Hematological Problems, Shock, Sepsis, and Multiple Organ Dysfunction, Burns, AKI, CKD

Kidney Dysfunction

Etiology & Pathophysiology

• Underlying causes of kidney dysfunction, including both acute and chronic perspectives.

Risk Factors

• Factors contributing to kidney dysfunction: diabetes, hypertension, etc.

Disseminated Intravascular Coagulation (DIC)

• A condition characterized by systemic activation of the coagulation process, leading to bleeding and organ dysfunction.

• Abnormal response to clotting. Fibergen (needed for clotting) and antithrombin

fibrinogen levels may be elevated, reflecting the increased consumption of clotting factors, while anti-coagulant proteins are often depleted, exacerbating the risk of bleeding complications

DIAGNOSE

D-dimer, PT/INR/PTT

*Always changing labs

*Quick diagnose is key

RISK

• Male, pale, low platelets, petechiae present, indicating potential thrombocytopenia and increased risk of bleeding.

Cancer, Sepsis- MODS, Mix Match blood= transfusion, hemolysis

SYMPTOMS

• (syncope) Fatigue and weakness due to anemia

• necrosis, stroke (kidney damage)

• Shortness of breath or difficulty breathing as a result of reduced oxygen-carrying capacity

• (tachypnea)Increased heart rate and palpitations as the body compensates for low blood volume

• Fever and chills indicating possible infection, particularly in sepsis

• Confusion or altered mental status as a result of decreased perfusion to the brain

Clinical Manifestations

• Bleeding: Signs include petechiae, purpura, and bleeding tendencies.

• Thrombotic: Thrombosis due to enhanced clotting tendency in DIC.

Diagnostics

• Laboratory tests to assess kidney function and coagulation status.

Nursing Management

• Strategies for monitoring and supporting patients with kidney dysfunction.

Coagulation Studies Lab Values

• PT: Normal 11 to 13.5 seconds

• aPTT: Normal 25 to 35 seconds

• INR: Normal 0.8 to 1.1 (2 to 3 if on Coumadin)

• Platelets: Normal 150,000 to 300,000/mm3

• Fibrinogen: Normal 200 to 400 mg/dL

Acute Kidney Injury

Etiology & Pathophysiology

• Different causes, such as prerenal, renal, and postrenal factors affecting kidney function.

  Rapid decline in kidney function

• Treatment

  I’s and O’s. BMP, give potassium =melons, potatoes, yogurt, bananas, nuts (pistachios) diuretics, insulin, steroids (inflammation)

Manifestations

• Typical presenting symptoms of acute kidney injury. up creatines, oliguria —400ml day), up volume, decrease pee, decrease potassium

• These may include decreased urine output, swelling due to fluid retention, fatigue, and confusion, as well as nausea and shortness of breath. Additionally, patients may exhibit changes in blood pressure and heart rate, indicating possible electrolyte imbalances.

• Hypokalemia, HA, N/V, seizures (give phenytoin), coma, equilibrium syndrome (during or after from rapid fluid levels)

Diagnostic Studies

• Tests for determining the extent and cause of renal dysfunction. BUN- Crea, output, urine analysis, ultrasound/ biopsy

• Serum creatinine and blood urea nitrogen (BUN) levels: Elevated levels indicate impaired kidney function.

• Urinalysis: Can help identify the presence of protein, blood, or other abnormalities in urine.

• Imaging studies (e.g., ultrasound): Useful for assessing kidney size, structure, and potential obstructions.

• Renal biopsy: May be performed in certain cases to determine the underlying pathology.

Nursing Care

• Care strategies tailored for patients with acute kidney injury.

Chronic Kidney Disease

Etiology & Pathophysiology

• The gradual loss of kidney function, including its multi-factorial causes. Irreversible.

• Risk - Diabetes Mellitus, AA, Glomerulonephritis, Polycystic Kidney Disease, toxic drugs and prolonged obstruction of the urinary tract.

Manifestations

• Common signs and symptoms of chronic kidney disease.

• HTN, anxiety, gastritis, up lipid, itchy, up or down thyroid, fatigue, impaired sodium

Diagnostic Studies

• Various tests used to monitor and evaluate kidney function.

• CMP, Biopsy, UA

Nursing Care

• Management and care strategies for patients with chronic kidney disease.

• Electrolytes, control htn , up calcium supplements, no protein phosphate or sodium, increase foods with potassium

• Monitor fluid intake and output to prevent overload.

• Educate patients on dietary restrictions and the importance of adherence to medication regimens.

• Assess for signs of anemia and consider erythropoiesis-stimulating agents as needed.

Peritoneal Dialysis = GFR less than 15

• Types:

  • Automated Peritoneal Dialysis - done in steps to allow for better control of fluid removal and solute clearance, typically involving the use of a machine that automatically fills and drains the dialysis fluid.

