Acute Biologic

Crisis
Congestive Heart Failure
Congestive Heart Failure
Left Side Heart Failure
Left Side
Heart
Failure
 Right
Side
Heart
Failure

Anasarca
 Right
Side
Heart
Failure

Ascites
 Right
Side
Heart
Failure

Ascites
Right Side
Heart
Failure

Peripheral
edema
Right Side Heart Failure
Jugular vein distention
Dysrhythmias
Dysrhythmias
Respiratory Failure
 Respiratory Failure
When The client can’t
eliminate CO2 fr. Alveoli

 CO2 retention
 Respiratory Failure
O2 is not absorbed by
alveoli

O2 level drops
CO2 > 45 mm Hg
Acute respiratory distress syndrome
 Causes Resp failure
Mechanical abnormality
in lungs or chest wall
Defect Resp control
center of brain
Severe Resp Infection
 ASSESSMENT
Alteration in breath sounds
Dyspnea

HA

Restlessness / confusion
Tachycardia

Cyanosis
 ASSESSMENT
 LOC

Dysrhythmias
 INTERVENTIONS
Identify
cause
Administer
O2
Mechanical
ventilator
 Renal Failure
Acute Renal Failure
Chronic Renal Failure
 Acute Renal Failure
Rapid onset of oliguria
(<400 ml /day) , with
severe rise in BUN &
creatinine
(Azotemia –
accumulation of nitrogen
in blood )
Causes of Acute Renal Failure

Pre-Renal Causes-
factors outside of
the kidney
 Causes of Acute Renal Failure

Pre-Renal Causes
Shock

Circulatory collapse

CVD

Hemorrhage

Severe vasoconstriction
 Causes of Acute Renal Failure

Intra-Renal Causes:
kidney diseases
Damage to kidney

Poisoning

Iron overload (BT)

Acute pyelonephritis
 Causes of Acute Renal Failure

Post-Renal Causes:
Obstruction in the
Urinary tract
Renal calculi

Prostatic tumor

Reproductive diseases
 Complications ARF
Hyperkalemia – most
dangerous
complication, may lead
to cardiac arrest if rise
in K+ is too fast
 Nursing Care ARF
Daily Weight
CVP monitoring

Diuretic as prescribed

Low protein, K,Na &

high carbohydrate diet
 Nursing Care ARF
Emergency mgt of
Hyper K : insulin &
dextrose , Kayexalate
enema
Chronic Renal failure
Chronic irreversible
progressive
reduction of
functioning renal
tissue
 Common causes CRF
Diabeticnephropathy
Hypertensive
nephropathy
Glomerulonephritis

Chronic pyelonephritis
 Stages CRF
1. Reduced Renal Reserve
high BUN no clinical
symptoms yet
2. Renal insufficiency- mild
Azotemia – impaired urine
concentration , nocturia
 Stages CRF
3. Renal failure – Severe
azotemia,
acidosis,concentrated
urine, severe anemia &
electrolyte imbalances
 Stages CRF
4. ESRD- Renal shutdown
severely decreased renal
function with clusters of
systemic symptoms
 CRF systemic SS
Hyper K, Hypernatremia,
Hypocalcemia
Anemia

Anorexia, nausea &

vomiting
 CRF systemic SS
Ammoniacal breath
Immunosuppression

HTN, CHF

Pulmonary edema

Severe pruritus

Peripheral neuropathy

Uremic amaurosis
 Nursing Care ESRD
Low Protein, Low Na
diet
Prepare client for
peritoneal /
hemodialysis
Monitor Anemia
 Nursing Care ESRD
Administer epoietin
alpha (Epogen),
diuretics,
antihypertensives as
prescribed
Kidney transplant
Peritoneal Dialysis
Peritoneal Dialysis
Hemodialysis
HEMODIALYSIS: Is the
diffusion of dissolved
particles from the blood
into the dialysate bath of
the hemodialysis machine
across the semipermeable
membrane of the
dialyzer.
Hemodialysis requires
vascular access:
Subclavian vein/ Femoral
vein (temporary)
Arteriovenous fistula,
arteriovenous shunt,/
arteriovenous graft
( Permanent)
Hemodialysis
Hemodialysis
Nursing Management:
Assess the integrity of
the hemodialysis access
site
Monitor VS

