RNSG 1341 CC EXAM 3 Blueprint
HHS MANIFESTATIONS
- NO ketoacidosis due to circulating insulin so early detection is extremely difficult. - absent or little ketones in urine - BG >600 hyperosmolality causes hypovolemia causes: - decreases renal perfusion so ANURIA - hypotension - thickened blood and increased risk of thrombosis - resembles stroke!! (somnolence, coma, seizures, hemiparesis, aphasia)
Patient Education for OSA
- NO sedatives (sedating drugs or alcohol 3-4 hrs before bedtime can worsen OSA) - lose weight!! (excess weight increases pressure on neck/chest) - be cautious driving due to excessive daytime sleepiness
Type 2 Diabetes - RISK FACTORS
- Obesity - Older adults - Family history (First-degree relative with diabetes) - Native American - Black - Female - HTN - Sedentary lifestyle - Metabolic syndrome (increased glucose, abdominal obesity, high BP, high triglycerides, low HDLs)
What are 2 adverse effects of Dipeptidyl Peptidase-4 (DDP-4) Inhibitors?
- Pancreatitis - allergic reactions
Contraindications for Beta Blockers
- Reynaud's disease - systolic heart failure - bradycardia - bronchial asthma (B2 blockers can promote bronchoconstriction) - diabetes mellitus (due to masking of hypoglycemia-induced tachycardia) - peripheral vascular disease (the drug may further compromise cerebral or peripheral blood flow) - abrupt discontinuation (black box warning)
Hypoglycemia TREATMENT
- Rule of 15 (have 15 grams of carbs and check your blood sugar after 15 minutes) - Table 48.19 for emergency treatment
Primary Hypertension Risk Factors
- Systolic BP rises with age - After age 50, SBP >140 mm Hg is a more important cardiovascular risk factor than diastolic BP - excessive alcohol intake --- men get 2 drinks; women 1 --- one glass = 12 oz beer; 5 oz wine (12% alcohol); 1.5 oz liquor/spirits (80-proof) - diabetes - high cholesterol and triglycerides - black patients - high-sodium intake - first-degree relative w/ HTN - young or middle aged men; after 64, women - obesity - low socioeconomic status - high stress - smokingggggg!!!!
Hypoglycemia PREVENTION
- Take meds as prescribed - Coordinate eating with meds - Eat adequate calories needed to exercise - Carry simple carbs at all times (hard candy, glucose tablets) - Check BG often (4-8 times/day) - Wear/carry diabetes identification
Hyperglycemia PREVENTION
- Take meds as prescribed - Eat healthy foods (complex carbs and low-protein diet) - Follow sick-day rules when ill - Check BG often (4-8 times/day) - Wear/carry diabetes identification
Clinical Manifestations of Deep vein thrombosis (DVT)
- Tenderness to pressure over involved vein - induration of overlying muscle - venous distention - edema - mild to moderate pain - deep reddish color to area caused by venous congestion - Some have no obvious physical changes in the affected extremity.
Noninsulin Injectable Agents slow gastric emptying. What does this have to do with oral medications?
- The delayed gastric emptying that occurs with these drugs may affect the absorption of oral medications. - Advise patients to take fast-acting oral medications at least 1 hour before injecting a GLP-1 agonist drug.
HHS TREATMENT
(very similar to DKA treatment) 1. ensure airway 2. give oxygen 3. establish IV access w/ LARGE-BORE catheter and begin fluid and electrolyte replacement 4. fluid resuscitation with 0.9% NaCl solution 1 L/hr until BP stabilized and urine output 30-60 mL/hr. 5. Begin continuous regular insulin drip 0.1 U/kg/hr. 6. ADD GLUCOSE when BG reaches 250; the rapid fluid infusion could cause hypoglycemia (potassium loss isn't as common in HHS)
COPD - Pathophysiology
- "airflow limitation not fully reversible during forced exhalation" caused by "loss of elastic recoil and airflow obstruction" caused by "excessive mucus, mucosal edema, and bronchospasm" - chronic inflammation causes bronchioles to lose shape and can become clogged with mucus ((sputum productive cough is not present in ALL COPD pts)) - alveoli are destroyed, forming fewer and larger alveoli - airways are obstructed, air is trapped in lungs during expiration - chest hyperexpands due to trapped air; barrel-shaped chest develops - residual air grows; lungs have lost elastic recoil - pt is trying to inspire air when lungs are in an "overinflated state" - pt is dyspneic with limited exercise capacity
Type 2 Diabetes
- "insulin resistant" - inadequate production OR use of insulin - inappropriate glucose production by the liver - NUTRITION is extremely responsible for Type 2 - CAN occur in skinny people! it all depends on their nutrition
Type 1 Diabetes
- "insulin-dependent diabetes" - used to be called "juvenile diabetes" - ABSENCE OF INSULIN - pancreas creates NO insulin Causes: - viral infection - destruction of pancreatic beta islet cells (either directly or by an autoimmune process) - AUTOIMMUNE DISEASE; antibodies destroy insulin or pancreatic islet cells
What do ACE Inhibitors do?
- (mainly lower BP) - ACE, which is responsible for converting angiotensin I (formed through the action of renin) to angiotensin II. - Angiotensin II is a potent vasoconstrictor and induces aldosterone secretion by the adrenal glands. - Aldosterone stimulates sodium and water resorption, which can raise BP. - these processes = renin-angiotensin-aldosterone system (RAAS) - ACE inhibitors are indicated for **heart failure** bc they inhibit aldosterone --- What does aldosterone do? promotes sodium/water reabsorption - This causes diuresis, which decreases blood volume and blood return to the heart - this decreases the work required of the heart
What do ARBs do?
- (mainly prevent vasoconstriction) - block vasoconstriction and the secretion of aldosterone - treat HTN! - treat heart failure! - potent vasodilators - DON'T cause the dry hacking cough of ACEs
** Airway Clearance Techniques - Nursing INTV. for COPD
- Effective Coughing - Chest Physiotherapy
Hyperglycemia MANIFESTATIONS
- Elevated BG - Polyuria - Glycosuria (glucose in urine) - Polyphagia AND THEN lack of appetite - Weakness, fatigue - N/V - Abdominal cramps - mood swings - Progression to DKA or HHS
metformin
- FIRST-LINE & PREVENTION for Type 2 - reduces hepatic (liver) glucose production - increases the uptake/use of glucose in (1) muscles and (2) adipose tissue - enhances insulin sensitivity in tissue - improves glucose transport into cells - may cause moderate weight loss (helpful in obese or prediabetic patients)
The Dawn Phenomenon of Insulin
- Hyperglycemia upon awakening - Two counterregulatory hormones (GH and cortisol) stimulate lipolysis, gluconeogenesis, and glycogenolysis, causing the hyperglycemia - more severe in teens and young adults due to GH - this is NOT rebound hyperglycemia like Somogyi!
Somogyi effect of Insulin
- Hypoglycemia at night - Hyperglycemia in the morning (rebound hyperglycemia) - a high dose of insulin at night causes a severe drop in BS - counterregulatory hormones (glucagon, epinephrine, GH, cortisol) stimulate lipolysis, gluconeogenesis, and glycogenolysis - which in turn cause rebound hyperglycemia
** Vitamin K Antagonists - warfarin
- INR monitors therapeutic levels - Vit K is the antidote; and fresh frozen plasma - give at the same time daily - NO NSAIDs - NO dark green leafy veggies (high in Vitamin K)
pt education about TB
- Most treatment failures occur because the patient (1) does not take the drug, (2) stops taking it too soon, or (3) takes it irregularly. - TB can relapse; teach pt the symptoms and have them seek care ASAP - cancer, immunosuppressive therapy, and prolonged illness can cause relapse - STOP smoking
Type 2 Diabetes - SYMPTOMS
- Type 2 diabetics are often asymptomatic - Fatigue - Recurrent infections (yeast infections are common 🙀) - 3 P's
Why are diabetic patients more susceptible to infection?
- WBC mobilization is dysfunctional - impaired phagocytosis by neutrophils and monocytes - persistent glycosuria can cause bladder infections
Vibration - Chest Physiotherapy - Airway Clearance Techniques - Nursing INTV. for COPD
- accomplished by tensing the hand and arm muscles repeatedly and pressing mildly with the flat of the hand on the affected area while the patient slowly exhales a deep breath - promote movement of secretions to larger airways - Commercially available mechanical chest vibrators are available for hospital and home use
Risk Factors for COPD
- aging - male - genetics - smoking - infection - asthma - air pollution - Occupational Chemicals and Dusts
Hypoglycemia CAUSES
- alcohol with NO food - too little, too late, or skipped meals - too much medication - too much exercise - weight loss without med adjustment - beta-blockers masking symptoms
*** acute exacerbations of COPD - COMPLICATIONS OF COPD
- an acute change in the patient's usual dyspnea, cough, and/or sputum - common and increasing in frequency as disease progresses (1-2/year) - mainly caused by bacterial or viral infection "What counts as severe?" New symptoms or worsening of the usual symptoms!! - use of accessory muscles - central cyanosis (bluish discoloration of the body and the visible mucous membranes) - edema in the lower extremities - unstable BP - right-sided heart failure - altered alertness
Pneumonia
- an acute infection of the lung parenchyma - 8th leading CoD in the US
Adverse Effects of ARBs
- angina - fatigue - hypoglycemia - UTI - anemia - weakness - Hyperkalemia and cough are less likely with ARBs than with ACEs - teratogenic in pregnancy
Chronic Complications of Diabetes
- angiopathy - retinopathy - nephropathy - neuropathy - complications of feet/lower extremities - skin complications - infection - psychological considerations
retinopathy TREATMENT
- annual testing for Type 2 pts - prevention w/ healthy BG levels and managed HTN - Laser photocoagulation therapy - Vitrectomy - Iluvien - Vascular endothelial growth factor (VEGF) blocking drugs reduce inflammation
How is retinopathy examined?
- annually - Funduscopic: dilated eye examination - Fundus photography
How is nephropathy examined?
- annually - Urine for albuminuria - Serum creatinine
Diabetes exchange lists
- another method for meal planning - Instead of counting carbohydrate, the person is given a meal plan with specific numbers of helpings from a list of exchanges for each meal and snack Recommended plate: - half of the plate filled with nonstarchy vegetables - one fourth filled with a starch - one fourth filled with a protein - 8 oz of nonfat milk - small piece of fresh fruit
Vitrectomy - retinopathy treatment
- aspiration of blood, membrane, and fibers from the inside of the eye through a small incision just behind the cornea - indicated for vitreous hemorrhage and retinal detachment of the macula
When does screening begin for diabetes-related neuropathy?
- at diagnosis for Type 2 - five years after diagnosis for Type 1
Exercise for Diabetics
- at least 150 min/wk (30 minutes, 5 days/week) of a moderate-intensity aerobic physical activity - Type 2 patients should perform resistance training 3 times per week
When is inhaled insulin given? (2)
- at the beginning of each meal - OR within 20 minutes of starting a meal
Name the 3 Treatments for Somogyi Effect
- bedtime snack - reducing the dose of insulin before bedtime - both
Your Type 2 patient is going to have surgery. What do you do and what do you tell them?
- begin IV fluids and insulin when patient goes NPO - inform Type 2 pt that insulin may be temporary and that it's not a sign of worsening diabetes!
What do Beta Blockers do?
- blocks beta receptors within myocardium - (nor)epinephrine usually stimulate these receptors; they're released in greater quantities during exercise too - increased HR makes the heart spend more time is systole (contraction); coronary arteries receive less blood; heart becomes ischemic; angina develops - slows HR at the sinoatrial node - also helps block the extra catecholamines ((nor)epinephrine) released after an MI - also suppress renin (the first step in RAAS) --- BBs inhibit renin; BVs of the kidney dilate; BP is reduced
What do Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors do?
