Exam 1 Review- Med Surg

Hypertension, Diabetes, Fluid Imbalances, Electrolyte Imbalances, Acid-Base Imbalances, Anemia

Define Essential (Primary) Hypertension

Most common hypertension, no known cause. 

Define Secondary Hypertension

Hypertension caused by disease states (kidney disease) or as an adverse effect of medications;

Treatment = removal of causative factor.

Risk Factors for Essential Hypertension (11)

• Positive Genetic History 

• Excess sodium intake 

• Inactivity 

• BMI > 25 

• High alcohol consumption 

• African American ethnicity 

• Smoking 

• Hyperlipidemia 

• Diabetes 

• Stress 

• Age > 60 or postmenopausal  

Expected BP Range

Systolic < 120

Diastolic < 80

Elevated BP Range

Systolic 120 – 129

Diastolic < 80

Stage 1 Hypertension BP Range

Systolic 130 – 139

Diastolic 80 -89

Stage 2 Hypertension Range

Systolic Equal to or > 140

Diastolic Equal to or > 90

Hypertensive Crisis BP Range

Systolic Greater than 180

Diastolic equal to or > 120

What Should Be Assessed Prior to Administrating Antihypertensives? (4)

BP & Pulse (withhold if low)

BUN & Creatinine

Electrolyte levels

Fluid Imbalances (edema, weight gain, I&O)

Hypertension Health Promotion (7)

• Maintain a BMI < 25 

• Diabetic clients should keep blood glucose within recommended range 

• Limit caffeine & alcohol; Smoking cessation 

• Use stress management techniques during stress 

• Aerobic Exercise 3x/week 

• DASH, Heart Healthy Diet 

• Limit Sodium & Fat intake 

Clinical Manifestations of Hypertension (6)

Few to no manifestations

• Headaches 

• Facial flushing 

• Dizziness 

• Fainting  

• Retinal Changes

• Visual Disturbances 

What are the 2 Beta Blockers to know?

metoprolol

atenolol

Why are Beta Blockers Contraindicated in Asthma

Bronchoconstriction Risk

Beta Blockers Action

Blocks beta adrenergic receptors (SNS) for lower BP & HR

What Should be Assessed Prior to Beta Blocker Administration?

BP & HR

When is it unsafe to give Beta Blockers?

Low BP & HR - worsens symptoms

2nd or 3rd degree heart block

Severe asthma

What is the Thiazide Diuretic to know?

Hydrochlorothiazide 

Labs That Should be Monitored with Diuretics

Electrolyte levels - potassium, sodium, calcium, magnesium

Renal function

Glucose & Uric acid - can increase with thiazides

Lab That IS Monitored with Diuretics

Potassium

Loop & Thiazide = hypokalemia

Potassium-Sparing = hyperkalemia

What can occur if potassium is low? S/S

Hypokalemia

Muscle weakness & cramps

Dysrhythmias (irregular pulse)

Fatigue

Constipation

What can occur if potassium is high? S/S

Hyperkalemia

Cardiac arrhythmias (peaked T wave)

Muscle weakness

Paresthesia

Diuretic Client Education

Monitor for S/S of hypokalemia & report

Keep all appointments to monitor treatment effectiveness & electrolyte levels

Take diuretics prior to 6 PM
Increase consumption of potassium (bananas)

Causes of Hypokalemia with Loop & Thiazide Diuretics

Inhibit water & sodium reabsorption & increase potassium excretion

Causes of Hyperkalemia with Potassium-Sparing Diuretics

Retain potassium

What are the 2 ACE inhibitors to know?

Lisinopril

Enalapril

Adverse Effects of ACE Inhibitors

Hypotension

Heart Failure Evidenced by Edema

Heart & Kidney Complications

Dry Cough - may indicate risk of angioedema

Angioedema

Priority Adverse Effect of ACE Inhibitors & Why

Dry Cough

Risk of angioedema

Define Angioedema

Swelling of tongue/glottis, can lead to life-threathening airway obstruction

What is a hypertensive crisis?

