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Shock
Arterial blood gases
Mechanical ventilation
Adult respiratory distress syndrome
Acute complications of Diabetes Mellitus-Euglycemic protocols
The Polys
Polyuria: excessive urination (with glycosuria)
Polydipsia: excessive thirst (from dehydration and hyperglycemia)
Polyphagia: excessive hunger (from using non-CHO sources for energy)
Ketoacidosis
Without insulin, fat is used for energy (gluconeogenesis)
Ketones result from breakdown of fatty acids
3 specific ketone bodies are produced
o Acetone (fruity breath)
o B hydroxybutyrate
o Acetoacetate
Ketones & Acid Base Balance
As ketones breakdown produce H+ ionsdrop in pH
Serum bicarbonate decreases in attempt to maintain pH
Result is severe metabolic acidosis
Ketoacidosis
As bicarbs decrease, breathing becomes deep and rapid (Kussmaul respirations) to
release acid in form of CO2
Acetone: doesnt cause acidosis (eliminated in lungs fruity breath)
Nursing Care
Monitor!
o Response to therapy
Fluid volume status: hourly urine output
Insulin levels: monitor BG hourly
Electrolytes (Na & K)monitor hourly
Mental status & LOCsudden complaints of HA may signal
cerebral edema. Hyponatremia may cause mental status changes
Cardiac statuscontinous EKG monitoring because of K probs
Patient and Family Education
o Listen: to gain insight into possible cause of hyperglycemic episode
o Possible issues: cost/availability of meds, not able to recognize stress/
infection, drug holiday, knowledge deficit, apathy or memory probs
(older adults)
Diabetes oral meds all rely on the insulin the body makes (so they will not be useful in
patients with type 1 diabetes. Most of these meds can be used in combo with each
other and with insulin
Oral medications
Medications
Action
Advantages
Meglitinides
Work quickly
Repaglinide
(Prandin)
of insulin
Nateglinide (Starlix)
Sulfonylureas
Glipizide (Glucotrol)
Glimepiride
Work quickly
of insulin
(Amaryl)
Glyburide (DiaBeta,
Glynase)
Dipeptidy peptidase-4
(DPP-4) inhibitors
Saxagliptin
release of glucose
headache; inflammation of
(Onglyza)
Sitagliptin (Januvia)
Linagliptin
(Tradjenta)
Biguanides
Metformin
(Fortamet,
liver; improve
decline in low-density
Glucophage, others)
sensitivity to insulin
lipoprotein (LDL), or
"bad," cholesterol
Thiazolidinediones
Improve sensitivity to
Rosiglitazone
high-density lipoprotein
(Avandia)
release of glucose
(HDL), or "good,"
Pioglitazone (Actos)
cholesterol
Alpha-glucosidase
inhibitors
Acarbose (Precose)
Miglitol (Glyset)
sugars
Injectable medications
Medications
Action
Advantages
Amylin mimetics
Hypoglycemia; nausea or
Pramlintide
(Symlin)
insulin injections
weight loss
Incretin mimetics
Nausea or vomiting;
Exenatide (Byetta)
Liraglutide (Victoza)
metformin and
weight loss
damage or failure
sulfonylurea
Autoimmune disease
Type II Diabetes
Insulin resistance
Deficient insulin secretion
Obesity contributes significantly,
resistance
losing
weight
decreases
insulin
Blood sugar control = 70-140 mg/dl. The ADA recommends keeping blood sugar
as close to 110 as possible.
Hemoglobin A1C expressed as a %, reflects the average blood glucose over the
past 3 months.
ADA now recommends that A1C be used to diagnose type 2 and screen for
prediabetes. Normal Hemoglobin A1C =5%.5.7-6.4 pre-diabetic. < 7.0 is the
target for a diabetic..
A1c (%)
6
7
8
9
10
Blood glucose
(mg/dL)
126
154
183
212
240
Thiazolidinediones TZDs glitazonesmechanism of action-decreases insulin resistance at the cell level. May cause
fluid retention, use caution with history of CHF.
*rosiglitazone(avandia)-liver function tests required!
pioglitazone(Actos)
BLACK BOX WARNING for Avandia increased risk of heart disease and
stroke. May cause fluid retention/edema, therefore contraindicated in pts. with
CHF.
September, 2010 FDA advised people to stop taking unless they were not able
to lower blood sugar with any other treatment.
In Europe, the FDA equivalent has stopped the use of this drug. (European
Medicines Agency)
Evidence- based Recommendation: TZDs ( avandia and actos) are NOT firstline options. Metformin is first line recommendation.
