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45 Cards in this Set
- Front
- Back
what is characterized by hypoglycemia, what is it assoc with, what sx does it show, how might these be masked
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HYPOglycemia: SNS stim (tachy, diaphoresis, anxiety)
altered mental status maked by B blockers! |
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how is DKA characterizeed
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1. hyperglycemia
2. ketonemia 3 acidmenia bc of lack of insulin and increased glucagon, GH, catecholamines, cortisol can lead to chock and death |
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how is hyoerosmolar hyperglycemic state characterized
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lack of insulin --> HYPERglycemia
mortality due to: MI or CVA can HYPOventilate |
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what are the 3 metabolic complications assocaited with DM
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1. HYPOglycemia
2. DKA 3. Hyperosmolar hyperglycemic state |
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what does EtOH do to DM
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predisposes to HYPOglycemia
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what is the initial treatment to pt with DM and altered mental status
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ABC
Airway- rarely required in DM but assess always Breathing- give O2 to any pt with altered mental status Circulation- HYPOtension --> IMMEDIATE administration with isotonic crystalloid. always do 2 IV lines **also do accu check, dextrose and monitor |
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how often is airway mgmt required in the pt w/DM w/metabolic complications
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not often!
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based on cardiac monitoring what are hte signs of requiring K supplements
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T or small U- consider early supplementation
Tall peaked T- consistent with hyperkalemia, and supplementation is withheld until the level of K is known |
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how often do you see polyuria, polydipsia adn polyphagia in DKA
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50%
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tell me what DM pts get dextrose
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all
*if accucheck shows HYPERglycemia it can be withheld until you get true values (sometimes accucheck is wrong). *typically you can do more harm from being HYPO than HYPER so they sometimes risk it and give dextrose even with a high sccucheck |
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tell me about the heart monitor and DM altered mental status
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assess rhythem
asses T waves for K levels (DKA- K is normal or high but falls FAST with tx, to prevent hypokalemia K is supplemented) Normal/Small T & U wave- consider early K supplementation Tall Peaked T- indicated hyperkalemia, hold off on supplementation |
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what happens to K in DM with DKA
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its normal to high but drops as we start to treat, use EKG to determine when to start supplementing K
**supplement with U waves *tall peaked T means HYPERkalemia, dont supplement |
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tell me about altered mental status and naloxone
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given to all pts
*cover against an occult opoid intoxication |
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what are the areas of focus in a Hx in a pt with DM w/altered mental status
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1. Activity
2. Meds- changes, dose, how often etc 3. food 4. B BLOCKERS, mask initial sx of tachy, diaphoretic, anxious 5. thirsty, hungry, pee lots 6. usual mental status 7. GI complaints 8. stress, trauma, infections 9, known complicationsof DM |
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what is DKA misdx as often
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gastroenteritis
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ABG and altered mental status
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pH assess degree of acidosis
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shoudl we do UA for DKA
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you bet!
glucose, ketones, infection, dehydration |
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whats the coma scale
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monitor pt, look for deterioration/improvement
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whats a flow sheet
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in pt w/DKA
serial recording of vitals, urine outflow, fluid intake, mental status, lab values do as a flow sheet so ppl can follow |
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besides just monitoring rhythem, ischemia and electrolytes, why is EKG important in DM
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DM have silent MI more often
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where do you focus on your PE with DM w/altered mental status
GEN VITALS COnsciousness HEENT HEART LUNGS ABD Extremities Neurologic |
1. GEN: dehydrated --> hypovolumic shock. fruity breath
2. Vitals: tachy, tachy penia (fast deep breath-kussmals) 3. consciousness: varies 4. HEENT: look for trauma, malignant otitis externa, meningitis, fundoscopic exam 5. Heart: dehydration, be sure there is perfusion 6. Lungs: kussmals, cxr for consolidations or aspirations 7. abd: hypokalemia will decrease bowel soudns. SIGNIFICANT pain w/o peritoneal signs of guarding and rebound 8. Ext: cap refill, turgor 9. neuro: intracranial pathology |
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whats kussmals
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rapid deep breathing with DKA
will smell fruity, tachypenic |
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define DKA
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Glucose >300 (typically btwn 500-800)
Ketones: >1.2 Acid: <7.3 pH or <15 Bicarb **acidosis can be PROFOUND |
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why get CBC in DM w/AMS
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WBC usually always increased (even w/o infection)
white count related to severity of DKA Hgb, HCt increased bc of dehydration |
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what electrolytes are important in DM w/AMS
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Na low- can be fake low
K normal then drops w/tx |
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what happenes to Na in DKA
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decreases
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renal fx and DKA, how are the results changed
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BUN increased bc of dehydration
Creatanine increased bc of ketones |
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what does it mean if someone with true DKA has normal measured ketones
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you make 3 ketones: acetone, acetoacetate, b hydroxy butyrate
B hydroxybutyrate is normally the highes but is not measured by nitroprusside rxn |
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what can ppt cerebral edema in DKA
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rapid decrease in serum osmolarity
2(Na) + glucose/18 + Bun/2.8 285-385 is normal |
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how do you calc serum OSM
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2 (Na) + glucose/18 + Bun/2.8
normal is 285-385 |
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why do you see hyaline causes in UA in DKA
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bc of dehydration
WBC- infection (high in blood always) glucose ketones |
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what are the main goials of DKA tx
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1. restore volume
2. normalize glucose 3. correct acidemia 4. correct/maintain electrolytes 5. restore normal serum OSM (285-385) |
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how is hypoglycemia controlled
what if its caused by oral hypoglycemic agents |
pt awake: oral glucose followed by protein meal
unconscious: IV glucose or IM glucagon oral hypoglycemic agents --> ADMIT |
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what is the MOST important part of therapy in DKA
how is it initially managed for stable and unstable pt |
fluids, will increase circulating volume AND dilute the sugar. it WONT clear ketones, need insulin for that
6L deficit! WOW Stable: 1L over 30 min, 2 L over 1-2 hrs UNstable: 2L NaCLgiven rapid and watch |
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how much does glucose fall in DKA when you restore fluids
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15-20%
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how do you lower glucose in DKA
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slow 100mg/dl/hr
give with insulin **when you get to like 250-300 glucose start adding dextrose |
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in DKA what is necessary to clear ketones
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insulin
**insulin is not given initially, hten given, then cut in half and continued until acidosis adn acedemia are resolved |
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what is a persons hypoglycemia is cause by increased amt of oral hypoglycemic agents
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ADMIT them
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do you give bicarb to correct for acidemia in DKA
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nope, you can but itsrisky
better to just use inculin to clear acids adn ketones |
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whats the infusion rate of K
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varies every hour!
be sure there are no spiked T's |
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as we treat DKA what do we want to monitor closely every hourr
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glucose
electrolytes OSM ABG |
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what fluid is given in HHS
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normal saline until stable then 0.45 NaCl
**want to lower at about 100mg/dl/hr **fluids will drop glucose about 25-30% |
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who is more sensitive to insulin DKA or HHC
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HHS, when you give it use less than in DKA
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when do you give K for HHS
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as soon as you get urine output
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what complicates HSH
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lots! its like the deal that HHS is complicated by other health complications and DKA usually wont have other associations
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