DKA, HHS, Hypoglycemia, Myxedema Coma, Thyroid Storm, SCI, Spinal Shock, Neurogenic Shock, Autonomic Dysreflexia

DIABETIC KETOACIDOSIS (DKA)

• Monitor for signs of increased ICP

• Blood glucose level falls LOW or FAST before brain can equilibrate

• Water moves from blood to CSF and brain

• Cerebral edema and increase ICP

Hyperglycemic Hyperosmotic Syndrome (HHS)

• a serious metabolic complication of diabetes mellitus ▪

• formerly known as HHNK

Hyperglycemic Hyperosmotic Syndrome (HHS) Causes:

• omission or sudden decrease in oral hypoglycemic dose

• TPN or tube feedings without sufficient water

• Renal disorder treatment (Peritoneal dialysis)

Hyperglycemic Hyperosmotic Syndrome (HHS) Clinical Manifestations:

• similar with DKA but without the ketoacidosis

Hyperglycemic Hyperosmotic Syndrome (HHS) Treatment:

• rapid fluid replacement to correct dehydration

• Decrease glucose levels

DKA Onset, Triggers Manifestations

• Onset

  • sudden

• Triggers

  • infection

  • other stressors

  • inadequate insulin dose

• Manifestations

  • Ketosis

    • Kussmaul’s respirations

    • “fruity” breath

    • nausea

    • abdominal pain

  • dehydration

  • electrolyte loss

  • polyuria, polydipsia

  • weight loss

  • dry skin

  • sunken eyes

  • soft eyeballs

  • lethargy

  • coma

HHS Onset, Triggers Manifestations

• Onset

  • gradual

• Triggers

  • infection

  • other stressors

  • poor fluid intake

• Manifestations

  • Neuro symptoms

  • dehydration

  • electrolyte loss

DKA Laboratory

• Serum Glucose

  • > 300 mg/dL

• Osmolarity

  • variable

• Serum Ketones

  • (+)

• Serum pH

  • < 7.35

• Serum HCO3

  • < 15 mEq/L

• Serum Na

  • Low, N or high

• Serum K

  • N, inc with acidosis

  • Low due to dehydration

• BUN

  • > 20 mg/dL

  • inc due to dehydration

• Creatinine

  • > 1.5 mg/dL

• Urine Ketones

  • (+)

HHS Laboratory

• Serum Glucose

  • > 800 mg/dL

• Osmolarity

  • 350 mOsm/L

• Serum Ketones

  • (-)

• Serum pH

  • > 7.4

• Serum HCO3

  • < 20 mEq/L

• Serum Na

  • N or low

• BUN

  • increase

• Creatinine

  • increase

• Urine Ketones

  • negative

DKA Summary

1. Hyperglycemia

2. Metabolic Acidosis

3. Ketotic

HHS Summary

1. Hyperglycemia

2. Absence of Significant Acidosis

3. High Serum Osmolality

Hypoglycemia Nursing Intervention

• Instruct to always carry some form of FAC

• If no FAC is available, any food should be eaten;

  • high-fat foods ????

  • slow the absorption of glucose and the hypoglycemic symptoms may not resolve quickly.

• Monitor for signs of HYPOGLYCEMIA UNAWARENESS

  • clients who may not experience warning signs of hypoglycemia until level is dangerously low

    • frequent episodes of hypoglycemia

    • older clients

    • taking β-adrenergic blocking agents

MYXEDEMA COMA

• A rare but serious disorder results from persistently low thyroid production

• Medical emergency with high mortality rate

• Coma can be precipitated by:

  • acute illness

  • rapid withdrawal of thyroid medication

  • anesthesia and surgery

  • Hypothermia

  • Use of sedatives and opioid analgesics.

MYXEDEMA COMA Assessment

• Hypotension

• Bradycardia

• Hypothermia

• Hyponatremia

• Hypoglycemia

• Generalized edema

• Respiratory failure

• Coma

MYXEDEMA COMA Nursing Interventions:

• Maintain a patent airway.

• Institute aspiration precautions.

• Administer as prescribed;

  • IV fluids (normal or hypertonic saline)

  • levothyroxine sodium IV

  • glucose IV

  • corticosteroids

• Assess the client’s temperature hourly.

• Monitor BP frequently.

• Keep the client warm.

• Monitor for changes in mental status.

• Monitor electrolyte and glucose levels.

THYROID STORM

• acute and life-threatening condition

• in a client with uncontrollable hyperthyroidism.

• Risk factors:

  • thyroid gland surgery and the release of thyroid hormone into the blood stream

  • severe infection and stress.

THYROID STORM Assessment:

• Elevated temperature (fever)

• Tachycardia

• Systolic hypertension

• Nausea, vomiting, and diarrhea

• Agitation, tremors, anxiety

• Irritability, agitation, restlessness, confusion,

• and seizures as the condition progresses

• Delirium and coma

THYROID STORM Nursing Interventions:

• Maintain a patent airway and adequate ventilation.

