UREMIC ENCEPHALOPATHY

Patient X Assessment

STEMI

GCS Score = 3

Jugular Vein Distention

Bilateral Crackles

Bipedal Edema

Bloody NGT Output

Hypotension - range (60/palp)

Coma

+ Arrest episode

Assessment

Diagnosis

History of Present Illness

ABGs

1 week PTA, patient had general body malaise accompanied by nonproductive coughing and easy fatiguability

1 day PTA, there was noted increase in sleeping time, and body weakness

Few hours PTA, there px experienced Difficulty of Breathing, Altered Sensorium and hence sought consult.

pH 6.908 Acidosis

pCO2 14.0 mmHg Alkalosis

HCO3 2.7 mmol/L Acidosis

Past Medical History

+ CKD Oct 2013 – no Hemodialysis

+ HTN

+CVD ICH

Partially Compensated Metabolic Acidosis

Changes in sensorium : loss of memory, impaired concentration, depression, delusions, lethargy, irritability, fatigue, insomnia, psychosis, stupor, catatonia, and coma.

Slurred speech, pruritus, muscle twitches, or restless legs.

• Anorexia
• Nausea
• Restlessness
• Drowsiness
• Diminished ability to concentrate
• Slowed cognitive functions
• More severe symptoms
• Vomiting
• Emotional volatility
• Decreased cognitive function
• Disorientation
• Confusion
• Bizarre behavior
• As uremic encephalopathy progresses, patients may develop seizures, stupor, and coma.

Serum K 6.9 High

Creatinine 2466.09 High

BUN 89.1 HIGH

Hemoglobin 33 g/L LOW

Hematocrit .10 L/L LOW

WBC 13.22 HIGH

Neutrophil .92 High

Lymphocytes .08 Low

PTT 54.3sec High

SGPT: 32 U/L HIGH

AlkalinePhosphatase 40 U/L LOW

Indirect Bilirubin 2.52 umoL/L LOW

Encephalophaties interfere with the function of the ascending reticular activating system and/or its projections to the cerebral cortex, leading to impairment of arousal and/or awareness .

Cerebral Dysfunctions*

Normal neuronal activity requires a balanced environment of electrolytes, water, amino acids, excitatory and inhibitory neurotransmitters, and metabolic substrates. In addition, normal blood flow, normal temperature, normal osmolality, and physiologic pH are required for optimal central nervous system function. Complex systems, including those mediating arousal and awareness and those involved in higher cognitive functions, are more likely to malfunction when the local milieu is deranged.

urea, guanidino compounds, uric acid, hippuric acid, various amino acids, polypeptides, polyamines, phenols and conjugates of phenol, phenolic and indolic acids, acetone, glucuronic acid, carnitine, myoinositol, sulphates, phosphates and middle molecules which should be excreted and regulated in the body remains in the blood stream

Sepsis*

Overview

Thank You Very Much!

Pathophysiology

Prevention

Decrease in GFR and the ability of the Kindeys to excrete waste products will lead to unregulated electrolytes and the accumulation of these called toxic materials inside the body

Do not skip or avoid scheduled dialysis. Take all medications as directed and have frequent assessments of mental status.

The presence of too much urea, a waste product produced by the breakdown of proteins, and other toxins that cause abnormality within the brain. Uremia occurs as a result of kidney failure.

Prognosis

Chronic Kidney Disease

The prognosis for a patient with encephalopathy depends on the initial causes and, in general, the length of time it takes to reverse, stop, or inhibit those causes. Consequently, the prognosis varies from patient to patient and ranges from complete recovery to a poor prognosis that often leads to permanent brain damage or death.

Decreased Cardiac Output

Hypotensive episodes

Capillary Refill > 2seconds

Pale nailbeds and conjuntivae

Spo2 = 92%

+ history of CVD ICH

+ CKD

+ Anemia

Laboratory results:

Low Hemoglobin and Hematocrit Levels

STEMI revealed in EKG

Goals and Objectives

Goal: to have adequate Cardiac Output

STO: Within the shift, the client will be able to have normal ranges of BP and CR and show no signs of adequate cardiac output and perfusion

LTO: After 3 days, the client will be able to have better hemoglobin and hematocrit levels

Nursing Care Plan

Fluid and Electrolyte Imbalance

Interventions

Monitor BP and CR

Observing for any signs of Cardiac distress

Regulating inotropes accordingly

Timely administration of cardiac drugs

Promoting rest and comfort

Decreasing stimuli

Positioning in Semi fowler's

Facilitation of proper use of BVM

Facilitation of adequate Co2 and O2 exchange

Goals and Objectives

Crackles on both lung fields

Bipedal Pitting Edema

Dry lips and pale nailbeds and conjunctivae

No Urine Output

(+) CKD V - No HD

Labs:

Elevated Potassium

Elevated Creatinine

Low Creatinine Clearance

Goal: To achieve normal fluid and electrolyte values

STO: Within the shift, the client will be able to; 1. show absence of congestion. 2. have adequate fluid intake

LTO: After 3 days, the client will be able to should decrease in edema and signs of fluid overload.

Plan

Intervention

Interventions

Monitoring of Input and Output

Observation for signs of congestion

Logrolling q 2h

Administration of medications as per order

Regulation of IV fluids

Limiting administration of free fluids

Referring latest laboratory results

Address the following factors when treating uremic encephalopathy, which are also included in the standard care of any patient with ESRD:

• Adequacy of dialysis
• Correction of anemia
• Regulation of calcium and phosphate metabolism

To avoid malnutrition in patients with ESRD, maintain adequate protein intake (>1 g/kg/d) and initiate dialysis (despite the presence of encephalopathy).

Nursing Diagnoses

Health Perception-Health Management Patterns

Risk for Infection

Risk for Falls

Ineffective Therapeutic regimen management

Nutritional-Metabolic Patterns

Imbalanced Nutrition Less than Body Requirements

Fluid and Electrolyte Imbalance

Excess fluid volume

Impaired Skin Integrity

Risk for imbalanced body temperature

Elimination Patterns

Bowel Incontinence

Impaired Urinary Elimination

Activity-Exercise Pattern

Activity Intolerance

Impaired Physical Mobility

Fatigue

Risk for Disuse Syndrome

Self-care deficit

Ineffective Airway clearance

Impaired Gas Exchange

Decreased Cardiac Output

Ineffective Tissue Perfusion

Medications

NaHCO3 - acidosis management

CaCo3 + Vit D - Calcium imbalance management

RI 10 u + D5050 - treatment of Hyperkalemia

Salbutamol- treatment of Hyperkalemia

Omeprazole - decreases gastric activity

Dobutamine - increases blood pressure

Levophed - increases blood pressure

UREMIC ENCEPHALOPATHY