Test 1 - Hemodynamics, Renal, Burns Flashcards
S/S of Sepsis
- Temperature greater than 102.2
- Progressive tachycardia and tachypnea
- Low platelets (thrombocytopenia)
- Hyperglycemia
- Insulin resistance
- Large amounts of residual tube feeding
Systemic Effects of Sepsis
-Fluid shifting (third spacing)
Hyperkalemia
Hyponatremia
-Hemoconcentration = poor perfusion
H&H ^^^; blood thickensParkland Formula
% burn (TBSA) x wt. in kg x 4 mL = fluid to replace
Give 1/2 in the first 8 hrs post-injury, and 1/2 in the next 16 hrs
TBSA calculation
F. Torso: 18% R. Torso: 18% RA: 9% LA: 9% LLE: 18% RLE: 18% Head: 9% Genitals: 1%
Assess Fluid Adequacy in Burns
Assess UOP:
- Regular Burn: 30 mL/hr - Electrical Burn: 70 mL/hr
NGT for burn patient (>20% TBSA)
- Ileus likely, and stomach acid production doesn’t stop and must be removed
- May remove at return of bowel sounds or passing of gas/stool
TPN - may need for patients with Ileus
- Give through central line
- Monitor BG
- If new TPN bag missing, hang D10 while getting new bag
Transfer Prep
Dry Gauze only!
Increased Risk of Death in Burn Injury
- Older than 60 yrs. old
- Burn >40%
- Inhalation Injury
S/S of CHF
- Crackles
- SOB
- Edema
- Pallor
- Cold/Clammy
- Increased cap refill time
- Decreased renal perfusion
- JVD
UOP
1 ml/kg/hr (~30 ml/hr)
Cardiac Output Equation
CO = HR x SV(oreload, afterload, contractility)
Starling Law
Greater stretch will produce greater CO –> to a point
Afterload (PVR and SVR)
PVR (Pulmonary Vascular Resistance): R. Ventricle
SVR (Systemic Vascular Resistance): L. Ventricle
Cardio Myopathy
Overstretched heart
Pulmonary Vascular Resistance (PVR)
37 - 250 dynes/sec/cm
Systemic Vascular Resistance (SVR)
800 - 1,400 dynes/sec/cm
Afterload (Increase/Decrease)
Vasoconstriction/Vasodilation
Factors that affect Preload
- Over-infusion
- R/L Ventricle fail or poor contractility
- Hemorrhage
- Extreme vasodilation
Dobutamine
Inotropic (increases contractility)
Atropine
Increases HR (and thus CO)
Dopamine
Vasopressor/Vasoconstrictor
Nitroglycerin
Vasodilator
NorEpinepherine (Levophed)
Increases contractility, vasoconstriction, and HR
Factors that raise vascular tone
HTN, vasopressors
Factors that lower vascular tone
Distributive shock, Nitro
Cardiac Output (value)
4-8 L/min
RA/CVP (R. Preload)
2-6 mmHg or 2-8 cm H2O
Wedge Pressure (L. Preload)
8-12 mmHg
If Wedge unavailable, check???
