Clinical Pharmacology: Exam 3

What hormones does the pancreas secrete, and what is their effect?

Insulin: reduces blood glucose levels Glucagon: increases blood glucose levels

What meds can be taken for an ulcer?

Mucosal protectant (Sucralfate), H2 blocker (Famotidine)

Do antidiarrheals treat the cause of diarrhea?

No. Antidiarrheals treat the symptoms of diarrhea but do not eliminate the cause.

Endocrine System: 3 major glands discussed

adrenal glands, pancreas and thyroid

Hyperthyroidism

•Anti-thyroid medications: (PTU) propylthiouracil •Can also be used in Grave's Disease Mechanism of Action: •Inhibits the synthesis of thyroid hormone (T3 & T4) Administration consideration: •3 equal doses at approximately 8 hrs intervals. •Monitor TSH & free T4 •Liver injury •Agranulocytosis (fever, sore throat) •If pt becomes pregnant notify provider immediately can cause fetal harm Teaching/education •Take medication at the same time each day •Monitor for hypothyroidism •Monitor weight 2-3 times per week •Can cause drowsiness; reports signs of sore throat, fever, headache, jaundice, bleeding or bruising •Do not abruptly stop medications

Glipizide, Glyburide, Glimepiride

•Class: Sulfonylurea •Mechanism of Action: •Stimulate the pancreas to release more insulin. •Peak of action: 1-3 hrs •Administration consideration •Can cause severe hypoglycemia must be given 30 min before meal. •Contraindicated in type 1 diabetes or for use of DKA. •Hypoglycemic action of sulfonylurea may potentiate NSAIDs •Photosensitivity and GI upset. •Can cause weight gain •Teaching/education •Take at the same time each day. •Controls hyperglycemia but does not cure diabetes. •Recognize the S/S of hyperglycemia & hypoglycemia •May cause disulfiram-like reaction •Use sunscreen

insulin glargine (Lantus) insulin detemir (Levemir)

•Long-acting insulin •Onset: 3-4 hr •Peak: none •Duration: >24 hr Administration consideration •Adm once a day •Beta blockers can mask symptoms of hypoglycemia Adverse/side effects •Hypoglycemia & hypokalemia

insulin lispro (Humalog) insulin aspart (Novolog)

•Rapid-acting insulin (a log rapidly rolls down a hill) •Onset: 10-30 min •Peak: 1-3 hrs •Duration: 3-5 hrs Administration consideration •Administer with meals or immediately after Adverse/side effects •Hypoglycemia & hypokalemia

Antidiarrheal medication classes:

1. Adsorbents •Help eliminate the toxin or bacteria from the GI tract 2. Antimotility •Slow peristalsis 3. Probiotics •Help restore the normal bacteria found in the lower intestine

A patient with diabetes mellitus type 2 is admitted to the hospital for hip replacement surgery. The nurse reviews the following orders: ·Diabetic diet with carb counting ·Scheduled base dose: Humalog 4 units before meals subcutaneous ·Bedside blood glucose testing before meals (ac) and at bedtime (hs) with sliding scale Humalog insulin: 150-175: 2 units 176-200: 4 units 201-225: 6 units 226-250: 8 units Over 250: call the provider Metformin 1000 mg twice daily PO Hypoglycemia protocol: blood glucose 60 or below: If awake and able to swallow: juice (16 oz) If unable to swallow Glucagon injection or gel. 10. The patient's blood glucose level is 223 at breakfast. What amount of insulin will the nurse administer?

10 units

When the nurse enters the room around 4 pm, the patient has become irritable and shaky. The nurse performs a bedside blood glucose and obtains a value of 58. What would be the nurse's next steps in priority order?

Administration of hypoglycemic protocol: If able to swallow: administer 15 grams of carbs (4oz of orange juice) If unable to swallow: administer glucagon IM or subcutaneously Recheck CBG in 15 minutes

What meds to avoid with an ulcer?

Aspirin, NSAID's

On admission, the patient's A1C was 10%. Discuss this lab value. What do the ranges indicate overall?

