Med Surg III - Diabetes Flashcards
What is DKA?
Diabetic Ketoacidosis
- deficiency of insulin
- hyperglycemia
- ketosis
- acidosis
- dehydration
- BS >250
DKA: What are some precipitating factors?
Illness Infection Inadequate insulin dosage Undiagnosed Type I diabetes Poor self-management Neglect
DKA: Pathophysiology?
- Circulating insulin is insufficient, elevation of counter-regulatory hormones (glucagon, cortisol, and growth hormone)
- Glucose is not used, so the body breaks down fat for energy
- Ketones (acid by-product of fat metabolism) removed in urine (Ketonuria)
- Ketosis alters pH balance
- Metabolic acidosis develops
- Electrolytes depleted - body attempting electrical neutrality, caused by polyuria (Na, K, Cl, Mg, Ph), hypovolemia
- Insulin def. impairs protein synthesis, degradation. Nitrogen losses.
- Insulin def. stimulates glucose production which leads to further hyperglycemia.
Signs of dehydration:
Poor skin turgor (if older, check chest, forehead for tenting) Dry mucous membranes Tachycardia Orthostatic hypotension Sunken eyeballs Lethargy
What is orthostatic hypotension:
Decreased bp when standing (may take up to 3 minutes to appear)
What are some clinical manifestations of DKA?
Dehydration Abdominal pain N/V Kussmaul respirations Blood glucose >250 pH <7.35 Ketones in blood and urine
What are Kussmaul respirations:
Body’s attempt to reverse metabolic acidosis.
Deep and rapid.
How to treat DKA?
- IV insertion … hydrate!
- Fluids - NS or 1/2 NS to quickly increase vol.
- K+ for hypokalemia
- at risk for vtac, vfib, place pt. on cardiac monitor
- Insulin bolus/insulin infusion
- Pt. becomes anxious/nervous/sweaty
- Get glucose reading hourly
What is HHNS:
Hyperosmolar Hyperglycemic Nonketotic Syndrome
Describe HHNS?
The pt. is able to produce enough insulin to prevent DKA, but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.
Some signs of HHNS?
No ketosis
Hypovolemic
Usually occurs in older adults with Type 2
Hospital admission - insert large bore IV cath for large volumes of IV fluids
How to care for a patient with HHNS?
IV fluids, NS or 1/2 NS Regular insulin - bolus then infusion Monitor lytes - polyuria Requires more fluid than DKA - pt. severely dehydrated, blood sugar severely high Cardiac monitoring
What is hypoglycemia?
Too much insulin
Symptoms mimic alcohol withdrawal
Blood glucose <70 mg/dl
Confusion, irritability, diaphoresis, tremors, hunger, weakness, visual disturbances
Treatment for hypoglycemia?
Check glucose Give 1/2 c. juice, pop, etc. Follow with complex carbohydrate and protein to prevent sugar crash Vital signs Document!!
Some complications of hypo/hyperglycemia?
Angiopathy - macrovascular - microvascular - retinopathy Nephropathy Neuropathy Infection
What is Angiopathy?
blood vessel disease
What is macrovascular angiopathy?
vascular cardio and PVD blood vessel disease. First indication of angiopathy.
What is microvascular angiopathy?
eyes, kidneys, and skin. Can take years to see evidence.
What is retinopathy?
microanurisms in capillary walls of eye, leaks out into eye, microvascular damage to eye.
What is nephropathy?
damage to the kidney treated with aggressive management with ACE inhibitors (prils)
What is neuropathy/sensory neuropathy?
nerve damage
Sensory - lops (loss of protective sensation)
-avoid high heels
-wash feet, dry, no soaking
-avoid heating pads, commercial callus and corn remover
-see specialist
Long-term complications of diabetes?
Neuropathy Pressure ulcers Blindness Stroke Amputation Dementia
What is autonomic neuropathy?
controls involuntary body functions.
What are signs of autonomic neuropathy?
Hypoglycemia unawareness Bowel incontinence Diarrhea Urinary retention Gastroparesis Cardiovascular abnormalities Sexual dysfunction
Why is infection a complication of hypo/hyperglycemia?
There is a defect in the mobilization of inflammatory cells which causes impairment of phagocytosis by neutrophils and monocytes.
