Exam 3 Flashcards
Normal urinary elimination maintains the concentration of ions needed for what 3 things?
- Neuro and muscle function
- Bone strength
- Cellular regeneration
- Maintains homeostatic regulation of bp for adequate circulation of oxygen and nutrients
What organs are part of the Upper urinary tract?
Kidneys and Ureters
What is part of the lower urinary tract
- Urinary bladder
- Urethra
- Pelvic floor
what is the step-by-step process of emptying the bladder?
Urine collects in the bladder –> Pressure stimulates stretch receptors –> Transmit impulses to the voiding reflex center of the spinal cord –> If time, the place is appropriate –> Conscious part of the brain relaxes external urethral sphincter muscle –> Urination occurs
Patterns of voiding (5 things)
- Vary by individual
- Everyone should void at least every 6 hours
- Most people void 6–7 times/day
- 4 to 10 times a day is considered normal
- Amount varies based on age, weight, daily fluid intake, types of fluid consumed, and meds (0.5 – 1.0 mL/kg/hr)
What are the factors that affect urinary elimination (6 things)
- Fluid and food intake
- Muscle tone
- Psychosocial factors
- Pathologic conditions
- Surgical and diagnostic procedures
- Medications
What causes alteration in urinary elimination?
- older or younger?
- system problem (hint)
- 2 others
- Age-related changes
- Acute/chronic diseases and their treatment
- pregnancy-stress incontinence
- Arthritis-functional issues
What can polyuria cause?
What is it caused by?
- Can cause excess fluid loss –> intense thirst, dehydration, and weight loss
- Caused by disease: diabetes mellitus, diabetes insipidus and kidney disease
What leads to polydipsia; what is it associated with?
compulsive intake of excessive amounts of fluid. This is associated with polyuria
What is Anuria
When you urinate 100 mL or less a day
What is Oliguria?
What is the amount range?
What can it signal?
Does it need to be reported?
Scant urine production
- <400 ml/day or 30ml/hr
- may signal impending renal failure
- needs to be reported
What are the 4 things that cause changes in urinary frequency?
- Inc. total fluid intake
- UTI
- stress
- pregnancy
What causes a sudden strong desire to void regardless of the volume of urine present
- unstable bladder contractions
- psychologic stress
- irritation of the urethra
- poor external sphincter control
What is Dysuria?
What are the causes?
Pain or difficulty voiding
Causes:
- stricture of the urethra, UTI, injury to the bladder/urethra
- Often individuals express the need to “push” to void or a “burning” during or after urination
What is urinary hesitancy and what is it associated with?
delayed or difficulty in initiating the void and is often associated with dysuria
What is a neurogenic bladder?
- What is it often due to?
- Does not perceive bladder fullness
- Unable to control urinary sphincters
- The bladder can be flaccid and distended, spastic with frequent involuntary urination
- Often due to a malfunction caused by damage to the spinal cord
Factors related to lower urinary tract symptoms
- Constipation
- IBS
- Sexual activity
- Delayed/premature voiding
What are nonmodifiable risk factors for alteration in urinary elimination
- Physical, cognitive, or developmental disability
- Family Hx of incontinence
What are genetic considerations for alteration in urinary elimination
- Spina bifida
- Myelomeningocele
What diseases related to aging, alter the urinary elimination process
- Parkinson disease
- Alzheimer’s disease (changes in cognitive function)
The increase in ______ and ________ increases with age
Urgency; frequency
What is part of the nursing assessment related to urinary elimination
- Check voiding pattern
- Description of urine and any changes (color, odor, sediment, clarity, pus blood)
- urine elimination problems (change in pattern or pain)
What is the physical examination for urinary elimination
- Abdomen
- Soft tissues of genitalia, perianal areas
- Urethral meatus
- Feces and urine
- Fluid volume status
What are anticholinergic medications
they reduce urinary frequency, treat incontinence
What are cholinergic medications
they promote urination
What are urinary analgesic
Helps to treat pain
what are Urinary antispasmodics?
treats spasms
4 types of diuretics
- Loop diuretics
- Thiazide diuretics
- Potassium-sparing diuretics
- Carbonic anhydrase inhibitors and osmotic diuretics
What is hemodialysis?
Blood flows through an external machine, and returns to the patient’s body
what is Peritoneal dialysis?
- Dialysis solution instilled into the abdominal cavity
- Must be done at frequent intervals
fetus excretes urine at what weeks
11-12th week
Urinary elimination through the lifespan in newborns
- Lower GFR
- kidney unable to rapidly excrete fluid (overhydration)
- Light yellow
- prone also to dehydration
- Can be cloudy due to mucus content and high specific gravity
- urine is odorless
- Tubes are short and narrow
- Monitor dehydration
Urinary elimination through the lifespan For childhood
- Kidney mature 1-2 year of life
- kidneys double in size
- urinate 6-8x a day
- Nocturnal enuresis (bedwetting) common in deep sleepers –> not a problem until after age 7
- Urine becomes concentrated and effectively appears as normal yellow to amber
18-24 months –> recognizes bladder fullness and is able to hold urine
2.5 – 3 years –> can perceive bladder fullness and hold urine and communicate need to void
- Daytime control –> 3years
- Full control –> 4-5 years
- Control during day precedes nighttime
- Need to remind on flushing and proper handwashing
- Teach proper wiping –> front to back!
Urinary elimination through the lifespan For Adults and Pregnancy
- After age 50, kidneys begin to diminish in size and function
Pregnancy: increases in frequency; GFR rises 50% (reabsorption increases) - Increase risk of UTI
Urinary Elimination through the Lifespan for Geriatric
- An estimated 30% of nephrons are lost by 80 years of age
- Renal blood flow decreases because of vascular changes and cardiac output decreases.
