NCLEX #4

What diagnostic test do we need to assess?

Blood glucose levels (70-110 fasting) HgbA1C

After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse performs an assessment on the client, knowing that which symptom is most indicative of this disorder? A.Fatigue B.Diarrhea C.Polydipsia D.Weight gain

C - (eliminate option 1 because of the word most) DI is characterized by polydipsia and polyuria, low specific urine gravity, anorexia and wt loss not wt gain

The client with DKA is given normal saline IV and regular insulin. In addition to hourly blood glucose monitoring, the nurse would look to what assessment data as early signs of clinical improvement? A.Respiratory rate of 12 to 15 and normal BP in standing position B.Temperature and pulse in normal range C.Improved level of consciousness (LOC) and decreasing urine output D.Client eats a full and respiratory rate is normal.

C - LOC responds quickly to changes in pH and restoration of fluids and electrolytes. UO decreases as hyperglycemia improves; resp system takes a few hours to respond to changes and will come down to a high normal rather than a low normal. Dehydration is usually so severe that it takes hours to rehydrate and increase strength of pulse.

What risks are associated with someone with DM

Heart, (HTN, CAD, PVD) Renal, Neuro, retinopathy, mephropathy, neuropathy

Types of Short Acting Insulin

Humulin R Novolin R = regular short

What management and treatment interventions

Diet Medications Insulin

Chronic Kidney Disease (CKD)

Progressive, irreversible loss of kidney function GFR ≤ 60 mL/min for 3 months or longer Stages 1-5

Creatinine

0.6 - 1.3 mg/dL

Nephrotoxic Drugs/Substances

Antibiotics - Amphotericin, Methicillin, Rifampin, Sulfonamides, Tetracycline, Vancomycin, Gentamycin (and other mycins) Antineoplastics - Cisplatin, Methotrexate NSAIDS - Celecoxib, Ibuprofen, Ketoralac, Naproxen Others - Captopril, Cyclosporine, Quinine Radiographic Contrast dyes Heavy Metals - Arsenic, Copper, Gold salts, Lead

treatment for Renal Calculi

Assess, monitor I &O, push fluids >3L / day; heat to flank, analgesics, strain urine, Surgery - cystoscopy (for stones in bladder); Extracorporeal shock wave lithotripsy (ESWL) (ultrasonic waves used to break up stones); Percutaneous Lithotripsy; Ureterolithotomy - surgical procedure to remove stone in ureter

The client is admitted with metabolic acidosis secondary to DKA. Which of the following does the nurse formulate as the priority nursing diagnosis? A.Impaired Urinary Elimination related to reduced output and muscle function B.Deficient fluid volume related to high urine output C.Ineffective breathing pattern related to hyperventilation D.Anxiety related to fears of long-term outcomes and discomfort

B The severe dehydration is highest priority, hyperventilation is a manifestation of the acidosis and does not reflect an ineffective breathing pattern

In developing a plan about hypoglycemia for a newly diagnosed Type I diabetic, which sign or symptom should the nurse include? A.Shakiness B.Increased thirst C.Fever D.Fruity breath

A - s/s of hypoglycemia include shakiness, sweating, pale cool skin, and irritability

Why should the client taking glucocorticosteroids as replacement therapy or to treat an existing disease never miss a dose or suddenly stop taking the medication?

Clients on long-term and high dose glucocorticoid therapy are at risk for suppression of Adrenocorticotropic hormone which can suppress cortisol, therefore the patient can go into acute adrenal insufficiency (Addisonian crisis). Clinical manifestations are hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, confusion, and shock.

Polycystic Kidney Disease

Cyst of the kidneys Genetic autosomal disease Clinical Manifestations Often asymptomatic til 30's Flank, lumbar, abd pain; fever, chills, recurrent UTIs, hematuria, proteinuria, pyuria, Calculi, HTN, palpable abd mass and enlarged kidneys Interventions Increase Na and H20 intake Bedrest if cyst ruptures and bleeding occur Manage symptoms for pain, fever, UTI Prepare for dialysis, renal transplant as leads to ESRD

Lispro insulin (Humalog) is prescribed for the client, and the client is instructed to administer the insulin before meals. When should the nurse instruct the client to administer the insulin? A.45 minutes before eating B. 60 minutes before eating C.90 minutes before eating D. Immediately before eating

D. Lispro insulin acts more rapidly than regular insulin and has a shorter duration of action. The effect of lispro insulin begins within 25 minutes after subcutaneous injection, peaks in 0.5 to 1.5 hours, and has a duration of action of approximately 5 hours. Because of its rapid onset, it can be administered from 15 minutes to immediately before eating. In contrast, regular insulin is generally administered 30 minutes before meals.

