Gas Exchange Issues: Past Paper Notes PDF

CONCEPT: GAS EXCHANGE Pneumothorax ‘- Thoracic Trauma/Flail Chest Chest Tube Drainage Professor Bernardo 1  Learning Objectives 1. Recognize etiology, pathophysiology, and clinica...

CONCEPT: GAS EXCHANGE Pneumothorax ‘- Thoracic Trauma/Flail Chest Chest Tube Drainage Professor Bernardo 1  Learning Objectives 1. Recognize etiology, pathophysiology, and clinical manifestations gas exchange issues (pleural effusion, pneumothorax, and chest trauma) ‘- *Please review content on atelectasis & pneumothorax 2. Describe medical management & pharmacologic treatments, and chest drainage system. 3. Use the nursing process as a framework for care of the patient with gas exchange issues 2 Chest Trauma pp. 589 - 591 Usually due to injuries Blunt - positive pressure inflicted to the chest wall = chest compression ‘- - MVA, falls - > rib fracture, lung injuries - > hypoxemia, atelectasis, pneumothorax, hemothorax, cardiac tamponade Penetrating - foreign object penetrates the chest wall 3  Assessment & Diagnostics Time of injury Mechanism of injury, type of injury, facial/neck injury, burns LOC, estimated blood loss, recent alcohol or‘- drug use Airway & breathing - symmetrical chest expansion v/s CXR, CT, Labs, ABG, Type & Cross, Lytes, EKG Trauma Center - mobilize trauma team, OR, Radiology, BB, ICU 4 Flail Chest Complication of blunt chest trauma - MVA, Falls, assault with a blunt weapon 3 or more adjacent rib ‘- fractures +/or sternum > free floating ribs/ detached rib/s (Flail) > chest wall instability > respiratory distress due to paradoxical chest movement 5  Management depends on extent of injury (rib fracture to severe flail chest) Rib fracture - supportive positioning, C-DB-T&P Multiple fractures of > 3 ribs ‘- - rib-plating for chest wall stabilization Ventilatory support - intubation with ABG monitoring Clearing secretions - suctioning Pain control - cautious use of IV opioids 6  Pleural Effusion Excessive collection of fluid in the pleural space Pleural fluid - normal 5-15ml lubricant for pleural movement ‘-without friction Rarely a primary disease; usually a secondary condition (HF, TB, pulmonary infections, cancer) 7 ‘- 8 ‘- 9  Clinical Manifestations: Pleural effusion Related to primary disease: Pneumonia – fever, chills, pleuritic chest pain Malignant origin – dyspnea, orthopnea, ‘- cough s/s depend on the severity of pleural effusion – small to moderate – with minimal or no SOB Larger pleural effusion - with dyspnea 10  Assessment & Diagnosis : Pleural effusion Breath sounds – decreased or absent Dull or flat on percussion Large pleural effusion – s/s of respiratory ‘-distress CXR, CT Pleural fluid analysis – culture, Gram stain, AFB stain (TB), cell count, cytology (CA) Pleural biopsy 11  Pneumothorax Breached parietal or visceral pleura with positive atmospheric pressure in the pleura causing air to enter the pleural space and cause atelectasis ‘- Normal pleural pressure – negative/sub atmospheric to maintain lung inflation Types: spontaneous, traumatic (open or tension pneumothorax) 12 Physical Assessment Check for: tracheal alignment Simple pneumothorax – trachea midline - Lung expansion decreased - Breath sounds diminished or absent - Chest percussion – normal or ‘- hyperresonance Tension pneumothorax – tracheal deviation away from affected side - Chest expansion decreased or fixed at hyper expansion - Breath sounds diminished or absent - Chest percussion – hyper resonance 13  Clinical Manifestations: Pneumothorax s/s depend on size, location, cause Pain - sudden and pleuritic ‘- or partial collapse Acute respiratory distress depending on total Anxiety Dyspnea, air hunger, use of accessory muscles Hypoxemia and central cyanosis *hypotension, tachycardia, diaphoresis 14  Medical Management Goal: lung re-expansion Chest tube (CT) Emergency – cover chest wound (towel, handkerchief, heel of hand) ‘- Instruct to strain with closed glottis – helps with lung re- expansion Petroleum Gauze 15  Medical Management Pleural Effusion and Pneumothorax Thoracentesis Thoracotomy - >1500 mL initial aspiration/>200mL/hour ‘- High flow supplemental oxygen Tension pneumothorax – 14G needle 2nd ICS, midclavicular line 16 Medical Management Objectives: Manage the cause, prevent re-accumulation of fluid, promote comfort, gas exchange Thoracentesis – remove fluid, obtain a specimen for analysis, relieve dyspnea Ultrasound-guided ‘- With or without chest tubes (CT) Chemical Pleurodesis – instill/aerosolize talc, clamp CT (60-90 min), frequent repositioning for chemical redistribution Surgery – pleurectomy PleurX catheter 17 CHEST TUBE ‘- Management and Nursing Care 18 Chest Tube Insertion Inserted in pleural space or mediastinum Purpose: drain fluid, blood, air ‘- or pus re-establish negative pressure lung re-expansion Restore intrapleural pressure 19 ‘- 20  Chest Tube Locations Pneumothorax - above the 2nd ICS, MCL Pleural effusion - 4th or 5th ICS MCL ‘- Post open heart surgery - pericardial under the sternum Prevent cardiac tamponade 21 ‘- 22 Chest Tube Drainage System 3 Chambers: Drainage Collection Water seal - sterile water 2cm ‘- prevents air re-entry to the lungs monitor add sterile water (evaporation) Suction control - wet/dry 23 Drainage Collection Chamber ‘- Calibrated to measure drainage With a “write on” surface Document date, time, amount Usually far right side 24 Water Seal Chamber Assess for: ‘- Tidaling Bubbling 25  Water Seal Chamber *Mediastinal CT no tidaling/no bubbling pulsations Tidaling - water rises with inhalation, falls with exhalation ‘- *indicate CT patency Opposite with MV *Cessation of Tidaling If CT indicated for pneumothorax, =lung re-expansion - confirm intermittent bubbling is expected with CXR or obstruction until resolved *Continuous bubbling = air leak!!! (exhalation, coughing sneezing) 26  Suction Control Chamber (wet vs dry) A. Atrium Ocean (Wet Water Seal System) A suction control chamber; B water- seal chamber; ‘- C air leak monitor; D collection chamber B. Atrium Oasis (Dry Suction Water- Seal System) uses mechanical regulator for vacuum control A dry suction regulator; B water-seal chamber; C air leak monitor; D collection chamber; E suction monitor 27 bellows.  Suction Chamber Wet Suction Dry Suction - (-20cm H20) Amount of suction applied to (-20cm H20) pleural space is determined by the level of water ‘- (-20cm H20) *less H20 = less suction Attach to suction source until gentle bubbling is present 28  Patient Assessment - depending on CT indication Dyspnea Asymmetrical chest wall Distended neck veins Percussion: Hemodynamic instability ‘-Hyperresonance Pleuritic chest pain Pneumothorax Cough Dull/flat Absent or reduced breath Hemothorax/pleural sounds on affected side effusion 29  Nursing Care: Pre-procedure: Consent, CXR, labs with Prep insertion site clotting factors, ABG Position - supine or semi-fowler’s Assess: allergies to local ‘- Psychological support anesthetic Patient teaching - C, DB, & T&P Prepare CT drainage system Baseline v/s, breathe sounds Pre-medicate with pain medication 30 Nursing Care: Intra -procedure: Assist provider CT below chest level Location of CT: No kinks, coils a.Base Promote ‘- b.Apex drainage by Set-up and settings gravity Dressing Secure on the v/s and response to floor/bed procedure 31 ‘- 32  Nursing Care: Post-procedure Assess: v/s Proper functioning of CT Color and resp effort - Level of water - wet Insertion site, dressing suction ‘- Patient teaching - C, DB, & - Suction or water seal T&P - Dry suction - check - Every 2 hours regulator dial - Ambulate - Tidaling and bubbling Promote drainage Pain management Position - semi to high CXR fowlers 33 Nursing Care: Post-procedure Drainage and output - color, amount Keep air vent open when suction is off. ‘- Avoid milking/stripping tubing unless ordered Monitor for SC air (crepitus) CXR post discontinuation to evaluate lung re-expansion Patient/family education for outpatient pleural catheter management 34 Check Institutional Policies: assess/report… Provider orders/ Use critical thinking Assess every hour first 8 hours post insertion then ‘- every 8 hours and PRN Notify PCP bright red blood >100 ml per hr. - bleeding Document & Monitor dark Timing and Color!!! bloody drainage 35 Crepitus/SC air Mark area Should not ‘- be growing Small – may be normal when CT is new Monitor patient 36 ‘- 37 AT THE BEDSIDE ‘- 38  Nursing Care Patient education on pleurx https://www.bd.com/en-us/products-and-solutions/products/product-families/pleurx-pl eural-catheter-system ‘- FYI 39  Complications Air Leaks Accidental dislodgement/ disconnection, or system breakage Tension Pneumothorax ‘- 40  Complication: Air Leaks Continuous bubbling in water seal chamber Locate the source - check all connections (distal to proximal) DO NOT CLAMP more than few seconds ‘- - “pinch” - Tension pneumothorax Tighten connections Replace drainage system Notify the provider 41  Complication Accidental dislodgement/ disconnection, or system breakage Tubing separates - instruct client to exhale & cough Removes air from pl space ‘- Chest tube tip - immerse in sterile water Dislodged - cover with dry sterile gauze Monitor patient, call for help Notify provider, anticipate CXR, reinsertion 42  Complication: