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Urinary Assessment: Chapter 43 Kidney Functions Maintain fluid, electrolytes, and acid-base balance Eliminate waste products Regulate BP Stimulate RBC production Regulate calcium and phosphorus metabolism Eliminate many drugs Blood Pressure Control Kidneys regulate blood pressure partly through maintenance of volume (formation/excretion of urine). The renin-angiotensin system is the other kidney-controlled mechanism that can contribute to rise in blood pressure. When blood pressure drops, the cells of the glomerulus release renin, which then activates angiotensin to cause vasoconstriction. Atrial natriuretic factor (ANF) is a hormone secreted from cells in the right atrium when right atrial blood pressure increases. ANF inhibits the secretion and effect of ADH and results in a large volume of dilute urine. Formation of Urine Glomerular filtration • Ultrafiltration of blood by glomerulus; beginning of urine formation o Requires hydrostatic pressure (supplied by the heart and assisted by vascular resistance [glomerular hydrostatic pressure]) and sufficient circulating volume. o Pressure in Bowman’s capsule opposes hydrostatic pressure and filtration; if glomerular pressure insufficient to force substances out of blood into tubules, filtration formation stops. • Glomerular filtration rate (GFR): amount of blood filtered by the glomeruli in a given time; normal is 125ml/min. • Filtrate formed has essentially same composition as blood plasma without the proteins; blood cells and proteins are usually to large to pass the glomerular membrane. Tubular function: the tubules and collecting ducts carry out the functions of reabsorption, secretion, and excretion. Reabsorption of water and electrolytes is controlled by antidiuretic hormone (ADH), released by the pituitary, and aldosterone secreted by the adrenal glands. • Proximal convoluted tubule: reabsorption of certain constituents of the glomerular filtration: 80% of electrolytes and H2O, all glucose and amino acids, and bicarbonate; secretes hydrogen and creatinine. • Loop of Henle: reabsorption of sodium and chloride in the ascending limb; reabsorption of water in the descending loop; concentrates/dilutes urine. • Distal convoluted tubule: secretes potassium, hydrogen ions, and ammonia; reabsorbs H2O (regulated by ADH); reabsorbs bicarbonate; regulates calcium and phosphate concentrations by parathyroid hormone, regulation of sodium and potassium by aldosterone. • Collecting ducts: receive urine from distal convoluted tubules and reabsorb water (ADH required). Normal adults produces 1 liter/day of urine; 1% excreted as urine. Urinalysis Findings Specific gravity: (1.003-1.030); specific gravity of morning urine specimen reflects maximum concentrating ability of kidney and is 1.025-1.030. Low specific gravity indicates dilute urine and possibly excessive diuresis. High specific gravity indicates dehydration. If it becomes fixed at about 1.010, this indicates renal inability to concentrate urine, suggesting that kidneys are progressing to end-stage renal disease. Protein: (0-150mg/24 hr or 0-18 mg/dl); persistent proteinuria is characteristic of acute or chronic renal disease, especially involving glomeruli. In absence of disease, positive reading may be caused by high-protein diet, strenuous exercise, dehydration, fever, or emotional stress.
Creatinine Clearance: determines amount of creatinine (waste product of protein breakdown) in urine over 24 hours, measures overall renal function • 24 hour urine specimen (preferred method of creatinine clearance test) o Discard first void o Collect all subsequent urine specimens for 24 hours o If specimen is accidentally discarded, the test must be restarted o Record exact start and finish of collection; include date and time
Blood Studies Potassium: kidneys are responsible for excreting majority of body’s potassium. In renal disease, K+ determinations are critical because K+ is one of the first electrolytes to become abnormal. Elevated K+ levels of > 6 mEq/L can lead to muscle weakness and fatal cardiac arrhythmias. A normal finding is 3.5-5.5 mEq/L. Calcium: is main mineral in bone and aids in muscle contraction, neurotransmission, and clotting. In renal disease, decreased reabsorption of calcium leads to renal osteodystrophy. A normal finding is 9-11 mg/dl. Phosphorus: inversely related to calcium. In renal disease, phosphorus levels are elevated because the kidney is the primary excretory organ. A normal finding is 2.8-4.5 mg/dl. Bicarbonate: most patients in renal failure have metabolic acidosis and low serum HCO3- levels. Normal finding is 20-30 mEq/L. Diagnostic Studies Intravenous pyelogram (IVP) • Fluoroscopic visualization of the urinary tract after injection with radiopaque dye • Nursing care: pretest o Assess for iodine allergy and anaphylactic reaction o Inform patient that procedure involves lying on table and having serial x-rays taken o Administer cathartic or enema the night before o Keep patient NPO for 8 hours • Nursing care: posttest – force fluids (if permitted) Cystoscopy • Use of a lighted scope to inspect the bladder • May be used to remove tumors, stones, or other foreign objects or to implant radium, place catheters in ureters • Nursing care: pretest o Explain to client procedure will be done under general or local anesthesia o Confirm consent form has been signed o Force fluids or give IV fluids if general anesthesia is to be used o General anesthesia: keep patient NPO o Local anesthesia: offer liquid breakfast o Give enema as ordered • Nursing care: posttest o Do not let patient walk alone immediately after procedure because orthostatic hypotension may occur o Monitor I&O and vital signs o Expect mild hematuria at first; urine will be pink tinged, subsiding over 24-48 hours; monitor for large clots o Advise patient that burning on urination and urinary frequency is normal and will subside o Provide warm sitz bath, mild analgesia as ordered to relieve discomfort
Nephrostomy Tubes • catheter inserted on a temporary basis to preserve renal function when a complete obstruction of the ureter is present – removes calculi • inserted directly into renal pelvis • attached to connecting tube for closed drainage • catheter should never be clamped • if c/o excessive pain or drainage – check catheter for patency • if irrigation is ordered – aseptic technique; no more than 5 ml of sterile saline gently instilled at one time to prevent over distention of the kidney pelvis and renal damage • complications: infection and secondary stone formation Nephrectomy: removal of entire kidney • Nursing Interventions o Preoperative: avoid nephrotoxic agents in any diagnostic tests advise client to expect flank pain after surgery o Postoperative: assess urine output every hour ensure adequate ventilation teach client to splint incision while turning, coughing, deep breathing adequate medication management, especially when T, C, DB encourage early ambulation D/C teaching: prevention of urinary stasis maintenance of acidic urine avoidance of activities that may injure remaining kidney no lifting heavy objects for at least 6 months report weight gain, decreased UO, flank pain, hematuria report if development of cold or infection last > 3 days
