Escolar Documentos
Profissional Documentos
Cultura Documentos
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
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
Chronic pyelonephritis
Stages CRF
Reduced Renal Reserve
high BUN no clinical
symptoms yet
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
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
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
1 8 hours :
st
7200 ml
2
= 3600 ml = 1st 8 hours
2 8 hours &
nd
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
Assessment
Main problem is
decreasing LOC bec of
accumulation of ammonia
Jaundice
Abdominal pain
Ascites
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
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:
Antithyroidmeds:
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
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
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