CHRONIC RENAL FAILURE is progressive. Beginning, BUN & CRE are about normal. Progressing: GFR 50% of normal. HTN begins. Next is renal failure. 20% of glom fx. Can’t filter. Can have uremia. Lastly, ESRF. Glomerular rate <5%. Patient needs to have dialysis. Affects all body systems.

DESTRUCTION of glomeruli

STAGES –
STAGE 1 – ↓ renal reserve. Reduced by 30-50% but there’s no acculumlateion of serum uremic products. May have polyuria and nocturia because the kidneys can’t concentrate urine. We do a 24° urine collection and it’s the only way you’ll find out.
STAGE 2 – Renal insufficiency. Metabolic waste accum. More from prolonged ↑ in pressure. Oliguria, edema from ↓ responsiveness to diuretics. Need to know Na, K+, CRE, BUN, Phos. Spec. Grav equal with 1.010 – BUN & CRE rise with loss of glomerulus. GFR goees down. 20-50% of normal.
STAGE 3 – excessive accumulation of metabolic waste. BUN and CRE go up. Can’t maintain homeostasis. Need replacement. GFR is <5% for ESRF. Renal replacement therapy.

CAUSES – can be ARF. Renal artery occlusion. Chronic obstriction, strictures. Recurrent infections. DM, metabolic disorders, uncontrolled HTN. Autoimmune disorders esp. lupus. Patients will start to develop fatigue, color. Ammonia like breath.

ASSESSMENT
KIDNEY changes. ↓ GFR you have lost 70-80% of renal fx. Kidneys are resilient. Can live with one kidney. Abnormal urine production. Poor h2o excretion because you can’t maintain water when you’re losing particles. Lose ability to concentrate urine. Water will transfer out with particles. Get polyuria initially. Inability to concentrate and polyuria combined is an early sign. Can cause hypovolemia. Have to consider both hyper and hypo volemia. Get lyte imbalances. BUN ↑ urine output ↓ get anuremic <100 and oliguric is <400 in 24° it progresses from hypovolemia to hypervolemia.
METABOLIC ∆’s – urea is the biprooduct of protein metab. Accurate is creatinine. ↓ levels of serum cre. Carb metab is altered. Have impaiored glu use from cell insensitive from altered insulin. The insulin stays in the system longer. Hyperinsulinemia. Worsens atherosclerosis and ↓ HDL. Sodium is excreted and can’t resorb. Polyuria causes Na depletion. This is a false low Na reading from the retention of the water. Urine output falls <500? K+ problems ↑ to 6 or above. (please verify this in the book). Diet and drugs can increase K+. getting K+ release with protein cell breakdown. PCN is potassium based. ACID BASE IMBALANCE ammonia production is ↓ and bicarb does not occur. Metab acidosis will occur. Then get Kussmaul breathing pattern to correct metab acidosis. You’ll see this if metab acidosis is severe. You’ll see this late. May see deep yawning from acid base imbalance. May develop uremic lung is thick sputum with minimum coughing. Put them on a fluid restriction. This can occur and frequently does. Bicarb stays 16-20 meq/L because phosphate becomes buffer. This demineralize bones. Calcium and phosphorus is influenced by vit d. PTH causes excretion of phosphate when there’s an excess. In renal f the phos is retained due to. Chronic hypocalcemia then causes phosphate excrete and the bones demineralize and lose density. Get fx easily. May ave spinal sclerosis. Lose tooth calcium. Sometimes calcium and phosphate and precipitate all over the body.
CARDIAC ∆ - HTN can be result or cause of CRF. RF will ↑ HTN. Control HTN, you’ll have a better outcome. Hyperlipidemia is from ↑ in LDL and ↓ of HDL. We exacerbate atherosclerosis. Heart failure. Anemia will worsen angina. Uremia has toxic affect on myocardium and may cause uremic cardiomyopathy. May get pericarditis from ↑ precipitate in cardiac tissue. Uremic pericarditis and can lead to blab la blab la.
RESP ∆ - fluid overload and breathing patterns. URI? They’ll have thick sputum. Teach them to cough and deep breath. Help to move those secretions out.
HEMATOLOGIC – Anemia. ↓ erythropoietin, ↓ RBC production. ↓ in RBC survival. May have ↓ of folic acid and iron and can’t make more RBC’s. get anemia from toxins ∆ the uremic fx. And have bleeding tendancies. PTH stimulation inhibits erythropoietin and causes a no make RBC situation. Get bruising and peteecheia, bleeding of nose, gums, etc. infection is a problem in RF. ↓ WBC at site of injury. ↓ antibody production. RF patients are extremely prone to infection. If we’ll do hemodialysis, it’s only 3 times a week.
GI∆ - uremia, metab acids. Causes inflammation of mucosa and ulcerations. Enzymes in mouth and causes uremic feter in mouth. Metallic taste in mouth and they don’t eat well. Anemia, malnutritionand weight loss. Peptic ulceration? Patients get uremic colitis with profound watery diarrhea or constipation. Abdominal pain and cramping.
NEURO ∆ - uremia causes headache from buildup of toxins. When GFR ↓ 10-15 may get uremic encephalopathy. Impaired thought process. Loss or recent memory. Perceptual errors in identifying people and objects. Goes into lethargy and keeps advancing. Atophy and demyelination of nerve fibers causeing peripheral neuropathy. Can occur in both. Pt. complains of sensory∆ - pain occurs in a glove or stocking pattern. Restless leg syndrome, numbness of extremity. Extremely difficult to control. Little that can be done. It becomes irreversible. Can have loss of motor fx. Can get asterixis.
MS ∆ - renal osteodystrophy – need activated vit d, but don’t have it. Osteoitis fibrosa. Coarse fibrotic in bones. Osteomylasia slow rate of bone formation. Bone fx are slow to heal.
INTEGUMENTARY – yellow or yellow gray color. Faded suntan. Bronze color. Administration of eryhropoeitin has ↓ this. Skin loses oils and turgor and gets pruritis. Uremic frost? Urea and phosphate evap. Looks like skin is salted and it’s crystals in skin. This is advanced. Needle sticks – can’t fight infections. Nails thin and brittle. They find ways.

