NEUROLOGIC EMERGENCIES

073119

Neuron – bridge to other neurons to communicate; transmits stimuli to organs; neurotransmission;

Spinal column supports and protects the cord
Brain: cerebrum, brain stem, and cerebellum

Frontal lobe Concentration, abstract
thought, memory, AND motor
function. Contains Broca's
area (motor control of
speech), affect, personality,
judgment and inhibitions
Parietal lobe spatial awareness (L-R
orientation)
Temporal memory of sound,
understanding of language
and music, and auditory
receptive areas
Occipital visual interpretation and
memory
Brain Stem
ASSESSMENT
Motor Examination,
Mental Status
Test Sensation
seizure hx, assessment on
ability to follow
visual exam, visual
perception, spatial
relationships,
hallucinations
cranial nerve testing
INTERVENTION
Physical, speech,
occupational, cognitive
therapies + pharmacologic
OT for safety and cognitive
retraining
seizure
prophylaxis/precaution,
driving restriction
OT for visual
therapy for CN deficit, pharma

Thalamus - relay station of all sensation except smell

Hypothalamus - thirst, hunger, thermoregulation, sleep-wake, BP, emotional responses
Basal ganglia - substantia nigra (dopamine), fine motor (hands and lower extremities)
Midbrain - auditory and visual reflex; connects pons and cerebellum
Pons - CNV (Trigeminal: sensory motor) and CNVIII (vestibulocochlear: hearing and balance).
Medulla Oblongata - reflex center for respiration, BP, HR, coughing, vomiting, swallowing, and sneezing.
CNIX (glossopharyngeal: motor and sensory - tongue and throat) and CNXII (hypoglossal: speech,
chewing, and swallowing).

Protective Structures
1. Skull
2. Meninges
3. DAP (Dura, Arachnoid, Pia)
4. BBB

CSF – colorless and clear fluid produce in the choroid plexus; flexible since it is easy to control; makes the
brain functional

Monroe Kellie Doctrine:

CSF can be managed via: Ventriculostomy or Spinal Tap

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Assessment of the Nervous System:

 LOC – COLDSCO
o Confusion o Disorientation [time, place, person]
o Obtundation o Stuporous [need pain to wake up]
o Lethargy o Coma - reflexes only

 Glasgow Coma Scale

o Eye Opening Response, Verbal Response, Motor Response (gross only)
o 3 = Lowest Score
o 15 = Highest Score
o GCS of 8 is 50/50 (50 chance to be reverted and 50% chance to be in coma)

FOUR (Full Outline of UnResponsiveness) Score – assesses the gross function and brain stem function
 0 = Lowest score
 16 = Highest score

EYE RESPONSE MOTOR RESPONSE BRAINSTEM INTUBATION SCORE

Open eyes
Obeys, makes sign, Pupils + corneas + Not intubated, normal
spontaneously, tracks, 4
e.g., “thumbs up” cough respirations
blinks to command
Opens eyes, does not Not intubated,
Localizes painful 1 pupil unreactive,
track or blink to Cheyne-Stokes 3
stimulus corneals + cough+
command respirations
Pupils - , corneals +,
cough NA
Eyes closed, open to Flexes to painful Not intubated,
2
loud voice stimulus irregular respirations
Pupils + , corneals -,
cough NA
Intubated, breathes
Eyes closed, open to Extends to painful Pupils - , corneals -,
above ventilator 1
painful stimulation stimulation cough +
settings
Intubated, breathes
Eyes remain closed No response / above ventilator
Pupils - , corneals -,
following painful Myoclonic status settings 0
cough -
stimulation epilepticus
Not intubated, apneic

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 EYE RESPONSE MOTOR RESPONSE BRAINSTEM INTUBATION
4 = able to follow Assessment of fine Pupil reflex: Assess intubation or rhythm of
without turning the gross and fine motor Use penlight respiration
head function Near = constrict
3 = with turning of the 2 = decorticate Far = dilate
head 1 = decerebrate 3 = Period of apnea is <10
1 = painful stimulation Corneal reflex: seconds, not >20 secs
(+) blink of the corner of
Elicit pain by the eye is touched 2 = candidate for mechanical
Squeeze/pinch the ventilator
finger, nipple, nail, 3 = Anisocoria (one eye
ear. has a different color or
AVOID sternal rub = only one eye is dilating)
maybe interpreted as
decortication. 0 = Automatically,
AVOID injured part patient is intubated;
brainstem issue.

BREATHING PATTERNS

Bag Valve Mask (Ambu bag) Usage:

1. Connect the bag (or oxygen reservoir, if included), mask and oxygen tube to the BVM.
2. If possible, use an airway adjunct (also known as a glottal-block or bite-block) to keep the tongue out
of the way. Otherwise, the tongue may block the airway and force air into the esophagus or stomach.
3. Position themselves behind the patient, above the patient’s head if the patient is lying on the floor.
4. Position the mask on the patient’s face and hold it in place firmly over the nose and mouth. This may
be easier with one person holding the mask in place and another person squeezing the bag.
5. To achieve a good seal, pull the chin up (rather than pushing the forehead down) to keep the airway
open.

