• Polyuria

• Polydipsia

• Polyphagia

• Weight loss

• N/V & abdominal pain

• Blurred Vision, headache, and weakness

• Fatigue and malaise

• Orthostatic hypotension

• Weak pulse

• Kussmal respirations

• Metabolic Acidosis

• Mental status chage

• Polyuria

• Polydipsia

• Polyphagia

• Blurred vision, headache, and weakness

• Orthostatic hypotension

• Mental status change

• Seizures and myoclonic jerking

• Coma

• Somnolence

• Hemiparesis

• Aphasia

• Infection

  • UTI

  • Pneumonia

  • Sepsis

  • Acute illness

  • Newly diagnosed DM II

• Initiate IV NaCl

• Insulin infusions

• Fluid replacement (LOTS!)

• Monitor serum potassium & replace as needed

• Correct underlying cause

• Illness

• Infection (most common)

• Inadequate insulin dose

• Undiagnosed DM I

• Poor self-management

• Neglect

• Patent airway, administer O2 if needed

• Fluid Resuscitation

• 0.45% or 0.9% NaCl

• 5% or 10% Dextrose when BS approaches 250 mg/dL

• Continuous insulin drip 0.1 U/kg/hr

• K+ replacement as needed

• Diabetic Ketoacidosis

DM II - A progressive condition due to the increasing inability of cells to respond to insulin (insulin resistance) and decreased production of insulin by the beta cells.

• Hyperglycemic hyperosmolar state

Indications: OSA, oxygen needs, pulmonary edema

• all about oxygen support

• keeps airway open during entire breathing cycle

• Leak proof mask with an exhalation port so C02 doesn’t build up (good to know, won't be on the exam) I just showed a nurse last night at work to make sure the exhalation port does NOT get covered with blankets to avoid issues.

• can cause hypotension

Indications: moderate respiratory failure or nocturnal respiratory support (good point, some pts need this for their OSA and central apneas, hypoventilation)

• nasal or face mask

• Instructor comment: pressure on insp/exp phase is a set value. (Ex. 14/6 would be 14cmH20 going into the lungs and leaving 6cmH20 behind to keep the alveoli to keep open and for better oxygenation) The insp pressure supports the work of breathing in resp distress/failure and is the ventilatory support part of this. 14 is supporting ventilation and the 6 is supporting oxygenation essentially.

• pushes in set pressure and leaves behind some of expiration *(Yes!)

• decreases WOB

• must be able to follow commands, *Yes! If they throw up, risk for aspiration! Get that mask off, ASAP!

• set rate can be applied *Also aids with ventilatory support and work of breathing

Resp: barotrauma, pneumothorax, volutrauma

GI: stress ulcers, NG to decompress *PPI med, NG always goes hand in hand with a vent

Nutritional therapy started within 48 hours

MSK: loss of muscle strength, atrophy

Infection: ventilator associated pneumonia (VAP)

Psychosocial: emotional stress, pain, fear, safety

• based on ideal body weight

• typically set between 6-8ml/kg

High tidal volumes may cause lung injury *(as well as pressures) volume and barotrauma

• typical initial applied PEEP is 5 cmH2O

• can use up to 20 cmH2O for those undergoing low tidal volume for ARDS

• can increase PEEP to maintain oxygenation and avoid going over 40 FiO2

• Room air = 21% FiO2

• Goal is to stay <40% (if needing more, increase PEEP)

• set initial high, can always go down *just did this with my postop vent patient last night and I was a good nurse and paged RT first for permission. ;)

• coughing

• secretions that need suctioning

• more sedation

• pt is "bucking" the vent

Low-Pressure alarm

• check connections

• unplanned extubation

• cuff leak

• tube displacement

Heater alarm

• need more water in container

• amount of breaths machine is set to give to the patient per minute

1. Volume Control (AC mode)

This is extra FYI: Don't need to know this for the exam. These 2 modes are ways to support the volume. Too complex for this course.

1. Synchronized Intermittent Mandatory Ventilation Volume Control (SIMV, SIMV-PS)

2. Pressure Support Ventilation (PS)

• If a pt triggers a breath, it will provide the same set volume/pressure to be delivered *key concept

• Vent ensures that all breaths are the same “controlled”

• Preferred mode to decrease work of breathing

*All good info here! Well done!