STEPHENS ED is looking for new grads.

REPRODUCTIVE ∆ - infertility, ↓ libido and ↓ estrogen and testosterone and ↓ sperm count. Pregnany is possible if they have dialysis.
PSYCHOSOCIAL – disrupt many aspects of patinet’s life. Can’t concentrate. Cease working, affects family relationships, work pattern. Affects. Do good job assessing coping.

NSG TX
Thirst is a big problem. We have them on fluid restriction. Limited to 600 + whatever they can put out. About 1L/day. Protein is restricted. This is ↑ phosphates and have to be careful. If patient is placed on hemodialysis, they can have more protein. 0.6 g / k / day protein. 50% of protein should be of high bio value. Have lots of amino acids. RESTRICTIONS: low sodium diets. Don’t aggrivate lyte imbalances. Salt substances have ↑ k+. Fruits and chocolate. Milk cheese products. Hold water soluable vitamins prior to dialysys. Phosphate binders need to be given at mealtime. Have to collaborate with nutritionist. If on dialysis, don’t want them to get > 1-3 kilos between tx. 1 is the best. 3 is upper extreme. MEDS – supp vitamins. Kayexalate to get rid of potassium. Can cause diarrhea and contains sugar alcohol and may be a laxative. Can ↑ na levels. Need to be aware of meds. Don’t give demoral. Morphine, oxycodone or acetaminophen are acceptable. COMFORT MEASURES – mouth care is essential. Metalic tast. Skin care – don’tuse a lot of soaps. Soothing lotions to replace oils in the skin. May not have fever when they get infection because they lost the ability to contol and lost ability to ↑ wbc.
HEALTH TEACHING –

HTN – ACE INHIBITORS slows renal failure early on as long as they don’t ↓ blood flow too much. CCB – lower BP and ↑ GFR and blood flow. BETAS – ↓ renin release. ARBs – sartins – controls. PHOSPHATE RETENTION – lower serum phos. Calcium carbonate (TUMS) or calcium acetate (phoslo) or phosphate binders. Give with meals and full glass of water. Phosphate gets absorbed within an hour of eating. No meds within 1-2° > getting phosphate binder. Prevents potassium absorption. They have a chewable. Avoid aluminum based rugs. Kidneys are needed to excrete magnesium. Don’t have mag based or alum based. LOW CALCIUM – give paricalcitol, ZEMPLAR – actually one of those meds. Promotes production of calcium and phosphorus and calcium homeostasis. Given in conjunction with dialysis and calcitonin. Vit D rich books – canned salmon, tuna, fish, cereals, fortified milks. CALCIMETIC agents (Zemplar) increase something (yawn). ↓ PTH stimulation.

METAB ACIDOSIS – administer soda bicarb sometimes. Don’t touch them.
ANEMIA – monitor H&H, given epogen. Has the same bio effects as ery. Takes 2-3 weeks to see result. Maintain crit at 36%. Careful of getting up too high. Not shaken. Rolled to mix. Never shaken. It will denature and destroy it. Arinesp can be given sub q or iv and require less injections. FOLIC Acid. Blood transfusions are prescribed rarely. If the patient gets unit of blood, you’re giving 250 mg of iron with each unit. Don’t oversdose on iron. Be aware of aspirin. Can prolong bleeding time.
GI BLEEDING – occult.

INFECTION AND INJURY – can have ↑ in potassium lvels. Can have no ↑ WBC or fever, look for redness.

Insulin may need to lower doses.
MUSCLE CRAMPS from lyte imbalances. Give replacements. Heat and massage helps.

OCULAR irritation – causes buring and itching of eyes. Keep calcium and phosphate under control. Give eyedrops. Flush eyes with lubricating fluid instead. Give good eye care.

INSOMNIA and fatigue – provide adeq. Rest periods. Get erythropoietin. Give iron, given mild depressants to halp with fatigue. Keep patients safe.
NEURO – monitor decision making ability. Keep side rails up. Comfort measures.

DIALYSIS
<15 GFR, acute poisonings, metab acidosis, uremia is not able to be managed. GOIAL: ↓ waste products. And get rid of fluid. It has a blood component, membrane. Dialasate bath does not need to be sterile because pores are too small. Water needs to meet criteria.