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6. Squeeze the bag until the chest rises, count six seconds between bag squeezes, about 10-12 times per
minute on an adult.
7. Avoid squeezing too quickly and over-ventilating the patient.
8. Note that the mask must seal and the patient’s chest must rise when the bag is squeezed. If this isn’t
happening, air isn’t getting into the lungs.

CONFUSION ASSESSMENT METHOD – to check for delirium; initially done in the ER

FEATURE ASSESSMENT
Usually obtained from a family member or nurse and shown by positive
responses to the following questions:
1. Acute onset and  “is there evidence of an acute change in mental status from the patient’s
fluctuating course baseline?”
 “Did the abnormal behavior fluctuate during the day, that is, tend to
come and go, or increase and decrease in severity”
Shown by a positive response to the following:
 “Did the patient have difficulty focusing attention, for example, being
2. Inattention
easily distractible or having difficulty keeping track of what was being
said?”
Shown by a positive response to the following:
 “Was the patient’s thinking disorganized or incoherent, such as rambling
3. Disorganized thinking
or irrelevant conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject?”
Shown by any answer other than “alert” to the following:
 “Overall, how would you rate this patient’s LOC?”
 Normal = alert
4. Altered level of
 Drowsy, easily aroused = lethargic
consciousness
 Unarousable = coma
 Hyperalert = vigilant
 Difficult to arouse = stupor

CRANIAL NERVE TEST

NERVE MAJOR FUNCTIONS ASSESSMENT
With eyes closed, the patient identifies
I Olfactory Se Smell familiar odors (coffee, tobacco). Each
nostril is tested separately.
Vision (acuity & field of
vision)
Snellen eye chart; visual fields;
II Optic Se Pupil refractory to light and
ophthalmoscopic examination
accommodation (afferent
impulse)
Eyelid elevation; most EOMs;
III Oculomotor Mo pupil size and reactivity For cranial nerves III, IV, and VI: test for
(efferent impulse) ocular rotations, conjugate movements,
EOM (turns eye downward & nystagmus. Test for pupillary reflexes, and
IV Trochlear Mo
laterally) inspect eyelids for ptosis.
VI Abducens Mo EOM (turns eye laterally)
Have patient close the eyes. Touch cotton
to forehead, cheeks, and jaw. Sensitivity to
superficial pain is tested by using the sharp
and dull ends of a broken tongue blade.
Alternate between the sharp point and
Chewing; facial and mouth
the dull end. Patient reports “sharp” or
V Trigeminal Mi sensation; corneal reflex
“dull” with each movement. If responses
(sensory)
are incorrect, test for temperature
sensation. Test tubes of cold and hot water
are used alternately.
While the patient looks up, lightly touch a
wisp of cotton against the temporal

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 surface of each cornea. A blink and
tearing are normal responses.
Have the patient clench and move the
jaw from side to side. Palpate the masseter
and temporal muscles, noting strength and
equality.
Observe for symmetry while the patient
performs facial movements: smiles,
whistles, elevates eyebrows, frowns, tightly
Facial expression; taste; closes eyelids against resistance (examiner
VII Facial Mi corneal reflex (motor); attempts to open them). Observe face for
eyelid & lip closure flaccid paralysis (shallow nasolabial folds).
Patient extends tongue. Ability to
discriminate between sugar and salt is
tested.
Whisper or watch-tick test
Acoustic/
VIII Se Hearing; equilibrium Test for lateralization (Weber)
Vestibulocochlear
Test for air and bone conduction (Rinne)
Assess patient’s ability to discriminate
Gag reflex; swallowing
IX Glossopharyngeal Mi between sugar and salt on posterior third
(sensory); taste
of the tongue.
Depress a tongue blade on posterior
tongue, or stimulate posterior pharynx to
Gag reflex and swallowing elicit gag reflex.
X Vagus Mi
(motor); speech (phonation) Note any hoarseness in voice.
Have patient say “ah.” Observe for
symmetric rise of uvula and soft palate.
Palpate and note strength of trapezius
muscles while patient shrugs shoulders
against resistance.
Shoulder movement; head
XI Spinal accessory Mo Palpate and note strength of each
rotation
sternocleidomastoid muscle as patient
turns head against opposing pressure of
the examiner’s hand.
While the patient protrudes the tongue,
any deviation or tremors are noted. The
Tongue movement; speech strength of the tongue is tested by having
XII Hypoglossal Mo
(articulation) the patient move the protruded tongue
from side to side against a tongue
depressor.

