HNN325 - EXAM PREP WEEK 1-6 QUESTIONS AND
ANSWERS WITH COMPLETE SOLUTION.
Nursing Problems & Pathophysiology for Increased Intracranial Pressure
Answer - 1. Ineffective airway clearance:
- Related to increased ICP, leading to decreased LOC, leading to decreased
cough reflux, leading to decreased effective secretion clearance and increased
risk of aspiration.
2. Decreased Cerebral Perfusion:
- Related to an increase in ICP, because of increased CSF absorption in the
spinal cord and compression of the venous system, leading to vasoconstriction,
leading to decreased oxygenation, leading to alterations in the cerebral tissue
volume.
3. Impaired Gas Exchange:
- Related to increased ICP, leading to cerebral oedema, which leads to a
decreased level of consciousness and decreased chest wall stability, abnormal
respiratory patterns and loss of protective airway refluxes, which leads to
decreased cough reflux, which restricts airway and secretion clearances,
leading to alveoli collapse and the decreased exchange of CO2 at the alveoli
level, leading to hypoxia.
4. Risk of infection:
- Related to increased ICP, leading to decreased level of consciousness and
decreased cough reflux, which restricts airway and secretion clearance, leading
to alveoli collapse. This leading to the pooling of secretions and an increased
risk of infection, leading to pneumonia.
,Respiratory Distress Signs & Symptoms Answer - - SOB: rapid, shallow breaths
(tachypnea)
-use of accessory muscles
-tripod position
-restlessness
-attempting to sit up or forward pale, diaphoretic, pursed lips
-tachycardia
-low Sp02 (<95%) or blood gases (high co2, low o2)
Pathophysiology of Pneumothorax Answer - - accumulation of air in the pleural
space due to thoracic trauma.
- pressure in pleural space is NEGATIVE
- atmospheric pressure is POSITIVE
- when a pneumothorax occurs atmospheric air enters the pleural space
- causes intrathoracic pressure to increase, decreasing available lung volume.
What are the three different types of "pneumothorax" Answer - 1.
Spontaneous
2. Traumatic
3. Tension (most life-threatening)
Tension Pneumothorax Answer - - injury to the chest wall or lung - which
allows air to enter the pleural space but prevents it from escaping, therefore,
increasing intrathoracic pressure.
- ventilation is impaired
,Traumatic Pneumothorax Answer - Caused by a blunt or penetrating injury to
the chest wall that disrupts the pleural membrane:
there are two types:
1. Open Pneumothorax
- occurs with penetrating chest trauma.
- allows air from the environment into the pleural space (i.e. gunshot wound).
2. Closed Pneumothorax
- occurs with blunt chest trauma
- allows air from the lung to leak into the pleural space (i.e. motor vehicle
accident, fall).
Spontaneous Pneumothorax Answer - - caused by a spontaneous rupture of a
bleb (air sac) on the lung surface, allowing air to enter the pleural space from
the airway.
- air accumulates in the pleural space until pressure is equalised or the lung
collapses and seals the surface.
Signs and Symptoms of Pneumothorax Answer - - chest pain on inhalation,
sharp/stabbing pain, moderate-severe pain.
- Tachycardia
- Shallow breathing
- Tachypnea
- Restlessness
Signs and Symptoms Tension Pneumothorax Answer - - deviated trachea
- absent breath sounds
- hyper expansion of the chest
- distended neck veins
, Pathophysiology of Haemothroax Answer - - blood in the pleural space
- due to thoracic trauma
- as blood builds in the pleural space it interferes with normal lung movement
- Resulting in SOB, poor ventilation + hypoxia
- impairs gas exchange & ventilation
Flail Chest Answer - -when a segment of the rib cage breaks due to trauma and
becomes detached from the rest of the chest wall
-occurs with multiple adjacent ribs are broken in multiple places, separating
wall moves independently
-physiological function of the chest wall is impaired as the flail segment is
sucked inwards during inhalation and moves outwards during exhalation. This
is called 'paradox movement'
-flail chest can affect the normal impairs gas exchange
-lung expansion is impaired, leading to increased WOB.
Pulmonary Contusion Answer - -or lung contusion is a bruise of the lung,
caused by blunt thoracic trauma
-often results from abrupt chest compression, followed by sudden
decompression (i.e. significant fall or crushing injury)
-damage to capillaries leads to blood and other fluids accumulating in the lung
tissue
-this excess fluid impairs gas exchange, leading to inadequate oxygen levels
(hypoxia)
Cardiac Tamponade Answer - -is the compression of the heart by the
accumulation of fluid in the pericardial sac
-cardiac tamponade is a type of pus, blood clot , or gas
ANSWERS WITH COMPLETE SOLUTION.
