A nurse is caring for a patient with a traumatic brain injury who exhibits signs of increased intracranial pressure and hypovolemic shock. What is the nurse's priority intervention?

C) Prepare for intubation to secure the airway.

A) Administer mannitol to reduce intracranial pressure.

B) Initiate fluid resuscitation with isotonic crystalloids.

C) Prepare for intubation to secure the airway.

D) Administer supplemental oxygen to improve SpO2 levels.

A patient is admitted with a Glasgow Coma Scale (GCS) score of 9, signs of increased intracranial pressure, and respiratory distress despite supplemental oxygen. The patient also shows signs of hypovolemic shock due to a pelvic fracture. Which intervention should the nurse prioritize to stabilize the patient's condition?

C) Prepare for endotracheal intubation to secure the airway

A) Administer intravenous mannitol to decrease intracranial pressure

B) Initiate continuous positive airway pressure (CPAP) to improve oxygenation

C) Prepare for endotracheal intubation to secure the airway

D) Start dopamine infusion to support blood pressure

A patient with a pelvic fracture and signs of increasing cerebral edema post-trauma is intubated and receiving fluid resuscitation. Despite initial stabilization, her Glasgow Coma Scale (GCS) remains at 9. What is the most critical nursing action to prioritize in this situation?

B) Prepare for the administration of hypertonic saline to address cerebral edema.

A) Monitor the patient's urine output every hour to assess renal function.

B) Prepare for the administration of hypertonic saline to address cerebral edema.

C) Reassess the patient's blood pressure and heart rate every 15 minutes.

D) Initiate passive range of motion exercises to prevent muscle atrophy.

A patient with a pelvic fracture is experiencing hypovolemic shock post-trauma. Despite fluid resuscitation and blood transfusions, the lactate level remains elevated at 3.8 mmol/L. Which of the following interventions should the nurse prioritize to address the persistent tissue hypoperfusion?

B) Administer vasopressors to maintain adequate mean arterial pressure.

A) Continue aggressive fluid resuscitation and monitor vital signs closely.

B) Administer vasopressors to maintain adequate mean arterial pressure.

C) Increase the frequency of blood transfusions to improve oxygen delivery.

D) Initiate mechanical ventilation with higher tidal volumes to enhance oxygenation.

A patient with a worsening right lung contusion is experiencing increased respiratory distress and has been placed on mechanical ventilation with high PEEP and prone positioning. Despite these interventions, the patient's oxygenation remains inadequate, and she exhibits signs of hemodynamic instability. Which nursing intervention is most appropriate to optimize respiratory function while maintaining hemodynamic stability?

B) Collaborate with the team to consider ECMO as a potential intervention.

A) Increase fluid administration to improve hemodynamic stability.

B) Collaborate with the team to consider ECMO as a potential intervention.

C) Adjust the ventilator settings to increase the FiO2 to 100%.

D) Administer diuretics to manage pulmonary edema aggressively.

A patient with worsening right lung contusion and signs of ARDS on mechanical ventilation is being managed with increased PEEP and prone positioning. Despite these interventions, the patient's blood pressure is 100/60 mmHg, heart rate is 115 bpm, and elevated lactate levels persist. What should the nurse prioritize in this situation?

D) Collaborate with the team to evaluate the patient's fluid status and adjust diuretics if necessary.

A) Increase the FiO2 to 100% to improve oxygenation.

B) Administer a fluid bolus to address potential hypovolemia.

C) Prepare for potential ECMO initiation as the next step.

D) Collaborate with the team to evaluate the patient's fluid status and adjust diuretics if necessary.

A patient in the ICU is exhibiting signs of worsening respiratory status and neurological decline. Despite interventions, her oxygen saturation remains low, and her GCS score has decreased. The healthcare team has ordered a CT scan revealing increased cerebral edema. Which nursing intervention is most critical at this time to prevent further deterioration?

D) Elevate the head of the bed to 30 degrees to decrease intracranial pressure.

