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Term 4 (PN) > 176 exam 1 > Flashcards

176 exam 1 Flashcards

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1
Q

What are common cause of a head injury?

A

Head injury

MVA

Assault

Falls

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2
Q

What are some different types of brain injury?

A

Scalp injuries (hematoma)

Concussion/ TBI (falls, blasts, injury, sports, MVA)

Contusion (bruising/bleeding into brain)

Intracerebral hemorrhage (stroke or bleeding w/in brain tissue; spontaneous)

Penetrating injuries (surgical intervention; through skull and brain tissue)

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3
Q

sudden - progresses rapidly - critical
- Burr holes

Important relationship between BP, pulse, & ICP (cushing’s triad)
- Monro-kellie-doctrine

S/s:
- Headache, light sensitivity/ pupillary changes (early)
- Change LOC/speech/vision (early)
- Cushing’s triad, change in vitals (late)
- Motor/sensory, Flaccid (unable to move) (late)

Clinical management:
- Semi-fowlers/ 30*, straight alignment, comfortable

  • Hyperventilation: Suction 10 seconds (decrease ICP, can cause anoxic brain injury), Ataxic breathing (Biot’s Breathing; unpredictable irregularity)
  • Fluid management: increase fluids to increase perfusion
  • Mechanical drainage: ICP monitor
  • Drug therapy: Mannitol, Decadron (MS)
  • avoid flexion of the hips, waist, neck and rotation of the head, enemas and laxatives, and valsalva maneuver

-administer oxygen via NC to improve cerebral perfusion

A

Increased Intracranial Pressure (IICP)

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4
Q

What are some Dx tests for IICP?

A

MRI (tumors), CT (bleeding)

Skull X-ray (fractures, abnorm bone)

EEG (brain waves, seizures)

Brain biopsy (stages tumors)

lumbar puncture/ spinal tap (tests spinal fluid, infection/ diseases)

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5
Q

Volume of cranium ( brain tissue, CSF, blood) is constant

Increase must be accompanied by decrease in one or the other

Fun Fact: Brain takes up 80% space

A

Monro-kellie-doctrine

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6
Q

Osmotic Diuretic

inhibits reabsorption of water and electrolytes

Use: Cerebral edema, TBI, encephalitis

Adverse: Seizure, tachycardia, HF, Circulatory overload

Nursing Considerations:
- Check vitals( for tachycardia)
- Monitor urine o/p (for dehydration)
- Monitor electrolytes (for electrolyte imbalance)
- BUN/Cr & liver panel
- May cause phlebitis at IV site
- Monitor neuro status
- Administer via a filter

Know it works when LOC, eye opening, urine o/p increase, & speech patterns all improve

A

Mannitol (Osmitrol)

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7
Q

Steroid - glucocorticoid - long acting

Decrease inflammation

use: Cerebral edema, allergic reaction, MS, meningitis

Side effect: Hypokalemia, hypotension

Adverse: HF, thrombocytopenia, angioedema

Monitor Bs, mood, & s/s of cushing’s syndrome, poor wound healing, liver panel, lipid levels, and cholesterol

A

Decadron (dexamethasone)

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8
Q

Hallmark symptoms of IICP

late sign and typically means brain is about to herniate

Rise in systolic BP, with unchanged diastolic BP, decreased HR & RR
- widening pulse pressure, bradycardia, and abnormal respirations
- cheyne-stroke RR (deep breaths)

Keep pressure at 20 (highest)

S/s:
- decreased BP
- increased Pulse
- Increased RR

A

Cushing’s triad

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9
Q

Where does most ICP issues occur?

A

Meninges

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10
Q

What are causes of intracranial complications?

A

Perfusion
- constant blood flow to the brain

Neurotransmission
- Adequate transmission of nerve function
- Stroke, seizure, MS, and dementia can impact

Glucose regulation
- constant glucose supply needed to maintain optimal brain function
- Blood brings glucose to brain
- Diabetes impacts

Pathology
- healthy brain tissue for optimal function
- MS, meningitis, & encephalitis impact

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11
Q

What are 3 types of medications usually administered to patients with IICP?

A

Osmotic Diuretics
- hyperosmolar drugs; draw water from the edematous brain tissue and reduces it in 15min for 5-6hrs

Corticosteroid
- need blood glucose levels closely monitored

Anticonvulsants
- Given to head injury patients

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12
Q

Would a lumbar puncture be performed if there is increased ICP present? Why?

A

No, brain herniation may be precipitated by increasing the pressure gradient between cranial vault and spinal cord

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13
Q

Mechanisms or conditions that impact intracranial processing and function

Need to maintain balance that promotes optimal brain function

A

Intracranial regulation

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14
Q

Who is at risk factors for intracranial issues?

A

Population
- elderly
- adolescence/ young adults
- young children
- athletes

Individuals
- depends of cause of injury/ pathology
- ex: pregnancies, HTN, meds, DM(2), stroke, Alz/dementia, genetics

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15
Q

What disorders affect Intracranial regulation?

A

Developmental/ genetic

Trauma (biggest)

inflammation/infection (meningitis, encephalitis, cerebral edema)

Neoplasms (brain tumor)

Degenerative process (MS, dementia)

Vascular disease (cell death d/t lack of blood flow)

Metabolic & endocrine disorders (glucose regulation)

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16
Q

used to assess level of consciousness in trauma patients
- not used under age 3

best eye, motor, and verbal response
- higher # = good, low # = bad

A

GCS

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17
Q

chronic, progressive, degenerative neurological disorder
- cause is unknown (mostly genetic predisposition)

usually affect ages 20-40 (women more affected than men)

Myelin sheath damaged by immune system and nerve signal is disrupted (demyelination)

S/s:
- Blurred vision/ vision changes
- Tinnitus, decreased hearing
- urinary retention (incontinence, superpubic cath)
- Paralysis, muscle spams, weakness
- Speech/ swallowing issues (peg tube)

Dx based off Hx
- MRI of spinal cord and brain to reveal plaques that characterize
- No Cure

A

Multiple Sclerosis (MS)

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18
Q

What are nursing interventions for MS?