HEMODIALYSIS – needs access. Subclavian and internal jugular is temporary. Prefer jugular. Catheter is ash-split cath. Double lumen cath. Red is where blood comes out and blue goes back in. we use temp. cath in emergencies for acute care. Femoral cath can only be used for a week. Need to be on bedrest. Can’t sit more than 45°. Check pulses, temp, etc. pulling of cath prevent. Microdrip of heparin. Not a pleasant way to be dialyzed. SHUNTS ARE USED RARELY from infection and thrombosis. Keep cannula clamps bedside.

ARTERIAL STEAL SYNDROME – stealing blood from extremity. Monitor for circulation distally.

HEMODIALYSYS NSG INTERVENTIONS

PERITONEAL DIALYSIS – only on 10% of dialyzed pt. it’s more like the kidney. The pe®itoneum is the membrane. Controaintications – abdominal surgeries or impending renal transplantation, chronic back problems and severe COPD. The solution is 1.5-2% glucose to hold the big molecules back. Can have a more normal diet. Outflow needs to bechecked for color or clarity. Clear and colorless is normal. 1st or 2nd is normal for slightly reddened. BROWN is perforated bowel, URINE is perforated bladder. PERITONITIS is a complication that occurs from this. From not adhering to aseptic technique. Can cause abd pain. Can putantibiotics in dialysate. From low pH of dialysate can cause abd pain. If bowel touches stuff, it can cause some irritation. Can relieve abd pain by putting heating pad on stomach.
CAPD – patient can take bag, 7 days a week.
AUTOMATED – uses machine to cycle it. Can be cumbersome. Done more at night.

HOMEOSTASIS, f&e balance and excretion.

BUN is the biproduct of protein metabolism and is entirely excreted by kidneys. Influenced by GI bleeds, dehydration. normal is 8-25 or 10 – 30.

CRE – specific indicator for filtration. Not altered by other factors. It is more specific than BUN. Formation and release and is proportional to muscle mass. This is the problem. When you get to the elderly and their muscle mass is ↓ and their excretion of CRE is also ↓. It does not rise for 12° > a problem. 0.6-1.3 is normal. Is a direct relationship between renal function. Doubles? Lost 50% of renal function. Triple, lost 75% of function. Normal CRE to BUN ratio is normal 10:1

Kidney secretes renin from ↓ in blood flow and ↓ sodium so angiotension II and then tat a ta . Responsible for erythropoietin from hypoxia and ↓ renal blood flow. RBC lives 3 months, 120 days. Responsible in PTH. Released in ↓ calcium levels. Kidney will activate vit d to have calcium absorption.

Kidney can synthesize prostiglandin and ↑ renal blood flow. When kidney fails, can’t synthesize prostiglandin.

Working unit is the nephron. Have approximately 1M nephrons. Glomurelus filters sodium. Tubes are responsible for reabsorption and 99% of water resprption happens. Pelvis of kidneys can only hold 3-5cc of fluid. Kidney receives 1200 cc blood a minute and 20-30% of blood. Normal filtration rate is 125ml per minute. Only 1ml per minute is excreted as urine. Look at the systolic blood pressure. When it falls ↓ 70, have no filtration. MAP needs to be > 70 to perfuse kidneys.

Gerontologic considerations: > 30 y.o. you lose weight and function of kidneys. By age 70 you lose 30-50% of glomerular structures.

ACUTE OR CHRONIC RENAL FAILURE. Most are poorly controlled DM, HTN and glomuleronephritis. Don’t’ need to remember fortest.

Lose 50% of functioning? May gain renal failure. If it’s gradual, you can lose up to 90% of the nephrons and still renally function.

AZOTEMIA – build up of waste in blood, but no manifestations.
UREMIA – when the levels rise, but sx develops.
UREMIC SYNDROME – deep trouble. End stage renal failure. All body systems are affected.

ACUTE RENAL FAILURE – lots of people have this. 15% of acute patients get renal failure. 50-80% patients with acute failure die. Volume depletion is the major culprit. It is reversible if quickly treated. OLIGURIA – less than 400 in 24° accompanied with ↑ BUN and CRE. And is reversible. Nonoliguric renal failure is better o have, but. CAUSED by …
Prognosis is going to depend on the cause. Normal or near normal kidney fx is going to return gradually. PRERENAL is most commonly the cause. Usu intravascular volume depletion. Dehydration may be from diuretic therapy. We can actually cause prerenal problems by the meds we give meds to. We can cause problems with ACE inhibitors, etc. we can ↓ blood flow thru nephrons. Ischemic or nephrotoxic problems like contrast media. Look at the slides to get an idea os nephrotoxic substances. On NSAIDS? We’re not going to produce prostaglandins. And it makes it prerenal. Hmmm. Interesting. Elderly get mucomist for contrast media testing.

NEPHROTOXIC – aminoglycosides – like gentomycin. Other drugs are acetominiphin. NSAIDS. Mercury, arsenic. Intrarenal. Acute pyelonephritis.

POSTRENAL – obstruction. Renal pelvis only have 3-5 cc and if there’s a back up and then blowing up the kidney. Can have one kidney blocked, but no renal failure. Have to have both kidneys involved.

