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High Risk Adult HEART FAILURE The inability of the heart to maintain adequate circulation to meet the metabolic

needs of the body ecause of an impaired pumping capability Cardiac output is diminished, and peripheral tissue is not perfused adequately. Congestion of the lungs and periphery may occur Classification 1. Acute heat failure 2. Chronic heart Failure Types of Heart Failure 1. Left Ventricular Failure (LVF) heart failure in which the left ventricle fails to contract forcefully enough to maintain a normal carciac output and peripheral perfusion. Causes: Myocardial infarction (MI), ischemic heart disease, cardiomyopathy Assessment: a. Signs of LVF are evident in the pulmonary system b. Cough, which may become productive with frothy sputum c. Dyspnea on exertion d. Orthopnea e. Paroxymal nocturnal dyspnea f. Presence of crackles on auscultation g. Tachycardia h. Pulsus alternans i. Fatigue j. Pallor k. Cyanosis l. Confusion and disorientation m. Signs of cereral anoxia S/S Acute Pulmonary Edema a. Severe dyspnea an orthopnea b. Pallor c. Tachycardia d. Expectoration of large amounts of blood-tinged, frothy sputum e. Wheezing and crackles on auscultation f. Bubbling respirations g. Acute anxiety, apprehension, restlessness h. Profuse sweating i. Cold, clammy skin j. Cyanosis k. Nasal flaring l. Use of accessory breathing muscles m. Tachypnea n. Hypocapnia, evidenced by muscle cramps, weakness, dizziness, and paresthesias 2. Right Ventricular Failure (RVF) an abnormal cardiac condition charcterized by the impairment of the right side of the heart ad congestion and elevated pressure in the systemic viens and capillaries. Causes: Left-sided heart failure most common Right ventricular infarction, pulmonic stenosis, and pulmonary hypertension Assessment a. Signs of right ventricular failure are evident in the systemic circulation b. Pitting, dependent edema in the feet, legs, sacrum, back, and buttocks c. Ascites from portal hypertension d. Tenderness of right upper quadrant, organomegaly e. Distended neck veins f. Pulsus alternans (regular alteration of weak and strong beats noted in the pulse) g. Abdominal pain, bloating h. Anorexia, nausea i. Fatigue j. Weight gain k. Nocturnal diuresis 3. Forward failure/Backward failure a. In forward failure, an inadequate output of the affected ventricle causes decreased perfusion to vital organs.

