Unit 3 & 4

A client with type 1 diabetes is placed on an insulin pump. Which is the priority short-term goal when teaching this client to control the diabetes?

"The client will demonstrate correct use of the insulin pump."

acid-base balance is

-expected in all well individuals -requires normal physiologic functioning -indication of homeostasis

Somogyi phenomenon

A rebound phenomenon that occurs in clients with type 1 diabetes mellitus. Normal or elevated blood glucose levels are present at bedtime; hypoglycemia occurs at about 2 to 3 am. Counterregulatory hormones, produced to prevent further hypoglycemia, result in hyperglycemia (evident in the prebreakfast blood glucose level). Treatment includes decreasing the evening (predinner or bedtime) dose of intermediate acting insulin or increasing the bedtime snack.

ABG interpretation

Based on pH, CO2 level, and bicarb level. R.O.M.E. Respiratory Opposites, Metabolic Equal. *see photo on phone*

Important notes on diuretics

DIURETICS ACT ON DIFFERENT SITES OF THE KIDNEY TUBULE Monitor VS, the best time to give diuretic would be early in the morning, daily weights are important, I&O q 4h. An increase of 2.2 to 2.5 is equivalent to the patient holding onto one liter of body fluid. Monitor for edema, slow repositioning, assess blood glucose (thiazide), check K level often (especially if pt on digoxin), if pt has trouble seeing, check K levels.

A client's breath has a sweet, fruity odor. Which condition is affecting this client?

Diabetic acidosis A client with diabetic acidosis has a sweet, fruity odor to the breath.

diabetic monitoring

Fasting blood sugar Glycosylate hemoglobin (A1C) Urine glucose & ketones Urine protein, albumin Serum lipids, electrolytes (typically a diabetic will have abnormal lipids. increased triglycerides, decreased HDL, increased total cholesterol... GOAL: LDLs less than 100, Triglycerides less than 150 and HDLs greater than 40.) Self monitoring blood sugar

Hyperglycemia

High blood sugar (greater than 250) Causes: inadequate amount of insulin. Clinical manifestations: Fruity-smelling breath. Nausea and vomiting. Shortness of breath. Dry mouth. Weakness. Confusion. Coma. Abdominal pain. Management: Fluid replacement. Electrolyte replacement. Insulin therapy.

Blood sugar mnemonic

Hot & dry = sugar high Cold & clammy = need some candy

HHNS

Hyperglycemia in Type 2 which is really just dehydration

Insulin onset, peak, duration

Insulin lispro has an onset of 0.25 hours, a peak action of 0.5 to 1.5 hours, and a duration of 3 to 4 hours. Insulin glargine has an onset of 1 to 1.5 hours, no peak action, and a duration of 20 to 24 hours. Neutral protamine Hagedorn (NPH) or intermediate-acting insulin has an onset of 1.5 hours, a peak action of 4 to 12 hours, and a duration of 18 to 24 hours. Regular insulin has an onset of 0.5 hours, a peak action of 1 to 5 hours, and a duration of 6 to 10 hours.

Osmotic Diuretics

Mannitol (Osmitrol) Action: Increases concentration, osmolarity in the blood, NA reabsorption in proximal tubules and loop of henle. SE: Pulmonary edema could develop, tachycardia (too fast of fluid loss) could also cause acid-base imbalance Implications: Commonly used in increased intracranial pressure, cerebral edema, and to reduce intraocular pressure for someone that has glaucoma. K wasting, freq used in emergent situations, diuresis can occur within 1-3 hr of administration. Crystallize easily when drug is exposed to low temp. Has to be given with a filter and commonly mixed with Dextrose. Give cautiously with patients that have heart disease and heart failure - stop immediately if you pick up on signs of HF

An adolescent with diabetes had a 6:30 AM fasting blood glucose level of 180 mg/dL (10.0 mmol/L). Which nursing action is a priority?

Tell the adolescent that the prescribed dose of rapid-acting insulin should be administered. A blood glucose level of 180 mg/dL (10.0 mmol/L) is above the average range, and the prescribed rapid-acting insulin is needed. Although exercise does decrease insulin requirements and does lower the blood glucose level, the immediate action of insulin is needed. Asking the adolescent to obtain an immediate glucometer reading is an action that will not correct the problem; the blood glucose level is already known. Food intake at this time will increase the level of blood glucose.

Acidosis (types of imbalances)

acidosis: retention of too much acid or loss of too much base respiratory acidosis: CO2 is retained metabolic acidosi: bicarb (HCO2) loss or H+ retention

Carbohydrate Counting

carbs are the main item that raises blood glucose carbs can be in number of servings or grams: 15 grams per serving starches, breads, milk, fruits portion sizes are important and differ by food even within food groups

Insulin glargine

has an onset of 1 to 1.5 hours, no peak action, and a duration of 20 to 24 hours.

