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Critical care nursing endocrine and hemodynamics lecture notes
Management Of Health Care (NURS 485)
University of Louisville
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Endocrine Critical Complications
Diabetes: o DM I: Insulin dependent Typically, juvenile onset Autoimmune o DM 2: Can be controlled by oral meds or diet May progress to needing insulin Typically, insulin resistance occurs later in life o When blood glucose levels rise above 200, begin to consider undiagnosed diabetes o Fasting glucose test is most accurate for diagnosis: Healthy level is < 100 100-125 is consider prediabetic > 125 diagnosable as diabetes o Oral glucose tolerance test: Sees how fast body metabolizes oral glucose Commonly done during pregnancy and to diagnosis diabetes Healthy is < 140 140-199 is pre-diabetic >200 is considered diabetic o HA1C: Healthy range is < 6. > 6 indicates glucose is not being managed well Can be used to diagnose diabetes complications from diabetes: o hypoglycemia: blood glucose < 70 s/s: nervousness dizziness hunger cold/clammy skin slurred speech progress into seizures treatment: oral buccal tablets 15 grams of carbs and recheck in 15 minutes and repeat as needed Can be treated with D50 (IV glucose push) if more emergent
o Hyperglycemia: Elevated blood glucose (DKA, HHNS) s/s: polydipsia polyuria polyphagia headache abdominal cramping blurred vision weakness/fatigue treatment depends on the type of diabetes they have and whether they are in DKA or HHNS o diabetic ketoacidosis: diagnostic criteria: blood glucose > 250 ** pH < 7. bicarb < 15 urine is positive for ketones ** s/s: polydipsia, polyuria, polyphagia dehydrated nausea/vomiting dry mucous membranes hypotension tachycardia stupor/non-responsive neuro symptoms fruity breath Kussmal respirations Treatment: Rehydrate Decrease glucose with an insulin drip IV o May also have to replace potassium Correct acidosis/bicarb/ketones Electrolyte replacement Cannot rehydrate too quickly; could cause cerebral edema o Hyperglycemic hyperosmolar syndrome (HHS): Serum glucose > or equal to 600 Serum osmolality > or equal to 320 Normal pH/bicarb and ketones are not present or are very mild Severe dehydration from osmotic diuresis Common with DM II Much slower onset than DKA Treatment:
o Treatment: Decrease circulating levels and supportive care PTU can decrease synthesis of thyroid hormone Can do passive cooling for hyperthermia, give Tylenol ASA is contraindicated Beta blocker or similar to decrease HR Decrease BP with medication Monitor airway and ABCs Ice packs Calm, safe environment Myxedema coma/crisis: o Life-threatening event from hypothyroidism o Hypoxia from neuro decline and hypothermia o Not producing enough thyroid hormone d/t stress, a systemic disease, thyroid removal, radioactive treatment, etc. o s/s: fatigue, weight gain, cold intolerance, hypoxic, increased CO2 levels, hypotension, low cardiac output, bradycardia, decreased neuro function, ventilatory issues o Treatment: Hormone replacement and supportive care Monitor airway Warm patient if hypothermic Treat infection if applicable T3 or T4 replacement, Synthroid Monitor ABGs Possible intubation Addisonian crisis: o Life-threatening event from adrenal insufficiency o Typically occurs rapidly: abrupt d/c of corticosteroids, recent surgery, recent illness, sepsis, trauma o s/s: headache, confusion, dehydration, electrolyte imbalance (hyperkalemia and hyponatremia), hypoglycemia, drowsiness, N/V o treatment: hydrocortisone IV bolus supportive care sodium replacement IV fluids Give K-extalate or IV insulin to decrease potassium levels Airway safety Fall preventions
Hemodynamics
Cardiac output: o Normal is 4-6 L/min o Determined from the HR and SV o Adjusts for pressure and flow o Oxygenation is dependent upon this delivery to the tissues (DO2) and consumption at a cellular level (VO2) o Cardiac index (CI) takes into account BMI: Normal is 2-4 L/min/m Heart rate: o Normal is 60-100 bpm measured through pulse or EKG o SNS innervation and catecholamines Stroke volume: o Volume ejected depends on preload, contractility, and afterload o Normal SV is 60-100 mL/beat o Frank-Starling’s law Relationship between myocardial fiber length and the force of contractions (more volume at the end of diastole increases the amount of strength during systole) o Tachycardia can decrease stroke volume o Preload: The “tank” or “stretch” Volume in ventricles at the end of diastole Central venous pressure (CVP) normal is 2-8 mmHg Must have a central line to get this reading Can be falsely elevated Useful but not good indicator of fluid volume status alone An increase in preload increases stroke volume and vice versa o Contractility: The pump or squeeze of the heart The ability of the heart muscle independent of preload and afterload Preload can affect factors contributing to the squeeze/ability to pump and ultimately the SV o Afterload: Resistance of the vasculature Ventricle must overcome afterload with each contraction to achieve a cardiac output Pressure the heart must work against outside of the heart SVR (systemic vascular resistance) – left ventricle Normal 800-1200 dynes-sec/cm- PVR (pulmonary vascular resistance) – right ventricle Normal < 240 dynes-sec/cm- Changes to a cardiac output/index: o Low or decreased cardiac output:
EV1000 clinical platform Continuous ScvO2 with special triple lumen Less invasive than a Swan catheter o Minimally invasive monitoring: FlocTrac system Monitors BP/HR, continuous CO, SV, and stroke volume variation (SVV) Normal SVV is 10-15% Only 100% accurate if patient is completely ventilated (not breathing on own at all) o Non-invasive monitoring: ClearSight system With EV1000 platform Monitors HR, BP, MAP, CO, SV, SVV, and SVR Finger cuff The less invasive, the less accurate Interpreting hemodynamic values: o Preload: PaO2, CVP, RAP, LVEDP Low LVEDP indicates hypovolemia, high indicates potential heart failure Low CVP also indicates hypovolemia o Contractility: SaO2, SV, CO, tissue perfusion o Afterload: HGB, PVR, SVR, BP Fluid vs vasoactive drips: o Crystalloid (isotonic, hypertonic, or hypotonic) Most common is normal saline or LR o Colloid o Blood products For active bleeding, past blood loss Packed RBC, plasma, platelets To increase volume/preload o Sympathomimetics Activates contraction Dopamine drips Improves contractility, increase SV and CO Dopamine at < 5 mcg increases volume quite a bit. 5-10 mcg increases HR, CO. > 10 mcg constricts BP more, loses some contractility. o Vasopressors Effects afterload, increases blood pressure Norepinephrine
Critical care nursing endocrine and hemodynamics lecture notes
Course: Management Of Health Care (NURS 485)
University: University of Louisville
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