Hyperkalemia

Clinical Picture
The patient may have:
-Muscular weakness
-Cardiac dysrhythmias
-ECG abnormalities
-Nausea

Immediate Intervention
-Assess VS; note cardiac rate & rhythm
-Administer oxygen
-Assess for patient IV access
-Assess recent laboratory results (BUN, creatinine,electrolytes)
-Notify physicianor NP
-Document patient's status,phone call to physician or NP & physician or NP response

Focused Assessment
-Monitor VS, & assess cardiac rhythm if available
-Assess LOC & orientation
-Assess musculoskeletal function
-Assess previous 2 days I&O

Stabilizing & Monitoring
-Obtain IV access
-Administer potassium-binding resins (Kayexalate) orally or rectally
-Monitor cardiac rhythm, I&O,serial potassium levels & other laboratory test
-Chart patient status & convey to physician

Be Prepared To
-Set up cardiac monitoring
-Administer IV calcium,sodium bicarbonate,insulin & glucose or furosemide per order
-Order or obtain laboratory test
-Order a 12-lead ECG
-Transfer to telemetry unit

Possible Etiologies
-Medication
-Chemotherapy
-Acute or chronic renal failure
-Hypoaldosteronism trauma
-Hemolysis
-Digitalis poisoning
-Acidosis
-Burns
-Insulin deficiency
-Uncontrolled hyperglycemia
-Excessive use of salt substitutes
-Metabolic acidosis

Bradycardia

Clinical Picture

-HR <60 bpm
-Nausea & vomitting, dizziness or lighteadedness.
-Sign- Altered LOC, Chest pain, Short of breath(SOB), Hypotension, pulmonary congestion, &/@ cyanosis

Immediate Interventions

-Have a patient sit or lie down in bed
-Administer supplemental oxygen
-Assess BP
-Notify physician or NP
-Obtain a 12-lead ECG
-Check for patient IV access
-Document patient's status,phone call to physician or NP, & physician @ NP response.

Focused Assessment

-Assess level of consciousness & orientation
-Assess BP & HR
-Assess respirations rate & effort; assess SaO2 if readily available
-Assess skin for colour, moistness, & temprature. Assess for associated symptoms (chest pain, SOB, hypotension)
-If patient on telemetry or cardiac monitor, assess ECG

Stabilizing & Monitoring

-Monitor VS
-Set up cardiac monitoring & monitor rate & rhythm
-Assess recent laboratory results
-Chart patient status & convey status to physician or NP

Be Prepared To

-Administer oral or IV medications as ordered
-Obtain or order laboratory tests
-Titrate oxygen to SaO2 >90%
-Obtain IV access if none available
-Assist with external pacing
-Transfer to ICU or telemetry unit

Possible Etiologies

-Medication toxicity
-Vasovagal response
-Hyperkalemia
-Hypothermia
-Hyperthyroidism
-Sepsis
-Severe infection
-Hypoglycemia
-Excellent physical condition (athletes)
-Myocardial infarction
-Shock

5 Important Steps

1. Assessement

-make an assessement before start the procedure.

2. Positioning

-look the possible position for the procedure.

3. Prepare equipment

-we have to prepare an enough equipments for the procedure. what instrument we will use.

4. Procedure

-do the procedure properly step by step

5. Record

-last but not least, record the procedure. when it done, what happen to the pt. or the location of the procedure,  or any important things to write in the record.

IMPORTANT!!
-if the procedure need to maintain an asepsis technic, so we MUST follow it.

(e.g : prepare an enough instruments)

Different Diagnosis : Chest Pain

(sumber dari google)

MI (Myocardial Infarction)

*Onset – Sudden, lasting longer than 30 min.

*Quality – Pressure, dull, achy, tightness

*Location/Radiation – Epigastric or substernal, usually left neck, jaw, arm or back

*Exacerbating Factor – Stress, excertion, or unprovoked

Angina

*Onset – Gradual or sudden, usually brief
*Quality – Pressure, tightness
*Location/Radiation – Chest, usually left neck, jaw and arm
*Exacerbating Factor – Exertion, stress, eating, cold temperature

Pleurisy

*Onset – Rapid
*Quality – Sharp, stabbing
*Location/Radiation – Points tenderness
*Exacerbating Factor- Inspiration

Musculoskeletal

*Onset – Variable
*Quality – Sharp, dull, aching
*Location/Radiation – Localized
*Exacerbating Factor – Movement, digital pressure, inspiration

Pericarditis

*Onset – Gradual

*Quality – Sharp, pleuritic

*Location/Radiation – Precardium

*Exacerbating Factor – Supine position

Aortic Dissection

*Onset – Sudden/Severe
*Quality – Tearing
*Location/Radiation – Chest, back
*Exacerbating Factor – Hypertension, smoking

Pulmonary Embolism

*Onset – Sudden
*Quality – Sharp-knife like, stabbing, pleuritic

*Location – Chest,back, over lungs area

*Exacerbating Factors – Dislodged thrombi, atrial fibrillation

Esophageal Ruptured

*Onset – Sudden/severe
*Quality – Sharp, burning
*Location/Radiation – Chest, throat, back
*Exacerbating Factors – Swallowing, vomitting

Burn

Burn is caused most commanly by fire (dry heat). It also can caused by friction, chemicals, electricity or radiation.

*friction - occurs when skin is scraped off by contact with a surface such as roads, carpets, or other hard

floor surfaces.

*Chemical – Most chemicals that cause burns are either strong acids or bases. Chemical burns can be

deceiving, however. Some agents can cause deep tissue damage not readily apparent when you first look at it.

*Electrical - often cause serious injury inside the body. Look for an entry and exit point as this is often a                     characteristic of this type of injury.

Inhalation burns – there may be burned lips, mouth, and throat.

Depth of burns :-

• Superficial (first degree) - The skin is red, hot and painful but without blisters. Damage is superficial and temporary.
• Partial-thickness (second degree) - The outer layer of skin is damaged. The skin has blisters besides being red, hot and painful.
• Full-thickness (third degree) - All layers of the skin are damaged. The skin may be pale and leathery, or charred. It is relatively painless on the point of the burn because the nerves are damaged. The pain experienced will more then likely result from the surrounding burns which are of lesser degree.

Rule of 9's & Parkland Formula

Rule of 9's

 Fluid Requirements = TBSA burned(%) x Wt (kg) x 4mL 

Give 1/2 of total requirements in 1st 8 hours, 

then give 2nd half over next 16 hours

*TBSA-total body surface area (percent of burned)

For example :

TBSA=40%

Wt.=60kg

Fluid requirement = TBSA burned (40%) x Wt. (60kg) x 4mL

Answer is 9.6 Liters for the first 24 hour.

Give half of the fluid requirement in the first 8 hours.

Then give the second half over next 16 hours.

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