Unit 2 Study Guide-Concepts of Care Patients with Diabetes Mellitus PDF

**Unit 2 Study Guide:** **[Chapter 59: Concepts of Care Patients with Diabetes Mellitus]** - Endocrine disorders: - Thyroid glands: - - Parathyroid glands: - - Pancreas: - Function: - Regulates digestion - Ensures glucose regu...

**Unit 2 Study Guide:** **[Chapter 59: Concepts of Care Patients with Diabetes Mellitus]** - Endocrine disorders: - Thyroid glands: - - Parathyroid glands: - - Pancreas: - Function: - Regulates digestion - Ensures glucose regulation - Includes: - Alpha cells - Secrete glucagon - Beta cells - Produce insulin and amylin - Glucagon: - Hormone that has balancing actions opposite of insulin - Prevents hypoglycemia - Triggers the release of glucose from liver & skeletal muscle - Called the "hormone of starvation" b/c secreted when food intake is low to release glucose from liver to keep blood glucose levels in normal range - Produced by alpha cells - Glycogenolysis - The breakdown of liver glycogen - Gluconeogenesis - The formation of glucose from the fat & proteins - Function: - Promotes glycogenolysis; increases blood sugar levels - Secretion control is made by: - Low blood glucose levels - Insulin: - Prevents hyperglycemia - Allows body cells to take up, use, & store carbs, fat, & protein - Called the "hormone of plenty" b/c secreted when food intake is high & moves glucose from blood into cells to keep blood glucose levels in normal range - Function: - Increase uptake of glucose into the cell; promotes glycogenesis; lowers blood sugar levels - Secretion control is made by: - Raised blood glucose levels - Made in the pancreas (organ located behind the stomach) - As blood glucose level rises after a meal, pancreas is triggered to release insulin - Clusters of cells called islets contain beta cells \> make the insulin \> release it into the blood - Somatostatin: - Function: - Mild inhibition of insulin & glucagon preventing fluctuations in blood glucose levels; decreases gut motility & secretion of digestive juices - Secretion control is made by: - Blood glucose levels - Testing: - FSBS: - Altered by eating habits on the day before the test (at least 8 hours before test) - Postpone administration of antidiabetic medication until after the level is drawn - Hemoglobin A1C: - Average blood glucose level during previous 120 days (lifespan of red blood cells) - Can help assess long-term glycemic control & predict risk for complications - Not altered by eating habits on the day before the test - Recommended at least twice yearly for those meeting expected treatment outcomes & have stable blood glucose control - Quarterly assessment is recommended for those whose therapy has changed or who are not meeting prescribed glycemic levels - Maintained at 7.0% or below - Expected reference range: 4%-6% - Clients' w/ diabetes reference range: 6.5%-8% w/ goes of \300 mg/dL) \> medical emergency - Oral glucose tolerance test (OGTT): - Test often used to diagnose gestational DM during pregnancy - Not generally used for routine diagnosis - Fasting BG level is drawn at start of test \> client instructed to consume a specific amount of glucose \> BG levels obtained every 30 min. for 2 hr. \> client must be assessed for hypoglycemia throughout procedure - FBG should be \ - DM Type II: - Basic Info: - Progressive disorder in which the person initially has insulin resistance that progresses to decreased beta cell secretion of insulin - Many pts. are obese - Specific causes are unknown - Cause: - Insulin resistance & beta cell failure have genetic & non genetic causes - Hereditary - Metabolic syndrome - Still, not all risks are known - Formally called adult-onset diabetes, most common type of diabetes - About 90-95% of ppl w/ diabetes have DM2 - Ppl can develop DM2 at any age, even during childhood, but this type of diabetes is most often associated w/ older age - DM2 is also associated w/ excess weight, physical activity, family history of diabetes, previous history of gestational diabetes, & certain ethnicities - Usually begins w/ insulin resistance, a condition linked to excess weight in which muscle, liver, & fat cells do not use insulin properly - As a result, body needs more insulin to help glucose enter cells to be used for energy - At first, pancreas keeps up w/ the added demand by producing more insulin - In time, pancreas loses its ability to produce enough insulin in response to meals, & blood glucose levels rise - Insulin's Jobs: - Facilitated diffusion: - Insulin assists glucose into the cells to use as energy - Helps liver hang onto glycogen - The liver stores glucose as glycogen - Inhibits glycogen breaking down into glucose - Type 1 vs. Type 2: - 1: - Cause: - Family history - Symptoms: - Bedwetting - Blurry vision - Frequent urination - Increased appetite & thirst - Mood changes & irritability - Tiredness & weakness - Unexplained weight loss - 2: - Cause: - Overweight and/or inactive - Family history - High blood pressure - Symptoms: - Increased appetite & thirst - Dark patches on armpits/neck - Frequent urination - Blurry vision - Tiredness & weakness - Unexplained weight loss - Metabolic syndrome: - Presence of at least 3 factors that increase the client's risk for cardiovascular events & developing DM2 - Simultaneous presence of metabolic factors increase risk for developing DM2 & cardiovascular disease - Features include: - Abdominal obesity - Hyperglycemia - Hypertension - Hyperlipidemia - Noncompliant diabetic: - - S/S: - Polyuria - Excess urine production and frequency from osmotic diuresis - Polydipsia - Excessive thirst due to dehydration - Loss of skin turgor, skin warm and dry - Dry mucous membranes - Weakness and malaise - Rapid weak pulse and hypotension - Polyphagia - Excessive hunger and eating caused from inability of cells to receive glucose (b/c of a lack of insulin or cellular resistance to available