Endocrine Flashcards
What does insulin do (FYI)
moves glucose from blood into the cells
Why is it important to know the peak, onset, and duration of insulin
So nurses know the most likely time for hypoglycemia to develop based on the insulin that was administered
Rapid-Acting insulin drug names
Insulin lispro (Humalog), Insulin aspart (Novolog), Insulin glulisine (Apidra)
Onset of rapid-acting insulin
- Most rapid onset (within 5-15 minutes), usually taken immediately before a meal
Peak of rapid-acting insulin
1 to 2 hours
Duration of rapid-acting insulin
3.5 to 5 hours
Short-acting insulin is AKA
Regular insulin
- Short-Acting: Regular insulin (Humulin __, Novolin __) [the name is literally regular insulin]
(Humulin R, Novolin R)
Onset of short-acting/regular insulin
- Onset (SQ): 30 to 60 minutes, usually taken 30 to 60 minutes before a meal
Peak of short-acting/regular insulin- what does it signify?
- Peak (SQ): 2 to 4 hours (means there’s a greatest risk for hypoglycemia after 2-4 hrs)
Duration of short-acting/regular insulin
6 to 8 hrs
Intermediate-Acting insulin drug name
NPH insulin (Novolin N, Humulin N)
Intermediate-Acting insulin onset
1-2 hrs
Intermediate-Acting insulin peak
4-8 hrs
Duration of Intermediate-Acting
also:
may be given ___ times ____ to provide glycemic control between ____ and during the ___
12-18 hours (about half a day), may be given two times daily to provide glycemic control between meals and during the night
Long-Acting (basal, background) insulin names
insulin glargine (Lantus), Insulin detemir (Levemir)
Onset of long-acting insulin
1-2 hrs
Peak of long-acting insulin
none (this is good; there’s way less risk for hypoglycemia)
Duration of long-acting insulin
24 hrs
Route of long-acting insulin
given subcutaneously (SQ), should not be mixed (in a single syringe) with other insulins, should never be given IV
Why is long-acting insulin called basal insulin?
- Mimics a healthy pancreas by delivering basal insulin constantly as a basal and then giving rapid-acting insulin as needed as a bolus
- Long-acting means it releases a constant and steady level of insulin, usually given once a day
Know the premixed insulin that is 2 different types of insulin already combined together in one vial.
- One vial contains two different insulins already combined (premixed)
- 70% NPH and 30% Regular insulin (Humulin 70/30)
- Mixture of intermediate and short-acting insulin
Review how to draw up two types of insulin in one syringe
When drawing up two types of insulin in one syringe, always withdraw the regular or rapid-acting insulin first.
Remember “RN”
- Insulin is always checked by ___ nurses who both sign the MAR (FYI)
2
Review injection technique for insulin. Why rotate injection sites?
Not rotating sites could cause lipohypertrophy
o Rotate injection sites and allow 1 inch between injection sites
o Rotating injection sites will facilitate the absorption of insulin and help prevent scarring
Insulin effect on an electrolyte
- Hypokalemia:
- Insulin can decrease blood potassium levels
Insulin interactions (1)
May cause hypoglycemia:
* Beta blockers can mask SNS response, making it difficult to identify hypoglycemia
* Sulfonylureas
* Meglitinides
* Excessive alcohol
Insulin interactions (2)
May cause hyperglycemia:
* Corticosteroids (prednisone); insulin dose may need to be increased
* Thiazide diuretics
Biguanide AKA Metformin (Glucophage) MOA
MOA: decreases glucose production by liver, improve insulin sensitivity
long version (FYI):
decreases glucose production in liver, decreases insulin resistance, does not stimulate insulin secretion from pancreas (so it does not cause significant hypoglycemia when used alone)
Metformin (glucophage) use
First choice drug for the treatment of type 2 DM
Metformin (glucophage) A/E
- GI (most common): anorexia, nausea, diarrhea, cramping – Give with a meal. Usually subside over time.
- Reduction in vitamin B12 levels after long-term use
Metformin (glucophage) toxicity
lactic acidosis (hyperventilation, myalgia) is rare but can be lethal (cannot use if creatinine > 1.4 mg/dL). Avoid alcohol.