PAP Diastolic pressure
Measuring Hemodynamics, requires patient to be
HOB @ 45 degress or less (Phlebostatic axis parallel to transducer)
Air Embolism S/S & Treatment
S/S: angina
Treatment: Trendelenburg, roll onto left side
Cardiac Tamponade
Fluid b/w layers of the heart
Cardiac Tamponade S/S and Treatment
S/S:
- Muffled S1 & S2
- Decreased CO & BP
- Incresed HR
Treatment: ask pt. to move, cough, or RN may remove PA cath
Lasix (Furosemide)
- Diuretic
- Give in CHF to remove excess fluids
Ejection Fracture (value)
60-70%
MAP equation
MAP = [ (2 x diastolic) + Systolic] / 3
Arterial Line Implications
- Allens Test: 7-10 seconds
- DO NOT PUSH IV DRUGS
- Observe waveform to determine placement
- MAP should be >65 mmHg (should be within 10 mmHg of manual MAP)
Kidney Functions
-Maintain fluid & e-lyte balance
-Regulate BP
-Produce HCO3 (bicarb)
-Filter waste
-Produce erythropoietin (stimulate RBC production)
-Hormone for Ca absorption
-Creates Urine (1500-2000 mL/day)
Minimum UOP: 30 mL/hr
Glomerular Filtration Rate (value)
Normal: >60
Sodium (value)
135 - 145
Potassium (value)
3.5 - 5.0
Specfic Gravity (value)
1.010 - 1.025
Specific Gravity HIGH/LOW
HIGH: Hypovolemia/dehydration, Elevated ADH/SIADH
LOW: Hypervolemia, Diabetes, Glomerulonephritis
Renal failure
Renal Biopsy (Implications)
Pre: Prone, NPO
Post: Supine, watch for bleeding, localized pain expected, hematuria up to 72 hrs
Polycystic Kidney Disease
Genetic disorder resulting in cysts
Autosomal Dominant PKD (one parent)
- Most common
- Cysts by age 30
- 50% pass to child
Autosomal Recessive PKD (both parents)
- RARE
- Cysts by birth/in womb
PKD S/S
- Abd/flank pain
- Increased abdominal birth
- HTN r/t renal ischemia
- Hematuria
- Constipation
Cysts can grow in liver, pancreas, and blood vessels
*High incidence of cerebral aneurysm, heart valve issues, kidney stones
PKD Implications
- Family history
- Abx
- Pain control
- Avoid constipation
- Control HTN (ACE inhibitors -angioedema risk)
- Notify HCP if HA doesn’t go away
- Dyialysis or transplant
Glomerularnephritis/GN (Acute Nephritic Sydrome)
Inflammation of glomerulus = decreased filtration of blood
GN Causes
Primary: genetic or immune
Most commonly: Upper Resp. Strep. Infection
Secondary
Types of GN:
Acute (AGN)
Chronic (CGN)
Acute Glomerulanephritis (AGN)
- Occurs 10 days after recent infection
- Ages 3 to 14
AGN Assessment Findings
-Fluid retention
Facial/peripheral edema
-HTN
-Dysuria/Oliguria
-Fatigue, N/V from high uremiaAGN Diagnostic Tests
- UA positive for: blood, protein, WBC
- Serum CR elevated
- Decreased GFR
- Renal biopsy
AGN Implications
- Daily weight
- Limit protein
- Strict I&O (output plus 500mL insensible loss)
- Limit potassium
Chronic Glomerularnephritis (CGN)
- Slow progression, occurs over 20-30 yr
- Symptomatic only in late stage
- Idiopathic
- Similar tests to AGN
GN S/S
- Anemia
- Fluid and e-lyte imbalance
- Hyperkalemia
- Hyopcalcemia
- Acidosis
Nephr-o-tic Syndrome
-High levels of Proteinuria (>3.5 in 24 hr)
Low oncotic pressure
-Idiopathic
-Most common in ages 32-7
-Liver is triggered to produce “bad” protein (protein & cholesterol)
Edema
Treat with: ACE, statins, diet per GFR (low sodium and cholesterol)
Diabetic Nephropathy
More than 1/2 of diabetics develop this
-Caused by progressive microvascular deterioration
Early indication of Diabetic Nephropathy
Persistent microalbuminuria (> 0.3 g/dL)
Implications for Diabetic Nephropathy
-Aggressive diabetic control: check A1C (less than 6.5)
-ACE Inhibitors (-pril)
BP control, protect kidneys, suppress inflammation,
control BP
-Avoid pregnancy
-Hypoglycemic episodes as kidney declines r/t increased free insulin