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 Mental Status
 Intellectual Function
 Thought Content
 Emotional Status
 Language Ability
 Impact on lifestyle
 Motor Ability
o Walk across room to examine posture and gait.
o Muscles are inspected and palpated
 Muscle Strength
• Muscle strength testing scale (1-5)

Balance and coordination

 Coordination in hands – perform rapid, alternating movements and point-to-point testing
 Pat each thigh as fast as possible
 Alternately pronate and supinate each hand
 Touch each of the fingers with the thumb in a consecutive motion
 Romberg’s test – to test for balance.
o The patient can be seated or stand with feet together and arms at the side, first with eyes
open and then with both eyes closed for 20 seconds.

Examining Sensory System

 Tactile sensation – lightly touching cotton wisp to areas of the body
 Pain – differentiate a sharp and dull of a broken cotton swap. Do not use safety pin.
 Vibration and proprioception – placing tuning fork at the bony prominence.
Proprioception (position sense) - awareness of position of parts of the body without looking at them

Examining the Reflex

 Deep Tendon Reflex – reflex hammer is struck briskly on the tendon that is stretched.

Superficial Reflex
 Corneal – use a clean wisp of cotton and lightly touching the outer corner of each eye on the sclera.
(+) = blink
 Gag reflex – elicited by gently touching the posterior pharynx with a cotton-tipped applicator; first on
one side of the uvula and then the other.
(+) equal elevation of the uvula and “gag” with stimulation
 Upper/lower abdominal, cremasteric (men only), and perianal
 Plantar reflex – elicited by stroking the lateral side of the foot with a tongue blade or the handle of a
reflex hammer.
Normal = toe flexion.
Abnormal = Toe fanning
Pathologic Reflex
 Babinski Reflex – elicited by stroking the lateral aspect of the sole of the foot
o Normal = toes contract draw together
o Abnormal = toes fan out and draw back

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Diagnostic Tests important in the ER
Computed Tomography Scan
Magnetic Resonance Imaging
Ultrasound
EEG (Electroencephalogram) –
electrical activity of the brain
Electromyogram - It helps
distinguish weakness due to
neuropathy weakness resulting
from other causes; Carpal
Tunnel Syndrome.
Lumbar Puncture – site is at L3-
L4 or L4-L5.
Check for allergies
No metallic objects
Done at the bedside
To check for blood flow or blood vessels
Transtemporal/transforaminal/transorbital
 Patient is deprived of sleep
 Standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours.
 The patient lies quietly during the test
 EEGs use a water-soluble lubricant for electrode contact (can be
wiped and removed by shampooing after)
 Sleep EEG uses collodion glue for electrode contact (requires
acetone for removal)
AVOID
 Antiseizure agents, tranquilizers, stimulants, and depressants (should be
withheld 24 to 48 hours)
 Stimulants (smoking, coffee, tea, chocolate, and cola)
 NPO (altered blood glucose level can cause changes in brain wave
patterns)
 Light meals only prior to procedure.
 Pacemaker is okay.
 Shampoo before and after; can be done after the procedure
provided that the hair and scalp is clean.
Expect a sensation similar to that of an IM injection as the needle is
inserted into the muscle.
The muscles examined may ache for a short time after the procedure.
1. Knee-chest position (Exposing operative site).
2. Local Anesthesia.
3. Consent secured by RN.
4. Contraindication: Increased ICP.
5. Flat on bed with only one pillow.
6. Sterile Container for the specimen.
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 NEUROLOGIC DISORDERS
INCREASED ICP (INTRACRANIAL PRESSURE)

Cerebral Perfusion Pressure (CPP) – this checks the distribution of Oxygen in the brain.
Normal CPP = 50-60 mm HG.

Intracranial Compliance – ability of the brain to respond to the changes in pressure.

Intracranial Compensation – blood and CSF
Computed by MAP-ICP
If a patient has ↑ICP, pressure increases by 20 mmHg.
For pedia, it should be an increase by 3-7 mmHg (may denote hydrocephalus; maybe be
evidenced by crying)
VS is dependent on the site of injury

HEAD INJURY
24-48 hours = (+) area of infarction hyperemia
48-72 hours = ↑ cerebral blood flow  ↑ cranial blood volume  ↑ICP (still has IC compliance &
compression)
No visible signs of ↑ ICP yet
>72 hours = (+) s/sx of ↑ ICP – Cushing’s Triad/Syndrome ---- Hyper, Brady, Brady
LOC/ headache – earliest sign of ↑ICP
Other signs: agitation, slowing of speech, and delay in response to verbal suggestions
Projectile vomiting, seizures, ocular issues, papilledema, anisocoria
(+) widened pulse pressure = >40 mmHg of difference
IF 160/90 = check for 15 mins, then verify again after 15 mins. Sudden change in pressure
can cause brain herniation

Interpreting ICP Waveforms

 Non-compliant brain will lead to A, B, C.
 Monitored using Ventriculostomy or Intraventricular
Catheter (most accurate)
 Skull is drilled to create a whole. Part of skull is
burrowed in the skin.
 When ICP is monitored with a fluid system,
transducer is calibrated at a particular reference
point. 1 inch above the air while patient is in supine
position. Should correspond to the foramen of
Monroe.

