Complex 2 Exam 2

Types of Fractures

1. Closed

2. Open

3. Spontaneous

4. Transverse

5. Oblique

6. Spiral

7. Comminuted

8. Greenstick

9. Fissure

Types of Fractures: Closed

skin remains intact and does not go through skin

Types of Fractures: Open

one will go through skin (priority problem = hypovolemia, infection, pain)

Types of Fractures: Spontaneous (pathological)

fractures occurs to bone that is weak from disease process (bone cancer or osteoporosis)

Types of Fractures: Transverse

straight across (horizontal clean break)

Types of Fractures: Oblique

slanted across (diagonal)

Types of Fractures: Spiral

twisting break (investigate abuse)

Types of Fractures: Commintated

break is into multiple parts (fragmented)

Types of Fractures: Greenstick

occurs on one side but does not extend completely through the bone (most common in kids)(look into child abuse)

Types of Fractures: Fissure

Hairline

Types of Fractures: Avulsion

Ligament/ Tendon pulls off part of the bone

Fractures: Clinical Manifestations

· Acute pain (immobilization, ice, elevate w analgesics)

· Muscle spams - due to pulling forces of bone due to not being aligned (treat this and pain will decrease)

· Deformity - internal rotation/shortened extremity

· Crepitus: grating sound

· Local swelling & discoloration/loss of function

· Edema

· Ecchymosis (bleeding in underlying tissue)

· SQ emphysema (LATE finding) = air bubbles under skin

Fractures Prioritization

1. Maintain ABCs - perfusion is BIG!!

- monitor for bleeding (internal and external)

- PAIN, SENSATION, TEMP, CAP REFILL, MOVEMENT (Check both pulses at same time)

2. Stabilize (Immobilize the injury - prevents further injury)

- Splint the injury, including the joints distal/proximal to the suspected fracture site & minimize movement

- Open fracture: cover with sterile dressing to prevent contamination, elevate above heart, ice, admin ABX

3. Assess neurovascular status before & after splinting

4. Remove clothing/jewelry from affected limb

5. Elevate above heart and apply ice (elevate for first 24-48hrs after cast applied -> peak inflammation)

6. What's the mechanism of injury? - may need tetanus shot

7. Keep them warm = cold NOT GOOD

Fractures: Complications

Infection: osteomyelitis (biggest risk in open fractures) culture before abx!!

Impaired Circulation - dependent edema, diminished pulses, cool/pale

DVT/PE: redness, swelling, warmth at localized area

Almost all pts are on DVT prophylaxis→ enoxaparin, positive D-dimer is they have a clot

- Anti-embolism stockings and SCDs to prevent DVTs

Fat embolism (similar to PE): petechial hemorrhage on chest/abdomen/head --> LATE sign (common in long bone fractures aka femur)

Tx: O2, steroids, vasopressors, fluid replacement, pain/anxiety management - NO CURE

Compartment syndrome = MED EMERGENCY

- Pressure from external: tight cast/dressings

- Pressure internal source: accumulation of bloods/fluids

- edema from blood pulling (edema can't go anywhere -> pressure on nerve endings -> pain) eventually leads to ischemia

Fractures: Nursing Interventions

· RICE: Rest, ice, compress, elevate
· Give FLUIDS!!, analgesics, antibiotics, muscle relaxants, anticoagulants
· Keep pt warm
· Neurovascular - 5 P's - Pain, paresthesia, pallor, pulses, paralysis
· Hemorrhage: watch for bruising/swelling
· Prep pt for immobilization device (cast= effective bc patient can't remove, weights = equal on both sides, skeletal traction - pin sites = one cotton swab per pin = clear drainage expected)

Amputations: priorization

1. ABC - assess circulation/perfusion (skin color, cap refill)

2. Bleeding? Circulation distal to the injury?

- Stop bleeding by applying direct pressure

- Elevate extremity above heart level - no longer than 24 - 48 hrs AFTER surgery

3. Insert 2 large bore IV's - 18 gauge or larger

4. FLUIDS FLUIDS

5.. Monitor VS/pain

- Admin pain meds

6. Determine if limb is salvageable - If the limb is completely detached→ wrap in sterile gauze, put it in a sealed bag, stick it in ice water and send it w the p