Carbonic Anhydrase Inhibitors

Acetazolamide (Diamox) Needed to maintain acid-base balance. Used with eye issues (intraocular pressure), may also be alternated with a loop diuretic if metabolic acidosis Can also crystalize. Contraindicated during the first trimester of pregnancy. Can also cause metabolic acidosis

Diabetes Pharmacologic Therapies

insulin oral antidiabetic agents drug interactions

A child is receiving 45 units of intermediate-acting insulin at 7:00 AM and 7:00 PM. Which statement by the nurse is most appropriate when discussing bedtime snacks with the parents?

"Provide a bedtime snack to prevent hypoglycemia during the night." Intermediate-acting insulin peaks in 4 to 12 hours; a bedtime snack will prevent hypoglycemia during the night. Offering a snack at bedtime if there are signs of hyperglycemia is unsafe because it will intensify the hyperglycemia; if hyperglycemia is present, the child needs insulin. Bedtime snacks are recommended for people taking intermediate-acting insulin. When hypoglycemia develops, the child will be asleep; the snack should be eaten before bed.

Fluid and Electrolyte Imbalance Nursing Dx

*Deficit fluid volume (dehydration) excessive fluid loss, NG suction, could lead to hypovolemia* Assess: noticing cues (weight loss, VS, peripheral pulses, cap refill, distended jugular veins, skin turgor/mucous membranes (tenting and dry mucous membranes), in children (atypical symptomatology, irritability, sleepy), older adults (decreased LOC, lack of attention) Lab values: increased BUN, increased HCT, increased specific gravity... indicates decreased fluid volume Analysis: deficient fluid volume, and risk for injury Management: strict I/O, check electrolytes, CBC, and urine-specific gravity, assess for hypotension and weak pulses, assess the respiratory system and tissue perfusion, check orientation, vision and hearing, reflexes, and muscle strength, check for weight changes, check for skin breakdown, and good oral care. (oral rehydration is the best intervention to promote hydration but it acts more gradually) *Excess fluid volume (p. 250)* Assessment: edema, weight, VS (increase BP, pulse rate), oxygenation (diminished or adventitious sounds, crackles, increase RR, orthopnea), perfusion (increased heart rate, bounding pulse), output (decreased urinary output) Pt may be anxious, altered mental status, nausea and vomiting Lab value: decreased HCT, HBG, and ALB Nursing dx: excess fluid volume, activity intolerance, risk for imaired skin integrity, impaired gas exchange

clinical manifestations respiratory alkalosis

tachypnea, inability to concentrate, LOC, seizures, deep and rapid breathing, hyperventilation, tachycardia, decreased or normal BP, hypokalemia, numbness and tingling of extremities, light headedness, N/V. causes: hyperventilation (anxiety, PE, fear) and mechanical ventilation

Daily regular insulin has been prescribed for a client with type 1 diabetes. The nurse administers the insulin at 8 AM. When will the nurse monitor the client for a potential hypoglycemic reaction?

Before lunch Regular insulin is short acting and peaks in 2 to 4 hours, which in this case will be at or before lunch. Breakfast is too soon; regular insulin peaks in 2 to 4 hours. Before dinner is too late; regular insulin peaks in 2 to 4 hours. The early afternoon is too late; regular insulin peaks in 2 to 4 hours.

An intravenous solution containing potassium inadvertently infused too rapidly. The client is prescribed insulin added to a solution of 10% dextrose in water. Which would the nurse identify as the purpose of the insulin?

Potassium follows insulin and glucose into the cells of the body, thereby raising the intracellular potassium level.

diabetes is diagnosed by...

Nonfasting glucose greater or equal to 200 taken anytime during the day symptoms OR Fasting glucose greater than or equal to 126 OR 2hr oral glucose tolerance test greater than or equal to 200 OR A1C > 6.5 A random PG level >200 mg/dL + polyuria, polydipsia, or polyphagia are also diagnostic for diabetes

clinical manifestations of metabolic acidosis

headache, decreased BP, hyperkalemia, muscle twitching, warm and flushed skin, N/V/D, changes in LOC, lethargy, Kussmaul respirations (rapid and deep), causes: DKA, severe diarrhea, renal failure, shock

hyperkalemia (>5)

*Etiology(causes):* "MACHINE" medications (ace inhibitors, NSAIDs, and K sparing diuretics), acidosis (metabolic, resp.), cellular destruction (burns, wounds), hypoaldosteronism, hemolysis, intake in excess, nephrons/renal failure, excretion being impaired. *Assessment: S/S:* muscle twitching, cramps, paresthesia, irritability, anxiety, decreased BP, EKG changes, dysrhythmias, abdominal cramping, and diarrhea. *Nurse Management:* This is an EMERGENCY! medications: insulin with dextrose, kayexalate. Dialysis and low K diet.