Renal Failure (2 types)
- Acute Kidney Injury (AKI)
- Chronic Kidney Disease (CKD)
Acute kidney Injury (AKI)
Rapid onset, reversible
Risk category for AKI: serum CR 1.5 x normal, or UOP <0.5 mL/kg/hr for more than 6 hr
Chronic Kidney Disease (CKD)/Chronic Renal Failure (CRF)
Slow onset, permanent damage
GFR <60
Types of AKI
3 Types:
Pre-renal: hypoperfusion volume
Intra-renal: intrinsic damage
Post-renal: obstruction
Phases of AKI
3 Phases:
Oliguric: UOP 100-400 mL/day, Increased BUn/CR, fluid overload, LOW sodium r/t dilution, HIGH potassium r/t no removal
Diuretic: UOP up to 5-10 L/day, Potassium and Sodium BOTH LOW
Recovery: output returns to normal 1-2 L/day
AKI Implications
- Monitor signs of fluid depletion/excess
- Daily weight
- Be aware of nephrotoxic substances (NSAIDs)
CRF
1 risk factor is diabetes
Progressive, irreversible
CKD becomes End Stage Renal Disease (ESRD)
Azotemia: accumulation of wastes in blood
Uremia: symptomatic azotemia
CRF Causes
Diabetes HTN Chronic urinary obstruction Autoimmune disorders Glomerular diseases
Changes in CRF/CKD
- HTN, HF
- Hyperkalemia
- Metabolic acidosis
- Uremic halitosis, N/V, anorexia, GI bleed
- Pericarditis, angina, pericardial friction rub
- Pleural friction rub
- Low erythropoietin, iron, and folic acid -> anemia
- Uremic frost
- Hypocalcemia
Implications of CRF/CKD
Fluid volume management
Stable Weight
PO fluids: 500 mL plus previous output
NA restriction
Monitor for S/S of HF: edema, crackles, SOB, tachycardia, anxiety
Diuretics, Morphine sulfate (for pain and
vasodilation)
Diet depends on type of dialysis and degree of kidney damage
Control BP for CRF/CKD
Caclium Blockers “pine”
ACE Inhibitors “pril”
Beta blockers “lol”
Alpha blockers “zosin”
S/S of abnormal bleeding
- Lethargy
- Hyoptension
- Pallor
- Tachycardia
- Tarry stool (use hemocult test)
CRF/CKD drug
Eopgen (Procrit)
stimulates RBC production
lifelong treatment
takes 2-6 weeks to have an effect
can cause HTN, bone pain, and increases clot risk
-may need multivitaminsHyperkalemia
Normal: 3.5-5.0
S/S:
Neuro- decreased reflexes and sensation
Resp- resp muscle paralysis
GI - N/V, diarrhea
CV: Peaked T waves, bradycardia, wide QRS, V-fib
Hyperkalemia options - mild
Dietary changes, avoid high potassium foods
-potatoes, oranges, broccoli, raisins, banana, salt substitute, avocado
Hyperkalemia options - severe
-Furosemide (lasix) - ototoxicity risk
-Kayexalate (sodium polstyrene sulfonate) - rectal
Beware of digoxin interaction, and ileus
-10 units IV regular insulin in D50 or use Albuterol (lowers potassium)
-Calcium gluconate: monitor for EKG changes (tall PT wave)
-Treat acidosis: sodium bicarb
-Dialysis
Phosphate Level (value)
2.5 - 4.5 mg/dL
Hyperphosphatemia
Level > 4.5
Renal failure retains phophorus and doesn’t have enough hormone to absorb calcium
Hyperphosphatemia management
- Avoid high phosphorus foods (processed meats, organs, avoado, peas)
- Administer phophate binders (calcium gluconate/Tums, sevelamer/Renagel)
- Meds with meals
- S/S of hypophosphatemia (weakness, anorexia, confusion)
- Avoid other meds
- Stool softner
To combat constipation
- Increase activity and add fiber
- No OTC w/o approval
- Avoid fleets enema (high phosphate)
- Avoid Milk of Magnesia, Maalox Mylanta
- Stool softner if ordered
Calcium Levels
8.5 - 10.5 mg/dL
Hypocalcemia Signs to check
Levels <8.5 mg/dL
Trousseau’s Sign: wrist spasm w/ BP cuff
Chvostek’s Sign: facial twitch when touched
Hypocalcemia S/S
Respiratory: larygneal spasm
Cardiovascular: dysrhythmias
Musculoskeletal: osteodystrophy, calcifications
To increase Calcium levels
