Organs

Rising systolic pressure with a widening pulse pressure, a slowing heart rate, and irregular breathing together mean the brainstem is being compressed. This is a late sign: the nurse calls the provider or rapid response team at once, keeps the head of the bed at about 30 degrees with the neck midline, and avoids anything that raises pressure, such as straining, coughing, or sharp hip flexion.

Decorticate posturing (arms bent in toward the chest, fists clenched, legs straight) points to damage higher up, in the cerebral hemispheres or the motor pathway above the brainstem's lower centers. Decerebrate posturing (arms and legs rigidly straight, forearms turned inward, toes pointed, head arched back) means the brainstem is involved and the outlook is worse. A shift from bending to extending is deterioration, and the nurse reports it immediately.

Sudden vertigo, vomiting, headache, and inability to stand or walk in a patient with normal arm and leg strength can be a cerebellar stroke, and it is easy to dismiss as a dizzy spell because face droop and arm drift may be absent. The nurse notes the time last known well, activates the stroke alert per facility protocol, keeps the patient in bed and NPO until a swallow screen is passed, and checks level of consciousness and pupils often. A swelling cerebellum can press on the brainstem, so any drop in level of consciousness is reported at once as an emergency.

Nystagmus is often the first sign of phenytoin toxicity, followed by ataxia and slurred speech as the level rises above the usual therapeutic range of 10 to 20 mcg/mL; acute alcohol intoxication causes the same picture. The nurse holds the next dose, notifies the provider, and obtains a phenytoin level as ordered, because another dose on top of a high level deepens the toxicity. Fall precautions go in place: bed low, call light in reach, and the nurse walks with the patient.

Facial droop, arm drift, and slurred speech mean a stroke until proven otherwise. The nurse records the exact time the patient was last seen normal, because the clot-dissolving window is measured from that moment, and keeps the patient NPO until a swallow screen is passed, because feeding a patient who cannot swallow safely causes aspiration.

Check that the pupils are equal and round and that they react to light and accommodation. Then have the patient follow a finger or penlight through the six cardinal fields, which tests cranial nerves III, IV, and VI. In a patient with a head injury or a dropping level of consciousness, a new dilated, sluggish, or fixed pupil on one side can mean the swelling brain is pressing on cranial nerve III, so the nurse calls the provider right away.

New flashes of light, a sudden shower of floaters, or a curtain or shadow across part of the vision means the retina may be pulling away. It does not hurt, so the nurse treats the patient's report as the emergency. The nurse limits activity as ordered, covers the eye, and gets the patient an urgent eye exam, because the detached part of the retina stops working and vision can be lost for good.

A child with a sudden high fever, drooling, a muffled voice, and stridor who sits upright leaning forward in the tripod position may have a swollen epiglottis that is about to block the airway. The nurse puts nothing in the mouth (no tongue blade, no throat swab), does not lay the child flat, and delays upsetting care such as an IV start, because crying or a throat exam can trigger complete obstruction. The nurse keeps the child calm on the parent's lap and gets the provider and emergency airway equipment to the bedside at once.

After a stroke, a gag reflex does not prove a safe swallow, so the nurse keeps the patient NPO until they pass a swallow screen; after a breathing tube is removed, the nurse follows the facility's swallow protocol. After a procedure that numbs the throat, such as a bronchoscopy or EGD, the nurse keeps the patient NPO until the gag reflex returns and the patient is alert. Once eating is allowed, the patient sits fully upright for meals and for about 30 minutes after, and the nurse treats coughing while eating, a wet or gurgly voice, or new fever or crackles as signs of aspiration.

The nerves that move the vocal cords run beside the thyroid, and bleeding in the neck can press on the airway, so the nurse regularly checks the voice, listens for stridor, and checks the dressing and the back of the neck for blood. Mild hoarseness is common, but a voice that gets worse, new stridor, or a neck that feels tight means the airway is at risk (low calcium can also cause laryngeal spasm; see Parathyroid glands). The nurse keeps suction, oxygen, and a tracheostomy set at the bedside and calls for help at the first sign of stridor rather than waiting for distress.

