Understanding Pulmonary Embolism: Causes, Symptoms, and
School
Grambling State University**We aren't endorsed by this school
Course
NUR 219
Subject
Nursing
Date
Dec 10, 2024
Pages
51
Uploaded by Lateria1
MED SURG 2 EXAM 2😭😢Sad Adventures of the Lung, Liver and Pancreas😢😭“Are you ok? You’re breathing WEIRD”THIS IS THE BEST TITLE YET!Pulmonary embolism - Pathophysiology➔Blockage in one of the pulmonary arteries in the lungs◆Caused by blood clots that travel to the lungs from deep veins in the legs or (rarely) other parts of the body. = DEEP VEIN THROMBOSIS◆When thrombus completely or partially obstructs a pulmonary artery or branches the alveolar dead space is increased●Gas exchange is impaired or then absent in the area◆Massive PE is best defined by the degree of hemodynamic instability ●Occlusion of outflow tract of the main pulmonary artery➔Blood clot that forms in a blood vessel in one area of the body, breaks off, and travels to another area of the body called an EMBOLUS.➔Embolus can lodge itself in the blood vessel and block blood supply to organs◆The blockage of a blood vessel by an embolus is called an EMBOLISM.◆Slower blood flow leads to clot formation➔VTE- Venous thromboembolism = blood clots - umbrella term that includes DVT and PE (1)➔RISK FACTORS-◆Surgery - LEADING CAUSE●Intervention- medication to prevent blood clots may be given before and after major surgery◆Immobility or reduced mobility, Oral contraceptive/hormone replacement therapy, prolonged air travel, pregnancy◆Kidney disease can also increase risk for blood clots◆Heart disease, Cancer (malignancy), clotting disorders, obesity, Hx of DVT, cigarette smoking, HFPulmonary embolism- Clinical Manifestations SATA(2)➔Hypoxemia- low O2 in the blood◆A clot in the lung somewhere is blocking the blood and can’t pass O2 = low O2 in blood➔Dyspnea- shortness of breath◆Blood carries O2 which need to breathe (gasping for air)1
◆Most frequent sign and appears suddenly, worse with exertion**➔Tachycardia- Fast heart rate - 140◆The heart kicks in to compensate by pumping faster to move blood faster through the body to increase O2.➔Tachypnea- Fast breathing - 32?it fast◆Not enough O2, breathing gets faster◆Most frequent sign**- very rapid respiratory rate➔Cough-◆Bloody or blood streaked sputum, pink tinged (Hemoptysis)➔Chest Pain-◆Inflammation from the clot◆Sudden and pleuritic**➔Anxiety-◆Racing heart, gasping for air, chest pain, can’t breathe.➔OTHER S/S: HYPOXIA◆Irregular heartbeat◆Syncope◆Lightheadedness or dizziness◆Excessive sweating◆Fever◆Leg pain or swelling◆Clammy or discolored skin➔Diagnostic Tests-◆V./Q. - ***MOST IMPORTANT TEST**●Also called a Ventilation (V) Perfusion (Q) scan●Made up of two scans that examine air flow and blood flow to lungs●Uses a small amount of radioactive substance called a tracer that helps look for diseases in the body●Compares the amount of perfusion in a lung segment with the degree of ventilation in that segment●What do you hear from patients when they breathe out? ◆Pulmonary Angiogram- GOLD STANDARD for diagnosis**◆Chest X-Ray- atelectasis◆ECHO- Enlarged right-sided heart chambers, tricuspid regurgitation◆ECG- rule out MI◆Pulse ox- hypoxic?◆ABG Analysis- hypoxemia and hypocapnia2
◆D-Dimer- fibrin (a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis)Pulmonary embolism- Treatments➔Massive PE is a LIFE-THREATENING EMERGENCY◆Immediate action is to stabilize the cardiopulmonary system●Oxygen is given IMMEDIATELY to relieve hypoxemia(3)●IV infusion lines●Prompt vasopressor therapy●Pulse ox, ABGs are preformed●ECG, Lab draw, Indwelling catheter is placed●IV morphine or sedatives are given◆**Patient c/o chest pain and trouble breathing = 1st action is to elevate HOB!!➔The treatment goal is to dissolve (lyse) the existing emboli and prevent new ones fromforming**➔Long term anticoagulation is also indicated from 10 days - 3 months following the PE and is critical in the prevention of recurrence of VTE.◆Heparin-●Anticoagulation prevent clots from forming●After thrombosis has developed, it can inhibit additional coagulation by inactivating thrombin○PREVENTS FURTHER THROMI○aPPT should be maintained at therapeutic level of 45-70 seconds (normal-25-35 seconds)◆Thrombolytics-●Used in patients with an acute PE who have hypotension and do not havea contraindication for potential bleeding risk.○Recombinant tissue plasminogen activator (activase)- tPA○Kabikinase (Streptase)◆Dissolve clots●Not to be used with stroke patients◆Embolectomy-●Artery in neck or groin to retrieve the clot◆IVC filters-●Placed to prevent further emboli in patients who remain at high risk and for patients who have a contraindication to anticoagulation○Looks like a head scratching/massage device from walmart3
Pulmonary embolism- PreventionNursing Care-➔Prevent Venous Stasis◆Encourage ambulation and active and passive left exercises to prevent venous stasis.◆Avoid sitting still for too long◆Encourage leg pumps in bed(4)◆DO NOT dangle legs◆Compression stockings and/or compression devices while in bed➔Manage oxygen therapy◆Assess for S/S of hypoxemia◆Monitor the pulse ox value◆Bed rest in a semi-fowler’s position to facilitate breathing◆Incentive spirometer➔Maintain IV line for meds and fluid therapy, monitor VS, cardiac dysrhythmias (tele)➔Monitor thrombolytic therapy◆INR or PTT- performed every 3-4 hours after infusion has started●Therapy causes lysis of deep vein thrombi and PE which helps dissolve clots◆Teaching about long-term anticoagulant therapy◆Reinforce the need for follow-up exams and lab draws➔Manage pain◆Turn patients frequently and reposition to improve ventilation-perfusion ratio.◆Semi-fowlers position to help breathing ➔Preventing Thrombus Formation◆Major nursing responsibility- we encourage ambulation and active/passage leg exercisesARDS (Acute Respiratory Distress Syndrome)- Diagnostics➔Physical Exam➔Health Hx➔BNP levels - rule out pulmonary edema➔Echo or TEE➔EKG - assess for any arrhythmias or ischemia➔Pulmonary artery catheterization➔Chest xray - rule out edema, effusion, and pneumonia4
➔Bronchoscopy - help ID cause➔Urine- rule out infection or kidney issues➔Sputum culture - look for bacteria or infection➔ABG - hypoxemiaARDS- Clinical manifestations➔Initially it closely resembles severe pulmonary edema◆Acute phase- marked by rapid onset of severe dyspnea ◆Then progresses to fibrosing alveolitis with persistent, severe hypoxemia●Pt has increased alveolar dead space (ventilation to alveoli but poor perfusion)●Pt has decreased pulmonary compliance (Stiff lungs- difficult to ventilate) ➔Intercostal retractions and crackles may be present as the fluid begins to leak into the alveolar interstitial space➔***Severe ARDS does NOT respond to supplemental O2***(5)➔SOB➔Fast breathing, or taking lots of rapid, shallow breaths➔Fast heart rate➔Coughing that produces phlegm➔Blue fingernails or blue tone to the skin or lips➔Extreme tiredness➔Fever➔Crackling sound in the lungs➔Chest pain, especially when trying to breathe deeply➔Low blood pressure➔ConfusionARDS - Treatment➔Supplemental Oxygen - intubation or ventilation➔Providing ventilatory PEEP (prevents alveoli collapse)(6) - Respiratory therapist➔Goal is PaO2 greater than 60mm Hh or an oxygen saturation level of greater that 90% at the lowest possible FiO2➔Inotropic or vasopressor agents➔Prone position➔Sedation➔Paralysis➔Diuretics - prevent fluid overload5