- blocks reabsorption of glucose by kidneys - this increases urinary glucose excretion
Efficacy of a Type 2 diabetic's diet is monitored by 4 things:
- blood sugar levels - A1C - lipid panel - BP
**** Adverse Effects of Beta Blockers
- bradycardia (duh) - decreased cardiac output (due to ↓ HR) - decreased cardiac contractility (which is what lowers the HR... lol) - bronchoconstriction (dyspnea, wheezing) - increased airway constriction in asthmatic or COPD pts - hypotension - impotence - can mask tachycardia of hypoglycemia (drug interaction with insulin or sulfonylureas) - can CAUSE hypo- and hyperglycemia --- delays Type 1 hypoglycemic recovery!! - fatigue, insomnia, weakness due to negative effects on cardiac and CVS - depression - constipation
** Upon auscultation of a pneumonia patient with consolidation, what 3 findings may be present?
- bronchial breath sounds - egophony (an increase in the sound of the patient's voice) - increased fremitus (vibration of the chest wall made by vocalization)
** Patient Education for Oxygen Therapy
- brush teeth several times daily - wash cannula prongs with soap/water x1-2/week - replace cannula every 2-4 weeks - no smoking near tank or mask; can burn face - no flammable liquids around oxygen (oil-paints, cleaning sprays) - no static charged items like wool - inform electrical company of your oxygen concentrator
Nutritional Therapy - Nursing INTV. for COPD
- can divide daily diet into 5-6 meals! - offer high-protein, high-calorie snacks between main meals - REST for 30 minutes BEFORE EATING - bronchodilators BEFORE EATING - AVOID exercise/treatments 1 hour before/after eating - supplemental O2 by nasal cannula while patient eats to maintain SpO2 - EAT HIGH-CALORIE FOODS FIRST - LIMIT LIQUIDS at mealtimes - COLD food is less filling than hot - If the patient is feeling less tired than normal, try to take advantage and eat a bigger meal - Avoid foods that you know cause gas (cabbage, beans, cauliflower) - Use milk or half-and-half instead of water in recipes (to increase calories) - Add grated cheese when possible (to increase calories) - Choose dessert recipes that contain egg (to increase calories)
Complications of Feet and Lower Extremities - chronic complications of diabetes
- can result from both micro- and macrovascular diseases
Which two ACE inhibitors would be best to give a patient with liver dysfunction? Why?
- captopril - lisinopril These are the only ACEs that are not "prodrugs". These 2 don't need to be metabolized in the liver to become active/effective.
3 Most Commonly Used Beta Blockers
- carvedilol (CHF, HTN, L ventricular dysfunction) - nebivolol (HTN) (causes less sexual dysfunction than the others) - metoprolol (angina)
Endothelial Damage
- caused by direct injury (surgery, intravascular catheterization, trauma, burns, prior VTE) - or indirect injury (chemotherapy, diabetes, sepsis) This damage stimulates platelet activation and starts the coagulation cascade --- predisposes the patient to thrombus development
Secondary Varicose Veins
- caused by direct injury, previous VTE, or excessive dilation May occur in: - esophagus (esophageal varices) - vulva - spermatic cords (varicoceles) - anorectal area (hemorrhoids) - abnormal arteriovenous (AV) connections
Left Ventricular Hypertrophy
- caused by sustained high BP that increases the cardiac workload (causes L ventricle to enlarge) - progressive LVH, esp with CAD, often leads to Heart Failure
What does smoking do?
- causes hyperplasia of cells -- in goblet cells, this increases mucus production -- reduces airway diameter and makes it harder to clear secretions - reduces the ciliary activity and may cause actual loss of cilia. - causes abnormal dilation of the distal air space with destruction of alveolar walls - Many cells develop large, atypical nuclei, which are considered a precancerous condition - causes chronic, enhanced inflammation of various parts of the lung with structural changes and repair (called remodeling)
Treatment of Intermittent Claudication
- cilostazol (inhibits platelet aggregation and increases vasodilation) (most effective) - pentoxifylline (improves the flexibility of RBCs and WBCs and decreases fibrinogen concentration, platelet adhesiveness, and blood viscosity)
Heparin
- continuous IV infusion for VTE treatment - requires frequent monitoring of clotting status as measured by APTT - heparin-induced thrombocytopenia (HIT) causes a severe, sudden reduction in the platelet count along with a paradoxical increase in venous or arterial thrombosis --- immediately stop heparin - long-term use can cause osteoporosis
**** Clinical Manifestations of Pneumonia
- cough (may or may not be productive) --- sputum may be green, yellow, rust-colored (bloody) - fever - chills - dyspnea - tachypnea - pleuritic chest pain - fine or coarse crackles over affected area - consolidation - pleural effusion - Atelectasis (complete or partial collapse of the entire lung or area (lobe) of the lung) OLDER ADULTS MAY NOT HAVE CLASSIC SIGNS - confusion/stupor may all you see
How is neuropathy examined?
- daily visual examination of feet - visual exam of feet at every doctor's appt - annual comprehensive foot exam (visual, sensory, palpation)
Risk Factors for Aspiration Pneumonia
- decreased level of consciousness (seizure, anesthesia, head injury, stroke, alcohol intake) - difficulty swallowing - insertion of nasogastric (NG) tubes with/without enteral feeding
DKA MANIFESTATIONS
- dehydration (dry mucous membranes, tachycardia, orthostatic hypotension) - (early) lethargy - (early) weakness - dry, loose skin - soft, sunken eyes - abdominal pain - anorexia - N/V - weak pulse - SWEET, FRUITY BREATH DUE TO ACETONE - Kussmaul respirations (rapid, deep breathing associated with dyspnea) ************** ((only happens in DKA, not HHS)) - BG >250 - blood pH <7.30 - blood bicarb <16 - ketonuria
Psychologic Considerations for Diabetes
- depression - anxiety - eating disorders - Diabetes Distress
Gestational Diabetes
- develops during pregnancy - higher risk for cesarean delivery - babies have a higher risk of perinatal death, birth injury, and neonatal complications - screening occurs at 24-28 weeks - often have normal BG 6 weeks postpartum - a hx of gestational diabetes is 63% risk of developing Type 2 diabetes within 16 years
Risk Factors for CVD
- diabetic women have a 4-6 times increased risk - diabetic men have 2-3 times increased risk - obesity - smoking (nicotine causes vasoconstriction) (extremely dangerous for diabetics; significantly increases their risk for blood vessel and CVD, stroke, and lower extremity amputation) - hypertension - high fat intake (atherosclerosis risk) - sedentary lifestyle
Diabetes Distress
- different from depression - encompasses the stress, fear, and burden of living with and managing a demanding chronic disease
What can be caused by chronic sleep loss?
- diminished ability to concentrate - impaired memory - failure to complete daily tasks - interpersonal difficulties - impotence in men - daytime sleepiness (can lead to car accidents)
Clinical Manifestations of Varicose Veins
- discomfort - heavy, achy feeling or pain after prolonged standing or sitting --- this is relieved by walking or limb elevation - pressure, itchy, burning, throbbing sensation - swelling - nocturnal leg cramps
Macrovascular Complications - angiopathy; chronic complication of diabetes
- diseases of the large and medium-size BVs - occur more often - have an earlier onset than micro Examples: - cerebrovascular disease (CVD) - cardiovascular disease - peripheral vascular disease
cor pulmonale - CLINICAL MANIFESTATIONS
- dyspnea (most common) - normal sounds or crackles in lung bases - S3 and S4 heart sounds - murmurs - distended neck veins - hepatomegaly with right upper quadrant tenderness - peripheral edema - weight gain - HIGH b-Type natriuretic peptide (BNP) levels***
**** Nursing Care for COPD
- educate on oxygen therapy - breathing retraining - airway clearance techniques - Airway Clearance Devices - Nutritional Therapy
angiopathy - Chronic Complications of Diabetes
- end-organ disease from damage to blood vessels caused by chronic Hyperglycemia - primary chronic complication - leading cause of diabetes-related death - two categories
** Classic SYMPTOMS of Chronic Stable Angina
- episodes lasts a few minutes - pain at rest is unusual - provoked by stress, exertion, emotional upset - some patients may deny pain - pressure, heaviness, discomfort in chest - a squeezing, heavy, tight, or suffocating sensation - substernal pain that RADIATES to jaw, neck, shoulders, arms - burning sensation between shoulder blades - indigestion feeling - DOESN'T usually change with change in position or breathing
asthma action plan
- esp important for patients with frequent, acute attacks - Short-Acting Beta Agonists (SABAs); 2-4 every 20 minutes, up to three times as a rescue plan For inpatient asthmatics: 1. measure HR and rhythm 2. monitor RR, BP, and WOB 3. monitor pulse ox, PEFR, and ABGS 4. auscultate lungs sounds 5. DECREASE anxiety; "talking down" - eye contact, use firm and calm voice to guide patient through Pursed-Lip Breathing; teach relaxation therapies 6. semi- or high-Fowler's - (louder wheezing may be heard as airways respond to meds) - therapy MUST continue after clinical improvement bc symptoms can take several days to improve
How is CVD examined?
- every visit (or at least annual) risk factor assessment - as needed (based on risk factors) exercise stress test; stress ECG, stress echocardiogram, stress nuclear imaging)
Aging - Risk Factors for COPD
- exact cause is unclear - loss of elastic recoil in lungs - stiffening of the chest wall; ribs less mobile --- shape of the rib cage gradually changes because of the increased residual volume (RV), causing it to enlarge and become more rounded - decrease in exercise tolerance
Indications for Beta Blockers
- exertional angina (that caused by exercise/ADLs) - MI (blocking catecholamines afterwards) - HTN - cardiac dysrhythmias (slow conduction through the AV nerve where these dysrhythmias occur from) - essential tremor - migraines (they're lipid-soluble and can enter the CNS)
*** Varicose Veins Risk Factors
- female - family hx of Chronic Venous Disease - weak vein structure - tobacco use - increasing age - obesity - multiparity (having had 2+ children) - hx of VTE - venous obstruction resulting from extrinsic pressure by tumors - thrombophilia - phlebitis - previous leg injury - occupations that require prolonged standing or sitting
Risk Factors for Asthma
- female (in adulthood) - nose/sinus problems - Respiratory Tract Infections (decreased airways; inflammation) - allergens (allergic reactions in susceptible people) - cigarette smoke (causes rapid decline of lung function) - air pollutants - occupational factors (irritants change airway responsiveness; pts often report arriving to work feeling well but leave much worse) - exercise (exercise-induced asthma (EIA) or exercise-induced bronchospasm (EIB)) - Drugs and Food Additives - Gastroesophageal Reflux Disease - Genetics - Immune Response - Psychological Factors
Iluvien - retinopathy treatment
- fluocinolone acetonide intravitreal implant - injectable microinsert that provides - continuous delivery of corticosteroid fluocinolone acetonide for 36 months - injected in the back of the patient's eye with an applicator that uses a 25-gauge needle, which allows for a self-sealing wound
Manifestations of OSA
- frequent arousals during sleep - insomnia - excessive daytime sleepiness - witnessed apneic episodes - loud snoring - morning headaches (from hypercapnia or increased BP that causes vasodilation of cerebral blood vessels) - personality changes - irritability - CV complications
Figure 48.4 lists 3 long-acting insulins. What are they?
- glargine (Lantus) - detemir (Levemir) - degludec (Tresiba)
Meglitinides end with what suffix? What are the 2 drugs?
- glinide repaglinide nateglinide
How do you treat the Dawn Phenomenon?
- increased insulin dose before bed - adjustment of insulin administration time
Type 2 Diabetes - Onset
- insidious; gradual - patients may go for years with undetected hyperglycemia and few (if any) symptoms - hyperglycemia sx develop when about 50-80% of pancreatic beta islet cells no longer secrete insulin - by the time of diagnosis, Type 2 patients have been diabetic for 6.5 years
What are the 3 major types of glucose-lowering agents (GLAs)?
- insulin - oral agents (OAs) - noninsulin injectable agents
Nursing Interventions during Illness in Diabetic Patients
- maintain normal diet if possible - increase noncaloric fluids - continue diabetic meds - if eating less than normal, supplement with carbohydrate-containing fluids while continuing meds - if patient is unable to eat/drink, CALL HCP
Diabetes-related nephropathy
- microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney
Type 1 Diabetes - RISK FACTORS
- more common under 40 yrs old - patients can be skinny, obese; whatever!
nonproliferative retinopathy
- most common - partial occlusion of small BVs cause microaneurysms in capillary walls - causes fluid leak and retinal edema, hard exudates, or intraretinal hemorrhages - may cause mild to severe vision loss (depending on which part of the retina is damaged) --- if the center of the retina (macula) is affected, vision loss can be severe
Sensory Neuropathy
- most common is "stocking-glove neuropathy" that affects the hands and/or feet bilaterally - loss of sensation (feels like walking on pillows; numbness) - pain (worst at night; may only occur at night) - paresthesia (tingling, burning, itching) - hypesthesia (extreme skin sensitivity; cannot even tolerate bedsheets) - can cause atrophy of small muscles, affecting fine motor movement
Superficial venous thrombosis
- most frequent complication of varicose veins - may occur spontaneously or after trauma, surgical procedures, or pregnancy - discomfort associated with varicose veins tends to be worse after episodes of superficial venous thrombosis
proliferative retinopathy
- most severe - involves retina and vitreous - retinal capillaries are occluded so body forms more (neovascularization) - new vessels are weak and hemorrhage, producing vitreous contraction (shrinking) - eventually, light is blocked from retina due to blood - PATIENT SEES black or red spots/lines - if the retina is pulled during a vitreous contraction, it could tear and cause retinal detachment (could cause total blindness)
Risk Factors for HHS
- over 60 years old (older adults are at increased risk bc they're already experiencing many of the causes of HHS) - Type 2 diabetics - acute illness, infection - impaired thirst sensation and/or a functional inability to replace fluids
negative physiologic consequences of sleep apnea
- overactivation of the sympathetic nervous system - increased vascular resistance - reduced oxygenation of the heart muscle
Asthma - Risk Factors for COPD
- patients with COPD may have asthma and vice versa - there is considerable pathological and functional overlap between asthma and COPD - AKA "asthma-COPD overlap syndrome"
Percussion - Chest Physiotherapy - Airway Clearance Techniques - Nursing INTV. for COPD
- performed in the appropriate postural drainage position - both hands in a cuplike position; fingers and thumbs closed (like you're scooping water) - cupped hand should create an air pocket between the patient's chest and the hand - used in an alternating rhythmic fashion - should hear a hollow sound - air-cushion impact facilitates the movement of thick mucus - FOR COMFORT, place thin towel/shirt/gown over the area to be percussed
What causes diabetes-related neuropathy?
