NURSE-UN 240 A&E1 Exam 2 Study Guide Latest Updated 2022
COPD
• Explain the risk factors, pathophysiology, clinical manifestations, and complications
... [Show More] associated with COPD
COPD
Chronic obstructive pulmonary disease (COPD) refers to chronic lung disorders that result in blocked air flow in the lungs. The two main COPD disorders are Emphysema and Chronic Bronchitis, the most common causes of respiratory failure. Damage from COPD is usually permanent and not reversible.
- Chronic Bronchitis: Chronic inflammation of the bronchi and the bronchioles causing constriction, congestion, mucosal edema (mucus production).
- Emphysema: Loss of lung elasticity and abnormal permanent enlargement of the air space distal to the terminal bronchioles
Essentially, both will lead to COPD (i.e. an obstruction issue), but the way there is different.
- For chronic bronchitis, it’s an airway problem
- For emphysema it’s an alveolar problem
Cigarette Smoking
Consequences (Due to increase in proteases): these will lead to the chronic obstruction issues.
● Decreased ciliary activity
● Possible loss of ciliated cells
● Cellular hyperplasia
● Production of mucus
● Reduction in airway diameter
● Increased difficulty in clearing secretions
Nicotine acts as a stimulant to the cardiovascular and sympathetic nervous system resulting in:
● Increased heart rate
● Peripheral vasoconstriction
● Increase blood pressure and cardiac workload
Assessment History:
● Risk Factors: age, gender, occupational history, family history etc.
● Check activity tolerance and dyspnea, determine orthopnea
● Unplanned weight loss
• Might not eat because getting enough oxygen becomes their main concern
Physical Assessment
● Usually assumes a ‘tripod’ position
• They will always be SOB
● Use of accessory muscles
● Wheezes
● Crackles may be present
● “Barrel Chest”
● Clubbing
● Cyanosis – late sign
● Use the Visual Analog Dyspnea Scale (VADS)
• You ask the patient to place a mark on the line to indicate his or her perceived breathing difficulty
• No SOB [ ]SOB as bad as can be
Diagnostic Tests
● Laboratory:
🞆 Arterial Blood Gas (ABG)
Hypercarbia or Hypercapnia (both mean increased CO2 in the blood)
Chronic Respiratory Acidosis can occur when you have high levels of CO2 in the blood.
In general, pH is related to increased CO2 retention, oxygen levels and ?
🞆 Complete Blood Count
Polycythemia could be present
● In response to low levels of O2
🞆 Alpha-1 AntiTrypsin Serum Level
Perform this test on a young, non-smoker, who does not fit the COPD profile. This is because some forms of emphysema have a genetic link, in which individuals inherit a deficiency in Alpha-1 AntiTrypsin.
● Alpha-1 Antitrypsin Deficiency is the most common genetic factor for emphasima 2.
🞆 Sputum Analysis
For hospitalized patients with acute respiratory infection
🞆 Decreased oxygen saturation
Know patient’s baseline
Oxygen saturation of patients with COPD is lower than normal, which means that they will have a lower baseline which is ok for them (even though normal range is from 95%-100%)
🞆 Chest X-Ray:
Not useful in early or moderate disease
Used to rule out other pulmonary conditions
You’ll see a flattened diaphragm and hyper-inflation of the lungs
● Patient Presentation:
🞆 Productive cough (especially for people with chronic bronchitis) lasting for at least 3 months in a year for at least consecutive 2 years is diagnostic of Chronic Bronchitis
• Describe spirometry and its indices used in the diagnosis of COPD
Diagnostic Tests
Pulmonary Function Test
● Test of lung volumes using a spirometer.
● What is Spirometry?
Spirometry is a method of assessing lung function by measuring the total volume of air the patient can hold and expel from the lungs after a maximal inhalation
🞆 The complex part is in interpreting the results
Spirometric Indicies VC - Vital capacity:
- A volume of a full breath exhaled in the patient’s own time and not forced.
RV – Residual Volume
- Volume of gas that remains in the lungs following maximal expiration TLC - Total Lung Capacity
- The total amount of air in the lungs after taking the deepest breath possible.
Standard Spirometric Indicies: These three are specific to the diagnosis of COPD FEV1 - Forced expiratory volume in one second:
- The volume of air expired in the first second of the exhalation FVC - Forced vital capacity:
- The total volume of air that can be forcibly exhaled in one breath FEV1/FVC ratio: this ratio is specific to COPD
- The fraction of air exhaled in the first second relative to the total volume exhaled
Predicted Normal Values Influenced by:
- Age
- Height
- Sex
- Ethnic Origin
Normal Spirometry Readings
If FEV1 is at least 80% or more than your baseline, that’s normal If FVC is 80% or more of you predicted value, it’s normal
The FEV1/FVC should be greater than 0.7-0.8, depending on age
Spirometry Readings in COPD
Typical findings are reduced FEV1/FVC (ratio of less than 70% suggests presence of obstructive lung disease and increased RV)
• Discuss priority nursing diagnoses and evidence-based interventions for patients who have COPD.
