Nursing 488: Multisystem Dysfunction - PDF

Nursing 488 Supporting Health III People with Life-Threatening Health Challenges Multisystem Dysfunction Shelley de Boer, RN, MN Catherine Fox RN, MN Bemi Lawal RN,MSN/ADM Cydnee Seneviratne RN, MN, PhD  Demonstrate an understanding of the nursing process across th...

Nursing 488 Supporting Health III People with Life-Threatening Health Challenges Multisystem Dysfunction Shelley de Boer, RN, MN Catherine Fox RN, MN Bemi Lawal RN,MSN/ADM Cydnee Seneviratne RN, MN, PhD  Demonstrate an understanding of the nursing process across the lifespan for individuals experiencing acute multi-system dysfunction. Objectives Explore, discuss, and identify common pharmacological interventions in caring for individuals with complex acute alterations in multiple system dysfunction, including shock and acid/base imbalance.  Shock Features Insufficient perfusion of tissue (delivery of blood) resulting in cellular hypoxia and death Life-threatening condition / medical emergency May be reversible with urgent interventions May progress to multi-organ failure and death despite urgent interventions There are multiple causes of shock that can be grouped by category Regardless of cause, hypotension is a key clinical finding that should signal its presence Gaistki & Mikkelson, cited in UpToDate, 2024, Definition, Classification, Etiology, and Pathophysiology of Shock in Adults , p. 1 The distribution of tissue injury and the resulting pattern of organ dysfunction may vary across patient populations. e.g., patients with pre-existing kidney disease are more likely to have renal dysfunction Figure 69.1, cited in Tyerman & Cobbett (2023) p. 1729  Main Abnormality in Forms of Shock Hypovolemic loss of blood volume Distributive arteries inappropriately dilate (blood flow is inappropriately distributed) Cardiogenic the heart cannot adequately pump blood Obstructive blockage to the flow of blood  Upstream Considerations Planning Safety Equipment Check Know the GOC designation for each patient Ensure you know the location of emergency buttons in each Identify patients at risk for shock and patient's room. anticipate/assess for symptoms. Review MEWS, Ensure the call bell and safety equipment and supplies are head-to-toe vital signs, intake/output, and lab present and functional at the bedside. trends as you plan your priorities for assessment Review the location of emergency equipment (i.e., crash cart, and monitoring. ambu-bag oropharyngeal airways, O2, suction equipment, anaphylaxis & naloxone kits, backboards, etc.) Safety/Baseline head to toe assessment Site-to-source line tracing includes all lines (02, NG, IV, catheter, etc.) Complete ASAP at the beginning of your shift Document ASAP so all members of the multidisciplinary team have the most up-to-date Communication/Collaboration information. Clear and timely communication is a patient safety imperative.  Prevention Early recognition Goals for Shock Interventions to restore mean arterial pressure (MAP) > 65 mmHg to achieve adequate oxygenation and perfusion  Clinical Presentation in the Major Types of Shock Shock Type Cardiovascular Respiratory Skin Neurological Renal ↓ BP, Tachycardia, Tachypnea, Crackles, Anxiety, confusion, ↓ Cardiogenic Cool, clammy, pallor ↓ CO, ↑ SVR Cyanosis perfusion ↓ Preload, ↓ BP, Hypovolemic Cool, clammy, pallor Anxiety, confusion ↓ Urine output Tachycardia Bradycardia, ↓ BP, Flaccid paralysis Neurogenic Warm or cool, dry Bladder dysfunction Temp instability (below injury) Shortness of breath, Flushing, Pruritus, Anaphylactic Tachycardia, ↓ BP Anxiety, ↓ LOC (late) Incontinence Wheezing, Stridor Urticaria, Angioedema Hyperventilation, Tachycardia, Temp Warm, flushed (early); Septic Resp. alkalosis → Confusion, agitation ↓ Urine output changes, ↓ BP cool, mottled (late) acidosis Obstructive ↓ CO, Tachycardia Shortness of breath Cool, clammy Anxiety, confusion ↓ Urine output Based on Table 69-4 (Sealock & Seneviratne, 2021)  Shock Type Oxygenation Circulation Drug Therapy Supportive Therapy Restore blood flow Treatment Cardiogenic Supplemental O₂ intubate if necessary (thrombolytics, angioplasty, assist devices) Nitrates, inotropes (e.g., dobutamine), diuretics Correct dysrhythmias Overview: Rapid fluid replacement (crystalloids, blood) via large- No specific drug therapy; focus Address cause (e.g., stop bleeding) Types of