LICEO DE CAGAYAN UNIVERSITYCOLLEGE OF NURSING

R.N PELEAZ BLVD., KAUSWAGAN, CAGAYAN DE ORO CITY

IN PARTIAL FULLFILMENT

OF THE REQUIREMENTS FOR

NCM501204 (MS-2 LECTURE)

SUBMITTED BY:Eusan John P. Nambatac

NCM 501204

PRESENTED TO:MR. JOEL DEFENSOR, RNClinical instructor/Lecturer

Shock - the cardiovascular system fails to perfuse the tissues adequately, resulting in widespread impairment of cellular metabolism.

PATHOPHYSIOLOGY

COMPENSATIONSTo maintain heart and brain functions

STIMULATE SYMPATHETHIC NERVOUS SYSTEM Thirst Anxiety, restlessness Tachycardia Vasoconstriction, pallor

RENIN-ANGIOTENSIN-ALDOSTERONE Vasoconstriction Retention of Sodium and water, oliguria

INCREASED SECRETION Retention of water

DIRECT EFFECTS OF DECREASED BLOOD PRESSURE

Lethargy, Weakness Anaerobic Metabolism Metabolic Acidosis

VASODILATION AND DECREASED CELL FUNCTION

Slow blood flow in Microcirculation

Ischemia in organs

Thrombus Forms

Decreased Function

Necrosis (e.g. Kidney)

DECREASED VENOUS RETURN

FURTHER DECREASED IN CARDIAC OUTPUT

Severe Acidosis CNS depression Organ Damage (e.g. acute

renal failure, lung damage)

DECOMPENSATION

Decreased Blood Pressure

Hypovolemic Shock -is caused by loss of whole blood (hemorrhage), plasma (burns), or interstitial fluid (diaphoresis, diabetes mellitus, diabetes insipidus, emesis, diarrhea, or diuresis) in large amount.

PATHOPHYSIOLOGY

Decreased Intravascular volume

Decreased Cardiac outputS/Sx: Decreased BP

Shift of interstitial fluid

Aldosterone, ADH

Spleenic Discharge

Increased Volume

Catecholamine release

Increased HR, contractility

Increased Cardiac Output

Increased SVR

More volume loss

Decreased Cardiac output

Decreased Tissue perfusion

Decreased Systemic and pulmonic pressures

Impaired cellular metabolism

EMERGENCY CARE MAMANGEMENT Don’t start an I.V infusion in the legs of shock patient who has suffered

abdominal trauma because infused fluid may escape through the ruptured vessel into the abdomen.

Place patient in supine position Cover and keep warm Call for assistance Administer Oxygen if possible Determine underlying cause and treat if possible, e.g., EpiPen

MEDICAL MANAGEMENTDiagnostic Test:Characteristic laboratory findings include

Low Hct and Decreased Hgb level and RBC and platelet counts. Elevate serum, K, Na, Lactate dehydrogenase, creatinie, and BUN levels. Increased urine specific gravity (greater than 1.020) and urine osmolality Decreased urine creatinie levels Decreased pH and partial pressure of arterial oxygen and increased partial

pressure of carbon dioxide.

In addition: X-rays Gastroscopy Aspiration of gastric content CBC

Treatment and drugs: Blood and fluid replacement For severe cases, an intra-aortic balloon pump, ventricular assist device, or

pneumatic antishock garment may be helpful Oxygen administration Application of pulse site pressure to avoid bleeding Dopamnie or another inotropic agent used for vigorous fluid resuscitation. Surgery is performed to correct the underlying proble

NURSING MANAGEMENT: Check for airway and adequate circulation. If blood pressure and HR are absent,

start CPR. Record patient’s blood pressure, PR and RR, and peripheral pulses every 15

minutes until the patient’s condition is stabilized. Monitor cardiac rhythm continuously.

Increased Oxygen when systole is below 80 mmHg and notify physician immediately

Start I.V infusion with NSS or LRS using large-bore (14G to 18G) catheter Insert an indwelling urinary catheter to measure urine output.

