Homework:
read CCN article on EBP and summarize it. Not due until May 12th. Can work in
groups of 2 or 3.
Case Study
1: 79 yo w/ colitis. in pain, given MS contin, then fentanyl, reports of agitation. Can't
wake her up, cries "Shark!" Not sure if she's in pain, delerious. Low LO, resp of 45-60
deep tachypneic for like 2 hrs. Got ABG:
7.53
15
88
95%
15
Why is she having tachypnea? She's in resp alkalosis. Why the bicarb--the renal system
takes too long to adjust...it wouldn't be the bicarb first because her respirations are way
OVER compensating. Did she have a stroke in her pons that's causing these respirations.
Turns out she came in w/ low bicarb.
What next?
Margi gave her a little dilaudid, she woke up all better and said she had the worst dream
about a shark. Staying on top of her pain worked out well.
Her withdrawal looked like a downer rather than an agitated, aggressive upper.
2:
ALTERED GLUCOSE METABOLISM
Objectives: Upon completion of this class, the student will be able to:
1. Differentiate between type 1 and type 2 diabetes mellitus;
2. Discuss the pathophysiology, clinical manifestations, and nursing management
of diabetic ketoacidosis and hyperglycemic hyperosmolar state;
3. Describe pharmacological management of type 1 & 2 diabetes;
4. Discuss patient education regarding complications of diabetes;
5. Discuss the influences of selected body systems on renal function;
6. Identify the categories of acute renal failure;
7. Discuss assessment and management of acute renal failure.
Case Scenarios
1. Your patient is a 68 yo woman with ESRD. She is admitted with sudden SOB
and severe edema LUE where her access is located. Assessment findings are crackles
½ up both bases, DOE, BP 178/110, HR 82, SR with occ. PVC. What other
assessment is indicated? What intervention is indicated and why?
2. Your patient is a 78 yo female with ESRD, peritonitis, and atrial fibrillation.
She is lethargic. Why?
3. You are caring for a 14 yo admitted with DKA. Her ED BS was 1440. What
other assessment is indicated? What intervention is a priority? What education is
indicated before discharge?
4. Your patient is NPO for laparoscopic cholecystectomy in 3 hours. She is DM
Type 2 and is complaining of feeling hypoglycemic. She is shakey and slightly
diaphoretic. What do you do?
DM 1: no insulin forever amen. Oral agents will never work for DM-1.
DKA:
onset
type 1
high BS, 2ndary to low insulin
hi BS makes osmotic diuretic so peeing out fluid
cells starving--> low LOC and fatigue
b/c starving burn fats and get keytones built up -->acidosis
fruity breath
to compensate for acid, kussmaul [irregular rapid shallow breathing]
electrolyte shift: dehyd, hypotensive, more hydrogen in blood from acidosis, the
potassium runs into the cells and out of the blood, so low serum high intracellular. This
Assess:
BS: 1440
VS: expect low BP, tach,
ABG: pH
Electrolytes, esp potassium.
Need to figure out why she got this way-- infex? drugs? Stimulant drugs incr the
metabolic rate so much that it will tip someone into DKA.
Tx: INSULIN. But not too fast b/c her BS and K and fluids will shift too fast and
cause cerebral edema. You want to bring the BS down 100 points per hour. So she will
get well over the next 12 hours. She'll get an insulin drip of Regular [only IV insulin],
get a loading dose and then a drip.
FLUIDS: IV, NS, maybe 200/hr
Evaluate:
BS Q 1hr
lytes q 4 hr.
Goal: get her alert, get BS and lytes back in range.
weeping teenagers in the hall: get them home, involve them in education later
If her sugars are at 450 and she's hungry, what do you do? Educate, give her something
super low sugar.
Discharge: get her friends and her educated to keep her on top of her sugars. get certified
diabetic educator, a doctor's appt tomorrow.
DM2, shaky, sweaty, NPO for lap choli, etc. Shaky means Nervous system changes.
BS: 85
Rx: give her sugar-- a snack or if NPO, you gotta give her some D5W.
Teaching: find out what they already know.
