NRSG 120 - Exam 1

diabetes mellitus - ___ (DM) is a chronic multisystem disease characterized by hyperglycemia related to abnormal insulin production, impaired insulin utilization, or both; 30 million Americans have diabetes mellitus - ___ (DM): - group of metabolic diseases - impaired glucose metabolism * chronic hyperglycemia ~ abnormal insulin secretion ~ impaired insulin action ~ long term organ damage (kidneys, liver, pancreas) diabetesq - ___ is the leading cause of adult blindness, end-stage renal disease, nontraumatic lower limb amputation; contributing factor to heart disease and stroke insulin - ___ lowers blood glucose and facilitates a stable, normal glucose range of approximately 70-110 mg/dL - produced by beta cells in the islets of langerhans of pancreas glucose; glycogen - insulin promotes ___ transport from the bloodstream across the cell membrane to the cytoplasm of the cell; cells break down glucose to make energy, and liver and muscle cells store excess glucose as ___ Type 1 - ___ DM, formerly known as juvenile-onset diabetes or insulin dependent diabetes - 5-10% of people with diabetes - autoimmune disorder- body develops antibodies against insulin and/or pancreatic beta cells that produce insulin pancreas - ___ function: - discharge powerful digestive enzymes in the small intestine to aid digestion of carbs, protein and fat - releases hormones insulin and glucagon in bloodstream - hormones involved in blood glucose (sugar) metabolism, regulate how body stores and uses food for energy exocrine - pancreas as an ___organ: - pancreatic juice - Trypsin - Amylase - lipase endocrine - pancreas as ___ organ: insulin glucagon somatostatin pancreatic polypeptide glucose - - energy source for cells - result of CHO metabolism - utilization: * metabolized to produce energy * stored as glycogen in liver or muscles * converted to fat increase; decrease - high blood glucose = ___ in insulin & ___ in glucagon decrease; increase - low blood glucose = ____ insulin & ___ glucagon counterregulatory hormones - glucagon, epinephrine, growth hormone, cortisol; work to oppose effects of insulin - increase blood glucose levels by: 1. stimulating glucose production and release by the liver 2. decreasing the movement of glucose into the cells glucagon - - produced by alpha cells of pancreas - acts on liver * break down glycogen * synthesize new glucose - regulate utilization of glucose and fats insulin - ___: - produced by beta cells of the pancreas * continuously released * increased release with food consumption - promotes glucose transport into cells - opposed by couterregulatory hormones (glucagon, epi, GH, cortisol) Type 1 - ___ diabetes: - genetic predisposition or exposure to virus - autoimmune response * islet cell antibodies * progressive destruction of beta cells * no insulin production - under 40 years of age type 1 - manifestations of ___ diabetes develop when the person's pancreas can no longer produce sufficient amounts of insulin to maintain normal glucose exogenous - the individual with type 1 diabetes requires insulin from an outside source (___ insulin), to sustain life diabetic ketoacidosis - without insulin, the patient will develop ___ (DKA), a lifethreatening condition resulting in metabolic acidosis type 1 - classic symptoms of ___ diabetes include: - weight loss - polydipsia - polyuria - polyphagia - weakness & fatigue - hyperglycemia - visual changes - ketoacidosis polydipsia - excessive thirst polyuria - excessive urination polyphagia - excessive hunger type 1 diabetes there is an absence of endogenous insulin - what is the major difference between type 1 and type 2 diabetes? type 2 - ___ diabetes, formerly known as adult-onset diabetes (AODM) or non-insulindependent diabetes (NIDDM); most prevalent; inadequate insulin secretion and insulin resistance; the pancreas usually produce some endogenous insulin, however the body either does not produce enough insulin or does not use it effectively or both type 2 - ___ diabetes: - insufficient or poorly utilized insulin * insulin