Med Surg Session 11: Renal

Session 11


Renal disorders


Know why you are giving diuretics

Empty the foley bag before the diuretic is administered so you can track the output closely. 

Can have pre, intra, and post renal injuries

  • Post renal is an obstruction
  • Intrarenal is Structural damage to the kidney can be caused by radiocontrast dye
  • Prerenal is a reduction in blood flow
  • Structural damage to the kidney


Things that increase the chance for infection in urinary system

  • Urinary stasis
  • High levels of glucose in the urine


Pyelonephritis – infection of the kidneys,

  • Give lots of fluids
  • Treat pain, infection, and nausea


Glomerulonephritis –

  • Look for blood in the urine
  • Proteinuria, high BUN, periorbital edema, and hematuria


Renal calculi –

  • rf – high protein, dehydration, warm climates
  • Flank and abdominal pain
  • Use a NON radio contrast CT scan
  • Manage pain!


BPH – benign prostatic hyperplasia

  • Digital rectal exams are the prefered method
  • Increase chance of renal stones due to urine retention.
  • May need a catheter placed to urinate properly.
  • Can give Alfa blockers to relax smooth muscle
    • A side effect of these is orthostatic hypotension
  • Three way foley is use to continuously irrigate the bladder and catheter to prevent clots from stopping up urine flow.


Prostate cancer –

  • Mimics BPH symptoms
  • Screen with DRE and PSA


Chronic kidney disease –  long term decrease in kidney function

  • Can have chronically high BUN and Cre levels
  • polyuria in the beginning, it will progress to oliguria
  • Often need dialysis
  • On HTN meds, Na and fluid restrictions, calcium based phosphate binders
  • Indications for dialysis – we wait as long as possible  because being dialyzed is not optimum for the patient.  
  • Types – hemo, and peritoneal
    • Peritoneal has a high chance for infection, but the person can do it at home and does not need to be hooked up to the dialysis machine for 12 hours a week.  4x day for about 30 mins each time.
    • Hemodialysis – 12 hours a week at the center
      • Have an Arteriovenous fistula for better access commonly in the forearm

Med Surg Session 10: GI

GI session 10


Gastritis – usually acute but can by chronic.

  • Often from an irritant such as increased Ibuprofen (or other NSAIDs) intake
  • Irritation of the stomach
  • May cough up blood
  • Gastroenteritis – inflammation of stomach an bowel.


PUD – Peptic Ulcer Disease –

  • gastric – superficial, more common in women, 50 and 60 y.o., pain after meals,
  • duodenal – Deep, more common in men, 35-45 yo, pain just below xiphoid process, H. pylori in 90%+
  • PPI’s tend to be better for recovery
  • H2 blockers tend to be better for prophylaxis of PUD
  • Surgeries are less common now because of the medications controlling it well
    • Billroth 1 stomach to Duodenum
    • Billroth 2: stomach to the Jejunum
  • Avoid SMOKING, NSAIDs, chocolate, and fatty foods


IBD -Inflammatory bowel disease

  • can be Crohn’s Dx (CD) or Ulcerative Colitis (UC)
  • CD – cobblestone (skip) lesions, can be throughout the whole bowel large or small, full thickness of bowel affected,
  • UC – continuous lesions, Partial thickness, Rectal bleeding, colonic dilation, colorectal cancer,
  • colonoscopy for visualization of the lesions
  • Drugs: to decrease inflammation: 5-Aminosalicylates, corticosteroids, immunosuppressants, antidiarrheals.
  • treatment: colectomy or Proctocolectomy (colostomy or ileostomy)
  • We are looking for dehydration, imbalance in electrolytes, Pain


Viral Hepatitis

  • inflammation of the liver
  • caused by drugs, chem, autoimmune, virus,
    • viral – a,b,c,d,e
  • s/s: tired, anorexia, nausea, abd pain, jaundice, hepatomegaly, occasional vomiting
  • Diagnosis with labs (do not need to know the specific bili and liver levels right now)
  • Types
    • A food born, and poor hygiene
    • B sexually transmitted
    • C iv drug and contaminated blood transfusion



  • proximal obstruction
    • accumulation of fluid and gas, this can lead to sepsis
  • Small BO
    • vomiting, dehydration, high pitched bowel sounds above obstruction, alkalosis, ABD distension.
  • Large BO
    • vomiting, high pitched bowel sounds above obstruction, ABD distension.
  • care: NPO, NG tube on suction, I/O, abd girth, IVF, and electrolytes.