Acute and Chronic Renal Failure: Chapter 45 Acute Renal Failure Sudden inability of the kidneys to regulate fluid and electrolyte balance and remove toxic products from the body. Accumulation of waste materials – build up of creatinine Azotemia – retention of nitrogenous wastes – esp. urea Uremia – azotemia progresses to signs and symptoms Reversible if problem that causes it is able to be corrected At Risk: elderly, vascular dx, renal dx, atherosclerosis, HTN Pathophysiology • Prerenal: factors interfering with perfusion and resulting in decreased blood flow and glomerular filtrate, ischemia, and oliguria; include CHF, cardiogenic shock, acute vasoconstriction, hemorrhage, burns, septicemia, hypotension; no renal tubular damage; unless ischemia is prolonged • Intrarenal: conditions that cause damage to the nephrons – problem with the filtering capabilities includes: acute tubular necrosis (ATN), endocarditis, diabetes mellitus, malignant HTN, acute glomerulonephritis, tumors, blood transfusion reactions, hypercalcemia, and nephrotoxins. o prolonged prerenal ischemia o parenchyma damage • Postrenal: obstruction of urine outflow anywhere from the tubules to the urethra; include calculi, BPH, tumors, strictures, blood clots, and trauma o impaired kidney function o almost always treatable before permanent kidney damage occurs
Clinical Course • Oliguric phase (caused by reduction in glomerular filtration rate); inability to excrete waste – no damage to renal tissue o duration 1-2 weeks o manifestations are changes in urinary output, fluid and electrolyte abnormalities, and uremia
urinary changes ♦ oliguria: urine output < 400 ml/24 hrs ♦ urinalysis: casts, RBC, WBC, fixed specific gravity (1.010), and urine osmolality at about 300 ♦ proteinuria – glomerular membrane dysfunction fluid volume excess ♦ decreased output – fluid retention occurs ♦ edema – weight gain approx. 20-30 lbs ♦ development of HTN Metabolic acidosis: kidneys cannot synthesis ammonia, which is needed for hydrogen excretion, or excrete acid products of metabolism. Bicarb gets all used up due to buffering hydrogen ions; kussmauls resp. ♦ uremic syndrome: n/v, anorexia, diarrhea, hiccups ♦ high specific gravity ♦ lethargy and stupor will occur if not treated Sodium balance ♦ hyponatremia: dilutional (pseudo-hyponatremia) ♦ damage tubules cannot conserve sodium – increased excretion through urine ♦ avoid excessive intake of sodium – may lead to volume expansion, HTN, and CHF ♦ uncontrolled hyponatremia or water excess – may lead to cerebral edema Potassium excess ♦ Hyperkalemia ♦ results in impaired ability of kidneys to excrete K+ ♦ massive trauma – damage cells release additional K+ in extracellular fluid ♦ acidosis worsens hyperkalemia as hydrogen enters the cells and K+ is driven out of cells into extracellular fluid ♦ immediate attention if rise > 6 mEq/L (fatal arrhythmias) Hematological disorders ♦ anemia – impaired erythropoietin production ♦ platelet abnormalties – risk for bleeding ♦ altered WBC – immunodeficiency – infections (major cause of death) Calcium deficit and phosphate excess ♦ results from decreased GI absorption of Ca+. ♦ Vit. D must be present to absorb Ca+ - only functioning kidneys can activate vit. D ♦ when hypocalcemia occurs parathyroid gland stimulates bone demineralization – releases Ca+ from bones – phosphate is released as well – decreased excretion from kidneys – results in hyperphosphatemia. Diuretic phase (slow, gradual increase in daily urine output) Nephrons not fully functional diuresis caused by osmotic diuresis from the high urea concentration – inability of tubules to concentrate urine; however kidneys have recovered ability to excrete
1-3 L/day but can reach 3-5 L or more/day Fluid may be very clear, may look like water At risk for hypovolemia, hyponatremia, hypokalemia BUN/Creatinine remains elevated near end of phase all imbalances slowly starts to normalize Recovery phase: renal function stabilizes with gradual improvement over next 3-12 mo. begins when GFR increases, concentrating ability improves kidneys are able to excrete and concentrate the urine
Collaborative Care: primary goals – eliminate cause, manage signs and symptoms, and prevent complications o First step: assess adequate intravascular volume and CO to ensure adequate perfusion to the kidneys. o Diuretic therapy often admin. with volume expanders to prevent fluid overload o General trend is to initiate early and frequent dialysis to minimize symptoms and prevent complications. o Restrict volume during the oliguric phase o Replace volume during the diuretic phase o Lower K+ levels Give regular insulin IV: K+ moves into cells when insulin is given. Glucose is given concurrently to prevent hypoglycemia. When affects of insulin diminish, K+ shifts back out of cells; or give 10% Calcium gluconate IV Na+ Bicarb: Therapy can correct acidosis and cause shift of K+ into cells. Calcium gluconate IV: given because of cardiac toxicity. Calcium raises the threshold for excitation, resulting in arrhythmias. Kayexalate PO or enema cation-exchange when resin is in bowel, K+ is exchanged for Na+ therapy removes 1 mEq of K+ per gram of drug It is mixed in water with sorbitol to produce osmotic diarrhea, allowing for evacuation of K+ rich stool from body may causes diarrhea – never give with paralytic ileus contraindicated in dehydrated patient Ace Inhibitors: decrease proteinuria and delay progression of renal failure (must be used cautiously in ESRD – can further decrease GFR and increase K+ levels Dialysis volume overload elevated K+ levels with EKG changes - hemodialysis can bring K+ levels to normal within 30 min. – 2 hrs. metabolic acidosis – bicarb < 15 mEq BUN > 120 significant changes in mental status pericarditis, pericardial effusion, or cardiac tamponade Continuous renal replacement therapy (CRRT) ♦ alternative or adjunctive method for treating ARF ♦ solutes and large volume of fluid removed slowly and continuously from hemodynamically unstable patient. ♦ contraindicated in: life-threatening manifestations of uremia (hyperkalemia, pericarditis) that require rapid resolution ♦ can be used in conjunction with HD for continuous fluid removal ♦ CRRT features that are different for HD
continuous rather than intermittent; large volumes can be removed over days versus hours solute removal can occur by convection (no dialysate required) in addition to osmosis and diffusion causes less hemodynamic instability (hypotension) does not require constant monitoring by a specialized HD nurse but does require a trained intensive care nurse does not require complicated HD equipment, but a modified blood pump is required filtrate changed every 24-48 hrs (loss of efficiency or clotting) ultrafiltrate should be clear yellow if ultrafiltrate becomes bloody or blood-tinged suspect rupture in filtrate membrane – stop treatment to prevent blood loss and infection monitor fluid and electrolyte balance hourly I&Os and daily weights hourly VS and hemodynamic status Nursing Management o Assessment Neuro – lethargy, altered memory Cardiac – at risk for fluid overload, assess heart sounds, watch BP – increase or decrease depending on what stage of failure, watch for arrhythmias Resp – kussmauls respirations (trying to blow off CO2), depending on stage at risk for fluid overload leading to pulmonary edema, pulmonary effusion GI – n/v, anorexia, diarrhea, hiccups GU – decreased UO in oliguria phase, increased and diluted in diuretic phase Labs – monitor closely o Implementation Maintain fluids and electrolytes balance during the oliguric and diuretic phases Accurate and Strict I&Os Daily weights – same time, same scale each day (1 kg is equivalent to 1000 ml of fluid) Monitor for infection Admin. humidified O2 Cough, turn, deep breath; incentive spirometry to prevent respiratory complications Skin care – risk – breakdown; bathe with tepid water and oils to reduce dryness and itching Mouth care – prevent stomatitis o Nutrition: primary goals are to control HTN, minimize edema, decrease urinary albumin losses, prevent protein malnutrition and muscle catabolism, supply adequate energy, and slow progression of renal disease High calorie, low protein, low K+ diet if dialysis is not used for treatment, 0.6 g of protein per kg body weight (but not less than 40 g/day. during oliguric stage, sodium may be restricted to 1000 to 2000 mg and K+ to 1000 mg/day o Patient teaching diet nephrotoxic drugs Chronic Renal Failure Progressive, irreversible destruction of the kidneys that continues until nephrons are replaced by scar tissue; loss of renal function gradual Before ESRD, management focuses on slowing the progression of CRF and avoiding complications. ESRD, management centers on reducing uremia by the use of various treatment modalities: conservative management, hemodialysis, peritoneal dialysis, and renal transplant. •
