Acute Renal Failure: Causes and Risk Factors

• Acute Renal Failure (ARF) is a self-limiting condition characterized by a sudden loss of kidney function, affecting urine excretion, nitrogenous waste removal, and fluid, electrolyte, and pH balance maintenance.
• ARF is categorized into pre-renal, intra-renal, and post-renal types and typically resolves after addressing the underlying issue.

Causes of Pre-renal AKI

• Hypovolemic shock can lead to pre-renal AKI.
• Vasodilation can cause pre-renal AKI.
• Third spacing of fluids can result in pre-renal AKI.
• Dehydration is a cause.
• Sepsis and Disseminated Intravascular Coagulation (DIC) are potential causes.
• Heart failure (HF) can lead to pre-renal AKI.
• Hypoxia from any origin.
• Trauma can induce pre-renal AKI.

Individuals at Risk for Pre-renal AKI

• Post-surgical patients are at risk.
• Cardiac pathology.
• Trauma patients.
• Burn patients.
• Anaphylaxis.

Causes of Intra-renal AKI

• Direct trauma to the kidneys.
• Acute glomerulonephritis.
• Acute pyelonephritis.
• Hemoglobinuria/myoglobinuria.
• Damage to other cells/tissues.
• Blood transfusion reactions.
• Nephrotoxins exposure to chemicals, organic solvents, and pesticides can cause intra-renal AKI
• Exposure to heavy metals like mercury, arsenic, and lead can cause intra-renal AKI.
• Certain drugs, including aminoglycosides, NSAIDs, acetaminophen, antineoplastic agents, vancomycin, neomycin, cocaine, lithium, contrast media, and cyclosporine can cause intra-renal AKI
• Snake (copperhead) and centipede venom can cause intra-renal AKI

Causes of Post-renal AKI

• Obstruction in the lower urinary tract, or external compression in the abdomen, outside the renal/urinary system.

Treatment of Pre-renal AKI

• Management focuses on correcting the underlying cause (e.g., hypovolemia, decreased cardiac output) rather than directly treating the kidney itself.
• Prevention is the most effective approach.

Treatment of Intra-renal AKI

• Correct the underlying problem to treat the issue.
• Infections can complicate treatment.
• Ensure the tubular membrane is intact to aid recovery.
• Patient survival depends on managing imbalances.

Treatment of Post-renal AKI

• Relieve the obstruction.

General Interventions for ARF

• Monitor for potential causative agents.
• Administer medications and assess their effectiveness.
• Implement dietary restrictions.
• Strict monitoring of intake and output (I&O) and weight measurements.
• Provide supportive care for both the patient and their family.
• Dialysis may be necessary.
• Dopamine (renal dose) and diuretics may be administered.

ARF Signs and Symptoms

• Oliguria.
• Increased levels of Blood Urea Nitrogen (BUN).
• Increased creatinine levels.

Dialysis Facts

• The solution used is sterile.
• Electrolytes, heparin, antibiotics, and insulin can be added to the solution.
• Glucose and osmolarity are adjusted to facilitate fluid removal.

Hemodialysis

• A process where dissolved particles diffuse from one compartment to another through a semi-permeable membrane.
• It cleanses accumulated wastes, removes excess fluids, and eliminates metabolic by-products.
• Maintains/restores the buffer system and electrolyte levels.

Complications of Hemodialysis

• Hypotension.
• Shock.
• Muscle cramps.
• Electrolyte changes.
• Sepsis.
• Blood loss.
• Hepatitis.
• Disequilibrium syndrome.
• Dialysis encephalopathy.

AV Fistula Assessment

• Auscultate for a bruit and palpate for a thrill.
• These findings indicate proper functioning.

Types of Peritoneal Dialysis

• Continuous Ambulatory Peritoneal Dialysis (CAPD).
• Automated Peritoneal Dialysis (CCPD).

Peritoneal Dialysis

• The peritoneum serves as the dialyzing membrane.
• Diffusion and osmosis principles are used to exchange fluids and solutes.
• The peritoneal cavity has an excellent blood supply for effective exchange.

