Pharm Exam 2 diabetes/pain

What are the two self monitored blood glucose types in the Nursing assesment

Intermittent and continuous

Intermittent blood glucose monitor

Finger stick to monitor blood glucose

Good to know BG right now

continuous self monitor

device that constantly measures BG levels

Glycated hemoglobin(A1C)

can monitor average glucose over the course of 90 days by checking percentage of sugar attached to RBC

A1c Glycemic levels target

Normal: 5.7%

Pre-diabetic: 5.7 -6.5%

Diabetes : higher than 6.5%

Non diabetic normal glycemic levels fasting/ premeal/post meal

Fasting: 80 - 99 mg/dl

Before meals: 80 - 99 mg/dl

After meals: 80 -140 mg/dl

Type 1 and 2 adult normal glycemic levels fasting/ premeal/post meal

and type 1 child adolescent

fasting: 80 - 130 mg/dl

before meals: 80 - 130 mg/dl

post meals: 80 - 180 mg/dl

out of range means too much/little for that person

Nursing process planning/outcome for diabetes

Have → client will have stable blood glucose by…

Remain → client will remain free from injury by…

Verbalize and Demonstrate - client will verbalize and demonstrate diabetes care management

Nursing process implementation for diabetes

Insulin therapy/ education

Glucose/insulin throughout day

at breakfast time insulin will be in higher concentration than blood glucose, after that BG concentration stays above insulin for the rest of day

glucose/insulin peaks every time you eat

4 insulin types

short duration fast acting

short duration slower acting

intermediate duration, slow acting

long duration, slowest acting

short duration fast acting insulin

Good for when you need a fast increase in insulin levels →after meals to reduce risk of hypoglycemia

Sub q injection usually only having effects for 4-5 hrs, but having highest blood glucose level of the ones

Ex: Insulin lipro, insulin aspart, insulin glulisine

short duration slower acting insulin

Still for after meals, but the effects are for up to 8 hours

peak of insulin blood level 2nd highest, but more at risk for hypoglycemia

Ex: regular insulin

intermediate duration, slow acting insulin

not as fast acting, but can lasts up to 15 hours with peak at 6 hrs.

Good for small increases of BG such as snacks.

Patient would need a combination of this and the other fast acting insulin to reduce peak of glucose levels, but to keep it monitored. needs two of these doses for 24 hr day

ex: NPH insulin

Long duration, slowest acting

only need 1 dose as this lasts for 24 hours

ex: insulin glargine, insulin detemir

Degludec - ultralong basal insulin over 24 hrs

different types of insulin therapy

Basal/bolus therapy

twice daily premixed therapy

continuous subcutaneous insulin infusion

Basal insulin therapy

Insulin with long effect →act to keep glucose in normal range

Also supresses glucose release from liver throughout day

1 dose needed a day(glargine or demetir)

bolus insulin therapy

insulin finger prick after each meal( usually 3 doses a day)

bad before bed time because it will cause hypoglycemia

basal/ bolus therapy

often used in combination with each other to regulate high peaks of BG and regulate normal levels throughout day.

the doses are at different times

If basal therapy not available, then bolus therapy/administration can be used with intermediate(regular insulin) in combination→usually an extra dose though

twice daily premixed therapy

• pharmacy can combine the NPH and regular insulin so that the patient only needs two injections per day 

• OR the patient can mix the insulin by themselves 

• they need to draw regular first, then the NPH to avoid contamination

Can be a 75/25 dose →means 75% NPH/25% regular

calculating how much insulin to give

based on unit to carbs ratio

weight of person directly effects dosing →check weight regularly

Ex: someone who is 150 lbs and has 12 grams of CHO needs 1 unit of insulin

4 types of insulin approved for continuous glucose monitor

Short acting ones include Regular, lispro, Aspart, Glusine

Unopened vial insulin storage

• do not freeze or expose to extreme heat

• refrigerate up to expiration date

Opened vial insulin storage

• good for 1 month 

• room temperature (reduces lipodystrophy → body unable to store or maintain healthy fat tissue)