Predisposing factors: recurrent infections, exacerbations of nephritis, urinary tract obstructions, diabetes mellitus, HTN Uremia is a syndrome that incorporates all signs and symptoms seen in chronic kidney disease Clinical Findings • lethargy, drowsiness, HA, nausea, pruritus • oliguria, anuria, vomiting, anemia, HTN, anasarca, uremic frost • decreased serum Ca+ and pH (metabolic acidosis) • increased serum phosphate and potassium • x-ray reveals renal osteodystrophy • kussmaul respirations, mental clouding, convulsions, coma, death
Therapeutic Interventions • conservative therapy is attempted before maintenance dialysis begins • goals of conservative therapy preserve existing renal function treat clinical manifestations prevent complications provide comfort • Fluid and Na+ restrictions • Medications Sodium Bicarb o treatment of metabolic acidosis (severe) o current standard is to give only after adequate ventilation, chest compressions, IV fluids and drug therapy fail to correct acidotic state o when administering monitor ABG – can lead to metabolic alkolosis o do not administer epi/norepinephrine and dopamine in same site as HCO3- because they are inactivated by solutions containing HCO3 Antihypertensive medications – delays progression by controlling HTN Epogen o to manage anemia secondary to renal failure, HIV, cancer o increases production of RBC o if receiving dialysis may require increased heparin to prevent clotting at connection sites o side effects senses of well being nausea/diarrhea hypertension clots arthralgias (joint pain) fatigue/weakness/dizziness injection site discomfort o Administration of epogen do not shake – may denature the glycoprotein causing inactivation use one dose per vial – do not reenter vial – discard left over – no preservatives use 1 ml or less per injection to decrease injection site discomfort Lasix – to treat fluid retention caused by renal dysfunction iron supplements – to correct anemia – do not give to phosphate binders because calcium binds to iron Folic acid 1 mg daily usually given – needed for RBC formation – removed by dialysis; if not replaced through diet or medications megaloblastic anemia may occur NSAIDs causes vasodilatin – worsens renal hypoperfusion – acetaminophen instead
Dietary management o Dietary modifications should be initiated as early as possible to minimize uremic toxicity, delay progression of renal disease, and prevent wasting and malnutrition. o Very low protein (20 grams); minimal essential amino acids makes body use its own excess urea nitrogen to synthesize the nonessential amino acids need for tissue protein production – slows progression of renal failure o magnesium containing acids: maalox, Mylanta; MOM should not be given because risk for hypermagnesium; magnesium is dependent on the kidneys for excretion o Low-phosphate - restricted to < 1000 mg/day – slows progression of renal failure calcium carbonate: calcium phosphate binders (tums and PhosLo) are used to bind phosphate, which is secreted through stool given with meals for effectiveness because most phosphate is absorbed within 1 hr after eating. causes constipation aluminum hydroxide (Amphojel, Alu-tab): lowers phosphate levels in patients with chronic renal failure – binds phosphate in GI tract o Fluid allowance conservative management and hemodialysis: urine output + 600 ml (insensible loss) peritoneal: often no restrictions o High-potassium foods Apricots Avocado Banana Cantaloupe Carrots, raw Dried beans, peas Dried fruits Melons
Oranges, orange juice Peanuts (also high in Na+) Potatoes, white and sweet Prune juice Spinach Tomatoes, tomato juice, tomato sauce Winter squash
Peritoneal Dialysis o dialyzing solution is introduced via a tenchoff catheter inserted in the peritoneal cavity; the peritoneal membrane is used as a dialyzing membrane to remove toxic substances, metabolic wastes and excess fluid; Dextrose is used as an osmotic agent in PD o Types CAPD: without machine by patient; involves approx. 3-4 exchanges/day, 7 days/wk CCPP: mechanical cycler – more nightly exchange during sleep NIPD: mechanical cycler – only nightly exchanges o warm solution to body temperature o assess VS before and every 15 min during first exchange, and every hour thereafter o have client void o Strict asepsis: wash hands 3 times, masks o monitor for signs of respiratory distress and peritonitis; reposition to promote drainage from abdomen; drain abdomen if respiratory distress occurs o inflow: allow solution to flow unrestricted into peritoneal cavity for prescribed period (10-20 min). o dwell: allow solution to remain in peritoneal cavity for prescribed period (30-45 min). o drain: unclamp outflow tube and allow to flow by gravity o Nitroglycerin, antihypertensive, and sedatives are withheld – hypotension episode o Dietary Management objective of nutritional therapy are to maintain good nutrition status while replacing albumin lost in the dialysate, minimize complications of fluid imbalance, minimize
symptoms of uremic toxicity and minimize metabolic disorders secondary to ESRD and peritoneal dialysis. higher protein recommended Hemoglobin, serum albumin, urea, and total serum protein – indicators for sufficient protein intake – values declines suddenly when protein intake decreases or when there is excessive loss during peritonitis Phosphorus restriction critical to prevent development of osteodystrophy Precautions diabetes – absorption of glucose for the PD dialysate blood glucose and hyperlipidemia are more difficult to control weight gain caused by the Kcalorie load of the dialysate dehydration – caused by excessive fluid removal and extracellular fluid deficits careful monitoring of blood glucose, I&Os, and weight are preventive measures o Complications back problems: extra wt. from dialysate Respiratory problems: fluids pushing on diaphragm fistulas peritonitis observe characteristics of dialysate outflow o clear pale yellow: normal o cloudy: infection, peritonitis: abd. pain and distention, diarrhea, vomiting, fever o brownish: bowel perforation o bloody: common during first few exchanges; abnormal if continues Hemodialysis: the client is attached (via a surgically created arteriovenous fistula or graft) to a machine that pumps the blood along a semi-permeable membrane; dialyzing solution is on the other side of the membrane and osmosis and/or diffusion of waste, toxins and fluid from the client occurs Assessment • data r/t urinary elimination patterns; urine color, consistency, odor, and amount • neurologic status including attention span, weakness, and neuropathies • breath – ammonia odor • skin – uremic frost or urochromatic pigmentation (bronze) • Mouth care/altered taste brush teeth 6-8 times/day rinse mouth with chilled mouthwash (commercial product or water mixed with lemon juice or vinegar) eat sour-ball candy chew gum before meals drink water with lemon or eat a small amount of sherbet or fruit sorbet When patient develop changes in taste, foods with sharp, distinct flavors may be useful in stimulating appetite • emotional status of client and family • Dietary Management phosphorus restricted – high levels of serum phosphate contributes to secondary hyperparathyroidism and raise the calcium-phosphorus product in plasma. foods high in phosphate are usually limited or avoided milk/milk products, cheese beef liver chocholate nuts/legumes The active form of vit. D is available in oral form (Rocaltrol) or IV form (Calcijex), which is given during hemodialysis Epogen can be given during dialysis (by IV) or SQ just after dialysis treatment. Oral or IV iron supplements is often necessary before administration of Epogen to replenish iron stores
