adult care 1 quiz 2

diabetes patient education

- disease process - physical activity - menu planning - medication - monitoring blood glucose - risk reduction - psychosocial

storage of insulin

- extreme temperatures alter the insulin molecule > less effective - insulin vials/pens in use may be left at room temp for up to 4 weeks unless higher than 86 degrees or below freezing - avoid prolonged exposure to direct sunlight - if traveling to hot climate, keep insulin in thermos or cooler to keep cool, NOT frozen - 2 drug insulin prefilled syringes are available and stable for up to 2 week when stored in fridge. roll in hands for 10-20 minutes to warm and re-suspend particles - 1 drug insulin prefilled syringes are stable for up to 30 days. store in vertical position with needle pointing up to avoid clumping of suspended insulin in needle

duodenal ulcers

- lesion: penetrating (associated with deformity of duodenal bulb from healing of recurrent ulcers) - location: first 1-2 cm of duodenum - gastric secretions: increaed - incidence: greater in men, but increasing in women especially post-menopausal. peak age 35-45. no increased cancer risk. H. pylori infection in 90%. associated with other diseases like COPD, pancreatic disease, hyperparathyroidism, ZES, chronic renal failure - s/s: burning, cramping, pressure-like pain across midepigastrum and upper abdomen. back pain with posterior ulcers. pain 2-5 hr after meals and mid morning, mid afternoon, middle of night. periodic and episodic. pain relief with antacids and food - recurrence: high

gastric ulcers

- lesion: superficial, smooth margins. round, oval or cone shaped - location: predominantly antrum, also body and fundus of stomach - gastric secretion: normal to decreased - incidence: greater in women. peak age 5-60. increased cancer risk. H pylori infection in 80%. increased with incompetent pyloric sphincter and bile reflux - s/s: burning or gaseous pressure in epigastrum. pain 1-2 hr after meals. penetrating ulcer, aggravation of discomfort with food - recurrence: high

right brain damage

- paralyzed on left side: hemiplegia - left side neglect - spatial perceptual deficits - tends to deny or minimize problems - rapid performance, short attention span - impulsive, safety problems - impaired judgment - impaired time concepts

left brain damage

- paralyzed right side: hemiplegia - impaired speech/language aphasias - impaired right/left discrimination - slow performance, cautious - aware of deficits: depression, anxiety - impaired comprehension related to language, math

infection and diabetes

- patient is more susceptible to infections because of defect in mobilization of WBCs and impaired phagocytosis by neutrophils and monocytes - persistent glycosuria may predispose patients to bladder infections - decreased circulation resulting from angiopathy can prevent or delay immune system response - antibiotics prevent infection from being major cause of death > prompt and vigorous - patients must practice good hand hygiene, avoid exposure to people who have a communicable illness, get an annual flu and pneumococcal vaccine

diabetic foot care

- wash feet daily with mild soap and warm water. test water temp first with elbow - pat feet dry gently, especially between toes - examine feet daily for cuts, blisters, swelling, redness, tender areas. - use lanolin on feet to prevent skin from drying/cracking. do not apply between toes - use mild foot powder on sweaty feet - do not use commercial remedies to remove calluses or corns - cleanse cuts with warm water and mild soap, covering with clean dressing. do not use iodine, rubbing alcohol or strong adhesives - report skin infections or non-healing sores to HCP immediately - cute toenails evenly with rounded contour of toes. do not cut down corners. best time is after shower or bath - separate overlapping toes with cotton or lamb's wool - avoid open toe, open heel, and high heel shoes. leather should are preferred over plastic. wear slippers with soles. do not go barefoot. inspect feet, socks and shoes for foreign objects before putting on - wear clean, absorbent cotton or wool socks or stockings that have not been mended. colored socks must be colorfast - do not wear clothing that leaves impressions, hindering circulation - do not use hot water bottles or heating pads to warm feet. wear socks. - guard against frostbite - exercise feet daily by walking or flexing and extending feet in suspended position. avoid prolonged sitting, standing and crossing of legs

national institutes of health stroke scale (NIHSS)

15 item neurologic exam used to evaluate the effect of an acute stroke range from 0-42. WANT A LOW SCORE items - LOC - LOC questions - LOC commands - best gaze - visual - facial palsy - motor and drift - limb ataxia - sensory - best language - dysarthria - extinction or inattention - distal motor function

metabolic syndrome

5 components: increased glucose levels, abdominal obesity, high BP, high triglycerides, decreased HDLs diagnosis: need 3 of 5 components higher risk for CAD, heart disease, stroke, diabetes, renal disease, polycystic ovary syndrome s/s - impaired fasting blood glucose, hypertension, abnormal cholesterol levels, obesity reversal of diagnosis - maintain healthy diet, exercise, positive lifestyle changes