Cardiogenic shock - is defined as “decreased cardiac output and evidenced of tissue hypoxia in the presence of adequate intravascular volume

PATHOPHYSIOLOGY

Decreased Cardiac Output

Compensatory rennin-aldosterone, ADH

Catecholamine compensatory release

Adequate or increased blood volume

Increased SVR

Increased Preload, stroke volume, and Heart rate

Systemic and pulmonary edema

Increased Myocardial oxygen requirements

Dyspnea

Decreased Cardiac output, Decreased ejection fraction

Increased Blood pressure

Decreased tissue perfusion

Impaired cellular metabolism

EMERGENCY CARE MANAGEMENT:

Don’t start an I.V infusion in the legs of shock patient who has suffered abdominal trauma because infused fluid may escape through the ruptured vessel into the abdomen.

MEDICAL MANAGEMENT:

Diagnostic Test:

Pulmonary artery pressure monitoring reveals Increased PAP and pulmonary artery wedge pressure.

Increased in left ventricular end-diastolic pressure and heightened resistance to left ventricular emptying caused by ineffective pumping and increased peripheral vascular resistance.

Thermodilution catheterization reveals a reduced cardiac index (less than 1.8 L/min/mL).

Invasive arterial pressure monitoring shows hypotension ABG analysis shows metabolic and respiratory acidosis and hypoxia ECG Serum enzymes measurement Cardiac catheterization Echocardiography

Treatment and drugs:

I.V drug therapy may include dopamine, a vassopresor to increase cardiac output, BP, and renal blood flow

Amrinone or dobutamine, an inotropic agent to increased myocardial contractility Norepinephrine Intra-aortic ballon pump

NURSING MANAGEMENT

In ICU, insert I.V infusions with NSS or LRS Monitor BP, PR, and RR. Insert indwelling urinary catheter to monitor urinary output Administer Osmotic diuresis, such as manitol, if ordered Check for any signs and symptoms and refer it to the physician.

Septic shock - Septic shock is a serious condition that occurs when an overwhelming infection leads to low blood pressure and low blood flow. The brain, heart, kidneys, and liver may not work properly or may fail.

PATHOPHYSIOLOGY

Predisposing Factor: Precipitating Factor: -Age (1-65 years old) - malnourishment-Chronic illness - invasive procedure-Immunosupression -infection

Bacteremia

Gram-positive organismGram-negative organism

Realse of exotoxins and enzymes

Release of endotoxins, protaenases, and other products

Act as triggering molecules and result in activation of

Neutrophils, endothelial, and monocytes-macrophage cell activity

Complement system

Kinin systemCoagulation cascade

Release of central endogenous mediators

(Tumor necrosis factor {TNF}; interleukins-1 [IL-1])

Release of pro- inflammatory cytokines

Endothelial cell damage

Decreased systemic vascular resistance

Depressed Myocardial function

Lactic acidosis

Leukopenia Thrombo-cytopenia

Vascular leakage

Pulmonary congestion

Tissue necrosis

Organ dysfunction

Hypotension

MEDICAL MANAGEMENT:Diagnostic Test:

Blood culture CBC BUN and Creatinine PT and PTT ECG Serum lactate dehydrogenase level Urinalysis ABG

Treatment and drugs: I.V, Intra-arterial, or urinary drainage catheter are in place Aggressive antimicrobial therapy Granulocytes transfusion may be used to in patients with severe neutropenia Oxygen therapy Colloid and crystalloid transfusion Diuretic (Furosemide) is given to maintain urine output Vassopresor (Dopamine)

NURSING MANAGEMENT: Remove I.V, Intra-arterial, or urinary drainage catheter and send it to the

laboratory to culture the presence of organism. Start I.V infusion with NSS or LRS Record patent’s BP, PR, and RR When blood pressure drop administer Oxygen Watch closely for signs of septic shock and refer it immediately to the physician. Use sterile technique.

Anaphylactic shock - Anaphylaxis is an severe, whole-body allergic reaction. After being exposed to a substance like bee sting venom, the person's immune system becomes sensitized to that allergen. On a later exposure, an allergic reaction may occur. This reaction is sudden, severe, and involves the whole body.

