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Pccn Review Part 2
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Pccn Review Part 2

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Progressive Critical Care Nurse Certification Review, Part 2 of 2

Progressive Critical Care Nurse Certification Review, Part 2 of 2

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  • helpful website that help others. This website has practice exams for various nursing classes as well as videos, presentations, notes, nclex help, and many other tools . Hope they help


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    • 1. <ul><ul><ul><li>“ Education is a progressive discovery of our own ignorance”  Will Durant  </li></ul></ul></ul>PCCN REVIEW PART 2 Sherry L. Knowles, RN, CCRN, CRNI
    • 2. <ul><li>TOPICS </li></ul><ul><li>Renal Alterations </li></ul><ul><ul><li>Acute Renal Failure </li></ul></ul><ul><ul><li>Electrolytes </li></ul></ul><ul><ul><li>IV Fluid Therapy </li></ul></ul><ul><li>Neurological Alterations </li></ul><ul><ul><li>AVM’s & Cerebral Aneurysms </li></ul></ul><ul><ul><li>Intracranial Hemorrhage </li></ul></ul><ul><ul><li>Stroke </li></ul></ul>PCCN REVIEW PART 2 <ul><li>Metabolic Alterations </li></ul><ul><ul><li>DKA & HNNK </li></ul></ul><ul><ul><li>DI & SIADH </li></ul></ul><ul><ul><li>DIC </li></ul></ul><ul><ul><li>Shock States </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul>
    • 3. <ul><li>OBJECTIVES </li></ul><ul><li>List the main functions of the kidney. </li></ul><ul><li>List the common diagnostic tests associated with renal function. </li></ul><ul><li>List the complications associated with acute renal failure. </li></ul><ul><li>Describe the common treatments of acute renal failure. </li></ul><ul><li>List the major signs & symptoms associated with electrolyte disturbances of sodium, potassium magnesium and calcium and phosphorus. </li></ul><ul><li>Define serum osmolality. </li></ul><ul><li>List the intracellular & extracellular fluid compartments of the body. </li></ul><ul><li>Describe the effects of hypotonic, isotonic and hypertonic IV fluids. </li></ul><ul><li>Describe the different treatments for intravascular depletion verses cellular dehydration. </li></ul><ul><li>Identify the risk factors and signs & symptoms of brain aneurysms and AVM’s. </li></ul><ul><li>Explain the current treatments available for brain aneurysms and AVM’s. </li></ul><ul><li>Describe the different types of intracranial hemorrhage and their associated signs & symptoms. </li></ul>PCCN REVIEW PART 2
    • 4. <ul><li>OBJECTIVES </li></ul><ul><li>List the potential complications of associated with intracranial hemorrhages, brain aneurysms and AVM repairs. </li></ul><ul><li>List the types of CVA’s, their risk factors and related pathophysiology. </li></ul><ul><li>Identify the recommended treatments for CVA’s. </li></ul><ul><li>Differentiate between the signs and symptoms of DKA and HHNK. </li></ul><ul><li>Describe the treatment of DKA and HHNK. </li></ul><ul><li>Differentiate between the signs and symptoms of DI and SIADH. </li></ul><ul><li>Describe the treatment of DI and SIADH. </li></ul><ul><li>List the signs & symptoms of Disseminated Intravascular Coagulation. </li></ul><ul><li>Explain the treatments for disseminated intravascular coagulation. </li></ul><ul><li>Understand the different stages of shock. </li></ul><ul><li>Differentiate between different types of shock. </li></ul><ul><li>Identify the different treatments used for the different types of shock. </li></ul><ul><li>Describe the stages of the sepsis syndrome. </li></ul><ul><li>Explain the treatment of septic shock. </li></ul>PCCN REVIEW
    • 5. <ul><li>Acute Renal Failure </li></ul><ul><li>Electrolytes </li></ul><ul><li>IV Fluid Therapy </li></ul>Renal Alterations
    • 6. <ul><li>WHAT DO THE KIDNEYS DO? </li></ul><ul><ul><li>Filter blood </li></ul></ul><ul><ul><ul><li>Regulates electrolytes </li></ul></ul></ul><ul><ul><li>Regulate blood pressure </li></ul></ul><ul><ul><ul><li>Renin-angiotensin system (RAS) </li></ul></ul></ul><ul><ul><li>Maintain acid/base balance </li></ul></ul><ul><ul><ul><li>Removes wastes, detoxifies blood </li></ul></ul></ul>Acute Renal Failure
    • 7. <ul><li>WHAT ELSE DO THE KIDNEYS DO? </li></ul><ul><ul><li>Stimulate RBC production </li></ul></ul><ul><ul><ul><li>Make erythopoietin </li></ul></ul></ul><ul><ul><li>Make corticosteroids </li></ul></ul><ul><ul><ul><li>Regulate kidney function </li></ul></ul></ul><ul><ul><li>Increase calcium absorption </li></ul></ul><ul><ul><ul><li>Convert Vitamin D to its active form  Calcitriol </li></ul></ul></ul>Acute Renal Failure
    • 8. The Kidney
    • 9. The Nephron
    • 10. <ul><li>Glomerulus </li></ul><ul><ul><li>Network of capillaries </li></ul></ul><ul><li>Bowman’s capsule </li></ul><ul><ul><li>Membrane that surrounds the glomerulus </li></ul></ul><ul><li>Renal Tubules </li></ul><ul><ul><li>Travel from cortex to medulla and back to cortex </li></ul></ul><ul><li>Collecting duct </li></ul><ul><ul><li>Within the medulla </li></ul></ul>The Nephron
    • 11. The Kidney <ul><li>The Renal Cortex Contains </li></ul><ul><ul><li>Bowman's Capsules </li></ul></ul><ul><ul><li>Glomerulus </li></ul></ul><ul><ul><li>Proximal Tubules </li></ul></ul><ul><ul><li>Distal Convoluted Tubules </li></ul></ul><ul><li>The Renal Medulla Contains </li></ul><ul><ul><li>The Pyramids </li></ul></ul><ul><ul><ul><li>Loop of Henle </li></ul></ul></ul><ul><ul><ul><li>Collecting Duct </li></ul></ul></ul><ul><ul><ul><li>Blood Vessels </li></ul></ul></ul>
    • 12. <ul><li>Lies within Cortex </li></ul><ul><li>Controls the activity of the nephron </li></ul><ul><li>Plays major role in the renin-angiontension-aldosterone system </li></ul>The Juxtaglomerular Apparatus
    • 13. Urine Formation
    • 14. <ul><li>DEFINITIONS </li></ul><ul><ul><li>Sudden interruption of kidney function resulting from obstruction, reduced circulation, or disease of the renal tissue </li></ul></ul><ul><ul><li>Rapid deterioration of renal function </li></ul></ul><ul><ul><ul><li>increase of creatinine of >0.5 mg/dl in <72hrs </li></ul></ul></ul><ul><ul><ul><li>“ azotemia” (accumulation of nitrogenous wastes) </li></ul></ul></ul><ul><ul><ul><li>elevated BUN and Creatinine levels </li></ul></ul></ul><ul><ul><ul><li>decreased urine output (usually but not always) </li></ul></ul></ul>Acute Renal Failure
    • 15. <ul><li>TERMINOLOGY </li></ul><ul><ul><li>Anuria: No UOP (or <100mL/24hrs) </li></ul></ul><ul><ul><li>Oliguria : UOP<400-500 mL/24hrs </li></ul></ul><ul><ul><li>Azotemia : (Increased BUN, Cr, Urea) </li></ul></ul><ul><ul><ul><li>May be prerenal, renal, postrenal </li></ul></ul></ul><ul><ul><ul><li>Does not require any clinical findings </li></ul></ul></ul><ul><ul><li>Chronic Renal Insufficiency </li></ul></ul><ul><ul><ul><li>Deterioration over months-years </li></ul></ul></ul><ul><ul><ul><li>GFR 10-20 mL/min, or 20-50% of normal </li></ul></ul></ul><ul><ul><li>ESRD: GFR <5% of mL/min </li></ul></ul>Acute Renal Failure
    • 16. <ul><li>PERSONS AT RISK </li></ul><ul><ul><li>Major surgery </li></ul></ul><ul><ul><li>Major trauma </li></ul></ul><ul><ul><li>Receiving nephrotoxic medications </li></ul></ul><ul><ul><li>Hypovolemia > 40 minutes </li></ul></ul><ul><ul><li>Elderly </li></ul></ul>Acute Renal Failure