HHS: hyperglycemic hyperosmolar syndrome [not ketotic, or acidic]
high BS than DKA even, blood turned to sludge. Margi's only seen it once in 35 years.
Type 2, slower onset, old people esp w/ infex.
research in the book- 2002, found better morbidity and mortality in post-op pts when the
BS is kept in 70-110, but newer research says that's not the case and you end up with
more cases of hypoglycemia. Little DM 1 kids are really in trouble w/ this b/c they get
overnight seizures from low BS as mom and dad are trying to follow the MD orders.
Endocrinologists are the best people to go to for BS management. If a pt is shaky he may
need a higher bs ordered.
risk factors from being DM:
CAD, eyes, nephrotox, neuropathy, poor perfusion, ARF, amputation.
Need to get their stuff checked yearly: microabluminuria, check their eyes, peripheral
neuropathy checks
Exercise: muscles uptake sugar w/o insulin so get that ass moving.
Drugs:
oral:
sulfonureas: stim beta cells to make insulin. lowers BS. advrse; hypoglycemia
glucophage/metphormin: uptake of glucose by cells and prevents liver from
storing glucose
glitizones: lowers BS.
post prandial checks: we don't do these too often.
RENAL
1. Your patient is a 68 yo woman with ESRD. She is admitted with sudden SOB and
severe edema LUE where her access is located. Assessment findings are crackles ½
up both bases, DOE, BP 178/110, HR 82, SR with occ. PVC. What other assessment
is indicated? What intervention is indicated and why?
she is fluid overloaded b/c not peeing, hypertensive w/ crackles maybe some HF.
Assess: check her access site/av graft first to confirm patency: bruit and thrill--if we don't
have access for dialysis we're in deep doodie, and she's got edema too so not so good.
check pulse and perfusion distal to the graft. SaO2, increase HOB. Check H&H to see if
her RBC production is down. Electrolytes [expect K up, esp w/ PVC's]. BUN and
creatinine. How to diagnose the severity of her illness? CXR-- want to know how much
fluid in the lungs. Figure out why she's in hosp today-- what brought her in, is she
depressed and sick of dialysis and not following her medical orders?
Tx: STAT dialysis. O2 b/c too much water in the lungs. Might need to repair her
av/graft, she can get a central line in the mean time for dialysis: don't just put anything
through that line, she needs it to not get clogged up.
During dialysis: it pulls off a certain amount of water, Bp can drop quickly; fixed with
fluid bolus.
ARF/ post septic shock
Kidneys get starved during sepsis and they hold salt and water.
Prerenal, intrarenal and post renal failure.
Most common is prerenal from hypoperfusion and necrosis. ABX that are nephrotoxic,
esp aminoglycosides [Gentamycin]. Gentamycin protocol is based on weight, BUN and
Creat, BMI. Can lead to intrarenal
Intrarenal: [ATN: acute tubular necrosis].
Postrenal: BPH, other mechanical obstructions.
Prevent it: check for hypotension, I/O, ensure >30 mL/hr.
CRRT: Continuous Renal Replacement Therapy
b/c the dialysis steals the fluids for a while, some pts can't hemodynamically handle this.
There's a machine that the blood goes through very slowly--it's like slow dialysis.
"CVVH: cont veno venous filtration." Got a catherther in the femoral vein. Know the
difference btwn this and dialysis. Expensive, labor intensive. This is for an acute
situation not chronic treatment.
Ca+ with renal failure: hypocalcemia. concerns with bones, muscles
hyperkalemic
which way do they go with mag, phos, etc?
Holding meds pre-dialysis. There are some meds that the pt might lose, and you also
don't want to give HTN drugs.
CAPD: continuous abd peritoneal dialysis. you can DIY at home yourself.
Do daily weight w/ dialysis pts, and we want to know how much fluid the dialysis took
off.
I.
NORMAL GLUCOSE METABOLISM
A.
Insulin:what does it do and how?
B.
Epinephrine, growth hormone, cortisol: what are they effects?
C.
Carbohydrate, fat, and protein metabolism: normal vs abnormal
II.
INSULIN DEFICIENCY
A.