Glycosylated hemoglobin, also called A1C, is used to assess long-term blood glucose levels over 3 months. The ADA states that A1C target levels vary according to age and health, but the generalized A1C target is less than 7%.

•Chapter 7 Case Study •M.S. is a 30-year-old patient with a complaint of heartburn as well as some burning upper abdominal pain for a couple months. M.S. has tried to manage the symptoms at home. M.S has a high carb diet, and drinks 2 caffeinated sodas every day and has been under a great deal of stress over the last few months. M.S. also drinks alcohol casually and has 2-3 beers on the weekends. 1. What risk factors can you identify from the history given?

High carb diet, caffeine intake and soda, stress, and alcohol use.

•Chapter 7 Case Study •M.S. is a 30-year-old patient with a complaint of heartburn as well as some burning upper abdominal pain for a couple months. M.S. has tried to manage the symptoms at home. M.S has a high carb diet, and drinks 2 caffeinated sodas every day and has been under a great deal of stress over the last few months. M.S. also drinks alcohol casually and has 2-3 beers on the weekends. 4. What education must be provided for M.S. regarding the proton pump inhibitor and its use?

It also should be administered about 20-30 minutes before breakfast on an empty stomach. Instruct patients to call their provider if their condition does not improve or gets worse, especially if bleeding occurs, avoid use of alcohol, NSAIDS, or foods that cause GI irritation should be discouraged.

Hypothyroidism

Levothyroxine (Synthroid) - synthetic T4 Administration consideration •Take with a full glass of water on empty stomach •Must be taken 30 min - 1 hr before breakfast •Levothyroxine & DM may worsen glycemic control and need higher doses of DM medication •TSH levels may increase during pregnancy and should be monitored closely •Levothyroxine- increases response of oral anticoagulant therapy: may need to decrease anticoagulant dose when levothyroxine dose is increased and monitor INR. Teaching/education •Do not stop abruptly (takes several weeks before they notice improve) •s/s of hyperthyroidism due to toxicity of medication •Do not take 4 hr before or after GI meds (antacid, iron or calcium) - decrease absorption of Synthroid. •Patient will take medication for the rest of their life. •Monitor weight and pulse regularly

The nurse reviews today's lab work and finds a creatinine of 1.8. She plans to call the provider to discuss the impact of the results on the medications ordered. Which medication may require a dosage adjustment based on these results and why?

Metformin is contraindicated in patients with kidney disease (e.g., serum creatinine levels ≥1.5 mg/dL [males] or ≥1.4 mg/dL [females]) and should be temporarily discontinued in patients undergoing radiologic studies involving intravascular administration of iodinated contrast materials because use of such products may result in acute alteration of renal function. It is also contraindicated in patients with metabolic acidosis.

•Chapter 7 Case Study •M.S. is a 30-year-old patient with a complaint of heartburn as well as some burning upper abdominal pain for a couple months. M.S. has tried to manage the symptoms at home. M.S has a high carb diet, and drinks 2 caffeinated sodas every day and has been under a great deal of stress over the last few months. M.S. also drinks alcohol casually and has 2-3 beers on the weekends. 3. The doctor would like start M.S. on a proton pump inhibitor. Choose one option he may use?

Omeprazole is a commonly used PPI that can be used to help with ulcers. Omeprazole was developed as an inhibitor of gastric acid secretion. Its binding action results in a bond that inactivates pump function, resulting in increases in gastric pH that are responsible for therapeutic effects. Adverse effects of omeprazole are generally minor, including effects such as headache, nausea, diarrhea, and abdominal pain. Often this drug is also typically used for short term therapy, which could be anywhere around 4-8 weeks.

4 examples of Proton Pump Inhibitors (PPI):

Pantoprazole, Esomeprazole, Omeprazole, Lansoprazole

Chapter 9 Case Study: •D.M. is a 35-year old patient presenting to the Emergency Room with complaints of increased urination, thirst and hunger with generalized fatigue. Over the last 3 weeks she has lost approximately 8 kg in weight. Physical assessment reveals dry skin and dry mucus membranes. A glucose level is checked and reads 825. The physician orders insulin for the patient. 3. Explain the four types of insulin.

