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medsurg exam 2
acute complications of diabetes
| Question | Answer |
|---|---|
| acute complications of diabetes | Hypoglycemia Hyperglycemia |
| hyperglycemia | Diabetic Ketoacidosis (DKA) Hyperosmolar Hyperglycemia State (HHS) aka Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) |
| hypoglycemia BS level | less than 70 |
| hypoglycemia is caused by | an excess of insulin or a lack of glucose available in the bloodstream |
| hypoglycemia symptoms | confusion, irritability, tremors, headache, weak, hungry |
| hypoglycemia symptoms can mimic | stroke and alcohol intoxication |
| hypoglycemia is | Abnormally low blood glucose levels |
| hypoglycemia shows | Adrenergic symptoms when below 70mg/dL CNS symptoms when below 50mg/dL brain cell death symptoms when below 20mg/dL |
| hypoglycemia Adrenergic symptoms are | nervousness, decreased glucagon, sweat, tremor, hunger, tachy, palps |
| hypoglycemia CNS symptoms are | brain failure: headache, confusion, memory lapses, slurred speech, numbness of lips and tongue, double vision, inability to concentrate, irrational behavior, seizures, drowsiness |
| hypoglycemia brain cell death symptoms are | seizures, coma, death |
| hypoglycemia treatment | rule of 15 |
| rule of 15 | Give 15 gm of fast-acting, concentrated carbohydrate and then retest blood glucose in 15 minutes |
| options for 15mg of carbs | 3 or 4 glucose tablets and if out then: 4–6 ounces of juice or regular soda (not diet soda) 6–10 hard candies 2–3 teaspoons of honey |
| what juice should you not give | OJ because increases K which is bad for kidneys |
| Retest blood glucose in 15 minutes and repeat if | < 70 mg/dL or if symptoms persist more than 10–15 minutes and testing is not possible |
| use hypoglycemic protocol when | pts have severe hypoglycemia BG<70 with decreased level of consciousness |
| pts who have severe hypoglycemia BG<70 with decreased level of consciousness are at risk for | aspiration |
| give pts have severe hypoglycemia BG<70 with decreased level of consciousness | 1 amp D50 IV push |
| 1 amp D50 IV push | pre packaged, hard to push make sure they have a good IV because you don't want to infiltrate because can cause necrosis |
| glucagon is for patients with severe hypoglycemia, decreased level of consciousness and aspiration risk who | do NOT have IV access |
| glucagon emergency kit | 1 mg powdered glucagon/sterile water |
| glucagon preparation | Reconstitute and give IM |
| glucagon administration | Adults and children over 44 lbs (20kg) receive full syringe; children under 44 lbs receive ½ syringe (0.5mg) |
| glucagon half life | Short half life (8-18 minutes) |
| glucagon often causes | n/v |
| after administration of glucagon | have pt lie on side to avoid aspiration |
| hyperglycemia types | DKA or HHS |
| hyperglycemia focused nursing assessment | Airway, breathing, and circulation (ABC) status Mental status Possible precipitating events (e.g., source of infection, myocardial infarction) Volume and electrolyte status |
| diabetic ketoacidosis is | Diabetic acidosis / Diabetic coma |
| cause of DKA | deficiency of insulin |
| causes of deficiency of insulin | Hyperglycemia Ketogenesis Metabolic acidosis + anion gap Dehydration - polyuria |
| DKA is | fatal if not treated |
| 25% of | new DM present with DKA, usually T1DM |
| DKA can develop in | less than 24 hrs |
| DKA plasma glucose | >250 to 800 mg/dl |
| DKA signs and symptoms | 3Ps Kussmaul’s resps N/v>50% Abd Pain 30% Coffee-ground emesis (hemorrhagic gastritis) 25% Fruity breath (acetone) Fever: infection Dehydration: 10% dry mucous membranes, tachy Consciousness ranges from alert to confused to a comatose state 20% |
| standard labs in DKA | Plasma glucose Electrolytes, BUN,Creatinine Effective serum osmolality Phosphorous Beta-hydroxybutyrate (serum acetone) Urinalysis by dipstick Arterial blood gas or venous pH CBC and differential EKG |
| electoylytes | insulin therapy will decrease serum K so monitor that |
| Beta-hydroxybutyrate (serum acetone) | 0.4-0.5 mMol/L, if >1 it is indicative of DKA |