Gallbladder Alterations

  • gallstones
  • Risk factors 5 Fs: female forty fat fertile, fare (white)
  • ERCP – tube down the esophagus to the common bile educt, to break up and pull out stones
  • The stones can block the duct of both the bile and the pancreatic enzymes causing pancreatitis.


Diverticulitis – inflammation of the diverticula, causing a perforation into the peritoneum.

diverticulosis – out pouching of the colon.

  • caused by constipation most of the time.



  • wory about perforation



  • extreme guarding and pain
  • surgery asap to clean out the cavity


Anti emetic meds

  • reglan
  • zofran

Med Surg 8: Oncology

Class 8: Cancer


Hyperplasia: proliferation of cells that are still organised

dysplasia: proliferation of cells that are becoming disorganized.

situ: in the normal location.

  • so if there is dysplasia in situ this means that the cancer is not yet invasive to other tissues.


Proto – oncogene: allows apoptosis to occur.

  • oncogene: a protooncogene that has been damaged and can no longer signal apoptosis at the right time or at all.


Tumor suppressor gene:


Immune system

  • T lymphocytes: deal with INtracellular foreign substances
  • B lymphocytes: deal with EXtracellular foreign substances
  • Immunologic escape: the process where the cancer can avoid our immune system safeguards.
  • Oncofetal antigens: in tumor cells as well as fetal cells
    • are not well differentiated


mutations in genes:

  • Primary cancer related genes: Oncogenes, tumor suppressor genes, DNA repair genes



  • self exams
  • cervical
  • breast
  • prostate – do not run psa on everyone any more no
  • ovarian – no general test
  • colon – at and after 50


biopsy will allow us to see the differentiation in the cell types

  • styles: Needle aspiration, Core or incisional, and excisional
  • all of these will give us a tissue sample of the cancer.


Stages – the extent of the disease and how invasive it is

  • 0 – situ (precancer, some dysplastic cells)
  • 1 – local tumor
  • 2 – limited local (lymph nodes)
  • 3 – extensive spread
  • 4 – metastasis

TNM classification

  • T = tumor size T1-T4
  • N = spread in the lymph nodes N0 – N3
  • M = metastasis 0 or 1


Grades – the differentiation of the cell types


Karnofsky scale 100% is perfect, and 0% is death


ECOG – eastern cooperative oncology group

  • 0 full active, 4 completely disabled, 5 death


hysterectomy types

  • Subtotal – remove uterus
  • total – and cervix
  • total and bilateral salpingo oophorectomy – and fallopian tubes and ovaries
  • Radical – and upper vagina, other tissue, and lymph nodes


palliation – comfort and symptom management


drug therapy – the goal is to combine drugs to minimize s/s and maximize the cancer killing effectiveness

  • chemo is an adjuvant to surgery (meaning that it is supportive therapy after the surgery to clean up the excess
  • only chemo certified RNs can give chemo.
  • be careful with waste/spills
  • special protocol for extravasation of IV
  • Ask when the last dose of chemo was and what was it?

Study tips:

  • Potential complications of dxs
  • what would I will

Med Surg Session 7: Neurologic Disorders

Session 7: Neurologic disorders


  • TIA – stroke signs and symptoms but with no dead tissue, this is a warning sign for another TIA or stroke
    • not a stroke
  • CVA – an incident that ends in the death of tissue that occurs under twenty four hours
  • FAST – face drooping, Arm weakness, Speech difficulty, time to dial 911
  • change in level of consciousness.
  • risk factors: DM, HTN, obesity
  • Nursing diagnosis: “risk for ineffective cerebral tissue perfusion related to reduction vessel blood flow and cerebral edema”
  • Be sure that the patient has a viable gag reflex.
    • aspiration is a high risk for stroke patients
  • Right sided CVA
    • left side paralysis
    • more impulsive
    • short attention span
    • no issues
  • Left sided CVA
    • right side paralysis
    • problem identifying left from right, and their own limbs
    • short attention span, uncontrollable emotional swings.
    • impaired speech (
      • global aphasia – cannot understand or get the words out/not real words
      • expressive aphasia – cannot express themselves with speech appropriately. Broca’s aphasia (trouble finding words, takes effort to speak),
      • receptive aphasia – cannot understand what other people are trying to communicate to them, the patient.  Wernicke’s aphasia (impaired ability to understand language)
  • Rehab
    • MSK – help set good posture, and encourage movement


  • thicken water and puree food due to the impaired gag reflex


  • Encephalitis case study (Acute inflammation of the brain)
    • summary: 59yo, change in LOC, expressive aphasia, HA 5/10, 39 degrees C, poor skin turgor and dry mucous membranes.
    • d/t: herpes zoster virus
    • treat with antiviral – acyclovir.
    • seroquel – to improve mental status, (mood stabilization)


Myasthenia Gravis

Define: A weakness and rapid fatigue of muscles under voluntary control that fluctuates.

