Midterm Critical Care PDF

M4 Lesson 1: Gastrointestinal Bleeding PEPTIC ULCER DISEASE (PUD) the most common cause of upper GI bleeding. A peptic ulcer is an ex...

M4 Lesson 1: Gastrointestinal Bleeding PEPTIC ULCER DISEASE (PUD) the most common cause of upper GI bleeding. A peptic ulcer is an excavation that forms in the GASTROINTESTINAL BLEEDING mucosal wall of the stomach, in the pylorus, in the Life-threatening GI bleeding usually occurs in the upper GI tracts duodenum, or in the esophagus. and requires immediate therapy to prevent complications. The erosion of a circumscribed area may extend as deep Patients presenting with sudden blood loss are at risk for as the muscle layers or through the muscle to the decreased tissue perfusion and oxygen-carrying capability, which peritoneum. can affect every organ in the body. Pathogenesis is related to the hypersecretion of gastric acid, coupled with impaired GI tract mucus secretion, Helicobacter pylori, an organism found in GI tract can be an implication to the pathogenesis of the PUD Classification Gastric ulcer. Gastric ulcers tend to occur in the lesser curvature of the stomach, near the pylorus. Duodenal ulcer. Peptic ulcers are more likely to occur in the duodenum than in the stomach. Esophageal ulcer. Esophageal ulcers occur as a result of the backward flow of HCl from the stomach into the esophagus. Common Sources of Upper Gastrointestinal Bleeding Peptic Ulcer Disease o Gastric ulcer o Duodenal Ulcer Varices o Esophageal o Gastric Pathologies of the Esophagus o Tumors o Mallory-Weiss Syndrome o Inflammation o Ulcers Clinical Manifestations Pathologies of the Stomach Melena: Dark tarry stool o Cancer Coffee-ground emesis o Erosive gastritis Hematemesis: vomiting blood o Stress ulcers Dyspepsia/ Epigastric pain o Tumors Nausea Pathologies of the small intestine Assessment and Findings o Peptic ulcer Esophagogastroduodenoscopy. Confirms the o Angiodysplasia presence of an ulcer and allows cytologic studies and biopsy to rule out H. pylori or cancer. Physical examination. A physical examination may reveal pain, epigastric tenderness, or abdominal distention. Barium study. A barium study of the upper GI tract may show an ulcer. Endoscopy. Endoscopy is the preferred diagnostic procedure because it allows direct visualization of inflammatory changes, ulcers, and lesions. Occult blood. Stools may be tested periodically until they are negative for occult blood. Carbon 13 (13C) urea breath test. Reflects activity of H. pylori. Medical Management P. B. M | 1  Pharmacologic therapy. Currently, the most commonly Explain diagnostic tests and administering medications used therapy for peptic ulcers is a combination of proton on schedule. pump inhibitors, and bismuth salts that suppress or Interact in a relaxing manner, help in identifying eradicate the infection. stressors, and explain effective coping techniques and Stress reduction and rest. Reducing environmental relaxation methods. stress requires physical and psychological modifications Encourage the family to participate in care and give on the patient’s part as well as the aid and cooperation emotional support. of family members and significant others. Monitoring and Managing Complications Smoking cessation. Studies have shown that smoking If hemorrhage is a concern: decreases the secretion of bicarbonate from the Assess for faintness or dizziness and nausea, before or pancreas into the duodenum, resulting in increased with bleeding; test stool for occult or gross acidity of the duodenum. blood; monitor vital signs frequently Dietary modification. Avoiding extremes of the (tachycardia, hypotension, and tachypnea). temperature of food and beverages and overstimulation Insert an indwelling urinary catheter and monitor from consumption of meat extracts, alcohol, coffee, and intake and output; insert and maintain an IV line for other caffeinated beverages, and diets rich in cream and infusing fluid and blood. milk should be implemented. Monitor laboratory values (hemoglobin and hematocrit). Surgical Management Insert and maintain a nasogastric tube and Pyloroplasty. Pyloroplasty involves monitor drainage; provide lavage as ordered. transecting nerves that stimulate the acid secretion and Monitor oxygen saturation and administering opening the pylorus. oxygen therapy. Antrectomy. Antrectomy is the removal of the pyloric Place the patient in the recumbent position with the portion of the stomach with anastomosis to either the legs elevated to prevent hypotension or place the patient duodenum or jejunum. on the left side to prevent aspiration from vomiting. Nursing Management Nursing Assessment Treat hypovolemic shock as indicated. If perforation and penetration are concerns: Assessment for a description of pain. Note and report symptoms of penetration (back and Assessment of relief measures to relieve the pain. epigastric pain not relieved by medications that Assessment of the characteristics of the vomitus. were effective in the past). Assessment of the patient’s usual food intake and food Note and report symptoms of perforation (sudden habits. abdominal pain, referred pain to shoulders, vomiting Nursing Diagnosis and collapse, extremely tender and rigid Acute pain related to the effect of gastric acid secretion abdomen, hypotension and tachycardia, or other signs on damaged tissue. of shock). Anxiety related to an acute illness. Home Management and Teaching Self-Care Imbalanced nutrition related to changes in the diet. Assist the patient in understanding the condition and Deficient knowledge about prevention of symptoms factors that help or aggravate it. and management of the condition. Teach patient about prescribed medications, including Nursing Care Planning & Goals name, dosage, frequency, and possible side effects. Relief of pain. Also, identify medications such as aspirin that patients Reduced anxiety. should avoid. Maintenance of nutritional requirements. Instruct patient about particular foods that will upset the gastric mucosa, such as coffee, tea, colas, and Knowledge about the management and prevention of alcohol, which have acid-producing potential. ulcer recurrence. Absence of complications. Encourage the patient to eat regular meals in a relaxed setting and to avoid overeating. Nursing Interventions Relieving Pain and Improving Nutrition Alert the patient to signs and symptoms of complications to be reported. These complications Administer prescribed medications. include hemorrhage (cool skin, confusion, increased Avoid aspirin, which is an anticoagulant, and foods heart rate, labored breathing, and blood in the stool), and beverages that contain acid-enhancing caffeine penetration and perforation (severe abdominal