TEST 2 Flashcards by lindsay mckenzie

DEFINITION: increased formation and secretion of urine

Diuresis

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DEFINITION: Abnormally low blood pressure that occurs when a person assumes a standing position from a sitting or lying position

Orthostatic hypotension

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DEFINITION: Abnormally high potassium concentration in the blood, most often because of defective kidney excretion, but it can also be due to excessive dietary potassium

Hyperkalemia

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DEFINITION: Gout (elevated uric acid); the arthritis caused by tissue buildup of uric acid crystals

Hyperuricemia

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DEFINITION: Abnormally low sodium concentration in the blood, caused by either inadequate excretion of water or excessive water in the bloodstream

Hyponatremia

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DEFINITION: The abnormal accumulation of fluid in interstitial spaces

Edema

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DEFINITION: An abnormal intraperitoneal accumulation of fluid (defined as a volume of 500 mL or greater) containing large amounts of protein and electrolytes

Ascites

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WHICH DRUG?

MECHANISM OF ACTION: Prevents reabsorption of sodium and water

loop diuretic (water pill): furosemide (LASIX)

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WHICH DRUG?

COMMON SIDE EFFECTS
Dehydration
Hypotension
Hypokalemia
Hyponatremia
Nausea, dizziness, and others

loop diuretic (water pill): furosemide (LASIX)

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WHICH DRUG?

DRUG INTERACTIONS

Aminoglycosides
Corticosteroids

loop diuretic (water pill): furosemide (LASIX)

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WHICH DRUG?

MECHANISM OF ACTION: Prevents reabsorption of sodium and water and prevents excretion of potassium

potassium-sparing diuretic: spironolactone

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WHICH DRUG?

COMMON SIDE EFFECTS
Hyperkalemia
Hyponatremia
Dehydration
Hypotension

potassium-sparing diuretic: spironolactone

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WHICH DRUG?

DRUG INTERACTIONS

Lithium
Angiotensin converting enzyme inhibitors
Potassium supplements

potassium-sparing diuretic: spironolactone

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WHICH DRUG?

MECHANISM OF ACTION: Prevents reabsorption of sodium and water and not as potent an action as with furosemide

Thiazide and Thiazide-Like Diuretics: hydrochlorothiazide

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WHICH DRUG?

COMMON SIDE EFFECTS
Hypokalemia
Hypotension
Hypovolemia
Hyponatremia

Thiazide and Thiazide-Like Diuretics: hydrochlorothiazide

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WHICH DRUG?

DRUG INTERACTIONS

Corticosteroids
Digoxin

Thiazide and Thiazide-Like Diuretics: hydrochlorothiazide

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WHICH DRUG?

RELATED NURSING DIAGNOSIS
Risk for injury related to possible fall from postural hypotension (a side effect of the diuretic)

Thiazide and Thiazide-Like Diuretics: hydrochlorothiazide

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WHICH DRUG?

MECHANISM OF ACTION: It produces an osmotic pressure in the glomerular filtrate, which, in turn, pulls fluid, primarily water, into the renal tubules from the surrounding tissues, resulting in diuresis

Osmotic Diuretics: MANNITOL

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WHICH DRUG?

COMMON SIDE EFFECTS
Headaches
Chest pains
Tachycardia
Blurred vision Chills
Fever

Osmotic Diuretics: MANNITOL

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Why is it dangerous to administer both a potassium supplement and agents such as spironolactone?

Spironolactone is a potassium-sparing diuretic. If it is given with a potassium supplement, the client could develop hyperkalemia, which could cause cardiac irregularities, and, if potassium levels are severely high, cardiac arrest could occur.

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Crystalloids are indicated in which conditions or disorders?

Crystalloids are substances in a solution that diffuse through a semi-permeable membrane. They are most commonly used as maintenance fluids, to promote urinary flow, and to replace body fluids when there are deficits. They are also used to manage fluid and electrolyte disturbances and treat shock, acute nephrosis, and acute liver failure.

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DEFINITION:
plasma proteins that increase the colloidal osmotic pressure and help move fluid from the interstitial compartment to the plasma compartment by pulling the fluid into the blood vessels.

Colloids

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___________ ___________ are administered either orally or through intravenous infusion but only if the intravenous dose is adequately diluted.

Potassium supplements

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Signs and symptoms of early _____________ include anorexia, lethargy, confusion, nausea, muscle weakness, and hypotension.

hypokalemia

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Normal serum potassium levels range from ____TO_____ mmol/L, and normal serum sodium levels range from ____TO_____ mmol/L.

3.5 to 5 135 to 145

________ __________ and packed _____ ___________ cells are currently the most commonly used oxygen-carrying resuscitation fluids.

Whole blood red blood

What type of caution would you give a client who is beginning treatment with a potassium-sparing diuretic?

Potassium-sparing diuretics are often combined with other types of diuretics to prevent hypokalemia. However, extreme caution should be used, and the client and his or her laboratory values should be monitored closely, especially if he or she is also taking potassium supplements or using a salt substitute. Hyperkalemia, which can be fatal if left untreated, may result.

Loop diuretics, which are very potent, work on the ascending loop of Henle to block ________ and ________ reabsorption.

sodium | chloride

Loop diuretics also block ________ reabsorption, resulting in diuresis and a reduction of preload and central venous pressure.

water

Loop diuretics also reduce peripheral resistance. With a decreased volume and a decreased peripheral resistance, _________ __________ also decreases.

blood pressure

______________ dehydration is caused by a loss of sodium and water from the body leading to a decrease in extracellular fluid (ECF) volume. Diarrhea, vomiting, or both are often causes.

Isotonic

______________ dehydration results when sodium loss is greater than water loss.

Hypotonic

The higher concentrations of solute inside the cells pull fluid from ___________ the cells (i.e., plasma and interstitial) into the cells.

outside

____________ dehydration is usually the result of renal insufficiency and inadequate aldosterone secretion.

Hypotonic

____________ dehydration occurs when water loss is more than sodium loss.

Hypertonic

____________ dehydration results in a concentration of solutes outside the cells and causes fluid in the cell to move outside the cell to the ECF; dehydration of the cells occurs.

Hypertonic

____________ dehydration usually occurs with fever accompanied by perspiration.

Hypertonic

______________ are fluids that supply water and sodium to maintain the osmotic gradient between extravascular and intravascular compartments.

Crystalloids

_____________ are generally used to maintain fluids for insensible fluid losses, to correct body fluid deficits, and to treat specific fluid and electrolyte disturbances.

Crystalloids

Examples are _____________ normal saline, hypertonic saline, D5W, Plasma-Lyte, and lactated Ringer’s.

Crystalloids

Other uses of _____________ include shock conditions, renal dialysis, burns, acute nephrosis, and cardiopulmonary bypass.

crystalloids

A _____________ is a large molecule or an aggregate of molecules that do not precipitate and are dispersed in another medium.

colloid

______________ are a substance in a solution that diffuses through a semi-permeable membrane.

Crystalloids

______________ solutions contain fluids and electrolytes normally found in the body.

Crystalloid

______________ do not contain proteins or colloids that are needed to maintain the colloid osmotic pressure to prevent water from leaving the plasma compartment.

Crystalloids

Compared to colloids, crystalloids are distributed ___________ into the interstitial and intracellular compartments, making them better for the treatment of _____________ than for expanding volume, as with hypovolemic shock.

faster | dehydration

_______________ cannot expand the plasma volume as well as the colloids because of the protein factor.

Crystalloids

The main purpose of ____________ is to remove excess water and sodium which relieves the symptoms associate with heart failure, hypertension and renal disease

diuretics

Diuretics act directly upon the __________ within the _____________ to accomplish removal of water and sodium

nephrons | kidneys

Which of the following laboratory values should the nurse assess to identify an adverse response to hydrochlorothiazide? a) Sodium levels b) Glucose levels c) Calcium levels d) Chlorine levels

b Hydrochlorothiazide can cause hyperglycemia.

Which of the following principles would the nurse use in teaching a patient why spironolactone (Aldactone) and furosemide (Lasix) are prescribed together? a) This combination prevents dehydration and hypovolemia b) This combination promotes diuresis but decreases the risk of hypokalemia c) Using two drugs increases osmolality of plasma and the glomerular filtration rate d) Moderate doses of two different types of diuretics are more effective than a large dose of one type

b Spironolactone (Aldactone) is a potassium-sparing diuretic; furosemide (Lasix) is a potassium-losing diuretic. Giving these together minimizes electrolyte imbalance.

For which of the following adverse effects will the nurse check the laboratory values of a patient who has started on furosemide (Lasix)? A Hypokalemia B Hypernatremia C Hyperchloremia D Hypophosphatemia

A Furosemide (Lasix) is a potent loop diuretic, resulting in the loss of potassium as well as water, sodium, and chloride.