- The ability to concentrate urine declines –> increasing the risk of dehydration
- Bladder muscle tone diminishes, causing increased frequency of urination and nocturia (voiding 2 or more times at night)
- Increase risk of UTI
- inc. risk of hyponatremia
- Given diuretics to treat various issues (hypertension, cardiac conditions can complicate inefficiencies in conc. of urine, electrolyte regulation
What is the pathophysiology of Urinary Incontinence
- Results from higher-than-normal bladder pressures or reduced urethral resistance
What are the contributing factors for urinary incontinence
- Use of diuretics
- Pregnancy
- Decreased levels of estrogen during menopause
- Relaxation of pelvic musculature
- Disruption of cerebral and nervous system control
- Disturbances of the bladder and its musculature
Risk factors for urinary incontinence
Older more than younger
Women more than men
Especially homebound or in an LTC facility
Obesity
Smoking
Diabetes
Inactivity
Pregnancy
Depression
Constipation
Dietary bladder irritants
Neurologic disorders
Frequent UTIs
Certain medications
Causes of Urinary Incontinence (types of incontinence)
Stress Incontinence
Urge Incontinence
Mixed Incontinence
Temporary Incontinence
What is non-reversible for urinary incontinence
- Acute confusion
- Depending on the underlying cause
Chronic Urinary Incontinence examples are…
Congenital disorders
- Epispadias
- Meningomyelocele
Acquired irreversible factors
- Central nervous system (CNS), spinal cord trauma
- Stroke
- Multiple sclerosis
- Parkinson disease
Cystocele
a bulge of the bladder into the vagina (bladder hernia)
What are the 5 types of incontinence?
- Stress incontinence
- Urge Incontinence
- Relfex incontinence
- Overflow incontinence
- Functional incontinence
What is stress incontinence
relaxation of the pelvic muscles and weakness of the urethra and tissue leading to decreased urethral resistance.
*may also be caused by increased pressure on the bladder from pregnancy, obesity, cystocele or urethrocele
What is Urge Incontinence
- Overactive detrusor muscle, leading to increase in pressure within the bladder (inability to inhibit voiding)
What is reflux incontinence
- What neurological condition is it a result of?
- condition results from a spasm of the detrusor muscle due to neurological impairment or tissue damage. Usually seen in patients with neurologic conditions such as MS and Spinal cord injury
What are some clinical therapies for urine incontinence
Medications for the underlying condition
Neuromodulation
Catheterization
Surgery
Lifestyle modifications
Behavioral therapy
Kegel exercise
Anticholinergic, Beta -3 agonist, estrogen
What is overflow incontinence
Lack of normal detrusor activity, leading to overfilling of the bladder and increased pressure.
Loss of urine is associated with an over distended bladder (urine leaks out) and urinary retention, urinary obstruction, or BPH
What is functional incontinence
Ability to respond to the need to urinate is impaired
- Seen in dementia and physical disabilities, and patients with impaired mobility
Factors outside of the urinary tract (immobility, requires assistance
is urinary retention more common in men or women and why?
Men because of BPH
What are several etiologies for urinary retention
- Mechanical obstruction or functional problem
- Acute inflammation
- Infection or trauma
- Scarring from repeated UTIs
- Renal calculi or bladder stones
- Anesthesia during surgery
- BPH
- Nerve/spine issues
- Congenital birth defects
Risk factors for Urinary Retention
Postoperative surgical procedures
Abdominal or pelvic surgery
Accidents to the brain or spinal cord
Infections of the brain or spinal cord
Advanced age
Male gender
Cognitive impairment/confusion
Diabetes
Constipation
Immobility
Emotional distress
History of UTIs
How to prevent urinary retention
- Void when the urge to urinate occurs
- Avoid medications that cause urinary retention
- Kegel exercises
- Preventing constipation
What sort of collaborations are used for Urinary Retention
- Diagnostic tests
- Non-pharmacologic therapy
- Pharmacologic therapy
- Surgery
What sort of diagnostic tests are done for urinary retention
- Post-void residual assessment
- Urinalysis
- Laboratory tests
PSA
Imaging scans
What sort of pharmacologic therapies are used for urinary retention
- alpha-adrenergic blockers
- antibiotics
Non-pharmacologic therapy for urinary retention
Treat immediately with complete emptying of the bladder via catheterization
May need an indwelling catheter or intermittent catheterization to prevent future urinary retention, and over-distention of the bladder until the underlying problem corrected
what would surgery help with in urinary retention
- Mechanical obstructions removed or repaired when possible
- Resection of the prostate gland for urinary retention related to BPH
- Correct a cystocele or rectocele
Suprapubic catheter long-term treatment
lifespan considerations for older adults in urine retention
- Weak detrusor muscle
- Reduced rate of urine flow
- Reduced ability to withhold voiding
- Enlarged prostate
**Pelvic organ prolapse
how is the urinary tract kept sterile
- adequate urine volume
- free flow of urine from the kidneys through the urinary meatus
- complete emptying of the bladder
- bacteria/pathogens that attempt to enter the urethra are “washed out” during voiding
- the acidity of the urine
- bacteriostatic properties of the bladder and urethral cells
what is cystitis is it the most common type of UTI??
Inflammation of the urinary bladder
- Yes , the most common
What is pyelonephritis
inflammation of the kidney and renal pelvis
- usually ascends to the kidney from the lower urinary tract
- ACUTE –> BACTERIAL
CHRONIC –> NONBACTERIAL
What is the most common cause of a catheter-associated UTI
Intra-lumen/healthcare worker caused when inserted, handled, and disconnected
What is a urostomy
surgically placed alternate route for urine via the abdominal wall
- may be temporary or permanent
when a patient is on bed rest, this leads to a decrease in what
peristalsis activity
what does anesthesia do to the bowels
it blocks the parasympathetic stimulation muscles of the colon and causes a decrease in movement
what is flatulence and what does it lead to?
excessive gases in the intestines or colon; gastric distention
what causes flatulence
- bacterial action on chyme
- swallowed air
- gas diffusing from the bloodstream
What is diverticular disease
-what type of -itis does it cause?
