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By: ROMMEL LUIS C. ISRAEL
III
Nursing Care of Clients with
Life Threatening Conditions,
Acutely ill / Multi Organ
Problems ,
High Acuity and Emergency
Situation
BY: ROMMEL LUIS C. ISRAEL III
1
THE TERM “LIFE-
THREATENING
CONDITION” MEANS
ANY DISEASE OR
CONDITION FROM
WHICH THE
LIKELIHOOD OF
IS PROBABLE UNLESS
THE COURSE OF THE
DISEASE OR
CONDITION IS
INTERRUPTED.
• What is an appropriate
response to a life-threatening
situation?
• Stay calm, and call your local
emergency number (such as 911).
Start CPR (cardiopulmonary
resuscitation) or rescue breathing,
if necessary and if you know the
proper technique. Place a
• semiconscious or unconscious
person in the recovery position
until the ambulance arrives.
BY: ROMMEL LUIS C. ISRAEL III
2
WHAT IS HIGH ACUITY PATIENT?
PURPOSE:
HIGH ACUITY UNITS (HAU) ARE HOSPITAL UNITS THAT
PROVIDE PATIENTS WITH MORE ACUTE CARE AND
CLOSER MONITORING THAN A GENERAL HOSPITAL
WARD BUT ARE NOT AS RESOURCE INTENSIVE AS AN
INTENSIVE CARE UNIT (ICU).
BY: ROMMEL LUIS C. ISRAEL III
3
THE MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS) CAN BE DEFINED AS THE DEVELOPMENT OF
POTENTIALLY REVERSIBLE PHYSIOLOGIC DERANGEMENT INVOLVING TWO OR MORE ORGAN SYSTEMS
NOT INVOLVED IN THE DISORDER THAT RESULTED IN ICU ADMISSION, AND ARISING IN THE WAKE OF A
POTENTIALLY LIFE-THREATENING PHYSIOLOGIC INSULT.
• Multiple organ dysfunction syndrome (MODS) is defined as
the progressive physiological dysfunction of two or more
organ systems where homeostasis cannot be maintained
without intervention. It is initiated by illness, injury or
infection and most commonly affects the heart, lungs, liver
and kidneys.
• An Overview of Multiple Organ
Dysfunction Syndrome -
Ausmed
https://www.ausmed.com › cpd ›
articles › multiple-organ
• The fundamental cause of MODS is attributed to
the conditions such as surgery, inflammation,
accident, infection, increased metabolic rate,
metabolic activity, and decreased perfusion.
BY: ROMMEL LUIS C. ISRAEL III
4
What would happen if your organ systems
stopped functioning properly?
AFTER ONE SYSTEM SHUTS DOWN, THE OTHERS WOULD SLOWLY START TO SHUT
DOWN AS WELL UNTIL THE BODY CAN NO LONGER MAINTAIN HOMEOSTASIS AND THE
PERSON WOULD SLOWLY DIE. 3. ALL SYSTEMS WOULD BE WORKING TOGETHER BUT THE MAIN
ONES WOULD BE MUSCULAR, NERVOUS, AND SKELETAL.
Interacting Body Systems and Homeostasis
http://sites.isdschools.org › useruploads › biology
Which organ fails
first in multi
organ failure?
Generally, the lung is the first organ to fail after injury
(failure after
3.7 +/- 2.8 days). Significant renal failure and the need for dialysis decreased to < 5%; other
signs of organ dysfunction (gastric, central nervous system) are difficult to verify.
Pattern of organ failure following severe trauma - PubMed https://pubmed.ncbi.nlm.nih.gov › ..
BY: ROMMEL LUIS C. ISRAEL III
5
MODS CAN AFFECT ANY ORGAN, BUT THE PRIMARY PLAYERS ARE THE LUNGS, HEART,
KIDNEYS, LIVER, BRAIN, AND BLOOD. THERE ARE MANY CAUSES OF MODS, BUT THE GENERAL
CATEGORIES INCLUDE MAJOR TRAUMA, SEVERE ILLNESS, AND WIDESPREAD INFECTION.
What are signs of organ dysfunction?
• The clinical signs of tissue hypoxia are largely
non-specific.
• However, increased respiratory rate, peripheries
that are either warm and vasodilated or cold
and vasoconstricted, poor urine output, and
mental dullness may indicate organ
dysfunction and should prompt a search for
reversible causes.
• ABC of intensive care: Organ
dysfunction - PMC - NCBI
https://www.ncbi.nlm.nih.gov ›
articles › PMC1115973
BY: ROMMEL LUIS C. ISRAEL III
6
Shock and Multiple Organ Dysfunction Syndrome
Shock is a life-threatening condition with a variety of underlying causes. It is characterized
by inadequate perfusion that,
if untreated, results in cell death. The progression of shock is neither linear nor
predictable, and shock states, especially
septic shock, comprise a current area of aggressive clinical research.
Nurses caring for patients with shock and for those at
risk for shock must understand the underlying mechanisms of shock and recognize its
subtle as well as more obvious signs.
Rapid assessment with early recognition and response to
shock states is essential to the patient’s recovery.
BY: ROMMEL LUIS C. ISRAEL III
7
Shock can
best be
defined as a
condition in
which
widespread
perfusion to
the cells is
inadequate to
deliver oxygen
and nutrients
to support
vital organs
and cellular
function
Adequate blood flow to the tissues and cells requires
an adequate cardiac pump, effecti vasculature or
circulatory system, and sufficient blood volume.
If one of these components is impaired, perfusion to
the tissues is threatened or compromised.
Without treatment, inadequate blood flow to the cells
results in poor delivery of oxygen and nutrients,
cellular hypoxia, and cell death that progresses to
organ dysfunction and eventually death.
BY: ROMMEL LUIS C. ISRAEL III
8
PATHOPHYSIOLOGY OF CELLULAR CHANGES
In shock, the cells lack an adequate blood supply and are deprived
of oxygen and nutrients; therefore, they must produce
energy through anaerobic metabolism. This results in low
energy yields from nutrients and an acidotic intracellular environment.
Because of these changes, normal cell function
ceases . The cell swells and the cell membrane becomes
more permeable, allowing electrolytes and fluids to
seep out of and into the cell. The sodium–potassium pump
becomes impaired; cell structures, primarily the mitochondria,
are damaged; and death of the cell results.
Glucose is the primary substrate required for
the production
of cellular energy in the form of ATP.
BY: ROMMEL LUIS C. ISRAEL III
9
Nurses must anticipate these therapies because they need to be implemented
with speed and accuracy.
Many of the interventions required in caring for patients with shock call for
close collaboration with other members of the health care team and rapid
implementation of prescribed therapies.
Nursing care of patients with shock requires ongoing systematic assessment.
BY: ROMMEL LUIS C. ISRAEL III
10
STAGES OF SHOCK
Shock is believed to progress along a
continuum of stages. Shock can be
identified as early or late, depending
on the
signs and symptoms and the
overall severity of organ
dysfunction.
Aconvenient way to understand
the physiologic
responses and subsequent clinical
signs and symptoms of
shock is to divide the continuum into
separate stages: compensatory
(stage 1), progressive (stage 2), and
irreversible
(stage 3).
The sympathetic nervous system and
subsequent release of
catecholamines (epinephrine and
norepinephrine). Patients
display the often-described “fight or
flight” response.
The body shunts blood from organs such
as the skin, kidneys,
and gastrointestinal tract to the brain,
heart, and
lungs to ensure adequate blood supply to
these vital organs.
As a result, the skin is cool and clammy,
bowel sounds are
hypoactive, and urine output decreases
in response to the
release of aldosterone and ADH.
BY: ROMMEL LUIS C. ISRAEL III
11
Clinical Manifestations
Despite a normal BP, the patient shows numerous clinical
signs indicating inadequate organ perfusion.
The result of inadequate perfusion is anaerobic metabolism
and a buildup of lactic acid, producing metabolic acidosis.
The respiratory rate increases in response to metabolic acidosis.
This rapid respiratory rate facilitates removal of excess
carbon dioxide but raises the blood pH and often causes a
compensatory respiratory alkalosis. The alkalotic state
causes mental status changes, such as confusion or
combativeness,
as well as arteriolar dilation. If treatment begins in
this stage of shock, the prognosis for the patient is better
than in later stages.
