NURS 334 EXAM 3

1. A client is scheduled for a preprandial blood sugar check. The blood sugar is 224 mg/dl. According to the sliding scale insulin schedule, the client is to receive 4 units of Regular insulin for a blood sugar from 201-250 mg/dl. You, the nurse prepare the insulin as ordered. Upon taking the insulin into the client's room, the client is vomiting and refuses to eat lunch. What would be an appropriate nursing action? a. Give the 4 units of Regular insulin and recheck the blood sugar in 30 minutes b. Give only 2 units of the Regular insulin because the client is vomiting c. Hold the 4 units of Regular insulin and notify the physician of client vomiting d. Hold the 4 units of Regular insulin and wait until the client is able to eat and drink and then give the insulin

C.

1. A client is scheduled for surgery the following morning and calls you, the nurse, who works for the client's primary care physician. The client wonders if he should take his scheduled insulin dosage before surgery the next morning. Your response is: a. "Yes, you may take your scheduled dose of insulin before surgery and we will check your blood sugar when you arrive at the ambulatory care center." b. "No, do not take any insulin before surgery because you will not eat or drink anything after midnight to prepare you for surgery." c. "I will check with your physician about if or how much insulin he/she would like you to take before surgery." d. "Check your blood sugar tomorrow morning before surgery and if it is >120mg/dl, take one half of the prescribed dose of your insulin."

C.

Exogenous Insulin

Exogenous insulin: insulin from an outside source- not created by body= endogenous is created by body -Required for type 1 diabetes -Prescribed for patients with type 2 diabetes who cannot manage blood glucose levels by other means

All patients with type 1 DM require..

Insulin

Respiratory Alkalosis

Hyperventilation Acute pain Acute anxiety or emotional distress

Storage of Insulin

Do not heat/freeze In-use vials may be left at room temperature up to 4 weeks Extra insulin should be refrigerated Avoid exposure to direct sunlight, extreme heat or cold Store prefilled syringes upright for 1 week if 2 insulin types; 30 days for one

Ambulatory and Home Care

Most important aspect is teaching. · Pulmonary rehabilitation · Activity considerations · Sexual activity · Sleep · Psychosocial considerations Activity considerations · Modify ADLs to - conserve energy · Walk - 15-20 min a day at least 3 times a week with gradual increases o Adequate rest should be allowed · Exercise related SOB should improve in 5 minutes after exercise Sexual activity- plan that when breathing is best, not SOB, use pursed lip breathing, Sleep- sleep sitting up on recliner Psychosocial considerations Nursing ManagementNursing Implementation

Nursing Care: resp acidosis

Nursing care: Resp Acidosis and the patient with a barbiturate/sedative overdose Prevention: · Related To titration of - drug · Assess - RR/BP/P premedication administration · Correct dose - mg/kg o Liver Function Tests o Kidney Function Tests · Early recognition/Early interventions: · Ambulation · VS · Deep Breathing (DB), IS · Medication education

Nursing Management HTN

Nursing evaluation Patient will: · Achieve and maintain goal BP · Understand, accept, and implement the therapeutic plan · Experience minimal or no unpleasant side effects of therapy

Nursing Planning HTN

Patient will · Achieve and maintain the goal BP · Understand and follow the therapeutic plan · Experience minimal or no unpleasant side effects of therapy · Be confident of ability to manage and cope with this condition

Angiopathy

-Damage to blood vessels secondary to chronic hyperglycemia -Leading cause of diabetes-related death -Macrovascular and microvascular -Tight glucose levels can prevent or minimize complications

DM leading cause of and major contributing factor

-Leading cause of -Adult blindness -End stage renal disease -Non traumatic lower limb amputations -Major contributing factor -Heart disease -Stroke

Travel Needs

-Medication, supplies, food, activity -Medical Alert- -Being sedentary for hours can raise glucose levels- encourage to get up and walk around for a while to prevent DVT, and increase BG

4. The nurse is monitoring for complications when caring for the client with a pulmonary embolism. Which ABG findings should indicate to the nurse that the client has respiratory alkalosis? 1. pH 7.54 PaCO2 25 mm Hg HCO3 24 mEq/L 2. pH 7.35 PaCO2 35 mm Hg HCO3 22 mEq/L 3. pH 7.50 PaCO2 40 mm Hg HCO3 28 mEq/L 4. pH 7.32 PaCO2 48 mm Hg HCO3 24 mEq/L

1. In respiratory alkalosis the pH is greater than normal, PaCO2 is less than 35 mm Hg. HCO3 is normal. Because a PE interferes with gas exchange, the respiratory center is stimulated to meet oxygenation demands. The tachypnea produces respiratory alkalsosis.

The nurse plans a class for patients who have newly diagnosed type 2 diabetes mellitus. Which goal is most appropriate? 1. make all patients responsible for the management of their disease. 2. involve the family and significant others in the care of these patients 3. enable the patients to become active participants in the management of their disease. 4. provide the patients with as much information as soon as possible to prevent complications.

3.

7. Your patient is hospitalized with a history of chronic emesis from purging. Based on the patient's history, you would monitor for which complication? 1. Hyperkalemia 2. Hyperchloremia 3. Metabolic alkalosis 4. Metabolic acidosis

3. You should monitor for metabolic alkalosis which occurs when there is a loss of acid such as with prolonged vomiting. Hypokalemia, not hyperkalemia is caused by diarrhea and vomiting

pH of body fluids

Acidic body fluids Gastric juices - 1.0-3.0 Urine - 5.0-6.0 Arterial blood - 7.38-7.42 Venous blood - 7.37 Cerebrospinal fluid - 7.32 Basic or alkaline body fluids Pancreatic fluid - 7.8-8.0

Resp alkalosis: Lab findings

Acute (short term) · ↓ PaCO2 · ↓ Pa02 or normal · HC03- normal · pH normal - slightly high Rationale: ↓ CO2 excretion from hyperventilation · compensatory response is HCO3 excretion from kidneys · HCO3 INC in ABGs Compensatory response is HCO3- excretion from kidney

Respiratory Acidosis..

Alveolar Hypoventilation · COPD · Asthma Attack · Pneumonia esp bacterial · Pulmonary edema Ineffective respiratory pump · Guillain- Barre Syndrome o the body's immune system attacks peripheral nervous system happens in health individuals with no comorbidities, first symptom is generalized weakness. Starts in lower extremities and paralyzes them in legs feet ankles, starts slow and moves up, gets worse before it gets better, major treatment is cortical steroids Central suppression of respiration · Opioid overdose

What will Alan's ABGs look like? What is the treatment?

Answers: 1. A diabetic ketoacidosis is a metabolic acidosis indicated by a pH <7.35 and a HCO3− <20 mEq/L. The PCO2 will be within the normal range if the acidosis is uncompensated but will be <35 mm Hg if compensation has occurred. The PaO2 will not be affected. 2. Administration of insulin to promote normal glucose metabolism and administration of fluids and electrolytes to replace those lost because of the hyperglycemia.

u Alan is a 17-year-old male who comes to the clinic saying he feels "bad," with fatigue, constant thirst, and frequent urination. u Focused assessment reveals rapid deep respirations (rate 28) with a fruity breath odor. u A capillary blood glucose is 484 mg/dL. 1. What type of acid-base imbalance would you expect Alan to have? 2. What is causing it? 3. What type of compensation would you expect or not expect? Explain.

Answers: 1. Metabolic acidosis 2. Breakdown of fats for energy secondary to lack of insulin and subsequent inability to utilize glucose for energy. Ketones are an acid byproduct of fat breakdown. 3. The deep, rapid respiratory rate (Kussmaul respirations) demonstrate respiratory compensation—may be partial or full, depending on longevity of the hyperglycemia.

u Anthony is a 54-year-old male with a history of nausea and vomiting for the past week. u He has been self-medicating himself with baking soda to control his abdominal discomfort. 1. What type of acid-base imbalance would you expect Anthony to have? 2. What is causing it? 3. What type of compensation would you expect or not expect? Explain

Answers: 1. Metabolic alkalosis 2. Loss of gastric acid and excess bicarbonate with baking soda ingestion 3. There is limited compensation for metabolic alkalosis. The kidneys can respond by increasing excretion of bicarbonate. The respiratory system can respond by decreasing respirations, but once the carbon dioxide level increases, stimulation of chemoreceptors results in increased ventilation.

Case Study u Mayna is an 18-year-old female who presents to the ED after a sexual assault. She is hysterical and in severe emotional distress. u Her BP is 140/96, heart rate 104, respiratory rate 38, and oxygen saturation 96%. Lung sounds are clear. 1. What type of acid-base imbalance would you expect Mayna to have? 2. What is causing it? 3. What type of compensation would you expect or not expect? Explain.

Answers: 1. Respiratory alkalosis 2. Hyperventilation secondary to anxiety and hysteria 3. None at this point—compensation would not be occurring yet in this acute event. However, buffering of acute respiratory alkalosis may occur with shifting of bicarbonate (HCO3-) into cells in exchange for Cl−. It would take several days for renal compensation to occur.

Pharmacotherapy: Impaired Tissue (Local) Perfusion

Anticoagulants, thrombolytics, lipid lowering agents, anti platelets agents and platelet inhibitors

Alterations with clinical manifestations

Arterial blood gases (ABGs) pH = 7.35-7.45 PaCO2 = 34-45mm Hg Bicarbonate = HCO3 22-26 mEq/L Pa02 = 80-100 mmHg Sa02 > 95% Base excess +/- 2.0 mEq/L

Vitrectomy

Aspiration of blood, membrane, and fibers inside the eye with small incision behind the cornea

1. A client is having their blood sugar checked in the clinic where you work. The client states their fasting blood sugar is 118 mg/dl. The client wants to know why the physician instructed them to watch their diet and exercise to prevent diabetes. Your explanation to the client is based on the knowledge that prediabetes: a. will always lead to a diagnosis of diabetes. b. can be prevented or delayed with proper diet and exercise. c. have fasting blood sugar levels between 130 and 150 d. have less incidence of developing complications of diabetes

B.

1. A nurse administers 15 units of glargine (Lantus) insulin at 2100 hours to a Hispanic client when the client's fingerstick blood glucose reading was 110mg/dL. At 2300 hours, a nursing assistant reports to the nurse that an evening snack was not given because the client was sleeping. Which instruction by the nurse is most appropriate? a. "You will need to wake he client to check he blood glucose and then give a snack. All diabetics get a snack at bedtime." b. "It is not necessary for this client to have a snack because glargine is absorbed very slowly over 24 hours and doesn't have a peak." c. "The next time the client wakes up, check a blood glucose level and then give a snack." d. "I will need to notify the physician because a snack at this time will affect the client's blood glucose level and he next dose of glargine insulin."

B.

1. A nurse is teaching a client who has been newly diagnosed with type 2 diabetes mellitus (DM). Which teaching point should the nurse emphasize? a. Use the arm when self-administering NPH insulin b. Exercise for 30 minutes daily, preferably after a meal c. Consume 30% of the daily calorie intake from protein foods d. Eat a 30-gram carbohydrate snack prior to strenuous activity

B.

HHS- Hyperosmolar Hyperglycemic Syndrome

Blood Sugar > 400 · Life threatening syndrome · Older patient · Patient has enough circulating insulin so ketoacidosis does not occur · Therapy similar to DKA Nursing Management DKA/HHS · Monitor · Same treatment as DKA · Renal status · Cardiopulmonary status · LOC

Body's compensation/treatment of metabolic alkalosis

Body's compensation: · Decreased RR to retain CO2 · Kidneys conserve H+ and eliminate HCO3- in alkaline urine: · Complicated by loss of Na+, K+, Cl- · Arterial blood: o Increased pH o Increased HCO3- Treatment required to restore metabolic balance · Correction of underlying disorder · Chloride containing solution: HCO3- ions replaced by Cl- ions

Metabolic Acidosis..

Body's compensation: · INC RR to blow off CO2 o Kussmaul's breathing o Deep and rapid RR · Kidneys conserve HCO3- (bicarb) and eliminate H+ ions in acidic urine (urine pH <5.0) Therapy required to restore metabolic balance · Correct underlying disorder o Diarrhea: replace fluids and lytes o Ketoacidosis: decrease blood glucose with insulin · Lactate solution to convert bicarb ions in the liver

Diagnosis of resp acidosis

ABGs, chest x ray- to rule out, pulmonary function test, history assessment, vitals, pulse ox, looking at assessment info, skin- color, temp, etc.