Complications of Peritoneal Dialysis

• Peritonitis.
• Abdominal pain.
• Insufficient flow.
  • Check for kinks or clogging.
  • Reposition the patient and massage the abdomen to improve flow.
• Leakage around the catheter site.
• Fever and cloudy drainage. Could indicate infection.

Peritoneal Dialysis Contraindications

• Peritonitis.
• Recent abdominal surgery.
• Abdominal adhesions.
• Impending transplant.

Nursing Interventions for Dialysis Patients

• Monitor vital signs, lab values, weight, I&O, and ensure adequate nutrition.
• Monitor the patency of the access device used for dialysis.
• Hold antihypertensives and sedatives before the procedure.
• Hold medications that can be filtered out during dialysis.
• Monitor for post-procedure complications.

Lab Result Indicative of Renal Disease

• Elevated creatinine (CRE).

Best Way to Monitor for Fluid Retention

• Weight and BP monitoring.

Cirrhosis

• A chronic liver condition characterized by inflammation, fibrotic changes, and significant loss of functional liver tissue.
• Fatty infiltration leads to disorganization of liver structures as interconnecting fibrous bands form.

Major Cirrhosis Complications

• Ascites.
• Varices.
• Encephalopathy.

Ascites

• Increased abdominal girth due to fluid accumulation.
• Often characterized by skinny extremities and a large abdomen.
• Fluid wave test can be used to determine presence.

Ascites Treatment

• Transjugular Intrahepatic Portal-systemic Shunt (TIPS) procedure, involving a stent to keep the vein open.
• Restriction of sodium intake aids in management.
• Paracentesis may need to be performed because the risk of infection is high. Give Albumin if has not been given in past 5 years.

Primary Assessment for Burns

• Focus on airway and breathing (ABCs).
• Thermal injuries can cause upper airway injury, pulmonary injury, carbon monoxide poisoning, or a combination of these.

Signs and Symptoms of Upper Airway Injury

• Facial burns.
• Singed nasal hairs.
• Progressive hoarseness.
• Stridor.
• Inability to swallow.
• Edema of the oropharynx.

Interventions for Upper Airway Injury

• Administer cool, humidified oxygen, and potentially intubate (ET tube).

Signs and Symptoms of Pulmonary Injury

• History of being in a closed space during the incident.
• Unconsciousness at the scene.
• Facial burns.
• Carbonaceous sputum.
• Signs of hypoxia, either early on or up to 24 hours after the incident.

Interventions for Pulmonary Injury

• Provide high-flow oxygen via a non-rebreather mask.
• Possible endotracheal intubation (ET).

First Degree Burn

• Caused by short flash exposure to high temperatures or prolonged exposure to lower temperatures (e.g., sunburn).
• Involves the epidermis only.
• No blistering occurs.
• No scar remains after healing.
• Only redness, mild edema, and increased sensitivity to heat are present.

Superficial Partial Thickness Burn (Second Degree)

• Affects the upper one-third of the dermis.
• Blood supply remains intact, resulting in a pink and moist wound appearance.
• The wound will blanch.
• Blisters will form.
• Painful due to intact nerves.
• Heals in approximately 10-21 days.
• No scarring, but minor pigment change may occur.

Deep Partial Thickness Burn (Second Degree)

• Extends deeper into the dermis.
• No blisters due to a thick layer of dead tissue that adheres to the dermis.
• The wound bed is red and dry.
• Fewer patent blood vessels are present.
• White areas may appear in deeper parts of the burn.
• Blanching may be slow or absent.
• Less pain due to nerve ending damage.
• Heals in 2-6 weeks with scarring.

Healing Protocol for Second Degree Burns

• Proper care will promote healing without grafting in most cases.
  • Wash with soap and water twice daily.
  • Apply antibiotic ointment (Bacitracin vs. Silvadene).
  • Use a non-adherent dressing.
  • Apply a dry sterile dressing.

Third Degree Burn

• A deep burn involving both the dermis and epidermis, as well as the subcutaneous layer.
• Skin appears white, leathery, or charred with no blanching.
• The coagulated dead skin is referred to as eschar.
• No pain is felt due to complete destruction of sensory nerve fibers.
• Will not heal on its own and requires grafting.

Circumferential Burn

• Completely surrounds a body part, such as the chest.
• If it's a 3rd degree burn, the eschar is tight and edema underneath restricts breathing.