7. Prepare for OR: labs (blood type & cross match) & consents

8. Surgical methods

Amputations: priorization - Open

used when active infection is present; skin flap is not sutured over the end of the limb so that the infection can drain; closed later

Amputations: priorization - Closed

skin flap is sutured over the limb, closing the site

Amputations evaluation

is there blood flowing to the distal portion of the extremity?
- 5 P's will be off: warm/cold, sensation, color - off
- Cap refill !!!!
Are blood vessels damaged?
- use doppler

Amputations: post-op interventions

- Hypovolemia = PRIORITY - measure pulses most proximal (above) to amputation AT THE SAME TIME

· Assess site for bleeding - have tourniquet at bedside

- Monitor for dehiscence

- Assess surgical site for S/Sx of infection

· Heat, inflammation, drainage

· Systemic: fever, tachycardia, abnormal labs

- Pain - Admin analgesics, non-pharm: positioning, distraction

- Prevent flexion contracture (Inability to straighten extremity)

· Elevate residual limb for the first 24-48hrs hours and avoid elevation after that; ROM exercises; have pt lie prone for 20-30 min several times a day; avoid prolonged sitting in a chair

- Provider does 1st dressing change after 24-48hr

- Monitor for phantom limb pain

Amputations: Treatment

calcitonin for the 1st wk, beta-blockers and gabapentin; you can also give baclofen (muscle relaxer), tell them this is a normal response

Compartment syndrome clinical manifestations: General

Medical EMERGENCY

- Damage occurs in 4-6 hrs→ DO NOT put on a cast if there is too much swelling

Compartment syndrome clinical manifestations: Decreased

Decreased compartment size (extrinsic)

- Due to tight splint/cast

Treatment: loosen/remove cast

Compartment syndrome clinical manifestations: Increased

Increased compartment size (intrinsic)

- Due to swelling/bleeding inside

Treatment: Fasciotomy→ surgically open fascia which will reduce pressure and increase perfusion, priority status: neurovascular checks (q-15 min)

Compartment syndrome assessment/prioritization (5 P's)

Pain: FIRST; unrelieved by medication/positioning/ & worse with passive ROM/stretching; if the pain is relieved by elevation/meds, it’s not compartment syndrome!!!!!!

Paresthesia: numbness, burning, & tingling are early signs

Pallor: paleness of the affected tissue, pale/cyanotic nail beds - EARLY sign

Paralysis: motor weakness & inability to move extremities are late signs (loss of control and sensation)

Pulselessness: last sign, check both pulses

Compartment syndrome evaluation of care

- Frequent neurovascular checks to evaluate the effectiveness of treatment
- Keep limb at the level of the heart
- Goal is to restore circulation & neurovascular preservation

Crush injuries clinical manifestations

Initial injury -> swelling + edema –> blood flow restricted –> ischemia –> necrosis

Crush wounds

- Abrasions, hematomas, contusions

- may not appear significant on outside -> inside can cause problems overtime (vessels, nerves) -> amputation

Degloving (shearing = skin avulsion or entire skin loss)

Traumatic amputation

Compartment syndrome - tightness

Crush injuries prioritization

- ABC: circulation = fluid → blood products LIFE OVER LIMB

- Put on a heart monitor (EKG) (bc crushed muscles release K+)

- Check urine for myoglobin (will cause kidney failure)

- Prevent rhabdomyolysis (breakdown of muscle tissue - causes release of myoglobin) (dark red/brown urine)

· Dark red/brown urine = give fluids & furosemide

- Preserve tissue

- Surgery

- Tetanus shot

Types of pain

- Chronic: > 3 months

- Acute: sudden onset

- Nociceptive: arises from damage or inflammation of tissue

· Somatic: joints, broken bone, muscles, skin, or connective tissues

· Visceral: organs

· Referred: gallbladder pain or angina (pain comes from heart but feel in left side of jaw)

- Breakthrough: temporary exacerbation (Incident/Idiopathic/End of dose med failure)

