CARE OF CLIENTS IN EMERGENT CONDITIONS Mouth

V/S routinely includes:  Missing teeth

 Cyanosis of the Lips
 Temperature
 Foreign Materials/ Vomitus
 Pulse Rate
 Respiratory Rate Neck
 Blood Pressure
 Tracheal deviation: is a clinical sign that
 Pain Scale
results from unequal intrathoracic
Nursing Alert: When obtained early in the pressure within the chest cavity
assessment, they help to establish baseline  Jugular Distention: is when the
information. increased pressure of the superior vena
cava causes the jugular vein to bulge,
Head to Toe Assessment
making it most visible on the right side
General Appearance of a person's neck.
 Tenderness
 Position/ Gait/ Posture
 LOC: restlessness is a danger signal Chest
 Cooperation
 Symmetry
 Skin Condition
 Tenderness/Pain
Head and Scalp  Ecchymosis
 Subcutaneous Emphysema:
 Bleeding Subcutaneous emphysema (SCE, SE) is
 Deformity and Depression when gas or air is in the layer under the
 Facial Symmetry skin. Subcutaneous refers to the tissue
Ears beneath the skin, and emphysema
refers to trapped air.
 Blood  Soft tissue injuries
 Clear Fluid (CSF)  Breath and Heart Sounds
 Battle’s Sign ( aka mastoid ecchymosis:
bluish discoloration of mastoid area) Abdomen

Eyes  Distention/ rigidity

 Tenderness/pain
 Pupil size and reaction to light  Guarding
 Extraocular motions  Bowel sounds
 Orbital Ecchymosis  Soft tissue
 Gross Vision
 Conjunctivae : examine for pallor or Pelvis
cyanosis  Stability
Nose  Tenderness

 Blood
 Clear Fluid ( CSF): Beta Transferrin
Genitalia 1st LEVEL: EMERGENT

 Bleeding - Conditions requiring immediate medical

 Wounds/Trauma interventions. Any delay in treatment is
 Priapism: Priapism is a prolonged potentially life or limb threatening.
erection of the penis. - Includes conditions such as:
 Rectal tone:  Airway compromise
 Pain  Cardiac Arrest
 Severe Shock
Extremities
 Cervical Spine Injury
 Pain  Multisystem Trauma
 Deformity and bruises  Altered LOC
 Pulse  eclampsia
 Sensation and Strength 2nd LEVEL: URGENT
 Soft tissue injury
 Capillary refill: Normal capillary refill - patients who present stable condition
time is usually less than 2 seconds. In but whose conditions require medical
newborn infants, capillary refill time can attention within a few hours.
be measured by pressing on the - There is no immediate threat to the life
sternum for five seconds with a finger or limb.
or thumb, and noting the time needed - Conditions such as:
for the color to return once the  Minor burns
pressure is released.  Minor Musculoskeletal injuries
 Edema  Dizziness
 Lacerations
Posterior: Observe cervical spine precautions in
trauma patients 3rd LEVEL: NONEMERGENT

 Soft tissue injury - Patients who present with chronic or

 Spinal Tenderness minor injuries. There is no danger to life
 Pain or Tenderness or limb.
- These patients are in no obvious
TRIAGE distress. Patients can wait for a few
- “ to sort” hours.
- Conditions such as:
Priorities of care and Triage Categories  Chronic Low Back pain
- Standard Triage categories are usually  Routine medication refills
developed within each emergency  Dental Problems
department.  Missed menses
- Most common triage systems consist of
three levels of acuity.
 REVIEW OF THE ENDOCRINE SYSTEM

 Endocrine Glands
 Pituitary Gland
 Adrenal Glands
 Pancreas
 Thyroid Glands
 Parathyroid Glands
 Gonads

SITES OF THE ENDOCRINE GLANDS

HORMONES OF THE ANTERIOR PITUITARY

GLAND

The Hypothalamus:

The part of the brain which mainly regulates

and controls the function of the pituitary gland.
This lies just above the pituitary gland.
THE GLANDS: Luteinizing Hormone (LH)