➔Nutritional support◆Require 35-45kcal/kg/day to meet caloric requirements◆Enteral feeding is the first consideration◆Parenteral nutrition◆High fat, low carbARDS- Mechanical Ventilation➔PEEP 🐣🐣🐣 - positive pressure maintained by the ventilator at the end of exhalation◆PEEP causes increased end-expiratory pressure- unnatural pattern of breathing and feels strange to the pt●Pt may become anxious and try to fight the ventilator◆Used for pts with ARDS to help maintain airway/respiratory function●High amounts of PEEP needed bc of collapsed sacs, stiffening of the lung and pulmonary edema○This high amount of pressure will open the sacs, improve gas exchange and help keep them clear of fluid○High amounts can cause issues with intrathoracic pressure and decrease cardiac output ◆To increase functional residual capacity◆Improves oxygenation with a lower fraction of inspired oxygen◆Fraction of inspired oxygen (FiO2): concentration of oxygen delivered (1.0=100% oxygen)➔A mechanical ventilator - positive or negative pressure breathing device - maintains ventilation and oxygen delivery for a prolonged period***◆ICU - critically ill◆General medical-surgical units◆Extended care facilities◆At homeARDS- Nursing Care of Patients on Ventilators➔ICU unit➔Oxygen administration➔Nebulizer therapy➔Chest physiotherapy➔Endotracheal intubation or tracheostomy➔Mechanical ventilation, suctioning6
➔Bronchoscopy➔Frequent turning- Prone positioning may be necessary➔Reduce anxiety➔Promote rest➔VAP- Ventilator-Associated Pneumonia◆Keep HOB elevated (30-45 degrees)◆Daily sedation vacations and readiness to extubate◆Peptic ulcer disease prophylaxis- Protonix◆Deep venous thrombosis (DVT) prophylaxis- Heparin, Warfarin, Lovenox◆Daily oral care with chlorhexidine➔Weaning◆Physiologically and hemodynamically stable**◆Demonstrates spontaneous breathing capability**◆Recovering from the acute stage of medical and surgical problems◆Cause of respiratory failure is sufficiently reversed ➔Patients may be anxious and “fight ventilator”**➔Assess for unnatural breathing pattern - vents feel strange to the patient➔Assess for tube blockage by kinking or retained secretions**➔Assess for other acute respiratory problems (pneumothorax and pain)➔Observe for a sudden decrease in oxygen level (dyspnea)**➔Observe for ventilator malfunctionMechanical Ventilators- Medications➔***ASSESS AIRWAY*** ➔Sedation◆The need for sedative therapy in critical care adults receiving mechanical ventilation is established to be 85% of ICU patients●They are given IV sedatives to help alleviate anxiety, pain and agitation➔Sedatives◆Lorazepam (Ativan)◆Midazolam (Versed)◆Dexmedetomidine (Precedex)◆Propofol (Diprivan)◆Short-acting barbiturates➔Regional◆Peripheral nerve blocks, spinal anesthetics, epidural anesthetics, general anesthesia7
➔Benzodiazepines produce amnesia, anxiolysis, sedation, and have anticonvulsant properties ◆Not paralyzed* they can still hear you➔Neuromuscular Blocking Agents (muscle relaxants)- paralyze pt◆Vecuronium (Norcuron)***Know this medication!!***●Maximum neuromuscular blockade occurs within 3-5 minutes●Duration of action is 25-40 minutes●Dose-dependent ◆Pancuronium ( Pavulon)◆Atracurium (Tracrium)◆Rocuronium (Zemuron)●🐣 Train-of-four test may be used to measure the level of neuromuscular blockade○Red electrode is closest to the heart○Find out what level the patient responds to using Train of 4.◆Neuromuscular stimulator level = sedation level●Watch so patient does not become disconnected from the ventilator, because respiratory muscles are paralyzed and the patient will be apneic***◆Act by temporarily suspendingnerve impulses at the neuromuscular junction do the nerve test thing(7) ◆Can be titrated to produce weakness through complete paralysis◆Helps to facilitate easy tracheal intubation and mechanical ventilation byrelaxingthe vocal cords, jaw, and associated respiratory muscles effects of Vecuronium(8)◆***Assessing patients airway and respiratory function following the administration is the most important nursing implication***◆The anesthetists ensures respiratory function during the period of anesthesiaMechanical Ventilators- Nursing Considerations➔***Talk to your patient -> let them know what’s going on. Patient is still be able to hear and it is scary for them to be in situation and not know whats going on***➔Nurse should say to bratty colleague : Patient is critically ill on a vent, there is plenty to assess and to reposition frequently(9)➔Unconscious - loses motor function➔Cannot breathe, talk or blink independently ➔Retains sensation and is awake and able to hear➔Make sure they do not become disconnected from the ventilator8
➔Alarms must be on at all times➔Eyecare - may not be able to blink independently➔VTE➔Skin breakdown - reposition frequently (Does not have to be major changes)Acute Respiratory Failure➔In acute respiratory failure, the ventilation or perfusion mechanisms in the lung are impaired.***➔Fluid builds up in the air sacs in your lungs➔Lungs can't release oxygen into your blood➔Thus, organs cannot get enough oxygen-rich blood to function (HYPOXEMIA)➔Can also develop acute respiratory failure if your lungs cant remove CO2 from your blood (HYPERCARBIA)➔Capillaries or tiny blood vessels, surrounding your air sacs can't properly exchange carbon dioxide for oxygen➔Condition can be either acute or chronic◆Acute- you experience immediate symptoms from not having enough oxygen in your body◆Chronic- In most cases, this failure may lead to death if its not treated quickly➔Central nervous system◆Drug overdose, head trauma, infection, hemorrhage, sleep apnea➔Neuromuscular dysfunction◆Myasthenia gravis, guillain-barre syndrome, amyotrophic lateral sclerosis, spinal cord trauma➔Musculoskeletal dysfunction◆Chest trauma, kyphoscoliosis, malnutrition➔Pulmonary dysfunction◆COPD, asthma, cystic fibrosis➔Oxygenation failure mechanisms◆Pneumonia, ARDS, heart failure, COPD, PE➔Restrictive lung diseases◆diseases that cause a decrease in lung volume➔Post-op medications◆Respiratory depression◆Can be too much or high of a dose➔Pain◆May interfere with deep breathing and coughing◆Patient cannot remove crap from lungs9
◆Pain may not be managed enough➔Drug or alcohol abuse➔Stroke Acute Respiratory Failure - Symptoms➔Early Symptoms◆Restlessness◆Fatigue◆Headache◆Dyspnea◆Air hunger◆Tachycardia◆Increased BP➔As hypoxemia progresses◆Confusion◆Lethargy◆Tachypnea◆Central cyanosis◆Diaphoresis◆Respiratory arrest◆Inability to complete full sentences◆Accessory muscle use- straining◆Altered mental status Acute Respiratory Failure - Treatment➔Ventilation➔Intubation Acute Respiratory Failure - Nursing Considerations➔Respiratory status➔ABG’s➔Vitals➔Turning schedule➔Mouth care➔Skin care➔Range of motion extremities10
