5Collaborative Management Analgesic/anti-pyretic/anti-inflammatoriesDisease-modifying anti-rheumatic drugs (DMARDs)Methotrexate (Rheumatrex): mainstay of therapyWatch! For bone marrow suppression & liver toxicityLefunomide (Arava): Similar to methotrexate, same side effectsMedicationsAnalgesic/anti-pyretic/anti-inflammatories: non-steroidal (NSAIDS)Watch! Prevent gastrointestinal inflammation: H2 blocking agent (ranitidine)Disease-modifying anti-rheumatic drugs (DMARDs): hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine)Methotrexate (Rheumatrex): mainstay of therapy – decreases joint swelling and painWatch! For bone marrow suppressionWatch! Liver toxicity – no alcoholLefunomide (Arava): Similar to methotrexate, same side effectsImmunosuppressants: azathioprine (Imuran), cyclophosphamide (cytoxan), prednisoneBiological response modifiers: neutralize tumor necrosis factor binding - etanercept (Enbrel) adalimumab (Humira)Glucocorticoids (steroids): anti-inflammatory, high risk complicationsWatch! Gastrointestinal inflammationWatch! Blood sugar elevationGold therapy: auranofin (Ridaura) oral or gold sodium thiomalate (Myochrysine)
6Collaborative Management, cont… Immunosuppressants:Biological response modifiers:Glucocorticoids (steroids)Watch! Gastrointestinal inflammation & blood sugar elevationGold therapyMedicationsAnalgesic/anti-pyretic/anti-inflammatories: non-steroidal (NSAIDS)Watch! Prevent gastrointestinal inflammation: H2 blocking agent (ranitidine)Disease-modifying anti-rheumatic drugs (DMARDs): hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine)Methotrexate (Rheumatrex): mainstay of therapy – decreases joint swelling and painWatch! For bone marrow suppressionWatch! Liver toxicity – no alcoholLefunomide (Arava): Similar to methotrexate, same side effectsImmunosuppressants: azathioprine (Imuran), cyclophosphamide (cytoxan), prednisoneBiological response modifiers: neutralize tumor necrosis factor binding - etanercept (Enbrel) adalimumab (Humira)Glucocorticoids (steroids): anti-inflammatory, high risk complicationsWatch! Gastrointestinal inflammationWatch! Blood sugar elevationGold therapy: auranofin (Ridaura) oral or gold sodium thiomalate (Myochrysine)
7Alternative Therapies Hypnosis, acupuncture, imagery, magnet or music therapyOmega-3 fatty acids: fish oil capsulesAntioxidant vitamins A, C, ETrace elements: zinc, selenium, copper, ironAsk patient if he/she is taking any of these…
8Non-pharmacologic Therapies Rest and positioning for comfortIce during inflammationHeat: paraffin wax dips or hot packs to manage pain, increase mobility
9Lupus Erythematosus Discoid: affects only the skin Systemic: chronic, progressive connective tissue inflammation causing nephritis (leading cause of death), pericarditis, pleural effusions, esophagitis, joint inflammation and inflamed skinDiscoid (affects only the skin) or systemic: chronic, progressive connective tissue inflammation causing nephritis (leading cause of death), pericarditis, pleural effusions, esophagitis, joint inflammation and inflamed skin
10Collaborative Management: Discoid Lupus Rash: Topical cortisoneSkin protection from sun, ultra-violetTeach: mild soap, no perfumes, use lotion, avoid drying substancesAlopecia (hair loss) is common: mild protein shampoo
11ExacerbationFever (major sign), abdominal pain, increased fatigue, headache, dizzinessCaused by stressSigns of inflammation in affected organsWill need hospitalization, may become rapidly critically illSystemic corticosteroidsCytotoxics: Imuran, Cytoxan
12Gout Manifestations: Renal calculi (stones) Hyper-uricemia - elevated serum uric acidJoint inflammation - very painfulTophi - sodium urate crystal deposits, commonly on outer ear, fingersImage Source: UCSD, Catalog of Clinical Images. Photography by Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical CenterGoutUrate crystals deposit in joints and other body tissues, causing inflammationManifestationsRenal calculi (stones)Hyper-uricemia: elevated serum uric acidJoint inflammation: very painful
13Acute Episode of Gout Sudden, severe joint pain and swelling Shiny red or purple skin around the jointExtreme tenderness in the joint area
14Collaborative Management of Acute Episode Colchicine (Colsalide)NSAIDAllopurinol (Zyloprim) or probenecid (Benemid)Watch! Aspirin and diuretics may start an attackAvoid emotional stressLow-urine diet: avoid organ meats, shellfish, oily fish with bonesAvoid excess alcoholPrevent stones - drink more fluids, increase acidity of urine with alkaline ash foods (citrus, milk)Collaborative Management of Acute EpisodeColchicine (Colsalide)NSAIDAllopurinol (Zyloprim) or probenecid (Benemid) to inhibit uric acid formation and promote its excretionWatch! Aspirin and diuretics may start an attackAvoid emotional stressDiet: low-urine diet Avoid organ meats, shellfish, oily fish with bonesAvoid excess alcohol.Prevent stones: drink more fluids, increase acidity of urine with alkaline ash foods (citrus, milk)
