MED SURG 3 FINAL

Septic shock is caused by?

Widespread infection

How can you reduce septic shock incidence

strict infection control practices

Septic Shock s/s

- tachypnea - tachycardia - hypoxia, hypocarbia - cool, clammy skin - MENTAL STATUS CHANGE - pallor and cyanosis - skin mottling - SEVERELY low bp with narrowed pulse pressure - High temp then it becomes low - seizures - decreased cardiac output - decreased urine output

Septic Shock Labs

- elevated bilirubin levels - decrease platelet - elevated lactate - elevated inflammatory markers (WBC, plasma, C-rp, procalcitonin)

What should be completed within 3 hours of patient presentation/symptoms in septic shock?

- Obtain blood culture prior to admin of antibiotics - Administer prescribed broad spectrum antibiotics

For septic shock, when do you initiate aggressive fluid resuscitation?

in patients with hypotension or elevated serum lactate (>4 mmol/L) → minimum initial fluid bolus of 30 mL/kg using crystalloid solutions

Since septic shock is most commonly caused by gram-negative bacteria, Joint Commission’s National Patient Safety Goals recommends the administration of

IV antibiotics that are effective against gram-negative bacteria within 1 hr of a septic shock diagnosis

What should be completed as soon as possible or within the first 6 hours of patient presentation/symptoms for septic shock

Begin vasopressor agents if hypotension is not improved (MAP < 65 mm Hg) after initial fluid resuscitation (norepinephrine)

For septic shock, if hypotension persists after initial fluid administration (MAP <65 mm Hg) or initial lactate was ≥4 mmol/L → reassess intravascular volume status and tissue perfusion using two of the following assessment parameters

Measure CVP (goal 8–12 mm Hg) • Measure ScO2 (goal > 70%) • Bedside cardiovascular ultrasound

What vasopressors are given for septic shock

Epinephrine, phenylephrine, vasopressin

When do you give broad spectrum antibiotics for septic shock

Admin should occur within 3 hours of admission to ED or within 1 hour of inpatient admission

Complication of septic shock

DIC -> creates hypoxia and anaerobic metabolism -> hemorrhage risk Pt can develop diffuse petechiae and ecchymoses

What is the most common health care-associated infection in the US

Catheter Associated Urinary Tract Infection

What causes CAUTI

Escherichia coli

What does untreated UTIs lead to?

pyelonephritis, urosepsis -> can lead to septic shock and death

How do you prevent CAUTI

- strict aseptic technique during insertion - frequently inspecting urine color, odor, and consistency - performing daily perineal care with soap and water - maintaining a closed system - Following the manufacturer’s instructions when using the catheter port to obtain urine specimens

CAUTI s/s

- low back or abdominal pain - tenderness over the bladder area - nausea - urinary frequency and urgency - feeling of incomplete bladder emptying or retention of urine - perineal itching - hematuria - pyuria - fever - vomiting - voiding in small amounts - nocturia - uretheral discharge - cloudy or foul smelling urine

CAUTI older adult s/s

-Confusion - Incontinence - Loss of appetite - Nocturia and dysuria - Hypotension, tachycardia, tachypnea, and fever (indications of urosepsis)

CAUTI + lab

- urinarylsis, urine culture and sensitivity - bacteria, sediment, wbc, rbc are present - positive leukocyte esterase and nitrates (68-88%)

Collect catherized urine specimens using

sterile technique

What labs are looked at if urosepsis is suspected

wbc and differential

What antibiotics are used to treat CAUTI

- Fluoroquinolones - Nitrofurantoin - Trimethoprim - Sulfonamides

Advise clients taking fluoroquinolones or sulfonamides that

- sun-sensitivity is increased and sunburn is a risk for even dark-skinned individuals - medications can precipitate in the renal tubules, so advise client to take these medications with a full glass of water and to increase fluid intake - take with food - take whole count - monitor and report watery diarrhea -> pseudomembranous colitis