Combination Insulin Therapy

Can mix short- or rapid-acting insulin with intermediate-acting insulin in same syringe Provides mealtime and basal coverage in one injection Commercially premixed or self-mix Mixing Insulins

Respiratory Acidosis info

Carbonic acid excess caused by · Hypoventilation · Respiratory failure Compensation · Kidneys conserve HCO3- and secrete H+ into urine Respiratory acidosis (carbonic acid excess) occurs whenever there is hypoventilation. -Hypoventilation results in a buildup of carbon dioxide, resulting in an accumulation of carbonic acid in the blood. Carbonic acid dissociates, liberating hydrogen ions, and there is a decrease in pH. -If carbon dioxide is not eliminated from the blood, acidosis results from the accumulation of carbonic acid. -To compensate, the kidneys conserve bicarbonate and secrete increased concentrations of hydrogen ion into the urine. -During acute respiratory acidosis, the renal compensatory mechanisms begin to operate within 24 hours. Until the renal mechanisms have an effect, the serum bicarbonate level will usually be normal.

Insulin is Categorized by

Categorized according to onset, peak action, and duration Rapid-acting- Humalog, Novolog Short-acting- Humulin, Novolin Intermediate-acting- NPH Long acting- glargine, detemir Can't mix long acting and rapid in a syringe together, want long acting to absorb itself Sliding scale insulin is dosing inulin based off BG, NPH or long acting are not scheduled dose and will be given as instructed, those are for more long term

Metabolic Alkalosis.......

Cause: Causes of Metabolic Alkalosis · Severe vomiting · Hyperaldosteronism · Diuretic abuse * · K+ loss

Categories of Perfusion

Central Perfusion · Force of blood movement generated by cardiac output · Requires adequate cardiac function, blood pressure, and blood volume · Cardiac output (CO) = Stroke volume X Heart rate Tissue or Local Perfusion · Volume of blood that flows to target tissue · Requires patent vessels, adequate hydrostatic pressure, and capillary permeability

Type 1 DM Clinical Manifestations

Classic symptoms: 3 Ps -Polyuria (frequent urination) -Polydipsia (excessive thirst) -Polyphagia (excessive hunger) -Weight loss -Weakness -Fatigue

Clinical Manifestations of HTN

Clinical Manifestations "Silent killer"à often times no symptoms of HTN, what constitutes for lifestyle treatment and meds- look at that Symptoms of severe hypertension · fatigues · dizziness · palpitations · angina · dyspnea

Clinical Manifestations of COPD

Clinical Manifestations Develops slowly Diagnosis is considered when there is: · Cough · Sputum production · dyspnea · exposure to risk factors · chest heaviness Dyspnea usually prompts medical attention. · Occurs with exertion in early stages · Present at rest with advanced disease Causes chest breathing · · Inefficient breathing May experience chest tightness with activity -check to see if using accessory muscles, intercostal muscles, doing any retracting, how effective is their breathing, Characteristically underweight with adequate caloric intake- skin is thin/figure is thin but has a big round chest Chronic fatigue

S/s of metabolic alkalosis

Clinical manifestations of Metabolic alkalosis Neurologic · Dizziness · Confusion · Headache Respiratory · Hypoventilation Cardiovascular · Tachycardia · Dysrhythmias RT hypo K+ GI · Nausea, vomiting, anorexia Neuromuscular · Tetany · Tremors · Tingling of fingers, toes · Muscle cramps · Seizures

S/S of resp alkalosis

Clinical manifestations of resp alkalosis Neurologic · Dizziness · Confusion · Headache · Circumoral Respiratory · Rapid, shallow Cardiovascular · Tachycardia · Dysrhythmias RT hypokalemia from compensation Neuromuscular · Tetany · Numbness · Tingling of extremities Hyperreflexia · Respiratory · Hyperventilation GI · Nausea, vomiting, abdominal pain

s/s of resp acidosis

Clinical manifestations: Related to CNS depression · ↓RR or shallow respirations · Nasal flaring · Accessory muscles · Sp02 < 80% · Dizziness · tachycardia · Vomiting: (consider aspiration) Symptoms are related to: · Dose · CNS depressants · Decreased CO2 reactivity in brainstem · Arterial CO2 levels as they increase

Pathophysiology of COPD

Common characteristics · Mucus hypersecretion · Dysfunction of cilia · Hyperinflation of lungs · Gas exchange abnormalities

Infection

Defect in mobilization of inflammatory cells and impaired phagocytosis Recurring or persistent infections- specifically recurrent yeast infection, loss of sensation due to neuropathy can Treat promptly and vigorously Patient teaching for prevention Hand hygiene Flu and pneumonia vaccine

Chronic Obstructive Pulmonary Disease (COPD)

Description= restriction of airflow in body Airflow limitation not fully reversible · Generally progressive · Abnormal inflammatory response of lungs to noxious particles or gases Includes · Chronic bronchitis · Emphysema Etiology Risk factors · Cigarette smoking- 4x higher prevalence, secondhand smoke, nicotine stimulates CNS · Occupational chemicals and dust · Air pollution · Infection · Heredity- genetics more common in men than in women, when women have COPD its more lethal · Aging · HIV · Tb Cultural and Ethnic Health Disparities- like access to care, etc. Good pictures/concept map in med surge book

Other Key Terms

Discuss the meaning of the listed key terms and their link to the concept definition. Ischemia- inadequate blood supply to organ or part of body especially heart muscle Infarction- tissue death caused by lack of o2 due to obstruction of tissues or blood supply Anoxia- absence of oxygen

Collaborative Care of HTN1

Drug Therapy and Patient Teaching Follow-up care: · Identify, report, and minimize side effects o Orthostatic hypotension o Sexual dysfunction o Dry mouth o Frequent urination § see table Lewis - time of day to take drug- provider will tell you the name, route, dose- won't tell time of day, with food or empty stomach, IV or if not safe to give with iv push,

Drugs for Retinopathy

Drugs to block action of vascular endothelial growth factor (VEGF)

Manifestations

Due to underlying condition causing acid base imbalance - If imbalance is from hyperventilating, or d/v/ loss of gastric contents, COPD, DKA, - Underlying condition and associated F & E imbalances - Hx focuses on respiratory, renal, and other conditions....Past Medical History (PMH) o Ask about recent history of vomiting or diarrhea, use of medications, alcohol intake o Any medications o Surgery/treatments o Chief complaint

Nutritional Therapy: Type 2 DM

Emphasis on achieving glucose, lipid, and BP goals Weight loss= give realistic goals -Nutritionally adequate meal plan with ↓ fat and CHO -Spacing meals throughout the day to get nutrition intake all day and make sure they're getting food throughout the day -Regular exercise= don't want to do extreme increase but do slow progression

Sexual Function- Autonomic Neuropathy

Erectile dysfunction- first signs of autonomic neuropathy in males, consider therapeutic counsling -Decreased libido -Vaginal infections

Evaluation

Expected Outcomes · Normal breath sounds · Effective coughing · Return of PaO2 to normal range · Improved mental status · Maintain weight · Normal protein levels · Feeling rested · When to seek help

Nursing Implementation Health promotion and ambulatory and home care HTN

Health promotion · Primary prevention via lifestyle modification · Individual patient evaluation and education · Screening programs · Cardiovascular risk factor modification Ambulatory and home care · Evaluate therapeutic effectiveness · Detect and report adverse effects · Assess and enhance compliance · Patient and caregiver teaching

Diagnostic Studies: Hemoglobin A1C levels

Hemoglobin A1C level: 6.5% or higher* -A1C=Glycosylated hemoglobin: reflects glucose levels over past 2 to 3 *months -Used to diagnose, monitor response to therapy, and screen patients with prediabetes -Goal: < 6.5% to 7%

Frequent Oral Care

High susceptibility of periodontal disease, need to make sure encourage daily brushing, flossing and visits dentist

Diagnostic Studies: Fasting Plasma Glucose Level

Higher than 126 mg/dL

Diagnostic Studies

History and physical exam Diagnosis confirmed by spirometry · Reduced FEV1/FVC ratio- forced expiratory volume or forced vital capacity- CO2 retention- cant force it back out of lungs · Increased residual volume Chest x-ray Right-sided Cardiac Catheterization- show right side of heart enlargement ECG Echocardiogram BNP Levels Sputum Culture and sensitivity COPD Assessment Test (CAT)= scale to rank pt. on SOB or ease of breathing Modified Medical Research Council (MMRC) Dyspnea Scale 6-minute walk test to determine O2 desaturation in the blood with exercise- put on treadmill no increase speed or incline, can they walk at comfortable pace for 6 min and unstressed without desating, BODE index ABG typical findings in later stages · Low PAO2 · Increased PaCO2 · Decreased pH · Increase bicarbonate level found in late stages of COPD

Omnipad Insulin Management System

Hold and deliver insulin, avoids the tubing, delivered via pod, usually hesitant to stop using it, need doctor note to keep using it and would need to check the isnulin

Hypertensive Crisis- Nursing/Collaborative Management

Hospitalization · IV drug therapy - titrated to MAP (mean arterial pressure) · Monitor - cardiac and renal function · Neurologic checks · Determine cause · Educate to avoid future crisis

Hypertensive Crisis

Hypertensive emergency · Occurs over - hours to days · BP> 220/140 with target organ disease Hypertensive urgency · Occurs over - days to weeks · Bp >180/110 with no clinical evidence of target organ disease Rate of rise more important than absolute value

Hypertensive Crisis Clinical Manifestations

Hypertensive encephalopathy · HA, n/v, seizures, confusion, coma Renal insufficiency Cardiac decompensation · MI, HF, pulmonary edema Aortic dissection

Consequences of perfusion

Impairment of central perfusion occurs when cardiac output is inadequate. Reduced cardiac output results in a reduction of oxygenated blood reaching the body tissues (systemic effect). · If severe, associated with - shock · If untreated, leads to - ischemia, cell injury, and cell death Impairment of tissue perfusion is associated with loss of vessel patency or permeability, or inadequate central perfusion Results in impaired blood flow to the affected body tissue (localized effect) · Leads to - ischemia, and ultimately cell death if uncorrected

Strepped Care Therapy

Goal - to control BP with minimal side effects · Step One = lifestyle modifications · Step Two = step one + med · Step Three = step two + 2nd med · Step Four = step 3 + 3rd med

Inter-professional Care: Goal of DM

Goals of diabetes management -Decrease symptoms -Promote well-being -Prevent acute complications -Delay onset and progression of long-term complications -Need to maintain blood glucose levels as near to normal as possibleà to prevent long term effects*

BP Classification

Isolated systolic hypertension · SBP >140 mm Hg with DBP <90 mm Hg Hypertension Stage 1 · SBP 140-149 or DBP 90-99 Hypertension Stage 2 · SBP >160 or DBP >100

Labs of resp acidosis

Lab: ABGs: ↓ - normal pH ↓ Pa02 ↑ PaC02 < 24 hours HCO3- normal > 24 hours HCO3- ↑ Rationale: · CO2 retention from hypoventilation

Common Diagnostic Tests

Laboratory tests · Creatine kinase, lactic dehydrogenase, natriuretic peptides, troponin, homocysteine, C-reactive protein, serum lipids, platelets, prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR) Electrocardiogram (EKG) Cardiac stress tests · Exercise or pharmacologic test- heart is stressed by giving a med Radiographic studies Chest x-ray, ultrasound, arteriogram

More on DKA

Less severe form may be treated on outpatient basis Hospitalize for severe fluid and electrolyte imbalance, fever, nausea/vomiting, diarrhea, altered mental state Also if communication with health care provider is lacking Diabetic Ketoacidosis (DKA) Ensure patent airway; administer O2 Establish IV access; begin fluid resuscitation NaCl, 0.45% or 0.9% Add 5% to 10% dextrose when blood glucose level approaches 250 mg/dL Continuous regular insulin drip, 0.1 U/kg/hr. Potassium replacement as needed Insulin therapy Correct dehydration, electrolyte imbalance, make sure outputting enough urine, bolus, follow up with insulin drip

Surgical Therapy

Lung volume reduction surgery · Remove diseased lung to enhance performance of remaining tissue Bullectomy Lung transplantation Especially for emphysema

Acid Base Regulations

Lungs- kick in then kidenys Kidneys ROME acronym R- Respiratory O- Opposite When pH goes up PCO2 goes down= alkalosis When pH goes down PCO2 goes up= acidosis M- Metabolic E- Equal pH goes up HCO3 goes up= alkalosis pH goes down HCO3 goes down= acidosis

Acid Base Balance is

Maintain a steady balance between acids and bases to achieve homeostasis Health problems lead to imbalance · Diabetes · Chronic obstructive pulmonary disease (COPD) · Kidney disease · Acute pain- like post op, trauma pt. · Hyperventilation- from trauma, fear, pain, etc. · Overdose (drug,alcohol)- drug and or alcohol · Diuretic overuse- most pt. don't intentionally do this, many pt. self-medicate or self-diagnose, so they might take extra dose of diuretic

Intermediate-acting insulin

NPH Duration 12 to 18 hours Peak 4 to 12 hours Can mix with short- and rapid-acting insulins Cloudy; must agitate to mix

Nursing Care for patient with metabolic alkalosis

Nursing care for patient with metabolic alkalosis Treat the cause · Stop the diuretics · Decrease the gastric suctioning · education Supportive care · fluid replacement · electrolyte replacement

Interprofessional Care: Patient Teaching

Nutritional therapy Drug therapy Exercise Self-monitoring of blood glucose Diet, exercise, and weight loss may be sufficient for patients with type 2 diabetes

Respiratory Acidosis....

