AMS - ATI
2 - Hyperglycemia Administer sliding scale insulin or plan for insulin to be added to the TPN solution. Monitor blood glucose
3 - Hypoglycemia Inform the provider and plan to give additional dextrose. Monitor frequent blood glucose.
Older adult clients may not be able to drive to the provider's office, grocery store, or pharmacy. Assess support systems available for older adult clients.
A fixed income may mean that there are limited funds for buying diabetic supplies, wound care supplies, insulin, and medications. This may result in complications.
Diabetic Screening: risk factors - obesity, hypertension, inactivity, hyperlipidemia, cigarette smoking, genetic history, elevated C-reactive protein (CRP), ethnic group, and women who have delivered infants weighing more than 9 lb
ADA - recommends screening a client who has a BMI greater than 24 and age greater than 45 years, or if a child is overweight and has additional risk factors.
Blood Transfusion - Types of reactions and onset
Acute hemolytic - immediate Febrile - 30 min to 6 hr after transfusion Mild allergic - During or up to 24 hr after transfusion Anaphylactic - immediate
Intermediate-acting insulin NPH insulin (Humulin N), detemir insulin (Levemir). Administered for glycemic control between meals and at night.
Administer NPH insulin subcutaneous only and as the only insulin to mix with short-acting insulin.
Juvenile hypothyroidism - Juvenile hypothyroidism is most often caused by chronic autoimmune thyroiditis and affects the growth and sexual maturation of the child. Clinical manifestations are similar to adult hypothyroidism, and the treatment reverses most of the clinical manifestations of the disease.
Adult hypothyroidism: Because older adult clients who have hypothyroidism may have manifestations that mimic the aging process, hypothyroidism is often undiagnosed in older adult clients, which can lead to potentially serious adverse effects from medications (sedatives, opiates, anesthetics)
Teach the client that thyroid replacement therapy is usually lifelong. - Therapeutic Use Levothyroxine replaces T4 and is used as thyroid hormone replacement therapy. Replacement of T4 also raises T3 levels, because some T4 is converted into T3.
Adverse effects are essentially the same as manifestations of hyperthyroidism: cardiac symptoms, such as hypertension and angina pectoris; insomnia, anxiety; weight loss; heat intolerance; increased body temperature; tremors; and menstrual irregularities
Instruct client how to inject exenatide subcutaneously. Teach client to take exenatide within 60 min before the morning and evening meal but not following the meal.
Advise client to withhold exenatide and notify the provider for severe abdominal pain. Teach the client how to recognize and treat hypoglycemia.
Wear clothing that is washable, wash clothing separate from clothing of others, and run the washing machine for a full cycle after washing contaminated clothing.
Advise the client to avoid infants or small children for 2 to 4 days after the procedure. Avoid contamination from saliva, do not share a toothbrush, and use disposable food service items (paper plates).
Nursing Interventions/Client Education Watch the client for decreased immune function. Monitor for hyperglycemia. Omalizumab can cause anaphylaxis.
Advise the client to report black, tarry stools. Observe the client for fluid retention and weight gain. This can be common. Monitor the client's throat and mouth for aphthous lesions (cold sores).
Short-acting beta2 agonists, such as albuterol (Proventil, Ventolin), provide rapid relief of acute symptoms and prevent exercise-induced asthma.
Albuterol - Watch the client for tremors and tachycardia.
Aluminum hydroxide gel - Avoid administering if client has gastrointestinal disorders; administer a stool softener with this medication
Aluminum hydroxide gel - Instruct the client to report constipation to the provider and to take 2 hr before or after receiving digoxin.
Stool softeners such as docusate sodium (Colace) are used for constipation
Anticholinergics such as propantheline are used for bladder dysfunction.
Immunomodulators such as interferon beta (Betaseron) are used to prevent and treat relapses
Anticonvulsants such as carbamazepine (Tegretol) are used for paresthesia.