Nitrofurantoin

an antibacterial medication where therapeutic levels are achieved in the urine only

Phenazopyridine

bladder analgesic used to treat UTIs - Medication will turn urine orange - Will not treat the infection, but it will help relieve bladder discomfort

CAUTI education

- shower, not bathe - clean and wipe front to back - drink at least 3L - no coffee, teas, colas, alcohol, and other fluids that are urinary tract irritants - void every 2-3 hrs during the day and completely empty the bladder

Parkinson's disease

Slowly progressing neurologic movement disorder that eventually leads to disability

What are the 4 main findings of Parkinson's

- tremor at rest - muscle rigidity - bradykinesia - postural instability

What causes Parkinson's to happen

Low dopamine (movement) High acetylcholine (Secretions)

dopamine

produces inhibitory effects on the muscles

acetylcholine

produces excitatory effects on the muscles

Stage 1 PD

Unilateral shaking or tremor of one limb

Stage II PD

Bilateral limb involvement occurs, making walking and balance difficult; mask-like face; slow, shuffling gait

Stage III PD

Physical movements slow down significantly, affecting walking more; postural instability

Stage IV PD

Tremors can decrease but akinesia and rigidity make day-to-day tasks difficult

Stage V PD

Client unable to stand or walk, is dependent for all care, and might exhibit dementia

All of PD s/s

• Resting tremor • Pill Rolling • Bradykinesia (slow movements)with rigidity • Postural and gait disturbances (shuffling gait) • Expressionless, fixed gaze, masklike • Autonomic: sweating, drooling, slurred speech, flushing, orthostatic hypotension, gastric and urinary retention • Dysphagia • Psychiatric changes: depression, anxiety, dementia, delirium, hallucinations

How do you diagnose parkinsons

Diagnosis is made based on manifestations, their progression, and by ruling out other disease

What drugs control PD symptoms and maintain functional independence

BALSA - bromocriptine, Amantadine, Levodopa, Selegline, Benztropine

Bromocriptine

Dopamine Agonist - may be used in conjunction with a dopaminergic (ex: levodopa) for better results - monitor for orthostatic hypotension, dyskinesias, and hallucinations

Amantadine

Antiviral, antiparkinsonian, anticholinergic - it increases dopamine - Monitor for discoloration of the skin that subsides when amantadine is discontinued - pt might experience anxiety, confusion, and anticholinergic effects - side effects: tremor, rigidity, bradykinesia

Dopaminergics

Levodopa - increases dopamine levels (leaves more in the brain) - may be combined with carbidopa to decrease metabolism of levodopa (conserves) - monitor for the wearing off phenomenon and dyskinesias (indicates the need to adjust the dosage or time of admin or the need for a medication holiday)

Carbidopa + Levodopa education

- slow onset 2-6 weeks to become effective - slow position changes - red, brown urine/sweat/salivia (NORMAL) - NO HIGH PROTEIN MEALS

Selegline

MAO-B inhibitor prevents the breakdown of dopamine Reduce the wearing off phenomenon when given with levodopa Severe reactions can occur when these medications are administered with sympathomimetics, meperidine, and fluoxetine Avoid foods high in tyramine, which can cause hypertensive crisis

Benztropine

anticholinergic treats tremors and rigidity NOT bradykinesia

Which antihistamines can be used to control PD s/s

- diphenhydramine hydrochloride (benadryl) - orphenadrine citrate (banflex) - phenindamine hydrochloride (neo-synephrine)

Parkinsons nutrition

Semisolid food with thick liquids encourage high fiber diet due to constipation Monitor swallowing, HOB UP or SIT UP Suction at bedside Monitor weight weekly PEG tube may be necessary to maintain nutrition supplemental feedings increase caloric intake