15Human Immunodeficiency Virus (HIV) Effects of HIV InfectionHIV, a retrovirus, invades the CD4+ lymphocyte and makes more HIV particles. This depletes the CD4+ lymphocyte supply, decreasing the body’s ability to see invading pathogens and mount a defense. The HIV particles replicate themselves using protease and then travel to new CD4 lymphocytes to make new HIV retriviruses. As the viral load increases and the CD4+ lymphocytes decrease, the patient eventually dies of opportunistic infections. The person develops acquired immunodeficiency syndrome (AIDS) when either the CD4+ count falls below 200 cells/mm3 or the patient develops an opportunistic infection.Image Source: Wikimedia Commons, Public Domain,
16Diagnosis Leukopenia Less than 500-16000 CD4+ cells/mm3 in AIDS Enzyme-linked immunosorbent assay (ELISA)Western blotViral load testingQuantitative RNA assaysP24 Antigen assayLymphocyte count: leukopeniaCD4+ cell count: less than cells/mm3 in AIDSEnzyme-linked immunosorbent assay (ELISA): inexpensive screen for HIV antibodiesWestern blot: more accurate HIV antibody detectionViral load testing: monitor disease progressionQuantitative RNA assays: detect viral load in small amountsP24 Antigen assay: quantifies amount of HIV viral core protein for treatment followup
17ManifestationsHIV: Fever, chills, night sweats, headaches, muscle achesAIDS: Signs of an opportunistic infection:shortness of breath or dry coughfatigueweight loss, nausea and vomiting, diarrheaswollen lymph nodesvisual changes, memory loss and confusionseizures, skin lesionsHIV: Fever, chills, night sweats, headaches, muscle achesAIDS: Signs of an opportunistic infection caused by organisms that are present in the environment and don’t usually cause disease in the normally functioning immune system.Possible manifestations include: shortness of breath or dry cough, fatigue, weight loss, nausea and vomiting, swollen lymph nodes, diarrhea, visual changes, memory loss and confusion, seizures, skin lesions
18Prevention Sexual Parenteral Health care workers Perinatal Prevention of HIV InfectionSexual: Abstinence, mutually monogamous sex with noninfected partner are the only absolutely safe measures. Highest risk is in practices that permit infected seminal fluid to contact mucous membranes or nonintact skin. Safer sex practices include use of a latex condom or barrier.Parenteral: Use of sterile needles, syringes and other drug paraphernalia. Proper cleaning between uses would include flushing with water and bleach.Health care workers: Prevent mucous membrane exposure using latex or other reliable barriers in all contact with non-intact skin, mucous membranes, blood and body fluids (Standard Precautions).Perinatal: Use of zidovudine during pregnancy, and/or a dose of nevirapine during labor and a dose to the newborn will decrease perinatal exposure from the HIV-positive mother. Possible exposure comes through the placenta, blood and vaginal secretions during labor, and breast milk.
19Immunocompromised? No crowds Don’t share personal items, bathe q day Wash hands, wash dishes, cupsLow bacteria dietAvoid pet litterCheck temperature dailyNo gardeningPrevention of AIDS in Immunocompromised PatientsAvoid crowds or ill peopleDo not share personal toilet articles: toothbrush, toothpaste, washcloth, deodorantBathe daily: wash armpits, groin, genitals, anal area twice dailyClean toothbrush daily with dishwasher or bleachWash hands thoroughly with antimicrobial soap before eating, drinking; after shaking hands, touching a pet, coming home, using toiletEat low bacteria diet: avoid salads, raw fruit and vegetables, undercooked meat, pepper, paprikaWash dishes, cups between useDo not drink water standing more than 15 minutesAvoid changing pet litter boxes or use glovesAvoid turtles and reptiles as petsDo not feed pets raw or undercooked meatTake your temperature at least once a dayReport to physician immediately: fever above 100°F (38°C), persistent cough, pus or foul-smelling drainage, presence of a boil or abscess, cloudy urine, burning on urinationTake all medications as prescribedDo not dig in the garden or work with houseplantsAvoid travel to areas with poor sanitation
20Anti-HIV Drugs Category Action Examples Nucleoside analog reverse transcriptase inhibitorsInhibit HIV replicationzidovudine (Retrovir), didanosine (Videx), zalcitabine (HIVID),Non-nucleoside analog reverse transcriptase inhibitorsSuppress viral replication, do not kill the virusnevirapine (Viramune), efavirenz (Sustiva)Protease inhibitorsBlock protease enzyme, prevents viral replicationritonavir (Norvir), indinavir (Crixivan)Fusion inhibitorsBlock fusion of HIV with host cellenfuvirtide (Fuzeon)
21Opportunistic Infections Pneumocystis carinii (most common)Toxoplasmosis gondii - from cat feces, undercooked meatCandida albicansCryptococcus neoformansHistoplasma capsulatumMycobacterium aviumMycobacterium tuberculosisCytomegalovirus (CMV)Herpes simplexKaposi’s sarcoma:Opportunistic Infections are not a threat to persons with normal immune systems, life-threatening risk for immune suppressed:ManifestationPCP Pneumonia (PCP)- most commonToxoplasmosis Neurologic deteriorationCandida GI inflammationCryptococcus MeningitisHistoplasma Respiratory initiallyMycobacterium avium Systemic, respiratoryMycobacterium tuberculosisCMV Retinitis, colitis, encephalitisHerpes simplex Peri-rectal, oral, genitalKaposi’s sarcoma Skin, mucous membrane lesionsImage Source: Wikimedia Commons, Public Domain,