obesity health risks

CV: increased LDLs, high triglycerides, decreased HDLs, hypertension > increased circulating blood volume, abnormal vasoconstriction, increased inflammation metabolic: hyperinsulinemia and insulin resistance > excess weight decreases effectiveness of insulin. pancreatic cells become overworked and become worn out. respiratory: sleep apnea, hypoventilation syndrome. increased fat around diaphragm > reduced chest wall compliance, increased work of breathing, decreased total lung capacity. poor sleep > increased appetite, impair metabolism, disrupt hormone levels GI/liver problems: GERD and gallstones form. nonalcoholic steatohepatitis (NASH) where lipids are deposited in the liver > can cause cirrhosis musculoskeletal: increased osteoarthritis > stress on weight bearing joints. increased fat triggers inflammatory mediators and contributes to cartilage deterioration. hyperuricemia and gout are common. cancer: preventable cause of cancer. linked to thyroid, liver, kidney, colorectal, breast, endometrial and gallbladder

medication induced injury

NSAIDs inhibit prostaglandin synthesis, increase gastric secretions, reduce integrity of mucosal barrier corticosteriods affect mucosal cell renal and decrease its protective effects

core measures for stroke

STK-1: venous thromboembolism prophylaxis STK-2: discharged on anti-thrombotic therapy STK-3: anti-coagulation therapy for AFib STK-4: thrombolytic therapy STK-5: anti-thrombotic therapy by end of hospital day 2 STK-6: discharged on statin med STK-8: stroke education STK-10: assessed for rehab

GI emergency management

abdominal and GI findings - abdominal pain - abdominal rigidity - hematemesis - melena - nausea hypovolemic shock - decreased BP - decreased pulse pressure - tachycardia - cool, clammy skin - decreased LOC - decrease urine output (0.5 mL/kg/hr) - slow capillary refill interventions - if unresponsive, assess ABCs - if responsive, monitor ABCs - establish IV access with large bore catheter and start fluid replacement therapy. insert a second large bore catheter if shock present - give oxygen via nasal cannula or nonrebreather mask - initiate ECG monitoring - obtain blood for CBC, clotting studies and type/cross match - insert NG tube as needed - insert indwelling urinary catheter - give IV PPI therapy to decrease acid secretion - ongoing monitoring - monitor vital signs, LOC, oxygen saturation, ECG, bowel sounds, I&O - assess amount and character of emesis - keep patient NPO - provide reassurance and emotional support to patient/caregiver

sleeve gastrectomy (gastric sleeve)

about 75% of stomach is removed. creation of sleeve shaped stomach with 60-150 mL capacity advantages - function of stomach preserved, no bypass of intestine, avoids complications of obstruction, anemia, vitamin deficiencies disadvantages - weight loss may be more limited than other types of surgery. leakage related to staples. irreversible.

dopamine receptor agonist

activates dopamine receptors in CNS. unknown how it it improves glucose levels

peptic ulcer disease

acute: associated with superficial erosion and minimal inflammation. short duration. resolves quickly when cause is identified and removed chronic: eroding through muscular wall with formation of fibrous tissue. long duration. present continuously for months or intermittently for a life time. more common. patho: normally protected by normotension > increased mucosal blood flow dilutes, removes and buffers H+ > normal tissue oxygenation and pH > disrupted - acid back diffusion: normotension > inadequate increase of mucosal blood flow > anoxia & acidosis > injury - shock > decreases mucosal blood flow > increases tissue anoxia and acidosis > severe injury complications - hemorrhage: upper GI bleeding, more common with duodenal. >nursing care: change in vital signs, increase in amount of redness of aspirate. pain decreases > blood neutralizes the acidic gastric contents - perforation: highest risk with large penetrating duodenal. ulcer penetrates the serosal surface with spillage of gastric or duodenal contents into peritoneal cavity > nursing care: take vital sings promptly, record every 15-30 min. temporarily stop all oral or NG meds/feedings. sudden severe pain in upper abdomen, spreading to back/neck. nausea/vomiting - gastric outlet obstruction: results in edema, inflammation, pylorospasm, fibrous scar tissue formation. belching/vomiting helps. can have constipation > nursing care: measure gastric residual volume > clamp NG tube intermittently. under 200 mL overnight clamp is normal. may see edema and inflammation treatment - conservative: adequate rest, dietary modifications, drug therapy, elimination of smoking and long-term follow up - acute care: NPO or NG tube connected to intermittent suction - IV fluid replacement - regular mouth care > dry mouth - cleaning/lubricating nares > facilitate breaking/decrease soreness - physical/emotional rest is helpful

adjustable gastric banding (ABG)