A

Encourage mobility (ROM exercises, PT/OT)

Nutrition ( increase fiber, fruit/veg, well balanced diet)

Skin care (avoid breakdown, reposition q2h)

Activity (balance rest/ exercise)

Control environment (avoid hot baths & monitor for urine retention)

protect from opportunistic diseases ( C-diff, pneumonia)

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19
Q

“Brain attack” - medical emergency
- S/s appear suddenly
- occurs more in men

S/s:
-“worst headache ever” (Hemorrhagic)
- stiff neck (Hemorrhagic)
- loss of consciousness (Hemorrhagic)
- seizure (Hemorrhagic)
- depends on area affected (Ischemic)
- one sided weakness (unilateral; Ischemic)
- vision changes (Ischemic)
- confusion (Ischemic)
- headache (Ischemic)
- dysphagia (Ischemic)

2 types:
- Hemorrhagic: hemorrhage into brain; shows on CT
- Ischemic: formation on embolus/ thromboses that occluded an artery; does NOT show on CT

A

Stroke (CVA - Cerebrovascular Accident)

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20
Q

What does BEFAST stand for?

A

B - Balance: sudden loss of balance?

E - Eye: vision changes?

F - Face: droop? have smile

A - Arms: weakness?

S - Speech: strange/slurred

T - Time: LKW, TPA given
w/in 3 hr

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21
Q

What are modifiable/non-modifiable risk factors for a stroke?

A

Modifiable:
- DM, HTN, high cholesterol, heart disease
- smoker, alc.
- obesity, sedentary lifestyle

Non-modifiable:
- age (50-75), gender (men)
- race, hereditary (latino, AA d/t HTN)
- previous hx

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22
Q

What neurological deficits could occur after a stroke?

A

Aphasia, dysarthria (communication issue)

Dysphagia (aspiration, malnutrition, check gag reflex, swallow study)

hemiplegia

unilateral neglect (patient doesn’t believe or “forgets” that side doesn’t work)

sensory impairment

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23
Q

What are some diagnostic tests for a stroke?

A

CT (fastest, determines stroke type)
-w/o contrast

MRI, ECG/EKG

EEG (later)

Cerebral & carotid angiography

Blood studies ( lipid, PT/INR)

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24
Q

Deficient blood flow to the brain from a partial or complete occlusion of an artery

Causes:
- Thrombotic (atherosclerosis; coagulation disorder/ chronic hypoxia)

  • Embolic (thrombus is endocardial layer of heart; rheumatic heart disease)

treatment:
- Thrombolytics such as tissue plasminogen activator (tPA, alteplase; acute ischemic stroke)

  • digests fibrin and fibrinogen and thus lyses the clot
  • platelet inhibitors and anticoagulants given if stroke is caused by thrombus or embolus (ischemic stroke) to prevent more clots (must be given after 24hrs if treated with TPA)
A

Ischemic stroke

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25
Q

Results from bleeding into the brain tissue or subarachnoid space
- the bleed causes damage by destroying and replacing brain tissue

an aneurysm is often the cause of hemorrhage

treatment:
- craniotomy: clipping the aneurysm/ removing the clot to prevent re-bleed

A

hemorrhagic stroke

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26
Q

Administered IV w/in 3hrs from onset stroke symptoms

breaks up clot causing stroke
- stronger than heparin

CT/MRI needed to confirm no hemorrhage exists in the brain

Monitor for bleeding - place on bleeding precaution

A

Thrombolytic (t-pa)

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27
Q

Infection of meninges, membrane around the brain and spinal cord, caused by a virus or bacteria

Vaccine given to prevent infection in people “living in crowds”
- travelers, military, dorms, ect

S/s (sudden; early recognition):
- fever, cold hands/feet,
- rash, pale, blotchy skin
- v/, headache, confusion/ changed LOC
- stiff neck (chin tuck), severe muscle pain
- light sensitivity

Dx tests:
- Lumbar puncture ( determines is bacterial or viral)
- CT/MRI (brain swelling, shows affect area, assesses for complications)
- Throat culture (detects/ identifies bacteria

A

Meningitis

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28
Q

What are two positive signs of meningitis?

A

Kernig’s sign
- resistance of leg while hip flexed 90* then raise foot

Brudzinski sign
- Head to chest w/ knees flexed

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29
Q

Most severe for of meningitis
- medical emergency

Can have seizure or neurological defects
- show s/s of swelling on brain

person to person contacts / contagious
- droplet isolation
- enters through nose & pharynx

Tx:
- Droplet isolation
- prompt recognition
- broad spectrum antibiotics

A

Bacterial meningitis

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30
Q

Least severe form of meningitis
- most common

not usually deadly
- recovery w/in 1-2 weeks

Tx:
- Rest
- Increase fluids (oral/IV)
- Meds to decrease fever and headache

A

Viral meningitis

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31
Q

Inflammation of the brain itself
- Usually viral - slower/ gradual onset
- resembles meningitis
- fatal if untreated

May be from HIV, ticks, mosquitoes, measles, pox or mumps

S/s:
- Neuro damage
- N/V/H/Fever
- Seizure, aphasia, paralysis
- stiff neck, muscle weakness
- Abd. pain
- Increased BP/ cushing’s triad

Tx:
- Safety precaution ( increase seizure & fall risk)
- meds for comfort
- therapy to increase strength, speech & ADLs
- Monitor vitals & neuro status

A

Encephalitis

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32
Q

What are some complications that you may see in encephalitis?

