Chapter 53 + 45 + 63
CHAPTER 53 - Diabetes
1. Describe the pathophysiology and clinical manifestations of diabetes.
2. Distinguish between type 1 and type 2 diabetes.
3. Describe the interprofessional care of a patient with diabetes.
4. Describe the role of nutrition and exercise in managing diabetes.
5. Discuss the nursing management of a patient with newly diagnosed diabetes.
6. Describe the nursing management of a patient with diabetes in the ambulatory and home care settings.
7. Relate the pathophysiology of acute and chronic complications of diabetes to the clinical manifestations.
8. Explain the interprofessional care and nursing management of a patient with acute and chronic complications of diabetes.
basal-bolus plan
The insulin approach that most closely mimics endogenous insulin production is the basal-bolus plan (often called intensive or physiologic insulin therapy). It consists of multiple daily insulin injections or an insulin pump together with frequent BGM or CGM. Injections include rapid- or short-acting (bolus) insulin before meals and intermediate- or long-acting (basal) background insulin once or twice a day
blood glucose monitoring (BGM)
critical part of DM management. By providing a current glucose reading, BGM lets the patient make decisions about food intake, activity patterns, and drug dosages.
dawn phenomenon
also characterized by hyperglycemia that is present on awakening. Two counterregulatory hormones (GH and cortisol), which are excreted in increased amounts in the early morning hours, may be the cause of this phenomenon.
diabetes mellitus (DM)
chronic multisystem disease characterized by hyperglycemia from abnormal insulin production, impaired insulin use, or both.
diabetes-related ketoacidosis (DKA)
DKA is caused by a profound deficiency of insulin. It is characterized by hyperglycemia, ketosis, acidosis, and dehydration. It is most likely to occur in people with type 1 DM. DKA may occur in people with type 2 DM in conditions of severe illness or stress in which the pancreas cannot meet the extra demand for insulin.
diabetes-related nephropathy
associated with damage to the small blood vessels that supply the glomeruli of the kidney. It is the leading cause of ESRD in the United States and is seen in 20% to 40% of people with DM.
diabetes-related neuropathy
nerve damage that occurs from the metabolic imbalances associated with DM. About 60% to 70% of patients with DM have some degree of neuropathy. The most common type affecting persons with DM is sensory neuropathy.
diabetes-related retinopathy
refers to the microvascular damage to the retina because of chronic hyperglycemia, nephropathy, and hypertension in people with DM. DM-related retinopathy is the leading cause of new cases of adult blindness.
hyperosmolar hyperglycemia syndrome (HHS)
life-threatening syndrome that can occur in patients with DM who are able to make enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion (Fig. 53.13). HHS is less common than DKA (Table 53.19). It often occurs in patients over 60 years of age with type 2 DM.
impaired fasting glucose (IFG)
IFG is diagnosed when fasting glucose levels are 100 to 125 mg/dL (5.56 to 6.9 mmol/L).
impaired glucose tolerance (IGT)
IGT is made if the 2-hour oral glucose tolerance test (OGTT) values are 140 to 199 mg/dL (7.8 to 11.0 mmol/L)
insulin resistance
This is a condition in which body tissues do not respond to the action of insulin because insulin receptors are unresponsive, insufficient in number, or both
prediabetes
Prediabetes is defined as impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or both. It is an intermediate stage between normal glucose homeostasis and DM. Glucose levels are high but not high enough to meet the diagnostic criteria for DM
Somogyi effect
Hyperglycemia in the morning may be due to the Somogyi effect. A high dose of insulin causes a decline in glucose levels during the night. As a result, counterregulatory hormones (e.g., glucagon, epinephrine, GH, cortisol) are released. They stimulate lipolysis, gluconeogenesis, and glycogenolysis, which in turn cause rebound hyperglycemia.
DIABETES MELLITUS
Etiology and Pathophysiology
Diabetes mellitus (more commonly referred to as diabetes) is a chronic multisystem disorder of glucose metabolism related to absent or insufficient insulin, impaired use of insulin, or both.
Current theories link the causes of diabetes to genetic, autoimmune, and environmental factors.
Type 1 Diabetes
Type 1 diabetes generally affects people under 40 years of age, although it can occur at any age.
Type 1 diabetes is the result of a long-standing autoimmune process in which the body’s own T cells attack and destroy pancreatic β -cells, which are the source of the body’s insulin.
Because the initial manifestation of type 1 diabetes is often rapid, the symptoms are usually acute.
The classic symptoms, polyuria, polydipsia, and polyphagia, are caused by hyperglycemia.
The person with type 1 diabetes requires insulin therapy to sustain life. Without insulin, the patient will develop diabetes-related ketoacidosis (DKA), a life-threatening condition resulting in metabolic acidosis.
Type 2 Diabetes
Type 2 diabetes accounts for around 90% of people with diabetes.
In type 2 diabetes, the pancreas usually continues to make some insulin. However, the insulin that is made is either insufficient for the needs of the body and/or is poorly used by the tissues.
There are many factors and several genes involved in the development of type 2 diabetes.
One of the most important risk factors for developing type 2 diabetes is obesity.
The manifestations of type 2 diabetes are more nonspecific and include fatigue, recurrent infections, recurrent vaginal yeast infections, prolonged wound healing, and visual changes.
Prediabetes
Prediabetes is a condition in which blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes.
Long-term damage to the body, especially the heart and blood vessels, may already be occurring in people with prediabetes.
Teach people with prediabetes to take action to prevent or delay the development of type 2 diabetes. Encourage them to have their blood glucose and A1C checked regularly
Gestational Diabetes
Gestational diabetes develops during pregnancy and is usually screened for and detected at 24 to 28 weeks of gestation by an oral glucose tolerance test.
Although most women with gestational diabetes will have normal glucose levels within 6 weeks postpartum, their risk for developing type 2 diabetes is 63% within 16 years.
Other Specific Types of Diabetes
Other types of diabetes can occur because of another medical condition or treatment that causes abnormal blood glucose levels. These conditions result from injury to, interference with, or destruction of the β-cell function of the pancreas.
Conditions include Cushing syndrome, hyperthyroidism, recurrent pancreatitis, cystic fibrosis, hemochromatosis, parenteral nutrition, or use of certain drugs, including corticosteroids or certain antipsychotics.
Diagnostic Studies
A diagnosis of diabetes is based on 1 of 4 methods: fasting plasma glucose, random plasma glucose measurement with symptoms, 2-hour oral glucose tolerance test, and/or an A1C test.