A) Increase the rate of IV fluids to improve cerebral perfusion.

B) Prepare the patient for urgent intubation to secure the airway.

C) Administer a sedative to reduce metabolic demand and calm the patient.

D) Elevate the head of the bed to 30 degrees to decrease intracranial pressure.

A patient with worsening respiratory function and decreasing Glasgow Coma Scale (GCS) score is being managed in the ICU. Despite adjustments to ventilator settings and prone positioning, the patient's oxygen saturation remains low. The team has initiated low-dose vasopressor support to stabilize hemodynamics. What is the most appropriate nursing intervention to prioritize at this time?

C) Monitor for signs of increased intracranial pressure and report changes immediately.

A) Increase the rate of IV fluid administration to improve blood pressure.

B) Prepare the patient for immediate intubation to secure the airway.

C) Monitor for signs of increased intracranial pressure and report changes immediately.

D) Encourage deep breathing exercises to improve lung function.

A patient with acute kidney injury (AKI) is being carefully monitored for fluid status and medication management. The patient's urine output has decreased, and serum creatinine levels have increased. Which nursing intervention is most appropriate to support renal function while minimizing the risk of pulmonary edema?

C) Increase fluid intake cautiously while monitoring respiratory status

A) Restrict fluid intake to prevent fluid overload

B) Administer loop diuretics to increase urine output

C) Increase fluid intake cautiously while monitoring respiratory status

D) Hold all nephrotoxic medications and reassess renal function in 24 hours

A patient with acute kidney injury (AKI) secondary to possible nephrotoxic medication and systemic inflammatory response syndrome (SIRS) is being monitored. Her urine output has decreased, and serum creatinine has significantly increased. Which intervention should the nurse prioritize to promote renal perfusion while minimizing fluid overload risk?

C) Implement strict intake and output monitoring

A) Administer a diuretic to increase urine output

B) Increase intravenous fluid rate to improve renal perfusion

C) Implement strict intake and output monitoring

D) Start renal replacement therapy immediately

Her injuries are: • Pelvic fracture • Severe brain injury with skull fracture left parietal region and 8 cm scalp laceration • Right lung contusion • Right ribs 3-6 fracture - Nursing Case Study

Pathophysiology

• Primary mechanism: Pelvic fracture - Results from high-impact trauma, disrupting the pelvic ring, leading to potential vascular injury and hemorrhage, which can cause hemodynamic instability and hypovolemic shock.

• Secondary mechanism: Severe brain injury with skull fracture - The skull fracture in the left parietal region may cause direct brain tissue damage, leading to intracranial hemorrhage, increased intracranial pressure, and resultant cerebral edema, impairing neurological function.

• Key complication: Right lung contusion - Blunt chest trauma causes alveolar hemorrhage and interstitial edema, impairing gas exchange, potentially leading to respiratory distress or failure. Fractures of ribs 3-6 exacerbate this by limiting chest wall movement, causing pain and further compromising ventilation.

Patient Profile

Demographics:

32-year-old female, construction worker

History:

• Key past medical history: Mild asthma, previous right ankle fracture

• Current medications: Albuterol inhaler as needed, daily multivitamin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe headache and difficulty breathing

• Key symptoms: Confusion, severe pain in the pelvic area, shortness of breath, dizziness, and nausea

• Vital signs: Blood pressure 145/90 mmHg, heart rate 110 bpm, respiratory rate 24 breaths per minute, temperature 37.5°C (99.5°F), SpO2 88% on room air

Section 1

Following the initial assessment, the patient's condition presents a concerning change. Her confusion has intensified, and she now exhibits signs of decreased responsiveness with a Glasgow Coma Scale (GCS) score dropping to 9, indicating moderate brain injury. This deterioration suggests increasing intracranial pressure (ICP) secondary to cerebral edema or an expanding intracranial hemorrhage. There are unequal pupils with the left pupil sluggish to react, pointing towards potential herniation. Her vital signs remain unstable, with a blood pressure of 150/95 mmHg, a heart rate of 115 bpm, and respiratory rate elevated at 28 breaths per minute. Despite supplemental oxygen, her SpO2 remains at 90%, indicating persistent respiratory distress, likely exacerbated by the right lung contusion and rib fractures.