Priority Nursing Diagnoses
• Hypoxemia with hypercapnia related to alveolar-capillary membrane changes, reduced airway size, ventilatory muscle fatigue, excessive mucus production, airway obstruction, diaphragm flattening, fatigue, and decreased energy
• Weight loss related to dyspnea, excessive secretions, anorexia, and fatigue
• Anxiety related to dyspnea, a change in health status, and situational crisis
• Activity Intolerance related to fatigue, dyspnea, and an imbalance between oxygen supply and demand
• Potential for pneumonia or other respiratory infections
Management: Drug Therapy
Bronchodilators
● Decreases airway resistance and hyperinflation and reduces dyspnea
● Examples:
🞆 Proventil, Albuterol
🞆 Atrovent/Ipratropium
Anti-inflammatory/Steroids
● Example: Pulmicort
🞆 Common for asthma and COPD patients
Combination inhalers
● Combivent – Albuterol and Atrovent
● Advair Diskus – Albuterol and Steroids
Management: Oxygen Therapy (MUST BE LOW FLOW) Low Flow O2 Therapy
● Raises PO2 in inspired air
● 2-4 liters/minute (maximum is 4 liters/minute) via nasal cannula or up to 40% via Venturi Mask
● Treats hypoxemia (avoid over-treatment)
● Goal: PaO2 – 60-65% and Saturation around 90%
● Humidification is commonly used
● Respiratory airways are generally very dry Chronic O2 therapy at home
● Improved prognosis
● Improved neuropsychologic function
● Increased exercise intolerance
● Reduced pulmonary hypertension
Management: Collaborative Care Positioning
● Teach them tripod position Exercise
● Encourage patient to remain as active as possible
Respiratory Therapy
● Pursed-lip breathing
🞆 Prolongs exhalation and prevents bronchiolar collapse and air trapping
● Diaphragmatic breathing
🞆 Focuses on using diaphragm instead of accessory muscles to achieve maximum inhalation and slow respiratory rate
Nutrition and Hydration:
● Difficulty eating and breathing at the same time leads to inadequate amounts being eaten
● So, give them small, frequent meals. It takes energy to eat, so the shorter the meals, the better
● Avoid high carbohydrate diet to prevent increase in CO2 load; Dietary supplements are recommended
● Patient should eat 5-6 small meals to avoid feeling bloated
● Fluids (intake of 2-3L/day is recommended unless contraindicated) should be taken between meals to help liquefy thick respiratory secretions
Preventing Respiratory Infections
● Teach patients to avoid large crowds, and stress the importance of receiving a pneumonia vaccination and a yearly influenza vaccine
Smoking Cessation
● Accelerated decline in pulmonary function slows and function usually improves
● Most significant factor in slowing the progression of the disease
Note: Even a 3-minute counseling to urge a smoker to quit, results in cessation rate of 5-10%. Health Education place an important role in smoking cessation
Documentation
Nursing informatics (NI) is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. NI supports consumers, patients, nurses, and other providers in their decision making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology.
Nursing Informatics: Scope and Standards of Practice, ANA 2008
• Explain why information and technology skills are essential for safe patient care and define informatics.
o Used to:
▪ communicate and coordinate patient care
▪ Manage knowledge
▪ Reduce error
▪ support decision making
o USE AND DEVELOP THE THEIR (Electronic Health Record)
o EBP SUPPORT FOR CLINICAL DECISIONS
o SMART USE OF DATA
▪ AVOID MEDICATION AND CLINICAL ERRORS!
Electronic Medical Record - An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.
Electronic Health Record - An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization.
▪ Physical assessment
▪ Admission nursing note
▪ Nursing care plan/Nursing Diagnoses
▪ Present complaint (e.g., symptoms)
▪ Past medical history
▪ Tests/Procedures/Treatment
▪ Discharge
▪ Medication administration
▪ Daily documentation
The electronic health record is seen as the future cornerstone of health information systems and is essential to improve patient safety and quality of care.
Real-time patient information is necessary to provide timely and effective care. When time is spent tracking down a laboratory result or a patient’s schedule for physical therapy, time is wasted and clinical decisions may be compromised.
Integrated EHR systems provide:
▪ Alerts about abnormal test results or other findings that need to come to the attention of a provider
▪ Clinical decision support tools such as linkage to protocols related to patient problems
▪ A centralized mechanism for access from different locations and institutions
▪ Efficient use of storage space for patient data
▪ Aggregation of data to assess quality measures
Barriers to EHR’s include:
▪ Implementation costs
▪ Training of large numbers of health care professionals
▪ Organizational culture
▪ Systems funding
▪ Lack of planning
▪ Not wanting to lose patient eye contact
▪ Slow computers
▪ Inability to type quickly
▪ Feeling that using the computer in front of the patient is rude
▪ Fear of decreased critical thinking
Personal Health Record - An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual
• Describe how technology and information management are related to quality and safety of patient care, particularly medication errors, and shift change.
Errors often occur at the time of a “hand off” during a shift change, transfer of a patient from one unit to another within the same institution, or between institutions
Using I-SBAR-R (Identify yourself, Situation, Background, Assessment, Recommendations, Readback and Document the Response) for every patient has helped nursing organize information, but still is used variably particularly during critical events in interdisciplinary communication
• Describe issues related to health informatics including privacy concerns, nursing “language,” complexity of health informatics, and future visions.
