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CRRT - Indications

Continuous flow of blood through the hemofilter to remove fluid and solute AKI; When PT is hemodynamically unstable

CRRT - Assessment - fluid overload

• I's and O's; Daily weights

• Hemodynamic monitoring

• Edema

• Rising BP

• Adventitious lung sounds

CRRT - Assessment - fluid deficit

ECF depletion; Decreased intravascular volume; Hemodynamic instability; hypotension

CRRT - Assessment - hemodynamic stability

Continuous VS monitoring

Watch for HYPOTENSION — r/t — Increased ultrafiltration rate; Blood leaks; disconnection

CRRT - Interventions for above clinical changes

• Continuous VS monitoring

  • Watch for HYPOTENSION r/t

    • Increased ultrafiltration rate

    • Blood leaks

    • disconnection

AKI - Expected assessment findings of fluid overload

• Edema

• Increased volume

• Rising weight

• Hemodynamic changes

AKI - Expected assessment findings of fluid deficit

• - ECF depletion

• Decreased intravascular volumn

• Decreased u/o — Oliguria; anuria

AKI labs

• Serum creatinine

• Creatinine clearance

• BUN

• Serum electrolytes

  • sodium

  • potassium

  • chlorine

• Urine electrolytes

• Fractional excretion of sodium

AKI - Interventions (for fluid balance and abnormal electrolytes)

• Obtain IV access

• Manage fluid balance

  • Admin IV fluids based on etiology

    • Crystalloids

      • NS

    • Colloids

      • Albumin

    • IVFV

      • Fluid restriction

      • Fluid removal

  • Restricted fluid intake based on etiology

  • Monitor

    • Potassium

    • Sodium

    • Calcium

      • Hypocalcemia

      • Replacement

      • non calcium based meds

    • Phosphorus

      • Hypophosphoremia

      • Dietary phos binding meds

      • Non aluminum based 

      • Acidosis

  • Fluid balance

    • Hemodynamic values

    • Daily weights

    • I’s and Os

  • Electrolyte imbalance

    • Hyperkalemia

    • Hypocalcemia

    • Hyponatermia

    • Hyperphosphatemia

    • Acid base imbalances

AKI - Prioritization of emergent interventions

Avoid nephrotoxic medications; Electrolytes balance — Potassium — Hyperkalemia; Ecg changes; Sodium — hypoNA; hyperNA

Hyperkalemia management

EKG changes; Interventions based on priority

Heparin induced thrombocytopenia (HIT) - signs/symptoms

• Neuro

  • Confusion

  • Headache

  • Impaired speech patterns

  • Hemiparesis or hemiplegia

• Vision disturbances

  • Dysarthia

  • Aphasia

  • Ataxia

  • Vertigo

  • Nystagmus

  • Sudden decrease in consciousness

• CV Chest

  • Diaphoresis

  • Pallor

  • Alterations in BP

  • dysrhythmias

• Pulmonary s/s

  • Dyspnea;

  • Pleuritic pain

  • Chest pain

  • Rales

  • Chest wall tenderness

  • Erythema

  • Palpable cord

  • Pain on passive dorsiflexion of food, spontaneous maintenance of relaxed foot in abnormal plantar (homans sign)

Heparin induced thrombocytopenia (HIT) - Lab values

Platelet count — Less than 100,000mm^3^; Sudden drop of 50% from pts baseline after initiation of heparin therapy