Parkinsons + Improving mobility

- daily exercise (walking, riding a stationary bicycle, swimming, and gardening) helps maintain joint mobility - stretching and ROM exercises promote joint flexibility - postural exercises (counters tendency of the head and neck to be drawn forward and down) - warm baths and massage - walk erect, watch horizon, use a wide based gait - frequent rest periods - proper shoes - use of assistive devices

Parkinsons + enhancing self care activities

- adaptive or assistive devices (hospital bed at home, over bed frame with a trapeze, rope tied to the food of the bed)

Parkinsons + bowel elimination

avoid laxatives follow a regular time pattern, increase fluid intake, eat foods with moderate fiber content raised toilet seat

Uterine cancer

cancer of the endometrium -> originating in the lining of the uterus most women are diagnosed after menopause

Types of Uterine Cancer

type 1 (estrogen dependent, low grade, favorable prognosis) type 2 (estrogen independent, high grade)

Older adults and african american women are at higher risk for

type 2 uterine cancer

s/s of uterine cancer

- Irregular and/or postmenopausal bleeding - Low-back, abdominal, or low pelvic pain

If a menopausal woman experiences bleeding, what should be done to rule to hyperplasia

endometrial aspiration

hyperplasia

possible precursor of endometrial cancer

Transvaginal ultrasound

used to measure the thickness of endometrium

women who are postmenopausal should have a

very thin endometrium due to low levels of estrogen a thicker lining warrants further investigation

What tumor markers are elevated in uterine cancer

Alpha-fetoprotein (AFP) is elevated Cancer antigen-125 (CA-125) is positive

What is the standard treatment for uterine cancer

Total hysterectomy with bilateral salpingectomy/ oophorectomy

Progestin therapy

used frequently for uterine cancer be prepared for such side effects as nausea, depression, rash, or mild fluid retention

Brachytherapy

- delivered inside the body - An applicator is placed in the vagina, then the radioactive isotope is placed in the applicator for several minutes - can occur 2-10 x / week, pt must remain in bed during the treatment - Understand that there is no radioactivity between treatments and there are no restrictions on interactions with others

External beam radiation therapy (EBRT)

delivered outside the body Can be used in combination with surgery, brachytherapy, and/or chemotherapy Often given for 4-6 weeks on an outpatient basis

Laparoscopy or a robot-assisted laparoscopic surgery

less invasive than abdominal surgery

Whole pelvis radiotherapy

may be used if there is any spread beyond the uterus

Breast Cancer

can be noninvasive (in situ) or invasive (most common) common sites of metastasis are bone, lung, brain, and liver

Triple negative breast cancer

an aggressive form of cancer in which cells lack receptors for estrogen, progesterone, and HER2

Breast feeding for a year or more decreases

breast cancer risk

Hormone replacement therapy and environmental estrogens have been linked to

breast cancer

breast cancer s/s

- breast change (appearance, texture, presence of lumps) - breast pain or soreness - skin changes (peau d'orange) - dimpling - breast tumors (usually small, irregularly shaped, firm, non-tender, and non-mobile) - increased vascularity, erythema - nipple discharge - nipple retraction or ulceration - enlarged lymph nodes

Male clients + breast cancer?

a mass around the areola that is hard and painless, nipple inversion, ulceration or swelling of the chest

When should clinical breast exam be conducted?

Every 3 years - ages 20-39 Yearly - OVER 40 yrs

When should breast self examination be conducted

monthly, on the same day every time

Biopsy

open or fine needle definitive diagnosis of cancer cell type

Stereotactic biopsy

non-surgical needle biopsy for breast tissue in which affected tissue is visualized via client lying prone on special table with mammogram machine underneath

BRCA1 and BRCA2

presence of gene mutation increases breast cancer risk

HER2

presence of excess of this indicates the need for targeted therapy

Consider genetic testing for BRCA1 and BRCA2 if at risk

two first-degree relatives diagnosed with breast cancer prior to age 50 or family history of breast and ovarian cancer