Calcitrol (rocaltrol) - activated vitamin D to trigger Ca absorption in GI
Calcium supplements
Phosphate binders
Goals of Dialysis
- Remove excess end products of protein metabolism (BUN/CR)
- Ensure safe levels of e-lytes
- Remove excess fluids
- Restore acid/base balance (remove acids, replace bicarb)
3 Types of dialysis
Hemodialysis (access fistula in arm), Peritoneal Dialysis (access peritoneal cavity), Continuous Renal Replacement Therapy (very slow for unstable patients)
Hemodialysis
2-3 sessions/wk for 3-4 hrs
- Need long term access on non-dominant hand(fistula or graft)
- Vas cath for temp use if needed immediately
HD contraindications
- Low BP (MAP <70), hemodynamically unstable
- Bleeding tendency/history
Nursing Care for HD
- wt b4/after dialysis (dry weight after should be lower)
- V/S
- Avoid invasive procedures post dialysis 4-6 hrs
- Dialysis removes meds except insulin, give them after
Disequilibrium Syndrome
- Rare, happens with first time HD pts
- Prolonged HD can cause cerebral edema
- S/S:
- Alt. LOC
- Seizure
- N/V
- Muscle cramps
- Monitor for depression
- Consider continuity of care
Pt teaching for access
Assess fistula for thrill and bruit
Continuous Renal Replacement Therapy (CRRT)
-Very slow dialysis
-Use for hemodynamically unstable pts
-Implications:
V/S
I&O
Labs
Hypothermia
S/S of infection
Peritoneal Dialysis (PD)
PD catheter into the abdominal cavity
1-2 L fluid infused by gravity over 10-20 minutes
4-8 hrs dwell time, then drain
Contraindications for PD
- Recent abd surgery -> adhesions, scars
- Peritonitis
- Excessive abd obesity
- COPD
Nursing care for PD (inflow)
-Monitor for peritonitis
Rigid abd, high fever, N/V -> stop infusion, call HCP
-Monitor V/S and wt
-Mild pain during inflow is normal
avoid cold dialysate
use heating pad to warm fluid (no microwave)
Elevate HOB
Nursing care for PD (outflow)
-Output must equal intake
-Poor/slow outflow
avoid constipation (enema prior)
reposition pt from side to side
milk tubing gently if clotted
continuous leakage (may need HD)
PD - RED FLAG
if cardiac arrest occurs during PD, drain immediately to allow best chest compression
Renal Transplant
Recipients (2-70 yr)- free from medical or psych problems that would increase complication risk
Donor (18-60 yr)- meet criteria, living related = “best”
Additional donor requirements
Type match Antibody screen Kideny function test Psych eval Able to be unpaid for 12 weeks for recovery
Renal transplant nursing care
- Daily wt, V/S (BP)
- Monitor output (foley)
- Diuresis normal at first (monitor e-lytes)
- Monitor for low fever, pain, increase BUN/CR, swelling, alt. mental status
Transplant patient education
- Immunosuppressants for life
- Keep daily record of wt, V/S, and UOP to monitor for rejection (report change immediately)
- Increased infection risk (avoid crowds, wear a mask, prophylactic abx)
- Pregnancy can cause complications
- Oral contraceptives work less
- No NSAIDs w/o approval
Increased BUN/CR
S/S of concentration r/t low volume
Increaed Wedge pressure (or diastolic PAP)
Left sided HF (CHF)
Basic Knowledge r/t burn
Skin is the largest organ
Skin functions:
sensory
protective barrier
maintain fluid/e-lyte balance
vitamin-D productionBurn Etiology
Skin can regrow if parts of dermis remain
Burns may cause alterations in anatomy and function
Superficial Burn
Only epidermal layer
Sunburn is most common superficial burn
No need for IVF or burn center
Skin layers
epidermis > dermis > fatty tissue
Superficial partial thickness burn
Epidermis and top layer of dermis burned
- Pain r/t exposed nerve endings
- wet, weeping blisters
- heals in 1-2 weeks
Deep partial thickness burn