Heparin induced thrombocytopenia (HIT) - Treatment/management

• Medical

  • Monitor plt count

  • Discontinue heparin

  • Test heparin for antibodies

  • Direct thrombin inhibitors — Argatroban

• Nursing

  • Decrease heparin exposure

  • Flush; Vascular access devices

  • Surveil for complications

    • DVT

    • Pulmonary emboli

    • Acute limb ischemia

    • Educate pt and family

    • Comfort and emotional support

    • Educate pts and family

DIC (disseminated intravascular coagulation) - Etiology

• proteins that control blood clotting become hyperactive throughout the body

• Always secondary to underlying condition

• Gram negative sepsis -- 20%; Neoplasms

• Obstetric complications

• Massive tissue injury

• Other causes

DIC (disseminated intravascular coagulation) - signs/symptoms

• r/t hemorrhage

  • Gum bleeding

  • Venipunctures

  • Old surgical sites

  • Epistaxis

  • Ecchymoses

  • Hemoptysi

  • Hematuria

  • Abdominal distension

  • Hemorrhage

  • Subarachnoid hemorrhage r/t thrombi

  • Peripheral cyanosis

  • Gangrene

  • Dysrhythmias

  • Chest pain

  • Acute MI

  • Pulmonary embolus

  • Resp failure

  • Oliguria

  • AKI

  • Diarrhea

  • Constipation

  • Bowel infarct

  • ALOC

  • Ischemic stroke

DIC (disseminated intravascular coagulation) - treatment/management

Nursing

• Support vital functions

• Bleeding precautions

• Comfort

• Surveil for complications

Medical

• Prevention

• Maintaining organ perfusion

• Slowing consumption of coagulation factors

• Platelet transfusions

Distinguish between HIT and DIC - Assessment findings including lab values

HIT — s/s — Neuro s/s — Confusion; Headache\ Impaired speech patterns; Hemiparesis or hemiplegia; Vision disturbances; Dysarthia; Aphasia; Ataxia; Vertigo; Nystagmus; Sudden decrease in consciousness; CV s/s — Chest; Diaphoresis; Pallor; Alterations in BP; dysrhythmias; Pulmonary s/s — Dyspnea; Pleuritic pain; Chest pain; Rales; Chest wall tenderness; Erythema; Palpable cord; Pain on passive dorsiflexion of food, spontaneous maintenance of relaxed foot in abnormal plantar (homans sign); Labs — Platelet count — Less than 100,000mm^3^; Sudden drop of 50% from pts baseline after initiation of heparin therapy; DIC

Distinguish between HIT and DIC - Treatment differences based on priority concerns

• HIT

  • Medical

    • Monitor plt count

    • Discontinue heparin

    • Test heparin for antibodies

    • Direct thrombin inhibitors

      • Argatroban

  • Nursing

    • Decrease heparin exposure

      • Flush

      • Vascular access devices

    • Surveil for complications

      • DVT

      • Pulmonary emboli

      • Acute limb ischemia

      • Educate pt and family

    • Comfort and emotional support

    • Educate pts and family

• DIC

  • Medical

    • Prevention

    • Maintaining organ perfusion

    • Slowing consumption of coagulation factors

    • Platelet transfusions

  • Nursing

    • Support vital functions

    • Bleeding precautions

    • Comfort

    • Surveil for complications

Sickle cell anemia - Signs and symptoms

• Low grade fever

• Bone

• Joint pain

Sickle cell anemia - Pathophysiology

RBCs form an abnormal sickle or crescent shape; Unable to carry adequate oxygen to tissues; Trapped in vasculature

Sickle cell anemia - treatment/management

Medical

• Bone marrow transplant

• Pain management

• Prevent infection

• Transfusion therapy

• Admin of hydroxyurea

Nursing

• Support vital functions

• Vital signs

• Hemodynamic parameters

• I&Os

• Lab values

• Mental status

• Skin

• Comfort and emotional support

• Surveil for complications

• Educate pt and family

Hip and Pelvic Traumas: Complications

• Hemorrhage

• Exsanguination

• Gait disturbances

• Erectile dysfunction

• GI tract trauma

• His dislocation

• Thromboembolic phenomena

  • 1Including fat emboli

  • Hypovolemic shock

  • Immobility

  • Infection

Hip and Pelvic Traumas: Management

• ABCs — HIGHEST PRIORITY

• Can cause hypovolemic shock

• Fluid volume status

  • Body weights

  • CNS parameters

• Notify

  • Delayed cap refill

  • Tachycardia

  • U/O less than .5mL/kg/hr

  • Alterations in LOC

Hip and Pelvic Traumas: Identification

• History — Injury

• MVA — Safety restraint; Driver or passenger; Sit in jury description & location

