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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:
TREATMENT TREATMENT
COMPLICATION COMPLICATION