Insulin administration

• roll vial between hands gently

• correct dose, needle, and syringe(1 mark means

• aseptic technique when drawing up and administering insulin

• injection sites

Insulin administration injections sites

think of a clock rotation

left arm → left abdomen → left thigh →right thigh → right arm → right abdomen

This reduced risk of lipodystrophy

insulin syringe marks

100 unit syringe means every mark is 2 doses of insulin

for30 or 50 unit syringe each mark means 1 dose of insulin

Treating hypoglycemia

happens when too much insulin is delivered →causes change in level of consciousness, tachycardia, sweating, shaking

Act right away if BG is lower than 80 mg/dl(Signs and symptoyms not enough, have to do test)

If alert, give 15 g CHO in form of 1 cup apple juice or glucose tablets

Reasses right after in 15 min

Treating hypoglycemia when unconscious

Give glucagon if at home

Give 50% dextrose if in hospital

Hyperglycemia

When you have too much glucose in your body →means low insulin

Effects → dehydration due to water following glucose to get excreted, increased hunger because lack of insulin means cells don’t get energy. polyphagia, polydipsia, polyuria

DKA

more consistent with T1DM, where no insulin causes body to uses ketones(from fats) as energy. Makes blood acidic which can be toxic to brain. rapid onset in hours

Blood/urine ketones generally a lot higher than HHS

Clinical manifestation include polyuria, polydipsia, acetone breathing/kussmaul breaths.

HHNKS

More associated with type 2 DM where some insulin is secreted but not enough,

BG is generally a lot higher than DKA, more than 600, and this is a gradual onset

Blood/urine ketones are generally a lot less than DKA and don’t change a lot.

Clincial manifestations are polyuria, polydipsia, confusion/lethargy, and more dehydration than DKA

Assesment part of DKA/HHS

Check Glucose level - DKA is between 250/500. HHNKS is higher than 600

Check ketones- more associated with DKA →emergency problem

Vital signs, look for Kuusmal breathing and BP → low BP is indicative of dehydration and Is a circualtion problem, takes precedence over high glucose because of ABC’s

Neurologic LOC → big changes in this is more HHS because of confusion/lethargy and dehydration

Basic metabolic panel → renal function, BG, acid base, fluid/electrolyte

3P’s (early signs)

Nursing diagnoses part of DKA/HHS

Its either “risk for” → two part statement

or

“deficent knowledge about diabetes management”

Nursing planning/outcome part of DKA/HHS

These are “Client Will” statements

these should be symptom related such as achieve fluid balance by or exhibit stable vital signs throughout shift.

Nursing implementations part of DKA/HHS

1. restore fluids by starting an IV line with either a isotonic or hypotonic NaCl. monitor these glucose levels because once BG gets below 250 mg/dl, you give a 5% dextrose solution to prevent Hypoglycemia.

2. Once restored glucose levels restore the electrolytes → If potassium below 3.3 mEq/L, hold insulin until potassium is correct because of cardiac issues with ECG

3. Reversing acidosis by starting regular continuous insulin(fast acting) by IV drop, until normal glucose levels

Serious consequence is Lactal

Nursing evaluation DKA/HHS

Client will statements

Ex: client will demonstrate and verbalize knowledge about diabetes management.

Type 2 diabetes medication Biguanides

Metformin(generic name) → usually most used and 1st option

MOfA: reduces prodcution of glucose by the liver and it increases tissues sensitivity to insulin, and slows CHO absorption in intestine.

Administration → take daily if extended release at nightime, if not take twice daily

Adverse effects: Lactic acidosis >4mmol/L, Gi discomfort and B12/folic acid deficiency

Education- “Stop medication 48 hours before and after a exam/procedure.

Adverse effects: of metformin

Lactic acidosis >4mmol/L, Gi discomfort and B12/folic acid deficiency

Contrast assessment includes a lot of excretion and causes competition with metformin excretion.

