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DKA: Risk factors

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Infections Initial presentation of type I DM Stress from surgery or trauma Malfunction of insulin pump** Eating disorders** or stress eating Glucocorticoids Stress not allowing Sleep** Other: time management of taking insulin**, financial resources low (can't afford insulin)*

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DKA: Clinical Presentation (What it looks like)

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**Blood glucose >250 (Usually >625 and <1000) Kussmaul Respirations** Acetone breath Coma or change in LOC Total body deficit of K+ (May have false normal) Ketone/GLucose in urine Dehyrdration of 6L Metabolic acidosis**, pH <7.3 FLushed, dry skin Polyuria, plydipsia, Polyphagia N/V Weight Loss (Profound)

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DKA: Nursing Interventions

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Priority=Airway #2 Breathing=respiratory support #3 Correct K+ to a high normal value! Fluid Replacement** Supportive measures

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DKA: Fluid Replacement

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Initial bolus of 1L of 0.9% NS** Add 5% Dextrose @ 250mL/dL when** plasma glucose level approaches 200mg/dL (prevent hypoglycemia and correct Ketosis) Target blood glucose reduction @ 75mg/dL (50-70/hr)** Serum K+ > 3.3mEq/L******

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DKA: Glucose Reduction Goals

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50-75/hr reduction = 75mg/dL** **If you decrease glucose too fast causes cerebral edema=death Serum K+ >3.3** Monitor stress and psychosocial issues

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DKA: Potassium Goals

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Keep between 4-5 mEq/L Must correct to prevent dysrrhythmias with fluid replacement

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Hyperosmotic Hyperglycemic State (HHS): RIsk Factors

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High cal parenteral nutrition B-blockers, thiazide diuretics, CCBs, Phenytoin, Glucocorticoid, TPN Not enough fluid intake (Nursing home residents, Mentally disabled)** Major illness stress response* Type II DM initial presentation

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How is HHS different from DKA?

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No ketosis higher levels of hyperglycemia (>1000)* Plasma osmolality about 350mOsm/kg* Greater body fluid devicit >9L** More profound LOC decrease (Coma)* Type II DM not TYpe I* Mild acidosis or not present* Absent DTRs** Positive Babinski sign**

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HHS: Nursing Interventions

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Airway and O2 #1 Fluid replacement same as DKA but more volume* Decrease CBG @ 75mg/dL slowly!!* K+ >3.3mEq/L** Insulin drip SUbcutaneous insulin when CBG is 200mg/dL** 50-75mg/dL/hr cbg reduction rate Monitor for fluid volume overload and cerebral edema (LOC, Lung sounds)

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HHS: Tx Goals

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Meet two of the following: 1. pH >7.3 2. HC3O >15 mEq/L 3. Anion gap <12 mEq/L

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Adrenal Crisis

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Life threatening absence of cortisol and aldosterone (corticosteroids)

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Adrenal Crisis: Cause and Risk Factors

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Primary: (results in Addison's Dx) 1. Destruction of adrenal gland (90%) 2. TB, Hemorrhage, infection, HIV Secondary: 1. Abrupt w/drawal from steroids** 2. Systemic inflammatory states (sepsis, vasculitis, sickle cell) 3. Hypothalmic Disorders

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Adrenal Crisis: Clinical Presentation (What it looks like)

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Low Na+ Hyperkalemia** Hypotension requiring vasopressors (Fluids won't work)** Hypovolemia** HxA and fatigue that worsens Severe fatigue LOC changes Hypoglycemia** Plasma cortisol <10mg/dL

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Adrenal Crisis: Nursing Interventions

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Fluid replacement with D5W and NS until hypovolemia stabilizes (5L in 1st 12-24 hrs) Pt education for preventing another crisis Meds: 1. Glucocorticoid replacement (Dexamethasone) 2. Pressors - Dopamine, norempinephrine

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How do you know if fluid replacement is working?