Look for fever, severe headache, a stiff neck that resists bending forward, light sensitivity, and a falling level of consciousness. Kernig sign is pain and resistance when the knee is straightened with the hip flexed. Brudzinski sign is the hips and knees bending when the neck is flexed. The nurse starts droplet precautions on suspicion, not after the culture result. Blood cultures are drawn and the first antibiotic dose is given right away, never held for the lumbar puncture or its results, because every hour of delay raises the risk of death and brain damage. A spreading purple rash with these signs points to meningococcal disease, which can bring septic shock fast.

Before the tap, the nurse reports any sign of raised intracranial pressure, such as a falling level of consciousness, unequal or sluggish pupils, or vomiting, because draining fluid from below can pull the brainstem down into the base of the skull. The nurse has the patient void, then positions them side-lying with knees to chest and chin tucked to open the lumbar spaces, and helps them hold still. Afterward the patient rests flat for the ordered time and drinks fluids. A headache that worsens sitting up and eases lying down means CSF is still leaking, so the nurse keeps the patient flat, encourages fluids, and reports it so the provider can consider a blood patch.

Clear or blood-tinged fluid from the nose or ear after head trauma is treated as CSF until proven otherwise. The nurse screens clear fluid for glucose or checks bloody drainage for a halo ring on gauze, lets it drain onto a loose dressing, and reports it. Nothing goes into the nose or ear: no packing, no nasal suctioning, no nasogastric tube, and no nose blowing, because the fracture that lets fluid out lets bacteria in, and a tube can pass through the broken skull base into the brain. The nurse then watches for fever and a stiff neck.

The nurse does not insert an NG tube or nasal suction catheter when a basilar skull fracture is known or suspected, such as clear fluid draining from the nose, bruising behind the ears, or bruising around both eyes. The bone above the nasal cavity may be broken, and a tube can pass into the brain, so tubes go through the mouth instead. The nurse tells the patient not to blow the nose and to avoid straining.

For an unconscious patient the nurse places the patient side-lying with the head turned so fluid drains out of the mouth, keeps suction ready, and uses a moistened swab or small amounts of fluid, never a large pour. With no reliable gag or cough reflex, pooled fluid runs into the lungs. Before surgery the nurse removes dentures and documents loose teeth, because anything loose in a sedated patient's mouth can be inhaled or block the airway.

Untreated low calcium moves from tingling lips and fingers to muscle cramps, seizures, and spasm of the vocal cords that closes the airway. The nurse keeps calcium gluconate, suction, and an airway at the bedside after thyroidectomy and treats stridor as an emergency.

Too little ADH (diabetes insipidus): the patient pours out liters of dilute urine with a specific gravity near 1.005, gets thirsty and dehydrated, and sodium climbs; the nurse tracks strict intake and output, replaces fluid, and gives desmopressin as ordered. Too much ADH (SIADH): urine is scant and concentrated, water is retained, sodium falls, and the patient becomes confused and can seize; the nurse restricts fluids, monitors sodium, and puts seizure precautions in place.

After surgery through the nose, the nurse keeps the head of bed raised, checks the nasal drip pad for a clear halo around blood and tests drainage for glucose (CSF), and teaches the patient not to blow the nose, cough hard, bend over, strain, or brush the front teeth until cleared, and to sneeze, if a sneeze comes, with the mouth open. Any of those can open the surgical seal and let bacteria reach the brain, so clear drainage, a new headache, or a stiff neck is reported at once.

Swelling around the surgical site often causes temporary diabetes insipidus. The nurse measures urine output every hour, reports sudden high volumes of pale urine, checks specific gravity, and watches sodium, because the patient can dehydrate into hypovolemia within hours.

Bleeding into the closed neck can press the trachea shut. The nurse checks the front dressing and slides a hand behind the neck for pooled blood, and watches for a neck that feels tight or swollen, stridor, trouble swallowing, or a voice growing weaker. Tightness or stridor means calling the surgeon and rapid response at once; a tracheostomy tray, suction, and oxygen stay at the bedside, and the patient stays in semi-Fowler position with the head and neck supported, not flexed or extended.

