exam 2 endocrine and metabolism

Question 1

Preg complicated by DM

Answer 1

An endocrine disorder characterized by hyperglycemia.
Caused from lack of insulin or lack of insulin effect
Key to optimal pregnancy outcome is strict glucose control

Question 2

absolute insulin insufficiency. Requires administration of exogenous insulin.

Answer 2

T1DM

Question 3

an insulin resistance with varying degrees of insulin deficiency

Answer 3

T2DM

Question 4

any degree of glucose intolerance with onset or recognition during pregnancy

Answer 4

GDM

Question 5

Effect of Pregnancy on Insulin Requirements in 1st Trimester?

Answer 5

Insulin production increased –> increased peripheral use of insulin –> results in decreased blood glucose (hypoglycemia).
Fetus siphons glucose from mother across placenta
N&V may –> drop in maternal blood glucose
Human placental lactogen (HPL) is secreted. This is an insulin antagonist.

Question 6

Insulin Requirements in 2nd and 3rd Trimesters?

Answer 6

By the end of the pregnancy, insulin requirements increase as much as 4 times the usual amount of insulin
With expulsion of placenta –> abrupt drop of hormones and return to pre-pregnant state. Insulin needs decrease.

Question 7

Maternal Risks and Complications?

Answer 7

Worsening of pre-existing disease  vascular problems - retinopathy
Hypoglycemia 1st half of pregnancy
Hyperglycemia - Ketoacidosis 2-3rd trimesters (high blood values)
Preeclampsia and Eclampsia
Polyhydramnios in 10-20% of diabetic
Dystocia (shoulder)

Question 8

Fetal Glucose and Insulin?

Answer 8

At first baby gets glucose from Mom
Baby pancreas produces own insulin by 10 weeks gestation

Question 9

What are the possible effects on the baby if mom has DM?

Answer 9

Macrosomia r/t excess glucose from Mom
Large for gestational age (LGA)
IUGR r/t maternal vascular involvement
Delayed lung maturity - RDS
Hypoglycemia after birth
Congenital anomalies
- Neural tube defects
- Skeletal defects (Sacral agenesis)

Question 10

Screening and Testing to R/O GDM?

Answer 10

50 gram oral glucose tolerance test
No fasting
May be routine for all clients at 24-28 weeks gestation
50 g oral glucose cola solution is given - blood is drawn in one hour
Glucose >130-140 mg/dL is positive - follow-up

3 hour oral glucose tolerance test (OGTT)
No caffeine or smoking 12 hours before the test
Load CHO (at least 3 days) - fasting p midnight (NPO)
100 g glucola - blood drawn at fasting, 1, 2, 3 hours
Positive test if 2 or more values equal or exceed

Question 11

Values of OGGT?

Answer 11

FBS < 95 mg/dL
1 hour < 180 mg/dL
2 hour < 155 mg/dL
3 hour <140 mg/dL

Question 12

Management of DM During Pregnancy?

Answer 12

glucose monitoring
diet
exercise
insulin therapy

Question 13

Glucose Monitoring to help Achieve Euglycemia?

Answer 13

Target ranges:
Premeal/Fasting >65mg/dL but < 105mg/dL
Postmeal (1 hour) <140mg/dL
Postmeal (2 hour) < 120mg/dL
2am – 6am > 60 mg/dL

Question 14

What is the long term monitoring?

Answer 14

Glycosylated hemoglobin A1c
- Shows what blood sugar has been over the past 2-6 weeks
- Some Hgb remains saturated with glucose for the life of the RBC
- Levels between 4 – 6.5% indicate good blood sugar control. Numbers > 6%, fair - poor control.
Urinalysis and cultures

Glycosylated hemoglobin  measure of control over previous 6 weeks

2.5- 5.9% = good control
6-8%        = fair control
> 8.0%     = poor control

Question 15

dietary management with DM?

Answer 15

Based on blood glucose levels
Goal is to minimize wide fluctuations of glucose levels in order to avoid

Question 16

Diet Management: Calories?

Answer 16

Based on BMI
35cal/kg/IBW/day (Non-obese) –> 25/kg/IBW/ day (Obese client)
Meals – 3X/day with 2 -3 snacks
CHO – no more than 55%
Regular meals – no skipping meals/snacks
Night snack with protein & at least 25 g complex carb are important to prevent a drop in blood glucose during the night

Question 17

exercise with DM?

