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142 Cards in this Set
- Front
- Back
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Mild hypoglycemia BG |
50-70 mg/dL |
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Treatment of mild hypoglycemia |
15/15 rule 1/2 cup of fruit juice (half of a clear plastic glass) Glucose Oral gel (GLutose 15) |
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What kind of juice do we give to a patient with mild hypoglycemia who is in CRF? |
Apple juice |
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Glucose Oral Gel must be used if patient is on |
acarbose ( precose or miglitol ( GLyset) |
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If a patient is not symptomatic but their glucose is less than 60 mg/dl what do we do? |
Treat the patient with glucose |
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How often to we recheck sugar level after giving glucose? |
Every 15 minutes until they are normal |
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Blood sugar level for pregnant patient |
60 |
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Blood sugar level for all others who arn't pregnant |
80 |
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Severe hypoglycemia BG |
<50 mg/dL |
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People with severe hypoglycemia can easily progress into |
Coma Seizure altered behavior |
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Treatment for severe hypoglycemia |
10-15 g of oral CHO D50 rate of 10ml over 1 minute IV PUSH Glucagon hormone- dilute then inject IM (only works if they have sugar in their system) within five minutes they may come around- have them eat afterwards as they still need sugar |
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ALterations in Macrocirculation |
Large vessels Undergoes changes in people with diabetes due to abnormalities in blood components ( platelets, RBC's, clotting factors and changes in arterial walls) |
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Alterations in Macrocirculation puts patients at risk for |
CAD HTN MI CVA PVD Frequent infection- gangrene Frequently decreased neurologic function |
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Peripheral or vascular insufficiency |
Basement membrane of vessels get thickened resulting in decreased tissue perfusion (caused from increases in sorbitol) |
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Intermittent claudicating |
pain during activity due to poor circulation |
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Alterations in Microcirculation |
Microhematuria diabetic retinopathy Diabetic Nephropathy |
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What do we worry about with alterations in microcirculation? |
Kidneys and EYes |
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Microhematuria |
non-visible blood in the urine usually found before people are diagnosed with diabetes |
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Diabetic retinopathy |
retinal capillary structure undergoes alterations in blood flow, leading to retinal ischemia and a breakdown in the blood-retinal barrier |
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Diabetic nephropathy |
a disease of the kidney characterized by the presence of albumin in the urine, hypertension, edema, and progressive renal insufficiency ( diabetes is the number one cause of renal failure) |
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Neuropathies |
Caused by the thickening of the blood vessels walls that supply the nerves so the nerves can't get blood and they die, also an accumulation of sorbitol, which impairs the swan cells. |
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What medication are given for neuropathies? |
Neurontin Gabapentin Lyrica |
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When a diabetic patient has neuropathies it affects |
ANS and peripheral nerves Sensory/motor impairment Cranial nerve disorders Impaired vasomotor function Impaired GI/GU function (Gastroparesis) |
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Distal paresthesias |
a subjective feeling of a change in sensation such as numbness or tingling |
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Complications of Neuropathies |
Increased risk of infection Periodontal disease Foot problems wound infection foot ulcers intermittent claudication |
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Foot care |
inspect and wash daily Check shoes before putting them on Don't walk barefoot use caution with hot water Don't cross your legs have a pro cut your toenails no open toed shoes Seek care for new foot problems |
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Early manifestations of Type 1 DM |
Polyuria polydipsia polyphagia weight loss glucosuria fatigue |
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Early manifestations of Type II DM |
polyuria polydipsia blurred vision |
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Progressive Complications of DM |
Hyperglycemia- diabetic ketoacidosis- hyperglycemic hyperosmolar nonketotic coma Hypoglycemia |
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Late complications of DM Neurologic |
Somatic and visceral neuropathies |
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Somatic neuropathies |
paresthesias Pain Loss of cutaneous sensation Loss of fine motor control |
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Visceral Neuropathies |
Sweating dysfunction Pupillary constriction Fixed heart rate constipation diarrhea incomplete bladder emptying sexual dysfunction |
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Sensory complications |
diabetic neuropathy cataracts glaucoma |
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Cardiovascular complications |
orthostatic hypotension accelerated atherosclerosis Cerebrovascular disease- STROKE CAD- MI PVD Blood viscosity and platelet disorders |
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Renal complications |
Hypertension albuminuria edema CRF |
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Musculoskeletal complications |
joint contractures |
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Integumentary complications |
foot ulcers gangrene of the feel atrophic changes |
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Immune system complications |
impaired healing chronic skin infections periodontal disease urinary tract infections lung infections vaginitis |