Treatment for Circumferential Burn

• Escharotomy to relieve pressure and improve oxygen flow and breathing. Incision through the eschar to decrease chest pressure leading to inc O2 flow and unrestricted breathing.

Electrical Burns

• Caused by sources such as lightning or direct/alternating current.
• Assessment involves identifying two wounds (entrance and exit).
  • Altered level of consciousness.
  • Cardiac dysrhythmias.
  • Possible myoglobinuria.

Chemical Burns

• Caused by acid, alkali, or petroleum-based substances.
  • Identify the cause and contact poison control for a specific antidote.
  • Severity of the burn depends on the duration of contact, concentration, and speed of care.

Thermal Burns

• Flame burn
  • Stop burning.
  • Stop-drop-roll.
  • Roll in blankets, etc.
  • Scalding.
  • Remove the source.
  • Cool water.
• Stop the burning process.
• Assess ABCs.
• Remove clothing.
• Wrap in CLEAN DRY SHEETS. (Reduce microorganism exposure & prevents sheets sticking to burn).
• Administer humidified oxygen (inhalation unknown).
• Establish IV access. (Do not delay transport).

Upper Airway Injury Characteristics

• Facial burns, singed nasal hairs, hoarseness, stridor, inability to swallow, oropharynx edema.
• Provide cool, humidified oxygen and consider ET tube insertion.

Pulmonary Injury Characteristics

• Usually occurs in a closed space, with the patient unconscious at the scene.
• Manifests with facial burns and carbonaceous sputum.
• Signs/symptoms of hypoxia may occur early or up to 24 hours later.
• Give high-flow oxygen via non-rebreather mask and consider ET tube.

Potential Complications of Burns

• Continuation of burning process.
• Edema.
• Fluid loss/shifts.
• Hidden injuries.
• Oxygenation issues.
• Pain.
• Psychosocial distress.
• Third spacing leading to hypotension & edema.
• Decreased GI motility that can lead to Curling's ulcer.

Pain Control for Burns

• Administered intravenously (IV) during the first 24-48 hours due to decreased perfusion and absorption.
• Gut function not optimal due to reduced perfusion.
• May require higher than normal doses.

Compartment Syndrome Control with Burns

• Escharotomy for circumferential burns.
• Fasciotomy.

Infection Control for Burns

• Topical and antimicrobial treatments to reduce infection risk.

Issues with Electrical Burns

• Altered level of consciousness.
• Cardiac dysrhythmias.
• Possible myoglobinuria.

Fluid and Effects Assessment

• Maintain vital organ function by balancing fluid administration to avoid complications of inadequate or excessive fluids.
• Perfuse organs without under or over fluid resuscitation.

Rule of 9's

• Quick method to estimate the Total Body Surface Area (TBSA) % in adults.
• Head and neck: 9%.
• Each upper extremity: 9%.
• Each lower extremity: 18%.
• Front trunk: 18%.
• Back trunk: 18%.
• Genitalia: 1%.

Trauma Primary Assessment

• Always prioritize ABCs first.
• A = Airway with cervical spine protection.
  • Patency - modified jaw thrust. -Supplemental oxygen.
  • Airway adjuncts - OP, ET, Cricothyrotomy, Tracheostomy.
  • Suction.
• B = Breathing.
  • Mouth-to-mask ventilation.
  • Bag-valve mask ventilation.
  • Ventilator.
  • Chest tube insertion.
    • high subcostal space for high pneumothorax.
    • 4th or 5th intercostal space for low pneumothorax.
• C = Circulation.
  • Check pulses (central: brachial, carotid, femoral).
  • Control obvious bleeding.
  • Treat hypovolemic shock.
  • PASG/MAST trousers.
  • Establish 2 large bore IVs.
  • Administer Lactated Ringers initially (crystalloid), saline, or blood.
  • Palpate pulse to prioritize but do not need to take BP at this time.
• D = Disability.
  • C-spine/spinal precautions at all times.
  • Glasgow Coma Scale (GCS) assessment.
  • AVPU (Alert, Verbal, Pain, Unresponsive) assessment.
  • Get current neuro status (Decerebrate to decorticate means neurological damage).
• E = Expose/Environmental.
  • Completely disrobe the patient for full visibility in secondary assessment.
  • Heat conservation as inc shivering means inc heat loss.