pain, (colas, tea, coffee, chocolate), along with decaffeinated rigid and tender abdomen, vomiting, elevated coffee. temperature, and increased heart rate), and pyloric Encourage the patient to eat regularly spaced meals in a obstruction (nausea, vomiting, distended abdomen, and relaxed atmosphere; obtain regular weights and abdominal pain). To identify obstruction, insert encourage dietary modifications. and monitor nasogastric tube; more than 400 mL Encourage relaxation techniques. residual suggests obstruction. Reducing Anxiety Smoking cessation Assess what the patient wants to know about the disease and evaluate the level of anxiety; encourage the patient to express fears openly and without criticism. P. B. M | 2  Anomalous presentation of human leukocyte antigen M4 Lesson 2: Liver failure (HLA) class II on the surface of hepatocytes causes a cell-mediated immune response against the liver Functions of the Liver: Making blood proteins that aid in clotting, transporting SIGNS AND SYMPTOMS oxygen, and supporting the immune system Fatigue, drowsiness and weight loss Manufacturing bile, a substance needed to help digest Fever and septicemia (blood poisoning) food Jaundice Helping the body store sugar (glucose) in the form of Ascites glycogen Hepatic encephalopathy Ridding the body of harmful substances in the bloodstream, including drugs and alcohol LAB INVESTIGATION Breaking down saturated fat and producing cholesterol CBC with platelets Liver failure occurs when your liver isn’t working well Prothrombin time enough to perform these tasks. Serum bilirubin: The level of bilirubin, a yellow substance Liver failure can be a life-threatening emergency that made when the body breaks down old red blood cells. requires immediate medical attention. High Bilirubin Levels means the liver isn’t processing bilirubin properly, leading to a buildup in the blood, LIVER FAILURE which causes jaundice (yellowing of the skin and The most severe clinical consequences of liver disease eyes). are hepatic failure. It generally develops as the end point Serum Albumin: The level of albumin, a protein made by of progressive damage to the liver. the liver that helps keep fluids in the bloodstream. Low 80% to 90% of hepatic function must be lost before Albumin Levels means the liver isn’t producing enough hepatic failure ensues. albumin, which can lead to fluid leaking out of blood vessels, causing swelling and fluid buildup (like in the CHRONIC LIVER FAILURE abdomen). Most common form of liver failure ALT-AST: Levels of enzymes released when liver cells are Inability of the liver to perform its normal synthetic and damaged. High Levels indicate that liver cells are being metabolic function as part of normal physiology. injured or dying. This is common in acute liver issues like Chronic liver failure is a deterioration of liver function hepatitis or toxic liver injury. that occurs over a long period of time, generally months ALP: An enzyme related to bile flow in the liver. High ALP to years Levels suggest there may be a blockage in the bile ducts It usually occurs in the context of cirrhosis or issues with bile flow, which can happen in certain liver diseases. CAUSES: RADIOLOGICAL INVESTIGATION 1. Cirrhosis Ultrasound Development of scar tissue that replaces normal MRI parenchyma. This scar tissue blocks the portal flow of Ultrasonography blood through the organ therefore disturbing normal EEG function. MR spectroscopy Damage to the hepatic parenchyma leads to activation CSF of the stellate cell, which increases fibrosis and TREATMENT obstructs blood flow in the circulation. The only curative treatment is liver transplantation ICU to maintain BP, pulse, mental status with 4 TYPES OF CIRRHOSIS nasogastric tube 1. Alcoholic (Laennec’s) cirrhosis Glucose to treat hypoglycemia 2. Postnecrotic cirrhosis Antibiotics 3. Biliary cirrhosis PREVENTION 4. Cardiac cirrhosis Get vaccinated against hepatitis A and B. Do not use multiple medications or illicit drugs unwisely. 2. Viral Hepatitis B Hepatitis C 3. Excessive alcohol intake If you have any member of the family of friend who is sick, avoid contact with blood or bodily fluids Chronic consumption of alcohol results in the secretion of pro-inflammatory cytokines (TNF-alpha, Interleukin 6 Eat healthy exercise and keep your weight down. and Interleukin 8). These factors cause inflammation, Do not drink alcohol apoptosis and eventually fibrosis of liver cells. Screening for Hepatocellular Cancer 4. Hemochromatosis Disorder related to deficiency of the iron regulatory hormone hepcidin. HHC is an autosomal recessive genetic disease in which increased intestinal absorption of iron causes accumulation in tissues, especially the liver, which may lead to organ damage. 5. Autoimmune hepatitis P. B. M | 3 ACUTE LIVER FAILURE Complications of Acute Liver Failure The clinical manifestation of sudden and severe hepatic CEREBRAL EDEMA injury with the onset of coma and coagulopathy up to Excessive fluid causes pressure to build in your brain, which can within 6 months. However, onset is usually Within 1-6 displace brain tissue outside of the space it normally occupies weeks from the onset of any signs of illness. (herniation). Cerebral edema can also deprive your brain of oxygen. Etiology 1. Acetaminophen-related Liver BLEEDING DISORDERS The most common cause of ALF in the US. A failing liver isn't able to produce sufficient amounts of clotting Caused by overdose & toxicity. - Caused by overdose & factors, which help blood to clot. People with acute liver failure toxicity. often develop bleeding from the gastrointestinal tract. Bleeding Acetaminophen-Alcohol poisoning may be difficult to control. 2. Drug-induced injuries 10% of drug-induced liver injuries progress to acute liver INFECTIONS failure. People with acute liver failure are at an increased risk of anti-infectives, anticonvulsants, and anti-inflammatory developing a variety of infections, particularly in the blood drugs most commonly implicated. and in the respiratory and urinary tracts. SIGNS AND SYMPTOMS OF ACUTE LIVER FAILURE KIDNEY FAILURE Yellowing of your skin and eyeballs (jaundice) Kidney failure often occurs following liver failure, especially in cases of acetaminophen overdose, which damages both your liver Pain in your upper right abdomen and your kidneys. Abdominal swelling Nausea COMA – MENTAL CONFUSION Vomiting difficulty concentrating and disorientation (hepatic A general sense of feeling unwell (malaise) encephalopathy) can progress to coma if liver function Disorientation or confusion does not return. Sleepiness MANAGEMENT OF COMPLICATIONS 1. Encephalopathy FOR ENCEPHALOPATHY 2. Cerebral edema Agents which reduce ammonia 3. Jaundice -Ornithine aspartate may aid conversion