aka lap-band, realize band inflatable band encircles stomach. creation of gastric pouch with about 30 mL (1 oz) capacity. later stretches to 60-90 mL. upper gastric pouch connected by very narrow channel to lower section of stomach advantages - food digestion occurs through normal process. band can be adjusted to increase or decrease restriction. can be reversed. absence of dumping syndrome. lack of malabsorption. low complication rate. disadvantages - some nausea/vomiting initially (due to eating too much too quickly). food intolerance, gastric dysmotility, regurgitation. problems with adjustment device. band may slip or erode into stomach wall. gastric perforation or obstruction may occur requiring surgery. weight loss may be more limited than with other types of surgery

body shape & health risks

android (apple) - characteristics: fat primarily in abdominal area. fat also distributed over upper body (neck, arms, shoulders). greater risk for obesity related complications - health risks: heart disease, diabetes, breast cancer, endometrial cancer, visceral fat more active, causing decreased insulin sensitivity, increased triglycerides, decreased HDL cholesterol, increased BP, increased free fatty acid released into blood gynoid (pear) - characteristics: fat mainly in the upper legs, has better prognosis but hard to treat - health risks: osteoporosis, varicose veins, cellulite, subcutaneous fat traps and stores dietary fat. trapped fatty acids stored as triglycerides

bupropion/naltrexone

antidepressant opioid antagonist side effects: nausea, constipation, headache, dizziness, insomnia, dry mouth, suicidal thoughts/behaviors, can increase BP and HR. can cause seizures. should not be used with patients who have uncontrolled hypertension or seizure disorders.

upper GI bleeding

arterial source bleeding: profuse, bright red bright red: has not been in contact with gastric HCl acid secretions coffee ground emesis: blood has been in stomach for some time obvious: blood is apparent. bright red, coffee ground emesis, black tarry stools occult: blood is not apparent. there are small amounts in vomit, gastric secretion, feces. detectable by guaiac test

dipeptidyl peptidase-4 inhibitors (DPP-4)

augments naturally occurring intestinal incretin hormones. promotes release of insulin and decreased secretion of glucagon, decreases fasting and postprandial glucose levels side effects: pancreatitis, allergic reaction nursing care: take only when blood sugar is rising (only effective) ex: alogliptin, linagliptin, saxagliptin, sitagliptin

helicobacter pylori

bacteria colonize the gastric epithelial cells within mucosa layer > bacteria makes urease > metabolizes urea producing ammonium chloride and other damaging chemicals. urease activates immune response with antibody production and inflammatory cytokines > increase gastric secretions > tissue damage

orlistat

block fat breakdown and absorption in intestine. inhibits action of intestinal lipases, resulting in undigested fat excreted feces. side effects: stool leakage, flatulence, diarrhea, abdominal bloating, especially if high-fat diet is consumed. severe liver injury. may need fat-soluble vitamin supplements.

sodium-glucose cotransporter 2 (SGLT2) inhibitors

blocks re-absorption of glucose by kidneys. increased urinary glucose excretion. side effects: increase risk for genital infections and UTIs, hypoglycemia nursing care: take before first meal of day ex: canagliflozin, dapagliflozin, empagliflozin, ertugliflozin

inhaled insulin

brand: afrezza onset: 12-15 minutes peak: 1 hr duration: 2.5-3 hrs

intermediate acting insulin

brands: NPH (Humulin N, Novolin N) onset: 1.5-4 hrs peak: 4-12 hrs duration: 12-18 hrs

long acting insulin

brands: glargine (lantus), detemir (levemir), degludec (tresiba) onset: 0.8-4 hrs peak: less defined/no pronounced peak duration: 16-24 hrs

rapid acting insulin

brands: lispro (humalog), aspart (novolog), glulisine (apidra) onset: 10-30 mins peak: 30 mins-3 hrs duration: 3-5 hrs

short acting insulin

brands: regular (Humulin R, Novolin R) onset: 30 mins-1 hr peak: 2-5 hrs duration: 5-8 hrs

bariatric surgical therapy

criteria - BMI > 40 - BMI > 35 with other significant comorbidities like hypertension, type 2 diabetes, heart failure, sleep apnea restrictive - reduces the size of the stomach > patient feels full more quickly or reduces amount allowed to enter stomach - malabsorptive > bypasses part of small intestine therefore nutrients and calories do not get absorbed into the body in the same way

diabetes nutrition

carbs: monitor carb counting - includes those from fruits, vegetables, grains, legumes, low-fat milk. fiber intake 25-30 g/day. protein: individualize goals. high protein diets not recommended for weight loss fat: individual goals. minimize trans fats. dietary cholesterol <200 mg/day. >2 servings of fish per week alcohol: limit to moderate amount ( max 1/day for women, 2/day for men). consume with food to reduce risk for nocturnal hypoglycemia. carbs taken with alcohol may raise blood glucose