PHASES of ACUTE RENAL FAILURE. OLIGURIA urine spec. grav is lox or fixed.
OLIGURIC ASSESSMENT: Oliguria <17CC/hr. in assessment, no going to have sx until… acute weight gain of 1-2 lbs per day. 1 litre of fluid is 1 kilogram or 2.2 lbs. going to depend on extent of fluid overload. Look for effusions. Headache, HTN. Vitals severity. Pulse is tachycardic, irregular. May have friction rubs. Neuro – accumulate in the brain. Complain of fatigue. Difficulty in cognition. Become unresponsive and go into seizures and coma. Halitosis or uremic odor (feter) from the build up of ammonia. Also have dry cracked mucous membranes. Skin dry. May have pruritis, generalized edema. May have yellowish, gray appearance. Tired all the time. As far as blood work – ↑ in potassium. H+ ion go into cell for exchange of potassium. Potassium >6 will have lethal dysrhythmias. VTACH, VFIB. Lots of PVC. BUN will ↑ 80-100. CRE 1-2 DL ina week or less is 8 or more. WBC’s will ↑. Phosphate will ↑, but it could be low. BUN CRE ratio will be 25:1. Bicarb is getting used up. H&H is going to drop. Na level will be normal or decreased. ↑ casts in urine. Urine sodium can be ↑ with a ↓ in serum sodium. Non-oliguric is dilute with a ↓ spec. grav. Sx tests: potassium around 6 – ECG with tall T waves, st depressed.

DIURETIC PHASE, output comes up to normal. Excessive urine output. However, initially dilute. Can rapidly deplete fluid and electrolyte. Excreting waste, but not concentrating urine. Can last 2-6 weeks after onset of oliguria. Going to lose electrolytes. Can cause hypotension. Improved LOC. Watch for hypokalemia and hyponatremia and hypovolemia. Gradual decline.

RECOVERY – depend on severity of failure, age, length of oliguric phase. Will be slow process. It can take 6 months to a year for the recovery phase to continue. This is when the pt is very vulnerable to further injury. Will still have low energy level. Will increase in their strength. LOC will get better. BUN & CRE stabilize. There may be some renal insufficiency. Pt can develop chronic renal failure.

TX for ACUTE FAILURE : monitor VS, & CVP – is 2-6 normal. FLUIDS: IV can be given if needed. If nonoliguric renal fluid. Others need packed red blood cells. In other patients, if it’s an oliguric problem, limited to 600 mL + what they put out 24 hours previous. Measure everything…add it up, plus 600 and that’s your fluid restriction for the next 24°. DIET: high rate of protein breakdown and need ↑ carb, low protein diet. Need to limit waste buildup because BUN and CRE and part of prot and muscle breakdown. Most of the carbs will come from carbs and fats. TPN or PPN. Give them fat emulsions instead of glucose. Consult with the dietitian and calculate their caloric needs. 0.6 grams protein per kilo. Can give amino acid suppliment PO. We would like to keep patients feeding orally or by enteral feedings. Keeps circ volume reduced. Preserve lean muscle mass. Preserve renal function. Maintain fluid balance. Next is control HYPOKALEMIA - give glucose and insulin and CALCIUM GLUCONATE and forces potassium back into the cell. SODA BICARB – forces potassium into cell. POLYSTTYRENE SIDIUM SULFONATE. EXCHASNGE RESIN – binds potattium and excretes it.

MEDS TX: Mannitol – osmotic diuretic to treat oliguric phase before it’s nonreversible. Move water. 30-60 minutes, lasts 6-8° and they will be given 50mL to see if they can have a urine output before giving mannitol. Given with iv filter. It crystallizes if not warm. Needs to be in a warm. It is the onee they’re giving. Lasix excrete sodium chloride. Lasix drops volume and increase failure by exacerbate volume problem. Peaks 1-2 hour. Onset 5 minutes. DURATION. is 2hours. Can give 1 gram a day of lasix. If they’re going to get toxic, they’ll get ototoxicity. Zyroxlin given to ↓ phosphate level. BUMEX – works like lasix and good at promoting phosphate and ____. Peaks 15 minutes, duration 3-4 hours. Bumex can ↓ blood volume and give circ collapse. Can be iven 1mg per hour. 1mg bumex is like 40mg lasix.

COMFORT MEASURES and ASSESSMENT: freq oral care. Check for driness and inflammation. Resp. – coughing turning. Observe for infection. CRE ↑ risk for infection. Infection is one of the leading causes of death. Watch for bleeding tendancies. Patients have a tendancy to bleed everywhere. Need emotional support. Caregivers need support. HEALTH TEACHING: need to be prepared for dialasis. May need to have counseling.

TRAUMA – do a rapid physical assessment when they first come in. rip the clothes off. When they come in, think about car accidents. Could be someone who fell off the bleachers. Assess for trauma. First thing you do is calculate that trauma score. Get that trauma score down.

ENVIRONMENTAL
HYPOTHERMIA – not going to rewarm them all at once. Only 1-2 degrees per hour.