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An acute event, surgery or infection causes a release of epinephrine, cortisol, growth hormone and glucagon that results in |
Hyperglycemia Blood shunts to vital organs and away from periphery. Inhibition of endogenous insulin release decreased uptake of circulating insulin |
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Blood shunts to vital organs and away from the periphery= |
vasoconstriction in periphery not absorbing things as well and blood supply is not as good in periphery |
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Medications that may cause hyperglycemia |
thiazide diuretics epinephrine pseudoephedrine phenylephrine- given for BP Propofol- a fat nicotinic acid phenytoin steroids thyroid preparations |
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For anything that causes changes in blood sugar the nurse should |
check blood sugars more often |
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Nutrition changes with illness |
change in oral intake initiation of tube feeding or TPN then check sugars more frequently |
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If long term TPN or Tube feedings what lab might you check and what needs to continue? |
KEYTONES insulin and oral agents |
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NPO GUIDELINES |
patient still gets basal insulin DO NOT GIVE NUTRITION INSULIN Correction insulin is always given to correct a high blood glucose |
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Managing ILL diabetics |
more frequent BS monitoring take 1/2 insulin dose if able to take liquids dont take diabetes oral medication until able to keep food down drink lots of fluids (some sweetened) take more blood sugars than normal |
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Nursing process for patients with diabetes |
altered skin integrity risk for infection risk for injury sexual dysfunction ineffective individual coping altered health maintenance |
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For the hospitalized patient with DM |
more frequent assessment reinforce teaching patient is used to managing disease consult with diabetic consulting service |
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Patient education |
education on medications blood glucose monitoring and range hypoglycemia hyperglycemia diet activity when to call provider |
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Education on medications |
some will increase blood sugar |
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Education on blood glucose monitoring and range |
different people have different range |
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Pulse pressure |
the difference between the systolic and diastolic pressure, normally about 40mmHg |
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MAP |
average pressure in the arterial circulation throughout the cardiac cycle Systolic BP + 2X diastolic BP/3 |
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What is the number one concern for patient w/peripheral vascular disorders with diabetes? |
Oxygenation of tissues |
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Assessment of patient with PVD and diabetes |
Patient history Chief complaint Medical/family history Psychosocial |
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Arterial sore |
sharp pain pale-white if they put their leg down in a dependent position there is rubor cool smooth shiny hairless skin wound itself has smooth edges and usually has gangrene blood flow not getting to extremities decreased pulses |
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Venous Sore |
dull pain bluish color or dark brown look warm distinguished by edema irregular shape and uneven border HOEMANS sign- calf pain on dorsi flexion |
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Hoemans sign |
calf pain on dorsi flexion |
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When doing a physical assessment of patient with PVD |
always perform bilaterally BP Inspect skin for color and hair loss palpatation of pulses both sides temp capillary refill pulsatile mass auscultation |
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Types of pulses |
hypokinetic hyperkinetic bigeminal pulses paradoxes pulse deficit |
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Hypokinetic pulse |
weak pulse- CHF, hypovolemia |
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Hyperkinetic pulse |
bounding pulse-aortic regurgitation, fluid overload |
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bigeminal pulse |
pulse that goes weak/strong/weak strong- could be PVC's |
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Pulses paradoxes |
strong vs weak depending on whether the patient is breathing in or out- potential cardiac tamponade, pericarditis |
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Pulse deficit |
slower radial pulse than apical pulse- dysrhythmias, CHF |
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Pulsatile Mass |
for abdominal aneurysm |
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Auscultation for Bruit |
swooshing noise blood makes when it rushes past an obstruction |
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Elderly considerations |
typically need a higher BP to get blood to the brain baroreceptors don't work well- not as sensitive loss of elasticity thinning of arteries Blood vessels- we see blood pooling because of insufficient valves More likely to have strokes BP is higher Pulses SKin |
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Cardiac output- SYSTOLIC |
HRxSV Ventricular contraction and ejection cardiac index 2.5-4.2 |
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Cardiac index |
2.5-4.2 |
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Diastolic |
vascular resistance BP= COxSVR |
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Systemic vascular resistance SVR |
means how tight the arteries are clamped down |
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What factors contribute to SVR |
vessel length, blood viscosity and vessel diameter and compliance |
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What do hormones in our bodies do to our arteries |
tightens or constricts |
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What should the MAP be to get blood to the brain |
60 |
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What is the normal MAP |