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Urine output and BP stabilization (Outcomes are met!)* UA output 50-60 mL/hr

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Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

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Produce excess ADH Stimulation of hypothalamus or pituitary to secrete ADH. Inability to secrete a dilute urine, fluid retention, hyponatremia

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SIADH: Causes and Risk Factors

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Small cell carcinoma of lung** Head injury or injury of hypothalamus or pituitary Malignancy near or of Hypothalamus or pituitary Cancer of prostate, pancreas, or duodenum Hodgkin's disease Viral Pneumonia TB, COPD Intracranial surgery Stroke Brain tumor

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SIADH: Clinical Presentation (What it looks like)

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Hyponatremia and hypo-osmolality*** Confusion HxA, seizures, coma Increased BP, CVP, and PAOP Increased RR, Dyspnea, crackles in lungs Frothy pink sputum Concentrated urine and decreased output UA sodium >20mEq/L Decreased BUN, Cr, and albumin Edema Increased ICP =Hypervolemia

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SIADH: Nursing Interventions

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Fluid restriction 800-1000mL/day** Liberal salt and protein intake Gradual return to baseline - NS slow** Oral care (spit don't swallow) Seizure Precautions if NA+ <120 Pt education

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Thyroid Storm

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Hyperthyroidism untreated Rare if normal thyroid gland

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Thyroid Storm: Clinical Presentation

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Severe fever* up to 106 Marked Tachycardia* Increased CO* = AHF Decreased BP* Tachypnea* Hyperthermia (severe)* A. FIb. Muscle weakness and fatigue Cramps

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Thyroid Storm: Nursing Interventions

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Beta Blockers* High-Dose glucocorticoid Cool, quiet environment, low stim High cal high protein diet Tx fever = tylenol, cooling blankets, ice packs Potassium Iodide, propylthiouracil to stop T cell conversions* O2 supportive therapy

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Diabetes Insipidus (DI)

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Absent or diminished release of ADH** from posterior pituitary = free water loss = osmolality and sodium to increase* 2 types: 1. Neurogenic 2. Nephrogenic**

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Nephrogenic DI

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Kidney collecting ducts and distal tubules are unresponsive to ADH**** (ADH being produced by posterior pituitary but kidneys won't respond to it)

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DI: Causes and Risk Factors - Neurogenic

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Idiopathic (congenital or autoimmune) Intracranial surgery Head trauma** Increased ICP Damage to pituitary or hypothalamus gland

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DI: Causes and Risk Factors - Nephrogenic

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Hereditary Renal Diseae Drugs: ethanol, phnytoin, lithium, demeclocycline, methoxyflurane

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DI: Clinical Presentation - Neurogenic only

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Abrupt onset of polyuria

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DI: Clinical Presentation - Nephrogenic only

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Gradual onset of polyuria Hypokalemia Hypercalcemia

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DI: Clinical Presentation (Both)

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Urine s pale and dilute hypovolemia = hypotension, tachycardia, low CVP Low specific gravity Neuro changes (Hypernatremia) Concentrated urine high serum osmolality elevated BUN

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DI: Nursing Interventions

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NA restriction replace free water with hypotonic solutions of dextrose ADH preps for neurogenic Vasopressin and Desmopressin Pt teaching Volume replacement Monitor for fluid overload!!*

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Myxedema

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Most life threatening form of hypothyroidism Opposite of Thyroid storm Coma Usually coincides with stressor (infection)** Usually elderly women Hypothermia**, stroke, trauma, critical illness

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Myxedema: Nursing Interventions

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Levothyroxine** (longer duration) Tx hypothermia** - warm room, passive warming with blankets=decrease metabolism Monitor gas exchange and resp status, tongue edema* ECG Decrease Sodium intake* No narcotics, must avoid resp depression

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Primary Survey for Trauma

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Rapid 1-2 min* evaluation Baseline data - identify and correct life threatening problems* Airway with C-spine stabilization Breathing Circulation DIsability Exposure

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Secondary Survey for Trauma

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Methodical head-to-toe assessment FUll vitals, 5x interventions 1. ECG 2. SPO2 3. NG 4. Foley 5. Labs Hix Comfort Inspect back

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ESI Triage

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Categorizes pt into most critical tx first <15 sec assess 5 level triage Incorporates illness severity, Resources, impending death** Level 1= impending death* Level 5= stubbed toe, Upper resp infection

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Golden Hour in Trauma

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1st hour of emergent care focusing on rapid asssessment, resuscitation, and tx