If the parathyroids were bruised or removed, calcium can fall in the first few days, and severe tetany can close the airway through laryngospasm. The nurse asks about tingling around the mouth and in the fingers at every check, reports the first tingling without waiting for a lab result, and keeps IV calcium gluconate available. Chvostek and Trousseau signs are covered with the parathyroid glands.

Thyroid storm is hot and fast: high fever, a racing pulse, agitation or confusion, often after surgery, infection, or stopping antithyroid drugs. The nurse cools the patient and gives acetaminophen, never aspirin, which frees more hormone; gives oxygen, IV fluids, the beta blocker, and the antithyroid drug before any iodine, as ordered. Myxedema coma is cold and slow: low temperature, slow pulse, low blood pressure, shallow breathing, and a patient hard to wake; the nurse supports the airway, warms with blankets rather than a heating device, gives IV levothyroxine as ordered, and avoids sedatives and opioids.

After axillary node dissection the nurse posts a sign at the bedside, places a restricted-limb band on the wrist, and allows no blood pressure, blood draw, injection, or IV on that arm. The arm has lost part of its lymph drainage, so squeezing it or breaking the skin can trigger lymphedema that may last for life. If an assistant starts a cuff on that arm, the nurse stops it right away.

The nurse counts the apical pulse for one full minute before giving digoxin and holds the dose and notifies the provider if an adult's rate is below 60. Digoxin slows conduction through the heart, so a dose given into a slow rate can deepen the bradycardia, and a slow rate can itself be a sign of toxicity. Low potassium raises the risk of digoxin toxicity, so the nurse checks the potassium level too.

For an adult, the nurse places the heel of the hand on the lower half of the sternum, in the center of the chest, and pushes 2 to 2.4 inches deep at 100 to 120 per minute, letting the chest recoil fully each time. Compressions work by squeezing the heart between the sternum and the spine, so hands placed off the sternum move less blood.

Air enters the pleural space and cannot escape, collapsing the lung and pushing the heart and trachea to the other side: sudden severe dyspnea, absent breath sounds on one side, trachea shifted away, distended neck veins, and falling blood pressure. The nurse stays with the patient, gives high-flow oxygen, calls for immediate help, and prepares for needle decompression. If a chest tube is already in place, the nurse checks it for clamps or kinks, because a blocked tube traps the air.

The nurse keeps the drainage system upright and below the chest, expects the water seal to rise and fall with breathing, and treats continuous bubbling in the water seal as an air leak to find and report. The tube is never routinely clamped, because clamping a tube with an air leak can cause a tension pneumothorax. If the tube pulls out, the nurse covers the site with a sterile dressing taped on three sides so air can escape but not enter, and calls the provider; if the tube disconnects, the nurse places its end in sterile water until a new system is ready.

With an absolute neutrophil count below 1000, and especially below 500, a temperature of 100.4 F or higher is treated as sepsis until proven otherwise: the nurse draws blood cultures and gets antibiotics started within the hour. The nurse protects the patient with strict handwashing, a private room, no fresh flowers or standing water, no raw fruit or vegetables per facility policy, no rectal temperatures or suppositories, and limits on visitors with any illness.

Measure nose to earlobe to xiphoid and mark the tube, sit the patient in high Fowler position, and advance the lubricated tube along the floor of the nostril. At the throat, have the patient tuck the chin and swallow (sips of water, or dry swallows if NPO), because swallowing closes off the airway and guides the tube into the esophagus. Coughing, choking, cyanosis, or inability to speak means the tube is in the airway, so pull it back at once; placement is confirmed by X-ray before first use, aspirate pH of about 5 or less supports gastric placement, and listening for injected air is not accepted.