of ammonia into 4. Change in liver span glutamine in muscle, 5. Right upper quadrant tenderness -Lactulose 6. Ascites 7. Hyperdynamic circulation CEREBRAL EDEMA brief hyperventilation can be used, particularly when herniation is TREATMENT suspected. Paracetamol=N-Acetylcysteine - Head-up position VIRUSES: - Early intubation o HAV, HBV declining in importance=Lamivudine o HEV now a common cause COAGULOPATHY o HSV and other Herpes group viruses= Aciclovir, - Platelet transfusions Ganciclovir - H2blockers may help prevent GI bleeding DRUGS: o Allopathic and non-allopathic=WITHDRAWAL INFECTION is treated with antibacterial and/or antifungal drugs; o Alcoholic hepatitis= Steroids, Pentoxifylline treatment is started as soon as patients show any sign of infection o Autoimmune hepatitis= Corticosteroids (sone) o Wilson’s disease= Chelation therapy RENAL FAILURE o Ischaemic Hepatitis= Restoration of hepatic - Volume control of acetaminophen o circulation - Early use of renal replacement therapy o Budd-Chiari syndrome = Hepatic decompression Nursing Management PREGNANCY: Nursing Assessment o GPH, Acute fatty Liver=Delivery Past health history Medications Chronic alcoholism Weight loss Nursing Diagnosis Imbalanced nutrition: less than body requirements Impaired skin integrity Ineffective breathing pattern Risk for injury P. B. M | 4 Nursing Implementation Acute Intervention Rest Edema and ascites Paracentesis Skin care Dyspnea Nutrition Ambulatory and Home Care Symptoms of complications When to seek medical attention Remission maintenance Abstinence from alcohol Nursing Evaluation Maintenance of normal body weight Maintenance of skin integrity Effective breathing pattern No injury No signs of infection Prevention of ALF The best way to prevent liver failure is to limit your risk of developing cirrhosis or hepatitis This can be done by following: dosage directions on all prescription, herbal and over- the-counter medications (including acetaminophen) avoiding risky behavior exercising caution when using any type of chemicals and living a healthy lifestyle. Follow instructions on medications: the patient must take the recommended dosage, and don't take more than that. Alcohol amount, if necessary, must be limited, no more than one drink a day for women of all ages and men older than 65 and no more than two drinks a day for younger men. Avoid smoking Vaccination against HBV Avoid contact with other people's blood and body fluids. Don't eat wild mushrooms Take care with aerosol sprays, insecticides, fungicides, paint and other toxic chemicals Healthy Weight as: Obesity can cause a condition called nonalcoholic fatty liver disease, which may include fatty liver, hepatitis and cirrhosis. P. B. M | 5  M5 Lesson 1: Acute Kidney Injury PRERENAL / ACUTE KIDNEY INJURY Definition: Physiologic conditions leading to decreased kidney perfusion without intrinsic damage. The most common renal problem seen in critically ill patients is the development of acute kidney injury (AKI), previously termed as Mechanism: acute renal failure (ARF). o Decrease in renal arterial perfusion → decreased filtration rate through the Acute Kidney Injury glomerulus. o Loss of protective autoregulation when is the abrupt decrease in renal function with progressive perfusion pressure < 80 mm Hg → further retention of metabolic waste products (eg, creatinine decrease in GFR. and urea). o Renal tubular function remains normal. Oliguria, urine output of less than 400 mL/day, is a common finding in AKI Effects: o Decreased GFR → kidneys cannot filter waste Characteristics: effectively. o Glomerular filtration rate (GFR) falls over hours o More Na+ and water reabsorbed → oliguria. to a few days. o Persistent decreased perfusion can cause o Accompanied by a rise in serum creatinine and irreversible damage → intrarenal AKI. urea nitrogen. Reversibility: Most prerenal AKI cases can be reversed o If left untreated, may complicate to chronic by treating the cause. renal failure. INTRARENAL / ACUTE KIDNEY INJURY Definition: Physiologic conditions causing damage to renal tubule, glomerulus, or renal blood vessels. Common Cause: Acute tubular necrosis (ATN). Nephrotoxic Insults: o Direct damage to the nephron primarily at the tubular epithelial layer. o This layer can regenerate → rapid healing after nephrotoxic insults. Ischemic/Inflammatory Insults: o Damage to nephron's basement membrane → regeneration not possible. o More likely to cause CKD than nephrotoxic insults. Pathophysiology: o Renal cellular damage → glomerulus acts as a filter, allowing protein and cellular debris to enter renal tubules, leading to obstruction. Contrast-Induced Nephropathy (CIN): Occurrence: About 10% of at-risk patients receiving contrast media. Risk Factors: Diabetes, advanced age, CKD, hypovolemia. Categories of AKI Characteristics: 1. Prerenal AKI: Caused by decreased blood flow to the o 25% increase in creatinine or an absolute kidneys. increase of 0.5 mg/dL from baseline within 48- 2. Intrarenal AKI: Caused by damage to the kidney tissues 72 hours. (tubules, glomeruli, blood vessels). o Resolves in 7-10 days. 3. Postrenal AKI: Caused by obstruction of urine flow from Symptoms: May be oliguric or have no decrease in urine the kidneys. output. Pathophysiological Changes: Medullary hypoxia due to Common Pathologic Pathway initial vasodilation followed by prolonged renal Decreased glomerular filtration rate (GFR) due to vasoconstriction and epithelial cell toxicity. reduction in renal blood flow. Critical Care Unit POSTRENAL / ACUTE KIDNEY INJURY Majority of AKI cases caused by impaired renal Definition: Physiologic conditions that obstruct urine perfusion, sepsis, and nephrotoxic agents. flow from the kidney to the urethral meatus. Effects: o Partial obstruction increases renal interstitial pressure → increases Bowman capsule pressure → opposes glomerular filtration. P. B. M | 6  o Complete obstruction leads to urine backup → o The relationship between glomerular filtration compresses the kidney → no urine output. rate (GFR) and serum creatinine level is not Rarity: Uncommon cause of AKI in critically ill patients. linear, especially early in disease. Treatment: Focused on removing the obstruction. o Serum creatinine rise may not be evident before 50% of GFR is lost. Current Treatment: Clinical Manifestations (AKI) o Mainly supportive in nature. o No therapeutic modalities have shown efficacy in treating AKI. o Therapeutic agents (e.g., dopamine, nesiritide, fenoldopam, mannitol) are not indicated and may be harmful. Primary Goals of Treatment: o Maintenance of volume homeostasis. o Correction of biochemical abnormalities. Measures to Achieve Goals: o Correction of fluid overload with furosemide. o Correction of severe acidosis with bicarbonate administration (important as a bridge to dialysis). o Correction of hyperkalemia. o Correction of hematologic abnormalities (e.g., anemia, uremic platelet dysfunction) with: ▪ Transfusions. ▪ Administration of desmopressin or estrogens. Nursing Management Nursing Goal Objective: Correct or eliminate any reversible causes of kidney failure. Support Measures: o Take accurate measurements of intake and Assessment and Findings output (including all body fluids). o Monitor vital signs. 