Mammography, tomosynthesis (3D mammography) MRI, ultrasound, CT scan, x-ray

visualization of the lesion

mammography is preferred over

x-ray

MRI and US provider better visualization of lesions for clients who have

dense breasts

nuclear imaging, breast specific gamma imaging

Scanning will display the uptake of the radioactive substance injected prior to the procedure

Positron emission mammography (PEM)

provides consistent images despite hormone fluctuations

Hormone therapy

Most effective in cancer cells with estrogen or progesterone receptors

Ovarian ablation

Luteinizing releasing hormone (LH-RH) ex: leuprolide or goserelin - inhibits estrogen synthesis - use in PREMENOPAUSAL clients to stop or prevent the growth of breast tumors

Selective estrogen receptor modulators (SERMs): toremifene (tamoxifen and raloxifene)

Used in females who are at high risk for breast cancer or who have advanced breast cancer • Suppress the growth of remaining cancer cells post-mastectomy or lumpectomy • Tamoxifen has been found to increase the risk of endometrial cancer, DVT and PE • Raloxifene does not share these adverse effects

Chemotherapy and/or radiation can augment or replace a mastectomy, depending on several factors

- client’s age - hormone status related to menopause - genetic predisposition - staging of disease

Clients who undergo chemotherapy are usually given a combination of several medications

cyclophosphamide, doxorubicin, and fluorouracil

Radiation therapy is usually reserved for clients who had a

lumpectomy or breast-conserving procedure

What is a priority concern due to radiation damage and generalized fatigue

skin care

What kind of therapy is most effective in breast cancer with HER2/neu gene

Target therapy

Trastuzumab, pertuzumab, and ado-trastuzumab emtansine

signal transduction inhibitors → inhibit proteins that are signals for cancer cells to grow

lumpectomy

breast conserving

modified radical mastectomy

lymph nodes removed

radical mastectomy

lymph nodes and muscle removed

Drainage tubes are usually left in for

1-3 weeks

Avoid placing the arm on the surgical side in a

dependent position will interfere with wound healing

Perform early arm and hand exercises

squeezing a rubber ball, elbow flexion and extension, and hand-wall climbing to prevent lymphedema and to regain full range of motion

Genetic counseling for clients who test positive for the BRCA1/BRCA2 genetic mutation includes recommendation

bilateral mastectomy and oophorectomy to prevent cancer occurrence

Sites of origin for most prostate cancer

posterior lobe outer gland epithelium

prostate cancer is usually

slow-growing in response to androgen (testosterone and dihydrotestosterone)

Risk factors for colon cancer

- History of vasectomy - age greater than 65 - family history - african american - high fat, complex carbs or low fiber diet - HPC1, BRCA1, or BRCA2 mutation - rapid growth of the prostate - exposure to environmental toxins such as arsenic

prostate cancer s/s

- urinary hesistancy, weak streak, urgency, frequency, nocturia - recurrent bladder infections - urinary retention - blood in urine and semen (late sign) - painful ejaculation - pain, particularly bone (pelvis, spine, hips, ribs) - unexplained weight loss - loss of sexual desire - penile discharge or scrotal pain - significant residual urine after voiding a small amount of urine - swollen lymph nodes, especially in the groin

Digital rectal examination (DRE)

look out for hard prostate with palpable irregularities

Gleason score of 7 or higher

moderately differentiated

Gleason score 8-10

poorly differentiated

Prostate specific antigen

elevation (greater than 4ng/mL) indicates possible prostate disease

Have the PSA assessed prior to DRE to

promote accuracy of results

Early prostate cancer antigen (EPCA-2)

possible serum maker for prostate cancer - Positive results are highly indicative for prostate cancer and eliminate the need for biopsy

Transrectal ultrasonography (TRUS)

visualization of lesions Understand the possible complications and post-procedure care → extra fluids, no strenuous exercise, manifestations to report An enema will be administered prior to procedure

Treatment for prostate cancer can be delayed up to

10 years following diagnosis

PLISSIT Model

permission, limited information, specific suggestions, intensive therapy Begins by asking the patient’s permission (P) to discuss sexual functioning - Limited information (LI) about sexual function may then be provided to the patient - As the discussion progresses, the nurse may offer specific suggestions (SS) for interventions - A professional who specializes in sex therapy may provide more intensive therapy (IT) as needed

Sipuleucel-T

a vaccine against cancer - Destroys existing cells and prevents future cancer development.