• Fall — Impact; Distance; Type of landing surface;

• Pain — Tenderness; Inability to void; Pain;

• Underlying medical disorders — Polycysic kidney disease; Frequent UTIs; Osteoporosis; Rheumatoid arthritis;

• Med history — Corticosteroids; Tetanus immunization

• Physical — Airway; Breathing; Circulation; Disability —

• Neuro; Exposure — Underlying disease; Ensure C spine is IMMOBILIZED

• Inspect — Abrasions; Pain and tenderness; Ecchymosis; Contusions; Lacerations; Groin; Genetalia; Suprapubic area; Frog leg positioning; instability

Hip and Pelvic Traumas: Complications, Management, identification

https://nursing.unboundmedicine.com/nursingcentral/view/Diseases-and-Disorders/73680/all/Pelvic%20Fractures?refer=true

FAST Ultrasound - Bed US

• Suprapubic view

  • Checks Retroperitoneal space/bladder

• RUQ

  • Checks hepatorenal space (Morison space) and diaphragm

• LUQ

  • Check splenorenal space

• Pericardial

  • Checks for tamponade

Trauma Surgery - Preop considerations

• Resuscitation

  • IV access

  • Isotonic fluids

  • Blood products

• AMPLE history

  • Allergies

  • Medications

  • PMH/pregnancy

  • Last meal

  • events/environment of injury

  • Correct coagulopathy

  • Acidosis

  • Hypothermia control

Trauma Surgery - Pre-op, Intra-op, and Post-op considerations - Intraop considerations

• Damage control

  • Control hemorrhage

  • Control contamination

  • Definitive repair

  • Ongoing blood product administration

  • Temperature management

  • Complications

    • Major vessel injury

    • Tissue perfusion

Trauma Surgery - Pre-op, Intra-op, and Post-op considerations - Post op considerations

• Ongoing hemodynamic monitoring

  • Trending of vital signs

  • Watch for continued bleeding, coagulopathy

  • and the lethal triad persisting into recovery

  • Pain management

  • DVT/VTE prophylaxis

  • Early mobilization

• Monitor for infection at the surgical site and systemically

  • sepsis risk is elevated in trauma patients due to wound contamination, invasive lines, and mechanical ventilation

• Watch for missed injuries —

  • rauma patients are at risk of injuries not caught in the initial survey due to patient factors

    • altered mental status

    • distracting pain

    • clinician factors

Flail Chest - s/s

• Segment is apparent on visual examination

• When breathing, goes in opposite directions — Lungs expand → chest sinks IN; Exhale → chest pokes OUT

• Rapid shallow respirations

• Tachycardia

• Pain

• Poor air movement

• Asymmetrical chest movement

• Crepitus on palpation of chest

Flail Chest - Management

• Ensuring adequate ventilation

• Supplemental oxygen

• Intubation and mechanical ventilation may be necessary

Flail Chest - Complications

• Underlying pulmonary contusion is common

• Respiratory failure from inadequate ventilation

• Atelectasis and pneumonia

Flail Chest - Identification

• Results from fracture of several consecutive ribs, in 2 or more separate places, causing an unstable segment (\"rack of ribs\")

• Instability of the segment causes paradoxical movement

  • the flail segment moves in the opposite direction from the rest of the chest wall during breathing

Management of open fractures - General principles

• irrigation and debridement of the wound

• tetanus prophylaxis

• Antibiotics

• surgical stabilization/fixation

Management of open fractures

• Open fractures carry a high infection risk because of environmental exposure at the fracture site

• Neurovascular status distal to the fracture must be assessed and monitored closely

Penetrating traumas - Management

• Primary survey (ABCDE) first

  • airway, breathing, circulation with hemorrhage control

• CT is the diagnostic standard

  • Bedside FAST ultrasound for rapid free-fluid screening

• Surgical exploration/repair as indicated by injury location and severity

Penetrating traumas - Complications

• Major hemorrhage and hemodynamic instability

• Organ-specific injury

  • liver, spleen, hollow viscus, cardiac, vascular depending on trajectory

• Infection

  • major risk of cerebral abscess if the skull/brain is involved or peritonitis/sepsis if abdominal organs are penetrated