1. Pituitary Gland - Ovaries or Testes

- pea-sized gland in the sella turcica at
the base of the brain which is referred
to as the Master Gland.
- produce hormones which also regulate
other endocrine glands in the body.
- Anterior Lobe: adenohypophysis;
Posterior Lobe: neurohypophysis
- These 2 lobes are connected to the
hypothalamus. The hypothalamus
controls the anterior lobe by releasing
hormones through connecting blood
vessels. The posterior lobe is controlled
by nerve impulses.
Hormones of the Pituitary Gland and Their
Target Glands/ Organs
- Secreted by adenohypophysis
Oxytocin
- Uterus and mammary glands
- Produced by the hypothalamus but
stored in the posterior pituitary
Prolactin (PRL)
- Mammary Glands
- Secreted by adenohypophysis
Vasopressin or Antidiuretic Hormone (ADH)
- Kidneys
- Produced by the hypothalamus but
stores in the posterior pituitary

Adrenocorticotropic Hormone (ACTH) Thyroid Stimulating Hormone (TSH)

- Adrenal glands - Thyroid Gland

- Secreted by adenohypophysis - Secreted by adenohypophysis

Beta- melanocyte Stimulating Hormone

- Skin
- Secreted by adenohypophysis

Beta- endorphins

- Brain and Immune System

- Secreted by adenohypophysis

Enkephalins

- Brain
- Secreted by adenohypophysis

Follicle- stimulating hormone (FSH)

- Ovaries or testes
- Secreted by adenohypophysis

Growth Hormone

- All body cells especially muscles and

bones
- Secreted by adenohypophysis
 CANCER OF THE GI SYSTEM
Gastric Cancer
Incidence:
- more common in men and blacks
- Incidence increases with age
Risk Factors:
- Chronic atrophic gastritis with intestinal
metaplasia
- Pernicious anemia or history of gastric
resections ( >15years)
- Adenomatous polyps
Clinical Manifestations
Early: Loss of appetite, blood (occult) in stools,
dyspepsia > 4 weeks, vomiting (which may be
coffee ground)
Late: Pain often induced by eating, weight loss,
loss of strength, anemia, metastasis to liver.
Management:
- Gastric resection
- Subtotal Gastrectomy ( with or without
gastroenterostomy)
/ Billroth 1 (gastroduodenostomy)
/ Billroth 2 )gastrojejunostomy)
- Chemotherapy
Nursing Interventions POST-OP:
- DBCT q 2h
- NG suction to remove fluids and gas in
stomach and prevent painful distention
- Change in diet
Complications POST GASTRIC Sx:
1. Dumping Syndrome
- a complex reaction that may occur
because of rapid emptying og gastric
contents.
- s/sx: palpitations, syncope, cold clammy
perspirations.
- MGT:
 Small frequent feedings
 Diet high in protein and fat and low in
carbohydrates
 Avoid Meals high in sugar, milk,
chocolate and sodium chloride
 Anticholinergic medications ac
2. Shock and Hemorrhage
- MGT:
 Monitor for change in mental status,
pallor, clammy skin, dizziness,
decreased BP
 Administer IV infusions and blood
transfusions
3. Phytobezoar Formation
- identified in clients post partial gastrectomy
and vagotomy.
- after gastric resection, the remaining gastric
tissues is unable to disintegrates and digests
fibrous materials, which congeals to form a
mess coated by mucus secretions of the
stomach.
- MGT:
 Avoid citrus fruits (skins and seeds) and
other fibrous food ( they tend to form
phytobezoars)
 Adequate chewing
 Hydration is important
Colorectal Cancer
Incidence:
- 10% - 15% of all new cases
- Equal in both sexes
- Common in clients over 50 years old
Risk Factors:
- Genes: deletions on chromosomes 17
and 18, which promotes mutation and
 transition of the mucosal cells to a
malignant state.
- 1 risk factor is age
- Diet high in fat and refined CHO’s but
low-fiber
- Linked to IBD’s, Colon Polyps, and
Turcot’s Syndrome

Clinical Manifestations:

Initially: asymptomatic

Advance: rectal bleeding, melena, change in

bowel habits.
CONTINUATION ENDOCRIN REVIEW
BIOLOGIC CRISIS CONDITION
Crisis disorders of the Thyroid Gland
- Thyroid storm
- Hashimoto’s Thyroiditis
- Myxedema Coma ( opposite of Thyroid
Storm)
THYROID STORM
- A medical emergency with a high
mortality due to untreated or
undertreated hyperthyroidism, stressful
illness or thyroid surgery.
PATHOPHYSIOLOGY:
- Increased systemic adrenergic activity
which leads to epinephrine (adrenal
medulla) overproduction and severe
hypermetabolism
- Triiodothyronine (T3)
- Thyroxine (T4)
- Adrenal Medulla secretes Epinephrine
and Norepinephrine which stimulates
the arteries to have a faster heart rate,
dilated bronchioles, breakdown of
glycogen into glucose.
S/Sx: (STORM PART OF THYROIDITIS)
- Marked delirium
- Severe tachycardia
- Vomiting
- Diarrhea
- Dehydration
- High Fever
Listed below are other symptoms of too much
T3 and T4 in your body (hyperthyroidism):
- Anxiety
- Irritability or moodiness
- Nervousness, hyperactivity
- Sweating or sensitivity to high
temperatures
- Hand trembling (shaking)
- Hair loss
- Missed or light menstrual periods
The following are other symptoms that may
indicate too little T3 and T4 in your body
(hypothyroidism):
- Trouble sleeping
- Tiredness and fatigue
- Difficulty concentrating
- Dry skin and hair
- Depression
- Sensitivity to cold temperature
- Frequent, heavy periods
- Joint and muscle pain
LAB TESTS:
1. Detect high levels of:
- T3 (triiodothyronine)
- T4 (
- TSH Levels ( increased when the thyroid
gland is underactive; decreased if
overactive)
2. TSH receptor antibody ( for Grave’s)
3. Thyroid Scan or Ultrasound
4. Radioactive Iodine (Technetium) Uptake
test is injected into the bloodstream. If
cancerous, the uptake or absorption of
the radioactive iodine is very fast.
MANAGEMENT OF THYROID STORM
1. DRIG THERAPY (suppresses the
production or manufacturing of the
thyroid hormones)
- Propylthiouracil
- Methimazole (Tapazole)
WOF: agranulocytosis
- Beta-blockers
- Digoxin
Given because of the
production of your thyroxine
which causes hypertension and
to (digoxin) strengthen the
contraction of the heart but not
 the speed. (inotropic
medication)
Chronotropic/catecholamines –
speeds up the rate of the
contractions
- Anticoagulants
2. Iodinated contrast agent
(Iopanoic Acid [Telepaque] and ipodate
sodium)
Iodides: inhibit the synthesis of thyroid
hormones (Lugol’s Solution/ SSKI (Super
saturated potassium iodine) Only be
used for a short time because they are
highly toxic)
3. Radioactive Iodine Therapy
4. Prednisone for Ophthalmology
SURGICAL MANAGEMENT OF THYOID STORM:
1. Thyroidectomy
Pre-op: Give Lugol’s Solution (Iodide) / SSKI
to prevent thyroid Storm
Immediate Post-op Nsg Interventions:
- Monitor for respiratort distress
 Ask the patient to spit out to check for
bleeding
- Have a tracheostomy set, 02 suction at
bedside
- Place the client on Semi-fowler’s position
- Monitor for laryngeal nerve damage
 Respiratory obstruction
 High pitched voice
 Stridor
 Dysphagia
 Restlessness
 Severe nerve damage: loss of voice
- Monitor for signs of hypocalcemia and
tetany
Hypocalcemia: Symptoms & Signs
 numbness and/or tingling of the
hands, feet, or lips,
 muscle cramps,
 muscle spasms,
 seizures,
 facial twitching,
 muscle weakness,
 lightheadedness, and.
 slow heartbeat.
- Prepare to administer calcium gluconate
(IV) or calcium chloride
- V/S taking every 15-30mins ( patient could
go into coma after a thyroid surgery)
- Administer antithyroid medications
- Monitor daily weight
- Provide rest periods
- Decrease stimulation; provide a cool
environment
- Provide diet high in CHO, CHON, Kcal,
Vitamins and Minerals (as much as 3000-
4000 kcal per day)
- No stimulants (coffee/tea)
- Protect eyes with dark glasses
HASHIMOTO’S THYROIDITIS
- An autoimmune disorder
- Form of chronic thyroiditis
- Aka Chronic Lymphocytic Thyroiditis
Etiology: No known cause, AUTOIMMUNE
Risk Factors:
- Genes
- Hormones
- Excess iodine
- Radiation exposure
Incidence:
- Common among middle-aged women (1:7),
but may also affect men and children

