Term | Definition |
Complications of DM (Pg. 927)
1. DKA.. what is it? onset? | Diabetic ketoacidosis: acute, life threatening hyperglycemia
-Rapid onset |
DKA hyperglycemia > ___
& resulting in .. | >300
Breakdown of body fat for energy; accumulation of ketones in the blood & urine |
2. HHS | Hyperglycemic-hyperosmolar state; acute, life-threatening profound hyperglycemia
-Generally occurs gradually over several days |
HHS hyperglycemia > ___ | >600
Hyperosmolarity that leads to dehydration, & an absence of ketones
-can lead to coma & death
-alteration in the sense of awareness; caused by insulin resistance = loss of fluids & lytes |
DKA risk factors;
type __ DM
insulin needs
carbs | Type 1 DM
Missed or reduced dose of insulin
Any condition that increases carb metabolism; physical/emotional stress, illness/infection (#1 cause), surgery/trauma |
Why does infection/stress/trauma etc. create a decreased effect of insulin? | BC increased hormone production occurs; (cortisol, epi/norepi, glucagon) & stimulates liver to produce glucose |
HHS risk factors; | -Residual insulin secretion; enough to prevent production of ketones but not keep glucose down
-Type 2 dm
-poor kidney function; can't excrete glucose into urine
-Infection/stress |
HHS; older adults w/ poor fluid intake become ___ & experience ____ d/t high BG | Dehydrated
osmotic diuresis |
Which meds could lead to HHS? | Glucocorticoids, diuretics, phenytoin (Dilantin), Propranolol (Inderal), & CCB |
S/S (listed and say whether its DKA, HHS, or both) Pg. 928
1. Polyuria | DKA & HHS (osmotic diuresis causing excess fluid loss) |
2. Polydipsia | DKA & HHS (osmotic diuresis causing excess fluid loss causing increased thirst) |
3. Polyphagia | DKA |
4. Wt Loss | DKA |
5. GI effects (Nausea, vomit, abdominal pain) | DKA (increased ketones & acidosis lead to this) |
6. Blurred vision, headache, weakness | DKA & HHS (fluid volume depletion caused by osmotic diuresis = dehydration) |
7. Orthostatic hypotension | DKA & HHS (dehydration) |
8. Fruity odor of breath | DKA (elevated ketone bodies (small fatty acids) used for energy that collect in the blood, which leads to metabolic acidosis) |
9. Kussmaul respirations | DKA (deep rapid respirations in attempt to excrete CO2 when in metabolic acidosis) |
10. Metabolic acidosis | DKA (caused by breakdown of stored glucose, protein, & fat to produce ketone bodies) |
11. Mental status changes | DKA & HHS (alert, sleepy or comatose) |
12. Seizures, myoclonic jerking | HHS (related to serum osmolarity > 350) |
13. Reversible paralysis | HHS (r/t to high serum osmolarity) |
Lab tests (Pg. 929) DKA & HHS
1. Serum glucose | DKA: >300
HHS: >600 |
2. Serum lytes
-sodium & potassium | DKA: Na+ ^ d/t water loss, K+ initial decrease d/t diuresis, may ^ d/t acidosis
HHS: Na+ ^ d/t water loss, K+ initial decrease d/t diuresis |
3. Serum renal studies
BUN & creatinine | DKA & HHS; ^ d/t dehydration
BUN; >30
Creat; >1.5 |
Normal BUN & creatinine | BUN: 10-20
Creatinine: .5-1.1 |
4. Ketones
-serum & urine | DKA: present in both
HHS: absent in both |
5. Serum osmolarity | DKA: high
HHS: >320 |
6. Serum pH (ABG) | DKA: <7.3 d.t metabolic acidosis (respiratory compensation/kussmaul)
HHS; normal PH >7.4 |
Nursing care:
Fluids start & follow w/ | Rapid isotonic (0.9% NS) replacement (monitor for FVE)
Follow with: hypotonic fluid (0.45% NS) |
Nursing care con't:
When serum glucose levels get down to 250... | Add glucose to IV fluids;
-Minimizes risk of cerebral edema d/t drastic changes in serum osmolarity & prevent hypoglycemia |
Nursing care con't again:
Insulin | Administer regular insulin (Humulin R) 0.1 unit/kg as an IV bolus dose & then follow w a con't IV infusion of regular insulin at 0.1 unit/kg/hr |
Why is IV regular insulin administered? | 4 minute half life
-avoiding delay of onset |
What is the goal of BG & how often should it be monitored? | <200 & monitor hourly |
Nursing care:
Potassium | Initially increased w insulin then will decrease into the cells; monitor for hypokalemia
-k+ replacement therapy in IV fluids
-make sure urinary output is ok before giving k+ |
Nursing care for severe acidosis: | Administer sodium bicarbonate by slow IV infusion for slow acidosis
(pH <7.0) |
Client education; | Medical alert bracelets encouraged
Hydrate; at least 3L water/day
-glucose q4h when ill
-carbs/lyte sport drinks when unable to eat food |