CC final: Forensics, Burns, Organ Transplant, Acute Renal Failure Flashcards
What type of bag should you put forensic evidence in?
Paper bag. Plastic ones will produce mold because of a lack of proper drying if the evidence is wet. If wet, allow to dry before sealing the paper bag. If unable to dry, seal in paper bag, place in plastic (bio-hazard bag), and do not seal the plastic bag. Put each item in separate bags. Trace evidence can be removed with transparent tape which can be placed onto paper evidence bag (hair fibers, etc)
What is the number one priority for the medical team with forensics?
To medically stabilize the patient. All attempts should be made to preserve/collect evidence unless the patient is in imminent danger of death.
When should you describe and document wounds during forensics?
definitely prior to any medical treatment (unless life-saving measures are required); and after treatment, if possible.
What do you do with evidence photographs (in relation to the police)?
They are a physical part of the medical chart and should NOT go with the police; they stay with the chart. Police have to have a subpoena to get them.
When photographing evidence, what is the best angle to take?
90 degree.
If you are unable to get paper bags to put evidence in, what is a good way to store the evidence at the time of removal (ie of clothes)?
Place 2 sheets (one on top of other) on the ground to place evidence on. Top sheet will go into paper evidence bag once all other evidence is collected and bagged and can be used to collect trace evidence. Bottom sheet sent to laundry. If space is limited, a sheet-lined cardboard box can be used for evidence to be placed in and the sheet can be sealed upon completion to be used for trace evidence.
What is the most important organ for evidence procurement?
skin
What do you do with dried secretions?
Moisten swab with NS or Sterile water, collect specimen, and place into plastic specimen container. Allow swabs to dry before sealing, if possible. Swab any area of the patient’s body that is not obviously explained by the injuries.
Can you cut clothing off the patient when getting forensic evidence?
If it has to be, cut away from obvious evidence (ie gunshot area).
How should you remove shrapnel (ie gun fragments, explosive fragments, etc)?
Should be removed only with rubber-tipped forceps (to avoid scratching) and place in plastic cup (not metal) (to avoid scratching)
What should you do if a weapon is found?
Handle carefully (with gloves); Give to police, if present, or to the security personnel. If they are legally registered (have a concealed carry license), they are allowed to have it legally but you will still give it to security until the patient is discharged.
What info should bags/specimen containers have?
ID information
Date
Time
Where obtained (location of body)
Are direct statements of patients in documentation admissible in court?
Yes.
What are some things you should document upon arrival ?
- State of emotions
- All noted wounds (before and after treatments)
- if gunshots, note suspected entrance and exit wound locations and conditions
- any residue, powder, soot, particles, etc
- Unusual odors (ie Ammonia (meth explosions))
- Behavior, attitude, preoccupation with items or persons
When is the RN exempt from HIPAA Violations during a forensic case?
If the people have a court order or subpoena
Signs of child abuse:
- Bruises on Posterior side of body, unusual patterns/stages of healing
- Burns (especially scalding)
- Missing/loosened teeth
- Skeletal injury (look at healing patterns)
S/s of Domestic Violence:
- Partner unwilling to leave patient alone during assessment
- Delay between injury and presentation
- Bilateral, multiple or patterned injuries
- Physical findings inconsistent with medical history
- Partner controlling
What abuse is mandatory to report in KY?
Adult: Any person over age 18 who is mentally or physically dysfunctional and unable to manage resources; Any person (regardless of age) who is a victim of abuse by spouse
Child: Any person under age of 18
What are some examples of Coroner’s Cases? What do you do with the body?
- Death by homicide/violence
- Result of Suicide
- Result of presence of drugs/poisons
- Unexplained death occurs while in a state mental institution or hospital
- Death sudden & unexplained
Don’t remove any lines/tubes/airways
Clothing/belongings go with body usually
Don’t clean body
If gun-shot residue is suspected on hands, place hands in paper bags & seal with tape
The most common intrarenal condition that may occur after prolonged ischemia (prerenal), exposure to nephrotoxic substances (ie some meds), or a combination of these =
Acute Tubular Necrosis (ATN)
The absence or suppression of urine =
Anuria
Increases in BUN and serum creatinine =
Azotemia
What is Oliguria?
Urine output less than 0.5 mL/kg/hr
What’s a normal BUN level?
7-20
Normal Creatinine level?
0.7-1.4
Retention of nitrogenous substances (ie urea) normally excreted by the kidneys =
Uremia
Occurs as a result of a pressure gradient; Blood flows through each glomerulus and water, electrolytes, and waste products are filtered out of the blood across a membrane and into Bowman’s capsule; should basically be protein free and contains electrolytes (Na, Cl, Phosphate), and nitrogenous waste products (creatinine, urea, uric acid); RBC’s, albumin, and globulin are too large to pass through it in a healthy kidney
Glomerular filtration
What is a normal GFR?