Acute Respiratory Failure - Pharmacology➔Furosemide or other loop diuretic - whichever question has the word furosemide in it, pick that lol we think its a pulmonary edema one(10)◆IV push orf as a continuous infusion◆Rapid therapeutic effect◆Blood pressure is monitored closely - be alert for hypotensive◆I&O’s◆Daily weights◆Monitor serum electrolytes and creatinine➔Vasodilators◆IV nitroglycerin or nitroprusside◆Symptom relief in pulmonary edema ➔BUFFER SYSTEMAcid-base Balance➔Body's balance between acidity and alkalinity is referred to as acid-base balance➔Bloods acid-base balance is precisely controlled because even a minor deviation from the normal range can severely affect many organs➔Body uses different mechanism to control the bloods acid-base balanceManagement of Acid-base balance- Compensations➔The pulmonary and renal systems compensate for each other to return pH to normal➔Blood gas analysis - specific acid-base problem➔1st line of defense - Buffers◆Soaks up hydrogen ions when too many are present or squeezing out hydrogen ions when too few are present➔2nd line of defense- respiratory system 6 to 12 hours◆Hyperventilation and hypoventilation will change amounts of arterial CO2➔3rd line of defense - renal system MOST POWERFUL◆Takes days to work completely◆Kidney movement of bicarbonate, formation of acids, formation of ammonium compensate depending on direction of pH changesMetabolic Acidosis11
➔The buildup of acid in the body due to kidney disease or kidney failure➔When your body fluids contain too much acid means◆your body is either not getting rid of enough acid◆Making too much acid◆Cannot balance the acid in your blood➔Kidneys are unable to remove enough acid from your blood➔Low calcium levels➔Manifestations◆Headache◆Confusion◆Drowsiness◆Increases respiratory rate and depth◆Nausea and vomiting◆Decreased blood pressure◆Cold and clammy skin◆Dysrhythmias◆Shock➔Diagnostics◆EKG◆ABG●hyperkalemia/hypokalemia (monitor closely)➔Medical Management◆Correct imbalance◆Give bicarb◆In chronic metabolic acidosis, treat calcium levels first(11)◆Avoid tetany➔Anion Gap◆Normal anion gap: DIRECT LOSS●Diarrhea●Fistulas●Renal insufficiency●Parenteral nutrition w/o bicarb●Lactate◆High anion gap acidosis: excessive accumulation of fixed acid●Metabolic acidosis●Ketoacidosis and lactic acidosis ●Late phase of salicylate poisoning●Uremia12
●Methanol or ethylene glycol toxicity●Ketoacidosis with starvation➔Pharmacology◆Giving bicarb - what to watch for? ●Watch for hypernatremia, hyperkalemia,( its one of these 2) (12) hypocalcemiaMetabolic Alkalosis➔High pH (decreases H+ concentration)➔High plasma bicarbonate concentration➔Produced by a gain of bicarbonate or a loss of H+➔Causes◆Gastric suctioning◆Vomiting (13)◆Pyloric stenosis◆Potassium loss- diuretic use◆Cushing's syndrome◆Long term antacid use➔Manifestations◆Hypercalcemia◆Tingling of the fingers and toes (tetany)◆Dizziness◆Hypertonic muscles◆Respirations are depressed◆Atrial tachycardia◆Hypokalemia develops◆Ventricular disturbances◆Decreased motility and paralytic ileus◆Chronic metabolic alkalosis symptom●Long term diuretic use(14)●Potassium decreases - PVC’s or U waves are seen on ECG➔Diagnostics◆ABG - pH greater than 7.45 and a serum bicarbonate concentration greater than 26mEq/L➔Medical Management◆Correct underlying problems◆I&O’s - GI loss◆Restore fluid volume13
◆Give electrolytes as needed◆Give tagamet◆Hypoventilation●The PaCO2 increases as the lungs attempt to compensate for the excess bicarbonate by retaining CO2●Hypokalemia●Urine chloride - ID the cause ➔Pharmacology◆Sodium chloride◆Potassium chloride◆Tagamet Respiratory Acidosis➔pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in HC03➔Causes◆Hypoventilation - inadequate excretion of CO2◆Acute pulmonary distress◆Aspiration of a foreign object◆Atelectasis◆Pneumothorax◆Overdose of sedatives◆Sleep apnea◆Chronic hypercapnia (Excessive CO2 in blood)◆Severe pneumonia and acute respiratory distress syndrome◆Muscular dystrophy◆Multiple sclerosis◆Myasthenia gravis◆Guillain-barre syndrome➔Acute◆Sudden spike in CO2 levels◆Medical emergency◆Without treatment, symptoms will get progressively worse and become life threatening●Manifestations○Breathlessness○Heading○Wheezing14
○Anxiety○Blurred vision○Restlessness○Cyanosis in the hands and feet○Without treatment or severe◆Sleepiness or fatigue◆Lethargy◆Delirium or confusion◆Involuntary muscle movements and twitching◆Possible seizure◆Personality changes◆Coma●Treatments○Look for underlying cause○Bronchodilators○Ventilation - BiPAP➔Chronic◆May not have symptoms◆Long time to develop◆Chemoreceptors in your brain alerted to elevated CO2 ventilation◆Receptors- less sensitive - miss the elevation●Manifestations○Memory loss○Coordination problems○Polycythemia○Pulmonary hypertension○Heart failure○Sleepiness and headaches (obstructive sleep apnea)○Emphysema (15)●Treatment○Look for underlying cause○Antibiotics○Diuretics○Bronchodilators○Corticosteroids○Mechanical ventilation➔Diagnostics◆ABG’s15
◆Urinalysis◆CBC- electrolytes◆Drug screen - OD◆Chest xray◆ECG◆Lung function tests - IS➔Pharmacology◆Sodium bicarb◆Bronchodilators●Albuterol●Salmeterol●levalbuterol◆Ventilation◆Antibiotics◆Thrombolytics◆anticoagsRespiratory Alkalosis➔pH is greater than 7.45 and the PaCO2 is less than 38mm Hg➔Occurs when you breathe too fast or too deep and carbon dioxide levels drop too low➔Causes◆Hyperventilation- panic attack or anxiety (16)◆Heart attack◆Pain◆Drug use◆Asthma◆Fever◆COPD◆Infection◆Pulmonary embolism◆Pregnancy➔Manifestations◆Dizziness◆Bloating◆Lightheadedness◆Numbness or muscle spasms (hands/feet)◆Discomfort in chest area16
◆Confusion◆Dry mouth◆Tingling in arms◆Heart palpitations/tachycardia◆SOB➔Diagnostics◆ABG’s◆Electrolytes◆Toxicology screen➔Treatment◆Breathe into bag - raise CO2◆Reassure patient◆Pursed lip breathing➔Pharmacology◆Paper bag - rebreathe CO2◆Anxiety meds - valium or benzos Management of Acid-base balance - Nursing Considerations➔Nursing Considerations◆Assess patient and labs◆Assess what patient vital signs are telling you◆Count patient's respirations for a full minute●What are the rate and depth?●Are they clues to impending or underlying respiratory or metabolic problems?◆What is the patient's LOC?●Confusion can be early sign of an acid-base disturbance◆Correlate your patients fluid balance and creatinine levels with kidney function◆Correlate assessment findings with patients dx●Do they match?●Is some clue pointing you in a different direction?◆Double check implications and adverse effects of all drugs you administer Management of Acid-base balance- ABG interpretation17
Management of Acid-base balance- Electrolyte imbalances with ABG imbalancesPulmonary edema/failure - Pathophysiology➔Abnormal accumulation of fluid in the interstitial spaces and alveoli of the lungs➔An acute event that results from left ventricular failure➔It can occur following acute MI or as an exacerbation of chronic HF➔When the left ventricle begins to fail, blood backs up into the pulmonary circulation, causing pulmonary interstitial edemaPulmonary edema/failure - Symptoms➔Difficulty breathing (dyspnea) or extreme SOB that worsens with activity or lying down**➔Feeling of suffocating/drowning that worsens lying down**➔Cough - frothysputum tinged with blood (pink)** - Sit up and dangle feet (17)➔Wheezing or gasping for breath➔Cold, clammy skin➔Anxiety➔Restlessness or sense or apprehension➔Bluish lips➔Tachycardia18