- Phantom: pain associated with an amputated limb or body part (tx: BB, antiepileptics, antidepressants)

- Neuropathic: changes in the central or peripheral nervous system (AKA nerve pain/phantom pain is neuropathic pain)

- Psychogenic= pain associated w depression; fewer endorphins; more susceptible to pain

Pain: Clinical Manifestations

facial expressions: grimacing wrinkled forehead

body movement: restlessness, pacing, gaurding

Moaning/crying

Decreased attention span

BP & Pulse cane increase w/ acute pain

Pain: Nursing Interventions

- Subjective/objective data (grimace&crying, tachycardia, diaphoresis)
- Pain assessment: PQRST, FACES (also objective)
- Treat underlying cause:
· Nonpharm: skin stimulation, distraction/relaxation/imagery, elevate extremity
· Pharm: (NSAIDs=chronic; Opioids=acute), PCA pump (only pt can push the button)
- Educate & reduce fear/anxiety

Urinary calculi: clinical manifestations

- Renal colic (severe pain that radiates to groin)

- Tachycardia, tachypnea, increased/decreased BP with pain

- Urinary frequency or dysuria

- flank pain

- Diaphoresis, pallor

- N/V

- Obstruction: MED EMERGENCY:

Oliguria <400ml/day or anuria < than 100 ml/day

- Hematuria - from passed stone (blood in urine) (notify provider if gross - not normal)

Urinary calculi: priority interventions

Relieve pain #1

- Opioids

- NSAIDs

- Muscle relaxers

- ABX

Lithotripsy: shock wave to break up stones

- Increase fluids to pee out pieces after procedure

Expected after procedure: hematuria (blood) in urine up to 24hrs & bruises on side and pain

NOT expected after procedure: fever/chills - infection

Urinary calculi plan of care/discharge teaching

Strain the urine to check for passage of stones

- Increase ambulation/ fluids 2.5-3L/day to pass stones

- no bedrest and never massage

Medications

- Thiazide diuretics: reabsorb Ca

- Allopurinol: uric acid reducer

- Potassium citrate/sodium bicarbonate: alkalize the stones

DIET:

- Limit sodium, calcium(dairy), animal protein

- Avoid oxidate (chocolate, wine) & high-phosphorous foods

- Limit purine sources: red meat, beer

Hypovolemia clinical manifestations

HYPOvolemia = blood/fluid loss
- dry furrowed tongue, thirst, N/V, anorexia, oliguria
- flattened neck veins & poor skin turgor
- diminished cap refill
- low-grade fever, hyperthermia
- tachypnea, tachycardia, thready pulse
- dizziness, syncope, confusion
- hypotension

Hypovolemia priority interventions

· Oral/IV therapy
· Monitor I/O & daily weight
· Monitor VS: BP, HR
· Monitor LOC
· Change positions slowly

Hypervolemia clinical manifestations

HYPERvolemia = Fluid volume excess

· Tachycardia, bounding pulse

· HTN, tachypnea

· Visual changes, seizures

· Crackles, cough, edema

· JVD & cool skin

Hypervolemia priority interventions

· Monitor I/O & daily weight (gain/loss of 1kg in 24 hr is 1 L of fluid)
· Auscultate lung sounds
· Monitor edema (Sodium-restriction & fluid restriction)
· Encourage rest
· Diuretics

Hyponatremia clinical manifestations <135

Stupor/coma

Anorexia (n/v)

Lethargy/confusion

Tendon reflexes decreased and rapid thready pulse

Limp muscles/weakness

Orthostatic hypotension/hypothermia

Seizures/headache/lightheaded

Stomach cramps, hyperactive bowel sounds

Hyponatremia priority interventions

· Intake sodium PO: beef broth, tomato juice (don't exceed 12 mEq/L in 24 hrs) = rapid raise neuro risk

· IV fluids: LR 0.9% isotonic saline

· Monitor LOC, VS, I&O, Daily weight

Hypernatremia clinical manifestations >145

Anorexia

Restlessness

Coma

Hyperthermia

Muscle twitching

Absent DTR (Deep Tendon Reflexes)