HYPERTHERMIA & HEAT RELATED – elderly are at much greater risk because they don’t sweat. Air temp > body temp is bad. ↑ humidity or lotsa radiant heat. HEAT CRAMPS are the least severe. We’ll see with electrolyte depletion. Muscles will go into spasm. They will replace water lost with electrolytes. Give electrolyte solutions. Tx: cool yourself, stretch. Get into a cool area. Air conditioning, shade. People should rest for two days. People should understand that electrolyte solution should be taken instead of just water. Water isn’t enough. HEAT EXHAUSTION – more severe form. Profound water and sodium loss. Inadequate peripheral circulation is a result. Brought in? > 38°C, but < 40°C. sx: in reaction mode, tachy, htn, nausea, vomiting, dizziness, muscle cramps, syncope. TX: cool them. HEAT STROKE – this is when thermoregulation has failed. May have dehydration. May be disturbance in the sweating mechanism. If you’re dehydrated, you need rapidly rehydration with dehydration. but not so if it’s from sweating failure. 40.8°C – 45. Skin hot and dry. CNS may not be fx as well. May have passed out. TX: go to next door neighbor. Think ABC’s. Probably need intubation, ventilation.need to have ↑ O2. Begin rapid cooling. Take their clothes down. Pack armpits and groins with ice packs. Turn on the air conditioning. Fan them. May lavage with ice water either orally, rectally or both. Be cautious with rehydration and look at LOC, urine output. Nsg Dx: fluid vol. def. may have anxious related to lack of o2. Goal will become electrolyte and fluid balanced. Fluid regulation will be taken care of.

NEAR-DROWNING: over 8,000 drowing. 40% are very young.
Tx: check cervical spine when ABC’s. don’t try to remove any water from the longs because you might aspirate as well. What’s happening? Water in the alveoli. Fresh water, we have fluid gets in. then there’s an alteration of surfactant and alveoli collapse. With salt water, it pulls blood in pulmonary capillaries and we have pulmonary edema. With fresh water, dilutes surfactant – they can still have pulmonary edema, but most common with salt water. When they go teaching is around respiratory situations that can occur. Pre-hospital. Always protect cspine. Get 2 large bore iv’s. Don’t get fluid from lungs. Get a sample of the water. Give O2. Look at abc’s. watch closely for resp failure or pulm. Edema. Near drownings may have another component – hypothermia. They’ll be on antibiotics.

DIDN”T TALK ABOUT BITES.

OVERDOSE – We use a lot of charcoal. It absorbs poison and then the person will be vomiting. It will be a mess.

TRIAGE SYSTEM – divide into groups of importance 3 CATEGORIES, normally in ER situation…EMERGENT threat to life, limb or eyes. Acute situation and patient needs to be seen within 15 minutes. Need to be seen immediately. We call a code on those patients so people are waiting for them. Resp, seizures, trauma, coma, shock or impending shock, chest pain, hemorrhage. URGENT – 20 minutes to 2-3°. Looking at people who need care. Usually major issue. Need to be taken care of promptly, but can wait. Remember that triage, they are assessed and given a wait time, but they are constantly re-assessed and looking for ∆’s in symptoms. NON-URGENT – can wait up to 4° and it’s OK. Sore throat. ======== this is not b&w.

TRIAGE ASSESSMENT –
PRIMARY SURVEY identifies issues with ABC’s. looking for obviosus like bleeding. Remove clothing. Depends on what they’re coming in for. Eye…wee won’t remove clothing. If they don’t know what’s wrong with them. Going to be looking for obv. Quick neuro with glasco coma scale. Think airway. In ER, cervical spine injuries. The patient has one until its proven they don’t have one. With airway, think upper torso. At the scene of the accident? Stabilize neck. They will come in with neck stabilization. Don’t take it off until we have a c-spine to tell us otherwise. Might have to put in an oral airway. Once the patient wakes up they won’t want it in. what if somebody had a partial airway obstruction…you’ll see stridor, retractions, restlessness. Labored, anxious. Usinx accessory muscles. Drooling. With circulation, I always think 2 large bors #16 needles as soon as possible. Foley. Are kidneys functioning? Done quickly, but covers a lot.
HISTORY – get it from friends, but hopefully someone can get it to you.
AMPLE
A(llerdies)
M(eds)
P(ast medical history – give them examples)
L(last oral intake)
E(vent – chief complaint)….
With this, this is the present of what’s happening.
PHYSICAL EXAMINATION – Head-to-toe. Looking for distress, state of awareness, speech, grooming, position, motor activity. Be alert to odors (alcohol, acetone, melena – dead protein like hamburg). Liver dysfunction has musty smell. Pungent odor. In a coma? Smell for liver smell, musty is distinct. Assess for pain. PQRST. Quality Radiate? Severity. Time – freq, how long, wat makes it happen?

LEGAL CONSIDERATIONS OF TRIAGE
DOCUMENTATION. Remember time. TELEPHONE TRIAGE – Don’t do it. Document it. If you need something, go to the ER. GENERAL

VICTIMS OF ABUSE – has to be reported. They have the right to keep it to themselves. Brown paper bags.

WOUND CARE
GOAL – is to initiate care that will promote healing.
ASSESSMENT: csm – circulation sensation and movement. The time between sustained and presented will affect suturing decisions. > 6°, ↓ chance of suturing because of sealing up bugs into the wound.
CT EXAMPLE: Got tetanus shot? <5 years, give tetanus toxoid to give active immunity if this person already immunized.
CT EXAMPLE: ER, caught hand in snowblower. I don’t know if I’ve had one. If you’re not sure, then they give tetanus immunoglogulin. Give them passive immunization from this. And then also give them tetanus toxoid. This promotes active immunization.
TETANUS PRONE is if anaerobes get into the wound.
THINK TETANUS with burns.

