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PCCN Review
Thrombocytopenia - answer Normal range 150,00-350,000, causes are heparin induced, DIC, Anti-platelet drugs DIC: Disseminated Intravascular Coagulopathy - answer Syndrome characterized by thrombus formation and hemorrhage. Forms clots in small blood vessels in the body. Secondary to stimulation of normal coagulation process, with resultant decrease in clotting factors and platelets-platelet dysfunction. Factors triggering DIC - answer Tissue factors: Tissue breakdown, Platelet aggregation: Sepsis, Injury to vascular endothelium and exposure to collagen... Etiology of DIC - answer Vascular disorders, Infection and Sepsis, Hematological and immune disorders, Anaphylaxis- histamine release with fluid movement causing edema and vasodilation, blood transfusion reaction, massive blood transfusion, prolonged cardiopulmonary bypass, sickle cell crisis, transplant reaction, trauma, burns, acute anoxia, crush and head injury, cancer, OB complications Presentation of DIC - answer Abnormal bleeding, signs of thrombosis, change in LOC, Chest pain, S-T & T wave changes, dyspnea, hypoxia, decreased urine output, protienuria, electrolyte imbalances, abdominal pain, diarrhea Clinical presentation of DIC - answer 1ST SIGN IS PETECHIAE, ecchymosis, purpura, and bleeding, Low platelets- <100,000, decreased fibrinogen <200 mg/100ml, decreased antithrombin III <70%, Increased PTT >60-90 seconds, Increased PT >15, Increased FDP/FSP >10g/mL, Increased D-Dimer >2mg/L (not clot specific, goes up in early sepsis) Treatment of DIC - answer Treat underlying cause, medical management, stop bleeding, correct hypovolemia, hypotension, hypoxia, acidosis, stop microclotting to maintain perfusion, give blood products for bleeding Packed RBC's - answer Action-Increase 02 capacity Indication- significantly decreased H&H, blood loss, active bleeding Administration-avoid fluid overload (CHF), blood filter, infuse 2-4 hours Complications- Transfusion reaction, infection, volume overload Platelet Products - answer Action: Coagulation components Indications: Platelet count or decreased platelet function Administration: component filter, rapid infusion
FFP (fresh frozen plasma) - answer Action: increase clotting factors, water and electrolytes, has no platelets Indications: coagulation deficiencies Factor V and VIII - answer Administration: filter, rapid infusion (can give over 2 hours) Complications: viral, fluid overload Cryoprecipitate - answer Indications: Given for DIC, von Willebrands Actions: raises factors VIII + XII, prevents and controls bleeding, contains fibrinogen and antithrombin III Administration- filter, give rapidly Adverse reactions of Blood transfusions - answer Hyperkalemia, hypocalcemia, decreased 23dpg , ammonia intoxication, hypothermia, infection, fluid overload, Transfusion-related acute lung injury (TRALI) occurs within 6 hours of transfusion Renal Blood flow requirements - answer MAP 80-180 mmHg Filtration ceases with MAP less than 40 mmHg Renal function assessment- creatinine, GFR, Urine output, weight changes/fluid changes Renal Labs - answer Serum osmolality: 275-295 (increased osmolality=dry) BUN/Creatinine ratio 10: If disproportionate, Dehydration, Blood in gut, Catabolic states are causes Hypovolemia - answer Tachycardia, NARROW pulse pressure, orthostatic hypotension, low filling pressures, high systemic vascular resistance, flat jugular veins, weakness, lethargy, anorexia, poor skin turgor, thirst, low-grade fever, syncope, oliguria, INCREASED BUN with NORMAL CREATININE, HIGH SERUM OSMOLALITY, INCREASED H&H (hemoconcentration). Management: Return Volume Hypervolemia Causes - answer Excessive fluid intake, retention of NA and water. Caused by stress response, steroid therapy, heart failure, liver failure, nephrotic syndrome, acute or chronic renal failure Hypervolemia presentation and treatments - answer Tachycardia, high blood pressure, high filling pressures, weight gain, JVD, tachypnea, dyspnea, lethargy, disorientation, indications of pulmonary or cerebral edema, LOW HGB, LOW SERUM OSMOLALITY, DECREASING BUN WITH NORMAL CREATININE Managmenet: Monitor I&O, Decrease excess volume, Dialysis, fluid restriction, diuretics, prevent complications
