Exam 1 - Nursing 302
Diabetes diagnosis tests
Albumin, Ketones, protein, glucose in urine
Counts as 2 fat exchanges in diabetic diet
Alcohol
Phase 3 of CAD development
Complicated lesions - plaque rupture - thrombus formation - further narrowing or total occlusion of vessel
What should you do if someone pulls out their PEG tube?
Contact the physician as soon as possible- do not reinsert the tube. Complete an incident report
Do you round up or down with insulin admin?
Always down, even it you get 3.9 units, you round down to 3
Drug therapy for chronic stable angina
Antiplatelet - aspirin, plavix Antianginals - nitroglycerin, isosorbide Ace Inhibitors - prils Beta blockers - olol Calcium Channel Blockers - pines, verapamil, diltazem Lipid-lowering drugs
Insulin with onset of 10-30 minutes
Aspart
Treatment of visual disturbances in a diabetic
Assistive devices - Magnifier on insulin bottle - Coding objects (with rubber bands) - Fluorescent lighting above object - Large font Tx: - Laser (photocoagulation) - Vitrectomy
Caused by profound deficiency of insulin, characterized by hyperglycemia, ketosis, acidosis, and dehydration
DKA
Leading cause of blindness, end stage renal disease and lower extremity amputations
Diabetes
What is DKA?
Diabetic ketoacidosis Usually occurs in Type I diabetes Life threatening Characterized by: - Absolute deficiency of insulin and increase of counter regulatory hormones
Enteral feeding complications
Displaced tubes: - Radiography is primary and only reliable method of confirming placement Aspiration: - Reduce risk by verifying placement, checking residuals, assessing bowel function, and elevating HOB to 30º during feedings - Continuous feedings reduce risk Diarrhea: - Talk to provider about delivering formulas at slower rate, diluting the formula, or changing the formula type
What should you do if someone pulls out their J-tube?
Do not reinsert!, Call the physician it will need to be replaced by the physician in order to get it into the jejunum.
Which insulin regimen most closely mimics endogenous insulin production?
Basal-bolus regimine - Short acting or rapid acting before meals, and; - Intermediate or long acting once or twice a day
What produces insulin in the islet of Langerhans of the pancreas?
Beta cells
ventricular dilation
Enlargement of the chambers of the heart due to an elevated pressure over time (usually in the LV) - Initially leads to increased CO and maintenance of BP and perfusion - over time, CO decreased due to overstretching
Phase 1 of CAD development
Fatty Streaks - lipids accumulate and migrate into smooth muscle cells - can be seen in the coronary arteries by age 20 - treatment that lowers LDL may reverse this process
Phase 2 of CAD development
Fibrous Plaque - collagen covers the fatty streaks - vessel lumen is narrows - blood flow is reduced - fissures can develop - can appear in the coronary arteries by age 30 and increase with age
Symptoms include shakiness, palpations, nervousness, diaphoresis, anxiety, hunger, and irritability
Hypoglycemia
Types of enteral/parenteral feeding schedules
Intermittently: Gravity bolus feedings a specific times during the day Cyclically: Pump feedings done daily for a set time period (ex: 0900-1300) Continuously: Pump feedings continuously infusing nutrition
Why is Lantus given at bedtime?
Lantus is approved only for bedtime dosing. That's because the pre-approval studies were conducted only using bedtime dosing, therefore the FDA approved the drug that way. But from experience, patients can also use Lantus in the morning. Lantus is a "peakless" insulin. Sometimes, the provider will cut the dose in half and give half in the morning and half in the evening. When a patient is NPO the Lantus dose is typically cut in half but a provider's order is needed for this.
What may occur if the same injection site is used?
Lipodystrophy
What insulin contains protamine?
Lispro
What lab value must be checked periodically when taking lipid lowering medications?
Liver enzymes - aspartate - alanine - CRP (is rhabdo is present)
RAAS system
Low BP and fluid/electrolytes --> fluid and salt retention --> vasoconstriction --> increased BP - responsible for the signs and symptoms of HF - over time, leads to a systemic inflammatory response
SNS system
Low stroke volume and CO --> catecholamine release--> peripheral vasoconstriction, increased HR, and increased contractibility --> increased CO - over time, leads to increased workload, preload, and O2 requirement of heart
MIC KEY tube
Low-profile tube that allows nutrients, fluid, and medicine directly into the stomach, bypassing mouth and esophagus
Will patients with type 2 diabetes ever need insulin?
