exam 4 presentaion first Flashcards
what do corticosteroids do
Glucocorticoids cause profound and varied metabolic effects and modify the body’s immune responses
Corticosteroids examples
Prednisone (PO) / methylprednisolone (IV) / hydrocortisone cream (topical)
what are corticosteroids used for
Used as replacement therapy in adrenal insufficiency (Addison’s)
various dermatologic, ophthalmologic, rheumatologic, pulmonary, hematologic, and gastrointestinal disorders
specific diseases corticoseroids
Endocrine disorders such as adrenocortical insufficiency
Rheumatic disorders such as rheumatoid arthritis
Collagen diseases such as systemic lupus erythematosus
Dermatologic diseases such as severe psoriasis
Allergic states such as contact dermatitis or drug hypersensitivity reactions
Ophthalmic diseases such as optic neuritis
Respiratory diseases such as asthma or COPD
Neoplastic diseases such as leukemia
good bad ugly corticosteroids
The Good:
Reduce inflammatory responses (suppressing
the immune system)
The Bad:
If stopped abruptly it cancause impaired stress response (HPA suppression)
The Ugly:Comes with great risks, adverse effects,and side effects
Corticosteroids Adverse & Side Effects
Osteoporosis / Fractures
Adrenal Suppression
-Development of Cushing’s syndrome
–Patients with adrenal disorders may develop altered corticosteroid secretion
Hyperglycemia & Diabetes
Cardiovascular Disease & Dyslipidemia
-Weight gain
Dermatological Events
-Thin, Fragile skin that bruises easily
- Poor wound healing
GI Events
-Peptic Ulcers
Emotional Disturbances
-Varying from euphoria, insomnia, mood swings, personality changes to severe
depression
Immunosuppression
-Increase the risk of Infection
- May mask some signs of infection, and new infections may appear during their
use.
risk factors corticosteroids
Diabetes
Dyslipidemia
Cerebrovascular Disease (CVA)
GI Disorders
Affective Disorders
Osteoporosis
Corticosteroids Teaching:
Never stop abruptly!!!–taper dose down gradually
Report adverse/side effects
Unusual swelling
Weight gain
Fatigue
Bone pain
Bruising
Non-healing sores
Visual/Behavioral disturbances
Report new signs of infection
Can cause immunosuppression making it difficult to detect signs of infection
what to monitor for corticosteroids and what diet
Monitor blood glucose levels
Can cause hyperglycemia
Eat diet high in protein, calcium, and potassium
ANTIDIABETICS
regulates what
Regulation of blood glucose levels by insulin and glucagon
what is glucose
Glucose is the preferred fuel for all body cells. The body derives glucose from the breakdown of
the carbohydrate-containing foods and drinks we consume.
where is glucose stored
Glucose not immediately taken up by cells for fuel can be stored by the liver and muscles as glycogen or converted to triglycerides and stored in the adipose tissue. Hormones regulate both the storage and the utilization of glucose as required
what receptors for glucose
Receptors located in the pancreas sense blood glucose levels, and subsequently, the pancreatic cells secrete glucagon or insulin to maintain normal levels.
INSULIN does what
Insulin facilitates the uptake of glucose into skeletal and adipose body cells. The presence of food in the intestine triggers the release of gastrointestinal tract hormones
insulin production
triggers insulin production and secretion by the beta cells of the pancreas. Once nutrient absorption occurs, the resulting surge in blood glucose levels further stimulates insulin secretion
insulin promotes and secreteion
insulin promotes triglyceride and protein synthesis.
The secretion of insulin is regulated through a negative feedback mechanism.
As blood glucose levels decrease, further insulin release is inhibited.
what cant happen wihtout insulin
Without insulin, glucose cannot enter cells
GLUCAGON why released
Receptors in the pancreas can sense the decline in blood glucose levels, such as during periods of fasting or during prolonged labor or exercise. In response, the alpha cells of the pancreas secrete the hormone glucagon
affects of glucagon
what does it stimulate
it stimulates glycogenolysis– liver convert stores of glycogen back into glucose. glucose is then released into the circulation for use by body cells.
It stimulates gluconeogenesis- liver take up amino acids from blood and convert into glucose.
