Pccn Review Part 2

8,076 views

Published on

Progressive Critical Care Nurse Certification Review, Part 2 of 2

Published in: Education, Health & Medicine
2 Comments
14 Likes
Statistics
Notes
  • 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


    http://www.rnpedia.com/
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Fioricet is often prescribed for tension headaches caused by contractions of the muscles in the neck and shoulder area. Buy now from http://www.fioricetsupply.com and make a deal for you.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total views
8,076
On SlideShare
0
From Embeds
0
Number of Embeds
28
Actions
Shares
0
Downloads
419
Comments
2
Likes
14
Embeds 0
No embeds

No notes for slide
  • Pccn Review Part 2

    1. 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. 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. 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. 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. 5. <ul><li>Acute Renal Failure </li></ul><ul><li>Electrolytes </li></ul><ul><li>IV Fluid Therapy </li></ul>Renal Alterations
    6. 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. 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. 8. The Kidney
    9. 9. The Nephron
    10. 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. 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. 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. 13. Urine Formation
    14. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 24. Pre-Renal or Intra-Renal?
    25. 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. 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. 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. 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. 29. Electrolyte Disturbances Na+ Ca++ Cl- Mg+ K+ PO 4 NH 3 Cu HCO 3 - NaCl
    30. 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. 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. 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. 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. 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. 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. 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. 37. Sine Wave
    38. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 67. Effect on Cells
    68. 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. 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. 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. 71. Intracellular (2/3) Extracellular (1/3) Solids 40% of Wt H 2 O H 2 O Na
    72. 72. Intra-vascular( 1/4) E.C . F . COMPARTMENTS Interstitial (3/4) H 2 O H 2 O Na Na Colloids & RBC’s
    73. 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. 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. 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. 76. 1 liter 5% Albumin Intravascular=1 liter Total body water ECF
    77. 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. 78. 1 liter 5% Dextrose Total body water ECF=1/3 = 300ml ICF=2/3 = 700ml Intravascular =1/4 of ECF~75ml
    79. 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. 80. <ul><ul><ul><li>BREAK </li></ul></ul></ul>PCCN REVIEW PART 1
    81. 81. <ul><li>Brain Aneurysms & AVM’s </li></ul><ul><li>Intracranial Hemorrhage </li></ul><ul><li>Stroke </li></ul>Neurological Alterations
    82. 82. The Human Brain
    83. 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. 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. 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. 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. 87. Brain Circulation
    88. 88. Arterial Circulation in the Brain
    89. 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. 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. 91. Treatment of Brain Aneurysms <ul><li>Surgery </li></ul><ul><li>– Craniotomy and clipping </li></ul><ul><li>Endovascular coiling </li></ul>
    92. 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. 93. Arterio-Venous Malformation
    94. 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. 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. 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. 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. 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. 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. 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. 101. AVM Post-Op Risks <ul><li>Perfusion-breakthrough bleeding </li></ul><ul><li>Endovascular occlusion </li></ul>
    102. 102. <ul><ul><li>Sudden onset of “the worst headache of my life” </li></ul></ul>Intracranial Hemorrhage
    103. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 119. Stroke
    120. 120. Stroke
    121. 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. 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. 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. 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. 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. 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. 127. <ul><ul><ul><li>BREAK </li></ul></ul></ul>PCCN REVIEW PART 1
    128. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 149. DIC
    150. 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. 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. 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. 153. <ul><li>DEFINITION </li></ul><ul><ul><li>Inadequate perfusion to body tissues </li></ul></ul>Shock
    154. 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. 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. 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. 157. <ul><li>TREATMENT </li></ul><ul><ul><li>Volume (IVF, Blood) </li></ul></ul>Hypovolemic Shock
    158. 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. 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. 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. 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. 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. 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. 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. 165. <ul><li> SIRS Sepsis Severe Septic MODS Death </li></ul><ul><li>Infection Sepsis Shock </li></ul>Sepsis Syndrome
    166. 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
    168. 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>
    169. 170. <ul><ul><ul><li>THE END </li></ul></ul></ul><ul><ul><ul><li>PART 2 </li></ul></ul></ul>PCCN REVIEW
    170. 171. <ul><ul><ul><li>THANK YOU! </li></ul></ul></ul>PCCN REVIEW
    171. 172. <ul><ul><ul><li>GOOD LUCK! </li></ul></ul></ul>PCCN REVIEW
    172. 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
    173. 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

    ×