RAPID: insulin lispro (Humalog), insulin aspart (Novolog), inhaled insulin (Afreeza) Onset: 15-30 minutes Peak effect: 1-3 hours Duration: 3 - 5 hours Administer within 15 minutes before a meal or immediately after a meal Afrezza is contraindicated in patients with asthma or COPD SHORT-ACTING: Humulin R, Novolin R Onset: 30 minutes Peak effect: 3 hours Duration: 8 hours Administer 30 minutes before a meal Can be given IV INTERMEDIATE: Humulin N, Novolin N Onset: 1-2 hours Peak effect: 6 hours (range 2.8-13 hours) Duration: up to 24 hours Administer once or twice daily Only administer subcutaneously Gently roll or invert vial/pen several times to re-suspend the insulin before administration LONG: insulin glargine (Lantus), insulin detemir (Levemir) Onset: 3-4 hours Peak effect: none Duration: >24 hours Administer once daily (sometimes dose is split and administered twice daily) Only administer subcutaneously Do not mix with other insulin

•Chapter 7 Case Study •M.S. is a 30-year-old patient with a complaint of heartburn as well as some burning upper abdominal pain for a couple months. M.S. has tried to manage the symptoms at home. M.S has a high carb diet, and drinks 2 caffeinated sodas every day and has been under a great deal of stress over the last few months. M.S. also drinks alcohol casually and has 2-3 beers on the weekends. 2. M.S. goes to her primary doctor. After an evaluation, an EGD is scheduled to evaluate the source of M.S. discomfort. What other questions may he ask regarding her symptoms?

The doctor may want to ask her when her upper abdominal pain occurs. Upper abdominal pain occurring 1-3 hours after a meal is characteristic of a duodenal ulcer. Since pain associated with these ulcers worsens on an empty stomach, knowing the timing of her pain with her associated meal schedule can yield a good amount of information. The doctor may also want to get a medication history from M.S. as many patients attempt to self-treat this disorder with OTC medications.

Short and Long-term complications of diabetes-related hypoglycemia:

The short- and long-term complications of diabetes-related hypoglycemia include precipitation of acute cerebrovascular disease, myocardial infarction, neurocognitive dysfunction, retinal cell death and loss of vision in addition to health-related quality of life issues pertaining to sleep, driving, employment, recreational activities involving exercise and travel.

•Chapter 7 Case Study •M.S. is a 30-year-old patient with a complaint of heartburn as well as some burning upper abdominal pain for a couple months. M.S. has tried to manage the symptoms at home. M.S has a high carb diet, and drinks 2 caffeinated sodas every day and has been under a great deal of stress over the last few months. M.S. also drinks alcohol casually and has 2-3 beers on the weekends. 6. What lifestyle modifications should you educate M.S. to make with her diagnosis to help improve her quality of life?

There are many different lifestyle changes one can make in order to improve and prevent both GERD and promote healing and future formation of ulcers. Since GERD is associated with obesity, continuing to maintain a healthy weight will help in prevention of symptoms. Avoiding fatty foods as well as decreasing or avoiding alcohol intake will also work to prevent these symptoms. Decreasing her consumption of caffeine will also aide in the prevention of instances of peptic ulcers. Maintaining a daily life free of high instances of stress can also prove effective in both the healing and prevention of future ulcers as well.

What hormones does the thyroid gland secrete, and what is their effect?