A patient admitted to the hospital with pneumonia and a history of chronic renal insufficiency is ordered furosemide (Lasix) 40 mg twice a day. Which of the following rationales explains the reason for the furosemide order? A Will increase blood oxygen levels B Will not cause potassium loss C Is effective in treating persons with renal insufficiency D Is effective in treating persons with pulmonary congestion

C Furosemide (Lasix) is effective in patients with creatinine clearance as low as 25 L/min (normal 125 L/min).

Which of the following dietary recommendations would the nurse make to a patient taking spironolactone (Aldactone)? A Avoid foods high in sodium, such as apples B To reduce the risk for low blood sugar, eat squash daily C Avoid foods high in potassium, such as bananas D Iron will interfere with the drug’s action, so avoid liver

C Spironolactone (Aldactone) is a potassium-sparing diuretic that could potentially cause hyperkalemia. Bananas are high in potassium and thus should be avoided.

The nurse would question the use of mannitol (Osmitrol) in which of the following patients? A 21-year-old patient with head injury B 47-year-old patient with anuria C 67-year-old patient who ingested a poisonous substance D 55-year-old patient with generalized edema

B Mannitol (Osmitrol) is not metabolized but is excreted unchanged by the kidneys. Potential water intoxication could occur if mannitol is given to a patient without urine output and thus renal function.

``` Which of the following symptoms is directly related to hyporkalemia? A Dry mouth B Ataxia C Impotence D Abdominal cramps ```

D Muscle-related symptoms, such as abdominal cramps, are associated with hypokalemia.

Which of the following would be the nurse’s best response when a patient asks about taking potassium supplements while taking spironalactone (Aldactone)? A “I will call your doctor and let him know of your concern.” B “That is a question for the doctor; nurses don’t know this information.” C “I agree. I will suggest that the dietician add potassium-rich foods to your diet.” D “You are on a diuretic that is potassium sparing, so there is no need for extra potassium.”

D Spironalactone (Aldactone) is a potassium-sparing diuretic, and additional potassium ingestion would put the patient at risk for hyperkalemia.

``` The nurse would expect to administer which of the following diuretics to treat a patient diagnosed with primary hyperaldosteronism? A amiloride (Midamor) B furosemide (Lasix) C triamterene D spironolactone (Aldactone) ```

D Spironolactone (Aldactone) is the direct antagonist for aldosterone.

``` The nurse prepares to administer which of the following diuretics to treat a patient suffering from acute pulmonary edema? A amiloride (Midamor) B furosemide (Lasix) C triamterene D spironolactone (Aldactone) ```

B Furosemide (Lasix) is a potent, rapid-acting diuretic that would be the drug of choice to treat acute pulmonary edema. Amiloride, triamterene, and spironolactone are not potent enough to cause the strong diuresis necessary to treat acute pulmonary edema.

``` Which of the following therapeutic effects of mannitol (Osmitrol) would the nurse anticipate? A Rapid loss of potassium B Pulmonary edema C Decreased intracranial pressure D Decreased intracranial bleeding ```

C Mannitol (Osmitrol) is an osmotic diuretic that pulls fluid from extravascular spaces into the bloodstream to be excreted in urine. This will decrease intracranial pressure caused by cerebral edema.

Gwen, 90, lives in a long-term care facility. She is ambulatory and continent but requires direction for her activities of daily living. Her medical diagnoses include congestive heart failure and Alzheimer's disease. Gwen has a number of medications to treat her conditions, including digoxin (Lanoxin), furosemide (Lasix), and potassium supplements. What potassium serum level result indicates that Gwen's potassium supplement may not be adequate? A 3.1 mmol/L B 3.5 mmol/L C 4.2 mmol/L D 2.2 mmol/L

D Serum potassium levels less than 3.0 mmol/L indicate that additional potassium supplements are required.

Gwen, 90, lives in a long-term care facility. She is ambulatory and continent but requires direction for her activities of daily living. Her medical diagnoses include congestive heart failure and Alzheimer's disease. Gwen has a number of medications to treat her conditions, including digoxin (Lanoxin), furosemide (Lasix), and potassium supplements. What nursing action recognizes that Gwen is at risk for falls related to her diuretic therapy? A Restrain Gwen in a chair during waking hours B Change Gwen's transfer to a mechanical lift C Place a commode at Gwen's bedside at night D Put an incontinent device on Gwen for sleeping hours

C To minimize Gwen's risk for falling at night, a commode should be placed at her bedside.

1 The nurse is reviewing the medications that have been ordered for a patient who has received a new prescription for a loop diuretic. Which of the following may have a possible interaction with the loop diuretic? a. NSAIDs b. warfarin c. penicillins d. vitamin C

2 When monitoring laboratory test results for patients receiving loop and thiazide diuretics, which of the following must the nurse look for? a. Decreased serum glucose levels b. Increased serum levels of sodium c. Decreased serum levels of potassium d. Increased serum levels of potassium

3 When the nurse is checking the laboratory data for a patient taking spironolactone (Aldactone), which result would be a potential concern? a. Serum sodium level of 140 mmol/L b. Serum potassium level of 3.6 mmol/L c. Serum potassium level of 5.8 mmol/L d. Serum magnesium level of 0.8 mmol/L

4 Which of the following statements should be included in patient education for an 81-year-old female with heart failure who is taking daily doses of spironolactone (Aldactone)? a. “Avoid foods that are high in potassium.” b. “Be sure to eat foods that are high in potassium.” c. “A weight gain of 1–1.25 kg in 24 hours is normal.” d. “Change positions slowly because this drug causes severe hypertension-induced syncope.”

5 A patient with diabetes has a new prescription for a thiazide diuretic. Which statement should the nurse include when teaching the patient about the thiazide drug? a. “There is nothing for you to be concerned about when you are taking the thiazide.” b. “You should take the thiazide at night to avoid interactions with the diabetes medicine.” c. “Monitor your blood glucose closely because the thiazide may cause the levels to decrease.” d. “Monitor your blood glucose closely because the thiazide may cause the levels to increase.”

Describe the antihypertensive effects of loop diuretics in the treatment of hypertension.

Loop diuretics, which are potent, work on the ascending loop of Henle to block sodium and chloride reabsorption. Thus, they also block water reabsorption, resulting in diuresis and a reduction of preload and central venous pressure. These drugs also reduce peripheral resistance. With a decreased volume and a decreased peripheral resistance, blood pressure also decreases.

Which of the following would be the priority nursing intervention when administering intravenous potassium? A Administer potassium as a bolus over 10 minutes B Administer medication using an intravenous pump C Apply ice packs to the site of intravenous administration D Teach the patient and family signs and symptoms of hypokalemia

B Too rapid an infusion of potassium can cause cardiac arrhythmias. Therefore, an intravenous infusion pump must always be a used.

``` Which of the following signs and symptoms of overdose manifestations would the nurse monitor when planning administration of hypertonic saline solution to treat a patient with severe hyponatremia? A Confusion and seizures B Vomiting and diarrhea C Lethargy and hypotension D Flushed skin and increased thirst ```

D Flushed skin and increased thirst are signs and symptoms of hypernatremia. Confusion and seizures, vomiting and diarrhea, and lethargy and hypotension are signs and symptoms of hyponatremia.

A patient receiving a unit of red blood cells suddenly develops shortness of breath, chills, and a fever. What is the nurse’s best action? A Discontinue the infusion of packed cells B Reassure the client that this is an expected reaction C Notify the physician while a peer monitors the blood transfusion D Decrease the infusion rate and reassess the client in 15 minutes

A Shortness of breath, chills, and a fever are signs and symptoms of a blood transfusion reaction that could escalate to anaphylaxis. Therefore, it is a priority to immediately stop the blood transfusion.

``` Along with platelet transfusions, the nurse would expect to administer which of the following to increase deficient clotting factors? A Fresh frozen plasma B Albumin C Plasma protein factors D Whole blood ```

A Fresh frozen plasma is indicated to increase clotting factors in patients with a known deficiency. Albumin and plasma protein factors do not contain clotting factors. Although whole blood does contain the same ingredients as fresh frozen plasma, the amount of volume that must be administered to give the patient the necessary clotting factors may be prohibitive in a patient with renal insufficiency.

