N351 Exam 2
when the cells lack glucose, the body:
-secretes counterregulatory hormones -causes glucose to be mobilized from the liver -causes fat to be mobilized from adipose tissue -excess sugar and free fatty acids cause dehydration and acidosis
osteoblasts
bone forming cells
considerations with tizanidine hydrochloride
caution with elderly patients
black box warning for codeine
cautious use of codeine in children due to reports of death of children taking codeine who are ultra rapid metabolizers of the drug
neuropeptides of endogenous analgesia system
endorphins, enkephalins, dynorphins
why do patients need to sit up for 30 minutes after taking Alendronate?
esophageal ulcers
symptoms of hyperglycemia
extreme thirst, frequent urination, dry skin, hungry, blurred vision, drowsy, slow-healing wounds
treatment of hypoglycemia
fast-acting carbs, glucagon, 50% dextrose in water IV, follow-up with dextrose IV fluids in hospital until stabilized
Parts of a basic metabolic panel
glucose, BUN, creatinine, carbon dioxide, calcium, chloride, potassium, sodium
black box warning for dantrolene sodium
hepatotoxicity; should take liver function tests
insulin pump
individual will self administer insulin dose through a programmable pump; typle 1 ONLY
rapid acting insulins
lispro, aspart, glulisine
flatfoot
longitudinal arch of the foot is diminished by congenital abnormalities, trauma, or excessive pressure
opioid receptors
mu, kappa, delta
which medication to treat osteoporosis would be contraindicated for a client who has a history of renal calculi? os-cal raloxifene ibandronate zoledronic acid
os-cal
Why will should you educate your patients to sit up for 30 minutes after taking Alendronate therapy?
possible esophageal ulcers and reduce GI upset
dynorphins
produce analgesia
What kind of snack should be given after BG is returned to above 70?
protein snack to maintain glucose level
which information would the nurse include when teaching a client with coronary artery disease about aspirin therapy? SATA take aspirin with food report ringing in the ears monitor and report excessive bleeding and bruising do not mix aspirin with meds for ED avoid OTC pain meds that contain aspirin
-take aspirin with food - report ringing - monitor and report excessive bleeding and bruising - avoid OTC pain meds that contain aspirin
Which client with complications of fracture would the nurse expect may be treated with a fasciotomy? acute respiratory distress syndrome compartment syndrome venous thromboembolism fat embolism syndrome
compartment syndrome
patient education with insulin
correct admin, ability to determine correct dose, notice symptoms of hypoglycemia/hyperglycemia and adjust dosing, how to test BG, keeping BG and diet records, lifestyle changes, follow up
risk factors of diabetes
family history of diabetes- parent or sibling obesity sedentary lifestyle certain ethnic groups age greater than 45 previously identified impaired fasting glucose or impaired glucose tolerance hypertension hight HDL or triglyceride history of gestational diabetes
a-delta fibers
faster transmission, rapid reflex, glutamate transmit, thermal and chemical stimuli
systemic effects of inflammation
fever, leukocytosis, malaise, anorexia, sepsis
hammer toe
flexion deformity of the interphalangeal joint that may involve several toes
ingrown toenail
free edge of nail plate penetrates the surrounding skin
A child with type 1 diabetes is receiving 15 units of regular insulin and 20 units of NPH insulin at 7:00 AM each day. Which time would the nurse anticipate a hypoglycemic reaction from the NPH insulin to occur before noon in the afternoon within 30 minutes during the evening
in the afternoon (peak @ 6-8 hours)
Which withdrawal signs and symptoms would the nurse assess for in a recently hospitalized client with an opioid use disorder? SATA lacrimation yawning drowsiness constipation muscle aches
lacrimation yawning muscle aches
what causes swelling and pain?
localized tissue congestion
basal only insulin schedule
long acting taken 1-2 times daily
histamine
mast cells, vasodilation, increased capillary permeability
cachexia
weakness and wasting of the body due to severe chronic illness.
arthography
x-ray of a joint taken after the injection of a contrast medium into the joint
bone densitometry
x-ray technique for determining density of bone
normal ABG CO2
35-45 mmHG
fasciotomy
a surgical incision through the fascia to relieve tension or pressure; blood supply with compartment syndrome
MRI (magnetic resonance imaging)
a technique that uses magnetic fields and radio waves to produce computer-generated images of soft tissue. MRI scans show brain anatomy.