- persistent hyperglycemia leads to an accumulation of sorbitol and fructose in the nerves that causes ischemic damage - results in reduced nerve conduction and demyelination
Precipitating Factors of Angina
- physical exertion; esp of the arms - temperature extremes - strong emotions - consumption of a heavy meal - tobacco use - sexual activity - stimulants - circadian rhythm (early morning after awakening)
Conservative Treatment of OSA
- positional therapy (sleeping on the side instead of their back) - elevation of head - oral appliance (mouth guard that brings the mandible and tongue forward to enlarge airway space) - support groups to discuss ways to resolve problems
Postural drainage - Chest Physiotherapy - Airway Clearance Techniques - Nursing INTV. for COPD
- positioning techniques that drain secretions from specific segments of the lungs and bronchi into the trachea - position depends on lung area affected - position is determined by: (1) pt assessment, (2) chest x-ray, (3) chest auscultation, (4) patient preference - Aerosolized bronchodilators and hydration therapy are usually given before postural drainage - maintain position for 5 minutes (used during percussion and vibration!) - often done 2-4 times daily! - schedule at least (1) one hour BEFORE meals or (2) three hours AFTER meals
Because ACE inhibitors cause diuresis, what drug interactions could cause problems?
- potassium-sparing dietetics - diuretics in general! --- ACE inhibitors promote potassium resorption in the kidney, although they promote sodium excretion due to their reduction of aldosterone secretion
metformin is used to prevent type 2 diabetes in who?
- prediabetic patients under 60 with risk factors (HTN or hx of gestational diabetes)
Gerontologic Considerations for Diabetes
- present in 25% of adults over 65 (due to decreased pancreatic beta islet cell functionality & altered carb metabolism) - more drugs interact with insulin action - many older adults go undiagnosed and untreated bc sx resemble changes associated with aging - increased hypoglycemic unawareness - increased functional limitations - coexisting medical problems - cognitive decline - education must be adapted to needs - response to drugs may be altered
diabetes-related nephropathy TREATMENT
- prevention and delay: maintain healthy BG - annual screening for albuminuria and serum creatinine - albuminuria indicates the use of ACE inhibitors or ARBs to treat HTN and delay the progression of nephropathy
Most common TB Treatment
- previously untreated TB consists of a 3-month initial phase with 4 drugs (isoniazid, rifampin, pyrazinamide, and ethambutol) - then 18 weeks of continuation drug therapy - AVOID alcohol - monitor for hepatitis
Calcium Channel Blockers
- primarily treat HTN & angina! - cause smooth muscle relaxation by blocking the binding of calcium to its receptors, which thereby prevents contraction - relaxation of coronary arteries (decrease of coronary tone) causes dilation, increasing blood flow to ischemic tissue (decreases pain) - relaxation of peripheral arteries decreases systemic vascular resistance and therefore the workload of the heart - depress conduction through SA and AV nodes; treats cardiac dysrhythmias - nimodipine is indicated solely for cerebral artery spasms associated with aneurysm rupture
Diabetic Ketoacidosis (DKA)
- profound deficiency of insulin - mostly seen in Type 1 diabetics - sometimes seen in Type 2 with severe illness or stress when the pancreas can't meet extra insulin demand
patient education involving airborne infection protocols
- pt must cover their nose/mouth with paper tissues EVERY time they cough, sneeze, or produce sputum - each tissue must be (1) put into a paper bag and thrown away or (2) flushed down the toilet - emphasize hand washing - MUST wear a standard isolation mask if they leave the negative-pressure room for any reason - minimize prolonged visitation - any close contacts MUST be identified and screened!!
Clinical Manifestations of HTN
- pts are often asymptomatic until target organ disease occurs - variety of symptoms secondary to the effects on blood vessels in the various organs and tissues or to the increased workload of the heart (fatigue, dizziness, palpitations, angina, dyspnea)
Who is at risk for Hypoglycemia Unawareness?
- pts with repeated episodes of hypoglycemia - older adults - patients who use β-adrenergic blockers
What are the 5 categories of insulins based on onset?
- rapid-acting - short-acting - intermediate-acting - long-acting - inhaled insulin
Necrotizing pneumonia
- rare complication of bacterial lung infection - causes the lung tissue to turn into a thick, liquid mass - Lung abscesses often occur Signs and Symptoms: - immediate respiratory insufficiency and/or failure - leukopenia - bleeding into the airways Treatment: - long-term antibiotics - possibly surgery
Laser photocoagulation therapy - retinopathy treatment
- reduces the risk for vision loss - destroys the ischemic areas of the retina that make growth factors that encourage neovascularization
Chronic Stable Angina
- refers to chest pain that occurs intermittently over a long period of time with a similar pattern of onset, duration, and intensity of symptoms - caused by significant narrowing of 1 or more coronary arteries by atherosclerosis - left anterior descending artery is 50%+ occluded***
CHF Patho
- response to myocardial injury and results in decreased heart function
** Nursing Interventions for Varicose Veins
- rest with limb elevation (15 degrees to limit edema) - graduated compression stockings (Remove them every 8 hours for short periods and then reapply) --- apply these stockings IN BED AND BEFORE RISING - leg strengthening exercises (walking) - exercise - teach that some bruising and discoloration is normal TEACH PREVENTION!! - avoid sitting/standing for long periods --- frequently flex and extend the hips, legs, and ankles and change positions - maintain ideal body weight - avoid injury to extremities - avoid constrictive clothing - walk daily - deep breathing promotes venous return
Screening for Diabetes in Asymptomatic, Undiagnosed Persons
- screen all adults with a BMI of >25 and additional risk factors (listed later) - in the absence of the criteria above, SCREEN BY 45 yrs old - repeat screening every 3 years
Risk factors for Complications of Feet and Lower Extremities - chronic complications of diabetes
- sensory neuropathy - peripheral artery disease (PAD) (reduction in blood flow to the lower extremities; reduces blood, oxygen, WBCs, nutrients) - clotting abnormalities - impaired immune function - autonomic neuropathy - smoking (increases risk of amputation)
Airborne infection isolation
- single-occupancy room - negative pressure - airflow of 6-12 exchanges per hour - patient remains there until either proven to not have TB or until they are no longer infectious
Where are insulin receptors located?
- skeletal muscle - fat - liver cells SO.... if a patient experiences trauma to muscles or liver, they will be at a higher risk for Type 2 diabetes!
***** Pulmonary vascular changes - COPD
- small pulmonary arteries vasoconstrict due to hypoxia - as the disease progresses, structure of BVs change - results in thickening of the vascular smooth muscle - due to alveoli destruction (including their capillaries!!!), pressure in the pulmonary circulation increases - this can cause PULMONARY HTN - this leads to HYPERTROPHY (enlargement) OF THE R VENTRICLE - THIS BECOMES RIGHT-SIDED HEART FAILURE (cor pulmonale)
Interprofessional Care for COPD
- smoking cessation - drug therapy (bronchodilators) - surgery - oxygen therapy
Microvascular Complications - angiopathy; chronic complication of diabetes
- sometimes present in Type 2 diabetics at the time of diagnosis - chronic hyperglycemia thickens capillaries and arterioles (small BVs) - can occur throughout the body most often occurs in the: 1. eyes (retinopathy) 2. kidneys (nephropathy) 3. nerves (neuropathy)
Pathophysiology of TB
- spread from person to person by airborne droplets expectorated when breathing, talking, singing, sneezing, and coughing - droplet is suspended in air for minutes to hours - someone inhales the droplet; humans are the only reservoir for TB - NOT spread by physical contact - small droplets lodge in bronchioles and alveoli - local inflammatory reaction occurs, and the focus (Ghon lesion) of infection is established - calcified TB granuloma forms ((hallmark of a primary TB infection)) - Most immunocompetent adults infected with TB can completely kill the mycobacteria - Some people have the mycobacteria in a nonreplicating dormant state --- 5-10% of these dormant patients develop active TB infection when the bacteria begin to multiply months or years later
ambulatory care of TB
- sputum culture is done monthly until 2 back-to-back smears are negative - homes should be well-ventilated - if infectious, pt should (1) sleep alone, (2) be outdoors as much as possible, (3) minimize time in public or congested areas like public transportation
What are the 2 main patient education points for Meglitinides?
- take 30 minutes before meals - DON'T take if you're skipping the meal
What are the 2 main patient education points for α-Glucosidase Inhibitors?
- take with FIRST BITE of meal - check 2 hour postprandial BG to determine efficacy
How is OSA diagnosed?
- the Berlin questionnaire and the STOP-BANG questionnaire assess clinical manifestations highly suspicious of OSA - PSG done in a clinical sleep lab Diagnosis requires: - apneic events or hypopneas of at least 10 seconds' duration - 5 events per hour ((can be as many as 30-50)) - 3-4% decrease in SpO2 during each event
Emphysema
- the destruction of alveoli without fibrosis - structural abnormality of COPD patients
passive smoking / environmental tobacco smoke (ETS)
- the exposure of nonsmokers to cigarette smoke Associated with: - decreased pulmonary function - increased respiratory symptoms - severe lower respiratory tract infections
Chronic bronchitis
- the presence of cough and sputum production for at least 3 months in each of 2 consecutive years - this is an independent disease that may precede or follow the development of airflow limitation - this is not a synonym for COPD
TB patients are ONLY discharged if:
- their household has already been exposed - AND if the pt no longer poses a risk to others
Peripheral Arterial Disease (PAD)
- thickened arterial walls - results in progressive narrowing of arteries in all extremities - worsens with age - primarily caused by Atherosclerosis - Symptoms occur when arteries are 60% to 75% blocked
Patient Education for OSA Surgical Treatment
- throat will be sore - foul breath is expected; rinse with diluted mouthwash or salt water for several days - snoring may persist until inflammation subsides - repeat PSG is done 3-4 months after surgery
*** Patient Education on PAD
- tobacco cessation - regular exercise - loose weight - control BP - DASH diet!! - proper foot care --- Tell patients to inspect their legs and feet daily for changes in skin color or texture --- Thick or overgrown toenails and calluses are potentially serious and need regular attention by an HCP - avoid knee-flexed positions - wear graduated compression stockings
Peripheral Arterial Disease (PAD) Risk Factors
- tobacco use (most important) - diabetes (major RF and increases the risk for amputation) - poor diet; hyperlipidemia - atherosclerosis - hypertension - high cholesterol - age 60-80 - family hx - waist circumference: --- ≥40" in men and ≥35" in women - men over 45 - women over 55 - black
diabetes-related neuropathy PAIN DRUGS
- topical creams (capsaicin; made from chili peppers; applied 3-4 times daily) - tricyclic antidepressants (amitriptyline; blocks norepi- and serotonin which transmit pain) - SSRIs and SNRIs (duloxetine; increase norepi- and serotonin to help regulate pain) - antiseizure drugs (gabapentin, pregabalin; decrease the release of neurotransmitters that transmit pain)
cor pulmonale - TREATMENT
- treat the underlying cause (includes COPD) - Continuous low-flow, long-term O2 therapy - use diuretics with caution (decreases in fluid volume from diuresis can worsen heart function) - Long-term anticoagulation therapy is started to help decrease the risk for venous thromboembolism (VTE)
Necrobiosis lipoidica diabeticorum - skin complication - chronic complications of diabetes
- uncommon - red-yellow lesions, with atrophic skin that becomes shiny and transparent, revealing tiny blood vessels under the surface - mostly in young women - MAY APPEAR BEFORE OTHER SIGNS OF DIABETES
What do ARBs primarily affect?
