Med Surg - Exam3- Mandy- ch49 lecture Flashcards Preview

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1

Islets of Langerhans

hormone secreting portion of pancreas
alpha & beta cells

2

alpha cells

Alpha cells: produce Glucagon in response to low blood glucose levels

3

beta cells

Beta cells: produce Insulin in response to high blood glucose-

4

insulin facilitates

glucose metabolism, glucose transport across cell membranes, and synthesis and storage of glucose, fats, and proteins

5

Glucagon

Glukegone hormone to increase blood sugar level. When low sugar, protein ingestion, and exercise

6

Glycogen

storage of glucose in liver

7

Insulin function

transport glucose into cell and incorporate into protein in muscle, glycogen in liver, and fat trigliceride to adipose tissue.
Fat(/adipose /’edapous/ tissue), glycogen, and protein are the three format of energy storage in human body.

8

counter regulatory hormones to insulin

: glucagon, epinephrine, growth hormone, and cortisol...raise blood glucose levels

9

counter regulatory hormones (of insulin)

*Respond to a decline in blood glucose level during fasting or overnight
*Stimulate lipolysis, gluconeogenesis, and glycogenolysis processes

10

Gluconeogenesis

Gluconeogenesis is the process of synthesizing glucose in the body from non-carbohydrate sources such as protein and fat.

11

Blycogenolysis

Blycogenolysis - is the breakdown of glycogen to glucose.

12

Lypolysis

Lipolysis: break down of lipid (fatty tissues) to fatty acid and glycerol.

13

Diabetes Mellitus (DM)

A chronic multisystem disease related to
Abnormal insulin production
Impaired insulin utilization
Or both

14

abnormal insulin production in

D1 and D2; insulin resistance due to fatigue/B cell defect

15

Pancreas of DM type 1

Autoimmune destruction of B cells
Autoantibodies present for months/years before clinical symptoms
No production of insulin

16

Pancreas of DM type 2

Defective B cell insulin secretion
Insulin resistance stimulates insulin secretion
Eventually exhausting B cells

17

Liver of DM type 2

Excess glucose production.
Inapprpriate regulation of glucose production

18

Adipose tissue of DM type 2

Decrease in Adiponectin and Increase in Leptin: results in altered glucose and fat metabolism

19

Muscle tissue of DM type 2

Defective insulin receptors
Insulin resistant
Decreased uptake of glucose results in hyperglycemia

20

all you really need to know is that DM2 involves...

metabolic problems in muscle, liver (glucose higher), and adipose tissue (high cholesterol)

21

TYPE 1 DM

Autoimmune disease, peak onset by 20 years old
Insulin dependent
Rapid & Acute
Classic symptoms: Polyuria, Polydipsia, Polyphagia
Others: weight loss, weakness, fatigue

22

TYPE 2 DM

*Major contributor for heart, renal disease, and stroke
*Associated with metabolic syndrom
*Asymptomatic in the early stage
*May have classic symptoms of type 1
*Nonspecific symptoms are common: fatigue, prolonged wound healing, visual changes

23

metabolic syndrome characterized by

-Insulin resistance, elevated insulin levels
-↑ triglycerides & Low-density lipoproteins, ↓High-density lipoproteins
-Hypertension

24

HDL

removes excess cholesterol from the body

25

Excessive LDL

LDL builds up on arterial walls and hardens to create plaque, constricting flow and contributing to heart disease.

26

Triglyceride

storage of fat for energy use

27

Cholesterol

for construction of cell and hormone

28

HDL for

transportation

29

Hyperglycemia causes a diabetic to produce

a high volume of glucose containing urine

30

other types of DM

prediabetes
gestational
secondary

31

prediabetes

Blood glucose levels are at borderlines
No symptom but damages may already occurred
Healthy eating, healthy weight, regular exercise, and monitoring blood glucose and symptoms can reduce the risk of DM

32

Impaired fasting glucose (IFG)

between 100 -125 mg/dl

33

to diagnose diabetes, fasting glucose needs

tested twice at more than 126 mg/dl

34

Impaired glucose tolerance (IGT)

2 hour oral glucose tolerance test (OGTT) level between
140 -199mg/dl

35

Diagnostics for DIABETES

*HbA1C ≥ 6.5%
*FG level ≥126 mg/dl
*OGTT: Two-hour plasma glucose level ≥ 200 mg/dl
*Random plasma glucose ≥ 200 mg/dl plus symptoms

