Nurs 122 Exam 3

Nurse's role in preventing drug resistance Actively participate in

"Pharmacy committee" meetings & learn what hospital is doing to address antibiotic resistance

Nonspecific immune response First line of defense

-Anatomic barriers -Mechanical forces -Chemical barriers -Individual factors

Sulfonylureas examples

-Glipizide [Glucotrol] -Glimepiride [Amaryl] -Glyburide [Diabeta, glynase, microsnase] -Insulin secretagogues

Inflammatory response: vascular response to injury

-Increased vasodilation -Increased capillary permeability -Fluid & plasma proteins shift [forming exudate]

Signs of inflammation [local]

-Redness -Warmth -Swelling -Pain -Loss of function

Inflammatory response is body's response to tissue injury or irritant Mechanical

-Trauma -Cells break open & we have to have WBC come

Diabetes: chronic medical condition

-does last a lifetime -we cant cure or heal it. But can control it

Antibiotics are no longer routinely used to treat infections because:

-many infections are caused by viruses, so antibiotics are not effective -antibiotics are often unlikely to speed up healing process and can cause side effects

Hypoglycemia common causes

-meal delayed or no eating -insulin timing -excessive exercise -alcohol

Aminoglycosides [gentamicin, neomycin, amikacin, tobramycin, streptomycin] end in

-mysin

Not everyone can use insulin pump

-to be on pump, need to be committed to managing diabetes, really understand food choices and how affects blood sugar, must check blood sugar multiple tiems a day to make sure not too low

Why establish an IV for her? [sepsis]

-to give IV fluids -to give meds -her BP is low, can increase volume status [give IV bolus fluid and get bp up]

Hypoglycemia can be caused by

-too little food or skip a meal -too much insulin or diabetes pills -more active than usual

Distributive shock:

-when bv lose tone, they become so open and floppy that not enough bp supplies organs

The immune system distinguishes what groups of foreign substances?

1) Antigens freely circulating in body 2) Self cells that display as aberrant

Sepsis/urosepsis - What orders do you implement first and why Establish peripheral IV 0.9% NS 1000 mL IV bolus Acetaminophen 650 mg Ceftriaxone 1g IVPB...after blood/urine cultures obtained Morphine 2 mg IV push every 2 hours prn-pain

1. Establish peripheral IV -C-circulatory priority required before IV fluids can be administered 2. 0.9% NS 1000 mL IV bolus -C-circulatory priority - low BP & obvious need for IV fluid resuscitation 3. Ceftriaxone 1 g IVPB... after blood urine -must Tx & go after source of present prob. Is not technically C priority so falls to #3 4. Morphine 2 mg IV push every 2 hours prn - pain -pain control is always higher priority & needs to be addressed sooner vs later but is not ABC priority 5. Acetaminophen 650 mg -Fever is beneficial & will not harm the pt

Hypoglycemia if not awake In acute care settings

20 to 50 mL of 50% dextrose IVP

Oral glucose tolerance test [OGTT] diabetes

200 mg/dl or higher

AIC of 10 average blood sugar

275

Insulin: rapid acting Lispro, aspart, glulisine Duration

3-4 hours

Check blood sugar

3-4 times a day in hospital

Regular: short acting insulin duration

3-6 hours

Regular: short acting insulin onset of action

30-60 minutes

AIC of more than or equal to 12 average blood sugar

345

Insulin: NPH intermediate acting peak

4-10 hours

Diabetes: hyperosmolar hyperglycemic syndrome [HHS] also [HHNK] Blood glucose >

400 mg/dL

Administration of insulin degree angle

45-90 depending on fat thickness of pt

The inflammatory reaction is normally characterized by

5 distinct signs, each of which is due to physiological response to tissue injury

WBC count normal

5,000-10,000 cells/mm^3

Normal WBC range

5,000-10,000 circulating in blood

Insulin: rapid acting Lispro, aspart, glulisine Onset

5-15 minutes

A1C prediabetes

5.7-6.4%

Prediabetes A1C levels :

5.7-6.4%

neutrophils start to rise within

6 hours of contracting bacterial infection.

A1C diabetes

6.5% or higher

Diabetes: neuropathy How many?

60-70% of pts w diabetes have some degree of neuropathy

A1C level Ideal goal ADA ACE

ADA ≤7.0% <6.5%

DKA: like

Acute hyperglycemia and pt is also acidotic -usually caused by profound deficiency of insulin -it can occur in type 2 but usually don't see it. -

Hypoglycemia: if give glucagon, -

After get blood glucose back up to 70, right away chase up with protein or carb to maintain blood sugar bc can plummet back down again [rebound hypoglycemia]

Septic shock medical management Nutritional therapy.

Aggressive nutritional supplementation is critical in management of septic shock bc malnutrition further impairs pt resistance to infection.

Sepsis nursing interventions · Infection control.

All invasive procedures must be carried out w aseptic technique after careful hand hygiene.

M.W. is to immunotherapy. What precautions does the nurse use during the administration of the allergen extract?

Allergen extracts are used for diagnosis and/or treatment of allergic diseases such as allergic rhinitis ("hay fever"). HCP, emergency equipment, emergency drugs, administer away from joint so tourniquet can be applied. Assess for systemic reactions - pruritis, urticaria, sneezing, laryngeal edema, hypotension. Observe patient for 20 minutes.

How do antihistamines act to relieve allergic symptoms? What information should the nurse include in teaching M.W. about using his antihistamines?

Antihistamines relieve allergic symptoms by competing w histamine for H2 receptor sites and thus block effect of Histamine.

Septic shock manifestations Changes in mentation.

As body slowly becomes acidotic, patient's mental status also deteriorates.

Sepsis/urosepsis What nursing assessment(s) will you need to initiate to identify this complication [septic shock]EARLY if it develops?

Assess HR for persistent elevation >90, BP that TRENDS downwards, pale skin color, diaphoresis, altered mental status, increased RR, decreased TREND of urine output that may indicate progression of acute renal failure.

Site of action: reacts against the invading foreign substance by recognizing the antigens present on the surface of the pathogen What type of lymphocyte is this?

B cell

DKA: treatment Monitor

BG every 1-2 hours

Sepsis Appropriate administration of IV antibiotics

Baseline blood cultures must be drawn prior to initiation of antibiotics to ensure appropriate pathogen is identified. Drawing labs, then starting antibiotics as ordered is nurse's responsibility.

Sepsis Assess, monitor, and optimize cardiac output

CO is typically compromised in sepsis. nurse must communicate w MD about this and how to Tx it, as some may need more fluid, or vasopressors, or both. Non-invasive CO monitoring (NICOM or central venous pressure monitoring (CVP are options.

Urine clarity: cloudy clinical significance?

Cloudy urine is usually consistent with infection. [normal is clear]

The three categories of Transmission-Based Precautions include:

Contact Precautions Droplet Precautions Airborne Precautions

Which T cell is this? Attacking the infected cells

Cytotoxic killer T cells

Diabetes: nephropathy main cause of

ESRD

Prediabetes IFG:

Fasting glucose levels higher than normal [>100 mg/dl, but <126 mg/dl]

Lactate: 3.2 Is this high, low or WNL?

HIGH [normal 0.5-2.2 mmol/L]

Creatinine: 1.5 Is this high, low or WNL?

HIGH normal 0.6-1.2 mg/dL

BUN: 35 Is this high, low or WNL?

HIGH normal 7-25 mg/dL

Diff between 1 unit and 1 mL is

HUGE -unit is super tiny doses

Which T cell is this? Regulating the attack process

Helper T cells

Septic shock prevention Prevent central line infections.

Hospitals must implement efficient programs to prevent central line infections, which is most dangerous route that can be involved in sepsis.

Specific immune response: After a lymphocyte recognizes an antigen as foreign, Antibody mediated immune response

Humoral immune response

DKA: treatment IV NS

I/L until BP stable/UOP > 30 cc/hour

What med give for type 1?

Insulin.

Inflammatory response: Examples of release of chemicals

Kinins, prostaglandin & histamine These chemicals work collectively to cause increased vasodilation & permeability of capillaries

Insulin regimens: Basal uses

Lantus and NPH

Child and adolescent School

Lice

Diabetes chronic complications: macrovascular Cardiovascular

MI and cerebrovascular [stroke] disease

Contact infection precautions When to use

MRSA/VRSA C-Diff Strep

-should we see nitrates in urine?

Means bacteria in urine

Which T cell is this? Remembering previous attacks so the next one is a more prompt attack

Memory T cells

-what acid base balance in DKA?

Metabolic acidosis. -bicarb low, pH low, elevation in counter regulatory hormones. -elevated glucose levels: Blocks protein synthesis??,

Biguandies -

Metformin

WBCs : >100 Clinical significance?

Most clinicians place highest significance on this specific finding in UA to determine presence of infection/UTI. Where WBCs are present, they are there for a reason! In this case, the level is high and reflects a positive UTI. Normal [less than 5 in urine]

-should we see protein in urine?

NO. if see large mlc in urine, that means kidneys are damaged. Glomerular should not be allowing large particles like that to pass through.

Oral hypoglycemic agents are

NOT insulin.

What precautions should be taken by the nurse during skin testing?

Never leave pt alone during testing. Have emergency equipment [oral airway, laryngoscope, ET tube, O2, IV, cardiac monitor, defibrillator), essential drugs - epinephrine, antihistamines, corticosteroids, vasopressors.

Nitrate: Positive Clinical significance?

Nitrates are byproduct of gram negative bacterial metabolism. In this context, most common culprit in women is E. coli. The nurse can make early assumption if positive that culprit bacteria causing infection and resultant urosepsis is E. coli. [normal negative]

Meds for type 2 diabetes

Oral hypoglycemic agent, incretin mimetics [biologics] -

*Remember that there are many physical exam findings that can be used to assess fluid volume status (i.e. dehydration).

Other key assessment findings include: decreased urine output, dry mucus membranes, decreased skin turgor.

Type 2 diabetes how many

Over 90% of patients w diabetes

Blood clots can lead to

PE and organ failure and tissue death

Thiazolidinediones:

Pioglitazone [Actos] rosiglitazone [Avandia]

Stress reduction interventions Identifying and using support systems

Providing spiritual support

Hypoglycemia if not awake Administer 1 mg of glucagon IM or subcutaneously Side effect

Rebound hypoglycemia

Creatinine elevated bc Mrs. Kelly bc sepsis/septic shock and lack of perfusion to the kidneys

Regardless of cause of hypotension, kidneys will ultimately take a hit If this lab is elevated, must be trended carefully to see what direction kidney function is going, esp if volume resuscitation has taken place & BP is restored to WNL

With A1C level

Regular assessments required

Storage of insulin IV administration

Regular only

Stages of sepsis: consensus conference definition Sepsis

SIRS plus culture-documented infection

CO =

SV x HR

SMBG

Self monitored blood glucose

Sepsis Assess, monitor, and support oxygen status

Septic pts may need significant resp support, depending on severity. Oxygen delivery and utilization is severely impaired, therefore nurse must assess frequently [ABG's, SpO2) and work w med team on interventions

Sepsis/urosepsis What is the worst possible/most likely complication to anticipate?

Septic shock that over time could progress to Multiple Organ Dysfunction Syndrome [MODS).

What can cause hypovolemic shock

Severe burn, blood or fluid loss from trauma [injury, cut, postoperatively], diarrhea, vomiting,

Septic shock

Severe sepsis with PERSISTENT signs of end organ damage hypotension [SBP < 90] Lactate > 4 mmol

Incretins do what

Stimulate decrease in blood glucose levels

Site of action: reacts against the body's cells that are recognized as being infected by a pathogen What type of lymphocyte is this?

T cell

Cellular immunity

T cells [lymphocytes]

Monitor vancomycin levels as ordered.

Teach pt to report any changes in hearing like -ringing in ears, -feeling of fullness in ears, -n/v w motion, -unsteady gait, -dizziness.

With penicillins and breastfeeding

Tell HCP if pregnant or breastfeeding, so can prescribe most suitable antibiotic for you.

Antibiotics interventions and rationales Monitor for photosensitivity.

Tetracyclines, fluoroquinolones, and sulfonamides can increase client's sensitivity to ultraviolet light and increase risk of sunburn.

Allergy skin test

The test is quick, inexpensive and sensitive. In this test antigen binds to IgE of mast cell on skin.

Accidentally taking an extra dose of antibiotics

There's increased risk of side effects if take 2 doses closer together than recommended.

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. What data from the histories are important and RELEVANT and have clinical significance for the nurse? While taking her bath today, she was weak and unable to get out of the tub and used the help button to call for medical assistance

This confirms the weakness & fatigue she has had past 3 days It is severe weakness & a clinical RED FLAG if she is unable to get out of bath tub and needed to call for assistance

Antibiotics can sometimes interact with other medicines or substances.

This means it can have an effect that is different to what you expected.

Sepsis/urosepsis - Collaborative care: medical management Acetaminophen 650 mg - rationale & expected outcome

Though fever can be beneficial in sepsis, most care providers will order to promote patient comfort. Lowering of fever

Secondary diabetes

Treatment of med condition that causes abnormal blood glucose level

The nurse identifies which lab findings reflects the signs and symptoms of infection? a) serum creatinine level of 2.4 mg/dL [183 umol/L] b) AST [SGOT] 15 uL [0.25 ukat/L] c) WBC count of 16,000 mm^3 d) WBC 4,000 mm^3

WBC count 16,000

Nonspecific immune response Second line of defense

WBC function

Leukotrienes are released by

WBCs and are responsible for vasodilation, chemotaxis and contraction of bronchial muscle.

Oral agents: antidiabetic medications

Work on 3 defects of T2DM

Septic shock preventions Early debriding of wounds.

Wounds should be debrided early so that necrotic tissue would be removed.

Elderly person if not able to perform blood glucose test

[dementia, not independent etc] will be checked less bc not able to do it on own

WBCs - elevated, trending up

[means worsening] -indicates inflammatory response

Macrophages

aid in healing process by engulfing bacteria and dead cells & ingesting them so area is clear for new cells to grow

DKA: treatment Ensure

airway/oxygen

Colloids:

albumin - something that pulls fluid into vascular space

You may experience a skin rash if you take penicillin and

allopurinol, which is used to treat gout.

Both the CDC and health organizations across the world are trying to reduce the use of

antibiotics, especially for health problems that are not serious.

Humoral immunity Products

antibodies

A person can also get passive immunity through

antibody-containing blood products like immune globulin which may be given when immediate protection from specific disease is needed

The humoral response aka

antibody-mediated response

Inflammatory response: Fever may be

beneficial

Type 1 diabetes Peak onset

between ages 11 and 13

Antibodies do what?

bind & inactivate specific antigens

Cephalosporins may increase the chance of

bleeding if taking blood-thinning medications (anticoagulants] such as heparin and warfarin.

Inflammatory response: fever

body temp above 101 F or 38.2 degrees C

Sepsis Assess, monitor, and manage body temp

body temp may be high or low, and we want to warm them if they're too cold [increase room temp, warming blankets) or cool them if fever is too high (antipyretic, cooling blanket, decrease room temp).

What is the inflammatory response?

body's natural response that occurs immediately following tissue damage

Inflammation is the

body's normal protective response to injury, irritation or surgery

Inflammation: This natural defense process

brings increased blood flow to area resulting in accumulation of fluid

Macrolides

broad spectrum antibiotics that end in "thromysin"

-erectile dysfunction: damage to nerves and

bv to penis.

The lymphatic system parallels

cardiovascular system

Aminoglycosides In hospital, blood levels are

carefully monitored to ensure there's safe amount of antibiotic in the blood.

Outside of hospital, diabetics

carry glucagon pen to give emergency sugar.

In very rare cases, fluoroquinolone antibiotics can

cause disabling, long-lasting or permanent side effects affecting joints, muscles and nervous system.

Anaphylactic shock

caused by allergic reaction

Neurogenic shock

caused by damage to nervous system

Although inflammation can be

caused by infection, they are not same and are treated differently

Hypovolemic shock

caused by too little blood volume

Inflammation can cause

cells to clump

Diabetic retinopathy Result of

chronic hyperglycemia

CKD

chronic kidney disease

Diabetes Mellitus

chronic multisystem disease

Fluoroquinolones (such as

ciprofloxacin and levofloxacin) -

Monocytes typically

circulate through blood for 1-3 days before migrating into tissues where they become macrophages or dendritic cells

The lymphatic system is part of

circulatory system & very important part of immune system

DDP-4 inhibitors Sitagliptin [Januvia]

class of oral diabetes med that work by prolonging effect of certain gut hormones called incretins

Serous drainage is

clear, thin, watery plasma

Diabetes foot complications Result from

combo of macrovascular and microvascular diseases

The inflammatory reaction is the

combo of number of overlapping reactions within body -Although a lot of these occur simultaneously, certain order of events may be seen

Glycemic management is best evaluated by

combo of results from SMBG or CGM and A1C.

MNT: when people

come to outpatient nutrition classes by dietitian

Either way, if an immune person

comes into contact w that disease in future, their immune system will recognize it & immediately produce antibodies needed to fight it

What increases risk for infection during hospitalization? Nursing/medical procedures

common modalities: IV lines, injections

Cellulitis

common, potentially serious bacterial skin infection

-so BANDS make us

concerned that infectious process is overwhelming body and no longer able to compensate w wbcs

-if creatinine levels rise,

concerned. -

Antibiotics interventions and rationales ■ Monitor for severe diarrhea. (The

condition may occur owing to superinfection or the possible adverse effect of antibiotic-associated pseudomembranous colitis, or AAPMC.)

Distributive shock

conditions that cause bv to lose their tone

Purulent exudate This kind of exudate

consistent w more severe infections & is commonly referred to as pus

Purulent or suppurative exudate

consists of plasma w both active & dead neutrophils, fibrinogen & necrotic parenchymal cells

Nurse's role in preventing drug resistance Check your patient's

culture and sensitivity reports and act as pt advocate by informing physician if bacteria are sensitive to narrow sepctrum antibiotic

Impact of infection on ADLs Pain

d/t swelling

Insulin regimens: Once

daily long-acting Lantus plus oral agents - common in T2DM

Diabetes: neuropathy Nerve

damage due to metabolic derangements of diabetes

Diabetes: nephropathy

damage to small bv that supply glomeruli kidney

Sepsis neuro

decrease in LOC

Sepsis cardio

decrease in bp -> heart increases HR to attempt to continue to circulat blood. Tachycardia.

Compromised host Stress

decreased immune response

As nurses, job is to

detect sepsis early -do through excellent assessment

Peak and trough levels are drawn to

determine drug's concentration within system

Acquired immunity

development of immunity either actively or passively

DSMES

diabetes self management education and support

Hypoglycemia: acute complication of

diabetes. Both type 1 and 2

A1C level Is now

diagnostic and monitors success of Tx

Diabetes meds

diet and lifestyle changes. Can combine long acting w oral hypoglycemic

Macrophages are

differentiated by tissue they reside

What increases risk for infection during hospitalization? Chronic diseases

diminish body's ability to fend off infection

Antibodies are

disease-specific

Diabetes chronic complications: macrovascular

diseases of large and medium size bv

Ex: runner with type 2 diabetes,

do not inject in legs

Passive acquired immunity

does not involve host's immune system

In type 2, pancreas

doesn't produce enough insulin

Contact infection precautions Mask/eye protection

during activities that may splash body fluids

Standard infection precautions Mask/eye protection

during activities that may splash body fluids

Gestational diabetes develops

during pregnancy

M.W., age 54, has been diagnosed as having perennial allergic rhinitis. He is to undergo skin testing to identify specific allergens. His health care provider has prescribed oral antihistamines for control of his symptoms. Subjective Data · Itching of eyes, nose, and throat · Stuffy nose, head congestion Objective Data · Physical examination · Clear nasal drainage: reddened eyes and lacrimation Describe the procedure the nurse uses to perform the skin testing. What results indicate a positive response?

either scratch test or prick test technique. Intradermal allergy testing is not used unless other methods do not result in conclusive reactions. A positive result is manifested by a local wheel - flare occurs within minutes.

Fluoroquinolones

end in -floxacin

TDM is important to

ensure amount of medication in pt blood stream is high enough to be therapeutic but not toxic

The most important ways to prevent antibiotic resistance are complete

entire course of any prescribed antibiotic so that it can be fully effective and not breed resistance

Macrolides (such as

erythromycin and clarithromycin) -

Serosanguineous fluid seems to be

everyone's favorite type of drainage to document but unfortunately it's not what want to see in wound

Storage of insulin Avoid

exposure to direct sunlight/heat

Active immunity results when

exposure to disease organism triggers immune system to produce antibodies to that disease

SOFA score helps determine

extent of person's organ function or rate of failure

L. G. is a 68-year-old man who goes to the hospital emergency department with a complaint of left foot pain. He has a 7-year history of type 2 diabetes that is controlled with metformin (Glucophage) 500 mg orally twice daily. Subjective Data -States he stepped on "something" in the yard a few days ago -States he is unable to bear weight on the left foot -Has been nauseated and "just haven't felt good" Objective Data Physical Examination -Blood pressure 160/90, pulse 110, respirations 24, temperature 99.8° F -Left foot swollen, red, and warm to touch -Open area on ball of left foot near first metatarsal, w tissue loss and irregular wound margins Measures 2 cm in diameter, with moderate amount of thick yellow drainage -Bilateral paresthesia in lower legs Diagnostic Studies -Blood glucose 350 mg/dL -White blood cell (WBC) count 19,200/µL; 80% neutrophils (12% bands) To protect the wound and promote healing,

extremity should be elevated & should avoid weight bearing -increase fluid intake to meet increased metabolic needs & provide diet high in protein, complex carbs, vitamins [vitamin C] and minerals [zinc] Heat may be applied after swelling has subsided to improve circulation

Signs of inflammation [systemic] Increase HR & RR

fever high metabolic demand

With localized infections,

fever may develop & pus may be present at site

Remember that the following VS will be altered with sepsis/septic shock...

fever, tachycardia w hypotension and each of these parameters must be TRENDED closely

Tighter glucose control :

fewer complications after surgery.

Fibrinous exudate is composed mainly of

fibrinogen & fibrin

The spleen helps

fight certain kinds of bacteria that cause pneumonia and meningitis

Immunoglobulin M [IgM] is

first antibody to be made by body to fight new infection

-sometimes foot sores might be

first contact w healthcare system. -can be painful, burning sensation, worse at night bc limb elevated not getting enough blood flow -uncontrolled glucose is contributing factor

Neutrophils are

first to injured site & function by neutralizing harmful bacteria

People at high risk of infection may also be

given antibiotics as precaution, known as antibiotic prophylaxis.

Type 2 diabetes: Onset

gradual

Urinalysis: -cloudy urine is consistent w

infection

Septicemia is caused by

infection in another part of body; this infection is typically severe

Systemic infections

infection in bloodstream

Exogenous insulin

insulin from outside sources

Only active immunity

is long-lasting

With anaphylaxis There may be other allergy symptoms, including

itchy, raised rash (hives , feeling or being sick, swelling (angioedema , or stomach pain.

An advantage of the RAST test is that

its results will not be affected by skin rashes or if patient has taken antihistamines

NK cells

keep cancer cells in check

Basically shock is

life-threatening condition that occurs when body is not getting enough blood flow

Anaphylaxis is a medical emergency and can be

life-threatening. Dial 911 immediately and ask for an ambulance if you think you or someone around you is experiencing anaphylaxis.

Tetracyclines and sensitivity to

light

Serous exudate

like a blister, it's clear

A urinalysis checks the urine for substances that are normally not in urine

like blood, too much protein, glucose, ketones and bilirubin

Airborne infection precautions Pt transport

mask on pt

Very high temperature accompanied by sweating and chills

may indicate septicemia

Very low WBC count

may indicate severe risk for infection

If you need treatment with cephalosporins, you

may need to have your dose of anticoagulants changed or additional blood monitoring.

Abnormal urinalysis results

may point to disease or illness

Hyperglycemia causes: -if diabetes,

maybe ate too many carbohydrates last night, or didn't take enough insulin, -

Sanguineous liquid

means red drainage from trauma to bv that may occur cleaning of wound or excessive movement of individual w wound immediately after wound emerges

WBC count and differential gives

measurement of phagocytes fighting infection and differential show what kind - neutrophils, monocytes, eosinophils in action

S/S septic shock The need for

med to maintain bp greater than or equal to 65 mm Hg

For bacteremia, if you recently had

medical or dental illness or procedure like wound infection or tooth extraction & have had any s/s like sudden fever, chills with or without shaking, see doctor right away

"Humor"

medieval term for body fluid

For diseases that have multiple routes of transmission (e.g., Severe Acute Respiratory Syndrome (SARS

more than one Transmission-Based Precautions category may be used. When used either singularly or in combination, they are always used in addition to Standard Precautions.

Tachycardia makes you

more tired -concerned tho if sliding into bradycardia

Neutrophils

most plentiful type

Insulin pen:

needle is really small

Fluoroquinolones are not

normally suitable for women who are pregnant or breastfeeding.

Insulin :

orange cap.

Newborn and infant

passive immunity until 6 months old

Incidence

pathogen X virulence/host defenses

Dawn phenomenon: esp if

pattern of elevated blood sugars in morning.

If IgG is high, this means

person has enough immunity on board & they're no longer infectious

If IgM is very low, this means

person is not very infectious

Nursing diagnosis: Risk for infection Secondary defense

phagocytes

Also, an episode of severe sepsis

places pts at higher risk for future infections

Spleen

plays multiple supporting roles in body

Inflammation management Oxygenation

poor circ have poor healing

Insulin rapid acting -

premeal insulin

White blood cells [leukocytes]

primary cells involved in -specific immune responses -nonspecific immune response

sepsis discharge and home guidelines Instructions on assessment.

pt and family should be taught about assessments needed to identify complications that may occur after discharge.

Septic shock manifestations To compensate for the decreased oxygen concentration,

pt tends to breathe faster, and also to eliminate more carbon dioxide from body.

sepsis nursing care: -give fluid based on

pt weight. Someone a lot smaller will require less IV fluids than larger person -

-cardiovascular: damage to autonomic nerves affecting CV system -

pts can end up w postural hypotension and painless MI bc cant feel it

Inflammation management Acute intervention Elevation

rest, immobilize, elevate, ice

Sepsis nursing interventions Assess physiologic status.

should assess patient's hemodynamic status, fluid intake and output, and nutritional status.

normal lactic acid levels in blood

should be low

Storage of insulin Extra insulin

should be refrigerated

Latex precaution protocols

should be used for pts identified as having positive latex allergy test or a hx of s/s r/t latex exposure.

People w insulin pump

should change site and tubing every 2-3 days

Basophils

small amount in body

Causes of hyperglycemia Nocturnal hypoglycemia

somogyi phenomenon and subsequent hyperglycemic rebound

Airborne infection precautions Mask/eye protection

special masks needed

Bun is not as

specific as creatinine but still relevant. -

Nurse's role in preventing drug resistance Always observe

standard & contact precautions when caring for pts w antibiotic resistant infections

Diabetics are more

susceptible to infections

Passive acquired immunity !!

temporary

If the skin reacts to the allergen,

there is an allergy; if there is no reaction, there is no allergy. antihistamines.

Shock most commonly occurs when

there is circulatory failure manifested as hypotension [ex: reduced tissue perfusion]

LET [leukocyte esterase] You would expect to see this positive if

there is significant presence of micro WBCs in urine. It is important to put more weight on micro count of WBCs vs. LET.

