Study Guide – Exam 4

Urinary Assessment: Chapter 43

Kidney Functions Maintain fluid, electrolytes, and acid-base balance Eliminate waste products Regulate BP Stimulate RBC production Regulate calcium and phosphorus metabolism Eliminate many drugs

Blood Pressure Control Kidneys regulate blood pressure partly through maintenance of volume (formation/excretion of urine). The renin-angiotensin system is the other kidney-controlled mechanism that can contribute to rise in blood

pressure. When blood pressure drops, the cells of the glomerulus release renin, which then activates angiotensin to cause vasoconstriction.

Atrial natriuretic factor (ANF) is a hormone secreted from cells in the right atrium when right atrial blood pressure increases. ANF inhibits the secretion and effect of ADH and results in a large volume of dilute urine.

Formation of Urine Glomerular filtration

Ultrafiltration of blood by glomerulus; beginning of urine formationo Requires hydrostatic pressure (supplied by the heart and assisted by vascular resistance

[glomerular hydrostatic pressure]) and sufficient circulating volume. o Pressure in Bowman’s capsule opposes hydrostatic pressure and filtration; if glomerular pressure

insufficient to force substances out of blood into tubules, filtration formation stops. Glomerular filtration rate (GFR): amount of blood filtered by the glomeruli in a given time; normal is

125ml/min. Filtrate formed has essentially same composition as blood plasma without the proteins; blood cells and

proteins are usually to large to pass the glomerular membrane. Tubular function: the tubules and collecting ducts carry out the functions of reabsorption, secretion, and excretion.

Reabsorption of water and electrolytes is controlled by antidiuretic hormone (ADH), released by the pituitary, and aldosterone secreted by the adrenal glands.

Proximal convoluted tubule: reabsorption of certain constituents of the glomerular filtration: 80% of electrolytes and H2O, all glucose and amino acids, and bicarbonate; secretes hydrogen and creatinine.

Loop of Henle: reabsorption of sodium and chloride in the ascending limb; reabsorption of water in the descending loop; concentrates/dilutes urine.

Distal convoluted tubule: secretes potassium, hydrogen ions, and ammonia; reabsorbs H2O (regulated by ADH); reabsorbs bicarbonate; regulates calcium and phosphate concentrations by parathyroid hormone, regulation of sodium and potassium by aldosterone.

Collecting ducts: receive urine from distal convoluted tubules and reabsorb water (ADH required). Normal adults produces 1 liter/day of urine; 1% excreted as urine.

Urinalysis Findings Specific gravity: (1.003-1.030); specific gravity of morning urine specimen reflects maximum concentrating

ability of kidney and is 1.025-1.030. Low specific gravity indicates dilute urine and possibly excessive diuresis. High specific gravity indicates dehydration. If it becomes fixed at about 1.010, this indicates renal inability to concentrate urine, suggesting that kidneys are progressing to end-stage renal disease.

Protein: (0-150mg/24 hr or 0-18 mg/dl); persistent proteinuria is characteristic of acute or chronic renal disease, especially involving glomeruli. In absence of disease, positive reading may be caused by high-protein diet, strenuous exercise, dehydration, fever, or emotional stress.

Creatinine Clearance: determines amount of creatinine (waste product of protein breakdown) in urine over 24 hours, measures overall renal function

24 hour urine specimen (preferred method of creatinine clearance test)o Discard first voido Collect all subsequent urine specimens for 24 hourso If specimen is accidentally discarded, the test must be restartedo Record exact start and finish of collection; include date and time

Blood Studies Potassium: kidneys are responsible for excreting majority of body’s potassium. In renal disease, K+

determinations are critical because K+ is one of the first electrolytes to become abnormal. Elevated K+ levels of > 6 mEq/L can lead to muscle weakness and fatal cardiac arrhythmias. A normal finding is 3.5-5.5 mEq/L.

Calcium: is main mineral in bone and aids in muscle contraction, neurotransmission, and clotting. In renal disease, decreased reabsorption of calcium leads to renal osteodystrophy. A normal finding is 9-11 mg/dl.

Phosphorus: inversely related to calcium. In renal disease, phosphorus levels are elevated because the kidney is the primary excretory organ. A normal finding is 2.8-4.5 mg/dl.

Bicarbonate: most patients in renal failure have metabolic acidosis and low serum HCO3- levels. Normal finding is 20-30 mEq/L.

Diagnostic Studies Intravenous pyelogram (IVP)

Fluoroscopic visualization of the urinary tract after injection with radiopaque dye Nursing care: pretest

o Assess for iodine allergy and anaphylactic reactiono Inform patient that procedure involves lying on table and having serial x-rays takeno Administer cathartic or enema the night beforeo Keep patient NPO for 8 hours

Nursing care: posttest – force fluids (if permitted)

Cystoscopy Use of a lighted scope to inspect the bladder May be used to remove tumors, stones, or other foreign objects or to implant radium, place catheters in

ureters Nursing care: pretest

o Explain to client procedure will be done under general or local anesthesiao Confirm consent form has been signedo Force fluids or give IV fluids if general anesthesia is to be usedo General anesthesia: keep patient NPOo Local anesthesia: offer liquid breakfasto Give enema as ordered

Nursing care: posttesto Do not let patient walk alone immediately after procedure because orthostatic hypotension may

occuro Monitor I&O and vital signs o Expect mild hematuria at first; urine will be pink tinged, subsiding over 24-48 hours; monitor for

large clotso Advise patient that burning on urination and urinary frequency is normal and will subsideo Provide warm sitz bath, mild analgesia as ordered to relieve discomfort

Nephrostomy Tubes catheter inserted on a temporary basis to preserve renal function when a complete obstruction of the

ureter is present – removes calculi inserted directly into renal pelvis attached to connecting tube for closed drainage catheter should never be clamped if c/o excessive pain or drainage – check catheter for patency if irrigation is ordered – aseptic technique; no more than 5 ml of sterile saline gently instilled at one time

to prevent over distention of the kidney pelvis and renal damage complications: infection and secondary stone formation

Nephrectomy: removal of entire kidney Nursing Interventions

o Preoperative: avoid nephrotoxic agents in any diagnostic tests advise client to expect flank pain after surgeryo Postoperative: assess urine output every hour ensure adequate ventilation

teach client to splint incision while turning, coughing, deep breathing adequate medication management, especially when T, C, DB

encourage early ambulation D/C teaching: prevention of urinary stasis maintenance of acidic urine avoidance of activities that may injure remaining kidney no lifting heavy objects for at least 6 months report weight gain, decreased UO, flank pain, hematuria report if development of cold or infection last > 3 days

Acute and Chronic Renal Failure: Chapter 45

Acute Renal Failure Sudden inability of the kidneys to regulate fluid and electrolyte balance and remove toxic products from the body. Accumulation of waste materials – build up of creatinine Azotemia – retention of nitrogenous wastes – esp. urea Uremia – azotemia progresses to signs and symptoms Reversible if problem that causes it is able to be corrected At Risk: elderly, vascular dx, renal dx, atherosclerosis, HTN Pathophysiology

Prerenal: factors interfering with perfusion and resulting in decreased blood flow and glomerular filtrate, ischemia, and oliguria; include CHF, cardiogenic shock, acute vasoconstriction, hemorrhage, burns, septicemia, hypotension; no renal tubular damage; unless ischemia is prolonged