Tension Pneumothorax Cause: clamping, kink, obstruction (blood clot), MV with high PEEP Assess: tracheal deviation ‘- Absent/diminished breath sounds - one sided Asymmetry Distended neck veins Respiratory distress - cyanosis Notify provider, RRT 43  Chest Tube Removal Indications: Lung re-expansion (CXR), adequate breathing & ventilation, v/s, LOC Pre-medicate - 30 minutes prior Supplies ‘- Valsalva maneuver - increase intrathoracic pressure, prevent PE Occlusive dressing CXR, v/s & breathing pattern, drainage CXR should show resolution of indication for CT drainage Gradual ambulation 44  G 20 needle Sample Collection ‘- 45 Port for c drain ollecti age on o s am f ple ‘- 46 Sample collection from luer lock ‘- Direct puncture with needle Tube is “self- healing” 47 ‘- 48 Chest Tube set-up & Maintenance ‘- 49 BUBBLING IN WATER SEAL CHAMBER ‘- 50 https://youtu.be/fY4FA2fxStY? si=V2NsVj3VgTSG0s56 ‘- 51 Additional Resources Chapter 6 Manage Chest Tube Drainage Systems - Nursing Advanced Skills - NCBI Boo kshelf (nih.gov) ‘- 52  CONCEPT: GAS EXCHANGE Chest Tube Drainage ‘- (Additional slides and video) - this is testable material!!! Note: Please download the PpT and read the speaker notes! Professor Bernardo 1 ‘- 2  ‘-. Access the videos on set-up and operation from this link: Atrium Oasis Dry Suction Water Seal Chest Drain (getinge.com) OR: getinge.com>products>find Atrium Oasis Dry Suction Water Seal Chest Drain 3 ‘- 4  References Anderson, D., Chen, S.A., Godoy, L.A., Brown, L.M., Cooke, D.T. (2022). Comprehensive review of chest tube management: A review. JAMA Surgery157(3):269– 274. doi:10.1001/jamasurg.2021.7050 ‘- Getinge (2024). Drainage solutions: Atrium Oasis dry suction water seal chest drain. https://www.getinge.com /int/products/atrium-oasis-dry-suction-water-seal-chest- drain/ Lecturio.com (2024). Wet vs dry chest tube comparison. Nursing_CS_Wet-vs-Dry-Chest-Tube-Comparisons_03.pdf (lecturio.com) 5  INTRACRANIAL REGULATION Joann Sands, DNP, RN, ANP-BC, NHDP-BC Fall 2024  Pre-Class Readings/Preparation Lippincott Brunner & Suddarth Textbook - Chapter 63 - pages 2056-2070 ATI Medical Surgical Nursing Textbook - Chapter 14 - Head Injuries ‘- Lippincott the Point Journal Article (found on the CoursePoint website) - Mild Traumatic Brain Injury in the Emergency Department: A clinical practice gap UpToDate article - Acute mild traumatic brain injury (concussion) in adults UpToDate article - Sequelae of mild traumatic brain injury UpToDate article - Management of acute moderate and severe traumatic brain injury 2  Pre-Class Readings/Preparation (Cont’d) Review website: - American Association of Neurological Surgeons - Concussion https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Co ncussion ‘- Review website: - National Institute of Neurologic Disorders and Stroke https://www.ninds.nih.gov/health-information/disorders/traumatic-brain-injury-t bi 3  Learning Objectives Differentiate alterations to intracranial regulation Outline the relationship between intracranial regulation and other concepts Analyze independent interventions nurses can implement for patients with alterations in intracranial regulation ‘- Summarize collaborative therapies used by interprofessional teams for patients with alterations in intracranial regulation Differentiate considerations related to the assessment and care of patients with alterations in intracranial regulation throughout the lifespan 4  Learning Objectives (Cont’d) Analyze traumatic brain injury as it relates to intracranial regulation Integrate knowledge of select concepts in the nursing management of complex health problems, incorporating evidence-based practice guidelines across the continuum of care ‘- Synthesize concepts of care for individuals, families, and populations across the lifespan, including the professional roles of interdisciplinary teams, community resources agencies, and family support systems. 5  Intracranial Regulation Definition & Scope Definition – Mechanisms of conditions that impact intracranial processing and function Scope – Refers to the processes that affect intracranial compensation and adaptive neurologic function ‘- The neurologic system regulates and integrates all body functions, muscle movements, senses, mental abilities, and emotions. It collects as sensory input, information from the internal and external environments, processes, and interprets the input, and causes responses that manifest as motor or sensory output. 6  Intracranial Regulation Attributes Normal physiologic process: Neurologic system divided into two parts – central nervous system (brain and spinal cord) and peripheral nervous system (cranial nerves and spinal nerves) ‘- to occur, whereas the - Somatic components of the PNS allows voluntary activities autonomic component of the PNS controls involuntary activities to maintain life (breathing, heart rate) Brain is the control center of the nervous system – - Regulates homeostasis within the body, controls basic functions such as breathing, allows problem solving, and judgement, forms memories and emotions, and regulates many more functions that allow life to continue and define who each individual is as a person 7  Intracranial Regulation Age Related Differences Infants and Children Babies have primitive reflexes – these arise in the spinal cord and do not require interpretation by the brain (startle reflex, sucking reflex) ‘- Older adults Normal neurologic changes associated with aging often go unnoticed in the older adult. These include memory loss, subtle loss of coordination, and slower or diminished reflexes. Neurologic changes may result from a variety of factors – medications, acute illness (infection), and progressive illness (Parkinson’s, dementia) Declines in mental status are not a normal result of aging and changes are often the result of an underlying disorder. Impulse transmission and reaction to stimuli are slower in older adults. 8  Intracranial Regulation Alterations Alterations to intracranial regulation may occur because of illness or injury. Assessment of the patterns of an individual’s signs and symptoms will help determine the extent of improvement or deterioration of intracranial regulation. ‘- A local brain injury or illness (in which only one area is affected) will cause a focal neurological deficit, but should not disrupt a patient’s level of consciousness. 9  Intracranial Regulation Negative Consequences Processes that disrupt the flow of blood and nutrients may cause widespread damage, impairing arousal and cognition. Changes in behavior and alterations in level of consciousness may be early signs of brain dysfunction ‘- As brain impairment progresses, more stimuli are required to elicit a response from the patient. Deceased consciousness, neurologic dysfunctions, and hemodynamic instabilities become more apparent as damage progresses Without successful intervention to stop progression of brain damage, death will occur. 10  Populations at Risk Patients at particular risk Poorly controlled diabetes Respiratory or cardiac failure ‘- All age groups – each age group has own number one cause of brain injury Athletes Male gender Military personnel 11  Causes Most common causes of TBI are falls (aging population) Motor vehicle accidents – used to be number one cause Being struck by objects ‘- Assaults Other/unknown 12  Assessment Infants – Measure head circumference and assess anterior and posterior fontanels Children – Consider child’s developmental age. Simple interview questions and a shorter assessment may be necessary ‘- Present procedures as a game; note child’s ability to understand and follow directions Older Adults – Allow time for them to think of a reply and to answer the question; do not assume they do not know the answer A full neurologic assessment can be lengthy; conduct assessment in several sessions if indicated and cease test if patient is noticeably fatigued. Exam and patient interview Notice patient’s dress and appearance, gait, use of assistive devices, facial movements, speech patterns, alertness, general comprehension of simple instructions. Physical exam – thorough neurologic exam includes assessment of cranial nerves, mental status, reflexes, muscle strength and coordination, and gait. Note length of symmetry between sides of the body. A complete neurologic exam is usually not performed in otherwise healthy patients 13  Diagnostics Cervical spine x-rays CT MRI ICP monitoring ‘- Calculation of cerebral perfusion pressure Glasgow Coma Scale EEG Cerebral angiography Therapeutic drug level monitoring Electrolyte and serum glucose monitoring No lumbar puncture in suspected increased ICP – can cause brain herniation 14  Clinical Management Maintain patent airway Initiate protocols to treat neurologic issues Prepare patient for surgical intervention if warranted ‘- Assess LOC, pupillary response, neurologic status Monitoring fluid intake and output Reducing environmental stimuli Take precautions to treat seizures, including padding side rails DVT prophylaxis 15  Clinical Management Airway – patent, intubated, tracheostomy, mechanical ventilation, able to breath on own? Circulation – BP, HR – adequate to perfuse body and brain? Peripheral IV’s, arterial lines, central venous line