Hypophosphatemia (< 3.5)

*Etiology(causes):* increased urinary loss, decreased intestinal absorption, alcoholism, poor dietary intake, vomiting, diarrhea, respiratory alkalosis *Assessment: S/S:* confusion, seizures, coma, chronic memory loss, lethargy, decreased strength, difficulty speaking, wx of resp. muscles and joints, stiffness, decreased BP and cardiac output. *Nurse Management:* increase intake of high P foods (eggs, nuts, whole grains, meat, fish/poultry, milk products). moderate: tx with PO P supplements severe: IV inf. of phosphate SLOWLY assess LOC, neurological changes are temporary, cardiac monitoring, evaluate mobility and presence of bone pain.

acid-base imbalance ...

-develops as a complication of other underlying conditions -never considered "normal" but may be "expected" if chronic condition (compensation)

Acid-base imbalances collaborative management

-nurses do not independently manage -interventions always geared toward tx underlying disease -associated with fluid and lyte imbalance -respiratory disturbances: respiratory support -metabolic disturbances: fluid and lytes support

Criteria for diagnosis of diabetes

Nonfasting glucose >200 mg/dl taken anytime during the day and symptoms OR Fasting glucose >126 mg/dl OR 2-hour 75-g Oral Glucose Tolerance Test > 200 mg/dl OR Gluycated Hemoglobin (A1C) > 6.5 %

Sodium bicorbonate in the large intestine

Neutralizes the acidic products from bacterial activity

Diabetes Management

diet, exercise, medication

nursing managment of respiratory acidosis

improve ventilation, lower CO2 levels, stimulate the pt, check VS, enhance gas exchange (positioning, breathing techniques), drug therapy to prevent hyperkalemia, trach suctioning, IS, cough and deep breathe

Pregnant with diabetes

screening (at 24-28 weeks) 25 years or older younger than 25 but obese family hx random glucose greater than 200 complications: genetic abnormalities, stillbirth first trimester: maternal insulin needs will increase second/third trimester: increases in placental hormones cause an insulin-resistant state. requiring an increase in the clients insulin dose. fetus produces its own insulin and pulls glucose from the mother baby at birth typically has a weight greater than 9-10 lbs (the result of excess fat, etc.) the neonate is prone to hypoglycemia, resp. distress syndrome, hypocalcemia, hyperbilirubinemia s/s of hypoglycemia: twitching, difficulty feeding, lethargy, cyanosis, apnea, seizures, tachypnea, retraction, grunting, nasal flaring monitor for signs or resp. distress, birth trauma, and congenital abnormalities. monitor bilirubin and blood glucose levels. monitor weight. feed the infant soon after birth with glucose water, breastmilk, or formula (as prescribed). administer glucose IV to treat hypoglycemia if necessary. monitor for apnea, tremors, and seizures. unstable temperature. hypoglycemia: lower than 40 in the first 72 hours or lower than 45 in the first 3 days of life.

clinical manifestations of respiratory acidosis

tachycardia, if severe bradycardia, dysrhythmias, ineffective shallow rapid breathing, pale skin, cyanotic, headache, dyspnea, hyperkalemia, confusion, lethargy, muscle weakness, hyperreflexia

blood glucose goals for a diabetic

to have a FBS of 70 - 130. 2hr after meals less than 160. Bedtime glucose of 90-150. A1C less than 7.

diabetes treatment goal

to have intensive control of a glucose level to dramatically decreases vascular and neuropathic complications achieve normal glucose levels without hypo/hyperglycemia and to prevent acute/chronic complications

nursing management of respiratory alkalosis

O2 therapy, anxiety reduction, rebreathing techniques, monitor ABG and lytes, maintain a calm and quiet environment, monitor resp rate and depth, monitor tachycardia or decreased BP

Alkalosis (types of imbalances)

retention of too much base or loss of too much acid respiratory alkalosis: CO2 loss metabolic alkalosis: HCO3 excess and H+ loss

Hypoglycemia

Abnormally low blood sugar (typically below 50-60) Causes: too much insulin or oral antihyperglycemic agent, too little food, or excessive physical activity Clinical manifestations: tachycardia, irritability, restlessness, excessive hunger, diaphoresis, depression, confusion, inability to concentrate, might feel cold and clammy, slurred speech Management: give 15g of fast-acting concentrated carb (4-6 oz of OJ, soda), check BG in 15 minutes again... retreat if less than 70. Provide a snack with protein and carb (PB crackers, fruit, or half a sandwich) UNLESS they plan to eat a meal within 30-60 minutes. Wait again for 15 minutes etc. Emergency measures: SQ glucagon 1mg or 25-50 ml of 50% dextrose IV (provides 10-25 grams of carbs) Severe hypoglycemia may cause disorientation, seizures, and loss of consciousness.