Thyroxine (T4) and Triiodothyronine (T3): stimulates basal metabolic rate Calcitonin: reduces blood Ca+ levels

Alendronate (Fosamax)

Uses: •Prevention & treatment of osteoporosis in postmenopausal women •Increase bone mass in men w/osteoporosis •Glucocorticoid-induced osteoporosis Administration consideration: •Adm. upon arising & at least 30 min before the first food, beverage, or medication of the day with plain water only (can cause esophageal ulcer, erosion, and perforation) •Pt should sit or stand for 30 min after admin •Contraindicated in pregnancy, hypocalcemia, & kidney disease •Concurrent calcium & vitamin D supplements may be required •Patients should participate in regular exercise to help increase bone strength Adverse/side effects: •Upper GI adverse events •Severe musculoskeletal pain •Risk of osteonecrosis of the jaw

Diagnosing Diabetes Mellitus

•A1C ≥6.5% •Fasting plasma glucose (FPG) ≥126mg/dL. Fasting is defined as no caloric intake for at least 8 hours.

Chapter 9 Case Study: •D.M. is a 35-year old patient presenting to the Emergency Room with complaints of increased urination, thirst and hunger with generalized fatigue. Over the last 3 weeks she has lost approximately 8 kg in weight. Physical assessment reveals dry skin and dry mucus membranes. A glucose level is checked and reads 825. The physician orders insulin for the patient. 8. List three common insulin injection sites and education to the patient regarding injections at home.

•Abdomen (2 inches from umbilicus), thigh, back of upper arm •The patient must be educated on the importance of rotating injection sites to prevent developing lipohypertrophy (build-up of scar tissue that affects insulin absorption).

What hormones does the adrenal gland secrete, and what is their effect?

•Adrenal cortex Aldosterone: increases blood Na+ levels Cortisol: increases blood sugar levels •Adrenal medulla Epinephrine and Norepinephrine: stimulate fight-or-flight response

Addison's Disease

•Also called adrenal insufficiency - the body doesn't produce enough cortisol & aldosterone. •You need to ADD steroid hormone •Causes: autoimmune (body attacks adrenal cortex) •S/S: salt cravings, N/V, irritability, sexual dysfunction in women, low blood pressure. See picture for more S/S.

•Chapter 7 Case Study •M.S. is a 30-year-old patient with a complaint of heartburn as well as some burning upper abdominal pain for a couple months. M.S. has tried to manage the symptoms at home. M.S has a high carb diet, and drinks 2 caffeinated sodas every day and has been under a great deal of stress over the last few months. M.S. also drinks alcohol casually and has 2-3 beers on the weekends. 5. After the EGD is complete, the diagnosis of GERD and a duodenal ulcer is made. What medications would you anticipate being added to her care given her diagnosis and why?

•Antacids- They neutralize gastric acidity and elevate the pH of the stomach to reduce the symptoms of heartburn. Elevated pH also inactivates pepsin, a digestive enzyme. •H2-Receptor Antagonist-Famotidine is used to treat GERD, peptic ulcer disease, erosive esophagitis, and hypersecretory conditions, or as adjunct treatment for the control of upper GI bleeding. OTC famotidine is also used to treat heartburn or sour stomach. •Proton Pump Inhibitors-A common proton pump inhibitor (PPI) is pantoprazole. PPIs are more powerful than antacids and H2-receptor antagonists. PPIs inhibit the secretion of hydrochloric acid, and the antisecretory effect lasts longer than 24 hours. • Mucosal Protectants- Sucralfate is a mucosal protectant used to cover and protect gastrointestinal ulcers.

Nurse's Role for Hyperacidity Medications

•Assessment •Abdominal assessment & bowel patterns. *Be familiar with sounds and when you'd hear them.* •Potential for medication interaction & side effects. •patient complains of chest pain, the nurse should perform a complete focused cardiac assessment and not assume it is GI-related because patients may erroneously attribute many cardiac conditions to "heartburn." •Implementation •Drug-drug/food interaction, or does medication need to be taken with food. •Cultural preferences •Plan of care •Evaluation •Improvement of symptoms •New or worsening symptoms could indicate life-threatening bleeding ulcer •Always report blood in vomit or stool.