After a stroke, the nurse keeps the patient NPO, including water and pills, until a swallow screen is passed. The nurse checks that the patient is alert and sitting upright, gives a small sip of water, and watches for coughing, throat clearing, or a wet, gurgly voice. A failed screen means the patient stays NPO and speech therapy is consulted, because food can slip silently into the lungs and cause aspiration pneumonia.

In cirrhosis, blood backs up into thin-walled veins of the lower esophagus that can rupture and bleed heavily. The nurse teaches the patient to avoid alcohol, aspirin and NSAIDs, straining, and heavy lifting. Vomiting blood is an emergency: protect the airway, check vital signs, start large-bore IV access, and notify the provider.

After intubation, and any time the tube may have moved, the nurse listens to both sides of the chest and watches both sides rise. Breath sounds on the right only, with the left chest still and the oxygen saturation falling, mean the tube is in the right main bronchus and the left lung is getting no air. The nurse checks the depth mark at the lip or teeth against the documented depth, notifies the provider at once, and expects the tube to be pulled back and a chest x-ray to confirm the tip sits above the carina.

The nurse keeps the obturator, a spare tube of the same size and one size smaller, suction, and a bag-valve mask at the bedside at all times, because a new stoma can narrow or close quickly if the tube comes out. Ties are changed with a second person holding the tube, and the old ties come off only after the new ones are secured. Stoma care is sterile in the hospital, and the inner cannula is cleaned or replaced as ordered.

A patient with adrenal insufficiency who meets a stressor (surgery, infection, or abruptly stopped steroids) develops profound hypotension, weakness, vomiting, low sodium, high potassium, and low glucose. The nurse gives IV hydrocortisone and fluids as ordered without waiting for lab confirmation, because the shock will not respond to fluids alone, and treats the high potassium and low glucose.

A tumor of the adrenal core dumps adrenaline in bursts, causing severe headache, sweating, palpitations, and dangerously high blood pressure. Pressing on the abdomen can trigger a surge that ends in stroke or heart attack, so the nurse avoids deep abdominal palpation, keeps the room calm, and monitors blood pressure closely.

The nurse keeps the patient NPO because surgery is likely, and never applies heat or gives laxatives or enemas: heat increases blood flow to the inflamed appendix, and laxatives and enemas stimulate the bowel, so both can make it burst. Sudden relief of pain followed by a rigid, board-like abdomen, fever, and a rising pulse means rupture and peritonitis. The nurse reports it immediately, places the patient in semi-Fowler's so infected fluid collects low in the pelvis instead of spreading upward, watches for sepsis, and expects IV antibiotics and urgent surgery.

In a patient with an injury at T6 or above, a distended bladder from a blocked or kinked catheter is the most common trigger of autonomic dysreflexia. At a sudden pounding headache and soaring blood pressure the nurse first sits the patient upright and lowers the legs to bring the pressure down, then goes straight to the bladder: unkink or flush the catheter, or catheterize if there is none, before checking the bowel or skin.

The kidney has a rich blood supply, so the nurse checks clotting studies and platelets beforehand and confirms blood thinners were held as ordered. The patient lies face down with a pillow under the abdomen and holds a breath as the needle goes in, so the kidney does not move. Afterward the patient stays on bed rest as ordered with frequent vital signs, and the nurse checks each void: some blood in the first 24 hours is common and should lighten, but bleeding that gets heavier, passes clots, lasts past 24 hours, or comes with flank pain, dizziness, a fast pulse, or falling blood pressure is reported at once.

When filtering falls, potassium is not excreted and climbs. The ECG shows tall, peaked T waves first, then a longer PR interval, a flattening P wave, and a widening QRS that can end in a lethal rhythm. The nurse follows potassium levels, holds potassium-containing IV fluids and supplements, teaches the patient to avoid salt substitutes (potassium chloride), places the patient on a cardiac monitor, and reports a high level with ECG changes immediately.

A healthy stoma is pink to red and moist; a dusky, purple, or black stoma means its blood supply is failing, so the nurse reports it to the surgeon at once. Output follows the segment: liquid from an ascending colostomy, mushy from a transverse one, and formed from a descending or sigmoid one, which can be irrigated to set a schedule. The nurse empties the pouch when it is one-third to one-half full so the weight does not break the seal.

