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Renal/Diabetic NCLEX Review: Covers Patho, Pharm, M/S, and Complex CareDiabetesDiagnostic Criteria: Pre-diabetes: A1c 5.7-6.5 Fasting: 100-125 mg/dL 2 hr: 140-199 mg/dL (oral glucose tolerance test)Diabetes A1c >6.5Fasting: >1262 hr: >200 (oral glucose tolerance testRandom: >200 with s/s of hyperglycemia Meds: Insulin types (trade name): Lispro (Humalog) (short acting): administer 5-10 min of mealRemember to use in combination with another as to provide coverage throughout day Onset: 15 min, Peaks 1-2 hrs, Duration 3-4 hrs. Also aspart (NovoLog) and glulisine (Apidra)Regular Insulin (Humulin R, Novolin R) : give before meal Onset: 30 min, peaks 2-4 hr, duration: 6-8 hrsTHE ONLY INSULIN GIVEN IV NPH (Humulin N): Onset: 30 min, peaks 6-14 hr, duration 16ish hours; 30-60 min of mealP protamine delays excretion Can be mixed with reg insulin (draw reg or lispro first, THEN NPH) If given with Lispro in morning, concern is with late afternoon (1500, 1600) 70/30; 70% NPH, 30% Regular insulin Onset: 30-60 min. Peaks 1.5-16 (HumuLin), 2-13 (Novolin), duration: up to 24 hrsInsulin glargine (lantus) Onset: 70 min, no peak, duration 24 hrsUsed for relatively constant BG level Once daily @ same time each dayCANNOT MIXInsulin detemir (Levemir) Similar to above Sub Q; Draw up CLEAR first and THEN cloudy. Rotate sites. Oral medications (FOR TYPE II ONLY) Generalities: use with cimetidine BAD (hypoglycemia), betablockers BAD (mask s/s of hypoglycemia) Metformin, acarbose, januvia only ones that WON’T CAUSE hypoglycemia Preferential to insulin, start with these and then add injectables Metformin: Inhibits glucose production and enhances periph uptakeBig concerns: B12 deficiency, lactic acidosis (CONTRAST DYE!), renal adjustments needed Contraindicated with Cimetidine DOES NOT CAUSE HYPOGLYCEMIA Glyburide (Diabeta): promotes insulin release and sensitivity Requires pancreatic functionCAN CAUSE HYPOGLYCEMIAGlitazone (Actos): decreases insulin resistance Monitor LIVER FUNCTION tests Can cause water retention: averse CV effects Glinides (example Prandin): Incr insulin release from pancreasAcarbose (Precose): inhibits alpha glucosidase, resulting in lower BGSE: gastric discomfort Sitagliptin (Januvia): increases increti activity (Increased insulin production) Can have effects on A1cByetta: injectable incretin memeticStimulates insulin production to promote satiety Give before meals, finger sticks Can cause hypoglycemia if used with sulfonylrea MUST BE MIXED IMMEDIATELY PRIOR TO ADMIN Meds that can contribute to secondary diabetes: Reverse transcriptase inhibitors (HAART) ChemotherapyGlucocorticoids Immunomodulators Chronic Diabetes Mgmt Smogoyi effect: undetected hypoglycemia in middle of night (3 am) leads to rebounding hyperglycemia in morningDawn effect: untreated hyperglycemia at HS leads to elevated BS in AM Mgmt goals: 80-120 pre-prandial<180 2 hrs post prandial (ideally only 30-50 pts higher) Mgmt goals for pre-existing DM and pregnancy: Preprandial, overnight: 60-99Peak postprandial: 100-129 A1c <6 Gestational diabetes mgmt. goals Fasting <951 hr post prandial <140 2 hrs post prandial <120 Inpatient less stringent: (RISK OF HYPOGLYCEMIA > HYPERGLYCEMIA) Premeal target 140, random <180 Education: Carb counting: 15 g carbs is a serving Food diary Hypoglycemia: s/sx HTN, diaphoresis, palpitations, apprehension/anxiety, tremor Chronic complications MacrovascularCardiacMicrovascularEye diseaseNephropathyFunctional damage (GFR >90)Glomerular damage (GFR 60-89) Overt (30-59), proteinuria Severe (15-29) increased BUN and CR, HTNEnd stage: GFR <10 mL/min; DIALYSIS requiredNeuropathy Managing hypoglycemia: 1 cup