med surg lecture-1

Medical-Surgical NursingMedical-Surgical Nursing

Fluids and ElectrolytesFluids and Electrolytes FluidsFluids

60%60% of an adult’s body weight is water of an adult’s body weight is water

Factors affecting body fluid compositionFactors affecting body fluid composition::

1. Age1. Age

2. Gender2. Gender

3. Body fat3. Body fat

Fluid Compartments in the bodyFluid Compartments in the body::

1. Intracellular space1. Intracellular space

-fluid in the cells-fluid in the cells

-approximately 2/3 of the total body water-approximately 2/3 of the total body water

-primarily located in the skeletal muscle mass-primarily located in the skeletal muscle mass

2. Extracellular Space2. Extracellular Space-body fluid outside the cells-body fluid outside the cells-divided into:-divided into:a. intravasculara. intravascular

>contains plasma>contains plasma>approximately 3L out of 6L blood volume>approximately 3L out of 6L blood volume

b. interstitialb. interstitial>fluid that surrounds the cells>fluid that surrounds the cells>approximately 11-12L in an average >approximately 11-12L in an average

adultadultc. transcellularc. transcellular

>smallest division of the ECF>smallest division of the ECF>approximately 1L of fluid>approximately 1L of fluid>CSF, synovial, pericardial, pleural, >CSF, synovial, pericardial, pleural,

intraocularintraocular

ElectrolytesElectrolytes

2 types:2 types:

1. Cations1. Cations

-sodium, potassium, calcium, magnesium and -sodium, potassium, calcium, magnesium and hydrogen ionshydrogen ions

2. Anions2. Anions

-phosphate, bicarbonate, chloride-phosphate, bicarbonate, chloride 3 Pressures Important in the Maintenance of 3 Pressures Important in the Maintenance of

Fluid BalanceFluid Balance

1. hydrostatic pressure1. hydrostatic pressure

2. osmotic pressure2. osmotic pressure

3. oncotic pressure3. oncotic pressure

Regulation of Body Fluid CompartmentsRegulation of Body Fluid Compartments

1. Osmosis and Osmolality1. Osmosis and Osmolality

2. Diffusion2. Diffusion

3. Filtration3. Filtration

4. Sodium-Potassium Pump4. Sodium-Potassium Pump Routes of Gains and LossesRoutes of Gains and Losses

1. Kidneys1. Kidneys

>approximately 1L in an average adult>approximately 1L in an average adult

>1mg/kg/hour>1mg/kg/hour

2. Skin2. Skin

>may vary from 0 – 1000ml or more>may vary from 0 – 1000ml or more

3. Lungs3. Lungs

>approximately at 400ml a day>approximately at 400ml a day

4. GI tract4. GI tract

>at 100 – 200ml a day>at 100 – 200ml a day

Laboratory Tests for Evaluating Fluid StatusLaboratory Tests for Evaluating Fluid Status

1. Osmolality1. Osmolality

serum Na x 2= glu/18 +BUN/3= Approx value of serum serum Na x 2= glu/18 +BUN/3= Approx value of serum osmolalityosmolality

OsmolarityOsmolarity

2. BUN 2. BUN

10 – 20mg/dl or 3.5 – 7 mmol/L10 – 20mg/dl or 3.5 – 7 mmol/L

3. Creatinine 3. Creatinine

0.7 – 1.5 mg/dl or 60 – 130mmol/L0.7 – 1.5 mg/dl or 60 – 130mmol/L

4. Hematocrit 4. Hematocrit

males: 0.44 - 0.52males: 0.44 - 0.52 females: 0.39 - 0.47females: 0.39 - 0.47

5. Urine Sodium5. Urine Sodium

50 – 220mEq/24 hours50 – 220mEq/24 hours

Homeostatic MechanismsHomeostatic Mechanisms1. Kidneys1. Kidneys

-filters 170L of blood a day-filters 170L of blood a day-excretes only 1.5L of urine/24 hours-excretes only 1.5L of urine/24 hours

2. Heart and Blood Vessel Functions2. Heart and Blood Vessel Functions3. Lungs3. Lungs4. Pituitary Function4. Pituitary Function5. Adrenal Functions5. Adrenal Functions6. Parathyroid Functions6. Parathyroid Functions7. Baroreceptors7. Baroreceptors

a. high pressure baroreceptorsa. high pressure baroreceptors-in the aortic arc and carotid sinus-in the aortic arc and carotid sinus-in the juxtaglomerular cells of the -in the juxtaglomerular cells of the

nephronnephron

b. low pressure baroreceptorsb. low pressure baroreceptors

-in the cardiac atria (left atrium)-in the cardiac atria (left atrium)

8. Renin - Angiotensin - Aldosterone System8. Renin - Angiotensin - Aldosterone System

Liver > Angiotensinogen > Angiotensin Liver > Angiotensinogen > Angiotensin (kidneys)(kidneys)

reninrenin

Angiotensin 2 (lungs) > Aldosterone (adrenals)Angiotensin 2 (lungs) > Aldosterone (adrenals)

ACEACE

9. ADH and Thirst9. ADH and Thirst

10. Osmoreceptors10. Osmoreceptors

11. Atrial Natriuretic Peptide11. Atrial Natriuretic Peptide

-at 20 – 77pg/ml (20 -77ng/L)-at 20 – 77pg/ml (20 -77ng/L)

Third Space Fluid ShiftThird Space Fluid Shift Fluid Volume DeficitFluid Volume Deficit

DehydrationDehydration>causes:>causes:

a. inadequate intakea. inadequate intakeb. abnormal fluid lossesb. abnormal fluid lossesc. other causesc. other causes -diabetes insipidus-diabetes insipidus -osmotic diuresis-osmotic diuresis -hemorrhage-hemorrhage -coma-coma

>signs and symptoms:>signs and symptoms:weight loss, poor skin turgor, oliguria, weight loss, poor skin turgor, oliguria, concentrated urine, postural hypotensionconcentrated urine, postural hypotension

rapid heart rate, decreased CVP, cool rapid heart rate, decreased CVP, cool clammy skin, inc temperatureclammy skin, inc temperature

>assessment:>assessment:

BUN and CreaBUN and Crea

HematocritHematocrit

Serum elecrolytesSerum elecrolytes

Urine specific gravityUrine specific gravity

Fluid Challenge TestFluid Challenge Test

>management:>management:

a. oral route of fluid replacementa. oral route of fluid replacement

-preferred method-preferred method

b. IV routeb. IV route

-isotonic then hypotonic-isotonic then hypotonic

c. monitoringc. monitoring

-weight, intake and output, V/S, CVP-weight, intake and output, V/S, CVP

level of consciousness, breath level of consciousness, breath sounds and skin colorsounds and skin color

>nursing management:>nursing management:

a. prevent fluid volume deficita. prevent fluid volume deficit

b. correct fluid volume deficitb. correct fluid volume deficit Fluid Volume ExcessFluid Volume Excess

-isotonic expansion of body water-isotonic expansion of body water

>cause:>cause:

a. abnormal retention of water and sodiuma. abnormal retention of water and sodium

>s/sx:>s/sx:

a. edemaa. edema b. distended neck veinsb. distended neck veins

c. cracklesc. crackles g. increased CVPg. increased CVPd. tachycardiad. tachycardia h. increased weighth. increased weighte. increased BPe. increased BP i. increased urine outputi. increased urine outputf. increased PP f. increased PP j. shortness of breathj. shortness of breath

>assessment:>assessment:BUNBUN CXRCXRHematocritHematocritSerum OsmolalitySerum OsmolalitySerum ElectrolytesSerum Electrolytes

>management:>management:a. withholding excessive administration of a. withholding excessive administration of

IVFIVFb. diureticsb. diureticsc. restriction of oral fluids (sodium)c. restriction of oral fluids (sodium)

1. Pharmacologic Therapy1. Pharmacologic Therapy2. Hemodialysis2. Hemodialysis3. Nutritional Therapy3. Nutritional Therapy

>nursing management:>nursing management:a. preventing fluid volume excessa. preventing fluid volume excessb. detecting and controlling fluid volume b. detecting and controlling fluid volume

excessexcessc. teaching patients about edemac. teaching patients about edema

Sodium DeficitSodium Deficit-refers to serum sodium level below 135mEq/L-refers to serum sodium level below 135mEq/L

>causes:>causes:a. vomitinga. vomiting d. fistulasd. fistulasb. diarrheab. diarrhea e. sweatinge. sweatingc. diureticsc. diuretics f. dilutional f. dilutional

hyponatremiahyponatremia

>s/sx:>s/sx:similar to dehydrationsimilar to dehydration

>assessment:>assessment:serum sodium of less than 135mEq/Lserum sodium of less than 135mEq/Lurine sodiumurine sodium

SIADH - >20mEq/LSIADH - >20mEq/Lsodium loss - <20mEq/Lsodium loss - <20mEq/L

>management:>management:a. sodium replacementa. sodium replacement

-by mouth, NGT or through -by mouth, NGT or through parenteral routeparenteral route-parenterally, must not exceed -parenterally, must not exceed 12mEq/L in 24 hours > 12mEq/L in 24 hours > osmoticosmotic

demyelinationdemyelination

b. SIADHb. SIADH

-give Demeclocycline or Lithium-give Demeclocycline or Lithium

c. water restrictionc. water restriction

-safer than sodium replacement-safer than sodium replacement

Sodium ExcessSodium Excess-sodium level higher than 145mEq/L-sodium level higher than 145mEq/L-can occur in patients with normal fluid volume or in -can occur in patients with normal fluid volume or in those with FVE or FVDthose with FVE or FVD

>causes:>causes:a.a. gain of sodium in excess of watergain of sodium in excess of water

(administration of hypertonic (administration of hypertonic saline)saline)

b.b. loss of water in excess of sodiumloss of water in excess of sodium(unconscious, cognitively (unconscious, cognitively

impaired impaired individuals, individuals, diarrhea,hyperventilation, diarrhea,hyperventilation, burns, burns, diabetes insipidus, heat stroke diabetes insipidus, heat stroke and and sea water drowning)sea water drowning)

>signs and symptoms:>signs and symptoms:predominantly neurologic predominantly neurologic

(cellullar (cellullar dehydration)dehydration)

Management:Management:>serum sodium should be reduced at a rate of 0.5->serum sodium should be reduced at a rate of 0.5-

1mEq/L1mEq/L1. IVF Therapy1. IVF Therapy

-hypotonic solution or isotonic non saline solution-hypotonic solution or isotonic non saline solution2. Diuretics2. Diuretics3. Desmopressin Acetate3. Desmopressin Acetate

Nursing Management:Nursing Management:1. Look for the hidden sources of sodium1. Look for the hidden sources of sodium2. Monitor for: body temperature, thirst and level of 2. Monitor for: body temperature, thirst and level of

consciousnessconsciousness3. Prevent hypernatremia3. Prevent hypernatremia4. Correct hypernatremia4. Correct hypernatremia

Potassium DeficitPotassium Deficit

-potassium serum level <3.5mEq/L-potassium serum level <3.5mEq/L

causes:causes:

>>alkalosisalkalosis, , GI lossesGI losses, , hyperaldosteronismhyperaldosteronism, , potassiumpotassium losing diureticslosing diuretics, other drugs , other drugs ((corticosteroidscorticosteroids, , amphotericin Bamphotericin B, , carbenicillin carbenicillin and and sodium penicillinsodium penicillin), ), insulin hypersecretioninsulin hypersecretion, , inability or unwillingness to eat a normal dietinability or unwillingness to eat a normal diet, , magnesium depletionmagnesium depletion, , Cushing’s syndromeCushing’s syndrome

signs and symptoms:signs and symptoms:

>fatigue, anorexia, nausea, vomiting, muscle >fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, weakness, leg cramps, decreased bowel motility, paresthesias, dysrhythmias and increased paresthesias, dysrhythmias and increased sensitivity to digitalis, glucose intolerancesensitivity to digitalis, glucose intolerance

Confirmatory tests:Confirmatory tests:

1. Decreased serum potassium1. Decreased serum potassium

2. ECG changes2. ECG changes

-flat or inverted T waves and depression of the -flat or inverted T waves and depression of the ST segmentsST segments

-elevation of the U waves-elevation of the U waves

3. Metabolic Alkalosis3. Metabolic Alkalosis

4. Urine potassium concentration of >20mEq/24 hours4. Urine potassium concentration of >20mEq/24 hours

Medical Management:Medical Management:

1. Potassium replacement therapy1. Potassium replacement therapy

-if without abnormal potassium loss, 40-80mEqs/day-if without abnormal potassium loss, 40-80mEqs/day

-oral (Kalium Durule) or IV (K chloride, K phosphate or -oral (Kalium Durule) or IV (K chloride, K phosphate or K acetate)K acetate)

Nursing Management:Nursing Management:

1. Monitoring for s/sx or progression of hypokalemia1. Monitoring for s/sx or progression of hypokalemia

2. Preventing hypokalemia2. Preventing hypokalemia

3. Correcting hypokalemia3. Correcting hypokalemia

4. Administering IV potassium4. Administering IV potassium

-after adequate urine flow -after adequate urine flow

-20mEqs/hour or less-20mEqs/hour or less

-30-40mEqs/L and below unless severe-30-40mEqs/L and below unless severe

Potassium ExcessPotassium Excess-less common but more severe than hypokalemia-less common but more severe than hypokalemia-causes:-causes:

>renal failure, excessive intake of potassium, >renal failure, excessive intake of potassium, infection, hyporaldosteronism and Addison’s infection, hyporaldosteronism and Addison’s disease, medications (disease, medications (KCl, heparin, ACE KCl, heparin, ACE inhibitors, NSAIDS and K sparing diuretics)inhibitors, NSAIDS and K sparing diuretics) and and acidosisacidosis-clinical manifestations:-clinical manifestations:

>dysrhythmias, skeletal muscle weakness and >dysrhythmias, skeletal muscle weakness and paralysisparalysis

>CNS and PNS involvement>CNS and PNS involvement>Flaccid quadriplegia, respiratory and speech >Flaccid quadriplegia, respiratory and speech

muscle paralysismuscle paralysis

Confirmatory tests:Confirmatory tests:1. ECG1. ECG

-peaked, narrow T waves, ST segment -peaked, narrow T waves, ST segment depression and a shortened QT intervaldepression and a shortened QT interval

-prolonged PR interval then absence of P wave-prolonged PR interval then absence of P wave2. ABG2. ABG3. Serum potassium level increase3. Serum potassium level increase

Medical Management:Medical Management:1. Monitoring of serum potassium with ECG findings1. Monitoring of serum potassium with ECG findings2. Emergency pharmacologic therapy2. Emergency pharmacologic therapy

>calcium gluconate or calcium chloride>calcium gluconate or calcium chloride>sodium bicarbonate>sodium bicarbonate>insulin and glucose>insulin and glucose>beta 2 agonist>beta 2 agonist

3. Dialysis3. Dialysis


1. Monitoring1. Monitoring

2. Preventing hyperkalemia2. Preventing hyperkalemia

3. Correcting hyperkalemia3. Correcting hyperkalemia

PseudohyperkalemiaPseudohyperkalemia

>use of tourniquet in an exercising muscle>use of tourniquet in an exercising muscle

>marked leukocytosis and thrombocytosis>marked leukocytosis and thrombocytosis

>familial pseudohyperkalemia>familial pseudohyperkalemia

Calcium DeficitCalcium Deficit-less than 8.5mg/dl of calcium in the serum-less than 8.5mg/dl of calcium in the serum-causes:-causes:

>hypoparathyroidism>hypoparathyroidism>those who received citrated blood>those who received citrated blood>pancreatitis, renal failure>pancreatitis, renal failure>vitamin D deficiency, magnesium deficiency>vitamin D deficiency, magnesium deficiency>medullary thyroid carcinoma>medullary thyroid carcinoma>low albumin levels, alkalosis and alcohol >low albumin levels, alkalosis and alcohol

abuseabuse-signs and symptoms:-signs and symptoms:

>tetany, seizures and mental changes>tetany, seizures and mental changes-confirmatory test:-confirmatory test:

>ECG- prolonged QT interval>ECG- prolonged QT interval

Management:Management:1. 1. Administer calcium saltsAdminister calcium salts

-calcium carbonate, calcium chloride, calcium -calcium carbonate, calcium chloride, calcium gluceptategluceptate

Risks:Risks:a.a. Sloughing of tissuesSloughing of tissuesb.b. Bradycardia then cardiac arrestBradycardia then cardiac arrestc.c. Digitalis toxicityDigitalis toxicity

2. IVF but not normal saline or solutions containing 2. IVF but not normal saline or solutions containing phosphates and bicarbonatephosphates and bicarbonate

3. Vitamin D therapy3. Vitamin D therapy4. Aluminum hydroxide, calcium acetate, calcium 4. Aluminum hydroxide, calcium acetate, calcium

carbonatecarbonate5. Nutritional therapy5. Nutritional therapy6. Screen for and treat hypomagnesemia6. Screen for and treat hypomagnesemia


1. Monitor hypocalcemia for patients at risk1. Monitor hypocalcemia for patients at risk

2. Airway management2. Airway management

3. Seizure precaution3. Seizure precaution

4. Patient education4. Patient education

-caffeine and alcohol decreases absorption-caffeine and alcohol decreases absorption

-nicotine increases excretion-nicotine increases excretion

-medications to decrease bone loss-medications to decrease bone loss

(alendronate, raloxifene and calcitonin)(alendronate, raloxifene and calcitonin)

Calcium ExcessCalcium Excess-with high mortality rate-with high mortality rate-causes:-causes:

>malignancies and hyperparathyroidism>malignancies and hyperparathyroidism>immobilization>immobilization>use of Thiazide diuretics>use of Thiazide diuretics>milk-alkali syndrome>milk-alkali syndrome>Vitamin A and D intoxication>Vitamin A and D intoxication

-signs and symptoms:-signs and symptoms:*proportional to the elevation of serum calcium*proportional to the elevation of serum calcium>muscle weakness, incoordination, anorexia >muscle weakness, incoordination, anorexia

and and constipationconstipation>cardiac arrest>cardiac arrest

>dehydration>dehydration>abdominal and/or bone pain>abdominal and/or bone pain>abdominal distention and paralytic ileus>abdominal distention and paralytic ileus>excessive urination then polyuria>excessive urination then polyuria>s/sx of PUD>s/sx of PUD>changes in the LOC and mental status>changes in the LOC and mental status*hypercalcemic crisis*hypercalcemic crisis

Laboratory tests:Laboratory tests:1. Serum calcium determination1. Serum calcium determination2. ECG2. ECG

- shortening of the QT interval and ST - shortening of the QT interval and ST segmentsegment

- prolongation of the PR interval- prolongation of the PR interval- dysrhythmias- dysrhythmias

3. Double antibody PTH test3. Double antibody PTH test

4. X-Ray - osteoporosis4. X-Ray - osteoporosis5. Sulkowitch test5. Sulkowitch testManagement:Management:1. Pharmacologic therapy1. Pharmacologic therapy

-dilute the serum calcium and promote its exc.-dilute the serum calcium and promote its exc.(normal saline, administer phosphates, diuretics, (normal saline, administer phosphates, diuretics,

calcitonin)calcitonin)-Cancer treatment-Cancer treatment-Corticosteroid therapy-Corticosteroid therapy

> to decrease bone turnover and tubular > to decrease bone turnover and tubular reabsorptionreabsorption

-Biphosphonates (pamidronate)-Biphosphonates (pamidronate)>causes myalgia, pyrexia and decreased WBC>causes myalgia, pyrexia and decreased WBC

-Mithramycin-Mithramycin>causes thrombocytopenia and nephrotoxicity >causes thrombocytopenia and nephrotoxicity

and and hepatotoxicityhepatotoxicity

-IV phosphates should be used with caution-IV phosphates should be used with caution

>Phospho-Soda, Neutra-Phos>Phospho-Soda, Neutra-Phos


1. Monitor the s/sx1. Monitor the s/sx

2. Increase mobility2. Increase mobility

3. Increase oral fluid intake3. Increase oral fluid intake

Chloride DeficitChloride Deficit-serum chloride level below 96mEq/L-serum chloride level below 96mEq/L-causes:-causes:

>chloride deficient formulas, salt restricted diets>chloride deficient formulas, salt restricted diets>GI tube drainage, severe vomiting and >GI tube drainage, severe vomiting and

diarrheadiarrhea-signs and symptoms:-signs and symptoms:

>hypokalemia, hyponatremia and metabolic >hypokalemia, hyponatremia and metabolic alkalosisalkalosis

(hyperexcitability of muscles, tetany, (hyperexcitability of muscles, tetany, hyperactivity of deep tendon reflexes, hyperactivity of deep tendon reflexes, weakness, weakness, twitching, muscle cramps, cardiac twitching, muscle cramps, cardiac dysrhythmias, dysrhythmias, seizures and coma)seizures and coma)-lab tests:-lab tests:

>serum chloride determination>serum chloride determination

>serum potassium and sodium determination>serum potassium and sodium determination

>ABG>ABG>urine chloride level decrease (normal value- >urine chloride level decrease (normal value-

110-250mEq/L)110-250mEq/L)-medical management:-medical management:

>chloride replacement>chloride replacementnormal saline and half strength salinenormal saline and half strength saline

>reevaluate the use of diuretics>reevaluate the use of diuretics>nutritional therapy>nutritional therapy

tomato juice, salty broth, canned tomato juice, salty broth, canned vegetables, processed meats and fruitsvegetables, processed meats and fruits

>restriction of free water intake>restriction of free water intake>ammonium chloride>ammonium chloride

-nursing management-nursing management

>monitoring of intake and output, ABG >monitoring of intake and output, ABG determination values, serum electrolyte determination values, serum electrolyte levels, LOC, muscle strength and levels, LOC, muscle strength and movementmovement

>vital signs and respiratory assessments>vital signs and respiratory assessments

>patient education as regards to replacement >patient education as regards to replacement therapytherapy

Chloride ExcessChloride Excess-serum chloride level higher than 106mEq/L-serum chloride level higher than 106mEq/L-associated with hypernatremia, bicarbonate loss -associated with hypernatremia, bicarbonate loss and and metabolic acidosismetabolic acidosis-causes:-causes:

>loss of bicarbonate (GI and/or renal)>loss of bicarbonate (GI and/or renal)-signs and symptoms:-signs and symptoms:

>metabolic acidosis, hypervolemia and >metabolic acidosis, hypervolemia and hypernatremiahypernatremia

(tachypnea, weakness, lethargy, deep rapid (tachypnea, weakness, lethargy, deep rapid respirations, diminished cognitive ability and respirations, diminished cognitive ability and hypertension)hypertension)

>decrease in CO, dysrhythmias and coma>decrease in CO, dysrhythmias and coma-lab tests:-lab tests:

>serum sodium and chloride determination>serum sodium and chloride determination>ABG- Bicarbonate less than 22mEq/L>ABG- Bicarbonate less than 22mEq/L

-normal anion gap (8-12mEq/L)-normal anion gap (8-12mEq/L)

>urine chloride concentration greater than >urine chloride concentration greater than 250mEq/L250mEq/L

-medical management:-medical management:>IVF therapy>IVF therapy

-Lactated Ringer’s Solution-Lactated Ringer’s Solution>IV sodium bicarbonate>IV sodium bicarbonate>Diuretics>Diuretics>Fluids, sodium and chloride restriction>Fluids, sodium and chloride restriction

-nursing management:-nursing management:>monitoring V/S, ABG, I&O>monitoring V/S, ABG, I&O>assessment of neurologic, respiratory and >assessment of neurologic, respiratory and

cardiac functionscardiac functions>patient education as regards to nutrition>patient education as regards to nutrition

Acid-Base BalanceAcid-Base Balance Normal blood pHNormal blood pH

-7.35 to 7.45-7.35 to 7.45 Blood pH compatible with lifeBlood pH compatible with life

-6.80 to 7.80-6.80 to 7.80 Buffer SystemsBuffer Systems

-maintains the blood pH by removing or releasing -maintains the blood pH by removing or releasing H+ ionsH+ ions

1. Bicarbonate-Carbonic Acid Buffer System1. Bicarbonate-Carbonic Acid Buffer System-the major extracellular buffer system-the major extracellular buffer system-Bicarbonate to Carbonic Acid Ratio is 20:1-Bicarbonate to Carbonic Acid Ratio is 20:1

2. Phosphate Buffer System2. Phosphate Buffer System3. Plasma proteins, RBC and Hemoglobin3. Plasma proteins, RBC and Hemoglobin

Organs involved in HCO3-H2CO3 System:Organs involved in HCO3-H2CO3 System:

1. Kidneys1. Kidneys

-activation is slower (hours to days) but more -activation is slower (hours to days) but more efficientefficient

-has the ability to regenerate and reabsorb or -has the ability to regenerate and reabsorb or excrete bicarbonatesexcrete bicarbonates

-has the ability to retain or excrete H+-has the ability to retain or excrete H+

-in acidosis: excrete H+ and conserve bicarbonate-in acidosis: excrete H+ and conserve bicarbonate

-in alkalosis: retain H+ and excrete bicarbonate-in alkalosis: retain H+ and excrete bicarbonate

-cannot compensate in renal failure-cannot compensate in renal failure

2. Lungs2. Lungs

-adjust ventilation in response to CO2 content of the -adjust ventilation in response to CO2 content of the bloodblood

-activation is faster but less efficient-activation is faster but less efficient

Acute and Chronic Metabolic AcidosisAcute and Chronic Metabolic Acidosis(Base Bicarbonate Deficit)(Base Bicarbonate Deficit)

-low pH; low plasma bicarbonate-low pH; low plasma bicarbonate-causes:-causes:

>gain of hydrogen ions or loss of bicarbonate>gain of hydrogen ions or loss of bicarbonate-2 forms:-2 forms:

A. High Anion Gap AcidosisA. High Anion Gap Acidosis-due to the accumulation of the -due to the accumulation of the unmeasured anions (phosphates, sulfates unmeasured anions (phosphates, sulfates and proteins)and proteins)

B. Normal Anion Gap Acidosis (B. Normal Anion Gap Acidosis (hyperchloremic hyperchloremic acidosis)acidosis)-due to the direct loss of bicarbonates-due to the direct loss of bicarbonates>diarrhea>diarrhea >diuretics>diuretics>lower intestinal fistulas>lower intestinal fistulas >renal ins.>renal ins.