Intraventricular Catheter
 Nursing Care Management:
• Aseptic technique
• Check for loose connection in the drainage system (can cause leakage and
contamination)
• Check character of CSF if cloudy or bloody. REFER!
• Patient is monitored for sign and symptoms of meningitis: fever, chills, nuchal (neck) rigidity,
and then headache.
• If draining (2/3 full), replace the bag and not use it again.

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Medications and Oxygen Therapy
 Hyperbaric Oxygenation = 100% O2. Usually connected to mechanical ventilator
 IVF - hypertonic solutions
 Diuretics: Mannitol – DOC to ↓ICP. Osmotic diuretic.
• Therapeutic: Increase LOC
• Common SE: Increase Urine Output
 Dexamethasone – inflammation; glucose monitoring
• S = Increase sugar, Increase Na, Increase Sex
• T = Teratogenic Mx:
• E = excrete calcium  Monitor glucose
• R = retain fats (buffalo hump)  Neutropenic precautions
• O = osteoporosis  Reverse isolation – if ↓ immune
• I = immunocompromised system
• D = delayed wound healing/Diabetes
• S = severe muscle wasting
 Barbiturates –induce coma to ↓O2 demand. Might cause coma for life;
o Phenytoin (SE: Gingival Hyperplasia / Mx: Meticulous oral care)
 Antihypertensives Drugs

Nursing Management for ICP:

 Limit fluid intake to 800 to 1200 ml/day, depending on the severity of the case.
 Seizure Precautions:

 3 side rails up denotes restraining the

patient – require consent.
 Position the patient – beside the wall.
 Check neuro functions
 Examine reflexes: biceps, triceps,
patellar, Achilles, brachioradialis
 DTR
 AVOID activities that could ↑ICP

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TRANSIENT ISCHEMIC ATTACK
Precursor of ischemic or hemorrhagic stoke. Resolves within 24 hours

Ischemic Stoke
 Diagnostic Test: CT Scan (TIBEL)
 Disruption may cause ischemia or infarction due to atherosclerosis or arteriosclerosis
 Common site is middle cerebral artery and internal carotid
 Therapy is applicable on completed stroke

Hemorrhagic Stroke
 Uncontrolled BP, AVM
 Intracranial and subarachnoid hemorrhage, bleeding

Patient is having Stroke if:

 Face Drooping
 (+) Pronator Drift - ask him or her to stand or sit. Ask the patient to close his or her eyes, then to stretch
out both arms with the palms facing up. Your patient should maintain this position for 20 to 30 seconds.
Observe both arms. If your patient's motor pathway is intact, the arms should remain in this position
equally
 Slurring of Speech
 Time

General Manifestations:
• Headache (↑ICP)
• Syncope (temporary loss of consciousness caused by a fall in blood pressure)
• Difficulty of speaking
• Vision issues in one eye
• Numbness
• Paresthesia
• Depending on the site of the brain if left of right. Refer to the illustration.

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Motor Loss
 Hemiplegia (paralysis of one side of the body)
 Nursing Intervention: Correct Positioning, Splint at night to the affected extremity, Exercised
passively: 4X-5X daily
 Hemiparesis (weakness on one side of the body)

Communication Loss
 Dysarthria (difficulty in speaking)
 Dysphasia (impaired speech)
 Expressive Aphasia – Broca’s area (broken words)
 Receptive Aphasia – Wernicke’s aphasia (word salad)
 Global Aphasia - Severe cases, HCP must be Patient! Simple instructions only. Don’t continue what
they are saying.

Perceptual Disturbances
 Homonymous Hemianopsia – loss of half of the visual field. Affected side of vision corresponds to the
paralyze side of the body.

Sensory Loss
 Agnosia – loss of ability in recognizing familiar objects perceived by one or more senses

ASSISTIVE DEVICES TO ENHANCE SELF-CARE AFTER STROKE

Eating Devices
Nonskid mats to stabilize plates
Plate guards – to prevent food from being pushed off plate
Wide-grip utensils – to accommodate a weak grasp
Bathing & Grooming Devices
Long-handled batch sponge
Grab bars, nonskid mats, handheld shower heads
Electric razors with head at 90° to handle
Shower and tub seats, stationary or on wheels
Toileting Aids
Raised toilet seat
Grab bars next to toilet
Dressing Aids
Velcro closures
Elastic shoelaces
Long-handled shoe horn
Mobility Aids
Canes, walkers, wheelchairs
Transfer devices such as transfer boards and belts