Intrarenal: conditions that cause damage to the nephrons – problem with the filtering capabilities includes: acute tubular necrosis (ATN), endocarditis, diabetes mellitus, malignant HTN, acute glomerulonephritis, tumors, blood transfusion reactions, hypercalcemia, and nephrotoxins.

o prolonged prerenal ischemiao parenchyma damage

Postrenal: obstruction of urine outflow anywhere from the tubules to the urethra; include calculi, BPH, tumors, strictures, blood clots, and trauma

o impaired kidney functiono almost always treatable before permanent kidney damage occurs

Clinical Course Oliguric phase (caused by reduction in glomerular filtration rate); inability to excrete waste – no damage

to renal tissueo duration 1-2 weekso manifestations are changes in urinary output, fluid and electrolyte abnormalities, and uremia

urinary changes oliguria: urine output < 400 ml/24 hrs urinalysis: casts, RBC, WBC, fixed specific gravity (1.010), and urine osmolality

at about 300 proteinuria – glomerular membrane dysfunction

fluid volume excess decreased output – fluid retention occurs edema – weight gain approx. 20-30 lbs development of HTN

Metabolic acidosis: kidneys cannot synthesis ammonia, which is needed for hydrogen excretion, or excrete acid products of metabolism. Bicarb gets all used up due to buffering hydrogen ions; kussmauls resp.

uremic syndrome: n/v, anorexia, diarrhea, hiccups high specific gravity lethargy and stupor will occur if not treated

Sodium balance hyponatremia: dilutional (pseudo-hyponatremia) damage tubules cannot conserve sodium – increased excretion through urine avoid excessive intake of sodium – may lead to volume expansion, HTN, and

CHF uncontrolled hyponatremia or water excess – may lead to cerebral edema

Potassium excess Hyperkalemia results in impaired ability of kidneys to excrete K+ massive trauma – damage cells release additional K+ in extracellular fluid acidosis worsens hyperkalemia as hydrogen enters the cells and K+ is driven out

of cells into extracellular fluid immediate attention if rise > 6 mEq/L (fatal arrhythmias)

Hematological disorders anemia – impaired erythropoietin production platelet abnormalties – risk for bleeding altered WBC – immunodeficiency – infections (major cause of death)

Calcium deficit and phosphate excess results from decreased GI absorption of Ca+. Vit. D must be present to absorb Ca+ - only functioning kidneys can activate vit.

D when hypocalcemia occurs parathyroid gland stimulates bone demineralization –

releases Ca+ from bones – phosphate is released as well – decreased excretion from kidneys – results in hyperphosphatemia.

o Diuretic phase (slow, gradual increase in daily urine output) Nephrons not fully functional diuresis caused by osmotic diuresis from the high urea concentration – inability of

tubules to concentrate urine; however kidneys have recovered ability to excrete 1-3 L/day but can reach 3-5 L or more/day Fluid may be very clear, may look like water At risk for hypovolemia, hyponatremia, hypokalemia BUN/Creatinine remains elevated near end of phase all imbalances slowly starts to normalize

o Recovery phase: renal function stabilizes with gradual improvement over next 3-12 mo. begins when GFR increases, concentrating ability improves kidneys are able to excrete and concentrate the urine

Collaborative Care: primary goals – eliminate cause, manage signs and symptoms, and prevent complicationso First step: assess adequate intravascular volume and CO to ensure adequate perfusion to the

kidneys.o Diuretic therapy often admin. with volume expanders to prevent fluid overloado General trend is to initiate early and frequent dialysis to minimize symptoms and prevent

complications.o Restrict volume during the oliguric phaseo Replace volume during the diuretic phaseo Lower K+ levels

Give regular insulin IV: K+ moves into cells when insulin is given. Glucose is given concurrently to prevent hypoglycemia. When affects of insulin diminish, K+ shifts back out of cells; or give 10% Calcium gluconate IV

Na+ Bicarb: Therapy can correct acidosis and cause shift of K+ into cells. Calcium gluconate IV: given because of cardiac toxicity. Calcium raises the threshold for

excitation, resulting in arrhythmias. Kayexalate

PO or enema cation-exchange when resin is in bowel, K+ is exchanged for Na+ therapy removes 1 mEq of K+ per gram of drug It is mixed in water with sorbitol to produce osmotic diarrhea, allowing for

evacuation of K+ rich stool from body may causes diarrhea – never give with paralytic ileus contraindicated in dehydrated patient

Ace Inhibitors: decrease proteinuria and delay progression of renal failure (must be used cautiously in ESRD – can further decrease GFR and increase K+ levels

Dialysis volume overload elevated K+ levels with EKG changes - hemodialysis can bring K+ levels to

normal within 30 min. – 2 hrs. metabolic acidosis – bicarb < 15 mEq BUN > 120 significant changes in mental status pericarditis, pericardial effusion, or cardiac tamponade Continuous renal replacement therapy (CRRT)

alternative or adjunctive method for treating ARF solutes and large volume of fluid removed slowly and continuously from

hemodynamically unstable patient. contraindicated in: life-threatening manifestations of uremia

(hyperkalemia, pericarditis) that require rapid resolution can be used in conjunction with HD for continuous fluid removal CRRT features that are different for HD

continuous rather than intermittent; large volumes can be removed over days versus hours

solute removal can occur by convection (no dialysate required) in addition to osmosis and diffusion

causes less hemodynamic instability (hypotension) does not require constant monitoring by a specialized HD nurse but

does require a trained intensive care nurse does not require complicated HD equipment, but a modified blood

pump is required filtrate changed every 24-48 hrs (loss of efficiency or clotting) ultrafiltrate should be clear yellow if ultrafiltrate becomes bloody or blood-tinged suspect rupture in

filtrate membrane – stop treatment to prevent blood loss and infection

monitor fluid and electrolyte balance hourly I&Os and daily weights hourly VS and hemodynamic status

Nursing Managemento Assessment

Neuro – lethargy, altered memory Cardiac – at risk for fluid overload, assess heart sounds, watch BP – increase or decrease

depending on what stage of failure, watch for arrhythmias Resp – kussmauls respirations (trying to blow off CO2), depending on stage at risk for fluid

overload leading to pulmonary edema, pulmonary effusion GI – n/v, anorexia, diarrhea, hiccups GU – decreased UO in oliguria phase, increased and diluted in diuretic phase Labs – monitor closely

o Implementation Maintain fluids and electrolytes balance during the oliguric and diuretic phases Accurate and Strict I&Os Daily weights – same time, same scale each day (1 kg is equivalent to 1000 ml of fluid) Monitor for infection Admin. humidified O2 Cough, turn, deep breath; incentive spirometry to prevent respiratory complications Skin care – risk – breakdown; bathe with tepid water and oils to reduce dryness and itching Mouth care – prevent stomatitis

o Nutrition: primary goals are to control HTN, minimize edema, decrease urinary albumin losses, prevent protein malnutrition and muscle catabolism, supply adequate energy, and slow progression of renal disease

High calorie, low protein, low K+ diet if dialysis is not used for treatment, 0.6 g of protein per kg body weight (but not less than 40

g/day. during oliguric stage, sodium may be restricted to 1000 to 2000 mg and K+ to 1000 mg/day

o Patient teaching diet nephrotoxic drugs

Chronic Renal Failure Progressive, irreversible destruction of the kidneys that continues until nephrons are replaced by scar tissue; loss

of renal function gradual Before ESRD, management focuses on slowing the progression of CRF and avoiding complications. ESRD, management centers on reducing uremia by the use of various treatment modalities: conservative

management, hemodialysis, peritoneal dialysis, and renal transplant. Predisposing factors: recurrent infections, exacerbations of nephritis, urinary tract obstructions, diabetes mellitus,