BY: ROMMEL LUIS C. ISRAEL III
12
Medical Management
Medical treatment is directed toward Identifying the cause of the shock, correcting
the underlying disorder so that shock does not progress, and supporting
those physiologic processes that thus far have responded successfully to the
threat.
Because compensation cannot be maintained indefinitely, measures such as fluid
replacement and medication therapy must be initiated to maintain an adequate
BP and reestablish and maintain adequate tissue perfusion (Otero,
et al., 2006).
BY: ROMMEL LUIS C. ISRAEL III
13
Nursing Management
As stated earlier, intervention as soon as possible along the
continuum of shock is the key to improving the patient’s prognosis.
The nurse must systematically assess the patient at risk for shock to
recognize the subtle clinical signs of the compensatory stage before
the patient’s BP drops.
Special considerations related to recognizing early signs of shock in
the elderly patient.
BY: ROMMEL LUIS C. ISRAEL III
14
Monitoring Tissue Perfusion
The nurse observes for changes in level of consciousness, vital signs
(including pulse pressure), urinary output, skin, and laboratory values
(eg, base deficit and lactic acid levels).
In the compensatory stage of shock, serum sodium and blood glucose
levels are elevated in response to the release of aldosterone and
catecholamines
BY: ROMMEL LUIS C. ISRAEL III
15
Monitoring Tissue Perfusion
The nurse should monitor the patient’s hemodynamic status
and promptly report deviations to the physician, assist in
identifying and treating the underlying disorder by continuous
in-depth assessment of the patient, administer prescribed
fluids and medications, and promote patient safety. Vital
signs are key indicators of hemodynamic status and BP is
an indirect measure of tissue
hypoxia.
The nurse should report a systolic BP lower than 90 mm Hg or a
drop in systolic BP of 40 mm Hg from baseline.
BY: ROMMEL LUIS C. ISRAEL III
16
Pulse pressure correlates well with stroke
volume. Pulse pressure is calculated by
subtracting the diastolic measurement from the
systolic measurement; the difference is the
pulse pressure (Cottingham, 2006).
Normally, the pulse pressure is 30 to 40 mm Hg.
Narrowing or decreased pulse pressure is an
earlier indicator of shock than a drop in systolic
BP.
BY: ROMMEL LUIS C. ISRAEL III
17
Decreased or narrowing pulse pressure, an early
indication of decreased stroke volume, is illustrated in the
followingexample:
Systolic BP Diastolic BP Pulse pressure
Normal pulse pressure:
120 mgHg 80 mm Hg 40 mm Hg
Narrowing of pulse pressure:
90 mm Hg 70 mm Hg 20 mm Hg
stroke volume, BP, and overall cardiac output.
BY: ROMMEL LUIS C. ISRAEL III
18
Elevation of the diastolic BP with release of
catecholamines and attempts to increase venous return
through vasoconstriction is an early compensatory
mechanism in response to decreased stroke volume,
BP, and overall cardiac output.
BY: ROMMEL LUIS C. ISRAEL III
19
Promoting Safety
The nurse must be vigilant for potential threats to the patient’s
safety, because a high anxiety level and altered mental
status impair judgment.
In this stage of shock, patients who were previously
cooperative and followed instructions may now disrupt IV
lines and catheters and complicate their condition.
Therefore, close monitoring and frequent reorientation
interventions are essential.
BY: ROMMEL LUIS C. ISRAEL III
20
NURSING ALERT
By the time BP drops, damage has already been occurring
at the cellular and tissue levels.
Therefore, the patient at risk for shock must be assessed
and monitored closely before the BP falls.
BY: ROMMEL LUIS C. ISRAEL III
21
• Continuous central venous oximetry (Scv–O2)
monitoring may be used to evaluate mixed venous
blood oxygen saturation and the severity of tissue
hypoperfusion states.
• A central catheter is introduced into the superior vena
cava (SVC), and a sensor on the catheter measures the
oxygen saturation of the blood in the SVC as blood
returns to the heart and pulmonary system for
reoxygenation.
• A normal Scc–O2 value is 70%.
• Body tissues use approximately 25% of the oxygen delivered to
them during normal metabolism.
• During states of stress, such as shock, more oxygen
is consumed and the Scv–O2 saturation is lower,
indicating that the tissues are consuming more
oxygen.
BY: ROMMEL LUIS C. ISRAEL III
22
Monitoring tissue oxygen consumption with
Scv–O2 is a minimally invasive measure to more
accurately assess tissue oxygenation in the
compensatory stage of shock before changes in vital
signs detect altered tissue perfusion (Dellinger, et al.,
2008; Goodrich, 2006; Otero,
et al., 2006).
New technologies allow clinicians to detect changes in
tissue perfusion before changes in classic signs (BP,
heart rate, and urine output) indicative of
hypoperfusion occur.
BY: ROMMEL LUIS C. ISRAEL III
23
Clinical Manifestations
Chances of survival depend on the patient’s
general health before the shock state as well
as the amount of time it takes
to restore tissue perfusion.
As shock progresses, organ systems
decompensate.
BY: ROMMEL LUIS C. ISRAEL III
24
1. Respiratory Effects
BY: ROMMEL LUIS C. ISRAEL III
25
• The lungs, which become compromised
early in shock, are affected at this stage.
• Subsequent decompensation of the lungs
increases the likelihood that mechanical
ventilation will be needed.
• Respirations are rapid and shallow.
• Crackles are heard over the lung fields.
BY: ROMMEL LUIS C. ISRAEL III
26
• Decreased pulmonary blood flow causes
arterial oxygen levels to decrease and carbon
dioxide levels to increase.
• Hypoxemia and biochemical mediators cause
an intense inflammatory response and
pulmonary vasoconstriction, perpetuating
pulmonary capillary hypoperfusion and
hypoxemia.
BY: ROMMEL LUIS C. ISRAEL III
27
2. GASTROINTESTINAL EFFECTS
BY: ROMMEL LUIS C. ISRAEL III
28
• Gastrointestinal (GI) ischemia can cause
stress ulcers in the stomach, putting the
patient at risk for GI bleeding.
• In the small intestine, the mucosa can
become necrotic and slough off, causing
bloody diarrhea.
• Beyond the local effects of impaired
perfusion, GI ischemia leads to bacterial toxin
translocation, in which bacterial toxins enter
the bloodstream through the lymphatic
system.
BY: ROMMEL LUIS C. ISRAEL III
29
• In addition to causing infection, bacterial
toxins can cause cardiac depression,
vasodilation, increased capillary permeability,
and an intense inflammatory response with
activation of additional biochemical mediators.
• The net result is interference with healthy
cellular functioning and their ability to
metabolize nutrients (Stapleton, Jones &
Heyland, 2007).
BY: ROMMEL LUIS C. ISRAEL III
30
3. HEMATOLOGIC EFFECTS
BY: ROMMEL LUIS C. ISRAEL III
31
The combination of
hypotension, sluggish blood
flow, metabolic acidosis,
coagulation system imbalance,
and generalized hypoxemia can
interfere with normal
hemostatic mechanisms.
In shock states, the
inflammatory cytokines activate
the clotting cascade, causing
deposition of microthrombi in
multiple areas of the body and
consumption of clotting
factors.
BY: ROMMEL LUIS C. ISRAEL III
32
The alterations of the hematologic system, including imbalance of the clotting cascade,
are linked to the overactivation of the inflammatory response of injury.
Disseminated intravascular coagulation (DIC) may occur either as a cause or as a
complication of shock.
In this condition, widespread clotting and bleeding occur simultaneously.
Bruises (ecchymoses) and bleeding (petechiae) may appear in the skin. Coagulation times
(eg, prothrombin time [PT], activated partial thromboplastin time are prolonged.
Clotting factors and platelets are consumed and require replacement therapy to achieve
hemostasis.
BY: ROMMEL LUIS C. ISRAEL III
33
Medical Management
Specific medical management in the progressive stage of shock
depends on the type of shock and its underlying cause.
It is also based on the degree of decompensation in
the organ systems. Medical management specific to each type of
shock is discussed later in this chapter.