Laboratory results reveal a hematocrit level of 28%, suggesting significant blood loss, likely from the pelvic fracture, which could lead to worsening hemodynamic instability. The patient is now tachycardic and hypotensive, with signs of hypovolemic shock becoming apparent as her blood pressure trends downward. Arterial blood gases show a pH of 7.30, PaCO2 of 48 mmHg, and PaO2 of 60 mmHg, indicating respiratory acidosis and hypoxemia, necessitating immediate intervention to improve ventilation and oxygenation. Her lactate level is elevated at 4 mmol/L, reflecting tissue hypoperfusion and possible anaerobic metabolism, raising concerns over potential organ dysfunction if not promptly corrected.

Given these findings, the clinical team must prioritize aggressive management to stabilize the patient's condition. This includes considering advanced airway management to secure adequate ventilation and prevent further neurological compromise, alongside fluid resuscitation and blood transfusion to address the hypovolemia. Continuous monitoring of neurological status and serial imaging may be necessary to guide further interventions. The interplay of these complications calls for coordinated efforts from a multidisciplinary team to address the complex interplay of traumatic injuries and evolving complications, setting the stage for critical decision-making in her ongoing care.

Section 2

The clinical team, acknowledging the critical nature of the patient's condition, swiftly initiates advanced airway management by intubating the patient to secure her airway and ensure adequate ventilation. This intervention aims to correct the respiratory acidosis and improve her oxygenation status, evidenced by an initial improvement in her SpO2, which rises to 94% post-intubation. The respiratory therapist adjusts the ventilator settings to optimize the patient's tidal volume and respiratory rate, aiding in the reduction of PaCO2 and addressing the hypoxemia. However, despite these measures, her GCS remains at 9, underscoring the ongoing risk of neurological deterioration.

Simultaneously, the team initiates aggressive fluid resuscitation, administering crystalloid fluids followed by blood transfusions to counteract the hypovolemic shock caused by the pelvic fracture. This intervention results in a slight improvement in her blood pressure, now at 110/70 mmHg, and a decrease in her heart rate to 105 bpm, indicating a positive response to fluid and blood volume restoration. Despite these efforts, the patient's lactate level remains elevated at 3.8 mmol/L, suggesting persistent tissue hypoperfusion and the need for continued hemodynamic support.

While these interventions provide some initial stabilization, the patient's neurological status remains a pressing concern. The neurosurgical team is consulted for an urgent CT scan of the head, which reveals signs of increasing cerebral edema but no significant expansion of intracranial hemorrhage. The team considers the administration of hypertonic saline or mannitol to reduce intracranial pressure while planning for possible surgical intervention should her condition worsen. The integration of multidisciplinary efforts is crucial at this juncture, as the patient's complex interplay of traumatic injuries necessitates vigilant monitoring and timely decision-making to prevent further complications and guide her recovery trajectory.

Section 3

As the clinical team continues to monitor the patient, a new complication emerges: the patient's right lung contusion begins to manifest more prominently, contributing to increasing respiratory distress despite the ongoing mechanical ventilation. Over the next few hours, the patient's oxygen saturation begins to decline again, dropping to 88%, and her PaO2 levels decrease to 60 mmHg on an FiO2 of 60%. Auscultation of the chest reveals diminished breath sounds on the right side, and the repeat chest X-ray shows evidence of worsening pulmonary contusion with patchy consolidations, suggesting an evolving pulmonary edema and possible early signs of acute respiratory distress syndrome (ARDS).

