Unit 5 & 6 Chapter 59 Diabetic Ketoacidosis and Hyperglycemic- Hyperosmolar State

Question 1

What is DKA

Answer 1

Complications of untreated hyperglycemia, metabolic acidosis , and increased ketones

Question 2

What type of diabettes is the patient with DKA mainly affected by?
A. Type 1
B. Type 2

Answer 2

A. Type 1
-skinny
-

Question 3

What is the cause of DKA

Answer 3

This condition results from the combination of insulin deficiency and an increase in hormone release that leads to increased liver and kidney glucose production.

occurs suddenly

Question 4

S/s of DKA

Answer 4

• Blood sugar over 300
• Ketones in urine
• Dehydration
• Metabolic acidosis
• Polyuria
• Polyphagia
• Polydypsia
• Fruity odor breath
• Kussmal respirations; deep rapid breathes
• Vomiting,
• Abdominal pain,
• Weakness,
• Confusion,
• Shock,
• Coma.
• Weak thread pulse
• Dry mucous membranes
• Hyperthermia
• Increased urine specific gravity

Question 5

Which of these definitions define kussmal respirations?
A. Deep rapid breaths
B. Shallow slow breathes
D. Deep slow breathes
D. Shallow rapid breathes

Answer 5

A. Deep rapid breaths

Question 6

What is the typical fluid initiated for a patient with Diabetic Ketoacidosis?
A. 0.45% Normal Saline
B. 3% Sodium chloride
C. Lactated Ringers
D. 0.9% Normal Saline

Answer 6

D. 0.9% Normal Saline

Question 7

What electrolyes fluid shift you expect to present for a patient with Diabetes Keto Acidosis?
A. Serum Sodium level 130
B. Serum Potassium level 6.0
C. Serum Magnesium level 2.4
D. Serum Calcium of 11.0

Answer 7

B. Serum Potassium level 6.0

HYPERKALEMIA

Mild-to-moderate hyperkalemia is common in patients with hyperglycemia. Insulin therapy, correction of acidosis, and volume expansion decrease serum potassium concentration.

Question 8

How would hyperkalemia present its self on a ECG?

A. ST depression
B. Absent p wave
C. Peak T waves
D. ST inversion

Answer 8

C. Peak T waves

Question 9

What fluid is given to prevent hypoglycemia to your patient who has gone through with blood glucose management?
A. 0.45% Normal Saline
B. 5% Dextrose in 0.45% NS
C. Lactated Ringers
D. 0.9% Normal Saline

Answer 9

B. 5% Dextrose in 0.45% NS

When blood glucose levels reach 250 mg/dL (13.8 mmol/L), give 5% dextrose in 0.45% saline. This solution helps prevent hypoglycemia and cerebral edema, which can occur when serum osmolarity declines too rapidly.

THERE SHOULD BE A STEADY DROP NOT A RAPID DROP IN BLOOD GLUCOSE THIS CAN CAUSE SERUM OSMARLITY TO SHIFT AND DECLINE RAPIDLY

Question 10

What is the function of Serum Osmarlity?

Answer 10

Osmolality indicates the concentration of all the particles dissolved in body fluid.

Question 11

When serum Osmarlity declines too rapidy, what are the typical signs and symptoms?
A. Hypernatremia
B. Hyperglycemia
C. Cerebral Edema
D. Weak thready Pulse

Answer 11

Cerebral Edema

-cerebral edema
-hypoglycemia

Question 12

What is the normal range for Serum Osmarality?

Answer 12

285-295

Question 13

Is IV Regular Insulin recommended for the tx of DKA
A. Yes
B. No

Answer 13

A.Yes

An initial IV bolus dose is given, followed by an IV continuous infusion. Continuous insulin infusion is used because insulin half-life is short and subcutaneous insulin has a delayed onset of action

Question 14

What are indications that DKA is resolved?
A. Blood glucose 360
B. HCO3 23
C. PaO2 80%
D. SaO2 97%

Answer 14

B. HCO3 23

DKA is considered resolved when blood glucose is less than 200 mg/mL (11.2 mmol/L) along with a serum bicarbonate level higher than 18 mEq/L (mmol/L),venous pH is higher than 7.30**, and a calculated anion gap is less than 12 mEq/L (mmol/L).