Occurrs: When lungs can't remove all the CO2 (retention of CO2 from hypoventilation) (review pathophys as needed) Signs & symptoms of respiratory acidosis: Related To: CO2 retention/hypercapnia- retaining CO2, pH goes down- when body takes hit that effects respiratory and levels of acid base the first thing that happens is the lungs kick in and the kidneys kick in, kidneys compensate by conserving bicaarb Breathlessness: · Increase RR, then Decrease RR as brain adapts to high CO2 levels · Skin: warm, flushed with increase CO2 levels Headache Blurred vision Restlessness Apprehension à Muscle twitching Tremors Convulsions, coma Confusion, easily fatigued, lethargy, SOB, sleepiness

Type 2 DM Clinical Manifestations

Nonspecific symptoms Classic symptoms of type 1 may manifest (3 Ps) Fatigue Recurrent infection Recurrent yeast infections Prolonged wound healings Visual changes

Range of pH

Normal is 7.35-7.45 On both ends of spectrum can be deadly if too acidotic or too alkalotic Lower than 6.8 death Higher than 7.8 death

Arterial Disease

Pain: Intermittent Claudication- progressing to pain at rest Pulses: diminished or absent Color: pale with elevation, dusky red when in dependent position Temp: cool Edema: absent or mild Ulcers: toes or point of trauma Other: gangrene may develop, thin shiny skin- loss of hair, thick nails

Venous Disease

Pain: None or- aching on dependency Pulses: normal, difficult to feel through the edema Color: normal or cyanotic on dependency. Brown pigmentation to lower extremeities Temp: normal Edema: present, marked Ulcers: sides of ankle Other: ulcers may develop, brown pigmentation around ankles, stasis dermatitis, thickening of skin

Perfusion

Perfusion refers to the flow of blood through arteries and capillaries, delivering nutrients and oxygen to cells and removing cellular waste products.

Definition of Hypertension

Persistent elevation of Systolic blood pressure ≥140 mm Hg OR Diastolic blood pressure ≥90 mm Hg OR Current use of antihypertensive drug(s)

Physical examination findings of COPD

Physical examination findings · Prolonged - expiratory phase- air trapping, prolonged because trying to get air out · Wheezes · Decreased - breath sounds · ↑ Anterior-posterior diameter - (barrel chest) · Tripod position- know if sitting up and leaning arms in tripod position will be easier for them to breathe, may get short of breath walking from recliner to bathroom and back, can sleep sitting up · Pursed lip breathing · Peripheral edema (ankles) · Hypoxemia · Hypercapnia Bluish-red color of skin -Polycythemia and cyanosis

Clinical Management

Primary Prevention · Smoking and nicotine cessation · Diet · Exercise · Weight control Clinical Management:Screening · Blood pressure screening, at what age should blood screening begin? How often should blood pressure screening occur? In adults 18+ bp is recommended every 2 years if within normal limits, in younger children is with well child visits or annually · Lipid screening, who should have lipid screening? How often? For male pt. without any risk factors recommendation is 35 years and women without risk factors is 45 years of age Clinical Management: Collaborative Interventions Treatment strategies depend on underlying condition The most common strategies include: · Diet modification and smoking cessation · Increased activity (conditioning) · Pharmacotherapy

Etiology of Hypertension

Primary hypertension · Also called essential or idiopathic hypertension · Elevated BP without an identified cause · 90% to 95% of all cases · Exact cause unknown but several contributing factors Secondary hypertension · Elevated BP with a specific cause · 5% to 10% of adult cases · Clinical findings relate to underlying cause · Treatment aimed at removing or treating cause

You are caring for JS who was admitted to the hospital with diabetic ketoacidosis (DKA). Julie has had a virus for 3 days prior to her hospitalization.Match the following: A. DKA B. HHS 1. More common in type 1 diabetics _____ _____ 2. Often caused by omission of insulin _____ _____ 3. Onset is usually over several days _____ 4. Acidotic with pH less than 7.30 ____ 5. Often caused by physiologic stress _____ 6. Absence of serum and urine ketones _____ 7. Kussmaul respirations _____ 8. Serum osmolality greater than 350 mOsm/L _____

Match the following: 1. More common in type 1 diabetics _A____ _____ 2. Often caused by omission of insulin __A___ _____ 3. Onset is usually over several days ___B__ 4. Acidotic with pH less than 7.30 ____A_ 5. Often caused by physiologic stress _____B 6. Absence of serum and urine ketones _____B 7. Kussmaul respirations _____A 8. Serum osmolality greater than 350 mOsm/L _____B

Nutritional Therapy Goals: Type 1 DM

Meal planning -Based on usual food intake and preferences -Balanced with insulin and exercise patterns= type 1 require insulin because not producing on their own Day-to-day consistency makes it easier to manage blood glucose levels More flexibility with rapid-acting insulin, multiple daily injections, and insulin pump When exercising it drops their BS don't want pt. to take insulin and then exercise, they need to have a snack with them at beginning, if diabetic for years will know their body well enough and will have a good plan.

Patient Teaching to prevent foot ulcers

Proper footwear- make sure no rubbing to cause injury on skin, etc. Avoidance of foot injury Skin and nail care Daily inspection of feet- the sooner they catch issues the quicker they can intervene Prompt treatment of small problems- can result in hospitalization Diligent wound care for foot ulcers- will go to outpatient wound care clinic to assess site and help treat it

What imbalance is this? pH 7.60 PaCO2 30 mm Hg PaO2 60 mm Hg HCO3− 22 mEq/L

Respiratory alkalosis pH is high. PaCO2 is low. HCO3− is normal. By using the ROME mnemonic, the respiratory component (PaCO2) is going in the opposite direction as the pH—thus the patient has respiratory alkalosis. Because the HCO3− is normal, there is no compensation.

Respiratory and physical therapy

Respiratory and physical therapy · Breathing retraining · Effective coughing · Airway clearance devices · Vest- vibration vest · Chest physiotherapy o Percussion o vibration o postural drainage Breathing retraining · Decreases dyspnea, improves oxygenation, and slows respiratory rate o Pursed lip breathing- prolongs the exhalation and prevents alvoli from collapsing, aids in decreasing air trapping Effective coughing · Main goals o Conserve energy o Reduce fatigue · Facilitate removal of secretions · Huff coughing · Chest physiotherapy Postural drainage- RT can help but in scope of nursing · Gravity assists in bronchial drainage. · Techniques are individualized according to patient's pulmonary condition and response to initial treatment. · Commonly ordered 2 to 4 times per day · Would do before meals or 2-3 hours after meals Flutter mucus clearance device · Provides positive expiratory pressure (PEP) treatment · Produces vibration in lungs to loosen mucus for expectoration · Handheld device · Aids in loosening secretions for the patient · Read in med surge as to what every device does

pH

Measure of H+ ion concentration · Increase H+ concentration= acidity · Decrease H+ concentration= alkalinity Blood is slightly alkaline at pH 7.35 to 7.45 · Less than 7.35 is acidosis · Greater than 7.45 is alkalosis

What imbalance is this? pH 7.18 PaCO2 38 mm Hg PaO2 70 mm Hg HCO3− 15 mEq/L

Metabolic acidosis pH is low. PaCO2 is normal. HCO3− is low. By using the ROME mnemonic, the metabolic component (HCO3− ) is going in the same direction as the pH—thus the patient has metabolic acidosis. Because the CO2 is normal, there is no compensation.

What imbalance is this? pH 7.58 PaCO2 35 mm Hg PaO2 75 mm Hg HCO3− 50 mEq/L

Metabolic alkalosis pH is high. PaCO2 is normal. HCO3− is high. By using the ROME mnemonic, the metabolic component (HCO2) is going in the same direction as the pH—thus the patient has metabolic alkalosis. Because the PaCO2 is normal, there is no compensation.

Metabolic Alkalosis lab findings

Metabolic alkalosis: Lab findings ↑ plasma pH PaCO2 normal ↑ PaCO2 ↑ HCO3- Rationale: Base HCO3- excess with renal excretion Loss of strong acid From Vomiting or excessive diarrhea Compensatory response is CO2 retention by lungs

Exercise

Start slowly after medical clearance Monitor blood glucose Glucose-lowering effect up to 48 hours after exercise- possible for hypoglycemia to happen long after the exercise Exercise 1 hour after a meal- if not possible want the pt. to have a 10-15 g carb snack before exercising Snack to prevent hypoglycemiaà carry fast acting glucose snack like hard candies Do not exercise if blood glucose level > 300 mg/dL and if ketones are present in urine Strenuous activity can be misinterpreted by the body as stress and have the counter regulatory hormone release and can cause increase in BS, moderate exercise is important to understand how far to push the body,

Nursing Assessment HTN

Subjective data · Past health history o Hypertension o Cardiovascular, cerebrovascular, renal, thyroid disease o Diabetes mellitus, pituitary disorders, obesity, dyslipidemia o Menopause or hormone replacement · Drugs · Subjective data o Family history o Salt and fat intake o Weight gain or loss o Nocturia o Fatigue, dyspnea on exertion, palpitations, pain o Dizziness, blurred vision o Erectile dysfunction o Stressful events · Objective data o Blood pressure readings o Heart sounds o Pulses o Edema o Body measurements o Mental status changes

Foot Complications

Microvascular and macrovascular diseases increases risk for injury and infection Sensory neuropathy and PAD are major risk factors for amputation Also clotting abnormalities, impaired immune function, autonomic neuropathy Smoking increases risk Patient teaching to prevent foot ulcers Neuropathic arthropathy (Charcot's foot)- results in ankle and foot changes that leads to joint disfunction and foot drop eventually

Diabetic Retinopathy

Microvascular damage to retina Most common cause of new cases of adult blindness Initially no changes in vision Annual eye examinations with dilation to monitor Maintain healthy blood glucose levels and manage hypertension Treatment -Laser photocoagulation, vitrectomy, drugs

Laser Photocoagulation

Most common Laser destroys ischemic areas of retina that produce the growth factors that encourage neovascularization, stopping areas that are affected in retina to preserve vision of pt.