• Review nursing notes – narrative, focus, soap, SBAR
Narrative note – same data in paragraph form
DON’T’s
• Alter patient’s record
• Write unacceptable abbreviations
• Write imprecise descriptions
• Chart ahead of time
• Include opinion not facts
DO’s
• Correct chart
• Reflect nursing process
• Write legibly
• Conversation with MD
• Time patient was provided care
• Tell the whole story without garnishing it
• Late entry
Hypertension
• Explain the risk factors, pathophysiology, clinical manifestations, and complications associated with hypertension.
Development of Hypertension It is a function of CO and PVR
This means that if CO increases, then we’ll see an increase in BP. Same with PVR.
- If stroke volume goes down, the heart compensates by increasing heart rate.
It does this in order to pump out the right amount of blood to the body. It needs to maintain a certain level of CO.
- SV could also be used to make sure that each time the heart beats, it does so efficiently and effectively
● Some meds decrease the HR, but increase the productivity of the heart
● Digoxin, for example will decrease the heart rate and increase the ability of the heart to beat more fully and forcefully. So, when you give it and assess your patient afterwards, these are things that you should observe
- PVR is affected by sympathetic activity—increased epinephrine can vasoconstrict, which will increase PVR (and thus BP)
- Renin-angiotensin mechanism can also affect PVR, because angiotensin II results in vasoconstriction
● Some meds can prevent the angiotensin II from being produced (called ACE inhibitors); these meds can thus reduce PVR and ultimately decrease BP.
Thus, BP is a function of how much blood gets out of your heart and the amount of PVR in your system.
o A thiazide diuretic increases urination, thus decreasing CO. This has a significant effect on lowering BP.
o We also have vasodilators, which decrease PVR thus decreasing BP
o Essential/Primary Hypertension: Usually asymptomatic (“silent killer”)
o Secondary Hypertension: results from renal diseases, Primary aldosterone’s, pheochromocytoma, Cushing’s Syndrome, medications, or a combination of these factors.
Essential/Primary Hypertension (95-98%)
Unknown etiology. While BP mechanisms are the same, the reason for the disease occurring in each individual is unknown.
Here are some risk factors, including modifiable (smoking, consumption of fatty foods, etc.) and non-modifiable (factors that you can’t change):
Family history of hypertension
African-American ethnicity
Hyperlipidemia
Smoking
Age greater than 60 years or post-menopausal
Excessive sodium and caffeine intake
Overweight/obesity
Physical inactivity
Excessive alcohol intake
High intake of salt or caffeine
Reduced intake of potassium, calcium, or magnesium
Excessive and continuous stress
Secondary Hypertension
These patients have HBP as a result of some other disease:
Renal disease
Involved with the RAA mechanism. A problem with kidneys leads to increased amounts of angiotensin II in the system, which leads to increased vasoconstriction, which raises BP
Primary aldosteronism
This involves increased aldosterone in the system. This increases tension of water and sodium in the system. This means that blood volume and thus CO is increased. That leads to a rise in BP
Pheochromocytoma
A condition in the adrenal medulla (secretes epinephrine and norepinephrine) which leads to excessive release of epi and norepi, which leads to an increase in vasoconstriction
Cushing’s syndrome
A lot of cortisol in the system, which causes an increase of the retention of water in your system (increases BV)
Medications
Meds are good to manage acute conditions, but taking them for a long time leads to side effects, including water retention
Important Facts Some disparities:
Incidence is highest among African-Americans
Incidence is higher among men compared to women until age 45
Incidence is higher among women compared to men after age 45 1 in every 3 Americans has hypertension (HTN)
47% do not have it under control
22% have pre-hypertension
Uncontrolled BP increases the risk of co-morbidities:
A 20mmHg (systolic)/10 mmHg diastolic increase in BP doubles the risk of Cardiovascular Disease (CVD)
Just a slight increase can have huge effects:
For example, a person with BP of 140/90 mmHg has twice the risk as a person with BP of 120/80 mmHg
Back to Hypertension
High BP begins a chain of cardiovascular events
- Myocardial infarction and Left ventricular hypertrophy and lead to heart failure, which can lead to death
• Discuss the different classifications of hypertension.
Blood Pressure Greater than 140/90 mm Hg Damages Target Organs Can lead to:
- Hemorrhage, stroke, and/or dementia
- Retinopathy
● Vessels in the back of the eye are particularly sensitive to changes in pressure
● It is one of the first organs in the body to feel the effects of hypertension
● This is why its imperitive to look at the back of the eye to make sure the blood vessels are perfused and intact
- Peripheral vascular disease
● Increase in deposition of plaques
- Renal failure
- LVH, CHD, and HF
Assessment
Accurate BP measurement requires:
- Proper Positioning
- Proper Arm Support
- Using the Right Cuff
- Correct Reading and Recording
Diagnostic Tests
Must be confirmed on 2 separate occasions
- Patient might have white coat syndrome (being at the doctor elevates BP) Diagnostic tests are done to assess secondary hypertension:
Kidney Disease: urinalysis, Blood Urea Nitrogen, Serum Creatinine, Glomerular Filtration Rate
Pheochromocytoma: presence of cathecholamines in the urine
Cushing’s Disease: elevated cortisol levels in the blood and presence of 17- ketosteroids in the urine
Xray and EKG– Left Ventricular Hypertrophy (LVH)
• Describe current and evidence-based recommendations and interventions to address and manage pre-hypertension and hypertension
JNC 8
• According to the 8th Joint National Committee* (JNC 8) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure:
• Hypertension Treatment Goals:
• Patients 60 and older: treatment should be initiated at a systolic blood pressure (SBP) of 150 mmHg or higher or a diastolic blood pressure (DBP) of 90 mmHg or higher.