70-100 |
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Pathophysiology of HTN |
the arterioles normally determine the SVR as their diameter changes in response to a variety of stimuli which includes Nervous system, Vascular endothelium, Renin-angiotension aldosterone |
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Nervous system |
stress or a drop in MAP stimulates the sympathetic nervous system |
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Catecholamine's |
epinephrine- very potent vasoconstrictor- increases SVR and makes it harder for your heart to beat against arteries- this is a problem that leads to heart failure |
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Vascular Endothelium |
baroreceptors send signals to the vasomotor control center in the medulla, the vascular endothelium sends vasoconstrictor and vasodilator substances through the body as well through the blood stream ANP BNP Adrenomedulin Vasopressin |
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Renal (Renin-angiotension Aldosterone) |
stimulated by decreased blood volume and pressure |
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Renin is released from |
juxtaglomerular cells |
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Renin converts |
angiotensinogen to angiontensin I |
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Angiotensin Converting Enzyme (ACE) converts |
Angiotensin I to angiotensin II- Ace inhibitors get blood volume down
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Angiotensin II |
Vasoconstrictor enhances reabsorption of Na and releases of aldosterone from the adrenal cortex Stimulates hypothalmus to release antidiuretic hormone and activates thirst center (this increases blood volume) Increases fluid reabsorption by decreasing peritubular hydrostatic pressure REduces GFR |
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When angiotensin II increases fluid absorption be decreasing peritubular hydrostatic pressure |
tells kidneys tl reabsorb more H2O |
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When angiotensin II stimulates hypothalamus to release antidiuretic hormone and activates thirst center |
this increases blood volume |
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High blood volume equals |
Higher blood pressure
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Low blood volume equals
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Lower blood pressure
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rigidity of vessels |
Especially in elderly who have harder vessels the heart have to work to push blood through rigid vessels so a higher pressure is needed
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Types of hypertension
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Primary, essential
Secondary |
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Primary hypertension
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elevated BP without a known cause 90% of all hypertension Usually have excess sodium in their system and they retain water Sympathetic Nervous system more sensitive- Patients commonly have cardiovascular risk factors- smoking hyperlipidemia, triglycerides etc |
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Secondary hypertension |
Specific cause sleep apnea kidney disease- any disease that affects renal blood flow endocrine problem-tumors of adrenal glands pregnancy-eclampsia drugs vascular- atherosclerosis, CHD neurologic problems- brain injury |
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What is the silent killer |
hypertension |
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Symptoms of HTN |
headache Cerebrovascular- blurred vision, stroke, syncope Cardiovascular- Chest pain, SOB Palpitations, edema,papilledema |
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Definition of papilledema |
Swelling around the eyes |
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Cardiovascular symptoms with HTN |
chest pain SOB Palpitations Edema Papilledema |
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Cerebrovascular symptoms with HTN |
Blurred vision stroke syncope dizziness |
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Risk factors for HTN |
smoking dyslipidemia diabetes age gender family history race diet excessive alcohol intake |
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what is the incidence for people aged 60-69 for HTN |
50% |
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What is the incidence for people over 70 for HTN |
75% |
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What is the incidence for HTN in people who don't know they have it |
30% |
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Out of the 59% of people who are being treated for HTN how many are effectively treated? |
34% |
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Target organ damage with HTN |
Cardiac Peripheral Vascular Neurological/central nervous system Renal EYES |
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Cardiac organ damage |
increased workload (SVR) with each beat thousands of times per day, this develops into HF and puts them at risk for heart attack and dysthrythimias |
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Peripheral Vascular damage with HTN |
affect on arteries and veins, getting to and from heart |
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Neurological/central veracious system damage related to HTN |
most obvious is stroke, infarction or hemorrhage, encephalopathy |
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Encephalopathy |
swelling of the brain- causes dizziness coma and changes in LOC and vomitting |
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Renal-encephalpothy problems with HTN |
huge problem. more pressure to the kidneys which are very sensitive to pressures, its works hard and they can go into failure or stenosis or aneurysms in renal artery |
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If a patient has normal blood pressure and then gets hypertensive they will usually look at what first? |
Kidneys |
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Eyes in relation to HTN |
you can tell if you have high blood pressure just by looking at the back of the eye- spasms, leakage of exudates, flamed shaped hemorrhages, ghost vessels, blurriness or blindness is a sign of hypertension that is out of control |
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Complications of HTN |