Although there are several differences in medical management by
type of shock, some medical interventions are common to all types.
BY: ROMMEL LUIS C. ISRAEL III
34
Medical Management
These include the use of appropriate IV fluids and
medications to restore tissue perfusion by the
following methods:
• Supporting the respiratory system
• Optimizing intravascular volume
• Supporting the pumping action of the heart
• Improving the competence of the vascular system
Other aspects of management may include early enteral
nutritional support, aggressive hyperglycemic control
with IV insulin (Hafidh, Reuter, Chassels, et al., 2007;
Vanhorebeek, Langouche & Van den Berghe, 2007),
• and use of antacids, histamine-2 (H2) blockers, or
antipeptic agents to reduce the risk of GI ulceration and
bleeding.
BY: ROMMEL LUIS C. ISRAEL III
35
Subjective nursing assessment is an
individualized, qualitative approach that does
not use objective, measurements, tools or
equipment.
Rather, it is based on individualized clinical
observation relating to the physical, emotional
and behavioural characteristics of the child and
family.
BY: ROMMEL LUIS C. ISRAEL III
36
What objective data does the nurse collect during a physical
assessment?
OBJECTIVE DATA IN NURSING IS DATA THAT IS MEASURED OR OBSERVED BY THE 5 SENSES.
EXAMPLES INCLUDE BLOOD PRESSURE, TEMPERATURE, SKIN COLOR AND TEXTURE, AND
HEART SOUNDS.
What is objective data in nursing assessment?
Objective data in nursing refers to information that can be measured
through physical examination, observation, or diagnostic testing.
Examples of objective data include, but
are not limited to, physical findings or patient behaviors observed by the
nurse, laboratory test results, and vital signs.
BY: ROMMEL LUIS C. ISRAEL III
37
SUBJECTIVE NURSING
DATA Objective Nursing Data
Subjective nursing data are collected
from sources other than the nurse's
observations. This type of data
represents the patient's perceptions,
feelings, or concerns as obtained
through the nursing interview. The
patient is considered the primary source
of subjective data. Other sources,
including the patient's family or
caregivers, and other members of the
healthcare team, are called secondary
sources.
Objective data in nursing refers to
information that can be measured
through physical examination,
observation, or diagnostic testing.
Examples of objective data include,
but are not limited to, physical
findings or patient behaviors
observed by the nurse, laboratory
test results, and vital signs.
BY: ROMMEL LUIS C. ISRAEL III
38
Examples Of Subjective Data In
Nursing
EXAMPLES OF OBJECTIVE DATA IN
NURSING
Chills
Congestion or Runny Nose
Constipation
Coughing
Diarrhea
Vomiting
Sweating
Sore throat
Dizzines
s
Exhaustion and Fatigue
Feeling Sleepy or Dizzy
Itching
Level of Consciousness
Loss of Appetite
Loss of Taste or Smell
Muscle or Body Aches
Nausea
Numbness
Pain
Shortness of Breath
Ambulation
Bleeding
Blood Urea and Creatinine Levels
Blood Pressure
Body Temperature
Demeanor
Full Blood Count
Heart Rate
Height and Weight
Overall Appearance
Respiratory Rate
Wound Appearance
X-Ray or Computed Tomography (CT)
Scans
BY: ROMMEL LUIS C. ISRAEL III
39
SUBJECTIVE DATA IS
IMPORTANT IN NURSING
Objective Data is Important In
Nursing
Because the patient is the primary source of
subjective data in nursing, this data can paint a
more thorough picture of what the patient is
experiencing, making it an essential part of care
plan development. Subjective data may signal
possible issues with the patient's psychological,
physiological, and sociological wellness.
Subjective data signals the nurse about things
that may be problematic for the patient and can
also indicate specific patient strengths that could
be useful when communicating with and caring for
patients.
Objective nursing data is an essential
part of patient assessments. Objective
data is the view of the patient's status
through the eyes of the assessing nurse.
While a patient may state, "My stomach
hurts," the nurse may observe changes in
his vital signs or abnormal lab results that
signal abnormal changes in the patient's
body and give practitioners an idea of
where to start the diagnosis process.
BY: ROMMEL LUIS C. ISRAEL III
40
OBJECTIVE PHYSICAL ASSESSMENT
EXAMPLES OF OBJECTIVE ASSESSMENT INCLUDE:
OBSERVING A CLIENT'S GAIT
PHYSICALLY FEELING A LUMP ON CLIENT'S LEG,
LISTENING TO A CLIENT'S HEART
TAPPING ON THE BODY TO ELICIT SOUNDS
AS WELL AS COLLECTING OR REVIEWING LABORATORY AND DIAGNOSTIC
TESTS SUCH AS BLOOD TESTS, URINE TESTS, X-RAY ETC.
Objective Assessment – Physical Examination Techniques: ANurse's ...
https://pressbooks.library.torontomu.ca › ippa › chapter-1
BY: ROMMEL LUIS C. ISRAEL III
41
Objective data includes:
observations of nonverbal indications of pain,
such as restlessness, facial grimacing and wincing,
moaning, and rubbing or guarding painful areas.
11.5Applying the Nursing Process – Nursing Fundamentals
https://wtcs.pressbooks.pub › chapter › 11-5-applying-the
BY: ROMMEL LUIS C. ISRAEL III
42
ANALYSIS/NURSING DIAGNOSIS OF MULTI ORGAN
FAILURE
Multi-Organ Failure syndrome (MOF) is a reason for admission
to intensive care or can occur during hospitalization.
It is characterized by associated failures of several organs
(heart, lungs, liver, kidneys, brain).
The prognosis is all the more gloomy as the number of affected
organs is high. It is due to an alteration of the microcirculation
responsible for an acute and lasting cellular hypoperfusion, encountered
during an aggression (trauma, pancreatitis, burns, states of cardiogenic
or hypovolemic septic shock) requiring substitutive treatments, artificial
ventilation, renal replacement therapy, hemodynamic support and
appropriate nutritional intake.
BY: ROMMEL LUIS C. ISRAEL III
43
Analysis/Nursing Diagnosis of multi Organ Failure
Objectives of Nursing Care
The therapeutic nursing objective is to anticipate clinical changes, notify the resuscitator
as soon as possible, in order to limit the aggravation of failures by the rapid introduction
of specific therapies.
This patient care involves close collaboration between the doctor and the
paramedical team. Clinical monitoring and monitoring are the main axes, associated
with the monitoring of specific treatments.
First time surveillance: The management of patients with MOF requires increased
nursing supervision, requiring theoretical and technical knowledge.
BY: ROMMEL LUIS C. ISRAEL III
44
Analysis/Nursing Diagnosis of multi Organ Failure
Objectives of Nursing Care
Cardio-Circulatory Failure: Cardiocirculatory failure is characterized by persistent
arterial hypotension despite adequate vascular filling. The objective is to assess the
impact of this failure on perfusion and therefore on tissue oxygenation.
Clinical monitoring: Involves mottling (signs of impaired peripheral circulation),
cyanosis, pinkish foaming bronchial secretions, and swollen jugular joints (signs of
heart failure). Biological monitoring is carried out on medical prescription by a dosage
of lactates (signs of cellular suffering), an arterial gas, a blood count, a blood ionogram,
a liver and kidney test.
BY: ROMMEL LUIS C. ISRAEL III
45
objectives
provided
recorded
to be achieved. The parameters
by these different
on a monitoring sheet or in
techniques are
a
computerized memory of patient parameters.
