NCM 118 (MS)_ PRELIMS.pdf

Week 2-3: MANAGEMENT OF OXYGEN THERAPY (Ms → FACE MASK (STANDARD MASK) Cha) Up to 60% oxygen can be supplied through the oxygen port at 6-10 LPM...

Week 2-3: MANAGEMENT OF OXYGEN THERAPY (Ms → FACE MASK (STANDARD MASK) Cha) Up to 60% oxygen can be supplied through the oxygen port at 6-10 LPM Oxygen Therapy 02 enters through the bottom port and exit → HOW AND WHEN TO PROVIDE SUPPLEMENTAL through the side holes OXYGEN? Oxygen flow should be higher than 5LPM 1. w/o respi distress — 2 lpm by nasal cannula ○ Potential to improper fitting 2. Mild respi distress — 5 to 6 lpm oxygen face mask ○ Patient may feel like suffocating 3. Severe respi distress — highest oxygen concentration → FACE MASK WITH OXYGEN RESERVOIR 4. COPD — may use venturi mask (most oxygen 1. Partial rebreather: 60-80% specific) Has openings 5. Serious cases — intubate then provide 100% 2. Non-rebreather: 80-100% oxygen 10-15 lpm Fit snugly to prevent room air from mixing with ***Note: Do not hesitate. When in doubt, provide oxygen oxygen inhaled from the reservoir bag Use for spontaneously breathing pts → HOW TO OBTAIN OXYGEN CONCENTRATION? Indications for Patients (facemask with oxygen reservoir) Seriously ill, responsive and spontaneously breathing but require O2 concentration Patient who may avoid tracheal intubation, if acute interventions produce a rapid clinical effect (e.g. acute pulmonary edema, COPD, severe asthma) For tracheal intubation but have an intact gag reflex For intubation but have clenched teeth or other physical barriers to immediate intubation (head injury, carbon monoxide poisoning, or near drowning) → VENTURI MASK Available in Fio2 24%, 28%, 35% and 40% Use 24% initially and observe for respiratory depression Use pulse oximeter to titrate preferred Pao2 level Greater control of oxygen concentration administered Preferred in COPD patients Only for spontaneously breathing patients → NASAL CANNULA (NASAL PRONGS) Note: high oxygen concentration in these pts may produce Provides up to 36% of oxygen (4 lpm) respiratory depression bc the increase in PaO2 blocks the Low-flow oxygen delivery system stimulant effect of hypoxia on the respiratory center No rebreathing of expired air Valuable in pts with COPD For SPONTANEOUSLY BREATHING PATIENTS Non-Invasive Ventilation (CPAP AND BiPAP) ONLY → NON-INVASIVE VENTILATION If flow rate of > 6 lpm: results to dry mucous Method of providing positive pressure ventilation membranes and headache without the use of an artificial airway Can easily be dislodged  Provision of ventilatory support through the IPAP (Inspiratory Positive Airway patient’s UPPER AIRWAY using a tight-fitting Pressure): airway pressure that is above mask or similar device attached to a NIV machine 0 cm H2O during the inspiratory phase of breathing THE MAIN GOAL IS AVOID INTUBATION!!! EPAP (Expiratory Positive Airway Pressure): airway pressure above 0cm NIV (2) different methods H2O during the expiratory phase of 1. CPAP or continuous positive airway pressure breathing Primary tx for OSA, a sleep disorder Adjustments are made depending on characterized by partial or complete the patient’s ventilatory and airway obstruction oxygenation status used in the inpatient setting for patients who are experiencing acute respiratory Indications for NIV ir NVPP impairment, continuously as part of Severe dyspnea in-home care for patients with Congestive HF respiratory impairment, and at home by Obstructive Sleep Apnea (OSA) patients who have OSA Pulmonary edema utilizes a flow generator and nasal Acute respiratory failure prongs, nasal mask, or a full face mask. COPD to work effectively, a tight seal must be NIV is NOT for UNSTABLE and CRITICALLY ILL patients maintained between the mask or prongs and the patient’s skin. → OSA An oxygen source is required if Condition where pt has 5 eps of APNEA that last supplemental oxygen is ordered. at least 10 seconds each within the one-hour time period while ASLEEP IMPORTANT!: can only be delivered if the