>excessive administration of chloride>excessive administration of chloride

>excessive administration of parenteral >excessive administration of parenteral solution without bicarbonatesolution without bicarbonate

-signs and symptoms:-signs and symptoms:

>headache, confusion, drowsiness>headache, confusion, drowsiness

>increased respiratory rate and depth>increased respiratory rate and depth

>nausea and vomiting>nausea and vomiting

>peripheral vasodilatation and decreased CO>peripheral vasodilatation and decreased CO

>decreased BP, cold and clammy skin, >decreased BP, cold and clammy skin, dysrhythmias and shockdysrhythmias and shock

-lab tests:-lab tests:

>ABG - low bicarbonate level and a low pH>ABG - low bicarbonate level and a low pH

>Serum potassium determination>Serum potassium determination

>Anion Gap Calculation>Anion Gap Calculation

>ECG>ECG

-medical management:-medical management:

>Eliminate excessive sources of chloride>Eliminate excessive sources of chloride

>Sodium bicarbonate>Sodium bicarbonate

-if pH is less than 7.1-if pH is less than 7.1

-if bicarbonate is less than 10mEq/L-if bicarbonate is less than 10mEq/L

>Serum potassium monitoring and reversal of >Serum potassium monitoring and reversal of potential hypokalemiapotential hypokalemia

>Reversal of potential hypocalcemia>Reversal of potential hypocalcemia

>Sodium Bicarbonate>Sodium Bicarbonate

>Dialysis>Dialysis

Acute and Chronic Metabolic AlkalosisAcute and Chronic Metabolic Alkalosis(Base Bicarbonate Excess)(Base Bicarbonate Excess)

-high pH; high plasma bicarbonate concentration-high pH; high plasma bicarbonate concentration-causes:-causes:

(due to gain of bicarbonates or loss of (due to gain of bicarbonates or loss of hydrogen hydrogen ions)ions)

>vomiting or gastric suction- most common>vomiting or gastric suction- most common>diuretics- loop and thiazides>diuretics- loop and thiazides>hyperaldosteronism and Cushing’s syndrome>hyperaldosteronism and Cushing’s syndrome>excessive alkali ingestion or administration>excessive alkali ingestion or administration>villous adenoma and cystic fibrosis>villous adenoma and cystic fibrosis

-signs and symptoms:-signs and symptoms:>decreased calcium ionization>decreased calcium ionization(tingling of the fingers, toes, dizziness (tingling of the fingers, toes, dizziness

and hypertonic muscles)and hypertonic muscles)>depressed respirations>depressed respirations>atrial arrhythmias then ventricular >atrial arrhythmias then ventricular

arrhythmiasarrhythmias>decreased motility then paralytic ileus>decreased motility then paralytic ileus

-lab tests:-lab tests:>ABG - pH greater than 7.45>ABG - pH greater than 7.45

- bicarbonate greater than 26mEq/L- bicarbonate greater than 26mEq/L>Serum potassium determination>Serum potassium determination>Urinary chloride levels>Urinary chloride levels

-medical management:-medical management:>Chloride replacement (KCl)>Chloride replacement (KCl)>IVF containing sufficient sodium and chloride>IVF containing sufficient sodium and chloride>H2R antagonists- in GI suctioning>H2R antagonists- in GI suctioning

>Carbonic Anhydrase Inhibitors>Carbonic Anhydrase Inhibitors

>I&O monitoring>I&O monitoring

Acute and Chronic Respiratory AcidosisAcute and Chronic Respiratory Acidosis

((Carbonic Acid ExcessCarbonic Acid Excess))

-pH is less than 7.35; paCO2 is higher than 42mmHg-pH is less than 7.35; paCO2 is higher than 42mmHg

-causes:-causes:

(due to inadequate excretion of CO2 > elevated (due to inadequate excretion of CO2 > elevated plasma CO2 > elevated plasma H2CO3)plasma CO2 > elevated plasma H2CO3)

>acute pulmonary edema>acute pulmonary edema >sedative >sedative overdoseoverdose

>aspiration of foreign body >aspiration of foreign body >severe >severe pneumoniapneumonia

>atelectasis>atelectasis >RDS>RDS

>pneumothorax>pneumothorax >MG, GBS>MG, GBS


>increased HR, RR, BP, mental cloudiness >increased HR, RR, BP, mental cloudiness and and feeling of fullness in the headfeeling of fullness in the head

>ventricular fibrillation>ventricular fibrillation>increased intracranial pressure, papilledema, >increased intracranial pressure, papilledema,

dilated conjunctival blood vesselsdilated conjunctival blood vessels>hyperkalemia>hyperkalemia

-lab tests:-lab tests:>ABG>ABG>Serum electrolyte determination>Serum electrolyte determination>Chest X-Ray>Chest X-Ray>ECG>ECG>Drug screen for overdose>Drug screen for overdose


>Pharmacologic>Pharmacologic

*bronchodilators*bronchodilators *thrombolytics*thrombolytics

*antibiotics*antibiotics *anticoagulants*anticoagulants

>Pulmonary hygiene>Pulmonary hygiene

>Adequate hydration>Adequate hydration

>Supplemental O2 with caution>Supplemental O2 with caution

>Mechanical ventilation>Mechanical ventilation

Acute and Chronic Respiratory AlkalosisAcute and Chronic Respiratory Alkalosis((Carbonic Acid DeficitCarbonic Acid Deficit))

-arterial pH of greater than 7.45; PaCO2 of less -arterial pH of greater than 7.45; PaCO2 of less than 38mmHgthan 38mmHg-causes:-causes:

(due to hyperventilation > blowing off of CO2 > (due to hyperventilation > blowing off of CO2 > decreased plasma carbonic acid decreased plasma carbonic acid

concentration)concentration)>extreme anxiety, hypoxemia, early phase of >extreme anxiety, hypoxemia, early phase of

Aspirin intoxication, gram negative Aspirin intoxication, gram negative bacteremia and inappropriate ventilator bacteremia and inappropriate ventilator settingssettings

>chronic hepatic insufficiency, cerebral tumors>chronic hepatic insufficiency, cerebral tumors-signs and symptoms:-signs and symptoms:

>lightheadedness, inability to concentrate>lightheadedness, inability to concentrate

>numbness and tingling from reduced ionized >numbness and tingling from reduced ionized calciumcalcium

>tinnitus, loss of consciousness>tinnitus, loss of consciousness

>tachycardia, atrial and ventricular arrhythmias>tachycardia, atrial and ventricular arrhythmias

-lab tests:-lab tests:

>ABG>ABG

>Serum electrolyte determination>Serum electrolyte determination

-management:-management:

>breath slowly or into a closed system>breath slowly or into a closed system

>sedatives>sedatives

Acid – Base Disturbances and CompensationAcid – Base Disturbances and Compensation

DisorderDisorder Initial EventInitial Event CompensationCompensation

Respiratory Respiratory AcidosisAcidosis

↑↑PaCO2;↑or N PaCO2;↑or N HCO3;↓ pHHCO3;↓ pH

Kidneys eliminate H+ Kidneys eliminate H+ & retain HCO3& retain HCO3

Respiratory Respiratory AlkalosisAlkalosis

↓↓PaCO2;↓or N PaCO2;↓or N HCO3;↑pHHCO3;↑pH

Kidneys conserve H+ Kidneys conserve H+ & excrete HCO3& excrete HCO3

Metabolic Metabolic AcidosisAcidosis

↓↓or N PaCO2; or N PaCO2; ↓HCO3;↓ pH↓HCO3;↓ pH

↓↓Lungs eliminate Lungs eliminate CO2 & conserve CO2 & conserve

HCO3HCO3

Metabolic Metabolic AlkalosisAlkalosis

↑↑or N PaCO2; or N PaCO2; ↑HCO3;↑ pH↑HCO3;↑ pH

Lungs Lungs ↓to↑ PaCO2, ↓to↑ PaCO2, kidneys conserve H+kidneys conserve H+

BurnsBurnsAutograftAutograft EscharotomyEscharotomy

HeterograftHeterograft FasciotomyFasciotomy

HomograftHomograft Rule of NinesRule of Nines

CarboxyhemoglobinCarboxyhemoglobin

4 Major Goals Relating to Burns4 Major Goals Relating to Burns

1. Prevention1. Prevention

2. Institution of lifesaving measures for the severely 2. Institution of lifesaving measures for the severely burned person.burned person.

3. Prevention of disability and disfigurement through 3. Prevention of disability and disfigurement through early, specialized, individual treatment.early, specialized, individual treatment.

4. Rehabilitation through reconstructive surgery and 4. Rehabilitation through reconstructive surgery and rehabilitation programs.rehabilitation programs.

Burn CategoriesBurn Categories Burns are sustained throughBurns are sustained through1. Thermal1. Thermal 1. Conduction1. Conduction2. Chemical2. Chemical 2. Electromagnetic radiation2. Electromagnetic radiation3. Radiation3. RadiationSkin destruction can lead to;Skin destruction can lead to;1. Increased fluid loss1. Increased fluid loss 4. Scarring, change in body image4. Scarring, change in body image2. Infection2. Infection 5. Compromised immunity5. Compromised immunity3. Hypothermia3. Hypothermia 6. Changes in function6. Changes in function

Classification of burns:Classification of burns:A. According to burn depth:A. According to burn depth:

1. Superficial Partial Thickness (Similar to First Degree 1. Superficial Partial Thickness (Similar to First Degree Burn)Burn)

-causes:-causes:

*sunburn*sunburn *low intensity flash*low intensity flash

-involves the epidermis and possibly a portion -involves the epidermis and possibly a portion of of the dermis the dermis


*tingling*tingling *pain that is soothed by *pain that is soothed by

*hyperesthesia*hyperesthesia coolingcooling

*reddened*reddened *possibly blisters*possibly blisters

*minimal or no *minimal or no

edemaedema

-complete recovery within a week; no scarring-complete recovery within a week; no scarring

-peel off-peel off

2. Deep Partial thickness (Similar to Second Degree 2. Deep Partial thickness (Similar to Second Degree Burn)Burn)

-causes:-causes:*scalds*scalds*flash flame*flash flame

-involves the epidermis, upper dermis, portion of -involves the epidermis, upper dermis, portion of the the deeper dermis deeper dermis

-s/sx:-s/sx:*pain*pain *sensitive to cold air*sensitive to cold air*hyperesthesia*hyperesthesia *blistered, weeping *blistered, weeping

surfacesurface*broken epidermis*broken epidermis *edema*edema

-recovery in 2-4 weeks-recovery in 2-4 weeks-some scarring and depigmentation contractures-some scarring and depigmentation contractures-infection may convert it to full thickness-infection may convert it to full thickness

3. Full Thickness (Similar to Third Degree)3. Full Thickness (Similar to Third Degree)-causes:-causes:

*flame*flame*prolonged exposure to hot liquids*prolonged exposure to hot liquids*electric current*electric current*chemical*chemical

-involves the epidermis, entire dermis and -involves the epidermis, entire dermis and sometimes subcutaneous tissue, may involve sometimes subcutaneous tissue, may involve connective tissue, muscle and boneconnective tissue, muscle and bone

-s/sx:-s/sx:*pain free*pain free *hemolysis*hemolysis*shock*shock *entrance and exit *entrance and exit

woundswounds*hematuria*hematuria *broken skin with *broken skin with

exposed exposed *edema*edema fatsfats

-eschar sloughs-eschar sloughs

-grafting necessary-grafting necessary

-scarring and loss of contour and function; -scarring and loss of contour and function; contracturescontractures

-loss of digits or extremity possible-loss of digits or extremity possible

Physiologic Responses to BurnsPhysiologic Responses to Burns

Local Pathophysiologic ResponseLocal Pathophysiologic Response

-if only less than 25% of the TBSA is involved-if only less than 25% of the TBSA is involved

Local and Systemic Pathophysiologic ResponseLocal and Systemic Pathophysiologic Response

-if more than 25% of the TBSA is involved-if more than 25% of the TBSA is involved

-maximal if burns cover 60% or more of the TBSA-maximal if burns cover 60% or more of the TBSA

1. Cardiovascular Response1. Cardiovascular Response

fluid loss > hypovolemia > decreased cardiac output > fluid loss > hypovolemia > decreased cardiac output > decreased BP > decreased perfusion and oxygen delivery decreased BP > decreased perfusion and oxygen delivery

> onset of burn shock > sympathetic response > > onset of burn shock > sympathetic response > peripheral vasoconstriction > further decrease in the peripheral vasoconstriction > further decrease in the COCO

-the greatest volume of fluid leak occurs in -the greatest volume of fluid leak occurs in 24 – 36 24 – 36 hourshours after the burn, peaking at after the burn, peaking at 6 – 8 hours6 – 8 hours

-basically caused by increased capillary permeability-basically caused by increased capillary permeability

-diuresis occurs for several days to 2 weeks-diuresis occurs for several days to 2 weeks

2. Burn Edema2. Burn Edema

-swelling maximal after 24 hours-swelling maximal after 24 hours

-begins to resolve 1-2 days post burn-begins to resolve 1-2 days post burn

-completely resolved after 7-10 days post injury-completely resolved after 7-10 days post injury

Edema > pressure on the small blood vessels Edema > pressure on the small blood vessels and nerves of distal extremity > ischemia > and nerves of distal extremity > ischemia > compartment syndromecompartment syndrome

3. Effects on Fluids and Electrolytes and Blood Volume3. Effects on Fluids and Electrolytes and Blood Volume

-evaporative loss through the burn wound (3-5 L)-evaporative loss through the burn wound (3-5 L)

-hyponatremia (dilutional due to fluid shift from -hyponatremia (dilutional due to fluid shift from interstitial to intravascular space)interstitial to intravascular space)

-hyperkalemia due to massive cell destruction-hyperkalemia due to massive cell destruction

*later results in hypokalemia due to dilution *later results in hypokalemia due to dilution caused caused by fluid shiftby fluid shift

-anemia due to blood loss and hemolysis-anemia due to blood loss and hemolysis

(though may be seen as polycythemia due to (though may be seen as polycythemia due to excessive plasma loss)excessive plasma loss)

4. Pulmonary Response4. Pulmonary Response

-inhalation injury > release of histamine, serotonin and -inhalation injury > release of histamine, serotonin and thromboxane > catecholamine release > hypoxiathromboxane > catecholamine release > hypoxia

-atelectasis may be present due to decreased surfactant-atelectasis may be present due to decreased surfactant

-types of pulmonary injury:-types of pulmonary injury:*upper airway injury*upper airway injury

-results from direct heat and edema-results from direct heat and edema*inhalation injury below the glottis*inhalation injury below the glottis

-usually results from carbon monoxide -usually results from carbon monoxide poisoningpoisoning-respiratory acidosis may occur over the first 5 days after -respiratory acidosis may occur over the first 5 days after the burnthe burn-indicators of a possible pulmonary damage;-indicators of a possible pulmonary damage;

*hx indicating that burn occurred in an enclosed *hx indicating that burn occurred in an enclosed spacespace

*burns of the face and neck*burns of the face and neck*singed nasal hair*singed nasal hair*hoarseness, voice change, dry cough, stridor*hoarseness, voice change, dry cough, stridor*bloody sputum*bloody sputum

*Labored breathing or tachypnea*Labored breathing or tachypnea

*Erythema or blistering of the oral or pharyngeal *Erythema or blistering of the oral or pharyngeal mucosamucosa

-possible consequences will be -possible consequences will be respiratory failure and respiratory failure and acute respiratory distress syndromeacute respiratory distress syndrome

4. Other Systemic Responses4. Other Systemic Responses

-hemolysis and muscle damage > release of hemoglobin -hemolysis and muscle damage > release of hemoglobin and myoglobin > acute tubular necrosis and renal failureand myoglobin > acute tubular necrosis and renal failure

-decreased immune response > sepsis-decreased immune response > sepsis

-loss of skin tissue > altered thermoregulation > -loss of skin tissue > altered thermoregulation > hypothermia > later hyperthermia due to hypothermia > later hyperthermia due to hypermetabolismhypermetabolism

-sympathetic hyperactivity > paralytic ileus and Curling’s -sympathetic hyperactivity > paralytic ileus and Curling’s ulcerulcer

Management:Management:1. Emergent/ Resuscitative Phase of Burn Care1. Emergent/ Resuscitative Phase of Burn Care

A. On the scene CareA. On the scene Care-airway, breathing and circulation-airway, breathing and circulation-disability, exposure and fluid resuscitation-disability, exposure and fluid resuscitation-duration (from onset of injury to completion of -duration (from onset of injury to completion of fluid resuscitationfluid resuscitation-priorities:-priorities:

*first aid*first aid*prevention of shock*prevention of shock*prevention of respiratory distress*prevention of respiratory distress*detection and treatment of concomitant *detection and treatment of concomitant

injuriesinjuries*wound assessment and initial care*wound assessment and initial care

-emergency procedures at the burn scene:-emergency procedures at the burn scene:*extinguish the flames*extinguish the flames*cool the burn*cool the burn*remove restrictive objects*remove restrictive objects*cover the wound*cover the wound*irrigate chemical burns*irrigate chemical burns

B. Emergency Medical Management:B. Emergency Medical Management:-transport to the nearest hospital > life-saving -transport to the nearest hospital > life-saving

measuresmeasures-ABC-ABC-humidification, bronchodilation, mucolytic agents, -humidification, bronchodilation, mucolytic agents,

coughingcoughing-ET tube insertion and assisted ventilation-ET tube insertion and assisted ventilation-continuous positive airway pressure-continuous positive airway pressure-assessment for head and neck injuries-assessment for head and neck injuries

-burn wound management-burn wound management

-IV access, CVP insertion-IV access, CVP insertion

-indwelling urinary catheter insertion-indwelling urinary catheter insertion

-baseline data-baseline data

-tetanus prophylaxis-tetanus prophylaxis

-adequate pain relief-adequate pain relief

C. Transfer to Burn CenterC. Transfer to Burn Center

D. Management of Fluid Loss and ShockD. Management of Fluid Loss and Shock

-fluid replacement therapy-fluid replacement therapy

-fluid requirements-fluid requirements

Problems AssociatedProblems Associated::

>Acute Resp and Renal Failure>Acute Resp and Renal Failure

>Distributive Shock>Distributive Shock

> Compartment Syndrome> Compartment Syndrome

2. Acute or Intermediate Phase of Burn Care2. Acute or Intermediate Phase of Burn Care

-begins 48 to 72 hours after the burn injury-begins 48 to 72 hours after the burn injury

-goals:-goals:

A. Infection PreventionA. Infection Prevention

-Staphylococcus, Pseudomonas, Proteus, E. -Staphylococcus, Pseudomonas, Proteus, E. coli, and Klebsiella coli, and Klebsiella

-Candida is also being implicated-Candida is also being implicated

-3 characteristics of burn wound sepsis:-3 characteristics of burn wound sepsis:

*100,000 bacteria/gram of tissue*100,000 bacteria/gram of tissue

*inflammation*inflammation

*sludging and thrombosis of dermal blood *sludging and thrombosis of dermal blood vesselsvessels

-early enteral feeding can be used for prevention-early enteral feeding can be used for prevention

B. Wound CleaningB. Wound Cleaning

-hydrotherapy-hydrotherapy

>use of tap water>use of tap water

>temperature of water should be >temperature of water should be maintained at 37.8Cmaintained at 37.8C

>room temperature should be >room temperature should be maintained maintained at 26.6-29.4Cat 26.6-29.4C

>should be limited to a 20-30 minute >should be limited to a 20-30 minute periodperiod

C. Topical Antibacterial therapyC. Topical Antibacterial therapy

-criteria for choosing antibiotics:-criteria for choosing antibiotics:

*effective against gram negative organisms*effective against gram negative organisms

*clinically effective*clinically effective

**penetrates the eschar but without systemic penetrates the eschar but without systemic toxicitytoxicity

*does not lose its effectiveness*does not lose its effectiveness*cost effective, available and acceptable *cost effective, available and acceptable *easy to apply*easy to apply-examples:-examples:1. Silver sulfadiazine1. Silver sulfadiazine2. Silver Nitrate2. Silver Nitrate3. Mafenide Acetate3. Mafenide Acetate

D. Wound DressingD. Wound DressingE. Dressing ChangesE. Dressing ChangesF. Wound DebridementF. Wound Debridement

-2 goals:-2 goals:*to remove tissue contaminated by *to remove tissue contaminated by

bacteriabacteria

*to remove devitalized tissue or burn eschar in *to remove devitalized tissue or burn eschar in preparation for grafting and wound healingpreparation for grafting and wound healing

G. Pain ManagementG. Pain Management

H. Nutritional SupportH. Nutritional Support

ShockShock--typestypes::

1. Hypovolemic Shock1. Hypovolemic Shock2. Cardiogenic Shock2. Cardiogenic Shock3. Circulatory Shock (Distributive Shock)3. Circulatory Shock (Distributive Shock)

> Septic Shock> Septic Shock> Neurogenic Shock> Neurogenic Shock> Anaphylactic Shock> Anaphylactic Shock

*Obstructive Shock*Obstructive Shock-Effect of shock to normal cellular functions-Effect of shock to normal cellular functions-Vascular Responses-Vascular Responses

1. Central Regulatory Mechanisms1. Central Regulatory Mechanisms2. Local Regulatory Mechanisms2. Local Regulatory Mechanisms

--Blood Pressure RegulationBlood Pressure RegulationBP= CO x TPRBP= CO x TPR CO= SV x HRCO= SV x HR

>Maintained by:>Maintained by:a. nervous systema. nervous systemb. endocrine systemb. endocrine systemc. chemicalsc. chemicals>Maintain tissue/organ perfusion:>Maintain tissue/organ perfusion:a. MAP= a. MAP= systolic BP + 2 (diastolic BP)systolic BP + 2 (diastolic BP)

33*should exceed 70-80 mmHg*should exceed 70-80 mmHg

-Stages of Shock-Stages of Shock1. Compensatory Stage1. Compensatory Stage

>BP is maintained within normal limits due to the >BP is maintained within normal limits due to the effect of normally functioning regulatory mechanismseffect of normally functioning regulatory mechanisms

>s/sx:>s/sx:

*metabolic acidosis*metabolic acidosis *mental status *mental status changechange

*tachypnea*tachypnea

>medical management:>medical management:

a. identify the cause of shocka. identify the cause of shock

b. correction of shockb. correction of shock

c. support of the regulatory mechanismsc. support of the regulatory mechanisms

>nursing management:>nursing management:

a. monitoring tissue perfusiona. monitoring tissue perfusion

*LOC*LOC *urine output*urine output

*V/S*V/S *skin*skin

*laboratory values*laboratory values

b. reducing anxietyb. reducing anxietyc. promoting safetyc. promoting safety

2. Progressive Stage2. Progressive Stage-exhaustion of the compensatory mechanisms-exhaustion of the compensatory mechanisms

*myocardial depression*myocardial depression*increased capillary permeability*increased capillary permeability

-assessment and dxtic findings:-assessment and dxtic findings:a. respiratory effectsa. respiratory effects

hypoxemia and hypercarbiahypoxemia and hypercarbiaintense inflammatory responseintense inflammatory responsedecreased surfactant productiondecreased surfactant productionacute respiratory distress syndromeacute respiratory distress syndrome

(acute lung injury, shock lung, non cardiogenic (acute lung injury, shock lung, non cardiogenic pulmonary edema)pulmonary edema)

b. cardiovascular effectsb. cardiovascular effects

dysrhythmiasdysrhythmias

myocardial infarctionmyocardial infarction

cardiac depressioncardiac depression

c. neurologic effectsc. neurologic effects

decreased cerebral perfusiondecreased cerebral perfusion

*mental status change*mental status change

*behavioral change*behavioral change

*pupillary dilation*pupillary dilation

d. renal effectsd. renal effects

MAP<80mmHgMAP<80mmHg

acute renal failureacute renal failure

e. hepatic effectse. hepatic effects

decreased blood flowdecreased blood flow

less ability to perform hepatic functionsless ability to perform hepatic functions

f. gastrointestinal effectsf. gastrointestinal effects

decreased blood flowdecreased blood flow

*PUD*PUD

*bloody diarrhea*bloody diarrhea

*sepsis*sepsis

g. hematologicg. hematologic

DIC DIC

shockshock


a. depends on the type of shocka. depends on the type of shock

b. depends on the decompensation of the b. depends on the decompensation of the organ organ systemssystems