➔Irregular heartbeat (palpitations)➔JVD➔Confusion/stuporPulmonary edema/failure - Diagnostics➔Make sure to differentiate if this is pneumonia or pulmonary edema➔ABG➔Electrolytes➔BUN, creatinine➔BNP➔Chest x-ray➔CT➔EKG, ECHO➔USPulmonary edema/failure - Prevention➔Diuretics◆Get rid of fluid accumulation in body➔Morphine◆Manage pain➔Upright position➔Manage weight◆Losing weight➔Limit salt intake◆Where salt goes, water goes➔BP medicationsPulmonary edema/failure- Nursing interventions➔Dangle feet**➔Position upright➔I&O➔Daily weights➔TelemetryPulmonary edema/failure- Complications19
Pulmonary edema/failure- Treatments➔O2➔Diuretics➔vasodilatorsHepatitis (A,B,C,D,E)- Modes of transmission➔Prodromal-◆Gradual onset of anorexia, malaise, and fatigue➔Convalescent-◆Viral hepatitis begins with the disappearance of jaundice and major symptoms.◆Malaise and susceptibility to fatigue may persist for weeks and even months following viral hepatitis.➔Icteric-◆May note dark urine, followed by pale-colored stools with GI symptoms- malaise,and develop right upper quadrant pain with hepatomegaly.➔Viral- MOST COMMON TYPE◆Hep A, B, C, D, E➔Alcoholic- ◆Caused by heavy alcohol use➔Toxic-◆Caused by poisons, chemicals, medicines, or supplements. ➔Autoimmune-◆Chronic type in which your body's immune system attacks your liver. ◆The cause is not known, but genetics and environment may play a role.Hepatitis (A,B,C,D,E)- Prevention➔Hepatitis A20
◆Fecal Oral route●Ingestion of food or liquids infected with the virus●More prevalent in countries with overcrowding and poor sanitation●Virus has been found in stool of infected patients before the onset of symptoms and during the first few days of illness.◆Incubation period is estimated between 2-6 weeks.➔Hepatitis A Symptoms-◆Resemble those of a mild, flu like upper respiratory tract infection with low grade fever.◆Anorexia (early sign), jaundice, dark urine, vague epigastric distress, nausea, heartburn, flatulence.◆Strong aversion to taste of cigarettes or smoke/strong odors◆Fatigue, sudden nausea/vomiting, abdominal pain/discomfort, clay colored BM, low-grade fever, joint pain.◆The liver and spleen are often moderately enlarged for a few days after onset.◆The antigen may be found in the stool 7-10 days before illness and for 2-3 weeks after symptoms appear. ➔Hepatitis A Prevention-◆Vaccinations - 2 doses (6-12 months apart)◆TRaveling, high risk groups, IV drug users, daycare workers(18), healthcare workers, hand hygiene, safe water supplies, proper control of sewage disposal. ➔Hepatitis A Interventions-◆Bedrest◆Diet- small feedings are given frequently◆IV fluids with glucose◆Physical activity restrictions●But ambulation is still encouraged➔Hepatitis B◆Blood and Body Fluids◆Most people who contract HBV develop antibodies and recover spontaneously in6 months.◆For some people Hep B infection can become chronic●Increases risk for developing liver failure, liver cancer, and cirrhosis.◆Infants and children are more likely to develop a chronic Hep B infection◆A VACCINE CAN PREVENT HEP B, but THERE IS NO CURE IF YOU HAVE THE CONDITION21
➔Hepatitis B Symptoms-◆Fever, fatigue◆Jaundice (skin/eyes), dark urine, N/V◆Clay-colored BM, joint pain, loss of appetite➔Hepatitis B Nursing Care-◆Coping skills for patient and family diet-●antacids or antiemetics●Need protein in the diet to repair the tissues◆Bed rest, follow up appointments, blood work,◆No ALCOHOL◆Good hygiene (hands/body)◆Entecavir, tenofovir, alpha-interferon, pegylated interferon➔Hepatitis B Prevention- SATA - tattoos, sex, needles - i selected all five(19)◆Vaccinations ●3 doses (over 6 months)◆Traveling◆High risk groups◆IV drug users◆Daycare workers, Healthcare workers◆End stage renal disease◆Chronic liver disease patients ◆DISPOSE SYRINGES, NEEDLES, LANCETS. USE GLOVES➔Hepatitis B Intervention-◆Know the HBV status of any sexual partners◆Use a new latex condom every time you have sex◆Don’t use illegal drugs●Use sterile needle each time you inject illicit drugs●Never share needles◆Be cautious about body piercings and tattoos◆Ask about Hep B vaccine before you travel●Given in series of 3 injections over 6 months22
➔Hepatitis B Medical Intervention-◆Injection- immunoglobulin (antibody) within 12 hours of exposure◆Rest/fluids◆Chronic - antiviral medications●Entecavir, (baraclude), tenofovir (viread), lamivudine (epivir), adefovir (Hepsera), and telbivudine (Tyzeka), Interferon◆Liver transplant●Can form scars and scabs on liver - can’t filter things - liver transplant➔Hepatitis C-◆Most COMMON CHRONIC BLOOD-BORNE INFECTION***◆A combination of 2 antiviral agents (peginterferon and ribavirin) effect in producing improvement in patients with Hep C and in treating relapses.➔Hepatitis D-◆Interferon alpha is the only licensed drug available in the treatment of HDV infection●High dose, long duration therapy for at least a year is recommended.●Water soluble Vitamins - A, D, E, K◆You can't have Hep D without having Hep B.➔Hepatitis E-◆Fecal- Oral route◆Similar to Hep B◆Abrupt onset◆Jaundice◆Can’t have Hep E without having Hep A➔Hepatitis E Prevention-◆Immunoglobulins ◆Hand hygieneHepatitis (A,B,C,D,E)- Risk Factors ➔Hepatitis A-◆Food contaminated with fecal matter, consuming water or shellfish from sewage-contaminated waters, poor hygiene, sexual activity.➔Hepatitis B-23
◆Having sex with an infected person◆Sharing dirty needles ◆Being in direct contact with infected blood, saliva, semen◆Getting needle stick injuries ◆Being transferred from mother to unborn child (birth)●All pregnant women should be tested for hepatitis B●Within 24 hours of birth, infants born to mothers with Hep B need to receive treatment with Hep B antibody and Hep B vaccine.➔Hepatitis C-◆Sharing needles◆Being in direct contact with infected blood◆Getting needle stick injuries or mucosal exposure to blood◆Having sex with an infected person is LESS COMMON◆LONG TERM DRUG USAGE***◆NO BENEFIT FROM REST, DIET, VITAMIN SUPPLEMENTS***◆Children born to women infected with Hep C virus◆Multpile sex partners, history of sexually transmitted infections, unprotected sex◆Past/current illicit IV/injection drug use➔Hepatitis D-◆IV or injection drugs◆Patients undergoing hemodialysis◆Recipients of multiple blood transfusions◆Sexual contact with those who ahve Hep B.➔Hepatitis E-◆Eating, drinking food, or water contaminated with the virus undercooked foods●Pork, venison, shellfish◆Uncommon in the Us but can occur after travel to a country where this infection is common◆Dangerous or fatal in pregnant womenHepatitis- Nutrition●Bed rest during acute stage and nutritious diet are important aspects of treatment○Small frequent feedings, supplemented by IV fluids with glucose if necessary 24
Dietary Management of Hepatitis●Advise patient to avoid substances (medications, herbs, illicit drugs, and toxins) that may affect liver function, such as St. John wort in patients taking hepatitis C virus protease inhibitors.●Be aware that that enteral feedings may be necessary if anorexia, nausea, and vomiting persist.●Carefully monitor fluid balance.●Instruct patient to abstain from alcohol during acute illness and for at least 6 months after recovery.●Provide intake of 25–30 kcal/day.●Provide protein intake of 1.2–1.5 g/kg/day.●Recommend small, frequent meals; minimize periods without food intake.Hepatitis Medications-********◆Nucleoside Analogs -Hep B●Pegylated interferon and antiviral agents●Lamivudine-○Patients who have evidence of Hep B viral replication and active inflammation of the liver○Post exposure●Ribavirin-○Oral antiviral drug administered in combination with peginterferon alpha-2a or peginterferon alpha-2b◆Acute HCV Therapy-●Pegylated interferon◆Supportive therapy-●Antiemetics●Do not use phenothiazines ●Sedative/Hypnotics◆Chronic HCV-●Pegylated a-interferon given with ribavirin●Direct acting antivirals (DAA)◆Chronic HBV)-25