Dietary management for diabetic

Goals of diet: to restore the normal BG levels to prevent hypo/hyperglycemia, to prevent longterm complications, maintain normal body weight, and to have a meal plan based on lifestyle/cultural/ethnic backgrounds. Meal plan tips: Eat whole unprocessed foods, non-starchy veggies, limit/avoid foods with added sugars or refined grains, drink water instead of sugary drinks, low carb vegetarian or Mediterranean diet. There is no magic diet! every body responds differently to different foods. find out what works for the individual...

Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

This will be a pt with a very high glucose level but will not be in ketosis! Occurs slowly over time. Has a high mortality rate. causes osmotic diuresis with loss of water and electrolytes, will have hypernatremia and increased osmolality. increased osmolarity and very high glucose levels (sometimes over 600), altered level of consciousness - due to lack of effective insulin. Severe dehydration. Clinical Manifestations: hypotension, dehydration, tachycardia, and various CNS effects. Management: rehydrate, administer insulin, monitor fluid and electrolyte status. Prevention: monitor glucose levels, manage diabetes, assess and promote self-care management skills.

Hypervolemia

bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, hypertension, urine specific gravity <1.010.

A client with hyperthyroidism is being treated with propylthiouracil (PTU). Which instruction will the nurse include in the teaching plan regarding this medication? Select all that apply. One, some, or all responses may be correct. "Avoid abrupt discontinuation of the medication." "Monitor your weight, pulse, and mood routinely." "You can expect an immediate response to this medication." "Also take an iodine replacement to aid metabolism of the medication." "Report side effects, such as sore throat, fever, joint pain, or oral lesions."

"Avoid abrupt discontinuation of the medication." "Monitor your weight, pulse, and mood routinely." "Report side effects, such as sore throat, fever, joint pain, or oral lesions."

The nurse is teaching a 12-year-old child about the action of insulin injections. Which statement indicates the child understands how insulin works in the body?

"Glucose is carried into cells where it is used for energy." Specialized insulin receptors on insulin-sensitive cells transport glucose through cell membranes, making it available for use. Insulin does not break down fats to release glucose, prevent glucose from being stored in the liver, or convert glucose into glycogen.

Which mechanism of action explains how propylthiouracil (PTU) manages hyperthyroidism?

It decreases production of thyroid hormones. PTU is a thyroid hormone antagonist that inhibits thyroid hormone synthesis by decreasing the use of iodine in the manufacture of these hormones. PTU does not affect the vascularity of the thyroid gland. Iodine-containing agents are given for severe hyperthyroidism and before a thyroidectomy. PTU does not affect the amount of already formed thyroid hormones.

Sick day rules

Understand sick day rules Don't eliminate insulin with N/V Consume small portions of CHO Check ketones andDrink fluids every hour blood sugar every 3 or 4 hours if cannot take fluid without vomiting call Dr.

Which intervention would be included in the plan of care for a client diagnosed with hyperthyroidism?

Arrange for sufficient rest periods. Promotion of rest to reduce metabolic demands is a challenging but essential task for a client who has hyperthyroidism. With hyperthyroidism, glucose tolerance is decreased, and the client is hyperglycemic. There is no indication that radioactive iodine has been given; therefore, the client does not emit radiation. The client will have an increased appetite.

Which sign or symptom would the nurse expect to find on assessment of a client with a blood glucose level of 55 mg/dL? Select all that apply. One, some, or all responses may be correct. Increased thirst Abdominal pain Frequent urination Cold, clammy skin 3+ glucose in urinalysis

Cold, clammy skin A client with a blood glucose level of 55 mg/dL indicates hypoglycemia. Clinical manifestations would include cold, clammy skin; tachycardia; nervousness; and slurred speech. A client with hyperglycemia would present with increased thirst (polydipsia), abdominal pain, increased urination (polyuria), and polyphagia. The client with hyperglycemia would have glycosuria.