TRAUMA
PRIMARY TRAUMA SURVEY –
ABCDE
Airway,cervical spine
Breathing
Circulation and hem control looking at chock
Disability taking about the neuro exam (ABPU – Alert? Verbal stimuli? Painful stimuli? Unresponsive?)
Exposing. Lose 30-40% before you see hypotension. Watching diligently. ER temp should be elevated.

SHOCK – hypovolemic (lost volume) or neurogenic shock (vasodilation of blood vessels). Important how to treat them. With neurogenic shock, we try to get the blood back instead of add to it.

TRAUMA SCORES. Glasco coma scale. They take the scale and incorporate. Scores here are up to 16. Condense it to 5 points. Respiratory is 4 points. Rate, expansion. Blood pressure and cap refill. Respiratory rate highest is 4. Under 10 is bad.

HEAD TRAUMA – we worry about cerebral tissue perfusion. This isn’t b&w either. Intracranial swelling. ↓LOC, pupillary. Positioning a head injury patient = HOB, gravity pulls the blood down. Semi-fowlers position is probably best. Pupils, motor response, strength. Pupils, reactivity, equal constriction. Speed of time to constrict. Check pupils = turn lights down.

SPINAL CORD TRAUMA – hypotension, brady cardia, verves causing vasodilation. Pay attention to neuro shock. Treat with vasopressors – given too fast too much can cause kidneys stop functioning. This gives us peripheral vasoconstriction. You’ll see feet legs problems. Goal is to constrict related to peripheral dilation. This is a dangerous drug. I can cause peripheral vascular failure. Promote circulation. Have large bore needles. Start steroid therapy for first 24°.

CHEST TRAUMA – patient comes in. physical assessent: resp exp, rate, expose, look for opening, look at the chest and look for paradoxical. Is there a flail chest? Do you hear a sucking wound? Listen anteriorly. Listen over the airways. Listen to ALL lung fields. PULMONARY CONTUSION – big problem is bleeding into lung tissue. Could be hypotensive. Careful about pumping fluid and blood into them because it’s not going to stop the bleeding into the lungs. Ride it out. Respiratory help. May be intubated so we can put PEEP. See sx of pulmonary edema, anxiety, coughing up bloody sputum, confusion. SUCKING CHEST WOUND – pleural cavity is open and has negative pressure. Then we have o2 in that area and we hear sucking. Cover the area with anything you have. Use hand if you had to. Need to make sure you have a release valve. They will end up having a chest tube. FLAIL CHEST – sand bag, HEMOPHEUMOTHORAX – both blood and air in the space. CARDIAC TAMPONADE – blood gathers in the pericardium.

ABDOMINAL TRAUMA – may not know for several days. Know what happened. Peritoneal lavage…use an IV solution. Insert cath, blood = OR. No blood.

GENITOURINARY TRAUMA – is the kidney working? Renal trauma. Lower UT trauma. Usually there aren’t problems. There is Penile trauma.

MUSCULOSKELETAL TRAUMA – tissue perfusion, circulation sensation and movement. Immobilize extremity. Not going to move the bone to where it belongs. Immobilization is to prevent further damage. Check for life threatening. 2 large bore needles. Get into what is injured. Bleeding? They lose a lot of blood. They can loose a lot of blot. Think about shock. Think about fluid and blood replacement. Thomas splint. Just like a hammock. In sling? Fingers are up – not hanging over. Hand involved? Then put hand up for venous return. COMPARTMENT SYNDROME – can put pressure on all the area. Treatment is prevention. Worried about necrosis of the tissue. No circulation in area. They will filet it or do a fasciotomy. They leave it open that way. Nsg dx for this one is for infection. FEMORAL FRACTURES – fat emboli is common with this. OPEN FX – infection is a big risk. They go for ORIF. JOINTS INVOLVEMENTS: don’t manipulate the joint. Ice can be on and off to reduce inflammation and cause constriction and cutting down bleeding.

environmental trauma – not to be confused with envoironmental emergencies.
HYPOTHERMIA – below 95°F or 32°C. women and obeise have more fat distribution. To ensure that we know that we pick up on this. Take their temp. in response to cold temp. body compensates with ↑ hr, shaking, goosepimples. Temp around 32-35 may be confused and slurred speech. If this isn’t reversed, lose LOC, vfib, then reflex bradycardia. Cold heart muscles don’t’ respond to defib attempts. Don’t stimulate them too much. Slow in rewarming them. Quick rewarming can put them into vfib. Need those IV and central lines. Watch gases. Already acidotic. Sudden changes in pH can cause cardiac arrhythmias. ANTICIPATE rewarming. Passively. Take off wet cold clothes. Put them in warm sleeping bag. We do not use external warming measures yet. Get blankets around them. No heat lamps. Because heat from outside, the core is still cold. A central line with a thermometer in it would be put in. That is necessary. May use peritoneal lavage. May use warmed IV fluids. Esophageal rewarming tube. Bypass machines can be used. Dialysis units can b used 2. Monitor them in CCU or ER throughout warming. Warm 1-2°C ↑ / °. Goal to have steady rise of 1°C / °. Look at the urinary output, vitals, neuros and assess q15m. Patients may come in looking like their dead. Patients can recover. Can use warm blankets. Quiet environment.
FROSTBITE – direct freezing or inadequate circulation. 4 classes – 1st degree is bluish or bluish white or white. 2nd degree extends into dermis and blisters. 3rd degree is full thickness and edema and filled with blood. There is necrosis. There’s no loss of body part. 4th degree is necrosis and loss of body part. It is painful. MGMT – warming in water 100-104°F. if it is warmer than that, you can cause tissue necrosis because of anaerobic tissue respiration.