• Patients younger than age 60 or those who have DM and Chronic Kidney Disease: treatment should be initiated at a DBP of 90 mmHg or higher or an SBP of 140 mmHg or higher and treat to goals below these respective thresholds.
Managing Hypertension
◦ Moderation of alcohol intake:
◦ No more than 2 drinks of ethanol (24 oz. beer, 10 oz. wine, 3 oz. 80- proof whiskey) per day in men and 1 drink for women or lighter weight person
◦ Exercise:
◦ 30 minutes of moderate activity on most days of the week
◦ DASH (Dietary Approaches to Stopping Hypertension)
◦ Medications:
◦ BP = CO X PVR
Medications:
● Blood Pressure = CO X PVR (Peripheral Vascular resistance)
● Examples:
• Diuretics eg. Thiazide (HydroDIURIL) or Loop diuretics (Lasix) or potassium sparing (spironalactone, Aldactone)
• Beta Blockers, (metoprolol, Lopressor)
• Angiotensin-Converting Enzyme (ACE) Inhibitors
(lisinopril, Zestril)
• Angiotensin Receptor Blockers (ARBs) drugs (losartan, Cozaar)
• Ca Channel Blockers (amlodopine, Norvasc)
Key points for Practice (from JNC 8)
Diabetes Mellitus
Definition of Diabetes Mellitus
- Diabetes mellitus is a group of metabolic diseases
characterized by hyperglycemia (increased sugar levels in the bloodstream) resulting from defects in insulin secretion, insulin action, or both.
- Involves improper metabolism of carbohydrates, fats and proteins
■ If you can’t get glucose in the traditional way, you will have to break down carbs, fats, and proteins in order to get glucose that way
■ It’s not the normal route, and can have major ramifications on the body
- The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels.
■ These long term complications are caused by glycosylation
Insulin
Facilitates the entry of glucose from the blood to the cells
- It acts as a key that opens the cell membrane, allowing glucose to move from the blood stream and into the cell
Comes from the pancreas, and is produced in the Islets of Langerhans (beta cells)
• Compare and contrast the risk factors, age of onset, manifestations and pathologic mechanisms of Type 1 and Type 2 DM
Type I is associated with an autoimmune disorder (where the pancreas and islets of Langerhans are targeted)
- This is why they have a near TOTAL lack of insulin-making beta cells Type II diabetes does not have a well-known etiology. Some things are associated with Type II:
- Obesity (increased adipose tissue may lead to a decreased sensitivity to the effects of insulin)
- Family history
Diabetes Mellitus
Type 1
- Also known as Juvenile-Onset DM
- Onset: Usually younger than 30
- Etiology: associated with an auto-immune reaction
- Hallmark: Lack of insulin and presence of islet cell antibodies (ICA)
- Symptoms: Abrupt
- Can be triggered by a viral infection
- Etiology viral infection (sometimes linked to onset)
- At risk if HLA-DR or HLA-DQ – may be linked to human leukocyte antigen on cells
- Usually thin
- Insulin dependent
- PO agents are ineffective
Type 2
- Also known as Adult-Onset DM
- Progressive disorder pancreas makes < insulin overtime and resistance occurs
❖ Pancreas is trying to make insulin but getting resistance and not
allowing cells to uptake the glucose
- Onset: Peaks in 50’s
- Etiology: Not well understood
- Hallmark: decreased insulin production and insulin resistance
o Metabolic Syndrome
▪ **Metabolic factors that increase risk for type 2 DM and CV disease – twofold increase for CV disease and fivefold increase for DM
▪ Abdominal obesity
▪ Hyperglycemia (constant)
▪ HTN
▪ Dyslipidemia
▪ Health Promotion: teach about lifestyle changes to improve health
healthy diet, keep BP under control, keep lipids under control
(may need statin drug)
Classic Symptoms/Clinical Manifestations Type 1
Type 2
- Weight Loss- loss of calories and water in urine
■ Hyperglycemia creates a hypertonic environment (a lot of solute in the blood). Increased urination can lead to weight loss
■ Glucose remains outside of the cells, meaning this you’re not feeding the cells. This can lead to weight loss
- Polydipsia (excessive thirst)
■ Cells become dehydrated
■ Most fluid leaves the cells due to the glucose that creates a gradient
- Polyuria (excessive urination)
- Polyphagia (excessive hunger)
■ Called abrupt because these symptoms are exactly what the patient will go into see a health care provider about
- Non-specific symptoms
- Fatigue
■ Due to the fact that you need glucose for energy
- Recurrent infections
■ Increase tonicity in blood makes it a good medium for pathogenic growth
- Prolonged wound healing
- Visual changes
■ Retina is extremely sensitive and this is why they are one of the first places in within DM is observed first
• Identify the diagnostic tests for screening and monitoring of DM
Are You Diabetic?