patient is breathing spontaneously because it does not include any CONTRAINDICATIONS mechanical breaths APNEA HYPOVENTILATION What is the desired outcome of CPAP? FACIAL BURNS OR TRAUMA prevention of OSA and effective management of CLAUSTROPHOBIA respiratory insufficiency (e.g., in patients with RESPIRATORY MUSCLE FATIGUE heart failure ; in preterm infants with underdeveloped lungs) Responsibilities Patient should be monitored carefully for Why is CPAP important? FATIGUE When provided to patients at risk for respiratory Signs : dyspnea, tachycardia, increasing PaCO2 failure, CPAP confers several benefits over level, increasing RR ventilation via an endotracheal tube. Sedation and Form recovery in the intensive care unit (ICU)—which ○ NOTE : for the USAGE OF THE are associated with longer hospital stays, higher ACCESSORY MUSCLES medical costs, and increased risk for ○ SWITCH to NON INVASIVE ASSISTED pneumonia—are not required VENTILATION: Bilevel Positive Airway has been shown to reduce the severity and Pressure(BiPAP) incidence of potential manifestations of OSA, including excessive daytime sleepiness (EDS), → NON INVASIVE ASSISTED VENTILATION: Bilevel cognitive impairment, decreased quality of life, Positive Airway Pressure(BiPAP) and an increased risk for hypertension, stroke, form of NIV in which ventilatory assistance is arrhythmia, and other cardiovascular sequelae provided by the delivery of two levels of airway pressure to the airway. 2. BiPAP or Bi-level positive airway pressure  BiPAP provides the same function as that of A sudden increase in respiratory distress can continuous positive airway pressure (CPAP), but indicate pneumothorax due to the increase in in addition detects and enhances the patient’s intrathoracic pressure inspiratory effort. Demonstrate to the patient how to quickly remove Most frequently used in the inpatient setting, the mask in case of vomiting to avoid aspiration moderate to severe COPD, or progressive neuromuscular disease Contraindications programmed to deliver the prescribed amount of – immediate need for intubation pressure support via nasal mask or a full – unstable cardiac or hemodynamic status facemask. – inability to clear oral secretions and/or absent a tight seal must be maintained between the gag reflex mask and the patient’s skin – altered level of consciousness and/or uncooperative patient BiPAP provides two alternating levels of positive airway – alteration in facial structure that precludes pressure: effective use of a BiPAP mask inspiratory positive airway pressure (IPAP) during inspiration Different Masks Use for Both a lower expiratory positive airway pressure 1. Nasal Mask — Covers the nose (EPAP) to permit passive exhalation. 2. Oronasal mask — Aspiration, regurgitation, and asphyxiation are potential problems Outcome To reduce the patient’s work of breathing and improve lung expansion and alveolar gas exchange To prevent atelectasis and airway collapse. BiPAP is administered: ○ – to provide mechanical ventilatory support for patients with acute respiratory failure, postoperative 3. Nasal pillow respiratory insufficiency, progressive - this are PRONGS that are inserted into the nose neuromuscular diseases, COPD, central - much smaller sleep apnea, and OSA in patients who -most comfortable for patients require additional ventilatory support For CPAP only not recommended for BiPAP than that offered with CPAP Complications : Nasal Congestion; Dry mouth; ○ – to facilitate weaning from mechanical Nose Bleeds ventilation in patients with underlying lung disorders Indications 1. ACUTE RESPIRATORY FAILURE 2. Acute Exacerbation of COPD 3. PULMONARY EDEMA IMPORTANT: BEST WAY TO KNOW IF BIPAP IS INDICATED IS TO LOOK AT THE ABG RESULTS OF THE 4. Full-Face Mask PATIENT Red Flags BiPAP should be reserved for patients with signs Basics of Mechanical Ventilation and symptoms of respiratory distress (e.g., tachypnea, tachycardia, diaphoresis) who are alert, cooperative, and able to protect the airway  the technique