Management of Other Body Systems Flashcards
what is diabetes mellitus?
chronic metabolic disorder characterized by elevated blood glucose levels (hyperglycemia) caused by defects in insulin secretion (from the pancreas), insulin action, or both
glucose can’t be utilized w/o ____
insulin
what is type 1 DM?
autoimmune destruction of the pancreas beta cells resulting in absolute insulin deficiency (body doesn’t produce insulin)
what are the key features of type 1 DM?
sudden onset, often in childhood/adolescence
presence of autoantibodies (ie islet cells antibodies)
dependence of exogenous insulin for survival
what are the complications of type 1 DM?
ketoacidosis, microvascular, and macrovascular damage
what is type 2 DM?
progressive insulin resistance and relative insulin deficiency
which type of DM has genetic predisposition and lifestyle contributing factors?
type 2
which type of DM has a gradual onset, typically in adults?
type 2
what are the key factors of type 2 DM?
insulin resistance in target tissues (muscle, liver, adipose)
impaired insulin secretion by pancreatic beta cells
often associated with obesity and metabolic syndrome
what are the complications of type 2 DM?
CV disease, neuopathy, nephropathy, retinopathy
what is the fasting plasma glucose levels with type 2 DM?
greater than or equal to 126 mg/dL
what is the 2 hour plasma glucose with type 2 DM?
greater than or equal to 200 mg/dL during OGTT
what is the HbA1c with type 2 DM?
greater than or equal to 6.5%
what does HbA1c measure?
blood sugar levels over the last 3 months
what happens when glucose isn’t being taken up?
w/o insulin, glucose is unable to be processed by the body
liver produces more glucose to feed the body, but w/o insulin, the glucose accumulates in the bloodstream
the body needs an alternative energy source so it breaks down fat, the fat breakdown produces ketones which buildup in the bloodstream
ketones and glucose are transferred into the urine and the kidneys use water to clear the blood from excess glucose and ketones
while the body attempts to get rid of the ketones and glucose, a lot of water is lost which can lead to dehydration and may worsen ketoacidosis
what is diabetic ketoacidosis?
when there is an insulin deficiency, the body breaks down fats bc it can’t use glucose for energy, which causes a buildup of ketones in the blood
what is the primary trigger for diabetic ketoacidosis?
insulin deficiency
what are the characteristics of diabetic ketoacidosis?
hyperglycemia
ketosis
metabolic acidosis
what is hyperglycemia?
high blood sugar (>250 mg/dL blood glucose) leading to osmotic diuresis and dehydration
what is ketosis?
accumulation of ketones caused by breakdown of fatty acid causing a metabolic acidosis
what are the ketone bodies produced?
acetoacetate
beta hydroxybutyrate
acetone
what may be the initial presentation in about 25-40% of type 1 diabetics?
ketoacidosis
what may occur in at least 34% of those with type 1 DM
ketoacidosis
what is the leading cause of morbidity/mortality in DM?
ketoacidosis
what are the clinical manifestations of ketoacidosis?
polyuria
polydipsia
polyphagia
altered mental status
nausea, vomiting, abdominal pain
rapid breathing
fruity breath odor
what is polyuria?
frequent urination
what is polydipsia?
excessive thirst
what is polyphagia?
excessive hunger
why does rapid breathing occur with ketoacidosis?
as a compensation for metabolic acidosis
why is there fruity breath with ketoacidosis?
acetone production
t/f: organs don’t work as well with high ketones
true
what are the symptoms of ketoacidosis?
high BG
foul odor breath
stomach ache with or without vomiting
severe cases can have trouble breathing
what are the causes of high BG in ketoacidosis?
forgetting to take insulin
using expired insulin or insulin not properly stored
what is the treatment of high BG in ketoacidosis?
check ketones if the BG is >300 mg/dL or when sick
what is the cause of foul odor breath in ketoacidosis?
illness
what is the treatment of foul odor breath in ketacidosis?
call the doctor if ketones are present
what is the cause of nausea with or without vomiting in ketoacidosis?
wrong dose insulin
what is the treatment for nausea in ketoacidosis?
drink extra water or sugar free liquids to stay hydrated
what is the cause of trouble breathing in severe cases of ketoacidosis?
insulin pump NOT working
what is the treatment for trouble breathing in severe cases of ketoacidosis?
