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Critical Care > Endocrine Exam 3 > Flashcards

Endocrine Exam 3 Flashcards

1
Q

diabetic ketoacidosis (DKA)

A
  1. uncontrolled hyperglycemia
  2. increased ketone production
  3. metabolic acidosis
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2
Q

DKA patho

A

NO INSULIN, so no glucose is being absorbed
-often initial presentation of type 1 DM
-missed doses of insulin

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3
Q

DKA causes

A
  1. infection!!! - pneumonia, UTI, abscess, sepsis
  2. trauma / surgery
  3. stress
  4. pregnancy
  5. growth spurts in children
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4
Q

DKA s/s

A
  1. flushed , dry skin
  2. dry mucous membranes
  3. decreased skin turgor
  4. tachycardia
  5. hypotension
  6. abd pain
  7. altered LOC
  8. kussmal RR
  9. acetone breath!!! - fruity breath
  10. n/v
  11. increased thirst - polydipsia!!!
  12. increased UO - polyuria
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5
Q

DKA labs

A
  1. CBC = WBC mildly elevated
  2. CMP =
    -blood glucose = high
    -serum bicarb = decreased
    -potassium = elevated –CAREFUL (decreased)
    -creatinine = elevated
    -ANION GAP = elevated
  3. ABGs = Metabolic acidosis
  4. UA = ketones and glucose
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6
Q

in DKA anion gap will be….

A

elevated r/t metabolic acidosis

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7
Q

DKA criteria

A
  1. blood glucose level > 250
  2. ketonuria
  3. pH < or = 7.3
  4. serum bicarb < 18
  5. positive anion gap
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8
Q

DKA actual complications

A

-hyperglycemia
-metabolic acidosis
-electrolyte imbalance
-dehydration

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9
Q

DKA potential complications

A

-respiratory compromise
-electrolyte imbalance
-fluid overload
-kidney injury

**cerebral edema

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10
Q

what is the most dangerous potential complication of DKA

A

cerebral edema!!

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11
Q

DKA respiratory support

A

may need ventilator support
prevent aspiration – NG tube for those vomiting and impaired mental status

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12
Q

DKA fluid replacement

A

initial fluid = NS
-1L bolus –> infusion of 10-15 mL during first hr
-shock s/s 20 mL

**sodium elevated or normal use hypotonic saline (0.45%) at slower rate!!!!

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13
Q

when is 5% dextrose added to fluids…

A

when serum glucose approaches 200 mg/dL

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14
Q

goal of fluid replacement

A

normovolemia , prevent fluid overload

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15
Q

fluid overload s/s

A
  1. tachypnea
  2. neck vein distention
  3. crackles
  4. increased pulmonary artery occlusion
  5. decreasing LOC –> CEREBRAL EDEMA
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16
Q

DKA insulin therapy

A

check POTASSIUM FIRST , should be > 3.3 prior to insulin given

-initial bolus is 0.1 unit regular insulin

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17
Q

transition of sub-q insulin….

A

when blood glucose is <200 …
1. venous pH > 7.3
2. serum bicarb is > 15
3. anion gap < or = 12

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18
Q

DKA electrolyte management

A

potassium!! - drops quickly after insulin therapy
-usually added to maintenance fluids after insulin is started

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19
Q

potassium management

A

maintain b/t 4-5 mEq / L
**UO must be 30 mL before administering IV potassium!!!

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20
Q

DKA nursing interventions

A

hemodynamic monitor
HOURLY i/o
HOURLY glucose check
neuro exams
fluid overload monitor

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21
Q

DKA education

A

maintain glucose level : diet, exercise, meds
monitor hemoglobin A1c
maintain regular schedule
insulin pump instructions
AVOID exercise / excessive activity when glucose > 240

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22
Q

hyperglycemic hyperosmolar state (HHS)

A
  1. hyperglycemia
  2. hyperosmolality
  3. dehydration
    ALL WITHOUT KETOACIDOSIS
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23
Q

HHS patho

A

occurs when there is enough insulin to prevent rapid dat breakdown and ketone release but not enough to prevent hyperglycemia

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24
Q

HHS risks

A

-type 2 DM
-older adults
-major illness and infection = stress response !!
-high cal tube feeds
-meds

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25
Q

HHS s/s

A
  1. flushed dry skin
  2. dry mucous membranes
  3. decreased skin turgor
  4. shallow RR
  5. altered LOC -worse than in DKA
  6. hypotension
  7. tachycardia
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26
Q

HHS labs

A
  1. CBC
  2. CMP
    -glucose increased
    -sodium increased
  3. increased serum osmolality
  4. ABGs:
    -pH > 7.3
    -bicarb > 15
  5. UA - no ketones
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27
Q