A1c: hemoglobin A1c (HgA1c)
- This test should be performed in the lab using method that is NGSP certified and standardized to the DCCT assay
■ Talks about the percent of hemoglobin that is bound to glucose
■ A good indication of glucose levels
■ <6.5% of hemoglobin should be coated with glucose Fasting plasma glucose greater than 126 mg/dL
- Fasting is defined as no caloric intake for at least 8 hours
2- hour plasma glucose greater than 200 mg/dL during an oral glucose tolerance test
- The test should be performed using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water
These three tests must be repeated to get the diabetes diagnosis
- Unless there is unequivocal hyperglycemia detected. It that case, one test is enough
Pre-Diabetes Leads to Diabetes Hemoglobin A1C
Normal is less than 6.5% (pre-diabetes: 5.7-6.4%)
Normal A1C reduces risk of retinopathy, nephropathy, and neuropathy Useful in determining glycemic levels over time
Diagnostic and monitors success of treatment
Continuing Care Visits ADA Minimum Standards Quarterly visits for those not meeting goals Semiannulally for stable patients
Lab evaluations:
- HbA1C
- Quarterly for those not meeting goals
- Semiannually for stable patients Lipids annually
Annual
- Opthamology exam
- Foot exam (more often in those at high risk)
Assessment for DM
• High risk factors
o Age – esp with type 2 (> 50 y/o)
o Gestational diabetes – higher likelihood of developing later in life
o Weight and weight change – healthy lifestyle and avoiding risk factors of metabolic syndrome
• Symptoms
o Fatigue (not getting enough glucose/energy into cells b/c of lack of insulin
or resistance)
o Polyuria – osmotic diuresis
o Polydipsia – putting out large amounts of fluid
▪ **problem w/ older adults b/c they have a deficient thirst mechanism
dehydration risk (by the time they get to this point there is already
a big problem). PLUS, they are already at risk for dehydration, due to less muscle mass.
o Polyphagia – cells not getting enough glucose
• Major and minor infections
o Infections can send patients into DKA or HHS (Ex. Pneumonia)
o Poor wound healing
• Changes in vision or sense of smell b/c of nervous system involvement
▪ Diagnostic Studies
• Fasting blood glucose levels > 126mg/dl diagnostic of DM even in older adults
(done on 2 separate occasions)
o Normal is < 100mg/dl
o Older adults – levels increase 1mg/dl per decade
• Glucose tolerance test levels > 200mg/dl indicate provisional dx of DM
o Normal is < 140mg/dl
• Glycsylated hemoglobin (HbA1c) levels > 6.5% indicate poor diabetic control
o Normal is 4-5.6%
o 5.7-6.4% is pre-diabetes – HEALTH PROMOTION necessary to prevent diabetes
o HbA1c is amount of glucose attached to the RBCs and gives 3-month snap shot of glucose control so it is a better test
• Urine Tests
o Ketone bodies
o Glucose – dipstick
o Tests for kidney function – urine albumin excretion, creatinine clearance (assess GFR)
• Determine priority nursing diagnoses for patients with Type 1 and Type 2 DM
Nursing Diagnosis
• Ineffective tissue perfusion related to interrupted blood flow secondary to development and progression of macroangiopthy and microangiopathy
• Risk for infection related to disease process
• Risk for impaired skin integrity
• Knowledge deficit
• Ineffective therapeutic regimen management
• Risk for injury
• Risk for infection
• Powerlessness
• Imbalanced nutrition: More than body requirements
Goals of Diabetes Management:
• Reduce symptoms
• Promote well-being
• Prevent acute complications
• Delay onset and progression of long-term complications
Interventions
o Nutrition – well-balanced diet, may have nutritionist work with them
o Self blood glucose monitoring at least 1x per day (preferably more)
o Exercise program that is appropriate for age and ability
o Stress management
o Drug Therapy
▪ Indicated for those with type 2 DM when diet, exercise, and stress management are ineffective
▪ Need to be individualized
▪ Shorter acting better for older persons b/c of the way that they eat
▪ Longer acting/once per day dosing better for adherence b/c less likely to miss a dose
▪ Most Type 2 diabetics can take oral agents to keep them in tight glucose control
• What do we see as 1st line/most often?