It stimulates lipolysis, the breakdown of stored triglycerides into free fatty acids and glycerol.
g;ucose level a1c level
Glucose level
(Normal Range):
80-130 mg/dL
Target A1c level:
7%
type 1 diabetes
Autoimmune disease impacting the beta cells of the pancreas
Beta cells do not produce insulin
Administer synthetic insulin instead
Irreversible but treatable
Use insulin to treat
type 2 diabetes
Acquired
–Result of poor diet and inactivity
Body cells become resistant to the effects of insulin
Reversable/preventable with weight loss, physical activity, healthy diet
Treated with oral medications (first) after diet and exercise are not successful
May require insulin if uncontrolled and during hospitalizations d/t stress
95% of all diabetes is Type II
nursing process diabetes assess implent eval
Assessment:
Continuous monitoring for hypo- and hyperglycemia. This is low and high blood glucose levels.
Assess patients with presence of stress or infection d/t increased blood glucose levels
Implementation:
Follow agency policies/guidelines for safe insulin administration
Administer insulin at timed intervals in accordance with meal-times to prevent hypoglycemia
Understand onset and peak of medication
Response/intervene quickly with the presence of hypoglycemia (per protocol)
Report event to provider immediately
Report to next RN in shift report
Evaluation:
Assess hemoglobin A1c or glycohemoglobin every 3, 6, 9, or 12 months depending on provider recommendation
Target A1c is 7% (but vary according to age and health)
hypolgycemia
protocols
monitor
caution w/
doses
Requires IMMEDIATE treatment by the nurse
Follow healthcare agency protocols ((( 15g of rapid digested carbohydrates (if tolerated) —-4 oz of fruit juice—– If NPO, give dextrose 50% IV or glucagon IM)))
MONITOR PATIENT CLOSELY!!!! and Hypokalemia
Caution w/ patients on Beta-Blockers as they can develop low blood sugars without symptoms
Doses may need adjustment w/ exercise
hypergylcemia
Result of too much sugar in the bloodstream (>130mg/dL on at least 2 separate occasions)
s/s hyperglycemia
Polyuria - increased urination
Polydipsia – increased thirst
Polyphagia – increased hunger
Weight loss
Fatigue
Non-healing wounds
Frequent infections
Blurred vision
if left untreated hyperglycemia can lead to
Heart disease and stroke
Lack of circulation: amputations or slow healing wounds
Nephropathy: kidney deterioration
Neuropathy: nerve degeneration (numbness/tingling)
Retinopathy: blindness
Diabetic Ketoacidosis
Not enough insulin in the blood to move glucose into
cells. Instead, the liver breaks down fat for fuel, a
process that produces acids called ketones
s/s Diabetic Ketoacidosis
Blood glucose levels >300mg/dL
Blurred vision
Fruity breath
Kussmaul’s respirations (deep/labored – form of
hyperventilation)
Flushed, dry, warm skin
Develops over several days
Diabetic Ketoacidosis if left untreated
coma
death
what is a high alert medication
Insulin is a high-alert medication that can be associated with significant patient harm when used in error
commonely ascoted errors with insulin
administration of wrong insulin type
Improper dosing (underdosing or overdosing)
Dose omissions
Incorrect delivery devices
Wrong route (IM versus SubQ)
Improper patient monitoring
onset
the length of time insulin hits your
bloodstream and begins to LOWER the blood
glucose
peak
the time during which insulin is at its peak,
or working its best
duration
the amount of time the insulin continues to work.
Insulin Pens what are they
Self-administration, to facilitate safe and accurate self-administration of insulin
Pre-labeled with the product name and barcode (syringes of insulin run the risk of being unlabeled)
Individually labeled with the patient’s name (barcoded with patient information)
Ready for administration
Improves prep time (not having to draw up insulin)
Reduces waste of medication
insulin pump adv
ncreased flexibility
Easier to handle sick days
Precise insulin delivery in smaller amounts
Reduced blood sugar variability
Helps manage overnight and early morning blood
sugar variations
insulin pump disav
Costly
Must test blood glucose 4-6 times daily or use a continuous glucose monitor (CGM)
Must be willing to count carbohydrates
Understand physical activity and carb intake will
require dose adjustments
Understand s/s of hyper- and hypoglycemia
Frequent appts with MD or diabetic educator/NP
insulin adminstration
Pinch the skin and put the needle in at a 45º
angle. Needs to go into the fat layer of the
skin(if fat, might be able to go at 90 degree angle)
Push the needle all the way into the skin. Let
go of the pinched skin. Inject the insulin slowly
and steadily until it is all in.
Leave the syringe in place for 10 seconds
after injecting
cinsiderations w/ insulin admistration
what to keep away from and where not to put
Keep your shots 1 inch (2.5 centimeters, cm) away from scars and 2 inches (5 cm) away from the
navel.
Do not put a shot in a spot that is bruised, swollen, or tender.