Peak and trough levels/Therapeutic drug monitoring For some medications,

there is very fine line between what is considered effective dose and toxic dose

Purulent exudate is

thick and opaque

Causes of hyperglycemia Incorrect

timing of basal dose

We want our patients' wounds

to be moist but not overly moist

Antibiotic instruct client during intravenous infusion

to report pain or other symptoms of discomfort immediately

Antibiotics are used to

treat or prevent some types of bacterial infection.

A urinalysis checks the urine for casts

tube-shaped proteins

Better control over blood sugar

, healthier they will be and less likelihood that will get long and short term diabetes complications.

the more antibiotics are used to treat trivial conditions

, the more likely they are to become ineffective for treating more serious conditions

Situations where antibiotics are given as a preventive treatment include:

- having an operation -after bite or wound that could get infected -have health problem that means you're at higher risk of infection like if you've had your spleen removed or you're having chemotherapy treatment

Septic shock documentation

- individual risk factors. · -assessment findings. · -results of lab tests and diagnostic studies. · -plan of care and teaching plan. · -client's responses to treatment, teaching, and actions performed. · modifications in the plan of care.

Hyperglycemia s/s

-3 Ps -weight loss -visual changes -can be asymptomatic

DKA s/s

-3 Ps [polyuria, polydipsia, polyphagia] -Dehydration -Poor skin turgor -Dry mucous membranes -Tachycardia -Orthostatic hypotension -Kussmaul's respirations -Acetone breath, sweet fruity breath

Diabetes Mellitus Diagnostic Studies

-A1C -Fasting plasma glucose level -Random or casual plasma glucose measurement -Two-hour OGTT

Metabolic syndrome

-Abdominal obesity -Hyperglycemia -Hypertension -Dyslipidemia

Nonspecific immune response: first line of defense Chemical barriers

-Acidity in GI -Vaginal flora -Fatty acids in skin

Types of immunity

-Adaptive immunity -Innate immunity

Rest & exercise interventions Promote comfort

-Address pain, itching, nausea -Offer back massage

Compromised host

-Advanced age -Preexisting diseases -Medical therapy -Stress -Breaks in skin & mucous membranes -Invasive devices -Stasis of body fluid -Inadequate nutrition -Humoral immune dysfunction -Drug therapy

Impact of infection on ADLs Family

-Airborne route - affect all? -Who stays home with the sick kids?

Types of distributive shock

-Anaphylactic shock -Septic shock -Neurogenic shock

Specific immune response: Lymphocyte recognizes antigen as foreign. Then what overlapping immune responses occur?

-Antibody mediated immune response -Cell mediated immune response

Health education: In febrile conditions

-Assess fever -Antipyretic use -Fluids

Humoral immunity Protection

-Bacteria -Extracellular viruses -Resp & GI pathogens

Chain of infection Infectious agent

-Bacteria -Fungi -Virus -Parasites

Inflammatory response is body's response to tissue injury or irritant Microbial

-Bacteria -Fungus -Parasite -When cells come in contact w antigen, it stimulates immune response

Humoral immunity Examples

-Bacterial infections -Anaphylactic shock -Transfusion reaction -Autoimmune diseases

Tell me something about long acting insulin

-CANNOT BE MIXED W ANY OTHER INSULIN -

Secondary diabetes What treatments for medical conditions might cause an abnormal blood glucose level?

-CORTICOSTEROIDS [PREDNISONE] -TPN -Thiazides -Phenytoin [Dilantin] -Atypical antipsychotics [clozapine]

Diagnostic tests and procedures: Diagnostic imaging

-CXR -MRI, CT scan

Sepsis/urosepsis What body system(s) will you most thoroughly assess based on the primary/priority concern?

-Cardiac- color, pulses, BP, HR, presence of diaphoresis -Renal-Closely assess urine output as marker of renal perfusion and worsening of acute renal failure.

Metabolic syndrome [syndrome X[

-Central obesity -High BP -High triglycerides -Low HDL-cholesterol -Insulin resistance

Nonspecific immune response: first line of defense Mechanical forces

-Ciliary action of resp tract -Urine stream -Coughing -Sneezing

What interventions will you initiate based on this priority? ineffective tissue perfusion: cardiac, renal, neuro (ANTICIPATE!)

-Closely TREND and monitor VS parameters of BP, HR, RR as well as color/temp of skin. -Assess and trend creatinine and urine output closely. -Assess mentation closely for any changes from current baseline.

Stress reduction interventions Changing perception of stressors or self

-Cognitive restructuring -Positive self talk

Inflammation management Acute intervention Observation

-Color -Odor -Drainage -Cover it -Size

Hypoglycemia signs and symptoms

-Confusion/irritability -Diaphoresis -Tremors -Hunger -Weakness -Visual disturbances

Chain of infection Mode of transmission

-Contact -Vehicle -Airborne -Vectorborne

Transmission of antibiotic resistant bacteria in hospitals The most common ways in which bacteria can be passed from person to person include

-Contact w contaminated hands of hospital staff -Contact w contaminated surfaces like door handles, over bed tables & call bells -Contact w contaminated equipment like stethoscopes and bp cuffs

Diabetes: nutritional therapy

-Critical piece -Not role of bedside RN - role of RD -Most challenging for many people -MNT - medical nutritional therapy -CHO counting -Nutrition for type 1 -Nutrition for type 2

Patient centered glycemic management Assess key patient characteristics

-Current lifestyle -Comorbidities [ex: ASCVD, CKD, HF] -Clinical characteristics [ex: age, HbA1C, weight] -Issues like motivation & depression -Cultural & socioeconomic context

Diabetes acute complications

-DKA [diabetic ketoacidosis] -Hypoglycemia -Hyperglycemia -HHNK: hyperglycemic hyperosmolar nonketotic syndrome

Inflammatory response is body's response to tissue injury or irritant Heat

-Damage to skin -Cold too -Inflammatory immune response kicks in

Thiazolidinediones: Pioglitazone (Actos) rosiglitazone (Avandia) what do they do

-Decrease insulin resistance -Inhibit hepatic gluconeogenesis -Reduces A1C approx 1.5%

Goals of diabetes management

-Decrease symptoms -Promote well-being -Prevent acute complications -Delay onset and progression of long-term complications

Diabetes: infection risk higher Why?

-Defect in mobilization of inflammatory cells -Impairment of phagocytosis by neutrophils & monocytes

Main functions of the inflammatory response

-Defend body against harmful substances -Dispose of dead or dying tissue -Promote renewal of normal tissue

Outcomes [Risk of infection]

-Demonstrate adequate knowledge -Use good health practices -Prevent occurrence of infections -Minimize potential complications -REMAINS FREE OF INFECTION

Survival skills: in and out of hospital

-Diabetes basics -Meal planning -activity/exercise -meds -monitoring -complications -coping -resources

Inflammatory response is body's response to tissue injury or irritant Chemical

-Drugs -Acids -Alkalosis

sepsis/urosepsis What psychosocial needs will this patient and/or family likely have that will need to be addressed?

-Emotional support -Knowledge and education about what is taking place and what care priorities will be in days ahead

Sepsis/urosepsis How can the nurse address these psychosocial needs?

-Emotional support -BE PRESENT and AVAILABLE. -Knowledge and education about what is taking place and what care priorities will be in days ahead The nurse can integrate pt/family education naturally while providing care by simply explaining at their level everything that nurse/physician has ordered and WHY it needs to be done. This is why it is essential for the nurse to know and DEEPLY understand rationale for both physician and nursing plan of care; so it can be readily taught and explained to pt/family at level they can understand.

Patient centered glycemic management Ongoing monitoring and support including

-Emotional well being -Check tolerability of med -Monitor glycemic status -Biofeedback

Factors that influence antibiotic therapy

-Empiric therapy -Culture & susceptibility -Resistance pattern -Which pathogen affects diff body areas -Drugs ability to penetrate tissue -Toxicity vs benefits [risks] -Cost

Sepsis/urosepsis Collaborative care: medical management

-Establish peripheral IV -0.9% NS 1000 mL IV bolus -Acetaminophen 650 mg -Ceftriaxone 1 g IVPB AFTER blood/urine cultures obtained -Morphine 2 mg IV push every 2 hours prn-pain

What interventions will you initiate based on this priority? Fluid volume deficit

-Establish peripheral IV -Fluid volume resuscitation -ISOTONIC solution- most common 0.9% NS. Anticipate at least one and likely two liters. -Reassess VS within 15 minutes after each IV bolus is administered.

Sepsis/urosepsis What nursing interventions will you initiate if this complication [septic shock] develops?

-Establish second IV, preferably a large bore IV [18 g). -Obtain VS every 15 minutes to TREND closely. -Contact primary care provider for need to transfer to ICU. -Anticipate need to start IV continuous vasopressors such as norepinephrine or neosynephrine.

Incretin Mimetics examples

-Exenatide [Byetta] -Liraglutide [Victoza]

Chronic complications diabetes: Microvascular Areas most noticeably affected

-Eyes [retinopathy] -Kidneys [nephropathy] -Skin -Erectile dysfunction

Diabetes: there is

-Faulty metabolism in CHO, PRO, fats -> hyperglycemia -Abnormal insulin production -Impaired insulin utilization

Nonspecific symptoms of infection

-Fever -Increased HR & RR -Inflammatory symptoms -Pain -Purulent drainage -Enlarged lymph nodes -Rash -GI symptoms

Stages of fever Defervescence

-Fever is broken -Sweaty -Te goes down

Thiazolidinediones: Pioglitazone (Actos) rosiglitazone (Avandia) Patient considerations

-Fluid retention/not use in CHF -May cause weight gain, edema -May reduce efficacy of oral contraceptives -LFTs

What interventions will you initiate based on this priority? Risk for falls

-Frequent/close observation. Place close to nursing station -Use tab alarm prn -Re-orient frequently

Cellular [cell mediated] immunity Examples

-Fungal infections -Tuberculosis -Graft rejection -Contact dermatitis -Cancer cells

Cellular [cell mediated] immunity Protection

-Fungus -Intracellular viruses -Tumor cells

Diabetes mellitus - patient teaching

-General facts about DM* -Self monitoring of blood glucose* -Nutritional therapy/CHO counting -Drug therapy* -Exercise -Foot care -Avoiding long term complications

Infection assessment - objective data

-General inspection -VS -Breath sounds -Bowel sounds -Palpate lymph nodes -Wounds, IV sites, drain sites

Other types of diabetes mellitus

-Gestational -Prediabetes -Secondary diabetes

Long acting insulin examples

-Glargine [Lantus] -detemir [Levemir]

Any 2 of the following is considered a positive screen for sepsis

-Glasgow coma scale < 13 -Systolic bp < 100 mm Hg -Resp rate > 22/min

Diabetes Mellitus Counter regulatory hormones Examples

-Glucagon, -epinephrine, -growth hormone, -cortisol

Invaders: common infectious diseases Bacteria

-Gram positive -Gram negative

White blood cells/Leukocytes are classified into what groups?

-Granulocytes -Nongranulocytes

Rest & exercise interventions Promote relaxation

-Guided imagery -Progressive muscle relaxation -Music therapy

Stages of fever Prodromal

-HA -tired -malaise

Inflammation management: chronic and home management

-Hand washing -Clients are taught clean dressing changes - "no touch" technique

Risk for infection: Interventions Client teaching

-Hand washing -What wound should look like -How to change dressing

Health education: disease prevention

-Health instruction r/t reduction in deaths due to vaccine - preventable infections -Health instruction regarding immunization requirements -Assessing client's current immunization status

Cellular immunity: T cells [lymphocytes]

-Helper Ts -Killer Ts [cytotoxic] -Suppressor Ts -Natural killer cells

Biguanides - Metformin Patient considerations

-Hold 48 hours before invasive procedure -GI considerations/diarrhea

Chain of infection Source

-Human beings -Animals -Inanimate objects

L.G., a 28-year-old diabetic, is admitted to the hospital with a cellulitis of her left lower leg. She had been applying heating pads to the leg for the last 48 hours, but the leg has become more painful and she has developed chilling. Subjective Data · Complains of pain and heaviness in her leg · States she cannot bear weight on her leg and has been in bed for 3 days · Lives alone and has not had anyone to help her with meals Objective Data Physical examination · Round, yellow-red, 2 cm diameter, 1-cm deep, open wound above the left medial malleolus with moderate amount of thick yellow drainage. · Left leg red from knee to ankle · Calf measurement on left 3 inches larger than right · Temperature 102 F (38.9 C) · Height 5 ft 4 in (160 cm); weight: 184 lb (83.7 kg) Laboratory test results · White blood cells (WBC): 18,300/uL (18.3 x 10⁹/L; 80% neutrophils, 12% bands) · Wound culture: Staphylococcus aureus What factors are present in this situation that could delay wound healing?

-Hx DM -possible circulatory impairment to lower extremities & altered blood glucose levels -increased weight -inadequate nutrients for healing possibly bc confinement to bed -has no one to help w meals & presence of infection in wound

Sulfonylureas [glucotrol, amaryl, diabeta, glynase, microsnase, insulin secretagogues] Patient considerations

-Hypoglycemia - severe -GI - diarrhea, nausea, constipation

DKA: planning Monitor

-I&O -BG -VS, oxygenation, breathing patterns

If we detect high blood glucose level but not high even to diagnose w diabetes,

-IGT: someone who fasted, gave them sugary drink and blood glucose is between 140 and 199 [that is prediabetes]. If they hit 200, that is a diagnosis of diabetes.

There is a whole sequence of events that leads to a fever

-IL-1 is like a match that is sparked -This spark lights up tissues, prostaglandin E -little flames of prostaglandin E then trigger firewood, our hypothalamus, to light up & produce powerful heat all over the place

Diabetes: DKA Precipitating factors

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

Subclasses of antibodies

-Immunoglobulin A [IgA] -Immunoglobulin G [IgG] -Immunoglobulin M [IgM] -Immunoglobulin E [IgE] -Immunoglobulin D [IgD]

Chain of infection Susceptible host

-Immunosuppressed elderly -Chronically ill -Trauma -Surgery

Biguanides - Metformin

-Improves glucose tolerance -Reduction A1C 1.5-1.8%

Nursing diagnosis: Risk for infection

-Inadequate primary defenses -Inadequate secondary defenses -Inadequate acquired immunity

Nursing management: nursing implementation Acute intervention for stress of illness and illness

-Increase BG level -Continue regular meal plan -Increase intake noncaloric fluids -Continue taking oral agents or insulin -Frequent monitoring of BG [Ketone testing if glucose > 240 mg/dl

What key indicators can be assessed that would indicate the use of the body's secondary defenses in response to pathogen invasion?

-Increased WBCs [neutrophils, monocytes, eosinophils] -Inflammation [heat, erythema, edema, pain] at site of infection -Fever

Diabetes exercise What does it do?

-Increases insulin receptor sites -Lowers blood glucose levels -Contributes to weight loss

Patient centered glycemic management Consider specific factors that impact choice of treatment

-Individualized HbA1C target -Impact on weight & hypoglycemia -Side effect profile of med -Complexity of regimen, ex: frequency, mode of administration -Choose regimen to optimize adherence & persistence -Access, cost & availability of med

Oral agents: antidiabetic medications Work on 3 defects of type 2 DM

-Insulin resistance -Decreased insulin production -Increased hepatic glucose production

Type 2 diabetes mellitus 4 major metabolic abnormalities

-Insulin resistance -Pancreas decreased ability to produce insulin -Inappropriate glucose production from liver -Alteration in production of hormones & adipokines

Killer Ts [cytotoxic] produce cytokines

-Interleukins -Interferon -TNF

Patient centered glycemic management shared decision making to create a management plan

-Involves educated & informed pt & fam & caregiver -Seeks pt preferences -Effective consultation includes motivational interviewing, goal setting & shared decision making -Empowers pt -Ensures access to DSMES

Rest & exercise interventions Create a restful environment

-Keep linens clean, dry, aligned -Maintain good body alignment -Keep room dark & quiet -Control temp/ventilation to pt preference

When tissue cells become injured, they release what chemicals to initiate the inflammatory response?

-Kinins -Prostaglandin -Histamine

Nursing diagnosis: Related [infection] [Risk of

-Knowledge deficit -Pain -Impaired physical mobility -Impaired skin integrity -Self esteem disturbance -Anxiety -Ineffective individual coping

Sepsis: nursing care Desired outcome

-Lessening immune response -Prevention cellular death -Resolution of infection -Minimizing damage from cellular oxygen deprivation & lactic acid buildup -Maximizing CO -Resolution of condition

Sepsis desired outcome

-Lessening immune response, -prevention cellular death, - resolution of infection, -minimizing damage from cellular oxygen deprivation -lactic acid build up, -maximizing CO -resolution of condition.

Inflammatory response: purpose

-Limit extent of injury -Remove cause of damage -Assist in healing process

Rapid acting insulin examples

-Lispro [Humalog] -Aspart [NovoLog] -glulisine [Apidra]

Nonspecific immune response: second line of defense WBC function

-Macro -Neutro -Antibodies

Types of leukocytes predominant in inflammatory response

-Macrophages -Neutrophils

Inflammatory response: Body's response to tissue injury or irritant

-Mechanical -Chemical -Microbial -Heat

Antibiotic resistant organisms

-Methicillin resistant staphylococcus aureus & epidermidis [MRSA/MRSE] -Penicillin resistant streptococcus pneumonia -Vancomycin resistant enterococci [VRE]

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. What data from the histories are important and RELEVANT and have clinical significance for the nurse

-More fatigued for last 3 days -Fever last 24 hours -Painful, burning sensation when she urinates as well as frequency of urination last week -Did not know what day it was. She is mentally alert w no history of confusion -While taking her bath today, she was weak and unable to get out of the tub and used the help button to call for medical assistance -Lives independently in a senior apartment retirement community -Widowed and has 2 daughters who are active and involved in her life

Chain of infection Portal of entry

-Mucous membranes -Nonintact skin -GI tract -GU tract -Resp tract

Types of adaptive immunity

-Natural -Artificial

Sepsis/urosepsis - collaborative care: medical management Establish peripheral IV - rationale and expected outcome

-Need IV access to initiate IV fluid resuscitation -IV established

What are the granulocytes?

-Neutrophils -Eosinophils -Basophils

Inflammation management: health promotion & maintenance

-Nutrition [protein, vitamin C] -Hygiene [hand washing]

Diabetes chronic complications: macrovascular Risk factors

-Obesity -Smoking -Hypertension -High fat intake -Sedentary lifestyle

Inflammation management Acute intervention

-Observation -VS -Fever management -Rest & immobilization -Elevation

Prior to administration of antibiotics

-Obtain complete health hx including allergies, drug history, and possible drug interactions. -Obtain specimens for C&S before initiating therapy. -Perform infection-focused physical exam including VS, WBC count, and sedimentation rate.

Nutrition interventions Improving the patient's appetite

-Offer frequent, small meals -Restrict liquid intake w meals -Keep environment neat and clean, free of unpleasant sights, odors, medical equipment -Provide/assist w oral hygiene -Provide pleasant eating environment -Serve food attractively -Arrange food so easily reached -Position pt comfortably for meals -Find out what pt likes to eat, if allowed, encourage foods from home -Control pain around clock; avoid painful procedures prior to meals

Inflammation more management

-Oxygenation -Heat & cold -Wound management -Infection control

Distinct signs of inflammatory reaction

-Pain -Swelling or edema -Redness -Heat -Loss of function

Types of artificial adaptive immunity

-Passive [antibody transfer] -Active [immunization]

Types of natural adaptive immunity

-Passive [maternal] -Active [infection]

B cell: The physical/chemical process of destruction includes

-Phagocytosis -Neutralization -Agglutination -Activation of complement

Classic symptoms of type 1 diabetes

-Polyuria [frequent urination) -Polydipsia [excessive thirst) -Polyphagia [excessive hunger)

Patient centered glycemic management Goals of care

-Prevent complications -Optimize quality of life

Risk for infection: Interventions Neutropenic precautions

-Private room -Gown, gloves, masks -No flowers -Fruit

Contact precautions need

-Private room or cohort -clean, nonsterile gloves when entering room, remove before exiting -clean, nonsterile gown when entering room if substantial contact w pt or potentially contaminated areas in pt environment is anticipated; remove before exiting -limit transport to essential purposes & ensure precautions are taken to minimize contamination of environmental surfaces and equipment -when possible, dedicate use of noncritical pt care equipment to single pt and avoid sharing between pts

Stages of fever

-Prodromal -Chill -Flush -Defervescence

Killer Ts [cytotoxic]

-Produce cytokines -Memory cells

Rest & exercise interventions Schedule nursing care to avoid interrupting sleep

-Provide rest after procedures/meals -Alter routines when able to promote rest/sleep -Do not wake if sleeping unless condition indicates need -Keep noise to minimum

More risk for infection interventions

-Pulmonary toilet -Comfort measures -Neutropenic precautions -Prevent spread of infection

Signs of inflammation [systemic]

-Pyrexia [fever] -Increase HR & RR -Anorexia -Fatigue -Weakness, malaise -Leukocytosis [increased WBCs]

Stress reduction interventions Stress management techniques

-Relaxation techniques -Meditation -visualization/imagery -humor -listening to music -engaging in art activities -exercise

Biguanides - Metformin Contraindicated

-Renal failure -Liver dysfunction -Severe infection

Patient centered glycemic management Review and agree on management plan

-Review management plan -Mutual agreement on changes -Ensure agreed modification of therapy is implemented in timely fashion to avoid clinical inertia -Decision cycle undertaken regularly [at least once/twice a year]

Sepsis: nursing diagnoses

-Risk for deficient fluid volume r/t massive vasodilation -Risk for decreased CO r/t decreased preload -Impaired gas exchange r/t interference w oxygen delivery -Risk for shock r/t infection

Sepsis can affect a lot of body systems and even cause their failure, so diagnosis is an important part of the process to establish the presence of sepsis. ·

-Risk for deficient fluid volume related to massive vasodilation. · Risk for decreased cardiac output related to decreased preload. · Impaired gas exchange related to interference with oxygen delivery. · Risk for shock related to infection.

Pneumonic to remember sepsis.

-S: suppressed immune system -E: extreme age [really old or really young] -P: postop [had invasive procedure] -T: transplant recipient [had invasive procedure] -I: indwelling catheter devices [risk for infection] C- chronic diseases [diabetes etc]

Patient centered glycemic management: ongoing monitoring and support including Biofeedback including

-SMBG -Weight -Step count -HbA -Blood pressure -Lipids

How assess septic?

-SOFA: sequential organ failure assessment -qSOFA: quick SOFA score [simple prompt tool to identify infected pts before even get to hospital]

Child and adolescent Parasites

-Scabies -Ringworm

What are the neutrophils?

-Segs -Bands

Properties of the immune response to an antigen

-Self recognition -Specificity -Systemic rather than local -Has a memory

Cellular [cell mediated] immunity Products

-Sensitized T cells -Lymphokines

Types of exudate

-Serous -Sanguineous -Serosanguineous -Catarrhal -Fibrinous -Hemorrhagic -Purulent

Nutrition interventions Assisting patients with meals

-Serve food one at a time, serve small amounts -Assist pt to eat & drink only as necessary, encourage independence -Provide privacy during meals if pt embarrassed -Maintain dignity, use napkin & not bib -Allow pt determine order eat foods -Sit down while feeding pt -Do not rush meal -Have casual conversation w pt while feeding to make mealtime more pleasant & relaxed -Prepare food on tray if pt can feed self

Hypoglycemia some symptoms

-Shaky -fast heartbeat -sweating -dizzy -anxious -hungry -blurry vision -weakness or fatigue -headache -irritable

Nonspecific immune response: first line of defense Anatomic barriers

-Skin -Mucous membranes -Normal flora

3rd line of defense in our body

-Skin -T & B cells -Antibodies

Nonspecific immune response: first line of defense Individual factors

-Some people are stronger than others -Hygiene -Nutrition

Chain of infection Portal of exit

-Sputum -Emesis -Stool -Blood

Walk me through type 2 diabetes

-Stomach changes food into glucose -Glucose enters bloodstream -Pancreas makes insulin -Insulin enters bloodstream -Glucose can't get into cells of body. Glucose builds up in bv

Oral agents: antidiabetic medications Examples

-Sulfonylureas -Biguanides -Thiazolidinediones [TZDs] -DDP - 4 inhibitors -Incretin Mimetics

Symptoms of inflammation

-Swelling -Pain -Increased warmth & redness of skin -Heat, redness -loss of function

Types of lymphocytes

-T cells -B cells -Natural killer [NK] cells

Cellular [cell mediated] immunity Cells involved

-T lymphocytes -Macrophages

Risk for infection: Interventions Tell me some more!

-TCDB -Antipyretics, cool wash cloth, replace sheets -Hand washing

Sepsis: it's about TIME watch for

-Temp: higher or lower than normal -Infection: may have s/s infection -Mental decline: confused, sleepy, difficult to rouse -Extremely ill: "I feel like I might die," severe pain or discomfort

Mrs. Flowers states "I just feel so alone in my room." Discuss the interventions that address this verbalized need.

-Touch -Time spent w pt needs to address more than just physical care modalities & to allow for discussion of how pt is coping and exploration of ways to meet psychosocial health needs

Inflammation management Acute intervention Fever management

-Ty -Manage if too high

Most common types of diabetes mellitus

-Type 1 -Type 2

Who gets insulin?

-Type 1 -Type 2 -Gestational -TPN, DKA -Hospitalized patients

Active acquired immunity How get?

-Vaccinations [artificial] -Exposure to a antigen [natural]

Stages of fever Chill

-Vasoconstriction -Cold -Shivering

Stages of fever Flush

-Vasodilation -More blood flow

Sepsis risk factors

-Very young or very old -Have compromised immune system -Have diabetes or cirrhosis -Are already very sick, often in hospital intensive care unit -Have wounds or injuries like burns -Have invasive devices like IV caths or breathing tubes -Have previously received antibiotics or corticosteroids

The lymphatic system is comprised of what components?

-Vessels -Nodes -Tonsils -Thymus -Spleen

Invaders: common infectious diseases Besides bacteria

-Virus -Fungi -Parasites -Helminthes

Urinalysis

-WBCs, bacteria -pH, glucose -clean catch or midstream

Besides the 3 Ps [polyuria, polydipsia, polyphagia] other clinical manifestations of type 1 diabetes mellitus

-Weight loss -Weakness/malaise/Fatigue/blurred vision -Ketoacidosis

hygiene interventions: Frequent hand washing

-When arriving & leaving pt room -Before & after contact w pt or articles in pt room -Before putting on gloves, after removing -After touching anything might be contaminated -Whenever hands visibly dirty

Diabetes: nephropathy Things to know

-Yearly screening -Microalbuminemia in urine -Serum creatinine

standard precautions hand hygiene

-after touching blood, body fluids, secretions, excretions & contaminated items -immediately after removing gloves & between pt contacts

Diabetes foot complications: Foot care:

-annual foot screenings really important. Specifically for sensory and neuropathic changes. -don't use callous removal products. -some places for pedicure, use fine blade to get off dead skin underneath feet, never use something like that. Don't use OTC callous removal products. Can cause cuts which can become infected. -be careful about types of creams used on feet. Can cause skin breakdown. -report any skin breakdown immediately to HCP -watch how cut toenails -cutting toenails straight across to prevent cuts -wear comfortable breathable shoes with flat sole. Leather, cotton.