HHS dx criteria

A
  1. blood glucose > or = 600 mg
  2. serum osmolality of 320 mOsm or >
  3. serum pH Greater than 7.3 = not acidic
  4. profound dehydration
  5. serum bicarb > 15
  6. absent ketonuria
  7. altered LOC
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28
Q

HHS management

A

same protocol as DKA

-initial fluid NS
-insulin therapy : check K+ first

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29
Q

Primary adrenal crisis

A

destruction of adrenal gland

-autoimmune
-cancer
-infection
-hemorrhage
-adrenalectomy
-genetics

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30
Q

secondary adrenal crisis

A

mechanisms decrease ACTH secretion

-abrupt withdrawal of corticosteroids!!!
-pituitary patho
-systemic inflammation - sepsis, sickle cell
-trauma

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31
Q

adrenal crisis risk

A
  1. medication :
    -steroids
    -phenytoin
    -barbituates
    -rifampin
  2. illness
    -infection
    -cancer
    -autoimmune disorder
    -disease tx w/ steroids
  3. family hx :
    -addison’s disease
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32
Q

adrenal crisis patho

A

life threatening absence of cortisol and aldosterone

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33
Q

deficiency of cortisol

A

-decrease glucose production
-decrease metabolism of fat and protein
-decrease appetite
-decrease intestinal motility
-decrease vascular tone
-decrease effect of catecholamines

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34
Q

deficiency of aldosterone

A

-decrease retention of sodium and water
-decrease circulating volume
-increase potassium and hydrogen ion reabsorption

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35
Q

adrenal crisis s/s

A
  1. hypotension
  2. weak rapid pulse
  3. cold, pale skin
  4. dysrhythmias
  5. HA
  6. fatigue
  7. weakness
  8. confusion , lethargy
  9. abdominal pain
  10. anorexia
  11. decreased UO
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36
Q

adrenal crisis labs

A
  1. CBC - increase eosinophils
  2. CMP -
    -decrease glucose
    -increase potassium
    -decrease sodium
    -increase BUN
  3. ABGs : metabolic acidosis
  4. Cortisol = DECREASED in crisis
  5. cosyntropin stimulation test
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37
Q

cosyntropin stimulation test

A
  1. obtain baseline cortisol level 30 min before test
  2. administer cosyntropin over 2 min
  3. check cortisol levels 60 min after administration
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38
Q

adrenal crisis actual complications

A
  1. hypovolemia
  2. decreased tissue perfusion
  3. electrolyte imbalance
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39
Q

adrenal crisis potential complications

A
  1. shock
  2. dysrhythmias
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40
Q

adrenal crisis fluids

A

D5NS : tx hypoglycemia , may get up to 5L

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41
Q

adrenal crisis glucocorticoid….

A

most important initially!!!!
-if no previous dx give dexamethasone
-if hx give Solu-Cortef

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42
Q

SE of adrenal crisis meds

A

-hyperglycemia
-cushing’s syndrome
-electrolyte disorder
-euphoria
-fluid retention
-masking infection
-HTN
-peptic ulcers!!!!
-n/v

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43
Q

adrenal crisis meds considerations

A
  1. GI bleed prophylaxis med!!!
  2. drug interactions
  3. no abrupt discontinuation
  4. monitor glucose / electrolytes
  5. monitor for fluid overload
  6. monitor for infection
  7. maintain nutrition
  8. mouth care
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44
Q

adrenal crisis nursing action

A
  1. VS and i/o
  2. s/s of GI bleed
  3. HOB 45 degrees
  4. education on pt s/s and prevention
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45
Q

corticosteroids can….

A

have big effects on GI tract, check for bleeding and tx prophylactically

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46
Q

myxedema coma

A

end stage of improperly tx, neglected, underdiagnosed HYPOthyroidism

47
Q

myxedema coma patho

A

pt experiences increased hormone use but had DECREASED hormone production… does not have enough

48
Q

myxedema coma risks

A
  1. infection
  2. trauma
  3. meds
  4. older women
  5. winter time
  6. hypothermia
49
Q

myxedema coma s/s

A
  1. decrease HR and BP
  2. pericardial effusion - distant heart sounds
  3. hypoventilation
  4. CO2 retention
  5. pleural effusion
  6. delirium
  7. seizures
    8.coma
  8. hypothermia
  9. sluggish movements
  10. edema
50
Q

myxedema coma labs

A
  1. CBC - decrease RBC and platelets
  2. CMP -
    -decrease sodium
    -decrease glucose
    -decrease potassium
  3. thyroid hormone
    -TSH increase if primary hypothyroidism
    -TSH levels will be normal or low if secondary
    -T3 and T4 decreased
51
Q

myxedema coma imaging

A
  1. CXR - pleural effusion
  2. EKG - U waves w/ decreased potassium
52
Q

myxedema coma thyroid meds

A

levothyroxine = PUSH OVER 5 min

liothyronine - avoid in older adults

53
Q

myxedema coma and sedatives

A

need more observation b/c the absorption of medication is slower and resp compromise could occur

**narcotics and hypnotics

54
Q

myxedema coma education

A

take meds!!!
-may be titrated depending on levels

55
Q

myxedema coma potential complications

A
  1. respiratory arrest
  2. cardiac arrest
56
Q

when intubating what is the order for medication….