Interprofessional Care
The goals of diabetes management are to reduce symptoms, promote well-being, prevent acute complications of hyperglycemia and hypoglycemia, and prevent or delay the onset and progression of long-term complications. These goals are most likely to be met when the patient maintains blood glucose levels as near to normal as possible.
Drug Therapy: Insulin
Exogenous (injected) insulin is needed when a patient has inadequate insulin to meet specific metabolic needs.
Insulin is divided into 2 main categories: short-acting (bolus) and long-acting (basal) insulin.
Bolus insulin is used at mealtimes to prevent postprandial hyperglycemia and/or to bring down an elevated glucose level.
Basal insulin provides a background level of insulin throughout the day.
A variety of insulin plans are recommended for patients depending on his or her needs and preferences.
Insulin is most often given by subcutaneous injection. IV administration of regular insulin can be given when immediate onset of action is desired.
The speed with which peak serum concentrations are reached varies with the anatomic site for injection. The fastest subcutaneous absorption is from the abdomen.
An insulin pump can be used to give continuous short-acting insulin. It is programmed to deliver a continuous infusion 24 hours a day with boluses at mealtime and to bring down elevated blood glucose levels.
Hypoglycemia, allergic reactions, lipodystrophy, hypertrophy, and the Somogyi effect are problems associated with insulin therapy.
Lipodystrophy may occur if the same injection sites are used frequently. The incidence has decreased with the use of human insulin.
Hypertrophy is a thickening of the subcutaneous tissue. Injecting into a hypertrophied site may result in erratic insulin absorption.
Elevated morning glucose levels may be due to the Somogyi effect. This is a rebound caused by hypoglycemia during the night that stimulates a counterregulatory response.
The dawn phenomenon is characterized by hyperglycemia that is present on awakening in the morning, resulting from the increased release of counterregulatory hormones in the predawn hours.
Drug Therapy: Oral and Noninsulin Injectable Agents
These agents primarily work on the 3 main defects of type 2 diabetes: (1) insulin resistance, (2) decreased insulin production, and (3) increased hepatic glucose production. These drugs may be used in combination with agents from other classes or with insulin to achieve blood glucose goals.
Oral Agents
Metformin (Glucophage) is a biguanide glucose-lowering agent. The primary action of metformin is to reduce glucose production by the liver. The ADA algorithm for the management of type 2 diabetes recommends the use of metformin combined with lifestyle interventions as the first-line therapy. Metformin is available in many combination drugs as well.
Sulfonylureas increase insulin production from the pancreas. Since they can cause hypoglycemia, it is important to teach patients how to recognize and manage low blood glucose.
Sulfonylureas are sometimes added if metformin and lifestyle interventions are not effective.
Meglitinides increase insulin production from the pancreas. Because they are rapidly absorbed and eliminated, they have a lower risk of hypoglycemia than with the sulfonylureas. They are taken before meals, usually resulting in dosing 3 times a day.
α-Glucosidase inhibitors, also known as “starch blockers,” work by slowing down carbohydrate absorption in the small intestine.
Thiazolidinediones are most effective for people who have insulin resistance. Due to their severe adverse effects, the 2 drugs in this class are rarely used.
Noninsulin Injectable Agents
Glucagon-like peptide (GLP)-1 receptor agonists target the incretin hormones. They stabilize blood glucose levels, slow gastric emptying, increase satiety, and have the additional effect of reducing body weight.
Sodium-glucose co-transporter 2 (SGLT2) inhibitors decrease renal glucose reabsorption and increase urinary glucose excretion.
Dipeptidyl peptidase IV (DPP-4) inhibitors slow the degradation of the incretin hormone GLP1. This results in inhibited secretion of glucagon, increased insulin secretion, slowed gastric emptying, and decreased appetite.
Pramlintide (Symlin) is a synthetic analog of human amylin, a hormone secreted by the β cells of the pancreas. It is only taken concurrently with insulin, and use can increase satiety and lower blood glucose levels.
Nutrition Therapy
The overall goal of nutrition therapy is to help people with diabetes make healthy food choices and eat a varied diet that will lead to target blood glucose levels.
For those using conventional, fixed insulin doses, day-to-day consistency in timing and amount of food eaten is important. Patients using a basal-bolus approach with rapid-acting insulin can adjust the dosage before meals based on the premeal glucose level and the carbohydrate content of the meal.
The emphasis of nutrition management in diabetes is placed on achieving glucose, lipid, and BP goals and achieving weight loss if the patient is overweight or obese.
People with diabetes are encouraged to follow the same healthy eating guidelines as those without: eat whole grains, healthy fat, and lean protein; limit saturated and trans fats, and increase plant-based foods.
Encourage patients to frankly discuss the use of alcohol with their HCPs because its use can make blood glucose harder to manage.
Exercise
Regular, consistent exercise is an essential part of diabetes and prediabetes management. Exercise increases insulin sensitivity and can have a direct effect on lowering blood glucose levels.
Patients who use insulin, sulfonylureas, or meglitinides are at increased risk for hypoglycemia, especially if they exercise at the time of peak drug action or eat too little to maintain target blood glucose levels. Teach them to exercise about 1 hour after a meal or have a 10- to 15-g carbohydrate snack and check their glucose before exercising.
Patients should delay activity if the blood glucose level is over 250 mg/dL and ketones are present in the urine. If hyperglycemia is present without ketosis, it is not necessary to postpone exercise.
Monitoring Blood Glucose
Blood glucose monitoring (BGM) is a cornerstone of diabetes management. Using current blood glucose readings, people can make informed self-management decisions about food, exercise, and medication.
The frequency of monitoring depends on several factors, including the patient’s glycemic goals, the type of diabetes that the patient has, the patient’s ability to monitor independently, the patient’s willingness to perform BGM, and cost. More people with diabetes are using continuous glucose monitoring in addition to, or instead of, finger-stick blood glucose monitoring.
Pancreas Transplantation
Pancreas transplantation can be used as a treatment option for people with type 1 diabetes. Transplants are done for patients with end-stage kidney disease and who had or are having a kidney transplant.
NURSING MANAGEMENT: DIABETES MELLITUS
Nursing responsibilities for the patient receiving insulin include proper administration, assessment of the patient’s response to insulin therapy, and teaching of the patient about administration of, storage, adjustment to, and side effects of insulin, particularly recognition and management of hypoglycemia.