Clinical Signs:
- 1st sign: GOITER
- Thyroid is form and smooth, moves freely,
painless
Periods of hyper- and Hypothyroidism
( Most common is Hypothyroidism)
S/Sx: cold intolerance, constipation, pale
and dry skin
- Unexplained weight gain : infrequent and
rarely exceeding 10-20lbs, most of which is
fluid
- Muscle weakness and aches, tenderness
stiffness, especially in shoulders and hips
which causes fatigue and sluggishness
- Menorrhagia and depression
LAB TEST FOR HASHIMOTO’s
- T4, TSH
- Increased serum Cholesterol
- Elevated antibody titer against
thyroperoxidase and thyroglobulin
MANAGEMENT OF HASHIMOTO’S DISEASE
1. Prevention: Prophylactic Iodine
Supplements to decrease the incidence
of iodine-def Goiter
2. Symptomatic Cases:
- Hormonal Replacement: levothyroxine
(Synthroid)
- Dosage is increased every 2-3 weeks
especially if the patient is an elderly (If
underdosed, the TSH remains elevated
with symptoms of Hypothyroidism and
if Overdosed, symptoms of
Hyperthyroidism.)
3. Hypophysectomy
4. Radiation Therapy
NURSING INTERVENTIONS
1. Decrease calorie, decrease cholesterol,
decrease saturated fat, high fiber diet
2. Assess for Constipation
3. Avoid sedatives and narcotics
4. Monitor for overdos of thyroid
medications because this can lead to:
- Tachycardia
- Restlessness
- Insomnia
5. Maintain a warm environment
PATIENTS MAY DEVELOP MYXEDEMA COMA
POST SURGERY…
Nursing Interventions:
1. Maintain a patent airway
2. Administer medications – Synthroid,
glucose, corticosteroids
3. Monitor V/S especially HR and BP
( might go down severely)
4. Monitor for changes in mental status (
because the client may become
lethargic and confused)
MYXEDEMA COMA ( people with
hypothyroidism)
Description: It is a loss of brain function as a
result of sever, longstanding low level of thyroid
hormones in the blood stream
Etiology: ppt by acute illness, rapid withdrawal
of thyroid medication, anesthesia, surgery,
hypothermia, use of opioids.
Incidence: more common in elderly women,
winter months
Precipitated by: Infection, medication, CVDs, - Coma
heart failure, trauma, or even drug therapy.
MANAGAMENT OF MYXEDEMA COMA:

1. Prevention: Daily Thyroid hormone

EFFECTS OF MYXEDEMA COMA: Replacement
2. Management is similar to patients with
1. Impaired cardiac contractility →
hypothyroidism
reduced SV (stroke volume) →
↓Cardiac Output Crisis disorders of the adrenal gland
Impaired Cardiac Contractility
ADRENAL CORTEX
→bradycardia and hypotension →
changes in ECG - Addison’s Disease
2. Central depression of ventilatory drive - Cushing’s Syndrome
with ↓ responsiveness to hypoxia and - Conn’s Syndrome
hypercapnia → hypoventilation →
respiratory acidosis ADRENAL MEDULLA
3. ↓ CO and peripheral vasoconstriction - Pheochromocytoma
→ ↓GFR → a decrease in water
excretion (RENIN) CUSHING’S SYNDROME
4. ↑ Serum ADH → hyponatremia and
impaired water excretion - Aka as hypercortisolism
5. Coagulopathy and acquired Von - Hormonal disorder cased by
Willebrand Syndrome (Acquired von prolonged exposure of the body’s
Willebrand syndrome (AVWS) is a rare tissues to high level of cortisol
bleeding disorder that is characterized
Etiology:
by structural or functional alterations in
von Willebrand factor (VWF) caused by - Pituitary gland adenoma
a range of lymphoproliferative, - Overuse of Corticosteroid
myeloproliferative, cardiovascular,
( Prednisone)
autoimmune, and other disorders.), and
- Adrenal Tumors which cause it to
↓ in Factors V, VII, VIII, IX, X → High risk
produce high amounts of cortisol.
for bleeding
6. GIT: mucopolysaccharide infiltration
and edema
Neuropathic changes in GI →
malabsorption, gastric atony, paralytic
ileus

SIGNS AND SYMPTOMS OF MYXEDEMA COMA:

- Hypotension
- Hypothermia
- Hyponatremia
- Hypoglycemia
- Bradycardia
- Respiratory Failure
 GOALS OF CARE:
1. Recognizing and treating underlying
cause early
2. Maintaining normal Adrenal
Function
3. Preventing Complications ( infection
and hyperglycemia)
S/Sx of Cushing’s Syndrome:
- Weight gain especially in the trunk,
face, and neck ( Buffalo Hump)
- Muscle wasting of the extremities
and weakness
- Moon face and ruddy complexion
-
- Abdominal purple striae
- Hyperglycemia
- Electrolyte imbalance (HyperNa,
HypoKa)
- Emotional changes and depression
- Thin, Fragile Skin
- Female Virilization: Amenorrhea,
Hirsutism (Beard Hair), and Breast
Atrophy
Male: Gynecomastia
Complications of CUSHING’S:
1. Osteoporosis
2. Peptic Ulcer (from steroid intake)
3. Lipidosis
4. HPN and Impaired Glucose
Intolerance
5. Sexual Dysfunction
LABORATORY TESTS:
1. ACTH Levels: determine whether the
syndrome is ACTH dependent
2. Dexamethasone Suppression Test :
1mg dexamethasone given at 11PM
and serum cholesterol taken at 8AM
the next day.
 - Cortisol level <5ug/dL excludes - Not enough glucocorticoids and
Cushing’s syndrome with 98% mineralocorticoids.
certainty
Etiology:
3. Radiologic Evaluation: tumor in the
pituitary gland or adrenal gland - In 3rd world countries: TB & HIV/AIDS
- In 1st world countries: autoimmune
NURSING INTERVENTIONS:
leads to atrophy, more common in
- Maintain muscle tone women than men
- Prevent accidents or falls and provide - Removal of glands, infection,
adequate rest neoplasm
- Protect client from exposure to
Secondary Addison’s Etiology:
infection
- Maintain skin integrity - Hypopituitarism may lead to ↓
- Minimize stress corticotropin secretion
- Monitor V/S ;WOF: HPN - Removal of non-endocrine
- Diet: LOW in calories, Sodium corticotropin- secreting tumor
HIGH in protein, Potassium, - Disorders in hypothalamic-pituitary
CA++, and Vitamin D function that diminish the production
- Monitor for urine glucose and of corticotropin
acetone, administer insulin if
necessary.
COLLABORATIVE MANAGEMENT:
1. Cytotoxic Agents
Eg: aminoglutethimide ( Cytaden)
trilostane (Modrastane)
mitotane ( Lysodren)
rationale: to decrease cortisol
production
2. HRT as needed
3. Prepare client for Adrenalectomy if
needed.

