HNN325 - Exam Prep week 1-6 Questions with Verified Solutions Graded A+
Nursing Problems & Pathophysiology for Increased Intracranial Pressure - Answers 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 - Answers - 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 - Answers - 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" - Answers 1. Spontaneous
2. Traumatic
3. Tension (most life-threatening)
Tension Pneumothorax - Answers - 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 - Answers 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 - Answers - 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 - Answers - chest pain on inhalation, sharp/stabbing
pain, moderate-severe pain.
- Tachycardia
,- Shallow breathing
- Tachypnea
- Restlessness
Signs and Symptoms Tension Pneumothorax - Answers - deviated trachea
- absent breath sounds
- hyper expansion of the chest
- distended neck veins
Pathophysiology of Haemothroax - Answers - 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 - Answers -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 - Answers -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 - Answers -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
-this leads to a slow or rapid compression of the heart
-the pressure or compression on the muscles occurs when the pericardial sac fills up with fluid
faster than it can stretch
Signs and Symptoms of Haemothroax - Answers -potential for hemorrhage
-on auscultation: diminished lung sounds
- when percussing: there will be a dull percussion tone over the blood
- Blood typically pools at the base of the lungs
- Assess for the signs and symptoms of bleeding (SOB, pain, clammy, pale), and the potential
for the development of hypovolemic shock.
Blunt Trauma - Answers -includes a large impact, but the skin is not broken, and is not always
visible from the skin.
examples; pulmonary contusion, pneumothorax, fractured ribs.
Penetrating trauma - Answers -an injury that occurs when an object pierces the skin and enters
the tissue
-creates an open wound
-examples - gunshot wound, knife wound.
Nursing Assessment & Management of a patient with Pneumothorax - Answers -nurses' main
focus should be maintaining adequate ventilation and oxygenation.
-a person with pneumothorax may be in acute respiratory distress, necessitating a rapid and
focused assessment.
- Health history: current symptoms and their duration, precipitating factors or activities if known
previous episodes of pneumothorax, smoking history, chronic pulmonary diseases such as
COPD.
Physical Assessment: (look, listen, fell
-general appearance and degree of apparent respiratory distress
- evidence of chest trauma
- vital signs (oxygen saturations)
Nursing Problems & Pathophysiology for Increased Intracranial Pressure - Answers 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 - Answers - 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 - Answers - 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" - Answers 1. Spontaneous
2. Traumatic
3. Tension (most life-threatening)
Tension Pneumothorax - Answers - 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 - Answers 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 - Answers - 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 - Answers - chest pain on inhalation, sharp/stabbing
pain, moderate-severe pain.
- Tachycardia
,- Shallow breathing
- Tachypnea
- Restlessness
Signs and Symptoms Tension Pneumothorax - Answers - deviated trachea
- absent breath sounds
- hyper expansion of the chest
- distended neck veins
Pathophysiology of Haemothroax - Answers - 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 - Answers -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 - Answers -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 - Answers -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
-this leads to a slow or rapid compression of the heart
-the pressure or compression on the muscles occurs when the pericardial sac fills up with fluid
faster than it can stretch
Signs and Symptoms of Haemothroax - Answers -potential for hemorrhage
-on auscultation: diminished lung sounds
- when percussing: there will be a dull percussion tone over the blood
- Blood typically pools at the base of the lungs
- Assess for the signs and symptoms of bleeding (SOB, pain, clammy, pale), and the potential
for the development of hypovolemic shock.
Blunt Trauma - Answers -includes a large impact, but the skin is not broken, and is not always
visible from the skin.
examples; pulmonary contusion, pneumothorax, fractured ribs.
Penetrating trauma - Answers -an injury that occurs when an object pierces the skin and enters
the tissue
-creates an open wound
-examples - gunshot wound, knife wound.
Nursing Assessment & Management of a patient with Pneumothorax - Answers -nurses' main
focus should be maintaining adequate ventilation and oxygenation.
-a person with pneumothorax may be in acute respiratory distress, necessitating a rapid and
focused assessment.
- Health history: current symptoms and their duration, precipitating factors or activities if known
previous episodes of pneumothorax, smoking history, chronic pulmonary diseases such as
COPD.
Physical Assessment: (look, listen, fell
-general appearance and degree of apparent respiratory distress
- evidence of chest trauma
- vital signs (oxygen saturations)