2 When preparing an intravenous solution that contains potassium, which of the following must the nurse know is a contraindication to the potassium infusion? a. Diarrhea b. Dehydration c. Serum potassium of 2.8 mmol/L d. Serum potassium of 5.6 mmol/L

3 Which of the following is a contraindication for albumin when assessing a patient who has an order for albumin administration? a. Heart failure b. Severe burns c. Acute liver failure d. Fluid-volume deficit

4 The nurse is preparing an infusion for a patient who has deficient clotting due to hemophilia. Which type of infusion will this patient receive? a. Albumin 5% b. Packed red blood cells c. Whole blood d. Fresh frozen plasma

5 While monitoring a patient who is receiving an infusion of 3% NS, which of the following should the nurse look for? a. Bradycardia b. Hypotension c. Fluid overload d. Decreased skin turgor

The five main types of diuretics are:

1. CAIs and loop, 2. osmotic, 3. potassiumsparing, 4. thiazide, 5. thiazide-like diuretics.

THE 4 most commonly used DIURETICS:

loop, potassiumsparing, thiazide, thiazide-like diuretics are

The nurse must remember that the loop diuretics are more ____________ than the thiazides, combination diuretics, and potassiumsparing diuretics.

potent

The two most commonly prescribed loop diuretics are ____________ and _____________.

furosemide | bumetanide

________________ is considered the prototypical thiazide diuretic and is used as adjunctive therapy to manage liver cirrhosis, edema, and heart failure.

Hydrochlorothiazide

Methods for monitoring for excess and deficit fluid volume states include THE FOLLOWING 4 ASSESSMENTS:

1. ASSESSMENT OF SKIN & MUCOUS MEMBRANES 2. PULSE RATE 3. INTAKE AND OUTPUT 4. DAILY WEIGHTS

Several days before transplant surgery, immunosuppressant therapy should begin by the _______ ___________, if at all possible, to help minimize the risk of ___________ that may be caused by _________ __________.

oral route infection intramuscular injections

This drug is used only for the prevention of liver and kidney transplant rejection.

tacrolimus

The primary immunosuppressant agent used in the prevention of kidney, liver, heart, and bone marrow transplant rejection.

cyclosporine

This drug is used with cyclosporine and corticosteroid therapy to prevent rejection of transplanted kidney grafts.

daclizumab

This drug is used as an adjunct medication to prevent rejection of kidney transplants and to treat severe rheumatoid arthritis.

azathioprine

This is the only immunosuppressant currently indicated for the treatment of multiple sclerosis. It reduces the frequency of MS relapses.

glatiramer acetate

Common side effects of ______________ include leukopenia, thrombocytopenia, and hepatotoxicity.

azathioprine

Cyclosporine is used in the prevention of ________ OF __________, such as with heart, liver, and kidney transplant.

rejection of organs

What laboratory studies should be done and monitored prior to the use of immunosuppressants.

Laboratory studies include hemoglobin, hematocrit, white blood cell, and platelet counts. Kidney and liver function studies should also be done

Which agents are used for prophylaxis of organ rejection?

IMMUNOSUPPRESSANTS

In general, by which of the following actions do immunosuppressants work? A Increasing antibody response B Suppressing T lymphocytes C Increasing natural killer (NK) cellular activity D Suppressing hepatic metabolism of steroids

B Immunosuppressants inhibit T lymphocyte synthesis, thus preventing an immune response to organ transplants.

``` Which of the following is an anticipated adverse effect of azathioprine (Imuran)? A Alopecia B Nausea C Tinnitus D Thrombocytopenia ```

D Common adverse effects of azathioprine (Imuran) include leukopenia, thrombocytopenia, and hepatotoxicity.

``` The nurse would anticipate administering which of the following medications to a patient demonstrating acute organ rejection? A sirolimus (Rapamune) B azathioprine (Imuran) C basiliximab (Simulect) D cyclosporine (Neoral) ```

D Cyclosporine (Neoral) is the primary immunosuppressant that is used to both prevent and treat organ rejection.

Before administering an immunosuppressant drug, the nurse should assess which of the following? A Hepatic enzymes B Blood urea nitrogen (BUN) and creatinine levels C Level of consciousness D All of the above

D Adverse reactions to immunosuppressants include neurotoxicity, renal toxicity, hepatotoxicity, and hypertension.

``` The nurse would teach a patient prescribed cyclosporine (Neoral) to avoid which of the following? A Sunscreen B Chocolate milk C Grapefruit juice D Acetaminophen ```

C Patients should avoid consuming grapefruit or grapefruit juice because they will increase the blood concentrations of cyclosporine. Sunscreen should be used to avoid photosensitivity, and the medication should be taken with food or chocolate milk to prevent gastrointestinal upset.

1 When assessing a patient who is to begin therapy with cyclosporine, which of the following patient conditions should the nurse recognize as one with which the drug must be used cautiously? a. Anemia b. Myalgia c. Glaucoma d. Kidney dysfunction

2 Which of the following would be a contraindication for glatiramer acetate? a. Acute myalgia b. Fluid overload c. Polycythemia d. Allergy to mannitol

3 During therapy with azathioprine (Imuran), which adverse effect must the nurse monitor for? a. Diarrhea b. Vomiting c. Bradycardia d. Thrombocytopenia

4 During a patient teaching session for a patient receiving an immunosuppressant drug, which statement should the nurse include? a. “You will remain on antibiotics to prevent infections.” b. “Be sure to take your medications with grapefruit juice to enhance its effects.” c. “It is better to use oral forms of these drugs to prevent the occurrence of thrush.” d. “It is important to use some form of contraception during treatment and for up to 12 weeks after the end of therapy.”

A 58-year-old recipient of a heart transplant is currently taking cyclosporine to prevent his immune system from rejecting his transplanted heart. How does cyclosporine prevent this patient's immune system from attacking his transplanted heart?

Cyclosporine works by inhibiting the activation of T cells by blocking the production and release of the cytokine mediator interleukin-2 (IL-2). This prevents IL-2 from attacking cells that appear to be foreign cells, such as cells of a transplanted organ.

Mr. G. is about to undergo a right lung transplant. Why should intramuscular injections be kept to a minimum during the time before his surgery?

Medications should be given orally if possible to prevent the risk of infection caused by altering the intact skin, which is the main means of protection and which provides a barrier to bacteria.

Patients taking immunosuppressants should be encouraged to avoid ____________ to minimize the risk for infection.

crowds

Patients should be educated about the adverse effects of _____________, which include headache and tremor, and advised to avoid consumption of grapefruit and grapefruit juice because of the potential for increase in blood concentrations.

cyclosporine

Patients who are to undergo transplant surgery and who are receiving cyclosporine should know that several days before surgery, they may be told to take it with ____________, and they may also be given an oral _______________ as prophylaxis for Candida infections.

corticosteroids | antifungal

_________________ decrease or prevent the body's immune response and include drugs such as azathioprine, cyclosporine, sirolimus, and tacrolimus.

Immunosuppressants

Nursing considerations include the possible administration of oral ________________ often given with immunosuppressants to treat oral ______________ that occurs as a result of immunosuppression and fungal overgrowth.

antifungals | candidiasis

WHAT KIND OF IMMUNIZING BIOLOGICAL? Antigenic (foreign) preparations of bacterial exotoxins

Toxoids

WHAT KIND OF IMMUNIZING BIOLOGICAL? - Detoxified with chemicals or heat - Weakened or “attenuated” (killed) - Cannot regress to a toxic form

TOXOIDS

WHAT KIND OF IMMUNIZING BIOLOGICAL? Suspensions of live, attenuated (weakened) or killed (inactivated) microorganisms

VACCINES

Vaccinations with live bacteria or virus provide ____________ immunity

lifelong

Vaccinations with killed bacteria or virus provide ____________ immunity, and ___________ shots are needed periodically

partial | booster

The amount of antibodies produced can be measured in the blood through a ___________ _________

antibody titre

THIS KIND OF IMMUNIZATION IS WHEN THE body is exposed to a relatively harmless form of an antigen (either weakened or dead)

ACTIVE IMMUNIZATION

LIVE VACCINATIONS given S/Q

Measles, mumps, and rubella virus vaccine

THIS KIND OF IMMUNIZATION IS WHEN serum or concentrated immune globulins from humans or animals are injected into a person

PASSIVE IMMUNIZATION

THIS KIND OF IMMUNIZATION IS WHEN the immune system is bypassed

PASSIVE

THIS KIND OF IMMUNIZATION IS short-lived, but it works more quickly

PASSIVE

THIS KIND OF IMMUNIZATION is naturally acquired passive immunity From mother to fetus through the placenta From mother to infant through breast milk

PASSIVE

2 Passive Immunization Drugs

Antitoxins | Immunoglobulins

INDICATIONS OF WHAT KIND OF IMMUNIZATION? - Prevents infection caused by bacterial toxins or viruses - Provides long-lasting or permanent immunity

ACTIVE

INDICATIONS OF WHAT KIND OF IMMUNIZATION? Provides quick immunity before a person’s own immune system has a chance to make antibodies (such as in cases of exposure to hepatitis B or rabies viruses)

PASSIVE

2 CONTRAINDICATIONS TO IMMUNIZATION

Drug allergy and allergy to egg products Febrile illness or temporary immunocompromised state (administration is best deferred until after recovery)

SERIOUS ADVERSE REACTIONS TO IMMUNIZATION

Fever higher than 39.4°C, encephalitis, convulsions, anaphylactic reaction, dyspnea, others

2 NURSING IMPLICATIONS TO GIVING IMMUNIZATIONS

1. Assess patient’s health history, medication history, allergies, pregnancy status 2. If discomfort occurs at the injection site, apply warm compresses and give acetaminophen

3 Key components to the Pandemic Preparedness and Response PLAN

1. Preparedness 2. Response 3. Recovery

You are caring for a 56 year old man who has recently been admitted because he is in a state of acute rejection of his transplanted heart which he received over a year ago. This client has been on cyclosporine, azathioprine, and prednisone at home and has now had muromonab added to help stop the acute rejection. There has been an outbreak of the influenza virus at your hospital. One of your co-workers suggests vaccinating your client with the flu vaccine that employees have been receiving. How should you respond to this co-worker?

Vaccines contain suspensions of live, attenuated, or killed micro-organisms that are used to promote artificially acquired immunity through activation of the injected individual’s immune system. If the injected individual’s immune system is pharmacologically immunosuppressed (and/or immunosuppressed because of a disease), then he or she cannot mount an antibody response to this foreign substance and runs the risk of actually acquiring the flu. This is especially true with vaccines other than those that are “killed” suspensions because the compromised or even the “aged” immune system could react with the non-killed forms of vaccines. Some immunizing agents are best deferred until after recovery from a febrile illness or temporary immunocompromised state (e.g., after cancer chemotherapy, and in this scenario, the client’s immune system has become compromised from the antirejection drugs). So you need to educate your colleague regarding the above scenario and share your knowledge and information (current drug references, pharmacist) with him or her.

What are the implications of not having a child properly immunized?

If not properly immunized, children are at risk for the diseases that are covered by the vaccines. Immunizations help produce dramatic declines in the transmission of these infectious, communicable diseases. All risks and benefits should be explained to every child advocate, parent, or legal guardian.

What impact have the changes to Canadian immunization schedules had on clients?

Healthcare reform has been invaluable to the goal of having every child immunized throughout the country Ontario is the only jurisdiction in North America to make the influenza vaccine available free to all residents.

Varicella infections occur mostly in which group(s) of people?

primarily occurs in children less than 8 years of age OR in individuals with compromised immune systems,

Explain the reasoning behind the use of the live oral poliovirus vaccine.

Live oral poliovirus vaccine (OPV) should be reserved for mass vaccination campaigns in developing countries to control outbreaks of paralytic polio. It results in increased herd immunity but can cause vaccine associated paralytic polio VAPP

List the side effects of immunizing agents.

