Med/Surg I Module 4, Part 2 of 4 Connective Tissue Diseases Rheumatoid Arthritis Lupus Erythematosus Gout

Rheumatoid Arthritis Pain, morning stiffness Early: Joint inflammation Late: deformities Photo courtesy of Charles Goldberg, M.D., UCSD Image Bank, http://medicine.ucsd.edu/clinicalimg/upper-rheumatoid-arthritis.html

Complications Baker’s cysts: enlarged popliteal bursae Synovitis, effusions in joints Subcutaneous nodules: usually ulnar surface of arm, fingers, along Achilles tendon Sjogren’s syndrome: dry eyes, mouth and vagina – secretory glands are obstructed Felty’s syndrome: hepatosplenomegaly, leucopenia Caplan’s syndrome: rheumatoid nodules in lungs

Laboratory Assessment Inflammatory connective tissue disease Rheumatoid factor (RF) Antinuclear antibody titer (ANA) Erythrocyte sedimentation rate (ESR)

Collaborative Management Analgesic/anti-pyretic/anti-inflammatories Disease-modifying anti-rheumatic drugs (DMARDs) Methotrexate (Rheumatrex): mainstay of therapy Watch! For bone marrow suppression & liver toxicity Lefunomide (Arava): Similar to methotrexate, same side effects Medications Analgesic/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 pain Watch! For bone marrow suppression Watch! Liver toxicity – no alcohol Lefunomide (Arava): Similar to methotrexate, same side effects Immunosuppressants: azathioprine (Imuran), cyclophosphamide (cytoxan), prednisone Biological response modifiers: neutralize tumor necrosis factor binding - etanercept (Enbrel) adalimumab (Humira) Glucocorticoids (steroids): anti-inflammatory, high risk complications Watch! Gastrointestinal inflammation Watch! Blood sugar elevation Gold therapy: auranofin (Ridaura) oral or gold sodium thiomalate (Myochrysine)

Collaborative Management, cont… Immunosuppressants: Biological response modifiers: Glucocorticoids (steroids) Watch! Gastrointestinal inflammation & blood sugar elevation Gold therapy Medications Analgesic/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 pain Watch! For bone marrow suppression Watch! Liver toxicity – no alcohol Lefunomide (Arava): Similar to methotrexate, same side effects Immunosuppressants: azathioprine (Imuran), cyclophosphamide (cytoxan), prednisone Biological response modifiers: neutralize tumor necrosis factor binding - etanercept (Enbrel) adalimumab (Humira) Glucocorticoids (steroids): anti-inflammatory, high risk complications Watch! Gastrointestinal inflammation Watch! Blood sugar elevation Gold therapy: auranofin (Ridaura) oral or gold sodium thiomalate (Myochrysine)

Alternative Therapies Hypnosis, acupuncture, imagery, magnet or music therapy Omega-3 fatty acids: fish oil capsules Antioxidant vitamins A, C, E Trace elements: zinc, selenium, copper, iron Ask patient if he/she is taking any of these…

Non-pharmacologic Therapies Rest and positioning for comfort Ice during inflammation Heat: paraffin wax dips or hot packs to manage pain, increase mobility

Lupus 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 skin Discoid (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

Collaborative Management: Discoid Lupus Rash: Topical cortisone Skin protection from sun, ultra-violet Teach: mild soap, no perfumes, use lotion, avoid drying substances Alopecia (hair loss) is common: mild protein shampoo

Exacerbation Fever (major sign), abdominal pain, increased fatigue, headache, dizziness Caused by stress Signs of inflammation in affected organs Will need hospitalization, may become rapidly critically ill Systemic corticosteroids Cytotoxics: Imuran, Cytoxan

Gout Manifestations: Renal calculi (stones) Hyper-uricemia - elevated serum uric acid Joint inflammation - very painful Tophi - sodium urate crystal deposits, commonly on outer ear, fingers Image Source: UCSD, Catalog of Clinical Images. Photography by Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical Center http://medicine.ucsd.edu/clinicalimg/Upper-tophaceous-gout4.html Gout Urate crystals deposit in joints and other body tissues, causing inflammation Manifestations Renal calculi (stones) Hyper-uricemia: elevated serum uric acid Joint inflammation: very painful

