FINAL COMPILATION NUR 327 latest complete compilation

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FINAL COMPILATION NUR 327 FINAL COMPILATION: *********************************************** DIABETES MELLITUS o Disorder of hyperglycemia  Defects in insulin secretion, insulin action ... or both  Leads to abnormalities in carbohydrate, protein, & fat metabolism o 4 major types  type 1 DM  type 2 DM  Gestational diabetes  Other specific types of diabetes o Role of Hormones  pancreas Produces hormones necessary for metabolism & cellular utilization of carbohydrates, proteins, & fats  Alpha cells: glucagon  Beta cells: insulin (destroyed in diabetes)  Delta cells: somatostatin o Blood Glucose Homeostasis  Body tissues & organs require constant supply of glucose  Normal blood glucose level maintained through actions of insulin & glucagon • ↑ glucose = ↑ insulin production o Type 1 Diabetes  Results from destruction of beta cells in pancreas • Insulin not produced o Beta cells are destroyed (absolute insulin deficiency) • Autoimmune or Idiopathic  Etiology • Most often occurs in childhood • Genetic predisposition (pg 741) • Environmental (viral or chemical)  Clinical manifestations • Hyperglycemia • Breakdown of body fats, proteins • Development of ketosis (not enough glucose for energy • Lack of insulin  hyperglycemia o Glucose cannot enter cells without insulin • Classic manifestations: o Polyuria (a lot of urine) o Glycosuria (sugar in the urine) o Polydipsia (thirsty) o Polyphagia (hungry) o Weight loss, malaise, fatigue  Type 1 DM requires exogenous insulin o Type 2 Diabetes Mellitus  Adult onset  Results from insulin resistance defect in compensatory insulin secretion  Pathophysiology and etiology • Function of insulin impaired by resistance • Demand for insulin exceeds supply  Pathophysiology and etiology • Can occur at any age • Major factor is cellular resistance to effect of insulin o Increased by obesity inactivity, meds, illnesses increasing age  Risk factors • Diabetes in parents or siblings • Obesity • Physical inactivity • Race/ethnicity • History of gestational diabetes • Polycystic ovary syndrome • Hypertension • Metabolic syndrome  Clinical manifestations • Slow onset of manifestations • Symptoms similar to type 1 • Treatment begins with: prescriptions for weight loss & increased activity o Complication of Diabetes  Involve many body systems  Alterations in cardiovascular system, neuropathy  Increased susceptibility to infection  Periodontal disease  Problems in the feet o Acute Complications  Hyperglycemia • Dawn phenomenon: Rise in blood glucose between 4–8 a.m. • Somogyi phenomenon: Combination hypoglycemia during night with rebound morning rise to hyperglycemia • Diabetic Ketoacidosis (TYPE 1 DM) o Absolute deficiency of insulin + increase in insulin counterregulatory hormones o Increased glucagon levels lead to DKA o May also occur when energy requirements increase o Four metabolic problems  Hyperosmolarity  Metabolic acidosis from accumulation of ketoacids  Extracellular volume depletion  Electrolyte imbalances from osmotic diuresis o Manifestations result from severe dehydration, acidosis  DKA requires immediate medical attention  Initial (8-10L) fluid to replace losses  IV fluids with 0.9 NS to 0.45% saline o Regular insulin used o Electrolyte imbalance requires monitoring • Hyperosmolar hyperglycemic state o Occurs in individuals with type 2 DM o Blood glucose levels >600 mg/dL (as high as 1,000-2000 mg/dL) o Serious, life-threatening o Precipitating factors o Slow onset o Results in severe dehydration o Treatment  Correct fluid & electrolyte imbalances  Lower blood glucose levels with insulin  Admit to ICU if blood glucose > 700 mg/dL • Establish, maintain ventilation • Correct shock with adequate intravenous fluid (IV) • If client is comatose, NG suction • Maintain fluid volume • Administer insulin to reduce blood glucose  Hypoglycemia • Common in type 1 DM • Insulin reaction o Intake of alcohol, drugs can cause • Manifestations o Compensatory autonomic nervous system response o Hypoglycemic unawareness • Treatment o 15g rapid acting sugar o Hospitalized if  Blood glucose less than 50 mg/dL  Coma, seizures  Altered behaviors  No adult can attend  Caused by sulfonylurea drug o Administer 25%–50% glucose solution o Glucagon 1mg SC, IM, or IV o Chronic Complications  Alterations in the cardiovascular system • Macrocirculation changes • Microcirculation changes  Diabetic retinopathy • Three stages to changes in retina o Stage I: nonproliferative o Stage II: preproliferative o Stage III: proliferative  Diabetic nephropathy • Thickening of basement membrane of glomeruli • Impairs renal function • hypertension accelerates progression  Alterations in the peripheral and autonomic nervous systems • Diabetic neuropathies o Thickening of walls of blood vessels (that supply nerves, cause decrease in nutrients) o Decreased nutrients to nerves o Demyelinization of Schwann cells slows nerve conduction o Formation, accumulation of sorbitol within