through which gas is moved toward inhibit the normal muscle tone of the and from the lungs through an external device airway connected directly to the patient. Note: Be familiar on the predictors of difficult laryngoscopy and intubation before deciding to intubate a patient who is What to look for? already breathing on his own Signs of upper airway obstruction Abnormal breath sounds (stridor, gurgling, Indications snoring) – cardiac arrest with ongoing chest compression Foreign body, blood or gastric contents in the – inability of conscious patient to ventilate mouth adequately Cyanosis – inability of the patient to protect the airway See-saw movements of the chest and abdomen. (coma) Likely in all unconscious patients due to muscular – inability of the rescuer to ventilate the flaccidity in the hypopharynx unconscious patient with conventional methods If these signs are present, possibility of Endotracheal (using bag valve mask) intubation! Complications Interruptions of chest compressions and Simple Airway Maneuvers ventilations for unacceptably long periods Clear the airway of any foreign material, blood, Esophageal intubation vomit Insertion of tracheal tube into 1 lung Loosen tight clothing around the neck Trauma to patient Proceed to airway control measures: ○ – lacerated lips and tongue 1. Head tilt and chin lift ○ – chipped teeth ☒ NOT if suspected cervical spine injury ○ – lacerated pharynx and trachea 2. Jaw Thrust ○ – injury to vocal cords ○ – pharyngeal-esophageal perforation ✔ done for suspected cervical spine injury ○ – vomiting and aspiration of gastric contents into the lower airway ○ – release of high levels of epinephrine and norepinephrine stimulated by tracheal intubation → ENDOTRACHEAL INTUBATION Gold standard of airway care in patients who can’t protect their airways or in those needing assistance with breathing Choices to facilitate intubation in the trauma patient 1. Awake intubation – topical anesthetics (xylocaine spray) 2. Rapid Sequence Intubation (RSI) – paralytic agents to quickly facilitate tube placement and to PRIMARY CONFIRMATION minimize the risk of aspiration 1. Confirm tube placement immediately, assessing the first breath delivered by the resuscitator bag.  2. Do the 6-point auscultation a. as the bag is squeezed, listen over the epigastrium and observe the chest wall for movement. If you hear stomach gurgling and see no chest wall expansion, you have intonated the esophagus. Stop ventilations. Remove the tracheal tube at once. Reattempt intubation. b. if the chest wall rises appropriately and stomach gurgling is not heard, listen to the lung fields: L and R anterior, L and R midaxillary and sterna notch – “tracheal” sounds should be readily heard here. 3. DOUBT? Use the LARYNGOSCOPE to see whether the tube is passing through the vocal Anchor using tape…. (What to remember?) cords 1. Insert an Oropharyngeal airway (OPA) to 4. TUBE IN PLACE? Reconfirm the tube mark at the prevent the patient from biting down on the tube. front teeth. 2. Dry the patient’s face and apply tincture of 5. Secure the tube with a commercial device benzoin to better ensure proper adhesion of the designed for this purpose. tape. 6. Once the tube is secured, insert an 3. Carry the tape right around the patient’s neck Oropharyngeal Airway (OPA) or pass a bite when anchoring the tube. Do not move the neck. block or both to prevent the patient from biting Do not tie it so tight that it occludes the external down and occluding the airway. jugular veins. 