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Diabetes Mellitus:
Signs and symptoms of diabetes (early and late)
EARLY: “Three Ps”
○ Polyuria - Frequent urination
○ Polydipsia - Extreme thirst
○ Polyphagia - Extreme hunger
LATE: Fatigue, weakness, vision changes (can lead to blindness if not checked/managed),
tingling or numbness in hands or feet (neuropathy), dry skin, skin lesions or wounds that are
slow to heal, recurrent infections
Lab values that are diagnostic of diabetes
Diagnostic Findings
● Fasting blood glucose 126 mg/Dl or more
● Casual glucose greater than or equal to 200 mg/dL
● 2 hour post load glucose greater than or equal to 200mg/dL on glucose tolerance test
● Hemoglobin A1C greater than or equal to 6.5%
○ Diagnostic test used for diabetes; measures average level of blood glucose control over
the previous 3 months
Ketones in urine, glycosuria
Random
70-115 (normal)
DM 200 +
Fasting
under 100 (normal)
DM 126+
GTT “tolerance” (test for type 2 diabetes)
Normal- under 140
DM 200+
HgB A1C (shows the levels of glucose over the past 3 months)
Normal- under 6.
DM-under 7% shows well controlled
Type 1 and Type 2 DM: Pathophysiology, risk factors, and treatments
TYPE 1
PATHO: Autoimmune dysfunction causes destruction of beta cells in the pancreas,
leading to a lack of insulin secretion
RISK FACTORS: Genetics (family hx), age less than 30m environmental (viruses or
toxins), immunological
TREATMENT: maintaining normal blood sugar levels through regular monitoring, insulin
therapy
TYPE 2 (the problem is you, you have impaired insulin production and resistance)
PATHO: Cells have quit responding to insulin “insulin resistant” and decreased insulin
production slowly over time
***** the two main problems r/t insulin in type 2 are:impaired resistance, impaired insulin
secretion
RISK FACTORS: Obesity, age over 30 years, hypertension, HDL less than 35 mg/dL or
triglycerides above 250, HX of gestational diabetes, race, genetics, poor diet
TREATMENT: Diet and exercise (first line of treatment); when that doesn’t work, oral
medications are started
Glucose monitoring, patient education
*The type 2 diabetic may need insulin during stress, surgery, or infection
Hypoglycemia and Hyperglycemia symptoms and treatments
HYPOGLYCEMIA
S/S: Diaphoresis, cool and clammy skin, hunger, nausea, rapid, shallow respirations, tachycardia,
palpitations, normal-high BP, headache, blurry vision, downiness, progress to coma, paresthesia,
weakness, muscle spasms, seizures
Assessment:
- Blood glucose levels usually between 250 and 800 mg/dL (can be lower or higher)
- Ketone bodies in blood and urine
- Electrolytes vary according to dehydration; increase in creatinine, Hct, and BUN
TREATMENT:
- #1 management of DKA is focused on correction of dehydration **
-rehydration with/IV fluid
Monitor I&O, vitals (BP), and lung sounds (watch out for crackles) = fluid volume
overload
-IV continuous infusion of regular insulin
-reverse acidosis and restore electrolyte balance
-monitor blood glucose, renal function and urinary output, ECG, electrolyte levels closely
-cautions but timely replacement of potassium is important to avoid arrhythmias
HHS (TYPE 2) lack of sufficient insulin- puts sugar into cell (no ketones)
S/S: hypotension, profound dehydration, tachycardia, and decreased LOC, seizures, hemiparesis
caused by cerebral dehydration
H-HIGHEST sugar over 600
H-HIGHER fluid loss and extreme dehydration
H- head change- confusion (neurological manifestations)
N-NO abdominal pain, NO ketones (no acid, NO kussmaul aka no fruity breathe)
S-slower onset and stable potassium
TREATMENT:
H-hydration first! 0.9 NS 1st, then hypotonic
S- stabilize sugars (insulin)
Insulin types including onset, peaks, and duration of action for each
Time Course Agent Onset Peak Duration
Rapid acting Lispro, Aspart,
Glulisine
15-30 min.
15 min.
5-15 min.
30-90 min.
1-3 hours
1 hour
5 hours or less
3-4 hours
5 hours
Short acting Regular 30-60 min. 2-3 hours 4-6 hours
Intermediate
acting
NPH 1-1.5 hours 4-12 hours Up to 24
hours
Long acting Glargine
Detemir
3-6 hours Continuous
(No real peak)
24 Hours
Rapid acting
Inhalation Powder
Afrezza Less than 15
min.