Duration: 3-12 months Metabolic processes gradually resolve Treatment of Acute renal failure - answer Support renal perfusion and improve GFR Volume Inotropes- Dopamine Diuretics Maintain fluid and electrolytes Diminish accumulation of nitrogenous wastes Avoid nephrotoxic agents, nurtrition, vanco/abt levels, prevent infection, Epogen for treating anemia Symptoms of Chronic renal failure - answer Fatigue, anemia, frequent hiccups, general ill feeling, itching, weight loss, n/v, HA, confusion, decreased sensation in hands, easy bruising, decreased or increased urine output. Diagnosis: UA, creatinine, creatinine clearance, potassium, metabolic acidosis, CT scan, MRI, Ultrasound, renal biopsy. Abnormal Ca+, phosphate, parathyroid hormone, Vit D metabolism, End-stage renal disease treatment - answer Fluid restrictions, diet control, blood pressure control, diabetes control, vitamin d supplements, drug monitoring, dialysis, control blood sugar, blood pressure Renal PEARLS - answer Seizures are seen with hyperphosphatemia S/S of hypophophatemia: weakness, reciprocal hypercalcemia causes apathy and confusion creatinine is the best indicator of renal function creatinine is inversely proportional to GFR Low serum sodium causes aldosterone releases Cirrhosis of the liver - answer liver cells are destroyed and replaced with fibrous tissue which results impaired liver function. Distortion, twisting, and constriction of central sections cause impedence of portal blood flow and portal hypertension occurs Portal hypertension - answer Causes esophageal varices and splenomegaly- thrombocytopenia, vitamin k deficiency, inability to produce adequate amount of bile, impaired carb, fat, protein metabolism, inability to store vitamins and manufacture clotting factors, inability to detoxify toxins or remove bacteria. Ammonia production- breaks down protein into ammonia, then liver converts ammonia into urea and is eliminated by the kidney Fulminant Liver Failure presentation - answer Jaundice, tachycardia, hypotension, fluid retention, ascites, decreased urine output, palmar erythema, bleeding, electrolyte imbalance, asterixis, HYPERVENTILATION-causing alkalosis and right pleural effusion, increased ICP, PVH, sepsis
Cirrhosis presentation - answer Azotemia, bruising, bleeding, nutritional abnormalities, fatigue, wt loss, impaired bilirubin metabolism Management of Cirrhosis and renal failure - answer Identify and treat cause of liver failure, avoid hepato-toxic drugs, etoh, monitor lft's, abc, aspiration pneumonia, ascites and fluid overload, pleural effusion on right, manage renal insufficiency, electrolyte imbalances LOW K AND LOW CA, HIGH PHOSPHORUS Pancreatitis - answer Causes hypocalcemia, releases necrotic toxins which causes an inflammatory response (SIRS, SEPSIS). Low Ca, K, hyperglycemia , amylase and lipase elevated, urine amylase increased, lfts high, MRI/CT shows pancreatic swelling Pancreatitis management - answer Decrease release of and destruction by pancreatic enzymes. Pain management, nutritional support, prevent infection/complications- hypovolemia, hypoglycemia, abscess, fistula, Sepsis Intestinal infarction management - answer Small bowel only has mesenteric artery for blood flow. Maintain circulating volume, pain control, bowel rest, NPO, NG tube, prepare surgical intervention, DC pressors GI infections - answer C-diff- GREATER THAN 3 DAYS OF WATERY FOUL SMELLING STOOL, WITH HISTORY OF ABT THERAPY and COLITIS Treatment- Flagyl and Vanco po GI PEARLS - answer arterial perfusion of the small intestine: superior mesenteric artery complications of pancreatitis- bilateral riles, atelectasis of left base, pleural effusion, and ARDS, HHNK, low CA Cullen's sign- ecchymosis around umbilicus Grey Turner Sign-ecchymosis in flank area Ker's sign-splenic rupture or air or fluid (blood) in free space of the abdominal compartment- left shoulder pain Diabetes Insipidus - answer Impaired renal conservation of water, resulting in polyuria, low urine specific gravity, dehydration, high serum Na+- caused by deficiency of antidiuretic hormone from pituitary Diabetes Insipidus clinical presentation - answer polyuria 5-15 L/day, thirst, fatigue, dehydration, confusion, seizures, lethargy, LOW urine specific gravit < 1.005, NA > 145 meq/liter, BUN elevated, serum osmolality increased, serum adh low Treatment- correct fluid deficit, hypotonic solutions, Vasopressin (ADH hormone), correct fluid deficit, DDAVP, Diapid