IV fluids and medications ‘- Determine neurologic pathology Treat underlying cause Prevent complications 16  Interrelated Concepts Homeostasis (acid-base balance, cellular regulation, clotting, electrolyte, fluid imbalance, gas exchange, thermoregulation) Cognition Mobility ‘- Oxygenation Safety Stress and coping Hormonal Regulation 17  Clinical Exemplars Concussion – Form of TBI Minor loss of normal brain function caused by a head injury. Traumatic Brain injury ‘- Result of a violent blow to the head or an object penetrating the skull (i.e. bullet) that causes injury to the brain or brain dysfunction. TBI results from external physical force, such as a blow or jolt to the head 18  LOC: Connuum from fully alert, oriented, and cognively intact with normal motor and sensory funcon Comatose Levels of Consciousness Altered Level of Consciousness: reduced state of wakefulness, awareness or alertness to smuli Minimally Conscious State: paent has inconsistent but reproducible signs of awareness Coma: clinical state of unarousable unresponsiveness with no purposeful movements or responses to internal or external smuli *Non-purposeful responses to pain or brain stem re%exes may be present  Brain Injury Traumatic brain injury (TBI) – caused by a blow to the head that causes the brain to have problems functioning. Causes injury to the brain or brain dysfunction Results from an external physical force (blow or jolt to the head) causing displacement of the brain within the skull and disruption of normal brain function. TBI can also be caused by a penetrating injury (i.e. bullet through the brain) ‘- Can be mild, moderate, or severe - Vast majority of TBI are mild – and are commonly known as concussions With significant injury, the brain tissue swells, leading to cerebral edema and increased ICP. Intracranial bleeding may also occur further contributing to increased ICP. Symptoms vary according to severity of injury (range from mild headache to death Loss of consciousness may occur in mild, moderate, or severe TBI injuries. Depends on how long patient was unconscious The ability to recover varies based widely on the severity and location within the brain that the injury occurred. 21  Head Concussion Mild traumatic brain injury that affects normal brain functions Occurs as a result of forceful blow (either direct or indirect) to the head. Common as a result of sports injuries and falls Indirect – whiplash ‘- Direct – helmet to helmet football injury Concussion can be difficult to diagnose, as symptoms may be minor or may not appear for days or even weeks after occurrence. Concussion is functional injury rather than structural Concussed brain looks normal on imaging Damage occurs at microscopic level and generally affects a large area of the brain Visible manifestations of what happens inside the head; nerve fibers are stretched and stretched 22  Head Concussion Signs and symptoms Can be subtle and may not appear immediately Common for first signs to show up 20 minutes to hours from the time of impact Generally seen in four areas ‘- - Physical – nausea or vomiting, dizzy, sensitivity to light and sound - Emotional – experience intense emotion. Cry easily or feel depressed, irritable, or anxious - Thinking and remembering – may have trouble thinking clearly, trouble remembering new information or concentrating on tasks or conversations; feel like they are in slow motion - Sleep – may sleep a lot more or a lot less than usual Observe for at least 48 hours for worsening signs such as loss of consciousness, increasing headache, repeated vomiting, slurred speech, confusion, unusual behaviors, seizures, and limb weakness or numbness Any of these worsening symptoms would require emergency care. 23  Head Concussion Usually resolves on its own with proper rest Majority fully recover (couple weeks  some longer) During recovery, the brain is much more vulnerable to further insults and any activities ‘- that may potentially cause another injury should be avoided. Repeated injury may exacerbate symptoms, result in permanent brain damage, and can be fatal. Rest, monitor symptoms, pain relief with Tylenol or Ibuprofen 24  Traumatic Brain Injury Epidemiology Account for 30% of all injury related deaths in the US Males > Females in all age categories Males more than 2 times as likely to be hospitalized than females Males three times as likely to die from a TBI than females ‘- People over 75 have the highest numbers and rates of TBI related hospitalizations and deaths. Incidence: Over 2.9 million ER visits per year 69,473 die 223,135 TBI related hospitalizations - Represents more than 611 TBI related hospitalizations and 190 TBI related deaths EVERY DAY 80,000 – 90,000 survive and live with life-long debilitating/loss of function 25  Traumatic Brain Injury Causes Object striking head Head striking non-moving object Acceleration/Deceleration of brain without external impact ‘- Foreign body penetrating brain Force from blast or explosion 26  Traumatic Brain Injury Definitions and Types Definition: Injury to the head or skull that is extensive enough to interfere with normal functioning Open head trauma: ‘- brain tissue or severe blunt Result of an object penetrating the skull and damaging the trauma that causes an opening of the skull causing damage to the dura mater and brain tissue Closed: Result of head acceleration then rapid deceleration or collision with blunt force causing damage to brain tissue Diffuse Axonal Injury: Shearing (tearing) of the brain’s connecting nerve fibers (axons) when the brain shifts and rotates inside the bony skull from primary injury 27 Shearing/tearing of long connecting nerve fibers (axons) when brain is injured—as it shifts and rotates inside the skull  Traumatic Brain Injury Primary and Secondary Injuries Primary Occurs at the time of injury Consequence of an external force causing direct contact with the head/brain, acceleration/deceleration, penetrating and blast waves‘- Shearing of tissue, tears, & bruising of brain tissue Causes extracranial focal injuries (contusions, external hematomas, skull fractures) as well as possible focal brain injuries (hematoma, concussion, diffuse axonal injury) Goal of initial treatment is prevention of secondary injury External – Contusion, lacerations, external hematomas, skull fracture Internal – Subdural hematoma, concussion, diffuse axonal injury 29  Traumatic Brain Injury Primary and Secondary Injuries Secondary Evolves over ensuing minutes-hours-days following initial injury Results from inadequate nutrients and oxygen to brain cells Hematoma formation, cerebral edema, increased ICP,‘-infection (open head injury) Identification, prevention, and treatment of secondary injury are the main foci of early management of severe TBI Intracranial – hemorrhage, cerebral edema, intracranial hypertension, seizures, Systemic – Hypotension, hyperthermia, hypoxia, infection, anemia, electrolyte imbalances 30 https://sportsclinicnq.com.au/concussions/ https://brainlaw.com/brain-injuries/traumatic-brain-injury-guide/ Open Head Injury ‘- 35  Screwdriver Nail gun https://ncbi.nlm.nih.gov/ pubmed/28068964 https://www.thenerve.net/journal/view.php?viewtype=pubreader&number=99#!po=50.0000  Traumatic Brain Injury Basilar Skull Fracture Skull fracture – associated with high impact mechanisms such as an assault with a weapon (bat, metal instrument). Direct blow to the head Non-depressed – close observation Depressed – surgery to elevate the skull and debridement‘- Basilar skill fracture – a fracture to the base of the skull; occurs in the floor of the skull CT scan can be used to diagnose a basilar skull fracture Raccoon eyes – bruising around the eyes Battle Sign – an area of ecchymosis may appear around mastoid process (behind the ear) Basal skull fractures suspected when CSF escapes from the ears and the nose. Halo sign – clear or yellow tinted ring surrounding a drop of blood when bloody drainage is placed on a piece of gauze 40 https://www.ncbi.nlm.nih.gov/books/NBK470175/figure/article- 18164.image.f1/ Traumatic Brain Injury ‘- 42 Traumatic Brain Injury Monro-Kellie Hypothesis ‘- 43  Traumatic Brain Injury Monro-Kellie Hypothesis/Brain herniation If one component increases in volume  then at least 1 of the remaining two MUST DECREASED. If you do not get compensation, the pressure and contents inside the cranial vault will continue to increase and will cause brain herniation Brain herniation ‘- - Protrusion of brain through one of the rigid intracranial barriers - Herniation: area of high pressure  area of low pressure (path of least resistance) - CT Scan – ‘midline shift’ – needs urgent intervention - Life threatening Signs and symptoms include fixed and/or dilated pupils, decrease in level of consciousness, abnormal respirations, and abnormal posturing. 