36

normal HBA1c

glycosylated hemoglobin. 4-6%

37

prediabetes HbA1C

5.7-6.4%

38

Oral contraceptives

could elevate OGTT

39

prediabetes FG

100-125 mg/dl

40

prediabetes OGTT

140-199 mg/dl

41

collaborative care of diabetes

medication
Nutritional therapy
Self-monitoring blood glucose
Exercise

42

Insulin Bolus

given before meals
Rapid acting or short acting

43

Rapid Acting Insulin

Lispro (Humalog),
aspart (NovoLog),
glulisine (Apidra)
Injected 0 to 15 minutes before meal
Onset of action 15 minutes

44

Short Acting Insulin

ie REGULAR insulin
Regular (Humulin R, Novolin R)
Injected 30 to 45 minutes before meal
Onset of action 30 to 60 minutes

45

BASAL Insulin

Basal – control glucose level between meals and overnights
Intermediate or long acting

46

Basal insulins

Basal – control glucose level between meals and overnights
Intermediate-acting: NPH (Humulin N, Novolin N)
Has a peak which can result in hypoglycemia
Long-acting: Glargine (Lantus) and Detemir (Levemir)
Injected once a day at bedtime or in the morning
Released steadily and continuously
Has no peak action thus decrease risk of hypoglycemia
Do not physically mixed with any other insulin or solution

47

Intermediate acting insulin

NPH (Humulin N, Novolin N)
Has a peak which can result in hypoglycemia

48

Long-acting insulin

Glargine (Lantus) and Detemir (Levemir

49

Long acting insulins
Lantus and Levemir for Basal

Injected once a day at bedtime or in the morning
Released steadily and continuously
Has no peak action thus decrease risk of hypoglycemia
Do not physically mixed with any other insulin or solution

50

NPH appearance

is cloudy

51

Rapid Acting times

onset: 10-30min
peak: 30min-3 hrs
duration: 3-5hr

52

Rapid Acting names

lispro Humalog
aspart NovoLog
gluslisine Apidra

53

Short Acting times

onset: 30-60min
peak: 2-5 hr
duration: 5-8 hr

54

Short Acting names

Regular: Humulin R
Novolin R

55

Intermediate acting times

onset: 1.5-4hr
peak 4-12 hr
duration 12-18 hr

56

Intermediate names

NPH: Humulin N, Novolin N

57

Long acting names

glargine Lantus
detemir Levemir

58

Long acting times

onset: .8 -4hr
peak: no pronounced peak
duration: 24 plus hours

59

mixing insulins

Mixing insulins: always withdraw Regular insulin first then NPH

60

combination insulin therapy

Short- or rapid-acting combined with intermediate-acting or long-acting insulin to provide basal-bolus coverage

There are commercially premixed formula available: 70/30, 75/25, 50/50

61

The client with type I diabetes mellitus is taught to take NPH (Humulin N) at 5 pm. each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time?

1 am, while sleeping

62

Insulin storage (4 points)

-Do not heat/freeze, extra insulin should be refrigerated
-In-use vials may be left at room temperature up to 4 weeks
-Avoid exposure to direct sunlight
-Vials or prefilled syringes should be generally rolled between the palms before injection

63

what size syringe to use for insulin?

0.3 or 0.5 ml syringe

64

How long to leave syringe in place after injection?

5 seconds

65

Administration of insulin:
what site has fastest absorbtion?

Abdomen, followed by arm, thigh, butt

66

Do not inject insulin into site..

that is to be exercised

67

Insulin & alcohol wiping

At home, by patient: not recommended.
In the hospital, by nurse: absolutely...to prevent HAIs

68

Insulin concentrations

usually 100 units/ml

69

Insulin injections should be

rotated within one particular site...this decreases variablility of absorption

70

only IV insulin

Regular insulin only

71

Both Somogyi and Dawn phenomenon

characterized by hyperglycemia in the morning

72

Is AM hyperglycemia because insulin dosage is too high or too low?

check blood glucose at 2-4am

73

Somogyi effect

Somogyi caused by hypoglycemia rebounded by counterreulatory hormone

74

Dawn phenomenon

Down phenonmenon due to counterregulatory hormone

75

Insulin pump

-Continuous infusion of a rapid-acting insulin
-Dosage can be temporarily increased and decreased by programming
-2-3 days rotate sites and change synringe.
-Plunzher.