Proper administration and assessment of the patient’s use of and response to oral and noninsulin injectable agents, and teaching the patient and family about these drugs, are all part of the nurse’s role.
The goals of diabetes self-management education are to guide the patient in becoming the most active participant in his or her care, while matching the level of self-management to the ability of the individual patient.
ACUTE COMPLICATIONS OF DIABETES MELLITUS
Diabetes-related ketoacidosis (DKA) is a life-threatening condition caused by a profound deficiency of insulin. It is characterized by hyperglycemia, ketosis, acidosis, and dehydration. It is most likely to occur in people with type 1 diabetes.
Hyperosmolar hyperglycemia syndrome (HHS) is a life-threatening syndrome that can occur in the patient with diabetes who is able to make enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.
Hypoglycemia, or low blood glucose, occurs when there is too much insulin in proportion to available glucose in the blood.
Hypoglycemia is often related to a mismatch in the timing of food intake and the peak action of insulin or oral glucose lowering agents that increase endogenous insulin secretion.
A critical role of the nurse is the prompt recognition of hypoglycemia and starting the appropriate treatment depending on the patient’s status.
CHRONIC COMPLICATIONS OF DIABETES MELLITUS
Chronic complications primarily include end-organ disease from damage to blood vessels from chronic hyperglycemia. These are divided into 2 categories: macrovascular complications and microvascular complications.
Macrovascular complications are diseases of the large and medium-sized blood vessels (heart, peripheral vascular system, and brain) that occur with greater frequency and with an earlier onset in people with diabetes.
Microvascular complications affect the tiny vessels of the eyes, kidneys, and nerves. They result from several pathways, all in response to chronic hyperglycemia.
Retinopathy refers to the process of microvascular damage in the back of the eyes because of chronic hyperglycemia. There are 2 types: proliferative and nonproliferative retinopathy. Because the earliest and most treatable stages cause no vision changes, teach persons with diabetes to have an annual dilated eye examination.
Nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidneys. Teach patients to get screened annually for albuminuria. A measurement of albumin-creatinine ratio from a urine specimen may also be used to assess renal function.
Neuropathy is nerve damage that occurs because of the metabolic derangements associated with diabetes. The 2 major categories of diabetes-related neuropathy are sensory neuropathy, which affects the peripheral nervous system, and autonomic neuropathy.
The most common form of sensory neuropathy is distal symmetric neuropathy, which affects the hands and/or feet bilaterally.
Autonomic neuropathy can affect nearly all body systems and lead to hypoglycemia unawareness, delayed gastric emptying (gastroparesis), constipation, diarrhea, urinary retention, and sexual dysfunction.
Complications of the Feet and Lower Extremities
Foot complications are one of the most common causes of hospitalization in the person with diabetes. Sensory neuropathy is a major risk factor for lower extremity amputation.
Because of the loss of protective sensations, proper care of the feet in patients with diabetes is critical to prevent infections.
Proper care of foot ulcers is critical to prevent amputations.
Skin Complications
Up to two thirds of people with type 1 and type 2 diabetes develop diabetes-related skin problems. Common problems include acanthosis nigricans, dermatopathy, and necrobiosis lipoidica diabeticorum.
Because skin is prone to injury, special care must be taken to protect it from injury and ulceration.
Infection
A person with diabetes is more susceptible to infections due to a defect in the mobilization of inflammatory cells and impaired phagocytosis by neutrophils and monocytes.
Antibiotic therapy for infections, which must be prompt and vigorous, has prevented infection from being a major cause of death in patients with diabetes.
Psychosocial Considerations
People with diabetes have increased rates of mental health disorders, particularly depression and distress.
Assess patients for the signs and symptoms of depression and distress at each visit.
Persons with type 1 diabetes, particularly young women, have an increased risk of developing an eating disorder in comparison to people without diabetes. Open and collaborative communication is critical for identifying these behaviors early. Use language that is person centered, strengths based, and empowering.
1. The nurse is assessing a patient newly diagnosed with type 1 diabetes. Which symptom reported by the patient correlates with the diagnosis?
a. Excessive thirst
b. Gradual weight gain
c. Overwhelming fatigue
d. Recurrent blurred vision
The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger).
2. When distinguishing between persons with type 1 diabetes from type 2 diabetes, the nurse is aware that
a. persons with type 1 diabetes require insulin therapy.
b. autoantibodies to pancreatic β-cells are found in type 2 diabetes.
c. persons with type 1 diabetes may be managed with metformin alone.
d. hyperosmolar hyperglycemia syndrome is more common in type 1 diabetes.
Patients with type 1 diabetes requires insulin therapy in order to survive and have autoantibodies to pancreatic β cells. Hyperosmolar hyperglycemia syndrome (HHS) is a life-threatening syndrome that can occur in a patient with type 2 diabetes who is able to make enough insulin to prevent diabetes related ketoacidosis (DKA) but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.
3. Goals of managing the patient with diabetes include (select all that apply)
a. keeping the target A1C greater than 9%.
b. teaching self-monitoring of glucose levels.
c. preventing complications of hypoglycemia.
d. monitoring for ophthalmologic complications.
e. maintaining the LDL cholesterol greater than 100 mg/dL (2.6 mmol/L).Goals of diabetes care include keeping the A1C less than 7%, preventing complications of both hyperglycemia and hypoglycemia, as well as preventing complications such as diabetic retinopathy and cardiovascular disease. The goal LDL for diabetics should be closer to 70 mg/dL.
4. Which patient statement demonstrates an understanding of the role of exercise in managing diabetes?
a. “I cannot exercise if I am taking insulin and metformin.”
b. “Exercise increases insulin resistance, so I will need a higher dose of insulin.”
c. “It is better to exercise before a meal if I take medication that causes hypoglycemia.”
d. “My insulin dose may need to be changed if I have low glucose levels after exercising.”
The glucose lowering effects of exercise can last up to 48 hours after the activity, so it is possible for hypoglycemia to occur long after the activity. Patients who exercise who also use drugs that can cause hypoglycemia may need to have their medications adjusted. Exercise is recommended for all persons with diabetes because it can decrease insulin resistance and lower blood glucose levels
5. You are caring for a patient with newly diagnosed type 2 diabetes who was started on metformin. What information should you include in discharge teaching? (Select all that apply.)
a. Need to reduce physical activity
b. Eliminate all forms of sugar from diet
c. Use of a portable blood glucose meter
d. Hypoglycemia prevention, symptoms, and treatment
e. Procedures that require IV contrast media are contraindicated
The nurse teaches the patient how to use the portable blood glucose monitor and how to recognize and treat signs and symptoms of hypoglycemia and hyperglycemia. These are referred to as “survival skills.”