resistance * impaired glucose tolerance * inappropriate glucose production by the liver * decreased ability to produce insulin * cytokines cause chronic inflammation endogenous insulin - self-made insulin type 2 - ___ diabetes has a gradual onset, marked hyperglycemia; risk factors include age, obesity, lack of exercise, heredity and ethnicity type 2 - symptoms of ___ diabetes may be same as type 1, some non-specific symptoms include fatigue, recurrent infections, prolonged wound healing and visual changes insulin resistance - a condition in which body tissues do not respond to the action of insulin because insulin receptors are unresponsive, are insufficient in number, or both. metabolic syndrome - ___ has 5 components: 1. elevated glucose levels 2. abdominal obesity 3. elevated BP 4. high levels of triglycerides 5. decreased levels of high-density lipoproteins (HDLs) * an individual with 3 of 5 components is considred to have this prediabets - ___ is defined as impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or both; an intermediate stage between normal glucose homeostasis and diabetes, in which the blood glucose levels are elevated but not high enough to meet the diagnostic criteria for diabetes 140; 199 - A diagnostic of IGT is made if the 2-hour oral glucose tolerance test (OGTT) values are ___ to ___ mg/dL 100; 125 - IFG is diagnosed when fasting blood glucose levels are ___ to ___ mg/dL impaired glucose tolerance - IGT impaired fasting glucose - IFG gestational - ___ diabetes develops during pregnancy; high risk women include women who are obese, advanced maternal age, family h(x) of diabetes 126 - fasting plasma glucose diagnostic level is greater than or equal to ___ mg/dL 200 - random plasma glucose diagnostic level is greater than or equal to ___ mg/dL 6.5% - hemoglobin A1C diagnostic level is greater than or equal to ___ fasting - defined as no caloric intake for at least 8 hours 200 - two-hour plasma glucose level greater than or equal to ___ mg/dL during an OGTT, is diagnostic of DM 200 - in a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose greater than or equal to ___ mg/dL is diagnostic for DM A1C - ___ measures the amount of glycosylated hemoglobin as a percentage total of hemoglobin. ex. ___ of 6.5% means that 6.5% of the total hemoglobin has glucose attached to it 2;3 - A1C provides a measurement of blood glucose levels over the previous ___ to ___ months, with increases in A1C reflecting elevated blood glucose levels 4-6% - what is the normal range of hemoglobin A1C? eAG= 28.7 x A1C - 46.7 - an estimated average glucose (eAG) can be determined from the AIC. What is the formula used? 70-110 - What is the normal range for blood glucose? c-peptide - by-product created when insulin is produced high - type 2 diabetes has ___ levels of c-peptide low - type 1 diabetes has ___ levels of c-peptide diabetic - ___ assessments: - weight - BP - glucose: fasting and A1C - lipid profile - serum creatinine (kidney function) - urine: albumin and creatinine (liver & kidney) - exams: eye, foot and dental immunizations: influenza, pneumonia, & hepatitis basal-bolus regimen - the insulin regimen that most closely mimics endogenous insulin production is the ___, which uses a rapid-or short acting bolus insulin before meals and intermediate-or long acting (basal) background insulin once or twice a day intensive; physiologic insulin therapy - the basal-bolus regimen is ___ or ___, consisting of multiple daily insulin injections together with frequent self-monitoring of blood glucose. the goal is to achieve a glucose level of 80-130 mg/dL before meals. rapid-acting - ___ insulin: - onset: 10-30 min - peak: 30 min - 3hr - duration: 3-5 hr - ex: lispro (Humalog); aspart (NovoLog) & glulisine (Apidra) short acting - ___ insulin: - onset: 30 min - 1hr - peak: 2-5hr - duration: 5-8 hr - ex: Regular (Humulin R, Novolin R) intermediate acting - ___ insulin: - onset: 1.5 - 4hr - peak: 4 - 12hr - duration: 12-18 hr - ex: NPH (Humulin N, Novolin N) long acting - ___ insulin: - onset: 0.8-4hr - peak: less defined or no pronounced peak - duration: 16-24 hr - ex: glargine (Lantus), detemir (Levemir) and degludec (Tresiba) inhaled - ___ insulin: - onset: 12-15 min - peak: 60 min - duration: 2.5-3 hr - ex: Afrezza long acting insulin - which type of insulin can't be mixed? metformin - the most effective first-line treatment for type 2 diabetes; primary action is to reduce glucose production by the liver; it also enhances insulin sensitivity at the tissue level and improves glucose transport into the cells; oral tablet oral - ___ agents improve production and use of insulin and/or glucose ex. Sulfonylureas, Meglitinides, Biguanides, a-Glucosidase inhibitors, Thiazolidinediones and DPP-IV inhibitors Dawn phenomenon - characterized by hyperglycemia that is present on awakening somogyi effect - hyperglycemia in the morning may be due to the ___, a high dose of insulin produces a decline in blood glucose levels during the night. as a result, counterregulatory hormones (glucagon, epinephrine, growth hormone, cortisol) are released, stimulating lipolysis, gluconegenesis, and glycogenolysis, which in turn produce rebound hyperglycemia atrophy - is the wasting of subcutaneous tissue and presents as indentations in injection sites hypertrophy - a thickening of the subcutaneous tissue Sulfonylureas - - oral agent - stimulate insulin release by decreasing glycogenolysis and gluconeogenesis - enhance insulin sensitivity - ex: Orinase, diabenese, glucotrol, diabeta, amaryl Meglitinides - - oral agent - stimulate insulin release - take 30 minutes before each meal right up to the time of the meal - ex: Prandin, Starlix Biguanide - - oral agent - decrease hepatic glucose production - enhance glucose use by tissues - ex: glucophage (metformin) Aplha glucosidase inhibitors - - oral agent - delay absorption of glucose - "starch blockers" - ex: Acarbose (precose), miglitol (Glyset) Thiazolidinediones - - oral agent - "insulin sensitizers" - most effective for people with insulin resistance - improve insulin sensitivity, transport, and utilization at target tissues - increase glucose uptake in muscle - decrease glucose production - ex: pioglitazone (actos), rosiglitazone (avandia) Amylin & Incretins - what hormones help lower glucose levels? dipeptidyl peptidase-4 (DPP-4) inhibitors - - oral agent taken PO qAM - block the action of the DPP-4 enzyme, which is responsible for inactivating incretin hormones (gastric inhibitoy peptide-GIP and glucagon like peptide 1- GLP-1); the result is an increase in insulin release, decrease in glucagon secretion and decrease in hepatic glucose production, slows gastric emptying, decrease appetite - ex: Januvia (sitagliptin) - major side effects: URI, sore throat & HA Byetta - - exenatide - SQ shot BID before morning and evening meals - use with oral hypogycemic - actions: * lead to insulin release in response to hyperglycemia * decrease postprandial glucagon secretion * decrease appetite * slows gastric emptying - take fast acting oral medications at least one hour before injecting glucogenesis - breakdown of glycogen to glucose Symlin - pramlintide acetate - SQ shot given with meals - use with insulin - actions * suppress postprandial glucagon secretion * slows gastric emptying * enhance satiety 18.5 - BMI below ____ is underweight 18.5-24.9 - BMI: normal or healthy 25-29.9 - BMI overweight 30 - BMI greater than ___ is obese self monitoring of blood glucose - ___ (SMBG)is a critical part of diabetes management, by providing a current blood glucose reading, enables the patient to make decisions regarding food intake, activity patterns, and medication dosage; detects hyperglycemia & hypoglycemia; requires fingerprick nutrition; exercise - According to ADA guidelines ___ and ___ improve metabolic control diabetics - individual meal plans for ___ should be 1. nutritionally balanced 2. monitor CHO intake 3. limit alcohol and saturated fats 4. include family increases - exercise ___ insulin sensitivity lowers - exercise ___ blood glucose levels decreases - exercise ___ insulin resistance