- what can it cause?
- Outpouching of the colon
- Mucosal lining of the bowel herniates through the bowel wall
- Diverticulitis
- Diverticula inflamed
- Can cause obstruction, perforation, bleeding
What is a bowel obstruction
- The inability of intestinal contents to move through the small or large bowel
Mechanical:
- This may be due to adhesions, hernias, intussusception, volvulus, tumors
Functional:
The inability of peristalsis to propel intestinal contents forward
What is Paralytic ileus?
- Intestinal muscles not moving or diminished
- Occur after surgery or drugs
- Risk of bowel necrosis and perforation
what is the biggest risk factor for bowel elimination
AGE
- Young children and older adults at higher risk for diarrhea, constipation, fecal incontinence
- Women at higher risk for fecal incontinence
- Immobility, disability, and chronic disease increase the risk of constipation
What are some diagnostic tests done for bowel elimination assessments
- Blood and fecal tests
- Digital rectal exam
- Anorectal manometry
- Colorectal transit study
What are some direct visualization procedures for bowel elimination
Colonoscopy
- Tissue samples can be obtained during colonoscopy
Esophagogastroduodenoscopy
- Esophagus, stomach, duodenum
Sigmoidoscopy
- Sigmoid colon
Upper GI
- Esophagus, stomach, small intestines with barium
What are 3 indirect visualization
Ultrasound
MRI
CT
Bowel elimination treatments
(independent interventions, collaborative therapies, pharmacologic therapy, surgery in case of…)
Independent interventions
- personal hygiene
- bowel training
- inc. fluid and fiber intake
Collaborative therapies
- medications
Pharmacologic therapy
- Constipation (stool softener)
- Diarrhea (antidiarrheal medications)
Surgery in case of
- Obstruction
- Ulceration
- Perforation
- Cancer ostomy care
4 ways to empty the colon
- Manual removal by a nurse
- Enemas
- Suppositories
- Oral meds
What consists of bowel training
D/C or decreased use of meds
Increase the level of activity
Diet-high fiber
Fluids
(Monitor BMs!)
Lifespan consideration in NEWBORNS AND INFANTS for bowel elimination
- bowel color depends on breastfeeding or formula feeding
- consistently soft and liquid
- Meconium –> transitional stool –> entirely fecal
Lifespan consideration in TODDLERS for bowel elimination
- Some control between 1.5 – 2 years
- Usually, control happens when the child becomes aware of the discomfort of soiled diapers
- In the U.S. –> 24 months –> many conditions affect toilet training –> sex, race, socioeconomic status, and culture
- Intussusception (telescoping of the intestines) is the most common cause of intestinal blockage – treated with an enema or surgery to prevent bowel perforation, infection, or necrosis.
- Intestinal obstruction –> volvulus (twisting of the loops of the bowel around a fixed point) –> early recognition and prompt surgery are necessary to prevent bowel ischemia perforation
Lifespan consideration in SCHOOL-AGE CHILDREN AND ADOLESCENTS for bowel elimination
Bowel habits similar to adults
Patterns vary in frequency, quantity, and consistency
May delay defecation for play or another activity
Lifespan consideration in PREGNANT WOMEN for bowel elimination
- Elevated progesterone levels –> delayed gastric emptying, decreased peristalsis
- May lead to bloating, constipation
- Enlarging uterus aggravates symptoms
- Hemorrhoids late in pregnancy
- Bowels sluggish after giving birth
- Pain may lead to delaying elimination
- Flatulence after cesarean birth
Lifespan consideration in OLDER ADULTS for bowel elimination
- What is common?
- what to tell older adults about laxatives?
Constipation is common
- Reduced activity levels
- Inadequate fluid and fiber intake
- Muscle weakness
- Medication side effects
- Responding to gastrocolic reflexes important
Laxative use inhibits natural reflexes and may cause constipation rather than relieving it
- Advise older adults that consistent use of laxatives will cause chronic constipation, interfere with electrolyte balance, reduce absorption of some vitamins
Changes in bowel habits over weeks should be referred to a primary care provider
Health Promotion for Bowel Elimination
Healthy lifestyle habits
- weight
- exercise
- blah blah
Screenings
Modifiable risk factors
- obesity
- pregnancy
- poor hygiene
what are patient outcomes/goals for bowel elimination
- the patient has formed stool
- education
- patient to absorb nutrients/fluids via the GI tract
how can a nurse advise a patient to eliminate the cause of diarrhea, replace lost fluids
- what foods to avoid?
- what type of diet?
- replace what?
- we should monitor what?
- Avoid spicy foods, raw fruits and vegetables, and dairy (except yogurt)
- The diet should be low residue (low fiber)-which may have a laxative effect
- Replace fluids and electrolytes (IV fluids may be required)
- Babies should continue to breastfeed
- Children should resume diet as tolerated
- Monitor labs & cultures, administer meds as needed
Antidiarrheals (r/o bacterial infection/cause of diarrhea first!)