Secondary Assessment of Trauma

• F: Full set of vital signs, focused adjuncts, and family presence.
• G: Give comfort measures.
• H: History and Head-to-toe assessment.
• I: Inspect posterior surfaces.

Focused Adjuncts (Trauma)

• ECG monitor.
• Pulse oximeter.
• Exhaled CO2 detector.
• Indwelling urinary catheter
• Gastric tube
• Radiographic and Diagnostic Tests
• Chest radiograph
• Pelvic radiograph
• Focused assessment sonography for trauma (FAST)
• Diagnostic peritoneal lavage (DPL)
• Computerized tomography (CT) scans

Indwelling Urinary Catheter

• Should NOT be inserted if there is blood at the meatus, a displaced prostate, blood in the scrotum, or suspicion of anterior pelvic fracture.

Gastric Tube

• Remember the vagus nerve may be stimulated during insertion leading to bradycardia.
• Aspirate should be tested for pH and the presence of blood.

Lab Studies (Trauma)

Blood typing (1st priority).

• Other tests
  • Hematocrit and hemoglobin
  • Arterial blood gasses
  • Electrolytes
  • Clotting studies
  • Pregnancy test
  • Toxicology screen

Comfort Measures (Trauma)

• Facilitate Family Presence.
• Comfort Measures for pain:
  • Injuries
  • Procedures -Diagnostic testing
• Environment:unpleasant sensation-emotional response

Interventions for Pain

• Remove pain-producing objects
• Determine level of pain
• Initiate pain management techniques
• Administer prescribed medications
• Monitor closely after pain medications have been administered

Additional Secondary Assessment Interventions

• Additional laboratory studies
• Additional radiographs
• Angiography
• Wound care
• Tetanus prophylaxis
• Administration of medications
• Preparation for admission, surgery, or transfer

History (Trauma)

M: Mechanisms of Injury Specific injury patterns can assist in determining extent of injuries.

• On-scene information from the pre-hospital personnel such as location of patient in vehicle, need for extrication, and length of time on scene should be obtained. I: Injuries suspected based on information provided by prehospital personnel. V: VS T: Treatment initiated in the field and the patient's response.

Patient-generated Information

• Past medical history.
• Comorbid factors.
• Allergies.
• LMP.
• Tetanus status.
• Pre-existing problems.

Head to Toe Assessment

General appearance Head/face/neck

• Complete neuro exam, pupils, reactivity
• Palpate cranium
• Maxillofacial exam
• Palpate cervical spines
• Observe neck for swelling, bruising, tracheal deviation Eyes/ears/nose Chest
• Observe for symmetry, bruising, palpation of fractures, subq air, auscultate for lung sounds or bowel sounds
• Heart sounds, rubs Abdomen
• Bruising, swelling, tenderness, lacerations Pelvis and genitals
• Inspect for obvious deformities, blood at meatus, lacerations, check rectal sphincter tone Extremities
• Deformities, lacerations, function Back - LOG ROLL, bruising, tenderness

Additional Interventions for Secondary Assessment

• Additional laboratory studies
• Additional radiographs
• Angiography
• Wound care
• Tetanus prophylaxis
• Administration of medications
• Preparation for admission, surgery, or transfer

Possible Trauma Complications

• Major blood loss: shock, DIC, multiple organ dysfunction
• Hemothorax/Pneumothorax: ARDS
• Abdominal trauma: sepsis, hemorrhage, shock, DIC
• Orthopedics trauma: hemorrhage, DIC, shock, fat embolism, ARDS, sepsis

Priority Assessment Example

• For women with neck lacerations, priority is to assess ABCs.

Mechanisms of Injury

• Blunt trauma: skin intact.
• Penetrating trauma: skin disruption.
• Direct: injury resulting from a dynamic energy load.
• Indirect: injury from secondary insult, lack of oxygen or blood supply, swelling and compartment syndrome.

Blunt Trauma

• Most injuries from MVC, bike, and falls.
• No skin disruption
• Injury due to acceleration, deceleration, compression and shearing of internal organs.