1. Oliguric Phase o Maintain proper electrolyte balance. Urine output 0.5mL/kg/hr Nausea and Vomiting Nursing Care Plans (NCP) and Nursing Diagnoses for Patients Irritability with Acute Renal Failure: Drowsiness, confusion, coma 1. Excess Fluid Volume 2. Risk for Decreased Cardiac Output Restlessness, twitching, seizure 3. Risk for Imbalanced Nutrition: Less Than Body Increased serum potassium, BUN, Creatinine Requirements Increased calcium, Sodium, pH, and CO2 4. Risk for Infection Anemia 5. Risk for Deficient Fluid Volume Pulmonary Edema, CHF 6. Deficient Knowledge Hypertension Albuminuria 2. Diuretic Phase or Recovery Phase Urinary output 4-5 L/d Increased serum BUN Sodium and Potassium loss in urine Increased mental and physical activity Medical Management Timing of Intervention: o Begin measures at the earliest indication of renal dysfunction. o Serum creatinine does not rise to abnormal levels until a large proportion of the renal mass is damaged. P. B. M | 7  3. Heart Disease: M5 Lesson 2: Chronic Kidney Disease o Research shows a link between kidney disease and heart disease. Definition: o People with heart disease are at higher risk for o Long-term condition where the kidneys don't kidney disease, and people with kidney disease work as well as they should. are at higher risk for heart disease. Common Characteristics: o Researchers are working to better understand o Often associated with getting older. the relationship between kidney disease and o Can affect anyone but is more common in heart disease. people who are black or of South Asian origin. 4. Family History of Kidney Failure: Progression: o If the patient's mother, father, sister, or brother o CKD can worsen over time. has kidney failure, the patient will be at risk for o Eventually, the kidneys may stop working CKD. altogether, but this is uncommon. o Kidney disease tends to run in families. o Many people with CKD are able to live long lives o If the patient has kidney disease, encourage with the condition. family members to get tested. 5. Age: Nature of CKD: o Indicates that the kidneys are damaged and o The chances of having kidney disease increase with age. can’t filter blood effectively. o Called “chronic” because the damage happens o The longer a person has had diabetes, high blood pressure, or heart disease, the more slowly over a long period of time. likely that person will have kidney disease. o Damage can cause wastes to build up in the 6. Ethnicity: body. o CKD can also cause other health problems. o African Americans, Hispanics, and American Indians tend to have a greater risk for CKD. Kidney Function o The greater risk is due mostly to higher rates of diabetes and high blood pressure among these Main Job: groups. o Filter extra water and wastes out of the blood to o Scientists are studying other possible reasons make urine. for this increased risk. Balancing Act: o Balance salts and minerals (such as calcium, Common Causes and Risk Factors phosphorus, sodium, and potassium) that The top three causes of CKD (in order of incidence) are circulate in the blood. diabetes, hypertension, and glomerulonephritis. Hormone Production: Diabetes and hypertension cause approximately 70% of o Make hormones that help control blood CKD cases. pressure, make red blood cells, and keep Other Risk Factors Include: bones strong. Congenital abnormalities (e.g., polycystic kidney disease, Alport syndrome, sickle cell disease) Risks of Kidney Disease Progression to Kidney Failure: Urinary tract or systemic infections o Kidney disease often gets worse over time and Family history of CKD may lead to kidney failure. Urinary or kidney stones o If the kidneys fail, a person will need dialysis or History of acute kidney injury or failure a kidney transplant to maintain good health. Urinary tract obstruction Autoimmune disease (e.g., scleroderma, systemic lupus erythematosus) Who is More Likely to Develop CKD? Nephrotoxin exposure from sources such as: A person may be at risk for kidney disease if they have: o Over-the-counter pain medications (e.g., 1. Diabetes: aspirin or ibuprofen) o Diabetes is the leading cause of CKD. o Prescribed pain relievers (e.g., oxycodone or o High blood glucose (blood sugar) from diabetes naproxen) can damage the blood vessels in the kidneys. o Other medications (e.g., antibiotics or o Almost 1 in 3 people with diabetes has CKD. antineoplastics) 2. High Blood Pressure: o Pesticides and heavy metals (e.g., lead, o High blood pressure is the second leading mercury, or arsenic) cause of CKD. o Like high blood glucose, high blood pressure Age 60 or older and ethnicity (African American, American Indian, Asian, Pacific Islander, or Hispanic). can also damage the blood vessels in a person's kidneys. o Almost 1 in 5 adults with high blood pressure has CKD. P. B. M | 8 Importance of Recognizing Risk Factors Because CKD often has no symptoms in the early stages, some Early-stage CKD can be asymptomatic, so recognizing people at a higher risk should be tested regularly. risk factors and alerting patients and providers to them is Regular testing is recommended if a person has: crucial for prevention, early diagnosis, and optimal High blood pressure disease management. Diabetes Acute kidney injury – sudden damage to the kidneys that Many people with chronic kidney disease (CKD) will not have causes them to stop working properly symptoms because it does not usually cause problems until it Cardiovascular disease – conditions that affect the reaches an advanced stage. heart, arteries, and veins, such as coronary heart disease or heart failure Early Stages of CKD Other conditions that can affect the kidneys – such as kidney stones, an enlarged prostate, or lupus Kidney disease does not tend to cause symptoms when it's at an early stage. A family history of advanced CKD or an inherited kidney disease This is because the body is usually able to cope with a significant reduction in kidney function. Protein or blood in your urine where there's no known cause Kidney disease is often only diagnosed at this stage if a A person is also more likely to develop kidney disease if they are routine test for another condition, such as a blood or black or of South Asian origin. urine