HTN Uremia is a syndrome that incorporates all signs and symptoms seen in chronic kidney disease Clinical Findings

lethargy, drowsiness, HA, nausea, pruritus oliguria, anuria, vomiting, anemia, HTN, anasarca, uremic frost decreased serum Ca+ and pH (metabolic acidosis) increased serum phosphate and potassium x-ray reveals renal osteodystrophy kussmaul respirations, mental clouding, convulsions, coma, death

Therapeutic Interventions conservative therapy is attempted before maintenance dialysis begins goals of conservative therapy

preserve existing renal function treat clinical manifestations prevent complications provide comfort

Fluid and Na+ restrictions Medications

Sodium Bicarb o treatment of metabolic acidosis (severe)o current standard is to give only after adequate ventilation, chest compressions, IV fluids

and drug therapy fail to correct acidotic stateo when administering monitor ABG – can lead to metabolic alkolosiso do not administer epi/norepinephrine and dopamine in same site as HCO3- because they

are inactivated by solutions containing HCO3- Antihypertensive medications – delays progression by controlling HTN Epogen

o to manage anemia secondary to renal failure, HIV, cancero increases production of RBC o if receiving dialysis may require increased heparin to prevent clotting at connection siteso side effects

senses of well being nausea/diarrhea hypertension clots arthralgias (joint pain) fatigue/weakness/dizziness injection site discomfort

o Administration of epogen do not shake – may denature the glycoprotein causing inactivation use one dose per vial – do not reenter vial – discard left over – no preservatives use 1 ml or less per injection to decrease injection site discomfort

Lasix – to treat fluid retention caused by renal dysfunction iron supplements – to correct anemia – do not give to phosphate binders because calcium binds to

iron Folic acid 1 mg daily usually given – needed for RBC formation – removed by dialysis; if not

replaced through diet or medications megaloblastic anemia may occur NSAIDs causes vasodilatin – worsens renal hypoperfusion – acetaminophen instead

Dietary managemento Dietary modifications should be initiated as early as possible to minimize uremic toxicity, delay

progression of renal disease, and prevent wasting and malnutrition.o Very low protein (20 grams); minimal essential amino acids makes body use its own excess urea

nitrogen to synthesize the nonessential amino acids need for tissue protein production – slows progression of renal failure

o magnesium containing acids: maalox, Mylanta; MOM should not be given because risk for hypermagnesium; magnesium is dependent on the kidneys for excretion

o Low-phosphate - restricted to < 1000 mg/day – slows progression of renal failure calcium carbonate: calcium phosphate binders (tums and PhosLo) are used to bind

phosphate, which is secreted through stool given with meals for effectiveness because most phosphate is absorbed within 1

hr after eating. causes constipation

aluminum hydroxide (Amphojel, Alu-tab): lowers phosphate levels in patients with chronic renal failure – binds phosphate in GI tract

o Fluid allowanceconservative management and hemodialysis: urine output + 600 ml (insensible loss) peritoneal: often no restrictions

o High-potassium foods Apricots Oranges, orange juice Avocado Peanuts (also high in Na+) Banana Potatoes, white and sweet Cantaloupe Prune juice Carrots, raw Spinach Dried beans, peas Tomatoes, tomato juice, tomato sauce Dried fruits Winter squash Melons

Peritoneal Dialysiso dialyzing solution is introduced via a tenchoff catheter inserted in the peritoneal cavity; the

peritoneal membrane is used as a dialyzing membrane to remove toxic substances, metabolic wastes and excess fluid; Dextrose is used as an osmotic agent in PD

o Types CAPD: without machine by patient; involves approx. 3-4 exchanges/day, 7 days/wk CCPP: mechanical cycler – more nightly exchange during sleep NIPD: mechanical cycler – only nightly exchanges

o warm solution to body temperatureo assess VS before and every 15 min during first exchange, and every hour thereaftero have client voido Strict asepsis: wash hands 3 times, maskso monitor for signs of respiratory distress and peritonitis; reposition to promote drainage from

abdomen; drain abdomen if respiratory distress occurso inflow: allow solution to flow unrestricted into peritoneal cavity for prescribed period (10-20

min).o dwell: allow solution to remain in peritoneal cavity for prescribed period (30-45 min).o drain: unclamp outflow tube and allow to flow by gravityo Nitroglycerin, antihypertensive, and sedatives are withheld – hypotension episodeo Dietary Management

objective of nutritional therapy are to maintain good nutrition status while replacing albumin lost in the dialysate, minimize complications of fluid imbalance, minimize symptoms of uremic toxicity and minimize metabolic disorders secondary to ESRD and peritoneal dialysis.

higher protein recommended Hemoglobin, serum albumin, urea, and total serum protein – indicators for sufficient

protein intake – values declines suddenly when protein intake decreases or when there is excessive loss during peritonitis

Phosphorus restriction critical to prevent development of osteodystrophy Precautions

diabetes – absorption of glucose for the PD dialysate blood glucose and hyperlipidemia are more difficult to control weight gain caused by the Kcalorie load of the dialysate dehydration – caused by excessive fluid removal and extracellular fluid deficits careful monitoring of blood glucose, I&Os, and weight are preventive measures

o Complications back problems: extra wt. from dialysate Respiratory problems: fluids pushing on diaphragm fistulas peritonitis observe characteristics of dialysate outflow

o clear pale yellow: normalo cloudy: infection, peritonitis: abd. pain and distention, diarrhea, vomiting, fever

o brownish: bowel perforationo bloody: common during first few exchanges; abnormal if continues

Hemodialysis: the client is attached (via a surgically created arteriovenous fistula or graft) to a machine that pumps the blood along a semi-permeable membrane; dialyzing solution is on the other side of the membrane and osmosis and/or diffusion of waste, toxins and fluid from the client occurs

Assessment data r/t urinary elimination patterns; urine color, consistency, odor, and amount neurologic status including attention span, weakness, and neuropathies breath – ammonia odor skin – uremic frost or urochromatic pigmentation (bronze) Mouth care/altered taste

brush teeth 6-8 times/day rinse mouth with chilled mouthwash (commercial product or water mixed with lemon juice or

vinegar) eat sour-ball candy chew gum before meals drink water with lemon or eat a small amount of sherbet or fruit sorbet When patient develop changes in taste, foods with sharp, distinct flavors may be useful in

stimulating appetite emotional status of client and family Dietary Management

phosphorus restricted – high levels of serum phosphate contributes to secondary hyperparathyroidism and raise the calcium-phosphorus product in plasma.

foods high in phosphate are usually limited or avoided milk/milk products, cheese beef liver chocholate nuts/legumes

The active form of vit. D is available in oral form (Rocaltrol) or IV form (Calcijex), which is given during hemodialysis

Epogen can be given during dialysis (by IV) or SQ just after dialysis treatment. Oral or IV iron supplements is often necessary before administration of Epogen to replenish iron stores

Nursing Managemento weigh before and after procedure with all types of dialysiso take VS before and after and q 15 min. during the procedure; assess for hypotension and

hemorrhage (heparin)o withhold antihypertensives, sedatives, and vasodilators to prevent hypotension (unless ordered

otherwise)o Monitor siteso Vas Cath – temporary o Graft or AV Fistula

Fistula anastomosed artery and vein needs 6-8 weeks to heal before use last longer than graft and less clot formation

