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ABCNCM 106.pdf
- 1. NCM106: NCM106: ACUTE ACUTE BIOLOGIC BIOLOGIC CRISIS CRISIS RANDOLPH CORNELIO M. CAPON, BSN, RN RANDOLPH CORNELIO M. CAPON, BSN, RN
- 2. SHOCK SHOCK
- 3. Types of SHOCK: Types of SHOCK: 1. 1. HYPOVOLEMIC HYPOVOLEMIC 2. 2. CARDIOGENIC CARDIOGENIC 3. 3. SEPTIC SEPTIC 4. 4. ANAPHY ANAPHYLACTIC LACTIC 5. 5. NEUROGENIC NEUROGENIC 6. 6. OBSTRUCTIVE OBSTRUCTIVE
- 4. Compensatory Mechanism: Compensatory Mechanism: Sympatho-Ad Sympatho-Adreno-Medullary Response reno-Medullary Response (SAMR) (SAMR) Antidiureti Antidiuretic Hormone (ADH) release c Hormone (ADH) release Renin Renin Angiotensin Angiotensin- - Aldosterone Aldosterone System System (RAAS) (RAAS) Sympathetic Nervous System (SNS) Stimulation Sympathetic Nervous System (SNS) Stimulation
- 5. General Signs and Symptoms: General Signs and Symptoms: Early Stage: Early Stage: SNS activation SNS activation Respiratory Alkalosis Respiratory Alkalosis Late Stage: Late Stage: hypotension hypotension Oliguria to anuria Oliguria to anuria Shallow breathing Shallow breathing Resp. and Metabolic Resp. and Metabolic Acidosis Acidosis
- 6. COLLABORATIVE MANAGEMENT: COLLABORATIVE MANAGEMENT: Promote fluid balance and cardiac output Promote fluid balance and cardiac output Assist with cardiac support Assist with cardiac support Assist with Respiratory Support Assist with Respiratory Support Assist with Renal Support Assist with Renal Support Assist with G.I Support Assist with G.I Support Promote Safety Promote Safety Administer Medication as ordered Administer Medication as ordered
- 10. 2 major types: 2 major types:
- 11. Signs and Symptoms: Signs and Symptoms: A. A. Headache Headache B. B. Increased Blood Pressure Increased Blood Pressure C. C. Nausea and Vomiting Nausea and Vomiting D. D. Dysphagia Dysphagia E. E. Focal and Neurological Focal and Neurological deficit deficit
- 12. E. Focal and E. Focal and Neurological deficits Neurological deficits Hemiparesis and Hemiparesis and Hemiplegia Hemiplegia Aphasia Aphasia Dysarthria Dysarthria Dysphagia Dysphagia Apraxia Apraxia Homonymous Homonymous Hemianopia Hemianopia Agnosia Agnosia Unilateral Neglect Unilateral Neglect
- 13. Risk Factors: Risk Factors: 1. 1. Smoking Smoking 2. 2. Sedentary Lifestyle Sedentary Lifestyle 3. 3. Prolonged Use of Oral Prolonged Use of Oral Contraceptives Contraceptives 4. 4. Obesity Obesity 5. 5. T Type A ype A Per Person sonali ality ty
- 14. Diagnostic Procedures: Diagnostic Procedures: 1. 1.CT Scan CT Scan 2. 2.Cerebral Arteriography Cerebral Arteriography
- 15. Nursing Management: Nursing Management: 1. 1. Administer O2 if indicated Administer O2 if indicated 2. 2. Elevate HOB 30-45 degrees angle Elevate HOB 30-45 degrees angle 3. 3. Avoid V Avoid Valsalva alsalva Maneuver Maneuver 4. 4. Assist NGT Assist NGT feeding if indicated feeding if indicated 5. 5. Assist PROM exercises Assist PROM exercises 6. 6. Prevent Complication of Immobility Prevent Complication of Immobility 7. 7. Promote Communication Promote Communication 8. 8. Care of Patient with Hemanopia Care of Patient with Hemanopia 9. 9. Administer Medications as o Administer Medications as ordered rdered
- 19. Signs and Symptoms: Signs and Symptoms: Earliest Sign: Earliest Sign: 1. 1. Change or decrease LOC Change or decrease LOC Other Signs: Other Signs: 2. N&V 2. N&V 3. Diplopia 3. Diplopia 4. Papilledema 4. Papilledema 5 5.Doll’s eye sign .Doll’s eye sign 6. Decorticate 6. Decorticate 7. Deccerebrate 7. Deccerebrate
- 20. Late Sign: Late Sign: 8.Vital Signs Changes 8.Vital Signs Changes
- 22. NURSI NURSING NG MANAG MANAGEMENT EMENT: : 1. 1. Maintain Patent airway and adequate Maintain Patent airway and adequate ventilation ventilation 2. 2. Assist to semi fow Assist to semi fowlers position lers position 3. 3. Limit fluid intake Limit fluid intake 4. 4. Avoid fac Avoid factors that increases ICP tors that increases ICP 5. 5. Promote safety Promote safety 6. 6. Encourage Rest Encourage Rest 7. 7. Administer Medication as ordered Administer Medication as ordered
- 23. BURN BURN
- 24. Causes of BURN: Causes of BURN: Thermal Burn Thermal Burn Chemical Burn Chemical Burn Electrical Burn Electrical Burn Radiation Burn Radiation Burn