test, detects a possible problem. If it's found at an early stage, medicine and regular tests Persons taking long-term medicines that can affect the to monitor it may help stop it becoming more advanced. kidneys, such as lithium, omeprazole, or non-steroidal anti- inflammatory drugs (NSAIDs), should also be tested regularly. Later Stages of CKD A number of symptoms can develop if kidney disease is not found Tests for CKD early or it gets worse despite treatment. Symptoms can include: 1. Blood Test: Weight loss and poor appetite o The main test for kidney disease is a blood test. Swollen ankles, feet, or hands – as a result of water The test measures the levels of a waste product retention (oedema) called creatinine in a person's blood. Shortness of breath o The doctor uses the blood test results, plus the Tiredness age, size, gender, and ethnic group to calculate how many millilitres of waste a person's Blood in your pee (urine) kidneys should be able to filter in a minute. An increased need to pee – particularly at night o This calculation is known as the estimated Difficulty sleeping (insomnia) glomerular filtration rate (eGFR). Itchy skin o Healthy kidneys should be able to filter more Muscle cramps than 90ml/min. A person may have CKD if the Feeling sick rate is lower than this. Headaches 2. Urine Test: o A urine test is also done to: Erectile dysfunction in men This stage of CKD is known as kidney failure, end-stage renal ▪ Check the levels of substances called disease, or established renal failure. It may eventually require albumin and creatinine in a person's urine – known as the albumin treatment with dialysis or a kidney transplant. ratio, or ACR. Diagnosis of Chronic Kidney Disease (CKD) ▪ Check for blood or protein in urine. o Alongside the eGFR, urine tests can help give a Chronic kidney disease (CKD) can be diagnosed with more accurate picture of how well the kidneys blood and urine tests. are working. In many cases, CKD is only found when a routine blood 3. Other Tests: or urine test that a person has for another problem o Sometimes other tests are also used to assess shows that the kidneys may not be working normally. the level of damage to the kidneys. These may include: Who Should Be Tested for CKD? ▪ An ultrasound scan, MRI scan, or CT A person must see a consult to his/her doctor if persistent scan – to see what the kidneys look symptoms of CKD, such as: like and check whether there are any Weight loss or poor appetite blockages. Swollen ankles, feet, or hands ▪ A kidney biopsy – a small sample of Shortness of breath kidney tissue is removed using a Tiredness needle, and the cells are examined Blood in your pee (urine) under a microscope for signs of damage. Peeing more than usual, particularly at night Test Results and Stages of CKD The doctor can look for other possible causes and arrange tests if The test results can be used to determine how damaged the necessary. kidneys are, known as the stage of CKD. This can help the care P. B. M | 9 provider or doctor decide the best treatment for the person and High Blood Pressure how often they should have tests to monitor the current condition. Good control of blood pressure is vital to protect the The eGFR results are given as a stage from 1 to 5: kidneys. Stage 1 (G1) – a normal eGFR above 90ml/min, but other People with kidney disease should usually aim to get tests have detected signs of kidney damage their blood pressure down to below 140/90mmHg, but Stage 2 (G2) – a slightly reduced eGFR of 60 to 89ml/min, they should aim for below 130/80mmHg if they also have with other signs of kidney damage diabetes. Stage 3a (G3a) – an eGFR of 45 to 59ml/min There are many types of blood pressure medicines, but Stage 3b (G3b) – an eGFR of 30 to 44ml/min angiotensin converting enzyme (ACE) inhibitors are often Stage 4 (G4) – an eGFR of 15 to 29ml/min used. Examples include ramipril, enalapril, and lisinopril. Stage 5 (G5) – an eGFR below 15ml/min, meaning the kidneys have lost almost all of their function Side effects of ACE inhibitors can include: The ACR result is given as a stage from 1 to 3: o A persistent dry cough A1 – an ACR of less than 3mg/mmol o Dizziness o Tiredness or weakness A2 – an ACR of 3 to 30mg/mmol o Headaches A3 – an ACR of more than 30mg/mmol If the side effects of ACE inhibitors are particularly For both eGFR and ACR, a higher stage indicates more severe troublesome, they can be given a medicine called an kidney disease. angiotensin-II receptor blocker (ARB) instead. MEDICAL MANAGEMENT High Cholesterol There's no cure for chronic kidney disease (CKD), but treatment can help relieve the symptoms and stop it from getting worse. The People with CKD have a higher risk of cardiovascular disease, including heart attack and stroke. treatment will depend on the stage of CKD. They may be prescribed medicines called statins to Main Treatments reduce the risk of developing cardiovascular disease. 1. Lifestyle Changes – To help you stay as healthy as Examples include atorvastatin and simvastatin. possible. Side effects of statins can include: 2. Medicine – To control associated problems, such as high o Headaches blood pressure and high cholesterol. o Feeling sick 3. Dialysis – Treatment to replicate some of the kidney's o Constipation or diarrhoea functions, which may be necessary in advanced (stage 5) o Muscle and joint pain CKD. 4. Kidney Transplant – This may also be necessary in Water Retention advanced (stage 5) CKD. A person may get swelling in their ankles, feet, and hands Lifestyle Changes if they have kidney disease due to the kidneys not The following lifestyle measures are usually recommended for effectively removing fluid from the blood, causing it to people with kidney disease: build up in body tissues (edema). Stop smoking if you smoke. They may be advised to reduce their daily salt and fluid Eat a healthy, balanced diet. intake, including fluids in food such as soups and Restrict your salt intake to less than 6g a day – that's yoghurts, to help reduce the swelling. around 1 teaspoon. In some cases, they may also be given diuretics (tablets Do regular exercise – aim to do at least 150 minutes a to help urinate more), such as furosemide. week. Side effects of diuretics can include dehydration and Manage your alcohol intake so you drink no more than reduced levels of sodium and potassium in the blood. the recommended limit of 14 units of alcohol a week. Anaemia Lose weight if you're overweight or obese. Avoid over-the-counter non-steroidal anti-inflammatory Many people with advanced-stage CKD develop anaemia, which is a lack of red blood cells. drugs (NSAIDs), such as ibuprofen, except when advised by a medical professional – these medicines can harm