Blood Transfusion Reaction - Medications
Antipyretics (acetaminophen [Tylenol]) - febrile Antihistamines (diphenhydramine [Benadryl]) - mild allergic Antihistamines, corticosteroids, vasopressors - anaphylactic
Corticosteroids such as prednisone - Increased risk for infection, hypervolemia, hypernatremia, hypokalemia, GI bleeding, and personality changes.
Antispasmodics such as dantrolene (Dantrium), tizanidine (Zanaflex), baclofen (Lioresal) and diazepam (Valium) are used to treat muscle spasticity.
ALS - Medication : Riluzole (Rilutek) is a glutamate antagonist that can slow the deterioration of motor neurons by decreasing the release of glutamic acid
Baclofen (Lioresal), dantrolene sodium (Dantrium), diazepam (Valium) ■ Antispasmodics are used to decrease spasticity.
A bone marrow
Biopsy is commonly performed to diagnose causes of blood disorders, such as anemia or thrombocytopenia, or to rule-out diseases, such as leukemia and other cancers, and infection
Blood Transfusion - Potential Complications
Circulatory overload: Administer oxygen. Monitor vital signs. Slow the infusion rate. Administer diuretics as prescribed. Notify the provider immediately
Apply local anesthetic to skin if indicated. Palpate skin to locate the port body septum to ensure proper insertion of the needle
Clean the skin with alcohol for at least 3. Apply local anesthetic to skin if indicated. Palpate skin to locate the port body septum to ensure proper insertion of the needle. seconds and allow to dry prior to insertion of the needle. Access with a noncoring (Huber) needle.
Hypothyroidism
Condition in which there is an inadequate amount of circulating thyroid hormones triiodothyronine (T3) and thyroxine (T4), causing a decrease in metabolic rate that affects all body systems.
Hypothyroidism is also classified by age of onset.
Cretinism - Cretinism is a state of severe hypothyroidism found in infants. When infants do not produce normal amounts of thyroid hormones, central nervous system development and skeletal maturation are altered, resulting in retardation of cognitive development, physical growth, or both.
Objective Data: Physical Assessment Findings; Impaired respiratory status (difficulty managing secretions, decreased respiratory effort); Decreased swallowing ability
Decreased muscle strength, especially of the face, eyes, and proximal portion of major muscle groups Incontinence Drooping eyelids - unilateral or bilateral
Digoxin - Take apical pulse for 1 min, and monitor laboratory levels for signs of toxicity.
Digoxin - Instruct the client not to take medication within 2 hr of eating, and teach client how to take an apical pulse for 1 min.
Client Education: Advise the client that the effects of the therapy may not be evident for 6 to 8 weeks. Advise the client to take medication as directed. Advise female clients to avoid becoming pregnant for 6 months.
Do not use same toilet as others for 2 weeks, sit down to urinate, and flush toilet three times. Take a laxative 2 to 3 days after treatment to rid the body of stool contaminated with radiation.
Hypothyroidism: - Late findings: Bradycardia, hypotension, dysrhythmias; Slow thought process and speech; Hypoventilation, pleural effusion Thickening of the skin; Thinning of hair on the eyebrows;
Dry, flaky skin; Swelling in face, hands, and feet (myxedema [non-pitting, mucinous edema]); Decreased acuity of taste and smell; Hoarse, raspy speech; Abnormal menstrual periods (menorrhagia/amenorrhea) and decreased libido;
Hypothyroidism - S/S: Early findings; Fatigue, lethargy, irritabilily Intolerance to cold Constipation ; Weight gain without an increase; in caloric intake; Pale skin; Thin, brittle fingernails; Depression; Thinning hair; Joint and/or muscle pain;
Early findings Fatigue, lethargy, irritabilily Intolerance to cold Constipation Weight gain without an increase in caloric intake Pale skin Thin, brittle fingernails Depression Thinning hair Joint and/or muscle pain
ASTHMA- Encourage the client to drink plenty of fluids to promote hydration. Encourage the client to take prednisone with food. Advise client to use this medication to prevent asthma, not for the onset of an attack.
