Exam 3 462 Flashcards
Describe Dawn Phenomenon
- occurs for everyone
- Hyperglycemia all night long
- An abnormal early-morning increase in blood sugar (glucose) — usually between 2 and 8 a.m.
Describe a Non-tunneled CVAD
- inserted directly into a central vein and is associated with a higher risk of infection
- either the chest or the neck
- can be inserted quickly at the bedside
- Dwell Time less than a month
Risk factors for type 2 diabetes include all of the following except: “a. Advanced age
b. Obesity
c. Smoking
d. Physical inactivity”
C. Smoking
Non-pharmacological interventions for pain
- Reposition
- massge
- Heat/Cold compress
- Distraction
- Elevation
- Humor
Signs and symptoms of DKA
- dehydration
- tachycardia
- dry loose skin
- eyeballs soft/sunken
- anorexia
- kushmal respirations
- orthostatic hypotension.
What does alcohol do for diabetic
- high risk for hypoglycemia
- impaire liver glucose production- glycogen breakdown
- EAT carbs prior to alcohol consumption
What is the oxygen concentration for a nasal cannula?
- 24-44%
- 1-6 LPM
Victims w/ difficulty breathing, unable to tolerate mask
Normal Value for Chloride
95 - 107 mEq/L
What symptoms might an older woman with diabetes mellitus complain?
perineal itching
Rationale: Older women might complain of perineal itching due to vaginal candidiasis.
nursing diagnosis for a patient with advanced respiratory diseases.
- Hyperthermia Related to Infectious Illness,
- ineffective airway clearance,
- pneumonia
- pulmonary embolism
- Activity Intolerance
- Inadequate Nutrition
- Social Isolation
- Impaired Gas Exchange.
- Anxiety.
- Risk for Infection
- Ineffective Coping
- Fatigue.
- Ineffective Breathing Pattern
- Insomnia
Name 4 examples of an acute illness?
- Pneumonia
- Delirium
- Shingles
- Apendicitis
“A diabetic patient has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. Following assessment of the patient, the nurse suspects diabetic ketoacidosis rather than hyperosmolar hyperglycemic syndrome based on the finding of
rapid, deep respirations
Glucose Value 2 hours after eating
Up to 140
Brown rice is what type of food
low glycemic index, a steady increasy in blood sugar
Create labs for someone with metabolic acidosis
low pH low HCO3
Name the primary veins for peripheral IV insertion
cephalic, median, cubital, basilic
Left Sided Heart Failure
- Most Common
- Pulmonary Congestion
- Crackles
- Poor Oxygenation
- S3, Increase Afterload
- Irregular Palpitations
- Pulmonary Edema
- Diastolic and systolic dysfunction
- Blood backing up into right atria
What does insulin do to potassium level
push potassium back into the cells,
What is a good diabetic meal plan
- guidelines for how we are all supposed to eat
- focused on the amount of carbohydrates.
Intradermal Needle Size and Gauge
- 3/8 -1/2”
- 26-28G
Clinical Manifestations for a patient with Venous Insufficienty
- Pooling of blood in the legs
- Damage to valves in the veins
- Eczema
- Edema
- Leathery brown skin
5 Reasons a nurse would avoid an area of the hand or arm for IV insertion
- Impede ADL’s
- Tender, Red, Rash, Infected
- Paralysis, Dialysis, Shunt or Mastectomy
- Site distal to previous venipuncture
- Distal to sclerosed, hardened, or phlebitic veins
An acute metabolic condition, usually is caused by absent or markedly decreased amounts of insulin
Diabetic ketoacidosis
Diabetes Mellitus Type 1- Signs & Symptoms
3P’s
- Polydipsia (thirst)
- Polyuria (urine)
- Polyphagia (hunger)
Characteristics of Circulatory Overload
- Excessive amounts of isotonic/hypertonic solution
- Too Rapid
- Overload is associated w/ increased risk of death
What ahould the nurse do if he/she believes a patient is a hypoglycemic?