80-125
With a MAP of <___ or >____, the kidneys will have a hard time adjusting to fluctuations in arterial BP. The GFR will ____ drastically with an extreme MAP.
60; 250; fall
Describe the RAAS (Renin-Angiotensin-Aldosterone System) Cascade:
Hypovolemia/Low BP/Renal Ischemia or Decreased Sodium Ion concentration of blood causes Renin production by cells in the Juxtaglomerular apparatus of the kidney; Renin plus Angiotensin (produced by the liver); Release of Angiotensin 1 from the liver (a weak vasoconstrictor); tells lungs to produce & secrete ACE which converts Angiotensin 1 to Angiotensin 2 (a major vasoconstrictor); this stimulates release of Aldosterone (causes retention/reabsorption of Na & H2O/potassium excretion)=more fluid in BV’s= Increased BP
Prerenal causes of ARF/AFI:
(60-70% of kidney probs); Interfere with renal perfusion
Volume depletion
Vasodilation/hypoperfusion
Decreased performance/Cardiac failure
Misc (meds (ie ACEI,NSAIDS–block Cox 1, the good Cox), sepsis, neurogenic shock)
What are the most common causes of ARF/AKI?
Prerenal Etiologies
How do ACE Inhibitors work?
Block Angiotensin 1 from converting to Angiotensin 2
What is often a 1st clue of stressed kidneys?
Decreased UO (because GFR decreases, solutes move more slowly=dec UO)
What is the most effective method of treatment for Prerenal ARF?
Increase fluid intake
Treatments for Pre-renal ARF:
With hypovolemia, give fluid volume challenge (type of fluid varies); UO should Increase within 10-20 mins, and if not seen within 30-45, then fluid challenge failed and may be repeated.
Meds to restore CO via increasing HR or BP as needed.
Restore defense mech’s (RAAS) by d/c-ing ACE/ARB’s
How do ARB’s work?
stop Angiotensin 2 from binding to its receptor sites.
Hypovolemia S/s?
Low CVP or PAWP Flat jugular veins Tachycardia Hypotension Poor Skin turgor Weight loss
Hypervolemia S/s?
Increased CVP or PAWP Distended jugular veins Rapid Heart Rate S3 Elevated BP Dyspnea Crackles Shallow, rapid respiration
When do you draw the peak and trough of meds?
Peak: When metabolites are at their highest (a/b 30-60 mins after latest dosage)
Trough: When at lowest: drawn right before next dose
What are some things you need to have caution with for Pre-renal ARF?
Diagnostic dyes and test that require extra filtering of substances, meds, etc.
If possible, avoid nephrotoxic substances
Peak and trough of known nephrotoxic meds to avoid toxicity (ie Antibiotics like Vancomycin, Gentamicin, etc)
Aseptic technique to avoid infections
Causes of Intrinsic/Intra-renal Failure:
Acute Glomerulonephritis Vascular Disease (malignant HTN, Hemolytic Uremic Syndrome--from E.coli exposure often) Tubular Obstruction (Rhabdomyolysis--huge release of myoglobin clogs kidneys) Acute Tubular Necrosis (the most common form of intra-renal failure)** Pre-renal failure is the most common cause of intra-renal failure**
Conditions or situations that are high risk for Intra-renal failure:
- Meds (NSAIDS, antibiotics, ACEi's) - Contrast media (dye) - Overdoses - Hemodialysis (especially on an otherwise healthy kidney, ie OD)
What is a first s/s of antibiotic toxicity?
Tinnitus
What are the two main types of ATN (Acute tubular necrosis)?
Ischemic & Toxic
What is Ichemic ATN due to?
Due to Prolonged Hypoxia
Causes the tubular cells to swell, slough off and then occlude the tubular lumen
Also permits profound renal vasoconstriction (can also be caused by pharm agents (neo, norep, ARB’s, etc)
What causes Toxic ATN?
Concentration of nephrotoxins in tubular system
Meds (aminoglycosides antibiotics–neomycin, tobramycin, gentamicin,etc)
Occurs 7-10 days after insult
Diagnostic dyes–usually within 48 hours
Aggressive hydration is main way to prevent this problem (assuming heart/lungs can handle it)
Stages of ATN (now usually only called Intra-renal Failure):
1) Onset
- begins with insult & until cell injury occurs–lasts 2-4 days
- Goal: determine cause & prevent progression of RF
- s/s: dec. UO, Inc. BUN/Cr slightly
2) Oliguric/Anuric
- main goal: support renal function & keep patient alive (inc. K+ is problematic)
* * <400 mL/day
- 10-14 days
3) Diuretic
- degree depends upon hydration state at time of onset, BUN/Cr slowly recover, lasts about 10 days
4) Convalescent
- Most fully recover
- Can last up to 1 year
What is the most sensitive indicator of kidney function?
