Responses to Alterations/Problems & its Pathophysiologic Basis in Life

Threathening Conditions, Acute Illness, High Acuity & Emergency Nursing

A. Responses to Altered Ventilatory Function

B. Responses to Altered Tissue Perfusion
C. Responses to Metabolic Gastrointestinal & Liver Alterations
D. Responses to Altered Elimination
E. Responses to Altered Perception
F. Multisystem Problems
G. Emergency Nursing

A. Responses to Altered Ventilatory Function

Altered ventilatory function refers to any condition that affects the ability of the
lungs to exchange gases. This presentation will cover the pathophysiology of altered
ventilatory function, common signs and symptoms, ways to mitigate risk factors, and
steps to take action.

Pathophysiology
* Altered ventilatory function can be caused by a variety of conditions, including
obstructive lung diseases, restrictive lung diseases, and neuromuscular disorders.

* Understanding the underlying pathophysiology of these conditions is essential for

effective management.

Obstructive Lung Disease

Obstructive lung diseases such as asthma, chronic obstructive pulmonary disease
(COPD), and bronchiectasis can cause airway obstruction and difficulty breathing.
Treatment may include bronchodilators, corticosteroids, and oxygen therapy.

Restrictive Lung Disease

* Restrictive lung diseases such as interstitial lung disease, sarcoidosis, and
pulmonary fibrosis can cause a decrease in lung volume and difficulty expanding the
lungs.

* Treatment may include corticosteroids, immunosuppressive therapy and oxygen

therapy.

Neuromascular Disorders
* Neuromuscular disorders such as muscular dystrophy and amyotrophic lateral
sclerosis (ALS) can affect the muscles involved in breathing.

* Treatment may include noninvasive ventilation, mechanical ventilation, and airway

clearance techniques
Signs and Symptoms
Common signs and symptoms of altered ventilatory function include shortness of
breath, wheezing, coughing, chest tightness, and fatigue.

It is important to recognize these symptoms and seek medical attention if they

persist or worsen.

Mitigating Risk Factors

Risk factors for altered ventilatory function include smoking, air pollution,
occupational exposure, and genetic predisposition.

Mitigating these risk factors through smoking cessation, environmental controls, and
genetic counseling can help prevent or manage the condition.

Taking Action
If you are experiencing symptoms of altered ventilatory function, it is important to
seek medical attention. Your healthcare provider may recommend lung function
tests, chest x-rays, or CT scans to diagnose the condition.

Treatment options will depend on the underlying cause and severity of the
condition.

Conclusion :
Altered ventilator function can have a significant impact on quality of life, but with
proper management, many people are able to lead full and active lives. By
understanding the pathophysiology, recognizing signs and symptoms, mitigating risk
factors, and taking prompt action, individuals can improve their respiratory health
and overall well-being.

B. Responses to Altered Tissue Perfusion

It is a potential for inadequate circulation of blood causing decreased oxygenation to
tissues resulting in cellular injury and inadequate tissue function.

Pathophysiology
Understanding the causes of inadequate perfusion, assessment, monitoring, and
interventions is imperative for nurses. Ineffective tissue perfusion can be a life-
threatening emergency requiring critical thinking and strict monitoring.

Signs and Symptoms/Complications

•Pallor
•Pain or discomfort
•Diminished or absent pulses.
•Delayed capillary refill
•Cyanosis
•Impaired sensation or numbness
•Weakness or loss of motor function.
Risk Factors
Ineffective peripheral Tissue Perfusion it occurs with insufficient blood flow,
decreased oxygen, or nutrients on a cellular level. There are may be related to
deficient knowledge of disease process, hypertension, smoking, sedentary lifestyle,
possibly evidenced by altered skin characteristics, diminished pulses, claudication,
delayed peripheral wound healing.

Actions
To promote optimal tissue perfusion nursing actions include:

•Monitoring vital signs regularly

•Maintaining proper positioning
•Encouraging physical activity and range of motion exercises
•Managing pain effectively
•Ensuring adequate hydration
•Administering prescribed medications
•Providing wound care, monitoring for complications
•Educating the client on lifestyle modifications, and collaborating with the
healthcare team.