Treatment

Diet (low carb but complex carbs ok in mod amts; avoid simple sugars)) Alcohol can lower BG and can cause hypoglycemia Oral antidiabetic meds (type II only) Insulin therapy Only short acting insulins given IV (Regular most commonly but now Lispro, Aspart, and Glulisine) other routes subq; insulin pumps (know how to adm insulin)

signs of hypoglycemia

Dizziness Moodiness Inability to concentrate Slurred Speech Shakiness

The client with SIADH is upset at not being able to drink fluids whenever she wants. How should you respond?

Explain to the patient their diagnosis. And that fluid needs to be restricted until electrolyes (sodium) is restored and fluid volume is normal. Teach of s/s Educate on proper fluid restrictions and sources of fluid to measure Weigh daily and report weight gain > 2 lbs/day Diet w/ sodium and potassium supplements if diuretics are prescribed Medication education

Causes of Renal Calculi

Family, high calcium, vitD, protein, oxalate, purine, or alkali diets; urinary stasis, dehydration, hypercalcemia, hyperparathyroidism, elevated uric acid (gout)

Fasting

Fasting means after not having anything to eat or drink (except water) for at least 8 hours before the test. This test is usually done first thing in the morning, before breakfast. Diabetes is diagnosed at fasting blood glucose of greater than or equal to 126 mg/dl.

SIADH

Fluid volume excess, increased BP, crackles in lung fields, distended jugular veins, taut skin, Intake > output, small amount of concentrated urine, vomiting, fatigue, nausea, muscle aches, abdominal cramps, weight gain w/o edema, excessive thirst As serum sodium levels decline leads to cerebral edema, altered level of consciousness, seizures, Headache, anorexia, & coma.

What to do when a patient in hypoglycemic?

Give them simple sugars! Orange Juice or Grape Juice Glucose tabs Glucose Tubes

Protein (24 hour urine)

Less than 150 mg/ 24 hours

Type 1 Diabetics

NEED INSULIN Diet and exercise

Types of Intermediate Acting Insulin

NPH ; 70/30

Peritoneal Dialysis

Peritoneal Dialysis •Use of peritoneal access catheter placed in ant abd wall •Allow immediate use once cath inserted •A cycle involves: inflow, dwell, and drain •Dialysate volumes from 1L - 3L, high glucose concentration increases osmotic forces. •Risk - peritonitis, abd pain with too rapid infusion, hyperglycemia, exit site infection, hernias, pulmonary complications, protein loss

Acute Kidney Injury

Rapid loss of kidney function Potentially reversible depending to severity of damage, however high mortality rates

Anything greater than 6.5

Means they are a diabetic

Stages of Chronic Kidney Disease

Stage 1 at risk GFR >90 dx and treat CVD; slow progression Stage 2: Mild CKD - 60-89 Stage 3: Mod 30-59 GFR evaluate and treat complications Stage 4: Severe GFR 15-29 preparation for kidney transplant Stage 5: ESKD <15mL dialysis or replacement required

Diabetes Insipidus Treatment

Monitor I&O (report UO > 200 ml/hr for 2 hours) Daily weights Monitor urine specific gravity Encourage fluid intake greater than urine output Use skin protective barriers Medication therapy as ordered Nursing Diagnosis: fluid volume deficit; risk for constipation, risk for impaired skin Integrity

Assessment

changes in weight, nutrition pattern, elimination pattern, VS, skin, wound healing, changes in vision, sensory perception (neuropathy), decreased activity tolerance. Polyuria, polydipsia, poly phagia, wt loss commonly seen in Type I Polyuria, polydipsia, blurred vision, fatigue, numbness, skin infections, and polyphagia in type II

Diagnosing Diabetes

The A1C test measures your average blood glucose for the past 2 to 3 months. The advantages of being diagnosed this way are that you don't have to fast or drink anything. Diabetes is diagnosed at an A1C of greater than or equal to 6.5%

Cystitis

or commonly referred to as UTI painful urination, frequency, and urgency are common s/s of cystitis or bladder infection. Also urine may have a foul odor and appear cloudy. Lower abd or back pain, hematuria, malaise, fever, chills, n/v, elevated WBC (Change in mental status is common in elderly) Caused by allergens, irritants (soaps, perfumes), urinary stasis, indwelling caths, sexual intercourse, use of spermicides

What assessment findings for a client with DM?