Penetrating Trauma

• Break in skin integrity.
• Extent of injury dependent upon length of instrument, type of instrument, velocity, angle, area invaded.

Stab Wounds

• Low velocity
• Length of instrument dependent
• Area invaded with little damage due to energy dissipation
• Usually predictable path of destruction

Firearms

• High velocity
• Projectile mass
• Fragmentation - more projectiles
• Direct tissue damage and shock wave damage
• Yaw and Tumble main culprits

Patterns of Injuries

• MVC predictable depending on impact
  • Frontal - down and under: knees, femur, chest, abdomen, head
  • Frontal up and over: impacting windshield, head trauma
  • Lateral - T-bone impact pattern: side impact injuries
  • Rear-end - Head and neck: whiplash Coup and countercoup

Pedestrians

Adults- Waddell's Triad

• Impact side leg
• Chest and abdomen.
• Skull contralateral

Child

• Femur
• Chest
• Head Ask how they were found and if anyone witnessed it

Falls/Jumps

• Injury function of age, distance, surface
• Predictable: Clacaneus, fractures of vertebral column, hands/arms (catching)
• Don Juan syndrome.

Bikes

Mostly children

• Not wearing helmets Injuries up and over handlebars fracture femurs/Head trauma
• Lateral strike - fractures on impact side, head trauma contralateral

Anticipation of Care Needs

Age-Related Variances-Pediatric:

• Most common - head trauma - large heads and higher center of gravity.
• Smaller mass - energy of trauma effects more tissues with less fat; multi-organ injuries common.
• Skeleton more elastic absorption and protection capability decreased.
• Sensitive to hypoxia - most common cause of arrest situation.

Pregnant

• Anatomical changes:
  • Bladder higher
  • Large uterus causes changes in position and protection of vital organs like liver and spleen
  • Decreased lung volume
• Hemodynamics Cardiac output increased, decreased H/H/anemia.
• Normally hypercoagulation state so prone to DIC if stressed.
• Leads to increased bleeding risk.

Geriatric

• Delayed reaction time
• Gait disturbances
• Decreased sensorium
• Normal aging of organ systems
• Chronic diseases
• Poly pharmacy
• Decreased reserves to stress

Normal ICP

Normal ICP is 10 mm Hg (upper threshold 20 mm Hg)

Fluids and Intracranial Pressure (ICP)

• Avoid giving hypotonic fluids to patients with increased ICP.
• Hypotonic fluids enter the cells and increase cerebral edema.

Causes of Cerebral Edema

• Lesions (tumors, abscesses, clots).
• Injury (contusions, hemorrhage, post-traumatic brain swelling/inflammation).
• Surgery.
• Infection.
• Toxins (lead and arsenic).
• Systemic metabolic conditions (liver and renal failure).

Early Signs/Symptoms of Increased Intracranial Pressure (IICP)

• Headache.
• Nausea/vomiting.
• Amnesia for events.
• Altered level of consciousness (LOC).
• Restlessness, drowsiness, changes in speech, loss of judgment.

Late Signs/Symptoms of Increased Intracranial Pressure (IICP)

• Dilated, nonreactive pupil.
• Unresponsiveness to verbal or painful stimuli.
• Abnormal posturing patterns (flexion, extension, flaccidity). Changes in respiratory pattern.

Very Late Signs/Symptoms of Increased Intracranial Pressure (IICP)

• Cushing's Triad:
  • Increased systolic pressure with widening pulse pressure.
  • Slow, bounding pulse.
  • Slow, irregular respirations.
• Changes in body temperature.
• HERNIATION and DEATH

Managing ICP

• TREAT PRIMARY CAUSE!
• Reduce edema formation
  • Diuretics (mannitol)
• Dexamethasone (decadron) for tumor
• Hypertonic saline (2-3%)
  • Check serum na+
• Reduce stimuli
• Reduce CO2 (hyperventilation) reduces venous engorgement and causes vasoconstriction
  • BE CAREFUL decreased blood flow can also cause anoxia and further tissue damage

RN Actions for Patient with Cerebral Edema

• Serial vital signs
• I & O
• Cranial checks
  • Pupil size, pupil response to light, eye movement, hand grasps
• WATCH IV FLUIDS!
• Reverse Trendelenburg position
• Avoid/reduce stimuli
  • Suctioning, movement, painful procedures