22Organ Transplants Autograft Highest success rate Isograft Highest success rateAllograft ↑ with compatibilityXenograft lowest success rateAutograft: Transplant of patient’s own tissueIsograft: Transplant from identical twinAllograft: Grafts between members of the same species with different genotypesXenograft: Transplant from animal species to a humanHighestHighest Increases with histocompatibility: human leukocyte antigen (HLA) type, blood type lowest
23Nursing Care Protect from infection Prevent rejection Patient teaching Strict aseptic technique with dressings, invasive linesWatch for subtle signs of infectionMonitor WBC, especially bands; monitor labs related to organ transplantedProtective/neutropenic isolation as indicatedSupply adequate nutritionChange invasive catheters, lines and sites, remove lines as soon as possiblePrevent transplant rejectionGive immunosuppressantsMonitor for adverse effects of medicationsAssess for graft rejection: tenderness, erythema, swelling over site; sudden weight gain, edema, hypertension; chills & fever; malaise, increased WBCMonitor laboratory studies for function of the transplanted organAssess for signs of graft-versus-host disease: maculopapular rash, erythema, hair loss, abdominal cramping & diarrhea, jaundice with elevated bilirubin and liver enzymesPatient teachingImportance of continuing medicationReport signs of rejectionHand washingMouth careTeach visitors to avoid contact if illPhoto source: Wikimedia Commons,Public Domain, US Government
24Transplant RejectionHyperacute: Immediate or up 2-3 days after new tissue transplantedAcute: 1 week to 3 months after transplantChronic: 4 months to years after transplantGraft-versus-Host Disease: First 100 daysTransplant RejectionHyperacute: Immediate or up 2-3 days after new tissue transplanted. Host has pre-existing antibodies to the antigens in donor organ. Most common in kidney transplants. Small clots form in transplanted organ, followed by ischemic necrosis, massive cellular destruction.Acute: 1 week to 3 months after transplant most common, most treatable. Antibodies cause vasculitis in transplanted organ destroying organ and inflammation causes lysis of organ cells. NOTE: acute rejection episodes do not necessarily result in organ loss.Chronic: 4 months to years after transplant. Similar to chronic inflammation, functional organ tissue is replaced with fibrotic tissue, reducing the organ’s function. Incurable, the fibrosis eventually leads to organ loss – occurs in all transplanted solid organs.Graft-versus-Host Disease: First 100 days, frequent, potentially fatal complication of bone marrow transplant. Body sees new bone marrow as foreign and tries to reject it. Since the patient is immune suppressed cannot reject new marrow; instead attacks its own cells: skin, liver, GI tract. Can become chronic, untreatable.
25Rejection Prophylaxis/Rx Cyclosporine (Sandimmune, Neoral)Azathioprine (Imuran)Mycophenolate (CellCept)Tacrolimus FK 506 (Prograf)Sirolimus (Rapamune)Corticosteroids (prednisone)Interleukin-2 receptor antagonistsAntithymocyte globulin (Atgam)Muromonab –CD3 (Orthoclone OKT3)Cyclosporine (Sandimmune, Neoral)Take at same time every day, mix liquid dose in a glass container with milk, chocolate milk, or orange juice (room temperature). No wax-lined or plastic disposable container. Stir it well, drink immediately. Dry the dropper used to measure the cyclosporine, but do not rinse it with water. Avoid grapefruitNephrotoxic, neurotoxic, hepatoxic; hyperglycemia, increases body & facial hair; gingival hyperplasiaAzathioprine (Imuran)Take at same time every day. Watch for signs of infection or bleeding.Hepatotoxic, nausea, vomiting, leucopenia, thrombocytopeniaMycophenolate (CellCept)Take each oral dose with a full glass of water, empty stomach, 1 hour before or 2 hours after a meal. Shake the oral suspension well just before you measure a dose. Measure the liquid with a marked measuring spoon or medicine cup. Do not open capsule or crush or chew a tablet. Do not use a pill that has been accidentally broken. The medicine from a crushed or broken pill can be dangerous if it gets in your eyes, mouth, or nose, or on your skin.Neutropenia, diarrhea, lymphoma, sepsisTacrolimus FK 506 (Prograf)Similar to cyclosporine. It is much more potent (weight for weight); incidence of infections may be higher; avoid grapefruit juiceDiarrhea, vomiting, stomach pain, loss of appetite, insomnia (neurotoxicity); high blood sugarSirolimus (Rapamune)Take 4 hours after cyclosporine. Mix oral solution with at least 2 ounces of water or orange juice in a glass or plastic container. Stir the mixture well and drink it immediately. Then, rinse the container with at least 4 ounces (1/2 cup, 120 mL) of additional water or orange juice, stir it well, and drink it to make sure that all of the medicine is taken. No grapefruit or grapefruit juice.Hyperlipidemia, decreased renal and liver function; anemia, thrombocytopeniaCorticosteroids (prednisone)Maintenance immunosuppression: know and watch for side effectsCushing's syndrome, osteoporosis, myopathy, cataracts, peptic ulcers; Glucose intolerance, hypercholesterolemia, skin fragility, adrenal suppressionInterleukin-2 receptor antagonistsGiven intravenously in hospital to treat or prevent acute rejectionAntithymocyte globulin (Atgam)Fever, chills, thrombocytopenia, leucopenia, rashMuromonab –CD3 (Orthoclone OKT3)Premedicate with hydrocortisone, acetaminophen, diphenhydramine; monitor vital signs closelyChills, fever, tachycardia, headache, tremor, blood pressure changes, nausea, vomiting, diarrhea, chest pain, dyspnea; Anaphylaxis