Metformin (glucophage) contraindication
- Contraindicated in patients with renal disease (creatinine clearance <30 mL/min or if creatinine > 1.4 mg/dL); metformin is primary excreted by kidneys
Also contraindicated in those with kidney/liver failure and alcoholism
Metformin (Glucophage) nursing considerations
- Should be taken with meals to minimize GI side effects
- Discontinue metformin 48 hours before and after diagnostic studies (CT/MRI) with IV contrast dye/iodine-containing contrast media
Drugs of thiazolidinediones (TZDs) end with
-zone
pioglitazone (Actos), rosiglitazone (Avandia)
MOA of thiazolidinediones (TZDs)
enhances cellular response to insulin by decreasing insulin resistance; basically improves sensitivity of cells to insulin
A/E of thiazolidinediones (TZDs)
- Peripheral edema (fluid retention), monitor weight
- May cause or exacerbate heart failure
- Hepatotoxicity; monitor LFTs, report jaundice, dark urine
Drugs of sulfonylureas
- Drugs: glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta)
MOA of sulfonylureas (and glinides- which is a different class but can study them together)
- Stimulate insulin release from pancreas; require a functioning pancreas.
A/E of Sulfonylureas
- **Hypoglycemia
- Sensitivity to sunlight**
- Nausea, vomiting, diarrhea; Give before breakfast
Drugs of alpha-glucosidase inhibitors and MOA
- Drug: acarbose (Precose), miglitol (Glyset)
MOA:
* Slow carbohydrate absorption and digestion
Sodium-glucose-cotransporter 2 inhibitors drugs
canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance)
Sodium-glucose-cotransporter 2 inhibitors MOA
excrete glucose through the urine by preventing its reabsorption in kidney; promotes weight loss
short answer: blows reabsorption of glucose
Sodium-glucose-cotransporter 2 inhibitors side effects
- Genital yeast infections (Candidiasis)
- Urinary tract infections
- Increased urination
serious adverse eff3ect: hypotension
DPP-4 Inhibitors drugs
-liptin
sitagliptin (Januvia), saxagliptin (Onglyza), linagliptin (Trajenta)
MOA of DPP-4 Inhibitors
short answer: promote incretin function
FYI-
MOA: Inhibit enzyme DPP-4, an enzyme that destroys the hormone incretin, results in increased in incretin levels:
* Increase glucose-dependent insulin release
* Decrease glucagon release
* Slow gastric emptying
* Decrease appetite
Overview of MOAs:
- ________: decreases glucose production by liver, improve insulin sensitivity
- ______ & ______: both stimulate the pancreas to produce more insulin
- _____________: improve sensitivity of cells to insulin
- ___________________: slow absorption of carbohydrate
- _______________: block reabsorption of glucose
- _________: promote incretin function
_________________: incretin mimetics
Options:
Thiazolidinediones
DPP-4 inhibitors
Metformin
(SQ) GLP-1 receptor agonists
Sulfonylureas and Glinides
SGLT2 Inhibitors
Alpha-glycosidase inhibitors
- Biguanide; AKA Metformin: decreases glucose production by liver, improve insulin sensitivity
- Sulfonylureas and Glinides: both stimulate the pancreas to produce more insulin
- Thiazolidinediones: improve sensitivity of cells to insulin
- Alpha-glycosidase Inhibitors: slow absorption of carbohydrate
- SGLT2 Inhibitors: block reabsorption of glucose
- DPP-4 Inhibitors: promote incretin function
- (SQ) GLP-1 receptor agonists: incretin mimetics
What class is a non-insulin injectable
- Incretin mimetics
Non-Insulin Injectables-
Incretin mimetics drugs
-tide
Incretin mimetics MOA
act like (mimic) the incretins in the body that lower blood sugar after eating.
FYI:
* Stimulate release of insulin from pancreas when glucose levels are high
* Decrease glucagon release
* Slow gastric emptying
* Increase satiety (decrease appetite)
* Lead to weight loss
Know what blood glucose level would indicate hypoglycemia
Blood sugar less than 70 mg/dL
Know signs and symptoms of hypoglycemia (know all)
- Diaphoresis/sweating
- Shakiness/tremor
- Persistent headache
- Tachycardia
- Anxiety
- Irritability
- Dizziness
- Confusion
Be familiar with how to treat hypoglycemia
If they’re conscious?