Nonspecific symptoms of infection GI symptoms

-anorexia -N&V -GI bug

Aminoglycosides The risk of damage to your kidneys and hearing is increased if you're taking 1 or more of the following medications:

-antifungals - used to treat fungal infections -cyclosporin - used to treat autoimmune conditions such as Crohn's disease and given to people who have had an organ transplant -diuretics - used to remove water from the body -muscle relaxants

Antibiotics may be used to treat bacterial infections that:

-are unlikely to clear up without antibiotics -could infect others -could take too long to clear without Tx -carry risk of more serious complications

Underlying cause of this sepsis:

-bacterial infection - what did it cause or activate? Inflammatory response. -pt is elderly, kidney issues - things that make her prone to having sepsis.

Why concerned about hypoglycemia?

-bc if progresse, leasds to loss of consciousness, seizures, coma, death.

Labs DKA:

-blood glucose really high more than 300.

Lactic acid [lactate]

-byproduct of anaerobic metabolism -blood test

Teaching to prevent low BG teach pt

-carry emergency sugar/food -not to go to bed w BG < 100 mg/dl

In some cases, antibiotics are prescribed for people who have an infection that keeps coming back or that's causing distress or an increased risk of complications, such as:

-cellulitis -urinary tract infection -genital herpes -rheumatic fever

Hypoglycemia - what to do? At the first sign

-check BG -if < 70, begin treatment -if > 70, investigate further for cause of s/s if BG monitoring not available, Tx should be initiated

Neutropenia with what?

-chemo -immunosuppressed -precautions

Once daily long acting lantus + oral agent

-common with type 2 -take lantus 10 units at bedtime and oral hypoglycemic agent -so no premeal injection -lantus just once a day Give premeal insulin based on blood sugar

Children and adolescent

-communicable diseases -accidents -sexually transmitted diseases -immunity compromised by malnutrition

Jean Kelly case study: -frequency, urgency, fever - classic symptoms of UTI

-confusion is symptom for UTI for elderly -

Blood sugar can go super high

-dangerous bc ABGs thrown off, feel terribly. -but blood sugar can go up really high before things go sideways But more worrisome in hypoglycemia

Adult and older adult

-decrease in cell & humoral immunity -nosocomial infections -defense system changes -urinary retention -impaired immune system -infection

Biguanides - Metformin Improves glucose tolerance

-decreases hepatic glucose tolerance -decreases intestinal absorption -increases glucose uptake and utilization

DKA s/s:

-dehydration caused by 3 P's -no energy bc cells and tissues getting no nutrition -tachycardia bc losing F&E. -kussmaul's respirations: rapid and deep. -fruity breath is from breakdown of ketones. -neurlogically: awake but lethargic. -skin flushed.

Spots of hemorrhage and aneurysms in bv of eyes [retinopathy]

-dilated and weak bv eyes -eventually cause blindness.

Also person willingness to be tested

-don't care or denial

Diabetic Nephropathy:

-eventually need dialysis or kidney transplant bc kidneys will lost ability to filter blood -equal for type 1 and 2

Chronic inflammation can result from

-failure to eliminate whatever was causing acute inflammation -autoimmune disorder that attacks normal healthy tissue, mistaking it for pathogen that causes disease

sepsis Why is she getting Tylenol?

-fever -pain control

priotitize orders

-first establish peripheral IV - why? Think airway breathing circulation. Circulation is priority here. -then can give fluid bolus and antibiotic and morphine.

vancomycin Other adverse effects that need to be reported immediately include

-generalized "tingling" [usually after IV dosing), -chills, -fever, -rash, and/or hives.

Autonomic neuropathy:

-grtoup of symptoms that occur when there is damage to nerves that manage every day body functions like gauging bp, digestion, bladder emptying, sweat glands, pupils etc

Some people are particularly vulnerable to infection, making antibiotics necessary. They include:

-had their spleen removed -having chemotherapy for cancer -sickle cell anaemia

Toddler and preschooler

-hands to mouth -fully mature immune system -vaccinations

for HHNK:

-have enough insulin so body does not produce ketones -acute complication of type 2 -bc occurs often in older adults, usually have Hx inadequate fluid intake.

Diabetes is a major contributing factor to

-heart disease -stroke

Inflammatory response: Anyway, there are important reasons for the fever

-high temp is great for killing pathogens -high temp speeds up important protective chemical reactions

With thiazolidinediones

-hypoglycemia not a problem here bc not actually increasing insulin production -often given in combo w oral hypoglycemic agent [so if this occurs, watch for hypoglycemia]

What would happen if overdosed pt with insulin?

-hypoglycemia.

When someone leaves hospital,

-if pt notice any of these things, call HCP [criteria for sepsis] -altered mental status, fast rr, low bp?

What causes DKA? -if have known diabetes:

-illness: sick, cant keep food down, body generally needs more insulin bc body under stressful situation. -Inadequate insulin dosing

Diabetic infectiions:

-immune system does not work properly -contributes more significantly to chronic complications

DDP-4 inhibitors Sitagliptin [Januvia] What do they do?

-increase GLP-1 levels -increase insulin secretion -lowers A1C 0.5-1% -side effects - few

Inflammation management Acute intervention Vital signs

-increase to inflammatory response bc high metab demand

Diabetes exercise:

-increases insulin receptor sites [mostly for type 2] -lowers blood glucose levels [both 1 and 2] -

Tetracyclines [ending in cycline"] Indications for these medications include things like

-infectious diseases -acne -peridontal disease

standard precautions respiratory hygiene

-instruct pts to cover mouth/nose when sneezing/coughing -tissue disposal in no-touch receptacles -hand hygiene after soiling hands w resp secretions -use mask or maintain spatial separation [>3 ft] if possible

When see IV admin of insulin?

-insulin drip in hospital when trying to lower blood sugar quickly -like with DKA - when blood sugar suuuper high, go on insulin drip. Get so many units of insulin per hour intravenously

A urinalysis involves checking the urine for

-its color -appearance [whether clear or cloudy] -any odor -pH level [acidity] -whether there are substances not normally in urine -cells, crystals and casts -whether contains bacteria or other germs

Diabetes: hyperosmolar hyperglycemic syndrome [HHS] also [HHNK]

-life threatening syndrome -less common than DKA

Macrolides such as erythromycin and clarithromycin can be particularly useful for treating

-lung and chest infections, or as alternative for people w a penicillin allergy, or to treat penicillin-resistant strains of bacteria

What condition can cause cardiogenic shock?

-myocardial infarction [large section of heart not being oxygenated] -rupture -clot -dangerous heart rhythm [ventricular tachycardia or fibrillation??]

Exposure to the disease organism can occur through

-natural immunity -vaccine-induced immunity

When acidotic w DKA,

-nauseous -vomiting -lose lots of electrolytes [sodium, potassium, chloride, magnesium] - our concern w potassium loss is cardiac arrhythmias.

standard precautions safe injection

-needles and syringes are single use devices -limit use of multidose vials & dedicate to single pt when possible

In hospital guidelines for BG Critical care

-no higher than 180 mg/dl once therapy has begun -BG to be maintained between 140-180 mg/dl

Type 2 diabetes: Symptoms

-nonspecific symptoms -fatigue -recurrent infections -prolonged wound healing -visual changes

Antibiotics should only be prescribed to treat health problems:

-not serious but are unlikely to clear up without antibiotics - such as acne -that are not serious but could spread to other people if not promptly treated - such as skin infection impetigo or sexually transmitted infection chlamydia -where evidence suggests that antibiotics could significantly speed up recovery - such as kidney infection -that carry risk of more serious complications - such as cellulitis or pneumonia

Insulin differs in regards to

-onset -peak -action -duration

Antibiotics may also be recommended for people who are more vulnerable to the harmful effects of infection. This may include:

-over 75 years -babies less than 72 hours old who have bacterial infection, or higher than average risk of developing one -heart failure -have to take insulin for diabetes -weakened immune system - either bc of underlying health condition like HIV or as side effect of certain treatments, like chemotherapy

Impact of infection on ADLs Individual

-pain -long term disability or disfigurement -fatigue -loss of appetite

L.G., a 28-year-old diabetic, is admitted to the hospital with a cellulitis of her left lower leg. She had been applying heating pads to the leg for the last 48 hours, but the leg has become more painful and she has developed chilling. Subjective Data · Complains of pain and heaviness in her leg · States she cannot bear weight on her leg and has been in bed for 3 days · Lives alone and has not had anyone to help her with meals Objective Data Physical examination · Round, yellow-red, 2 cm diameter, 1-cm deep, open wound above the left medial malleolus with moderate amount of thick yellow drainage. · Left leg red from knee to ankle · Calf measurement on left 3 inches larger than right · Temperature 102 F (38.9 C) · Height 5 ft 4 in (160 cm); weight: 184 lb (83.7 kg) Laboratory test results · White blood cells (WBC): 18,300/uL (18.3 x 10⁹/L; 80% neutrophils, 12% bands) · Wound culture: Staphylococcus aureus What clinical manifestations of inflammation are present in LG?

-pain -redness of leg -edema of leg -fever

Eosinophil: This condition most often indicates

-parasitic infection -allergic reaction -cancer

Passive acquired immunity examples

-passed from mother to fetus/baby -injection of immunoglobulins into client

Sepsis: assessment must have one or more of the following signs to be diagnosed with severe sepsis

-patches of discolored skin -decreased urination -changes in mental ability -low platelet [blood clotting cells] count -probs breathing -abnormal heart functions -chills due to fall in body temp -unconsciousness -extreme weakness

Tetracyclines are not usually recommended unless absolutely necessary in:

-people with kidney disease - except doxycycline, which can be used -people w liver disease -people w lupus - which can cause skin problems, joint pain and swelling, and fatigue -children under the age of 12 -pregnant or breastfeeding women

Examples of cause of sepsis

-pneumonia, -UTI, -infection in bloodstream [bacteremia), etc. It doesn't have to be bacterial infection, it can be virus or fungus as well.

Sepsis and septic shock · Signs and symptoms. Assess if the patient has

-positive blood culture, -currently receiving antibiotics, -had examination or chest x-ray, or has a suspected infected wound.

standard precautions safe handling

-potentially contaminated equipment or surfaces in pt environment -environmental cleaning & disinfection per facility policy

Droplet precautions need

-private room or cohort -special air flow is not needed & door may remain open -wear mask [surgical or isolation] if working within 3 ft of pt [some facilities require mask for all entries into room] -droplet mask on pt when leaving room if tolerated -limit transport to essential purposes only -follow resp hygiene/cough etiquette -gown & gloves as per standard precautions and facility policy

airborne precautions need

-private room w monitored negative pressure ventilation of 6-12 air exchanges per hour; airborne infection isolation room [AIIR] preferred -discharge of air to outside or HEPA-filtered before recirculation -door and windows must be kept closed at all times -resp protection [usually N-95 mas] for susceptible persons must be worn prior to entering room & removed after leaving room -droplet mask on pt when leaving room if tolerated; follow resp hygiene/cough etiquette -limit transport to essential purposes only -if possible, non-immune healthcare workers should not care for pts w vaccine preventable airborne diseases

Insulin is characterized as

-rapid acting -short acting -intermediate acting -long acting

Basal: lantus and NPH

-rare

Classic signs of infection

-redness -swelling -increased pain -purulent discharge from incisions -injury -exit sites of tubes [IV tubings] -drains -catheters

some stuff for dka

-replace potassium bc peeing a lot. Cardiac monitor. -if at acidotic, higherrisk for arrthymias. -replace fluid and correct deficits [sodium, potassium] and to normalize blood sugar [goals]

SOFA score is based on scores for the:

-resp -CV -hepatic -coagulation -renal -neuro

15 year old boy who came in w appendicitis and had appendix removed

-risk for sepsis

Diabetes: nutritional therapy:

-role of registered dietitian -

Penicillins may need to be used at lower doses and with extra caution if you have:

-severe kidney disease -liver disease

Adult and older adult Defense system changes

-skin -cough -peristalsis

Transmission based precautions

-special instructions based on disease specific recs -should always be used in addition to standard precautions

NK cells where?

-spleen -bone marrow -lymph nodes

You can get active acquired immunity through Exposure to an a antigen [natural]

-stimulate antibody production -measles or chicken pox

Why would we look at her magnesium, sodium and potassium?

-they are all essential for cardiac electrical conduction -magnesium at 1.8 = stable

Regular insulin is...

-this is the only insulin that can be given intravenously [can also be given subq]

Septicemia The most common infections that lead to septicemia are

-urinary tract infections -lung infections like pneumonia -kidney infections -infections in abdominal area

Hypoglycemia unawareness:

-when person doesn't experience any warning signs which increases risk for low blood sugar levels -

60 year old pt in hospital who is coming in for kidney surgery. At risk for sepsis?

-yes

Elderly pt w diabetes who just had surgery. Are they at risk for sepsis?

-yes

Ex: 40 year old female in hospital for kidney issues. Has foley cath and IV in place. Is she at risk for developing sepsis?

-yes.

50% basal and 50% premeal -based on

0.5-1 unit per kg/daily -ex: need 75 units total. Divided into 2. 50% basal, 50% premeal insulin. So 37.5 units will be long lasting and other 37.5 divided again by 3 for each meal. So they will get another 12.5 units of fast acting insulin before each meal. That's the 50-50 basal and premeal regimen.

As many as

1 in 5 people who suffer shock will die from it

U100 insulin

1 mL contains 100 units of insulin vials contain 10 mL/1000 units Pens contain 3 mL/300 units

Hypoglycemia if not awake Administer

1 mg of glucagon IM or subcutaneously

A client diagnosed with type 1 diabetes is placed on a 1,800 calorie/day diet. The nurse instructs the client to use which food as a suitable exchange for a pat of butter? a) half cup of milk b) 2 cups of yogurt c) half cup of cabbage d) 1 tbsp of mayo

1 tbsp of mayo

One common type of NCLEX question asks...what should the nurse do FIRST? The following are in the order they should be implemented in practice: [for sepsis case study]

1) Fluid volume deficit [C-circulation] -Establish IV access and start IV fluid resuscitation based on physician orders. 2) Ineffective tissue perfusion[C-circulation) -This nursing priority must be considered if sepsis progresses to septic shock. 3) Obtain all required blood work and blood cultures so that IV antibiotics can be administered ASAP. -This can also be concise and relevant nursing priority that is not NANDA! 4) Risk for falls must also be considered with her present weakness.

Diabetes Theories link cause to single/ combination of these factors

1) Genetic 2) Autoimmune 3) Environmental -Viral -obesity

Initial resuscitation for sepsis and septic shock [begin immediately]

1) Measure lactate level 2) Obtain blood cultures before administering antibiotics 3) Administer broad-spectrum antibiotics 4) Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate > 4 mmol/L 5) Apply vasopressors if hypotensive during or after fluid resuscitation to maintain mean arterial pressure > or equal to 65 mm Hg

Stages of inflammatory reaction

1) Tissue injury 2) Release of chemicals

Cell injury ->

1) cell death 2) momentary local vasoconstriction

Depending on the kind of foreign invasion, what immune responses occur?

1) humoral response 2) cell-mediated response

If cell injury -> cell death -> release of kinins, histamine, prostaglandins ->

1) local vasodilation 2) increased capillary permeability

The pathophysiology of sepsis involves an evolving process. The following shows the process of how sepsis works its way inside of our body.

1. Microorganisms invade body tissues and in turn, pts exhibit immune response. 2. immune response provokes activation of biochemical cytokines & mediators associated w inflammatory response. 3. Increased cap permeability and vasodilation interrupt body's ability to provide adequate perfusion, oxygen, and nutrients to tissues and cells. 4. Proinflammatory and anti-inflammatory cytokines released during inflammatory response and activates coagulation system that forms clots whether or not there is bleeding. 5. imbalance of inflammatory response and clotting and fibrinolysis cascades are critical elements of physiologic progression of sepsis in affected pts

Insulin: NPH intermediate acting duration

10-16 hours

FPG prediabetes

100 mg/dl to 125 mg/dl

U100 - there's

100 units of insulin per mL of fluid

Diabetes: diabetic ketoacidosis [DKA] how many

100,000 each year in ER w DKA

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Relevant VS data?

101.8 F/38.8 C [oral] 110 reg R 24 BP 102/50 MAP: 67 Right flank pain, continuous, 5/10 Supine: 110, 102/50 Standing: 132, 92/42

FPG diabetes

126 mg/dl or higher

AIC less than 6% average blood glucose

135

Oral glucose tolerance test [OGTT] prediabetes

140 to 199 mg/dl

Hypoglycemia - treatment If alert enough to swallow

15-20 g/simple CHO -4-6 oz fruit juice -regular soft drink

Sepsis needs

2 SIRS + Confirmed or suspected infection

Severe sepsis:

2 SIRS + confirmed infection + signs of organ damage

Stages of sepsis: consensus conference definition Systemic inflammatory response syndrome [SIRS]

2 or more of the following: -T more than 38 C or less than 36 C -HR > 90 -RR > 20 -WBC count > 12 x 10^9/L or < 4 x 10^9/L or 10% immature forms [bands]

How can you measure qSOFA?

2 or more: -Altered mental status -Fast respiratory rate -Low blood pressure

Regular: short acting insulin peak

2-3 hours

Insulin: NPH intermediate acting onset

2-4 hours

DX of Prediabetes: IGT:

2-hour plasma glucose higher than normal[(between 140 and 199 mg/dl]

Diabetes mellitus diagnostic studies AIC

2020 guidelines When A1C test is used to Dx diabetes, A1C level of 6.5 percent or higher on 2 separate occasions indicates diabetes.

Gestational diabetes is detected at

24 to 28 weeks of gestation

Insulin: rapid acting Lispro, aspart, glulisine Peak

60-90 minutes

Normal blood sugar:

70-130 -when get up in morning, expect to see this.

Someone w DKA can even have up to

800 or 900. They will feel like crap.

MAP goal

> or equal to 70

Diabetes Mellitus diagnostic studies Fasting plasma glucose level:

>126 mg/dl*

-both types -

A1C, fasting plasma glucose levels, glucose tolerance test, glucose monitoring, -care: decrease s/s, insulin therapy w oral hypoglycemic agents,

Sepsis/urosepsis What nursing priority will guide your plan of care?

ABCs of priority setting are ALWAYS RELEVANT and must be used when there are multiple problems or concerns that need to be addressed.

Compromised host Humoral immune dysfunction

AIDS, cancer

L.G., a 28-year-old diabetic, is admitted to the hospital with a cellulitis of her left lower leg. She had been applying heating pads to the leg for the last 48 hours, but the leg has become more painful and she has developed chilling. Subjective Data · Complains of pain and heaviness in her leg · States she cannot bear weight on her leg and has been in bed for 3 days · Lives alone and has not had anyone to help her with meals Objective Data Physical examination · Round, yellow-red, 2 cm diameter, 1-cm deep, open wound above the left medial malleolus with moderate amount of thick yellow drainage. · Left leg red from knee to ankle · Calf measurement on left 3 inches larger than right · Temperature 102 F (38.9 C) · Height 5 ft 4 in (160 cm); weight: 184 lb (83.7 kg) Laboratory test results · White blood cells (WBC): 18,300/uL (18.3 x 10⁹/L; 80% neutrophils, 12% bands) · Wound culture: Staphylococcus aureus Based on the assessment data provided, what are the priority nursing diagnoses? Are there any collaborative problems?

Acute pain r/t inflammation of left leg Hyperthermia r/t inflammatory process Risk for deficient fluid volume r/t an increased metabolic rate Risk for imbalanced nutrition Potential complication: septicemia

L. G. is a 68-year-old man who goes to the hospital emergency department with a complaint of left foot pain. He has a 7-year history of type 2 diabetes that is controlled with metformin (Glucophage) 500 mg orally twice daily. Subjective Data -States he stepped on "something" in the yard a few days ago -States he is unable to bear weight on the left foot -Has been nauseated and "just haven't felt good" Objective Data Physical Examination -Blood pressure 160/90, pulse 110, respirations 24, temperature 99.8° F -Left foot swollen, red, and warm to touch -Open area on ball of left foot near first metatarsal, w tissue loss and irregular wound margins Measures 2 cm in diameter, with moderate amount of thick yellow drainage -Bilateral paresthesia in lower legs Diagnostic Studies -Blood glucose 350 mg/dL -White blood cell (WBC) count 19,200/µL; 80% neutrophils (12% bands) How do you explain the slight elevation in LGs temperature?

Although lab results, increased pulse & RR, nausea, malaise indicate systemic infection, temp is just slightly elevated This might be bc older adults often have blunted febrile response to infection -Body temp might not rise to level expected for younger adult or may be delayed in onset

Sepsis/urosepsis - Collaborative care: medical management Ceftriaxone 1g IVPB...after blood/urine cultures obtained

As third generation broad-spectrum cephalosporin, it binds to bacterial cell wall membrane, causing cell death. Therapeutic Effects: Bactericidal action against susceptible bacteria. Spectrum: Similar to that of second-generation cephalosporins, but activity against staphylococci is less, while activity against gram-negative pathogens is greater. - Will not see immediate response in resolving infection, but would expect to see improvement over the next 24 hours

L.G., a 28-year-old diabetic, is admitted to the hospital with a cellulitis of her left lower leg. She had been applying heating pads to the leg for the last 48 hours, but the leg has become more painful and she has developed chilling. Subjective Data · Complains of pain and heaviness in her leg · States she cannot bear weight on her leg and has been in bed for 3 days · Lives alone and has not had anyone to help her with meals Objective Data Physical examination · Round, yellow-red, 2 cm diameter, 1-cm deep, open wound above the left medial malleolus with moderate amount of thick yellow drainage. · Left leg red from knee to ankle · Calf measurement on left 3 inches larger than right · Temperature 102 F (38.9 C) · Height 5 ft 4 in (160 cm); weight: 184 lb (83.7 kg) Laboratory test results · White blood cells (WBC): 18,300/uL (18.3 x 10⁹/L; 80% neutrophils, 12% bands) · Wound culture: Staphylococcus aureus LGs HCP orders aspirin to be given PRN for a temperature above 102 F/38.9 C. How does the aspirin act to interfere with the fever mechanism? Why is the aspirin to be given only if the temperature is above 102 F? To prevent cycling of chills and diaphoresis, how should the nurse administer the aspirin?

Aspirin interferes w synthesis & release of prostaglandins which are responsible in part for fever & also act on heat regulation center in hypothalamus, resulting in peripheral dilation & heat loss.

Humoral response/antibody-mediated response involves

B cells that recognize antigens or pathogens that are circulating in lymph of blood

Humoral immunity Cells involved

B lymphocytes

Hypoglycemia - treatment If alert enough to swallow Recheck

BG 15 minutes after Tx

B.N., a 41-year-old female who is a dental hygienist, has had several surgeries over the past five years due to a knee injury. She presents to the outpatient surgery department today for her last reconstructive surgery. Her past medical history indicates she had asthma as a child and had one occurrence of contact dermatitis. She tells you she has no known drug allergies. You start B.N.'s IV and perform a saline flush. Within three minutes, B.N. states that her IV site itches, and a few minutes later she begins to complain of tightness in her throat. Subjective Data States IV site itches States throat and neck feel tight and says "I feel like I can't breathe" Objective Data Vital signs: Temp 98.8° F, Heart rate 120, Respiratory rate 32, Blood pressure 100/60 Oxygen saturation 85% Wheezing in all lung fields Restless Swelling at IV site Based on this reaction, to what foods should BN be tested for allergies?

BN should be tested for allergies to bananas, avocados, chestnuts, kiwis, tomatoes, water chestnuts, guavas, hazelnuts, potatoes, peaches, grapes, apricots bc in people w latex allergies, 70% have positive allergy test to at least one of these related foods

B.N., a 41-year-old female who is a dental hygienist, has had several surgeries over the past five years due to a knee injury. She presents to the outpatient surgery department today for her last reconstructive surgery. Her past medical history indicates she had asthma as a child and had one occurrence of contact dermatitis. She tells you she has no known drug allergies. You start B.N.'s IV and perform a saline flush. Within three minutes, B.N. states that her IV site itches, and a few minutes later she begins to complain of tightness in her throat. Subjective Data States IV site itches States throat and neck feel tight and says "I feel like I can't breathe" Objective Data Vital signs: Temp 98.8° F, Heart rate 120, Respiratory rate 32, Blood pressure 100/60 Oxygen saturation 85% Wheezing in all lung fields Restless Swelling at IV site What type of altered immune response is BN experiencing?

Based on symptoms of wheezing, tachypnea, tachycardia and hypotension, BN experiencing allergic response It is classified as type 1: IgE-mediated anaphylactic reaction

Why often see lantus given at bedtime?

Bc cant be mixed with anything else so not giving pt 2 diff injections all at same time.

-type 1 classic cardinal symptoms: why happen?

Bc no insulin. So glucose levels keep going up and up in bloodstream. This acts as osmotic diuretic. Pulls water out of cells into bloodstream. So pee a lot and thirst bc pee and hungry bc no glucose going into cells to feed cells.

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Creatinine: 1.5 Clinical significance?

Bc there is no history of renal disease, this value is extremely significant Bc creatinine is much more reliable indicator of kidney function/filtration of metabolic waste compared to BUN, it is elevated in Mrs. Kelly bc sepsis/septic shock & lack of perfusion to kidneys

Metformin is the only

Biguanide -works by reducing glucose production by liver

DKA: laboratory results

Blood glucose > 300 mg/dL Arterial blood pH below 7.30 Serum bicarbonate level < 15 mEq/L Ketones in blood and urine

Type 1 diabetes What labs?

Blood sugar, A1C [glcyocolated hemoglobin] Impaired glucose tolerance: person fasts. Give sugary drink w lots of carbohydrates as well. Usually 75 g. when they drink it, see how much of sugar gets transported by insulin, if still high concentration, can assume don't have adequate insulin production or transportation to manage glucose levels. (take blood sugar before fast,

sepsis early stages: tachycardia.

Body still compensating. Heart trying to pump blood. High resp rate. Skin might still be warm and flushed bc HR is so high

Mr. M., a 45-year-old quadriplegic, is being treated for an infected stage IV sacral pressure ulcer. The wound cultures have indicated the presence of multidrug-resistant Staphylococcus aureus (MRSA). The physician has ordered intra venous vancomycin to be given every 12 hours, application of wet-to-dry dressing (twice a day) as part of the treatment, as well as a referral to the wound care nurse. In addition, Mr. M. ia placed on contact precautions because of the MRSA. What can you do to minimize complications during vancomycin infusions?

Carefully monitor infusion site for signs of infiltration and phlebitis bc extravasation may cause local skin irritation and damage. Ensure infusion is given over at least 1 hour, using an infusion pump; -higher doses are infused over longer period of time. adequate hydration [at least 2 L of fluids/24 hours unless contraindicated) is most important to prevent nephrotoxicity.

B.N., a 41-year-old female who is a dental hygienist, has had several surgeries over the past five years due to a knee injury. She presents to the outpatient surgery department today for her last reconstructive surgery. Her past medical history indicates she had asthma as a child and had one occurrence of contact dermatitis. She tells you she has no known drug allergies. You start B.N.'s IV and perform a saline flush. Within three minutes, B.N. states that her IV site itches, and a few minutes later she begins to complain of tightness in her throat. Subjective Data States IV site itches States throat and neck feel tight and says "I feel like I can't breathe" Objective Data Vital signs: Temp 98.8° F, Heart rate 120, Respiratory rate 32, Blood pressure 100/60 Oxygen saturation 85% Wheezing in all lung fields Restless Swelling at IV site What is the apparent causative factor and what were potential sources of exposure?