DON’T exercise until ketones are no longer present
why is reduced EF with HF an issue?
bc not as much blood is being pumped out leading to poor endurance, elevated HR, OH, and tiredness
what conditions may result from ketoacidosis that need medical management?
severe ischemic cardiomyopathy with acute HF with reduced EF
hypoxic respiratory failure
NSTEMI/acute coronary syndrome
hypokalemia/hypomagnesemia
what other organ systems should we consider with diabetic pts?
endocrine
cardiac
pulmonary
renal
liver
hematology
what systems are included in the PT systems review?
MSK
CVP
integ
neuro
what are the exercise considerations with DM?
insuline injection timing, place, and type
HR response
t/f: we want pts with DM to have stable glucose levels b4 working with them
true
b4 working with a pt with DM, where do we want there BG levels?
80-100
if a pt has low BG, what should we do?
give them juice or a sugar tablet
after a pt is extubated, what should we do?
a cough assessment and breathing exercises
during day 1 in acute care, what are we doing?
early mobilization
during day 3 in acute care, what are we doing?
EOB
during day 6 in acute care, what are we doing?
independent ambulation
during day 8 in acute care, what are we doing?
D/C?
what is hypovolemic shock a result of?
fluid loss
what is caridogenic shock a result of?
ineffective heart pump
what is septic shock a result of?
infection
what does any type of shock lead to?
multisystem organ failure
what is the renal function?
to filter the blood and tightly control electrolytes
what are the 4 major functions of the kidneys?
filtration of the blood and excretion to remove wastes
regulation of electrolyte balance for tight control of Na, K, Cl, and P
regulation of pH or acid/base balance
regulation of blood volume and BP
what is the renin-angiotensin-aldosterone mechanism?
decreased Bp stimulates special cells in the kidneys that release renin in the blood
renin cleaves off part of the plasma proteins, angiotensin, that triggers an enzyme cascaderesulting in conversion to angiotensin 2 (a potent stimulator of aldosterone release) leading to aldosterone release
what turns angiotensin 1 to angiotensin 2?
ACE
what is glomerular filtration rate (GFR)?
the volume of nitrate formed by both the kidneys per minute
the heart pumps about how many liters of blood per minute under resting conditions?
5L
the heart pumps about 5L of blood per minute under resting conditions, which is about ___% of CO
25
what % of blood pumped per minute enters the kidneys to be filtered?
20%
how many liters of blood are pumped per day in males?
180 L
how many liters of blood are pumped per day in females?
150 L
what % of the filtrate of blood is returned to circulation by reabsorption?
99%
about how many liters of urine are produced per day?
1-2 L
what are the characteristics of pre-renal failure?
drop in CO
reduced GFR
CMP changes
decreased urine output
t/f: there is s drop in blood volume due to GI loss leading to a drop in MAP in pre-renal failure
true
t/f: there is reduced renal blood flow and subsequent perfusion of fewer nephrons in pre-renal failure
true
what are the CMP changes in pre-renal failure?
reabsorption of Na to limited fluid loss in an attempt to increase blood volume
altered electrolyte balance: elevated K, BUN, and creatinine
what are the characteristics of renal failure?
prolonged drop in CO
decreased urine output
CMP changes
does pre-renal failure or renal failure have a drop in CO that is unresponsive to a fluid bolus (not peeing out what they are taking in) and acute tubular necrosis?
renal failure
decreased urine output in renal failure is due to what?
proximal and distal convoluted tubules not reabsorbing Na bc water follows Na
what are the CMP changes in renal failure?