    • 17. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Azotemia </li></ul></ul><ul><ul><li>Hyperkalemia </li></ul></ul><ul><ul><li>Electrolyte Disturbances </li></ul></ul><ul><ul><ul><li> K+  phosphate </li></ul></ul></ul><ul><ul><ul><li> Na+  calcium </li></ul></ul></ul><ul><ul><ul><li> Cr  BUN </li></ul></ul></ul><ul><ul><li>Metabolic acidosis </li></ul></ul><ul><ul><li>Nausea/Vomiting </li></ul></ul><ul><li>Oliguria - anuria </li></ul><ul><li>HTN </li></ul><ul><li>Hypovolemia </li></ul><ul><li>Pulmonary edema </li></ul><ul><li>Ascites </li></ul><ul><li>Metabolic acidosis </li></ul><ul><li>Asterixis </li></ul><ul><li>Encephalopathy </li></ul>Acute Renal Failure
    • 18. <ul><li>COMPLICATIONS </li></ul><ul><ul><li>Results in retention of toxins, fluids, and end products of metabolism </li></ul></ul><ul><ul><li>May be reversible with medical treatment </li></ul></ul>Acute Renal Failure
    • 19. <ul><li>DIAGNOSTIC TESTS </li></ul><ul><ul><li>H&P </li></ul></ul><ul><ul><li>BUN, creatinine, sodium, potassium, pH, bicarb, Hgb and Hct </li></ul></ul><ul><ul><li>Urine studies </li></ul></ul><ul><ul><li>US of kidneys </li></ul></ul><ul><ul><li>24 hour urine for protein and creatinine </li></ul></ul><ul><ul><li>Urine eosinophils </li></ul></ul>Acute Renal Failure
    • 20. <ul><li>OTHER DIAGNOSTIC TESTS </li></ul><ul><ul><li>Albumin, glucose, prealbumin </li></ul></ul><ul><ul><li>KUB </li></ul></ul><ul><ul><li>ABD and renal CT/MRI </li></ul></ul><ul><ul><li>Retrograde pyloegram </li></ul></ul><ul><ul><li>Renal biopsy </li></ul></ul><ul><ul><li>Post-void residual or catheterization </li></ul></ul>Acute Renal Failure
    • 21. <ul><li>PHASES </li></ul><ul><ul><li>Onset </li></ul></ul><ul><ul><ul><li>1-3 days with  BUN and  creatinine and possible decreased UOP </li></ul></ul></ul><ul><ul><li>Oliguric </li></ul></ul><ul><ul><ul><li>UOP < 400/day,  BUN,  Cr,  P04,  K, may last up to 14 days </li></ul></ul></ul><ul><ul><li>Diuretic </li></ul></ul><ul><ul><ul><li>UOP  to as much as 4000 mL/day but without waste products, may begin to see improvement at end of this stage </li></ul></ul></ul><ul><ul><li>Recovery </li></ul></ul><ul><ul><ul><li>things go back to normal or may remain insufficient and become chronic </li></ul></ul></ul>Acute Renal Failure
    • 22. <ul><li>CAUSES </li></ul><ul><ul><li>Pre-renal (hypoperfusion) </li></ul></ul><ul><ul><li>Renal (intrinsic) </li></ul></ul><ul><ul><li>Post-renal (obstructive) </li></ul></ul>Acute Renal Failure
    • 23. <ul><li>SPECIFIC CAUSES </li></ul><ul><ul><li>Prerenal </li></ul></ul><ul><ul><ul><li>Hypovolemia, shock, blood loss, embolism, pooling of fluid due to ascites or burns, cardiovascular disorders, sepsis </li></ul></ul></ul><ul><ul><li>Intrarenal </li></ul></ul><ul><ul><ul><li>ATN, nephrotoxic agents, infections, ischemia acute tubular necrosis, acute nephritis, polycystic kidney disease </li></ul></ul></ul><ul><ul><li>Postrenal </li></ul></ul><ul><ul><ul><li>Stones, blood clots, BPH, urethral edema from invasive procedures, renal calculi </li></ul></ul></ul>Acute Renal Failure
    • 24. Pre-Renal or Intra-Renal?
    • 25. <ul><ul><li>TREATMENT </li></ul></ul><ul><ul><ul><li>Make/consider the diagnosis </li></ul></ul></ul><ul><ul><ul><li>Treat life threatening conditions </li></ul></ul></ul><ul><ul><ul><li>Identify the cause if possible </li></ul></ul></ul><ul><ul><ul><ul><li>Hypovolemia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Toxic agents (drugs, myoglobin) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Obstruction </li></ul></ul></ul></ul><ul><ul><ul><li>Treat reversible elements </li></ul></ul></ul><ul><ul><ul><ul><li>Hydrate </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Remove drug </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Relieve obstruction </li></ul></ul></ul></ul>Acute Renal Failure
    • 26. <ul><li>NURSING CARE </li></ul><ul><ul><li>Fluid and dietary restrictions </li></ul></ul><ul><ul><ul><li>Protein, potassium & phosphate restriction </li></ul></ul></ul><ul><ul><li>Maintain electrolytes </li></ul></ul><ul><ul><li>D/C or reduce causative agent </li></ul></ul><ul><ul><li>Adjust medication doses </li></ul></ul><ul><ul><li>May need dialysis to jump start renal function </li></ul></ul><ul><ul><li>May need to stimulate production of urine with IV fluids, Dopamine, diuretics, etc. </li></ul></ul>Acute Renal Failure
    • 27. <ul><li>DIALYSIS </li></ul><ul><ul><li>Hemodialysis </li></ul></ul><ul><ul><li>Peritoneal Dialysis </li></ul></ul><ul><ul><li>Continuous Renal Replacement Therapy (CRRT) </li></ul></ul>Acute Renal Failure
    • 28. <ul><ul><li>TREATMENT </li></ul></ul><ul><ul><ul><li>Strict I&O </li></ul></ul></ul><ul><ul><ul><li>Daily weights </li></ul></ul></ul><ul><ul><ul><li>Watch for heart failure </li></ul></ul></ul><ul><ul><ul><li>Monitor lab results </li></ul></ul></ul><ul><ul><ul><li>Watch for hyperkalemia </li></ul></ul></ul><ul><ul><li>Watch for hyper/hypoglycemia </li></ul></ul><ul><ul><li>Maintain nutrition </li></ul></ul><ul><ul><li>Mouth care </li></ul></ul><ul><ul><li>Monitor skin </li></ul></ul><ul><ul><li>S & S of Hyperkalemia: Malaise, anorexia, parenthesia, muscle weakness,EKG changes </li></ul></ul>Chronic Renal Failure
    • 29. Electrolyte Disturbances Na+ Ca++ Cl- Mg+ K+ PO 4 NH 3 Cu HCO 3 - NaCl
    • 30. <ul><li>Dominant intracellular electrolyte </li></ul><ul><li>Primary buffer in the cell </li></ul>K+ Potassium (K + ) Normal serum K+ level: 3.5-5.5 mEq/L
    • 31. <ul><ul><li>INVOLVED IN </li></ul></ul><ul><ul><li>Muscle contraction </li></ul></ul><ul><ul><li>Nerve impulses </li></ul></ul><ul><ul><li>Cell membrane function </li></ul></ul><ul><ul><li>Attracting water into the ICF </li></ul></ul><ul><ul><li>Imbalances interfere with neuromuscular function and may cause cardiac rhythm disturbances </li></ul></ul>Potassium (K + )
    • 32. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Weakness, malaise, lethargy </li></ul></ul><ul><ul><li>Anorexia </li></ul></ul><ul><ul><li>Muscle cramps </li></ul></ul><ul><ul><li>Paresthesias </li></ul></ul><ul><ul><li>Dysrhythmias </li></ul></ul>Hyperkalemia
    • 33. <ul><li>K > 5.5 -6 </li></ul><ul><li>Tall, peaked T’s </li></ul><ul><li>Wide QRS </li></ul><ul><li>Prolong PR </li></ul><ul><li>Diminished P </li></ul><ul><li>Prolonged QT </li></ul><ul><li>QRS-T wave merge = “sine wave” </li></ul>Hyperkalemia
    • 34. <ul><li>CAUSES </li></ul><ul><ul><li>Chronic or acute renal failure </li></ul></ul><ul><ul><li>Burns </li></ul></ul><ul><ul><li>Crush injuries </li></ul></ul><ul><ul><li>Excessive use of Potassium salts </li></ul></ul>Hyperkalemia
    • 35. <ul><li>TREATMENT </li></ul><ul><ul><li>Calcium Gluconate (carbonate) </li></ul></ul><ul><ul><li>Calcium Chloride </li></ul></ul><ul><ul><li>Sodium Bicarbonate </li></ul></ul><ul><ul><li>Insulin/glucose </li></ul></ul><ul><ul><li>Kayexalate </li></ul></ul><ul><ul><li>Lasix </li></ul></ul><ul><ul><li>Albuterol </li></ul></ul><ul><ul><li>Hemodialysis </li></ul></ul>Hyperkalemia
    • 36. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Malaise </li></ul></ul><ul><ul><li>Skeletal muscle weakness </li></ul></ul><ul><ul><li>Decreased reflexes </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Excessive thirst </li></ul></ul><ul><ul><li>Cardiac arrhythmias and cardiac arrest </li></ul></ul><ul><ul><li>Flattened T wave </li></ul></ul><ul><ul><li>U wave </li></ul></ul>Hypokalemia
    • 37. Sine Wave
