HHNC vs DKA

HHNC (Hyperglycemic Hyperosmolar Non-Ketotic Coma)

• Typically seen in type 2 diabetes
• Characterized by very high blood glucose levels, often above 600 mg/dL
• Little to no ketone production occurs insulin levels are sufficient to prevent ketogenesis, but not enough to control blood glucose
• Symptoms include severe dehydration, mental confusion, and altered consciousness
• A key feature is the absence of acidosis
• Treatment involves Fluids, Insulin, Potassium, Electrolytes, and addressing the Root cause

DKA (Diabetic Ketoacidosis)

• Most commonly seen in type 1 diabetes but can occur in type 2
• Blood glucose levels are usually elevated above 300 mg/dL
• Ketones are produced due to insulin deficiency, leading to metabolic acidosis
• Acidosis is a hallmark, resulting in low blood pH from ketones
• Symptoms include polydipsia, polyuria, polyphagia, nausea and vomiting, rapid weak pulse, breath smells like ketones, confusion, and Kussmaul respirations
• Interventions include ensuring airway patency, monitoring vital signs, administering fluids (0.9% NaCl), initiating insulin drip, and assessing breath sounds

Hypoglycemia Complications

• Confusion, dizziness, and fainting can occur
• Seizures or loss of consciousness can occur in severe cases
• Coma or even death can result if not treated promptly
• Long-term, recurrent hypoglycemia can lead to a fear of hypoglycemia and reduced awareness of symptoms

Hypoglycemia Signs and Symptoms

• Shakiness is a sign
• Irritability is a sign
• Nervousness is a sign
• Tachycardia is a sign
• Palpitations are a sign
• Hunger is a sign
• Diaphoresis is a sign
• Pallor is a sign
• Paresthesias is a sign
• Headache is a sign
• Poor concentration is a sign
• Slurred speech is a sign
• Blurred vision is a sign
• Confusion is a sign
• Lethargy is a sign
• Loss of consciousness is a sign
• Coma can occur
• Death can occur

Hypoglycemia Prevention

• Regularly monitor blood sugar levels
• Eat balanced meals and snacks, especially with complex carbohydrates
• Adjust insulin doses based on activity levels and food intake
• Educate patients on recognizing early signs and carrying fast-acting carbohydrates

Hyperglycemia Signs and Symptoms

• Blurred vision is a symptom
• Pruritus is a symptom
• Paresthesias, peripheral neuropathy, lethargy, weakness, and irritability are symptoms
• Polydipsia, polyuria, and polyphagia (three "P"s) are symptoms
• Non-healing wounds are a symptom
• Increased respiratory rate (Kussmaul's respirations) is a symptom

Somogyi Effect

• Undetected hypoglycemia during sleep causes the body to mobilize glucose reserves
• Can cause rebound hyperglycemia and potentially DKA
• Counter-regulatory hormones like glucagon, cortisol, and epinephrine are released in response to low blood sugar, causing a rise in glucose levels
• High morning blood glucose levels can occur, even with overnight hypoglycemia

Somogyi Effect Management

• Less insulin
• Adjusting insulin dose or timing
• Ensure blood glucose levels are checked before bed

Dawn Phenomenon

• Hyperglycemia upon waking due to the release of counter-regulatory hormones at dawn
• Growth hormone is a major culprit, affecting adolescents and young adults
• Treatment involves adjusting insulin timing

Rapid-Acting Insulin

• Examples include Humalog, Lispro, and Aspart
• Administer 0-15 minutes before a meal
• Onset: 10-30 minutes
• Peak: 30 minutes to 3 hours
• Duration: 3-5 hours

Short-Acting Insulin

• Regular insulin is an example
• Administer 30-45 minutes before a meal
• Onset: 30 minutes to 1 hour
• Peak: 2-5 hours
• Duration: 5-8 hours

Intermediate-Acting Insulin

• NPH is an example
• Onset: 2-4 hours
• Peak: 4-10 hours
• Duration: 12-18 hours

Long-Acting Insulin

• Lantus, Glargine, and Detemir are examples
• Onset: 1-2 hours
• Peak: No true peak, continuous release
• Duration: 18-24 hours