6. What is the priority action for the nurse to take if the patient with type 2 diabetes reports headache, nervousness, and dizziness?
a. Administer glucagon.
b. Give insulin as ordered.
c. Check the patient’s glucose level.
d. Assess for other signs of neurologic stroke.
Check blood glucose whenever hypoglycemia is suspected so that immediate action can be taken if necessary
7. A patient with diabetes has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessing the patient, the nurse suspects diabetes-related ketoacidosis rather than hyperosmolar hyperglycemia syndrome based on the finding of
a. polyuria.
b. severe dehydration.
c. rapid, deep respirations.
d. decreased serum potassium.
Signs and symptoms of DKA include manifestations of dehydration, such as poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. Early symptoms may include lethargy and weakness. As the patient becomes severely dehydrated, the skin becomes dry and loose, and the eyeballs become soft and sunken. Abdominal pain is another symptom of DKA that may be accompanied by anorexia and vomiting. Kussmaul respirations
(i.e., rapid, deep breathing associated with dyspnea) are the body’s attempt to reverse metabolic acidosis through the exhalation of excess carbon dioxide. Acetone is identified on the breath as a sweet, fruity odor. Laboratory findings include a blood glucose level greater than 250 mg/dL, arterial blood pH less than 7.30, serum bicarbonate level less than 15 mEq/L, and moderate to high ketone levels in the urine or blood.
8. Which are appropriate therapies for patients with diabetes? (Select all that apply.)
a. Use of statins to reduce CVD risk
b. Use of diuretics to treat nephropathy
c. Use of β-blockers to treat retinopathy
d. Use of serotonin agonists to decrease appetite
e. Use of ACE or ARB inhibitors to treat nephropathy
In patients with diabetes who have albuminuria, angiotensin-converting enzyme
(ACE) inhibitors (e.g., lisinopril) or angiotensin II receptor antagonists (ARBs) (e.g., losartan) are used. Both classes of drugs are used to treat hypertension and delay the progression of nephropathy in patients with diabetes. The statin drugs are the most widely used lipid-lowering agents
A patient with diabetes is scheduled for a fasting glucose level at 8:00 AM. The nurse teaches the patient to only drink water after what time?
6:00 PM on the evening before the test
Midnight before the test
4:00 AM on the day of the test
7:00 AM on the day of the test
Typically, a patient is ordered to be NPO for 8 hours before a fasting glucose level. For this reason, the patient who has a lab draw at 8:00 AM should not have any food or beverages containing any calories after midnight.
The nurse teaches a patient recently diagnosed with type 1 diabetes about insulin administration. Which patient statement requires an intervention by the nurse?
“I will discard any insulin bottle that is cloudy in appearance.”
“The best injection site for insulin administration is in my abdomen.”
“I can wash the site with soap and water before insulin administration.”
“I may keep my insulin at room temperature (75°F) for up to 1 month.”
Intermediate-acting insulin and combination-premixed insulin will be cloudy in appearance. Routine hygiene such as washing with soap and rinsing with water is adequate for skin preparation for the patient during self-injections. Insulin vials that the patient is currently using may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86°F (30°C) or below freezing (<32°F [0°C]). Rotating sites to different anatomic sites are no longer recommended. Patients should rotate the injection within one site, such as the abdomen.
A person with type 1 diabetes reports a headache, changes in vision, and being anxious. A portable glucose monitor is not available. Which action would the nurse advise the patient to take?
Eat a piece of pizza.
Drink some diet pop.
Eat 15 g of simple carbohydrates.
Take an extra dose of rapid-acting insulin.
When a patient with type 1 diabetes is unsure about the meaning of the symptoms they are experiencing, they should treat for hypoglycemia to prevent seizures and coma from occurring. Have the patient check the glucose as soon as possible. The fat in the pizza and the diet pop would not allow the glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease the glucose level.
The nurse is assigned to care for a person newly diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the person to actively participate in managing diabetes, what would be the nurse’s initial intervention?
Assess the person’s perception of what it means to have diabetes.
Ask the person to write down their current knowledge about diabetes.
Set goals for the person to actively participate in managing his diabetes.
Assume responsibility for all the person’s care to decrease stress level.
For teaching to be effective, the first step is to do an assessment. Teaching can be individualized after the nurse is aware of what a diagnosis of diabetes means to the person. After the initial assessment, current knowledge can be assessed, and goals should be mutually set. Assuming responsibility for all the person’s care will not facilitate their health.
The nurse is teaching a patient who has diabetes about vascular complications of diabetes. What information is appropriate for the nurse to include?
Macroangiopathy only occurs in patients with type 2 diabetes who have severe disease.
Microangiopathy most often affects the capillary membranes of the eyes, kidneys, and skin.
Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by most patients with diabetes.
Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control.
Microangiopathy occurs in diabetes. When it affects the eyes, it is called diabetic retinopathy. When the kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Macroangiopathy can occur in either type 1 or type 2 diabetes and contributes to cerebrovascular, cardiovascular, and peripheral vascular disease. Sexual impotency and slowed gastric emptying result from microangiopathy and neuropathy.
The nurse is teaching a patient with type 2 diabetes about exercise to help control glucose. The nurse determines the patient understands the teaching when the patient states:
“I will go running when my blood sugar is too high to lower it.”
“I will go fishing frequently and pack a healthy lunch with plenty of water.”
“I do not need to increase my exercise routine since I am on my feet all day at work.”
“I will take a brisk 30-minute walk 5 days/wk and do resistance training 3 times a week.”
The best exercise plan for the person with type 2 diabetes is for 30 minutes of moderate activity 5 days/wk and resistance training 3 times a week. Brisk walking is moderate activity. Fishing and walking at work are light activity, and running is considered vigorous activity.
A person is admitted with diabetes, malnutrition, cellulitis, and a potassium level of 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result? (Select all that apply.)
The level is consistent with renal insufficiency from renal nephropathy.
The level may be high because of dehydration that accompanies hyperglycemia.
The level may be raised due to metabolic ketoacidosis caused by hyperglycemia.
The patient may be excreting sodium and retaining potassium from malnutrition.
This level shows adequate treatment of the cellulitis and acceptable glucose control.
