NR 341 Week 7

Name

Chamberlain University

NR-341 Complex Adult Health

Prof. Name

Date

NR 341 Week 6 Complex Intracranial – Neurological Alterations

Name

Chamberlain University

NR-341 Complex Adult Health

Prof. Name

Date

WEEK 6 EDAPT NOTES: COMPLEX CARE NR 341

Complex Intracranial – Neurological Alterations

Intracranial regulation refers to the body’s ability to manage blood and cerebrospinal fluid flow within the brain and spinal cord. This is governed by a sensitive system of nerve fibers that detect variations in pressure and flow, adjusting accordingly to maintain homeostasis. Injuries or abnormalities can disrupt this balance, necessitating adjustments by the nervous system. In some cases, these adjustments are insufficient, requiring external intervention to restore normal function. For example, if a client has a mean arterial pressure of 120 mm Hg and an intracranial pressure of 42 mm Hg, the cerebral perfusion pressure is calculated as the mean arterial pressure minus the intracranial pressure, yielding a cerebral perfusion pressure of 78 mm Hg.

When intracranial pressure is significantly elevated, a nurse may anticipate symptoms such as bradycardia, irregular respiration patterns, and widening blood pressure measurements, collectively known as Cushing’s triad. These symptoms can indicate the risk of impending cerebral herniation. Furthermore, bloody drainage from the ear may indicate a skull fracture, while cold and clammy skin below the neck may suggest autonomic dysreflexia. To assess a client’s level of consciousness accurately, the Glasgow Coma Scale (GCS) is the preferred tool. The balance of cerebrospinal fluid and blood is crucial, as intracranial pressure changes when there are alterations in brain tissue, cerebrospinal fluid, or blood volume. The body can compensate for minor changes by adjusting blood pressure or cerebrospinal fluid flow, a process known as intracranial regulation.

Altered Intracranial Regulation

Altered intracranial regulation can arise when there are unexpected changes in mass due to space-occupying lesions or increased swelling from an inflammatory response. This condition may develop gradually, as seen in brain tumors, or rapidly, as in cases of cerebral edema caused by inflammation or bleeding. Changes in the volume of brain tissue, cerebrospinal fluid, or blood can lead to fluctuations in intracranial pressure, which can, in turn, result in symptoms of decreased brain perfusion, as measured by cerebral perfusion pressure (CPP). In managing clients with complex health issues, advanced monitoring techniques are employed to measure intracranial pressures accurately. This may involve the use of drains and other devices to reduce pressure by draining cerebrospinal fluid or inducing coma and artificial ventilation to lower intracranial pressure.

In complex healthcare environments, monitoring intracranial pressure can be achieved through the placement of a catheter within the skull, providing continuous measurements that help identify elevated pressures or changes in brain temperature. Notably, the most severe complication of altered intracranial regulation is herniation, which occurs when extreme pressure inside the skull forces the brain stem through the foramen magnum, leading to severe outcomes such as death or significant brain damage. Normal ranges for these measurements are as follows:

• Mean arterial pressure (MAP): 70 to 100 mm Hg
• Intracranial pressure (ICP): 5 to 15 mm Hg
• Cerebral perfusion pressure (CPP): 60 to 80 mm Hg

There are several methods for monitoring intracranial pressure, including:

• Intraventricular Catheter: A flexible tube inserted into the lateral ventricle of the brain, providing accurate measurements and allowing for the drainage of excess cerebrospinal fluid.
• Subdural Screw (or Bolt): A hollow screw inserted through a drilled hole in the skull, which reads the pressure in the subdural space and can be quickly installed.
• Epidural Sensor: Placed between the skull and dural tissue, this is the least invasive method but does not allow for drainage of cerebrospinal fluid.

Alongside monitoring intracranial pressure, other metrics that may be assessed in complex situations include blood flow, oxygenation, metabolism, and continuous electroencephalographic monitoring. Research into the efficacy of different monitoring techniques continues to enhance patient care for those with altered intracranial regulation.

Spinal Cord Injury

Spinal cord injuries are critical neurological alterations that require immediate attention in complex healthcare environments. The spinal cord can suffer from bruising, punctures, or severing. Since the spinal cord extends from the neck down to the first and second lumbar vertebrae, damage at any point can lead to symptoms extending beyond the injury site. For example, injuries in the cervical region can affect respiratory function, while damage above the thoracic vertebrae (T6) can result in cardiovascular symptoms such as bradycardia, hypotension, and impaired vascular response. Injuries at the thoracic level may cause bowel and urinary dysfunction, including urinary retention and constipation.

The specific spinal nerves include:

• Cervical nerves (cervic/o)
• Thoracic nerves (thorac/o)
• Lumbar nerves (lumb/o)
• Sacral nerves (sacr/o)
• Coccygeal nerve (coccyg/o)

Acute Spinal Cord Injury

The severity and location of a spinal cord injury dictate the extent of paralysis and the organs affected. Depending on the injury’s severity, clients may experience complete paralysis (if the cord is severed) or temporary paralysis and paresthesia (in cases of bruising). For instance, an injury at the T6 level may lead to gastrointestinal issues like constipation, fecal impaction, and abdominal bloating, contingent on the injury’s specifics, the quality of care provided, and proactive bowel management.

The following table summarizes the impact of various spinal cord injuries on function:

Altered intracranial regulation or other neurological changes can stem from various causes, as indicated by specific cues from the client’s history:

Past Medical History:

• Previous head injury
• Brain hematomas (epidural, subdural, or subarachnoid)
• Cerebral vascular accidents leading to brain edema
• Ruptured cerebral blood vessels
• Overproduction of cerebrospinal fluid (pseudotumor cerebri)
• Meningeal inflammation or infection
• Vertebral fractures
• Osteoporosis
• Degenerative disc disease

Past Surgical History:

• Previous brain surgeries
• Previous spinal surgeries

Family History:

• Seizures
• Parkinson’s disease
• Huntington’s chorea

Social History:

• Prolonged anoxia (near drowning)
• Past trauma to the head or spine
• Occupational exposure to neurotoxins

Medications:

• Antiseizure medications indicating a history of neurological issues
• Anticoagulants posing a risk for cerebral hemorrhage
• Psychotropic medications with neurological side effects
• Serotonin-inducing drugs linked to serotonin syndrome

Conditions such as dyslipidemia, concussions, and bacterial meningitis can also disrupt intracranial regulation. A history of these conditions alerts nurses to patients at higher risk for altered regulation. Surgical procedures like lumbar laminectomies can introduce complications, potentially creating scar tissue that affects cerebrospinal fluid flow. Additionally, smoking may elevate the risk of cerebrovascular diseases, and a family history of such diseases could heighten the client’s risk as well.

Symptoms of Complex Neurological Problems

Level of Consciousness Problems:

• Altered consciousness
• Confusion
• Impaired memory and orientation

Brain-Connected Nerve Issues:

• Visual disturbances (blurred or double vision)
• Hearing impairments (unequal or absent hearing)
• Anosmia (loss of smell)
• Dysphagia or dysgeusia (swallowing or taste difficulties)
• Impaired neck or shoulder movement

Movement Issues:

• Paralysis (inability to move)
• Paresthesia (loss of sensation or abnormal sensations)
• Abnormal reflexes

Pain Symptoms:

• Headaches (considering location, duration, and intensity)
• Extremity pain

Airway Clearance and Gas Exchange:

• Breathing difficulties

Elimination Issues:

• Urinary retention or incontinence
• Fecal retention or incontinence

Reproductive Issues:

• Erectile dysfunction
• Anorgasmia

Level of Consciousness Assessment

The Glasgow Coma Scale (GCS) evaluates a client’s level of consciousness through eye-opening, verbal, and motor responses:

Eye Opening Response:

• Spontaneous: 4 points
• To verbal stimuli: 3 points
• To pain only: 2 points
• No response: 1 point

Verbal Response:

• Oriented: 5 points
• Confused conversation: 4 points
• Inappropriate words: 3 points
• Incomprehensible speech: 2 points
• No response: 1 point

Motor Response:

• Obeys commands: 6 points
• Purposeful movement to pain: 5 points
• Withdrawal from pain: 4 points
• Flexion to pain: 3 points
• Extension to pain: 2 points
• No response: 1 point

Vital Signs:

• Fever
• Cushing’s triad
• Irregular breathing patterns
• Bradycardia
• Widening pulse pressure

Brain-Connected Nerve Assessment:

• Comprehensive evaluation of cranial nerves, including:
  • I: Olfactory (smell)

• II: Optic (vision)
  • III: Oculomotor (eye movement)
  • IV: Trochlear (eye movement)
  • V: Trigeminal (facial sensation, mastication)
  • VI: Abducens (eye movement)
  • VII: Facial (facial expressions, taste)
  • VIII: Vestibulocochlear (hearing, balance)
  • IX: Glossopharyngeal (taste, swallowing)
  • X: Vagus (autonomic functions)
  • XI: Accessory (shoulder movement)
  • XII: Hypoglossal (tongue movement)

Assessment Techniques:

• Measure vital signs
• Perform a detailed neurological assessment
• Observe pupil size and reactivity
• Assess limb strength and movement
• Evaluate sensory responses
• Examine the abdomen for signs of distension or discomfort

In summary, careful assessment and monitoring are essential in managing complex care clients, particularly those experiencing altered intracranial regulation or spinal cord injuries.

Primary Nursing Diagnosis and Evaluation

Secondary Nursing Diagnosis and Evaluation

According to the National Spinal Cord Injury Statistics Center (2020), approximately 300–400 individuals sustain spinal cord injuries annually. Nearly three-quarters of these injuries stem from motor vehicle accidents, falls, gunshot wounds, and motorcycle accidents. Preventive measures should emphasize safe driving practices, including enhanced speed enforcement and the consistent use of seat belts and airbags. Additionally, increased safety gear usage when working at heights and improvements in gun control and motorcycle safety are vital areas for prevention.

Causes of Spinal Cord Injury

Post-injury, the primary causes of mortality in clients with spinal cord injuries include:

• Diseases of the respiratory system (21.4%)
• Infective and parasitic diseases (12%)
• Neoplasms (10.8%)
• Heart disease (10.4%)

In acute care settings for spinal cord injuries, it is crucial to address the secondary effects of the injury. The top priorities always include maintaining airway, breathing, and circulation. Clients must be immobilized to prevent further damage to the spinal cord.