44  Glasgow Coma Scale Used to assess a patient’s level of consciousness. Used to gauge severity of the brain injury How alert and responsive they are to their environment and stimuli around them. Get a baseline, frequent scoring throughout shift, determine if they are improving, declining, remaining the same. Take patient’s best response No precedence of one score over another ‘- Assessing three things: Eye opening Verbal Motor Scoring Total range from 3-15 (max) Higher score  more favorable outcome Glasgow Coma Scale 46  Glasgow Coma Scale Eye Verbal Motor 6 Obeys commands 5 Oriented Localizes pain 4 Spontaneous Confused ‘- Withdraws from pain 3 To command Inappropriate words Flexion posturing (Decorticate) 2 To pain Incomprehensible Extensor posturing (Decerebrate) 1 No opening No verbal response No motor response 47  Knowledge Check Determine this patient’s Glasgow Coma Scale. The patient is sitting up in their bed, watching the television and looks at you and smiles when you walk into the room. When you ask the patient person, place, and time questions, they tell you their correct name but state they are at their daughter’s house and it is 2001. They are able to shrug their ‘- shoulders, squeeze your fingers, and stick out their tongue when asked. What is this patient’s GCS? 49  Rancho Los Amigos Describes the cognitive and behavioral patterns found in brain injury patients as they recover from injury Helpful in assessing the patient because it does not require his or her cooperation. ‘- Provides a brief description of progress during recovery process and help track behavioral, cognitive, and emotional changes that take place during healing. Originally developed by the head injury team at the Rancho Los Amigos Hospital in California to assess patients emerging from a coma. RLAS originally had 8 levels; the revision added levels 9 and 10 to better reflect highest levels of recovery Each level is behavioral and the rate must decide which level best describes the patient’s present behaviors 50  Rancho Los Amigos Level I – No response; total assistance No response to external stimuli Level II – Generalized response: Total Assistance ‘- stimuli Responds inconsistently and non-purposefully to external Responses are often the same regardless of the stimulus Level III – Localized Response: Total Assistance Responds inconsistently and specifically to external stimuli Responses are directly related to the stimulus, for example patient withdraws or vocalizes to painful stimuli Responds to more familiar people (friends and family) versus strangers 51  Rancho Los Amigos Level IV – Confused/Agitated: Maximal Assistance The patient is a hyperactive state with bizarre and non-purposeful behavior Demonstrates agitated behavior that originates more from internal confusion than the external environment Absent short-term memory ‘- Level V – Confused, inappropriate. Non-agitated: Maximal Assistance Shows increase in consistency with following and responding to simple commands Responses are non-purposeful and random to more complex commands Behavior and verbalization is often inappropriate, and individual appears confused and often confabulates If action or tasks is demonstrated, the individual can perform, but does not initiate tasks on own Memory is severely impaired and learning new information difficult Different from level IV in that individual does not demonstrate agitation to internal stimuli. They can show agitation to unpleasant external stimuli 52  Rancho Los Amigos Level VI – Confused, appropriate; Moderate assistance Able to follow simple commands consistently Able to retain learning for familiar tasks they performed pre-injury (brushing teeth, washing face) however unable to retain learning for new tasks ‘- Demonstrates increased awareness of self, situation, and environment but unaware of specific impairments and safety concerns Responses may be incorrect secondary to memory impairments but appropriate to the situation Level VII - Automatic; appropriate. Minimal assistance for Daily Living Skills Oriented in familiar settings Able to perform daily routine automatically with minimal to absent confusion Demonstrates carry over for new tasks and learning in addition to familiar tasks Superficially aware of one’s diagnosis but unaware of specific impairments Continues to demonstrate lack of insight, decreased judgement and safety awareness Beginning to show interest in social and recreational activities in structured settings Requires at least minimal supervision for learning and safety purposes 53  Rancho Los Amigos Level VIII – Purposeful, appropriate. Stand-by assistance Consistently oriented to person, place, and time Independently carries out familiar tasks in a non-distracting environment Beginning to show awareness of specific impairments ‘-and how they interfere with tasks, however, requires standing by assistance to compensate Able to use assistive memory devices to recall daily schedule Acknowledges other’s emotional states and requires only minimal assistance to respond appropriately Demonstrates improvement of memory and ability to consolidate the past and future events Often depressed, irritable, with low frustration threshold 54  Rancho Los Amigos Level IX – Purposeful, appropriate. Stand-by assistance on request Able to shift between different tasks and complete them independently Aware of and acknowledges impairments when they interfere with tasks and able to use compensatory strategies to cope ‘- Unable to independently anticipate obstacles that may arise secondary to impairment With assistance, able to think about consequences of actions and decisions Acknowledges the emotional needs of others with stand-by assistance Continues to demonstrate depression and low frustration threshold 55  Rancho Los Amigos Level X - Purposeful, appropriate. Modified Independent Able to multi-task in many different environments with extra time or devices to assist Able to create own methods and tools for memory retention Independently anticipates obstacles that may occur as a result‘- of impairments and take corrective actions Able to independently make decisions and act appropriately but may require more time or compensatory strategies Demonstrate intermittent periods of depression and low frustration threshold when under stress Able to appropriately interact with others in social situations Rancho Los Amigos Scale 56  Traumatic Brain Injury Mild Concussions – concussions result from jostling, jarring or shaking of brain  bruising brain tissue (contusion) GCS 13-15 Concussions are manifested by loss of consciousness and/or loss of memory Negative neuro imaging No neurological changes ‘- Recovery: weeks to months without specific treatment Post concussion symptoms Headache Dizziness Poor memory Difficulty concentrating Fatigue Irritability 57  Traumatic Brain Injury Note on CTE Chronic traumatic encephalopathy Due to repeated head injuries. Can occur in people who have repeated blows to the head and repeated concussions (boxers, football players) Causes the death of nerve cells in the brain, known as degeneration ‘- CTE gets worse over time Diagnosis can only be made after death, on autopsy Symptoms Memory and thinking problems Confusion Personality changes Erratic behavior including aggression, depression, and suicidal thinking Problems paying attention and organizing thoughts Difficulty with balance and motor skills Individuals may not experience these potential signs of CTE until years or decades after brain injuries occur 58  Traumatic Brain Injury Moderate and Severe Moderate Loss of consciousness from 15-20 minutes to a few hours; followed by a few days or weeks of confusion GCS score 9-12 May experience long-term neuro deficits Requires extensive rehabilitation - Return to pre-injury lifestyle is possible ‘- Severe Affects less than 10% of patients Loss of consciousness for 6 hours or longer after injury or a period of clarity. People who remain unconscious for a very long time may be in a coma or a vegetative state or minimally conscious state. GCS 3-8 Requires extensive rehab Usually sustain many long-term neurologic deficits ** There are overlaps in the symptoms of each of these classifications. The terms mild, moderate, and severe may not correlate or describe the expected outcomes in a person’s life. 60  Traumatic Brain Injury Long-term Brain injury may cause changes in a person’s way of life Changes may include altered level of consciousness, being unaware of surroundings, and unable to respond to stimuli Other changes may include: ‘- Damage to the brain which may lead to changes in mental, physical, and emotional behavior Changes may for a short time or forever Trouble with memory, learning, or judgement Loss of motor function Seizures Problems in communicating that could lead to frustration, conflicts, and more injuries; impulsivity Changes in actions and feelings that cause anger or moodiness Problems with senses – hearing, smelling, or moodiness 61  Traumatic Brain Injury Medical Treatment Goal is to stabilize the patient Prevent secondary injury/complications Prevent hematoma formation Hematomas are space occupying lesions which compress vital brain tissue  increased ICP Pharmacotherapy Aimed at decreased ICP ‘- Antiepileptics Pain control Diagnostic testing ABCD Airway – maintain patent airway (airway protection – intubation usually required for a GCS < 9) Breathing Circulation Disability Cervical spine stabilization Oxygenation Complete head to toe thorough examination Assess and manage associated injuries 62  Traumatic Brain Injury Nursing Care Nursing Care During Acute Phase: Monitor ICP Assess alteration of LOC and orientation Assess