insulin) & the body's use of protein & fat for energy (which causes ketosis) - Client can display weight loss - Kussmaul respirations - Increased respiratory rate & depth in attempt to excrete carbon dioxide & acid due to metabolic acidosis - Recurrent Infections - Ask clients about the occurrence of vaginal yeast infections - Other possible manifestations: - Acetone/fruity breath odor (due to accumulation of ketones) - Headache - Nausea - Vomiting - Abdominal pain - Inability to concentrate - Fatigue - Weakness - Vision changes (blurred vision) - Slow healing of wounds (sores that do not heal) - Decreased level of consciousness - Seizures leading to coma - Medications: - Be aware of drug interactions w/ steroids - Aspirin Therapy: - Primary prevention for patients at risk for heart disease - Metformin - Decreases liver glucose production & decreases intestinal absorption of glucose - Improves insulin sensitivity \ increases peripheral glucose uptake & utilization - Can cause lactic acidosis in pts. w/ kidney impairment & should not be used by anyone w/ kidney disease - Hold drug before & after using contrast or any surgical procedure requiring anesthesia until adequate kidney function is established to prevent lactic acidosis - Lowers blood glucose by inhibiting liver glucose production, decreasing intestinal absorption of glucose, and increasing insulin sensitivity - Teach: - Do not drink alcohol - Decrease risk for lactic acidosis - Stop drug before imaging using contrast & start 48 hours after - Increased risk for kidney damage & lactic acidosis - Take B12 & folic acid supplements - Common side effects: - GI problems - Increases tissue sensitivity - Slows carbohydrate absorption in the intestines - Hypoglycemic agent - Glimepiride - Long-acting dose - More adherence - Insulin stimulator (second-generation sulfonylurea agent) - Lower blood glucose levels by triggering the release of preformed insulin from beta cells - Teach: - Be aware of s/s of hypoglycemia - Drug lowers blood glucose levels - Take with or just before meals to prevent hypoglycemia - About 30 min before meals - Interacts with many other drugs (consult provider before taking) - Beta-blockers can mask tachycardia typically seen during hypoglycemia - Avoid alcohol due to disulfiram effect - Stimulate insulin released from pancreatic beta cells and are used for patients who are still able to produce insulin - Increase tissue sensitivity to insulin following long-term use - Associated with lower risk of hypoglycemia attacks, less weight gain and better glycemic control than Glipizide - Hypoglycemic agent - Glipizide - Same as Glimepiride - Pioglitazone - Insulin sensitizer - Lower blood glucose by decreasing liver glucose production and improving the sensitivity of insulin receptors - Increases sensitivity to insulin - Teach: - Pts w/ CVD need to weigh themselves daily & report weight gain of more than 2 lbs. in 1 day or 4 lbs. in 1 week - Drug increases risk for heart failure - Monitor for fluid retention, especially in clients who have a history of heart failure - Report vision changes - Drug increases risk for macular edema - Monitor elevation of ALT, LDH, & triglyceride levels - Monitor for hepatotoxicity - Report SOB, decreased exercise tolerance, jaundice, or dark urine - Use additional contraception methods b/c the medication reduces the blood levels of oral contraceptives & stimulate ovulation - Have liver function tests at baseline & every 3-6 months thereafter - Common side effects: - Weight gain - Peripheral edema - Hypoglycemic agent - Diet Plan: - Balance between the intake of nutrients, the expenditure of energy, & the dose & timing of insulin or oral antidiabetic agents - Carbohydrates: 45% of total daily intake - Simple sugars - Complex carbohydrates - Recommended to be from vegetables, fruits, whole grains, legumes, dairy - Protein: 15%-20% of total daily intake, depending on kidney function - Low in fat, low in saturated fat, low in cholesterol - Unsaturated & polyunsaturated fats: 20%-35% of total daily intake - Saturated, trans fatty acids principal dietary determinants of plasma LDL cholesterol - Consistency in the amount of food consumed & regularity in mealtimes (promotes blood glucose control) - Diet low in saturated fats to decreases LDL, assist in weight loss for secondary prevention of diabetes, & reduce risk of heart disease - Include sources of omega-3 fatty acids & fiber to lower cholesterol, improve blood glucose for those w/ DM, for secondary prevention of DM, & to reduce risk of heart disease - Physical activity at least 3 times per week (150 min/week) - Consult dietician - Restrict calories & increase physical activity to facilitate weight loss & prevent obesity - Include fiber in diet to increase carbohydrate metabolism & to help control cholesterol levels - Treats, prevents gastrointestinal disorders - Use artificial sweeteners - Non-caloric & nutritive - "sugar-free" & "dietetic" on labels - Only exercise when blood glucose is between 80-250 mg/dL - Do not exercise if ketones are present in urine - Sodium - Hypertension a concern in ppl w/ DM - Alcohol - Not totally prohibited - Sick Day Management: - SICK: - Sugar: - Check your blood glucose level every 2-3 hours necessary (even more frequently for pregnant women & children) - Insulin: - Always continue to take your insulin even when you are sick to avoid DKA - Carbs: - Make sure you take in enough carbs & drink enough fluids - If your glucose level is high, stick with sugar-free drinks - If your glucose level is low, drink carb-containing drinks - Ketones: - Check your blood or urine levels every 4 hours - Take rapid-acting insulin if ketones are present - Remember to drink plenty of water to flush the ketones out of your system - Notify provider if ill - Monitor blood glucose every 2-4 hours - Continue to take insulin or oral hypoglycemic agents - Consume 