A

sedative THEN paralytic

**keep in mind for myxedema coma oversedation is possible d/t slow metabolism

57
Q

thyroid storm

A

occurs in untreated hyperthyroidism
-precipitated by stress r/t
-underlying illness
-general anesthesia
-surgery
-infection
-stroke
-DKA
-trauma

58
Q

thyroid storm s/s

A

abrupt onset :
-severe fever : up to 106
-warm, moist skin
-tachycardia
-tremors
-HF
-systolic murmur!!!
-respiratory failure
-abd pain
-diarrhea
-weight loss
-shallow respirations

59
Q

thyroid storm labs

A
  1. CBC : WBC increase , RBC decrease
  2. CMP :
    -increase sodium
    -increase glucose
    -increase BUN
    -increase calcium
    Thyroid hormone :
    -decrease TSH
    -increase T3 and T4
  3. ABG : normal
60
Q

thyroid storm meds

A
  1. Beta blocker - propranolol
  2. Tapazole - lack immediate effect!
  3. SSKI - given 1-2 hours after antithyroid (tapazole) medications
61
Q

thyroid storm supportive care

A
  1. fever control : acetaminophen
  2. O2 administration
  3. vitals and i/o
  4. eye lubricant for exophthalmos
  5. high calorie , high protein diet
62
Q

thyroid storm supportive care

A
  1. fever control : acetaminophen
  2. O2 administration
  3. vitals and i/o
  4. eye lubricant for exophthalmos
  5. high calorie , high protein dietthy
63
Q

thyroid storm education

A
  1. consume adequate calories
  2. long term treatment : medications or surgery
64
Q

definitive treatment thyroid storm

A

thyroidectomy :
-given potassium iodine before surgery

post op:
-VOICE CHANGE = laryngeal nerve damage
-bleeding
-hypocalcemia

65
Q

what is needed at bedside after thyroidectomy….

A

airway / O2 supplies
suction
trach tray

66
Q

diabetes insipidus

A

primary cause is traumatic injury to posterior pituitary or hypothalamus

67
Q

neurogenic DI

A

ADH deficiency
-idiopathic
-intracranial surgery!!
-tumor
-infection : meningitis / encephalitis
-TB
-severe head trauma

68
Q

nephrogenic DI

A

ADH insensitivity
-hereditary
-renal disease
-multisystem disorder affecting kidney
-medications

69
Q

secondary DI

A

-idiopathic
-psychogenic polydipsia
-sarcoidosis
-excessive IV fluids
-medications

70
Q

diabetes insipidus patho

A

impaired renal conservation of water = polyuria , > 3L / 24 hours

71
Q

neurogenic DI s/s

A

occurs suddenly with abrupt onset of polyuria

72
Q

nephrogenic DI s/s

A

will have gradual onset

73
Q

DI s/s

A

-pale dilute urine
-polydipsia
-hypovolemia
-hypernatremia

74
Q

hypovolemia s/s

A
  1. hypotension
  2. decreased skin turgor
  3. tachycardia
  4. dry mucous membranes
  5. weight loss
  6. low R atrial and pulmonary occlusion pressure
75
Q

hypernatremia s/s

A
  1. altered mental status
  2. weakness
  3. focal neurological deficit
  4. ataxia
76
Q

DI labs

A

-low urine osmolality!!!
-decreased urine specific gravity!!
-high serum osmolality
CBC : increase H and H
CMP :
-increase sodium
-increase calcium
-decrease potassium
-increase BUN

77
Q

DI dx criteria

A
  1. urine specific gravity : < 1.005
  2. urine osmolality : < 200 mOsm
  3. water deprivation test
    -serum osmolality increases w/ no increase in urine osmolality
78
Q

water deprivation test

A

all water is withheld and urine osmolality and pts weight’s are measured hourly

**not appropriate for pts that are critical

79
Q

DI complications

A

dehydration
hypovolemia
hypernatremia

80
Q

DI potential complications

A

circulatory collapse
neuro complications : r/t hypernatremia

81
Q

DI volume replacement

A
  1. hypovolemia = D5W corrects hypernatremia and replaces lost water
  2. PO when able
82
Q