- Determine if they can swallow, could aspirate
- check gag reflex
- Check Blood glucose, if less than 70
- If can swallo, give them carbohydrate, skim milk. Protein prevents rebound effect
What direction is the bevel facing for an intradermal medication
up
Diagnostic Testing for Heart failure
- BNP
- ANP
- Creatnine Kinase
- Troponin
- Fibronogen
- Chest Xray
- EKG
- Coronary Angiogram
- Echogram
What is the highest priority for a patient with DVT or VTE
Skin Integrity b/c of amputation risk
Aspiration Pneumonia Definition
- Aspirated something into their lungs
- Decreased LOC
Lab Value when fully compensated
pH will be normal
The nurse is teaching a community class to peole with Type 2 diabetes mellitus. What is the explanation for that?
Cells become resistant to circulating insulin
Normally insulin binds to special receptor sites on the cells and initiates a series of reactions involved in metabolism. In Type 2 diabetes these reactions are diminished primarily as a result of obesity and aging.”
Care for DKa
- Fluid/electrolyte imbalance
- normal saline 0.45%
- blood glucose level
- acidosis
- IV insulin
If a diabetic has ketoacidosis what will potassium be?
- hyperkalemia
- hypovolemia
- Renal failure
What angle do you hold the needle for an average sized subQ injection?
45 degrees
Explain polyphagia for diabetes
We get hungry because our cells are starving for energy.
What should diabetic patient due prior to exercise
eat a snack. No need for carbohydrate intake when blood glucose lis over 100 before activity.
Fats for diabetic
- Less than 200 mg/day
- less than 7%
“When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask?
lost any weight? Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy.
This type of illness is sudden. It can last 3-6 months. It can also be reversed
Acute Illness
A blood sugar is well controlled when hemoglobin A1c is what percentage?
7%
HYPER- glycemia mneumonic
hot/dry sugar high
Nursing Diagnoses for patient with VTE
- Ineffective Peripheral Tissue Perfusion
- Acute Pain
- Risk for impaired physical mobility
- Risk for Embolization
- Impaired Skin Integrity
When administering an intradermal injection, what angle should the nurse position the needle for insertion?
5-15 degrees
Trauma Assessment Priorities
- Airway
- Breathing
- Circulation
- Disability
- Examine
- Fahrenheit
- Get vitals
- Head to toe assess
- Intervention
What is the oxygen concentration for a Resuscitation mask w/ oxygen inlet (simple mask)?
- 35-55%
- 6-15 LPM
Victims who are NOT breathing, or difficulty breathing
Clinical Manifestations for Hypervolemia?
- Pulse is bounding JVD
- High BP
- Tachypneic
- dyspnea
- crackles
- headache, confusion, muscle spasms
- Anorexia, weight gain, ascites
- peripheral edema
“A frail elderly patient with a diagnosis of type 2 diabetes mellitus has been ill with pneumonia. The cliet’s intake has been very poor, and she is admitted to the hospital for observation and management as needed. What is the most likely problem with this patient?
Hyperglycemic hyperosmolar non-ketotic coma.
How far should the drip chamber be filled?
1/3 -1/2 full
“What insulin type can be given by IV?
Regular Insulin
Etiology for Thromboembolism
- PICC line
- Bed Rest
- Previous Hx
- Heart Failure
- COPD
- Smoking
- Obesity
the leaking of IV fluid into the tissue surrounding the vein. This occurs when IV fluids continue to be delivered even though the tip of the catheter is no longer in the vessel or is blocked.
Infiltration
Acutal Problem means
we have evidence (AEB)
A well written nursing diagnosis contains 3 components
Diagnosis,
Related To
As Evidence By
What is the name of the device which controls the IV flow rate for gravity infusion?
Roller Clamp “EID”
Administration of an intermittent IV medication such as an antibiotic, given in a small IV bag of fluid is called..
Secondary IV solution (Piggy Back)
If someone has diabetes but not ketoacidosis they are
hypokalemia
PE interventions?