| as indicated labs in DKA | Blood, urine, throat cultures CXR (pneumonia or HF) Magnesium (cardiac arrhythmias, alcohol, diuretics) A1C level – to determine if hyperglycemic episode is acute or chronic |
| BG confirmations of DKA | > 250 mg/dL (usually higher) |
| CO2 confirmations of DKA | <15 |
| anion gap confirmations of DKA | elevated (normal is 12 + 4 depending on specific analyzer utilized) |
| serum and urine ketones confirmations of DKA | positive |
| arterial and venous pH confirmations of DKA | <7.3 |
| Β hydroxybuterate confirmations of DKA | > 1 mmol/L (or + serum acetone) |
| Hyperosmolar Hyperglycemia State (HHS) is | Life threatening; high mortality rate |
| in a pt with HHS, | Pt is able to produce enough insulin to prevent DKA |
| HHS: Severe hyperglycemia | (BG >600 mg/dL) Without acidosis or elevated anion gap |
| HHS can cause | osmotic diuresis and extracellular fluid depletion |
| what types of diabetics will go into HHS | T2D because they have enough insulin to not go into DKA |
| HHS is usually triggered by | a comorbid event |
| treatment of HHS is | similar to DKA |
| HHS: caution | central pontine myelinolysis if treated too rapidly, so bring down slowly |
| signs and symptoms of HHS | 3 “p’s” Hypotension, profound dehydration, tachycardia Negative urine and serum ketones despite severe hyperglycemia Fever (usually > 38C)- Skin is hot but you do not sweat Cerebral dehydration with variable symptoms |
| Cerebral dehydration: variable symptoms | headache, confusion, possible hallucinations, paralysis/weakness on one side, stimulants, inability to speak properly |
| HHS triggers | Infection Renal Disorders MI Medications Excessive alcohol intake which leads to polyuria & dehydration Chronic illness Bleeding ulcer Too little insulin or oral anti-diabetic agents. Recent surgery |
| medications that trigger HHS | diuretics, steroids or beta blockers |
| HHS lab values: serum osmolality | >320 mOsm/kg |
| HHS lab values: plasma glucose level | >600 mg/dL |
| HHS lab values: elevated serum sodium levels | show intense dehydration |
| HHS lab values: any ketoacidosis? | no |
| HHS lab values: arterial pH | >7.3 |
| HHS lab values: HCO3 | >15 mEq/L |
| immediate care of DKA and HHS | IV hydration (0.9% NaCl or 0.45% NaCl) IV insulin infusion Cardio-pulmonary support Correct electrolyte imbalance |
| different tests for caring of a pt with DKA or HHS | Tests for glucose every hour until pt is stable Serum electrolytes every 1-2 hrs until pt is stable, then every 4-6 hrs Venous pH (for DKA) every 2-4 hrs |
| continued care of pt with DKA and HHS | monitor the following: Vital signs Level of Consciousness Cardiac rhythm O2 saturation Intake and output (foley catheter)– important! |
| transition from IV to | subcutaneous insulin when stable |
| euglycemia DKA risk factors | infection, surgery, fasting, alcohol intake, acute vascular events, trauma, prolonged physical activity or exercise |
| prevention of DKA and HHS | Diabetic education Sick-day management Home monitoring of BG and ketones Reducing insulin when pts arent eating Digestible liquid diets when sick Guidelines for when pts should seek attention Supplemental short-acting insulin regimens |
| somogyi phenomenon | Rebound hyperglycemia |
| somogyi phenomenon: low blood glucose at night (around 3:00-4:00 AM) results in release of | Epinephrine, cortisol, glucagon and growth hormone liver releases glucose |
| in somogyi phenomenon, BG rebounds | resulting in hyperglycemia in AM |
| symptoms of somogyi phenomenon | High levels of blood glucose when waking up in the morning Low glucose in the middle of the night Headache upon wakening Night sweats Blurred vision Confusion Fatigue |
| treatment of somogyi phenomenon | preventing the drop |
| dawn phenomenon is | Elevated glucose in the morning |
| dawn phenomenon is due to | surge of cortisol, epinephrine, glucagon, growth hormones the body produces in early morning liver releases glucose |
| dawn phenomenon is normal occurrence for anyone but | People with diabetes because they do not have normal insulin response to adjust and fasting blood glucose is elevated |
Created by:
leh195