C. Responses to Metabolic Gastrointestinal & Liver Alterations

Assessment
- Assess px’s physical & psychological statuses & interpret lab data
A. Altered Gastrointestinal Function
1. General Nutritional Status Interview
-Should begin with questions regarding client’s dietary habits
2. Health History
-Elicit a description of present illness and chief complaint or symptoms through
COLDSPA

PHYSICAL ASSESSMENT
1. Inspection
-Performed first noting any skin changes, nodules, skin lesions, scarring and/or
discolorations
2. Auscultation
-Determines character, location, frequency of bowel sounds
3. Percussion
- Size, density of the abdominal organs
4. Palpation
- Performed last so that the sounds from palpation aren’t auscultated
DIAGNOSTIC ASSESSMENT
A. Non-Invasive
1. Hepatobiliary Scan
- A non-invasive nuclear medicine study using radioactive materials
2. Upper GIT study/series (Barium Swallow
-To visualize the esophagus, stomach, duodenum, and jejunum
3. Lower GI study/series (Barium enema)
-A fluoroscopic and radiographic examination of large intestine
4. Capillary Blood Glucose Monitoring
-Convenient way of monitoring blood glucose patterns

B. Invasive
1. Esophagogastroduodenoscopy (EGD)
-An upper GI fibroscopy
flexible fiber-optic endoscope inserted into the esophagus, passed through the
stomach and into the duodenum.
2. Percutaneous Transhepatic Cholangiography (PTC)
-A fluoroscopic examination of the intrahepatic and extrahepatic biliary
3. Liver Biopsy
-Sampling liver tissue by needle aspiration for histologic analysis
4. Serum Blood Studies
- Usually begin w/ serum lab studies

NURSING DIAGNOSES
- Acute/Chronic Pain related to Lesions Secondary to Increased Gastric secretions
- Imbalanced Nutrition: Less than Body Requirements related to Anorexia
- Impaired Comfort related to Pruritus
- Excess Fluid Volume related to Portal Hypertension
- Pain related to Liver Enlargement
- High Risk for Ineffective Therapeutic Regimen related to Lack of Knowledge
- Decreased Cardiac Output related to Alterations in Preload
- Deficient Fluid Volume related to Absolute Blood Loss
- Anxiety related to Threat to Biologic, Psychologic and or Social Integrity
- Hyperthermia related to Increased Metabolic Rate

PLANNING
* Administering Volume Replacement
* Controlling bleeding
* Maintaining surveillance for complications
* Administering fluids, insulin, and electrolytes
* Monitor Response to therapy
* Normalize body temperature
* Patient education
IMPLEMENTATION
A. Medical/Surgical Management
-Volume Restoration
1. Nasogastric Suction Tubes
Types:
- Levin
-Salem Pump

2. Esophagogastric Balloon Tamponade Tubes

- Done via placement of Minnesota tube which are multi-lumen gastric tubes, placed
nasally & extended into the stomach.

3. Subtotal Gastrectomy
- a generic term referring to any surgery that involves partial removal of the
stomach, maybe accomplished by either a Billroth I or Billroth II procedure.
4. Liver Transplantation
- Surgery to remove a diseased liver and replace it with a healthy one.
5. Bariatric Surgery
-Gastric bypass and other weight-loss surgeries—known collectively as bariatric
surgery—involves making changes to the digestive system to help lose weight.
Complications
- Rejection
Immune system works to destroy foreign substances that invades the body. The
immune system, however, can’t distinguish between transplanted liver and
unwanted invaders, such as viruses and bacteria.
- Infection
Antirejection drugs that suppress immune system are needed to prevent the liver
from being rejected, it places patient at increased risk for infections.

Pharmacologic Management Complimentary/Alternative Therapy

1. Ginger
2.Bitter Gourd or Bitter Melon (Ampalaya)

VII. CLIENT EDUCATION

VIII. EVALUATION OF OUTCOME OF CARE

D. Responses to Altered Elimination

Elimination refers to the bodily process of expelling waste products from the body by
emptying either the bowels or the bladder. When patients experience an alteration
in bowel or bladder habits, they often feel embarrassment and are reluctant to seek
help.

