Exam 3

Trust the process! :)

Emergency Nursing Role

Rapid assessment and treatment of patients during the initial phase of acute illness

Triage

Disaster differ from ED triage

Triage: Primary Survey

A. Airway

B. Breathing

C. Circulation

D. Disability

Triage: Secondary Survey

VS

S/S

Allergies

Meds

Past med history

Last meal eaten r/t surgery

Events leading up to

Lye/White Phosphorus

* Do not flush with H2O
* Brush away

Carbon Monoxide

* Red as a cherry
* Mad as a hatter
* Treat with:

100% every single time

Mass Casualty-SMART

* Respirations
* Perfusion
* Mental Status

Red - Emergent

RR >30

CR >2

Can’t follow commands

* Facial trauma
* Eye trauma b/c brain

Yellow

Everyone else

RR below 30

CR normal

Green - Walking Wounded

Can get up and walk

Black - Open Airway

No respirations or low respirations

No pulse or thready pulse

Unresponsive

If toxic specific…

Poison control

Poisoning/Overdose: Decrease absorption

* Gastric lavage
* charcoal
* dermal cleansing

Poisoning/Overdose: Enhance Elimination

* Cathartics
* Bowel irrigation
* Hemodialysis
* Chelating agents
* Antidotes

Bioterrorism

Use of biological agents to inflict harm or death

* #1 Anthrax: not contagious

Decontamination: 3 goals?

1. Don’t allow contaminated pt’s to enter (lock down entrance and exit)
2. Decontaminate as fast as possible
3. Protect the team from secondary exposure (proper PPE)

* MSDSS Material safety data sheets

Poisoning/Overdose all based upon?

time

Hospice is based on the concept of?

“Comfort beyond cure”

Where can hospice be done?

* home
* facilities

What is the requirement to be considered for hospice?

Physician must sign a contract that states pt has 6 months to live

* terminal diagnosis

Hospice pt can’t seek (blank) for issues related to terminal diagnosis

medical treatment

Hospice care is?

Holistic

* Goes beyond traditional medicine

Chronic Kidney Disease: what is it?

Significant decrease in renal function

* Occurs over long period of time
* Irreversible

Kidney: Glomerulus is responsible for?

Reabsorption of creatinine

* If not doing job, creatinine builds up in blood

Creatinine is a good indicator for?

How glomerulus is working

* Kidney function

Creatinine normal level?

0\.5-1.2 mg/dL

GFR

Glomerular Filtration Rate

What is the GFR?

Rate that glomerulus filters waste, ions and h2o in blood

Normal GFR Level

>90 mL/min

* Calculated based on creatinine clearance level and gender

If GFR is low…

Glomerulus = not clearing out

BUN: what is it?

Breakdown of protein in liver

* It is a measure of urea/hydration status

If urea is elevated?

Backup of urea

* stops urinating

Creatinine is…

Elevated waste products from breakdown of muscles

* Kidney Function

Urination output

If decreased, kidney stops pulling excess h2o = fluid overload

Oliguria

Anuria

CKD: Stage 1

Kidney damage with normal renal function

* GFR >90 but has proteinuria for 3 mon. or longer

CKD: Stage 2

Kidney damage minimal with mild loss of renal function

* GFR 60-89

CKD: Stage 3

Mild-to-severe loss of renal function

* GFR 30-59

CKD: Stage 4

Severe loss of renal function

* GFR 15-29

CKD: Stage 5

End-stage renal disease

* GFR

What hormones does kidney produce?

* Renin
* EPO

What does renin do?

Role is to raise BP

* Glomerulus filters less H2O
* BP then decreases
* So then renin is released

What does EPO do?

Erythropoietin

* Helps create RBCs in bone marrow
* If decreased = anemia

Kidneys activate?

Vitamin D

* Helps body reabsorb calcium from food
* Hypocalcemia → Hypermagnesemia

Hypocalcemia →

Hypermagnesemia

Hypermagnesemia level

> 2.6

Hypermagnesemia presents with?

* Diminished/absent DTRs


* Lethargic
* Avoid magnesium based laxatives or antacids

Give IV ______ for Hypermag?

IV Calcium

Hyperkalemia: give?

Kayexalate

Hyperphosphatemia level

> 4.5 mg/dL

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Treatment for hyperphosphatemia/hypocalcemia

* Phos-lo: phosphate binder
* give with food
* Calcium acetate
* Calcium carbonate

Hypocalcemia level

< 8.6 mg/dL * nephron damage

Phosphate binds to calcium =

Ca+ decrease

* vitamin B activation
* pulls calcium from food

What causes kidney disease?

* HTN (spec. diabetes, afr amer)
* Nephrotoxic drugs
* Acute kidney injury
* Infection

Treatment: Early stage with normal GFR

* Controls BP and glucose


* ACE, ARBs
* Monitor GFR and BP regularly

Treatment: Advanced stages where GFR is abnormal

* Dialysis
* Kidney transplant
* Diet changes

Uremia

Elevated waste products in blood

Uremic frost

deposits of urea crystals on skin via sweat

* itches

Uremic Frost s/s

* Altered mental status
* Itches
* Blood pH will be decreased = Kussmaul’s

Tx for uremic frost

* Neuro assessment r/t change in MS
* Diet less in protein

Anemia: what is it?