Graft artificial less time required before use

for both types: watch site for clotting; check clotting time and administer heparin as prescribed; monitor for patency of internal fistula between treatments by palpating of internal fistula by palpating for a thrill and auscultating for a bruit

avoid venipucture, IV, BP on shunt arm if site occludes – notify MD (may use thrombolytic if clotted

o assess for complications

Hypotension – results from rapid fluid removal (hypovolemia), decreased CO, and decreased SVR; may precipitate light headedness, n/v, seizures, vision changes, and chest pain – treatment: decrease volume of fluid being removed and infuse NS (100-300 ml)

Muscle cramps – result from rapid removal of Na+ and water – treatment: reducing ultrafiltration rate and infusing hypertonic saline or NS bolus

Loss of blood – blood not being completely rinsed from the dialyzer, accidental separation of blood tubing, dialysis membrane rupture, or bleeding after removal of needles at the end of dialysis; postdialysis – significant risk due to admin. of heparin

Hepatitis (C)/Sepsis – the lack of adherence to precautions used to prevent infection Dialysis disequilibrium syndrome – rapid changes in composition of extracellular fluid

(urea, sodium, and other solutes is removed more quickly from the blood than from cerebral spinal fluid and the brain) – causes cerebral edema: assess for nausea, vomiting, headache, elevated BP, disorientation, leg cramps, seizures and peripheral paresthesias – treatment: slowing or stopping dialysis and infusing hypertonic solution, albumin, or mannitol to draw fluid from the brain cells back into the systemic circulation – preventative measures: first dialysis treatment purposely short with limited total solute removal – most commonly occurs when BUN is high

Mannitol osmotic diuretic treatment of cerebral edema and ICP action: inhibits reabsoption of electrolytes and water by affecting

pressure of glomerular filtrate side effects: hypo/hypernatremia, hypo/hyperkalemia, dehydration, dry

mouth, blurred vision highly irritating to veins held when serum osmolality exceeds 310-320 indications for nurses

use filter needle – crystals may form in solution and syringe and thus be inadvertently injected

after drawing up medication, new filter must be used to inject medication

carefully assess neuro status, monitor lab studies – including serum osmolality; accurate I&O (substantial diuresis)

Kidney Transplant o human leukocyte antigen (HLA) test and tissue and blood typing are done to decrease risk of

rejection; least risk of rejection occurs if donor and recipient are identical twins.o client’s own kidney is not removed unless it is infected or enlarged; new kidney is placed

generally in the iliac fossa retroperitoneal and the donors ureter is attached to the bladder to prevent reflux of urine.

o steroids and immunosuppressives (azathioprine/Imuran) Nursing Management

o prepare client and family emotionally for possible outcomes of surgeryo maintain patency of drainage tubes, including foley; gross hematuria or clots are not expected

post-opo monitor fluid and electrolyte balance; initial output is increased because of Na+ diuresis; sharp

decrease may signal rejectiono monitor wt. and VS, particularly temp; isolation may be necessary to prevent infectiono observe s/s of opportunistic infection; teach client need to prevent infection by avoiding crowds

and using aseptic technique

o administer steroids and immunosuppressants as ordered to prevent rejection Cyclosporine (Sandimmune): does not cause significant bone marrow depression; assess

for HTN; blood chemistry alterations (hypermagnesemia, hyperkalemia, decreased sodium bicarb); neruologic functioning

Azathioprine (Imuran): assess for manifestations of anemia, leucopenia, thrombocytopenia, oral lesions

Cyclophosphamide (Cytoxan): assess for alopecia, HTN, kidney/liver toxicity, leucopenia

Antilymphocytic globulin (ALG), antithymocytic globulin (ATG): assess for fever, chills, anaphylactic shock, HTN, rash, headache

Corticosteroids (prednisone, solu-medrol: asses for peptic ulcer and GI bleeding, sodium/water retention, muscle weakness, delayed healing, mood alterations, hyperglycemia, and acne.

o observe for and teach client signs of rejection: malaise, fever, flank pain or tenderness, decreasing UO, sudden weight gain, increasing BP; serum creatinine will increase and decrease in creatinine clearance

o Dietary Management Kcalories high posttransplant period – stress from surgery and catabolism Glucose intolerance – steroid therapy

o resumption of activity and avoidance of contact sports in which the transplanted kidney may be injured

Chapter 15: Cancer

Cancer- a group of more than 200 diseases characterized by uncontrolled and unregulated growth of cells. It is the second most common cause of death in the United States.

Altered Cell Growth and Proliferation normal tissue contains large # of mature cells of uniform size and shape during development cells undergo differentiation in size, appearance and arrangement cell proliferation starts with a stem cell that enters the cell cycle and divides into 2 identical cells these cells function and the die; abnormal changes in cell growth can be malignant or benign

Altered Cell Growth (benign) benign neoplasm involve cellular proliferation and mature cells grows slowly, but orderly and don’t invade surrounding tissue can cause harm through pressure on vital structures benign tumors remain localized, do not metastasize or spread and don’t reoccur when removed

Altered Cell Growth (malignant) malignant cells – basic structure and activity – deranged causes are poorly understood; normal restraints on growth are defective cell proliferates out of control rate of growth varies depending on the type of cell

Development of Cancer initiation- mutation in the cell’s genetic structure resulting from an inherited mutation, an error that occurs

during DNA replication, or following exposure to a carcinogen (chemical, radiation, or viral agent.) promotion- characterized by the reversible proliferation of the altered cell.

promoting factors includeo dietary fat, obesityo cigarette smokingo alcohol consumptiono prolonged severe stress.

progression- characterized increased growth rate of the tumor, as well as increased invasiveness and metastasis. (clinical evidence)

metastasis- spread from primary site to distant site tumor angiogenesis- formation of blood vessels within the tumor itself.

Classification of Cancer carcinomas- originate from ectoderm (skin and glands) and endoderm (mucous membrane lining from

respiratory tract GI, and GU tract.) sarcomas- originate from mesoderm (connective tissue, muscle, bone, and fat.) lymphomas and leukemias- originate from the hematopoietic system Histological grading of tumors

Grade I- cells differ slightly from normal cells (mild dysplasia) and are well differentiated. Grade II- cells are more abnormal (moderate dysplasia) and moderately differentiated. Grade III- cells are very abnormal (severe dysplasia) and poorly differentiated. Grade IV- cells are immature and primitive (anaplasia) and undifferentiated; cells of origin is

difficult to determine.

