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adult test #2 blueprint questions

Terms in this set (73)

Insulin deficiency causes:
- When insufficient insulin, glucose cannot be properly used for energy→ body breaks down fat as secondary source of fuel
-Ketones: acidic by-products of fat metabolism
- Alter pH balance→ metabolic acidosis
-Ketonuria
-Electrolytes become depleted as cations are eliminated along with anionic ketones in an attempt to maintain electrical neutrality
-Insulin deficiency impairs protein synthesis→excessive protein degradation→ nitrogen losses from tissues
-Insulin deficiency stimulates production of glucose from amino acids (proteins) in the liver→ further hyperglycemia


If Left untreated:
- Leads to severe depletion of sodium, potassium, chloride, magnesium, phosphate
- Vomiting caused by acidosis→ more fluid and electrolyte loss
-Eventually hypovolemia→ shock will occur→ renal failure→ comatose as result of dehydration, electrolyte imbalance, acidosis→ death


Clinical Manifestations:

-s/s of dehydration-->Poor skin turgor, dry mucous membranes, tachycardia, orthosttic hypotension

-Early symptoms: Lethargy, weakness, Abdominal pain with anorexia and vomiting

-Later on: Kussmaul respirations (Rapid, deep breathing associated with dyspnea= body's attempt to reverse metabolic acidosis through exhalation of excess CO2; Acetone is noted on breath as fruity/sweet)

Lab findings:
-Blood glucose> 250
-Arterial blood pH less than 7.30
-Serum bicarb levels less than 15
- Moderate to large Ketones in urine or blood Ketones


Treatment:
-Hospitalization not always required

-Initial interventions:
1.Ensure Patient airway and admin O2

2. Establish IV access with large-bore catheter to begin fluid and electrolyte replacement

3. Typical infusion: 0.45% or 0.9% NaCl at a rate to restore urine output to 30-60 mL/hr and to raise blood pressure--> When blood glucose approach 250, 5% dextrose is added to prevent hypoglycemia

4. Regular Insulin withheld until fulid resuscitation and K is 3.5 or higher; Started at 0.1 unit/kg/hr by continuous infusion. If glucose lowered too quickly→ cerebral edema; Blood glucose reduction of 36-54 mg/dL/hr is ideal; To decrease glucose in blood and send it to starving cell= Ketones are decreased (b/c not needed anymore)

Potential treatment problems
-Incorrect fluid replacement can cause sudden fall in serum sodium→ cerebral edema
-Monitor fluid overload in pt with renal or cardiac problems
-Obtain serum potassium level BEFORE insulin started (if hypokalemic, insulin admin causes further decrease in K levels)
-Early K replacement=essential b/c hypokalemia cause of unnecessary and avoidable death during DKA treatment
-Monitor continuously b/c insulin drives K into cells= hypokalemia
-Rapid insulin infusion allows for water and potassium to enter cell along with glucose and can lead to depletion of vascular volume (hypovolemia) and hypokalemia
-Cardiac problems
-ECG reflects K levels and cardiac response
-Hypovolemic shock (check skin), tachycardia
-Assess blood glucose and urine tests (ketones)
-Risk of thrombosis (due to severe hyperosmolarity), subQ heparin doses (5000 units q8h prophylactic)

***once DKA is treated, determine the cause of the pt DKA because infection is most common
Pathophysiology:
-Extreme hyperglycemia
-Severe osmotic diuresis
-Fluid volume deficit
-Decreased Na+, K+, phosphorus
-Electrolyte imbalance
-Profound dehydration
-Hyperosmolality
-Hypovolemia
-Decreased renal perfusion-> Oliguria, Anuria
-Hypotension-->Tissue anoxia, Increased lactic acid
-Hemoconcentration-> Hyperviscosity, Thrombosis
-All leads to seizures, shock, coma, death

-Occurs in patients with diabetes who are able to produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis and extracellular fluid depletion

-Less common than DKA, often in patients over 60 with Type 2 DM

Common causes
-Infection: UTI, pneumonia
-Sepsis
-Any acute illness
-Newly diagnosed type 2 DM
-Often related to impaired thirst sensation and/or functional inability to replace fluids

Similar to DKA but has distinct differences in clinical manifestations:
-Presents fewer earlier symptoms due to some pancreas function
-Then boom→ very severe hyperglycemia
-More severe neuro symptoms (somnolence, coma, seizures, hemiparesis: weakness in one side of body, aphasia: trouble speaking and understanding written and verbal language)
-*Symptoms resemble a stroke (cerebrovascular accident) so immediate determination of glucose level is critical for correct diagnosis and treatment
-The hyperosmolality calls for major fluid replacement
-BG may be 600 mg/dL

Lab values
-Blood glucose > 600
-Marked increase in serum osmolarity
-Ketone bodies are absent or minimal in both blood and urine

Treatment
-Similar to DKA
1. Immediate IV fluids of NS or ½ NS
2. Then regular insulin by infusion after fluid replacement
3. Then switch to D5W when glucose levels around 250 mg to avoid hypoglycemia
-Pre surgery, to alleviate risk of thyrotoxicosis, iodine treatment, PTU, and beta blockers may be used (gets the patient to a euthyroid state)

Iodine is mixed with water/juice and admin after meals...use straw
-Assess pt for s/s of iodine toxicity: Swelling of buccal mucosa/ other mucous membraines
Excessive salivation...decrease nerves
N&V
Skin reactions
If toxicity occurs, iodine admin should be discontinued and MD notified
-oxygen therapy: ECG-->watch for arythmias
-provide calm, darker, environment
-change sheets frequently
-encourage exercise to release nerves
-keep HOB elevated for enlarged eyes