76

Oral agents that increase insulin production from the pancreas

SULFONYLUREAS (Glipizide (Glucotrol), Glyburide (Micronase), Glimepiride (Amaryl)
*MEGLITINIDES (Repaglinide (Prandin), Nateglinide (Starlix)

SIDE EFFECT: hypoglycemia

77

Meglinides

Oral agent, increases insulin production, short acting
*take 30 minutes before each meal

78

Sulfonylureas: Glucotrol, Micronase, Amaryl

Oral agent that increases insulin production and release from pancreas

79

Megliniede

like regular insulin, comes & goes fast

80

postprandial

post meal

81

Oral agent that reduces glucose production by liver

Biguanides: Metformin (Glucophage)

82

Metformin (Glucophage)

Do not use in pt with kidney or liver disease, or heart failure. Hold B4 & 48 hrs after contrast procedures or till kidney function is normal

83

Oral agents that delay the absorption of glucose from intestines

α – Glucosidase Inhibitors
take with the first bite of the meal, effective on controlling post-meal blood glucose, effectiveness to be measured 2 hours after the meal.
Acarbose (Precose)

84

Acarbose (Precose)

α – Glucosidase Inhibitors
take with the first bite of the meal, effective on controlling post-meal blood glucose, effectiveness to be measured 2 hours after the meal.

85

Biguanides do not

promote weight gain, beneficial to people with prediabetes

86

Metformine

increases lactic acidosis...kidney problem

87

oral agents that improve insulin sensitivity

Thiazolidiediones

88

Thiazolidiediones

IMPROVES INSULIN SENSITIVITY. does not increase insulin production, thus will not cause hypoglycemia

89

Thiazolidinediones: drug names

IMPROVES INSULIN SENSITIVITY.
Pioglitazone (Actos), Rosiglitazone (Avandia)

90

Thiazolidinediones

impair liver function, do not use in pt with MI, stroke or heart failure

91

DDP-4 inhibitor

Oral agent: blocks dipeptidyl peptidase-4, which decreases insulin production.

92

DDP-4 inhibitors do not cause

weight gain or hypoglycemia

93

DDP-4 inhibitor names

Sitagliptin (Januvia)

94

Byetta

3rd category of DM med. from Gila monster saliva. stimulates insulin production and decreases liver sugar production. causes weight loss.

95

Non insulin Injectable Agents. Names

Exenatide (Byetta)
Praminitide (Symlin)

96

Noninsulin Injectable Agents

Increase insulin sysnthesis and release from the pancrease. Inhibit glucagon secretion, & Delays gastric emptying. watch for hypoglycemia.

97

Exenatide (Byetta)

Noninsulin injectable: Glucagon like peptide 1 (GLP1) Receptor Agonist.
Need to take oral medication >1 hour before injecting Byetta.

98

What to teach pt about glyburide (Micronase, DiaBeta, Glynase)?

Glyburide stimulates insulin production and release from the pancreas.

99

Glyburide is a sulfonylurea it

sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, because hypoglycemia can occur with this class of medication.

100

Metformin should be held...

held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide.

101

Glucagon secretion & glyburide

Glucagon secretion is not affected by glyburide.

102

nutritional therapy: Carbohydrates, 7pts

*miniumum of 130g/day
*CHOs from fruits, veggies, grains legumes, milk
*use a method: carb counting, exchange lists, portion control
*use Glycemic index
*sucrose containing food subbed for other CHOs
*Fiber:25-30g/day
*Nonnutritive sweetners ok.

103

Nutritional therapy - protein

15-20% of calories
high protein diets for wt loss, not recommended

104

Nutritional therapy - fat

low fat: 20-30% total calories
saturated fat <200 mg/day

105

Alcohol & diabetes

Alcohol consumption : can cause severe hypoglycemia, should be consumed with food

106

Glycemic index (GI):

Glycemic index (GI): rises in blood glucose level after consuming carbohydrate-containing food.

107

a slice of bread is

Simple complex carbohydrate
1 slice of bread – 15 g one serving

108

Alcohol inhibits liver to

break down glycogen to glucose thus cause hypoglycemia. Liver busy with detoxicating alcohol
Normally, the liver releases glucose to maintain blood sugar levels. But when you drink alcohol, the liver is busy breaking the alcohol down, so it does a poor job of releasing glucose into the bloodstream.

109

SMBG

Self Monitoring Blood Glucose
ie AccuCheck

110

When NOT to exercise?

Hold exercise if glucose ≤ 100 mg/dl or ≥ 250 mg/dl, or if ketones are present in the urine.

111

When TO exercise?