Most patients with type 2 diabetes will eventually need insulin to keep their diabetes in control. In general, the sooner insulin is started, the better off the patient will be in terms of preventing complications
Microvascular complication associated with damage to the small blood vessels that supply the glomeruli
Nephropathy
Nerve damage that occur because of metabolic derangements is called?
Neuropathy
Would you need to check tube feeding residuals for someone with a J tube? Why or why not?
No, a jejunal tube and the jejunum does not act as a reservoir to hold large tube feeding volumes.
If someone had routine oral medications ordered, would you give them via the jejunal tube? Why or why not?
No- the medications will not be absorbed the same in the jejunum as they would be if they were administered in the stomach.
What type of insulin is more likely to cause hypoglycemia?
Short acting
A type of insulin dependent cell and tissue
Skeletal and adipose
How should prefilled syringes be stored and for how long?
Syringe with 2 types of insulin: - Up to 1 week in refrigerator Syringe with 1 type of insulin: - Up to 30 days in refrigerator
Why do you return the residuals into the stomach during enteral feeding?
Want to return electrolytes and nutrients
For enteral feedings, what are three things the nurse can do to reduce the risk of aspiration?
a. If there is facial trauma, nasal polyps, or another facial issue, use G or J tube instead of NG tube b. Keep client in 30-45 degree position during and after feeding c. Check residuals to make sure it is a safe amount d. Confirm tube placement with x-ray to ensure tube is not in the lungs
What are three things that can be done to reduce incidence of diarrhea for enteral feedings?
a. Use a formula that includes soluble fiber or add it to an existing formula b. Reduce the rate of feeding, either from a pump or gravity feeding c. Make sure the formula is at room temperature when administering
Which statement would be correct for a patient with type 2 diabetes who was admitted to the hospital with pneumonia? a. The patient must receive insulin therapy to precent ketoacidosis. b. The patient has islet cell antibodies that have destroyed the pancreas's ability to produce insulin. c. The patient has minimal or absent endogenous insulin secretion and requires daily insulin injections. d. The patient may have sufficient endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemic syndrome.
d. The patient may have sufficient endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemic syndrome.
Which of the following is an appropriate order? a. Change tubing every 36-48 hours b. Crush an enteric-coated aspirin and administer via G tube c. Administer Effexor (venlafaxine) XR via G tube d. Use tap water for flushes e. Administer feeding even if bowel sounds are absent
d. Use tap water for flushes
What is HHS?
hyperosmolar hyperglycemic state More common in type two diabetics Characterized by: plasma osmolarity of 340 or greater, glucose of > 600, and altered LOC
How long can opened insulin vials and pens be stored at room temperature?
up to 4 weeks
Coronary Artery Disease
caused by the buildup of plaque resulting in arteries to become hardened and narrows due to chronic endothelial injury
Chronic stable angina
chest pain that occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms
Foot care for diabetics
- Do not smoke - Inspect feet daily - No bare feet - Trim toenails - Use lotion - Report non-healing breaks - Complete foot assessment with provider at least 4 times a year.
Indications for parenteral nutrition
1. Inadequate GI peristalsis resulting from bowel manipulation during surgery 2. Bowel obstruction 3. Prolonged bowel rest needed for pancreatitis, ileus, etc. 4. Several malnutrition, significant weight loss, and/or enteral therapy is not possible
Compensatory mechanisms of the overloaded heart
1. Neurohormonal response - renin-angiotensin-aldosterone system (RAAS) - Sympathetic nervous system 2. Ventricular dilation 3. ventricular hypertrophy
When you are preparing to administer a mixture of Regular insulin and NPH insulin, place the steps to properly mix the insulins in order
1. Place the appropriate amount if air in the NPH insulin vial.2. Place the appropriate amount of air in the Regular insulin vial 3. Withdraw the Regular insulin into the syringe 4. Withdraw the NPH insulin into the syringe
Short Acting Insulin
30-60 minutes 2-4 hours 6-8 hours
For adults, at or above what amount of residual contents should the nurse stop all actions and contact the provider?
500 ml
Indications for enteral nutrition
- Functional GI system - Client can't swallow from trauma - Decreased consciousness - Critical illness causing metabolic stress - Inappropriate sucking reflex
Nutritional guidelines for diabetic children
- Be aware of food portions - Provide 3 meals throughout the day + snacks - Do not use dietetic foods (unnecessary) - Urge child not to omit meals - Maintain positive outlook - Keep complex carbs available for exercise
When to check residuals for enteral feedings
- Before med/formula feeding for all tubes EXCEPT J TUBE - Push 20-30 ml of air into tube - Pull back until resistance - Return contents to stomach
What is the honeymoon period?