Diabetic Diet Components for T2DM

• Reduce caloric intake if obese
• Diet alone may be sufficient for glucose control
• Timing of meals is not as essential as with Type I unless using NPH or other medications
• A snack is necessary if using insulin or other diabetic drugs
• Need 20g of CHO per hour if exercising and using insulin
• Carbohydrates should focus on complex carbs like whole grains, legumes, and vegetables with a low glycemic index
• Lean proteins: chicken, fish, tofu, and legumes help manage hunger and stabilize blood sugar
• Healthy Fats: Include unsaturated fats like olive oil, nuts, and avocado
• High-fiber foods help to regulate blood sugar and improve digestion
• Fruits and vegetables, rich in vitamins, minerals, and fiber, should be consumed in appropriate portions

How a Diabetic Diet Helps

• Balancing carbohydrates and fiber helps regulate blood sugar
• Small, frequent meals prevent large fluctuations in glucose levels
• Proper portion control and consistent meal timing helps achieve stable blood sugar levels throughout the day

Effects of Exercise on Blood Sugar

• Physical activity increases insulin sensitivity and can lower blood glucose levels by promoting glucose uptake by muscles
• Hypoglycemia risk is increased, especially in those using insulin or insulin secretagogues

Precautions for Exercise with Diabetes

• Monitor blood sugar before, during, and after exercise
• Have a source of fast-acting glucose available
• Adjust insulin or medication doses with healthcare provider guidance
• Stay hydrated and avoid exercising during periods of high blood sugar

Diabetes Insipidus (DI)

• Caused by a deficiency of antidiuretic hormone (ADH) or resistance to its effects on the kidneys
• Results in the inability of the kidneys to concentrate urine, causing excessive urination (polyuria) and thirst (polydipsia) which leads to dehydration if not treated
• Central DI is caused by insufficient ADH production in the hypothalamus or pituitary
• Nephrogenic DI occurs when the kidneys do not respond to ADH

DI Complications

• Dehydration can result
• Hypovolemic shock (hypotension, tachycardia, poor skin tugor, dry mucous membranes, weight loss) can result
• Hypernatremia can result
• Neuro changes from brain cell dehydration due to hypernatremia can result
• Seizures, coma, and death can result
• Electrolyte imbalances: K+, Mg2+, Ca2+, and PO4 can occur
• Cerebral edema can occue
• Low urine specific gravity (dilute)

DI vs DM

• DM involves high blood glucose levels due to problems with insulin production or function
• DI primarily disturbs fluid balance and does not cause high blood glucose levels

Hyperthyroidism

• Overproduction of thyroid hormones (T3 and T4), often due to Graves' disease, thyroid nodules, or inflammation
• Symptoms include weight loss, rapid heartbeat (tachycardia), anxiety, tremors, heat intolerance, excessive sweating, and bulging eyes (in Graves' disease)
• Treatment includes medications like antithyroid drugs (e.g., methimazole), radioactive iodine therapy, or surgery to remove part of the thyroid

Hypothyroidism

• Underproduction of thyroid hormones, often due to Hashimoto’s thyroiditis, iodine deficiency, or thyroid surgery
• Symptoms: Weight gain, fatigue, depression, cold intolerance, dry skin, constipation, and slow heart rate
• Treatment involves thyroid hormone replacement therapy (e.g., levothyroxine)

Hyperparathyroidism

• Overproduction of parathyroid hormone (PTH), often due to a parathyroid adenoma (benign tumor) or hyperplasia
• Symptoms include painful muscle cramps, termors, high calcium levels (hypercalcemia ^ Ca+), leading to fatigue, weakness, kidney stones, osteoporosis, and abdominal pain.
• Treatment is Surgical removal of the parathyroid gland(s)

Hypoparathyroidism

• Underproduction of PTH, often due to surgical removal of the parathyroid glands, autoimmune diseases, or genetic disorders
• Symptoms: Low calcium levels (hypocalcemia ! Ca+), leading to muscle cramps, tetany, numbness, and seizures
• Treatment involves calcium and vitamin D supplements

Post-Operative Complications of Parathyroid Surgery (Post Thyroidectomy)

• Hypocalcemia (! Ca+) and tetany due to damage or removal of the parathyroid glands can occur
• Recurrent laryngeal nerve injury, leading to hoarseness or difficulty swallowing can occur
• Hemorrhage can occur
• Respiratory Distress (due to swelling) can occur
• Infection at the surgical site. can occur