Glycosuria predisposes to bladder infections because bugs like sugar!
Hemoglobin A1c Test
Glycosalated Hgb - 4-6% normal - 7-9% elevated - 7% and less for diabetics Gives average blood glucose over 90 days.
What is the carbohydrate count for 1800 ADA diet?
4 breakfast 4 lunch 5 dinner 2 snack 15 total
What is carbohydrate count for 2000 ADA diet?
4 breakfast 5 lunch 5 dinner 3 snack 17 total
What education should nurse give to diabetic pt?
S&S Feet Monitor BS Survival Skills Med instructions Sick Day management
What are possible poor outcomes as a result of hypo/hyperglycemia?
Loss of consciousness
Seizures
Death
What is the Rule of 15:
Give 15 g. carbs, check blood glucose in 15 minutes.
What is considered to be a carbohydrate?
Bread Grains Cereal Fruit Vegetables Milk Any sweetened items
For what diagnostic testing should Glucophage (Metformin) be held for?
All diagnostic tests using contrast media (when taken together, kidneys may not be able to properly elim. Glucophage from blood). Restart 3 days later.
What item is important to have in pt.’s room prior to giving insulin?
Food tray!
What should nurse do when DKA patient’s glucose is below 250?
decrease the insulin infusion rate and add IV solution containing dextrose
treatment for neuropathy
control glucose
Creams - capsaicin (dangerous for lower extremities)
tricyclic antidepressants
anti-seizure meds
ways to decrease complications of diabetes
educate patient on tight glucose control, lower their weight, exercise, stop smoking, dialysis
when should you look for symptoms of hypoglycemia
at peak times (oral hyperglycemics last longer)
what is ulcerative colitis
chronic, recurrent inflammation of intestinal tract (cause unknown)
where does ulcerative colitis begin
in the rectum, spreads up colon
what age group is most affected by ulcerative colitis
15 - 25, and 60 - 80
S & S of ulcerative colitis
bloody stools, abdominal pain/cramping, fever, anorexia, and rebound tenderness (report rebound tend. immediately)
complications of ulcerative colitis
increased risk of colorectal cancer, hemorrhage, malabsorption, liver disease, osteoporosis, colon can become paralyzed and not function
what diagnostic results would ulcerative colitis have
decrease sodium, dehydration, increase hematocrit, iron deficiency, and blood, mucus, or pus in stool
treatment for ulcerative colitis
rest the bowel (NPO), control inflammation, combat infection, correct malnutrition (TPN), alleviate stress, drug Sulfasalazine (must be taken with meals)
diet for ulcerative colitis (after acute phase of NPO)
high calorie, high protein, low fiber, vitamin and iron supplements, avoid cold foods and stop smoking
what should patient do if they are having more than 10 stools per day
go to the ER
what is Crohn’s disease
inflammatory bowel disorder (usually small intestine) on any part of the GI tract. it is lifelong with unpredictable periods of remissions and recurrences
clinical manifestations of Chron’s
insidious (creeps up on them), diarrhea, fatigue, abdominal pain, weight loss, fever, non-bloody diarrhea
complications of Chron’s
strictures, obstructions, fistulas, impaired absorption, arthritis, liver disease, kidney stones
how is Chron’s diagnosed
History (bowel movements) & physical (abdominal tenderness). Cobblestone pattern shown on barium study, increase in WBC, decrease in Albumin
Treatment for Chron’s
75% need surgery (does not cure), corticosteroids to reduce inflammation, immunosuppressive agents, Flagyl (topical) if perianal area affected, Remicade (prevents activity of TNF)
Diet for pt with Chron’s
high calorie, high protein, low fat, low fiber, Vitamin B12
what is Celiac Sprue
malabsorption disorder, intolerance to dietary wheat proteins, gluten, barley, oats
How does Celiac Sprue present
weight loss and diarrhea containing fat deposits
what is diverticulitis
inflammation of diverticulum (out-pouch of mucosa of the intestinal wall
treatment for diverticulitis Acute
NPO, parenteral fluids, NG tube to drain bile…assess for pain and observe for peritonitis
diet for pt with diverticulitis
high fiber, avoid nuts, seeds, raspberries, strawberries
Common for all hepatitis pt’s
