EXAM 6 Flashcards
Onset of DKA
SUDDEN
ONSET of HHS
GRADUAL
Precipitating factors of DKA
Infection
Stress
INADEQUATE INSULIN DOSAGE
Precipitating factors of HHS
Infection/Stress
INADEQUATE FLUID INTAKE
Manifestations of DKA
Ketosis: Kussmaul respirations: “rotting fruit” breath Nausea/ ABD pain.
DEHYDRATION or electrolyte loss: Polyuria/Polydipsia/ Weight loss/Dry Skin/Sunken eyes/Soft eyeballs/lethargy/ Coma.
Manifestations of HHS
Altered CNS function with neurologic symptoms.
DEHYDRATION or ELECTROLYTE LOSS.
Glucose for DKA
Greater than 300
Glucose for HHS
Greater than 600
Osmolarity DKA
HIGH or NORMAL
Osmolarity of HHS
GREATER than 320
SERUM KETONES IN DKA
POSITIVE at 1:2 dilutions
SERUM KETONES IN HHS
NEGATIVE
SERUM PH in DKA
LESS than 7.5
SERUM PH in HHS
GREATER THAN 7.35
HCO3 in DKA
LESS than 15
HCO3 in HHS
GREATER than 20
Serum SODIUM for DKA
Low/NORMAL/high
Serum SODIUM HHS
Normal or LOW
BUN in DKA
Greater than 30
ELEVATED because of DEHYDRATION
BUN in DKA
ELEVATED
CREATinine in DKA
GREATER than 1.5
Because of DEHYDRATION
Creatinine of HHS
ELEVATED
Urine ketones for DKA
POSITIVE
Urine Ketones for HHS
Negative
DKA occurs in what type of diabetic?
Type 1
What is the most common precipitating factor of DKA?
Infection
What is the mortality rate even with treatment?
10%
What is the onset time of DKA?
4-10hrs
What will be your potassium levels with DKA?
HIGH
What will be you VS with DKA?
Tachycardia Hypotension Tachypnea (Kussmaul Respirations) Normal to low O2 Abdominal Pain Normal to slightly high Temp
What will be the assessment findings of DKA?
Dry skin Flushed skin Polyuria Polydipsia Polyphagia Decreased LOC
What will the H&H be for DKA?
Hemoconcentration= HIGH H&H
HEMATOCRIT
GREATER than 45-52% for men
Greater than 37-48% women
HEMOGLOBIN GREATER than 13.5-17.5 for men Greater than 12.0-15.5 for women
Will people with DKA experience vomiting?
YES
What will a patients CVP be in DKA?
Below 9
What will a patient in DKA ABG’s be?
PH LOW less than 7.3
CO2 LOW less than 35
Bicarbonate LOW less than 22
What are the four priorities for a patient with DKA?
AIRWAY
HYDRATION
ELECTROLYTES
GLUCOSE
What are nursing interventions with a patient who has DKA?
AIRWAY & Breathing Cardiac monitoring & VS Chest X-ray Hourly BS Comfort Fluid&Insulin Patent IVs Safety Nutrition (slow-clear liquids to start) LOC Simple explanations reassurance 2-4hr BMPs VS Q15min Accurate I&O QHR LOC QHR CVP measurement Foley catheter Labs- WBC/CHEM/UA/ABGs 2 large bore IV's or central line.
What underlying diagnosis might elderly have to change nursing interventions for DKA?
CVD
RF
How do you restore volume and maintain perfusion for DKA?
0.9% NS 15-20mL/kg/hr for 1 HR BOLUS
0.45% NS 4-14 mL/kg/hr until glucose drops to 250
D5W 1/2NS as maintenance
Fluids need to replace volume loss 6-10 LITERS !!!!!
What is the drug therapy for DKA?
IV BOLUS 0.1U/kg
Continuous infusion 0.1U/kg/hr
SQ insulin when PO food/water returns
When is DKA considered an end point?
BS 200mg/mL
Serum bicarbonate: 18
Venous PH: 7.3 or greater
Anion gap less than 12
What are precautions when administering insulin for DKA?
ALWAYS use and insulin syringe
Insulin has to be PIGGYBACKED so it doesn’t clot off.
When is bicarbonate needed in DKA?
With a PH level below 7.0 or a bicarbonate level below 5.