Schwann cells impairs nerve conduction  Peripheral neuropathies • Polyneuropathies o Most common, bilateral sensory disorder (Distal parenthesis pain, cold feet) • Mononeuropathies o Affect single nerve o Manifestations may include  Palsy of third cranial (occulomotor) nerve: headache, eye pain, inability to move eye up or down  Radiculopathy  Diabetic femoral neuropathy  Entrapment or compression of medial nerve • Visceral neuropathies o Sweating dysfunction o Abnormal pupillary function o Cardiovascular dysfunction o Gastrointestinal dysfunction o Genitourinary dysfunction  Alterations in mood Strains of living w/ complex self-care, risk of depression  Increased susceptibility to infection Vascular, neurological impairments, nephrosclerosis, urinary retention  Periodontal disease Progesses more rapidly if poorly controlled  Complications involving the feet • Result of angiopathy, neuropathy, infection • Vascular changes usually bilateral • Diabetic neuropathy produces multiple problems o Most common trauma o Begins as superficial ulcer o Collaboration  Closely controlled blood glucose  Focus of treatment: Maintain blood glucose at nearly normal levels through • Medications, Dietary management, exercise (if type 2 DM eats right & exercise they can get off medications) o Diagnostic Tests  ADA diagnostic criteria • Symptoms of diabetes + plasma glucose (PG) > 200 mg/dL  Hemoglobin A1C > 6.5% hemoglobin • Fasting plasma glucose (FPG) > 126 mg/dL • Two-hour PG > 200 mg/dL  oral glucose tolerance test (OGTT)  Following levels for FPG • Normal FG: 100 mg/dL • Impaired FG (IFG): > 100 and < 126 mg/dL • Diagnosis of diabetes: >126 mg/dL  Prediabetes • Blood sugar between 100–126 mg/dL • At increased risk of developing diabetes  Diabetes management monitoring • Fasting blood glucose (FBG): 70-110 mg/dL • Glycosylated hemoglobin (A1C) o Average blood glucose over 7%- 9% prediabetes <6% • Urine glucose, ketones • Urine test for presence of protein as albumin • Serum cholesterol, triglyceride levels • Serum electrolytes o Monitoring Blood Glucose  Daily monitoring  Urine testing for ketones and glucose  Self-monitoring of blood glucose (SMBG) • Allows individual with diabetes to monitor, achieve control • Decreases danger of hypoglycemia • 3–4 times a day with type 1 DM • ADA provides list of monitoring machines • Continuous glucose monitor—new pump • Equipment needed: •  Factors that affect glucose meter performance • Clients with higher hematocrit • meds may cause inaccurate results • Be sure test strips compatible with meter o Insulin  With type 1 DM: lifelong exogenous source of insulin  Unable to control glucose levels with oral antidiabetics and/or diet  With physical stress, taking oral corticosteroids  With DKA & HHS  High-calorie tube feedings, parenteral nutrition  Clients with type 2 diabetes • Cannot be managed with oral medications when hospitalized • ICU patients o Less morbidity with intensive insulin therapy • Decreases risk of postoperative infections • IV insulin infusions o Maintain normal blood glucose o Frequent monitoring o Types of Insulin  Insulin lispro (humalog) • Rapid-acting, ultra-short-acting  Regular insulin • Modified crystalline insulin (short-acting) • Clear • ONLY INSULIN THAT CAN BE GIVEN intravenously • Used to treat DKA  NPH insulins • Intermediate acting • Preparations appear cloudy when properly mixed  Insulin glargine • 24-hour, long-acting • Constant effect, No peak time  Dispensed as: • 100 unit/mL (U-100) • 500 unit/mL (U-500) o Used in cases of insulin resistance (require large amounts) o Nursing implications • All insulins given parentally (shot) • subcutaneously • Regular, rapid-acting insulins used in continuous subcutaneous insulin infusion (CSII) devices  Pumps allow more normal regulation of blood glucose • Programmed insulin • Needle site must be kept clean  Special injection products  Vials at room temperature up to 4 weeks  Regular insulin requires no mixing • Other types require gentle rolling  Nursing implications • Rotate sites • Do not massage site after injection • Pressure may be applied • Techniques for minimizing painful injections • Lipodystrophy (sight becomes immune to the insulin) lipoatrophy o Hypoglycemic Agents  Used to treat individuals w/type 2 DM • Stimulate or increase insulin secretion • Prevent breakdown of glycogen to glucose  oral preparations  Injectable: exanatide (Byetta)  Aspirin therapy: Once-daily dose of 81–325 mg enteric-coated o Nutrition  Management: Balance intake of nutrients expenditure of energy, dose and timing of meds  ADA guidelines • Maintain near normal blood levels • Achieve optimal serum lipid levels • Provide adequate calories to maintain or attain reasonable weight • Prevent and treat acute complications of insulin-treated DM • Improve overall health with optimal nutrition  Carbohydrate intake: 45%- 65% of daily diet • Plant foods, milk, some dairy • Sucrose substituted for other carbohydrates (no straight sugar)  Protein intake: 15%-20% total daily kilocalorie intake • Low in