Severely elevated blood pressure

Occurs when client do not adhere to medications

Life-threatening

Manifestations of a Hypertensive crisis

Severe Headaches

Very High BP

Blurred vision

Dizziness & Disorientation

Epistaxis

Nursing actions during a hypertensive crisis (6)

• Recognize manifestations 

• Administer IV Antihypertensives – nitroprusside, nicardipine, labetalol 

• Goal – Lower BP by 20-25% in first hour; do not drop less than 140/90 

• Medication Administration – monitor BP every 5-15 minutes 

• Assess Neuro Status – Pupils, LOC, Muscle strength; cerebrovascular changes

• Monitor ECG to assess cardiac status 

Define Type 1 Diabetes

Autoimmune destruction of beta cells that produce insulin cause insufficient insulin 

Define Type 2 Diabetes

Progressive condition due to inability of body’s cells to respond to present insulin (insulin resistance)

Who Should be Screened for Diabetes? (9)

• BMI > 25 

• 1^st degree relative with diabetes 

• 45 years or older 

• Sedentary Lifestyle 

• History of vascular disease, PCOS, gestational diabetes, birth to an infant > 9 lbs 

• African American, Hispanic, Asian, American Indian, or Pacific Islander 

• BP consistently greater than 140/90 

• A1C > 5.7%, impaired fasting glucose, impaired glucose tolerance 

• HDL < 35; Triglycerides > 250 

How are diabetic screenings completed?

A1C or fasting blood glucose

Prediabetic Reference Ranges

Glucose above expected range but below diabetic range

A1C - 5.7 - 6.4%

Diagnostic Criteria for Diabetes (4)

Manifestations of diabetes (3 Ps, kussmaul, infections) && random blood glucose > 200

Fasting blood glucose > 126

2 hr postprandial glucose > 200 with oral glucose tolerance test

A1C - > or equal to 6.5

Normal Fasting Blood Glucose Range

No food for > or equal to 8 hrs.

70 - 100

Normal Postprandial Blood Glucose Range

2 hrs after eating

< 140

Normal Random Blood Glucose Test

< 200

Normal A1C

< 5.7

Hypoglycemia Levels

< 70

Hyperglycemia Levels

> 140 fasting

> 200 random

Diabetic A1C Range

6.5 - 8%

A1C Goal for Diabetics

< 7 %

General Hypoglycemia S/S (9)

• Mild shakiness 

• Confusion 

• Sweating  

• Palpitations 

• Headache 

• Lack of coordination 

• Blurred vision 

• Seizures & coma 

Slow Glucose Decline Hypoglycemia S/S (4)

• Headache 

• Confusion 

• Fatigue 

• Drowsiness 

Rapid Glucose Decline Hypoglycemia S/S

• Tachycardia 

• Diaphoresis 

• Nervousness 

Interventions to Treat Hypoglycemia

Fast-acting carbs

Glucagon or IV dextrose

When are Carbohydrates Given in Hypoglycemia

If client is able to swallow & is responsive

Carbohydrate Hypoglycemia Intervention

Administer 15-20 g of readily absorbable carbs

Recheck BG after 15 mins

Retreat if manifestations continue or glucose is < 70

Fast Acting Carbs/Glucose

4-6 oz of fruit/soft drinks

Glucose tablets/gel

6-10 hard candies

1 tbsp of honey

When is Glucagon Given

Unconscious Clients

When are Glucagon & IV Dextrose Given

For clients unable to swallow

Glucagon Intervention Hypoglycemia

Place client in lateral position to prevent aspiration

Administer Glucagon SubQ or IM

Repeat in 10 mins if still unconscious

Once conscious consume oral carbs 

Hyperglycemia S/S

3 Ps -Polydipsia, Polyuria, Polyphagia

Hot, dry skin 

Fruity Breath 

Regular Insulin (Short Acting) - Examples

Humalin R

Novolin R

Regular Insulin - Onset, Peak, & Duration

Onset - 30 mins - 1 hr

Peak 2-5 hrs

Duration - 5 - 8 hrs

When is Regular Insulin Administered

15-30 minutes before meals to control postprandial hyperglycemia

Long-Acting Insulin - Examples

Glargine

Detemir

Long-Acting Insulin - Onset, Peak, Duration

Onset - 1 - 4 hrs

Peak - None

Duration - Dose dependent

Small dose duration = 12 hrs

Large dose duration = 24 hrs

Long-Acting Insulin - Dose Dependent Duration Range

12 - 24 hrs.

What Insulins are Mixed

Regular & NPH

Steps for Mixing Insulin

1. Inspect Vials for contaminants

2. Roll NPH between palms

3. Clean vial tops with alcohol

4. Inject air into NPH & pull needle out

5. Inject air into Regular

6. Withdrawal regular insulin dose

7. Withdrawl NPH insulin dose

8. Confirm dose (2 confirmation)

What is the Biguanide Drug to know?

