Acute Biological Crisis

Acute Biologic Crisis

CRITICAL CARE NURSING

nurse licensed professional who provides care to meet the patient s individualized needs in response to potentially life-threatening conditions in an environment supportive of highly technological, collaborative and holistic care.

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The intensive care unit is not merely a room or series of room filled with patients attached to interventional technology; it is the home of an organization : the intensive care team.

THE INTENSIVE CARE TEAM Doctor  Nurses  Therapists  Nutritionists  Chaplains and other support staff, builds an environment for healing or dying. 

LEVELS OF ICU CARE 

LEVEL I – PROVIDES MONITORING, OBSERVATION AND SHORT TERM VENTILATION.

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LEVEL II – PROVIDES OBSERVATION, MONITORING & LONG TERM VENTILATION WITH RESIDENT DOCTORS.

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LEVEL III – PROVIDES ALL ASPECTS OF INTENSIVE CARE INCLUDING INVASIVE HEMODYNAMIC MONITORING & DIALYSIS.

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Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems

SEVEN Cs OF CRITICAL CARE Compassion  Communication  Consideration (to patients, relatives and colleagues) and avoidance of Conflict.  Comfort: prevention of suffering  Carefulness (avoidance of injury)  Consistency  Closure (ethics and withdrawal of care ) 

CRITICAL CARE NURSE 

A critical care nurse is a licensed professional nurse who is responsible for ensuring that acutely and critically ill patients and their families receive optimal care .

Nurse Competencies 

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Clinical Judgment Advocacy/moral agency Caring practice Collaboration Systems thinking Response to diversity Clinical inquiry Facilitator of learning

Critical care unit 

is a specially designed and equipped facility staffed by skilled personnel to provide effective and safe care for dependent patients with a life threatening problem.

THE AIM OF THE CRITICAL CARE 

is to see that one provides a care such that patient improves and survives the acute illness or tides over the acute exacerbation of the chronic illness.

THE EVOLUTION OF CRITICAL CARE Forty years of development in critical care and critical care nursing has given rise to a recognized specialty in nursing practice .  Critical care units have evolved over the last four decades in response to medical advances . 

HISTORICAL PRESPECTIVES 

Florence nightingale recognized the need to consider the severity of illness in bed allocation of patients and placed the seriously ill patients near the nurses’ station.

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1923, John Hopkins University Hospital developed a special care unit for neurosurgical patients .

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Modern medicines boomed to its higher ladder after world war 2

HISTORICAL PRESPECTIVES 

As surgical techniques advanced it became necessary that post operative patient required careful monitoring and this came about the recovery room.

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In 1950, the epidemic of poliomyelitis necessitated thousands of patients requiring respiratory assist devices and intensive nursing care.

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At the same time came about newer horizons in cardiothoracic surgery, with refinements in intraoperative membrane oxygen techniques.

HISTORICAL PRESPECTIVES 

In 1953, Manchester Memorial Hospital opened a four bedded unit at Philadelphia was started.

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By 1957, there were 20 units in USA and

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In 1958,the number increased to 150.

Medical staff 

Intensivists are the best senior medical Staff to be appointed to the ICU. He/she will be the director. Less preferred are other specialists from Anesthesia, medicine and chest

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Junior staff are intensive care trainees and trainees on deputation from other disciplines.

NURSING STAFF 

The major teaching tertiary care ICU will require trained nurses in critical care. It may be ideal to have an in house training program for critical Care nursing.

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The number of nurses ideally required for such units is 1:1 ratio.

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The number of trained nurses should be also worked out by the type of ICU, the workload and work statistics and type of patient load.

UNIT DIRECTOR Specific requirements : Training, interest, and time availability to give clinical, administrative, and educational direction to the ICU.  Board certification in critical care medicine.  Time and commitment to maintain active and regular involvement in the care of patients in the unit. 

UNIT DIRECTOR 

Availability to the unit 24 hrs a day, 7 days a week for both clinical and administrative matters.

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Active involvement in local and/or national critical care societies.

UNIT DIRECTOR Participation in continuing education programs in the field of critical care medicine.  Active involvement as an advisor and participant in organizing care of the critically ill patient in the community as a whole.  Active participation in the education of unit staff. Active participation in the review of the appropriate use of ICU resources in the hospital. 

