ADN 235 Final exam outline / ADN235 Final exam study guide, latest spring 2020/2021

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DIABETES: DKA - interventions from priority (best to least) - what would you expect to be ordered ● Hyperglycemia (> 300 mg/dL) ● Metabolic acidosis ● Increased production of ketones �... � Results: ○ combination of insulin deficiency ○ liver and kidney glucose production and decreased use of glucose in the peripheral tissues ○ Occurs most in DM I, but seen in DM 2 - severe stress, surgery, trauma and most common cause INFECTION ○ Hyperglycemia leads to osmotic diuresis with dehydration and electrolyte loss. ● Manifestations: ○ 3 P’s, vomiting, abdominal pain, dehydration, weakness, confusion, shock, coma ○ Mental Status can vary - alert to profound coma ○ as ketones rise - pH of blood decreases - acidosis occurs ○ Kussmaul respirations (very deep and rapid respirations) cause respiratory alkalosis to correct metabolic acidosis by exhaling carbon dioxide. ○ Na - low or normal - depending on severity ○ K - depend on how long DKA existed before treatment. After therapy, K levels drop off quickly. Interventions: ● Assess: Airway, LOC, hydration status, electrolytes, and blood glucose ● Fluid/Electrolyte mgt: assess fluid status; risk for dehydration/shock; fluid overload ● 1st: Provide rapid isotonic fluid (0.9% sodium chloride) replacement to maintain perfusion to vital organs. ● Initial Infusion of 0.9% sodium chloride are 15-20 mL/kg/hr during 1st hr ● 2nd outcome achieved more slowly. fluid replacement depends on BP, electrolytes, urine output. In general 0.45% sodium chloride , infused at 4-14 mL/kg/hr ● when Glucose levels reach 250 mg/dL infuse 5% dextrose in 0.45% sodium chloride to prevent hypoglycemia and cerebral edema. ● Insulin therapy used to lower serum glucose by about 50 to 75 mg/dL/hr by continuous IV infusion ● DKA is considered resolved when BG < 200 mg/dL; pH > 7.3 ● mild-moderate hyperkalemia is common initially. ● Insulin therapy, correction of acidosis, and volume expansion = decreased serum K. To prevent hypokalemia: K replacement is initiated after serum levels fall below upper limits of normal. ** Before giving IV POTASSIUM solutions, make sure the urine output is at least 30 mL/hr Teaching: Teach measures to prevent dehydration: ● unless contraindicated: consume 2-3 L/day of water ● if BG levels are low, consume liquids with sugar ● monitor BG every 4 hr when ill, and continue to take insulin! ● teach clients to check urine for ketones if BG is > 240 mg/dL ● consume liquids with carbohydrates and electrolytes when unable to eat solid foods KNOW your insulins: rapid acting, short acting. Intermediate acting & long acting Know onset, peak, & durations Insulin Preparations Name of Insulin Onset of Action Time of Peak Effect Length of Action Insulin glulisine (Apidra) Insulin lispro (Humalog) Insulin aspart (NovoLog) Rapid Acting (15 minutes) 1 hour after injection 2- 4 hours Humulin R Novolin R Regular or Short Acting (30 minutes) 2- 3 hours after injection 3-6 hours NPH (Humulin N, Novolin N) Intermediate Acting (2-4 hours) 4- 12 hours after injection 12- 18 hours Insulin detemir (Levemir) insulin glargine (Lantus) Long-Acting (reaches bloodstream after several hours) No time of peak effect, lowers glucose fairly evenly over 24 hours 24 hours What can be draw up in same syringe, how to do so. ● Clear to Cloudy- NPH is CLOUDY and REGULAR is CLEAR ● Cannot draw up long acting insulin with anything else Early signs & symptoms - labs ● 3 P’s ○ Polyuria (urinating a lot) ○ Polydipsia (drinking a lot) ○ Polyphagia (eating a lot) ● Extreme fatigue ● Blurry Vision ● Cuts/Bruises slow to heal ● Weight loss – even though you are eating more (type 1) ● Tingling, pain, or numbness in the hands/feet (type 2) ● LABS: ○ FPG/FBS: >126 mg/dL ○ 2 hours plasma glucose (OGTT): >200 mg/dL ○ A1C: >6.5% ○ Random glucose: >200 mg/dL (w/ symptoms of hyperglycemia: 3 Ps) Signs of metabolic syndrome Presence of metabolic features & cardiovascular disease ● Abdominal obesity (40” or greater males; 35” or greater females) ● FBS 100 mg/dL ● abnormal A1C - > 7.0% ● Hypertension/Hyperlipidemia ○ 130/85* AHA <120/<80 Type 1 - ways to prevent DKA 1. Make healthy eating and physical activity part of your daily routine 2. Monitor your blood sugar level (3-4 times per day) 3. Adjust your insulin dosage as needed (stress, illness, surgery) 4. Stay hydrated 5. Check for ketones Type 2 - ways to prevent HHS DEHYDRATION MAJOR CAUSE occurs most often older patients (DM2) age r/t changes to thirst perception, poor urine concentrating abilities, use of diuretics Other causes: MI, sepsis, pancreatitis, stroke, certain drug therapy (glucocorticoids, phenytoin, beta blockers, and calcium channel blockers) ● Priority - Increase blood volume ○ (NSS) shock or severe hypotension ○ (½ NSS - 0.45% sodium chloride) ○ Infuse at 1L/hour (1,000 ml) until BP and urine output are adequate Sick day guidelines Notify HCP if ill ● Monitor BS Q 4 hrs. ● Test urine for ketones if glucose 240 mg/dL ● continue to take insulin or oral hypoglycemic agents ● prevent dehydration: drink 8-12 oz. of sugar free liquids every hour you are awake. If BS is below target, drink fluids with sugar ● continue to eat at meal times ● if unable to eat solids, consume easily tolerated foods or liquids equal to carb content of meal ● call PCP: persistent n/v, temp 101 ENDOCRINE: Hypophysectomy - what is it used to treat, teaching, safety, monitoring Removal of the Pituitary gland (hypophysis) Pituitary tumors Cushing’s syndrome: Pituitary Adenoma Teaching for hypophysectomy: o Nasal packing will be present for 2-3 days after surgery o Necessary to breathe through the nose and a mustache dressing (drip pad) will be placed under the nose o NOT to brush teeth, blow the nose, or bend forward after surgery. Why? Intercranial pressure o Use dental floss or oral rinses o Decreased sense of smell is expected – will return in 3-4 months o Avoid straining with Bowel Movements – increase fluids, eating high fiber foods, stool softeners o Will require hormone replacement therapy Post Op o Frequent Neuro Checks ************************CONTINUED****************** [Show More]

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