Factors Influencing BP

Sympathetic nervous system (SNS) · Activation increases HR and cardiac contractility · Vasoconstriction and renin release · Increases CO and SVR Baroreceptors · Sensitive to stretching · Send impulses to sympathetic vasomotor center Vascular endothelium · Produces vasoactive substances to maintain low arterial tone Renal system · Control sodium excretion and ECF volume · RAAS system · Prostaglandins Endocrine system · Epinephrine and norepinephrine from adrenal medulla · Aldosterone from adrenal cortex · ADH from posterior pituitary

Clinical Manifestations of Resp Acidosis

Symptoms of AB imbalance: Symptoms related to: · Hypercapnia · Hypoxia · Tachypnea · Dyspnea VS changes T - increases P - increases RR - decrease BP - decrease 02 sat - decrease Mentation changes - depends on degree of hypoxia, like confusion, lethargy

Prehypertension Definition

Systolic BP: 120 to 139 mm Hg OR Diastolic BP: 80 to 89 mm Hg

Complications of HTN

Target organ diseases occur most frequently in the · Heart · Brain · Peripheral vascular disease · Kidney · Eyes

Interrelated Concepts

· Gas exchange · Pain · Clotting · Cognition · Mobility · Elimination · Inflammation · Patient education

Precipitating Factors- DKA

· Illness · Infection · Inadequate insulin dosage · Undiagnosed type 1 diabetes · Poor self-management · Neglect

Reasons for Noncompliance

· Inadequate teaching · Side effects · Return to normal BP · Lack of motivation · Financial · Lack of trust

Step Down Therapy

· Medications decreased slowly once a client has been controlled for one year and at least four office visits · Regular follow-up is essential

Patient and caregiver teaching includes

· Nutritional therapy · Drug therapy · Physical activity · Home BP monitoring (if appropriate) · Tobacco cessation (if applicable)

Calcium Channel Blockers

increase na excretion and cause vasodilation, ultimately lower bp, side effectS: bradycardia, naeausea, dizziness, HA, flushing, cautions with the use of these, contraindicated if pt. is already in heart block, if pt. eats grapefruit or grapefruit juice can decrease effectiveness of the drug · Norvasc · Cardiazem · Plendil · Procardia · Nifedipine · Verapomil

Inotropic

o Used to - to improve circulation o Dopamine o Norepinephrine

Prevention of resp acidosis

early intervention, not allowing it to happen, primary, secondary, tertiary prevention, smoking cessation, better teaching like if taking alcohol don't take with other meds, wt. loss,

Acid Base Regulation

Three mechanisms to regulate acid-base balance and keep pH between 7.35 and 7.45 · Buffer system-fastest acting, primary regulator of acid base, has chemical reaction, acts chemically to change strong acids to weak acids or binds acids to neutralize them, when body has depleted ability to buffer any longer than lungs and kidney step in · Respiratory system- can respond within couple of minutes, lungs help maintain normal pH by excreting CO2 and water, and compensate by fist hyperventilating and then hypo ventilating and decrease respiratory rate · Renal system- urine pH changes and reabsorbs more bicarb and when used up the kidneys will start to fail or pt. who have renal failure would not be able to correct acid base in body · Other buffers are phosphate, protein, hemoglobin, cellular shifts- not as strong

Nursing Care/Collaborative treatment

Treat the cause (pain, anxiety) Aggressive: · Re breather mask to rebreathe CO2 · Breathing into a small brown bag · Guided breathing to slow down RR and facilitate an o Increase O2 intake o Increase CO2 intake

Etiology and Pathophysiology of DM

*Combination of causative factors -Genetic, -Autoimmune -Environmental- viruses, obesity *Absent/insufficient insulin and/or poor utilization of insulin *Normal glucose and insulin metabolism -Produced by b-cells in islets of Langerhans -Released continuously into bloodstream in small increments with larger amounts released after food -Stabilizes glucose level in range of 70 to 110 mg/dL *Insulin: -promotes glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell -Cells break down glucose to make energy -Liver and muscle cells store excess glucose as glycogen -Skeletal muscle and adipose tissue are considered insulin-dependent tissues *Counter regulatory hormones -Glucagon, epinephrine, growth hormone, cortisol -Oppose effects of insulin -Stimulates glucose production and release by the liver -Decrease movement of glucose into cells -Help maintain normal blood glucose levels

Gestational Diabetes

- 5-10% -Develops during pregnancy -Increases risk of need for cesarean delivery and of perinatal complications -Screen high-risk patients first visit; others at 24 to 28 weeks of gestation -Usually glucose levels normal 6 weeks post-partum -32% chance to develop Type 2 DM after 16 years

Direct Vasodilators

- relax BV, side effects- tachy, angina, flushing, · Corlopam- fenoldopam · Apresoline · Nipride · Nitroglycerin · Hydralazine · Minoxidil

MEDS

- steroids, diuretics, supplements of K, Ca, Mg, Na o OTC - cathartics, enemas, laxatives, antacids (mg and HCO3) o Salt use o Diet pills o Herbs

Clinical Manifestations of DKA

-Dehydration -Poor skin turgor -Dry mucous membrane -Tachycardia—130+ or 160-170 -Orthostatic hypotension -Lethargy and weakness early -Skin dry and loose; eyes soft and sunken -Abdominal pain, anorexia, nausea/vomiting -Kussmaul respirations- rapid deep breaths associated with SOB, to reverse metabolic acidosis by exhaling off excess CO2 - Sweet, fruity breath odor -Blood glucose level of ≥ 250 mg/dL -Blood pH lower than 7.30 -Serum bicarbonate level < 16 mEq/L -Moderate to high ketone levels in urine or serum by the time they are hospitalized Less severe form may be treated on outpatient basis Hospitalize for severe fluid and electrolyte imbalance, fever, nausea/vomiting, diarrhea, altered mental state Also, communication with health care provider is lacking If secondary illness they need to be hospitalized to control both situation s

Diet Teaching

-Dietitian initially provides instruction -Carbohydrate countingà carbs are an important source of energy, fiber, vitamins, minerals, and need to be included in diet, misconception is that they should be avoid all together, carbs should be balanced and eat the ones that are nutritionally better -Serving size is 15 g of CHO -Typically, 45 to 60 g per meal -Insulin dose based on number of CHOs consumed -Patient teaching essential- show sample food labels to know how many carbs in each product, -Don't give insulin in the hospital until they are done eating because they might not have eaten the food that is high in carb and dose is based on the carbs they ate

Macrovascular Angiopathy

-Diseases of large and medium-sized blood vessels -Greater frequency and earlier onset in patients with diabetes -Cerebrovascular disease -Cardiovascular disease -Peripheral vascular disease -Decrease risk factors (yearly screening) -Obesity -Smoking- increases risk for stroke, lower extremity amputation, CVD -Hypertension -High fat intake -Sedentary lifestyle -Screen for and treat hyperlipidemia

Continuous Glucose Monitoring

-Displays glucose values with updating every 1 to 5 minutes -Helps identify trends and track patterns -Alerts to hypoglycemia or hyperglycemia -Some allow for forearm or palm- when pt. have a lot of callous but don't recommend to use them when BS are very low or readings are changing rapidly,

Symptoms of Hypoxia

-Early--> RAT is Late to BED Restlessness, anxiety, tachycardia/tachypnea Bradycardia, extreme restlessness Dyspnea (severe) -In pediatrics: FINES Feeding difficulty, inspiratory stridor, nares flare, expiratory grunting, sternal retractions

Self Monitoring of Blood Glucose

-Enables decisions regarding diet, exercise, and medication -Accurate record of glucose fluctuations—gives better picture of where they are at during different times of the day, when did they have lows and how can they helps so there isn't as much fluctuation -Helps identify hyperglycemia and hypoglycemia- symptoms are similar and may struggle to know how to treat it until they can identify how it affects them -Helps maintain glycemic goals A must for insulin users-> have to know an accurate number in order to dose correctly -Frequency of testing varies- some test 8x a day or once a day or morning and night, as pt. knows their body better, they might test less and less -Alternative blood sampling sites -Data uploaded to computer or app

Type 2 Diabetes Mellitus

-Formerly known as adult-onset diabetes (AODM) or non-insulin-dependent diabetes (NIDDM) -Most prevalent type (90% to 95%) -Many risk factors: -Overweight, obesity, advanced age, family Hx -Increasing prevalence in children -Greater prevalence in ethnic groups -Pancreas continues to produce some endogenous insulin but -Not enough insulin is produced or the body does not use insulin effectively -Major distinction: In type 1 diabetes there is an absence of endogenous insulin -Metabolic syndrome increases risk for type 2 diabetes-elevated glucose levels, abdominal obesity, elevated BP, elevated levesl of triglycerides, decreased levels of HDLs -Gradual onset -Hyperglycemia may go many years without being detected -Often discovered with routine laboratory testing -At time of diagnosis -About 50% to 80% of β cells are no longer secreting insulin -Average person has had diabetes for 6.5 years

Type 1 Diabetes Mellitus

-Formerly known as juvenile-onset or insulin-dependent diabetes -Generally affects people under age 40 -Can occur at any age -Autoimmune disorder -Body develops antibodies against insulin and/or pancreatic β cells that produce insulin=not enough insulin to survive -Genetic link -Idiopathic diabetes -Autoantibodies are present for months to years before symptoms occur -Pancreas can no longer produce insulinNecessitates insulin -Rapid onset with ketoacidosis -Patient may have temporary remission after initial treatment

Administration of Insulin

-Given by subcutaneous injection -Regular insulin may be given IV -Cannot be taken orally -Absorption is fastest from abdomen, followed by arm, thigh, and buttock -Don't inject at sites that will be exercised -Administration of insulin -Usually available as U100 insulin (1 mL contains 100 U of insulin) -Syringes marked for units: various sizes -Only user recaps syringe -No alcohol swab for self injection; wash with soap and water -Inject at 45-90 degree angle

Problems with Insulin Therapy

-Hypoglycemia -Allergic reaction- usually local reactions like redness at site, true insulin allergy is very rare, usually can give low dose of antihistamine or avoid using site because usually will resolve on own -Lipodystrophy- hypertrophy of sub Q tissue, atrophy or hypertrophy- important to rotate sites, using same sites can become inflamed or break down, atrophy is wasting of sub q hypertrophy is thickening- can make isnulin difficult to absorb properly for both- injection might be ok but absorption might not absorb correctly.

Beta Adrenergic Blockers

· Tenormin- atenolol · Lopressor- metropolol · Inderal- propranolol- non cardioselective blocker

Neurogenic Bladder- Autonomic Neuropathy

→ urinary retention= can have difficulty voiding, or infrequent voiding, -Empty frequently, use Credé's maneuver= massage downward to help pt. complete bladder emptying -Medications- -Self-catheterization

Oral Agents

Work on 3 defects of type 2 diabetes -Insulin resistance- if not giving themselves insulin -Decreased insulin production -Increased hepatic glucose production -Can be used in combination with insulins

Alcohol

-Limit to moderate amount 1 drink/day for women; 2 drinks/day for men -Inhibits gluconeogenesis by liver Can cause severe hypoglycemia -Blood glucose levels must be monitored while consuming alcohol -Might want to eat carbs while drinking, and think about what drinking, don't drink mixed drinks with sweetened mixers, drink sugar free mixes or light dry wines

Rapid Acting (Bolus)

-Lispro, aspart, glulisine -Onset of action 15 minutes -Injected within 15 minutes of mealtime

Dawn Phenomenon

-Morning hyperglycemia present on awakening -May be due to release of counterregulatory hormones in predawn hours -Growth hormone and cortisol- adolescents usually have a higher release of these two -Can take BS between 2-4 am to diagnose this, do this to take BS before counterregulatory hormones are released

Ambulatory Care

-Overall goal is to enable patient or caregiver to reach an optimal level of independence in self-care activities -Increased risk for other chronic conditions -Successful interaction with interprofessional team -Assess patient's ability to perform SMBG and insulin injection -Use assistive devices as needed Assess patient/caregiver knowledge and ability to manage diet, medication, and exercise- have bio stabilizer, dosing aids, have magnifying glasses that can be attached to the insulin syringes -Teach manifestations and how to treat hypoglycemia and hyperglycemia

Nutritional Therapy

-counseling -education -ongoing monitoring -interdisciplinary -Nurses, diabetic educators, PCP, social workers= other team members involved -Registered dietitian with expertise in diabetes management -Might be hard for diabetics if they have comorbidities like obesity

8. The nurse assesses the client who presents to the ED with a panic attack. Which findings should prompt the nurse to confer with the HCP about obtaining ABG's? Select all that apply. 1. Respirations 40 bpm 2. Tingling in the fingers 3. Muscle twitching 4. Salivation 5.Increased urination

1,2,3 Respiratory alkalosis may occur with a panic attack due to blowing off of carbon dioxide with hyperventilation. Tingling occurs in respiratory in resp alkalosis due to the increase in neuromuscular excitability associated with hyperventilation. Muscle twitching occurs from neuromuscular excitability associated with hyperventilation.