b. In backward failure, blood backs up behind the affected ventricle, causing increased pressure in the atrium behind the affected ventricle. 4. Low output/High output a. In low-output failure, not enough cardiac output is available to meet the demands of the body. b. High-output failure occurs when a condition causes the heart to work harder to meet the demands of the body. 5. Systolic failure/Diastolic failure a. Systolic failure leads to problems with contraction and the ejection of the blood. b. Diastolic failure leads to problems with the heart relaxing and filling with blood. Immeidate Management 1. Place the client in high Fowlers position, with the legs in a dependent position, toreuce pulmonary congestion and relieve edema. 2. Administer oxygen in high concentrations by mask orcannula as prescribed to improve gas exchange and pulmonary function. 3. Prepare for intubation and ventilator suport if required; monitor lung sounds for crackles and decreased breath sounds 4. Suction fluidsas neededto maintain a patent airway. 5. Assess level of consciousness 6. Provide reassurance to the client. 7. Monitor vital signs closely, noting tachycardia or pulsus alternans. 8. Monitor for hypotension resulting from decreased tissue perfusion or hypertension resulting from anxiety or history of hypertension. 9. Monitor heart rate and for dysrhythmias by using a cardiac monitor 10. Asess for edema in depended ares and in the sacral, lumbar, and posterior thigh region in the client on bed rest. 11. Insert a Foley catheter as prescribed and monitor urine output closely following administration of a diuretic. 12. Monitor intake and output. 13. Avoid the unnecessary IV administration of fluids. 14. Adminsiter morphine sulfate as prescribed to provide sedation and vasolidation, and monitor for respiratory depression or hypotension after administer. Pharmacologic Interventions 1. Administer diuretics as prscribed to reduce preload, enhance renal excretion of sodium and water, reduce circulating blood bolume, and reduce pulmonary congestion. 2. Administer digitalis as prescribed to increase ventiruclar contractility and improve cardiac output. 3. Administer bronchodilators as prescribed for severe bronchospasm or bronchoconstriction. 4. Adminster additional inotropic medications, such as dopamine (Intropin) or dobutamine (Dobutrex), as prescribed to facilitate myocaridal contractility and enhance stroke volume. 5. Adminster vasodilators as prescribed to reduce afterload, increase the capacity of the systemic venous bed, and decrese venous return to he heart. 6. Monitor weight to determine a response to treatment. 7. Assess for hepatomegaly and ascites, and measure and record abdominal girth. 8. Monitor peripheral pulses. 9. Analyze arterial blood gas results and electrolyte values for imbalances. 10. Monitor potassium level closely, which may decrease as a resutl of diuretic therapy, and adminsiter potassium supplements as prescribed to prevent digitalis toxicity. Following the acute episode 1. Encourage the client to verbalize feelings about the lifestyle changes requried as a result of the heart failure. 2. Assist the client to identify precipitating risk factors of heart failure and methods of eliminating these risk factors. 3. Instruct the client to avoid large amounts of caffeine, found in coffee, tea, cocoa, chocolate, and some carbonated beverages. 4. Instruct the client about the prescribed low-sodium, low-fat, and low-cholesterol diet. 5. Provide the client with a list of potassium-rich foods becausediuretics can cause hypokalemia (except for potassium-sparing diuretics). 6. Instruct the client regarding fluid restriction, if prescribed, advising the client to spread the fluid out during the dayand to suck on hard candy to reduce thirst. 7. Instruct the client to balance priods of activity and rest. 8. Advise the client to avoid isometic activities, which increase pressure in the heart. 9. Instruct the client to monitor daily weight. 10. Instruct the client to report signs of fluid retention such as edema or weight gain. Pharmacologic intervention 1. Instruct the client in the prescribed medication regimen, which may include digoxin (Lanoxin), a diuretic, and vasodilators 2. Advise the client to notify the physician if side effects occur from the medications 3. Advise the client to avoid over-the-counter medications.

4. Instruct the client to contact the physician if he or she is unable to take medications necause of illness. RESPIRATORY FAILURE A. Description 1. Respiratory failure occurs when the client cannot eliminate carbon dioxide from the alveoli. 2. The carbon dioxide retention results in hypoxemia. 3. Oxygen reaches the alveoli but cannot be absorbed or used properly. 4. The lungs can move air sufficiently but canot oxygenate the pulmonary blood properly. 5. Respiratory failure occurs as a result of a mechanical abnormality of the lungs or chest wall, a defect in the respiratory control center in the brain, or an impairment in the function of the respiratory muscles. 6. The PaCO2 level is greater than 45 mm Hg. B. Assessment 1. Dyspnea 2. Headache 3. Restlessness 4. Confusion 5. Tachycardia 6. Cyanosis 7. Dyrhythmias 8. Decresed level of consciousness 9. Alterations in respirations and breath sounds C. Interventions 1. Identify and treat the cause of respiratory failure 2. Administer oxygen to maintain the PaO2, level greater than 60 to 70 mm Hg. 3. Position the client in high Fowlers position. 4. Encourage deep breathing 5. Administer bronchodilators as prescribed 6. Prepare the client for mechanical ventilation if supplemental oxygen cannot maintain acceptable PaO2 levels. ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) A. Description 1. Acute respiratory distress syndrome is a form of acute respiratory failure that occurs as a complication of some other condition, is caused by a diffuse lung injury, and leads to extravascular lung fluid. 2. The major site of injury is the alveolar capillary membrane. 3. The interstitial edema causes compression and obliteration of the terminal airways and leads to reduced lung volume and compliance. 4. The ABGs identify respiratory acidosis and hypoxemia that does not respond to an increased percentage of oxygen. 5. The chest x-ray film shows interstitial edema. Causes 1. Sepsis 2. Fluid overload 3. Shock 4. Trauma 5. Neurological injuries 6. Burns 7. Diseminated intravascular coagulation 8. Drug ingestion 9. Inhanlation of toxic substances B. Assessment 1. Tachypnea 2. Dyspnea 3. Decreased breath sounds 4. Deteriorating blood gas levels 5. Hypoxemia despite high concentrations of delivered oxygen 6. Decreased pulmonary compliance 7. Pulmonary infiltrates C. Interventions 1. Identify and treat cause of the ARDS 2. Administer 02 as prescribed. 3. Position client in high Fowlers position 4. Restrict fluid intake as prescribed 5. Provide respiratory treatments as prescribed

