exam 2 endocrine and metabolism Flashcards
Preg complicated by DM
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
absolute insulin insufficiency. Requires administration of exogenous insulin.
T1DM
an insulin resistance with varying degrees of insulin deficiency
T2DM
any degree of glucose intolerance with onset or recognition during pregnancy
GDM
Effect of Pregnancy on Insulin Requirements in 1st Trimester?
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.
Insulin Requirements in 2nd and 3rd Trimesters?
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.
Maternal Risks and Complications?
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)
Fetal Glucose and Insulin?
At first baby gets glucose from Mom
Baby pancreas produces own insulin by 10 weeks gestation
What are the possible effects on the baby if mom has DM?
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)
Screening and Testing to R/O GDM?
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
Values of OGGT?
FBS < 95 mg/dL
1 hour < 180 mg/dL
2 hour < 155 mg/dL
3 hour <140 mg/dL
Management of DM During Pregnancy?
glucose monitoring
diet
exercise
insulin therapy
Glucose Monitoring to help Achieve Euglycemia?
Target ranges:
Premeal/Fasting >65mg/dL but < 105mg/dL
Postmeal (1 hour) <140mg/dL
Postmeal (2 hour) < 120mg/dL
2am – 6am > 60 mg/dL
What is the long term monitoring?
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
dietary management with DM?
Based on blood glucose levels
Goal is to minimize wide fluctuations of glucose levels in order to avoid
Diet Management: Calories?
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
exercise with DM?
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
insulin therapy with DM?
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
Risk Factors for Hypoglycemia?
Too little food
Too large insulin dose
Stress
Illness/Vomiting or diarrhea
Exercise
symptoms of hypoglycemia?
Nervousness
HA
Shaking/irritable
Hunger
Blurred vision
Diaphoresis
treatment of hypoglycemia?
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
What is hyperglycemia?
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
what is fetal surveillance?
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…
what is important about timing of delivery?
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
what is the management of DM during labor and birth?
Regular insulin infusing piggybacked into IV
Fluids and insulin titrated to maintain glucose < 140 mg/dL
Hourly glucose checks
What what is important to note in the second stage of labor?
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
what is important to note with postpartum?
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
family planning interventions?
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
Assessment of Client Entering Health Care System Risk Factors?
Family history of diabetes
Ethnic group at risk (example native American)
Maternal obesity
Previous LGA infant
Previous unexplained stillbirth
Risk Factors for GDM?
fam history
previous stillbirth
pervious LGA infant
ethnic group at risk
maternal obesity
Infant of Diabetic Mother (IDM) symptoms of hypoglycemia?
Jittery
Apnea
Tachypnea
Cyanosis
Hypotonia
Unstable temperature
treatment for infant hypoglycemia?
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
treatment for infant hypoglycemia?
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
what is important to know about hyperemesis?
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) .
what are the possible causes of hyperemesis?
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
what are the clinical symptoms of hyperemesis?
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+
what are the fetal risk of hyperemesis?
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
Assessment of Client with Hyperemesis?
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)
what is the management of hyperemesis?
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)
what are the meds for hyperemesis?
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
what is the nutrition for hyperemesis?
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
Other Nursing Interventions for Client with Hyperemesis?
Emesis basin, emesis bag or bath pan
Provide oral hygiene
Provide a quiet restful environment
Cool wet washcloths
what is Maternal Phenylketonuria?
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
what is a Low Phenylalanine Dietduring pregnancy?
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
what is a Low Phenylalanine Dietduring pregnancy?
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
what is the PKU treatment during pregnancy?
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