• If a patient triggers a breath, it is driven by the pts effort, but not “controlled”

• Pressure support (PS) will provide assistance with pts own breath

Supports spontaneous breaths

*This is explained so well!!!

• every spontaneous breath it will assist up to the set pressure

• Pressure Control (PC Mode)

• PC-IMV (assistive volume)

• Regulated by how much time for inspiration

•Protects the lungs from too much pressure (key!!!)

• condition that alters gas exchange

Ex: COPD, pulmonary embolism, pulmonary edema, ARDS, asthma, cystic fibrosis

• Pneumonia or pulmonary emboli

• Toxic chemical inhalation

• Aspiration of stomach contents

• DIC

• Chest trauma

• Sepsis (most common cause)

• Drug ingestion/toxicity

• Multiple blood transfusions

• SIRS (Systemic Inflammatory Response Syndrome)

• a systemic inflammatory response effecting the alveolar-capillary membrane and causes the space to fill with fluid

• It causes a reduction of surfactant that weakens the alveoli, which causes collapse or filling of fluid, leading to worsening edema

• Can be localized lung damage or from the effects of other systemic problems 

• Mortality is around 58%, or higher with additional co-morbidities *Yes, know it is a high mortality rate

• Dyspnea, tachypnea, cough, restlessness

• Lung sounds may be normal or may reveal fine, scattered crackles

• Chest x-ray may be normal or reveal minimal scattered interstitial infiltrates 

• Abnormal ABGs

• Mild hypoxemia and resp alkalosis caused by hyperventilation, then worsening with resp acidosis

• Non-cardiogenic pulm edema may not show until 30% increase in fluid content in the lungs

• May not show for several hours from initial injury to 1-2 days afterward

• WOB increases despite initial findings of normal PaO₂ or SaO₂

• ABG findings w/ acute hypercapnic resp acidosis

• Lungs with increased fluid accumulation and decreased lung compliance

• Tachycardia, diaphoresis, changes in mental status, cyanosis, and pallor 

• Lung sounds w/ diffuse crackles

• CXR and CT worsening with bilat pulm infiltrates, “ground glass” & “white out” appearance

• either direct or indirect

• leads to an acute inflammatory response 

Acute phase (1-7 days) 

• leads to increased capillary permeability and fluid of the vascular space and into the tissues and lungs

Intermediate phase (8-14 days) 

Late phase (>15 days)

*Can take 6 to 12 months to fully recover (if they survive)

• Need to change to pressure control ventilation to preserve lung function ->Too much pressure causes further lung injury

ARDS critically needs oxygenation intervention

• balance with Fi02 percentages and the amount of PEEP to keep the alveoli open for air exchange. 

High PEEP = Decrease venous return and CO                           

High Fi02 = 02 toxicity.

harder to ventilate *So true unfortunately

•Hyperglycemia

•Ketosis

•Acidosis

•Dehydration

•Mostly seen in DM I

Clinical presentation

Neuro: Fatigue, malaise, confusion

MSK: Muscle weakness

Resp: Shallow respirations,

GI: Abdominal distension, N/V

CV: Hypotension and weak pulse

•Cellular dehydration occurs as the intravascular space draws fluid from intracellular and interstitial spaces.  

Often not easy to recognize or diagnose, especially if patient is deteriorating rapidly

• Anticoagulants

  • Heparin, Enoxaparin, Warfarin (need to know!)

• Vena cava filter (avoids reoccurrence)

• Embolectomy

• Need decompression in the pleural space for air or fluid

• This confirms hemothorax

Chest Tube

• Tube placed in the pleural space to drain fluid, blood, or air. Restores negative pressure to reinflate the lung

• Can be inserted in an emergency at the bedside, or in the OR through a thoracotomy incision.

• Upon removing by provider, tell pt to take a deep breath and hold. Less chance with air emboli

• Dressing is applied: Airtight sterile petroleum jelly gauze dressing, secure in place. 