What is important to assess before giving IV potassium solutions?
URRINE output is AT LEAST 30ml/HR.
What are s/s of HYPOKALEMIA?
Fatigue Malaise Confusion Muscle Weakness Shallow respirations Abdominal distention Paralytic ileus Hypotension Weak pulse
What is a common cause of death with DKA treatment?
Hypokalemia
What are the “sick day” rules for a patient with diabetes to monitor for DKA?
Monitor BG levels Q4HR
Test urine for ketones when BS is greater than 240.
Continue Insulin regimen.
Drink 8-12oz of SUGAR FREE fluid per hour of awakens.
If BS is low drink sugar drinks.
Continue to eat.
Get plenty of rest.
What are the danger signals that a diabetic need to notify HCP about?
Persistent N/V
Moderate or large Ketones
BG high after 2 dose of insulin.
Temp above 101.5 or fever for longer than 24hrs.
How do you perform an anion gap?
SODIUM minus the result of your CL added to your Bicarbonate.
What is the normal anion gap?
7-9
What is the goal for insulin therapy?
Drop the glucose by 50-75 units PER HOUR.
What does the anion gap need to be to represent metabolic acidosis?
GREATER than 10-12.
What do you do to prevent hypokalemia with insulin treatment for DKA?
Potassium replacement is initiated after serum levels fall below 5.0.
When nausea is present with a patient that is ill and has diabetics what is the intervention?
Take liquids that contains both glucose and electrolytes: Soda pop/ diluted fruit juice/Gatorade
What is the most common manifestations of HHS?
BS above 600 Dehydration Hyper osmolarity Hypokalemia Decrease renal perfusion ELDERLY TYPE 2 diabetics
What are the causes of HHS?
Infection Stress Environment MI Sepsis Pancreatitis Stroke Medications
Are there ketones in HHS? WHY?
NO KETONES.
Because there is just enough insulin production to prevent ketoacidosis
Why does HHS happen more often in the elderly?
Decreased kidney function which leads to decreased ability for the kidneys to re absorb the glucose which leads to increased glucose levels or HHS. DEHYDRATION also leads to decreased volume which further reduces glomerular filtration rate and casing glucose levels to rise.
What is the mortality rate for the orderly population that have HHS?
40-70%
Will HHS occur in adequately hydrated patients?
NO
What types of drugs can lead to HHS?
Glucocorticoids Diuretics Phenytoin (Dilantin) Beta Blockers Calcium Channel Blockers
What might people with HHS have that people with DKA wont have?
Seizures
Reversible Paralysis
When will a coma occur with someone who has HHS?
When serum osmolarity is greater than 350
What does the severity of hyperglycemia cause with patients who have HHS?
Extreme diuresis
Sever DEHYDRATION
Severe electrolyte loss
What is the expected outcome with a patient who has HHS?
Restore glucose levels within 36-72hrs
REHYDRATE
When does CNS function return with a patient who has HHS?
Hours after blood glucose levels have returned to normal.
What is the first priority for someone with HHS?
FLUID REPLACEMENT.
What is used for sever shock or hypotension for HHS?
Normal saline
What is used to treat HHS w/o shock or hypotension?
Half normal saline (0.45% chloride)
Infuse at 1hr/L until CVP or pulmonary capillary wedge pressure begins to rise OR until BP and urine output are adequate.
Then reduced to 100-200ml/hr
1/2 fluid deficit is replaced in 12hrs and the rest is given in the next 36hrs.
What is used to determine the rate of infusion for HHS AFTER fluid deficit (12hrs) is replaced?
Body weight
Urine Output
Kidney function
Presence or absence of of pulmonary congestion and jugular venous distention.
What do you need to monitor in patients with CHF, Kidney disease, or acute kidney injury?
Central Venous Pressure
How often do you assess the patient, and what for?
Hourly Signs of cerebral edema Abrupt changes in mental status Abnormal neurologic signs Coma
What can lack of improvement of LOC mean in a pt with HHS?
May indicate inadequate rates of fluid replacement OR reduction in plasma(blood) osmolarity.
What can a regression after initial improvement of HHS mean?
TOO rapid reduction in blood osmolarity.
What is best evidence in fluid management of HHS?
SLOW BUT STAEDY.
What will you immediately report if seen in a patient with HHS during treatment?