6. Administer diuretics, anticoagulants, or corticosteroids as prescribed. 7. Prepare the client for intubation and mechanical ventialtion using PEEP. RENAL FAILURE A. Description Renal failure is the loss of kidney function Causes PRERENAL Intavascular volume depletion, decreased cardiac output, and vascular failure caused by vasodilation or obstruction INTRARENAL Tubular necrosis, nephrotoxicity, alterations in renal blood flow. POSTRENAL Obstruction of urine flow between the kidney and urethral meatus and bladder neck obstruction Types A. Acute Renal Failure - The sudden loss of kidney function and is caused by renal cell damage from ischeia or toxic substances. - occurs abruptly and can be reversible - leads to hypoperfusion, cell death, and decompensation in renal function - the prognosis depends on the cause and the condition of the client - near-normal or normal kidney function may resume gradually. Causes a. Infection b. Renal artery occlusion c. Obstruction d. Acute kidney disease e. Dehydration f. Diuretic therapy g. Ischemia from hypovolemia, heart failure, septic shock, or blood loss h. Toxic substances such as medications, particularly antibiotics Phases 1. Oliguric Phase a. Duration of 8-15 days; and the longer the duration, the less chance of recovery b. Sudden drop in urine output; urine output less than 400 ml/day due to decreased GFR c. Urine specific gravity is decreased d. Anorexia, nausea, and vomiting e. Hypertension f. Decreased skin turgor g. Pruritus h. Tingling of the extremities i. Drowsiness progressing to disorientation to coma j. Edema k. Dyrhythmias l. Signs of congestion heart failure (CHF) and pulmonary edema m. Signs of pericarditis n. Signs of acidosis o. Hyperkalemia p. Sodium level normal or decreased q. Fluid overload r. Elevated BUN and Creatinine 2. Diuretic Phase a. Urine output rises slowly, and then diuretics occurs (4 to 5 L/day) b. Excessive urine output idicates recovery of damaged nephrons c. Hypotension occurs d. Tachycardia occurs e. Level of consciousness improves f. Increase in GFR g. Hypokalemia h. Hyponatremia i. Hypovolemia j. Gradual decline in BUN and Creatinine 3. Recovery Phase (convalescent) a. Recovery is a slow process; complete recovery may take 1 to 2 years b. Urine volume is normal c. Increase in strength occurs

d. e. f. g. h.

Level of consciousness occurs Blood urea nitrogen is stable and normal Client can develop chronic renal failure Stable and normal blood urea nitrogen Complete recovery may take 1 to 2 years

CHRONIC RENAL FAILURE (CRF) 1. Description a. Chronic Renal Failure is the progressive loss and ongoing deterioration in kidney function that occurs slowly over a period of time. b. It occurs in stages, is irreversible, and results in uremia or end-stage renal disease c. It affects all of the major body systems and requires dialysis or kidney transplant to maintain life. d. Hypervolemia can occur because of the inability of the kidneys to excrete sodium and water, or hypervolemia can occur because of the inability of the kidneys to conserve sodium and water. Stages of CRF Stage I. DIMINISHED RENAL RESERVE Renal function is reduced. No accumulation of metabolic waste occurs. The healthier kidney compensates Nocturia and polyuria occur as a result of decreased ablity to concentrate urine. Stage II. RENAL INSUFFICIENCY Metabolic wastes begin to accumulate Oliguria and edema occur as a result of decreased responsiveness to diuretics. Stage III. END STAGE Excessive accumulation of metabolic wastes occurs. Kidneys are unable to maintain homeostasis. Dialysis or other rnal replacement therapy is required. Causes of CRF a. May follow acute ARF b. Renal artery occulusion c. Chronic urinary obstruction d. Recurrent infections e. Hypertension f. Metabolic disorders g. Diabetes Mellitus h. Autoimmune disorders Assessment a. Anorexia and nausea b. Headache c. Weakness and fatigue d. Hypertension e. Confusion and lethargy; followed by convulsion and coma f. Kussmauls respirations g. Diarrhea or constipation h. Muscle twitching and numbness of the extremities i. Decreased urine output j. Decreased or fixed urine specific gravity k. Proteinuria l. Anemia m. Azotemia n. Fluid overload and signs of heart failure o. Uremic frost: a layer of urea crystals from evaporated perspiration that appears on the face, eyebrows, axilla, and groin in clients with advanced uremic syndrome. Interventions a. Monitor vital signs b. Monitor urine and intake and output (hourly in acute renal failure) c. Monitor weight, noting that an increase of to 1 lb daily indicates fluid retention. d. Monitor BUN, creatinine, and electrolyte values. e. Monitor for acidosis and treat with sodium bicarbonate as prescribed. f. Assess urinalysis for protein, hematuria, casts, and specific gravity g. Monitor level of consciousness h. Assess for signs of infections because the client may not demonstrate a temperature or an increased WBC count. i. Assess for dysrhtmias because a potassium level above 6 mEq/L will cause tall peaked T waves, a prolonged PR interval, and a widened QRS complex. j. Monitor for edema.

