Diabetes Type One Patho: no insulin production S&S: polyuria, polydipsia, polyphagia, weight loss, risk of infections, rapid

onset, insulin dependent, familial tendency, peak onset: 10-15, preclinical period (with autoantibodies), abrupt onset RN: teach about exercise (check BG before, during & after exercise, eat small carb snack before, bring a snack while exercising); teach about insulin

Diabetes Type Two Patho: beta cell poop out; insulin resistance, insulin production, glucose production by the liver, hormonal issues r/t fat metabolism (adipokines), gradual onset @ risk: obese S&S: blurry vision, recurring infections, dry itchy skin, slow healing cuts and bruises, loss of feeling/tingling Diet: reduced fat and calorie diet (should be focused on achieving glucose, lipid & BP goals)

Hypoglycemia (<70)-#1 complication S&S: TIRED (tachycardia, irritable, restless, excessive hunger, diaphoresis & depression); confused ( LOC), cold, clammy, fatigued, shaky RN: First: check BG; Second: give patient 15-20g fast acting carb (Juice, soft drink, low fat milk). Check BG again in 15 minutes.

RN: encourage exercise (will cell sensitivity to insulin); teach about Oral Agents Diabetes Type 1 & 2:

RN:

Diagnosis: Fasting plasma glucose >126 on more than 1 occasion (fasting =8 hours without calorie intake) Checking BG is a nursing intervention you can check it as often as you want (cannot administer insulin freely) assess patient @ the peak of insulin (when patient is most @ risk for hypoglycemia) assess for complications (hypoglycemia, hyperglycemia) 2,000 calorie diet: 50-60% carbs, <10% protein, alcohol in moderation (teach about effect of alcohol) monitor BG ac and hs; monitor BG every hour when sick do not change insulin regimen when sick (notify MD if unable to keep fluids and foods down) teach patient about annual eye exams, foot care (white socks, inspect feet-must go to podiatrist), lifestyle modifications (weight loss if overweight, smoking), routine blood work (checking the kidneys BUN & creatine & albumin), @ risk for yeast Cushings Syndrome Addisons Disease Patho: decrease in corticosteroid hormones Patho: decreased corticosteroids (autoimmune) S&S: bronze pigment, hypoglycemia, weight loss, postural S&S: moon face, trunk obesity, susceptibility to infections, hypotension, weakness, GI disturbances gynecomastia, osteoporosis, hyperglycemia, personality changes, Adrenal Crisis: profound fatigue, dehydration, vascular thin skin, bruising, think extremities, edema, GI distress Medication: post adrenalectomy, patient will need corticosteroids collapse, renal shutdown ( Na, K+). post operatively assess for Addisons Medication: corticosteroids RN: assess for Addisons (N/V is first sign) after adrenalectomy, assess for cardiovascular complications (edema), do not abruptly stop corticosteroids (will send them into Addisons) RN: teach patient about corticosteroid treatment (double dose for minor stress & triple dose for major stress), IV fluids for dehydration and electrolyte imbalance (not a bolus); educate them about S&S of Adrenal Crisis (teach about urine output, staying hydrated, assess stress). Patient will need an IM emergency kit of corticosteroids Hypothyroidism Patho: decreased T3 and T4 S&S: intolerance to cold, dry skin, thick tongue (slow speech), brittle nails, constipation, hair loss, extreme fatigue. Late S&S: subnormal temperature, bradycardia, weight gain, LOC, thickened skin, cardiac complications. Can progress into Myxedema Coma (unconscious and unresponsive)

DKA (more common in type 1) Patho: high blood sugar, metabolic acidosis ( pH), ketones are present, HCO3 <15 S&S: lethargic, weak, severe dehydration, abdominal pain/vomiting/anorexia, Kussamauls breathing, signs of hyperglycemia, sweet breath odor RN: First: ABCD; second: IV Access (give 0.45% NS Bolus, will switch to 5% dextrose to prevent hypoglycemia); third: hang insulin drip (0.1 U/kg/hr); fourth: monitor electrolytes. Bring patient down 100 points per hour.

