of increased ICP due to the risk of downward herniation of the brain

    • This can lead to pressure on cardiac/respiratory centers in the brainstem and potentially death

Inteprofessional care: ischemic strokes

• Acute care

  • Symptoms onset time is the most important part of the patient’s history

  • Care goals

    • Preserve life

    • Prevent further brain damage

    • Reduce disability

  • For emergency care, patients should go to the nearest certisfied stroke center

    • If one’s not available. they should be sent to the closest place offering emergency stroke care

  • For unconscious patients, care starts with ABC assessment

  • Perform baseline neuro assessment

  • Monitor closely for signs of increasing neuro deficit

  • Elevated BP is common after strokes

    • It can be protective to maintain cerebral perfusion, but also detrimental

    • For patients who don’t receive fibrinolytic therapy, antihypertensive usages is recommended only if BP is markedly increased (SBP >220 mmHg or DBP >120 mmHg)

    • For patients on fibrinolytic therapy, BP must be <185/110 mmHg, then maintained at/below 180/105 mmHg for at least 24 hours after fibrinolytic therapy

  • In acute strokes, IV antihypertensives are preferred

  • Fluid/electrolyte balance must be carefully controlled

    • Goal is to keep patient adequately hydrated to promote perfusion and decrease further brain injury

    • Decisions are made based on:

      • Extent of intracranial edema

      • Manifestations of increased ICP

      • Central venous pressure levels

      • Electrolyte levels

      • I/O

    • Overhydration can compromise perfusion by increasing ICP and cerebral edema

    • Adequate fluid intake is a priority

    • Monitor urine output to ensure + prevent dehydration

    • Hyponatremia can occur if ADH secretion increases

    • IV solutions with glucose and water are avoided because they’re hypotonic and can further increase cerebral edema and ICP

    • Glycemic control should be maintained

  • Increased ICP is less likely to happen, but usually peaks in 72 hours and cause brain herniation

    • Management includes

      • Elevating heads of the bed

      • Keep the head + neck aligned

      • Avoid hip flexion

      • Manage fever (keep temp between 96.8 - 98.6 F)

      • Drug therapy to prevent seizures

      • Pain management

      • Prevent constipation

• Drug therapy

  • Fibrinolytic therapy should not be delayed

  • IV tissue plasminogen activator (tPA) can reestablish blood flow through a blocked artery and prevent cell death in patients with acute onset of ischemic stroke

    • Must be given 3 - 4.5 hours of symptom onset

    • Careful screening must be done before drug admin

      • Noncontrast CT/MRI to rule out hemorrhagic stroke

      • Blood tests for coagulation disorders

      • Screening for recent history of GI bleeding, stroke, or head trauma in the last 3 months

      • Major surgery in 14 days

      • Recent active internal bleeding in 22 days

    • During infusion, close monitor vitals and neuro status to assess for signs of improvements or for potential deterioration related to intracerebral hemorrhage

    • BP control (SBP <185 mmHg) is critical during treatment and for 24 hours after

  • Patients can receive intraarterial tPA if mechanical thrombectomy isn’t an option

    • For effectiveness, must be given in 6 hours of symptom onset

  • Anticoagulant use in the emergency phase isn’t recommended due to the risk for intracranial hemorrhage

    • High aspirin doses can be started in 24-48 hours after symptom onset

  • After patient stabilization and to prevent further clot formation, patients with strokes caused by thrombi/emboli can be treated with anticoagulants and platelet inhibitors

Interprofessional care: hemorrhagic strokes

• Drug therapy

  • Anticoagulants and platelet inhibitors are contraindicated

  • Involves hypertension management

  • Oral + IV agents can be used to maintain BP in a normal/high-normal range (SBP <160 mmHg)

  • Seizure prophylaxis is patient-specific

• Surgical therapy

  • Includes immediate evacuation of:

    • Aneurysm-induced hematomas

    • Cerebellar hematomas >3 cm

  • Treatment of arteriovenous malformations is surgical resection and/or radiosurgery

  • Catheter embolization of affected vessels can block the blood supply to the AVM

  • Aneurysms are often treated by permanent clipping/coiling the aneurysm to prevent rebleeding

  • Interventional radiology procedures include coiling and flow diversion

  • After clipping/coiling hyperdynamic therapy (hemodilution-induced hypertension) can be started to increased mean arterial pressure and cerebral perfusion

  • Volume expansion is achieved with crystalloid/colloid solutions

  • Patients with subarachnoid hemorrhage can receive nimodipine to treat cerebral vasospasms and minimize cerebral damage

Etiology + patho: spinal cord injuries

• Types

  • Primary injury

    • Results form direct physical trauma to the spinal cord due to blunt/penetrating trauma

    • Trauma can cause cord compression via bone displacement, interruption of blood supply, or distraction from pulling

    • Penetrating trauma can cause tearing + transection

  • Secondary injury

    • Ongoing, progressive damage that occurs after primary injury

    • Causes further permanent damage

    • Starts a few mins after injury + lasts for months

    • Cascades of events results in edema, ischemia, and inflammation → cell death, blood-brain barrier disruption, and demyelination

    • Edema from inflammation is especially harmful due to limited space for tissue expansion → cord compression

      • Extends above + below the injury, increasing ischemic damage

      • In 24 hours, permanent damage can occur

    • Apoptosis continues for weeks, contributing to post-injury demyelination

    • Inflammatory response at the site of the initial injury focuses on clearing up the initial cell debris without damaging normal tissue

      • Results in a central non-neural core of connective tissue (glial scar)

      • Glial scars create physical barriers that restrict spinal cord cells from migration + regeneration → irreversible nerve damage + permanent neuro deficit

• Spinal + neurogenic shock

  • Spinal shock can occur shortly after injury; characterized by loss of deep tendon + sphincter reflexes, sensation loss, and flaccid paralysis below level of injury

    • Lasts days to weeks

    • Often masks post-injury neuro function

  • Neurogenic shock can occur in cervical or high thoracic injury (T6 or higher)

    • Occurs form unopposed parasympathetic response due to loss of sympathetic nervous system innervation

    • Causes peripheral vasodilation, venous pooling, and decreased cardiac output

    • Manifestations

      • Significant hypotension (<90 mmHg)

      • Bradycardia

      • Temp dysregulation

    • Can persist for as long as 5 weeks post-injury

    • Hypotension can result in poor perfusion + oxygenation to the spinal cord and worsen spinal cord ischemia

• Classification

  • Mechanism of injury

    • Flexion

    • Flexion-rotation

      • Most unstable; ligaments that stabilize the spine are torn

      • Most often contributes to severe neuro deficits

    • Hyperextension

    • Vertical compression

    • Extension-rotation

    • Lateral flexion

  • Level of injury

    • Skeletal level

      • Vertebral level with the most damage to vertebra + related ligaments

    • Neurologic level

      • Lowest segment of the spinal cord with normal sensory and motor function on both sides of the body

    • Can be cervical, thoracic, lumbar, or sacral

      • Cervical + lumbar injuries are most common because those areas are associated with the greatest flexibility + movement

    • Injury from C1 - T1 can cause tetraplegia

      • Degree of impairment in the arms after cervical injury depends on level of injury

        • Lower level = more functionality retained

    • Paraplegia can occur in injuries below T2

  • Degree of injury

    • Complete

      • Results in total loss of sensory + motor function below level of injury

    • Incomplete

      • Results in a mixed loss of voluntary motor activity + sensation and leaves some tracts intact

      • Degree of sensory + motor loss depends on the level of injury and reflects specific damaged nerve tracts