Symptoms of anaemia include: your kidneys if you have kidney disease. o Tiredness o Lack of energy Medicine o Shortness of breath There's no medicine specifically for CKD, but medicine can help o A pounding, fluttering, or irregular heartbeat control many of the problems that cause the condition and the (palpitations) complications that can happen as a result of it. A person may need If a person has anaemia, they may be given injections of to take medicine to treat or prevent the different problems caused a medicine called erythropoietin. This is a hormone that by CKD. helps the body produce more red blood cells. Iron supplements may also be recommended if there is an iron deficiency. P. B. M | 10 Bone Problems However, there's still a shortage of donors, and a person If a person's kidneys are severely damaged, they can get could wait months or years for a transplant. They may a build-up of phosphate in their body because the need to have dialysis while waiting for a transplant. kidneys cannot get rid of it. This can lead to thinning of Survival rates for kidney transplants are very good. About 90% the bones. of transplants still function after 5 years, and many work usefully A person may be advised to limit the amount of food that after 10 years or more. is high in phosphate, such as red meat, dairy products, eggs, and fish. Chronic renal failure (CRF) or chronic kidney disease (CKD) is the If this does not lower the phosphate level enough, they end result of a gradual, progressive loss of kidney function. The may be given medicines called phosphate binders. loss of function may be so slow that you do not have symptoms Commonly used medicines include calcium acetate and until your kidneys have almost stopped working. calcium carbonate. The final stage of chronic kidney disease is called end-stage renal Some people with CKD also have low levels of vitamin D, disease (ESRD). At this stage, the kidneys are no longer able to which is necessary for healthy bones. They may be given remove enough wastes and excess fluids from the body. At this a supplement called colecalciferol or ergocalciferol to point, a person would need dialysis or a kidney transplant. boost their vitamin D level. Glomerulonephritis Chronic renal failure (CRF) or chronic kidney disease (CKD) is Kidney disease can be caused by inflammation of the the end result of a gradual, progressive loss of kidney function. filters inside the kidneys, known as glomerulonephritis. The loss of function may be so slow that you do not have In some cases, this happens as a result of the immune symptoms until your kidneys have almost stopped working. system mistakenly attacking the kidneys. If a kidney biopsy finds this is the cause of kidney The final stage of chronic kidney disease is called end-stage problems, they may be prescribed medicine to reduce renal disease (ESRD). At this stage, the kidneys are no longer the activity of the immune system, such as a steroid or a able to remove enough wastes and excess fluids from the body. medicine called cyclophosphamide. At this point, a person would need dialysis or a kidney transplant. Improving Muscle Strength If a person is having a bad flare-up and is unable to exercise, they may be offered electrical stimulation to make their muscles stronger. This involves placing M1 Lesson 1: Hospital Triage electrodes on a person's skin and sending small electrical impulses to weak muscles, usually in arms or legs. Routine Hospital Triage: Directs all available resources to the most critically ill Dialysis patients. For a small proportion of people with CKD, the kidneys will Focuses on the patients' current condition, regardless eventually stop working. This usually happens gradually, so there of potential outcome. should be time to plan the next stage of treatment. One of the Field Triage (or Hospital Triage during a Disaster): options when CKD reaches this stage is dialysis. This method Involves scarce resources. removes waste products and excess fluid from the blood. Aims to benefit the most people possible. Types of Dialysis PRINCIPLES OF EMERGENCY CARE 1. Hemodialysis – This involves diverting blood into an Emergency care is a care that must be rendered without external machine, where it's filtered before being delay. returned to the body. It is usually done about 3 times a week, either at the hospital or at home. In an ED, several patients with diverse health problems— some life-threatening, some not—may present to the ED 2. Peritoneal Dialysis – This involves pumping dialysis fluid simultaneously. into a space inside the tummy to draw out waste products from the blood as they pass through vessels One of the first principles of emergency care is triage. lining the inside of the tummy. It is normally done at home several times a day or overnight. Triage comes from the French word "trier," meaning "to sort." In the daily routine of the ED, triage is used to sort Kidney Transplant patients into groups based on: An alternative to dialysis for people with severely reduced kidney o The severity of their health problems. function is a kidney transplant. This is often the most effective o The immediacy with which these problems treatment for advanced kidney disease, but it involves major must be treated. surgery and taking medicines (immunosuppressants) for the rest of your life to stop your body from attacking the donor organ. Triage Process: A person can live with one kidney, which means donor Collecting pertinent information about patients who are kidneys can come from living or recently deceased seeking emergency care. donors. Initiating a decision-making procedure that uses a valid and reliable triage acuity designation system. P. B. M | 11  o Rapid and accurate triage decisions are TRIAGE SYSTEM important for successful ED operations and Three categories (common): optimal patient outcomes. 1. Emergent patients: o The process includes: o Have the highest priority. ▪ Collecting pertinent patient 2. Urgent patients: information. o Have serious health problems, but not ▪ Prioritizing the needs. immediately life-threatening. ▪ Performing a focused assessment. 