Decrease in RBCs

RBCs help transport?

O2

Decreased EPO leads to?

Hematuria

What mineral deficiency presents in anemia?

* Iron
* Folic acid
* Vitamin B12

Anemia presents with?

* Decreased O2
* Pale
* Confusion
* Delayed cap refill

Treatment for Anemia

* O2
* HOB elevated
* Iron
* EPO (Epo-gen or erythropoietin)
* Transfusion

Kidneys: Low Urine Output S/S

* Monitor I & O’s
* Daily weights
* Swelling
* Lung sounds = crackles
* Monitor BP and respiratory status
* Fluid restriction
* Low protein diet

What diet would we want to put low urine output pt on?

low protein diet

What is hemodialysis?

Removal of waste by diffusion and osmosis

* ultrafiltration

Where is shunt placed?

Into the arm

How often is hemodialysis done?

3x a week

3-4 hours of treatment

What to give for hemodialysis?

calcium gluconate

* glues down the heart muscles

insulin

* push K+ into cell

Before dialysis, assess…

Fluid and fistula (shunt)

Hemodialysis: With fluids…

* weights
* vs and edema

Hemodialysis: With fistula…

* feel a thrill (vibration)
* hear a bruit

Hold meds…

* Antihypertensives
* Ace
* Arbs
* Beta Blockers
* Ca+ Channel Blockers
* Nifedipine
* Verapamil
* Diltiazem
* Diuretics
* Furosemide
* HCTZ
* Dilators

Antihypertensives spare

potassium (k+)

Washed out medications are?

antibx

dig

water-soluble vitamins (B, C, Folic acid)

Washed out meds are…

not being used and not as effective

IV heparin given to?

prevent blood clotting

5 P’s of Hemodialysis

1. Pale skin (pallor)
2. Paresthesia
3. Pulses diminished
4. Poor cap refill
5. Pain (distal-shunt)

Hemodialysis: graft?

* artery to vein using synth tube
* don’t touch access site
* temporary

Hemodialysis: fistula?

* Connect artery → vein perm
* 3-4 mon. for it to mature and be used

Peritoneal dialysis

peritoneal lining in abdomen serves as filtration membrane

* dialysate

What diet would you encourage for peritoneal dialysis pt?

high protein diet

Peritoneal Dialysis: Before…

* take weight
* warm solution (dialysate)

Peritoneal dialysis has increased risk of?

infection

Peritoneal dialysis: risk of infection symptoms?

* sterile technique (priority)
* fever
* tachycardia
* cloudy drainage

symptoms

* sterile technique (priority)


* fever
* tachycardia
* cloudy drainage

peritonitis

Deadly priority - key signs

* Crackles at lung bases
* Rapid respirations
* Dyspnea

What to do for dyspnea, rapid resps, and crackles?

raise HOB

Peritoneal dialysis: What could cause for more to be in than out?

* kink in bag
* should be lower
* check level of drainage bag

Anthrax

•Most likely weaponized biologic agent available and has been recognized as a highly debilitating agent for centuries.  Anthrax is not contagious.



•Caused by Bacillus anthracis and can be contracted through the digestive system, abrasions in the skin, or inhalation in the lungs.



•Transmitted by direct contact with bacteria and spores; becomes active when enters a living host (no person-to-person spread)

Anthrax S/S

* **Skin** (skin lesions)


* **GI** (nausea, vomiting, diarrhea, abdominal pain)
* lungs most severe form (fever, muscle aches, fatigue, resp failure, shock)

Anthrax Tx

•__**Treated with ciprofloxacin (Cipro), doxycycline, or penicillin.**__



•__**Standard precautions because patient is not contagious**__

Radiation Exposure

§Can occur from accidental exposure or terrorist attack.



§“Dirty Bombs”—explosive packaged with radioactive material.



§Hospitals need to be prepared, recognize s/s of exposure, protect others from contamination, and decontaminate victims.



§ Decontamination  can usually be done with soap and water outside ER is preferred.



§Other considerations include strict isolation, protective gear for staff, containment of run-off water, and careful disposal of wastes.

Radiation Exposure Effects Stages: Prodromal

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* Presents with Symptoms
* Occurs 48-72 hrs after exposure
* S/S include: nausea, vomiting, loss of appetite, fatigue, and bloody diarrhea

Radiation Exposure Effects Stages: Latent

* Symptom-free period


* Occurs after resolution of prodromal phase, can last up to 3 weeks
* S/S- decrease WBC, RBC, PLT

Radiation Exposure Effects Stages: Illness

* Occurs after latent phase
* S/S- infection, f/e imbalance, bleeding, diarrhea, shock, altered LOC