    • 38. <ul><li>CAUSES </li></ul><ul><ul><li>Reduced dietary intake </li></ul></ul><ul><ul><li>Poor absorption by the body </li></ul></ul><ul><ul><li>Vomiting and/or diarrhea </li></ul></ul><ul><ul><li>Renal disease </li></ul></ul><ul><ul><li>Medications (typically diuretics) </li></ul></ul>Hypokalemia
    • 39. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Cold, clammy, pale skin </li></ul></ul><ul><ul><li>Nervousness </li></ul></ul><ul><ul><li>Shakiness, lack of coordination, staggering gait </li></ul></ul><ul><ul><li>Irritability, hostility, and strange behavior </li></ul></ul><ul><ul><li>Difficulty concentrating </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Excessive hunger </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Blurred vision and dizziness </li></ul></ul><ul><ul><li>Abdominal pain or nausea </li></ul></ul><ul><ul><li>Fainting and unconsciousness </li></ul></ul>Hypoglycemia
    • 40. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><li>Cardiovascular Signs </li></ul><ul><li> Palpitations </li></ul><ul><li> Tachycardia </li></ul><ul><li> Anxiety </li></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Diaphoresis </li></ul></ul><ul><ul><li>Pale, cool skin </li></ul></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><li>Neurological Signs </li></ul><ul><ul><ul><li>Agitation </li></ul></ul></ul><ul><ul><ul><li>Confusion </li></ul></ul></ul><ul><ul><ul><li>Slurred Speech </li></ul></ul></ul><ul><ul><ul><li>Staggering Gait </li></ul></ul></ul><ul><ul><ul><li>Paraplegia </li></ul></ul></ul><ul><ul><ul><li>Seizures </li></ul></ul></ul><ul><ul><ul><li>Coma </li></ul></ul></ul>Acute Hypoglycemia
    • 41. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Thirst </li></ul></ul><ul><ul><li>Polyuria </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>Nausea, vomiting </li></ul></ul><ul><ul><li>DKA </li></ul></ul><ul><ul><li>HNNK </li></ul></ul>Hyperglycemia Normal serum Glu level: 70 - 110 mg/dL
    • 42. <ul><li>Dominant extracellur electrolyte </li></ul><ul><li>Chief determinant of osmolality </li></ul>NaCl Sodium (Na + ) Normal serum Na+ level: 135-145 mEq/L
    • 43. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Deficiency of sodium in the blood </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Muscle weakness </li></ul></ul><ul><ul><li>Mental Confusion </li></ul></ul>Hyponatremia
    • 44. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Excess sodium in the blood </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Muscle twitching </li></ul></ul><ul><ul><li>Mental confusion </li></ul></ul><ul><ul><li>Coma </li></ul></ul>Hypernatremia
    • 45. <ul><li>Activates many enzymes </li></ul><ul><li>50% is insoluble in bone </li></ul><ul><li>45% is intracellular </li></ul><ul><li>5% is extracellular </li></ul>Mg+ Magnesium (Mg + ) Normal serum Mg+ level: 1.5 - 2.5 mg/dL
    • 46. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Tremors </li></ul></ul><ul><ul><li>Positive Chvostek & Trousseau </li></ul></ul><ul><ul><li>Nystagmus </li></ul></ul><ul><ul><li>Confusion/Hallucinations </li></ul></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>Hyperactive deep reflexes </li></ul></ul><ul><ul><li>Seizures </li></ul></ul>Hypomagnesemia <ul><ul><li>Dysrhythmias </li></ul></ul><ul><ul><li>ECG Changes </li></ul></ul><ul><ul><ul><li>Flat T wave </li></ul></ul></ul><ul><ul><ul><li>ST interval depression </li></ul></ul></ul><ul><ul><ul><li>Prolonged QT interval </li></ul></ul></ul><ul><ul><ul><ul><li>May lead to Torsade de Pointes </li></ul></ul></ul></ul>
    • 47. <ul><li>CAUSES </li></ul><ul><ul><li>Alcoholism </li></ul></ul><ul><ul><li>Malabsorption </li></ul></ul><ul><ul><li>Starvation </li></ul></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>Diuresis </li></ul></ul>Hypomagnesemia
    • 48. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Peaked T wave </li></ul></ul><ul><ul><li>Bradycardia </li></ul></ul><ul><ul><li>CNS Depression </li></ul></ul><ul><ul><li>Areflexia </li></ul></ul><ul><ul><li>Sedation </li></ul></ul><ul><ul><li>Respiratory paralysis </li></ul></ul>Hypermagnesemia
    • 49. <ul><li>CAUSES </li></ul><ul><ul><li>Not common </li></ul></ul><ul><ul><li>Occurs with chronic renal insufficiency </li></ul></ul><ul><ul><li>Treatment is hemodialysis </li></ul></ul>Hypermagnesemia
    • 50. <ul><li>ESSENTIAL FOR </li></ul><ul><ul><li>Neuromuscular transmission </li></ul></ul><ul><ul><li>Growth and ossification of bones </li></ul></ul><ul><ul><li>Muscle contraction </li></ul></ul>Ca++ Calcium (Ca ++ ) Normal serum Ca++ level: 8 - 11 mg/dL
    • 51. <ul><li>INVOLVED IN </li></ul><ul><ul><li>Blood clotting </li></ul></ul><ul><ul><li>Nerve impulse </li></ul></ul><ul><ul><li>Muscle contraction </li></ul></ul>Ca++ Calcium (Ca ++ ) Excreted through urine, feces, and perspiration
    • 52. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Tetany (cramps/convulsions in wrists and ankles) </li></ul></ul><ul><ul><li>Weak heart muscle </li></ul></ul><ul><ul><li>Increased clotting time </li></ul></ul><ul><ul><li>Prolonged QT interval </li></ul></ul><ul><ul><ul><li>May lead to Torsade de Pointes </li></ul></ul></ul><ul><ul><li>Abnormal behavior </li></ul></ul><ul><ul><li>Chvostek's sign (facial twitching) </li></ul></ul><ul><ul><li>Paresthesia </li></ul></ul>Hypocalcemia
    • 53. <ul><li>CAUSES </li></ul><ul><ul><li>Renal insufficiency </li></ul></ul><ul><ul><li>Decreased intake or malabsorption of Calcium </li></ul></ul><ul><ul><li>Deficiency in or inability to activate Vitamin D </li></ul></ul>Hypocalcemia
    • 54. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Kidney stones </li></ul></ul><ul><ul><li>Bone pain </li></ul></ul><ul><ul><li>Hypotonicity of muscles (decreased tone) </li></ul></ul><ul><ul><li>Altered mental status </li></ul></ul><ul><ul><li>Cardiac arrhythmias </li></ul></ul><ul><ul><li>Shortened QT interval </li></ul></ul>Hypercalcemia
    • 55. <ul><li>CAUSES </li></ul><ul><ul><li>Neoplasms (tumors) </li></ul></ul><ul><ul><li>Excessive administration of Vitamin D </li></ul></ul>Hypercalcemia <ul><li>TREATMENT </li></ul><ul><ul><li>Usually aimed at underlying disease and hydration </li></ul></ul><ul><ul><li>Severe hypercalcemia may be treated with forced diuresis </li></ul></ul>
    • 56. <ul><li>INVOLVED IN </li></ul><ul><ul><li>Energy metabolism </li></ul></ul><ul><ul><li>Genetic coding </li></ul></ul><ul><ul><li>Cell function </li></ul></ul><ul><ul><li>Bone formation </li></ul></ul>PO 4 Phosphorus (P, PO 4 ) Normal serum PO4 level: 2.5-4.5 mg/dL
    • 57. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Respiratory difficulty </li></ul></ul><ul><ul><li>Confusion </li></ul></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Coma </li></ul></ul>Hypophosphatemia
    • 58. <ul><li>CAUSES </li></ul><ul><ul><li>Severe infections </li></ul></ul><ul><ul><li>Kidney failure </li></ul></ul><ul><ul><li>Thyroid failure </li></ul></ul><ul><ul><li>Parathyroid Failure </li></ul></ul><ul><ul><li>Often associated with hypercalcemia or hypomagnesemia or too much Vitamin D </li></ul></ul><ul><ul><li>Cell destruction - from chemotherapy, when the tumor cells die at a fast rate </li></ul></ul><ul><ul><ul><li>Can cause tumor lysis syndrome </li></ul></ul></ul>Hypophosphatemia
    • 59. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Elevated blood phosphate level </li></ul></ul><ul><ul><li>There are no symptoms of hyperphosphatemia </li></ul></ul>Hyperphosphatemia