Nausea/Vomiting

Dry mucous membranes, Diarrhea

Orthostatic hypotension

Thirst, Tachycardia

Seizure

Hypernatremia priority interventions

· Admin loop diuretics for poor kidney excretion

· NS 0.3%: hypotonic, gradual decrease in sodium

· Monitor LOC and ensure safety, I&O

· Monitor HR and lung sounds

· Oral hygiene to decrease thirst

· Encourage water intake

Hypokalemia clinical manifestations <3.5

Lethargy

Leg cramps

Limp muscles/decreased DTR

Low, shallow respirations

Lethal cardiac rhythms - Inverted/flat T wave, ST depression, elevated U wave

Lots of urine (polyuria)

Skeletal muscle weakness (Altered LOC/confusion/coma)

U wave increase

Constipation/hypoactive bowel sounds/abd distention

Toxic effects of digoxin

Irregular, weak thready pulse

Ortho hypotension

Numbness/parasthesia

Hypokalemia priority interventions

- Potassium replacement - IV never push nor SQ or IM
· PO: avocados, broccoli, dairy products, whole grains
- Fall precautions d/t muscle weakness
- EKG monitoring
- Monitor LOC, urine output, bowel sounds
- Monitor O2 levels
- Assess DTR & muscle weakness

Hyperkalemia clinical manifestations >5.1

Muscle cramps/weakness

Urine abnormalities (oliguria)

Respiratory distress

Decreased cardiac contractility

ECG changes - peaked T wave, widened QRS

Reflexes decreased

Hyperkalemia priority interventions

· EKG monitoring
· Potassium-restricted diet
· Severe: calcium gluconate or dialysis
· Loop diuretics (furosemide)
· IV insulin glucose

Hypocalcemia clinical manifestations <8.4

· Chvostek's sign
· Trousseau's sign (hand/finger spasm with BP cuff inflation)
· Paresthesia of fingers & lips
· Muscle spasms/twitching
· Seizures
· Prolonged QT interval and ST segment
· Tetany
· Hyperactive bowel sounds, diarrhea, abdominal cramps

Hypocalcemia priority interventions

PO/IV calcium (vitamin D enhances absorption)
- PO: dairy products, canned salmon, sardines, dark leafy veggies
· Seizure & fall precautions/avoid overstimulation
· Severe: calcium gluconate or calcium chloride

Hypomagnesemia clinical manifestations <1.3

· HTN

· Flat/inverted T wave, ST depression, widened QRS

· Hyperactive DTR's

· Paresthesia,

· Muscle tetany

· Seizures

· Chvostek's & Trousseau's

· Hypoactive bowel sounds, constipation, abdominal distension

· Depressed mood, apathy, agitation

Hypomagnesemia priority interventions

foods high in magnesium
- peanut butter, coco, dark leafy veggies, nuts, whole grains, seafood

-PO magnesium sulfate for mild/IV if severe
-Have calcium gluconate ready to reverse hypermagnesemia if needed

Acute kidney injury: prerenal

- reduction of blood flow to the kidneys -> can't get urine out of body, build-up of waste/oliguria (problem w/ perfusion not a kidney problem) (fix perfusion!)

· Can lead to intrarenal

· Reversible when blood flow is restored

Causes for prerenal AKI:

- Distributive shock

- Decreased CO (HF,MI,damage to heart muscle), hypovolemia/dehydration, embolus, burns

Acute kidney injury: intrarenal

· Direct damage to the kidney from lack of oxygen
· Tumor, trauma, chemical (NSAIDS, alcohol, etc)
· More than just blood flow compromised = cells are dying
· Irreversible

Acute kidney injury: postrenal

· Result of bilateral obstruction (urethra/ureters)
· Renal calculi/tumor/BPH/spinal injury
· Blockage in urinary tract --> urine can't leave --> pressure dynamics get thrown off --> blood doesn't get filtered = decreased kidney function
· Reversible if caught soon enough (easiest to fix)