ADDISON’S DISEASE
- Aka adrenal hypofunction or adrenal
adrenocortical insufficiency
- Relatively uncommon but chronic
disorder that occurs in people of all
ages and in both sexes
S/Sx of ADDISON’s DISEASE IS THE PATIENT IN CRISIS?
- Confusion 1. ↑ K, Ca++ and BUN
- Fatigue 2. ↑ Hct, lymphocyte and eosinophil
- GI disturbances and wt loss 3. X-ray ( small heart and adrenal
- Hyperkalemia calcification)
- Bronze Pigmentation / tanning of the 4. ↓ Plasma cortisol levels ( <10mg/dl
skin in AM and lower levels at night)
- Hypoglycemia 5. ↓ Serum Na levels
- Postural Hypertension
- Muscle Weakness
- Px history will reveal synthetic
steroid use, adrenal surgery or recent
infection
WHAT TESTS WILL TELL YOU
1. Corticotropin level measurements
2. Rapid Corticotropin tests (ACTH
stimulation tests)
NATURE OF ADRENAL CRISIS
- A life-threatening complication of
addison’s Dse
- Critical deficiency of
mineralocorticoids and
glucocorticoids
- Emergency situation that requires
immediate, vigorous treatment
MANAGEMENT OF ADDISON’S DISEASE - Hypernatremia and Hypokalemia
(WOF: cardiac arrythmia)
1. Lifelong corticosteroid therapy
- Metabolic alkalosis
2. For crisis control:
- ↑ urine aldosterone level
- Prompt IV Bolus of 100mg
Hydrocortisone followed by LAB TESTS FOR CONN’S SYNDROME:
hydrocortisone diluted with
1. SCREENING TEST
dextrose in NSS and given until the
patient becomes stable.
a. PAC:PRA Ratio
NURSING INTERVENTIONS - the 1st test used in patients
suspected of having 1 ͦ
1. Administer Medications ( steroids)
hyperaldosteronism measures
as ordered
the plasma aldosterone
2. Monitor V/S
concentration (PAC) to plasma
3. Decrease stress in environment
renin activity (PRA) ratio.
4. Daily weight, I & O
- the levels of aldosterone and
5. Small frequent feedings
renin are measured in the blood.
DIET: HIGH in CHO, Na, and CHON
- a high ratio of PAC to PRA
Rationale: to prevent hypoglycemia
suggests 1 ͦ hyperaldosteronism;
and hyponatremia and provide
however, additional testing may
adequate nutrition.
be needed to confirm the
PRIMARY HYPERALDOSTERONISM diagnosis.

- Aka CONN’S SYNDROME 2. CONFIRMATORY TESTS ( 3)