Answer 17

Exercise monitored very closely
30-60 minutes walking or swimming a day or 10-20 minutes period throughout the day
Snack of protein or complex CHO before exercise
Monitor glucose before, during and after exercise

Question 18

insulin therapy with DM?

Answer 18

2/3 of daily insulin dose is given at breakfast  combination of intermediate or long-acting and short-acting insulin

1/3 of day insulin is given in the evening  combination of long- and short-acting insulin

Question 19

Risk Factors for Hypoglycemia?

Answer 19

Too little food
Too large insulin dose
Stress
Illness/Vomiting or diarrhea
Exercise

Question 20

symptoms of hypoglycemia?

Answer 20

Nervousness
HA
Shaking/irritable
Hunger
Blurred vision
Diaphoresis

Question 21

treatment of hypoglycemia?

Answer 21

Check blood glucose
< 70 mg/dL eat or drink 8-16 g simple Cho (hard candy, skim milk, unsweetened OJ or soda (not diet) or SL glucose paste)
Rest X 15 min  Recheck glucose
If > 70 mg/dL eat a meal with protein to stabilize glucose level
Notify caregiver if continues <70 mg/dL

Question 22

What is hyperglycemia?

Answer 22

Hyperglycemia - glucose > 130 mg/dL
Ketones in urine
Skin: Dry and flushed
Thirst with frequent urination
Kussmaul respirations with fruity odor to breath (r/t ketones and acetonuria)
– Treatment = Regular insulin as ordered
– Evaluation = Monitor blood sugars and urine
– Call MD
DKA – Medical Emergency

Question 23

what is fetal surveillance?

Answer 23

MSAFP at 15-20 weeks gestation
US for anomalies, AF volume, fetal size
Fetal echocardiogram at 20-22 weeks especially if poor control early in pregnancy
Biophysical Profile
NST 1-2X weekly from 34 weeks gestation
FM (kick) daily from 28 weeks…

Question 24

what is important about timing of delivery?

Answer 24

Optimal time 38.5-40 weeks gestation
Elective induction between 39-40 weeks
Reasons for earlier delivery:
- Poor metabolic control
- Hypertensive disorder getting worse
- Macrosomia
- IUGR

Question 25

what is the management of DM during labor and birth?

Answer 25

Regular insulin infusing piggybacked into IV Fluids and insulin titrated to maintain glucose < 140 mg/dL Hourly glucose checks

Question 26

What what is important to note in the second stage of labor?

Answer 26

Voluntary pushing requires energy -- glucose checks performed more frequently Monitor for Failure to Progress Shoulder dystocia CPD --> Cephalopelvic Disproportion - baby’s head is bigger than mother’s pelvic area for delivery

Question 27

what is important to note with postpartum?

Answer 27

Insulin requirement decrease is dramatic with removal of placenta and insulin antagonists. Poor metabolic control can delay lactogenesis and milk production Breast feeding helps to stabilize diabetes Maintain integrity of nipples and areola --> prevent risk of infection

Question 28

family planning interventions?

Answer 28

Oral contraceptives are controversial r/t effect on Carbohydrate metabolism and risk of thrombus Appropriate contraceptives - Barrier methods - Implants (Nexplanon) - Transdermal patch or transvaginal ring (As long as the client is not obese) - IUD

Question 29

Assessment of Client Entering Health Care System Risk Factors?

Answer 29

Family history of diabetes Ethnic group at risk (example native American) Maternal obesity Previous LGA infant Previous unexplained stillbirth

Question 30

Risk Factors for GDM?

Answer 30

fam history previous stillbirth pervious LGA infant ethnic group at risk maternal obesity

Question 31

Infant of Diabetic Mother (IDM) symptoms of hypoglycemia?

Answer 31

Jittery Apnea Tachypnea Cyanosis Hypotonia Unstable temperature

Question 32

treatment for infant hypoglycemia?

Answer 32

Normal Serum Glucose = 40-45 mg/dL Routine heel sticks for glucose checks Early and frequent feeding of breast milk, formula or D5W NGT if poor feeding or respiratory rate is increased

Question 32

treatment for infant hypoglycemia?

Answer 32

Normal Serum Glucose = 40-45 mg/dL Routine heel sticks for glucose checks Early and frequent feeding of breast milk, formula or D5W NGT if poor feeding or respiratory rate is increased

Question 33

what is important to know about hyperemesis?

