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Med Surg Michaela > DKA HHS > Flashcards

DKA HHS Flashcards

1
Q

What is DKA?

A

Uncontrolled hyperglycemia, metabolic acidosis, and increased production of ketones. Results in insulin deficiency and an increase in hormone release that leads to increased liver and kidney glucose in peripheral tissues.

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2
Q

What does the increase in all the changes for DKA result in lab wise?

A

Increase in ketoacid production with resultant ketonemia and metabolic acidosis.
Potassium levels just depending on how long DKA existed before treatment.

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3
Q

What are the lab results for DKA r/t serum glucose?

A

Above 300

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4
Q

What are the lab results for DKA r/t serum ketones?

A

Positive 1:2 dilutions

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5
Q

What are the lab results for DKA r/t serum pH?

A

Below 7.35

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6
Q

What are the lab results for DKA r/t HCO3-?

A

Below 15

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7
Q

What are the lab results for DKA r/t Na?

A

Low normal or high

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8
Q

What are the lab results for DKA r/t BUN?

A

Above 30. Elevated due to the dehydration.

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9
Q

What are the lab results for DKA r/t creatinine?

A

Above 1.5 elevated cause the dehydration

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10
Q

What are the lab results for DKA r/t ketones?

A

Positive

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11
Q

What is the most common precipitating factor for DKA?

A

Infection, death is among 10% of these cases without appropriate treatment.

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12
Q

What does hyperglycemia lead to with DKA?

A

Osmotic diuresis with dehydration and electrolyte loss.

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13
Q

What are the classic manifestations of DKA?

A 
Polyuria
Polydipsia
Vomiting
Abdominal pain
Dehydration
Weakness
Confusion
Shock
Com
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14
Q

What happens as the ketones rise with DKA?

A

The pH of the blood decreases and acidosis occur.

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15
Q

Why do the kussmaul respirations occur with DKA?

A

They attempt to correct the respiratory alkalosis in an attempt to correct metabolic acidosis by exhaling the carbon dioxide

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16
Q

What behaviors with DKA show control of their blood sugar and episodes?

A

Maintain blood sugar within target range.

Adjust insulin to match eating patterns and during illness.

Maintain easily digestible liquid diet contain carbohydrate and salt when nauseated.

Urine ketone testing

And know when to see help

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17
Q

What interventions are done for blood glucose management with DKA?

A

First asses airway, level of consciousness, hydration status, electrolytes, and blood glucose level.

Check BP, pulse and resp every 15 minutes.
Record urine output, temperature and mental status every hour.
If central venous pressure presents asses every 30 minutes.

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18
Q

What interventions are done for fluid and electrolyte management?

A 
Asses for:
Acute weight loss
Thirst
Decrease skin turgor
Dry mucous membranes
Olguria with hung specific gravity 
Weak rapid pulse
Flattened neck veins
Increased temp
Decreased central venous pressure
Muscle weakness
Postural hypotension
Cool, clammy, pale skin
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19
Q

What are manifestations of DKA fluid overload?

A 
Weight gain
Full and bounding pulses
Distended neck veins
Pulmonary crackles
Peripheral edema
Elevated central venous pressure

Active pulmonary edema can occur quickly.

Hypertension is common especially in patients with kidney failure

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20
Q

How are the kidneys affected by DKA?

A

With severe hyperglycemia the kidneys are less able to respond to changes in pH or fluid volume, electrolyte imbalances, concentrate urine, or regulate blood osmolArity.

Risk for kidney failure rises.

Cardiovascular disease can cause fluid retention.

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21
Q

What do you need to asses with patients with poor kidney function and fluid retention in DKA?

A

Edema around the eyes and in limbs
Increasing blood pressure
Jugular venous distinction ( increase with volume overload, if severe the pulsation may not be seen even if pt is lying flat)
Orthostatic hypotension

Edema usually not present till interstitial volume increases by 2 to 3 L.

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22
Q

What is tachycardia a compensatory mechanism for DKA?

A

To increase cardiac output.
Older adults may not exhibit tachycardia if they are taking beta blockers or calcium channel blockers.