Elderly patients may present complex intracranial regulation issues that can be confused with age-related changes or new-onset dementia. Therefore, a comprehensive medical and medication history is vital for identifying potential causes of altered intracranial regulation that may be less apparent in younger clients. Medications can interfere with blood clotting mechanisms, and certain activities, such as shaving or walking barefoot, pose risks for bleeding. Unwitnessed falls may also suggest underlying injuries that could be life-threatening.

NR 341 Week 6 Complex Intracranial – Neurological Alterations

In younger populations, intracranial regulation problems are often due to traumatic injuries or congenital issues such as spina bifida, cerebral palsy, or congenital malformations that lead to hydrocephalus. These individuals may experience chronic neurological problems as they age. Birth history and any childhood trauma are essential factors to review with the client.

For instance, Angela Everheart, a 57-year-old female brought to the emergency department (ED), presented with a Glasgow Coma Scale score of 4. This score is based on assessments indicating that her eyes do not open and she is verbally unresponsive. Additionally, she exhibited “decerebrate posturing” and had an unequal dilated pupil on the right side. Other concerning signs included widening systolic and diastolic blood pressure, bradycardia, and absent respirations with an inability to obtain an oxygen saturation reading.

Glasgow Coma Scale Eye Opening Response:

• Spontaneous: opens with blinking at baseline (4 points)
• To verbal stimuli, command, speech (3 points)
• To pain only (not applied to face) (2 points)
• No response (1 point)

Verbal Response:

• Oriented (5 points)
• Confused conversation but able to answer questions (4 points)
• Inappropriate words (3 points)
• Incomprehensible speech (2 points)
• No response (1 point)

Motor Response:

• Obeys commands for movement (6 points)
• Purposeful movement to painful stimulus (5 points)
• Withdraws in response (4 points)
• Flexion in response to pain (decorticate posturing) (3 points)
• Extension response in response to pain (decerebrate posturing) (2 points)
• No response (1 point)

The absence of respirations suggests respiratory arrest. Signs of abnormal pupils, decreased Glasgow Coma Scale scores, widening pulse pressure, and bradycardia may indicate increased intracranial pressure. Autonomic dysreflexia is closely associated with skin assessment changes in spinal cord injury patients, sharing symptoms with neurogenic shock. An epidural hematoma represents an emergency that can develop within 24 hours of a head injury.

Nursing Diagnosis and Potential Actions

The sequence of nursing actions, prioritized from high to low, includes:

1. Repositioning the head, neck, and jaw to open the airway.
2. Obtaining an airway using emergency equipment if the client cannot breathe independently.
3. Initiating artificial ventilation.
4. Administering oxygen as prescribed.
5. Administering medications to reduce blood pressure.
6. Elevating the head of the bed above 30 degrees to aid in decreasing intracranial pressure.

The Arizona Department of Health has allocated a $1 million grant aimed at implementing strategies to reduce spinal cord injuries statewide. Public health nurses should recommend preventative measures that will benefit the largest demographic. Given that one-third of spinal cord injuries occur due to motor vehicle accidents, advocating for enhanced speed reduction strategies and increased seat belt usage would likely impact the greatest number of individuals. In contrast, diving and motorcycle accidents account for only 6% of spinal cord injuries, indicating that while new safety measures may help, they would not affect as many people. The same rationale applies to gun regulation.

Nursing Goals and Actions

Head Injury Considerations

Head injuries are frequent occurrences in the United States, typically resulting from blunt force trauma due to automobile accidents, falls, workplace injuries, or violence. Cerebral contusions can lead to increased intracranial pressure due to cerebral edema. A basilar skull fracture allows blood and edema to escape outside the skull, whereas a spinal cord injury may cause localized edema but is less likely to elevate intracranial pressure. Scalp lacerations are external injuries that do not penetrate the brain but may indicate underlying blunt force trauma.

Coup-contrecoup injuries occur due to rapid deceleration

forces resulting in brain damage. Traumatic brain injuries can result in significant deficits, including memory impairment and loss of balance. Injury severity is classified using the Glasgow Coma Scale, which provides a reliable assessment of conscious awareness.

Head Injury Assessment and Nursing Considerations

At the scene of the incident, Sally experienced a brief loss of consciousness, after which she regained the ability to communicate without issues. However, within an hour, her condition deteriorated as she became increasingly drowsy and less responsive to inquiries. She vomited once and complained of a headache. Given Sally’s symptoms, an epidural hematoma is the most likely diagnosis. This condition typically presents with a loss of consciousness, followed by a lucid interval, after which the individual’s consciousness declines. Symptoms associated with an epidural hematoma may include headaches, nausea, and vomiting. In contrast, a subdural hematoma usually leads to a gradual decline in consciousness over 24 to 48 hours, while a concussion generally does not involve loss of consciousness. Intraventricular hemorrhage often results in focal neurological symptoms such as paralysis. For any patient with a head injury, a thorough assessment is essential to identify additional factors that might influence the severity of the injury and the challenges related to recovery.

Assessment Factors

To effectively assess a client with a head injury, it is critical to consider the following factors:

The assessment of a client with a head injury should prioritize immediate injury evaluation and the potential for cerebral edema. Due to the seriousness of head injuries, assessments should be conducted in a rapid sequence to identify urgent nursing interventions. Notably, changes in airway and blood pressure are frequently associated with cerebral edema or hemorrhage and can be life-threatening if not addressed promptly.

Immediate Nursing Actions and Assessment

In cases of severe head trauma resulting in unconsciousness, assessing cranial nerve function is essential to gather pertinent information about the patient’s condition. Specifically, the Oculomotor nerve (cranial nerve III) should be assessed for pupillary response to light, as changes in the speed and size of the pupils can indicate significant head injury. Unlike other cranial nerves, this nerve can be assessed even if the patient is not fully conscious.

In the event of skull fractures, various signs and symptoms can indicate the fracture location:

Nursing Diagnoses and Potential Actions

The nursing diagnoses for patients with head injuries may include acute confusion, decreased intracranial adaptive capacity, ineffective tissue perfusion, ineffective thermoregulation, impaired memory, pain, imbalanced nutrition, and risk for infection. Each diagnosis presents unique assessment cues:

To address decreased intracranial adaptive capacity and ineffective tissue perfusion, nursing actions may include elevating the head of the bed, administering antihypertensives, hyperventilating if on a ventilator, inducing a coma, administering diuretics and anti-inflammatories, and assisting with drainage or craniotomy as needed. For clients with imbalanced nutrition and risk for infection, nursing actions may involve administering tube feedings, documenting strict intake and output, daily weighing, turning or moving patients every two hours, changing dressings for external devices, and ensuring hand hygiene.

Medications for Head Injury Management

The management of acute head injury may involve various medications:

Evaluation of Outcomes

The evaluation of a client with a head injury focuses on several priority care goals, including ensuring adequate oxygenation, perfusion, and maintaining normal intracranial pressure and cerebral perfusion pressure. Additionally, monitoring for fever or signs of infection, meeting nutritional needs, and noting improvement in cognitive function through radiologic studies are essential aspects of care. Improvement can be indicated by normal oxygen saturation, temperature, albumin levels, and an increased Glasgow Coma Scale score, whereas worsening conditions may be characterized by decreased cerebral perfusion pressure, increased intracranial pressure, and heightened cerebral edema.

Diagnostic Tools and Monitoring

A computerized tomography (CT) scan or magnetic resonance imaging (MRI) may be employed to exclude the presence of a structural lesion that could be causing seizures. Additionally, abnormalities detected through an electroencephalogram (EEG) can assist in identifying the seizure type and locating the seizure focus. However, it is essential to note that an EEG is not definitive; individuals without seizure disorders can exhibit abnormal EEG results, while those with a seizure disorder may have normal results between seizure episodes.

Ongoing Monitoring: For patients prescribed antiepileptic medications, serum drug levels are routinely monitored. Therapeutic drug ranges serve merely as a guideline for therapy; therefore, it is possible for clients to experience therapeutic effects, such as the absence of seizures, even with subtherapeutic drug levels.

Antiepileptic Drugs

The most commonly prescribed medications for managing tonic-clonic and focal-onset seizures include phenytoin (Dilantin), carbamazepine (Tegretol), phenobarbital, and divalproex. In contrast, ethosuximide (Zarontin), divalproex, and clonazepam (Klonopin) are primarily used for generalized onset nonmotor and myoclonic seizures. The overarching goal of drug therapy is to prevent seizures while minimizing side effects. Should seizure control not be achieved with a single medication, adjustments to the dosage or administration timing may be made, or a second drug may be introduced.

Surgical and Alternative Treatments: For clients who do not respond to drug therapy and have a clearly defined seizure origin, surgical resection may be an option. In cases where a focal point for surgical removal cannot be identified, vagal nerve stimulation may be used as an adjunct to medication. The precise mechanism of action for this treatment remains unknown. Responsive neurostimulation continuously monitors the EEG for abnormalities and provides electrical stimulation as necessary, functioning similarly to a cardiac pacemaker. Another alternative is the ketogenic diet, a specialized high-fat, low-carbohydrate regimen that can help control seizures in some patients.

Note: Treatment for seizures is determined based on the specific seizure type.

Nursing Assessment

When caring for a client experiencing seizures, the nurse should conduct a comprehensive assessment encompassing the physical exam, health history, and medication review.

Health History:

• History of seizures, birth defects, or anoxic episodes.
• Previous central nervous system trauma, tumors, or infections.
• Incidents of stroke, metabolic disorders, or alcohol use.
• Family history of seizure disorders.

Medications:

• Review of current medications.
• Assessment of adherence to antiepileptic regimens.
• Evaluation for adverse effects, as antiepileptic drugs primarily influence the central nervous system.

Neurologic Assessment: Evaluating for dose-related toxicity includes testing for nystagmus, as well as assessing hand coordination, gait, cognitive function, and overall alertness.

Information About Seizure Episodes:

• Documentation of auras, precipitating events, symptoms, duration, frequency, and intensity of seizures.

Review of Laboratory Tests and Diagnostic Results:

• Complete blood count, renal function, and liver function tests establish baseline health.
• EEG, MRI, and CT scans provide further insights into seizure activity and potential epilepsy diagnosis.
• Serum drug levels are monitored to ensure therapeutic adherence, evaluate treatment efficacy, and prevent toxicity.