Management Common To All Types Of ShockManagement Common To All Types Of Shock

a. optimize intravascular volumea. optimize intravascular volume

b. supporting the pumping action of the heartb. supporting the pumping action of the heart

c. improving the competence of the vascular c. improving the competence of the vascular systemsystem

Nursing ManagementNursing Management::

a. preventing complicationsa. preventing complications

b. promoting rest and comfortb. promoting rest and comfort

c. supporting family membersc. supporting family members

3. Irreversible Stage3. Irreversible Stage

-severe organ damage-severe organ damage

-can no longer respond to treatment-can no longer respond to treatment

-survival is less likely-survival is less likely


a. same with the progressive stagea. same with the progressive stage

-nursing management:-nursing management:

a. same with progressive shocka. same with progressive shock

b. moral support to the familyb. moral support to the family

c. ethical issues (living will) c. ethical issues (living will)

Clinical Findings in the Stages of ShockClinical Findings in the Stages of Shock

FindingFinding CompensatoryCompensatory ProgressiveProgressive IrreversibleIrreversible

BPBP normalnormal Systolic <80 -Systolic <80 -90mmHg90mmHg

Mechanical or Mechanical or pharma supportpharma support

HRHR >100bpm>100bpm >150bpm>150bpm erratic, asystoleerratic, asystole

RespirationRespiration >20 breaths/ >20 breaths/ minmin

Rapid, shallow Rapid, shallow cracklescrackles

IntubationIntubation

SkinSkin cold, clammycold, clammy Mottled, Mottled, petechiaepetechiae

JaundiceJaundice

Urine Urine OutputOutput

decreaseddecreased 0.5ml/kg/hr0.5ml/kg/hr anuria, needs anuria, needs dialysisdialysis

MentationMentation confusionconfusion LethargyLethargy ComaComa

FindingFinding CompensatoryCompensatory ProgressiveProgressive IrreversibleIrreversible

A/B BalanceA/B Balance Resp AlkalosisResp Alkalosis Met AcidosisMet Acidosis Profound Profound AcidosisAcidosis

HYPOVOLEMIC SHOCKHYPOVOLEMIC SHOCK

-most common type of shock-most common type of shock

-characterized by decreased intravascular volume of -characterized by decreased intravascular volume of 15-25%15-25%

-predisposing factors:-predisposing factors:

External: External: Fluid LossesFluid Losses Internal: Internal: Fluid ShiftsFluid Shifts

a. traumaa. trauma a. hemorrhagea. hemorrhage

b. surgeryb. surgery b. burnsb. burns

c. vomitingc. vomiting c. ascitesc. ascites

d. diarrhead. diarrhea d. peritonitisd. peritonitis

e. diuresise. diuresis e. dehydratione. dehydration

f. diabetes insipidusf. diabetes insipidus


>goals:>goals:

a. restore intravascular volumea. restore intravascular volume

b. redistribute fluid volumeb. redistribute fluid volume

c. correct the underlying causec. correct the underlying cause

*pharmacologic therapy*pharmacologic therapy

desmopressindesmopressin anti-emeticanti-emetic

insulininsulin anti-diarrheaanti-diarrhea


a. administering blood and fluids safelya. administering blood and fluids safely

CARDIOGENIC SHOCKCARDIOGENIC SHOCK

-due to cardiac failure-due to cardiac failure

-either coronary and non coronary-either coronary and non coronary

Coronary FactorsCoronary Factors Non Coronary FactorsNon Coronary Factors

a. myocardial infarctiona. myocardial infarction a. cardiomyopathiesa. cardiomyopathiesb. valvular damageb. valvular damagec. cardiac tamponadec. cardiac tamponade

d. dysrhythmiasd. dysrhythmias


a. anginal paina. anginal pain

b. hemodynamic instabilityb. hemodynamic instability

c. dysrhythmiasc. dysrhythmias

--medical managementmedical management::

a. correction of underlying causea. correction of underlying cause

b. initiation of first line treatmentb. initiation of first line treatment

*supplemental oxygen*supplemental oxygen *vasoactive medications*vasoactive medications

*controlling chest pain*controlling chest pain *controlling HR*controlling HR

*selected fluid support*selected fluid support *mechanical cardiac *mechanical cardiac supportsupport

c. pharmacologic therapyc. pharmacologic therapy

*dobutamine*dobutamine *nitroglycerine*nitroglycerine

*dopamine*dopamine *vasoactive meds*vasoactive meds

*anti-arrhythmic meds*anti-arrhythmic meds

d. fluid therapyd. fluid therapy

--nursing managementnursing management::

a. preventing cardiogenic shocka. preventing cardiogenic shock

b. administering meds and IV fluidsb. administering meds and IV fluids

c. maintaining mechanical devicesc. maintaining mechanical devices

d. enhancing safety and comfortd. enhancing safety and comfort

CIRCULATORY SHOCKCIRCULATORY SHOCK

vasodilationvasodilation

maldistribution of blood volumemaldistribution of blood volume

decreased venous returndecreased venous return

decreased stroke volumedecreased stroke volume

decreased cardiac outputdecreased cardiac output

decreased tissue perfusiondecreased tissue perfusion

A. Septic ShockA. Septic Shock

-risk factors:-risk factors:

a. immunosuppressiona. immunosuppression

b. extremes of ageb. extremes of age d. chronic illnessd. chronic illness

c. malnutritionc. malnutrition e. invasive procedurese. invasive procedures

--medical managementmedical management::

a. pharmacologic therapya. pharmacologic therapy

b. nutritional therapyb. nutritional therapy

--nursing managementnursing management::

a. supportive to the medical managementa. supportive to the medical management

B. Neurogenic ShockB. Neurogenic Shock

-occurs due to the loss of sympathetic tone-occurs due to the loss of sympathetic tone


a. spinal cord injurya. spinal cord injury c. depressant medsc. depressant meds

b. spinal anesthesiab. spinal anesthesia d. hypoglycemiad. hypoglycemia


a. restoring sympathetic tonea. restoring sympathetic tone


a. elevate the head of the bed 30 degreesa. elevate the head of the bed 30 degrees

( in spinal/epidural anesthesia)( in spinal/epidural anesthesia)

b. immobilize the patientb. immobilize the patient

(in spinal cord injury)(in spinal cord injury)

c. elastic compression stockingsc. elastic compression stockings

d. feet elevationd. feet elevation

e. heparin/low molecular weight heparine. heparin/low molecular weight heparin

f. pneumatic compression of the legsf. pneumatic compression of the legs

g. passive ROMg. passive ROM

C. Anaphylactic ShockC. Anaphylactic Shockantigen-antibody reaction brought about by severe antigen-antibody reaction brought about by severe

allergic reactionallergic reaction

provokes mast cells to release chemical mediators like provokes mast cells to release chemical mediators like histamine and bradykininhistamine and bradykinin

widespread vasodilatation and capillary permeabilitywidespread vasodilatation and capillary permeability-predisposing factors:-predisposing factors:

a. drug sensitivitya. drug sensitivity c. bee sting allergyc. bee sting allergyb. transfusion reactionb. transfusion reaction d. latex sensitivityd. latex sensitivity

-medical management:-medical management:a. removal of the causative agenta. removal of the causative agentb. restore vascular tone (epinephrine)b. restore vascular tone (epinephrine)c. antihistamines and bronchodilatorsc. antihistamines and bronchodilators


a. assess for previous hypersensitivity reactionsa. assess for previous hypersensitivity reactions

b. prevention of future exposure to antigensb. prevention of future exposure to antigens

c. identification of new antigensc. identification of new antigens

d. patient educationd. patient education

RENAL DISEASESRENAL DISEASESTerms:Terms:1. aldosterone1. aldosterone 9. hematuria9. hematuria2. antidiuretic hormone2. antidiuretic hormone 10. nocturia10. nocturia3. anuria3. anuria 11. oliguria11. oliguria4. bacteriuria4. bacteriuria 12. proteinuria12. proteinuria5. clearance5. clearance 13. pyuria13. pyuria6. dysuria6. dysuria 14. Valsalva Leak Point 14. Valsalva Leak Point 7. frequency7. frequency ManeuverManeuver8. GFR8. GFR 15. vesicoureteral reflux15. vesicoureteral reflux

Test of Urine Specific Gravity:Test of Urine Specific Gravity:1. Osmolality1. Osmolality 2. Specific gravity2. Specific gravity

KidneysKidneys

-retroperitoneal organs-retroperitoneal organs

-120 – 170g-120 – 170g

-12cm long, 6cm wide and 2.5cm thick-12cm long, 6cm wide and 2.5cm thick

-with 8 – 18 pyramids-with 8 – 18 pyramids

-with 4 -13 minor calyces-with 4 -13 minor calyces

-with 2 – 3 major calyces-with 2 – 3 major calyces

-with protective structures:-with protective structures:

a. Pararenal fata. Pararenal fat

b. Gerota’s fasciab. Gerota’s fascia

c. Perirenal fatc. Perirenal fat

d. Renal capsuled. Renal capsule

NephronNephron

-basic structural and functional unit of the kidney-basic structural and functional unit of the kidney

3 Processes of Urine Formation3 Processes of Urine Formation

1. Glomerular Filtration1. Glomerular Filtration

2. Tubular Reabsorption2. Tubular Reabsorption

3. Tubular Secretion3. Tubular Secretion Renal function begins to decrease at a rate of 1% Renal function begins to decrease at a rate of 1%

each year at 30.each year at 30.

A. Acute PyelonephritisA. Acute Pyelonephritis

-bacterial infection of the renal pelvis, tubules and -bacterial infection of the renal pelvis, tubules and interstitial tissueinterstitial tissue

-an ascending infection-an ascending infection


a. vesico-ureteral refluxa. vesico-ureteral reflux

b. urinary tract obstructionb. urinary tract obstruction

-enlarged kidney-enlarged kidney

-with abscess on the renal capsule and at the -with abscess on the renal capsule and at the cortico-medullary junctioncortico-medullary junction

-s/sx:-s/sx:

>fever and chills>fever and chills >costo-vertebral angle>costo-vertebral angle

>leucocytosis>leucocytosis tenderness tenderness

>bacteriuria and >bacteriuria and >flank pain>flank pain

pyuria dysuriapyuria dysuria >inc. urinary frequency>inc. urinary frequency

-dx:-dx:

>UTZ>UTZ >Nuclear scan>Nuclear scan

>CT scan>CT scan >IVP>IVP

>Urine Culture & Sensitivity Test>Urine Culture & Sensitivity Test

Medical Management:Medical Management:a. uncomplicateda. uncomplicated

-no dehydration, no nausea and vomiting, no -no dehydration, no nausea and vomiting, no sepsissepsis

>2 weeks of oral antibiotics>2 weeks of oral antibioticsTrimethoprim-SulfamethoxazoleTrimethoprim-SulfamethoxazoleCiprofloxacinCiprofloxacinGentamicin with or without AmpicillinGentamicin with or without AmpicillinThird Generation CephalosporinsThird Generation Cephalosporins

>6 weeks of oral antibiotics if with relapse>6 weeks of oral antibiotics if with relapse*urine culture 2 weeks after antibiotic therapy*urine culture 2 weeks after antibiotic therapy

b. complicatedb. complicated-pregnant patients-pregnant patients>hospitalization (antibiotics from IV to oral)>hospitalization (antibiotics from IV to oral)

B. Chronic PyelonephritisB. Chronic Pyelonephritis

-repeated acute pyelonephritis >> chronic -repeated acute pyelonephritis >> chronic pyelonephritispyelonephritis

-no s/sx unless there’s an acute exacerbation-no s/sx unless there’s an acute exacerbation

-kidneys scarred, contracted and non functional-kidneys scarred, contracted and non functional


fatiguefatigue polyuriapolyuria

headacheheadache excessive thirstexcessive thirst

anorexiaanorexia weight lossweight loss

-diagnosis:-diagnosis:

creatinine and BUN clearancecreatinine and BUN clearance

creatinine levelscreatinine levels

intravenous pyelographyintravenous pyelography

-complications:-complications:a. ESRDa. ESRDb. hypertensionb. hypertensionc. formation of renal stonesc. formation of renal stones

-may be due to the presence of urea -may be due to the presence of urea splitting splitting microorganismsmicroorganisms-medical management:-medical management:

a. urine culture and sensitivity guided antibiotic a. urine culture and sensitivity guided antibiotic therapy therapy

NitrofurantoinNitrofurantoinTMP-SMZTMP-SMZ

-nursing management:-nursing management:a. monitoringa. monitoring

-I&O-I&Ob. oral fluids b. oral fluids (3-4L/day)(3-4L/day)

c. symptomaticc. symptomatic-antipyretics-antipyretics

d. educationd. education-advise bed rest-advise bed rest-prevention of UTI-prevention of UTI

C. Acute GlomerulonephritisC. Acute Glomerulonephritis-primarily a disease of children older than 2 years old-primarily a disease of children older than 2 years old-may affect any age-may affect any age-causes:-causes:

>autoimmune>autoimmuneSLESLE

>streptococcal>streptococcalAcute Post Streptococcal Acute Post Streptococcal

GlomerulonephritisGlomerulonephritis

Acute Post Streptococcal GlomerulonephritisAcute Post Streptococcal Glomerulonephritis

-2 to 3 weeks after-2 to 3 weeks after

>impetigo>impetigo

>sorethroat>sorethroat-signs and symptoms:-signs and symptoms:

hematuriahematuria hypertensionhypertension

tea colored urinetea colored urine headache, malaise, flank headache, malaise, flank painpain

proteinuriaproteinuria (+) kidney punch(+) kidney punch

inc serum BUN and creainc serum BUN and crea congestioncongestion

anemiaanemia confusion, somnolenceconfusion, somnolence

edemaedema and seizuresand seizures

Group A Beta-Hemolytic Streptococcal InfectionGroup A Beta-Hemolytic Streptococcal Infection

Antigen-Antibody ReactionAntigen-Antibody Reaction

Deposition in the GlomerulusDeposition in the Glomerulus

Increased Production of Epithelial Cells in the Increased Production of Epithelial Cells in the GlomerulusGlomerulus

WBC InfiltrationWBC Infiltration

ThickeningThickening

ScarringScarring

Decreased GFRDecreased GFR


a. kidney biopsya. kidney biopsy

b. electron microscopyb. electron microscopy

c. immunoflourescence analysisc. immunoflourescence analysis

d. Anti-Streptolysin O Titerd. Anti-Streptolysin O Titer

Anti-DNAse B TiterAnti-DNAse B Titer

e. Serum Complement Determinatione. Serum Complement Determination

-decreased-decreased

-will normalize in 2 – 8 weeks-will normalize in 2 – 8 weeks

IgA NephropathyIgA Nephropathy

-most common type of primary glomerulonephritis-most common type of primary glomerulonephritis

-Inc IgA; with normal serum complement-Inc IgA; with normal serum complement

-complications:-complications:

a. Hypertensive Encephalopathya. Hypertensive Encephalopathy

b. Heart Failureb. Heart Failure

c. Pulmonary Edemac. Pulmonary Edema

Rapidly Progressive GlomerulonephritisRapidly Progressive Glomerulonephritis-patient deteriorates in weeks to months-patient deteriorates in weeks to months-course is more severe and more rapid-course is more severe and more rapid

Management To GlomerulonephritisManagement To GlomerulonephritisGoals:Goals:1. Treat symptoms1. Treat symptoms2. Preserve renal function2. Preserve renal function3. Treat complications3. Treat complications

a. antibioticsa. antibiotics d. protein restrictiond. protein restriction

b. steroidsb. steroids e. sodium restrictione. sodium restrictionc. cytotoxic agentsc. cytotoxic agents f. diureticsf. diuretics

g. dialysisg. dialysis

D. Chronic GlomerulonephritisD. Chronic Glomerulonephritis

-components:-components:

repeated acute glomerulonephritisrepeated acute glomerulonephritis

hypertensive nephrosclerosishypertensive nephrosclerosis

hyperlipidemiahyperlipidemia

chronic tubulo-interstitial injurychronic tubulo-interstitial injury

hemodynamically mediated glomerular sclerosishemodynamically mediated glomerular sclerosis

-contraction of the kidneys to 1/5 of its original size-contraction of the kidneys to 1/5 of its original size

-deformed kidneys-deformed kidneys

-may result to ESRD-may result to ESRD


may be asymptomaticmay be asymptomatic hypertensionhypertension

inc BUN and Creainc BUN and Crea bipedal edemabipedal edema

retinal hemorrhagesretinal hemorrhages ophthalmoscopyophthalmoscopy

papilledemapapilledemaweight lossweight lossweakness and irritabilityweakness and irritabilitynocturianocturiaGIT disturbancesGIT disturbancesanemiaanemiaheart failureheart failureperipheral neuropathy, decreased DTRperipheral neuropathy, decreased DTRpulsus paradosuspulsus paradosus

-diagnosis:-diagnosis:1. Urinalysis - fixed sp. Gravity at 1.0101. Urinalysis - fixed sp. Gravity at 1.010

proteinuria; urinary castsproteinuria; urinary casts

2. serum chemistry2. serum chemistry

-hyperkalemia-hyperkalemia --hypoalbuminemiahypoalbuminemia

-hyperphosphatemia-hyperphosphatemia -hypocalcemia-hypocalcemia

-hypermagnesemia-hypermagnesemia

3. CBC3. CBC

-anemia-anemia

4. Chest X-Ray4. Chest X-Ray

-cardiomegaly-cardiomegaly

-pulmonary edema-pulmonary edema

5. ECG5. ECG

-left ventricular hypertrophy-left ventricular hypertrophy


1. treatment of hypertension1. treatment of hypertension

2. weight monitoring2. weight monitoring

3. give proteins of high biologic value3. give proteins of high biologic value

4. adequate calories4. adequate calories

5. dialysis5. dialysis


1. monitoring1. monitoring

E. Nephrotic SyndromeE. Nephrotic Syndrome

-components:-components:

proteinuriaproteinuria hyperlipidemiahyperlipidemia

hypoalbuminemiahypoalbuminemia

-causes:-causes:

a. chronic glomerulonephritisa. chronic glomerulonephritis

b. diabetes mellitusb. diabetes mellitus

c. amyloidosisc. amyloidosis

d. SLEd. SLE

e. multiple myelomae. multiple myeloma

f. renal vein thrombosisf. renal vein thrombosis


edema edema (soft and pitting)(soft and pitting)

-eyes, dependent area and abdomen-eyes, dependent area and abdomen

malaisemalaise irritabilityirritability

headacheheadache fatiguefatigue


1. Urinalysis1. Urinalysis

-proteinuria (3-3.5g/day)-proteinuria (3-3.5g/day)

-inc WBC-inc WBC

2. Protein Electrophoresis2. Protein Electrophoresis

ImmunoelectrophoresisImmunoelectrophoresis

3. Biopsy3. Biopsy

4. AntiC1q antibodies (SLE)4. AntiC1q antibodies (SLE)


a. infectiona. infection d. acute RFd. acute RF

b. thromboembolismb. thromboembolism e. pulmonary embolie. pulmonary emboli

c. accelerated atherosclerosisc. accelerated atherosclerosis


1. diuretics1. diuretics

2. ACE inhibitors2. ACE inhibitors

3. immunosuppressants3. immunosuppressants

4. steroids4. steroids

5. hypolipidemic agents5. hypolipidemic agents

6. sodium restriction6. sodium restriction

7. CHON intake of 0.8g/kg/day7. CHON intake of 0.8g/kg/day

low saturated fatslow saturated fats

UrolithiasisUrolithiasis-stones or calculi in the urinary tract-stones or calculi in the urinary tract-supersaturation of substances such as calcium -supersaturation of substances such as calcium oxalate, calcium phosphate and uric acidoxalate, calcium phosphate and uric acid-signs and symptoms:-signs and symptoms:

>depends on:>depends on:*the site of obstruction*the site of obstruction*edema*edema*infection *infection

-assessment and diagnosis-assessment and diagnosis>IVP, Intravenous Urography>IVP, Intravenous Urography>Retrograde Pyelography>Retrograde Pyelography>UTZ>UTZ>serum chemistries and 24 urine tests>serum chemistries and 24 urine tests

deficiency of citrate, mgdeficiency of citrate, mgnephrocalcin & uropontinnephrocalcin & uropontin

dehydrationdehydration

infectioninfection

UrolithiasisUrolithiasis

urinary stasisurinary stasis

periods of immobilityperiods of immobility

hypercalciuria and hypercalcemiahypercalciuria and hypercalcemia

-causes of hypercalcemia and hypercalciuria:-causes of hypercalcemia and hypercalciuria:a. hyperparathyroidisma. hyperparathyroidismb. renal tubular acidosisb. renal tubular acidosisc. cancersc. cancersd. granulomatous diseased. granulomatous diseasee. excessive intake of Vitamin De. excessive intake of Vitamin Df. excessive intake of milk and alkalif. excessive intake of milk and alkalig. myeloproliferative diseaseg. myeloproliferative disease

-substances other than calcium that may precipitate -substances other than calcium that may precipitate and form stonesand form stones

a. uric acida. uric acid-5%-10% of renal stones-5%-10% of renal stones-gout, myeloproliferative disorders-gout, myeloproliferative disorders

b. struviteb. struvite-15% of renal stones-15% of renal stones-in persistently alkaline and ammonia -in persistently alkaline and ammonia

rich rich urine urine (caused by urease-splitting bacteria)(caused by urease-splitting bacteria)-in neurogenic bladder, foreign bodies -in neurogenic bladder, foreign bodies

and and recurrent UTIrecurrent UTIc. cystinec. cystine

-1%-2% of renal stones-1%-2% of renal stones-hereditary defect in the renal absorption-hereditary defect in the renal absorption

-medicines that increases the risk of urolithiasis-medicines that increases the risk of urolithiasisa. acetazolamidea. acetazolamide d. laxativesd. laxativesb. Vitamin Db. Vitamin D e. high doses of aspirine. high doses of aspirinc. antacidsc. antacids


a. eradicate the stone a. eradicate the stone

b. determine the stone typeb. determine the stone type

c. prevent nephron destructionc. prevent nephron destruction

d. control infectiond. control infection

e. relieve any obstructione. relieve any obstruction

>Opioid Analgesics>Opioid Analgesics

NSAIDsNSAIDs

>Hot Baths and Moist Heat to the flank >Hot Baths and Moist Heat to the flank area area

>Advise to increase oral fluid intake>Advise to increase oral fluid intake

(urine output of >2L/day is advisable)(urine output of >2L/day is advisable)

-specific management:-specific management:

1. Calcium stones1. Calcium stones

-restrict proteins and sodium in the diet-restrict proteins and sodium in the diet

-acidify the urine using Ammonium -acidify the urine using Ammonium chloride chloride or Acetohydroxamic Acid or Acetohydroxamic Acid

-Cellulose sodium phosphate-Cellulose sodium phosphate

(binds calcium from food)(binds calcium from food)

-thiazide diuretics -thiazide diuretics (if caused by inc PTH)(if caused by inc PTH)

2. Uric Acid Stones2. Uric Acid Stones

-low purine diet -low purine diet (shellfish, mushrooms, (shellfish, mushrooms, asparagus, organ meats) asparagus, organ meats)

-Allopurinol-Allopurinol

-alkalinize the urine-alkalinize the urine

3. Cystine 3. Cystine

-low protein diet-low protein diet

-penicillamine -penicillamine (to decrease excretion (to decrease excretion through the urine)through the urine)

4. Oxalate 4. Oxalate

-dilute the urine-dilute the urine

-limit oxalate containing foods-limit oxalate containing foods

(spinach, strawberries, rhubarb, tea, (spinach, strawberries, rhubarb, tea, peanuts and wheat bran)peanuts and wheat bran)

-surgical management:-surgical management:

a. Ureteroscopya. Ureteroscopy

b. Extracorporeal Shock Wave Lithotripsyb. Extracorporeal Shock Wave Lithotripsy

c. Percutaneous Nephrostomy or Nephrolithotomyc. Percutaneous Nephrostomy or Nephrolithotomy

Acute Renal FailureAcute Renal Failure

-sudden and almost complete loss of renal function-sudden and almost complete loss of renal function


*oliguria*oliguria *normal urine output*normal urine output

*anuria*anuria *rising serum creatinine *rising serum creatinine and BUNand BUN

Categories of ARFCategories of ARF

1. Prerenal1. Prerenal

-shock-shock

2. Intrarenal2. Intrarenal

-the result of actual parenchymal damage-the result of actual parenchymal damage

-use of nephrotoxic drugs (NSAIDs and ACE inh)-use of nephrotoxic drugs (NSAIDs and ACE inh)

3. Postrenal3. Postrenal-the result of an obstruction in the distal urinary tract-the result of an obstruction in the distal urinary tract

Four Clinical Phases of ARFFour Clinical Phases of ARF1. Initiation1. Initiation

-begins with the initial insult and ends when oliguria -begins with the initial insult and ends when oliguria developsdevelops

2. Oliguria2. Oliguria-rise in the serum of waste products of metabolism-rise in the serum of waste products of metabolism-rise in serum potassium and magnesium-rise in serum potassium and magnesium