Clinical staging Stage 0- cancer in situ

Stage I- tumor limited to the tissue of origin; localized tumor growth Stage II- limited local spread Stage III- extensive local and regional spread Stage IV- metastasis

TNM classification- used to determine the extent of the disease process of cancer according to three

parameters: T- Tumor size N- Degree of regional spread to the lymph nodes M- Metastasis

Prevention of Cancer primary prevention- exercise, well balance diet, avoid exposure to carcinogens. secondary prevention- screenings; pap smear, mammogram, sigmoidoscopy, and rectal exam tertiary prevention- after diagnosis

Warning Signs of Cancer C- change in bowel or bladder A- sore that does not heal U- unusual bleeding or discharge from any body orifice T- thickening or a lump in the breast or elsewhere I- indigestion or difficulty swallowing O- obvious change in wart or mole N- nagging cough or hoarseness

Treatment Goals cure control palliation

Types of Treatment Surgery- cancer that arise from tissue with slow rate and proliferation or replication is the most amenable to

surgical treatment. Radiation- local treatment modality for cancer.

external- external beam radiation; exposure to radiation from a treatment machine. internal- brachytherapy; “close” treatment and consists of the implantation or insertion of radioactive

materials directly into the tumor or in close proximity to the tumor. cautions: time, distance, shielding organize care to minimize exposure time; greater the distance away from subject the less

exposure side effects of radiation

fatigue – (most common), teach energy conservation, explain fatigue is expected anorexia – weigh constantly, diet – increase protein increase calories bone marrow suppression – myelosuppression, affects WBC, RBC, platelets – risks for infection,

anemia, bleeding – monitor labs frequently skin reactions – erythema, wet desquamation, and dry desquamation

o for wet desquamation – results in discomfort and drainage; must be kept clean, dry and protected from further damage. Prevention of infection and facilitation of wound healing are therapeutic goals.

o for dry reactions- uncomfortable and results in pruritus; lubricated with a nonirritating lotion or solution that contains no metal, alcohol, perfume, or additives that can irritate the skin.

o protect skin from extreme temperatures to prevent traumao no heating pads, ice packets or hot water bottleso Avoid constricting garments, rubbing, harsh chemicals, and deodorants.

Chemotherapy the use of chemicals as a systemic therapy primary therapy for leukemia and lymphomas drugs create changes in cell cycle phases; interrupt cell growth and replication methods of administrations

oral and intravenous routes are most common IV concern: vesicants – tissue breakdown and necrosis – always get blood return before using IV

site to admin. chemo agents that when accidentally infiltrated into the skin cause severe local tissue breakdown and

necrosis.o S/S of infiltration- pain, swelling, redness, and presence of vesicles on the skin.o administered by means of a central vascular access device indicated in instances of

limited vascular access, intensive chemotherapy, continuous infusion of vesicant agents, projected long-term need for vascular access.

side effects N/V (most common) fatigue, anorexia bone marrow suppression – monitor frequent blood counts – infection – risk for neutropenia –

should be instructed to call with a temperature of 100.5 degrees F. or greater pancytopenia – reduction in all cellular elements of blood, WBCs, RBCs, platelets N/V/D – fluid and electrolyte imbalances, nutrition deficits, weakness, weight loss – use

antiemetics 30-60 min before meals; teach them when the feel like eating to eat really well alopecia skin problems – hperpigmentation , nail bed changes; photosensitivity cystitis – increase fluids – monitor renal function septicemia – life threatening to cancer patients – monitor labs

Nursing Care stomatitis – cleanse mouth with plain water or dilute H2O2 after meals; can use baking soda

solution (avoid commercial mouthwashes) assess knowledge – teaching r/t birth control – during treatment and up to 2 yrs after treatment sterility may occur – can do sperm banking malnutrition

o protein and caloric malnutrition characterized by fat and muscle depletion. o high protein intake- milk, eggs, cheese, meat, poultry, and fisho high caloric intake- mayonnaise, butter, sour cream, peanut butter, jelly, ice cream, and

honeyo altered taste- avoid voids that are disliked, experiment with spices and seasonings to

mask taste alterations

Oncologic Emergencies obstructive

caused by tumor obstruction of an organ or blood vessel superior vena cava syndrome: tumor is obstructing the superior vena cava; will see JVD,

peripheral edema, periorbital edema, SOB, difficulty swallowing spinal cord compression syndrome: tumor in epidural space, s/s – weakness, lethargy, intense

back pain, motor weakness, sensory loss; treated via radiation third space syndrome: shifting of fluid in vascular space to interstitial area (hypovolemic shock) –

causes: pt undergoes extensive surgical procedure, septic shock intestinal obstruction; watch fluid and electrolyte balance carefully

metabolic caused by the production of ectopic hormones directly from the tumor or secondary to cancer

treatment syndrome of inappropriate antidiuretic hormone (SIADS): certain types of cancer will act like

ADH, cancer cells start to manufacture, store, release ADH causing fluid retention. S/S: extensive weight gain, anorexia, n/v, can lead to seizure and coma because of unregulated ADH – tx: fluid restrictions

hypercalcemia: bone cancer – s/s: apathy, depression, fatigue, muscle weakness, EKG changes tumor lysis syndrome: triggered by chemo, which starts killing large # of cells all at once, end up

seeing hyperphosphatemia, hyperkalemia, hypocalcemia septic shock, and DIC

Infiltrative Emergencies Cardiac Tamponade: pericardial sac has too much fluid, prevents heart from contracting, usually results

from radiation to chest Carotid Artery Rupture: seen with cancer of head or neck, results from surgery or radiation

Cancers of the Mouth, Throat, and Neck Head and Neck Cancer

squamous cell in origin male to female ratio – 2:1 50 yrs or older etiology: smoking and alcohol Manifestations

oral cavityo early: painless growth; ulcers, change in fit of dentureso late: pain – may be aggravated by acidic foods

oropharynx/larynxo early: asymptomatico late: unilateral sore throat, otolgia (pain radiating to the ear), hoarseness, lump in throat,

dysphagia, hemoptysis, wt loss, cough, blood tinged sputum, enlarged cervical lymph nodes

Dx Studies visual exam of mouth x-ray MRI laryngoscopy CT scan biopsy

Collaborative Care and Nursing Measures staging – TNM – tumor, nodes, metastasis radiation – external – curative or palliative; affects voice chemo – before or after surgery surgery

o Laryngectomy – partial 2 types – hemelaryngectomy, superglotic allows preservation of voice vertical neck incision; ½ of larynx resected temporary cuffed trach post-op peri-op – NG inserted, Protect NG tube NG feeds x 1 week; risk for aspiration after NG removed, concern remains for aspiration – glottis edema

o Laryngectomy – total advanced ca no voice post-op; permanent trach nutrition – initially TPN – advanced to enteral tube feedings Jackson-Pratt drain

o Radical Neck Dissection remove metastasis ca; pre-op radiation remove nodes, IJ vein sternocleidomastoid muscle, spinal accessory nerve usually unilateral

o Composite Resection radical neck dissection and tongue, mandible or floor of mouth

Hemodynamics respiratory assessment IV fluids suctioning and trach care VS – frequent chest PT HOB – 30 degrees pain control: analgesics 30-60 min before meals avoid neck flexion evaluate communication measure drainage incision care and flap care reinforce dressing teach neck support and exercises after healing notify Dr. if drainage is frank or excessive

Complications airway laryngeal edema fibrosis of neck and larynx esophageal stenosis nutritional deficits infection fistula carotid artery rupture – oncological emergency

Post-op Nutrition IV fluids x 24 to 48 hrs NG feedings – observe tolerance and adjust amount, time, and formula if n/v, diarrhea, or distention

occurs – swallowing returns give small amounts of water – suctioning may be needed due to prevent aspiration

supraglottic swallow – minimizes risk for aspiration may be helpful to start with carbonated beverages – give cues to liquids position avoid thin watery fluids take deep breath to aerate lungs valsalva maneuver to approximate cords place food in mouth and swallow cough to remove food from top of vocal cords, then swallow breathe after cough-swallow sequence to prevent aspiration of food collected on top of vocal

cords

Liver Cancer primary – hepatocellular carcinoma (associated with chronic liver disease, including Hepatitis B & C metastasize – lungs Clinical Manifestations

hepatomegaly, wt loss, peripheral edema, acites, portal HTN dull abdominal pain in epigastric or right upper quad jaundice, anorexia, n/v, and extreme weakness pulmonary emboli

