K so im working on my first case study and am a tad bit lost. Ive been researching for hours but am getting discouraged... anyone know of a good website to look this up? All the ones I search nothing correlates with the data given as a whole... heres the scenario:
Patient is diabetic, had cancerous tumor removed one day ago... complains of nausea. Several hours later, she was found nconscious with Cheyene-Stokes respirations, Pulse 67, BP 60 systolic, ABGS drawn: Ph 7.13 HCO3 19.8 O2 sat 18.4% (IS THIS EVEN POSSIBLE?) PaCO2 59.5 PaO2 18.8
Ive been trying to find data and assess the situation but am getting discouraged really easily. Im trying to figure out what a diagnosis for this could be... I ws thinking respiratory acidosis due to the increased PaCo2 level and her bicarbonate level being low....
Thanks again to everyones responses. It was a cancerous tumor..thats all that was said. to the ER nurse...I fully agree with you. I already thought immediately f ABCs but ha..i have to have a diagnosis for my case study... (no fun) Thanks again to everyone
*Unconscious (Prior mentation and length of onset? Pupils?)
*Cheyene-Stokes respirations (Kussmaul's is normally seen for DKA. Cheyene-Stokes is usually seen CNS disease, meningitis, medication reactions, PNA, and worsening CHF or other CV disorders.)
*BP 60 systolic
You have a mixture of problems including oxygenation, ventilation and perfusion as well as the pt being unconscious. All lead to an emergent situation. Assist respirations with a BVM with an FiO2 1.0, establish an IV while getting a Rapid Response or Code Team to the patient's bedside. Have a list of recent medications given handy.
Trendelenberg would be a nice addition. 2 large bore Iv's come in handy, expect the need for a central line if this goes on very long. Intubation and ventilator to stabilize A & B, NG tube (nausea?), Foley catheter, I hope there's an ICU bed available. Call the attending and or surgeon, vasopressors sound good, you'll need several IV pumps, do you see an physical changes? Distended abdomen? Bleeding on the dressing? Any bowel sounds? I wouldn't expect DKA with a known diabetic with a glucose of only 383. DX's right now are acidosis, respiratory failure, hypotension, hypokalemia. I'd bet on a CVA.
I am just curious... as a nurse it is not your job to diagnose... do they maybe mean a "nursing diagnosis"? as in inadequate tissue perfusion r/t__________ m/b___________ .... i find it weird that you have to "diagnose" the patient. Or is it one of those questions asking you to apply your knowledge to the situation and take your best informed guess to what is going on?
hi. i'm just a pre-nursing student, but this seems really interesting. i read that diabetic patients are at greater risk for higher rate of postoperative infection and hyperglycemia, thus in for higher mortality rate.
my limited thought-process goes:
1) elevated cortisol level postoperatively
2) cortisol counteracts insulin à now elevated blood glucose level via gluconeogensis
3) cortisol suppresses immunity by preventing t-cell proliferation
4) now patient at higher risk for systemic infection
5) onset of sepsis à leads to cardiovascular failure (hypoxemia, hypotension, and respiratory acidosis)
6) unconscious patient
i am totally reaching for anything in my limited knowledge. please, let us know what the dx is. i am really curious to find out.
Specializes in MED/SURG STROKE UNIT, LTC SUPER., IMU.
overview
hyperkalemia is higher-than-normal levels of potassium in the blood.
alternative names
high potassium; potassium - high
causes
potassium is involved in regulating muscle tissue, and is part of digestion, metabolism, and homeostasis (maintaining a balance between the many electrical and chemical processes of the body).
hyperkalemia occurs when the level of potassium in the bloodstream is higher than normal. this may be related to an increase in total body potassium or the excess release of potassium from the cells into the bloodstream.
the kidneys normally remove excess potassium from the body. most cases of hyperkalemia are caused by disorders that reduce the kidneys' ability to get rid of potassium.this may result from disorders such as:
the hormone aldosterone regulates kidney removal of sodium and potassium. lack of aldosterone can result in hyperkalemia with an increase in total body potassium. addison's disease is one disorder that causes reduced aldosterone production.
any time potassium is released from the cells, it may build up in the fluid outside the cells and in the bloodstream. acidosis leads to the movement of potassium from inside the cells to the fluid outside the cells. tissue injury can cause the cells to release potassium. such injury includes:
burns
disorders that cause blood cells to burst (hemolytic conditions)
gastrointestinal bleeding
rhabdomyolysis from drugs, alcoholism, coma, or certain infections
surgery
traumatic injury
tumors
if the kidney is working properly, and there is enough aldosterone, tissue trauma alone rarely leads to hyperkalemia. a normally functioning kidney will remove the excess potassium that has been released from the cells.