Hormone therapy + prostate cancer

Leuprolide, goserelin, triptorelin - Used in advanced prostate cancer to produce chemical castration. - Be aware that hot flashes are an adverse effect - Impotence and decreased libido can also be adverse effects - Monitor for osteoporosis, which can occur due to testosterone suppression

Flutamide, bicalutamide, nilutamide

Used alone or in conjunction with a LH-RH agonist - Gynecomastia is a possible adverse medication effect - Have liver function tests monitored frequently - If primary medications are not successful → high-dose ketoconazole (anti-fungal that inhibits cytochrome P450 enzymes which are required for the synthesis of androgens and other steroids) or estrogen (diethylstilbestrol) can be given - Requires steroid supplementation to prevent adrenal insufficiency

What is the first line treatment for prostate cancer

radical prostatectomy not beneficial if the cancer has spread to the lymph nodes, bones, or other organs

What does radical prostatectomy entail

removal of the prostate gland, along with the seminal vesicles, the cuff at the bladder neck, and the regional lymph nodes

complications of radical prostatectomy

urinary incontinence and erectile dysfunction

Androgen Deprivation Therapy

used to suppress androgenic stimuli to the prostate by decreasing the level of circulating plasma testosterone or interrupting the conversion to or binding of DHT accomplished by bilateral orchiectomy (removal of one or both of the testes) causes hot flushing

Masectomy + care after surgery

compression sleeve elevated arm above heart numbness is expected along the affected arm (dissipate over several months, resolves within a year) lymph node swelling, expected

PSA levels may also be elevated if the patient has

BPH

How to get a definite diagnosis for prostate cancer

get a biopsy

Hepatitis

inflammation of liver cells, commonly caused by a viral infection classified as acute or chronic

Cirrhosis

permanent scarring of liver that is usually caused by chronic inflammation

Five definitive types of viral hepatitis that cause liver disease have been identified

A, B, C, D, E

nonviral causes of hepatitis

alcohol autoimmune disease where the body attacks itself

Hepatitis A

fecal-oral contaminated food or water, especially shellfish contact with infected stool (incontinent individuals, anal sexual activity)

Hepatitis B

- Unprotected sex with infected individual - Infants born to infected mothers - Contact with infected blood - Substance use disorder (injectable substances)

Hepatitis C

Substance use disorder (injectable substances) - Blood, blood products, or organ transplants - Contaminated needle sticks, unsanitary tattoo equipment - Sexual contact

Hepatitis D

Co-infection with Hep B - Substance use disorder (injectable substances) - Unprotected sex with infected individua

Hepatitis E

Fecal-oral contaminated drinking water

Risk factors for hepatitis C

- Unscreened blood transfusions (prior to 1992) - Hemodialysis - Percutaneous exposure → dirty needles, sharp instruments, body piercing, tattooing, use of another person’s substance use paraphernalia or personal hygiene tools - Ingestion of food prepared by a hepatitis-infected person who does not practice proper sanitation precautions - Travel/residence in underdeveloped country → using tap water to clean food products, drinking contaminated water - Eating or living in crowded environments → correctional facilities, dormitories, universities, long-term care facilities, military base housing

hepatitis s/s

- Influenza-like manifestations - Fatigue - Decreased appetite with nausea - Abdominal pain - Joint pain - Fever - Vomiting - Dark-colored urine - Clay-colored stool - Jaundice