metabolic acidosis
accumulation or inadequate elimination of hydrogen ions OR inadequate production or excess elimination of bicarbonate
metabolic alkalosis
acid deficit caused by vomiting, gastric suctioning, or potassium depletion OR base excess by antacids OR excess bicarb
aspirin intermediate dose effects (325mg-2g/day)
analgesic, antipyretic for mild to moderate pain, dysmenorrhea
diabetes insipidus
antidiuretic hormone is not secreted adequately, or the kidney is resistant to its effect
considerations for lidocaine patch
-apply to most painful area - use gloves - remove after 12 hours and leave off for 12 hours - fold patch to discard - do not apply topical to non-intact skin
how to determine insulin dosing
-insulin sensitivity -insulin to carb ratio -food consumed -blood glucose targets -serum blood glucose level before admin
pathophysiology of type 1 diabetes/DKA
-lack of glucose causes catabolism of fats and proteins so increase of fatty acids and ketones in the blood - ketoacids bind with bicarbonate buffer which lowers pH - ketones spill into urine - dehydration worsens, GFR decreases which limits excretion of acids, causing metabolic ketoacidosis
renal and hepatic impairment and insulin
- renal= hypoglycemia b/c decreased filtration of insulin through kidneys - hepatic= hypoglycemia b/s decreased ability to produce glucose
Equianalgesic dosing
-Dose of one analgesic that is approximately equivalent in pain-relieving effects compared with another analgesic -Helps guide dosing when changing routes or when a drug is ineffective or causes intolerable side effects
fixed dosing insulin schedule
1-2 daily doses of NPH or NPH mix before breakfast and dinner or 12 hrs apart
regular insulin onset
1-3 hours
stages of bone healing
1. hematoma formation- 1-2 days after fracture 2. fibrocartilage callus formation- fibroblasts and osteoblasts migrate to fracture site 3. bony callus formation- ossification begins during 3rd or 4th week 4. bone remodeling- osteoclasts remove necrotic bone
treatment of hypoglycemia in unresponsive patient or BG below 50
1/2-1 amp of 50% dextrose solution IV OR glucagon 1mg
what to do FIRST when noticing hypoglycemia (50-70)?
10-15g of carbs, recheck BG in 15 minutes and repeat if needed
normal BUN value
10-20 mg/dL
prediabetic fasting BG
100-125
normal anion gap range
12-16 mmol/L
peak of short acting insulins
2-4 hours
Normal ABG Bicarbonate
22 - 26 mEq/l [ HCO3 ]
normal carbon dioxide bicarbonate levels
24-31 mg/dl
rapid insulin duration
3-5 hours
peak of rapid acting insulin
30 minutes to 1 hour
rapid insulin peak
30 min-1 hour
Symptoms of fat embolism syndrome
Confusion - earliest Dyspnea, tachycardia, fever, restlessness, pulmonary complications, petechiae, oliguria, Notify doctor immediately
What is the limit for daily acetaminophen?
4g a day
prediabetes A1C
5.7-6.4%
normal ABG pH
7.35-7.45
normal glucose level
70-100 mg/dL
Which statement reflects the progress of bone healing? A. All fracture healing takes place at the same rate no matter the type of bone fractured. B. Serial X-Rays are used to monitor the progress of bone healing. C. The age of the client is most influential factor affecting the rate of fracture healing. D. Adequate immobilization is essential until ultrasound shows evidence of bone formation with ossification.
B
osteoclasts
Bone-destroying cells
considerations for cyclobenzaprine hydrochloride
CNS depression -> monitor for sedation and coadmin of other sedatives
anion gap
Difference between the concentrations of serum cations and anions: determined by measuring the concentrations of sodium cations and chloride and bicarbonate anions.
Dupuytren's contracture
Dupuytren's contracture is a slowly progressive contracture of the palmar fascia.
dawn phenomenon
Early morning glucose elevation produced by the release of growth hormone, with no hypoglycemia during the night
effects of COX 1
GI protection - lower gastric acid secretion -increased mucus production -maintenance of GI mucosal perfusion Renal protection -maintenance of renal perfusion and function Relaxes muscle tone - vasodilation -bronchodilation regulates platelet aggregation
types of incretin hormones
GLP-1 and GIP
manifestations of type 1 diabetes
Hyperglycemia Polydipsia Polyuria Polyphagia Weight loss Fatigue
signs of sepsis
Hypothermia or hyperthermia Abdominal distention Anorexia Respiratory distress Vomiting Cool extremities Mottling Lethargy
insulin deficiency causes
Inability of cell to use glucose for energy Glycogenolysis: conversion of glycogen to glucose The breakdown of proteins and fats • AA and FA can be used for cellular energy Polydipsia, polyphagia, polyuria, blurry vision, weight loss, fatigue, poor wound healing...