PATHOPHYSIOLOGY

MEDICAL MANAGEMENT:

Treatment: Removing causative antigen

Antigen (allergen)

Complement, Histamine, kinins, prostaglandins

Peripheral vasodilatation

Increased SVR

Constriction of extra vascular smooth muscle (brochoconstriction, laryngo-spasm, gastrointestinal cramps)

Increased Capillary permeability

Extravasation of intravascular fluids

Edema Relative hypovolemia

Decreased Cardiac output

Decreased tissue perfusion

Impaired cellular metabolism

Antibody (IgE)

Administering medications that resolve and restore vascular tone. Epinephrine is given Benadryl is given Nebulized meds., such as albuterol (proventil) CPR is performed if cardiac arrest occur I.V lines administer

NURSING MANAGEMENT: Assess the patient for any allergic reaction and provide precaution Prevent further exposure to antigens When new allergy identified, the nurse advices the patient to wear or carry

identification that names the specific allergens or antigens Observe for any types of symptoms and refer it accordingly Maintain Hypoallergenic diet

Neurogenic shock - Anaphylaxis is an severe, whole-body allergic reaction. After being exposed to a substance like bee sting venom, the person's immune system becomes sensitized to that allergen. On a later exposure, an allergic reaction may occur. This reaction is sudden, severe, and involves the whole body.

PATHOPHYSIOLOGY

Predisposing Factor: Precipitating Factor:-Age -trauma to the spinal cord resulting in the -gender sudden loss of autonomic and motor reflexes below the injury level.

Decreased Sympathetic and/or Increased parasympathetic stimulation

Decreased Vascular tone

Massive vasodilatation

Decreased SVR

Inadequate cardiac output

Decreased tissue perfusion

Impaired cellular metabolism

MEDICAL MANAGEMENT:

Restoring sympathetic tone Position patient properly If hypoglycemia occur, administer glucose

NURSING MANGEMENT:

Elevate and maintain the head of the bed at least 30 degrees when patient receive spinal or epidural anesthesia

Elevate head prevent spread of anesthetic Immobilizing the patient to prevent further damage to the spinal cord Check for daily pain, redness, tenderness and warmth of the calves. Administer drug of heparin or low-molecular-weight heparin (lovenox) as

prescribed

EMERGENCY CARE MANAGEMENT

If possible treat patient in Trendelenburg position Large volumes of fluid may be needed to restore normal hemodynamics Dopamine (Intropin) is often used either alone or in combination with other

inotropic agents. Vasopressors (Ephedrine) Atropine (speeds up heart rate and Cardiac Output)

Hypertension- is an intermittent or sustained elevation of diastolic or systolic blood pressure. Serial blood pressure measurement used to classify hypertension;Pre-hypertension Systolic blood pressure is greater than 120 but less than 140 mmHg or diastolic pressure greater than 80 but less than 90 mmHg. Stage 1 hypertension systolic pressure greater than 139 but less than 160 mmHg or diastolic greater than 89 but less than 100 mmHg and Stage 2 hypertension systolic blood pressure greater than 159 mmHg or diastolic blood pressure greater than 99 mmHg.

MEDICAL MANAGEMENT:

Diagnostic Test:

Urinalysis Excretory Urography Serum potassium level ECG Opthalmoscopy Oral captopril to test for renovascular hypertension

Treatment and drugs:

Beta-adrenergic blocker Calcium channel blocker ACE inhibitors Weight reduction Alcohol, smoke and salt restriction Promote compliance of medication

NURSING MANAGEMENT:

Ask patient if he/she is taking prescribed hypertensive drugs Monitor Blood pressure Monitor Pulse pressure Avoid patient that can provoke increased blood pressure like prohibition of

alcohol, smoking, salt-intake, fatty-foods, and high cholesterol foods and also avoid caffeine-beverages.

Promote health Teachings on proper compliance of medication and prohibition

PATHOPHYSIOLOGY

Kidney release RENIN into the bloodstream

RENIN helps convert angiotensin I in liver

Angiotensin I is converted to angiotensin II (a potent vasoconstrictor) in lungs

Angiotensin II

Aldosterone: Causes Na and water retension

Retained Na and Water Increased Blood Volume

Arteriolar constriction Increased Peripheral vascular resistance

Increased Blood pressure and vascular resistance to hypertension

RISK FACTORS:Diabetes MellitusFamily HistoryAdvance ageObesitySedentary LifestyleStressSmokingHigh intake of Na, saturated fats and alcohol

MEDICAL MANAGEMENT:

Diagnostic Test:

Urinalysis Excretory Urography Serum potassium level ECG Opthalmoscopy Oral captopril to test for renovascular hypertension

Treatment and drugs:

Beta-adrenergic blocker Calcium channel blocker ACE inhibitors Weight reduction Alcohol, smoke and salt restriction Promote compliance of medication

NURSING MANAGEMENT:

Ask patient if he/she is taking prescribed hypertensive drugs Monitor Blood pressure Monitor Pulse pressure Avoid patient that can provoke increased blood pressure like prohibition of

alcohol, smoking, salt-intake, fatty-foods, and high cholesterol foods and also avoid caffeine-beverages.