- Blood sugars normalize initially with first use of insulin for therapy - After about 2 months to 1 year, the islet cells fail again and more insulin is required --make your patients aware of this before initiating treatment
Dawn phenomenon effect
- Characterized by hyperglycemia that is present on awakening in the morning due to the release of counter regulatory hormones on the predawn hours - Suggested that cortisol and growth hormone may be factors causing this - Treatment for this is adjust the timing and increase insulin if necessary
Signs and symptoms of diabetes
- Frequent urination - Excessive thirst - Fatigue - Very dry skin - Sores that are slow to heal - More infections than usual - Tingling or numbness in the hands - Dehydration - Unexplained weight loss - Extreme hunger - Sudden vision change
Primary causes for HF
- Hypertension - CAD - Rheumatic heart disease - Congenital heart defects - Pulmonary hypertension - Cardiomyopathy - Hyperthyroidism - Valvular disorders - Myocarditis
What to do if patient has hypoglycemia with decreased LOC or is NPO?
- IV 50% dextrose or (if dextrose not available) - Glucagon
Care of family with individual experiencing Type 1 diabetes
- Prepare same meals for family as individual - Group education cooking classes - Assess individual educational needs considering lifestyle, attitude, goals, ethnic, home, background
Non-modifiable risk factors for CAD
- Increasing age - gender (men) - Ethnicity (white) - family history
Clinical manifestations of DKA
- Ketones in urine and plasma - Blood glucose > 250/300 - Osmolarity >340 - Decreased blood pH < 7.3 - HCO3 18 or less - LOC - Vomiting
Clinical manifestations of diabetes neuropathy
- Loss of sensation, pain, weakness Foot ulcer/deformities, amputations CV GI GU
Interventions to reduce hypertension
- Monitor BP regularly - Take prescribed BP drugs - Reduce salt intake - Stop tobacco - Control or reduce weight - Physical activity daily
Clinical manifestations of HHS
- Normal plasma ketones - Gradual onset - Life threatening - Infection is most common precipitating factor - Severe dehydration --> dry skin, extreme thirst, altered LOC - Hyperthermia - Motor and sensory impairment - Positive Babinski's sign and seizures
Causes of hypoglycemia in diabetics
- Too much insulin/oral agents - Deficient food intake/changes in absorption - Exercise - Alcohol - Older adults - Certain drugs may mask symptoms: Beta blockers
Exercise guidelines for diabetics
- Warm up and cool down periods - Low intensity aerobic best - walk, swim - 20 to 40 minutes performed 4 to 7 days/week - Keep logs to note progress - Before exercise; if glucose is ≤100, eat a CHO - Before exercise; if glucose is ≥ 250, delay exercise until ketones are gone; hydrate
What increase O2 demand in chronic stable angina patients?
- aortic stenosis - cardiomyopathy - dysrhythmias - left ventricular hypertrophy - tachycardia - anxiety - hypertension - hyperlipidemia - hyperthyroidism - physical exertion - substance abuse
What decreases O2 supply in chronic stable angina patients?
- coronary artery atherosclerosis - coronary artery spasm - coronary artery thrombosis - dysrhythmias - heart failure - valve disorder - anemia - asthma - COPD - hypovolemia - Hypoxia - pneumonia - substance abuse
Action of Niacin with CAD
- inhibits synthesis and secretion of VLDL and LDL - decreased LDL - decreases triglycerides - increases HDL
Interventions to reduce physical inactivity
- maintain at least 30 minutes of activity minimum 5 days/week - increase activities to a fitness level
Precipitating factors to chronic stable angina
- physical exertion - temperature extremes - strong emotions - tobacco use - consumption of heavy metal - sex - stimulants - circadian rhythm patterns
Interventions to reduce elevated serum lipids
- reduce total fat intake - reduce saturated fat intake - take prescribed lipid reducing drugs - adjust caloric intake to maintain or decrease weight - physical activity daily - increase complex carbs, fiber, and vegetable protein
Treatment strategy for chronic stable angina
- reduction of risk factors - anti platelet and lipid lowering drug therapy - nitrates, ACE, b-blockers, C+ channel blockers
Modifiable risk factors for CAD
- serum lipids - BP >140/90 - Diabetes - Tobacco use - Physical activity - Obesity
Intermediate Acting Insulin
1-2 hours 4-12 hours 4-24 hours
What interventions would you implement if someone begins to vomit and how would you prioritize them?