How do you diagnose hepatitis

liver biopsy

How do you perform liver biopsy

- informed consent - supine position with URQ exposed - apply pressure to puncture site - assess client to right side lying position and maintain for several hours post procedure - assess for pneumothorax due to accidental puncture of pleura or lung

hepatitis treatment

avoid alcohol recommend vaccine to ppl who travel, illegal drug users, men who have sex with men, ppl with chronic liver disease,

Hepatitis A vaccine is reccomended for

post exposure protection

immunoglobulin

recommended for post-exposure protection for clients older than 40 years, younger than 12 months, who have chronic liver disease, who are immunosuppressed, or whoare allergic to the vaccine

What meds to use for chronic hepatitis infection

antivirals tenofovir, adefovir dipivoxil, interferon alfa-2b, peginterferon alfa-2a, lamivudine, entecavir, and telbivudine

How to treat hepatitis C

combination therapy with peginterferon alfa-2a and ribavirin is the preferred treatment

Hepatitis E

no meds, supportive care

Lab values for hepatitis

elevated bilirubin elevated PT, aPTT low albumin elevated AST, ALT

Hepatitis + Nutrition

- small frequent meals to prevent nausea - low protein - low fat foods until nausea subsides - frequent rest period

what to do with hepatitis?

protected sex avoid drinking alcohol and acetaminophen avoid sharing shaving razors and toothbrushes

complications of hepatitis

- acute liver failure - cirrhosis - liver cancer - gallbladder issues

Cholelithiasis

the presence of gallstones in the gallbladder from bile or cholesterol can be acute or chronic can obstruct the pancreatic duct -> pancreatitis

bile

used for the digestion of fats produced in the liver and stored in gallbladder

Risk factors for cholelithiasis

- more common in females - use of some oral bc - treatment with high dose estrogen (prostate cancer) - obesity - genetic predisposition - older adults - type 2 diabetes or crohns disease - low calorie, liquid protein diets - rapid weight loss - native american or mexican american - cystic fibrosis

cholelithiasis s/s

sharp pain in the URQ -> radiates to right shoulder pain with deep inspiration during right subcostal palpation -> murphy's sign intense pain (increase HR, pallor, diaphoresis w/ nausea and vomiting after eating high fat food) rebound tenderness (blumbergs sign) dyspepsia, eructation, flatulence fever distended abdomen jaundice icterus clay colored stool steatorrhea dark urine bleeding distress following fatty meal pruritus older adults (may not show typical symptoms, may show s/s of septic shock)

What labs do you test for cholelithiasis

- wbc (elevated) - bilirubin (elevated) - amylase, lipase (increased) - AST, ALP, LDH (increased) tells us the common bile duct obstructed

What can you use to test for cholelithiasis

- ultrasound - abdominal x-ray or CT scan - hepatobiliary scan (HIDA) (IV injection of contrast) - endoscopic retrograde cholangiopancreatography - magnetic resonance cholangiopancreatography

cholelithiasis nutrition

- low fat diet, rich in HDL (seafood, nuts, olive oil) - high in carbs and proteins - fat restriction usually lifted in 4-6 weeks - avoid gas forming foods (beans, cabbage, cauliflower, broccoli) - consider weight reduction - take fat-soluble vitamins or bile salts as prescribed to enhance absorption and aid with digestion

Lithotripsy

nonsurgical approaches shock waves are used to break up gallstones, provides only temporary solutions to gallstone problems

Bile acid (chenodiol, ursodiol)

gradually dissolves cholesterol-based gallstones - report abdominal pain, diarrhea, or vomiting - limited to 2 years of admin, requires a gallbladder ultrasound every 6 months during the first year to determine effectiveness

laparoscopic cholecystectomy

- the standard of therapy for symptomatic gallstones - instruct client to report an absence of drainage with mainfestations of nausea and pain (can indicate obstruction in the T-tube) - clamp the tube 1 hr before and after meals to provide the bile necessary for food digestion - monitor for bile peritonitis (pain, fever, jaundice) - expect removal of the tube in 1-3 weeks

cholecystitis

inflammation of the gallbladder typically caused by gallstones (cholelithiasis) that block the ducts leading out of the gallbladder resulting in a backup of bile which causes inflammation

cholecystitis s/s

- RUQ pain "radiates to the right shoulder" - fever with chills - tachycardia

risk factors for cholecystitis

- high fat diet - obesity - age over 40

How do you treat cholecystitis

- NPO (no eating or drinking since eating can cause more pain and complications) - lithotripsy - cholecystectomy (Surgical removal of the gallbladder)

