A simple description of a less understood topic in Intensive Care Medicine. Aim to make understanding and management easy for the residents and prevention steps for all ICU workers.
Sickle cell nephropathy (SCN) is presence of sickled erythrocytes in the renal medulla that result in decreased medullary blood flow, ischemia, microinfarcts and papillary necrosis in the kidneys
A simple description of a less understood topic in Intensive Care Medicine. Aim to make understanding and management easy for the residents and prevention steps for all ICU workers.
Sickle cell nephropathy (SCN) is presence of sickled erythrocytes in the renal medulla that result in decreased medullary blood flow, ischemia, microinfarcts and papillary necrosis in the kidneys
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
3. PHYSIOLOGY
Potassium is a major intracellular cation
Total body K+ content in a normal adult -3000-
4000mEq
98% Intracellular , 2% in ECF
Normal homeostatic mechanisms maintain the
serum K level within a narrow range (3.5-5.0
mEq/L).
4. The primary mechanisms maintaining this balance
are the buffering of ECF potassium against a large
ICF potassium pool (via the Na-K pump)
Na-K ATPase pump actively transports Na+ out of
the cell and K+ into the cell in a 3:2 ratio
Renal excretion – Major route of excess K+
elimination
Approx 90% of K+ excretion occurs in the urine,
less than 10% excreted through sweat or stool.
5. Within the kidneys, K+ excretion occurs mostly in
the principal cells of the cortical collecting duct
(CCD).
Urinary K+ excretion depends on :
1. luminal Na+ delivery to the DCT and the CCD,
2.effect of Aldosterone and other adrenal
corticosteroids with mineralocorticoid activity.
6.
7.
8. HYPERKALEMIA
Defined as a plasma potassium level of >5.5
mEq/L
Causes of Hyperkalemia
I. Pseudohyperkalemia
Artifactual increase in K+- Venepuncture, clenching
Cellular efflux; thrombocytosis, erythrocytosis,
leukocytosis,
in vitro hemolysis
Hereditary defects in red cell membrane
9. II. Intra- to extracellular shift
Acidosis – Uptake of H+, efflux of K+
NAGMA
Hyperosmolality; hypertonic dextrose, mannitol,
- Solvent Drag effect
β2-Adrenergic antagonists (noncardioselective
agents)
Suppresses catecholamine stimulated renin release- in turn
aldosterone synthesis
Digoxin and related glycosides (yellow oleander,
10. Hyperkalemic periodic paralysis- Episodic attack of
muscle weakness asso with Hyper k+. Na Muscle
channelopathy
Lysine, arginine, and ε-aminocaproic acid
(structurally similar, positively charged)
Succinylcholine; depolarises Muscle cells, Efflux
of K+ through AChRs . Contraindicated in thermal
trauma, neuromuscular injury, disuse atrophy, mucositis, or
prolonged immobilization- upregulated AChRs
Rapid tumor lysis / Rhabdomyolysis
11. III. Inadequate excretion
A. Inhibition of the renin-angiotensin-
aldosterone axis;
(↑ risk of hyperkalemia when these drugs are
used in combination)
Angiotensin-converting enzyme (ACE) inhibitors
Renin inhibitors; aliskiren
(in combination with ACE inhibitors or angiotensin
receptor blockers [ARBs])
12. Angiotensin receptor blockers (ARBs)
Blockade of the mineralocorticoid receptor:
- spironolactone, eplerenone,
Blockade of the epithelial sodium channel
(ENaC): amiloride, triamterene, trimethoprim,
pentamidine, nafamostat
B. Decreased distal delivery
Congestive heart failure
Volume depletion
14. Chronic kidney disease, advanced age
Pseudohypoaldosteronism type II: defects in
WNK1 or WNK4 kinases, Kelch-like 3 (KLHL3), or
Cullin 3 (CUL3)
In The above said conditions –most Pt will be
volume expanded- secondary increse in circulating
ANP that inhibit both Renal renin release and
adrenal aldosterone release
15. D. Renal resistance to mineralocorticoid
Tubulointerstitial diseases:
SLE, amyloidosis, sickle cell anemia, obstructive
uropathy, post–acute tubular necrosis
Hereditary:
pseudohypoaldosteronism type I; defects in the
mineralocorticoid receptor or the epithelial sodium
channel (ENaC)
E. Advanced renal insufficiency
Chronic kidney disease
End-stage renal disease
Acute oliguric kidney injury
18. Clinical Features
Most of Hyperkalemic individuals are asymptomatic.