What is fecal incontinence
loss of voluntary control of fecal and gaseous discharge through the anal sphincter
- Less common than urinary incontinence
- May occur at specific times or irregularly
- Patients often reluctant to reveal because of embarrassment or shame
What is the pathophysiology of fecal incontinence
- Impaired functioning of the anal sphincter or its nerve supply
- Usually manifestation of an underlying disorder
Partial
Inability to control flatus or prevent minor soiling
Major
Inability to control feces of normal consistency
- Usually a manifestation of another disorder
- Neurologic disorders, Depression, Traumatic injuries, Inflammatory process, Masses, hemorrhoids, or deformity in the anus
What are the risk factors for fecal incontinence
- Older age
- Female gender
- Age-related changes in anal-sphincter tone
- Response to rectal distention
- Smoking
- Increased BMI
How to prevent fecal incontinence
Controlling the cause of fecal incontinence
- Constipation
- Diarrhea
Non-pharmacologic therapies for fecal incontinence
High-fiber diet
Ample fluid intake
Scheduled toileting
Regular exercise
Kegel exercises
Biofeedback
Pharmacologic therapy for fecal incontinence
Medications to relieve diarrhea or constipation
Antimicrobial agent for diarrhea caused by infection
Temporary use of lubricants, bulk-forming laxatives, and stool softeners to clear impacted stool
Types of surgery for fecal incontinence
Surgical repair of damage to sphincter or rectal prolapse
Artificial anal sphincter
Dynamic graciloplasty
Radiofrequency anal sphincter remodeling
Permanent colostomy to control fecal output when other measures fail
what is encopresis
abnormal elimination pattern
Lifespan considerations for fecal incontinence in children and adolescents
- Recurrent soiling or passage of stool at inappropriate times by a child who should have achieved bowel continence
- More common among boys
- More common with a history of constipation
- Primary: Never achieved bowel control
- Secondary: Have had bowel continence for several months
- Underlying constipation cause
Birth of sibling - Move to a new house, new school
Anger, and control issues related to bowel training - Diet
- Full schedule
- Genetic predisposition
Lifespan considerations for fecal incontinence in pregnancy
- More incontinent late in pregnancy than after delivery
- Incontinence during labor, delivery
- Fecal incontinence is probable if stool is present in the sigmoid colon or rectum
- Incontinence due to proximity of birth canal to rectum, anus
Postpartum incontinence
- Due to biomechanical changes during pregnancy
- Changes in the function of the rectum, anus
- Sphincter disruption, nerve damage
Lifespan considerations for fecal incontinence in older adults
Multifactorial etiology
- The delicate balance between stool consistency, the physical integrity of anatomic structures involved in bowel elimination
- Not a normal change of aging
- Decreasing muscle tone, and rectal sensation from cumulative local trauma
- Chronic disease
- Polypharmacy
- Fecal impaction from inactivity, immobility, and reduced fluid intake
- Cognitively intact, physically able older adults should be considered for treatment
- Alleviate psychosocial effects
- Alleviate burden to care providers, healthcare systems
What is a part of the observation and patient overview for fecal incontinence
- Signs and symptoms of bowel elimination problems
- Frequent, urgent, untimely requests to use the bathroom
- Question the patient further about elimination problems
- Presence of fecal odor, soiled clothing
- Patient agitation
- Extent, onset, and duration of elimination problems
- Contributing factors
- History of the spinal cord, anorectal injury or surgery
- Chronic diseases
- Medications, alternative therapies
- Nutrition
- Hydration
What is a part of the physical examination for fecal incontinence?
- Palpation of abdomen
- Bowel sounds
- DRE
- Assess for hemorrhoids, anal fissures
- Assess for abnormalities of the abdomen, perineum
What should be implemented for fecal incontinence assessment?
- Promoting regular defecation
- Perineal skincare
- Bowel training programs
- Digital removal of fecal impaction
- Use of fecal incontinence pouch
- Teaching about lifestyle modifications
- promote regular defecation
- Maintain skin integrity
- Provide emotional support
What is part of the care following an anal sphincter surgery (3 parts)
- Cuff around the anal canal
- Pressure-regulating balloon
- Pump that inflates the cuff
Bowel movement occurs when the cuff is deflated
The cuff automatically inflates in 10 minutes
Enemas and rectal medications harmful with this device in place
What to educate patients for home care on fecal incontinence
-Topics for patient and family education
-Facilitating toileting
-Monitoring bowel elimination pattern
-Dietary alterations
-Medications
-Exercise and self-care
What is considered constipation?
- Reduce the frequency of bowel movements
- Passage of fewer than three bowel movements/week
- Difficult passage of dry, hard stool, or no stool
What is the pathophysiology of constipation?
- Can it be caused by medications?
- Occurs when the slow movement of feces through the large intestine –> allowing for more resorption of fluid
- Decreased motility –> due to inactivity or other
- Medications
- May have feelings of incomplete stool evacuation after defecation
- May reflect the primary problem or underlying disorder
What is the most common type of constipation?
Normal-transit constipation
related to: Meds, activity level, diet, emotional factors
What is the primary reason for constipation
aka functional constipation
- colonic transit time; anorectal outlet obstruction
What is a secondary reason for constipation
- Hypothyroidism, multiple sclerosis
- Opioid medications
- Diet
What 3 causes of constipation (what categories do they fall in)
- behavioral
- physiological
- Psychological
Dietary methods to prevent constipation
- High-fiber diet
- Drinking plenty of fluids
- Fiber supplements
What are behavioral methods to prevent constipation
- Exercising regularly
- Not ignoring the urge to defecate
Are stool softeners and laxatives that are used to prevent constipation okay to use for long-term use?
No, only for short term use
What is considered chronic constipation
According to Rome IV criteria: symptoms for at least 12 weeks with onset of symptoms 6 months before diagnosis (2 or more criteria need to be met for ¼ or 25% of BMs)
What are the symptoms of chronic constipation
- Straining with defecation
- Lumpy or hard stools
- Sensation of incomplete emptying
- Use of manual maneuvers to facilitate emptying –> digital evacuation, support of the pelvic floor
- less than 3 bowel movements/week
- Loose stools are atypical without the use of laxatives
- Absence of IBS
What are pharmacological therapies for constipation
- Laxatives
- Cathartics, enemas for severe constipation
how to diagnose constipation in children and adolescents
-Greater than or equal to 1 episode of incontinence per week
-Hx of excessive volitional stool retention
-Hx of painful or hard bowel movements
-Presence of large fecal mass in the rectum
-Hx of large-diameter stools that may obstruct the toilet
can iron supplements cause constipation
yes
what are the contributing factors for constipation in older adults
Lack of teeth or ill-fitting, broken, or lost dentures
Periodontal disease
Lack of fiber
Low fluid intake
Advertising encourages overuse of laxatives, suppositories, enemas
Further, impair ability to maintain a healthy pattern of bowel movement
What are the symptoms of fecal impaction
- Odorous leakage
- Constipation of solid stool
-Rectal pain - Frequent but nonproductive desire to defecate
- A general feeling of illness
- Anorexia
- Nausea and vomiting
- Abdominal distention and cramping
- The sensation of fullness in the rectal area
A mass increase in pressure in the colon leads to…..
increase risk for ulceration and perforation
How is fecal impaction recognized?