Pancreatitis

Inflammation of pancreas comes from auto digestion of pancreas

what causes pancreatitis

- Alcohol abuse - gallbladder disease - cystic fibrosis - surgeries or diagnostic procedures (ERCP)

pancreatitis s/s

- LUQ pain that radiates to the back - bruising (turner's and cullen sign) - liver disease symptoms (jaundice, hypotension (internal bleeding, ascites) - abdominal guarding and tenderness

turners sign

bruising or ecchmoysis on flanks or side of body

cullen sign

edema and bruising around belly button umbilicus

pancreatitis labs

- elevated amylase, lipase - elevated glucose - elevated WBC - elevated PT, aPTT - elevated bilirubin

Complications of pancreatitis

- ARDS (results from massive inflammation) - Peritonitis

Pancreatitis treatment

- NPO for at least 24 hrs - Insert NG tube for suction - IV meds like hydromorphone, no morphine - IV fluids - monitor glucose - Antacids (PPI), H2 blockers (Famotidine) BLAND LOW FAT, LOW SUGAR DIET enzymes with meals

PASS

P - pull pin A - aim hose S - squeeze nozzle S - sweep (use hose in a sweeping motion)

The hot water heater in the home should not be set higher than

120 F

First degree burn (superficial)

Tingling, hypersensitivity, pain (soothed by cooling), peeling, itching reddened, blanches with pressure, dry, minimal or no edema, possible blistering

Second degree burn (partial thickness)

Pain, hypersensitivity, sensitive to air currents blistered, mottled red base, disrupted epidermis, weeping surface, edema

Third degree burn (full thickness)

insensate, shock, myoglobinuria (red pigment in urine), possible contact points dry, coagulated vessels may be visible, edema

Fourth degree burn (full thickness that involves fat, fascia, muscle and/or bone)

shock, myoglobinuria charred

Rule of Nines

a quick way to estimate the extent of burns in adults through dividing the body into multiples of nine and the sum total of these parts is equal to the total body surface area injured. Head and neck (9%) Chest and upper back (9% each) Arm (9% each) Abdomen and lower back (9% each) Genital area (1%) Leg (18% each)

Lund and Browder Method

recognizes the percentage of surface area of various anatomic parts, especially the head and the legs, as it relates to the age of the patient. The initial evaluation made on arrival of the patient to the hospital should be revised within the first 72 hours, because demarcation of the wound and its depth present themselves more clearly by this time

Palmer Method

In patients with scattered burns, or very large burns with minimal sparing, the method is an expeditious method to determine extent of injury. The size of the patient’s hand, including the fingers, is approximately 1% of that patient’s TBSA

If the burn exceeds 20% to 25% TBSA

a nasogastric tube is inserted and connected to low intermittent suction because there are patients with large burns that become nauseated

What is applied to partial thickness burns

topical antibiotics filled dressings ex: silver sulfadiazine, bacitracin

Lactated ringers

crystalloid of choice to improve tissue and organ perfusion caused by plasma loss

Meds for burns

Opioids (large doses of IV morphine for patients with significant burns) - NSAIDs - Anxiolytics - Anesthetic agents

Chemoprophylaxis

Tetanus immunization should be updated, if necessary, for any burns deeper than superficial thickness

For burns classified as severe (> 20% TBSA), fluid resuscitation should be

initiated to maintain urine output > 0.5 mL/kg/hour.

