Acute Biologic Crisis

Acute Biologic Crisis

Congestive Heart Failure

Congestive Heart Failure

Left Side Heart Failure

Left Side Heart Failure

Right Side Heart Failure Anasarca

Right Side Heart Failure Ascites

Right Side Heart Failure Ascites

Right Side Heart Failure

Peripheral edema

Right Side Heart Failure Jugular vein distention

Dysrhythmias

Dysrhythmias

Respiratory Failure

Respiratory Failure When

The client can’t eliminate CO2 fr. Alveoli



CO2 retention

Respiratory Failure

O2 is not absorbed by alveoli

O2 level drops CO2 > 45 mm Hg

Acute respiratory distress syndrome

Causes Resp failure Mechanical

abnormality in lungs or chest wall Defect Resp control center of brain Severe Resp Infection

ASSESSMENT Alteration

in breath sounds

Dyspnea HA Restlessness Tachycardia Cyanosis

/ confusion

ASSESSMENT 

LOC

Dysrhythmias

INTERVENTIONS Identify

cause Administer O2 Mechanical ventilator

Renal Failure Acute

Renal Failure Chronic Renal Failure

Acute Renal Failure

Rapid onset of oliguria (<400 ml /day) , with severe rise in BUN & creatinine (Azotemia – accumulation of nitrogen in blood )

Causes of Acute Renal Failure Pre-Renal

Causesfactors outside of the kidney

Causes of Acute Renal Failure

Pre-Renal Causes Shock Circulatory collapse CVD Hemorrhage Severe vasoconstriction

Causes of Acute Renal Failure

Intra-Renal Causes: kidney diseases Damage to kidney Poisoning Iron overload (BT) Acute pyelonephritis

Causes of Acute Renal Failure

Post-Renal Causes: Obstruction in the Urinary tract Renal calculi Prostatic tumor Reproductive diseases

Complications ARF Hyperkalemia – most dangerous complication, may lead to cardiac arrest if rise in K+ is too fast

Nursing Care ARF Daily

Weight CVP monitoring Diuretic as prescribed Low protein, K,Na & high carbohydrate diet

Nursing Care ARF Emergency

mgt of Hyper K : insulin & dextrose , Kayexalate enema

Chronic Renal failure

Chronic irreversible progressive reduction of functioning renal tissue

Common causes CRF Diabetic

nephropathy Hypertensive nephropathy Glomerulonephritis Chronic pyelonephritis

Stages CRF 



Reduced Renal Reserve high BUN no clinical symptoms yet Renal insufficiency- mild Azotemia – impaired urine concentration , nocturia

Stages CRF 3. Renal failure – Severe azotemia, acidosis,concentrated urine, severe anemia & electrolyte imbalances

Stages CRF 4. ESRD- Renal shutdown severely decreased renal function with clusters of systemic symptoms

CRF systemic SS Hyper

K, Hypernatremia, Hypocalcemia Anemia Anorexia, nausea & vomiting

CRF systemic SS

Ammoniacal

breath Immunosuppression HTN, CHF Pulmonary edema Severe pruritus Peripheral neuropathy Uremic amaurosis

Nursing Care ESRD Low

Protein, Low Na

diet Prepare client for peritoneal / hemodialysis Monitor Anemia

Nursing Care ESRD Administer

epoietin alpha (Epogen), diuretics, antihypertensives as prescribed Kidney transplant

Peritoneal Dialysis

Peritoneal Dialysis

Hemodialysis

HEMODIALYSIS:

Is the diffusion of dissolved particles from the blood into the dialysate bath of the hemodialysis machine across the semipermeable membrane of the dialyzer.

Hemodialysis

requires vascular access: Subclavian vein/ Femoral vein (temporary) Arteriovenous fistula, arteriovenous shunt,/ arteriovenous graft ( Permanent)

Hemodialysis

Hemodialysis

Nursing

Management: Assess the integrity of the hemodialysis access site Monitor VS Assess client for fluid overload

 Nursing

Weigh

Management:

the client before and after the dialysis treatment ( to determine fluid loss) Hold meds that can be dialyzed off Monitor for SS of Shock & Disequilibrium syndrome

Complication:

Disequilibrium Syndrome – is the rapid change in composition of extracellular fluid where the solutes of the blood are removed from the blood faster than that of the CSF, causing osmotic movement of fluid into the CSF causing cerebral edema.