Pathophysiology: Genetic disorder that leads to an autoimmune response that attacks Ach receptor.

S/Sx: first weakness with no pain, then eventually fatigue once the Dx progresses. Eye lid and ball droop, difficulty swallowing and chewing, change in voice, drooping face/jaw, cannot hold head upright.

Diagnosis: Neuro test, Edrophonium test (if MM strength comes back after the med is administered MG is indicated), ice pack test, Blood test to look for the antibodies that attack the ach receptors.  

Treatment: Cholinesterase inhibitors, steroids, and immunosuppressants


Multiple Sclerosis

Define: A disease of unknown etiology that causes damage to the myelin sheath and disrupts the nerve path.

Pathophysiology: the creation of plaques (lesions), and the degradation of myelin sheath.

S/Sx: Pain in the eyes and back, tremors, difficulty walking, slurred speech, double or blurred vision.  

Diagnosis: there are multiple parts to the diagnosis medical history and neurological assessment then tests are done to reveal damage and reactions (MRI, Spinal Tap, Evoked potentials).

Treatment: cannot cure, only slow progression and speed up recovery from acute attacks. give steroids, and do a plasma exchange if this is a new onset that did not respond to the steroids.



Define: abnormal electrical activity in the brain. Generalized is when both sides of the brain are affected, and partial is when a specific area is affected these can spread throughout the brain though.

Pathophysiology: paroxysmal manifestations of the electrical properties of the cerebral cortex. A seizure results when a sudden imbalance occurs between the excitatory and inhibitory forces within the network of cortical neurons in favor of a sudden-onset net excitation.

S/Sx: mm contractions or spasms, an Aura, pain, fatigue

Diagnosis: EEG, Neuro test, blood test for infection and genetic disposition

Treatment: carbamazepine, diazepam, anticonvulsants


Parkinson’s disease

Define: CNS dx that can cause tremors

Pathophysiology: a gradual loss in the levels of dopamine. throwing off the atch dopamine balance.

S/Sx: tremors, bradykinesia, and rigidity

Diagnosis: no specific diagnosis, just ordering tests to rule out other diseases

Treatment: increase dopamine in the brain: levodopa with carbidopa, MAOBs(eldepryl), COMP-T inhibitors(Entacapone), amantadine, and anticholinergics.


Bacterial Meningitis

Define: inflammation of the brain and spinal cord membranes caused by bacterial infection

Pathophysiology: bacteria such as streptococcus pneumoniae invade the bloodstream, cross the blood brain barrier, then colonize in the CSF

S/Sx: pain in the back and neck from inflammation, then infection s/s

Diagnosis: spinal puncture to get A sample of the CSF and grow a culture to find out what is in the chord.

Treatment: IV antibiotics, and corticosteroids,

  • Vancomycin – check ototoxicity and nephrotoxicity, it is a vesicant, kills gram-positive bacteria by binding to the cell wall. ANAPHYLAXIS and Red Man syndrome can develop
    • for meningitis, endocarditis, osteomyelitis
  • To prevent get a vaccine, then stress hand washing.


Guillain Barre

Define: paralysis that starts in the legs and moves up the levels of the spinal cord triggered by an infection

Pathophysiology: demyelination in an ascending pattern

S/Sx: ascending paralysis

Diagnosis: peripheral neuro exam, and electrolyte imbalances

Treatment: Plasma exchange(to remove harmful antibodies), and immunoglobulin therapy (put in immunoglobulins that block the antibodies that contribute to GB).


Med Surg session 6: Cardiovascular



Session 6




Cardiac index is the CO when the size of the person is taken into account.

  • normal is 2-4
  • This accounts for: 100lb person with 8L CO and a 300 lb person with a 8L CO

the higher the SVR the tighter the blood vessels are.

  • Systemic vascular resistance
  • this is low in neurogenic shock, and septic shock.