• Missed injury along the trajectory of the penetrating object

Penetrating traumas - Identification

• Entry and exit sites

• Bullet holes counted should be even

• Discoloration, seat belt signs

• Decreased bowel sounds

• Cullens

  • Eccymosis around umbilicus

• Greys turner

  • Ecchymosis to flanks

• Distended abdomen

  • Peritonitis

  • Rebound tenderness

• Kehrs sign

  • Pain in tip of shoulder due to presence of blood or irritants in peritoneal cavity

Tension Pneumothorax - Management

• Needle decompression

• Lung re-expansion to restore oxygen and ventilation

• Removing air and or fluid from pleural space ASAP

• Restoring negative pressure in chest cavity ASAP

Tension Pneumothorax - Complications

• Untreated, progressive air accumulation compresses the heart and great vessels → leading to obstructive shock and cardiac arrest

• Respiratory failure from inability to ventilate the affected lung

Tension Pneumothorax - Identification

• Distended neck veins

• Reduced breath sounds

• Deviated trachea to the unaffected side

Hemothorax - Management

• Lung re-expansion to restore oxygen and ventilation

• Removing air and or fluid from pleural space ASAP

• Restoring negative pressure in chest cavity ASAP

Hemothorax - Complications

• Hemorrhagic shock from ongoing/large-volume blood loss

• Retained hemothorax can lead to empyema or fibrothorax if not adequately drained

Hemothorax - Identification

• Dyspnea

• Tachypnea

• Asymmetrical chest

• Tachycardia

• Decreased or absent breath sounds on the injured site

• Chest pain

• Decreased O2 stat

• Hypotension in LATER stages

Glasgow Coma Scale Scoring - My Extra Value Meal Costs 4.56 - Eyes

Eyes — 1-4

1. None 2. To pain 3. To voice 4. spontaneous

Glasgow Coma Scale Scoring - Verbal

1-5

1. None 2. No words, only sounds 3. Words but not sounds 4. Disorientated conversations 5. Normal conversation

Glasgow Coma Scale Scoring - Motor

1-6

1. None 2. Decerebrate 3. Decoricate posture 4. Withdraws to pain 5. Localized to pain 6. Normal

Glasgow Coma Scale Scoring - Score

• Mild brain injury — 13-15

• Moderate brain injujry — 9-13

• Severe - less than 8 — Less than 8 we intubate;

Intracranial pressure - s/s

• Altered LOC

• changes in GCS

• pupillary changes

• posturing (decorticate/decerebrate)

• other signs of neurologic deterioration as ICP rises

Intracranial pressure - Management

• Ongoing assessment of vital signs and hemodynamics

• Recognize and reduce ICP

• Maintain adequate cerebral perfusion pressure (CPP)

• Suctioning as needed (carefully, since it can transiently raise ICP)

• Capnography monitoring

• Maintain normothermia

• Control of environmental stimuli

Intracranial pressure - Complications

Herniation — one of the major causes of death from secondary injury after TBI.

Diffuse Axonal Injury - Def

• Posttraumatic coma that is not caused by a mass lesion

• It takes 12-24 hours to develop and may persist longer

• Clinical signs

  • Decreased LOC

  • Increased ICP

  • Posturing

  • Global cerebral edema

  • 90& remain in vegetative state

• Treatment

  • Support of vital functions

TBI - Potential complications

• Skull fracture

  • open (dura torn) or closed (dura intact); vault or basilar fractures; assess for Battle sign and CSF leakage (rhinorrhea/otorrhea)

• Concussion

  • minor diffuse injury with brief LOC disruption, amnesia, headache, dizziness, nausea, irritability, poor concentration, impaired memory, fatigue

• Contusion ("bruising of the brain")

  •  from acceleration/deceleration injury, coup-contrecoup pattern, diagnosed via CT

• Epidural hematoma

  • bleeding between skull and dura, often from middle meningeal artery laceration; classic presentation is brief LOC followed by a lucid interval, then a dilated/fixed pupil; treated with surgery