      • Five major associated syndromes

        • Central cord

        • Anterior cord

        • Brown-Séquard

        • Cauda-equina

        • Conus medullaris

Clinical manifestations: spinal cord injuries

• C-spine injuries

  • Dysnpea/apnea

  • Quadriplegia

  • Cervical injuries above C3 present special problems because of the total loss of respiratory muscle function

    • Patients have respiratory arrest within minutes of injury if not intubated

  • Patients with high C-spine injury C3-5 have respiratory insufficiency due to loss of phrenic nerve innervation to the diaphragm and decreased chest + abdominal wall strength

  • Patients with complete injury above C5 should be intubated immediately

• T-spine injuries often result in paraplegia

  • C + T-spine injuries cause paralysis of abdominal muscles and often the intercostal muscles

    • Patients can’t cough effectively enough to remove secretions → increased risk for aspiration, atelectasis, and pneumonia

    • Hypoventilation + impairment of intercostal muscles lead to decreased vital capacity + tidal volume

  • Any cord injury above T6 leads to sympathetic nervous system dysfunction

    • Can result in bradycardia, peripheral vasodilation, and hypotension (neurogenic shock)

• Lumbar/sacral spine injuries often result in decreasing control of

  • Legs

  • Bowel/bladder function

  • Sexual function

Nursing care: spinal cord injuries

• Health promo

  • ID high-risk patients + provide education

  • Support measures to combat distracted/impaired driving

  • Teach peoples to use child safety seats + helmets for motor/bicyclists

  • Promote programs for older adults aimed at preventing accidental death + injury

  • Emphasize the importance of health promo + screening behaviors after injuries

• Acute care

  • Immobilization

    • Maintain necks in neutral positions

    • Closed reductions with skeletal traction is used for early realignment of C-spine injuries

      • If pin displacement occurs, hold patient’s head in neutral position + call for help

      • Immobilize the head while providers reinsert tongs

    • Pin care is essential; clean pins twice daily with CHG

    • Skin care is vital; decreased sensation + circulation increase the risk for skin breakdown

    • Remove patient backboards asap + replace with other forms of immobilization to prevent skin breakdown in the coccygeal + occipital areas

    • Fit C-collars properly

    • Assess areas under any devices used for immobilization

  • Respiratory problems

    • Monitor patients for respiratory compromise

    • Regularly assess

      • Breath sounds

      • ABGs

      • Tidal volume

      • Vital capacity

      • Skin color

      • Breathing patterns

      • Subjective comments about breathing ability

      • Amount + color of sputum

    • Patients who can’t count to 20 without taking a breath need immediate attention

    • Provide measures to maintain ventilation

      • Apply oxygen + provide appropriate ventilatory support until ABGs stabilize

      • If patients are exhausted from labored breathing or ABGs show inadequate oxygenation/ventilation, endotracheal intubation or tracheostomy, and mechanical ventilation is needed

    • Perform suctioning if crackles or coarse breath sounds are present

  • Cardiovascular instability

    • Frequently assess vitals

    • If bradycardia is symptomatic, give anticholinergics (atropine)

    • Maintain SBP >90 mmHg and keep MAP between 85-90 mmHg for first 7 days after injury

    • Manage hypotension with fluid replacement + vasopressors

    • Maintain normal blood volume

      • Monitor H/H per protocol

      • Assess patients for sign of hypovolemic shock from hemorrhage

    • Assess orthostatic BP when mobilizing the patients

      • For symptomatic patients, use abdominal binders + TED hoses to promote venous return

      • Give meds to increase intravascular volume (salt tabs, fludrocortisone) as ordered

      • Midodrine can be given to promote vasoconstriction + increase venous return

    • Use low-molecular-weight heparin in combo with SCDs or TED hoses to promote venous return + reduce VTE risk

  • Elimination

    • Maintain patency of Foleys

      • Check catheters to prevent kinking and ensure free flow of urine

      • Use strict aseptic technique for catheter care to prevent infection

      • Encourage large fluid intake while catheters are in place

    • When patients are stable, assess best means of managing long-term urine function

      • Straight caths are the preferred methods

        • Should be done 4-6 times/day to prevent bacterial overgrowth from urine stasis

        • Keep urine residuals <500 mL to prevent bladder distention

        • If signs of a UTI present, send specimens for culturing

    • Start bowel programs to combat constipation from neurogenic bowel

      • Can be started with patients still in bed, but when they start sitting, they should be upright on a bedside commode

    • Enforce measures to reduce constipation

Interprofessional care: spinal cord injuries

• Prehospital

  • Spinal motion should be restricted with a combo of a rigid C-collar and a supportive backboard with straps

  • Most patients are kept supine, and some in revere Trendelenburg

  • Sedation can be given to keep combative patients safe from further injury

  • Intubation to secure airways is done asap for patients with respiratory distress

  • End-tidal CO2 monitoring can help determine the need for rapid sequence intubation

  • Thorough assessments determine the degree of deficit and the level + degree of injury

• Acute care

  • Obtain histories + mechanism of injury

  • Assess injury extent perceived by patient or EMS

  • Ensure secure airway

  • Maintain O2 sats >92% and MAP >85 mmHg

  • Avoid SBP <90 mmHg

    • Neurogenic shock is treated with IV fluids + pressors to maintain SBP >90 mmHg after other causes of hypotension are ruled out

  • Perform complete neuro assessments using ASIA tool

    • Muscle groups are tested with + against gravity, alone + with resistance, on both sides of the body

      • Record strength, symmetry, and spontaneous movement

    • Complete sensory assessment, including touch + pain, as tested by pinprick

      • Start at toes + work upward to the head

  • Assess rectal tone

    • Voluntary anal contractions indicate incomplete injuries

  • Note presence of priapism

  • If time + conditions permit, assess position sense + vibration

  • Note signs of concussion + increased ICP

  • Assess for musculoskeletal injuries + trauma to internal organs

    • The only clue to internal trauma + bleeding may be a rapidly dropping BP + increasing pulse

  • Move patients via logrolls during transfers + when repositioning to prevent further injury

  • Monitor respiratory, cardiac, urinary, and GI functions

  • Drug therapy

    • VTE prophylaxis should start in 72 hours of injury unless contraindicated

      • Internal/external bleeding

      • Recent surgery

      • For those with abnormal kidney function, heparin is best

    • Vasopressors are used in the acute phase of injury as adjuvant treatment

      • They maintain MAP to improve perfusion to the spinal cord

      • Complication risk is high

        • V-tach

        • Troponin elevation

        • Metabolic acidosis

        • A-fib

Complications: spinal cord injuries

• Autonomic dysreflexia

  • Massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system

  • Involves stimulation of sensory receptors below injury level

  • Most common precipitating cause is a distended bladder/rectum, but any sensory stimulation can cause it

  • Life-threatening + requires immediate resolution

  • Proper ID + elimination of inciting stimulus can resolve the event

    • If untreated, can lead to status epilepticus, stroke, MI, and death

  • Clinical manifestations

    • Hypertension

    • Throbbing headache

    • Marked diaphoresis above injury level

    • Bradycardia

    • Piloerection from pilomotor spasm

    • Flushing, above injury level

    • Blurred/spotty vision

    • Nasal congestion

    • Anxiety

    • Nausea

  • Measure BP when patients with spinal cord injuries report headaches

  • Suspected in adults with SBP elevation of 20-40 mmHg above baseline

  • Interventions

    • Elevate head of bed 45 degrees or sit patients upright

    • Determine cause

      • Most commonly bladder distention; immediate catheterization can be done

      • If catheters are in placed, check for kinks/folds in tubing

      • If clogged, perform small-volume irrigation slowly and gently to open or insert a new one