Self-Care Management
 The first step is to carry out all self-care activities
on the unaffected side
 A small towel is easier to control while drying
after bathing
 Boxed paper tissues are easier to use than a roll
of toilet tissue
 Keep the environment organized and
uncluttered
 Use of a large mirror while dressing promotes the
patient’s awareness of what he or she is putting
on the affected side
 Patients with a decreased field of vision should
be approached on the side where visual
perception is intact
 The patient can be educated to turn the head
in the direction of the defective visual field to
compensate for this loss
 The nurse should make eye contact with the
patient and draw his or her attention to the
affected side by encouraging the patient to
move the head
 Nurse may also want to stand at a position that
encourages the patient to move or turn to
visualize who is in the room
 Homonymous Hemianopsia: It is important for
the nurse to constantly remind the patient of the
other side of the body; to maintain alignment of
the extremities; and, if possible, to place the
extremities where the patient can see them.

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Medical Management:
 Ischemic stroke only
 Tissue Plasminogen Activator
• Onset: 4.5 hours
• Consent
 Corticosteroids: Dexamethasome
• Inflammation to prevent cerebral edema and ↓ICP
 O2 if O2 sat is <92%
 Elevation of head to 25-30 (↓ICP and handle oral secretions)

Intubation (Acute Phase)

 Due to respiratory depression
 Contraindication: Facial deformity, rupture/injury

Physical Therapy
 Speech
 Occupational
 After stabilization of physiological needs of the patient
 For completed stroke only

Adequate Nutrition
 Based on the calorie needs of the patient

TPN
 IV thru CVP in the SVC
 No other lines should be joined in the TPN when administering
 Avoid infection
 UTI
 Prone to wounds
 Check dressing site for signs of inflammation
 Hypertonic – Rich in glucose
 Make sure to have Glucometer on bedside
 Infusion rates are decreased slowly to prevent hypoglycemia

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 RENAL EMERGENCIES
080719
Difference:
Amanita phalloides – a.k.a. “death cap”, produces most poisonous mushroom toxins.
o α-amanitin – principal toxic constituent which damages the liver and kidneys, causing
hepatic and renal failure that can be fatal.
Amanita citrine – a.k.a. “false death cap”

Kidney Functions
Metabolic waste excretion
 BUN – byproduct of protein
 Creatinine - Muscle
 Electrolytes
 H2O
Erythropoietin production
 Responsible for RBC production
BP Regulation
 Renin Angiotensin Aldosterone System
Acid-Base Balance
 If Acidic, kidneys will excrete acid and generate bicarbonate
 If Alkalinic, kidneys will retain acid and excrete bicarbonate
Vitamin D Production
 Aided by ergocalciferol and cholecalciferol that promotes increase in
calcium absorption

Anatomy:
 Nephrons – basic unit of the kidney
 Loop of Henle – Loop Diuretics act in this part of the kidney
 Glomerulus – semi permeable membrane that filters waste products in the body
[same concept in dialysis (peritoneum or dialyzer)]
 Aging renal and Urinary system:
o Kidneys: ↓ ability to concentrate urine, ↓ GFR, ↓ nephrons (higher risk from
nephrotoxic drugs)
o Urinary Bladder: ↓ bladder size, tone of detrusor muscle. May lead to dysuria,
urinary frequency, incontinence, or urine retention
o Female – pelvic muscle weakens (prone to UTI, incontinence, and urethral
irritation)
 Kegel’s Exercise
 Strengthens the pelvic floor
 Avoids tearing of the perineum
 Better contraction
 Healing process is better
o Prostate – male (BPH) which starts at 4y/o; lies at the back of the bladder =
leads to difficulty voiding and urine retention.
o Incontinent – loss of the voluntary muscle function during urination
o Urinary Frequency – ihi ka ng ihi and volume does not matter
o Urinary Urgency – nakakaramdam ka ng ihi, pero walang ihi

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ACUTE TUBULAR NECROSIS
 Acute kidney failure/Acute kidney injury
 Inability of the kidneys to remove the body’s metabolic wastes or perform their regulatory functions
 Systemic disease and is final common pathway of many different kidney and UTI
 Ischemic or nephrotoxic

Types of Kidney Failure:

o Acute – <6 months. sudden onset and almost complete loss of kidney function; reversible
(kidney function does not return to normal; if recurring, may bear a “scar” that could
progress into chronic)
o Chronic – gradual, progressive deterioration/loss of kidney function; irreversible

Types of Injury (Cause)

Pre-renal – before kidney Intrarenal – within the kidney Post-renal – below kidney
Impaired perfusion Drugs that Obstructions along the
Diseases DESTROY the kidneys urinary tract
Dyes

INITIATION OLIGURIC DIURETIC RECOVERY

Initial assault to the Sudden decrease in UO Gradual decrease in UO May take 33-12 months
kidney <400mL Lab result stabilizes
Azotemia
Hyperkalemia

