Peds exam 3a - Endo (major) Flashcards
T1DM dx
-FPG: >126
-PG: >200 2hr post glucose test
-CBG: >200 w/ the 3 P’s
Pre DM
-impaired FG: 100-125
-impaired GT: 140-199 2hr post glucose test
do children w/ T1DM need to restrict their carbs
no -> for whatever carbs they take in they just have to dose themselves
nutritional mgt of T1DM
-balanced diet
-increased exercise = increased intake needs
-high sugar foods in moderation
rapid acting insulin
aspart (novolog), lispro (humalog)
-right after they eat
-onset:15 mins
-peak: 1hr
-duration: 3-4hr
short acting insulin
regular insulin
-onset:30 mins
-peak: 3hrs
-duration: 6-8hrs
intermediate acting
NPH/lente
-onset:1-2 hrs
-peak: 6-8hrs
-duration: 12-18hrs
long acting insulin
glargine (lantus), detemir (levemir)
-onset:4-6hrs
-peak: 8-20hrs
-duration: 24hrs
when to check urine ketones
-anytime BG levels are >240 on two separate reads
-during illness
-BG levels >240 one time on a pump
if you have positive urine ketones, what are you at risk for
going into DKA contact doctor or just come into emergency room before DKA occurs
Insulin dosing
will be on exam, sig & final
-ratio: 1 unit for every 18g carbs
-correction: 1 unit for every 50 above BG of 150
example) BS 227, 48 carbs consumed -> 227-150 = 77/50 -> 1.54 units & 48/18 = 2.66 units
total insulin needed = 1.54 + 2.66 = 4.2 units
development issues w/ DM mgt for a toddler
-parents need to differentiate misbehavior from hypogly
-encourage child to report “feeling funny”
-expect food jags
-give choices of mgt
development issues w/ DM mgt for a preschooler
-reassure child who views dm mgt as punishment
-encourage child to participate in simple dm tasks
-teach child to report “lows” to an adult
-teach child what to eat when “low”
development issues w/ DM mgt for a school ager
-educate school personnel
-encourage age appropriate independence
-all activities DM must be supervised
-encourage extra curricular activities & participation in social groups
-11 to 12 yr old are able to perform an occasional injection
development issues w/ DM mgt for an adolescent
-more capable of performing self care activities
-know which foods fit into meal plan & how to adjust
-more willing to perform multiple injections
-risk takers/invincible-> “i can sleep until 1pm and not need to take insulin” “I can’t drink alcohol and be fine”
-needs continued parental involvement & support
what to do when you are a T1DM and drink alcohol
they need to dose for it (from clinical) and they need to have a snack (from lecture)
sick day mgt for DM
-use same dosing and give insulin as scheduled (stress can increase BS)
-check blood sugar more frequently
-monitor urine for ketones
~hydrate
normal fasting glucose
80-120
what food is 15grams of carbs
-small pack of skittles
-8oz of white milk no chocolate milk
-4oz of orange or apple juice
~frosting, starbursts
-glucose tabs
honey if over 1yr
if a child is extremely hypoglycemic, what do you do
rule of 15 wont work bc unable to swallow
1mg glucagon -> subQ or IM then place pt in recovery position to prevent aspiration and then feed after they awake
nursing consideration of glucagon
has an expiration date
causes of hyperglycemia
-too much food (carbs)
-too little activity
-too little insulin
-illness/infection
S/s of hypergly
-high BG
-high levels of glucose in urine
-frequent urination
-increased thirst
hypergly treatment
-check urine ketones, if increased call HCP
-increase caffeine free fluids
do not increase activity
the anion gap
tells us the state of acidosis the body is in
-Gap = (Na+K) - (Cl + HCO3)
-a high gap indicates metabolic acidosis & DKA
acidosis
-ketones build up in the blood, making it acidic
-pH below 7.35
-S/s: deep rapid breathing, confusion/lethargy, abdominal pain
ketosis
cells aren’t getting glucose so your body starts to burn fat as energy producing ketones (an acidic substances), when excess ketones (0.3-0.7) are present you get ketosis
ketoacidosis
-severe form of ketosis
-deflects levels of 7.0mmol/L or higher
-lower pH to 7.3 or less
DKA
hypergly + ketosis + acidosis
-BS >300
-S/s: deep rapid breathing (kussmaul breathinng,breathing off CO2), very dry mouth, fruity breath, N/V, lethargy/drowsiness, osmotic dyuresis
life threatening & needs immediate treatment
what is the biggest problem while treating DKA
cerebral edema (60-90% of DKA mortality)
usually treatment of DKA is very successful & our protocols are based around preventing C. edema
goals of DKA treatment
-correct dehydration
-correct acidosis & reverse ketosis
-restore normal glucose levels
-avoid complications in therapy
DKA treatment
1)fluid replacement w/ 10mL/kg 0.9% NS IV priority- 1st hr
2)lyte replacement over 48hr (0.9% NS + 20 mEq/L KPhos + 20 mEq/L KCl) 2nd hr
3)insulin therapy 0.1u/kg/hr drip 2nd hr (do not give bolus)
-begin dextrose infusion when BG reaches 250-300 (D5 0.45% NS + 20 mEq/L KPhos + 20 mEq/L KCl)
4)careful monitoring, D/c fluids when pt tolerates oral fluids & then give SubQ insulin and stop the drip
what is our goal w/ low dose insulin therapy & when do we stop the drip during DKA therapy
-decrease BG by 100mg/dL/hr
-drip should be continued until pH is greater than 7.3 and/or HCO is greater than 15 + serum ketones have cleared
do not stop just based on BG levels
when should bicarb therapy be considered during DKA treatment
-severe acidemia
-life threatening hyperK
what part of DKA treatment prevents cerebral edema
adding the dextrose to the IV fluids so we don’t drop the BG too fast
hourly rounds for pt in DKA
-VS
-neuro checks
-accurate I&Os
-point of care testing BG level
-K+ levels
notify HCP immediately if change in labs
q2 hour rounding for pt in DKA
-urine ketones
-Serum B-OH
-lytes, hematocrit, ABGs, BUN, serum glucose
-cardiac monitoring (continuous)
-amount of administered insulin
insulin rate and dose checked by 2 nurses
extra measures for DKA pt
-oxygen
-peripheral IV catheter
-if altered mental status: secure airway, NG suction, bladder cath