      • If stool impaction, apply anesthetic ointments to avoid increasing symptoms, then perform digital rectal exam

    • Notify provider

    • Remove all skin stimuli (constrictive clothes, tight shoes)

    • Monitor BP

    • If symptoms persist after source removal, give rapid-onset + short-duration agents (nitroglycerin, nitroprusside, hydralazine)

      • Continue careful monitoring until vitals stabilize

    • Teach patients + caregivers to recognize causes + symptoms; they must know the extreme danger and know to call for help if needed

• Neurogenic bladder

  • The type of bladder dysfunction determines management options

  • When patients stabilize + assessments show return of neuro reflexes, urodynamic testing + urine cultures can be done

  • Patients need a comprehensive program to manage bladder function

    • For chosen plans, teach patients + caregivers successful self-management

    • Teach about various management techniques, how to obtain supplies, care of supplies + equipment, and when to seek health care

  • Meds

    • Anticholinergics suppress bladder contraction

    • Alpha-adrenergic blockers relax the urethral sphincter

    • Antispasmodics decrease spasticity of pelvic floor muscles

    • Botulism toxin helps patients with neurogenic detrusor overactivity who can’t tolerate or have an inadequate response to anticholinergics

  • Evaluate long-term use of Foleys due to high CAUTI incidence, fistula formation, and diverticula

    • Patients must have adequate fluid intake (3-4 L/day)

    • Regularly check catheter patency

  • Straight caths are the first-line option for bladder management

    • Initially done q4h

    • Measure PVR before catheterization

      • If <200 mL, the time interval until catheterization can be extended

      • If >500 mL, the time interval is reduced

    • Usually done 4-6 times/day

• Neurogenic bowel

  • Usual measures for constipation prevention include high-fiber diets + adequate fluid intake

  • Suppositories + small-volume enemas and digital stimulation (done 20-30 mins after suppository insertion may be needed

  • For patients with upper motor neuron injuries, digital stimulation can relax external sphincters to promote defecation

  • Stool softeners can help regulate stool consistency

  • Oral stimulant laxatives should be used only when necessary and not on a regular basis

  • Valsalva maneuvers + manual stimulation are useful in patients with lower motor neuron injuries

    • Valsalva is used in patients with injuries below T12

  • Generally, bowel movements every other day is adequate, but consider pre-injury bowel patterns

  • Defecation timing is important; planning bowel evacuation for 30-60 mins after first meals of the day can enhance success by taking advantage of the gastrocolic reflex induced by eating

  • Discuss timing of bowel programs so there are no interruptions when patients are performing therapy

  • Record all bowel movements, including amount, time, and consistency

hyperacute rejection

• Occurs in 24 hours of transplantation

• Occurs because recipient had preexisting antibodies against the transplanted tissue/organ

• No treatment exists; transplanted organ must be removed

• Rare due improved immunosuppression meds + final tests done before transplantations to determine recipient sensitivity to donor HLAs

acute rejection

• Most often occurs in the first 6 months of transplantation

• Usually cell-mediated response by recipient lymphocytes, which are activated against donated tissue/organ

• Can occur when recipients develop antibodies to the transplanted organ (humoral rejection)

• Common, especially with organs from deceased donors

• Usually reversed with additional immunosuppressant therapy

  • Increased corticosteroids or poly/monoclonal antibodies

chronic rejection

• Occurs over months/years + is irreversible

• Can occur from unknown reasons or from repeated episodes of acute rejection

• Results in fibrosis + scarring

  • Heart → accelerated CAD

  • Lung → bronchiolitis obliterans

  • Liver → Loss of bile ducts

  • Kidney → Fibrosis + glomerulopathy

• No definitive treatment; care is mainly supportive

Immunosuppression therapy + side effects

• Calcineurin inhibitors (cyclosporine, tacrolimus)

  • Work by preventing cell-mediated attacks against transplanted organ

  • Patients should avoid grapefruit/grapefruit juice; increases toxicity

  • Side effects

    • Kidney toxicity

    • Increased infection risk

    • Neurotoxicity (tremors/seizures)

    • Lymphoma

    • Hypertension

    • Hirsutism

    • Leukopenia

    • Gingival hyperplasia

• Purine synthesis antagonists

  • Azathioprine

    • Side effects

      • Bone marrow suppression

        • Neutropenia

        • Anemia

        • Thrombocytopenia

  • Mycophenolate mofetil

    • Inhibits purine synthesis + suppressive effects on T + B cells

    • Can only be reconstituted in D5W

    • Never bolus doses; admin over 2 hours

    • Side effects mediated by lowering doses or giving smaller doses more often

    • Side effects

      • N/V/D

      • Neutropenia

      • Thrombocytopenia

      • Increased infection risk

      • Increased cancer risk

• Sirolimus

  • Suppresses T-cell activation + proliferation

  • Side effects

    • Increased infection risk

    • Leukopenia

    • Anemia

    • Thrombocytopenia

    • Hyperlipidemia

    • Hypercholesterolemia

    • Arthralgias

    • Diarrhea

    • Increased cancer risk

Clinical manifestations: graft v. host disease

• Skin

  • Can be an itchy/painful maculopapular rash

  • Initially involves palms + soles

  • Can progress to generalized erythema + bullous formation + desquamation

• Liver

  • Can range from mild jaundice + high liver enzymes → hepatic coma

• GI tract

  • Manifestations

    • Mild/severe diarrhea

    • Severe abdominal pain

    • GI bleeding

    • Malabsorption

Nursing + interprofessional care: graft v. host disease

• No adequate treatment exists

  • Corticosteroids are most often used, but enhance infection risk

  • Immunosuppression has been most effective in prevention rather than treatment

  • Radiating blood products before admin can help prevent T-cell replication

Clinical manifestations: malnutrition

• Most obvious signs are seen in the:

  • Skin

    • Dry + scaly

    • Brittle nails

    • Rashes

    • Hair loss

  • Mouth

    • Crusting + ulceration

    • Tongue changes

  • Muscles

    • Decreased mass

    • Weakness + fatigue

  • CNS

    • Mental changes (confusion, irritability)

• Delayed wound healing

• Increased infection risk

• Anemia

Nursing + interprofessional care: malnutrition

• Assessment

  • TJC requires nutrition screening for all patients in 24 hours of admission with detailed assessments for at-risk patients

  • The Malnutrition Universal Screening Tool + Nutrition Risk Screening are commonly used with adults in acute care

  • Mini Nutritional Assessments are used for older adults

  • Obtain height, weight, and girth measurements

  • Calculate BMI

    • <18.5 = underweight

    • 18.5 - 24.9 = normal weight

    • 25 - 29.9 = overweight

    • 30+ = obese

    • 40+ = extremely obese

  • When possible, measure actual height instead of using patient’s self-report

  • When assessing weight, obtain a detailed weight history, noting weight loss + intentionality and duration

    • Losses of >5% of usual weight over 6 months is a critical indicator for further assessment, especially in older adults

    • If involuntary losses are >10% of usual weight, determine the reason

• Health promo

  • Teach + reinforce healthy eating habits

    • Use MyPlate, the Dietary Guidelines for Americans, and Nutrition Facts food labels to promote health nutrition

  • Help patients find reliable internet sources that provide evidence-based food + nutrition recommendations

• Acute care

  • Collab with providers + dieticians to ID patients with malnutrition and implement appropriate interventions to meet patient’s nutrition needs

