Adult-Gero Unit 1

Metabolic Syndrome

Simultaneous presence of metabolic factors that increase risk for type 2 DM in many people

• abdominal obesity

• hyperglycemia

• hypertension

• hyperlipidemia

Diabetic Screening

BMI above 25 AND one of more of following:

• first degree relative who has DM

• age 45 or older

• Sedentary lifestyle

• H/O vascular disease, PCOS, gestation DM, or giving birth to a baby >9#

• african, hispanic, asian, indigenous heritage, BP consistently > 140/90 mmHg

• HgA1C greater than 5.7% impaired fasting glucose, or impaired glucose tolerance

• HDL <35 mg/dL or triglyceride >250 mg/dL

Absence of Insulin

• hyperglycemia

• 3 P’s (polyuria, polydipsia, polyphagia)

• ketone bodies

• hemoconcetration, hypovolemia, hyperviscosity, hypoperfusion, and hypoxia

• acidosis - can cause Kussmaul respirations

Chronic Complications of Diabetes

Macrovasular Disease

• cardiovascular, cerebrovascular, and reduced immunity

Microvascular disease

• eye complications

• diabetic peripheral neruopathy

• diabetic autonomic neuropathy

• diabetic nephropathy

• sexual dysfunction

• cognitive dysfunction

Components of the Comprehensive Diabetes Medical Evaluation

Assessment—Recognizing Cues —> Risk Factors & Symptoms

Physical Exam

Lab

• A1C - twice per year if well controlled, every 3 months i adjustments or poor control

Annually:

• lipid profile (total cholesterol, LDL, HDL, tryglycerides)

• liver function tests

• urinary microalbumin

• serum creatinine and GFR

• TSH in T1DM

• serum potassium levels if taking ACE inhibitors, ARBs, diuretics

Analysis: Analyze Cues

Potential for injury (ex: foot), impaired would healing, hiabetic neuropathy, kidney disease, hypoglycemia, DKA, HHS, and coma

Planning and Implementation: Generate Solutions & Take Action

Prevent injury from hyperglycemia, peripheral neuropathy, or injury from reduce vision

Prevent hypoglycemia, DKA, or HHS

Manage pain

Recommendations: Glucose Monitoring

Patients on multiple-dose insulin (MDI) or insulin pump therapy should do SMBG

• at least prior to meals and snacks

• occasionally postprandial

• at bedtime

• prior to exercise

• after they suspect low blood glucose

• after treating low blood glucose until they are normoglycemic

• prior to critical tasks such as driving

Collaborative Management

• keep A1C <7%, older adults <8%

• keep pre-prandial plasma glucose between 70-130mg/dL

• keep post prandial plasma glucose < 180 mg/dL

• control of diabetes and its complications is major focus for health promotion activities

Medication Management

T1DM = insulin and food intake

T2DM = oral antidiabetic agents used with diet and exercise

• biguanides

• second generation sulfonylureas

• meglitinides

• thiazolidinediones

• alpha-glucosidase inhibitors

• DPP-4 inhibitors

New Drugs for Diabetes and T2DM

Non-insulin injectables

• incretin mimetic: secreted from the gut (GLP-1) (Ozempic- injections and Rybelsus- oral)

• modulate glucose metabolism working with release of insulin from B-cells

• Inhibits release of glucagon by pancreatic a cells

Amylin mimetic: co-secreted with insulin from the B-cells (Byetta, Symlin)

• Inhibits food intake

• Delays gastric emptying

• Decreases blood glucose levels

Both are release after meals and improve glucose metabolism

Nutrition Therapy

Limit alcohol intake

Carbs 40-50% of meals (1 serving = 15 g_

Physical Activity

Exercise after meals

Advise people with diabetes to perform at least 150 min/week of moderate-intensity aerobic physical activity, spread over at least 3 days per week with no more than 2 consecutive days w/o exercise

Asthma

• intermittent and reversible obstruction

• inflammation or airway hyperresponsiveness

• manifestations: mucosal edema, bronchoconstriction, excessive mucus production

• “barrel chest”

COPD

Emphysema

• loss of lung elasticity and hyperinflation of lung tissue

• destruction of alveoli and decreased surfagce area for gas exchange

• CO2 retention, respiratory acidosis

Chronic bronchitis

• inflammation of bronchi and bronchioles due to chronic exposure to irritants

Asthma Nonsurgical Management

• breathing techniques

• positioning (tripod)

• effective coughing

• oxygen therapy

• exercise conditioning

• suctioning

• hydration

• smoking cessation

Asthma Drug Therapy

• beta-adrenergic agents

• cholinergic antagonists

• methylxanthines

• corticosteroids (inhaled and systemic)

• mucolytics

Obstructive Sleep Apnea

• episodic, sleep-state dependent collapse of upper airways

• periodic reductions or cessations in ventilation

• hypoxia, hypercapnia, arousals from sleep

Obstructive Sleep Apnea Risk Factors

• obesity

• male > female

• hypothyroidism

• acromegaly

• large tonsils or adenoids

Arterial Blood Gas

Arterial puncture or arterial line

• heparinized syringe

• Allen’s test

• Education - pain

• Hold direct pressure

• Monitor for bleeding/hematoma

Pneumonia

Excess fluid in lungs

Result in inflammatory process

Inflammation caused by infectious organisms or inhalation of irritating agents

Inflammation of interstitial space, alveoli, and bronchioles

Pneumonia Clinical Progression

penetrate mucosa → WBC migration → capillary leak → edema → fluid collection

Causes of PNA

Infectious

• bacteria

• viruses

• mycoplasmas

• fungi

• rickettsiae

• protozoa

• helminths (worms)

Non-infectious

• inhalation of toxic gases, chemical fumes, and smoke

• Aspiration of water, food, fluid, and vomitus

Community Acquired Pneumonia (CAP)

Community setting or not within 48 hours of being in the hospital

Usually bacteria or viral

Health Care Acquired Pneumonia (HCAP)

PNA associated with hospital stay or one that occurs shortly after a hospital stay

More likely to be resistant to antibiotics

Aspiration Pneumonia

a lung infection that happens when you breathe food, liquid, vomit, or saliva into your lungs instead of swallowing it properly

Ventilator Associated Pnuemonia (VAP) or Ventilator Associated Event (VAE)

Associated with endotracheal intubation and mechanical ventilation

Occurs within 48-72 hours of mechanical ventilation

PNA Assessment - ROS

Strep

• chest/pleuritic pain

• high fever if abrupt onset

• chills

Others:

• dyspnea and cough

• nausea and cough

• fatigue

• myalgias and headache

• pharyngitis

• anxiety

Older adult

• weakness, fatigue, lethargy

• comfusion

• poor appetite

• abd pain

• may NOT have fever/cough

Diagnosing PNA

Diagnostic evaluation (esp. if hospitalized)

• chest x-ray (CXR)

• 2 sets of pre-treatment blood cultures

• sputum gram stain and culture - if patient has productive cough

• Antibiotics should not be withheld while trying to obtain sputum

CXR revealing opacity AND at least two:

• temp >38C

• productive cough

• chest pain

• SOB

• altered breath sounds

• if age > 65 include tachyp