Promote health Teachings on proper compliance of medication and prohibition

Acute Respiratory Failure – is characterized by acute lung inflammation and diffuse alveolocapillary injury with non-cardiogenic pulmonary edema.

PATHOPHYSIOLOGY

Increased capillary permeability

Cell Damage

Fluid protein leaks into alveoli and interstitial tissue

PULMONARY EDEMADECREASED SURFACTANT PRODUCTION

Decreased compliance, labored inspiration

RESPIRATORY INSUFFIECIENCY

Decreased Oxygen ExchangeHypoxemiaDecreased Lung volumeAtelectasis

RESPIRATORY FAILURE

ALVEOLAR OR PULMONARY CAPILLARY WALL INJURY

MEDICAL MANAGEMENT:

Diagnostic Test ABG analysis CXR ECG Pulse oximetry CBC Serum electrolytes Pulmonary artery catheterization

Treatment and drugs:

Cautious oxygen therapy (nasal prongs or Venturi mask) If Respiratory Acidosis persist, Mechanical ventilation with an Edotracheal is

attached or Tracheostomy Antibiotics Bronchodilators Corticosteroids If cor pulmonale and cardiac output decreased administer Inotropic agents,

vasopresors, and diuretics may ordered

NURSING MANAGEMENT:

Orient the patient to the treatment unit to prevent anxiety To reverse hypoxemia, administer oxygen as ordered Maintain patent airway Monitor BP, RR and PR Place patient in semi-fowlers position

Diabetic Ketoacidosis – is caused by an absence or markedly inadequate amount of insulin. This results in orders in the metabolism of carbohydrates, protein and fats.

The three main clinical features of DKA are HYPERGLYCEMIA, DEHYDRATION AND ELECTROLYTE LOSS AND ACIDOSIS.

Predisposing Factor: Precipitating Factor:-Hereditary -surgery-Age (19 below) -diabetes 1 and 2-Type A personality -stress-Obesity -alcohol/drug abuse-Genetics -infection

PATHOPHYSIOLOGY

MEDICAL MANAGEMENT:

Decreased Insulin

Increased Release of fatty acids

Decreased insulin use

Increased ketone formation

Increased levels of hormone associated with stress

Increased cathecholamines, cortisol, and growth hormone

Increased glucose production

Increased glucagon

Increased blood glucose level

Accumulation of β-hydroxybutyrate and acetoacetic acids in the blood

Ketones in urine Solute diuresis

Polyuria

Dehydration

Increased thirst

Polydepsia

Hyperosmolality

Metabolic AcidosisSugar in urine

hypovolemia

Shock

CNS depression

Kussmaul respirations

Diagnostic Test:

Blood glucose level Na and K serum level Creatinie BUN CBC ECG Urinalysis FBS

Treatment and drugs:

Rehydration (fluid replacement NSS) When glucose level reaches to 300 mg/dL Iv solution may change to Dextrose of

5% in water (D5W) to prevent precipitous decline in blood glucose level. Regular insulin Human insulin

NURSING MANAGEMENT:

Monitor Intake and Output Monitor vital signs Monitor diabetic effects on cardiovascular system Provide meticulous skin care Provide Health Teaching

Hepatic Encephalopathy-a life-threatening complication of the liver disease, occurs with profound liver failure and may result from the accumulation of ammonia and other toxic metabolites in the blood.

PATHOPHYSIOLOGY

Ammonia

Entering the blood stream

Converting ammonia to urea

Muscle cellsAbsorption GI tract Liberation from

kidneyS/Sx:Edema, bleeding

Increased ammonia concentration in the blood

Brain dysfunctionS/Sx:Motor disturbances, minor mental changes

Damage

HEPATIC ENCEPHALOPATHY

EMERGENCY CARE MANAGEMENT:

Don’t give a semi-comatose or comatose patent sedative because these depend the coma. Protect the comatose patient’s eyes from corneal injury by using artificial tears or eye patches.

