232 acute care

Question 1

progressive alterations to kidney function

risk level catergory serum creatinine, GFR and urine output

Answer 1

Increased Creatinine x 1.5
Decrease in GFR >25%

urine output
<0.5mL/Kg/hr
>6 hours

Question 2

progressive alterations to kidney function

injury level catergory serum creatinine, GFR and urine output

Answer 2

Increased Creatinine x 2
Decrease in GFR >50%

urine output
<0.5mL/Kg/hr
>12 hours

Question 3

progressive alterations to kidney function

faiure level catergory of serum creatinine, GFR and urine output

Answer 3

Increased Creatinine x 3
Decrease in GFR >75%

urine output
<0.3mL/Kg/hr
>24 hours or

Anuria >12 hours

Question 4

progressive alterations to kidney function

loss level catergory serum creatinine, GFR and urine output

Answer 4

Complete loss of kidney function >4 weeks

Question 5

progressive alterations to kidney function

end stage level catergory serum creatinine, GFR and urine output

Answer 5

End-stage kidney disease >3 months

Question 6

classifications of acute kidney injury

Answer 6

prerenal
intrareal
post renal

Question 7

Prerenal Acute Kidney Injury

Answer 7

Caused by impaired renal blood flow
Renal vasoconstriction
Hypotension
Hypovolaemia
Haemorrhage
Inadequate cardiac output
GFR declines because of a decrease in filtration pressure
Failure to restore blood volume or flow will cause irreversible cell injury

Question 8

Intrarenal acute kidney injury

Answer 8

Intrarenal causes
Acute Tubular necrosis r/t prerenal kidney injury
Nephrotoxic acute tubular necrosis
Acute glomerulonephritis
Vascular disease – malignant hypertension, disseminated intravascular coagulation, renal vasculitis
Allograft rejection
Interstitial disease – drug allergy, infection, tumour growth

Question 9

Acute Tubular necrosis

Answer 9

Caused by ischaemia
After surgery
Sepsis
Obstetric complications
Severe trauma including burns
Nephrotoxins (radiocontrast media, antibiotics)
Hypotension assoc. with hypovolaemia
Ischaemia generates free radicals that cause cell swelling, injury and necrosis
Reversible – depends on recovery of injured cells, removal of necrotic cells and intratubular casts, regeneration of tubular cells

Question 10

Manifestations of ATN

Answer 10

Initiation Phase
Hours or days
Onset of causative event to tubular injury
Maintenance phase
Oliguric or non-oliguric Phase
Transition to oliguric – Decrease in GFR, retention of metabolic wastes (creatinine, urea and sulfate).
Urine output at lowest
Fluid retention – oedema, water intoxication and pulmonary congestion or oedema
Recovery phase
Repair of renal tissue takes place
Gradual increase in urine output, creatinine levels Fall

Question 11

Postrenal acute kidney injury

Answer 11

Caused by urinary tract obstruction that places pressure on the kidney
Gradual decrease in GFR

Question 12

Oliguria in AKI

Answer 12

Tubular obstruction theory
Necrosis of the tubules leads to sloughing cells and ischaemic oedema that obstructs the tubules. Backpressure leads to a reduction In GFR
Back-leak theory
GFR constant, tubular reabsorption of filtrate accelerated through alteration in permeability
Alterations to renal blood flow
Arteriolar vasoconstriction caused by release of angiotensin II, or blood moving from the cortex to the medulla. Autoregulation of blood flow impaired  decreased GFR.

Question 13

kidney injury management principles

Answer 13

Correct fluid and electrolyte imbalances
Treat infections
Maintain nutrition
Monitor impact on medication regime
May require renal replacement therapy (haemodialysis)

Question 14

what are the islets of langerhan

Answer 14

small clusters of endocrine tissue

Account for 2% of weight of pancreas

Question 15

endocrine functions

Answer 15

Produce hormones secreted into bloodstream

Involved in nutrient balance (blood glucose levels) and gastrointestinal functions

Question 16

what are the cells of the pancreas and what do they produce

Answer 16

Insulin produced by beta cells
Glucagon produced by alpha cells
Somatostatin by delta cells

Question 17

Gluconeogenesis ?

Answer 17

– the formation of glucose, especially by the liver from carbohydrate sources such as amino acids and the glycerol portion of fats

Question 18

Glycogenolysis ?