Causative factor appears to be exposure to latex -Exposure may have been in tourniquet used to start IV, gloves nurse was wearing to start IV, adhesive used to secure IV, rubber plunger in disposable syringe or if saline flush was drawn up from vial from rubber top of vial

Antibiotics interventions and rationales ■ Determine the interactions of the prescribed antibiotics with various foods and beverages. (

Certain food and beverages will interfere with medication's effectiveness.)

Compromised host Drug therapy

Chemo, abx, steroids

Insulin basically

Decreases glucose in bloodstream

Mr. M., a 45-year-old quadriplegic, is being treated for an infected stage IV sacral pressure ulcer. The wound cultures have indicated the presence of multidrug-resistant Staphylococcus aureus (MRSA). The physician has ordered intra venous vancomycin to be given every 12 hours, application of wet-to-dry dressing (twice a day) as part of the treatment, as well as a referral to the wound care nurse. In addition, Mr. M. ia placed on contact precautions because of the MRSA. Two days later, Mr. M. complains of feeling "hot" in his face and neck, and itching in those same areas. His face and neck are flushed, what do you suspect is happening?

Did you suspect an allergic reaction? More likely, he is experiencing "red man syndrome" which may occur when vancomycin is infused too quickly. This common adverse effect is bothersome but usually nor harmful and involves flushing and/or itching of head, face, neck and upper trunk area. It can usually be alleviated by slowing rate of infusion to 1 hour or longer.

Septic shock medical management Pharmacologic therapy.

Drotrecogin alfa is used to act as antithrombotic, anti-inflammatory, and profibrinolytic agent.

Sepsis/urosepsis - Collaborative care: medical management 0.9% NS 1000 mL IV bolus - rationale & expected outcome

Early fluid resuscitation is standard of care in sepsis due to fluid volume deficit secondary to third spacing w inflammatory process as well as resultant vasodilation. Improvement in fluid volume deficit manifested by decrease in HR and elevation in SBP.

Septic shock cause · Extremes of age.

Elderly people and infants are more prone to septic shock bc weak immune system.

B.N., a 41-year-old female who is a dental hygienist, has had several surgeries over the past five years due to a knee injury. She presents to the outpatient surgery department today for her last reconstructive surgery. Her past medical history indicates she had asthma as a child and had one occurrence of contact dermatitis. She tells you she has no known drug allergies. You start B.N.'s IV and perform a saline flush. Within three minutes, B.N. states that her IV site itches, and a few minutes later she begins to complain of tightness in her throat. Subjective Data States IV site itches States throat and neck feel tight and says "I feel like I can't breathe" Objective Data Vital signs: Temp 98.8° F, Heart rate 120, Respiratory rate 32, Blood pressure 100/60 Oxygen saturation 85% Wheezing in all lung fields Restless Swelling at IV site What are the priority nursing interventions in this situation? What medications might you expect the HCP to prescribe?

Ensure patent airway & administer high-flow oxygen via non-rebreather mask -Anticipate possible intubation -Maintain IV access -Monitor VS & maintain BP w IV fluids -Anticipate administering epinephrine [Adrenalin], nebulized albuterol [Proventil], diphenhydramine hydrochloride [Benadryl], IV and corticosteroids

Septic shock preventions Equipment cleanliness.

Equipment used for pt, esp ones involved in invasive procedures, must be properly cleaned and maintained to avoid harboring harmful microorganisms that can enter body.

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. What data from the histories are important and RELEVANT and have clinical significance for the nurse? Fever in the last 24 hours

Fever reflects the SIRS initiated by immune system & is there for reason - to help body fight off invading microorganisms by increasing production of neutrophils -first responders of immune system that are macrophages -elevated temp also makes it less hospitable for bacteria to thrive & multiply

Mr. M., a 45-year-old quadriplegic, is being treated for an infected stage IV sacral pressure ulcer. The wound cultures have indicated the presence of multidrug-resistant Staphylococcus aureus [MRSA). The physician has ordered intra venous vancomycin to be given every 12 hours, application of wet-to-dry dressing [twice a day) as part of the treatment, as well as a referral to the wound care nurse. In addition, Mr. M. is placed on contact precautions because of the MRSA. What will you assess before starting the vancomycin infusion?

First, make sure he is not allergic to Vancomycin. Baseline renal function studies and hearing tests must also be performed bc of possible nephrototxic and ototoxic effects. In addition, baseline VS, esp bp, need to be assessed. Be sure to collect any specimens that are needed for cultures before beginning the med. The intravenous site must be assessed for patency. In addition, the "six rights" need to be performed before administering the drug.

Type 1 diabetes

Formerly known as "juvenile onset" or "insulin dependent" diabetes It is an autoimmune disease

Fluoroquinolones [end in -floxacin] Notably,

GI distress is common side effect w these drugs

Where are eosinophils mainly found?

GI tract but not as plentiful as neutrophils

LET [leukocyte esterase): Positive Clinical significance?

Gross determinant of presence of WBCs in urine. It detects presence of enzyme esterase released by leukocytes. [normal is negative]

The most common test is allergy skin testing.

HCP pricks skin and introduces small amount of allergen. Many allergenic extracts are available to the clinician.

L.G., a 28-year-old diabetic, is admitted to the hospital with a cellulitis of her left lower leg. She had been applying heating pads to the leg for the last 48 hours, but the leg has become more painful and she has developed chilling. Subjective Data · Complains of pain and heaviness in her leg · States she cannot bear weight on her leg and has been in bed for 3 days · Lives alone and has not had anyone to help her with meals Objective Data Physical examination · Round, yellow-red, 2 cm diameter, 1-cm deep, open wound above the left medial malleolus with moderate amount of thick yellow drainage. · Left leg red from knee to ankle · Calf measurement on left 3 inches larger than right · Temperature 102 F (38.9 C) · Height 5 ft 4 in (160 cm); weight: 184 lb (83.7 kg) Laboratory test results · White blood cells (WBC): 18,300/uL (18.3 x 10⁹/L; 80% neutrophils, 12% bands) · Wound culture: Staphylococcus aureus What are the priority precautions to prevent transmission of infection in the care of LGs wound?

Hand washing before application of clean gloves & immediately after removal -Clean gloves when in contact w infected materials like dressings or linens w exudates - biohazard disposal or dressings & gloves

Septic shock assessment Blood studies.

Hematologic test must also be performed to check on perfusion of blood.

Macrophages are monocytes that migrated from the blood into any tissue in body

Here they aid in phagocytosis to eliminate harmful materials like -foreign substances -cellular debris -cancer cells

Skin testing indicates M.W. has an allergy to household dust. What information should the nurse include in teaching M.W. to control his exposure to this allergen?

Household dust is controlled w air conditioners and air filtration systems in home as well as daily damp dusting and frequent vacuuming w high filtration vacuum bags.

B.N., a 41-year-old female who is a dental hygienist, has had several surgeries over the past five years due to a knee injury. She presents to the outpatient surgery department today for her last reconstructive surgery. Her past medical history indicates she had asthma as a child and had one occurrence of contact dermatitis. She tells you she has no known drug allergies. You start B.N.'s IV and perform a saline flush. Within three minutes, B.N. states that her IV site itches, and a few minutes later she begins to complain of tightness in her throat. Subjective Data States IV site itches States throat and neck feel tight and says "I feel like I can't breathe" Objective Data Vital signs: Temp 98.8° F, Heart rate 120, Respiratory rate 32, Blood pressure 100/60 Oxygen saturation 85% Wheezing in all lung fields Restless Swelling at IV site What were BN's risk factors for this type of reaction?

Hx asthma & contact dermatitis -Source of contact dermatitis should have been investigated to identify causative agent BN is dental hygienist & has had several surgeries so may have had long term multiple exposures to latex products -In health Hx, she should have been asked if she has had any allergic reactions to latex products

Antibiotics interventions and rationales ■ Monitor renal function such as

I&O ratios and urine color and consistency. Monitor lab work including serum creatinine and BUN.

Prediabetes: -millions of people have this -how diagnosed?

IGT: impaired glucose tolerance ?? common test for diabetes IFG: impaired fasting glucose??? Common test

Macrolides [azithromycin, clarithromycin, erythromycin] When these drugs are indicated for

IV infusion, remember med should be diluted & administered slowly to prevent common prob of thrombophlebitis

Compromised host Invasive devices

IV, catheter

B.N., a 41-year-old female who is a dental hygienist, has had several surgeries over the past five years due to a knee injury. She presents to the outpatient surgery department today for her last reconstructive surgery. Her past medical history indicates she had asthma as a child and had one occurrence of contact dermatitis. She tells you she has no known drug allergies. You start B.N.'s IV and perform a saline flush. Within three minutes, B.N. states that her IV site itches, and a few minutes later she begins to complain of tightness in her throat. Subjective Data States IV site itches States throat and neck feel tight and says "I feel like I can't breathe" Objective Data Vital signs: Temp 98.8° F, Heart rate 120, Respiratory rate 32, Blood pressure 100/60 Oxygen saturation 85% Wheezing in all lung fields Restless Swelling at IV site how can such reactions be prevented from occurring?

Identify pts and health care workers sensitized to latex w thorough health hx and investigate any complaints of latex contact symptoms.

Take whole course of antibiotics even if start feeling better -why?

If don't, can make body more resistant to those bacteria. -antibiotics kill bad stuff but also kill good stuff. Will kill healthy gut bacteria and cause upset stomach.

Which immunoglobulin is this? provides local protection to exposed mucous membranes

IgA

What antibodies are often measured together?

IgA, IgG, IgM

Which immunoglobulin is this? exact function unknown

IgD

Which immunoglobulin is this? involved in allergic and anaphylactic response

IgE

M.W., age 54, has been diagnosed as having perennial allergic rhinitis. He is to undergo skin testing to identify specific allergens. His health care provider has prescribed oral antihistamines for control of his symptoms. Subjective Data · Itching of eyes, nose, and throat · Stuffy nose, head congestion Objective Data · Physical examination · Clear nasal drainage: reddened eyes and lacrimation What immunoglobulins and chemical mediators are involved in MW's allergic reaction?

IgE immunoglobulin involved in most allergic reactions Chemical mediators active in pt allergic rhinitis include: -Histamine -Serotonin -Slow releasing substances like anaphylaxis -Eosinophil chemical factor -Competent anaphylatoxins

Most common type of antibody found in circulation

IgG

Which immunoglobulin is this? activates complement system active against bacteria & viruses

IgG

Which immunoglobulin is this? first antibody produced with primary immune response

IgM

Antibiotics interventions and rationales ■ Monitor for hypersensitivity reaction. (

Immediate hypersensitivity reaction may occur within 2 to 30 minutes; accelerated occurs in 1 to 72 hours, and delayed after 72 hours.)

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Relevant VS data? Right flank pain, continuous, 5/10

In this scenario w known dysuria, presence of flank pain is clinically significant & must be recognized by nurse This is most likely due to pyelonephritis or progression of urinary infection in lower tract, migrating to kidneys. This makes her infection more serious and represents clinical progression of infection in urinary tract.

◦Glucagon, epinephrine, growth hormone, cortisol

Increase blood glucose levels

-what makes someone insulin resistant?

Increased waist circum. High bp. High cholest.

M.W., age 54, has been diagnosed as having perennial allergic rhinitis. He is to undergo skin testing to identify specific allergens. His health care provider has prescribed oral antihistamines for control of his symptoms. Subjective Data · Itching of eyes, nose, and throat · Stuffy nose, head congestion Objective Data · Physical examination · Clear nasal drainage: reddened eyes and lacrimation Based on the assessment data provided, what are the priority nursing diagnoses? Are there any collaborative problems?

Ineffective health maintenance r/t insufficient knowledge Risk for injury r/t effects of antihistamines Potential complications: anaphylaxis

Child and adolescent Accidents

Inflammatory response

droplet precautions Examples of Diseases:

Influenza, meningococcal meningitis, mumps, rubella, diphtheria, pneumonic plague, pertussis and infections caused by multidrug resistant Streptococcus pneumonia.

type 2 diabetes insulin

Insulin produced is either insufficient or poorly utilized by tissues

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. What data from the histories are important and RELEVANT and have clinical significance for the nurse? Lives independently in senior apartment retirement community

Is functioning at high level for 82 year old woman & is independent at this time -It is important for the nurse to re-evaluate functional status anytime there is hospital admission to ensure safety -If there is ever a question, consult social services

NPH -what should we think about as nurse?

Issue is after evening dose, will go to bed. Ex: around 9pm. So that's time pt needs a bedtime snack. Bc pt has insulin, will peak 4-10 hours but not eating anything, so all insulin and no sugar, so need snack to hold through night. -ex: half peanut butter sandwich or apple w peanut butter -bed time snack is to prevent hypoglycemia

Type 1 diabetes What body systems directly affected by that?

It starts in the pancreas. Glucose is sitting in bloodstream waiting but no insulin is coming. So has sugar hanging out in blood circulating Brain needs sugar all the time. Affects every body system here.

L.G., a 28-year-old diabetic, is admitted to the hospital with a cellulitis of her left lower leg. She had been applying heating pads to the leg for the last 48 hours, but the leg has become more painful and she has developed chilling. Subjective Data · Complains of pain and heaviness in her leg · States she cannot bear weight on her leg and has been in bed for 3 days · Lives alone and has not had anyone to help her with meals Objective Data Physical examination · Round, yellow-red, 2 cm diameter, 1-cm deep, open wound above the left medial malleolus with moderate amount of thick yellow drainage. · Left leg red from knee to ankle · Calf measurement on left 3 inches larger than right · Temperature 102 F (38.9 C) · Height 5 ft 4 in (160 cm); weight: 184 lb (83.7 kg) Laboratory test results · White blood cells (WBC): 18,300/uL (18.3 x 10⁹/L; 80% neutrophils, 12% bands) · Wound culture: Staphylococcus aureus What type of wound dressing would promote healing of the open wound?

Keep moist w continuous cleansing to remove nonviable tissue & to absorb excess drainage Moist gauze or absorption dressing would be best choice in wound that is infected -Use sterile technique

Specific gravity: 1.032 Clinical significance?

Knowing that dehydration is likely overlay in this scenario, this elevation is abnormal but expected and confirms significance of volume depletion and resultant urine concentration. [normal is 1.015-1.030]

Protein: 2+ Clinical significance?

Knowing that protein is large molecule, this elevation could represent damage to glomeruli that is expected as renal disease progresses w those who have diabetes. Normal is negative

L. G. is a 68-year-old man who goes to the hospital emergency department with a complaint of left foot pain. He has a 7-year history of type 2 diabetes that is controlled with metformin (Glucophage) 500 mg orally twice daily. Subjective Data -States he stepped on "something" in the yard a few days ago -States he is unable to bear weight on the left foot -Has been nauseated and "just haven't felt good" Objective Data Physical Examination -Blood pressure 160/90, pulse 110, respirations 24, temperature 99.8° F -Left foot swollen, red, and warm to touch -Open area on ball of left foot near first metatarsal, w tissue loss and irregular wound margins Measures 2 cm in diameter, with moderate amount of thick yellow drainage -Bilateral paresthesia in lower legs Diagnostic Studies -Blood glucose 350 mg/dL -White blood cell (WBC) count 19,200/µL; 80% neutrophils (12% bands) What factors may interfere with or delay the healing of LGs wound?

LG is at risk for delayed wound healing bc presence of infection, decreased blood supply, elevated blood glucose, lack of knowledge r/t wound care & presence of peripheral neuropathy

L. G. is a 68-year-old man who goes to the hospital emergency department with a complaint of left foot pain. He has a 7-year history of type 2 diabetes that is controlled with metformin (Glucophage) 500 mg orally twice daily. Subjective Data -States he stepped on "something" in the yard a few days ago -States he is unable to bear weight on the left foot -Has been nauseated and "just haven't felt good" Objective Data Physical Examination -Blood pressure 160/90, pulse 110, respirations 24, temperature 99.8° F -Left foot swollen, red, and warm to touch -Open area on ball of left foot near first metatarsal, w tissue loss and irregular wound margins Measures 2 cm in diameter, with moderate amount of thick yellow drainage -Bilateral paresthesia in lower legs Diagnostic Studies -Blood glucose 350 mg/dL -White blood cell (WBC) count 19,200/µL; 80% neutrophils (12% bands) What will be LGs priority discharge teaching needs?

LG will require teaching regarding wound care [use mirror to see wound on bottom of foot if others not available to assess] -Monitor s/s infection [redness, heat, pain, swelling, fatigue, malaise, anorexia, nausea, fever] -Benefit from review of diabetes self management and foot care

L. G. is a 68-year-old man who goes to the hospital emergency department with a complaint of left foot pain. He has a 7-year history of type 2 diabetes that is controlled with metformin (Glucophage) 500 mg orally twice daily. Subjective Data -States he stepped on "something" in the yard a few days ago -States he is unable to bear weight on the left foot -Has been nauseated and "just haven't felt good" Objective Data Physical Examination -Blood pressure 160/90, pulse 110, respirations 24, temperature 99.8° F -Left foot swollen, red, and warm to touch -Open area on ball of left foot near first metatarsal, w tissue loss and irregular wound margins Measures 2 cm in diameter, with moderate amount of thick yellow drainage -Bilateral paresthesia in lower legs Diagnostic Studies -Blood glucose 350 mg/dL -White blood cell (WBC) count 19,200/µL; 80% neutrophils (12% bands) By what method will LGs wound heal?

LGs wound will heal by secondary intention -this is bc loss of tissue & irregular margins which indicate wound edges will not be able to be approximated

Intermediate acting insulin examples

NPH

N:

NPH - long acting insulin

How can the key procedures of surgical asepsis impact care for pts on this surgical unit?

Need surgical asepsis for -starting IV line -administering injection -performing sterile dressing change

L. G. is a 68-year-old man who goes to the hospital emergency department with a complaint of left foot pain. He has a 7-year history of type 2 diabetes that is controlled with metformin (Glucophage) 500 mg orally twice daily. Subjective Data -States he stepped on "something" in the yard a few days ago -States he is unable to bear weight on the left foot -Has been nauseated and "just haven't felt good" Objective Data Physical Examination -Blood pressure 160/90, pulse 110, respirations 24, temperature 99.8° F -Left foot swollen, red, and warm to touch -Open area on ball of left foot near first metatarsal, w tissue loss and irregular wound margins Measures 2 cm in diameter, with moderate amount of thick yellow drainage -Bilateral paresthesia in lower legs Diagnostic Studies -Blood glucose 350 mg/dL -White blood cell (WBC) count 19,200/µL; 80% neutrophils (12% bands) LG will be admitted to the medical unit. What nursing interventions should be included in his plan of care?

Need to provide proper wound care, cleaning & debriding wound as needed & promote moist environment to stimulate wound healing -Administer ordered meds to treat infection -Continue monitoring VS & blood glucose -Provide Tx to return blood glucose to normal [management of diabetic probs]

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. What data from the histories are important and RELEVANT and have clinical significance for the nurse? Did not know what day it was. She is mentally alert with no history of confusion.

New onset confusion is always clinical RED FLAG in elderly & when clustered w other symptoms is not representing neurologic prob but is commonly seen w infection like UTI

-should we see WBCs in urine?

No. pt does have wbcs in urine. Shows there is presence of UTI.

Aminoglycosides such as gentamicin and tobramycin are used to treat

ONLY IN HOSPITALS; very serious illnesses such as septicaemia, bc can cause serious side effects, like hearing loss and kidney damage;

dka -what kind of insulin would give?

Only regular insulin can be given IV. So bolus of regular IV.

Sepsis/urosepsis - Collaborative care: medical management Morphine 2 mg IV push every 2 hours prn-pain

Opioid narcotic- Bind to opiate receptors in CNS. Alter perception of and response to painful stimuli while producing generalized CNS depression. - Pain decreased

Mr. M., a 45-year-old quadriplegic, is being treated for an infected stage IV sacral pressure ulcer. The wound cultures have indicated the presence of multidrug-resistant Staphylococcus aureus (MRSA). The physician has ordered intra venous vancomycin to be given every 12 hours, application of wet-to-dry dressing (twice a day) as part of the treatment, as well as a referral to the wound care nurse. In addition, Mr. M. ia placed on contact precautions because of the MRSA. The physician orders measurement of vancomycin blood levels. What is the therapeutic goal when vancomycin levels are monitored?

Optimal blood levels of vancomycin should be at peak level of 18 to 50 mcg/mL and a trough level of 10 to 20 mcg/mL. However, peak level are no longer routinely recommended, and only trough levels are commonly monitored. Trough levels are drawn before the next dose. Due to an increase in resistance, many clinicians use trough level of 15 - 20 mcg/mL as their goal.

Sepsis Optimize fluid-volume status

Patients suffering from sepsis usually require massive fluid resuscitation.

In hospital guidelines for BG Noncritically ill treated with insulin

Premeal glucose target should be less than 140 mg/dl w random BG levels at less than 180

Contact precautions Special Factors:

Private room or rooms w pt/resident who has similar dx. pt/resident should stay in room except for medically necessary procedures or therapies. Gloves for any contact w pt/resident or touching anything in room. Gown if it is likely that clothing will be in contact w any pt/resident or any surfaces in pt/resident care environment. Mask and eye protection if splashing or splattering of any contaminated substance is likely. pt/resident care items such as bp cuff, stethoscopes or thermometer should be "dedicated" (used only for that pt/resident and disinfected or discarded after pt/resident is discharged

droplet precautions Special Factors:

Private room or rooms w pt/resident who has similar dx. pt/resident should stay in room except for medically necessary procedures; a mask should be worn when out of the room. A regular/surgical mask should be used for any potential exposure within three feet of the patient/resident. Gloves and gowns are required when delivering patient/resident care in droplet precautions. Patient/resident care items such as blood pressure cuff, etc. should be dedicated to that patient/resident. Patient/resident should be taught to cover their nose and mouth with tissues when coughing or sneezing and to discard tissues into a bag.

airborne precautions special factors

Private room with special ventilation; door must be kept closed. The patient/resident should stay in his or her room except for essential reasons; a special mask should be worn when out of the room. Respirators are worn by personnel if the patient/resident has or is suspected of having an airborne illness. In general, students are not usually fitted for respirators. Respirators are worn for chickenpox or measles only if the employee entering has not had the disease or has not been immunized. Gloves: Worn when in contact w respiratory secretions. Patient/resident care items such as blood pressure cuffs, etc. should be dedicated and disinfected or discarded after the patient/resident is discharged. Patient/resident should be taught to cover their nose and mouth with tissues when coughing or sneezing and to discard tissues in a bag.

hygiene interventions: Meeting hygiene needs

Providing complete/partial bed bath -Provide perineal care -Provide oral care: brushing/flossing, denture care

Patient centered glycemic management Implement management plan

Pts not meeting goals generally should be seen at least every 3 months as long as process is being made; more frequent contact initially is often desirable for DSMES

Septic shock cause Chronic illness.

Pts w longstanding illness are put at risk for sepsis bc body's immune system is already weakened by existing pathogens.

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Glucose: 184 Clinical significance?

Pts w sepsis usually have elevated blood glucose levels which is associated w poor outcomes Insulin therapy is used to maintain levels as close to normal as possible or at least < 180 mg/dL

What can you do to engage yourself with this patient's experience, and show that he/she matters to you as a person?

Regardless of clinical setting, remember importance of touch and presence as provide care. If you are using Swanson's Caring framework following practical caring interventions can be "tools" in your caring toolbox to use depending on the circumstance and the patient needs -Comforting -Little things to comfort-whatever it may be-are needed and appreciated! i.e.,hand or foot massage for pain control -Anticipating their needs -Staying one step ahead and not behind, esp in crisis,is essential! -Is everything where patient can reach it before you leave the room? -Performing competently/skillfully -Remember that when a nurse or student nurse does their job well and competently, this demonstrates caring to the patient! -Preserving dignity -Maintaining privacy at all times is essential and is all too easily forgotten because of pressing physical needs that may be present. -Pulling the curtain as well as covering exposed genitalia is all that is needed. They are little things, but so important to preserve human dignity. -Accomplishing bodily functions which are disrupted with someone else present is significant. Be respectful of privacy issues. -Informing/explaining-patient education -Even in a crisis, simply explain all that you are doing. If your patient is not able to respond but family are present, explaing to them all that you are doing and why. This is truly the "art" of nursing and makes such a difference when done in practice!

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Relevant VS data? Supine: 110, 102/50 Standing: 132, 92/42

Review abnormal orthostatic BP findings Increase of 20 beats or more from lying baseline is by itself POSITIVE finding & is usually seen in mild to moderate dehydration from my clinical experience

Sepsis order

SIRS -> Sepsis -> Severe sepsis -> Septic shock

Person starts w

SIRS before sepsis

Severe sepsis

Sepsis + Signs of end organ damage Hypotension [SBP < 90] Lactate > 4 mmol

Sepsis complications · Severe sepsis.

Sepsis could progress to severe sepsis w symptoms of -organ dysfunction, -hypotension or hypoperfusion, -lactic acidosis, -oliguria, -altered LOC -coagulation disorders, -altered hepatic functions. ·

Sepsis Communicate with and educate patient and loved one

Sepsis is serious and scary. -essential to educate pt and support system at every step of way so they are able to let you know if feel/act diff, if things change, and also to prevent them from unnecessarily worrying or interfering w very needed interventions

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. What is the primary problem that your patient is most likely presenting?

Sepsis/urosepsis

-circulating supplies of insulin is insufficient or nonexistent therefore glucose cant be used as energy source. So no sugar in body. So body starts to break down fat. [fat is secondary source of fuel]. Brain needs glucose all the time but not available. So all glucose sit in blood vessels. Blood sugar climbing higher and higher. -ketosis part: acidic byproduct of fat metabolism. Ketones are produced as acidic byproduct of fat metabolism. Bc there is excess here bc body just using up fat as energy source, we see excess of these ketones. Ketones can be measured in blood, urine, -can cause problems in acid base balance. Ketones alter pH. -what acid base balance in DKA? Metabolic acidosis. -bicarb low, pH low, elevation in counter regulatory hormones. -elevated glucose levels: Blocks protein synthesis??, Glucose in bv act as osmotic diuretic -pee a lot -very dehydrated

So no sugar in body. So body starts to break down fat. [fat is secondary source of fuel]. Brain needs glucose all the time but not available. So all glucose sit in blood vessels. Blood sugar climbing higher and higher.

Antibiotics interventions and rationales ■ Monitor for symptoms of ototoxicity. (

Some antibiotics, such as aminoglycosides and vancomycin, may cause vestibular or auditory nerve damage.)

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Magnesium: 1.8 [previous 1.9] Trend

Stable

Some bacteria have developed resistance to antibiotics that were once commonly used to treat them For example,

Staphylococcus aureus [golden staph or MRSA] and Neisseria gonorrhoeae [cause of gonorrhea] are now almost always resistant to benzyl penicillin in the past, these infections were usually controlled by penicillin

Antibiotics and rationales interventions ■ Administer drug around the clock. (

Steady administration maintains effective blood levels.)