Analysis/Nursing Diagnosis of multi Organ Failure
Non-Invasive Monitoring Includes
One cardioscope per patient connected to a central
monitoring unit: heart rate monitoring and alarm settings allow
rapid identification of any rhythmic change, type of atrial
fibrillation, extrasystoles,tachycardia or bradycardia, justifying
medical intervention to nitiate appropriate therapy; Taking
blood pressure in the cuff every 15 minutes with recording
of systolic, diastolic and mean blood pressure. The alarms are
set according to the therapeutic
BY: ROMMEL LUIS C. ISRAEL III
46
Invasive Monitoring Includes
Sterile placement of catheters by the doctor according to department
protocols. The nurse prepares the necessary material and serves the
operator sterilely. Changes of tubing and dressings are redone in
accordance with the protocol of the service. There are several
catheter devices: Arterial catheterization is an invasive device
allowing the continuous monitoring of blood pressure, the realization
of iterative blood samples, the monitoring of the repulsed pressure
delta (Delta PP), measurement of the systolic-diastolic differential
during a respiratory cycle in the patient who is intubated, ventilated,
adapted to the ventilator and in sinus rhythm. It informs us about the
need for a filling (›13% = signs of hypovolaemia)
ANALYSIS/NURSING DIAGNOSIS OF MULTI ORGAN
FAILURE
BY: ROMMEL LUIS C. ISRAEL III
47
•Pulse Pressure = Systolic Blood Pressure – Diastolic Blood
Pressure
The systolic blood pressure is defined as the maximum
pressure experienced in the aorta when the heart contracts and ejects
blood into the aorta from the left ventricle (approximately 120
mmHg).
The diastolic blood pressure is the minimum pressure
experienced in the aorta when the heart is relaxing before ejecting
blood into the aorta from the left ventricle (approximately 80
mmHg).
Normal pulse pressure is, therefore, approximately 40 mmHg.
Achange in pulse pressure (delta Pp) is proportional to volume change
(delta-V) but inversely proportional to arterial compliance.
BY: ROMMEL LUIS C. ISRAEL III
48
How do you manage multiple
organ failure?
The management of MODS requires a
multidisciplinary approach that includes
antibiotics for sepsis control,
microcirculatory and respiratory support
for reperfusion, organ-targeted drugs,
and the correction of coagulation
abnormalities, acid-base imbalance;
metabolic issues, and electrolyte
imbalance.
Multiple organ dysfunction syndrome: Contemporary
insights ...
https://www.ncbi.nlm.nih.gov › articles ›
PMC7884906
Planning
1. PLANNING FOR HEALTH
PROMOTION
The multiple organ dysfunction syndrome is both
a syndrome and a form of clinical shorthand for
the approach to patient care that is exemplified by
contemporary ICU practice.As a syndrome, it is
intimately linked to the adaptive host response to
injury or infection, and it is to be expected that
interventions that can modulate the expression of
this response will ultimately prove effective in
improving clinical outcome. As a clinical
shorthand, it categorizes the range of
interventions available to support critically ill
patients, and underlines the prime importance of
recognizing the potential for iatrogenic harm
implicit in the increasingly complex and
technological repertoire we use to care for them.
BY: ROMMEL LUIS C. ISRAEL III
49
2. Planning for Health Restoration and Maintenance
PLANNING
MODS is difficult to treat, escalates quickly and is often fatal. Therefore, early
detection is crucial in preventing its progression (Wang et al. 2017).
Positive patient outcomes rely on immediate recognition, ICU admission
and invasive organ support.
Management and treatment may include:
•Identifying and treating the underlying causes, comorbidities or
complications;
•Fluid resuscitation to increase perfusion
•Support care and monitoring:
• Multi-organ support;
• Mechanical or non-invasive ventilation;
• Maintaining fluid homeostasis; and
• Renal replacement therapy
BY: ROMMEL LUIS C. ISRAEL III
50
Implementation of Care of Clients
1.INDEPENDENT NURSING CARE
a. Physiologic Care
b. Psychosocial Care
c. Spiritual Care
2. Independent Care
a. Pharmacological Therapeutics
b. Complementary and alternative Therapies
c. Nutritional and Diet Therapy
d. Surgical Intervention
e. Immunologic Therapy
BY: ROMMEL LUIS C. ISRAEL III
51
IMPLEMENTATION OF CARE OF
CLIENTS
1.Independent Nursing Care
Independent nursing interventions are the tasks that a nurse can perform
without input from another discipline, particularly without a physician's order. These
interventions include many basic comfort care actions such as providing water,
repositioning a patient, providing toileting assistance, and bathing.Nursing
Intervention Examples & Classification -
Study.com
https://study.com › ... › The Profession of Nursing
Common nursing interventions include:
•Bedside care and assistance.
•Administration of medication.
•Postpartum support.
•Feeding assistance.
•Monitoring of vitals and recovery progress.
BY: ROMMEL LUIS C. ISRAEL III
52
Implementation of Care of Clients
1.INDEPENDENT NURSING CARE
a. Physiologic Care
•Physiological Adaptation - managing and providing care for clients
with acute, chronic or life threatening physical health conditions.
• Related content includes but is not limited to:
• Alterations in Body Systems
• Medical Emergencies
• Fluid and Electrolyte Imbalances
• Pathophysiology
• Hemodynamics
• Unexpected Response to Therapies
• Illness Management
BY: ROMMEL LUIS C. ISRAEL III
53
1.INDEPENDENT NURSING CARE
Implementation of Care of Clients
a. Physiologic Care
How do you prepare a patient physiologically for surgery?
Preparing for Surgery
1.Stop drinking and eating for a certain period of time before the
time of surgery.
2.Bathe or clean, and possibly shave the area to be operated on.
3.Undergo various blood tests, X-rays, electrocardiograms, or
other procedures necessary for surgery.
BY: ROMMEL LUIS C. ISRAEL III
54
IMPLEMENTATION OF CARE OF
CLIENTS
1.Independent Nursing Care
b. Psychosocial Care
Psychosocial interventions include such strategies as stress management, self-coping
skills, relapse prevention, and psychoeducation. They also include psychological therapies,
such as cognitive behavioral strategies or motivational interviewing techniques.
Psychosocial Treatments
The term psychosocial refers to an individual’s psychological development in and interaction with
their social environment. Psychosocial treatments (interventions) include structured counseling,
motivational enhancement, case management, care-coordination, psychotherapy and
relapse prevention
BY: ROMMEL LUIS C. ISRAEL III
55
IMPLEMENTATION OF CARE OF CLIENTS
1.Independent Nursing Care
c. Spiritual Care
Spiritual care is an important component of holistic nursing care. To implement spiritual care, the
nurse must assess, diagnose, and respond to the needs of each patient and her or his significant
others. Meeting the spiritual care needs of the patient can lead to physical healing, reduction of
pain, and personal growth. Nurses providing spiritual care experience lower stress and less
burnout.
THE ROLE OF THE NURSE IN SPIRITUAL CARE
To provide spiritual care, the nurse needs to be able to conduct a spiritual assessment;
recognize the difference between religious and spiritual needs; identify appropriate spiritual care
interventions; and determine when it is appropriate to deliver spiritual care.
The Essence of Spiritual Care | Springer Publishing
https://connect.springerpub.com › entity_view › node › ful
BY: ROMMEL LUIS C. ISRAEL III
56
2. INDEPENDENT CARE
Implementation of Care of Clients
a. Pharmacological Therapeutics
Nursing responsibilities in drug therapy
The 7 responsibilities are: (1) Management of therapeutic
and adverse effects of medication; (2) Management of
medication adherence; (3) Management of patient
medication self-management; (4) Management of patient
education and information; (5) Prescription management;
(6) Medication safety management.
Nurses' responsibilities and tasks in pharmaceutical care: A scoping ...
https://onlinelibrary.wiley.com › doi › full › nop2
BY: ROMMEL LUIS C. ISRAEL III
57
The nurse’s responsibilities
Drug therapy plays a major part in the treatment of patients. Traditionally,
medicines have been prescribed by doctors and the nurse’s responsibility has been to
ensure safe and reliable administration and to monitor side-effects. However, in 1994 the
law was changed to allow district nurses and health visitors employed in pilot sites
throughout England to prescribe from a limited formulary. Many of the preparations
they were initially able to prescribe were for over-the-counter preparations. In 1998 it
became possible for all appropriately qualified community nurses to prescribe
from a limited nursing formulary. From 2003, any registered nurse could undertake training
to enable them to become a nurse prescriber and prescribe from a broader Nurse
Prescribers’ Extended Formulary. In 2006 the law changed again, enabling nurses who
had undergone the requisite training to prescribe from the full range of drugs in the
British National Formulary (with the exception of most controlled drugs) provided this was
in their sphere of competence.