- Rotate patient
- High fowlers
- oxygen (non-rebreather)
- Continuous vital signs
- I/O’s
- Anticoagulants/Thrombolytics
A patient is admitted with diabetes mellitus, has a glucose level of 380 mg/dl, and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which of the following respiratory patterns would the nurse expect to find?
Kussmaaul Respirations
the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored.
Complication of Type II Diabetes
Hyperosmola hyperglycemic syndrome
Normal Value PCO2
34-45
Normal Value for Potassium
3.5 - 5 mEq/L
Describe a port CVAD?
- for patients who require long-term, intermittent vascular access
- completely under the skin, there is no need to cover the device while bathing or showering
- less frequent flushing
Insulin Definition
allows sugar to go from the blood into the cells for energy.
Define Ventilator Acquired Pneumonia
- 48 hours after intubation, before the onset of the event
6 Rights of Medication Administration
- Patient
- Time
- Medication
- Dose
- Route
- Documentation
Acute pain is directly related to…
tissue damage
Intermediate Acting Insulin Onset/Peak
onset 1 to 2 hours, peak 6 to 14 hours
The guidelines for Carbohydrate
Counting as medical nutrition therapy for diabetes mellitus includes
- Flexibility in types and amounts of foods consumed
- Including adequate servings of fruits, vegetables and the dairy group
- Applicable to with either Type 1 or Type 2 diabetes mellitusb. Unlimited intake of total fat, saturated fat and cholesterol”
Hyperglycemia
dry skin, dehydrated
Short Acting Onset/Peak
onset 30-60 min, peak 1 to 5 hours
what is lipodystrophy
scar tissue, if you do not rotate injection sites
IV calcs for regulating an IV pump are usually measured in…
hours
Techniques for increasing venous distention in preparation for needle insertion
- apply tourniquet 6-12” above chosen site
- apply warmth to extremity for several min.
What angle do you hold the needle for an obese patient for a SubQ injection
90 degrees
“The risk factors for type 1 diabetes include all of the following except:
“a. Diet
b. Genetic
c. Autoimmune
d. Environmental”
A. Diet
“The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with Type 1 diabetes at 1600. Which action should the nurse implement?
- ensure the client eats the bedtime snack
- Humulin N peaks in 6-8 hours, making the client at risk for hypoglycemia around midnight
- This snack will prevent nighttime hypoglycemia.
What is the oxygen concentration for a non rebreather mask?
- Up to 90%
- 10-15 LPM
Breathing victims only
Normal Value for HCO3
22-26
What is the problem with exercise and insulin site location?
it can metabolize too quickly
HYPO glycemia
cold clammy need candy
A normal fasting (no food for eight hours) blood sugar level is
between 70 and 99 mg/dL
Explain Polyuria for diabetes
The body tries to remove excess glucose by producing extra urine. The body then requires more water.
What degree angle for an IM injection?
90 degrees
The nurse determines the patient’s IV has infiltrated. What would be the appropriate action by the nurse?
- Stop the infusion
- Monitor patient
- apply heat or cold for hypotonic or isotonic
- apply cold for hypertonic
How long can hypoglycemia occur after exercise
up to 48 hours
SubQ needle size and guage?
- 5/8”
- 25G
Reasons for hypovolemia
- ng drainage,
- burns (3rd spacing),
- dehydration,
- shift of plasma into interstitial spaces,
- peritonitis,
- ascites (abdomen)
This is the inadvertent administration of a vesicant fluid or solution into the surrounding tissue
Extravasation
What is Acute Arterial Ischemic Disorder?
- Sudden interruption in arterial blood supply to an organ or tissue
- May orginiate from aneurism, or left sided heart failure
Diabetes is balancing what
insulin, diet, exercise
nursing assessment data which would require immediate medical intervention for a patient with arterial insufficiency.
A resting ankle-brachial index less than 1 is abnormal
Rapid Acting
onset 10-15mintues
peak 30 to 90 minutes.
