med surg unit 4

what percentage of the united states has diabetes?

10.5%

what percentage of diabetics in the united states didn’t know they had diabetes?

21.4%

what percentage of diabetics in the united states are over 65?

36.8%

what is the normal process of glucose control?

when blood sugar is low, glucagon is released from pancreatic alpha cells & triggers liver to release stored glycogen into glucose

glucose is transported to target cells

when blood sugar is high, insulin is released from pancreatic beta cels & drives glucose into the cells, therefore lowering blood sugar

what is the pathophysiology of type 1 diabetes?

autoimmune process caused by genetic & environmental factors that causes a lack of insulin production

what is the pathophysiology of type 2 diabetes?

insulin resistance, defects at cell membrane, & beta cell failure cause insulin production to decrease

what are the clinical manifestations of diabetes? (include specific ones for type 1 & 2)

polyuria, polydipsia, polyphagia, fatigue

type 1 - weight loss

type 2 - poor wound healing, cardiovascular disease, renal insufficiency, recurring infection

how is diabetes diagnosed?

ha1c (average BG over 6 to 8 weeks) - greater than 6.5

fasting plasma glucose (BG after no caloric intake for 8 hours) - greater than 126

2 hour postprandial glucose - greater than 200

random plasma glucose - greater than 200

**can be elevated with recent carb restrictions, illness, medications, & bed rest

what are some rapid-acting insulins?

humalog, lispro, novolog, & aspart

what is the onset, peak, & duration of rapid-acting insulins?

onset - 10 to 30 min

peak - 30 to 90 min

duration - 3 to 5 hr

what are some short-acting insulins?

regular humulin, novolin

what is the onset, peak, & duration of short-acting insulins?

onset - 30 to 60 min

peak - 2 to 5 hr

duration - 5 to 8 hr

what are some intermediate-acting insulins?

nph

what is the onset, peak, & duration of intermediate-acting insulins?

onset - 1 to 2 hr

peak - 4 to 12 hr

duration - 18 to 24 hr

what are some long-acting insulins?

lantus, glargine, levemir

what is the onset, peak, & duration of long-acting insulins?

onset - 1 to 2 hr

peak - none

duration - 20 to 24 hr

what are some treatments for hypoglycemia?

oral - 15 to 20 g glucose (juice, soda, bread, crackers)

IV - 25 to 50 mL D50

IM - 1 mg glucagon

what are some complications of type 1 diabetes?

hypoglycemia (BG less than 65), which causes SNS & CNS compensation

DKA (body gets energy from fat & releases glucagon & cortisol, which lowers pH & causes electrolyte imbalances)

dawn phenomenon (increased BG in the morning due to growth hormone, glucagon, & cortisol release)

somogyi effect (increased BG in the morning due to excessive insulin at bedtime)

what are some complications of type 2 diabetes?

metabolic syndrome (increased triglycerides & LDLs & HTN)

decreased immune response

vascular disease

neuropathy

how do you manage type 1 diabetes?

treatment - insulin, isotonic fluids

considerations - vitals, i/o, BG, potassium

how do you manage type 2 diabetes?

treatment - oral medications (increase insulin, lower insulin resistance, & slow reabsorption of carbs)

considerations - BG, diet, exercise, weight loss, carb intake, alcohol restriction

what are some self-care strategies for diabetes?

infection control - hygiene, dental visits, foot care

weight loss - diet, exercise, medications

travel - carry snacks & medical id, walk every 2 hours to prevent DVT

what are some complications of gastric bypass surgery?

short term - DVT, pressure ulcer, infections

long term - band slippage, obstruction, hernia, vitamin deficiency, anemia, dumping syndrome

what are some risk factors for metabolic syndrome?

obesity, HTN, smoking, hypercholesterolemia

how do you manage metabolic syndrome?

reduce cholesterol, smoking cessation, lower BP, reduce BG

how do you manage obesity?

diet - reduction of 500 to 1000 calories/day, loss of 1 to 2 lb/week

exercise - 30 min/day of moderate intensity

behavioral therapy - food logs, social support

medication - phentermine, lorcaserin, orlistat (Xenical)

surgery - gastric bypass, gastric banding, sleeve gastrectomy

what are some dietary considerations for a patient with a cardiac disorder?

decreased saturated fats & cholesterol

increased complex carbs

fat intake as 25-35% of total calories

increase omega 3s

high fiber

DASH - grains, veggies, fruits, nuts, dried fruit, lean meats, dairies

what is included in the history assessment of the GI system?

dietary practices, nutrition, preventative health, weight changes, appetite changes, stool changes, pain

what is included in the physical assessment of the GI system?

inspection - hernia (bulging masses), aneurysm (pulsatile masses), jaundice, cullen’s sign, hemorrhoids

auscultation - bowel sounds

percussion - tympany (gas), dullness (fluid, constipation)

palpation - peritonitis (rigid, pain, guarding), mass

what do hypoactive bowel sounds indicate?

