Wk 3: Caring for a Diabetic Pt/ Nutrition Flashcards
Type 1 DM
autoimmune destruction of Beta cells in our pancreas
-S/sx more abrupt
-common in youth
-NO ENDOGENOUS insulin production
-MUST have insulin replacement
type 2 DM
Beta cells in pancreas wear out and body becomes immune or resistant to insulin/body cells do not respond to insulin
-common in adults
-can go undiagnosed for long time
-some need insulin with PO meds
what are the 3 P’s of type 1 DM?
polyphagia -> excessive hunger
polydipsia -> excessive thirst
polyuria -> frequent urination
Common Symptoms of Diabetes
three P’s
fatigue
recurrent infections
slow healing
Non-modifiable risk factors for type 2 DM
family Hx
over 45 y/o
race/ethnicity
history of gestational diabetes
Modifiable risk factors for type 2 DM
Physical inactivity
High body fat/overweight
HTN
HLD
What labs are involved in monitoring diabetes ?
-Fasting BG (no food/drink for 8 hours)
Nml <126
-Casual BG
What labs are involved in monitoring diabetes ?
-Fasting BG (no food/drink for 8 hours)
Nml <126
-Orala Glucose Tolerance Test (to Dx gestational diabetes)
-Glycosylated Hemoglobin (HbA1C)
-Casual BG
Nml <200
-urine ketones
-lipid profile
low HDL, high LDL, high triglycerides
HbA1C test
-Average BG over 3 months
-used to Dx and evaluate effectiveness of interventions
-nml is 4-6%
> 6.5% is considered diabetic
acceptable range for diabetics is 6-8%
How do you take an Oral Glucose Tolerance Test
-consume oral glucose
-glucose taken every 30 minutes until 2 hours have passed
-fasting should be <110
- at 1 hour should be <180
-at 2 hours should be <140
A1C levels for
-Diabetics
-Pre-diabetes
-Normal
-diabetic: 6.5 or above
-Pre-diabetes: 5.7 - 6.4
-Normal: ~5
Fasting Plasma Glucose levels for
-diabetes
-pre-diabetes
-normal
-diabetes: 126 or above
-pre-diabetes: 100-125
-normal: 99 or below
oral glucose tolerance test for
-diabetes
-pre-diabetes
-normal
-diabetes: 200 or above
-pre-diabetes: 140-199
-normal: 139 or below
What is the criteria for a DM diagnosis
at least one of the following:
-A1C of 6.5% or higher
-fasting BG >126
-OGTT 2Hr level of 200
-Sx of hyperglycemia, a random BG >200, or hyperglycemia treatment
*usually a repeat lab is done before official diagnosis
*for Type 1 DM would beed an islet cell autoantibody test
What can you do for a pre-diabetic pateint?
-teach
-lifestyle modifications
-encourage close monitoring of BG and A1C
-monitor for: fatigue, slow healing, frequently being sick
-diet modification
What are some pharmacological considerations for a diabetic patient (specifically type 2 DM) when they are sick or hospitalized
-oral meds may be stopped when in the hospital
-might be put on insulin when in hospital, even if they do not normally take it
-BG can rise when sick
-hold metformin prior to surgeries
-Pt may be more prone to DKA or HHNS
-PO intake may be less, may need to alter insulin dose
-steroids make BG rise
When a patient with DM is sick, when should (you or) they call their provider
-urine ketones
BG >250
Temp >101.5 w/o response from Tylenol
Confusion/Disoriented/ Rapid Breathing
N/V/D
Fluid intolerance
sick >2 days
Frequency of BG checks depends on what
glycemic goals
type of diabetes
medication regimen
access to supplies and equipment
patients willingness
When would rapid or short acting insulin be given?
before each meal
When would lantus or long acting insulin be given?
at bedtime
Since Insulin is a high alert drug, what should you be checking/ know prior to administering it?
-current BG level
-check current diet order
-onset/peak/duration of insulin
-S/Sx of hypoglycemia
What do you do if your diabetic patient is NPO?
may need medication dosage change
What should you always do with a patient with a new diagnosis of DM?
-Make sure to educate properly about side effects, when to time insulin doses, and S/sx for hypoglycemia
-always observe new patients self-administer insulin
Hypoglycemia criteria and treatment
BG <70
Trx:
-FSBG
-rule of 15
What is the rule of 15?
if Pt is hypoglycemic but still able to swallow give 15g of simple carbohydrates
-FSBG in 15 minutes then eat regular meal
-if still <70 then repeat steps
(15g CHO should increase BG by 50)
Simple CHO include: 4Oz juice, regular soda, 3 glucose tabs
What can you give a patient that is hypoglycemic if they are unable to swallow or are unconscious?
