How fast is the progression of symptoms for type 1 diabetes mellitus?

destruction of pancreatic beta cells, autoimmune

Which type of diabetes mellitus has decreased or defective insulin receptors?

type 2

How is the plasma insulin produced in type 1 diabetes mellitus?

What is the treatment for people with type 1 diabetes mellitus?

What is a normal range for blood glucose?

What is FBG?

promotes consevation of energy and building of energy stores by:
stimulating cellular transport of glucose, amino acids, nucleotides, potassium and by synthesis of glycogen, amino acids, proteins, fatty acids, triglycerides

What are the indications for the drug insulin?

Type 1 diabetes Mellitus, Type 2 diabetes mellitus (stress, pregnancy, surgery, infection)

What unit is the drug insulin measured in?

1 mL= 100 USP Units

How are the different insulin drugs categorized?

ultralente (Humulin U)

insulin glargine (Lantus)
insulin detemir (Levemir)

When is the peak time for intermediate acting insulin?

What are the routes for insulin administration?

• monitor blood glucose as ordered and prn
• monitor injection sites for lipohypertrophy (rotation of sites to decrease damage, injections in the abdomen are most rapidly absorbed, staying within the same anatomical area decreased fluctuations)
• technique for mixing insulins
• encourage patient to wear a Medic-Alert bracelet
• carry glucose at all times

What are the side effects of human insulin (Exubera)?

• too much insulin given
• meals are missed or delayed
• excessive exercise
• vomiting or diarrhea
• side effect of another drug
• drinking alcohol

• shakiness
• headache
• cold sweats, clammy
• pale, cool skin
• anxiety, irritability
• difficulty concentrating
• confusion, drowsiness
• blurred vision
• nausea
• increased appetite

How is hypoglycemia treated?

• 4-6 oz fruit juice or soft drink
• 2 tbsp raisins
• 8 oz low fat or skim milk
• 1 tbsp honey
• 3-4 glucose tablets
• 1/2-1 tube glucose gel
  

• not enough insulin used
• eat large amounts of food
• little exercise
• side effect of another drug
• fever or illness

When are 1st generatino sulfonylureas [tolbutamide (Orinase)] used?  Why?

What are effects of biguanides [metformin (Glucophage)]?

• decreased hepatic glucose output (decreased gluconeogenesis)
• increased peripheral glucose utilization (insulin sensitizer)

What is sitagliptin (Januvia)?

• metformin/glyburide (Glucovance)
• metformin/glypizide (Metaglip)
• metformin/rosiglitazone (Avandamet)

• encourage diet restrictions and exercise to maintain glycemic control
• weigh at least once per week
• test blood glucose regularly
• assess DM complications: skin for poor healing, renal function, etc
• monitor for signs of hypoglycemia and hyperglycemia
• follow-up with physician for lab studies
• contraindications: alcohol (increased risk of altering blood glucose and source of calories), anticoagulants, beta-blockers
• monitor for symptoms of iver function problems
• encourage patient to carry glucose source at all times

• breakdown of glycogen
• decreased glycogen synthesis
• stimulates biosynthesis of glucose

• assess for hypoglycemia
• monitor blood glucose before and after administration and up to four hours after patient regains consciousness
• document VS and LOC
• may interace with anticoagulants to produce bleeding
• monitor respirations, risk for aspiration- turn patient on side
• if LOC permits, administer glucose via the oral route

• stimuation of energy use (basal metabolic rate, temperature regulation)
• stimulation of the heart (increased force and contraction of the heart, increase for oxygen demand)
• promotion of growth and development (development of the CNS (brain), growth and maturation of skeletal muscle, carbohydrate, lipid, protein metabolism, gastrointestinal function, fluid balance)

_______ acts on the thyroid to release _______________.

• changes in facial expression
• cold/dry skin
• brittle hair
• hair loss
• decreased heart rate
• hypothermia
• lethargy
• fatigue
• intolerance to cold
• constipation
• increased weight

What is myxedema?