Acute Episode of Gout Sudden, severe joint pain and swelling Shiny red or purple skin around the joint Extreme tenderness in the joint area

Collaborative Management of Acute Episode Colchicine (Colsalide) NSAID Allopurinol (Zyloprim) or probenecid (Benemid) Watch! Aspirin and diuretics may start an attack Avoid emotional stress Low-urine diet: avoid organ meats, shellfish, oily fish with bones Avoid excess alcohol Prevent stones - drink more fluids, increase acidity of urine with alkaline ash foods (citrus, milk) Collaborative Management of Acute Episode Colchicine (Colsalide) NSAID Allopurinol (Zyloprim) or probenecid (Benemid) to inhibit uric acid formation and promote its excretion Watch! Aspirin and diuretics may start an attack Avoid emotional stress Diet: low-urine diet Avoid organ meats, shellfish, oily fish with bones Avoid excess alcohol. Prevent stones: drink more fluids, increase acidity of urine with alkaline ash foods (citrus, milk)

Human Immunodeficiency Virus (HIV) Effects of HIV Infection HIV, 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, http://commons.wikimedia.org/wiki/Image:800px-HIV_Viron.png

Diagnosis Leukopenia Less than 500-16000 CD4+ cells/mm3 in AIDS Enzyme-linked immunosorbent assay (ELISA) Western blot Viral load testing Quantitative RNA assays P24 Antigen assay Lymphocyte count: leukopenia CD4+ cell count: less than 500-16000 cells/mm3 in AIDS Enzyme-linked immunosorbent assay (ELISA): inexpensive screen for HIV antibodies Western blot: more accurate HIV antibody detection Viral load testing: monitor disease progression Quantitative RNA assays: detect viral load in small amounts P24 Antigen assay: quantifies amount of HIV viral core protein for treatment followup

Manifestations HIV: Fever, chills, night sweats, headaches, muscle aches AIDS: Signs of an opportunistic infection: shortness of breath or dry cough fatigue weight loss, nausea and vomiting, diarrhea swollen lymph nodes visual changes, memory loss and confusion seizures, skin lesions HIV: Fever, chills, night sweats, headaches, muscle aches AIDS: 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

Prevention Sexual Parenteral Health care workers Perinatal Prevention of HIV Infection Sexual: 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.

Immunocompromised? No crowds Don’t share personal items, bathe q day Wash hands, wash dishes, cups Low bacteria diet Avoid pet litter Check temperature daily No gardening Prevention of AIDS in Immunocompromised Patients Avoid crowds or ill people Do not share personal toilet articles: toothbrush, toothpaste, washcloth, deodorant Bathe daily: wash armpits, groin, genitals, anal area twice daily Clean toothbrush daily with dishwasher or bleach Wash hands thoroughly with antimicrobial soap before eating, drinking; after shaking hands, touching a pet, coming home, using toilet Eat low bacteria diet: avoid salads, raw fruit and vegetables, undercooked meat, pepper, paprika Wash dishes, cups between use Do not drink water standing more than 15 minutes Avoid changing pet litter boxes or use gloves Avoid turtles and reptiles as pets Do not feed pets raw or undercooked meat Take your temperature at least once a day Report 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 urination Take all medications as prescribed Do not dig in the garden or work with houseplants Avoid travel to areas with poor sanitation

Anti-HIV Drugs Category Action Examples Nucleoside analog reverse transcriptase inhibitors Inhibit HIV replication zidovudine (Retrovir), didanosine (Videx), zalcitabine (HIVID), Non-nucleoside analog reverse transcriptase inhibitors Suppress viral replication, do not kill the virus nevirapine (Viramune), efavirenz (Sustiva) Protease inhibitors Block protease enzyme, prevents viral replication ritonavir (Norvir), indinavir (Crixivan) Fusion inhibitors Block fusion of HIV with host cell enfuvirtide (Fuzeon)