IM Glucagon
IV D50
What are some symptoms of hypoglycemia?
diaphoresis, blurred vision, dizziness, anxiety, hunger, irritability, shakiness, fast heart beat, headache, weakness, fatigue
What are some causes of hyperglycemia?
what are some manifestations of it?
causes: illness, infection, self-management issues, stress
manifestations: weakness, fatigue, blurry vision, headache, N/V/D
Insulin Pumps
-SQ continuous infusions of rapid acting insulin
-be aware of: infections at pump site and increased risk of DKA if pump malfunctions
Macrovascular Complications of DM
damage to large vessels like:
-coronary arteries
-peripheral vascular
-cerebral vascular
*much higher risk for CVD
Microvascular Complications for DM
damage to capillaries:
-retinopathies
-nephropathies
-neuropathies
Loss of Protective Sensation (LOPS)
prevents patients from being aware that injury has occurred
-related to neuropathy
Diabetic foot care steps
- wash feet daily
- pat dry
- inspect feet daily
- use lanolin to prevent dryness
- mild foot powder for sweat
6.no commercial remedies - clean cuts with mild soap (NOT iodine/alcohol/adhesives)
- report skin infections
- trim nails
- separate overlapping toes with cotton
- do not go barefoot
- clean/ absorbent socks
- no hot water bottles
Nutritional considerations for diabetics
high fiber
low fat
low cholesterol
carb counting (especially with T1)
whole grains
sugar free alternatives work well
limit alcohol intake
**NEVER tell a patient to not eat a certain food group
Integumentary Concerns d/t DM
- Diabetic Dermopathy: reddish-brown spots
- Acanthosis Nigricans: brown/black thickening of skin
- Necrobiosis lipoidica diabeticorum: red patches around blood vessels
*all can improve when DM is being treated/controlled properly
What is the difference between Enteral and parenteral nutrition?
Parenteral -> providing nutrition outside of the GI tract, through IV nutrition/ TNP
Enteral -> preferred way of getting nutrition, through the GI tract
what are the three main functions of the GI tract?
transportation
digestion
absorption
what is the flow if the GI tract from mouth to anus?
through the mouth
down the esophagus
esophageal sphincter
stomach
pyloric sphincter
small intestine (duodenum, jejunum, ileum)
large intestine (colon/sigmoid) (water reabsorption)
rectum
anus
complications with malnutrition
-malnutrition leads to higher readmission rates
-dysrhythmias
-skin breakdown
-sepsis
-hemorrhage
-increased length of stay
-delayed surgical healing
What is malnutrition?
-lack of nutritional intake
-can be be present in underweight or obese Pt
What are the importances of good nutrition?
-reach/ maintain healthy weight
-reduce risk of chronic Dz
-promote overall health
dietary guidelines
- follow healthy eating pattern
- variety of nutrient dense foods
- limit added sugars/sat. fats/ sodium intake
- shift to healthier foods
support healthy eating patterns
what influences a persons nutrition intake?
appetite
negative experiences
disease, illness
medications
environmental factors (income/education)
developmental needs
alternative food patterns(religion/culture)
Nutritional Considerations for Older Adults
chronic illness
medications
GI changes
decreased metabolic rate
cognitive impairment
available transportation
functional ability
fixed income
usually need calcium supplements
What are the five steps to the assessment of nutritional status?
screening
anthropometry
laboratory and biochemical tests
diet and health history
physical examination
Nutritional assessment: screening
-subjective: what they report
-objective: height/weight
-identifying risk factors of malnutrition: weight loss Sx
-using standardized tools:
SGA/MNA/MST
Nutritional assessment: anthropometry
-study of measurement and proportions of human body
-measure size/ makeup of body
-BMI
-skin fold measures
-fat percentage
-registered dietitians can assist
BMI calculations
BMI = 703 x [lb/in(^2)}
BMI= kg/m(^2)
nutritional assessment: Laboratory
no single lab test to determine nutrition
Factors that affect lab results:
fluid balance
liver and kidney function
presence of Dz
Common labs:
Total protein, albumin, prealbumin, hemoglobin
Total Protein
combination of albumin and globulin constitute
Nml range: 6.4-8.3
Albumin
indicator for CHRONIC illness
synthesized in the liver
half life of 21 days
Nml: 3.5-5.0
Prealbumin
indicator for ACUTE conditions
half life of 2 days
Nml range: 15-36
Hemoglobin
protein responsible for transferring O2
if low should eat iron rich foods
Nml Range for males: 14-18
Nml range for females: 12-16
Nutritional assessment: nutritional history
diet history
healthy history
other history: age, socioeconomic status, culture, religion
Nutritional assessment: physical examination
What does a person with a healthy nutritional assessment present with?
alert & erect appearance
BMI WNL
neuro intact w/ EMV of 15
VS WNL
no GI complaints
no musculoskeletal abnormalities
shiny hair
no facial/ neck swelling
lips are pink, free of lesions or swelling
pink tongue
teeth are clean and white
MMM that are red colored with no lesions
Nutritional assessment: physical examination
What does a person with malnutrition present with during their examiantion?