ileus, constipation

what do hyperactive bowel sounds indicate?

ileus, diarrhea, IBD

what do bruits indicate in the GI system?

arterial obstruction

what are some diagnostic studies for the GI system & what do they correlate to?

h/h - blood loss

cbc - blood loss, infection

cmp - liver, electrolytes, creatinine

pt/inr - clotting

ua - kidney infection

occult blood - GI bleed

amylase/lipase - pancreatitis

gastric analysis - pH, h. pylori, GI bleed

LFTs (AST/ALT) - increased with alcohol, statins, & Tylenol

KUB x-ray

ultrasound

endoscopy

barium study (**contraindicated if perforation is suspected)

what are some age-related changes of the GI system?

slowing function, dysphagia, loss of appetite, constipation, incontinence

what is stomatitis?

painful inflammation of the oral mucosa

primary - ulcer, canker sore, herpes

secondary - decreased immune response from chemo & radiation

what are the clinical manifestations of stomatitis?

dry, red, cracked mucosa; mouth ulcers; open/bleeding sores; pain

how do you manage stomatitis?

salt rinses q4, topical analgesics, moisturizers, antifungals (for thrush), antivirals, lidocaine

what are some complications of stomatitis?

dysphagia, xerostomia

what is a hiatal hernia?

portion of the stomach protruding through LES into the esophagus

sliding - due to trauma, genetics, or anatomy

rolling - due to anatomical deficit

what are the clinical manifestations of a hiatal hernia?

sliding - heartburn, regurgitation, chest pain, dysphagia, belching

rolling - fullness & breathlessness after eating, suffocation, angina worsened with laying down

what are some complications of a hiatal hernia?

sliding - GERD

rolling - obstruction, incarcerations, volvulus, iron deficiency anemia

how is a hiatal hernia diagnosed?

upper abdominal x-ray, endoscopy, barium swallow, EGD

how do you manage a hiatal hernia?

smaller, frequent meals, elevate HOB after eating, weight loss

medication - antacids, PPIs, H2 blockers

surgery - nissen fundoplication (**gold standard)

what is gastroesophageal reflux disease (GERD)?

acid reflux from the stomach into the esophagus, causing inflammation

how is GERD diagnosed?

pH monitoring, esophageal motility testing, EGD, barium swallow

what are the clinical manifestations of GERD?

heartburn, wheezing, coughing, dyspnea, sore throat, lump in throat, choking, regurgitation

what are some complications of GERD?

airway spasms, bronchitis, pneumonia, esophagitis (ulceration/scar tissue), esophageal stricture, barrett’s esophagus (metaplasia)

how do you manage GERD?

antacids, PPIs, H2 blockers, prokinetics

what is the difference between lefort 1, 2, & 3 with oral trauma?

1 - mandible

2 - mandible, orbital

3 - mandible, orbital, temporal

how do you diagnose oral trauma?

blood cell count, serum chemistry analysis, ABG, x-ray, CT/MRI

what are the clinical manifestations of oral trauma?

increased RR, stridor, SOB, decreased O2, tachycardia, changes in LOC, bleeding, swelling, edema, loss of teeth, pain

what are some complications of oral trauma?

short term - airway compromise, aspiration of teeth, infection, inadequate nutrition, cerebrospinal leak (meningitis)

long term - pain, TMJ, disfigurement

how do you manage oral trauma?

establish & maintain airway, control bleeding, prophylactic antibiotic

how is esophageal cancer classified?

squamous cell carcinoma - upper 2/3 of esophagus

adenocarcinoma - lower 1/3 of esophagus

how do you diagnose esophageal cancer?

barium swallow, CT, PET, endoscopic ultrasonography, thoracoscopy, laparoscopy

what are the clinical manifestations of esophageal cancer?

progressive dysphagia, inability to eat, unintentional weight loss

how do you manage esophageal cancer?

yoga, meditation, spirituality, religion, nutrition

surgery - esophagectomy (interventions: parenteral fluids, NG, high calorie/protein, upright position, observe for leakage, IS, infection prevention)

how do you diagnose gastritis?

x-ray, endoscopy, histological exam, fecal occult blood test, biopsy, CBC, B12

what are the clinical manifestations of gastritis?

epigastric pain, weight loss, decreased appetite, blood in stool or emesis, dehydration, hypovolemic shock

how do you manage gastritis?

fluid replacement, smoking cessation, pain management, removal of cause, vitals, i/o, cbc, cmp, monitor for blood, decrease use of NSAIDs

medication - H2 blockers, PPIs, antacids, sucralfate, antibiotics, B12

surgery - vagotomy, gastrectomy, pyloroplasty

diet - NPO to clear liquids; bland foods; no caffeine; small, frequent meals

what does epigastric pain indicate?

gastritis, duodenal ulcer

what are the clinical manifestations of gastroenteritis?

anorexia, distention, dehydration, electrolyte imbalance, hyperactive bowels, hypotension, dry mucus membranes

how do you diagnose gastroenteritis?