Before the procedure the nurse confirms PT/INR and platelet results and teaches the patient to exhale and hold the breath while the needle goes in, so the liver stays still. Afterward the patient lies on the right side with a small pillow under the rib margin for as long as facility policy sets, so body weight presses the puncture site against the chest wall. The liver is very vascular, so the nurse checks vital signs often; mild soreness or right shoulder pain is common, but a rising pulse, falling blood pressure, or severe or worsening abdominal or shoulder pain is reported at once as possible bleeding.

Scarring blocks blood flow from the gut into the liver, so fluid leaks into the abdomen and blood backs up into fragile esophageal varices. The nurse weighs the patient daily and measures abdominal girth at the same marked spot, has the patient empty the bladder before paracentesis, and watches blood pressure afterward because removing a large volume of fluid can drop it. Vomiting blood in a patient with cirrhosis is treated as a variceal bleed until proven otherwise, and it is more dangerous because the scarred liver makes fewer clotting factors.

The maximum for a healthy adult is 4 grams a day, lower with regular alcohol use or liver disease, and the nurse teaches patients to count the acetaminophen hidden in combination products; in overdose a toxic breakdown product builds up and kills liver cells, often while the patient still looks well. The acetaminophen level is drawn at least 4 hours after ingestion, because earlier levels cannot guide treatment, and the nurse gives acetylcysteine as ordered as early as possible, ideally within 8 hours. Patients taking drugs that can harm the liver are taught to report dark urine, pale stools, yellow skin or eyes, and right upper quadrant pain.

A missed period, one-sided lower abdominal pain, and spotting in a patient of childbearing age mean ectopic pregnancy until a pregnancy test and ultrasound rule it out. Sudden sharp pain, pain in the shoulder, dizziness, a fast pulse, and falling blood pressure mean the tube has ruptured and she is bleeding inside: the nurse starts two large-bore IVs, sends a type and crossmatch, keeps her NPO, and prepares her for surgery. An Rh-negative patient needs Rh immune globulin.

Bluish bruising around the umbilicus (Cullen's sign) or on the flanks (Grey Turner's sign) points to bleeding behind the abdominal lining: report it at once and watch for shock. Lipase digests the fat around the gland, and the freed fatty acids bind calcium, so the nurse checks for a hand spasm under an inflated blood pressure cuff (Trousseau's sign) or a facial twitch when the cheek is tapped (Chvostek's sign) and reports either one right away.

Sudden, severe one-sided scrotal pain with swelling, nausea, and a testis that sits high or sideways means the cord has twisted and cut off its own blood supply. The nurse treats this as a surgical emergency and gets the patient to the provider now, because the testis dies within hours without detorsion; this is not an infection to observe with ice and antibiotics.

Look for severe abdominal pain, a board-like rigid abdomen, rebound tenderness, absent or faint bowel sounds, fever, a fast pulse, and shallow breathing in a patient who lies still with knees drawn up. The nurse reports these at once, keeps the patient NPO, expects an NG tube to suction, IV fluids, and antibiotics, and places the patient in semi-Fowler position to ease breathing and help fluid collect low in the pelvis. Fluid shifts into the abdomen and infection spreads to the blood, so the nurse watches for falling blood pressure and rising heart rate.

Painless, bright red bleeding late in pregnancy points to placenta previa, where the placenta lies over or near the cervix; the nurse does not do a vaginal exam or place anything in the vagina, because it can tear the placenta and cause hemorrhage. Painful bleeding with a rigid, tender uterus points to abruption; blood can hide behind the placenta, so the nurse watches maternal vital signs and the fetal heart rate for shock even when little blood shows.

If the cord is seen or felt ahead of the presenting part, the nurse calls for help, uses a sterile gloved hand to lift the presenting part off the cord, and holds it there until birth. The mother is placed in knee-chest or Trendelenburg so gravity eases pressure on the cord. The nurse never pushes the cord back in, because handling it can make the vessels spasm and cut off the baby's oxygen.