    • 60. <ul><li>TREATMENT </li></ul><ul><ul><li>Calcium Carbonate tablets </li></ul></ul><ul><ul><li>Aluminum hydroxide </li></ul></ul><ul><ul><ul><li>Can cause aluminum toxicity </li></ul></ul></ul>Hyperphosphatemia
    • 61. <ul><li>OSMOLALITY </li></ul><ul><ul><li>Concentration of a solution </li></ul></ul><ul><ul><li>The higher the osmolality the greater its pulling power for water </li></ul></ul>IV Fluid Therapy Normal serum osmolality is 275 to 295 mOsm/L
    • 62. <ul><li>Sodium = major solute in plasma </li></ul><ul><ul><li>Estimated serum osmolality = 2 X serum Na </li></ul></ul><ul><li>Urea (BUN) and glucose are large molecules that  serum osmolality </li></ul><ul><ul><li>When either or both are elevated, the serum osmolality will be higher than 2 times the sodium level, so the following formula is more accurate: </li></ul></ul><ul><ul><li>Serum osmolality = 2 X serum Na + BUN + glucose </li></ul></ul><ul><ul><li> 3 18 </li></ul></ul>Serum Osmolality
    • 63. Major Mediators of Sodium and Water Balance <ul><li>Angiotensin II </li></ul><ul><li>Aldosterone </li></ul><ul><li>Antidiuretic hormone (ADH) </li></ul>
    • 64. Renin-Angiotensin-Aldosterone Angiotensin II  1. Stimulates production of aldosterone 2. Acts directly on arterioles to cause vasoconstriction 3. Stimulates Na + /H + exchange in the proximal tubule Aldosterone  1. Stimulates reabsorption of Na + and excretion of K + in the late distal tubule 2. Stimulates activity of H + ATPase pumps in the late distal tubule
    • 65. Antidiuretic Hormone (ADH) <ul><li>Synthesized in the hypothalamus and stored in the posterior pituitary </li></ul><ul><li>Released in response to plasma hyperosmolality and decreased circulating volume </li></ul><ul><li>Actions of ADH </li></ul><ul><ul><li>Increases the water permeability of the collecting tubule (makes kidneys reabsorb more water) </li></ul></ul><ul><ul><li>Mildly increases vascular resistance </li></ul></ul>
    • 66. <ul><ul><li>Isotonic – same osmolality as serum </li></ul></ul><ul><ul><li>Hypotonic – lower osmolality than serum </li></ul></ul><ul><ul><li>Hypertonic – higher osmolality than serum </li></ul></ul>IV Fluid Therapy
    • 67. Effect on Cells
    • 68. IV Solutions D5NS D51/2 NS NS ½ NS D50W D10W D5W Hypotonic in the body D5W Hypertonic Hypertonic Isotonic Hypotonic Hypertonic Hypertonic Isotonic Hypertonic Hypertonic Hypertonic Hypertonic Hypertonic Isotonic Hypertonic PRBC’s Hetastarch Dextran Albumin D5LR LR 3% NaCl
    • 69. IV Solutions Pulls fluid into vascular space Hypertonic Solutions Hydrates extracellular compartment Isotonic Solutions Used for cellular dehydration Not used with head injuries Hypotonic Solutions Hypotonic in the body D5W
    • 70. Daily Fluid Balance Intake: 1-1.5 L Insensible Loss - Lungs 0.3 L - Sweat 0.1 L Urine: 1.0 to 1.5 L
    • 71. Intracellular (2/3) Extracellular (1/3) Solids 40% of Wt H 2 O H 2 O Na
    • 72. Intra-vascular( 1/4) E.C . F . COMPARTMENTS Interstitial (3/4) H 2 O H 2 O Na Na Colloids & RBC’s
    • 73. “ Third Space” <ul><li>Third space refers to collection of fluids (usually isotonic) that is sequestered in potential spaces. </li></ul><ul><li>This situation is not normal and the fluid is derived from extracellular fluid. </li></ul>
    • 74. Principles of Treatment <ul><li>How much volume? </li></ul><ul><ul><li>Need to estimate fluid deficit </li></ul></ul><ul><li>Which fluid? </li></ul><ul><ul><li>Which fluid compartment is predominantly affected? </li></ul></ul><ul><ul><li>Must evaluate other acid/base, electrolyte & nutrition needs </li></ul></ul>
    • 75. Fluid Replacement Products <ul><li>Crystalloids – able to pass through semi permeable membranes </li></ul><ul><ul><li>Isotonic solutions </li></ul></ul><ul><ul><li>Hypotonic solutions </li></ul></ul><ul><ul><li>Hypertonic solutions </li></ul></ul><ul><li>Colloids – do not cross the semi permeable membrane and remain in the intravascular space for several days (pulling fluid out of the intracellular and interstitial space) </li></ul><ul><ul><li>Albumin </li></ul></ul><ul><ul><li>Dextran </li></ul></ul><ul><ul><li>Hetastarch </li></ul></ul>
    • 76. 1 liter 5% Albumin Intravascular=1 liter Total body water ECF
    • 77. 1 Liter 0.9% saline Total body water ECF=1 liter ICF=0 Intravascular =1/4 ECF=250 ml Interstitial=3/4 of ECF=750ml
    • 78. 1 liter 5% Dextrose Total body water ECF=1/3 = 300ml ICF=2/3 = 700ml Intravascular =1/4 of ECF~75ml
    • 79. Ringers Lactate <ul><li>Infusion of Ringer Lactate solution may lead to metabolic alkalosis because of the presence of lactate ions </li></ul><ul><li>Lactated Ringer’s should be used with great care with patients with hyperkalemia, severe renal failure, and hepatic insufficiency </li></ul><ul><li>Solutions containing lactate are not for use in the treatment of lactic acidosis </li></ul>
    • 80. <ul><ul><ul><li>BREAK </li></ul></ul></ul>PCCN REVIEW PART 1
    • 81. <ul><li>Brain Aneurysms & AVM’s </li></ul><ul><li>Intracranial Hemorrhage </li></ul><ul><li>Stroke </li></ul>Neurological Alterations
    • 82. The Human Brain
    • 83. Cerebral Spinal Fluid The serum-like fluid that circulates through the ventricles of the brain, the cavity of the spinal cord, and the subarachnoid space
    • 84. <ul><li>Brain Aneurysm </li></ul><ul><ul><li>An intracranial aneurysm is a weak or thin spot on a blood vessel in the brain that balloons out and fills with blood </li></ul></ul><ul><li>AV Malformation (AVM) </li></ul><ul><ul><li>Arteriovenous malformation (AVM) of the brain is a &quot;short circuit“ between the arteries and veins </li></ul></ul>Brain Aneurysms & AVM’s
    • 85. Intracranial Aneurysms <ul><li>Usually occur at bifurcations and branches of the large arteries located in the Circle of Willis </li></ul><ul><li>The most common sites include the: </li></ul><ul><ul><li>Anterior Communicating artery (30 - 35%) </li></ul></ul><ul><ul><li>Bifurcation of the Internal Carotid and Posterior Communicating artery (30 - 35%) </li></ul></ul><ul><ul><li>Bifurcation of Middle cerebral (20%) </li></ul></ul><ul><ul><li>Basilar artery bifurcation (5%) </li></ul></ul><ul><ul><li>Remaining posterior circulation arteries (5%) </li></ul></ul>
    • 86. Types of Aneurysms <ul><li>Saccular aneurysm </li></ul><ul><ul><li>Occurs at bifurcations </li></ul></ul><ul><li>Fusiform aneurysm </li></ul><ul><ul><li>Often in basilar artery </li></ul></ul><ul><li>Dissecting aneurysm </li></ul><ul><li>Ruptured aneurysm </li></ul>
    • 87. Brain Circulation
    • 88. Arterial Circulation in the Brain
    • 89. <ul><li>RISK FACTORS </li></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Coarctation of the aorta </li></ul></ul><ul><ul><li>Dissections/trauma </li></ul></ul><ul><ul><li>Intracranial neoplasm </li></ul></ul><ul><ul><li>Polycystic kidney disease </li></ul></ul><ul><ul><li>Abnormal vessels or High-flow states (eg, vascular malformations, fistulae) </li></ul></ul><ul><ul><li>Hypercholesterolemia </li></ul></ul><ul><ul><li>Connective tissue disorders (eg, Marfan, Ehlers-Danlos) </li></ul></ul>Intracranial Aneurysms