Which T cell is this? Suppress the attack when the need is no longer present

Suppressor T cells

L. G. is a 68-year-old man who goes to the hospital emergency department with a complaint of left foot pain. He has a 7-year history of type 2 diabetes that is controlled with metformin (Glucophage) 500 mg orally twice daily. Subjective Data -States he stepped on "something" in the yard a few days ago -States he is unable to bear weight on the left foot -Has been nauseated and "just haven't felt good" Objective Data Physical Examination -Blood pressure 160/90, pulse 110, respirations 24, temperature 99.8° F -Left foot swollen, red, and warm to touch -Open area on ball of left foot near first metatarsal, w tissue loss and irregular wound margins Measures 2 cm in diameter, with moderate amount of thick yellow drainage -Bilateral paresthesia in lower legs Diagnostic Studies -Blood glucose 350 mg/dL -White blood cell (WBC) count 19,200/µL; 80% neutrophils (12% bands) Are LGs manifestations of inflammation local or systemic? What information supports your response?

Systemic bc lab results, abnormal VS, nausea, malaise. S/s local = redness, heat, pain, swelling, loss of function. S/s systemic = increased WBC, shift to left, malaise, nausea, anorexia, increased pulse and resp rate,fever

In HIV

T cells become a prob - they don't know when to stop; they attack good tissue

Which disease is a 70 year old African American client at highest risk of developing? a) osteoporosis b) hyperthyroidism c) T2DM d) skin cancer

T2DM

SIRS

T: > 100.4 F or less than 96.8 F RR: > 20 HR: > 90 WBC: > 12,000 or < 4,000, > 10% bands PCO2: < 32 mm Hg

Compromised host Stasis of body fluid

TCDB, fluid stasis host for bacteria

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Chest x-ray: no infiltrates or other abnormalities. No changes from last previous. Clinical significance?

There is no pneumonia as source of infection & urine/urosepsis is still the source

The immune system distinguishes groups of foreign substances: One group consists of antigens that are freely circulating in the body

These include molecules, viruses and foreign cells

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. What data from the histories are important and RELEVANT and have clinical significance for the nurse? Painful, burning sensation when she urinates as well as frequency of urination the last week

These symptoms classic w UTI -Suspecting a urinary infection, nurse needs to know that if pt meets SIRS criteria, they should suspect sepsis

Two tests are commonly used for diagnosing allergy symptoms.

These tests are used to detect allergen-specific IgE.

MRSA, C diff and multi drug resistant tuberculosis

These types of infections can be serious and challenging to treat, and are becoming an increasing cause of disability and death across the world.

UA: Bacteria: Large Clinical significance?

This confirms the other markers that are more reliable and specific for UTI. This marker on UA does not consistently follow presence of infection, but in this scenario, it does!

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Relevant VS data? BP: 102/50 MAP: 67

Though BP technically within normal range, nurse must recognize is in LOW range of normal. When combined with what we know in this scenario regarding Jean's fluid volume deficit and risk of sepsis, this warrants close observation and must be TRENDED closely. Jean also has Hx of hypertension so this is probably "hypotension" for her MAP is more important than SBP and DBP bc gives nurse better clue as to organ perfusion

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. What data from the histories are important and RELEVANT and have clinical significance for the nurse? More fatigued for the last 3 days

Though a general complaint, when clustered w other symptoms of fever, this is indicating there is likely a PROBLEM present

Septic shock assessment · Blood culture.

To identify microorganism responsible for disease, blood culture must be performed.

sepsis Why ceftriaxone [IV piggyback] -why getting this antibiotic?

To kill bacteria. -why ceftriaxione in particular? It's broad spectrum.

Septic shock prevention · Strict infection control practices.

To prevent invasion of microorganisms inside body, infection must be put at bay through effective aseptic techniques and interventions.

Mr. M., a 45-year-old quadriplegic, is being treated for an infected stage IV sacral pressure ulcer. The wound cultures have indicated the presence of multidrug-resistant Staphylococcus aureus (MRSA). The physician has ordered intra venous vancomycin to be given every 12 hours, application of wet-to-dry dressing (twice a day) as part of the treatment, as well as a referral to the wound care nurse. In addition, Mr. M. ia placed on contact precautions because of the MRSA. What is the single best action you can take to prevent the spread of Mr. M.'s MRSA infection?

To prevent spread of methicillin-resistant staphylococcus aureas (MRSA), hand washing must be performed before and after every pt contact. In addition, guidelines for those precautions need to be followed strictly bc Mr. M. is on contact isolation.

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. BUN: 35 {previous 14] Trend: improve/worsening/stable

Trending UP... worsening

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Creatinine 1.5 [previous 1.1] Trend: improve/worsening/stable

Trending UP... worsening

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Glucose: 184 [previous 128] Trend: improve/worsening/stable

Trending UP... worsening

Most prevalent type of diabetes

Type 2

Risk for infection: Interventions Immunizations

UTD

General appearance: resting comfortably, appears in no acute distress Resp: breath sounds clear w equal aeration bilaterally, nonlabored resp effort Cardiac: pink, warm and dry, no edema, heart sounds regular - S1S2, pulses strong, equal w palpation at radial/pedal/post-tibial landmarks Neuro: alert & oriented x2 - is not consistently oriented to date and place, c/o dizziness when she sits up GI: abdomen soft/nontender, bowel sounds audible per auscultation in all 4 quadrants GU: dysuria and frequency of urination persists, right flank tenderness to gentle palpation Skin: skin integrity intact, lips dry, oral mucosa tacky dry Relevant assessment data? Genitourinary

UTI most likely source of infection in Mrs. Kelly Right flank pain tenderness is consistent w localized inflammation consistent w kidney infection [pyelonephritis]

Diagnostic: Hemoglobin A1C/glycosylated hemoglobin [A1C Level)

Useful in determining glycemic levels over time

L.G., a 28-year-old diabetic, is admitted to the hospital with a cellulitis of her left lower leg. She had been applying heating pads to the leg for the last 48 hours, but the leg has become more painful and she has developed chilling. Subjective Data · Complains of pain and heaviness in her leg · States she cannot bear weight on her leg and has been in bed for 3 days · Lives alone and has not had anyone to help her with meals Objective Data Physical examination · Round, yellow-red, 2 cm diameter, 1-cm deep, open wound above the left medial malleolus with moderate amount of thick yellow drainage. · Left leg red from knee to ankle · Calf measurement on left 3 inches larger than right · Temperature 102 F (38.9 C) · Height 5 ft 4 in (160 cm); weight: 184 lb (83.7 kg) Laboratory test results · White blood cells (WBC): 18,300/uL (18.3 x 10⁹/L; 80% neutrophils, 12% bands) · Wound culture: Staphylococcus aureus What is the significance of LGs WBC count and differential?

WBC count is increased indicating pronounced leukocytosis that would be seen in acute inflammation -Neutrophils normally 50-70% of white cells & here increased to 80% -this indicates early response of neutrophils to tissue damage -She also has shift to left in that normally only 0-8% of neutrophils in blood are immature, she has 12% -All those findings are consistent with acute inflammatory process

Magnesium: 1.8 Is this high, low or WNL?

WNL [normal 1.6-2.0 mEq/L]

Potassium: 3.8 Is this high, low or WNL?

WNL [normal 3.5-5.0 mEq/L]

Hgb: 14.4 Is this high, low or WNL?

WNL [normal 12-16 g/dL]

Sodium: 140 Is this high, low or WNL?

WNL [normal 135-145 mEq/L]

Platelets: 246 Is this high, low or WNL?

WNL [normal 150-450x 10^3/uL]

Band forms: 2 Is this high, low or WNL?

WNL [normal 3-5%]

somogyi and dawn how tell the difference between these 2?

Wake up between 2 or 3 several nights in a row and check blood sugar. If low at that time, smogyi. If normal or high side, dawn phenomenon. -

Prediabetes

When BG levels are higher than normal but not high enough for Dx of DM

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Relevant VS data? T: 101.8 F, 110 reg, R 24

With infection of any kind, sepsis is 2+ of SIRs [temp > 100.4, < 96.8], HR > 90, RR > 20, WBC > 12,000 or < 4,000, bands > 10% All 3 of these VS components meet SIRS criteria. Therefore, nurse must recognize that Jean is likely septic & is at risk for progression to septic shock. This must be recognized by nurse and is another critical RED FLAG

L. G. is a 68-year-old man who goes to the hospital emergency department with a complaint of left foot pain. He has a 7-year history of type 2 diabetes that is controlled with metformin (Glucophage) 500 mg orally twice daily. Subjective Data -States he stepped on "something" in the yard a few days ago -States he is unable to bear weight on the left foot -Has been nauseated and "just haven't felt good" Objective Data Physical Examination -Blood pressure 160/90, pulse 110, respirations 24, temperature 99.8° F -Left foot swollen, red, and warm to touch -Open area on ball of left foot near first metatarsal, w tissue loss and irregular wound margins Measures 2 cm in diameter, with moderate amount of thick yellow drainage -Bilateral paresthesia in lower legs Diagnostic Studies -Blood glucose 350 mg/dL -White blood cell (WBC) count 19,200/µL; 80% neutrophils (12% bands) What other diagnostic tests may be needed to help establish a diagnosis?

Wound cultures to determine causative organism of infection -Albumin, protein levels to assess nutritional status -Hgb A1C to assess glucose control -Bone scan to check for osteomyelitis -Vascular studies to evaluate blood flow to lower extremities

Sepsis: syndrome

[several layers of s/s attached to it]

The nurse observes a staff member enter the client's room wearing a fit-tested respiratory device. The nurse determines care is appropriate if that staff member is caring for which client? a) A client diagnosed with varicella b) A client diagnosed with mumps c) a client diagnosed with vancomycin-resistant enterococcus [VRE] d) a client diagnosed with pneumonia

a client diagnosed with varicella

Pts on insulin pumps know

a lot about them so listen to pts

A client diagnosed with type 1 diabetes asks the nurse "why don't people with type 2 diabetes develop diabetic ketoacidosis [DKA]? which is the best explanation for the nurse to give? a) A person with type 2 diabetes would not have high enough blood glucose to produce DKA b) a person with type 2 diabetes has stores of insulin that can be released to prevent DKA c) a person with type 2 diabetes can generally prevent development of DKA with diet d) a person with type 2 diabetes is able to produce some insulin to respond to increased blood glucose

a person with type 2 diabetes is able to produce some insulin to respond to increased blood glucose

Antibiotics In most cases, the allergic reaction is mild to moderate and can take the form of:

a raised, itchy skin rash (urticaria, or hives coughing wheezing tightness of the throat, which can cause breathing difficulties

allergy skin test In a sensitized individual,

a wheel and flare reaction, which is associated with itching, is noticed in 15-20 minutes.

Pathogenicity

ability to cause harm

Invasiveness

ability to penetrate tissues

Antibiotic resistant bacteria are

able to survive and even multiply in presence of antibiotic

Hemorrhaging represents

abnormal discovery in wound

High WBC count

above 11,000

Diabetes: hyperosmolar hyperglycemic syndrome [HHS] also [HHNK] Ketones

absent

ANC

absolute neutrophil count; less than 1,000

Treating hyperglycemia Check

accuracy & timing of dose/meal/activity

Fluoroquinolones and severe

aches and pains

-ketosis part:

acidic byproduct of fat metabolism.

Ketones are produced as

acidic byproduct of fat metabolism. Bc there is excess here bc body just using up fat as energy source, we see excess of these ketones.

The adaptive immune system aka

acquired immunity system

Inflammatory response: These substances [chemicals] also

act as chemical messengers that attract some of body's natural defense cells - a mechanism known as chemotaxis

Septic shock manifestations The inflammatory response is

activated bc of invasion of pathogens.

Sepsis/urosepsis After precipitating event which is usually bacterial infection that has entered bloodstream,

activation of widespread inflammatory response [SIRS]

Diabetes: diabetic ketoacidosis [DKA] it is

acute event characterized by -Hyperglycemia -Ketosis/acidosis -Dehydration

Inflammation can be

acute or chronic

Monocytes play an important role in

adaptive immunity process

Fibrinous exudate

adhesions [internal scar tissue that connects tissues not normally connected]

how to counteract each: -smogyi:

adjust evening meal, give bedtime snack. Make sure there is more protein and fat rather than carbohydrates in evening hours. So gets released slowly over many hours during night.

hypoglycemia -if pt not alert enough to swallow,

administer mg of glucagon intramuscularly or subcutaneously.

Sepsis nursing interventions Pharmacologic therapy. The nurse should

administer prescribed IV fluids and meds including antibiotic agents and vasoactive medications. ·

-Broad-spectrum antibiotics must be

administered within first hour of suspected sepsis; this is clinical priority in this scenario.

Sepsis: nursing care Appropriate

administration of IV antibiotics

Type 2 diabetes Aka:

adult onset or non insulin dependent DM

-type 2:

adult onset, metabolic abnormalities, high abdominal girth, hyperglycemia, hyperlipidema, HTN

Lactate > 2 associated with

adverse prognosis; even worse prognosis w levels > 4 [Epocrates]

The most common side effects of antibiotics

affect the digestive system. These happen in around 1 in 10 people.

Chronic complications diabetes: Microvascular Clinical manifestations usually appear

after 10-20 years of diabetes

Hypoglycemia - what can you do? Check blood glucose again

after 15 minutes -if still low, treat again -if symptoms don;t stop, call HCP

The nurse provides care for a client diagnosed with poorly controlled type 1 diabetes mellitus. Which finding is the earliest manifestation of diabetic nephropathy a) increased urinary output b) periorbital edema c) increased serum potassium d) albumin in the urine

albumin in the urine

General rules about insulin: no

alcohol swab on site needed before injection

standard precautions are based on the principle that

all blood, body fluids, secretions, excretions except sweat, nonintact skin & mucous membranes may contain transmissible infectious agents

Bacteremia, viremia & parasitemia

all forms of sepsis [bloodstream infection]

Standard infection precautions When to use

all patients

standard precautions apply to

all pts regardless of suspected or confirmed infection status in all health care settings

Diabetic retinopathy: -after 15 years,

all type 1 and over 80$ of type 2 wll have some type of retinal damage

In susceptible individuals,

allergens lead to production of immunoglobulin E (IgE).

Bradykinin is also involved in

allergic response. It is involved in vasodilation, vascular permeability and pain transmission.

Compromised host Preexisting diseases

already battling something; it wears down body

Insulin: NPH intermediate acting usually see this given

am/pm

A1C level shows

amt glucose attached to Hgb over RBC life span 90-120 days

Sepsis: -it's

an infection -can have life threatening organ dysfunction

Insulin is never

an oral medication -no such thing as oral insulin There is oral hypoglycemic agent

Lactate elevation reflects

anaerobic metabolism that is found in any shock state due to poor perfusion or increased presence of microorganisms

Bacteremia is

analogous to viremia [presence of virus in blood] & parasitemia [presence of parasite in blood]

Sepsis: nursing care Communicate with

and educate pt and loved ones

Risk for infection: Interventions Nutrition

and hydration

You may need to avoid taking medication that contains high levels of minerals or iron, as this can block the beneficial effects of fluoroquinolones. This includes:

antacids zinc supplements some types of multivitamin supplements

Antibiotics interventions and rationales ■ Monitor intake of OTC products such as

antacids, calcium supplements, iron products, and laxatives containing magnesium. These products interfere with absorption of many antibiotics.

Nurses role in educating patients to prevent antibiotic resistance Take

antibiotic exactly as HCP tells you -do not skip doses -complete prescribed course of Tx even if feeling better -if Tx stops too soon, some bacteria may survive and re-infect you

Nurses role in educating patients to prevent antibiotic resistance Ask whether

antibiotic is really best treatment for your illness

Empiric therapy

antibiotic therapy initiated prior to culture results

Definitive therapy

antibiotic therapy tailored from culture results

Pseudomembranous colitis or C. difficile

antibiotics disrupt normal gut flora creating overgrowth of C. dificile

Superinfection

antibiotics eliminate or reduce normal flora, causing overgrowth of other bacteria or fungi

Nurses role in educating patients to prevent antibiotic resistance Do not take

antibiotics prescribed for someone else -Antibiotic may not be appropriate for your illness

Around 1 in 15 people have an allergic reaction to

antibiotics, esp penicillin and cephalosporins.

Some people may have an allergic reaction to

antibiotics, esp penicillin and type called cephalosporins. In very rare cases, this can lead to a serious allergic reaction [anaphylaxis), which is a medical emergency.

Basophils contain

anticoagulant heparin which prevents blood from clotting too quickly

Diagnostic tests and procedures: Serology tests

antigen antibody rxn

Droplet infection precautions mask/eye protection

any time within 3 ft of pt

(Some antibiotics such as the aminoglycosides

are nephrotoxic.)

In DKA: -these pts

are really sick

If you accidentally take more than 1 extra dose of your antibiotic,

are worried or you get severe side effects, speak to your GP.

General rules about insulin: usually available

as U100

The spleen acts

as filter for blood as part of immune system

Sepsis/urosepsis Decreased CO

as result of decreased preload as less venous return comes back to right side of heart

Inflammation management Infection control

asepsis

If you want to check that your medicines are safe to take with your antibiotics,

ask your GP or local pharmacist.

Macrophages

assist in phagocytosis

Immunoglobulin E [IgE]

associated mainly w allergic reactions

Nosocomial infection

associated with health care delivery

People with a history of allergies, such as

asthma, eczema or hay fever, are at higher risk of developing serious allergic reaction [anaphylaxis) to penicillins, although cases are rare.

Contact infection precautions Gloves

at all times in contact w pt

Contact infection precautions Gown

at all times in contact w pt

Localized infections can usually be treated

at home but if not cared for properly, more serious infection may develop & spread

Macrophages arrive

at injured site within 72 hours of injury & may remain in area for weeks after injury

Best time to test someone'sblood sugar: -type 1:

at least 4 times a day. Before every meal. Before bedtime. Before and after exercise.

ASCVD

atherosclerotic cardiovascular disease

The chemicals that are released when tissue cells become injured

attract body's natural defense cells [aka chemostaxis]

Pathophysiology of Type 1 Diabetes:

autoimmune disorder where body attacks own insulin producing cells in pancreas.

L. G. is a 68-year-old man who goes to the hospital emergency department with a complaint of left foot pain. He has a 7-year history of type 2 diabetes that is controlled with metformin (Glucophage) 500 mg orally twice daily. Subjective Data -States he stepped on "something" in the yard a few days ago -States he is unable to bear weight on the left foot -Has been nauseated and "just haven't felt good" Objective Data Physical Examination -Blood pressure 160/90, pulse 110, respirations 24, temperature 99.8° F -Left foot swollen, red, and warm to touch -Open area on ball of left foot near first metatarsal, w tissue loss and irregular wound margins Measures 2 cm in diameter, with moderate amount of thick yellow drainage -Bilateral paresthesia in lower legs Diagnostic Studies -Blood glucose 350 mg/dL -White blood cell (WBC) count 19,200/µL; 80% neutrophils (12% bands) Nurse should assess

availability of fam and friends who can help LG when he is discharged -consider referral to home health agency if needed

A1C looks at

average blood glucose attached to RBCs -bc RBCs live in body for 2-3 months, it looks at blood glucose over time -it's a good test -it gives broader picture at how tightly controlled someone is. That's what we want for someone w diabetes.

if symptoms of latex allergy appear,

avoid direct contact w latex products; and wear Medic Alert bracelet and carry epinephrine pen.

Fluoroquinolones [end in floxacin] important teaching points

avoid taking these drugs with milk or antacids

Have to protect

babies bc so many people are not getting immunized -babies can't get certain vaccines until 6-12 months so exposure to unimmunized children can be dangerous

Septicemia is dangerous bc

bacteria & their toxins can be carried through bloodstream to entire body

Antibiotic resistant bacteria

bacteria not controlled or killed by antibiotics

Multi-resistant organisms [MRO]

bacteria resistant to many antibiotics

Microorganisms that live naturally in the body are not considered infections For example,

bacteria that normally live within mouth & intestine are not infections

Neutrophils -they tell us it is a

bacterial infection if elevated. -

Insulin regimens: 50%

basal and 50% premeal

Give premeal insulin

based on blood sugar

Septic shock manifestations Hypotension occurs

bc of vasodilation.

Skin testing is preferred to RAST

bc skin testing is more sensitive, less expensive and tests for more allergens.

The risk of kidney and hearing damage has to

be balanced against benefits of using aminoglycosides to treat life-threatening conditions such as septicaemia.

type 2 diabetes can

be prevented or delayed by wt loss & physical activity

Want to prevent sepsis to

becoming septic shock [when bp drops too much]

Airborne infection precautions Hand washing

before and after pt contact

Contact infection precautions Hand washing

before and after pt contact

Droplet infection precautions hand washing

before and after pt contact

Standard infection precautions Hand washing

before and after pt contact

Antibiotics pt teaching ■ Advise client to consult with healthcare provider

before using OTC medications or herbal products.

The focus of the hour-1 sepsis bundle

begin resuscitation and management immediately

As with any medicine, antibiotics can cause side effects. Most antibiotics do not cause problems if they're used properly and serious side effects are rare. The common side effects include:

being sick feeling sick bloating and indigestion diarrhea

Low WBC count

below 4,500

Sepsis can also cause

blood clots to form in organs & extremities leading to varying degrees of organ failure and tissue death [gangrene]

As sepsis worsens,

blood flow to vital organs like brain, heart and kidneys becomes impaired

GLP1: stimulates

blood glucose and increase insulin secretion??

Hypoglycemia

blood glucose less than 70 mg/dl

Good diabetes management: -maintain

blood glucose level near normal -normal BP -normal lipids -esp type 2 - risk for CAD, kidney disease -general feeling of wellness -prevent acute complications like DKA [for type 1] -long term complications: vision probs, neuro probs, -collaborative care achieved w team: physician that specializes in diabetes, dietican, pharmacist,

Hypoglycemia - what can you do? Check

blood glucose right away -if can't check, treat anyway

Hemorrhagic exudate

blood leaking into tissue

So if tray isn't there yet and already gave insulin and started working and no food yet,

blood sugar can drop too low -bc when eat, food breaks down and blood sugar rises, and rapid acting insulin helps blood sugar when we eat

Within 45 min-1 hour of eating,

blood sugar is highest which is peak of this rapid acting insulin.

Exercise lowers

blood sugar.

Treating hyperglycemia Monitor

blood sugars

ESR [erythrocyte sedimentation rate [sed rate] what is it?

blood test that can reveal inflammatory activity in body

Ketones can be measured in

blood, urine, -can cause problems in acid base balance.

Septic shock manifestations Decreased urine output.

body conserves water to avoid undergoing dehydration bc of the inflammatory process.

-under normal circumstances,

body does good job when have inflammatory process or infection going on -body releases chemicals into bloodstream to fight infection

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. WBC: 13.2 Clinical significance?

body is mounting systemic immune response to underlying infection WBC elevation is due primarily to increased production of neutrophils who are "first responders" of immune system in response to infection

Bands tells us

body is overwhelmed and kicking out wbcs so fast bc wbcs currently recruited are overwhelmed by infection -so they indicate things are getting worse

If haven't eaten for long time,

body still needs glucose

Sepsis: nursing care Assess, monitor and manage

body temp

Inflammatory response

body's response to tissue injury or irritant

DKA: treatment Insulin

bolus Regular IV 5-10 units then drip

Where are monocytes and macrophages released from?

bone marrow

Hypoglycemia - what can you do? treat

by eating 3-4 glucose tablets or 3-5 hard candies can chew quickly [like peppermints] or by drinking 4 ounces of fruit juice or 1/2 can regular soda pop

Insulin is dosed

by unit.

Some fluoroquinolones can intensify the effects of

caffeine [stimulant found in coffee, tea and cola), which can make you feel irritable, restless and cause problems falling asleep (insomnia

Nutrition for type 2

calorie reduction

However, some forms of penicillin, such as amoxicillin,

can be used in combination with methotrexate.

Most infection-causing bacteria

can become resistant to at least some antibiotics

Septic shock cause Invasive procedures.

can introduce microorganisms inside body that could lead to sepsis.

Any type of infection [bacterial, viral or fungal]

can lead to sepsis, most likely varieties include -pneumonia -infection of digestive system -infection of kidney, bladder & other parts of urinary system -bloodstream infection [bacteremia]

Septic shock cause Malnourishment.

can lower body's defenses, making it susceptible to invasion of pathogens.

The immune system distinguishes groups of foreign substances: A second group consists of self cells that display as aberrant

can originate from antigens that have been engulfed & broken down [exogenous antigens] or from virus-infected & tumor cells that are actively synthesizing foreign proteins [endogenous antigens]

Some antibiotics, such as rifampicin and rifabutin,

can reduce the effectiveness of the contraceptive pill.

Without prompt treatment, bacteremia

can spread to other areas like heart valves or other tissues or progress to severe sepsis & septic shock which may be life threatening

CHO counting:

carbohydrate counting.

Sepsis: nursing care Assess, monitor and optimize

cardiac output

Infectious DISEASE

caused or transmitted by PARASITE

-gastroparesis:autonomic neurooathy -

causes delayed emptying of gut. So with this type of autonomic neuropathy, pt exoeriences nausea, possibly vomiting bc gut is not emptying fully and equal concern is that it will impact insulin timing. If give insulin and not emptying gut, concern that blood sugar can go low. -so encourage to empty gut by being active. Possibly walking. Make sure move bowels regularly.

-sepsis is one of leading

causes of death - surviving sepsis campaign created to spread awareness and improve Dx and recognition w use of appropriate and timely care and develop guidelines and implement variety of performance improve guidelines

Lack of blood flow means

cells and organs do not get enough oxygen and nutrients to function properly

We have cancer

cells in body but don't get cancer bc NK cells which keep cancer cells suppressed

Type 2 diabetes: -insulin resistance:

cells in muscles and liver don't respond well to insulin, then it has to use glucose from blood for energy. To make up for it, pancreas makes more insulin, but doesn't help bc not really being used and over time, blood sugar levels go up. -

Cephalosporins (such as

cephalexin) -

Cephalosporins [prefix cef- and cephalexin] Important exam point to remember here

cephalosporins are drugs we give to when pt allergic to penicillin

■ No alcohol intake with

cephalosporins.

Peak and trough levels/Therapeutic drug monitoring Peak and trough levels may be ordered for

certain antibiotics like: amikacin, gentamicin, tobramycin and vancomycin

Humoral response/antibody-mediated response This response follows

chain of events & eventually B cells produce memory cells

If someone in families have type 1 diabetes,

chances are it's heritable trait

While a client is being treated for a wound infection, it is most important for the nurse to routinely perform which action? a) check and record pt temp b) send samples of wound drainage for culture c) assess perfusion in area d) evaluate results of blood culture

check and record pt temp

Hypoglycemia -first

check blood glucose' -don't want to give a diet soft drink or full fat milk. Diet soft drinks no sugar. Full fat milk have fat which slows down sugar absorption. Want something absorbed quickly which is juice

Infection assessment: General inspection

check wound

A urinalysis involves

checking appearance, concentration & content of urine

Inflammatory response is a

chemical response to injury

Inflammatory response: Leukocyte migration

chemotaxis leads to migration of certain WBCs [leukocytes] to damaged area

-type 1:

childhood onset, autoimmune, with 3 P's as major s/s.