IMPLEMENTATION OF CARE OF CLIENTS
BY: ROMMEL LUIS C. ISRAEL III
58
accurately,
recording that the drug has been given and observing the patient’s response.
Prior to administration the nurse must know the reason for, action and usual
dosage of the drug; this should enable him or her to recognize and question
mistakes in prescribing. When in doubt about a prescription, advice should be
sought and, if necessary, the doctor should be consulted. Observations should be
made for therapeutic and adverse effects. The nurse should realize that the patient’s
condition may alter the effect of a drug and that there may be interactions with
concurrent treatment. The nurse is greatly assisted in these circumstances by the
pharmacist, with whom a good working relationship will enhance the safety of patient
care.
Implementation of Care of Clients
2. Independent Care
Nursing aspects of administration
The nurse is responsible for interpreting the prescription
BY: ROMMEL LUIS C. ISRAEL III
59

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Nursing Care of Patients with Life Threatening Conditions, High Acuity Situations and Multiple Organ Dysfunction Syndrome

  • 1. By: ROMMEL LUIS C. ISRAEL III Nursing Care of Clients with Life Threatening Conditions, Acutely ill / Multi Organ Problems , High Acuity and Emergency Situation BY: ROMMEL LUIS C. ISRAEL III 1
  • 2. THE TERM “LIFE- THREATENING CONDITION” MEANS ANY DISEASE OR CONDITION FROM WHICH THE LIKELIHOOD OF IS PROBABLE UNLESS THE COURSE OF THE DISEASE OR CONDITION IS INTERRUPTED. • What is an appropriate response to a life-threatening situation? • Stay calm, and call your local emergency number (such as 911). Start CPR (cardiopulmonary resuscitation) or rescue breathing, if necessary and if you know the proper technique. Place a • semiconscious or unconscious person in the recovery position until the ambulance arrives. BY: ROMMEL LUIS C. ISRAEL III 2
  • 3. WHAT IS HIGH ACUITY PATIENT? PURPOSE: HIGH ACUITY UNITS (HAU) ARE HOSPITAL UNITS THAT PROVIDE PATIENTS WITH MORE ACUTE CARE AND CLOSER MONITORING THAN A GENERAL HOSPITAL WARD BUT ARE NOT AS RESOURCE INTENSIVE AS AN INTENSIVE CARE UNIT (ICU). BY: ROMMEL LUIS C. ISRAEL III 3
  • 4. THE MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS) CAN BE DEFINED AS THE DEVELOPMENT OF POTENTIALLY REVERSIBLE PHYSIOLOGIC DERANGEMENT INVOLVING TWO OR MORE ORGAN SYSTEMS NOT INVOLVED IN THE DISORDER THAT RESULTED IN ICU ADMISSION, AND ARISING IN THE WAKE OF A POTENTIALLY LIFE-THREATENING PHYSIOLOGIC INSULT. • Multiple organ dysfunction syndrome (MODS) is defined as the progressive physiological dysfunction of two or more organ systems where homeostasis cannot be maintained without intervention. It is initiated by illness, injury or infection and most commonly affects the heart, lungs, liver and kidneys. • An Overview of Multiple Organ Dysfunction Syndrome - Ausmed https://www.ausmed.com › cpd › articles › multiple-organ • The fundamental cause of MODS is attributed to the conditions such as surgery, inflammation, accident, infection, increased metabolic rate, metabolic activity, and decreased perfusion. BY: ROMMEL LUIS C. ISRAEL III 4
  • 5. What would happen if your organ systems stopped functioning properly? AFTER ONE SYSTEM SHUTS DOWN, THE OTHERS WOULD SLOWLY START TO SHUT DOWN AS WELL UNTIL THE BODY CAN NO LONGER MAINTAIN HOMEOSTASIS AND THE PERSON WOULD SLOWLY DIE. 3. ALL SYSTEMS WOULD BE WORKING TOGETHER BUT THE MAIN ONES WOULD BE MUSCULAR, NERVOUS, AND SKELETAL. Interacting Body Systems and Homeostasis http://sites.isdschools.org › useruploads › biology Which organ fails first in multi organ failure? Generally, the lung is the first organ to fail after injury (failure after 3.7 +/- 2.8 days). Significant renal failure and the need for dialysis decreased to < 5%; other signs of organ dysfunction (gastric, central nervous system) are difficult to verify. Pattern of organ failure following severe trauma - PubMed https://pubmed.ncbi.nlm.nih.gov › .. BY: ROMMEL LUIS C. ISRAEL III 5
  • 6. MODS CAN AFFECT ANY ORGAN, BUT THE PRIMARY PLAYERS ARE THE LUNGS, HEART, KIDNEYS, LIVER, BRAIN, AND BLOOD. THERE ARE MANY CAUSES OF MODS, BUT THE GENERAL CATEGORIES INCLUDE MAJOR TRAUMA, SEVERE ILLNESS, AND WIDESPREAD INFECTION. What are signs of organ dysfunction? • The clinical signs of tissue hypoxia are largely non-specific. • However, increased respiratory rate, peripheries that are either warm and vasodilated or cold and vasoconstricted, poor urine output, and mental dullness may indicate organ dysfunction and should prompt a search for reversible causes. • ABC of intensive care: Organ dysfunction - PMC - NCBI https://www.ncbi.nlm.nih.gov › articles › PMC1115973 BY: ROMMEL LUIS C. ISRAEL III 6
  • 7. Shock and Multiple Organ Dysfunction Syndrome Shock is a life-threatening condition with a variety of underlying causes. It is characterized by inadequate perfusion that, if untreated, results in cell death. The progression of shock is neither linear nor predictable, and shock states, especially septic shock, comprise a current area of aggressive clinical research. Nurses caring for patients with shock and for those at risk for shock must understand the underlying mechanisms of shock and recognize its subtle as well as more obvious signs. Rapid assessment with early recognition and response to shock states is essential to the patient’s recovery. BY: ROMMEL LUIS C. ISRAEL III 7
  • 8. Shock can best be defined as a condition in which widespread perfusion to the cells is inadequate to deliver oxygen and nutrients to support vital organs and cellular function Adequate blood flow to the tissues and cells requires an adequate cardiac pump, effecti vasculature or circulatory system, and sufficient blood volume. If one of these components is impaired, perfusion to the tissues is threatened or compromised. Without treatment, inadequate blood flow to the cells results in poor delivery of oxygen and nutrients, cellular hypoxia, and cell death that progresses to organ dysfunction and eventually death. BY: ROMMEL LUIS C. ISRAEL III 8
  • 9. PATHOPHYSIOLOGY OF CELLULAR CHANGES In shock, the cells lack an adequate blood supply and are deprived of oxygen and nutrients; therefore, they must produce energy through anaerobic metabolism. This results in low energy yields from nutrients and an acidotic intracellular environment. Because of these changes, normal cell function ceases . The cell swells and the cell membrane becomes more permeable, allowing electrolytes and fluids to seep out of and into the cell. The sodium–potassium pump becomes impaired; cell structures, primarily the mitochondria, are damaged; and death of the cell results. Glucose is the primary substrate required for the production of cellular energy in the form of ATP. BY: ROMMEL LUIS C. ISRAEL III 9
  • 10. Nurses must anticipate these therapies because they need to be implemented with speed and accuracy. Many of the interventions required in caring for patients with shock call for close collaboration with other members of the health care team and rapid implementation of prescribed therapies. Nursing care of patients with shock requires ongoing systematic assessment. BY: ROMMEL LUIS C. ISRAEL III 10
  • 11. STAGES OF SHOCK Shock is believed to progress along a continuum of stages. Shock can be identified as early or late, depending on the signs and symptoms and the overall severity of organ dysfunction. Aconvenient way to understand the physiologic responses and subsequent clinical signs and symptoms of shock is to divide the continuum into separate stages: compensatory (stage 1), progressive (stage 2), and irreversible (stage 3). The sympathetic nervous system and subsequent release of catecholamines (epinephrine and norepinephrine). Patients display the often-described “fight or flight” response. The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain, heart, and lungs to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, bowel sounds are hypoactive, and urine output decreases in response to the release of aldosterone and ADH. BY: ROMMEL LUIS C. ISRAEL III 11
  • 12. Clinical Manifestations Despite a normal BP, the patient shows numerous clinical signs indicating inadequate organ perfusion. The result of inadequate perfusion is anaerobic metabolism and a buildup of lactic acid, producing metabolic acidosis. The respiratory rate increases in response to metabolic acidosis. This rapid respiratory rate facilitates removal of excess carbon dioxide but raises the blood pH and often causes a compensatory respiratory alkalosis. The alkalotic state causes mental status changes, such as confusion or combativeness, as well as arteriolar dilation. If treatment begins in this stage of shock, the prognosis for the patient is better than in later stages. BY: ROMMEL LUIS C. ISRAEL III 12