- Administer oral form of glucose (glucose tablets or gel, corn syrup, honey, fruit juice, or non-diet soft drink)
Be familiar with how to treat hypoglycemia
If they’re unconscious?
- Administer Glucagon or 50% Dextrose (D50W)
- Turn the patient on the side until patient becomes alert to prevent aspiration
- Administer a second dose of Glucagon in 15 minutes if patient remains unconscious
Use glucagon when
the sugar is gone (fyi)
When is glucagon used
Uses: emergency treatment of severe hypoglycemia
How is glucagon administered
IM or SQ
Know the diabetes treatment goals (blood glucose level ranges)
* For most patients: HbA1C less than __%
* Blood glucose before meals: __ to ___ mg/dL
* ____ hours after meals: less than ___ mg/dL
- For most patients: HbA1C < 7%
- Blood glucose before meals: 80 to 130 mg/dL
- Two hours after meals: < 180 mg/dL
What drug is used to treat hypothyroidism
levothyroxine (Synthroid)
A/E of levothyroxine (for hypothyroidism)
- Nervousness, insomnia, tremor, tachycardia, palpitations
restlessness, heat intolerance, angina, dysrhythmias, & myocardial infarction
Pt. teaching for of levothyroxine
- Take in morning, on an empty stomach, by itself
- Don’t take w/ food, other drugs, or vitamins can affect absorption
- Best to take other medications 4-5 hours after levothyroxine
- Can increase anticoagulant effects of warfarin (report bleeding)
- Instruct patient to never stop drug abruptly; therapy is usually for life
- Dose adjusted according to the patient’s symptoms & laboratory data
Hyperthyroidism- what are the anti-thyroid medications?
propylthiouracil (PTU) and methimazole (Tapazole)
A/E of propylthiouracil (PTU) and methimazole (Tapazole)
for HYPERthyroidism
- CNS: drowsiness, headache, dizziness
- GI: hepatotoxicity, nausea, vomiting, diarrhea, loss of taste
- Derm: rash, skin discoloration, urticaria
- Hemat: agranulocytosis -> severe leukopenia -> low WBC -> infections, thrombocytopenia -> low platelets -> bleeding
- MS: arthralgia
What to monitor for anti-thyroid drugs (hyperthyroidism)
- Thyroid storm (hyperthyroidism): tachycardia, palpitations, nervousness, insomnia, diaphoresis, heat intolerance, tremors, weight loss, diarrhea.
- Agranulocytosis: report sore throat, fever, and stop treatment. Monitor complete blood count (CBC) for low WBC and platelets. Filgrastim can be used to increase WBC and can cause bone pain.
- Monitor thyroid function studies (TSH, T3, T4) at baseline and periodically.
- May cause ↑ liver function tests: monitor jaundice, dark urine, light-colored stools.
*Radioactive Iodine is contraindicated in
pregnancy, lactation, and children
- Nonradioactive strong iodine solutions include..
- SSKI (saturated solution potassium iodide)
- Lugol’s solution
Uses of SSKI (saturated solution potassium iodide) and Lugol’s solution
- Preoperative prep for thyroidectomy – decreases gland vascularity and surgical blood loss
- Adjunctive therapy – inhibit release of thyroid hormones
adverse effects/reporting of SSKI (saturated solution potassium iodide) and Lugol’s solution
- Iodine poisoning (“Iodism”): metallic taste, burning sensations in mouth, sore teeth and gums; discontinue treatment and notify provider
- GI: abdominal pain, diarrhea, nausea, vomiting; discontinue if severe GI distress
- Severe toxicity– iodine can cause corrosive injury to the GI tract
- Skin rash
Pt. education on SSKI (saturated solution potassium iodide) and Lugol’s solution
- Avoid foods high in iodine (seafood, fish liver oils, iodized salt).
- Take with juice to improve taste. Avoid giving with milk; absorption decreased by dairy.
- Drink with a straw to decrease staining of teeth.
- Take at the same time each day to maintain levels.
- Do NOT use during pregnancy or lactation (category D).