Do not put a shot in a spot that is lumpy, firm, or numb (this is a very common cause of insulin not working the way it should).
Rotate sites to prevent lipodystrophy
rapid acting insulin examples
Insulin lispro (Humalog) / insulin aspart (Novolog) / Afrezza (inhaled)
rapid acting insulin moa
Lowers blood glucose by stimulating peripheral glucose uptake by skeletal muscle and fat and by inhibiting hepatic glucose production (replaces insulin / moves sugar)
rapid acting insulin indications
Rapid acting
Called prandial insulins because they are administered with meals, mimicking effects of insulin released w/ food intake
Individualized based on carbohydrate intake, premeal glucose levels, and anticipated activity
rapid acting insulin nursing considerations
Should be given 15 minutes before meal or with meal
Should appear clear and colorless, inspect before giving
rapid acting insulin adverse affects
Hypoglycemia
*Hypokalemia
Bronchospasms (Afrezza)
rapid acting insulin opd
o-15-30 min
p-1-3 hrs
d-3-5hrs
short acting insulin
Humulin R / Novolin R
short acting insulin moa
Regulation of glucose metabolism. Works by replacing the insulin that is normally produced by the body and by helping move sugar from the blood into other body tissues where it is used for energy
short acting insulin indications
Short-acting
Administered with meals, mimicking effects of insulin released w/ food intake
Individualized based on carbohydrate intake, premeal glucose levels, and anticipated activity
short acting insulin consdierations
Given subcutaneously
It is the only insulin that can be administered intravenously under close supervision of blood glucose and potassium levels.
short acting insulin adverse affecdt
Hypokalemia
Hypoglycemia
short acting insulin opd
o-3o min
p-3hrs
d-8hrs
intermediate acting insulin
Humulin N / Novolin N / NPH
intermediate acting insulin moa
Works by replacing the insulin that is normally produced by the body and by helping move sugar from the blood into other body tissues where it is used for energy
intermediate acting insulin indications
Intermediate-acting
Given once or twice daily
intermediate acting insulin nursong consdieratin
Only administer subcutaneously
Gently roll or invert vial/pen to resuspend insulin before giving
White and cloudy – understand how to draw up!!!
Can be mixed w/ short or rapid-acting insulin
intermediate acting insulin adverse
Hypokalemia
Hypoglycemia
intermediate acting insulin opd
Onset 1-2 hours
Peak 6 hours
Duration Up to 24 hours
long acting insulin
Insulin glargine (Lantus)
long acting insulin moa
Works by replacing the insulin that is normally produced by the body and by helping move sugar from the blood into other body tissues where it is used for energy
long acting insulin Indications
Long-acting
Given once daily (dose may be split for twice daily dosing)
long acting insulin Nursing Considerations
Administer subcutaneously
Inspect the bottle for discoloration or matter
DO NOT MIX WITH OTHER INSULINS!
long acting insulin adverse
Hypokalemia
Hypoglycemia
long acting insulin opd
Onset 3-4 hours
Peak none
Duration > 24 hours
Hypoglycemic
glucagon
glucagon moa
Increases blood glucose concentration during
an episode of hypoglycemia
glucagon indications
Treatment of severe hypoglycemia (low blood
sugar)
Injectable (given is unable to swallow
carbohydrates safely)
glucagon admisnted
Subcutaneous (SubQ)
Intramuscular (IM)
Intravenous (IV
glucagon peak
13-20 minutes after SubQ or IM injection
Sulfonylurea (Oral Antihyperglycemic) example
Glipizide
Glipizide moa
Stimulate the release of insulin from the pancreas & increases sensitivity at receptor cells
Glipizide considerations
peak onset
Peak onset of action is 1-3 hours after first dose
Glipizide pt educations
Take at the same time each day
Helps control hyperglycemia but does not cure diabetes
Instruct patient on s/s of hyper- and hypoglycemia
Do not drink alcohol, may cause disulfiram-like reaction
Glipizide adverse effects
Weight gain
Hypoglycemia
May be caused by NSAIDs and other highly protein bound drugs
Biguanide (Oral Antihyperglycemic)
Metformin
Metformin moa
Decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization
Metformin consdieratios
Contraindicated in patient’s w/ kidney disease
Metformin pt educ
Stop immediately w/ s/s of lactic acidosis
Malaise, myalgias, respiratory distress, increasing somnolence, abdominal
distress
Hold/stop if having radiologic study requiring iodinated contrast
Does not produce hypoglycemia
Take at the same time each day
May cause metallic taste in the mouth
Metformin adverse
Diarrhea, N/V, weakness, flatulence, indigestion, abdominal discomfort, and headache
Immediately hold w/ signs of hypoxemia, dehydration or sepsis
DPP-IV Inhibitor (Oral Antihyperglycemic)
Sitagliptin (Januvia)
Sitagliptin (Januvia) moa
Increases insulin production and decreases hepatic glucose overproduction by inhibiting dipeptidyl peptidase-4 (DPP-4) enzyme
Sitagliptin (Januvia) pt education
Take at the same time each day (can be taken w/ or w/o
food)
Helps control episodes of hyperglycemia but does not cure diabetes
Instruct patient on s/s of hyper- and hypoglycemia
STOP w/ hypersensitivity and follow-up with provider
Sitagliptin (Januvia) adverse
Can cause hypoglycemia
Synthesis/Release of Thyroid Hormones:
Thyroid hormone production is dependent upon iodine, forming T3 and T4
A negative feedback loop controls the regulation of thyroid hormone levels
.