Dry mucous membranes may be caused by anticholinergic drugs.
Postural hypotension may occur with antihypertensive therapy.

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23
Q

What is the first out come with fluid therapy with DKA ?

A

Restore volume and maintain perfusion to brain, heart and kidneys.

Initial rate is 0.9% sodium chloride are 15 to 20 mL/kg/hr during the first hour.

24
Q

What is the second outcome of replacing total body fluid losses?

A

Achieved more slowly.
The fluid of choice depends on BP, hydration, serum electrolyte levels and urine output.

Generally hypotonic fluid is used 0.45% sodium chloride infused at 4 to 14 mL/kg/hr after initial fluid bolus.

When blood glucose reaches 250, 5% dextrose in 0.45% saline this prevents hypoglycemia and cerebral edema which can occur with serum osmolarity declines to rapidly.

25
Q

What is the drug treatment for DKA?

A

Insulin therapy rate of 50 to 75 mL/dL/hr

Initially there is an IV bolus dose of 0.1 unit/kg followed by infusion of 0.1unit/kg/hr.

Continuous infusion is used cause 1/2 life is short.

Subq insulin is used when they can tolerate oral fluids and ketosis has stopped.

26
Q

When is DKA considered resolved?

A

When blood glucose is below 200.
Serum bicarbonate higher then 18
Venous pH higher the 7.3
And ion gap less then 12

27
Q

What is a normal ion gap?

A

It is between 7-9.

And anion gap greater then 10-12 indicated metabolic acidosis.

28
Q

What is the treatment for hyperkalemia In DKA?

A

Insulin therapy, correction of acidosis, and volume expansion decrease serum potassium levels.

29
Q

When is potassium replacement initiated with hypokalemia?

A

After serum levels fall below the normal upper limit of 5.0.

30
Q

What are the s/s of hypokalemia?

A 
Fatigue
Malaise 
Confusion 
Muscle weakness
Shallow resp.
Abdominal distention or paralytic ileus
Hypotension
Weak pulse

Common cause of death in DKA

31
Q

When giving potassium containing solutions what should you make sure the urine is at?

A

You need an output of at least 30 mL/hr

32
Q

When is bicarbonate used for DKA?

A

Only with severe acidosis.
Give slowly IV infusion over several hours.
Usually indicate if pH is 7.0 or less or serum bicarbonate less then 5 mEq/L

33
Q

When should the pt be taught to check blood sugars with DKA?

A

Every 4-6 hours or as long as theses manifestations occur, anorexia, nausea and vomiting are present or glucose levels exceed 250.

Check urine ketone levels when BS reach 300

34
Q

What teaching needs to be done with DKA regarding dehydration?

A

Drink at least 2L/day.
Increase fluid intake with infection.
If nausea is present take liquids containing both glucose and electrolytes ( Soda pop, diluted fruit juices, sport drinks).

If sick a BS are elevated or normal take 8-12 ounces of calorie feee and caffeine liquids every hour or while awake to prevent dehydration.

35
Q

Can liquids contain carbohydrates be take if the diabetic cannot eat solid foods?

A

Yes, ingest at least 150 g of carbohydrates daily to prevent starvation ketosis.

36
Q

With DKA when should the provider be contacted?

A

Blood glucose exceed 250
Ketonuria that last for more then 24 hours.
The patient cannot take food or fluids.
Illness last more than 1-2 days.

With illness monitor for hyperglycemia state.
Do omit insulin therapy with illness.

37
Q

What are the guideline rules for a patient with sick day with hyperglycemia?

A

Notify healthcare provider if you are ill.
Monitor blood glucose every 4 hours.
Test urine ketones if blood glucose exceeds 240.
8-12 ounces of sugars fee liquid every hour while awake.
Eat meals.
Can’t eat food add carbohydrate food or liquids to digest the content of your normal meals.
Call primary if (persistant nausea and vomiting, moderate or large ketones, blood glucose elevation after two supplemental doses of insulin, high temp (101.5) of increasing fever or fever for more then 24 hours)
Get plenty of feast.