Combination Drugs
*Glucovance-Glyburide/metformin-sulfonylurea + biguanide
*Avandamet-rosiglitazone/metformin TZD + biguanide
Types of Insulin
Insulin Lispro
Adult, adolescence, child
SQ 15 min before meals
Continuous SQ infusion (external insulin pump)
With infusion total daily dose should be based on previous regimen
50% given at meal related boluses remainder in basal infusion
Rapid acting
Onset 15-30 mins
Peak 30 mins to 1.5 hours
Duration 3-5 hours
Insulin Glargine
Adult and child
SQ 10 international units/day
Range 2-10 international units/day
Long acting
Onset 1.5 hours
No peak
Duration >24 hours
Regular Insulin
Adult
IV 5-10 units/hr until desired response then switch to SQ
SQ 30 mins before meal
Short acting
Onset 30 mins
Peak 2.5-5 hours
Duration 7 hours
Whenregular insulin is administered IV monitor glucose, K+, often to prevent fatal
hypoglycemia, and hypokalemia
Side Effects: blurred vision, dry mouth, flushing, rash, swelling, redness, peripheral
edema, hypoglycemia, anaphylaxis
Interactions:
Nursing Considerations
Assess urine ketones during illness; insulin requirement may increase during stress,
illness, and surgery
Assess hypoglycemic reaction that can occur during peak time (sweating, weakness,
dizziness, chills, confusion, headache, nausea, rapid weak pulse, fatigue, tachy
Assess hyperglycemia, acetone breath, polyuria, fatigue, polydipsia, flushed, dry
skin, lethargy
Acute Respiratory Distress Syndrome (ARDS) & Acute Lung Injury (SIRS)
o Nursing actions:
Assist in positioning client; interpret and communicate results
ECG
Therapeutic Procedures
Intubation and mechanical ventilation
o Artificial airway insertion with mechanical ventilation
o Nursing actions
Monitor ECG, SaO2, breath sounds, and color
Sedate as needed
Reassure patient
Suction ready
Preintubation
Oxygenate with 100% oxygen
Assist ventilation with manual resuscitation bag and face
mask
Have emergency equip ready
Postintubation
Assess bilateral breath sounds, symmetrical chest
movement, and check xray to confirm placement of
endotracheal tube
Secure endotracheal tube per guidelines
Assess balloon cuff for air leaks periodically
PEEP
Positive pressure is applied at the end of expiration to
keep the alveoli expanded
PEEP is added to the ventilator setting to increase
oxygenation and improve lung expansion
Wont be able to speak while endo tube in
Kinetic therapy
A special kinetic bed that rotates laterally alters clients
position to reduce atelectasis and improve ventilation
Nursing actions
o Begin slowly and gradually increase the degree of
rotation as tolerated
o Monitor ECG, SaO2, breath sounds, and BP
o Stop is pt becomes distressed
o Routine skin care to prevent skin breakdown
o Sedate as needed
Outcomes
o Pt will be able to breath independently with no
resp assistance
Actions
Reposition and suction Q2
Routine skin care
Implement ROM
2 phase condition:
1. Acute exudative phase
a. Activation of neutrophils (PMNs-polymorphonuclear neutrophils)
b. The bodies nonspecific first responders to infection, injury, or
inflammation
c. Neutrophil activity
i. Release pro-inflammatory cytokines (TNF & interleukins) & other
substances
ii. Activate macrophages
iii. Neutrophils migrate into pulmonary circulation through
endothelial walls of pulmonary capillaries into lung
d. Results
i. Alveolar-capillary membrane damage (fluid starts leaking into
alveoli)
ii. Edema and flooded alveoli
iii. Inactivated surfactant (type II cells)
iv. Inflammation in lungs
v. Create classic features of ARDS: hypoxemia, decreased lung
compliance, increased respiratory rate
2. Fibroproliferative phase
Towards the end of acute exudative phase, collagen and fibrin deposits begin to
collect in lungs
In FP phase, fibrin matrix develops (hyaline membrane) in alveoli
Results:
o 1. Lungs become even stiffer (harder to ventilate)
o 2. Increased hypoxia and increased CO2
Xray findings:
o As alveoli fill with fluid, see white patches on xray
o white out sometimes used to described what is seen on xray
o physical findings at this time: significantly decreased breath sounds
Medical Care
maintain respiratory function
o intubation and ventilation using positive pressure
o identify and treat causative factors
Nursing Care
Three mainstays:
o Prevent complications (infections, aspiration, skin breakdown,
contractures, nutrition)
o Provide adequate support (family care)
Ventilation
Lab Values
CVP (central venous pressure) 2-8mm
Amount of blood flow to right side of heart
Normal pulmonary wedge 6-12
Wedges into pulmonary artery, reflects pressure in the L side of the heart
D-dimer <250ng/mL
Sedimentation rate <20 mm/hr
BUN 5-25 mg/dl
Creatinine0.5-1.5
WBCs 4500-10,000
RBCs
Platelets 150,000-400,000
Hemoglobin (Hb) 13.5-17.5 M 12.0-16.0 F
Hematocrit (Hct) 41-53 M 36-46% F
Potassium 3.5-5.0
Sodium 135-145
Phosphorus 2.5-4.5 mg/dl
Alanine amniotransferase (ALT) serum 4-35 units/liter
Aspartate aminotransferase (AST) serum 8-33 units/liter