So...
Since I don't really have anything cool to write about...I have decided that I am going to post medical diagnosis of the week. Out of all the days I work, I will pick one diagnosis that I think is the most interesting and I will post it. Here is this weeks...
HHNKNonketotic Hyperosmolar Coma
Pathophysiology
Most often an initial presentation of NIDDM or in patients with mild NIDDM
Usually seen in elderly population with underlying chronic disease, esp. CV or renal
2/3 without previous history DM
Often precipitated by infection, MI, CVA
Mechanism unknown-Hyperglycemia occurs, but ketoacidosis does not, allowing more severe hyperglycemia, extracellular and intracellular dehydration than in DKA - hyperosmolality results causing mental status changes
Mortality: 20-60%
Diagnosis
Coma or altered mental status - usually cause for evaluation
Profound dehydration, tachycardia, hypotension
Focal neurologic signs (hemiparesis, hemisensory
loss, focal sz) not uncommon
Polydipsia, polyuria, polyphagia - may not be known, or overlooked
Visual complaints
Tachypnea
, fever possible
Smell of acetone on breath absent
High suspicion in NIDDM, nursing home pt as condition develops slowly (days-weeks)
Labs
Hyperglycemia-glucose > 800 mg/dL [44 mmol/L], usually >= 1,000 mg/dL [55 mmol/L], check serum glucose
No ketoacidosis
Serum osmolarity
> 350
Glycosuria
Serum lytes - Na+ & K+
BUN/Cr
ABG (usually without acidosis)
CBC/UA/CXR to R/O infection
ECG to R/O MI
DDx
DKA
Dehydration
CVA
Precipitants include: MI, CVA, GI bleed, infections, pancreatitis, uremia/CRF, subdural
hematoma, peripheral vascular occlusion
Treatment/Disposition
O2, monitor
IVF 0.9NS rapidly (1.5L over 1-2hrs) to stabilize BP & keep U/O >50cc/hr; use 0.45% NaCl if HTN or hypernatremia >155mEq/L [>155 mmol/L]; add 20-40mEq KCL/L as soon as adeq. renal fxn. confirmed
Replace 1/2 of estimated TBW deficit during first 12 hours, the rest during the next 24 hours (too rapid correction may cause cerebral edema)
Average deficit is 8-12 liters
Add dextrose to solution when glucose is 250 mg/dL [13.8 mmol/L]
Monitor CVP & I & Os
Reg.
insulin 0.1U/kg IVP followed by reg. insulin drip at 0.1U/kg/hr
Insulin requirements less than in DKA
Monitor glucose, lytes, cardiac status, I & Os q.hr d/c insulin when <350 mg/dL [19.3 mmol/L]
Admit to ICU
Consult endocrinologist
Nursing Considerations
Maintain airway and oxygenation
Careful I/O and fluid and electrolyte
replacement
Always double check insulin doses in IV bags and syringes w/another nurse
Maintain skin integrity
Provide for pt safety
Provide emotional support to pt/family
as a rectal tube. This was the first time I did and and once I made sure it was leak proof...it actually does work.
as a rectal tube. This was the first time I did and and once I made sure it was leak proof...it actually does work.