- vascular smooth muscle - the adrenal gland
Nitrates
- vasodilators!! - predominantly affects venous vascular beds - potent on coronary arteries --- causes redistribution of blood and oxygen to previously ischemic myocardial tissue and reduction of anginal symptoms. - used to treat stable, unstable, and vasospastic (Prinzmetal) angina
Hypoglycemia MANIFESTATIONS
- very high (>300) BG dropping very quickly (<150) - BS <70 - Cold, clammy skin - Numb toes/fingers/mouth - Tachycardia - Palpitations - Diaphoresis - Pallor - Nervousness, tremors - Dizziness, fainting - Unsteady gait - Polyphagia (hunger) - Seizures, coma Neuroglycopenia (altered mental functioning); These mimic alcohol intoxication! - Slurred speech - visual disturbances - stupor - confusion - coma
Proper Foot Care
- visually inspect DAILY - wash daily w/ WARM water - test temp with elbow first - PAT dry, esp between toes - apply lanolin BUT NOT between toes - DON'T use commercial products do remove callouses, corns - ROUND toenails - DON'T cut down toenail corners - Trim toenails after shower/bath ONLY (they're softer then) - Protective, closed-toed shoes ONLY - NO BAREFOOT - Cotton or wool socks ONLY - NEVER use heating pads to warm feet
Primary (Idiopathic) Varicose Veins
- weakness of vein walls - leaflets of vein valve are incompetent and allow backwards flow of blood (especially when standing) - this increased venous pressure causes further venous distention - most common in women
What are the side effects of Thiazolidinediones?
- weight gain pioglitazone: - increased risk for bladder cancer - may worsen heart failure rosiglitazone: - increased risk for cardiovascular events (MI, stroke)
What are 2 side effects of Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors?
- ↑ Risk for genital infections and UTIs - Hypoglycemia
ACE Inhibitors usually end in what suffix?
-(a)pril
What do most Calcium Channel Blockers end with? What are the main two that don't share this ending?
-(i)pine 1. verapamil 2. diltiazem
Beta Blockers usually end in what suffix?
-(o)lol
MAJOR risks with OSA are CV complications:
Apnea causes: - hypoxia - nocturnal arousals - increased pressure in the thoracic cavity These can lead to negative physiologic consequences
What is commonly used to treat severe hypoglycemia?
If BS is <60, give a half amp of D50 - these patients will likely be unconscious and you may mistake them for being DEAD. - during a code, you MUST!! tell doctor if your patient is diabetic
How do you check to see if the cause of morning hyperglycemia is the Dawn Phenomenon?
If a patient has morning hyperglycemia, checking blood glucose levels between 2:00 and 4:00 AM for HYPERglycemia will help determine if the cause is the Dawn Phenomenon. - treat w/ increased insulin dose before bed
How do you check to see if the cause of morning hyperglycemia is the Somogyi effect?
If a patient has morning hyperglycemia, checking blood glucose levels between 2:00 and 4:00 AM for HYPOglycemia will help determine if the cause is the Somogyi effect. - treat w/ decreased insulin dose before bed
Occupational Chemicals and Dusts - Risk Factors for COPD
If a person has intense or prolonged exposure to various dusts, vapors, irritants, or fumes in the workplace, symptoms of lung impairment consistent with COPD can develop. If a person has occupational exposure and smokes, the risk for COPD increases.
Why are long- or intermediate-acting insulins given?
In addition to mealtime insulin, people with type 1 diabetes use a long- or intermediate-acting basal (background) insulin to MAINTAIN BS IN BETWEEN MEALS AND OVERNIGHT
What is the (1) onset, (2) peak, and (3) duration of long-acting insulin? **MUST KNOW**
LONG-ACTING INSULIN onset: 0.8 - 4 hrs peak: no pronounced/defined peak duration: 16 - 24 hrs
What do Dipeptidyl Peptidase-4 (DDP-4) Inhibitors do?
Inhibit DDP-4 which usually blocks Incretin hormones. Incretin hormones and Dipeptidyl Peptidase-4 (DDP-4) Inhibitors do the same thing! - Increases insulin release, decreases glucagon secretion, and decreases hepatic glucose production
Effective Coughing - Airway Clearance Techniques - Nursing INTV. for COPD
COPD pts often don't cough effectively due to fear of spastic coughing that would worsen dyspnea. - HUFF COUGHING will help 1. Position patient sitting; feet on floor; head flexed a bit; forearms supported by pillows; shoulders relaxed 2. FIRST teach diaphragmatic breathing 3. Place pt's hands on lower lateral chest wall 4. Breathing from diaphragm, INHALE slow through MOUTH 5. You should feel hand move outward (while placed on lateral chest wall) 6. HOLD BREATH 2-3 SECONDS 7. Forcefully exhale with a huff (like you're fogging up a mirror) (3 total huffs without coughing normally) 8. Cough up sputum when it's felt in breathing tubes 9. REST for 5-10 regular breaths 10. Repeat 3-5 cycles of Huff Coughing until mucus is clear or until patient is tired
T/F Aspirin prevents blood clots.
FALSE - Aspirin is NOTTTTT!! VTE prophylaxis
T/F If the Accu-Chek reads "L" or "H", this is not a problem.
FALSE If the glucose reader just says "L" or "H", this means that the readings are out of the machine's parameters! THIS IS A MEDICAL EMERGENCY. per Ketcherside, TREAT FIRST and then do another stat glucose.
**** PATIENT TEACHING for Acute Exacerbations of COPD
Early recognition of the 3 Primary Manifestations! 1. Increased dyspnea 2. Increased sputum volume 3. Increased sputum purulence Catching this early can allow for early start of treatment in order to avoid hospitalization and possible acute respiratory failure.
Hypoglycemia EMERGENCY TREATMENT (table 48.19)
FIRST: (per book!!) - check BG, if possible - assess to determine hypo- or hyper- - correct condition - assess to determine cause CONSCIOUS PT: - ingest 15g of fast-acting carbs - wait 15 min and test BG again - if <70, ingest another 15g - once BG is stable, ingest carbs + protein or fat if meal is more than 1 hr away - call HCP IMMEDIATELY if symptoms don't subside after 2-3 doses of fast-acting carbs WORSENING SX OR UNCONCIOUS PT: - subq or IM injection of 1 mg glucagon - OR an IV 20-50 mL of D50 - turn patient on side to prevent aspiration
Resistant HTN (table 32.9)
Failure to reach goal BP with appropriate therapy and drug regimen: increased risk of stroke or MI - excess salt intake - volume retention from kidney disease - inadequate diuretics - erythropoietin - licorice - Improper BP measurements (i.e., inappropriate BP cuff size) - Inadequate drug doses - Inappropriate drug therapy - Poor adherence to drug regimen (e.g., due to side effects, finances) - White coat syndrome
Pancreas Transplant
For Type 1 Diabetics. Patient must have: 1. Hx or frequent, acute, and severe metabolic conditions that require medical attention (hypo/hyperglycemia; ketoacidosis) 2. incapacitating clinical/emotional problems with exogenous insulin therapy 3. consistent failure of insulin-based management to prevent acute complications
Type 2 Diabetic Nutritional Therapy
Must center on meeting goals: glucose, lipid, and BP - 5-7% moderate weight loss improves insulin sensitivity - space out meals - exercise
Can long-acting insulins be diluted or mixed with any other insulin in the same vial or syringe?
NO
A Type 1 diabetic patient is about to exercise. They note that their BS is >250 with ketones present. Should they begin vigorous exercise? WHY?
NO. Delay vigorous activity until ketones are gone. Drink fluids. Why? The body can perceive strenuous activity as a stress, causing a release of counterregulatory hormones and a temporary elevation of blood glucose. In a person with type 1 diabetes who has hyperglycemia and ketones, exercise can worsen these conditions. No ketones? No need to delay exercise.
Figure 48.4 lists 1 intermediate-acting insulin. What is it?
NPH (Humulin N, Novolin N)
Charcot's foot "rocker-bottom foot"
Neuropathic arthropathy - results in ankle and foot changes that leads to joint dysfunction and footdrop - gradual changes that promote an abnormal distribution of weight over the foot
Does a pancreas transplant reverse the long-term renal and neurological complications of diabetes?
No, it's only partially effective there
What is the (1) onset, (2) peak, and (3) duration of rapid-acting insulin? **MUST KNOW**
RAPID-ACTING INSULIN onset: 10-30 minutes peak: 30 minutes to 3 hours duration: 3-5 hours
Sliding scale insulin orders use ONLY what two kinds of insulin?
Rapid- and short-acting because both cause a quick drop in BS.
Figure 48.4 lists 1 short-acting insulin. What is it?
Regular (Humulin R, Novolin R)
TREATMENT of acute exacerbations of COPD
Short-Acting Beta Agonists (SABAs) and oral systemic corticosteroids
** What should you teach patients about Self-Monitoring of Blood Glucose (SMBG)?
TEST: - before meals - 2 hrs after first bite of meals - every 4 hrs during illness - before/after exercise - when hypoglycemia is suspected EDUCATE: - monitoring/recording BG to review - prep and injection of insulin - sx of hypoglycemia and how to treat (carry candy, wear ID bracelet)
***HINT HINT*** Ketcherside said that we will need to be able to predict WHEN a patient could have an adverse reaction to their insulin!!
THIS MEANS MEMORIZE FIGURE 48.4 (I'm going to have all of this written out in this quizlet)
((I think that it's by the onset time that we need to begin monitoring for adverse effects.))
The book says that rapid-acting insulins have an onset of 15 minutes and so should be given 15 minutes before a meal. The rapid-acting analogs most closely mimic natural insulin secretion in response to a meal. So if that's when the insulin starts working, that's when we'd most likely first see an adverse reaction begin. I emailed Ketcherside just in case.
basal-bolus plan
The insulin approach that most closely mimics endogenous insulin. Consists of multiple daily insulin injections (or an insulin pump) together with frequent self-monitoring of blood glucose (or a continuous glucose monitoring system). Injections include rapid- or short-acting (bolus) insulin before meals and intermediate- or long-acting (basal) background insulin once or twice a day. The goal is to achieve a glucose level as close to normal as possible, as much of the time as possible. This is referred to as "time in range."
What are the appropriate ranges for a lipid panel?
Total cholesterol: Below 200 mg/dL HDL (good) cholesterol: Above 60 mg/dL LDL (bad) cholesterol: Below 100 mg/dL (For people with diabetes: Below 70 mg/dL) Triglycerides: Below 150 mg/dL
The most pronounced symptom of ACE Inhibitor overdose is hypotension. What is the treatment?
Treatment is symptomatic and supportive and includes (1) the administration of intravenous fluids to expand the blood volume. (2) Hemodialysis is effective for the removal of captopril and lisinopril.
For type 1 diabetes, what is likely to occur if they don't use 24-hour background insulin?
Without 24-hour background insulin, people with type 1 diabetes are more prone to developing DKA.
Troponin
a result between 0.04 and 0.39 ng/ml often indicates a problem with the heart - increase 4-6 hrs after an MI - peak at 10-24 hrs - return to baseline after 2 weeks - The presence of biomarkers helps distinguish between UA (negative biomarkers) and NSTEMI (positive biomarkers)
** Atherosclerosis symptoms
basically, Ketcherside kept saying that ischemia to the heart is going to cause pain so angina is the main symptom
Why is insulin not taken orally?
because it is inactivated by gastric fluids
Why can't you inject insulin IM?
because rapid and unpredictable absorption could result in hypoglycemia ((The abdomen is preferred for insulin injection because it has the most predictable blood flow. Muscle use disrupts blood flow and may change insulin absorption time))
Insulin Resistance
body tissues do not respond to the action of insulin because insulin receptors are: - unresponsive - are insufficient in number - or both
Hypercoagulability of Blood
caused by: - severe anemias - polycythemia - cancers - nephrotic syndrome
Left-Sided Heart Failure - SIGNS
• Left ventricular heaves • ↑ HR • Pulsus alternans (alternating pulses: strong, weak) • PMI displaced inferiorly and left of the midclavicular line (LV hypertrophy) • ↓ PaO2, slight ↑ PaCO2 (poor O2 exchange) • Crackles (pulmonary edema) • S3 and S4 heart sounds • Pleural effusion • Changes in mental status • Restlessness, confusion • Shallow respirations up to 32-40/min • Dry, hacking cough • Frothy, pink-tinged sputum (advanced pulmonary edema)
Prediabetes
defined as: - impaired glucose tolerance (IGT) - impaired fasting glucose (IFG) - or both These patients are in an intermediate stage between normal BG homeostasis and diabetes. - often asymptomatic; HOWEVER, long-term damage may already be occurring - patients at increased risk for Type 2 diabetes
Which long-acting insulin is often given twice daily?
detemir
Type 1 Diabetes - Need for Insulin
every single Type 1 diabetic will require insulin therapy for the rest of their lives
Reticular Varicose Veins
flat, less tortuous, blue-green
Diaphragmatic (abdominal) breathing - COPD
focuses on using the diaphragm instead of the accessory muscles of the chest to (1) achieve maximum inhalation and (2) slow the respiratory rate - may increased WOB and dyspnea - moderate to severe COPD patients are contraindicated for diaphragmatic breathing
Nursing Health Promotion - Asthma
focuses primarily on teaching both the patient and caregiver - ID and avoid known triggers and irritants - avoid NSAIDs, aspirin, propranolol (β-blockers inhibit bronchodilation) - weight loss improves asthma control - maintain a fluid intake of 2 to 3 L/day,
Patients with sputum smear-positive TB are considered infectious for how long?
for the first 2 weeks after starting treatment
Thiazide Diuretics
hydrochlorothiazide - supplement with potassium-rich food monitor for: - orthostatic hypotension - hypokalemia (sodium restriction helps balance this) - alkalosis
DVT Risk Factors
hypercoagulability of blood - female smokers (Smoking causes hypercoagulability by increasing plasma fibrinogen and homocysteine levels and activating the intrinsic coagulation pathway) - women of childbearing age - women on oral contraceptives - postmenopausal on oral hormone therapy - family hx of VTE - over 35
How is prediabetes impaired glucose tolerance (IGT) diagnosed?
if the 2-hour oral glucose tolerance test (OGTT) values are 140 to 199
HACKING DRY COUGH
in order of which classes causes this most often: 1. ACEs 2. Beta Blockers 3. ARBs - if your patient develops a dry hacking cough on an ACE Inhibitor, your HCP will change them to an ARB.