• Subdural hematoma

  • acute (severe blow, altered LOC, unequal pupils, surgical), subacute (develops 4 days–3 weeks post-injury), or chronic (21+ days post-injury; may need craniotomy, burr holes, or catheter drainage)

• Intracerebral hemorrhage (ICH)

  •  bleeding deep within brain tissue; traumatic causes include depressed skull fractures, penetrating injury, or acceleration-deceleration; managed surgically or nonsurgically

• Penetrating injury

  • missile injuries (GSW, knife, nail gun) causing focal damage; major risk of infection and cerebral abscess

TBI - Prophylaxis

• preventing hypotension

• hypercapnia

• elevated ICP

• maintaining normothermia

• limiting environmental stimuli that could spike ICP.

TBI - Secondary injuries

• Tissue ischemia

• Hypotension

• Hypercapnia

• Cerebral edema

Spinal Cord Injuries - s/s

• Airway

• Stabilization

• Spinal shock

• Neurogenic shock

Spinal Cord Injuries - Management

• Medical

  • Preserve neurologic function

  • Surgical

    • Stabilization

    • Decompression

    • Laminectomy

    • Spinal fusion

    • Pedicle screw fixation

    • Verbal plates

    • Bone grafting

  • Nonsurgical

    • Cervical

      • Immobilization

      • Fracture realignment

      • Tongs

      • Halo traction brace

    • Thoracolumbar injury

      • Immobilization

• Nursing

  • Optimize hemodynamic stability

  • Assess, monitor, and trend the GCS score

    • Poikilothemy

  • Maximize psychosocial adaptation

  • Organ systems and complications

  • Resp status and airway

  • Bowel program

  • Urinary catheterization

  • Pressure injuries

  • Contractures

  • PRIORITIES PLEASE FOCUS ON

    • Optimizing hemodynamic stability

    • Preventing life threatening complications while maximizing the function of all organ systems

Spinal Cord Injuries - Identification

• Dermatome mapping to localize the neurological level

• ASIA Impairment Scale (A = complete, B–D = varying degrees of incomplete, E = normal)

• CT and MRI for diagnosis; cervical spine clearance follows EAST guidelines based on whether the patient is awake/alert/neurologically intact vs. has pain, altered mental status, or is obtunded

Spinal Cord Injuries - Neurogenic shock

• Occurs after cervical or high thoracic SCI due to loss of sympathetic outflow below the injury level, leaving parasympathetic tone unopposed

• Presentation

  • bradycardia

  • hypotension

  • hypothermia/poikilothermy (loss of ability to regulate temperature) distinguishes it from hypovolemic shock, which presents with tachycardia

• Management

  • hemodynamic support (IV fluids, vasopressors if needed to maintain adequate spinal cord perfusion pressure)

  • atropine or pacing for symptomatic bradycardia

  • temperature regulation

Spinal Cord Injuries - Autonomic dysreflexia

• A medical emergency seen in SCI patients with injury at T6 or above, occurring after the acute phase once spinal shock resolves

• Triggered by a noxious stimulus below the level of injury (most commonly bladder distention, also fecal impaction, skin breakdown, or tight clothing)

• Presentation: sudden severe hypertension, bradycardia, pounding headache, flushing/diaphoresis above the injury level, and pallor/goosebumps below it

Spinal Cord Injuries - s/s, management, complication, and identification (including neurogenic shock, autonomic dysreflexia)

Danger signs of neurological decline following head injury

• Drop in GCS score — even a 1–2 point decline matters; watch each component (eye opening, verbal, motor) individually, not just the total

• Pupillary changes — a new dilated and/or fixed pupil, especially unilateral, is a hallmark of an expanding mass lesion (e.g., epidural hematoma) causing herniation

• New or worsening posturing — progression from decorticate (flexion) to decerebrate (extension) posturing indicates worsening brainstem involvement

• Deterioration after a lucid interval — classic for epidural hematoma: brief loss of consciousness, followed by a period of apparent normalcy, then rapid decline