●Focus on decreased●Pegylated interferon●Entecavir●TenofovirHepatitis- Medication Induced➔Toxic-◆Exposure to hepatotoxic chemicals, medications, botanical agents, or other toxic agents in the early treatments and removal of the causative agent➔Signs and Symptoms-◆Anorexia, N/V - usual symptoms◆Jaundice and hepatomegaly ◆Clotting issues◆Delirium, coma, seizure◆Symptoms are more intense for these patients➔Drug Induced - Can Be Severe-SATA(20)◆Chills, fever, rash, pruritus, arthralgia, anorexia, headache, nausea ***◆Later- jaundice, dark urine, enlarged/tender liver●After offending medication is withdrawn, symptoms may gradually disappear○Anesthetic agents○Medications used to treat rheumatic.musculoskeletal disease○Antidepressants (WE ARE SCREWED) ○Psychotropic medications○Anticonvulsant, antituberculosis agents ○CORTICOSTEROIDS➔OVERALL PREVENTION◆Get the vaccines for HEP A AND HEP B**◆Use a condom◆Don’t share needles◆PRACTICE GOOD HAND HYGIENE (SOAP AND WATER) **◆Don't use infected persons items◆Take precautions when getting any tattoos or body piercings26
◆Take precautions when traveling to areas of the work with poor sanitation (makesure you get vaccines before you go)◆Drink BOTTLED WATER while traveling (or you will be in the shitter)Pancreatitis- Pathophysiology➔Pancreas is a long, skinny gland located in the upper abdomen (epigastric region) behindthe stomach◆Can be mild or severe (necrotizing) another name for pancreatitis.(21)◆Can be acute or chronic➔The most common cause of pancreatitis is stones in the gallbladder.◆Stones pass through the common bile duct to enter small intestines, stones get stuck and cause obstruction of normal flow of pancreatic fluid leading to pancreatic injury◆Plays a role in endocrine - insulin/glucagon that are secreted into the bloodstream◆Plays a role in exocrine - digestive enzymes secreted into duodenum to digest food.●Enzymes break down macromolecules○Carbohydrates, lipids, proteins◆If cause is not found, IDIOPATHIC. ** NO IDEA WHAT IS GOING ONPancreatitis- Clinical manifestations➔Alcoholism- most common cause in men(22)➔Gallbladder disease- biliary stones - most common in women◆ASK ABOUT HISTORY OF ETOH ➔Abdominal pain - midepigastric ◆Rigid, indicates peritonitis (very painful) - Most cause for concern in acute(23)➔Progressive abdominal distention➔Decreased bowel activity➔N/V, low grade fever, leukocytosis, hypotension, tachycardia, ➔Jaundice (possibly)➔LUQ OR MID EPIGASTRIUM COMMONLY RADIATES TO THE SHOULDER OR BACK◆OFTEN OCCURING 24-48 HOURS AFTER FATTY MEAL OR HEAVY ALCOHOL INTAKE➔CAN HAVE ABDOMINAL TENDERNESS WITH GUARDING AND RIGIDITY27
◆CAN BE DEEP, SEVERE, PIERCING, CONTINUOUS PAIN, FREQUENT ONSET WHENPATIENT IS LYING DOWN➔Cullen Sign-◆Circle pattern ◆Around umbilicus➔Grey-Turner Sign-◆No pattern/shape ◆In the flank area.➔Diagnostic Tests-◆Serum amylase and lipase- PRIMARY TESTS***◆Serum glucose◆Serum calcium - will be decreased◆Liver functions tests◆MRI, CT, X-RAY - show enlargementPancreatitis- Treatment➔NPO to reduce pancreatic secretions - initially➔NO ALCOHOL➔Small frequent feeding - once they can eat◆High carbohydrates➔Bland diet with no stimulants - NO CAFFEINE➔Supplemental fat-soluble vitamins (A, D, E, K)➔TPN in severe malnutrition➔REMEMBER PATIENTS CANNOT DIGEST PROTEIN AND FATS◆Bland diet◆Rest pancreas to digest➔RELIEF OF PAIN - non stop pain meds - Give IV morphine (24)➔Prevention/control of shock➔Reduction of pancreatic secretions➔Control of fluid and electrolyte imbalances28
Pancreatitis- Nursing Management-➔#1 priority - relieve pain and decrease secretion of pancreatic enzymes◆Parenteral opioids- morphine, hydromorphone, fentanyl◆PCA pump or bolus◆Pain assessments➔Comfort care and effectiveness of medications➔Oral feeding is withheld➔Fluids are given➔Gastric enzymes➔NG tube insertion and maintenance, oral hygiene➔Bedrest- Semi Fowlers- most comfortable➔Monitor ABGs, pulse Ox, daily weights, I&O➔Monitor/measure abdominal girth for distention **➔Monitor labs- low calcium and magnesium**Pancreatitis Medications-➔Cimetidine (Tagamet)/Ranitidine (Zantac)◆Decrease pancreatic activity by inhibiting the secretion of gastric acid➔Pantoprazole (Protonix) Proton Pump Inhibitors-◆May be used for patients who do not tolerate H2 antagonists or for whom this therapy is ineffective➔Morphine, Fetanyl, Dilaudid-◆IV for severe pain➔Zofran-◆Nausea➔Antibiotics-◆Infection➔Glucose Levels-◆Pancreas is affected/not eatingPancreatitis- Complications➔Respond quickly to changes in patient status - think SHOCK!◆Hypovolemic◆Hemorrhage◆Septic◆Multiple Organ Dysfunction Syndrome (MODS)➔Increasing pain needs to be reported to MD immediately.29
Chronic Pancreatitis- Causes➔The most common cause is long-term alcohol abuse◆Men◆70% are linked to alcohol consumption➔Malnutrition➔Diabetes➔Obstruction➔Metabolic disturbances➔Trauma, pseudocysts, Systemic diseases (Lupus/CF)Chronic Pancreatitis- Clinical manifestations➔Pain in upper abdomen - recurring and severe➔Diarrhea/Fatty stools-◆Smelly, loose, pale, doesn’t flush away easily (malabsorption)(25)➔Nausea/vomiting➔SOB, fatigue, excessive thirst, unexplained weight loss (fear of eating)➔Progressive to more severe symptoms-◆Pain - more severe, more frequent, longer duration, constant pancreatic fluids in your abdomen◆Jaundice, internal bleeding, intestinal blockage➔Diagnostic tests-◆Serum amylase and lipase◆Serum bilirubin◆Alkaline phosphatase, mild leukocytosis, increased sed rate, secretin stimulation test, blood glucose levels, ERCP, X-rays, ultrasounds, CT, US.➔Surgical-◆The goal is to restore drainage reduce, pain, and attacks.(26)◆Pancreaticojejunostomy◆Endoscopic or laparoscopic intervention◆StentsChronic Pancreatitis- Treatment➔Effective pain management 30
◆IV morphine, fentanyl, hydromorphone➔Low-fat, bland diet➔Supplemental pancreatic enzymes➔ELIMINATE ALCOHOL➔Bile salts to facilitate absorption of fat-soluble vitamins (ADEK)➔Control diabetes and teach to monitor blood glucose➔Antacids and anticholinergics to decrease gastric acids➔Small frequent meals, patients do not tolerate fatty, rich, and stimulation foods.Enteral Nutrition➔Refer to any method of feeding that uses the GI tract to deliver part or all of a person caloric requirements➔It can include-◆Normal oral diet◆Use of liquid supplements◆Delivery of part or all the daily requirements by use of a tube◆NG tube (tube feeding)Parenteral Nutrition-➔IV administration (blood stream) of nutrition for patients that cannot eat or absorb enough food through tube feeding formula or by mouth to maintain good nutrition status◆Protein◆Carbohydrates◆Fats◆Minerals/Vitamins◆Electrolytes➔Delivers concentrated nutrients/solutions IV to maintain or supplement nutritional balance when oral or enteral nutrition is inadequate or not possible.Components of TPN-➔Carbohydrates➔Fat emulsion (lipids) VERY STICKY➔Protein (amino acids)➔Water31