• Pneumothorax

• postop chest drainage

• pleural effusion

• pulm empyema

When chest tube is placed at the base, its to drain fluid

When chest tube is placed near the apex, its to drain air

• Interferes with the kidneys ability to filter blood

• Causes:

  • Hypovolemia, dehydration, excessive bleeding, heart failure, low cardiac output, med SE, sepsis

*Likely reversible, most common

• Acure tubular necrosis, swelling and scaring related to kidney injury

• Causes:

  • Prolonged ischemia, nephrotoxins, glomerulonephritis, infections, meds

• Unable to urinate

• Kidney swell and it leads to damage

• Causes:

  • Kidney stones, structural, prostate hyperplasia

*Always treatable, <5% AKI

• onset of injury

Oliguric phase: (UOP <400ml/day; 1-14 days)

• Fluid/electrolyte imbalances (high K+, low NA+ and CA+)

• Oliguria most common 70%

• Elevated BUN and creatinine levels, met acidosis, anemia, cerebral edema

Diuretic phase: (UOP 1-3L/day; may reach 5L)

• Caused by osmotic diuresis from uremia and unable to concentrate urine

• Hypovolemia and hypotension as a result

  • pt is dumping urine

Recovery phase: (when GFR improves)

• Allowing BUN and creatinine to plateau and then decrease

• Improvements may occur in 1-2 weeks but may be up tp 12mos.

AV Graft: made of synthetic materials, forms a bridge between the arterial and venous supply, higher infection risk, takes about 3-4 weeks to heal and be ready for use

Temporary Double Lumen Venous Catheter:

placed in the IJ when immediate access is required, DO NOT ACCESS LINE, monitor for infection, dislodgement

Avoid lifting heavy item with access arm

Avoid sleeping on top of extremity

Call provider if: bleeding >30min after holding pressure, no thrill or bruit (poor vascular flow), or signs of infection with fever, redness, or drainage.

Dressing: Maintain the integrity, not get it wet, cover during showers. Do not change it!

Keep HD site clean, protect site and keep it clean and do not wear jewelry, tight clothing

Stage 2: 60-89 ml/min

Stage 3: 30-59 ml/min

Stage 4: 15-29 ml/min

Stage 5: <15 ml/min or treatment by dialysis (ESRF)

• Quick and efficient

• Weekly exchanges as an outpatient 3-4x/wk and 3-5hrs sessions

• Prolongs life

• No limit as to how long one can remain on dialysis

• Allows wait for kidney transplant

• Exchange rate 3-4 hrs

• AV fistula takes 6 wks to cure

• AV graft ready in 2-4 wks

• Stresses a compromised CV system

• Does not remove phos

• Access may clot

• Heparin required

• May need dietary restrictions

• Dialyzable drugs

• Assess fluid status (wt, BP, edema, lung and heart sounds)

• Condition of vascular access and determine patency (Thrills and bruit)

• What meds need to be held

• Compare weight difference between last post dialysis and the present pre-dialysis weight

  • This determines the ultrafiltration or the amount of fluid to be removed

• Be alert for any changes in condition

• Assess, monitor, support, and educate during the tx

• Monitor for complications

  • Clotting, air bubbles, temp of dialysate, regulation of the ultrafiltration

• Wt considerations:

  • Between dialysis txs 2-3kg gain is ideal, more than this will significantly increase the workload of the heart and impact long term survival

• Monitor labs

• Take BP (q30-60 mins as rapid changes can occur)

• Opportunity for nurse to teach about renal diet or reinforce fluid restrictions

• Monitor VS and lab values (BUN, creatinine, electrolyte, Hct), decreases in BP and labs are common

• Compare wt to estimate amount of fluid and procedure removed (1L = 1kg)

• Assess - any complications, bleeding, infection at access site, disequilibrium syndrome, hypovolemia, dizziness, tachycardia

• Avoid invasive procedures for 4-6hrs after dialysis due to the risk of bleeding as a result of anticoagulation AV fistula and AV graft precautions

• Dextrose based solution

• Potassium added to prevent low K

• Antibiotics added

•Availability and convenience

•Comorbid Conditions

•Dialysis center and location

•Pt’s home situation and home therapies

•Method of clinician reimbursement

•Ability to tolerate volume shifts

600mL for insensible losses

= 24hr total intake

Spontaneous pneumothorax- hyper-resonance on percussion

Hemo thorax- dull on percussion.