Nursing Actions During Seizures

Initial Monitoring and Care:

• Ensure the patient’s airway is clear, provide suctioning as necessary, and prepare for potential intubation. Avoid inserting an oral airway during an active seizure to prevent mouth or dental injury.
• Protect the patient from harm by removing any hazardous objects, loosening tight clothing, and padding side rails. Restraint should be avoided.
• Establish intravenous (IV) access; anticipate that the healthcare provider may order medications such as phenobarbital or benzodiazepines (e.g., diazepam, midazolam, lorazepam) to halt the seizure.
• Document seizure activity, including the time, sequence, and body parts involved, while monitoring vital signs, consciousness levels, and oxygen saturation. Remain with the patient until the seizure concludes.

Ongoing Monitoring and Care:

• After a seizure, provide reassurance and orient the patient.
• Assist with ventilation if the patient fails to breathe independently post-seizure.
• Conduct a postictal assessment detailing the patient’s level of consciousness, vital signs, pupil response, memory loss, muscle soreness, speech disorders (such as aphasia or dysarthria), any weakness or paralysis, sleep duration, and the duration of each symptom.

Example Scenario:

The nurse is caring for a client with seizures stemming from a brain tumor, who is prescribed carbamazepine 200 mg twice daily at 08:00 and 20:00. If the client experiences a seizure at 12:00, the nurse should stay with the patient throughout the seizure, monitor vital signs and oxygen levels, and document the seizure’s length and characteristics. Restraint is contraindicated; thus, the nurse should remove any potential hazards and pad side rails. The nurse should not administer an extra dose of carbamazepine but should prepare to give IV medications if needed.

Overall Goals: The primary objectives for a patient with a seizure disorder are to remain injury-free during seizures, achieve optimal mental and physical functioning while on antiepileptic medications, and maintain satisfactory psychosocial functioning.

Nursing Diagnoses for Seizure Disorder

1. Impaired breathing
2. Difficulty coping
3. Risk for fall-related injury

In the case of a client with uncontrolled generalized onset motor seizures, the most significant risk is fall-related injury due to the nature of the seizures affecting both sides of the body. Ensuring patient safety during seizures is paramount, as clients may fall and experience confusion during the postictal phase.

Client Education

• Carbamazepine Interaction: Clients should avoid consuming grapefruit or citrus juice while taking carbamazepine, as these can lead to toxicity.
• Medication Withdrawal: Stopping antiepileptic medications can precipitate seizures.
• Medication Weaning: For individuals who have been seizure-free for an extended period (2 to 5 years) and exhibit normal neurological exams and EEG results, healthcare providers may consider gradually tapering off antiepileptic medications.
• Adherence to Treatment: The efficacy of treatment diminishes if clients do not adhere to prescribed regimens due to adverse effects. Providers should collaborate with clients to establish a suitable medication plan.

Note: All antiepileptic medications carry a black box warning regarding the need to report suicidal thoughts or worsening depression immediately to healthcare providers. The most common side effects of these medications include dizziness, drowsiness, and gastrointestinal disturbances.

The nurse also provides education to a newly diagnosed epilepsy client on recognizing seizure triggers. Clients should be made aware that factors such as missed medication doses, psychological stress, sleep deprivation, excessive alcohol consumption, and illness can trigger seizures.

NR 341 Week 6 Complex Intracranial – Neurological Alterations

When discussing driving eligibility, clients should understand that laws regarding seizure-free periods before obtaining a driver’s license vary by state, typically ranging from 3 months to 1 year. Clients with epilepsy should be directed to reputable resources like the Epilepsy Foundation for self-education and support. They should also be encouraged to wear a medical alert bracelet or carry a medical alert card to inform others of their condition in emergencies.

If a client taking phenytoin exhibits mood changes or suicidal thoughts, these findings should be reported to the healthcare provider immediately, as they pose a significant risk. Although non-adherence to the medication regimen should also be communicated for management purposes, addressing suicidal ideations is of greater urgency. Common adverse effects like dizziness, drowsiness, and gastrointestinal upset are expected and should be monitored.

Delegation of Tasks

In a medical-surgical unit, nurses must delegate appropriately to unlicensed assistive personnel (UAP). The nurse may assign tasks that fall within the UAP’s scope, such as placing emergency equipment (e.g., suction devices, bag-valve-mask, and oxygen tubing) at the bedside. UAPs are not permitted to administer medications, document assessments, or provide education.

When administering medications at 08:00, the nurse should prioritize based on potential harm from delayed medication. The first medication administered should be for the client on an antiepileptic drug, specifically phenytoin, to maintain stable blood levels and prevent seizures. Next, ibuprofen for pain should be administered, followed by atorvastatin for high cholesterol. The final client to receive their medication would be the one prescribed a multivitamin, as it is the least time-sensitive.

Clinical Manifestations of Seizure Phases:

• Prodromal Phase: Clients may report anxiety and sleep disturbances hours or days before a seizure.
• Aural Phase: Occurs just before the ictal phase and may include manifestations like incontinence, diaphoresis, loss of consciousness, pallor, flushing, cyanosis, or tachycardia.
• Ictal Phase: Characterized by the actual seizure, which can involve tonic, clonic, absence, or myoclonic activity.
• Postictal Phase: Follows the seizure and may involve altered consciousness, lethargy, confusion, or headaches.

Risk of Status Epilepticus: A patient demonstrating continuous seizure activity lasting approximately 5 minutes is at a high risk for developing status epilepticus. The environment should be cleared to reduce the risk of injury, and since the client’s oxygen saturation is 95%, hypoxia is currently not the highest concern.

The nurse should order the insertion of a peripheral intravenous line and continuously monitor vital signs and levels of consciousness, as intravenous medications may be required to terminate the seizure. It is crucial not to leave the patient unattended during a seizure; thus, delegating the task

of obtaining IV supplies is appropriate. Communication with authorized family members should be postponed until immediate health needs are addressed.

During the postictal phase, clients may present with typical manifestations such as disorientation, lethargy, and headaches. Continuous observation for any further seizure activity is warranted. Adverse effects of phenobarbital may include drowsiness, though disorientation and headaches are not typical.

References

American Epilepsy Society. (2021). Guidelines for the diagnosis and management of epilepsy. Epilepsy & Behavior, 116, 107892. https://doi.org/10.1016/j.yebeh.2021.107892

Durgin, T. (2022). Antiepileptic drugs: A comprehensive guide. Journal of Clinical Neurology, 18(1), 1-12. https://doi.org/10.3988/jcn.2022.18.1.1

National Institute of Neurological Disorders and Stroke. (2022). Epilepsy fact sheet. Retrieved from https://www.ninds.nih.gov/health-information/patient-caregiver-education/epilepsy-fact-sheet

Shorvon, S. D. (2020). The history of epilepsy. Epileptic Disorders, 22(4), 415-421. https://doi.org/10.1684/epd.2020.1161

Harding, A. (2020). Clinical considerations in head injury management. Journal of Neurology, 67(3), 456-467.

American Association of Neurological Surgeons. (2023). Management of head injury. Retrieved from https://www.aans.org

NR 341 Week 6 Complex Intracranial – Neurological Alterations

Centers for Disease Control and Prevention. (2024). Traumatic brain injury in the United States. Retrieved from https://www.cdc.gov/traumaticbraininjury

NR 341 Week 5 Nursing Care: Trauma and Emergency

Name

Chamberlain University

NR-341 Complex Adult Health

Prof. Name

Date

Nursing Care for Trauma: Key Considerations

The nursing care for a homeless client presenting to the emergency department with hypothermia, indicated by a core body temperature of 87ºF (30.5ºC), requires thorough assessment and understanding of potential findings. Nurses should anticipate various assessment outcomes, including bradypnea, lethargy, absent patellar reflex, dilated pupils, shivering, hypertension, elevated hematocrit levels at 55%, Kussmaul respirations, and tachycardia.

Submersion injuries are critical considerations, especially as they primarily affect children. These injuries occur when an individual becomes hypoxic due to immersion in liquid, leading to fluid imbalances as water is aspirated. In cases of hypotonic freshwater exposure, absorption through alveoli causes pulmonary edema, while hypertonic saltwater can draw fluid from the circulatory system, impairing gas exchange and resulting in hypoxia. Compensatory mechanisms divert blood to the lungs, depriving other organs of oxygen and potentially resulting in cerebral injury and edema. Treatment focuses on correcting hypoxia and fluid imbalances while supporting physiological function, with rewarming procedures necessary if hypothermia is present.

Trauma Types and Management

Penetrating trauma occurs when an object pierces the skin, leading to open wounds. Common examples include gunshot and stab wounds, with penetrating head trauma often resulting in high mortality rates and permanent neurological deficits. Neck injuries pose risks for hemorrhage and spinal cord damage, while abdominal trauma severity is determined by the involved organs. Extremity trauma may cause lasting disabilities due to hemorrhage, and angulated fractures can lead to penetrating injuries.

Adequate resuscitation indicators include stable hemodynamic and renal parameters, normalized core body temperature, serum lactate levels below 2 mmol/L, and no base deficit. Arterial pH should range from 7.35 to 7.45, with hemoglobin above 9 g/dL, and normal serum calcium and potassium levels. Coagulation profiles should also be within normal limits, ensuring pain is managed effectively.

Emergency Preparedness and Triage

Emergencies can arise from internal threats, such as power loss and facility damage from natural disasters, or external threats, including biological, chemical, hazardous, radiologic, or explosive events. In a mass casualty incident, the priority is to assess and categorize injuries as life-threatening, urgent but not life-threatening, minor, or extensive/deceased. Life-threatening injuries demand immediate intervention, whereas urgent cases require assessment but are not immediately life-threatening. Minor injuries can withstand delayed treatment, while extensive injuries indicate a low likelihood of survival.

Using the START (Simple Triage and Rapid Treatment) method, triage color tags are assigned based on the severity of injuries. For example, a victim who is not breathing and has no radial pulse should receive a black tag, indicating deceased status. In contrast, a victim with weak and thready pulse and shallow respirations should be tagged red, signifying a need for immediate attention.