Low blood levels of T3 and T4 stimulate the release of thyrotropin-releasing hormone (TRH) from the hypothalamus, which triggers secretion of TSH from the anterior pituitary.
High blood levels impair the secretion of TSH
Hypothyroidism
Low blood levels of thyroid hormones
* Caused by inflammation of thyroid gland
hypothroidism treatment
Long-term hormone replacement therapy
Levothyroxin
s/s hypothyroidism
Low metabolic rate / weight gain
Cold extremities
Constipation
Reduced libido
Menstrual irregularities
Reduced mental activity
hyperthyroidism
high levels of thyroid hormones
Caused by a pituitary or thyroid tumor
Graves’ disease
Result of an autoimmune reaction where antibodies
overstimulate the follicle cells of thyroid glan
hyperthyroidism treatment
Radioactive Iodine (RAI)
Thyroid surgery
Propylthiouracil (PTU
hyperthyroidism s/s
Increased metabolic rate / weight loss
Excessive body heat / sweating
Diarrhea
Tremors / Nervous agitation
Increased heart rate (palpitations)
Exophthalmos (bulging eyes)
Thyroid Replacement Medication
Levothyroxine
Levothyroxine moa
Synthetic T4 hormone
exerts the same physiologic effect as endogenous T4, thereby maintaining normal T4 levels when a deficiency is present.
Treatment for hypothyroidism
Levothyroxine consideations
Take with a full glass of water
Take 30 minutes before breakfast and at least 4 hours before or after drugs known to interfere with absorption (antacids, iron, calcium supplements). Single, daily dose
Levothyroxine pt education
Take at the same time each day
Serum thyroid levels will be monitored closely. Dose may be adjusted by provider.
Condition is not curable – requires lifelong treatment
.
Monitor and notify PCP with s/s of hyperthyroidism
Monitor weight and pulse regularly (due to risk of hyperthyroidism
Levothyroxine adverse afects
Over treatment may cause symptoms of hyperthyroidism with increased heart rate,
cardiac wall thickness,
and cardiac contractility that may precipitate angina or arrhythmias,
particularly in patients with
cardiovascular disease and in elderly patients.
Several drug-drug interactions
Antithyroid Medication
Propylthiouracil (PTU)
Propylthiouracil (PTU) moa
Medication used to treat hyperthyroidism or to control symptoms of hyperthyroidism in preparation for thyroidectomy or radioactive iodine therapy.
Inhibits the production of T4
Propylthiouracil (PTU) considerations
Given every 8 hours
May cause hypothyroidism, monitor TSH and T4 levels regularly
Propylthiouracil (PTU) pt eduation
If patient becomes pregnant, immediately notify PCP
Propylthiouracil (PTU) adverse affects
hypothyroidism
Liver Failure
Agranulocytosis (low neutrophil count)
Vasculitis (inflammation of blood vessels)
Fetal Harm
Radioactive Iodine (I-131 or RAI)Mechanism of Action
Pill or liquid given to destroy thyroid gland and
thyroid cancer cells
Radioactive Iodine (I-131 or RAI)* Considerations
Harmful to pregnant women and small children
Avoid / limit contact
Radioactive Iodine (I-131 or RAI)* Patient Education
Sleep in separate bed
Flush toilet 2-3 times daily
Increase fluid intake
Cover cough and dispose of Kleenex carefully
Radioactive Iodine (I-131 or RAI)* Adverse Effects
Hypothyroidism
Patient will likely need thyroid replacement
therapy