50 min. 2-3 hours
RAPID ACTING “15 minutes feels like an hour during 3 rapid responses”
Agent: lispro, Aspart, Glulisine
Onset: 15-30 min, 15 min, 5-15 min
Peak: 30-90 min,
Duration: 5 hours or less, 3-4 hours, 5 hours
Indications: used for rapid reduction of glucose level to treat postprandial
hyperglycemia, or to prevent nocturnal hypoglycemia
- Make sure they eat within 5-15 minutes of an injection, can crash quickly if not
given food.
*Patient must be eating during peak times and no exercise b/c it lowers blood
sugar
SHORT ACTING
Agent: regular (clear)
Onset: 30-60 min
Peak: 2-3 hours
Duration: 4-6 hours
Indication: usually given 15 min before a meal; may be taken alone or in combination
with longer-acting insulin
*Ready to go IV, ONLY insulin that can be given IV
INTERMEDIATE ACTING
Agent: NPH (cloudy)
Onset: 1-1.5 hours
Peak: 4-12 hours
Duration: up to 24 hours
Drug-drug interaction: beta-blockers can mask s/s of hypoglycemia
Biguanides (Metformin)
*Metformin is the first line medication choice for type 2 diabetes.
Adverse effects: hypoglycemia, lactic acidosis, GI upset, allergic skin reactions
Contraindications: impaired liver function or alcohol abuse
*If a pt is receiving contrast for a cat scan, what should be held? This is because concurrent use
of iodine can bring on renal failure.
Nursing implications: monitor blood glucose for hypoglycemia and other potential side effects
GLP-1 agonists (Liraglutide)
Adverse effects: hypoglycemia, headache, nausea, anorexia, diarrhea, allergic skin reaction,
pancreatitis, renal impairment, thyroid tumors
Contraindications:
Nursing implications: monitor blood glucose for hypoglycemia and other potential side effects
Thiazolidinediones (pioglitazone)
Adverse effects: URI, headache, edema, weight gain, myalgia, liver impairment, elevated
cholesterol
Contraindications:
Nursing implications: monitor blood glucose for hypoglycemia and other potential side effects
Perfusion:
ECG- Strips
● P wave: the part of an ECG that reflects conduction of an electrical impulse through the atrium;
atrial depolarization (atrium contracting)
● QRS complex: the part of an ECG that reflects conduction of an electrical impulse through the
ventricles; ventricular depolarization (ventricles contracting)
● T wave: the part of an ECG that reflects repolarization of the ventricles (ventricles relaxing)
Heart Sounds and what they mean
S1- first heart sound- atrioventricular valve closure (tricuspid and mitral)
S2-second heart sound- ventricular valve closure (aortic and pulmonic)
S3- abnormal heart sound. Heard in early diastole, heard immediately after S2. younger
individual common but in the elderly it is a significant finding indicating fluid volume overload-
CHF exacerbation
S4- abnormal heart sound. Heard in late diastole. Heard just before S1. this is caused by blood
being forced into a non-compliant ventricle from HTN-CAD
Murmurs - created by turbulent blood flow (caused by valves that did not fully close), causes a
swishing sound
Stenosis - artery is narrowed causing a hoarse sound, due to hardened arteries
Sympathetic/Parasympathetic (know the handout that was provided) Beta 1 - 1 heart
Beta 2- 2 lungs
Coronary artery disease prevention, diagnosis, and treatments
CAD
PREVENTION: exercise, healthy diet, cessation of smoking, take medication as prescribed,
monitor cholesterol, managing HTN, controlling diabetes
DIAGNOSIS: stress test, cardiac cath, echo, EKG, risk factors, lab test-troponins, CPK-MB
TREATMENTS:
Chest pain: diagnosis, and treatments- Nursing implications for diagnostic procedures.
DIAGNOSIS:
O (onset) “when did the pain begin”
P (pain) “where is the pain? Can you point to it”
Q (quality) “ how would you describe pain/”
- what they do is inject this radioactive iodine property into the thyroid gland and it will
destroy the thyroid tissue. It's going to result in a surgically-induced hypothyroid state for
the rest of their life
HYPOTHYROIDISM “ Hashimoto's” LOW T3 & T4 -HIGH TSH
Myxedema coma- very low/slow:airway, breathing, low BP = DEATH!