bariatric surgery post-operative care

cardiopulmonary complications, thrombus formation, anastomosis leaks, electrolyte imbalance transfer from surgery may require many stiff members > keep head 45 degrees to reduce abdominal pressure and increase lung expansion diligently turn and ambulate VTE hypoxemia, pulmonary hypertension, polycythemia wound infection, dehiscence, delayed healing

hyperglycemia

cause - illness, infection, corticosteriods, too much food, too little or no diabetes med, inactivity, emotional, physical stress, poor absorption of insulin manifestations: more gradual onset, elevated blood glucose, increase in urination, increase in appetite followed by lack of, weakness, fatigue, blurred vision, headache, glycosuria, nausea/vomiting, abdominal cramps, progression to DKA or HHS, mood swings treatment - get medical care - continue diabetes meds as prescribed - check blood glucose frequently and check urine for ketones - drink fluids at least on an hourly basis - contact PCP about ketonuria prevent - take meds properly (dose and time) - make healthy food choices - follow sick-day rules when ill - check blood glucose routinely - carry/wear diabetes ID

diabetic ketoacidosis

caused by profound deficiency of insulin characterized by hyperglycemia, ketoacidosis, acidosis and dehydration. precipitating factors: illness, infection, inadequate insulin dosage, undiagnosed type 1, lack of education/understanding/resources, neglect most likely to occur in type 1

cerebral autoregulation

changes in diameter of cerebral blood vessels in response to changes in pressure so that the blood flow to the brain stays constant. changes in response to arterial carbon dioxide

diabetes mellitus

chronic multi-system disease characterized by hyperglycemia from abnormal insulin production, impaired insulin use or both 7th leading cause of death in US heart disease death rates and risk for strokes are 2-4 times higher. also comorbidities of hypertension and high cholesterol levels are common.

gastroesophageal reflux disease (GERD)

chronic symptom of mucosal damage caused by reflux of stomach acid into lower esophagus. not a disease, syndrome acidic gastric secretions causes esophageal irritation and inflammation s/s - pyrosis/heartburn: burning, tight sensation felt intermittently beneath the lower sternum and spreading upward toward the throat - dyspepsia/regurgitation: pain or discomfort centered in the upper abdomen mainly around midline. hot, bitter, sour liquid coming up the throat sometimes into the mouth evaluation - occurs more than 2/week, severe, associated with dysphagia or occurs at night and wakes person from sleep, older adults complications - esophagitis leading to esophageal ulcers and increased risk of cancer - barrett's esophagus: esophageal metaplasia > reversible change from one cell type to another due to abnormal stimulus - respiratory: cough, bronchospasm, laryngospasm, cricopharyngeal spasm > due to gastric secretions irritating upper airway, asthma, chronic bronchitis, pneumonia - dental erosion diagnostic - endoscopy, biopsy, cytologic specimens, manometric studies, radionuclide test, ambulatory esophageal pH monitoring

hypoglycemic unawareness

condition in which a person does not have the warning signs and symptoms until reaches a critical point > incoherent, combative, or lose consciousness. at risk are those with repeated episodes of hypoglycemia, older adults, or who use beta-adrenergic blockers

GERD treatments

conservative therapy: lifestyle modifications, nutritional therapy, drug therapy HCl acid suppression (antacids): reduce acidity of gastric refluxate PPIs: effective in healing esophagitis, decrease incidence of esophageal strictures - long term use: decreased bone density, kidney disease, vitamin b12 and magnesium deficiencies, increased risk for dementia - dexilant, nexium, prevacid, priolsec, zegerid, protonix, aciphex H2 receptor blockers: reduce symptoms and promote esophageal healing in 50% of patients. decrease HCL acid secretion, decrease conversion pepsinogen to pepsin - Pepcid, Axid, Zantac antiulcer drugs: act to form a protective layer and serve as a barrier against acid, bile salts, enzymes in stomach - carafate

special considerations for bariatric surgery

considerable abdominal pain after > could be from anastomosis leak avoid gulping wound > drainage type, incision, condition, signs of infection monitor vital signs give room temp water and low-sugar clear liquids > 15 mL every 10-15 min. gradually increase. goal is 90 mL every 30 min by day post-op day 1 low fat, full liquid diet on day 3

angiopathy

damage of blood vessels. accumulation of damaging by-products of glucose metabolism (associated with nerve damage), formation of abnormal glucose molecules in basement membrane of small blood vessels or derangement in RBC function that leads to decreased oxygenation to tissues considered chronic complication.