3. Diuresis3. Diuresis-with gradually increasing urine output-with gradually increasing urine output-renal function may still be markedly abnormal-renal function may still be markedly abnormal

4. Recovery Period4. Recovery Period

-improvement of renal function-improvement of renal function

-may take 3-12 months-may take 3-12 months

-with normal laboratory values-with normal laboratory values

-with permanent 1-3% reduction in GFR-with permanent 1-3% reduction in GFR

CharacteristicsCharacteristics PrerenalPrerenal IntrarenalIntrarenal PostrenalPostrenal

EtiologyEtiology hypoperfusionhypoperfusion parenchymal parenchymal damagedamage

obstructionobstruction

BUN valueBUN value increasedincreased increasedincreased IncreasedIncreased

Creatinine valueCreatinine value increasedincreased increasedincreased IncreasedIncreased

Urine outputUrine output decreaseddecreased varies, often varies, often decreaseddecreased

varies, may be varies, may be decreased or decreased or anuriaanuria

Urine sodiumUrine sodium Decreased, Decreased, <20mEq/L<20mEq/L

Increased, Increased, >40mEq/L>40mEq/L

Varies, often Varies, often <20mEq/L<20mEq/L

Urinary Urinary SedimentSediment

Normal, few Normal, few hyaline castshyaline casts

Abnormal Abnormal castscasts

Usually normalUsually normal

CharacteristicsCharacteristics PrerenalPrerenal IntrarenalIntrarenal PostrenalPostrenal

Urine osmolalityUrine osmolality Increased Increased to to 500mOms500mOms

Abnormal Abnormal casts and casts and debrisdebris

Usually Usually normalnormal

Urine specific Urine specific gravitygravity

IncreasedIncreased Low normal, Low normal, 1.0101.010

VariesVaries

-associated problems:-associated problems:*metabolic acidosis*metabolic acidosis*hyperphophatemia and hypocalcemia*hyperphophatemia and hypocalcemia*anemia*anemia

-prevention:-prevention:*prevention of exposure to nephrotoxic drugs*prevention of exposure to nephrotoxic drugs

-aminoglycosides, cyclosporine, -aminoglycosides, cyclosporine, amphotericinBamphotericinB

*serum BUN and creatinine monitoring*serum BUN and creatinine monitoring-management:-management:

a. restore chemical balance and prevent a. restore chemical balance and prevent complicationscomplications

b. identification and treatment of the underlying b. identification and treatment of the underlying causecause

c. maintain fluid balancec. maintain fluid balance-BP, CVP, serum and urine elect., fluid -BP, CVP, serum and urine elect., fluid

losesloses

d. monitoring for over hydrationd. monitoring for over hydration

-dyspnea, crackles, distended neck veins-dyspnea, crackles, distended neck veins

-Furosemide, Ethacrynic Acid-Furosemide, Ethacrynic Acid

e. dialysise. dialysis

-to prevent serious complications-to prevent serious complications

*hyperkalemia*hyperkalemia

*severe metabolic acidosis*severe metabolic acidosis

*pericarditis*pericarditis

*pulmonary edema *pulmonary edema

f. pharmacologicf. pharmacologic

-cation exchange resin-cation exchange resin

(sodium polystyrene sulfonate-kayexalate)(sodium polystyrene sulfonate-kayexalate)

-retention enema-retention enema

-diuretic therapy-diuretic therapy

-low dopamine dose -low dopamine dose (1-3g/kg)(1-3g/kg)

-phosphate binding agents -phosphate binding agents (AlOH)(AlOH)

g. nutritional therapyg. nutritional therapy

-give additional proteins -give additional proteins (1g/kg/day (1g/kg/day during during the oliguric phase) the oliguric phase)

-high potassium and phosphate foods -high potassium and phosphate foods are are restricted restricted (banana, citrus and coffee)(banana, citrus and coffee)

-potassium restricted to 20-40mEq/day-potassium restricted to 20-40mEq/day

-sodium restricted to 2g/day-sodium restricted to 2g/day

-may require parenteral nutrition-may require parenteral nutrition


a. monitoring fluid and electrolyte balancea. monitoring fluid and electrolyte balance

b. reducing metabolic rateb. reducing metabolic rate

-bed rest, prevention of fever and infection-bed rest, prevention of fever and infection

c. promoting pulmonary functionc. promoting pulmonary function

-assistance in changing positions-assistance in changing positions

-advise to cough and deep breath-advise to cough and deep breath

d. preventing infectiond. preventing infection

-asepsis-asepsis

-avoid inserting an indwelling urinary -avoid inserting an indwelling urinary catheter catheter

e. providing skin caree. providing skin care

f. providing supportf. providing support

Chronic Renal FailureChronic Renal Failure-is a progressive irreversible deterioration in renal -is a progressive irreversible deterioration in renal functionfunction-with uremia or azotemia -with uremia or azotemia (severity of build up will be (severity of build up will be proportional to the severity of s/sx)proportional to the severity of s/sx)-prognosis will be determined by the presence or -prognosis will be determined by the presence or absence of absence of hypertensionhypertension and and proteinuriaproteinuria-causes:-causes:

*diabetes mellitus- most common*diabetes mellitus- most common*hypertension*hypertension*chronic glomerulonephritis*chronic glomerulonephritis*obstruction of the urinary tract*obstruction of the urinary tract*polycystic kidney disease*polycystic kidney disease*infections*infections*nephrotoxic medications*nephrotoxic medications

- stages:- stages:

Stage 1Stage 1

--Reduced Renal ReserveReduced Renal Reserve

-40%-75% loss of nephron function-40%-75% loss of nephron function

-usually asymptomatic-usually asymptomatic

Stage 2Stage 2

--Renal InsufficiencyRenal Insufficiency

-75%-90% loss of nephron function-75%-90% loss of nephron function

-increase in serum BUN and creatinine-increase in serum BUN and creatinine

-inability to concentrate urine-inability to concentrate urine

-anemia may develop-anemia may develop

-with polyuria and nocturia-with polyuria and nocturia

Stage 3Stage 3--End Stage Renal DiseaseEnd Stage Renal Disease-<10% of nephron function remaining-<10% of nephron function remaining-regulatory, excretory and hormonal -regulatory, excretory and hormonal functions are lost functions are lost-requires dialysis-requires dialysis

-signs and symptoms:-signs and symptoms:cardiovascularcardiovascular

*hypertension*hypertension *pulmonary edema*pulmonary edema*heart failure*heart failure *pericarditis*pericarditis

dermatologicdermatologic*pruritus*pruritus*uremic frost (deposit of urea crystals)*uremic frost (deposit of urea crystals) GI and Neurologic s&sxGI and Neurologic s&sx

-assessment and diagnosis-assessment and diagnosisa. glomerular filtration ratea. glomerular filtration rate

creatinine clearancecreatinine clearanceb. serum electrolytesb. serum electrolytesc. ABGc. ABGd. CBCd. CBC

-complications-complicationsa. Hyperkalemiaa. Hyperkalemiab. Pericarditis, Pleural Effusion and Cardiac b. Pericarditis, Pleural Effusion and Cardiac

TamponadeTamponadec. Hypertensionc. Hypertensiond. Anemiad. Anemiae. Bone Diseasee. Bone Disease

-medical management:-medical management:a. maintain kidney function and homeostasisa. maintain kidney function and homeostasisb. treat the underlying cause and contributory b. treat the underlying cause and contributory factors factors

>medications>medications >dialysis>dialysis>diet therapy>diet therapy

1. Pharmacologic Therapy1. Pharmacologic Therapya. antihypertensivesa. antihypertensives

> includes intravascular volume control> includes intravascular volume control*fluid restriction*fluid restriction*sodium restriction*sodium restriction

b. sodium bicarbonateb. sodium bicarbonatec. erythropoietinc. erythropoietin

>will achieve a Hct of 33%-38%>will achieve a Hct of 33%-38%

>IV or SC 3x a week>IV or SC 3x a week>takes 2-6 weeks to increase Hct>takes 2-6 weeks to increase Hct>A/R:>A/R:

*hypertension*hypertension*increased clotting of vascular *increased clotting of vascular

access sitesaccess sites*seizures*seizures*depletion of body iron stores*depletion of body iron stores

d. iron supplementationd. iron supplementatione. antiseizure agentse. antiseizure agents

>Diazepam>Diazepam>Phenytoin>Phenytoin

f. antacidsf. antacids

>aluminum based antacids>aluminum based antacidsneurologic symptomsneurologic symptomsosteomalaciaosteomalacia

>calcium carbonate>calcium carbonate2. Nutritional Therapy2. Nutritional Therapy

-regulation of protein intake-regulation of protein intake-regulation of fluid intake-regulation of fluid intake ((500-600ml500-600ml more than the previous day’s 24 more than the previous day’s 24

hour UO)hour UO)-regulation of sodium intake-regulation of sodium intake-regulation of potassium-regulation of potassium-adequate calories and vitamins-adequate calories and vitamins

3. Dialysis3. Dialysis-to prevent hyperkalemia-to prevent hyperkalemia


a. avoid the complications of reduced renal a. avoid the complications of reduced renal functionfunction

b. assess fluid statusb. assess fluid status

c. identify potential sources of the imbalancec. identify potential sources of the imbalance

d. implement a dietary programd. implement a dietary program

e. encourage self care and independencee. encourage self care and independence

Cardiovascular SystemCardiovascular SystemDefinition of TermsDefinition of Terms

1. Preload – 1. Preload – venous blood returnvenous blood return; degree of stretch ; degree of stretch of cardiac muscle fibers at the end of of cardiac muscle fibers at the end of diastolediastole

2. Afterload – 2. Afterload – BP in arteryBP in artery; amt of resistance to ; amt of resistance to ejection of blood from ventricleejection of blood from ventricle

3. Depolarization – 3. Depolarization – activeactive; caused by entry of Na ; caused by entry of Na while K exits cellwhile K exits cell

4. Repolarization – 4. Repolarization – restrest; caused by reentry of K to ; caused by reentry of K to the cell while Na exitsthe cell while Na exits

5. Systole – 5. Systole – blood supply to all except the heartblood supply to all except the heart; ; ventricular contraction from ejection of ventricular contraction from ejection of blood from ventricles to pulmonary artery blood from ventricles to pulmonary artery and aortaand aorta

6. Diastole – 6. Diastole – blood supply to the heartblood supply to the heart; period of ; period of ventricular relaxation resulting in ventricular relaxation resulting in ventricular fillingventricular filling

7. Cardiac Output – 7. Cardiac Output – blood volume per minuteblood volume per minute; ; normal = 5L/min (resting adult heart)normal = 5L/min (resting adult heart)

8. Stroke Volume – 8. Stroke Volume – blood volume per contractionblood volume per contraction; ; normal = 70mL (resting heart)normal = 70mL (resting heart)

9. Baroreceptors – nerve fibers located in the 9. Baroreceptors – nerve fibers located in the aortic arch and carotid arteries that aortic arch and carotid arteries that

are are responsible for reflex control of BPresponsible for reflex control of BP10. Postural/ Orthostatic Hypotension – 10. Postural/ Orthostatic Hypotension – result to result to

syncope (blood drops to brain = syncope (blood drops to brain = faint)faint); ; usually 10mmHg systolic or usually 10mmHg systolic or moremore

Anatomy and PhysiologyAnatomy and Physiology

1. Heart Valves1. Heart Valves

2. Heart Chambers2. Heart Chambers

3. Coronary Arteries3. Coronary Arteries

4. Cardiac Muscle4. Cardiac Muscle

5. Cardiac Conduction System5. Cardiac Conduction System

6. Cardiac Hemodynamics6. Cardiac Hemodynamics

>Cardiac Pressures>Cardiac Pressures

*right ventricular systole *left ventricular systole*right ventricular systole *left ventricular systole

(15-25mmHg)(15-25mmHg) (110-130mmHg)(110-130mmHg)

*PA diastolic pressure*PA diastolic pressure *resting aortic pressure *resting aortic pressure

(8-15mmHg)(8-15mmHg) (80mmHg)(80mmHg)

**4-12mmHg4-12mmHg on both on both ventriclesventricles and and atria atria at at the end of diastolethe end of diastole

7. Cardiac Output7. Cardiac Outputpreloadpreloadafterloadafterload stroke volumestroke volumecontractilitycontractility

baroreceptorsbaroreceptors heart rateheart rate

Gender DifferencesGender Differences1. resting rate1. resting rate2. stroke volume2. stroke volume higher in womenhigher in women3. ejection fraction3. ejection fraction

4. conduction time is briefer in women4. conduction time is briefer in women5. arteries occlude more easily in women with 5. arteries occlude more easily in women with atherosclerosisatherosclerosis6. effects of estrogen in cardiovascular system of 6. effects of estrogen in cardiovascular system of womenwomen

-regulation of vasomotor tone-regulation of vasomotor tone-response to vascular injury-response to vascular injury-good liver function-good liver function-increased coagulation proteins-increased coagulation proteins-decreased fibrinolytic substances-decreased fibrinolytic substances

Diagnostic Work-upsDiagnostic Work-upsPurposes:Purposes:

1. to aid in the diagnosis of diseases1. to aid in the diagnosis of diseases2. for prognostication2. for prognostication3. to screen patients at risk of diseases3. to screen patients at risk of diseases

4. monitor serum concentration of meds4. monitor serum concentration of meds5. monitor therapeutic effects of meds5. monitor therapeutic effects of meds

A. Cardiac EnzymesA. Cardiac Enzymes>Creatine Kinase (CK)>Creatine Kinase (CK)

*MB*MB -most specific enzyme for MI-most specific enzyme for MI -first enzyme level to rise in MI-first enzyme level to rise in MI*MM and BB*MM and BB -other isoenzymes-other isoenzymes

>Lactate Dehydrogenase>Lactate Dehydrogenase-peaks 2-3days after MI-peaks 2-3days after MI

>Myoglobin>Myoglobin-starts to increase 1-3hours after MI; 4--starts to increase 1-3hours after MI; 4-

12hours 12hours (peak)(peak)

>Troponin I>Troponin I-contractile proteins found in cardiac muscles -contractile proteins found in cardiac muscles

onlyonly-starts to rise 3-4 hours after MI-starts to rise 3-4 hours after MI-peaks in 4-24 hours and remain elevated for 1-3 -peaks in 4-24 hours and remain elevated for 1-3

weeksweeksB. Blood ChemistryB. Blood Chemistry

>Lipid Profile>Lipid Profile*Total Cholesterol*Total Cholesterol -should be less than 200mg/dl-should be less than 200mg/dl*Serum Lipoproteins*Serum LipoproteinsLDLLDL - should be less than 130mg/dl- should be less than 130mg/dlHDLHDL - should be 35-65mg/dl - should be 35-65mg/dl in men in men - should be less than 35 to 85mg/dl - should be less than 35 to 85mg/dl in Fin FTAGTAG - should be 40-150mg/dl- should be 40-150mg/dl

Factors that may elevate TAG levelFactors that may elevate TAG level::

1. obesity1. obesity

2. alcohol use2. alcohol use

3. diabetes3. diabetes

Factors that contribute variations in cholesterol levelFactors that contribute variations in cholesterol level ::

1. age1. age 4. exercise4. exercise 7. tobacco use7. tobacco use

2. gender2. gender 5. genetics5. genetics 8. stress level8. stress level

3. diet3. diet 6. menopause6. menopause

Factors that lower HDL levelFactors that lower HDL level

1. smoking1. smoking 4. physical inactivity4. physical inactivity

2. diabetes2. diabetes

3. obesity3. obesity

>Serum Electrolytes>Serum Electrolytes

>BUN and Creatinine>BUN and Creatinine

>Serum Glucose Level>Serum Glucose Level

C. Coagulation StudiesC. Coagulation Studies

>PTT>PTT

-effects of Heparin therapy-effects of Heparin therapy

-intrinsic pathway-intrinsic pathway

-1.5 to 2.5x of their baseline values-1.5 to 2.5x of their baseline values

>PT>PT

-effects of Warfarin therapy-effects of Warfarin therapy

-extrinsic pathway-extrinsic pathway

-2.5-3.5x (INR)-2.5-3.5x (INR)

D. Hematologic StudiesD. Hematologic Studies

>CBC>CBC

-WBC monitoring in immunocompromised patient -WBC monitoring in immunocompromised patient after heart transplantationafter heart transplantation

-associated anemia will aggravate CAD-associated anemia will aggravate CAD

E. Chest X-RayE. Chest X-Ray

-for the evaluation of the size, position and contour of -for the evaluation of the size, position and contour of the heartthe heart

-cardiac and pericardial calcification-cardiac and pericardial calcification

F. ECGF. ECG

>Continuous ECG Monitoring>Continuous ECG Monitoring

a. Hardwire Cardiac Monitoringa. Hardwire Cardiac Monitoring

b. Telemetryb. Telemetry

c. Transtelephoningc. Transtelephoning

G. Cardiac Stress TestingG. Cardiac Stress Testinga. Exercise Stress Testa. Exercise Stress Test

-by using a treadmill or stationary bike-by using a treadmill or stationary bikeb. Pharmacologic Stress Testb. Pharmacologic Stress Test

-by using Dipyridamole or Adenosine-by using Dipyridamole or Adenosinec. Emotional Stress Testc. Emotional Stress TestPurposes of Cardiac Stress TestPurposes of Cardiac Stress Test

>to evaluate CAD>to evaluate CAD>to determine the cause of chest pain>to determine the cause of chest pain>to assess the functional capacity of the heart >to assess the functional capacity of the heart

after MI or surgeryafter MI or surgery>to evaluate the effectiveness of anti-anginal >to evaluate the effectiveness of anti-anginal

drugsdrugs>to evaluate dysrhythmias after physical exercise>to evaluate dysrhythmias after physical exercise>to determine specific goals for a fitness program>to determine specific goals for a fitness program

H. EchocardiographyH. Echocardiography

-to determine:-to determine:

a. pericardial effusionsa. pericardial effusions

b. etiology of heart murmursb. etiology of heart murmurs

c. function of prosthetic heart valvesc. function of prosthetic heart valves

d. chamber sized. chamber size

e. ventricular wall motione. ventricular wall motion

*Transesophageal Echocardiography*Transesophageal Echocardiography

-with 6 hours of fasting prior-with 6 hours of fasting prior

-IV line-IV line

-with local anesthetic and sedation-with local anesthetic and sedation

-BP and ECG monitoring-BP and ECG monitoring

-after the study:-after the study:extension of fasting for another 4 hoursextension of fasting for another 4 hoursmonitoring for 30 – 60 minutesmonitoring for 30 – 60 minutessorethroat for the next 24 hourssorethroat for the next 24 hours

I. Radionuclide ImagingI. Radionuclide Imaging>to evaluate:>to evaluate:

a. coronary artery perfusiona. coronary artery perfusionb. myocardial ischemia and infarctionb. myocardial ischemia and infarctionc. left ventricular functionc. left ventricular function

>uses:>uses:Thallium 201Thallium 201 emits gamma emits gamma

raysraysTechnetium 99mTechnetium 99m detected by scintillation detected by scintillation

cameracamera

>types:>types:a. Myocardial Perfusion Imaginga. Myocardial Perfusion Imagingb. Computed Tomographyb. Computed Tomographyc. Positron Emission Tomographyc. Positron Emission Tomographyd. Magnetic Resonance Imagingd. Magnetic Resonance Imaging

J. Cardiac CatheterizationJ. Cardiac Catheterization-catheter advancement guided by fluoroscopy-catheter advancement guided by fluoroscopy-to measure oxygen saturation and pressures on -to measure oxygen saturation and pressures on right and left side of the heartright and left side of the heart-needs:-needs:

a. IV linea. IV lineb. BP and ECG monitoringb. BP and ECG monitoringc. resuscitation equipment at bedsidec. resuscitation equipment at bedside

-uses contrast agent (iodine based)-uses contrast agent (iodine based)

-complications: (right sided cardiac catheterization)-complications: (right sided cardiac catheterization)a. dysrhythmiasa. dysrhythmias d. cardiac perforationd. cardiac perforationb. venous spasmb. venous spasm e. cardiac arreste. cardiac arrestc. infectionc. infection

-complications: (left sided cardiac catheterization)-complications: (left sided cardiac catheterization)a. dysrhythmiasa. dysrhythmias d. systemic embolizationd. systemic embolizationb. MIb. MIc. perforationc. perforation

-nursing interventions (pre-op)-nursing interventions (pre-op)1. fasting for 8 – 12 hours1. fasting for 8 – 12 hours2. explain that the procedure will take 2 hours or 2. explain that the procedure will take 2 hours or

lessless3. with mild to moderate sedation3. with mild to moderate sedation4. explain the anticipated sensations (flushing, 4. explain the anticipated sensations (flushing,

inc HR)inc HR)

5. ask the patient to breath deeply or hold the 5. ask the patient to breath deeply or hold the breathbreath

>to lower the diaphram for better >to lower the diaphram for better visualization visualization>ask the patient to cough>ask the patient to cough (to disrupt a dysrhythmia and to clear (to disrupt a dysrhythmia and to clear

the the contrast agent from the arteries) contrast agent from the arteries) -nursing interventions (post-op):-nursing interventions (post-op):

1. observe the site for 1. observe the site for bleedingbleeding and and hematomahematoma2. assess peripheral pulses on the same ext q 2. assess peripheral pulses on the same ext q

15mins for 4 hours then q 1 – 2 hours15mins for 4 hours then q 1 – 2 hours3. evaluate temperature and color of the 3. evaluate temperature and color of the

affected affected extremityextremity4. ask the patient to report signs and 4. ask the patient to report signs and

symptoms symptoms of arterial insufficiency (pain, of arterial insufficiency (pain, numbness numbness and tingling)and tingling)

5. monitor for dysrhythmias and vasovagal 5. monitor for dysrhythmias and vasovagal reactionreaction

*bradycardia*bradycardia >may be>may be *hypotension *hypotension precipitated by aprecipitated by a *nausea *nausea distended bladderdistended bladder

>prompt interventions:>prompt interventions: -raise the feet and -raise the feet and

legslegs -administer IVF and IV-administer IVF and IV

atropineatropine6. explain that the patient should be in supine 6. explain that the patient should be in supine

position for 2 – 6 hoursposition for 2 – 6 hours7. analgesics7. analgesics8. report chest pain, bleeding and sudden8. report chest pain, bleeding and sudden

discomfortdiscomfort9. increase fluid intake to flush out the dye9. increase fluid intake to flush out the dye10. watch out for orthostatic hypotension10. watch out for orthostatic hypotension

Hemodynamic MonitoringHemodynamic Monitoring1. Central Venous Pressure1. Central Venous Pressure2. Pulmonary Artery Pressure2. Pulmonary Artery Pressure3. Intra-arterial BP Monitoring3. Intra-arterial BP MonitoringCentral Venous PressureCentral Venous Pressure

-pressure in the vena cava or right atrium is used to:-pressure in the vena cava or right atrium is used to:a. assess right ventricular functiona. assess right ventricular functionb. venous blood return to the right side of the b. venous blood return to the right side of the

heartheart-nursing interventions:-nursing interventions:

a. application of dry, sterile dressinga. application of dry, sterile dressing-should be dry and occlusive-should be dry and occlusive

b. chest x-ray to confirm placementb. chest x-ray to confirm placementc. daily inspection for signs of c. daily inspection for signs of infection infection

(complication)(complication)

d. watch out for d. watch out for air embolismair embolism (complication) (complication)e. maintenance of the transducer in e. maintenance of the transducer in

phlebotactic phlebotactic axisaxis*normal range:*normal range:

0 – 8 mmHg >>> Pressure Monitoring System0 – 8 mmHg >>> Pressure Monitoring System3 – 8 cmH2O >> Water Manometer System3 – 8 cmH2O >> Water Manometer System

Pulmonary Artery Pressure MonitoringPulmonary Artery Pressure Monitoring-assessment of left ventricular function-assessment of left ventricular function-etiology of shock-etiology of shock-response to vasoactive medications-response to vasoactive medications-can measure:-can measure:

1. CVP or right atrial pressure1. CVP or right atrial pressure2. pulmonary artery systolic and diastolic 2. pulmonary artery systolic and diastolic

pressure (25/9 mmHg)pressure (25/9 mmHg)

3. Mean Pulmonary Artery Pressure (15mmHg)3. Mean Pulmonary Artery Pressure (15mmHg)4. Pulmonary Artery Wedge Pressure 4. Pulmonary Artery Wedge Pressure

(4.5 to 13 mmHg)(4.5 to 13 mmHg)-nursing interventions:-nursing interventions:

a. Maintenance of the transducer at a. Maintenance of the transducer at phlebotactic phlebotactic axisaxis

b. Watch out for complications:b. Watch out for complications:-infections-infections-pulmonary artery rupture-pulmonary artery rupture-pulmonary thromboembolism-pulmonary thromboembolism-pulmonary infarction-pulmonary infarction-catheter kinking-catheter kinking-dysrhythmias-dysrhythmias-air embolism-air embolism

Intra-arterial BP MonitoringIntra-arterial BP Monitoring-direct and continuous BP measurements-direct and continuous BP measurements-ABG measurements-ABG measurements-to obtain blood samples-to obtain blood samples*after selection of an area (site)>> assess *after selection of an area (site)>> assess

collateral collateral circulationcirculation

a. Allen’s testa. Allen’s testb. Doppler testb. Doppler test

-nursing interventions:-nursing interventions:a. observe asepsisa. observe asepsisb. watch out for complications:b. watch out for complications:

-local obstruction with distal ischemia-local obstruction with distal ischemia-external hemorrhage-external hemorrhage-massive ecchymosis-massive ecchymosis

-dissection-dissection-air embolism-air embolism-blood loss-blood loss-pain-pain-arteriospasm-arteriospasm-infection-infection

HypertensionHypertension-terms related:-terms related:

>hypertensive emergency>hypertensive emergency>hypertensive urgency>hypertensive urgency>rebound hypertension>rebound hypertension

-types:-types:a. Primary Hypertensiona. Primary Hypertension b. Secondary b. Secondary

Hypertension Hypertension

-BP monitoring:-BP monitoring:

*normal BP*normal BP >>>> recheck in 2 yearsrecheck in 2 years

*high normal*high normal >>>> recheck in 1 yearrecheck in 1 year

*first stage*first stage >>>> confirm in 2 monthsconfirm in 2 months

*second stage*second stage >>>> confirm in 1 monthconfirm in 1 month

*third stage*third stage >>>> confirm immediatelyconfirm immediately

-as a sign-as a sign

-as a risk factor-as a risk factor

-as a disease-as a disease

-risk factors:-risk factors:

a. smokinga. smoking d. age older than 60 d. age older than 60 yearsyears

b. dyslipidemiab. dyslipidemia e. gender (men)e. gender (men)

c. diabetes mellitusc. diabetes mellitus f. family history of CVDf. family history of CVD

-hypothesis:-hypothesis:a. increased sympathetic activitya. increased sympathetic activityb. renin-angiotensin-aldosterone systemb. renin-angiotensin-aldosterone systemc. increased absorption of chloridec. increased absorption of chlorided. decreased vasodilation of arteriolesd. decreased vasodilation of arterioles

-complications:-complications:a. myocardial infarctiona. myocardial infarctionb. heart failureb. heart failurec. renal failurec. renal failured. stroke/ cerebro-vascular accidentd. stroke/ cerebro-vascular accidente. impaired visione. impaired vision

-gerontologic considerations:-gerontologic considerations:a. accumulation of atherosclerotic plaquea. accumulation of atherosclerotic plaque

b. fragmentation of arterial elastinsb. fragmentation of arterial elastins

c. increased collagen depositsc. increased collagen deposits

d. impaired vasodilatationsd. impaired vasodilatations


a. urinalysisa. urinalysis f. creatinine clearancef. creatinine clearance

b. blood chemistryb. blood chemistry g. renin levelg. renin level

c. 12-lead ECGc. 12-lead ECG h. 24 hour urine proteinh. 24 hour urine protein

d. chest x-rayd. chest x-ray

e. echocardiographye. echocardiography


a. pharmacologic therapya. pharmacologic therapy

b. dietary therapyb. dietary therapy

-nursing interventions:-nursing interventions:

a. patient educationa. patient education

>avoid risk factors>avoid risk factors

>promote healthy lifestyle>promote healthy lifestyle

Peripheral Arterial Occlusive DiseasePeripheral Arterial Occlusive Disease-usually involves the segment of the aorta below the -usually involves the segment of the aorta below the renal artery to the popliteal arteryrenal artery to the popliteal artery-risk factors:-risk factors:

a. age (elderly)a. age (elderly)b. diabetes mellitusb. diabetes mellitus

-clinical manifestations:-clinical manifestations:a. intermittent claudicationa. intermittent claudicationb. coldness or numbness of the affected b. coldness or numbness of the affected

extremityextremityc. skin and nail changesc. skin and nail changesd. ulcerations and gangrened. ulcerations and gangrenee. bruitse. bruitsf. diminished to absent peripheral pulsesf. diminished to absent peripheral pulsesg. muscle atrophyg. muscle atrophy

-medical management:-medical management:a. pharmacologic therapya. pharmacologic therapy

*Pentoxyphylline*Pentoxyphylline-increases RBC flexibility and -increases RBC flexibility and decreases blood viscositydecreases blood viscosity

*Cilostazol*Cilostazol-inhibits platelet aggregation-inhibits platelet aggregation-increases vasodilatation-increases vasodilatation-inhibits smooth muscle proliferation-inhibits smooth muscle proliferation

*Aspirin, Ticlopidine, Clopidogrel*Aspirin, Ticlopidine, Clopidogrel-antiplatelets-antiplatelets

b. surgical management:b. surgical management:vascular graftingvascular graftingendarterectomyendarterectomy

-nursing management:-nursing management:a. maintain circulationa. maintain circulation

*doppler*doppler*pulses*pulses*color*color q 1 hour x 8 q 1 hour x 8

hourshours*temperature*temperature q 2 hours x q 2 hours x *capillary refill*capillary refill 24 hours24 hours*motor and sensory*motor and sensory

b. monitoring for potential complicationsb. monitoring for potential complications*urine output*urine output*CVP & PR*CVP & PR*mental status*mental status*hematoma*hematoma

c. avoidance of leg crossing or dependency of c. avoidance of leg crossing or dependency of the lower extremitythe lower extremity

d. reduce edemad. reduce edema -elevate the affected -elevate the affected extremityextremity

-exercise-exercisee. stockingse. stockings

-may not be necessary-may not be necessary Upper Extremity Arterial Occlussive DiseaseUpper Extremity Arterial Occlussive Disease

-due to: -due to: a. atherosclerosisa. atherosclerosisb. traumab. trauma

-clinical management:-clinical management:a. forearm claudicationa. forearm claudicationb. poor motor functionb. poor motor function

-diagnosis-diagnosisa. difference of 20mmHg of BP between 2 armsa. difference of 20mmHg of BP between 2 armsb. duplex ultrasonographyb. duplex ultrasonographyc. transcranial doppler evaluationc. transcranial doppler evaluation

-management:-management:a. surgerya. surgery

*PTA*PTA*carotid to subclavian artery bypass*carotid to subclavian artery bypass*axillary to axillary bypass*axillary to axillary bypass*autogenous reimplantation of the *autogenous reimplantation of the

subclavian to carotid arterysubclavian to carotid artery AneurismAneurism Aortic DissectionAortic Dissection Raynaud’s PhenomenonRaynaud’s Phenomenon

Deep Vein ThrombosisDeep Vein ThrombosisVenous thrombosisVenous thrombosisThrombophlebitis/ PhlebothrombosisThrombophlebitis/ Phlebothrombosis-of unknown cause-of unknown cause-with predisposing factors:-with predisposing factors:

(Virchow’s triad)(Virchow’s triad)A. stasis of bloodA. stasis of blood

>heart failure>heart failure >vasodilators>vasodilators>shock>shock >immobility>immobility

B. vessel wall injuryB. vessel wall injury>trauma>trauma >chemical irritation>chemical irritation

C. altered blood coagulationC. altered blood coagulation>abrupt withdrawal from anticoagulants>abrupt withdrawal from anticoagulants

>OCP>OCP

>severe blood dyscrasias>severe blood dyscrasias

-manifestations:-manifestations:

a. nonspecifica. nonspecific

b. phlegmasia cerulea dolensb. phlegmasia cerulea dolens

>massive iliofemoral venous thrombosis>massive iliofemoral venous thrombosis

>entire extremity is massively swollen, >entire extremity is massively swollen, tense, painful and cool to touchtense, painful and cool to touch

*deep vein involvement*deep vein involvement

-edema of the affected extremity-edema of the affected extremity

-affected extremity is warmer to touch-affected extremity is warmer to touch

-tenderness-tenderness

*superficial vein involvement*superficial vein involvement-pain-pain -redness-redness-tenderness -tenderness -warmth-warmth

-assessment-assessmenta. historya. history

>varicose veins>varicose veins >obese>obese>hypercoagulation>hypercoagulation >elderly>elderly>neoplastic disease>neoplastic disease >OCP>OCP>cardiovascular disease>cardiovascular disease>recent major surgery>recent major surgery

b. physical assessmentb. physical assessment-prevention-prevention

a. application of elastic compression stockingsa. application of elastic compression stockings

b. use of intermittent pneumatic compression b. use of intermittent pneumatic compression devicedevice

c. positioningc. positioning

d. exercised. exercise

-medical management-medical management

1. anticoagulation therapy1. anticoagulation therapy

a. unfractionated heparina. unfractionated heparin

-sc or iv (intermittent infusion) for -sc or iv (intermittent infusion) for 5-5- 7days7days

-given with Warfarin-given with Warfarin

-coagulation study monitoring-coagulation study monitoring

b. low molecular weight heparinb. low molecular weight heparin

-with longer half life-with longer half life

-can be used in pregnant women-can be used in pregnant women-less toxic-less toxic

c. thrombolytic therapyc. thrombolytic therapy-alteplase, reteplase, t-PA-alteplase, reteplase, t-PA streptokinasestreptokinase-should be given within the first three -should be given within the first three -effects less significant after 5 days-effects less significant after 5 days

-surgical management-surgical management>when pharmacologic therapy is contraindicated>when pharmacologic therapy is contraindicateda. thrombectomya. thrombectomyb. vena cava filterb. vena cava filter

-nursing management-nursing managementa. assessing and monitoring anticoagulant a. assessing and monitoring anticoagulant

therapytherapy

b. monitoring and managing potential b. monitoring and managing potential complicationscomplications>bleeding>bleeding>thrombocytopenia>thrombocytopenia>drug interactions>drug interactions

c. provide comfortc. provide comfort>bed rest>bed rest>elevation of the leg>elevation of the leg>elastic compression stockings>elastic compression stockings>analgesics>analgesics>application of warm moist packs>application of warm moist packs

d. intermittent pneumatic compression devisesd. intermittent pneumatic compression devises>with 35 to 55 mmHg>with 35 to 55 mmHg

e. positioninge. positioning

>feet higher than the heart>feet higher than the heart

f. exercisesf. exercises

>passive then active exercises>passive then active exercises

>deep breathing exercises>deep breathing exercises

>early ambulation>early ambulation

*avoid sitting for more than 2 hours*avoid sitting for more than 2 hours

*walking for at least 10minutes *walking for at least 10minutes every every after 2 hoursafter 2 hours

Varicose VeinsVaricose Veins

-abnormally dilated, tortuous, superficial veins -abnormally dilated, tortuous, superficial veins caused by the incompetent venous valvescaused by the incompetent venous valves

-may occur in the lower extremities and esophagus-may occur in the lower extremities and esophagus

-predisposing factors-predisposing factors

>old age>old age

>pregnancy>pregnancy

>prolonged standing>prolonged standing

>genetic predisposition>genetic predisposition

-has 2 types:-has 2 types:

a. primarya. primary

-without involvement of the deep veins-without involvement of the deep veins

b. secondaryb. secondary

-resulting from the obstruction of the -resulting from the obstruction of the deep deep veinsveins

-manifestations-manifestations

>dull aches>dull aches >increased muscle >increased muscle

>muscle cramps>muscle cramps fatiguefatigue

>ankle edema>ankle edema

>feeling of heaviness>feeling of heaviness

-assessment-assessment

a. duplex scana. duplex scan

b. air plethysmographyb. air plethysmography

c. venographyc. venography

-prevention-preventiona. avoidance of wearing tight socks or a. avoidance of wearing tight socks or

constricting panty girdleconstricting panty girdleb. avoidance of crossing the thighsb. avoidance of crossing the thighsc. avoidance of prolonged standingc. avoidance of prolonged standingd. frequent position changesd. frequent position changese. elevating the affected extremity when tirede. elevating the affected extremity when tiredf. walking 1 to 2 miles each dayf. walking 1 to 2 miles each dayg. using the stairs instead of elevatorsg. using the stairs instead of elevatorsh. elastic compression stockingsh. elastic compression stockingsi. weight reduction planningi. weight reduction planning

-management-management>surgery>surgery

>sclerotherapy>sclerotherapy

-with application of elastic compression -with application of elastic compression bandages for 5 daysbandages for 5 days

Acquired Valvular DisordersAcquired Valvular Disorders Mitral Valve ProlapseMitral Valve Prolapse

-usually produces no symptoms-usually produces no symptoms-mostly in women-mostly in women-mitral valve balloons back into the left atrium during -mitral valve balloons back into the left atrium during systolesystole-signs and symptoms:-signs and symptoms:

-asymptomatic-asymptomatic -palpitations-palpitations-shortness of breath-shortness of breath -syncope-syncope-light headedness-light headedness -chest pain-chest pain-dizziness-dizziness -anxiety-anxiety

-diagnosis:-diagnosis:-mitral clicks-mitral clicks-murmur of mitral regurgitations-murmur of mitral regurgitations


a. symptomatica. symptomatic

b. elimination of stimulantsb. elimination of stimulants

c. anti-arrhythmic medsc. anti-arrhythmic meds

d. beta blockers/ calcium channel blockersd. beta blockers/ calcium channel blockers


a. condition can be genetically transmitteda. condition can be genetically transmitted

b. use of prophylactic antibioticsb. use of prophylactic antibiotics

-for patients with systolic click and a -for patients with systolic click and a murmur murmur

c. instruct to avoid stimulantsc. instruct to avoid stimulants

d. diet, activity and sleepd. diet, activity and sleep

Mitral RegurgitationMitral Regurgitation-signs and symptoms:-signs and symptoms:

a. chronic- asymptomatica. chronic- asymptomaticb. acute - severe congestive heart failureb. acute - severe congestive heart failure

dyspneadyspneafatiguefatigue most common most common

symptomssymptomsweaknessweaknesspalpitationspalpitationsshortness of breath on exertionshortness of breath on exertioncoughcough

-diagnosis:-diagnosis:a. systolic murmura. systolic murmurb. echocardiographyb. echocardiography


similar to congestive heart failuresimilar to congestive heart failure Mitral StenosisMitral Stenosis

-causes-causes

rheumatic endocarditisrheumatic endocarditis


>dyspnea on exertion>dyspnea on exertion

>fatigue (low cardiac output)>fatigue (low cardiac output)

>hemoptysis>hemoptysis

>cough>cough


>weak pulses>weak pulses

>diastolic murmur>diastolic murmur

-low pitched rumbling sound at the apex-low pitched rumbling sound at the apex

>echocardiography>echocardiography

>ECG and cardiac catheterization with >ECG and cardiac catheterization with angiographyangiography

-to determine the severity of mitral stenosis-to determine the severity of mitral stenosis


a. prophylactic antibioticsa. prophylactic antibiotics

b. anticoagulantsb. anticoagulants

c. treatment of CHFc. treatment of CHF

d. surgeryd. surgery

-valvuloplasty-valvuloplasty

-valve replacement-valve replacement

Aortic RegurgitationAortic Regurgitation-causes:-causes:

>endocarditis>endocarditis>syphilis>syphilis>dissecting aneurism>dissecting aneurism>deterioration of an aortic valve replacement>deterioration of an aortic valve replacement

-signs and symptoms:-signs and symptoms:>asymptomatic>asymptomatic>forceful heart beat (head and neck)>forceful heart beat (head and neck) exertional dyspnea and fatigueexertional dyspnea and fatigue signs of left ventricular failuresigns of left ventricular failure

-diagnosis:-diagnosis:>diastolic murmur (high pitched blowing >diastolic murmur (high pitched blowing

sound)sound)

>widened pulse pressure>widened pulse pressure

>water hammer pulse>water hammer pulse

>echocardiography, ECG, MRI and cardiac >echocardiography, ECG, MRI and cardiac catheterizationcatheterization


a. antibiotic prophylaxisa. antibiotic prophylaxis

b. valvuloplasty or valve replacementb. valvuloplasty or valve replacement Aortic StenosisAortic Stenosis

-cause:-cause:

*rheumatic endocarditis*rheumatic endocarditis


>asymptomatic>asymptomatic

>exertional dyspnea>exertional dyspnea

>dizziness>dizziness due to left ventricular due to left ventricular failurefailure

>syncope>syncope

>chest pain>chest pain


>systolic murmur>systolic murmur

-loud, rough-loud, rough

-crescendo-decrescendo-crescendo-decrescendo

>12 lead ECG>12 lead ECG

> echocardiography> echocardiography


a. antibiotic prophylaxisa. antibiotic prophylaxis

b. valvuloplastyb. valvuloplasty

c. valve replacementc. valve replacement

Cardiac DysrhythmiasCardiac Dysrhythmias Sinus Node DysrhythmiasSinus Node Dysrhythmias

1. Sinus Bradycardia1. Sinus Bradycardia

-causes:-causes:

*lower metabolic needs *lower metabolic needs (hypothyroidism, (hypothyroidism, hypothermia, hypothermia, sleep)sleep)

*vagal stimulation *vagal stimulation (vomiting, suctioning, extreme (vomiting, suctioning, extreme pain)pain)

*medications *medications (calcium channel blockers, beta (calcium channel blockers, beta blockers)blockers)

*increased intracranial pressure*increased intracranial pressure

*myocardial infarction*myocardial infarction

-treatment:-treatment:

*atropine sulfate*atropine sulfate

*catecholamines*catecholamines

2. Sinus Tachycardia2. Sinus Tachycardia

-causes:-causes:

*acute blood loss*acute blood loss *pain*pain

*anemia*anemia *hypermetabolic state*hypermetabolic state

*shock*shock *fever*fever

*hypervolemia*hypervolemia *anxiety*anxiety

*hypovolemia*hypovolemia *sympathomimetic *sympathomimetic medsmeds

*congestive heart failure*congestive heart failure

-decreased diastolic filling-decreased diastolic filling

decreased cardiac outputdecreased cardiac output

-syncope-syncope -acute pulmonary edema-acute pulmonary edema

-decreased BP-decreased BP

-management:-management:a. Ca channel blockersa. Ca channel blockersb. Beta blockersb. Beta blockers

3. Sinus Arrhythmias3. Sinus Arrhythmias-no significant hemodynamic effects-no significant hemodynamic effects-not treated usually-not treated usually

Atrial DysrhythmiasAtrial Dysrhythmias1. Premature Atrial Complex1. Premature Atrial Complex

-begins before the next impulse of the SA node-begins before the next impulse of the SA node-causes:-causes:

>caffeine, alcohol>caffeine, alcoholnicotinenicotine

>stretched atrial myocardium>stretched atrial myocardium

>anxiety>anxiety>hypokalemia>hypokalemia>hypermetabolic state>hypermetabolic state>atrial ischemia, injury or infarction>atrial ischemia, injury or infarction

-management:-management:>directed toward the cause>directed toward the cause

2. Atrial Flutter2. Atrial Flutter-only at the atrium at a rate of 250-400/minute-only at the atrium at a rate of 250-400/minute-therapeutic block at the AV node-therapeutic block at the AV node-causes:-causes:

>advanced age>advanced age >hypertension>hypertension>valvular heart disease>valvular heart disease >cardiomyopathy>cardiomyopathy>coronary artery disease>coronary artery disease >hyperthyroidism>hyperthyroidism

>pulmonary disease>pulmonary disease

>acute moderate to heavy ingestion of alcohol>acute moderate to heavy ingestion of alcohol

(holiday heart syndrome)(holiday heart syndrome)

>aftermath of open heart surgery>aftermath of open heart surgery


*chest pain*chest pain *low BP*low BP

*shortness of breath*shortness of breath


>electrical cardioversion>electrical cardioversion

>if stable>if stable

-digitalis-digitalis

-beta blockers-beta blockers

-calcium channel blockers-calcium channel blockers

3. Atrial Fibrillation3. Atrial Fibrillation

-rapid, disorganized and uncoordinated twitching of -rapid, disorganized and uncoordinated twitching of atrial musculatureatrial musculature

-with decreased stroke volume-with decreased stroke volume

-with decreased diastole >> decreased coronary -with decreased diastole >> decreased coronary artery perfusion >> increase the risk of myocardial artery perfusion >> increase the risk of myocardial ischemiaischemia

-increased risk of thrombus formation within the atria -increased risk of thrombus formation within the atria >> embolism>> embolism

-2 to 5x increased risk of stroke-2 to 5x increased risk of stroke

-same causes as with atrial flutter-same causes as with atrial flutter

-s/sx:-s/sx:

*irregular palpitations*irregular palpitations *malaise*malaise

*fatigue*fatigue

-treatment:-treatment:>same as with atrial flutter>same as with atrial flutter>cardioversion (if present in less than 48 hours >cardioversion (if present in less than 48 hours

unless the patient is on anticoagulant unless the patient is on anticoagulant treatment) treatment)>anti-arrhythmic meds:>anti-arrhythmic meds:

-amiodarone, flecainide, ibutilide-amiodarone, flecainide, ibutilide>adenosine (treatment and diagnosis)>adenosine (treatment and diagnosis)>pacemaker insertion>pacemaker insertion

Ventricular DysrhythmiasVentricular Dysrhythmias1. Premature Ventricular Complex1. Premature Ventricular Complex

-an impulse that starts at the left ventricle and is -an impulse that starts at the left ventricle and is conducted through the ventricles before the next conducted through the ventricles before the next normal sinus impulsenormal sinus impulse-causes:-causes:

*caffeine, nicotine and alcohol*caffeine, nicotine and alcohol

*cardiac dysrhythmias and infarction*cardiac dysrhythmias and infarction*increased workload to the heart *increased workload to the heart (exercise, (exercise,

fever, hypervolemia, heart failure, fever, hypervolemia, heart failure, tachycardia)tachycardia)

*digitalis toxicity*digitalis toxicity*hypoxia, acidosis*hypoxia, acidosis*electrolyte imbalances *electrolyte imbalances (hypokalemia)(hypokalemia)

-with danger of ventricular tachycardia if with MI-with danger of ventricular tachycardia if with MI-bigeminy, trigeminy…-bigeminy, trigeminy…-signs and symptoms:-signs and symptoms:

>asymptomatic>asymptomatic>with skipped beats>with skipped beats

-treatment:-treatment:>treat the cause>treat the causeLidocaine- short term and immediate therapyLidocaine- short term and immediate therapy

2. Ventricular Tachycardia2. Ventricular Tachycardia-3 or more PVCs in a row occurring at a rate -3 or more PVCs in a row occurring at a rate exceeding 100 beats/minuteexceeding 100 beats/minute-causes are similar to PVCs-causes are similar to PVCs-usually associated with CAD preceding to PVC-usually associated with CAD preceding to PVC-an emergency: pulseless and unresponsive-an emergency: pulseless and unresponsive-treatment:-treatment:

>if stable:>if stable:-attach to ECG-attach to ECG

>if unstable:>if unstable:-cardioversion or defibrillation-cardioversion or defibrillation

3. Ventricular Fibrillation3. Ventricular Fibrillation-rapid but disorganized ventricular rhythm-rapid but disorganized ventricular rhythm-no atrial activity-no atrial activity

-causes:-causes:>electrical shock>electrical shock>brugada syndrome>brugada syndrome

-normal heart, few or no risk factor for -normal heart, few or no risk factor for CAD, and a family history of sudden CAD, and a family history of sudden cardiac death cardiac death

-signs and symptoms:-signs and symptoms:>no heartbeat>no heartbeat>no pulse>no pulse>no respiration>no respiration

-management:-management:>immediate defibrillation>immediate defibrillation>vasoactive meds>vasoactive meds>anti-arrhythmic meds>anti-arrhythmic meds

4. Ventricular Asystole4. Ventricular Asystole

HEMATOLOGYHEMATOLOGYHematologic SystemHematologic System1. Blood1. Blood 2. Reticulo-endothelial 2. Reticulo-endothelial

a. Plasmaa. Plasma -liver -liver -albumin-albumin -spleen-spleen-globulin-globulin -bone marrow-bone marrow-fibrinogen-fibrinogen-electrolytes-electrolytes-waste products-waste products

b. cellular componentb. cellular component-RBC-RBC-WBC-WBC-platelets-platelets

Functions of the bloodFunctions of the blood

a. carriera. carrier

-oxygen and nutrients-oxygen and nutrients

-waste products-waste products

b. hemostasisb. hemostasis HematopoiesisHematopoiesis

a. intramedullarya. intramedullary

b. extramedullaryb. extramedullary RBCRBC

-approximately 8 micrometers-approximately 8 micrometers

-flexible, can pass through a small blood vessel-flexible, can pass through a small blood vessel

-made up of hemoglobin (95% of cell mass)-made up of hemoglobin (95% of cell mass)

ErythropoietinErythropoietin-response to low RBC count-response to low RBC count-stimulate the BM-stimulate the BM-for erythropoiesis-for erythropoiesis

>>requires iron, folic acid, pyridoxine and requires iron, folic acid, pyridoxine and cyanocobalamincyanocobalamin

Iron Stores and MetabolismIron Stores and Metabolism-diet:-diet:

>10-15 mg of elemental iron/day in a well >10-15 mg of elemental iron/day in a well balanced dietbalanced diet

>only 0.5 to 1 mg is absorbed >> transferrin >only 0.5 to 1 mg is absorbed >> transferrin >> >> normoblast >> hemoglobinnormoblast >> hemoglobin-total body iron content:-total body iron content:

>3 grams>3 grams

-normal concentration value:-normal concentration value:>75-175ug/dl for males>75-175ug/dl for males>65-165 ug/dl for females>65-165 ug/dl for females