Metformin (Glucophage)
• Drugs that simulate pancreas to try to put out more insulin and try to help sensitize cells to uptake glucose
• Have to be aware of onset and peak when
administering b/c need to make sure
patient eats (risk for hypoglycemia)
• May need to give more than one med b/c they act on different parts of the body
▪ Insulin therapy – all type 1 and some type 2
• Rapid, regular, intermediate, long acting
forms
o Rapid (Humolog, Novolog) – onset 15 min, peak 1 hour, duration 2-4 hours; give within 10 minutes of mealtime
o Regular (Humulin, Novulin R) – onset 30 min, peak 2-3 hours, duration 3-6 hours; give within 20-30 minutes of mealtime
o Intermediate (NPH) – onset 2 hours, peak 4-12 hours, duration up to 18 hours
o Long (Lantus) – stays in body and mimics basal insulin; even insulin release evenly over 24 hours
• Should rotate insulin within 1 anatomic
area so that rates of absorption are
similar
o **abdomen has best absorption rate
• Mixing insulin
o CLEAR TO CLOUDY
o Draw up clear (rapid/regular) 1st and then cloudy (intermediate) to prevent contaminating a short-acting insulin with a long-acting insulin
• Insulin pump – allows pt to have good
control – can check blood glucose level,
have basal dose constantly, and have bolus when needed
• IV drip 100 units regular insulin/100mL
0.9% NS in an acute situation
o Intensive teaching about foot care – foot injury is #1 cause leading to hospitalization
o Full foot assessment
o Wound care
o Manage chronic neuropathic pain
▪ Anticonvulsants
▪ Tricyclic antidepressants
o Education about hypoglycemia and treatment - **elderly at increased
risk**
• Recognize the importance of early diagnosis and control of blood glucose to prevent complications
Acute Complications
Hypoglycemia (Blood Glucose less than 70 mg/dl)
- Primary Causes
• Too much insulin
• Decreased food intake
- Common Manifestations
• Confusion/irritability
• Diaphoresis
• Tremors
• Hunger
• Weakness and visual disturbances
• Can mimic alcohol intoxication
• Untreated can progress to loss of consciousness, seizures, coma, and death
If you notice a change in the level of consciousness of a diabetes patient, check their blood sugar, because it could be hypoglycemia
Treatment of Hypoglycemia
Treatment of Mild Hypoglycemia (Blood Sugar less than 60 mg/dL)
- If alert enough to swallow
❖ 15 to 20 grams of simple carbohydrate (don’t want to give too much because then you’re risking hyperglycemia)
❖ ½ cup fruit juice or
❖ ½ cup regular soft drink
- Recheck blood sugar 15 minutes after treatment
- Repeat until blood sugar is above 70 mg/dl
- Patient should eat regularly scheduled meal/snack to prevent rebound hypoglycemia
- Check blood sugar again 45-60 minutes after treatment
- In Severe Hypoglycemia (Blood Sugar less than 20 mg/dL) or if no improvement after 2 or 3 doses of simple carbohydrate or patient not alert enough to swallow
❖ Administer 1 mg of glucagon IM or subcutaneously. Side effect: Rebound hypoglycemia
❖ In acute care settings
❖ 20 to 50 ml of 50% Dextrose intravenous (IV) push
❖ Have patient ingest a complex carbohydrate after recovery
Severe Forms of Hyperglycemia (Hyperglycemic Crisis)
Hyperglycemia: Blood glucose >200mg/dl Type 1:
- Diabetic Ketoacidosis (DKA)
❖ Blood Glucose Level – more than 300 mg/dL
❖ Positive ketones in the blood and urine
❖ Because body has to break down fats to get glucose for energy
❖ Ketones is the byproduct, and can lead to an acidotic situation
❖ Signs and Symptoms:
❖ Kussamaul’s Respiration
❖ Characterized by increased rate and depth (hyperventilating to get rid of increased levels of CO2—acid—in the system)
❖ Remember that acid increases because of the presence of ketones
Type 2:
❖ “Fruity” breath
❖ Nausea and abdominal pain
❖ Manifestations of Dehydration!
❖ Results from high levels of sugars in the blood
- Hyperglycemic Hyperosmolar State (HHS)
❖ Blood Glucose Level – more than 600 mg/dL
❖ Negative ketones in the blood and urine
❖ Because it occurs in people with type 2 diabetes, and they do have some insulin in the blood (granted, it’s a low level of glucose)
❖ Signs and Symptoms:
❖ Neurologic symptoms
❖ Manifestations of Dehydration!
❖ Results from high levels of sugar in the blood The two things we discussed are severe, acute side effects of diabetes
- DKA is very specific for Type 1 people (although those with Type 2 can get it as well, it’s much more common in Type 1)
❖ It happens mostly because the body is forced to utilize other sources of energy due to complete lack of insulin
❖ The only way to get rid of these increased levels of acid is through the urine or through the lungs
- HHS is more specific to Type 2 individuals
We treat both of these conditions by giving the patient insulin through a continuous IV pump
- You just really have to be careful that receiving this regular insulin will not lead to hypoglycemia
❖ Check blood sugar every 10-15 minutes as a preventative measure
Chronic Complications
Microvascular (small vessel diseases)
- Eye disease (retinopathy)
- Renal disease (nephropathy)
- Nerve disease ( both peripheral and autonomic neuropathy)
Macrovascular (large vessel diseases)
- Cardiovascular disease:
■ MI
■ CHF
■ Elevated Blood Pressure
Vascular Disease is the single largest causative factor in the mortality of those with diabetes
Glaucoma Cataract
Diabetic Retinopathy Heart Disease
High Blood Pressure Nervous System Disease Amputations
Foot Ulcers
Delayed Wound Healing Dental Disease Complications of Pregnancy Sexual Dysfunction
• Discuss problems related to diabetes in older adults
o Priority Problems
▪ Preventing hypoglycemia – they are at increased risk!