Cervical Spine Immobilization Needs

• Assess/stabilize effective airway
• Immobilize to prevent further damage
• Maintain airway patency and effective breathing pattern
• Assess level of cord injury/stabilize with braces as ordered
• Administer IV fluids JUDICIOUSLY
• High-dose steroids to reduce swelling
• Warmth

Causes of Autonomic Dysreflexia

• Hyperreflexia
• Usually seen with SCI at T-6 or higher and represents uninhibited sympathetic discharge
• Some stimuli (bladder distension, bowel impaction, labor, temperature change, pain, UTI) stimulates excessive sympathetic nervous system stimulation below lesion
• Systemic vasoconstriction causes sweating, anxiety, hypertension, blurred vision, headache
• Parasympathetic nervous system attempts to compensate but inadequate

Untreated Autonomic Dysreflexia

If left untreated can lead to:

• CVA
• Renal failure
• Atrial fibrillation
• Seizures

Nursing Interventions for Autonomic Dysreflexia

• Raise head of bed
• Notify MD immediately
• Loosen tight clothing
• Check Foley catheter for obstruction/check for bladder distension
• Check rectum for impaction
• Cool of the room
• Monitor BP q10-15 min
• Vasodilators

Nursing Interventions with Spinal Cord Injury

• Serial vital signs
• I & O
• Cranial checks
  • Pupil size, pupil response to light, eye movement, hand grasps
• WATCH IV FLUIDS!
• Reverse Trendelenburg position
• Avoid/reduce stimuli
  • Suctioning, movement, painful procedures
• Assess/stabilize effective airway
• Immobilize to prevent further damage
• Assess level of cord injury
• Assess for autonomic dysreflexia
• Stabilize spine
  • Braces/surgery
• Psychological assessment

US Federal Transfer Law: Emergency Medical Treatment and Active Labor Act (EMTALA)

• Patients must be medically screened and once an emergency medical treatment is determined, the patient must be stabilized.
• Unstabilized patients may be transferred if the patient requests in writing and the physician documents that the benefit of transfer outweighs the risk of not transferring.
• ALWAYS STABILIZE A PATIENT BEFORE TRANSFERRING EVEN IF YOUR CENTER DOESN'T SPECIALIZE, YOU MUST STABILIZE FIRST.

Interfacility Transfer Protocols and Procedures

• Identify appropriate patients
• Identify medical authority responsible
• Identify appropriate facility
• Type of transportation needed
• Clinical protocols/standing orders
• How to arrange
• Family guidelines
• Forms
• Protocol for special situations

Transport Considerations

• Burns
• Head Injuries
• Spinal cord injuries
• Multiple system trauma
• Limb/digit amputation
• Children/Pregnant/Elderly or others with co-morbidities Modes of Transport

Air Transport

• Altitude changes
• Barometric pressure
• Thermal changes
• Humidity changes
• Gravitation changes
• Noise
• Vibration SPACE!

Phases of Transport

• Notification and acceptance by the receiving facility AFTER ASSESSMENT AND STABILIZATION
• Preparation by the transport team
• Turnover to the receiving facility
• Post-transport continuous quality improvement monitoring

Level One Trauma Center

• Provides more research, education, and medical education.
• Trauma services provided (ex. neurosurgery) 24/7.

Level 1-3 Trauma Centers

• Level 1-3 has a 24-hour surgeon available.

Level 4 Trauma Center

• Level 4 is where you stabilize the patient for transfer (freestanding ERs).

RN Role in Transport

• Treatments and diagnostics requested by receiving facility.
• Physician is responsible for activating transfer and assuring acceptance
• Ensuring appropriate personnel and equipment

Transport Interventions

• ABC's
• Urinary catheter, N/G tube, splints, dressings
• Tetanus
• Antibiotics
• Antianxiety
• Analgesics
• Radiologic and lab studies Copies of medical record, diagnostics
• Transfer consent
• Checklist completion
• Call report to receiving hospital
• TALK TO PATIENT AND FAMILY ALLOW VISITATION IF POSSIBLE

Transport Complications

• Inadequate airway
• Dysrhythmias
• Physiological instability
• Rough, rapid, disorganized transport
• Inadequate monitoring
• Long distance travel
• Discontinuation of medication effects Patient position

Interfacility Transport RN Role

• Monitor ABCs
• Monitor vital signs
• Monitor devices
• Adhere to protocols
• Communicate with receiving facility
• Document

With Transport Report

• Mechanism of injury
• Prehospital history
• Patient assessment and interventions
• Results of diagnostic procedures
• Vital signs
• Transport data

Authorization

• RN DOES NOT HAVE THE AUTHORITY TO TRANSFER.
  • MD decides where the pt will go based on their needs.