GCS Monitor vital signs, EKG, thermoregulation ‘- Notify provider of any changes Monitor for seizure/safety precautions Monitor I/O and fluid and electrolytes Nutrition Infection Environment – calm, quiet, low lights Family/Psychosocial Immobility 63  Traumatic Brain Injury Nursing Care Cluster care to allow for minimal interruptions Ensure call light is within reach of the patient Allow adequate time for patient to respond to questions and make decisions Have the patient repeat verbal or written instructions ‘- Administer prescribed medications, monitor their effect Ensure the patient is getting enough sleep each day, eating a well-balanced diet Provide aid to assist in orientation (calendar, clock, seasonal pictures) Reorient patient if needed Note cyclic changes in mentation or behavior, such as evening confusion (sundowning) Place familiar objects within reach; encourage patient to discuss objects Collaborate with the psychologist or neurologist if a mental health evaluation is needed Collaborate with social work and discharge planning to provide community resources and support 64  Traumatic Brain Injury Prognosis Ability to recover depends upon the severity of injury and extent of brain damage, GCS, and time spent in coma Approximately 65% of persons with TBI will survive 35% are moderately disabled ‘- Remainder are severely disabled or in vegetative state Brain death Consider organ donation Family support 65  Traumatic Brain Injury Pharmacotherapy Antibiotics – open head injury, ventricular drain or sensor Anticonvulsants – (Phenytoin, Carbamazepine) Prevent seizures ‘- Steroids – (Solu-Medrol, Dexamethasone) Decrease inflammation Barbiturates (Phenobarbital) Sedation  decreased metabolic rate for patient’s with elevated ICP Diuretics Osmoc Diurecs - (Diamox, Mannitol) decrease volume for elevated ICP Loop Diurecs - (Lasix) decrease volume 66  Traumatic Brain Injury Post-TBI manifestations Alteration in Cognition Difficulty processing information, short attention span, decreased ability to concentrate, problems with memory, language, judgment, problem solving Perceptive Symptoms ‘- Changes in vision, hearing, touch, balance, pain, and sensation Physical Symptoms Persistent headache, extreme physical and mental fatigue, impaired speech, gait disturbances, seizures, loss of strength, imbalance, coordination, movement, and swallowing Behavior/Emotional Symptoms Apathy, irritability, impatience, impulsivity, lack of inhibition, emotional lability, new family dynamics 67  Traumatic Brain Injury Rehab Team approach Team consists of physicians, advanced practice providers (NP/PA), nurse, psychologist, physical therapist, occupational therapist, speech therapist, social workers, dietician, recreational therapist ‘- Rehabilitation nurse Works closely with the team to manage medical problems and preventing complications Assess the patient’s self-care, bowel and bladder function, sexual function, diet, and ability to move Assist with the treatments of other team members Educate the patient and their family about their TBI and any medications they take 68  Discharge Plan from acute rehab Depends on many factors: Insurance Family support Safe home environment ‘- Degree of injury Different for every patient: Discharge home with in-home rehab services Discharge home with outpatient rehab services Discharge to a residential TBI program Discharge to a long-term care facility 69  Education for Home Discharge Call provider for Decreased LOC Headache which is not resolving, especially if it accompanies other neurologic ‘- symptoms (increased confusion, vision changes, decreased LOC) Persistent nausea and vomiting (especially if it accompanies other neurologic symptoms) Bleeding from any orifice (especially nose, ears) New onset weakness/paralysis Fever Seizures Trouble walking or talking 70  Knowledge Check A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial nerve function ‘- C. Oxygen saturation 71  Knowledge Check The Glasgow Coma Scale assesses which areas of response to stimuli? ‘- 72  Knowledge Check You are assessing a patient who was involved in a motor vehicle accident and sustained a traumatic brain injury. The patient is minimally responsive. You complete an assessment and determine the patient’s GCS score is 7. What is the level of brain injury in this patient? ‘- A. Mild B. Moderate C. Severe D. Unable to determine 73 QUESTIONS ‘- 74  GRIEF AND LOSS CONCEPT AND EXEMPLARS Dr Megan Heimerl Fall 2024 NSG 411 https://www.youtube.com/watch?v=o07C5KquSOA  GRIEF  An inner emotional reaction or response to loss  A universal experience  Can occur due to separation or death  divorce, loss of a body part, job, house, pet  other de8nitions  a normal, complex process includes emotional, physical, spiritual social and intellectual responses and behaviors by which individuals, families and communities incorporate a loss into their daily lives  a broad range of feelings and behaviors that have come in after a loss  an internal experience of the person who has experienced a loss MOURNING  Actions and expressions of grief including the symbols and ceremonies  funeral, celebration of life BEREAVEMENT  Includes both grief and mourning parentheses outward display of grief) as a person deals with death  Can result in depression  Previously had to be experiencing bereavement for greater than two months so as to receive a diagnosis of bereavement  Currently can receive a diagnosis of depression almost immediately so treatment is not delayed  TYPES OF LOSS Necessary loss: part of the cycle of life; anticipated but can still be intensely felt Actual loss: any loss of a valued person or item  Perceived loss: any loss de8ned by a client that is not obvious to others  Situational loss: unanticipated loss caused by an external event  Maturational loss: losses normally expected due to the developmental processes of life  First child gets a sibling  Parent of a single child has her child go to school THEORIES OF GRIEF  Kubler Ross  Bolwby  Engel  Worden KUBLER-ROSS: 5 STAGES OF GRIEF Denial: the client has diAculty believing in terminal diagnosis or loss Anger: anger is directed toward self, others, objects  Bargaining: the client negotiates for more time or cure  Depression: the client is overwhelmingly saddened by the inability to change the situation  Acceptance: the client accepts what is happening and plans for the future BOWLBY: FOUR STAGES OF GRIEF  Numbness or protest: the client is in denial over the reality of the loss and experiences feelings of shock  Disequilibrium: the client focuses on the loss and has an intense desire to regain what was lost  Disorganization and despair: the client feels hopelessness which impacts the client's ability to carry out tasks of daily living  Reorganization: the client reaches acceptance of the loss ENGEL: FIVE STAGES OF GRIEF  Shock and disbelief: the client experiences a sense of numbness and denial over the loss  Developing awareness: the client becomes aware of the reality of the loss resulting in intense feelings of grief  Restitution: the client carries out cultural or religious rituals following the loss such as a funeral  Resolution of the loss: the client is preoccupied with the loss over about 12 month time period this preoccupation gradually decreases  Recovery: the client moved past the preoccupation and forward with life WORDEN: FOUR TASKS OF MOURNING  Task 1: accept the reality of the loss  Task 2: processing the pain of grief. Client uses coping mechanisms to deal with emotional pain of loss  Task 3: adjusting to a world without the lost entity. Client changes the environment to accommodate the absence  Task 4: 8nding and enduring connection with the loss entity in the midst of embarking on a new life. Client 8nds a way to keep the loss entity a part of their life while at the same time moving forward with life and establishing new relationships  1. Recognize: experiencing the loss, understanding that it is real and that it has happened 2. React: emotional response to loss, feeling the feelings 3. Recollect and re experience: loved one’s memories are reviewed and relived TASKS OF 4. Relinquish: accept that the world has GRIEVING changed as a result of the loss so that there is no turning back 5. Readjust: beginning to return to daily life loss feels less acute and overwhelming 6. Reinvest: accepting changes that have occurred, reentering the world, forming new relationships and commitments   Current stage of development  Interpersonal relationships and social support network FACTORS  Type and signi8cance of the loss INFLUENCING  Culture and ethnicity LOSS, GRIEF,  Spiritual and religious beliefs and practices COPING  Prior experience with loss  Socioeconomic status RISK FACTORS FOR COMPLICATED GRIEVING  Being dependent on deceased  Unexpected death at a young age through violence or by a “socially unacceptable” manner (suicide, abortion, OD)-> This can also lead to disenfranchised grief, but more to come on that later  Inadequate coping skills or lack of social support pre-existing mental health issues (depression, substance use disorder) TYPES OF GRIEF  Anticipatory grief  Normal grief  Complicated grief  Delayed or inhibited grief  Distorted or exaggerated grief  Chronic or