Changes in LOC
Changes in pupil size or reaction
Seizures
When is IV insulin therapy administered?
AFTER adequate fluids have been replaced.
What is the the typical insulin intervention for HHS?
BLOUS dose of 0.15u/kg IV followed by an infusion of 0.1u/kg/hr until blood glucose levels fall to 250.
What d you want to reduce the blood glucose levels by for HHS?
50-70 per hour.
What do you need to monitor when a patient with HHS is receiving insulin therapy? And what are the signs&symptoms?
Hypokalemia Sx/S: Muscle weakness Hypotension Weak pulses Fatigue Malaise Paralytic Ileus Confusion Abdominal distention
When is potassium therapy initiated for HHS?
When urine output is adequate
How after are serum electrolytes assessed with HHS?
Every one to two hours until stable.
Why is continuous cardiac monitoring needed during HHS and DKA?
Hypokalemia or Hyperkalemia
Who participates in education for a patient with diabetics and diabetic control? SIX
Nurses Physicians Pharmacists Social Worker Psychologist Registered dietician
What is is DI? And what is it caused by?
A WATER LOSS PROBLEM
Caused by either and ADH deficiency OR an inability of the kidneys to respond to ADH.
What are the manifestations of DI?
Decreased ADH Dehydration Increased urination Increased serum NA (pulling out of cells) Decreased urine NA (diluted) Decreased specific gravity Increased Solute (dehydration/hemoconcentration) Decreased Solution (dehydration) Decreased Plasma Osmolarity
What is the most common electrolyte imbalance of DI?
Increased Sodium levels.
What can lead to death in DI?
If thirst mechanism is poor or absent or if the person is unable to obtain water, DEHYDRATION becomes more severe and can lead to DEATH.
What do you have to ensure that no patient is deprived of for DI?
DON’T DEPRIVE fluids any longer than 4 hours because they can not reduce urine output.
What is nephrogenic diabetes insipidus? What gene is most commonly inherited?
A genetic disorder caused in which the kidney tubules do not respond to the actions of ADH.
Most commonly inherited as an X-linked recessive disorder AVPR2 gene.
What is primary diabetes insipidus?
Defect of the hypothalamus gland or posterior pituitary gland, resulting in a lack of ADH production or release.
What is secondary diabetes insipidus?
Most often results in tumors in or near the PPG or the hypothalamus
Also can be from head trauma, infectious process, brain surgery, or metastatic tumors.
What is drug-related diabetes insipidus?
Usually caused by lithium carbonate and demeclocycline. These drugs can interfere with the response of the kidneys to ADH.
What are the manifestations of DI?
DEHYDRATION
Increased urination
Excessive thirst
What are the manifestations of DEHYDRATION?
Poor skin turgor Dry or cracked mucous membranes Tachycardia Weak peripheral pulses Decreased BP Decreased pulse pressure Orthostatic hypotension Distended Neck Veins (supine position) Increased RR Dry skin Decreased LOC Concentrated dark urine with high SG
What are the key features of DI?
Hypotension Tachycardia Weak peripheral pulses Hemonconcentration Increased urine output Dilute urine, low specific gravity Poor turgor Dry mucous membranes Decreased cognition Ataxia Increased thirst Irritability
What is the first step in diagnosis to DI?
Measure a 24hr fluid intake and output without restrictions.
DI is considered if output is more than 4L during this period and is greater than the volume ingested.
Urine is dilute with a SG LESS than 1.005 and low osmolarity (50-200)
What is the drug of choice for DI?
Desmopressin ( a synthetic for of vasopressin) given orally or intranasally in a metered spray.
Each spray delivered 10mcg
Mild 2-3 sprays daily
Severe ADH IV or IM
What are side effects of intranasal form of desmopressin?
Ulceration of mucous membranes Allergy Sensation of chest tightness Lung inhalation of the spray If these occur or if the patient has a URI an oral or subQ vasopressin is used instead.
What is the difference between the parenteral and oral or intranasal desmopressin forms?
Parenteral from is 10x stronger.
What is the nursing management for a patient with DI?
Early detection of dehydration Maintaining adequate hydration Accurately measuring I&O Checking urine specific gravity Daily weight Urge pt to drink oral fluids Ensure potency of IV and catheter
What is the management for lifelong DI?