Nursing Management o weigh before and after procedure with all types of dialysis o take VS before and after and q 15 min. during the procedure; assess for hypotension and hemorrhage (heparin) o withhold antihypertensives, sedatives, and vasodilators to prevent hypotension (unless ordered otherwise) o Monitor sites o Vas Cath – temporary o Graft or AV Fistula Fistula ♦ anastomosed artery and vein ♦ needs 6-8 weeks to heal before use ♦ last longer than graft and less clot formation Graft ♦ artificial ♦ less time required before use for both types: watch site for clotting; check clotting time and administer heparin as prescribed; monitor for patency of internal fistula between treatments by palpating of internal fistula by palpating for a thrill and auscultating for a bruit avoid venipucture, IV, BP on shunt arm if site occludes – notify MD (may use thrombolytic if clotted
assess for complications Hypotension – results from rapid fluid removal (hypovolemia), decreased CO, and decreased SVR; may precipitate light headedness, n/v, seizures, vision changes, and chest pain – treatment: decrease volume of fluid being removed and infuse NS (100-300 ml) Muscle cramps – result from rapid removal of Na+ and water – treatment: reducing ultrafiltration rate and infusing hypertonic saline or NS bolus Loss of blood – blood not being completely rinsed from the dialyzer, accidental separation of blood tubing, dialysis membrane rupture, or bleeding after removal of needles at the end of dialysis; postdialysis – significant risk due to admin. of heparin Hepatitis (C)/Sepsis – the lack of adherence to precautions used to prevent infection Dialysis disequilibrium syndrome – rapid changes in composition of extracellular fluid (urea, sodium, and other solutes is removed more quickly from the blood than from cerebral spinal fluid and the brain) – causes cerebral edema: assess for nausea, vomiting, headache, elevated BP, disorientation, leg cramps, seizures and peripheral paresthesias – treatment: slowing or stopping dialysis and infusing hypertonic solution, albumin, or mannitol to draw fluid from the brain cells back into the systemic circulation – preventative measures: first dialysis treatment purposely short with limited total solute removal – most commonly occurs when BUN is high Mannitol ♦ osmotic diuretic ♦ treatment of cerebral edema and ICP ♦ action: inhibits reabsoption of electrolytes and water by affecting pressure of glomerular filtrate ♦ side effects: hypo/hypernatremia, hypo/hyperkalemia, dehydration, dry mouth, blurred vision ♦ highly irritating to veins ♦ held when serum osmolality exceeds 310-320
♦ indications for nurses • use filter needle – crystals may form in solution and syringe and thus be inadvertently injected • after drawing up medication, new filter must be used to inject medication • carefully assess neuro status, monitor lab studies – including serum osmolality; accurate I&O (substantial diuresis) • Kidney Transplant o human leukocyte antigen (HLA) test and tissue and blood typing are done to decrease risk of rejection; least risk of rejection occurs if donor and recipient are identical twins. o client’s own kidney is not removed unless it is infected or enlarged; new kidney is placed generally in the iliac fossa retroperitoneal and the donors ureter is attached to the bladder to prevent reflux of urine. o steroids and immunosuppressives (azathioprine/Imuran) Nursing Management o prepare client and family emotionally for possible outcomes of surgery o maintain patency of drainage tubes, including foley; gross hematuria or clots are not expected post-op o monitor fluid and electrolyte balance; initial output is increased because of Na+ diuresis; sharp decrease may signal rejection o monitor wt. and VS, particularly temp; isolation may be necessary to prevent infection o observe s/s of opportunistic infection; teach client need to prevent infection by avoiding crowds and using aseptic technique
administer steroids and immunosuppressants as ordered to prevent rejection Cyclosporine (Sandimmune): does not cause significant bone marrow depression; assess for HTN; blood chemistry alterations (hypermagnesemia, hyperkalemia, decreased sodium bicarb); neruologic functioning Azathioprine (Imuran): assess for manifestations of anemia, leucopenia, thrombocytopenia, oral lesions Cyclophosphamide (Cytoxan): assess for alopecia, HTN, kidney/liver toxicity, leucopenia Antilymphocytic globulin (ALG), antithymocytic globulin (ATG): assess for fever, chills, anaphylactic shock, HTN, rash, headache Corticosteroids (prednisone, solu-medrol: asses for peptic ulcer and GI bleeding, sodium/water retention, muscle weakness, delayed healing, mood alterations, hyperglycemia, and acne. observe for and teach client signs of rejection: malaise, fever, flank pain or tenderness, decreasing UO, sudden weight gain, increasing BP; serum creatinine will increase and decrease in creatinine clearance Dietary Management Kcalories high posttransplant period – stress from surgery and catabolism Glucose intolerance – steroid therapy resumption of activity and avoidance of contact sports in which the transplanted kidney may be injured
Chapter 15: Cancer Cancer- a group of more than 200 diseases characterized by uncontrolled and unregulated growth of cells. It is the second most common cause of death in the United States. Altered Cell Growth and Proliferation • normal tissue contains large # of mature cells of uniform size and shape • during development cells undergo differentiation in size, appearance and arrangement • cell proliferation starts with a stem cell that enters the cell cycle and divides into 2 identical cells • these cells function and the die; abnormal changes in cell growth can be malignant or benign Altered Cell Growth (benign) • benign neoplasm involve cellular proliferation and mature cells • grows slowly, but orderly and don’t invade surrounding tissue • can cause harm through pressure on vital structures • benign tumors remain localized, do not metastasize or spread and don’t reoccur when removed Altered Cell Growth (malignant) • malignant cells – basic structure and activity – deranged • causes are poorly understood; normal restraints on growth are defective • cell proliferates out of control • rate of growth varies depending on the type of cell Development of Cancer • initiation- mutation in the cell’s genetic structure resulting from an inherited mutation, an error that occurs during DNA replication, or following exposure to a carcinogen (chemical, radiation, or viral agent.) • promotion- characterized by the reversible proliferation of the altered cell.
promoting factors include o dietary fat, obesity o cigarette smoking o alcohol consumption o prolonged severe stress. progression- characterized increased growth rate of the tumor, as well as increased invasiveness and metastasis. (clinical evidence) metastasis- spread from primary site to distant site tumor angiogenesis- formation of blood vessels within the tumor itself.