Vitamin B12 and Folic Acid MetabolismVitamin B12 and Folic Acid Metabolism-required in the synthesis of DNA-required in the synthesis of DNA

ANEMIAANEMIA3 Broad Causes:3 Broad Causes:

1. loss of RBC1. loss of RBC2. inadequate production2. inadequate production3. increased destruction3. increased destruction

1. Types of Anemia due to decreased production of 1. Types of Anemia due to decreased production of RBCRBCa. Iron Deficiency Anemiaa. Iron Deficiency Anemia C. Folate DeficiencyC. Folate Deficiencyb. Vitamin B12 deficiencyb. Vitamin B12 deficiency D. Dec. Erythropoietin D. Dec. Erythropoietin

2. anemia due to blood loss2. anemia due to blood loss3. Types of anemia due to increased destruction 3. Types of anemia due to increased destruction

(hemolytic)(hemolytic)a. altered erythropoiesisa. altered erythropoiesis

>sickle cell anemia>sickle cell anemia>thalassemia>thalassemia>hemoglobinopathies>hemoglobinopathies

b. hypersplenismb. hypersplenismc. drug induced anemiac. drug induced anemiad. autoimmune anemiad. autoimmune anemia

Clinical manifestations:Clinical manifestations:(fatigue- most common)(fatigue- most common)>severity depends on:>severity depends on:

1. speed with which anemia has developed1. speed with which anemia has developed

2. duration of anemia2. duration of anemia

3. metabolic requirements of the individual3. metabolic requirements of the individual

4. presence of other disorders4. presence of other disorders Complications:Complications:

1. Congestive Heart Failure1. Congestive Heart Failure

2. Paresthesia2. Paresthesia

3. Confusion3. Confusion Nursing Diagnosis:Nursing Diagnosis:

1. Activity Intolerance related to Fatigue, Weakness and 1. Activity Intolerance related to Fatigue, Weakness and Generalized MalaiseGeneralized Malaise

2. Altered Nutrition: Less than body Requirements 2. Altered Nutrition: Less than body Requirements related to Inadequate Intake of Essential Nutrientsrelated to Inadequate Intake of Essential Nutrients

3. Altered Tissue Perfusion r/t Inadequate Blood Volume3. Altered Tissue Perfusion r/t Inadequate Blood Volume

Nursing Interventions:Nursing Interventions:

1. Managing fatigue1. Managing fatigue

-the most frequent symptom and complication-the most frequent symptom and complication

-profound impact on ones level of functioning and -profound impact on ones level of functioning and quality of lifequality of life

2. Maintain adequate nutrition2. Maintain adequate nutrition

-well balanced diet-well balanced diet

-avoidance of alcohol-avoidance of alcohol

-dietary teaching-dietary teaching

-dietary supplements-dietary supplements

3. Maintain adequate perfusion3. Maintain adequate perfusion

-transfusion-transfusion

-supplemental oxygen/vital signs monitoring-supplemental oxygen/vital signs monitoring

4. Complying with prescribed therapy4. Complying with prescribed therapy

5. Monitoring and managing potential complications5. Monitoring and managing potential complications

a. CHFa. CHF

b. paresthesiab. paresthesia

c. confusionc. confusion

Hypoproliferative AnemiasHypoproliferative Anemias Iron Deficiency AnemiaIron Deficiency Anemia

-causes:-causes:

>decreased dietary intake of iron>decreased dietary intake of iron

>blood loss>blood loss

*menorrhagia*menorrhagia

*PUD (alcoholics)*PUD (alcoholics)

-clinical manifestations:-clinical manifestations:>smooth, sore tongue>smooth, sore tongue>brittle and ridged nails>brittle and ridged nails>angular cheilosis>angular cheilosis

-diagnosis:-diagnosis:a. BMAa. BMAb. serum ferritin/TIBCb. serum ferritin/TIBCc. peripheral blood smear (dec MCV)c. peripheral blood smear (dec MCV)d. CBC (dec Hgb and Hct)d. CBC (dec Hgb and Hct)

-management:-management:a. Iron supplementationa. Iron supplementation(Ferrous SO4, Ferrous Fumarate or Ferrous (Ferrous SO4, Ferrous Fumarate or Ferrous

Gluconate)Gluconate)-should be taken for 6-12 months-should be taken for 6-12 months

*if oral iron preparation is not tolerated, give *if oral iron preparation is not tolerated, give iron dextran iron dextran (IM or IV)(IM or IV)

-Nursing Management:-Nursing Management:

1. Diet1. Diet

-should take foods rich in iron-should take foods rich in iron

*organ meats*organ meats *green leafy vegetables*green leafy vegetables

*beans*beans *raisins*raisins

-should take foods rich in vitamin C-should take foods rich in vitamin C

-take iron with an empty stomach-take iron with an empty stomach

-if with GI distress, take with food (-if with GI distress, take with food (but but absorption absorption will be decreased by 50%will be decreased by 50%))

-liquid oral iron preparation-liquid oral iron preparation

Anemia in Renal DiseaseAnemia in Renal Disease

-ESRD:-ESRD:

>less likely to develop unless serum creatinine >less likely to develop unless serum creatinine exceeds 3mg/dlexceeds 3mg/dl

-Dialysis:-Dialysis:

>may lose blood into the dializer >> folic acid >may lose blood into the dializer >> folic acid deficiency and iron deficiencydeficiency and iron deficiency

-Management:-Management:

1. Recombinant Erythropoietin1. Recombinant Erythropoietin

>A/R: HPN- may inc Hct by 33-38%>A/R: HPN- may inc Hct by 33-38%

(dose needs to be titrated and administer anti-(dose needs to be titrated and administer anti-HPN)HPN)

2. Oral iron and folic acid supplementation2. Oral iron and folic acid supplementation

Anemia of Chronic DiseasesAnemia of Chronic Diseases

-due to chronic disease of inflammation, infection -due to chronic disease of inflammation, infection and/or malignancyand/or malignancy

-mild to moderate anemia-mild to moderate anemia

-insidious onset over a period of 6-8 weeks-insidious onset over a period of 6-8 weeks

-Hct seldom less than 25%-Hct seldom less than 25%

-Hgb seldom less than 9 g/dl-Hgb seldom less than 9 g/dl

-erythropoietin levels are low-erythropoietin levels are low

-moderate shortening of the RBC lifespan-moderate shortening of the RBC lifespan


>no need>no need

>treatment of the underlying cause>treatment of the underlying cause

Aplastic AnemiaAplastic Anemia

-may lead to pancytopenia-may lead to pancytopenia

-damage to the BM stem cells-damage to the BM stem cells

-replacement of the marrow with fat-replacement of the marrow with fat

-also has neutropenia and thrombocytopenia-also has neutropenia and thrombocytopenia

-forms:-forms:

>congenital>congenital >idiopathic>idiopathic

>acquired>acquired

-clinical manifestations: (insidious onset)-clinical manifestations: (insidious onset)

>infection>infection

>anemia>anemia

>bruising>bruising

--causescauses:: 1. chemicals1. chemicals

-pesticides-pesticides-glue-glue

2. medications2. medications-antimicrobials (Chloramphenicol)-antimicrobials (Chloramphenicol)-gold compounds-gold compounds-sulfonamides-sulfonamides

--assessment and diagnosisassessment and diagnosis:: 1. BMA1. BMA--medical managementmedical management:: 1. BM transplant or Peripheral Stem Cell Transplant1. BM transplant or Peripheral Stem Cell Transplant 2. Immunosuppressive therapy2. Immunosuppressive therapy

3. Withdrawal of the offending agent3. Withdrawal of the offending agent4. RBC and platelet transfusion4. RBC and platelet transfusion Megaloblastic AnemiaMegaloblastic Anemia

-may lead to pancytopenia-may lead to pancytopenia-due to vitamin B12 and Folic Acid Deficiency-due to vitamin B12 and Folic Acid Deficiency

(abnormal DNA synthesis)(abnormal DNA synthesis)-Hgb may be as low as 4-5 gm/dl-Hgb may be as low as 4-5 gm/dl-WBC count may be as low as 2000-3000/mm3-WBC count may be as low as 2000-3000/mm3-platelet count of less than 50000/mm3-platelet count of less than 50000/mm3-RBC (increase in MCV)-RBC (increase in MCV)

Folic Acid DeficiencyFolic Acid Deficiency-causes:-causes:

*depletion in 4 months time without sufficient *depletion in 4 months time without sufficient folic acid in the diet (green leafy vegetables folic acid in the diet (green leafy vegetables and and liver)liver)

*increased folic acid requirement (pregnancy, *increased folic acid requirement (pregnancy,

alcoholism and chronic blood loss)alcoholism and chronic blood loss) Cyanocobalamin deficiencyCyanocobalamin deficiency

-causes:-causes:

*strict vegetarians (no meat or dairy products)*strict vegetarians (no meat or dairy products)

*absence of intrinsic factor*absence of intrinsic factor

*faulty absorption in the ileum*faulty absorption in the ileum

Clinical manifestations:Clinical manifestations:

a. Hemolytic s/sxa. Hemolytic s/sx

-unique to vit B12 def-unique to vit B12 def

b. GI and Nervous system effectsb. GI and Nervous system effects

Assessment and Diagnostic Findings:Assessment and Diagnostic Findings:

a. Schilling Testa. Schilling Test


a. increase folic acid in the diet and take a. increase folic acid in the diet and take 1 mg1 mg of of folic acid daily folic acid daily (IM for patients with (IM for patients with

malabsorption)malabsorption)

b. Vit B12 replacementb. Vit B12 replacement

-oral supplements-oral supplements

-fortified soy milk-fortified soy milk

*if with intrinsic factor deficiency and *if with intrinsic factor deficiency and malabsorption, monthly IM injection of malabsorption, monthly IM injection of cyanocobalamin at a dose of 1000ugcyanocobalamin at a dose of 1000ug


a. mild jaundicea. mild jaundice

b. vitiligob. vitiligo

c. premature graying of the hairc. premature graying of the hair

d. smooth, red and sore tongued. smooth, red and sore tongue

e. unstable gaite. unstable gaitf. impaired position and vibration sensef. impaired position and vibration sense

Myelodysplastic SyndromeMyelodysplastic Syndrome-is a group of disorder of myeloid stem cells causing -is a group of disorder of myeloid stem cells causing dysplasia of one or more cell typesdysplasia of one or more cell types-most common feature is the dysplasia of the RBCs -most common feature is the dysplasia of the RBCs >> macrocytic anemia >> macrocytic anemia (WBC & platelets may be (WBC & platelets may be affected)affected)-may evolve into -may evolve into Acute Myeloid LeukemiaAcute Myeloid Leukemia-types:-types:

a. Primarya. Primary>more than 80% (elderly)>more than 80% (elderly)

b. Secondaryb. Secondary>exposure to chemicals; poorer prognosis>exposure to chemicals; poorer prognosis

-clinical manifestations:-clinical manifestations:

a. variablea. variable

-assessment and diagnosis:-assessment and diagnosis:

a. CBCa. CBC

>RBC, WBC & platelets are decreased>RBC, WBC & platelets are decreased

b. decreased serum erythropoietinb. decreased serum erythropoietin


a. bone marrow transplantationa. bone marrow transplantation

b. blood transfusion (needs chelation of iron)b. blood transfusion (needs chelation of iron)

c. platelet transfusionc. platelet transfusion

d. growth factors (G-CSF)d. growth factors (G-CSF)

e. erythropoietine. erythropoietin


1. prevention of infection1. prevention of infection2. instructions on the risks of bleeding2. instructions on the risks of bleeding

*chelation therapy is best administered as a *chelation therapy is best administered as a subcutaneous infusion over 10-12 hours often at subcutaneous infusion over 10-12 hours often at nightnight*close monitoring of lab values for anticipation of *close monitoring of lab values for anticipation of transfusion and determination of response to transfusion and determination of response to

growth factorsgrowth factors

Hemolytic AnemiasHemolytic Anemias Sickle Cell AnemiaSickle Cell Anemia

-a result of inheritance of sickle hemoglobin gene-a result of inheritance of sickle hemoglobin gene-sickled Hgb-sickled Hgb

*crystal formation when exposed to low oxygen *crystal formation when exposed to low oxygen tension, deformed, rigid and sickled RBC > tension, deformed, rigid and sickled RBC >

ischemia & infarctionischemia & infarction

-sickling process is intermittent -sickling process is intermittent (with exposure to low (with exposure to low oxygen tension and cold environment)oxygen tension and cold environment)

-assessment and diagnostic findings-assessment and diagnostic findings

>sickle cell trait:>sickle cell trait:

*normal RBC*normal RBC

*normal WBC*normal WBC

*normal platelets*normal platelets

>sickle cell anemia>sickle cell anemia

*decreased Hct*decreased Hct

*sickled cells on smear*sickled cells on smear

-confirmatory test:-confirmatory test:

Hemoglobin electrophoresisHemoglobin electrophoresis

-clinical manifestations:-clinical manifestations:

*Hgb 7-10mg/dl*Hgb 7-10mg/dl

*jaundice*jaundice

*enlargement of the bones of the face and the skull*enlargement of the bones of the face and the skull

*tachycardia, cardiac murmurs and enlarged heart*tachycardia, cardiac murmurs and enlarged heart

*dysrhythmias and heart failure*dysrhythmias and heart failure

*susceptible to infection primarily *susceptible to infection primarily pneumoniapneumonia and and osteomyelitisosteomyelitis

*chronic hemolysis and thrombosis >> ischemia and *chronic hemolysis and thrombosis >> ischemia and necrosis of organs with slowed circulation (necrosis of organs with slowed circulation (spleen, spleen, lungslungs and and CNSCNS))


1. stroke1. stroke

2. infection2. infection3. renal failure3. renal failure4. impotence4. impotence5. heart failure5. heart failure6. pulmonary hypertension6. pulmonary hypertension

Sickle Cell CrisisSickle Cell Crisis-3 types:-3 types:1. Very painful sickle cell crisis1. Very painful sickle cell crisis

> due to tissue hypoxia and necrosis> due to tissue hypoxia and necrosis2. Aplastic crisis2. Aplastic crisis

> due to infection of human parvovirus> due to infection of human parvovirus> Hgb decreases rapidly that the BM cannot > Hgb decreases rapidly that the BM cannot

compensate compensate

3. Sequestration Crisis3. Sequestration Crisis>pooling of sickled cells in an organ>pooling of sickled cells in an organ

*spleen >> splenic infarction >> *spleen >> splenic infarction >> autosplenectomyautosplenectomy

Acute Chest SyndromeAcute Chest Syndrome-decreased hemoglobin and hematocrit (rapid)-decreased hemoglobin and hematocrit (rapid)-fever-fever-tachycardia-tachycardia-bilateral chest film infiltrate-bilateral chest film infiltrate-causes:-causes: -diagnostic tests:-diagnostic tests:

*infection*infection *CXR*CXR*fat embolism*fat embolism *incentive spirometry*incentive spirometry

-treatment:-treatment: *bronchoscopy*bronchoscopy*antibiotics*antibiotics *phospholipase A2 det*phospholipase A2 det

*fluid restriction*fluid restriction*corticosteroid*corticosteroid*transfusion*transfusion

>decreases phospholipase A2>decreases phospholipase A2-prognosis:-prognosis:

>usually diagnosed during childhood>usually diagnosed during childhood-medical management:-medical management:

>3 treatment modalities:>3 treatment modalities:a. BM transplantationa. BM transplantationb. Hydroxyureab. Hydroxyurea

*increases the concentration of fetal Hgb*increases the concentration of fetal Hgb*decreases vaso-occlusive crisis*decreases vaso-occlusive crisis

c. Long term RBC transfusionc. Long term RBC transfusion

Adverse Effects of Adverse Effects of HydroxyureaHydroxyurea1. chronic suppression of WBC formation1. chronic suppression of WBC formation2. teratogenesis2. teratogenesis3. potential for later development of pregnancy3. potential for later development of pregnancy

Complications of TransfusionComplications of Transfusion1. Iron Overload1. Iron Overload

-needs chelation therapy-needs chelation therapy2. poor venous access2. poor venous access3. alloimmunization due to repeated transfusion3. alloimmunization due to repeated transfusion*exchange transfusion*exchange transfusion

Treatment:Treatment:1. Supportive1. Supportive

>pain management>pain management

*folic acid supplementation*folic acid supplementation

2. Prompt use of antibiotics2. Prompt use of antibiotics

-nursing diagnosis:-nursing diagnosis:

1. Pain related to tissue hypoxia1. Pain related to tissue hypoxia

2. Risk for infection2. Risk for infection

3. Powerlessness related to illness induced 3. Powerlessness related to illness induced powerlessnesspowerlessness

4. Knowledge deficit regarding prevention of crisis4. Knowledge deficit regarding prevention of crisis

-goals:-goals:

1. Relief of pain1. Relief of pain

2. Decreased incidence of crisis2. Decreased incidence of crisis

3. Enhanced self esteem and power3. Enhanced self esteem and power

4. Absence of complications4. Absence of complications

-nursing interventions:-nursing interventions:

1. Management of pain1. Management of pain

2. preventing and managing infections2. preventing and managing infections

3. promoting coping skills3. promoting coping skills

4. Minimizing knowledge deficit4. Minimizing knowledge deficit

5. Monitoring and managing potential complications5. Monitoring and managing potential complications

-leg ulcers-leg ulcers

-priapism leading to impotence-priapism leading to impotence

-chronic pain and substance abuse-chronic pain and substance abuse ThalassemiasThalassemias

-a hereditary disorder associated with defective -a hereditary disorder associated with defective hemoglobin chain synthesishemoglobin chain synthesis

-characterized by microcytosis and hypochromia-characterized by microcytosis and hypochromia

-imbalance in the configuration of hemoglobin >> -imbalance in the configuration of hemoglobin >> increased rigidity of RBC >> hemolysisincreased rigidity of RBC >> hemolysis

-2 types:-2 types:

(according to the globin chain diminished)(according to the globin chain diminished)

a. alpha thalassemiaa. alpha thalassemia

-milder and often without symptoms-milder and often without symptoms

b. beta thalassemiab. beta thalassemia

-more severe and lethal-more severe and lethal

Alpha ThalassemiaAlpha Thalassemia Clinical Syndromes:Clinical Syndromes:

1. Silent Carrier1. Silent Carrier

-asymptomatic-asymptomatic

-deletion of a single alpha globin gene-deletion of a single alpha globin gene

-barely detectable reduction in alpha globin -barely detectable reduction in alpha globin gene gene synthesissynthesis

2. Alpha Thalassemia Trait2. Alpha Thalassemia Trait

-deletion of 2 globin gene-deletion of 2 globin gene

-minimal or no anemia and no abnormal physical -minimal or no anemia and no abnormal physical signssigns

3. Hemoglobin H Disease3. Hemoglobin H Disease

-deletion of the 3 out of 4 alpha globin gene-deletion of the 3 out of 4 alpha globin gene

-hemoglobin H has extremely high O2 affinity -hemoglobin H has extremely high O2 affinity and therefore not useful for O2 exchangeand therefore not useful for O2 exchange

-with moderately severe anemia-with moderately severe anemia

4. Hydrops fetalis4. Hydrops fetalis

-most severe form-most severe form

-deletion of the 4 alpha globin gene -deletion of the 4 alpha globin gene

-in the fetus > gamma globin chains in excess -in the fetus > gamma globin chains in excess form tetramers (hemoglobin Bart) > extremely form tetramers (hemoglobin Bart) > extremely

increased oxygen affinity > unable to deliver increased oxygen affinity > unable to deliver oxygen to the tissues oxygen to the tissues > severe anoxia> severe anoxia

Beta ThalassemiaBeta Thalassemia Clinical Syndromes:Clinical Syndromes:

1. Thalassemia Major1. Thalassemia Major

-lead to severe transfusion dependent anemia-lead to severe transfusion dependent anemia

-severe anemia and first become manifested -severe anemia and first become manifested 6-6- 9mos after birth 9mos after birth (hemoglobin synthesis (hemoglobin synthesis switches switches from HgbF to HgbA)from HgbF to HgbA)

-if untransfused, Hgb may range between 3--if untransfused, Hgb may range between 3-6gm/dl 6gm/dl (with marked anisocytosis and microcytic, (with marked anisocytosis and microcytic, hypochromic anemia)hypochromic anemia)

-aggregated alpha chains are taken up by the spleen-aggregated alpha chains are taken up by the spleen-increased reticulocytes but erythropoiesis is -increased reticulocytes but erythropoiesis is ineffectiveineffective-clinical course:-clinical course:

short or brief because of death at an early ageshort or brief because of death at an early age2. Thalassemia Minor2. Thalassemia Minor

-resistant against falcifarum malaria-resistant against falcifarum malaria-asymptomatic and anemia is mild if present-asymptomatic and anemia is mild if present

G6PD DeficiencyG6PD Deficiency(G6PD is essential for membrane stability)(G6PD is essential for membrane stability)-would result to chronic hemolytic anemia-would result to chronic hemolytic anemia-hemolysis only when under stress, infection or due -hemolysis only when under stress, infection or due

to the use of certain medications to the use of certain medications (oxidant (oxidant drugs)drugs)

--inherited as X-linked diseaseinherited as X-linked disease

-oxidant drugs:-oxidant drugs:

>anti-malarial agents>anti-malarial agents>sulfonamides>sulfonamides>nitrofurantoin>nitrofurantoin>analgesics (ASA, Phenacetin)>analgesics (ASA, Phenacetin)>thiazides>thiazides>chloramphenicol>chloramphenicol>para-amino-salisylic acid>para-amino-salisylic acid>vitamin K>vitamin K

-clinical manifestations:-clinical manifestations:>s/sx of hemolysis>s/sx of hemolysis*reticulocytosis*reticulocytosis *jaundice*jaundice*hemoglobinuria*hemoglobinuria *pallor*pallor

-presence of Heinz bodies -presence of Heinz bodies (taken up by the (taken up by the spleen)spleen)-assessment and diagnostic findings:-assessment and diagnostic findings:

>qualitative assay for G6PD>qualitative assay for G6PD-medical management:-medical management:

a. withdrawal of the offending agenta. withdrawal of the offending agentb. transfusionb. transfusion

-only in severe hemolytic states-only in severe hemolytic statesc. health educationc. health education

-avoid triggering factors-avoid triggering factors Hereditary SpherocytosisHereditary Spherocytosis

-Is also a type of hemolytic anemia-Is also a type of hemolytic anemia-Abnormal permeability of RBC membrane > -Abnormal permeability of RBC membrane > spherocytosis > taken up by the liver > hemolysisspherocytosis > taken up by the liver > hemolysis

-treatment:-treatment:>surgical removal of the spleen >surgical removal of the spleen (splenectomy)(splenectomy)

Immune Hemolytic AnemiaImmune Hemolytic Anemia-due to exposure of RBCs to antibodies-due to exposure of RBCs to antibodies

formation of alloantibodiesformation of alloantibodies destruction of RBCsdestruction of RBCs (intravascular hemolysis)(intravascular hemolysis)

-usually result from hemolytic transfusion reactions-usually result from hemolytic transfusion reactions-RBCs may be destroyed also because of poor level -RBCs may be destroyed also because of poor level

of suppressor lymphocytes > antibody formation of suppressor lymphocytes > antibody formation (IgG)(IgG)

-2 types:-2 types:1. warm body antibodies1. warm body antibodies

>bind to RBCs most active in warm conditions >bind to RBCs most active in warm conditions (37C)(37C)

>most common >most common (IgG usually but sometimes IgA)(IgG usually but sometimes IgA)>mostly extravascular>mostly extravascular

2. Cold-body Antibodies2. Cold-body Antibodies>react in cold environment>react in cold environment>usually IgM>usually IgM>usually occur acutely during recovery from viral >usually occur acutely during recovery from viral infections, chronically with lymphoproliferative infections, chronically with lymphoproliferative

disorderdisorder>self limited intravascular hemolysis>self limited intravascular hemolysis

-clinical manifestations:-clinical manifestations:(variable depending on the severity)(variable depending on the severity)a. splenomegaly in 80% of casesa. splenomegaly in 80% of casesb. hepatomegalyb. hepatomegalyc. lymphadenopathyc. lymphadenopathyd. jaundiced. jaundice

-assessment and diagnostic findings:-assessment and diagnostic findings:a. CBCa. CBC

-decreased Hgb and Hct-decreased Hgb and Hctb. peripheral blood smearb. peripheral blood smear

-increased reticulocytes-increased reticulocytesc. serum chemistryc. serum chemistry

-increased serum bilirubin-increased serum bilirubin-medical management:-medical management:

a. withdrawal of the offending agenta. withdrawal of the offending agentb. increased doses of corticosteroids (1 b. increased doses of corticosteroids (1

mg/kg/day)mg/kg/day)c. blood transfusionsc. blood transfusions

-slowly and cautiously (10-15ml for 20--slowly and cautiously (10-15ml for 20-30mins)30mins)

d. splenectomyd. splenectomy

e. immunosuppressive therapye. immunosuppressive therapy

-if splenectomy and steroids fail-if splenectomy and steroids fail

-cyclophosphamide (more rapid effect but -cyclophosphamide (more rapid effect but more toxic)more toxic)