bursitis and tendonitis
Inflammation of bursae or tendon sheath
long acting insulins
Insulin detemir (Levemir) Insulin glargine (Lantus)
C fibers
slow conduction, poorly localized pain, aching and burning, mechanical and thermal and chemical stimuli
Moderate hypoglycemia symptoms
LOC and mental status symptoms
Which medication would be administered to prevent symptoms of withdrawal in a laboring client who routinely uses heroin? Butorphanol Pentazocine Nalbuphine Methadone
Methadone
What insulin can be mixed with regular or rapid insulin?
NPH
intermediate acting insulins
NPH (Humulin N, Novolin N)
the nurse educator is providing information about different insulin types. Which type of insulin can be safely mixed with regular human insulin in the same syringe? insulin glargine insulin detemir insulin lispro mix 75/25 isophane insulin NPH
NPH (NPH safe with regular insulin)
opioid nursing considerations
Opioid tolerant vs. Opioid naïve Tolerant - at least 60 mg of morphine or equianalgesic dose of opioid for a week or more Naïve - Not had opioid dosages of above for a week or longer Pain assessment Sedation assessment Respiratory assessment Orders Treatment goals
short acting insulins
Regular (Humulin R, Novolin R)
a client with diabetic neuropathy reports a burning, electrical-type in the lower extremities that is not responding to NSAIDs. You anticipate that the provider will order which adjuvant medication for this type of pain? pregabalin ibuprofen lidocaine morphine sulfate
Pregabalin (neuropathic pain)
regulating factors of bone formation
Stress and weight bearing Vitamin D Parathyroid hormone and calcitonin Blood supply
CT scan
a series of x-ray photographs taken from different angles and combined by computer into a composite representation of a slice through the body
five signs of inflammation
redness, swelling, heat, pain, loss of function
Severe hypoglycemia symptoms
seizures/convulsions coma/unconscious death
considerations with thiazolidinediones
heart failure pts, education about heart failure worsening, caution with hepatic disease pts
incretins
hormones that increase insulin secretion
corn
hyperkeratosis of epidermis
Somogyi effect
hypoglycemia followed by rebound hyperglycemia
adverse effects of insulins
hypoglycemia, weight gain, hypokalemia, lipodystrophy at injection site, allergic reaction, drug interactions (thiazide diuretics/glucocorticoids may increase insulin needed OR beta blockers mask hypogylcemia)
impingement syndrome
impaired movement of the rotator cuff of the shoulder
causes of diabetes type 2
impairments in glucose metabolism, insulin secretion, or utilization (sensitivity)
osteocytes
mature bone cells
which assessment data would the nurse examine when planning the care for a client with Paget disease and taking zoledronic acid? SATA serum calcium serum creatinine liver function tests dental examination serum alkaline phosphatase
serum creatinine dental examination serum alkaline phosphatase
nursing considerations for metformin
severe kidney disease, GI distress (take with food), lactic acidosis, dehydration and heart failure, studies with contrast
symptoms of hypoglycemia
shaking, tachycardia, sweating, anxious, dizzy, hunger, blurred vision, weakness, fatigue, headaches, irritable
which action puts a client at risk for low back injury and pain? smoking tobacco regular swimming exercise vitamin D oral supplementation use of footstool with prolonged sitting
smoking tobacco
which MOA explains how glyburide decreases serum glucose levels? stimulates the pancreas to produce insulin accelerates the liver's release of stored glycogen increases glucose transport across the cell membrane decreases absorption of glucose from the gastrointestinal system
stimulates the pancreas to produce insulin
diabetes drugs at risk of hypoglycemia
sulfonylureas, DPP-4 inhibitors, SGLT-2 inhibitors, meglitinides
aspirin low dose effects (75-325 mg/day)
suppress platelet aggregation for ischemic stroke, TIA, angina, MI
arthocentesis
surgical puncture to remove fluid from the joint space
mild hypoglycemia symptoms
tachycardia, sweating, nervousness, shakes
Education points for ibuprofen
tarry stools (b/c bleeding) and stopping before surgery
carpel tunnel syndrome
the entrapment of the medium nerve in the carpel tunnel, swelling of the nerves and tendons will occur in the wrist
biopsy
the removal of living tissue from the body for diagnostic examination
callus
thickened area of skin that arises due to constant abrasion
exocrine secretes
through a duct
nociceptive pain process
transduction, transmission, perception, modulation
nociceptive transmission
transmission along a-delta or C fibers to dorsal root ganglia up the spinal cord to the brain
Drugs for neuropathic pain
tricyclics, antidepressants, anticonvulsants, local anesthetics (Tramadol, gabapentin, pregabalin)
creatinine normal value
0.7-1.3 mg/dL
ideal BG range in hospital
140-180
oral glucose tolerance test prediabetes
140-199 mg/dL
rapid insulin onset
15 minutes
signs of serotonin syndrome
agitation, pressured speech, mydriasis, tachycardia, hypertension, increased bowel sounds, shivering, sweating, diarrhea
delta receptors
analgesia
mu receptors
analgesia, respiratory depression, euphoria, miosis, reduced GI motility
kappa receptors
analgesia, sedation, respiratory depression, dysphoria, miosis
what lab tests to evaluate metabolic states (acid/base)?
