Module 1 Exam Objectives Study Guide

Advanced Diabetes

 Describe the etiology, clinical manifestations, diagnostic findings, drug therapy,

dietary needs and nursing care for the following complications of diabetes:
o Diabetic Ketoacidosis (DKA)
 Etiology: A profound deficiency of insulin most likely to occur in type 1
diabetics. Could be related to a “sick” pancreas, liver or an
illness/virus.
 Manifestations
 Hyperglycemia: BGL >250
 Ketosis: moderate to high levels of ketones in urine or serum
*This is specific to DKA!
 Acidosis: blood pH <7.30
 Dehydration: dry mucous membranes, tachycardia, OH, weak,
lethargy, eyes soft/sunken, abd pain(pancreas is hurt), anorexia,
N/V
 Kussmaul breathing: deep, rapid, irregular, dyspnea
 Fruity, sweet breath
 Electrolyte imbalance possible: decreased sodium,
potassium, bicarb, chloride, magnesium, phosphate
 Expected Lab Ranges:
 pH LOW <7.30 (7.35-7.45)
 Glucose HIGH > 250 (74-106)
 Bicarb LOW <16 (21-28)
 Sodium LOW (136-145)
 Potassium LOW (3.5-5)
 Chloride LOW (98-106)
 Magnesium LOW (1.3-2.1)
 Phosphate LOW (3.0-4.5)
 What are the potential manifestations associated with the electrolyte
imbalances of DKA?
 Hyponatremia: HA, confusion, nausea, hallucinations,
decreased attention, dysphasia, cerebral edema
 Hypokalemia: weakness & cramping, arrythmias, constipation
(*associated w/hypomagnesemia)
 Hypobicarbonatemia: HA, fatigue, acid-base imbalance sx
(metabolic acidosis)
 Hypochloremia: lack of sx until extremely low – then confusion
& swelling
 Hypomagnesemia: tremor, personality changes, Trousseau
sign, Chvostek sign (*associated w/hyponatremia)
 Hypophosphatemia: muscle cramps, weakness, numbness,
decreased bone density (if prolonged)
  Diagnostics/Findings:

 H&P
 Blood studies: CBC, pH, ketones, electrolytes, BUN, ABGs
 Treatments/Medications:
 Ensure patent airway, admin O2!
 Establish large bore IV to admin NaCl 0.45% or 0.9%. As BGL
approaches 250 add 5-10% dextrose to prevent rebound
hypoglycemia. *start 2 IVs
 Continuous insulin drip 0.1u/kg/hr
 Potassium replacement as needed. *insulin should be given
alongside potassium
 Admin bicarb if pH is <7
 Dietary/Nutrition:
 Nursing Indications:
 Monitor IV fluids, insulin therapy, electrolytes
 Assess renal and cardiopulmonary status, LOC
o Hyperosmolar Hyperglycemic Syndrome (HHS)
 Etiology: Life threatening syndrome of extreme hyperglycemia most
commonly occurring in older patients with type 2 diabetes. They have
enough insulin in circulation to prevent DKA but not enough to prevent
severe hyperglycemia.
 May be caused by UTIs, pneumonia, sepsis, infection, and newly
diagnosed type 2 diabetes. Impaired thrist sensation and/or
inability to replace fluids
 Manifestations:
 Often has fewer symptoms in early stages which allows BGL to
climb very high before manifestations occur
 Severe neurologic manifestations due to increase serum
osmolality: coma, seizure, hemiparesis, aphasia
 Diagnostics/Findings:
 Ketones will be absent or minimal in blood/urine
 Treatments/Medications:
 Similar to DKA: IV insulin and NaCl infusions, more fluid
replacement, monitor and replace potassium as needed
 Correct underlying condition
 Dietary/Nutrition:
 Nursing Indications:
 Monitor IV fluids, insulin therapy, electrolytes
 Assess renal and cardiopulmonary status, LOC

o Hypoglycemia
 Etiology: BGL less that 70 begin treatment, Higher than 70 look for
alternate cause of symptoms. Can be caused by too much insulin, not
 enough food or delayed eating, too much exercise. Can also be a
rebound effect of dropping hyperglycemia
 Manifestations:
 Tachycardia, Shaking, Sweating, Nervousness or anxiety,
Irritability or confusion, Dizziness,
 “Pale, cool, clammy give me candy”
 Diagnostics/Findings:
 BGL <70
 Treatments/Medications: if critically low or 2-3 rounds of 15g snacks
 50% dextrose 20-50ml IV push
 1mg Glucagon IM or subQ if PT unable to swallow
 Why do we still treat a symptomatic patient for hypoglycemia if
we don’t have an available glucometer? always treat the
symptoms don’t wait for a number because everyone is different
and can be symptomatic at different numbers
 Dietary/Nutrition:
 RULE OF 15’s
o Give 15g of a simple carb (fruit juice, regular soda 4-6oz)
o Recheck BGL in 15 min (repeat if <70)
o After recovery follow with a complex carb (starchy vegies,
legumes, whole grains)
 Nursing Indications:
 Monitor BGL closely and avoid over treatment into
hyperglycemia
 Teach Pt S/S of hypoglycemia and Rule of 15 management, eat
at regular intervals and adjust insulin to exercise
o Gestational Diabetes
 Etiology: Onset of carb/glucose intolerance during pregnancy.
 Risk Factors:
 Overweight (BMI 25-29.9), Obese (BMI 30-39.9), Morbidly obese
(BMI >40)
 Maternal age >25yrs
 GDM in previous pregnancy
 Hx of abnormal glucose tolerance
 Family hx GDM
 High risk ethnic group
 Manifestations:
 Mom: Preeclampsia, ketoacidosis, hydramnios, dystocia
 Baby: congenital malformations, big baby, fetal hypoglycemia
(baby needs to eat asap), respiratory distress syndrome