15:1 ratio of BUN:Cr
altered electrolyte balance: low K, high BUN, high Cr
what are the different types of renal replacement therapy (RRT)?
IHD (intermittent)
CRRT (continuous)
PIRRT (peritoneal)
t/f: CRRT provides more gradual fluid removal and solute clearance over prolonged treatment times compared to intermittent
true
what pts often use CRRT?
hemodynamically unstable pts
where are the common access points for RRT?
subclavian
internal jugular
femoral
what is the progression of liver failure?
healthy liver–>fatty liver–>liver fibrosis–>liver cirrhosis
what is the most common form of liver failure we will see?
fatty liver disease (alcoholic of non-alcoholic)
what are the various causes of liver disease?
fatty liver diseases
viral (hep B, C, D)
autimmune
chronic biliary disease
cardiovascular
storage diseases
other rare causes
what is the score used to classify liver one year survival rates?
Child-Pugh score
what is the score used to determine the severity of liver disease for transplantation?
MELD (model for end-stage liver disease)
what is the MELD score?
a combo of INR, creatinine, bilirubin, and sodium to create a score of 0-40 (higher score=higher severity) to determine liver disease severity for transplant
pts with a MELD score >___ will have their MELD re-calculated weekly
25
if sarcopenia is accounted for in MELD, how many points are added?
10
what causes jaundice?
increased bilirubin
if someone has liver necrosis, what are two key signs to look for?
light color stool
dark urine
t/f: alcoholic liver disease is a spectrum of disease which includes fatty liver w/ or w/o hepatitis, alcoholic hepatitis to cirrhosis
true
pt with severe alcohol use disorder mostly develop what disease?
chronic liver disease
what is the most frequent cause of CLD (chronic liver disease)?
severe alcohol use disorder
what is at risk drinking for men?
> 14 drinks/week
OR
4 drinks/occasion
what is at risk drinking for women and those over 65?
> 7 drinks/week
OR
3 drinks/occasion
more than ___ drinks/week in men is severe drinking from a liver toxicity standpoint
21
more than ___ drinks/week in women is severe drinking from a liver toxicity standpoint
14
what % of pts w/liver cirrhosis have hepatopulmonary syndrome?
5-32%
what is hepatopulmonary syndrome?
a combo of liver dysfxn or portal HTN, intrapulmonary vascular dilation, and abnormal oxygenation
what are the s/s of hepatopulmonary syndrome?
SOB (esp with sitting, standing, or exertion)
digital clubbing
spider angioma
cyanosis
what is spider angioma?
like varicose veins but much smaller and seen throughout the body
t/f: spider angioma is NOT a good sign
true
t/f: SpO2 can drop very quickly with hepatopulmonary syndrome, but we still have to mobilize them
true
the initial screening for hepatopulmonary syndrome involved what VS?
pulse ox to evaluate PaO2
O2 sat <____% indicates PaO2<70mmHg and is considered a (+) screen for hepatopulmonary syndrome
96
how is hepatopulmonary syndrome treated?
transplant
what are the implications of hepatopulmonary syndrome?
pace activities or maybe not able to treat
what is portal HTN?
when pressure of the blood entering the liver (via portal veins) is greater than the pressure of the blood in the inferior vena cava blood gets backed up and causes engorged veins (esp at the stomach and esophagus) and can lead to varicies and gastroesophageal bleeding
how is portal HTN treated?
beta blockers
transjugular intrahepatic portosystemic shunt (TIPS)
what is TIPS?
it’s a shunt that creates a bypass bw the portal vein and the hepatic vein
what are the implications of portal HTN?
make sure the pt is breathing (look for Valsalva)
highest pressures occur at night, after eating, and in response to coughing, sneezing, and exercise
GI bleeds
when a pt has portal HTN, what should we teach them?
how to modify and reduce pressure with anything that increases intraabdominal pressure (ie, coughing, straining at stool, improper lifting)
what should we do with pts with portal HTN and GI bleeds?