use standard precautions
what does elevation in T3 or T4 signify
hyperthyroidism
what do low T3 or T4 values signify
hypothyroidism
treatment for hypothyroidism
monitor vitals, admin thyroid replacement drugs, provide roughage and fluids for constipation, warm environment, avoid sedatives & opioids, monitor for OD of meds (start low and go slow), meds are increased over weeks
treatment for hyperthyroidism
provide rest, admin sedatives, cool and quiet environment, daily weight, high calorie diet, admin anti-thyroid meds (PTU, iodine), admin propanolol for tachycardia
treatment for myxedema coma
1 is maintain patent airway, aspiration precautions, meds, take hourly temperature, keep warm
HBsAG
hepatitis B surface antigen, if present indicates hep B infection
IgM
indicates acute hepatitis A
IgG
indicates past hepatitis A infection
Hepatitis A
fecal-oral, can go away
Hepatitis B
blood or body secretions, adequate rest and nutrition are most important treatments (no cure)…contact precautions
Hepatitis B teaching
no alcohol for one year, watch meds metabolized in liver, family members should be tested, use condoms
once jaundice is gone, are Hep B patients fully recovered
NO
who should be tested for Hep C
everyone with history of IV drug use
how is Hep C transmitted
percutaneously (IV drug use, transfusions, sex, tattoos, body piercing, organ transplant).
treatment for Hep C
interferon and ribaviron
what is needed for Hep D to infect body
Hep B, same route of transmission
Hep E usually comes from what
contaminated water or poor sanitation (fecal-oral)
preicteric phase of Hep
initially may be asymptomatic, 1 - 21 days, GI symptoms, anorexia, malaise, HA, right upper quadrant pain
Icteric phase of Hep
jaundice (seen in sclera, palms, soles, skin, hard palate)
posticteric phase of Hep
malaise and fatigue, hepatomegaly…jaundice may be gone
Lab value associated with Hepatitis
increased biliruben > 1.5 (also clay colored stools may be present)
complications of hepatitis
liver failure, cirrhosis, hepatocellular carcinoma
clinical manifestations of cirrhosis
GI complaints, enlarged liver, jaundice, spider angiomas, portal hypertension, pruritus, esophageal varices, ascites
highest priority for patient with esophageal varices
maintaining airway (they may rupture). Can do banding to correct them
what should patient do before a paracentesis
empty their bladder
how can ascites be treated
paracentesis (drain the fluid)
what can lead to encephalopathy
increase in ammonia levels
why monitor albumin level in cirrhosis patients
the low pressure caused by hypoalbuminemia is the reason for ascites and edema
hepatic encephalopathy treatment
use lactalose to trap ammonia in the gut, do not d/c for diarrhea because it improves neural function
meds that can be use for cirrhosis
histamine blockers and beta blockers
asterixis
flapping tremors (have patient extend arms) cirrhosis complication
fetor hepaticus
musty sweet odor of breath (poopy mouth) cirrhosis complication
treatment for liver cancer
palliative, or transplant
acute pancreatitis manifestations
pain severe and unrelenting, may be epigastric pain, abdominal pain in LUQ that radiates to back, N/V, BS absent or decreased, fever, leukocytosis, tachycardia, jaundice
highest priority for acute pancreatitis
respiratory failure
lab values associated with acute pancreatitis
elevated glucose, amylase, and lipase, risk for hypocalcemia
Trousseau’s
carpal spasm when blood pressure cuff is inflated, sign of hypocalcemia
Chvostek’s
contraction of facial muscle when you tap on face, sign of hypocalcemia
treatment for acute pancreatitis
pain relief (morphine), prevent shock (fluid replacement), reduce secretions (NPO, NG suction, Tagament, Prilosec), and treat the infection causing it
chronic pancreatitis manifestations
lot of pain, weight loss, jaundice, steatorrhea (fatty stools), diabetes
treatment for chronic pancreatitis
pain relief, can not tolerate fatty foods, control diabetes, bland, low fat, high CHO diet
whipple
surgery involving resection of the pancreas, duodenum, distal portion of stomach, and common bile duct
risk factors for pancreatic cancer
smoking, diabetes, high fat diet