 Diagnostics/Findings:
 Glucose challenge test between 24-28wks.
o Ingest 50gm oral glucose if BGL is >140 after 1 hour then
OGTT is needed
 Oral Glucose Challenge Test (OGTT) is gold standard
o Fasting BGL followed by ingestion of 100gm oral glucose,
hourly BGL check
o 2 abnormal hourly test = failed/abnormal
 Fasting >95, 1 hour >180, 2 hour >155, 3 hour >140
 Treatments/Medications:
 Dietary/Nutrition:
 Nursing Indications:
 Utilization of critical thinking in the care of patients with diabetes.
o Discuss the differences in pathophysiology of DKA and HHS:
 DKA: Primarily in mismanaged or undiagnosed Type 1 diabetes, BGL
>250, ketones present, metabolic acidosis, Kussmaul breathing,
PH<7.35
 HHS: Primarily in mismanaged or undiagnosed Type 2 diabetes,
BGL>600, absent ketones, Acidosis is absent
o Discuss the differences and similarities in clinical manifestations of DKA and
HHS.

DKA HHS
Polyuria ✅ ✅
Polydipsia ✅ ✅
Weight loss ✅ ✅
GI Effect ✅
Vision issues, weakness, ABD ✅ ✅
pain
Orthostatic hypotension ✅ ✅
Fruity Breath ✅
Kussmaul breathing ✅
 Metabolic Acidosis ✅
AMS ✅ ✅
Seizure ✅
Reversable paralysis ✅
o Discuss the Interprofessional management of DKA and HHS.
 Frequent vital and BGL monitoring until stable and watch for rebound
hypotension
 Monitor for S/S of dehydration or fluid overload with fluid replacement
therapy
 EKG monitoring for cardiac effects and urinary output
 Assess for acute neurological changes
 PT education to prevent reoccurrence
o Discuss why DKA frequently occurs:
 10-year-old established diabetic on November first – why?
 Overeating candy = HYPERglycemia
 12-year-old newly diagnosed diabetic – why?
 Didn't know they had diabetes
 17-year-old diabetic high school student – why?
 Unwilling and/or unable to properly manage disease
o What are the potential consequences of unmanaged diabetics that remain
chronically hyper or hypoglycemic? Are they specific to type I or type II?
 Develop a teaching plan for patients with complications related to diabetes.
o Discuss “Sick Day Guidelines” for diabetic patients and parents of diabetic
children.
 Assess glucose and ketones q2-4hr until results are normal.
 Contact HCP if BGL is high for more than 6hrs, if urine ketones last
longer than 6hrs, if unable to take fluid/food for 4 hr, fever of 101.5
degrees F, illness lasts longer than 24hrs or becomes dehydrated,
severe abd pain occurs, or experience any unexplained symptoms.
 Continue taking insulin even if unable to eat solid foods or are vomiting
– insulin needs may stay the same or increase during illness. Continue
taking usual oral dose of diabetic medications during illness. If BGL is
<70 mg/dL and you take oral medications to lower BGL contact your
HCP for guidance.
 Dietary guidelines include to continue trying to eat and drink even if
vomiting, diarrhea, or hyperglycemia occur. Goals include 45-50g carbs
every 3-4hr, if foods aren’t tolerated, attempt carbohydrate rich liquids
or soft foods; there are 15g of carbs in the following:
 ½ cup regular soda, 1 double popsicle, ½ regular Jell-O, 1 cup
Gatorade, 1 cup soup, ½ cup fruit juice, 1 slice toast, 6 soda
crackers (saltines)
o What places a patient at risk for:

 Hyperglycemic events
  Hypoglycemic events
 Required Reading:
o Lewis, 12th edition: Chapter 53: pgs. 1309 - 1319
o Ashwill, 6th edition: Chapter 26: pgs. 555 – 563
 Advanced Respiratory
 Describe the etiology, clinical manifestations, diagnostic findings, drug therapy,
dietary needs and nursing care for the following types of advanced respiratory
disorders:
o Lung abscesses
o Environmental lung disease
o Lung cancer
o Pneumothorax
o Hemothorax
o Chest trauma/ rib fractures
o Pulmonary effusion/ pleurisy
o Idiopathic pulmonary fibrosis
o Pulmonary edema/ Pulmonary embolism
o Pulmonary hypertension
o Lung transplant
o Respiratory failure
o Acute respiratory distress syndrome
 Describe cultural considerations related to the above disorders that affect the
respiratory system.
 Discuss concepts of caring when providing nursing care to a patient with
complications related to the respiratory system.
 Discuss the utilization of critical thinking in the care of patients with respiratory
disorders.
 Develop a teaching plan for the patient with an advanced respiratory disorder.
 Discuss legal and ethical considerations related to advanced disorders of the
respiratory system.
 Required Reading:
o Lewis, 12th edition: Chapter 30: pgs. 610 – 629 & Chapter 32: pgs. 672 –
692
 Recommended:
o ATI Targeted Medical – Surgical Practice Test – Respiratory