DI neurogenic hormone replacement

A

DESMOPRESSIN- ADH replacement
**inject over 1 min

83
Q

desmopressin SE

A

HA
nausea
mild abd cramps

84
Q

desmopressin monitor

A

dyspnea
HTN
weight gain
hyponatremia
HA
drowsiness

85
Q

DI nursing interventions

A

-I/O monitor
-IV access
-meds
-oral fluids

86
Q

DI education

A

-medications
-when to call dr
-daily weights
-drinking according to thirst and not over drinking

87
Q

DI 7 D’s

A
  1. diuresis (high UO)
  2. diluted urine (pale, low specific gravity)
  3. dry inside (hyperosmolality, hypernatremia)
  4. drinking a lot
  5. dehydrated mucous membranes
  6. decrease BP
  7. desmopressin
88
Q

SIADH

A

excess secretion of ADH

89
Q

SIADH causes

A

-head injury
-hemorrhage
-stroke
-surgery
-tumor
-small cell cancer of ling
-pancreatic cancer
-pneumonia
-NSAIDs
-ACE inhibitors

90
Q

SIADH s/s

A

-edema
-crackles!!!
-pink frothy sputum
-increase respirations
-confusion
-seizure
-HA
-n/v
-increased BP

91
Q

SIADH labs

A

-CBC : h and h low
-CMP : decrease sodium
-Serum osmolality : decrease
-Urine osmolality : increase
-UA : urine specific gravity increase

92
Q

SIADH dx

A

based on decrease UO
increase urine specific gravity
decrease sodium
decrease serum osmolality

93
Q

SIADH complication

A

fluid volume overload

-edema and crackles

94
Q

SIADH potential complication

A

s/s of hyponatremia
cerebral edema

95
Q

SIADH tx goal

A

-tx underlying cause
-eliminate water excess
-increase serum osmolality

96
Q

SIADH fluids

A

on fluid restriction
-less than 1,000mL / day

97
Q

SIADH meds

A
  1. 3% saline via central line
    -use a PUMP!!!
    -do NOT go over 50 mL/hr
    -monitor sodium every 4 hrs
    -wean solution
    -mental status change
    -lung sounds
    -i/o hourly
  2. diuretics
  3. demeclocycline
98
Q

when should 3% saline be held…

A

when sodium is > 155 mEq

99
Q

SIADH nuring action

A
  1. vitals
  2. i/o
  3. seizure precuation
  4. fluid restriction
  5. s/s of fluid overload
100
Q

SIADH education

A

AVOID NSAIDs
fluid restriction
cerebral edema s/s
daily weight

101
Q

SIADH 7 S’s

A
  1. stop urination (low UO)
  2. sticky / thick urine (high specific gravity)
  3. soaked inside (hypoosmolality, hyponatreamia)
  4. sodium low
  5. seizures
  6. severe high BP
  7. stop all fluids , give salt (3% IV) , diuretics
102
Q

phenochromocytoma

A

excessive catecholamines may lead to life threatening HTN or cardiac dysrhythmias

103
Q

phenochromocytoma s/s

A
  1. severe HA
  2. severe HTN : >250 / 140
  3. tachycardia
  4. palpitations
  5. excessive sweating
  6. hypermetabolism
  7. hyperglycemia
104
Q

what do you NOT do when assessing a pt with phenochromocytoma…

A

do NOT palpate the abdomen!!!

105
Q

phenochromocytoma labs

A

-increase blood glucose
-increase metanephrines
-increase normetanephrines

106
Q

plasma free metanephrines / normetanephrines test…

A

pts must lay down 30 min prior to blood collection!!!

107
Q

urine matanephrines / normetanephrines test…

A

pts should avoid
-bananas
-chocolate
-vanilla
-tea
-coffee

108
Q

phenochromocytoma dx

A

based on presentation, urine and plasma levels, imaging

109
Q

phenochromocytoma imaging

A

abd CT
head CT

110
Q

phenochromocytoma medication

A
  1. BP mamagement
    -nipride : IV admin
    -alpha adrenergic blocker : Cardura
  2. HR control
    -beta blockers
111
Q

phenochromocytoma surgery

A

Adrenalectomy is definitive tx

  1. preop: alpha adrenergic blocker 7-10 days before surgery , GLUCOCORTICOID morning of surgery
  2. postop- monitor BP, HR , glucose

**bilateral adrenalectomy = cortisol daily!!!

112
Q

phenochromocytoma nursing action

A
  1. elevate HOB
  2. quiet non stimulating environment
  3. cardiac monitor
113
Q

phenochromocytoma education

A

s/s of adrenal insufficiency
post op care

Critical Care (15 decks)

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