What is Altered Elimination?

Can occur as a result of a physical abnormality, a sensory impairment, or as a
secondary cause of a disorder or disease.

Causes Symptoms
UTIs Sudden, urgent need to urinate.
Cystitis Frequent urination
Multiple sclerosis Nighttime urination.
Tetraplegia Pain while urinating.
Dementia Difficulty producing urine.
Enlarged prostate Urinary retention
Stroke Bladder swelling
Urologic surgeries Incontinence
Chronic kidney disease
 Complications Treatments
UTIs * Medication
Kidney infection * Catheterization
Bladder damage * Pelvic floor exercises increased fluid
Kidney damage intake
Urinary incontinence * Bladder retraining.

Nursing intervention
* Educate on bladder training
* Encourage water intake
* Limit other fluids
* Educate on supplements
* Educate on proper hygiene
* Educate on medications

E. Responses to Altered Perception

Perception
Being able to both recognize environmental stimuli and actions in response to these
stimuli.

Stimulus
Anything that causes response is stimulus.

Altered Perception
Is a change in the amount of patterning of incoming stimuli, accompanied by a
diminished, exaggerated, distorted, or impaired response to such stimuli.

Sensory Altered Perception

Sensory-perceptual alteration can be defined as when there is a change in the
pattern of sensory stimuli, followed by an abnormal response to such stimuli. Such
perceptions could be increased, decreased, or distorted with the patient's hearing,
vision, touch sensation, smell, or kinesthetic responses to stimuli.

Symptoms
Such changes in the pattern of responses to stimuli lead to changes in a patient’s
behavior, sensory acuity, decision-making process, and problem-solving abilities.

Sensory deprivation in isolated patients can lead to anxiety, depression, aggression,

hallucinations, and psychotic reactions.

Sensory deprivation occurs when an individual receives a stimulus that is reduced or

below the threshold of normal.
Risk Factors
Risk factors to such alterations can be broadly due to acute illnesses, patient factors
related to chronic medical conditions, aging, or due to environmental or iatrogenic
causes.

Hearing impairment, loss of vision, loss of smell or taste, aging, trauma, electrolyte
imbalance, seizure disorder, mental health problems, and genetic causes.

Complications
The main complication is stress and potential harm to the patient due to an unsafe
environment. Alterations not only increase the stress upon the patient, but patients
can be at risk of falls, injuries, and perhaps can be a danger to themselves or to
others due to their violent behaviors.

Treatment & Management

The patient can be supported to be re-oriented to time, place, and person. This can
be done by engaging the patient in a conversation about the current news, weather,
or asking them about their hobbies or experiences. They should be frequently
monitored and settled in a comfortable environment that is devoid of excessive
stimuli (bright lights, noises within the ICU).

To treat or prevent ICU delirium, a multicomponent intervention should be adapted.

This includes both pharmacological and non-pharmacological However, the response
to pharmacological intervention with antipsychotics is variable.

Another review states that the use of pharmacological interventions for the
prevention and management of delirium is associated with poor outcomes.
Henceforth, pharmacological intervention to manage delirium in the ICU is not
recommended interventions.

Non-pharmacological intervention
* The use of earplugs and eye masks
* Noise control strategies and music therapy
* Bright light therapy
* Cognitively stimulating activities
* Medication Review
F. Multisystem Problems
- Multi-system Problem refers to a situation where multiple systems or organs in the
body are affected or compromised. It means that there are issues or dysfunctions
present in more than one system, leading to a complex health condition.

TYPES:
(1) Shock
(2) Systemic Inflammatory Response Syndrome (SIRS)
(3) Multi-Organ Dysfunction Syndrome (MODS)

1 Shock
- It is a critical condition brought on by the sudden drop in blood flow through the
body. Shock may result from trauma, heatstroke, blood loss, an allergic reaction,
severe infection, poisoning, severe burns or other causes. When a person is in shock,
his or her organs aren't getting enough blood or oxygen.