Cushing's Syndrome

• The Cause is overproduction of cortisol, often due to adrenal tumors, pituitary tumors (Cushing’s disease), or long-term use of corticosteroid medications
• Symptoms: Weight gain (especially in the abdomen and face), buffalo hump, round face (moon face), skin thinning, bruising, hypertension, and increased risk of infections
• Treatment involves surgery to remove the tumor, medication to reduce cortisol production, or radiation therapy

Addison's Disease

• The Cause is underproduction of cortisol and aldosterone, usually due to autoimmune destruction of the adrenal glands
• Symptoms: Fatigue, weight loss, low blood pressure, salt cravings, hyperpigmentation (darkening of the skin), and hypoglycemia
• Treatment involves steroid replacement therapy (e.g., hydrocortisone, fludrocortisone) and treating the underlying cause

Key Difference Between Cushing's and Addison's

• Cushing's syndrome involves excess cortisol
• Addison's disease involves insufficient cortisol

Adrenal Insufficiency

• Adrenal glands do not produce enough cortisol and aldosterone

Primary Adrenal Insufficiency (Addison's disease)

• Adrenal glands themselves are damaged

Secondary Adrenal Insufficiency

• Pituitary or hypothalamus fails to produce enough ACTH

Symptoms of Adrenal Insufficiency

• Fatigue is a symptoms
• Weight loss is a symptoms
• Nausea is a symptoms
• Vomiting is a symptoms
• Muscle weakness is a symptoms
• Low blood pressure is a symptoms
• Hyperpigmentation, darkening of the skin can also occur.

Treatment for Adrenal Insufficiency

• Replacement therapy (hydrocortisone)
• Mineralocorticoid replacement (fludrocortisone)

SIADH (Syndrome of Inappropriate Antidiuretic Hormone)

• Body produces too much antidiuretic hormone (ADH)
• Leads to water retention, dilutional hyponatremia (low sodium levels), and reduced urine output

SIADH Causes

• Head injuries
• Brain tumors
• Lung cancer
• Certain medications (e.g., SSRIs, anticonvulsants)
• Infections

SIADH Symptoms

• Nausea
• Vomiting
• Confusion
• Seizures
• Muscle cramps

SIADH Treatment

• Fluid restriction
• Salt supplementation
• Medications like demeclocycline or vasopressin receptor antagonists (e.g., tolvaptan)

SIADH Diagnostics

• High urine osmolality (kidneys are reabsorbing water and concentrating the urine)
• High urine specific gravity (more waste in urine, kidneys cannot filter)
• Low serum osmolality
• Decreased hematocrit, BUN, and serum sodium

Dangerous Sodium Levels

• 116-125 mEq/L can lead to changes in LOC, nausea/vomiting, and muscle cramping
• Less than 116 mEq/L can lead to seizures, coma, and death

Acute Renal Failure

• Sudden loss of kidney function
• Often caused by sudden injury, infection, or obstruction of urine flow
• Can be reversible if treated promptly

Danger Signs of Acute Renal Failure

• Decreased urine output indicates hypovolemia
• Decreased blood pressure indicates decreased cardiac output and hypotension

Chronic Renal Failure

• Gradual loss of kidney function over time
• Often caused by conditions like diabetes or hypertension
• Irreversible and can eventually lead to end-stage kidney disease (ESKD)

Dialysis

• Medical treatment when kidneys are no longer able to filter waste products from the blood
• Hemodialysis (machine to filter the blood) or peritoneal dialysis (lining of the abdomen as a filter)

Indication for Dialysis

• End-stage renal failure
• Kidneys are functioning at less than 15% of their capacity

Assessment of Hemodialysis

• Assess for a bruit and thrill
• Assess for Fever or signs of infection
• Assess for uncontrolled bleeding from access site
• Assess for severe hypotension or chest pain
• Assess for Confusion/seizures
• Assess for sudden drop in LOC

Continuous Bladder Irrigation (CBI)

• Medical procedure where a sterile solution is continuously flushed through the bladder via a catheter
• Often done after bladder surgery or to prevent clots from forming
• Keeps the bladder clear of debris, blood clots, or obstructions
• Reduces the risk of infection