Shock Hypovolemic Supplemental O₂ bore IVs on fluids Septic Aggressive fluid resuscitation; Antibiotics, vasopressors (e.g., Obtain cultures, control Supplemental O₂ intubate if monitor CVP, PAOP dopamine) glucose levels necessary Neurogenic Cautious fluid administration Vasopressors (e.g., Stabilize spinal cord, Maintain airway phenylephrine), atropine monitor temperature supplemental O₂ if needed Anaphylactic Aggressive fluid resuscitation Epinephrine, antihistamines, Identify/remove cause, Optimize O₂ with colloids bronchodilators premedicate as needed Intubate if necessary Based on Table 69-11 (Sealock & Seneviratne, 2021  Septic Continuum Multiple organ Infection Bacteremia Sepsis Septic shock dysfunction death syndrome  Urgent Clinical Assessment and Common Laboratory and Diagnostic Imaging Investigations STAT ABGs Troponin CBC D-Dimer Electrolytes C-reactive protein (CRP) Creatinine blood cultures Glomerular filtration rate Sputum culture (GFR) Urinalysis (Urine R&M) Liver panel Urine for culture and Calcium sensitivity (C&S) Phosphate Chest radiograph (CXR) Magnesium ECG INR CT Pulmonary Angiogram PTT (CTPE) to rule out PE.  Prevention Recognition Immediate communication/collaboration Immediate action Nursing Ensure patent airway Interventions Communication (primary nurse, NI, Code 66, outreach team, etc.) Maximize oxygen delivery (caution in patients with COPD) IV access (>1) and volume resuscitation (MAP > 65 mmHg) Septic Shock STAT blood cultures, swabs, lactate, CBC, etc. Empiric antibiotics STAT (following blood cultures) Vigilant vital sign assessment (i.e., q 15, 30, 1h as indicated) Systematic head-to-toe assessments monitoring for  effects of cytokines and hypoperfusion  Additional complications from multiple organ dysfunction syndrome (MODs), including ARDs, DIC, AKI, etc. Intake and output (i.e., q1h) Follow-up labs (ABGs, CBC, electrolytes) Treat nutritional and metabolic needs (protein-calorie malnutrition is common) Ongoing documentation and evaluation of interventions Collaborative Care Septic Shock  Collaborative Care Septic Shock Nutrition is vital to decreasing morbidity from shock. ◦ Monitor protein, nitrogen balance, BUN, glucose, and electrolytes. ◦ Anticipate the possibility of enteral nutrition within the first 24 hours. ◦ Anticipate total parenteral nutrition (TPN) if enteral feedings are contraindicated or fail to meet at least 80% of caloric requirements Serum glucose < 10 mmol/L Stress ulcer prophylaxis may be indicated if additional risk factors for GI bleed exist. If the patient has been intubated/ventilated, skin breakdown may have formed.  Prevention is key  Plan to prevent shock  Practice universal precautions Key Points  Aseptic ports of entry (i.e., 02 devices, SL, etc.)  Advocate for removal of catheters at earliest opportunity  Identify those at risk  Elderly  Immunocompromised Actively monitor for early warning signs as part of daily nursing practice; everyone is at risk for septic shock while ill and in acute care.  Nursing interventions Complications of fluid Prevention resuscitation Recognition Hypothermia Nursing Immediate Coagulopathy communication/collaboration Interventions Immediate action Ongoing Vital signs IV access (multiple saline locks) Head-to-toe assessments Vigilant monitoring of vital signs Hypovolemic Shock Intake/output Point of Care Ultrasound Management focuses on (POCUS) of the jugular and Treating the underlying cause IVC Correcting the volume deficit Daily weight (most inpatient Addressing electrolyte or acid/base beds can weigh) imbalances Common classes of fluid replacement Crystalloid solutions Colloid-containing solutions (rare) Blood products  Anaphylaxis Prevention  Beginning with shift preparation, always note your patient's allergies and any history of anaphylaxis.  During your initial safety assessment and emergency equipment check, verify that the patient’s allergy band is present on their arm and that the allergies listed match those in Connect Care. If they do not match, promptly inform your primary nurse and nursing instructor.  Prior to administering medications, always provide clear explanations of the medication's name and purpose and clarify any history of allergy. Recognize  Symptom recognition Simultaneously, immediately call for help. Use clear, closed-looped communication. As nursing students, you do not have the knowledge or experience to handle any aspect of anaphylaxis independently.  