prolonged grief  Disenfranchised grief  ANTICIPATORY LOSS A person displays loss and grief behaviors for loss that has not yet taken place  Often seen in families of terminally ill patients  Recommendations:  Acknowledge feelings  Find out what to expect  Practice self-care  Support  Say what you need to say  Try not to put life on hold   This grief is considered uncomplicated  Can include anger, resentment, withdrawal, hopelessness, guilt but should change to acceptance with time  Should achieve some acceptance by 6 months after loss NORMAL  Somatic manifestations: chest pain, palpitations, GRIEF headache, nausea, changes in sleep patterns, fatigue NORMAL SIGNS OF GRIEVING Assumption of the lost loved one’s mannerisms or speech patterns Denial or disbelief that the loss occurred Feeling of emptiness in the stomach or abdomen Feelings of restlessness Heaviness in the chest Inability to complete tasks, even simple ones Inability to concentrate Loss of appetite Intense anger at the departed loved one NORMAL SIGNS OF GRIEVING Mood swings from anger to guilt Need to take care of others, to protect them Need to tell and retell stories about their loved one and the death experience Sensing of feeling the loved one’s presence Sleep disruptions such as insomnia or extreme wakefulness Tightness in the throat Unexpected and unpredictable bouts of crying Wandering aimlessly through the house or neighborhood EMOTIONAL RESPONSES TO GRIEF  Anger, sadness, anxiety  ‘He should have stopped smoking years ago”  “I should have taken him to the doctor sooner”  “it took too long for the doctor to diagnose him”  Have you seen any of these in your clinical experience?  DELAYED OR INHIBITED GRIEF  Individual does not demonstrate expected behaviors of normal grief  Cultural expectations can inMuence the development of delayed or inhibited grief  Individuals can remain in the denial stage for an extended time  Because individual cannot progress through the stages of grief, a subsequent minor loss can trigger the grief response DISTORTED OR EXAGGERATED GRIEF  Individual experiences the emotional and/or somatic manifestations associated with normal grief but to an exaggerated level  Individual is unable to perform activities of daily living  Individual can remain in the anger stage of the grief process and direct anger towards themselves or others  Can develop clinical depression  CHRONIC OR PROLONGED GRIEF  Maladaptive response that is diAcult to identify due to varying lengths of time the individuals take to work through the stages or tasks of grief  Individual can remain in the denial stage of grief and remain unable to accept the reality of the loss  Chronic or prolonged grief can result in the individual’s inability to perform activities of daily living  DISENFRANCHISED GRIEF  Grief and entails an experience loss that cannot be publicly shared (“other partner”) or is not socially accepted for example suicide or pregnancy termination  Allow time for grieving  Educate individual and family on stages of grief NURSING  Identify expected grieving behaviors INTERVENTION  Use therapeutic communication -> name the emotion S:  Be OK with silence and personal presence FACILITATING  Avoid communication that inhibits open expression of MOURNING feelings (oNering false hope, giving advice, changing subject, shifting focus)  Don’t make comments like “God’s will” NURSING INTERVENTIONS: FACILITATING MOURNING  Avoid cliches (better place now)  Assist individual to accept reality  Support eNorts to move on, encourage new relationships, support groups, community resources  Assess for indications of ineNective coping  Involve spiritual advisor mental health counselors as appropriate PSYCHOSOCIAL CARE  Use an interprofessional approach  Provide care to individual and family  Discuss speci8c concerns such as 8nancial or role changes  Facilitate communication between individual, family, provider  Encourage individuals to participate in religious or spiritual practices that bring comfort  Assist the individual and clarifying personal values to facilitate eNective decision making DECREASE FEAR OF DYING ALONE 1 2 3 4 Answer call bells Keep the Allow families to If at home, move in the timely individual remain with the back to a central manner and informed of individual as location rather make frequent procedures much as possible than an isolated contact bedroom  Suggest that time members you can visits in a manner that promotes individuals requests  Ensure family receives appropriate information as treatment plan changes  Provide privacy SUPPORT  Determine feeling members desire to provide FOR physical care GRIEVING  Educate family about physical changes during active dying FAMILY  Allow families to express feelings MEETING THE NEEDS OF THE DYING PATIENT  Address physiological needs: hygiene, pain, nutrition, Muids, movement, elimination, respiratory care  Address psychological needs: Fears of the unknown, pain, separation, dying alone, leaving loved ones, loss of dignity, loss of control  Address spiritual needs: Religious vs spiritual care  Clinical experiences? OTHER TYPES OF LOSS  Physiological: amputation, mastectomy, hysterectomy, loss of mobility  Safety loss: DV, gun violence, child abuse  Loss of security: change in relationships such as birth, marriage, divorce, illness  Loss of self esteem: perceived change in value; death of a loved one, broken relationship, loss of job, retirement  Loss related to self actualization: external or internal crisis that blocks or inhibits the ful8llment of personal goals and individual potential PERINATAL LOSS  Perinatal loss: any pregnancy loss and or neonatal death up to one month of age  Profound experience for the family  Unique mourning because the infant is a large part of the parent's identity  Feelings that it can't be real https://www.youtube.com/watch?v=o2BJsFkzSYU WAYS TO HELP  Be genuine  Explain exactly what is suspected/has occurred  Allow the woman and her support system time to come to terms with the loss before reviewing next medical steps  Call her at home  Allow the woman to leave the oAce through a side or back door  Allow the woman to recover on L&D or a medical Moor versus the Postpartum Floor  Stop lullaby from playing after each birth  Assure parents that it is normal to feel uncomfortable at this time Allow parents to spend as much time as they need with their baby Make repeated oNers for holding the baby Name the baby Provide privacy, but do not abandon the parents Encourage relatives and friends to see the baby, according to the NURSING parents’ wishes INTERVENTION Warn about gasping and muscle contractions Reassure parents that their baby was not alone, not afraid and S not in pain at the time of death Reassure parents that nothing more could be done Provide mementos to create memories Ensure that spiritual support is available Take pictures. Most hospitals do. Families may not want them right away Explain the need and procedure for an autopsy Explain options and procedures for memorial services  Symptoms of grieving in men were found to be PERINATA similar to those of women, except that men L LOSS: report less crying and feel less need to talk about MEN VS their loss. Tend to internalize and WOMEN deny their grief, or attempt to distract themselves rather than speaking about their loss. SIBLINGS By the age of two or three, the child can usually begin to grasp Preschoolers will still these essential details of dramatically distort death if provided with causality. “Magical concrete but impersonal thinking” examples, such as a dead insect or small animal. CHILDREN’S DISTURBED REACTIONS TO PERINATAL SIBLING LOSS WERE STRONGLY ASSOCIATED WITH Engaging the child in A failure by parents to destructive patterns of provide accurate and Parental unresolved grief family interaction, clear information about usually leading to some including scapegoating, the loss and to support disruption in parenting. extreme the child’s feelings. overprotectiveness, or using a subsequent child as a replacement for the dead baby POSITIVE HELP FROM THE COMMUNITY Most valued support was emotional Self-help/Support groups (home based and understanding in the forms of being internet based) physically present, empathizing with grief and oNering encouragement. GRIEF FROM PERINATAL LOSS  Intense distress and grief in the 8rst year  15% continue with intense grief after 12 months.  Most studies report grief declining 9 months to 2 years after the loss  Miscarriage: most women had a decrease in grief by 6 weeks after. CHILDRENS’ RESPONSE TO LOSS  CHILDHOOD BEREAVEMENT United Nations International Childrens Emergency Fund (UNICEF), worldwide nearly 140 million kids < aged 18 yrs. experienced death of one or both parents Grief process in young people  Relies on adults'  Developmental process  Age  Not heavily studied  DEVELOPMENTAL RESPONSE TO LOSS Preschool Aged 3-5 yrs.  Egocentric (they focus on themselves)  Magical thinking  Feelings of punishment, responsibility of death  Emotions vary from sadness, anger, anxiety, guilt  Interpret separation as punishment  View dying as temporary because no concept of time  DEVELOPMENTAL RESPONSE TO LOSS School Aged 6-12 yrs.  