Men often present with Heart disease around 50 yo and have generic symptoms

  • Chest, jaw, left shoulder pain, SOB

Women present in a less typical way and onset around 60 yo

  • nausea, vomiting, anxiety, back or arm pain, fatigue




  • JNC8 are the new guidelines
  • keep DM and CKD pts under 140/90
  • HT crisis
  • emergency
  • severe HA, seizures, coma
  • HCT (hydrochlorothiazide) is the first line drug for HTN



  • to prevent the increase of this disease, Exercise, blood glucose management
  • Drugs that this person would be on: ASA, plavix, Beta blocker, (not a diuretic necessarily because we are trying to directly decrease HR and the ability to form a thromboembolism)



  • Chronic stable angina – pain upon exertion that is relieved with nitro and rest. Predictable.
    • the cause is usually atherosclerosis
    • medications for this: nitro, beta blockers, ASA, CCB
      • take 8-12hr time off of nitro (usually at night) because when used too chronically it loses effectiveness.
  • Vasospastic angina (prinzmetal)
    • doesn’t happen upon exertion, happens randomly
    • treat with CCBs relax vessels and make them less spastic
  • When to worry
    • persisting longer than 5 mins call 911, then take two more tablets total in five minute intervals


Myocardial Infarction

  • irreversible necrotic tissue
  • troponins labs will be high
  • usually in the left ventricle
  • Diagnostics for MIs
    • ECG changes
      • STEMI – st elevation MI
  • Clot busters () (fibrinolytic therapy) are given if there is no cath lab in the hospital to use a balloon to move the clot against the artery wall.  
    • TPA, alteplase, streptokinase
  • Cardiac catheterization (PCI)
    • inserted through the femoral artery (sometimes the radial)
    • goes into the heart arteries to balloon open up the artery section.
    • Check KIDNEY FXN! the dye used to visualize the clot and PCI are hard on the kidneys
  • MONA – morphine (pain, vasodilation, and cheap), O2, Nitro, ASA


Heart failure

  • left sided
    • EF > 40% (normal is 50%-70%
    • systolic HF (HFrEF)- reserved (decreased) ejection fraction
    • diastolic HY(HFpEF) – preserved ejection fraction
  • Drugs to increase CO
    • diuretics, ACE, ARBs, Beta and CCBs (if the EF is not too small)
  • VAD – Ventricular assist Device – used so the heart does not have to work. it is inside the person’s body.



  • 3 types: dilated, hypertrophic, and restrictive
  • Dilated: most common, decrease in CO,
    • the volume in the heart chambers increases, and there are thin walls
  • Hypertrophy: Increased O2 consumption in the Heart muscle, and decreased volume of blood that can flow into the ventricles during diastole.
    • volume in the chambers decreases, the heart walls are thick.


PVD (peripheral Vascular Disease)

  • decreased peripheral perfusion from a decrease in the size of peripheral blood vessels
  • pathology similar to atherosclerosis, but in the periphery
  • s/s: slows healing, pain, decreased pulses, ulcers, and edema
  • can affect the arteries, or venous system (tends to affect the venous system more often)


Peripheral venous disease –

  • Risk factors: venous stasis, Immobile, hypercoagulability, increased viscosity (often from dehydration),
  • s/s: increase in: heat, malaise, erythema
  • Encourage mobility


DVT – deep vein thrombosis

  • prevent with: tight stockings, auto compression devices (compress the legs at regular intervals to increase venous return and decrease stasis), AMBULATE.
  • If a clot develops then put the patient on bed rest so they do not throw the clot
    • Drugs once there is a clot: (thrombolytics) TPA, alteplase, and streptokinase
  • If the clot detaches it will end up in the lungs (if there is a patent foramen ovale (hole in the septum in the heart) the clot can pass through that hole then end up in the brain).



  • aortic aneurysm – out pouch of the aorta
    • can repair with surgery by adding in a graft to strengthen the wall and bypass the aneurysm site.
    • Diagnosis from a CT scan with Dye to visualise the pouch
    • TAA- thoracic Aortic aneurysm
      • send embolisms to the brain and extremities
    • AAA – Abdominal aortic aneurysm
      • sends embolisms to the kidneys and lower extremities (cannot get to the upper extremities or brain because of the low position of the aneurysm)


patients with DM and now has angina may present differently when their heart is ischemic

  • Hyperglycemia, nausea, malaise
  • Also Pioglitazone (actos) may increase the chance of exacerbating the patient’s HF


Lasix (furosemide) things to look for to measure effectiveness

  • decreased weight, urine output, BP decreasing, decreased edema
  • Monitor these labs: K, BUN and Creatinine, (electrolytes and kidney function)


