Nitroglycerin - Vasodilator

Lose fluid, lowers BP, Lowers HR

Monitor the BP and HR before giving drug (making sure level is not low) then again 30 minutes post giving drug.

Lasix- Loop diuretic (Wastes potassium)

Monitor Potassium

Check lab values: electrolytes, K+

Check renal function

S/S - Discolored sputum, crackles, DULLNESS when percuss (palpate)- consolidation in the area of the lung

-Egophany, whisper test, pectoriloquy, bronchophony

-Order: a chest xray and sputum if suspicious of pneumonia.

Give: Mucinex (expectorant) - Thins the mucus

Rescue inhaler (Albuterol), Fast acting

Bronchodilator

Check: oxygen saturation level, if below <92, give nasal canula (oxygen supplement)

***Assess respiratory status*** 

Assessment is an invention (assess 1st- can be something blocking airway, choking etc. think about what else can be occurring)

Bronchoscopy=scope goes into bronchial tubes in lungs

Look for polyps, nodules, growths, infected area

Give a lidocaine spray to mouth and goes down throat to numb it, patient is awake.

Teach: Check "gag reflex" with tongue depressor to see if they're ready/safe to eat. If gag, known that numbness has worn off.

S/S = BP (low), Vitals (heart rate fast)

Check: color of skin (pale), cap refill (>3 sec to refill), skin temp(cold), sensation, circulation

check site itself - inflammation, irrititation

Can apply pressure if site starts to bleed.

SE: Lab results (electrolytes, K+)

VS: Blood pressure

"-lol" = "little old lady" ; given by mouth or IV

Beta- blocker = treats BP

Expected results: decreased BP, Heart rate

*Know patients normal BP before giving medication

**MONA**

Give an aspirin, nitroglycerine (vasodilates), morphine (pain), oxygen

Diagnostic test:EKG (compare to past EKG)

Education for hx of acute MI:

Aspirin, Nitroglycerine (3 in a row,every 5-10min?)

Can be angina, want to teach patient what to look for

Regular- Onset/15-30 min Peak/2-4 hrs

NPH- Onset/1-2 hrs, Peak/8 hrs

EX/ Pt is given reg insulin at 10:00am, what time would patient see sugar drop? Answer- Between 12 and 2pm

Fatigue (all day exhausted), LOUD snoring

*Due to decreased oxygen to the brain

When giving a hypertensive med to a patient, when would you hold the drug?

BP: <100 systolic <60 diastolic (unless this is normal BP)

<60 diastolic would question giving metopolol

*Check both arms for BP to ensure there is no error

Kidney functions, ECHO cardiogram, ultrasound of heart

chest x-ray (check for fluid in lungs), BNP (tells if pt is in fluid overload)

Long acting, control inhaler

Teach patient to take 2x a day as prescribed (controls breathing) - better than taking oral corticosteroids

It will not help if cant breathe, need rescue inhaler (dont want patient to use often)

Can get thrush (rinse mouth)

Left sided = S4, Left leads to Right side

Right sided = S3, JVD, edema

Anticoagulant - prevents clot formation

Pt needs to take it every day for life, otherwise could have a stroke

Confused, irritable, anxious

** fighting for air**

*Give SQ, "RN"

Can mix regular NPH and Regular

**Draw up reg to 5units, then 10 units of NPH=15 total units

Glargine (cant be mixed!)-need a separate syringe to give

Pt will give himself/herself two pricks. If see patient combining all three meds - need to educate.

3 Ps = Polyurea, polydysea, polyphagia

hyper/hypo glycema, mental status altered, renal problems, ulcers at feet

Can result in amputation if non-adherent

**Vision blurred= Retinopathy**

**Peripheral neuropathy= Fingers, toes**

MI=  Q Wave - heart attack

ST elevation- emergent treatment of MI, Need to put in stent within 15 min

Triponin levels - see if there's an upward trent over 12 hrs

CKMB levels- measure muscle breakdown levels. Want level to be low.

Men- Hispanic

Women- Hispanic

Men- White Non-Hispanic

Women- White Non- Hispanic

"Diabetes" = "To go through"

"Mellitus" = "Sweet"

Sweet urine.