juice/soda, recheck 15 min. chase 1 ampule D50 IVGlucagon SQ Managing acute complications: DKA and HHNS DKA: typically type 1, THINK ACIDOSIS HHNS: higher BG levels (little bit of insulin keeps cells chugging along) , less complications of pHMgmt: HYDRATEWhy first? If we move all the insulin intracellular, osmotic gradient could cause dehydration, CV collapse Looking for UO 30-60 cc/hrSpecial considerations: renal disease/CV disease (FLUID OVERLOAD) Once glucose is dilutionaly brought down to 200-250 mg/dL switch from NS or LR to D51/2NS INSULINFrequent BS checks (q hr on drip, q 2 not on drip) Initial bolus of reg insulin at 0.1unit/kg body weight Followed by drip of 0.1 unit/kg/hrExpect plasma glucose to drop by 50-70 mg/dL q hr Once at 200 mg/dL, insulin can be dropped to 0.05 -0.1 units/kg/hr (3-6 units/hr) CORRECT ACIDOSISBicarb indicated for pt with severe acidosis below pH 7.0ELECTROLYTES! Before initiating insulin, check K+, replace if below 3.3 Insulin can rapidly drop serum potassium ECG monitoring for severe DKA Renal: Common renal care Renal dietLOW to moderate prn: prevents production of urea, potassium, phosphate, H+ HIGH CarbWater restriction (varies) Sodium (to prevent fluid retention), potassium restrictions: Avocado, banana, cantaloupe, carrrots, fish, mushrooms, oranges, potatoes, beef, pork, veal, raisins, spinach, strawberries, tomatoes Phosphate restriction (to prevent exacerbation of hypocalcemia): Fish, pumpkin, squash, nuts, pork, beef, chicken, organ meats, whole grain cereal, dairyStrict Is and Os Labs: BUN: 10-20 Cr: 0.7-1.2 BUN/CR: 10:1-20:1 Amonia: 15-45 LFT’s (AST/ALT): 10-30/10-40 Bilirubin: 0.2-1.2 Alkaline phosphate: 38-126 Daily weights Dialysis Renal medications: see medication list (DRUGS WITH RENAL CONCERNS) DiureticsProximal tubule diuretics (acetazolamide [Diamox]): Inhibits carbonic anhydrase to prevent reabsorption of bicarb Produces alkaline urineincr excretion of weak acid drugsContr: allergy to sulfonamides Can cause hyperglycemia, renal calculi Loop (furosemide): Inhibit resorption of Na and CL in ascending loop of HenleGreater peak incr in urine output, faster acting, increase hypocalcemia CAN USE WITH LOW GFR!K wasting! Thiazide (HCTZ): Contraindicated with renal disease Chemical similarity to sulfonamides Inhibits Na and Cl resorption LATER in the tubule CAN INCREASE serum levels of CA, Glucose, and uric acid Potassium sparing: Spironolactone (aldactone) Blocks aldosterone to promote Na and water excretion Urinary retentionNifedipine (Procardia): decr inflammation and promotes ureter relaxation Antihypertensive, calcium channel blocker Bethanechol chloride (Urecholine): cholinergic, urinary stimulant Use cautiously in pt with hx of seizure, hyperthyroidismCan cause bronchospasm, heartblock, syncopy, bradyUrgencyAssess bladder 1 hr after sc injection, catheterization may be ordered for distention if not relieved by meds ATROPINE given for OD BPH 5-alpha-reductase inhibitors: finasteride (Proscar)Prevents conversion of testosterone to potent DHT, results in prostate shrinkage SE: decreased libido, impotency, decreased ejaculate Alapha adrenergic receptor blockers (terazosin): Blocks alpha 1 receptors, prevents vasoconstriction results in vasodilation Less cardiac effect (NO BETA) Relaxes urinary sphincter SE: weakness, edema of lower extremities, new onset orthostatics, syncopy, SOB FIRST DOSE HYPOTENSIVE RXN Electrolyte correct s/t AKD or CKDAluminum hydroxide, calcium acedtate: bind excess phosphate Calcitriol: vit D supplementation UTIPhenazopyridine (Pyridium): symptomatic relief of Should not be used for more than 1-2 days after initation of tx, may hide symptoms Nitrofurantoin (macrobid/ furadantin): anti-infective prescribed for UTI Pulmonary fibrosis, chest pain, hepatotoxicity, BEERS ListSulfamethoxazole (Bactrim): antiprotozoal, sulfonamide Neurogenic Bladder Oxybutynin (Ditropan): anticholinergic/antispasmodicAlieveiates frequency/urgency Antichol: tachy, retention, cns depression Renal disease mgmt. Aging and renal changesLoss of 30-50% of nephron by 75Decreased GFRNocturia: lack of urine concentration Decr drug clearance Decr Vit D absorption, leads to decreased Calcium retention Prostatic enlargement Pyelonephritis: inflammation of renal parenchyma andpelvis (collecting system)Can lead to scarring, CKDS/sx: Acute: fatigue, fever/chills, n/v, flank pain, dysuria, urgency Chronic: HTN, inability to conserve Na (HYPONATREMIA), HYPERKALEMIA Urine collection, adequate hydration , abx therapyNeed to make renal considerations about meds until recovery (IV contrast dye, nephrotoxic drugs) Glomerulonephritis: autoimmune and non-autoimmune Causes: bacterial/viral infx, Lupus, drugs, scleroderma (vascular damage build up), systemic infxS/sx: hematuria, RBCs, proteinuria, HTN, oliguria, elevated BUN/serum Cr, periorbital edema Tx with abx and immunosuppressive agents and prevent chronic complications Diuretics and antihypertensives Plasmapheresis for autoimmune pts Renal calculi 4 common types: calcium oxalate, uric acid, struvite, cysteine S/sx: renal colic (pain occurs with peristaltic actions of ureters), hematuria, n/v, pain that moves Nursing priority is pain mgmt. Urine c/s, straining urine, 24 hr collectionEncourage fluids WITHOUT forcing Diet: restrict sodium, and certain foods depending on stone typePurine: sardines, herring, liverCalcium: dairy products, fruits, nuts Oxalate: dark green veggies, tomatoes, nuts Bladder CA Risk factors Recurrent renal calculi, jet/fuel, dyes/textiles, radiation, indwelling catheters Education: no smoking, assess for s/s of UTI, urologic follow upChronic Kidney DiseaseKEY POINTS Polyuria (low specific gravity), elevated BUN, serum Cr, impaired glucose use (need to monitor insulin dosing)ElectrolytesHyperkalemia, altered Na+hypocalcemia (hyperphosphatemia, REMEMBER THE INVERSE RELATIONSHIP) Metabolic acidosis: ineffective excretion of H+ and defective generation of bicarb HEMO: Anemia: decr EPO production, defect platelet function (BLEEDING)CV: fluid overloadResp issues GI: incr ammonia production from bact uremic fetor, anorexia, n/v, Neurologic issues: incr nitrogenous waste products (AMS) Colaborative care: Hyperkalemia: diet restrictions kayexalate, IV Ca gluconate HTN: sodium/fluid restrictions, antihypertensivesAnemia: EPO IV (HD) or SQ (PD), iron supplementsCKD: Mineral bone disorder: restrict phosphate intake Calcium based phosphate binders to excrete in stool, Vit D for hypocalcemia Acute Kidney Injury (AKI) Similar principles to care of chronic kidney disease; can lead to chronic 3 phases: Oliguric: critical to monitor electrolytes, pH balance, fluid status; 10-14 daysELECTROLYTES ONE OF THE BIGGEST CONCERNS: Hyperkalemia rectified with Calcium gluconate, kayexolate, IV sodium bicarb, dialysis, D50 insulin IV Diuretic phase: biggest concern is hypovolemia/hypotension; 1- 3wksRecovery phase: gradual increase of GFR over 12 months 3 Etiologies: Pre-renal: LOW FLOW STATE (hypoperfusion; can lead to ATN) Expected findings: initially hyponatremia (RAAS pathway will be activated to retain Na+ and fluid) BUN:Cr will be >20:1 due to low flow state Urine specific gravity will be concentrated (>1.010 due to low fluid output) Renal (intrarenal): acute tubular necrosis. Renal vasoconstriction creates cellular edema, which cuses intracellular obstructions and ultimately leaking of