gestational diabetes

predisposing conditions: older than 35 yo, obesity, multiple gestations and a family hx of diabetes can occur during the 2nd or 3rd trimester occurs when the pancreas cannot respond to the demand of more insulin screening: women should be screened between 24-28 weeks of pregnancy. a 3hr oral glucose test is performed to confirm GDM. Typically treated by diet alone but some women might need insulin. treatment: oral hypoglycemic agents are never used during pregnancy. typically resolves at the end of pregnancy but they have an increased risk for developing type 2 interventions: increase caloric intake with adequate insulin therapy (so glucose will move into the cells), include insulin, exercise, and blood glucose determinations to maintain a BG level between 65-130. observe for signs of hyperglycemia (glucose and ketones in urine). monitor weight. assess for signs of maternal complications (such as preeclampsia; s/s: hypertension, protein in the urine, and edema). monitor for signs of infection. instruct the client to report any signs of infection. assess the fetal status and monitor for signs of fetal compromise. carefully regulate insulin and provide glucose IV as prescribed because labor depletes glycogen. observe the mother closely postpartum for hypoglycemic reaction (because drop in insulin requirements). monitor for postpartum hemorrhage

Dawn phenomenon

raise of blood sugar between 4 and 8 am that is not a response to hypoglycemia. occurs both in type I and II

causes of acidosis

respiratory acidosis: hypoventilation, resp depression from medications such as poisons, opioids, brain trauma, over-hydration, chest trauma, neuromuscular disease, airway obstruction, COPD, asthma or inadequate ventilation. metabolic acidosis: excess production of H+ ions (DKA), lactic acidosis, cardiac arrest, strenuous exercise, starvation, excessive intake of antacids, renal failure or severe lung problems, dehydration, excess elimination seen with diarrhea or in pt with ileostomies

clinical manifestations of metabolic alkalosis

restlessness, lethargy, tachycardia, hypotension, dysrhythmia, numbness of extremities and mouth, hyperreflexia, confusion, decreased LOC, dizziness, convulsions, hypokalemia, compensatory hyperventilation N/V/D.

A client is prescribed metformin extended release to control type 2 diabetes mellitus. Which statement made by this client indicates the need for further education?

"I will stop taking metformin for 24 hours before and after having a test involving dye." Metformin must be withheld for 48 hours before the use of iodinated contrast materials to prevent lactic acidosis. Metformin is restarted when kidney function has returned to normal. Metformin is taken with food to avoid adverse gastrointestinal effects. If crushed or chewed, metformin XL will be released too rapidly and may lead to hypoglycemia. Muscular and abdominal discomfort is a potential sign of lactic acidosis and must be reported to the health care provider.

After a surgical thyroidectomy a client exhibits carpopedal spasm and tremors. The client reports tingling in the fingers and around the mouth. The nurse suspects a deficiency in which mineral?

Calcium The client is exhibiting signs and symptoms of hypocalcemia, which occurs with accidental removal of the parathyroid glands; calcium gluconate is administered to treat hypocalcemia. Deficits in potassium, magnesium, and sodium do not cause these classic manifestations.

gestational diabetes mellitus

diabetes that develops during pregnancy and that usually resolves after pregnancy

early manifestations of type 2 diabetes

polyuria, polydipsia, blurred vision

early manifestations of type 1 diabetes

polyuria, polydipsia, weight loss, glycosuria, fatigue

K levels in acidosis

potassium goes up in acidosis

Ketoacidosis Summary

Can occur in any age group Type 1 DM results from excessive fat metabolism as a result of insulin deficiency (Hyperglycemia, dehydration, ketosis, acidosis, hyperkalemia) Considered medical emergency Collaborative treatment (nurse cannot treat independently) Fluid replacement (0.45% or 0.9% NaCl) IV insulin therapy

A client had a gastric bypass procedure to treat morbid obesity. After surgery, the client reports weakness, sweating, palpitations, and dizziness after eating. Which should the nurse recommend?

Divide daily caloric intake into six smaller meals. The client's clinical manifestations are related to dumping syndrome from the gastric bypass procedure. Smaller meals along with other interventions will help minimize this response. After gastric bypass, a bolus of hypertonic fluid enters the intestines before carbohydrates and electrolytes are diluted. Extracellular fluid is drawn into the bowel lumen; this causes a decrease in plasma volume, distention of the bowel lumen, and rapid intestinal transit. Protein intake should be increased, not decreased, to meet energy needs and promote healing. Fluids should be avoided at mealtimes because they increase volume in the stomach and decrease the transit time of gastric contents from the stomach to the intestine, which contributes to dumping syndrome. An upright position decreases the transit time of gastric contents moving from the stomach to the intestines via gravity, which contributes to dumping syndrome; clients may lie flat for a short time after eating.