Polyuria or polydipsia are indications of the needle for another dose.
Drugs for DI can cause fluid overload so teach patients to weigh themselves daily.
Signs of fluid overload include weight gain of 2.2lbs or other signs of water toxicity (headache, acute confusion) CALL 911
What is syndrome of inappropriate antidiuretic hormone (SIADH) or Schwartz-Bartter syndrome?
A problem in which vasopressin(antidiuretic hormone) is secreted even when plasma osmolarity is low or normal.
When does SIAHD occur?
Cancer Pneumonia Lung abscesses Active TB PNEUMOTHORAX Chronic lung disease Mycoses Positive pressure ventilation Trauma Infection Tumors Strokes Porphyria Lupus Vincrisitne Cyclophosphamide Carbamazepine Opioids Tricyclics antidepressants General anesthetic Fluoroquinolone
What are the manifestations of SIADH?
Early= water retention, N/V, anorexia Recent weight gain. Free water (not salt) is retained so no edema HYPONATREMIA Lethargy Headaches Hostility Disorientation Change in LOC Late: decreased responsiveness/seizure/coma Full bundling pulse Hypothermia Decrease in urine volume Urine osmolarity INCREASE Plasma Volume Increase Plasma Osmolarity DECREASE Increased urine NA levels Increased urine SG Increased urine concentration
What can help diagnose SIADH?
Radioimmunoassay of ADH along with clinical manifestations.
What are the medical interventions for SIADH?
Restricting fluid intake.
Promoting excretion of water.
Replacing lost NA
Interfering with the action of ADH
What are nursing interventions for SIADH?
Monitoring response to therapy
Preventing complications
Teaching the patient about fluid restrictions and drug therapy
Preventing injury
Measure I&O
Daily weight greater than 2.2lbs(1L/1000mL of fluid) is concern
Frequent oral rinses
Why is fluid restriction essential for SIADH?
Fluid intake further dilutes plasma NA levels. In some cases fluid intake may be kept as low as 500 to 1000mL per day.
USE SALINE INSTEAD OF WATER FOR EVERYTHING
What is drug therapy with patient who have hyponatremia with SIADH?
Tolvaptan ORAL or conivaptan IV
VASOPRESSIN ANTAGONISTS
Promote water excretion WITHOUT NA loss.
TOLVAPTAN BBW: rapid INCREASE in NA levels greater than 12/24hr can cause CNS demyelination that can lead to death. ALSO high doses or doses longer than 30 days SIGNIFICANT risk for liver failure and death.
ONLY ADMINISTER IN HOSPITAL SETTING
What is the drug therapy for patient who have near normal NA levels or heart failure and SIADH?
Diuretics: be careful for further NA loss.
Demeclocycline: oral antibiotic may also help correct disturbed fluid and electrolytes
What solution is used to treat SIADH when NA levels are very low?
HYPERTONIC SALINE (3% NaCL) Give IV cautiously because my add to existing fluid overload and promote heart failure.
What can ANY patients response to therapy lead to?
Fluid overload which leads to pulmonary edema and heart failure.
What is the older adult with SIADH at risk for with these ________ secondary diseases?
With cardiac problems, kidney problems, or liver problems, the older adult is at great risk for fluid overload.
What are the s/sx of fluid overload? How often do you assess?
Bounding pulse Distended neck veins Crackles in lungs Increasing peripheral edema Reduced urine output AT LEAST EVERY 2hrs
Pulmonary edema can occur VERY QUICKLY and can lead to death.
If these signs are present NOTIFY THE HCP IMMEDIATELY
What is critical when serum NA levels fall below 120 in patients with SIADH?
PROVIDING SAFE ENVIRONMENT
Possible neurological changes and risk for seizures increases.
assess neuro changes and subtle changes such as muscle twitching.
Check A&Ox3 EVERY 2 HOURS
Reduce environmental noise and lightening to prevent overstimulation.
What is an addisonian crisis?
LIFE THREATENING EVENT in which the need for cortisol and aldosterone is GREATER than the available supply.
Often occurs to a stressful event: (surgery/ trauma/ severe infection)
What is the emergency care HORMONE REPLACEMENT regimen for and addisonian crisis?