Encourage client to avoid persons with respiratory infections. Use good mouth care. Do not stop the use of this type of medication suddenly.
Epoetin alfa - Instruct the client about having blood tests twice a week and how to take blood pressure.
Epoetin alfa - Administer by subcutaneous route, and monitor for hypertension.
Exenatide is prescribed along with an oral antidiabetic medication, such as metformin or a sulfonylurea medication, for clients who have type 2 diabetes mellitus to improve diabetes control.
Exenatide improves insulin secretion by the pancreas, decreases secretion of glucagon, and slows gastric emptying
Ferrous sulfate - Instruct the client to take medication with food and that stools will be dark in color.
Ferrous sulfate - Administer following dialysis and with a stool softener
Furosemide - Monitor intake and output and blood pressure.
Furosemide - Instruct the client to weigh self each morning and to notify provider of light - headedness, excess thirst, and unusual coughing
Long-acting insulin Glargine insulin (Lantus) Administered once daily, anytime during the day but always at the same time each day.
Glargine insulin forms microprecipitates that dissolves slowly over 24 hr and maintains a steady blood sugar level with no peaks or troughs.
MG - Atropine
Have atropine available, which is the antidote for edrophonium (bradycardia, sweating, and abdominal cramps).
Exenatide A/E: GI effects, such as nausea and vomiting Pancreatitis manifested by acute abdominal pain and possibly severe vomiting
Hypoglycemia, especially when taken concurrently with a sulfonylurea medication, such as glipizide
Asthma - Combination agents (bronchodilator and anti-inflammatory) Ipratropium and albuterol (Combivent) Fluticasone and salmeterol (Advair)
If prescribed separately for inhalation administration at the same time, administer the bronchodilator first in order to increase the absorption of the anti-inflammatory agent
Combination agents (bronchodilator and anti-inflammatory) Ipratropium and albuterol (Combivent) Fluticasone and salmeterol (Advair)
If prescribed separately for inhalation administration at the same time, administer the bronchodilator first in order to increase the absorption of the anti-inflammatory agent
Medication - MS
Immunosuppressive agents such as azathioprine (Imuran) and cyclosporine (Sandimmune) - Long-term effects include increased risk for infection, hypertension, and kidney dysfunction.
Implanted port :a 1 year or more. Description - Port is comprised of a small reservoir covered by a thick septum.
Indications - Long-term (a year or more) need for vascular access; commonly used for chemotherapy.
Peripherally inserted central catheter - PICC
Indications - administration of blood, long-term administration of chemotherapeutic agents, antibiotics, and total parenteral nutrition
Infiltration and Extravasation
Infiltration is fluid leaking into surrounding subcutaneous tissue, and extravasation is unintentional infiltration of a vesicant medication that causes tissue damage
Vasodilators (nitroglycerin, sodium nitroprusside) decrease preload and afterload.
Inotropic agents, such as digoxin (Lanoxin) and dobutamine (Dobutrex), improve cardiac output.
Tunneled percutaneous central catheter For long-term use. Indications - Frequent and long-term need for vascular access
Insertion location - A portion of the catheter lies in a subcutaneous tunnel separating the point where the catheter enters the vein from where it enters the skin with a cuff. Tissue granulates into the cuff to provide a mechanical barrier to organisms and an anchoring for the catheter.
Peripherally inserted central catheter Description - 40 to 65 cm with single or multiple lumens Length of use - up to 12 months
Insertion location - basilic or cephalic vein at least one finger's breadth below or above the antecubital fossa; the catheter should be advanced until the tip is positioned in the lower one-third of the superior vena cava.