alpha-glucosidase inhibitors

decreased carb absorption in intestines, decreased post-meal hyperglycemia side effects: gas, abdominal pain, diarrhea nursing care: take with first bite of each meal ex: acarbose, miglitol

thiazolidinediones

decreased production of glucose by liver, increased tissue sensitivity to insulin side effects: weight gain, edema. pioglitazone: may increase risk for bladder cancer and worsen heart failure. rosiglitazone: may increase risk for CV events ex: pioglitazone, rosiglitazone

incretin mimetic/glucagon-like peptide 1 (GLP-1) receptor agonists

decreases glucagon secretion, promoting insulin release and gastric emptying, decrease insulin demand by decreasing fasting and postprandial hyperglycemia. noninsulin injectable agents side effects: nausea, vomiting, hypoglycemia, diarrhea, headache nursing care: DO NOT administer AFTER meal, administer exenatide subcutaneously 60 minutes before morning and evening meal. oral meds should never be taken within 1 hour of oral exenatide or 2 hours after an injection of exenatide ex: albiglutide, dulaglutide, exenatide, liraglutide, lixisenatide, semaglutide

dumping syndrome

direct result of surgical removal of a large part of the stomach and pyloric sphincter > stomach no longer has control over amount of gastric chyme. large bolus of hypertonic fluid enters intestine causing fluid to be drawn into bowel lumen which decreases plasma volume, distends bowel lumen, rapid intestinal transition most at risk immediate after surgery and a couple months later **fluid shift: hypertonic food pulls water into the intestine from the body (vascular/organs) diet: lower in hypertonic carbs. do not eliminate completely causes hypoglycemia s/s - symptoms begin 15-30 min after eating - feelings of generalized weakness - sweating - palpations - dizziness - abdominal cramps - bowel sounds - urge to defecate - diarrhea can be deadly!

waist to hip ratio

distribution of subcutaneous and visceral adipose tissue 0.8 is best, >0.8 means more truncal fat waist should be smaller than hips waist ----- hip

obesity drug therapy

drugs should never be used alone adults with BMI >30 or >27 with at least 1 weight related condition like hypertension, type 2 diabetes, dislipidemia

stress, acute illness, surgery and diabetes

emotional/physical stress can increase blood glucose levels and result in hyperglycemia: need extra insulin, more frequent blood glucose monitoring (every 4 hours) food intake is important. increase in noncaloric fluids like water, sugar free gelatin, decaffeinated beverages with normal diet. abnormal diet: supplement with carbs-containing fluids like low sodium soup, regular sweetened decaf soft drinks

diabetes diagnostic studies

fasting glucose: no caloric intake for at least 8 hours. must repeat test to make sure not a lab error. diagnosed: 126 mg/dL or greater random plasma glucose: classic symptoms of hyperglycemic crisis or clear symptoms with level of 200 mg/dL or higher. no repeat test needed oral glucose tolerance test (ogtt): 2 hour plasma glucose level. usually used for diagnosis of gestational diabetes, not routine diagnosis. diagnosed: 200 mg/dL or higher with glucose load of 75g > process: fasting glucose drawn at beginning, consume certain amount, then levels obtained every 30 minutes for 2 hours > results: fasting = less than 110, at 1 hour = less than 180, at 2 hours = less than 140 hemoglobin A1C: aka glycosylated hemoglobin (HbA1c), best indicator of average blood glucose level for past 120 days. diagnosed: greater than 6.5%

insulin counter-regulatory hormones

glucagon, epinephrine, growth hormone, cortisol increase blood glucose levels by stimulating glucose production and release by the liver and decreasing movement of glucose into cells

diabetes nursing care

goals - reduce symptoms - promote well being - prevent acute complications related to hyper or hypoglycemia - prevent or delay onset of progression of long-term complications - follow up programs - teaching patient about nutrition therapy, exercise therapy and self-monitoring assessment - history and physical exam - blood tests - urine complete urinalysis, albuminuria, acetone - BP - ECG - funduscopic examination (dilated eye) - dental exam - neurologic exam, including monofilament test for sensation of lower extremities - ankle-brachial index - foot exam - monitoring weight

amylin mimetic

suppresses glucagon secretion and controls postprandial blood glucose levels. used in patients who are taking insulin for more effective glucose control noninsulin injectable agent side effects: hypoglycemia, nausea, vomiting, decreased appetite, headache nursing care: administer subcutaneous immediately before each major meal

potential problems with insulin

hypoglycemia allergic reactions: self-limiting within 1-3 months, may improve with low dose antihistamine lipodystrophy/hypertrophy: loss of subcutaneous fatty tissue > occur if same injection sites are used frequently. develop thickened subcutaneous tissue. treatment: do not use site for 6 months somogyi effect: hyperglycemia in morning. treatment: check blood glucose at 2-4 am. eat bedtime snack. reduce dose of insulin. dawn phenomenon: hyperglycemia that is present or awakening. treatment: increase insulin dose or adjust administration time

prediabetes

impaired glucose tolerance, impaired fasting glucose or both intermediate stage between normal glucose homeostasis and diabetes > glucose levels are elevated but not high enough for diagnosis criteria increased risk for developing type 2 usually no symptoms, can cause long-term damage to heart and blood vessels can take action to prevent or delay development