1.The nurse is caring for the client admitted with dehydration. Which factors should the nurse explore as contributing to the client's dehydration? Select all that apply 1. Diarrhea 2. Hemorrhage 3. Diabetic ketoacidosis 4. Hypoventilation 5. Decreased urination

1,2,3, Fluid volume deficit occurs with abnormal loss of body fluids, including diarrhea. Hemorrhage can result in fluid volume deficit from a large loss of volume. DKA is a risk factor or cause of dehydration because increased blood glucose levels cause diuresis. Hyperventilation and not hypoventilation is a risk factor or cause of dehydration.

The nurse is caring for a patient with type 1 DM who is admitted for diabetic ketoacidosis. The nurse would expect which lab test result? 1. hypokalemia 2. fluid overload 3. hypoglycemia 4. hyperphosphatemia

1.

What would Jeri's ABGs look like? What is the treatment?

1. Respiratory acidosis reflected by pH <7.35 and PCO2 >45 mm Hg. The HCO3 will be normal (20 to 30 mEq/L) if her respiratory depression has lasted less than 24 hours; if longer than 24 hours, the HCO3may be elevated as the result of compensation. The PaO2 may be less than 80 mm Hg because of respiratory depression leading to hypoxemia. 2. Determine the cause of the respiratory depression. If induced by opioids or benzodiazepines, treat with appropriate antagonists. If induced by alcohol or other CNS depressants, breathing must be stimulated until the effects of drugs have worn off. Mechanical ventilation may be necessary to increase respiratory rate and depth, increasing oxygenation and promoting excretion of carbon dioxide.

Case Study u Jeri is a 22-year-old female who has been on a 3-day party binge. u Her friends bring her to the ED after being unable to awaken her. u Assessment reveals shallow respirations with a rate of 8/min, diminished breath sounds, and decreased level of consciousness. 1. What type of acid-base imbalance would you expect Jeri to have? 2. What is causing it? 3. What type of compensation would you expect or not expect? Explain.

1. Respiratory acidosis. 2. Hypoventilation secondary to alcohol ingestion 3. Compensation might be noted if the respiratory depression has been present for 24 hours or more: The HCO3− may be elevated as the result of renal compensation. If her respiratory depression has lasted less than 24 hours, there will not yet be any renal compensation.

You are caring for JS who was admitted to the hospital with diabetic ketoacidosis (DKA). Julie has had a virus for 3 days prior to her hospitalization. You understand that the initial treatment for JS would include: 1. Administering oxygen (Y or N) because of acidosis 2. Establishing an IV line for access (Y) because giving insulin IV 3. Administering 0.9% NaCl for rehydration (Y) because fluid of choice 4. Infusing NPH Insulin (N) because you are giving rapid Monitor K levels

1. Y 2. Y 3. Y 4. N

A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dl. Which statement by the nurse is best? 1. " You will develop type 2 diabetes within 5 years." 2. "You are at increased risk for developing diabetes." 3. "the test is normal, diabetes is not a problem." 4. "the lab test results is positive for type 1 diabetes"

2

10. In the ICU, the critical care nurse assesses a patient admitted with an asthma attack who has a RR of 10 and an oxygen saturation of 88%. Which intervention should the nurse implement 1st? 1. Call the Rapid Response Team (RRT) 2. Increase the oxygen to 10 LPM 3. Check the patient's ABG results 4. Administer the fast-acting inhaler

2. 1st action is to increase the patient's oxygen to 100% Rapid Response Team is called when nurse assesses a patient whose condition is deteriorating. Purpose of the RRT is to intervene to prevent a code blue situation. May need to call RRT but increase oxygen 1st. Should check ABG results, but not until after increasing oxygen. Fast-acting inhaler should be used, but not until after the oxygen has been increased and a RRT called.

6. The patient has arterial blood gas results of pH 7.50, PaCO2 35 mm Hg, and HCO3 30 mmol/L. Which nursing interpretation of the client's acid-base imbalance is correct? 1. Respiratory alkalosis 2. Metabolic alkalosis 3. Respiraotry acidosis 4. Metabolic acidosis

2. A pH of 7.50 indicates alkalosis. The HCO3 of 30 mmol/L is above the normal range of 20 to 24 mmol/L is above the normal range of 20 to 24 mmol/L, indicating the primary acid-base imbalance is metabolic alkalosis.

Diagnostic Studies: Two hour plasma glucose level during OGTT:

200mg/dL (with glucose load of 75g)

A patient with type 1 diabetes calls the clinic with complaints of nausea, vomiting, and diarrhea. it is most important that the nurse advise the patient to. 1. Withhold the regular dose of insulin 2. drink cool fluids with high glucose content 3. check the blood glucose level every 1 to 3 hours 4. Use a less strenuous form of exercise than usual until the illness resolves.

3.

COPD can go into-

acute respiratory failure Caused by · Exacerbations · Discontinuing bronchodilator or corticosteroid medication · Overuse of sedatives, benzodiazepines, and opioids · Surgery or severe, painful illness involving chest or abdomen Exacerbation of COPD can cause - Depression and Anxiety · COPD patients experience many losses. · If patient becomes anxious because of dyspnea, teach pursed lip breathing.

2.The child is prescribed oral rehydration therapy to treat dehydration from vomiting and diarrhea. Which intervention should the nurse implement? 1. Give 50 to 100 mL/kg of sterile water every 4 hours 2. Give 40 to 50 mL/kg of rehydration solution every hour 3. Give 40 to 50 mL/kg of rehydration solution over 4 hours 4. Give 50 to 100 mL/kg of tap water every hour for 4 hours

3. Nurse should start with small sips of rehydration solution and increase it so the child receives 40 to 50 mL/kg over 4 hours. Water is not indicated as a fluid for rehydration because it lacks glucose, sodium, and potassium. Giving 40 to 50 mL/kg of rehydration solution every hour could increase nausea and vomiting from fullness. Tap water is not indicated as a fluid for rehydration.

3. The patient with DKA has a blood sugar of 320 mg/dL., a Resp rate of 32, and a deep, regular respiratory effort. The nurse should implement interventions for which acid-base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

3. The nurse should implement interventions for treating metabolic acidosis. In DKA, the elevated blood sugar results in polyuria with a resultant decrease in the pH and HCO3 levels. Kussmaul respirations allow the body to "blow off" excess carbon dioxide to compensate for the acidotic state and the decreased HCO3. DKA is a metabolic not respiratory acid-base imbalance. It is acidotic, not an alkalotic imbalance.

9. The nurse ordered the loop diuretic, bumetanide (Bumex), to be administered STAT to a client diagnosed with pulmonary edema. After 4 hours, which of the following assessment data indicates the client may be experiencing a complication of the medication? 1. The client develops jugular vein distention 2. The client has bilateral rales and rhonchi 3. The client complains of painful leg cramps 4. The client's output is greater than the intake

4. Leg cramps may indicate a low serum potassium level, which can occur as a result of the administration of a diuretic Could see jugular vein distention with CHF Rales and rhonchi are symptoms of pulmonary edema 4 - would indicate medication is effective and not a complication.

A patient with an acid-base imbalance has an altered potassium level. The nurse recognizes that the potassium level is altered because? 1.In alkalosis, potassium is shifted into extracellular fluid to bind excessive bicarbonate. 2.Potassium is returned to extracellular fluid when metabolic acidosis is corrected. 3.Hyperkalemia causes an alkalosis that results in potassium being shifted into the cells. 4.Acidosis causes hydrogen ions in the blood to be exchanged for potassium from the cells.

4. Rationale: Changes in pH (hydrogen ion concentration) will affect potassium balance. In acidosis, hydrogen ions accumulate in the intracellular fluid (ICF), and potassium shifts out of the cell to the extracellular fluid to maintain a balance of cations across the cell membrane. In alkalosis, ICF levels of hydrogen diminish, and potassium shifts into the cell. If a deficit of H+ occurs in the extracellular fluid, potassium will shift into the cell. Acidosis is associated with hyperkalemia, and alkalosis is associated with hypokalemia.

Chronic complications of DM

Angiopathy, microvascular antipathy, microvascular angiopathy, diabetic retinopathy, diabetic nephropathy, diabetic neuropathy, foot complications, infections

1. A diabetic client who is taking insulin lispro (Humalog) injections would be advised to eat: A. Within 30 minutes after the injection B. 1 hour after the injection C. At anytime, because timing of meals with lispro injections is unnecessary D. 2 hours before the injection

A.

1. After a thorough evaluation, a nurse concludes that the efforts of a client with type 2 diabetes mellitus (DM) to control blood glucose levels have been highly effective over the last 3 months. Which finding supports the nurse's conclusion? a. Hemoglobin A1C level of 5% b. No incidence of diabetic ketoacidosis (DKA) c. No ketones in the urine d. Negative oral glucose tolerance test (OGTT)

A.

Complications of resp acidosis

if don't treat and do the right thing, the patient will decline see respiratory failure, go into shock

Angiotensin Inhibitors

inhibit the angiotensin converting- side effects: dizziness, tastelessness, dry non productive irritating cough, angioedema, NSAIDs- reduce effectiveness and aspirin can as well, · Lotensin · Capoten · Vasotec · Zestril · Altace · Monopril

Insulin Pump

is what body would provide itself, is programmed and gives injection- rapid acting insulin Continuous subcutaneous infusion Battery-operated device Connected to a catheter inserted into subcutaneous tissue in abdominal wall Program basal and bolus doses that can vary throughout the day Potential for keeping blood glucose levels in a tighter range

A1C

looking at long term, don't want to repeat the test immediately, want to wait

PMH

o F and E disorders o AB problems o How resoled o Meds, diuretics o Diabetic - Cardiac - fluid retention, use diuretics - GI - intestinal disorders - Chron's disease, excessive vomiting

Antiplatelets agents and platelet inhibitors

o Used to - dilate the vessels o Aspirin o Clopidogrel (Plavix) o Persantine

Vasodilators

o Used to - dilate vessels and ultimately improve circulation o Nitroglycerin o Hydralazine

Vasopressors

o Used to - improve circulation o Isoproterenol (Isoprel) o Dobutamine (Dobutex)

Lipid Lowering Agents

o Used to - lower the lipid levels, are the statins, reductase inhibitors, when they first came out they thought to be safe but side effects are that they cause liver problems, memory loss, increase risk for cancer, suppress immune system, o Atorvastatin (Lipitor) o Fluvastatin (Lescol) o Lovastatin (Mevacor) o Pitavastatin (Livsalo, Pravachool) o Rosuvastatin (Crestor) o Simvastatin (Zocor)

Antianginal Agents

o Used to - to treat chest pain, and ultimately improve circulation and decrease chest pain or angina o Nitroglycerine o Nitro-bid o Nitro-dur o Isosorbide dinitrate

Thrombolytics

o Used to - treat strokes and heart attacks, all given IV in controlled situation, end in ase, bust up blood clotsà to break the clots apart o Lanoteplase o Reteplase o Staphylokinase o Streptokinase o Urokinase

Metabolism

the processes of biochemical reactions occurring in the body's cells that are necessary to produce energy, repair, and facilitate the growth of cells, and maintain life.