A

Change LOC, IICP

Sensory/ motor changes

Change in speech

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33
Q

Sudden change in behavior d/t electrical hyperactivity in the brain

can lead to permanent neuro damage d/t depletion of O2 & glucose stored in the brain

Causes:
- Trauma, infection, epilepsy
- reduced cerebral perfusion
- Electrolyte disturbance ( hypoglycemia, acidosis, dehydration, metabolic panel)
- tumors, stress, drugs
- genetic tendencies

Dx:
- Rule out specific problems (aura)
- EEG (detects brain wave activity)

4 types:
- focal, generalized, acute symptomatic seizure, & unprovoked seizure

Anticonvulsant drug therapy
- DONT STOP TAKING MEDS

A

Seizure

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34
Q

Affects one area of the cortex affected during onset seizure
- most commonly occurs with epilepsy

Retained or impaired awareness
- may appear awake but usually do not respond to instructions or questions

Can tell when seizure is about to begin
- seizure typically lasts < 3 min
- Aura typically precedes the seizure

A

Focal Seizure

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35
Q

Affects the whole brain
- most common
-Loss of consciousness

tonic clonic
- fall/ slumped, stiffness, jerking, frothing, cyanosis
- post-ictal stage
- injury risk
- about 1 min long

Myoclonic
- brief jerking/ stiffness

Absent
- “staring spells”
- eye blinking, lip smacking
- 5-10 seconds long

A

Generalized seizure

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36
Q

Type of seizure caused by TBI, & drugs/ alc. withdrawal

A

Acute symptomatic seizure

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37
Q

Seizure of unknown cause, nervous system disorder, or older brain injury

A

unprovoked seizure

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38
Q

Medical emergency d/t continuous seizure for over 30 min
- depletes O2 and glucose from the brain resulting in permanent brain damage

IV anticonvulsants, neuromuscular blocks or general anesthetics used to stop/ slow activity

Tx:
- resolve underlying cause
- dose of meds gradually increase until therapeutic level achieved
- Combination of anticonvulsants may b e needed to help control activity
- DO NOT STOP TAKING (can lead to severe seizure activity)
- Ask when last seizure was

Management:
- safety precautions (do not leave client)
- padded side rails, side lying position
- move from harmful objects
- Remove loose fitting clothing, don’t restrain
- provide privacy, note time and duration
- provide education on stress, alc/caffeine, and meds (keppra, lorazepam, ect)
- if aura = find safe place

A

Status epilepticus

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39
Q

inhibits seizure activity (antiseizure)
- reduces pain

Use: generalized tonic-clonic seizures; status epileptic

Side effects:
- Hypotension
- Slurred speech
- Agranulocytosis
- Skin rash
- N/V/Constipation

adverse reactions:
- V-fib, bradycardia, cardiac arrest
- hepatitis

Interventions:
- Given IV
- Monitor BP & HR (report bradycardia)
- safety precautions ( if Ataxic or drowsy)

A

Dilantin (phenytoin)

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40
Q

Antiseizure/anticonvulsant/mood stabilizer
- slows transmission of impulses in the CNS
- prevents seizure
- reduces pain

Use: tonic-clonic, complex-partial, mixed seizures

Side effects:
-Drowsy/ ataxia (lose muscle control)
- fluctuating BP
- HF, urine retention
- Rash, hepatitis
- Aplastic anemia (body stops producing new blood cells)
- Agranulocytosis
- Increased BUN

Adverse reaction:
- Stevens-Johnson syndrome

Interventions:
- Monitor BP
- Avoid Alc. and excessive sunlight
-Report fever, jaundice, bruising/ bleeding

A

Tegretol (carbamazepine)

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41
Q

antiseizure/ antipsychotic
- PO/IV

used to decreases seizure activity
- simple, complex, absent seizures

Side effects:
- Lethargy/ dizziness
- Ataxia (lose muscle control)
- Thrombocytopenia
- N/V/H, weight gain
- Tumor, Alopecia

Interventions:
- Monitor Blood work
- Safety precaution (if drowsy)

A

depakote (valproic acid )

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42
Q

Antiseizure/ Anticonvulsant ( PO/IV)
- stabilise electrical activity in the brain and prevent seizures
- Decreases severity and incidence of seizures

Side effects:
- Somnolence (strong desire for sleep, or sleeping for unusually long periods)
- Dizzy, impaired coordination
- Abnorm. behavior
- Fatigue, infection

adverse reaction:
- hepatitis
- stevens-johnson syndrome

Interventions:
- Safety precaution (if drowsy)
- Ask when last seizure was
- Interacts w/ other drugs
- No Alc.
- DO NOT STOP TAKING
- May alter RBC, WBC, and liver function

A

Keppra (levetiracetam)

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43
Q

Antiseizure/ Sedative/ benzodiazepines (PO, IM, IV)
- Initial tx of epilepsy
- Also used before surgery and medical procedures to relieve anxiety

Side effects:
- Drowsy, rash
- N/V/D
- Resp. depression
- Hypotension
- Phlebitis

adverse reaction:
- ECG changes
- Tachycardia
- Apnea
- Cardiac arrest (IV, rapid)

Interventions:
- Safety precaution (if drowsy)
- Monitor for extravasation
- Monitor BP

A

Ativan (Lorazepam)

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44
Q

Antiseizure/ Sedative (IV)
- can treat anxiety, muscle spasms, MS, CIWA and seizures

Side effects:
- Hypotension
- Blurred vision
- Slurred speech

Adverse reaction: Resp. depression

Interventions:
- Assess IV site
- Monitor vitals
- May go into alc./drug withdrawal

A

Diazepam (Valium)

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45
Q

MS agent given subq

action: modifies immune responses responsible for MS by serving as a decoy to local antibodies

Side effects:
- n/v/d
- blurred vision
- tachycardia
-ecchymosis

adverse reactions:
- vaginal hemorrhage
- laryngospasms

A

Glatiramer acetate (Copaxone)

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46
Q

Short term confusional state w/ sudden onset (reversible/ transient)
- disturbance in consciousness that impairs awareness of environment

Management:
- Treat cause
- infection give antibiotics, agitation give antipsychotics
- drug interaction = change med

  • Private room w/ minimal stimulus, reorientate, family objects in room, keep same nursing staff (impaired cognition)
  • Nonpharm interventions to help sleep/ relax, plan activities to get uninterrupted sleep, nightlight (sleep disturbance; sundowner)

-Bed lowest position, allow pt to sit in chair, encourage visitors (potential injury)

Stimulate mind & maintain activity
- keep hydrated/ well nourished (hypovolemia risk)

Watch for electrolyte imbalance

Goals: Safety, comfort, decrease anxiety

A

Delirium

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47
Q

What are some causes of Delirium?

Helpful Hint: think “PINCHME”

A
  • P: Pain
  • I: Infection
  • N: Nutrition
  • C: Constipation/ urinary retention
  • H: Hydration
  • M: Meds
  • E: Environmental triggers
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48
Q

What lab results would you see in a patient with delirium?