The client admitted on a backboard, with cervical immobilization and significant leg deformities, should have vital signs monitored closely, including blood pressure, heart rate, respiratory rate, and oxygen saturation. Essential nursing interventions include removing wet clothing to minimize heat loss, facilitating lab tests, and initiating ECG monitoring.

Table of Nursing Care Considerations

Traction and Its Types

Traction is a therapeutic method used primarily to alleviate pain, immobilize the body, or aid in the reduction of fractures. There are two main types of traction utilized in medical practice: skin traction and skeletal traction.

Skin Traction is typically used as a temporary measure until skeletal traction or surgery becomes feasible. This method involves applying boots or splints directly to the skin, which helps decrease muscle spasms. Traction weights serve as the pulling force to maintain the necessary alignment.

Skeletal Traction, on the other hand, offers a long-term solution by inserting pins or wires into the bone. Weights are then attached to these devices to ensure proper alignment and immobilization of the injured body part. However, one significant complication associated with skeletal traction is the risk of infection.

Compartment Syndrome

Compartment syndrome is an urgent medical condition characterized by swelling that leads to increased pressure within a confined anatomical space, known as a muscle compartment. This elevated pressure compromises the function of blood vessels and nerves within the compartment, resulting in diminished perfusion. Continuous neurovascular assessment is crucial in monitoring for signs of compartment syndrome. Symptoms may include pulselessness distal to the injury, severe pain, pallor, paresthesia, paralysis, and poikilothermia.

It is important to avoid elevating the affected extremity above heart level or applying cold compresses, as these actions can exacerbate the condition through vasoconstriction. Surgical intervention, such as fasciotomy, is often required to relieve the pressure, with the surgical site typically left open for several days to monitor for infection. In severe cases, amputation may become necessary.

Fat Embolism Syndrome

Fat embolism syndrome occurs when fat globules enter the bloodstream, often following fractures of long bones, ribs, tibia, or pelvis. Early recognition is vital to prevent potentially fatal outcomes. Symptoms generally manifest within 24 to 48 hours and can include severe respiratory distress, chest pain, tachypnea, cyanosis, dyspnea, apprehension, anxiety, tachycardia, hypoxemia, and petechiae on the neck, chest wall, axilla, mucous membranes, and conjunctiva.

Treatment focuses on preventing hypovolemic shock, providing respiratory support, correcting acidosis, and administering blood transfusions. Vasopressors may also be used for hemodynamic stability. Moreover, it is critical to prevent secondary injuries by ensuring careful immobilization and handling of long bone fractures and minimizing movement before stabilization.

Rhabdomyolysis

Rhabdomyolysis is a syndrome that arises from the breakdown of damaged skeletal muscle cells, resulting in the release of myoglobin into the bloodstream. This myoglobin can precipitate and obstruct renal tubules, leading to acute kidney injury (AKI). Common signs of rhabdomyolysis include dark reddish-brown urine, alongside other symptoms indicative of AKI.

Types of Burns

Burn injuries can be categorized into different types, each with unique characteristics and management requirements.

Thermal Burns are caused by exposure to flames, flashes, scalds, or contact with hot objects. The severity of thermal burns depends on the burning agent’s temperature and the duration of contact. Scald injuries frequently occur in bathrooms and kitchens, while flash and contact burns can arise during cooking or burning debris.

Chemical Burns result from contact with acids, alkalis, and organic compounds. Common acids include hydrochloric, oxalic, and hydrofluoric acid; while alkalis can include cement, oven cleaners, and industrial cleaners. Organic compounds such as chemical disinfectants and petroleum products also pose a risk.

Smoke and Inhalation Burns occur when noxious chemicals or hot air are inhaled, leading to damage to the respiratory tract. These types of burns can quickly lead to airway compromise and pulmonary edema, making smoke inhalation a significant predictor of mortality in burn patients.

Electrical Burns result from the intense heat generated by electric currents, with severity depending on voltage, tissue resistance, current pathways, and duration of current flow. Bone and fat tissues are generally more resistant to damage, whereas nerves and blood vessels are the least resistant.

Cold Thermal Injuries are caused by frostbite, which affects tissues due to exposure to cold temperatures.

Depth and Location of Burns

The depth of burns is classified as follows:

• Superficial Partial Thickness (1st degree): Involves only the epidermis, with intact tactile and pain sensations.
• Deep Partial Thickness (2nd degree): Involves both the epidermis and dermis, allowing for potential epithelial regeneration.
• Full Thickness (3rd and 4th degree): Involves destruction of all skin elements and local nerve endings, necessitating surgical intervention for healing.

Assessing the exact extent and depth of a burn injury can be challenging during the emergent phase due to edema and inflammation obscuring injury demarcation. The location of the burn also plays a critical role in determining severity. Burns on the face, neck, or circumferential areas of the chest can compromise breathing, while burns to the hands, feet, and eyes can hinder self-care. Burns on thin-skinned areas like the ears and nose are at a higher risk for infection, as are those in the buttocks or perineum due to potential contamination.

Rule of Nines and Risk Factors

The Rule of Nines and the Lund-Browder chart are tools used for the initial assessment of burn patients to estimate the percentage of total body surface area (TBSA) affected. For instance, using the Lund-Browder Chart:

• 3½% (face) + 1% (anterior neck) + 6½% (right anterior trunk) + 2% + 1½% (anterior right arm) + 3½% (anterior right lower leg) = 18% TBSA.

Using the Rule of Nines might yield:

• 4½% (face) + 9% (anterior upper chest & neck) + 4½% (anterior right arm) + 4½% (anterior right lower leg) = 22½% TBSA.

Risk factors for poor burn recovery include preexisting conditions such as heart, lung, or kidney diseases, which can complicate recovery due to increased bodily demands. Diabetes and peripheral vascular disease can delay healing, particularly for leg or foot burns. Malnutrition significantly hinders recovery from burn injuries, and the presence of additional trauma such as fractures or head injuries complicates the recovery process further.

Priorities in Burn Management

The priority in managing burn injuries is to remove the source of the burn and halt the burning process. Cooling the affected area within one minute is critical to minimize injury depth. Immediate removal of chemicals from the skin is essential, and in cases of significant burns (greater than 10% TBSA) or suspected inhalation burns, healthcare providers should focus on the ABCs of assessment:

• Airway: Assess patency, check for soot around the nostrils, singed nasal hair, and observe for darkened mucous membranes.
• Breathing: Evaluate ventilation adequacy.
• Circulation: Check pulses and elevate burned limbs above heart level to reduce pain and swelling.

Continuous monitoring for lung-related injuries is vital, noting any excessive secretions, difficulty swallowing, hoarseness, stridor, chest wall retractions, altered mental status, dyspnea, or wheezing. Avoid cooling large burns for more than 10 minutes to prevent hypothermia, and do not submerge burned areas in cold water or use ice, as this can cause vasoconstriction and decrease perfusion.

Phases of Burn Management

Phase 1: Emergent (Resuscitative)

This phase addresses immediate life-threatening issues resulting from burn injuries and typically lasts up to 72 hours. The primary concerns include hypovolemic shock and edema, necessitating fluid mobilization and diuresis. Preventative measures against infection, hypothermia, and emotional support are also essential. Increased capillary permeability causes significant fluid shifts from the intravascular to the interstitial space, leading to fluid loss that can result in hypovolemic shock. Fluid replacement, particularly with Lactated Ringer’s solution, is necessary to restore vascular space fluid levels.

Phase 2: Acute (Wound Healing)

The acute phase begins with the mobilization of extracellular fluid and diuresis, concluding when partial-thickness wounds heal or full-thickness burns are covered with skin grafts. This phase can last from weeks to months. As fluid returns to the intravascular space and diuresis begins, edema subsides, and bowel sounds return. Partial-thickness burns can heal if kept free from infection and dryness, while full-thickness burns require surgical intervention for healing.

Phase 3: Rehabilitation (Restorative)

This phase begins when the patient’s wounds have nearly healed, allowing them to engage in self-care activities. This stage can last for years, focusing on reestablishing a functional role in society and addressing any necessary cosmetic reconstructive surgery. Priorities include psychosocial well-being and prevention of scarring and contractures. Continuous physical and occupational therapy is crucial for maintaining muscle strength and optimal joint function. Common complications during this phase include skin and joint contractures and hypertrophic scarring.

Fluid Replacement and Nutritional Support

The Parkland Formula is utilized to determine the appropriate amount of fluid replacement within the first 24 hours post-burn:

1. Calculate TBSA % and multiply by 4 ml and the patient’s body weight in kilograms.
2. Administer half of the calculated fluid over the first 8 hours.
3. Administer the remaining half over the subsequent 16 hours.

For example, a patient weighing 19 kg with burns covering 38% of their body would require 2,888 ml total fluid

replacement over the first 24 hours.

Nutritional support is essential in promoting healing and maintaining lean body mass, often requiring higher caloric intake to sustain metabolic demands.

Skin Graft Types and Complications

There are several types of skin grafts:

1. Autografts: Skin taken from the same patient.
2. Allografts: Skin taken from another person.
3. Xenografts: Skin taken from another species (often porcine).
4. Synthetic grafts: Materials used to promote healing.

Complications can arise from the grafting process, such as hematoma, seroma, and infection. Additionally, surgical debridement may be necessary for nonviable tissue.

Conclusion

The comprehensive management of trauma involves recognizing and addressing the potential for various complications that can arise from burn injuries. Early assessment, timely interventions, and coordinated care are essential in ensuring optimal outcomes for affected individuals.

References

American Heart Association. (2022). Advanced cardiovascular life support (ACLS) provider manual.

Chamberlain, R. S., & Sarin, E. (2023). Principles of trauma management.

Harris, J. D., & Miller, D. J. (2021). Management of traumatic brain injury. Journal of Neurotrauma, 38(7), 1012-1024.

NR 341 Week 5 Nursing Care: Trauma and Emergency

National Institute of Health. (2024). Trauma care: A multidisciplinary approach.

World Health Organization. (2023). Emergency preparedness and response.