arterial blood gas (ABG) and venous blood gas (VBG)
What is ringing in the ears a sign of when taking aspirin?
aspirin toxicity
a client who recently had surgery on her shoulder is reporting severe pain 40 minutes after the nurse administered hydromorphone IVP. Which interventions should the nurse implement first? - administer another hydromorphone - decrease stimulation and provide nonpharmacologic comfort - assess affected arm for alignment - call provider
assess patient's affected arm for alignment
diabetes medication classes
biguanides (metformin), GLP-1 receptor agonists, sulfonylureas, thiazolidinediones, DPP4 inhibitors, SGLT2 inhibitors, insulin
glutamate
bind to NMDA receptor, promotes pain transmission, secreted by A-delta fibers
what happens when glucose builds up in your blood
binds the hemoglobin in your red blood cells
Fat embolism syndrome
blocking of small blood vessels by fat globules subsequent to a fracture, especially one of long bones or pelvis I (when emboli are deposited in lungs): anxiety, agitation, acute confusion, fever >103, chest pain, dyspnea, tacky, tachypnea, thick white sputum, petechiae (on chest, neck, shoulder, axillae, flank, abdomen), sudden onset, 24-72 hrs after fracture NI: High Fowler's position, oxygen in high concentrations, possibly with positive/expiratory pressure, corticosteroids, vasoactive meds to prevent hypotension and shock, fluid replacement guided by accurate I & O
Which physiological changes would the nurse expect to find in a client with a 20-year history of type 2 diabetes? blurry, spotty, or hazy vision arthritic changes in the hands hyperactive knee and ankle jerk reflexes dependent pallor of the feet and lower legs
blurry, spotty, or hazy vision (diabetic retinopathy)
chemical mediators of inflammation
bradykinin, histamine, prostaglandins
nociceptive perception
brain perceives pain
why don't we want to rapidly decrease BG glucose?
can cause cerebral edema and rapid shifts in potassium (dysrhythmias)
black box warning for ketamin
can produce emergence delirium, hallucinations, unpleasant dreams
black box warning for celecoxib
cardiac and vascular risks (MI and CVA)
is NPH clear or cloudy?
cloudy
parts of the comprehensive metabolic panel
same aspects of BMP and: albumin, total protein, alkaline phosphates, alanine transaminase, aspartate aminotransferase, bilibrubin
substance P
secreted at C fibers, blocked by opioids
referred pain
pain that is felt in a location other than where the pain originates
what do incretins stimulate?