-azathioprine (less rapid effect but less -azathioprine (less rapid effect but less toxic)toxic)

f. Immunoglobulin administrationf. Immunoglobulin administration


a. prevention of infectiona. prevention of infection

*after splenectomy; during steroid and *after splenectomy; during steroid and immunosuppressive therapyimmunosuppressive therapy

Hereditary HemochromatosisHereditary Hemochromatosis

-deposition of excessive iron in the liver, myocardium, -deposition of excessive iron in the liver, myocardium, testes, thyroid and pancreastestes, thyroid and pancreas

-women are less affected than men-women are less affected than men-signs and symptoms:-signs and symptoms:

a. weaknessa. weaknessb. lethargyb. lethargyc. arthralgiac. arthralgiad. weight lossd. weight losse. loss of libidoe. loss of libidof. skin hyperpigmentationf. skin hyperpigmentationg. cardiac dysrrhythmias and g. cardiac dysrrhythmias and

cardiomyopathy > cardiomyopathy > edema and dyspneaedema and dyspneah. endocrine involvementh. endocrine involvement

*hypothyroidism*hypothyroidism *diminished libido*diminished libido*hypogonadism*hypogonadism

may lead to may lead to Hepatocellular CarcinomaHepatocellular Carcinoma


a. liver biopsya. liver biopsy-definitive test-definitive test

-medical management:-medical management:a. therapeutic phlebotomya. therapeutic phlebotomy

-removing whole blood from a vein-removing whole blood from a vein-every 1–3 year period-every 1–3 year period

-nursing management:-nursing management:a. diet low in iron is not that importanta. diet low in iron is not that importantb. prevent liver injury such as alcoholismb. prevent liver injury such as alcoholismc. alpha feto-protein determinationc. alpha feto-protein determination

-serial screening test for hepatoma-serial screening test for hepatomad. monitor for signs and symptoms of organ d. monitor for signs and symptoms of organ

dysfunctiondysfunction

PolycythemiaPolycythemia Polycythemia Vera or Primary PolycythemiaPolycythemia Vera or Primary Polycythemia

-may lead to Acute Myeloid Leukemia-may lead to Acute Myeloid Leukemia-myeloid stem cells have escaped normal control -myeloid stem cells have escaped normal control mechanismsmechanisms-Increased RBC count -Increased RBC count (predominating sign)(predominating sign)involvement of the spleen in hematopoiesisinvolvement of the spleen in hematopoiesis

fibrosis of the bone marrowfibrosis of the bone marrow (burnt or spent phase)(burnt or spent phase)

-signs and symptoms:-signs and symptoms:>ruddy complexion>ruddy complexion>splenomegaly>splenomegaly>pruritus >pruritus (due to histamine)(due to histamine)

>headache>headache

>dizziness>dizziness

>tinnitus>tinnitus due to an increased due to an increased >paresthesias>paresthesias blood volumeblood volume

>fatigue>fatigue

>blurred vision>blurred vision

>angina>angina

>claudication>claudication due to increased blood due to increased blood

>dyspnea>dyspnea viscosityviscosity

>thrombophlebitis>thrombophlebitis

>erythromyalgia - burning sensation of the >erythromyalgia - burning sensation of the fingers and toes fingers and toes

-assessment and diagnostic findings:-assessment and diagnostic findings:

1. increased RBC mass (nuclear medicine 1. increased RBC mass (nuclear medicine procedure)procedure)

-normal in erythropoietin-normal in erythropoietin

2. normal oxygen saturation level2. normal oxygen saturation level

3. enlarged spleen3. enlarged spleen

-other signs:-other signs:

1. increased WBC and Platelet count1. increased WBC and Platelet count

2. increased vitamin B122. increased vitamin B12

3. increased alkaline phosphatase3. increased alkaline phosphatase

-complication-complication

1. thrombosis - may lead to stroke or MI1. thrombosis - may lead to stroke or MI

2. bleeding2. bleeding

-medical management:-medical management:1. therapeutic phlebotomy1. therapeutic phlebotomy

>500ml once or twice weekly>500ml once or twice weekly>to reduce the blood cell mass>to reduce the blood cell mass

2. radioactive phosphorus2. radioactive phosphorus>to suppress marrow function but may >to suppress marrow function but may increase the risk of leukemiaincrease the risk of leukemia

-nursing management:-nursing management:1. patient education1. patient education

>avoid Aspirin>avoid Aspirin to decrease the to decrease the risk risk

>minimize alcohol>minimize alcohol of bleedingof bleeding>cool or tepid water bath>cool or tepid water bath

-for itchiness-for itchiness-antihistamines are not effective-antihistamines are not effective

Secondary PolycythemiaSecondary Polycythemia-due to excessive production of erythropoietin-due to excessive production of erythropoietin as a reaction to:as a reaction to:

>smoking>smoking>COPD>COPD>cyanotic heart disease>cyanotic heart disease>increased altitude>increased altitude

-medical management:-medical management:1. Therapeutic Phlebotomy1. Therapeutic Phlebotomy

Leukopenia and NeutropeniaLeukopenia and Neutropenia-may result from:-may result from:

*ionizing radiation*ionizing radiation*long term use of steroids*long term use of steroids

*uremia*uremia*neoplasms*neoplasms

-diagnosis:-diagnosis:Absolute Neutrophil CountAbsolute Neutrophil Count= = % neutrophils + % bands% neutrophils + % bands X total WBC X total WBC

countcount 100100

-clinical manifestations:-clinical manifestations:infectionsinfections

-medical management:-medical management:1. withdrawal of the offending agent1. withdrawal of the offending agent2. corticosteroids2. corticosteroids3. withholding or decreasing the dose of chemotherapy 3. withholding or decreasing the dose of chemotherapy or radiotherapyor radiotherapy4. culture of blood, urine and sputum; CXR > monitoring4. culture of blood, urine and sputum; CXR > monitoring


1. infection control1. infection control

Bleeding DisorderBleeding Disorder

-vascular in origin >> localized-vascular in origin >> localized

-platelets or coagulation factor defects >> -platelets or coagulation factor defects >> widespreadwidespread

Primary ThrombocythemiaPrimary Thrombocythemia

-also called essential thrombocythemia-also called essential thrombocythemia

-stem cell disorder in the bone marrow-stem cell disorder in the bone marrow

-platelet count-platelet count >> 600,000/mm3>> 600,000/mm3

>> size is abnormal>> size is abnormal

increased RBCincreased RBC

increased WBCincreased WBC

-clinical manifestations:-clinical manifestations:>usually asymptomatic>usually asymptomatic>hemorrhage or vasooclusion of the >hemorrhage or vasooclusion of the

microvasculaturemicrovasculature>painful, burning, warmth and redness on the >painful, burning, warmth and redness on the

localizedlocalizedarea of the extremity area of the extremity (due to an increased platelet (due to an increased platelet

ct.)ct.)-diagnosis:-diagnosis:

>CBC and other blood tests>CBC and other blood tests(not necessary to perform BMA and biopsy)(not necessary to perform BMA and biopsy)

*median survival is 10 years*median survival is 10 years-medical management: (controversial)-medical management: (controversial)1. Low Dose Aspirin1. Low Dose Aspirin

-in young patient without aggravating factors like -in young patient without aggravating factors like atherosclerosis, smoking and peripheral vascular atherosclerosis, smoking and peripheral vascular diseasedisease

2. Hydroxyurea2. Hydroxyurea-chemotherapeutic agents to lower down the -chemotherapeutic agents to lower down the

platelet platelet count count AnagrelideAnagrelide

-more specific than Hydroxyurea-more specific than Hydroxyurea-side effects: severe headache-side effects: severe headache

Alpha InterferonAlpha Interferon-lower the platelet count by unknown mechanisms-lower the platelet count by unknown mechanisms

-sc 3x a week-sc 3x a week-very expensive-very expensive-side effects:-side effects:

>fatigue>fatigue >dizziness>dizziness>weakness>weakness >anemia>anemia>memory defects>memory defects >liver dysfunction>liver dysfunction

3. Platelet Pheresis3. Platelet Pheresis-to reduce platelets with transient effects-to reduce platelets with transient effects

-nursing management:-nursing management:1. Patient education1. Patient education

>risk of bleeding and thrombosis>risk of bleeding and thrombosis>signs of bleeding and thrombosis >signs of bleeding and thrombosis

(visual (visual changes, tingling and changes, tingling and weakness)weakness)

Secondary ThrombocytosisSecondary Thrombocytosis-increased platelet production-increased platelet production-an increase above 1 “M” count is rare-an increase above 1 “M” count is rare-platelet function is normal-platelet function is normal

>survival time is normal or increased>survival time is normal or increased

-triggering factors:-triggering factors:

>chronic inflammatory disorders>chronic inflammatory disorders

>iron deficiency>iron deficiency >acute hemorrhage>acute hemorrhage

>malignant disease>malignant disease >splenectomy>splenectomy Idiopathic Thrombocytopenic PurpuraIdiopathic Thrombocytopenic Purpura

-affects all ages-affects all ages

-more common to children and women-more common to children and women

-2 types:-2 types:

a. acutea. acute

>predominantly in children>predominantly in children

>often 1-6 weeks after a viral illness>often 1-6 weeks after a viral illness

>self-limited >self-limited (remission within 6 months)(remission within 6 months)

b. chronicb. chronic

-hypothetical causes:-hypothetical causes:

a. exposure to sulfa drugs, quininea. exposure to sulfa drugs, quinine

b. SLEb. SLE

c. pregnancyc. pregnancy

d. autoimmunityd. autoimmunity


a. plateletsa. platelets

>less than 20,000/mm3 or even less >less than 20,000/mm3 or even less than than 5,000/mm35,000/mm3

b. bruising, heavy menses and petechiae on b. bruising, heavy menses and petechiae on the the extremities and trunk extremities and trunk

*2 types of purpura*2 types of purpura

a. dry purpuraa. dry purpura-simple bruising or petechiae-simple bruising or petechiae-tend to have fewer complications-tend to have fewer complications

b. wet purpurab. wet purpura-GIT bleeding-GIT bleeding-hemoptysis-hemoptysis-intracranial bleeding-intracranial bleeding

-assessment and diagnostic findings:-assessment and diagnostic findings:decreased platelet countdecreased platelet countdecreased megakaryocytesdecreased megakaryocytes


a. safe platelet counta. safe platelet count

-risk of bleeding starts at a platelet count of -risk of bleeding starts at a platelet count of 10,000/mm3 and below10,000/mm3 and below

b. withdrawal of the offending agentb. withdrawal of the offending agent

c. immunosuppressive therapyc. immunosuppressive therapy

to incto inc -mainstay of short term treatment-mainstay of short term treatment

plt ctplt ct -to block the binding receptors in -to block the binding receptors in macrophagesmacrophages

*Prednisone 1mg/kg*Prednisone 1mg/kg

-effective in 75% of cases-effective in 75% of cases

-can be used also for maintenance at a -can be used also for maintenance at a dose dose of 2.5 to 10mg QOD of 2.5 to 10mg QOD

*Cyclophosphamide*Cyclophosphamide

*Azathioprine*Azathioprine

*Dexamethasone*Dexamethasone

*Vincristine*Vincristine

d. intravenous immunoglobulind. intravenous immunoglobulin

-binding the receptors on the macrophages-binding the receptors on the macrophages

-1g/kg for 2 days -1g/kg for 2 days (very expensive)(very expensive)

e. splenectomye. splenectomy

-effective in 50% of cases-effective in 50% of cases

-at risk of sepsis -at risk of sepsis (should receive vaccines)(should receive vaccines)

*Pneumovax*Pneumovax should be should be givengiven

*Haemophilus influenzae B*Haemophilus influenzae B within 2-3 wkswithin 2-3 wks

*Meningococcal vaccines*Meningococcal vaccines prior to procprior to proc

-nursing management:-nursing management:a. history takinga. history taking

-viral infection-viral infection-intake of sulfa containing drugs-intake of sulfa containing drugs

b. neurologic assessmentb. neurologic assessment-in addition to physical examination-in addition to physical examination-vital signs: don’t use the rectal route-vital signs: don’t use the rectal route

c. patient educationc. patient education-s/sx of bleeding-s/sx of bleeding-whom to contact in case of emergency-whom to contact in case of emergency-avoidance of sulfa containing drugs-avoidance of sulfa containing drugs-compliance to pharmacologic therapy -compliance to pharmacologic therapy

(tapering)(tapering)-frequency of monitoring the platelet count-frequency of monitoring the platelet count

d. avoid the risk of bleedingd. avoid the risk of bleeding

-no constipation-no constipation

-use electric razors only-use electric razors only

-use soft bristled tooth brush-use soft bristled tooth brush

-refrain from vigorous sexual intercourse-refrain from vigorous sexual intercourse

e. education of the disadvantages of corticosteroid e. education of the disadvantages of corticosteroid treatmenttreatment

-osteoporosis-osteoporosis should receive should receive CaCa

-proximal muscle wasting-proximal muscle wasting and vit D and vit D -dental caries-dental caries supplementssupplements

-cataract formation-cataract formation

Pulmonary DisordersPulmonary Disorders Acute Respiratory Distress SyndromeAcute Respiratory Distress Syndrome

-characteristics: (in the absence of LV Failure)-characteristics: (in the absence of LV Failure)

*sudden or progressive pulmonary edema*sudden or progressive pulmonary edema

*increasing bilateral infiltrates on CXR*increasing bilateral infiltrates on CXR

*hypoxemia refractory to oxygen *hypoxemia refractory to oxygen supplementationsupplementation

*reduced lung compliance*reduced lung compliance

-with a high mortality rate as high as 50-60%-with a high mortality rate as high as 50-60%

-multiple organ system failure with sepsis -multiple organ system failure with sepsis (most (most common cause of death)common cause of death)

acute lung injuryacute lung injury

alveolar capillary leakalveolar capillary leak

microvascular microvascular a. pulmonary edema a. pulmonary edema surfactant surfactant

obstructionobstruction b. hyaline membrane b. hyaline membrane defectdefect

c. microatelectasisc. microatelectasis decreased decreased

V/Q mismatch V/Q mismatch compliance compliance

right to left shuntright to left shunt

pulmonary hypertensionpulmonary hypertension dyspneadyspnea

hypoxemiahypoxemia

increased dead spaceincreased dead space increased work increased work of of

increased minute ventilationincreased minute ventilation breathingbreathing

-causes:-causes:*aspiration (gastric acid)*aspiration (gastric acid)*drug ingestion and overdose*drug ingestion and overdose*hematologic disorders*hematologic disorders

-DIC, massive transfusion-DIC, massive transfusion*prolonged inhalation of high concentrations of *prolonged inhalation of high concentrations of O2, smoke or corrosive substance O2, smoke or corrosive substance*localized infection*localized infection*metabolic disorders (pancreatitis)*metabolic disorders (pancreatitis)*shock*shock*major surgery*major surgery*fat or air embolism*fat or air embolism*sepsis*sepsis


*rapid onset of dyspnea*rapid onset of dyspnea

-12 to 48 hours after the initiating event-12 to 48 hours after the initiating event

*arterial hypoxemia not responsive to O2 *arterial hypoxemia not responsive to O2 therapytherapy

*pulmonary edema*pulmonary edema

-quickly worsen-quickly worsen

-assessment and diagnostics:-assessment and diagnostics:

*history and physical exam*history and physical exam

-retractions and crackles-retractions and crackles

*CXR*CXR

*pulse oximetry*pulse oximetry

*ABG*ABG

-management:-management:a. identification and treatment of the a. identification and treatment of the

underlying underlying conditionconditionb. aggressive, supportive careb. aggressive, supportive care

-intubation and mechanical ventilation-intubation and mechanical ventilationc. circulatory supportc. circulatory support

-IVF-IVFd. nutritional support (35-45kcal/kg/day)d. nutritional support (35-45kcal/kg/day)e. O2 inhalatione. O2 inhalationf. PEEP (positive end expiratory pressure)f. PEEP (positive end expiratory pressure)

-critical in ARDS-critical in ARDS-improves the oxygenation-improves the oxygenation-increase the functional residual capacity-increase the functional residual capacity

h. pharmacologic therapyh. pharmacologic therapy-interleukin-1 receptor antagonist -interleukin-1 receptor antagonist

(anakinra)(anakinra)-neutrophil inhibitors-neutrophil inhibitors-pulmonary specific vasodilators-pulmonary specific vasodilators-surfactant replacement therapy-surfactant replacement therapy-antisepsis therapy-antisepsis therapy-antioxidant therapy-antioxidant therapy-corticosteroids-corticosteroids

-nursing management:-nursing management:a. close monitoringa. close monitoringb. respiratory modalitiesb. respiratory modalities

-O2 inhalation, nebulizer therapy, chest -O2 inhalation, nebulizer therapy, chest physiotherapy, ET intubation, suctioning, physiotherapy, ET intubation, suctioning, mechanical ventilation and bronchoscopymechanical ventilation and bronchoscopy

c. positioningc. positioning

-to improve ventilation-to improve ventilation

d. reduce anxiety and agitationd. reduce anxiety and agitation

-explain all procedure and provide care in a -explain all procedure and provide care in a calm and reassuring manner calm and reassuring manner

e. continuous assessment (ventilator setting)e. continuous assessment (ventilator setting)

-presence of tube blockade by kinking or -presence of tube blockade by kinking or retained secretions retained secretions

-acute respiratory problems (pneumothorax)-acute respiratory problems (pneumothorax)

-sudden hypoxemia-sudden hypoxemia

-ventilator malfunction-ventilator malfunction

f. sedationf. sedation

-to decrease the patient’s O2 consumption-to decrease the patient’s O2 consumption

-to allow the ventilator provide full -to allow the ventilator provide full respiratory respiratory supportsupport

-to decrease anxiety-to decrease anxietyg. administration of neuromuscular blocking g. administration of neuromuscular blocking

agentsagents-alternative to sedation-alternative to sedation

Acute Respiratory FailureAcute Respiratory Failure-is a sudden life threatening deterioration of the gas -is a sudden life threatening deterioration of the gas exchange function of the lungexchange function of the lung-fall in arterial oxygen tension to less than 50mmHg and -fall in arterial oxygen tension to less than 50mmHg and

a rise in CO2 tension to more than 50mmHg and a rise in CO2 tension to more than 50mmHg and with an arterial pH of less than 7.35with an arterial pH of less than 7.35-mechanisms:-mechanisms:

*alveolar hypoventilation*alveolar hypoventilation *V/Q mismatch*V/Q mismatch*diffusion abnormalities*diffusion abnormalities *shunting*shunting

-causes:-causes:

a. decreased respiratory drivea. decreased respiratory drive

-severe brain injury-severe brain injury-brainstem lesions-brainstem lesions-use of sedatives-use of sedatives-metabolic disorders (hypothyroidism)-metabolic disorders (hypothyroidism)

b. dysfunction of the chest wallb. dysfunction of the chest wall-diseases of the muscles, nerves, spinal -diseases of the muscles, nerves, spinal cord and neuromuscular junction cord and neuromuscular junction

c. dysfunction of the lung parenchymac. dysfunction of the lung parenchyma-pleural effusion-pleural effusion-upper airway obstruction-upper airway obstruction-pneumothorax-pneumothorax

-signs and symptoms:-signs and symptoms:*all related to hypoxemia and hypoxia*all related to hypoxemia and hypoxia

restlessnessrestlessness dyspneadyspneafatiguefatigue air hunger air hunger headacheheadache tachycardia and inc BPtachycardia and inc BP

confusion, lethargy, tachycardia,confusion, lethargy, tachycardia, tachypnea, central cyanosistachypnea, central cyanosis

respiratory arrestrespiratory arrest-management:-management:

a. correct the underlying causea. correct the underlying causeb. restore adequate gas exchange (ET with b. restore adequate gas exchange (ET with

ventilator)ventilator)

surfactant replacement therapysurfactant replacement therapy antiseptic agentsantiseptic agents antioxidant therapyantioxidant therapy corticosteroidscorticosteroidsc. nutritional therapyc. nutritional therapy

Chronic Obstructive Pulmonary DiseaseChronic Obstructive Pulmonary Disease-airflow limitation not fully reversible-airflow limitation not fully reversible-types:-types:a. chronic bronchitisa. chronic bronchitisb. emphysemab. emphysema

A. Chronic BronchitisA. Chronic Bronchitis-cough with sputum for at least 3 months in each of -cough with sputum for at least 3 months in each of 2 consecutive years2 consecutive years

Smoke/environmental pollutantsSmoke/environmental pollutantsHypersecretion of mucus and inflammationHypersecretion of mucus and inflammation

B. EmphysemaB. EmphysemaDestruction of the walls of distended alveoliDestruction of the walls of distended alveoli

Impaired gas exchangeImpaired gas exchange-2 types:-2 types:1. panlobular1. panlobular

>respiratory bronchiole, alveolar duct and alveoli >respiratory bronchiole, alveolar duct and alveoli are are destroyeddestroyed2. centrilobular2. centrilobular

>destruction of the center of the secondary lobule>destruction of the center of the secondary lobule-risk factors:-risk factors:

1. environmental1. environmental>cigarette smoking>cigarette smoking

>prolonged and intense exposure to >prolonged and intense exposure to occupational dusts and chemicals occupational dusts and chemicals>indoor air pollution>indoor air pollution>outdoor air pollution>outdoor air pollution

2. host2. host>alpha-1-antitrypsin deficiency>alpha-1-antitrypsin deficiency

-3 primary symptoms:-3 primary symptoms:a. cougha. coughb. sputumb. sputumc. dyspnea on exertionc. dyspnea on exertion

-assessment and diagnosis:-assessment and diagnosis:>spirometry>spirometry

-complications:-complications:a. respiratory failurea. respiratory failure

b. respiratory insufficiencyb. respiratory insufficiency-medical management:-medical management:

a. risk reductiona. risk reductionb. pharmacologic therapyb. pharmacologic therapy

*bronchodilators*bronchodilators>MDI>MDI>nebulization>nebulization>oral (pill or liquid)>oral (pill or liquid)

beta adrenergic agonistbeta adrenergic agonist anticholinergic agentsanticholinergic agents methylxanthinesmethylxanthines*corticosteroids*corticosteroids oral or IV (Beclomethasone, oral or IV (Beclomethasone,

Fluticasone)Fluticasone)

*vaccines*vaccines>influenzae and pneumococcal>influenzae and pneumococcal

*alpha-1-antitrypsin augmentation *alpha-1-antitrypsin augmentation therapytherapy

*antibiotics*antibiotics*mucolytics*mucolytics*antitussives*antitussives

c. surgical management:c. surgical management:*bullectomy*bullectomy*lung volume reduction surgery*lung volume reduction surgery*lung transplantation*lung transplantation

-nursing management:-nursing management:a. patient educationa. patient education

*breathing exercises*breathing exercises

*inspiratory muscle training*inspiratory muscle training

*activity pairing*activity pairing

*self care activities*self care activities

*physical conditioning*physical conditioning

*oxygen therapy*oxygen therapy

*nutritional therapy*nutritional therapy

*coping measures*coping measures

AsthmaAsthma-a reversible chronic inflammatory disease of the -a reversible chronic inflammatory disease of the airwaysairways-triad:-triad:

*airway hyperresponsiveness*airway hyperresponsiveness*mucosal edema*mucosal edema*excessive mucus production*excessive mucus production

-signs and symptoms:-signs and symptoms:*cough*cough *wheezing *wheezing *chest tightness*chest tightness *dyspnea*dyspnea

-causes:-causes:a. allergy- strongest predisposing factora. allergy- strongest predisposing factor

>seasonal (weed pollens, grass>seasonal (weed pollens, grass>perennial (molds, dust, roaches)>perennial (molds, dust, roaches)

b. airway irritants (perfumes, smoke, cold, b. airway irritants (perfumes, smoke, cold, heat)heat)

c. exercisec. exercise

d. stress or emotional upsetd. stress or emotional upset

e. sinusitis e. sinusitis

f. medicationsf. medications

g. viral respiratory tract infectionsg. viral respiratory tract infections

h. gastro-esophageal refluxh. gastro-esophageal reflux

-pathophysiology-pathophysiology

bronchospasmbronchospasm mucosal edemamucosal edema exc mucus secretionexc mucus secretion

bronchial musclebronchial muscle mucosal gland mucosal gland enlargementenlargement

hypertrophyhypertrophy thick tenacious secretionsthick tenacious secretions

alveolar hyperinflationalveolar hyperinflation

chronic asthmachronic asthma

(chronic airway inflammation)(chronic airway inflammation)

airway subbasement membrane fibrosisairway subbasement membrane fibrosis

airway narrowingairway narrowing irreversible airflow irreversible airflow limitationlimitation


*cough*cough usually at night or early in the usually at night or early in the *dyspnea*dyspnea morning due to circadian morning due to circadian *wheezing*wheezing variationsvariations

*diaphoresis*diaphoresis *hypoxemia*hypoxemia

*tachycardia*tachycardia *central cyanosis*central cyanosis

*widened pulse pressure*widened pulse pressure

-types according to severity:-types according to severity:A. Mild IntermittentA. Mild Intermittent

-symptoms -symptoms <<2 times a week2 times a week-asymptomatic and normal PEF between -asymptomatic and normal PEF between

exacerbationsexacerbations-exacerbations are brief; intensity may vary-exacerbations are brief; intensity may vary-night time symptoms -night time symptoms <<2 times a month2 times a month