It’s a different mindset. Think outside of the box of acute care. You have to be a generalist and specialist. Know body systems and what can go wrong with them. Probably one of the greatest places to work as far as health promotion and prevention. Don’t have much downtime.

RESPONSIBILITIES – have interpersonal skills. Everyone complains about the wait time. Triage people complaints. Need to know how to triage appropriately. People don’t always agree with you. Nurses are accountable for all those you have triage. Make sure things aren’t changing. Also have to be able to interact with public. Coordinate patient and family care. Promote disease prevention and healthy living.

CHANGING TIMES & EXPANDED ROLE – role of the ER nurse has expanded. Collaboration is a huge piece. We have orders that are laying there, when the patient comes in, you decide what to implement. Always ER doctors, but you need to act and decide. You’re responsible for knowing what this arrhythmias are and what you’re going to do with this patient.

CONSUMERS of the ER
Pediatrics are a great number of consumers there. Elderly account for 25% of emergency care. This year

ROLES OF ED NURSE
Crisis Management
Post Traumatic Stress
Death and dying – were they DOA? Then you have to call the family? Have to keeep the body there so they can come and identify. Being with the family and feeling their feelings. Keep in mind organ donation.

EMERGENCY DOCTRINE – if they cannot give consent, need treatment. Implied consent. Legal information related to this. 2 doctors can sign for this saying that they needed the treatment. EXPRESS CONSENT. They tell us somehow.

TREATMENT PROTOCOLS – ER, one for every Dx that might be in the ER arena.

DUTY TO TREAT – they will get their due treatment. Part of COBRA.

NEWS MEDIA – someone in the org is responsible for speaking about the patient. Confidentiality is very important.

OBLIGATIONS FOR REPORTABLE DISEASES.
To Public health – report STD except AIDS. Any communicable diseases. Any animal bites.
Legal – that must be reported: report anything that is violence suspicion. Any child elder abuse. Any neglect. Any suicides. MV accidents have to be reported. Any diseases and food-borne diseases.

CORONOR’s LAWS: any suspicious death. Have to have an autopsy. Died during death? Stillburth, drownings, accidents. Drug overdoses. All need autopsy.

PRESERVING CHAIN OF EVIDENCE – very important. Anything you preserve: go in a brown paper bag. Plastic can cause moisture or heat and destroy evidence. Don’t wash pt before evidence has been collected.

SEARCH OR SEIZURE – we can go through the stuff. If you find a weapon.

PATIENT DISCHARGE – big piece in teaching. This is where you need to know. Verbally tell them, you have them write out or tell you. Then evaluate the teaching.

BORDERLINE – MEDICAL TX Benzodiazopines, mood stabilizers.

NARCISSISTIC – Grandiose. All about them.

CLUSTER C: Anxious or fearful (Avoidant, Dependent, OCD). They don’t take risks because they’re fearful of failure. Take it to heard. Super sensitive. They will not seek out relationships because of fear. Not the one to go to a party. They don’t trust people. They’re lonely. Egodystonic. They know they’re not like everyone else. They really want closeness, but fear of rejectikon gets in the way. NSG MGMNT – help them disccuss fear and inadequacy.

DEPENDANT PERSON – have an excessive need of others to take care of them. If they have a relationship, they attach hemselves. If they lose them, then they attach themselves to another very quickly. They feel uncomfortable when alone. They won’t express because they fear rejection. They will even allow themselves to be mistreated just to be attached. They see world as glass half empty. They don’t feel they can take care of themselves.
NSG MGMNT: Encourage them to make decisions. Role Play.

OCPO – perfectionist, non-flexible person. Has a lot of difficulty expressing emotions. Don’t want to make mistakes. Very meticulous. Employers like these people. Tend to be very rigid. Very polite socially. Can be very pompus. They are company people. They will be exploited. They see themselves as very dependable. Anybody who isn’t, they have contempt for. They deal with the world by keeping that control. NSG MEMNT: Helping them to understand that they can make mistakes. It’s OK to not be perfectionists. It’s OK to not have control over things.

MULTIPLE PERSONANLITY DISORDER is now known as dissociative disorder.

PERSONALITY DISORDERS
inflexible, enduring, pervasive maladaptive & cause significant functional impairment or subjective distress. AXIS 2. Most common personality disorder is borderline personality disorder. Other one is anti-social personality disorder. They’re the criminal. They’ve committed some terrible crime.

Cluster A – odd or eccentruc
Cluster B
Cluster C – most receptive

These people don’t seek treatment because they don’t see there’s a problem. Antisocial usued to be known as sociopath. What percentage of the population has mood disorders 1%. Personality disorders take up 10-15% OF All mental illness. Egosyntonic – rarely seek tx. Blame others. Egodystonic (cluster c is usually this) – we see this population.

Personality disorders – not good tx now.

Schizotypal – magical thinking.

Borderline – suicide attempt gets them into the hallway. They see the world as good / bad, black and white. Unstable relationships. Tx – dialectic behavioral therapy. These patients have no sense of self-esteem. Cutting patients will often say that cutting release the emotion of pain.