NR 341 Week 4 Nursing Care: Complex Fluid Balance Alteration

Name

Chamberlain University

NR-341 Complex Adult Health

Prof. Name

Date

Nursing Care: Complex Fluid Balance Alterations

Fluid balance disorders in nursing care are multifaceted and can arise from severe burns, trauma, sepsis, and heart failure. These conditions may disturb fluid and electrolyte homeostasis, posing unique challenges for patient management. When caring for patients with fluid imbalances, nurses must tailor interventions to support cardiac output, fluid retention, or elimination as appropriate. For instance, when a patient experiences hypovolemia and decreased preload, administering 0.9% normal saline as an intravenous bolus can help increase preload and improve cardiac output, as opposed to other interventions like nifedipine or furosemide, which may lower preload. When managing a patient with acute respiratory distress syndrome (ARDS), mechanical ventilation can contribute to fluid retention. This occurs due to reduced renal perfusion, which leads to renin release, and subsequently, increased aldosterone secretion, resulting in fluid retention.

Elderly patients admitted with dehydration present unique challenges in fluid management. One example involves administering sodium-free fluids like D5W to correct hypovolemia; however, this intervention may risk complications such as cerebral swelling. In cases where dehydration leads to hyponatremia or fluid overload, careful monitoring of electrolyte levels is essential.

Factors Affecting Fluid Balance and Management

Fluid movement between body compartments is driven by osmosis and diffusion, regulated by three main hormones: aldosterone, antidiuretic hormone (ADH), and natriuretic peptides. Aldosterone plays a role in sodium retention and potassium excretion, often triggered by severe hypotension or hypovolemia. ADH, produced by the pituitary gland, signals renal cells to reabsorb water, reducing urine output while diluting blood plasma. This hormone’s regulation can be altered in conditions like diabetes insipidus or the syndrome of inappropriate ADH secretion (SIADH). In critically ill patients, dysnatremia is a common issue, with either hyponatremia or hypernatremia potentially arising due to improper fluid management or kidney impairment. To address these imbalances, interventions may include restricting water and sodium intake in hypervolemic hyponatremia or administering isotonic solutions for hypernatremic states.

Risk factors for fluid imbalances include cardiac dysfunction, renal impairment, gastrointestinal losses, and certain medications like diuretics. Managing these factors is essential, as dysregulation can lead to fluid volume deficits or excess.

Hemodynamic Monitoring and Nursing Responsibilities

Effective hemodynamic monitoring is central to managing fluid balance in critically ill patients, especially when treating hypo- or hypervolemia. Nurses must be adept in using devices that measure pulmonary artery wedge pressure (PAWP), central venous pressure (CVP), and arterial blood pressure. PAWP offers insights into left ventricular function and helps gauge fluid volume status, with high PAWP values indicating fluid overload and low values indicating volume depletion. Similarly, CVP values assist in diagnosing hypo- or hypervolemia. Ensuring correct setup, zeroing, and calibration of monitoring equipment is crucial to obtain accurate readings.

For patients requiring invasive monitoring, nurses play an active role in equipment preparation, patient education, and monitoring for complications such as infection, thrombus formation, or neurovascular impairment. Continuous renal replacement therapy (CRRT) may be necessary for critically ill patients with fluid overload or impaired kidney function, providing a steady form of fluid removal that stabilizes hemodynamic parameters without excessive strain. Unlike intermittent hemodialysis (IHD), CRRT minimizes fluid shifts, thus offering a safer option for patients in unstable conditions.

Table: Overview of Fluid Management Considerations

Continuous Renal Replacement Therapy (CRRT) Nursing Care

Nursing care during Continuous Renal Replacement Therapy (CRRT) encompasses a range of critical assessments and interventions aimed at monitoring and maintaining patient stability. Initially, nurses should prepare for CRRT by conducting a baseline assessment, which includes monitoring hourly output, assessing fluid volume status, and adjusting fluid replacement as needed based on hourly fluid balances. Regular neurologic assessments and monitoring of electrolyte and acid-base balance are essential. Additionally, the nurse should evaluate the patient’s temperature, assess for signs of bleeding and infection, monitor coagulation status, and ensure the circuit remains patent.

For patients undergoing hemodynamic monitoring, the transducer must be accurately referenced and zeroed. This involves identifying the phlebostatic axis, positioning the transducer appropriately, opening the reference stopcock to room air, and confirming a zero reading on the monitor. In cases where pulmonary auscultation reveals worsening crackles and dyspnea, or when hemodynamic parameters indicate abnormalities—such as decreased cardiac output or elevated pressures—critical interventions may be necessary. Prioritizing accurate readings, zeroing the transducer, and anticipating medication adjustments or additional interventions like dobutamine may be warranted to stabilize the patient.

Shock Nursing Care and Prioritization

Shock is defined as a state of inadequate tissue perfusion resulting in impaired cellular function and potential organ failure. Various forms of shock—cardiogenic, hypovolemic, distributive, and obstructive—can develop based on underlying factors that compromise oxygen delivery. Cardiogenic shock arises from the heart’s inability to pump adequately, often due to conditions such as myocardial infarction or cardiomyopathy. Hypovolemic shock is the most common type and is primarily caused by inadequate fluid volume within the intravascular space. Distributive shock, encompassing septic, anaphylactic, and neurogenic forms, involves systemic vasodilation. Obstructive shock, meanwhile, results from a physical impediment to blood flow, like a pulmonary embolism.

To manage these states, nurses prioritize assessments and interventions specific to each shock type. For example, in cardiogenic shock, cardiac output, stroke volume, and oxygen delivery are critical metrics requiring optimization. Hemodynamic monitoring, medication administration, oxygen therapy, and possibly mechanical assist devices (such as intraaortic balloon pumps or ventricular assist devices) are used to support cardiac function and tissue perfusion. Nurses should be adept at interpreting diagnostic markers like cardiac biomarkers, B-type natriuretic peptide (BNP), and other parameters to guide treatment.

Hypovolemic Shock and Medical Management

In hypovolemic shock, intravascular volume reduction leads to decreased venous return, reduced stroke volume, and diminished cardiac output, all of which jeopardize adequate tissue perfusion. Absolute hypovolemia results from direct fluid loss, while relative hypovolemia involves fluid shifts from the intravascular to the extravascular compartments. Initial compensatory mechanisms, such as the release of catecholamines, aldosterone, and antidiuretic hormone, help maintain vital organ perfusion. However, substantial fluid loss beyond 30% overwhelms compensatory efforts, leading to hypotension, impaired renal function, and decreased cerebral perfusion.

Early signs of hypovolemic shock include anxiety, tachycardia, delayed capillary refill, and pallor. In managing hypovolemic shock, prompt volume replacement with warmed crystalloid solutions or blood products is essential. In severe cases, medical management may also include vasopressors to maintain hemodynamic stability. Monitoring intake, output, laboratory studies, and hemodynamic parameters is critical in managing hypovolemic shock and ensuring effective intervention.

Table 1: Nursing Interventions for CRRT and Types of Shock

Blood Loss and Shock Types

When blood loss reaches a critical level of 1500 ml, immediate administration of packed red cells, along with fresh frozen plasma and platelets, is essential to restore clotting factors. Maintaining arterial oxygen saturation is crucial, often achieved through supplemental oxygen or mechanical ventilation. For unstable patients, positioning in the supine position can assist in stabilizing vital functions.

In cases of distributive shock, widespread vasodilation and increased capillary permeability lead to pooling of blood within the vessels, causing tissue hypoperfusion and impaired cellular metabolism. Distributive shock encompasses three primary types: neurogenic, septic, and anaphylactic.

1. Neurogenic Shock
   Neurogenic shock typically occurs within 30 minutes following a spinal cord injury, especially in the cervical or high thoracic region, and can persist for up to six weeks. This type of shock results from a significant loss of sympathetic nervous system vasoconstrictor tone, leading to extensive vasodilation. Key indicators include hypotension (due to vasodilation), bradycardia (from unopposed parasympathetic tone), and hypothermia due to hypothalamic dysfunction affecting temperature regulation.

2. Septic Shock
   Septic shock arises from an overwhelming inflammatory response, commonly triggered by gram-positive or negative bacterial infections, leading to systemic inflammatory response syndrome (SIRS) and subsequent shock. Common symptoms include tachypnea, tachycardia, and hypotension. Respiratory failure is frequent, initially presenting as respiratory alkalosis due to compensatory hyperventilation, eventually progressing to respiratory acidosis. Other signs include variable temperature and skin changes, progressing from warm and flushed to cool and mottled.

3. Anaphylactic Shock
   This life-threatening hypersensitivity reaction occurs in response to an external agent, causing sudden and severe vasodilation, release of vasoactive mediators, and increased capillary permeability. This rapid response leads to relative hypovolemia, diminished cardiac output, and respiratory distress marked by symptoms like laryngeal edema, bronchospasm, tachycardia, dyspnea, and chest pain.

Diagnostic Findings in Distributive Shock

• Neurogenic Shock: May include flaccid paralysis below the injury level and loss of reflex activity.
• Septic Shock: Often characterized by elevated or reduced white blood cells, decreased platelets, elevated lactate levels, hyperglycemia, increased urine specific gravity, hyponatremia, and positive blood cultures.
• Anaphylactic Shock: Sudden onset of respiratory distress, especially in individuals with known allergies.

Management Approaches

Effective management of distributive shock varies by type. For neurogenic shock, treatment includes stabilizing the spine and using vasopressors to maintain blood pressure. Septic shock management focuses on IV fluid resuscitation, vasopressors, antibiotics, and glucose control. For anaphylactic shock, maintaining an open airway is paramount, with medications like epinephrine, IV fluids, and antihistamines used to counteract the reaction.

Obstructive Shock

Obstructive shock results from physical obstruction in blood flow, commonly due to conditions like cardiac tamponade, tension pneumothorax, or pulmonary embolism. Symptoms include decreased cardiac output and increased afterload. Management focuses on relieving the obstruction through interventions like mechanical decompression, anticoagulant therapy, or surgery, depending on the cause.

Nursing Care: Renal Failure and Kidney Injury

Acute kidney injury (AKI) denotes a sudden decline in kidney function, often associated with life-threatening conditions such as shock or heart failure. Prerenal, intrarenal, and postrenal causes vary from decreased blood flow and glomerular perfusion to direct tissue damage from nephrotoxins or physical obstructions. Nursing care aims to monitor and address complications like fluid imbalance, metabolic acidosis, and electrolyte disturbances to stabilize kidney function.

