Intracranial Hypertension or and purposeless

Increased ICP movements

 Pupillary changes and impaired
ocular movements
 Weakness in one extremity or
one side
 Headache: constant, increasing
in intensity, or aggravated by
movement or straining

Manifestations of Increased ICP—

Late
 Respiratory and vasomotor
changes
 VS: increase in systolic blood
pressure, widening of pulse
 Cerebral blood flow (CBF) and pressure, and slowing of the
autoregulation heart rate; pulse may fluctuate
 CBF rapidly from tachycardia to
 50 mL/100 g brain tissue per bradycardia and temperature
minute increase
 Brain is 2% weight  Cushing’s triad:
 Brain requires 15% to 20% of bradycardia, hypertension,
resting cardiac output and bradypnea
 Projectile vomiting
 Autoregulation  Further deterioration of LOC;
 Range: 50 to 150 mm Hg mean stupor to coma
arterial blood pressure (MAP)  Hemiplegia, decortication,
 Arterial blood gases decerebration, or flaccidity
 Metabolic activity in brain  Respiratory pattern alterations
including Cheyne-Stokes
 ICP and CPP breathing and arrest
 CCP (cerebral perfusion  Loss of brain stem reflexes:
pressure) is closely linked to pupil, gag, corneal, and
ICP swallowing
 CCP = MAP (mean arterial
pressure) – ICP Nursing Process—Assessment of the
 Normal CCP is 70 to 100 Patient With Increased Intracranial
 A CCP of less than 50 results in Pressure
permanent neuralgic damage  Conduct frequent and ongoing
neurologic assessment
Manifestations of Increased ICP—  Evaluate neurologic status as
Early completely as possible
 Changes in level of  Glasgow Coma Scale
consciousness  Pupil checks
 Any change in condition  Assess selected cranial nerves
 Restlessness, confusion,  Take frequent vital signs
increasing drowsiness,  Assess intracranial pressure
increased respiratory effort,
 Intracranial Hypertension  Infection
 Assessment and diagnosis
 Signs and symptoms of Nursing Process—Planning the Care
Increased ICP of the Patient With Increased
 Decreased level of Intracranial Pressure
consciousness (earliest)  Major goals may include:
 Cushing’s triad  Maintenance of patent airway
(bradycardia, systolic  Normalization of respirations
hypertension, and  Adequate cerebral tissue
bradypnea) perfusion
 Diminished brainstem  Respirations
reflexes  Fluid balance
 Papilledema  Absence of infection
 Abnormal flexion  Absence of complications
(decerebrate posturing)
Medical and nursing management
 Signs and symptoms of  Positioning and other nursing
increased ICP activities
 Abnormal extension  Avoid positions that decrease
(decorticate posturing) venous return from head:
 Unequal pupil size Trendelenburg, prone, extreme
 Projectile vomiting hip flexion
 Decreased pupillary  Decrease intrathoracic pressure
reaction to light  Avoid use of positive end-
 Altered breathing patterns expiratory pressure
 Headache  Decrease intraabdominal pressure
 Avoid Valsalva maneuver
Location of the Foramen of Monro for
Calibration of ICP Monitoring Hyperventilation
System  Maintain Paco2 at 35 mm Hg (±2
mm Hg)
 Avoid prolonged hypocarbia
 Fio2 less than 60%
 Avoid oxygen toxicity
Nursing Process—Diagnosis of the  Temperature control
Patient With Increased Intracranial  Hyperthermia increases
Pressure cerebral metabolic rate
 Ineffective airway clearance  Antipyretics
 Ineffective breathing pattern  Cooling devices
 Ineffective cerebral perfusion  Hypothermia decreases cerebral
 Deficient fluid volume related metabolic rate
to fluid restriction
 Risk for infection related to ICP  Blood pressure control
monitoring  Maintain in high normal range
 Sedation
Collaborative Problems/Potential  Antihypertensive drugs
Complications  Cotreatment with beta-blockers
 Brain stem herniation  Relationship between blood
 Diabetes insipidus pressure and ICP
 SIADH
 Intracranial Hypertension
(continued)