  • Assess nutrition during physical assessments

  • ID risk factors + rationale behind them

  • Teach patients + caregivers the importance of good nutrition

    • Discuss rationale for daily weights, + I/O

  • Measure height + weight on admission

  • If can eat PO, obtain daily calorie count + diet dairy to give an accurate of food intake

  • Help patients + caregivers choose high-calorie and high-protein foods unless medically contraindicated

    • Offering foods the patient likes enhances intake

  • Ensure environments are conducive to eating

    • Provide quiet time

    • Offer hand + oral hygiene

    • Help patients get comfortable positions

    • Place bedside tables at right heights + clear of clutter

    • Place urinals, basins, and bedpans out of sight

    • Open cartons + packages if needed

    • Protect mealtimes for unnecessary interruptions by performing nonurgent care before/after mealtime

  • Malnourished patients may need between-meal supplements; if patients can’t consume enough nutrients via high calorie + protein diets, consider oral liquid supplements

  • Monitor for refeeding syndrome

    • Body’s response to the switch from starvation to a fed state in the initial phase of nutrition therapy in patients who are severely malnourished

    • Risk factors

      • Chronic alcohol use

      • Cancer

      • Trauma

      • IBD

      • Major surgery

    • Manifestations

      • Hypophosphatemia

      • Hyperglycemia

      • Fluid retention

      • Hypokalemia

      • Hypomagnesemia

      • Dysrhythmias

      • Respiratory arrest

• Ambulatory care

  • Teach patients + caregivers about the cause for malnutrition and ways to avoid

    • Malnourishment can recur

    • Adhering to their diet for a few weeks can’t fully restore a normal nutrition state; can take months to reach such a goal

  • Assess ability to follow diet instructions considering past eating habits, religious/ethnic preferences, age, income, resources, and general health

  • Emphasize the need for continual follow-up care to achieve + maintain rehab

  • Determine needs for nutritious meals + snacks after discharge

  • Encourage patient self-assessment of progress by having them weigh themselves 1-2x/week + keep weight record

Health risks: obesity

• Cardiovascular problems

  • Android obesity is the best predictor of cardiovascular disease + strokes in men + women

    • It’s linked with increased LDLs, high triglycerides, and decreased HDLs

  • Hypertension can occur due to

    • Increased circulating blood volume

    • Abnormal vasoconstriction

    • Increased inflammation (damaging blood vessels)

    • Increased risk for sleep apnea (raises BP)

  • Excess body fat can lead chronic inflammation through the body, especially blood vessels, increasing the risk for heart disease

• Diabetes

  • Obesity is the greatest risk for developing T2D

  • Hyperinsulinemia + insulin resistance are often found in obesity

  • Excess weight decreases insulin effectiveness → hyperglycemia

  • Obesity complicates management of T2D by increasing insulin resistance + glucose intolerance

    • Adiponectin (adipokine that increases insulin sensitivity) is decreased → decreased drug effectiveness

• GI + liver problems

  • GERD + gallstones are more prevalent

  • Nonalcoholic steatohepatitis (NASH) is a condition in which lipids are deposited in the liver → fatty liver

  • NASH can increase hepatic glucose production, worsen to cirrhosis and lead to death

• Respiratory + sleep problems

  • Increased fat mass → sleep apnea + obesity hypoventilation syndrome

  • Poor sleep + sleep deprivation can increase appetite

    • Building up sleep debt over a matter of days can impair metabolism and disrupt hormone levels

    • Leptin levels fall in those who are sleep deprived → increased appetite

• Musculoskeletal problems

  • Obesity is associated with an increased incidence of osteoarthritis from the stress put on weight-bearing joints, especially knees + hips

  • Increased body fat triggers inflammatory mediators + contributes to cartilage deterioration

  • Hyperuricemia + gout often occurs in patients who are obese and those with metabolic syndrome

• Cancer

  • Obesity is the one of the most preventable causes of cancer

  • Cancers linked to excess body fat

    • Breast

    • Endometrial

    • Esophageal

    • Gallbladder

    • Kidney

    • Liver

    • Ovarian

    • Stomach

    • Thyroid

• Psychosocial problems

  • Obesity is heavily stigmatized, which can have a emotional toll on psychologic wellbeing

Restrictive bariatric surgeries

• Adjustable gastric banding

  • Involves limiting stomach size with an inflatable band placed around the fundus of the stomach

  • Band is connected to a SQ port that can be in/deflated to meet patient needs

  • Divides the stomach into 2 unequal parts

    • Upper part acts as the new stomach; it holds less → patients feel full faster

    • Bands delays stomach emptying, providing patients with further satiety

  • Can be modified/reversed at later dates if needed

  • Preferred option for patients who are surgical risks because its done laparoscopically

  • Risks

    • Band slippage

    • Some food intolerance

  • Patients must follow strict diets to lose + not regain the weight

• Sleeve gastrectomy (gastric sleeve)

  • ~75% of the stomach is removed, leaving a sleeve-shaped stomach

  • Size is reduce + function preserved

  • Eliminates hormones made in the stomach that stimulate hunger (ghrelin)

• Gastric plication

  • Reduces stomach size by folding stomach inwards

  • Reversible

• Intragastric balloons

  • Use inflated balloons to occupy stomach space

  • Helps patients feel more full + reduce amount of food they can eat

  • Contraindications

    • Past GI surgery

    • IBD

    • Large hiatal hernia

    • Delayed gastric emptying

    • Active H. pylori infection

  • Side effects

    • N/V

    • Abdominal pain

    • Indigestion

Combo (restrictive + malabsorptive) bariatric surgeries

• Roux-en-Y gastric bypass

  • Combo of restrictive + malabsorptive surgery

  • Results in food bypassing 90% of the stomach, duodenum, and a small segment of the jejunum

  • Complications

    • GI tract leaks

    • Gastric remnant distention

    • Ulcers

    • Gallstones

    • Hernias

    • Iron deficiency anemia

    • Cobalamin deficiency → chronic anemia

    • Dumping syndrome

      • Too rapid emptying of gastric contents into the small intestine → overwhelming nutrient digestion

      • Manifestations

        • N/V/D

        • Weakness

        • Faintness

      • Patients are discouraged from eating sugary foods for prevention

Complications: bariatric surgeries

Nursing care: bariatric surgeries

• Preop

  • Interview patients to obtain past + current health info and assistive devices currently use

  • Focus on IDing comorbidities that increase the risk for postop complications

  • Have plans in place before patients arrive so they receive optimal care + don’t feel embarrassed

    • Have appropriately size gowns, beds, and commodes that accommodate increased body sizes + needed patient transfer equipment

    • Use larger BP cuffs to avoid measurement errors + ensure availability and placement in patient room

  • Wheelchairs with removable arms that’s large enough to safely accommodate patients + pass easily through doors should be available

  • Modify assessment methods/tools to ensure accuracy

  • Teach coughing + deep breathing techniques and methods to turning to prevent pulmonary complications

    • Show appropriate use of incentive spirometry

  • If patients use CPAPs at home, arrange for its use in the hospital

  • Special considerations

    • Ensure patients understand the procedure

    • Emphasize frequent assessments of vitals + general assessments to monitor for complications

    • Tell patients they’ll be helped with ambulation soon after surgery

• Postop

  • Initially focuses on careful assessment + immediate intervention cardiopulmonary complication

  • During patient transfers, keep airways stabilized

  • If sedation persists after surgery, be prepared to perform head-tilt jaw thrusts to keep oral + nasal airways open

  • Keep heads of bed elevated to reduce abdominal pressure + increased lung expansion