Opportunistic Infections Pneumocystis carinii (most common) Toxoplasmosis gondii - from cat feces, undercooked meat Candida albicans Cryptococcus neoformans Histoplasma capsulatum Mycobacterium avium Mycobacterium tuberculosis Cytomegalovirus (CMV) Herpes simplex Kaposi’s sarcoma: Opportunistic Infections are not a threat to persons with normal immune systems, life-threatening risk for immune suppressed: Manifestation PCP Pneumonia (PCP)- most common Toxoplasmosis Neurologic deterioration Candida GI inflammation Cryptococcus Meningitis Histoplasma Respiratory initially Mycobacterium avium Systemic, respiratory Mycobacterium tuberculosis CMV Retinitis, colitis, encephalitis Herpes simplex Peri-rectal, oral, genital Kaposi’s sarcoma Skin, mucous membrane lesions Image Source: Wikimedia Commons, Public Domain, http://commons.wikimedia.org/wiki/Image:Kaposi%27s_Sarcoma.jpg

Organ Transplants Autograft Highest success rate Isograft Highest success rate Allograft ↑ with compatibility Xenograft lowest success rate Autograft: Transplant of patient’s own tissue Isograft: Transplant from identical twin Allograft: Grafts between members of the same species with different genotypes Xenograft: Transplant from animal species to a human HighestHighest Increases with histocompatibility: human leukocyte antigen (HLA) type, blood type lowest

Nursing Care Protect from infection Prevent rejection Patient teaching Strict aseptic technique with dressings, invasive lines Watch for subtle signs of infection Monitor WBC, especially bands; monitor labs related to organ transplanted Protective/neutropenic isolation as indicated Supply adequate nutrition Change invasive catheters, lines and sites, remove lines as soon as possible Prevent transplant rejection Give immunosuppressants Monitor for adverse effects of medications Assess for graft rejection: tenderness, erythema, swelling over site; sudden weight gain, edema, hypertension; chills & fever; malaise, increased WBC Monitor laboratory studies for function of the transplanted organ Assess for signs of graft-versus-host disease: maculopapular rash, erythema, hair loss, abdominal cramping & diarrhea, jaundice with elevated bilirubin and liver enzymes Patient teaching Importance of continuing medication Report signs of rejection Hand washing Mouth care Teach visitors to avoid contact if ill Photo source: Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Kidtransplant.jpg Public Domain, US Government

Transplant Rejection Hyperacute: Immediate or up 2-3 days after new tissue transplanted Acute: 1 week to 3 months after transplant Chronic: 4 months to years after transplant Graft-versus-Host Disease: First 100 days Transplant Rejection Hyperacute: 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.

Rejection Prophylaxis/Rx Cyclosporine (Sandimmune, Neoral) Azathioprine (Imuran) Mycophenolate (CellCept) Tacrolimus FK 506 (Prograf) Sirolimus (Rapamune) Corticosteroids (prednisone) Interleukin-2 receptor antagonists Antithymocyte 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 grapefruit Nephrotoxic, neurotoxic, hepatoxic; hyperglycemia, increases body & facial hair; gingival hyperplasia Azathioprine (Imuran) Take at same time every day. Watch for signs of infection or bleeding. Hepatotoxic, nausea, vomiting, leucopenia, thrombocytopenia Mycophenolate (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, sepsis Tacrolimus FK 506 (Prograf) Similar to cyclosporine. It is much more potent (weight for weight); incidence of infections may be higher; avoid grapefruit juice Diarrhea, vomiting, stomach pain, loss of appetite, insomnia (neurotoxicity); high blood sugar Sirolimus (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, thrombocytopenia Corticosteroids (prednisone) Maintenance immunosuppression: know and watch for side effects Cushing's syndrome, osteoporosis, myopathy, cataracts, peptic ulcers; Glucose intolerance, hypercholesterolemia, skin fragility, adrenal suppression Interleukin-2 receptor antagonists Given intravenously in hospital to treat or prevent acute rejection Antithymocyte globulin (Atgam) Fever, chills, thrombocytopenia, leucopenia, rash Muromonab –CD3 (Orthoclone OKT3) Premedicate with hydrocortisone, acetaminophen, diphenhydramine; monitor vital signs closely Chills, fever, tachycardia, headache, tremor, blood pressure changes, nausea, vomiting, diarrhea, chest pain, dyspnea; Anaphylaxis