Describe the purpose of pursed lip breathing in the COPD Patient
To reduce overall work of brathing
What is a treatment for dawn phenomneon?
increase insulin at bedtimes
Whenever insulin is peaking what should we be wathcing for?
hypoglycemia
IM / Z-Track needle size and gauge?
- 1-1/2”
- 21-23G
2” if patient is obese
When is immediate action required for a patient with pneumonia
respiratory rate increases above 20/min
Benefits of using an insulin pump
- fewer swings
- increased flexibility in diet
- accuracy of insulin doses and delivery;
*
What is the timeframe of administering and IM injection?
1mL every 10 seconds
How do you replace potassium (hypokalemia)?
- Never IV Push
- Oral
- Monitor I/O
- Potatoes, Avocado, Banana
Types of Insulin
- long acting (basal) once a day
- rapid/short acting (bolus) before meals
Hypoglycemia- Signs and Symptoms
TIRED
- Tachycardia
- Irritability
- Restless
- Excessive hunger
- Diaphoresis/Depression
Respiratory Acidosis Labs
- pH Low
- PCO2 High
Describe a PICC line
- inserted in the upper arm but its tip goes past the shoulder and ends in the superior vena cava.
- chest x-ray is done to confirm proper placemen
- less risk for phlebitis/infiltration
- stay in place for a year or more
- IV therapies that continue for 4 wks
Hyperosmolar Hyperglycemic Syndrome
- which high blood sugars cause severe dehydration, increases in osmolarity and a high risk of complications, coma and death.
This type of illness lasts longer than 6 months. The onset is gradual, and irreversible.
Chronic illness
What is the oxgen concentration for a bag valve mask (BVM)?
- 90% or more
- 15LMP or HIGHER
Victims who are not breathing/having A LOT of difficulty breathing
What is the core problem a patient would have with PE
perfusion
What information should be listed on IV site dressing? x4
- Guage
- Date
- Time
- Initials
Which electrolyte replacement should the nurse anticipate being ordered by thehealth-care provider in the client diagnosed with DKA who has just been admitted tothe ICD?
- Glucose.
- )Potassium.
- Calcium.
- Sodium
Potassium
This is the term for
inflammation of the walls of a vein.
phlebitis
Long Acting Insulin onset/peak
onset 70 minutes, peak none
Treatment for HHS
- FLUIDS FIRST
- serious dehydration
- normal saline
blood urea nitrogen (BUN)
8 - 21
8 bun twists x 3
The nurse is caring for a client who has normal glucose levels at bedtime, hypoglycemia at 2am and hyperglycemia in the morning. What is this client likely experiencing?
The Somogyi Effect
What happens in type 2 diabetes?
- the pancreas produces insulin, but the insulin is insufficient for the body’s needs or the cells do not respond to the insulin appropriately.
Signs of COPD
- productive cough for 3 or more months in each of 2 successive years
- Dyspnea
- Chronic Fatigue
- Bluish Red Color Skin
- Pulmonary Hypertension
What is the cornerstone of care for a person with diabetes
meal plan
Clinical Manifestation for PE
- dyspnea/tachypnea
- dry cough
- distended neck veins
- cyanosis
- hypotension
- Dysrhymia
- Impending doom
- chest pain
- Blood tinged sputum
- sudden death
Lab values when only partially compensated
all three values will be abnormal. One value will be working harder to compensate.
Labs for someone with Metabolic Alkalosis
High pH High HCO3
Name some SubQ injection sites?
- outser aspect of the upper arm,
- Abdomen below costal margin
- Anterior aspect of the thigh
Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment?
- A) BP 126/80
- B) A1C 9%
- C)FBG 130mg/dL
- D) LDL cholesterol 100mg/dL
B) A1C 9%
Describe the patient with advance COPD and Cor Pulmonale
- Damaged to lung tissue
- Acute respiratory failure
- Depression/anxiety.
- Anger.
- Pulmonary Hypertension.
A client with diabetes melllitus has a blood glucose of 644mg/dl. The nurse intreprets that this client is most at risk of developing which type of acid base imbalance?
metabolic acidosis
The body breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis.”