7. Look for MOISTURE CONDENSATION on the 4. Anchor the tube at the corner of the mouth, not in inside of the tracheal tube with exhalation (not the midline 100 % accurate) SECONDARY CONFIRMATION Cons Barotrauma — Injury to the lungs or other ✔ END-Tidal CO2 detector device air-filled spaces caused by changes in pressure, - the device reacts with a color change to CO2 often due to mechanical ventilation or rapid exhaled from the lungs altitude changes. - absence of CO2 response from the detector Volutrauma — Lung injury resulting from generally means that the tube is in the over-distension of alveoli due to excessive tidal esophagus. volumes during mechanical ventilation. Atelectrauma — Lung injury caused by repeated ***MOST ACCURATE CONFIRMATORY METHOD IS opening and closing of collapsed alveoli CHEST X RAY Indications Airway Compromise – airway patency is in doubt or patient may be at risk of losing patency Need to Protect the Airway – For some reason the patient’s ability to sneeze, gag or cough has been d ulled and aspiration is possible. Respiratory Failure – 2 Types ○ Hypoxemic Respiratory Failure PaO2 < 60 mmHg in an otherwise healthy individual ○ Hypercapnic Respiratory Failure  - PaCO2 > 50 mmHg in an This will decrease the likelihood that adverse otherwise healthy individual consequences of supplemental oxygen will AKA “Ventilatory Failure” develop, such as absorption atelectasis, - Caused by increased WOB, accentuation of hypercapnia, airway injury, and ↓ventilatory drive, or muscle parenchymal injury fatigue Positive End-Expiratory Pressure (PEEP) Applied PEEP is generally added to mitigate end-expiratory alveolar collapse. A typical initial applied PEEP is 5 cmH2O. However, up to 20 cmH2O may be used in patients undergoing low tidal volume ventilation for acute respiratory distress syndrome (ARDS) Flow Rate The peak flow rate is the maximum flow delivered by the ventilator during inspiration. Definitions Peak flow rates of 60L per minute may be Volume Ventilation: Pre-set Tidal volume will be sufficient, although higher rates are frequently delivered to the patient. necessary. An insufficient peak flow rate is Pressure Ventilation: Pre-set Inspiratory pressure characterized by dyspnea, spuriously low peak will be delivered to the patient. inspiratory pressures, and scalloping of the Mandatory breaths: Breaths that the ventilator inspiratory pressure tracing delivers to the patient at a set frequency, volume, flow. Inspiratory Time: Expiratory Time Relationship (I:E Ratio) Spontaneous breaths: Patient initiated breath During spontaneous breathing, the normal I:E ratio is 1:2, indicating that for normal patients the Tidal Volume exhalation time is about twice as long as Tidal volume (symbol VT or TV) is the lung inhalation time. volume representing the normal volume of air If exhalation time is too short “breath stacking” displaced between normal inhalation and occurs resulting in an increase in end-expiratory exhalation when extr a effort is not applied. pressure also called auto-PEEP. In a healthy, young human adult, tidal volume is Depending on the disease process, such as in approximately 500 mL per inspiration or 7 mL/kg ARDS, the I:E ratio can be changed to improve of body mass ventilation TIDAL VOLUME = 8-12ML X IBW Modes of Ventilation (most commonly used) Respiratory rate A/C : Assist-Control An optimal method for setting the respiratory rate SIMV / (PS) : Synchronized Intermittent Mandatory has not been established. Ventilation (with Pressure-support) For most patients, an initial respiratory rate PSV: Pressure Support Ventilation. between 12 and 16 breaths per minute is PCV: Pressure Control Ventilation. reasonable NIPPV : Non-invasive mechanical ventilation. CPAP: Continuous positive airway pressure. Fraction of Inspired Oxygen BIPAP: Bi-level positive airway pressure. Fraction of inspired oxygen (FiO2) is the fraction of oxygen in the volume being measured The lowest possible fraction of inspired oxygen (FiO2) necessary to meet oxygenation goals should be used.  