  • Administer oxygen as needed

  • Implement VTE precautions; diligence in turning + ambulation will help

    • Patients usually will start walking the evening after surgery and then at least 3-4 times/day

    • Have proper help + equipment available

  • Assess skin often

    • Keep skin fold clean + dry to prevent dermatitis + infection

    • Implement measures to reduce pressure injuries

  • Special considerations

    • Give pain meds PRN

    • Monitor vitals to help ID problems

    • Patients usually start low-sugar, clear-liquid diets in 24 hours postop

      • Start with 150mL increments every 10-15 mins; if no nausea/problems arise, gradually increase intake to a goal of 90 mL/30 mins

    • Teach patients to avoid gulping fluids or drinking with straws to reduce the incidence of air swallowing

    • Instruct patients to avoid caffeinated drinks

• Ambulatory care

  • Patients must clearly understand their diet restrictions

    • They’re usually discharged on full liquid diets

    • In 10-14 days, depending on tolerance, pureed/soft foods + vitamin supplementation is started

    • Most patients start usual diets 4-6 weeks postop

    • Diets are usually high in protein with some carbs + fiber

      • They should consist of 6 small feedings/day

    • Patients shouldn’t drink fluid with meals; increases risks of diarrhea + dumping syndrome

    • Calorie-dense foods should be avoided to permit more nutritious food to be consumed

    • Teach patients to eat slowly + stop when feeling full

  • Emphasize the importance of follow-up care due to potential complications

    • Teach patient to inform providers of any changes to physical/emotional condition

    • Patient should take multivitamins with folate, calcium, vitamin D, iron, and cobalamin for life

    • Peptic ulceration, dumping syndrome, and small bowel obstructions can be seen late in recovery and rehab stage

  • Psychologic issues can arise postop

    • Assess social functioning, self-esteem, sex life, and ADLs in follow-up care

    • Be prepped to provide support + assist patients in moving away from negative feelings

    • Help patients adjust to new body image several months postop

    • Discuss the possibility of excess loose skin postop + during the rehab phase

    • Don’t hesitate to encourage counseling for unresolved psychologic issues

  • Encourage women to postpone pregnancy for 12-18 months postop

Etiology + patho: peptic ulcer disease

• Ulcers develop only in acidic environments, but excess acid isn’t needed for development

• Risk factors

  • H. pylori

    • Major risk factor

    • Infection usually occurs during childhood with transmission form family to kids, possibly through fecal → oral or oral → oral

  • Medication-related

    • NSAID use is responsible for most non-H. pylori ulcers

    • NSAID use + H. pylori infection increases risk of peptic ulcer disease

    • Corticosteroids and anticoagulants + NSAIDs increase risk

  • Lifestyle factors

    • High alcohol intake can cause acute mucosa lesions

    • Alcohol + smoking stimulate acid secretion

    • Coffee is a strong stimulant of gastric acid secretion

    • Smoking + psychologic distress (stress + depression) can delay ulcer healing upon development

Clinical manifestations: peptic ulcer disease

• Gastric

  • Epigastric pain, 1-2 hours after meals

    • Described as burning/gaseous

    • If ulcer erodes through mucosa, food can worsen pain

• Duodenal

  • Pain occurs when in contact with stomach acid

    • Food eases pain; symptoms occur 2-5 hours after eating

    • Described as burning/cramping

    • Located in midepigastric region, beneath xiphoid process

  • Back pain

• N/V

• Early satiety

• Some patient can be asymptomatic “silent peptic ulcers”

  • More likely to occur in older adults + those on NSAIDs

Complications: peptic ulcer disease

• GI bleeding

  • Most common; duodenal ulcers cause more bleeding episodes

• Perforation

  • Most lethal complication

  • Risk is highest with large penetrating duodenal ulcers

  • Clinical manifestations

    • Sudden + severe upper abdominal pain that radiates quickly throughout the abdomen

    • Radiating pain to the back + shoulders

    • Pain unrelieved by food/antacids

    • Abdominal rigidity; appears board-like

    • Absent bowel sounds

    • N/V

    • Increased + weak pulse

  • Untreated, bacterial peritonitis can occur in 6-12 hours; severity is proportional to the amount + duration of spillage through the perforation

  • Immediate management

    • Stop spillage of gastric/duodenal contents into the peritoneal cavity

      • NG tubes provide continuous aspiration + gastric decompression to stop spillage throughout the perforation

      • For duodenal aspiration, NG tubs are placed as close to the perforation site as possible to promote decompression

    • Restore blood volume

      • Replaced with LR + albumin solutions

        • Substitute for fluids lost from vascular + interstitial space as peritonitis

      • Packed RBCs can be needed

      • CVLs + Foleys can be placed + monitored hourly

      • Patients with a history of heart disease need ECG monitoring or a PA cath for assessing left ventricular function

      • Broad-spectrum antibiotics are started immediately to treat bacterial peritonitis

  • Small perforations can seal themselves + symptoms stop

    • Can lead to fibrinous fusion of the duodenum or gastric curvature to adjacent tissues (mainly the liver) and strictures that can obstruct the flow of intestinal contents and the passage of stool

  • Large perforations need immediate surgical closure; laparoscopic or open repair depends on ulcer location + provider preference

• Gastric outlet obstruction

  • Obstruction is the distal stomach + duodenum is the result of edema, inflammation, pylorospasm, or fibrous scar tissue formation

  • Patients report discomfort + pain that’s worse at the end of the day as the stomach fills + dilates

    • Burping/vomiting can provide some relief

    • Vomiting is common + often projectile in nature

      • Vomitus can contain food particles that were consumed hours/days before

  • Constipation occurs from dehydration + decreased diet intake form anorexia

  • Treatment aims to decompress the stomach, correct fluid/electrolyte imbalances, and improve patient general health

    • NG tubes can provide continuous decompression, allowing the ulcer to start healing + edema is subside

    • Pain relief results from decompression

    • IV fluids/electrolytes are replaced according to the degree of dehydration, vomiting, and electrolyte imbalance shown by lab tests

    • PPI/H2 receptor blockers are used if obstruction are due to active ulcers

Interprofessional care: peptic ulcer disease

• Conservative

  • Consists of adequate rest, drug therapy, smoking cessation, diet mods (if needed), and long-term follow-up care

  • Pain disappears after 3-6 days

  • Ulcer healing is slower; completion can take 3-9 weeks, depending on size, treatment, and patient adherence to care plan

  • Follow-up endoscopic exams are done 3-6 months after diagnosis + treatment

  • Aspirin + nonselective NSAIDs are stopped for 4-6 weeks

    • Wen aspirin must be continued, its given with a PPI, H2 receptor blocker, or misoprostol

    • Enteric-coated aspirin decreases localized irritation but doesn’t reduce overall risk for GI bleeding

• Drug therapy

  • Focuses on reducing gastric acid secretion and/or eliminating H. pylori infection

  • Patients with H. pylori infections need treatment with antibiotics + PPIs

  • Due to high recurrence rates, interruptions/sudden cessation of meds can be harmful

    • Encourage patients to adhere to therapy + continue with follow-up care as ordered

    • Teach patients + caregivers about each prescribed med, its rationale, and expected benefits

    • Review actions to take if pain + discomfort recur or if there’s blood in vomit/stool

  • Antibiotics

    • Is prescribed with a PPI for 14 days

    • If patients are allergic to penicillin, metronidazole is used instead

    • Bismuth can given alone or in a combo capsule with bismuth, tetracycline, and metronidazole