RAPID INFUSION OF NS OR DEXTROSE 5% in NS
Initial dose of EITHER hydrocortisone sodium 100-300mg OR dexamethasone 4-12mg IV BOLUS
Administer an additional 100mg of hydrocortisone sodium by continuous IV infusion over next 8hrs
Give hydrocortisone 50mg IM concomitantly every 12hrs
Initiate an H2 histamine blocker (ranitidine) IV for ulcer prevention
What is the emergency care HYPERKALEMIA regimen for and addisonian crisis?
Administer insulin (20-50 units) with dextrose (20-50mg) in NS to shift K into cells
Administer KAYEXALATE
Give lord or thiazide diuretic
AVIOD Ksparing diuretics
K restrictions no avocado/spinach/banana/whitebeans/sweetato
Monitor I&Os
Monitor HR/rhythm/and ECG for manifestations of hyperkalemia: bradycardia/heart block/tall peaked Twaves/fibrillation/asystole
What is the emergency care HYPOGLYCEMIA regimen for and addisonian crisis?
ADMINISTER PRESCRIBED IV GLUCOSE
ADMINISTER GLUCAGON
MAINTAIN IV ACCESS
MONITOR BLOOD GLUCOSE LEVELS HOURLY
CONTINUOUS ECG
WHAT IS PRIMARY ADDISONS DISEASE or adrenal hypofunction?
Autoimmune TB Metastatic Cancer AIDS Hemorrhage Gram- SEPSIS Adrenalectomy Abdominal radiation therapy Mitotane drug and toxins
What is the cause of secondary causes of Addison’s disease or adrenal hypofunction?
Pituitary Tumors
Postpartum Pituitary necrosis
Hypophysectomy
High dose pituitary or whole brain radiation
What are manifestations of Addison’s disease?
Lethargy (depressed/confused/psychotic) Fatigue Muscle/joint weakness Salt craving Anorexia N/V/D/Constipation Abdominal pain Weight loss Women:menstrual changes Men: impotence Vitiligo Hyperpigmentation Hypotension
What are the lab values with Addison’s disease of adrenal hypofunction? And the manifestations of each?
Hypoglycemia (sweating/headaches/tachycardia/&tremors)
Hyponatremia
Hyperkalemia (dysrhythmias/ irregular HR=cardiac arrest)
Hypercalcemia
Low serum cortisol
Elevated BUN
What is the most definitive test for adrenal insufficiency?
ACTH stimulation (provocation) test.
ACTH is given IV and plasma cortisol levels are obtained in 30min intervals.
PRIMARY: absent or decreased
SECONDARY: increased
What are imaging testing to assess for Adrenal insufficiency or Addison’s disease?
Skull X-ray/CT/MRI and arteriography may determine the cause of pituitary problems.
CT may also show adrenal atrophy
What are the nursing interventions for Addison’s Disease?
Because of hyperkalemia CARIAC FUNCTION is a nursing priority.
Promoting fluid balance
Monitoring for fluid deficit
Preventing poor glucose regulation with hypoglycemia
VS 1-4hrs
Weight pt daily
Record I&O
Monitor lab values (identify hemconcentration=^Hematocrit or BUN)
What is the common drug regimen for Addison’s disease?
Cortisone 25-50mg orally WTH MEALS (GI irritation can occur)
Hydrocortisone 20-50mg orally S/Sx of excessive drug therapy: rapid weight gain/round face/fluid retention=Cushing Syndrome
Prednisone 5-10mg orally daily REPORT: sever diarrhea/vomiting/fever. May need to ^during illness
Fludrocortisone 0.5-0.2mg orally MONITOR: BP (hypertension is s/e) REPORT: weight gain or edema. (Na/retention is possible)
What is Cushing Disease (hypercortisolism)and what is it caused by?
Excess secretion of cortisol from the adrenal cortex.
Problem with the adrenal cortex itself OR problem in the ANTERIOR pituitary gland OR problem with the hypothalamus.
Who does Cushing’s DISEASE effect more often?
WOMEN
What is Cushing SYNDROME?
GLUCOCORTICOID therapy can also lead to problems of hypercortisolism= CUSHINGS SYNDROME
Endogenous secretion= Cushing’s Disease Causes?
Bilateral adrenal hyperplasia
Pituitary increase production of ACIH
Malignancies of lung/GI/pancreas
Adrenal carcinomas
Exogenous Administration= Cushings SYNDROME Causes?