Three P's - Polyuria, Polydipsia, Polyphagia

Treatment for DKA

Treatment: - IVF rehydration (NS bolus then 200-500 mL/hr until stabilized); insulin (typically reg insulin drip); electrolytes, supportive care may need mechanical ventilation for resp failure and vasopressors for hypotension. Make sure you monitor LOC as cerebral edema may develop w/ NS bolus and insulin can cause hypoglycemia KCL replacement once acidosis is reversed and insulin is administered because K shifts into the instracellular compartment and serum level can drop quickly. Necessary to monitor ECG and cardio status Restore fluids loss, electrolytes, and glucose. Monitor I&Os; BG, Urine, O2, and resp pattern

What is the difference between Type I and Type II

Type I - early onset typically children Type II - adult onset common in African Americans and Native Americans

Glomerulonephritis

- inflammation of glomeruli affects both kidneys s/s - hematuria, proteinuria, elevated BUN, elevated serum creatinine levels, generalized edema, htn, oliguria, proteinuria, fluid retention, Tx on symptomatic treatment,

Kidney Transplant

•Human kidney transplant •Recipient must take immunosuppressive medications for life •Postoperative Care: VS; LOC, dressing; TCDB; strict aseptic technique; monitor UO & I &O closely; observe for s/s of rejection; manage pain; monitor labs and urinalysis; cardiac monitoring; daily wts; fluid restrictions •Rejection: (Box 62-12) •Hyperacute •Acute •Chronic

Hemodialysis

•Requires vascular access device •Arteriovenous Fistulas •Arteriovenous grafts •Temporary Vascular Access catheters •Two insertion sites one for removing blood and one for return of dialyzed blood •Blood is heparinized to prevent clotting •Pre-assessment: wt, vs, edema, heart, lung sounds, temp, general condition •During - frequent VS q 30 mins; elevation of feet; monitoring for complications

Kidney Transplant Procedure

Type and histocompatibility testing necessary; screening of donor, family preferred Pre-op care - consent, preparation for sx and post care; dialysis 24 hours prior to sx; no infections of either donor and recipient Post-op - urine output is usually immediate if living donor - HD may be performed until adequate kidney function established; urine output less than 100ml/hr should be reported; give diuretics; fluids as prescribed; Position pat in semi-fowlers Foley care - usually intact 3-5 days urine will be pink initially •Hyperacute - immediate, no uo; must remove kidney and provide HD •Acute - days to months after sx; sharp drop in UO; BUN & Cr rise, fever, swelling, tenderness. Usually reversible with high dose corticosteroids and increased immunosuppressive agents •Chronic - immunosuppressive agents and may need retransplantation if necessary.

Urinalysis

Urine Specific Gravity - 1.016 - 1.022; Color; pH (5-9); protein; glucose; ketones; & Blood

Diagnostic Findings for Diabetes Insipidus

Urine specific gravity < 1.005 Urine osmolality <300 Positive water deprivation test Serum sodium > 145mEq/L Identify the primary cause of DI

Phases of AKI

1. Onset -precipitating event usually no s/s 2. Oliguric Phase - lasts 8-15 days; sudden decrease in urine output; s/s HTN, edema, dysrhythmias, HF, pulm edema, anorexia, n/v, Kussmauls resp, changes in LOC, pericarditis 3. Diuretic Phase - slow increase of urine output; dehydration; hypotension, tachycardia; LOC improves 4. Recovery Phase - slow process may take 1-2 years. Urine volume returns to normal; strength increases, recover to near normal values

Primary Functions of Kidney

1. Regulate the volume and composition of extracellular fluid 2. Excrete waste products from the body 3. Maintain acid-base balance 4. Excrete bacterial toxins, water soluble drugs, and drug metabolites 5. Secrete renin to regulate the blood pressure and erythropoietin to stimulate RBC productions 6. Synthesize Vit D for calcium absorption and regulate parathyroid hormone

Risk Factors for Type II Diabetes

age, family history, ethnic group, social class, fetal nutrition and early growth pattern, diet (SFA), inadequate physical activity, central obesity, metabolic syndrome

Pyelonephritis Treatment

assess monitor nutritional status; I & O; fluid and electrolyte balances, VS, increase fluid intake to 2 L; antipyretics as needed, antibiotics as needed, (mild may be treated at home, severe hospitialization for 24-48 hr with IV antibiotics) surgery for extreme cases as it may lead to septic shock, CKD, hypertension