8-12 oz. of sugar-free, noncaffeinated liquid every hour to prevent dehydration - If blood glucose is below the prescribed range, drinking fluids containing sugar is acceptable - Meet carbohydrate needs through soft food (custard, cream soup, gelatin, graham crackers) 6-8 times per day if possible - If not, consume liquids equal to usual carbohydrate content - Test urine for ketones as prescribed & report to provider if they are outside the expected reference range - Tested is recommended every 3-4 hours or if the blood glucose exceeds 240 mg/dL - Rest - Call provider for the following: - Presence of moderate to large urine ketones or ketonuria for more than 24 hours - Blood glucose greater than 250 mg/dL that does not resolve with treatment - Fever greater than 101.5F, does not respond to acetaminophen, or lasts more than 24 hours - Feeling disoriented or confused - Experiencing rapid breathing - Persistent nausea, vomiting, or diarrhea - Inability to tolerate liquids - Illness lasts longer than 2 days - Complications: - Macrovascular: - Coronary artery disease: - Major risk factor for development of MI - Hypertension: - Affects 75% of all ppl with DM - Stroke (cerebrovascular accident) - Ppl w/ DM 2-4 times more likely to have a stroke - Peripheral vascular disease: - Lower extremities - Related to hyperglycemia - Damage can result in gangrene - Neuropathy: - Microvascular complication - Results from microvascular disease of the kidneys - Microalbuminuria, presence of abnormal level of albumin in urine - Nerve dysfunction - Increased susceptibility to infection - Mood alterations - Increased risk of depression - Financial, emotional, social distress - Visceral neuropathies - Sweating dysfunction - Abnormal pupillary function - Cardiovascular dysfunction - Gastrointestinal dysfunction - Genitourinary dysfunction - Diabetic Peripheral Neuropathy (DPN): - Progressive deterioration of nerve function that results in loss of sensory perception - First causes pain leading to loss of sensation - Damage to motor nerve fibers leads to muscle weakness - Slow onset - Affects both sides of body, progresses, & is permanent - Late complications: - Foot ulcers - Deformities - Damage to nerve fibers in the autonomic nervous system can cause dysfunction in every organ - Factors leading to neuropathy: - Hyperglycemia - Long duration of DM - Hyperlipidemia - Damaged blood vessels leading to reduced neuronal oxygen & other nutrients - Increased genetic susceptibility to nerve damage - Smoking, nicotine, & alcohol use - Hyperglycemia leading to DPN: - Occurs through blood vessel changes & reduced tissue perfusion \> nerve hypoxia \> poor nerve impulse transmission - Excessive glucose converted to sorbitol \> collects in nerves \> impairs motor nerve conduction - Polyneuropathies - Bilateral sensory disorders - Mononeuropathies - Isolated, affecting a single nerve - Diabetic Autonomic Neuropathy: - AKA Cardiovascular Autonomic Neuropathy (CAN) - Affects sympathetic and parasympathetic nerves of heart & blood vessels - Undiagnosed in DM - Contributes to: - Left ventricular dysfunction - Painless MI - Exercise intolerance - Most often leads to orthostatic hypotension & syncope - Problems caused from: - Failure of heart & arteries to respond to position changes \> increased heart rate & vascular tone \> blood flow to brain is interrupted briefly - Increase risk for falls (especially older adults) - Can affect entire GI system - Common GI problems include: - Gastroesophageal reflex - Delayed gastric emptying (gastroparesis) - Delayed gastric retention - Early satiety - Heartburn - Nausea - Vomiting - Anorexia - Most common GI problem with DM: - Constipation - Intermittent - May alternate with bouts of diarrhea - Urinary problems: - Incomplete bladder emptying - Urine retention - Leads to: - Kidney problems - Early symptoms: - Frequency - Urgency - Later symptoms: - Inability to sense bladder fullness - Incontinence - Retinopathy: - Microvascular complication - Microvascular damage, hemorrhages lead to scarring of retina - Risk of blindness, cataracts - Vision problems - Diabetic retinopathy (DR) - Nearly all patients w/ DM have some form/degree of DR - Has few symptoms until vision loss occurs - Related to problems that block retinal blood vessels & causes them to leak leading to retinal hypoxia - Non proliferative DR: - Growth of new retinal blood vessels (neovascularization) - Retinal blood flow is low \> retinal cells secrete growth factors \> stimulate formation of new blood vessels - New vessels are thing, fragile & bleed easily - This leads to vision loss - Develops slowly rarely reduces vision to the point of blindness - Non proliferative DR causes structural problems in retinal vessels with areas of: - Poor retinal circulation - Edema - Hard fatty deposits in eye - Retinal hemorrhages - Central vision may be impaired by macular edema w/ increased blood vessel permeability & deposits of hard exudates at center of retina - DR can also occur from: - Macular degeneration - Corneal scarring - Changes in lens shape or clarity - Prevention: - Control of: - Blood glucose - Blood pressure - Blood lipid levels - Routine appointments with ophthalmologist - DKA: - Lack of sufficient insulin related to undiagnosed or untreated DM1 or nonadherence to a diabetic regimen - Reduced or missed dose of insulin (insufficient dosing of insulin or error in dosage) - Any condition that increases carbohydrate metabolism (physical or emotional stress, illness) - Infection is the most common cause - Increased hormone production (cortisol, glucagon, epinephrine) that stimulates the liver to produce glucose & decreases the effect of insulin - Blood Glucose: - Greater than 300 mg/dL (up to 800 mg/dL is typical) - Ketones: - Present in blood & urine - Blood Osmolarity: - High - Blood Electrolytes: - Na: - Below, within, or above the expected