A

High BUN & Cr

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49
Q

What are factors that contribute to delirium?

A

Infections:
- meningitis, encephalitis, HIV, UTI
- Bacteremia, septicemia

Cardiovascular disease:
- Hypovolemia, CHF

Metabolic conditions:
- Fluid / electrolytes, DM
- Hepatic/renal/pulm, failure

Vascular incidents:
- Stroke, chronic subdural hematoma

Trauma:
- Head injury, burns, hip fracture

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50
Q

NCLEX QUESTION

The nurse is collecting data from a client, and the client’s spouse reports that the client is taking donepezil hydrochloride (Aricept). Which disorder should the nurse suspect that this client may have based on the use of this medication?

A. Dementia
B. Schizophrenia
C. Seizure disorder
D. Obsessive-compulsive disorder

A

A. Dementia

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51
Q

NCLEX QUESTION

Which of these clinical observations should the UAP report to the LPN for a client with a brain tumor who is taking dexamethasone?
(Select all that apply)

A. Weight gain of 3 lbs since yesterday

B. Tremors and diaphoretic skin

C. Blood pressure change from 150/90 to 120/78

D. Complaints of a sore throat

E. Moist cough

A

A. Weight gain of 3 lbs since yesterday

D. Complaints of a sore throat

E. Moist cough

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52
Q

NCLEX QUESTION

A student nurse was asked which of the following best describes dementia. Which of the following best describes the condition?

A. Memory loss occurring as part of the natural consequence of aging.

B. Difficulty coping with physical and psychological change.

C. Severe cognitive impairment that occurs rapidly.

D. Loss of cognitive abilities, impairing ability to perform activities of daily living.

A

D. Loss of cognitive abilities, impairing ability to perform activities of daily living.

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53
Q

NCLEX QUESTION

WHEN CARING FOR A PATIENT AFTER A HEAD INJURY, THE NURSE WOULD BE MOST CONCERNED WITH ASSESSMENT FINDINGS WHICH INCLUDE RESPIRATORY CHANGES ALONG WITH WHAT OTHER FINDINGS?

A. HYPERTENSION AND TACHYCARDIA

B. HYPOTENSION AND TACHYCARDIA

C. HYPOTENSION AND BRADYCARDIA

D. HYPERTENSION AND BRADYCARDIA

A

D. HYPERTENSION AND BRADYCARDIA

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54
Q

What are example of Mild neurocognitive Disorder?

A

Missing appointments

Forgetting when to take meds

Overwhelmed by activities

Loss of directions

Fixes:
- calendars
- Med holder
- Clocks, Planners
- Maps, GPS, time management (be home before dark)

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55
Q

Impaired ability to remember, think, or make decisions that interferes with doing everyday activities
- Not a part of normal aging
- Not a disease, but a clinical symptom

nursing interventions:
- Allow pt to perform what they can (impaired ADLs)

  • Remove distraction from table, high protein foods (inadequate nutrition)
  • Keep awake during the day (sleep disturbances)
  • Safe environment (potential injury)
  • establish toilet schedule, or urinary intervention (urinary incontinence safety)
  • Agitation may mean pain, hunger, stress, fear, or toileting
A

Dementia

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56
Q

What are some nursing interventions for dementia?

A

Cognitive function:
- Diff. staying on task, diff. with decision making, carrying out plans & activities

  • impairment to long & short term memory

-Inability to understand or use words

  • Unable to perform usual activities
    (Ex:driving)

-saying/doing inappropriate things, personality changes, insensitivity

Allow pt to perform what they can, establish toilet schedule (impaired ADLs)

Remove distraction from table, high protein foods ( inadequate nutrition)

Keep awake during the day (sleep disturbances)

Safe environment ( potential injury)

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57
Q

What are 3 different types of dementia?

A

Alzheimer’s Disease (most common)

Vascular dementia

Lewy Body Dementia

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58
Q

What are some dx associated with dementia?

A

TBI, subdural hematoma

Brain tumor

Neurosyphilis

AIDS

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59
Q

What medications would you give to a patient with Alz/dementia to slow down progression?

A

Donepezil (Aricept) - mild to severe

Memantine (Namenda) - mod to severe, used later

antidepressants & antipsychotics

HELPFUL FACT: Most meds act to increase the amount of acetylcholine in the brain

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60
Q

When are medications for Alz/dementia most effective?

A

Early to middle stage of Alzheimer’s disease

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61
Q

Treats symptoms of Alzheimer’s disease, seizures, and Afib (PO)
- Mild to severe

Helps improve your attention, memory and ability to complete your daily tasks

Contradictions: Does Not prevent/ slow neurodegeneration by AD

Side effects:
- N/V/D
- Dyspepsia

Adverse:
- Bradycardia

Nursing considerations:
- Notify HCP if HR < 60bpm

A

Donepezil (Aricept)

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62
Q

Treats dementia associated w/ Alzheimer’s disease (PO)
- Type of glutamate (amino acid that acts as a neurotransmitter in your brain) receptor
- Mod to Severe AD

Contradictions: Show improved behavior
& cognition bu decline in ADLs

Side effects:
- Headache
- Restlessness
- Insomnia

Adverse:
- Increased motor activity, agitation

Interventions:
- Monitor Ph of urine

A

Namenda (memantine)

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63
Q

A stored form of glucose found in liver and muscle cells

Used when Blood sugar drops

A

Glycogen

64
Q

Utilization of glycogen stored and hormones are increased with stress related conditions both physical and emotional
- oppose action of other hormones

Is required to raise BS

Ex: Glucagon, cortisol, steroids, epinephrine

A

Counter regulatory hormones

65
Q

Maintaining optimal blood glucose levels (70 - 100)

Insulin: lowers blood glucose

Glucagon: raises blood glucose

Also known as glycemic control.

A

Glucose regulation

66
Q

protein hormone synthesized in the pancreas that regulates blood sugar levels by facilitating the uptake of glucose into tissues

Rotate injection site to prevent lipohypertrophy & lipoatrophy
- DO NOT massage
- Heat & exercise increase absorption rate

lowers blood glucose

AKA “beta cells”
- acts as key that allows sugar into the cell

A

Insulin

67
Q

Process of producing glucose from a non-carb source

Body breaks down protein and fats for energy

occurs when blood glucose is low.