  • 13. Medical Management Medical treatment is directed toward Identifying the cause of the shock, correcting the underlying disorder so that shock does not progress, and supporting those physiologic processes that thus far have responded successfully to the threat. Because compensation cannot be maintained indefinitely, measures such as fluid replacement and medication therapy must be initiated to maintain an adequate BP and reestablish and maintain adequate tissue perfusion (Otero, et al., 2006). BY: ROMMEL LUIS C. ISRAEL III 13
  • 14. Nursing Management As stated earlier, intervention as soon as possible along the continuum of shock is the key to improving the patient’s prognosis. The nurse must systematically assess the patient at risk for shock to recognize the subtle clinical signs of the compensatory stage before the patient’s BP drops. Special considerations related to recognizing early signs of shock in the elderly patient. BY: ROMMEL LUIS C. ISRAEL III 14
  • 15. Monitoring Tissue Perfusion The nurse observes for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and laboratory values (eg, base deficit and lactic acid levels). In the compensatory stage of shock, serum sodium and blood glucose levels are elevated in response to the release of aldosterone and catecholamines BY: ROMMEL LUIS C. ISRAEL III 15
  • 16. Monitoring Tissue Perfusion The nurse should monitor the patient’s hemodynamic status and promptly report deviations to the physician, assist in identifying and treating the underlying disorder by continuous in-depth assessment of the patient, administer prescribed fluids and medications, and promote patient safety. Vital signs are key indicators of hemodynamic status and BP is an indirect measure of tissue hypoxia. The nurse should report a systolic BP lower than 90 mm Hg or a drop in systolic BP of 40 mm Hg from baseline. BY: ROMMEL LUIS C. ISRAEL III 16
  • 17. Pulse pressure correlates well with stroke volume. Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure (Cottingham, 2006). Normally, the pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP. BY: ROMMEL LUIS C. ISRAEL III 17
  • 18. Decreased or narrowing pulse pressure, an early indication of decreased stroke volume, is illustrated in the followingexample: Systolic BP Diastolic BP Pulse pressure Normal pulse pressure: 120 mgHg 80 mm Hg 40 mm Hg Narrowing of pulse pressure: 90 mm Hg 70 mm Hg 20 mm Hg stroke volume, BP, and overall cardiac output. BY: ROMMEL LUIS C. ISRAEL III 18
  • 19. Elevation of the diastolic BP with release of catecholamines and attempts to increase venous return through vasoconstriction is an early compensatory mechanism in response to decreased stroke volume, BP, and overall cardiac output. BY: ROMMEL LUIS C. ISRAEL III 19
  • 20. Promoting Safety The nurse must be vigilant for potential threats to the patient’s safety, because a high anxiety level and altered mental status impair judgment. In this stage of shock, patients who were previously cooperative and followed instructions may now disrupt IV lines and catheters and complicate their condition. Therefore, close monitoring and frequent reorientation interventions are essential. BY: ROMMEL LUIS C. ISRAEL III 20
  • 21. NURSING ALERT By the time BP drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be assessed and monitored closely before the BP falls. BY: ROMMEL LUIS C. ISRAEL III 21
  • 22. • Continuous central venous oximetry (Scv–O2) monitoring may be used to evaluate mixed venous blood oxygen saturation and the severity of tissue hypoperfusion states. • A central catheter is introduced into the superior vena cava (SVC), and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and pulmonary system for reoxygenation. • A normal Scc–O2 value is 70%. • Body tissues use approximately 25% of the oxygen delivered to them during normal metabolism. • During states of stress, such as shock, more oxygen is consumed and the Scv–O2 saturation is lower, indicating that the tissues are consuming more oxygen. BY: ROMMEL LUIS C. ISRAEL III 22
  • 23. Monitoring tissue oxygen consumption with Scv–O2 is a minimally invasive measure to more accurately assess tissue oxygenation in the compensatory stage of shock before changes in vital signs detect altered tissue perfusion (Dellinger, et al., 2008; Goodrich, 2006; Otero, et al., 2006). New technologies allow clinicians to detect changes in tissue perfusion before changes in classic signs (BP, heart rate, and urine output) indicative of hypoperfusion occur. BY: ROMMEL LUIS C. ISRAEL III 23
  • 24. Clinical Manifestations Chances of survival depend on the patient’s general health before the shock state as well as the amount of time it takes to restore tissue perfusion. As shock progresses, organ systems decompensate. BY: ROMMEL LUIS C. ISRAEL III 24
  • 25. 1. Respiratory Effects BY: ROMMEL LUIS C. ISRAEL III 25
  • 26. • The lungs, which become compromised early in shock, are affected at this stage. • Subsequent decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. • Respirations are rapid and shallow. • Crackles are heard over the lung fields. BY: ROMMEL LUIS C. ISRAEL III 26
  • 27. • Decreased pulmonary blood flow causes arterial oxygen levels to decrease and carbon dioxide levels to increase. • Hypoxemia and biochemical mediators cause an intense inflammatory response and pulmonary vasoconstriction, perpetuating pulmonary capillary hypoperfusion and hypoxemia. BY: ROMMEL LUIS C. ISRAEL III 27
  • 28. 2. GASTROINTESTINAL EFFECTS BY: ROMMEL LUIS C. ISRAEL III 28
  • 29. • Gastrointestinal (GI) ischemia can cause stress ulcers in the stomach, putting the patient at risk for GI bleeding. • In the small intestine, the mucosa can become necrotic and slough off, causing bloody diarrhea. • Beyond the local effects of impaired perfusion, GI ischemia leads to bacterial toxin translocation, in which bacterial toxins enter the bloodstream through the lymphatic system. BY: ROMMEL LUIS C. ISRAEL III 29
  • 30. • In addition to causing infection, bacterial toxins can cause cardiac depression, vasodilation, increased capillary permeability, and an intense inflammatory response with activation of additional biochemical mediators. • The net result is interference with healthy cellular functioning and their ability to metabolize nutrients (Stapleton, Jones & Heyland, 2007). BY: ROMMEL LUIS C. ISRAEL III 30
  • 31. 3. HEMATOLOGIC EFFECTS BY: ROMMEL LUIS C. ISRAEL III 31
  • 32. The combination of hypotension, sluggish blood flow, metabolic acidosis, coagulation system imbalance, and generalized hypoxemia can interfere with normal hemostatic mechanisms. In shock states, the inflammatory cytokines activate the clotting cascade, causing deposition of microthrombi in multiple areas of the body and consumption of clotting factors. BY: ROMMEL LUIS C. ISRAEL III 32
  • 33. The alterations of the hematologic system, including imbalance of the clotting cascade, are linked to the overactivation of the inflammatory response of injury. Disseminated intravascular coagulation (DIC) may occur either as a cause or as a complication of shock. In this condition, widespread clotting and bleeding occur simultaneously. Bruises (ecchymoses) and bleeding (petechiae) may appear in the skin. Coagulation times (eg, prothrombin time [PT], activated partial thromboplastin time are prolonged. Clotting factors and platelets are consumed and require replacement therapy to achieve hemostasis. BY: ROMMEL LUIS C. ISRAEL III 33
  • 34. Medical Management Specific medical management in the progressive stage of shock depends on the type of shock and its underlying cause. It is also based on the degree of decompensation in the organ systems. Medical management specific to each type of shock is discussed later in this chapter. Although there are several differences in medical management by type of shock, some medical interventions are common to all types. BY: ROMMEL LUIS C. ISRAEL III 34
  • 35. Medical Management These include the use of appropriate IV fluids and medications to restore tissue perfusion by the following methods: • Supporting the respiratory system • Optimizing intravascular volume • Supporting the pumping action of the heart • Improving the competence of the vascular system Other aspects of management may include early enteral nutritional support, aggressive hyperglycemic control with IV insulin (Hafidh, Reuter, Chassels, et al., 2007; Vanhorebeek, Langouche & Van den Berghe, 2007), • and use of antacids, histamine-2 (H2) blockers, or antipeptic agents to reduce the risk of GI ulceration and bleeding. BY: ROMMEL LUIS C. ISRAEL III 35