Diagnostics liver scan CT, MRI hepatic arteriography, endoscopic retrograde cholangiopancreatography (ERCP) liver biopsy AFP – hepatocellular carcinoma and helps distinguish primary ca from metastasis ca

Collaborative Care and Nursing Measures palliative localized tumor – lobectomy chemotherapy

5-fluorouracil (5-FU) leucovorin raltitrexed (Tomudex) experimental drugs chemoembolization: catheter placed in arteries to the tumor and an embolic agent is administered,

often mixed with chemo agent – embolic agent reduces blood supply allowing greater exposure to liver cells to the chemo drugs

nursing interventionso keep patient comfortableo Nutrition

monitor wt; small frequent meals; give patient food preference oral care before meals – to remove foul taste and improve taste antiemetics

Hepatic Encephalopathy (potential complication)

monitor for encephalopathy – orientation to time and place, speech, blood pH, and ammonia levels – liver unable to convert accumulating ammonia to urea for renal excretion

encourage fluids (if not restricted) and give laxatives and enemas as ordered to decrease production of ammonia

low protein – no protein diet as ordered (ammonia, break down product of protein) high caloric intake (without complications) 3000/day; high carbohydrate and moderate to low fat low sodium diet – pt with acites and edema limit exercise – exercise produces ammonia as a by-product of metabolism lactulose – acid environment discourages bacterial growth - lactulose traps ammonia in gut and the

laxative effect expels the ammonia from the colon

Acute Pancreatitis acute inflammatory process Signs and Symptoms

abdominal pain left upper quad or mid-epigastric pain radiating to back pain – severe, deep, piercing and steady; not relieved by vomiting aggravated by eating and onset when in recumbent position

n/v low-grade fever leukocytosis hypotension, tachycardia jaundice bowel sounds decreased or absent

Diagnostics: Primary tests: serum amylase/lipase elevated; and urine amylase levels elevated Secondary tests: blood glucose elevated, serum calcium decreased, serum triglycerides elevated

Collaborative Care Conservative Therapy

aggressive hydration pain management management of metabolic complications minimizing pancreatic enzymes

Drug Therapy Demerol or Morphine nitroglycerin or papaverine – relaxes smooth muscles and pain relief antispasmodics (Bentyl) – decreases vagal stimulation, motility, pancreatic outflow (inhibition of

volume and concentration of bicarb and enzymatic secretions); contraindicated in paralytic ileus Nutritional Therapy

NPO NG suction – to reduce vomiting, gastric distention and prevent gastric acid contents from

entering the duodenum when food is allowed – small frequent feedings high in carbohydrates; bland with no stimulants

Chronic Pancreatitis Progressive destruction of the pancreas with fibrotic replacement of pancreatic tissue Signs and Symptoms

pain – location same as acute pancreatitis except c/o heavy, gnawing feeling or something burning and cramp-like; not relieved with food or antacids

diabetes mellitus malabsorption, wt. loss steatorrhea (fatty stools)/foul smelling clay stools; constipation, dark urine mild jaudice

Diagnostics secretin stimulation test which stimulates production of bicarb

decreased secretions decreased bicarb concentration

Collaborative Care identical to that of acute pancreatitis but may include pancreatic enzyme replacement and control of

diabetes alcohol totally eliminated diet – bland; low in fat, high in carbohydrates pancreatic extracts given with meals or snacks; assess stools to see if effective if diabetes develop, it is controlled with insulin or oral hypoglycemics

Pancreatic Cancer adenocarcinomas Signs and Symptoms

abdominal pain (dull, aching); extreme, unrelenting pain anorexia, rapid and progressive wt loss nausea jaundice

Diagnostic Studies Transabdominal ultrasound CT Tumor markers: CA19-9/CEA (less specific more relevant in colon cancer

Collaborative Care surgery (most effective) radical pancreaticoduodenectomy or Whipple’s procedure

resection of the proximal pancreas, the adjoining duodenum, distal portion of the stomach, and the distal segment of the common bile duct

an anastomosis of the pancreatic duct, common bile duct, and stomach to the jejunum is done radiation – pain relief

Nursing Care: basically same as in acute/chronic pancreatitis symptomatic and supportive care medications and comfort measures to relieve pain – before peak of pain reached psychologic support – essential, especially during times of anxiety and depression helping patient and family through grieving process

NOTE: one of the most important medical interventions to increase nutrient intake is pain control.

Anticancer Drugs Alkyating Agents: Cytoxan

largest group of anticancer drugs analogue of nitrogen mustard – prescribed orally and IV kill cells by forming cross-links on DNA strands used to treat breast, lung, ovarian cancers; Hodgkin’s; leukemias; and lymphomas; an immunosuppressant

agent Side Effects

bone marrow suppression alopecia n/v, diarrhea, wt loss hematuria impotence, sterility, ovarian fibrosis headache, dizziness, dermatitis

Nursing Measures: well hydrated to prevent hemorrhagic cystitis (bleeding that results from severe bladder inflammation)

Antimetabolics: Methotrexate for treating solid tumors, sarcomas, choriocarcinoma, leukemia interferes with folic acid metabolism – result is inhibition of DNA synthesis and cell reproduction

at higher doses clients should be well hydrated keep urine pH 7.0 for drug solubility for excretion higher does require use of leucovorin as a rescue for normal cells Side Effects

arachnoiditis (IT use only): assess for nuchal rigidity, headache, fever, confusion, drowsiness, weakness, or seizures

anorexia, n/v, stomatitis hepatotoxicity anemia, leucopenia, thrombocytopenia

Nursing Implementations injection preparation: biological cabnet – wear gloves, gown, and mask while handling assess for bleeding: avoid IM injections and rectal temperatures if platelet count is low assess for signs of infection during neutropenia encourage pt to drink at least 2 liters/day to decrease uric acid levels; allopurinol

Anti-tumor Antibiotics: Adriamycin therapeutic effects

affects bleeding time Doxorubicin

o to treat breast, bladder, ovarian, and lung cancers; leukemias; lymphomaso inhibits DNA and RNA synthesis; immunosuppressant activity

Plicamycino to correct hypercalcemia and hypercalciuria; to treat testicular carcinomao inhibits hypercalcemia action of Vit. D and action by the parathyroid hormone; inhibits

DNA and RNA synthesis side effects

doxorubicin and plicamycin: stomatitis, anorexia, n/v, diarrhea, rash doxorubicin: alopecia plicamycin: dizziness, weakness, headache, mental depression

Nursing Implementations avoid aspirin, anticoagulants, and thrombolytics cyclophosphamide with doxorubicin can increase chance of hemorrhagic cystitis

Plant Alkaloids: Vinblastine (Velban) treatment of cancer: testes, breast, and kidney; lymphomas, lymphosarcomas, and neuroblastomas binds to protein of mitotic spindle, causing metaphase arrest – cell replication halted side effects: n/v, alopecia

Burns

Etiology

Burn – occurs when there is injury to the tissues of the body caused by heat, chemicals, electrical current, or radiation.