Acute kidney injury clinical manifestations

- Anemia→ fatigue, pallor, dizziness, confusion, tachycardia
- Fluid overload→ edema, crackles, dyspnea, weight gain, JVD, tachycardia
- Hyperkalemia→ peaked T waves, N/V/D, ab cramps, muscle weakness
- Might see metabolic acidosis (kussmauls, warm, brady/tacypnea)
- 100-400mL in 24 hrs w/ or w/o diuretics (oliguria)

Acute kidney injury plan of care/interventions

1. IVF: low dose dopamine increases flow to kidneys
- watch for s/sx fluid overload: edema, CVP above 6, bounding pulse, tachycardia, HTN
- respiratory assessment: crackles
- strict I/O, daily weight
2. IVF alone doesn't always help -> furosemide/mannitol
- Force fluids to flush kidneys
3. no nephrotoxins: contrasts and -mycins and NSAIDS
4. if IVF then IVF + diuretics doesn't work = dialysis

AKI risk factors

Chronic kidney disease
Heart failure

Acute kidney injury nutrition

· Increase protein/if on dialysis = decrease protein if not
· Decrease potassium, sodium, phosphorus, magnesium
· Restrict fluid intake

Hemodialysis complications clinical manifestations

· Clotting = no bruit/thrill
· Infection = purulent drainage, redness, swelling, cloudy drained dialysate
· Disequilibrium syndrome = N/V, HA, LOC changes, agitation/restlessness, seizure
· Hypotension = dizziness, tachycardia
· Anemia= fatigue, pale

Hemodialysis complications priority interventions: Clotting

- Avoid compression of access site, NO IV/BP on arm

- Assess graft for thrill/bruit

- Heparin – anticoagulant

Hemodialysis complications priority interventions: Infection

- NO BP/IV sticks

- Aseptic technique, standard precautions

Hemodialysis complications priority interventions: Disequilibrium syndrome

- SLOW dialysate exchange rate

- Notify provider IMMEDIATELY

- Admin anticonvulsants or barbiturates

Hemodialysis complications priority interventions: Hypotension

- SLOW dialysis exchange rate

- Give IVF or albumin

- Lower HOB

- Severe hypotension & not responding to fluids = STOP dialysis

Hemodialysis complications priority interventions: Anemia

- Admin erythropoietin, blood transfusion, folate

- Monitor H/H & RBC

Hemodialysis: AV access

· Need consent
· Palpate for thrill and auscultate bruit few x a day
· Bleeding > 30 min day = contact provider
· 5 Ps: pallor and paresthesia is earliest sign of clot
· Pre/post dialysis weight (dry weight = post dialysis)
- NO sleeping on arm, BP on arm and avoid lifting over 5 lbs

Renal transplant candidate eligibility

1. Anuric: 100 or less ml/24hrs

2. Proteinuria: protein in urine + hematuria

3. Azotemia: nitrogen in blood, elevated BUN/Creat

4. Severe hyperkalemia, hypernatremia

5. Fluid volume excess conditions: HF, pulmonary edema, JVD

6. Recipient’s tissue must match the donor’s tissue - ABO and histocompatability (kidneys from relatives is best)

Renal transplant candidate eligibility: CANNOT

1. Older than 70; younger than 2 (immunocompromised)

2. Currently have or have had cancer

3. Have a chemical dependency (addicted to drugs)

Renal transplant teaching

- immunosuppressants for the rest of life (no grapefruit juice, concentrated sugars, carbs)
- monitor incision, adhere to meds, go to follow-up appts, prevent infections (avoid crowds, wear a mask), exercise and eat healthy foods
- Monitor for rejection: pain, bloody urine or no urine, fever, HTN
- 1L of fluid= 2.2 lbs; be suspicious of fluid retention; DAILY WEIGHTS!
- low fat, high fiber, high protein, restrict sodium

Renal transplant complications: general

#1 indicator of complication (except infection) → decrease in UO

Organ rejection

- Hyperacute: occurs w/in 48 hrs; blood clots form in kidney and destroy it = immediately remove donor kidney

- Acute occurs 1wk - 2 yrs after transplant due to antibody response = increase doses of immunosuppressive meds

- Chronic (gradually over mths - years) = conservative until dialysis is needed

Renal transplant complications: Ischemia

- Donor kidney has hypoxic injury from taking too long to be transferred; biopsy distinguishes it from rejection