Metformin (Glucophage)

•Class: Biguanides •Mechanism of Action: •Decrease glucose production in the liver and increase glucose uptake by the cells •Does not produce hypoglycemia •Administration consideration •GI upset (diarrhea and abdominal discomfort) •B12 deficiency •Lactic acidosis •Metallic taste •Contraindicated in kidney disease (patients with eGFR <30 mL/min) •Cause small decrease in LDL cholesterol level and triglycerides •Teaching/education •Take medication with meals to prevent GI upset •Do not use alcohol •Discontinue medication for procedures requiring contrast dye or NPO (1-2 days before) •Monitor for s/s of lactic acidosis: dizziness, diarrhea, hypotension, bradycardia, weakness •Off-label use for polycystic ovary syndrome (PCOS)

Hyperthyroidism

•Excessive production of thyroid hormones •Causes: -Too much iodine -Grave's Disease (autoimmune) #1 cause -Goiter (nodular growth produces excessive thyroid hormone) -Thyroid replacement medication (toxicity) •Life threatening complications: thyroid storm •S/S: Weight loss, heat intolerance, goiter, restless, irritable, increased HR and bounding pulses, diarrhea, unable to focus, nervousness, agitation, menstrual problems •Treatment: -antithyroid: PTU, Tapazole, iodine solution -beta blockers: Inderal -radioactive therapy

Herbal and vitamin supplements

•Ginger has been used in traditional Indian and Chinese medicine as an antiemetic. •Can cause reflux and heartburn and may potentially cause bleeding because of its anticoagulant effects •Dosages of up to 2 g per day in divided doses of 250 mg are considered safe even in pregnant women. •Pyridoxine (vitamin B6) has also been recommended for treating nausea and vomiting in pregnancy. •Typical dosages of pyridoxine 10 to 25 mg every eight hours cause minimal adverse effects.

Signs & Symptoms of Diabetes Mellitus

•Hyperglycemia •3 P's: polyuria, polydipsia, polyphagia •Warm and dry skin- "Warm and dry, sugar's high" •Dehydration: weak pulses, decreased skin turgor •Weight loss, fruity breath, Kussmaul respirations (increased rate & depth), nausea, vomiting, weakness, and lethargy

Glucagon

•Hyperglycemic agent - will increase blood sugar •Ideal for unconscious patients or patients unable to swallow •Mechanism of action: •Stimulate the break down of glycogen into glucose in the liver •Side effects •GI upsets: nausea & vomiting •Key Points •Administer subq or IM. •Provide patient with food if safely able to swallow. Check CBG 15 minutes after. ***When the glucose is gone, you give glucagon!***

The nurse is caring for two patients in the Endocrine clinic. Patient A has been diagnosed with hypothyroidism and receives a prescription for levothyroxine. Patient B is being seen for an abnormal growth on his neck. Patient B receives lab results showing an increase in TSH. How does the nurse explain the growth in his neck and treatment for hyperthyroidism?

•Hyperthyroidism can lead to an increased metabolic rate, excessive body heat and sweating, diarrhea, weight loss, tremors, and increased heart rate. The person's eyes may bulge (called exophthalmos) as antibodies produce inflammation in the soft tissues of the orbits. The person may also develop a goiter. •Dietary iodine deficiency can result in the impaired ability to synthesize T3 and T4, leading to a variety of severe disorders. When T3 and T4 cannot be produced, TSH is secreted in increasing amounts. As a result of this hyperstimulation, thyroglobulin and colloid accumulate in the thyroid gland and increase the overall size of the thyroid gland, a condition called a goiter.

Short-term complications of diabetes:

•Hypoglycemia •Hyperglycemia •DKA •HHA

The nurse is caring for two patients in the Endocrine clinic. Patient A has been diagnosed with hypothyroidism and receives a prescription for levothyroxine. Patient B is being seen for an abnormal growth on his neck. What education should the nurse provide Patient A regarding taking this medication? List the signs and symptoms related to hypothyroidism.