What are the side effects of levothyroxine (Synthroid, Levoxyl, Levothroid)?

• decreases absorption (calcium supplemens, aluminum antacids, iron supplements)
• increases absorption (Coumadin, Dilantin, Tegretol, Zoloft, phenobarbital, catecholamines)

• life long therapy
• take on an empty stomach, in morning before breakfast
• take at the same time each day
• routine blood studies (TSH= 1-3mU/L) to determine effectiveness
• educate patient about symptoms to report
• inform physician before surgeries or treatments

• increased heart rate
• hysrhythmias
• angina, nervousness, insomnia, muscle weakness/atrophy
• increased BMR
• hyperthermia
• intolerance to heat
• warm/moist skin
• decreased weight
• increased appetite
• diarrhea
• protruding eyes

• surgical removal of the thyroid
• ablation of thyroid with radioactive iodine
• anti-thyroid drugs

• hyperthyroidism
• adjunct to radiation therapy
• preoperative suppression of gland before removal surgery
• thyrotoxic crisis

• elemental iodine + potassium iodide
• suppressant effect on the thyroid before surgery
• can be toxic

• promotion of growth- increased bone length, increased muscle mass
• promotion of protein synthesis by holding on to nitrogen
• alteration of carbohydrate metabolism- high blood glucose, high insulin levels

• hyperglycemia
• hypothyroidism
• interaction with glucocorticoids

• monitor for growth rate and weight during therapy
• examine annually for epiphyseal closure
• warn of pain and swelling at injection site
• monitor for hypothyroidism
• refrigerate any unused reconstituted medication, do not use if cloudy or contains particulate matter, mix gently/do not shake

• diabetes insipidus (decreased ADH)
• esophageal varices
• noctural enuresis

What are side effects of vasopressin (Pitression), desmopressin (DDAVP)?

• monitor for chest pain, MI, HTN, SOB
• carefully assess fluid status (I&O, urine specific gravity, weight)
• monitor EKG and serum electrolytes
• caution with patients with CAD and other vascular disease

• carbohydrate metabolism
• protein metabolism
• fat metabolism
• CV system
• skeletal muscles
• CNS
• stress
• inflammatory process

they are secreted when needed by negative feedback: hypothalamus to CRF to anterior pituitary to ACTH to adrenal cortex to cortisol and glucocorticoids

• truncal obesity
• thinning of extremities
• hyperglycemia
• glycosuuria
• edema (sodium/water retention)
• HTN
• osteoporosis
• muscle weakness
• myopathy
• hirsutism
• menstrual irregularities
• decreased resistance to infection
• fluid/fat redistribution (moon face, buffalo hump)
• mood changes

surgical removal of tumor, cancer

Chronic replacement therapy- adrenal cortical insufficiency
nonendocrine diseases (anti-inflammatory properties): (rheumatoid arthritis, SLE, ulcerative colitis, Crohn's disease, allergic reactions, asthma, skin conditions, neoplasms, suppression of organ/tissue rejection, general inflammatory conditions.)

• osteoporosis
• infection
• high glucose
• myopathy
• fluid (sodium/water retention ) changes
• electrolyte disturbance (decreased potassium)
• growth retardation
• psychological changes
• cataracts, glaucoma
• PUD
• poor wound healing
• Cushing's syndrome

• NSAIDs
• digoxin, diuretics
• vaccines
• diseases- HTN, DM, CHF, PUD, HIV/AIDS

• do not administer to patients with fungal or TB infections, AIDS
• carefully monitor blood glucose
• caution with patients who have GI inflammation or ulcers- bleeding
• monitor fluid status
• avoid administering vaccinations during treatment
• caution with the elderly (HTN, osteoporosis)
• eye exams are recommended when therapy persists over 6 weeks
• monitor growth rate in children
• may prescribe sodium restrictions, potassium supplements
• educate patient about reporting any signs of infection
• discuss drug-induced body image disturbances

• prescribe the lowest dose for the shortest duration
• complex dosing schedule must be followed
• do not abruptly discontinue, taper steroids when discontinuing
• alternate-day therapy

What are the actions of calcium?

calcitonin is a hormone produced by the thyroid gland.  it decreases calcium levels in the blood when levels are too high.