1. Clear the airway- may need to suction or reposition her 2. Place feeding on hold 3. Assess position of tube 4. Assess other signs of tube feeding intolerance. Prioritize the interventions by ABCs- protecting the airway should come first.
Rapid Acting Insulin
15-30 minutes 60-90 minutes 3 - 5 hours
Long Acting Insulin
2-4 hours No peak 24 hours
You are caring for a patient with newly diagnosed type 1 diabetes. What information is essential to include in your patient teaching before discharge from the hospital (Select all that apply)? A. Insulin administration. B. Elimination of sugar from diet. C. Need to reduce physical activity. D. Use of a portable blood glucose monitor. E. Hypoglycemia prevention, symptoms, and treatment.
A. Insulin administration. D. Use of a portable blood glucose monitor. E. Hypoglycemia prevention, symptoms, and treatment.
Pathophysiology of CAD
Chronic endothelial injury caused by: - hypertension - tobacco use - hyperlipidemia - hyperhomocysteinemia - diabetes - infection - toxins
What is the priority action for the nurse to take if the patient with type 2 diabetes complains of blurred vision and irritability? A. Call the physician. B. Administer insulin as ordered. C. Check the patient's blood glucose level. D. Assess for other neurologic symptoms.
C. Check the patient's blood glucose level.
patient with diabetes has a serum glucose level of 824 mg/dL (45 ng mmol/L) and is unresponsive. After assessing the patient, the nurse suspects diabetic ketoacidosis rather than hyperosmolar hyperglycemic syndrome based on the finding: A.Polyuria B. Severe dehydration. C. Rapid, deep respirations. D.Decreased serum potassium.
C. Rapid, deep respirations.
Which tissues require insulin to enable the movement of glucose into the tissue cells? (select all that apply) A. Liver B. Brain C. Adipose D. Blood cells E. Skeletal muscle
C.Adipose E.Skeletal muscle
Nutritional recommendations for diabetes patient
Carbs: - carbs from fruits and vegetables - Count carbs - 25-30 grams of fiber Protein: - High protein diet not recommended Fat: - Minimize trans fat - <200 mg/day of cholesterol - ≥2 servings of fish per week Alcohol: - 1 drink per day for women and 2 for men MAX - Consume alcohol with food - Moderate alcohol consumption has no effect on glucose or insulin concentration
Life threatening condition when the patient is able to produce enough insulin to prevent DKA, but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion
Hyperosmolar hyperglycemic syndrome
Initial plan for type 2 diabetes
Correct diet Exercise Stress reduction Weight loss as needed
Treatment of HHS and DKA
Correction of fluid and electrolyte imbalance and provide insulin to lower hyperglycemia - Need to correct K+ deficit before administering insulin Establish and maintain adequate ventilation Blood sugar goal is to reach below 250
A counter regulatory hormone that can increase blood glucose
Cortisol
Stimulates glucose production and release by the liver
Counter regulatory hormones
Characterized by hyperglycemia that is present on awakening
Dawn phenomenon
What does the treatment of chronic stable angina aim to do?
Decrease O2 demand Increase O2 availability
G-J tube
Gastrostomy-jejunostomy tube - Allows administration vent of stomach for air and drainage as well as gives an alternate way for feeding
Enteral nutrition
Giving nutrients into the gastro-intestinal tract through a feeding tube - Lower risk of infection and easier for body to handle in comparison to parenteral - CLEAN procedure - Insertion sites: nasal, oral, gastric, or jejunal - Exit sites: gastric or jejunal
Parenteral nutrition (TPN)
Giving nutrients through a catheter inserted into a vein - Used when GI tract is not functioning properly - STERILE procedure
What should never be mixed with another insulin?
Glargine
The liver and muscle cells store this excess glucose as:
Glycogen
ventricular hypertrophy
Increase in the muscle mass and heart wall thickness in response to overwork and strain - initially, increases contractile power, leading to increased CO and tissue perfusion - over time, has poor contractibility, requires more O2 to perform work, has poor coronary artery circulation, and is prone to dysrhythmias
What is an anabolic, or store type of hormone?