26Anaphylaxis Difficulty breathing Wheezing Abnormal high-pitched breath soundsConfusion, slurred speechRapid, weak pulse, palpitationsSkin redness, hives, generalized itchingProfound hypotensionBronchospasm and laryngospasmPulmonary edemaAnaphylaxis results from hypersensitivity reaction to an allergen. This occurs after the patient has been previously exposed and developed antibodies to the foreign substance. Large amounts of histamine are released causing increased cell permeability and massive vasodilation. This may result in:Difficulty breathingWheezingAbnormal high-pitched breath soundsConfusion, slurred speechRapid, weak pulse, palpitationsSkin redness, hives, generalized itchingProfound hypotensionBronchospasm and laryngospasmPulmonary edema
27Emergency ManagementAirway: Assess for laryngospasm, stridor – may need immediate intubationBreathing: oxygen at high flow rate, L/minute, monitor oxygen saturationCirculation: Assess for dysrhythmias, hypotension
28Reverse the ReactionPlace tourniquet per protocol proximal to allergen point of entryEpinephrine (Adrenalin) intravenous: (Does patient have an Epi-Pen?)Diphenhydramine (Benadryl) intravenousDopamine for persistent hypotension to vasoconstrictGive antidote if appropriateReverse the Reaction:Place tourniquet per protocol proximal to allergen point of entryEpinephrine (Adrenalin) intravenous: constricts blood vessels, dilates bronchioles (Does patient have an Epi-Pen?)Diphenhydramine (Benadryl) intravenousDopamine for persistent hypotension to vasoconstrictGive antidote if appropriate
29Stabilize Intravenous fluids: crystalloids, colloids Monitor for decompensation, repeat epinephrine
30Diabetes Mellitus Type 1 Type 2 Type 3 (gestational) Type 1 Diabetes MellitusType 1 diabetes is often called juvenile or insulin-dependent diabetes. In this type of diabetes, cells of the pancreas produce little or no insulin, the hormone that allows glucose to enter body cells. Without enough insulin, glucose builds up in the bloodstream instead of going into the cells. The body is unable to use this glucose for energy despite high levels in the bloodstream. This leads to increased hunger. In addition, the high levels of glucose in the blood cause the patient to urinate more, which in turn causes excessive thirst. Within 5 to 10 years, the insulin-producing beta cells of the pancreas are completely destroyed and the body can not longer produce insulin.Type 1 diabetes can occur at any age, but it usually starts in people younger than 30. Symptoms are usually severe and occur rapidly.Type 2 Diabetes MellitusUnlike Type 1 Diabetes, in which the body can’t produce normal amounts of insulin, in type 2 diabetes the body is unable to respond to insulin normally. Children and teens with the condition tend to be overweight, and it is believed that excess body fat plays a role in the insulin resistance that characterizes the disease. In fact, the rising prevalence of this type of diabetes in children has paralleled the dramatically increasing rates of obesity among children and teens in recent years. The symptoms and possible complications of type 2 diabetes are basically the same as those of type 1.Type 3 Diabetes Mellitus (gestational)Gestational diabetes is a carbohydrate intolerance of variable severity that starts or is first recognized during pregnancy. Gestational diabetes is usually diagnosed during the 24th to 28th weeks of pregnancy. In many cases, the blood glucose level returns to normal after delivery.Image Source: Wikimedia Commons, Public Domain,
31Diagnosis Fasting blood glucose Oral glucose tolerance test Glycosylated hemoglobin assay (HgA1C)Serum protein and albumin24-hour urine creatinine clearance
32Common Signs and Symptoms of Hyperglycemia Other Symptoms Might IncludeFatigueBlurred visionWeight lossPoor wound healing (cuts, scrapes, etc.)Dry mouthDry or itchy skinImpotence (male)Recurrent infections such as vaginal yeast infections, groin rash, or external ear infections (swimmers ear)Common Signs and Symptoms of Hyperglycemia
33Common Signs and Symptoms of Hyperglycemia The Classic SymptomsPolyphagia (frequently hungry)Polyuria (frequently urinating)Polydipsia (frequently thirsty)Common Signs and Symptoms of Hyperglycemia
34Ketoacidosis Hyperglycemia: > 250 mg/dL Dehydration: hot, dry, flushed skinMetabolic acidosis: pH < 7.3Electrolyte imbalance: loss of potassium, sodiumNausea and vomitingKussmaul’s respirations: increased rate and depthKetone breath: fruity, alcohol-like