What do the Sulfonylureas do? What are 2 major side effects of this?
increase insulin production in the pancreas - hypoglycemia - weight gain
Aggressive Treatment for OSA
indicated for severe OSA (>15 apnea/hypopnea events/hour) - continuous positive airway pressure (CPAP) by mask IS NUMBER ONE --- high-flow blower maintains positive pressure, enlarging the airway 5-25 cm to prevent collapse during inspiration/expiration - bilevel positive airway pressure (BiPAP), can deliver a higher inspiration pressure and a lower pressure during expiration (some pts can't exhale against the high pressure of CPAP) - BOTH MUST BE USED FOR A MINIMUM OF 4 HOURS NIGHTLY TO REDUCE THE NEGATIVE CV EFFECTS OF OSA
2 categories of diabetic neuropathy
sensory autonomic
** Anti-Factor Xa for Enoxaparin
should have zero Anti-Factor Xa in healthy patients. 0.2 - 1.5 units/mL of Anti-Factor Xa in therapeutic range ???
What is the main ACE inhibitor used?
lisinopril
Chest Physiotherapy - Airway Clearance Techniques - Nursing INTV. for COPD
mainly used for patients with excessive bronchial secretions - Postural drainage - Percussion - Vibration Only done by someone properly trained. Complications: - fractured ribs - bruising - hypoxemia - discomfort - stress - bronchospasms
Which OA of Biguanide class is the only med available in the US?
metformin
*** Risk Factors of OSA
modifiable: - obesity (BMI >30) - neck circumference greater than 17" - smokers - excessive daytime sleepiness nonmodifiable: - 65+ yrs old - acromegaly - craniofacial abnormalities that affect the upper airway - more common in men before menopause, then it's equal
How do you test for Loss of Protective Sensation (LOPS)?
monofilament - done by applying a thin, flexible filament to several spots on the plantar surface of the foot and asking the patient to report if it is felt. - Insensitivity to a monofilament greatly increases the risk for foot ulcers that can lead to amputation
Can sublingual nitroglycerin be stored in a different container, like in a locket from that scene in latest Conjuring movie?
no! - Sublingual nitroglycerin tablets must be stored in their original container because exposure to air and moisture can inactivate the drug.
2 Classifications of Retinopathy - chronic complication of diabetes
nonproliferative or proliferative
exercise-induced bronchospasm (EIB)
occurs after vigorous exercise, not during it (jogging, aerobics, walking briskly, climbing stairs)
Venous Stasis
occurs when the valves are dysfunctional or the muscles of the extremities are inactive - obesity - pregnancy - chronic CHF - chronic atrial fibrillation - traveling on long trips without regular exercise - prolonged surgical procedure - immobile for long periods (spinal cord injury, fractured hip, limb paralysis)
*** FEMALE SYMPTOMS OF HEART DISEASE (Gender Differences on pg 701)
often "atypical", underreported, underserved symptoms. - fatigue (often first sign) - shortness of breath - upper back pain - indigestion - weakness - sleep problems - palpitations - anxiety
Potassium-Sparing Diuretics
spironolactone, amiloride, triamterene - caution with ACEs and ARBs --- watch for hyperkalemia - monitor for orthostatic hypotension
Diabetes-related dermopathy - chronic complications of diabetes
the most common skin complication w/ diabetes - characterized by reddish brown, round or oval patches - initially scaly then flatten out until they INDENT - often on shins; can be on thighs, forearm, side of foot, scalp, trunk
Where is pramlintide injected?
thigh or abdomen NOT in the arm bc absorption here is too variable.
Patients with respiratory issues should ALWAYS be assessed for:
tuberculosis
For patients with lung disease, should the affected lung be up or down in reference to patient positioning?
up! you want to drain the lung secretions into the trachea. the good, healthy lung will be down. (if the patient's left lung is bad, position the pt on their R side so their left lung is up)
Patient Education - Peak Flow Meter - Asthma
peak flow meter may tell you if there is narrowing in the airways hours, sometimes even days, before you have any asthma symptoms - you're trying to show your Peak Expiratory Flow Rate (PEFR) - take readings twice daily for 2-3 weeks, between noon and 1400 - take readings BEFORE taking meds 1. move indicator to the bottom of the system 2. stand up 3. take a deep breath, filling lungs totally 4. put mouthpiece between lips and exhale as hard/fast as possible in ONE blow Green Zone - 80% of your personal best number; takes meds as normal Yellow Zone - 50 to <80% of your personal best; take SABA; consistent yellow zones suggest that the asthma isn't handled well Red Zone - <50% of your personal best number; Medical Emergency; Take SABA and either call HCP or go to ED
How is prediabetes impaired fasting glucose (IFG) diagnosed?
when fasting blood glucose levels are 100 to 125
**** Angina Equivalent
women and older adults report atypical symptoms of angina - dyspnea - nausea - mid-epigastric discomfort - fatigue
polysomnography (PSG)
physiologic measures of brain waves, eye movements, and muscle tone that shows the pattern of nighttime sleep - shows rapid eye movement (REM) sleep and non-rapid eye movement (NREM) sleep
Name the Amylin Analog medication
pramlintide
exercise-induced asthma (EIA)
pronounced during activities in which there is exposure to cold, dry air - swimming in an indoor heated pool is less likely to cause symptoms than downhill skiing
What is the antidote for heparin?
protamine sulfate
T/F Thiazolidinediones are rarely used in the US due to adverse side effects.
T
What do Thiazolidinediones do?
"insulin sensitizers" MOST effective in those w/ insulin resistance - reduces hepatic (liver) glucose production - increases the uptake/use of glucose in (1) muscles and (2) adipose tissue - enhances insulin sensitivity in tissue - improves glucose transport into cells
What do α-Glucosidase Inhibitors do?
"starch blockers" - they slow absorption of carbs in the small intestine
*** APTT LEVELS FOR HEPARIN
((healthy pt not on meds)) Normal APTT for heparin: 30 - 40 seconds ((clot-prone pt on meds)) Therapeutic APTT for heparin: 46 - 70 seconds
*** INR LEVELS FOR WARFARIN
((healthy pt not on meds)) Normal INR for warfarin: 0.75 - 1.25 ((clot-prone pt on meds)) Therapeutic INR for warfarin: 2 - 3
** Breathing Retraining - Nursing INTV. for COPD
(1) pursed-lip breathing and (2) diaphragmatic breathing - (PLB) is to prolong exhalation, which prevents bronchiolar collapse and air trapping - slows RR
Telangiectasias
(spider veins) - small (smaller than 1 mm) blue-black, purple, or red
MEMORIZE****** Diagnosis of diabetes is made using 1 of the following 4 methods:
- A1C of 6.5% or higher - Fasting plasma glucose (FPG) level of ≥126 - 2hr plasma glucose level of ≥200 during an OGTT, using a 75g glucose load - a random BG of ≥200 in a patient with hyperglycemic symptoms ((THE FIRST 3 TESTS MUST BE REPEATED ON ANOTHER VISIT!!!! THE LAST CAN BE DONE ONCE FOR A DX))
PAD Treatment
- ACE Inhibitors - aspirin daily - clopidrogrel (Plavix) - warfarin IS NOT RECOMMENDED for prevention of stroke in PAD patients
Gerontologic Considerations: COPD
- ACE inhibitors may cause a dry cough or worsen a present cough - β-blockers can block the β2 receptors in the airway and cause bronchoconstriction - co-morbidities can make it harder for patients to cope with the stress of an exacerbation - cognitive impairment and complexity of the multiple medications at different times of the day can cause treatment nonadherence - simplify the medication regimen with written large-font action plans - Review MDI technique during clinic visits and have DPI or spacers prescribed (if possible) due to arthritic hands - Monitoring of ocular pressures, bone densitometry, and using the lowest possible ICS dose is recommended Summary: - Older adults have physiologic changes, including reduced lean body mass, decreased respiratory muscle strength, increased dyspnea, and lower exercise tolerance that may increase the burden of disease from COPD. - This may lead to a higher incidence of acute exacerbations, which require hospitalization
Obstructive Sleep Apnea (OSA)
- AKA "obstructive sleep apnea-hypopnea syndrome (OSAHS)" - characterized by partial or complete upper airway obstruction during sleep - cessation of respiratory airflow (90% or greater reduction) lasting longer than 10 seconds - shallow respirations (30%-90% reduction in airflow) - Each obstruction may last from 10 to 90 seconds - may cause hypoxemia and hypercapnia
Reactivation TB
- AKA "post-primary TB" - TB disease occurring 2+ years after the initial infection
Risk Factors for Pneumonia
- Abdominal or chest surgery - Age >65 years - Air pollution - Altered consciousness: alcoholism, head injury, seizures, anesthesia, drug overdose, stroke - Bed rest and prolonged immobility - Chronic diseases: chronic lung and liver disease, diabetes, heart disease, cancer, chronic kidney disease - Debilitating illness - Exposure to bats, birds, rabbits, and farm animal droppings (excrement) - Immunosuppressive disease and/or therapy (corticosteroids, cancer chemotherapy, HIV infection, immunosuppressive therapy after organ transplant) - Inhalation or aspiration of noxious substances - Intestinal and gastric feedings via nasogastric or nasointestinal tubes - IV drug use - Malnutrition - Recent antibiotic therapy - Resident of a long-term care facility - Smoking - Tracheal intubation (endotracheal intubation, tracheostomy) - upper respiratory infection (URI)
Table 48.9 lists activity levels. What are their 8 examples for moderate activity?
- Active housework - Bicycling (light) - Bowling - Dancing - Gardening - Golf - Roller skating - Walking briskly
Acute Respiratory Failure - complications of COPD
- All too often, COPD patients wait too long to contact their HCP when they first develop symptoms suggestive of an exacerbation. - Similarly, suddenly stopping a bronchodilator or corticosteroid medication may cause respiratory failure
What are the two classes of Noninsulin Injectable Agents?
- Amylin Analogs - Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists
What are the 7 main classes of OAs and noninsulin injectable agents?