 Initiating
o Initial insult and ends with oliguria which is less than 0.5 ml/kg
o Recurring UTI (asymptomatic)
 Oliguric (MEBPAV)
o Minimum of 400ml needs to excreted by the body in order to get rid of waste products
within 24 hour period (Urine output is dependent on the persons weight)
o ↑serum concentration (BUN and creatinine); risk for hyperkalemia (heart attack, WARNING!
6 mEq/ml = tachycardia).
o The non-oliguric form happens if patient hast taken nephrotoxic drugs. Normal Urine output
but has a decreased renal function. Normally can be seen in CBC with high levels of BUN.
o Consider psychiatric issues/LOC (delusions) d/to poisoning of creatinine; ↓sensorium
o ↑urine specific gravity in terms of urinalysis
o Patients on oliguric phase may die d/to azotemia.
o ABG – metabolic acidosis
 Diuretic (1-3 weeks)
o Recovery phase of GFR (↑). Body compensations.
o ↓CBC, ↓ urine specific gravity
o Dehydration may be present
o ↑ uremic symptoms = body is removing the waste products
o If patient did no go to recovery, may lead to chronic renal failure
 Recovery
o Recovery signals in the improvement of renal function that takes 3 to 12 months.
o Lab values returned to normal
o GFR reduction of 1-3%.

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 GFR Criteria* UO Criteria*
↑S. Crea x 1.5 UO < .5 ml/kg/h
Risk or x 6 hr
↓GFR > 25% High Sensitivity

↑S. Crea x 2
UO < .5 ml/kg/h
or
Injury x 12 hr
↓GFR > 50%

↑S. Crea x 3 UO < .3 ml/kg/h

↓GFR > 75% x 24 hr

Oliguria
Failure or or
S.Crea ≥4mg/dL Anuria x 12 hrs

Persistent ARF** = complete loss of

Loss kidney function > 4 weeks
High Specificity
ESKD (>3 months)
ESKD

 RIFLE – If patient stayed at the Oliguric Phase, it will progress to AKI or CRF
 RIF (Grades of AKI Severity) LE (outcomes of lost; result of RIF, Chronic) Classification System for Acute
Kidney Injury:
o Risk
 0.5ml/kg/hr
 6-hour shift
 Example: 75kg X 0.5ml/kg/hr = 37.50 ml/hr
 225-228 ml on a 6-hour shift
 Any amount <228 ml in a 6-hour shift = at risk for renal failure
 According to Brunner, 30cc/hour should be normal; however UO=dependent on the
patient’s weight.
 REFER only if UO is below the target in a 6-hour shift.
 If q1 at a 6-hour shift, 3 consecutive UO out of target
 Anything < expected UO at a 6-hour shift
 If Lab values will be used,
o Injury
 0.5ml/kg/hr
 Expected UO is less than the target within the 12-hour period
 Considering the example of 37.50 ml/hr X 12 hours = 450 ml in 12 hours. If this goes
below than 450ml. Then it is considered as injury
o Failure
 0.3ml/kg/hr
 Oliguric Phase
 Expected UO is less than the target within 24-hour shift or anuria in 12-hour shift.
 Considering the example above: 75kg X 0.3ml/kg/hr = 22.55 ml/hr
 540 ml on a 24-hour shift. Anything less than this results from Failure

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  Check for any kinks to get an accurate data for urine output. FC is needed to be
checked.
o Loss
 Complete loss of kidney function >4 weeks (1month)
o ESKD (End Stage Kidney Disease)
 >3 months

CLINICAL MANIFESTATIONS:
 Azotemia (ASx)
 Uremia
 Uremic encephalopathy (Tremors, Ataxia, Slurred speech, Asterixis)
 Uremic syndrome (Pruritus, Uremic frost, Meta aci, Pulmo congestion, Confusion, Hypertension, Uremic
fetor/frost, Anemia)

Assessment: PA
o Consider the body systems like cardiovascular, respiratory, integumentary, neuro-
musculoskeletal, GI system, etc.

Assessment: Diagnostics
 UA (Timed Urine Collection – 24-hour urine collection)
o Normal urine = clear/amber
o Abnormal = cloudy
o Adriamycin makes urine orange
o Check kidneys ability to concentrate/dilute urine
o Determine disorder in glucose metabolism
o Determine levels of constituents
o Refrigerate and preserve as needed
o Prepare 1-liter bottle, large basin with continuous flow of ice (container must be submerged)
o Procedure:
 At the start of the collection period have the client VOID and DISCARD the urine
 At the END of the collection time, ask the client to EMPTY THE BLADDER and SAVE the
urine as part of the specimen.
 Failure to collect the urine during the collection time will mean that the procedure
should be restarted.
 CBC (BUN, Creatinine, Potassium)
o REPORT! Potassium level 6 mEq/L
 ↓HCT (Viscous blood) = Men: 35%-47% Female: 35%-45%
 ECG Changes = U wave = tachycardia
 ABG = Metabolic acidosis
 Renal Biopsy