• hypercalcemia
• hypocalcemia
• rickets
• Paget's disease of the bone
• hypoparathyroidism
• hyperparathyroidism

• usually asymptomatic
• kidney drainage
• dysrhythmias
• calcium deposits

• cancer
• hyperparathyroidism
• vitamin D toxicity

• defective bone growth
• skeletal deformities

• deficiency of vitamin D
• limited exposure to sunlight

• increased bone reabsorption
• abnormal bone formation
• asymptomatic

• analgesics
• antiinflammatories
• calcitonin

• hypercalcemia
• po- constipation, increased gastric acid secretion

• prednisone, tetracyclines, thyroid hormone, thiazide diuretics
• decreased calcium absorption- spinach, beets, bran/whole grain cereals

• do not administer with bran cereals, indicated drugs (several hours apart)
• chewable tablets are preferred
• take no more than 600 mg at one time
• do not switch between brands (not equivalent)
• take with large glass of water, with or after meals

10 million (80% older women)

34 million have risk for developing 

• bone densitometry (all women beginning at age 60-65)
• presenting symptoms
• thorough patient history, family history

• personal history of fracture as an adult
• history of fracture in close relative
• Caucasian/Asian race
• advanced age
• female gender
• dementia
• poor health, frailty

• current cigarette smoking
• low body weight (<127 lbs)
• estrogen deficiency (menopause)
• low calcium intake
• alcoholism
• impaired eyesight
• recurrent falls
• inadequate physical activity
• poor health, frailty

• alendronate (Fosamax)
• risedronate (Actonel)
• ibandronate sodium (Boniva)

suppresses resorption of bone by decreasing osteoclast function

remains active in bone for several weeks, months 

• prevention and treatment of postmenopausal osteoporosis
• male osteoporosis
• glucocorticoid-induced ostoeoporosis

• esophagitis, gastritis, ulcers
• gas production
• acid reflux
• Actonel- arthralgia, diarrhea, HA, rash, N, GI upset

• administration protocol- give with 8 ounces of water, do not eat for 30 minutes, remain upright for at least 30 minutes [pill must pass esophagus]
• avoid chewing or sucking tablet
• report any adverse GI symptoms to physician
• contraindicated in patients who have swallowing problems
• maintain calcium intake in presence of drug

• take Boniva as instructed by your healthcare provider
• take Boniva first thing in the morning
• wait at least 1 hour before eating or drinking anything except plain water
• swallow Boniva whole (do not chew or suck) with at least 6 to 8 ounces of plain water
• do not take Boniva with mineral water, sparkling water, coffee, tea, milk, or juice
• avoid taking any other oral medicine, including calcium, antacids, or vitamins
• avoid lying down for at least 60 minutes after taking Boniva to help decrease the risk of stomach problems

• prevention and treatment of osteoporosis, alternative to estrogen
• selective estrogen receptor modulators (SERMs)
• preserves bone mineral density and lowers cholesterol
• side effect- DVT and PE
• less risk of breast and endometrial cancer
• obtain baseline BMD
• ensure adequate intake of calcium and vitamin D

• form of PTH
• only drug for osteoporosis that increases bone formation (not bone resorption)
• daily SC injections

• raloxifene (Evista)
• teriparatide (Forteo
• estrogen therapy
• daily calcium supplemetns and daily vitamin D supplements

• constriction of blood vessels to slow blood loss
• formation of a platelet plug- platelets adhere to site of vessel injury which leads to platelet aggregation.  the plug is unstable, reinforced with fibrin
• coagulation- the production of fibrin clot
• removal of clots