The additional stress of cellulitis may lead to an increase in the person’s serum glucose levels. Dehydration may cause hemoconcentration, resulting in elevated serum readings. The kidneys may have difficulty excreting potassium if renal insufficiency exists. Finally, the nurse must consider the potential for metabolic ketoacidosis because potassium will leave the cell when hydrogen enters to compensate for a low pH. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus, it is not a contributing factor to this patient’s potassium level. The increased potassium level does not show adequate treatment of cellulitis or acceptable glucose control.
The nurse caring for a person hospitalized with diabetes would look for which laboratory test result to obtain information on their past glucose control?
Prealbumin level
Urine ketone level
Fasting glucose level
Glycosylated hemoglobin level
A glycosylated hemoglobin level detects the amount of glucose that is bound to red blood cells (RBCs). When circulating glucose levels are high, glucose attaches to the RBCs and remains there for the life of the blood cell, which is approximately 120 days. Thus, the test can give an indication of glycemic control over approximately 2 to 3 months. The prealbumin level is used to establish nutritional status and is unrelated to past glucose control. The urine ketone level will only show that hyperglycemia or starvation is probably currently occurring. The fasting glucose level only indicates current glucose control.
A person with type 2 diabetes asks the nurse what “type 2” means. What is the most appropriate response?
“With type 2 diabetes, the body of the pancreas becomes inflamed.”
“With type 2 diabetes, the person is totally dependent on an outside source of insulin.”
“With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased.”
“With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas.”
In type 2 diabetes, the secretion of insulin by the pancreas is reduced and/or the cells of the body become resistant to insulin. The pancreas becomes inflamed with pancreatitis. The person is totally dependent on exogenous insulin and may have had autoantibodies destroy the β-cells in the pancreas with type 1 diabetes.
The nurse has been teaching a person with diabetes how to perform blood glucose monitoring (BGM). During evaluation of the person’s technique, the nurse identifies a need for additional teaching when the person does what?
Chooses a puncture site in the center of the finger pad.
Washes hands with soap and water to cleanse the site to be used.
Warms the finger before puncturing the finger to obtain a drop of blood.
Tells the nurse that the result of 110 mg/dL indicates good control of diabetes.
The person should select a site on the sides of the fingertips, not on the center of the finger pad because this area contains many nerve endings and would be unnecessarily painful. Washing hands, warming the finger, and knowing the results that indicate good control all show understanding of the teaching.
Which patient with type 1 diabetes has the highest risk for developing hypoglycemic unawareness?
A 58-yr-old patient with diabetic retinopathy
A 73-yr-old patient who takes propranolol (Inderal)
A 19-yr-old patient who is on the college track team
A 24-yr-old patient with a hemoglobin A1C of 8.9%
Hypoglycemic unawareness is a condition in which a person does not have the warning signs and symptoms of hypoglycemia until the person becomes incoherent and combative or loses consciousness. Hypoglycemic awareness is related to autonomic neuropathy of diabetes that interferes with the secretion of counterregulatory hormones that produce these symptoms. Older patients and patients who use β-adrenergic blockers (e.g., propranolol) are at risk for hypoglycemic unawareness.
The nurse teaches a person with diabetes about a healthy eating plan. Which statement made by the person indicates that teaching was successful?
“I plan to lose 25 pounds this year by following a high-protein diet.”
“I may have a hypoglycemic reaction if I drink alcohol on an empty stomach.”
“I should include more fiber in my diet than a person who does not have diabetes.”
“If I use an insulin pump, I will not need to limit foods with saturated fat in my diet.”
Eating carbohydrates when drinking alcohol reduces the risk for alcohol-induced hypoglycemia. Intensified insulin therapy, such as the use of an insulin pump, allows considerable flexibility in food selection and can be adjusted for alterations from usual eating and exercise habits. However, saturated fat intake should still be limited to less than 7% of total daily calories. Daily fiber intake of 14 g/1000 kcal is recommended for the general population and for people with diabetes. High-protein diets are not recommended for weight loss.
The nurse has taught a patient admitted with diabetes principles of foot care. The nurse evaluates that the patient understands the instructions if the patient makes what statement?
“I should only walk barefoot in nice dry weather.”
“I should look at the condition of my feet every day.”
“I will need to cut back the number of times I shower per week.”
“My shoes should fit nice and tight because they will give me firm support.”
People with diabetes need to inspect their feet daily for broken areas that are at risk for infection and delayed wound healing. Properly fitted (not tight) shoes should be worn at all times. Routine care includes regular bathing.
The nurse is assisting a patient with newly diagnosed type 2 diabetes to learn dietary planning as part of the initial management of diabetes. The nurse would encourage the patient to limit intake of which foods to help reduce the percent of fat in the diet?
Cheese
Broccoli
Chicken
Oranges
Cheese is a product derived from animal sources and is higher in fat and calories than vegetables, fruit, and poultry. Excess fat in the diet is limited to help avoid macrovascular changes.
The newly diagnosed patient with type 2 diabetes has been prescribed metformin. What would the nurse teach the patient about how this medication works?
Increases insulin production from the pancreas.
Slows the absorption of carbohydrate in the small intestine.
Reduces glucose production by the liver and enhances insulin sensitivity.
Increases insulin release from the pancreas and inhibits glucagon secretion.
Metformin is a biguanide that reduces glucose production by the liver and enhances the tissue’s insulin sensitivity. Sulfonylureas and meglitinides increase insulin production from the pancreas. α-Glucosidase inhibitors slow the absorption of carbohydrate in the intestine. Glucagon-like peptide receptor agonists increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and decrease gastric emptying.
The nurse is assessing a patient newly diagnosed with type 2 diabetes. Which symptom reported by the patient correlates with the diagnosis?
Excessive thirst
Gradual weight gain
Overwhelming fatigue
Recurrent blurred vision
The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger). Weight gain, fatigue, and blurred vision may all occur with type 2 diabetes but are not classic manifestations.
The patient received regular insulin 10 units subcutaneously at 8:30 PM for a glucose level of 253 mg/dL. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin’s peak action?
8:40 PM to 9:00 PM
9:00 PM to 11:30 PM
10:30 PM to 1:30 AM
12:30 AM to 8:30 AM
Regular insulin exerts peak action in 2 to 5 hours, making the patient most at risk for hypoglycemia between 10:30 PM and 1:30 AM. Rapid-acting insulin’s onset is between 10 and 30 minutes with peak action and hypoglycemia most likely to occur between 9:00 PM and 11:30 PM. With intermediate acting insulin, hypoglycemia may occur from 12:30 AM to 8:30 AM.