Types of Burn Injury Thermal: flame, flash burn, scalding, contact with hot objects (most common) Chemical

result of tissue injury and destruction from necrotizing substances acid (most common) alkali (most difficult to manage); adheres to tissue, causing protein hydrolysis and

liquefaction – damage continues even when alkali is neutralized (ex. cleaning agents, drain cleaners, and lyes

chlorine gas – inhaled – respiratory distress Tissue destruction may continue up to 72 hrs

Smoke and Inhalation: damage tissue of respiratory tract; redness and airway edema Types of smoke inhalation

carbon monoxide poisoningo carbon monoxide and asphyxiation account for majority of deaths in fire

victims o symptom – cherry red appearance

Inhalation injury above glottis thermally produced inhalation of hot air, steam, or smoke symptoms: mucosal burns – redness, blisters, edema – mechanical obstruction clue: look for singed hair, facial burns, hoarseness, difficulty swallowing

Inhalation injury below glottis chemically produced related to length of exposure to smoke, toxic fumes later symptoms 12-24 hrs – pulmonary edema, ARDS

Electrical burns intense heat from electrical current = coagulation necrosis severity depends on voltage, tissue resistance travel path of current, substantial length of

current exposureClassification of Burn Injury

Depth Partial or full thickness burns

Partial Thicknesso Superficial (1st degree)

depth: epidermis only causes: sun burn, quick heat flash, splashes of hot liquids sensation: painful characteristics: erythema, blanching on pressure, pain and mild swelling,

no vesicles or blisters o Deep (2nd degree)

depth: epidermis and dermis cause: flame, flash, scald, contact burns, chemical tar sensation: very painful characteristics: fluid filled vesicles that are red, shiny, wet (if vesicle has

ruptured)

Full Thicknesso Third and fourth degree

depth: all skin layers and nerve endings; may involvement of muscles, tendons, and bones

cause: flame, scald, chemical, tar, electric current sensation: little or no pain characteristics: dry, waxy, white, leathery, or hard skin; visible

thrombosed vessels Extent

Lund-Browder : determines extent of the burn injury by using client’s age in proportion in relative body-part size

Rule of Nines – body is divided into multiplications of 9 head and neck 9% each arm 18% each leg 18% trunk 36% genitalia 1%

Severity of burn Major: partial thickness > 25%; full thickness > or = 10% Moderate: partial thickness 15-25%; full thickness < 10% Minor: partial thickness < 15%; full thickness < 2%

Location Head, neck, and chest burns – at risk for pulmonary complications – mechanical obstruction –

from edema or eschar formation Arms and legs – can cause extremities to be contracted and not functional Perineal – at higher risk for infection

Patient Risk Factors Elderly heals more slowly preexisting cardiovascular, respiratory, or renal disease – poor prognosis r/t tremendous

demands placed on body by a burn injury DM, peripheral vascular disease – high risk for poor healing and gangrene, especially with foot

and leg burns General debilitation – alcoholism, drug abuse, and malnutrition – renders patient less competent

to deal with a burn injury Phase of burn management

Pre Hospital Remove person away from source of burn; smother burn beginning with head Small thermal burn, < 10%, tx is cover with cool tap water cloth Large thermal burn – focus – ABCs

o not advisable to immerse the burned body part in cool water – leads to extensive heat loss

o don’t use ice – frost bite smoke inhalation

o ensure patent airwayo 100% humidified O2

chemical: o remove from burning agento remove clothing contained with chemicalo lavage the affected area with copious amounts of water

electrical:o note victim position, identify entry/exit routes (identifies organs involved)

o maintain airwayo wrap in dry, clean sheet or blanket to prevent further contamination of wound and

provide warmtho assess how and when burn occurred o muscle contractions can fracture long bones and vertebrae o all patient with electrical burns should be considered at risk for potential cervical

spine injury and immobilization should be used during transporto electrical shock can cause immediate cardiac standstill or fibrillation (CPR)o Risks

cardiac arrest and arrhythmias (24-48 hrs after injury) monitor continuously

severe metabolic acidosis – sodium bicarb myoglobinuria – can lead to acute renal tubular necrosis (ATN) treatment

LR sufficient enough to maintain UO at 75-100 ml/hr until myoglobin and hemoglobin have been flushed from circulatory

Osmotic diuretics – mannitol – maintain UO – along with sodium bicarb to alkalinize urine

Emergent Phase (resuscitative) Plasma to interstitial fluid shifts causing hypovolemic shock Begin to see large fluid loss – loss of water, plasma proteins (albumin) – second and third

spacing Insensible fluid loss (skin and respiratory) 200-400 ml/hr; (normal loss is 30-50 ml/hr) sodium – interstitial space – until edema ceases potassium shift – damage cells and hemolyzed RBC Clinical Manifestations

o shock r/t pain and hypovolemiao blisterso shivering r/t chilling caused by heat loss, anxiety, or pain

Complicationso Cardiovascular

arrhythmias, hypovolemic shock – irreversible shock compartment syndrome – escharotomy (scalpel incision through full

thickness eschar) restores circulation sludging – adequate fluid replacement

o Respiratory upper airway burns that cause edema formation and obstruction of airway inhalation injury – alveolar level secondary to chemical fumes or smoke

o Urinary ATN r/t hypovolemia – decreased blood flow to kidneys causing renal

ischemia myoglobin and hemoglobin obstruction – adequate fluid replacement and

diuretics Collaborative Management

Preserve body function Prevent infection Restore skin integrity Provide support and comfort; restore patient to normal living pattern

Emergent Phase Interventionso airway management

early nasotracheal or endotracheal – eliminates necessity for emergency tracheostomy

ventilator assistance with PEEP ABGs humidified O2 @ 100% r/t carbon dioxide poisoning high Fowler’s (unless spinal injury) prevention of pulmonary complications possible fiberoptic bronchoscopy to assess lower respiratory tract r/t

smoke inhalation encourage cough, deep breath every hour; reposition Q 2 hrs

o Fluid Therapy 2 IV lines – at least an 18, because of massive fluid resuscitation; usually

instituted with burns > 15% TBSA Crystalloids – LR, 5% dextrose, and saline

Isotonic solutions neutral; same osmolality (particles) of fluids ECF and ICF Need for isotonic solutions: ideally for a person who has a fluid

ECF volume deficit; fluid or Na+ losses; hypovolemic shock; GI loss, surgical loss, burns

Nursing interventions: monitor labs when giving 0.9% NaCl, may result in elevated Na+ and Cl levels

Colloids – albumin, hespan, and dextran; beneficial when capillary permeability returns to normal or near normal

Foley – strict I&Os, measuring adequacy of fluid resuscitation Weigh daily Brooke Formula Parkland Formula

4 ml LR/kg/TBSA burn = total fluid requirements for 1st 24 hrs after burn

½ of total in first 8 hrs ¼ of total in second 8 hrs ¼ of total in third 8 hrs example: 70 kg patient with a 50% TBSA burn: 4 ml x 70 kg x 50% TBSA = 14,000 ml

Parameters for adequate fluid replacement UO: 30-50 ml/hr in an adult; 75-100 ml/hr for electrical burn in an

adult Cardiopulmonary: BP (systolic > 90-100), pulse rate (< 120),

respiration (16-20); BP most appropriately measured by A-line; peripheral often invalid r/t vasoconstriction and edema

Sensorium: alert and oriented x 3

o wound care delayed until patent airway, adequate circulation, and adequate fluid

replacement have been established Prevent wound infection

cleansing and debridement use hydrotherapy for no more than 30 min. to prevent electrolyte

loss Travase ointment: enzymatic debrider to dissolve dead tissue Elase ointment

This medication breaks up and helps remove dead skin and tissue to encourage healing of wounds. It is used to promote healing of wounds such as burns, ulcers, surgical wounds, circumcision or episiotomy.