k. Administer prescribed diet; usually a moderate protein intake (to decrease the workload of the heart) and a high-carbohydrate, low-potassium and low-phosphorus diet is prescribed. l. Restrict sodium intake as prescribed, based on the electrolyte level. m. Daily fluid allowances may be 400 mL to 1000 mL plus measured urinaly output. n. Administer sodium polystyrene sulfonate (Kayexelate) to lower potassium level as prescribed o. Be alert to the mechanism for metabolism and excretion of all meds p. Prepare the client for dialysis as prescribed.

Special problems in Renal Failure a. Anemia b. Gastrointestinal bleeding c. Hypertension d. Hypervolemia e. Hypovolemia f. Infection and injury g. Insomnia and fatigue h. Low calcium i. Metabolic acidosis j. Muscle cramps k. Neurological changes l. Ocular irritation m. Phosphorus retention n. Potassium retention o. Pruritus p. Psychosocial problems HEMODIALYSIS - Is the diffusion of dissolved particles from one fluid compartment into another across a semipermeable membrane - The clients blood flows through one compartment, and the dialysate is in another fluid compartment Functions of Hemodialysis It cleanses the blood of accumulated waste products It remvoes the by-products of protein metabolism such as urea, creatinine, and uric acid. It removes excessive fluids. It maintians or restores the buffer system of the body and well as electrolytes levels Principles of hemodialysis Diffusion the movement of particles from an area of greater concentration to one of lesser concentration Osmosis is the movement of fluids across a semipermeable membrane from an area of lesser concentration to an area of greater concentration of particles. Ultrafiltration is the movement of fluid across a semipermeable membrane as a result of artificially created pressure gradient. Dialysate Bath A dialysate bath is composed of water and major electrolytes. It need not be sterile because bacteria are too large to pass through, however, it myst meet specific standards, and water treatment systems are used to ensure a safe water supply. Interventions Monitor vital signs. Monitor laboratory values before, duringand after dialysis Assess the client for fluid overload before the procedure Assess patency of the blood access device Weigh the client before and after the procedure to determine fluid loss Hold antihypertensives and other medications that can affect the BP before the procedure as prescribed. Hold medications that could be dialyzed off, such as water soluble vitamins and certain antibiotics. Monitor for schock and hypervolemia during the procedure Provide adequate nutrition (client may eat before the procedure) Complications of hemodialysis A. Disequilibrium Syndrome 1. Description a. A rapid change in the composition of the extracellular fluid occurs during hemodialysis. b. Solutes are revomed from the blood faster than from the cerebrospinal fluid and brain; fluid is pulled into the brain, causing edema 2. Assessment a. Nausea b. Vomiting c. Headache

