Acute Respiratory Failure Sudden and life-threathening deterioration of the gas exchange function of the lungs Increased CO2

production, decreased O2 exchange Causes Chronic Respiratory Failure 1. COPD 2. Neuromuscular disease Pathophysiology: 1. Alveolar hypoventilation 2. Diffusion abnormalities 3. Ventilation-perfussion mismatching 4. Shunting Classification of Common Cause of ARF Decreased Respiratory Drive Causes: 1. brain injury 2. large lesion in the brainstem (multiple sclerosis) 3. use of sedative medications 4. metabolic disorders (hypothyroidism) Dysfunction of Chest wall 1. muscular dystrophy 2. polymyositis 3. myasthenia gravis 4. peripheral nerve disorders 5. amyotopic lateral sclerosis 6. Guillain-Barre syndrome 7. cervical spinal injury Dysfunction of the lung Parenchyma 1. Pleural effusion 2. hemothorax 3. pneumothorax 4. Upper airways obstruction 5. pneumonia, status asthmaticus, lobar atelectasis, pulmonary edema Other causes: Surgery, Pain, Clinical Manifestation: restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, tachypnea, central cyanosis, diaphoresis and respiratory arrest Use of accessory muscles, decreased breath sounds, no adequate ventilation Management: Intubation and mechanical ventilation

ACUTE RENAL FAILURE Acute renal failure (ARF), also known as acute kidney failure or acute kidney injury, is a rapid loss of renal function due to damage to the kidneys, resulting in retention of nitrogenous (urea and creatinine) and non-nitrogenous waste products that are normally excreted by the kidney. Effects: Metabolic acidosis (acidification of the blood) hyperkalaemia (elevated potassium levels) changes in body fluid balance effects on many other organ systems Characterised by: oliguria or anuria (decrease or cessation of urine production) although nonoliguric ARF may occur CAUSES: 1. Pre-renal (causes in the blood supply): 2. hypovolemia (decreased blood volume) 3. usually from shock or dehydration and fluid loss or excessive diuretics use 4. hepatorenal syndrome in which renal perfusion is compromised in liver failure 5. vascular problems, such as atheroembolic disease and renal vein thrombosis (which can occur as a complication of the nephrotic syndrome) 6. infection usually sepsis, systemic inflammation due to infection Renal (damage to the kidney itself): 1. toxins or medication (e.g. some NSAIDs, aminoglycoside antibiotics, iodinated contrast, lithium) 2. rhabdomyolysis (breakdown of muscle tissue) - the resultant release of myoglobin in the blood affects the kidney; it can be caused by injury (especially crush injury and extensive blunt trauma), statins, stimulants and some other drugs 3. hemolysis (breakdown of red blood cells) - the hemoglobin damages the tubules; it may be caused by various conditions such as sickle-cell disease, and lupus erythematosus 4. multiple myeloma, either due to hypercalcemia or "cast nephropathy" (multiple myeloma can also cause chronic renal failure by a different mechanism) 5. acute glomerulonephritis which may be due to a variety of causes, such as anti glomerular basement membrane disease/Goodpasture's syndrome, Wegener's granulomatosis or acute lupus nephritis with systemic lupus erythematosus Post-renal (obstructive causes in the urinary tract) due to: 1. medication interfering with normal bladder emptying. 2. benign prostatic hypertrophy or prostate cancer. 3. kidney stones. 4. due to abdominal malignancy (e.g. ovarian cancer, colorectal cancer). 5. obstructed urinary catheter.

Nursing Interventions: 1. Monitor and Maintain Fluid and Electrolyte Balance a. Obtain baseline data b. Measure I&O hourly c. Administer IV fluid and electrolytes as prescribed d. Weigh client once a day e. Monitor lab values, including the ABG, electrolytes 2. Monitor alteration in fluid balance a. Monitor VS, PAP, PCWP, CVP as needed b. Weigh client c. Monitor I&O d. Assess for hypovolemia q 1 hour 1. maintain adequate ventilation 2. decrease fluid intake as ordered 3. administer diuretics, cardiac glycosides, and anti-hypertensives as ordered, monitor for the effects e. Replace fluid as ordered f. Monitor ECG g. Check urine, serum osmolality and osmolarity, urine specific gravity 3. Promote optimal nutritional status a. weigh daily b. maintain strict I & O c. administer TPN as ordered d. Enteral feeding: Check for residual and inform the physician e. Restrict protein intake 4. Prevent complication from impaired mobility a. pulmonary embolism b. skin breakdown c. atelectasis Frequent turning and repositioning, massage the body prominence, assess the skin always 5. Prevent fever and infection a. take rectal temp, give antipyretic/blanket as needed b. assess for signs of infection c. strict aseptic technique on wound and catheter care 6. Support client and significant others and reduce fear and anxiety a. explain the disease process b. explain all the procedures that will be done, and answer all the queries, at an easily understandable way 7. Provide care for clients receiving dialysis 8. Provide client teaching a. adherence to the treatment plan b. signs and symptoms of the disease c. importance of planned rest periods d. used of prescribed drugs only