• Signs of rising ICP — altered LOC, vomiting, headache worsening, changes in respiratory pattern

• New focal neurologic deficits or asymmetry — new weakness, sensory changes, or asymmetric findings not present on initial exam

• Battle sign or CSF leakage (rhinorrhea or otorrhea) — suggests a basilar skull fracture and warrants close monitoring for meningitis risk

• Vital sign changes tied to secondary injury — hypotension or hypercapnia, both of which worsen cerebral ischemia and edema

• Seizure activity — a new seizure after head injury can signal worsening injury or increased ICP 

Complications of Peptic Ulcer Disease - Assessment

• VS

  • Increased HR

  • Decreased BP

  • Thready pulse

  • Increased RR

  • oliguria

• Mental status changes

• Peripheral pulse palpation

• Urine output

• Hematemesis

• Hematochezia

• Melena

• H&H levels

• Risk factors

  • H pylori 

  • NSAID use

  • Liver cirrhosis

• Obvious bleeding

  • Bloody vomit

  • Fresh BRIGHT red blood, “coffee grounds”

• Melena

  • Black, tarry stools

  • Blood digestion in GI tract

  • Black appearance – due to iron

• Labs

  • CBC

  • BUN

  • Electrolytes

  • PT/PTT

  • Liver enzyme measurement

  • ABG

  • Cross matching 4 blood

  • Test vomit and stool for gross and occult blood

Complications of Peptic Ulcer Disease - Treatment

• Patent airway

• Supplemental oxygen

• Maintain BP

• 2 large bore caths

• IV fluid resuscitation

  • Crystalloids

  • Colloids

  • Blood and blood products

  • Insert NG tube

    • Evacuate blood

    • Perform gastric lavage

  • Patient and family education

Complications of Peptic Ulcer Disease - Management of GI bleed

• Medical

  • Neutralization or suppression of gastric acids

  • Airway protection

  • Fluid resuscitation

  • Correction of comorbidities

• Nursing

  • Risk for stress ulcers and GI hemorrhage

  • Gastric pH measurement

  • Assess for signs of GI bleeding

  • Administer volume replacement

  • Initiate gastric lavage

  • Surveil for complications

    • Gastric Perforation

  • Educate the PT and family

Complications of Peptic Ulcer Disease - Management of hypovolemic shock

• Assess for shock

  • Tachycardia

  • Weak pulse

  • Cool clammy skin

  • Hypotension

  • Prolonged cap refill

  • apprehension

• Fluid resuscitation

• Blood products PRN

• Assess for shock — Tachycardia; Weak pulse; Cool clammy skin; Hypotension; Prolonged cap refill; apprehension; Fluid resuscitation; Blood products PRN