▪ Risk for injury r/t hyperglycemia, sensory alterations, disturbed sensory perception
▪ Risk for delayed surgical recovery r/t endocrine and vascular effects of DM (delayed wound healing)
▪ Chronic pain r/t peripheral nerve dysfunction
▪ Ineffective tissue perfusion (renal) r/t impaired oxygen transport across
capillaries
▪ Risk for kidney disease
▪ **GOAL: very tight control of glucose levels**
▪ Potential for:
• Hypoglycemia
• DKA
• HHS
• Coma
Summary of Chronic complications:
■ Heart Disease
■ High Blood Pressure
■ Nervous System Disease
■ Amputations
■ Pressure Injuries (foot)
■ Delayed Wound Healing
■ Dental Disease
■ Complications of Pregnancy
■ Sexual Dysfunction
OLDER ADULTS
• Older patients are at increased risk for poor nutrition, hypoglycemia, and especially dehydration – a factor in the development of hyperglycemic- hyperosmolar state (HHS).
o Many factors contribute to malnutrition.
▪ Nutrition needs of the older adult change as the person's taste, smell, and appetite diminish and ability to obtain and prepare food decreases.
• Older patients who prepare their own food or have tooth loss or poorly fitting dentures may not eat enough food.
o Neuropathy with gastric retention or diarrhea compounds poor food intake. Impaired cognition and depression may disrupt self- care.
• Older patients may have a marginal food supply because of inadequate income, may have poor understanding of meal-planning needs, or may live alone and have reduced incentive to prepare or eat proper meals.
o They may eat in restaurants or live in situations in which they have little control over meal preparation.
o Regular visits by home health nurses can assist older patients in following a diabetic meal plan.
• A realistic approach to nutrition therapy is essential for the older patient with diabetes.
o Changing the eating habits of 60 to 70 years is very difficult.
o The nurse, dietitian, and patient assess the patient's usual eating patterns.
o Teach the older patient taking antidiabetic drugs about the
importance of eating meals and snacks at the same time every day, eating the same amount of food from day to day, and eating all food allowed on the diet.
Peripheral Vascular Disease
Peripheral Arterial Disease “PAD” (another name for PVD, because most symptoms are relegated to the arterial system)
Disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation
Obstruction is classified as either outflow versus inflow obstruction
- The groin the line of demarcation
- The inguinal ligament artery
❖ Any damage to vasculature above is considered inflow
❖ Anything below the common iliac artery (which perfuses renal artery)
❖ Anything below it is considered outflow
❖ The more distal the site is, the more at risk that site is to be affected
• Discuss the pathophysiology and clinical manifestations of patients with the following vascular conditions:
o Peripheral Arterial Disease
Peripheral Arterial Disease Stage I: Asymptomatic
- Body can compensate for lack of blood flow to lower extremities for a while, so you don’t feel any
Stage II: Claudication
- Leg pain and intermittent claudication are the same thing
- It is similar to chest pain, because there is decrease blood flow to the legs
- Similar to chest pain, in that patient will stop walking to relieve the pain
Stage III: Rest pain
- If the condition worsens, you move into this stage Stage IV: Necrosis/gangrene
- Occurs when we totally cut off blood flow
Peripheral Arterial Disease: Clinical Manifestations Inflow disease
o Discomfort in the lower back, buttocks, or thighs
o These are the areas that have decreased circulation Outflow disease
o Burning or cramping in the calves, ankles, feet, and toes You’ll find the following during assessment:
o Hair loss and dry, scaly, pale or mottled skin and thickened toenails
o Severe arterial disease
• Extremity is cold and gray-blue or darkened
• Pallor may occur with extremity elevation
• Dependent rubor; and/or muscle atrophy
• Redness of lower extremities as a result of increased dependency of the lower extremities
Diagnostic Assessments
Assess for 6 P’s (pain, pallor, pulselessness (might need to use a Doppler), paresthesia (tingling sensation as a result of decrease blood flow), paralysis, poikilothermia (the legs will feel very cool as a result of the decreased blood flow)
- Can be all of them
- Can also be a combination of a few of them Imaging assessment
• Arteriography: inject dye into arteries to see if there is narrowing of the vasculature
• Uses a contrast medium
• An invasive procedure
• Need patient prep and MUST get consent
• Nurse needs to find out if patient has an iodine allergy Other diagnostic tests:
• Ankle-brachial index (ABI)—non-invasive
• Ankle Blood Pressure/Brachial Blood Pressure: take an ankle BP, then take brachial BP; compare the two
• [Right ankle BP/Right Arm BP= Ratio]
• Ratio of less than 0.9 is diagnostic of PAD
• Exercise tolerance testing
• Put them on a treadmill and monitor results
• Instead of asking a patient for chest pain, you ask them about leg pain
• Plethysmography
• Attach an electrode on lower extremities to measure how much blood flows down there
• Non-invasive
o Aneurysm
Aneurysms
Aneurysm: a permanent localized dilation of an artery, enlarging the artery to twice its normal diameter
• Cause: Atherosclerosis, Hyperlipidemia, Hypertension
• Chronic conditions such as atherosclerosis will damage arteries, and make it more prone to other diseases and conditions
• It will loose elasticity and functionality
• Types:
• Fusiform aneurysm
• All the layers of the artery are affected
• Saccular aneurysm
• Only one of the areas is affected
• Locations
• Can form anywhere that you have arteries or veins
• Usually refers to arteries, but it does actually include veins as well
• Most dangerous ones are arterial
• Will lead to huge circulation issues
Abdominal Aortic Aneurysm (AAA)
• Most common aneurysm
• Abdominal aorta is a huge artery, and can cause huge issues if it bursts, because all of the lower extremities will be affected (abdominal aorta will bring blood to these areas)
• There is a genetic predisposition to developing aneurysms
• Marfan’s Syndrome (weak arterial disorder due to weak connective tissue)
• If small, patients won’t even notice any symptoms
• Aneurysms more than 5 cm in diameter is when you will begin to see symptoms:
• Pain in the abdomen, flank, or back
• Usually steady with a gnawing quality, is unaffected by movement, and may last for hours or days.