35Treatment for Ketoacidosis Fluid replacementReplace electrolytesGive insulin: Initial bolus dose followed by infusion of regular insulinNOTE: insulin may adsorb into the plastic or glass container, decreasing its potency – flush IV line with at least 50 ml of insulin infusion before connecting to patientClosely monitor blood sugar at least hourlyKeep a syringe of 50% dextrose immediately available for hypoglycemiaTreat AcidosisTreatment for KetoacidosisFluid replacement:1 L 0.9% intravenous saline over one hour followed by 0.45% saline – may need 6-10 liters in first 24 hoursWhen blood sugar drops below 250 mg/dL give 5% dextrose in 0.45% salineNOTE: If serum osmolarity falls too fast, hypoglycemia and cerebral edema can resultElectrolytes:Replace potassiumNOTE: no faster than 10 mEq/hour in peripheral IV or 20 mEq/hr in central lineGive insulin:Initial bolus dose followed by infusion of regular insulinNOTE: insulin may adsorb into the plastic or glass container, decreasing its potency – flush IV line with at least 50 ml of insulin infusion before connecting to patientClosely monitor blood sugar at least hourlyKeep a syringe of 50% dextrose immediately available for hypoglycemiaTreat Acidosis:pH should rise as fluids and insulin are replacedUse bicarbonate only for extreme acidosis: pH < 7.0
36Patient Education: Hyperglycemia Follow sick day rulesMonitor capillary glucose every 4 hoursContinue to take insulin or oral antidiabetic agentsDrink 8-12 ounces of liquids every hourContinue to eat at regular timesGet plenty of restCall physician for persistent nausea, vomiting, glucose elevation despite medication, high or increasing fever, diarrheaPatient Education: HyperglycemiaFollow sick day rules:Monitor capillary glucose every 4 hoursContinue to take insulin or oral antidiabetic agentsDrink 8-12 ounces of liquids every hourContinue to eat at regular timesGet plenty of restCall physician for persistent nausea, vomiting, glucose elevation despite medication, high or increasing fever, diarrhea
37Hyperosmolar Hyperglycemic Non-ketotic Syndrome (HHNS) Type II diabetic, some insulin secretedIngests large amount sugar, decreased fluidIn HHNS the hyperglycemia is more profound, increasing the blood osmolarity and diuresis.DehydrationElectrolyte imbalanceDecreased neurologic functionSeizuresHyperosmolar Hyperglycemic Non-ketotic Syndrome (HHNS)The type II diabetic secretes just enough insulin to prevent ketosis but not hyperglycemia. When this patient ingests large amounts of sugar along with decreased amounts of fluid, this syndrome will develop.In HHNS the hyperglycemia is more profound, increasing the blood osmolarity and diuresis. The patient has severe, life-threatening dehydration and electrolyte imbalance. Neurologic function decreases and the patient may have seizures.
38Collaborative Management First priority: replace fluid volume with intravenous saline.The preferred solution is 0.45% saline to correct the water deficit rapidly and the sodium deficit more slowly (to prevent seizures)Give 1000 ml/hr until central venous pressure, blood pressure and urine output are adequateReduce the rate to ml/hr until the estimated water deficit is replacedMonitor hourly for: cerebral edema, mental status changes, abnormal neurologic signs, signs of fluid overloadCollaborative ManagementFirst priority: replace fluid volume with intravenous saline.The preferred solution is 0.45% saline to correct the water deficit rapidly and the sodium deficit more slowly (to prevent seizures)Give 1000 ml/hr until central venous pressure, blood pressure and urine output are adequateReduce the rate to ml/hr until the estimated water deficit is replacedMonitor hourly for: cerebral edema, mental status changes, abnormal neurologic signs, signs of fluid overload
39Insulin:Intravenous insulin is given at a rate of 10 units/hr to supplement blood glucose reduction by rehydration.Blood sugar should decrease no faster than 10% per hour.
40Insulin Injection Sites Photo source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK),
41Common Signs and Symptoms of Hypoglycemia Early SymptomsHungerTremblingPalpitationsAnxietySweatingClamminessCommon Signs and Symptoms of HypoglycemiaEarly Symptoms Might Include Hunger,Trembling, Palpitations, Anxiety, Sweating, ClamminessLate Symptoms Might Include Difficulty thinking, Confusion, Headache, Seizures
42Late Symptoms Might Include Difficulty thinkingConfusionHeadacheSeizures
43Emergency Treatment: Hypoglycemia Glucagon intravenous orDextrose 50% intravenous – repeat according to blood sugarNOTE: high glucose will damage the tissue if it leaks5% dextrose in water intravenously
44Patient Teaching: Hypoglycemia Check blood sugar: if less than 60 mg/dL:Treat with 15 grams of glucose or equivalentWait 15 minutes and retestIf blood sugar is still less than 60 mg/dL, treat with another 15 grams of glucosePatient Teaching: Hypoglycemia1. Check blood sugar: if less than 60 mg/dL:Treat with 15 grams of glucose or equivalent: 3 Glucose Tablets, or a 10 oz. glass of skim milk, or a 4 oz. glass of juice. Avoid eating candy bars or chocolate for a quick blood sugar fix, as they contain fat and will slow the rise of sugar in the blood.Wait 15 minutes and retest. It takes 15 minutes for the food or glucose tablets to raise your blood sugar.If blood sugar is still less than 60 mg/dL, treat with another 15 grams of glucose.