Diabetic Ketoacidosis (DKA)

a complication of diabetes that is caused by having too little insulin; also called hyperglycemia levels are typically 300 or higher Caused by: the absence or inadequate amount of insulin (abnormal metabolism of carbs, proteins, and fats) S/S: nausea/vomiting and abdominal pain. Breath smells like juicy fruit gum. Kussmaul respirations, tachycardia, hypotension, acidosis, high blood sugar, hyperkalemia, polyuria Onset over 4-10 hours Management: rehydration (IV fluids. may need 6-10L. Initially, .9 NS, and then .45 NS... when glucose comes down the IV fluids can be replaced with D5 NS) insulin, electrolyte replacement Serum pH = low, so respirations are rapid and deep to compensate. First, assess the airway. Then administer insulin Hypokalemia is a common cause of death in DKA so prior to K administration ensure the client has a urinary output of greater than or equal to 30 ml/hr

how does the nurse recognize when an imbalance is developing or has developed?

clinical findings (subjective/objective data) and diagnostic tests (ABG, K+ shift within/out of the cell)

Insulin lispro

has an onset of 0.25 hours, a peak action of 0.5 to 1.5 hours, and a duration of 3 to 4 hours.

fluid and electrolyte balance

maintenance of the proper amounts and kinds of fluids and minerals in each compartment of the body

care plan/evaluation for diabetes

client describes: -how to administer meds, respond to side effects -strategies for reducing the risk of infection client demonstrates: -meal planning compliant with the ADA -proper foot care and inspection -proper procedure for monitoring blood sugar levels evaluation: client will demonstrate age-appropriate understanding of -self management through medication -exercise -diet -blood glucose self monitoring skin integrity will remain intact client will remain free of infection client will remain free of injury

Hypovolemia

increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety, dry mucous membranes, oliguria, orthostatic hypotension. Urine specific gravity >1.030

Hypokalemia (< 3.5)

*Etiology(causes):* gi losses, diarrhea, vomiting, suctioning, diuresis, wounds/burns, diuretics (loop), laxatives (excessive), corticosteroids and some antibiotics, a diet too low in K (rare), DKA, metabolic acidosis, and anemia. *Assessment: S/S:* fatigue, weakness (legs... early sign), numbness/paraesthesia, leg cramping, deep tendon reflexes will be decreased or absent. paralysis can involve respiratory muscles -> breakdown of muscle fibers -> myoglobulin in the urine. may develop anorexia, n/v, constipation, and cramping. *Nurse Management:* encourage a diet high in K (spinach, broccoli, green beans, tomato juice, potatoes, banana, cantaloupe, watermelon, strawberries, oranges, meat, nuts, seeds, avocados, milk, raisins, whole grains. monitor serum K levels for pt taking loop or thiazide diuretics. protect pt from injury. maintain a safe environment.

hyperphosphatemia (>4.5)

*Etiology(causes):* major cause is ARF. increased intake of foods high in P. excessive use of laxatives/enemas (fleet), increased intake of vitamin D, chemo for certain cancers. *Assessment: S/S:* tetany, twitching of muscles (hands and feet), tingling, numbness, cramps, nervousness, irritability, apprehension, anorexia, n/v, tachycardia, dysrhythmias *Nurse Management:* decreased foods high in P (foods low in P are fruits and veggies) avoid laxatives/enemas, assess for constipation, assess for tetany. MEDS: sevelamer and amphojel *remember: increased P, decreased Ca*

Hypomagnesesmia (< 1.5)

*Etiology(causes):* malabsorption disorders (IBS, bowel resection, bariatric surgery), alcoholism, medications (diuretics, chemo drugs), metabolic acidosis. *Assessment: S/S:* altered LOC, confusion, irritability, insomnia, delusions, muscular wx, excitability, tremors, twitching, hyperactive DTRs, EKG changes, n/v, anorexia, dysphasia, halos around lights, yellow-tinged vision. if on Dig. low Mg may cause retention of Dig. *Nurse Management:* increase fluid intake, replace Mg (PO or Mag Sulfate IV) NEVER as an IV push! assess for decreased patellar reflex, increased BP, assess for rep difficulty, encourage intake of Mg-rich foods (chocolate, dried beans/peas, green leafy veggies, whole grains, nuts, seafood, and meats.)

Hypermagnesemia (> 2.5)

*Etiology(causes):* renal failure, diabetes, leukemia, ingestion of large amounts of Mg (TUMS, MAALOX) *Assessment: S/S:* muscle weakness, diaphoresis, hypotension, decreased HR, DTR, and LOC. flushing. *Nurse Management:* if severe treat with IV calcium gluconate. mechanical ventilation to relieve rep. depression. Diuretics as ordered (if normal renal function). if caused by a med... D/C med that caused... dialysis if RF caused the issue. Assess mental status and reflexes, report absent STRs, I/Os. ECG monitor.