Leathery, White, Non-Painful Burns

• Full thickness burns

Interventions for Patient with Autonomic Dysreflexia

• Call HCP to order anti-hypertensive meds
• Elevate HOB to 45 degrees, loosen clothing, assess for bladder and bowel distension
• Anti-HTN meds

Electrical Injury

• For a client experienced an electrical injury with an entrance wound on the left hand and an exit wound site on the left foot the priority assessment data that should be obtained from client immediately on admission is heart rate and rhythm (ABCs).

Arteriovenous Fistula

• The best way to check for patency of the arteriovenous fistula for hemodialysis is to palpate the fistula throughout its length to assess for a thrill.

Arteriovenous Fistula (AV) Education

• In a client with fistula make sure client knows to check for the thrill, bruit, peripheral circulation, and ensure they cannot access ONLY ASSESS fistula

Caring for Head & Neck Trauma

• When caring for a client with a head and neck trauma following a vehicular crash, the nurse's initial action is to immobilize the cervical area.

Peritoneal Dialysis Color

• If you are caring for a client who is undergoing peritoneal dialysis and note the color of the returned fluid to appear cloudy and slightly pink-tinged, then the best action is to stop the dialysis flow and notify the health care provider.

Kidney Dysfunction

• Prerenal = Before Kidneys (cardiac and fluid related).
• Intrarenal = Within Kidneys (Infection and stone).
• Postrenal = After Kidneys (Something Blocking Flow; 45 Y/O with Renal Calculi in Ureters).

ABCDE Sequence Trauma

• A jaw thrust chin lift maneuver is used for airway purposes.
• Assessing respirations, looking for symmetry in chest wall, put on O2, is the next step once the airway if established.
• IV access is the next step after the airway and breathing are secured.
• Disability assessment (APVU, GCS) is next.
• Finishing up with removing clothing.
• Then followed by a full assessment→ VS, adjuncts, Foley, etc.

Burn Patient Assessment

• With a burn patient assessment a finding of inhalation injury would be a brassy cough.

Fluid Resuscitation

• Successfully fluid resuscitation indicated by UOP 50 mL or cc/hr.

Normal ICP (Intracranial Pressure) Range

• Normal ICP range is 0-15

Increase Intracranial Pressure (ICP) Medical Term

• With increased Intracranial pressure (ICP) from head trauma the medication of choice to use to lower the pressure is mannitol or 3% solution.

Expected Outcome With Stat Dose of Mannitol (Inc. ICP)

• (SATA) (Select all that apply) -Increase intravascular fluid volume
• Improvement in Glasgow Coma Scale (GCS)
• Increase urine out put

Increase Potassium (K+)

• Medication of choice with hyperkalemia is Kayexalate.

Fluid Volume Determination

• The best way to determine fluid volume and Na+ status with CRF (Chronic Renal Failure) is daily weight and BP

Burn Patient Assessment

• When a client is admitted to unit after being trapped in house fire and has experience singed hair, black sputum, with carbon monoxide poison then the assessment of greatest choice is Carboxyhemoglobin levels.

IV Pump Calculation

• If Pt with 500 cc bag to infuse at 0.7 mL/min… Then following would be how to calculate how long for infusion to be completed. -0. 7 (60) = 42 cc/hr 500/42 12 hrs = is answer.

Labs that are related to liver vs kidney function

• With liver disease lab values increase with the levels of Ammonia
• With kidney disease labs increase with levels of Creatinine

Issues Related to the Liver

• Encompass all the related diseases from Varices, Ascities and Encephalopathy

Medications for Encephalopathy

• Lactulose would be a medication given for encephalopathy.