45To prevent hypoglycemia: Eat and take medications on timeMake sure to eat enough food for the medication you are takingDo not drink alcohol without eating foodCarry some form of carbohydrates with you in case there is a meal delayBe aware of the time of day - if you are taking insulin, your blood sugar will be the lowest before a mealPlan your exerciseReport all unexplained hypoglycemia episodes to your doctor2. To prevent hypoglycemia:Eat and take medications on time.Make sure to eat enough food for the medication you are taking.Do not drink alcohol without eating food.Be prepared and carry some form of carbohydrates with you in case there is a meal delay.Be aware of the time of day - if you are taking insulin, your blood sugar will be the lowest before a meal.Plan your exercise. Eat more to cover unplanned exercise which may lower your blood sugar too much.Report all unexplained hypoglycemia episodes to your doctor.
46Diabetic Diet Different categories Portion size 1600-2800 calories The Diabetes Food Pyramid is a little different than the USDA Food Guide Pyramid because it groups foods based on their carbohydrate and protein content instead of their classification as a food. To have about the same carbohydrate content in each serving, the portion sizes are a little different too. For example: you will find potatoes and other starchy vegetables in the grains, beans and starchy vegetables group instead of the vegetables group. Cheese is in the meat group instead of the milk group. A serving of pasta or rice is 1/3 cup in the Diabetes Food Pyramid and ½ cup in the USDA pyramid. Fruit juice is ½ cup in the Diabetes Food Pyramid and ¾ cup in the USDA pyramid. This difference is to make the carbohydrate about the same in all the servings listed. The Diabetes Pyramid gives a range of servings. If you follow the minimum number of servings in each group, you would eat about 1600 calories and if you eat at the upper end of the range, it would be about 2800 calories. Most women would eat at the lower end of the range and many men would eat in the middle to high end of the range if they are very active. The exact number of servings you need depends on your diabetes goals, calorie and nutrition needs, your lifestyle, and the foods you like to eat. Divide the number of servings you should eat among the meals and snacks you eat each day.Diabetes Food PyramidSource: National Diabetes Education Program/NIH
47Diabetes Food Serving per Day Grains and starches: 6-11Vegetables: 3-5Fruit: 2-4Milk: 2-3Meat and meat substitutes: 4-6 ozFats, sweets and alcohol: 0?Following is a description of each group and the recommended range of servings of each group.Grains and Starches At the base of the pyramid are bread, cereal, rice, and pasta. These foods contain mostly carbohydrates. The foods in this group are made mostly of grains, such as wheat, rye, and oats. Starchy vegetables like potatoes, peas, and corn also belong to this group, along with dry beans such as black eyed peas and pinto beans. Starchy vegetables and beans are in this group because they have about as much carbohydrate in one serving as a slice of bread. So, you should count them as carbohydrates for your meal plan. Choose 6-11 servings per day. Remember, not many people would eat the maximum number of servings. Most people are toward the lower end of the range. Serving sizes are: 1 slice of bread, ¼ of a bagel (1 ounce), ½ an English muffin or pita bread, 1, 6-inch tortilla, ¾ cup dry cereal, ½ cup cooked cereal, ½ cup potato, yam, peas, corn, or cooked beans; 1 cup winter squash, 1/3 cup of rice or pastaVegetablesAll vegetables are naturally low in fat and good choices to include often in your meals or have them as a low calorie snack. Vegetables are full of vitamins, minerals and fiber. This group includes spinach, chicory, sorrel, Swiss chard, broccoli, cabbage, bok choy, brussels sprouts, cauliflower, and kale, carrots, tomatoes, cucumbers, and lettuce. Starchy vegetables such as potatoes, corn, peas, and lima beans are counted in the starch and grain group for diabetes meal planning. Choose at least 3-5 servings per day. A serving is: 1 cup raw or ½ cup cookedFruitThe next layer of the pyramid is fruits, which also contain carbohydrates. They have plenty of vitamins, minerals, and fiber. This group includes blackberries, cantaloupe, strawberries, oranges, apples, bananas, peaches, pears, apricots, and grapes. Choose 2-4 servings per day. A serving is: ½ cup canned fruit, 1 small fresh fruit, 2 tbs dried fruit, 1 cup of melon or raspberries, 1 ¼ cup of whole strawberriesMilkMilk products contain a lot of protein and calcium as well as many other vitamins. Choose non-fat or low-fat dairy products for the great taste and nutrition without the saturated fat. Choose 2-3 servings per day. A serving is: 1 cup non-fat or low-fat milk, 1 cup of yogurt,Meat and Meat SubstitutesThe meat group includes beef, chicken, turkey, fish, eggs, tofu, dried beans, cheese, cottage cheese and peanut butter. Meat and meat substitutes are great sources of protein and many vitamins and minerals.Choose from lean meats, poultry and fish and cut all the visible fat off meat. Keep your portion sizes small. Three ounces is about the size of a deck of cards. You only need 4-6 ounces for the whole day. Choose 4-6 oz per day divided between meals. Equal to 1 oz of meat: ¼ cup cottage cheese, 1 egg, 1 Tbsp peanut butter, ½ cup tofuFats, Sweets, and AlcoholThings like potato chips, candy, cookies, cakes, crackers, and fried foods contain a lot of fat or sugar. They aren't as nutritious as vegetables or grains. Serving sizes include: ½ cup ice cream, 1 small cupcake or muffin, 2 small cookies