Acute Tubular Necrosis – Management

1. Safety - manipulate the environment, rest periods (maximize nursing intervention, limit visitors)
2. Diet therapy
a. Low Na, low CHON, low K (AVOID root crops), and high calorie diet
b. Fluid restriction – accurate I&O monitoring
c. Daily weight – early in the AM, same clothing, same weighing scale
3. Drug therapy – check if drugs are nephrotoxic
a. Supplemental vitamins (vitamin K) – make sure hat OTC meds does not interfere with the
therapy or the prescribed drugs that are given to the patient
b. Sodium bicarbonate – to counteract metabolic acidosis
ER = given parenterally, slow IV push – may cause rapid alkalosis)
c. D50/50 – to correct potassium level
Osmotic process where glucose aids in putting K inside the cell
4. Dialysis
5. 5D’s of Acute Tubular Necrosis Management
o Diet, Drugs, Dialysis, Diazepam, D?????

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DIALYSIS
 Hemodialysis – AV Fistula (takes 3 months for it to be used)
o ER = immediate access – Inserting double-lumen, non-cuffed, large-bore catheter. Sites:
1. Subclavian – most preferred - (+)complications; vein is harder to find in fat patients
2. Internal jugular – most accessible
3. Femoral vein
o Contraindicated – (+) blood infection

 Peritoneal Dialysis –emergency case and if patient’s blood is infected.

o Prepare Tenckhoff catheter before referring the patient to ward.
o 20-30 mins for the dwelling time – to release toxic substances

IHD – infection control CRRT – Better and more expensive

Access Site Vascular or fistula Vascular (central line)
Equipment Requires special dialyzer Does not require a special dialyzer
Training Skilled HD nurse Non-HD nurse
Timing Intermittent Continuous (24 hours)
Solute Removal Osmosis and diffusion Convection
Cardiovascular Effects Hypotension Few effects

Intermittent Hemodialysis Considerations:

1. Before the procedure:
 Patient should eat because hemodialysis causes fatigue
 Check BP
2. Cumulative hourly output:
 Odor
 Color
3. Bleeding assessment
 Coagulation tests
 Check medications – heparin
4. Infection precautions – to prevent blood borne disorders
5. Ensure patient is euthermic – no fever
6. Positioning
 Improper positioning may lead to:
 Hypotension
 Rashes/blisters/bed sores

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 METABOLIC EMERGENCIES
082819

Focus on emergency: GLUCOSE REGULATION

 Central – regulated by hypothalamus and  Adrenal glands – cortisol regulation (SSS)
pituitary gland.  Thyroid and parathyroid glands
 Peripheral – involve the other glands  Pineal body will not affect the body
 Thymus gland – mainly for foreign bodies
 Negative feedback mechanism
Brain  Pituitary  Gland  Target tissue

Anatomy & Physiology

Endocrine System
Pancreas
a. Endocrine function:
*Islets of Langerhans - tissue which contains primary endocrine cells:
Alpha Glucagon ↑ blood glucose by glycogenolysis (converting glycogen to
glucose)
Opposite of Insulin
Beta Insulin  ↓blood glucose
 Promotes storage of fat & synthesis of CHON
Delta Somatostatin Inhibits:
 Growth hormone
 Thyroid-stimulating hormone
 Insulin
 Glucagon

Brunner:
hypoglycemic effect; interferes growth hormone & glucagon
release

b. Exocrine function - to release enzymes to help the process of digestion

Secretin – major stimulus for HCO3 Pancreatic enzymes:
secretion from the pancreas  Protease
Vagus nerve  Amylase – digests CHO
 Lipase – digests fats
 Trypsin – digests CHON

Normal Glucose/CBG 70 - 110 mg/dl

l
3.90 - 6.10 mmol/l
Temperature 37.5 C (99.5 F)
OsmolaRity unit = osmoles per kilogRam
OsmolaLity unit = osmoles per Liter
low (diluted) <1.010
Urine Specific Gravity
high (solute) >1.020
BUN 10.00
Creatinine 1.00
Underweight <18.50
Normal range 18.50 - 24.99
BMI
Overweight ≥25.00
Obese ≥30.00

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DIAGNOSTICS
HgbA1c – “Glycosylated hemoglobin” – most accurate; checks the glucose attached to the hemoglobin
for the span of 3 months.

OGTT – “Oral Glucose Tolerance Test”

Before the test, a sample of blood is withdrawn (for baseline)
Drink glucose solution; another blood sample is taken an hour after ingesting.
At the 2nd hour, glucose is usually increased but it is insignificant
Glucose should return to normal level at the 3rd hour. If it failed to return to normal, DM is suspected

FBS – Fasting Blood Sugar – fasting for 8-12 hours, then the blood is taken.