obesity

increase in number of adipocytes (hyperplasia) and increase in their size (hypertrophy) primary: excess calorie intake over energy expenditure for body's metabolic demand secondary: results from various congenital or chromosomal anomalies, metabolic syndrome, CNS lesions/disorders and drugs involves genetic/biologic factors that are influenced by environmental and psychosocial factors

waist circumference

indicates where you store your weight. around waist increases CV risk men: >40 inches women: >35 inches

liraglutide

induces satiety. used to treat type 2 diabetes. injected. side effects: thyroid tumors, pancreatitis

organs store vs require glucose

insulin dependent: skeletal muscle & adipose tissue need for adequate function, but not directly dependent: brain, liver, blood cells store excess glucose as glycogen: liver & muscle cells

normal insulin metabolism

insulin: beta cells in islets of langerhans of pancreas > hormone continuously released into bloodstream in small amounts, increased with food ingestion lowers blood glucose & stabilizes at 74-106 mg/dL promotes glucose transport from bloodstream across cell membrane to cytoplasm > glucose > energy anabolic or storage hormone: after a meal inhibits gluconeogenesis and enhances fat deposition of adipose tissue and increases protein synthesis synthesized from proinsulin

hemorrhagic stroke

intracerebral: bleeding within the brain caused by a ruptured vessel (basal ganglia), hypertension is most important/common cause - s/s: neurologic deficits, headache, nausea, vomiting, decreased LOC, hypertension subarachnoid: intracranial bleeding into cerebrospinal fluid-filled space between the arachnoid and pia mater membranes on the surface of the brain - risk increases with age. more common in women. - silent killer because people usually don't have warning signs or symptoms until aneurysm ruptures - s/s: leaking of aneurysm, LOC, focal neurological deficits (cranial nerve deficits), nausea, vomiting, seizures, stiff neck

tight or intensive therapy

keeping blood glucose levels as near to normal as possible for as much of the time as possible type 1 benefits: reduced risk for developing retinopathy, neuropathy and common microvascular complications type 2 benefits: lowered risk for diabetes-related eye, kidney and neurologic problems. 25% reduction of microvascular disease and 16% for MI

hyperosmolar hyperglycemic syndrome

life threatening syndrome that can occur with diabetes patient who is able to make enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, ECF depletion less common than DKA occurs in patients over 60 y/o with type 2 causes: UTIs, pneumonia, sepsis, any acute illness, newly diagnosed type 2 often related to impaired thirst sensation and/or functional inability to replace fluids

type 1 diabetes

patho: autoimmune disorder in which body develops antibodies against insulin and/or the pancreatic beta cells that make insulin onset: rapid; islet cells auto-antibodies responsible for beta-cell destruction are present for months to years before onset of s/s. classic symptoms: polydipsia (excessive thirst), polyuria (excessive urination), polyphagia (excessive hunger) s/s - rapid, first s/s acute - ketoacidosis honeymoon period: newly diagnosed patients may have remission for 3-12 months after starting treatment. needs little injected insulin because beta-cell production still sufficient

phentermine/topiramate

sympathomimetic, decreases appetite side effects: dizziness, insomnia, dry mouth. must avoid pregnancy. can increase HR. do not use in patients with glaucoma or hyperthyroidism.

hypoglycemia

low blood glucose that occurs when there is too much insulin compared to available glucose in the body causes - alcohol intake without food - too little food - delayed, omitted, inadequate intake - too much diabetes meds - too much exercise without adequate food intake - diabetes med or food taken at wrong time - loss of weight without change in med - use of beta-adrenergic blockers interfering with recognition of symptoms manifestations - rapid onset, pattern of manifestations changes over time - blood glucose is <70 mg/dL - cold, clammy skin - numbness of fingers, toes, mouth - tachycardia - emotional changes - headache - nervousness, tremors - faintness, dizziness - unsteady gait, slurred speech - hunger - changes in vision - seizures, coma treatment - check blood glucose - determine cause of - with conscious patient: eat or drink 15 g of quick acting carbs (4-6 oz of regular soda, 5-8 lifesavers candy, 1 tbsp syrup or honey, 4 tsp jelly, 4-6 oz OJ, commercial dextrose products per label instructions). wait 15 min. check blood glucose again. if still below 70 mg/dL, repeat treatment of 15 g carbs. - once stable, give additional food of carbs plus protein or fat (crackers with peanut butter or cheese), if next meal is more than 1 hour away or is engaged in physical activity - notify PCP or emergency service if symptoms do not subside after 2-3 doses of quick-acting carbs - with worsening symptoms or unconscious patient: subcut or IM injection of 1 mg glucagon or IV admin of 20-50 mL of 50% glucose - turn patient to side to prevent aspiration

roux-en-y gastric bypass

most common pouch is created to connect stomach and jejunum. remaining stomach and first segment of small intestine are bypassed. advantages - lower incidence of malnutrition/diarrhea. better weight loss than restrictive procedures. rapid improvement with weight-related comorbidities. good long-term results disadvantages - irreversible procedure. can cause anemia, calcium deficiency, folic acid deficiency. dumping syndrome. leak at anastomosis.

