NRS 440 exam

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NRS 440 exam
2011-04-02 23:58:22
Acute care

Diabetes, EKG, ARF
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  1. Pathophysiology of DKA
    Lack of insulin=glucose not properly used for energy so body breaks down fats stores for fuel=excretion of ketones (metabolic acidosis) and electrolytes are depleted. Hyperosmolality, volume depletion, ketoacidosis
  2. Signs & Symptoms of DKA
    • S+S:
    • Drowsiness-coma, polyuria-polydipsia, kassmaul breathing-fruity breath, dehydration, glucose >300, metabolic acidosis, hypokalemia
  3. Management of DKA
    • *Initial goal is to obtain IV access
    • 1. Fluid replacement:usually 0.45% or 0.9% NaCl to restore urine output (when glucose reaches 250, 5% dextrose is added to prevent hypoglycemia)
    • 2.Insulin Administration: Regular insulin to correct hyperglycemia and hyperketonemia. Goal is to lower sugars by 100mg/hr to prevent cerebral edema
    • 3. Electrolyte replacement: Potassium! Do not really do much with Na bicarb bc insulin and fluids should correct it on it's own
  4. Pathophysiology of HHNC
    • [Hyperosmolor Hyperglycemia NonKetonic Coma]
    • *has enough insulin so ketoacidosis and kussmaul breathing does NOT occur. Similar to DKA
  5. S+S of HHNC
    • S+S:
    • Typically type II diabetic, slower onset, drowsiness, polyuria, VERY HIGH glucose >800, dehydration, usually normal K

    *NO Hyperventilation or Kussmaul breathing, or ketoacidosis
  6. Management of HHNC
    • -Immediate IV Fluid intake of 0.9 or 0.45% NaCl (HHNC requires greater fluid replacement)
    • -Regular Insulin IV bolus followed by infusion after fluid replacement. Don't drop sugars too fast (100mg/hr at a time)
    • -Monitor cardiac and renal status, potential for fluid overload, watch Potassium
  7. Pathophysiology of Hypoglycemia
    • Too MUCH insulin in proportion to available glucose in blood.
    • -This causes glucose to drop <70.
    • -Can affect mental function bc brain needs constant supply of glucose
    • *CAUSES: too much insulin, poor diet, excessive exercise
  8. S+S of hypoglycemia
    • S+S:
    • confusion, irritibility, diaphoresis, tremors, hungar, weakness. Can mimic alcohol intoxication
  9. Management of Hypoglycemia
    • *If conscious, give 15gm of simple carb (6-8 skittles, 4oz OJ, soda, honey). Check sugar in 15 min. and repeat if no change
    • *IM glucagon in deltoid (1mg) if unconscious or if above not working
  10. The 3 factors into diagnosing diabetes
    • 1. S+S (polyuria, polydipsia, weight loss) and glucose >200 @ any time of day regardless of meals
    • 2. Plasma glucose of 126 or greater after fasting 8 or more hours
    • 3. A 2 hour postprandial glucose level of 200 or greater
  11. Duration of Biguanides
    12 hours
  12. Action of Biguanides
    Decreases liver output of glucose and increases insulin sensitivity
  13. Important points about Biguanides
    • *NOT recommended with kidney/liver problems, CHF, alcohol abuse, or in pts older than 80
    • *Can cause gas, bloating, & loose stools
    • *Hold for 48 hours after tests with contrast dye
    • *CONTRAINDICATED if Creatinine is:
    • >1.4 for females & >1.5 in men

  14. Duration of Alpha-glucosidase (carbohydrate) Inhibitors
    2 hours
  15. Action of Alpha-glucosidase (carbohydrate) Inhibitors
    Slows absorption of carbs to lessen the rise in post-prandial glucose
  16. Important Points of Alpha-glucosidase (carbohydrate) Inhibitors
    • *Take with first bite of each meal
    • -DO NOT take if meal is missed
    • *Causes gas and bloating
    • *Liver tests required every 3 months for first year of therapy
    • *NOT recommended in IBD, cirrhosis, malabsorption/intestinal obstruction
    • *Hypoglycemia MUST be treated with glucose gel/tablets or milk
  17. Duration of Thiazolidinediones (TZDs)
    16-34 hours
  18. Action of Thiazolidinediones (TZDs)
    Increase insulin sensitivity
  19. Important Points of Thiazolidinediones (TZDs)
    • *takes 6-12 weeks for full effect
    • *Liver test every 2 months for first year
    • *DO NOT USE in pts with NYHA class III or IV heart failure

    [Black Box Warning]
  20. Sulfonylureas
    • 1. (Glyburide) 12-24 hours
    • -Increases insulin output from pancreas for basal and postprandial control of glucose
    • -Cross reactivity with sulfa allergy; metabolized in liver and excreted in urine/bile; Caution in elderly; check renal function with prolonged hypoglycemia; weight gain
    • 2. (Glipizide) 10-24 hours
    • -Increases insulin output from pancreas
    • -Cross reactivity with sulfa; ideal in renal insufficiency since there are NO active metabolites
    • 3. (Glimepiride) 24 hours
    • -Increases insulin output from pancreas
    • -Causes least hypoglycemia out of ALL; avoid use in severe liver disease