Monitor for complications Endocrine PEARLS - answer Normal serum osmolality is 275- acidosis causes shit of cellular K to serum SIADH- low Na, restrict fluid, 3% saline DI- hi Na; dehydration-give vasopressin (antidiuretic hormone) Cerebral perfusion pressure - answer CPP= MAP- intracranial pressure (ICP) Normal CPP range - answer 60-100 mmhg (Remember 70) Normal ICP - answer 5- Normal MAP - answer 70-105- (Must be atleast 85 to make a CPP of 70, if ICP is 15 Nursing care of brain-inured patient - answer ABC's, airway/ventilation, aspiration, ICP, CPP, MAP, DVT/PE, infections, volume status, rehab potential, B&B function Clinical picture of increasing ICP - answer FIRST ALWAYS: Change in mental status VS changes- pule pressure widens, bradycardia Cranial nerve changes: change in pupil size- small and less reactive at first, vision, corneal reflex, swallow, contralateral motor changes, vomiting, HA, seizures Early signs of ICP - answer Cushing's Triad Change in behavior- irritable Change in VS pupils restrict and become sluggishly reactive Complications of increased ICP - answer Further ischemia, seizures, DI or SIADH, hydrocephalus, DVT, stress ulcers, Respiratory insufficiency, Increased c02, decreased respirations-slow and shallow Hydrocephalus - answer accumulation of CSF causing increased ICP Treatment is shunt placement Subdural Hematoma - answer venous bleed spnontaneously, older, ETOH Treatment Burr hole evacuation Epidural hematoma - answer linear skull fracture, usually arterial bleeding. event causing unconsciousness, awake and normal, rapid decline and unconsciousness again Subarachnoid hemorrhage - answer Intracranial bleed into the CSF filled space between the arachnoid and pia meter membranes on the surface of the brain, bleeding into the ventricular system. Frequently caused by hypertension and leaking aneurysm
SAH clinical presentation - answer Changes in LOC, severe headache, htn, seizure activity, identify vasospasm 3-21 days Treatment of Vasospasm - answer Triple H Therapy- CALCIUM CHANNEL BLOCKERS Hypertension Hypervolemia Hemodilution Spinal shock - answer Occurs within minutes and up to 3 months. T6 or higher injury. Vasodilation with significant HYPOTENSION AND Bradycardia, loss of temperature regulation- Treat with fluids and steroids Brown-Sequard injury - answer damage to on half of the spinal cord, resulting in paralysis on the ipsilateral side, contralateral loss of pain and temperature sensation Autonomic Dysreflexia - answer After spinal shock is over- massive sympathetic discharge where the spinal cord cannot communicate with the brain.- Full bladder, stool impaction, skin pain. Treatment is to eliminate the cause, give antihypertensives Status Epilepticus - answer Sudden, paroxysmal episode of exaggerated activity or seizures- Can be from withdrawl symptoms or toxic level of drugs. Give drugs, monitor ABC's Neurological PEARLS - answer Increased ICP- slow breathing, retain C Can have GI bleeding/stress ulcers Amicar- antifibrinolytic used to prevent re-bleeding T5 injury-loss of sympathetic nervous stimulation causes bradycardia and hypotension Shock - answer Condition of insufficient perfusion to cells and vital organs causing tissue hypoxia, perfusion is inadequate to sustain life SIRS- systemic inflammatory response syndrome - answer systemic response to a variety of insults that begin as local inflammation The Inflammatory Cascade - answer Criteria is 2 or more of the following Tachycardia > Hyperapnea RR 20 or PaCO2 <32 mmhg Hypothermia <36 degrees and >38 degrees WBC >12000 or < Definitions - answer SIRS- fever + leukocytosis SIRS + infection= Sepsis Sespis + MODS= Severe Sepsis