Med Surg: Class 5


Class 5 MSK


MSK assessment

  • History
  • Physical assessment
    • inspection, Palpation, motion, strength opposition, gait
  • PTH, Ca levels, Phosphorus PO4, Vit D, Creatinine Kinase (CK)
  • X-ray, and bone density scan


Broad issues

  • Pain, Neurovascular compromise (edema, mm spasm, loss of peripheral pulses, cap refill, and neurologic sensitivity), Immobility



  • loss of bone density over time.
  • diagnosis when 25%-40% of bone calcium lost.
  • x-ray or bone density scan
  • manifests as: pathological fractures, may not present with s/s, bone pain,
  • Drugs: fosamax (alledramate), keep the Ca in the bone and prevent absorption
    • Omeprazole may (PPI’s) may decrease Ca absorption.  
  • Lifestyle changes: Weight bearing exercise, Ca and Vit D supplementation,
  • avoid: alcohol smoking, and carbonated beverages
  • Risk Factors: small thin women, inactive lifestyle, white/asian, ETOH, Chronic Steroid use, Postmenopausal (lower estrogen levels)



  • reduction – realigning the bone
  • closed reduction is “pulling traction” and the bone is realigned without
  • ORIF -open reduction internal fixation (surgical procedure)
  • Healing: hematoma, granulation tissue, callus formation, ossification, consolidation, remodeling.
  • complications: NEUROVASCULAR IMPAIRMENT, Pain, DVT, Fat embolism, Osteomyelitis, Myoglobinuria (leads to acute renal failure because it is a protein that is hard on the kidneys)


Fat embolism – comes from the bone marrow often in long bone fractures.

    • includes the micro vasculature, can go into ARDS (acute resp. distress syndrome), petechiae, neuro issues (change in LOC).
    • the issues arise from the emboli getting stuck in the lungs, brain, or other microvasculature.
    • Cannot really treat this once it is lodged.


Compartment syndrome

  • from MM trauma, the muscle swells and pressure increases
  • 6 Ps: pain, paresthesia, pallor, pulseless, pressure, paralysis.
  • treat with a fasciotomy to relieve the pressure



  • pulling the bone to allow for realignment to occur correctly.
  • types
    • Manual, Skin or Bucks, and skeletal(drill into bone)
  • complications
    • sheer, urine retention (from pain meds and positioning), DVT, constipation, psychological issues, and fat emboli.
    • AWFUL: Atelectasis, Wasting bone, Functional MM loss, Urine retention, Lastly constipation

Internal fixation

  • adding screws or plates, to help the bone heal correctly
  • stay in permanently


External fixation:

  • drill into the bone to anchor, then a system outside the body holds those anchors until it is healed then they are taken out,
  • Clean the Pins consistently, about TID


Rheumatoid arthritis

  • There are many many types and can affect the whole body not just the joints.



  • buildup of uric acid in blood, then the crystals collect (especially in the big toe)
  • Med: NSAID’s, colchicine, ibuprofen


THA – total hip arthroplasty (Replacement)

TKA – total knee arthroplasty (replacement)


Med Surg: Class 4:

Diabetes Mellitus


Class 4


Insulin vs. Glucagon, GH, epinephrine, cortisol


Glucagon – turns glycogen and fat into fuel


insulin – moving glucose and nutrients into cells


Type 1 – autoimmune dx, destroys beta cells

  • some genetic and environmental factors contribute to this
  • onset is not always young
  • scandinavian countries have the highest rates.
  • antibodies that can be tested for to diagnose DM1
    • GAD antibodies
    • insulin autoantibodies
    • c-peptide levels


type 2 DM

  • factors that contribute to insulin resistance:
    • genetic factors
    • diet
    • obesity
    • physical inactivity
  • if both parents have DM2 the child has a 50% chance of getting DM2
  • Progressive decline of Beta cell function


Gestational DM

  • DM that is diagnosed during pregnancy and leaves after
  • 20% of pregnant woman will get this
  • HPL – human placental lactogen, increases glucose levels to allow the baby to get more glucose
    • If there is too much glu the baby can become too fat and cause birth issues


secondary DM

  • chronic pancreatitis
  • Hormonal disorders
    • cushing’s disorder
    • acromegaly
  • cystic fibrosis
  • down syndrome
  • drug induced
    • nicotinic acid
    • HIV meds
    • anti rejection meds – prograph
    • glucocorticoids – dexamethasone
    • chemotherapy –