Answer 18

– breakdown of stored glucose to increase the blood glucose levels

Question 19

Glucagon ?

Answer 19

– hormone produced by the alpha cells, stimulating the breakdown of glycogen in the liver, the formation of carbohydrates in the liver and the breakdown of lipids in both the liver and adipose tissue

Question 20

main categorises for diabetes

Answer 20

Three main categories

Type 1 Diabetes Mellitus
Characterised by an absolute insulin deficiency

Type 2 Diabetes Mellitus
Insulin resistance with an accompanying deficiency in insulin production

Gestational Diabetes

Question 21

describe type 1 diabetes

Answer 21

Autoimmune Destruction of the Beta (β) cells in the Islets of Langerhans

Severe or absolute lack of insulin caused by the loss of β cells

Slowly progressive autoimmune T-cell mediated disease that destroys the β cells

Concurrent abnormal production by alpha (α) cells with an increase production of glucagon.

Hyperglycaemia and ketonaemia can result from insulin deficiency however the excess of glucagon facilitates the other metabolic alterations seen in diabetes.

Question 22

type 1 diabetes clinical maifestations

Answer 22

Classical Presentation
Polyphagia (increased hunger)
Polydipsia (increased thirst)
Polyuria (increased urine production)
Weight Loss
Ketoacidosis
Sweet Smelling Breath

Question 23

type 1 diabetes assessment and management

Answer 23

Urinalysis
Presence of classic signs and symptoms
Management Aim
Avoid swings in insulin and glucose levels
Mimic body’s natural patterns
Monitoring Blood Glucose Levels
Long Term – Glycolated haemoglobin A1c 
The future
Islet cell transplantation

Question 24

describe type 2 diabetes mellitus

Answer 24

Currently around 1.7 millions Australians have diabetes (of which 85% have Type 2 diabetes)

280 Australian develop diabetes every day (1 every 5 minutes)

Total annual cost in Australia is approx. $14.6 billion

Fastest growing chronic disease in Australia

Question 25

describe type 2 diabetes

Answer 25

Fasting hyperglycaemia occurs despite insulin being available Cellular Insulin resistance No ketoacidosis Gradual increase in hyperglycaemia Metabolic Abnormalities Insulin resistance Increased glucose production by the liver Impaired secretion of insulin by β cells

Question 26

type 2 diabetes risk factors

Answer 26

History of diabetes in parents or siblings Obesity Physical inactivity Race/ethnicity

Question 27

type 2 diabetes clinical manifestations

Answer 27

``` Slow onset Hyperglycaemia – polyuria and polydipsia Blurred vision Fatigue Paresthesia Skin infections ```

Question 28

type 2 diabetes management

Answer 28

Changes in diet and exercise Hypoglycaemic medication possibly in combination with insulin

Question 29

describe gestational diabetes

Answer 29

Occurs during pregnancy and resolves once the infant and the placenta have been delivered Glucose intolerance appears during pregnancy -New routine screening and screening of high risk women Family history of diabetes Some ethnic groups have a higher risk Advanced maternal age History of large babies Prior history of gestational diabetes or polycystic ovary syndrome Overweight prior to pregnancy (BMI >35) Women on corticosteroids or antipsychotics

Question 30

complications of diabetes

Answer 30

``` Alterations in Blood Glucose Alterations in cardiovascular system Neuropathies Increased susceptibility to infection Peridontal disease ```

Question 31

describe diabetes ketoacidosis

Answer 31

Four metabolic problems: - Hyperosmolality from hyperglycaemia and dehydration - Metabolic acidosis from an accumulation of ketoacids - Extracellular volume depletion from osmotic diuresis - Electrolyte imbalances (potassium and sodium) from osmotic diuresis Increased risk during physical or emotional stress – surgery, illness, infection, trauma, omitted insulin Occurs in Type 1 Diabetes