Creatinine
What is Post-renal failure generally caused by? What occurs?
Generally deals with obstruction
Lowers GFR & Tubular fluid flow
Increased Na, water, & urea reabsorption lowering Na urine concentration & Increasing Urine Osmolality, BUN, & Cr.
Requires blockage of both kidneys (or unilateral if only one kidney present)
After obstruction is cleared, profuse urination may present (1 L/h at times); watch electrolytes closely. Don’t let all the fluids come out at once (will cause bladder spasms); clamp f/c, wait 20 mins, & restart
What will the BUN and Creatinine be like with ARF?
BUN INCREASED due to dec urine flow rate (increased urea absorption); Creatinine INCREASED due to GFR decrease
How do you do a 24-hour urine?
1) patient empties bladder, exact time is recorded, and specimen is discarded.
2) All urine for the next 24 hours is saved in container & stored in refrigerator.
3) Exactly 24 hours after the start, the patient voids again, and the specimen is saved.
4) The serum creatinine level is assessed at the end of 24 hours.
5) The urine is sent to the lab for testing. (urine can also be saved from an indwelling catheter.
The test is valid only if the collection includes all the urine you pass in a 24-hour period. The test will be inaccurate and may have to be repeated if, for any reason, some of the urine you pass during the 24-hour period is not put into the collection container.
Urine kept on ice. If they accidentally go in the toilet, you’ll have to restart.
What does a 24-hour urine check specifically?
Creatinine Clearance. The most accurate reflection of reduction in nephron functioning.
Name 3 nursing diagnoses for the patient with Acute Kidney Injury:
- Excess fluid volume r/t Na/H2O retention & excess intake
- Risk for Infection r/t depressed immune response secondary to uremia & impaired skin integrity
- Imbalanced nutrition: less than body requirements related to uremia, altered mucous membranes, & dietary restrictions.
What’s the least common type of ARF?
Post-renal ARF
Type of Dialysis that’s intermittent, can be temporary or permanent, usually in adjunct to kidney transplant; if long-term, shunt is placed.
Intermittent Hemodialysis
Type of Dialysis utilized only in the ICU, is very intense & continuous, usually utilized to rest heart/vital organs =
CRRT (continuous renal reperfusion/replacement Therapy)
Least invasive type of Dialysis that does not require a shunt; instill osmotic solution into abdominal cavity =
Peritoneal Dialysis
What is the most common type of Dialysis?
Intermittent Hemodialysis
What is CRRT often used for ?
People with HF
Indications for Dialysis: (7):
ARF CRF Fluid Overload PE HF Electrolyte Imbalances Overdoses
What do you do if a patient is on Intermittent Hemodialysis and they are also on meds?
Make sure you give meds 2 hours prior (or if you can wait, give after). If on continuous IV’s, you can just let run. Piggybacks instilled 2 hours prior (or stopped).
What med is often given with Dialysis?
Heparin. So check PTT
What is the most common complication from Peritoneal Dialysis?
Peritonitis.
What organization do you contact to talk/deal with patients getting Organ Transplantation?
KODA (Kentucky Organ Donor Affiliates).
Who started the online database used for the collection, storage, analysis, and publication of all data dealing with the patient organ donor waiting list, organ matching, and transplants? What’s it called? Why’s it important?
UNOS went online with their database in 99’; it’s called UNet; You have to be in this system to get transplant
When an organ becomes available, a list of potential recipients is generated according to the ranking of what? (6) What happens after that?
1) Blood type
2) Tissue type (Antigen/Antibody)
3) Size of the organ
4) Medical urgency of the recipient
5) Time on waiting list
6) Distance between the donor & recipient
All of first 4 things being equal, longest on list gets it.
BTSUTD “Billy took Susie up to Denver”
The procurement coordinator (usually an RN) contacts transplant physician of top candidate to offer the organ. If surgeon decides it’s not suitable, the same process happens with the next ranked candidate. Physician has last say in whether they are good to get it.
Surgical teams notified.
Kidney & pancreas are required to have additional lab tests to test immune system compatibility.
For an organ transplant, a heart or lung are best within ____ hours; Liver can be stored up to _____
6; 24 hours