 Diuretics and volume maintenance

 Osmotic diuretics
 Mannitol
 Serum osmolality 300 to
320 mOsm/L
 Nonosmotic diuretics
 Furosemide (Lasix)
 Volume maintenance Pharmacologic Agents
 Control of metabolic demand  Anticonvulsants
 Barbiturate therapy  Barbiturates
 Osmotic diuretics
 Loop diuretics
 Calcium channel blockers
 Local anesthetics
 Thrombolytics

Seizure control
 Anticonvulsant medications
 Seizures increase metabolic rate

 Abnormal episodes of motor,

 Herniation syndromes sensory, autonomic, or psychic
 Herniation of intracerebral contents activity (or a combination of these)
results in shifting tissue from one resulting from a sudden, abnormal,
compartment of the brain to another uncontrolled electrical discharge
and places pressure on cerebral from cerebral neurons
vessels and vital function centers  Classification of seizures:
 Supratentorial herniation  Partial seizures: begin in one
 Uncal herniation part of the brain
 Central herniation  Simple partial: consciousness
 Cingulate herniation remains intact
 Transcalvarial herniation  Complex partial: impairment of
 Infratentorial herniation consciousness
 Upward herniation  Generalized seizures: involve
 Downward cerebellar the whole brain
herniation

Herniation Syndromes
Specific Causes of Seizures
 Cerebrovascular disease
 Hypoxemia
 Fever (childhood)
 Head injury
 Hypertension
 Central nervous system
infections
  Metabolic and toxic conditions
 Brain tumor 2. Contracture development leading to
 Drug and alcohol withdrawal impaired physical mobility can occur
 Allergies following a major burn injury. Splints
are applied to prevent or correct
Plan of Care for a Patient contractures. Priority nursing actions
Experiencing a Seizure concerning this therapy include all of the
 Observation and documentation following EXCEPT
of patient signs and symptoms a. daily assessment for proper fit and
before, during, and after seizure effectiveness.
 Nursing actions during seizure b. removal and reapplication on the
for patient safety and protection prescribed schedule.
 After seizure care, prevent c. allowing for frequent breaks from
complications splint use with a one hour on, one hour
off schedule
Guidelines for Seizure Care d. patient education concerning the need
for splinting.

3. Which assessment finding assists the

nurse in confirming inhalation injury?
A.Wheezing
B. Decreased blood pressure
C. Nausea
D. Headache

4. Which statement best exemplifies a

good understanding of rehabilitation
after a full-thickness burn injury?
a. “I am fully recovered when all the
wounds are closed.”
Questions: b. “I will eventually be able to perform
1. A patient involved in a house fire is all my former activities.”
brought by ambulance to your c. “My goal is to achieve the highest
emergency department. He is breathing level of functioning that I can.”
spontaneously but appears agitated. He d. “There is never full recovery from a
does not respond appropriately to major burn injury.”
questions. You assume he has inhaled
carbon monoxide and is suffering from
carbon monoxide (CO) poisoning. Your 5.The client with a new burn injury asks
first action is to the nurse why he is receiving
a. ask the physician to order a STAT intravenous cimetidine (Tagamet). What
chest radiograph to rule out a is the nurse’s best response?
pneumothorax. a. “Tagamet will stimulate intestinal
b. apply a pulse oximeter to one of his movement.”
unburned fingers. B. “Tagamet can help prevent
c. call the local hyperbaric chamber to hypovolemic shock.”
check on their availability. C. “This will help prevent stomach
d. administer 100% high-flow oxygen ulcers.”
via a non-rebreather facemask. D.“This drug will help prevent kidney
damage.”
 4.The nurse should teach the diabetic
6. A 68-year-old patient is brought to the client that which of the following is the
emergency department after a house fire. most common symptom of
He fell asleep with a lit cigarette and the hypoglycemia?
couch ignited. What do you do first? a. Nervousness.
a. Clean the wounds and remove b. Anorexia.
blisters. c. Kussmaul's respirations.
B. Assess the airway and provide 100% d. Bradycardia.
oxygen.
C. Place a Foley catheter and assess for 5. A client presents to the emergency
myoglobin. room with HHNKS. The nurse would
D. Place a central intravenous access identify which of the following nursing
and provide antibiotics. diagnoses as a priority problem?
a. Disturbed Sleep Pattern.
b. Impaired Health Maintenance.
MAJOR BURN INJURY c. Imbalanced Nutrition: Less than Body
1. A client with type 1 DM is admitted Requirements.
to the emergency department. Which of d. Deficient Fluid Volume.
the following respiratory patterns
requires immediate action?
a. Deep, rapid respirations with long Diabetic Emergencies
expirations.
b. Shallow respirations with long PATHOPHYSIOLOGY OF HHNKS
expirations
c. Regular depth of respirations with
frequent pauses.
d. Short expirations and inspirations.