  • PPIs

    • More effective than H2 receptor blockers in reducing gastric acid secretion + promoting ulcer healing

    • Used in combo with antibiotics to treat ulcers caused by H. pylori

  • Cytoprotective drugs

    • Sucralfate is used for short-term ulcer treatment; provides mucosal protection for the esophagus, stomach, and duodenum

    • Most effective in acidic environments; give 60 mins before/after antacids

    • Reduces bioavailability of

      • Cimetidine

      • Digoxin

      • Warfarin

      • Phenytoin

      • Tetracycline

  • Adjunct drugs

    • H2 receptor blockers + antacids can used as adjunct therapy to promote healing

    • Antacids neutralize stomach acid → reducing acid content of chyme reaching the duodenum

      • Some can bind to bile salts (aluminum hydroxide) → decreasing damaging effects of bile on gastric mucosa

    • Misoprostol prevents gastric ulcers caused by NSAIDs + low dose aspirin therapy

      • Can cause diarrhea + abdominal pain

      • Teratogenic; pregnant patients should avoid

    • TCAs (imipramine, doxepin)

      • Help with pain relief via effects on afferent pain fiber transmission

      • Anticholinergic effects → reduced acid secretion

    • Anticholinergics can also be used

• Nutrition therapy

  • No specific diets helps to treat

  • Patients should consume things that don’t cause distressing symptoms

  • Common irritable foods

    • Pepper

    • Carbonated drinks

    • Broths

    • Hot + spicy

    • Caffeinated foods/drinks

  • Patients should avoid alcohol; it delays healing

• Surgical therapy

  • Reserved for those who are unresponsive to medical management or concerns about stomach cancers

Nursing care: peptic ulcer disease

• Health promo

  • ID at-risk patients

  • Encourage patients on ulcerogenic meds to take them with food

  • Teach patients to report symptoms related to gastric irritation, including epigastric pain, to their providers

• Acute care

  • Explain to patients + caregivers the rationale for therapies

  • Provide regular regular oral care to relieve dry mouths

  • Clean + lubricate nares to decreased soreness

  • Take vitals initially and then at least hourly to detect + treat shock

  • Give IV fluids as ordered

  • Record I/O

  • Promote quiet + restful environments

  • Give pain meds as ordered

    • Be cautious when give sedatives to patients who are becoming increasingly restless; meds can mask signs of shock form GI bleeds

  • GI bleeding

    • Changes in vitals + increase in amount and redness of aspirate can indicate bleeding

    • Pain often decreased because blood helps neutralize acidic gastric contents

    • Maintain NG tube patency so that blood clots don’t obstruct tubes

  • Perforation

    • If patients develop manifestations of perforations, notify providers immediately

    • Take vitals promptly + record q15-30mins

    • Give IV fluids as ordered to replace the depleted plasma volume

    • Give pain meds as ordered

    • If possible, prep patients + caregivers on the possibility/reality of surgical therapy

  • Gastric outlet obstruction

    • Regularly irrigate NG tube with normal saline per agency policy to assist proper functioning

    • Reposition patients from side to side so that the tubes are constantly lying the mucosal surface

    • Maintain accurate I/O records, especially of the gastric aspirate

    • To check for ongoing obstruction, clamp NG tubs intermittently and measure gastric residual volume

      • Frequency + amount of time that tubes are clamped are related to the amount of aspirate obtained and patient comfort level

      • Common method is to clamp tubes overnight (8-12 hours) and measure gastric residual volume in the morning

      • When aspirate is <200 mL, patients can start clear liquid diets; fluids start at 30 mL/hr and gradually increased

        • As gastric residual decreased, solids are added, and tubes removed

    • If patients resume oral feeds and symptoms of obstruction are noted, notify providers immediately

      • Usually, gastric aspiration is continued until edema + inflammation resolve

      • IV fluids/electrolytes keep patients hydrated

    • If conservative therapy fails, surgery is done after the acute phase passes

• Ambulatory care

  • Teach patients about prescribed drugs, actions, side effects, and dangers if omitted

    • Ensure patients know not to take OTCs unless approved by providers

    • Tell patients to check with providers before changing from a prescription → OTC H2 receptor block/PPI med to avoid side effects and incorrect dosing

  • Obtain info on patient psychosocial status

    • Provide info on negative effects of alcohol and cigarettes on ulcers + healing

  • Teach patients with chronic peptic ulcer disease about potential complication + actions to take until they see provider

  • Emphasize the need for long-term follow-up care

  • Encourage patients to seek immediate intervention if symptoms recur

  • Patient teaching

    • Avoid distressing foods, such as acidic foods

    • Avoid smoking + alcohol

    • Avoid OTCs unless approved by provider

    • Don’t change brands of meds without provider approval

    • Followed prescribed drug therapy to prevent relapse

    • Report

      • Increased N/V

      • Increased epigastric pain

      • Blood emesis/tarry stools

    • Learn + use effective stress management methods

    • Share concerns about lifestyle change + living with chronic condition

Etiology + patho: gastric ulcers

• Can occur in any part of the stomach; most often in the antrum

• Less common than duodenal

• Higher mortality rate

• More likely to cause obstructions

• Risk factors

  • H. pylori

  • NSAIDs

  • Bile reflux

Etiology + patho: duodenal ulcers

• Account for most occurrences

• Can occur at any age

• H. pylori is the most common risk factors

• Development is often related to high stomach acid secretion

• Tend to occur continuously for a weeks/months, disappear, and recur later

• Risk factors

  • COPD

  • Cirrhosis

  • Pancreatitis

  • Hyperparathyroidism

  • CKD

  • Zollinger-Ellison syndrome

Nursing care: bowel resection surgery

• Preop

  • Special considerations

    • Psychologic prep

    • Educational prep

    • Selecting the best stoma site

  • If possible, WOCNs should visit with patients + caregivers to determine patient ability to perform self-care, ID support systems, and determine and mods that can promote learning during recovery

  • Psych + emotional support are important, as patients start to cope with the changes in body image + elimination

  • Patients + caregivers should understand the extent of surgery planned

    • Provide them with chances to share concerns/questions; will enhance patient feelings of control + coping ability

  • WOCNs should choose the site where ostomies will be + mark abdomens before surgery

    • Sites should be within the rectus muscle, on a flat surface, and in a place where patients can see

    • When possible, it should be discreetly hidden under clothes + appropriate for normal activities

• Postop

  • If patients’ wound are closed/partially closed, assess integrity of the incision

  • Monitor for complications

    • Delayed wound healing

    • Hemorrhage

    • Fistulas

    • Infections

  • Assess wounds regularly + record bleeding, excess drainage, and unusual odors

  • Monitor for edema, redness, and drainage, as well as fever and a high WBC count

  • Keep areas around drains clean + dry

  • Patients with open wounds with packing need meticulous care

  • Reinforce dressings + change often during first several hours postop when drainage is likely to be profuse

  • Carefully assess all drainage for amount, color, and consistency

  • If ostomies are present, assess stoma + place clear pouching system

    • Stomas should be rosy pink → red + mildly swollen

    • Assess + document stoma color q4h + ensure there’s excess bleeding

    • Report any sustained color changes or bleeding to providers

    • Edema will resolve over the first 6 weeks

  • Colostomies start functioning when peristalsis returns

    • Record volume, color, and consistency of drainage

    • When done on colons not cleared preop, stool will drain when peristalsis returns

    • If colons were cleared preop, stool will produce a few days after patients start eating again

    • Excess gas are common during the first 2 week; assure patients that this is temporary

  • In the first 24-48 hours postop, drainage amount form ileostomies can be negligible