• Abdominal mass is pulsatile.
• This is a hallmark warning sign
• This is why the first thing you need to do is INSPECT (look for this pulsation)
• Rupture is the most frequent complication and is life threatening.
• This is called dissection, and is considered a medical emergency
Thoracic Aortic Aneurysm (TAA)
• Assess for back pain and manifestation of compression of the aneurysm on adjacent structures.
• Assess for shortness of breath, hoarseness, and difficulty swallowing.
• Occasionally a mass may be visible above the suprasternal notch.
• Can see pulsations or a nodule
• Sudden excruciating back or chest pain is symptomatic of thoracic rupture.
Diagnostic Assessment
• X-ray
• CT
• Aortic arteriography
• More specifically focused on the aorta, but is similar to the procedure described above
• Ultrasonography
Aortic Dissection
• May be caused by a sudden tear in the aortic intima, opening the way for blood to enter the aortic wall
• Blood pools here, which decreases blood flow and CO, and you can see signs and symptoms of shock
• Allows for blood to go in between the three layers of the artery, which is not where we want it
• Pain described as tearing, ripping, and stabbing
• Emergency care goals include:
• Elimination of pain
• Reduction of blood pressure
• Decrease in the velocity of left ventricular ejection (a decrease in CO, because the blood isn’t getting to the heart; it’s getting trapped in the layers of the artery)
o Buerger’s Disease
Buerger’s Disease
Common in young people who smoke; may also be familiar. It’s an ulcer found on the tips of your fingers or toes.
Both arteries and veins are affected.
• Thromboangiitis Obliterans
• Relatively uncommon occlusive disease limited to the medium and small arteries and veins
• Often identified with tobacco smoking Nursing interventions
- Smoking cessation (can see improvement in symptoms)
- Assess for circulation in the area to help prevent infection
- Monitor other areas of lower extremities (i.e. keep an eye on other fingers and toes)
o Raynaud’s Diseases
Raynaud’s Phenomenon
• Caused by vasospasm of the arterioles and arteries of the upper and lower extremities
• An occlusive disease caused by vasospasm of arterioles
• Etiology is unknown
• A familiar predisposition is suspected
• Could be caused by increased calcium in your system
• Extreme cold can cause vasospasm
• Drug therapy
• Calcium blockers can help decrease vasospasm
• Reinforcement of patient education:
• Minimizing exposure to cold
• Smoking cessation
• Should also always assess their pain levels
o Deep Vein Thrombosis (DVT)
Venous Thromboembolism
• Deep vein thrombosis (DVT)
• Risk for Pulmonary embolism
• Virchow’s triad:
• Venous Stasis
• Exercise leg, get patient out of bed
• Vessel Injury
• Pay special attention to veins that have just been analyzed, because clots could form there
• Hypercoagulability
• People on hormones are at risk
• Other medications can also increase risk
• Highest incidence of clot formation occurs in patients who have undergone hip surgery, total knee replacement, or open prostate surgery.
Risk Factors
• Active Cancer
• Paralysis or Casting of an Extremity
• Bedridden (>3 days) or major surgery in last 3 months
• Localized tenderness along the venous system
• Swelling of the legs
• Calf swelling > than 3 cm larger
• Pitting edema
• Dilated superficial veins
• Previous history of DVT
Diagnostic Assessment
• Physical Assessment Findings:
• Calf or groin tenderness or pain
• Sudden onset of unilateral swelling of the leg
• Checking Homans’ sign—not advised
• Ask patient to dorsiflex foot (point toe towards nose)
• DON’T ask patient to do it if you see unilateral edema, because you could dislodge the clot
• Localized edema
• Venous flow studies
• Magnetic Resonance Imaging
• Doppler can be used
• Will give patient Heparin to treat it
• Differentiate among arterial, venous and diabetic ulcers
Arterial Ulcers
• History
o Complain of pain during walking
• Appearance
o At the end of the toes or between toes
• Other Significant Findings
o Decrease in arterial pulse
o Cool to touch
o Neurologic signs present in severe cases
Venous Ulcers
• History
o Not associated with pain during walking
• Appearance
o Found in ankle area
• Other Significant Findings
o Ankle discoloration and edema
o Pulses present
o No neurologic deficits
Diabetic Ulcers
• History
o Won’t feel any pain
• Appearance
o Found at the bottom of the feet
• Other Significant Findings
o Pulses usually present
o Cool or warm feet [Show Less]