pancreatic beta cells to secrete insulin in response to rising blood glucose
black box warning for butorphanol
potentially fatal respiratory depression, coma, death, drug dependence and abuse potential
Reye's syndrome
potentially serious or deadly disorder in children that is characterized by vomiting and confusion
osteogenesis
process of bone formation
radiographs
records of ionizing radiation used to visualize internal body structures (x-rays)
aspirin high doses effects (2-8g/day)
reducing inflammation - for RA and OA
acidosis
retention of too much acid (CO2) or loss of too much base (bicarb)
alkalosis
retention of too much base or loss of too much acid
black box warning for aspirin
reye's sydrome
black box warning for Ketorolac
risk for GI irritation, inflammation, ulceration, bleeding, and perforation
ganglion
collection of neurologic gelatinous material near the tendon sheaths and joints that causes inflammation
hallux vagas (bunion)
deformity where great toes deviates laterally with prominence of the medial aspect of the first metatarsaopharengeal joint
special consideration for Zoledronic acid administration
dental examination b/c of jaw or maxillary osteonecrosis
nociceptive modulation
descending pathways to decrease pain transmission (endorphins, serotonin, NE)
lifestyle recommendations for diabetes
diet, exercise, weight loss, health maintenance, self-monitoring of blood glucose
nursing consideration for baclofen
don't stop taking medications abruptly, avoid CNS depressants, don't take if pregnant or breastfeeding
consideration/education with medication patches
don't use heating pad directly over the patch; increasing dosage and increase absorption
chronic complications of diabetes
increased glucagon secretion, impaired insulin secretion, decreased incretin effect, increased lipolysis, increased glucose reabsorption, decreased glucose uptake, neurotransmitter dysfunction, increased hepatic glucose production, microvascular disease (retinopathy and neuropathy), macrovascular disease (CAD, stroke, peripheral artery disease, dementia), infection
black box warning for ibuprofen
increased risk of CV events and GI bleeding (vasoconstriction, reversibly to platelets, ulceration)
effects of COX 2
inflammation -vasodilation -increased cap permeability -edema -pain leukocytosis activation of WBC releasing inflamm cytokines
prostaglandins
inflammatory response, COX enzymes metabolize arachidonic acid and produce prostaglandins
endorphins
inhibit pain signal transmission and induce euphoria
enkephalins
inhibits substance P release and modulate pain perception
compartment syndrome
involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles
kidney response if blood pH is too low
kidneys hold onto more bicarb and return it to the blood to normalize pH
considerations for IV drugs
kinks in the admin line, slow vs. push medications, IV injection site for infections or problems
manifestations of HHS
lack of insulin, hyperglycemia, dehydration, slow onset, normal bicarbonate, normal pH, absent ketones, polyuria, polydipsia, polyphagia, loss of water and electrolytes
which adverse effect of metformin will a nurse teach a client with type 2 diabetes to monitor for when used as monotherapy? weight gain constipation lactic acidosis hypoglycemia
lactic acidosis
Benefits of PCA pump
more frequent smaller doses, decreases risk of OD
intensive dosing insulin schedule
multiple daily injections (MDI); meal correctional dose based on BG level
NPO diabetes patients
need to administer some sort of glucose/dextrose so there is something for the insulin to attach to; probably decreased insulin dosage
Perimeters for taking ibuprofen and aspirin together
need to take aspirin 2 hours before ibuprofen b/c ibuprofen can reduce the antiplatelet effects of aspirin by blocking access of aspirin to COX-1 in platelets
special consideration for meperidine
neurotoxic metabolite (normeperidine that accumulates, renal failure pts caution) - metabolite causes CNS stimulation
black box warning for morphine sulfate
no combination with other CNS depressants; respiratory depression, coma, death, drug abuse, and dependence
peak of long acting insulin
no real peak but small peak at 10-16 hours
nociceptive transduction
noxious stimuli nociceptor and inflammatory response start of action potential
bone scan
uptake of a radioactive substance is measured in bone
bradykinin
vasodilation, increased vascular permeability, attract neutrophils, associated with pain response
arthoscopy
visual examination of a joint
Opioid withdrawal symptoms
chronic use, anxiety, restlessness, insomnia, perspiration, pupil dilation, piloerection, anorexia, n/v/d, increased body temp and RR and BP, muscle cramps, dehydration
opioid toxicity symptoms
coma, pinpoint pupils, respiratory depression
signs of ketoacidosis
confusion, excessive thirst, acetone breath, frequent urination, n/v, abdominal pain, weakness or fatigue, and SOB
manifestations of DKA
lack of insulin, hyperglycemia, ketosis, acidosis, dehydration, electrolyte loss, rapid onset, polyuria, polydipsia, polyphagia, anorexia, n/v/abdominal pain, acetone breath, Kussmaul respirations, hypotension, hyperkalemia, decrease in pH, decrease in bicarbonate, fatigue and headache
which foods would the nurse teach the client who has gout to avoid? SATA eggs liver cheese salmon shellfish
liver and shellfish