``` fever, adenopathy, minor rash, soreness at the injection site, arthritis, urticaria, fever greater than 39°C, encephalitis, convulsions, peripheral neuropathy, unconsciousness, dyspnea, and cyanosis. ```

Rh0(D) immune globulin is indicated for what type of condition?

Rh0(D) immune globulin is indicated for postpartum antibody suppression

If a bite occurs from an animal suspected of rabies, what is the schedule for immunization?

a total of five 1 ml intramuscular injections on days 0, 3, 7, 14, and 28 following an animal bite when there is concern for rabies transmission (bites from any animal whose rabies immunization status is unknown or when the animal escapes and cannot be observed for signs of rabies).

Which of the following statements most accurately describes the pharmacodynamics of vaccines? A Vaccines provide passive immunity B Vaccines work by suppressing immunoglobulins C Vaccines work by stimulating the humoral immune system D Vaccines prevent the formation of antibodies against a specific antigen

C Vaccines work by stimulating the humoral immune system, which synthesizes immunoglobulins. They also stimulate the formation of antibodies against their specific antigen, providing active immunity.

``` Which of the following would the nurse monitor for when administering vaccinations? A Myalgias B Anaphylaxis C Pain at the injection site D Signs and symptoms of infection ```

B Anaphylaxis is a potential life-threatening adverse reaction to vaccines. Pain and myalgias can occur but are not life threatening.

Which of the following instructions is important for patients receiving tetanus toxoid to receive? A To increase fluid and fibre in diet to prevent constipation B That soreness at injection site is a common reaction C That they will have a lifetime immunity from this injection D That this medication must be repeated weekly for 4 weeks.

C Myalgia at the injection site is a common adverse effect of tetanus toxoid.

Which of the following statements is true of the human papillomavirus (HPV) vaccine (Gardasil)? A It is recommended for all prepubescent adolescents B It is useful in preventing cervical cancer C Most women have passive immunity and do not require the vaccine D It is only indicated for women who have abnormal pap smear results

B The human papillomavirus is responsible for a large proportion of cervical cancers.

Canadian pandemic preparedness planning is focused on which of the following types of pandemic? A Anthrax B Methicillin-resistant Staphylococcus aureus (MRSA) C Influenza D Hepatitis

C A type of influenza pandemic is suspected in the near future, and Canadian efforts are designed to prepare the public in terms of immunity through vaccinations.

1 When assessing a patient who will be receiving a passive immunizing drug, which condition will the nurse consider to be a possible contraindication? a. Anemia b. Pregnancy c. Ear infection d. Common cold

2 When giving a vaccination to an infant, which adverse effect should the nurse tell the mother to expect? a. Chills b. Dyspnea c. Fever over 39.4°C d. Soreness at the injection site

3 After a suspected hepatitis B exposure, prophylactic doses of which of the following would be given to the individual? a. Immune serum globulin b. Hepatitis B virus vaccine c. Hepatitis B immune globulin d. Rh0(D) immune globulin

4 During a routine checkup, a 72-year-old patient is advised to receive an influenza vaccine injection. He questions this, saying, “I had one last year. Why do I need another one?” What is an appropriate response from the nurse? a. “The effectiveness of the vaccine wears off after 6 months.” b. “When you reach age 65, you need boosters on an annual basis.” c. “Taking the flu vaccine each year allows you to build your immunity to a higher level each time.” d. “Each year a new vaccine is developed on the basis of flu strains that are likely to be in circulation.”

is the process in which a complete and long-lasting immunity to infection develops because the body is exposed to a disease antigen. It can be a natural immunization (having the disease) or an artificial immunization (having received a vaccine or toxoid). 

Active immunization

is the process in which substances that contain antibodies or antitoxins that can kill or inactivate pathogens by binding to their antigens are administered. These substances are directly injected into a person (host), and they provide that host with the means to fend off infection, bypassing the host’s own immune system. This is not a long-term type of immunity.

Passive immunization

____________ and ____________ are synthetic chemicals that are structurally similar to ADH (Antidiuretic hormone)

vasopressin | desmopressin

Somatropin and somatrem are the two __________ _____________ products that are made through recombinant measures.

growth hormone

Your client is excited that he is beginning therapy with pituitary agents and is positive about a cure. What would be your most appropriate response and why?

After the client has spoken with the physician, and with others involved in his or her care, about the disease and its symptomatic treatment, you would need to explain to the client that the use of pituitary agents does not produce a cure. These agents provide symptomatic improvement, such as normal fluid volume and electrolyte status and a positive body image. Suggest and encourage support groups and psychotherapy if the client is distressed enough to require this type of supportive regimen.

The target of the adrenocorticotropic hormone is the ____________ gland.

adrenal

Growth hormone regulates ____________ and __________ processes and promotes skeletal and muscle ___________.

growth anabolic growth

Antidiuretic hormone has the function of increasing water _____________. It concentrates the urine and causes potent _______________.

reabsorption | vasoconstriction

______________ mimics the antidiuretic hormone.

Vasopressin

______________ targets mammary glands, stimulates the ejection of milk, and contracts uterine smooth muscle.

Oxytocin

The contraindications for ________________ are in people whose bones have not stopped growing and a client who has any evidence of an active tumour.

somatropin

``` In which of the following conditions is somatropin (Humatrope) contraindicated? A Dwarfism B Acromegaly C Hypopituitarism D Addison’s disease ```

B Somatropin (Humatrope) is a synthetic form of growth hormone. Acromegaly is caused by excessive growth hormone, and thus this drug would be contraindicated.

``` Which of the following would be a priority nursing diagnosis for a client receiving desmopressin (DDAVP)? A Potential for injury B Alteration in comfort C Alteration in fluid volume D Knowledge deficit ```

C Desmopressin (DDAVP) is a form of antidiuretic hormone, which increases sodium and water retention, leading to an alteration in fluid volume. Although the nursing diagnoses of potential for injury, alteration in comfort, and knowledge deficit may be appropriate, they are not a priority using Maslow’s hierarchy of needs.

``` Which of the following would the nurse monitor to assess the therapeutic effectiveness of vasopressin (Pressyn)? A Relief of pain B Serum albumin levels C Urine specific gravity D Reduced inflammation ```

C Vasopressin (Pressyn) causes decreased water excretion in the renal tubule, thus increasing urine specific gravity. It is used to treat diabetes insipidus, which presents with a low urine specific gravity.