3. Nonurgent patients: ▪ Assigning an acuity level, all in a time- o Have episodic illnesses. sensitive manner. o Accuracy in problem identification is crucial in Serious Car Accident clinical decision-making, especially in the Cardiac Event including triage encounter, and requires the nurse to: MOST URGENT (emergent) suspected heart attack ▪ Establish boundaries of physiological Suspected Stroke and psychological stability. Severe Burns ▪ Predict the potential trajectory of the Mental Health Crisis patient’s condition. Severe Trouble breathing Large Broken Bones To make effective and safe triage decisions, nurses must URGENT Allergic Reaction draw from an extensive internal base of knowledge and Seizure experience to identify salient cues and act based on the Falls patient presentation. For performing triage, the Emergency Nurses Sprained ankles Association (ENA) supports the use of a reliable, valid, Cough or Congestion five-level scale such as: LESS URGENT (non-urgent) Tooth or Earache o The Emergency Severity Index (ESI) or Need stitches o The Canadian Emergency Department Triage and Acuity Scale (CTAS). Emergency Department (ED) Triage Systems ENA Position Statement Facilitate the categorization of emergency patients It is the position of the Emergency Nurses Association according to their disease severity and determine both (ENA) that: treatment priority and treatment location. 1. Triage is a critical assessment process performed by: o A registered nurse or nurse practitioner with: Four different five-level triage systems are internationally ▪ A minimum of one year of accepted: emergency nursing experience. 1. Australasian Triage Scale (ATS, Australasia): ▪ Appropriate additional credentials o Allows categorization based on symptoms and education, including certification using specific descriptors. in emergency nursing. 2. Manchester Triage System (MTS, UK): ▪ Continuing education in trauma, o Uses defined presentational flow charts pediatrics, and cardiac care, with combined with indicators. verification or certification in those 3. Canadian Triage and Acuity Scale (CTAS, Canada): subspecialties as needed. o Based on the ATS but also includes diagnoses. 2. Emergency nurses complete: 4. Emergency Severity Index (ESI, USA): o A comprehensive, evidence-based triage o First excludes life-threatening and severe education course. disease before stratification according to o A clinical orientation with an experienced estimated resource utilization. preceptor to improve their triage knowledge The goal of all triage systems is to reduce the in-hospital and skills. mortality and to minimize time to treatment, length of stay, and 3. Triage nurses are involved in an ongoing triage resource utilization competency validation process that includes: o Observation and chart review. o Remediation and further education when needed. 4. Emergency department leadership ensures that: o Registered nurses receive the right education. o They demonstrate the knowledge application and situational awareness needed to function as a triage nurse according to professional and accreditation standards. 5. Emergency nurses support and participate in research related to the triage process. P. B. M | 12 Australian Triage Scale (ATS) Trauma categories can vary from state to state. Clinical tool used to establish the maximum waiting time for medical assessment and treatment of a patient. Trauma Center Verification: o An evaluation process done by the American Aims of ATS: College of Surgeons (ACS) to: Ensure that patients presenting to emergency ▪ Evaluate and improve trauma care. departments (EDs) are treated in the order of their o The ACS does not designate trauma centers; it clinical urgency. verifies the presence of specific resources Allocate patients to the most appropriate assessment listed in Resources for Optimal Care of the and treatment area. Injured Patient. Help describe the departmental case-mix. o These resources include: ▪ Commitment. ▪ Readiness. ▪ Resources. ▪ Policies. ▪ Patient care. ▪ Performance improvement. o This is a voluntary process for the trauma center being verified and lasts for a 3-year period. Facilities can be designated/verified as: o Adult and/or Pediatric Trauma Centers. o It is not uncommon for facilities to have different designations for each group (e.g., a trauma center may be a Level I Adult facility and Category 1 (RED) also a Level II Pediatric Facility). Life threatening conditions Category 2 (ORANGE) A Level I Trauma Center is a comprehensive regional resource Imminently life threatening, time sensitive treatment that is a tertiary care facility central to the trauma system. It is needed, or severe pain capable of providing total care for every aspect of injury—from Category 3 (GREEN) prevention through rehabilitation. Potentially life threatening, situational urgency, or severe pain A Level II Trauma Center is a comprehensive facility that provides Category 4 (BLUE) essential trauma care. It is equipped to manage most injuries and Potentially serious condition, situational urgency, or has the capability to provide initial care for trauma patients before complex case they are transferred to a Level I center if needed. A Level II center Category 5 (WHITE) has resources for stabilization, surgical intervention, and critical Less urgent or Clinical Administrative Problems care. A Level III Trauma Center has demonstrated an ability to provide Assessment and Documentation prompt assessment, resuscitation, surgery, intensive care, and Minimum information to be obtained from the patient or stabilization of injured patients, along with emergency operations. the person who accompanied the patient to the ED (as long as that person is not suspected of abuse or neglect): A Level IV Trauma Center has demonstrated an ability to provide o The obtained information must be advanced trauma life support (ATLS) prior to the transfer of documented. patients to a higher-level trauma center. It provides evaluation, stabilization, and diagnostic capabilities for injured patients. Asking questions is key to making appropriate triage decisions. A Level V Trauma Center provides initial evaluation, stabilization, and diagnostic capabilities, and prepares patients for transfer to TRAUMA CENTER LEVELS (in the US) higher levels of care. The different levels (i.e., Level I, II, III, IV, or V) refer to: o The types of resources available in a trauma center. o The number of patients admitted yearly. P. B. M | 13  Examples of Emergency Operations Plan Contents M1 Lesson 2 Hospital Incident Command System Plan Implementation Notification of Emergency Four Phases of Emergency Management Emergency Phone System Media Center Resource Procurement Child Care – Emergency Bed Utilization Surge Capacity/Diversion Acute Care Site establishment Crisis Staffing Shelter Availability Critical Incident Stress Debriefing MITIGATION Care of Deceased Preventing future emergencies or minimizing their effects Includes any activities that prevent an emergency, reduce the chance an emergency will happen, or reduce Incident Command System (ICS) Basics the damaging effects of unavoidable emergencies. Mitigation activities take place before and after What is ICS? emergencies. The Incident Command System (ICS) is a standardized approach to the command, control, and coordination