A patient, admitted with diabetes, has a glucose level of 580 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find?
Central apnea
Hypoventilation
Kussmaul respirations
Cheyne-Stokes respirations
In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored. Central apnea occurs because the brain temporarily stops sending signals to the muscles that control breathing, which is unrelated to ketoacidosis. Hypoventilation and Cheyne-Stokes respirations do not occur with ketoacidosis.
A patient with diabetes who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively?
Avoid sick people and wash hands.
Obtain comprehensive dental care.
Maintain hemoglobin A1C below 7%.
Coughing and deep breathing with splinting.
A person with diabetes is at high risk for postoperative infections. The most important preoperative teaching to prevent a postoperative infection in the heart is to have the patient obtain comprehensive dental care because the risk of septicemia and infective endocarditis increases with poor dental health. Avoiding sick people, hand washing, maintaining hemoglobin A1C below 7%, and coughing and deep breathing with splinting would be important for any type of surgery but are not the priority for this patient with mitral valve replacement.
The nurse is reviewing laboratory results for a patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes?
Increased triglyceride levels
Increased high-density lipoproteins (HDL)
Decreased low-density lipoproteins (LDL)
Decreased very-low-density lipoproteins (VLDL)
Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. Increased HDL, decreased LDL, and decreased VLDL are positive in relation to atherosclerosis development.
The nurse is reviewing laboratory results for the clinic patients to be seen today. Which patient meets the diagnostic criteria for diabetes?
A 21-yr-old with a hemoglobin A1C of 8.4%
A 35-yr-old with a fasting glucose of 111 mg/dL
A 68-yr-old with a random glucose of 190 mg/dL
A 78-yr-old with a 2-hour glucose tolerance glucose of 184 mg/dL
Criteria for a diagnosis of diabetes include a hemoglobin A1C of 6.5% or greater, fasting glucose level of 126 mg/dL or greater, 2-hour glucose level of 200 mg/dL or greater during an oral glucose tolerance test, or classic symptoms of hyperglycemia or hyperglycemic crisis with a random glucose of 200 mg/dL or greater.
The nurse is teaching a patient with type 2 diabetes how to prevent diabetic nephropathy. Which patient statement indicates that teaching has been successful?
“Smokeless tobacco products decrease the risk of kidney damage.”
“I can help control my blood pressure by avoiding foods high in salt.”
“I should have yearly dilated eye examinations by an ophthalmologist.”
“I will avoid hypoglycemia by keeping my blood sugar above 180 mg/dL.”
The ADA recommends persons with type 2 diabetes should consume less than 2,300 mg of salt daily. People with type 2 diabetes need to have a dilated eye examination by an ophthalmologist or a specially trained optometrist at the time of diagnosis and annually thereafter for early detection and treatment. Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. Risk factors for the development of diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia.
A person with type 2 diabetes has a urinary tract infection (UTI), is difficult to arouse, and has a glucose level of 642 mg/dL. When the nurse assesses the urine, there are no ketones present. What nursing action is appropriate?
Routine insulin therapy and exercise
Administer a different antibiotic for the UTI
Cardiac monitoring to detect potassium changes
Administer IV fluids rapidly to correct dehydration
This person has manifestations of hyperosmolar hyperglycemic syndrome (HHS). Cardiac monitoring will be needed because of the changes in the potassium level related to fluid and insulin therapy and the osmotic diuresis from the elevated serum glucose level. Routine insulin would not be enough, and exercise could be dangerous for this patient. Extra insulin will be needed. The type of antibiotic will not affect HHS. There will be a large amount of IV fluid administered, but it will be given slowly because this patient is older and may have cardiac or renal compromise, requiring hemodynamic monitoring to avoid fluid overload during fluid replacement.
CHAPTER 45 - Obesity
CHAPTER 45 - Obesity
1. Discuss the epidemiology and etiology of obesity.
2. Explain the health risks associated with obesity.
3. Use classification systems to determine body size.
4. Discuss comprehensive therapy for the patient with obesity.
5. Distinguish among the bariatric surgical procedures used to treat obesity.
6. Describe the nursing and interprofessional management related to surgical therapies for obesity.
7. Describe the etiology, clinical manifestations, and nursing and interprofessional management of metabolic syndrome.
bariatric surgery
involves surgery on the stomach and/or intestines to help a person with extreme obesity lose weight
body mass index (BMI)
The most common way we classify weight is the body mass index (BMI). We calculate BMI by dividing a person’s weight (in kilograms) by the square of the height in meters
extreme obesity
The term extreme obesity (morbid or severe obesity) is used for those with a BMI greater than 40 kg/m2.
lipectomy
(adipectomy) is the surgical removal of excess skin and adipose tissue. It is often done on the abdomen of people who are obese or have lost a lot of weight to remove flabby folds of tissue
metabolic syndrome
Metabolic syndrome is a group of metabolic risk factors that increase a person’s chance of developing CVD, stroke, and diabetes. Just over 1 in 3 adults have metabolic syndrome.
obese
Those with a BMI of 30 kg/m2 or above are considered obese.
obesity
excessively high amount of body fat or adipose tissue
overweight
A BMI of 25 to 29.9 kg/m2 is classified as being overweight
waist-to-hip ratio (WHR)
another way to assess obesity. Calculate the WHR by dividing the waist measurement by the hip measurement. In women, the ratio should be 0.8 or less, and in men, it should be 1.0 or less.
KEY POINTS
Etiology and Pathophysiology
Obesity is a complex, multifactorial disease. It is the result of an energy imbalance where one takes in more calories than is needed for the body’s physical and metabolic functions. This results in an abnormal increase and accumulation of fat cells.
Many factors, including genetic and environmental influences, can contribute to obesity. Personal decisions about food choices, portion sizes, and exercise also are factors.
Most obese persons have primary obesity, which is excess calorie intake over energy expenditure for the body’s metabolic demands. Others have secondary obesity, in which a medical problem caused the weight gain.
Health Risks Associated With Obesity
Many problems occur at higher rates in people who are obese than in people of normal weight. Mortality rates rise as obesity increases. Besides health problems, many persons have a reduced quality of life
Obesity is a significant risk factor for cardiovascular disease and hypertension in both men and women.
Many patients with type 2 diabetes are obese.
Obesity can lead to several medical problems, including osteoarthritis, sleep apnea, gastroesophageal reflux disease (GERD), gallstones, non-alcoholic steatohepatitis, and cancer.
