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NURS 3320 MED SURG EXAM 2 | NURS 3320 MED SURG EXAM

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NURS 3320 MED SURG EXAM 2 – Northeastern University Med Surg Exam 2 Management with Diabetes Care of Patient with Diabetes Diabetes • About 26 millions people with diabetes in US alone ... o Huge problem in the US • Many undiagnosed o 1/3 undiagnosed: so not treated • Higher risk population include African American, Native Americans and Hispanic population o Develop complications higher risk of mortality o Complications of unmanaged diabetes: ♣ Non-traumatic ambulation ♣ Blindness ♣ Kidney disease ♣ Heart attack and stroke o Hospitalization rate 2.5 x greater than healthy adults and 5x greater for children Risk Factors • Family History • Obesity • Race/Ethnicity • Age o Over 45 years old • Previously impaired fasting glucose or impaired glucose tolerance • Hypertension o Greater than 140/90 • High cholesterol or triglycerides • Gestational diabetes o Delivered a baby larger than 9 pounds Patho Review • Type 1 and type 2 o Gestational and pre-diabetes • Disease of the pancreas o Islet of Langerhans: endocrine islet cells o Beta cell: secrete insulin o Insulin ♣ Takes glucose in blood to area that need it ♣ Tells livers and muscle cells to form glycogen stores ♣ Enhances stores of dietary fat in adipose tissue ♣ Speeds transport of protein in cells ♣ Inhibits breakdown of stored fat Type 1 Diabetes • No insulin • Insulin dependent, juvenile diabetes, childhood onset • Beta cells are destroyed o Alpha cells release glucagon (release stored glucose) • Little to no insulin production o Insulin is usually always released in small basal amounts • Insulin cannot do its job hyperglycemia occurs • In short: o Beta cells destroyed o Little/no insulin production o Insulin cannot do its job o Hyperglycemia • A metabolic disorder marked by NO insulin production or secretion from the destruction of the beta cells in the islet of Langerhans in the pancreas Type 2 Diabetes • Adult onset or non-insulin dependent diabetes • Most common • Obesity is primary risk • Insulin resistance • Impaired insulin secretion • Risk factors: o Obesity o Growing in children due to obesity • Aspects: o Insulin resistance o Impaired insulin resistance • Pancreases: o Secrete insulin but body can’t utilize it glucose in blood ♣ More insulin secreted ♣ Beta cells cannot keep up • A metabolic disorder marked by insulin resistance and impaired insulin secretion Diagnosing Diabetes • Radom plasma glucose levels of >200mg/dL o At anytime of the day • Fasting plasma glucose levels or > 126mg/dL o No calorie intake for 8 hours • 2 hour post-load glucose =200mg/dL o Oral glucose tolerance test 75 g of anhydrase glucose • Diagnosis is a plasma reading: finger stick Assessing patient with Diabetes • History o Blood sugar history o How much insulin: how does the patient respond o Are they alert and oriented times 3 • VS o Orthostatic hypotension o Hypertension • Pt history o Symptoms related to diagnosis o Hyperglycemic o How often does the pt become hypoglycemic: ♣ How do they treat it ♣ Any certain time during the day o Blood sugar monitoring ♣ How often do they check it ♣ What device do they use o Management of diabetes ♣ Any issues (GI PVD o Diet ♣ Low carb? ♣ How well do they follow diet o Exercise ♣ How often do they exercise ♣ What is their exercise routine o Are the able to follow diabetes treatment o Any complications due to diabetes • Physical exam o Height and weight o Skin assessment, lower extremity ♣ Any neuropathy o Pulses o Neuro checks ♣ Any sensory deficits o Oral exam o Hair distribution o Any open areas or signs of infection o Is there sensation in the toes? o GI: ♣ Bowel sounds ♣ Look at bowel patterns • Keep in minds o Insulin hypodystrophy/ hypertrophy ♣ Fatty deposits or hard areas • Due to injection o Teach rotation of injection site • Labs o Blood glucose monitoring ♣ Hypoglycemia protocol • Juice • Rec-check • Administration of glucagon or IV dextrose o Hemoglobin AIC ♣ Overall picture of management of blood glucose o Fasting lipid o Microalbumin o Kidney ♣ BUN ♣ Creatinin o Urine analysis Goal • Normal Blood Sugar o 70- 100 mg/dL o >180 after eating o Hemoglobin: ♣ AIC: below 7% • Keep blood sugar controlled • Goals: depending on assessment o Compliance of diabetic management • Goals: o Compliance of diabetic regimen o Medical management o Exercise Intervention • Monitor blood sugars o Check before meals, 9am , 3pm • Assessment o Include pt compliance and understanding • Administer insulin o Long acting: maintain basal rate o Rapid acting: for prancial spike o Sliding scale: based on glucose readings • Diabetic diet o 50-60% carbs (whole grains) o 20-30% fats o fiber lowers blood glucose o Exercise: helps maintain healthy weight • Monitor other labs • Pt teaching: o Teach about changing habits o Signs and symptoms of hypo/hyper glycaemia o Maintain diabetic diet o How to administer insulin Pt teaching • How does your patient learn o Brochure o Demonstration o Teach back • Diet: o 2 starch, 3 proteins, 1 veg, 1 fruit, 1 fat, “free item” o Encourage steady low carb diet o Encourage them to keep a log ♣ Document eating ♣ Blood sugar ♣ What insulin used o Limit alcohol consumption • Medical management • Sick day rules o Continue to takes meds as usually and check glucose levels more frequently and report blood glucose before taking more insulin o Drink fluids and monitor glucose levels more frequently • How does insulin work • How to inject insulin • How to monitor for complications • Hyperglycemia/ hypoglycemia management Hyperglycemia • Extreme thirst • Urination • Dry skin • Hunger • Blurred vision • Nausea • Drowsiness Hypoglycemia • Shaking • Fast HR • Sweating • Dizziness • Anxious • Hunger • Impaired vision • Weakness/ fatigue • Headache • Irritable • Confused • CAN LEAD TO COMA • Treat with juice/ snack Morning hyperglycemia • Insulin waning • Dawn phenomenon • Somogyi effect Insulin • Rapid acting (lispro/Humalog, aspar/novalog) o Onset: 5-15 mins o Peak: 1 hour o Duration: 2-4 hours o Rapid reduction of glucose levels • Short acting, regular insulin (Humalog R, novalog R) o Onset 1-1.5 hours o Peak: 2-3 hours o Duration: 4-6 hours o Been approved for IV from (Rarely used) o Given 20-30 mins before a meal • Intermediate NPH o Onset: 2-4 hours o Peak: 4-12 hours o Duration: 16-20 o Usually taken after food o Not taken several times a day • Long acting (glargen/ lantus) o Onset: 1 hours o Peak: no peak ♣ Hallmark is no peak, continuous management o Duration: 24 hours ♣ Base dose in the evening once a day ♣ May be given 2 times a day depending on the patient Oral Anti-diabetics • Type 2 diabetes management o Lifestyle changes (diet and weight) o Oral diabetics • 1st generation sulfonylureas (orinase) o NSAID/Comadin interaction • 2nd generation sulfonylureas (glucitrol, diabeta, amaryl) • Biguanides (Glucophage, metformin) • Alpha- Glucosidase inhibitors (precise • Side effects/ nursing management o Monitor hypoglycemia o Urine ketone o Blood glucose monitor o GI side effect DKA • Cause by no insulin • Features include: o Hypoglycemia o Dehydration/ electrolyte loss o Acidosis • Management o Rehydration o Restoring electrolytes o Managing acid base imbalance o Decreasing anxiety o Monitoring for complications Evaluation • Blood sugar • Insulin e o Effects of insulin • All assessment • All labs • All interventions o Teach back method Endocrine Care of Patient with Thyroid Disorder Patho Review • Endocrine gland o Lower neck o T4 and T3 :amino acids bound with iodine ♣ Made and stored until signal release o Synthesis is dependent on iodine o TSH: secretion of T3 and T4 o Calcitonin: brings Ca into bone • Negative feed back system o Pituitary release TSH o Low T3 T4: high TSH o High T3 and T4: low TSH • Hyper: High T3 and T4 high metabolism • Hypo: low T3 and T4 slow metabolism Hypothyroidism • Low T3 and T4 • Can be mild to severe • Causes: o Number 1 cause: autoimmune disorder ♣ Hashimotos o Other causes: birth defects, atrophy with aging, therapy from hyperthyroids, other medications, cancers, radiation, iodine deficiency, failure of pituitary • Clinical Manifestations o Think body slowing down o Fatigue, hair loss, brittle nails, dry skin, hoarse/husky voice, menstrual disturbances, low pulse rate, low BP, low body temp o Extra sensitive to opioids • Symptoms o Cold intolerance o Receding hairline o Dull-blank expression o Extreme fatigue o Thick tongue o Slowed speech o Anorexia o Brittle nails o Menstrual disturbances o Hair loss o Apathy o Lethargy o Dry skin o Constipation o Muscles achiness and weakness • Late Symptoms o Subnormal temp o Bradycardia o Weight gain o Decrease LOC o Thickened skin o Cardiac complications • Myxedema Coma o Extreme form of hypothyroidism o Life threatening pt goes into coma o Participated by infection o Patient not taking medications o Diminished cognition status o Low RR Medical Management of Hypothyroidism • Thyroid replacement (levothyroxine/ synthroid) • Dosing based on TSH levels (T3 and T4) o Want TSH in certain range o Start low and then adjust the dose • Caution with patient who have pre-existing cardiovascular disease o Body is used to low oxygenation so it has cardiovascular effects o Angina and MI due to increased demand ♣ Especially if there is already a history ♣ Discontinue and call doctor