Exercise daily same time same amount
Best to excise 1-2 hours after meals

112

Small CHO snack..

can be taken during exercise to prevent hypoglycemia

113

Exercise & SMBG

Monitor blood glucose levels before, during, and after exercise

114

Diabetics need ___ B4 exercise

Need medical clearance before exercise

115

When patient is ill,

When patient is ill, blood glucose should be tested at least every 4 hours

116

Nursing Management of DM:
Overall Goals (5)

*Active pt participation
*fewer/no episodes of acute hyper/hypoglycemic emergencies
*maintain normal blood glucose levels
*prevent/delay chronic complications
*lifestyle adjustments w/ minimal stress

117

Nursing Management of DM
Acute interventions:

Under stress of illness and surgery: *Blood glucose level could be high
*Continue regular meal plan, increase intake of noncaloric fluids
*Continue taking oral agents and insulin
*Closely monitor blood glucose

118

Nursing Management:
Ambulatory & home care
Tables 49-13--15
6 points

*Reach an optimal level of independence
*Insulin therapy and oral agent
*Personal hygiene with emphasis on foot care
*Medical identification and travel card
*Patient and family teaching
*Learn early symptoms of hyperglycemia and hypoglycemia

119

A client with type 1 diabetes calls the clinic with complaints of nausea, vomiting, and diarrhea. The nurse should advise the client to

Check the blood glucose level every 2 to 4 hours

120

Acute Complications

see table 49-16 pg 1175

121

Diabetic ketoacidosis (DKA)
caused by

profound deficiency of insulin

122

DKA characterized by....
6 points

*Hyperglycemia (glucose > 250 mg/dl)
*Ketosis (ketones in blood and urine)
*Acidosis (blood PH < 7.3, bicarbonate < 15 mEq/L)
*Dehydration (poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension)
*Kumaul respirations: rapid deep breathing to attempt to reverse metabolic acidosis
*Sweet fruity odor, abdominal pain, nausea/vomiting

123

DKA is common in

Common in type 1 or poor self management

124

ketone

by product of fat metabolism

125

fruity odor

is acetone, simplest ketone

126

pH range: normal

7.35-7.45

127

Bicarbonate range: normal

21-28

128

DKA interventions table 49-18
Emergency Management

Airway patency, O2 administration
*Correct fluid/electrolyte imbalance
IV infusion 0.45% or 0.9% NaCl to restore urine output and raise blood pressure
*Early potassium replacement – insulin drives potassium into the cells and lead to hypokalemia
*Insulin therapy start when fluid resuscitation begins and potassium is normal
*When blood glucose levels approach 250 mg/dl, 5% dextrose added to regimen to prevent hypoglycemia

129

HHS

Hyperosmolar Hyperglycemic Syndrome

130

HHS 5 points

*Common in patients over 60 years with type 2
*Caused by dehydration – require greater fluid replacement
*Patient has enough circulating insulin so ketoacidosis does not occur (Absent/minimal ketone bodies in blood or urine)
*Produces fewer symptoms in earlier stages
*Neurologic manifestations occur

131

glucose level in HHS

more than 600

132

HHS vs DKA in terms of fluids

HHS requires greater fluid replacement

133

Hypoglycemia

Low blood glucose < 70 mg/dl

134

hypoglycemia caused by

mismatch in timing of food intake and peak action of insulin or oral hypoglycemic agents

135

common manifestations of hypoglycemia

Common manifestations: confusion, irritability, diaphoresis, tremors, hunger, weakness, visual disturbances, can mimic alcohol intoxication

136

untreated hypoglycemia

Untreated can progress to loss of consciousness, seizures, coma, and death

137

Nursing management of DKA/HHS: Patient closely monitored. Administer:

IV fluids
Insulin therapy
Electrolytes

138

Nursing management of DKA/HHS: Patient closely monitored. Assess:

Cardiac monitoring - EKG
Renal status
Cardiopulmonary status
Level of consciousness

139

An unresponsive client with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to

insert a large-bore IV catheter.
HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patient’s blood glucose and would be contraindicated.

140

AT first sign of Hypoglycemia:

Check blood glucose
If 70 mg/dl, investigate further for causes

141

If having hypoglycemic symptoms, and monitoring equipment is not available:

treatment should be initiated
If alert enough to swallow, 15 to 20 g of a simple carbohydrate, avoid foods with fat

142

Hypoglyemia:
Hypoglycemia (cont’d)
Avoid____ and overtreatment by __________.
Recheck blood sugar _______ after treatment.
Repeat until blood sugar ________.
Patient should eat regularly scheduled meal/snack (complex carbohydrate) to prevent rebound _________.
Check blood sugar again ________ after treatment.

If no improvement after _____ or patient not alert enough to swallow, then:
Administer ___________.

In acute care settings: give ________ IV push.