MEDICAL MANAGEMENT:

Diagnostic Test:

Serum ammonia level ECG CT Scan MRI

Treatment:

Elimination of ammonia from the GI tract include SORBITOL-INDUCED CATHARSIS

Reduction of dietary protein Continuous aspiration of blood in the stomach Administration of lactulose to reduce serum ammonia level. Administer Neomycin through retention enema Potassium supplements Diuretics Salt-poor album to maintain fluid and electrolyte balance. Hemodialysis Exchange Transfusion

NURSING MANAGEMENT:

Frequently assess the patient’s level of consciousness Promote rest, comfort and quiet atmosphere Administer medication as ordered Use appropriate safety measures. Provide Health Teaching

Chronic Renal Failure (End-stage Renal Failure)-is the progressive loss of renal function over a period of months or years in which there is less than 10% of remaining renal function and dialysis or kidney transplant is required to sustained life.

PATHOPHYSIOLOGY

Predisposing Factors: Precipitating Factors:-Genetics -diabetic nephropathy -Age -hypertensive nephrosclerosis-Gender

EMERGENCY CARE MANAGEMENT:

Careful monitor of serum level to detect hyperkalemia

Renal Injury

Loss of nephrons Increased angiotensin II.

Glomerular capillary hypertension

Increased Glomerular permeability and filtration

Proteinuria

Increased Tubular protein reabsorption

Tubulointerstitial inflammation and fibrosis

Renal scaring

Systemic hypertension

Emergency treatment is Dialysis Therapy Administration of 50% hypertonic glucose I.V, regular insulin, calcium glocunate

I.V, sodium bicarbonate I.V and cation exchange resins such as sodium polystyrene sulfate.

Cardiac tamponade resulting from pericardial effusion may result require emergency pericardial tap or surgery.

Diagnostic Test:

Elevated BUN, serum Creatinine, sodium and potassium level Decreased arterial pH and bicarbonate levels Low Hct and Hgb Increased blood glucose level ABG analysis X-RAY Kidney-ureter-bladder radiography Excretory urography Nephrotomography Renal scan Renal arteriography show reduced kidney size Abdominal X-RAY Abdominal CT Scan MRI Ultrasonography Renal biopsy EEG

Treatment and drugs:

Low-protein diet High-calorie diet prevents Ketoacidosis Restrict sodium, phosphorus and potassium Maintaining fluid balance Monitoring vital signs, weight changes and urine volume Loop diuretic (furosemide) Cardiac glycosides in small amount does used to mobilize the fluids causing the

edema Antihypertensive Antiemetics given before meals Cimitidine, omreprazole or ranitidine may decrease gastric irritation Methylcellulose or docusate can help prevent constipation Folate supplements Severe anemia requires infusion of fresh frozen packed cells or washed packed

cells Synthethic erythropoietin (epoietin alfa)

Antipruritic, such as trimeprazine or diphenydramine, can relieve itching, Aluminum hydroxide gel can lower serum phosphate levels Supplementary vitamins and essential amino acids Calcium and phosphorus imbalance may be treated with phosphate binding

agents, calcium supplements and reduction of phosphorus in the diet Hemodialysis or peritoneal dialysis Kidney transplantation best choice of treatment

NURSING MAMNGEMENT:

Provide good skin care, bath patient daily Provide good oral hygiene Offer small, palatable, nutritious meal Monitor patients hyperkalemia, watch for cramping of the legs and abdomen and

for diarrhea Carefully assess the patient’s hydration status Monitor for bone or joint complications Encourage the patient to perform deep-breathing and coughing exercise to

prevent pulmonary congestion Maintain aseptic technique Carefully observe and document seizure activity Observe for sings of bleeding Schedule medication administration carefully If patient requires dialysis, check the vascular access every 2 hours for patency

and the arm used for adequate blood supply and intact nerve function Withhold the morning dose of antihypertensive on the day of dialysis, check for

disequilibrium syndrome.

Hypothyroidism – results from suboptimal levels of thyroid hormone. Thyroid deficiency can affect all body functions and can range from mild , subclinical forms to myxedema, an advanced form.