There are five main types of shock include:

(1) Cardiogenic shock (due to heart problems)
(2) Hypovolemic shock (caused by too little blood volume)
(3) Anaphylactic shock (caused by allergic reaction)
(4) Septic shock (due to infections)
(5) Neurogenic shock (caused by damage to the nervous system)

2 Systemic Inflammatory Response Syndrome (SIRS)

It is a systemic inflammatory response to a variety of insults. It is characterized by a
sequence of host phenotypic and metabolic responses to systemic inflammation in
organs remote from the initial insult.

- It is typically triggered by an infection, trauma, burn, or other severe insults to

the body.

Triggers:
- Mechanical tissue trauma: burns, crush injuries, surgical procedures
- Abscess formation: intraabdominal, extremities
- Ischemic or necrotic tissue: pancreatitis, vascular disease, myocardial infarction
- Microbial invasion: bacteria, viruses, fungi
- Endotoxin release: gram-negative bacteria
- Global perfusion deficits: post-cardiac resuscitation, shock states

Management
underlying cause needs to be identified and treated. This may involve antibiotics for
infections, fluids and medications to stabilize blood pressure, and supportive care for
organ dysfunction.
3 Multi-Organ Dysfunction Syndrome (MODS)
- It is a complex and life-threatening condition that occurs when multiple organ
systems in the body fail to function properly. It is often a result of severe illness or
injury, such as sepsis, trauma, or major surgery.

Clinical Manifestations of MODS can vary depending on the organs affected, but
common signs and symptoms include:
(1) Respiratory dysfunction: Difficulty breathing, rapid breathing, low oxygen levels,
and respiratory distress.
(2) Cardiovascular dysfunction: Low blood pressure, rapid or irregular heartbeat,
decreased urine output, cool and clammy skin, and signs of shock.
(3) Renal dysfunction: Decreased urine output, abnormal levels of electrolytes in the
blood, and fluid retention.
(4) Hepatic dysfunction: Jaundice (yellowing of the skin and eyes), abnormal liver
function tests, and clotting abnormalities.
(5) Gastrointestinal dysfunction: Abdominal pain, nausea, vomiting, diarrhea, and
gastrointestinal bleeding.
(6) Neurological dysfunction: Altered mental status, confusion, seizures, and coma.
(7) Hematological dysfunction: Anemia, abnormal bleeding or clotting, and
decreased platelet count.

* Sequential Organ Failure Assessment (SOFA)

To assess MODS and it's effect on the patient, the healthcare providers often use the
Sequential Organ Failure Assessment (SOFA) score. This scoring system evaluates the
function of six organ systems (respiratory, cardiovascular, renal, hepatic,
coagulation, and neurological) and assigns a score based on the severity of
dysfunction.
- A higher SOFA score indicates a more severe condition and a higher risk of
mortality.

Diagnostic Studies
- Blood tests to assess organ function
- Imaging studies (such as X-rays or CT scans) to evaluate organ damage
- Specific tests to identify the underlying cause of MODS

Drug Therapy
Medications to support organ function such as:
- Vasopressors to maintain blood pressure
- Antibiotics to treat or prevent infection
- Diuretics to manage fluid balance.
Nursing Management
- Focuses on close monitoring of the patient's vital signs.
- Identifying and treating the underlying causes, comorbidities, or complication.
- Fluid resuscitation to increase perfusion.
- Provide education and support to the patient and their family throughout the
treatment process.

Conclusion
MODS is a complex and challenging condition, but with prompt and effective
management, the prognosis can improve. It requires a collaborative effort from the
healthcare team and ongoing support from nursing professionals to provide
comprehensive care to patients with MODS.

G. Emergency Nursing
-A specialty in which nurse's care for patients in the emergency or critical phase of
their illness or injury and frequently is the first point of contact for patients.
The philosophy of emergency management has broadened to include the concept
that an emergency is whatever the patient or the family considers it to be.

Triage
The word triage comes from the French word trier, meaning “to sort.” In the daily
routine of the ED, triage is used to sort patients into groups based on the severity of
their health problems and the immediacy with which these problems must be
treated.
Five-Level Emergency Severity Index
* Provides a reliable, valid tool for determination of acuity.
* It determines the parameters for rapid identification of those who need immediate
care.