Ex: Keto Diet

A

Gluconeogenesis

68
Q

acts as key that allows sugar out of the cell

AKA “alpha cells”

A

glucagon

69
Q

How does the pancreas participate in the negative feedback system in body?

A

Pancreas secretes insulin when serum glucose rises

Insulin has an effect on transporting glucose into the cell

As serum decreases, the pancreas prohibits insulin secretion

70
Q

The inability of the cells to respond to insulin

common w/ metabolic syndrome and type 2 DM

A

insulin resistance

71
Q

Elevated BS (>100)
- occurs in type 2 DM

Can result from:
- Insufficient insulin production / secretions
- Deficient hormone signaling
- Excessive counterregulatory hormone secretion

S/s: (Think “FLUSHED”)
- F: Flushed skin/ fruit like breath (acetone)
- L: Listless/ lethargic
- U: Unusual thirst, hunger,urine o/p (3 p’s)
- S: Skin warm/ dry, poor wound healing
- H: hyperventilation (kussmaul RR - deep/rapid breathing)
- E: Emesis, increased N/V ( late findings)
- D: Drowsiness, decreased appetite (N/V)

A

Hyperglycemia

72
Q

BS less than normal (<70)
- occurs in type 1 & 2

S/s:
- Tremors, tachycardia
- Clammy skin, cold
- Alt consciousness, irritability
- Hunger
- seizure/ stroke like s/s
- diaphoresis
- Apathy (severe lethargy)

Can result from:
- Insufficient intake
- Adverse reaction to meds
- Excessive exercise

A

Hypoglycemia

73
Q

What are some diagnostic testing for diabetes?

A

Glucose screening:
- Fasting, GTT, Glycosylated hemoglobin (HgbA1c; below 7%)

Antibody testing:
-Glutamic acid decarboxylase (GAD), C-peptide

lipid analysis:
- Triglycerides, HDL, LDL

Renal function tests:
- BUN/Cr, albumin in urine,

C-reactive peptide

74
Q

What is the lab value for cholesterol?

A

< 200 mg/dl

75
Q

What is the lab value for HDL?

A

Males: > 45mg/dl

Females: > 55mg/dl

(want high)

76
Q

DM dx test

level > 100 and < 126 is indicative of prediabetes of impaired fasting glucose

A level of 126 or higher on two separate occasions is indicative of diabetes

A random blood glucose measurement > 200 with s/s of diabetes if conclusive

A

Fasting glucose

77
Q

DM dx test

Most sensitive measure of glucose metabolism

Can often detect early Diabetes

A

Glucose Tolerance Test (GTT)

78
Q

DM dx test

Measures average blood glucose reading and estimates glucose control for the prior 3 months

A reading of 6.5% is indicative of diabetes

An A1c of 70% has been associated w/ reduced risk for complications of diabetes
- recommended goal for glucose control

A

Glycosylated hemoglobin (HgbA1c)

79
Q

Most common Antibody test for type 1 DM

A

Glutamic Acid Decarboxylase (GAD)

80
Q

Direct measure of insulin levels

CPT & fasting insulin may help determine quality of residual insulin prediction

A

C-peptide test

81
Q

How are renal function tests used in DM?

A

To detect early indication of renal disease associated w/ diabetes
- microscopic protein in urine

BUN/Cr

82
Q

Made by body during times of stress/ infection

elevated in people w/ DM and associated w/ the inflammatory of insulin

A

C- reactive protein (CRP)

83
Q

What do HDL levels indicate with DM?

A

Severity of insulin

84
Q

T/F: When glucose levels are high, triglyceride levels will also be high

A

True
- Triglycerides are general reflection of glycemic control

85
Q

What is the lab value for LDL?

A

< 70 mg/dl

86
Q

What is the lab value for triglycerides?

A

<150 mg/dl

87
Q

What is the lab value for BUN/Cr?

A

BUN: 10-20

Cr: 0.6-1.2

88
Q

What is the lab value for C-reactive protein?

A

< 1.0 mg/L

89
Q

List secondary preventions (screenings) used to detect complications in Diabetes:

A

A1C checked 2x/year

Annual renal function and lipid tests

Annual dental, foot, and eye exams

90
Q

What is the 15x15x15 rule?

A

Used for low blood sugar between 55-69 mg/dL

have 15 grams of carbs and check your blood sugar after 15 minutes

If it’s still below your target range, have another serving

Repeat these steps until it’s in your target range.

91
Q

Chronic disorder characterized by impaired metabolism & vascular neurologic complications

Increase risk for heart disease, blindness, amputation, renal disease & pregnancy complications

Diet should be mix of carbs, proteins
& fats

Complex carbs prefered:
- Fruit/veg, wheat bread, ect

Check Bs before & after exercise
- DO NOT exercise during insulin peak (increases risk for hypoglycemia)

A

Diabetes

92
Q

What type of exercises are recommended for patients with diabetes?

A

Aerobic: Running, walking, swimming, biking

Anaerobic: Weight lifting, yoga, ect

93
Q

Insulin produced by own body

Type 2: inadequate endogenous insulin & the bodies inability to use insulin correctly

A

Endogenous insulin

94
Q

Insulin obtained from other sources
- brings sugar into the body

Type 1: absence of endogenous insulin

A

Exogenous Insulin

95
Q

absence of endogenous insulin
- NO oral glucose

Autoimmune process possibly triggered by viral infection, destroys beta cells (insulin)
- if sick, check BS q2-3hr, give insulin as scheduled & check urine (BS >200 breaks down ketones)

Affected people need exogenous insulin for life

Goal: Have controlled Bs
- BS 120-140 depending on person

A

Type 1 DM

96
Q

How do you manage Type 1 DM?

A

Med therapy:
- IV insulin drip (regular/short)

Nutrition therapy:
- Monitor calories & weight

Check BS before exercise

Manage stress/ acute illness
- increased BS d/t cortisone (counter reg. hormone)

Snack in middle of day and before bed to prevent BS from decreasing at night

97
Q

What are s/s of type 1 DM?