Cirrhosis

• Chronic liver disease where normal liver tissue is replaced with scar tissue (fibrosis)
• Leads to progressive loss of liver function

Cirrhosis Manifestations

• Fibrosis/scarring of the liver
• Portal hypertension
• Low albumin
• Ascites (fluid in the abdomen)
• Crackles
• Edema
• Esophageal varices
• Decreased albumin

Cirrhosis Common Symptoms

• Fatigue
• Weakness
• Loss of appetite and weight loss
• Abdominal bloating
• Jaundice (yellowing of skin/eyes)
• Clay-colored stool

Cirrhosis Abnormal Symptoms

• Vomiting blood (due to ruptured varices)
• Confusion or drowsiness (hepatic encephalopathy)
• Muscle wasting
• Bruising or bleeding easily (due to impaired clotting)

Treatment for Alcoholic Cirrhosis

• Alcohol cessation
• Treat complications such as ascites, encephalopathy, bleeding varices, and infections

Treatments for Specific Cirrhosis Complications

• Ascites: Low sodium diet, diuretics (spironolactone), paracentesis
• Encephalopathy: Lactulose and rifaximin
• Low albumin is a complication
• Bleeding from varices: Beta-blockers, endoscopic banding, TIPS procedure, vitamin K

Cirrhosis Diet

• Increase calories and protein
• Include vitamin B1 (thiamine), folic acid, B12, A, D, E, K, zinc, and magnesium

Cirrhosis Labs

• Liver function (AST, ALT, bilirubin) test
• Clotting (INR) test
• Albumin level
• Ammonia levels
• Electrolytes and kidney function test

Liver Transplant

• Watch for confusion, swelling, and bleeding
• Monitor daily weight and belly size
• Educate on fall prevention
• Educate about avoiding alcohol and liver-damaging medications (like NSAIDs)

Treatment for Liver Disease

• Lactulose (decreases albumin)
• Diet changes (low sodium, potassium, phosphorus, and protein)
• Fluid restrictions
• Blood pressure control (ACE inhibitors or ARBs)
• Blood sugar control (in diabetics)
• Treat anemia with iron or Epoetin
• Phosphate binders and vitamin D
• Regular labs and nephrologist visits
• Dialysis or transplant if end-stage

Nursing Priorities for Liver Disease

• Monitor I&O, daily weight
• Watch for electrolyte imbalances (especially ↑K, ↑phosphorus, ↓calcium)
• Prevent infection
• Educate on diet, meds, and fluid limits
• Support for dialysis or transplant prep

Balanced Diet

• Lean proteins (chicken, fish, tofu, eggs)
• Whole grains (brown rice, oats, quinoa)
• Vegetables & fruits (fresh, cooked, or low-sodium canned)
• Healthy fats (olive oil, avocado, nuts (unsalted))
• High-calorie snacks if underweight (e.g., smoothies, nut butter)

Beneficial Food Advice for Liver

• Coffee (some research shows it may protect liver cells)

Foods to Avoid for Liver

• Alcohol
• Salt-heavy foods (canned soups, deli meats, chips, pickles, high-fat/fried foods)
• Red meat (limit in hepatic encephalopathy to ammonia)
• Simple sugars (soda, candy)

Pancreatitis

• Inflammation of the pancreas (acute or chronic)
• Autodigestion of pancreatic tissue by enzymes
• Edema or necrosis of pancreas
• Can lead to systemic inflammation

Pancreatitis Common Symptoms

• Sudden, severe upper abdominal pain (often radiating to the back)
• Nausea and vomiting
• Fever
• Increased heart rate
• Abdominal tenderness

Pancreatitis Abnormal Symptoms

• Cullen’s sign (bruising around the navel)
• Grey-Turner’s sign (flank bruising)
• Hypocalcemia (tetany, muscle spasms)
• Pancreatic pseudocysts or abscess

Pancreatitis Electrolyte Imbalance

• High Glucose (hyperglycemia can be as high as 500-900)
• Decreased Calcium
• Decreased Potassium
• Decreased Magnesium

Cholelithiasis (Gallstones)

• Formation of stones within the gallbladder, typically made of cholesterol or bilirubin