• suppresses coagulation by helping antithrombin inactivate clotting facots, prevents conversion of prothrombin to thrombin which leads to the inhibiting of the formation of fibrin from fibrinogen
• no fibrinolytic activity (does not dissolve existing clots but can prevent the extension of existing clots)

• prophylaxis of venous thrombosis (especially postoperatively)
• diseases: pulmonary embolism, emerging stroke, DVT- better than anticoagulants in preventing pulmonary complications with thrombophlebitis
• prevent blood clotting in surgery of the heart or blood vessels, blood transfusions, hemodialysis
• adjunct to thrombolytic treatment

• obtain baseline vitals for BP, HR, CBC, platelets, H & H, PTT
• determine preexisting health conditions that would contraindicate heparin (ex: active hemorrhage, thrombocytopenia, hemophilia, PUD)
• determine current medicine regimens- any other druginteractions or other anticoagulants/platelet inhibitors(ex: ASA, NSAIDs- risk of hemorrhage; nitroglycerin diminishes heparin's effectiveness)
• ask about heparin allerty (heparin-induced thrombocytopenia- HIT)
• assess for factors that increase the risk for bleeding such as elderly, HTN, CVD, liver or renal failure, GI bleed
• clotting studies

• heparin-induced thrombocytopenia -HIT)
• potentially fatal immune-mediated disorder
• low platelet counts- (type 1- 100,000 to 150,000) (type 2 <100,000) + thrombosis.  monitor platelet counts during heparin therapy (2-3 times a week).
• incidence of type 2 is 1-3% among patients who receive heparin for more than 4 days.
• signs: cyanosis of fingers and toes, limb ischemia, CVA, MI, PE
• can lead to digit or limb amputation, organ failure, death
• treatment- stop heparin, and administer lepirudin (Refludan), agatroban (Acova).  the most common side effect of this antidote is bleeding.  monitor PTT.

hemorrhage.  10% of patients develop bleeding, at any site, can be fatal

early signs of bleeding- (skin- ecchymosis [bruising], petechia, hematomas), (nosebleeds, excessive bleeding from gums/cuts/wounds/tube insertion sites/menses/eyes), (internal bleeding- abdomin pain/swelling, backache, dizziness, headache, hematemesis, hematuria, hemoptysis, bloody/black stools, swollen/stiff/painful joints)

 check urine and stools for occult blood daily and monitor the platelet count

 other side effects: cold, cyanotic, painful, tingling hands and feet, chest pain, chills, increased temperature, wheezing, rash, pruritis, hives, rhinitis, anaphylaxis, local irritation at injection site

• dispensed in Units, check the haparin concentration on the vial carefully
• subcutaneous route- smallest gauge needle (25 or 27g), 1/2-5/8 inch needle, syringe selection (1cc or 3cc?), bunching technique, inject deep into fatty tissue above the iliac crest or into the abdomen, avoid injecting inside a 2 inch radius around the umbilicus; away from scars or lesions, DO NOT aspirate or massage the site, withdraw needle slowly and gently, apply direct pressure to site after needle removed for 1-2 minutes prn, document location, rotate sites, onset delayed by 1-2 hours, usual dosing: 5000-10000 Units SC q8-12h
• intravenous route (intermittent or continuous)- loading dose before continuous infusion of heparin, dosed according to weight, must use an infusion pump for precision, apply pressure to any venipuncture or injection sites, heparinized versus nonhaparinized flush solution controversy, stop heparin immediately when signs of bleeding occur (chills, low back pain [abdominal bleeding], or spontaneous bleeding), dosing; bolus of 5000 Units followed by 30,000 Units/day

• enoxaparin (Lovenox)
• dalteparin (Fragmin)
• ardeparin (Normifo)
• tinzaparin (Innohep)

• more solubility so rapid onset
• greater bio-availability after SC injection and longer half-life which means it is more predictable
• fewer incidences of hemorrhage complications
• daily coagulation studies (aPTT) are not needed- predictable antithrombotic effect
• standard fixed dose (1 mg/kg administered once a day or twice a day SC)
• first dose received 12 to 24 hours after surgery
• therapy continues at home for a total of 7-10 days of treatment up to 3 weeks, safe for outpatient use
• easy to self-administer by patients
• less likely to cause thrombocytopenia
• LMW heparin once or twice daily as safe and effective as IV heparin
• more expensive