Metformin

What should clients monitor for when taking metformin? S/S

Lactic acidosis

Myalgia (muscle pain & cramps)

Sluggishness

Somnolence

Hyperventilation

What should clients take metformin with & why?

Take with food to decrease adverse GI effects

What should client’s avoid when taking metformin?

Avoid alcohol

Increases lactic acidosis risk

What are the 2 Sulfonylureas to know?

Glipizide

Glimepiride

What should the client avoid when taking sulfonylureas?

Alcohol

Disulfiram reaction

All Antidiabetics have a risk of what?

Risk for hypoglycemia

Define Dehydration

Lack of fluid in body from insufficient intake or excess loss.

Define Hypovolemia (fluid volume deficit)

Isotonic dehydration

Lack of water & electrolytes decreasing blood volume

Dehydration S/S (10)

• Dizziness 

• Dry mouth & mucous membranes  

• Tongue – Dry, furrowed (grooves), shrunken 

• Decreased Urine Output & dark & concentrated urine 

• Dry Skin 

• Thirst 

• Headache 

• Vitals - Low BP, fever, tachycardia, 

• Hypothermia - as fever goes down 

• Chest pain 

Body Temperature in Dehydration (2)

Fever - can result in skin loss (sweating) resulting in dehydration

Prolonged fever - body will try to maintain homeostasis by causing hypothermia & cold skin

Why are the elderly higher at risk of dehydration? (4)

Loss of skin elasticity

Kidney - decreased glomerular filtration & concentrating ability

Loss of muscle mass - Muscles hold onto more water

Diminshed thirst sensastion

What are the interventions for hypotension? (5)

• Assess gait stability & encourage client to ask for assistance when ambulating (fall risk) 

• Encourage client to change positions slowly 

• Rehydrate & Administer IV fluids/blood transfusions if needed 

• Vasoconstrictors – increase BP & improve myocardial perfusion 

• Frequently monitor BP & HR & LOC 

What is Urine Specific Gravity?

A measure of the kidney’s ability to concentrate or dilute urine

Measure hydration & renal function

What is Normal Range of Urine Specific Gravity

1.005 - 1.030

Urine Specific Gravity for Dehydration

> than 1.030

High Urine Specific Gravity - Urine Appearance

Urine will be more concentrated.

Dark yellow to amber, strong odor, possibly cloudy

Define Overhydration

Too much fluid in body from excess intake or ineffective removal.

Define Fluid Overload

Excess of water/fluid (hemodilution); Risk of pulmonary edema & CHF

Define Hypervolemia

Fluid volume excess (excess water & electrolytes)

S/S of Overhydration

• Vitals – Tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure  

• Tongue Appearance – swollen, enlarged & moist; impressions of teeth may be present  

• Neuro – Changes in mental status, confusion, seizures, increased ICP

• Respiratory – SOB, dyspnea, crackles, increased RR, dry cough that can become productive with foamy, frothy, bloody sputum (flash pulmonary edema)  

• Others – Pitting edema of extremities, cool skin, ascites, nausea, weight gain 

What Does the Tongue look like in Over hydration?

Swollen, enlarged & moist; impressions of teeth may be present  

1+ Pitting Edema

< 2 mm depression barely detectable

Immediate rebound 

2+ Pitting Edema

2-4 mm deep pit

Few seconds to rebound

3+ Pitting Edema

5-7 mm deep pit

10 to 12 seconds to rebound

4+ Pitting Edema

> 7 mm very deep pit

20 seconds to rebound

S/S of Fluid Overload (Vitals)

Hypertension, tachycardia, tachypnea, increased RR, decreased O2 sat

Interventions for Fluid Overload

• D – diuretics 

• R- restrict fluids & sodium 

• A – assess daily weight 

• I – I & O 

• N – Na+ levels monitored & other electrolytes 

How much Weight Gain is Stable in Heart Failure?

2 lbs a day = stable

How Much Weigh Gain is Bad?

> 2 lbs a day or 5 lbs in a week = fluid overload

1 kg (2.2 lbs) =

1 L of fluid

Excess weight gain may indicate?

Worsening heart failure or pulmonary edema

Sodium Range

136 - 145

Hyponatremia Levels

Below 136

S/S of Hyponatremia

Muscle cramps, confusion, weakness

Hypervolemic

What Type of IV solutions treat Hyponatremia?

Hypertonic (high salt)