Cholelithiasis Manifestations

• May be asymptomatic (silent stones)
• Can obstruct bile ducts
• Biliary colic (pain due to blockage)

Cholelithiasis Common Symptoms

• RUQ (right upper quadrant) pain, especially after fatty meals
• Nausea and vomiting
• Bloating, indigestion

Cholelithiasis Abnormal Symptoms

• Jaundice (if bile flow is obstructed)
• Fever and chills (if infection occurs - cholecystitis)
• Clay-colored stools, dark urine (due to bile obstruction)

Liver Biopsy Position

• Positioning for a liver biopsy to ensure safety and accuracy

Liver Biopsy Common Position

• Supine or slightly turned to the left side, with the right arm raised above the head to expose the right upper quadrant

Post-Liver Biopsy

• Right side-lying position with a small pillow or rolled towel under the site to apply pressure and prevent bleeding

Abnormal Symptoms After a Liver Biopsy

• Severe abdominal pain (could indicate internal bleeding)
• Shoulder pain (referred pain from diaphragm irritation)
• Dizziness or drop in blood pressure( hemorrhage)

Hepatitis

• Inflammation of the liver caused by viruses (Hep A, B, C, etc.), alcohol, drugs, or autoimmune disease
• Hepatocellular injury
• Elevated liver enzymes (ALT, AST)
• Impaired bile excretion

Common Hepatitis Symptoms

• Fatigue
• Malaise
• Jaundice
• Nausea
• Vomiting
• RUQ discomfort

Abnormal Hepatitis Symptoms

• Prolonged bleeding time (due to decreased clotting factors)
• Confusion (hepatic encephalopathy)
• Dark urine
• Light stools

Jaundice

• Yellow discoloration of the skin, sclera (eyes), and mucous membranes due to elevated bilirubin levels
• Hyperbilirubinemia (usually >2.5 mg/dL)
• Can be pre-hepatic (e.g. hemolysis), hepatic (e.g. hepatitis), or post-hepatic (e.g. bile duct obstruction)
• Yellowing of skin and eyes
• Itching (pruritus)
• Dark urine
• Fatigue

Esophageal Varices

• Develop in response to increased portal blood pressure
• Distended tortuous vessels that can rupture secondary to coughing, sneezing, vomiting, or ingestion of foods high in roughage
• Bleeding can be abrupt and painless, leading to death

Esophageal Varices Priority

• Monitor VS closely – especially signs of hypovolemic shock
• Monitor for hematemesis and melena
• Prepare for blood transfusion
• Keep NPO
• Elevate HOB to prevent aspiration
• Watch for signs of hepatic encephalopathy

Asterixis

• Definition
• Definition: Asterixis is a brief, non-rhythmic involuntary muscle twitching or “flapping” movement, usually observed when the arms are extended and wrists dorsiflexed like telling someone to stop

Metabolic Causes Hepatic or Renal

• Hepatic encephalopathy most common
• Uremic encephalopathy
• kidney failure
• Hypercapnia CO 3 retention (advanced COPD or respiratory failure)
• Structural brain lesions thalamus, cerebellum, or basal ganglia most commonly
• Drug toxicity phenytoin, valproate, barbiturates, benzodiazepines
• Decreased BUN Creatinine
• Increased ! Sodium
• Increased ! Potassium
• Decreased ! CA Calcium
• Check for SIADH which leads to increased BUN

Important Reminders for Test Taking

• Remember when prioritizing care THINK Airway Breathing (Ventilation) Circulation
• Read the questions carefully
• Be aware of dietary concerns for certain diseases
• Dietary concerns for certain diseases are important so make sure you know what these are for specific disease states
• Know difference between diseases paying particular attention to the hormones/major electrolytes levels that are affected in each disease process
• Sodium
• Potassium
• Albumin
• Calcium

Check for These Medications when Testing Patient

• Prednisone
• Heparin
• Insulins
• Antibiotics

Is The Patient Breathing

• YES-> Rapid Response
• NO=> Code Blue (Cardiac or Respiratory Rest )

Foley Cath Care

• Make sure hands are clean
• Peri-care must be daily
• Drainage bag below bladder
• Tubing free of kinks
• Monitor output higher than 30ml/hr
• Secure catheter
• Empty bag regularly
• Document I&O