- Biguanides *** - Sulfonylureas *** - Meglitinides (safer than usual insulins) *** - α-Glucosidase Inhibitors - Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors - Dipeptidyl Peptidase-4 (DDP-4) Inhibitors - Thiazolidinediones
General Patient Education for COPD (TABLE 28.24)
- COPD CANNOT BE CURED - activities should be increased GRADUALLY (if recovery takes 5+ minutes, you're doing too much) - keep a record log of exercise/activity - make a schedule for all activities so time for rest is accounted for - sit as much as possible (severe COPD) - EXHALE while pushing/pulling/exerting effort (inhale on rest) - coordinated walking with slow, pursed-lip breathing - exercise training of arms to improve functioning and reduce dyspnea - maintain a healthy weight - Smoking cessation is the only way to slow the progression of COPD (in smokers, ofc) - Avoiding or controlling exposure to pollutants/irritants - Avoid people who are sick - encourage influenza and pneumococcal pneumonia vaccines - patients with a family hx of COPD or AATD should be screened regularly (spirometry screening) - try to combine activities to conserve energy - explore alternative ways to perform ADLs that conserve energy (tripod posture, mirror stand, and electric razor vs standing and shaving) - encourage using typed messages to speak (due to dyspnea) - assess mental health!!! depression, guilt, denial, fear - support groups, CBT, buspirone (no benzos) - use an inhaled bronchodilator before sexual activity - coordinate all activities for (1) when breathing best (usually late morning/early afternoon), (2) use pursed-lip breathing, (3) avoid activity after eating/drinking alcohol, (4) use O2
**Nonpharmacological Interventions to Reduce/Control Blood Pressure
- DASH diet may decrease SBP by 11 mm Hg! - Regular moderate exercise may decrease SBP by 4-9 mm Hg - every kg lost is 1 mm Hg decrease in BP - sodium should be under 1500-2300 mg/day - read all food/drug labels (baking soda in toothpaste counts as sodium)
Adverse Effects of ACE Inhibitors
- DRY HACKING COUGH (most common with ACEs) - HYPOTENSION - teratogenic in the last 2 trimesters - Hyperkalemia (DON'T give with spironolactone!) --- ACE inhibitors promote potassium resorption in the kidney, although they promote sodium excretion due to their reduction of aldosterone secretion - decreased renal function - fatigue, dizziness, mood changes, and headaches - loss of taste - angioedema (laryngeal swelling) (a strong vascular reaction involving inflammation of submucosal tissues, which can progress to anaphylaxis)
Hyperglycemia TREATMENT
- Diabetes meds as prescribed - Check BG often and record - Check for ketones in urine and record - Drink fluids on an hourly basis - Call HCP if ketonuria
Hyperglycemia CLINICAL COURSE
- GRADUAL onset - The definition of elevated BG varies per person based on personal glucose targets (so not everyone with a BG of 110 is considered hyperglycemic)
nursing interventions involving airborne infection protocols
- HEPA masks must be worn when entering room --- MUST be refitted if (1) your weight changes, (2) you have facial/Botox or dental changes, (3) there is a new model of the mask available --- otherwise, annual "fit testing" is ok
risk factors for diabetes-related nephropathy
- HTN - genetic predisposition - smoking - chronic hyperglycemia
Indications for ACE Inhibitors
- HTN - heart failure - acute MI - reduce blood pressure by decreasing SVR!! - prevent sodium and water resorption by inhibiting aldosterone secretion; this causes diuresis!!
long-term effects of OSA
- HTN - cardiac dysrhythmias - arteriosclerosis - heart failure - cardiovascular-related mortality
What can cause reactivation TB?
- Immunosuppression - diabetes - poor nutrition - aging - pregnancy - stress - chronic disease
Lipodystrophy and Atrophy with Insulin
- Lipodystrophy (loss of subcutaneous fatty tissue) may occur if the same injection sites are used frequently --- Human insulin has significantly reduced this - Atrophy, which is uncommon, is the wasting of subcutaneous tissue and presents as indentations in injection sites
Diuretic Therapy
- Loop Diuretics - Potassium-Sparing Diuretics - Thiazide Diuretics
metformin DRUG ALERT *****
- MUST HOLD MED if surgery/procedure W/ CONTRAST!! - metformin + contrast = AKI (acute kidney injury) - (1) one to two days BEFORE - (2) 48 hrs AFTER - serum creatinine MUST be within normal limits (WNL) before starting metformin again; this shows normal kidney functioning**** - TAKE w/ food to minimize GI upset
Patients who are traveling or are visually impaired may prefill their syringes. What main 4 teaching points do you tell these patients?
- Prefilled syringes of mixed insulin are stable for 1 week in the fridge. - Prefilled syringes of one insulin are stable for 30 days in the fridge. - Syringes must be stored NEEDLE UP to avoid clumping of suspended insulin. - NOT ALL insulins can be prefilled.
***** COMPLICATIONS OF COPD
- Pulmonary HTN - cor pulmonale - acute exacerbations - acute respiratory failure
Hypoglycemia CLINICAL COURSE
- RAPID onset - Pattern of manifestations changes over time
**** cor pulmonale - Complication of COPD
- RIGHT-SIDED HEART FAILURE - late manifestation of COPD (doesn't develop in all pts) - this worsens the pt's prognosis - Pulmonary HTN results in increased right ventricle pressure, causing hypertrophy of R ventricle, causing R CHF
*** A1C does what? What is the range?
- Reflects glucose levels over the past 2-3 months. Hemoglobin A1C will prove if the patient has been adherent to treatment or not!! It's only within range if BS has been consistently within range. - GOAL: <6.5 - 7%
T/F Anticoagulant therapy does not dissolve the clot.
T - Clot lysis begins naturally through the body's intrinsic fibrinolytic system
COPD - Clinical Manifestations
- SLOW development - chronic intermittent cough (FIRST SIGN) - inability to expire air (MAIN CHARACTERISTIC) - chest heaviness - unable to take deep breaths - use of intercostal and accessory muscles to breathe - rationalization statements: "I'm getting older" or "I'm out of shape" - barrel-shaped chest - hypoxemia (LATE); may first develop with exercise - pt is dyspneic with limited exercise capacity - dyspnea at rest (late) - pursed-lip breathing - tripod position; pt sits upright with arms supported on a fixed surface to breathe - Excess mucus production, resulting in a chronic productive cough, is a feature of persons with predominant chronic bronchitis ((not all COPD patients)) - Pulmonary vascular changes resulting in mild to moderate pulmonary HTN may occur late in the course of COPD - fatigue; highly prevalent symptom that affects the patient's ADLs -weight loss - anorexia - Edema in the ankles (may be the only sign of R-sided heart involvement) - SpO2 <88% on room air - polycythemia (develops from increased production of red blood cells as the body tries to compensate for chronic hypoxemia) - hemoglobin reaches 20+ - but, patient is likely to have chronic anemia (so hemoglobin and hematocrit will probably be low) - cyanosis
Infection - Risk Factors for COPD
- Severe recurring respiratory tract infections in CHILDHOOD have been associated with reduced lung function and increased respiratory symptoms in adulthood - any relevance of recurrent infections in adults in unclear - HIV-positive patients and TB-positive patients are all at higher risk for COPD
What do Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists do?
- Slows gastric emptying - decreases glucagon secretion - Stimulates release of insulin - ↑ Satiety (satisfied feeling of being full after eating)
What does pramlintide do?
- Slows gastric emptying - decreases glucagon secretion - decreases endogenous glucose output from liver - ↑ Satiety (satisfied feeling of being full after eating)
Coronary Artery Disease - complication of HTN
- When atherosclerosis affects arteries that carry blood to the heart muscle, it's called coronary artery disease (CAD) - HTN disrupts the coronary artery endothelium which results in a rigid arterial wall with a narrowed lumen --- this accounts for the high rate of CAD, angina, and MI
Why is sublingual nitroglycerin preferred over oral?
- When given orally, nitroglycerin goes to the liver to be metabolized before it can become active in the body. During this process, a very large amount of the nitroglycerin is removed from the circulation. This is called a "large first-pass effect" - the area under the tongue and inside the cheek is highly vascular - This means that the nitroglycerin is absorbed quickly and directly into the bloodstream - hence its therapeutic effects occur rapidly.
Hypoglycemia Unawareness
- a condition in which a person does not have the warning signs and symptoms of hypoglycemia until the glucose level reaches a critical point - pt may become incoherent, combative, unconcious - often caused by diabetes-related autonomic neuropathy
Idiopathic Diabetes
- a form of type 1 diabetes that is strongly inherited and not related to autoimmunity - only occurs in a small number of people - most often of Hispanic, African, or Asian ancestry.
Acanthosis nigricans - skin complication - chronic complications of diabetes
- a manifestation of insulin resistance - velvety light brown to black skin thickening, mainly on flexures, axillae, and the neck - looks like dirt!
Chronic obstructive pulmonary disease (COPD)
- a preventable, treatable, but often progressive disease characterized by persistent airflow limitation - associated with an enhanced chronic inflammatory response in the airways and lungs - primarily caused by (1) cigarette smoking and (2) other noxious particles and gases
Latent autoimmune diabetes in adults (LADA)
- a slowly progressing autoimmune form of type 1 diabetes - occurs in adults and is often mistaken for type 2 diabetes
Deep vein thrombosis (DVT)
- a thrombus in a deep vein, most often the iliac and/or femoral veins thrombus = (blood clot) with vein inflammation
Besides hyperglycemia, what other 2 things might the patient report upon awakening due to the Somogyi effect?
- headaches upon awakening - pt recalls having night sweats or nightmares
Heart Failure
- heart's compensatory mechanisms are overwhelmed and the heart can no longer pump enough blood to meet the body's demands Symptoms: - SoB on exertion - paroxysmal nocturnal dyspnea - fatigue
Airway Clearance Devices - Nursing INTV. for COPD
- help mobilize secretions - better tolerated than CPT and are faster - use positive expiratory pressure (PEP) Devices: - Flutter --- pt exhales through the Flutter, the steel ball moves, which causes oscillations (vibrations) in the airways and loosens mucus --- pt MUST be sat upright - Acapella --- combines the benefits of both PEP and airway vibrations to mobilize secretions --- can be used sitting, standing, reclining - TheraPEP Therapy System --- provides sustained PEP and while delivering aerosols so that the patient can inhale and exhale through it --- pressure indicator gives visual feedback about the pressure that the patient needs to hold in an exhalation to receive the PEP - High-Frequency Chest Wall Oscillation --- pulse generator delivers air to the inflatable vest, which vibrates the chest, dislodging mucus from the airways, mobilizes the mucus, and moves it toward larger airways --- can be used alone, weights 23-30 lbs, is quiet, comes in a suitcase (portable)
Asthma
- heterogenous disease characterized by bronchial hyperreactivity with reversible expiratory airflow limitation - episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night or in the early morning - clinical course of asthma is unpredictable
Risk Factors for TB:
- homelessness - residents of inner-city neighborhoods - foreign-born people - those living or working in institutions (long-term care facilities, prisons, shelters, hospitals) - IV injecting drug users - overcrowded living conditions - less than optimal sanitation - poor access to health care - Immunosuppression from any cause (HIV infection, cancer, long-term corticosteroid use) - (1) Asians, (2) Hispanics, (3) black patients
What are side effects of the noninsulin injectable agents?
- hypoglycemia - N/V - headache pramlintide: - decreased appetite Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists: - diarrhea
What are 5 complications with insulin therapy?
- hypoglycemia - allergic reactions - lipodystrophy - hypertrophy - the Somogyi effect
What are 2 major side effects of Meglitinides? What is their onset time? Why is this helpful?
- hypoglycemia - weight gain Rapid onset of Meglitinides decreases the risk for hypoglycemia! This makes Meglitinides safer than insulin!
Hyperglycemia CAUSES
- illness, infection - corticosteroids - too much food - too little medication - too little exercise - stress (emotional or physical) - poor absorption of insulin
Signs/Symptoms of Peripheral Artery Disease (PAD)
- intermittent claudication - pain at rest - cold feet - loss of hair - delayed capillary filling - dependent rubor (redness of the skin that occurs when the extremity is in a dependent position)
Type 1 Diabetes - SYMPTOMS
- ketoacidosis begins and the patient becomes symptomatic - 3 P's (polydipsia, polyphagia, polyuria) - fatigue - weight loss
contraindications of calcium channel blockers
- known drug allergy - acute MI - second- or third-degree AV block (unless pt has a pacemaker) - hypotension
Contraindications for ACE Inhibitors
- known drug allergy - hyperkalemia - pregnancy/breastfeeding - respiratory disease (dry hacking cough)
Contraindications of ARBs
- known drug allergy - pregnancy/breastfeeding Caution: - older adults - renal dysfunction - concurrent antihypertensives
Contraindications for Nitroglycerin
- known drug allergy - severe anemia - closed-angle glaucoma - hypotension - severe head injury - concurrent use of sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) --- these patients could bottom out and die lol
Hyperosmolar hyperglycemia syndrome (HHS)
- life-threatening syndrome that can occur in the patient with diabetes who is able to make enough insulin to prevent DKA, but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion - less common than DKA
Figure 48.4 lists 3 rapid-acting insulins. What are they?
- lispro (Humalog) - aspart (Novolog) - glulisine (Apridra)
Allergic Reactions to Insulin
- local inflammatory reaction to insulin injection site - itching, erythema, and burning - may be self-limiting within 1-3 months or may be treated with a low dose of antihistamine - true allergic reaction is rare!! (hives and anaphylaxis) --- it's more often associated with preservatives used or the latex stoppers on the vials than the insulin
Diabetes-related neuropathy
- nerve damage that occurs because of the metabolic imbalances associated with diabetes - most common is Sensory neuropathy -- can lead to the loss of protective sensation in the lower limbs
Nitroglycerin
- nitrate; so it's a vasodilator - Rapid-acting dosage form - used to treat acute anginal attacks!** - prevention of angina while in situations likely to provoke an attack**
Causes of OSA
- no single cause - multiple factors can influence airway patency and the tone of airway musculature
Genetics - Risk Factors for COPD
- nonsmokers can develop COPD - Alpha-1 Antitrypsin Deficiency (AATD) is the only genetic link identified - it's a serum protein made by the liver and normally found in the lungs - it's main job is to protect normal lung tissue from attack by proteases during inflammation related to smoking and infections - Severe AATD leads to premature bullous emphysema in the lungs
What do BNP levels usually do? How is this different for cor pulmonale?