TREATMENT:
L-levothyroxine (levo=hypo)
L- life long + long slow onset
E- early morning/empty stomach x1 daily (not at night)
V-very active (HIGH HR & BP) report “agitation/confusion)
O-oh the baby is fine! (pregnancy safe)
NO food- take 1 hr before breakfast
Never abruptly stop = myxedema coma
Thyroid Cancer- surgical interventions, treatment, complication, patient teaching, nursing
implications
*not done unless other treatments have not worked
SURGICAL INTERVENTIONS: thyroidectomy is the treatment of choice for thyroid cancer
TREATMENTS:
COMPLICATION: more invasive procedure and the parathyroid are attached which gives a
chance of accidentally removing them
PATIENT TEACHING:
preoperative education: dietary guidance to meet patient’s metabolic needs, avoidance of
caffeinated beverages and other stimulants, explanation of tests and procedures, and head and
neck support used after surgery
NURSING IMPLICATIONS:
monitor calcium
Postoperative Care
● Monitor respirations; potential airway impairment, vitals
● Monitor for potential bleeding and hematoma formation; check posterior dressing
(where blood would go).
○ Monitor for internal bleeding (frequent swallowing)
● Assess pain and provide pain relief measures
● Semi-Fowler position, support head and neck, esp turrning, teach pre op.
● Assess voice, discourage talking 48 hours
○ Find another mehtod for pt to communicate such as writing on a whiteboard
● Potential hypocalcaemia related to injury or removal of parathyroid glands; refer to Chart
Post Op
● Increase in Nutrients needed, vitamins, snacks.
● Coffee, tea, cola avoided due to caffeine.
● Prevent emotional strain
● Visitors limited
● Cool room– perspire
● Deep breathing only
● Voice rest 48 hours
● Voice checks may be done...ah......ck for nerve damage
● Avoid hyperextending head and neck
● Suction, trach kit in room for emergency
● Possible accidental removal parathyroids. Watch for tetany.
● Or edema that occludes parathyroid and decreases calcium in blood.
● s/s: Numbness, tingling, toes, fingers, mouth.
● Carpopedal spasms, muscle spasms wrists and feet.
Hypothalamus- main function
Located in the brain, it links the nervous system to the endocrine system. Synthesizing and
secreting neurohormones or releasing hormones. Also controls body temp, hunger, thirst, and
circadian cycle
Growth Hormone – Anterior Pituitary - (over function/under function)
HYPERPITUITARISM
S/S: truncal obesity =+ moon face + buffalo hump, unusual hair growth “hirsutism”, purple
striae, HIGH BP , sugar, weight
TX: -surgery, cut out tumor = replace steroids
-SLOWLY decrease steroids “taper off gradually”
Vasopressin- Posterior Pituitary- ADH- (Over function/under function)
*SIADH soaked inside
-low urine output, high specific gravity, hypo osmolality, hyponatremia (sodium low= headaches
& seizures), HIGH BP
Causes: small cell lung cancer, severe brain trauma, sepsis infections of brain
TX: STOP ALL FLUIDS + GIVE SALT + diuretics
DI “dehydrated”
-dry inside, high urine output, low specific gravity, hyper osmolality, hypernatremia, LOW BP
Causes: damage to brain (tumors, trauma, surgery)
TX: desmopressin/vasopressin (decreases urine output) caution: headaches!
Parathyroid- (hypofunction/hyperfunction)- s/s, assessment techniques
HYPERPARATHYROIDISM
S/S: HIGH calcium in the blood. PTH makes bones weak by taking calcium from its storages
STONES= kidney stones
MOANS= fractured bones
GROANS= constipation
ASSESSMENT TECHNIQUES:
HYPOPARATHYROIDISM
S/S: LOW calcium in the blood
1.Trousseau's sign:
-Twerk with BP cuff
2.Chovetek’s sign
-Cheeky smile when stroking the face
- Diarrhea
ASSESSMENT TECHNIQUES:
Primary & Secondary- Osteoporosis/Osteopenia: assessment, diagnosis, risk factors, prevention,
treatments, patient teaching/side effects with medications.