Classification of Cancer • carcinomas- originate from ectoderm (skin and glands) and endoderm (mucous membrane lining from respiratory tract GI, and GU tract.) • sarcomas- originate from mesoderm (connective tissue, muscle, bone, and fat.) • lymphomas and leukemias- originate from the hematopoietic system • Histological grading of tumors Grade I- cells differ slightly from normal cells (mild dysplasia) and are well differentiated. Grade II- cells are more abnormal (moderate dysplasia) and moderately differentiated. Grade III- cells are very abnormal (severe dysplasia) and poorly differentiated. Grade IV- cells are immature and primitive (anaplasia) and undifferentiated; cells of origin is difficult to determine. Clinical staging • Stage 0- cancer in situ Stage I- tumor limited to the tissue of origin; localized tumor growth Stage II- limited local spread Stage III- extensive local and regional spread Stage IV- metastasis
TNM classification- used to determine the extent of the disease process of cancer according to three parameters: T- Tumor size N- Degree of regional spread to the lymph nodes M- Metastasis
Prevention of Cancer primary prevention- exercise, well balance diet, avoid exposure to carcinogens. secondary prevention- screenings; pap smear, mammogram, sigmoidoscopy, and rectal exam tertiary prevention- after diagnosis Warning Signs of Cancer C- change in bowel or bladder A- sore that does not heal U- unusual bleeding or discharge from any body orifice T- thickening or a lump in the breast or elsewhere I- indigestion or difficulty swallowing O- obvious change in wart or mole N- nagging cough or hoarseness Treatment Goals
cure control palliation
Types of Treatment Surgery- cancer that arise from tissue with slow rate and proliferation or replication is the most amenable to surgical treatment. Radiation- local treatment modality for cancer. • external- external beam radiation; exposure to radiation from a treatment machine. • internal- brachytherapy; “close” treatment and consists of the implantation or insertion of radioactive materials directly into the tumor or in close proximity to the tumor. cautions: time, distance, shielding organize care to minimize exposure time; greater the distance away from subject the less exposure • side effects of radiation fatigue – (most common), teach energy conservation, explain fatigue is expected anorexia – weigh constantly, diet – increase protein increase calories bone marrow suppression – myelosuppression, affects WBC, RBC, platelets – risks for infection, anemia, bleeding – monitor labs frequently skin reactions – erythema, wet desquamation, and dry desquamation o for wet desquamation – results in discomfort and drainage; must be kept clean, dry and protected from further damage. Prevention of infection and facilitation of wound healing are therapeutic goals. o for dry reactions- uncomfortable and results in pruritus; lubricated with a nonirritating lotion or solution that contains no metal, alcohol, perfume, or additives that can irritate the skin. o protect skin from extreme temperatures to prevent trauma o no heating pads, ice packets or hot water bottles o Avoid constricting garments, rubbing, harsh chemicals, and deodorants. Chemotherapy • the use of chemicals as a systemic therapy • primary therapy for leukemia and lymphomas • drugs create changes in cell cycle phases; interrupt cell growth and replication • methods of administrations oral and intravenous routes are most common IV concern: vesicants – tissue breakdown and necrosis – always get blood return before using IV site to admin. chemo agents that when accidentally infiltrated into the skin cause severe local tissue breakdown and necrosis. o S/S of infiltration- pain, swelling, redness, and presence of vesicles on the skin. o administered by means of a central vascular access device indicated in instances of limited vascular access, intensive chemotherapy, continuous infusion of vesicant agents, projected long-term need for vascular access. • side effects N/V (most common) fatigue, anorexia bone marrow suppression – monitor frequent blood counts – infection – risk for neutropenia – should be instructed to call with a temperature of 100.5 degrees F. or greater pancytopenia – reduction in all cellular elements of blood, WBCs, RBCs, platelets N/V/D – fluid and electrolyte imbalances, nutrition deficits, weakness, weight loss – use antiemetics 30-60 min before meals; teach them when the feel like eating to eat really well alopecia
skin problems – hperpigmentation , nail bed changes; photosensitivity cystitis – increase fluids – monitor renal function septicemia – life threatening to cancer patients – monitor labs Nursing Care stomatitis – cleanse mouth with plain water or dilute H2O2 after meals; can use baking soda solution (avoid commercial mouthwashes) assess knowledge – teaching r/t birth control – during treatment and up to 2 yrs after treatment sterility may occur – can do sperm banking malnutrition o protein and caloric malnutrition characterized by fat and muscle depletion. o high protein intake- milk, eggs, cheese, meat, poultry, and fish o high caloric intake- mayonnaise, butter, sour cream, peanut butter, jelly, ice cream, and honey o altered taste- avoid voids that are disliked, experiment with spices and seasonings to mask taste alterations
Oncologic Emergencies • obstructive caused by tumor obstruction of an organ or blood vessel superior vena cava syndrome: tumor is obstructing the superior vena cava; will see JVD, peripheral edema, periorbital edema, SOB, difficulty swallowing spinal cord compression syndrome: tumor in epidural space, s/s – weakness, lethargy, intense back pain, motor weakness, sensory loss; treated via radiation third space syndrome: shifting of fluid in vascular space to interstitial area (hypovolemic shock) – causes: pt undergoes extensive surgical procedure, septic shock intestinal obstruction; watch fluid and electrolyte balance carefully • metabolic caused by the production of ectopic hormones directly from the tumor or secondary to cancer treatment syndrome of inappropriate antidiuretic hormone (SIADS): certain types of cancer will act like ADH, cancer cells start to manufacture, store, release ADH causing fluid retention. S/S: extensive weight gain, anorexia, n/v, can lead to seizure and coma because of unregulated ADH – tx: fluid restrictions hypercalcemia: bone cancer – s/s: apathy, depression, fatigue, muscle weakness, EKG changes tumor lysis syndrome: triggered by chemo, which starts killing large # of cells all at once, end up seeing hyperphosphatemia, hyperkalemia, hypocalcemia septic shock, and DIC Infiltrative Emergencies • Cardiac Tamponade: pericardial sac has too much fluid, prevents heart from contracting, usually results from radiation to chest • Carotid Artery Rupture: seen with cancer of head or neck, results from surgery or radiation
Cancers of the Mouth, Throat, and Neck Head and Neck Cancer • squamous cell in origin • male to female ratio – 2:1 • 50 yrs or older • etiology: smoking and alcohol • Manifestations oral cavity o early: painless growth; ulcers, change in fit of dentures
o late: pain – may be aggravated by acidic foods oropharynx/larynx o early: asymptomatic o late: unilateral sore throat, otolgia (pain radiating to the ear), hoarseness, lump in throat, dysphagia, hemoptysis, wt loss, cough, blood tinged sputum, enlarged cervical lymph nodes • Dx Studies visual exam of mouth x-ray MRI laryngoscopy CT scan biopsy • Collaborative Care and Nursing Measures staging – TNM – tumor, nodes, metastasis radiation – external – curative or palliative; affects voice chemo – before or after surgery surgery o Laryngectomy – partial ♦ 2 types – hemelaryngectomy, superglotic ♦ allows preservation of voice ♦ vertical neck incision; ½ of larynx resected ♦ temporary cuffed trach post-op ♦ peri-op – NG inserted, Protect NG tube ♦ NG feeds x 1 week; risk for aspiration ♦ after NG removed, concern remains for aspiration – glottis edema o Laryngectomy – total ♦ advanced ca ♦ no voice post-op; permanent trach ♦ nutrition – initially TPN – advanced to enteral tube feedings ♦ Jackson-Pratt drain o Radical Neck Dissection ♦ remove metastasis ca; pre-op radiation ♦ remove nodes, IJ vein sternocleidomastoid muscle, spinal accessory nerve ♦ usually unilateral o Composite Resection ♦ radical neck dissection and tongue, mandible or floor of mouth Hemodynamics respiratory assessment IV fluids suctioning and trach care VS – frequent chest PT HOB – 30 degrees pain control: analgesics 30-60 min before meals avoid neck flexion evaluate communication measure drainage incision care and flap care reinforce dressing teach neck support and exercises after healing notify Dr. if drainage is frank or excessive Complications • airway • laryngeal edema • fibrosis of neck and larynx • esophageal stenosis • nutritional deficits • infection • fistula • carotid artery rupture – oncological emergency Post-op Nutrition