Which symptom best indicates to the home health nurse that a client has an infection? a) client has a rash b) client has a heart murmur c) client has lymphadenopathy d) client has nystagmus

client has lymphadenopathy

Infection assessment appearance of urine

cloudy, turbid, foul-smelling urine w visible sediment is indicative of urinary tract or bladder infection

Antibodies cause

clumping making bacteria/virus more susceptible to phagocytosis

A client reports increased thirst, frequent urination and hunger. The client is diagnosed with type 1 diabetes. Which symptom reported by the client causes the nurse the most concern when planning care for the client? a) fatigue b) difficulty sleeping c) constant thirst d) perineal itching

constant thirst

Hemorrhagic exudate This situation may

constitute emergency requiring physician assistance to control bleeding if large amounts of blood flow from wound site

Due to active MRSA in urine, what precautions?

contact -pt private room or in room w pt w active infection caused by same organism & no other infections -wear clean gown & gloves when anticipate any contact w pt or any contaminated items in room -either dispose of all items entering room within room, or disinfect them per institutional policy prior to removing from room -double bag all linen & trash & clearly mark as contaminated

Indirect contact transmission involves

contact of susceptible host w contaminated intermediate object.

Airborne infection precautions Gloves

contact w blood or body fluids

Droplet infection precautions gloves

contact w blood or body fluids

Standard infection precautions Gloves

contact w blood or body fluids

With type 2 diabetes Pancreas

continues to produce some endogenous insulin

Insulin pump:

continuous infusion of insulin, 24 hours a day. Like an external pancreas. Programmed to deliver amount depending on food choices, lifestyle.

Many septic patients with fluctuating body temps may have

continuous temp monitoring [via foley, rectal tube, or endotracheal tube)

Sepsis is a

continuum, there is laddering of symptoms

Differential count

counts diff number of WBCs

Aminoglycosides These side effects do not happen with aminoglycoside

creams and eardrops if they're used properly.

qSOFA 2 or more

criteria suggests greater risk of poor outcome

Inflammation management: health promotion and maintenance Hygiene Hand washing

decrease infection

Sepsis: bp will continue to

decrease without Tx and pt will progress through stages all way to septic shock. Can be deadly.

What increases risk for infection during hospitalization? Medications

decreased immunity is common side effect of med

Sepsis/urosepsis After maldistribution of volume

decreased venous return... lowers PRELOAD as determinant of CO [this too will lower BP due to decreased CO]

dry mucous membranes indicates

dehydration.

Cellular [cell mediated] immunity Reaction

delayed

Sepsis bundles

designed for bedside application of key elements of surviving sepsis campaign guidelines

T cells

destroy body's own cells that have themselves been taken over by viruses or become cancerous

Urinalysis is used to

detect & manage wide range of disorders like UTIs, kidney disease & diabetes

Take antibiotics as

directed on packet or pt info leaflet that comes w med, or as instructed by GP or pharmacist.

Diabetes exercise best

done after meals

TDM

done when administering certain antibiotics

Insulin regimens: Intensified

dosing = basal plus bolus BG above target get correction dose

Exudate aka

drainage

Suspected influenza, what precautions?

droplet -wear mask and eye protection when within 3 ft of pt

Antihistamines Side effects:

drowsiness, impaired coordination, dry mouth, GI upset, urinary retention, dizziness.

Erythrocyte sedimentation rate is affected by

drugs and other conditions

d/t

due to

Distinct signs of inflammatory reaction Pain

due to chemicals released by damaged cells

Sepsis/urosepsis After SIRS, hypodynamic state

due to decreased cardiac output [CO]

Cardiogenic shock

due to heart problems

Distinct signs of inflammatory reaction Heat

due to increase in blood flow to area

Distinct signs of inflammatory reaction Loss of function

due to increased swelling & pain

Septic shock

due to infections

Distinct signs of inflammatory reaction Swelling or edema

due to influx of fluid into damaged region

Distinct signs of inflammatory reaction Redness

due to vasodilation - widening of bv & bleeding in joint or structure

You can take most penicillins

during pregnancy and breastfeeding in usual doses.

Aminoglycosides are only used

during pregnancy if your doctor believes they're essential.

standard precautions gown

during procedures & pt care activities w anticipated exposure of skin/clothes to body fluids, secretions, excretions

standard precautions mask/eye protection

during procedures and pt care activities w anticipated splashes or sprays of blood, body fluids or secretions

RAST test It tests for

dust mites, pollens, molds and pet dander but less helpful for food, drugs or venom.

know the symptoms of latex allergy

e.g., skin rash, hives, flushing, itching); i

For sepsis,

each minute without diagnosis and treatment reduces survival

Hypoglycemia - treatment If alert enough to swallow Patient should

eat regularly scheduled meal/snack to prevent hypoglycemia

A client with a diagnosis of type 1 diabetes mellitus receives treatment for diabetic ketoacidosis. Which signs and/or symptoms confirm the diagnosis of diabetic ketoacidosis? a) elevated blood sugar and low serum bicarbonate b) Cheyne-Stokes respirations and increase in pH c) Complete coma and metabolic alkalosis d) elevated temp and resp acidosis

elevated blood sugar and low serum bicarbonate

Erythrocyte sedimentation rate

elevated in infection and other inflammatory conditions

L. G. is a 68-year-old man who goes to the hospital emergency department with a complaint of left foot pain. He has a 7-year history of type 2 diabetes that is controlled with metformin (Glucophage) 500 mg orally twice daily. Subjective Data -States he stepped on "something" in the yard a few days ago -States he is unable to bear weight on the left foot -Has been nauseated and "just haven't felt good" Objective Data Physical Examination -Blood pressure 160/90, pulse 110, respirations 24, temperature 99.8° F -Left foot swollen, red, and warm to touch -Open area on ball of left foot near first metatarsal, w tissue loss and irregular wound margins Measures 2 cm in diameter, with moderate amount of thick yellow drainage -Bilateral paresthesia in lower legs Diagnostic Studies -Blood glucose 350 mg/dL -White blood cell (WBC) count 19,200/µL; 80% neutrophils (12% bands) What s the significance of the WBC count?

elevated number WBCs & neutrophils reflect inflammatory response -neutrophils are first leukocytes to arrive at site of inflammation -finding of immature neutrophils [bands] is called shift to left & is common finding in pts w acute bacterial infections

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Neutrophils 93%

elevation of neutrophils in response to bacterial infection begins as early as 6 hours after initial insult This percentage elevation w increase in overall WBC reveals body is responding to significant invasion of bacteria & has gone systemic

ESRD

end-stage renal disease

Diabetes: hyperosmolar hyperglycemic syndrome [HHS] also [HHNK] Patient has

enough circulating insulin so ketoacidosis does not occur

Cephalosporins [prefix cef- and cephalexin] Educate pt to

esp avoid alcohol w these drugs as their concurrent use can induce state of alcohol intolerance

Nonspecific symptoms of infection Fever

esp if had surgery

Antibiotics interventions and rationales ■ Monitor for superinfection,

especially in elderly, debilitated, or immunosuppressed clients. Increased risk for superinfections is due to elimination of normal flora.)

Time is of the

essence in sepsis recognition and treatment.

Diabetes exercise

essential part of diabetes management

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Magnesium: 1.8 Clinical significance?

essential to normal cardiac electrical conduction as is K+ If too high or low, can predispose to rhythm changes that can be life threatening

An A1c by itself,

even if accompanied w frequent blood sugar checks, may not capture this complete picture of 24 hour glucose variability.

sepsis -focus:

every hour in managing and resuscitating pts immediately when suspect could be in sepsis. Who is responsible for this? Nurses.

Impact of infection on ADLs TB

everyone has to be treated

Nurse's role in preventing drug resistance Read

evidence-based and best practice recommendations

Nursing diagnosis: Risk for infection Inadequate primary defenses

ex: broken skin integrity, tissue damage

Sepsis give crystalloid fluids - [

ex: crystalloid - normal saline] - think balanced electrolyte composition. Also lactated ringers [bc want to keep bp up so give bolus of crystalloid fluid]

The radioallergosorbent test (RAST)

examines blood to determine serum allergen specific IgE levels.

Can't have infection without inflammation

except in neutropenic pts

how to counteract -dawn phenomenon:

exercise during evenings to help morning blood sugar in better range. --

Immunoglobulin D [IgD]

exists in small amounts in blood; least understood antibody

Microvascular: -small bv in

eyes, kidneys, skin, erectile dysfunction -usually happens to people who have not managed diabetes well for years -doesn't happen initially

Abdominal fat causes

fat cells to release proinflammatory chemicals which makes body less sensitive to insulin

Initial symptoms of anaphylaxis are often the same as a mild allergic reaction. They include:

feeling lightheaded or faint breathing difficulties - like fast, shallow breathing wheezing a fast heartbeat clammy skin confusion and anxiety collapsing or losing consciousness

If cell injury -> cell death -> release of kinins, histamine, prostaglandins -> increased capillary permeability ->

fluid exudate

If cell injury -> cell death -> release of kinins, histamine, prostaglandins -> local vasodilation -> hyperemia -> increased capillary permeability ->

fluid exudate

antibiotic client teaching ■ Instruct client to increase

fluid intake to 2,000 to 3,000 ml/day.

Sepsis: nursing care Optimize

fluid-volume status

DKA: planning Restore

fluid/electrolyte, glucose balance w IV infusions

Fluoroquinolones [end in -floxacin] Additionally, another commonly tested fact here although rare is

fluoroquinolones can cause Achilles tendon rupture

Sepsis nursing care: -thorough

focused cardiac assessment [abnormal heart rhythms, tachycardia

Causes of hyperglycemia Poor

food choices

Teaching to prevent low BG adjust

food insulin if planning to exercise

Some antibiotics need to be taken with

food, while others need to be taken on an empty stomach . Always read the patient information leaflet that comes with your medicine.

Hypoglycemia - treatment Avoid

foods with fat -decrease absorption of sugar

Use one site [ex: abdomen]

for period of time [ex: 2 or 3 weeks] -then rotate to another site -why? Bc diff parts of body have diff absorption rates. -also give tissue opportunity to heal so doesn't stop absorping insulin effectively.

Exogenous insulin is prescribed

for pt w type 2 diabetes who cannot control blood glucose by other means

Diagnostic tests and procedures: Culture & sensitivity

for the right Abx

Tetracyclines [ending in cycline] cause bone deformities and teeth discoloration

for this reason, they should not be administered to children under age of 8 or pregnant women

standard precautions PPE - gloves

for touching blood, body fluids, secretions, excretions, contaminated items, mucous membranes, nonintact skin

Immunoglobulin A [IgA]

found in high concentrations in mucous membranes particularly those lining resp passages & GI tract as well as in saliva & tears

Lungs: alveolar macrophages

found in pulmonary alveolus and "clean" respiratory surfaces

Immunoglobulin M [IgM]

found mainly in blood & lymph fluid

Sanguineous exudate is

fresh bleeding, seen in deep partial-thickness and full thickness wounds

Specific immune response has a memory

from B cells so it can't be attacked again from same antigen; it stops & destroys that antigen before it attacks us

Storage of insulin Fastest absorption

from abdomen, followed by arm, thigh, buttock

Memory cells provide

future immunity

Immune globulin aka

gamma globulin

Contact precautions Examples of Diseases:

gastrointestinal infections [including diarrhea of unknown origin), wound and skin infections (e.g. impetigo and colonization with multidrug-resistant bacteria (e.g. methicillin-resistant Staphylococcus aureus (MRSA

Nosocomial infection Control and prevention

gel in and gel out

Aminoglycosides (such as

gentamicin and tobramycin) -

Many mild bacterial infections

get better on their own without using antibiotics.

Type 1 diabetes Priority nursing assessment:

get glucose back into cells. Measure blood glucose level. Treat appropriately.

Anyone can be at risk for

getting sepsis.

Nurse's role in preventing drug resistance Always

give antibiotics on time and avoid skipping a dose

Long acting insulin [basal] -doesn't matter if

given at night or morning but what matters is it's consistent -works like nondamaged pancreas [releases insulin steadily and continuously throughout day[ -no peak action!! Works for 24 hours. -doesn't work for pts w really high and erratic needs for insulin -but for people really tightly controlled or getting supplemented w oral hypoglycemia, works really well

IgG is

given from mother to baby for 3 months

Why are IgA, IgG and IgM often measured together?

gives doctors important info about immune system functioning esp r/t infection or autoimmune disease

Ketone testing if

glucose > 240 mg/dl

Liver has important function in

glucose control -liver also manufactures glucagon -liver plays integral role in metabolism of glucose, storage an dputting glucose out in times of need

Diabetes chronic complications: macrovascular Tight

glucose control may delay atherosclerotic process

we don't want

glucose in bloodstream

Normal Insulin Metabolism Promotes

glucose transport from bloodstream across cell membrane to cytoplasm of cell

Metformin also enhances

glucose transport into cells

C diff

gold standard = wash hands

The most important ways to prevent antibiotic resistance are Practice

good hygiene like hand washing and use appropriate infection control procedures

Overweight or obese =

greater risk for developing type 2 diabetes esp if excessive weight is around abdomen

Virulence

growth & multiplication; how fast

Do not take one of the penicillin-based antibiotics if

had an allergic reaction to them in the past.

Insulin resistance:

hall mark of type 2 diabetes

Most important aspect of medical asepsis

hand hygiene

Risk for infection: Interventions Personal hygiene

hand washing

Each IgG

has 2 antigen binding sites

This patient should be taught to take antihistamines on a reaction basis because he

has perennial allergic rhinitis that is not limited to contact seasonal allergies.

Inflammatory response: Fever if not too high

hastens destruction of bacteria by increasing phagocytosis and by producing immune bodies

The granulocytes, which include neutrophils, eosinophils and basophils

have granules in cell cytoplasm

Septic shock cause · Patients with immunosuppression

have greater chances of acquiring septic shock bc have decreased immune system, making it easier for microorganisms to invade body tissues.

Prediabetes: may

have it and may be moving toward it but cant feel it yet.

With an infection of any kind, sepsis is identified by

having 2 or more of following criteria of SIRS -Temp > 100.4 F or < 96.8 -HR > 90 -RR > 20 -WBC > 12,000 or < 4,000 -Bands > 10%

HA

headache

HF

heart failure

Hypovolemic shock -makes

heart unable to pump enough blood to body -can cause many organs to stop working

Storage of insulin Do not

heat/freeze

Metformin: -always

held before invasive procedure like cardiac catheterization or angiogram or surgery -can cause kidney failure and lactic acidosis -don't give to underlying kidney disease

With retinopathy, you can see

hemorrhage, aneurysms

You can get active acquired immunity through Vaccinations [artificial]

hepatitis B vaccine

Neutrophil: 93% Is this high, low or WNL

high [normal 42-72]

Glucose: 184 Is this high, low or WNL?

high [normal 70-110 mg/dL]

WBC 13.2 Is this high, low or WNL?

high [normal is 4.5-11.0 mm^3]

Hyperglycemia

high levels of glucose in blood > 200 mg/dL

Nonspecific symptoms of infection Increased HR & RR

high metab demand

Nurses must keep in mind that the risks of sepsis and

high mortality rate associated w sepsis, severe sepsis, and septic shock.

Higher AIC =

higher risk for diabetes complications.

Usually allergies are diagnosed on

history and physical exam, but in some cases testing can be employed.

Lymphocytes have

homing pattern

Airborne infection precautions Linen

hospital protocol

Contact infection precautions Linen

hospital protocol

Droplet infection precautions linen

hospital protocol

Standard infection precautions Linen

hospital protocol

Aminoglycosides are normally only used in

hospital to treat life-threatening health conditions such as septicemia, as they can cause kidney damage in people with pre-existing kidney disease.

The nurse recognizes which symptoms are characteristic of impending diabetic ketoacidosis? a) hyperreflexia, babinski reflex, numbness b) hot, dry, flushed skin, excessive thirst, rapid pulse c) hot flashes, severe hunger, bradycardia d) profuse diaphoresis, headache, bradycardia

hot, dry, flushed skin, excessive thirst, rapid pulse

always look at trend -

how is person trending? We get more concerned when see HR start to slow, when UO really starts to drop]

Duration:

how long insulin continues to lower blood sugar.

Nurse's role in preventing drug resistance Be vigilant about

how your unit uses antibiotics; ask local infectious diseases team

White blood cells [leukocytes] Specific immune responses

humoral

Lymphocytes are responsible for

humoral & cellular immunity

Infection assessment: bowel sounds

hyperactive, GI infection

Sepsis/urosepsis After increased capillary permeability, fluid leakage, third spacing -> TACHYCARDIA bc compensating for decreased CO

hyperdynamic state as body attempts to increase CO [pt looks better but is actually worsening]

If cell injury -> cell death -> release of kinins, histamine, prostaglandins -> local vasodilation ->

hyperemia

Too much insulin, too little food can cause

hypoglycemia -

-we always worry more about

hypoglycemia than hyperglycemia bc someone can go into coma and die from becoming hypoglycemic

Stages of sepsis: consensus conference definition Septic shock

hypotension [despite fluid resuscitation] plus hypoperfusion

Inflammation management Heat and cold

ice first within 24 hours to reduce swelling, then heat to promote circulation

Treatment of septic shock and sepsis include

identification and elimination of cause of infection -Fluid replacement therapy -Pharmacologic therapy -Nutritional therapy

The current treatment of septic shock and sepsis include

identification and elimination of the cause of infection.

Peak and trough levels/Therapeutic drug monitoring help determine

if drug is in toxic range or if dosage of med needs to be increased [that is, there's not enough drug in blood to bring about desired therapeutic effect]

-specific gravity tells us [

if urine is heavy, means there's stuff in it or it's concentrated so she's dehydrated]

In established diabetics,

illness and infection = precipitating factors

Monocytes

immature macrophages

Bands

immature neutrophils

Newborn and infant has

immature thermoregulatory mechanisms

Humoral immunity Reaction

immediate

Shock requires

immediate treatment and can get worse very rapidly

Cell mediated immunity is what?

immune response that does not involve antibodies but rather involves activation of phagocytes, antigen specific cytotoxic T-lymphocytes & release of various cytokines in response to antigen

Compromised host Advanced age

immune system is not as strong

Active acquired immunity occurs when

immune system is stimulated/produce antibodies due to invasion of microorganisms

What's cell-mediated [cellular] immunity?

immunity independent of antibody but dependent on recognition of antigen by T cells & their subsequent destruction of cells bearing antigen or on secretion by T cells of lymphokines that enhance ability of phagocytes to eliminate antigen

With passive acquired immunity,

immunity is transferred to recipient

Antibodies aka

immunoglobulins [Ig]

Adult and older adult Shingles

impaired immune response - even if they had chicken pox

Inflammation management: health promotion and maintenance Nutrition: Protein

important in healing tissue

Because of the toxic side effects of aminoglycosides [gentamicin, neomycin, amikacin, tobramycin, streptomycin[

important to measure peak and trough levels for pts taking these drugs

Administer vasoactive medications to

improve systemic vascular resistance -epinephrine, norepinephrine [these work to either increase or decrease bp and HR?]

Nurses are critical to

improving outcomes for pts w sepsis

B cells mature where?

in bone

Immunoglobulin E [IgE] is found

in lungs, skin & mucous membranes

Basophils appear

in many specific kinds of inflammatory reactions, particularly those that cause allergic symptoms

Antibodies are formed

in response to antigen

Fibrin clots are formed

in response to injuries to any part of vascular system

T cells mature where?

in thymus

Neutropenia does what

increase infection risk

Sulfonylureas -bc these

increase insulin production, people usually take them first thing in morning or in evening but important that they eat shortly after taking these bc if haven't eaten and blood sugar running low to begin with like before a meal, then blood sugar might drop too much and drop into state of hypoglycemia [below 70] -take 30 minutes before a meal -

If cell injury -> cell death -> release of kinins, histamine, prostaglandins -> local vasodilation -> hyperemia ->

increased capillary permeability

If cell injury -> cell death -> release of kinins, histamine, prostaglandins -> local vasodilation -> hyperemia 0>

increased capillary permeability

Sepsis/urosepsis After immune system initiates mediators of inflammatory response [increased temp, slightly increased HR, mild hypotension]

increased capillary permeability... fluid leakage... third spacing [which results in TACHYCARDIA as body begins to compensate for decreased CO

What increases risk for infection during hospitalization? Environmental factors

increased exposure to pathogens due to hospitalization

Acute inflammation is achieved by

increased movement of plasma & leukocytes [esp granulocytes] from blood into injured tissues

Type 2 diabetes Prevalence

increases w age; Genetic basis

An increasing WBC count

indicates body's efforts to combat ptahogens

Somogyi Result:

individual wakes up w higher blood glucose out of target range.

Infectious droplets are released when

infected person sneezes or coughs and large droplet spray may spread as far as three feet.

Sepsis: nursing care Prevent

infection

White blood cells [leukocytes] Over 10,000

infection

Sepsis is caused by

infection & can happen to anyone

Bands occur when

infection is severe or prolonged

In older patients,

infection may be present without increased WBC count

Septicemia:

infection of blood that is full body

Exposure to the disease organism can occur through: natural immunity

infection w the actual disease

constant high blood sugar level drives

inflammation and accelerates atherosclerosis -can damage walls of arteries and make more likely to fill w fatty deposit

When inflammation is chronic,

inflammation reflects ongoing response to longer-term medical condition like arthritis

There can be

inflammation without infection but not infection without inflammation

White blood cells [leukocytes] Nonspecific immune response

inflammatory

Sanguineous exudate A small amount may be normal during

inflammatory stage but we don't want to see blood in wound exudate as may indicate trauma to wound bed

Serous drainage is normal during

inflammatory stage of wound healing & smaller amounts is considered normal wound drainage

Sanguineous represents

infrequent finding in wound

Hypoglycemia if not awake Have pt

ingest complex carb after recovery

- DKA is sometimes

initial manifestation of type 1.

Acute inflammation

initial response of body to harmful stimuli

Shock is

initially reversible but must be recognized and treated immediately to prevent progression to irreversible organ dysfunction

Sepsis/urosepsis After SIRS, the immune system

initiates mediators of inflammatory response w physiologic consequences [increased temp, slightly increased HR, mild hypotension]

Insulin: rapid acting Lispro, aspart, glulisine given when?

injected 0 to 15 minutes before meal

Regular: short acting insulin given when?

injected 30 to 45 minutes before meal

Insulin: long acting - Lantus/glargine [Basal] given when?

injected once a day at bedtime or in morning

Storage of insulin Rotate

injection sites within one particular site

Aminoglycosides like gentamicin and tobramycin they're usually given by

injection, but may be given as drops for some ear or eye infections

septic shock discharge and home guidelines · Prevent shock episodes.

instruct pt and family strategies to prevent shock episodes through identifying factors implicated in initial episodes.

rapid acting insulin - give

insulin after have food tray in front of them.

Langerham's ? -

insulin producing part of pancreas.

Major cause of type 2:

insulin resistance

Thiazolidinediones: improve

insulin sensitivity of receptors. Improves insulin working at tissues

Treating hyperglycemia Review

insulin, food, activity plan

Thiazolidinediones: Pioglitazone (Actos) rosiglitazone (Avandia) Known as

insulins ensitizers

What increases risk for infection during hospitalization? Smoking

interferes w normal resp functioning including natural measures to protect pulmonary system: -chest expansion -coughing -sneezing -decreased cilia function

NPH

intermediate acting insulin

insulin continuously releases

into bloodstream normally in pulsatile small increments

Exposure to the disease organism can occur through: Vaccine-induced immunity

introduction of a killed or weakened form of disease organism through vaccination

Infection

invasion & multiplication of microorganisms like bacteria, viruses & parasites that are not normally present within body

Urinalysis Most clinicians will treat if WBC

is >5 with symptoms.

Though > 80% neutrophil elevation

is clinical red flag, 90% must be recognized as esp concerning & may be referred to as "left shift"

Infection assessment: antibiotic therapy

is determined by pathogens identified

A review of the AGP Report

is recommended at each visit for those using CGM technology.

Sepsis The challenge is that

it can present w very subtle symptoms and progress quickly.

The lymphatic system is unique in that

it is 1 way system that returns lymph fluid via vessels to CV system for eventual elimination of toxic byproducts by end organs like kidney, liver, colon, skin & lungs

When sepsis initially presents,

it is not uncommon to have a relatively normal physical assessment. Mrs. Kelly does not appear to be that sick. Because early recognition is crucial to prevent an adverse outcome, the VS data are especially relevant and indicate that Mrs. Kelly is already in sepsis/SIRS regardless of how benign her physical assessment may appear.

When it comes to sepsis, remember

it's about TIME

-if next day, muscles still sore -

it's residual effect of lactic acid buildup.

Local reaction would require

just an anti-inflammatory cream.

Bands: -immature WBCs -if low and normal,

keep watching those -bc if she progresses to severe sepsis or septic shock, then those will trend up in her bands so keep eye on those -

With sepsis The immune system

kicks into overdrive, for whatever reason & cannot be calmed down.

Cephalosporins may not be suitable if you have

kidney disease, but if you need one you will probably be given a lower than usual dose.

BUN they indicate

kidney failure or kidney issue

Creatinine is associated with

kidney malfunction

Sepsis GU:

kidneys are dependent on heart to create good GFR. Heart is dependent on kidneys. Kidneys take 25% of circulating blood. But now theyre not filtering waste. So increase in bun and creatinine. Decrease in urinary output - why? Bc decrease in cardiac output. This leads to acute kidney failure bc lack of perfusion. Leads to kidney damage. Integumentary: clammy, cool to touch bc not enough blood circulating. Pale.

Antibiotics work by

killing bacteria or preventing them from spreading. But they do not work for everything.

Sepsis: nursing care Prompt

lab draws

Septic shock manifestations Elevated lactate level.

lactate level is elevated bc there is maldistribution of blood.

Strenuouse xercise can cause

lactic acid buildup but also conditions like heart failure, pneumonia, severe infection, shock,

Draw lab for

lactic acid for sepsis.

S/S septic shock High levels of

lactic acid in blood [serum lactate] after having received adequate fluid replacement

If lactic acid levels too high, leads to

lactic acidosis -we know there is some kind of oxygenation deprivation going on

Monocytes are the

largest type of WBC

However, passive immunity

lasts only for few weeks or months

Hemorrhaging indicates

leaking bv putting out blood

Onset:

length of time before insulin reaches bloodstream and begins to lower blood sugar

The overuse of antibiotics in recent years means they're becoming

less effective and has led to emergence of "superbugs".

RAST test It is

less helpful than skin tests, as it is not as sensitive, more expensive and limited in what it can test for.