Advantages of Each Mode Mode Advantages Assist Control Reduced work of breathing compared Ventilation (AC) to spontaneous breathing AC Volume Ventilation Guarantees delivery of set tidal volume AC Pressure Control Allows limitation of peak inspiratory Ventilation pressures Pressure Support Patient comfort, improved patient Ventilation (PSV) ventilator interaction Mechanical complications Synchronized Less interference with normal 1. Hypoventilation with atelectasis with respiratory Intermittent cardiovascular function acidosis or hypoxemia. Mandatory Ventilation 2. Hyperventilation with hypocapnia and respiratory (SIMV) alkalosis 3. Barotrauma Disadvantages of Each Mode a. Closed pneumothorax, Mode Disadvantages b. Tension pneumothorax, c. Pneumomediastinum, Assist Control Potential adverse hemodynamic effects, d. Subcutaneous emphysema. Ventilation (AC) may lead to inappropriate 4. Inadequate nebulization or humidification hyperventilation 5. Overheated inspired air, resulting in hyperthermia AC Volume Ventilation May lead to excessive inspiratory Physiological Complications pressures 1. Fluid overload with humidified air and sodium AC Pressure Control Potential hyper- or hypoventilation with chloride (NaCl) retention Ventilation lung resistance/compliance changes 2. Depressed cardiac function and hypotension 3. Stress ulcers Pressure Support Apnea alarm is only back-up, variable 4. Paralytic ileus Ventilation (PSV) patient tolerance 5. Gastric distension 6. Starvation Synchronized Increased work of breathing compared Intermittent to AC 7. Dyssynchronous breathing pattern Mandatory Ventilation (SIMV) Ventilator Alarms Low Pressure Alarm High Pressure Alarm Complications of Mechanical Ventilation 1. Airway Complications Total or partial Secretions, coughing disconnect or gagging 2. Mechanical complications Loss of airway (total Patient fighting 3. Physiological Complications or partial ventilator (vent extubation) asynchrony) Airway Complications Air leak Condensate (water) 1. Aspiration in tubing 2. Decreased clearance of secretions Obstructed, kinked 3. Nosocomial or ventilator-acquired pneumonia ET tube Increased resistance (bronchospasm) Decreased compliance  (pulmonary edema, concentration pneumothorax) 7.45 = alkalosis Nursing Interventions PaCO2 35-45 mmHg Partial pressure of carbon 1. Maintain airway patency & oxygenation dioxide (C O2 ) in arterial 2. Promote comfort blood 3. Maintain fluid & electrolytes balance 45 mmHg= 5. Maintain urinary & bowel elimination hypercapnia 6. Maintain eye , mouth and cleanliness and integrity 7. Maintain mobility/ musculoskeletal function PaO2 80-100mmHg Partial pressure of oxygen 8. Maintain safety:- (O2 ) in arterial blood 9. Provide psychological support 92% Effective breathing patterns ABGs prn Hemodynamic stability increased/stable hgb Adequate tissue perfusion UO >30cc/hr Endoscopic evaluation and treatment Maximize O2 carrying capacity of the blood Supplemental O2 Intubation and ventilation Restoration of normovolemia GI Disorders in Critical Care Setting Fluid resuscitation ○ Isotonic crystalloid → ACUTE GASTROINTESTINAL BLEEDING normal saline Definition ○ Transfusions ○ Non-Variceal Upper GI Bleed ○ RBCs, Platelets, FFP Peptic Ulcer Disease ○ Blood warming  Serial hemoglobins ○ Cullen’s sign: bluish discoloration Determining location, nature, and around the umbilicus resolution of the bleeding ○ Grey Turner’s Sign: bluish discoloration Endoscopy, PPI, surgical on the flanks consult ○ Severity: age, obesity, organ failure, Prevention of recurrent diagnostic studies bleeding ○ Hemodynamic status ○ Gastric acid s/s hypovolemia suppression s/s ↓ tissue perfusion ○ Minimize precipitating s/s hypoxemia factors ○ Nutritional status Nursing Considerations ○ Infection ○ Maintenance of Pancreatic necrosis / sepsis breathing patterns ○ Hx and predisposing factors ○ Provisions of comfort Alcohol (AWS risk) and safety Gallstones (retained CBD ○ Lessen anxiety stones) ○ Prevention of Nursing Interventions complications ○ Oxygen supplementation Surgery ○ Collaborative Mgmt Fluid resuscitation Diagnostic Tests Pain management ○ UGI Bleed (diagnostic & therapeutic) Prevent hypoxemia Upper endoscopy Antibiotic administration ○ LGI Bleed (diagnostic & therapeutic) Prevent and treat infection Colonoscopy Prevent complications ○ Surgery → ACUTE PANCREATITIS ○ Nursing Considerations Definition: Adequate nutrition ○ Caused gallstones or excessive alcohol Comfort and safety