e. signs and symptoms of UTI or respiratory infection, report immediately DIALYSIS Removal by artificial means of metabolic waste, excess electrolytes, and excess fluids from clients with renal failure Principles: Diffusion and Osmosis Purposes: 1. remove the end product of CHON metabolism 2. Maintain safe levels of electrolytes 3. Correct acidosis and replenish blood bicarbonates 4. remove excess fluids from the blood Types: 1. Hemodialysis 2. Peritoneal dialysis HEMODIALYSIS Shunting of the blood from the client's vascular system through and artificial dializing machine, and return of the dialized blood into the client;s circulation. Dialysis coil acts as a semipermeable membrane and the dialysate is a especially prepared solution Access Routes: 1. External AV shunt one cannula is inserted into an artery and the other into the vein both are brought out to the skin surface and connected by a Ushaped tube Nursing care: a. auscultate for bruit and palpate for thrill b. change sterile dressing daily c. no BP taking, venipuncture IV administration of drugs on the shunt arm 2. AV fistula internal anastomosis of an artery to an adjacent vein in a sideways position. Fistula is accessed for hemodialysis by venipuncture, take 4-6 weeks to be ready for use Nursing care: a. avoid restrictive clothing/dressing b. report bleeding and discoloration 3. Femoral/Subclavian cannulation insertion of a catheter into one of these large veins for easy access to circulation: the procedure is similar to CVP insertion 4. Graft piece of bovine artery or vein, Gore Tex material, or saphenous veins Nursing care BEFORE and DURING hemodialysis 1. have the client void 2. chart the client's weight 3. VS q 30minutes during the procedure

4. ensure bed rest and frequent position changes 5. Headache and nausea may occur 6. monitor for signs of bleeding since blood has been heparinized for procedure Nursing Care AFTER dialysis: 1. get the client's weight 2. assess for complications: 1. HYPOVOLEMIC SHOCK 2. DIALYSIS DISEQUILIBRIUM SYNDROME urea is removed from the blood more rapidly than from the brain PERITONEAL DIALYSIS Inroduction of a specially prepared dialysate solution into the abdominal cavity Nursing care: 1. weigh 2. VS q 15minutes on the first cycle and q 1hour thereafter 3. Assemble the specially prepared dialysate solution with added medications 4. have the client void 5. warm dialysate 6. assist physician for Trocar insertion 7. INFLOW 10 to 20 minutes 8. DWELL 30 45 minutes 9. DRAIN unclamp and allow to flow by gravity 10. observe the characteristics of the dialysate outflow a. clear, pale yellow NORMAL b. cloudy INFECTION, PERITONITIS c. brownish BOWEL PERFORATION d. bloody common during the first exchanges but abnormal if it continues 11. Monitor I&O and maintain records 12. Assess for complications: a. peritonitis b. respiratory difficulty c. protein loss Continuous Ambulatory Peritoneal Dialysis for ambulatory client; done at home

INCREASED INTRACRANIAL PRESSURE rise in normal brain pressure, normal pressure is 7- 15mmHg Causes: rise in cerebrospinal fluid pressure increased pressure within the brain matter caused by lesions swelling within the brain matter Many conditions can increase intracranial pressure Aneurysm rupture and subarachnoid hemorrhage Brain tumor

Encephalitis Hydrocephalus Hypertensive brain hemorrhage Intraventricular hemorrhage Meningitis Severe head injury Subdural hematoma Status epilepticus Stroke

Metabolic Emergencies Diabetic Ketoacidosis (DKA) Diabetic Ketoacidosis occurs due to relative or absolute lack of insulin. Common precipitants include a new diagnosis of type 1 diabetes, infection and deliberate omission of insulin. Diagnosis elevated plasma and/or urinary ketones metabolic acidosis (raised H+/low serum bicarbonate) Assessment: intra and extra-vascular volume depletion with reduced skin turgor, tachycardia and hypotension (late features) rapid and deep sighing respirations, smell of ketones ketonuria vomiting/abdominal pain drowsiness/reduced conscious level Management insulin intravenous insulin, fluids and electrolytes is required to restore the metabolic equilibrium Acute Complications hypokalemia, cerebral edema, ARDS, thromboembolism Acute Hypoglycemia Acute Pancreatitis a potentially life-threatening disorder characterized by inflammation of the pancreas that may also involve peripancreatic tissues or remote organ systems, or both. CAUSES: excess alcohol intake, gallstones, trauma, infection, drugs, toxins, hyperlipidemia, or hypercalcemia Manifestation: abdominal pain, ranging from mild, tolerable discomfort to severe incapacitating distress pain is most intense in the epigastrium or periumbilical region, and often radiates to the back signs of shock, namely tachycardia and hypotension.

Ecchymoses in the periumbilical area (Cullens sign) or flanks (Turners sign) indicate hemorrhagic pancreatitis. Diagnosis: Elevated serum levels of amylase and lipase X-ray, ultrasound, CT-Scan

Treatment Hydration Analgesia Meperidine is given not morphine to prevent spasm of the sphincter of Oddi, w/o for toxicity esp in pt with renal failure Nutrition per orem unless there is nausea and vomiting, NGT may be used, or TPN Infection and Antibiotic Therapy Massive bleeding