- normally used to distinguish causes of dyspnea (cardiac OR respiratory) - in cor pulmonale, the cause of the heart failure is the lung disease
Latent TB infection (LTBI)
- occurs in a person who does not have active TB disease - have a positive skin test but are asymptomatic - cannot transmit the TB bacteria to others but can develop active TB disease at some point
Primary TB Infection
- occurs when the bacteria are inhaled and start an inflammatory reaction - Most people mount effective immune responses to encapsulate these organisms for the rest of their lives, preventing the initial infection from progressing to disease - If the initial immune response is not adequate, the body cannot contain the organisms. - As a result, the bacteria replicate and active TB disease results
diabulimia
- only affects Type 1 diabetics - when the patient skips their insulin on purpose in order to lose weight - leads to weight loss, hyperglycemia, and glycosuria because the food ingested cannot be used for energy without adequate insulin
Insulins differ by 3 things:
- onset - peak - duration
Air Pollution - Risk Factors for COPD
- outdoor air pollution - exposure to coal - exposure to biomass fuels used in indoor heating/cooking in poorly ventilated areas
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors end with what suffix? What are the 3 drugs?
-gliflozin Canagliflozin Dapagliflozin Empagliflozin (Jardiance)
Dipeptidyl Peptidase-4 (DDP-4) Inhibitors end with what suffix? What are the four drugs?
-gliptins Alogliptin Sitagliptin Saxagliptin Linagliptin
Sulfonylureas end with what suffix? What are the 3 drugs?
-ide glimepiride glipizide glyburide
Thiazolidinediones end with what suffix? What are the 2 drugs?
-litazone Pioglitazone Rosiglitazone
What suffix do most ARBs end with?
-sartan
Acute Complications of Diabetes
1. Acute Illness and Surgery 2. Hypoglycemia 3. Diabetic ketoacidosis (DKA) 4. Hyperosmolar Hyperglycemic Syndrome (HHS)
The Noninsulin Injectable Agents end with what suffix?
-tide
Classifications of TB (Class 0-5)
0. Zero TB infection; not infected (zero hx of exposure; negative tuberculin test) 1. TB exposure; NOT infected (hx of exposure; negative tuberculin test) 2. Latent TB infection; no disease (positive tuberculin test; negative bacteriological studies; no clinical evidence of TB) 3. TB, clinically active (positive tuberculin and bacteriological studies; clinical evidence of current disease) 4. TB, but NOT clinically active (no current disease; hx of previous episode; positive tuberculin test; negative bacteriological test; no clinical evidence of current disease) 5. TB suspect; (diagnosis pending). Patient should not be in this classification for >3 mo
For some patients, insulin doses are tailored to the amount of carbs to be consumed. What is the usually dose relationship between insulin and carbs?
1 U/15 g carbohydrate 2 U/25 g carbohydrate
*** Clinical Manifestations of Peripheral Artery Disease
1. **Intermittent Claudication (muscle pain with exercise due to lactic acid; resolves with rest and elevation; reproducible) --- iliac arteries is butt and thigh pain --- femoral or popliteal is calf pain 2. **REDUCED BLOOD FLOW --- thin, shiny, taut --- no hair on legs --- poor leg pulses --- pallor in elevated legs; hyperemia when dependent --- cool to touch 3. Progressive PAD CAN CAUSE REST PAIN THAT WORSENS WITH LIMB ELEVATION --- most often happens at night 4. Critical limb ischemia (CLI) 5. Can be asymptomatic 6. Atypical sx (burning, heaviness, pressure, tightness) in atypical locations (ankle, foot, hamstrings, hip, knee, shin) 7. Paresthesia due to nerve tissue ischemia 8. **Arterial (ischemic) ulcers most often occur over bony prominences on the toes, feet, and lower legs
** Diagnosis of Chronic Angina
1. Detailed H&P 2. 12-lead ECG 3. Lab tests for cardiac biomarkers (drawn three times q6h over 24-hrs) 4. Risk factors for CAD 5. Chest C-ray to look at heart 6. Exercise stress test - Cardiac Catheterization is gold standard to ID and localize CAD.
How does airway obstruction happen in OSA?
1. narrowing of the air passages with relaxation of muscle tone during sleep 2. AND/OR the tongue and soft palate falls backward to partially or completely obstruct the pharynx
Asthma Triad
1. nasal polyps 2. asthma 3. sensitivity to salicylic acid (aspirin) and NSAIDs
How can chronic hyperglycemia cause cell/tissue damage?
1. the accumulation of damaging by-products of glucose metabolism, such as sorbitol, damages nerve cells 2. the formation of abnormal glucose molecules in the basement membrane of small blood vessels (which serve the eyes and kidneys) 3. RBC dysfunction leads to decreased oxygenation in these tissues
Virchow's Triad (3 key factors that cause venous thrombosis)
1. venous stasis 2. damage of the endothelium (inner lining of the vein) 3. hypercoagulability of the blood
** Patient Education - Dry Powder Inhaler (DPI)
1. Remove mouthpiece 2. Load med into inhaler - DO NOT SHAKE DPI 3. Tilt head away from inhaler and breathe out as much air as possible; don't exhale into inhaler! 4. Close lips tight around inhaler 5. Inhale DEEP and QUICK 6. HOLD BREATH for at least 10 seconds!!
What 3 things are contraindicated for metformin?
1. Renal, hepatic, cardiac disease; may cause lactic acidosis (rare complication of metformin accumulation) 3. iodine-based contrast 4. Excessive alcohol intake
** Patient Education - Metered-Dose Inhaler (MDI)
1. Take off cap and SHAKE inhaler 2. Breathe out all the way 3. Hold inhaler about 2" away from mouth 4. Begin inhaling SLOWLY, then press down on inhaler ONCE. 5. Continue to breathe in, as DEEP as possible 6. HOLD BREATH for 10 seconds 7. If the medicine is an Inhaled Quick-Relief, then wait 1 minute between doses; all others require no wait -- using a spacer or gargling water/mouthwash between uses will help prevent hoarseness, and dry cough (local side effects caused by inhalation of corticosteroids)
Types of Pneumonia
1. Viral pneumonia 2. Bacterial pneumonia 3. Aspiration 4. Necrotizing 5. Opportunistic
Interventions for patients strongly suspected to have TB: (3)
1. airborne isolation precautions 2. medical workup (chest x-ray; sputum smear and culture) 3. appropriate drug therapy
CHF Signs/Symptoms
1. dyspnea (early) (most common) - Orthopnea, or dyspnea in the recumbent position, is redistribution of fluid from the lower extremities into the lungs while supine --- relieved with sitting up - Paroxysmal nocturnal dyspnea (PND) is caused by fluid accumulation in the lungs entering the alveoli while supine 2. A chronic, nonproductive cough that is worse in the recumbent position 3. Tachycardia (early) 4. Palpitations 5. Edema 6. Anuria - but then Nocturia bc of increased renal perfusion while supine 7. Skin mottling 8. Syncope 9. Insomnia 10. Angina 11. Weight Changes
DKA TREATMENT
1. ensure airway 2. give oxygen 3. establish IV access w/ LARGE-BORE catheter and begin fluid and electrolyte replacement 4. fluid resuscitation with 0.9% NaCl solution 1 L/hr until BP stabilized and urine output 30-60 mL/hr. 5. Monitor and replace potassium before starting insulin therapy. Insulin drives K+ into cells leading to hypokalemia; potentially life-threatening. 6. Begin continuous regular insulin drip 0.1 U/kg/hr.
Adverse Effects of Nitroglycerin
1. headache (diminishes soon) - postural hypotension - If nitrate-induced vasodilation occurs too rapidly, the cardiovascular system over-compensates and increases the heart rate, a condition referred to as "reflex tachycardia" - the large shift in blood volume (due to vasodilation) triggers a false sensation of blood loss; HR increases to move the "smaller amount of blood" towards the vital organs (the heart included) - contact dermatitis (skin inflammation) - tolerance develops quickly in patients taking nitrates around the clock
Risk Factors for DKA
1. illness 2. infection 3. inadequate insulin dosages 4. undiagnosed Type 1 diabetes 5. lack of education, understanding, or resources 6. neglect
Symptoms of TB
1. initial dry cough that often becomes productive with mucoid or mucopurulent sputum 2. constitutional symptoms (fatigue, malaise, anorexia, unexplained weight loss, low-grade fevers, night sweats) 3. late sign is dyspnea 4. hemoptysis (coughing up blood)
Steps of DKA
1. insulin supply is insufficient; glucose isn't able to be used to create energy 2. body breaks down fat stores as secondary fuel source 3. ketones are acidic by-products of fat metabolism 4. ketosis alters the pH balance, causing metabolic acidosis to develop 5. ketonuria is a process that occurs when ketone bodies are excreted in the urine 6. During this process, electrolytes that are cations are also excreted with the anionic ketones to try to maintain electrical neutrality 7. severe depletion of sodium, potassium, chloride, magnesium, and phosphate 8. Vomiting caused by the acidosis results in more F/E losses. 9. Eventually, hypovolemia, followed by shock, will ensue. 10. Renal failure from hypovolemic shock causes the retention of ketones and glucose, and the acidosis progresses. 11. Untreated, the patient becomes comatose from dehydration, electrolyte imbalance, and acidosis. 12. Untreated, death is inevitable.
A serving size of carbohydrates is how many grams?
15 g
When should you check BS after a meal to determine if the bolus insulin dose was adequate?
2 hours after the first bite of the meal
When do TB symptoms begin?
2-3 weeks after infection or reactivation
*** Anticoagulant Therapy
3 Classifications: 1. Vitamin K Antagonists (ex. warfarin) 2. Thrombin inhibitors (direct and indirect) 3. Factor Xa Inhibitors
Sputum Collection for TB
3 consecutive samples are needed - each collected at 8- to 24-hour intervals - at least one should be an early morning specimen (ideally, they are all early morning and before brushing teeth or eating)
Insulin vials/pens can be left at room temperature for how long?
4 weeks
How often should patients monitor their own BS?
4-8 times per day These patient either use multiple insulin injections or they have an insulin pump. (Pts with less frequent injections, those not using insulin, or those whose diabetes is managed with diet will just monitor as often as needed.)
150 min/wk of moderate exercise can decrease the risk of Type 2 diabetes by ____%?
34-58% !!!!
WBC count
5000-10,000/μL
*** What is the range of Blood Sugar?
74 to 106
When is insulin given according to the basal-bolus plan? BUT!!!! What are Ketcherside's rules that he wants us to remember about when we give insulin?
AC + HS before meals and at bedtime (7, 12, 5, bedtime) 1. DO NOT ADMINISTER INSULIN (rapid- or short-) UNLESS THERE IS FOOD IN THE ROOM!!! 2. You need to MAKE SURE that these patients are actually going to eat their meals. 3. Administration of insulin needs to be a separate round! Give insulin to all of your diabetic patients WITH breakfast. When you're done, then you go and give the rest of the regular medications. 4. If it's been longer than 1 hr since the last BS draw, DO IT AGAIN.
What does ACE Inhibitors have to do with ventricular remodeling?
ACE Inhibitors prevent Ventricular Remodeling! - MI can cause left ventricular hypertrophy (ventricular remodeling) - ACE inhibitors are Cardioprotective because they've decrease afterload and preload, preventing this hypertrophy
Why are ACE Inhibitors popular with diabetic patients?
ACE Inhibitors reduce glomerular filtration pressure which is a kidney protective effect - they slow the progression of diabetic nephropathy!
What is the antidote for severe bradycardia (which is a huge adverse effect of beta-blockers)?
ATROPINE - Also, hemodialysis can help eliminate BBs in the event of a serious overdose.
Type 1 Diabetes - Onset
Abrupt! but it may have been present for years
Acute Illness and Surgery - Diabetes
Acute illness, injury, and surgery may evoke a counterregulatory hormone response, resulting in hyperglycemia. - check blood glucose at least every 4 hours during times of illness - acutely ill patients with type 1 diabetes and a blood glucose greater than 240 should check urine for ketones every 3 to 4 hours - BS of >300 twice in a row or high ketones should call HCP ASAP - Type 1 diabetics may need increased insulin to prevent DKA - In critically ill patients, insulin therapy may be started if the blood glucose is persistently greater than 180 mg/dL
Figure 48.4 lists 1 inhaled insulin. What is it?