- Recognized by the passage of liquid foul-smelling fecal material in the absence of formed stool
- Liquid portion of feces seeps around impacted mass
- Assessed by digital rectal examination (DRE)
What is an ostomy
A surgical procedure to divert fecal matter out via abdominal wall
What is the nursing care for a stoma?
- Monitor surgical site (should heal within 8 weeks)
- Control odor
- Educate on care of stoma, care of skin surrounding the stoma
- Monitor intake/output
- Encourage the patient to look at, and care for ostomy
What should the patient be educated about if they have a stoma?
- Reason for stoma
- Demonstrate self-care
- Verbalize fears
- Knows where/how to obtain supplies
- Describe f/u care and resources
- Demonstrates positive body image
Promoting healthy elimination habits
- Maintaining a healthy weight
- Exercising regularly
- Good toileting habits
- Avoiding delayed voiding and defecation
- Avoiding using pelvic floor muscles to force urine - flow/prevent straining
- Adequate fluid, and fiber in the diet
- Treating constipation or diarrhea as it occurs
Not smoking - Avoiding food and drinks that contain bladder and bowel irritants
What is metabolism?
collection of biochemical reactions that occur in the body’s cells
Produce energy
Repair cells
Maintain life
Much of the metabolic process takes place in the digestive system
What are hormones
- chemical messengers secreted by endocrine glands to regulate:
Regulate metabolism
Growth
Reproduction
Fluid and electrolyte balance
Sex differentiation
Other functions within the cell
Adrenal glands, what is the hormone that helps with glucose control
Mineralocorticoids (Aldosterone)
◦ Reabsorption of water and sodium in kidneys
Glucocorticoids (cortisol and cortisone), how do they help with glucose control
◦ Regulate carbohydrate metabolism
◦ Suppress inflammatory response, and inhibit immune system effectiveness
Gonadocorticoids, how does it help with glucose control
◦ Dehydroepiandrosterone (DHEA)
◦ Adrenal medulla
◦ Epinephrine and norepinephrine
Pancreas, how does it help with glucose control?
◦ Carbohydrate metabolism,
◦ –> including blood glucose levels
◦ Alpha cells: glucagon
◦ Beta cells: insulin
◦ Delta cells: somatostatin
What are the 2 disorders of the pancreas?
Type 1 and Type 2 diabetes
Diabetes mellitus (DM)
What is it a disorder of and what are the results of the defects
Disorder of hyperglycemia
Results from defects in:
Insulin secretion
Insulin action
Both
This leads to abnormalities in carbohydrate, protein, and fat
metabolism
What are the 4 major types of diabetes mellitus
Type 1 DM (T1D)
Caused by autoimmune destruction of beta cells
Type 2 DM (T2D)
Cased by gradual loss on insulin secretion by beta
cells
Gestational diabetes
Diagnosed in 2nd and 3rd trimester of pregnancy
–> insulin resist
Other specific types of diabetes –> rare
Caused by
monogenic diabetics syndromes
exocrine pancreas disease
diabetes is caused by certain drugs or chemicals
Islets of Langerhans consist of what 3 types of cells
- Alpha
- Beta
- Delta
What are Alpha cells
Alpha cells produce glucagon
Released when blood glucose levels < 70 mg/dL
Promotes the breakdown of glycogen
Decrease glucose oxidation via glycogenolysis
Increase blood glucose levels via gluconeogenesis
What are Beta cells
Beta cells produce insulin
Secreted as blood levels start to rise such as after a meal
Facilitates movement of glucose across cell membranes into
cells
Stimulates conversion of glucose to glycogen in the liver and
muscles
Incretin hormones are secreted in the intestine in response to food
consumption
What are Delta cells
Delta cells produce somatostatin
Neurotransmitter that inhibits secretion of glucagon and insulin
Slows gastric motility — increases the time available for food
What is the name for the opposite action of insulin? when hormones increase glucose levels during increased metabolic needs, stress, growth, and hypoglycemia
Counterregulatory hormones
What destroys beta cells of islets of Langerhans
A combination of
genetic pre-disposition
environmental factors –> trigger a cell-mediated autoimmune reaction
Begins with insulitis
Inflammation of the islets of Langerhans
- Destruction of beta cells
Creates a need for exogenous insulin
It is variable but tends to occur more rapidly in infants and children and slower in adults
Hemoglobin A1c is used to measure blood glucose levels over the previous 1 to 3 months
2 or more autoantibodies are strong predictors for…
hyperglycemia and diabetes
immune-mediated diabetes occurs more frequently in older adults or children
Children
Idiopathic disorder
No known etiology
Strongly familial
Insulin deficiency and no beta-cell autoantibodies
Prone to DKA
Predominately African or Asian descent
What are the 3 classic symptoms of Type 1 DM ( including 3 P’s)
Polyuria
Polydipsia
Polyphagia
Weight loss as fats and proteins used for energy (gluconeogenesis)
Symptoms:
malaise, fatigue, blurred vision,
dehydration, hypotension, tachycardia
What are the complications of Type 1 DM
Hyperglycemia
Diabetic ketoacidosis
Hypoglycemia
Hyperosmolar hyperglycemic state
Microvascular and macrovascular
complications
Increased susceptibility to infection
Periodontal disease
Interactions of complications – problems in the feet
Depression
Diabetic distress
Hyperglycemia, what is the dawn phenomenon
Rise in blood glucose between 4 a.m. and 8 a.m.