Assess client for fluid

overload
 Nursing Management:
Weigh the client before and
after the dialysis treatment
( to determine fluid loss)
Hold meds that can be
dialyzed off
Monitor for SS of Shock &
Disequilibrium syndrome
Complication: Disequilibrium
Syndrome – is the rapid
change in composition of
extracellular fluid where the
solutes of the blood are
removed from the blood faster
than that of the CSF, causing
osmotic movement of fluid into
the CSF causing cerebral
edema.
 Nursing Management:
Disequilibrium syndrome:
Assess for Nausea &
vomiting
Assess for headache

Restlessness, agitation &

or confusion
Watch out for seizures
 Nursing Management: Disequilibrium
syndrome:
Notify physician if SS of
disequlibrium syndrome
occurs
Reduce environmental
stimuli
 Dialyze the patient at a shorter
period and at a slower rate
Kidney Transplant
 The Nursing
process starts
with
ASSESSMENT
 Ang pitong
katotohanan ukol sa
Cranial Nerves
GCS atbp.
Assessment
1. Cranial Nerve II
Optic Nerve-=
Hindi lahat
nang nakikita
mo ay hindi iyo.
2. Upon Inspection
Hindi mo
kayang
bilangin ang
buhok mo.
3. Cranial nerve XII
Hypoglossal nerve
Hindi lahat nang
ngipin mo ay abot
nang dila mo.
4.Glasgow Coma Scale
Subukannang
mga tanga ang
pangatlong
assessment
 5. Human Error
Angpangatlo
ay mali
6. Cranial nerve VII
Facial nerve
Mapapangitika
kasi nagmukha
kang tanga
 7. Law of Karma
Ipasa mo ito sa
ibang
istudyante nang
OC para
makaganti ka.
 Burns

Celldestruction of
the layers of the skin
and resultant
depletion of fluid and
electrolytes
 Types of Burns
Thermal : exposure to flame
Chemical: exposure to
strong acids or alkali
Electrical: Caused by
electrical strong electrical
current results in internal
tissue injury
Burn Depth:
Superficial thickness burn (1st
degree)- mild to severe
erythema of skin, blanches
with pressure – heals in 3-7
days
Partial thickness burn(2nd
degree) – large blisters;
painful heals 2-3 weeks
Burn Depth:
Full thickness burns (3rd
degree) – white yellow
deep red to black (eschar)
disruption of blood flow, no
pain; scarring and wound
contractures will develop.
Grafting is required; healing
takes weeks to months
Burn Depth:
Deep full thickness burn(4th
degree) – Involves injury
to muscle and bone=
appears black(eschars) –
hard and inelastic healing
takes weeks to months;
grafts are required
 Nursing Diagnosis

Decreased Cardiac
output Related to
Fluid shifts
 Rule Of 9
Head and neck 9%
Anterior trunk 18%
( chest-9 abdomen-9)
Posterior trunk-18%
 Rule Of 9
Arms 9% each
(forearms only or
upper arms only
4.5%)
Legs – 18% each

Perineum-1%
Rule of 9
PARKLAND (BAXTER)
FORMULA FOR FLUID
REPLACEMENT
 4ml Lactated Ringer’s
sol x Kg body mass x
total percentage of body
surface burned
PARKLAND (BAXTER)
•1st 8 hours = ½ of total
24 hour fluid replacement
•next 8 hours = ¼ of
total
•last 8 hours= ¼ of total
A man Suffered from a 3rd degree burn
involving the head and neck, front of
the torso (chest & abdomen), and
whole left arm. Weight is 50 kg

Calculate the:
TBSA burned
24 hour fluid replacement in ml
1st 8 hours fluid replacement
2nd 8 hour
remaining 8 hour
TBSA:
Head & neck= 9%
front of torso = 18%
Whole left arm =
9%
TBSA burned 36%
24 hour replacement:
Parkland Baxter
formula
4mlX 50 kgs x (TBSA)36%

= 7200 ml
1st 8 hours :
7200 ml
2
= 3600 ml = 1st 8 hours
2nd 8 hours &
remaining 8 hours
respectively :
3600 ml
2
= 1800 ml = 2nd 8 hours
= 1800 ml = last 8 hours
MANAGEMENT OF BURNS:
Administer fluids as
prescribed
Maintain a high calorie, high
protein diet
Monitor intake and output