•Hypothyroidism is a disorder characterized by a low metabolic rate, weight gain, cold extremities, constipation, reduced libido, menstrual irregularities, and reduced mental activity, and requires long-term thyroid hormone replacement therapy. •Patients should take thyroid replacement medications at the same time each day. Patients should be aware that thyroid replacement medications do not cure hypothyroidism and therapy is lifelong. Patients should notify their healthcare provider if they experience signs of headache, diarrhea, sweating, or heat intolerance. Medications should be spaced four hours apart from medications like antacid, iron, or calcium supplements. Patients will be followed closely by their healthcare provider regarding their response to medication therapy and serum thyroid levels will be taken. Levothyroxine should be taken as a single daily dose, on an empty stomach, one-half to one hour before breakfast •Administer levothyroxine at least 4 hours before or after drugs known to interfere with levothyroxine sodium tablets absorption •Anticipate lower dosages in elderly patients with pre-existing cardiac disease •May interact with several medications so read drug label thoroughly on initial administration for potential effects

Chapter 9 Case Study: •D.M. is a 35-year old patient presenting to the Emergency Room with complaints of increased urination, thirst and hunger with generalized fatigue. Over the last 3 weeks she has lost approximately 8 kg in weight. Physical assessment reveals dry skin and dry mucus membranes. A glucose level is checked and reads 825. The physician orders insulin for the patient. 1. Explain the action of insulin in the body and how it will help?

•Insulin facilitates the uptake of glucose into skeletal and adipose body cells. The presence of food in the intestine triggers the release of gastrointestinal tract hormones. This, in turn, triggers insulin production and secretion by the beta cells of the pancreas. Once nutrient absorption occurs, the resulting surge in blood glucose levels further stimulates insulin secretion. •Insulin triggers the rapid movement of glucose transporter vesicles to the cell membrane, where they are exposed to the extracellular fluid. The transporters then move glucose by facilitated diffusion into the cell interior. •Insulin also reduces blood glucose levels by stimulating glycolysis, the metabolism of glucose for generation of ATP. It further stimulates the liver to convert excess glucose into glycogen for storage, and it inhibits enzymes involved in glycogenolysis and gluconeogenesis. Finally, insulin promotes triglyceride and protein synthesis. The secretion of insulin is regulated through a negative feedback mechanism. As blood glucose levels decrease, further insulin release is inhibited.

Hyperglycemia: Diabetic ketoacidosis (DKA)

•Life-threatening complication of diabetes that causes increased blood glucose, ketones in the blood and urine. Most commonly seen in type 1 diabetes. •Risk factors: -Infections, illness, stress, and untreated or undiagnosed type 1 diabetes •Signs and symptoms: -Hyperglycemia: 3 P's: polydipsia, polyphagia, polyuria and weight loss, fruity breath odor, Kussmaul respirations (deep & labored breathing), and dehydration. •Labs will differentiate DKA from HHS. •DKA: blood glucose >300 mg/dL, ketones will be present in the urine and blood; metabolic acidosis and hyperkalemia. •HHS: blood glucose >600 mg/dL, no ketones in urine or blood.

Hypothyroidism

•Low production of thyroid hormones •Cause: -Not enough iodine -Hashimoto disease (autoimmune) -Antithyroid medication (toxicity): PTU, Tapazole -Pituitary tumor: stops releasing TSH, T3 & T4 increase •Life threatening complications: Myxedema coma •S/S: Weight gain, cold intolerance, possible goiter (Hashimoto), extremely tired, fatigue, decreased HR, constipation, memory loss, myxedema (swelling skin, waxy appearance), depression, dry skin, menstrual problems •Treatment: -Thyroid replacement meds: Synthroid -Avoid sedatives/narcotics: chances of myxedema coma

Scopolamine

•Mechanism of Action •Anticholinergics block ACh receptors in the vestibular center and within the brain to prevent nausea-inducing stimuli •Administration consideration •Transdermal patch delivers continuous release of scopolamine •Contraindicated in pt with glaucoma •Reported to exacerbate psychosis, induce seizures & cause drowsiness •Can decrease GI motility & cause urinary retention •Remove before undergoing MRI •Teaching & education •May impair mental and/or physical abilities •Can cause temporary dilation of pupils resulting in blurred vision if made contact to eyes •Wash hands thoroughly after handling transdermal patch. •Fold patch after removal

Stimulants: bisacodyl (Dulcolax)