Nursing Problems & Pathophysiology for Increased Intracranial Pressure
Answer - 1. Ineffective airway clearance:
- Related to increased ICP, leading to decreased LOC, leading to decreased
cough reflux, leading to decreased effective secretion clearance and increased
risk of aspiration.
2. Decreased Cerebral Perfusion:
- Related to an increase in ICP, because of increased CSF absorption in the
spinal cord and compression of the venous system, leading to vasoconstriction,
leading to decreased oxygenation, leading to alterations in the cerebral tissue
volume.
3. Impaired Gas Exchange:
- Related to increased ICP, leading to cerebral oedema, which leads to a
decreased level of consciousness and decreased chest wall stability, abnormal
respiratory patterns and loss of protective airway refluxes, which leads to
decreased cough reflux, which restricts airway and secretion clearances,
leading to alveoli collapse and the decreased exchange of CO2 at the alveoli
level, leading to hypoxia.
4. Risk of infection:
- Related to increased ICP, leading to decreased level of consciousness and
decreased cough reflux, which restricts airway and secretion clearance, leading
to alveoli collapse. This leading to the pooling of secretions and an increased
risk of infection, leading to pneumonia.
,Respiratory Distress Signs & Symptoms Answer - - SOB: rapid, shallow breaths
(tachypnea)
-use of accessory muscles
-tripod position
-restlessness
-attempting to sit up or forward pale, diaphoretic, pursed lips
-tachycardia
-low Sp02 (<95%) or blood gases (high co2, low o2)
Pathophysiology of Pneumothorax Answer - - accumulation of air in the pleural
space due to thoracic trauma.
- pressure in pleural space is NEGATIVE
- atmospheric pressure is POSITIVE
- when a pneumothorax occurs atmospheric air enters the pleural space
- causes intrathoracic pressure to increase, decreasing available lung volume.
What are the three different types of "pneumothorax" Answer - 1.
Spontaneous
2. Traumatic
3. Tension (most life-threatening)
Tension Pneumothorax Answer - - injury to the chest wall or lung - which
allows air to enter the pleural space but prevents it from escaping, therefore,
increasing intrathoracic pressure.
- ventilation is impaired
,Traumatic Pneumothorax Answer - Caused by a blunt or penetrating injury to
the chest wall that disrupts the pleural membrane:
there are two types:
1. Open Pneumothorax
- occurs with penetrating chest trauma.
- allows air from the environment into the pleural space (i.e. gunshot wound).
2. Closed Pneumothorax
- occurs with blunt chest trauma
- allows air from the lung to leak into the pleural space (i.e. motor vehicle
accident, fall).
Spontaneous Pneumothorax Answer - - caused by a spontaneous rupture of a
bleb (air sac) on the lung surface, allowing air to enter the pleural space from
the airway.
- air accumulates in the pleural space until pressure is equalised or the lung
collapses and seals the surface.
Signs and Symptoms of Pneumothorax Answer - - chest pain on inhalation,
sharp/stabbing pain, moderate-severe pain.
- Tachycardia
- Shallow breathing
- Tachypnea
- Restlessness
Signs and Symptoms Tension Pneumothorax Answer - - deviated trachea
- absent breath sounds
- hyper expansion of the chest
- distended neck veins
, Pathophysiology of Haemothroax Answer - - blood in the pleural space
- due to thoracic trauma
- as blood builds in the pleural space it interferes with normal lung movement
- Resulting in SOB, poor ventilation + hypoxia
- impairs gas exchange & ventilation
Flail Chest Answer - -when a segment of the rib cage breaks due to trauma and
becomes detached from the rest of the chest wall
-occurs with multiple adjacent ribs are broken in multiple places, separating
wall moves independently
-physiological function of the chest wall is impaired as the flail segment is
sucked inwards during inhalation and moves outwards during exhalation. This
is called 'paradox movement'
-flail chest can affect the normal impairs gas exchange
-lung expansion is impaired, leading to increased WOB.
Pulmonary Contusion Answer - -or lung contusion is a bruise of the lung,
caused by blunt thoracic trauma
-often results from abrupt chest compression, followed by sudden
decompression (i.e. significant fall or crushing injury)
-damage to capillaries leads to blood and other fluids accumulating in the lung
tissue
-this excess fluid impairs gas exchange, leading to inadequate oxygen levels
(hypoxia)
Cardiac Tamponade Answer - -is the compression of the heart by the
accumulation of fluid in the pericardial sac
-cardiac tamponade is a type of pus, blood clot , or gas
