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148 Cards in this Set
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shock and/or dehydration
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increase pulse - tachycardia
decrease b/p (<80) decrease urine output cold and clammy |
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DKA nursing priorities
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Get an IV access
start an insulin drip fluids bicarb electrolyte panel |
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HHNS nsg diagnosis
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fluid volume deficit
seizure precaution infection such UTI |
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lactic acidosis
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utilize anaerobic metabolism for energy
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ammonia and CO2
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breakdown proteins for energy
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ketoacidosis
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breakdown fat for energy
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main difference between DKA and HHNS
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ketones and metabolic acidosis
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when do you know tx is successful for DKA
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urinary output increases
blood sugar increases |
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what happens if blood sugar drops too fast
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seizures
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DKA s/s
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kussmaul respirations
fruity breath metabolic acidosis (abd pain) type 1 diabetic - based on H&P ketones (urine or blood) glucose > 300 probably has some insulin in body |
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HHNS s/s
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glucose > 600
type II - definite insulin in body blurred vision dehydration hypokalemia |
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treatment for HHNS
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slow insulin drip (regular)
FSBS every hour fluid start with 1/2 NS adding glucose when BS drop = change to D5W |
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what does adding glucose do to the body
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it may help prevent cerebral edema which may cause seizures
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diabetes s/s
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increase urinary output
increase thirst increase hunger weight changes |
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s/s hyperkalemia
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high T waves - peak arrythmias
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what happens when insulin is given by IV
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insulin makes the cell membrane more permeable to potassium so cells fill up with potassium but vascular space is depleted. lab values will show a decrease in potassium but sodium will be norm or high. tx - give potassium but be sure to monitor values to prevent hyperkalemia
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if potassium is 3.0 or lower
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contact physician
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prevention of DKA
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take insulin with carbs
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s/s HHNS
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confusion
polyuria polydipsia |
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s/s hypoglycemia
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changes in LOC
hungry shaky anxiety cold sweat |
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DKA fluid volume deficient
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decrease of fluid volume may lead to renal failure and/or death
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action of NS
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it actually pulls glucose back into the cells
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s/s hypovolemic
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decrease urine output - increase specific gravity
decrease b/p increase pulse decrease H&H cold and clammy skin decrease capillary refill |
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why is the skin cool and clammy
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the blood is pooling to the main organs - heart, brain and lungs
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s/s rejection
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decrease urine output
pain fever |
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cardio - left side
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if the left side is weak then the output is decreased which leads to volume pooling in the ventricles causing heart failure, pulmonary edema, frothy sputum and crackles
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cardiac tamponade
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fluid in the pericardial sac
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which is the thinnest side of the heart
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(R) side of the heart
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what happens when (R) side of heart starts filling up
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blood backs up into the jugular vein leading to distention
decrease cardiac output which results in decrease b/p and increase pulse |
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treatment for (R) sided HF
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pericardial centesis
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when do you know tx for (R) sided HF is successful
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when b/p increase and pulse decreases
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what is sepsis
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it is a serious body-wide response to bacteria or another infection
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what is the precursor of SIRS
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white blood cells released
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bactremia leads to
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shock
MODS DIC |
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the 3 Ws of sepsis
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wind
wound water |
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predisposing factors to sepsis
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age and wounds
pneumonia ruptured diverticulus UTI decubitus |
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how to prevent sepsis
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ventilator associated pneumonia (VAP)
catheter-related infections surgical site infections urinary tract infections |
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what is ventilator associated pneumonia (VAP)
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airway infection that develops at least 48 hours after intubation (most commonly a week later)
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ventilator associated pneumonia bundle
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elevate HOP
daily sedation (vacations) and assessment of readiness to extubate peptic ulcer disease prophylaxis deep vein thrombosis prophylaxis |
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prevention of catheter-related infections
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handwashing
maximal barrier precautions upon insertion chlorhexidine skin antisepsis optimal catheter site selection - subclavian preferred site daily review of line necessity and removal of the CVC as early as possible |
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prevention of surgical site infections
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clipping rather than shaving the surgical site
appropriate ABT for length of time one hour prior to surgical incision and d/c 24 hours after surgery, 48 hours after cardiac surgery |
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prevention of UTI
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avoid unnecessary catheterization
insertion using aseptic technique maintaining a close drainage system ensure dependent drainage and unobstructed urine flow minimizing manipulation of urine collection system |
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acute lung injury
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tachypnea
hypoxemia |