Hyponatremia (<135)

*Etiology(causes):* vomiting, diarrhea, suctioning (GI losses), tap water enemas, GI surgery, bulimia, perspiration, burns, diuretics, and excess fluid intake. *Assessment: S/S:* irritability, altered level of consciousness, lethargy, headache, muscle twitching, weakness, fatigue, seizures, coma, weight loss, N/V. *Nurse Management:* encouraging the intake of high sodium foods (ham, bacon, pickles, potato chips, anchovies, cheese...) IV: 0.45% NS, D5 NS. implement fluid restrictions, monitor weight, strict I/Os, protect pt from injury, provide a safe environment, monitor LOC, BP, HR, and orthostatic hypotension. intravascular overload: tachypnea, tachycardia, SOB.

hypernatremia (>145)

*Etiology(causes):* water loss, inadequate water intake, sodium gain. increased risk in infants and immobile clients (those who cannot drink voluntarily) M.O.D.E.L. medications, osmotic diuretics, diabetes, excess water loss, low water intake -> leading to dehydration *Assessment: S/S:* "You're FIRED" fever and increased fluid retention (and increased BP), restlessness, edema, decreased urinary output -skin flushed, agitation, low-grade fever, thirst *Nurse Management:* correct SLOWLY! decrease Na intake, educate pt to read food labels and avoid Na... IV: D5W will dilute serum sodium. 0.45% NS. encourage fluid intake, tachycardia, increased temp (>101) maintain a safe environment. increased BP indicates fluid overload and decreased BP indicates a fluid deficit.

Loop Diuretics

Furosemide (Lasix), Bumetanide (Bumex). Action: bind reversibly to a Cl channel receptor site in the ascending limb of the loop of henle, inhibiting the reabsorption of filtered sodium and chloride Side effects: hypovolemia, ototoxicity, hypokalemia, hyponatremia, hyperglycemia, *digoxin toxicity*, lithium toxicity, increased urine volume, orthostatic hypotension, dizziness, diarrhea, headache, GI upset, and electrolyte problems. blurred vision and photosensitivity. Can cause hearing loss if IV push is administered too quickly. Implications: Increase intake of foods high in protein. This is the diuretic of choice for those that have renal disease

Thiazide diuretics

Hydrochlorothiazide (HCTZ, Hydrodiuril) Action: works on the distal convoluted tubule to promote K, Na, Cl, Mg, water secretion. Also act on arterioles causing vasoconstriction. They CAN affect glucose tolerance which would result in higher blood sugar results in clients that are non-diabetic. SE: dizziness, headache, constipation, skin rash Implications: important to use in clients with NORMAL renal function Can enhance digoxin! *not effective in IMMEDIATE diuresis

interpretation of ABG

Normal: pH 7.35, PaCO2 35-45, HCO3 22-26 Resp. acidosis: low pH, high PaCO2, normal HCO3 Resp. alkalosis: high pH, low PaCO2, normal HCO2 Metabolic acidosis: low pH, normal PaCO2, low HCO3 Metabolic alkalosis: high pH, normal PaCO2, high HCO3

The nurse is caring for a client who is scheduled for gastric bypass to treat morbid obesity. To minimize clinical manifestations of dumping syndrome, the client will be placed on which type of dietary plan?

Small, frequent feeding schedule Small feedings reduce the amount of bulk passing into the jejunum and reduce the fluid that shifts into the jejunum. Although a diet high in roughage may be avoided, a low-residue, bland diet is not necessary. Total fluid intake does not have to be restricted; however, fluids should not be taken immediately before, during, or after a meal because they promote rapid stomach emptying. Concentrated sweets pass rapidly out of the stomach and increase fluid shifts; the diet should be low in carbohydrates. Relatively high protein is needed to promote tissue repair.

Potassium sparing diuretics

Spironolactone (Aldactone) Action: Direct effect on distal tubule of the kidney (you won't lose K like the other categories) SE: HIGH risk for hyperkalemia, dehydration, menstrual irregularities, impotence in men, fatigue, headache, imbalance, GI disturbance Implications: instruct intake of K rich foods. Report cramps, weakness, fatigue, nausea. *fun fact: in dermatology, spironolactone is used for pimple breakouts

The nurse has 100 units regular insulin in 100-mL normal saline for infusion. There is a prescription to calculate the infusion rate based on the client's glucose levels using the formula: Glucose mg/dL ÷ 100 = __ units/h. The client's glucose level is 350 mg/dL. The insulin will need to infuse at how many milliliters per hour?

The client's glucose = 350 mg/dL. 350 ÷ 100 = 3.5 units/h. The pharmacy dispensed 100 units regular insulin in 100 mL normal saline. 100/100 = 1:1 ratio. Therefore 3.5 units/hour = 3.5 mL/h.