• first lint therapy for prevention of DVT: following hip or knee replacement surgeries, general surgery, cardiovascular surgery, trauma patients, without preventative anticoagulant treatment, up to 40-70% of patients havign major orthopedic procedures and 15-30% of patients with abdominal surgery will develop DVT.
• treat established DVT
• ischemic stroke, PE, MI

• bleeding- slightly fewer hemorrhagic complications than heparin
• same as heparin
• HIT- 10 times lower incidence than with heparin

• administer SC based on body weight
• comes in prefilled syringes
• injection: stored at room temperature, supine position with abdomen visible, administer the correct dosage, DO NOT expel the air bubble in the syringe before injection, inject in right or left side of abdomen in "love handles," insert the needle in a 90 degree angle, DO NOT  aspirate or massage te site, take at the same time each day
• assess abdomen for bruising after injections

• fondaparinus (Arixtra)
• danaparoid (Organon)

• bleeding- may cause more bleeding than LMWHs
• anemia, fever, N, V
• does not cause HIT

• administered once each day
• clotting lab studies are not needed

severe heparin overdose only (frank hemorrhage, elevated PTT) by IV administration

with minor overdoses, stop the drug infusion

• suppresses coagulation by acting as an antagonist of vitamin K
• interferes with the synthesis of vitamin K-dependent clotting factors in the liver
• no fibrinolytic activity (does not dissolve existing clots but can prevent the extension of existing clots)

• usually started on the day that heparin is started
• given concurrently with heparin for at least 3 to 5 days while heparin is tapered off [until INR remains within the recommended range for 24-36 hours]
• onset of action for oral anticoagulant drugs is slow- 99% bound to protein
• anticoagulant effects are delayed, duration is prolonged

long term prophylaxis of thrombosis (drug of choice)

     DVT, pulmonary thromboemboli

     heart valve replacement surgery

     atrial fibrillation

prevent TIAs, recurrent MI 

What are the advantages of warfarin (Coumadin)?

not used for emergency use

ASA may be more effective when preventing a stroke 

• similar to heparin therapy
• determine the concurrent administration of contraindicated drugs
• obtain baseline values for BP, HR, CBC, platelets, H & H, PT
• clotting studies

PT (prothrombin time)

    normal = 12 seconds

    1.3-1.5 times normal control- prevention

    1.5-2 times normal control- high risk

INR (international normalized value)  

    2-3 normal (2,5-3,5 for valve replacements, recurrent MI)

    more accurate than PT

    standardized values, mathematical correction to PT ratio (WHO)

    measured daily during initial 5 days, 2x/week for next 1-2 weeks,           1x/week for next 1-2 months, every 2-4 weeks after

    home testing

• hemorrhage/bleeding- any bleeding that does not stop, bleeding gums, nosebleeds, red or pink-tinged urine, red or black stools, faintness/weakness, headaches stomach pain, skin rask, skin changes (bruising)
• anorexia, abdominal cramps, leukopenia, N, V, diarrhea, hematuria, alopecia

• severe thrombocytopenia
• uncontrollable bleeding
• spinal procedures
• hemophilia
• PUD
• surgical procedures
• liver disease
• alcoholism

• taper gradually over 3 to 4 weeks
• avoid giving injections, venipuncture if possible
• monitor PT/INR as indicated
• encourage compliance and safety through patient education