Question 32

Diabetic Ketoacidosis – Manifestations and Treatment

Answer 32

``` Manifestations – flushed skin, increased thirst, fruity breath, decreased BP, increased HR, Kussmauls Respirations, confusion, Nausea, vomiting, abdominal pain, fatigue, weight loss, blurred vision Treatment Immediate medical intervention Primary Survey – Prioritise ABC IV hydration Regular Insulin Potassium Replacement Continuous cardiac monitoring ```

Question 33

Describe the hyperosmolar hyperglycaemic state

Answer 33

Plasma Osmolality >340 mmol/kg Elevated Blood Glucose levels >33.3mmol/L Altered Levels of consciousness Precipitating Factors – infection, therapeutic agents or procedures, acute or chronic illness. Hyperglycaemia  increased urine output  plasma volume decreases and glomerular filtration rate decreases  glucose is retained and water lost  increase in glucose and sodium lead to increased serum osmolality  severe dehydration  intracellular water reduced in all tissue including brain

Question 34

Describe the hyperosmolar hyperglycaemic state manifestation and Treatment

Answer 34

``` Manifestations - Flushed skin, increased thirst, decreased BP, increased HR, lethargic, nausea and vomiting, abdominal pain, fatigue, weight loss, malaise, extreme thirst, seizures Treatment Similar to DKA Primary Survey – ABCDE Intravenous fluid Potassium replacement Insulin administration ```

Question 35

Hypoglycaemia - Manifestations

Answer 35

Autonomic nervous system- hunger, shakiness, nausea, irritability, anxiety, rapid pulse impaired cerebral function- strange or unusaual feeling, slurred speech, headache, blurred vision, decreasing levels of conciousness, difficulty thinking, inability to concentrate

Question 36

Hypoglycaemia - Treatment

Answer 36

-Mild 15 g rapid acting or simple sugar (fruit juice, lollies, honey) Followed by a meal with complex carbohydrates Review diabetes management plan if occurring frequently -Severe Blood glucose <3mmol/L Conscious and alert – 10-15g of oral carbohydrate Altered consciousness – parenteral glucose or glucagon

Question 37

host?

Answer 37

Host – any organism capable of supporting the nutritional and physical growth requirements of another organism

Question 38

Infection?

Answer 38

Infection – presence and multiplication of an organism within another living organism leading to injury to the host

Question 39

Colonisation ?

Answer 39

Colonisation – act of an organism establishing a presence in another organism

Question 40

Microflora?

Answer 40

Microflora – the harmless and normal bacteria that inhabits either internal or external surfaces of the human body

Question 41

Mutualism?

Answer 41

Mutualism – an interaction where both the microorganism and the host benefit from the interaction

Question 42

Parasitic Relationship?

Answer 42

Parasitic Relationship – infecting organism benefits from the relationship but the host either gains nothing or is harmed from the interaction

Question 43

Infectious Disease?

Answer 43

Infectious Disease – is when the host sustains an injury from a parasitic relationship

Question 44

Virulence?

Answer 44

Virulence – the disease producing potential of the microorganism

Question 45

Pathogens?

Answer 45

Pathogens – virulent microorganisms that are rarely found in the absence of disease

Question 46

Saprophytes?

Answer 46

Saprophytes – organisms that obtain their growth from dead or decaying material in the environment

Question 47

Opportunistic pathogens?

Answer 47

Opportunistic pathogens – produce infectious disease when the health and immunity of the host is weakened.

Question 48

Agents of Infections Disease

Answer 48

Prions Creutzfeldt Jakob disease Viruses Bacteria Fungi - Yeasts – candida albicans - Moulds Parasites - Protozoa - Helminths – include nematodes (roundworms), cestodes (tapeworms) trematodes (flukes) - Anthropods –vectors of disease (ticks, mosquitos, biting flies) ectoparasites (mites-scabies, chiggers, lice-head, body or pubic and fleas)

Question 49

Describe viruses

Answer 49

Classification Type of viral genome – either single or double stranded DNA or RNA Physical characteristics – size, presence or absence of a membrane envelope Mode of transmission – anthropod-borne viruses, enteroviruses Target tissue Type of disease produced Structure Enveloped viruses – enclosed within a lipoprotein envelope derived from the cell membrane of the parasitised host cell such as herpesvirus group, influenza and poxviruses

Question 50

describe virus replication

Answer 50

Latent viruses – enter the host cell and insert their genome into the host cell chromosome where it remains in a latent state without causing disease Herpesvirus group – chicken pox, zoster, cold sores, genital herpes, infectious mononucleosis Retroviruses – after entry into the host cell, a viral enzyme translates the viral RNA into DNA. Viral DNA is integrated into the host chromosome where it exists in a latent state HIV – human immunodeficiency virus Oncogenic Viruses – transform host cells into malignant cells during replication Human papillomavirus