    • When peristalsis returns, output can be as high as 1500 - 1800 mL/day

    • If the small bowel is shortened by surgery, drainage can be greater due to the loss of absorptive functions provided by the colon + delay provided by the ileocecal valve

    • Observe patients for fluid/electrolyte imbalances, particularly potassium + sodium

    • Over a period of days/weeks, proximal small bowel adapts + increases fluid absorption; feces will thicken to a paste-like consistency + volume will decreased to ~500 mL/day

    • Patients, especially those with Crohn’s are at risk for developing obstructions during the first 30 days postop

  • After intraoperative manipulation of the anal canal, transient incontinence of mucus can occur

    • Have patients start Kegel exercises ~4 weeks postop to strengthen the pelvic floor + sphincter muscles

    • Teach patients to perform perianal skincare to protect the epidermis from mucous damage and maceration

      • They should gently the skin with a mild cleanser, rinse well, and dry thoroughly

    • Some report phantom rectal pain or still feel the need to have a bowel movement; normal + will subside over time

      • Be aware to distinguish phantom pain from perineal abscess pain

• Sexuality

  • Discuss sexuality + sexual functions with patients; help them realize that it takes time to adjust to the pouch + body changes before feeling secure with sex

  • Teach patients to empty pouches before sex

• Ostomy care

  • Inpatient care

    • Assess + document stoma + peristomal skin appearance

    • Assess patient prep for ostomy care

    • Help patient with managing psych impact of stoma + effect on body image and self esteem

    • Choose appropriate ostomy pouching system

    • Monitor volume, color, and odor of drainage

    • Develop care plan for peristomal skin care

    • Teach ostomy self-care to patients

    • Irrigate new ostomies, if needed

    • Teach patient + caregiver about proper diet choices

  • Patient teaching

    • Explain ostomy + functionality + rationale for operation

    • Demonstrate + request return demo of:

      • How to remove old barriers, clean peristomal skin, and properly apply new barriers

      • Apply, empty, clean, and remove pouch

      • Empty pouch before 1/3 full

    • Irrigate ostomy to regulate bowel elimination (optional)

    • Explain how to contact WOCN

    • Describe how to obtain ostomy supplies

    • Explain diet + fluid management

      • Avoid foods that cause diarrhea/gas

      • Maintain fluid intake of 3k L/day, unless contraindicated

      • Increase fluid intake in hot weather

      • Recognize signs of fluid/electrolyte imbalance

      • Chew food well to reduce blockage risk

• Psychologic adaptation

  • Provide info in an easily understood manner + help patients develop confidence + competence in stoma management

  • Help patients ID coping methods

  • Encourage participation + support from families/caregivers/friends

  • Encourage patients to share concerns + ask questions

Etiology + patho: abdominal trauma

• Blunt trauma often occurs from MVCs, direct blows, and falls

  • May not be obvious due to no open wound

  • Compression + shearing injuries can occur with blunt trauma

• Penetrating injuries occur when GSWs/stabbings leave obvious + open wounds

• When solid organs are injured, bleeding can be profuse → hypovolemic shock

• When content form hollow organs spill into the peritoneal cavity → peritonitis risk

Clinical manifestations: abdominal trauma

• Intraabdominal injuries are often associated with

  • Rib fractures

  • Fractured pelvis

  • Spinal injury

  • Thoracic injury

• Patients in MVCs can have contusions/abrasions across the lower abdomen

  • Indicative of internal organ trauma from seatbelts

  • Seatbelts can produce blunt trauma to abdominal organs by pressing intestines + pancreas into the spinal column

• Guarding + splinting of the abdominal wall (indicative of peritonitis)

• Hard + distended abdomen (indicative of intraabdominal bleeding)

• Decreased/absent bowel sounds

• Abrasions/bruising over the abdomen

• Abdominal pain

• Hematemesis/hematuria

• Signs of hypovolemic shock

  • Hypotension

  • Tachycardia

  • Decreased LOC

  • Tachypnea

• Cullen sign (bruising around the umbilicus)

• Grey Turner sign (bruising around the flanks)

• Bowel sounds in the chest, with diaphragm rupture

• Bruit auscultation → arterial damage

Nursing + interprofessional care: abdominal trauma

• Volume expanders + blood are given if patients are hypotensive

• NG tubes + low suction will decompress stomach + prevent aspiration

• Frequent + ongoing assessments are done to monitor fluid status, detect deteriorations, and determine surgical needs

• Do not remove impaled objects until skilled care is available

Etiology + patho: abdominal compartment syndrome

• Sustained/repeated excessively high pressure (>12 mmHg) in the abdomen; aka abdominal hypertension

  • Anything that increases volume in the abdominal cavity increases abdominal pressure

  • High pressure restricts ventilation → respiratory failure

  • High pressures decrease cardiac output, venous return, and arterial perfusion of organs

• Causes

  • Fluid resuscitation

  • Ascites

  • Abdominal trauma

  • Surgery

  • Bleeding

Clinical manifestations: abdominal compartment syndrome

• Distended abdomen

• Decreased urine output

• Increased ventilator pressures

• Hypotension

Nursing + interprofessional care: abdominal compartment syndrome

• Often measured via bladder catheter

• ID cause + intervene to improve abdominal wall compliance

• Evacuate intraluminal contents

• Surgical decompression

Etiology + patho: ischemic bowel

• Reduced blood flow → oxygen starvation to intestines, possibly leading to tissue damage, necrosis, and perforation

• Causes

  • Blocked arteries (atherosclerosis)

  • Blood clots (embolism)

  • Venous thrombosis

  • Hypotension

Clinical manifestations: ischemic bowel

• Sudden + intense abdominal pain often disproportionate to physical exam findings

• Vomiting

• Bloody diarrhea

• Confusion (severe)

Nursing + interprofessional care: ischemic bowel

• Restore blood flow immediately

  • IV fluids

  • Bowel rest

  • Antibiotics

  • Surgical intervention

    • Remove clots

    • Bypass blocked vessels

    • Remove necrotic tissue

Etiology + patho: acute liver failure

• Characterized by a rapid onset of severe liver dysfunction in one with no history of liver disease

• Often accompanied by hepatic encephalopathy

• Causes

  • Meds (most common)

    • Acetaminophen

    • Isoniazid

    • Sulfa-containing drugs

    • Anticonvulsants

  • Herbal + diet supplements

  • Autoimmune hepatitis

  • Viral hepatitis, especially HBV

Clinical manifestations: acute liver failure

• Jaundice

• Coagulation problems

• Encephalopathy

• Fatigue

• Nausea

• Appetite loss

• Right sided abdominal pain

• Confusion

• Coma

Complications: acute liver failure

• Cerebral edema

• Renal failure

• Hypoglycemia

• Metabolic acidosis

• Sepsis

• Multiorgan failure

Diagnostic studies: acute liver failure

• Lab tests

  • High bilirubin

  • Prolonged PT time

  • High liver enzymes

  • Blood chemistry, especially glucose

  • CBC

  • Acetaminophen level

  • Toxin screens

  • Viral hepatitis virology, especially HAV + HBV

  • Ceruloplasmin + alpha-1 antitrypsin levels

  • Iron

  • Ammonia

  • Autoantibodies

• CT/MRI, to give info on liver size + contour, tumor/ascites presence, and patency of blood vessels

Nursing + interprofessional care: acute liver failure

• Planning for transfer to a transplant center should start for patients with grade 1-2 encephalopathy because patients can worsen rapidly

  • Early transfer is important because the risks involved with transport can increase or prevent transfer if stage 3-4 encephalopathy develops