glomercular filtrate BUN: CR will be <20:1 Post-renal : obstructionFoley cath is quick assessment tool Care for renal proceduresRenal biopsy Used with glomerulonephritis Bed rest 6 hrs, assess bleedingApply pressure dressing at site Monitor urine for frank bleeding Peritoneal Dialysis (PD) v Hemodialysis (HD) Both: solutes and water move from blood into diasylate (or other way, depending on diagnosis, labs) PD (peritoneal dialysis): Excess fluid removed by increasing OSMOLALITY of dialysate (add glucose) 1L or 2L bags of fluid with [glucose] of 1.5%, 2.5%, or 4.25%Exchange: process of draining and filling takes about 30-40 minutes STERILE PROCEDURETypical orders: 4 exchanges a day with dwell time of 4-6 hrsInflow: amt of solution (prescribed) infused through established catheter over approx. 10 min. Following inflow process, tubing is clamped to prevent no airDwell Phase/Time: diffusion and osmosis between blood and cavity (20-30 min, up to 8 hrs) Drain Phase: 15-30 min Can be aunomated or ambulatory (manually changed out) ASEPTIC TECHNIQUE CRITICAL to avoid peritonitis Contraindications: hx of multiple abd surgeries/abdominal pathologies Recurrent abd wall/inguinal herniasExcessive obesityPre-existing vertebral diseaseCOPD ComplicationsAbd pain: change catheter placement, slow infusion rate, assess for infx Outlfow problem (less than 80% of inflow): kink, omentum wrapped around catheter, migration out of pelvic region, full bowel HerniasLower back painBleeding: several days after placement may indicate active intraperitoneal bleed (check BP, HCT) Pulmonary: atelectasis, pna, and bronchitis (Pulmonary toilet)Encapsulating Sclerosing Peritonitis and loss of ultrafiltration: usually requires progression to HD Pros: fewer dietary restriction, greater mobility, better BP control, better control fo BG and avoidance of bleeding (don’t need to heparinize) Cons: PERITONITIS HD (hemodialysis) Excess fluid removed by increasing pressure in blood compartment or decreasing pressure in dialysate (Fluid flows from CV->dialysate by pressure gradients) Used in someone with stable or elevated, advantageous in HYPERKALEMIA Arteriovenous Grafts take 2-4 weeks to heal/access Tempoary access given to subclavian, IJ, or femoral (Risks of hemothroax, pneumothorax, infx, thrombosis)CANNOT USE FOR LAB: high doses of heparin Pre-dialysis RN care: weight, BP, temp, assess edema, auscultate lung/heart sounds GIVES PITURE OVERALL OF FLUID Procedure: Prime with NSHeparin added to blood as flows to dialyzer Blood returned Dialysis terminated by flushing dialyzer with NS Firm pressure to graft (HEPARIN!)ComplicationHYPOTENSION: tx with infusion of NS, hold BP meds prior if pt has hx of hypotension Muscle cramps: decrease ultrafiltration rate, NS bolus, glucose, mannitol (osmotic diuretic) Disequilbirium syndrome: cerebral edma caused by fluid shifting in the brain (N/v, confusion, restlessness, HA, twitching/jerkingslow/stop dialysis, infuse hypertonic NaCl solution, mannitol to draw fluid from brain back to circulation Continuous renal replacement therapy (CRRT): for the pt who is hemodynamically unstable, continuous removal of toxins Difference between this and HD based on Pressures and Potassiums (HD: variable potassium, CRRT: variable pressure) ICU RN can run Dependent on BP, but we can manage BP PRACTICE QUESTIONS: Diabetes (64): Saunders Chapter 54 (p. 657): 571-580, 584, 585, 589, 592, 593Saunders Chapter 55 (p. 677): 600-602, 604, 605, 606, 616 Lippincott Chapter 8 (p. 501): 20-56, 107-112 Renal (147): Saunders Ch 62 (p. 869): 736-755 Saunders Ch 63 (p. 880): 756-770 Lippincott Ch 9 (p. 524): 1-111 ................
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