Obesity in older adults can worsen age-related declines in physical function and lead to frailty and disability.
NURSING AND INTERPROFESSIONAL MANAGEMENT: OBESITY
The first step in the treatment of obesity is to determine whether any physical conditions are present that may be causing or contributing to obesity. Obtain a health history and assess for any co-morbid diseases associated with obesity.
Measurements obtained may include height, weight, BMI, waist circumference, waist-to-hip ratio, and body shape.
The degree to which a patient is classified as underweight, healthy (normal) weight, overweight, or obese can be assessed by using body weight, a body mass index (BMI) chart, waist circumference, or waist-to-hip ratio.
People with fat primarily in the abdominal area (apple-shaped body) are at a greater risk for obesity-related complications than those whose fat is mainly in the upper legs (pear-shaped body).
The overall goals are that the patient with obesity will (1) modify eating patterns, (2) take part in a regular exercise, (3) achieve and maintain weight loss to a specified level, and (4) minimize or prevent health problems related to obesity.
Obesity is considered a chronic condition that requires day-to-day attention to lose weight and maintain weight loss. The management should include lifestyle changes revolving around a combination of diet and behavior modification, exercise, and sometimes drug therapy.
Motivation is an essential ingredient for successful achievement of weight loss.
Restricting dietary intake so that it is below energy requirements is a cornerstone for any weight loss or maintenance program. There is no best diet for weight loss. Any diet can work if it reduces caloric intake compared to expenditure and is one to which the patient will adhere.
Persons on low-calorie and very-low-calorie diets need frequent professional monitoring because the severe energy restriction places them at risk for multiple nutrient deficiencies.
Exercise is an important part of a weight control program. Exercise should be done daily, preferably for 30 to 60 minutes.
Useful basic techniques for behavioral modification include self-monitoring, stimulus control, and rewards.
Patients trying to lose weight often find support groups useful.
Drug therapy is reserved for adults with a BMI of 30 kg/m2 or greater (obese) or adults with a BMI of 27 kg/m2 or greater (overweight) who have at least 1 weight-related condition, such as hypertension, type 2 diabetes, or dyslipidemia
SURGICAL THERAPY
Bariatric surgery is currently the only treatment that has a successful and lasting impact for sustained weight loss for those with extreme obesity.
Surgeries are classified as restrictive, malabsorptive, or a combination of restrictive and malabsorptive surgeries.
Restrictive surgery reduces either the size of the stomach, which causes the patient to feel full more quickly, or the amount allowed to enter the stomach.
In malabsorptive procedures, the small intestine is shortened or bypassed so less food absorbed.
Concerns after bariatric surgery include wound healing, pain, and risk for infection. Early ambulation after surgery is important along with careful assessment for problems.
Long term follow- up is necessary after bariatric surgery as late complications after bariatric surgery include anemia, vitamin deficiencies, and psychosocial problems.
When obese patients have surgery, they are likely to have other comorbidities, including diabetes, altered cardiorespiratory function, abnormal metabolic function, hemostasis, and atherosclerosis, that place them at risk for complications related to surgery.
METABOLIC SYNDROME
Metabolic syndrome is a collection of risk factors that increase a person’s chance of developing cardiovascular disease and diabetes.
The signs of metabolic syndrome are impaired fasting blood glucose, hypertension, abnormal cholesterol levels, and obesity.
There is no specific management of metabolic syndrome.
Interventions focus on reducing risk factors of cardiovascular disease and type 2 diabetes:
reducing LDL cholesterol, stopping smoking, lowering BP, losing weight, and reducing glucose levels.
1. Which statement best describes the cause of obesity?
a. Obesity primarily results from a genetic predisposition.
b. Psychosocial factors can override the effects of genetics in causing obesity.
c. Genetic factors are more important than environmental factors in causing obesity.
d. Obesity is the result of complex interactions between genetic and environmental factors.
The cause of obesity involves significant genetic and biologic susceptibility factors that are highly influenced by environmental and psychosocial factors.
2. Health risks associated with obesity include (select all that apply)
a. colorectal cancer.
b. rheumatoid arthritis.
c. polycystic ovary syndrome.
d. nonalcoholic steatohepatitis.
e. systemic lupus erythematosus.
Health risks associated with obesity include cardiovascular disease, hypertension, sleep apnea, type 2 diabetes, osteoarthritis, gout, gastroesophageal reflux disease, gallstones, nonalcoholic steatohepatitis, fatty liver and cirrhosis, and breast, endometrial, kidney, colorectal, pancreas, esophagus, and gallbladder cancers.
3. The obesity classification that is most often associated with cardiovascular health problems is
a. primary obesity.
b. secondary obesity.
c. gynoid fat distribution.
d. android fat distribution.
A person with fat primarily in the abdominal area (i.e., whose body is apple shaped) is at greater risk for obesity-related complications (e.g., heart disease) than is a person whose fat is primarily in the upper legs (i.e., whose body is pear shaped). Those whose fat is distributed over the abdomen and upper body (i.e., neck, arms, and shoulders) are classified as having android obesity.
4. The best nutrition therapy plan for a person who is obese
a. is high in animal protein.
b. is fat-free and low in carbohydrates.
c. restricts intake to under 800 calories per day.
d. lowers calories with foods from all the basic groups.
Lower caloric intake is a cornerstone for any weight loss or maintenance program. A good weight loss plan should include foods from the 4 basic food groups and be nutritionally sound.
5. This bariatric surgical procedure involves creating a gastric pouch that is reversible, and no malabsorption occurs. Which procedure is this?
a. Vertical gastric banding
b. Biliopancreatic diversion
c. Roux-en-Y gastric bypass
d. adjustable gastric banding
With adjustable gastric banding (AGB), the stomach size is limited by an inflatable band placed around the fundus of the stomach. The band is connected to a subcutaneous port and can be inflated or deflated to change the stoma size to meet the patient’s needs as weight is lost. The procedure is done laparoscopically and, if needed, can be modified or reversed after the first procedure.
6. A patient with extreme obesity has undergone Roux-en-Y gastric bypass surgery. In planning postoperative care, the nurse expects that the patient
a. may have severe diarrhea early in the postoperative period.
b. will not be allowed to ambulate for 1 to 2 days postoperatively.
c. will have small amounts of oral liquids within the first 24 hours.
d. will require nasogastric suction until the drainage is pale yellow.