NURSE MANAGER 

An RN (registered nurse) with a BSN (bachelor of science in nursing) or preferably an MSN (master of science in nursing) degree

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Certification in critical care or equivalent graduate education At least 2 yrs experience working in a critical care unit

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Experience with health information systems, quality improvement/risk management activities, and healthcare economics

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Ability to ensure that critical care nursing practice meets appropriate standards .

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Preparation to participate in the on-site education of critical care unit nursing staff

NURSE MANAGER 

Ability to foster a cooperative atmosphere with regard to the training of nurses, physicians, pharmacists, respiratory therapists, and other personnel involved in the care of critical care unit patients

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Regular participation in ongoing continuing nursing education

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Knowledge about current advances in the field of critical care nursing

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Participation in strategic planning and redesign efforts

Critical Care Unit Nursing Requirements 

All patient care is carried out directly by or under supervision of a trained critical care nurse.

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All nurses working in critical care should complete a clinical/didactic critical care course before assuming full responsibility for patient care.

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Unit orientation is required before assuming responsibility for patient care.

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Nurse-to-patient ratios should be based on patient acuity according to written hospital policies.

Critical Care Unit nursing requirements 

All critical care nurses must participate in continuing education.

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An appropriate number of nurses should be trained in highly specialized techniques such as renal replacement therapy, intra-aortic balloon pump monitoring, and intracranial pressure monitoring.

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All nurses should be familiar with the indications for and complications of renal replacement therapy.

RESPIRATORY CARE PERSONNEL REQUIREMENTS  Respiratory care services should be available

24 hrs a day, 7 days a week. 

An appropriate number of respiratory therapists with specialized training must be available to the unit at all times.

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Therapists must undergo orientation to the unit before providing care to ICU patients.

RESPIRATORY CARE PERSONNEL REQUIREMENTS 

The therapist must have expertise in the use of mechanical ventilators, including the various ventilator modes.

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Proficiency in the transport of critically ill patients is required.

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Respiratory therapists should participate in continuing education and quality improvement related to their unit activities.

PHYSICIAN SUBSPECIALISTS General surgeon or trauma surgeon  Neurosurgeon Cardiovascular surgeon  Obstetric-gynecologic surgeon  Urologist  Thoraco-Vascular surgeon  Anesthesiologist  Cardiologist  Pulmonologist 

PHYSICIAN SUBSPECIALISTS Gastroenterologist  Hematologist  Infectious disease specialist  Nephrologist  Neurologist Orthopedic surgeon 

Physiotherapists prevents and treat chest problems, assist mobilization, and prevent contractures in immobilized patients  Pharmacists advise on potential drug interactions and side effects, and drug dosing in patients with liver or renal dysfunction  Dietitians Advise on nutritional requirements and feeds  Microbiologists Advise on treatment and infection control  Medical physics technicians Maintain equipment, including patient monitors, ventilators, hemofiltration machines, and blood gas analyzers 

OTHER PERSONNEL A variety of other personnel may contribute significantly to the efficient operation of the ICU.  Unit clerks  physical therapists  occupational therapists  Advanced practice nurses  Physician assistants  Dietary specialists  Biomedical engineers.

LABORATORY SERVICES 

A clinical laboratory should be available on a 24-hr basis to provide basic hematologic, chemistry, blood gas, and toxicology analysis.

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Laboratory tests must be obtained in a timely manner, immediately in some instances. "STAT" or "bedside" laboratories adjacent to the ICU or rapid transport systems.

Radiology and Imaging Services  The

diagnostic and therapeutic radiologic procedures should be immediately available to ICU patients, 24 hrs per day.

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chest radiographs affect decision making in critically ill patients.

ORGANIZATION OF ICU 

It requires intelligent planning.

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One must keep the need of the hospital and its location.

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An institute may plan beds into multiple units under separate management by single discipline specialist medical ICU, surgical ICU, CCU, burns ICU, trauma ICU, etc.

DEFINITION OF INTENSIVE CARE UNIT EQUIPMENTS 

Intensive care unit (ICU) equipment includes patient monitoring, respiratory and cardiac support, pain management, emergency resuscitation devices, and other life support equipment designed to care for patients who are seriously injured, have a critical or lifethreatening illness, or have undergone a major surgical procedure, thereby requiring 24-hour care and monitoring.