Antihypertensives

used to lower BP in individuals

(Basal) Background Insulin:

used to manage glucose levels in between meals and overnight

Diagnostic Studies: Classic Symptoms of hyperglycemia

with random plasma glucose level of 200 mg/dL or higher

Nursing Care with overdose- resp acidosis

· 02 support - · Humidification - · Hydration - check skin turgor, I%O · Positioning - · VS · ABGs · CXR - · CBC - to rule out possible infection · Incentive Spirometer, Deep Breathing · Reverse effects · Opiates: Naloxone (Narcan) · Minimize effects of drugs using by making sure dose is correct, right route, etc. · Sedatives & Respiratory support/ventilation

Creatine Kinase

· 1. Is an enzyme found primarily in the brain and skeletal muscle and heart m.s. see an elevated creatinine kinase when the heart muscle is damaged

Lactic Dehydrogenase

· 2. Is an enzyme that is a nonspecific test, when elevated indicates tissue damage on body

Natriuretic Peptides

· 3. Peptide or biomarker that is used to diagnose CHF, MI,

Troponin

· 4. Diagnose Heart attack, there is troponin 1 or troponin T levels

Homocysteine

· 5. Ammino acid that elevates when heart has been damaged or elevate when stroke or blood clot

C-reactive protein

· Acute face reactant, protein made in liver, elevates when there is inflammation or injury to body, looked at more than blood count sometimes when inflammation in body

Common causes of Resp alkalosis

· Acute pain · CHF · High altitudes · Hypermetabolic states (fever, anemia, thyrotoxicosis) · Septicemia · Brain injury · Early salicylate intoxication · Hysteria/hyperventilation

Risk Factors of primary HTN

· Age - systolic bp changes with age usually after 50 · Alcohol - excessive alcohol intake, if risk factor for HTN limit intake · Tobacco use - smoking increases CVD · Diabetes mellitus - more common in diabetics · Elevated serum lipids - · Excess dietary sodium - · Gender - more prevalent in males than in females until mid 50 then in women more than men · Family history - · Obesity -greatest risk factor for those who carry weight in midsection, highest risk factor · Ethnicity - 2x higher in African Americans · Sedentary lifestyle - regular physical activity to decrease wt and bp · Socioeconomic status - lack of education, money for healthy food · Stress -

Common Causes of Resp Acidosis

· Airway Diseases o COPD o Asthma o Pneumonia · Medication induced o Barbituate or sedative OD o Pain medications o Benzodiazepines o Alcohol · Chest wall abnormality/restriction · Obesity · Sleep apnea · Prematurity · Restrictive lung diseases · Atelectasis - Resp muscle weakness/diseases · Guillian Barre disease · Mechanical hypoventilation · Cerebral edema RT head injury · Chest wall abnormalities/restriction o Restrictive lung disease · Cerebral edema related to head injury o Reactive airway disease o Respiratory syncytial virus o Pulmonary embolism o CHF o Trauma

Antiarrhythmics

· Antiarrhythmics o Used to - improve rhythm of heart, improve rate and rhytm o Tambovcor (flecainide) o Procanbid (procainamide) o Cordarone (amiodarone) o Betapace (sotalol)

Anticoagulants

· Anticoagulants- they thin the blood o Coumadin- oral o Heparin- subq, can give IV in controlled situation with IV drip o Lovenox- subq o Xarelto

DKA Lab Findings

· Blood Glucose - >300 mg/dl · ABGs - pH <7.30 · HCO3 - < 15 mEq/L · Ketones in blood and urine · Electrolyte abnormalities

Tissue (Local Perfusion)

· Bypass and/or graft surgery- done to restore blood flow to heart by diverting blood around an area of blockage · Stent or angioplasty- placed in artery to keep from collapsing · Endarterectomy- surgical removal of part of the inner lining and go in and remove plaque and deposits that are formed

Alpha Adrenergic Blockers

· Cardura- doxazosin · Minipress- prazosin

DKA s/s

· Dehydration o Poor skin turgor o Dry mucous membranes o Tachycardia o Orthostatic hypotension · Lethargy and weakness early · Skin dry and loose; eyes soft and sunken · Abdominal pain, nausea, vomiting · Diabetic Ketoacidosis (DKA) · Abdominal pain, anorexia, nausea/vomiting · Kussmaul respirations · Sweet, fruity breath odor · Blood glucose level -??? higher elevated · Blood pH lower than 7.30 · Serum bicarbonate level lower than 16 mEq/L · Moderate to high ketone levels in urine or serum

Metabolic Acidosis ....

· Diabetic Ketoacidosis · Aspirin Overdose Loss of bicarbonate · Prolonged diarrhea · Draining intestinal or pancreatic fistula

Diabetic Ketoacidosis DKA acute complications

· Diabetic ketoacidosis (DKA) is extremely elevated BS · Hyperosmolar hyperglycemic syndrome (HHS) complication of uncontrolled diabetes, they don't have ketones · Hypoglycemia · Caused by profound deficiency of insulin · Characterized by o Hyperglycemia o Ketosis o Acidosis o Dehydration- extreme dehydration · Most likely to occur in type 1 diabetes

Hypertension

· Direct relationship between hypertension and cardiovascular disease · Affects 46% of adults in U.S. · Additional 30% have prehypertension · High priority health concern identified in Healthy People 2020

Drug Therapy

· Diuretics · Adrenergic inhibitors · Direct vasodilators · Angiotensin inhibitors · Calcium channel blockers · Newest treatment: o Triple pill § Combination medication of (Telmisartan, Amlodipine, Chlorthalidone)

HTN in older persons

· Increased incidence with age · Isolated systolic hypertension (ISH): Most common form of hypertension in individuals age >50 · Older adults are more likely to have "white coat" hypertension · Age-related physical changes contribute to HTN · Altered drug absorption, metabolism, and excretion · Often a wide gap between the first Korotkoff sound and subsequent beats is called the auscultatory gapà know what that meanas · ↑ risk for orthostatic hypotension · Also postprandial hypotension

Measures to enhance compliance

· Individualize plan · Active patient participation · Select affordable drugs · Involve caregivers · Combination drugs Patient teaching

Central Perfusion Collaborative Care

· Pacemaker insertion- small device placed into the patient's chest, to help control heart rhythm used low energy impulse to prompt heart to beat at normal rate, can be used for pt. with abnormally slow HR · Electrical cardioversion- medical procedure to restore normal HR, sends small electrical shock to heart, and to get to re beat at normal HR · Ablation therapy- minimally invasive procedure and destroy a piece of abnormal tissue that can cause heart to beat abnormally · Intraaortic balloon pump- insert balloon pump, mechanical device that increases coronary blood flow and o2, deflates in systole and inflates in diastole, · Cardiac valve surgery- replace a defective valve · Cardiac transplant-

Treatment of resp acidosis

depends on clinical situation, some include like bronchodilators, o2, elevate HOB, bipap, cpap,

Nutritional Therapy Goals

ADA healthy food choices- diabetics can eat the same foods the general population can but need to pay close attention, Maintain blood glucose levels to as close to normal as safely possible Normal lipid profiles and blood pressure Prevent or slow complications Individual needs; personal, cultural preferences Maintain pleasure of eating= more education about diet can still eat the foods they enjoy

What will Anthony's ABGs look like? What is the treatment?

ANS: 1. The metabolic alkalosis in this case would be reflected by a pH >7.45 and a HCO3− >30 mEq/L. Because of the duration of this condition, compensation may be indicated by a PCO2 >45 mm Hg. 2. Determine the underlying cause of the vomiting if possible, and stop the use of baking soda (sodium bicarbonate). Antiemetic drugs and nasogastric intubation may help relieve the vomiting, and IV replacement of fluids and electrolytes may be necessary.

What do Mayna's ABGs look like? What is the treatment?

Answers: 1. Respiratory alkalosis indicated by pH >7.45 and PCO2 <35 mm Hg. The HCO3− will be normal (20 to 30 mEq/L) because compensation will not occur in this acute event. 2. Relieve her anxiety and coax her to take slow breaths. Carbon dioxide may be administered by mask, or she may be asked to breathe into a paper bag placed over her nose and mouth.

Long Acting (Basal)

Long-acting (basal) -Insulin glargine (Lantus) and detemir (Levemir) -Released steadily and continuously with no peak action for many people -Administered once or twice a day -Do not mix with any other insulin or solution

Hyperosmolar Hyperglycemic Syndrome

(HHS less common than DKA) -Life-threatening syndrome= syndrome that can occur in diabetics who are able to produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion, happens in older 60+ pt. with type 2 DM -Occurs with type 2 diabetes -Precipitating factors -UTIs, pneumonia, sepsis -Acute illness -Newly diagnosed type 2 diabetes -Impaired thirst sensation and/or inability to replace fluids -Also HX of inadequate fluid intake, increasing mental depression, polyuria -Enough circulating insulin to prevent ketoacidosis -Fewer symptoms lead to higher glucose levels (>600 mg/dL) -More severe neurologic manifestations because of ↑ serum osmolality -Such as decreased LOC, coma, seizures, hemiparesis, CHF, resemble stroke so determination of glucose level is very important -Ketones absent or minimal in blood and urine with HHS- defining factor between DKA and HHS -Medical Emergency -High mortality rate -Therapy similar to that for DKA -IV insulin and NaCl infusions- half or normal NS -More fluid replacement needed- great volumes of fluid replacement needed -Monitor serum potassium and replace as needed -Correct underlying precipitating cause to make sure to correct

Inhaled Insulin

-Afrezza -Rapid-acting inhaled insulin -Administered at beginning of each meal or within 20 minutes after starting a meal -Not a substitute for long-acting insulin -Don't want to use with pt. with respiratory disease, because of bronchospasms

Insulin Regimens

-Basal-bolus regimen- spikes -Most closely mimics endogenous insulin production -Rapid- or short-acting (bolus) insulin before meals -Intermediate- or long-acting (basal) background insulin once or twice a day -Less intense regimens can also be used - Mealtime Insulin (Bolus)

Diabetic Ketoacidosis (DKA)

-Caused by profound deficiency of insulin -Characterized by -Hyperglycemia -Ketosis -Acidosis -Dehydration -Most likely to occur in type 1 diabetes but people with type 2 that have severe illness or stress when pancreas can't meet demands of insulin can experience DKA also -Precipitating factors -Illness -Infection -Inadequate insulin dosage -Undiagnosed type 1 diabetes -Poor self-management= most likely cause -Neglect -Insulin deficiency will also impair protein synthesis which causes excessive protein degradation. Results in nitrogen losses from tissues and stimulates production of glucose from amino acids in liver and leads to further hyperglycemia, because deficiency of insulin the additional glucose can't be use and BG levels rise further- leads to osmotic diuresis and will eventually cause depletion of sodium, potassium, chloride, magnesium, and phosphate making pt. incredibly dehydrated When lose electrolytes will have vomiting which leads to further loss

Somogyi Effect

-Rebound effect in which an overdose of insulin causes hypoglycemia -Release of counterregulatory hormones causes rebound hyperglycemia -Wake up with hypoglycemia if low bs from 2-4 its because we gave too much

Short-acting (Bolus)

-Regular with onset of action 30 to 60 minutes -Injected 30 to 45 minutes before meal -Onset of action 30 to 60 minutes

Microvascular Angiopathy

-Thickening of vessel membranes in capillaries and arterioles -Specific to diabetes and includes -Retinopathy -Nephropathy -Dermopathy Usually appear 10 to 20 years after diagnosis

Hypoglycemia

-Too much insulin in proportion to glucose in the blood -Blood glucose level < 70 mg/dL -Neuroendocrine hormones released -Autonomic nervous system activated

Untreated hypoglycemia can progress to...

-Untreated hypoglycemia can progress to loss of consciousness, seizures, coma, and death- consider taking BG levels to rule out Causes -Too much insulin or oral hypoglycemic agents -Too little food -Delaying time of eating -Too much exercise -Symptoms can also occur when high glucose level falls too rapidly

Foot Care

-younger might not understand the importance of footcare -Inspect daily -Avoid going barefoot -Proper footwear- make sure the shoes aren't rubbing or causing irritation - -How to treat cuts- when they aren't healing as quickly need to reiterate importance of antiseptic ointment and covering area with sterile pad

Nursing Implementation: Acute Illness and Surgery

-↑ Blood glucose level secondary to counterregulatory hormones -Frequent monitoring of blood glucose -Ketone testing if glucose level exceeds 240 mg/dL -Report glucose levels exceeding 300 mg/dL twice or moderate to high ketone levels -Usually, BG is checked every 4 hrs., and check ketones every 3 hr. -Make sure if pt. at home checking levels that they know when to report that as well -Elevated BG lead to poor healing and infection, have to keep closer look on BG levels -Increase insulin for type 1 diabetes -Type 2 diabetes may necessitate insulin therapy -Acute Illness -Maintain normal diet if able -Increase noncaloric fluids- don't want pt. to get dehydrated -Continue taking antidiabetic medications- if N/V might not be possible but continue to take as prescribed with insulin -If normal diet not possible, supplement with CHO-containing fluids while continuing medications -Like low sodium soups, juices, or sugar sweetened soft drinks- because want to make sure they aren't low BS that causes counter regulatory release

A patient has the following ABG results: pH 7.48, PaO2 86 mm Hg, PaCO2 44 mm Hg, HCO3− 29 mEq/L. When assessing the patient, the nurse would expect the patient to have 1.Muscle cramping 2.Warm, flushed skin 3.Respiratory rate of 36 4.Blood pressure of 94/52

1. Rationale: • The patient is experiencing metabolic alkalosis (elevated pH and elevated HCO3− ). Clinical manifestations of metabolic alkalosis include hypertonic muscles and cramping and reduced respiratory rate. Hypotension and warm, flushed skin may occur with respiratory acidosis.