    • 90. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Usually asymptomatic until rupture </li></ul></ul><ul><ul><ul><li>Cranial Nerve Palsy </li></ul></ul></ul><ul><ul><ul><li>Dilated Pupils </li></ul></ul></ul><ul><ul><ul><li>Double Vision </li></ul></ul></ul><ul><ul><ul><li>Pain Above and Behind Eye </li></ul></ul></ul><ul><ul><ul><li>Localized Headache </li></ul></ul></ul><ul><ul><li>Warning signs prior rupture </li></ul></ul><ul><ul><ul><li>Localized Headache </li></ul></ul></ul><ul><ul><ul><li>Nausea & Vomiting </li></ul></ul></ul><ul><ul><ul><li>Stiff Neck </li></ul></ul></ul><ul><ul><ul><li>Blurred or Double Vision </li></ul></ul></ul><ul><ul><ul><li>Sensitivity to Light (photophobia) </li></ul></ul></ul><ul><ul><ul><li>Loss of Sensation </li></ul></ul></ul>Intracranial Aneurysms
    • 91. Treatment of Brain Aneurysms <ul><li>Surgery </li></ul><ul><li>– Craniotomy and clipping </li></ul><ul><li>Endovascular coiling </li></ul>
    • 92. Aneurysm Post-Op Risks <ul><li>Rebleeding </li></ul><ul><ul><li>Most frequently within the first 24 hours </li></ul></ul><ul><ul><li>Up to 20% of patients rebleed within 14 days </li></ul></ul><ul><ul><li>Main preventative measure is control of blood pressure (preferably beta blockers) </li></ul></ul><ul><li>Vasospasm </li></ul><ul><ul><li>Usually occurs before 3 days or after 10 days (post bleed) </li></ul></ul><ul><ul><li>May require hypervolemic therapy </li></ul></ul><ul><li>Hydrocephalus </li></ul><ul><li>Hyponatremia </li></ul><ul><li>Fluids / Electrolytes </li></ul>
    • 93. Arterio-Venous Malformation
    • 94. <ul><li>The arteries and veins have a direct connection, bypassing the capillary network </li></ul><ul><li>Presents with ongoing headaches, seizures, hemorrhage, or progressive neurological dysfunction </li></ul>Arterio-Venous Malformation
    • 95. Arterio-Venous Malformation <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Headaches </li></ul></ul><ul><ul><li>“ Whooshing&quot; Sound (Bruit) </li></ul></ul><ul><ul><li>Other Signs </li></ul></ul><ul><ul><ul><li>Subtle behavioral changes </li></ul></ul></ul><ul><ul><ul><li>Communication or thinking disturbances </li></ul></ul></ul><ul><ul><ul><li>Loss of coordination and balance </li></ul></ul></ul><ul><ul><ul><li>Paralysis or weakness in one part of the body </li></ul></ul></ul><ul><ul><ul><li>Visual disturbances </li></ul></ul></ul><ul><ul><ul><li>Abnormal sensations </li></ul></ul></ul>
    • 96. Arterio-Venous Malformation <ul><li>COMPLICATIONS </li></ul><ul><ul><li>Hemorrhage (into surrounding tissue) </li></ul></ul><ul><ul><li>Ischemia </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Brain Cell Death </li></ul></ul>
    • 97. Arterio-Venous Malformation <ul><li>DIAGNOSIS </li></ul><ul><ul><li>MRI (including MR Angiography) as well as CT Angiography help identify AVM’s </li></ul></ul><ul><ul><li>Cerebral Angiography is a prerequisite to treatment </li></ul></ul><ul><ul><ul><li>To identify the precise anatomy and configuration of both the lesion and the feeding and draining vessels </li></ul></ul></ul>
    • 98. Arterio-Venous Malformation <ul><li>TREATMENT </li></ul><ul><ul><li>Surgery </li></ul></ul><ul><ul><ul><li>Usually delayed </li></ul></ul></ul><ul><ul><ul><li>Open ligation and/or resection of the AVM </li></ul></ul></ul><ul><ul><li>Radiosurgery </li></ul></ul><ul><ul><li>Embolization </li></ul></ul><ul><ul><ul><li>Usually as adjunct to surgery </li></ul></ul></ul><ul><ul><li>Observation </li></ul></ul>
    • 99. Arterio-Venous Malformation <ul><li>RADIOSURGERY </li></ul><ul><ul><li>Believed to &quot;work&quot; by initiating an &quot;inflammatory&quot; response in the pathological blood vessels ultimately resulting in their progressive narrowing and ultimate closure </li></ul></ul><ul><ul><li>The risk for hemorrhage is not reduced during this lag time </li></ul></ul><ul><ul><li>There is the added risk of radiation necrosis of adjacent healthy brain tissue or brain cyst formation </li></ul></ul>
    • 100. Brain Radiosurgery <ul><li>ADVANTAGES </li></ul><ul><ul><li>Noninvasive </li></ul></ul><ul><ul><li>Can access all anatomic locations of the brain </li></ul></ul><ul><li>DISADVANTAGES </li></ul><ul><ul><li>Can only treat smaller lesions (<3 cm in diameter) </li></ul></ul><ul><ul><li>Requires 2 or more years to complete </li></ul></ul>
    • 101. AVM Post-Op Risks <ul><li>Perfusion-breakthrough bleeding </li></ul><ul><li>Endovascular occlusion </li></ul>
    • 102. <ul><ul><li>Sudden onset of “the worst headache of my life” </li></ul></ul>Intracranial Hemorrhage
    • 103. <ul><li>Epidural </li></ul><ul><li>Subdural </li></ul><ul><li>Subarachnoid </li></ul><ul><li>Intraparencymal </li></ul><ul><li>Intraventricular </li></ul><ul><li>Cerebellar </li></ul>Intracranial Hemorrhage
    • 104. <ul><li>ICH is a dynamic, not a static process </li></ul><ul><li>Hemorrhage volume can increase over time </li></ul><ul><li>CT scan is the most important diagnostic tool </li></ul><ul><li>Managing blood pressure is extremely important </li></ul><ul><li>Must aggressively manage fever and seizures </li></ul><ul><li>Consider hyperventilation and paralytics in setting of increased ICP and deterioration </li></ul>Intracranial Hemorrhage
    • 105. Treatment of ICH <ul><li>KEY CONCEPTS </li></ul><ul><ul><li>Intracranial Pressure </li></ul></ul><ul><ul><ul><ul><li>Elevated when ICP >20 mm Hg </li></ul></ul></ul></ul><ul><ul><li>Cerebral Perfusion Pressure </li></ul></ul><ul><ul><ul><ul><li>CPP = MAP - ICP </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Must maintain CPP > 70 mm Hg </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Example: MAP = 100, ICP = 20 </li></ul></ul></ul></ul><ul><ul><ul><ul><li> CPP = 80 mmHg </li></ul></ul></ul></ul>
    • 106. Subarachnoid Hemorrhage (SAH) <ul><li>DEFINITION </li></ul><ul><ul><li>When a blood vessel just outside the brain ruptures, the area of the skull surrounding the brain (the subarachnoid space) rapidly fills with blood </li></ul></ul>
    • 107. Subarachnoid Hemorrhage (SAH) <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Sudden, intense headache </li></ul></ul><ul><ul><li>Neck pain </li></ul></ul><ul><ul><li>Nausea or vomiting  </li></ul></ul><ul><ul><li>Neck stiffness </li></ul></ul><ul><ul><li>Photophobia </li></ul></ul><ul><li>Sudden onset of “the worst headache of my life” </li></ul>
    • 108. Subarachnoid Hemorrhage (SAH) <ul><li>SAH may be spontaneous or traumatic </li></ul><ul><li>Spontaneous SAH causes </li></ul><ul><ul><li>Cerebral aneurysms </li></ul></ul><ul><ul><li>AV malformations </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><li>Uncommon causes </li></ul><ul><ul><li>Neoplasms, venous angiomas, infections </li></ul></ul>
    • 109. <ul><li>Warning bleeds” are relatively common </li></ul><ul><li>Sentinel headache 30-50% </li></ul><ul><li>Early diagnosis prior to rupture will improve outcomes </li></ul><ul><li>50% of patients die within 48 hours irrespective of therapy </li></ul>Subarachnoid Hemorrhage
    • 110. <ul><li>Often accompanied by a period of unconsciousness (50% never wake up) </li></ul><ul><li>Common signs include neck stiffness, photophobia, headache </li></ul><ul><li>20% have ECG evidence of myocardial ischemia </li></ul>Subarachnoid Hemorrhage
    • 111. Complications of SAH <ul><li>Hydrocephalus may develop within the first 24 hours because of obstruction of CSF outflow in the ventricular system by clotted blood </li></ul><ul><li>Rebleeding of SAH occurs in 20% of patients in the first 2 weeks. Peak incidence of rebleeding occurs the day after SAH and may be from lysis of the aneurysmal clot </li></ul><ul><li>Vasospasm from arterial smooth muscle contraction (symptomatic in 36% of patients) </li></ul>