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Exposure of Pt to Radioactive Material (Primary Intervention)

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Shower decontamination**

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Abdominal Trauma

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Looks like: Pain in area or referred to shoulder (spleen), hypotension, costobertebral tenderness, hematuria, bruising over lower ribs, hemorrhage or shock to kidneys Tx: FAST**** Focused Assessment with Sonography for Trauma********

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Blast Injury

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Blunt, penetrating trauma Organ injury Gas organ injury (eardrums, lungs, intestines) Primary: Change in air pressure causing tissue damage (Shock wave) Secondary: Debris impale the body Tertiary: Body thrown by force=Blunt trauma Quarternary: Chemical, thermal, Bio exposure

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Heat Stroke: Tx

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Stabilize ABC (100% O2 for hypermetabolic state, mechanical vent) Rapidly reduce temp** Cooling Methods**: 1. Remove clothing* 2. Cover with wet sheets* 3. Place pt in front of large fan* 4. Immerse in ice water bath* 5. Admin cool fluids or lavage with cool fluids*

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Pulmonary Contusion

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From blunt or penetrating trauma to chest MVC** One of the most common causes of death after chest trauma Often results in ARDS** Long term vent, focus on pain relief Careful with fluid admin for pulmonary edema

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Pulmonary Contusion: Clinical Presentation

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Chest wall abrasions or bruising* Signs of hypoxia on room air* Bloody secretions* Chest wall ecchymosis* Bruising of lung tissue*

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Tension Pneumothorax

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Emergency** Increased intrapleural and intrathoracic pressures= Compression of heart Can result in cardiovascular collapse

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Tension Pneumothorax: Clinical Presentation

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Absence of breath sounds on the affected side** Severe resp distress and chest pain Tracheal deviation Tachycardia and hypotension

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Tension Pneumothorax: Nursing Interventions

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Immediate decompression with needle thoracostomy** Prepare for chest tube insertion on affected side**

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Hypovolemia

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Decreased cardiac output with trauma most often caused by hypovolemia from blood loss**

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Hypovolemia: Intraosseous Procedures

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For fluid resuscitation If cannot get two large bore IV lines Can access in Sternum, legs, arms, or pelvis**

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Hypovolemia: Complications

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Hypothermia - Prevent by warming fluids** Coagulopathies - Citrate in banked blood may induce hypocalcemia** Avoid massive transfusions

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Hypovolemia: Life-Threatening Blood Loss

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Dr may request unmatched, type specific or O blood** O pos for adult male and females over 40** Will give medications with to control any possible reactions

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Hypothermia: Complications

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Myocardial dysfunction* Coagulpathies (Calcium)* Reduced Perfusion* Dysrhythmias (PVCs cause death)* Risk for bleeding because cannot clot

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Hypothermia: Tx

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Warm trauma room* External heating device (force air warmer)* Warm fluids and blood products for rapid infusion** Transfusion with clotting factors** Watch Calcium*****

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Compartment Syndrome: Neuro Assessment

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5 P's: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia*** Increasing throbbing pain not relieved with narcotics*

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Rhabdomyolysis: Risk Factors

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Crush Injuries** Being struck by lightning* Anything that causes a lot of muscle damage** compartment syndrome burns Compromises Renal blood flow**

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Rhabdomyolysis: Fluid Resuscitation

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Want to flush myoglobin from renal tubules Use osmotic diuretics and sodium bicarb with IV fluids Titrate IV fluids to achive UA output of 100-200 mL/hr****

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Fat Embolism: Risk Factors

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Long Bone injury** Multiple fractures = scenario with femur fracture**

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Fat Embolism: Clinical Presentation

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Low grade fever new onset tachycardia, dyspnea, increased Resp effort, and hypoxemia Petechial rash

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Fat Embolism: Tx

answer

Stabilization of fractured extremities to minimize movement to prevent release of fat****

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Cervical Injury: Nursing Interventions

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Maintain complete spinal immobilization* Prepare for cervical traction or halo device* Must stay immobilized until they go for surgery to be fused** Airway is priority, then O2 (Breathing), then immobilization** Have suction nearby in case of vomiting while strapped to board External Fixation - pin care, watch for infection** Halo brace** Do not under straps!!*

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Basilar Skull Fracture

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Assess for Battle sign (bruising behind ear) Cerebrospinal fluid may be present No NG tube!