Renal transplant complications: Renal artery stenosis

- Scarring of surgical anastomosis (connection)

- Bruit over anastomosis site & decrease in urinary output, increasing BUN/Cr

- Monitor for peripheral edema & frequent BP checks

Infection

- low- grade fever, dyspnea, fatigue, altered LOC

- Infection at site = redness, drainage

Renal transplant complications: Infection

- low- grade fever, dyspnea, fatigue, altered LOC

- Infection at site = redness, drainage

UTI clinical manifestations: general

· Lower back or abdominal discomfort

· N/V, fever

· Urinary frequency & urgency

· Dysuria

· Feeling of incomplete bladder emptying

· Hematuria

· Pyuria (pus in urine)

UTI’s Clinical Manifestations: Older adult

- hypoTN, tachycardia, tachypnea, fever = UROSEPSIS

- Incontinence

- Mental confusion d/t ammonia build up

- Loss of appetite

- Nocturia & dysuria

UTI prioritization

- culture before ABX !!!

- increase fluids to flush bacteria

- early removal of catheters or avoid indwelling catheters

- routine peri care

- phenazopyridine: bladder analgesic, will not Tx infection just helps with burning pain; turns urine red/orange (can stain)

- avoid caffeine

- warm sitz bath, heating pads

UTI complications

· Urethral obstruction

· Pyelonephritis: can damage kidneys

· Chronic kidney disease

· Urosepsis (left untreated) can lead to septic shock and death

What is Glomerulonephritis?

inflammation of the glomerular capillary membrane; immune complex disease, not an infection (usually caused by strep)

Glomerulonephritis clinical manifestations

· Hematuria (reddish brown or cola colored urine)

· Proteinuria - frothy

· Oliguria

· Fluid volume excess

· Anorexia/nausea/HA

· Back pain

· Low-grade fever

· Older adults: looks like fluid volume excess (FVE):

- Can progress to nephrotic syndrome

- HTN, dyspnea, edema, LOC changes

Glomerulonephritis priority interventions

- treat with ABX

- Most effective way for determining fluid imbalance: DAILY WEIGHTS

- Initiate bed rest

- Decrease inflammation: immunosuppressives, corticosteroids(can decrease protein loss)

- DECREASE protein loss = priority

Glomerulonephritis pharm

- ABX: penicillin, erythromycin

- Diuretics: NO fluids

- Antihypertensives: ACE, ARB

· Decrease HTN to avoid encephalopathy

· Retention of sodium leads to seizures

· Furosemide + sodium restriction

- Corticosteroids: inflammation

- Plasmapheresis:

· Filters damaging antibodies (plasma)

· Usually done in dialysis

· Monitor for: hypovolemia, tetany, infection

What is Pyelonephritis?

inflammation of the renal pelvis and parenchyma; due to an infection that ascends into the kidney from the lower urinary tract; usually caused by E. coli

Pyelonephritis clinical manifestations?

· Chills

· High-grade fever

· Malaise

· Flank pain radiating to the umbilicus

· Urinary frequency, discolored urine

· Vomiting

· Costovertebral angle tenderness (dull flank pain that leads to umbilicus)

· Can lead to urosepsis

Pyelonephritis priority interventions

· Culture before ABX
· Push fluids to flush bacteria
· Encourage rest
· Warm, moist, compress to affected flank
· Monitor for renal failure: BUN/Cr, dark urine
· Pyelolithotomy: stone removal
· Nephrectomy: removal of kidney
· Urethroplasty: corrects damage to urethra from scarring

Pyelonephritis (kidney infection) pharm

· Analgesics (phenazopyridine) (only helps with burning not infection)
· Antipyretics
· ABX
· Anti-emetics

Hyperthermia priority clinical manifestations

· >102 in children
· >101 in adults
· Start treating at 100.4!
· >106: neural/brain damage & can cause seizures
· Flushing, warm skin, tachycardia, tachypnea
· Hyperventilation