body mass index (BMI)

most common measurement of obesity weight (lbs) x 703 -------------------- height squared (inches) underweight: > 18.5 normal: 18.5-24.9 overweight: 25-29.9 obese: > 30 morbidly obese: > 40

stroke manifestations

motor function impairment of mobility, respiratory function, swallowing, speech, gag reflex, self care abilities motor deficits: akinesia (loss of skilled voluntary movements), impaired integration of movements, changes in muscle tone, altered reflexes communication: - nonfluent: minimal speech activity with slow speech that requires effort - fluent: speech is present but has little meaningful communication - global aphasia: total inability to communicate - dysarthria: problem with the muscular control of speech affect: hard time controlling their emotions > exaggerated or unpredictable responses > depression, frustration intellectual function: impair memory and judgement. left side > memory problems related to language. right side > tend to be impulsive and move quickly. spatial-perceptual problems - erroneous perception of self in space, also trouble with judging distances - agnosia: inability to recognize an object by site, touch hearing - apraxia: inability to carry out learned sequential movements on command elimination - constipation often occurs > immobility, weak abdominal muscles, dehydration, decreased response to defecation reflex, can be due to in ability to communicate need

assessing patient treated with glucose-lowering agents

newly diagnosed or re-evaluation of plan - affective: what emotions/attitudes are displaying - cognitive: able to understand why insulin or OAs are needed. understand concepts of asepsis, combining insulin, side effects of meds. remember to take more than 1 dose/day. takes meds at right times in relation to meals - psychomotor: physically able to prepare and accurately give doses follow up - effectiveness: hyperglycemia. record show blood glucose levels in or out of target range. is A1C in healthy range - self-management behaviors: having hyperglycemia or hypoglycemia, how are episodes managed. determined reason for hypo or hyper. how much insulin or OA is patient taking and what time. adjusting insulin dose? why and by how much? exercise pattern changed? making healthy food choices? meals taken at times corresponding to peak insulin action? - side effects: atrophy or hypertrophy at injection sites. hypoglycemia - how often, time, symptoms, nightmares, night sweats, early am headache. skin rash or upset GI. gained or lost weight.

stroke diagnostic tools

non-contrast head CT or MRI

NG care

observe gastric aspirate for color, amount, odor observe tube closely because blood easily clots and clogs tubes

insulin regimen

once a day/single dose: intermediate at bedtime. should provide nighttime coverage OR long acting in AM or bedtime. does not cover postprandial blood glucose levels twice a day/split-mixed dose: intermediate and regular OR rapid before breakfast and at dinner. with both, patient must eat at certain times to avoid hypoglycemia three times a day/combination of mixed and single: intermediate and regular or rapid before breakfast + regular or rapid before dinner + intermediate at bedtime. decreased potential for 2-3 AM hypoglycemia basal bolus/multiple dose: regular or rapid before breakfast, lunch and dinner + long acting once or twice a day OR regular and rapid before breakfast lunch and dinner + intermediate twice a day. more flexibility is allowed at meal times and for amount of food intake

stroke

patho: if blood flow to brain is totally interrupted, neurologic metabolism is altered in 30 seconds, metabolism stops in 2 minutes, cellular death occurs in 5 minutes increased ICP causes brain compression and reduced cerebral blood flow. non-modifiable risk factors: gender, age, ethnicity/race, family history modifiable risk factors: hypertension, heart disease, diabetes, smoking, obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet, drug/alcohol use nursing care: goal is to reduce secondary injury related to ICP

type 2 diabetes

patho: not enough insulin being produced or body isn't able to use it effectively (insulin resistance) or both metabolic abnormalities - insulin resistance - marked decrease in ability of pancreas to make insulin - inappropriate glucose production by the liver - altered production of hormones and cytokines by adipose tissue s/s - nonspecific - polyuria, polydipsia, polyphagia - fatigue - recurrent infections, vaginal yest/candida infections - vision problems - prolonged wound healing

hiatal hernia

protrusion of a part of the stomach upward through the opening in the diaphragm

biguanides

reduces production of glucose by liver, increase tissue sensitivity to insulin, decreased carb absorption in intestine first line treatment side effects: diarrhea, lactic acidosis nursing care: take with food, take B12 and folic acid supplements. must be held 1-2 days before IV contract media given and for 48 hrs after ex: metformin

microvascular

result from thickening of vessel membranes in capillaries and arterioles in response to chronic hyperglycemia. most noticeably affect the eyes, kidneys and nerves complications - women with diabetes have a 4-6 times increased risk for CVD - men with diabetes have a 2-3 times increased risk for CVD decrease risks by treating obesity, smoking, hypertension, high fat intake and sedentary lifestyle