Alterations:
1.
impaired cellular uptake and use of glucose
2.
increased extracellular glucose
3.
increased mobilization of fats
4.
tissue depletion of protein
B.
Insulin deficits and carbohydrate, fat, and protein metabolism
C.
Insulin deficits and fluid and electrolyte balance
III.
DIABETES MELLITUS
A.
Types:
1.
1: describe
2.
2: describe
B.
Assessment
1.
history: medical, meds, activity, education, compliance
2.
dietary history
3.
labs: FBS, HbA1C
C.
Management
1.
diet
2.
exercise: daily
3.
blood glucose monitoring: daily and HbA1C every 3-6 months
4.
feet exam daily
5.
micoalbuminuria sample annually
6.
retinopathy exam annually
7.
medications
a.
insulin: know types!
b.
oral agents: know these!
D.
Diabetic Crises
1.
Hypoglycemic Coma
a.
clinical presentation
b.
slow vs rapid onset
c.
management: conscious vs unconscious
2.
DKA
a.
Pathophysiology
b.
Cardinal signs/symptoms: hyperglycemia; metabolic acidosis, osmotic diuresis,
compensation
c.
Assessment
d.
Causes
e.
Management: correct fluid/lyte imbalances, decrease serum glucose, correct
acidosis, prevent complications, provide client education
f.
Nursing diagnoses
3.
HHS
a.
Pathophysiology
b.
Clinical presentation
c.
Management
E.
Evidence-based Practice:
1.
Reduction of complications with intensive insulin therapy (maintain glucose
80-110) with Type 1 diabetics
2.
continuous insulin infusion provided better glucose control and lower
mortality rate with CABG patients
F.
Exogenous Insulin Therapy
1.
factors that influence insulin: drug interactions, exercise, acute illness,
nutritional support
2.
side effects: what are they?
3.
continuous low-dose IV infusion
4.
Somogyi effect
G.
Chronic Complications
1.
peripheral neuropathies
2.
microvascular disease
3.
macrovascular disease
4.
increased risk of infection
IV.
ACUTE RENAL DYSFUNCTION
A.
Normal kidney function
1.
functions:
2.
effects of aging on renal function:
3.
influences of body systems: CV, nervous, endocrine
B.
Acute Renal Failure
1.
Prerenal:
a.
causes: excessive fluid loss, decreased renal perfusion, drug-related
glomerular hemodynamics
b.
assessment
2.
Intrinsic:
a.
causes: ischemia, nephrotoxicity, intratubular obstruction; ATN
b.
assessment
3.
Postrenal:
a.
mechanical causes:
b.
functional causes:
4.
Phases:
a.
onset
b.
maintenance
c.
recovery
C.
Effects of Renal Dysfunction on Fluid and Electrolyte Balance
1.
Electrolytes: what changes occur?
a.
K:
b.
Na:
c.
Ca & PHO4
d.
Mg
2.
Metabolic acidosis
3.
Fluid balance: what changes occur?
D.
Assessment
1.
History: drugs, hypotension, tumor, infection
2.
Physical Exam:
a.
Neurologic effects:
b.
CV effects:
c.
Pulmonary effects:
d.
GI effects:
e.
Hematologic effects:
f.
Integumentary effects:
g.
Skeletal effects:
4.
Labs/Diagnostics:
a.
BUN/creatinine
b.
Electrolytes
c.
Osmolality
d.
24 hr urine for creatinine clearance
e.
renal biopsy
f.
CT
g.
Ultrasound
E.
Management
1.
Fluid overload reduction: restriction, diuresis, dialysis
2.
Catabolic processes: nutritional support; specific diet: what?
3.
Correct lyte imbalance
4.
Prevent infection
F.
Dialysis
1.
Hemodialysis: why and how?
2.
CRRT: why and how?
3.
Peritoneal dialysis: why and how?
4.
Nursing responsibilities
a.
goals:
b.
care:
c.
V.
drugs:
HIGH-ACUITY PATIENT WITH CHRONIC RENAL FAILURE
A.
Stages of chronic renal failure
B.
Nursing Considerations