Patients should be encouraged to avoid abrupt _______________ of pituitary drugs because of the negative impact on pituitary hormones and the impact on blood levels of the hormones.

discontinuation

Pituitary drugs are used to either ___________ or ______________ the action of endogenous pituitary hormones.

mimic | antagonize

Drugs that ___________ the action of endogenous pituitary hormones include cosyntropin, somatropin, vasopressin, and desmopressin.

mimic

Drugs that _______________ the actions of endogenous pituitary hormones include octreotide, which suppresses or inhibits certain symptoms related to carcinoid tumours.

antagonize

somatropin is a(n) __________ pituitary drug

vasopressin (Pressyn) and desmopressin (DDAVP) are __________ pituitary drugs

posterior

THE FOLLOWING ARE USES OF WHAT KIND OF DRUGS? - Diagnostic aids to determine hypofunction or hyperfunction of a specific hormonal function - Replacement therapy to make up for hormone deficiency

PITUITARY

WHAT PITUITARY DRUG? - Are recombinantly made growth hormones (GH) - Stimulate skeletal growth in patients with deficient GH, such as hypopituitary dwarfism - AIDS wasting syndrome

somatropin (Humatrope) and somatrem

WHAT PITUITARY DRUG? | Carcinoid tumours secrete vasoactive intestinal polypeptide (VIP)

octreotide (Sandostatin)

WHAT PITUITARY DRUG? - Used in the treatment of diabetes insipidus - Used in the treatment of various types of bleeding, especially gastrointestinal (GI) bleeding - Used for bed wetting

vasopressin (Pressyn) and desmopressin (DDAVP)

desmopressin (DDAVP) and vasopressin (Pressyn) should ___________ severe thirst and ____________ urinary output

reduce | decrease

3 The nurse is reviewing the medication list for a patient who will be starting therapy with somatropin. Which drug has effects that need to be addressed before the patient starts this new drug? a. Penicillin b. Thyroid hormones c. Antidepressant therapy d. NSAID therapy for arthritis

5 When monitoring the therapeutic effects of intranasal desmopressin in a patient who has diabetes insipidus, which assessment would the nurse look for as an indication that the medication therapy is successful? a. Decreased thirst b. Decreased diarrhea c. Improved nasal patency d. Increased insulin levels

Your client has been taking thyroid agents for about 16 months and has recently noted palpitations and some heat intolerance. Should you be concerned about this or is this a fairly benign reaction to thyroid replacement? Explain your answer.

Yes, you should be concerned. Increased pulse rate, palpitations, chest pain, irritability, nervousness, heat intolerance, and increased sweating may indicate excessive amounts of thyroid supplements and the need for a reduction in dosage by the physician.

Levothyroxine may be safely interchanged with other agents without any concern to the client. True or false?

False. It is recommended that clients not switch agents to avoid a variance in therapeutic effects and adverse effects.

Propylthioruracil is used for ______________

hyperthyroidism.

Omitting doses of thyroid hormone could possibly result in _________________

hypothyroidism.

Too much _______________ hormone may result in depression, constipation, loss of appetite, weight gain, cold intolerance, syncope, nervousness, irritability, and tachycardia.

thyroid

Drug interactions associated with ____________ hormones include other antithyroid medications, oral anticoagulants, digitalis glycosides, cholestyramine, hypoglycemic agents, and epinephrine.

thyroid

Radioactive iodine (131I) works by destroying the ___________ ___________ and is used to treat thyroid ____________.

thyroid gland | cancer

WHAT THYROID CONDITION? Caused by hyposecretion of thyroid hormone during youth Characterized by low metabolic rate, retarded growth and sexual development, possibly mental retardation Identified in newborn screening with heel stick

CRETINISM

WHAT THYROID CONDITION? Characterized by decreased metabolic rate, loss of mental and physical stamina, weight gain, loss of hair, firm edema, yellow dullness of the skin - Underactive thyroid = slug

Myxedema

A _____________, an enlargement of the thyroid gland, may result from overstimulation by elevated levels of TSH

goitre

WHICH Thyroid Augmentation Drug? | Synthetic thyroid hormone T4

levothyroxine (Eltroxin, Euthyrox, Synthroid)

TRUE OR FALSE? THYROID DRUGS CAN BE INTERCHANGED FREELY.

FALSE

________________ is the preferred thyroid augmentation drug because its hormonal content is standardized; therefore, its effect is predictable

levothyroxine

TOO MUCH thyroid augmentation MEDS LEAD TO WHAT ADVERSE EFFECT?

HYPERTHYROIDISM-LIKE SYMPTOMS | OPPOSITE OF SLUG

The metabolism of many drugs is affected by the altered body metabolism of hypothyroid states. Consequently, dosages of many drugs may need to be ______________

adjusted

Thyroid drugs increase the degradation of vitamin K–dependent ______________ factors

clotting

levothyroxine can increase requirements for ____________ and _____________

INSULIN | digoxin

IF SOMEONE TAKES _______________ MEDS, THEY MAY NEED HIGHER SYNTHROID DOSES TO GET TO OPTIMAL LEVELS

SEIZURE

WHICH THYROID DRUG HAS A REALLY LONG Half-life: of 9 to 10 days

levothyroxine sodium (Eltroxin, Euthyrox, Synthroid)

Which of the following statements demonstrates understanding of discharge medications for a patient receiving levothyroxine (Eltroxin)? A “I will double my dose if I gain more than 0.45 kg per day.” B “I can expect to see relief of my symptoms within 1 week.” C “It is best to take the medication on an empty stomach.” D “I will take this medication in the morning so as not to interfere with sleep.”

D Levothyroxine (Eltroxin) increases basal metabolism and thus wakefulness.

``` With which of the following manifestations would the nurse suspect excessive thyroid replacement in a patient taking levothyroxine (Eltroxin)? A Irritability B Bradycardia C Weight gain D Intolerance to cold ```

A Irritability is a symptom of hyperthyroidism. Irritability is an indication of levothyroxine (Eltroxin) toxicity.

``` Patients taking levothyroxine (Eltroxin) and warfarin (Coumadin) should be monitored for which of the following? A Cardiac arrhythmias B Excessive weight loss C Increased risk of bleeding D Increased risk of deep vein thrombosis ```

D Levothyroxine (Eltroxin) can compete with protein-binding sites of warfarin (Coumadin), allowing more warfarin to be unbound (or free), thus increasing effects of warfarin and risk of bleeding.

A patient receiving propylthiouracil (PTU) asks the nurse to explain the connection between the medication and his symptoms. What is the nurse’s best response? A “PTU helps your thyroid gland use iodine and synthesize hormones better.” B “PTU inhibits the formation of new thyroid hormone, thus gradually returning your metabolism to normal.” C “PTU inactivates any circulating thyroid hormone, thus decreasing signs and symptoms of hyperthyroidism.” D “PTU stimulates the pituitary gland to secrete thyroid-stimulating hormone (TSH), which inhibits the production of hormones by the thyroid gland.”

B Propylthiouracil (PTU) is an antithyroid medication used to treat hyperthyroidism. It works by inhibiting the synthesis of new thyroid hormone. It does not inactivate present hormone.

``` Which of the following foods should the nurse teach patients taking antithyroid medications to avoid? A Milk B Eggs C Seafood D Chicken ```

C Seafood contains high amounts of iodine and regular consumption could lead to toxicity.

Which of the following statements demonstrates patient understanding of radioactive iodine (I-131) therapy? A “I will need to take this drug on a daily basis for at least 1 year.” B “This drug will help decrease my cold intolerance and weight gain.” C “I will have to isolate myself from my family for 1 week so as not to expose them to radiation.” D “This drug will be taken up by the thyroid gland and destroy the cells to reduce my hyperthyroidism.”

D Radioactive iodine is an antithyroid medication that is administered orally for one or two doses only. It concentrates in the thyroid gland, enabling the radiation to destroy the hyperplastic cells.

``` When assessing for potential toxicity to propylthiouracil, the nurse will monitor the patient for changes in which of the following laboratory tests? A Complete blood count (CBC) B B-type natriuretic peptide (BNP) C Liver enzymes D Renal function tests ```

A Several blood dyscrasias, including thrombocytopenia and leukopenia can occur, with antithyroid drugs. A CBC is the blood test to monitor thrombocyte (platelet) and white blood cell counts.

Which patient statement indicates that drug treatment for hypothyroidism is effective? A “My heart has stopped palpating.” B “I feel more optimistic and not gloomy all the time.” C “I am sleeping better and feel rested.” D “My menstrual periods have returned.”

B A symptom of hypothyroidism is depression. Therefore, effective hormone replacement should elevate the patient’s affect.