Not a response to hypoglycemia
Cause unknown, might relate to nocturnal increase in growth hormone
ACUTE complication
What is the Somogyi phenomenon aka rebound hyperglycemia
Combination of hypoglycemia during the night with a rebound morning rise to
hyperglycemia
What is DKA
diabetic ketoacidosis ACUTE complication
Life-threatening metabolic disorder
Manifested by:
Hyperglycemia
Metabolic Acidosis
Ketosis - accumulation of ketone bodies
from the metabolism of fatty acids
Can occur in both Type 1 and Type 2 DM
Increase incidence of Type 1 DM
What are the acute complications of Diabetic Ketoacidosis
ACUTE complication
- no insulin
- lack of insulin
- glucagon from the liver increases production
What can cause insulin-related precipitating factors?
Non-adherence to insulin regimen
Under-dosing
Skipping doses
Insulin pump failure
Conditions that can cause:
infection, trauma, thyrotoxicosis, surgery, acute
MI
Medication triggers:
corticosteroids, sympathomimetics, atypical
antipsychotics
What are the symptoms of hyperglycemia in DKA
ACUTE complication
Symptoms: polyuria, polydipsia, weakness, nausea, vomiting, abdominal pain, mental status changes, Kussmaul respirations, acetone breath
Lab values: blood glucose > 250mg/dL
pH < 7.2
ketones in urine or blood
What is the goal for someone who has Hyperglycemia from DKA
Restore ECF volume - improve tissue
perfusion
Reduce hyperglycemia
flush ketones from the body
- Restore Electrolyte balances (if needed)
What is the cause of Hypoglycemia (metabolic reason)
ACUTE complication
A mismatch between insulin intake, physical activity, carbohydrate availability
What causes hypoglycemia in hospitalized patients
NPO status
Vomiting
Abruptly stopping or reducing corticosteroid meds
Improper timing of insulin to meal and variable
meal times
What are the clinical manifestations of hypoglycemia
The result from compensatory autonomic nervous system response
Pallor (pale), tremors, palpitations, anxiety and diaphoresis hunger
Vary, especially in older adults
Sudden onset
Severe hypoglycemia may cause death
What are the 3 levels and ranges of hypoglycemia
Level 1: Glucose > 54 mg/dL and < 70
mg/dL
Level 2: Glucose <54 mg/dL
Level 3: altered mental status; loss of
consciousness, seizure, coma, death
what are the signs and symptoms of hypoglycemia
- anxious
- sweaty
- hungry
- confused
- blurred vision
- double vision
- shaky
- irritable
- cool, clammy skin
What is diabetic retinopathy
Leading cause of blindness in individuals 20–74
years of age
Vitrectomy used to treat vitreous hemorrhage
What is the etiology of diabetic neuropathy (what is happening that causes it?)
Hyperglycemia and hyperlipidemia
damage nerves and microvasculature
Types: peripheral, focal, proximal,
autonomic
Peripheral most common
What is polyneuropathies
involve multiple nerves fibers
What is mononeuropathies
affecting one nerve (peripheral)
is proximal neuropathy common?
- what kind of pain does it cause?
uncommon; causes pain in the hip, buttock, thigh
What does autonomic neuropathy affect?
affects sweat glands, CV, GI, and GU systems
What is the TX for Diabetic neuropathy
regabalin, duloxetine, tapentadol
Topical treatments offer some relief
What is diabetic neuropathy
A disease of the kidneys characterized by
- Presence of albumin in urine
- hypertension
- edema
- progressive renal insufficiency
is the pathologic origin of diabetic nephropathy unknown?
yes
Why does Glomerulosclerosis occur
occurs d/t accumulation of
larger proteins – makes the basement membrane
functional leaking – allowing the protein to be lost in
the urine
What is the major cause of heat disease in people with diabetes
atherosclerosis
what are 2 additional risk factors for CAD
- HTN
- Dyslipidemia
Are people with DM prone to MI
YES
what are the numbers for hypertension
greater than 140/90
Does diabetes increase the risk of a stroke?
Yes, Especially in older adults with Type 2
DM
Potentially life-threatening
PVD is more common in people with either type 1 or type 2 diabetes?
type 2 diabetes
What causes PVD in diabetic patients?
- atherosclerosis development
Impaired peripheral vascular circulation leads to PV insufficiency with intermittent
claudication (pain) in LE and ulceration of feet
Gangrene
Combination of vascular disease,
neuropathy, and increased risk for infection
Most common cause of amputations
for DM
For type 1 diabetes why is there an increased susceptibility to infection?
Immune system deficiencies
Hyperglycemia
Skin/mucous membrane
colonization
Vascular complications
Reduced sensation
Autonomic neuropathy
Hospitalized patients with glucose levels> 220 mg/dL — higher rates of infection
Periodontal disease
- Progresses more rapidly if diabetes is poorly controlled
- d/t microangiopathy with changes in vascularization of the gums
Gingivitis (inflammation of gums)
Periodontitis (inflammation of the bones underlying the gums)
Chronic complications for a diabetic foot
Most common
Cracks and fissures caused by dry skin or infections
Blisters from improperly fitting shoes
Pressure from stockings or shoes; foreign objects in a show
Ingrown toenails
Walking barefoot
Usually begin as superficial skin ulcer
Eventually extends deeper, into
muscle and bone
If untreated, gangrene can develop
Who is part of the team in collaboration with the patient’s care
Certified diabetes educator, nurse,
family physician, specialist, dietitian,
podiatrist and psychologist or psychiatrists
(family and friends as well
What is the main focus of treatment for type 1 diabetes (4 things)
Maintain blood glucose at nearly normal levels
Medication
Dietary management
Exercise
What are 4 diagnostic screening tests
Fasting plasma glucose (F P G) >126 mg/dL
Two-hour plasma glucose >200 mg/dL during oral glucose tolerance test (O G T T)
Hemoglobin A1C greater than or equal to 6.5%
Symptoms of diabetes plus casual plasma
glucose (PG) concentrations > 200 mg/dL
What is a part of the Diabetes management monitoring related to Diagnostic tests?