Nontunneled percutaneous central catheter: Description - 15 to 20 cm in length with one to three lumens Length of use - short-term use only
Insertion location - subclavian vein, jugular vein; tip in the distal third of the superior venacava Indications - administration of blood, long-term administration of chemotherapeutic agents, antibiotics, and total parenteral nutrition
Insulin glargine
Insulin glargine, a long-acting insulin, does not have a peak effect time, but is fairly stable in effect after metabolized
Insulin lispro
Insulin lispro has a peak effect around 30 min to 2.5 hr following administration
A bone marrow Pre Ensure that the client has signed the informed consent form. Position the client in a prone or side-lying position.
Intra Administer sedative medication. Assist with the procedure. Apply pressure to the biopsy site. Place a sterile dressing over the biopsy site.
Ipratropium - Advise the client to suck on hard candies to help relieve dry mouth; increase fluid intake; and report headache, blurred vision, or palpitations, which may indicate toxicity of ipratropium.
Ipratropium - Observe the client for dry mouth. Monitor the client's heart rate
Myasthenia gravis (MG)
It is caused by antibodies that interfere with the transmission of acetylcholine at the neuromuscular junction
Myasthenia gravis (MG) is a progressive autoimmune disease that produces severe muscular weakness.
It is characterized by periods of exacerbation and remission. Muscle weakness improves with rest and worsens with increased activity.
Diagnostic Procedures
Laboratory Tests: Cerebrospinal fluid analysis. Diagnostic Procedures: MRI of the brain and spine
Acarbose can cause liver toxicity when taken long-term.
Liver function tests should be monitored periodically while the client takes this medication
Blood Transfusion - Sepsis and septic shock
Maintain patent airway. Administer oxygen. Administer antibiotics as prescribed. Obtain blood samples for culture. Administer vasopressors in late phase. Elevate client's feet. Assess for disseminated intravascular coagulation.
Tensilon testing: Baseline assessment of the cranial muscle strength is done. Edrophonium (Tensilon) is administered
Medication inhibits the breakdown of acetylcholine, making it available for use at the neuromuscular junction.
Diabetic neuropathy Caused from damage to sensory nerve fibers resulting in numbness and pain. Is progressive, may affect every aspect of the body, and can lead to ischemia and infection.
Monitor blood glucose levels to keep within an acceptable range to slow progression. ■ Provide foot care.
Nursing Considerations:
Monitor liver function tests - hepatotoxic risk. Assess for dizziness, vertigo, and somnolence.
Rapid-acting diuretics, such as furosemide (Lasix) and bumetanide (Bumex), promote fluid excretion.
Morphine decreases sympathetic nervous system response and anxiety and promotes mild vasodilation.
Laboratory Tests - Increased creatine kinase (CK-BB) level Diagnostic Procedures Electromyogram (EMG) - Reduction in number of functioning motor units of peripheral nerves
Muscle biopsy - Reduction in number of motor units of peripheral nerves and atrophic muscle fibers
NPH
NPH insulin has a peak effect around 6 to 14 hr following administration.
Occlusion is a blockage in the access device that impedes flow.
Nursing Actions Flush the line at least every 12 hr (3 mL for peripheral, 10 mL for central lines) to maintain patency
Diabetic nephropathy Damage to the kidneys from prolonged elevated blood glucose levels and dehydration
Nursing Actions Monitor hydration and kidney function (I&O, serum creatinine). Report an hourly output of less than 30 mL/hr.
Complications: ALS: Respiratory failure may necessitate mechanical ventilation.
Nursing Actions - Assess respiratory status and be prepared to provide ventilatory support as needed per the client's advance directives.
Complications: ALS: Pneumonia can be caused by respiratory muscle weakness and paralysis contributing to ineffective airway exchange.
Nursing Actions - Assess respiratory status routinely and administer antimicrobial therapy as indicated.
Rapid-acting insulin Lispro insulin (Humalog), aspart insulin (Novolog), glulisine insulin (Apidra). Administer before meals to control postprandial rise in blood glucose.
Onset is rapid, 10 to 30 min depending on which insulin is administered. Administer in conjunction with intermediate- or long-acting insulin to provide glycemic control between meals and at night.