ERI review course 13, 14, 15, 16 oncampus in kirk 103 in auditorium.

Mon Apr 7 speaker 10-11 am – susan seppels to talk to youaboitu the UMS matriculations RN to BSN.

BIO-TERRORISM –

Anthrax – bacillus. Creates a respiratory problem. Bacterial spores form in the alveoli. Toxins from the spores cause hemorrhage. Inhale anthrax is very mortal. Pulmonary edema, bloody cough. Incubation is 1-2 days to 6 weeks. Abrupt in onset. Septeemia, meningitis. Respiratory failure. Anthrax is no person to person spread. Found in nature. Most commonly in domestic and wild hoofed animals. Antibiotics with sx. Sipro, doxycycline. Vaccine is available? Is available. Very limited availability. Had vaccine? 30 days prophylactic. No vaccine, 60 days.

SMALL POX – similar to chicken pox. US stopped vaccination in 1971. Globally in 1980. Reson: felt the side effects were too much for the risk that the disease now posed to us. CLINICAL MANIFESTATIONS – incubation 7-17 days, onset sudden, fever headache, runny nose, lesions. Highly contagious. Spread directly, droplet and handling contaminated matereials. Isolation. Vaccination for those exposed. Working in hospital, comein and it is suspected that they hgave been oxposed to the disease – what are you going to do? Isolate them. Use negative air. Decontamination areas.

BOTULISM – spore. Anaerobe. Found in soil. Lethal. Spores give off neurotoxins that cause neuroparalysis. Incubation is 12-72 hours. Sx are GI, cranial nerve involvement and flaccid paralysis and respiratory failure. Spread thru air or food. No person to person contact. Improperly canned foods. No vaccine available. Is an antitoxin.

HEMORRHAGIC FEVER – several viruses. Most familiar with is the Ebola virus. Life threatening. Little vial . sx fever, organ failure. Viruses carried by rodents and mosquitoes. Can be person to person, body fluids. Virus can be aerosoled by bioterrorist. No IM injections. No antiplatelet drugs. On isolation. Effective. Movies. Knowing the disaster plan.

, smallpox, botulism, hemorrhagic fever: know these from the book.

EATING DISORDERS

ANOREXIA NERVOSA – anorexia means appetite and they don’t really have a loss of appetite. Considered a thought disorder. Onset in adolescence. Female are more apt to have this. Most are females. Recognized a long time ago. Cat. As ego-syntonic – behavior that agrees with one’s thoughts desires & values. Criteria. Needs to have weight loss of 15% below weight. Comorbidity. They’re hypothermic. Tend to have lanugo. Amenorrhea. May not be menstruating. They may have an obsession in food. Can be life-threatening. Karen carpenter died of anorexia. She was extremely emaciated. She died of complications. Jane Fonda. It’s a method of control. Tey tend to have electrolyte imbalances. Gastric complications. Some have been known to ruprure stomach. Have ketones from starvation. ↑ urine spec. grav. ↓ CO. one of the ways it can be detected. Dental visit may reveal loss of enamel. Russel sign. Calous and bruising on back of hand. Abnormal EKG. Heart muscle gets rigid. Develop tears in esophagus. Might complain of sore throat. Try to sabotage plan. Be consistent. Have ↓ WBC. Parotid gland enlargement. Beta-carotene producing yellow skin. Looked at some of these individuals. Some will have ↑ cortisol in CSF. ↑ levels of endogenous opiates. May contribute of denial. They are hingry, though. Narcan be administered. Predisposition in families. THEORY: psychodynamic influences – they have disturbance in mother child interactions. Really unhealthy family dynamics.

WHAT’S DIFFERENT BULIMIA NERVOSA? They have normal weight. They look normal. They have the same behavior. Binging or purging. Binge are done in secret. Stops because it becomes uncomfortable. Normal weight. Onset is > dieting. This is ego-dystonic. They feel guilty about their food patterns. Have a higher incidence of ____ disorders. They have russel sign. What brings them in is the 75% below ideal weight.

TX ANOREXIA/BULIMIA
Plan of care is weight gain of 2-3 lbs per week. Observe while eating, what, when, adequate? Do not have access to bathroom after eating. Eating plan developed with the awareness of patient. Supplements. All of that will be very threatening. Lots of reasons to not want to do that. Restricting their calories is a way to control their life. Help them to find ways of control in their life. Develop some insight. Not going to happen over night. Assess family dynamics. Offering journaling. Refer to family counseling. Medications will be antidepressants. Antipsychotics. This is an alteration of thought process.

April 7th after class. Susan Sepples from USM to talk about importance of continuing on in education.

Disasters
Think of yourself as being part of the disaster plan. Disasters affects many people. Events. Types are natural, man-made.

Levels of disaster: LEVEL I – local. LEVEL II – aid from local communities and organizations. LEVEL III – disaster overwhelmes local and regional assets.

DISASTER RESOURCES – MEMA, FEMA, American Red Cross is voluntary and have been given accountabilities. They give free resources. Local DHS. Boy Scouts, goodwill.

RN EDUCATIONAL COMPETENCIES in MASS CASUALTIES

In Disaster planning.

STAGES OF disaster involvement.

Triage: emergent, urgent, something else.

The biggest problems that victims and workers is stress. – lack of control, family members.