    • 112. Re-bleeding After SAH <ul><li>Re-bleeding occurs most frequently within the first 24 hrs </li></ul><ul><li>Up to 20% of patients rebleed within 14 days </li></ul><ul><li>The main preventative measure is to control the blood pressure – preferably beta blockers </li></ul><ul><li>Early clipping of the aneurysm allows hypertensive and hypervolemic therapy to prevent vasospasm </li></ul>
    • 113. Vasospasm After SAH <ul><li>Worst time is day 7 to day 10 (most frequent time for vasospasms) </li></ul><ul><li>Diagnosed by neurologic exam, transcranial doppler and angiography </li></ul><ul><li>May use calcium channel blockers </li></ul><ul><ul><li>Reduces vasospasm, neurological deficit, cerebral infarction and mortality </li></ul></ul><ul><li>May use some antispasmodics </li></ul>
    • 114. Vasospasm & HHH Therapy <ul><li>Hemodilution </li></ul><ul><ul><li>Hct 30-35% </li></ul></ul><ul><li>Hypertension </li></ul><ul><ul><li>Phenylephrine / Norepinephrine </li></ul></ul><ul><ul><li>BP titration to CPP/exam </li></ul></ul><ul><li>Hypervolemia </li></ul><ul><ul><li>Colloids/crystalloids </li></ul></ul>
    • 115. Other Vasospasm Therapy <ul><li>Angioplasty </li></ul><ul><ul><li>BP management during procedure </li></ul></ul><ul><ul><li>Reperfusion issues </li></ul></ul><ul><ul><li>Timing </li></ul></ul><ul><li>Papaverine Infusion </li></ul><ul><ul><li>Side effects </li></ul></ul><ul><ul><li>Repeated trips </li></ul></ul>
    • 116. <ul><li>Neurologic deficits from cerebral ischemia, peaks at days 4-12 </li></ul><ul><li>Hypothalamic dysfunction causes excessive sympathetic stimulation, which may lead to myocardial ischemia or labile BP </li></ul><ul><li>Hyponatremia may result from cerebral salt wasting / SIADH </li></ul><ul><li>Nosocomial pneumonia and other such complications </li></ul><ul><li>Pulmonary edema neurogenic & non-neurogenic </li></ul>Other Complications of SAH
    • 117. <ul><li>Identify and treat the causative lesion </li></ul><ul><ul><li>Thus preventing re-bleeding </li></ul></ul><ul><li>Treat hydrocephalus </li></ul><ul><li>Treating and prevent vasospasm </li></ul>Treatment of SAH
    • 118. <ul><li>Maintain systolic BP >130mmHg </li></ul><ul><ul><li>Use vasopressors if necessary to maintain CPP and reduce ischemic complications from vasospasm </li></ul></ul><ul><ul><li>Generally avoid vasodilators (except calcium channel blockers) </li></ul></ul>Treatment of SAH
    • 119. Stroke
    • 120. Stroke
    • 121. <ul><li>RISK FACTORS </li></ul><ul><li>TIA </li></ul><ul><li>CAD </li></ul><ul><li>High Blood Pressure </li></ul><ul><li>High Cholesterol </li></ul><ul><li>Smoking </li></ul><ul><li>Heart Disease </li></ul><ul><li>Diabetes </li></ul><ul><li>Excessive alcohol </li></ul><ul><li>Family History </li></ul><ul><li>Age </li></ul><ul><li>Sex </li></ul><ul><li>Race </li></ul><ul><li>Obesity </li></ul>Annual risk of stroke: Increases with age Stroke
    • 122. <ul><li>Computed Tomography (CT) </li></ul><ul><li>Magnetic Resonance Imaging (MRI) </li></ul><ul><li>Cerebral Angiography: identify responsible vessel </li></ul><ul><li>Carotid Ultrasound: carotid artery stenosis </li></ul><ul><li>Echocardiogram: identify blood clot from heart </li></ul><ul><li>Electrocardiogram (ECG): underlying heart conditions </li></ul><ul><li>Heart monitors, blood work and more tests!! </li></ul>Stroke Tests
    • 123. CT MRI <ul><li>http://www.strokecenter.org/education/ais_ct_tool/ct04/ct04-frames.htm </li></ul>http://www.strokecenter.org/education/ais_ct_tool/index.htm
    • 124. <ul><li>Tissue plasminogen activator (tPA) can be given within three hours from the onset of symptoms </li></ul><ul><li>Heparin </li></ul><ul><li>Intra-arterial thrombolysis </li></ul><ul><li>Hemicraniectomy </li></ul><ul><li>In addition to being used to treat strokes, the following can also be used as preventative measures </li></ul><ul><ul><li>Anticoagulants/Antiplatelets </li></ul></ul><ul><ul><li>Carotid Endarterectomy </li></ul></ul><ul><ul><li>Angioplasty/Stents </li></ul></ul>Treatment of Ischemic CVA
    • 125. <ul><li>Surgery is often required to remove pooled blood from the brain and to repair damaged blood vessels </li></ul><ul><li>Prevention: </li></ul><ul><ul><li>An obstruction is introduced to prevent rupture and bleeding of aneurysms and AVM’s </li></ul></ul><ul><ul><li>Surgical Intervention </li></ul></ul><ul><ul><li>Endovascular Procedures </li></ul></ul>Treatment of Hemorrhagic CVA
    • 126. <ul><li>Control high Blood Pressure </li></ul><ul><li>Lower cholesterol </li></ul><ul><li>Quit smoking </li></ul><ul><li>Control diabetes </li></ul><ul><li>Maintain healthy weight </li></ul><ul><li>Exercise </li></ul><ul><li>Manage stress </li></ul><ul><li>Eat a healthy diet </li></ul>Prevention of CVA
    • 127. <ul><ul><ul><li>BREAK </li></ul></ul></ul>PCCN REVIEW PART 1
    • 128. <ul><li>DKA & HHNK </li></ul><ul><li>DI & SIADH </li></ul><ul><li>DIC </li></ul><ul><li>Shock States </li></ul><ul><li>Sepsis </li></ul>Metabolic Alterations
    • 129. Diabetic Ketoacidosis <ul><li>What is DKA? </li></ul><ul><ul><li>Diabetic Ketoacidosis </li></ul></ul><ul><ul><li>A life-threatening complication seen with Diabetes Mellitus Type 1 </li></ul></ul>
    • 130. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Serum Glucose 300-800 </li></ul></ul><ul><ul><li>Ketoacidosis Present </li></ul></ul><ul><ul><li>Large Serum And Urine Ketones </li></ul></ul><ul><ul><li>Fruity Breath </li></ul></ul><ul><ul><li>Kussmaul Respirations </li></ul></ul><ul><ul><li>Serum pH < 7.3 </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul>Diabetic Ketoacidosis
    • 131. HHNK <ul><li>What is HHNK? </li></ul><ul><ul><ul><li>Hyperglycemic Hyperosmolar Nonketonic Coma </li></ul></ul></ul><ul><ul><ul><li>A life threatening complication seen with Diabetes Mellitus Type 2 </li></ul></ul></ul>
    • 132. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Serum Glucose 600-2000 </li></ul></ul><ul><ul><li>Ketoacidosis Not Present </li></ul></ul><ul><ul><li>Absent Or Slight Serum And Urine Ketones </li></ul></ul><ul><ul><li>Normal Breath </li></ul></ul><ul><ul><li>Shallow Respirations </li></ul></ul><ul><ul><li>Serum pH Normal </li></ul></ul><ul><ul><li>Severe Dehydration </li></ul></ul>HHNK
    • 133. DKA vs HHNK <ul><li>DKA </li></ul><ul><li>Faster Onset </li></ul><ul><li>Glucose 300-800 </li></ul><ul><li>Acidosis </li></ul><ul><li>Fruity Breath </li></ul><ul><li>Kussmaul Respirations </li></ul><ul><li> HHNK </li></ul><ul><li>Slower Onset </li></ul><ul><li>Glucose 600-2000 </li></ul><ul><li>No Acidosis </li></ul><ul><li>Normal Breath </li></ul><ul><li>Shallow Respirations </li></ul>
    • 134. Treatment of DKA & HHNK <ul><li>Reverse Dehydration </li></ul><ul><ul><ul><ul><ul><li>NS, then ½ NS </li></ul></ul></ul></ul></ul><ul><li>Restore Glucose Levels </li></ul><ul><ul><ul><ul><ul><li>D 5 ½ NS When Glu 250 </li></ul></ul></ul></ul></ul><ul><li>Restore Electrolytes </li></ul>
    • 135. <ul><li>What is Diabetes Insipitus? </li></ul><ul><ul><li>A Condition resulting from too little ADH </li></ul></ul><ul><li>Why is it called Diabetes Insipitus? </li></ul><ul><ul><li>The term Diabetes refers to polyuria </li></ul></ul>Diabetes Insipitus
    • 136. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Polyuria </li></ul></ul><ul><ul><li>Severe Hypovolemia </li></ul></ul><ul><ul><li>Severe Dehydration </li></ul></ul><ul><ul><li>Elevated Serum Osmolality </li></ul></ul><ul><ul><li>Elevated Serum Sodium </li></ul></ul><ul><ul><li>Shock </li></ul></ul>Diabetes Insipitus