C-peptide –to support the diagnosis of DM. C-peptide is released if ↑blood glucose.

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HYPOGLYCEMIA Blood glucose = <50-60 mg/dL or 2.7 – 3.3 mmol/l

Causes
 Too much insulin or OHA
 Too little food
 Excessive physical activity

Adrenergic symptoms (mild hypogly)

↓blood glucose  SNS stimulation  epi & norepi release
Sweating Palpitation
Tremor Nervousness
Tachycardia Hunger

CNS symptoms (moderate and severe hypogly)

↓blood glucose  brain cell deprivation = CNS impairment

Management
15 g of a fast-acting concentrated source of carbohydrate
• Three or four commercially prepared glucose tablets
• 4 to 6 oz of fruit juice or regular soda
• 6 to 10 Life Savers or other hard candies
• 2 to 3 teaspoons of sugar or honey

HYPERGLYCEMIA
Elevated blood glucose level—fasting level >110 mg/dL or 6.1 mmol/L
2-hour postprandial level >140 mg/dL or 7.8 mmol/L

Causes Signs and symptoms

Stress Blurring of vision
Infection Dominant 3Ps

P
Obesity olyuria
Lifestyle – activities, diet olydipsia
olyphagia

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CHRONIC HYPERGLYCEMIA
DIABETES MELLITUS
Risk Factors Signs and symptoms
 Bad diet  Thirst
 Lifestyle  Excess urine
 Stress  Hunger
 No exercise  Blurred vision
 Thinning

Insulin Name Onset Peak Duration

Rapid-acting Lispro (Humalog) 10-15 mins 1 hour 3 hours
Aspart (Novolog) 4-6 hours
Short-acting Regular (Humalog ½ - 1 hour 2-3 hours 4-6 hours
/ Humulin R)
Intermediate NPH (Humulin N, 2-4 hours 6-12 hours 16-20 hours
Lente)
Long-acting Ultralente 6-8 hours 12-16 hours 20-30 hours
Very long-acting Glargine (Lantus 1 hour - 24 hours

ORAL HYPOGLYCEMIC AGENTS

Sulfonylureas - Stimulate Chlorpropamide Longer plasma half life ( Tolbutamide
beta cells to produce (Diabenese)
insulin Tolbutamide (Orinase)

1st generation
2nd generation Glipizide (Glucatrol) Shorter plasma half life (Glipizide)
Glyburide (Micronase)
Glimepiride (Amaryl)
Biguanides Metformin (Glucophage) Reduce glucose production by liver; increase
Metformin + Glyburide use of glucose by muscles and fat cells
(Glucovance) (Metformin)
Thiazolidinediones Pioglitazone(Actos) Improve insulin sensitivity (Avandia)
Rosiglitazone(Avandia)
Alpha Glucoside Acarbose(Precose) Delay carbohydrate absorption (Acarbose)
Inhibitors

Meglitinides Repaglinide(Prandin) Stimulate quick release of insulin

Nateglinide(Starix) (Repaglinide)
DPP-4 inhibitor Stimulates the release of insulin in a glucose
dependent manner and decreases the levels of
glucagon in the circulation

INSULIN PUMP
“Continuous subcutaneous insulin infusion”
- small, externally worn devices that closely mimic the functioning of the normal pancreas
- contain a 3-mL syringe attached to a long (24- to 42-in), thin, narrow-lumen tube with a needle or
Teflon catheter attached to the end
- needle/catheter – changed every 3 days
- Bolus dose before each meal, depends on the anticipated food intake and activity level.

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DIABETES-RELATED COMPLICATIONS

DKA HHS
Onset Adolescents and older adults with type 1 Older adults with type 2 DM
DM
Symptoms
Confusion, lethargy Lethargy
Warm, dry, flushed skin Warm, dry, flushed skin
Weakness Weakness
Anorexia, nausea Tachycardia
Abdominal pain Rapid respirations
Tachycardia (-)acetone breath
Fruity, acetone breath Thirst
Deep, rapid respirations (Kussmaul’s)
Thirst
Laboratory values
Blood glucose 300-800 mg/dL 600-2000 mg/dL
Serum osmolality Elevated but usually <330 mOsm/L Significantly elevated >350 mOsm/L
ABG pH <7.35 Normal-to-mild acidosis
HCO3 <15 mEq/L

Metabolic acidosis with compensatory

respiratory alkalosis
Serum ketones (+) (-)
Urine (+) glucose (-) glucose
(+) ketones (-) ketones
ECG ST depression – hypokalemia
Tall T waves – hyperkalemia
Interventions
Insulin Rapid-acting Fast-acting insulin
IVF PNSS – rapid initial replacement PNSS/D5W
When BP is normal, switch to 0.45% NS

Serum Osmolality
- concentration of solute particles in the blood.
N=280-300 mOsm/kg

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