In response to these changes, the respiratory therapist, in collaboration with the critical care team, adjusts the ventilator settings to include a higher positive end-expiratory pressure (PEEP) to improve alveolar recruitment and oxygenation. Additionally, the team initiates a trial of prone positioning to enhance ventilation-perfusion matching in the affected lung. Concurrently, the patient's fluid status is carefully reassessed, leading to the decision to cautiously manage fluids to prevent further exacerbation of pulmonary edema while ensuring adequate perfusion to vital organs.

Despite these interventions, the patient’s hemodynamic stability remains tenuous, with her blood pressure fluctuating, now at 100/60 mmHg, and heart rate increasing slightly to 115 bpm. The elevated lactate level persists, indicating ongoing tissue hypoxia. The team is now faced with balancing the delicate needs of her respiratory and circulatory systems while closely monitoring for any signs of neurological deterioration. This situation requires the continuous integration of clinical data and a multidisciplinary approach to optimize the patient's complex and dynamic condition, setting the stage for potential further interventions such as extracorporeal membrane oxygenation (ECMO) if conventional measures fail to stabilize her respiratory status.

Section 4

As the clinical team continues to monitor the patient closely, a new complication emerges. Despite the adjustments in ventilator settings and the implementation of prone positioning, the patient's respiratory status does not exhibit the desired improvement. Her oxygen saturation continues to hover around 88%, and her PaO2 remains low at 58 mmHg. A follow-up chest X-ray reveals increasing consolidation in the right lung, and there is new evidence of a small right-sided pleural effusion. These findings suggest that the pulmonary edema is worsening, and there is a growing concern about the potential progression to full-blown acute respiratory distress syndrome (ARDS).

Simultaneously, the patient's neurological status is becoming more concerning. Her Glasgow Coma Scale (GCS) score has decreased from 9 to 7, indicating further deterioration in her level of consciousness. This decline prompts the team to order an urgent CT scan of the brain to evaluate for any new or expanding intracranial pathology. The CT scan reveals an increase in cerebral edema around the site of the initial brain injury, raising concerns about potential herniation. The neurosurgery team is urgently consulted to assess the need for possible surgical intervention or other measures to alleviate intracranial pressure.

The patient's hemodynamic status continues to be unstable, with blood pressure readings fluctuating between 95/55 mmHg and 105/65 mmHg, while her heart rate remains elevated at 120 bpm. Laboratory results show a persistent elevation in lactate levels at 4 mmol/L, indicating ongoing tissue hypoxia. The team recognizes the need to stabilize her hemodynamics to prevent further neurological compromise. The decision is made to initiate low-dose vasopressor support while cautiously adjusting fluid management to maintain adequate cerebral perfusion without exacerbating pulmonary complications. These developments highlight the complexity of the patient's condition, requiring continuous reevaluation and adaptation of the treatment plan.

Section 5

As the clinical team continues to manage the patient's complex condition, a new complication arises that further challenges their efforts. Upon reassessment, the patient's renal function appears to be deteriorating. Her urine output has significantly decreased to less than 20 mL/hour over the past six hours, and her serum creatinine levels have increased from 1.2 mg/dL to 2.5 mg/dL, indicating acute kidney injury (AKI). This development raises concerns about the impact of both the injury and the treatment interventions on her renal system, necessitating a careful review of her fluid and medication management.

The team initiates a nephrology consult to evaluate the underlying causes of the AKI and to determine the most appropriate interventions. Potential contributors such as nephrotoxic medications, hypoperfusion due to hemodynamic instability, and the impact of systemic inflammatory response syndrome (SIRS) are considered. The nephrologist recommends adjusting the patient's medication regimen to avoid further nephrotoxicity and suggests increasing her fluid intake cautiously to promote renal perfusion while remaining vigilant about the risk of worsening pulmonary edema.

These renal complications further complicate the patient's clinical picture, highlighting the intricate balance required in her care. The team must now carefully weigh the need for maintaining adequate renal perfusion against the risks of exacerbating her respiratory distress and intracranial pressure. This ongoing challenge underscores the importance of dynamic clinical reasoning in adapting her treatment plan to address the interplay of multiple organ systems, setting the stage for subsequent adjustments in her management strategy.