HHS Patho: very high BG, may or may not have ketones S&S: hyperglycemia, profound dehydration, hypotension, hemoconcentration, renal profusion RN: First: ABCD; second: IV Access (give 0.45% NS Bolus, will switch to 5% dextrose to prevent hypoglycemia); third: hang insulin drip (0.1 U/kg/hr); fourth: monitor electrolytes. Bring patient down 100 points per hour.

Hyperthyroidism Patho: increased T3 and T4 S&S: everything speeds up; intolerance to heat, BP and HR, tremors, facial flushing, nail clubbing, weight loss, bulging eyes, diarrhea RN: post thyroidectomy assess airway, high fowlers position,

Anemia Patho: decreased RBC (H&H is decreasing) S&S: pallor, cool skin, yellow skin & sclera, low BP, heart palpitations and HR, splenomegaly, changed stool color, muscle weakness and fatigue, SOB. Severe S&S: fainting, HF, angina, chest pain

teach patient that they will need lifelong thyroid replacement (Synthroid); assess for Thyroid Storm (tachycardia, HF, shock, fever, restlessness, agitation, seizure, mental confusion).

Diet: usually low calorie (because they have weight gain) Medication: Synthroid RN: patient could progress to a coma assess respiratory status; assess cardiac status, teach patient that treatment is lifelong (Synthroid) Megaloblastic Anemia Patho: Vitamin B12 and folic acid deficiency S&S: same as anemia (pallor, yellow skin, HR), red/pink tongue; cobalamin deficiency can lead to confusion and alteration in LOC. Common in alcoholics. RN: teach patient about good nutrition, teach patient that vitamin B12 injections will be required for the rest of their life Sickle Cell Disease Patho: two amino acids change place which changes the protein; in the presence of O2 the cell crystallizes and changes shape (becomes banana shaped). Banana shaped cells do not carry O2 as well and they get stuck in narrow joints and capillaries leads to ischemic pain S&S: pain (#1), fever, RR & HR Sickle Cell Crisis: pain, fever, swelling, HTN, N/V, RR Complications: occur with organs lungs (@ risk for pneumonia), kidneys (renal failure), brain (clots, strokes, MI, HF), eyes (retinal detachment) Medication: morphine drip (helps with oxygenation) RN: give O2 (@ least 2-4 L), IV access and dump fluids (will puff up the cells), encourage rest, administer pain meds, treat & monitor infections, assess lungs, assess kidneys (lab tests; I&O-we are dumping fluid, need to make sure kidneys can handle it). Teach patient: avoid high altitudes, stay hydrated, treat infections, & monitor for S&S of complications

RN: identify underlying cause, identify the type of anemia (may need to teach to increase iron intake (liver, meat, green leafy vegetables) or to take an iron supplement (ferrous sulfate)).

Thalassemia Patho: abnormal production of hemoglobin; autosomal recessive major (25%), minor (50%), unaffected (25%) S&S: major =major physical and mental implications diagnosed @ birth; minor =may be asymptomatic with mild anemic symptoms RN: they will need blood transfusions, keep hemoglobin >10, spleen is removed when child is young, assess patient for pulmonary HTN and pulmonary complications (have ability to carry O2). Acute blood loss Patho: can lead to anemia S&S: depend on how much blood is lost (will have HR and BP), will usually have pain, will not see a in H&H until 2-3 days after the blood loss RN: identify source of blood loss, replace the blood (type & cross), give IV fluids to replace volume and BP

Aplastic Anemia Patho: in RBC, WBC and platelets S&S: signs of anemia (because RBC), increase susceptibility to infections (because WBC) and risk for hemorrhage (because platelets) RN: we are worried about sepsis (assess for an increase in temperature FEVER) and hemorrhage. Polycythemia Patho: increase in RBC; vera = in RBC, WBC and platelets; secondary =triggered by another issue (such as COPD). in RBC is the result of low O2, pulmonary issues or chronic disease. S&S: Hypervolemia and hyperviscosity makes them @ risk for angina, HF, thrombus (DVT) RN: manage the issue that is causing oxygenation (keep an O2 stat of 95-100%), teach patient to avoid anything that vasoconstricts (smoking), avoid anything that triggers an increased demand for O2, thrombus prevention (need to be ambulating), need to stay hydrated. May need to have 500 mL of blood withdrawn every 3-4 months