- A condition where 1 or both adrenal
cortex produce too much a. Captopril Suppression Test
aldosterone - A patient is given a single dose
ETIOLOGY: of captopril, after which the
levels of aldosterone and renin
- Unilateral aldosterone-producing in the blood are measured.
adrenal tumor (2/3) - in patients with 1 ͦ
- Bilateral adrenal hyperplasia if the hyperaldosteronism, the level of
adrenal gland aldosterone in the blood is still
- More frequent in women ( 30-50 yo) high and the level of renin is low
ASSESSMENT FINDINGS even after captopril
administration.
- Elevated BP
- Headache b. 24-H Urinary Excretion of
- Muscle weakness Aldosterone Test
- Polyuria - In this test, the patient eats a
- Polydipsia high salt diet for 5 days before
 measuring the amount of
aldosterone in the urine over a
24-hour period.
- In patients with 1 ͦ
hyperaldosteronism, aldosterone
will not be suppressed by the
salt load, and the level of
aldosterone in the urine will be
high.
c. Saline Suppression Test
- In this test, the patient is given
a salt solution through an IV,
after which the levels of
aldosterone and renin in the
blood are measured.
- in patients with 1 ͦ
hyperaldosteronism, the level of
aldosterone in the blood is still
high and the level of renin is low
even after the salt loading.
NURSING INTERVENTIONS
1. Monitor vital signs, INO, daily weight
2. Maintain a Na-restriction as ordered
3. Administer spironolactone (
Aldactone) and K+ supplements as
ordered
4. Wear Medic-Alert bracelet
5. Give glucocorticoids pre and post Op
6. Prepare the client for adrenalectomy
7. Provide client teaching and
discharge planning concerning the
use and side effects of medications;
signs and symptoms of hypo or
hyperaldosteronism; and the need
for frequent BP checks and follow up
care.
* Side effects of ADRENALECTOMY,
especially when the entire gland is
suddenly removed,
HYPOALDOSTERONISM CAN OCCUR*
CRISIS DISORDERS OF THE
PANCREAS
Diabetes Mellitus
- DKA
- HHNC
PATHOPHYSIOLOGY OF DM
 Lack of insulin causes hyperglycemia
 Body excretes excess glucose
through kidneys → osmotic diuresis
→ polyuria → dehydration →
polydipsia
 Cellular starvation → polyphagia
 The body turns fats and CHON for
energy; but in the absence of
glucose in the cell, fats cannot be
completely metabolized and ketones
are produced.
DIABETIC KETOACIDOSIS
- Characterized by hyperglycemia and
accumulation of ketones in the body
causing metabolic acidosis
- Occurs in insulin-dependent DM
client which usually develops over
24H but can develop faster especially
in young children
Precipitating Factors
- Undiagnosed diabetes
- Neglect of treatment
- Infection
- Physical or emotional stress
- Growth spurt or during puberty
Signs and Symptoms of DKA: LEVELS OF CONSIOUSNESS:
- 3 P’s
/ Polyphagia
/ Polydipsia
/ Polyuria
- Nausea and Vomiting
- Abdominal (cranky) pain
- Skin warm and dry, and flushed 90/60 HYPOTENSION
- Altered LOC BP:
- Hypotension Systolic: less than 120, more than 90
- Tachycardia Diastolic: less than 80, more than 60
( Hypotension and Tachycardia
because before the patient goes into Management of DKA:
shock, weak but fast heartbeat, rapid - Check for urine/blood ketones if
and shallow respirations) blood glucose is 15mmol/L
- Kussmaul’s respiration/ - Extra or additional insulin
Hyperventilation Sliding scale
- Acetone breath (fruity odor)
- All signs of dehydration: (secondary
to acidosis and hyperglycemia)
“Cold and clammy, need some
candy”
“warm and dry, sugar is high”
>Infant or young child
/Dry mouth and tongue
/No tears when crying
/No wet diapers for three hours - Drink plenty of unsweetened fluids
/Sunken eyes, cheeks - If patient has not taken anything,
/Sunken soft spot on top of skull replace meals with snacks and drinks
/Listlessness or irritability containing CHO

>Adult
/Extreme thirst
/Less frequent urination
/Dark-colored urine
/Fatigue
/Dizziness
/Confusion
 Emergency Management: (for both DKA and
HHNC)
- Treat dehydration first with 0.9%
(Normal Saline) or 0.45% (half
strength saline)
Then: shift to D5W when glucose
level is down to 250-300mg/dL
WOF: too rapid correction, it can
cause rapid fluid shifts
( brain edema and increased ICP,
ARDS)
HYPERGLYCEMIC - Regular Insulin= 0.1 unit/kg bolus and
then 0.1 u/k/h drip
HYPEROSMOLAR NONKETOIC
Ex: 60kgs x 0.1 = amount of IV BOLUS
COMA (HHNC) - Correcting electrolyte imbalance
WOF: hypokalemia as a result of the
- Characterized by hyperglycemia and
treatment. WOF sever acidosis (pH <
a hyperosmolar state without ketosis
7.1 ), DKA patients may have to be
- Occurs in NIDDM people ( typically
given NaHC03
elderly people) who frequently has
high blood glucose (over 40mmol/L)
Precipitating Factors:
- Undiagnosed DM
- Infections or other stress
- Certain medications
- Dialysis
- Hyperalimentation (TPN)
- Major burns
Clinical Manifestations:
- Frequent vomiting
- Irritability
- Hyperactivity
- Unpredictable behavior
/ display bizarre, schizoid behavioral
pattern (screaming episodes, head
banging, arm biting, disorientation)
- Fright reaction
/ response to strong stimuli
(catatonic position)
CRISIS DISORDERS OF THE
NERVOUS SYSTEM

MYASTHENIA GRAVIS