Monitor for infections of

burn site
 Burn Medications:
Nitrofurazone ( Furacin) –
broad spectrum antibiotic
ointment or cream – used
when bacterial resistance
to other drugs is a problem
: apply 1/16 inch thick film
directly to burn
 Burn Medications:
Mafenide ( Sulfamylon) –
water soluble cream
bacteriostatic gr + - bacteria-
apply 1/16 inch directly to
burn – notify physician if
hyperventilation occurs as this
drug may ppt. metabolic
acidosis.
 Burn Medications:
Silver Sulfadiazene
( Silvadene) – cream Broad
spectrum to gr+ - ; does not
cause metabolic acidosis – keep
burn covered at all times with
Sulfadiazine – (1/16 inch thick);
 Monitor CBC – causes leukopenia
 Burn Medications:
Silver Nitrate – Antiseptic
solution against gr-, dressings
are applied to the burn and
then kept moist with Silver
nitrate ; used on extensive
burns that may precipitate
fluid and electrolyte
imbalance.
LIVER CIRRHOSIS - A
chronic progressive
disease of the liver
characterized by diffused
damage to cells.
( Fibrosis & Nodule
formation) .
Types:
Laennec’s cirrhosis –
Alcohol induced
Postnecrotic c – massive
liver necrosis as a result of
viral hepatitis
LIVER BIOPSY –
Removal of a living
tissue sample for
analysis.
 Open biopsy- With
Abdominal Incision under
GA
 Closed biopsy – Needle
aspiration for histologic
study = performed under
local anesth.
Preprocedure care
closed / needle biopsy
– teach client to
refrain from taking
aspirin or NSAIDS
Post procedure needle
biopsy – position on
right sidelying during
initial 1-2 hours to
prevent hemorrhage and
bile leakage, give vit. K
if prescribed.
Complications of Cirrhosis –

 Portal HTN – as a result of

obstruction /hardening of liver
tissue inc in pressure in portal
vein
Ascites – as a result of portal
HTN – fluid accumulates in
abdomen
Complications of Cirrhosis –
Esophageal varices –
Fragile thin walled
distended veins in the
esophagus that is prone to
rupture
Coagulation defects –
decreased synthesis of bile
Dec. absorption of fat sol
vitamins ex. Vit.K
Nursing Diagnosis:
Fluid Volume Deficit rel to
hemorrhage ( bleeding
esophageal varices)
Risk of Injury rel to
change in level of
consciousness’
Liver Failure – ESLD-
inability of liver to
function – rise in
ammonia blood level,
leading to Hepatic
Coma.
 Nursing Interventions

Assessment
Main problem is
decreasing LOC bec of
accumulation of ammonia
Jaundice

Abdominal pain
Ascites

Spider angioma on nose

cheeks upper thorax and
shoulders
Hepatomegaly

Fetor hepaticus (fruity

breath)
Asterixis(flapping
tremors)- wrist &
fingers
Laboratories: inc in
Ammonia Level N=
ammonia 15-110 ug/dl
Asterixis(flapping
tremors)- wrist &
fingers
Laboratories: inc in
Ammonia Level N=
ammonia 15-110 ug/dl
 Nursing Interventions
Elevate Head of bed to min
DOB
Provide vitamins B
complex, A,DEK & C
Low protein diet as
prescribed to dec ammonia
production
 Nursing Interventions
Weigh & measure
abdominal girth daily
If IM drugs are
needed= use only
small gauge needles
& inject only when
needed
 Nursing Interventions
Esophageal varices -
Sengstaken –
Blakemore tube is
applied to stop
bleeding E varices) –
have scissors at the
bedside
 Nursing Interventions
Administer Lactulose as
prescribed ( dec. pH w/c dec
production of ammonia by the
bacteria & facilitates the
excretion of ammonia
Administer
Neomycin(Mycifradin)- inhibit
bacteria = dec production of
ammonia
 Nursing Interventions
Teach client to
avoid hepatotoxic
drugs
DKA( Diabetic
Ketoacidosis)
/ HHNS
( Hyperglycemic
Hyperosmolar
nonketotic Syndrome)
DKA- Is a life
threatening
complication of DM
type 1 = develops
bec of severe
insulin deficiency
MANIFESTATATIONS =
Hyperglycemia,
dehydration, electrolyte
loss and acidosis
CAUSE; Missed insulin
dose, or infection
HHNS- SIMILAR TO
dka WITH EXTTREME
hyperglycemia except
that in HHNS there is
no acidosis. This is for
DM type 2
ASSESSMENT:
Blood glucose – 300
– 800 mg/dl
Low bicarbonate &
low pH
Dehydration
ASSESSMENT:

Mental status
changes
Neurological deficits

Seizures
 NURSING DX:
Fluid Volume deficit Rt
hyperosmolar diuresis
Risk for injury RT
Mental status changes
NURSING INTERVENTION:

Administer Insulin IV
push 5-10 units 1st
then IV infusion
NURSING INTERVENTION:
Restore Fluids ( administer
fluids as prescribed)
–Treat dehydration w/ rapid
infusion of NSS or .45%
saline
–when blood glucose reaches
250-300 mg/dl D5NS, or D5
.45%Saline is used
NURSING INTERVENTION:
Always use infusion pump
for IV insulin
Monitor serum potassium (
initially as a result of
acidosis Hyperkalemia is
present upon admin of
insulin K+ level drops)
NURSING INTERVENTION:

Monitor LOC= too

rapid decrease in
blood glucose may
cause cerebral edema
ADDISON’S DISEASE
– Is the
hyposecretion of
adrenal cortex
hormones
ADDISONIAN CRISIS/
Acute Adrenal Insufficiency-
Is a life threatening disorder
caused by acute adrenal
insufficiency precipitated by
stress, infection, trauma or
surgery. Without appropriate
hormonal replacement it may
lead to shock.
ASSESSMENT:
Severe headache

Sudden Severe lower

leg & lower back pain
Generalized weakness

Shock
NURSING INTERVENTION addisonian
crisis:

Correct hypoglycemia
IV D5 glucose push
Prepare to administer
glucocorticoid IV
(Solucortef)
NURSING INTERVENTION addisonian
crisis:

Following crisis –
glucocorticoids orally
Monitor blood
pressure to assess for
shock
NURSING INTERVENTION addisonian
crisis:

Monitor LOC
Protect client from
infection
Monitor electrolyte
imbalances
THYROID CRISIS – (THROID
STORM/ Thyrotoxicosis)-
Acute life threatening condition
that occurs in a client with
uncontrollable hyperthyroidism
– maybe a result of
manipulation of thyroid gland
during surgery(release of
thyroid hormones to
bloodstream)
THYROID CRISIS –
(THROID STORM/
Thyrotoxicosis)-
Causes: Undiagnosed ,
untreated
hyperthyroidism,
infection, trauma
Medical management:
Antithyroid
medications; beta
blockers;
glucocorticoids &
iodides are given before
surgery to prevent
thyroid crisis
Medical management:
Antithyroid meds:
Iodide, Propylthiouracil,
Methimazole
Iodides/ Iodine = Reduce
the vascularity of the
thyroid gland before
thyroidectomy,
Medical management:
Iodides= used in the
treatment of thyroid
storm because it enables
the storage of TH in the
thyroid gland.
Medical management:

However it is given
only for 10-14 days

Because eventually it
looses its effect on
the thyroid gland.
NURSING
INTERVENTION:
ASSESSMENT : elevated
Temp ( high fever);
tachycardia; agitation;
tremors
Maintain a patent airway
NURSING INTERVENTION:

Administer
antithyroid meds as
prescribed ( sodium
iodide solution)
Monitor VS
MULTI ORGAN DYSFUNCTION
SYNDROME (MODS)
SEPSIS, DEAD TISSUE,
PNEUMONITIS, PANCREATITIS

RESPIRATORY FAILURE
INTUBATION (maybe stable
for 7-14 days)

MALFUNCTION of GI
SEEDING OF BACTERIA FR.
GI TO OTHER ORGANS

HYPERMETABOLIC
STATE
HYPERMETABOLIC STATE
(hyperglycemia, hyperlactacidemia,
ulceration in GI-
seeding of bacteria from GI to other
organs)
(skin breakdown, loss of muscle
mass, delayed healing of surgical
wounds)
(mortality rate 60%)
LIVER FAILURE(jaundice),
RENAL FAILURE
(mortality rate 90-100%)
Criteria for Dx of
MODS
 Cardiovascular Failure
presence of 1 or more of the ff:
<54 bpm
Systolic < 60 mm Hg

Vtach/ V fib

pH < 7.24

 Respiratory Failure

RR< 5/min
RR> 49/min
Renal Failure presence of 1 or
more of the ff:
Output < 479 ml/24 hr
or < 159 ml/ 8 hr
BUN > 100mg/dl

Crea > 3.5mg/dl

Hematologic Failure presence
of 1 or more of the ff:
WBC < 1000 uL
Platelets < 20,000

HCT < 20%

Hepatic failure presence of both
of the FF:
Bilirubin > 6 mg %
PT > 4 sec over
control in absence of
anticoagulation
(normal PT – 11-12sec)
Neurologic Failure

GCS < 6 in
absence of
sedation
Med MGT:
Control of infection w/
antibiotics ( common MRSA
& Vancomycin resistant
Aggressive pulmonary care
mech vent & O2
(intubation)
Enteral (NGT) feeding
 NRSNG MGT:
Limited : effective
client & family
coping