Archive | November 2010

Multiple organ dysfunction syndrome

Presence of altered organ function in acutely ill patients such that homeostasis cannot be maintained without intervention.

Involves two or more organ systems.

Pickwickian Syndrome

named after the Dickens’ character Pickwickian who exhibited the same symptoms.

Etiology:

A group of symptoms that generally accompany obesity.

Manifestations:

lethargy, somnolence, hypoventilation, and polycythemia

HYPERCAPNIC RESPIRATORY FAILURE

Respiratory failure due to icreased carbon dioxide in the blood stream and decreased oxygen levels. Results in compromised gas exchange and tissue perfusion.

Normal reference values:
Oxygen PaO2 > 60 mmHg. In kPa, PaO2 values should be above 8.
Carbon dioxide PaCO2 < 45 mmHg. In kPa, PaCO2 should be less than 6.6kPa.

Hypercapnic respiratory failure: PaCO2 > 50 mmHg (i.e. 6.5kPa). This indicates inadequate alveolar ventilation

CAUSES:

Severe asthma
Obesity
Polyneuropathy
Head and neck injuries
Chronic obstructive pulmonary disease
Drug overdose, poisoning
Myxoedema
Adult respiratory distress syndrome
Pulmonary oedema
Poliomyelitis
Myasthenia gravis
Reduced breathing effort

ACUTE versus CHRONIC HYERCAPNIC RESPIRATORY FAILURE:

Chronic respiratory failure

may take several days to develop

results in increased bicarbonate concentration, and pH is slightly decreased.

Acute respiratory failure

develops over minutes to hours.

pH < 7.3.

Continuous Bladder Irrigation (CBI)

 Continuous Bladder Irrigation

 

Two types:

  1. Closed CBI
  2. Open CBI

 

Closed Bladder Irrigation:

  • provides intermittent or continuous irrigation of the catheter without disrupting the sterile connection between the catheter and the drainage system.
  • Intervention: Limits UTI risk
  • Set-up: involves continuous infusion of sterile solution into the bladder
  • Via: triple lumen catheter
  • Application: following genitourinary surgery preventing urinary tract occlusion by clots
  • do not disconnect a urinary catheter and drainage system unless the catheter is being irrigated using intermittent open technique

 

  • use normal saline
  • antiseptic technique

 

Pre-procedural checks:

  • check patient record to determine purpose for bladder irrigation
  • check physician’s orders to determine:
  1. type and amount of irrigant
  2. frequency of irrigation: rate and if continuous or intermittent.

 

Assessment:

  1. Colour of urine
  2. Presence of mucus, clots or sediment
  3. Palpate the bladder
  4. For CBI assess ongoing urinary output
  5. For CBI assess amount of irrigant inputting
  6. note amt remaining in bag to be imputed
  7. Assess for abdominal pain or spasms
  8. Assess for sensation of bladder fullness
  9. Assess for urinary bypass
  10. Assess for signs and symptoms of UTI

 

Complications:

  • If output is less than input, catheter may be obstructed by clots or mucous or tubing kinked
  • If urinary output has stopped and catheter patency cannot be re-established through manual irrigation stop CBI and notify physician

 Documentation:

 

  • Time CBI initiated
  • Amt and type of irrigant soln
  • character (presence of clots) and change in character of urinary returns
  • in & outs – change bag, drainage emptied
  • patient’s tolerance for the procedure
  • bladder spasms or pain

Negative pressure wound therapy (VAC therapy)

 

eg. Vacuum assisted closure brand = VAC

  • controlled negative pressure controls and assists wound healing
  • optimizes blood flow
  • removes exudate
  • maintains moist wound bed
  • hypothesis that it stimulates angiogensis and relieves edema increasing dermal perfusion
  • a dressing is placed into the wound maintains wound bed moisture
  • a suction device is placed over the dressing
  • transparent air tight dressing covers dressing, wound and suction device
  • dressing changes occur q48h

 

 

  • know wound etiology to prevent recurrence and promote healing
  • area requires adequate perfusion for VAC use

 

Who may order VAC use:

  1. Plastic surgeons
  2. Vascular Surgeons
  3. Enterostomal therapy (ET) nurses

 

Each track pad on the VAC drsg is a sensor that measures exudate outflow and prevents exsanguination

Indications

  1. pressure ulcers
  1. diabetic ulcers
  2. traumatic wounds
  3. venous stasis ulcers
  1. abdominal wound dehiscence
  2. preparing wound flap or grafts
  3. securing flaps or grafts post op
  4. acute, traumatic and chronic wounds
  5. cardiothoracic wounds
  6. partial or full thickness burns

 