Complications of Peptic Ulcer Disease - Upper

Upper GI Bleed

Complications of Cirrhosis -Assessment

• S/S

  • Jaundice

  • Headache

  • Hyperventilation

  • Mental status changes

  • Palmar erythema

  • Spider nevi

  • Bruises

  • Edema

  • Asterixis

  • Grading of encephalopathy

Complications of Cirrhosis - Management

• Medical

  • Antibiotics

  • Lactulose

• Nursing

  • Protect from injury

  • Surveli for complications

    • Resp depression

    • Cardiac arrest

    • Hourly neuro assessment

  • Educate pt and family

Complications of Cirrhosis - Treatment

Treatment

Complications of alcohol-related acute pancreatitis - Assessment

• S/S

  • Sudden abdominal pain

  • N/V

  • Fever

  • Diaphoresis

  • Weakness

  • Tachypnea

  • Hypotension

  • Tachycardia

• Physical

  • Hypoactive bowel sounds

  • abdominal tenderness

  • Guarding

  • Distension

  • tympany

Complications of alcohol-related acute pancreatitis - Management

• Medical

  • Pain

  • Fluids

    • IV crystalloids and colloids

  • Nutrition

    • Enteral feedings

      • Straight into GI

  • Systemic

    • ARDS

    • AKI

    • GI bleed

  • Local complications

    • Pancreatic necrosis

    • Pancreatic pseudocyst

• Nursing

  • Comfort & emotional

    • Pain management

  • Surveil for complications

    • Intraabdominal hypertension

    • Pancreatic infection

  • PT education

    • Dietary guidelines

    • Pancreatic enzyme replacement therapy

    • Diabetes education

    • Alcohol cessation

• Pharmacology

  • Antacids

  • Histamine blocking agents

  • Gastric mucosal agents

  • Gastric proton pump inhibitors

  • Vasopressin

  • somatostatin

• Fluid resuscitation

  • IV crystalloids and colloids

    • LR

• Labs to monitor

  • Elevated ammylase

  • Elevated lipase

• Prioritization

Liver failure - labs to monitor

• Prolonged PT times

• Elevated bilirubin levels

• Elevated Aspartate aminotransferase

• Elevated Alkaline phosphatase

• Elevated Ammonia

• Decreased serum albumin 

Diabetic Ketoacidosis - Assessment

• Clinical s/s

  • Malaise

  • Headache

  • Polyuria

  • Polydipsia

  • Polyphagia

  • N/V

  • Extreme fatigue

  • Weight loss

  • CNS depression

  • Dehydration s/s

Diabetic Ketoacidosis - Management

• Monitor therapy response

  • Hourly BG

  • Hourly urine

  • I’s and O’s

  • VS

    • HR

    • BP

  • Hemodynamic values

• Transition to SUBQ insulin

• Surveil for complications

  • Hyponatremia

  • Cerebral edema

    • LOC

• Skin care

• Oral hygiene

• Infection prevention

Diabetic Ketoacidosis - Treatment

• SUBQ insulin

• Fluids

• Manage fluid balance

• IV insulin

• Treat underlying infections

• Monitor acidosis

• Monitor anion gap

• Monitor and replace electrolytes

  • K, Mg, phosphate

• Monitor serum bicarb

  • If low

• Promote nutrition

• Pt and family education

Diabetic Ketoacidosis - Labs to monitor

• Hyperglycemia

• Ketones

• Acidosis

Diabetic Ketoacidosis - Prioritization

• VS and labs

  • Blood glucose

  • Ketone blood and urine

  • Anion gap

  • Electrolytes

    • K, Mg

    • Blood pH

    • CO2/serum bicarb

• Clinical assessment

  • Acetone breath (fruity)

  • Kussmaul breathing

  • Mental status changes

• History and risk factors

  • New diabetes onset

  • On inulin or meds?

  • New infection onset

  • Acute illness onset

  • Assess for fluid balance deficits

  • Rule out pancreatitis

Hypothyroidism/Myxedema Coma - Assessment

• s/s

  • Lethargic to coma

  • Low temperature

  • Brady cardia

  • Hypotension

  • Slow respiratory rate

  • Respiratory acidosis

  • Skin thickened, rough to touch

• High TSH

• Low free T4

Hypothyroidism/Myxedema Coma - Management

• Medical

  • Ventilator support

  • Correction of F&E imbalance

  • Correction of multisystem abnormalities

  • Corticosteroid supplementation

  • Thyroid hormone replacement therapy

• Nursing

  • Pulmonary

    • ABG monitoring

  • Dysrhythmias

    • ECG monitoring

  • Thermoregulation

    • Rewarming

  • Thyroid replacement therapy

  • Skin care

  • Elimination

  • Patient education

Hypothyroidism/Myxedema Coma - Treatment

• Interventions

  • Intubation, mechanical ventilation depending on LOC, hypoxemia, hypercarbia, and metabolic derangement