Thyroxine (T4) and triiodothyronine (T3) are the two hormones produced by the ____________ gland; thyroid hormone is made by iodination and coupling with the amino acid tyrosine

thyroid

Thyroid ___________ is generally done carefully by a health care provider, with frequent monitoring of serum levels until there appears to be stabilization. Nurses must monitor and review laboratory values to be sure that serum levels are within normal limits to avoid possible _____________.

replacement | toxicity

Hyperthyroidism is caused by ___________ secretion of thyroid hormone from the thyroid gland and may be attributed to different diseases (Graves' disease, Plummer's disease, and multinodular disease) or drugs.

excessive

Patients should report the occurrence of excitability, _____________, or anxiety to their health care provider because these symptoms may indicate _____________ toxicity.

irritability | levothyroxine

1 When monitoring the lab values of a patient who is taking antithyroid drugs, which of the following should the nurse know to watch for? a. Decreased blood urea nitrogen b. Increased platelet counts c. Increased blood glucose levels d. Decreased white blood cell counts

2 The pharmacy has called a patient to notify her that the current brand of thyroid replacement hormone is on back order. The patient calls the clinic to ask what she should do. What is the best response by the nurse? a. “You should stop the medication until your current brand is available.” b. “Go ahead and take the other brand that the pharmacy has available for now.” c. “You can split the thyroid pills that you have left so that they will last longer.” d. “Let me ask your physician what should be done; we will need to watch how you do if you switch brands.”

3 When assessing the older adult patient, which of the following nonspecific symptoms of hypothyroidism should the nurse look for? a. Leukopenia, anemia b. Weight loss, dry cough c. Loss of appetite, polyuria d. Cold intolerance, depression

4 To help with the insomnia associated with thyroid hormone replacement therapy, which of the following should the nurse encourage the patient to do? a. Take the dose first thing in the morning. b. Use a sedative to assist with falling asleep. c. Reduce the dosage as needed if sleep is impaired. d. Take one half the dose at lunch time and the other half 2 hours later.

5 The nurse is teaching a patient who has a new prescription for thyroid hormone. Which adverse effect should the patient notify the physician of? a. Anxiety b. Headache c. Palpitations d. Appetite changes

form of hyperthyroidism that can be precipitated by stress, or by an infection, or by the sudden withdrawal of thyroid hormones (owing to a thyroidectomy or an abrupt withdrawal of antithyroid drugs).

THYROID STORM

DEFINITION: A type of glucose intolerance that develops during pregnancy.

gestational

DEFINITION: The hormone that stimulates the conversion of glycogen to glucose.

glucagon

DEFINITION: In hypoglycemia, the blood glucose level is less than ____.

2.8 mmol/L

DEFINITION: The condition in which the blood glucose level is greater than 7 mmol/L.

hyperglycemia

DEFINITION: An eye disorder resulting from long-term uncontrolled diabetes.

retinopathy

DEFINITION: Inflammation or degeneration of the peripheral nerves resulting from long-term uncontrolled diabetes.

neuropathy

DEFINITION: This type of diabetes most commonly occurs in children or adolescents.

type 1

DEFINITION: This type of diabetes is the most common form.

TYPE 2

DEFINITION: A rapid-acting insulin.

lispro insulin

DEFINITION: A long-acting insulin.

insulin glargine

DEFINITION: A second-generation sulphonylurea used as an oral antidiabetic agent.

gliclazide

DEFINITION: An oral antihyperglycemic agent that increases the sensitivity of peripheral tissue to insulin.

metformin

DEFINITION: Chronic excessive intake of water.

polydipsia

DEFINITION: Excessive eating.

polyphagia

DEFINITION: A severe metabolic complication of uncontrolled type 1 diabetes.

diabetic ketoacidosis

Signs and symptoms of _____________ include restlessness, hunger, irritability, nervousness, tachycardia, shakiness, pallor, sweating, headache, confusion, and memory difficulties.

hypoglycemia

Common causes of ______________ include too much medication or medication administered at the wrong time; delayed, missed, or inadequate food intake; increased activity/exercise; and alcohol ingestion.

hypoglycemia

Clients with _________ __________ should avoid alcohol consumption because alcohol is broken down in the body to simple carbohydrates, which leads to increases in blood glucose. In addition, alcohol can increase insulin’s ____________ effects.

diabetes mellitus | hypoglycemic

Oral hypoglycemics may be used in type 1 diabetes at any time during treatment. True or false?

False. In order for the oral agents to work there must be functioning beta cells in the pancreas. Clients who are insulin dependent do not have any functioning beta cells.

___________ ___________ insulin dosing is a method in which regular insulin doses are adjusted according to blood glucose test results at regular intervals during the day.

Sliding scale

3 main symptoms of Diabetes Mellitus

Polyuria - PEEING Polydipsia - THIRST Polyphagia - HUNGER

TYPE 1 OR TYPE 2 DIABETES? - characterized by a lack of insulin production or the production of defective insulin - affected patients need exogenous insulin

TYPE 1

TYPE 1 OR TYPE 2 DIABETES? - most common type of diabetes mellitus - caused by insulin deficiency and insulin resistance

TYPE 2

2 Major Long-Term Complications of Diabetes Mellitus

1. Macrovascular (atherosclerotic plaque) Coronary arteries Cerebral arteries Peripheral vessels 2. Microvascular (capillary damage) Retinopathy Neuropathy Nephropathy

``` WHICH ACUTE DIABETIC COMPLICATION: Extreme hyperglycemia Presence of ketones in the serum Acidosis Dehydration Electrolyte imbalances Leads to coma and death if not treated ```

Diabetic ketoacidosis

Fasting plasma glucose (FPG) levels MORE THAN ________ mmol/L but less than ________ mmol/L may indicate “prediabetes”

6 | 6.9

Treatment for Diabetes Mellitus - TYPE 1?

INSULIN THERAPY

Treatment for Diabetes Mellitus - TYPE 2?

- Lifestyle changes - Oral drug therapy - Insulin when the above no longer provide glycemic control

WHICH KIND OF INSULIN? - Have a rapid onset of action (10 to 15 minutes) - CLEAR - MAKE SURE FOOD IS AVAILABLE - Have a shorter duration of action ``` Include: insulin aspart (NovoRapid) insulin lispro (Humalog) insulin glulisine (Apidra) ```

Rapid-acting insulins

WHICH KIND OF INSULIN? - Onset of 30 to 60 minutes - regular insulin (Humulin R, Novolin ge Toronto) - The only insulin product that can be given by IV bolus, IV infusion, or even intramuscularly

Short-acting insulins

WHICH KIND OF INSULIN? - insulin isophane, also called NPH (Humulin-N, Novolin ge NPH) - Has a CLOUDY appearance - Is slower in onset and has a more prolonged duration than endogenous insulin

Intermediate-acting

EXMPLE OF COMBINATION INSULIN PRODUCT

regular insulin 30% and NPH 70% (Humulin 30/70;

DEFINITION: Subcutaneous short-acting or regular insulin doses are adjusted according to blood glucose test results

Sliding-Scale Insulin Dosing

TRUE OR FALSE? Oral antidiabetic drugs may not be effective unless the patient also makes behavioural or lifestyle changes

TRUE

WHICH Oral Antidiabetic Drug? First generation: chlorpropamide (Novo-Propamide), tolbutamide Second generation: glyburide (Diabeta, Euglucon, generic)

Sulfonylureas

WHICH Oral Antidiabetic Drug? metformin (Glucophage) Should be first-line therapy

Biguanides

WHICH Oral Antidiabetic Drug? also known as glitazones pioglitazone (Actos), rosiglitazone (Avandia)

Thiazolidinediones

Mechanism of Action: Sulfonylureas (GLIBURIDE) - Stimulate insulin secretion from the ________ cells of the ___________, thus increasing insulin levels - Result: lower blood glucose levels

beta | pancreas

Mechanism of Action: Biguanides (METFORMIN) - ____________ production of glucose - Do not increase insulin secretion from the ____________ - Make you produce ________ blood sugar

Decrease pancreas less

Mechanism of Action: Thiazolidinediones (AVANDIA) Decrease insulin ______________ Are referred to as insulin-____________ drugs

resistance | sensitizing

Mechanism of Action: ALPHA-glucosidase inhibitors | Must be taken with ___________ to prevent excessive postprandial blood glucose elevations

meals

2 CONTRAINDICATIONS TO ORAL DIABETIC DRUGS:

- Severe liver or kidney disease | - Active hypoglycemia

ADVERSE EFFECTS: Sulfonylureas

Hypoglycemia, hematological effects, nausea, epigastric fullness, heartburn, many others

ADVERSE EFFECTS: metformin (Glucophage)

Primarily affects gastrointestinal (GI) tract: abdominal bloating, nausea, cramping, diarrhea, feeling of fullness

metformin Does not cause _______________

hypoglycemia

ADVERSE EFFECTS: Thiazo’liverd’inediones

hepatic toxicity—monitor liver alanine aminotransferase (ALT) levels

DEFINITION: Abnormally low blood glucose level (below 2.8 mmol/L)

HYPOGLYCEMIA

SYMPTOMS OF HYPOGLYCEMIA

Confusion, irritability, tremor, sweating

TRUE OR FALSE? | When drawing up two types of insulin in one syringe, always withdraw the regular or rapid-acting insulin first

TRUE

TRUE OR FALSE? | metformin is on an empty stomach

FALSE | taken with meals to reduce GI effects

TRUE OR FALSE? | alpha-glucosidase inhibitors are given with the first bite of each main meal

TRUE

WHAT ARE THE NURSING ACTIONS If hypoglycemia occurs:

Give glucagon Have the patient eat glucose tablets or gel, corn syrup, honey, fruit juice, or nondiet soft drink Have the patient eat a small snack such as crackers or half a sandwich