The nurse adjusts the three-way catheter irrigation to keep the drainage light pink without clots, and subtracts the irrigant from total output to get true urine output. If drainage stops, the nurse stops the inflow, checks the tubing, irrigates only as ordered, and calls the provider, because a blocked catheter lets the bladder swell against the raw, bleeding prostate bed. Bright red drainage or large clots are reported at once, and so are new confusion, nausea, a slow pulse, or rising blood pressure, which can mean fluid absorbed during surgery has dropped the sodium.

Ileostomy output is liquid, constant, and full of digestive enzymes that break down skin, so the barrier opening is cut only about 1/16 to 1/8 inch larger than the stoma and the pouch is emptied when about one-third full. An ileostomy is never irrigated. A healthy stoma is pink or red and moist; a dusky, purple, or black stoma means its blood supply is failing and is reported at once.

After a left-sided blow, fall, or seat-belt injury, the nurse watches for left upper quadrant pain and left shoulder pain (Kehr's sign), which comes from blood irritating the diaphragm. A rising heart rate, falling blood pressure, and pale, cool skin mean hypovolemic shock, so the nurse places two large-bore IVs, gives fluids or blood as ordered, and does not press deeply on the abdomen. Because bleeding can show up late, a patient sent home after left-sided trauma is taught to return at once for new belly or left shoulder pain, dizziness, or fainting.

In a young child with sickle cell disease, sudden pallor, weakness, a quickly growing left upper abdomen, and falling blood pressure mean blood is pooling in the spleen. The nurse treats this as shock, gets help, and prepares for a blood transfusion. Parents are taught how to feel their child's spleen and to come in right away if it gets bigger.

Without a spleen, infection from encapsulated bacteria such as pneumococcus, meningococcus, and Hib can turn into sepsis within hours. The nurse teaches that any fever means going to the emergency department now, not waiting it out at home, and reports a fever in this patient right away. The nurse also confirms pneumococcal, meningococcal, and Hib vaccines are given (ideally before an elective splenectomy) and teaches the patient to wear a medical alert ID and take any emergency antibiotic exactly as prescribed.

Before the first feeding the nurse confirms tube position with an X-ray; after that, aspirate pH of about 5 or lower supports a gastric tip, while a higher pH suggests the intestine or the lung. The nurse checks gastric residual per protocol, keeps the head of the bed at 30 to 45 degrees during and after feeds, and flushes with water before and after every feeding and medication.

Sudden severe epigastric pain with a rigid, board-like abdomen, absent bowel sounds, and a patient who lies still means the stomach has leaked into the peritoneum. The nurse makes the patient NPO, notifies the provider at once, starts IV access, and prepares for surgery, because peritonitis and sepsis follow within hours.

Infected urine trapped behind a blocking stone can spread into the blood quickly, and antibiotics alone will not clear it until the provider drains the kidney with a ureteral stent or a nephrostomy tube. Fever, chills, a rising heart rate, or a falling blood pressure in a patient with a stone is reported immediately. The nurse draws the ordered blood and urine cultures before the first antibiotic dose, starts the ordered IV fluids and antibiotics, prepares the patient for the drainage procedure, and watches blood pressure, mental status, and urine output for signs of septic shock.

After the bladder is removed, the ureters are joined to a short piece of small intestine that opens on the abdomen as a stoma and drains urine all the time, so mucus shreds in the urine are expected. The nurse checks that the stoma is pink or red and moist and reports a dusky, purple, or black stoma at once because its blood supply is failing; a conduit that stops draining or whose output drops sharply is also reported at once, because blocked urine backs up toward the kidneys. The nurse keeps the pouch emptied and the skin around the stoma dry to prevent breakdown, and teaches that foul-smelling urine with fever or flank pain signals infection.