If present - symptoms are nonspecific and
predominantly related to muscular or cardiac functions.
The most common - weakness and fatigue.
Occasionally, frank muscle paralysis or shortness of
breath.
Patients also may complain of palpitations or chest pain.
Arrythmias occur- Sinus Brady, Sinus arrest, VT, VF, Asystole
Patients may report nausea, vomiting, and paresthesias
19.
20.
21. ECG Changes
ECG findings generally correlate with the
potassium level,
Potentially life-threatening arrhythmias - occur
without warning at almost any level of
hyperkalemia.
In patients with organic heart disease and an
abnormal baseline ECG, bradycardia may be the
only new ECG abnormality.
22. K+ 5.5-6.5 mEq/L - Early changes include tall,
peaked T waves with a narrow base, best seen in
precordial leads;
shortened QT interval; and
ST-segment depression.
K+ level of 6.5-8.0 mEq/L,
in addition to peaked T waves,
Widening of the QRS
Prolonged PR interval
Decreased or disappearing P wave
Amplified R wave
24. K+ level higher than 8.0 mEq/L,
The ECG shows absence of P wave,
progressive QRS widening, and
intraventricular/fascicular/bundle-branch blocks.
The progressively widened QRS eventually merges
with the T wave, forming a sine wave pattern.
Ventricular fibrillation or asystole follows.
29. Tests In Evaluation of Hyperkalemia
RFT
Serum Electrolytes- including Mg, Ca
Urine potassium, sodium, and osmolality
Complete blood count (CBC)
Metabolic profile
ECG
30. Trans-tubular potassium gradient (TTKG)
TTKG is an index reflecting the conservation of
potassium in the cortical collecting ducts (CCD) of
the kidneys.
It is useful in diagnosing the causes of
hyperkalemia or hypokalemia.
TTKG estimates the ratio of potassium in the lumen
of the CCD to that in the peritubular capillaries.
TTKG= Urine K/ Serum K x serum Osm/Urine
osm
31.
32. TREATMENT
3 main approaches to the treatment of
hyperkalemia :
●Antagonizing the membrane effects of potassium
with calcium
●Driving extracellular potassium into the cells
●Removing excess potassium from the body
33. ECG manifestations of hyperkalemia- a medical
emergency and treated urgently.
Patients with significant hyperkalemia (K+≥6.5 mM) in
the absence of ECG changes should also be
aggressively managed
Immediate antagonism of the cardiac
effects of hyperkalemia
IV calcium serves to protect the heart,
recommended dose is 10 mL of 10% calcium
gluconate, infused intravenously over 2–3 min with
cardiac monitoring.
34. Rapid reduction in plasma K+
concentration by redistribution into cells.
Insulin lowers plasma K+ concentration by shifting
K+ into cells - GI Bolus
β2-agonists, most commonly albuterol, are
effective but underused agents for the acute
management of hyperkalemia.
– Salbutamol Nebulisations
35. Removal of potassium.
use of cation exchange resins, Diuretics, and/or
Hemodialysis.
Cation Exchange Resins
sodium polystyrene sulfonate (SPS) exchanges Na+ for
K+in the gastrointestinal tract and increases the fecal
excretion of K+
Dose of SPS is 15–30 g of powder, almost always
given in a premade suspension with 33% sorbitol.
The effect of SPS on plasma K+ concentration is slow;
the full effect may take up to 24 h and usually requires
repeated doses every 4–6 h.
36. Therapy with intravenous saline may be beneficial
in hypovolemic patients with oliguria and decreased
distal delivery of Na+, with the associated
reductions in renal K+ excretion.
Loop and Thiazide diuretics can be used to
reduce plasma K+ concentration in volume-replete
or hypervolemic patients with sufficient renal
function
usually combined with iv saline or isotonic
bicarbonate to achieve or maintain euvolemia
37. Sodium Bicarbonate may be given for the
treatment of significant metabolic acidosis .
Reversible causes of impaired renal function asso
with hyperkalemia.
Includes hypovolemia, NSAIDs, urinary tract
obstruction, and inhibitors of the renin-angiotensin-
aldosterone system (RAAS), which can also directly
cause hyperkalemia
RX- Removal of offending agent & Hydration
38. Hemodialysis is the most effective and reliable
method to reduce plasma K+ .
The amount of K+ removed during hemodialysis
depends on
The relative distribution of K+ between ICF and
ECF
The type and surface area of the dialyzer used,
dialysate and blood flow rates,
dialysate flow rate, dialysis duration, and the
plasma-to- dialysate K+ gradient.