increases - exercise ___ circulation increases - exercise ___ muscle tone decreases - exercise ___ cholesterol exescise - ___ helps with weight management after - it is best for diabetics to exercise ___ meals before, during and after - when should diabetics monitor blood glucose when exercising? CHO - diabetics should have small ___ snacks during exercise 45-90 - insulin injections (SQ) are given at ___ angle; be sure to rotate sites Lipodystrophy - problem associated with insulin; atrophy or hypertrophy of subcutaneous tissue atrophy - the wasting of subcutaneous tissue and presents as indentations in injection sites hyertrophy - thickening of the subcutaneous tissue pancreas transplant - ___ can be used as a treatment option for patients with type 1 diabetes; usually done for patients who have end stage renal disease and have had or plan to have a kidney transplant diabetic ketoacidosis - ___ (DKA) is caused by a profound deficiency of insulin and is characterized by hyperglycemia, ketosis, acidosis and dehydration, Kussmaul's, and electrolyte imbalance; body using fat for energy; ketones - acidic by products of fat metabolism that can cause serious problems whey they become excessive in blood; alters pH balance, causing metabolic acidosis poor skin turgor dry mucus membranes tachycardia orthostatic hypotension lethary and weakness acetone on breath as sweet, fruity odor - what are some symptoms of DKA? IV hydration insulin correct electrolyte imbalance - treatment for DKA: hyperosmolar hyperglycemic syndrome - ___ (HHS): life threatening syndrome that can occur in the patient with diabetes who is able to produce enough insulin to prevent DKA, but not enough to prevent severe hyperglycemia, osmotic diuresis, and ECF depletion, dehydration, electrolyte changes and neurological changes patient has enough circulation insulin so that ketoacidosis does not occur - what is the main difference between DKA and HHS? immediate IV fluid administration insulin correct electrolyte imbalance - treatment for HHS: hypoglycemia - low blood glucose, occurs when there is too much insulin in proportion to available glucose in the blood; glucose drops to less than 70; counterregulatory hormones are release and the ANS is activated Shakiness. Dizziness. Sweating. Hunger. Irritability or moodiness. Anxiety or nervousness. Headache. - what are some symptoms of hypoglycemia? 15 - blood glucose less than 70 is treated by ingesting ___ g of a simple (fast acting) CHO such as 4-6 oz of fruit juice or a regular soft drink; known as "rule of 15" contact HCP - after 2-3 doses of ingesting 15g of a simple card and glucose is still less than 70, what should be done next if at home? dextrose; glucagon - in an acute care setting, pt's with hypoglycemia may be treated with 20-50 mL of 50% __ IV push. if pt is not not alert enough to swallow and no IV access available, another option is to administer 1 mg of ___ by IM or SQ injection angiopathy - chronic complications associated with diabetes are primarily those of endorgan disease from damage to blood vessels ___ secondary to chronic hyperglycemia; one of the leading cause causes of diabetes-related deaths; divided into two categories: macrovascular and microvascular macrovascular - ___ complications are diseases of the large and medium size blood vessels that occur with greater frequency and with earlier onset in people with diabetes - cerebrovascular, cardiovascular, and peripheral vascular disease - CVA (stroke) - MI microvascular - ___ complications result from thickening of the vessel membranes in the capillaries and arterioles in response to conditions of chronic hyperglycemia; specific diabetes - retinopathy, nephropathy and neuropathy - present in some patients with type 2 diabetes at diagnosis diabetic retinopathy - microvascular damage to the retina as a result of chronic hyperglycemia; most common cause of news cases of adult blindness Nonproliferative diabetic - ___ retinopathy, the most common form, partial occlusion of the small blood vessels in the retina cause