Inpatient Management Flashcards
(51 cards)
What are the 20 rules of Kirby’s rules for inpatient management?
Fluid balance
Albumin/oncotic pressure
Electrolyte and acid/base
Mentation
Heart rate, rhythm, contractility
Blood pressure
Body temp
Oxygenation and ventilation
RBCs/Haemoglobin
Coagulation cascade
Renal function
GI motility
Nutrition
Glucose
Immune status and antibiotics
Wound healing and bandages
Drug dose and metabolism
Pain control
Nurses - good communication, involve them
TLC
Why is fluid overload detrimental?
the increase in interstitial fluid load increases the diffusion distance for oxygen, nutrients and waste products between the blood and cells. This is particularly detrimental to renal and lung function. Similarly, a fluid deficit is detrimental through affecting perfusion and cellular dehydration promotes catabolism, insulin resistance and cellular stress.
What should be checked regularly to assess hydration and perfusion?
Mucous membranes
Pulse rate and quality
Blood pressure
Peripheral oedema
Chest auscultation and lung ultrasound for pulmonary oedema
What are the possible solutions for incorrect fluid balance?
Changing fluid therapy rates
Diuretics
What is rule 2 of Kirby’s rules for inpatient management
Albumin/oncotic pressure
What are the clinical signs of fluid overload + hypoalbuminea?
Peripheral oedema
Pulmonary oedema on auscultation/ultrasound
Flat caudal vena cava
Low blood pressure (hypotension)
Poor pulses
Patient is also losing fluid inappropriately to interstitial space
What are the solutions to hypoalbuminea?
Food! – need to increase protein intake; feeding tube indicated.
Plasma transfusion for oncotic support.
Synthetic colloids highly controversial – increased risk of acute kidney injury.
What is rule 3 of Kirby’s rules for inpatient management?
Electrolyte and acid/base
What electrolytes are commonly affected in critical illness and what are the clinical signs of these?
K - due to reduced intake:
- weakness, low head carriage
Na - losses, redistribution secondary to hyperglycaemia:
- mentation disturbances - cerebral swelling or dehydration
Cl - with Na losses, or GI loss e.g., vomiting:
How is electrolyte balance monitored in inpatient management?
Blood/gas machine or biochem
What is the treatment for electrolyte imbalance?
Usually supplementation with fluids i.e. ‘spiking’ the bag.
Where electrolytes are high – specific treatment approaches, care with correcting sodium quickly due to rapid osmotic changes leading to either flooding the brain, or dehydrating it.
What are the types and clinical signs of acidaemia?
What are the types and clinical signs of alkalosis?
How is acid/base imbalance diagnosed?
pH (blood gas machine)
PCO2 (blood gas machine)
Clinical signs – RR
What is the treatment for acid/base imbalance?
Appropriate fluid therapy i.e. hartmanns (alkalinising) or saline (acidifying)
Treat the underlying e.g. pain
What is the most likely cause of inappropriate bradycardia in inpatient management?
Hypokalaemia
Describe the assessment of arrythmias in inpatient management
commonly associated with systemic disease, the myocardium is very sensitive. Commonly VTach is seen; have anti-arrythmics available e.g. lidocaine (sodium channel blocker)
Intermittent or continuous ECG monitoring
Describe the assessment of contractility in inpatient management
can be poor with systemic disease e.g. sepsis, or a sign of cardiac disease e.g. DCM/late stage HCM
POCUS will allow you to assess the heart’s fractional shortening/ejection fraction rapidly and determine whether a positive inotrope is needed e.g. pimobendan
Combined with blood pressure may help to confirm output failure
What do systolic and diastolic pressure give an indirect measure of?
Systolic pressure – indirect measurement of cardiac contraction force
Diastolic pressure – indirect measure of vascular tone
How can blood pressure monitoring be used to assess the problem for hypotension?
Low total blood pressure - > consider hypovolaemia
Primarily a low diastolic pressure (big gap) - > consider inappropriate vasodilation i.e. distributive shock (e.g. sepsis/SIRS)
Primarily a low systolic pressure (small gap) - > consider poor contraction force.
What are the causes of hypothermia in inpatient management?
Reduced energy conservation e.g. anaesthesia, wet, exposure
Reduced energy production e.g. starvation/metabolic exhaustion/hypoxia
What are the causes of hyperthermia in inpatient management?
Increased energy conservation e.g. BOAS, hyperthermia on a hot day, exercise
Increased energy production e.g. inflammation/infection -> Pyrexia.
What is the treatment for hypothermia in inpatient care?
Consider the underlying disease
When warming, aim to correct the temperature slowly e.g. 0.5-1oC per hour
Prolonged hypothermia may have reduced metabolic rate and have a protective quality to it – rapid rewarming may result in an energy/metabolic mismatch (Heart and Brain may be particularly susceptible)
Describe the basic monitoring of oxygenation and ventilation for inpatient management
Mucous membrane colour
Resp rate and effort
Pulse oximetry
Lung ultrasound