Teach pt about comfort and safety measures:
-Coughing and deep breathing
-Leg exercises
-Support head manually while turning in bed (minimizes stress on suture line after surgery)
-ROM exercises on neck practiced

Explain routine post op care like IV infusions

Tell pt that talking is likely difficult after surgery for short time..hoarseness is normal 3-4 days postop

at bedside have O2, suction, and trach tray

post op, decrease caloric intake, avoid hot weather, get regular exercise, monitor hormone balance

Airway complications
-Recurrent laryngeal nerve damage→ vocal cord paralysis→ if both cords then spastic airway obstruction will occur= require immediate tracheostomy
-Other causes of labored respirations: excess edema of neck, hemorrhage, hematoma formation, laryngeal stridor (harsh, vibratory sound that occurs on inspiration and expiration as a result of edema on laryngeal nerve)
-laryngal stridor may be treated with calcium (caused from damage to the parathyroid gland)

Rationale for all post op priority care
-Assess pt every 2 hr for 24 hours for s/s hemorrhage, tracheal compression (irregular breathing, neck swelling, frequent swallowing, sensations of fullness at incision site, choking, blood on anterior or posterior dressings)
-Pt in semi-fowlers position and support pt head with pillows, avoid flexion of neck and any tension on suture lines
-Monitor vitals (Trousseau's sign and chvostek's sign should be monitored for 72 hours)
-Expect some hoarseness for 3-4 days post op
-Control post op pain
-there is a risk of post op thyroid storm bc the vitals are all out of whack..high temp, heart failure, heart attack, shock
-decrease caloric intake to decrease risk of hypothyroidism (risk will go away with hyperplasia and hormone replacement therapy)
-some iodine (seafood 1-2x per week; normal salt)

Discharge instructions:
-monitor hormone balances periodically
-decrease caloric intake
-regular exercise
-avoid heat
-radioactive iodine therapy on outpt basis
-regular followup care
-lifelong thyroid replacement instruction (after complete thyroidectomy)
-monitor for signs and symptoms of thyroid failure

what is carpal spasm (trousseau's sign)?
-twitching fingers

why does it occur?
-sign of tetany (damage or inadvertent removal or parathyroid glands)

what are the nursing interventions for this occurrence?
-IV calcium salts like calcium gluconate or gluceptate should be available
Caused by an excess of corticosteroids particularly glucocorticoids which regulare metabolism, increase blood glucose levels and serve critical role in the physiologic stress response

more common in women aged 20-40

causes:
-ACTH (adrenocorticotropic Hormone)-secreting ectopic tissue (with lung cancer)
- pituitary tumor
- adrenal tumors
-meds

goal of care: normalize hormone secretion. Sometimes this is not possible bc of the patients need for exogenous steroid meds

leg exercises and ambulation are very important because of the risk for clotting

Clinical manifestations
-Weight gain
-Hyperglycemia; Associated with Cortisol-induced insulin resistance
-Protein/muscle wasting; Caused by catabolic effects of Cortisol on peripheral tissue
-Osteoporosis; From loss of protein matrix in bone; Leads to bone and back pain as well
-Loss of collagen makes skin weaker and thinner= easily bruised
-Catabolic processes predominate= delayed wound healing
-Mood disturbances (irritability, anxiety, euphoria), insomnia, irrationality, psychosis may occur
-Hypertension; From mineralcorticoid excess (secondary to fluid retention)
-Adrenal androgen excess; Severe acne in women; Feminization in men
-Menstrual disorders and hirsutism in women, Gynecomastia and impotence in men
-risk for infection
-imbalanced nutrition
-disturbed self esteem
-impaired skin integrity

First indications
-Centripetal (truncal) obesity or generalized obesity
- Moon facies (fullness of face)
- Purplish red striae (usually depressed below skin surface on abdomen, breast, or buttocks)
-Hirsutism in women
-Menstrual disorders in women
-Hypertension
-Unexplained hypokalemia

Tx depends on the cause
-drug therapy
-tumor removal or radiation for pituitary adenoma
Glucocorticoids:
-reduce inflammation, elevates Bp, and elevates blood glucose for energy during stress
-are used for arthritis, allergic responses, transplants, autoimmune conditions, anti-lymphocytic (cancer treatment)
-palliative not curative
-abrupt withdrawal can be life threatening

Mineralocorticoids:
-aldosterone
-regulate Na+ and K+ balance

Androgens:
-stimulate growth and development of sexual features in both genders

absence of these chemicals can lead to cardiovascular collapse

patient care needs/teaching for med administration during times of increased stress:
Dosing:
-Glucocorticoids given in divided doses, 2/3 in morning, 1/3 in afternoon
-Mineralocorticoids given once daily, usually AM
-Dosage schedule reflects normal circadian rhythm in endogenous hormone secretion= DC side effects of hormone replacement therapy
-With increased stress= increased dose required
-Doses doubled for minor stress (Resp infection, dental work)
-Tripled for major stress (Divorce, loss of parent)
-When in doubt, better to err on side of overreplacement
-plan diet high in protein, calcium, and potassium, and low in fat and simple CHOs
-regular schedule of sleep, rest, and exercise
-recognize edema and restrict sodium with edema
-monitor glucose and report hyperglycemia
-notify physician on PUD symptoms
-annual eye exam for cataracts
-safety measures to avoid injury
-avoid sick people and have good hygiene

If vomiting and diarrhea occur (like with flu), electrolyte replacement therapy is necessary

Teach pt s/s of steroid deficiency and excess (Cushings syndrome)

Pt should wear med alert bracelet and carry wallet card

Certain meds may require increased dose (Phenytoin, barbiturates, rifampin, antacids; Estrogen inhibits steroid metabolism)

Pt should carry emergency kit at all times with 100 mg of IM hydrocortisone, syringes, instructions for use