➔Electrolytes➔Vitamins and trace mineralsAspiration Prevention-➔Check residual every 4-6 hours and before feeding to see if tolerating the feeding.◆Will hold feeding if residual is too high➔These patients need to be at 30 angle or higher when receiving tube feeding◆Minimizes aspiration➔Do not lay patients flat while tube feeding is infusing and before a procedure◆Turn off tube feeding when going to CT, MRI about 30 minutes before goingTypes of Tubes-➔NG Tube-◆Starts in the nose and ends in the stomach➔Orogastric Tube (OGT)-◆Starts in the mouth and ends in the stomach➔Gastroenteric Tube-◆Starts in the nose and ends in the intestines◆Subtypes are: nasojejunal and nasoduodenal tubes➔Oroenteric Tube-◆Starts in the mouth and ends in the intestines➔Gastrostomy Tube (G- Tube)-◆Placed through the skin of the abdomen straight into the stomach◆Subtypes are: PEG, PRG, button tube➔Jejunostomy Tube (J-Tube)-◆Placed through the skin of the abdomen straight through into the intestines◆Subtypes are: PEJ, PRJ tubesThings to Know About Feedings-➔Bag should only hang for 24 hours ◆Made in pharmacy using aseptic technique and sent up/placed in the refrigerator.➔Tubing gets changed every 24 hours for lipids ◆72 hours for regular without lipids➔If TPN sits out beyond the time it should, fat emulsion portion at room temp becomes a medium for microorganism growth32
◆Patients can become extremely ill with fevers and vomiting➔If TPN is completed before new bag arrives, hang 5% dextrose solution ◆D5W, 5%, 10%, 20% dextrose◆Watch for hypoglycemia!!Cirrhosis- Pathophysiology➔Late stage liver disease where healthy liver tissue is replaced with scar tissue and the liver is permanently damaged. ◆Scar tissue keeps your liver from working properly.◆Scar tissue blocks the flow of blood through the liver and slows the liver's ability to process nutrients, hormones, drugs, and natural toxins (poisons)●Many types of liver diseases and conditions can injure healthy liver cells, causing cell death and inflammation, followed by cell repair and finally tissue scarring as a result from the repair process.◆Reduces the production of proteins and other substances made by the liver➔Cirrhosis eventually keeps the liver from working properly➔Late stage cirrhosis is life-threateningTypes of Cirrhosis-➔Alcoholic cirrhosis-◆Scar tissue characteristically surrounds the portal areas.◆Most frequently caused by alcoholism and is the MOST COMMON TYPE OF CIRRHOSIS.➔Postnecrotic cirrhosis-◆Broad bands or scar tissue is a late result of a previous bout of acute viral hepatitis.(27)➔Biliary cirrhosis- (less common)◆Scarring occurs in the liver around the bile ducts.◆Results from chronic biliary obstruction and infection (cholangitis)Cirrhosis- Treatments ●Treatment is usually symptomatic○Including antacids or H2 antagonists to decrease gastric distress and minimize the possibility of GI bleeding●Vitamins○Organic compounds that help to release energy from carbohydrates, fats and proteins33
○Used to improve health and prevent or treat illness○Early recognition and treatment with vitamins can prevent mild deficiency ●Minerals○These maintain acid-base balance and osmotic pressure○Occur in the body and foods mainly in ionic form●Nutritional products○Enteral nutrition○Parenteral nutrition■Hopefully used for short term (3-5 days) the goal is to provide adequate amounts of fluids and electrolytes ■For long term use the goal is to provide nutrients required for normal body functioning (including tissue repair)●Potassium-sparing Diuretics○Spironolactone (Aldactone):reduces retention of sodium and water■Adverse effects: dizzy, headache, abdominal cramping, diarrhea○Amiloride (Midamor) and TTriamterene (Dyrenium)■These drugs decrease the exchange of sodium for potassium and have similar diuretic activity●Thiazolidinediones ○Rosiglitazone maleate (Avandia)■Stimulates receptors on muscle, fat and liver cells●Increasing or restoring the effectiveness of circulating insulin■Adverse effects include liver injury and diarrheaCirrhosis- Clinical manifestations➔Fever- Mild➔Epistaxis - Nosebleed➔Hypotension➔Jaundice➔Weight loss➔Bruising➔Weakness➔Late stage symptoms- (28 Sata quizlet)◆Easy bruising and bleeding◆Jaundice◆Itchy skin34
◆Edema◆Ascites - abdominal girth measurements◆Spider-like blood vessels surround small, red spots on skin (telangiectasia) ◆IN MEN:●Loss of sex drive, enlarged breasts (gynecomastia), shrunken testicles◆IN WOMEN:●Premature menopause (no longer having your period)◆Brownish or orange color urine◆Light colors stool◆Confusion- difficulty thinking, memory loss, personality changes◆Blood in stool◆Redness - palms of the handsCirrhosis- Complications-➔Edema and ascites➔Infections➔Malnutrition➔Buildup of toxins in the brain◆Hepatic encephalopathy➔Jaundice➔Bone Disease- calcium - fractures➔Increased risk of liver cancer➔Multiorgan failureCirrhosis- Nursing Care-➔Rest➔I&Os➔Daily weights◆Fluid volume excess ◆Salt and fluid restrictions➔Abdominal girth➔Assess for edema◆Fluid volume excess➔Protection of the side rails◆Seizures➔Bleeding precautions-◆Clotting factors➔Assess mental status35
➔Assess for oliguria➔Once eating and stronger-◆Activity followed by rest periods.Cirrhosis- Treatment➔Medications to alleviate symptoms- NO CURE (awww booo)(29)◆Spironolactone (Aldactone)●Reduces retention of salt and water○Give with food○Max effect takes 6 weeks ○Same time every morning◆Rosiglitazone maleate (Avandia)●Restoring effectivement of circulating insulin○Monitor liver enzymes q2mo for 1 year○Take with meals○Glucose checks○Assess cardiac and lung sounds◆Histamine 2 Receptor Antagonists (Cimetidine, famotidine, nizatidine, ranitidine)●Inhibits secretion of gastric acid, decreasing the acidity of gastric juices●Prevent and treat heartburn PUD, GERD, esophagitis, GI bleeding due to stress ulcers.◆Proton Pump Inhibitors (Omeprazole, esomeprazole, lansoprazole, pantoprazole,rabeprazole)-●Binds irreversibility to the gastric proton pump to prevent the release of gastric acid.●Protonix- Decrease gastric acid◆Herbals-●Milk Thistle just document in patient chart(30)36
○Treats jaundice and other symptoms●May be okay to takeCirrhosis- Patient Education➔Provide dietary instruction, including exclusion of alcohol➔Refer to alcoholics anonymous (AA), psychiatric care counseling, spiritual advisor if indicated ➔Continue sodium restriction◆Stress avoidance of raw shellfish➔Educate patient and family using written instructions, reinforcement, support➔Encourage rest and probably change in lifestyle ◆Adequate dietary intake and elimination of alcohol➔Instruct family about symptoms of impending encephalopathy and possible bleeding tendencies and susceptibility to infection➔Offer support and encouragement to the patient and provide positive feedback when the patient experiences success.➔Refer patients to home care nurses, and assist in transition from hospital to home.Acute renal failure- Classification➔Also called Acute Kidney Injury➔Sudden episode of kidney failure or kidney damage that happens within a few hours or days◆Rapid loss of renal funcion due to damaged kidneys➔AKI causes a buildup of waste products in your blood and makes it hard for your kidneys to keep the right balance of fluid in your body◆Injury (structural damage)◆Impairment (loss of function)◆A syndrome that rarely has a sole and distinct pathophysiology ➔Underlying causes need to be addressed promptly before kidney injury develops➔Conditions that reduce blood flow to the kidney and impair kidney function◆Hypovolemia◆Hypotension◆Reduced cardiac output and heart failure ◆Obstruction of kidney or lower urinary tract by tumor, blood clot or kidney stone◆Bilateral obstruction of the renal arteries or veins37