• follow strict adherence to dosing schedule
• able to recognize excessive bleeding and bruising- report to MD
• take anticoagulant at same time each day
• change dose only if directed
• wear medical ID bracelet
• avoid other medications unless ordered by MD
• do not take ASA or ibuprofen
• avoid multivitamins or foods containing vitamin K (consistent intake of green leafy vegetables)
• drink adequate amount of fluids
• use an electric razor for shaving
• if cut, apply pressure for 5 to 10 minutes
• avoid/limit alcohol
• inform dentist/physicians about anticoagulant use
• avoid constrictive clothing, crossing legs, sitting or standing for long periods (promotes slow blood circulation, do not walk barefoot
• regular exercise but avoid hazardous activities (such as contact sports of active sports)
• smoking increases dose requirements
• must monitor PT routinely

• more susceptible to effects of anticoagulants leads to lower maintenance dose required
• close supervision and monitoring
• monitor for prolonged bleeding from gums/skin/nose, bruising, blood in urine/stool
• carry Medic-Alert bracelet/card
• careful with any drug that causes gastric irritation leads to a risk of GI bleed
• limit alcohol, causes liver disease and an increased sensitivity to anticoagulants
• caution: increased effect with malnurtrition, diarrhea
• caution: decreased effect with consumption of vitamin K containing foods

• antidote for warfarin overdose by antagonizing warfarin's actions and reversing warfarin-induced inhibition of clotting factors
• prevent hemorrhage in neonates

• severe anaphylactoid reaction (flushing, hypotension, SV collapse)

• monitor PT
• dilute IV and give slowly over 2-3 hours
• large doses can lead to resistance to warfarin
• if vitamin K therapyis unsuccessful, infust clotting factors

• ASA
• clopidogrel (Plavix)
• aspirin/extended-release dipyridamole (Aggrenox)

• suppress platelet aggregation
• prevention of thrombosis in arteries

• primary prevention of first MI and recurrent MI
• prevention of stroke with history TIAs

• low dose- 81 mg
• high dose- 325 mg

• GI bleeding
• hemorrhagic stroke

• use enteric-coated, buffered forms
• monitor for bleeding
• use only under physician supervison
• avoid other anticoagulant agents
• cessation before surgery?

• same as ASA
• abdominal pain
• dyspepsia
• diarrhea
• rash

• HA, dizziness
• GI upset (N,V, diarrhea, abdominal pain, dyspepsia)

• streptokinase (Streptase)
• alteplase (tPA, Activase)
• tenecteplase (TNKase)
• reteplase (Retavase)
• anistreplase (Eminase)
• urokinase (Abbokinase)

• Streptase= acute MI (infuse within 4-6 hours through a catheter into the occluded coronary artery), DVT, PE
• tPA= acute MI, PE, ischemic stroke

• bleeding (recent wounds, sites of needle puncture, invasive procudure)(severe bleeding- stop infusion, pressure dressings, blood replacement)(lower risk of bleeding- minimize physical movement, avoid SC/IM injections, avoid invasive procedures, avoid anticoagulants and antiplatelet agents
• intracranial hemorrhage
• at beginning of treatment- allerrgic reactions/anaphylaxis (if this happens, discontinue infusion and give epinephrine, antihistamines, and steroids
• hypotension
• fever

• contraindicated in any patient with active bleeding, recent surgery, uncontrolled hypertension (cerebral hemorrhage possible)
• perform coagulation tests before administratio, H & H, platelets

• careful nursing assessment for complications of bleeding
• monitor thrombin time (TT), APTT, PT, H & H, platelet count
• observe extremities and palpate pulses of affected extremities for signs of circulatory failure
• heparin therapy follows treatment

• epoetin alfa [Erythropoietin](Epogen, Procrit)
• darbepoetin alfa (Aranesp)
• filgrastim (Neupogen)
• pegfilgrastim (Neulasta)
• oprelvekin (Interleukin-11, Neumega)

• chemical that is identical to human eyrthropoietin- stimulates erythropoietin in the bone marrow (for increasing RBCs)
• no kidney function or poorly functioning kidneys- little or no erythropoietin is manufactured- decreased RBC production (anemia)

• anemia with chronic renal failure
• severe anemia with AIDS, chemotherapy treatment
• elective non-cardiac surgery (decreases the need for transfusions)