Use of Glucocorticoids in treatment of: Asthma Autoimmune disorders Organ transplantation Cancer chemotherapy Allergic responses Chronic fibrosis
Is Cushing’s Syndrome or Cushing’s Disease more common?
SYNDROME
What are the key features of a patient with Cushing’s Disease/Syndrome?
Moon face
Edema
Acne
Buffalo Hump
Truncal Obesity
Weight Gain
Hypertension
Frequent Dependent Edema
Bruising
Petechiae
Muscle Atrophy (extremities)
Osteoporosis
Pathologic features
Decreased height to vertebral collapse
Aseptic necrosis of the femur head
Slow or poor healing of bone fractures
Thinnning skin
Striae (stretch marks) and increased skin pigmentation
^risk for infection
Decreased immune function
Decreased inflammatory responses
Manifestations of infection/inflammation may be masked.What are the cardiac changes that occur with Cushing’s disease?
Water and Na are retained leading to hypervolemia and edema formation. BP is elevated Pulses are full and bounding
What is glucose levels with Cushing’s syndrome?
HIGH
what are some emotional changes related to Cushing’s disease?
"Don't feel like themselves" Mood swings Irritability Confusion Depression Crying/laughing inappropriately Difficulties concentrating Sleep difficulties/ fatigue
what are the lab tests for Cushing’s Disease?
Blood/Salivary/Urine cortisol levels
24hr urine for ^CALCIUM/^cortisol/^androgens/^K+/^Glucose.
ACTH levels are elevated in PITUITARY
ACTH levels are low in STEROID USE
what is a normal salivary cortisol level?
2.0
What is dexamethasone suppression testing?
Over night or 3-day period set doses of dexamethasone are given. A 24hr urine collection follows the drug.
If cortisol levels are SUPPRESSED by the drug Cushing’s is not present.
What are some addition lab findings for Cushing’s disease?
Increased Blood GLUCOSE levels
Decreased Lymphocyte count
Increased Sodium levels
Decreased Serum Calcium levels
What are imaging tests that can be performed for Cushing’s disease?
X-ray CT scan MRI Arteriography Identify leasions of adrenal/lung/pituitary/GI/or pancreas
What are priority nursing diagnosis for Cushing’s disease?
SAFTEY: skin integrity/bleeding/intact skeleton
Fluid overload: pulmonary edema/heart failure
INJURY: think skin/poor wound healing/bone density loss.
Risk for INFECTION
Change positions Q2hr
What is the drug therapy for a patient with Cushing’s disease?
DRUG that INTERFERE’s with ACTH production: Cyproheptadine
DECREASE IN CORTISOL PRODUCTION: Metyrapone/aminoglutethimide/ketoconazole
TUMORS: Mitotane
Type 2 diabetes: Korlym= BBW= don’t use in pregnancy
Pituitary: Signifor
What is nutrition therapy for patients with Cushing’s Disease?
Fluid and Na restrictions.
Monitoring I&O
Daily weight 1lb=500mL of retained water
Urine Specific gravity below 1.005=fluid overload
What is the possible surgical management of Cushing’s Disease?
Hypophysectomy: removal of Pituitary Gland
Adrenalectomy: removal of adrenal gland
Removal of tumors.
What is POST/OP care for Cushing’s disease?
Correct fluid&electrolyte balance BEFORE surgery. Monitor blood Na/K+/Chloride levels. Cardiac monitoring Hyperglycemia controlled before surgery. Hand washing Side rails up High calorie/high protein diet Glucocorticoid preparations are given before surgery.
Adrenalectomy: Assess for Shock q15min (hypotension/weak pulse/decrease in urine output. Monitor VS CVP Serum electrolytes
What are priority nursing interventions for a patient with Cushing’s disease?
Injury Prevention: Skin assessment/ protection/gentle handling
Assess skin for reddened areas/excoriation/breakdown/edema
Pad bony prominences/turn Q2hr
Avoid activities that can result in skin trauma
Soft toothbrush/electric razor
Keep skin clean&dry
excessive dryness use lotion
What is diets for Cushing’s Disease?
Generous amounts of Milk/cheese/yogurt/green leafy root vegetables/
AVOID caffeine/alcohol=increase risk for GI ulcers/promote bone density loss.