Using sterile technique, the nurse advances the lubricated catheter about 2 to 3 inches in a woman, or about 7 to 9 inches in a man with the penis held at 90 degrees, until urine flows, then advances it further before inflating the balloon: about 1 to 2 inches more in a woman, to the Y-junction in a man. A balloon inflated inside the urethra tears it, causing bleeding, pain, and later scarring. If the catheter meets resistance, the nurse stops, does not force it, and notifies the provider.

The nurse returns the foreskin over the glans at the end of every catheter insertion and every round of catheter care. Left retracted, it tightens behind the glans, the glans swells, and blood flow is cut off. If the foreskin cannot be brought forward over a swollen glans, the nurse notifies the provider at once, because the tissue can die without prompt treatment.

A uterus that will not stay contracted (atony) is the leading cause. A pad soaked in about 15 minutes, a steady trickle, large clots, or a rising pulse with falling blood pressure sends the nurse to massage the fundus, empty the bladder, give oxytocin as ordered, and call for help, because a postpartum patient can lose a liter before her pressure moves.

Burns of the face or neck, singed nasal hair, soot in the mouth or sputum, hoarseness, or a fire in a closed space point to inhalation injury. Airway swelling can build over hours, so the nurse gives 100 percent oxygen, watches for stridor and a worsening voice, and prepares for early intubation before the airway closes. A normal pulse oximetry reading does not rule out carbon monoxide poisoning, because the device cannot tell carbon monoxide from oxygen on hemoglobin.

The Parkland formula is 4 mL of lactated Ringer's x kg x percent of body surface with partial- or full-thickness burns (superficial burns are not counted) over 24 hours, with half in the first 8 hours counted from the time of the burn, not from arrival, and the rest over the next 16. The nurse runs fluid through large-bore IV access and tracks hourly urine output, reporting output below about 0.5 mL/kg per hour (about 30 mL per hour in an adult) so the rate can be adjusted. A burn that circles a limb or the chest tightens as it swells, so the nurse checks distal pulses, capillary refill, and sensation, or breathing effort for a chest burn, at least hourly and reports any change at once so an escharotomy can relieve the pressure.

C1 to C4 means ventilator dependence, because the phrenic nerve to the diaphragm leaves the cord at C3 to C5; a C6 injury keeps wrist extension, so the patient can grip with a tenodesis motion, feed, and transfer with a sliding board. The nurse uses the same reasoning in Guillain-Barre: weakness climbs from the legs upward, so measure vital capacity on a schedule, and a steady fall toward about 15 mL/kg is the trigger to prepare for intubation before the diaphragm fails.

A pounding headache, sudden severe hypertension, flushing and sweating above the injury, and bradycardia in a patient with a lesion at T6 or higher is dysreflexia until proven otherwise. The nurse sits the patient upright with the legs down, loosens anything tight, and hunts the trigger in order: full bladder first, then bowel, then skin, checking blood pressure every few minutes and giving the ordered fast-acting antihypertensive if removing the trigger does not bring it down.

After a femoral catheterization the patient keeps the leg straight with the head of the bed no higher than about 30 degrees for the ordered bed-rest time. The nurse compares pedal pulses, color, warmth, sensation, and capillary refill of that foot with the other foot, because a clot or hematoma can cut off blood flow to the leg. A cool, pale, or pulseless foot is reported at once.

If the site bleeds or a hematoma grows, the nurse presses firmly just above the skin puncture, because the hole in the artery sits slightly higher than the hole in the skin, and keeps pressing while calling for help. New back or flank pain with a falling blood pressure and rising heart rate points to bleeding behind the abdomen (retroperitoneal bleed), which may show no blood at the site, and is reported right away.

In an unresponsive child the nurse checks the carotid or femoral pulse (the brachial in an infant) for no more than 10 seconds, and starts compressions if there is no definite pulse, or if the heart rate is under 60 with poor perfusion despite breathing support. The femoral is a central pulse, so in shock it often can still be felt after the radial and pedal pulses are gone. A weak or fading femoral pulse means shock is far along, so the nurse calls the rapid response team at once.