Diagnostics

blood glucose; serum ketones, elevated HgbA1C (range: 5.5-7); two-hour glucose tolerance test; urine for glucose and ketones

Treatment of Acute Kidney Injury

Acute Kidney Injury

Alcohol and diabetes

client is at risk for hypoglycemia. Body looks at alcohol as toxin. 2 drink maximum (12oz of beer, 5 oz of wine, 1 oz hard liquor)

An external insulin pump is prescribed for a client with diabetes mellitus and the client asks the nurse about the functioning of the pump. The nurse bases the response on which information about the pump? A.Is timed to release programmed doses of short-duration or NPH insulin into the bloodstream at specific intervals B.Continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels C.Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream D.Gives a small continuous dose of short-duration insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal

A - An insulin pump provides a small continuous dose of short-duration (rapid or short-acting) insulin subcutaneously throughout the day and night, and the client can self-administer a bolus with an additional dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.

Glimepiride (Amaryl) is prescribed for a client with diabetes mellitus. The nurse instructs the client to avoid consuming which food while taking this medication? A.Alcohol B.Organ meats C.Whole grain cereals D.Carbonated beverages

A - When alcohol is combined with glimepiride (Amaryl), a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication. The items in options 2, 3, and 4 do not need to be avoided.

A client with new onset type I DM asks why he needs to check his blood glucose level so frequently. The nurse explains that frequent coverage with insulin to keep the blood glucose level between 70-120mg/dL is important for which reason? A.Chronic elevated blood glucose levels damage cells and cause multiple organ damage B.High glucose levels cause the body to use proteins for energy, causing lactic acidosis C.Early identification of hypoglycemia before the onset of symptoms is easier to treat D.Carbohydrates are constantly being converted to glucose and transported in the bloody by insulin.

A - chronic hyperglycemia leads to retinopathy, nephropathy, and neuropathy. Lactic acidosis occurs with DKA and metabolism of fat. Insulin is needed to carry glucose across the cell membrane into the cell not to be transported in the blood.

Urea Nitrogen (24 hour urine)

6-17 g/24 hours

A client who suffered a brain injury after falling off a ladder has recently developed SIADH. What findings indicate that the treatment he's receiving for SIADH is effective?Select all that apply. A.Decrease in body weight B.Rise in blood pressure and a drop in heart rate C.Absence of wheezes in lungs D.Increase in urine output E.Decrease in urine osmolarity

A, D, and E

Who needs dialysis? (Check the vowels: AEIOU)

A- Acid-Base Problems E- Electrolyte Problems I- Intoxications O- Overload of fluids U - Uremic Symptoms

Pre-renal caused by

hypovolemia, dehydration, diuretic therapy, shock

Diagnosis of Acute Kidney Injury

increased serum creatinine, increased BUN (80-100), hyponatremia if prerenal or hypernatremia if intrarenal, hyperkalemia, hyperphosphatemia, hypocalcemia, decreased Hct, metabolic acidosis, KUB, ultrasound, CT, biopsy, Cystogram or pyelography)

Glimepiride

is a sulfonylurea stimulates the production of insulin and you must avoid alcohol

OGTT (oral glucose tolerance test)

is a two-hour test that checks your blood glucose levels before and 2 hours after you drink a special sweet drink. It tells the doctor how your body processes glucose. Diabetes is diagnosed at 2 hour blood glucose of greater than or equal to 200 mg/dl

Pyelonephritis

is an infection of the kidney pelvis, can be associated with chronic UTI, increased risk for men >65 with prostatitis and hypertrophy of the prostate, pregnancy, chronic renal calculi S/S chills, abd pain, n/v/, burning/frequency with urination, nocturia, fever, hypertension DX: labs, urinalysis, elevated BUN and Creatinitne, KUB, US, IVP

Type II Diabetes

lack of insulin or resistance to insulin (cant metabolize carbohydrates) most common - unknown cause but risk factors include obesity, diet, older adults and more common in African Americans and Hispanics

Causes of Chronic Kidney Disease (CKD)

leading causes r/t DM & HTN, chronic urinary obstruction, recurrent infections, renal artery occlusion, autoimmune disorders

What is DKA

life threatening metabolic acidosis resulting from persistent hyperglycemia and breakdown of fats into glucose. Caused by stress, exercise, infection, trauma, or delayed insulin administration