consumption. ↓ anxiety ○ Patho: autodigestion Diagnostic Tests ○ Mild: edematous/interstitial ○ Endoscopy ○ Moderately Severe: hypovolemia, pain, organ failure ○ Severe: necrotizing ○ Gallstone pancreatitis: do ERCP → ESOPHAGEAL VARICES Definition ○ swollen veins in the lower esophagus that occur due to increased pressure in the portal vein ○ often resulting from liver cirrhosis. ○ can rupture and cause severe bleeding Assessment  Assessment ○ history of liver disease, alcohol use, and previous variceal bleeding. ○ signs of liver disease (jaundice, ascites, spider angiomata) and check for signs of bleeding (tachycardia, hypotension). ○ melena, hematemesis, or any signs of gastrointestinal bleeding. Nursing Interventions ○ Beta-blockers: reduce portal pressure ○ Avoid alcohol and NSAIDS Diagnostic Tests ○ Endoscopy ○ Liver function tests ○ CBC Gastric Tubes → NASOGASTRIC TUBES Levin (plastic 125cm (length) Circular markings at or rubber) 14-18 (size) intervals along the tube Single (lumen) serve as guidelines for insertion Gastric sump 120cm Smaller lumen acts as a vent or Salem 12-18 (plastic) Double Moss 90 Contains both a gastric 12-16 decompression lumen and a Triple duodenal lumen for postoperative feedings Sengstaken- Triple Two lumens are used to Blakemore inflate the gastric and (rubber) esophageal balloons, and one tube is reserved for suction or drainage → NASOENTERIC FEEDING TUBES Dobhoff or 60-175 Tungsten-weight EnteraFlo 8-12 ed tip, (poly-urethane Single radiopaque, or silicone stylet rubber) → ENTERAL (EN) a.k.a TUBE FEEDING Indications Enteral Nutrition (EN) ○ Anorexia ○ Orofacial fractures ○ Head and neck cancer ○ Neurologic or psychiatric conditions that prevent oral intake ○ Extensive burns, or critical illness Nursing Management ○ Maintaining EN Infusions Check Tube placement prior feeding and meds Assess Bowel sounds Flush tubings as needed ○ Ensuring Patient Safety Medications in the safest form Aspiration risk ○ Collaborate With Dietitian and Pharmacist Contraindications Enteral Problems ○ GI obstruction ○ Constipation ○ Prolonged ileus ○ Dehydration ○ Severe diarrhea or vomiting ○ Diarrhea ○ Enterocutaneous fistula ○ Vomiting  ○ Calories, protein, electrolytes, trace elements and vitamins → COMPLICATION OF GASTRIC SURGERY DUMPING SYNDROME ○ PROBLEM: rapid gastric emptying — occurs when food moves from your stomach into your small bowel too quickly ○ Feeling of fullness — give small frequent meals ○ N/V — DOC: antiemetic ○ Increased peristalsis — diarrhea may lead to dehydration ○ Diet: fats and proteins — logner to digest ○ AVOID: SUGAR, fiber and carbs — promotes rapid gastric emptying Fluids at meal time → PARENTERAL NUTRITION (PN) ○ Position: LOW FOWLER’S administration of nutrients directly into the ○ After meals — SUPINE bloodstream Indications: PERNICIOUS ANEMIA ○ Chronic severe diarrhea and vomiting ○ PROBLEM: lack of intrinsic factor ○ Complicated surgery or trauma resulting in vitamin b12 ○ GI obstruction ○ Clinical hallmark: BEEFY RED TONGUE ○ GI tract anomalies and fistulae ○ Diagnostic test: SCHILLING”S TEST ○ Intractable diarrhea ○ Management ○ Severe anorexia nervosa Vit b12 im injection ○ Severe malabsorption ○ 1st mo — weekly ○ Short bowel syndrome ○ 2nd mo — monthly for life Neurologic Critical Care Composition  Frontal lobe: personality, behavior, emotion, → CIRCLE OF WILLIS intellectual functions Temporal lobe: hearing, taste, smell Parietal lobe: sensation Occipital lobe: visual reception Cerebellum: motor coordination, equilibrium, balance Medulla Oblongata: reflex, autonomic control → BRAIN HOMUNCULUS Neurologic Disorders → INCREASED ICP - a visual representation of the body's sensory and motor functions mapped onto the surface of the brain, illustrating how different areas correspond to specific body parts. - represents either the motor or the sensory Decreased Cerebral Blood Flow distribution along the cerebral cortex of the brain Cerebral Edema Changes in ICP are closely linked with cerebral perfusion