fat, cholesterol • Lower than most individuals consume  Dietary fats: less then 7% total kcal/day • Cholesterol <200 mg/day  Dietary fiber • Helpful in treating, preventing constipation • Recommended 20–35 g/day  Sodium: 1,000 mg per 1,000 kcal  Diabetic diet plan • Restrict amount of refined sugar • Nonnutritive sweeteners with caution • Alcohol consumption o Signs of intoxication, hypoglycemia similar o Light beer recommended alcoholic drink • Individualize meal planning o Sick-Day Management  Sick, surgery = Glucose levels increase  Guidelines • Monitor blood glucose at least 4x a day • Test urine for ketone if BG > 240 mg/dL • Continue to take normal insulin/hypoglycemic dose • Sip 8–12 oz fluid each hour • Substitute easily digested liquids • Call healthcare provider o Exercise  Regular exercise improves fitness, emotional state • Weight control • Improved work capacity  Avoid exercise in extremes of cold, avoid during periods of poor glucose control  Time in relation to meals, injections  Type 2 >> exercise may decrease need for oral hypoglycemic agents o Surgery  Replacing, transplanting pancreas, [pancreatic cells] or beta cells* beta cells type 1 DM  Surgery alters self-management • Hyperglycemia, protein stores decreased • High risk for postoperative infection- delayed wound healing • High risk for fluid, electrolyte imbalances • Hypoglycemia, DKA  Preoperative screening, glucose monitoring  Insulin dosing individualized • Client (type 1 or 2 DM) with pre-op glucose • Schedule procedure early • Postoperative care • Regular glucose monitoring o Nursing Process  Three levels of client teaching • Survival skills • Home management • Improving lifestyle educating clients  Assessment • Health history o Hx of diabetes o Hx of dizziness, numbness or tingling in hands/feet o Pain when walking, frequent voiding, change in weight, appetite o Infections, healing problems w/ GI fxn altered sex fxn • Physical assessment • Older adults o Aware of normal aging changes  Diagnosis Deficit knowledge, etc.  Planning • Client describes o How to administer medications o Respond to side effects appropriately • Client demonstrates o Meal planning complaint w/ American diabetic association diet o Proper foot care & inspection o Proper procedure for monitoring blood sugar well  Implementation • Individualized education about: o Normal metabolism o Diabetes, how diabetes changes metabolism o How diet helps keep blood glucose WNL o How exercise helps lower blood glucose o Self-monitoring of blood glucose o Medications insulin, intravenous agents, oral agents o Manifestations of acute complications o Hygiene  Including skin care, dental care, and foot care o Sick-day management o Helpful resources • Adapt teaching to special needs  Implementation: Maintain Skin Integrity • Baseline ongoing assessment • Musculoskeletal assessment- that includes foot and ankles joint range of motion bone abnormalities, gait patterns, use of assistive devices for walking, abnormal wear patterns on shoes • Neurological assessment • Vascular examination • Assessment of hydration status • Assessment for lesions, fissures, b/t toes, corns, calluses, plantar warts • Peripheral neuropathies, vascular disease o Teach foot hygeine o Smoking cessation o Maintaining blood glucose o PRIORITY: foot care  Implementation: Promote Healthy Behaviors • Use, teach meticulous hand washing • Monitor for manifestations of infection • Discuss importance of skin care • Teach dental health measures • Teach women symptoms, preventive measures for Candida albicans  Implementation: Maintain Safety • Assess for presence of contributing or causative factors • Reduce environmental hazards • Monitor for and teach client, family o Manifestations of DKA in client with type 1 DM o HHS in client with type 2 DM o Signs, symptoms, treatment manifestations of hypoglycemic • Recommend the client wears a medical alert bracelet or necklace  Implementation: Promote Effective Coping • Client faced with lifelong changes • Assess client's psychosocial resources • Explore with client & family the effects o Treatment, occupation, energy levels, relationships • Teach constructive problem solving • Provide information about support groups and resources  Evaluation • Client demonstrates age-appropriate understanding of: o Self-management through medication diet o Exercise o diet o Blood glucose self-monitoring • Client's skin integrity remains intact • Client remains free of infection • Client remains free of injury ************************************************ OBESITY OBESITY • Obesity  excess of adipose tissue  Most prevalent preventable health problem in U.S.  Has serious physiology and psychological consequences  Associated with increased morbidity and mortality  35% adults in U.S. are obese  17% of children in U.S. are obese • Pathophysiology  Energy is required for all body activities  ADLs  Cell and tissue function……………………………………………………………………………………………….continued………………………………………………………… [Show More]

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