monitor hemodynamics
weigh the risks vs benefits of mobilization with a recent bleed
s/s monitoring
what are the s/s of a GI bleed?
anemia
fatigue
SOB
dark stool is above the stomach (upper GI bleed)
what is hepatic encephalopaty (HE)?
a significant complication from liver disease caused by liver insufficiency and/or portal systemic shunting that results in elevated ammonia and systematic inflammation that causes significant neurocognitive changes
a pt with HE may have elevated levels of what?
ammonia (a neurotoxin)
t/f: HE causes significant neurocognitive changes
true
what are the symptoms of HE?
change in personality
agitation
lethargy
inappropriate behavior
confusion
coma
what is the incidence of HE?
30-40% of pts with liver disease develop HE
how is HE treated?
lactulose to release ammonia production and absorption
anti-microbials
what grade HE is a pt dependent but good for d/c?
grade 1
what grade HE is the goal to protect the pt from harm?
grade 2
what grade HE is the priority positioning?
grade 4
what is sarcopenia?
a condition of low muscle mass as evidenced by reduced muscles cross sectional area cause by an imbalance bw protein synthesis and breakdown
what may sarcopenia be caused by?
dietary intake
portal HTN complications
pro-inflammatory cytokines
hyperammonemia
limited physical activity
what is the incidence of sarcopenia?
as high as 30-70% of pts w/liver failure
how is sarcopenia treated?
nutrition (specifically protein and BCAA)
physical exercise
meds (vit D in geriatrics but not researched)
what are the implications of sarcopenia?
there is a higher risk for complications, longer LOS in hospital, poorer clinical outcomes post-transplant, and mortality
anticipate fxnal mobility deficits
what % of pts with liver cirrhosis have ascites?
5-10%
what is the most common complication of cirrhosis resulting from portal HTN and liver insufficiency?
ascites
what is the theory behind why ascites occurs?
reorganization of hemodynamics (inc hydrostatic pressure)–>inc vasodilation–> sodium and water retention
how is ascites treated?
diuretics
regular out of bed activities
large volume paracentesis (needle draws out fluid)
sodium restriction
albumin infusion
when would we use large volume paracentesis removal with ascites?
when there is so much fluid the pt can’t breathe
what are the implications of ascites?
physical exam
monitor body mechanics
assess for edema
balance
positioning considerations for respiratory function
what position should be avoided with ascites?
supine bc it makes it difficult for them to breathe
what is the reference range for bilirubin?
0.2-1.3 mg/dL
what is bilirubin?
an orange-yellow colored waste formed in the liver from the breakdown of hemoglobin that is normally excreted by bile
if bilirubin is high, what does this mean?
the liver isn’t flushing waste efficiently
what physical exam findings would be present with high bilirubin?
jaundice
yellow sclera
what is the reference range for ammonia?
15-60 mcg/dL
what is ammonia?
a nitrogen waste product normally excreted via urine
if ammonia is high, this could mean that kidney/liver fxn is correlated to what?
HE
what is the reference range for creatinine?
0.38-1.02 mg/dL
what is creatinine?
a waste products produced by muscle breakdown of creatine
normally flushed from the body via the kidneys which filter almost all of it from the blood to urine
if creatinine is high, what could this mean?
kidney problems
t/f: if a pt has high creatinine, they may have a reduced ability to clear medications
true
what is the reference range for albumin?
3.5-5.2 g/dL
what is albumin?
a liver protein that maintains osmotic pressure of the blood compartment
provides tissue nourishment
transports hormones, vitamins, drugs, and other substances throughout the body
what is the reference range for INR?
0.8-1.3
how is the INR calculated?
fromt he PTT (# of sec it takes for a sample of blood to clot when a reagent is added)
if INR is high, what is the risk?
bleeding
fall risk
exercise intolerance
what is included in observation for liver disease?
abdominal girth
muscle wasting
integ color integrity, edema
what is included in the physical exam for liver disease?
abdominal palpation for hepato/splenomegaly
posture
strength testing
balance
endurance