  • Continuous Ambulatory Peritoneal Dialysis - every 8 hours - fixable- fewer diet restrictions, allows patients to manage their own treatment while maintaining a more normal lifestyle, promoting independence and flexibility.

• Complications:

  • Infection at the site, peritonitis, hernia, lower back pain, bleeding, pulmonary complications, and protein loss.

• Dialysate imported into port - warm to decrease pain

  septic - no infection, cannot be done if pt had any stomach surgery, fluid (2l in 10 mins, monitor VS Q15/30 min, clamp line then let it sit for 4/6 hours then drain for 15/30 mins

  *Bag needs to be below site, (supine or low fowlers) reduces pressure and helps drain

Hemodialysis - removes potassium

• Vascular Access: Importance of creating effective vascular access. Pulse -thrill (listen and feel)

• Key terms: Thrill, Bruit, Steal syndrome.

Vitals signs Q30 mins, check weight if a gain of more than 2lb a day - fluid overload (lung crackles)

• Dialyzers & Dialysate: Functionality of equipment used in hemodialysis.

• Complications: Managing potential complications related to dialysis.

• epoetin after destruction of RBCS

Shock & Sepsis

Shock - a life-threatening condition that occurs when the body is not getting enough blood flow, leading to inadequate oxygen delivery to tissues and organs.

• Patho shock - results from failure of the circulatory system to compensate

• interstitial - outside of the blood vessels, where fluid can accumulate and contribute to tissue edema, further exacerbating the effects of shock.

• intravascular- the space within blood vessels, where blood circulates and plays a crucial role in maintaining blood pressure and ensuring adequate perfusion to vital organs. (blood volume)

• Cardiovascular shock - (when compensations fail) fails to function in one of the four types: volume, cardiogenic, distributive, or obstructive, leading to inadequate blood flow and oxygen delivery to tissues.

• First up in RR = increase 02 = lung compensating

• C/O confusion = no cranial perfusion

  GOAL - up supply and decrease demand

• Fluid resuscitation- Drug = replace, blood transfusion, o2, vent

Measures Shock

After fluids then vasopressin or nitro epi, isotonic fluids

Cardiogenic - SVR-up then increase vasodilation

SVR- down then decrease vasodilation

PAWP increase cardio output decrease = diuretic

PO increase = less blood in the ventricular preload

Sepsis - a severe response to infection that can lead to tissue damage, organ failure, and death if not treated promptly. It is characterized by the presence of infection along with systemic inflammatory response syndrome (SIRS), which can escalate to septic shock.

Substance and cell in and out of vesicle - capillary permeability

Lecture Objectives

• Relating pathophysiology to clinical manifestations of various shock types.

• Comparing effects on major body systems due to shock, sepsis, SIRS, and MODS.

• Discussing interprofessional care strategies for managing shock and MODS.

Fluid Compartments

Types of Fluid Compartments

• Intracellular fluid (ICF)

• Extracellular fluid (Interstitium and Plasma)

Shock Overview

Definition

• Understanding what constitutes shock in clinical practice.

Types of Shock

• Cardiogenic Shock: Heart fails to pump effectively, leading to acute tissue hypoprofusion.

• Hypovolemic Shock: Due to severe blood or fluid loss, impacting venous return and cardiac output.

• Neurogenic Shock: Resulting from spinal cord injury, causing vasodilation and hypotension.

• Anaphylactic Shock: Severe allergic reaction resulting in systemic vasodilation and increased capillary permeability.

• Obstructive Shock: Physical obstruction to blood flow leading to circulatory failure.

Sepsis and Septic Shock

• Sepsis: An exaggerated inflammatory response to infection that can lead to organ dysfunction and systemic shock.

• Septic Shock Criteria: Diagnosis involves recognizing symptoms like persistent hypotension despite resuscitation and potential end-organ dysfunction.

Diagnostic Tools for Sepsis

• Qsofa Tool: Assessment tool to identify the risk of poor outcomes in sepsis:

  • Altered mental status

  • Rapid respiratory rate

  • Low blood pressure

Treatment Strategies

• Focus on rapid diagnosis and intervention to restore hemodynamic stability and manage infection (Septic Shock Bundle).

Nursing Management

General Strategies

• Optimization of oxygen delivery, fluid management, and pharmacologic interventions are critical in shock management.

Specific Management Based on Shock Type

• Cardiogenic Shock: Interventions may include cardiac catheterization and drug therapy.

• Hypovolemic Shock: Focus on IV fluid resuscitation, blood products as needed.

• Septic Shock: Aggressively administer fluids, antibiotics, and possible vasopressors.

• Anaphylactic Shock: Use of epinephrine and support of airway management.

• Obstructive Shock: Address underlying mechanical problems with appropriate interventions.

Rehabilitation Phase

• Importance of supportive care for recovery, including emotional, psychological, and physical rehabilitation post-burn injuries.

Conclusion

• Understanding the complexity of shock states, their management, and the nursing care required for diverse patient paths.