METABOLIC RESPONSES TO STRESS, ACUTE HEMATOLOGIC DYSFUNCTION, ALTERED IMMUNE FUNCTION
Objectives: Upon completion of this class, the student will be able to:
1. Recognize the typical metabolic alterations in the high acuity patient;
2. Describe major nutritional changes with specific disease states;
3. Discuss nursing responsibilities with parenteral and enteral nutrition;
4. Discuss the assessment and management of specific hematologic disorders;
5. Discuss the function of cellular components of the immune system;
6. Describe the effects of aging, malnutrition, truma, and stress on the immune system functions;
7. Discuss nursing considerations in assessment and care of the immunocompromised patient.
Case Scenarios
1. Your 84 yo female patient, admitted with acute GI bleeding, has been NPO for three days. What nutritional needs does she have and how can they be met?
2. Your patient is now receiving TPN at 100 ml/hr. What are priority nursing assessment and interventions regarding this nutrition?
3. You are caring for a patient on a ventilator with COPD with pneumonia. When can he receive tube feedings? How much? What nursing assessment is indicated? What nursing action is indicated every 4 hours and prn?
4. Your patient is a 64 yo male admitted with acute left flank pain. CT reveals a renal mass and hematoma in that area. He is HIV positive. What is indicated regarding his immunocompromised state?
I. NUTRITION
what happens w/ malnut? Less energy, prolonged wound healing. People w/ burns, shock, infex, are hypermetabolic and need to be fed.
A. Components
B. Metabolism
C. Anabolism, catabolism
D. Aerobic, Anerobic
E. Energy production
F. Assessment
1. history: what is pertinent?
Cultural stuff, ht weight, your diet, dysphagia, IBS, dentures, GI hx, income, access to the store. Pt appearance, pt dehydration. Wt loss or gain. HF.
2. labs: which ones?
Prealbumin and albumin.
3. physiologic data: what increases energy expenditure?
II. METABOLIC ALTERATIONS: describe assessment and management of each of the following:
any trouble in the body requires more food!
A. GI tract
B. Nutrition/malnutrition
C. Stress Response
D. Refeeding Syndrome
E. Hepatic failure
F. Pulmonary Failure
G. Renal Failure
H. Cardiac Failure
I. Gut Failure
J. Burns
K. Traumatic Brain Injury
II. ENTERAL NUTRITION
Tube feed vs TPN. We prefer tube feeding so long as pt is able to digest and BM and all. MD's and RN's are hesitant to feed pt if no BS, however this is hogwash. You need the food to stimulate [at a very low rate] the gut to move, so don't hold TF unless residuals >100. Beware SBO, paralytic ileus post op. Use the gut if you can. From admit, think about their nutritional needs.
If you start pt on TF, start low and slow incr as tol. Resid Q4. Bolus vs continuous: continuous is better absorbed, but w/ normal GI function in rehab setting bolus is ok. J tubes better than G tube. How do you know if J TF is too much? no residuals but look for distention or BS or BM.
A. Criteria for selection: use the gut if GI tract is functioning
B. Benefits:
C. Contraindications:
D. Complications:
Aspiration
E. Nursing Considerations:
III. TPN
A. Indications:
B. Complications:
Infection, can't give TPN peripherally unless something. FSBS frequently, may need to add insulin to the bag.
C. Nursing Considerations:
EXAM 3:
IV. ACUTE HEMATOLOGIC DYSFUNCTION
A. Blood components: know!
B. Anemia: impaired oxygen transport
1. assessment: tissue hypoxia, cause
2. types: decreased RBC production (iron def, cancer, chemo), increased RBC destruction (SSA, hemolytic anemia)
3. increased blood loss: why? this is the usual one, esp w/ trauma pts
Low H&H means low O2 to the body.
Case: trauma w/ blood loss
We do: T&C [type and cross], PRBC's.
Other cause of blood loss w/o trauma: DIC, surg, GI bleed, miscarraige, heavy menses.
When we look at H&H: check the morning and the 'trending'
RN does: check labs, trends, transfuse if needed.
C. White Cell Disorders
1. neutropenia: abnormally low level of neutrophils
WBC's, chemo and marrow suppressants.
2. causes:
3. clinical manifestations:
4. management
High WBCS: infection.
D. Leukemia
too many ______in the blood
1. causes:
cancer
2. acute vs chronic
3. clinical manifestations
4. management
E. Hemostasis Disorders
1. thrombocytopenia:
Idiopathic thrombocytopenia, chemo,
2. DIC
pregnancy, sepsis, trauma.
a. Cascade: platelet activation, clot formation, fibirnolysis
b. clinical findings
d-dimer, fibrinogen, bleeding from small injuries, bruising rapidly,
c. risk factors: sepsis, trauma, shock, abrupio placenta, liver disease, ABO incompatibility, cancer
d. management:
Heparin, b/c you need to stop the clotting from happening more.
V. ALTERED IMMUNE FUNCTION
A. Normal immune function:
1. purpose:
2. components:
3. types: natural, acquired
4. antigen-antibody response
5. cells: T, B, monocyte-macrophage system, mediators
6. mechanisms: specific, nonspecific,
B. Hypersensitivity & Autoimmunity
1. immunoglobulin hypersensitivity: type I & II response
2. autoimmune disorders: know 10
C. Aging, malnutrition, stress, trauma effects on the Immune System
1. aging: how?
less immune
2. malnutrition: how?
less immune b/c not enough proteins for making antibodies and cells
3. stress: how?
less b/c cortisol, decr B&T cell function
long term illness can also lower B&T function
4. trauma: how?
Margi likes IGA b/c it works at point of entry. IGG is the one we have in highest quantity.
D. HIV Disease
1. primary and secondary immunodeficiencies
2. AIDS
HIV with illnesses and <200 T cell count (CD4).
3. clinical manifestations
VI. IMMUNOCOMPETENCE IN THE HIGH-ACUITY PATIENT
A. Assessment:
1. fever
Who doesn't have a fever despite infex? Old people
cold shock: less common but elderly can go hyperthermic w/ infex
2. poor wound healing
Figure out why not.
3. point pain
what?
4. white oral patches
Thrush 2ndary to ABX, also vag candida
5. LOC changes
6. abnormal CBC with differential
7. abnormal coagulation studies
8. secondary infections
9. immunosuppressive drugs
10. other risk factors: DM, ETOH, malnutrition, renal failure, splenectomy
B. Goals: reestablish immunocompetence and prevent complications
C. Nursing Diagnoses: list 3
risk 4 infex
inpaired skin