Fasting blood glucose (FBG or FBS)
Hemoglobin (A1C)
Average blood glucose over 1–3 months
Lipid profile
Urinary albumin/creatinine ratio (> or = 30
mg/g creatinine) - diagnosis of albuminuria
Estimated glomerular filtration rate (GFR)
Serum and urine ketones
Serum electrolytes
Difference between self-monitoring blood glucose and continuous glucose monitoring?
Self-monitoring blood glucose
(SMBG)
Lancet to obtain a drop of blood to
place in a monitoring device
Continuous glucose monitoring
(CGM)
The sensor under the skin continuously
monitors glucose levels
When should you monitor your glucose as a diabetic patient?
Before eating meals and snacks
At bedtime
Periodically after meals
Before exercising
If a low blood glucose level is suspected
Following treatment for low blood glucose until glucose levels return to normal
Before a safety-related activity, such as
driving.
What are pharmacologic therapies for Type 1 diabetic patients and what are 5 types
Insulin
- T1D requires lifelong insulin source
- need long-acting insulin to control levels with meals and overnight
- need rapid-acting before meals to cover spikes in BG
Types of insulin:
Rapid-acting
Short-acting
Intermediate-acting
Long-acting
Combinations
What are the insulin regimens?
given first based on weight and split up throughout the day and then rest is based on the patient’s actual BG levels
recommended nutrition management based on the ADA
Healthy eating habits
Wide variety of foods in proper
proportions
High in nutrients, low in calories
Processed foods and added sugar to be
avoided
Individualize proportion of
carbohydrates, fats, and protein for the
patient
What are the nutrition guidelines related to Carbs, proteins, and fats?
Carbohydrates
Count grams of carbohydrates per
meal to determine dose of insulin
Protein
Without renal disease: 1 to 1.5
g/kg/body weight/day or 15-20%
total calories
Diabetic nephropathy: 0.8 g/kg body
weight/day
Fats
20-35% total calories
Focus on monounsaturated and
polyunsaturated fats
Eliminate trans fats
Nutrition management for Sodium, Fiber, alcohol, and non-nutritive sweeteners
Sodium
Limited to <2300 mg/day
Fiber
Increasing fiber may lower A1c
Minimum 14 g of fiber/1000 kcal
Alcohol
Same as for the general public
Women: 1 drink per day
Men: 2 drinks per day
Can cause hypoglycemia, weight gain,
or hyperglycemia if a large amount
ingested
Non-nutritive sweeteners
Reduce the use because of the potential for
weight gain
For exercise, when should you check to monitor BG levels?
before, during, and after exercise
Lifespan Considerations in Children and Adolescents
T1D in Children and adolescents
Clinical manifestations
Hyperglycemia
Increased thirst, hunger, urination
Fatigue
Blurred vision
Weight loss
Usually acute, requires emergency intervention
DKA: dehydration, electrolyte imbalance
Quick diagnosis, and treatment required to prevent deterioration
Therapy aimed at
Correcting acidosis
Restoring fluid and electrolyte balance
Achieving euglycemia
Diagnostic tests
A1C level greater than or equal to 6.5% + random blood PG level
Greater than or equal to 200 mg/dL or fasting
What are the risk factors for Type 1 DM
exposure to environmental triggers
Drugs, pollutants, dietary considerations, stress, infections, gut flora
No way to prevent Type 1 DM
Identification of autoantibodies in relatives with Type 1 DM provides an opportunity for education and follow-up
for early detection
Sick-Day Management
When an individual with diabetes is sick
or has surgery:
Notify HCP if vomiting or diarrhea
persists beyond 6 hours, fever, or
sickness continues for several days
without improvement
Seek medical attention for vomiting,
diarrhea, and symptoms of DKA
Obtain self-monitor blood glucose levels
every 3 to 4 hours
Notify HCP if levels are elevated despite
insulin administration
Continue long-acting or basal insulin
Notify HCP if levels remain > 240
mg/dL despite extra insulin
Monitor urine or blood for ketones
Notify HCP if moderate or large
amounts ketones present
Drink fluids every hour to avoid
dehydration and consume carbohydrates
Water, tea, diet soda, broth
Why is exercise beneficial for diabetic patients (6 things)
Manages glucose levels
Improves health
Weight loss
Reduce insulin resistance
Enhance emotional health
Reduce cholesterol and triglycerides
before exercising, what should you do to avoid injury?
Wear proper footwear and examine feet before and after exercise
Consult with HCP before starting an exercise program if autonomic neuropathy present
Discuss the exercise with the ophthalmologist if retinopathy present
For a diabetic patient, what is an increased risk post-surgery?