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s/s sepsis
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fever, chills, hypotension
decreased skin perfusion decreased capillary refill or mottling decreased urine output significant edema or positive fluid balance hyperglycemia |
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liver dysfunction
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jaundice (plasma bilirubin greater than 4)
coagulapathy (INR > 1.5 and/or PTT > 60) decreased protein C levels increased D-dimer levels |
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gastointestinal injury
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stress ulceration
ileus (absent bowel sounds) and malabsorption hypotension lactic acidosis |
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cardiac dsyfunction
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tachycardia
dysrhythmias decreased CVP or PA pressures high or low cardiac outputs |
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sepsis resuscitation bundle
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best if complete within the first 6 hours
administer an initial minimum of 20 ml/kg of crystalloid or a colloid use vasopressors for hypotension not responding to initial fluid resuscitation to maintain a MAP greater than 80 |
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three vasopressors used in septic shock
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dopamine
norepinephrine vasopressin |
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causes of hypovolemic shock
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body fluid depletion
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examples of hypovolemic shock
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hemorrhage
dehydration |
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treatment of hypovolemic shock
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fluid resuscitation and treat the causes
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causes of cardiogenic shock
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pump failure (body fluid normal)
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examples of cardiogenic shock
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MI
ventricular dysrhthmias cardiomyopathies |
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treatment for cardiogenic shock
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treat cause and use drugs to increase cardiac output or decrease peripheral vascular resistance such as vasodilators
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causes of distributive shock
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decreased vascular tone (body fluid normal)
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examples of distributive shock
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anesthesia
spinal cord injury head trauma anaphylaxis sepsis |
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treatment for distributive shock
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treat the cause and give fluids to sustain vascular volume until stable; the veins are dilated and floppy so the surgeon needs to hurry the surgery
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clinical diagnosis of shock
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systolic b/p < 80
MAP < 60 urine output < 30 ml/hr cold and clammy skin restlessness |
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classification for all types of shock
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anaerobic cellular metabolism leading to tissue hypoxia and cell death
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dopamine
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increases MAP primarily by increasing stroke volume and increasing heart rate
minimal effect on systemic vascular resistance when administered by continuous infusion should begin to have an effect within 2 to 5 minutes |
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norepinephrine
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usually results in a significant increase in MAP with little change in HR or cardiac output
more effective than dopamine at reversing hypotension in septic shock patients that are resistant to fluid resuscitation initial response should begin in 1 to 2 minutes |
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vasopressin
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an increase in MAP without an increase in cardiac index or HR should be detectable within one hour
there should not be a decrease in urine output continue to observe for adequate tissue perfusion and cardiac output |
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dissemintated intravascular coagulation (DIC)
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toxins that cause small clots to form within the capillaries and clotting factors are "used up" and the client begins to bleed
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what is the purpose of administration of recombinant human activated protein
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it prevents clotting
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postmortem organ donation contraindications
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uncontrolled sepsis
active viral infections (Hep B or C, and CMV) HIV positive serology any malignancy (except a primary intracranial tumor) |
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three cardinal finding in brain death
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coma or unresponsiveness
absence of brain stem reflexes apnea |
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s/s absence of brain stem reflexes
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pupillary reflexes
oculocephalic reflex testing (doll's eyes) oculovestibular testing (ears) facial sensation and facial motor response (trig) absence of pharyngeal and tracheal reflexes (no cough or gag reflex when suction) |
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types of rejections
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hyperacute rejection
accelerated rejection chronic rejection |
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s/s kidney rejection
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elevated BUN and creatinine with decrease output
weight gain, edema, increased b/p, fever, chils, elevated WBC, graft swelling and tenderness |
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tx for kidney transplants
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corticosteroids
antilymphocyte antibodies (Rabbit ATG) |
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alcohol withdrawal syndrome (AWS)
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develop in individuasl with habitual alcohol intake who t=stop or signifiv=cantly decrease their alcohol consumption
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acute liver failure
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rare condition characterized by a rapid decline in liver function that occurs in a person without preexisting liver disease
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acute liver failure (ALF) is also called
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fulminant hepatic failure
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acetaminophen overdosing
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leading cause of ALF
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cirrhosis
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the end stage of chronic liver disease
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cirrhosis results
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disorders such as hepatitis and alcoholic misuse that damage liver cells over time
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cirrhosis or CLF
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characterized by progressive deterioration in liver function and development of portal HTN
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chronic liver failure tx
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treat the underlying disease in hopes of halting the process while preventing or treating complications and evaluating the pt for transplantation
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alcohol
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CNS depressant
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depressant
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a substance that slows down the nervous system and its transmission of messages
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alcohol removed
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when alcohol is no longer acting as a depressant, the compensatory actions cause excessive CNS excitability.