Diagnose DM2 (above these normal ranges)

  • A1c 5.7-6.5%
  • fasting plasma glucose 100-125 mg/dL
  • 2 hour PG 140 – 199 mg/dL in the OGTT



  • metformin decreases chance by 30%
  • metformin + lifestyle is a decrease of 60% chance


Inpatient glu targets

  • non ICU
  • pre meal >140
  • random > 180
  • ICU
    • 140-180


Diabetes Meds


  • Metformin
    • reduction of insulin resistance, decrease liver glu production
    • PO route
    • S/E: gastrointestinal discomfort
    • if creatinine is above 1.5 risk of renal disease
  • Sulfonureas (glyburide, glipizide)
    • stim insulin production
    • S/E: hypoglycemia
  • Meglitinides
    • short term insulin secretion
  • thiazolidinediones (pioglitazone Actos)
    • reduction of insulin resistance
    • gain about 10 lbs of water weight
    • use with caution in CHF and liver Dx
    • 4 week onset, bone loss
  • SGLT2 inhibitors (invokana Canagliflozin) (jardiance Empagliflozin)
    • reduce renal glu reabsorption and increase secretion
    • S/E: weight loss, UTI
  • Incretin mimetics (bayetta bid) (bydureon 1x week)
    • stim insulin secretion, suppress glucagon, slows gastric emptying
    • GLP- Agonist
    • S/E: weight loss, N/V/D



  • Basal insulin (best injected in the abdomen)
    • Long acting (detemir and glargine)
      • no peak duration of 24hr
    • intermediate acting (NPH)
      • peak 6-12hr duration of 12-20hr
  • bolus insulins (given after the meal to be sure that they ate it. the injection can go any where you can pinch an inch)
    • rapid acting (humalog, Novolog) 5-15min onset
    • short acting (regular (humulin, Novolin) 30-60min onset


  • Insulin pumps
    • rapid acting insulin that is infused all day to replace the basal. when the person eats they put in their blood sugar and amount of carbs about to eat.
    • there are also sensors that can track the glucose level in the blood using and sensor that needs to be calibrated with a finger stick BID. This is very helpful with trending the glucose level.
    • Nursing considerations
      • the person needs to be alert and oriented to use it
      • double check what the person is telling you about the pump
      • still use finger stick in the hospital as a double check because we are liable
      • still a SQ catheter injection to deliver the medication


Acute complications:


  • Diabetic acidosis
    • increase in ketone acid from the body breaking down fat rapidly
    • Labs
      • glucose >250
      • CO2 <15
      • Anion Gap [Na – (Cl + HCO3)] increased (acidic) 
    • almost always in people with DM1
    • s/s: n/v, polyuria, polydipsia, kussmaul respirations, tachycardia


  • HHNK
    • higher blood glucose than with DKA
    • spill glucose in urine
    • more common in DM2
    • same treatment as DKA



  • treatment
    • Glucagon to increase hepatic glucose release
    • Epinephrine to reduce glucose uptake and increase hepatic glu production
  • s/s HTN, diaphoresis, unique to the person and there may be no symptoms
  • hypoglycemia unawareness – lowers the level that the hypoglycemia is felt by the person


Long term complications



  • blood vessels are damaged
  • create black spots in vision
  • nonproliferative – occurs in about 10 years
  • Proliferative – neovascularization, from retinal hypoxia
  • macular edema –

macular edema





  • stage 1 functional change gfr increases (GFR >90)
  • Stage 2 glomerular damage (GFR 60-89)
  • stage 3 overt nephropathy (GFR 30-59)
  • Stage 4 severe nephropathy (GFR 15-29)
  • Stage 5 end stage need dialysis (>15)


  • need a renal diet low potassium, refined foods ( doesn’t mesh well with DM diet)



  • first painfull then painless once the nerve is full glycosylated
  • fall risk, (have bad proprioception)


Autonomic neuropathy

  • Gastrointestinal – gastroparesis
    • anorexia, nausea, vomiting
    • diagnosis from radioactive food(eggs) visualised by medical scintigraphy


  • cystopathy
    • cannot sense full bladder
  • ED
    • Poor blood flow (most meds do not work because it just works to increase blood flow not nerve response)
  • female sexual dysfunction  


Cardiovascular disease


  • from increased platelet aggregation, decreased fibrinolytic activity, HTN, Hyperlipidemia
  • s/s: are not common MI s/s and can be “silent”