Types of Rapid Insulin

most end in log - Novolog(Aspart)/Humolog (Lispro)/Apidra (Glulisine)

Treatment for Cystitis

obtain urine C&S; push fluids, administer antibx, treat sx, maintain ph of 5.5 by consuming foods to maintain acidic urine, avoid irritants,

Diabetes Insipidus Symptoms

polyuria; clear urine Polydipsia Dry, cool, skin Tachycardia Electrolyte concentration Low specific gravity Hypotension Changes of LOC Hypernatremia Fatigue and generalized weakness Weight loss, constipation SHOCK and Coma

Severe hypoglycemia

seizures, coma, less than 50, altered behavior, 15 mg oral CHO if conscious, IV glucose 25-50% solution, IV D5W, glucagon injection, buccal administration,

Retrograde cystography

uses contrast dye helps diagnose ruptured or neurogenic bladder and other conditions

Expected findings in Acute Kidney Injury

decreased uo; fluid overload, edema, dysrhythmia r/t hyperkalemia; crackles, decreased ox sat, SOB, lethargy, muscle twitching, szs, dry skin and mucous membranes

Type I Diabetes

destruction of beta cells of pancreas. Genetic predisposition most commonly found in children and adolescents (lack of insulin production and result in hyperglycemia and ketosis (ketones in blood resulting from gluconeogenesis of fats)

Renal Venography

detect renal vein thrombosis

Renal Angiography

detects cysts, renal artery stenosis, and renal infarction

24 hour urine

discard first sample then collect for 24 hours refrigerate or keep on ice; last urine of 24 hour goes in sample.

Clinical Manifestations of Chronic Kidney Disease

fatigue, anemia, varying urine output, nausea/vomiting; apathy; lethargy; confusion; sensory loss; seizures; Kussmal resp associated with deep coma; pallor; itchy skin; "uremic frost" tremors; HTN; pericardial effusion; HF; pleural effusion; cardiac tamponade; pulm edema; gastritis (possible GI bleed); ecchymosis; purpura; bone pain; pathological fractures; decreased sexual function, insomnia

Insulin glargine (Lantus) is prescribed for a client with diabetes mellitus. The nurse should tell the client that it is best to take the insulin at which time? A.At bedtime B.1 hour after each meal C.15 minutes before the morning and evening meal D.Before each meal, on the basis of blood glucose level

A. Insulin glargine is a long-acting recombinant DNA human insulin that is used to treat type 1 and type 2 diabetes mellitus. It has a 24-hour duration of action and is administered once a day, usually at bedtime. Therefore, options 2, 3, and 4 are incorrect times.

The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? A.Withdraws NPH insulin first B.Withdraws the regular insulin first C.Injects are into the NPH insulin vial first D.Injects an amount of air equal to the desired dose of insulin into each vial

A. When preparing a mixture of short-acting insulin such as regular insulin with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type. Options 2, 3, and 4 identify correct actions for preparing NPH and short-acting insulin.

The nurse is caring for a client who is taking 4 units of regular insulin and 30 units of NPH insulin at 8:00 am. The nurse keeps which of the following in mind regarding this regimen? Select all that apply. A.Assess client for hypoglycemia shortly before lunch B.Assess client for hypoglycemia at dinnertime C.Shake vial of insulin to disperse insulin particles evenly D.Administer room temperature insulin only E.Neither insulin can be administered intravenously

A.Assess client for hypoglycemia shortly before lunch B.Assess client for hypoglycemia at dinnertime D.Administer room temperature insulin only

Which of the following assessments may be related to the low serum sodium seen in patients with syndrome of inappropriate secretion of antidiuretic hormone? A.Central nervous system changes B.High urinary output C.Hypotension D.Weight loss

A.Central nervous system changes

A client is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply. A.Hypoglycemia may be experienced before dinnertime. B.The insulin dose should be decreased if illness occurs. C.The insulin should be administered at room temperature. D.The insulin vial needs to be shaken vigorously to break up the precipitates. E.The NPH insulin should be drawn into the syringe first, then the regular insulin.

1.Hypoglycemia may be experienced before dinnertime. 3.The insulin should be administered at room temperature. Humulin NPH is an intermediate-acting insulin. The onset of action is 1.5 hours, it peaks in 4 to 12 hours, and its duration of action is 24 hours. Regular insulin is a short-acting insulin. Depending on the type, the onset of action is 0.5 hour, it peaks in 2 to 5.5 hours, and its duration is 5 to 8 hours. Hypoglycemic reactions most likely occur during peak time. Insulin should be at room temperature when administered. Clients may need their insulin dosages increased during times of illness. Insulin vials should never be shaken vigorously. Regular insulin is always drawn up before NPH.