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Non Burn Dermal Injury: Clinical presentation

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Toxic Epidermal Necrolysis (TEN) from* environmental agent* Stevens-Johnson Syndrome * Initial fever and flu-like symptoms* Erythema and blisters develop within 24-96 hrs**

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Burns: Rule of 9s

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Chest is 9%* Trunk is 18%* Head is 9% Leg is 18% (one side) Arm is 9% (one side)

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Burns: Parkland Forumula

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4mL x kg x % burned** Give half in first 8 hrs* Give second half over 16 hrs* Use LR first 24 hrs then can switch to D5W

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Burns: Pain Management

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Opiates IV in a higher than normal dosage** PCA* with basal rate Give pain meds before any dressing change or intervention Substance abuse will have higher tolerance and need higher drug amounts* (see a lot of burn patients that are alcoholics or abusers) Increased metabolism makes them not last as long* Pre-medicate** Anxiolytic

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Burns: Sign it was a meth lab

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Hands, face burned Agitated Change story and does not match symptoms*

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Burns: Wound Care

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*Topical Antimicrobial Autograft* creates partial thickness wound from site* Premedicate before movement* ROM active and passive* Bandage fingers and toes individually* Splint extremeties extended while pt is resting to prevent contractures* Allograft/homograft = Temporary*, from person Xenograft = Temporary, from animal* Sheet nonmeched graft = over joint, face, hands* Compression used to decrease scars (Keloids)*

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Burns: ROM

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Hourly for 5 mins Prevent edema

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Burns: Vacuum Assisted Closure Devices (VAC) NPWT (Neg Pressure Wound Therapy)

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Creates negative-pressure dressing Remove wound fluid and provide a closed, moist wound healing environment* Stimulates perfusion* Earlier Re-epithelization*

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Burns: Intraabdominal Hypertension

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**Serial IAP measurements via bladder pressure are performed on pt with: 40%< burns* 20% burns with inhalation* With fluid resuscitation greater than expected* Symptoms:** tense abdomen Decreasing UA output Elevated airway pressure Hypercapnea Hypoxemia

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Burns: Risk for Infection

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Wash hands* Aseptic Wound care* Combined IV and topical antibiotics* rotate topical sites Multiple invasive lines, IV, foley, ETT, take out at first available time to reduce chance of infection***

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Burns: Abdominal Compartment Syndrome

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Monitor circumferential full-thickness burns**, can restrict breathing if on chest or abdomen* s/sx: tense abdomen, decrease urine, tachypnea, increased CO2, decreased O2* APP=MAP-IAP (intraabdominal pressure)**

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Burns: SIlver Nitrate

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Effective against wide spectrum of common wound pathogens**

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Burns: Hands, Feet, Joints

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Fingers and toes wrapped individually* Active or passive ROM to prevent atrophy, reduce shortening of ligaments, prevent contractures, decrease edema** Splinting and antideformity positioning are required to maintain function and prevent deformities of affected part**

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Burns: Suspected Abuse

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Suspicious burn marks must be reported* Separate pt from caregivers to assess*** Maintain patient safety

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Burns: Inhalation Injury

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Facial Burns Presence of soot around mouth and nose Singed nasal Hairs= airway swelling = intubate** Key is to protect airway and early intubation due to risk for edema***

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Burns: Chemical Burns

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Deep every second, must be removed safely Dry chemicals= brush off then irrigate* Carefully remove clothing so not to spread agent* Methamphetamine injury is common** Call MSDS and do what they say****

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Burns: Electrical/Lightening Injury - Complications

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Cardiac dysrhythmias* Cardiopulmonary arrest* Rhabdomyolysis = Myoglobulinuria* Compartment syndrome* Long bone fractures* Neuro deficit* Seizures* Associate with curling ulcers (peptic)** Acute Cataract Formation*

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Burns: Electrical/Lightening Injury - Clinical Presentation

answer

Tetanic muscle contraction Resp muscle paralysis* Cutaneous injury superficial Lightning = Cardiopulmonary arrest AC higher probability of cause cardiac arrest with V fib.**

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