Question 15

After initiation of IV Insulin, what complication should you monitor for?
A. Dry warm skin
B. Serum Potassium Level 1.5
C. Serum Calcium 11.0
D. Constipation

Answer 15

B. Serum Potassium Level 1.5

Assess for signs of hypokalemia, including fatigue, malaise, confusion, muscle weakness, shallow respirations, abdominal distention or paralytic ileus, hypotension, and weak pulse.

Question 16

Your patient’s urine output has been 15ml/hr for 2 hours. He has a diagnosis of Diabetes Ketoacidosis and his potassium level is 3.3. What action requires further teaching?
A. Administering PO potassium chloride powder with water.
B. Placing the patient on a cardiac monitor
C. Assessing the patients hydration status
D. Assessing the clients urine for ketones

Answer 16

A. Administering PO potassium chloride powder with water.

Before giving IV potassium-containing solutions, ensure that urine output is at least 30 mL/hr.

Question 17

When is Bicardbinoate replaced?

Answer 17

Bicarbonate is used only for severe acidosis. Sodium bicarbonate, given by slow IV infusion over several hours, is indicated when the arterial pH is 7.0 or less or the serum bicarbonate level is less than 5 mEq/L (5 mmol/L).

Question 18

Patient Teaching for DKA

Answer 18

Teach the patient and family to check blood glucose levels every 4 to 6 hours as long as symptoms such as anorexia, nausea, and vomiting are present and as long as glucose levels exceed 250 mg/dL (13.8 mmol/L). Teach them to check urine ketone levels when blood glucose levels exceed 300 mg/dL (16.7 mmol/L).

Teach the patient to prevent dehydration by maintaining food and fluid intake. Suggest that he or she drink at least 2 L of fluid daily and increase this amount when infection is present.

When nausea is present, instruct the patient to take liquids containing both glucose and electrolytes (e.g., regular sugar-sweetened soda pop, diluted fruit juice, and sports drinks [Gatorade]).

When the blood glucose level is normal or elevated, the patient should take 8 to 12 ounces (240 to 360 mL) of calorie-free and caffeine-free liquids every hour while awake to prevent dehydration.

Instruct the patient and family to consult the diabetes health care provider or primary health care provider when these problems occur:
* Blood glucose exceeds 250 mg/dL (13.8 mmol/L) and does not respond to therapy.
* Ketonuria lasts for more than 24 hours.
* The patient cannot take food or fluids.
* Illness lasts more than 1 to 2 days.

Question 20

Sick Day Rules

Answer 20

• Notify your primary health care provider or diabetes health care provider that you are ill.
• Monitor your blood glucose at least every 4 hours.
  Test your urine for ketones when your blood glucose level is greater than 240 mg/dL (13.8 mmol/L).
• Continue to take insulin or other antidiabetic agents, unless instructed otherwise by your primary health care provider.
  **To prevent dehydration, drink 8 to 12 ounces (240 to 360 mL) of sugar-free liquids every hour that you are awake. If your blood glucose level is below your target range, drink fluids that contain sugar.
• Continue to eat meals at regular times.
• If unable to tolerate solid food because of nausea, consume more easily tolerated foods or liquids equal to the carbohydrate content of your usual meal.

* Call your diabetes health care provider for any of these problems:*

• Persistent nausea and vomiting
• Moderate or high ketones
• Blood glucose elevation after two supplemental doses of insulin
  High (101.5°F [38.6°C]) temperature or increasing fever; fever for more than 24 hours
• Treat diarrhea, nausea, vomiting, fever as directed by your diabetes health care provider.
  Get plenty of rest.

Question 21

What is HHS

Answer 21

GRADUAL
MORE SEVERE DEHYDRATION
IS MORE LETHAL THAN DKA

Hyperglycemic-hyperosmolar state (HHS) is a hyperosmolar (increased blood osmolarity) state caused by hyperglycemia.