Why would each of these interventions be completed? You review the lab reports from blood drawn 1 hour after the administration of IV Insulin, what would you expect? 1. Hyponatremia (Y or N) 2. Hypercalcemia (N) 3. Hypoglycemia (N) 4. Hypokalemia (Y) insulin causes K to move into the cells causing this

1. N 2. N 3. N 4. Y

Treatment of HTN

1. Lifestyle Modifications Weight reduction · Weight loss of 1 kg may decrease - Systolic bp by 1 mm Hg · Calorie restriction and - physical activity DASH eating plan · Fruits, vegetables, fat free or low fat milk, whole grains, fish, poultry, beans, seeds, and nuts Physical activity- if appropriate for age of pt. · Moderate-intensity aerobic activity - 30 minutes, most days of the week (goal 150 minutes/week) · Vigorous-intensity aerobic activity at least 20 minutes - 3 days a week · Muscle-strengthening activities at least - 2 times a week · Flexibility and balance exercises - 2 times a week Avoidance of tobacco products · Nicotine causes vasoconstriction and elevated BP · Smoking cessation reduces risk factors within - 1 year Psychosocial risk factors · Low socioeconomic status, social isolation and lack of support, stress, negative emotions · Activate SNS and stress hormones Drug Therapy Reduce SVR- stroke volume resistance in circulation Decrease volume of circulating blood

Interpretation of ABGs

1. Look at each of the values 2. Look at pH first- can tell if acidosis or alkalosis 3. Use ROME to determine respiratory or metabolic 4. Determine if patient is compensating 5. Assess the PaO2 and O2 saturation.

Mixing Insulin

1. wash hands 2. Gently rotate NPH insulin bottle 3. Wipe off tops of insulin vials with alcohol sponge 4. Draw back amount of air into the syringe that equals total dose 5. Inject air equal to NPH dose into NPH vial. Remove syringe from vial. 6. Inject air equal to regular dose into regular vial 7. Invert regular insulin bottle and withdraw regular insulin dose 8. Without adding more air to NPH vial, carefully withdraw NPH dose and add to regular insulin already in syringe

Which of the following sick-day rules should the nurse include in patient teaching (Select all that apply) 1. Continue eating regular meals if possible (Y or N) to keep BS up 2. Increase the intake of noncaloric fluids (Y) helps prevent dehydration 3. Take insulin as prescribed (Y) 4. Check glucose once daily (No) notoften enough more like q 4 hr 5. Test for ketones if glucose is greater than 240 mg/dL (Y) indicators of poor control 6. Report moderate ketones to the Healthcare provider (Y)

1. y 2. y 3. y 4. no 5. y 6. y

12. The patient who is 1 day postop following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first? 1. Assess the client's pulse oximeter reading 2. Notify the Rapid Response Team 3. Prepare to administer dopamine, a vasopressor 4. Increase the patient's surgical dressing

2. The Rapid Response Team was mandated by The Joint Commission. It is a team of health care Professionals who respond to patients who are breathing but who the nurse things are in an emergency. Patient is in distress; therefore, nurse needs to DO something and not just check a pulse oximeter. Trendelenburg position is used for patient in hypovolemic shock and not respiratory distress.

5. The nurse assigned to care for multiple patients is reviewing the lab reports. Based on the information provided, in which sequence should the nurse assess the clients? Prioritize the order in which the nurse should plan to assess the clients. 1. The client with renal insufficiency whose serum potassium level is 5.2 mEq/L 2. The client with hyperemesis whose serum sodium level is 122 mEq/L 3. The client recovering following head trauma whose serum osmolality is 290 mOsm/kg 4. The client with DM whose ABG results are pH = 7.22, PaCO2 = 35 mm Hg, HCO3 = 1.5 mEq/L

4,2,1,3 4. The patient with DM whose ABG = metabolic acidosis. A compensatory mechanism will include Kussmaul respirations to eliminate excess acid. Airway assessment is priority, and further assessment is needed to determine the underlying cause for the metabolic acidosis 2. the client with hyperemesis whose serum sodium is 122 - patient is experiencing severe hyponatremia and is at risk for seizures. Safety a major concern 1. renal insufficiency - patient's serum potassium level is slightly above the normal and patient should be assessed for signs of hyperkalemia 3. serum osmolality level is normal. This patient is the most stable.

As a nurse, you know that during the initial treatment of diabetic ketoacidosis, the provider will order which solution? 1. D5W 2. D5 0.45% saline 3. Lactated Ringer's solution 4. 0.9% saline

4.

1. A home-health nurse is planning the first home visit for a 60-year-old client newly diagnosed with type 2 diabetes mellitus. The client has been instructed to take 70/30 combination insulin in the morning and at suppertime. Which interventions should be included in the client's plan of care for diabetics? SELECT ALL THAT APPLY. CREDIT GIVEN ONLY FOR ALL CORRECT ANSWERS. a. Instruct the client to inspect the feet daily b. Ensure that the client eats a bedtime snack c. Assess the clients ability to read small print d. Teach the client to perform a hemoglobin A1c test daily

A, B, C

Diagnostic Studies of HTN

Ambulatory blood pressure monitoring (ABPM) · Noninvasive, fully automated system that measures BP at preset intervals over 24-hour period · Teach patient to hold arm still and keep diary · Many applications for use Measurement of BP -Labs too: Urinalysis- identifies if kidneys are affected BMP-good place to start CBC- baseline information, rule out target organ information BUN and serum creatinine- normal Bun 7-20, normal creatinine 0.5-1.5- tell us about glomerular function Creatinine clearance- might be done to see how well pt. is able to excrete creatinine Serum electrolytes, glucose- concerned about potassium and sodium Serum lipid profile- if at risk for CVD or atherosclerosis Uric acid levels- gives baseline and if on diuretic can affect uric acid and causes it to rise ECG- tells about heart status if have cardiac involvement Echocardiogram- if suspect blood ventricular heart failure can do an echo Eye exam (ophthalmic exam)- refer and get a good exam

Diagnostics of Perfusion

Ankle Brachial Index · Compares - screens for peripheral vascular diseawse bp of lower exgtemeities to upper (divide by highest · A low AB Index - Doppler Flow Studies Ultrasound Goal - early intervention, good education, healthy diet, physically active lifestyle, reduce Risk factors - if have HTN keep in good control, if DM good control, manage lipids, keep Na down, if smoker cut down Treatment - lifestyle changes, exercise, diet, healthy life style, some meds like ace inhibitors,

Adrenergic Inhibitors

Another name - Central Acting Alpha Adrenergic Antagonists- reduce sympathetic outflow from CNS, how they decrease bp Side effects: dry mouth, sedation, nausea, dizziness, sleep disturbance, bad dreams, weird dreams, bizarre, restlessness, depression, erectile dysfunction, sudden discontinuation can cause rebound HTN, tachycardia, HA, · Catapres- clonidine · Clonidine patch · Tenex- guanfacine · Aldomet- methyldopa

Drug Therapy- COPD

Bronchodilators · Relax smooth muscle in the airway · Improve ventilation of the lungs · Decrease dyspnea and increase forced expiratory volume · Inhaled route is preferred · When symptoms are controlled-have to stay on meds cant step back down with meds like asthma Commonly used bronchodilators · β2-Adrenergic agonists o Alupent, Proventil, Ventolin · Anticholinergics o Atrovent (albuterol and ipratropium combined as DuoNeb) · Methylxanthines o Theophylline, aminophylline Long-acting anticholinergic · Tiotropium (Spiriva) Inhaled corticosteroid therapy- steroids cause thrush in mouth can cause yeast infection they suppress the immune system and leaving vulnerable for virus, infection, etc. · Used for moderate to severe cases · Fluticasone/salmeterol (Advair) Antibiotic therapy · Azithromycin (Zithromax) Phosphodiesterase inhibitor · Roflumilast (Daliresp) Combivent Respimat (ipratropium and albuterol) O2 therapy is used to · Keep O2 saturation - >90% during rest, sleep, and exertion, or · PaO2 greater - than 60 mmHg · Humidified - oxygen

1. A clinic nurse is evaluating a client with type 1 diabetes who intends to enroll in a tennis class. Which statement made by the client indicates that the client understands the effects of exercise on insulin demand? a. "I will carry a high-fat, high-calorie food, such as a cookie." b. "I will administer 1 unit of lispro insulin prior to playing tennis." c. "I will eat a 15-gram carbohydrate snack before playing tennis." d. "I will decrease the meal prior to the class by 15-grams of carbohydrates."

C.

1. The home care nurse is visiting a child newly diagnosed with DM. The nurse is instructing the child and parents regarding actions to take if hypoglycemic reactions occur. The nurse tells the child to: A. Drink 8 ounces of diet cola at the first sign of weakness B. Report to the ER if the blood glucose is 60mg/dL C. Carry hard candies whenever leaving home in case of hypoglycemic reaction occurs D. Administer glucagon immediately if shakiness is felt

C.

Autonomic Neuropathy

Can affect nearly all body systems Gastroparesis- gastric emptying -Delayed gastric emptying -Can produce anorexia, nausea, vomiting, reflux and can trigger hypoglycemia because delays food absorption

Complications of COPD

Cor pulmonale- right side hypertrophy · ECG, Chest x-ray, right-sided cardiac catheterization · Echocardiogram, BNP levels- B-type naturetic peptide- helps diagnose heart failure or rule out MI, stroke o Manifested by dyspnea, cough, sputum Exacerbations of COPD Acute respiratory failure Peptic ulcer disease Depression/anxiety

Diuretics

DIURETICS- none of these can cross the blood brain barrier, in general they inhibit the reabsorption of sodium and chloride, fluid and electrolyte imbalances can happen because these can pull out too much fluid, can measure fluid output to check and make sure its working, daily wt., bp and have a baseline, listen for lung sounds- for pulmonary edema, hypokalemia unless potassium sparing and, fluid depletion, lower bp and have orthostatic hypotensionà have to worry about falls and safety, considerations- assess, check peripheral edema, orhto hypo, fluid intake/output, if pt. take NSAID- can decrease effectiveness of diuretics · Thiazides o Naturetin, Diuril o HydroDIURIL · Loop Diuretics o Lasix · Aldosterone Receptor o Aldactone · Potassium--sparing o Midamor

Acute Complications of DM

DKA, HHS, Hypoglycemia

Diabetic Nephropathy

Damage to small blood vessels that supply the glomeruli of the kidney Leading cause of end-stage renal disease Risk factors -Maintaining BG levels is the biggest risk factor- to help reduce risk -Hypertension -Genetics -Smoking -Chronic hyperglycemia

Metabolic Alkalosis

Gain of Base · Diuretic therapy Excessive excretion of metabolic acid · Repeated vomiting The nurse is assessing Mr. Williams who has recently diagnosed with COPD. Mr. Williams states that he has smoked for 20 years and is employed by a chemical company. He also says that there were no safety regulations at the plant until 5 years ago What is the difference between chronic bronchitis and emphysema? Chronic bronchitis- pt. has to have had a cough for 3 consecutive months in 2 consecutive years, produce a lot of sputum, cough up a lot of sputum Emphysema- chronic enlargement of alveolar sac, walls of alveolar erode

Human Insulin

Genetically engineered in laboratories- derived from yeast cells or bacteria genetically engineered.