reference range - K: - Elevated initially due to potassium leaving the cells - Following treatment with fluids & insulin, potassium re-enters cells causing hypokalemia - Kidney Function: - BUN & creatinine are increased secondary to dehydration - BUN greater than 30 mg/dL - Creatinine greater than 1.5 mg/dL - Arterial Blood Gases: - Metabolic acidosis w/ respiratory compensation (kussmaul respirations) - pH less than 7.35 - Sodium bicarbonate 0-15 mEq/L - Bicarbonate 1-15 mEq/L - Hyperglycemic Hyperosmolar state: - Sustained osmotic diuresis results in a hyperglycemic hyperosmolar state, resulting from one of the following: - Lack of sufficient insulin related to undiagnosed or poorly managed DM - There is sufficient endogenous insulin present to prevent the development of ketosis, but not enough to prevent hyperglycemia - Inadequate fluid intake or poor kidney function - Common in older adult clients who have DM2 - Older adults' clients often seek medical attention later when much sicker, & have age-related changes that affect the body's ability to recover (decreased ability for urine concentration, decreased thirst perception) - Other factors that contribute to the development of HHS include infection, stress, medical conditions (MI, cerebral vascular injury, sepsis), & some medications (glucocorticoids, thiazide diuretics, phenytoin, beta blockers, calcium channel blockers) - Blood glucose: - Greater than 600 mg/dL - Blood Electrolytes: - Na: - Within or below the expected reference range - K: - Within or above the expected reference range as a result of dehydration - Must monitor for decrease after treatment is started - Kidney Function: - BUN & creatinine are increased secondary to dehydration - BUN greater than 30 mg/dL - Creatinine greater than 1.5 mg/dL - Ketones: - Absent in blood & urine - Blood Osmolarity: - Greater than 320 mOsm/L - With DKA, mild to moderate hyperkalemia is common for clients who have hyperglycemia - Insulin therapy, correction of acidosis, & volume expansion decreases blood potassium concentration - Potassium replacement needs to be initiated when potassium levels fall below 5.0 - Monitor for fatigue, malaise, confusion, muscle weakness, shallow respirations, abdominal distention, paralytic ileus, hypotension, & weak pulse - Arterial Blood Gases: - Absence of acidosis - pH greater than 7.4 - Bicarbonate greater than 20 mEq/L - Hypoglycemia: - BS below 70 mg/dL - Mild: - 15g of a rapid-acting sugar - Severe: - Hospitalization - 10-15g of an oral carbohydrate - s/s: - Hunger - Headache - Tremors - Sweating - Confusion - Mild shakiness - Palpitations - Lack of coordination blurred vision - Seizures - Coma - Teach client measures to take in response to manifestations - When glucose declines slowly, manifestations relate to the central nervous system - Headache - Confusion - Fatigue - Drowsiness - With rapid glucose decline, the sympathetic nervous system is affected - Tachycardia - Diaphoresis - Nervousness - If client is unconscious, place client in lateral position to prevent aspiration & administer glucagon subq or IM - Notify provider - Repeat in 10 min. if client is still unconscious - Glucagon or IV 50% dextrose appropriate for clients who cannot swallow - Avoid: - Excess insulin - Exercise - Alcohol on an empty stomach - Eat about the same amounts & at the same time periods daily - Hyperglycemia - Manifestations: - Hot - Dry skin - Fruity breath - Encourage oral fluid intake of sugar-free fluids to prevent dehydration - Administer insulin as prescribed - Test urine for ketones & report if outside of the expected reference range - Consult provider if manifestations progress - Somogyi phenomenon - Dawn phenomenon - Susceptibility: - Reduced immunity - Combination of vascular changes & hyperglycemia causes this due to reduced white blood cells activity, inhibiting gas exchange in tissues, and promoting the growth of microorganisms - Increased risk for developing infection on exposure to bacteria & other organisms - Infections can become more serious quicker - Can lead to major complications (sepsis) - Sensory deficits resulting in inattention to trauma - Vascular deficits decreasing circulation to injured area - Periodontal disease - Progresses more rapidly in those w/ DM - Gingivitis - Periodontitis - Chronic: - Relationship between hyperglycemia & vascular complications - Vascular damage often manifested through atherosclerosis - Inflammatory process set off by hyperglycemia - Increase insulin resistance - Damage in endothelium - Teaching: - Complications involving feet: - High risk for amputation of a lower extremity - Result of angiopathy, neuropathy, & infection - Most common sources of foot trauma: - Cracks & fissures caused by dry skin or infections such as athlete's foot - Blisters - Pressure from stockings or shoes - Ingrown toenails - Direct trauma - Foot Care: - Inspect feet daily - Wash feet daily w/ mild soap & warm water - Test water temperature w/ the arms or a thermometer before washing feet - Do not soak feet - Pat feet dry gently, especially between toes - Avoid lotions between toes to decrease excess moisture & prevent infection - Use mild foot powder (powder w/cornstarch) on sweaty feet - Don't use commercial remedies for the removal if calluses or corns, which can increase the risk for tissue injury & infection - Consult a podiatrist - Separate overlapping toes w/cotton or lamb's wool - Avoid open-toe, open-heal shoes - Leather shoes are preferred - Wear shoes that fit correctly - Wear slippers w/ soles - Do not go barefoot - Wear clean, absorbent socks or stockings that are made of cotton or wool & have not been mended - Wear socks at night if the feet get cold - Do not use hot water bottles or heating pads to warm feet - Avoid prolonged sitting, standing, & crossing of legs - Cleanse cuts w/ warm water & mild soap, gently dry, & apply a dry dressing - Monitor