2. The client with DM says, "If I could

just avoid what you call carbohydrates
in my diet, I guess I would be okay."
The nurse should base the response to
this comment on the knowledge that
diabetes affects metabolism of which of
the following?
a. Carbohydrates only.
b. Fats and carbohydrates only.
c. Protein and carbohydrates only.
d. Proteins, fats, and carbohydrates.
3. The client with type 1 DM is taught to
take isophane insulin suspension NPH HHNK: Manifestations
(Humulin N) at 5 pm each day. The
client should be instructed that the  Signs of dehydration
greatest risk for hypoglycemia will  Hypertension/hypotension
occur at about what time?  Decreased CVP
a. 11 am, shortly before lunch.  Neurologic impairments
b. 1 pm, shortly after lunch.
c. 6 pm, shortly after dinner. Management
d. 1 am, while sleeping.
 Fluid replacement w/isotonic  Bicarbonate infusion with
fluid w/in 1st 12 hrs then severe acidosis
hypotonic in the following 24  Insulin drip (.1-.2U/kg/hr)
hrs.  Correct electrolyte imbalances
 Insulin drip till 300mg/dl then  Monitor cardiac, pulmonary
shift to D5 containing IV and neurologic status
 Monitor CV and neuro status
 Monitor for embolic 1. A client developed shock after a
complications and institute severe myocardial infarction and has
preventive measures now developed acute renal failure. The
client's family asks the nurse why the
PATHOPHYSIOLOGY OF DKA client has developed acute renal failure.
The nurse should base the response on
the knowledge that there was

a. a decrease in the blood flow through

the kidneys
b. an obstruction of urine flow from the
kidneys.
c. a blood clot formed in the kidneys.
d. structural damage to the kidney
resulting in acute tubular necrosis.

2. In the oliguric phase of acute renal

failure, the nurse should anticipate the
development of which of the following
complications?
DKA: Manifestations
a. Pulmonary edema.
 Signs of dehydration b. Metabolic alkalosis.
 Ketosis c. Hypotension
 Metabolic acidosis leading to d. Hypokalemia.
kussmaul’s breathing
 Ketonuria 3. In assessing the client recently
 Weakness diagnosed with acute glomerular
 Anorexia nephritis, the nurse asks which question
 Vomiting to determine potential contributing
 Abdominal pain factors?
 Decreased LOC
 TachycardiaOrthostatic a. “Are you sexually active?”
hypotension b. “Do you have pain or burning on
urination?”
Management c. “Has anyone in your family had
chronic kidney problems?”
 Monitor CBG and ABG d. “Have you had any type of infection
 Replace fluids and electrolytes: within the last 2 weeks?”
rapid replacement with PNSS
then with hypotonic solution 4. The client with glomerular nephritis
(.45%NS) has a glomerular filtration rate (GFR) of
40 mL/min, as measured by a 24-hour
creatinine clearance. Which is the  May result in death from
nurse’s interpretation of this finding? acidosis, potassium
intoxication, pulmonary edema,
a. Excessive glomerular filtration rate, or infection
client at risk for dehydration\  May progress from the anuric
b. Excessive glomerular filtration rate, or oliguric phase through the
client at risk for fluid overload diuretic phase to the
c. Reduced glomerular filtration rate, convalescent phase (which can
client at risk for dehydration take 6 to 12 months) to
d. Reduced glomerular filtration rate, recovery of function
client at risk for fluid overload  May progress to chronic renal
failure; chronic renal failure
Oncologic Emergencies may develop as a separate
entity and does not have to be a
Types sequela of acute failure