Inflammation management Acute intervention Rest & immobilization

less pain w stabilization

FPG normal

less than 100 mg/dl

Oral glucose tolerance test [OGTT] normal

less than 140 mg/dl

Neutropenia

less than 4,000 WBCs

Diabetes: diabetic ketoacidosis [DKA] mortality

less than 5%

A1C normal

less than 5.7%

Sepsis: complications Sepsis ranges from

less to more severe

DKA treatment: -very

lethargic so make sure O2 sat at least 92

White blood cells aka

leukocytes

General appearance: resting comfortably, appears in no acute distress Resp: breath sounds clear w equal aeration bilaterally, nonlabored resp effort Cardiac: pink, warm and dry, no edema, heart sounds regular - S1S2, pulses strong, equal w palpation at radial/pedal/post-tibial landmarks Neuro: alert & oriented x2 - is not consistently oriented to date and place, c/o dizziness when she sits up GI: abdomen soft/nontender, bowel sounds audible per auscultation in all 4 quadrants GU: dysuria and frequency of urination persists, right flank tenderness to gentle palpation Skin: skin integrity intact, lips dry, oral mucosa tacky dry Relevant assessment data? Skin

lips dry + dry and tacky mucosa represents lack of saliva consistent w dehydration This is simple & practical way to assess overall fluid status as well so incorporate this in nursing assessment esp in those w known or suspected fluid volume deficit

Exudate/drainage

liquid produced by body in response to tissue damage

AST is for

liver

Active immunity is

long-lasting & sometimes life-long

Chronic inflammation refers to

long-term inflammation & can last several months and even years [TB, arthritis, asthma]

DKA: -decreased LOC can

look like really drunk

Diagnostic tests and procedures: Diagnostic imaging - MRI, CT scan

looks for infection source, neuro infection, abscesses in body

The nurse provides care for a client diagnosed with type 1 diabetes. The nurse identifies which is the primary cause of dehydration in the client with diabetic ketoacidosis [DKA] a) loss of fluid due to hyperventilation b) loss of fluid through perspiration c) loss of fluids due to vomiting d) loss of fluid due to osmotic diuresis

loss of fluid due to osmotic diuresis

Risk for infection: Interventions Protect skin and mucous membranes

lotion, prevent cracking

Thiazolidinediones: Pioglitazone (Actos) rosiglitazone (Avandia) Start

low dose, titrated every 2-4 weeks -weeks to months to take effect

Diagnostic tests and procedures: Diagnostic imaging - CXR

lung infection

-HTN starts at that

macrovascular level w damage to bv bv high levels circulating blood glucose all time.

Diabetes: counter regulatory hormones help

maintain normal blood glucose levels

When there is a lot of fat around liver [fatty liver],

makes it less responsive to insulin leaving too much glucose in blood.

Sepsis/urosepsis After vasodilation [compensation attempts wearing down resulting in more severe hypodynamic state]

maldistribution of volume [third spacing that will also influence decreasing BP and increasing HR]

Prostaglandins are released by

many diff body tissues and they increase action of histamine.

Droplet infection precautions pt transport

mask on pt

Storage of insulin In-use vials/pens

may be left at room temp up to 4 weeks

Antibiotics are normally recommended if you're having a type of surgery that carries a high risk of infection. For example,

may be prescribed antibiotics if you're going to have: -some types of eye surgery - like cataract surgery or glaucoma surgery -joint replacement surgery -breast implant surgery -pacemaker surgery -surgery to remove gall bladder -surgery to remove appendix

Different types of insulin

may be used for combination therapy

Taking the wrong medicine

may delay correct treatment and allow bacteria to multiply

The biggest worry is that new strains of bacteria

may emerge that cannot be treated by any existing antibiotics.

Type 2 diabetes: Person

may go many years w undetected hyperglycemia

However, a moderate to heavy amount of serous fluid

may indicate high bioburden [lots of microorganisms, number of bacteria living on surface that has not been sterilized]

temp of greater than 37.7 [99.8 F]

may indicate infection

Example of antibodies are disease-specific

measles antibody will protect person who is exposed to measles disease but will have no effect if person is exposed to mumps

Airborne infection precautions When to use

measles, TB

Since A1C does not provide

measure of glycemic variability or hypoglycemia, AGP [ambulatory glucose profile] is esp helpful for those prone to bigger glycemic swings.

Read the information leaflet that comes with your

medicine carefully and discuss any concerns w pharmacist or GP.

With antibodies,

memory B-cells remain in lymphoid tissue

Droplet infection precautions when to use

meningitis, pertussis

Sepsis: what type of imbalance

metabolic acidosis

Inflammatory response: Fever increases

metabolism by 7% w each degree above 100 F

It's usually recommended that you avoid taking penicillin at the same time as

methotrexate, which is used to treat psoriasis, rheumatoid arthritis and some forms of cancer. This is because combining the 2 medications can cause a range of unpleasant and sometimes serious side effects.

-early signs of kidney damage is by yearly screening - for

microalbuminemia in urine. Will be picked up by dip stick.

All type 1 and 2 should have yearly screenings looking for

microalbuminuria.

Diabetic retinopathy

microvascular damage to retina

Antibiotics side effects digestive These side effects are usually

mild and should pass once you finish course of treatment. If you get any additional side effects, contact your GP or the doctor in charge of your care for advice.

Most people recover from

mild sepsis but average mortality rate for septic shock is about 40%

Contact infection precautions Pt transport

min contamination of environment

standard precautions it is the

minimal protection that should be used for care of all pts at all times to protect HCW & to prevent srpead from HCW to pt

Antibiotic resistance can be prevented by

minimizing unnecessary prescribing & overprescribing of antibiotics -correct use of prescribed antibiotics -good hygiene and infection control

Some antibiotics do not

mix well with other medicines, like contraceptive pill and alcohol.

NPH can be

mixed w premeal insulin

Sepsis nursing interventions Monitor blood levels. The nurse must

monitor -antibiotic toxicity, -BUN, -creatinine, -WBC, -hemoglobin, -hematocrit, -platelet levels, -coagulation studies. ·

Gestational diabetes: -need to

monitor higher glucose circulating levels are brought to baby and baby can put on extra weight and be larger. -so these women should exercise and have good diet

Sepsis nursing interventions Management of fever. The nurse must

monitor patient closely for shivering.

Macrophages are

monocytes that have migrated from bloodstream into any tissue in body

Vasodilation

more WBC to area therefore warmth & swelling

Stress level puts out

more cortisol - drives up blood sugar.

Inflammatory response: That's because scientists have found

more evidence that elevated body temp helps certain types of immune cells to work better

Nonspecific symptoms of infection Enlarged lymph nodes

more macro, neutro, waste products go to lymph

A bigger reaction is associated with a

more severe allergy.

Leukocytosis

more than 10,000 WBC

Chronic complications: - DM -macrovascular:

more than 50% w DM die from cardiovascular and stroke complications

Where did qSOFA come from?

more than 800,000 EHR encounters at 177 hospitals worldwide, including community & academic, rural, suburban and urban, public, private and federal hospitals

Immunoglobulin G [IgG]

most abundant type of antibody; found in all body fluids & protects against bacterial & viral infections

Diabetes foot complications

most common cause of hospitalization in diabetes

Unless working in pediatric setting,

most pts will have type 2 diabetes.

Cell-mediated response involves

mostly T cells & responds to any cell that displays aberrant MHC markers including cells invaded by pathogens, tumor cells or transplanted cells

Complications of diabetes: HHNK:

mostly complication of type 2

Intradermal testing - which is

much more sensitive than percutaneous testing - can be done by introducing the allergen into the dermis with a percutaneous needle.

Catarrhal exudate

mucus in runny nose; is seen in nose & throat & is characterized by high content of mucous

In allergic rhinitis

mucus membranes of eyes, nose, ears and pharynx become inflamed in allergic rhinitis.

Macrophages can

multiply

-lactic acid: made by

muscle tissue and rbcs which carry oxygen to lungs and body -

Type 1 and insulin

must have to live

Microorganisms that live

naturally in body are not considered infections

counter regulatory hormones -these are hormones we

naturally produce that oppose what insulin does [have opposite effect of insulin] -these increase blood sugar -these provide release glucose

Some bacteria are

naturally resistant to some antibiotics ex: benzyl penicillin has very little effect on most organisms found in human digestive system [gut]

Diabetic neuropathy: -type of

nerve damage occur in diabetics -high blood sugar can injure nerve fibers throughout body -people w diabetes, neuropathy most often damages nerves in legs and feet. -

Lymphatic system is comprised of

network of lymphatic vessels that carry clear fluid called lymph directionally towards heart

Who is the first one there?

neutrophils

Once cells are damaged,

neutrophils come in, starts bringing inflammation & starts immune response

Purulent exudate is

never normal in wound bed

Example of passive immunity

newborn baby acquires passive immunity from its mother through placenta

Type 1 diabetes: make

no insulin at all.

Standard infection precautions Pt transport

no limitations

Passive acquired immunity is only temporarily, immediate protection

no memory cells

An infection may cause

no symptoms & be subclinical or it may cause symptoms & be clinically apparent

Insulin: long acting - Lantus/glargine [Basal] peak action

none

Innate immunity refers to

nonspecific defense mechanisms that come into play immediately or within hours of antigen's appearance in body

4,500-11,000

normal WBC count

Insulin maintains

normal blood glucose level 70-130 mg/dl

Gestational diabetes usually

normal glucose levels at 6 weeks postpartum

Bands typically see them as

normal range even if pt has infection bc body doing what supposed to do

Inflammatory response: Fever is

not a disease but it is a sign

Child and adolescent Adolescents may

not be eating so well, sleep patterns are off, not well rested which compromises immune system

Insulin: long acting - Lantus/glargine [Basal] can

not be mixed w any other insulin or solution

Sepsis GI:

not getting enough oxygen to GI tract. Pt will feel nauseous bc slow GI. May vomit, have diarrhea.

General rules about insulin: Do

not inject in site to be exercised

Hypoglycemia - treatment If alert enough to swallow Do

not overtreat

Natural immunity

not produced by immune response

Administration of insulin Do

not recap needle

A sed rate test is

not stand-alone diagnostic tool but can help doctor diagnose or monitor progress of inflammatory disease

Nurses role in educating patients to prevent antibiotic resistance Do

not take antibiotic for viral infection like cold or flu

Type 2 diabetes: malfunction bc

not using insulin proplerly, not going into cells, liver thinks need to put out more sugar in body to meet body needs but that just raises blood sugar level without blood sugar being absorbed

Mild to moderate fevers [103 F] are

not usually harmful & may benefit defense mechanisms

Cellulitis is

not usually spread from person to person

The action of most antihistamines is

not very effective against histamine-induced bronchoconstriction.

SOFA [sequential organ failure assessment] score

numerically quantifies number and severity of failed organs

Sepsis nursing interventions Collaboration.

nurse must collaborate w the other members of healthcare team to identify site and source of sepsis and specific organisms involved. ·

sepsis/urosepsis What is the patient likely experiencing/feeling right now in this situation?

nurse needs to put self in place of pt to identify what is experienced in this situation. pt is likely aware of seriousness of current change in status and may be fearful and anxious. Support pt and family by intentionally giving them as much info about current status and explain plan of care from both nursing and medical perspective. KNOWLEDGE is POWER from pt perspective, and when nurse provides info, will DECREASE anxiety and fear and make real diff in pt well-being.

The nurse instructs the client recently diagnosed with type 1 diabetes about proper meal planning. Which action should the nurse take FIRST? a) instruct pt about importance of eating regular meals b) inform pt that 50-60% of calories should come from carbohydrates c) obtain diet history that includes pt favorite foods and usual meal patterns d) teach pt how to use exchange list for meal planning

obtain diet history

When inflammation is acute,

occurs as immediate response to trauma [injury or surgery], usually within 2 hours

Septicemia

occurs when bacterial infection elsewhere in body like lungs or skin enters bloodstream

White blood cells are part

of immune response

Septicemia The exact source

of infection often can't be determined

Treating hyperglycemia Expiration

of insulin

Septic shock is one

of most common types of circulatory shock and incidences of this disease continue to rise despite technology.

Diabetic retinopathy Most common cause

of new cases of blindness in people 20-74 years old

Septic shock: -some kind

of poisoning to blood w infection or something else -bacteria enters bloodstream or other toxins

-earliest and most treatable stages of diabetic retinopathy

often produce no changes in vision -teach pts should have annual dilated eye exam -only by looking at retina can eye doctor see damage occurring

Hypoglycemia onset

often sudden; may pass out if untreated

In the spleen,

old RBCs are recycled in spleen and platelets & WBCs are stored there

What increases risk for infection during hospitalization? Developmental stage/air

older adults more susceptible hosts bc immune response declines w aging -Skin, primary defense, becomes less elastic and more prone to breakdown

Macrophages take

on various names depending on tissue to which they migrated ex: lungs - alveolar macrophages

Fluoroquinolones such as ciprofloxacin and levofloxacin are broad-spectrum antibiotics that were

once used to treat wide range of infections, esp resp and urinary tract infections. no longer used routinely bc of the risk of serious side effects

General appearance: resting comfortably, appears in no acute distress Resp: breath sounds clear w equal aeration bilaterally, nonlabored resp effort Cardiac: pink, warm and dry, no edema, heart sounds regular - S1S2, pulses strong, equal w palpation at radial/pedal/post-tibial landmarks Neuro: alert & oriented x2 - is not consistently oriented to date and place, c/o dizziness when she sits up GI: abdomen soft/nontender, bowel sounds audible per auscultation in all 4 quadrants GU: dysuria and frequency of urination persists, right flank tenderness to gentle palpation Skin: skin integrity intact, lips dry, oral mucosa tacky dry Relevant assessment data? c/o dizziness when sits up

ongoing dizziness when sits up most likely reflects fluid volume deficit & orthostatic finding even if orthostatic BPs were not performed

Passive acquired immunity Mother to baby

only 3-6 months

Cellulitis might

only affect skin surface or might also affect tissues underlying your skin & can spread to lymph nodes and bloodstream

Incretin Mimetics used

only on T2DM

Passive acquired immunity is

only temporarily, immediate protection

Antipyretics are often prescribed

only to control high fevers. To prevent acute swing should be given regularly.

Inflammation management Wound management

open, closed, drsg

Cephalosporins If you're pregnant or breastfeeding -

or have a rare inherited blood disorder called acute porphyria - check with your doctor, midwife or pharmacist before taking cephalosporins.

Opportunistic

organism causes infection under right circumstances

With shock, many

organs can be damaged as a result

Essentially, the cause of sepsis is

original infection.

Glucose in bv act as

osmotic diuretic -pee a lot -very dehydrated

Teaching to prevent low BG Find

out cause

Sepsis is essentially

overactive/uncontrolled immune response to infection.

Inflammatory response: Quite commonly, tissue injury is as a result of

overuse, commonly known as microtrauma

Septic shock manifestations · Since the ability of the body to provide

oxygen and nutrients is interrupted, heart compensates by pumping faster.

Sepsis: nursing care Assess, monitor and support

oxygen status

Ketones alter

pH.

With hypovolemia,

pay attention to hypotension.

Diagnostic tests and procedures: Drug monitoring

peak & trough

Penicillins (such as

penicillin and amoxicillin

■ No acidic fruit juices with

penicillins.

Type 1 diabetes Most often occurs in

people under 30 years of age

Some antibiotics are not suitable for

people w certain med problems, or women who are pregnant or breastfeeding.

Antibiotics client teaching ■ Instruct client to notify healthcare provider if symptoms

persist or worsen.

diabetic neuropathy theory:

persistent hyperglycemia leads to accmumulation of sugar in nerves which damages nerve conduction in myelinization. Destroys nerves. So nerve damage causes pts not to be able to feel bottom of feet. So get cut on foot and doesn't heal and gets infected. Once gets infected, also don't heal very well. Over time, can become gangrenous and toe needs to be amputated. This occurs equally in type 1 and 2. -neuropathies can proceed or accompany Dx of diabetes.

Causes of hyperglycemia Dawn

phenomenon & Somogyi effect

Innate immunity: nonspecific defense mechanisms

physical barriers like -skin -chemicals in blood -immune system cells that attack foreign cells in body

Direct contact transmission involves the

physical transfer of microorganisms to a susceptible host from an infected or colonized person.

Macrolides Do not take macrolides if you have

porphyria - a rare inherited blood disorder. If you're pregnant or breastfeeding, the only type of macrolide you can take is erythromycin (also called by the brand names Erymax, Erythrocin, Erythroped or Erythroped A) unless a different antibiotic is recommended by your doctor.

Sepsis

potentially life-threatening condition caused by body's response to infection

The SOFA score provides

potentially valuable prognostic info on in-hospital survival

Nosocomial infection reasons for increased incidence

practitioners use poor aseptic technique

Insulin regimens: Basal plus

pre-meal insulins

Antibiotics are sometimes given as a

precaution to prevent, rather than treat, an infection. This is called antibiotic prophylaxis.

Type 2 and insulin

preferred method for treating hyperglycemia when oral agents are not working

Storage of insulin Abdomen

preferred site

Cephalosporins

prefix cef- with exception of cephalexin

Administration of insulin Insulin pens

preloaded w insulin now available

Only ever take antibiotics

prescribed for you - never "borrow" them from a friend or family member.

Infection process

presence & growth of microorganism that causes tissue damage

Septis and septic shock assessment Signs of acute organ dysfunction. Assess for

presence of -hypotension, -tachypnea, -tachycardia, -decreased urine output, -clotting disorder, -hepatic abnormalities.

Sepsis complications Multiple organ dysfunction syndrome.

presence of altered function of one or more organs in acutely ill pt requiring intervention and support of organs to achieve physiologic functioning required for homeostasis.

Immunity to a disease is achieved through

presence of antibodies to that disease in person's system

Bacteremia refers to

presence of bacteria in blood [bacteremia] & not a poisonous substance in blood

Contact precautions recommended when

presence of excessive wound drainage, fecal incontinence or other discharges from body suggest increased risk for environmental contamination and transmission of infection

Bacteremia

presence of live bacteria in bloodstream

Cellular [cell mediated] immunity Memory cells

present

Humoral immunity Memory cells

present

Risk for infection: Interventions Ambulation and positioning

prevent fluid stasis

Inflammation management: health promotion and maintenance Nutrition: Vitamin C

prevent infection

Diabetes: diabetic ketoacidosis [DKA] this is

preventable -most likely occurs in type 1

Prophylactic antibiotic therapy

preventative, given before surgery

B cells

produce antibodies that are used to attack invading bacteria, viruses & toxins

Diabetes: diabetic ketoacidosis [DKA]

profound deficiency of insulin

Common mediators involved in allergic rhinitis include

prostaglandins, histamine, bradykinin and leukotrienes.

Major advantage of passive immunity

protection is immediate whereas active immunity takes time [usually several weeks] to develop

Inflammatory response: Fever is a

protective function of body bc rise in temp prevents growth of organisms causing disease

Receiving chemotherapy for skin cancer, what precautions

protective isolation -pt is unusually vulnerable & at high risk for infection, needs to be protected from organisms brought in by healthcare workers and visitors -HCW caring for pt should not be providing care for other pts w active infections -When pt in protective isolation need to leave room, should wear mask and have minimal contact w others -All entering pt room wear mask and wash hands. Clean or sterile gown over clothing, keep outside of gown from contact w surfaces outside room -Once gown on, don gloves. If mask or gown become wet while provide care, change. -On exiting room, remove mask, gloves, gown. Do not use again -

Immune globulin/gamma globulin

protein found in blood that fights infection

Kidney damange =

protein gets through glomerular filter which it shouldn't.

Compromised host Inadequate nutrition

protein, vitamin C

Antibodies

proteins produced by body to neutralize or destroy toxins or disease-carrying organisms

Passive immunity

provided when person is given antibodies to disease rather than producing them through own immune system

Sepsis Prevent infection.

pt already has heightened inflammatory response, we don't want to make it worse w another pathogen.

Diabetes: hyperosmolar hyperglycemic syndrome [HHS] also [HHNK] often occurs in

pts over 60 years w type 2

L.G., a 28-year-old diabetic, is admitted to the hospital with a cellulitis of her left lower leg. She had been applying heating pads to the leg for the last 48 hours, but the leg has become more painful and she has developed chilling. Subjective Data · Complains of pain and heaviness in her leg · States she cannot bear weight on her leg and has been in bed for 3 days · Lives alone and has not had anyone to help her with meals Objective Data Physical examination · Round, yellow-red, 2 cm diameter, 1-cm deep, open wound above the left medial malleolus with moderate amount of thick yellow drainage. · Left leg red from knee to ankle · Calf measurement on left 3 inches larger than right · Temperature 102 F (38.9 C) · Height 5 ft 4 in (160 cm); weight: 184 lb (83.7 kg) Laboratory test results · White blood cells (WBC): 18,300/uL (18.3 x 10⁹/L; 80% neutrophils, 12% bands) · Wound culture: Staphylococcus aureus What type of exudate is draining from the open wound?

purulent, yellow wound

Purulent exudate

pus, WBC in exudate like abscess and infection

Rapid acting: -tell pts to

put call light on when food tray comes -that's when you'll give it. -before shift, take blood sugar level. Tell pt to say when tray comes, will give insulin. -why? Bc ex: blood sugar 130 and gave rapid acting insulin and tray wasn't there yet, insulin would start working right away -blood sugar can drop and go lower than we want.

Inflammatory response: Temp raised in response to

pyrogens/cytokines [act as messengers] -produced by macrophages & T cells

How can you quickly recognize sepsis?

qSOFA -quick -Sepsis-related -Organ -Failure -Assessment

Among patients with a suspected sepsis infection,

qSOFA score can be used to screen for those likely to have sepsis

Causes of hyperglycemia Insufficient

quantity of overnight insulin - basal insulin

Recognizing sepsis through

quick sofa and sofa score as well as applying sepsis bundles - important for nurses

Septicemia can

quickly become life threatening; must be treated in hospital

Causes of hyperglycemia: Dawn phenomenon and somogyi effect Both can

raise fasting blood glucose levels in morning but for diff reasons

Sepsis Resp:

rate high. Increased HR. ABGs = metabolic acidosis. Pt has increase in lactic acid. Anaerobic metabolism - not enough oxygen circulating. This will slow down GI tract

Glycemic management The overall goal is to

reach Time in Target Range [70-180) at least 70% percent of the time w minimal hypo and hyperglycemia.

Specific immune response: Lymphocyte

recognizes antigen as foreign

Teaching to prevent low BG Have pt

record BG

What increases risk for infection during hospitalization? Illness or injury

recuperation from surgery, presence of infection

Nonspecific symptoms of infection inflammatory symptoms

red swelled

Droplet Precautions are designed to

reduce risk of droplet transmission of infectious agents.

Airborne Precautions are designed to

reduce risk or eliminate airborne transmission of infectious agents. The infectious particles are so small that they can remain suspended in air for long periods of time and are carried on air currents.

Contact Precautions are designed to

reduce the risk of transmission of microorganisms by direct or indirect contact.

-kidney disease can be significantly

reduced when blood glucose controlled -

Sulfonylureas [glucotrol, amaryl, diabeta, glynase, microsnase, insulin secretagogues] What do they do?

reduces A1C by 1-2%

Undifferentiated shock

refers to situation where shock is recognized but cause is unclear

Short acting insulin examples

regular

Regular: short acting insulin

regular - only one given IV -also given subcutaneous when transitioning from IV to SQ

R:

regular or short acting insulin

Diabetes: counter regulatory hormones provide

regulated release of glucose for energy

lectin and cytokines and adipokines are

regulators of appetite and satiety and energy expenditure -so for someone w type 2, chronic inflammatory state. -so we also see alteration in production of these hormones

ESR [erythrocyte sedimentation rate [sed rate]

relatively simple, inexpensive, nonspecific test that has been used for many years to help detect inflammation associated w conditions like infections, cancers & autoimmune diseases

If cell injury -> cell death

release of kinins, histamine, prostaglandins

An infection may

remain localized or it may spread through blood or lymphatic vessels to become systemic [bodywide]

Initial resuscitation for sepsis and septic shock [begin immediately] Step 1: measure lactate level

remeasure lactate if initial lactate elevated [> 2 mmol/L]

To help remember the macrolide [azithromycin, clarithromycin, erythromycin] antibiotics,

remember "ACE" for azithromycin, clarithromycin and erythromycin

DKA: treatment Potassium

replacement

Treating hyperglycemia When to

report hyperglycemia to HCP

IgG

represents approximately 75% of serum antibodies in humans

Frequently septic patients will

require central venous catheter and foley catheter. These are invasive lines that can easily get infected but are necessary when pt is that ill

Type 1 diabetes Will

require insulin for life!

Antibiotic client teaching ■ Explain the purpose of

required laboratory tests and scheduled follow-up with healthcare provider.

Causes of hyperglycemia Insulin

resistance

Some bacteria have developed

resistance to antibiotics that were once commonly used to treat them

Malnutrition impairs

resistance to infection.

Secondary diabetes usually

resolves when underlying condition is treated

Macrolides [azithromycin, clarithromycin, erythromycin] are commonly given for

resp infections & often are used as alternative for pts w penicillin allergy

Localized infections

restricted to one particular part of body & areas affected are usually red, tender, swollen & warm

Heating or freezing insulin

retards action of insulin

If a patient who is taking an aminoglycoside [gentamicin, neomycin, amikacin, tobramycin, streptomycin] is complaining of

ringing of ears, should clue you in as a red flag!!

Apple shaped

risk for diabetes

Normal A1C reduces

risk of retinopathy, nephropathy, neuropathy

Nurses must keep in mind

risks of sepsis & high mortality rate associated w sepsis, severe sepsis and septic shock

Why would they order a chest xray? -

rule out anything else like pneumonia and to get a baseline -checked to see if pneumonia as source of infection -so UTI is only source of infection here

Antibiotics interventions and rationales ■ Monitor IV site for

s/s of tissue irritation, severe pain, and extravasation. ( These are signs of infiltration.)

Culture, urine:

sample of urine placed in culture medium & evaluated for growth of MRSA

Nurses role in educating patients to prevent antibiotic resistance Do not

save some of antibiotic for next time get sick -discard any leftover med once have completed prescribed course of treatment

Macrophages are like

scavenger cells that clean up debris from neutrophils & get cleared away by lymph system

-often use sliding scale insulin for

secondary diabetes

If you suspect sepsis,

see doctor urgently -call 911 or go to hospital and say "I am concerned about sepsis"

Sepsis later stages: severe sepsis, trending toward septic shock -

see oliguria, anuria, cool clammy skin, HR starting to slow, - bc indidivudla starting to decompensate.

Basal + premeal insulin: -ex:

see pt on 10-20 units of lantus at bedtime. Then also will have 5-10 units of rapid acting before meals.

Tetracyclines can make your skin

sensitive to sunlight and artificial sources of light, such as sun lamps and sunbeds. Avoid prolonged exposure to bright light while taking these medicines.

Diabetes: neuropathy Most common

sensory loss

Broad spectrum antibiotics given for

sepsis bc do both gram positive and negative bacteria?? -why get 2 blood cultures? Accuracy. Also bc to get both anaerobic and aerobic cultures.

Why is sepsis important?

sepsis is a top hospital killer

Stages of sepsis: consensus conference definition Severe sepsis

sepsis plus organ dysfunction, hypotension or hypoperfusion [including but not limited to lactic acidosis, oliguria or acute mental status changes]

Septic shock is associated with

sepsis.

Septicemia If left untreated,

septicemia can progress to sepsis

Antibiotic resistance is

serious public health prob

In rare cases, an antibiotic can cause

severe and potentially life-threatening allergic reaction known as anaphylaxis.

Hypovolemic shock: -

severe blood or other fluid loss

Rapid infusion of vancomycin can cause

severe hypotension and nephrotxic and ototoxic effects.

-lactate: trending higher, so

she is leaning toward sepsis.

Tell me about bands

shift to the left

Passive acquired immunity Injection of immune globulins

short active IgG period

Other macrolides besides erythromycin

should not be used during pregnancy, unless advised by a specialist.

Diabetes: hyperosmolar hyperglycemic syndrome [HHS] also [HHNK] treatment

similar to DKA

qSOFA is

simple prompt to identify infected pts who are likely to be septic outside ICU

Prostaglandins are released at

site of inflammation and are also involved in pain and are linked to body temp

Nonspecific symptoms of infection Rash

skin infection

Cellulitis Most commonly affected area

skin on lower legs [though cellulitis can occur anywhere on body or face]

If forget to take dose of antibiotics But if it's almost time for the next dose,

skip missed dose and continue regular dosing schedule. Do not take double dose to make up for missed one.