is signs and symptoms occur • Increased O2 demands • Angina/ dysrhythmias • Drug-drug interactions: space dosing to prevent interaction o Iron, magnesium decrease absorption o Digitalis : TH decreases effectiveness o Anticoagulants: TSH increases risk for bleeding • Take 1 hour before food o Must be taken on empty stomach o Often taken first thing in the morning Nursing Management • Assessment o HR: apical pulse o Check weight o Focus on VS o Make sure patient is getting right dose of medication o Be careful of opioids ♣ Slowed metabolism • Pt teaching o Teach about disease and side effects of disease o Teach about medication administration ♣ Take correct dose and when to take it ♣ Life long medication ♣ Should see changes in symptoms after taking medication • May start feeling symptoms in the other direction o Follow up appointments o Dietary education ♣ Look out for weight loss ♣ Fiber and water intake • Care plan Hyperthyroidism • Causes: graves disease, toxic goiter, tumor, treatment of hypothyroidism, thyroiditis - - - - - - - - - - - - - - - • Assicated with and similar to Hep B o Similar risk factors, incubation o Symptoms: flu like ♣ Likely to develop hepatitc failure • Treatment: o Anti-viral o Rate of re-occurrence is high o Minimize risk factors Hep E • Develop Jaundice • Fecal oral route, similar to A o Contaminated water, poor sanitation • Abrupt onset, self limiting o Has to run its course o Limited treatment • No Chronic Form • Incubation: 15-65 days Nonviral Hepatitis • Toxic Hep o Exposure to chemicals, medications, botanical agents, alcohol, pain relievers, herbs and supplements, industrial chemicals o Recovery may be rapid removal of the toxic agents o Bad enough exposure leads to fulminant hepatic failure • Drug Induced Hep o Acute liver failure o Onset: chills, fever, rash, nausea, anorexia ♣ Symptoms can go away if drugs stop ♣ Tylenol most common caused • Remove drug and hoping damage can be reversed • High dose of corticosteroids • Fulminant Hepatic Failure o Acute liver failure o As a result of non-viral hepatitis o Develops within 8 weeks of jaundice ♣ Hyper acute, sub acute, and acute o Outcome not great ♣ Potentially reversible ♣ 20-50% survival rate Care and Management of Patients with Biliary Disorders Gallbladder • Sac like organ on inferior aspect of liver o When you eat bile is secreted o Gallstone= hardened bile o Blockage: pain when eating • Contains bile, H20, and electrolytes • What if there is an obstruction • Cholithiasis: gall stones • Cholicystitis: inflammation Pancreas • Many endocrine and exocrine function • Alpha cells= glucagon • Beta cells= insulin • Delta cells= somatostatin • Digestive enzymes o Amylase: carbs o Trypsin: proteins o Lipase: fats Gallbladder Disease • Cholecystis o Can be acute or cronic o Inflammation of gallbladder o Obstruction causes gallbladder to fill up can rupture • Cholelithiasis o Gallstones o Build up of bile salts and cholesterol • Risk Factors o Obesity o Multiple pregnancy o Native America, south/west Spanish o Weight fluctuation/ rapid weight loss o High dose estrogen treatment o CF o Diabetes • Clinical Manifestation o Pain in right upper quadrant o Jaundice o Change in urine or stool o Vitamin deficiency • Treatment o Focus on pain o Diagnosed with X-ray/ ultrasound o Surgically remove stones or the gallbladder Pancreatitis • Acute of chronic inflammatory disorder • Auto-digestion of the pancreas o Exocrine function of the pancreas o Hyper secretion due to blockage and digests pancreas instead of food o Risk factors ♣ Choliocistics, viral, bacterial, alcoholism, peptic ulcer, hyper lipidemia, hyper calicemia, steroid use • Medical emergency o Can be fatal • Clinical Manifestation o Severe pain in abdomen and back ♣ Can occur after meals o Abdominal distention o Mass abdomen o Decreased bowel sounds o Rigid board like abdomen o Bruising around umbilicus o Fever o Jaundice • Labs o Increase amalyse and lipase o Hypocalcemia o Hyperglycemia o Gluocseria o Increase bilirubin • Medical Management o Treat symptoms o NPO ♣ Don’t stimulate pancreas o Parental nutrition o Manage pain ♣ Morphine o Critical care/ intensive care o Stent to assist biliary drainage Nursing Management • Nursing is aimed at managing comfort • NPO, maybe NGT o NGT: decompression • Hygiene o Good oral hygiene and mouth care • Skin integrity o Skin assessment • Fluids and electrolytes • Vitals as ordered • Preventing complication o Hemorrhage o Shock The Nursing Process • Assessments o Acute pain o Fluid and electrolyte disturbances o Ineffective breathing patterns • Plan Goals • Interventions to meet goals • Evaluate interventions [Show More]

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