Mechanical Ventilators

Syringe pump

Hemodialysis Machine

Lifter

Swan Ganz Catheter

ICP Monitor

Ventriculoperitoneal Shunt

Sengstaken-blakemore tube

Salem-sump Tube

Levine Tube

Gastrostomy tube (G-tube)

Paracentesis

Tracheostomy and Endotracheal Tube

Chest Tube

Urinary catheter/tube

Colostomy

Wound Drains

Common Problems Seen in Critical Care Setting 1. Anxiety 2. Impaired communication 3. Sleep deprivation 4. ICU psychosis Common procedures 1. Hemodynamic monitoring 2. Circulatory assist device IABP 3. Artificial Airway 4. Mechanical Ventilator

Complications 1. Sepsis 2. Multiple Organ System Failure 3. Shock

Nursing Interventions 1. Anxiety related to fear of death, unknown patients and significant others; ineffective coping mechanism . Tx: Family participation, biobehavioral intervention 2. Impaired communication related to barriers : ET , newTT, or trauma Tx : Acknowledge patient’s concern ; reassurance ; alleviate common difficulties; family feedback

3. Sleep deprivation : lack of consistent REM and NREM Tx: Meds ;Family visits ; rest periods; decreased environmental stimulation 4. ICU psychosis -acute confusional state sec.to CNS stimulants, narcotics, depressants, steroids/ sleep deprivation, sensory overload, F/E imbalance, dec. Oxygen, infection, head trauma, brain disorders

Hemodynamic Monitoring 1. Cardiac Output – volume of blood that is ejected from the heart in 1 minute. - determined by the HR x SV expelled per heart beat. - NV- 4-8L/min. 2. Pre-load – amount of stretch in the LV just before ventricular contraction at the end of diastole. 3. Afterload – tension the ventricle must overcome to eject the blood into the arterial systems (pulmonary and aortic); measured by the systemic vascular resistance. 4. Cardiac index – is the CO by the BSA - better indicator of the body’s ability to perfuse the tissues effectively than CO. - NV- 2.5 – 4.0 L/min/m 2

Types of Hemodynamic Monitoring 1. Arterial lines – provides a direct, intra-arterial measurement of BP; assist in the continuous measurement of SBP, DBP and MAP. Method : a 20 g arterial catheter inserted into the radial, brachial or femoral artery connected to high pressure tubing leading to a pressure transducer and amplifier.

Nursing Management : Same mechanics in CVP reading 1. Drawing a – blood sample – flush A line with valve flush device to allow return of sharp arterial waveform thru a 3 way stopcock. 2. Change dressings 24-48 hrs., IV solutions and IV tubings per hosp. policy 48-72 hrs. 3. Watch out for complications : bleeding from insertion site , hemorrhage, infection- systemic , air embolus, thrombosis, occlusion of circulation with loss circulation distal to insertion site. 4. Perform Allen Test prior to radial artery insertion and freq. monitor distal pulses.

2. Swan-Ganz Catheter – Pulmonary Artery Balloon Flow provide indirect measurement of LV function for detection and treatment of CP changes. Method : a 5 lumen, balloon tipped , flow directed catheter connected to a pressure transducer and pressurized heparin flush system is inserted thru a percutaneous or cutdown venous site and directed into the RA. Site : subclavian vein most common

Indications :

a. a need to monitor PAP and or PCWP- indirectly reflect LV function. b. provide information about CO, tissue perfusion and BV. c. Obtain venous blood specimens d. Proximal orts used for continuous fluid or medication infusion.

Nursing Management : 1. Level and secure transducer at the phlebostatic axis – 4th ICS, MAL – serves as a reference point for the RA. 2. Taking readings – record PA Systolic and Diastolic Pressures to obtain a PCWP or LVEDP , then inflate the catheter balloon slowly, watch for waveform changes-dampening indicates wedging. 3. After reading has been recorded, allow the balloon to deflate passively and lock it out tp prevent accidental wedging- take all reading at the end of expiration.

4. W/O for complications : dysrrhythmias, infection, air embolism,catheter occlusion, pneumothorax, thrombus formation. 3. Circulatory Assist Device – Intra-Aortic Balloon Pump a counterpulsation device that assists to augment CO and to provide adequate rest and recovery.

Indications : cardiogenic shock heart failure support before heart transplantation unstable angina failure to wean from CP bypass after coronary bypass surgery

Nursing Management :

1. Assist with placement as needed and maintain sterility with dressing changes. 2. Monitor and record effectiveness – inc. CO, inc. BP, inc. U.O., inc. LOC, palpable peripheral pulses, improved ischemic EKG changes.