ischemic stroke

results from inadequate blood flow to the brain from partial or complete occlusion of an artery thrombotic stroke - episodes of ischemia that leads to infarction evolves over period of several hours to days - injury to blood vessel wall and formulation of blood clot - TIA precedes this - extent of stroke depends on rapidity of onset, size of damaged area, presence of collateral circulation embolic stroke - sudden ischemia that leads to infarction - when an embolus lodges in and occludes a cerebral artery resulting in infarction and edema of the area supplied by the involved vessel - recurrence is common because symptoms are rapid and usually there is some improvement

long term complications

retinopathy > annually - funduscopic: dilated eye exam, fundus photography nephropathy > annually - urine for albuminuria, serum creatinine neuropathy (foot and lower extremities) - visual exam of feet > daily by patient/every HCP visit - comprehensive foot exam > annually - visual exam - sensory exam with monofilament and tuning fork - palpation (pulses, temp, callus formation) cardiovascular disease - risk factor assessment: hypertension, dysplipidemia, smoking, family history of premature CAD, presence of albuminuria > every visit, at least annually - exercise stress testing > as needed based on risk factors sexual dysfunction

ABCD2

risk factors - age > 60 = 1 - systolic BP >140 or diastolic >90 = 1 - clinical features of TIA > unilateral weakness with/without speech impairment = 2 OR speech impairment without unilateral weakness = 1 - duration >60 min = 2 OR duration 10-59 min = 1 - diabetes = 1 score 0-7 - 0-3: hospitalization not needed unless there is another indication - 4-5: hospitalization in most situations - 6-7: hospitalization

transient ischemic attack (TIA)

short episode of ischemia but no infarction symptoms last less than 1 hour warning because they are small/tiny embolisms blocking the blood flow. meaning larger ones can form

expected gastric aspirate issues

small volume of bloody drainage for first 2-3 hours > bleeding at anastomosis site is common should darken within 24 hours of surgery color changes to yellow-green within 36-48 hours

meglitinides

stimulate insulin release from pancreas, administered for post-meal hyperglycemia side effects: weight gain, hypoglycemia nursing care: take 30 min before meal ex: nateglinide, repaglinide

second generation sulfonylureas

stimulate insulin release from pancreas. decrease in blood sugar levels, increase tissue sensitivity insulin (long-term use) side effects: weight gain, hypoglycemia nursing care: take 30 minutes before meals ex: glimepiride, glipizide, glyburide

lorcaserin

suppresses appetite and creates a sense of satiety side effects: headache, dizziness, fatigue, nausea, dry mouth, constipation

drug therapy

type 1: require exogenous insulin to survive > multiple injections daily (4 or more) or continuous insulin infusion via insulin pump type 2: progressive needs; combination of nutrition, exercise, oral antidiabetics and noninsulin injectables at some point may not manage levels, therefore may need exogenous insulin during severe stress (illness/surgery)

tissue plasminogen activator (tPA)

used to produce localized fibrinolysis by binding to the fibrin the thrombi, aka breaks down clot timing is most important - MUST BE GIVEN 3-4 HOURS OF ONSET OF SYMPTOMS

postprandial hypoglycemia

variant of dumping syndrome result in uncontrolled gastric emptying of bolus of fluid high in carbs into small intestine which results in hyperglycemia. then release excess amounts of insulin into circulation resulting in reflex hypoglycemia. s/s - sweating - weakness - mental confusion - palpitations - tachycardia - anxiety - occur 2 hours after eating

collateral circulation

vessels in brain make an alternative route for blood flow to reach damaged areas. can develop over time to compensate for a decrease in CBF

lower esophageal sphincter (LES)

when doesn't function properly, allows the gastric contents from the stomach to enter the esophagus when lying down or with increased intra-abdominal pressure decrease factors - alcohol - chocolate - drugs > anticholinergics, beta adrenergic blockers, calcium channel blockers, diazepam, morphine sulfate, nitrates, progesterone, theophyline - fatty foods - nicotine - peppermint, spearmint - tea, coffee (caffeine) increase factors - bethanechol - metoclopramide

asymptomatic diabetes screening

who: - all adults who are overweight (BMI >25) and have additional risk factors like first degree relative with, physically inactive, ethnic races - black, hispanic, native american, asian american, pacific islander, women who delivered baby weight >9 lbs or diagnosed with gestational diabetes, hypertensive or on meds for, HDL level >35 mg/dL and or triglyceride >250 mg/dL, women with polycystic ovary syndrome, A1C >5.7%, IGT or IFG on previous screening, other conditions associated with insulin resistance - in absence of criteria above, begin at 45 y/o - if results are normal, at least every 3 years