``` Which rapid-acting insulin starts working in less than 15 minutes after administration? A insulin lispro (Humalog) B insulin glargine (Lantus) C regular insulin (Humulin-R) D insulin detemir (Levemir) ```

A Insulin lispro (Humalog) is a rapid-acting insulin. Insulin glargine (Lantus) and insulin detemir (Levemir) are long acting. Regular insulin (Humalin-R) is short acting.

``` Which new long-acting insulin mimics natural, basal insulin with its duration of 24 hours? A insulin lispro (Humalog) B insulin glargine (Lantus) C regular insulin (Humulin-R) D insulin detemir (Levemir) ```

B Insulin glargine (Lantus) has a duration of action of 24 hours with no peaks, mimicking the natural, basal insulin secretion of the pancreas.

``` Which insulin is used for continuous intravenous infusions? A insulin lispro (Humalog) B insulin glargine (Lantus) C regular insulin (Humulin-R) D insulin detemir (Levemir) ```

C Regular insulin (Humulin-R) is the only insulin used for intravenous therapy.

``` Into which of the following sites should insulin be injected for the most consistent absorption? A Arm B Thigh C Abdomen D Buttocks ```

C The abdomen has the most consistent absorption because the blood flow to the subcutaneous tissue typically is not as affected by muscular movements as it could be in the arm or thigh; therefore, it should be used for insulin injection.

``` Assuming the patient eats breakfast at 8:30 AM, lunch at noon, and dinner at 6:00 PM, at what time is the patient at the highest risk of hypoglycemia following an 8:00 AM dose of neutral protamine Hagedorn (NPH) insulin? A 10 AM B 2 PM C 5 PM D 8 PM ```

C Breakfast eaten at 8:30 AM would cover the onset of NPH insulin, and lunch at noon will cover the 2 PM time frame. However, if the client does not eat a mid-afternoon snack, the NPH insulin may be peaking just before dinner at 6 PM, without sufficient glucose on hand to prevent hypoglycemia.

How do α-glucosidase inhibitors differ from the sulfonylureas? A α-glucosidase inhibitors stimulate pancreatic insulin release B α-glucosidase inhibitors increase the sensitivity of insulin receptor sites C α-glucosidase inhibitors delay the absorption of glucose, leading to lower glucose levels D α-glucosidase inhibitors cannot be used in combination with other antidiabetic agents

C α-glucosidase is an enzyme necessary for the absorption of glucose from the gastrointestinal tract. Inhibiting this enzyme inhibits glucose absorption, delaying rises in postprandial serum glucose levels.

How do the sulfonylureas lower serum glucose levels? A By increasing β-cell stimulation to release insulin B By delaying glucose absorption in the gut C By blocking adipose deposit conversion to glucose D By blocking the action of glucagon on muscle stores

A The three major pharmacodynamic actions of sulfonylurea drugs include increasing β-cell stimulation for insulin release, decreasing hepatic glucose production, and increasing insulin sensitivity.

``` Which of the following drugs will put the patient at risk for unrecognized hypoglycemia if he or she has insulin concurrently prescribed? A acetylsalicylic acid (aspirin) B codeine C Thiazide diuretics D β-adrenergic blockers ```

D β-adrenergic blockers block the initial sympathetic response to hypoglycemia; therefore, the patient will not exhibit the initial symptoms of nervousness, diaphoresis, and sweating that typically alert the patient to the onset of hypoglycemia.

Which of the following is important when mixing 30 units regular insulin and 70 units NPH insulin in the same syringe? A Rotate sites at least once weekly and label the sites used on a diagram B Inform the patient that mixing insulins will help increase insulin production C Draw up the regular insulin into the syringe first, followed by the cloudy NPH insulin D Use a 23- to 25-gauge syringe with a 1-cm needle for maximum absorption

C Drawing up the regular insulin into the syringe first prevents accidental mixture of NPH insulin into the vial of regular insulin, which could cause an alteration in the onset of action of the regular insulin.

``` Which of the following drugs would be recommended during diabetes teaching to treat hypoglycemia? A acarbose (Glucobay) B glucagon C proponolol D bumetanide ```

B Glucagon stimulates glycogenolysis, raising serum glucose levels.

A sliding scale insulin administration regime is more likely to be ordered for which of the following patients? A Type 1 diabetes management for a healthy 2-year-old child B Type 1 diabetes management for a 16-year-old girl starting menses C Type 2 diabetes management for a freshly postoperative older adult patient D Type 2 diabetes management for a patient with glaucoma

C Sliding scale regimes are normally ordered during times of additional stress in the life of a person with diabetes. An operative procedure is an example of an additional stressor that will cause a rise in blood glucose levels in response to the stressor.

Which of the following patient statements indicate that medication therapy for a patient with type 2 diabetes is effective? A “I have more energy to perform my daily activities.” B “I am drinking more water to satisfy my extreme thirst.” C “I always have to know where the public washrooms are as I urinate frequently.” D “I am gaining weight as I am hungry most of the day.”

A Once serum glucose levels are regulated, signs of hyperglycemia should disappear. Having energy stores to draw from to complete activities of daily living is an indicator that the insulin is sufficient to remove glucose from the blood into energy stores. Thirst, polyuria, and hunger are signs of extreme hyperglycemia.

Which of the following statements accurately reflects the advantages of using an insulin pump? A Insulin delivery goes directly into the bloodstream, thereby mimicking the action of a healthy pancreas B Normal blood glucose levels are maintained through the basal/bolus insulin action C Hypoglycemia is reduced through the glucose bolus delivery option on the pump D Increasing the occurrence of the dawn phenomenon thereby reduces periods of extreme hyperglycemia

B Insulin pumps allow both tight control and flexibility in management of type 1 diabetes. Normal blood glucose levels can be tightly managed by administering both a basal rate of insulin and bolus amount when needed.

``` When caring for a patient newly diagnosed with gestational diabetes, the nurse would question which of the following medication orders? A Insulin glargine (Lantus) B glipizide C Insulin glulisine (Apidra) D NPH insulin (Humulin-N) ```

B All currently available oral hypoglycemic drugs are contraindicated for pregnant patients due to the lack of consistent evidence that firmly supports the safe use for pregnant patients.

1 Which of the following is most appropriate regarding the nurse's administration of lispro to a hospitalized patient? a. It should be given half an hour before a meal. b. It should be given half an hour after a meal. c. It should given 15 minutes before the patient begins a meal. d. The timing of the insulin injection does not matter with lispro.

2 Which of the following statements would be appropriate to include in the patient teaching for type 2 diabetics? a. “Insulin injections are never used with type 2 diabetes.” b. “Because you are not taking insulin injections, it is not necessary to measure your blood glucose levels.” c. “Alcohol should be avoided because it can cause your blood glucose to fall to lower-than-normal levels.” d. “Patients with type 2 diabetes usually have better control over their diabetes than those with type 1 diabetes.”

3 Which of the following is a therapeutic response to oral antihyperglycemic drugs? a. Weight gain of 5 kg b. Fewer episodes of DKA c. Hemoglobin A1c levels of 6% d. Glucose levels of 9.5 mmol/L

4 When teaching the patient about drugs that interact with insulin, which of the following over-the-counter products should the nurse instruct the patient to avoid, unless otherwise instructed by the physician? a. Vitamin C b. Cough syrups c. Iron supplements d. Acetaminophen products

5 A patient with type 2 diabetes has a new prescription for repaglinide (GlucoNorm). After a week, she calls the office to ask what to do because she keeps missing meals. “I work right through lunch sometimes, and I'm not sure if I should take it or not. What should I do?” What is the nurse's best response? a. “Go ahead and take the pill when you first remember that you missed it.” b. “You should try not to skip meals, but if that happens, you should also skip that dose of repaglinide.” c. “Take both pills with the next meal and try to eat a little extra to make up for what you missed at lunchtime.” d. “We will probably need to change your prescription to insulin injections because you can't eat meals on a regular basis.”

What actions would be necessary in the nursing care of the patient with type 1 diabetes mellitus who is on NPO status for surgery but has orders for the usual morning dose of Humulin N insulin? Explain your answer. (al 616) al, Linda Lane Lilley et. Pharmacology for Canadian Health Care Practice, 2nd Edition. Elsevier Health Sciences, 2011. .

If the patient is to have nothing by mouth (i.e., is NPO) in preparation for surgery and still receives the usual morning dosage of Humulin N insulin, there will be no carbohydrates for the insulin to work on. Therefore, the individual’s blood sugar will drop significantly with hypoglycemia, and subsequent patient injury (tachycardia, palpitations, confusion, drowsiness) is possible; if the hypoglycemia is severe, convulsions and coma are possible. The insulin should not be given to a patient who is NPO, but the physician should be notified and orders clarified.

Insulin normally facilitates removal of ___________ from the blood and its storage as glycogen in the ______________.

glucose | liver

The nurse should always check for allergies to specific medications and to ____________ before giving insulin.

pork

Information on __________ care and the prevention of ____________ should be part of the patient education given to individuals with diabetes.

foot | infection

The nurse must remember that oral antidiabetic drugs are not to be used in __________ ___________.

pregnant women

Patients should be encouraged to avoid ___________ and _____________, follow all dietary instructions, and never skip meals or skip insulin. (al 614) al, Linda Lane Lilley et. Pharmacology for Canadian Health Care Practice, 2nd Edition. Elsevier Health Sciences, 2011. .

smoking | alcohol

QUICK TREATMENT FOR HYPOGLYCEMIA:

having quick sources of glucose on hand such as candy, sugar packets, OTC glucose tablets, sugar cubes, honey, corn syrup, orange juice, and nondiet soda beverages

QUICK TREATMENT FOR HYPERGLYCEMIA:

having more insulin on hand

Patients should be informed about situations or conditions that lead to altered serum glucose SUCH AS:

``` fever, illness, stress, increased activity or exercise, surgery, emotional distress ```

Patients should be informed to notify the physician if the patient notes any:

``` yellow discoloration of the skin, dark urine, fever, sore throat, weakness, unusual bleeding easy bruising (with any antidiabetic drug regimen) ```

Patients should be educated about not skipping _____________ or _______________; if problems with either occur, patients should contact their health care provider.

meals | MEDICATIONS

TRUE OR FALSE? | Some of the oral antihyperglycemic drugs cause sensitivity to light

TRUE thus patients should always wear protective eyewear and sunscreen and avoid unprotected sun exposure (including use of tanning beds).

Prednisone may be used to treat a variety of disorders and conditions.

Oral prednisone is often used with autoimmune disorders, collagen disorders, inflammatory conditions, immunosuppression, and palliative effects of selected neoplasms.

Fludrocortisone is a synthetic mineralocorticoid used as replacement therapy in adrenocortical insufficiency and with those suffering from chronic severe __________ ______________.

postural hypotension

LIST 5 COMMON SIDE EFFECTS OF PREDNISON

``` gastrointestinal upset, fragile skin hyperglycemia heart failure edema ```

____________ (pregnancy category C) can cross the placenta and produce fetal abnormalities. They may also be secreted in breast milk and cause ______________ in the nursing infant.

Corticosteroids | abnormalities

All adrenal cortex hormones are ___________ hormones

steroid

_________________ inhibit or help control inflammatory and immune responses

Glucocorticoids

Different adrenal drugs differ in their potency, duration of action, and the extent to which they cause salt and fluid ______________

retention

adrenal drug indications

Dermatological diseases Exacerbations of chronic respiratory illnesses, such as asthma and COPD Organ transplant (decrease immune response)

adverse effects of adrenal drugs:

1. hyperglycemia 2. fragile skin 3. peptic ulcers 4. cardiac problems (hypertension) related to electrolyte imbalance 5. steroid psychosis 6. muscle weakness

Sudden discontinuation of these adrenal drugs can precipitate an ________ __________ caused by a sudden drop in serum levels of cortisone

adrenal crisis

Biological functions of ______________ include anti-inflammatory actions; maintenance of normal blood pressure; carbohydrate, protein, and fat metabolism; and stress effects.

glucocorticoids

Biological functions of _______________ include sodium and water reabsorption, blood pressure control, and maintaining of potassium levels and pH levels of blood.

mineralcorticoids

1 Which of the following statements is correct regarding corticosteroids? a. They have few adverse effects. b. They are often used for their anti-inflammatory effects. c. They may be administered only by inhalant dosage forms. d. They may be used long term without major complications.

2 Which statement of the patient shows a poor understanding of the teaching about oral corticosteroid therapy that the patient has received? a. “I should take this drug with food or milk.” b. “I will report any fever or sore throat symptoms.” c. “I will stay away from anyone who has a cold or infection.” d. “I can stop this medication if I have severe adverse effects.”

3 During long-term corticosteroid therapy, the nurse should monitor the patient for Cushing's syndrome. Which of the following characteristics is usually manifested by this syndrome? a. Weight loss b. Truncal obesity c. Muscle thickening d. Thickened hair growth

4 A patient has been prescribed a daily dose of prednisone. At what time of day should the patient take the medication to help reduce adrenal suppression? a. In the morning b. At lunchtime c. At dinnertime d. At bedtime

5 Which teaching is appropriate for a patient who is taking an inhaled glucocorticoid for asthma? a. “Blow your nose after taking the medication.” b. “Do not rinse the mouth after taking the medication.” c. “Exhale while pushing in on the canister of the inhaler.” d. “Rinse the mouth thoroughly after taking the medication.”

1 A 19-year-old man is admitted through the emergency department after a motorcycle accident. He is conscious upon admission, has stable vital signs, and has minimal cuts and abrasions on the left side of his body. You perform a thorough neurological examination and find absence of sensation to light touch and pinprick and lower extremity paralysis. Reflexes are absent below the groin area. The physician orders high-dose intravenous methylprednisolone. What is the purpose of this medication.

Methylprednisolone most likely was ordered to help decrease the cerebral edema associated with head injury after the accident and to decrease any swelling around the spinal cord.

When preparing to administer prednisone, the nurse is influenced by which of the following facts about glucocorticoids? A Glucocorticoids should be administered with food to diminish the risk of gastric irritation B Glucocorticoids are usually administered on a strict, unchanging schedule in order to prevent adverse reactions C Glucocorticoids should not be administered intravenously secondary to the risk of hypotension when given parenterally D Glucocorticoids are usually administered early in the evening to coincide with the natural secretion pattern of the adrenal cortex

A Glucocorticoids can cause gastrointestinal distress and should be administered with food. The normal circadian secretion of the adrenal cortex is early morning to wake the patient up, not early evening. These medications should be tapered off slowly to prevent adrenal crisis, and they can be administered intravenously.

Which of the following statements about glucocorticoids is most accurate? A They decrease serum sodium and glucose levels B They influence carbohydrate, lipid, and protein metabolism C They are produced in decreased amounts during times of stress D They stimulate defense mechanisms to produce immunity

B Glucocorticoids play a major role in carbohydrate, lipid, and protein metabolism within the body. They suppress the immune system, increase sodium and glucose levels, and they are produced in increasing amounts during stress.

Which of the following patient conditions would cause the nurse to question a corticosteroid order? A Septic shock B Chronic obstructive pulmonary disease (COPD) exacerbation C Rheumatoid arthritis D Uncontrolled diabetes mellitus

D A common adverse effect of steroid therapy is hyperglycemia.

``` Which of the following signs and symptoms would the nurse monitor for when assessing for potential adverse effects of fludrocortisones (Florinef)? A Hypoatremia B Hypercalcemia C Hypokalemia D Hypovolemia ```

C Fludrocortisone (Florinef) has mineralocorticoid properties, resulting in sodium and fluid retention along with potassium excretion.

``` Discharge teaching for a patient receiving glucocorticoid therapy should include the preferred use of which of the following medications for pain management? A acetylsalicylic acid (aspirin) B ibuprofen (Advil) C acetaminophen (Tylenol) D naproxen sodium ```

C Acetaminophen (Tylenol) does not cause gastrointestinal distress, as do acetylsalicylic acid (aspirin), ibuprofen (Advil), naproxen sodium, and glucocorticoids.

``` Abrupt withdrawal of long-term corticoid steroid therapy puts the patient at risk for what type of condition? A Cushing’s syndrome B Thyroid storm C Adrenal insufficiency D Candidiasis septic shock ```

C Abruptly stopping long-term steroid therapy puts the patient at risk for Addisonian crisis or adrenal insufficiency, a life-threatening condition.

What teaching content should the nurse include for a patient using a steroid inhaler? A Rinse the mouth after each use B Minimize use of an inhaler to every other day C Swish and swallow with mycostatin after each use D Boil the mouth piece every week

A A complication of steroid inhaler use is the development of oral (fungal) candidiasis. Rinsing the mouth after each use decreases the risk of fungal overgrowth in the oral cavities.