A

Polyuria (dehydration/ hypovolemic shock)

Polyphagia (no glucose for cell energy)

polydipsia (d/t diuretics)

weight loss (10lb/week)

weakness/fatigue

Hyperglycemia/DKA

98
Q

Lispro (Humalog)
Aspart (Novolog)

Clear insulin; most common

Given before pt eats

Onset: 10-30 minutes
Peak: 2hrs
Duration 3-5hrs

A

Rapid insulin

99
Q

Humulin R
Novolin R

Clear

Only insulin able to be administered by IV
- Takes longer to kick in

Onset: 30min-1hr
Peak: 2-3hrs
Duration: 5-8hrs

A

Short/ Regular insulin

100
Q

Humilin N
Novolin N

Cloudy; roll to mix

Onset: 2-4hrs
Peak: 4-12hrs
Duration: 12-16hrs

A

Intermediate Insulin/ NPH

101
Q

Glargine (lantus) - give seperatly
Detemir (levemir)

Clear; given in AM/PM

Onset: 1hr
Peak: N/A
Duration: up to 24hrs

A

Long acting insulin

102
Q

Lumps/swelling under skin at insulin injection site

A

Lipohypertrophy

103
Q

Hollow/ pitting of subq tissue at insulin injection site

A

Lipoatrophy

104
Q

Can be controlled by sedentary lifestyle and lack of activities
- NOT insulin dependent
- insulin sensitivity may decrease

Older adults
- 80% overweight
- Gradual, may be Asymptomatic
- Hx high BP

S/s like type 1

treatment: diet, exercise, & oral meds

A

Type 2 DM

105
Q

T/F - You should not mix short and rapid insulin together

A

True

106
Q

Where are 3 insulin injection sites?

A

Side/ back of upper arm

Abdomen

Front of thigh

107
Q

Before meals

A

AC

108
Q

At bedtime

A

HS

109
Q

At 0730, a patient’s Bs was 285. How much insulin should you administer? (sliding scale order)

A) 4 units
B) 8 units
C) 12 units
D) 15 units

A

B) 8 units

110
Q

At 1230, a patient’s Bs was 220. How much insulin should you administer? (sliding scale order)

A) 4 units
B) 8 units
C) 12 units
D) 15 units

A

A) 4 units

111
Q

At 1730, a patient’s Bs was 315. How much insulin should you administer? (sliding scale order)

A) 4 units
B) 8 units
C) 12 units
D) 15 units

A

C) 12 units

112
Q

At 2003, a patient’s Bs was 398. How much insulin should you administer? (sliding scale order)

A) 4 units
B) 8 units
C) 12 units
D) 15 units

A

D) 15 units

113
Q

At 1800, a patient’s Bs was 408. How much insulin should you administer? (sliding scale order)

A) 4 units and call physician
B) 8 units and call physician
C) 12 units and call physician
D) 15 units and call physician

A

D) 15 units and call physician

114
Q

Your patient has an order for glargine (lantus) 22 units SQ and insulin lispro 4 units SQ (sliding scale order) at HS. How would you prepare and administer the medications to your patient?

A

Prepare Lantus separately

115
Q

The nurse reinforces teaching for a client regarding how to mix regular insulin and NPH insulin in the same syringe. Which action performed by the patient would indicate the need for further teaching?

A) Withdraws the NPH insulin first

B) Withdraws the regular insulin first

C) Injects air into the NPH vial first

D) injects an amount of air equal to the desired dose of insulin into the vial

A

A) Withdraws the NPH insulin first

draw up Regular insulin before NPH insulin

116
Q

What does type 2 DM result from?

A

High cholesterol

High BP/ HTN

Obesity

Insulin resistance

117
Q

oral hypoglycemic that reduces hepatic glucose production and lowers fasting blood glucose levels
- initial treatment for T2DM

Increases use of glucose in muscle cells

Does not cause hypoglycemia when used alone but increased risk when used with sulfonylurea d/t increase in insulin

S/s:
- Does not promote weight gain & may help improve lipid levels
- N/V/D (GI problems)

BLACK BOX WARNING - Do not give w/ radiologic contrast (can lead to kidney failure & Lactic acids)
- HOLD MED 48hrs after contrast
- Adverse reaction: Lactic acids

monitor for hypoglycemic reactions, renal studies, & CBC

A

Metformin (Glucophage)
- class: Biguanides

118
Q

oral hypoglycemic that stimulates the pancreas to secrete insulin lowering blood sugar by causing the release of your body’s natural insulin
- Piggy backed w/ metformin (increases risk of hypoglycemia)

used with a proper diet and exercise program to control hyperglycemia in T2DM

Decreases glucose production & metabolism by liver

Side effects:
- Weight gain
- Sulf. allergy

Adverse reaction:
- Hepatotoxicity
- Jaundice
- Hypoglycemia

Assess for hyper/hypoglycemic reactions & monitor vitals

Can increase liver function and kidney function labs

A

Glipizide (Glucotrol XL)
- Class: sulfonylurea

119
Q

oral hypoglycemic that assists the body to remove excessive glucose
- Decreases kidneys absorption of glucose, which promotes increase of glucose excretion in urine

Frequent urination, dizziness, or lightheadedness may occur
- get up slowly when rising from a sitting or lying position.

Adverse reaction:
- UTI, decreased urination, glucosuria
- signs of kidney problems
- Hyperkalemia
- N/V, abdominal pain
- Dyspnea
- increased LDL
- hypoglycemia

Monitor for DKA and Renal impairment

A

Empagliflozin (jardiance)
- Class: SGLT-2

120
Q

oral hypoglycemic that works to lower blood sugar, helping the pancreas make more insulin, decreasing the amount of sugar
- used for type 2 diabetes
- Slows gastric emptying

Improves blood sugar levels and lowers the risk of major cardiovascular events like stroke, heart attack or death, for adults with type 2 diabetes with heart disease

Does NOT replace the need for insulin

Adverse reactions:
- pancreatitis/ severe abd pain
- Thyroid cancer
- Renal damage/ Jaundice
- Hypoglycemia
- Allergic reaction

Assess skin, renal studies & Bs

A

Semaglutide (Ozempic)

121
Q

oral hypoglycemic that stimulates the pancreas to release insulin
- improves glucose homeostasis

DO NOT take if on insulin

adverse reaction:
- Acute renal failure
- UTI
- Pancreatitis (rare)
- Anaphylaxis
- increased liver enzymes

A

Sitagliptin (Januvia)
- Class: DPP-4

122
Q

What are some nursing interventions for DKA?