•Mechanism of Action •Causes intestines to contract, inducing the stool to move through the colon •Administration considerations •Oral dosage or rectal suppositories are available •Instruct pt to retain suppository for about 15 - 20 minutes •Patient must be in Sim's position for administration •Teaching & education •Bowel movement generally produced in 15 minutes •May cause stomach cramps, dizziness, or rectal burning

Proton Pump Inhibitors (PPI)

•Mechanism of action •Act on gastric parietal cells to lower stomach's acidity. Gastric cells are responsible for secreting hydrochloric acid. PPIs inhibit hydrogen so that it won't be released & trigger further gastric acid production. Reduses dyspepsia. •Uses •PUD, GERD in adults & children >5 yrs. By allowing esophagus to heal & prevent further damage. Zollinger-Ellison syndrome in adults & H. Pylori infections. •Administration Consideration •PPI can interfere w/liver metabolism of other drugs •IV pantoprazole can exacerbate zinc deficiency & long-term therapy can cause hypomagnesemia •Teaching & education •Call provider if symptoms do not improve or get worse, especially if bleeding occurs. •Discourage use of alcohol, NSAIDs, or food that cause GI irritation. •Encourage magnesium rich foods for those on long therapy. •PPIs can increase the risk of fractures and pneumonia and can cause acid rebound when treatment stops.

Mucosal Protectant: Sucralfate

•Mechanism of action •Covers the ulcer site in the GI tract & protects it against further attack by acid, pepsin, and bile salts. It is minimally absorbed by the GI tract •Uses •Treatment of ulcers •Administration consideration •Take on an empty stomach, 2 hrs after or 1 hr before meals and at bedtime. •Constipation may occur •Should be used cautiously in patients with chronic renal failure or those receiving dialysis •Teaching & education •Call provider if condition does not improve or get worse.

Corticosteroids- Adrenal Cortex

•Produces aldosterone and cortisol •Pituitary gland regulates cortisol production by releasing ACTH & this causes the adrenal cortex to release cortisol •Cortisol: steroid hormome "stress hormone" -Helps the body deal with stress (illness, trauma) -Increases blood glucose, breaks down fats, proteins, & carbs -Role in electrolyte balance (Na & K+)

Insulin Key Points

•Recognize S/S of hyperglycemia & hypoglycemia •Lipohypertrophy: build up of scar tissue caused by not rotating injection sites. •Insulin doses may need to be increased during times of illness. •Stress, infection, illness will cause an increase in glucose •Hypoglycemia: -Conscious: Administer 15 g of glucose = 4 oz of orange or 8 oz of milk -Unconscious: Administer glucagon IM •Never mix insulin glargine (long) with other insulins •You can mix short acting (Regular) with intermediate acting insulin (NPH) •Clear (Regular) before cloudy (NPH) •RN = registered nurse = regular then NPH (cloudy) •Short acting (Regular) looks cloudy or discolored, do not administer = discard •The only insulin that should be cloudy is NPH (Humulin N, Novolin N) •Insulin & Potassium = insulin forces potassium back into the cell, causing potassium levels to decrease. Always monitor K+ when using insulin.

Chapter 9 Case Study: •D.M. is a 35-year old patient presenting to the Emergency Room with complaints of increased urination, thirst and hunger with generalized fatigue. Over the last 3 weeks she has lost approximately 8 kg in weight. Physical assessment reveals dry skin and dry mucus membranes. A glucose level is checked and reads 825. The physician orders insulin for the patient. 2. The nurse discusses with D.M. hypoglycemia. What are the priority signs and symptoms to monitor?

•Shaky, jittery, sweaty •Hungry, Headache •Blurred vision, Sleepy or tired •Dizzy or lightheaded •Confused or disoriented •Pale, Uncoordinated, Irritable or nervous •Argumentative or combative •Changed behavior or personality •Trouble concentrating •Weak, Fast or irregular heart beat •Unable to eat or drink •Seizures or convulsions (jerky movements) •Unconsciousness

Humulin R (Regular) Novolin R

•Short-acting insulin •Onset: 30 min-1hr •Peak: 2-4 hrs •Duration: 4-8 hrs Administration consideration •30 min before meals Adverse/side effects •Hypoglycemia & hypokalemia

What education would you provide to a patient taking an oral glucocorticoid?