fatigue, apathetic, cachectic, sunken chest, humped back
obesity, overweight or underweight
inattentive, irritable, confused, decreased reflexes
VS WNL
GI: anorexia, indigestion constipation, N/V/D
weak, poor tone, “wasted” appearance, bowlegged, visible ribs
rough/dry/pale skin
brittle nails
face/neck is swollen, dark skin under eyes
pale conjunctivae, dry eyes
gums: spongey, receding, bleeding, inflamed
Tongue: swelling, raw
teeth: missing/ broken
mucus membranes: swollen, oral lesions
nursing problems related to nutrition
imbalanced nutrition (more or less)
impaired swallowing
risk for aspiration
diarrhea, constipation, nausea
impaired dentition
fatigue
risk for unstable BG
What are some nursing implementations you can do regarding a patients nutrition?
health promotion
advancing diet
diet selection
care of common nutritional issues
measuring I&O
obtaining height and weight
What are the components of selecting a diet for a patient?
the amount of calories needed
ability for the patient to eat (teeth? cant chew?)
any alterations to GI tract (bariatric Sx)
any special considerations based on heath status (DM)
What are some different kinds of diets?
regular PO
liquid diets
modified texture
therapeutic diets modified for nutrients
supplements
What are some examples of a modified texture diet?
mechanical soft
pureed
minced
ground
chopped
what is allowed in a clear liquid diet
water
black coffee
tea w/o cream
fat free broth
lemonade
sports drinks
gelatin
popsicles
*anything you can see through that is easily digestable
before you enact a fluid diet, what are two considerations you should bring up
- is the patient on fluid restrictions?
HF, kidney failure, low serum sodium - do they need a modified consistency of their liquids?
before you enact a fluid diet, what are two considerations you should bring up
- is the patient on fluid restrictions?
HF, kidney failure, low serum sodium - do they need a modified consistency of their liquids?
thin vs thick liquids
dysphagia Pt’s
risk for aspiration
What are the different liquid consistencies ?
thin-> water, coffee, tea, soda
nectar-like -> can drip off a spoon
spoon thick -> pudding consistency
Honey like-> honey consistency
what are some therapeutic diet orders?
consistent carbohydrate
cardiac diet (low Na+, low sat fat, low cholesterol)
low residue (undigested food)
high fiber
gluten free
lactose free
bland
what determines a persons diet tolerance?
no N/V/D
no abdominal distention
normal bowel sounds
What are some common nutritional issues ?
anorexia
inability to feed self
dysphagia
nausea and vomiting
what are some things the nurse can do to increase a patients appetite
treat cause
use creative approaches to stimulate appetite
change environment
smaller / more frequent meals
allow for food preferences
seasoning food
oral hygiene
ensure patient is comfortable
medications for appetite stimulation
assisting a patient with oral feedings
protect safety/independence/dignity
tray within reach
assess risk of aspiration
does patient need to be supervised?
any visual deficits? plate as a clock
decrease motor skills -> adaptive utensils
what are some complications for dysphagia ?
aspiration PNA
dehydration
malnutrition
weight loss
What does the nurse need to do when the patient is on strict I&O?
measure all intake and output
record it in the patients medical record
measure in either mL or amount of occurrences
can be delegated to tech
educate the patient & family on participation
assess and monitor trends
What kind of patients would be in strict I&O’s?
Critical care patients
unstable patients
Post-op Pt
Pt with h/o HF, liver failure or renal failure
malnourished Pt
NPO pt
Pt on diuretics
changes in weight
What counts as intake?
oral intake
IV fluids
blood products
tube feedings
flushes
what counts as output?
urine
BM
emesis
drainage tubes (JP, chest tubes)
What is a feeding tube that leads through an artificial external opening into the stomach?
PEG tube
What is a feeding tube that leads through an artificial external opening into the small intestine?
PEJ tube
how do you confirm the placement of a PEG or PEJ tube?
XR
(also pH test with aspirated secretions and inserting air into tube then auscultating)
If the patient has a risk for gastric reflux then what type of tube should be used?
jejunum tube
What are some indications that the patient may need enteral nutrition?
prolonged anorexia
severe protein-energy malnutrition
coma
impaired swallowing
critical illness
Benefits of Enteral over Parenteral nutrition
reduced chance of sepsis
minimize hyper-metabolic response to trauma
decreased hospital mortality
maintains intestinal structure and function, decreased chance of atrophy
S/Sx of tube feeding intolerance
high gastric residuals
nausea
cramping
vomiting
diarrhea
Bolus vs Pump tube feedings
bolus is intermittent
pump is continuous
Complications of tube feedings
pulmonary aspirations
constipation
abdominal cramping
N/V/D
tube occlusion or displacement
delayed gastric emptying
serum electrolyte imbalance
fluid overload
hyperoslmolar dehydration
nursing assessment of feeding tubes
abdominal focused exam
check for surrounding skin breakdown
assess nutritional status
assess for intolerance
I&O
monitor labs
how often to check gastric residual in stomach
check continuous feedings every q 4-6 hrs
check intermittent feedings before giving feeding
what does high gastric residual indicate?
delayed gastric emptying
> 250 ml hold for 1 hr and recheck
500 ml hold and notify HCP
what do do when administering medications through a feeding tube
follow 5 rights of med admin
ensure med can be administered through tube
always verify placement
flush with water before and after administration
administer one med at a time