increased intake of potassium can cause hyperkalemia if kidney function is poor. salt substitutes often contain potassium, as do many "low-salt" packaged foods.
hyperkalemia may be caused by medications, including medications that affect kidney function (potassium sparing diuretics, such as spironolactone, amiloride, or triamterene) and potassium supplements (especially intravenous potassium).
symptoms
hyperkalemia often has no symptoms. occasionally, people may have the following symptoms:
cardiac arrest (absent heartbeat) may occur at any time during the treatment of hyperkalemia. hospitalization and close monitoring are required.
acute treatment
emergency treatment is indicated if the potassium is very high, or if severe symptoms are present, including changes in the ecg.
the goal of acute treatment is to protect the body from the effects of hyperkalemia. acute treatment may include:
cation-exchange resin medications, such as sodium polystyrene sulfonate (kayexalate) -- to attach to potassium and cause it to be removed from the gastrointestinal tract
dialysis -- to reduce total body potassium levels, especially if kidney function is compromised
diuretic medications (water pills) -- to decrease total body potassium
intravenous calcium -- to temporarily treat muscle and heart effects of hyperkalemia
intravenous glucose and insulin -- to reverse severe symptoms long enough to correct the cause of the hyperkalemia
sodium bicarbonate -- to reverse hyperkalemia caused by acidosis
long-term treatment
long-term treatment includes treating the cause of the problem and disorders associated with hyperkalemia.
treatment of chronic renal failure may include:
limiting potassium in the diet, including reducing or stopping potassium supplements
taking "loop diuretics" to reduce potassium and fluid levels in people with chronic renal failure
people with kidney failure or a history of hyperkalemia should not use a salt substitute as part of a low-salt diet.
prognosis
the outcome with this condition varies. in some people, the disorder causes deadly complications, while others tolerate it well.
complications
arrhythmias
cardiac arrest
changes in nerve and muscle (neuromuscular) control
when to contact a doctor
go to the emergency room or call the local emergency number (such as 911) if you have symptoms of hyperkalemia. emergency symptoms include:
absent or weak heartbeat
changes in breathing pattern
loss of consciousness
nausea
weakness
prevention
treat disorders that may cause hyperkalemia promptly. monitor serum potassium if you have one of these conditions.
your doctor should assess your kidney function before and while you take potassium supplements. you should not take these supplements unless you have adequate urine output and kidney function.
doesnt say...just says that it was in the abdomen. It states that the o2 sat was 18.4%...is that even possible? seems way off. the only thing I can think of is metabolic acidosis due to increased Paco2 and lowered bicarbonate...
Bowel sounds, size, firmness, the amount coming out of the NG, skin warm, cool or damp, signs of hypovolemia and urine urine put should be checked. Since the patient had adominal surgery, there are many things that can create problems including infection, tear in the bowel or ischemia. These things should be included in the post operative care of a patient section.
An ABG in the simplest terms only identifies that something is wrong causing acidosis or alkalosis for respiratory, metabolic or mixed. It can identify problems that require immediate action but more may be needed to determine the best route for a solution for correction. The anion gap will help point the direction toward the kidneys or other causes loss of bicarbonate such as in the GI tract. Sometimes when programs only teach the oversimplified ABG interpretation, they miss much of the important information. But then, it depends on how much you are expect to identify or form a working diagnosis. If you were on a Rapid Response, Code or transport team, you might need more indepth knowledge since it might be your responsibility to identify, initiate treatment and stabilize the patient. Anyone who works in a critical care or the ED area should also know a little more than the basic ABG interpretation. The basic interpretation just tells you have a problem and the direction it is heading. Knowing a little more and along with the clinical presentation of the patient, you can tell if intubation can be avoided by correcting the problem. If you look past the pH to question other problems if can also keep you from making a fatal mistake like putting CPAP/BiPAP hastily on someone with an abdominal problem.
Courtcatt
165 Posts
Thanks again to everyones responses. It was a cancerous tumor..thats all that was said. to the ER nurse...I fully agree with you. I already thought immediately f ABCs but ha..i have to have a diagnosis for my case study... (no fun) Thanks again to everyone