•Teach patients taking long-term prednisone therapy to never abruptly stop taking the medication and to report any adverse/side effects or new signs of infection. •Glucocorticoid medication can cause immunosuppression, which makes it more difficult to detect signs of infection. Patients should seek advice from healthcare providers regarding vaccination administration while on glucocorticoids. Patients should report unusual swelling, weight gain, fatigue, bone pain, bruising, non-healing sores, visual and behavioral disturbances to the provider. •Use of glucocorticoid therapy may cause an increase in blood glucose levels. Patients should be advised to consume diets that are high in protein, calcium, and potassium.

Why is it important to know Onset, Peak & Duration of Insulin?

•The major side effect/complication of insulin is hypoglycemia •By knowing onset, peak, and duration, nurses can monitor (or even predict) symptoms of hypoglycemia. •The PEAK time is the time during which insulin is at maximum strength in terms of lowering blood sugar. •Peak time is when you would expect s/s of hypoglycemia to occur if any. •Know how to mix NPH (cloudy) and Regular Insulin (Clear) •Know how to store insulin •Know how to add total units in a syringe

Explain the difference between type 1 and type 2 diabetes.

•Type 1 diabetes is an autoimmune disease affecting the beta cells of the pancreas. The beta cells of people with type 1 diabetes do not produce insulin; thus, synthetic insulin must be administered by injection or infusion. •Type 2 diabetes accounts for approximately 95 percent of all cases. It is acquired, and lifestyle factors such as poor diet and inactivity greatly increase a person's risk. In type 2 diabetes, the body's cells become resistant to the effects of insulin. In response, the pancreas increases its insulin secretion, but over time, the beta cells become exhausted. In many cases, type 2 diabetes can be reversed by moderate weight loss, regular physical activity, and consumption of a healthy diet. However, if blood glucose levels cannot be controlled, oral diabetic medication is implemented and eventually the type 2 diabetic may require insulin.

Treatment for Diabetes (Type 1 & 2)

•Type 1: -Requires insulin for life. Can not take oral medications •Type 2: -Oral medications and/or insulin

Prednisone, Methylprednisolone, Hydrocortisone Class: glucocorticoids

•Used to decrease inflammation & suppress the body's immune response. •Adverse/side effects •Fluid & electrolyte imbalances •Increased blood glucose •Muscle weakness •Peptic ulcer disease (PUD) •Thin, fragile skin that bruises easily •Weight gain •Poor wound healing •Development of Cushing's syndrome (too much hormone) •May mask signs of infection & new infection may appear •Psychic derangement: euphoria, insomnia, mood swings, personality changes to severe depression.

Endocrine sytem

•Uses hormones to communicate by glands in our body: testes, ovaries, pituitary, thyroid, parathyroid, adrenal, pancreas and pineal. •Glands can be endocrine and nonendocrine. Assist with chemical and hormone responses. •Three major glands discussed will be: adrenal glands, pancreas and the thyroid. •Hormone levels are regulated by the negative feedback loop. Inhibition of further secretion of hormone in response to adequate levels of that hormone.

What does the A1C test measure?

•When sugar enters your bloodstream, it attaches to hemoglobin, a protein in your red blood cells. •Everybody has some sugar attached to their hemoglobin, but people with higher blood sugar levels have more. •The A1C test measures the percentage of your red blood cells that have sugar-coated hemoglobin.

What is the A1C test?

•is a simple blood test that measures your average blood sugar levels over the past 3 months. •Main test providers use to diagnose and manage prediabetes and diabetes. •Higher A1C levels are linked to diabetes complications, so reaching and maintaining your individual A1C goal is really important if you have diabetes. •Normal: <5.7% •Prediabetic: 5.7%-6.4% •Diabetic: ≥6.5%