3. Monitor circulation, sensation and motor function in leg of insertion , keep the affected leg straight at all times. 4. Keep HOB elevated at least 30 degrees to prevent migration of the balloon. 5. Monitor Sx : hematuria ( excessive anti coagulants ) excessive oozing from catheter insertion sites positive guiac in the stool abnormal PT,PTT and platelet counts

6. Complications : air/foreign body embolus if balloon should rupture thrombus formation at insertion site loss of distal circulation migration of catheter dissection of aorta sepsis complications of immobility

Common Complications in the ICU : SEPSIS -a diffuse, inflammatory systemic response to a chemical, mechanical, bacterial or microbial assault if untreated leads to shock. -Severe sepsis : hypoperfusion,organ dysfunction, hypotension, septic shock, multi organ systemic failure, death.

Management : 1. ABC 2. D- disability/ drugs : Inotropics, Vasodilators 3. E-expose : V/S : CVP, ECG 4. F-fluids , nutrition 5. anti pyretics/antibiotics MOSF Cause : failure of one or more body systems after a major insult to the body such as infection, trauma, severe illness, persistent hypotension and hypoxia.

4 Major Systems : 1. Pulmonary dysfunction 2. Renal dysfunction 3. CV dysfunction 4. Coagulation system failure

S/Sx: per organ dysfunction leads to dec. LOC then coma with bleeding and fibrinolysis.

Dx;

1. ABG- severe acidosis 2. WBCs – dec. platelet less than 80,000/mm 3 3. dec. fibrinogen 4. inc. PT,PTT, hgb, hct , severe anemia 5. inc. urea, BUN 6. inc. cardiac, hepatic enzymes 7. inc. serum K 8. CXR – interstitial edema and hypoperfusion

Tx: 1. V/S,CVP 8-10 mmHg 2.ABC 3. Hemodialysis 4.Nutritional suspport 5. Antibiotics 6.Bleeding control 7.Limit activities SHOCK -a state of imbalance between O 2 supply and demand in the body that leads to inadequate blood flow to organs, poor tissue perfusion- possibly fatal cellular dysfunction.

Classification: 1. Loss of CBV – hypovolemic 2. Dec. pump function – cardiogenic 3. Spinal cord injury – Neurogenic 4. Overwhelming presence of endogenous mediators causing inflammatory response – septic Compensatory Mechanisms : 1. SNS- massive release of NE 2. Endocrine -ADH

S/Sx : Early Stage : normal BP, slightly increase CR, normal to slightly dec.U.O., slight restlessness, anxiety, thirst Next Stage : progressive shock state – claasic shock sx ; cool clammy pale skin, dec. capillary refill, tachycardia, tachypnea, dec. BP, CO, temp., U.O., LOC, metabolic acidosis Later Stage : Sx of specific organ failure : anuria, slow thready pulse, ARDS, bleeding, coagulation dysfunction, coma.

Dx: 1. dec. hgb/hct 2. ABG- acidosis 3. inc. serum lactate and K 4. inc. cardiac hepatic GI enzymes 5. inc. BUN crea – RF 6. initially increase glucose to decrease glucose stores 7. dec. sp. grav. urine 8. depletion of clotting studies 9. ST ischemic changes ECG

Management : 1. ABCDEFGH 2. BT.IV NSS, LR, O 2, Vasopressors, vasodilators, inotropics 3. Correct acidosis- anaphylactic and septic shock 4. Comfort measures 5. V/S,UO,,peripheral circulation, titrate meds., thorough assessment 6. Cardiac dysrythmias, coagulation dysfunction, I^O, hemodynamic status 7. dec. external stimuli, family teaching

ARDS Acute RDS -a syndrome char. by a non-cardiac type of pulmonary edema and increasing hypoxemia despite administration of tx measures formerly known as adult resp. distress syndrome. S/Sx : 1. labored respirations 2. restlessness 3. dry, non productive cough 4. cyanosis 5. pallor 6. adventitious breath sounds with used of accessory muscles with retraction

Dx : 1. CXR – white out due to bilateral diffuse infiltrates 2. PFT – dec. in compliance , lung capacity 3. Increase peak inspiratory pressures 4. ABG- initially resp. alkalosis due to hyperventilation then acidosis. 5. Inc. hemodynamic monitoring – PA Systolic and Diastolic Pressures with normal PAWP.