- Can be used in conjunction with other therapy because effects are not usually permanent.
- Report any s/s of iodism.
Review how beta blockers can be useful in patients with hyperthyroidism
Beta blockers (Propranolol) are used to decrease tremors and decrease heart rate
Drugs impacting pituitary gland:
Growth Hormone- what drug?
Somatropin
Growth Hormone/ Somatropin A/E
- Adverse effects:
- Hyperglycemia (polyuria, polydipsia, polyphagia)
- Interacts w/ glucocorticoid steroids
Growth Hormone/ Somatropin nursing implications
Nursing implications:
* administer injections at bedtime
* Monitor height & weight, usually monthly;
* If no stimulation of growth occurs, discontinue drug
Posterior Pituitary drugs- ADH; the drugs are __________ or ______; used for _______ ________
Vasopressin or desmopressin; used for diabetes insipidus
Vasopressin and desmopressin MOA
water reabsorption & decreased urine production
Vasopressin and desmopressin A/E
- Hyponatremia
- Water intoxication (excessive water retention) – drowsiness, headache
- Increased blood pressure
Vasopressin and desmopressin nursing implications
- Monitor intake and output (I&O), thirst, weight, and BP
- Expect urine osmolality and urine specific gravity to increase
- If being used for DI, dose will be adjusted based on urine output
- Drink only enough water to satisfy thirst
- If intranasal, clear nasal passage before using
- If SQ, rotate injection sites
- _______ of ___________ Antidiuretic Hormone (SIADH): ________ (Tegretol) can cause
- Body makes ___ ___ ____
- Body retains too much ____, can result in ________(muscle cramps, weakness)
Too much ADH-
* Syndrome of Inappropriate Antidiuretic Hormone (SIADH): Carbamazepine (Tegretol) can cause
* Body makes too much ADH
* Body retains too much water, can result in hyponatremia (muscle cramps, weakness)
Treatment of Syndrome of Inappropriate Antidiuretic Hormone (SIADH):
it’s MOA
and something to keep in mind
- Treatment: demeclocycline, a tetracycline that blocks the action of ADH and increases urine output. Do not take with iron, antacids, or dairy products.
Drugs affecting adrenal gland- class
Corticosteroids
Drugs affecting adrenal gland- class is corticosteroids- what drugs?
Glucocorticoids: hydrocortisone, prednisone, dexamethasone, methylprednisolone
* Drugs “-sone”
Mineralocorticoid: fludrocortisone
A/E of long-term use of corticosteroids
- Delayed wound healing – Increased Risk for infections
- Hyperglycemia (worsening of diabetes)
- Irritability/depression/mood swings
- Thinning of skin, bruising
- Peptic ulcers (coffee ground emesis, tarry stools)
- Weight gain (increased appetite), report > 5 lb/week
- Increased BP (salt/water retention)
- Muscle weakness
- Osteoporosis (bone loss)
- Abnormal fat distribution – Cushing’s syndrome (long term steroid use)
How does glucocorticoid, such as prednisone, affect glucose levels?
Can get Cushing’s syndrome-
* Occurs with prolonged or frequent use of glucocorticoids
* Report if:
* Moon face, buffalo hump, muscle weakness, facial erythema.
hyperglycemia
Drugs affecting the adrenal gland- corticosteroids
Know patient teaching for preventing steroid withdrawal syndrome
Do not stop drug suddenly if used long-term to prevent steroid withdrawal syndrome
Review ACTH and why the need to taper glucocorticoid drugs
- Drug doses must be tapered down (dose decreased) very gradually
- If corticosteroids are suddenly withdrawn, abrupt withdrawal s/s (hypo-adrenal crisis, shock) can occur
- Hypotension
- Weakness
- Shock
- Can be fatal!
Know the adverse effects of Interferon
◦ Flu-like reactions
◦ CNS: Depression/suicidal ideation (need to report), bone marrow depression
◦ Hepatotoxicity
Review the actions of mineralocorticoid – fludrocortisone (Florinef)
- Works by decreasing the amount of sodium that is lost in the urine and increasing urinary potassium excretion (causes potassium loss).
- Retention of sodium and water -> can lead to high BP, edema