Thrombocytopenia Patho: decrease in platelets (<150,000) (platelets live 8-10 days) 2 types: 1) ITP (immune thrombocytopenia purpra platelets are covered with an Ig that is recognized as an antigen by the spleen; platelets live 1-3 days; must remove the spleen) 2) HITS heparin induced thrombocytopenia stop the heparin

Hemophelia Patho: lacking part of the clotting cascade (Hemophelia A lacks Factor 8 & Hemophelia B lacks factor 9) S&S: they cannot stop bleeding/cannot form a clot slow persistent bleeding or uncontrollable hemorrhage. They get nose bleeds easily, very high risk for GI bleeds, bruising & hematomas and they can bleed into joints. RN: prevent & treat bleeding, may need transfusion, RICE

DIC Patho: Clotting cascade runs out; happens in very sick people (shock, sepsis, heat stroke, severe injury, trauma) S&S: any skin change in a chronically ill patient should be a red flag pallor, petechiae, purpura, oozing blood, hematomas, GI bleed signs, tachycardia, hypotension Diagnostics: H&H, red colored urine, bowel movements will be black + red, pt & ptt, d-diemer

RN: avoid aspirin, monitor for bleeding, they may need platelet transfusion, do not blow nose forcefully, do not use electric razor, do not pluck or tweeze, use soft bristle toothbrush, floss gently Neutropenia Patho: decrease in neutrophils (<1500); body loses the ability to fight infections and the S&S of infection are not apparent (neutrophils cause the S&S of infection redness, heat, pus, warmth). Usually the result of immunosuppressive therapy, cancer patients are @ risk RN: strict infection prevention (hand washing), isolation (some hospitals have neutropenic precautions), assess very closely for a slight increase in temperature (this would be a big deal)

(rest, ice, compression, elevate if they get up & move, the blood will go to different parts of the body). Teach patient to seek care for any swelling Disorders of the Spleen Disorders that effect the spleen: sickle cell, ITP, infections, any liver issues Splenectomy removal of the spleen RN: post splenectomy: observe for hemorrhage (spleen is very vascular), @ lifelong risk for hemorrhage (no extra RBC or WBC in storage), encourage patient to receive pneumovax vaccine

RN: identify early, volume replacement, blood replacement, oxygen, give clotting factors (proplex-T) Blood Products Summary Universal donor =Type O; universal recipient =AB Needle gauge: 18 gauge; possible w/23 but increased risk for hemolysis Y-tubing with filter required (must use NS, no dextrose) Consent is required; ID process 2 RN check, check #s, type, RH, expiration Essential to get baseline vital signs Blood must be hung within 30 minutes RN must stay with patient for first 15 minutes, VS @ 15 2-4 hours allowed for infusion Infuse platelets in 15-20 minutes Blood Reactions Febrile, nonhemolytic: small increase in temperature, not severe, do not need to stop blood; RNs decision Allergic Reaction: always stop blood (if any complaints of Pruitis, etc) stop blood and then assess Circulatory overload: crackles will be present; slow the rate and keep an eye on the patient @ risk: HF patient Acute Hemolytic: immediate spike in fever after 10 mL infuse (chills, fever, low back pain, flushing, increased HR, decreased BP) can lead to DIC: STOP it TRALI (transfusion related acute lung injury): pulmonary issues during transfusion, problem is with the donor blood Sepsis: identify and treat as sepsis; will see it @ end of transfusion or days after

Lab Values: RBC: males: 4.5-6; females: 4-5 WBC: 4,000-11,000 Hemoglobin: males: 13.5-18; females: 12-16 Hematocrit: males: 40-51%; females: 38-44% Platelets: 150,000-400,000 PT: 10-14 seconds (extrinsic pathway) Ptt: 30-45 seconds (intrinsic pathway) BUN: 10-30 mg/dl Creatinine: 0.5-1.5 Iron: 50-150 T3: 110-230 T4: 5-12