Pathology : 1. Primary Insult 2. Chemical mediators released 3.Interstitial edema 4. Alveolar edema 5. Damaged surfactant producing cells 6. Dec. lung compliance 7. Atelectasis, hyaline membrane formation 8. Inc. work of breathing 9. Impaired gas exchange 10. Respiratory failure

Tx : 1. O2 3. Sedation to tolerate mech. Ventilation 4. Fluid therapy- crystalloids, colloids – IVC volume 5. Hemodynamic monitoring 6. Treat underlying cause of ARDS- antibiotics 7. Provide nutritional support – CHON balance 8. Steroid therapy – stabilize cellular membrane and dec. fluid shifts 9. Diuretic therapy 10. Comfort, positioning HOB elevated 11. V/S, EKG, Neuro 12. Conserve energy-schedule activities/family teaching

CARDIOPULMONARY RESUSCITATION BCLS – to recognize cardiac or resp. arrest and re establish or provide airway breathing pattern and effective circulation until the client responds or until another type of life support is initiated. HT / CL maneuver, jaw thrust maneuver LLF M-M/ ambu bag Closed CC Adult one rescuer: 15:2 for 4 cycles : 1 minute 1 ½ inches compression lower 1/3 sternum at a rate of 100 times per minute.

ACLS – manages the airway thru ET intubation or use of an advanced airway device. - ET placement check - Venous access peripheral IV g 16-18 Drugs:

Fibrillation, Pulseless Vtach : 1. Epinephrine 1mg repeated 3-5 min, IV; tracheal adm. 2-2.5mg in 10 ml NSS 2. Vasopressin –Pitressin 40 U or ET single dose once only 3. Amiodarone- Cordarone 300mg IV 4. Lidocaine-Xylocaine-1-1.5mg/kg IV 5. Lidocaine drip 1-4 mg/min for maintenance infusion 6. Procainamide 20mg/min IV 7. Na HCO3- 1 MEQ/kg/IV bolus

Asystole: pulseless electrical activity 1. Epinephrine 2. At SO 4 3. CPR/ transcutaneous pacing Bradycardia 1. At SO 4 Ventricular fibrillation -chaotic rhythm, rapid disorganized depolarization of ventricles Tx: defibrillation – 200-300-360 joules / O 2 / CPR / Epinephrine lidocaine amniodarone

Ventricular Tachycardia -rapid ventricular contraction 100bpm above VR – 150-250 bpm QRS more than .12 sec. wide, bizarre Tx : hemodynamically stable: O 2 / lidocaine amniodarone to dec. irritability

PVC -ectopic beats occur earlier than expected followed by a compensatory pause. Salvos: 1. more than 6/min PVC 2. paired 3. multifocal –differing shapes 4. R on T Tx: Lidocaine

SVT

-more than 100 bpm originating above the ventricle but not in the sinus node. -AR more than 140 bpm VR depends on degree of block Tx : 1. Attempt vagal nerve stimulation 2. Adenosine 6 mg rapid IVP 3. Verapamil – Isoptin 2.5-5mg Iv over 2 mins. 4. Synchronized Cardioversion

Nursing Role During a Code :

Call Code CPR, paraphernalia Determine team leader Serial assessments and documentation Crowd control Psychosocial needs of family, room mates and staff

Diabetic Ketoacidosis -a complication of IDDM, a condition arising from a lack of insulin resulting in a derangement of CHO, CHON and fat metabolism with DHN and electrolyte imbalance. Ketoacidosis occurs when FA are broken down to ketone bodies because of absoloute or relative deficiency of insulin.

Etiology : As the need for cellular fuel grows more critical , the body begins to draw on its fat and CHON stores for energy. Increase fatty acids are metabolized from adipose tissue cells and transported to the liver.  Liver in turn, accelerates the rate and produces ketone bodies ( KETOGENESIS ) for catabolism by other body tissues particularly muscle.  As increase metabolism- increase ketone bodies – accumulate in the blood  ( KETOSIS ); spill into urine ( KETONURIA ); metabolic acidosis develops develops from acidic effect of ketoacetoacetate and Bhydroxybutyrate---- severe acidosis 

Precipitating Factors : 1. taking too little insulin 2. omitting doses of insulin 3. failing to meet increased for insulin due to surgery, trauma pregnancy puberty or febrile illness. 4. developing insulin resistance owing to insulin antibodies or severe emotional stress.