◆GOAL: treat and correct before the kidneys are permanently damaged, the increased BUN and creatinine levels, oliguria and other signs may be reversedClassifications of Acute Kidney Injury (RIFLE) (31)◆R: risk◆I: injury◆F: failure◆L: loss◆ESKD: end stage kidney disease●1) risk, injury, and failure are considered grades of AKI severity●2) loss and ESKD are considered outcomes of loss that require some form of renal replacement therapyAcute renal failure- Pre/Intra/Post renal➔Prerenal - sudden and severe drop in blood pressure (shock) or interruption of blood flow to the kidneys from severe injury or illness (hypoperfusion of kidneys)(32)➔Intrarenal- direct damage to the kidneys by inflammation, toxins, drugs, infection, or reduced blood supply (acute damage)➔Postrenal- sudden obstruction of urine flow due to enlarged prostate, kidney stones, bladder tumor, or injury4 Phases of AKI1)Theinitiation period begins with the initial insult and ends when oliguria develops2)The oliguriaperiod is accompanied by an increase in urea, creatinine, uric acid, organic acids, as well as potassium and magnesiuma)Minimum amount of urine needed to rid the body of normal metabolic waste products is 400mL in 24 hours or 0.5mL/kg/hrb)In this phase, uremic symptoms first appear and life threatening conditions such as hyperkalemia develop★Oliguria - <400mL/day - occurs w/n 1-7 days of kidney injury★Urinalysis - casts, RBC, WBC, sp gr fixated at 1.010★Metabolic Acidosis★Hyperkalemia and Hyponatremia★Elevated BUN and Creatinine★Fatigue and Malaise3)The diuresis period - a gradual increase in urine output, which signals that glomerular filtration has started to recover. Laboratory values stabilize and eventually decrease★Gradual increase in urine output - 1-3 L/day, may reach 3-5 L/day38
★Hypovolemia, Dehydration★Hypotension★BUN and Creatinine levels begin to normalize4)The recovery period signals the improvement of renal functions and may take 3 to 12 months. Laboratory values return to normal ★Begins when GFR increases★BUN and Creatinine levels plateau, then decreaseAcute Renal Failure Symptoms➔**You might not notice any symptoms of AKI at first**➔Not enough urine (oliguric)➔Swelling in legs, ankesl, feet - retention➔Feeling tired or drowsy➔Trouble catching breath➔Feeling confused➔Nausea➔Pain or pressure in chest➔Dry mucous membranes➔Twitching➔Lethargic➔JVD➔SEVERE AKI- seizures or fall into coma➔Radiocontrast-induced nephropathy (CIN)◆Major cause of hospital acquired AKI◆Preventable◆1% require dialysis or hospitalization◆Assess●baseline levels of creatinine greater than 2 mg/dl (high-risk patient)◆Prevention●Limit exposure●Monitor medications - nephrotoxic●Prehydrate before procedure with NS - creatinine level 4 so give IV(33)●Administer bicarb before the procedure GRF decrease = creatinine increase(34)Acute renal failure diagnostics/labs39
➔Diagnostics◆US, CT, MRI◆Urinalysis◆Renal scan - how kidney is working - IR◆Biopsy ◆Early detection (3 R’s)●Recognition ●Response●Referral ➔Labs◆Low specific gravity◆Hematuria◆Prerenal azotemia - decreased sodium◆Intrarenal azotemia - increased sodium◆BUN level - increases steadily◆Serum creatinine levels◆Decreased GFR, oliguria, anuria, - high risk for hyperkalemia◆Phosphates increased - calcium decreased◆Low hemoglobinAcute renal failure- Precautions➔Restore balance➔Eliminate the underlying cause➔Maintain fluid balance➔Avoid fluid excess➔Rehydrate➔Stop post op hemorrhage➔GI losses (V/D) - give medications➔Relieve obstruction➔Blood transfusion➔Dialysis➔Medication ◆should be monitored closely - can’t filter them out◆Aminoglycosides◆Gentamicin◆Tobramycin◆Colistimethate40
◆Cyclosporine➔NSAIDS◆may cause interstitial nephritis➔Contrast dye◆Limit exposure◆N-acetylcysteine and sodium bicarbonate before and during procedures reduce risk◆Prehydration with saline➔Dehydration◆Make fluids available to elderly patients➔Bowel Preps◆Watch for dehydrationChronic Renal Failure Nursing Care➔Daily weights➔I&O➔High calorie, low protein, low potassium, low sodium diet◆Avoid high potassium foods and sports drinks - high sodium◆Avoid potassium or phosphorus (bananas, citrus fruits and juices, coffee)➔After diuretic phase ◆high protein, high calorie diet◆Encourage to resume activities gradually➔Monitor fluid and electrolytes - hyperkalemia➔Reduce metabolic rate- bed rest may be needed➔Alterations in heart sounds and breath sounds◆Edema- can lead to skin breakdown◆JVD➔Increased difficulty in breathing◆Cough and IS use➔Maintain bedrest➔Foley care - *prevent infections* - avoid catheter if possible Chronic renal failure- Clinical manifestations➔Begins with a slow decline in renal function and is irreversible➔When damaged kidneys have been unable to process waste efficiently for longer than 3 months, as indicated by abnormal creatinine levels41
➔Unless preceded by AKI initially, there may not be any signs or symptoms of kidney disease and substantial damage can occur before the disease is detected in the early stakes of CKD➔Serum creatinine levels may even be normal, but the kidneys begin leaking protein or red blood cells into the urine➔By the time the disease is detected, the GFR can be substantially reduced➔Psychological◆Withdrawn◆Behavior changes◆Depression➔Neurological◆Weakness/fatigue◆Confusion ➔Hematological◆Anemia◆Bleeding tendencies◆Increased serum K➔Cardiovascular◆Increased BP◆Increased CVP◆Pitting edema◆Periorbital edema◆Pericarditis➔Skin◆Dry flaky◆Pruritus◆Ecchymosis◆Purpura◆Yellow-gray skin color➔Pulmonary◆SOB◆Depressed cough◆Thick sputum➔GI◆Ammonia odor to breath◆Metallic taste◆Mouth/gum ulcerations◆Anorexia42
◆Nausea/vomiting ➔Musculoskeletal◆Cramps◆Renal osteodystrophy◆Bone pain➔Hemodialysis◆Evaluate access site for patency and signs of infection◆DO NOTtake blood pressure or obtain blood samples from extremity that has access siteESRD - End Stage Renal Disease➔Most severe stage of chronic kidney disease➔Your kidneys are no longer working well enough for you to live without dialysis or kidneytransplant - need one or the other➔Best way to prevent ESRD (kidney failure) is to prevent CKD➔Preventable factors ◆Diabetes◆HTN◆Heart disease➔Non Preventable factors◆Family hx◆African American, Hispanic, Native American, AsianChronic renal failure- Diagnostics➔GFR - decreases (due to non functioning glomeruli)➔Creatinine clearance - decreases➔Serum creatinine and BUN levels increase➔Urine tests - check the level of protein albumin in your urine➔Imaging tests:◆Ultrasound◆MRI◆CT scan◆Kidney tissue biopsyChronic renal failure - Clinical Manifestations➔*d/t accumulation of uremic waste products*➔Nausea/ vomiting43
