Professional Documents
Culture Documents
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
Formation of Urine
Glomerular filtration
• Ultrafiltration of blood by glomerulus; beginning of urine formation
o 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
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 reaction
o Inform patient that procedure involves lying on table and having serial x-rays taken
o Administer cathartic or enema the night before
o 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 anesthesia
o Confirm consent form has been signed
o Force fluids or give IV fluids if general anesthesia is to be used
o General anesthesia: keep patient NPO
o Local anesthesia: offer liquid breakfast
o Give enema as ordered
• Nursing care: posttest
o Do not let patient walk alone immediately after procedure because orthostatic hypotension may
occur
o 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 clots
o Advise patient that burning on urination and urinary frequency is normal and will subside
o 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 surgery
o 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
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
complications
o 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 overload
o General trend is to initiate early and frequent dialysis to minimize symptoms and prevent
complications.
o Restrict volume during the oliguric phase
o Replace volume during the diuretic phase
o 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 Management
o 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 state
o when administering monitor ABG – can lead to metabolic alkolosis
o 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, cancer
o increases production of RBC
o if receiving dialysis may require increased heparin to prevent clotting at connection sites
o 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 management
o 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 allowance
conservative 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 Dialysis
o 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 temperature
o assess VS before and every 15 min during first exchange, and every hour thereafter
o have client void
o Strict asepsis: wash hands 3 times, masks
o monitor for signs of respiratory distress and peritonitis; reposition to promote drainage from
abdomen; drain abdomen if respiratory distress occurs
o 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 gravity
o Nitroglycerin, antihypertensive, and sedatives are withheld – hypotension episode
o 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: normal
o cloudy: infection, peritonitis: abd. pain and distention, diarrhea, vomiting, fever
o brownish: bowel perforation
o 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 Management
o weigh before and after procedure with all types of dialysis
o 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 sites
o 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
• 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 surgery
o maintain patency of drainage tubes, including foley; gross hematuria or clots are not expected
post-op
o monitor fluid and electrolyte balance; initial output is increased because of Na+ diuresis; sharp
decrease may signal rejection
o monitor wt. and VS, particularly temp; isolation may be necessary to prevent infection
o observe s/s of opportunistic infection; teach client need to prevent infection by avoiding crowds
and using aseptic technique
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.
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
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 trauma
o no heating pads, ice packets or hot water bottles
o 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 fish
o high caloric intake- mayonnaise, butter, sour cream, peanut butter, jelly, ice cream, and
honey
o 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
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 interventions
o keep patient comfortable
o 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; lymphomas
o inhibits DNA and RNA synthesis; immunosuppressant activity
Plicamycin
o to correct hypercalcemia and hypercalciuria; to treat testicular carcinoma
o 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 poisoning
o 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 exposure
Classification of Burn Injury
Depth
• Partial or full thickness burns
Partial Thickness
o 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 Thickness
o 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 airway
o 100% humidified O2
chemical:
o remove from burning agent
o remove clothing contained with chemical
o lavage the affected area with copious amounts of water
electrical:
o note victim position, identify entry/exit routes (identifies organs involved)
o maintain airway
o wrap in dry, clean sheet or blanket to prevent further contamination of wound and
provide warmth
o 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 transport
o 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 hypovolemia
o blisters
o shivering r/t chilling caused by heat loss, anxiety, or pain
Complications
o 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
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 antibiotic
o 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 diuresis
o 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 process
o 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