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NCM106:

ACUTE
BIOLOGIC
CRISIS
RANDOLPH CORNELIO M. CAPON, BSN, RN
SHOCK
Types of SHOCK:
1. HYPOVOLEMIC
2. CARDIOGENIC
3. SEPTIC
4. ANAPHYLACTIC
5. NEUROGENIC
6. OBSTRUCTIVE
Compensatory Mechanism:
Sympatho-Adreno-Medullary Response (SAMR)
 Antidiuretic Hormone (ADH) release
 Renin Angiotensin- Aldosterone System (RAAS)
 Sympathetic Nervous System (SNS) Stimulation
General Signs and Symptoms:
Early Stage:
 SNS activation
 Respiratory Alkalosis

Late Stage:
 hypotension
 Oliguria to anuria
 Shallow breathing
 Resp. and Metabolic
Acidosis
COLLABORATIVE MANAGEMENT:
 Promote fluid balance and cardiac output
 Assist with cardiac support
 Assist with Respiratory Support
 Assist with Renal Support
 Assist with G.I Support
 Promote Safety
 Administer Medication as ordered
CEREBROVASCULAR ACCIDENT
CEREBROVASCULAR ACCIDENT
(stroke, apoplexy)
2 major types:
Signs and Symptoms:
A. Headache
B. Increased Blood Pressure
C. Nausea and Vomiting
D. Dysphagia
E. Focal and Neurological
deficit
E. Focal and
Neurological deficits
 Hemiparesis and
Hemiplegia
 Aphasia
 Dysarthria
 Dysphagia
 Apraxia
 Homonymous
Hemianopia
 Agnosia
 Unilateral Neglect
Risk Factors:
1. Smoking
2. Sedentary Lifestyle
3. Prolonged Use of Oral
Contraceptives
4. Obesity
5. Type A Personality
Diagnostic Procedures:
1. CT Scan
2. Cerebral Arteriography
Nursing Management:
1. Administer O2 if indicated
2. Elevate HOB 30-45 degrees angle
3. Avoid Valsalva Maneuver
4. Assist NGT feeding if indicated
5. Assist PROM exercises
6. Prevent Complication of Immobility
7. Promote Communication
8. Care of Patient with Hemanopia
9. Administer Medications as ordered
INCREASED INTRACRANIAL PRESSURE
INCREASED INTRACRANIAL PRESSURE
Signs and Symptoms:
Earliest Sign:
1. Change or decrease LOC

Other Signs:
2. N&V
3. Diplopia
4. Papilledema
5.Doll’s eye sign
6. Decorticate
7. Deccerebrate
Late Sign:
8.Vital Signs Changes
Increased ICP
NURSING MANAGEMENT:
1. Maintain Patent airway and adequate
ventilation
2. Assist to semi fowlers position
3. Limit fluid intake
4. Avoid factors that increases ICP
5. Promote safety
6. Encourage Rest
7. Administer Medication as ordered
BURN
Causes of BURN:
Thermal Burn
 Chemical Burn
 Electrical Burn
 Radiation Burn
Depth of Skin Involved
 First Degree
 Second Degree
 Third Degree
STAGES of Burn:
 Shock/ Fluid Accumulation/ Emergent Phase
 Diuretic/ Fluid Remobilization Phase
 Recovery Phase
First Aid Intervention
1. Immense affected part in cold water
2. Drop and Roll
3. Throw a blanket over the client
4. Encourage Anti-
contracture positioning
Priority Action in case of Fire:

R emove the client


A ctivate the fire alarm
C onfine the fire
E xtinguish the fire
To use the fire extinguisher, do the following:

P ull the pin


A im at the base of the flame
S queeze the handle
S weep from side to side
Collaborative Management:
1. Promote respiratory function
2. Promote fluid-electrolyte and acid-base balance
3. Relieve Pain
4. Prevent Infection
5. Assist in Hydrotherapy
6. Assist in debribement
7. Assist in Skin grafting
8. Promote G.I support
9. Provide Fluid Replacement
10. Assist in Rehabilitation Phase
Classic Sign of DM
Types of DM:
1. IDDM 2. NIDDM

-juvenile onset/ Non obese -adult onset/ Obese


-leads to destruction of pancreatic -Lack insulin receptor binding site
cells leading to deficiency of insulin -- asymptomatic
production.

TREATMENT TREATMENT

-Insulin Therapy -OHA


-Exercise after meals - diet
- Exercise

COMPLICATION COMPLICATION

- DKA - HHNS/ HONKC


DIABETIC KETOACIDOSIS
1. 3 P’s & 1 G
2. Weight Loss
3. Anorexia, N/V
4. CNS Depression
5. Kussmaul’s Respiration
6. (+) Acetone breath
NURSING Management:
1. Assist in Mechanical Ventilation
2. Administer 0.9% NaCl followed by 0.45% NaCl IV fluids
3. Monitor VS, I&O, plasma sugar levels
4. Administer Medications as ordered (e.i., Insulin therapy)
Types of Insulin
TYPE COLOR/ ONSET PEAK DURATION
CONSISTEN
CY

1. RAPID Clear 2-4 hours


acting
(Regular
insulin)

2. Cloudy 8-16 hours


INTERMEDIA
TE acting
(NPH)

3. LONG Cloudy 16-24 hours


acting
(Ultralente)
DX and Lab Exam for DM
a. FBS
b. OGTT
c. RBS
d. Alpha glycosylated hemoglobin
NURSING Management:
1. Foot care management
2. Same as DKA EXCEPT
don’t give Na HCO3!
3. Annual eye &kidney exam
4. Assist surgical procedure

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