Question 51

describe bactreria classification

Answer 51

Atmospheric conditions - Aerobes – require oxygen for growth and development - Anaerobes – cannot survive in an oxygen containing environment - Facultatively anaerobic – can adapt metabolism to either Staining - Gram-positive (stained purple by a primary basic dye)Streptococcus pyogenes - Gram-negative (not stained purple but counterstained red by a second dye) Legionella pneumophila - Acid-fast stain (resistant to the decolourisation of a primary stain when treated with a solution of acid alcohol) Mycobacterium tuberculosis Taxonomy -Classified into a small group of genetically related organisms (genus) and then further subdivided into individual species Staphylococcus (genus) aureus (species)

Question 52

Portals of entry?

Answer 52

``` Penetration Direct Contact Vertical transmission Ingestion Inhalation ```

Question 53

sources of infection?

Answer 53

-Endogenous vs exogenous Endogenous – acquired from hosts own microbial flora such as opportunistic infection) Exogenous – acquired from external environment such as water, food, soil etc - Carrier Human – mother to child transmission Inanimate object or fomite such as toys or tissues Zoonosis – animal to human transmission such as rabies from a bite or scratch - Place Hospital acquired (nosocomial) Community acquired - Body substance Blood, faeces, body fluids, respiratory secretions and urine

Question 54

describe hospital inquired infection?

Answer 54

Acquired by individuals either during or immediately after a stay in a healthcare setting Either endogenous or exogenous Four Priority HAI (based on seriousness and associated costs - Surgical site infection - Staphylococcus aureus blood stream infection - Clostridium difficile infection - Central Line acquired blood stream infection MRSA – Methicillin-resistant Staphylococcus aureus

Question 55

describe clinical presentation of infection

Answer 55

Localised Specific and reflect site of infection Diarrhoea, rash, convulsions, haemorrhage and pneumonia Systemic Nonspecific and shared Fever, myalgia, headache and lethargy Overt or covert

Question 56

Describe different disease courses of infection

Answer 56

``` Incubation Period Prodromal stage Acute stage Convalescent stage Resolution stage ```

Question 57

describe infection diagnosis

Answer 57

Culture – propagation of a microorganism outside of the body on artificial growth media - Identification based on microscopic appearance - Gram stain reaction - morphology Serology - Measuring serum antibodies in the diseased hosts