Anaphylaxis Difficulty breathing Wheezing Abnormal high-pitched breath sounds Confusion, slurred speech Rapid, weak pulse, palpitations Skin redness, hives, generalized itching Profound hypotension Bronchospasm and laryngospasm Pulmonary edema Anaphylaxis 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 breathing Wheezing Abnormal high-pitched breath sounds Confusion, slurred speech Rapid, weak pulse, palpitations Skin redness, hives, generalized itching Profound hypotension Bronchospasm and laryngospasm Pulmonary edema

Emergency Management Airway: Assess for laryngospasm, stridor – may need immediate intubation Breathing: oxygen at high flow rate, 10-15 L/minute, monitor oxygen saturation Circulation: Assess for dysrhythmias, hypotension

Reverse the Reaction Place tourniquet per protocol proximal to allergen point of entry Epinephrine (Adrenalin) intravenous: (Does patient have an Epi-Pen?) Diphenhydramine (Benadryl) intravenous Dopamine for persistent hypotension to vasoconstrict Give antidote if appropriate Reverse the Reaction: Place tourniquet per protocol proximal to allergen point of entry Epinephrine (Adrenalin) intravenous: constricts blood vessels, dilates bronchioles (Does patient have an Epi-Pen?) Diphenhydramine (Benadryl) intravenous Dopamine for persistent hypotension to vasoconstrict Give antidote if appropriate

Stabilize Intravenous fluids: crystalloids, colloids Monitor for decompensation, repeat epinephrine

Diabetes Mellitus Type 1 Type 2 Type 3 (gestational) Type 1 Diabetes Mellitus Type 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 Mellitus Unlike 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, http://commons.wikimedia.org/wiki/Image:Orange_juice_1.jpg

Diagnosis Fasting blood glucose Oral glucose tolerance test Glycosylated hemoglobin assay (HgA1C) Serum protein and albumin 24-hour urine creatinine clearance

Common Signs and Symptoms of Hyperglycemia Other Symptoms Might Include Fatigue Blurred vision Weight loss Poor wound healing (cuts, scrapes, etc.) Dry mouth Dry or itchy skin Impotence (male) Recurrent infections such as vaginal yeast infections, groin rash, or external ear infections (swimmers ear) Common Signs and Symptoms of Hyperglycemia

Common Signs and Symptoms of Hyperglycemia The Classic Symptoms Polyphagia (frequently hungry) Polyuria (frequently urinating) Polydipsia (frequently thirsty) Common Signs and Symptoms of Hyperglycemia

Ketoacidosis Hyperglycemia: > 250 mg/dL Dehydration: hot, dry, flushed skin Metabolic acidosis: pH < 7.3 Electrolyte imbalance: loss of potassium, sodium Nausea and vomiting Kussmaul’s respirations: increased rate and depth Ketone breath: fruity, alcohol-like

Treatment for Ketoacidosis Fluid replacement Replace electrolytes Give insulin: Initial bolus dose followed by infusion of regular insulin NOTE: 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 patient Closely monitor blood sugar at least hourly Keep a syringe of 50% dextrose immediately available for hypoglycemia Treat Acidosis Treatment for Ketoacidosis Fluid replacement: 1 L 0.9% intravenous saline over one hour followed by 0.45% saline – may need 6-10 liters in first 24 hours When blood sugar drops below 250 mg/dL give 5% dextrose in 0.45% saline NOTE: If serum osmolarity falls too fast, hypoglycemia and cerebral edema can result Electrolytes: Replace potassium NOTE: no faster than 10 mEq/hour in peripheral IV or 20 mEq/hr in central line Give insulin: Initial bolus dose followed by infusion of regular insulin NOTE: 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 patient Closely monitor blood sugar at least hourly Keep a syringe of 50% dextrose immediately available for hypoglycemia Treat Acidosis: pH should rise as fluids and insulin are replaced Use bicarbonate only for extreme acidosis: pH < 7.0

Patient Education: Hyperglycemia Follow sick day rules Monitor capillary glucose every 4 hours Continue to take insulin or oral antidiabetic agents Drink 8-12 ounces of liquids every hour Continue to eat at regular times Get plenty of rest Call physician for persistent nausea, vomiting, glucose elevation despite medication, high or increasing fever, diarrhea Patient Education: Hyperglycemia Follow sick day rules: Monitor capillary glucose every 4 hours Continue to take insulin or oral antidiabetic agents Drink 8-12 ounces of liquids every hour Continue to eat at regular times Get plenty of rest Call physician for persistent nausea, vomiting, glucose elevation despite medication, high or increasing fever, diarrhea

Hyperosmolar Hyperglycemic Non-ketotic Syndrome (HHNS) Type II diabetic, some insulin secreted Ingests large amount sugar, decreased fluid In HHNS the hyperglycemia is more profound, increasing the blood osmolarity and diuresis. Dehydration Electrolyte imbalance Decreased neurologic function Seizures Hyperosmolar 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.