Diagnosing Diabetes

(5 ways)

1. The stomach changes food into glucose

2. Glucose enters the bloodstream

3. The pancreas makes little or no insulin

4. Little or no insulin enters the bloodstream

5. Glucose builds up in the bloodstream

With T1DM, can see varying ratios throughout the day, for example, 1:12 for breakfast, 1:15 for lunch, 1:20 for dinner  

Onset <15 mins

Peak 0.5- 3 hours

Duration 3-5 hours

Note: If mixing with NPH, rapid acting insulin should be drawn into the syringe first. Mixture should be given immediately to avoid effects on peak action.

EX/ Lispro, Aspart, Glulisine

Onset 0.5- 1 hour

Peak 2-4 hours

Duration 4-8 hours

Note: May be mixed with NPH in same syringe. Mixing order should be the clear regular drawn up first, then the cloudy NPH ("clear to cloudy")

EX/ Regular (Novolin R or Humulin R)

Onset 2-4 hours

Peak 4-10 hours

Duration 10-18 hours

Note: Available as pen or vial to be used with syringe.

Onset 4-6 hours

Peak Same action through out the day

Duration 24 hours

Note: DO NOT mix with other insulin.

Available in pen or in vial.

Blood glucose: <70mg/dl

Signs/symptoms: Shake/extremely hungry, lightheaded/weak, cold/clammy skin, personality change, inability to waken

Causes: Too much diabetes meds, too much activity, not enough carb, alcohol, advancing age

Treatment: 15/15

They help make the pancreas make more insulin. They work by stimulating the beta cells in the pancreas to release more insulin.

EX/ 1. Sulfonylureas - These drugs are generally taken 2x a day before meals

2. Meglitinides/ Nateglinide- They were similarly to Sulyonylureas except they act immediately in response to food, are very short acting and need to be taken before each meal.

Oral agents, insulin secreters:

Common side effects

Low blood sugar is the most common side effect and can be caused by taking too much of the drug, not eating enough carbs, or an unexpected increase in activity.

Other less common side effects include :

skin reactions

stomach upset

increased sensitivity to the sun

brown urine

These drugs mainly slow the release of glucose from the liver and has a slight effect on helping the body use the insulin better. They should be taken with food for best results. Most frequently used diabetes drugs.

EX/ Metformin or Fortamet

Diarrhea, nausea/ vomiting, metallic taste

Side effects usually subside if dosage is increased very gradually.

Lactic acidosis is very rare though can be serious.

Who should not take metformin:

people with certain kidney or liver diseases

people who drink alcohol more than 2-4 drinks a week should check with their doctor

people with serious infections or complicated heart problems 

They help insulin work better in muscle or fat, they lower insulin resistance, and have a small effect on slowing the release of sugar from the liver.

TZDs are taken once or twice daily.

EX/ Rosiglitazone, Pioglitazone

SE:Headache, Muscle ache, swelling or fluid retention, liver damage

Considerations: Have been associated with liver abnormalities, may make contraceptive pills less effective

Starch blockers.

Slows or blocks the breakdown of starches and certain sugars in the intestines. Actions slow the rise in blood sugar levels following a meal. Should be taken with first bite of meal. EX/ Acarbose, Miglitol

SE: Intestinal gas, diarrhea, abdominal pain

Considerations: Those with any type of bowel disease or significant kidney disease shouldn't take this.

While taking a combination drug may be easier, you should remember if you combine two drugs into one- you are still at risk for the side effects of both medications.

EX/ Glucovance, Metaglip, Avandamet

Incretins 

S/S:  severe dehydration, 3 Ps, fatigue, N,V, breath w/ fruity (alcohol) smell as the body attempts to remove ketoacids, as acidosis worsens, may lead to Kussmaul respirations w/ increase rate and rhythm, tachycardia and hypotension, may lead to stupor and death.

Mortality rate of 20-40%. Seen in elderly, obese, w/ co-morbid conditions. Gradual onset and may be viewed as a CVA due to neuro involvement (confusion / lethargy). Treat w/ fluid replacement while avoiding cerebral or pulmonary edema.

60% of total body fluid

Primarily in skeletal muscle mass

40% of total body fluid

Interstitital - 80% of ECF 11L

Intravascular- 20% of ECF 3L Plasma

Transcellular -1 L (not counted in fluid calculations)

digestive secretions; perspiration; and cerebrospinal, pleural, synovial, intraocular, gonadal, and pericardial fluids.