Primary Survey
An assessment of the patient triaged to the emergent or resuscitation category that
focuses on stabilizing life-threatening conditions; uses the mnemonic ABCDE, which
stands for;
A-airway
B-breathing
C-circulation
D-disability
E-exposure

Secondary Survey
An assessment of the patient triaged to the emergent or resuscitation category that
commences after the primary survey is completed and life-threatening insults
addressed.
Includes the following:
Complete health history
Head-to-toe assessment
Diagnostic and laboratory testing
Insertion or application of monitoring devices such as ECG

History
A structured assessment conducted to generate a comprehensive picture of a
patient's health and health problems.

This includes;
Patient's medical history
Past surgical history
Family medical history
Social history
Allergies
Medications the patient is taking or may have recently stopped taking

Common Medical Emergencies

Foreign Body Obstruction
Airway obstruction, also known as foreign body airway obstruction, happens when a
small item gets stuck in a person’s throat or upper airway and makes it hard for a
person to breathe.
Symptoms
• choking or gagging
• sudden violent coughing
• vomiting
• noisy breathing or wheezing
• struggling to breathe
• turning blue
Treatment
1.The person may cough the item up.
2.An emergency medical responder or other health care provider may be able to
dislodge the item with thrusts to the child's back, chest, or abdomen.
3. Surgery may be necessary to remove an item that has gotten stuck or is causing
internal damage to the person’s airways or stomach.
4. Parents should seek emergency medical care for their child right away if their child
is struggling to breathe, turns blue, or has swallowed a magnet or battery.
Heat Stroke
A response to heat characterized by extremely high temperature and disturbance of
sweating mechanism.

Signs and Symptoms

Raised body temperature.
Extreme confusion.
Weakness
Seizures
Unconsciousness
Rapid, shallow breathing.

Management
Cool the victim.
Keep the victim cool as you await for medical help.

Poisoning
* Ways in Which Poisoning May Occur
Ingestion
Inhalation
Injection
Absorption

* Common Household Poison

Sleeping pills
Pain relievers
Insect poisons
Kerosene

* Ingested poison is one that is introduced into the digestive tract by way of the
mouth.
Signs and Symptoms
Altered mental status.
Burns around the mouth.
Nausea and vomiting
Abdominal pain.
Diarrhea
Management :
Try to identify poison.
Place the victim on his or her left side.
Monitor ABCs.
Check for allergic reaction
* Inhaled poison is a poison breathed into the lungs.
Signs and Symptoms
Breathing difficulty.
Chest pain.
Cough, hoarseness, burning sensation
Cyanosis
Dizziness, headache.
Seizures
Management :
Remove the victim from the toxic envi.immediately.
Monitor ABCs.
Seek medical attention.

Absorbed poison is a poison that enters the body through the skin.
Signs and Symptoms
Burns
Itching
Irritation
Redness, rash, blisters
Management :
Remove the clothing.
Use dry cloth to blot the poison from the skin.
Flood the area with generous amount of water.
Continually monitor the patient’s vital sign.

Injected poison is a poison that enters the body through a bite, sting, or syringe.
Insect bites
Signs and Symptoms Spider bites
Stinger may be present. Signs and Symptoms
Pain Bite mark.
Swelling Swelling
Possible allergic reactions. Pain
Nausea and vomiting.
Management :
Difficulty breathing or swallowing
Remove stinger.
Wash wound. Management
Cover the wound Wash wound.
Apply a cold pack. Appy a cold pack.
Watch for signals for allergic reaction. Get medical care.
Call emergency

Conclusion
(AID)
A- sk for help.
I- ntervene
D- on't allow further harm to the patient.
Clinical Death is when your heart stops pumping blood. Without CPR,
Biological Death begins to set in about 4-6 minutes later. Biological Death is where
the victim's brain is damaged and cells in the victim's heart, brain and other organs
die from a lack of oxygen. The damage caused by Biological Death is irreversible.