Hypertensive crisis Malignant hypertension |
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Hypertensive crisis |
life threatening 180-120- get to the ER needs treatment within 1 hour |
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Malignant hypertension |
the WORST! diatonic blood pressure great than 130 give the same drugs if you don't treat it immediately the patient will die. |
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Signs and symptoms of malignant hypertension |
stroke retinal hemorrhage heart attack papilledema- optic disc swelling |
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IV medication for malignant HTN and Hypertensive crisis |
Nitroglycerin nitropreside- IV vasodilator lasix- to get rid of fluid hydralazine- relaxes vessels Lebatolol- mixed alpha/beta blocker- IV push med |
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IV HTN medications are what |
violent meds and can drop pressures 30-50 points in seconds. Need to be careful..we are trying to drop their pressures 25-30% which can take up to 6 hours to get where we want...and we absolutely want below 160 diastolic |
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Proper blood pressure measurement |
How many readings? Equipement patient instructed to rest 5 minutes before taking it proper cuff size placement of cuff |
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How many readings for BP |
we want at least 2 the current method is they do 5-6 and they throw the first one out |
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Equipment for BP |
use a calibrated manometer |
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Patient instructions for taking BP |
Rest for 5 minutes before taking it avoid stimuli for 30 minutes no restrictive clothing they should sit with their arm at heart level with their arm slightly flexed |
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Proper cuff size |
make sure the bladder is over 80 % of their arm diameter |
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Placement of cuff |
palpate the area and place stethoscope overit |
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inflate the cuff |
listen for korotkoff sounds |
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Labs/diagnostic tests for HTN |
blood pressure electrolytes creatinine, BUN Urine analysis Echocardiogram to look at kidneys |
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Nursing care of the hypertension patient - Step 1 |
lifestyle modification-
dash siet exervise control weight modify diet limit sodium quit smoking limit alcohol limit stress |
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Nursing care of the hypertension patient Step 2 |
If after step 1 then: continue lifestyle modifications Add medications |
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Medications for HTN |
thiazide diuretics ace inhibitor angiotensin receptor blocker beta blocker calcium channel blocker aldosterone antagonist adrenergic inhibitors alpha blockers direct vasodilators |
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Thiazide diuretics |
CHEAP Hydrochlorothizide- usually first thing given |
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ACE inhibitor |
more protective but they are kidney protective, we might give these depending on race and diabetes patients Captopril- 25-150mg BID TID Enalapril 10-40 mg/day Lisinopril- 5-40 mg/day |
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Side effects of Ace inhibitor |
cough angioedema |
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Angiotensin Receptor Blocker--The TANS |
if they can't use ACE (ace cough) with ARB's there is a less chance of cough, less side effects Losartan-25-100mg 1-2 doses Valsartan 80-320mg/day |
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Beta Blocker |
negative inotrope, decreases contraction and heart rate so we get decreased blood pressure beta blockers are extremely valuable for long term use, they are shown to be one of only 2 drugs that make people live longer- the other is aspirin. Decrease myocardial oxygen demand (decrease angina), check BP and HR, Erectile dysfunction can occur. Beta blockers interfere with angiotensin and aldosterone Atenolol- 50-100 mg per day Metoprolol- 25-100 mg/day |
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Calcium channel blocker |
decrease peripheral vascular resistance and dilate peripheral arteries these are good for people with arteriole disease and they work well with the elderly Diltiazem 30 mg q 6hours |
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Aldosterone antagonist |
spironolactone 25-100 mg/day k sparing |
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Adrenergic Inhibitors |
central alpha agonists Clonidine- catapress 0.1-0.3mg/day this is a patch you don't mess with ..Good for in compliant patients Methyldopa (aldomet) |
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Alpha blockers |
good for older men. Help with BP and help with prostate blockage of urine Prazosin (minipress)1mg/day BID-QID up to 20mg/day Doxazosin (Cardura) Terazosin (Hytrin) |
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Direct Vasodilators |
cause hair growth especially in women Hydrazine- 10-50 mg QID Minoxidil 10-40 mg daily |
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Non-compelling indications for HTN |
if people just have hypertension and no other major disease then they start with the ones on the top and max out then move to the next and max out and if none of them work they try two drugs thiazide diuretic Ace inhibitor Angiotensin Receptor Blocker Beta blocker Calcium channel blocker 2 drug combination if SBP>160 DBP>100 |
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Compelling indications |
based on benefits from outcome studies or existing clinical guidelines people with these conditions we will give certain drug cocktails. May also depend on race too. HF S/P myocardial infarction high risk CVD Diabetes CKD Recurrent stroke prevention |
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Nursing diagnosis that pertain to the hypertensive patient |
decreased cardiac output fluid volume excess altered nutrition altered health maintenance activity intolerance- fatigue risk for injury ineffective coping anxiety fatigue knowledge deficit- complex |
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Reasons for not complying with recommendations to control hypertension |
expensive complex they don't feel the symptoms |