Thiazolidinediones T2DM medication

Generic name →Pioglitazone

MofA: reduces production of glucose by the liver and increasing insulin sensitivity

Effects: bladder cancer, can stimualte ovulation, and heart failure

Sulfonylureas T2DM medication

Generic name →glipizide

MofA → Promote insulin release from pancreas

Taken once dail and be sure to monitor blood glucose levels

Adverse/Side effects → Hypoglycemia, disulfiram reaction(vomitng. abdominal discomfort, bad feeling →avoid alcohol)

Meglitinides T2DM

generic →repaglinde or nateglinide

Same as the sulfonylureas/glipizide, but there is no disulifram reaction(more expensive drug)

Still risk of hypoglycemia

Alpha glucosidase inhibitors T2DM medication

generic → Acarbose

MofA → Delay absorption of dietary CHO from intestine →causes more carbohydrates to be eliminated in feces

administer with meals otherwise this medication has no target

Important education is If hypoglycemic, do not use sucrose to fix this, Give dextrose tablets so it’s not reabsorbed in liver

Incretin hormone

Metabolic hormones released from small intestine that lowers BG after eating by stimulating insulin release

Dipeptidyl 4 inhibitors T2DM

generic:Sitagliptin

daily

MofA → Enhances incretin hormones, stimulates glucose dependent release of insulin, suppress glucagon release of liver

Risks → hypersensitivity reaction/pancreatitis→ usually more common in early doses, if signs of allergic reaction, call provider and stop medication

Education: possible UTI’s b/c of increase in urine concentration/excretion

Canaglifolzin(generic name)

Under sodium glucose co transporter 2 inhibitors category(dont need to know for exam)

MofA:prevent kidney from reabsorbing glucose in blood

daily

adverse effect/education → possible UTI’s b/c of glucose concentration and increased urination. monitor for uti’s

GLP1’s

generic→Exenatide IR(immediate release) and Er(extended release)

Sub Q Injection always before meal. If IR (daily or twice daily), ER? once a week

MofA: mimics Incretin(agonist), stimulates glucose dependent release of insulin, slows gastric emptying, increase sense of satiety

education: give oral drugs 1 hr before injection, don"‘t take if pregnant

Pramlintide(generic)

MofA → delays gastric emptying, suppressing glucagon secretion, increase sense of satiety

Inject with meals

Education for diabetic individuals

Diet, exercise, illness, foot care

Diet education

Meal planning in relation to insulin administration(charts)

Alcohol consumption can increase risk of hypo or hyperglycemia

exercise education for diabetes

Exercise 3x a week

Monitor for possible hyperglycemia(can impact healing because of blood vessels)

also montior hypoglycemia

Sick day rules for daibetics

measure BG more frequently(every 4 hours) → do not stop medications

drink plenty of fluids: 4-6 oz every half hour

Weigh yourself every day, if weight loss over 5 pounds during illness can be high BG

check ketones/ temp in morning and evening. fever could be infection related.

Other education

Check eyes/nerves → too much glucose can damage nerves and may not be able to detect hyperglycemia

Retinopathy/nephropathy.

Acute pain

• Protective, temporary, self-limiting, direct cause

• Physiological and behavioral responses

Chronic pain

• Not protective, longer than 6 months, persisting

• Depression, fatigue, decreased level of functioning

• Cancer or non-cancer

Neuropathic pain

Abnormal processing of sensory input

• Intense, shooting, burning, “pins and needles

Nociceptive pain

To tissue

Objective pain assessment

• Physiological response (tachycardia, HTN, diaphoresis, muscle tension)

• Behavioral response (grimacing, moaning, flinching, guarding)

Pain-related nursing diagnoses

• Impaired comfort

• Acute pain

• Chronic pain

• Labor pain

Non-pharmacological interventions for pain

• 
  Cognitive behavior – rethink about daily activities/therapy

• Cutaneous skin stimulation

• Distraction

• Relaxation

• Imagery

• Acupuncture

Whats considered “severe pain”

Higher than 7 on a scale of 1-10

COX

converts arachidonic acid to prostagalndins

Includes COX 1 and COX 2

COX 1

Always present in body no matter what

Produces prostaglandins that gives us GI protection and platelet function in blood(ability to form clots)