pressure (CPP) ○ CPP must be maintained at 70 to 80 mm Hg  ○ Subarachnoid hemorrhage; Hydrocephalus; Brain tumors; Stroke; Meningitis → GLASGOW COMA SCALE → COMMON MANIFESTATIONS OF BRAIN TUMORS LOCATED IN SPECIFIC AREAS OF THE BRAIN Frontal Lobe ○ Behavioral changes such as loss of tact and tenacity ○ Expressive aphasia ○ Motor weakness on opposite side of body → CUSHING REFLEX ○ Focal seizures on opposite side of body Hypothalamus – Temperature control Temporal Lobe ○ Auditory hallucinations ○ Receptive aphasia ○ Psychomotor seizures pituitary gland ○ Diabetes insipidus ○ Cushingoid features ○ Acromegaly ○ Visual field defects parietal lobe ○ Loss of sensation on opposite side of the body ○ Abnormal sensations Occipital lobe – Visual disturbances → ICP MONITORING Cerebellopontine angle May be indicated in severely ill but salvageable ○ Acoustic nerve tumor patients with: ○ Tinnitus ○ Severe head injury with a GCS between ○ Hearing loss 3 and 8 and in patients with an Cerebellum abnormal CT who are over the age of ○ Ataxic gait 40, have a BP less than 90mmHg ○ Post-pointing (inability to reach for an systolic, or motor posturing object) ○ Disturbances in coordination → NURSING MGMT ASSESS NVS q1-2hrs, pupil size and response POSITION : SEMI-FOWLERS (Head and neck in neutral position) Fluid Restriction as prescribed Maintain Normal Body temperature Provide a quiet environment ○ away from the nurses’ station ○ Lights at low, limit noxious stimulation, TV, radio ○ Avoid caffeine containing beverages and cigar MEDICAL MANAGEMENT: ○ OSMOTIC DIURETICS: MANNITOL ○ CORTICOSTEROIDS → CEREBROVASCULAR DISORDER  → HEMORRHAGIC STROKE Intraparenchymal Intraventricular Subarachnoid Subdural Epidural Location Inside of the brain Inside of the ventricle Between the Between the dura and Between the dura and arachnoid and the pia the arachnoid the skull mater Imaging Mechanism High BP, trauma, Can be associated Rupture of aneurysms Trauma Trauma or after arteriovenous, with both or arteriovenous surgery malformation, tumor, intraparenchymal and malformations or etc subarachnoid trauma hemorrhages Source Arterial or venous Arterial or venous Predominantly arterial Venous (bridging Arterial veins) Shape Typically rounded Conforms to Tracks along the sulci Crescent Lentiform ventricular shape and fissures Presentation Acute (sudden onset Acute (sudden onset Acute (worst May be insidious Acute (skull fracture of headache, N/V) of headache, N/V) headache of life) (worsening headache) and altered mental status) → ISCHEMIC STROKE Thrombotic Embolic Lacunar Etiology - Occurs during sleep - Occurs while awake Small lesions seen mainly - Perfusion failure distal - Due mainly to cardiac - Putamen, pons, to site of severe stenosis source thalamus, caudate, or occlusion of major internal capsule/corna vessels radiata Presentation Slowly progressive deficit Sudden, immediate deficit Abrupt or gradual onset (seizures may occur)  The nurse should delay placing a nasogastric (NG) tube, Foley catheter, or arterial line during administration of the thrombolytic. These should be considered prior to the start of rtPA Week 4: ALTERATION IN METABOLISM: ACUTE COMPLICATIONS OF DM (Doc Acey) DM produces too little insulin, or cells stop responding to insulin. It results in hyperglycemia. Type 1 DM: genetic autoimmune response. Type 2 DM: lifestyle factors, such as obesity TYPE 1 DM TYPE 2 DM GESTATIONAL DM Other Other Other names: names: names: GDM IDDM NIDDM Onset: 2nd / Onset: Onset: 3rd JUVENILE ADULT / Trimester Beta Cells: – OBESE MGT: Insulin: – Beta Cells: + METFORMIN MGT: Insulin: + & INSULIN MGT: OHA GLYBURIDE Risk Factors Fam hx, genetics, geography, age Clinical Mx The three "polys" of DM are: Polydipsia (increased thirst) Polyuria (increased urine production) Polyphagia (increased hunger) 1.Glucosuria 2.Hyperglycemia 3.Weight loss 4.Fatigue and weakness 5.Blurred vision Diagnostic Tests → THROMBOLYTIC THERAPY (rtPA) Recombinant Tissue 1. Fasting Blood Glucose (FBG) = NPO Plasminogen