Question 22

Does HHS typically occur in tyoe on or type 2
A. Type 1
B. Type 2

Answer 22

B. Type 2

Question 23

What would indicate that HHS is resolved?
A. Serum osmolality has decreased from 400 to 295.
B. Ketones present in urine
C. Hypertension
D. decreased level of consciousness

Answer 23

A. Serum osmolality has decreased from 400 to 295.

Question 24

What can induce HHS for type 2 diabetics?

Answer 24

Myocardial infarction, sepsis, pancreatitis, stroke, and some drugs (glucocorticoids, diuretics, phenytoin, beta-blockers, and calcium channel blockers) also may cause or contribute to HHS.

Question 25

Do patients with DKA OR HHS have seizures OR REVERSIBLYE PARALYSIS?
A. DKA
B. HHS

Answer 25

B. HHS

Unlike DKA, patients with HHS may have seizures and reversible paralysis.

Question 26

What can induce seizures in a patient with HHS?
A .decreased environmental stimuli
B. low-sounding alarms
C. limit family visitations
D. Increased serum osmolality

Answer 26

D. Increased serum osmolality

The degree of neurologic impairment is related to serum osmolarity, with coma occurring once serum osmolarity is greater than 350 mOsm/L (350 mmol/L). Normal serum osmolarity is between 270 mOsm (270 mmol/L) and 300 mOsm/L (300 mmol/L).

Question 27

What fluid and electrolyte imbalance would you suspect for a patient with HHS?

pH: 7.55 PaO2 80 SaO2: 95 HCO3: 30 CO2: 35

a. Metabolic acidosis
b. Respiratory Acidosis
c. Respiratory Alkaline
d. Metabolic Alkalosis

Answer 27

Metabolic Alkalosis

d. Metabolic Alkalosis

Question 28

What are S/s of HHS

Answer 28

Blood glucose levels may exceed 600 mg/dL
severe dehydration
No ketones
* seizure risk
* metabolic alkalosis
*

HHS occurs most often in older patients with type 2 DM, many of whom are unaware they have the disease

Question 29

What is the tx for HHS

Answer 29

-The expected outcomes of therapy are to rehydrate the patient and restore normal blood glucose levels within 36 to 72 hours.

-iv fluid

Question 30

HHS, should you monitor for cerebral edema?

Answer 30

Assess the patient hourly for signs of cerebral edema (i.e., abrupt changes in mental status, abnormal neurologic signs, and coma).

Question 31

The Insulin-Dependent Patient With Diabetes During a Home or Clinic Visit

Answer 31

• Assess overall mental status, wakefulness, ability to participate in a conversation.
• Take vital signs and weight:
• Fever could indicate infection.
• Are blood pressure and weight within target range? If not, why?
• Ask the patient about any change in vision; check current visual acuity.
• Inspect oral mucous membranes, gums, and teeth.
• Ask about injection areas used; inspect areas being used; assess whether the patient is using areas and rotating sites appropriately.
• Inspect skin for intactness, wounds that have not healed, new sores, ulcers, bruises, or burns; assess any previously known wounds for infection, progression of healing.
• Ask the patient how often and how he or she performs foot care.
• Assess lower extremities and feet for peripheral pulses, lack of or decreased sensation, abnormal sensations, breaks in skin integrity, condition of toes and nails.
• Ask about the color and consistency of stools and frequency of bowel movements; assess abdomen for bowel sounds.
• Review patient’s home health diary:
• Is blood glucose within targeted range? If not, why?
• Is glucose monitoring being recorded often enough?
• Is the patient’s food intake adequate and appropriate? If not,
  why?
• Is exercise occurring regularly? If not, why?
• Assess the patient’s ability to perform self-monitoring of blood glucose.
• Assess the patient’s procedures for obtaining and storing insulin and syringes, cleaning equipment, disposing of syringes and needles.
• Assess the patient’s insulin preparation and injection technique.
• Assess the patient’s knowledge of drug therapy and which side effects to look for.