COX 2

only activatedwhen you have an tissue injury

Produces prostaglandins that cause inflammation → which causes edema → then causes pain

Asprin

MofA: Blocks COX 1 and COX 2

Adverse effects: reduces inflammation, pain, fever, but also reduces GI protection/platelets ability to form clots. increases risk for bleeding

Oral medication(NSAID) meant for adults that is enteric coated(protects itself from stomach)

NSAIDs

MofA: Inhibit COX 1 and COX 2

generic names:Meloxicam(prescription), ibuprofen/naproxen

Either iV/PO

metabolism- hepatic(liver) and excretion is renal

Adverse effects →GI/cardiac issues, stroke, hypersensitivity, high prevelance for kidney damage

Celecoxib

MofA: inhibits Cox 2(inflamation/pain)

prescription based oral NSAID that affects all tissues

adverse effects→cardiovascular issues/ sulfa allergy, and renal damage

Acetaminophen

MofA: Inhibits COX in the CNS only(distribution) →suppresses pain and fever but not inflammation

NOT an NSAID, delivered by PO or IV

Adverse effects→ overdose, liver injury

Metabolism is liver, and excretion is renal

Considerations for using these non opioid pain meds

It is used for mild pain level less than 7

You want a pain reduction, but also want to reduce reliance on it

Opioids

Prescription based used for moderate to severe pain

Another Pharmacological intervention that binds to opioid receptors in the brain and spinal cord(CNS) to reduce pain

Tramadol

MofA: Blocks uptake of norepinephrine(excitatory) and serotonin, Weak agonist of mu opioid receptors(responsible for pain relief/happiness)

Adverse effects: can intensify CNS depressants(alcohol/benzos)

Look for seretonin syndrome symptoyms

Monitor for constipation → Dont need to discontinue

Strong opioid agonists medications

Morphine, fentanyl, hydromorphone, meperidine

Strong opioid agonists features

MofA: Mimic the actions of mu receptors(control pain relief, reward, breathing) Systemic

Can be administered Po,IV, IM injection, suppository

Adverse effects: Respiratory depression(A Problem), sedation, constipation, orthostatic hypotension, brith defects(B/c its fat soluble)

What are the moderate opioid agonists.

Codeine(prodrug → not activated until liver), oxycodone, hydrocodone

MofA - same as strong opioid

Adverse effects - same as strong opioids, monitor level of consiousness

• PO absorption

• CNS and periphery distribution

Opioid nursing administration

pain assessment → look for pain alternatives

avoiding withdrawal, dosage determination/scheduling.

Narcan

• naloxone

• opioid antagonists for overdoses

• administered as a nasal spray or injection

Methylnaltrexone

• opioid antagonist for constipation

• Selective mu opioid antagonist in the GI system only*

• Not used for overdoses because it doesn’t reach receptors beyond the GI system

• SubQ or PO absorption

• Periphery distribution

• Metabolism - hepatic minimal

• Excretion - urine and feces

Pain evaluation

make sure to monitor for adverse effects and assessing if pain goal was met, and ifn ot waht will happen next.

Opioid use disorder

• problematic opioid use causing clinically significant impairment or distress

• recurrent and problematic

Missuse

• Using opioids outside of prescribed instructions but without compulsive use

• Occasional or situational

Tolerance/physical dependence

• The body has adapted to a dose and requires an increase in dose for the same amount of pain relief; can happen to everyone, even at the regular dose

• Usually no cravings or loss of control

medications used for neuropathic pain

Gabapentin and pregabalin

Gabapentin

used for neuropathic pain

MofA:Binds to calcium channels and reduces release of excitatory neurotransmitters, supporting Gaba’s inhibitory action on neuronal firing

effects →somnolence(sleepiness during day), physical withdrawal

patient education → Do not stop taking it even if pain stops, reduce doses gradually

Pregablin(must know)

For neuropathic pain

MofA: binds with calcium channels on nerve terminals and inhibits calcium influx

Effects: hypersensitivity, rhabdo →these are the differences