Answer 33

Severe vomiting of pregnancy that causes weight loss of at least 5% of prepregnancy weight. Accompanied by dehydration, electrolyte imbalance, nutritional deficiencies and ketonuria. Usually begins at 4 weeks and can last up until 20 weeks of pregnancy. Could be caused by increasing levels of estrogen, progesterone & human chorionic gonadotrophins (hCG) .

Question 34

what are the possible causes of hyperemesis?

Answer 34

High levels of hCG or estrogen May be associated with hyperthyroidism during pregnancy Esophageal reflux, reduced gastric motility, and decreased secretion of free hydrochloric acid Psychosocial factors

Question 35

what are the clinical symptoms of hyperemesis?

Answer 35

Inability to retain even clear liquids Significant weight loss > 5% Symptoms of dehydration ( poor skin turgor, dry mucous membranes, decreased BP, increased pulse, concentrated urine, low output) Symptoms of starvation (Elevated BUN and ketonuria) Electrolyte imbalance of Na, Cl and K+

Question 36

what are the fetal risk of hyperemesis?

Answer 36

IUGR Abnormal development (anomalies) Preterm birth SGA Death from lack of nutrition, hypoxia or maternal ketoacidosis -- accumulation o f ketones in the blood from hyperglycemia that leads to metabolic acidosis. Be very careful with Terbutaline and corticosteroids – these can contribute to DKA

Question 37

Assessment of Client with Hyperemesis?

Answer 37

Subjective Intractable vomiting beyond 20 weeks Weight loss Signs of Dehydration Poor skin turgor Dry mucosa Concentrated urine Signs of electrolyte or acid-base imbalance Fetid, fruity breath odor from Metabolic Acidosis Ketones in urine Signs of Starvation muscle wasting jaundice bleeding gums (vitamin deficiency)

Question 38

what is the management of hyperemesis?

Answer 38

IV fluids with glucose, electrolytes, and vitamins to replace fluid and imbalances NPO until dehydration resolved and for 48 hours after vomiting has stopped I and O including emesis Daily weights Small frequent meals once 48 hours with no vomitus (Dry to wet every 2-3 hours)

Question 39

what are the meds for hyperemesis?

Answer 39

Antiemetic medications & others to control N/V: Pyridoxine (B6) alone or with doxylamine (Unisom) Vesprin or Compazine Phenergan Zofran Reglan Nexium (purple pill) or Pepcid Steroid Therapy Enteral or parenteral nutrition

Question 40

what is the nutrition for hyperemesis?

Answer 40

NPO until vomiting subsides Slowly advance diet as tolerated Wet to dry diet Clear liquids, herbal teas, salty foods Avoid caffeine, carbonated beverages AVOID HIGH FAT, GREASY AND HIGHLY SEASONED FOODS AVOID LIQUIDS WITH MEALS Upright position X 1-2 hours after eating

Question 41

Other Nursing Interventions for Client with Hyperemesis?

Answer 41

Emesis basin, emesis bag or bath pan Provide oral hygiene Provide a quiet restful environment Cool wet washcloths

Question 42

what is Maternal Phenylketonuria?

Answer 42

Caused by deficiency in enzyme phenylalanine hydrolase Toxic accumulation of phenylalanine in blood interferes with brain development Dietary therapy for PKU is continued throughout life Lack of dietary compliance during pregnancy place infant at risk for microcephaly, intellectual disability, seizures, growth impairment, congenital heart defects and PKU

Question 43

what is a Low Phenylalanine Dietduring pregnancy?

Answer 43

Eliminate all high-protein foods including meat, poultry, fish, dairy, eggs, beans & nuts. NO aspartame products (Equal, NutraSweet) Things not Off Limits Phenylalanine-free medical protein drinks Precisely measured amounts of fruits, vegetables, bread & pasta

Question 44

what is a Low Phenylalanine Dietduring pregnancy?

Answer 44

Eliminate all high-protein foods including meat, poultry, fish, dairy, eggs, beans & nuts. NO aspartame products (Equal, NutraSweet) Things not Off Limits Phenylalanine-free medical protein drinks Precisely measured amounts of fruits, vegetables, bread & pasta

Question 45

what is the PKU treatment during pregnancy?

Answer 45

Low protein diet…excludes meat, eggs, milk and nuts Maternal phenylalanine levels should remain less than 6 mg/dL for 3 months before conception and remain 2-6 mg/dL during pregnancy Breast feeding discouraged r/t mild concentrations of phenylalanine Baby- phenylalanine-free formula