Collaborative 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 adequate Reduce the rate to 100-200 ml/hr until the estimated water deficit is replaced Monitor hourly for: cerebral edema, mental status changes, abnormal neurologic signs, signs of fluid overload Collaborative 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 adequate Reduce the rate to 100-200 ml/hr until the estimated water deficit is replaced Monitor hourly for: cerebral edema, mental status changes, abnormal neurologic signs, signs of fluid overload

Insulin: 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.

Insulin Injection Sites Photo source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez/index.htm

Common Signs and Symptoms of Hypoglycemia Early Symptoms Hunger Trembling Palpitations Anxiety Sweating Clamminess Common Signs and Symptoms of Hypoglycemia Early Symptoms Might Include Hunger,Trembling, Palpitations, Anxiety, Sweating, Clamminess Late Symptoms Might Include Difficulty thinking, Confusion, Headache, Seizures

Late Symptoms Might Include Difficulty thinking Confusion Headache Seizures

Emergency Treatment: Hypoglycemia Glucagon intravenous or Dextrose 50% intravenous – repeat according to blood sugar NOTE: high glucose will damage the tissue if it leaks 5% dextrose in water intravenously

Patient Teaching: Hypoglycemia Check blood sugar: if less than 60 mg/dL: Treat with 15 grams of glucose or equivalent Wait 15 minutes and retest If blood sugar is still less than 60 mg/dL, treat with another 15 grams of glucose Patient Teaching: Hypoglycemia 1. 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.

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 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 Report all unexplained hypoglycemia episodes to your doctor 2. 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.

Diabetic 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. http://www.diabetes.org/nutrition-and-recipes/nutrition/foodpyramid.jsp Diabetes Food Pyramid Source: National Diabetes Education Program/NIH http://ndep.nih.gov/diabetes/MealPlanner/pyramid.htm

Diabetes Food Serving per Day Grains and starches: 6-11 Vegetables: 3-5 Fruit: 2-4 Milk: 2-3 Meat and meat substitutes: 4-6 oz Fats, 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 pasta Vegetables All 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 cooked Fruit The 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 strawberries Milk Milk 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 Substitutes The 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 tofu Fats, Sweets, and Alcohol Things 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 http://www.diabetes.org/nutrition-and-recipes/nutrition/foodpyramid.jsp

Glycemic Index 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. 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 Index The 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.

LOW GLYCEMIC INDEX FOODS (55 or less) choose most often Skim milk Plain Yogurt Soy beverage Apple/plum/orange Sweet potato Oat bran bread All-Bran™ Converted or Parboiled rice Pumpernickel bread Al dente (firm) pasta Lentils/kidney/baked beans Chick peas

MEDIUM GLYCEMIC INDEX FOODS (56-69) choose more often Banana Pineapple Raisins New potatoes Oatmeal Split pea or green pea soup Brown rice Couscous Basmati rice Shredded wheat cereal Whole wheat bread Rye bread Popcorn

Teach: Exercise Regular exercise is essential for carbohydrate metabolism and insulin sensitivity. Hypoglycemia can occur during and for 24 hours after exercise Check glucose levels before and after exercise Do not exercise within one hour of insulin injection or at peak insulin action Insulin dosage may need to be decreased before exercise Teach: Exercise Regular exercise is essential for carbohydrate metabolism and insulin sensitivity. Hypoglycemia can occur during and for 24 hours after exercise Check glucose levels before and after exercise Do not exercise within one hour of insulin injection or at peak insulin action Insulin dosage may need to be decreased before exercise A carbohydrate snack for exercise will help maintain glucose levels: 15-30 g for every 30-60 minutes of exercise Take a simple sugar (hard candy) when exercising if symptoms of hypoglycemia occur Low intensity aerobic exercise for longer periods is most effective: walking briskly, running, jogging, stationary or regular bicycling, swimming, dancing