history, stool culture, PCR

how do you manage gastroenteritis?

fluid replacement, antidiarrheals, pepto-bismol, antiemetics, antibiotics

diet - NPO to clear liquids; bland foods; no caffeine or milk; small, frequent sips of fluid

what is peptic ulcer disease?

erosion & ulceration of GI mucosa from hydrochloric acid & pepsin

for what condition is it common to have no symptoms?

peptic ulcer disease (due to lack of sensory fibers; silent ulcers are common in elderly & with NSAIDs)

what are the clinical manifestations of peptic ulcer disease?

gastric ulcer - burning, gassy, worse after meals, not relieved by antacids

duodenal ulcer - burning, epigastric pain, worse when fasting, relieved by antacids

what are some complications of peptic ulcer disease?

hemorrhage, penetration, perforation, adenocarcinoma, obstruction

how do you diagnose peptic ulcer disease?

biopsy (H. pylori), endoscopy, barium swallow, CBC, liver enzymes, serum amylase, stool examination

how do you manage peptic ulcer disease?

rest, smoking cessation, fluid/blood replacement, pain management

medication - antacids, PPIs, H2 blockers, sucralfate, misoprostol (**not in pregnancy)

surgery - endoscopy, vagotomy (to reduce acid production), pyloroplasty (widening of stomach opening), gastrectomy

diet - bland food; avoid eating within 2 hr of bedtime; avoid spicy food, caffeine, & alcohol

what are the clinical manifestations of gastric cancer?

heartburn, abdominal pain, feeling full, back pain, anorexia

advanced - iron deficiency anemia, palpable mass, enlarged lymph nodes, weakness, fatigue, weight loss, metastasis

what does back pain indicate?

gastric cancer

how do you diagnose gastric cancer?

upper GI endoscopy, barium swallow, biopsy, CT, CBC

how do you manage gastric cancer?

chemo, radiation, surgery, antiemetics, opioids, vitamins, NG

what is a hernia?

protrusion of abdominal contents due to weakened abdominal wall

what are some risk factors for hernias?

obesity, smoking, malnutrition, pregnancy, wound tension, medications, heavy lifting, abdominal surgery, straining

how do you diagnose a hernia?

physical exam, herniography with contrast, CT/MRI

what are the clinical manifestations of a hernia?

strangulation, pain, vomiting, distention, fever, tachycardia

how do you manage a hernia?

surgery - herniorrhaphy (to fix hernia), hernioplasty (to fix hernia & add mesh), temporary colostomy, binder

**surgery is immediately required to prevent gangrene

what is a hemorrhoid?

swollen vein in anorectal area that can be internal or external

how do you diagnose a hemorrhoid?

external - inspection

internal - digital exam, anoscope, sigmoidoscopy

what are the clinical manifestations of a hemorrhoid?

pain, pruritis, bleeding, prolapse

what are some complications of hemorrhoids?

infection, pain, urinary retention, impaction, sphincter damage, bleeding, abscess

how do you manage a hemorrhoid?

surgery - ligation, bipolar/infrared/laser coagulation, sclerotherapy, cryosurgery, hemorrhoidectomy

what are the clinical manifestations of irritable bowel syndrome?

pain improved with defecation; loose, frequent stools; distention; mucus; sensation of incomplete evacuation; fatigue; headache; sleep disturbances

what are some complications of IBS?

psychosocial effects, isolation, malabsorption

how do you manage IBS?

nutrition diary, high fiber, stress reduction, ginger, antidiarrheals, imodium, avoid trigger foods, smoking cessation

what is irritable bowel disease a combination of?

crohn’s & ulcerative colitis

what are some triggers of IBD?

infection, medication, smoking

what does crohn’s disease affect?

mouth to anus

what does ulcerative colitis affect?

large intestines & mucosa

what are the clinical manifestations of IBD?

diarrhea, cramps, fever, weight loss, fluid/nutrition imbalance, anemia, delayed growth, mouth ulcers, rectal bleeding, skin/joint/eye irritation

how do you diagnose IBD?

CBC, CRP

how do you manage IBD?

rest; perianal care; small, frequent meals; alleviate stress

diet - avoid chocolate, milk, caffeine, citrus, & alcohol

medication - antimicrobials (Cipro), glucocorticoids (dexamethasone, budesonide), antidiarrheals (Lomotil, Imodium)

what is narcotic bowel sydrome?

narcotic-induced constipation

what are the clinical manifestations of narcotic bowel syndrome?

chronic, intermittent cramping; abdominal pain

how do you manage narcotic bowel syndrome?

wean off narcotics, antidepressants, fluids, treat withdrawal

what is short bowel syndrome?

100 cm or more is removed in a bowel resection, affecting absorption

what are the clinical manifestations of short bowel syndrome?

diarrhea, steatorrhea

how do you manage short bowel syndrome?

fluid/electrolytes, nutrition, PPIs, opioids, antidiarrheals

diet - high carb, low fat, fiber, small meals, TPN