➔Loss of appetite➔Fatigue and weakness➔Changes in how much you urinate➔Chest pain - if fluid builds up around the lining of heart➔SOB - if fluid builds up in the lungs➔Swelling of feet and ankles➔High blood pressure (hypertension) - difficult to control➔Headache➔Difficult sleeping➔Decreased mental sharpness➔Muscle twitches and cramps➔Persistent itching➔Metallic taste➔Asterixis - (35)◆person loses motor control of some parts of body◆Commonly called flapping hand tremor ◆Loss of muscle control and irregular jerking movement in hands 5 Stages of Kidney Disease➔Stage 1◆GFR >90◆Normal or high function➔Stage 2◆89>GFR>60◆Mildly decreased function➔Stage 3A◆59>GFR>40◆Mild to moderately decreased function➔Stage 3B◆44>GFR>30◆Mild to moderately decreased function➔Stage 4◆29>GFR>15◆Severely decreased function➔Stage 5◆GFR<15◆Kidney failure44
Chronic renal failure- Nutrition➔Diet◆Regulation of protein intake◆Fluid intake to balance fluid losses◆Sodium intake to balance sodium losses◆Restriction of potassium◆Avoid alcohol ◆SATA: dont pick calories and calcium - pick the other three(36)Chronic renal failure- Treatments➔Medications◆Calcium phosphorus binders◆Antihypertensives◆Anticonvulsants ◆Erythropoietin➔DialysisChronic Renal failure - Nursing education➔Worsening signs and symptoms of kidney disease◆Nausea◆Vomiting◆Change in usual urine output◆Ammonia odor on breath➔Signs and symptoms of hyperkalemia◆Muscle weakness◆Diarrhea◆Abdominal cramps➔Signs and symptoms of access problems◆Clotted fistula or graft◆Infection➔Follow up exams➔Diet and restrictions The Kidney Bean - Some considerations45
➔The aging kidney is less able to compensate for changes in fluid volume, solute load, cardiac output➔More susceptible to AKI➔Dehydration is associated with:◆Polypharmacy●Diuretics, laxatives, drugs that suppress appetite or consciousness◆Acute febrile illness◆Being bedridden➔Cardiovascular disease or diabetes mellitus can increase the risk of developing AKI➔Aminoglycosides, gentamicin can be nephrotoxic◆Monitor kidney function with creatinine labs Dialysis- Indications➔GOALS◆Remove excess fluid and toxins◆Balance electrolytes(37)◆Manage and correct acidosis Dialysis- Hemodialysis➔Hemodialysis◆Acutely ill and require short term dialysis for days to weeks until kidney function resumes ◆Long-term or permanent renal replacement therapy ◆Prevents death but does not cure kidney disease and does not compensate for the loss of endocrine or metabolic activities of the kidneys◆3 times a week◆3 to 5 hours in an outpatient setting◆Home - time & frequency can be different per patient◆Requires a vascular access site●Arteriovenous shunt●Port●Fistula◆Advantages●Home and/or at a dialysis center●Removes fluid rapidly●Excellent for potassium removal46
●Less protein loss●Lowers serum triglycerides quickly ●Quickly removes urea and creatinine●Temporary access may be obtained quickly◆Disadvantages●Problems obtaining vascular access●Very strict diet and fluid limits●Heparin may be required to keep access open●Blood loss, which contributes to anemia●Trained personnel required●Permanent access requires a surgical procedure●Several hours to recover from treatment●Strict diet maintaining low phosphorus and potassium intake★AV Fistula➔Must have good veins➔Fistula is a connection of the vein to the artery directly➔After the operation the vein needs to mature and get bigger and thicker in size before it can be successfully used for dialysis➔Most durable option because if it matures successfully, it lasts much longer than an AV grafts➔AV fistulas are much less likely to clot than grafts➔Make sure you are checking a patient's fistula ◆Listen for bruit ◆Palpate for thrill➔Presence of a thrill and bruit indicate adequate blood flow through fistula ★AV Graft➔If veins are not good quality➔There is a synthetic Teflon graft connecting the artery to the vein ➔Advantage◆can be used as early as 2 weeks➔Disadvantage◆Graft does not last as long as a fistula 47
◆Half of these grafts will clot off in the first year➔***If a patient ℅ pain and coldness on the arm of the graft, make sure you report the patients symptoms to the doctor***◆Can be an indication of distal ischemia that may require revision➔★Hemodialysis Nursing Care➔Assess for toxic levels of medications◆Water soluble◆Fat soluble➔Promote good nutrition and fluid intake ◆Prevent uremia◆Protein restriction ●1.2 to 1.3 g/kg daily◆Fluid restrictions ●Daily urine output plus 500 mL/day◆Sodium restrictions ●2 to 3 g/day◆Potassium restriction◆Phosphorus restriction➔Monitor vitals➔Psychological needs ◆Patient ◆Family Dialysis Types - Peritoneal➔Peritoneal◆Requires access via an implanted port with a catheter placed in the anterior wall of the abdomen➔Automated peritoneal dialysis (APD)◆Accomplish dialysis while they sleep◆Machine cycles four or more exchanges per night ◆1 to 2 hours per exchange ➔Continuous ambulatory peritoneal dialysis (CAPD)◆Manually◆1.5 to 3 L of peritoneal dialysate48
◆At least four times daily - dwell times averaging 4 hours●Ex: one schedule exchanges at 7:00am, 12:00pm, 5:00pm, 10:00pm➔Advantages◆No need for vascular access◆Less dietary and fluid restrictions◆Better BP control◆Not as complicated as hemodialysis◆Can be done at home◆Causes fewer cardiovascular problems◆Increased mobility◆Easier to manage for patients with diabetes ➔Disadvantages◆Infections risk (peritonitis) ◆Chronic back pain or hernia◆Risk of hyperglycemia◆Surgery needed for catheter placement◆Catheter may migrate◆Contraindicated for patients with abdominal surgeries◆Transporting solutions and pump needed for travel◆Increased risk of hyperlipidemia◆Must be done daily◆Nutritional complications●Patients tend to gain weight overtime d/t calories from dextrose in the dialysate◆***if a patient is struggling to drain dialysate from the abdomen, gentle massagecan help***◆***warm the dialysate to prevent cramps*** ★Peritoneal Nursing Care ➔Psychological needs◆Patient◆Family➔Watch electrolytes➔Pruritus and pain secondary to neuropathy➔Vitals➔Prevent infection➔Daily or 3-4 times weekly routine catheter site care is typically performed during showering or bathing49
➔Warm dialysate to body temperature with a heating pad to prevent discomfort(38) ➔Diet restrictions - Limit SATA(39)◆Protein◆Sodium◆Potassium◆Phosphorus◆FluidsDialysis- Process➔Dialyser◆Hollow-fiber device containing thousands of tiny capillary tubes that carry the blood through the artificial kidney◆Semipermeable membrane allows toxins, fluids, and electrolytes to pass across the membrane◆Blood crosses the membrane into the dialysate solution where wastes are removed and discarded Dialysis- Safety Pharmacological treatment- Complications➔Hyperkalemia◆Kayexalate(40)◆Bicarb◆Calcium gluconate◆Glucose50
◆Insulin➔Constipation◆Sorbitol ➔Renal impairment◆Calcium➔Pulmonary edema◆Lasix➔Edema - renal, hepatic◆Lasix◆Bumex◆Hydrochlorothiazide◆Spironolactone - this might be on there for cirrhosis ➔Fluid volume excess◆Mannitol➔Anemia◆Epogen◆Procrit 41: question 150mL/hr IV fluids for kidney pt in hospital with infection42: offer palliative care to old conservative ladyTwo - abg Two or 3 - med math 51