two types of wound treatment Open method: wound covered with topical antibiotic without drsg. Multiple dressing changes: sterile gauze drsg. impregnated with or

laid over a topical antibiotico Pharmacological

Analgesics early postburn period

IV Morphine sulfate extraction from opium it can cause respiratory depression, orthostatic

hypotension, urinary retention constipation antidote: narcan

IM injections will not be absorbed adequately in burned or edematous areas causing pooling of medications in tissues – when mobilization begins, inadvertently overdose

Medicate 30 min. before wound care Sedative – benzodiazepine: zanax, valium Tetanus – potential for wound contamination Antibiotics

Aminoglycoside adverse reaction: mainly nephrotoxicity may decrease K+ and magnesium levels urine output should be at least 600 ml/day check for hearing loss: ototoxiciy check that therapeutic drug monitoring (TDM) has been

ordered for peak and trough drug levels Gentamicin is 5-10 – blood should be drawn 45-60 min

after drug has been administered for peak levels and min before next drug dosing for trough levels. Drug peak values should be 10-12 and trough values should be 0.5-2

monitor s/s of superinfection: stomatitis, vaginitis, and/or genital itching

Cephalosporin bactericidal assess allergies (do not give any type or class if allergic) monitor s/s of superinfection: stomatitis, vaginitis, and/or

genital itching

advise to ingest buttermilk or yogurt to prevent superinfection

instruct diabetic not to use Clinitest tablets for urine glucose testing because of false results; Tes-Tape or Clinistix may be used, or Chemstrip bG may be used for blood glucose testing.

take with food if GI irritation occurs Antimicrobial – sulfamylan, bacitracin, bactiban, silvadene; topical as well

as systemic silver nitrate (sulfamylan)

anti-infective cream for second and third degree burns, particularly electrical burns

possible pain on application provide daily baths for removal of previous applied cream handle carefully; solution leaves a gray or black stain on

skin, clothing, and utensils keep drsg. wet with solution; dryness increases

concentration and causes precipitation of silver salts in wound

acid-base disturbance because it is a carbonic anhydrase inhibitor

may cause electrolyte imbalance if used extensively (hypokalemia)

silvadene cream antibiotic cream – prevent and treat infection of second and

third degree burns painless applications- alleviates pain(cooling effect) and

prevents drying observe for hypersensitivity reaction (sulfa) rash, itching,

burning sensation in unburned area excessive or extensive use may cause sulfa crystals

(crystalluria) H2 blockers – tagamet, zantac; prevent stress ulcer

tagamet has many drug interactions and side effects by inhibiting hepatic drug metabolism, it enhances effects

of oral anticoagulants, theophylline, caffeine, dilantin, valium, inderal, Phenobarbital, and CCB

zantac treatment of peptic ulcers, GERD, stress ulcer side effects: confusion, arrhythmias, hepatotoxicity, anemia contraindications: severe renal or liver disease administer with meals or immediately after and at HS; if

dose is once daily administer at HS shake oral suspension

Hespan

Made from starch and acts as volume expander; is at least effective as albumin; can exert osmotic effect for up to 36 hours

All types of shock

Use cautiously in CHF, renal failure, or bleeding disorders (due to anticoagulant effect)

Albumin Action: increase plasma colloid osmotic pressure; rapid volume

expansion All types of shock except cardiogenic Monitor for circulatory overload Side Effects: chills, fever, and urticaria

o Nutrition Fluid replacement takes first priority over nutrition in the initial emergent

phase NG tube to low intermittent suction – paralytic ileus within few hours due

to body’s response to major trauma After bowel sounds return 48-72 hrs after injury oral intake initiated with

clear liquids progressing to high-calorie, high-protein, high carbohydrate diet with vitamin and mineral supplements. (5,000 kcal/day)

failure to provide adequate calories and protein leads to malnutrition and delayed healing

serve small meal portions not freely given water – rather calorie counting liquids early and continuous enteral feedings promotes optimal conditions for

wound healing and immunocompetence Acute phase

o mobilization of extracellular fluid and subsequent diuresiso Shock Phase (Hypovolemic shock); first 24-48 hrs

dehydration decreased BP, increased pulse decreased UO thirst

o Clinical manifestations removed eschar – epithelialization begins at wound margins and appears

red or pink scar tissue 10-14 days epithelial buds close in wounds without surgical intervention full thickness wounds require surgical debridement and skin grafting to

speed healing processo Laboratory Values

Sodium hyponatremia – if hydrotherapy too long (>20-30 min) hypotonicity of bath water pulls sodium from open burns other causes: excessive GI drainage, diarrhea, and excessive water

intake

dilutional hyponatremia – water intoxification – to avoid drink fluids other than water such as juice, soft drinks, or nutritional supplements

Signs and Symptoms weakness, fatigue, dizziness

muscle cramps headache tachycardia confusion

hypernatremia – may occur following successful fluid replacement if copious amount of hypertonic solutions were required

other causes: improper tube feedings or improper fluid administration

Signs and Symptoms thirst dried, furry tongue lethargy, confusion possible seizures

Potassium Hyperkalemia – renal failure, adrenocortical insufficiency, or

massive deep muscle injury cardiac arrhythmias and ventricular failure muscle weakness and EKG changes observed clinically Hypokalemia – lengthy hydrotherapy other causes: vomiting, diarrhea, prolonged GI suction, prolonged

IV therapy without K+ supplement Constant K+ losses occur through burn wound

elevated Hct metabolic acidosis

o Complications Infection Cardiovascular

arrhythmias, hypovolemic shock – irreversible shock compartment syndrome – escharotomy (scalpel incision through

full thickness eschar) restores circulation sludging – adequate fluid replacement

Neurologic disorientation combative hallucinations and frequent nightmare-like episodes delirium (occurs often at night)

Musculoskeletal limited ROM contractures (because of pain patient prefers flexed position for

comfort) splinting beneficial Gastrointestinal

paralytic ileus – sepsis diarrhea (most common) – supplemental feedings, antibiotics constipation – side effect of narcotics, decreased mobility, and

low-fiber diet NG tube: to prevent/control Curling’s ulcer – stress (best treatment

is prevention) antacids and H2 blockers: zantac, tagamet which inhibits histamine and stimulation of hydrochloric acid secretion (keeps gastric pH < 5)

Test stools for occult blood Endocrine

increase blood glucose – stress mediated cortisol and catecholamine release

increase in insulin production and release – insulin effectiveness decreased – insulin insensitivity – elevated blood glucose

hyperglycemia – increased caloric intake – supplemental insulin, not decreased feedings

Diuretic Phase (2-5 days postburn)o interstitial fluid returns to the vascular compartmento elevated BP, increased UOo Labs

hypokalemia hyponatremia metabolic acidosis

Rehabilitation Phaseo starts when diuresis is completed and wound healing and coverage begin and

patient can resume level of self-care activitieso dry, waxy-white appearance of full thickness burn changing to dark brown; wet

shiny, and serous exudates in partial thicknesso Complications

Contractures – result of shortening of scar tissue in the flexor tissues of a joint

Pain – patient prefers flexed position for comfort – positioning, splinting, and exercise to minimize complication – continue until skin matures

o Labs: hyponatremia