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IV fluids x 24 to 48 hrs NG feedings – observe tolerance and adjust amount, time, and formula if n/v, diarrhea, or distention occurs – swallowing returns give small amounts of water – suctioning may be needed due to prevent aspiration supraglottic swallow – minimizes risk for aspiration may be helpful to start with carbonated beverages – give cues to liquids position avoid thin watery fluids take deep breath to aerate lungs valsalva maneuver to approximate cords place food in mouth and swallow cough to remove food from top of vocal cords, then swallow breathe after cough-swallow sequence to prevent aspiration of food collected on top of vocal cords
Liver Cancer primary – hepatocellular carcinoma (associated with chronic liver disease, including Hepatitis B & C metastasize – lungs Clinical Manifestations • hepatomegaly, wt loss, peripheral edema, acites, portal HTN • dull abdominal pain in epigastric or right upper quad • jaundice, anorexia, n/v, and extreme weakness • pulmonary emboli Diagnostics • liver scan • CT, MRI • hepatic arteriography, endoscopic retrograde cholangiopancreatography (ERCP) • liver biopsy • AFP – hepatocellular carcinoma and helps distinguish primary ca from metastasis ca Collaborative Care and Nursing Measures • palliative • localized tumor – lobectomy • chemotherapy 5-fluorouracil (5-FU) leucovorin raltitrexed (Tomudex) experimental drugs chemoembolization: catheter placed in arteries to the tumor and an embolic agent is administered, often mixed with chemo agent – embolic agent reduces blood supply allowing greater exposure to liver cells to the chemo drugs nursing interventions o keep patient comfortable o Nutrition ♦ monitor wt; small frequent meals; give patient food preference ♦ oral care before meals – to remove foul taste and improve taste ♦ antiemetics Hepatic Encephalopathy (potential complication) • monitor for encephalopathy – orientation to time and place, speech, blood pH, and ammonia levels – liver unable to convert accumulating ammonia to urea for renal excretion • encourage fluids (if not restricted) and give laxatives and enemas as ordered to decrease production of ammonia • low protein – no protein diet as ordered (ammonia, break down product of protein) • high caloric intake (without complications) 3000/day; high carbohydrate and moderate to low fat
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low sodium diet – pt with acites and edema limit exercise – exercise produces ammonia as a by-product of metabolism lactulose – acid environment discourages bacterial growth - lactulose traps ammonia in gut and the laxative effect expels the ammonia from the colon
Acute Pancreatitis acute inflammatory process Signs and Symptoms • abdominal pain left upper quad or mid-epigastric pain radiating to back pain – severe, deep, piercing and steady; not relieved by vomiting aggravated by eating and onset when in recumbent position • n/v • low-grade fever • leukocytosis • hypotension, tachycardia • jaundice • bowel sounds decreased or absent Diagnostics: • Primary tests: serum amylase/lipase elevated; and urine amylase levels elevated • Secondary tests: blood glucose elevated, serum calcium decreased, serum triglycerides elevated Collaborative Care • Conservative Therapy aggressive hydration pain management management of metabolic complications minimizing pancreatic enzymes • Drug Therapy Demerol or Morphine nitroglycerin or papaverine – relaxes smooth muscles and pain relief antispasmodics (Bentyl) – decreases vagal stimulation, motility, pancreatic outflow (inhibition of volume and concentration of bicarb and enzymatic secretions); contraindicated in paralytic ileus • Nutritional Therapy NPO NG suction – to reduce vomiting, gastric distention and prevent gastric acid contents from entering the duodenum when food is allowed – small frequent feedings high in carbohydrates; bland with no stimulants Chronic Pancreatitis Progressive destruction of the pancreas with fibrotic replacement of pancreatic tissue Signs and Symptoms • pain – location same as acute pancreatitis except c/o heavy, gnawing feeling or something burning and cramp-like; not relieved with food or antacids • diabetes mellitus • malabsorption, wt. loss • steatorrhea (fatty stools)/foul smelling clay stools; constipation, dark urine • mild jaudice Diagnostics • secretin stimulation test which stimulates production of bicarb decreased secretions decreased bicarb concentration
Collaborative Care • identical to that of acute pancreatitis but may include pancreatic enzyme replacement and control of diabetes alcohol totally eliminated diet – bland; low in fat, high in carbohydrates pancreatic extracts given with meals or snacks; assess stools to see if effective if diabetes develop, it is controlled with insulin or oral hypoglycemics
Pancreatic Cancer adenocarcinomas Signs and Symptoms • abdominal pain (dull, aching); extreme, unrelenting pain • anorexia, rapid and progressive wt loss • nausea • jaundice Diagnostic Studies • Transabdominal ultrasound • CT • Tumor markers: CA19-9/CEA (less specific more relevant in colon cancer Collaborative Care • surgery (most effective) • radical pancreaticoduodenectomy or Whipple’s procedure resection of the proximal pancreas, the adjoining duodenum, distal portion of the stomach, and the distal segment of the common bile duct an anastomosis of the pancreatic duct, common bile duct, and stomach to the jejunum is done • radiation – pain relief Nursing Care: basically same as in acute/chronic pancreatitis • symptomatic and supportive care • medications and comfort measures to relieve pain – before peak of pain reached • psychologic support – essential, especially during times of anxiety and depression • helping patient and family through grieving process NOTE: one of the most important medical interventions to increase nutrient intake is pain control. Anticancer Drugs Alkyating Agents: Cytoxan • largest group of anticancer drugs • analogue of nitrogen mustard – prescribed orally and IV • kill cells by forming cross-links on DNA strands • used to treat breast, lung, ovarian cancers; Hodgkin’s; leukemias; and lymphomas; an immunosuppressant agent • Side Effects bone marrow suppression alopecia n/v, diarrhea, wt loss hematuria impotence, sterility, ovarian fibrosis headache, dizziness, dermatitis • Nursing Measures: well hydrated to prevent hemorrhagic cystitis (bleeding that results from severe bladder inflammation) Antimetabolics: Methotrexate
for treating solid tumors, sarcomas, choriocarcinoma, leukemia interferes with folic acid metabolism – result is inhibition of DNA synthesis and cell reproduction at higher doses clients should be well hydrated keep urine pH 7.0 for drug solubility for excretion higher does require use of leucovorin as a rescue for normal cells Side Effects arachnoiditis (IT use only): assess for nuchal rigidity, headache, fever, confusion, drowsiness, weakness, or seizures anorexia, n/v, stomatitis hepatotoxicity anemia, leucopenia, thrombocytopenia • Nursing Implementations injection preparation: biological cabnet – wear gloves, gown, and mask while handling assess for bleeding: avoid IM injections and rectal temperatures if platelet count is low assess for signs of infection during neutropenia encourage pt to drink at least 2 liters/day to decrease uric acid levels; allopurinol Anti-tumor Antibiotics: Adriamycin • therapeutic effects affects bleeding time Doxorubicin o to treat breast, bladder, ovarian, and lung cancers; leukemias; lymphomas o inhibits DNA and RNA synthesis; immunosuppressant activity Plicamycin o to correct hypercalcemia and hypercalciuria; to treat testicular carcinoma o inhibits hypercalcemia action of Vit. D and action by the parathyroid hormone; inhibits DNA and RNA synthesis • side effects doxorubicin and plicamycin: stomatitis, anorexia, n/v, diarrhea, rash doxorubicin: alopecia plicamycin: dizziness, weakness, headache, mental depression • Nursing Implementations avoid aspirin, anticoagulants, and thrombolytics cyclophosphamide with doxorubicin can increase chance of hemorrhagic cystitis Plant Alkaloids: Vinblastine (Velban) • treatment of cancer: testes, breast, and kidney; lymphomas, lymphosarcomas, and neuroblastomas • binds to protein of mitotic spindle, causing metaphase arrest – cell replication halted • side effects: n/v, alopecia