    • 137. <ul><li>CAUSES </li></ul><ul><ul><li>Decreased ADH </li></ul></ul><ul><ul><li>Neurological Surgery </li></ul></ul><ul><ul><li>Head Trauma </li></ul></ul><ul><ul><li>Dilantin or Lithium </li></ul></ul>Diabetes Insipitus
    • 138. <ul><li>TREATMENT </li></ul><ul><ul><li>Fluid Resuscitation </li></ul></ul><ul><ul><li>ADH Replacement </li></ul></ul><ul><ul><ul><li>Vasopressin, Pitressin, DDAVP </li></ul></ul></ul><ul><ul><li>Treat The Cause </li></ul></ul>Diabetes Insipitus
    • 139. <ul><li>What is SIADH? </li></ul><ul><ul><li>Syndrome of Inappropriate ADH </li></ul></ul><ul><ul><li>Too much ADH </li></ul></ul>SIADH
    • 140. SIADH <ul><li>SIGNS & SYMPTOMS </li></ul><ul><li>Hyponatremia </li></ul><ul><li>Low Serum Sodium </li></ul><ul><ul><li>Serum NA < 135 </li></ul></ul><ul><li>Low Serum Osmolality </li></ul><ul><li>High Urine Osmolality </li></ul><ul><li>Elevated Specific Gravity </li></ul><ul><ul><li>Urine specific gravity </li></ul></ul><ul><ul><li>> 1.030 </li></ul></ul><ul><li>Elevated Urine Osmolality </li></ul><ul><li>Elevated ADH Level </li></ul><ul><li>Weight Gain Without Edema </li></ul><ul><li>Elevated CVP, PAP, PAWP </li></ul><ul><li>Hypertension </li></ul><ul><li>Concentrated And  UOP </li></ul><ul><li>Headache </li></ul><ul><li>Altered LOC </li></ul><ul><li>Seizures </li></ul>
    • 141. <ul><li>CAUSES </li></ul><ul><ul><li>Head Trauma </li></ul></ul><ul><ul><li>Oat Cell Carcinoma </li></ul></ul><ul><ul><li>Other Cancers </li></ul></ul><ul><ul><li>Viral Pneumonia </li></ul></ul>SIADH <ul><ul><li>Medications </li></ul></ul><ul><ul><li>Stress </li></ul></ul><ul><ul><li>Mechanical Ventilation </li></ul></ul>
    • 142. <ul><li>TREATMENT </li></ul><ul><ul><li>Monitor Fluid Balance, Monitor I & O </li></ul></ul><ul><ul><li>Restrict Fluids </li></ul></ul><ul><ul><li>Replace Na+ loss when necessary </li></ul></ul><ul><ul><li>May Give 3% (Hypertonic) Saline </li></ul></ul><ul><ul><li>May Give Dilantin or Lithium </li></ul></ul><ul><ul><li>May require PA Catheter For Monitoring </li></ul></ul><ul><ul><li>May Give Diuretics </li></ul></ul>SIADH
    • 143. DI vs SIADH <ul><li>DI </li></ul><ul><li>Too Little ADH </li></ul><ul><li>Dehydration </li></ul><ul><li>High Serum Sodium </li></ul><ul><li>High Serum Osmolality </li></ul><ul><li>Low Urine Osmolality </li></ul><ul><li> SIADH </li></ul><ul><li>Too Much ADH </li></ul><ul><li>Water Intoxication </li></ul><ul><li>Low Serum Sodium </li></ul><ul><li>Low Serum Osmolality </li></ul><ul><li>High Urine Osmolality </li></ul>
    • 144. DI vs SIADH Treatment <ul><li>DI </li></ul><ul><li>Lots of Fluids </li></ul><ul><li>Hold Dilantin </li></ul><ul><li>Hold Lithium </li></ul><ul><li>Give ADH </li></ul><ul><li> SIADH </li></ul><ul><li>Fluid Restriction </li></ul><ul><li>May Give Dilantin </li></ul><ul><li>May Give Lithium </li></ul><ul><li>3% Saline </li></ul>
    • 145. <ul><li>What is DIC? </li></ul><ul><ul><li>Disseminate Intravascular Coagulation </li></ul></ul><ul><ul><li>A clotting disorder that ultimately causes bleeding </li></ul></ul>DIC
    • 146. <ul><li>Caused by over-activation of the clotting pathways </li></ul><ul><li>Causes widespread fibrin deposits </li></ul><ul><li>Bleeding and renal failure are most common manifestations </li></ul><ul><li>Treating the underlying disease is the most important step </li></ul>DIC
    • 147. Disseminated Intravascular Coagulation Systemic activation of coagulation Intravascular deposition of fibrin Depletion of platelets and coagulation factors BLEEDING Thrombosis of small and midsize vessels with organ failure
    • 148. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Bleeding </li></ul></ul><ul><ul><li>Thrombosis </li></ul></ul><ul><ul><li>Organ Failure </li></ul></ul>DIC
    • 149. DIC
    • 150. <ul><li>CAUSES </li></ul><ul><ul><li>Massive Tissue Injuries </li></ul></ul><ul><ul><li>Obstetric Emergencies </li></ul></ul><ul><ul><li>Septicemia </li></ul></ul><ul><ul><li>Cancers </li></ul></ul><ul><ul><li>Vascular Disorders </li></ul></ul><ul><ul><li>Systemic Disorders </li></ul></ul><ul><ul><li>Many More Causes </li></ul></ul>DIC
    • 151. <ul><li>CLOTTING FACTORS DEPLETED </li></ul><ul><ul><li>Platelets  </li></ul></ul><ul><ul><li>Fibrinogen  </li></ul></ul><ul><ul><li>Protein C  </li></ul></ul><ul><ul><li>Antithrombin  </li></ul></ul>DIC Lab Results <ul><li>CLOTTING TESTS ELEVATED </li></ul><ul><ul><li>PT  </li></ul></ul><ul><ul><li>aPTT  </li></ul></ul><ul><ul><li>Fibrin degradation products (D-dimer)  </li></ul></ul>
    • 152. <ul><li>TREATMENT </li></ul><ul><ul><li>Treat the Cause </li></ul></ul><ul><ul><li>Replace Clotting Factors </li></ul></ul><ul><ul><li>Anticoagulation Therapy (Heparin) </li></ul></ul>DIC
    • 153. <ul><li>DEFINITION </li></ul><ul><ul><li>Inadequate perfusion to body tissues </li></ul></ul>Shock
    • 154. <ul><li>COMPENSATORY MECHANISMS </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><ul><li>Attempts to deliver more blood to the tissues </li></ul></ul></ul><ul><ul><li>Vasoconstriction </li></ul></ul><ul><ul><ul><li>Attempts to maintain adequate BP in order to adequately perfuse the body tissues </li></ul></ul></ul><ul><ul><li>Increased ADH Secretion </li></ul></ul><ul><ul><ul><li>ADH makes the body hold onto water in an effort to maintain volume and thus enough blood pressure to perfuse the body tissues </li></ul></ul></ul>Shock
    • 155. <ul><li>Hypovolemic Shock </li></ul><ul><ul><li>Inadequate perfusion to the tissues due to insufficient intravascular volume </li></ul></ul><ul><li>Cardiogenic Shock </li></ul><ul><ul><li>Inadequate perfusion to the tissues due to heart failure </li></ul></ul><ul><li>Distributive Shock </li></ul><ul><ul><li>Inadequate perfusion to the tissues due to blood flow out of the intravascular space causing insufficient intravascular volume </li></ul></ul><ul><ul><li>Anaphylactic, Septic, and Spinal Shock </li></ul></ul><ul><li>Obstructive Shock </li></ul><ul><ul><li>Inadequate perfusion to the tissues due to obstruction of blood flow </li></ul></ul>Types of Shock
    • 156. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Low BP Tachycardia </li></ul></ul><ul><ul><li>Orthostatic Hypotension Restlessness </li></ul></ul><ul><ul><li>Confusion Agitation (or listless) </li></ul></ul><ul><ul><li>Thirst Pallor </li></ul></ul><ul><ul><li>Cool, Clammy Skin  Resp. Rate </li></ul></ul><ul><ul><li> UOP  CO </li></ul></ul><ul><ul><li> PAWP  CVP </li></ul></ul><ul><ul><li> SVR  Lactate Levels </li></ul></ul>Hypovolemic Shock
    • 157. <ul><li>TREATMENT </li></ul><ul><ul><li>Volume (IVF, Blood) </li></ul></ul>Hypovolemic Shock
    • 158. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Low BP Restlessness </li></ul></ul><ul><ul><li>Agitation (or listless) Confusion </li></ul></ul><ul><ul><li>Tachycardia Pallor </li></ul></ul><ul><ul><li> UOP  CO </li></ul></ul><ul><ul><li> PAWP (low with RVF)  CVP </li></ul></ul><ul><ul><li> SVR  Lactate Levels </li></ul></ul><ul><ul><li>JVD Peripheral Edema </li></ul></ul><ul><ul><li>Ventricular Gallop (S3) Dyspnea </li></ul></ul><ul><ul><li>Pulmonary Crackles </li></ul></ul>Cardiogenic Shock
    • 159. <ul><li>TREATMENT </li></ul><ul><ul><li>Bedrest O2 </li></ul></ul><ul><ul><li> CO Positive Inotropes </li></ul></ul><ul><ul><li> Preload & Afterload Diuretics </li></ul></ul><ul><ul><li> Vasodilators Positioning </li></ul></ul><ul><ul><li> Myocardial Demand IABP </li></ul></ul>Cardiogenic Shock