Polyphagia (excessive hunger and eating) caused from inability of cells to receive glucose (cells are starving); Client may display weight loss. Metabolic acidosis. Kussmaul respirations -
Other: acetone/fruity breath odor ; headache, nausea, vomiting, abdominal pain, inability to concentrate, decreased level of consciousness, and seizures leading to coma.
TPN provides a nutritionally complete solution. It can be used when caloric needs are very high, when the anticipated duration of therapy is greater than 7 days, or when the solution to be administered is hypertonic (composed of greater than 10% dextrose). It can only be administered in a central vein.
PPN can provide a nutritionally complete solution. However, it is administered into a peripheral vein, resulting in a limited nutritional value. It is indicated for clients who require short-term nutritional support with fewer calories per day. The solution must be isotonic and contain no more than 10% dextrose and 5% amino acids
Risk Factors: Obesity, physical inactivity, high triglycerides (greater than 250 mg/dL), and hypertension may lead to the development of insulin resistance and type 2 diabetes.
Pancreatitis and Cushing's syndrome are secondary causes of diabetes.
Death usually occurs due to respiratory failure within 3 to 5 years of the initial manifestations. The cause of ALS is unknown, and there is no cure.
Physical Assessment Findings: Muscle weakness - usually begins in one part of the body Muscle atrophy; Dysphagia ; Dysarthria; Hyperreflexia of deep tendon reflexes;
MS is an autoimmune disorder characterized by the development of plaque in the white matter of the central nervous system.
Plaque damages the myelin sheath and interferes with impulse transmission between the CNS and the body.
A bone marrow - Post Monitor for evidence of infection and bleeding. Apply ice to the biopsy site. Administer mild analgesics; avoid aspirin or medications that affect clotting
Potential Complications: Bleeding and infection
Pramlintide delays oral medication absorption, so oral medications should be taken 1 to 2 hr after pramlintide injection
Pramlintide should not be mixed in a syringe with any type of insulin
Short-acting beta2 agonists, such as albuterol (Proventil, Ventolin)
Provide rapid relief of acute symptoms and prevent exercise-induced asthma.
DKA Lack of sufficient insulin related to undiagnosed or untreated type 1 diabetes mellitus or nonadherence to a diabetic regimen
Reduced or missed dose of insulin (insufficient dosing of insulin or error in dosage)
Regular insulin
Regular insulin has a peak effect around 1 to 5 hr following administration
Identify three complications of TPN
Related Content 1 - Infection and sepsis Monitor for manifestations of fever, chills, increased WBCs, and redness around catheter insertion site.
Repaglinide should not be taken just before bedtime; Repaglinide is not taken upon awakening in the morning
Repaglinide causes a rapid, short-lived release of insulin. The client should take this medication within 30 min before each meal so that insulin is available when food is digested
Client Education: A bone marrow: Explain the procedure to be performed: use of local anesthesia, sensation of pressure or brief pain.
Report excessive bleeding and evidence of infection to the provider. Check the biopsy site daily. It should be clean, dry and intact. If there are sutures, return in 7 to 10 days for removal.
Corticosteroids such as prednisone
Report increased weakness and jaundice to provider. Avoid stopping baclofen abruptly.
Salmeterol - Asthma
Salmeterol - Advise client to use to prevent an asthma attack and not at the onset of an attack
Sodium polystyrene - Instruct the client to take a mild laxative if constipated, and teach how to take blood pressure
Sodium polystyrene - Monitor for hypokalemia, and restrict sodium intake.
Assessment: Myasthenia gravis Risk factors associated with rheumatoid arthritis, scleroderma, and systemic lupus erythematosus
Subjective Data: Progressive muscle weakness; Diplopia; Difficulty chewing and swallowing; Respiratory dysfunction; Bowel and bladder dysfunction; Poor posture; Fatigue after exertion
Exenatide
Teach the client that exenatide should not be given within 1 hr of oral antibiotics, acetaminophen, or an oral contraceptive due to its ability to slow gastric emptying
Teach the client to take levothyroxine on an empty stomach, usually 1 hr before breakfast.
