TBSN Unit 4 Review

• The review is for Unit 4 TBSN Exam

What Foods Should ESRD Patients Avoid

• High potassium foods should be avoided
• High phosphorus foods should be avoided
• Highly processed foods should be avoided
• Salt intake should be avoided

GI Bleeds

• Peptic ulcers are the most common cause of GI bleeds
• Check vitals first for hypovolemia if a patient has a GI bleed and is vomiting red blood profusely
• If the patient has been in the hospital for a while with a GI bleed and is stable but suddenly has baseline LOC changes, you will need to act

ER Priorities for Vomiting Blood

• If a patient is vomiting 1,000ml of blood, administer fluids and keep the patient hemodynamically stable
• Inserting a nasogastric tube could be considered
• Obtaining the type and cross test could be considered
• Insertion of large bore IVs with normal saline could be considered
• Giving Protonix IV to the patient could be considered

Case Study

• Give Tylenol
• Start 2 large bore IVs
• Get a NG tube in place
• Do a swallow study
• Collect labs
• Monitor vitals every 15 minutes

Diet for Burns

• Burn victims need increased nutritious calories
• burn victims need high protein in their diet
• Burn victims need good fats, vitamins, and minerals that come with higher calories
• Calories for burn victims should come from whole products like meats, dairy, veggies, and fruit, not dense or fast food

Formulas

• Remember the Rule of 9's, there will be a diagram on the test
• Memorize the Parkland Formula: 4mL/kg/%TBSA, make sure to change the patient's weight from lbs to kg

Expected Labs in DKA

• pH is 7.29 or less than 7.3, indicating acidosis
• Blood glucose is over 300
• Bicarbonate levels are less than 18
• Anion Gaps are above 15
• Ketones are present in urine or blood

Kussmauls

• Kussmauls are fast, deep breaths
• Kussmauls occur in response to metabolic acidosis
• Lungs try to remove carbon dioxide during Kussmauls
• This is a respiratory compensation

Glucose Levels

• If a patient has a glucose level below 50 and has a decreased LOC, an amp of D50 IV will work the fastest

Stages of AKI

• Pre-Renal: GFR is below 60, dehydration, heart failure, and hypotension
• Intra-Renal: Acute tubular necrosis
• Post-Renal: Blockages from a BPH tumor or from infections like a UTI
• Normal GFR is 90-120
• Less than 15 GFR is ESRD
• Below 60 GFR is usually pre-renal failure

Lab Values in ATN

• BUN levels elevate
• Creatinine levels elevate
• Electrolytes like potassium may elevate

Case Study AKI

• Assess other options to determine the reason for AKI if a patient is in renal failure, shows no signs of obstruction or decreased perfusion, has no disease process that would hurt the kidney, and is generally healthy

DKA Knowledge

• Ketones are largely present in DKA but not in HHS
• Sugars should be checked every hour for DKA or HHS in critical care
• DKA is a lack of insulin
• Lack of insulin promotes metabolism of fat stores, which produces large amounts of acidic ketones

Severe Dehydration in DKA & HHS

• An excessive amount of glucose enters the renal tubules and draws a large amount of water
• A large amount of water that ends up producing a significant amount of urine which is known as osmotic diuresis
• Osmotic diuresis leads to volume depletion and dehydration

Hemo

• Hemodialysis removes excess water via ultrafiltration with a UFR
• Hemodialysis removes toxins like urea and creatinine through a dialyzer with a semipermeable membrane with osmosis and diffusion
• This process is hard on the heart because of the higher BFR and pressure.
• A higher BFR exposes blood to the dialyzer membrane leading to better toxin removal in a shorter time

Hemodialysis Rules

• Care of the fistula requires no tight clothing, needle sticks, or blood pressures on the arm of the fistula
• The patient should avoid heavy lifting with the arm of the fistula
• General time frame of needing dialysis is 3 times a week

Hemolysis

• Chlorine is the number one enemy
• A blood leak that occurs while giving CRRT or Hemo and the bath mixes with the blood such in the bicarb, acid or dextrose could also cause hemolysis

Hemodialysis and CRRT

• BFR is fast in hemo and slow in CRRT
• CRRT provides time for the kidneys to rest and recover
• CRRT is for the critically ill and Hemo is for stable patients
• Labs are drawn every 6 hours in CRRT
• Labs for Hemo are weekly or monthly

Patient Baseline

• After acute upper GI bleed due to AV malformation for 2.5 days, if a patient becomes restless with confusion and wants to leave AMA, report the following to the physician
  • Potassium level of 5
  • Over night with 1.5 lb weight gain
  • Decreasing LOC changes
  • Temperature change to 99.0

Hemo & CRRT Complications

• Infection
• Air embolism
• Hypotension
• Dysrhythmias
• Nausea and Vomiting
• Bleeding

Symptoms of Fluid Overload

• Shortness of breath
• Lung crackles
• Wet lung sounds that are coarse
• Tachypnea and anxiety

Circumferential Burn

• Remember when caring for these types of burns that it can mimic compartment syndrome
• Capillary refill and checking pulses is the gold standard besides checking for infection

Full Thickness Burns

• Insensitive
• Does not blanch
• Deep exposure to muscle

Organ Donation

• Life share or the organ procurement organization should be called for a patient on the vent declared brain dead

Transplant Rules

• No cold food, it must be hot
• No ice
• No water from the tap or from a well
• Medications are strictly taken on time, same time each day
• Stay away from immunocompromised people
• Immunosuppressant drugs for a lifetime
• Ongoing medical care for life
• Follow a healthy lifestyle
• Prevent infection
• Patients need to be paired with non-infectious patients

Signs of Organ Rejection

• If liver, then upper right quad pain, if kidney, usually lower back pain
• A patient may have a decrease in LOC
• A patient may present allergic or itching symptoms
• A patient may also spike a fever
• Change in color
• Change in urination

Kidney Transplant

• 2 weeks after a transplant, a patient is admitted for weakness and potential infection, report these lab values for possible kidney rejection
  • Creatinine of 5
  • HGB 15
  • WBC 4
  • Sodium 137

Possible Organ Donor

• A patient that has no brain activity that is 36 from an MVA

Unit 4 Blueprint

• There are 4 math questions
• Chapter 27 = 8
• Chapter 28 = 9
• Chapter 38 = 7
• Chapter 41 = 9
• Chapter 44 = 7
• Chapter 50 = 10

Math Questions

• The problem will start off in units/KG/Hour
• Remember the Rule of Nines, there will be a chart on the test
• Remember the Parkland Formula for the first 8 hours
• There will be a regular dimensional analysis that is very basic