48Glycemic IndexRanks carbohydrate-rich foods according to their glycemic response.Foods that raise the blood glucose level quickly have a higher GI rating than foods that raise blood glucose level more slowly. In general, the lower the rating, the better the quality of carbohydrate.Choose low and medium GI foods more often than high GI foods.A GI of 55 or less ranks as low, a GI of 56 to 69 is medium, and a GI of 70 or more ranks as high.Glycemic IndexThe Glycemic Index (GI) ranks carbohydrate-rich foods according to their glycemic response. Foods that raise the blood glucose level quickly have a higher GI rating than foods that raise blood glucose level more slowly. In general, the lower the rating, the better the quality of carbohydrate.Not only do low GI foods raise blood glucose more slowly and to a less dramatic peak than higher GI foods, but most low GI foods are all-around healthier choices.Low GI foods are usually lower in calories and fat, while also being high in fiber, nutrients and antioxidants.Choosing low GI foods more often may help increase levels of HDL (healthy) cholesterol in the blood and might help control appetite, as they tend to keep you feeling fuller, longer.Choose low and medium GI foods more often than high GI foods. A GI of 55 or less ranks as low, a GI of 56 to 69 is medium, and a GI of 70 or more ranks as high.
49LOW GLYCEMIC INDEX FOODS (55 or less) choose most often Skim milkPlain YogurtSoy beverageApple/plum/orangeSweet potatoOat bran breadAll-Bran™Converted or Parboiled ricePumpernickel breadAl dente (firm) pastaLentils/kidney/baked beansChick peas
50MEDIUM GLYCEMIC INDEX FOODS (56-69) choose more often BananaPineappleRaisinsNew potatoesOatmealSplit pea or green pea soupBrown riceCouscousBasmati riceShredded wheat cerealWhole wheat breadRye breadPopcorn
51Teach: ExerciseRegular exercise is essential for carbohydrate metabolism and insulin sensitivity.Hypoglycemia can occur during and for 24 hours after exerciseCheck glucose levels before and after exerciseDo not exercise within one hour of insulin injection or at peak insulin actionInsulin dosage may need to be decreased before exerciseTeach: ExerciseRegular exercise is essential for carbohydrate metabolism and insulin sensitivity.Hypoglycemia can occur during and for 24 hours after exerciseCheck glucose levels before and after exerciseDo not exercise within one hour of insulin injection or at peak insulin actionInsulin dosage may need to be decreased before exerciseA carbohydrate snack for exercise will help maintain glucose levels: g for every minutes of exerciseTake a simple sugar (hard candy) when exercising if symptoms of hypoglycemia occurLow intensity aerobic exercise for longer periods is most effective: walking briskly, running, jogging, stationary or regular bicycling, swimming, dancing
52Teach: Exercise (cont…) A carbohydrate snack for exercise will help maintain glucose levels: g for every minutes of exerciseTake a simple sugar (hard candy) when exercising if symptoms of hypoglycemia occurLow intensity aerobic exercise for longer periods is most effectiveTeach: ExerciseRegular exercise is essential for carbohydrate metabolism and insulin sensitivity.Hypoglycemia can occur during and for 24 hours after exerciseCheck glucose levels before and after exerciseDo not exercise within one hour of insulin injection or at peak insulin actionInsulin dosage may need to be decreased before exerciseA carbohydrate snack for exercise will help maintain glucose levels: g for every minutes of exerciseTake a simple sugar (hard candy) when exercising if symptoms of hypoglycemia occurLow intensity aerobic exercise for longer periods is most effective: walking briskly, running, jogging, stationary or regular bicycling, swimming, dancing
53Complications Cardiovascular disease Kidney disease Retinopathy NeuropathyFoot complicationsSkin complicationsGastroparesisErectile dysfunctionDepressionComplicationsChronic hyperglycemia causes irreversible structural changes, decreased microcirculation and organ damage. Diabetes carries an increased risk for heart attack, stroke, and complications related to poor circulation. Good, consistent control of blood sugar will prevent these complications.Cardiovascular DiseaseThe most common complication of diabetes, extensive coronary artery disease leads to myocardial infarction in both type 1 and type 2 diabetics.Kidney Disease Diabetes can damage the kidneys, which not only can cause them to fail, but can also make them lose their ability to filter out waste products. Persistent albuminuria with a decreased glomerular filtration rate progresses to end-stage renal disease.Retinopathy Diabetes can cause eye problems and may lead to blindness. People with diabetes do have a higher risk of blindness than people without diabetes. Both hyper- and hypo-glycemia lead to eye changes. Cataracts occur at a younger age.Diabetic Neuropathy and Nerve