healing & seek intervention promptly - Nursing management: - Frequent blood glucose checks, teach self-checks - Foot care & observation for wounds or sore - Vital signs - Observe for signs of decreased circulation - Observe for signs of decreased sensation - With hypoglycemia (\ remove waste & excess fluid from blood - Test estimates how much blood passes through the glomeruli filters each minute - Results of a blood test that measures creatinine, a waste product filtered by the kidneys - Factors included in test: - Age - Weight - Height - Gender - Race - Creatinine - Results from protein & muscle breakdown - Kidney disease is the only condition that increases blood creatinine levels - Kidney function loss of at least 50% causes an elevation of blood creatinine values - Although muscle mass & amount of creatinine decreases w/age, the blood creatinine values remain constant in older adults who do not have kidney disease - BUN - Blood urea nitrogen - Results from the breakdown of protein in the liver, creating the byproduct urea nitrogen excreted by the kidneys - Factors affecting BUN: - Dehydration - Infection - Chemotherapy - Steroid therapy - Reabsorption of blood in the liver from damaged tissue - Elevated BUN suggests kidney disease - b/c liver failure limits urea production, BUN is decreased when liver & kidney failure occur - Specific Gravity - - KUB - - Acute Kidney Injury - PowerPoint info: - Rapid reduction in kidney function resulting in failure to maintain fluid & electrolyte balance & acid-base balance - Occurs over a few hours or days - Causes systemic effects & complications - Can result in death - Acute renal failure - A condition in which the kidneys suddenly can't filter waste from the blood - Kidneys aren't working as they should - Often sudden & usually reversible - RIFLE: Risk, Injury, Failure, Loss, ESKD - Episode of sudden kidney damage or failure - Reduced blood flow to the kidneys can interfere w/ the kidney's ability to filter blood - Most common cause: - Hypovolemia - Other causes: - Low blood volume - Heart failure - Medication side effects - Sepsis (& other diseases) can cause damage directly to the kidneys & lead to AKI - Overuse of medications (ibuprofen) can overtax the kidneys' ability to filter out waste, leading AKI - Health Promotion & Disease Prevention: - Drink at least 2 L daily - Consult w/ provider regarding prescribed fluid restriction if needed - Stop smoking - Maintain a healthy weight - Use NSAIDs & other prescribed medications cautiously - Control diabetes & hypertension to prevent complications - Take all antibiotics prescribed for infections - S/S - Cardiovascular: - Hypertension, fluid overload (dependent & generalized edema), dysrhythmia (hyperkalemia) - Respiratory: - Crackles, decreased oxygenation, shortness of breath - Renal: - Scant to normal or excessive urine output, depending on the phase, possible hematuria - PowerPoint: decreased urine output - Neurologic: - Lethargy, muscle twitching, seizures - Integumentary: - Dry skin & mucous membranes - Risk Factors: - Age - Diabetes - Assessment - Prerenal acute kidney injury: - Renal vascular obstruction - Shock - Decreased cardiac output causing decreased renal profusion - Sepsis - Hypovolemia - Peripheral vascular resistance - Use of aspirin, ibuprofen, or NSAIDs - Liver failure - Intrarenal acute kidney injury: - Physical injury: - Trauma - Hypoxia injury: - Renal artery or vein stenosis or thrombosis - Chemical injury: - Acute nephrotoxins (antibiotics, contrast dye, heavy metals, blood transfusion reaction, alcohol, cocaine) - Immunologic injury: - Infection, vasculitis, acute glomerulonephritis - Postrenal cute kidney injury: - Stone, tumor, bladder atony - Prostate hyperplasia, urethral stricture - Spinal cord disease or injury - Prerenal: - Blood loss - Infection - Dehydration - Burns - Myocardial infarction - Intrarenal: - Glomerulonephritis - Lupus - Cholesterol deposits that obstruct the blood flow in the kidney - Medications, such as chemotherapy, antibiotics, & contrast media - Postrenal: - Bladder, cervical, colon, or prostate cancer - Stones - Enlarged prostate - Blood clots in the urinary tract - Phases: - Onset: - Begins w/ the onset of the event, ends when oliguria develops, & lasts for hours to days - Most easily reversible if caught early in this stage - Oliguria: - Begins w/ the kidney insult; urine output is 100-400 mL/24 hr. with or without diuretics; lasts for 1-3 weeks - Diuresis: - Begins when the kidneys start to recover; diuresis of a large amount of fluid occurs; can last for 2-6 weeks - Recovery: - Continues until kidney function is fully restored & can take up to 12 months - Classes - Stage 1 (risk stage): - Blood creatinine 1.5-1.9 times baseline & urine output less than 0.5 mL/kg/hr. for 6 hr. or more - Stage 2 (injury stage): - Blood creatinine 2-2.9 times baseline & urine output less than 0.5 mL/kg/hr. for 12 hr. or more - Stage 3 (failure stage): - Blood creatinine 3 times baseline & urine output less than 0.3 mL/kg/hr. for 12 hr. or more - Types: - Prerenal: - Occurs as a result of volume depletion & prolonged reduction of blood flow to the kidneys, which leads to ischemia of the nephrons - Occurs before damage to the kidney - Early intervention restoring fluid volume deficit can reverse AKI & prevent chronic kidney disease (CKD) - Intrarenal: - Occurs as a result of direct damage to the kidney from lack of oxygen, indicating damage to the glomeruli, nephrons, or tubules - Postrenal: - Occurs as a result of bilateral obstruction of structures leaving the kidney - Labs - Blood creatinine gradually increases 1-2 mg/dL every 24-48 hrs., or 1-6 mg/dL in 1 week or less - Blood urea nitrogen (BUN) can increase to 80-100 mg/dL within 1 week - Urine specific gravity varies in postrenal type; can be elevated up to 1.030 in prerenal type or diluted as low as 1.000 in intrarenal