Epidermis to bottom layer of dermis
- varying levels of pain and decreased sensation
- soft/dry eschar
- heals in 2-6 weeks
Full thickness burn
Entire epidermis and majority of dermis
- Cherry red color
- Decreased or absent cap refill
- Hard, non-elastic eschar
- May involve bone & muscle
- Heals in weeks to months
Deep Partial and Full Thickness Burn - Eschar
Eschar must be removed to allow healing to begin
Circumfrential burn
Full thickness burn all the way around digit, limb, or torso
Affects circulation distal to injury (touriquet effect*)
DO NOT ELEVATE until escharotomy -> may worsen condition
Escharotomy
Cuts made in eschar to release pressure
Not painful, but may need sedation
Fasiotomy
Incision into the fascia surround the muscle to improve circulation
- Deeper than escharotomy
- Painful
Inhalation injury
S/S:
- Facial burns
- Singed nasal and facial hairs
- Soot (carbonaceous) sputum
- Naso or orpharyncerythema
- Excessive agitation (r/t hypoxia)
- Tachypnea
- Inability to swallow (r/t airway edema)
- Dyspena (r/t airway edema)
Carbon Monoxide Poisoning
CO is odorless, colorless, tasteless S/S: -cherry red skin (40% or higher) -HA, confusion, hypotension, tinnitus, vertigo, Nausea >50%: coma, seizure, death
Pulse ox will give false high
Systemic effects of burns
CV: hypotension, tachycardia, absent cap refill and pulse
Renal: decreased perfusion, little to no UOP, proteinuria/myoglobinuria
Metabolic effect of burns
- Increased metabolism up to 3 yrs post injury
- Double normal resting energy use and nutrition need
- Supplemental nutrition needed
- Based on TBSA and other factors
Immunological effect of burns
-Loss of skin integrity and release of inflammatory factors
-High risk for infection and sepsis
If pt. survives 1st 24 hrs, sepsis is #1 COD
S/S of Sepsis
Temperature >102.2 F (39 C) Progressive tachycardia and tachypnea Low platelets Hyperglycemia Insulin Resistance Large amounts of tube feed residual
Fluid Shift (third spacing)
Plasma moves to interstitial space
Hyperkalemia/Hyponatremia r/t release of K from damaged cells
Hemoconcentration: causes poor perfusion
H&H increases; blood thickens w/o plasma
Factors to consider with burns
Chemical: protect self
Radiation: transfer to decontamination to protect self
Electric: EKG, no TBSA to measure
Burn implications
Airway: need NGT w/ >20% TBSA
may need TPN for nutrition
Fluid replacement: needs 2 large bore IV or central line, calculate with Parkland Formula
Fluid adequacy evaluation for burns
UOP:
70 ml/hr for electrical burn
30 ml/hr for all other burns
BP: >100
HR: <120
CVP: 5-10 mmHgFluid remobilization
- After first 48-72, edema is reabsorbed
- Hypokalemia and Hyponatremia
- Met. acidosis r/t HCO3 excretion in urine
- Hemodilution (transfusion needed if HCT <20)
Conditions for graft survival
Constant contact
Constant immobilization
Adequate vascularization
Meticulous skin care
NO HEATING PADS
Implications for infection control
Hand washing #1 S/S of infection IV abx Cough, deep breathe, ICS HBO therapy
Implications for pain control
-Routinely and frequently
-Pain is what patient says
-No PO, SQ, IM meds (body is damaged and can’t absorb, tetanus shot still IM)
-S/E: respiratory depression, ileus (20% burn need NGT to prevent ileus and remove excess stomach acid if occurs)
BS or BM to know removal time of NGT
TPN
If new bag missing, hang D10 until new bag is found to prevent hypoglycemia
Burn Transfer Prep
DRY GAUZE ONLY
Inotropic Drug
Dobutamine: given to increase contractility w/ good BP
Vasopressors
Nor-Epi and Dopamine: given to vause vasoconstriction
Diuretics
Lasix and Bumex: given to reduce BP and get rid of excess fluid