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alcohol abuse
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is a pattern of maladaptive behavior coupled with other social problems
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alcohol abuse 1
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failure to fulfill school, social, or work obligations
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alcohol abuse 2
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recurrent alcohol use in physically hazardous situations
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alcohol abuse 3
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reucrrent legal problems related to substance abuse
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alcohol abuse 4
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despite alcohol related social and interpersonal problems, continues to use alcohol
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alcohol dependency
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a pattern of maladaptive behavior associated with one or more other symptoms
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alcohol dependency 1
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withdrawal symptoms
proof of tolerance |
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alcohol dependency 2
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relentless desire to cut down or control use
occupational, social and recreational tasks that are given up |
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alcohol dependency 3
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alcohol taken in larger amts than planned
time is spent obtaining, using, and recovering from the alcohol |
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alcohol dependency 5
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alcohol use continues regardless of physical and psychological troubles
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kindling effect
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occurs when brain cells that have been involved in an episode once are more likely to do so again, and more cells will become sensitized over time
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kindling effect withdrawal symptoms
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seizures
alcoholic hallucinosis withdrawal delirium delirium tremens (DTs) |
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habitual alcohol intake
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may result in alcohol withdrawal syndrome, autonomic and neuropsychiatric manifestations
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management of habitual alcohol intake
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CIWA-Ar
symptom triggered therapy medications supportive medications prevent progression decrease severity |
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severe AWS
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increased mortality
increased number of complications increased time in ICU |
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mild AWS
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majority have an uneventful recovery
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CAGE questionaire
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CUT down drinking
Annoyed by criticism Guilty feelings Eye opener |
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goals for AWS
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identify at risk patients
establish severity control manifestations maintain fluid and electrolyte balance minimize affect on concurrent illnesses prevent complications |
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medications for AWS
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symptome triggered therapy
CIWA-Ar total score sedation benzodiazepines propofol thiamine fluid and electrolytes replacement tx of hypoglycemia |
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nursing considerations for AWS
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promote safety, comfort, and dignity
provision of adequate nutrition coping (patient and family) |
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prevention of complications of AWS
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seizures
DTs fluid and electrolyte imbalances respiratory/cardiac events |
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s/s of AWS
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n/v
tremor sweating anxiety agitation headache disorientation tactile, visual, and auditory disturbances |
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minor AWS
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6 - 12 hours
peak 24 - 36 hours resolve after 48 hours |
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vitamin deficiencies
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folic acid
thiamine |
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wernicke's encephalopathy
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syndrome characterized by ataxia, ophthalmoplegia, confusion, and impairment of short-term memory
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ataxia
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lack of muscle coordination
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delirium tremens
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severe form of alcohol withdrawal that involves sudden and severe mental or neurological changes
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delirium tremens occur
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within 72 hours after last drink, but may occur up to 7 - 10 days after last drink
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delirium tremens is the most
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severe complication of withdrawal
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alcohol withdrawal seizures
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"rum fits" usually occurs in 6 - 48 hours
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hallucinosis
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occurs in 12 - 24 hours
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goal of tx for AWS
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prevent, recognize, and tx symptoms; halt progression; provide a safe and dignified withdrawal; prevent and treat complications
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symptom-triggered therapy
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preferred method of medication administration
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benzodiazepine
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diazepam (valium)
lorazepam (ativan) midazolam (versed) |
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diazepam (valium)
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long acting benzodiazepine
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lorazepam (ativan)
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intermediate acting benzodiazepine
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oxazepam (serax)
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intermediate acting benzodiazepine
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midazolam (Versed)
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short-acting benzodiazepine
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haldol
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not recommended
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thiamine
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an essential for normal metabolism and utilization of glucose
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alcohol depletes
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liver glycogen stores and impairs glucogenesis (the formation of glucose from glycogen)
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IV dextrose with thiamine
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necessary to prevent Wernicke's encephalolpathy and/or Korsakoff's syndrome
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wernicke's encephalopathy
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acute neurological complication which results in confusion, abnormal gait and paralysis of certain eye muscles
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korsakoff's syndrome
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nutritional deficiency which results in selective memory disturbances and amnesia
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parenteral route
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preferred because the oral route can have erratic absorption
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alcohol inhibits secretion of which hormone
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ADH which causes an increase in urine output; since ADH is no longer inhibited the patient has fluid retention.
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which fluids are given
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D51//2 NS or NS
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potassium levels
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below 3.5
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low potassium
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inadequate intake
excessive diuresis v/d |
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low potassium sign/symptoms
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ventricular dysrhythmias
flattened or inverted T wave prominent U waves prolonged QT and ST depression |
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magnesium during withdrawal
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it shifts into cells secondary to metabolic changes, including alcohol ketoacidosis, lactic acidosis, and hypoglycemia
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low potassium and low calcium
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low magnesium
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hypomagnesia
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tremor, spasms, twitching
anorexia, n/v behavioral change (mood changes, confusion, insomnia) tachycardia, HTN, and cardiac dysrhythmias, ECG changes (inverted or flat T waves), positive chvostek's sign |
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pacifism aggression
fear of loss pain |
Magnesium Mg
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calcium gluconate
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use for magnesium toxicity
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hypoglycemia caused by
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liver failure because alcohol exhaust liver glycogen stores and impairs glycogenesis.
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management of hypoglycemia
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administration of thiamine to prevent wernicke-korsakoff syndrome
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acute liver failure caused by
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toxins (acetaminophen)
hepatitis shock |
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chronic liver failure caused by
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alcohol
hepatitis non-alcoholic fatty |
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chronic liver failure leads to
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cirrhosis
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cirrhosis leads to
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portal HTN
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nutrition
glands, bones, skin blood, chest, heart, R lung |
.Calc carb
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chronic liver failure tx
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prevention of complications and/or transplantation
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pancreatitis
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usually associated with alcohol abuse
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paracentesis
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medical procedure involving a needle drainage of fluid from a body cavity, most commonly the peritoneal cavity in the abdomen
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paracentesis
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medical procedure involving a needle drainage of fluid from a body cavity, most commonly the peritoneal cavity in the abdomen
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