Teach the client that thyroid replacement therapy is usually lifelong. Monitor for adverse effects that indicate that the dosage needs to be reduced.
Laboratory Tests -
The expected reference range for T3 is 70 to 205 ng/dL, and the expected reference range for T 4 is 4 to 12 mcg/dL.)
Exenatide
The nurse should monitor daily blood glucose testing by the client, periodic HbA1c tests, and periodic kidney function testing. Exenatide should be used cautiously in clients who have any renal impairment.
Nursing Care: Adverse effects include cardiac effects, chest pain, hypertension, and palpitations, especially in older adults
The nurse should monitor thyroid function tests: T3, T4, and TSH
The older adult is at risk for altered metabolism of medication due to decreased kidney and liver function because of the aging process.
The older adult may have visional alterations; yellowing of lens, decreased depth perception, cataracts, which can affect ability to read information and attend to medication administration.
Radioactive iodine (131 I) is administered orally 24 hr prior to a thyroid scan.
The thyroid absorbs the radiation, which results in destruction of cells that produce thyroid hormone
Anticholinergic medications, such as ipratropium (Atrovent), block the parasympathetic nervous system.
This allows for the sympathetic nervous system effects of increased bronchodilation and decreased pulmonary secretions. These medications are long-acting and used to prevent bronchospasms
Amyotrophic lateral sclerosis (ALS) is a degenerative neurological disorder of the upper and lower motor neurons that results in deterioration and death of the motor neurons.
This results in progressive paralysis and muscle wasting that eventually causes respiratory paralysis and death. Cognitive function is not usually affected
Vision and hearing deficits may interfere with the understanding of teaching, reading of materials, and preparation of medications.
Tissue deterioration secondary to aging may impact the client's ability to prepare food, care for self, perform ADLs, perform foot/wound care, and perform glucose monitoring.
Type 1 diabetes mellitus is an autoimmune dysfunction involving the destruction of beta cells, which produce insulin in the islets of Langerhans of the pancreas. Immune system cells and antibodies are present in circulation and may also be triggered by certain genetic tissue types or viral infections.
Type 1 diabetes mellitus usually occurs at a young age, and there are no successful interventions to prevent the disease.
Short-acting insulin Regular insulin (Humulin R, Novolin R). Administer 30 to 60 min before meals to control postprandial hyperglycemia. Available in two concentrations.
U-500 is reserved for the client who has insulin resistance and is never administered IV. U-100 is prescribed for most clients and may be administered IV
Pramlintide can cause hypoglycemia, especially when the client also takes insulin, so it is important to eat a meal after injecting this medication.
Unused medication in the open pramlintide vial should be discarded after 28 day' Unused medication in the open pramlintide vial should be discarded after 28 day
Methylxanthines, such as theophylline (Theo-24), require close monitoring of serum medication levels due to a narrow therapeutic range.
Use only when other treatments are ineffective. Theophylline - Monitor the client's serum levels for toxicity. Side effects will include tachycardia, nausea, and diarrhea
Hypoglycemia - S/S
Weight gain greater than 1 kg/day Inform the provider and anticipate a decrease in the concentration, rate of administration or volume of lipid emulsion. Monitor the client's intake of oral nutrients
Hyperglycemia - blood glucose level usually greater than 250 mg/dL. Polyuria (excess urine production and frequency) from osmotic diuresis
olydipsia (excessive thirst) due to dehydration Loss of skin turgor, skin warm and dry Dry mucous membranes Weakness and malaise Rapid weak pulse and hypotension
Any condition that increases carbohydrate metabolism, such as physical or emotional stress, illness, infection (No. 1 cause of DKA), surgery, or trauma that requires an increased need for insulin
☐ Increased hormone production (e.g., cortisol, glucagon, epinephrine) stimulates the liver to produce glucose and decreases the effect of insulin.