Neurologic Disorders in Acute Kidney Injury (AKI)

As nitrogenous waste products build up in the brain, various neurologic changes can occur. Initial symptoms may include fatigue and difficulty concentrating. As the condition progresses, more severe manifestations such as seizures and coma may develop.

Diagnostic Studies

1. Urinalysis

   • Presence of urine sediment, including cells, casts, or protein, may suggest intrarenal disorders.
   • Urine osmolality, sodium, and specific gravity aid in identifying the specific cause of AKI.
   • Hematuria, pyuria, and crystals may be observed with intrarenal AKI. Glucose and protein levels should also be monitored.

2. Imaging Studies

   • Kidney Ultrasound: Assesses for obstructions.
   • Renal Scan: Evaluates kidney blood flow, tubular function, and the collecting system.
   • CT Scan: Detects lesions, masses, obstructions, and vascular anomalies.
   • Renal Biopsy: The most definitive method for confirming intrarenal causes.

Medical Management

The primary goals in managing AKI are eliminating the underlying cause, managing symptoms, and preventing complications.

• Fluid Restriction: Limits daily intake to 600 mL plus any previous 24-hour fluid loss.
• Diuretic Therapy: Utilizes loop or osmotic diuretics to promote fluid excretion.
• Potassium Management: To avoid hyperkalemia, which is a potentially life-threatening complication, the following measures are used:
  • Insulin (IV): Temporarily shifts potassium into cells, with concurrent IV glucose to prevent hypoglycemia.
  • Sodium Bicarbonate: Helps to shift potassium into cells by correcting acidosis.
  • Calcium Gluconate (IV): Stabilizes cardiac cell membranes.
  • Sodium Polystyrene Sulfonate: Removes potassium via stool.
  • Dialysis: The most effective method for removing potassium rapidly.

Dialysis in AKI

Dialysis is essential for removing waste products and correcting fluid and electrolyte imbalances. There are two primary types:

1. Peritoneal Dialysis: Uses the peritoneal membrane as a semipermeable barrier. Although suitable for AKI, hemodialysis is more common.

2. Hemodialysis: Uses an artificial membrane in contact with the blood. Indications for hemodialysis include a glomerular filtration rate (GFR) below 15 mL/min and complications like encephalopathy and hyperkalemia.

Vascular Access

1. Temporary Access for AKI: A double-lumen catheter is placed in the internal jugular or femoral vein.
2. Permanent Access for Chronic Kidney Disease (CKD): A subcutaneous arteriovenous fistula (AVF) provides rapid blood flow for hemodialysis.

Continuous Renal Replacement Therapy (CRRT)

CRRT is used to manage fluid overload and hemodynamic instability in critically ill patients. Unlike intermittent hemodialysis, CRRT offers continuous, gentle removal of fluids and waste, improving hemodynamic stability and reducing the risk of cerebral edema. CRRT is primarily used when other methods are insufficient, and its duration can extend up to 30-40 days, with the hemofilter changed every 24-48 hours (Granado & Mehta, 2016).

Dialysis Disequilibrium Syndrome (DDS)

DDS may occur during initial dialysis sessions due to rapid fluid shifts, causing cerebral edema and neurologic symptoms such as headache, confusion, and muscle cramps. Treatment involves discontinuing dialysis and providing supportive care, including airway management and osmotic diuretics.

Nutritional Therapy

In AKI, nutritional support aims to maintain caloric intake and minimize protein breakdown. Patients are advised to consume 30-35 kcal/kg of body weight, prioritize calories from carbohydrates and fats, and restrict sodium intake to prevent edema. Enteral nutrition is preferred, with parenteral nutrition used only if gastrointestinal function is impaired.

Nursing Assessment in AKI

Effective nursing assessment and intervention are crucial in managing AKI. Key responsibilities include:

• Daily weight monitoring (1 kg = 1000 mL fluid).
• Tracking intake, output, and vital signs.
• Monitoring for edema, mental status, and level of consciousness.
• Observing lung sounds for fluid accumulation.
• Evaluating heart sounds for abnormal rhythms or friction rubs.
• Assessing for skin integrity and signs of infection.

References

Assembly Health and Senior Services Committee Statement to Assembly, No. 4098 State of New Jersey. Njleg.state.nj.us. (2011). Retrieved from https://www.njleg.state.nj.us/2010/Bills/A4500/4098_S1.PDF.

Durable Powers of Attorney for Health Care. Lawhelp.org. (2016). Retrieved from https://www.lawhelp.org/dc/resource/frequently-asked-questions-about-durable-power.

New Jersey Board of Nursing: Law and Public Safety. Njconsumeraffairs.gov. (2020). Retrieved from https://www.njconsumeraffairs.gov/regulations/Chapter-37-New-Jersey-Board-ofNursing.pdf.

NR 341 Week 4 Nursing Care: Complex Fluid Balance Alteration

American Association of Critical-Care Nurses. (2020). Critical care nursing care guidelines. AACN Publications.

Johnson, K., & Foster, L. (2019). Essentials of shock management in nursing practice. Elsevier.

Roberts, R., & Weber, T. (2021). Continuous renal replacement therapy and hemodynamic support in intensive care. Springer.

NR 341 Week 3

Name

Chamberlain University

NR-341 Complex Adult Health

Prof. Name

Date

NR 341 Week 2 Client Comfort and End of Life Care

Name

Chamberlain University

NR-341 Complex Adult Health

Prof. Name

Date

Reflective Journal

In the hospice care simulation, I reflected on past experiences caring for patients with similar needs. As a nurse working in the Neurological Unit at St. Joseph’s University Medical Center in Paterson, I often encounter patients experiencing their first or recurring strokes. These patients frequently present with complex underlying conditions. I have observed family dynamics and reactions firsthand when patients express a desire to discontinue treatment due to fatigue or emotional strain. In the simulation, the patient’s daughter disregarded her mother’s wishes, which reflected an emotional response that, while understandable, can lead to patient guilt. This guilt might cause patients to feel pressured into continuing treatment they no longer desire. To improve my clinical practice, I would prioritize open communication with both patients and families. This approach is essential when emotions are heightened, as is often the case in end-of-life situations, where information may be overwhelming. Engaging in direct dialogue with the patient can offer them a safe space to voice their needs. Additionally, I would advocate for speaking with the patient privately before family involvement, allowing them to discuss their wishes without external pressure and addressing any questions they might have.

Question One

According to the State Board of Nursing in New Jersey, registered nurses bear a responsibility for managing patient pain effectively. The American Nurses Association (ANA) highlights an ethical duty for nurses to alleviate pain and suffering. Nurses are responsible for conducting a comprehensive medical history, including the pain’s nature, frequency, and severity, and assessing any history of substance abuse. Such an assessment ensures appropriate nursing diagnoses and effective pain management planning. If a patient has a history of substance use, the nurse must exercise caution in medication administration, exploring alternative pain management options when necessary (New Jersey Board of Nursing: Law and Public Safety, 2020).

Question Two

In New Jersey, when a patient lacks a medical power of attorney, the state designates a sequence of individuals to make medical decisions on the patient’s behalf. These include a court-appointed guardian or conservator, the patient’s spouse or domestic partner, and an adult child. Each of these parties has legal authority to make decisions such as hospital admission or discharge, determining treatment and medication plans, and authorizing access to medical records (Durable Powers of Attorney for Health Care, 2016).

Question Three

State law in New Jersey defines patient incapacity as a condition determined by the attending physician, who must confirm, to a reasonable degree of medical certainty, that the patient lacks decision-making capacity. This determination includes an assessment of the cause and extent of incapacity, along with the potential for recovery. Under state law, an incapacitated person is someone who is impaired due to mental illness or deficiency and is unable to effectively manage their personal affairs (Assembly Health and Senior Services Committee Statement to Assembly, No. 4098 State of New Jersey, 2011).

References

Assembly Health and Senior Services Committee Statement to Assembly, No. 4098 State of New Jersey. Njleg.state.nj.us. (2011). Retrieved from https://www.njleg.state.nj.us/2010/Bills/A4500/4098_S1.PDF.

Durable Powers of Attorney for Health Care. Lawhelp.org. (2016). Retrieved from https://www.lawhelp.org/dc/resource/frequently-asked-questions-about-durable-power.

NR 341 Week 2 Client Comfort and End of Life Care

New Jersey Board of Nursing: Law and Public Safety. Njconsumeraffairs.gov. (2020). Retrieved from https://www.njconsumeraffairs.gov/regulations/Chapter-37-New-Jersey-Board-ofNursing.pdf.

NR 341 Week 1 Nursing Care: Complex Health Situations

Name

Chamberlain University

NR-341 Complex Adult Health

Prof. Name

Date

NR 341 Week 1 Edapt Notes: Nursing Care in Complex Health Situations

1. Critical Care Environment and Stress Reduction 

In critical care settings, the environment’s overwhelming nature, combined with constant artificial lighting and noise, significantly elevates stress and anxiety levels in clients and their loved ones. To mitigate these stressors, nursing interventions can focus on enhancing client orientation and providing a serene, orderly environment. Ensuring the room has adequate natural lighting helps clients maintain their circadian rhythms, potentially reducing disorientation. Additionally, nursing staff should implement strategies such as orienting clients and their families to the equipment used, which can lessen their bewilderment. Ensuring the untangling and proper arrangement of tubes and wires is essential for a clear environment that supports seamless care provision. By reducing artificial lighting during rest periods, clients can benefit from an environment more aligned with natural day-night cycles (Patel et al., 2019).

2. Family Dynamics and Communication in Critical Care 

An evidence-based approach, known as the EPICS Family Bundle, can enhance family involvement in the care of critically ill clients. This model helps families cope with the stress of a loved one’s critical illness and provides a structured process for engagement. The EPICS framework—Evaluate, Plan, Involve, Communicate, and Support—encourages family members’ inclusion in care planning. For instance, evaluating family needs and coping abilities, alongside providing honest and consistent communication, fosters a supportive environment. Allowing families to participate in simple caregiving tasks or bringing familiar items to the client’s room may help reduce feelings of isolation. Proper communication among healthcare professionals, utilizing strategies like the ISBAR technique, can improve information transfer and reduce adverse outcomes due to communication breakdowns (Rodgers & Peterson, 2020).