 Metabolic Emergencies CAUSES OF ARF

 Disseminated Intravascular  PRE RENAL

Coagulation  INTRA RENAL
 Sepsis  POST RENAL
 Tumor Lysis Syndrome
 Syndrome of Inappropriate Pathophysiology
Secretion of Antidiuretic
Hormone Depending on the cause, several
 Anaphylaxis different pathophysiologic mechanisms
may operate in ARF:
 Structural Emergencies
1. Tubular obstruction
 Increased Intracranial Pressure 2. Back-leak of filtrate through
 Spinal Cord Compression damaged tubules
 Superior Vena Cava Syndrome 3. Hemodynamic (vascular) alterations
 Cardiac Tamponade
Results of Damage to the Renal
Renal Failure tubules

Acute Renal Failure  Damage to the renal tubules may be

produced by ischemic or
 Usually follows direct trauma nephrotoxic damage. Tubular
to the kidneys or overwhelming damage can lead to decreased
physiologic stress (e.g., burns,
septicemia, nephrotoxic drugs
and chemicals, hemolytic blood
transfusion reaction, severe
shock, renal vascular occlusion) glomerulofiltration through
that decreases blood flow to the increased intrarenal tension and
glomeruli or to the nephrons decreased blood flow.
 Sudden and almost complete
loss of glomerular and/or Assessment
tubular function
1. Daily weight j. Decreased serum levels of:
2. Signs of hyperkalemia and
hyponatremia 1) Calcium
3. History of clinical symptoms and 2) Sodium
potential causative factors 3) pH
4) Carbon dioxide combining
power