microaneurysms to develop in the capillary walls, mild to severe vision loss proliferative diabetic - ___ retinopathy, most severe form, involves the retina and vitreous; diabetic nephropathy - microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney; leading cause of end stage renal disease diabetic neuropathy - nerve damage that occurs because of the metabolic derangements associated with DM; most common sensory; can lead to loss of protective sensation in the lower extremities, increase risk for lower limb amputation dermopathy - diabetes related ___; most common diabetic lesion, characterized by reddish brown, round or oval patches; initially scaly and then they flatten out and become indented; on shins, thighs, forearms, side of foot, scalp and trunk acanthosis nigricans - manifestation of insulin resistance; appear as velvety light brown to black skin thickening, predominantly seen on flexures, axillae, and the neck necrobiosis lipoidica diabetic - usually appears as red-yellow lesions, with atrophic skin that becomes shiny and transparent revealing tiny blood vessels under the surface; uncommon; occurs more frequently in young women infections - a person with diabetes is more susceptible to ___ because of a defect in the mobilization of WBCs and an impaired phagocytosis by neutrophils and monocytes 100-125 - fasting glucose ___ = prediabetes IFG less than 140 - 2 hr PP or 75-gram OGTT ___ = prediabetes IFG <100 - fasting glucose ___ = prediabetes, IGT 140-199 - 2 hr PP or 75 gram OGTT ___ = prediabetes, IGT 100-125 - fasting glucose ___ = prediabetes IFG & IGT 140-499 - 2 hr PP or 75 gram OGTT ___ = prediabetes IFG & IGT 126 - fasting glucose greater than or equal to ___ = diabetes 200 - 2 hr PP or 75 gram OGTT greater than or equal to ___ = diabetes 15 g simple carb-15 min-15 g - treatment of hypoglycemia: Anithistamines - treatment given for allergic reaction to insulin: room temp insulin, rotate sites - treatment for lipodystrophy associated with insulin: decrease insulin dose - treatment of somogyi effect associated with insulin: adjust timing of insulin - treatment of dawn phenomenon associated with insulin prediabetic - A1C of 6-6.4% is considered diabetes - AIC of 6.5% and up is considered diagnostic for ___ 7.0% - AIC of ___ is encouraged for diabetics Hypoglycemic unawareness - Person does not experience warning signs/symptoms, increasing risk for decreased blood glucose levels Related to autonomic neuropathy hormones - chemical substances produced by endocrine glands that control and regulate the activity of certain target cells or organs TSH - the size of the thyroid gland is related to ___ secretion 1. thyroxine (T4) 2. triiodothyronine (T3) 3. calcitonin - What are the three hormones produced, stored and secreted by the thyroid gland? iodine - ___ is necessary for synthesis of both T3 and T4 TSH - - thyroid stimulating hormone - secreted from anterior pituitary gland - stimulates thyroid hormone production and release thyrotropin-releasing hormone - when circulating levels of thyroid hormone are low, the hypothalamus releases ___ (TRH); causes the anterior pituitary to release TSH inhibit - high circulating thyroid hormone levels ___ the secretion of both TRH from the hypothalamus and TSH from the anterior pituitary gland calcitonin - ___ is made by C cells (parafollicular cells) of the thyroid gland in response to high circulating calcium levels - lowers serum calcium levels by: 1. inhibiting the transfer of Ca from bone to blood 2. increasing Ca storage in bone 3. increasing renal excretion of Ca and phosphorus calcitonin; parathyroid hormone - ___ and ___ (PTH) regulate calcium balance thyroid - - controls cellular metabolism - needed for growth and development goiter - enlarged thyroid gland; thyroid cells are stimulated to grow; this may result in overactive thyroid (hyperthyroidism) or an underactive thyroid (hypothyroidism); most common cause is lack of iodine thyroiditis - inflammation of the thyroid gland, encompasses several clinical disorders; frequent cause of