MedU Clipp 15 and 16 Flashcards
What is the most accurate method of determine
dehydration status?
- Subtract teh Patient’s current weight from his or her weight immediately prior to the illness
- Convert the difference into a “Percent Dehydration”
What aspects of the physical exam can help you determine dehydration status?
- Weight
- Vital Signs (HR and BP)
- HEENT exam (Fontanel, eyes sunken, mucous prod.)
- Skin Turgor, Temp, Perfusion
- Mental Status / Level of Activity
What are the (3) lvls of Dehydration?
- Minimal ( 0 - 3% )
- Mild to Moderate ( 3 - 9% )
- Sever ( > 10% )
Why is Oral Rehydration better than IV therapy?
- Cheaper
- Done at Home
What is the best prevention against the spread of Gastroenteritis?
Good Handwashing
What is the preferred therapy for Sever Dehydration?
- IV Bolus Therapy
- 20 mL/kg of Normal Saline or Lactated Ringer’s
DDx for Recurrent Emesis in the Infant?
- GERD
- Viral Gastroenteritis
- Malrotation and/or Volvulus
- Inborn errof of Metabolism
- Pyloric Stenosis
- Intussusception
- CNS disease
- UTI
What provides Spanish speaking patients with an interpreter?
- Title VI of the Civil Rights Act of 1964
What are the factors in the
Glasgow Coma Scale (GCS)?
- Eye-Opening Response
- Verbal Response
- Motor Response
How is the Eye Opening Response of the GCS scored?
- NO EYE opening
- Eyes open w/ PAIN
- Eyes open w/ VERBAL command
- Eyes open SPONTANEOUSLY
How is the Verbal Response of the GSC scaled?
- NO VERBAL response
- INCOMPREHENSIBLE sounds
- INNAPROPRIATE words
- CONFUSED but able to answer QUESTIONS
- ORIENTATED
How is the Motor Response of teh GCS scaled?
- NO MOTOR response, flaccid
- Extensor response, DECEREBRATE posture
- Abnormal flexion, DECORTICATE posture
- WITHDRAWS from Pain
- LOCALIZES Pain
- OBEYS Commands
A GCS score of XX requires aggressive intervention?
8
Why do Children have a Higher Risk of
Dehydration than Adults?
- Higher Surface Area to Body Mass ratio
- relative area of evaporation is increased
- Higher Basal Metabolic Rates
- Generates Heat, Expends Water
- Higher % of Body Mass that is Water
- Infants 70%
- Children 65%
- Adults 60%
(8) DDx of Vomiting and Altered Mental Status?
- DKA
- Toxic Ingestion
- Gastrointestinal Obstruction
- Increased Intracranial Pressure (ICP)
- Gastroenteritis
- Appendicitis
- Bacterial pneumonia
- Pyelonephritis
(4) Diagnosing Diabetes Mellitus?
- Symptoms of Diabetes (Polyuria, Polydipsia, Unexplained Weight Loss) plus Random Plasma Glucose > 200 mg/dL
- Fasting Blood Glucose > 126 mg/dL (no caloric intake for at least 8 hours)
- 2-hour Postload Glucose > 200 mg/dL during an Oral Glucose Tolerance Test (GTT)
- HbA1c > 6.5% in an Adult is diagnostic of Diabetes
Diagnosing Diabetic Ketoacidosis (DKA)?
- Vomiting
- Tachypnea
- Mental Status Changes
- Dehydration
- DDx
- Random Glucose > 200 mg/dL
- Venous pH < 7.3 or Serum Bicarbonate < 15 mEq/L
- Moderate / Large Ketonuria or Ketonemia
How do you treat DKA?
- Insulin and Fluid Resuscitation
- Insulin 0.1 units/kg/hour after initial volume expansion
- 1 hour after fluids push insulin
- BiCarb should not be given because of Paradoxical CNS Acidosis and Hypokalemia and BiCarb is associated w/ increased risk of Cerebral Edema, the most common DM a/ death in children
- Only add Potassium after serum lvl evaluated
- Admit
Signs and Symptoms of DKA?
- Vomiting
- Weight Loss
- Dehydration
- Shortness of Breath
- Abdominal Pain
- Change in the Level of Consciousness
Lab Values a/w DKA?
- pH
- Sodium
- Potassium
- Bicarbonate
- Creatinine
- Glucose
- Serum Ketones
- Urine Ketones
Lab Values a/w DKA?
- pH - Decreased - Acidodic
- Sodium - Decreased - Hyponatremia
- Potassium - normal
- Bicarbonate - Decreased - Acidodic
- Creatinine - Elevated - PreRenal Azotemia
- Serum Glucose - Elevated - DKA
- Serum Ketones - Elevated -
- Urine Ketones - Elevated - Spill Over
Isotonic / Isonatremic?
- Na = 130 - 150 mEq/L
- Loss of both sodium and water
- Acute Gastroenteritis and Diarrhea
- 12 hour replacement
Hypotonic / Hyponatremic
- Na < 130 mEq/L
- Consumption of Diluted Fluids or Water w/ Dehydration
- A/w Adrenal Insufficiency
- 24 hours to replace
- Rapid Correction –> Central Pontine Myelinolysis
- -> dmg to myelin sheath of nerve cells
- -> dmg to pons
Hypertonic / Hypernatremic
- Na > 150 mEq/L
- Loss of water exceed Na losses
- High Mortality
- A/w Breastfeeding failure, Innapropriate use of Rehydration Solutions (Boiled milk), Diabetes Insipidus
- 48 hours to Replace
- Too-rapid of a Correction –> Cerebral Edema
(3) Methods for Calculating Maintenance Fluids?
- Caloric Expenditure
- Body Surface
- Holliday-Segar method (easiest)
- 100 mL/kg/day x the first 10 kg body weight
- 50 mL/kg/day x the second 10 kg body weight
- 20 mL/kg/day x each additional 1 kg body weight
What are signs of Cerebral Edema
and Increased Intracranial Pressure?
- Slowing of HR
- Increasing BP
- A/w DKA mgmt - before mgmt begins and up to 24 hours after initiation of treatment
- Risk Factors:
- High BUN
- Prolonged Acidosis w/ Hypocapnia
- Attenuated measured Serum Sodium
- Administration of Bicarbonate
Components of Admission Oders:
ADC VANDISMAL?
- A - admit
- D - Diagnoses
- C - Condition
- V - Vital
- A - Activity
- N - Nursing
- D - Diet
- I - IV
- S - Studies
- M - Medications
- A - Allergies
- L - Labs
Potential Rx Managment of DM?
- Metformin
- Primary for DM2
- Alternative for DM1
- Pramlintide
- Adjunctive for DM1
Admission Orders for Patient in DKA?
- Continuous Monitoring of Vitals
- Hourly Neuro Checks
- Monitor Fluid INs and OUTs
- Insulin Orders
- Serum Glucose every 60 minutes
- Serum Calcium, Magnesium, and Phosphorus now
- Check Serum pH (VBG) every 60 minutes
- Urine dipstick for Ketones
What are the signs of Cerebral Edema in DKA?
- Irregular Respirations
- Headache
- Vomiting
- Third Nerve Palsy
- High Blood Pressure
What is Cushing’s Triad of Increased
Intracranial Pressure?
- HTN
- Inappropriate Slowing of HR
- Irregular Respirations (Cheyne-Stokes respirations)
- Increased ICRP
- -> Vagal Stimulation
- -> Gastric Acid Secretion
- -> Followed by Epigastric Discomfort, Headaches, and Non-bilious Vomiting.