Anaphylaxis Remove/Stop the cause. Position Patient Recumbent position, legs elevated as tolerated. Immediately communicate/collaborate Recovery position if vomiting/emesis Assess ABCs while concurrently anticipating If pregnant, left side, elevate legs if tolerated.  Intramuscular (IM) epinephrine at earliest opportunity  Supplemental oxygen Sudden cardiac arrest can occur if the individual  STAT IV insertion(s) for Intravenous (IV) volume resuscitation suddenly changes position Document (i.e., suddenly sits or stands) due to empty ventricle Onset, symptoms, time support was requested, and syndrome. means (i.e., staff assist bell, Code, etc.) Reassess Time support arrived Head-to-toe assessments actions taken (meds given, etc.) Vital signs patient progress This includes several hours post (risk of biphasic) Plan for follow-up Report per RLS as indicated. Alberta Health Services 2020 Anaphylaxis Management: Administration of Intramuscular Epinephrine, p. 1-10. Alberta Health Services Anaphylaxis Management Policy  Epinephrine, administered intramuscularly (IM) is the first-line treatment for anaphylaxis, as it is the only medication that affects multiple body systems (AHS, 2024) As a peripheral vasoconstrictor, epinephrine IM rapidly reduces Anaphylaxis Upper airway edema Hypotension Epinephrine IM increases the heart rate (chronotropic effect) and enhances the force of heart contractions (inotropic effect), which First line treatment helps to combat hypotension. INTRAMUSCULAR Epinephrine IM reduces bronchospasm and the release of inflammatory EPINEPHRINE mediators. Epinephrine should be administered intramuscularly (IM) regardless of vascular access. The optimal administration site is the mid-anterior lateral thigh (vastus lateralis muscle). https://insite.albertahealthservices.ca/Assets/tms/hpsp/modules/tms-hpsp- anaphylaxis-management/index.htm  Anaphylaxis Kits Ensure you know the location of your unit's anaphylaxis kit. Ampule of epinephrine that states “For IM use ONLY” 1mL syringe SafetyGlide needle #25g generally used for pediatrics, #22g, generally used for adults 18g blunt fill needle (w filter) Alcohol swabs Cited at AHS, Insite, 2024  Anaphylactic Shock Adjunct Medications Glucocorticoid (IV) may be ordered to prevent rebound/biphasic reactions Antihistamines do not prevent or relieve airway obstruction, hypotension, shock, or gastrointestinal symptoms. Antihistamines can alleviate symptoms such as pruritus, flushing, and hives and may be used after intramuscular epinephrine once the patient is stabilized. Antihistamines can contribute to Hypotension Cause anaphylaxis itself Impair self-recognition of symptoms (sedating properties) Cause paradoxical excitement in young children https://insite.albertahealthservices.ca/Assets/tms/hpsp/modules/tms- hpsp-anaphylaxis-management/index.html  Crystalloids Solutions containing fluids and electrolytes that are normally found in the body Do not contain proteins (colloids) There is no risk of viral transmission, anaphylaxis, or alteration in the coagulation profile. For patients experiencing severe volume depletion or hypovolemic shock not caused by bleeding, crystalloid solutions are generally preferred over those containing colloids (Cited in UpToDate, 2024, Treatment of Severe Hypovolemia or hypovolemic Shock in Adults, p. 4) Used as maintenance fluids to Compensate for insensible fluid losses Replace fluids Manage specific fluid and electrolyte disturbances  Tonicity Isotonic - Same Size Placing a cell into an isotonic solutions will have no net effect on the cell as the tonicity (osmolality) of the cell is equal to the fluid. Hypertonic - Cells Shrink Placing a cell into a Hypertonic solution will draw water out on the cell, and the cell will shrink. Hypotonic - Cells Burst Placing a cell into a hypotonic solution will attempt to shift fluid into the cell, the cell will swell and may burst.  