Activator 2. Oral Glucose Tolerance Test (OGTT) a separate IV for administration Fasting baseline: 70-110mg/dL at least 2 large bore IVs 30-minute sample: 110-170mg/dL patient receiving rtPA should be admitted to ICU 60-minute sample: 120-170mg/dL Vital signs and Neuro signs Q 15 minutes x 2 90-minute sample: 100-140mg/dL hours, Q 30 minutes x 6 hours and Q 1 hour x 16 120-minute sample: 70-120mg/dL hours Usually for pregnant women infusion should be discontinued if the patient NPO develops severe headache, hypertension, or 3. Capillary Glucose Monitoring = : No NPO nausea and vomiting  Done before meals odor in the breath 4. Glycosylated Hemoglobin (HbA1C) Metabolic acidosis – causing deep, regular Normal: 3.5-6% respirations (Kussmaul's), flushed appearance and dry skin No NPO Thirst Measures the amount of glucose in hemoglobin Polyuria Monitor effectivity of treatment & compliance Drowsiness Ingestion of glucose concentrate Anorexia or vomiting Can lead to shock and coma if not treated COMPLICATIONS OF DIABETES MELLITUS promptly ACUTE CHRONIC Management 1. Fluid Replacement = PNSS ❑ HYPOGLYCEMIA 1. MACROVASCULAR 2. Insulin Drip = Regular Insulin − Coronary Artery Disease 3. Electrolyte Replacement = Potassium Chloride (HE IS TIRED) − Cerebrovascular supplement 4. Stay hydrated by drinking 8 ounces of ▪ HE-adache Accident caffeine-free fluids every hours. ▪ IS – Irritable/Sweating − Diabetic Foot 5. Contact the physician if blood glucose is over 250 mg/dl ▪ T-remors for six or more hours or if client has urine ketones that long. ▪ I-rritability 2. MICROVASCULAR - ▪ R-estlessness Nephropathy (kidney → HYPEROSMOLAR HYPERGLYCEMIC NONKETOTIC ▪ E-xcessive hunger failure) STATE (H H S) ▪ D-iaphoresis - Retinopathy (eye sight) complication of diabetes mellitus type 2. Untreated high blood sugar levels result in high ❑ DKA (>250mg/dL) 3. NEUROPATHY (Risk for serum osmolarity, without ketoacidosis. ✓ > Type I complication burns) HHS has a gradual onset and is more common in ✓ > (-) Beta cells older adults. ✓ > (-) insulin Extreme hyperglycemia without ketosis and acidosis ❑ HHNS (>600mg/dL) Assessment and Management of HHNS: same ✓ > (-) Ketones with DKA REMEMBER!!! REMEMBER!!! HHS, formerly called hyperglycemic hyperosmolar Management for hypoglycemia: nonketotic coma (HHNC), is rare but has a high 10-15 grams of fast acting simple carbohydrates mortality rate. Prevention, early recognition and ○ 2-3 tsp of sugar or honey quick interventions are vital. ○ 3-4 pcs of glucose tablets ○ 4-6 oz of regular soda / orange juice Clinical Mx ○ 6-10 pcs of hard candy Severe hyperglycemia; usually greater than 600 mg/dL (33.33 mmol/L) IF unable to tolerate orally → Give Dextrose 50% in 50 ml pH less than 7.4 (D5050) Ketones – negative Profound dehydration → DIABETIC KETOACIDOSIS (DKA) Altered level of consciousness acute complication of DM. DKA results from Usually precipitated by physical stress, such as an severe insulin deficiency and has a sudden onset. infection Etiology In non-diabetics, HHNC can occur due to tube feedings typically caused by undiagnosed diabetes or the without supplemental water or a too rapid rate of infusion inadequacy of the prescribed therapy. for parenteral nutrition. Physical stress such as surgery, illness or trauma can cause DKA in a person with DM. Interprofessional Care Aggressive intravenous rehydration with normal Clinical Mx saline or Lactated Ringers Blood sugar levels greater than 300 mg/dL (16.67 Lowering of the blood sugar with a short-acting mmol/L) insulin, such as regular insulin given through Serum pH less than 7.35 continuous intravenous infusion Elevated ketone levels – causes a sweet, fruity When blood sugar levels fall below 250 mg/dL,  the IV solution should be changed to a dextrose-containing solution, e.g., 0.9% NaCl/5% dextrose MANAGEMENT OF DM 1. Diet – Regular meal schedule including snacks 2. Exercise – recommendation 3 times a week 3. Insulin - for Type 1 DM 4. Oral Hypoglycemic Agents (OHA) - for Type 2 DM