Afrezza
What is a helpful about long-acting insulins lack of a peak action time?
Because they lack peak action time, the risk for hypoglycemia from this type of insulin is greatly reduced!
WHEN should patients check their BS in relation to exercise?
Before AND after exercise!
Which ACE inhibitor wouldn't be appropriate for a patient who is likely to be nonadherent to their treatment?
Captopril has the shortest half-life and therefore must be dosed more frequently than any of the other ACE inhibitors.
(((MOVING ON TO RESPIRATORY)))
I'm just going by the blueprint
What is the (1) onset, (2) peak, and (3) duration of inhaled insulin? **MUST KNOW**
INHALED INSULIN onset: 12-15 minutes peak: 1 hr duration: 2.5 - 3 hrs
What is the (1) onset, (2) peak, and (3) duration of intermediate-acting insulin? **MUST KNOW**
INTERMEDIATE-ACTING INSULIN onset: 1.5 - 4 hrs peak: 4 - 12 hrs duration: 12 - 18 hrs
Type 1 Diabetic Nutritional Therapy
Day-to-day consistency in meal planning makes it easier to manage BG levels. meals are: - based on usual food intake and preferences - balanced with insulin and exercise patterns
diabetes-related neuropathy TREATMENT
Managing blood glucose is the only treatment for diabetes-related neuropathy. It is effective in many, but not all, cases. Drug therapy may be used to treat neuropathic symptoms, especially pain. At the start of therapy, symptoms usually increase, followed by relief of pain in 2 to 3 weeks.
Overlap therapy
Enoxaparin to warfarin will become overlap therapy. 5 days of overlap therapy can sometimes start in the hospital and continue until they're home. THIS OVERLAP MUST BE DONE. If the patient has to do this overlap for 3 days, THEY HAVE TO KNOW EXACTLY HOW TO DO IT. TRAINA FAMILY MEMBER OR GET AN ORDER FOR HOME HEALTH!!!!! Must, must, must be able to complete the overlap therapy.
***We're going to have to identify whether a patient is hypo- or hyperglycemic!!!***
On the next slides, I did NOT put the manifestations they share!! - headaches - blurry vision
sickle cell crisis
GET PT OUT OF CRISIS ASAP TO PREVENT ORGAN DAMAGE make sure they're on O2 HoB up promote rest so the body isn't challenged for oxygen fluids to prevent clotting VTE prophylaxis to prevent blood clots Pain management is ongoing until they're out of this crisis treat infections give folic acid
What is the main difference between HHS and DKA?
HHS usually has enough circulating insulin so that ketoacidosis does not occur. What does this mean? LESS EARLY SYMPTOMS. - blood glucose levels can climb quite high before the problem is recognized (can be in the 600s+ before it's caught)
Hypertrophy with Insulin
Hypertrophy happens more often and is a thickening of the subcutaneous tissue - usually regresses if pt doesn't use the affected site for minimum 6 months - continuing to use this site will result in erratic insulin absorption
Bariatric Surgery for Type 2 Diabetes
Indicated if the diabetes or associated co-morbidities are hard to manage with lifestyle and drug therapy.
Why are complex carbs better than simple carbs?
Insulin spikes after we eat meals. The body breaks down simple carbs faster, causing a dramatic insulin spike. Complex carbs (like in PLANT-BASED DIETS) are broken down slower, causing a slower release of insulin!
((Mini-refresher while I've mentioned right-sided HF...)) Left-sided heart failure shows edema where? Right-sided heart failure shows edema where?
Left-Lungs; Pulmonary Edema with Left-sided HF Right-Rest of Body; Peripheral Edema with Right-sided HF
Is pramlintide used concurrently with insulin or alone? What does this suggest?
MUST be used concurrently- it is NOT a replacement for insulin. - When pramlintide is used, the bolus dose of insulin should be reduced!! --- the concurrent use increases the risk for hypoglycemia in the 3 hrs following injection (esp in Type 1)
For type 1 diabetic patients, Afrezza MUST be given with what?
MUST be used in combination with a long-acting insulin for Type 1 patients
2 Categories of Angiopathy - chronic complication of diabetes
Macrovascular & Microvascular complications
What patients are contraindicated for inhaled insulin? Why?
Patients who (1) smoke or have (2) respiratory diseases such as COPD or asthma should not have inhaled insulin! - Afrezza can cause BRONCHOSPASMS!!!
Hematocrit (Hct)
Measure of packed cell volume of RBCs expressed as a percentage of the total blood volume female: 37 - 47% male: 42 - 52%
Hemoglobin
Measures gas-carrying capacity of RBC female: 12 - 16 male: 14 - 18
Total RBC count
Number of circulating RBCs per volume of blood female: 4.2 - 5.4 male: 4.7 - 6.1
platelets
Number of circulating platelets 150,000-400,000 × 103/L
* Adverse Effects of Calcium Channel Blockers
OVEREXPRESSION OF THERAPEUTIC EFFECTS - rapid, dramatic reduction of BP (hypotension) - bradycardia - palpitations - constipation - nausea - peripheral edema - flushing - dyspnea
WHEN should diabetic patients exercise? Why does this matter?
Patients on BS-lowering drugs (insulin, OAs, etc) should exercise: - 1 hour AFTER a meal - OR have a 10-15 carb snack and check BS before exercising - if needed, eat a small carb snack every 30 min Why is this important? BECAUSE the glucose-lowering effects of exercise can last up to 48 hours (so hypoglycemia can occur long after the activity!!)
Assessing Pneumonia Severity Using Expanded CURB-65
Patients receive 1 point for each of the following indicators: - C: Confusion (compared to baseline) - U: BUN >20 mg/dL - R: Respiratory rate ≥30 breaths/min - B: Systolic blood pressure <90 mm Hg or diastolic blood pressure ≤60 mm Hg - 65: ≥Age 65 yr - LDH: >230 μ/L - Albumin: <3.5 g/dL - Platelet count: <100 × 109/L Scores decide the patient's perceived risk and where they should be treated: 0-2; low; outpatient 3-4; intermediate; inpatient 5-8; high; ICU
How is Angiopathy preventable?
Patients with type 1 diabetes could significantly reduce risk of microvascular complications by keeping blood glucose levels near normal most of the time (tight or intensive therapy)
Type 2 Diabetes - Need for Insulin
Required for some; may progress to need it
Elevated BP Range
SBP: 120-129 AND DBP: <80
HTN, Stage 1 Range
SBP: 130-139 OR DBP: 80-89
Normal BP Range
SBP: <120 AND DBP: <80
HTN, Stage 2 Range
SBP: ≥140 OR DBP: ≥90
What is the (1) onset, (2) peak, and (3) duration of short-acting insulin? **MUST KNOW**
SHORT-ACTING INSULIN onset: 30 minutes to 1 hr peak: 2-5 hrs duration: 5-8 hrs
What do the Meglitinides do? What are 2 major side effects of this?
Stimulates a rapid and short-lived release of insulin from the pancreas
What increases with a long peak?
The risk for hypoglycemia increases with a long peak. For example: Intermediate-acting insulin (NPH) can be used as a basal (background) insulin. It has a duration of 12 to 18 hours. The disadvantage of NPH is that it has a peak ranging from 4 to 12 hours, which can result in hypoglycemia.
Does exercise and weight loss more benefit Type 1 or Type 2 diabetics?
The therapeutic benefits of regular physical activity may result in a decreased need for diabetes medications to reach target blood glucose goals in people with type 2 diabetes.
T/F Oral agents (OAs) and noninsulin injectable agents primarily work on defects of Type 2 diabetes.
True! 1. Insulin resistance 2. Decreased insulin production 3. Increased hepatic glucose production
T/F Diabetics eat the same food as nondiabetics.
True! Fiber 25-30 g/day. Minimize TRANS fats. Cholesterol <200 mg/day. 2+ servings of fish weekly! Moderate alcohol consumption has no acute effect on glucose and insulin concentrations! Mixed drinks may raise BG. Consume alcohol with food.
4 Classes of Diabetes
Type 1 Type 2 Gestational Other (specific types with various causes)
When is pneumonia likely to occur?
When defense mechanisms become incompetent or are overwhelmed by the virulence or quantity of infectious agents! 1. Aspiration of normal flora from the nasopharynx or oropharynx 2. Inhalation of microbes in the air 3. Hematogenous spread from a primary infection elsewhere in the body
PURSED-LIP BREATHING - COPD
When to use: - before/during/after activity causing SoB Steps: 1. INHALE deep/slow through nose 2. EXHALE slow through pursed lips (like whistling) 3. Relax face; no puffed-out cheeks 4. Exhale should last x3 longer than inhale 5. Repeat 8-10 repetitions about 3-4 times daily
Does illness have an effect on BS? What does this mean for patient education?
YES During times of illness, check blood glucose levels at 4-hour intervals to determine the effects of the illness on glucose levels.
You're needing to draw up a short- and intermediate-acting insulin. Which insulins are these and in what order do you proceed? ((Think about what we were taught to do in lab))
Your short-acting is Regular insulin. Your intermediate-acting insulin is NPH. Cloudy, clear, clear, cloudy 1. Inject air into CLOUDY NPH vial. 2. Inject air into CLEAR Regular vial; don't remove syringe. 3. Draw up CLEAR Regular. 4. Draw up CLOUDY NPH; draw must be exact! You cannot push any mixed meds out of the syringe into the NPH vial.
Critical limb ischemia (CLI)
a condition characterized by (1) chronic ischemic rest pain lasting more than 2 weeks, (2) nonhealing arterial leg ulcers, or (3) gangrene of the leg from PAD
Name the 2 α-Glucosidase Inhibitors
acarbose miglitol
Primary TB
active disease development of TB within the first 2 years of infection
Autonomic Neuropathy
can affect nearly all body systems and lead to: - hypoglycemia unawareness - bowel incontinence and diarrhea - urinary retention (use Crede's, self-cath, empty frequently) - gastroparesis (delayed gastric emptying) - CV abnormalities (painless MI, postural hypotension, resting tachycardia) - sexual dysfunction (ED, decreased libido in women) - ED IS USUALLY THE FIRST SIGN
Varicose Veins
dilated (3 mm or larger in diameter), tortuous superficial veins - most common in women - form in response to backward (retrograde) blood flow and increased venous pressure - several different types
Congenital Varicose Veins
due to chromosomal defects
** Upon percussion of a pneumonia patient with pleural effusion, what may you find?
dullness to percussion over the affected area
Primary Hypertension
elevated blood pressure without an identified cause
Loop Diuretics
furosemide and bumetanide - more for heart failure, not so much HTN - watch for orthostatic hypotension - effective even with renal failure
Surgical Treatment of OSA
goal is to reduce collapsibility and increase patency of the upper airway, including oral, nasal, and pharyngeal passages 1. uvulopalatopharyngoplasty (UPPP or UP3) removes obstructing tissues (tonsils, uvula, posterior soft palate) 2. genioglossal advancement and hyoid myotomy (GAHM) advances the attachment of the muscular part of the tongue on the mandible --- if GAHM is done, then UPPP is usually done as well 3. Radiofrequency ablation (RFA) of obstructive tissues alone or in combination with other surgical techniques (this is the least invasive option) 4. Implantation of neurostimulators (one type stimulates the hypoglossal nerve to increase the tone of airway muscles)
Opportunistic Pneumonia
inflammation and infection of the lower respiratory tract in immunocompromised patients - Persons at risk include those with altered immune responses (malnutrition; HIV patients; cancer patients)
Type 1 "Honeymoon Period"
remission of diabetes that lasts 3-12 months after the patient's INITIAL treatment - pt may need very little insulin bc β-cell insulin production is still sufficient for healthy blood glucose levels - THIS ENDS. THIS IS NOT PERMANENT. IMPORTANT TEACHING POINT. THIS WILL NOT EVER OCCUR AGAIN.
Aspiration Pneumonia
results from the abnormal entry of material from the mouth or stomach into the trachea and lungs - aspirated material triggers an inflammatory response !!!! until cultures and results are obtained, therapy is based on: - probable cause - severity of illness - patient factors (malnutrition; current use of antibiotics)
Right-Sided Heart Failure - SYMPTOMS
• Fatigue • Anxiety, depression • Right upper quadrant pain • Anorexia and GI bloating • Nausea
Right-Sided Heart Failure - SIGNS
• Right ventricular heaves • ↑ HR • Murmurs • Jugular venous distention • Edema (e.g., pedal, scrotum, sacrum) • Weight gain • Ascites • Anasarca (massive generalized body edema) • Hepatomegaly (liver enlargement
Left-Sided Heart Failure - SYMPTOMS
• Weakness, fatigue • Anxiety, depression • Dyspnea • Paroxysmal nocturnal dyspnea • Orthopnea • Nocturia