d. Hypertension e. Restlessness and agitation f. confusion g. Seizures 3. Interventions a. Monitor for signs of Disequilibrium Syndrome b. Notify the physician if signs of DS occur c. Reduce environmental stimuli d. Prepare to dialyze the client for shorter period at reduced blood flow rates to prevent occurrence. B. Dialysis Encephalopathy 1. Description: An aluminum toxicity occurs as a result of aluminum in the water sources used in the dialysae and the ingestion of aluminum-containing antacids (phosphate binders) 2. Assessment a. Progressive neurological impairment b. Mental cloudiness c. Speech disturbance d. Muscle incoordination e. Dementia f. bone pain g. Seizures 3. Interventions a. Monitor for signs and notify the physician if these signs occur. b. Administer aluminum-chelating agents as prescribed so that the aluminum is greed up and dialyzed from the body. PERITONEAL DIALYSIS A. Description 1. The peritoneum is the dialyzing membrane and substitues for kidney function during kidney failure. 2. It works on the principles of diffusion and osmosis, and the dialysis occurs via the transfer of fluid and solute from the bloodstream through the peritoneum. B. Contraindications to Peritoneal Dialysis 1. Peritonitis 2. Recent abdominal surgery 3. Abdominal adhesions 4. Impending renal transplant C. Dialysate Solution Solution is sterile. Solution contains electrolytes and minerals, a specific osmolarity, a specific glucose concentration, and other medication additives as prescribed. The higher the glucose concentration, the greater the amount of fluid removed during an exchange. Increasing the glucose concenration increased the concentration of active particles that cause osmosis and increases the rate of ultrafiltration and the amount of fluid removed. If hyperkalemia is not a problem, potassium may be added to each bag of solution. Heparin is added to the dialysate solution to prevent clotting of the catheter. Prophylactic antibiotics may be added to dialysate to prevent peritonitis Insulin may be added to the dialysate for the client with DM. Types of Peritoneal Dialysis 1. Continuous Ambulatory Peritoneal Dialysis (CAPD) Resembles renal function because it is a continuous process. It does not require a machine for the procedure It promotes client independence The client performs self-dialysis 24 hours a day 7 days a week. Usually four dialysis cycles are administered in 24 hours, including an 8-hour dwell time overnight. One and a half to 2 L of dialysate are instilled into the abdomen 4 times daily and allowed to dwell as prescribed. The dialysis bag, attached to the catheter, is folded and carrried under the clients clothing until time for outflow. After dwell, the bag is placed lower than the insertion site sot that fluid drians by gravity flow When full, the bag is changed, new dialysate is instilled into the abdomen, and the process continues. 2. Peritoneal Dialysis infusion Description 1. One infusion (inflow), dwell, and outflow is considered one exchange. 2. Dialysis infusion uses an open system that presents a risk of infection 3. Inflow: the infusion of 1 to 2 L of dialysate as prescribed is infused by gravity into the peritoneal space, which usually takes 10 to 20 minutes.

4. Dwell time: the amount of time that the dialysate solution remains in the peritoneal cavity is prescribed by the physician and can last 20 to 30 minutes to 8 or more hours depending on the type of dialysis used. 5. Outflow: Fluid drians out of body by gravity into the drainage bag. Interventions before treatment 1. Monitor vital signs 2. Obtain weight 3. Have the client void if possible 4. Assess electrolyte and glucose levels Interventions during treatment 1. Monitor vital signs 2. Monitor for signs of infection 3. Monitor for respiratory distres, pain or discomfort 4. Monito for signs of pulmonary edema 5. Monitor for hypotension and hypertension 6. Monitor for malaise, nausea, vomiting 7. Asess the catheter site dresing for weness or bleeding 8. Monitor dwelling as prescribed by the physician and initiate outflow. 9. Do not allow dwell time to extend beyond the physicians order because this increases the risk for hyperglycemia 10. Turn the clent from side to side if the outflow is slow to start. 11. Monitor outflow, which should be continuous stream after the clamp is opened 12. Monitor outflow for color and clarity. a. Characteristics of outflow b. During the first or initial exchanges, the outflow may be bloody; outflow shold be clar and colorless thereafter c. A brown outflow indicates bowel perforation d. If the outflow is the same color as urine, this indicates bladder perforation e. Cloudy outflow indicates peritonitis 13. Monitor intake and output accurately 14. If outflow is less than inflow, the difference is equal to the amount absorbed or ratained by the client during dialysis and should be counted as intake. COMPLICATIONS OF PERITONEAL DIALYSIS 1. Abdominal pain 2. Bladder or bowel perforation 3. Insufficient outflow 4. Leakage around the catheter site 5. Peritonitis BURN INJURIES A. Description: Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolytes. B. Burn Size 1. Small burns: the response of the body to injury is localized to the injured area. 2. Large or extensive burns a. Large burns consist of 25% or more of the total body surface area b. The response of the body to the injury is systemic c. The burn affects all of the major systems of the body. Method to Estimate Extent of Injury Rule of Nines Head and neck: Anterior trunk:18% Posterior trunk: Arms (9% each) Legs (18% each) Perineum: Burn Depth 1. Superficial-thickness burn (similar to first degree burn) a. Mild to severe erythema (pink to red) is present, but no blisters b. Skin blanches with pressure. c. Burn is painful, with tingling sensation d. Pain is eased by cooling. e. Discomfort lasts about 48 hours, healing occurs in about 3 to 7 days f. Skin grafts are not required. 2. Partial-thickness superficial burn (similar to second-degree burn) 9% 18% 18% 36% 1%