 Nursing

Management: Disequilibrium syndrome:

Assess

for Nausea & vomiting Assess for headache Restlessness, agitation & or confusion Watch out for seizures



Nursing Management: Disequilibrium syndrome:

Notify

physician if SS of disequlibrium syndrome occurs Reduce environmental stimuli  Dialyze

the patient at a shorter period and at a slower rate

Kidney Transplant

The Nursing process starts with ASSESSMENT

Ang pitong katotohanan ukol sa Cranial Nerves GCS atbp.

Assessment

1. Cranial Nerve II Optic

Nerve-=

Hindi

lahat nang nakikita mo ay hindi iyo.

2. Upon Inspection Hindi

mo kayang bilangin ang buhok mo.

3. Cranial nerve XII Hypoglossal

nerve Hindi lahat nang ngipin mo ay abot nang dila mo.

4.Glasgow Coma Scale Subukan

nang mga tanga ang pangatlong assessment

5. Human Error Ang

pangatlo ay mali

6. Cranial nerve VII Facial

nerve

Mapapangiti

ka kasi nagmukha kang tanga

7. Law of Karma Ipasa mo ito sa ibang istudyante nang OC para makaganti ka.

Burns Cell

destruction of the layers of the skin and resultant depletion of fluid and electrolytes

Types of Burns Thermal : exposure to flame Chemical: exposure to strong acids or alkali Electrical: Caused by electrical strong electrical current results in internal tissue injury

Burn Depth:

Superficial thickness burn (1st degree)- mild to severe erythema of skin, blanches with pressure – heals in 3-7 days Partial thickness burn(2nd degree) – large blisters; painful heals 2-3 weeks

Burn Depth:

Full thickness burns (3rd degree) – white yellow deep red to black (eschar) disruption of blood flow, no pain; scarring and wound contractures will develop. Grafting is required; healing takes weeks to months

Burn Depth:

Deep full thickness burn(4th degree) – Involves injury to muscle and bone= appears black(eschars) – hard and inelastic healing takes weeks to months; grafts are required

Nursing Diagnosis

Decreased Cardiac output Related to Fluid shifts

Head

Rule Of 9

and neck 9% Anterior trunk 18% ( chest-9 abdomen-9) Posterior trunk-18%

Rule Of 9 Arms

9% each (forearms only or upper arms only 4.5%) Legs – 18% each Perineum-1%

Rule of 9

PARKLAND

(BAXTER) FORMULA FOR FLUID REPLACEMENT  4ml Lactated Ringer’s sol x Kg body mass x total percentage of body surface burned

PARKLAND

(BAXTER)

•1st 8 hours = ½ of total 24 hour fluid replacement •next 8 hours = ¼ of total •last 8 hours= ¼ of total

A man Suffered from a 3rd degree burn involving the head and neck, front of the torso (chest & abdomen), and whole left arm. Weight is 50 kg Calculate the: TBSA burned 24 hour fluid replacement in ml 1st 8 hours fluid replacement 2nd 8 hour remaining 8 hour

TBSA: Head & neck= 9% front of torso = 18% Whole left arm = 9% TBSA burned 36%

24 hour replacement: Parkland Baxter formula 4mlX 50 kgs x (TBSA)36%

=

7200 ml

1 8 hours : st

7200 ml 2 = 3600 ml = 1st 8 hours

2 8 hours & remaining 8 hours respectively : nd

3600 ml 2 = 1800 ml = 2nd 8 hours = 1800 ml = last 8 hours

MANAGEMENT OF BURNS: Administer fluids as prescribed Maintain a high calorie, high protein diet Monitor intake and output Monitor for infections of burn site

Burn Medications: Nitrofurazone

( Furacin) – broad spectrum antibiotic ointment or cream – used when bacterial resistance to other drugs is a problem : apply 1/16 inch thick film directly to burn

Burn Medications: Mafenide ( Sulfamylon) – water soluble cream bacteriostatic gr + bacteria- apply 1/16 inch directly to burn – notify physician if hyperventilation occurs as this drug may ppt. metabolic acidosis.