  • 36. Subjective nursing assessment is an individualized, qualitative approach that does not use objective, measurements, tools or equipment. Rather, it is based on individualized clinical observation relating to the physical, emotional and behavioural characteristics of the child and family. BY: ROMMEL LUIS C. ISRAEL III 36
  • 37. What objective data does the nurse collect during a physical assessment? OBJECTIVE DATA IN NURSING IS DATA THAT IS MEASURED OR OBSERVED BY THE 5 SENSES. EXAMPLES INCLUDE BLOOD PRESSURE, TEMPERATURE, SKIN COLOR AND TEXTURE, AND HEART SOUNDS. What is objective data in nursing assessment? Objective data in nursing refers to information that can be measured through physical examination, observation, or diagnostic testing. Examples of objective data include, but are not limited to, physical findings or patient behaviors observed by the nurse, laboratory test results, and vital signs. BY: ROMMEL LUIS C. ISRAEL III 37
  • 38. SUBJECTIVE NURSING DATA Objective Nursing Data Subjective nursing data are collected from sources other than the nurse's observations. This type of data represents the patient's perceptions, feelings, or concerns as obtained through the nursing interview. The patient is considered the primary source of subjective data. Other sources, including the patient's family or caregivers, and other members of the healthcare team, are called secondary sources. Objective data in nursing refers to information that can be measured through physical examination, observation, or diagnostic testing. Examples of objective data include, but are not limited to, physical findings or patient behaviors observed by the nurse, laboratory test results, and vital signs. BY: ROMMEL LUIS C. ISRAEL III 38
  • 39. Examples Of Subjective Data In Nursing EXAMPLES OF OBJECTIVE DATA IN NURSING Chills Congestion or Runny Nose Constipation Coughing Diarrhea Vomiting Sweating Sore throat Dizzines s Exhaustion and Fatigue Feeling Sleepy or Dizzy Itching Level of Consciousness Loss of Appetite Loss of Taste or Smell Muscle or Body Aches Nausea Numbness Pain Shortness of Breath Ambulation Bleeding Blood Urea and Creatinine Levels Blood Pressure Body Temperature Demeanor Full Blood Count Heart Rate Height and Weight Overall Appearance Respiratory Rate Wound Appearance X-Ray or Computed Tomography (CT) Scans BY: ROMMEL LUIS C. ISRAEL III 39
  • 40. SUBJECTIVE DATA IS IMPORTANT IN NURSING Objective Data is Important In Nursing Because the patient is the primary source of subjective data in nursing, this data can paint a more thorough picture of what the patient is experiencing, making it an essential part of care plan development. Subjective data may signal possible issues with the patient's psychological, physiological, and sociological wellness. Subjective data signals the nurse about things that may be problematic for the patient and can also indicate specific patient strengths that could be useful when communicating with and caring for patients. Objective nursing data is an essential part of patient assessments. Objective data is the view of the patient's status through the eyes of the assessing nurse. While a patient may state, "My stomach hurts," the nurse may observe changes in his vital signs or abnormal lab results that signal abnormal changes in the patient's body and give practitioners an idea of where to start the diagnosis process. BY: ROMMEL LUIS C. ISRAEL III 40
  • 41. OBJECTIVE PHYSICAL ASSESSMENT EXAMPLES OF OBJECTIVE ASSESSMENT INCLUDE: OBSERVING A CLIENT'S GAIT PHYSICALLY FEELING A LUMP ON CLIENT'S LEG, LISTENING TO A CLIENT'S HEART TAPPING ON THE BODY TO ELICIT SOUNDS AS WELL AS COLLECTING OR REVIEWING LABORATORY AND DIAGNOSTIC TESTS SUCH AS BLOOD TESTS, URINE TESTS, X-RAY ETC. Objective Assessment – Physical Examination Techniques: ANurse's ... https://pressbooks.library.torontomu.ca › ippa › chapter-1 BY: ROMMEL LUIS C. ISRAEL III 41
  • 42. Objective data includes: observations of nonverbal indications of pain, such as restlessness, facial grimacing and wincing, moaning, and rubbing or guarding painful areas. 11.5Applying the Nursing Process – Nursing Fundamentals https://wtcs.pressbooks.pub › chapter › 11-5-applying-the BY: ROMMEL LUIS C. ISRAEL III 42
  • 43. ANALYSIS/NURSING DIAGNOSIS OF MULTI ORGAN FAILURE Multi-Organ Failure syndrome (MOF) is a reason for admission to intensive care or can occur during hospitalization. It is characterized by associated failures of several organs (heart, lungs, liver, kidneys, brain). The prognosis is all the more gloomy as the number of affected organs is high. It is due to an alteration of the microcirculation responsible for an acute and lasting cellular hypoperfusion, encountered during an aggression (trauma, pancreatitis, burns, states of cardiogenic or hypovolemic septic shock) requiring substitutive treatments, artificial ventilation, renal replacement therapy, hemodynamic support and appropriate nutritional intake. BY: ROMMEL LUIS C. ISRAEL III 43
  • 44. Analysis/Nursing Diagnosis of multi Organ Failure Objectives of Nursing Care The therapeutic nursing objective is to anticipate clinical changes, notify the resuscitator as soon as possible, in order to limit the aggravation of failures by the rapid introduction of specific therapies. This patient care involves close collaboration between the doctor and the paramedical team. Clinical monitoring and monitoring are the main axes, associated with the monitoring of specific treatments. First time surveillance: The management of patients with MOF requires increased nursing supervision, requiring theoretical and technical knowledge. BY: ROMMEL LUIS C. ISRAEL III 44
  • 45. Analysis/Nursing Diagnosis of multi Organ Failure Objectives of Nursing Care Cardio-Circulatory Failure: Cardiocirculatory failure is characterized by persistent arterial hypotension despite adequate vascular filling. The objective is to assess the impact of this failure on perfusion and therefore on tissue oxygenation. Clinical monitoring: Involves mottling (signs of impaired peripheral circulation), cyanosis, pinkish foaming bronchial secretions, and swollen jugular joints (signs of heart failure). Biological monitoring is carried out on medical prescription by a dosage of lactates (signs of cellular suffering), an arterial gas, a blood count, a blood ionogram, a liver and kidney test. BY: ROMMEL LUIS C. ISRAEL III 45
  • 46. objectives provided recorded to be achieved. The parameters by these different on a monitoring sheet or in techniques are a computerized memory of patient parameters. Analysis/Nursing Diagnosis of multi Organ Failure Non-Invasive Monitoring Includes One cardioscope per patient connected to a central monitoring unit: heart rate monitoring and alarm settings allow rapid identification of any rhythmic change, type of atrial fibrillation, extrasystoles,tachycardia or bradycardia, justifying medical intervention to nitiate appropriate therapy; Taking blood pressure in the cuff every 15 minutes with recording of systolic, diastolic and mean blood pressure. The alarms are set according to the therapeutic BY: ROMMEL LUIS C. ISRAEL III 46
  • 47. Invasive Monitoring Includes Sterile placement of catheters by the doctor according to department protocols. The nurse prepares the necessary material and serves the operator sterilely. Changes of tubing and dressings are redone in accordance with the protocol of the service. There are several catheter devices: Arterial catheterization is an invasive device allowing the continuous monitoring of blood pressure, the realization of iterative blood samples, the monitoring of the repulsed pressure delta (Delta PP), measurement of the systolic-diastolic differential during a respiratory cycle in the patient who is intubated, ventilated, adapted to the ventilator and in sinus rhythm. It informs us about the need for a filling (›13% = signs of hypovolaemia) ANALYSIS/NURSING DIAGNOSIS OF MULTI ORGAN FAILURE BY: ROMMEL LUIS C. ISRAEL III 47