Damage One of the most common complications of diabetes is diabetic neuropathy. Progressive deterioration of nerves affects the entire body, especially the lower extremities which may lead to amputation. The patient experiences decreased sensation along with the feeling that an extremity is asleep: tingling, burning, tightness or aching usually starts in the feet and progresses to the knee.Foot Complications People with diabetes can develop many different foot problems. Foot problems most often happen when there is nerve damage in the feet or when blood flow is poor.Skin Complications As many as one-third of people with diabetes will have a skin disorder caused or affected by diabetes at some time in their lives. In fact, such problems are sometimes the first sign that a person has diabetes. Luckily, most skin conditions can be prevented or easily treated if caught early.Gastroparesis and Diabetes Gastroparesis is delayed gastric emptying that affects people with both type 1 and type 2 diabetes. This may lead to malnutrition and hypoglycemia.Male Erectile DysfunctionThe inability to achieve and maintain an erection occurs at an earlier age and a higher rate than the general population. Depression Feeling down once in a while is normal. But some people feel a sadness that just won't go away. Life seems hopeless. Feeling this way most of the day for two weeks or more is a sign of serious depression.Photo source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK),
54TransplantationWhole pancreas or islet cell transplants will provide normal glucose control. Organ or cell availability continues to be limited. Potential complications include:long-term immunosuppressionvenous thrombosisrejectioninfection
55Endocrine Organs Hypothalamus Pituitary Thyroid Thymus Parathyroids Adrenal glandsPancreasOvaries/TestesWhat does each gland do?Hypothalamus: controls pituitaryPitiuitary: “master gland”Anterior lobe: growth hormone, ACTH (adrenal gland), TSH (thyroid gland), FSH ovaries, testes), LH (ovaries, testes), prolactin (mammary glands)Posterior lobe: ADH (re-asborb water), oxytocin (smooth muscle contraction)Thyroid: secretes T4 (metabolic rate), T3 & calcitonin (bone resorption)Parathyroids: secretes PTH (regulates serum calcium & phosphate)Adrenal glands:Medulla: secretes catecholamine (epinephrine, norepinephrine) – sympathetic responseCortex: secretes glucocorticoids (cortisol- metabolism, stress response), mineralocorticoids (aldosterone-sodium + water regulation), androgens & estrogenPancreas: enzymes (digestion), beta cells (insulin production)Source: U.S. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program
57Trans-Sphenoidal Hypophysectomy Neuro checksWatch! Diabetes InsipidusWatch dressing: Postnasal drip?Teach: avoid cough, blow nose, sneezeWatch for MeningitisReplace hormonesThyroidGlucocorticoidsNeuro checks q 1 hours x 24 hoursWatch! DI: excess urine production will lead to dehydration – replace fluids, give vasopressin (Pirtressin or ADH)Watch dressing: change mustache dressing as ordered (may leave tape layers) Postnasal drip: Is this CSF? How can you tell? (halo sign=light yellow at edge of drainage; tests positive for glucose) keep HOB upTeach to avoid coughing: increases incisional pressure, can cause CSF leakMeningitis: headache, fever, nuchal rigidity (Brudzinski’s & Kernig’s signs)Replace hormones: will need permanent replacement
58Thyroid Disorders Hyperthyroidism (Grave’s Disease) Hypothyroidism (Myxedema)Fatigue, hair loss, cold intolerance, constipationHyperthyroid Rx: suppress gland with PTU or Tapazole; then radioactive iodine or thyroidectomyHypothyroidism: thyroid replacement
59Thyroidectomy Position: Semi-fowler’s, avoid neck extension Watch! Hemorrhage 1st 24 hoursLaryngeal stridorTetany (what are the early signs?)Laryngeal nerve damageThyroid stormHemorrhage: check dressing frequently – will probably be a drainStridor: use humidified oxygen, keep tracheostomy tray at bedsideTetany: If parathyroid glands removed accidentally, hypocalcemia results. Early signs of low calcium = numbness and tingling of mouth, toes, fingersLaryngeal nerve: hoarseness (also may be sign of impending airway occlusion)Thyroid storm: rare unless patient not given anti-thyroid drugs preop. S&S: fever, tachycardia, systolic hypertension
60Parathyroid Disorders HyperparathyroidismHypercalcemiaBone damageHypoparathyroidismMuscle crampsChvostek’s & Trousseau’s signsHypoparathyroid: give IV calcium
61Adrenal Disorders Addison’s crisis Cushing’s disease Hypovolemia, low Na+HypoglycemiaHyperkalemia => acidosisCushing’s diseaseMoon face, buffalo hump, truncal obesityHypertensionBruisingAdrenal insufficiency. This condition is characterized by decreased function of the adrenal cortex and the consequent underproduction of adrenal corticosteroid hormones. The symptoms of adrenal insufficiency may include weakness, fatigue, abdominal pain, nausea, dehydration, and skin changes. Doctors treat adrenal insufficiency by giving replacement corticosteroid hormones.Addison’s: replace cortisol, sodium, water, sugar; kayexalate to get rid of KCushing’s: Whose fault is it – the adrenals or the pituitary? If it’s an adrenal tumor, surgically remove.
62Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the Microsoft Office Clip Art Gallery.