TAEM10: Endocrine Emergency - Nurse

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อาจารย์พิชญา ทองโพธิ์

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<ul><li> 1. [email_address]</li></ul> <p> 2. </p> <ul><li>( Hypoglycemia ) </li></ul> <ul><li>( Hyperglycemic Crisis )</li></ul> <ul><li><ul><li>( Diabetic Ketoacidosis, DKA )</li></ul></li></ul> <ul><li><ul><li>(Hyperosmolar Hyperglycemic Syndrome, HHS or Non-ketotic Hyperglycemia)</li></ul></li></ul> <p> 3. ( Hypoglycemia ) </p> <p>Triage Ongoing Assessment &amp; Monitoring Discharge planning 4. Triage Nurse </p> <ul><li>Rapid Assessment + DTX </li></ul> <p> 5. 80 1 </p> <ul><li>3 days PTA6 / NO N/V2 days PTA 1 days PTA </li></ul> <ul><li>GA: </li></ul> <ul><li>BP 150/80PR 84RR 18T 35CR &gt; 2 sec</li></ul> <ul><li>DTX 21 mg% </li></ul> <p> 6. 84 3 . </p> <ul><li>U/D DM HT Dementia1 day PTA 3 hrs. PTA ( Gliben x 1, Metformin 1 x1) </li></ul> <ul><li>GA: </li></ul> <ul><li>BP 142/72PR 107RR 22T 36.7</li></ul> <ul><li>DTX41 mg% </li></ul> <p> 7. 47 10 </p> <ul><li>U/D DM3 1 hrs. PTA </li></ul> <ul><li>GA: </li></ul> <ul><li>BP 140/80PR 92RR 22T 36.7</li></ul> <ul><li>O2 sat 98% pupil RTL BE 3 mm</li></ul> <ul><li>DTX31 mg% </li></ul> <p> 8. </p> <ul><li>Subjective Data </li></ul> <ul><li><ul><li>CC / PI </li></ul></li></ul> <ul><li><ul><li><ul><li>Rapid onset </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>No recent food intake </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Alcohol ingestion in the last 36 hrs. </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Weakness , dizziness </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Lethargy , alter mental status </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Nausea </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Anxiety </li></ul></li></ul></li></ul> <p>Emergency Nursing, 2007 9. Early physical Signs (Autonomic nervous System dysfunction) Neurological disturbances (Neuroglycopenic symptoms ) Gastro-intestinal disturbances pallor, Cool, diaphoretic skin Sweating and clamminess Tachycardia anxiety orRestlessness Irritability Palpitation Tremors Confusion Agitation or aggression Loss of co-ordination coma orSeizures Headache Slurred speech Diplopia orBlured vision Nausea and vomiting Abdominal pain 10. </p> <ul><li>Subjective Data </li></ul> <ul><li><ul><li>PI </li></ul></li></ul> <ul><li><ul><li><ul><li>( infection )</li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li> (increased amounts of exercise or physical activity)</li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>(Alteration in lifestyle circumstances )</li></ul></li></ul></li></ul> <p> 11. </p> <ul><li>Subjective Data </li></ul> <ul><li><ul><li>PI </li></ul></li></ul> <ul><li><ul><li><ul><li>(irregular eating habits)</li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>( Alteration to insulin or oral hypoglycemia ) </li></ul></li></ul></li></ul> <p> 12. </p> <ul><li>Subjective Data </li></ul> <ul><li><ul><li>PH </li></ul></li></ul> <ul><li><ul><li><ul><li>DM Alcoholism </li></ul></li></ul></li></ul> <p> 13. </p> <ul><li>Objective Data </li></ul> <ul><li><ul><li>GA </li></ul></li></ul> <ul><li><ul><li><ul><li>LOC, Behavior, affect </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>RR</li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Temp </li></ul></li></ul></li></ul> <p>Emergency Nursing, 2007 14. </p> <ul><li>oxygen</li></ul> <ul><li> Lab [ CBC BS BUN Cr ELyte] glucose </li></ul> <ul><li>NS VS </li></ul> <p> 15. </p> <ul><li>DTX </li></ul> <ul><li><ul><li>BS90 140 mg/dL </li></ul></li></ul> <p> 16. </p> <ul><li> Disturbed thought processr/t insufficient blood glucose to brain </li></ul> <ul><li> Imbalanced Nutrition: less than body requirements r/t imbalance of glucose and insulin level </li></ul> <p> 17. </p> <ul><li> Ineffective health maintenance r/t deficient knowledge regarding disease process, self-care </li></ul> <p> 18. ER </p> <ul><li> ( Hypoglycemic Unawareness )</li></ul> <ul><li>( Diabetes Self-management )</li></ul> <p> 19. </p> <ul><li>( Compliance ) </li></ul> <p> 20. 