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Burns Etiology Burn – occurs when there is injury to the tissues of the body caused by heat, chemicals, electrical current, or radiation. Types of Burn Injury • Thermal: flame, flash burn, scalding, contact with hot objects (most common) • Chemical result of tissue injury and destruction from necrotizing substances acid (most common) alkali (most difficult to manage); adheres to tissue, causing protein hydrolysis and liquefaction – damage continues even when alkali is neutralized (ex. cleaning agents, drain cleaners, and lyes chlorine gas – inhaled – respiratory distress Tissue destruction may continue up to 72 hrs • Smoke and Inhalation: damage tissue of respiratory tract; redness and airway edema Types of smoke inhalation ♦ carbon monoxide poisoning o carbon monoxide and asphyxiation account for majority of deaths in fire victims o symptom – cherry red appearance Inhalation injury above glottis ♦ thermally produced ♦ inhalation of hot air, steam, or smoke ♦ symptoms: mucosal burns – redness, blisters, edema – mechanical obstruction ♦ clue: look for singed hair, facial burns, hoarseness, difficulty swallowing Inhalation injury below glottis ♦ chemically produced ♦ related to length of exposure to smoke, toxic fumes ♦ later symptoms 12-24 hrs – pulmonary edema, ARDS • Electrical burns intense heat from electrical current = coagulation necrosis severity depends on voltage, tissue resistance travel path of current, substantial length of current exposure Classification of Burn Injury Depth • Partial or full thickness burns Partial Thickness o Superficial (1st degree) ♦ depth: epidermis only ♦ causes: sun burn, quick heat flash, splashes of hot liquids ♦ sensation: painful ♦ characteristics: erythema, blanching on pressure, pain and mild swelling, no vesicles or blisters o Deep (2nd degree) ♦ depth: epidermis and dermis
♦ cause: flame, flash, scald, contact burns, chemical tar ♦ sensation: very painful ♦ characteristics: fluid filled vesicles that are red, shiny, wet (if vesicle has ruptured) Full Thickness o Third and fourth degree ♦ depth: all skin layers and nerve endings; may involvement of muscles, tendons, and bones ♦ cause: flame, scald, chemical, tar, electric current ♦ sensation: little or no pain ♦ characteristics: dry, waxy, white, leathery, or hard skin; visible thrombosed vessels Extent • Lund-Browder : determines extent of the burn injury by using client’s age in proportion in relative body-part size • Rule of Nines – body is divided into multiplications of 9 head and neck 9% each arm 18% each leg 18% trunk 36% genitalia 1% • Severity of burn Major: partial thickness > 25%; full thickness > or = 10% Moderate: partial thickness 15-25%; full thickness < 10% Minor: partial thickness < 15%; full thickness < 2% Location • Head, neck, and chest burns – at risk for pulmonary complications – mechanical obstruction – from edema or eschar formation • Arms and legs – can cause extremities to be contracted and not functional • Perineal – at higher risk for infection Patient Risk Factors • Elderly heals more slowly • preexisting cardiovascular, respiratory, or renal disease – poor prognosis r/t tremendous demands placed on body by a burn injury • DM, peripheral vascular disease – high risk for poor healing and gangrene, especially with foot and leg burns • General debilitation – alcoholism, drug abuse, and malnutrition – renders patient less competent to deal with a burn injury Phase of burn management • Pre Hospital Remove person away from source of burn; smother burn beginning with head Small thermal burn, < 10%, tx is cover with cool tap water cloth Large thermal burn – focus – ABCs o not advisable to immerse the burned body part in cool water – leads to extensive heat loss o don’t use ice – frost bite smoke inhalation
o ensure patent airway o 100% humidified O2 chemical: o remove from burning agent o remove clothing contained with chemical o lavage the affected area with copious amounts of water electrical: o note victim position, identify entry/exit routes (identifies organs involved) o maintain airway o wrap in dry, clean sheet or blanket to prevent further contamination of wound and provide warmth o assess how and when burn occurred o muscle contractions can fracture long bones and vertebrae o all patient with electrical burns should be considered at risk for potential cervical spine injury and immobilization should be used during transport o electrical shock can cause immediate cardiac standstill or fibrillation (CPR) o Risks ♦ cardiac arrest and arrhythmias (24-48 hrs after injury) monitor continuously ♦ severe metabolic acidosis – sodium bicarb ♦ myoglobinuria – can lead to acute renal tubular necrosis (ATN) ♦ treatment LR sufficient enough to maintain UO at 75-100 ml/hr until myoglobin and hemoglobin have been flushed from circulatory Osmotic diuretics – mannitol – maintain UO – along with sodium bicarb to alkalinize urine Emergent Phase (resuscitative) Plasma to interstitial fluid shifts causing hypovolemic shock Begin to see large fluid loss – loss of water, plasma proteins (albumin) – second and third spacing Insensible fluid loss (skin and respiratory) 200-400 ml/hr; (normal loss is 30-50 ml/hr) sodium – interstitial space – until edema ceases potassium shift – damage cells and hemolyzed RBC Clinical Manifestations o shock r/t pain and hypovolemia o blisters o shivering r/t chilling caused by heat loss, anxiety, or pain Complications o Cardiovascular ♦ arrhythmias, hypovolemic shock – irreversible shock ♦ compartment syndrome – escharotomy (scalpel incision through full thickness eschar) restores circulation ♦ sludging – adequate fluid replacement o Respiratory ♦ upper airway burns that cause edema formation and obstruction of airway ♦ inhalation injury – alveolar level secondary to chemical fumes or smoke
o Urinary ♦ ATN r/t hypovolemia – decreased blood flow to kidneys causing renal ischemia ♦ myoglobin and hemoglobin obstruction – adequate fluid replacement and diuretics Collaborative Management Preserve body function Prevent infection Restore skin integrity Provide support and comfort; restore patient to normal living pattern Emergent Phase Interventions o airway management ♦ early nasotracheal or endotracheal – eliminates necessity for emergency tracheostomy ♦ ventilator assistance with PEEP ♦ ABGs ♦ humidified O2 @ 100% r/t carbon dioxide poisoning ♦ high Fowler’s (unless spinal injury) ♦ prevention of pulmonary complications ♦ possible fiberoptic bronchoscopy to assess lower respiratory tract r/t smoke inhalation ♦ encourage cough, deep breath every hour; reposition Q 2 hrs o Fluid Therapy ♦ 2 IV lines – at least an 18, because of massive fluid resuscitation; usually instituted with burns > 15% TBSA ♦ Crystalloids – LR, 5% dextrose, and saline Isotonic solutions neutral; same osmolality (particles) of fluids ECF and ICF Need for isotonic solutions: ideally for a person who has a fluid ECF volume deficit; fluid or Na+ losses; hypovolemic shock; GI loss, surgical loss, burns Nursing interventions: monitor labs when giving 0.9% NaCl, may result in elevated Na+ and Cl levels ♦ Colloids – albumin, hespan, and dextran; beneficial when capillary permeability returns to normal or near normal ♦ Foley – strict I&Os, measuring adequacy of fluid resuscitation ♦ Weigh daily ♦ Brooke Formula ♦ Parkland Formula 4 ml LR/kg/TBSA burn = total fluid requirements for 1st 24 hrs after burn ½ of total in first 8 hrs ¼ of total in second 8 hrs ¼ of total in third 8 hrs example: 70 kg patient with a 50% TBSA burn: 4 ml x 70 kg x 50% TBSA = 14,000 ml ♦ Parameters for adequate fluid replacement
UO: 30-50 ml/hr in an adult; 75-100 ml/hr for electrical burn in an adult Cardiopulmonary: BP (systolic > 90-100), pulse rate (< 120), respiration (16-20); BP most appropriately measured by A-line; peripheral often invalid r/t vasoconstriction and edema Sensorium: alert and oriented x 3