Intravenous (IV) Solutions Isotonic solutions 0.9% normal saline D5W Normal serum osmolality 275 – 295mOml/L Ringer’s Lactate D5W in 0.225% saline IV Solution Osmolarity Hypotonic solutions 0.45% saline NaCL (0.9%) 308mOsm/L D5W (physiologically) Hypertonic solutions Lactated Ringer’s 273mOsm/L D10W 3.0% saline D5W in 0.45% saline (DKA during maintenance) D5W in 0.9% normal saline D5W has an osmolality 275mOsm/L NS (0.9%) has an osmolality of 308mOsml/L Normal serum osmolality  Fluid Shifts and Edema Osmotic Pressure The ability of a solution to draw water across a semipermeable membrane. Isotonic crystalloid solution (Normal Saline, Lactated Ringers) Oncotic Pressure Plasma proteins (colloidal osmotic pressure) is osmotic pressure exerted by colloids in solution. Plasma proteins exert this pressure and, as a result, pull water from the interstitial space to the vascular system Colloid solution (large proteins: albumin, globulin, fibrinogen) Hydrostatic Pressure in arterial (30-40 mmHg) and venous (10-15 mmHg) ends of the capillary, the force exerted by a fluid (in this context, blood) against the walls of its container (in this case, the blood vessel walls). Hydrostatic pressure varies along the length of the capillary bed and between arterial and venous ends. Capillary Permeability is increased for pts with burns or allergic inflammatory reactions  Fluid Shifts and Edema Systemic signs Neuro, EENT, Resp, CVC, GI, GU, MSK, Integ. Peripheral: systemic swelling, pitting edema Central e.g., ascites, pleural & interstitial spaces Serum Osmolality Serum osmolality: a measure of the solute concentration of the blood [sodium, glucose and urea] (↑ = fluid volume deficit, ↓ = fluid volume excess) Urine Osmolality Urine osmolality – a measure of the solute concentration of urine [nitrogenous wastes – creatinine, urea, and uric acid] (↑ = fluid volume deficit, ↓ = fluid volume excess)  The main goal of using vasopressors is to elevate blood pressure to achieve a mean arterial pressure (MAP) of greater than 65 mmHg. Adrenergic Drugs Dobutamine: Primarily stimulates β₁ receptors on heart muscles, increasing contractility Vasopressor Dopamine: At low doses, may dilate visceral (gut) arteries, e.g., Medications to the kidneys. At higher doses, it constricts all arteries (α₁). This medication is used less frequently. Epinephrine: Administered IV in cardiac arrest IM in anaphylaxis. Norepinephrine or phenylephrine: First-line therapy. Constricts arteries (α₁) and increases heart contractility (β₁). Vasoactive Medications Common Effects are medications Have a variety of related to the include effects on the alpha specific dose dobutamine and beta adrenergic of the dopamine receptors adrenergic epinephrine drug norepinephrine phenylephrine  Vasoactive Medications Nursing Considerations Ideally, administered through a central line (rather than a peripheral IV) If extravasation occurs, it can lead to tissue ischemia or necrosis. Vigilantly monitor vital signs The patient will be in a specialized critical care setting, i.e., ICU/CCU/Trauma/ER. Vasoactive Medications Adverse Effects CNS: headache, restlessness, tremors, nervousness, dizziness, insomnia CV: chest pain, vasoconstriction, hypertension, tachycardia (positive chronotropy), fluctuations in blood pressure, and palpitations or dysrhythmias GI: anorexia, dry mouth, nausea, vomiting Cardiogenic Shock  Urgent Clinical Assessment and Common Laboratory and Diagnostic Imaging Investigations STAT ABGs Troponin CBC D-Dimer Electrolytes C-reactive protein (CRP) Creatinine blood cultures Glomerular filtration rate Sputum culture (GFR) Urinalysis Liver panel Urine for culture and Calcium sensitivity (C&S) Phosphate Chest radiograph (CXR) Magnesium ECG INR CT Pulmonary Angiogram PTT (CTPE) to rule out PE.  Coronary Revascularization Heart Bypass Surgery (CABG) Angiogram & Angioplasty Sunnybrook Coronary Artery Angioplasty (Radial Access) Collaborative Care Cardiogenic Shock Restore blood flow to the myocardium Thrombolytic therapy Angioplasty with stenting Emergency revascularization (Emergency CABG) Valve replacement (if flail valve) Pericardiocentesis. (if tamponade) Pacemaker for heart block Obstructive Shock Treatment Interventions are based on the cause of the obstruction Pericardiocentesis for cardiac tamponade Needle decompression or chest tube insertion for tension pneumothorax Thrombolytics or embolectomy for pulmonary embolism  Venothromboembolic Disease Diagnosis Nursing Interventions Computed Tomography Pulmonary Angiogram If ordered, activity as tolerated (AAT), encourage mobility (CTPA) and assess tolerance to mobility (Any D-Dimer (needs interpretation) syncope/presyncope, shortness of breath on exertion VQ Scan (SOBOE), chest pain with mobility, diaphoresis, etc. Patient