• Protect renal function by maintaining adequate fluid balance, avoiding nephrotoxic drugs, and promptly IDing + treating infection

• Monitor + manage hemodynamic + renal function, glucose, electrolytes, and acid-base status

• Conduct frequent neuro evals for signs of increased ICP

  • Elevate heads of bed to 30 degrees

  • Avoid excessive patient stimulation (straining/Valsalva maneuvers)

• Assess patients regularly for baseline LOC + orientation; report changes immediately

• Avoid sedative use due to their effects on mental status; they can be confused for worsening encephalopathy

• Use minimal doses of benzos due to delayed metabolism by failing livers

• Closely observe patients to prevent injuries + pad bedrails to avoid injury from possible seizures

• Monitor I/O for renal function

• Provide good skin + oral care to avoid breakdown + infection

Etiology + patho: acute pancreatitis

• Most commonly caused by gallbladder disease (gallstones); is more common in women

  • Next commonly caused by chronic alcohol use; is more common in men

• Most pathologic mechanism is autodigestion of the pancreas; the causative factors injure pancreatic cells or activate pancreatic enzymes instead of in the intestine

  • Can be due to reflux of bile acids into the pancreatic ducts through an open/distended sphincter of Oddi

• Further classed as:

  • Mild pancreatitis

  • Severe pancreatitis

    • About half of patients have permanent decreases in pancreatic endocrine and exocrine function

Clinical manifestations: acute pancreatitis

• Abdominal pain is the main manifestation

  • Is caused by pancreatic distention, peritoneal irritation, and biliary tract obstruction

  • Is usually in the LUQ but may be epigastric

  • Often radiates to the back due to the retroperitoneal location of the pancreas

  • Has sudden onset and described as severe, deep, piercing, and continuous/steady

  • Worsened by eating but not relieved by vomiting; may be accompanied by flushing, cyanosis, and dyspnea

  • Often starts when patient is recumbent

• N/V

• Low-grade fever

• Leukocytosis

• Hypotension

• Tachycardia

• Jaundice

• Abdominal tenderness + guarding

• Decreased/absent bowel sounds

• Paralytic ileus → abdominal distention

• Crackles

• Grey Turner sign

• Cullen sign

• Shock

Complications: acute pancreatitis

• Severity of acute pancreatitis depends on the extent of pancreatic destruction

• Pseudocyst

  • Accumulation of fluid, pancreatic enzymes, tissue debris, and inflammatory exudates surrounded by a wall next to the pancreas

  • Manifestations

    • Abdominal pain

    • Palpable epigastric mass

    • N/V

    • Anorexia

  • Spotted by CT, MRI, and endoscopic ultrasound

  • Treatment options

    • Surgical drainage

    • Percutaneous catheter placement + drainage

    • Endoscopic drainage

• Abscess

  • Infected pseudocyst; results from extensive necrosis in the pancreas

  • Manifestations

    • Upper abdominal pain

    • Abdominal mass

    • High fever

    • Leukocytosis

• Autodigestion

• Main systemic complications are cardiovascular and pulmonary

  • Pulmonary complications are due to the passage of exudate-containing pancreatic enzymes from the peritoneal cavity through transdiaphragmatic lymph channels

  • Enzyme-induced inflammation of the diaphragm occurs, with the result being atelectasis caused by reduced diaphragm movement

• Trypsin can activate prothrombin and plasminogen, increasing patient risk for intravascular thrombi, pulmonary emboli, and disseminated intravascular coagulation

• Hypotension can occur from fluid shifts sepsis

Interprofessional care: acute pancreatitis

• Conservative therapy

  • Treatment focused on supportive care

  • Includes:

    • Aggressive hydration

    • Pain management

    • Management of metabolic complications

    • Minimizing pancreatic stimulation

  • Atropine and other anticholinergics are avoided when paralytic ileus is present because they can slow GI motility and make the problem worse

  • Patients with severe pancreatitis have glucose levels monitored for hyperglycemia

  • Blood volume replacements are given if shock is present

    • Central venous pressure readings can help determine fluid replacement requirements

  • It’s important to reduce/suppress pancreatic enzymes to decrease pancreatic stimulations and let it rest

    • Methods:

      • NPO status

      • NG suctioning to reduce vomiting and gastric distention and to prevent gastric acidic contents from entering the duodenum

  • Monitor patients at risk of acute necrotizing pancreatitis closely to start antibiotic therapy if necrosis and infection occur

• Surgical therapy

  • May be done when the diagnosis is uncertain or if the patient fails to response to conservative therapy

• Nutrition therapy

  • Initially, patients with acute pancreatitis are made NPO to reduce pancreatic secretion

  • Depending on severity, enteral nutrition is started

    • Parenteral nutrition is reserved for those who can’t tolerate enteral nutrition due to infection risk

  • As pancreatitis resolves, oral intake resumes

    • When food is allowed, start with small, frequent feedings

      • High carb diets are used because they’re the least stimulating to the exocrine pancreas

  • Suspect intolerance to oral foods when:

    • Patient reports pain

    • Abdominal girth increases

    • Serum amylase and lipase levels increase

Nursing care: acute pancreatitis

• Health promo

  • Major factors:

    • Assessing the patient for risk factors

    • Encouraging early treatment of these factors to prevent acute pancreatitis

  • Encourage cessation of alcohol intake, especially if they have history of pancreatitis

• Acute care

  • Monitor vitals; hypotension, fever, and tachypnea can compromise hemodynamic stability

  • Monitor response to IV fluid

  • Closely assess fluid/electrolyte balance

  • Assess respiratory function

  • Due to hypocalcemia risk, assess for signs of tetany (jerking, irritability, muscular twitching, numbness/tingling around lips and fingers)

  • Assess for positive Chvostek/Trousseau sign

  • Monitor magnesium levels; hypomagnesemia can develop

  • Assess + document duration of pain relief

    • Comfortable positioning, frequent position changes, and relieving N/V help reduce restlessness accompanying pain

  • Oral/nasal care for NPO or NG intubated patients relieve dryness of the mouth and nose

  • Observe for fever pr other signs of infection in patients with pancreatitis

  • Respiratory tract infections are common and cause patients to take shallow, guarded abdominal breaths

    • Prevention methods:

      • Turning

      • Coughing

      • Deep breathing

      • Semi-Fowler’s positioning

  • Observe for signs of paralytic ileus, renal failure, and mental changes

• Ambulatory care

  • PT may be needed due to loss of physical and muscle strength

  • Continued care to prevent infection and detect complications is important

  • Counseling about alcohol abstinence is important to prevent patients from future attack and developing chronic pancreatitis

  • Patients should avoid smoking, as nicotine stimulates the pancreas

  • Teach patient + caregiver on treatment plans, including the importance of taking the required meds and following the recommended diet

    • Diet teaching should include fat restriction; fat stimulates the pancreas

  • Encourage carbs as they are less stimulating to the pancreas

  • Teach patient + caregiver to recognize and report symptoms of infection, diabetes, or steatorrhea (foul smelling, fatty stools)

Etiology + patho: chronic pancreatitis

• Continuous, prolonged, inflammatory, and fibrosing process of the pancreas

• Pancreas is progressively destroyed + replaced by fibrotic tissue

• Most common cause of nonobstructive pancreatitis (most common type of chronic pancreatitis) is chronic alcohol use

• Most common cause of obstructive pancreatitis is inflammation of the sphincter of Oddi form gallstones

  • Cancers of the ampulla of Vater, duodenum, or pancreas are also causative