- infection, delayed wound healing
- Risk of complications
Things to consider pre and post-surgery for a diabetic patient
Achieve optimal blood glucose control before surgery
Instructions regarding when to fast, medications to take, insulin adjustments
Preoperative blood glucose levels between 80 and 180 mg/dL
On the morning of surgery, reduce NPH by 50%, long-acting or basal pump by 60-80%
Premixed Regular/NPH not given when fasting
Check blood glucose every 4 to 6 hours while fasting
Patients with T1D are at risk for DKA if insufficient insulin given
Once oral intake resumes, regular dosing can begin
Lifespan Considerations Children and Adolescents specifically on glucose monitoring and insulin
Glucose monitoring
Before meals: 90-130 mg/dL
Bedtime/overnight: 90-159 mg/dL
Glycemic goals should be individualized
A1c goal <7.5%
Different targets because of erratic oral intake, activity
By age 6–8, most children can take some responsibility for blood glucose monitoring, insulin injection
Insulin
Exogenous insulin will be a lifelong requirement
Newly diagnosed children may go through the partial remission phase
Probably from the activation of remaining beta cells
Important to take insulin to preserve beta cells as long as possible
Lifespan Considerations for Pregnancy
Preconception counseling addressing
importance of glycemic control
Glycemic control is essential to reduce risks
Spontaneous abortion
Congenital anomalies
Preeclampsia
Intrauterine fetal demise
Macrosomia
Neonatal hypoglycemia
Neonatal hyperbilirubinemia
Target A1C in pregnancy: <6.5%
Changes in insulin dosages may be
necessary
Increased risk of diabetic retinopathy
Lifespan Considerations for Older Adults
Age is a risk factor for diabetes
More likely to die prematurely and have
functional disabilities
Muscle atrophy
Stroke
Cardiovascular events
Hypertension
Complex concerns
Risk for polypharmacy
Depression
Cognitive impairment
Urinary incontinence
Falls
Pain
Manifestations
May not include polyuria, thirst
Signs and symptoms of hypo-,
hyperglycemia is mistaken for other
conditions
Screening criteria
Same as other adults
Testing should start at age 45 and
repeated every 3 years
Increased risk for CV disease
Poorly controlled A1c, elevated
cholesterol and triglycerides and
hypertension
Assess for CV disease with every
encounter
For Nursing Process, what do we educate the patient about on Type 1 DM?
Time of diagnosis
Yearly appointments
Complications
Transitions in care
Focus
Self-management of medication, nutrition, exercise
Reduce the risk of complications
Achieve glycemic control
Promote positive mental health
For Diabetes, what should we observe during patient interviews?
Symptoms of diabetes
Knowledge of diabetes
Self-monitoring blood glucose level
Lifestyle habits
Change in weight, appetite, infections, healing
Problems with gastrointestinal (GI) function or urination
Altered sexual function
For Diabetes, what should we check during Physical Assessment?
Height–weight ratio
Vital signs: orthostatic blood pressure
Visual acuity
Sensory ability in extremities
Touch
Temperature
Vibration
Reflexes
Cranial nerves
Peripheral pulses
Skin and hair
what does ventilation consists of?
inspiration -> exchange of O2 exchanged for CO2
expiration -> Co2 expelled from body
What is respiration
the exchange of O2 and CO2 at the cellular level
the trachea is the entrance of…
air into the lungs
What is Eupnea
breathing within the EXPECTED resp. rates
alveoli is the site of…
gas exchange
visceral pleura
covers surface of each lung
function of parietal pleura
lines inside of chest wall
function of pleural space
the region between them
bronchial sounds sound like what?
loud, high-pitched
- longer on exhalation than inhalation
broncho-vesicular sounds sound like what?
medium in loudness and pitch, heard on each side of sternum, between scapulae
Vesicular sounds sound like what?
soft-low pitched
- heard over peripheral lung fields
the drive to breathe depends on the ___ in the arterial blood
CO2
HypoxEMIA leads to what?
Hypoxia
dyspnea relates to what 3 things
- tachypnea
- diaphoresis
- fluid in the lungs
What do ABGs tell you about the blood?
the pH
CO2 stimulates the ____ to breathe
DRIVE
Are retractions an early or late stage of hypoxia, what is cyanosis?
early, cyanosis is late
Sputum, inflammation, lung collapse, and fluid volume excess are examples of…
airflow in the alveolus being blocked
Blood clots, plaque buildup, and emphysema alveoli are examples of…
Blood flow in capillaries being blocked
tachypnea resp rate?
greater than 20
hyperventilation def
rapid, deep inhalation and exhalation of air from lungs
hypoventilation def
abnormally slow respiratory rate — inadequate o2 delivery to lungs
respiratory depression def
decrease in the rate and depth of breathing
bradypnea resp rate?
less than 10
resp. arrest characterized by…
apnea
Dyspnea
labored/respiratory breathing or SOB
orthopnea def
difficulty breathing when supine
Kussmaul breathing
- occurs in acidosis or alkalosis?
- metabolic acidosis (DKA)
- Deep-rapid breaths
- Inc. elimination of CO2 - affecting the acid-base balance
Cheyne-Stokes respiration done prior to what
Death
Biot Respiration
shallow breathing with periods of apnea
- occurs in CNS disorder
pneumothorax is when…
air enters pleural space and causes loss of negative pressure
- causes lung collapse
pneumothorax is treated with a…
Chest Tube
Factors affecting the heart’s ability to circulate blood
(3 things)
- Hypertension
- Atherosclerosis
- CHF
extra:
- obesity
- Type 2 diabetes
- Smoking
- Stress and Anxiety
tobacco smoking for resp causes 2 things…
- Increased mucus production
- Reduced cilia action in airway passages
Signs of hypoxia
- increased restlessness, irritability, unexplained sudden confusion
- Rapid heart rate + rapid resp. rate
wheeze = ?
= asthma
crackles = ?
fluid
Rhonchi =
= secretions in large airways
pleural friction rub = ?
friction pleural surfaces
asthma def
persistent inflammation of lungs
** how to prevent asthma **
modifying the home environment ***
- control dust
- remove carpet
- remove pets
- no smoking
common manifestations of asthma
coughing, wheezing, dif. breathing, chest tightness, mucus production, tachypnea, tachycardia, anxiety, stress
what is the status asthmaticus def
- Severe from of asthma that is prolonged
- untreated leads to coma, resp. failure, death.
Asthma diagnostic tests
PEFR - peak expiratory flow rate
- allergic asthma: scratch or patch testing, IgE testing
bronchodilators function
relax smooth muscles of the airway
pneumococcal or lobar pneumonia is abrupt or takes a while to develop?
Abrupt