a. Large blisters cover an extensive area. b. Edema is present c. Mottled red base and broken epidermis, with a wet, shiny, and weeping surface are characteristic. d. Burn is painful e. Injured area is sensitive to cold air. f. Superficial partial thickness burn heals in 2 to 3 weeks g. Deep partial thickness burn heals in 3 to 6 weeks h. Grafts may be used if the healing process is prolonged. 3. Full-thickness burn (similar to third-degree burn) a. Burn leaves a deep red, black, white, yellow, brown area. b. Injured surface appears dry. c. Edema is present d. Burn causes tissue disruption with fat exposed. e. Burn causes little or no pain f. Spontaneous healing will not occur. g. Burn requires removal of eschar and split or full-thickness skin grafting h. Scarring and would contractures are likely to develop without preventive measures. i. Healing takes weeks to months 4. Deep full-thickness burn (similar to fourth-degree burn) a. Burn involves injury to the muscle and bone. b. Injured area appears black c. Edema is absent d. Pain is absent e. No blisters are present f. Eschar is hard and inelastic g. Healing time takes weeks to months h. Grafts are required. Types of Burns 1. 2. 3. 4. Thermal burns caused by exposure to flames, hot liquids, steam, or hot objects Chemical burns caused by tissue contact with strong acids, alkalis, or organic compounds Electrical burns caused by heat generated by an electrical energy as it passes through the body Radiation burns are caused by exposure to ultraviolet light, x-rays or a radioactive source.

PHASES SOF MANAGEMENT OF THE BURN INJURY 1. Emergent Phase permeability, functioning. begins at the time of injury and ends with the restoration of capillary usually at 48 to 72 hours following the injury. The primary goal is to prevent hypovolemic shock and preserve vital organ This phase includes prehospital care and emergency room care

2. Resuscitative Phase begins with the initiation of fluids and ends when capillary integrity returns to near-normal levels and the large fluid shifts have decreased. The amount of fluid administered is based on clients weight and extent of injury. Most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital The goal is to prevent shock by maintaining adequate circulating blood volume and maintaining vital organ perfusion Common Fluid Resuscitation Formulas for First 24 Hours after a Burn Injury Formula Solution Infusion Rate Modified Brooke 2.0 mL/kg per percent TBSA Burned Parkland (Baxter) 4 mL/kg per percent TBSA burned Lactated Ringers Half in first 8 hours Half in next 16 hours Half in first 8 hours One-quarter each next 8 hours

Lactated Ringers

3. Acute Phase The acute phase begins when the client is hemodynamically stable, capillary permeability is restored, and diuresis has begun. This phase usually begins 48 to 72 hours after the time of imjury Emphasis during this phase is placed on restorative therapy, and the phase continues until wound closure is achieved

The focus is on infection control, wound care, wound closure, nutritional support, pain management, and physical therapy 4. Rehabilitative Phase Rehabilitation is the final phase of burn care. The phase overlaps and acute care phase and goes will beyond hospitalization Goals of this phase are designed so that the client can gain independence and achieve maximal function Goals a. Promote wound healing b. Minimize deformities c. Increase strength and function d. Provide emotional support