type - Electrolytes: sodium can be decreased (prerenal azotemia) or increased (intrarenal azotemia); hyperkalemia, hyperphosphatemia, hypocalcemia - Hematocrit: decreased - Urinalysis: presence of sediment (RBC, casts) - ABG: metabolic acidosis - Imagining assessments - MAG3 - - X-ray: - Kidneys, ureters, bladder (KUB or "flat plate") without use of contrast dye - Allows for visualization of structures & detects renal calculi, strictures, calcium deposits, or obstructions - KUB can detect the presence of gas within the GI tract & ascites - Nursing Actions: - Ask client if pregnant - Tell clients to remove clothes over the area & all jewelry & metal objects - No known complications - CT: - Provides 3-dimensional imaging of the renal/urinary system to assess for kidney size & obstruction, cysts, or masses - IV contrast media (iodine-based) enhances images - Nursing actions: - Ask client if pregnant - Check for iodine allergy - Tell clients to remove all clothes over the area & all jewelry & metal objects - Check for metformin use - May need to withhold due to effect on kidneys - Monitor for signs of delayed allergic reaction to contrast - Increase fluid intake following procedure - US: - Assesses size of kidneys, & images the ureters, bladder, masses, cysts, calculi, & obstructions of the lower urinary tract - Good alternative to excretory urography - Nursing actions: - Provide skin care by removing gel after procedure - Other diagnostic assessments - Kidney biopsy: - Removal of sample of tissue by excision or needle aspiration for cytological (histological) exam - Complications: - Hemorrhage - Monitor hypotension, tachycardia, dizziness, or back pain - Infection - Cloudy, foul-smelling urine, urgency, urine positive for leukocytes, nitrates, sediment & RBCs - Urinary retention - Liver/bowel puncture during biopsy - Abdominal pain - Tenderness - Rigidity - Decreased bowel sounds - Nursing actions: - NPO 4 hours prior to procedure - Client placed prone with pillow under abdomen prior to procedure - Monitor hgb. & hct. Post - Monitor urine output & hematuria post - Teach client prescribed bed rest - Teaching: - Nutrition - Implement potassium, phosphate sodium, & magnesium restrictions, if prescribed (depending on the stage of injury) - Possible total parenteral nutrition (TPN) - Protein requirements are individualized based on several factors included client's nutritional status, catabolic response, & cause of injury - Dietitian to calculate protein, calorie, & fluid needs - Restrictions/Interventions - Restrict fluid intake as prescribed - Monitor fluid intake & output strictly - Avoid using nephrotoxic medications - If necessary, give these medications sparingly & decrease the medication dosage - Avoid hypotension, maintain fluid balance - Frequently monitor lab values - Closely watch I/O - Drug therapy - Kidney replacement therapy (intermittent versus continuous) - Chronic Kidney Disease - PowerPoint Info: - Progressive, irreversible disorder; kidney function does not recover - End-stage kidney disease (ESKD) - Azotemia - Uremia - Uremic syndrome - A condition in which the kidneys lose the ability to remove waste & balance fluids - Loss of all kidney function over time (kidneys haven't worked well for months) - Longstanding DM can lead to renal failure - Creatinine - Creatinine is a chemical waste product of creatine - Creatine is a chemical made by the body & is used to supply energy mainly to muscles - Test is done to see how well your kidneys work - Creatinine is removed from the body entirely by the kidneys - Most common cause: - Hypertension - DM - Health Promotion & Disease Prevention: - Drink at least 2 L water daily - Consult w/ provider regarding any restrictions - Stop smoking - Limit alcohol intake - Use diet & exercise to manage weight & prevent or control diabetes & hypertension - Adhere to medication prescription guidelines to prevent kidney damage - Test for albumin in the urine yearly (clients who have diabetes or hypertension) - Take all antibiotics until completed - Limit over-the-counter NSAIDs - S/S - Nausea, fatigue, lethargy, involuntary movement of legs, depression, intractable hiccups - Most findings are related to fluid volume overload - Neurologic: - Lethargy, decreased attention span, slurred speech, tremors or jerky movements, ataxia, seizures, coma - Sensory changes - Cardiovascular: - Fluid overload (jugular distention; sacrum, ocular, or peripheral edema), hyperlipidemia, hypertension, dysrhythmias, heart failure, orthostatic hypotension, peaked T wave on ECG (hyperkalemia) - Respiratory: - Uremic halitosis w/ deep sighing, yawning, SOB, tachypnea, hyperpnea, Kussmaul respirations, crackles, pleural friction rub, frothy pink sputum - Hematologic: - Anemia (pallor, weakness, dizziness), ecchymoses, petechiae, melena - Abnormal bleeding - Gastrointestinal: - Ulcers in mouth & throat, foul breath, blood in stools, vomiting - Mouth inflammation - Musculoskeletal: - Osteodystrophy (thin fragile bones) - Renal: - Urine contains protein, blood, particles; change in the amount, color, concentration - Skin: - Decreased skin turgor, yellow cast to skin, dry, pruritus (itching), urea crystal on skin (uremic frost) - Discoloration to skin - Reproductive: - Erectile dysfunction - Assessment - End-stage kidney disease exists when 90% of the functioning nephrons are destroyed & are no longer able to maintain fluid, electrolyte, & acid-base homeostasis - Dialysis or kidney transplantation can maintain life, but neither is a cure for CKD - Weight & height - Medical history, especially of kidney or urologic origin - Drug use - Dietary habits - GI & GU problems - Energy level - Psychosocial: - Anxiety, fear - Coping styles - Family relations - Social activity - Work - Body image - Sexual activity - Lab assessment: - Various blood & urine tests - GFR estimated from serum creatinine, age, gender, race, & body