goiter hyperthyroidism - ___: - hyperactivity of the thyroid gland with sustained increase in synthesis and release of thyroid hormones - most common form is Grave's disease - more common in women than men, 20-40 years old hyperthyroidism - signs and symptoms of ___: - goiter - exophthalmos (eye bulging) - HTN & tachycardia - heat intolerance - weight loss - diarrhea - nervousness / irritability thyrotoxicosis - physiological effects or clinical syndrome of hypermetabolism resulting from excess circulating levels of T3 an T4 or both; usually occurs with hypothyroidism graves disease - an autoimmune disease of unknown etiology characterized by diffuse thyroid enlargement and excess thyroid hormone secretion ophthalmopathy - abnormal eye appearance of function thyroid storm - acute thyrotoxicosis (also called thyrotoxic crisis or ___) is an acute, severe, and rare condition that occurs when excessive amounts of thyroid hormones are released into the circulation (uncontrolled hyperthyroidism) - life threatening emergency 1. tachycardia 2. heart failure 3. shock 4. hyperthermia (fever- up to 106F, 41.1C) 5. agiation 6. delirium 7. seizures 8. abdominal pain 9 N/V/D 10. coma 11. HTN - What are the signs and symptoms of a thyroid storm? 1. antithyroid 2. beta blockers - ending in lol 3. glucocoriticoids - what is used to treat a thyroid storm? slows sympathetic nervous stimulation; thereby decreasing tachycardia, nervousness, irritability, and tremors - why are beta blockers administered for a thyroid storm? hyperthyroidism - causes of ___: 1. autoimmune (Graves) 2. excess TSH from pituitary gland 3. neoplasm (abnormal and excessive tissue growth) 4. thyroiditis 5. excessive intake of thyroid medication thyroidectomy - surgical removal of the thyroid gland; surgical treatment for hyperthyroidism; total or subtotal hypothyroidism nerve damage infection pain airway obstruction calcium levels bleedeing - what are some post-op concerns after a thyroidectomy? thyroidectomy - after a ___ open patient's mouth and make sure there is no bleeding, this may obstruct airways ice cubes using a straw - what are two things contraindicated in a patient that has had thyroidectomy? tapazole - - antithyroid medication - inhibit the synthesis of thyroid hormones - indications for use include Grave's disease, hyperthyroidism iodine - ___ is available as saturation solution of potassium iodine (SSKI) and lugol's solution - used with other antithyroid drugs to prepare patient for thyroidectomy or for treatment of thyroid storm (thyroidtoxicosis) - large doses inhibit synthesis of T3 and T4 and block the release of these hormones into circulation Propylthiouracil - ___ considered first line therapy in thyrotoxicosis; blocks the peripheral conversion of T4 to T3 Radioactive iodine therapy - ___ (RAI) is the treatment of choice for nonpregnant adults; damages or destroys thyroid tissue, thus limiting thyroid hormone secretion high calorie - with the increased metabolic rate in hyperthyroid patients, there is a high potential for the patient to have a nutritional deficit. a ___ diet ( cal / day) may be needed to satisfy hunger, prevent tissue breakdown and decrease weight loss - distribute in frequent small meals - limit caffeine Hypothyroidism - ___: - a deficiency of thyroid hormone that causes a general slowing of the metabolic rate; decreased thyroid hormone secretion primary; secondary - hypothyroidism can be classified as ___ or ___ primary - ___ hypothyroidism is caused by destruction of thyroid tissue or defective hormone synthesis secondary - ___ hypothyroidism is caused by pituitary disease with decreased TSH secretion or hypothalamic dysfunction with decreased TRH secretion iodine - ___ deficiency is the most common cause of hypothyroidism hypothyroidism - symptoms of ___: - bradycardia - cold intolerance - weight gain - constipation - lethargy - forgetfullness primary - the causes of ___ hypothyroidism include: - defect in gland - congenital - treatment for hyperthyroidism - thyroiditis (autoimmune) - iodine deficiency