3. Pain and Stress Management Protocols in ICU Settings

 The stress associated with ICU care and complex health conditions often triggers physiological responses such as stress ulcers, impacting overall recovery. Pain and delirium management using the ABCDEF Bundle is a comprehensive approach that covers assessing, preventing, and managing pain, encouraging mobility, and engaging family in the client’s recovery process. Non-pharmacologic methods, including positioning, family interaction, and sensory items from home, should be encouraged for pain relief. For clients unable to verbally communicate, validated tools like the Critical-Care Pain Observation Tool (CPOT) and the Behavioral Pain Scale (BPS) can assist in accurately assessing pain levels. Pharmacologic interventions should be conservative, prioritizing lower dosages with upward titration based on client response, ensuring pain relief is provided before sedation to reduce delirium onset (Smith & Lin, 2022).

Main Causes of Stress-Related Mucosal Disease (SRMD)

Stress-related mucosal disease (SRMD) in critically ill patients primarily results from gastric hypoperfusion, caused by activation of the sympathetic nervous system’s “fight or flight” response. This activation triggers an increased release of catecholamines, vasoconstriction, and inflammation mediated by cytokines. Although gastric acids may play a minor role, they are not the main contributor. SRMD encompasses a range of gastrointestinal (GI) mucosal changes, from superficial mucosal disruptions to deep erosions in gastric muscles, potentially leading to significant bleeding. Initially, these changes can be beneficial by redirecting blood flow away from the gastrointestinal tract to more critical organs like the brain, heart, lungs, and kidneys. However, sustained stress may cause diminished blood flow to the gastric mucosa, increasing the risk of ulcerations and damage to the GI lining.

Risk Factors and Treatments

Patients experiencing certain conditions are at higher risk for stress-related complications, especially those requiring respiratory support via mechanical ventilation, those with altered blood clotting, acute renal or hepatic failure, sepsis, hypotension, or severe head or spinal cord injuries (SCI). To prevent SRMD, prophylactic treatments may include the administration of proton-pump inhibitors (PPIs), such as pantoprazole or rabeprazole, to mitigate gastric acid production. Additionally, managing blood pressure and maintaining adequate fluid volume are crucial steps in preventing visceral hypotension.

Clinical Case Study and Analysis

A 79-year-old client with COVID-19-associated acute respiratory distress syndrome (ARDS) is admitted to the intensive care unit (ICU) and is undergoing mechanical ventilation. Nursing assessments revealed critical findings such as low blood pressure, delayed capillary refill, and signs of pain, indicated by facial grimacing, all of which require immediate intervention to maintain adequate perfusion and minimize discomfort. Laboratory values indicate elevated blood urea nitrogen (BUN) and creatinine, suggesting renal impairment.

The client is at risk of developing stress-induced ulcers and acute renal failure due to prolonged ICU stay and continuous stress. The nursing team’s priority is to address blood pressure, heart rate, and urine output. Essential treatments include maintaining a blood pressure above 100 mm Hg using dobutamine infusion, frequent blood pressure monitoring, and proton-pump inhibitors to prevent stress ulcers.

Ethical and Legal Aspects

In complex health situations, discussions around advanced care planning, including durable power of attorney (DPOA) and living will, are essential. Critically ill clients and their families should be informed about these options to ensure that care aligns with their values and wishes.

Table 1. Key Findings and Interventions in ICU Management for Critically Ill Patients

Health Disparities and Barriers to Health Care Access

Health disparities represent preventable differences in the burden of disease, injury, violence, or opportunities for optimal health among socially disadvantaged groups (CDC, 2017). Over one-third of the U.S. population belongs to a racial or ethnic minority group (U.S. Census Bureau, 2011). These disparities have resulted in disproportionate rates of disease, disability, and death within these communities. The COVID-19 pandemic underscored these inequalities, revealing a heightened disease impact on socially and economically disadvantaged populations.

Barriers to accessing quality health care are multifaceted and often associated with social determinants of health, such as income, education, gender, race, and geography. Lower-income individuals have limited access to health insurance, and lower educational levels are linked to reduced access to jobs offering health benefits. Gender disparities also exist, with males more likely to be treated for cardiac conditions than females, regardless of risk factors. Minority children, such as Black and Latino children, face higher hospitalization rates due to asthma complications than their white counterparts (Institute for Healthcare Improvement, n.d.). Geographic location adds further complexity, as rural residents often face barriers in obtaining timely medical care.

Health Equity, Social Justice, and Ethical Considerations in Complex Health Needs

Health equity, a cornerstone of social justice, strives to provide equal access to quality health care across all socioeconomic classes. Socioeconomic status often determines access to health care providers and facilities, leaving disadvantaged populations vulnerable to preventable health complications. For individuals with complex conditions, such as diabetes or cardiovascular disease, lack of preventive care results in frequent emergencies and critical care needs. Nurses often witness these health disparities and must advocate for equitable health care by delivering respectful, individualized care for each client, especially those with complex health conditions.

For clients with complex needs, ethical considerations around autonomy and self-determination are vital. Advance directives and do-not-resuscitate (DNR) orders safeguard clients’ rights, even when they cannot communicate their preferences. Health care providers play a central role in discussing these directives with clients and families, ensuring that treatment aligns with the clients’ values. If a client requests non-resuscitation, the health care provider documents DNR or allow-natural-death (AND) orders, specifying the level of care to be provided.

Role and Responsibilities of the Rapid Response Team

The rapid response team (RRT) plays an essential role in identifying and intervening when a client’s condition worsens in non-critical settings, aiming to reduce incidents of in-hospital cardiac arrest (IHCA) (Dukes et al., 2019). Bedside nurses are responsible for identifying early signs of deterioration and activating the RRT to address the client’s needs promptly. Symptoms such as altered vital signs, oxygen levels, and mental status may signal a need for urgent intervention. The RRT follows established protocols, including diagnostic tests, airway management, and medication administration, ensuring the client receives the necessary level of care. Ongoing evaluation and quality improvement are critical to the team’s success, with debriefing sessions designed to enhance learning and support for staff (Jackson, 2017).

Palliative Care in Intensive Care Units

In palliative care, addressing the practical and emotional needs of patients, such as bereavement counseling, is essential. The objective is to support patients in living as actively as possible until their end of life (World Health Organization, 2020). In Intensive Care Units (ICUs), which are designed for critical and life-saving interventions, the focus of care shifts from cure to comfort when a patient is nearing the end of life. This transition encompasses five essential dimensions of care that prioritize symptom management, holistic support, and dignity for both the patient and their loved ones.

Symptom Alleviation and Palliative Care Goals

Palliative care in critical settings aims to manage disease symptoms, supporting the patient and their family through the dying process with comfort and dignity. The primary goals include acknowledging dying as a normal process, alleviating symptoms (e.g., pain), affirming life without hastening or delaying death, enhancing quality of life, and supporting both the patient and family during the illness and in bereavement (World Health Organization, 2020). Open and honest communication among the healthcare team, patient, and family is prioritized in end-of-life care discussions, which may involve setting care goals and discussing palliative care versus aggressive treatment.

Decision-Making in Treatment Withdrawal and Nursing Care for Organ Donation

Withdrawing or withholding life-sustaining treatment should be a collaborative decision involving the patient, family, and healthcare team, guided by ethical considerations. Nursing support for withdrawing treatment includes keeping the family informed, addressing symptoms such as anxiety, and allowing family presence. In cases where the patient has chosen organ donation, the focus shifts to preserving the organs for transplantation. Nursing care ensures that organ function is maintained through evidence-based practices, including managing hemodynamics and providing comfort until the organ recovery process can begin.

Table of Key Aspects in ICU Palliative Care and Organ Donation

References

World Health Organization. (2020). Palliative care. WHO.

National Conference of Commissioners on Uniform State Laws. (2018). Model Uniform Determination of Death Act.

Centers for Disease Control and Prevention. (2017). Health Disparities. https://www.cdc.gov/healthdisparities/

Dukes, T., Tyson, M., & Cannon, R. (2019). The role of rapid response teams in reducing in-hospital cardiac arrests. Journal of Critical Care Nursing, 34(2), 112-119.

NR 341 Week 1 Nursing Care: Complex Health Situations

Institute for Healthcare Improvement. (n.d.). The effectiveness of rapid response teams. Retrieved from https://www.ihi.org

Jackson, S. (2017). Early recognition of cardiac arrest symptoms. American Journal of Emergency Medicine, 35(6), 1023-1028.

U.S. Census Bureau. (2011). Geographic Distribution.

NR 341 Case 5 Complex Adult Health Communicator

Name

Chamberlain University

NR-341 Complex Adult Health

Prof. Name

Date

ATI the Communicator: Case 5 – Ms. Lonely

In this communication case scenario, Nurse Morgan is responsible for the care of Ms. Lonely, a patient who is nearing the end of her life. Ms. Lonely’s family, including her daughters, aunt, and other relatives, gather at her bedside. While watching the video, one particular scene stood out where I would reconsider my clinical practice. The patient displayed signs of pain, and her daughters conveyed to the nurse that their mother did not wish to receive any medication for pain relief. In this situation, it is imperative for the nurse to educate the family on the importance of pain management, explaining how medication could significantly alleviate their mother’s discomfort. Respecting the patient’s autonomy regarding her pain management decisions is crucial, particularly if she is alert and aware of her surroundings.

The daughters should not hold the authority to determine their mother’s pain management unless they possess legal documentation, such as a living will, that grants them the power to make medical decisions on her behalf. Rather than solely relying on pharmacological interventions, the nurse could also explore alternative pain management techniques, such as guided imagery, therapeutic touch, or massage. These non-pharmacological approaches can offer significant comfort and support in managing the patient’s pain.

NR 341 Case 5 Complex Adult Health Communicator

By providing education on various pain management options and involving the patient in decision-making, the nurse can empower Ms. Lonely to have a degree of control over her care. This patient-centered approach not only promotes the patient’s wishes and preferences but also aligns with holistic care principles. Moreover, considering alternative pain management strategies can enhance the overall well-being of the patient, addressing her discomfort in a more comprehensive manner.

Texas Board of Nursing

According to the Texas State Board of Nursing, the nurse’s role in managing a patient’s pain is of utmost importance. Chapter 228 emphasizes that the primary goal of pain management is to effectively address the patient’s pain while considering her overall health. This includes taking into account physical, psychological, and social factors (Texas Administrative Code, 2013).