• Administer as prescribed;

  • Antithyroid medications : PTU

  • Iodides

  • Propranolol

  • Glucocorticoids : HYDROCORTISONE

• Monitor vital signs. • Monitor continually for cardiac dysrhythmias.

• Administer non-salicylate antipyretics as prescribed (salicylates increase free thyroid hormone levels).

• Use a cooling blanket to decrease temperature

THYROID STORM Easy Nursing Interventions:

1. ABCs

2. Propranolol

• 1 mg IV

3. Propylthiouracil

• 1000 mg PO

4. Hydrocortisone

• 300 mg IV

5. Look for underlying cause

THYROID STORM Prevention:

• Administration before thyroid surgery;

• Antithyroid drugs

• Beta blockers

• Glucocorticoids

• Iodides

Normal Intra Cranial Pressure

• 7-15 mmHg

• The pressure exerted by fluids inside the skull, including cerebrospinal fluid and blood, on the brain tissue

Increased ICP

• Increased Systolic BP

• Decrease Pulse

• Decrease Respirations

Shock

• Decrease Systolic BP

• Increased Pulse

• Increased Respirations

Spinal Cord Injury (SCI)

• Trauma to the spinal cord

• Causes;

  • partial

  • complete disruption of the nerve tracts and neurons

• Involves;

  • Contusion

  • Laceration

  • compression of the cord

Spinal Cord Injury (SCI) - Causes:

• motor vehicle crashes

• Falls

• sporting and industrial accidents

• gunshot or stab wounds

Spinal Cord Injury (SCI) - Result:

• Spinal cord edema

• compromised capillary circulation and venous return

• SC necrosis

Spinal Cord Injury (SCI) - Sequela:

• Loss of;

  • motor function

  • Sensation reflex activity

  • bowel and bladder control

Spinal Cord Injury (SCI) - Complications:

• respiratory failure

• autonomic dysreflexia

• spinal shock

• further cord damage

• death

Most frequently involved vertebrae SCI

• C5, C6 and C7

• T 12

• L1

REMEMBER IN SCI

• Always suspect SCI when trauma occurs until this injury is ruled out.

• Immobilize the client on a spinal backboard with the head in a neutral position

  • to prevent an incomplete injury from becoming complete.

SCI - Emergency Interventions:

• Emergency management is critical

  • improper movement can cause further damage and loss of neurological function

• Assess the respiratory pattern and maintain a patent airway

• Prevent head flexion, rotation, or extension

• During immobilization

  • maintain traction and alignment on the head by placing hands on both sides of the head by the ears

• Maintain an extended position

• Logroll the client

• No part of the body should be twisted or turned, and the client is not allowed to assume a sitting position

• In the ER, a cervical fracture should be placed immediately in skeletal traction via skull tongs or halo traction

  • to immobilize the cervical spine and reduce the fracture and dislocation

Spinal Shock

• A complete but temporary loss of motor, sensory, reflex, and autonomic function that occurs immediately after injury

  • cord’s response to the injury

• usually lasts less than 48 hours but can continue for several weeks

• Peripheral neurons become temporarily unresponsive to brain stimuli

Neurogenic Shock

• occurs most commonly in clients with injuries above T6

• usually is experienced soon after the injury

• Massive vasodilation occurs, leading to;

  • pooling of the blood in blood vessels

  • tissue hypoperfusion

  • impaired cellular metabolism.

• Disruption of autonomic pathways → loss of sympathetic tone and vasodilation

Neurogenic Shock Assessment

• Hypotension

• Bradycardia

Spinal Shock Assessment

• Flaccid paralysis

• Loss of reflex activity below the level of the injury

• Bradycardia

• Hypotension

• Paralytic ileus

Spinal and Neurogenic Shock Interventions:

• Monitor for;

  • signs of shock following a spinal cord injury

    • hypotension and bradycardia

    • reflex activity

    • Bowel and urinary retention

    • Return of reflexes

• Assess bowel sounds

• Provide supportive measures as prescribed, based on the presence of symptoms

Autonomic Dysreflexia

• Also known as autonomic hyperreflexia

• It generally occurs;

  • after the period of spinal shock is resolved

  • injuries above T6 and in cervical lesions

• Triggers;

  • visceral distention

  • distended bladder or

  • impacted rectum

• It is a neurological emergency

• Sequela:

  • hypertensive stroke

Autonomic Dysreflexia Assessment

• Sudden onset

• severe throbbing headache

• Severe hypertension and bradycardia

• Flushing above the level of the injury

• Pale extremities below the level of the injury

• Nasal stuffiness

• Nausea

• Dilated pupils or blurred vision

• Sweating

• Piloerection (goose bumps)

• Restlessness and a feeling of apprehension

Autonomic Dysreflexia Nursing Priority Actions:

1. Raise the HOB and ask that the health care provider (HCP) be notified

2. Loosen tight clothing on the client

3. Check for bladder distention or other noxious stimulus

4. Administer an antihypertensive medication

5. Document the occurrence, treatment, and response.