58 1 </p> <ul><li>U/D DM 2 1 </li></ul> <ul><li>10 Days PTA 4 .</li></ul> <ul><li> BP 128/76 mmHg PR 130/min RR 24/min T 36 C </li></ul> <p> 21. 58 1 </p> <ul><li>DTX 560 mg% </li></ul> <ul><li>GA:</li></ul> <ul><li><ul><li>dry lips </li></ul></li></ul> <ul><li><ul><li>sunken eye balls </li></ul></li></ul> <ul><li><ul><li>warm &amp; dry skin </li></ul></li></ul> <ul><li><ul><li>kussmaul breathing </li></ul></li></ul> <p> 22. ( Hyperglycemic Crisis ) </p> <ul><li>Dehydrate </li></ul> <ul><li>Elyte imbalance </li></ul> <p>Metabolic Acidosis </p> <ul><li>( cerebral edema )</li></ul> <p>DKA HHS 23. DKA </p> <ul><li>/ </li></ul> <ul><li> 24 - 48 .</li></ul> <ul><li> ( Stress ) </li></ul> <p> 24. DKA </p> <ul><li>/( ) </li></ul> <p> 25. HHS </p> <ul><li>/ </li></ul> <ul><li>DKA </li></ul> <ul><li> ( Stress )</li></ul> <p> 26. DKA </p> <ul><li>/ </li></ul> <ul><li> UTI/ Stress </li></ul> <p> 27. HHS </p> <ul><li>/ </li></ul> <ul><li>DMT2 </li></ul> <ul><li> StrokeMyocardial infarction </li></ul> <p> 28. HHS </p> <ul><li>/( ) </li></ul> <ul><li> Beta-Blockers, Histamine 2 Blockers (H2RA) </li></ul> <ul><li>Stress </li></ul> <p> 29. </p> <ul><li>GA:( Level of Consciousness), (Behavior), ( Affect) : </li></ul> <ul><li>Vital Signs: Tachycardia, Orthostatic Hypotension,Kussmauls Respiration( pH7.2 ) </li></ul> <ul><li> ( flushed )poor skin turgor</li></ul> <p> 30. </p> <ul><li>ABCs </li></ul> <ul><li>2 Crystalloid FluidsIV drip in 1-2 . 0.45% NSS IV drip</li></ul> <ul><li> monitor EKGSat O 2 </li></ul> <p> 31. </p> <ul><li> NG tube</li></ul> <ul><li> Urine Output </li></ul> <ul><li>insulin , NaHCO3, Potassium </li></ul> <p> ( ) 32. </p> <ul><li>Monitor NSCerebral Edema </li></ul> <ul><li>Monitor Hemodynamic Status15 60 </li></ul> <p> 33. </p> <ul><li> 1 .Elyte2 . </li></ul> <ul><li> - </li></ul> <ul><li> Sat O 2 Capillary RefillRespiratory distress Syndrome </li></ul> <p> ( ) 34. </p> <ul><li>DKA </li></ul> <ul><li><ul><li>Hypokalemia </li></ul></li></ul> <ul><li><ul><li>Hypoglycemia</li></ul></li></ul> <ul><li><ul><li>Hyperglycemia </li></ul></li></ul> <ul><li><ul><li>Cerebral Edema </li></ul></li></ul> <ul><li><ul><li>ARDSSevere DKA </li></ul></li></ul> <ul><li><ul><li>Hyperchloremia metabolic acidosis </li></ul></li></ul> <p> ( ) 35. </p> <ul><li><ul><li>pH </li></ul></li></ul> <ul><li><ul><li>Blood Glucose 100 200 mg/dL </li></ul></li></ul> <ul><li><ul><li>Serum K+4 5 mEq/L </li></ul></li></ul> <ul><li><ul><li>Serum Osmolality 285 300 mOsm/kg </li></ul></li></ul> <p> ( ) 36. </p> <ul><li> Deficient Fluid Volume r/t excess excretion of urine, nausea, vomiting, increased respiration </li></ul> <p> : DKA 37. </p> <ul><li> Impaired memory r/t fluid and electrolyte imbalance </li></ul> <p> : DKA 38. </p> <ul><li> Ineffective therapeutic regimenmanagement r/t denial of illness, lack ofunderstanding of preventive measures, and adequate blood sugar control </li></ul> <p> : DKA 39. </p> <ul><li> Noncompliance: diabetic regimen r/t ineffective coping with chronic disease </li></ul> <p> : DKA 40. </p> <ul><li>Risk for unstable blood glucose level </li></ul> <p> : DKA 41. </p> <ul><li> Deficient Fluid Volume r/t Hyperglycemia resulting in polyuria </li></ul> <p> : HHS 42. </p> <ul><li> ,Disturbed thought process r/t hyperglycemia, presence of excessive metabolic acids </li></ul> <p> : HHS 43. </p> <ul><li> Ineffective management of therapeutic regimen r/t lack of understanding of preventive measure adequate blood sugar control </li></ul> <p> : HHS 44. </p> <ul><li> ( :,)Risk for infection: risk factors: hyperglycemia, changes in vascular system </li></ul> <ul><li> Risk for unstable blood glucose level </li></ul> <p> : HHS 45. </p> <p> Rapid Assessment &amp; Triage Ongoing Assessment &amp; Monitoring Discharge planning Care Delivery</p>