  • VAC is suitable to high exudate wounds
  • used for treated osteomylitis wounds
  • VACs may used directly over hoffman`s pins

 

Counterindications

  1. if cancer is in situ VAC is contraindicated as the area is highly vascularized and the patient is at risk for exsanguination
  2. unexplored nonenteric fistulas, fistual end must be determined
  3. Infections must be treated prior to VAC use
  4. necrotic tissue with eschar presentation
  5. non-enteric and unexplored fistulas
  6. do not place VAC over exposed blood vessel or organs

 

Care of wound with tendon or visible pulsing vessel:

  • interface area with gelnet, mepatil or vasaline gauze

 

Documentation:

  • chart number and type of dressing components inserted into wound bed so that all may be removed with each dressing change

Protecting intact skin:

  • protect the intact skin on the wound and VAC interface by covering intact area with tegaderm

 

VAC drape (forms the air tight overlay)

  • place side 1 of the drape against the patient, over the black foam packing
  • The track pad is then stuck over the hole the nurse cuts in the drape to allow evacuation of exudate

 

VAC dressing change

  • a half hour prior to drsg change unluerlock VAC tubing and inject saline down tube to pt
  • track pad and tubing are changed at same time
  • wound exudate collection canister is changed weekly
  • if two wounds are in close proximity one VAC may be used
  • intact skin between the 2 wounds must be protected by tegaderm, then foam overlay
  • the track pad hole is placed in the middle of the two wounds
  • zilocaine may be used on wound bed to assist patient wound care tolerance
  • note that excess drape may be used to patch an air leak

Peripartum perineal tear classifications

Perineal tears

These are classified into 4 degrees:

 

  • 1st-degree tears are where the fourchette and vaginal mucosa are damaged and the underlying muscles are exposed, but not torn.
  • 2nd-degree tears are to the posterior vaginal walls and perennial muscles, but the anal sphincter is intact.
  • 3rd-degree tears extend to the anal sphincter that is torn, but the rectal mucosa is intact.
  • 4th-degree tears are where the anal canal is opened, and the tear may spread to the rectum.

Chest tube assessment and care

 

Complications resulting in the need for a chest tube:

  1. Pleural effusion
  2. Hemothorax
  3. Empyema (pus)
  • Symptoms:

 

  1. Dyspnea
  2. Cough
  3. Chest Pain
  4. Fever
  5. Malaise

 

Mediastinal Chest tube purpose:

  • removal of blood or fluid from around the heart

 

Documentation:

  1. Volume of drainage (date and time)
  2. Suction Rate
  3. Nature of drainage (measure and character)
  4. mark on pneumothorax container then replace when full

 

Drainage System Troubleshooting:

  • No tidling indicates the system is not patent or that lungs have expanded to normal
  • Intermittent bubbling is normal, if continuous bubbling occurs the tube has been displaced
  • rapid bubbling may indicate air leak around incision or tear in pulmonary pleura

 

Assessments:

  1. Patient
  2. Site
  3. Tubing
  4. Timing = q15min for first hr after insertion, then q4h

 

Patient Assessment:

  1. vital signs
  2. oxygen saturation
  3. level of orientation
  4. respiratory assessment
  • signs and symptoms of increased respiratory distress:
  • displaced trachea
  • decreased breath sounds over both affected and unaffected sides
  • marked cyanosis
  • asymmetrical chest movements
  • chest pain:
  • sharp, stabbing chest pain – indicative of tension pneumothorax
  • pain on inspiration – indicative of hemothorax or pneumothorax
  • hypotension
  • tachycardia
  • pain scale
  1. Hg and Hct

 

Site assessment:

  1. Chest tube Dressing and surrounding insertion site -norm = Dry and Intact
  2. Drainage
  3. Subcutaneous emphysema
  4. Sudden increase in drainage of more than 70ml may indicate new thoracic bleeding

 

Tubing assessment:

  • tight system connections
  • appropriately taped
  • tubing not kinked, or obstructed
  • prevent dependent loops
  • avoid milking or stripping the drainage in tubing

 

Drainage Unit Chambers:

  • Set upright
  • insure drainage collector is below the level of the patient`s chest
  • ensure tidling is occurring with patient inspirations and expiration
  • lung re-expansion may have occurred if no tidling occurs and 2-3 days have passed
  • An air leak may be indicated by fluid bubbling left to right when facing system.
  • assess the suction level is as per doctors orders
  • sudden halt in drainage may indicate clot or other blockage in the drainage system
  • Know expected drainage colour when assessing

 

Clamp tubing (but only for seconds) when:

  • locating leaks
  • replacing the system
  • as per physicians orders to trial if pneumothorax has resolved
  • 2 non-toothed clamps should be at the patient`s bedside at all times