Clinical findings k. Anemia

l. Albumin in urine
 Subjective m. Decreased specific gravity

a. Lethargy and drowsiness that can

progress from stupor to coma
b. Irritability and headache Therapeutic interventions
c. Circumoral numbness
d. Tingling extremities 1. Direct treatment toward correcting
e. Anorexia the underlying cause of renal failure
(e.g., treat shock, eliminate drugs
 Objective and toxins, treat transfusion
reactions, restore integrity of
a. Sudden dramatic drop in urinary urinary tract)
output appearing a few hours after 2. Maintain client on complete bed rest
the causative event 3. Diet therapy
b. Oliguria: urinary output less than
400 ml but more than 100 ml/24 a. Protein low to moderate according
hours; anuria: urinary output less to tolerance: 30 to 50 g
than 100ml/24 hours b. Carbohydrate relatively high for
c. Restlessness, twitching, convulsions energy: 300 to 400 g
d. Nausea and vomiting c. Fat relatively moderate: 70 to 90 g
e. Skin pallor, anemia, and increased d. Calories adequate for maintenance
bleeding time, which can progress and to prevent tissue breakdown:
to epistaxis and internal hemorrhage 2000 to 2500 daily
f. Ammonia (urine) odor to breath and e. Sodium controlled according to
perspiration, which can progress to serum levels and excretion
uremic frost on skin and pruritus tolerance: varying from 400 to 2000
g. Generalized edema, hypervolemia, mg
hypertension, and increased venous f. Potassium controlled according to
pressure, which can progress to serum levels and excretion
pulmonary edema and congestive capacities: varying from 1300 to
heart failure 1900 mg
h. In addition, respirations are deep g. Water controlled according to
and rapid as a compensatory excretion: about 800 to 1000 ml;
response to the developing careful intake and output records
metabolic acidosis vital
i. Elevated serum levels of h. Calcium intake of 1000 mg/day is
needed to prevent or delay
1) BUN progression of renal osteodystrophy,
2) Creatinine or demineralization of bone, which
3) Potassium can result from chronic acidosis and
 altered vitamin A metabolism; 13. Protect client from injury caused by
because of dietary restrictions, bleeding tendency, the possibility of
supplementation may be prescribed; convulsions, and a clouded sensorium
calcium supplements, however, 14. Allow the client as much choice as
should not be given unless serum possible in the selection of food while
phosphate is under control because recognizing that little variation is
of risk of precipitation of calcium possible
phosphate in the kidney 15. Provide mouth care before, after, and
between meals
4. Frequent monitoring of vital signs 16. Administer dietary and electrolyte
and intake and output supplements as ordered
5. Packed cells, electrolytes, and 17. Administer antiemetics to control
glucose IV as necessary nausea and sodium-free antacids to
6. Exchange resins to decrease serum reduce GI irritation
potassium
7. Antibiotics to reduce possibility of Evaluation/Outcomes
infection
8. Peritoneal dialysis or hemodialysis 1. Maintains adequate dietary intake
9. Surgical intervention if kidney 2. Remains free of infection
transplant is a viable alternative 3. Remains free from injury
4. Describes treatment protocols and
Interventions plans for compliance
5. Maintains fluid and electrolyte
1. Monitor intake and output at frequent balance within acceptable limits
intervals
2. Limit fluid intake as ordered 1. Diet therapy for a hypertensive person
3. Observe for signs of overhydration 1 day after a myocardial infarction
(e.g., dependent, pitting, sacral, or would include all the following
periorbital edema; crackles or dyspnea; EXCEPT
headache, distended neck veins, and 2.
hypertension) 3.
4. Continue to monitor for hyperkalemia 4.
and hyponatremia
5. Administer electrolytes as ordered
6. Provide periods of undisturbed rest to
conserve energy and oxygen
7. Protect client from cross-infection
8. Observe for early signs and
symptoms of complications (e.g.,
hemorrhage, convulsions, cardiac
problems, pulmonary edema) The patient
9. Provide special skin care frequently to history
prevent breakdown and remove uremic plays an
frost important
10. Monitor vital signs and physical role in
status at frequent intervals; record and assessing
report any deviations immediately the
11. Administer antibiotics as ordered patient’s
12. Encourage intake of diet as ordered nutritional
and record amount consumed status.
Significant laboratory and clinical
findings in the patient with
cardiovascular disease include
3. A patient on mechanical ventilation is
receiving total parenteral nutrition 10 The nurse is providing care to a
(TPN). Which of the following is
5. true?
4. Ms. S is mechanically ventilated and
is receiving enteral nutrition via a
nasogastric tube. To help ensure feeding
tolerance, the nurse checks residual
volumes every 4 hours. During a
residual check later in the shift, the
nurse aspirates a total residual volume of
350 mL. The nurse will patient on fibrinolytic therapy. Which of
5. Mr. K is a 56-year-old man admitted the following statements from the
to the critical care unit with acute patient warrants further assessment and
respiratory distress syndrome. He is intervention by the critical care nurse?
intubated and mechanically ventilated. a. "My back is killing me!"
He is becoming increasingly agitated,
and the high-pressure alarm on the B. "There is blood on my toothbrush!"
ventilator has been frequently triggered.
The nurse's first intervention for Mr. K c. "Look at the bruises on my arms!"
would be to
6. A patient with a serum potassium D. "My arm is bleeding where my IV is!
level of 6.8 mEq/L may exhibit
electrocardiographic changes of 11.A client presents with chest trauma,
7. The patient with ventricular complaints of dyspnea, shortness of
fibrillation is breath, tachypnea, and tracheal deviation
to the right. In addition, the client’s
8. An essential aspect of teaching that tongue is blue-gray. Which of the
may prevent recurrence of heart failure following assessment data would be
is most consistent with this presentation?

a. notifying the physician if a 2-lb a. PaO288, P.CO₂ 55

weight gain occurs in 24 hours. B. Absent breath sounds in all right lung
b. compliance with diuretic therapy. fields
c. taking nitroglycerin if chest pain C. Absent breath sounds in all left lung
occurs. fields
d. assessment of an apical pulse. D. Diminished breath sounds in all fields

9. The classic description of pain

associated with aortic dissection is

a. substernal pressure.
b. tearing in the chest, abdomen, or
back.
c. numbness and tingling in the left arm.
D
d. patient is asymptomatic.