A

start an IV

Check bs every hour

administer oxygen via NC or nonrebreather

insert foley cath

monitor cardiac status

123
Q

What are some nursing interventions for DM?

A

Good skin care

report abnormalities
-cuts, scratches, or lesions

Special foot care
- wash with soap and water
- inspect for cracks, blisters or foreign objects
- socks daily
- toenails clipped straight across (need HCP order)
- sturdy, properly fitting shoes

eye exam every 6-12 months to diagnose/ treat diabetes related vision changes (retinopathy)

NO hot water bottles/ heating pads on feet (may cause burn that were not felt)

124
Q

How do you mix insulin?

A

Clear before Cloudy (NPH)!!!

  1. draw up air to equal total insulin
  2. wipe vial runner with alcohol
  3. inject the amount of air to equal the amount of cloudy insulin into the cloudy vial. BE CAREFUL NOT TO INJECT INTO THE SOLUTION
  4. Inject the remaining air into clear vial and draw up the clear insulin
  5. reinsert the needle into the cloudy vial and withdraw the desired amount

Do not massage area

given subq at 90* angle

give lantus separate

125
Q

measures best eye opening, motor, & verbal response

Lowest = 3 (more serious)

Highest = 15 (better)

A

Glascow Coma Scale (GCS)

126
Q

Full Outline of Unresponsiveness

May be used on pt’s with neurological conditions
- stroke
- craniotomy
- traumatic brain injury (TBI)

Evaluates: (no total score)
- eye response
- motor response
- brainstem reflexes
- resp. patterns

allows for improved evaluation for pt’s on vents

A

four score coma scale

127
Q

What is the normal WBC range?

A

5,000-10,000 cells/mcL

128
Q

What is the normal RBC range?

A

4.0-6.0 million (x10^6/mL)

129
Q

a medical condition associated with a group of metabolic risk factors
- obesity, diabetes (T2) , high cholesterol, hypertension, heart disease, and stroke

Precursor to Diabetes

Pts often have:
_ Impaired glucose tolerance
- insulin resistance, hyperglycemia
- HTN
- Low HDLs, elevated triglycerides
- ALtered size (large waist) & density of LDL

Treatment :
-weight loss, dietary & lifestyle changes
-reduce sugar & refined grains

A

metabolic syndrome

130
Q

individuals w/ impaired fasting glucose (Bs 100-126), impaired GTT or both

need to receive education on weight reduction and increase physical activity

Testing should begin at age 45 or sooner if symptoms appear

A

Prediabetes

131
Q

What are some risk factors for metabolic syndrome?

A

Impaired glucose tolerance

Insulin resistance

HTN, hyperglycemia

elevated triglycerides

Low HDL (want high)

Alt. size and density of LDL
- Large waist

132
Q

anticoagulant found in blood and tissue cells
- IV

action:
- prevents conversion of fibrinogen to fibrin & prothrombin to thrombin (prevents clots)

use:
- prevention of treatment of DVT, PE,MI, and open heart surgery

side effects:
- fever, chills, headache, rash, ect

adverse reaction:
- hematuria, hemorrhage

A

Heparin

133
Q

Anticoagulant (blood thinner)
- PO
- vitamin K antidote

action:
- interferes with blood clotting

side effects:
- nausea, rash, anemia, ect

adverse effects:
- hematuria and hemorrhage

BBW: monitor for bleeding

A

Warfarin (Coumadin)

134
Q

NCLEX QUESTION

A hospitalized Patient is prescribed steroid medications (Prednisone) to treat their acute illness. This patient is NOT diabetic. Why is the patient prescribed insulin for elevated blood glucose levels?

A

The steroid raises Bs. The insulin is given to lower the Bs

135
Q

When is the best time to administer the insulin Aspart (Novolog)?

A

Before meals

136
Q

A client begins taking a sulfonylurea once daily. The nurse would observe for which intended effect of this type of medication?

A

Decreased blood glucose

137
Q

What is the treatment for a patient who is nonresponsive, cool & clammy to touch, and a blood glucose level of 34?

A

Glucagon

138
Q

NCLEX QUESTION

Insulin Glargine, is prescribed for a client with DM. The nurse tells the client that which is the best time to take the insulin?

A.) 1 hr after each meal

B.) Once daily at same time each day

C.) 15 min before breakfast, lunch, and dinner

D.) Before each meal on the basis of the blood glucose level

A

B.) Once daily at same time each day

139
Q

NCLEX QUESTION

A client newly diagnosed with type 1 DM is taking intermediate-acting insulin at 0700 daily. The nurse should monitor the client closely for which s/s in the late afternoon?

A.) Hunger, shakiness, cool/clammy skin

B.) thirst, red/dry skin, fruity breath

C.) Increased appetite & abd. pain

D.) Increased urination & rapid breathing

A

A.) Hunger, shakiness, cool/clammy skin

140
Q

NCLEX QUESTION

Which term is used to describe speech impaired to the point that the person has almost no ability to communicate?

A.) Global aphasia
B.) Expressive aphasia
C.) Receptive aphasia
D.) Nonfluent aphasia

A

A.) Global aphasia

141
Q

NCLEX QUESTION

The nurse educates a client with diabetes on proper use of insulin glargine. The nurse determines further education is needed after which client statement?

A.) “I will rotate injection sites on my abdomen.”

B.) “I will use a sliding scale to determine my dose.”

C.) “I will throw out an opened vial after 28 days.”

D.) “I will keep my opened pen at room temperature.”

A

B.) “I will use a sliding scale to determine my dose.”

Explanation: Sliding scale doses of insulin are for short- or rapid-acting insulins only.
Long-acting insulins like glargine are not dosed using a sliding scale

142
Q

NCLEX QUESTION

The nurse triages a client with a history of type 1 diabetes who reports abdominal pain, nausea, weakness, and thirst. Fruity odor on the client’s breath is noted. A bedside glucose check shows the client’s blood sugar is 323 mg/dL (17.9 mmol/L). The nurse prepares for which drug therapy?