size - Imaging assessment: - X-ray findings - Kidney or CT scan - Interventions: - Vital signs - Vascular access - Frequently monitor laboratory values - Closely watch I/O - Drug therapy - Nutrition therapy - Activity/rest - Kidney replacement therapy (intermittent versus continuous) - Stages - Stage 1: - Minimal kidney damage when GFR within expected reference range (greater than 90 mL/min) - Mild kidney damage - Kidneys work as well as normal - Stage 2: - Mild kidney damage w/ mildly decreased GFR (60-89 mL/min) - Mild kidney damage - Kidneys still work well - Stage 3: - Moderate kidney damage w/ moderate decrease in GFR (30-59 mL/min) - 3a: - 45-59 - Mild to moderate kidney damage - Kidneys don't work as well as they should - 3b: - 30-44 - Moderate to severe damage - Kidneys are close to not working at all - Stage 4: - Severe kidney damage w/ severe decrease in GFR (15-29 mL/min) - Severe kidney damage - Kidneys are close to not working at all - Stage 5: - ESKD: Kidney failure & end-stage renal disease w/ little or no glomerular filtration (less than 15 mL/min) - Most severe kidney damage - Kidneys are very close to not working or have stopped working (failed) - Risk Factors - Older adult clients - Due to aging (decreased number of functioning nephrons, decreased GFR) - Older adult clients on bed rest, confused, have a lack of thirst, & do not have easy access to water - Acute kidney injury - DM - Chronic glomerulonephritis - Nephrotoxic medications (gentamicin, NSAIDs) or chemicals - Hypertension, especially in African American clients - Autoimmune disorders (systemic lupus erythematosus) - Polycystic kidney disease - Pyelonephrosis - Renal artery stenosis - Recurrent severe infections - Labs: - Urinalysis: - Hematuria, proteinuria, & decrease in specific gravity - Blood Creatinine: - Gradual increase over months to years for CKD exceeding 4 mg/dL; can increase to 15-30 mg/dL - BUN: - Gradual increase w/ elevated blood creatinine over months to years for CKD; can increase 10-20 times the creatinine finding - Blood Electrolytes: - Decreased sodium (dilutional) & calcium, increased potassium, phosphorus, & magnesium - CBC: - Decreased hemoglobin & hematocrit from anemia secondary to the loss of erythropoietin in CKD (treatment for these: diuretic) - Medication: - Epoetin Alfa - Stimulates production of red blood cells; given for anemia - Furosemide - Loop-diuretics administered to excrete excess fluids - Avoid administering to a client who has end-stage kidney disease - Clients can also receive thiazide diuretics, potassium-sparing diuretics, & osmotic diuretics - Teaching: - Nutrition - High in carbohydrates & moderate in fat - Restrict intake of fluids (based on urinary output) - Control protein intake based on the client's stage of CKD & type of dialysis prescribed - Restrict dietary sodium, potassium, phosphorus, & magnesium - Obtain a detailed medication & herb history to determine the client's risk for continued kidney injury - Restrictions - Restrict intake of fluids (based on urinary output) - Restrict dietary sodium, potassium, phosphorus, & magnesium - Report: - Urinary elimination patterns - Amount, color, odor, & consistency - Vital signs - Blood pressure can be increased or decreased - Weight - 1 kg (2.2 lb.) daily weight increase is approximately 1 L of fluid retained - Client Education: - Monitor the daily intake of carbohydrates, proteins, sodium, & potassium - Monitor fluid intake according to prescribed fluid restriction - Avoid antacids containing magnesium - Take rest periods from activity - Follow instructions for home or outpatient peritoneal dialysis or hemodialysis - Measure blood pressure & weight at home - Ask questions & discuss fears - Diet, exercise, & take medication as prescribed - Notify the provider of skin breakdown - Complications: - Potential complications include: - Electrolyte imbalance - Dysrhythmias - Fluid overload - Hypertension - Metabolic acidosis - Secondary infection - Uremia - Kidney Replacement - Hemodialysis - PowerPoint Info: - Dialysis settings - Procedure - Anticoagulation - Vascular access - Nursing care - Post-dialysis care - Shunts blood from the body through a dialyzer & back into circulation (shunt in arm) - Requires vascular access - Started when manifestations of uremia become severe - Potential Diagnoses: - Renal insufficiency - Acute kidney injury - Chronic kidney disease - Medication or illicit drug toxicity - Persistent hyperkalemia - Pulmonary edema - Severe hypertension - Hypervolemia that does not respond to diuretics - Client presentation: - Fluid volume changes, electrolyte & pH imbalances, & nitrogenous wastes - Manifestations include fluid overload, neurologic changes, bleeding, & uremia (cognitive impairment, pruritus, nausea, vomiting) - Pre-Procedure: - Check for informed consent - Use a temporary hemodialysis dual-lumen catheter or subq device until the provider inserts a long-term device & it is available for access - Assess the patency of a long-term device: arteriovenous (AV) fistula or AV graft (presence of bruit, palpable thrill, distal pulses, circulation) - Avoid measuring blood pressure, administering injections, performing venipunctures, or inserting IV catheters on or into an arm with an access site - Elevate extremity following surgical creation of an AV fistula to reduce swelling - Access vital signs, laboratory values (BUN, blood creatinine, electrolytes, Hct) & weight - Discuss with the provider medications to withhold until after dialysis - Withhold dialyzable medications & medications that lower blood pressure - Beta-blocker (-lol) - Intra-Procedure: - Monitor for complications during dialysis - Dialysis circuit clotting, air bubbles in blood tubing, temperature of the dialysate, regulation of the ultrafiltration - Hypotension, cramping, vomiting, bleeding at the access site, contamination of