- 25. Depth of Skin Involved Depth of Skin Involved First Degree First Degree Second Degree Second Degree Third Degree Third Degree
- 26. ST STAGES AGES of B of Burn: urn: Shock/ Fluid Accumulation/ Emergent Phase Shock/ Fluid Accumulation/ Emergent Phase Diuretic/ Fluid Remobilization Phase Diuretic/ Fluid Remobilization Phase Recovery Phase Recovery Phase
- 27. First First Aid I Aid Intervention ntervention 1. 1. Immense affected part in cold water Immense affected part in cold water 2. 2. Drop and Roll Drop and Roll 3. 3. Throw a blanket over the client Throw a blanket over the client 4. 4. Encourage Anti- Encourage Anti- contracture positioning contracture positioning
- 28. Priority Priority Action in Action in case of F case of Fire: ire: R R em emov ove e th the cl e clie ient nt A A ct ctiv ivat ate e th the fir e fire ala e alarm rm C C on onfi fine ne th the f e fir ire e xt xtin ingu guis ish h th the e fi fire re
- 29. E E T To u o use t se the he fire fire exting extinguisher uisher, , do the following: do the following: P P u ul ll l t th he p e pi in n A A im im at t at the b he base ase of t of the he fla flame me S S qu quee eeze ze th the e ha hand ndle le weep from side to side weep from side to side
- 30. S S Collaborative Management: Collaborative Management: 1. 1. Promote respiratory function Promote respiratory function 2. 2. Promote fluid-electrolyte and Promote fluid-electrolyte and acid-base balance acid-base balance 3. 3. Relieve Pain Relieve Pain 4. 4. Prevent Infection Prevent Infection 5. 5. Assist in Assist in Hydrotherapy Hydrotherapy 6. 6. Assist in Assist in debribement debribement 7. 7. Assist in Assist in Skin grafting Skin grafting 8. 8. Promote G.I support Promote G.I support 9. 9. Provide Fluid Replacement Provide Fluid Replacement 10. 10. Assist in Assist in Rehabili Rehabilitation Phase tation Phase
- 32. Classic Sign of DM Classic Sign of DM
- 33. Types of DM: Types of DM: 1 1. . I ID DD DM M 2 2. . N NI ID DD DM M -juvenile onset/ Non obese -juvenile onset/ Non obese -leads to destruction of pancreatic -leads to destruction of pancreatic cells le cells leadin ading g to defi to deficiency of i ciency of insuli nsulin n production. production. -ad -adult ult ons onset/ O et/ Obes bese e -Lack insulin receptor binding site -Lack insulin receptor binding site -- -- asy asympt mptoma omatic tic T TR RE EA AT TM ME EN NT T T TR RE EA AT TM ME EN NT T -Insulin Therapy -Insulin Therapy -Exercise after meals -Exercise after meals -OHA -OHA - - d di ie et t - - Ex Exer erci cise se C CO OM MP PL LI IC CA AT TI IO ON N C CO OM MP PL LI IC CA AT TI IO ON N
- 34. - - D DK KA A - - H HH HN NS S/ / H HO ON NK KC C DIABETIC KETOACIDOSIS DIABETIC KETOACIDOSIS
- 35. 1. 1. 3 P’s & 1 G 3 P’s & 1 G 2. 2. Weight Loss Weight Loss 3. 3. Anorexia, N/V Anorexia, N/V 4. 4. CNS Depression CNS Depression 5. 5. Kussmaul’s Kussmaul’s Respiration Respiration 6. 6. (+) Acetone breath (+) Acetone breath
- 36. NURSING Management: NURSING Management: 1. 1. Assist in Assist in Mechanica Mechanical V l Ventilation entilation 2. 2. Adminis Administer 0.9% NaCl ter 0.9% NaCl followed by 0. followed by 0.45% NaCl 45% NaCl IV fluids IV fluids 3. 3. Monitor Monitor VS, VS, I&O, I&O, plasma plasma sugar sugar levels levels 4. 4. Adminis Administer Medications as ter Medications as ordered (e.i., Insul ordered (e.i., Insulin therapy) in therapy)
- 37. Types of Insulin Types of Insulin T TY YP PE E C CO OL LO OR R/ / CONSISTEN CONSISTEN CY CY O ON NS SE ET T P PE EA AK K D DU UR RA AT TI IO ON N 1 1. . R RA AP PI ID D acting acting (Regular (Regular insulin) insulin) C Cl le ea ar r 2 2- -4 4 h ho ou ur rs s 2. 2. INTERMEDIA INTERMEDIA TE acting TE acting (NPH) (NPH) C Cl lo ou ud dy y 8 8- -1 16 6 h ho ou ur rs s 3. LONG 3. LONG acting acting (Ultralente) (Ultralente) C Cl lo ou ud dy y 1 16 6- -2 24 4 h ho ou ur rs s
- 39. DX and Lab Exam for DM DX and Lab Exam for DM a. a. FBS FBS b. b. OGTT OGTT c. c. RBS RBS d. d. Alpha gly Alpha glycosylated cosylated hemoglob hemoglobin in
- 40. NURSING Management: NURSING Management: 1. 1. Foot care management Foot care management 2. 2. Same as Same as DKA DKA EXCEPT EXCEPT don’t give Na HCO3! don’t give Na HCO3! 3. 3. Annual eye & Annual eye &kidney exam kidney exam 4. 4. Assist su Assist surgical procedu rgical procedure re