Start to respond to logical or factual explanations  Begin to have an adult concept of death (inevitable, irreversible common universal) which generally applies to older children 9-12yrs  Experience fear of the disease process, death process, unknown  Fear may manifest as “uncooperative” behavior  Curious: what happens after death  Work it out through play-> encourage this!  DEVELOPMENTAL RESPONSE TO LOSS Adolescent Aged 12-20 yrs.  Have an adult like concept of death  Can have diAculty accepting but accepting death because they are discovering who they are and establishing an identity  Rely more on peers than the inMuence of parents  Can be unable to relate to peers and communicate with parents  Can become increasingly stressed by changes in physical appearance due to medications or illnesses  Can experience guilt and shame  INTERVENTIONS  Be aware of cultural belief of the family  Be mindful not to impose your beliefs on the child or family  Be supportive  Encourage/educate writing, drawing, journalling (age appropriate)  Provide information for age-appropriate coping strategies  Encourage child to express feelings  Assure child about normalcy in feelings (sad, angry, confused)  Answer any questions  Refer to therapist when appropriate ELDERLY RESPONSE TO LOSS ELDERS RESPONSE TO LOSS  Predeath Grief (anticipatory)  Acute Grief  Adaptation  Integrated Grief  Prolonged Grief Disorder DEMENTIA Care giver may experience grief WHO video on how to May go through the 5 stages of grief support caregivers of dementia loved ones, 4:06 mins Caregiver coping strategies: Accept the feelings https://youtu.be/k7x8Zqy Acknowledge feelings 6FAQ?si=Il57KwiR1SXWN c7V Expression of grief is caregiver centered Talk it through Join a support group Take respite time Donald's story, caring Not everyone will understand for someone with Normalize grief dementia, 3:44 mins Share memories https://youtu.be/vybgN qwHEsQ?si=0SG1j10Ye 93PYtQw   Death is expected within a limited time period  Provider tells the patients of the terminal illness but discussion may involve nurse as well as clergy and other health care professionals  important that the patient and family understand likely progression of disease TERMINAL  cultural inMuences may dictate how much information ILLNESS AND desired and which family members are to be informed LOSS  cultural inMuences may dictate how much information is desired and which family members are to be informed  “We will be learning things about your health as a result of the diagnostic testing we are doing. Do you want to receive this information or would you prefer that we give this to a family member or someone else of your choosing?”  Any experiences in clinical or life with this? TERMINAL ILLNESS AND LOSS ENect on patient Competent patients have the right to consent to or refuse medical treatment ENect on family With patient permission, encourage your family and signi8cant others to participate in planning of the patients care Anticipate sibling conMicts Some families may want to make arrangements with the patients depending on which stage of grief they are in MI AND LOSS  To improve the quality of life of patient who is having MI must make lifestyle adjustments To promote healthy living  Avoid activity that produces CP, SOB, fatigue  stop smoking  Manage BP and BG  Take walks  Alternate rest and physical activity  Must manage loss of what they were once able to do versus what they're now able to do TAKOTSUBO’S (BROKEN HEART SYNDROME/ STRESS CARDIOMYOPATHY)  Pathophysiology not entirely understood  Presents after a stressful situation such as a sudden loss of a partner  Manifest like a classic MI: CP, SOB, ST elevation, elevated trops  Left ventricular systolic dysfunction  BUT NO CORONARY ARTERY DISEASE OR ANGIOGRAPHIC EVIDENCE OF ACUTE PLAQUER RUPTURE MI AND LOSS  Factors that increase the likelihood of developing anxiety and depression after MI  History of depression  Low income  Younger age  Isolation STROKE AND LOSS  Factors that may inMuence grief in the setting of stroke  Lack of understanding  Loss of social supports  Loss of roles and changes for patients and caregivers  Management:  Referrals, support group, communication AMPUTATION AND LOSS  Amputation is the removal of a body part by surgical procedure or trauma  Majority of amputations are consequence of vascular disease especially diabetes  AAs are at heightened risk of having amputations AMPUTATION AND LOSS  Individuals who undergo amputation need support as they grieve the loss and change in body image  Anger, bitterness, hostility  psychological issues such as denial, anxiety, avoidance may be inMuenced by the type of support the patient receives from the rehab team, eNectiveness of pain management, how quickly ADL's and the use of prostheses that are learned  Educate on prostheses and capabilities, emphasize walking capacity -> gives patients a sense of control and promotes independence AMPUTATION AND LOSS  Trauma = usually young and healthy  More likely to heal rapidly and be able to physically participate in vigorous rehab programs  Holistic multidisciplinary support in order to accept this sudden change in body image, stress of hospitalization, LT rehab, modi8cation of lifestyle, underlying event https://www.health.mil/News/Gallery/ Dvids-Videos/2023/06/07/video886062  Homeosta sis: Gas Exchange Dr Megan Heimerl NSG 411 Fall 2024 Concept Revisit  Process by which oxygen is transported to cells and carbon dioxide is transported from cells Requires neurologic, respiratory, and Gas cardiovascular systems: Exchange Lungs delivery O2 to pulm capillaries where it is carried by hemoglobin to cells (NSG 316 After cell metabolism, CO2 is carried in hemoglobin to the lungs where is it exhaled Revisit) Important that each one of these systems is functioning optimally -- brain, lungs, cardiovascular -- to optimize gas exchange Terms to Recall Hypoxemia: reduced oxygen of arterial blood Hypoxia: Insu5cient oxygen reaching cells Ischemia: insu5cient 6ow of oxygenated blood to tissues that may result in hypoxemia and cell injury or death Anoxia: Total lack of oxygen in body tissues Acute Respiratory Distress in the Newborn https://www.youtube.com/watch?v=j3ypU lLMRLs 5:12  Is a major cause of morbidity (the leading cause) and mortality in preterm neonates Develops within the @rst 24 hours of life (usually immediately after delivery or within @rst minutes or hours after delivery) If untreated, can produce worsening symptoms over 48 to 72 hours Can begin to resolve after 72 hours, with dramatic improvements and shortened clinical course, with use of Overview antenatal steroids, exogenous surfactant, and continuous positive airway pressure (CPAP) Also known as neonatal respiratory distress syndrome, infant respiratory distress syndrome, and surfactant deciency RDS incidence is inversely related to gestational age, with 98% of neonates born at 24 weeks having the condition; at 34 weeks, the incidence is much less at 5%, and at 37 weeks, only 1%.  In the United States, RDS is among the most common causes of death within the @rst month of life. Approximately 24,000 babies born in the United States each year develop RDS. RDS is most common in neonates of Overview mothers with diabetes, neonates delivered by cesarean birth, and neonates delivered suddenly after antepartum hemorrhage. RDS morbidity is approximately 10 times higher in countries with large areas of poverty  Respiratory System Adaptions Gas exchange transferred from placenta to lungs Aeration of the lungs, establishment of pulmonary gas exchange, changing fetal circulation to adult type -> gas exchange Hypercapnia, hypoxia, acidosis -> stimulate respirations Surfactant: surface tension reducing lipoprotein in NB’s lungs Reduces surface tension at end expiration-> prevents alveolar collapse -> prevents atelectasis-> prevents loss of lung volume Increases surface tension during lung expansion -> facilitates recoil on inspiration Etiology and Pathophys Respiratory disorder primarily caused by de@ciency of pulmonary surfactant in an immature lung-> poor gas exchange and ventilatory failures In neonates born between the 27th and 37th weeks of gestation, inadequate amounts of surfactant can lead to RDS. The result is widespread atelectasis, leading to inadequate alveolar ventilation, hypoventilation, and shunting of blood through collapsed lung areas. Hypoxemia, hypocarbia, and acidosis result. Compensatory grunting occurs, producing positive end-expiratory pressure (PEEP) that helps prevent further alveolar collapse. Causes and Risk Factors Surfactant de@ciency, usually due to preterm birth Preterm deliverity Perinatal asphyxia (meconium staining, cord prolapse, nuchal cord) Maternal diabetes mellitus PROM Maternal use of barbiturates or narcotics close to birth Maternal HTN Cesarean without labor Maternal bleeding during third trimester Hypovolemia Clinical Manifestations Tachypnea (RR >60) Nasal 6aring Expiratory grunting Retractions Labored breathing with prolonged expiration Fine crackles on auscultation Cyanosis Unresponsiveness, 6accidity, apnea with decreased breath sounds (severe)  Labs Imaging ABGs Chest x CBC ray Culture Low lung and volumes Diagnostics Ground sensitivity glass of blood, urine, CSF Blood Glucose Medical Management General: Mechanical