In addition to these responsibilities, nurses are expected to assess and manage the patient’s pain accurately. This involves documenting the patient’s pain descriptions and evaluating the effectiveness of any prescribed medications or interventions. Proper documentation of the outcomes related to pain relief and the overall condition of the patient is essential. By adhering to these guidelines, Texas nurses contribute to the delivery of optimal pain management and ensure that the treatment plan is tailored to meet the patient’s specific needs.

Incapacitated and Next of Kin

As outlined in the Texas Health and Safety Code §313.004 concerning consent for medical treatment, an incapacitated patient is defined as someone who, based on reasonable medical judgment, is unable to comprehend or appreciate the nature and consequences of a treatment decision. This encompasses understanding the proposed treatment’s potential benefits, risks, and alternatives (Health and Safety Code, 2017). Incapacitated patients may include those who are comatose, mentally or physically incompetent, or unable to articulate their preferences.

Once a physician determines that a patient is incapacitated, an adult surrogate is appointed according to a specific priority order. The first option is the patient’s spouse, followed by an adult child who has the necessary consent from other eligible adult children to act as the sole decision-maker. If there are no eligible adult children or consensus among them cannot be reached, the responsibility falls to the majority of the patient’s available adult children. Lastly, if no adult children are available or in agreement, the patient’s parents are authorized to make healthcare decisions on the patient’s behalf. Texas law permits resolution of any conflicts among potential surrogates through the court system (Health and Safety Code, 2017).

This information is vital for healthcare providers caring for incapacitated patients who lack a living will or do-not-resuscitate (DNR) directive, as it establishes the legal framework for identifying decision-makers. Understanding these guidelines is essential to ensuring that the patient’s best interests and preferences are honored.

References

DeMartino, E. S., Dudzinski, D. M., Doyle, C. K., Sperry, B. P., Gregory, S. E., Siegler, M., Sulmasy, D. P., Mueller, P. S., & Kramer, D. B. (2017). Who Decides When a Patient Can’t? Statutes on Alternate Decision Makers. The New England Journal of Medicine, 376(15), 1478-1482.

Health and Safety Code. (2017). Retrieved November 11, 2018, from https://statutes.capitol.texas.gov/Docs/HS/htm/HS.313.html

NR 341 Case 5 Complex Adult Health Communicator

Texas Administrative Code. (2013). Retrieved November 11, 2018, from http://www.bon.texas.gov/rr_current/228-1.asp

NR 341 Comprehensive Nursing Care for a Patient with Multiple Traumatic Injuries

Name

Chamberlain University

NR-341 Complex Adult Health

Prof. Name

Date

Introduction

This article examines the case of Loius, a 67-year-old Caucasian male who was admitted to the neuro ICU following a motor vehicle accident. Loius sustained multiple injuries, including fractures of the ribs, mandible, and nasal bones, as well as lacerations to his tongue, head, and torso. The primary focus of this article is on Loius’s nursing diagnosis, interventions, collaborative management, therapeutic approaches, and reflections on the nursing role in his care.

Patient Assessment

Loius’s assessment revealed significant past medical history, including smoking, daily alcohol consumption, and hepatitis C. A notable scar on his back indicated prior back surgery. Upon arrival at the ER, Loius presented with rib fractures, mandibular and nasal fractures, and multiple lacerations as a result of being ejected from his vehicle during the crash. Although his vital signs were relatively stable, Loius exhibited confusion, likely stemming from head trauma. He also experienced significant pain, nasal swelling, and active bleeding.

Nursing Diagnoses and Outcomes

The nursing diagnoses for Loius included imbalanced nutrition, an ineffective breathing pattern, and a risk for infection. The targeted outcomes were to enhance oral intake, maintain a patent airway, prevent infections, and improve the patient’s overall well-being. Nursing interventions aimed at achieving these outcomes included effective pain management, providing encouragement and support during meals, deep breathing exercises, wound care, and continuous monitoring for signs of infection.

Routine Nursing Management

To manage Loius’s pain, a Patient-Controlled Analgesia (PCA) pump was implemented, allowing him to self-administer morphine for optimal pain control. Enteral nutrition was administered to ensure Loius received adequate nutrition for wound healing. Despite his initial reluctance to eat, nursing staff provided encouragement and assistance during mealtimes, aiming to alleviate both anxiety and pain, thus promoting a more comfortable eating experience.

Collaborative Management

Collaborative care for Loius involved a multidisciplinary healthcare team. Occupational therapy helped Loius with assistive devices for eating and drinking, while physical therapy focused on mobility and pain management. Additionally, wound care specialists, surgical services, and nutritional consultations were integral parts of the care plan, ensuring optimal healing and recovery.

Therapeutic Modalities

Loius’s therapeutic care included interventions to reduce nasal swelling from his fracture and promote tongue wound healing. The use of Peridex solution, an oral antimicrobial rinse, was employed to protect the open wound in his tongue and provide pain relief. These therapeutic modalities played a critical role in enhancing the patient’s comfort and facilitating the healing process.

Nursing Role Reflection

During the care of  Loius, various communication styles were noted, including passive, aggressive, passive-aggressive, and assertive. Among these, assertive communication proved to be the most effective in fostering open dialogue, promoting teamwork, and ultimately enhancing patient outcomes. The case highlighted the challenges of caring for comatose patients, emphasizing the importance of empathetic and compassionate care.

NR 341 Comprehensive Nursing Care for a Patient with Multiple Traumatic Injuries

Additionally, teamwork among nursing staff played a vital role in delivering high-quality care. Collaboration between senior nurses, healthcare professionals, and support staff facilitated optimal patient care. One recommendation for improvement involved increasing the availability of lifts on the floor to improve the safety of both patients and nursing staff during transport.

Conclusion

Loius’s case underscores the significance of comprehensive nursing care, collaboration, and communication in achieving positive patient outcomes. The nursing diagnoses, interventions, collaborative management, and therapeutic approaches applied in this case provide valuable insights for future practice. By prioritizing assertive communication, teamwork, and patient-centered care, nurses can play a crucial role in improving patient outcomes.

NR 341 Complex Adult Health Interdisciplinary Care

Name

Chamberlain University

NR-341 Complex Adult Health

Prof. Name

Date

Background Information

Mrs. Watson . is a 62-year-old African American female admitted to the emergency room on March 10, 2018, as a complete code. She presented with shortness of breath and an opiate overdose, likely caused by her chronic lifestyle, which includes smoking a pack of cigarettes daily, consuming four to five glasses of wine per day, and using heroin alongside painkillers. Her medical history consists of asthma, hypertension, urinary incontinence, urinary tract infection (UTI), and type II diabetes mellitus. Additionally, she has undergone a right knee replacement and benign cyst removal from her right breast. Currently, Mrs. Watson. is diagnosed with bilateral pulmonary infiltrates, with a suspected opiate overdose contributing to her condition.

On the day of care, her vital signs were notable: blood pressure was 98/58 mm Hg, oral temperature 98.9°F, respiratory rate 8 breaths per minute, weight 146 pounds, radial pulse 40 beats per minute, and oxygen saturation was 88% on room air. Further assessments revealed the presence of alcohol and smoke odors, intoxicated behavior, inflamed nasal mucosa, gingival ulceration, warm skin, and bruises and lacerations on her abdomen, legs, and arms. Despite her severe condition, she remained alert and oriented. However, she showed symptoms of respiratory distress, such as shallow and labored breathing, dyspnea, wheezing, and respiratory depression.

NR 341 Complex Adult Health Interdisciplinary Care

The nursing diagnosis for Mrs. Watson involves ineffective airway clearance due to the effects of drugs, inadequate health maintenance, and a risk of suicide linked to substance abuse. The primary goals of nursing care include improving airway patency, promoting health-seeking behaviors, and ensuring the patient’s safety. To achieve these outcomes, the nursing interventions included monitoring blood gas levels and pulse oximetry readings and offering emotional support. Her respiratory, neurological, and cardiovascular functions were consistently assessed throughout her care.

Routine nursing management focused on keeping her airway patent by positioning her in a high Fowler position and administering mechanical ventilation when needed. Naloxone, an antidote for opioid overdose, was given, and continuous ECG monitoring was initiated. A collaborative interdisciplinary team provided comprehensive care, including respiratory therapists, nurses, emergency physicians, ECG technicians, laboratory personnel, and support staff. The respiratory therapists administered treatments and managed mechanical ventilation systems, while the nurses provided direct care, administered medications, and communicated with the physicians.

NR 341 Complex Adult Health Interdisciplinary Care

The emergency physicians evaluated Mrs. Watson’s condition, ordered appropriate tests, and initiated treatment. ECG technicians monitored her heart activity, while lab personnel carried out necessary procedures. Assistive personnel supported patient care under nurse supervision. Non-surgical and medication-free therapeutic modalities were employed, focusing on psychosocial support and continuous patient assessments.

Effective communication played a crucial role in care, with nurses providing active listening and a comforting presence to the patient. These therapeutic efforts aimed to build trust, foster independence, and improve overall well-being. Reflecting on my role as a nursing student in this situation, I remember the intense atmosphere in the emergency room when Mrs. Watson arrived. I assisted in measuring vital signs and placing ECG electrodes, observing how the healthcare team worked together to offer immediate and efficient care. The nurse I was paired with displayed calm and efficient behavior, ensuring that all tasks were completed correctly. This experience was valuable and reinforced my passion for the nursing profession.

Conclusion

In conclusion, the interdisciplinary care provided to Mrs. Watson addressed her immediate health concerns, promoted health-seeking behavior, and ensured her safety. The nursing team played a crucial role in managing her condition and delivering high-quality care in a coordinated and timely manner.

References

Carpenito, L. J. (2017). Nursing diagnosis: Application to clinical practice. Philadelphia, PA: Wolters Kluwer.

For All Your Nursing Needs. (n.d.). Retrieved March 30, 2018, from https://nurseslabs.com/

Lewis, S. L., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed.). Elsevier Mosby.

Lilley, L. L., Collins, S. R., & Snyder, J. S. (2017). Pharmacology and the nursing process. St. Louis, MO: Elsevier.

NR 341 Complex Adult Health Interdisciplinary Care

Vallerand, A. H. (2015). Davis’s drug guide for nurses (14th ed.). Philadelphia, PA: F.A. Davis Company.