Burn Medications: Silver

Sulfadiazene ( Silvadene) – cream Broad spectrum to gr+ - ; does not cause metabolic acidosis – keep burn covered at all times with Sulfadiazine – (1/16 inch thick); 

Monitor CBC – causes leukopenia

Burn Medications: Silver

Nitrate – Antiseptic solution against gr-, dressings are applied to the burn and then kept moist with Silver nitrate ; used on extensive burns that may precipitate fluid and electrolyte imbalance.

LIVER CIRRHOSIS - A chronic progressive disease of the liver characterized by diffused damage to cells. ( Fibrosis & Nodule formation) .

Types: Laennec’s cirrhosis – Alcohol induced Postnecrotic c – massive liver necrosis as a result of viral hepatitis

LIVER BIOPSY – Removal of a living tissue sample for analysis.

Open biopsy- With Abdominal Incision under GA  Closed biopsy – Needle aspiration for histologic study = performed under local anesth. 

Preprocedure

care closed / needle biopsy – teach client to refrain from taking aspirin or NSAIDS

Post

procedure needle biopsy – position on right sidelying during initial 1-2 hours to prevent hemorrhage and bile leakage, give vit. K if prescribed.

Complications of Cirrhosis –

Portal HTN – as a result of obstruction /hardening of liver tissue inc in pressure in portal vein Ascites – as a result of portal HTN – fluid accumulates in abdomen 

Complications of Cirrhosis – Esophageal

varices – Fragile thin walled distended veins in the esophagus that is prone to rupture Coagulation defects – decreased synthesis of bile Dec. absorption of fat sol vitamins ex. Vit.K

Nursing

Diagnosis: Fluid Volume Deficit rel to hemorrhage ( bleeding esophageal varices) Risk of Injury rel to change in level of consciousness’

Liver Failure – ESLDinability of liver to function – rise in ammonia blood level, leading to Hepatic Coma.

Nursing Interventions

Assessment Main

problem is decreasing LOC bec of accumulation of ammonia Jaundice Abdominal pain

Ascites Spider

angioma on nose cheeks upper thorax and shoulders Hepatomegaly Fetor hepaticus (fruity breath)

Asterixis

(flapping tremors)- wrist & fingers Laboratories: inc in Ammonia Level N= ammonia 15-110 ug/dl

Asterixis

(flapping tremors)- wrist & fingers Laboratories: inc in Ammonia Level N= ammonia 15-110 ug/dl

Nursing Interventions Elevate

Head of bed to min DOB Provide vitamins B complex, A,DEK & C Low protein diet as prescribed to dec ammonia production

Nursing Interventions Weigh

& measure abdominal girth daily If IM drugs are needed= use only small gauge needles & inject only when needed

Nursing Interventions Esophageal

varices Sengstaken – Blakemore tube is applied to stop bleeding E varices) – have scissors at the bedside

Nursing Interventions Administer Lactulose as prescribed ( dec. pH w/c dec production of ammonia by the bacteria & facilitates the excretion of ammonia Administer Neomycin(Mycifradin)inhibit bacteria = dec production of ammonia

Nursing Interventions

Teach

client to avoid hepatotoxic drugs

DKA( Diabetic Ketoacidosis) / HHNS ( Hyperglycemic Hyperosmolar nonketotic Syndrome)

DKA-

Is a life threatening complication of DM type 1 = develops bec of severe insulin deficiency

MANIFESTATATIONS

=

Hyperglycemia, dehydration, electrolyte loss and acidosis CAUSE; Missed insulin dose, or infection

HHNS-

SIMILAR TO dka WITH EXTTREME hyperglycemia except that in HHNS there is no acidosis. This is for DM type 2

ASSESSMENT: Blood glucose – 300 – 800 mg/dl Low bicarbonate & low pH Dehydration

ASSESSMENT:

Mental

status changes Neurological deficits Seizures

NURSING DX: Fluid Volume deficit Rt hyperosmolar diuresis Risk for injury RT Mental status changes

NURSING INTERVENTION:

Administer

Insulin IV push 5-10 units 1st then IV infusion

NURSING INTERVENTION: Restore

Fluids ( administer fluids as prescribed) –Treat dehydration w/ rapid infusion of NSS or .45% saline –when blood glucose reaches 250-300 mg/dl D5NS, or D5 .45%Saline is used