Insulin
Enteral feeding locations
Orogastric Nasogastric (NG) Nasojejunal (NJ) Gastrostomy (Gastric) (G) Jejunostomy (J) Gastro-jejunal (GJ)
G/PEG tube
Percutaneous Endoscopic Gastrostomy tube - Allows nutrients, fluid, and medicine directly into the stomach, bypassing mouth and esophagus
Means excessive thirst
Polydipsia
The 3 Ps of diabetes
Polydipsia (excessive thirst) Polyuria (Frequent urination) Polyphagia (excessive hunger)
Classic symptom of hyperglycemia crisis
Polyuria
What is the genetic link?
Predisposition to type 1 diabetes which is related to the leukocyte antigen
Somogyi effect
Rebound effect in which an overdose of insulin causes hypoglycemia - Occurs during sleep - Headache and nightmares - Counteregulatory hormones are released and produce a rebound hyperglycemia Tx: - administer less insulin before bed
What type of insulin has an onset of 30 min to 1 hour and duration of 5-8 hours?
Regular
What should you do if someone pulls their NG tube out?
Replace it and obtain an abdominal xray to verify placement. A physician's order is not needed
Microvascular damage to retina is called:
Retinopathy
How do you verify that an NG tube is in the stomach?
Reviewed x-ray and verified that the measurement on the tubing at the nare was unchanged.
What temperature should you administer enteral nutrition at?
Room temperature
How should you rotate injection sites in children?
Rotate after each injection to prevent lipodystrophy - After ^ occurs, insulin doesn't absorb well from the injection site
Causes of non-compliance in diabetics
Sometimes lack of knowledge, lack of power: Role of nurse to empower - Peer pressure - Lack of motivation - unaware of consequences - Poor family history of previous members - Inadequate finances - Unfamiliar with health care system - Lack of advocate - History of obesity
Meds most commonly prescribed for lipid lowering
Statins - blocks cholesterol synthesis and increase LDL receptors in liver - Decrease LDL - decrease triglycerides - increase HDL
What should you do if you try to flush the J tube and you are unable to flush it?
Use a little more force, try to push and pull on the syringe. If this doesn't work, we can call the physician and get an order to administer crushed meds such as pancrealipase (which is a synthetic pancreatic enzyme) into the tube and then wait 30 minutes to see if the clog in the tube clears.
What to do if patient has hypoglycemia and is awake and alert?
Treat with 1 CHO (glucose 50-70) or Treat with 2 CHO (glucose <50)
Clinical manifestation of diabetes
Type 1 - Polyuria - Polydipsia - Polyphagia - Ketoacidosis Type 2 - Polyuria - Polydipsia - Polyphagia - Fatigue - Recurrent infection - Recurrent vaginal infection - Prolonged wound healing - Visual disturbances
What are the major differences between the 2 types of diabetes? Type of onset? Islet cells? Endogenous insulin?
Type 1 Pathophysiology: Genetic via human leukocyte antigens Onset: Symptoms abrupt Islet cells: antibodies present at onset Endogenous insulin: Absent Type 2 Pathophysiology: Insulin resistance and inadequate production Onset: May go undiagnosed for years Islet cells: antibodies absent Endogenous insulin: Initially increased in response to insulin resistance. Secretion diminishes over time
What are the 'rounding rules' for insulin administration?
When preparing insulin, only round at the end of the calculation and always round down to prevent giving too much insulin to a patient.
Is hyperglycemia life threatening?
Yes
What assessments would you use to determine if the tube feeding rate should be increased
You would advance the tube feeding rate if there was an absence of nausea, vomiting, abdominal pain, and distention. You would also advance the rate if bowel sounds were present.
Enteral feeding steps
a. Check medications for appropriate route, time, and dosage b. Listen to bowel sounds and Elevate HOB to 30º c. Confirm tube placement (measurement and xray) d. Check residuals e. Return residuals to stomach f. 30 ml flush g. Administer medication with 5 ml between meds h. 5 ml flush between meds and bolus i. Perform bolus feeding j. 30 ml flush
Polydipsia and Polyuria related to diabetes mellitus are primarily due to a. The release of ketones from cells during fat metabolism. b. Fluid shifts resulting from the osmotic effect of hyperglycemia. c. Damage to the kidneys from exposure to high levels of glucose. d. Changes in RBCs resulting from attachment of excessive glucose to hemoglobin.
b. Fluid shifts resulting from the osmotic effect of hyperglycemia.
What should the goals of nutrition therapy for the patient with type 2 diabetes include? a. Ideal body weight b. Normal serum glucose and lipid levels c. A special diabetic diet using dietetic foods d. Five small meals per day with a bedtime snack
b. Normal serum glucose and lipid levels