Monitoring Encourage passive range of motion, coughing and deep breathing exercises if ordered bedrest. Hemodynamics, vital signs (tachycardia, low BP, Teach pt to self-administer if going home on SC doses sl. Elevated temp), 02 requirements, mobility, Teach diet and activity restrictions as ordered. color, level of distress, etc. Teach signs and symptoms of bleed. Symptoms: patient comfort (i.e. chest pain at Highlight the potential significance of falls, which can rest or with mobility), pre-syncope or dizziness lead to serious injuries and complications. with mobility. Nursing Implications Continuously observe the patient's condition to identify any changes in their status. Planning and promptly implementing nursing interventions and therapies. Evaluation of the patient’s response to therapy Providing emotional support to the patient and family Collaborating with other members of the health team to coordinate care  In spinal cord injury Nursing Interventions C-spine precautions: stabilize the cervical spine with collar (note, all nurses must have patient care unit education/approval to participate in any c-spine Neurogenic Shock precautions). Treatment of hypotension and bradycardia with vasopressors and (potentially) atropine. Fluids are used cautiously, as hypotension is generally unrelated to fluid loss. Prevent and monitor for hypothermia. Likely indwelling catheter Nutrition, once medically stable, is critical. Prevention of skin breakdown is essential.  Disseminated Intravascular Coagulation (DIC) DIC is always caused by an underlying disease or condition The underlying problem must be treated for DIC to resolve Evolves rapidly (over hours to days)  bleeding Diagnosed through thrombocytopenia, elevated PTT, INR, elevated D-Dimer (or serum fibrin degradation products), and a decreasing fibrinogen level Supportive Therapy Platelet therapy Coagulation factors (in fresh frozen plasma) Fibrinogen (in cryoprecipitate) to control severe bleeding.  Respiratory Failure & Acute Respiratory Distress Syndrome Nursing Interventions  Treatment of the underlying disorder  Oxygen/Ventilation  Fluid balance  Medications  Nutrition  Patient teaching  Family-centred care  Urgent Clinical Assessment and Common Laboratory and Diagnostic Imaging Investigations STAT ABGs Troponin CBC D-Dimer Electrolytes C-reactive protein (CRP) Creatinine blood cultures Glomerular filtration rate Sputum culture (GFR) Urinalysis Liver panel Urine for culture and Calcium sensitivity (C&S) Phosphate Chest radiograph (CXR) Magnesium ECG INR CT Pulmonary Angiogram PTT (CTPE) to rule out PE.  History and physical exam Pulse Oximetry Diagnostics ABG’s Chest radiograph (CXR) Acute Respiratory Failure Nursing and Collaborative Management Nursing Diagnoses Planning: Overall Goals Impaired gas exchange ABG values within patient's baseline Ineffective airway clearance Breath sounds within patient's baseline Ineffective breathing pattern No dyspnea or breathing patterns within patient's baseline Risk for fluid volume imbalance Effective cough and ability to clear secretions  Acute Respiratory Failure Drug Therapy Bronchodilators: used for the relief of bronchospasm Corticosteroids: administered to reduce airway inflammation Diuretics or nitrates may be indicated if heart failure is present to reduce pulmonary congestion IV antibiotics: for treatment of infection Oxygen (note whether the patient is a C02 retainer as this influences Sa02 goals) Collaborative Care Acute Respiratory Distress Syndrome (ARDS) The patient is typically transferred to the ICU, intubated, and placed on mechanical ventilation with positive end-expiratory pressure (PEEP).  Acute Respiratory Distress Syndrome (ARDS) Prone Positioning for ARDS  Health Promotion Priorities for Patients with (or at risk) for Respiratory Conditions Coughing/deep breathing Encourage patients to notify the nurse immediately of chest pain/tightness or increasing shortness of breath. Encourage avoidance of venous stasis by moving regularly and/or performing ROM exercises.  Immediate Support Criteria Code 66 Code Blue Immediate response for life-threatening Purpose Early intervention for deteriorating patients emergencies  Threatened airway  Unresponsive and not breathing  Respiratory rate 30 Activation Criteria  No pulse  Acute changes in SaO₂ despite increased O₂  Immediate need for resuscitation  Heart rate