Question 58

Treatment of Infectious Disease

Answer 58

``` Antibacterial Agents Antiviral Agents Antifungal agents Surgical Interventions -Drainage -Debridement -Removal ```

Question 59

iv fluid administration steps

Answer 59

- 5 moments - 6 rights - follow chart and administration standard - open infusion set on tray - open tubing- make sure the roller is down prior to piercing the bag - pierce bag on clean flat surface - hang it up - squeeze the chamber gently 2-3 times, until it is about half way full - close the roller shut once the fluid has reached the end of the line. your line is now primed - in order to increase the drip rate, push the roller up. to decrease push roller down - follow drip rate calculation methods

Question 60

how to prime an iv line manually, gravity

Answer 60

- look at med order and patient - look at bag for details, contamination, sedimentation or compromise - roller down, cap off and pierce bag - hang up on iv stand, prime by getting fluid into chamber - primed because there is fluid coming out -

Question 61

why do we prime iv line

Answer 61

- to ensure no air can enter the venous circulation when line is attached to the patient at cannula

Question 62

how to calculate iv dose

Answer 62

- giving sets are most commonly 20 drops/ ml (adults) and 60 drops/ ml (paediatrics) - to calculate drip rate in drops/ min (volume in hours) x (drop factor/ 60). refer to medsafe for practice - need to count that we are getting the correct amount to drops per min - connect bag to patient prior to counting drip rate. positioning cannula vein diameter. size of cannula may all effect drip rate.

Question 63

how to do IDC male

Answer 63

-clean trolley -collect your equipment and start by opening the catheter pack onto the trolley surface - avoid contamination opening by using the corners of the pack - using whitre drape reposition the trays . allow space in the middle for other equipment - as drape is now contaminated it can be set aside and used during the procedure - pour chlorehexide or similar cleaning solution into one side of the tray with gauze - open lignocaine and place onto sterile field - place catheter onto sterile filed - remove gauze swabs from the opposite end of the tray, being careful to only make contact with the handle of the forceps -add 10 ml of water for injection (for inflating the balloon of the catheter) -open 10ml syringe onto sterile field for drawing up the water for injection repeat hand hygiene then don sterile gloves - draw 10ml of water for injection - carefully open drape then place over patient - bring over the tray containing chrhex soaked gauze swabs and lignocaine gel -using sterile drape from the pack carefully place around the penis ensuring your dominant hand stays uncontaminated - clean meatus using forceps, one swab at a time with a single downwards motion from anterior to posterior - use your towel to gently retract the foreskin to visualise meatus if necessary - lubricate external surface of the meatus using the lignocaine gel, then gently insert the nozzle into urethral meatus and slowly inject whole amount - hold the meatus closed keeping shaft vertical for 1-2 minutes to prevent gel from seeping out - place the tray holding the catheter and syringe containing WFI inbetween the patients legs on the sterile field - pick the catheter up approx 5-6 cm from the tip and introduce it into the meatus - gently advance catheter until urine is flowing. if you meet resistance do not force the catheter - you would usually advance the catheter all the way to the bifurcation and only inflate the balloon once urine is flowing - Reassure pt that almost done, observe signs of pain as balloon is inflating- if notice discomfort or pt says they feel pain DO NOT continue to inflate balloon, instead reposition catheter, ensure urine is flowing and try again -if foreskin was pulled back for insertion, ensure this is returned to normal position- if patient is able you can ask them to do this - dispose equipment, makr pt comfortable, document in pt notes- date time complications pain/ discomfort size and type of catheter used amount of water used to inflate balloon fluid balance chart add and stickers required by facility

Question 64

what may cause resistance during male cathertisation

Answer 64

sometimes there may be slight resistance while catheter is moving past the prostate . cyou can ask patient to cough and take some deep breaths while you advance past it . it is important that your patient is as relaxed as possible during the procedure, so reassurance and distraction may be required

Question 65

male catheter removal

Answer 65

non sterile gloves and 10 ml syringe to remove water inflating the balloon. attach the syringe to the port and allow the balloon to passively deflate then gently aspirate the syringe to ensure that the balloon deflation is complete ask your patient to take slow deep breasths and as the patient exhales gently remove the catheter. dispose according to facility policy

Question 66

how to do female cathertisation

Answer 66

- hand hygiene - open cath pack on tray on tray - avoid contamination opening by using the corners of the pack - using whitre drape reposition the trays . allow space in the middle for other equipment - as drape is now contaminated it can be set aside and used during the procedure - pour chlorehexide or similar cleaning solution into one side of the tray with gauze - open lignocaine and place onto sterile field - explain procedure, gain consent, be aware of patients cultural needs and offer chaperone - check for latex allergy, position pt supine with knees bent, hips flexed and supported as necessary, feet apart or heels together ( if this is uncomfortable - left lateral side with right knee bent up - don sterile gloves and open sterile drape to place under patient between legs - be careful not to contaminate your sterile gloves when positioning the drape - draw up water for injection into 10ml syringe for inflating the balloon - squeeze lignocaine gel onto proximal 6cm of the catheter without nozzle touching the catheter, reserve half of the gel for inserting into urethra - bring tray with cleansing solution, gauze and lignocaine over to patient - using gauze to seperate the labia at the vulva with non dominant hand to expose the urethra - using forceps in dominant hand, clean meatus using one swab at a time, in a single downward motion from above the meatus down towards the anus - start at the outside working inwards, repeat until all 5 swabs are used and region is visibly clean - lubricate the external meatus using the gel syringe, then gently nozzle into the urethral meatus and inject gel and wait 3-5 minutes - bring tray with catheter over and place between patients legs - using dominant hand, pick up the catheter approx. 5-6cm from the tip and introduce it into the meatus in an upward and backward direction. gently advance till urine flow - ensure tray is close to patientso urine doesn't flow into bed - once urine is flowing , advance catheter further 6-7 cm and inflate the the balloon with water for injection - have drainage bag ready, and connect carefully without contaminating the open lumen. this is also a good time to collect a urine sample if required - withdraw catheter gently until resistance is felt - ensure pt is comfortable, cath is secure and clear equipment, discarding waste accordingly - document in pt notes- date time complications pain/ discomfort size and type of catheter/size, used amount of water used to inflate balloon, fluid balance chart add and stickers required by facility, urine characteristics determine plan of care for requency of urinanry measures and frequency of IDC changes