ventilation with PEEP, nasal intermittent positive pressure ventilation (NIPPV), noninvasive CPAP, or nasal continuous positive airway pressure (nCPAP) Heated and humidi@ed high-6ow oxygen via nasal cannula for respiratory support For a neonate who can't maintain adequate gas exchange, high-frequency oscillation ventilation Radiant warmer or incubator to maintain a neutral thermal environment Extracorporeal membrane oxygenation (ECMO) (last resort) Pharmacology Lung surfactant (beractant, calfactant, lucinactant) Restores surfactant and improves respiratory compliance for newborns who are premature and have RDS Nursing actions ABGs, RR, skin color before and after administration Suction ET tube Avoid suctioning in ET tube for 1 hr after administration Steroids for mother (betamethasone and dexamethasone)  Nursing Management Suction the NB’s mouth, trachea, and nose as needed Thermoregulation Mouth and skin care Correct respiratory acidosis with ventilatory support Correct metabolic acidosis with sodium bicarbonate Maintain oxygenation Monitor pulse ox Parental nutrition Monitor lab results, I&Os, weight  Nursing Management Collaborate with respiratory therapy with use of CPAP, high-6ow oxygen, PEEP, NIPPV, as applicable and ordered, to reduce the need for mechanical ventilation and surfactant administration and to decrease the risk of BPD. Adjust PEEP or CPAP settings, as applicable, according to ABG results and the practitioner's orders Administer supplemental warm, humidi@ed oxygen, as prescribed, based on oxygen saturation level and ABG results Frequently check hemodynamic parameters and blood pressure, as ordered or according to facility protocol Ensure a patent airway; suction, as necessary, to remove secretions  Implement measures to prevent infection: Provide meticulous skin care. Adhere to standard precautions and good hand hygiene practices. Inspect insertion sites of invasive devices. Nursing Provide care to invasive device access sites, as indicated. Provide oral care every 2 hours or according to facility protocol. Manageme Assist with the insertion of or insert a nasogastric or orogastric tube for tube feedings, as ordered. nt Administer tube feedings, as ordered. Obtain a daily weight on the same scale, at the same time of day, with the same amount of clothing. Cluster nursing activities to minimize energy expenditure and provide frequent uninterrupted rest periods. Encourage the use of energy-conservation measures. Provide a calm environment and promote gentle handling of the neonate. Institute measures to maintain a neutral thermal environment; protect the neonate from sources of heat loss. Nursing Management Encourage the family or caregiver to ask questions and ensure their understanding of the disease process. Actively listen and answer all questions honestly. Provide support to the child and family or caregiver. Consult with a child life specialist to provide age-appropriate distractions and support. Provide emotional support and clear explanations of care measures and treatments. Encourage the family or caregiver to participate in the neonate's care. Model positive parenting behaviors and safe sleep practices. Advise the family or caregiver that recovery can be prolonged, depending on the neonate's status and birth weight. Prepare the family or caregiver for possible tracheostomy or extracorporeal membrane oxygenation, as indicated. Arrange for spiritual care at the parents' or family's request. Refer the family or caregiver to a local support group for families of neonates with prematurity, RDS, or chronic disorders, as appropriate. Collaborate with social services to provide counseling, community resources, and support. https://www.youtube.com/watch? v=tncs4bB7Lbo Cystic Fibrosis (CF) Overview Chronic, progressive, inherited, incurable genetic disease that aects the exocrine (mucus-secreting) glands Transmitted as an autosomal recessive trait Genetic mutation that involves chloride transport across epithelial membranes (more than 1,000 speci@c mutations of the gene have been identi@ed) Overview Characterized by major aberrations in sweat gland, respiratory, and GI functions Accounts for almost all cases of pancreatic enzyme de@ciency in children Produces clinical eLects soon after birth or possibly over several years Typically diagnosed within the @rst 2 years of life but may be diagnosed in adulthood Typically results in death from end-stage lung disease (pneumonia, emphysema, or atelectasis) Reduces lifespan to 28 to 47.7 years  Etiology and Pathophys Autosomal recessive mutation Causes of symptoms: increased viscosity of bronchial, pancreatic, hepatic, intestinal, and other reproductive mucus gland secretions and consequent destruction of glandular ducts Most common fatal genetic disease in white children. A 25% chance of transmission exists with each pregnancy when both parents are carriers of the recessive gene. Clinical Manifestations- Respiratory Stasis of mucous + Thick mucous = blocked air ways and increased risk of respiratory infection Early: Wheezing, ronchi, non productive cough Increased involvement: dyspnea, paroxysmal cough, emphysema and atelectasis on chest x ray Advanced involvement: cyanosis, barrel shaped chest, clubbing, multiple episodes of acute bronchitis or pneumonia Obstructive airway disease: emphysema (hyperin6ation lungs, air trapping) -> HF, pulm HTN, nail blubbing Clinical Manifestations- GI Remember: increased mucous -> blocks ducts (pancreatic and gall) that releases pancreatic enzymes Steatorrhea: Voracious Large, frothy, Distended De@ciency of appetite bulky, greasy, abdomen, thin fat soluble (early), loss of foul smelling arms and legs vitamins appetite (late) stools Weight loss or Prolapse of failure to gain Anemia Re6ux rectum weight, delayed growth Clinical Manifestations- Integumentary Sweat, tears, saliva have excessively high content of sodium and chloride Clinical Manifestations- Endo and Repo Decreased insulin production -> diabetes Delayed puberty Viscous cervical mucus Risk for Decreased or absent sperm Infertility Diagnostics A newborn screening test (NBS) is positive for CF Sweat chloride test Device stimulates sweat production Collect sweat from two diLerent sites Evaluate sweat for high chloride: Conrmed CF if : chloride is >40meq/L in infants < 3mos OR >60meq/L in all others Stool specimen : fat and enzymes PFTs: eval airways Chest xray: atelectasis, emphysema Nursing and Collaborative Management General Based on involved organ systems Chest physiotherapy, nebulization therapy, and breathing exercises several times per day Airway clearance techniques (6utter valve) Noninvasive positive-pressure ventilation (bilevel positive airway pressure) Gene therapy (experimental) Annual in6uenza vaccination Physical therapy for joint maintenance Blood glucose management Spirometry (recommended to start at age 3 years, if developmentally appropriate) Diet Salt supplements High-fat, high-protein, high-calorie diet Vitamin A, D, E, and K supplements Pharmacology Bronchodilators: Nursing considerations- monitor for tremors and tachycardia ICS Antibiotics Pancreatic enzymes: given with all meals and sometimes snacks. Increased dosage with eating high fat foods Vitamins: ADEK Nursing and Collaborative Management Activity Activity as tolerated Routine exercise Educate and Prepare for Surgery Gastrostomy tube placement for supplemental feedings and management of GI tract complications Lung transplantation (bilateral because a diseased lung would act as a source of infected secretions, threatening the transplanted lung) Liver transplantation (for progressive liver failure) Nursing and Collaborative Management Provide emotional support to the child and family related to the chronic, lifelong nature of the condition and frequent exacerbations. Promote a reasonable quality of life for the child and family. Include family members in all phases of the child's care to promote feelings of control over the situation. Educate the child and family regarding the child's health status, reviewing details of the condition and its treatment. Encourage the child and family to verbalize questions, feelings, and concerns. Actively listen, answer questions honestly. Consult with a child life specialist to provide age-appropriate distractions and support. Collaborate with social services to provide counseling, community resources, and support. Consult with care management to ensure that all home-going needs are met prior to discharge. Reinforce the importance of social development and friendships with peers both with and without CF because healthy friendships are associated with increased treatment adherence and quality of life in adolescents. Collaborate with the family and practitioners to develop individualized treatment plans and goals that address barriers to care. Anemia  Abnormally low amount of circulating RBCs, Hgb concentration, or both De@nition Indicator of underlying disease or disorder Results in diminished oxygen carrying capacity and delivery to tissues and organs Etiology and Pathophys 1. Blood loss Hemorrhage PUD Menorrhagia 2. Inadequate RBC production (hypoproliferative) -> bone marrow can’t produce enough RBCs De@ciency of necessary components (folic acid, i