o wound care ♦ delayed until patent airway, adequate circulation, and adequate fluid replacement have been established ♦ Prevent wound infection ♦ cleansing and debridement use hydrotherapy for no more than 30 min. to prevent electrolyte loss Travase ointment: enzymatic debrider to dissolve dead tissue Elase ointment This medication breaks up and helps remove dead skin and tissue to encourage healing of wounds. It is used to promote healing of wounds such as burns, ulcers, surgical wounds, circumcision or episiotomy. ♦ two types of wound treatment Open method: wound covered with topical antibiotic without drsg. Multiple dressing changes: sterile gauze drsg. impregnated with or laid over a topical antibiotic o Pharmacological ♦ Analgesics early postburn period • IV Morphine sulfate extraction from opium it can cause respiratory depression, orthostatic hypotension, urinary retention constipation antidote: narcan • IM injections will not be absorbed adequately in burned or edematous areas causing pooling of medications in tissues – when mobilization begins, inadvertently overdose • Medicate 30 min. before wound care ♦ Sedative – benzodiazepine: zanax, valium ♦ Tetanus – potential for wound contamination ♦ Antibiotics Aminoglycoside adverse reaction: mainly nephrotoxicity may decrease K+ and magnesium levels urine output should be at least 600 ml/day
check for hearing loss: ototoxiciy check that therapeutic drug monitoring (TDM) has been ordered for peak and trough drug levels Gentamicin is 5-10 – blood should be drawn 45-60 min after drug has been administered for peak levels and min before next drug dosing for trough levels. Drug peak values should be 10-12 and trough values should be 0.5-2 monitor s/s of superinfection: stomatitis, vaginitis, and/or genital itching
Cephalosporin bactericidal assess allergies (do not give any type or class if allergic) monitor s/s of superinfection: stomatitis, vaginitis, and/or genital itching advise to ingest buttermilk or yogurt to prevent superinfection instruct diabetic not to use Clinitest tablets for urine glucose testing because of false results; Tes-Tape or Clinistix may be used, or Chemstrip bG may be used for blood glucose testing. take with food if GI irritation occurs ♦ Antimicrobial – sulfamylan, bacitracin, bactiban, silvadene; topical as well as systemic silver nitrate (sulfamylan) anti-infective cream for second and third degree burns, particularly electrical burns possible pain on application provide daily baths for removal of previous applied cream handle carefully; solution leaves a gray or black stain on skin, clothing, and utensils keep drsg. wet with solution; dryness increases concentration and causes precipitation of silver salts in wound acid-base disturbance because it is a carbonic anhydrase inhibitor may cause electrolyte imbalance if used extensively (hypokalemia) silvadene cream antibiotic cream – prevent and treat infection of second and third degree burns painless applications- alleviates pain(cooling effect) and prevents drying observe for hypersensitivity reaction (sulfa) rash, itching, burning sensation in unburned area
excessive or extensive use may cause sulfa crystals (crystalluria) ♦ H2 blockers – tagamet, zantac; prevent stress ulcer tagamet has many drug interactions and side effects by inhibiting hepatic drug metabolism, it enhances effects of oral anticoagulants, theophylline, caffeine, dilantin, valium, inderal, Phenobarbital, and CCB zantac treatment of peptic ulcers, GERD, stress ulcer side effects: confusion, arrhythmias, hepatotoxicity, anemia contraindications: severe renal or liver disease administer with meals or immediately after and at HS; if dose is once daily administer at HS shake oral suspension ♦ Hespan Made from starch and acts as volume expander; is at least effective as albumin; can exert osmotic effect for up to 36 hours All types of shock Use cautiously in CHF, renal failure, or bleeding disorders (due to anticoagulant effect) ♦ Albumin Action: increase plasma colloid osmotic pressure; rapid volume expansion All types of shock except cardiogenic Monitor for circulatory overload Side Effects: chills, fever, and urticaria o Nutrition ♦ Fluid replacement takes first priority over nutrition in the initial emergent phase ♦ NG tube to low intermittent suction – paralytic ileus within few hours due to body’s response to major trauma ♦ After bowel sounds return 48-72 hrs after injury oral intake initiated with clear liquids progressing to high-calorie, high-protein, high carbohydrate diet with vitamin and mineral supplements. (5,000 kcal/day) ♦ failure to provide adequate calories and protein leads to malnutrition and delayed healing ♦ serve small meal portions ♦ not freely given water – rather calorie counting liquids ♦ early and continuous enteral feedings promotes optimal conditions for wound healing and immunocompetence Acute phase o mobilization of extracellular fluid and subsequent diuresis o Shock Phase (Hypovolemic shock); first 24-48 hrs dehydration decreased BP, increased pulse
decreased UO thirst o Clinical manifestations ♦ removed eschar – epithelialization begins at wound margins and appears red or pink scar tissue ♦ 10-14 days epithelial buds close in wounds without surgical intervention ♦ full thickness wounds require surgical debridement and skin grafting to speed healing process o Laboratory Values ♦ Sodium • hyponatremia – if hydrotherapy too long (>20-30 min) • hypotonicity of bath water pulls sodium from open burns • other causes: excessive GI drainage, diarrhea, and excessive water intake
dilutional hyponatremia – water intoxification – to avoid drink fluids other than water such as juice, soft drinks, or nutritional supplements • Signs and Symptoms weakness, fatigue, dizziness muscle cramps headache tachycardia confusion • hypernatremia – may occur following successful fluid replacement if copious amount of hypertonic solutions were required • other causes: improper tube feedings or improper fluid administration • Signs and Symptoms thirst dried, furry tongue lethargy, confusion possible seizures ♦ Potassium • Hyperkalemia – renal failure, adrenocortical insufficiency, or massive deep muscle injury • cardiac arrhythmias and ventricular failure • muscle weakness and EKG changes observed clinically • Hypokalemia – lengthy hydrotherapy • other causes: vomiting, diarrhea, prolonged GI suction, prolonged IV therapy without K+ supplement • Constant K+ losses occur through burn wound ♦ elevated Hct ♦ metabolic acidosis
o Complications ♦ Infection ♦ Cardiovascular • arrhythmias, hypovolemic shock – irreversible shock • compartment syndrome – escharotomy (scalpel incision through full thickness eschar) restores circulation • sludging – adequate fluid replacement ♦ Neurologic • disorientation • combative • hallucinations and frequent nightmare-like episodes • delirium (occurs often at night) ♦ Musculoskeletal • limited ROM • contractures (because of pain patient prefers flexed position for comfort) splinting beneficial ♦ Gastrointestinal • paralytic ileus – sepsis • diarrhea (most common) – supplemental feedings, antibiotics • constipation – side effect of narcotics, decreased mobility, and lowfiber diet • NG tube: to prevent/control Curling’s ulcer – stress (best treatment is prevention) antacids and H2 blockers: zantac, tagamet which inhibits histamine and stimulation of hydrochloric acid secretion (keeps gastric pH < 5) • Test stools for occult blood ♦ Endocrine • increase blood glucose – stress mediated cortisol and catecholamine release • increase in insulin production and release – insulin effectiveness decreased – insulin insensitivity – elevated blood glucose • hyperglycemia – increased caloric intake – supplemental insulin, not decreased feedings Diuretic Phase (2-5 days postburn) o interstitial fluid returns to the vascular compartment o elevated BP, increased UO o Labs ♦ hypokalemia ♦ hyponatremia ♦ metabolic acidosis Rehabilitation Phase o starts when diuresis is completed and wound healing and coverage begin and patient can resume level of self-care activities o dry, waxy-white appearance of full thickness burn changing to dark brown; wet shiny, and serous exudates in partial thickness o Complications
♦ Contractures – result of shortening of scar tissue in the flexor tissues of a joint ♦ Pain – patient prefers flexed position for comfort – positioning, splinting, and exercise to minimize complication – continue until skin matures o Labs: hyponatremia
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