Hyperthermia nursing interventions

- Antipyretics: ibuprofen/acetaminophen (alternate Q3)
- Increase fluids & rest
- Heat exhaustion
· Cooling blankets
· Decrease temp in room
· Apply ice bag covered with towel to groin, arms, & neck
· Cover with sheet only
· High concentration of O2
· Supine w legs elevated

Hypothermia priority clinical manifestations

Mild: 89.6-95F

- Fatigue, slurred speech, confusion, tachycardia, tachypnea, shivering

Moderate: everything decreases

- decreased LOC, RR, pulse, BP

Severe: below 83F

- No RR or pulse, vfib, dilated & unresponsive pupils

Acidosis

Hypercoagulability or DIC (disseminated intravascular coagulation)

- Blood freezes

Hypothermia nursing interventions

- Warm blankets -> warm up, but not too fast -> dilation too fast -> BP & CO drop more
- Warm IV fluids: do not microwave
- Remove all clothing & assess, dry the pt, reduce exposure

Hypersensitivity/anaphylactic shock clinical manifestations

· Swelling tongue, drooling (not able to swallow)
· Stridor, labored fast breaths
· No O2, red flushed skin --> cyanosis/pale
· Angioedema (systemwide vasodilation)
· Wheezing then no air movement
· Hypotension, tachycardia
· Diaphoresis
· Decreased LOC

Hypersensitivity/anaphylactic shock priority interventions

· Intubate if RR < 6, NPA (nasopharyngeal airway)

· O2 and STAT ABGS

Give meds in this order

1. Epi (IM/SQ) – not IV - prevent vasodilation by constricting

2. Diphenhydramine (IV/IM)

3. Ranitidine: blocks histamine release

4. Methylprednisolone IVP for inflammation (cortocoidsteroid)

Systemic inflammatory response syndrome (SIRS) clinical manifestations

· System wide vasodilation: weak thready pulse
· Fever > 100.4
· WBC > 12,000 then sudden drop
· Hypotension
· Tachycardia (HR above 90)
· Tachypnea (RR above 20)
· Septic shock
· Mental status change

Systemic inflammatory response syndrome (SIRS) 11 risk factors

· Hospitalization
· Debilitating chronic illness
· Poor nutritional status
· Post-invasive surgery
· Older age
· Immunocompromised
· Cardiac abnormalities
· Heart valve replacement
· Rheumatic fever
· Long duration of strep
· IV substance use

Systemic inflammatory response syndrome (SIRS) nursing interventions

- Cultures before ABX

- Give O2 (NC for COPD; non rebreather everyone else)

- Check lactate

- Give fluids/meds through central line & use to check CVP, increase the MAP

(SIRS → sepsis, sepsis becomes septic shock, and septic shock becomes MODS)

Multi-organ dysfunction syndrome (MODS) clinical manifestations: Lungs

go FIRST

- Acute respiratory distress syndrome (ARDS)

· Intubate to maintain respiratory function

· Short-term hyperventilating to decrease their CO2 (5-10min) – draw ABG

Multi-organ dysfunction syndrome (MODS) clinical manifestations: Kidneys

check urinary output

Multi-organ dysfunction syndrome (MODS) clinical manifestations: Liver

increased ammonia & decreased LOC

Multi-organ dysfunction syndrome (MODS) clinical manifestations: Heart

- Fails after lungs & kidneys

- Decreased coronary artery perfusion/cardiac contractility

Multi-organ dysfunction syndrome (MODS) clinical manifestations: GI

necrosis

Multi-organ dysfunction syndrome (MODS) Dx

· Loss of function of 2 or more organs

· Lactate level > 2

· Lungs: low PaO2 & PaCO2 levels, ABG

· Kidneys: BUN/Cr

· Liver: increased ammonia levels, decreased LOC

· BNP > 900 - HF

Multi-organ dysfunction syndrome (MODS) Dx : steps

(therapeutics and diagnostics)

1. Deliver high-flow oxygen >94% T

2. Take blood cultures D

3. Administer empiric IV ABX T

4. Measure serum lactate (normal is less 2) D

- Tells you the degree of which the organs are working

5. Start IVF T

6. Accurate urineoutput measurement