equipment - Monitor vital signs & coagulation studies during dialysis - Monitor for bleeding, such as oozing from insertion site - Administer anticoagulants, such as heparin - Provide emotional support & offer activities (books, magazines, music, cards, or television) - Post-Procedure: - Monitor vital signs & laboratory values (BUN, blood creatinine, electrolytes, Hct) - Decreases in blood pressure & changes in laboratory values are common following dialysis - Compare the client's pre-procedure weight with the post-procedure weight as a way to estimate the amount of fluid the procedure removed - 1 L fluid equals 1 kg - Assess for: - Complications (hypotension, clotting of vascular access, headache, muscle cramps, bleeding) - Indications of bleeding or infections at the access site - Findings of disequilibrium syndrome (nausea, vomiting, headache) - Findings of hypovolemia (hypotension, dizziness, tachycardia) - Avoid invasive procedures for 4-6 hrs. after dialysis due to the risk of bleeding as a result of anticoagulation - Reinforce AV fistula or AV graft precautions - Alert nurse of early findings of disequilibrium syndrome, such as nausea & headache - Check the access site at intervals following dialysis - Apply light pressure if bleeding - Contact provider if bleeding from the insertion site lasts longer than 30 min. following dialysis, for no thrill/bruit, or findings of infection - Take medications & supplements to replace folate loss - Eat well-balanced meals to include foods high in folate (beans, green vegetables), & take supplements - Each exchange during dialysis depletes protein, requiring the client to increase protein intake over pre-dialysis limitations, but it still might require some restriction - Avoid lifting heavy objects w/ the access/site arm - Avoid carrying objects that compress or constrict the extremity - Avoid sleeping on top of the extremity w/ the vascular access - Perform hand exercises that promote fistula maturation - Complications - Clotting/infection of the access site - Anticoagulants prevent blood clots from forming - Monitor for hemorrhage at the insertion site - Cannulation can introduce infections at the access site - Immunosuppressive disorders increase the risk for infection - Advanced age is a risk factor for dialysis-induced hypotension & access site complications due to chronic illness or fragile veins - Use surgical aseptic technique during cannulation - Avoid compression of the access site - Avoid venipuncture or blood pressure measurements on the extremity w/ the access site - Administer anticoagulants - Assess the graft site for a palpable thrill or audible bruit indicating vascular flow - Assess the access site for redness, swelling, or drainage - Monitor for fever - Teaching: - S/S infection - Hemodialysis will be needed 3 times per week for 3--4-hour sessions - Involves: - 2 needles, 1 into an artery & the other into a vein - Peritoneal Dialysis (PD): - Instillation of dialysate solution into the peritoneal cavity followed by a prescribed dwell time - Peritoneum serves as a semipermeable filtration membrane \> wastes products such as urea, creatinine, excess fluids, & electrolytes are filtered through peritoneum from an area of high concentration (blood) to an area of low concentration (dialysis) - After prescribed dwell time, the dialysate outflow, or effluent, containing excess fluids, electrolytes, & waste products flow out of the peritoneum into a drainage bag - Client should have intact peritoneal membrane without adhesions from infections or multiple surgeries - Siliconized rubber catheter placed into abdominal cavity for infusion of dialysate - Treats clients requiring dialysis who: - Are unable to tolerate anticoagulation - Have difficulty with vascular access - Have chronic infections or are unstable - Have chronic diseases (DM, heart failure, severe hypertension) - Types of PD (selection depends on patient's ability & lifestyle): - Continuous ambulatory - 7 days/week for 4-8 hrs. - Clients can continue normal activities during this - Multiple-bag continuous ambulatory - Automated - 30-minute exchange repeated over 8-10 hours while sleeping - Intermittent - Continuous cycle - 24-hour dialysis - Exchange occurs at night while sleeping \> final exchange left to dwell during the day - Exchange for control of fluids, electrolytes, nitrogenous wastes, blood pressure, & acid-base balance - Complications: - Peritonitis - Allow microorganisms into the peritoneum & cause peritonitis - Life-threatening illness if not taken care of - Pain - Tunnel infections - Infections at access site result from leakage of dialysate \> can lead to peritonitis - Poor dialysate flow (inflow/outflow) - Causes include: - Obstruction or twisting of the tubing - Constipation - Client positioning - Fibrin clot formation - Catheter displacement - Reposition client - Milk tubing to break up clots - Fibrin clot formation - Dialysate leakage - Hyperglycemia and Hyperlipidemia - Hyperglycemia: can result from glucose in the dialysate - Blood can absorb glucose from the dialysate - Hyperlipidemia: can occur from long-term therapy & lead to hypertension - Protein loss - Peritoneal dialysis can remove protein from the blood as well as excess fluid, wastes, & electrolyte - Follow renal diet w/ increased dietary protein - Nursing care: - Before treatment: - Evaluate baseline vital signs, weight, laboratory tests - Continually monitor patient for respiratory distress, pain, discomfort - Monitor prescribed dwell time, initiate outflow - Observe outflow amount & pattern - Evaluation: - Achieve & maintain appropriate fluid & electrolyte balance - Maintain an adequate nutrition status - Avoid infection at the vascular access site - Use effective coping strategies - Prevent or slow systemic complications of CKD, including osteodystrophy - Report an absence of physical signs of anxiety or depression