B. Mild persistentB. Mild persistent-symptoms >2 times a week but <1 time a day-symptoms >2 times a week but <1 time a day-exacerbations may affect activity-exacerbations may affect activity-night time symptoms >2 times a month-night time symptoms >2 times a month

C. Moderate PersistentC. Moderate Persistent-daily symptoms-daily symptoms-daily use of inhaled short acting beta2 agonist-daily use of inhaled short acting beta2 agonist

-exacerbations affect activity-exacerbations affect activity

-exacerbations -exacerbations >>2 times a week; may last days2 times a week; may last days

-night time symptoms >1 time a week-night time symptoms >1 time a week

D. Severe PersistentD. Severe Persistent

-continual symptoms-continual symptoms

-limited physical activity-limited physical activity

-frequent exacerbations-frequent exacerbations

-frequent night time symptoms-frequent night time symptoms

-assessment and diagnostics:-assessment and diagnostics:*clinical history and physical assessment*clinical history and physical assessment*sputum/blood tests*sputum/blood tests

>eosinophilia>eosinophilia*serology*serology

>elevated IgE>elevated IgE*ABG*ABG

>hypoxemia>hypoxemia>hypocapnia then hypercapnia>hypocapnia then hypercapnia

*pulse oximetry*pulse oximetry>hypoxemia>hypoxemia

-prevention:-prevention:a. identificaton and avoidance of allergensa. identificaton and avoidance of allergens


a. status asthmaticusa. status asthmaticus

b. respiratory failureb. respiratory failure

c. pneumoniac. pneumonia

d. atelectasisd. atelectasis


a. Long Acting Medicationsa. Long Acting Medications

*corticosteroids*corticosteroids

-most potent and effective-most potent and effective

-inhaled preparations commonly -inhaled preparations commonly causes causes oral thrushoral thrush

-fluticasone, beclomethasone, -fluticasone, beclomethasone, budesonidebudesonide

*mast cell stabilizer*mast cell stabilizer

-for mild to moderate asthma only-for mild to moderate asthma only

(prophylaxis)(prophylaxis)

- cromolyn sodium and nedocromil- cromolyn sodium and nedocromil

*beta 2 agonist*beta 2 agonist

-to control symptoms especially at night-to control symptoms especially at night

-prophylaxis of exercise induced -prophylaxis of exercise induced asthmaasthma

-salmeterol, albuterol, formoterol-salmeterol, albuterol, formoterol

*methylxanthines*methylxanthines

-mild to moderate bronchodilator-mild to moderate bronchodilator

-mainly for the relief of night time sx-mainly for the relief of night time sx

(theophylline as mild anti-inflammatory)(theophylline as mild anti-inflammatory)

*leukotriene modifiers (inhibitors)*leukotriene modifiers (inhibitors)

-may be added or be used as an -may be added or be used as an alternative to inhaled corticosteroids alternative to inhaled corticosteroids

-zafirlukast, montelukast, zileuton-zafirlukast, montelukast, zileuton

B. Quick Relief MedicationsB. Quick Relief Medications

*short acting beta 2 agonist*short acting beta 2 agonist

-to relieve acute symptoms-to relieve acute symptoms

-to prevent exercise induced asthma-to prevent exercise induced asthma

-may be combined with an -may be combined with an anticholinergic anticholinergic

-salbutamol, combivent -salbutamol, combivent (salbutamol+ipratropium bromide)(salbutamol+ipratropium bromide)

>management of asthma exacerbation>management of asthma exacerbation

-early treatment and education of the patient-early treatment and education of the patient

*quick relief medications*quick relief medications*corticosteroids*corticosteroids*O2 inhalation*O2 inhalation*serial measurement of lung function*serial measurement of lung function

-peak flow meter (FEV)-peak flow meter (FEV) Status AsthmaticusStatus Asthmaticus

-severe and persistent asthma that does not -severe and persistent asthma that does not respond to conventional therapyrespond to conventional therapy-may last longer than 24 hours-may last longer than 24 hours-causes:-causes:

*infection*infection *dehydration*dehydration*anxiety*anxiety *inc adrenergic blockage*inc adrenergic blockage*nebulizer abuse*nebulizer abuse *irritants (aspirin)*irritants (aspirin)

-pathophysiology:-pathophysiology:

similar to bronchial asthmasimilar to bronchial asthma

*hypoxemia and respiratory alkalosis >>> *hypoxemia and respiratory alkalosis >>> respiratory respiratory acidosisacidosis


similar to asthmasimilar to asthma

(extent of wheezing does not indicate the severity (extent of wheezing does not indicate the severity of of attack)attack)


*pulmonary function study*pulmonary function study

-most accurate-most accurate

*ABG*ABG

-respiratory alkalosis (most frequent finding)-respiratory alkalosis (most frequent finding)


*short acting beta adrenergic agonist and *short acting beta adrenergic agonist and steroidsteroid

*O2 inhalation*O2 inhalation

*IVF*IVF

*mechanical ventilation*mechanical ventilation BronchiectasisBronchiectasis

-is a chronic irreversible dilation of the bronchi and -is a chronic irreversible dilation of the bronchi and bronchiolesbronchioles

-causes:-causes:

*airway obstruction*airway obstruction

*diffuse airway injury*diffuse airway injury

*pulmonary infections and complications*pulmonary infections and complications

*genetic disorders (cystic fibrosis)*genetic disorders (cystic fibrosis)

*abnormal host defense (ciliary dyskinesia)*abnormal host defense (ciliary dyskinesia)

*idiopathic causes*idiopathic causes

-pathophysiology:-pathophysiology:

chronic airway inflammationchronic airway inflammation

bronchial wall damagebronchial wall damage

bronchial obstructionbronchial obstruction

(due to thick sputum)(due to thick sputum)

bronchial distention and distortionbronchial distention and distortion

(localized; segmental/lobar-lower lobes usually)(localized; segmental/lobar-lower lobes usually)

inflammation of the peribronchial tissuesinflammation of the peribronchial tissues

alveolar collapsealveolar collapse

pulmonary scarring/fibrosispulmonary scarring/fibrosis


*chronic cough*chronic cough

*excessive production of purulent sputum*excessive production of purulent sputum

*hemoptysis*hemoptysis

*clubbing of the fingers*clubbing of the fingers

*repeated pulmonary infections*repeated pulmonary infections


*history and physical assessment*history and physical assessment

-prolonged history of productive cough-prolonged history of productive cough

*sputum exam*sputum exam

-consistently negative for tubercle bacilli-consistently negative for tubercle bacilli

*CT scan*CT scan

-bronchial dilatation-bronchial dilatation


a. bronchial drainagea. bronchial drainage

-to clear excessive secretions-to clear excessive secretions

-to prevent or control infection-to prevent or control infection

*postural drainage*postural drainage*bronchodilators*bronchodilators

*bronchoscopy*bronchoscopy

*chest physiotherapy*chest physiotherapy

b. smoking cessationb. smoking cessation

c. infection controlc. infection control

-antimicrobial therapy (year round)-antimicrobial therapy (year round)

-vaccination (influenza and pneumococcal -vaccination (influenza and pneumococcal pneumonia)pneumonia)

d. surgeryd. surgery

-for patients who continue to expectorate large -for patients who continue to expectorate large volume of phlegmvolume of phlegm

-for patients with repeated bouts of pneumonia -for patients with repeated bouts of pneumonia and hemoptysisand hemoptysis

*segmental resection*segmental resection

*lobectomy*lobectomy

*pneumonectomy*pneumonectomy


*atelectasis*atelectasis *bronchopleural fistula*bronchopleural fistula

*pneumonia*pneumonia *empyema*empyema


a. supportive and symptomatica. supportive and symptomatic

b. assistance to clear secretionsb. assistance to clear secretions

c. patient educationc. patient education

-smoking cessation-smoking cessation

-infection prevention-infection prevention

-postural drainage-postural drainage

-activity/rest-activity/rest

-nutrition-nutrition

Pulmonary EdemaPulmonary Edema

-abnormal accumulation of fluids in the lung tissue -abnormal accumulation of fluids in the lung tissue and/or alveolar spaceand/or alveolar space

-a severe, life threatening condition-a severe, life threatening condition

-causes:-causes:

*left ventricular failure*left ventricular failure

*hypervolemia*hypervolemia

*sudden increase in the intravascular pressure *sudden increase in the intravascular pressure in in the lungs the lungs (post operative pneumonectomy)(post operative pneumonectomy)

>>flash pulmonary edemaflash pulmonary edema

*rapid re-inflation of the lungs after the *rapid re-inflation of the lungs after the removal of air from a pneumothorax or removal of air from a pneumothorax or

evacuation of fluid from a large pleural evacuation of fluid from a large pleural effusioneffusion

>>re-expansion pulmonary edemare-expansion pulmonary edema


>increasing respiratory distress>increasing respiratory distress

-dyspnea-dyspnea -central cyanosis-central cyanosis

-hunger-hunger -confusion/stupor-confusion/stupor

>foamy, frothy, and often blood tinged >foamy, frothy, and often blood tinged secretionssecretions

--assessment and diagnostic findings:assessment and diagnostic findings:a. physical examinationa. physical examination

>crackles>crackles-initially in the base and posterior part of the -initially in the base and posterior part of the

lungslungs-progress toward the apices-progress toward the apices

>tachycardia>tachycardiab. chest x-rayb. chest x-ray

>increased interstitial markings>increased interstitial markingsc. pulse oximetryc. pulse oximetryd. arterial blood gas determinationd. arterial blood gas determination--medical management:medical management:a. correction of the underlying causea. correction of the underlying causeb. vasodilatorsb. vasodilators

c. inotropic agentsc. inotropic agents

d. afterload or preload agentsd. afterload or preload agents

e. contractility medse. contractility meds

f. diuretics and fluid restrictionf. diuretics and fluid restriction

g. oxygenation and mechanical ventilationg. oxygenation and mechanical ventilation

h. morphineh. morphine

--nursing management:nursing management:

supportive to the medical managementsupportive to the medical management Pulmonary HypertensionPulmonary Hypertension

-systolic pulmonary artery pressure exceeding 30mmHg-systolic pulmonary artery pressure exceeding 30mmHg

-mean pulmonary artery pressure exceeding 25mmHg-mean pulmonary artery pressure exceeding 25mmHg

-2 Types:-2 Types:

1. Primary Pulmonary Hypertension1. Primary Pulmonary Hypertension

-with no evidence of pulmonary or cardiac -with no evidence of pulmonary or cardiac disease or pulmonary embolismdisease or pulmonary embolism

-more common in women 20-40 y/o-more common in women 20-40 y/o

-high mortality within 5 years of diagnosis-high mortality within 5 years of diagnosis

2. Secondary Pulmonary Hypertension2. Secondary Pulmonary Hypertension

-more common-more common

-secondary to existing cardiac and -secondary to existing cardiac and pulmonary pulmonary disease (hypoxemia)disease (hypoxemia)

--

HypoxemiaHypoxemia HypercapniaHypercapnia Pulmonary EmbolismPulmonary Embolism

Pulmonary Artery ConstrictionPulmonary Artery Constriction

Increased Pulmonary Vascular resistanceIncreased Pulmonary Vascular resistance

Increased Right Ventricular WorkloadIncreased Right Ventricular Workload

Right Ventricular HypertrophyRight Ventricular Hypertrophy

Right Ventricular FailureRight Ventricular Failure


*dyspnea*dyspnea

-main symptom initially with exertion -main symptom initially with exertion then then eventually at resteventually at rest

*substernal chest pain*substernal chest pain

*weakness*weakness *syncope*syncope

*fatigue*fatigue *occasional hemoptysis*occasional hemoptysis

*right sided heart failure*right sided heart failure-peripheral edema, ascites, neck vein-peripheral edema, ascites, neck veinengorgement, liver engorgement, cracklesengorgement, liver engorgement, crackles

-assessment and diagnosis:-assessment and diagnosis:*clinical history and physical examination*clinical history and physical examination*CXR*CXR*pulmonary function studies*pulmonary function studies

-normal, or slight decrease in VC and -normal, or slight decrease in VC and compliancecompliance

-mild decrease in diffusing capacity-mild decrease in diffusing capacity*electrocardiogram*electrocardiogram

-right ventricular hypertrophy-right ventricular hypertrophy-right axis deviation-right axis deviation-tall peaked T waves (inferior leads)-tall peaked T waves (inferior leads)-tall R waves, ST segment depression, T -tall R waves, ST segment depression, T

wave wave inversion (anterior leads)inversion (anterior leads)

*echocardiogram*echocardiogram

-can assess the progression of the -can assess the progression of the diseasedisease

*ventilation perfusion scan*ventilation perfusion scan

-defects in the pulmonary vasculature -defects in the pulmonary vasculature such such as pulmonary embolias pulmonary emboli

*cardiac catheterization*cardiac catheterization-elevated pulmonary arterial pressure-elevated pulmonary arterial pressure

*lung biopsy*lung biopsy-through thoracotomy or thoracoscopy-through thoracotomy or thoracoscopy

-medical management:-medical management:Goal:Goal:

1. to manage the underlying cardiac or 1. to manage the underlying cardiac or pulmonary condition pulmonary condition

A. Supplemental OxygenA. Supplemental Oxygen

-reverses vasoconstriction-reverses vasoconstriction

-reduces pulmonary hypertension-reduces pulmonary hypertension

B. Pulmonary VasodilatorsB. Pulmonary Vasodilators

(calcium channel blockers, IV (calcium channel blockers, IV prostacyclin)prostacyclin)

-reduces pulmonary vascular resistance-reduces pulmonary vascular resistance

-increases the cardiac output-increases the cardiac output

C. AnticoagulantsC. Anticoagulants if with cor if with cor D. Fluid RestrictionD. Fluid Restriction pulmonalepulmonale

E. DiureticsE. Diuretics

F. Cardiac GlycosidesF. Cardiac Glycosides

G. Heart-Lung TransplantationG. Heart-Lung Transplantation

-nursing management:-nursing management:1. identify high risk patients1. identify high risk patients

-COPD, pulmonary emboli, congenital -COPD, pulmonary emboli, congenital heart heart disease, mitral valve diseasedisease, mitral valve disease

2. monitor s/sx2. monitor s/sx3. administer oxygen therapy appropriately3. administer oxygen therapy appropriately4. home use oxygen supplementation4. home use oxygen supplementation

Cor pulmonaleCor pulmonale-characterized by:-characterized by:

a. right ventricular enlargementa. right ventricular enlargementb. pulmonary congestionb. pulmonary congestion

-causes:-causes:a. COPDa. COPD

-most frequent-most frequent

b. deformities of the thoracic cageb. deformities of the thoracic cagec. massive obesityc. massive obesityd. primary embolismd. primary embolisme. disorders of the nervous systeme. disorders of the nervous systemf. disorders of the respiratory musclesf. disorders of the respiratory musclesg. disorders of the chest wallg. disorders of the chest wallh. disorders of the pulmonary arterial treeh. disorders of the pulmonary arterial tree

Lung DiseaseLung DiseaseHypoxemia and HypercapniaHypoxemia and Hypercapnia

Pulmonary HypertensionPulmonary Hypertension Increased Work Load to the Right VentriclesIncreased Work Load to the Right Ventricles

Right Sided Heart EnlargementRight Sided Heart EnlargementRight Sided Heart FailureRight Sided Heart Failure


*s/sx of the underlying pulmonary disease*s/sx of the underlying pulmonary disease

*s/sx of right sided heart failure*s/sx of right sided heart failure


goals:goals:

1. improvement of ventilation1. improvement of ventilation

2. treatment of the underlying lung disease 2. treatment of the underlying lung disease

3. treatment of the manifestations of the heart3. treatment of the manifestations of the heart

A. Continuous 24 Hour O2 TherapyA. Continuous 24 Hour O2 Therapy

-improvement may require 4--improvement may require 4-6weeks 6weeks of O2 therapy of O2 therapy

-monitor -monitor pulse oximetrypulse oximetry and and ABGABG

B. Chest Physiotherapy and Bronchial B. Chest Physiotherapy and Bronchial Hygiene ManeuversHygiene Maneuvers

C. BronchodilatorsC. Bronchodilators

D. ET Intubation and Mechanical D. ET Intubation and Mechanical VentilationVentilation

E. Bed RestE. Bed Rest

F. Sodium RestrictionF. Sodium Restriction

G. Diuretic TherapyG. Diuretic Therapy

H. Digitalis TherapyH. Digitalis Therapy

I. ECG MonitoringI. ECG Monitoring


*supportive to the medical management*supportive to the medical management

Pulmonary EmbolismPulmonary Embolism-obstruction of the pulmonary artery or one of its -obstruction of the pulmonary artery or one of its branches by a thrombus or thrombibranches by a thrombus or thrombi-causes:-causes:

*venous thrombosis*venous thrombosis*atrial fibrillation*atrial fibrillation

Occlusion of the Pulmonary ArteryOcclusion of the Pulmonary ArteryIncreased Alveolar Dead SpaceIncreased Alveolar Dead SpaceVentilation/Perfusion ImbalanceVentilation/Perfusion Imbalance

Hypoxemia and HypercapniaHypoxemia and HypercapniaPulmonary HypertensionPulmonary HypertensionRight Ventricular FailureRight Ventricular Failure

ShockShock


*dyspnea*dyspnea-most frequent symptom-most frequent symptom

*tachypnea*tachypnea-most frequent sign-most frequent sign

*chest pain*chest pain-sudden and pleuritic-sudden and pleuritic-mimics angina pectoris-mimics angina pectoris

*anxiety, fever, tachycardia, apprehension, *anxiety, fever, tachycardia, apprehension, cough, cough, diaphoresis, hemoptysis, diaphoresis, hemoptysis, syncopesyncope-less than 10% progresses to pulmonary infarction-less than 10% progresses to pulmonary infarction-assessment and diagnosis:-assessment and diagnosis:

a. Ventilation Perfusion Scan a. Ventilation Perfusion Scan (test of choice)(test of choice)b. Pulmonary Angiography b. Pulmonary Angiography (gold standard)(gold standard)

c. CXRc. CXR

-infiltrates-infiltrates

-atelectasis-atelectasis

-pleural effusion-pleural effusion

-elevation of the diaphragm-elevation of the diaphragm

d. ECGd. ECG

-sinus tachycardia-sinus tachycardia

-PR interval progression-PR interval progression

-non specific T wave changes-non specific T wave changes

e. Peripheral Vascular Studiese. Peripheral Vascular Studies

f. ABGf. ABG

-prevention:-prevention:

*prevention of *prevention of DEEP VEIN THROMBOSISDEEP VEIN THROMBOSIS


a. Emergency Managementa. Emergency Management*Nasal O2 Therapy*Nasal O2 Therapy*IV access*IV access*Perfusion Scan, ABG, Hemodynamic *Perfusion Scan, ABG, Hemodynamic

MeasurementsMeasurements*Dobutamine or Dopamine*Dobutamine or Dopamine*ECG*ECG*Digitalis Glycosides, IV Diuretics and *Digitalis Glycosides, IV Diuretics and

Anti-Anti- arrhythmics when appropriatearrhythmics when appropriate*Blood Studies*Blood Studies*ET Intubation and Mechanical *ET Intubation and Mechanical

VentilationVentilation*Indwelling Urinary Catheter Insertion*Indwelling Urinary Catheter Insertion*Small Doses of Sedatives or Morphine*Small Doses of Sedatives or Morphine

b. General Managementb. General Management*O2 therapy*O2 therapy*elastic compression stockings*elastic compression stockings*intermittent pneumatic leg compression*intermittent pneumatic leg compression*elevation of the leg*elevation of the leg

c. Pharmacologic Managementc. Pharmacologic Management*Anticoagulation Therapy*Anticoagulation Therapy

HeparinHeparin (IV bolus of 5T to 10T “U” (IV bolus of 5T to 10T “U” then infusion of 18U/kg/hour not to then infusion of 18U/kg/hour not to exceed 600U/hour)exceed 600U/hour)WarfarinWarfarin (begun within 24 hours (begun within 24 hours

after after initiating Heparin therapy)initiating Heparin therapy)*Thrombolytic Therapy*Thrombolytic Therapy

Urokinase, Streptokinase, Urokinase, Streptokinase, AlteplaseAlteplase

CI: CI: CVA w/in the past 2 monthsCVA w/in the past 2 monthsactive bleeding w/in the past active bleeding w/in the past

10 10 daysdaysrecent labor & deliveryrecent labor & deliverysevere hypertensionsevere hypertension

d. Surgical Management:d. Surgical Management:*embolectomy*embolectomy*interruption of the inferior vena cava*interruption of the inferior vena cava

Teflon clipsTeflon clips-nursing management:-nursing management:

a. Minimizing the risk of pulmonary embolisma. Minimizing the risk of pulmonary embolismb. Preventing thrombus formationb. Preventing thrombus formationc. Assessing for potential pulmonary embolismc. Assessing for potential pulmonary embolismd. Monitoring thrombolytic therapyd. Monitoring thrombolytic therapy

e. managing paine. managing pain

f. managing O2 therapyf. managing O2 therapy

g. relieving anxietyg. relieving anxiety

h. monitoring for complicationsh. monitoring for complications

i. post op nursing carei. post op nursing care

Diabetic KetoacidosisDiabetic Ketoacidosis-is caused by an absent or markedly inadequate -is caused by an absent or markedly inadequate amount of insulinamount of insulin-results in disorder in the metabolism of -results in disorder in the metabolism of carbohydrate, protein and fatcarbohydrate, protein and fat-3 main clinical features of DKA:-3 main clinical features of DKA:

*hyperglycemia*hyperglycemia*dehydration and electrolyte loss*dehydration and electrolyte loss*acidosis*acidosis

-assessment and diagnostic findings:-assessment and diagnostic findings:*blood glucose level*blood glucose level

-300 to 800 mg/dl-300 to 800 mg/dl*serum bicarbonate*serum bicarbonate

-0-15mEq/L-0-15mEq/L

*serum pH*serum pH

-low: 6.8-7.3-low: 6.8-7.3

*PCO2*PCO2

-low: 10-30mmHg-low: 10-30mmHg

-reflects respiratory compensation for -reflects respiratory compensation for acidosisacidosis

*ketone bodies*ketone bodies

-elevated in the blood and in the urine-elevated in the blood and in the urine

*electrolyte depletion*electrolyte depletion

*BUN, creatinine, hgb and hct*BUN, creatinine, hgb and hct

-elevated due to water loss-elevated due to water loss

-lack of insulin -decreased utilization

increased breakdown of fat of glucose by muscle,

increased fatty acids fat and liver

increased ketone bodies -increased production

-acetone breath of glucose by liver

-poor appetite hyperglycemia

-nausea

-blurred vision polyuria

acidosis dehydration

-nausea -weakness

-vomiting -headache

-abdominal pain increased thirst

increasingly rapid respirations

-prevention:

a. full compliance to the medical treatment of diabetes mellitus

b. good hydration

c. good nutrition

d. monitoring of blood and urine ketones every 3-4 hours

-management:

a. rehydration

>6-10 L of IVF

>plain NSS or half strength saline

b. restoring electrolytes

>ECG monitoring

*reversing acidosis:

-insulin

-nursing management:

*same as in DM

Addison’s Disease Cushing’s Syndrome

Sugar Hypoglycemia, hyperkalemia

Hyperglycemia,hypokalemia

Salt Hyponatremia Hypernatremia

Sex Decreased libido Sexual urge not merely affected

Physical Appearance

Not seen, more on symptoms

Buffalo hump, moonface, pitting edema, hirsutism, breast atrophy, purple striae on abdomen, easy bruising, facial flushing, acne, hyperpigmentation

Diet High Na, CHON, CHO intake except K

Low Na, CHO, fats but high CHON and K intake

Hyperthyroidism (Thyroid Crisis)

Hypothyroidism (Myxedema Coma)

Grave’s Disease; inc. amt. of T3&T4

Dec. T3T4; causes in adult – myxedema, child cretinism

Inc. appetite – wt. loss due to inc. metabolism, heat intolerance, all VS increase, exopthalmos-pathognomonic symptom, amenorrhea

Dec. appetite – wt. gain due to decreased. metabolism, all VS decrease, decreased menstruation

Inc. caloric diet; watch out for thyrotoxicosis (triad):

a. Tachycardia

b. Hyperthermia

c. agitation

Dec. caloric diet, force fluid

Meds: SSKI (Lugol’s solution), PTU prophylthiuracil

Meds: Levothyroxin (T4) synthroid

DKA HHNSAcute complication of type1 DM due to severe hyperglycemia, leading to CNS depression & coma

Hyperglycemia w/o ketosis is commonly on DM type2

Polyuria, Polydipsia, Polyphagia, Glycosuria, Pathognomonic

Sx:

>acetone breath– fruity odor

>kussmul’s respiration– rapid, shallow breathing

Hypotension, extreme thirst, dehydration, tachycardia, hypokalemia, hyponatremia

Mx: monitor VS; I/O

Meds: Insulin therapy (IV), counteract acidosis – Na HCO3

Tx: give insulin, inc. fluid

med surg lecture-1

Documents

serum sodium level

body fluid composition

fluid csf

fluid status

interstitial fluid

sodium ssx

normal fluid volume

gain of sodium