NURSING INTERVENTION:

Always

use infusion pump for IV insulin Monitor serum potassium ( initially as a result of acidosis Hyperkalemia is present upon admin of insulin K+ level drops)

NURSING INTERVENTION:

Monitor

LOC= too rapid decrease in blood glucose may cause cerebral edema

ADDISON’S DISEASE – Is the hyposecretion of adrenal cortex hormones

ADDISONIAN

CRISIS/ Acute Adrenal Insufficiency- Is a life threatening disorder caused by acute adrenal insufficiency precipitated by stress, infection, trauma or surgery. Without appropriate hormonal replacement it may lead to shock.

ASSESSMENT: Severe headache Sudden Severe lower leg & lower back pain Generalized weakness Shock

NURSING INTERVENTION addisonian crisis:

Correct

hypoglycemia IV D5 glucose push Prepare to administer glucocorticoid IV (Solucortef)

NURSING INTERVENTION addisonian crisis:

Following

crisis – glucocorticoids orally Monitor blood pressure to assess for shock

NURSING INTERVENTION addisonian crisis:

Monitor

LOC Protect client from infection Monitor electrolyte imbalances

THYROID CRISIS – (THROID STORM/ Thyrotoxicosis)Acute life threatening condition that occurs in a client with uncontrollable hyperthyroidism – maybe a result of manipulation of thyroid gland during surgery(release of thyroid hormones to bloodstream)

THYROID CRISIS – (THROID STORM/ Thyrotoxicosis)Causes: Undiagnosed , untreated hyperthyroidism, infection, trauma

Medical management: Antithyroid medications; beta blockers; glucocorticoids & iodides are given before surgery to prevent thyroid crisis

Medical management:

Antithyroid

meds: Iodide, Propylthiouracil, Methimazole Iodides/ Iodine = Reduce the vascularity of the thyroid gland before thyroidectomy,

Medical management:

Iodides=

used in the treatment of thyroid storm because it enables the storage of TH in the thyroid gland.

Medical management:

However

it is given only for 10-14 days Because eventually it looses its effect on the thyroid gland.

NURSING INTERVENTION: ASSESSMENT : elevated Temp ( high fever); tachycardia; agitation; tremors Maintain a patent airway

NURSING INTERVENTION:

Administer

antithyroid meds as prescribed ( sodium iodide solution) Monitor VS

MULTI ORGAN DYSFUNCTION SYNDROME (MODS) SEPSIS, DEAD TISSUE, PNEUMONITIS, PANCREATITIS

RESPIRATORY FAILURE

INTUBATION (maybe stable for 7-14 days)

MALFUNCTION of GI

SEEDING OF BACTERIA FR. GI TO OTHER ORGANS

HYPERMETABOLIC STATE

HYPERMETABOLIC STATE (hyperglycemia, hyperlactacidemia, ulceration in GIseeding of bacteria from GI to other organs) (skin breakdown, loss of muscle mass, delayed healing of surgical wounds) (mortality rate 60%)

LIVER FAILURE(jaundice), RENAL FAILURE (mortality rate 90-100%)

Criteria for Dx of MODS

Cardiovascular Failure presence of 1 or more of the ff: <54

bpm Systolic < 60 mm Hg Vtach/ V fib pH < 7.24

Respiratory Failure RR

< 5/min RR> 49/min

Renal Failure presence of 1 or more of the ff: Output

< 479 ml/24 hr or < 159 ml/ 8 hr BUN > 100mg/dl Crea > 3.5mg/dl

Hematologic Failure presence of 1 or more of the ff: WBC

< 1000 uL Platelets < 20,000 HCT < 20%

Hepatic failure presence of both of the FF: Bilirubin

> 6 mg % PT > 4 sec over control in absence of anticoagulation (normal PT – 11-12sec)

Neurologic Failure

GCS < 6 in absence of sedation

Med MGT: Control of infection w/ antibiotics ( common MRSA & Vancomycin resistant Aggressive pulmonary care mech vent & O2 (intubation) Enteral (NGT) feeding

NRSNG MGT: Limited : effective client & family coping