Hypoglycemia:
Avoid fat and overtreatment by simple carbohydrate
Recheck blood sugar 15 minutes after treatment
Repeat until blood sugar >70 mg/dl
Patient should eat regularly scheduled meal/snack (complex carbohydrate) to prevent rebound hypoglycemia
Check blood sugar again 45 minutes after treatment

If no improvement after 2 or 3 doses of simple carbohydrate or patient not alert enough to swallow, then:
Administer 1 mg of glucagon IM or subcutaneously
In acute care settings: 20 to 50 ml of 50% dextrose IV push

143

Intramuscular Glucagon stimulates

the liver to produce glycogen to supply glucose

144

Which action should the nurse take after a 36-year-old patient treated with intramuscular glucagon for hypoglycemia regains consciousness?

Give the patient a snack of peanut butter and crackers

145

After Glucagon administration what can happen? what could prevent?

Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia...cheese and crackers will stabilize blood glucose...The patient should be assessed for symptoms of hypoglycemia after glucagon administration.

146

Acute complications of DM

HHS
DKA
hypoglycemia

147

Chronic Complications of DM:

Angiopathy (micro & macrovascular)
Retinopathy
Nephropathy
Neuropathy
feet & lower extremities
skin
infections
psychologic considerations

148

Angiopathy

Blood vessel damage secondary to chronic hyperglycemia resulting in organ disease

149

Macrovascular angiopathy

*Diseases of large and medium-sized blood vessels, caused by altered lipid metabolism
*Risk factors: Obesity, Smoking, Hypertension, High-fat intake, Sedentary lifestyle
*Control of blood pressure and lipid panel is the key to prevent cardiovascular diseases

150

Risk factors for Macrovascular angiopathy in DM pts

Obesity, Smoking, Hypertension, High-fat intake, Sedentary lifestyle

151

Key to prevent CVD in DM pts

Control of blood pressure and lipid panel is the key to prevent cardiovascular diseases

152

Microvascular angiopathy specific to DM

Result from thickening of vessel membranes in capillaries and arterioles in response to chronic hyperglycemia
*Affect eyes, kidneys, skin

153

Lab value:
Cholestrol

<200 mg/dL

154

Lab value:
LDL

<130 mg/dL

155

Lab value:
HDL
male & female

Male: >45
Female: >55 mg/dL

156

Lab value:
triglycerides

< 150

157

Diabetic retinopathy

Microvascular damage to retina
Early detection: patient should have annual eye examination

158

diabetic nephropathy:
associated with:
leading cause of:
prevent by:

Associated with damage to small blood vessels that supply the glomeruli of the kidney

Leading cause of end-stage renal disease

Prevention/delay: glucose and hypertension control, annual screening of kidney function

159

nonproliferative retinopathy

most common form.
partial occlusion of the small blood vessels in the retina causes microaneurysms in capillary walls that leak causing retinal edema & hard exudates or intraretinal hemorrhages.

160

proliferative retinopathy

most severe form
involves retina & vitreous. capillaries become occluded, body compensates by neovascularization to supply retina w/ blood. the new vessels are fragile & hemorrhage easily, producing vitreous contraction.
pt sees black & red spots

161

Paresthesia

an abnormal sensation, typically tingling or pricking (“pins and needles”), caused chiefly by pressure on or damage to peripheral nerves.

162

% of DM pts with some degree of neuropathy

60-70%

163

Diabetic neuropathy

nerve damage due to metabolic derangements associated w/ DM.

164

most common neuropathy

sensory neuropathy

165

2 categories of diabetic neuropathy

sensory - affects peripheral nervous system
autonomic- affects all body systems

166

Sensory neuropathy

affects hands and/or feet bilaterally
Characteristics include Loss of sensation, abnormal sensations, and pain
Foot injury and ulcerations can occur without feeling pain

167

Autonomic neuropathy : complications

Autonomic neuropathy: can affect nearly all body systems

Complications: delayed gastric emptying, orthostatic hypotension, tachycardia, painless myocardial infarction, sexual dysfunction, neurogenic bladder – urine retention

168

Most common cause of hospitalization for DM pts

Foot complications

169

Risk factors for foot complications

Sensory neuropathy
Peripheral arterial disease
Others: smoking, clotting abnormalities, impaired immune function, autonomic neuropathy

170

monofilament screening

screen annually for sensation on plantar surface of foot.
apply thin, flexible filament to several spots on plantar foot surface..does pt feel?

171

Annual testing for pt with DM 2

Blood pressure
serum creatinine
urine: for microalbuminuria
monofilament test of foot