ATI CUSTOM: AH2- FA25- Exam 2

A. Administer vasopressors to support blood pressure
MODS often develops from septic or distributive shock, leading to severe hypotension and poor perfusion. Vasopressors such as norepinephrine or dopamine help maintain mean arterial pressure (MAP ≥ 65 mm Hg) to ensure adequate organ perfusion.
C. Monitor intake and output
Strict monitoring of urine output and fluid balance is essential for evaluating kidney function and the effectiveness of resuscitation efforts. Decreasing urine output may indicate worsening renal perfusion and progression of MODS.
D. Increase intravascular volume with fluid resuscitation
Aggressive IV fluid replacement restores circulating volume and improves perfusion to prevent further organ ischemia. Balanced crystalloids, such as Lactated Ringer’s or normal saline, are typically used early in management.
E. Monitor lung sounds for manifestations of pulmonary edema
As fluids and vasopressors are administered, the nurse must monitor for fluid overload and pulmonary edema, a common complication in MODS. Crackles, dyspnea, or decreasing oxygen saturation may indicate worsening respiratory compromise or acute respiratory distress syndrome (ARDS).

A. Heart rate
A heart rate of 52 bpm indicates bradycardia, which is a critical sign of neurogenic shock resulting from disruption of sympathetic input to the heart. The nurse must immediately notify the provider and prepare for interventions such as IV fluids or atropine to maintain perfusion.
B. CT scan results
The CT scan showing a T3 spinal fracture with inflammation confirms a high thoracic injury, which places the client at significant risk for neurogenic shock and respiratory compromise. This finding requires immediate follow-up for stabilization and prevention of further spinal cord damage.
C. Skins flushed
Warm, flushed skin occurs because of loss of sympathetic tone, leading to massive vasodilation and poor thermoregulation—another hallmark of neurogenic shock. This sign, combined with bradycardia and hypotension, signals hemodynamic instability.
E. Blood pressure
A blood pressure of 80/60 mmHg reflects severe hypotension due to loss of vasomotor control below the level of injury. It requires immediate intervention with fluids and possibly vasopressors to maintain adequate cerebral and organ perfusion.

C. Cardiac tamponade
Cardiac tamponade is a classic cause of obstructive shock, which occurs when a physical obstruction prevents adequate filling or outflow of blood from the heart, leading to decreased cardiac output and tissue perfusion. In tamponade, fluid accumulates in the pericardial sac, compressing the heart and impairing ventricular filling. This results in hypotension, jugular vein distension, and muffled heart sounds—known as Beck’s triad.

C. Mannitol
Mannitol is an osmotic diuretic used to decrease intracranial pressure by drawing fluid from cerebral tissues into the vascular space, where it is excreted by the kidneys. This reduces cerebral edema and improves cerebral perfusion pressure (CPP). The nurse should closely monitor serum osmolality, urine output, and electrolytes to prevent dehydration or renal injury during therapy.

D. Monitor hourly urine output for a minimum of 30 mL/hr
In burn patients, urine output is the most reliable indicator of adequate fluid resuscitation. The nurse should monitor hourly urine output, maintaining at least 30 mL/hr (or 0.5 mL/kg/hr) in adults to ensure proper renal perfusion and tissue hydration. This measurement reflects the effectiveness of fluid replacement and guides adjustments in IV therapy. Adequate urine output signifies stable hemodynamics and sufficient circulating volume.

B. Episodes of apnea
Episodes of apnea are an abnormal respiratory pattern caused by pressure on the brainstem, which controls breathing. In clients with increased intracranial pressure (ICP), intermittent apnea signifies that the medulla oblongata is being compressed. This is a critical finding in Cushing’s Triad, as irregular or absent respirations indicate the body is losing its ability to regulate vital functions, requiring immediate intervention to prevent respiratory arrest and herniation.
C. Widening pulse pressure
A widening pulse pressure—rising systolic and falling diastolic pressure—is a hallmark of Cushing’s Triad. This occurs because the body attempts to maintain cerebral perfusion by increasing systolic pressure in response to elevated ICP. The brain’s autoregulatory mechanism causes systemic hypertension as it tries to push blood past the compressed cerebral vessels, signifying worsening intracranial pressure and impending herniation.
D. Increased blood pressure
Elevated systolic blood pressure represents the body’s compensatory mechanism to maintain cerebral perfusion pressure (CPP) despite elevated ICP. The sympathetic nervous system triggers vasoconstriction to sustain brain perfusion. However, as ICP rises further, this increase in blood pressure becomes a dangerous sign of decompensation and brainstem involvement, demanding rapid treatment to lower ICP and stabilize the client.
E. Shallow breathing
Shallow breathing indicates reduced respiratory drive from pressure on the brainstem’s respiratory center. In Cushing’s Triad, the respiratory pattern becomes irregular—shallow breaths alternating with periods of apnea. This abnormal breathing pattern signals that the brain’s vital centers are failing to regulate gas exchange, necessitating immediate airway support and ventilatory management to prevent hypoxia and respiratory failure.
F. Bradycardia
Bradycardia occurs due to stimulation of the vagus nerve from rising intracranial pressure. As the brainstem becomes compressed, parasympathetic output increases, slowing the heart rate. A heart rate of 50–60 beats per minute in the context of elevated ICP is a classic and ominous finding of Cushing’s Triad. This is a late, preterminal sign requiring immediate medical intervention to prevent brain herniation and death.

C. 10,800 mL
Let’s calculate step-by-step using the Parkland Formula:
Parkland Formula: 4 mL × %TBSA burned × body weight (kg)
Given:
● %TBSA (both legs completely) = 18% each × 2 = 36%
● Weight = 75 kg
Calculation: 4 × 36 × 75 = 10,800 mL over the first 24 hours.
Therefore, the total amount of Lactated Ringer’s to administer in the first 24 hours is 10,800 mL.
● First 8 hours: Half (5,400 mL)
● Next 16 hours: Remaining half (5,400 mL)

B. Managing sedation
Adequate sedation helps reduce agitation, coughing, and restlessness, all of which can increase ICP. Sedatives and analgesics lower cerebral metabolic demand and help maintain a calm environment, preventing sudden ICP spikes.
C. Elevating the head of the bed 30°
Positioning the head at a 30° angle promotes venous drainage from the brain while maintaining adequate cerebral perfusion. Flat positioning or excessive elevation can worsen ICP or decrease cerebral blood flow.
D. Ensuring proper ventriculostomy transducer levels
Accurate leveling of the ventriculostomy transducer (typically at the tragus of the ear, aligned with the foramen of Monro) ensures precise ICP measurements and drainage of cerebrospinal fluid when indicated. Incorrect leveling can lead to over- or under-drainage.
E. Monitoring volume status
Maintaining euvolemia is critical. Both dehydration (reducing cerebral perfusion) and fluid overload (increasing cerebral edema) can worsen intracranial pressure. Monitoring intake, output, and hemodynamic status ensures stable perfusion.

B. Insert a nasogastric tube
After a spinal cord injury, especially during spinal shock, bowel sounds may be absent due to paralytic ileus caused by loss of autonomic control over the gastrointestinal tract. The nurse should anticipate an order to insert a nasogastric (NG) tube to decompress the stomach, prevent distention, vomiting, and aspiration. The NG tube removes accumulated gas and secretions until peristalsis returns, preventing further complications such as bowel perforation.