Hydrostatic Pressure:

Pressure exerted by the fluid on the walls of the blood vessel

So hydrostatic pressure ________ fluid from area of more pressure to area of lower pressure, while osmotic pressure ______fluid towards area of higher concentration of solutes (in this case the solutes are the proteins).

FILL IN THE BLANKS.

1. Pushes

2. Pulls

Remember that hydrostatic pressure forces water _______ of a solution, whereas osmotic pressure draws water _____a solution.

FILL IN THE BLANKS.

1. Out

2. Into

The sodium-potassium pump is the key to functions such as cardiac and renal activity, as well as all general transport processes into and out of the cell. The pump  forms the basis for our ability to absorb a considerable number of nutrients, excrete waste products from the kidneys and regulate the water balance in the cells. If this little pump stopped pumping sodium ions out of the cells, the latter would rapidly swell up because of the infiltration of water and finally burst.

Sensible (noticeable) fluid loss refers to fluid loss that is visible, just as urine, stool, blood loss in surgery, and perspiration.

Insensible fluid loss is not visible and not really measurable.

• BUN: 7 to 20 mg/dL
• CO2 (carbon dioxide): 20 to 29 mmol/L
• Creatinine: 0.8 to 1.4 mg/dL
• Glucose: 64 to 128 mg/dL
• Serum chloride: 101 to 111 mmol/L
• Serum potassium: 3.7 to 5.2 mEq/L
• Serum sodium: 136 to 144 mEq/L

Congestive heart failure

• Excessive protein levels in the gastrointestinal tract
• Gastrointestinal bleeding
• Hypovolemia
• Heart attack
• Kidney disease, including glomerulonephritis, pyelonephritis, and acute tubular necrosis
• Kidney failure
• Shock
• Urinary tract obstruction

• Liver failure
• Low protein diet
• Malnutrition
• Over-hydration

High potassium levels can be due to:

Hyperkalemia

• Addison's disease (rare)
• Blood transfusion
• Certain medications
• Crushed tissue injury
• Hyperkalemic periodic paralysis
• Hypoaldosteronism (very rare)
• Kidney failure
• Metabolic or respiratory acidosis
• Red blood cell destruction
• Too much potassium in your diet

Low levels of potassium can be due to:

Hypokalemia

• Chronic diarrhea
• Cushing syndrome (rare)
• Diuretics such as hydrochlorothiazide, furosemide, and indapamide
• Hyperaldosteronism
• Hypokalemic periodic paralysis
• Not enough potassium in the diet
• Renal artery stenosis
• Renal tubular acidosis (rare)
• Vomiting

Higher than normal sodium levels:

hypernatremia

• Cushing syndrome
• Diabetes insipidus
• Hyperaldosteronism
• Increased fluid loss due to excessive sweating, diarrhea, use of diuretics, or burns
• Too much salt or sodium bicarbonate in your diet
• Use of certain medicines, including birth control pills, corticosteroids, laxatives, lithium, and NSAIDs such as ibuprofen or naproxen

Lower than normal Sodium levels can be due to:

hyponatremia

•  Addison's disease
• Dehydration, vomiting, diarrhea
• An increase in total body water seen in those with heart failure, certain kidney diseases, or cirrhosis of the liver
• Ketonuria
• SIADH
• Too much of the hormone vasopressin
• Use of medications such as diuretics (water pills), morphine, and SSRI antidepressants

Normal H&H Levels:

Hemaglobin

Hemoglobin is the oxygen-carrying protein pigment in the blood, specifically in the red blood cells.

• Adult males: 14-18 gm/dl
• Adult women: 12-16 gm/dl
• Men after middle age: 12.4-14.9 gm/dl
• Women after middle age: 11.7-13.8 gm/dl

Normal H&H levels:

Hematocrit

The hematocrit is the proportion, by volume, of the blood that consists of red blood cells.

• Adult males: 42-54%
• Adult women: 38-46%

For someone who doesnt have diabetes: 4.5 to 6 percent

Prediabetic: 5.7 and 6.4 percent

Diabetic: 6.5 percent or higher on two separate tests