Creatinine (24 hour urine)

15-25 mg/kg in 24 hours

Creatinine Clearance

70-135 mL/min

BUN

8-25 mg/dL;

A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide (DiaBeta) daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL. Which medication, if added to the client's regimen, may have contributed to the hyperglycemia? A.Prednisone B.Phenelzine C.Atenolol D.Allopurinol

A.Prednisone Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Option 2, a monoamine oxidase inhibitor, and option 3, a b-blocker, have their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents, causing increased levels of the oral agents, which can lead to hypoglycemia.

Who has a higher chance of developing Type II Diabetes?

African Americans, Hispanics and Native Americans

Diagnostic Findings in DKA

BG greater than 300; plasma pH less than 7.35; HCO3 less than 15 mEq/L; serum ketones, urine +ketones and glucose; changes in serum sodium and hyperkalemia.

Post-renal caused by

BPH, renal/kidney stones, tumors, cystitis

Acute Kidney Injury Phases

Begins with onset and ends with oliguria (100-400 ml/24 hrs) with or w/o diuretics lasts 1-3 wks; Diuresis begins when kidney starts to recover and can last 2-6 wks; Recovery continues until kidney function is fully restored

A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time should the nurse plan to assess the client for a hypoglycemic reaction? A.10:00 B.11:00 C.17:00 D.23:00

C. Humulin N is an intermediate-acting insulin. The onset of action is 1.5 hours, it peaks in 4 to 12 hours, and the duration of action is 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time.

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar state (HHS) is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? A.Endotracheal intubation B.100 units of NPH insulin C.IV of NS D.IV infusion of sodium bicarbonate

C.The primary goal of treatment in hyperglycemic hyperosmolar state (HHS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS.

Symptoms of DKA

Dehydration; metabolic acidosis, nausea, vomiting, excessive thirst, malaise, polyuria, Kussmual respirations, dry skin with poor turgor, abd pain, hypotension, weak thready pulse, and can lead to coma and death!!!

Biguanides

Glucophage /Metformin increase insulin sensitivity must be cautious if client has renal disease and if receiving contrast dyes b/c of renal and acidosis

Types of Long Acting Insulin

Insulin Glargine (LANTUS) or Levemir *never mix!*

Subjective Data

PMH including medications Nutrition/diet Elimination s/s of disorders of renal/urinary system: ◦Dysuria/pain ◦Edema ◦Neuro = headache, fatigue, vision, itching ◦Anorexia, wt loss, n/v, excessive thirst

Metformin

Page 660 Causes lots of GI disturbances because of Diarrhea

Intermediate Acting Insulin

Onset 1.5 hours Peak 4-12 Duration 16 - 24

Rapid Insulin

Onset 15 min Peak 1hr Duration 3

Long Acting Insulin

Onset 2 - 4 hrs Duration 24 hours

Short Acting Insulin

Onset 30 mins Peak 2-4 hrs Duration 4-7

What are the causes?

Pre-renal - decreased blood flow to kidneys Intrarenal - disease, ischemia, or toxic conditions within the kidneys Postrenal - any condition that obstructs urine flow

Objective Data

Skin - color changes, uric frost, itching Ammonia odor on breath Abdomen - distension, palpate bladder, masses or tenderness Percuss - Costovertebral angle tenderness Auscultate - renal arteries for bruits

Intrarenal caused by

glomerulonephritis, vasc d/o, toxic agents, or severe infections nephrotoxicity

Treatment of CKD

•Dialysis or kidney transplant •Symptomatic and management of related complications (i.e. Anemia, GI oral, electrolyte imbalances, etc) •Diet modification - low protein, high carbohydrate, low na, low K, low phosphorous (refer to Lewis table 47-10) •Nursing: Cardiac monitoring, VS, Daily Wts, I&Os, restrict fluids as ordered, monitor fluid and electrolytes, manage n/v; provide rest periods; skin care, Medication therapy •Avoid - nephrotoxic drugs, NSAIDS, ACE Inhibitors; IV contrast dye; meds that contain magnesium (i.e. MOM), aluminum hydroxide- antacids (Maalox or Mylanta)