Week 13 Discussion ~ Medical Surgical Nursing
What is the difference between Type I and Type II Diabetes?
Type I – an autoimmune disorder in which beta cells of the pancreas are destroyed in a genetically susceptible person and no insulin is produced. o Is abrupt in onset o Requires insulin injections to prevent hyperglycemia and ketosis and to sustain health. o Represents fewer than 10% of all people who have diabetes. o Occurs primarily in childhood or adolescence but can occur at any age. o Causes patients to be thin and underweight. o May follow a viral infection; viral infection can trigger autoimmune antibody formation. o Can lead to ketoacidosis. Type II – a problem resulting from a reduction in the ability of most cells to respond to insulin (insulin resistance), poor control of liver glucose output, and decreased beta cell function. o Is generally slow in onset o May require oral antidiabetic drug therapy or insulin to correct hyperglycemia. o Is usually found in middle-aged and older adults but may occur in younger people. o May be part of the metabolic syndrome. o Occurs more often among obese people. o Is usually not associated with ketoacidosis. o Represents about 90% of all people who have diabetes. o May be present for years before it is diagnosed.
Jennifer Cook
Page 1
Week 13 Discussion ~ Medical Surgical Nursing Features
Age at Onset
Type I Juvenile-onset Diabetes Ketosis-Prone Diabetes Insulin-Dependent Diabetes Mellitus (IDDM) Usually younger than 30 yr. Occurs at any age
Symptoms Etiology
Abrupt onset, thirst, hunger, increased urine output, weight loss Viral infection
Former Names
Pathology Antigen patterns Antibodies Endogenous Insulin and CPeptide Inheritance Nutritional Status Insulin Medical Nutrition Therapy
Pancreatic beta-cell destruction HLA-DR, HLA-DO ICA’s present at DX
Type II Adult-onset Diabetes Ketosis-Resistant Diabetes Non-Insulin-Dependent Diabetes Mellitus (NIDDM) Peaks in 50’s; may occur earlier Frequently none; thirst, fatigue, blurred vision, vascular or neural complications Not known Insulin resistance Dysfunctional pancreatic beta cell None None
None Complex Usually non-obese All dependent on insulin Mandatory
Low, normal, or high Dominant, multifactorial 60% to 80% obese Required for 20% to 30% Mandatory
What is the onset and peak action of regular and NPH insulin?
Regular – Short-Acting Insulin o Onset – 0.5 hr. o Peak - Humulin R: 2-4 hrs., Novolin R: 2.5-5 hrs. (Most Common ones) NPH – Intermediate-Acting Insulin (Most Common: includes Humulin N, Novolin N) o Onset – 1.5 hrs. o Peak – 4-12 hrs.
Jennifer Cook
Page 2
Week 13 Discussion ~ Medical Surgical Nursing
What are the current recommendations related to rotation of insulin injection sites? Absorption is fastest in the abdomen. Rotating injection site areas prevents lipohypertrophy (increased fat deposits in the skin) and lipoatrophy (loss of fatty tissue, leaving an uneven appearance). Rotation within one anatomic site is preferred to rotation from one area to another to prevent day-to-day changes in absorption. The abdomen (except for a 2-inch radius around the navel) is the preferred injection site area because it provides the most rapid insulin absorption. Client should select a site within his/her injection area that has not been used in the past month.
Jennifer Cook
Page 3
Week 13 Discussion ~ Medical Surgical Nursing What teaching would you give the client who will begin taking Metformin?
Take drug with food. Report symptoms of lactic acidosis: malaise, unusual muscle pain, respiratory distress, increasing somnolence, and abdominal distress. Report any illness that causes severe vomiting, diarrhea, or fever. Withhold Metformin for 48 hours before use of iodinated contrast materials used in certain radiographic studies. Tablets must be swallowed whole and never crushed or chewed.
Differentiate between signs and symptoms and treatment of hypo and hyperglycemia?