• hypertension related to high H & H-- high blood viscosity (polycythemia)-- high blood pressure, tachycardia
• joint and bone pain, muscle weakness, chest pain, edema, weight gain, HA
• N, V, diarrhea
• seizures
• clotting of shunt for dialysis

• determine hematocrit before treatment begins and twice weekly until target level is reached and maintenance dose is established
• contraindicated for hypertensive patients-- monitor blood pressure and treat with HTN drugs
• cost: 8-weeks treatment for a 70 kg patient with the starting dose of 150 Units/Kg 3x/week dose= $3000
• need for iron supplements
• perform neurological exams fo the risk of seizures
• do not shake vial, give only one dose/vial, store in refrigerator
• patient education (dietary sources of iron, folic acid, B12; monitor BP routinely; self administation techniques)

• long acting erythropoietin with longer half-life (2 days)
• given less frequently
• only indication-- CRF

• high neutrophil count in cancer patients
• treatment of severe chronic neutropenia

• bone pain (25%)- dose related, mild to moderate
• leukocytosis

• store at room temperature up to 6 hours
• do not shake
• obtain CBC prior to initial administration and twice weekly after

• long acting G-CSF
• dosing- one SC dose injected 24 hours after each round of chemotherapy every 2 weeks

• patients taking myelosuppressive chemotherapy
• lessen need for platelet transfusions

• fluid retention (edema, anemia)
• cardiac dysrhythmias (tachhycardia, atrial fibrillation, atrial flutter)

• do not shake
• must be used within 3 hours after reconstitution
• store in refrigerator
• monitor baseline CBC and platelet counts, fluid/electrolyte status
• administerr 4 to 6 hours after chemotherapy until platelet count reaches about 50,000/mm^3

• replacement of fluids and electrolytes [must maintain a balance of fluids and electrolytes in the intracellular and extracellular spaces]
• correction of acid base imbalances
• administration of medications [immediate, predictable action]
• access for emergency situations
• measurement of blood pressure [arterial pressure monitoring]
• administration of essential nutrients
• blood products

• highly concentrated, hypertonic solution to provide nutrition when the GI route is not accessible [calories, fluids/20-70% dextrose, electrolytes, vitamins, minerals, trace elements, amino acids, lipids/flat emulsions]
• long term administration through a central line
• nutritionally complete

• provision of nutrients via the GI tract (feeding by tube)
• indicated for patients with a healthy GI trract but cannot or will not ingest enough nutrition and patients with a digestive or absorptive disorder that does not allow use of the GI tract
• It is composed of amino acids, carbohydrates, fats, other (electrolytes, vitamins, trace elements)

• whole blood= all blood components
• plasma fractions (FFP)= plasma + plasma proteins + clotting factors
• packed red blood cells (PRBC)= red blood cells + 100cc plasma
• platelets

• CHF
• too much fluid (IV fluid overdose)
• accumulation of fluid in cavities
• renal problems

• edema
• weight gain
• JVD
• moist skin
• a lot of urine output
• high BP (HTN)

• sweating (diaphoresis)
• excessive urination
• GI losses
• hemorrhage
• diuretics
• lack of fluid intake

• poor skin turgur
• dry skin/hair
• dizziness
• headache
• hypotension
• fatigue
• decreased weight
• sluggish cap refill
• dry mucous membranes
• decreased urine output

• passive movement of fluid across a membrane from an area of low solute concentration to an area of higher solute concentration- balancing the solutes between areas by moving fluids [solutes= dextrose, electrolytes]
• trying to maintain an equilibrium between fluids and solutes
• albumin (protein) attracts water ["water magnet"] and holds it inside the blood vessel

• match
• same solute concentration as another solution
• equally concentrations between 2 compartments, already in balance

• low
• lower solute concentration than another solution
• fluid shifts from a hypotonic solution into a more concentrated area to equalize concentrations

• high
• a higher solute concentration than another solution
• fluid will move from an area of low concentration to dilute or equalize the area of high concentration