Minimizing Risk for DVT/VTE
- Exercise
- Walk
- DO NOT cross legs
- Ted Hose
a chemical agent that causes burns and destruction of tissue both internally and externally
Vesicant
What is the technique for administering IV Bolus (push)
- Flush w/ normal saline first
- administer medication
- Flush again
- Monitor Pt’s tolerance
- Document any adverse effects
What are 2 groups of drugs for diabetes
- Insulin- subQ, not given orally b/c destroyed by gastric enzymes
- antidiabetic agents
Glycemic Index
- how fast blood sugar rises, based on the carbohydrate containing food
Type 2 diabetes meal plan
calorie reduction, achieving glucose control, blood pressure, high fiber
Signs (AEB) Hypokalemia
6L’s
- Lethargy
- Lethat cardiac arrhthymia
- Leg cramps
- Limp Muscles
- Low, shallow respirations
- Less stool (constipation)
When discontinuting an IV for a paitent who is receiving anticoagulant medication such as heparin, the nurse should hold pressure on the IV site for how many minutes?
5-10 minutes
Protein for diabetic
15-20%
Calculate the IV flow rate for 1200 mls of NS to be infused in 6 hours. The infusion set is calibrated for drop factor 15 gtts/mL=_______gtts/min?
1200/6= 200
200x15/60(for minutes)=
50 gtts/min
What are 4 examples of Chronic Illness
- Diabetes
- COPD
- Parkinsons
- MS
What is the term used to clear the tubing of air before administering fluids to a patient?
Priming
Hospital Acquired Pneumonia
- Occurring 48 hours or longer after admission
- Not incubating at time of hospitalization
Discharge instructions for a patient with peripheral vascular disease
- look at feet every night
- avoid exposure to cold or hot
- wear loose clothing
- stop smoking
- avoid caffeine
- Monitor blood glucose
When on an anticoagulation for VTE, how should vitamin K be used?
even and consistent
What hand should you use for initial IV site selection?
non-dominant hand
Name a side effect of the insuline pump?
weight gain
Describe a Tunneled CVAD
- inserted into a central vein and the remainder is tunneled subcutaneously to a distant exit site
- tunneling helps secure catheter in place & reduce infection
- inserted in the chest
- placed in a surgical or radiology suite
- may remain in place for several months to years
A nurse is caring for a client with type 1 diabetes mellitus. Which client complaint would alert the nurse to the presence of a possible hypoglycemic reaction ?
classically as nervousness, irritability, and tremors.
A nurse is preparing a plan of care for a client with diabetes mellitus who has hyerglycemia. The priority nursing diagnosis would be:
Deficient fluid volume. An increased blood glucose level will cause the kidneys to excrete the glucose in the urine
What is the cause of JVD
- Right Sided Heart Failure
- increase the central venous pressure and the amount of jugular vein distention.
The 6Ps of Acute Arterial Ischemic Disorder
- Pain
- Pallor
- Pulselessness
- Parasthesia
- Poikilothermia (inability to maintain temp)
- paralysis
Clinical Manifestation of a patient with Chronic Arterial Disease
- Arteries narrowed
- Atherosclerosis
- Inc Risk for Heart Attack/Stroke
- Pallow
- Parasthesia
- Inadequate around boney prominents
- Gangrene/Amputation
- Weak Pulses
Name 3 location sites for IM injection
- Vastis Lateralis
- Deltoid
- Ventrogluteal
The client, an 18-year-old female, 5’4’’ tall, weighing 113 kg, comes to the clinic for a wound on her lower leg that has not healed for the last two (2) weeks. Which diseaseprocess would the nurse suspect that the client has developed?
Type 2 diabetes is a disorder that usually occurs around the age of 40, but it is now being detected in children and young adultsas a result of obesity and sedentary life-styles. Wounds that do not heal are a hall-mark sign of Type 2 diabetes.
If the patient is NOT alert enough to swallow and is hypoglycemic?
- 50% dextrose IV
- or Glucagon IM, SubQ
- takes awhile to kick in