PATHOPHYSIOLOGY

MEDICAL MANAGEMENTDiagnostic Test:

Serum TSH levels Serum cholesterol Serum sodium level Radioisotope scanning Skull X-RAY

Treatment and drugs: Thyroid hormone replacement I.V administration Hydrocortisone therapy Iodine supplements

NURSING MANGEMENT: Keep accurate vital signs Monitor cardiovascular status Encourage patient to cough and breath

Loss of thyroid tissue

Primary Hypothyroidism

Decreased TH, Increased secretion of TSH, and goiter

Secondary hypothyroidism

Caused by the pituitary’s failure to synthesize adequate amounts of TSH

Pituitary Tumors

Hypothyroidism

Hypoglycemia - (abnormally low blood glucose level) occurs when the blood glucose falls to less than 50- 60 mg/dL. It can be caused by too much insulin or oral hypoglycemic agents, too little food, or excessive physical activity. Hypoglycemia may occur at any time of the day or night. It often occurs before meals especially if meals are delayed or snacks are omitted.

EMERGENCY CARE MANAGEMENT:

For patient with severe hypoglycemia (producing confusion or coma), initial treatment is usually I.V administration of a bolus of dextrose 50% solution.

This is followed by continuous infusion of glucose until the patient can eat a meal.

A patient who experience adrenergic reactions without CNS symptoms may receive oral carbohydrates (parenteral therapy isn’t required)

Diagnostic Test:

Glucometer readings 5-hour glucose tolerant test C-peptide assay

Treatment:

Dietary modification Frequent meals Avoid simple carbohydrates Anticholinergic to slow gastric emptying For fasting hypoglycemia, surgery and drug therapy may be required Nondiuretic thiazide (diazoxide) Administer I.V

NURSING MANAGEMENT:

Watch for and report any signs and symptoms of hypoglycemia Implement measure to patient who is unconscious Monitor infusion of hypertonic glucose Measure patient blood glucose with the use of HGT Monitor effect of drug therapy, and watch for development of any adverse

reactions Provide family health teaching

PATHOPHYSIOLOGY

RISK FACTORS:Too much insulin or oral hypoglycemic agentsToo little foodExcessive exercise

hypoglycemia Blood glucose level drops rapidly

Cells break down fatty and amino acids into adenosine triphosphate (ATP) for energy

Brain cells can’t use ATP for energy

Neuroglycopenia Early glucose deprivation in brain tissue causes mild cerebral dysfunction

CNS symptoms These include headache, dizziness, restlessness, and decreased mental capacity.

AUTONOMIC NERVOUS SYSTEM STIMULATION

Pancreas Sympathetic nerves and epinephrine rapid stimulate glucagons secretions; epinephrine inhibits insulin secretions

Adrenal glands Sympathetic nerves stimulate epinephrine secretions (rapid response). Hypothalamus stimulates pituitary gland to secrete corticotrophin, which acts on the adrenal cortex to cause cortisol secretions (delayed response).

Stomach Hypothalamus stimulates hunger; parasympathetic nerves increase gastric juices contractions.

Liver Sympathetic nerves directly stimulate glycogenolysis; epinephrine, glucagons, cortisol, and growth hormone increase gluconeogenesis; glucagons also stimulates glycogenolysis

Muscle Hypothalamus stimulates pituitary to secrete growth hormone (delayed response), which –along with epinephrine and cotisol-inhibits glucagons use

Adrenergic changes these include hunger, weakness, diaphoresis, tachycardia, pallor, anxiety, and rebound hyperglycemia.

EMERGENCY CARE MANAGEMENT:

For patient with severe hypoglycemia (producing confusion or coma), initial treatment is usually I.V administration of a bolus of dextrose 50% solution.

This is followed by continuous infusion of glucose until the patient can eat a meal.

A patient who experience adrenergic reactions without CNS symptoms may receive oral carbohydrates (parenteral therapy isn’t required)

Diagnostic Test:

Glucometer readings 5-hour glucose tolerant test C-peptide assay

Treatment:

Dietary modification Frequent meals Avoid simple carbohydrates Anticholinergic to slow gastric emptying For fasting hypoglycemia, surgery and drug therapy may be required Nondiuretic thiazide (diazoxide) Administer I.V

NURSING MANAGEMENT:

Watch for and report any signs and symptoms of hypoglycemia Implement measure to patient who is unconscious Monitor infusion of hypertonic glucose Measure patient blood glucose with the use of HGT Monitor effect of drug therapy, and watch for development of any adverse

reactions Provide family health teaching