Monthly Archives: September 2012

NCLEX Practice Question of the Day: Prioritization, Cardiac

A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing actions should take priority?

a. A complete history with emphasis on preceding events

b. An electrocardiogram (EKG)

c. Careful assessment of vital signs

d. Chest exam with auscultation

 

Answer in the comments.

More practice NCLEX-RN questions.
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Medical-Surgical: Left versus Right Heart Failure

LEFT HEART FAILURE

  • left = “lungs” = respiratory symptoms
  • blood backs up into the lungs due to failure of the left side of the heart
  • classic symptoms: dyspnea, crackles in lungs

RIGHT HEART FAILURE

  • blood backs up into the periphery due to failure of the right side of the heart
  • classic symptoms: edema, jugular vein distention (JVD), hepatomegaly, splenomegaly
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Medical-Surgical: Diabetes Mellitus

Diabetes Mellitus (DM), otherwise known as diabetes, is a “group of diseases characterized by high blood glucose levels that result from defects in the body’s ability to produce and/or use insulin” (American Diabetes Association [ADA], 2012).

Types of Diabetes

  • Type I – autoimmune destruction of insulin-producing beta cells; present at birth; may also be referred to as insulin-dependent DM
  • Type II – characterized as insulin resistance or decreased ability of pancreas to produce insulin; occurs later in life; may also be referred to as non-insulin-dependent DM
  • Gestational – present during pregnancy

How is DM diagnosed?

  • less than 100 mg/dL = normal
  • 100 to 126 mg/dL impaired fasting glucose (IFG) = prediabetes
  • greater than 126 mg/dL = diabetes
  • two hour oral glucose test > 200 with glucose load of 75g
  • diagnosis of DM must be confirmed on a subsequent day with FBS, TFG or 2 hour glucose tolerance test

Glycosylated hemoglobin, also known as A1C, measures glucose control over the past 3 months.

How do we manage DM?

  • Nutrition:
    – For Type I DM, insulin doses are balanced with usual food intake and exercise. Patient must be consistent with the timing of insulin administration and amount of food consumed (especially carbohydrates [CHO]).
    – For Type 2 DM, initial dietary management aimed at decreasing calories, fats and simple sugars. Weight loss may help improve glycemic control (recommended weight loss of 5-7%).
  • Exercise may help decrease insulin resistance, lower blood glucose levels directly, improve circulation and muscle tone
    a caution about exercise and DM: AVOID exercise if hyperglycemia is present WITH ketosis
    – exercise lowers blood glucose levels for about 48 hours after activity
    – patients should exercise for 1 hour after a meal or have a 10-15g CHO snack
    – patients must check their blood glucose before, during and after exercise
    *do NOT exercise if blood glucose is less than 100
  • Drug therapy:
    – insulin: given subcutaneously or IV (only Regular can be given IV); different types of insulin with different onsets and peaks**; abdomen is highest rate of absorption followed by the arm, thigh then buttocks
    – oral agents: sulfonylureas, meglinitides, metformin

**Insulin types, peaks, onsets and durations

Complications of DM

  • Hypoglycemia
    – caused by too much insulin or by too much exercise compared to the amount of food eaten
    – BG < 70 mg/dL
    – symptoms: “wet and shaky” – cold sweats, weakness, irritability, pallor, increased HR, confusion, fatigue
    – treatment: give a fast acting CHO; when symptoms improve, give a long lasting CHO; Glucagon injection also given
  • Diabetic Ketoacidosis
     defined as a profound deficiency in insulin leading to an extremely elevated BG level 
    most likely occurs in type I DM, but can occur in type II DM during stress or illness
    – symptoms: polyuria, dry mouth, thirst, restlessness, sunken eyeballs, Kussmaul respirations, CNS changes, fruity breath, ketonuria
    – treatment: 1.) low dose regular insulin (0.1 units) in normal saline (NS) IV; 2.) when BG reaches 250, glucose is added to the IV to prevent hypoglycemia; 3.) replace electrolytes; 4.) prevent cerebral edema and monitor VS, I&O and cardiac status
  • Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)
    – 
    a life-threatening syndrome that occurs mainly in type II DM and leads to an extremely elevated BG level
    – symptoms: polyuria, dehydration; but NO ketones
    – treatment: 1.) rapid replacement of fluid via IV NS or 1/2NS; 2.) administer regular insulin via IV; 3.) when BG reaches 250, glucose is added to the IV to prevent hypoglycemia; 4.) replace electrolytes and monitor VS, I&O and cardiac status

Complications associated with insulin therapy

  • Allergy – now rare due to use of human insulin
  • Lipodystrophy – occurs if the same injections sites are used subsequently; hypertrophy may also occur is a site is not used for 6 months; this is also rare with human insulin
  • Somogyi effect – body abnormally overreacts to hypoglycemia occurring at night or during sleep by increasing BG levels; elevated BG noted on morning BG checks and is associated with undetected hypoglycemia during sleep; treatment with less insulin
  • Dawn phenomenon – hyperglycemia is present in the morning due to counter-regulatory hormones released in the predawn hours; treatment by adjusting timing of insulin or increasing insulin
Content Sources:
American Diabetes Association.
Medical-Surgical Nursing: Assessment and Management of Clinical Problems.
Diabetes Self-management.
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Psych Medications: Mood Stabilizers

Anti-manic and Mood Stabilizing drugs (Lithium, Depakote, Lamictal, Tegretol, Trileptal)

  • LITHIUM is the drug of choice for controlling manic episodes
  • lithium has a narrow therapeutic index (~0.6-1.2), familiarize yourself with the different LEVELS OF TOXICITY
  • normal SE of lithium include fine tremors, mild thirst, mild nausea and general discomfort – if they persist, may indicate toxicity
  • remember that DEHYDRATION (excess nausea, diarrhea, sweating, diuretics) may cause lithium TOXICITY
  • SE of toxicity include coarse tremors, persistent GI upset, confusion, muscle irritabbility, ECG changes, incoordination
  • lithium level of > 2.5 may = DEATH
  • Tegretol may cause agranulocytosis – monitor WBCs
  • Lamictal may cause Steven-Johnson’s – monitor platelets
  • Depakote may cause hepatotoxicity and thrombocytopenia – monitor LFTs and platelets
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Psych Medications: Benzodiazepines

Benzodiazepines/Non-benzodiazepine Anxiolytics (Ativan, Klonopin, Valium, Xanax, Librium, Buspar, Inderal)

  • [Val and Xan the Klo Ind the Bus] “Val and Xan the Klown In the Bus”
  • benzos increase GABA, have rapid onset
  • few drug interactions, but can interact with other CNS depressants (alcohol) and manifest as sedation or death
  • there is potential for ABUSE, be cautious when giving to patients with history of substance abuse
  • benzos must be tapered to lessen S&S of withdrawal (fatigue, irritability, insomnia, tremors)
  • BUSPAR is a special drug: takes a while to work, so often is taken with a benzo while waiting for therapeutic effect; no potential for abuse; high cost
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