A wet chemical should be removed as soon as possible with

copious amounts of water

Dry substances should be

gently brushed off the skin before the area is flushed The skin should be flushed with a constant stream of cool water as the patient’s clothing is removed.

Acute kidney injury

Sudden cessation of renal function that occurs when blood flow to the kidneys is significantly compromised Manifestations occur abruptly

Phases of AKI

- initiation - oliguria - diuresis - recovery

Initiation

begins with the onset of the event, ends when oliguria develops, and lasts for hours to days

oliguria

begins with the kidney insult, urine output is 100-400 mL/24 hr with or without diuretics, and lasts for 1-3 weeks uremic s/s happen here + hyperkalemia high specific gravity, anorexia, n/v

diuresis

begins when the kidneys start to recover; diuresis of a large amount of fluid occurs; and can last for 2-6 weeks - Laboratory values stabilize and eventually decrease - The patient must be observed closely for dehydration during this phase Low specific gravity

Recovery

continues until kidney function is fully restored and can take up to 12 months

Stage I (Risk stage)

blood creatinine 1.5-1.9x baseline and urine output less than 0.5 mL/kg/hr for 6 hrs or more

Stage 2 (injury stage)

blood creatinine 2-2.9x baseline and urine output less than 0.5 mL/ kg/hr for 12 hrs or more

Stage 3 (failure stage)

blood creatinine 3x baseline and urine output less than 0.3 mL/kg/hr for 12 hrs or more

Risk factors for AKI

- Renal vascular obstruction - Shock - Decreased cardiac output - Sepsis - Hypovolemia - Peripheral vascular resistance - Use of aspirin, ibuprofen, or NSAIDs - Liver failure - Trauma - Hypoxic injury → renal artery or vein stenosis or thrombosis - Chemical injury → acute nephrotoxins (antibiotics (vancomycin, gentamycin), CONTRAST DYE, heavy metals, blood transfusion reaction, alcohol, cocaine) - Immunologic injury → infection, vasculitis, acute glomerulonephritis - Stone, tumor, bladder atony - Prostate hyperplasia, urethral stricture - Spinal cord disease or injury

AKI s/s

- Cardiovascular → hypertension, fluid overload (dependent and generalized edema), dysrhythmia (hyperkalemia) - Respiratory → crackles, decreased oxygenation, shortness of breath - Renal → scant to normal or excessive urine output, depending on the phase, possible hematuria - Neurologic → lethargy, muscle twitching, seizures - Integumentary → dry skin and mucous membranes - Progressive metabolic acidosis

How do you treat AKI

- Monitor fluid intake and output strictly - sodium, potassium, phosphate, and magnesium restrictions - low protein diet - renal replacement therapy, hemodialysis, peritoneal dialysis - IV fluid therapy - diuretics

For AKI caused by medication nephrotoxicity, administer

Calcium channel blocker to prevent the movement of calcium into the kidney cells and to maintain cell integrity and increase the glomerular filtration rate (GFR)

Sodium polystyrene sulfonate (AKI)

replaces sodium with potassium in the intestinal tract to promote potassium excretion

Sodium bicarbonate

severe metabolic acidosis

hyperphosphatemia

phosphate-binding agents

Stage 1 CKD

90+ GFR

Stage 2 CKD

60-89 GFR

Stage 3 CKD

15-29 GFR

Stage 4 CKD

15 or less GFR

Stage 5 CKD

dialysis or kidney transplant

cause of CKD

* Older age * They lose 10% of renal function each decade * Uncontrolled diabetes * Uncontrolled hypertension * Unchecked autoimmune * Infection * Acute kidney failure * Polycystic kidney disease * pyelonephrosis * chronic glomerulonephritis * nephrotoxic medications (gentamicin, NSAID) chemicals

Hypertensive crisis + CKD

headache, n/v, change in mental status hypertension can cause stroke MI, or kidney damage

CKD can cause

metabolic acidosis