of emergency PREPAREDNESS response incident management. (Federal Emergency Preparing to manage an emergency Management Agency [FEMA], 2018) Includes plans or preparations made to save lives and to When is ICS Used? help response and rescue operations. ICS has evolved to an incident management system for Preparedness activities occur prior to an emergency. “all hazards” and can be used in small or large-scale Examples: Evacuation plans and stockpiling food. incidents. Essentially anything that may impact daily operations. RESPONSE Some examples include: Responding safely to an emergency o Hazardous Materials (HAZMAT) incidents Includes actions taken to save lives and prevent further o Planned events (e.g., concerts, official visits, property damage in an emergency situation. Response is sporting events, festivals) putting your preparedness plans into action. o Fires Response activities occur during an emergency. o Mass casualty incidents Example: Seeking shelter from a tornado. o Active shooter/bomb threat o Lack of resources RECOVERY o High census Recovering from an emergency o Technological incidents o Natural disasters Includes actions taken to return to a normal or an even o Wide-area search and rescue missions safer situation following an emergency. Recovery occurs after an emergency. Plain Language and Common Terminology Recovery includes repairing any damage or entering any ICS requires common terminology, so all agencies have downtime documentation and can take weeks, months, the ability to collaborate. The goal when using plain and sometimes years. language and common terminology is to ensure efficient, clear communication among all parties involved in managing an incident. For effective communication: o Use common terms or clear text that any person can comprehend o Do not use radio codes, agency-specific codes, acronyms, or jargon (FEMA, 2018) P. B. M | 14 Chain of Command vs. Unity of Command HICS Command Staff Chain of command The command staff maintains the overall management of an o Refers to the orderly line of authority within the incident through setting incident objectives, strategies, and ranks of the incident management structure. response priorities. Unity of Command Incident Commander: Every incident will have an o Means that every individual has a designated incident commander. Typically, they are the most senior supervisor to whom he or she reports when person on duty at the time of the incident and have the managing the incident. These principles clarify authority to make decisions for the organization and reporting relationships and eliminate the provide overall direction for the HIMT. confusion caused by multiple, conflicting o The first person responding to the incident fills directives. (FEMA, 2018) the role of the Incident Commander until another person with more experience/training Hospital Incident Command System has arrived. The HICS structure is an ICS structure specifically designed for o The Incident Commander should have the level hospitals. of training, experience, and expertise to serve in HICS can be used in both emergent incidents or non-emergent this capacity. events. o Qualifications to serve as an Incident Functions are performed by the Hospital Incident Commander are not based on rank, grade, or Management Team (HIMT). (Hospital Incident Command technical expertise. System [HICS], 2014), (Weden, 2016) Liaison Officer: o Serves as a bridge between the internal HIMT Benefits of using HICS: and external emergency response partners. Flexible and adaptable to meet specific needs and This includes maintaining updates on the capabilities of hospitals organization’s status, bed availability, and participating in conference calls with the local Can staff anywhere from 1 – 70 positions as needed or regional Emergency Operations Center and Customizable healthcare coalition and other community Component of an Emergency Operations Plan response partners. Efficient response Safety Officer: Integration with community o Organizes and enforces scene and facility Federal preparedness and response grant compliant protection, traffic security, and safe practices Accreditation compliance for response personnel. Resource management Public Information Officer: o Coordinates information sharing internally Hospital Incident Management Team (HIMT) within the organization for staff messaging and The HIMT structure depicts HICS functions with hotline updates, and externally to media identified roles for how responsibilities are distributed consistent with the local Emergency among the assigned team members. Operations Center. Color coded by function: Medical/Technical Specialists: o Command (White) o Persons with specialized expertise (e.g., o Finance and Administration (Green) infectious diseases, legal affairs, medical o Logistics (Yellow) ethics). o Operations (Red) o Planning (Blue) HICS General Staff HICS General Staff are divided into sections and led by There should always be a succession plan for all key corresponding section chiefs. roles in HICS. o A “3-deep” approach allows for leaders who Operations Section Chief may be unavailable and for sustained events in Planning Section Chief which relief will be needed for key roles. (FEMA, Logistics Section Chief 2018), (SEAPRO, 2019) Finance and Administration Section Chief Hospital Incident Command System Operations Section Chief Command & General Staff The Operations Section Chief is responsible for: Implementing tactics based on incident objectives. Organizing, allocating, and directing the strategic resources. Managing the Staging Area if applicable. Determining the need to assign resources to support mission objectives. Planning Section Chief The Planning Section Chief is responsible for: P. B. M | 15  Developing plans for incident documentation. Tracking the status of all resources given to the incident. Gathering, evaluating, and disseminating situational awareness information. Developing tactics for demobilization. Preparing the Incident Action Plan (IAP) and leading the briefing. Logistics Section Chief The Logistics Section Chief is responsible for: Providing communication for planning and establishing resources. Setting up and maintaining incident facilities. Organizing food services. All support needs of the incident such as tracking and responding to resource requests. Acquiring resources from internal and external sources. Finance and Administration Section Chief The Finance and Administration Section Chief is responsible for: Monitoring personnel time. Negotiating and monitoring any necessary contracts. Analyzing costs. Completing necessary reimbursement documentation related to compensation for injury and damage to property/fatalities. P. B. M | 16