Hypoglycemia o S/S – Cool, clammy skin; anxious, nervous, irritable, mental confusion, seizures, coma, weakness, double vision, blurred vision, hunger, tachycardia, palpitations, Glucose < 70 mg/dL, negative for ketones. o TX – Mild: treat with 10 to 15 g of carbohydrate (can use glucose tablets or glucose gel, or various types of foods like fruit juice, hard candies, saltines, etc.); Moderate: treat with 15 to 30 g of rapidly absorbed carbohydrate, take additional food, such as low-fat milk or cheese, after 10 to 15 minutes. Severe: treat by administering 1 mg of glucagon IM or Subcu, give 2nd dose in 10 minutes if person remains unconscious, call PCP immediately, if still unconscious, transport to ER, give small meal when person wakes up and is no longer nauseated. Hyperglycemia o S/S – Warm, moist skin; dehydration, Rapid, deep respirations - Kussmaul type; acetone odor (“fruity” odor) to breath, mental status varies from alert to stuporous, obtunded, or frank coma, acidosis; hypercapnia; abdominal cramps, nausea, and vomiting, decreased neck vein filling, orthostatic hypotension, tachycardia, poor skin turgor, Glucose > 250 mg/dL, positive for ketones. o TX – Regular exercise, maintain diabetes diet regimen, insulin adjustments, regular monitoring of blood glucose levels, take medication as directed.
Jennifer Cook
Page 4
Week 13 Discussion ~ Medical Surgical Nursing
Jennifer Cook
Page 5
Week 13 Discussion ~ Medical Surgical Nursing
Describe DKA, cause and treatment? It occurs in people with Type I DM and is most often precipitated by illness, especially infection. It is characterized by uncontrolled hyperglycemia, metabolic acidosis, and increased production of ketones.
Cause – Lack of insulin and ketosis. Results from the combination of insulin deficiency and an increase in counter regulatory hormone release. Hormonal changes lead to increased use liver and kidney glucose production and decreased glucose regulatory hormones leads to the production of ketoacids with resultant ketonemia and metabolic acidosis. TX – (Pretty much the same as Hyperglycemia, except is an emergency situation). Blood glucose management, Fluid replacement, Electrolyte replacement, Insulin therapy, and Acidosis management (Hypokalemia is a common cause of death in the TX of DKA).
Jennifer Cook
Page 6
Week 13 Discussion ~ Medical Surgical Nursing
List possible complications and prevention interventions for a client with a cast.
Complications o Infection o Circulation Impairment o Peripheral Nerve damage o Skin Breakdown o Pneumonia or Atelectasis o Thromboembolism o Joint Contracture o Muscle Atrophy Prevention o Handle wet cast carefully with the palms of hands to prevent indentations and resultant pressure areas on the patient’s skin. o Prevent skin irritation from rough cast edges by petaling the cast with the placement of small strips of tape over the rough edges.
Jennifer Cook
Page 7
Week 13 Discussion ~ Medical Surgical Nursing o Cut a window over wound areas so wound can be observed and cared for. o Ensure cast is not too tight by inserting a finger between the cast and skin. o Notify the health care provider when a cast is too tight so it can be cut with a cast cutter to relieve pressure or allow tissue swelling. 2 halves can then be held together with an ace bandage. o Inspect cast daily for drainage, cracking, crumbling, alignment, and fit o Smell cast for foul odor and palpate it for hot areas every shift.
Discuss rheumatoid arthritis and its associated management. Rheumatoid arthritis (RA) is a chronic, progressive, systemic inflammatory autoimmune disease process that damages and destroys synovial joints. Transformed antibodies (rheumatoid factors [RF’s]) attack healthy tissue, especially synovium, causing inflammation. Onset may be acute and severe or slow and insidious, and the pattern of illness progression includes remissions and exacerbations. Permanent joint changes may be avoided or mitigated when RA is diagnosed early. Early aggressive treatment to suppress synovitis may lead to a remission. Systemic means that inflammatory factors related to this disease affect more than the joints. Affected body systems include cardiovascular (vasculitis, myocarditis, pericarditis), lung (pleurisy, pneumonitis), eyes, and skin. Inflammatory factors also contribute to anorexia, weight loss, and nutritional derangements. Genetic factors combine with environmental conditions and interact to trigger RA. Female reproductive hormones may influence the development of RA, because the disease affects more women than men. Management Includes:
Drug Therapy o Disease-modifying antirheumatic drugs (DMARD’s) – slow progression of mild RA before it progresses. Ex. Plaquenil, Azulfidine o NSAID’S – Drug of choice for pain. o Biological response modifiers (BRM’s) – interfere with the action of different inflammatory mediators. Ex. Enbrel, Humira, Orencia. o Steroidal anti-inflammatory drugs o Other immunosuppressive drugs o Analgesic drugs Nonpharmacologic Management o Rest, positioning, ice, and heat o Plasmapheresis (plasma exchange) o Hypnosis, acupuncture, magnet therapy, imagery, or music therapy o Stress management o Nutrition
Jennifer Cook
Page 8
Week 13 Discussion ~ Medical Surgical Nursing
o Nutritional supplements Promotion of Self-Care Management of Fatigue Enhancement of Body Image
What is Osteomalacia? Softening of the bone tissue related to vitamins D deficiency, causing inadequate deposits of calcium and phosphorus in the bone matrix. Occurs most in older adults.