    • 160. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Low BP Tachycardia </li></ul></ul><ul><ul><li>Restlessness Confusion </li></ul></ul><ul><ul><li>Agitation (or listless) Thirst </li></ul></ul><ul><ul><li>Pallor Warm Feeling </li></ul></ul><ul><ul><li>Pruritus Hives </li></ul></ul><ul><ul><li>Angioedema Bronchoconstriction </li></ul></ul><ul><ul><li>Wheezing Laryngoedema </li></ul></ul><ul><ul><li>Dyspnea Cool, Clammy Skin </li></ul></ul><ul><ul><li> UOP  CO </li></ul></ul><ul><ul><li> PAWP  CVP </li></ul></ul><ul><ul><li> SVR  Lactate Levels </li></ul></ul>Anaphylactic Shock
    • 161. <ul><li>TREATMENT </li></ul><ul><ul><li>Epinephrine </li></ul></ul><ul><ul><li>IVF </li></ul></ul><ul><ul><li>Vasoconstrictors </li></ul></ul><ul><ul><li>Support/Maintain Airway </li></ul></ul>Anaphylactic Shock
    • 162. <ul><li>EARLY STAGE (Hyperdynamic) </li></ul><ul><ul><li>Normal BP Tachycardia </li></ul></ul><ul><ul><li>Confusion Agitation (or listless) </li></ul></ul><ul><ul><li> Respiratory Rate Temperature </li></ul></ul><ul><ul><li>Normal Color Normal or  UOP </li></ul></ul><ul><ul><li>Normal PAWP  CO  SVR </li></ul></ul><ul><li>LATE STAGE (Hypodynamic) </li></ul><ul><ul><li>Low BP Tachycardia </li></ul></ul><ul><ul><li>Orthostatic Hypotension Restlessness </li></ul></ul><ul><ul><li>Confusion Agitation (or listless) </li></ul></ul><ul><ul><li>Thirst Pallor </li></ul></ul><ul><ul><li>Cool, Clammy Skin  UOP </li></ul></ul><ul><ul><li> CO  PAWP </li></ul></ul><ul><ul><li> CVP  SVR </li></ul></ul><ul><ul><li> Lactate Levels </li></ul></ul>Septic Shock
    • 163. <ul><li>TREATMENT </li></ul><ul><ul><li>IVF (150cc/hr or wide open) </li></ul></ul><ul><ul><li>Treat Cause (Pan culture, antibiotics) </li></ul></ul><ul><ul><li>Vasoconstrictors in warm phase </li></ul></ul><ul><ul><li>Treat Temp as needed </li></ul></ul>Septic Shock
    • 164. <ul><li>CAUSES </li></ul><ul><ul><li>Pulmonary Embolus Tamponade </li></ul></ul><ul><ul><li>Tension Pneumothorax Aortic Aneurysm </li></ul></ul><ul><li>TREATMENT </li></ul><ul><ul><li>Treat the Cause </li></ul></ul>Obstructive Shock
    • 165. <ul><li> SIRS Sepsis Severe Septic MODS Death </li></ul><ul><li>Infection Sepsis Shock </li></ul>Sepsis Syndrome
    • 166. Sepsis Syndrome <ul><li>Sepsis </li></ul><ul><ul><li>SIRS’ response with presumed/confirmed infection </li></ul></ul><ul><li>Severe Sepsis </li></ul><ul><ul><li>Sepsis associated with organ dysfunction, hypoperfusion (lactic acidosis, oliguria, altered mental status etc.), or hypotension (SBP < 90 mmHg or ↓ SBP > 40 mmHg) </li></ul></ul><ul><li>Septic Shock </li></ul><ul><ul><li>Sepsis with perfusion abnormalities and hypotension despite adequate fluid resuscitation </li></ul></ul>
    • 167.  
    • 168. Homeostasis Gets Lost
    • 169. <ul><li>Improve Perfusion </li></ul><ul><ul><ul><li>Prevent organ dysfunction </li></ul></ul></ul>Treatment for Sepsis <ul><li>Treat The Cause </li></ul><ul><ul><ul><li>Seek primary site of infection </li></ul></ul></ul><ul><ul><ul><li>Direct therapy to primary cause </li></ul></ul></ul><ul><li>Stabilize The Patient </li></ul><ul><ul><ul><li>Fluids (lots of fluids) </li></ul></ul></ul><ul><ul><ul><li>Vasoconstrictors </li></ul></ul></ul>
    • 170. <ul><ul><ul><li>THE END </li></ul></ul></ul><ul><ul><ul><li>PART 2 </li></ul></ul></ul>PCCN REVIEW
    • 171. <ul><ul><ul><li>THANK YOU! </li></ul></ul></ul>PCCN REVIEW
    • 172. <ul><ul><ul><li>GOOD LUCK! </li></ul></ul></ul>PCCN REVIEW
    • 173. <ul><ul><ul><ul><ul><li>American Stroke Association. (2007). Acute and Preventative Treatments. Retrieved March 4, 2007 from http:// www.strokeassociation.org/presenter.jhtml?identifier =2532 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Anderson, L. (July 2001). Abdominal Aortic Aneurysm, Journal of Cardiovascular Nursing:15(4):1–14, July 2001. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Balk, R. A. (2000). Severe sepsis and septic shock. Critical Care Clinics; (2)179-92. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Block, C., and Manning, H. (2002). Prevention of acute renal failure in the critically ill. American Journal of Respiratory and Critical Care Medicine; (165)320-324. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Brenner, B. M., and Rector, F.C. (2000). The kidney (6th ed), Vol I. Philadelphia: W.B. Saunders Company; (1)399-416. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Brettler S. (2005). Endovascular coiling for cerebral aneurysms. AACN Clinical Issues; (16)515-525. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Britz, G. W. (2005). ISAT trial: Coiling or clipping for intracranial aneurysms? Lancet; (366)783-785. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Campbell, D. (2003). How acute renal failure puts the breaks on kidney function. Nursing 2003; (33)59-63. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Guyton, A. C., and Hall, J. E. (2000). Unit V: The kidneys and body fluids. In A. C. Guyton & J. E. Hall. Textbook of medical physiology (10th ed.). Philadelphia: W.B. Saunders Company; pg. 264-379. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Impact of Stroke. (2007). American Stroke Association. Retrieved March 4, 2007 from http:// www.strokeassociation.org/presenter.jhtml?identifier =1033 </li></ul></ul></ul></ul></ul>Resources
    • 174. <ul><ul><ul><ul><ul><li>Khurana, V. G., Friedman, J. A., Meyer, F. B. (2004). Chapter 11: Biology of Cerebral Blood Vessels and Blood Flow. In Le Roux, P. D., Winn, H. R., Newell, D. W. (eds). Management of Cerebral Aneurysms, Philadelphia, WB Saunders, pp 139-167, 2003. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Marino, P. L. (2006, September). The ICU Book. Lippincott Williams & Wilkins: Philadelphia. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Metheny, N. (2000). Fluid and Electrolyte Balance: Nursing Considerations (4th ed.) Philadelphia: Lippincott Williams & Wilkins; (4)158-200. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Nettina, S. M. (2005). Diseases and Disorders in Lippincott Manual of Nursing Practice Handbook (3rd ed.), page 414. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Rivers, E. P. (2006, February). Early goal-directed therapy in severe sepsis and septic shock: converting science to reality. Chest; 129(2):217-8. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Rucker, D. (2006, June). Diabetic Ketoacidosis. Retrieved Feb 28, 2007 from http://www.emedicine.com/emerg/topic135.htm. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Schmidt, T. (2000). “Assessing a Sodium and Fluid Imbalance”, Nursing 2000; (30) Number 1, p18. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sterns, R.H., Silver, S. M., Spital, A., Robertson, G. L., Seldin, D. W., Giebisch, G. (2000). The Kidney: Physiology & Pathophysiology. Philadelphia PA: Lippincott Williams & Wilkins, Inc; pgs. 1133–52 & 1217–38. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Thelan, L. A., Urden, L. D., Lough, M. E. (2006). Critical care: Diagnosis and Treatment for repair of abdominal aortic aneurysm. St. Louis, Mo.: Mosby/Elsevier. pg 145-188. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Urden, L., Lough, M. E. & Stacy, K. L. (2005). Thelan's Critical Care Nursing: Diagnosis and Management (5th ed). S </li></ul></ul></ul></ul></ul>Resources Continued

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