OSTEOPOROSIS
ASSESSMENT: fractures, rounding of upper back ( “dowagers hump” ), asymptomatic (until
they fx something), inches of height loss , low back, neck, hip pain on palpation/activity that puts
pressure
DIAGNOSIS: DEXA scan
RISK FACTORS:
Ca & Vit D intake low
Age -postmenopausal
Lifestyle- smoker, regular etoh use, sedentary /immobile
Caucasian or asian women
Inherited
Underweight- BM1 <19; thin, small frame\
Medications- glucocorticoids> anticonvulsants
PREVENTION: diet rich iron Ca & Vit D; lifestyle= WB exercises (cardio good for heart, wt
lifting good for mm. & bones), ID strength/weakness
TREATMENTS: Ca & Vit D , Bisphosonates (fosamax/alendronate), calcitonin, estrogen/HRT
(Raloxifene) , PTH
PATIENT TEACHING: teach fosamax/alendronate taken on empty stomach 1 hr before eating
breakfast.must sit up for 30-60 mins after taking b/c very caustic
● Exacerbations
● Cough, productive or not
● Generalized wheezing
● Chest tightness and dyspnea
● Diaphoresis
● Tachycardia
● Hypoxemia and central cyanosis
PREVENTION: stop smoking cessation
DIAGNOSIS:
TREATMENTS:
Medications Management for Asthma
● Stepwise, refer to Figure 24-7 (Hinkle & Cheever)
● Quick-relief medications
○ Beta 2
-adrenergic agonists - albuterol
○ Anticholinergics - ipratropium
● Long-acting medications
○ Corticosteroids
○ Long-acting beta 2
-adrenergic agonists
○ Leukotriene modifiers
Medications to Treat Asthma
● Bronchodilators
● Inhaled corticosteroids
● Leukotriene receptor agonists
● Xanthines
● Short-acting beta-agonist (sympathomimetics)
Pneumonia: assessment findings, prevention, diagnosis
ASSESSMENT FINDINGS:
-vital signs-fever, tachycardia, tachypnea
-secretions: amount, odor, color
-productive cough: frequency and severity
-tachypnea, shortness of breath
-inspect and auscultate chest- crackles, rhonchi and wheezes
-changes in mental status, fatigue, anorexia, nausea/vomiting, weakness, tachypnea, tachycardia
PREVENTION:
-encourage smoking cessation
-Promote coughing and expectoration of secretions
-reposition frequently to prevent aspiration
DIAGNOSIS: inflammation of the lungs (alveoli and bronchioles)
Aspiration Pneumonia: Assessment, diagnosis, prevention, risk factors Chest Tubes
ASSESSMENT:
● Signs of aspiration:
○ Coughing after a meal
○ Fever
○ Hoarse Voice
○ Wheezing
○ Breath Odor
○ Runny Nose
○ Teary eyes
s/s: SOB, fever, tachycardia, low O2 sat, agitation, unable to lay flat,
INTERVENTIONS/PREVENTION:
● Keep HOB elevated >30 degrees
● Use sedatives as sparingly as possible. (decreases peristalsis)
● Avoid stimulation of gag reflex with suctioning or other procedures
● Check for placement before tube feedings- avoid bolus feedings in the high risk patients.
(continuous feeds for those who are not able to move around)
● Thickened fluids for swallowing problems
● When there is concern for possible aspiration, contact physician for a Speech Therapist
Consultation- swallow study test.
DIAGNOSIS: chest x-ray
RISK FACTORS:
1.cough and exhale immediately; if the tube becomes dislodged, ask the patient to
cough and exhale as much as possible
2. apply occlusive (petroleum gauze) dressing secured on 3 SIDES
*ONLY TAPE 3 TO LET THE AIR FREE *
Essential equipment to have at the bedside of a client with a closed chest drainage
system?
-sterile connecter, sterile petroleum gauze, padded clamp
Drainage tubing
Without contamination- antiseptic swab and reconnect
If the water seal is damaged, we place the distal end into 250 ml of sterile saline
NEVER CLAMP THE CHEST TUBE
Oxygen Delivery devices and purpose
NC-Nasal cannula
1-6 liters per min (LPM)
25-40% O
-used for short term or long term (e.g low oxygen after surgery)
-use humifaction for long term use
Simple face mask
6-10 LPM
40-60% O
-used in exchange to partial rebreather & non-rebreather
Partial rebreather
6-10 LPM
Looks very similar to the non-rebreather; key difference is the flutter valves on the
sides
NRB non-rebreather
10-15 LPM *MEDICAL EMERGENCIES
60-100% O
Key points
-used during carbon monoxide poisoning
-if the reservoir bag is fully deflated on inspiration= increase oxygen flow
*DO NOT open the flutter valves or tighten face mask straps
Venturi mask
4-10 FiO2; most precise oxygen delivery device
V for venturi mask for V-very accurate O
-typically used for patients with COPD; contraindicated in pregnant women
Face tent
Used facial trauma and burns
High humification
BIPAP
-used for worsening COPD who have high levels of CO2 retention (hypercapnic);
BIPAP is a positive pressure machine that forcefully PUSHES air deep into the
lungs giving much needed oxygen while expelling CO2!!
Strep Throat – s/s, diagnosis, treatment, patient teaching Tonsillectomy- s/s to report-
monitoring, patient teaching
STREP THROAT
S/S:
Sore throat
Pain with swallowing
Fever
Swollen and enlarged lymph nodes