A.) Insulin detemir

B.) Insulin degludec

C.) Regular insulin

A

C.) Regular insulin

143
Q

NCLEX QUESTION

The nurse receives a call from a client with type 2 diabetes. The client reports mid-morning blood sugars in the 60s for the last three days. Which oral antidiabetic medication is most likely causing this reaction?

A.) Sitagliptin phosphate, 100 mg, once per day

B.) Metformin, 1,000 mg, twice per day with meals

C.) Glipizide, 10 mg, daily 30 minutes before breakfast

A

C.) Glipizide, 10 mg, daily 30 minutes before breakfast

Explanation: Glipizide is a sulfonylurea oral antidiabetic medication that works by stimulating insulin release from the pancreas, reducing glucose produced by the liver, and increasing insulin sensitivity

144
Q

NCLEX QUESTION

The nurse cares for clients in a major stroke center emergency department. Which client with suspected ischemic stroke is a likely candidate for alteplase?

A.) The client is currently experiencing heavy menstruation

B.) The client presenting to the hospital five hours after symptom onset

C.) The client with a blood pressure reading of 205/112 mm Hg

D.) The client presenting following a serious motor vehicle accident

A

A.) The client is currently experiencing heavy menstruation

Explanation: There is no contraindication for alteplase therapy in women experiencing menstruation.

145
Q

NCLEX QUESTION

The nurse educates a client with diabetes on mixing insulins. Which client statement demonstrates understanding?

A.) “I will draw the rapid-acting insulin into the syringe before the glargine.”

B.) will vigorously shake the NPH vial before drawing into the syringe.”

C.) “I will put air into the NPH vial before putting air into the fast-acting vial.”

D.) “I will draw the NPH insulin into the syringe before the regular insulin.”

A

C.) “I will put air into the NPH vial before putting air into the fast-acting vial.”

Explanation: Air should be injected into the NPH
vial, making sure the needle does not touch the insulin, before injecting air into the fast-acting vial

146
Q

NCLEX QUESTION

A client with diabetes type 1 is admitted to the emergency room with COVID-19-like symptoms. Which symptoms should the nurse report immediately?
Select all that apply.

A.) Blood glucose of 475 mg/dL
B.) Coughing and temperature of 99.8 F
C.) Deep rapid breathing
D.) Abdominal cramping
E.) ABGs with pH of 7.45

A

A.) Blood glucose of 475 mg/dL
C.) Deep rapid breathing
D.) Abdominal cramping

147
Q

NCLEX QUESTION

A patient has impaired glucose tolerance, high serum insulin hypertension elevated triglycerides low high density cholesterol and altered size and density of low density lipoproteins (LDL) cholesterol’s. Which distorted is cooler associated with these characters?

A.) Retinopathy
B.) Neuropathy
C.) metabolic syndrome
D.) macrovascular syndrome

A

C.) metabolic syndrome

148
Q

NCLEX QUESTION

Which medication is most likely to cause hypoglycemia when taken alone

A.) Sitagliptin
B.) Glipizide
C.) Metformin

A

B.) Glipizide

Explanation: Glipizide is a sulfonylurea medication used to increase the release of insulin from the pancreas

149
Q

Life threatening emergency caused by insulin deficiency (acute onset: 4-10hrs)
- More common in T1DM but also seen in T2DM

Results in metabolism disorder of carbs, fats, & protein
- pt in state of metabolic acidosis

S/s:
- Kussmaul RR ( deep/rapid breathing)
- “Fruity” breath, polyuria
- Hypotension
- Hyperkalemia

Tx:
- IV fluids (Hydration; isotonic solution first)
- IV insulin drip until metabolic acidosis is corrected (regular/short acting)
- Electrolyte replacement
- Check Anion gap

A

DKA

150
Q

How will labs look during DKA?

A

Blood Glucose: 300-500

Ketone +

Decreased Na, & increased K

Increased Anion gap

Ph: < 7.3 or lower
CO2: decreased
HCO3: < 15 or lower

151
Q

Bs > 600 w/ no ketones

Occurs in T2DM d/t illness, infection, or being older age

Lack of insulin or inability to use available insulin can cause osmotic diuresis

Development of dehydration & hypernatremia

S/s:
- High sugar
- Increase fluid loss/ extreme dehydration
- Change in LOC, Confusion
- No ketones, no acid
- Slower onset & stable Potassium

Tx:
- Hydrate (isotonic solution then hypotonic)
- Stabilize sugars (IV insulin; short/ rapid)
- IV bolus, titration
- SubQ injection

A

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

152
Q

Breaks down stored glycogen in liver & converts it to glucose

Side effect:
- N/V
- Hyperglycemia

Adverse:
- Hypokalemia

Turn on side during emesis (Vomiting)

A

Glucagon

153
Q

A microvascular complication associated w/ DM (T1/T2) increasing the risk for cataracts & glaucoma
- Leading cause of new-onset blindness

S/s:
- Spots/ floaters
- Seeing “cobwebs”
- Visual changes

No warning signs

yearly eye exams

A

Retinopathy

154
Q

A microvascular complication associated w/ DM (T1/T2) increasing factors contributing to kidney failure:
- Poor Bs control
- High BP
- Fam hx

Early detection/treatment slows development/ progression of kidney disease

S/s:
- ELevated BP
- Increased BUN/Cr
- Decreased urine o/p ( <30mL or gradually decreasing = concerning)

Decrease risk of kidney damage by:
- Controlling Bs
- Maintaining good hygiene
- Controlling BP

A

Nephropathy

155
Q

Pathological change in nerve tissue related to poor glucose control, damage to nerves, & chemical changes in nerve cells
- Microvascular complication associated w/ DM (T1/T2)

A

Neuropathy

156
Q

Chronic high Bs plays role in development of atherosclerosis

Associated w/ coronary heart disease, stokes, periph. Vascular disease

Risks:
- Central obesity
- Hyperlipidemia
- High Bp
- sedentary lifestyle

Tx:
- weight loss/ exercise
- Smoking cessation

A

Macrovascular complications associated w/ DM

Term 4 (PN) (13 decks)

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