• Heat warmer to raise temperature

• Normalize BP and HR

• Administer hydrocortisone if associated adrenal dysfunction

• Treat underlying infections

• Correct metabolic abnormalities

• Patient and family education

Hypothyroidism/Myxedema Coma - Pharmacology

Thyroid hormone replacement

Hypothyroidism/Myxedema Coma - Labs to monitor

• TSH

• Free T4

• Metabolic pannel

Hypothyroidism/Myxedema Coma - Prioritization

• Assessment

  • VS

    • BP

    • HR

    • Temp

  • History and RF

    • Hypothyroidism history

    • Thermoregulatory

      • Cold

      • Low temperatures

    • CV

      • Bradycardia

      • Hypotension

    • Neuro

      • Stupor

      • Coma

      • Seizures

    • GI

      • Constipation

      • GI ileus

      • Weight gain

    • Assess for associated endocrine dysfunction

      • Adrenal

      • pituitary

Diabetes Insipidus - Assessment

• s/s

  • Dilute urine in high volume

  • Low urine osmolality

  • Low urine specific gravity

  • High serum sodium

  • High serum osmolality

  • Elevated ICP in central DI

  • ADH not produces

Diabetes Insipidus - Management

• Medical

  • Volume restoration

  • Meds

    • DDAVP

      • Desmopresin

• Nursing

  • Rapid fluids

  • VS

  • Urinary catheter

  • PT and family education

Diabetes Insipidus - Treatment

• Priority interventions

  • Replace ADP

    • DDAVP

    • Vasopressin

• Monitor U/O in response to vasopressin

• IV fluid resuscitation

  • Crystalloids

• Monitor serum sodium & osmolality

• Monitor urine sodium & osmolality

• Patient and family education

Diabetes Insipidus - Pharmacology

• DDAVP

• Vasopressin

Diabetes Insipidus - Labs to monitor

• Serum osmolality

• serum sodium

• Urine osmolality

• Urine specific gravity

Diabetes Insipidus - Prioritization

• Assessments

  • VS

    • ICP

  • Urine output

  • Herniation

    • ICP elevation

    • Check pupils

    • Altered LOC

SIADH - Assessment

• s/s

  • Dilution hyponatremia

    • Low serum sodium

    • Low serum osmolality

  • Low urine output

    • High urine sodium

  • Excess ADH produced

    • ADH level is not tested

SIADH - Management

• Medical

  • Differentiate from other causes

  • Stop medication causing SIADH

  • Fluid restriction

    • 500 to 100 mL/day

  • Sodium replacement

    • Osmotic demyelination

  • Medications

    • Vasopressin receptor antagonists

      • Vaptans

    • Aquadiuresis

• Nursing

  • Fluid restriction

  • I&O

  • Labs

  • Moisten the mouth

  • Weight

SIADH - Treatment

• Correct fluid and sodium balance

• Restrict fluid intake

• Pharm

  • Vaptans

  • Dont restrict fluids

• Replaced sodium slowly

  • Do NOT raise more than 10mEq in 23 hrs

    • 3%hypertonic sodium

    • 0.9% crystalloid

  • Monitor serum sodium and osmolality

  • Monitor urine sodium & osmolality

  • PT and family education

SIADH - Labs to monitor

• Serum sodium

• Serum osmolality

• Urine osmolality

SIADH - Prioritization

• Assessments

  • VS

  • Mental status change

  • Seizures

  • Coma

  • High risk factors

    • Malignancies

      • Small cell carcinoma

  • Head injury

  • medications

SIADH - assessment, management, treatment, pharmacology, labs to monitor, prioritization

Pharmacology

HHS (hyperglycemic hyperosmolar state) - Assessment

• s/s

  • Type II diabetes

  • Very high blood glucosis

  • Diuresis

  • Electrolyte imbalance

  • Normal acid base balance

  • Elevated serum osmolality

  • Dehydration

HHS (hyperglycemic hyperosmolar state) - Treatment

• Priority interventions

  • Obtain IV access

  • Manage fluid balance

    • IV fluids based on level of dehydration

  • Insulin per protocol

  • Treat underlying infections

  • Monitor and replace electrolytes

    • K, Mg, phosphate

    • Monitor serum osmolality in HHS

    • Promote nutrition

    • Patient and family education

HHS (hyperglycemic hyperosmolar state) - Labs to monitor

• Resolution

  • Serum osmolality <315

  • Anion gap normal

  • BG normal

• Glucose

• Ketone

• pH

• Osmolality

• Sodium

• K

• Bicarb

• Phosphate

• Urine acetone