4 Pathologic events in DKA 1.Incomplete lipid metabolism 2. DHN 3. Metabolic acidosis 4. Electrolyte imbalance

S/Sx :              

- hyperglycemia glycosuria polydipsia ketonemia ketonuria metabolic acidosis Kussmaul’s respiration acetone breath-dec. acetone combining power DHN dry skin sunken eyeballs flushed face electrolyte imbalance tachycardia

Management : Prevent complications 1. Adequate ventilation 2. Fluid replacement-NaHCO3,NaCl,K 3. Insulin 4. Indwelling FC 5. IVF,D5050 IV 6. Hgt ,ABG,CXR,12 lead EKG

HHNK- Hyperglycemic Hyperosmolar Nonketotic Coma

-a condition resulting from elevated concentration of blood glucose - level which increases the osmolarity of blood without significant ketoacidosis.

Causes : 1. large NaHCO3 infusion as in CPR 2. marked hyperglycemia 3. uremia with increased BUN 4. Na retention from adrenal steroid Tx: 1. Insulin 2. F/E 3. Dialysis

S/Sx:

1. increased temp. 41 C 2. DHN 3. irritability 4. frustration 5. cardiac dysrythmias 6. CHF 7. delirium 8. diarrhea/N/V

RENAL FAILURE

-state of total or nearly total loss of the kidney’s ability to maintain F/E balance and excrete waste products. -inability of the kidney to function normally or effectively.

Renal Insufficiency -designates significant loss of renal function but with a function requiring to maintain a normal environment provided no additional stress is added. Azotemia -accumulation of nitrogenous wastes within the blood, not life threatening without a decreased output. Uremia -an azotemia progressing to a symptomatic state.

Types of Renal Failure : A.Acute RF -a sudden, complete or nearly complete loss of kidney function which develops rapidly over a period of day or few weeks. Output drops suddenly to less than 400ml/day.

3 Phases : 1.Oliguric Phase – begins shortly after injury and is char. By gradually decreasing U.O. 2.Anuric Phase – there is total absence of urine production. 3. Polyuric Phase – recovery , there is marked diuresis, there may be rather marked wasting of various electrolytes, esp. Na, K, HCO3.

Causes : 1. Pre-renal – when the lesion or cause is before the kidney. - shock, mismatch BT 2. Renal – when the lesion is found in the kidney itself. - nephritis,nephrotoxic infection 3. Post renal – reached the kidney - obstruction of the urinary tract : renal calculi.

B. Chronic RF -gradual deterioration of kidney function occurring over months or years.

3 Stages: 1. Stage of diminished renal reserve- renal function is impaired but metabolic wastes do not accumulate in the blood and the BUN remains normal.

2. Stage of renal insufficiency – metabolic wastes begin to accumulate in the blood and there is a slight increase in BUN. 3. Stage of uremia – the kidney loses its ability to maintain homeostasis.U.O. is usually scanty, electrolyte balance is severely disturbed and nitrogenous wastes accumulate in high concentrations.

3 Causes : 1. Pre-renal -gout,DM,sub acute endocarditis 2. Renal -SLE,pyelonephritis,GN 3.Post renal -prostatic obstruction

S/Sx :           

alteration in U.O. weak,easily fatigued becomes increasingly drowsy HA and slight breathlessness and lethargic restlessness and insomnia dry, skin and mucous membrane halitosis- urineferous breath loss of appetite, intractable N/V CNS manifestation- anxiety, irritability, hallucination, mental wandering, muscle twitching, coma HPN anemia edematous, tend to bruise easily

Management : 1. Diet: dec. CHON, essential amino acid, -controlled K 1,500mg, 20g very low CHON, minimal essential AA. 2. Tx of Infection : unnecessary surgery and instrumentation are avoided; antibiotics

3. Tx of alterations in Body Chemistry -limit CHON metabolism and K ; -hyperkalemia –peaked T wave, depressed ST segment, flaccid paralysis,slow respiration, anxiety, convulsions Tx: Kayexalate –contain Na in a compound absorbed by the GIT. While in the GIT, the Na exchange places with serum K ; and K becomes part of the non absorbable compound.

-Ca gluconate- as an emergency measure when the K level is dangerously high and cardiac arrythmias are imminent. -Glucose and insulin- insulin causes glucose to go into cell; as glucose moves into the cell, it takes with it and reduce the serum K.

-Na HCO 3 – treat acidosis.

Aggressive Mgmt : 1. Hemodialysis 2. Peritoneal Dialysis

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