Nursing Diagnosis of HTN

Ineffective self-health management Anxiety Sexual dysfunction Risk for decreased cardiac perfusion Risk for ineffective cerebral and renal perfusion Potential complications: stroke, MI

Inadequate Central Perfusion: Infants and Children

Infants · Poor feeding · Poor weight gain · Failure to thrive · Dusky color · Fatigue · SOB · Pain Toddlers and children · Squatting and fatigue, squatting improves perfusion · Developmental delay (failure to hit milestones) Importance of clinical findings with toddlers/infants/children - HX, physical, assessment, heart lungs sounds, look at entire clinical picture

Other types of Insulin

Insulin Pen

Diabetic Neuropathy

Nerve damage due to metabolic derangements of diabetes 60% to 70% of patients with diabetes have some degree of neuropathy Reduced nerve conduction and demyelination Sensory or autonomic See severe wounds because pt. don't see/feel it Often leads to neurotrophic ulceration -Can have severe lacerations without pain -Can cause atrophy of small m.s of hands and feet and causing deformities and limiting fine motor movement

Collaborative Care of HTN

Overall goals · Control blood pressureà by doing this we will decrease: · Reduce CVD risk factors and target organ disease

Acid Base (AB) Imbalances

Overview of pH H+

Risk Factors of Perfusion

Populations at Greatest Risk Impaired perfusion can potentially occur among all individuals, regardless of age, gender, race, or socioeconomic status. The populations at greatest risk are: · Middle-aged and older adults · Men more frequently · African Americans- higher incidents · Individual risk factors o Smoking, obesity, sedentary lifestyle, traumatic injury to body, severe illness, chronic illness like diabetes, HTN, Hx of hyperlipidemia, heat disease, trauma, MI, pulmonary embolism, blood clot

Cardiovascular abnormalities- of Autonomic neuropathy

Postural hypotension-can be risk for falls, resting tachycardia, painless myocardial infarction

Respiratory Alkalosis- don't see as often

S&S of Respiratory Alkalosis Related to: deep respiratory rate, hypocapnia & hypoxia: Central and peripheral nervous system · Dizziness · Confusion · Tingling of extremities/paresthesia · Convulsionà coma Cerebral vasoconstriction · HA Carpal pedal spasm · Spasms in the fingers and toes

Resp Acidosis and the Patient with barbiturates/sedative overdose

Sedatives and narcotics May also include · Barbiturates · alcohol · opiates · valium- sedative Also known as: hypercapnic respiratory failure respiratory failure ventilator failure · PaCO2 - >45 mmHg · pH -<7.35 · HCO3- no compensation

Common Manifestations of Hypoglycemia

Shakiness Palpitations Nervousness Diaphoresis Anxiety Hunger Pallor Altered mental functioning Also brain requires a constant supply of glucose to continue to function Manifestations are speaking disturbances, visual disturbances, decreased LOC, confusion, coma, mimic symptoms of stroke or alcohol intoxication

Exacerbations of COPD

Signaled by change in usual · Dyspnea · Cough · Sputum Bacterial and viral infections

Collaborative Care and Treatment COPD

Smoking cessation · Biggest impact in reducing risk of developing COPD · Accelerated decline in pulmonary function slows to almost nonsmoking levels. Exacerbations Treatment · Short-acting bronchodilators · Corticosteroids · Antibiotics- only use if they have an infection · Supplemental oxygen therapy

BP Measurement

Take in both arms initially Proper size and placementof cuff Can use forearm if needed · Document site Assess for orthostatic hypotension · BP and pulse supine, sitting, and standing · Measure within 1 to 2 minutes of position change · Positive if ↓ of 20 mm Hg or more in SBP, ↓10 mm Hg or more in DBP, or ↑ 20 beats/minute or more in heart rate

11. You are the nurse on a medical unit assigned to care for the following patients during your 7am to 7pm shift. Based on the information provided, determine the order in which the patients should be seen and your reasoning behind your decision. (so list them in order as to who you would see 1st, 2nd, etc.) _____ Mr. Brody, a 42-year-old African American male, diagnosed with abdominal pain, etiology unknown. _____ Ms. White, a 60-year-old Asian female admitted with a diagnosis of bacterial pneumonia on IV antibiotics _____ Mr. Gonzales, a 48-year-old Hispanic male, diagnosed with chest pain rule out myocardial infarction _____ Ms. Smith, a 24-year-old Caucasian female, diagnosed with diabetic ketoacidosis. _____ Mr. George, a 38-year-old white male, diagnosed with renal calculi

__3___ Mr. Brody, a 42-year-old African American male, diagnosed with abdominal pain, etiology unknown. ___5__ Ms. White, a 60-year-old Asian female admitted with a diagnosis of bacterial pneumonia on IV antibiotics ___1__ Mr. Gonzales, a 48-year-old Hispanic male, diagnosed with chest pain rule out myocardial infarction ___2__ Ms. Smith, a 24-year-old Caucasian female, diagnosed with diabetic ketoacidosis. ___4__ Mr. George, a 38-year-old white male, diagnosed with renal calculi Chest pain and MI should be seen first. ABCs. DKA should be seen next to determine blood glucose and to determine whether insulin is needed. Then could see either Mr. Brody or Mr. George. Both have issues with pain, pain does , not kill but should be addressed to make sure that neither is experiencing pain at this time. Mr. White, with bacterial pneumonia, can be seen last. He has been there long enough to be diagnosed and should have had antibiotic started.

Match the following characteristics as they relate to complications of diabetes (answers may be used more than once) 1. Microvascular 2. Macrovascular 3. Autonomic Neuropathy 4. Sensory Neuropathy _____a. Urinary retention _____b. Damage to small vessels that supply the renal glomeruli ___ _ c. Related to altered lipid metabolism of diabetes ____d. Microaneurysms and destruction of retinal capillaries _____e. Atrophy of small muscles of the hands and feet _____f. Capillary and arteriole membrane thickening specific to diabetes ____ g. Pain and paresthesia of the legs _____ h. Ulceration and amputation of the lower extremities ___4__i. Foot ulcers without patient feeling pain _____j. Nausea and or vomiting _____k. Ischemic heart disease _____l. Painless myocardial infarction _____m. Male impotence

___3__a. Urinary retention ___1__b. Damage to small vessels that supply the renal glomeruli ___2 _ c. Related to altered lipid metabolism of diabetes ___1__d. Microaneurysms and destruction of retinal capillaries ___4__e. Atrophy of small muscles of the hands and feet ___1__f. Capillary and arteriole membrane thickening specific to diabetes ___4_ g. Pain and paresthesia of the legs ___2__ h. Ulceration and amputation of the lower extremities ___4__i. Foot ulcers without patient feeling pain ___3__j. Nausea and or vomiting ___2__k. Ischemic heart disease ___3__l. Painless myocardial infarction ___3__m. Male impotence

Diabetes Melitus

a chronic multisystem disease characterized by hyperglycemia related to abnormal insulin production, impaired insulin utilization, or both Affects 29.1 million peopleSeventh leading cause of death

Patho of HTN

· Persistently increased SVR · Abnormalities in any mechanisms involved in maintenance of normal BP Pathophysiology Genetic links · Different sets of genes regulate BP at different times · Although known contribution small, current research ongoing Water and sodium retention · Only 1 in 3 people who consume high sodium diet develop hypertension · High sodium intake may activate a number of pressor mechanisms, resulting in water retention Stress and increased SNS activity · Causes increased vasoconstriction · ↑ HR · ↑ renin release Altered renin-angiotensin-aldosterone system (RAAS) · Increased renin activates RAAS · Renin levels do not decrease in response to elevated BP Insulin resistance and hyperinsulinemia · High insulin concentration stimulates SNS activity and impairs nitric oxide-mediated vasodilation Endothelium dysfunction · Impaired response to nitric oxide vasodilation · Elevated endothelin → vasoconstriction

Nutritional Therapy COPD

· Weight loss and malnutrition are common. o Full stomach- doesn't do well with this because causes difficulty breathing o Difficulty breathing o To decrease dyspnea and conserve energy · Rest at least 30 min before · Nutritional therapy Supplemental O2 may be helpful. Eat five to six small meals to avoid bloating and early satiety. Avoid · Foods that - require a lot of chewing · Exercises/treatment - 1 hour before and after eating · Gas-producing - gas producing foods · High-calorie, high-protein diet is recommended. Fluids (intake of 3 L/day) should be taken between meals

Metabolic Acidosis Info

• Metabolic acidosis occurs when an acid other than carbonic acid accumulates in the body or when bicarbonate is lost in body fluids. • Ketoacid accumulation in diabetic ketoacidosis and lactic acid accumulation with shock are examples of acid accumulation. • Severe diarrhea results in loss of bicarbonate. • In renal disease, the kidneys lose their ability to reabsorb bicarbonate and secrete hydrogen ions. • To compensate for metabolic acidosis the kidneys attempt to excrete additional acid and the lungs increase CO2 excretion. The patient often develops Kussmaul respirations (deep, rapid breathing). • If metabolic acidosis is present, calculating the anion gap can help determine the source of metabolic acidosis. The anion gap is the difference between the measured serum cations and anions in ECF. • You calculate an anion gap by using the following formula: • Anion Gap = Na+—(HCO3− + Cl −) • A normal anion gap is 8 to 12 mmol/L. The anion gap increases in metabolic acidosis associated with acid gain (e.g., lactic acidosis, diabetic ketoacidosis), but is normal in metabolic acidosis caused by bicarbonate loss (e.g., diarrhea). • Excess carbonic acid or base bicarbonate deficit caused by · Ketoacidosis · Lactic acid accumulation (shock) · Severe diarrhea · Kidney disease- Compensatory mechanisms · Increased CO2 excretion by lungs o Kussmaul respirations (deep and rapid) Anion gap - = Na+ (-) (cl+ HCO3) - Normal: 8-12 mmol/L - Increased with acid gain

Metabolic Alkalosis info

• Metabolic alkalosis (base bicarbonate excess) occurs when a loss of acid (prolonged vomiting or gastric suction) or a gain in HCO3− (e.g., ingestion of baking soda) occurs. • Renal excretion of HCO3− occurs in response to metabolic alkalosis. • The lung's compensatory response is limited. The respiratory rate decreases in order to increase plasma CO2. However, once hypoxemia occurs or plasma CO2 reaches a certain level, stimulation of chemoreceptors increases respirations. Base bicarbonate excess caused by · Prolonged vomiting or gastric suction · Gain of HCO3 Compensatory mechanisms · Renal excretion of HCO3 · Decreased respiratory rate to increase plasma CO2 (limited)

Respiratory Alkalosis info

• Respiratory alkalosis is carbonic acid deficit that occurs with hyperventilation, or an increase in respiratory rate or volume. • The primary cause of respiratory alkalosis is hypoxemia from acute pulmonary disorders. • Hyperventilation can occur as a physiologic response to metabolic acidosis and increased metabolic demands (e.g., fever). Pain, anxiety, and some CNS disorders can increase respirations without a physiologic need. • Pain, anxiety, and CNS disorders can increase the ventilation rate. Hyperventilation "blows off" CO2, leading to a decreased carbonic acid concentration in the blood and an increased pH. • Compensated respiratory alkalosis is rare. In acute respiratory alkalosis, aggressive treatment of the causes of hypoxemia is essential and usually does not allow time for compensation to occur. Some buffering may occur with shifting of bicarbonate (HCO3−) into cells in exchange for Cl−. In chronic respiratory alkalosis that occurs with pulmonary fibrosis or CNS disorders, compensation may include renal excretion of bicarbonate. Carbonic acid deficit caused by · Hypoxemia from acute pulmonary disorders · Hyperventilation Compensation · Rarely occurs when acute · Can buffer with bicarbonate shift · Renal compensation if chronic

Prediabetes

↑ Risk for developing type 2 diabetes -Impaired glucose tolerance (IGT)OGTT - 140-199 mg/dL -Impaired fasting glucose (IFG) -Fasting glucose 100-125 mg/dL -Intermediate stage between normal glucose homeostasis and diabetes -Asymptomatic but long-term damage already occurring -Patient teaching important -Undergo screening -Manage for symptoms of diabetes -Maintain healthy weight, exercise, make healthy food choices