Diabetes exercise Several

small CHO snacks can be taken every 30 minutes during exercise to prevent hypoglycemia

Sepsis starts

small then balloons quickly.

Histamine is contained in

some WBCs and mast cells and are released during inflammation.

Inflammatory response: Although highly beneficial to the body's defense strategies,

some chemicals also increase sensitivity of pain fibers in area & so area becomes painful

Best time to test someone's blood sugar -type 2:

some people once a month if managed really well. Some people diet is issue and need long lasting insulin and oral hypoglycemic, can be several times a day depending on how well controlled.

Secondary diabetes: -pts that are on

some sort of medication like steroids cause blood sugar to increase and also TPN

Sepsis is like

someone turned dial all way up on immune system and ripped dial off dashboard.

A client diagnosed with type 1 diabetes mellitus contacts the nurse to report experiencing night sweats, headaches when arising in the morning and slight weight gain.The client's urine tests are negativefor glucose and positive for ketones. The client's fasting blood glucose is 300 mg/dL [16.65 mmol/L]. The nurse identifies the client may be experiencing which condition? a) DKA b) Hyperglycemic hyperosmolar nonketotic coma c) graves disease d) somogyi phenomenon

somogyi phenomenon

Antibiotic client teaching ■ Instruct client to report side effects

specific to the prescribed antibiotic therapy.

Antibiotics interventions and rationales ■ Monitor for side effects

specific to various antibiotic therapies.

Specific immune response targets

specifically initiated & targeted against particular antigens like bacteria, viruses or damaged tissue

Patient centered glycemic management agree on management plan

specify SMART goals -specific -measurable -achievable -realistic -time limited

Penicillin resistant streptococcus pneumonia

spread in daycare centers

Cellulitis can

spread rapidly to other parts of body

Cellulitis Left untreated,

spreading infection can rapidly turn life-threatening -important to seek immediate medical attention if cellulitis symptoms occur

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Bands: 2 [previous: 1] Trend: improve/worsening/stable

stable... WNL

The nurse observes a staff member prepare to leave the room of a client on droplet precautions. The nurse intervenes if which action is observed? a) staff member removes first glove by grasping the cuff and pulling glove inside out over hand b) staff member holds onto outer surface of face mask while pulling mask away from face c) staff member unties gown and removes it without touching outside of gown d) nurse performs hand hygiene

staff member holds onto outer surface of face mask while pulling mask away from face

A1C and estimated and estimated average glucose [eAG] This data is invaluable to help

start process of prob solving to decrease hypo and hyperglycemic events and increase time in target.

Specific immune response

started by introduction of foreign substance [antigen] into body

Shock

state of cellular and tissue hypoxia

Medical asepsis refers to

state of cleanliness that decreases potential for spread of infection

Insulin: long acting - Lantus/glargine [Basal] released

steadily and continuously

Lymphocytes derive from

stem cells in bone marrow

White blood cells [leukocytes] derive from

stem cells in bone marrow

Compromised host Medical therapy

steroids, abx

Type 2: how is it diff thsn type 1? -

still making some insulin but not being used properly. but can be insulin resistance. Can be managed through diet and exercise sometimes.

Treating hyperglycemia Proper

storage or insulin

Liver both

stores and produces sugar

Superbugs

strains of bacteria that have developed resistance to many different types of antibiotics, including: MRSA [methicillin-resistant Staphylococcus aureus) Clostridium difficile (C. diff) the bacteria that cause multi-drug-resistant tuberculosis

Risk for infection: Interventions Rest and relaxation

stress decrease immune response

Causes of hyperglycemia Illness

stress, altered absorption

All insulins can be given

subcutaneously

Septic shock is a

subset of sepsis in which particularly profound circulatory, cellular and metabolic abnormalities are associated w greater risk of mortality than w sepsis alone

Antigen

substance that induces formation of antibodies bc it is recognized by immune system as threat

Tetracyclines end in

suffix -cycline

-brains always needs

sugar to function properly -so counter regulatory hormones kick in and increase sugar but blood sugar is already really high and don't have mechanisms to get those sugars into cells where they need to be so blood sugar increases even more and that is complication of diabetes

Antibiotics pt teaching ■ Instruct client to report signs and symptoms of

superinfection such as fever; black hairy tongue; stomatitis; loose, foul-smelling stools; vaginal discharge; or cough.

Transmission-Based Precautions are designed to

supplement standard precautions in pts/residents w documented or suspected infection/colonization of highly transmissible or epidemiologically important pathogens.

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. What data from the histories are important and RELEVANT and have clinical significance for the nurse? Widowed and has 2 daughters who are active and involved in her life

supportive family is positive influence that will increase her ability to maintain current autonomy

The IgE attaches to

surface of mast cell which cause release of many diff mediators.

-Dawn phenomenon: caused by

surge of hormones body puts out in early morning hours.

What increases risk for infection during hospitalization? Break in first line of defense

surgical incisions

People with type 1 diabetes will not

survive without insulin

All insulins come

suspended or dissolved in liquid -standard

Infection assessment: Any

suspicious drainage should be cultured

Cellulitis appears as

swollen, red area of skin that feels hot & tender

Antibiotics interventions and rationales ■ Monitor vital signs and

symptoms of infection to determine antibacterial effectiveness. (Another drug or different dosage may be required.)

As the body mounts this protective response,

symptoms of inflammation develop

Septic shock is characterized by

symptoms of sepsis plus hypotension and hypoperfusion despite adequate fluid volume replacement.

Sepsis:

syndrome in response to infection

Sepsis is a!

systemic response to infection.

When it comes to antibiotics,

take doctor's advice on whether need them or not.

If you forget to take a dose of your antibiotics,

take that dose as soon as remember and then continue to take course of antibiotics as normal. But if it's almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one.

It's recommended that you do not drink alcohol while

taking antibiotics in general. However, as long as drink in moderation, alcohol is unlikely to interact significantly with your medicine.

Antibiotic resistance is a big problem -

taking antibiotics when do not need them can mean they will not work for you in future.

Purulent exudate can be

tan, yellow, green or brown in color

sepsis discharge and home guidelines Treatment modalities.

teach pt and family about treatment modalities like emergency administration of meds, IV therapy, parenteral or enteral nutrition, skin care, exercise, and ambulation.

Infection assessment: Elevated temperature

temp of up to 38 C [100.4 F] 48 hours post-op is usually related to surgical stress after 48 hours

Fluoroquinolones [end in -floxacin] With this in mind, if the patient complains of

tendon pain, inflammation or swelling, med should be immediately discontinued

Stop taking fluoroquinolone treatment straight away and see your GP if you get a serious side effect including:

tendon, muscle or joint pain - usually in knee, elbow or shoulder tingling, numbness or pins and needles

Do not take a macrolide antibiotic with any of the following medications unless directly instructed to by your GP, as the combination could cause heart problems:

terfenadine, astemizole and mizolastine - these are all antihistamines used to treat allergic conditions such as hay fever amisulpride - used to treat episodes of psychosis tolterodine - used to treat urinary incontinence statins - used to treat high cholesterol

Oral glucose tolerance test:

test for impaired glucose tolerances by giving sugary drink -parameter to be diagnosed w prediabetes is between 140 and 199

What is a urinalysis?

test of urine

Tetracyclines (such as

tetracycline and doxycycline) -

Tetracyclines [ending in cycline] Important side effects to note

tetracyclines cause bone deformities and teeth discoloration

■ No dairy/calcium products with

tetracyclines.

basal rate of insulin

that our body normally produces

Antibiotics pt teaching ■ Instruct client to discontinue

the medication and inform healthcare provider if symptoms of hypersensitivity reaction develop, such as wheezing; shortness of breath; swelling of face, tongue, or hands; and itching or rash.

Check with your GP or pharmacist before taking a fluoroquinolone if you're currently taking:

theophylline - used to treat asthma; also found in some cough and cold medicines non-steroidal anti-inflammatory drug (NSAID) painkillers - such as ibuprofen ciclosporin probenecid - used to treat gout clozapine - used to treat schizophrenia ropinirole - used to treat Parkinson's disease tizanadine - used to treat muscle spasms glibenclamide - used to treat diabetes cisapride - used to treat indigestion, heartburn, vomiting or nausea tricyclic antidepressants - such as amitriptyline steroids (corticosteroids) - such as prednisolone)

Antimicrobial therapy: peak and trough blood levels aka

therapeutic drug monitoring - TDM

If you previously had an allergic reaction to penicillin,

there's a chance that you may also be allergic to cephalosporins.

Antibiotics can come as creams, lotions, sprays and drops -

these are often used to treat skin infections and eye or ear infections

Antibiotics can come as injections -

these can be given as injection or through drip directly into blood or muscle, and are used for more serious infections

Antibiotics can come as: tablets, capsules or liquid that you drink -

these can be used to treat most types of mild to moderate infections in body

-but in sepsis, body's response to

these chemicals is out of balance. Triggers change that can damage multiple organs. Body's response goes into overdrive in response to infection

Macrolides [azithromycin, clarithromycin, erythromycin] As a warning here,

these drugs can cause dysrhythmias from QT segment prolongation & also have association w C difficile overgrowth [esp clarithromycin]

When tissue cells become injured,

they release number of chemicals that initiate inflammatory response

Tetracyclines [ending in cycline] Education point to remember

they should NOT be given with milk, antacids or iron

Hemorrhagic exudate consistency

thicker than sanguinous fluid

Sanguineous exudate The consistency appears

thin & watery w sanguinous fluid

Sanguineous exudate

thin, watery & pale red to pink in color

seropurulent exudate

thin, watery, cloudy & yellow to tan in color

Serosanguineous fluid

thin, watery, pale red to pink in color

Because she has both a drop of BP and increase in HR as well as being symptomatic, orthostatic hypotension

this confirms that you are seeing moderate to severe fluid volume depletion. Anticipate IV fluid resuscitation.

Antibiotics may be recommended for a wound that has a high chance of becoming infected -

this could be an animal or human bite, for example, or a wound that has come into contact with soil or feces.

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Lactate: 3.2 Clinical significance?

this is most concerning finding that must be assessed and trended carefully Lactate elevation confirms possibility of SEPSIS progressing to SEPTIC SHOCK

Inflammatory response: When chemicals are released,

this leads to increased blood flow to injured site

Also look at specific pt -

this may be a normal bp but it's not normal for this pt

The most important ways to prevent antibiotic resistance are minimize unnecessary prescribing and overprescribing of antibiotics

this occurs when people expect doctors to prescribe antibiotics for viral illness [antibiotics do not work against viruses] or when antibiotics are prescribed for conditions that do not require them

General appearance: resting comfortably, appears in no acute distress Resp: breath sounds clear w equal aeration bilaterally, nonlabored resp effort Cardiac: pink, warm and dry, no edema, heart sounds regular - S1S2, pulses strong, equal w palpation at radial/pedal/post-tibial landmarks Neuro: alert & oriented x2 - is not consistently oriented to date and place, c/o dizziness when she sits up GI: abdomen soft/nontender, bowel sounds audible per auscultation in all 4 quadrants GU: dysuria and frequency of urination persists, right flank tenderness to gentle palpation Skin: skin integrity intact, lips dry, oral mucosa tacky dry Relevant assessment data? Neurologic

this reflects change in mental status commonly seen in UTI or sepsis w elderly & is always clinical RED FLAG

If a decrease in 20 points or more of mm/Hg in SBP is seen from lying to standing in addition to the increase in HR,

this reflects moderate to severe fluid volume deficit/dehydration.

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. BUN: 35 Clinical significance?

though BUN is not as specific as creatinine for measuring kidney function, it is important for nurse to recognize relevance when there is elevated creatinine & to cluster this value w creatinine in renal failure or fluid loss & dehydration It will typically trend upwards when creatinine is elevated

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Band forms: 2 Clinical significance?

though normal, bands are RELEVANT here bc they will be elevated if pt is sliding into septic shock or overwhelming infection & body begins to kick out these immature neutrophils

how to prevent and delay diabetic nephropathy

tight glucose control, A1C levels less than 7, bp management, ACE inhibitor [blood pressure control meds but for people w diabetes, protective mechanism against kidneys - it's a prophylactic measure - even if don't have HTN]

Benefit of pump:

tight glucose control.

Peak time:

time insulin as at maximum strength.

Time zero/time presentation

time of triage in ED or if presenting from another care venue, from earliest chart annotation consistent w all elements of sepsis [formerly severe sepsis] or septic shock ascertained through chart review

Inflammatory response: Tissue injury

tissue damage may occur from trauma like tackle, collision or from awkward fall

Type 1 diabetes -some people have a

tissue type that makes them more susceptible -or ex: 2 sisters worked closely with virus. After recovered, their pancreas no longer made insulin. -beta cells attacked by body

Septic shock medical management · Fluid replacement therapy.

to correct tissue hypoperfusion, so aggressive fluid resuscitation must be implemented.

Septic shock assessment Liver function test.

to detect any alteration in function of liver.

Airborne infection precautions Gown

to prevent soiling from body fluids

Droplet infection precautions gown

to prevent soiling from body fluids

Standard infection precautions Gown

to prevent soiling from body fluids

GNATS

to remember aminoglcosides -gentamicin -neomycin -amikacin [tricky outlier] -tobramycin -streptomycin

Dawn pehenomenon and somogyi effect: -somogyu: caused by

too much insulin in blood during night. Can happen to people taking long acting insulin. [ex: lantis] or if on NPH [intermediate] insulin and don't eat bedtime snack. Blood sugar will drop while sleeping so in response counter regulatory hormones kick in to counteract drop. This is rebound hyperglycemia.

Aminoglycosides [gentamicin, neomycin, amikacin, tobramycin, streptomycin] have the potential to have

toxic side effects like nephrotoxicity and ototoxicity

Airborne precautions prevent

transmission of infectious diseases that are spread by airborne droplets < or equal to 5 microns that remain infectious and suspended in air for long periods of time over long distances and can be widely dispersed by air currents

Contact precautions prevents

transmission of infectious organisms spread by direct or indirect contact w pt or pt environment

Droplet precautions prevents

transmission of infectious organisms spread by droplets > 5 microns through close resp or mucous membrane contact w resp secretions through coughing, sneezing, talking or droplet inducing procedures

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. Neutrophils: 93% [previous 68%] Trend: improve/worsening/stable

trending UP... worsening

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Jean lives independently in a senior apartment retirement community. She is widowed and has 2 daughters who are active and involved in her life. T: 101.8 F/38.8 C [oral], P 110 [regular], R 24 [regular], BP 102/50, O2 sat 98% room air. PQRST: nothing, ache, right flank, 5/10, continuous. The nurse recognizes the need to validate concern of fluid volume deficit and performs set of orthostatic VS & obtains: supine 110, 102/50. Standing 132, 92/42. WBC 13.2 [previous: 8.8] Trend: improve/worsening/stable

trending UP... worsening

Sepsis As the healthcare team, we are trying to

turn immune response down as best we can... but it is VERY challenging.

If going to surgery, have to

turn insulin pump off, -bc before, during and after, prob on sliding scale insulin

TCDB

turn, cough, deep breathe

NPH [intermediate acting insulin] -we give this

twice a day [morning and again around 5-6 pm]. Why? If gave in morning at 7 or 8, that covers pretty much whole day. Then have to give another dose to cover rest of night so if gave it at 5 or 6 along with dinner, [that's when we mix insulin [regular or rapid acting w intermediate acting - clear and cloudy] that covers next 12 hours -that's how NPH covers full 24 hours.

Sepsis is manifested by

two or more of SIRS (Systemic Inflammatory Response Syndrome) criteria as consequence of documented or presumed infection.

DKA: mostly from

type 1

Exogenous insulin is required for

type 1 diabetes

Sulfonylureas: -for

type 2 diabetes -these increase insulin production by increasing self receptor site?

A lymphocyte is a

type of WBC that is part of immune system

Immunoglobulin G

type of antibody

Eosinophils

type of disease-fighting WBC

Lactic acidosis:

type of metabolic acidosis -look - is respsystem coming in to help? Look at trends. Is it compensated?

Septicemia Many

types of bacteria can lead to septicemia

Diabetic nephropathy -cause:

uncontrolled diabetes and uncontrolled HTN, smoking, chronic hyperglycemia [all associated w end stage renal disease[

Proper nutrion: keeps diabetes

under much better control -more controlled blood sugar is, better the outcomes are. Fewer long and short term complications.

Fibrin

underlying fabric of blood clots is protein polymer called fibrin

Insulin regimens: 0.5-1

unit per kg/daily

Nurse's role in preventing drug resistance Participate in

unit-based surveillance studies to learn about trends in resistant infection

Accidentally taking 1 extra dose of your antibiotic is

unlikely to cause you any serious harm. But it will increase your chances of getting side effects, like pain in stomach, diarrhea, and feeling or being sick.

DKA: treatment Insulin drip

until blood glucose levels approach 250 mg/dL 1-2 unit/hr 0.5 unit/kg/hr 5% dextrose added to regimen Prevent hypoglycemia

Hypoglycemia - treatment If alert enough to swallow Repeat

until blood sugar > 70 mg/dl

UTD

up to date

Incretin mimetics: usually

use at home. -inhibit release of glucagon -slow glucose absorption -beneficial in a little bit of weight loss

General rules about insulin: ONLY

use insulin syringes!

The National Institute for Occupational Safety and Health guidelines for preventing allergic latex reactions in the workplace include

using nonlatex gloves for activities that are not likely to involve contact with infectious materials; use powder-free gloves; don't use oil-based creams when wearing latex gloves; wash hands thoroughly after removing latex gloves;

Nutrition for: -Type 1:

usual diet w exercise

You can take erythromycin at the

usual doses throughout your pregnancy and while you're breastfeeding.

Inflammatory response: As a general rule, you must recall that fever

usually associated w infection -but people can have fever due to many other things such as cancer

Sepsis/urosepsis Precipitating event

usually bacterial infection that has entered bloodstream [sepsis]

Antibiotics These mild to moderate allergic reactions can

usually be successfully treated by taking antihistamines. But if you're concerned, or your symptoms don't get better with treatment, call your GP for advice. If you cannot contact your GP, call NHS 111.

Early treatment of sepsis

usually w antibiotics & large amounts of intravenous fluids, improves chances for survival

Diabetes concept map: -can be issue of impaired

utilization of insulin depending on type and/or abnormal insulin production

airborne precautions Examples of Diseases:

varicella (chickenpox] , tuberculosis, measles.

Penicillins such as penicillin and amoxicillin are widely used to treat

variety of infections like -skin infections, -chest infections -urinary tract infections

Histamine is involved in

vasodilation, smooth muscle spasm and vascular permeability.

Sepsis/urosepsis After body attempts to increase CO [pt looks better but is actually worsening]

vasodilation... further lowering BP & persistent tachycardia [compensation attempts wearing down resulting in more severe hypodynamic state]

Basophils also contain

vasodilator histamine which promotes blood flow to tissues

sepsis Temp can be

very high or very low

Sepsis

very serious medical condition characterized by inflammatory state of entire body caused by infection

1. Prompt lab draws o Labs in sepsis diagnosis and treatment

very time sensitive. imperative the nurse is drawing labs promptly, as this evaluates effectiveness of Tx and determines next steps.

Systemic infection may be

viral, bacterial or another & sometimes is caused by specific bacterial toxins, in blood or tissues

Frequent reassessment of

vitals for sepsis

Check with your GP or pharmacist before taking a tetracycline if you're currently taking:

vitamin A supplements retinoids - such as acitretin, isotretinoin and tretinoin, which are used to treat severe acne blood-thinning medication diuretics kaolin-pectin and bismuth subsalicylate - used to treat diarrhoea medicines to treat diabetes - such as insulin atovaquone - used to treat pneumonia antacids - used to treat indigestion and heartburn sucralfate - used to treat ulcers lithium - used to treat bipolar disorder and severe depression digoxin - used to treat heart rhythm disorders methotrexate strontium ranelate - used to treat osteoporosis colestipol or colestyramine - used to treat high cholesterol ergotamine and methysergide - used to treat migraines

Side effects of antibiotics that affect the digestive system include:

vomiting nausea (feeling like you may vomit) diarrhoea bloating and indigestion abdominal pain loss of appetite

Asepsis is KEY

w all pt care but in particular septic patient.

Diabetes chronic complications: macrovascular occur

w greater frequency and w earlier onset in diabetes

Palpitations,s weating, anxiety [

warn blood sugar is dropping]

Sepsis bundles: -surviving spsis campaign:

way to recognize sepsis.

What is primary problem pt most likely presenting with? -confirmed UTI, meets criteria for SIRS -

we are worried about sepsis. [bc SIRS + confirmed infection]]

When we have inflammation,

we don't necessarily have an infection

When we have an infection,

we have inflammation

In this snapshot ADP Report example below, we see that the A1c is 7.6%, but when we look at the right hand Time in Range side,

we quickly note that this individual is struggling w frequent lows and very low glucose levels coupled w hyperglycemia. The time is range is only 47%.

Specific immune response The body recognizes

what belongs there & what doesn't; typically targets what is "not self," not part of itself

Nurses role in educating patients to prevent antibiotic resistance Ask

what else can do, rather than taking antibiotic, to feel better sooner

Type of drainage tells us

what's going on in wound

Allergic reaction

when immune system overreacts to environmental antigens like pollen or pet dander

Dialysis =

when kidneys are not working

Regular insulin [short acting] -usually given

when someone is NPO like before surgery -longre duration than rapid acting

-so when lactic acid levels rise,

when there is decrease in oxygen -ex: someone exercising strenuously, lactic acid increases but that;s temporary. Then stop exercising, they go back down again.

Inflammatory response: Release of chemicals

when tissue cells become injured, they release number of chemicals that initiate inflammatory response

Even in the context of a patient who is critically ill,

when you simply and matter-of-factly share what you are doing and why, it demonstrates caring and support that is needed.

Serosanguineous fluid The pink tinge

which comes from red blood cells, indicates damage to capillaries w dressing changes

why is qSOFA useful?

while only 1 in 4 infected pts have 2+, they account for 3 out of 4 deaths

It's best to completely avoid alcohol

while taking metronidazole or tinidazole, and for 48 hours afterwards, as this combination can cause very unpleasant side effects, such as: feeling and being sick stomach pain hot flushes headaches

Tetracyclines such as tetracycline and doxycycline can be used to treat

wide range of infections, but are commonly used to treat acne and skin condition called rosacea

Cephalosporins such as cephalexin are used to treat

wide range of infections, but some are also effective for treating more serious infections like septicaemia and meningitis

What is vasodilation?

widening of blood capillaries

People who are allergic to one type of penicillin

will be allergic to all of them.

Nurses role in educating patients to prevent antibiotic resistance Talk

with HCP above antibiotic resistance

Antibiotics interventions and rationales ■ Monitor client for compliance

with antibiotic therapy. Adhering to prescribing guidelines increase drug's effectiveness.)

Neutrophils increase

with infection

Sepsis This is a very complex issue which affects many body systems,

with overall mortality rate anywhere from 27-36% and higher in patients in intensive care settings).

Antibiotics do not

work for viral infections such as colds and flu, and most coughs and sore throats.

Helminths

worm-like organisms living in & feeding on living hosts, receiving nourishment & protection while disrupting host's nutrient absorption causing weakness & disease

Compromised host Breaks in skin and mucous membranes

wounds, stoma

Infection assessment Color of respiratory secretions

yellow or yellow-green sputum is indicative of resp infection

Can put good bacteria back w

yogurt, probiotics.

Although there are other drugs that end in -mysin

you can remember aminoglycosides by mnemonic GNATS

Nurses role in educating patients to prevent antibiotic resistance If your health care provider determines

you do not have bacterial infection, ask about other ways to help relieve symptoms -do not pressure provider to prescribe antibiotic

If you're prescribed rifampicin or rifabutin,

you may need to use additional contraception, such as condoms, while taking antibiotics. Speak to your GP, nurse or pharmacist for advice.

Insulin: long acting - Lantus/glargine [Basal] this is what

you will see in acute care

Sepsis Nursing Care Plan Objective Data

· Elevated temp (over 101 F · Low temp (below 96.8 F · HR over 90 · RR over 20 · Respiratory distress · Decreasing UO · Hypotension · Decreasing platelet count · Edema · Hyperglycemia (no hx diabetes · Altered LOC · Mental status changes · Increase in WBC, bands · Low SVO2 · High lactic acid · Increasing creatinine

Sepsis Nursing Care Plan Subjective Data:

· Pain · Difficulty breathing

Sepsis evaluation

· Patient displayed hemodynamic stability. · Patient verbalized understanding of the disease process. Patient achieved timely wound healing

Sepsis Healthcare team members should be prepared with a care plan for the patient for a more systematic and detailed achievement of the goals.

· Patient will display hemodynamic stability. · Patient will verbalize understanding of the disease process. · Patient will achieve timely wound healing.

Antibiotics are no longer routinely used to treat:

· chest infections · ear infections in children · sore throats

Diabetes mellitus diagnostic studies Random or casual plasma glucose measurement:

≥ 200 mg/dl plus symptoms

Diabetes mellitus diagnostic studies Two-hour OGTT level:

≥ 200 mg/dl using a glucose load of 75 g

Antibiotic client education Encourage client to:

■ Avoid direct exposure to sunlight during and after therapy. ■ Wear protective clothing, sunglasses, and sunscreen when in the sun.

Antibiotic client teaching Instruct client to notify healthcare provider of:

■ Changes in hearing, ringing in ears, or full feeling in ears. ■ N/V with motion, ataxia, nystagmus, or dizziness.

Antibiotic client teaching Instruct client about the importance of:

■ Completing the prescription as ordered. ■ Follow-up care after antibiotic therapy is completed

Antibiotics pt teaching Instruct client to: consult & consume

■ Consult HCP before taking antidiarrheal drugs, which could cause retention of harmful bacteria. ■ Consume cultured dairy products w live active cultures, such as kefir, yogurt, or buttermilk, to help maintain normal intestinal flora.

Antibiotics potential nursing diagnoses

■ Infection ■ Injury, Risk for ■ Knowledge, Deficient, related to disease process, transmission, and drug therapy ■ Noncompliance, related to therapeutic regimen

Antibiotics goals and expected outcomes The client will:

■ Report reduction in symptoms related to diagnosed infection and have negative results for laboratory and diagnostic tests for presenting infection. ■ Demonstrate understanding of drug's action by accurately describing drug side effects and precautions ■ Immediately report rash, shortness of breath, swelling, fever, stomatitis, loose stools, vaginal discharge, or cough. ■ Complete the full course of antibiotic therapy and comply with follow-up care

Antibiotics pt teaching Instruct client to: take & complete

■ Take medication on schedule. ■ Complete entire prescription even if feeling better, to prevent development of resistant bacteria.

Antibiotic evaluation of outcome criteria evaluate the effectiveness of drug therapy by confirming that client goals and expected outcomes have been met (see "Planning").

■pt reports reduction in symptoms and has improved lab results. ■ pt demonstrates understanding of the drug's action by accurately describing drug side effects and actions. ■ pt accurately states s/s to be reported toHCP ■ pt completes full course of therapy and complies with follow-up care.

Diabetes is the leading cause of

◦End-stage renal disease ◦Adult blindness -Nontraumatic lower limb amputations