  • 48. •Pulse Pressure = Systolic Blood Pressure – Diastolic Blood Pressure The systolic blood pressure is defined as the maximum pressure experienced in the aorta when the heart contracts and ejects blood into the aorta from the left ventricle (approximately 120 mmHg). The diastolic blood pressure is the minimum pressure experienced in the aorta when the heart is relaxing before ejecting blood into the aorta from the left ventricle (approximately 80 mmHg). Normal pulse pressure is, therefore, approximately 40 mmHg. Achange in pulse pressure (delta Pp) is proportional to volume change (delta-V) but inversely proportional to arterial compliance. BY: ROMMEL LUIS C. ISRAEL III 48
  • 49. How do you manage multiple organ failure? The management of MODS requires a multidisciplinary approach that includes antibiotics for sepsis control, microcirculatory and respiratory support for reperfusion, organ-targeted drugs, and the correction of coagulation abnormalities, acid-base imbalance; metabolic issues, and electrolyte imbalance. Multiple organ dysfunction syndrome: Contemporary insights ... https://www.ncbi.nlm.nih.gov › articles › PMC7884906 Planning 1. PLANNING FOR HEALTH PROMOTION The multiple organ dysfunction syndrome is both a syndrome and a form of clinical shorthand for the approach to patient care that is exemplified by contemporary ICU practice.As a syndrome, it is intimately linked to the adaptive host response to injury or infection, and it is to be expected that interventions that can modulate the expression of this response will ultimately prove effective in improving clinical outcome. As a clinical shorthand, it categorizes the range of interventions available to support critically ill patients, and underlines the prime importance of recognizing the potential for iatrogenic harm implicit in the increasingly complex and technological repertoire we use to care for them. BY: ROMMEL LUIS C. ISRAEL III 49
  • 50. 2. Planning for Health Restoration and Maintenance PLANNING MODS is difficult to treat, escalates quickly and is often fatal. Therefore, early detection is crucial in preventing its progression (Wang et al. 2017). Positive patient outcomes rely on immediate recognition, ICU admission and invasive organ support. Management and treatment may include: •Identifying and treating the underlying causes, comorbidities or complications; •Fluid resuscitation to increase perfusion •Support care and monitoring: • Multi-organ support; • Mechanical or non-invasive ventilation; • Maintaining fluid homeostasis; and • Renal replacement therapy BY: ROMMEL LUIS C. ISRAEL III 50
  • 51. Implementation of Care of Clients 1.INDEPENDENT NURSING CARE a. Physiologic Care b. Psychosocial Care c. Spiritual Care 2. Independent Care a. Pharmacological Therapeutics b. Complementary and alternative Therapies c. Nutritional and Diet Therapy d. Surgical Intervention e. Immunologic Therapy BY: ROMMEL LUIS C. ISRAEL III 51
  • 52. IMPLEMENTATION OF CARE OF CLIENTS 1.Independent Nursing Care Independent nursing interventions are the tasks that a nurse can perform without input from another discipline, particularly without a physician's order. These interventions include many basic comfort care actions such as providing water, repositioning a patient, providing toileting assistance, and bathing.Nursing Intervention Examples & Classification - Study.com https://study.com › ... › The Profession of Nursing Common nursing interventions include: •Bedside care and assistance. •Administration of medication. •Postpartum support. •Feeding assistance. •Monitoring of vitals and recovery progress. BY: ROMMEL LUIS C. ISRAEL III 52
  • 53. Implementation of Care of Clients 1.INDEPENDENT NURSING CARE a. Physiologic Care •Physiological Adaptation - managing and providing care for clients with acute, chronic or life threatening physical health conditions. • Related content includes but is not limited to: • Alterations in Body Systems • Medical Emergencies • Fluid and Electrolyte Imbalances • Pathophysiology • Hemodynamics • Unexpected Response to Therapies • Illness Management BY: ROMMEL LUIS C. ISRAEL III 53
  • 54. 1.INDEPENDENT NURSING CARE Implementation of Care of Clients a. Physiologic Care How do you prepare a patient physiologically for surgery? Preparing for Surgery 1.Stop drinking and eating for a certain period of time before the time of surgery. 2.Bathe or clean, and possibly shave the area to be operated on. 3.Undergo various blood tests, X-rays, electrocardiograms, or other procedures necessary for surgery. BY: ROMMEL LUIS C. ISRAEL III 54
  • 55. IMPLEMENTATION OF CARE OF CLIENTS 1.Independent Nursing Care b. Psychosocial Care Psychosocial interventions include such strategies as stress management, self-coping skills, relapse prevention, and psychoeducation. They also include psychological therapies, such as cognitive behavioral strategies or motivational interviewing techniques. Psychosocial Treatments The term psychosocial refers to an individual’s psychological development in and interaction with their social environment. Psychosocial treatments (interventions) include structured counseling, motivational enhancement, case management, care-coordination, psychotherapy and relapse prevention BY: ROMMEL LUIS C. ISRAEL III 55
  • 56. IMPLEMENTATION OF CARE OF CLIENTS 1.Independent Nursing Care c. Spiritual Care Spiritual care is an important component of holistic nursing care. To implement spiritual care, the nurse must assess, diagnose, and respond to the needs of each patient and her or his significant others. Meeting the spiritual care needs of the patient can lead to physical healing, reduction of pain, and personal growth. Nurses providing spiritual care experience lower stress and less burnout. THE ROLE OF THE NURSE IN SPIRITUAL CARE To provide spiritual care, the nurse needs to be able to conduct a spiritual assessment; recognize the difference between religious and spiritual needs; identify appropriate spiritual care interventions; and determine when it is appropriate to deliver spiritual care. The Essence of Spiritual Care | Springer Publishing https://connect.springerpub.com › entity_view › node › ful BY: ROMMEL LUIS C. ISRAEL III 56
  • 57. 2. INDEPENDENT CARE Implementation of Care of Clients a. Pharmacological Therapeutics Nursing responsibilities in drug therapy The 7 responsibilities are: (1) Management of therapeutic and adverse effects of medication; (2) Management of medication adherence; (3) Management of patient medication self-management; (4) Management of patient education and information; (5) Prescription management; (6) Medication safety management. Nurses' responsibilities and tasks in pharmaceutical care: A scoping ... https://onlinelibrary.wiley.com › doi › full › nop2 BY: ROMMEL LUIS C. ISRAEL III 57
  • 58. The nurse’s responsibilities Drug therapy plays a major part in the treatment of patients. Traditionally, medicines have been prescribed by doctors and the nurse’s responsibility has been to ensure safe and reliable administration and to monitor side-effects. However, in 1994 the law was changed to allow district nurses and health visitors employed in pilot sites throughout England to prescribe from a limited formulary. Many of the preparations they were initially able to prescribe were for over-the-counter preparations. In 1998 it became possible for all appropriately qualified community nurses to prescribe from a limited nursing formulary. From 2003, any registered nurse could undertake training to enable them to become a nurse prescriber and prescribe from a broader Nurse Prescribers’ Extended Formulary. In 2006 the law changed again, enabling nurses who had undergone the requisite training to prescribe from the full range of drugs in the British National Formulary (with the exception of most controlled drugs) provided this was in their sphere of competence. IMPLEMENTATION OF CARE OF CLIENTS BY: ROMMEL LUIS C. ISRAEL III 58
  • 59. accurately, recording that the drug has been given and observing the patient’s response. Prior to administration the nurse must know the reason for, action and usual dosage of the drug; this should enable him or her to recognize and question mistakes in prescribing. When in doubt about a prescription, advice should be sought and, if necessary, the doctor should be consulted. Observations should be made for therapeutic and adverse effects. The nurse should realize that the patient’s condition may alter the effect of a drug and that there may be interactions with concurrent treatment. The nurse is greatly assisted in these circumstances by the pharmacist, with whom a good working relationship will enhance the safety of patient care. Implementation of Care of Clients 2. Independent Care Nursing aspects of administration The nurse is responsible for interpreting the prescription BY: ROMMEL LUIS C. ISRAEL III 59