38
Q

What is hyperglycemic hyperosmolar state (HHS)?

A

increased blood osmolarity caused by hyperglycemia. usually results from a sustained osmotic diuresis.

39
Q

What happens with the kidneys with HHS?

A

kidney impairment allows for high blood glucose levels. as blood concentration of glucose exceed the renal threshold the kidneys capacity to reabsorb glucose is exceeded.

40
Q

What is the Blood sugar with HHS?

A 
above 600
absent or low ketones
osmolarity above 320
pH is above 7.4
HCO3 is above 20
Na normal or low
BUN elevated
Creatinine elevated
41
Q

What is the onset with HHS?

A

gradual
usually with infection, other stressors, poor fluid intake
altered CNS function with neurologic symptoms
dehydration and electrolyte loss same for DKA.

42
Q

Who does HHS usually occur in?

A

elderly with type 2 diabetes, many do not know they have diabetes.
HHS does not occur in adequately hydrated patients
older adults at increased risk for dehydration (decreased thirst, diuretics, poor urine concentrating abilities)

43
Q

What are some medical issues/meds that can cause HHS?

A 
MI
sepsis
pancreatitis
stroke
steroids 
diuretics
CCB
Dilantin
Beta Blockers
44
Q

What are the CNS changes with HHS?

A

confusion to complete coma.
they may have seizures and reversible paralysis.
It is related to the serum osmolarity greater the 350.

45
Q

Does the patient with HHS secrete insulin?

A

yes, just enough to prevent ketosis but not enough to prevent hyperglycemia.
The increased osmolarity, leads to diuresis with severe dehydration and electrolyte loss.

46
Q

What is the severity of CNS problems related to with HHS?

A

the level of hyperosmolarity and cellular dehydration. Restoring fluid balance in the brain takes hours and CNS function is not restored till hours after BS returned to normal

47
Q

What is the first intervention with HHS?

A

fluid replacement to increase blood volume.
if shock or sever hypotension use normal saline.
if not then use 0.45% NS

48
Q

How fast should the fluid be infused with HHS?

A

1L/hr until central venous pressure or pulmonary capillary wedge begins to rise back to normal or urine output back to normal.
Then reduce 100-200 mL/hr.
Half of the fluid is replaced within the first 12 hours then the rest over the next 36 hours.

49
Q

What changes with the body determines the rate of the fluid with HHS?

A

body weight, urine output, kidney function, and presence or absence of pulmonary congestion or jugular vein distention.

50
Q

What are the s/s of cerebral edema?

A

Ass pt q 1 hr.
any abrupt change in LOC
abnormal neurological signs
coma

51
Q

How fast should the patient with HHS make a turn around?

A

slow but steady improvement in CNS function is best evidence that fluid replacement is satisfactory.

lack of improvement not enough fluid

regression after initial improvement indicated to rapid reduction in blood osmolarity

52
Q

When is IV insulin administered with HHS?

A

after adequate fluids have been replaced

53
Q

What is the initial dose with insulin in HHS?

A

0.15 unit/kg iv bolus
0.1 unit/kg/hr until BS fall below 250.
a reduction of 50-70 in BS is an expected outcome

54
Q

Should the patient with HHS be monitor for hypokalemia?

A

Yes, because potassium may be high or normal r/t the dehydration.
potassium replacement is not initiated until adequate urine output.

55
Q

What is some self management with HHS?

A

1st assess the patients learning need and readiness to learn.
Start with what the patients knows and build from their.
provide written materials.
assess learning and literacy cause they will need to read insulin labels.
Assess anything that could cause error in medication, tremor, double vision etc.
if acutally ill they are need only basic teaching when in the hospital.

56
Q

What information is needed to give to patient for survival?

A

an-simple information on patho of diabetes

  • learning how to administer insulin
  • tx and prevention of hypo/hyperglycemia
  • diet info
  • monitor BS and ketones
  • sick day management
  • where to buy supplies
  • when and how to notify PCP
57
Q

Can hyperglycemia present before an infection can?

A

Yes

Med Surg Michaela (2 decks)

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