Explain GERD, its medical management including dietary concerns. It is the most common upper GI disorder in the US. It occurs as the result of the backward flow (reflux) of GI contents into the esophagus. Reflux produces symptoms by exposing the esophageal mucosa to the irritating effects of gastric or duodenal contents, resulting in inflammation. Can lead to strictures or Barrett’s esophagus.
Jennifer Cook
Page 9
Week 13 Discussion ~ Medical Surgical Nursing Clinical Manifestations – Dyspepsia (heartburn), Regurgitation (may lead to aspiration or bronchitis), Eructation (belching), Flatulence (gas), coughing, hoarseness, or wheezing at night, water brash (hyper salivation), dysphagia, odynophagia (painful swallowing), epigastric pain, nausea, pyrosis (retrosternal burning), Globus (feeling of something in back of throat), pharyngitis, dental caries (severe cases). Management – Nutrition therapy, Lifestyle changes, and Drug Therapy
Nutrition – limit or eliminate foods that decrease LES pressure, such as chocolate, alcohol, fatty foods (especially fried), caffeine, and carbonated beverages. The client should also restrict spicy and acidic foods (orange juice, tomatoes) until esophageal healing can occur. Peppermint can also aggravate symptoms. Large meals should be avoided. Eat 4 to 6 small meals per day. Do not eat for at least 3 hours before going to bed. Eat slowly and thoroughly. Lifestyle – Elevate HOB by 6 to 12 inches for sleep. Sleep on right side-lying position. Smoking and alcohol cessation. Weight reduction. Avoid wearing constrictive clothing, lifting heavy objects or straining, and working in a bent-over or stooped position. Possibly eliminate NSAID’s, nitrates, and calcium channel blockers as they can cause reflux. Drug Therapy – Antacids, histamine blockers, and proton pump inhibitors (PPI’s).
Define hiatal hernia and describe associated client teaching. A hernia is a weakness in the abdominal muscle wall through which a segment of bowel or other abdominal structure protrudes. Increased intra-abdominal pressure can contribute to hernia formation. It is also called diaphragmatic hernias; involve protrusion of the stomach through the esophageal hiatus of the diaphragm into the chest. The esophageal hiatus is the opening in the diaphragm through which the esophagus passes from the thorax to the abdomen. Most patients with hiatal hernias are asymptomatic, but some may have daily symptoms similar to those with GERD. Client Teaching
Nonsurgical Management – Similar to those for GERD and include drug therapy, nutrition therapy, and lifestyle changes. Surgical Management o Avoid lifting and restrict stair climbing for 2 to 6 weeks after surgical repair. o Inspect the surgical wound daily and report the incidence of swelling, redness, tenderness, or discharge to the physician. o Report S/S of infection or fever to the physician. o Avoid prolonged coughing episodes to prevent dehiscence of the fundoplication.
Jennifer Cook
Page 10
Week 13 Discussion ~ Medical Surgical Nursing o Stop smoking o About diet modifications, including weight loss goals if needed, eating small portions, avoiding irritating foods and liquids, and reporting recurrence of reflux symptoms to the physician. o Avoid straining and prevent constipation; stool softeners or bulk laxatives may be needed.
References Ignatavicius, D. (2013). Medical-surgical nursing: Patient-centered collaborative care (7th ed.). St. Louis: Elsevier Saunders. Winkelman, C. (2013). Clinical companion, Ignatavicius Workman, Medical-surgical nursing: Patient-centered collaborative care. (7th ed.). St. Louis, MO: Elsevier Saunders.
Jennifer Cook
Page 11