Teach: Exercise (cont…) A carbohydrate snack for exercise will help maintain glucose levels: 15-30 g for every 30-60 minutes of exercise Take a simple sugar (hard candy) when exercising if symptoms of hypoglycemia occur Low intensity aerobic exercise for longer periods is most effective Teach: Exercise Regular exercise is essential for carbohydrate metabolism and insulin sensitivity. Hypoglycemia can occur during and for 24 hours after exercise Check glucose levels before and after exercise Do not exercise within one hour of insulin injection or at peak insulin action Insulin dosage may need to be decreased before exercise A carbohydrate snack for exercise will help maintain glucose levels: 15-30 g for every 30-60 minutes of exercise Take a simple sugar (hard candy) when exercising if symptoms of hypoglycemia occur Low intensity aerobic exercise for longer periods is most effective: walking briskly, running, jogging, stationary or regular bicycling, swimming, dancing

Complications Cardiovascular disease Kidney disease Retinopathy Neuropathy Foot complications Skin complications Gastroparesis Erectile dysfunction Depression Complications Chronic 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 Disease The 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 Dysfunction The 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), http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez/index.htm

Transplantation Whole pancreas or islet cell transplants will provide normal glucose control. Organ or cell availability continues to be limited. Potential complications include: long-term immunosuppression venous thrombosis rejection infection

Endocrine Organs Hypothalamus Pituitary Thyroid Thymus Parathyroids Adrenal glands Pancreas Ovaries/Testes What does each gland do? Hypothalamus: controls pituitary Pitiuitary: “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 response Cortex: secretes glucocorticoids (cortisol- metabolism, stress response), mineralocorticoids (aldosterone-sodium + water regulation), androgens & estrogen Pancreas: enzymes (digestion), beta cells (insulin production) Source: U.S. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program http://training.seer.cancer.gov/module_anatomy/unit10_3_dige_regions.html

Pituitary Disorders Secondary hormonal imbalances Acromegaly TSH, ACTH, FSH Acromegaly Overproduction of growth hormone Diabetes Insipidus ADH deficiency SIADH Excess ADH DI: vasopressin (DDAVP) + fluid replacement: weigh daily at home, I&O in hospital SIADH: fluid restriction, 3% saline

Trans-Sphenoidal Hypophysectomy Neuro checks Watch! Diabetes Insipidus Watch dressing: Postnasal drip? Teach: avoid cough, blow nose, sneeze Watch for Meningitis Replace hormones Thyroid Glucocorticoids Neuro checks q 1 hours x 24 hours Watch! 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 up Teach to avoid coughing: increases incisional pressure, can cause CSF leak Meningitis: headache, fever, nuchal rigidity (Brudzinski’s & Kernig’s signs) Replace hormones: will need permanent replacement

Thyroid Disorders Hyperthyroidism (Grave’s Disease) Hypothyroidism (Myxedema) Fatigue, hair loss, cold intolerance, constipation Hyperthyroid Rx: suppress gland with PTU or Tapazole; then radioactive iodine or thyroidectomy Hypothyroidism: thyroid replacement

Thyroidectomy Position: Semi-fowler’s, avoid neck extension Watch! Hemorrhage 1st 24 hours Laryngeal stridor Tetany (what are the early signs?) Laryngeal nerve damage Thyroid storm Hemorrhage: check dressing frequently – will probably be a drain Stridor: use humidified oxygen, keep tracheostomy tray at bedside Tetany: If parathyroid glands removed accidentally, hypocalcemia results. Early signs of low calcium = numbness and tingling of mouth, toes, fingers Laryngeal 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

Parathyroid Disorders Hyperparathyroidism Hypercalcemia Bone damage Hypoparathyroidism Muscle cramps Chvostek’s & Trousseau’s signs Hypoparathyroid: give IV calcium

Adrenal Disorders Addison’s crisis Cushing’s disease Hypovolemia, low Na+ Hypoglycemia Hyperkalemia => acidosis Cushing’s disease Moon face, buffalo hump, truncal obesity Hypertension Bruising Adrenal 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 K Cushing’s: Whose fault is it – the adrenals or the pituitary? If it’s an adrenal tumor, surgically remove.

Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.