Which finding in a client with hypothyroidism and hypertension who reports taking an extra dose of levothyroxine indicates the need to obtain a thyroid function panel? Select all that apply. One, some, or all responses may be correct. Tremors Diaphoresis Nervousness Temperature 101°F Heart rate 116 beats/min

Tremors, Diaphoresis, Nervousness, Temperature 101°F, Heart rate 116 beats/min Clients with hypothyroidism can develop thyrotoxicosis from an acute overdose of thyroid hormone. Tremors, diaphoresis, and nervousness are all signs of thyrotoxicosis. Clients may also be hyperthermic and tachycardic.

what medical conditions place individuals at risk for acid base imbalances?

asthma, pneumonia, pulmonary edema, pulmonary embolism renal failure, liver failure and pancreatitis -infants/children -adults/elderly

An adolescent with type 1 diabetes mellitus is admitted to the intensive care unit in ketoacidosis with a blood glucose level of 170 mg/dL (9.4 mmol/L). A continuous insulin infusion is started. Which adverse reaction to the infusion is *most* important for the nurse to monitor?

hypokalemia Insulin moves potassium into the cells along with glucose, thus lowering the serum potassium level. Insulin does not lead to a reduced blood volume. Insulin does not directly alter the sodium levels. Insulin does not affect the calcium levels.

nursing diagnoses for diabetes

deficient knowledge sexual dysfunction ineffective coping risk for impaired skin integrity risk for infection risk for injury risk for deficient fluid volume

acid-base balance

equilibrium between acid and base concentrations in the body fluids normal cell function depends on H+ ions concentration to be kept in a narrow range normal pH is 7.35-7.45 acid: releases H+ ions base: accepts H+ ions chemical buffers will act in seconds to keep pH in a narrow range. ABGs are most often used to monitor acid-base balance.

A client is diagnosed with hyperthyroidism and is treated with I-131. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms would be included in the teaching? Select all that apply. One, some, or all responses may be correct. Fatigue Dry skin Insomnia Intolerance to heat Progressive weight gain

fatigue, dry skin, progressive weight gain Fatigue is caused by a decreased metabolic rate associated with hypothyroidism. Dry skin most likely is caused by decreased glandular function associated with hypothyroidism. Progressive weight gain is associated with hypothyroidism in response to a decrease in the metabolic rate because of insufficient thyroid hormone. Insomnia is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone. Intolerance to heat is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone.

Regular insulin

has an onset of 0.5 hours, a peak action of 1 to 5 hours, and a duration of 6 to 10 hours.

Neutral protamine Hagedorn (NPH) or intermediate-acting insulin

has an onset of 1.5 hours, a peak action of 4 to 12 hours, and a duration of 18 to 24 hours.

Exercise Guide for Diabetic Fitness (FIT)

helps lower glucose helps rate reduction decreases BP and stress improves circulation increases HDL (good cholesterol) insulin decreases with exercise. clients on insulin should eat a 15g carb snack prior to workout to prevent hypoglycemia. need to monitor glucose level closely. Recommended types of exercise: aerobic exercise is encouraged (walking or jogging, biking, swimming, skiing and dancing) Recommended frequency: 3-4 times a week for 40-60 minutes at the same time of day. Avoid exercise at the insulin peak! (when glucose will be the lowest) Avoid exercise in extreme hot and cold Avoid is BG is above 250 or ketones in urine Do's and Don'ts: carry a snack, wear an ID bracelet, carry emergency cash, monitor glucose before during and after, exercise with someone else, do not inject insulin into the part exercised, don't exercise before meals and don't drink alcohol before during exercise.

long term complications of diabetes

macrovascular disease -accelerated atherosclerotic changes -coronary artery disease, cerebrovascular disease, peripheral vascular disease microvascular disease -diabetic retinopathy and nephropathy neuropathic changes -peripheral neuropathy, autonomic neuropathies, hypoglycemic unawareness, sudomotor neuropathy, and sexual dysfunction (gastroparesis, can occur in diabetics, characterized by nausea, vomiting, and abdominal distension)

Diuretics

purpose: decrease hypertension SBP>130, decrease edema effects: increased urine flow (diuresis), natriuresis (sodium loss in the urine), loss of other electrolytes (K, Mg, Ca...)

causes of alkalosis

respiratory alkalosis: hyperventilation due to fear, anxiety and intracerebral trauma, overdose of aspirin, hypoxemia, high altitudes, shock or early-stage pneumonia, fever metabolic alkalosis: oral ingestion of bases, losing gastric secretions through vomiting or suction, increase dig toxicity