A low-sugar, clear-liquid diet is usually started within 24 hours after surgery. Begin with 15-mL increments every 10 to 15 minutes. If the patient does not have any nausea or other problems, gradually increase intake to a goal of 90 mL every 30 minutes.
7. Which criteria must be met for a diagnosis of metabolic syndrome? (select all that apply)
a. Hypertension
b. High triglycerides
c. Elevated plasma glucose
d. Increased waist circumference
e. Decreased low-density lipoproteins
Three of the following 5 criteria must be met for a diagnosis of metabolic syndrome:
→ Waist circumference of 40 inches or more in men and 35 inches or more in women
→Triglyceride levels higher than 150 mg/dL or need for drug treatment for high triglyceride levels
→High-density lipoprotein (HDL) cholesterol levels lower than 40 mg/dL in men and lower than
50 mg/dL in women or need for drug treatment for reduced HDL cholesterol levels
→Blood pressure: 130 mm Hg or higher systolic or 85 mm Hg or higher diastolic, or need for drug treatment for hypertension
→Fasting blood glucose level of 100 mg/dL or higher, or need for drug treatment for elevated glucose levels
The nurse cares for a patient after bariatric surgery. The nurse determines that discharge teaching related to diet is successful if the patient makes which statement?
“Fluid intake should be at least 2000 mL/day with meals to avoid dehydration.”
“A high-protein diet that is low in carbohydrates and fat will prevent diarrhea.”
“Food should be high in fiber to prevent constipation from the pain medication.”
“Three meals a day with no snacks between meals will provide optimal nutrition.”
The diet generally prescribed is high in protein and low in carbohydrates, fat, and roughage and consists of 6 small feedings daily. Fluids should not be ingested with the meal, and in some cases, fluids should be restricted to less than 1000 mL/day. Fluids and foods high in carbohydrate tend to promote diarrhea and symptoms of the dumping syndrome. Calorically dense foods, such as foods high in fat, should be avoided to permit more nutritionally sound food to be consumed.
An older adult patient with a body mass index (BMI) of 35 kg/m2, type 2 diabetes, hypercholesterolemia, and irritable bowel syndrome (IBS) is seeking assistance in losing weight. The patient states “I have trouble stopping eating when I should, but I do not want to have bariatric surgery.” Which drug therapy would the nurse question if it is prescribed for this patient?
Plenity
Orlistat (Xenical)
Phentermine (Adipex-P)
Phentermine and topiramate (Qsymia)
Orlistat (Xenical), which blocks fat breakdown and absorption in the intestine, produces some unpleasant gastrointestinal side effects. This drug would not be appropriate for someone with IBS. Plenity produces gel pieces increase the volume of stomach and small intestine contents and induces satiety. Phentermine (Adipex-P) needs to be used for a limited period of time (3 months or less). Qsymia is a combination of two drugs, phentermine and topiramate. Phentermine is a sympathomimetic agent that suppresses appetite and topiramate induces a sense of satiety.
Which patient has the greatest morbidity risk?
Male 6 ft, 1 in tall; BMI 29 kg/m2
Female 5 ft, 6 in tall; weight 150 lbs
Male with waist circumference 46 in
Female 5 ft, 10 in tall; obesity class III
The patient in class III obesity has the risk for disease because class III denotes severe obesity or a BMI greater than 40 kg/m2. The patient with the waist circumference of 46 in has a high risk for disease, but without the BMI or obesity class, a more precise determination cannot be made. The female who is 5 ft, 6 in tall has a normal weight for her height. The male patient who is over 6 ft tall is overweight, which increases his risk of disease, but a more precise determination cannot be made without the waist circumference.
A nurse in the PACU is caring for a severely obese patient who had surgery to repair a lower leg fracture. Which assessment is most important?
Cardiac rhythm
Surgical dressing
Postoperative pain
Oxygen saturation
After surgery, an older or severely obese patient should be closely monitored for oxygen desaturation. The body stores anesthetics in adipose tissue, placing patients with excess adipose tissue (e.g., obesity, older) at risk for resedation. As adipose cells release anesthetic back into the bloodstream, the patient may become sedated after surgery. This may depress the respiratory rate and decrease oxygen saturation.
A patient with morbid obesity has elected to have the Roux-en-Y gastric bypass (RYGB) procedure. The nurse will know the patient understands the preoperative teaching when the patient makes which statement?
“This surgery will preserve the function of my stomach.”
“This surgery will remove the fat cells from my abdomen.”
“This surgery can be modified whenever I need it to be changed.”
“This surgery decreases how much I can eat and how many calories I can absorb.”
The RYGB decreases the size of the stomach to a gastric pouch and attaches it directly to the small intestine so food bypasses 90% of the stomach, the duodenum, and a small segment of the jejunum. The vertical sleeve gastrectomy removes 85% of the stomach but preserves the function of the stomach. Lipectomy and liposuction remove fat tissue from the abdomen or other areas. Adjustable gastric banding can be modified or reversed at a later date.
In developing a weight loss program with a middle aged female patient who weighs 197 lbs, the nurse encourages the patient to set a weight loss goal of how many pounds in 4 weeks?
1 to 2
3 to 5
4 to 8
5 to 10
A realistic weight loss goal for patients is 1 to 2 pounds/wk, which prevents the patient from becoming frustrated at not meeting weight loss goals.
The nurse is caring for a patient with a herniated lumbar disc. The patient realizes that weight loss is necessary to lessen back strain. The patient is 5 ft, 6 in tall and weighs 186 lbs (84.5 kg) with a body mass index (BMI) of 28 kg/m2. The nurse explains this measurement places her in which weight category?
Normal weight
Overweight
Obese
Severely obese
A normal BMI is 18.5 to 24.9 kg/m2, and a BMI of 25 to 29.9 kg/m2 is considered overweight. A BMI of 30.0 to 39.9 kg/m2 is considered obese, and a BMI of 40 kg/m2 or greater is severely obese.
In developing an effective weight loss plan for a patient who expresses willingness to try to lose weight, what would the nurse assess first?
The length of time the patient has been obese
The patient’s current level of physical activity
The patient’s social, emotional, and behavioral influences on obesity
Anthropometric measurements, such as body mass index and skinfold thickness
Eating patterns are established early in life and eating has many meanings for people. To establish a weight loss plan that will be successful for the patient, the nurse would first explore the social, emotional, and behavioral influences on the patient’s eating patterns. The duration of obesity, current physical activity level, and current anthropometric measurements are not as important for the weight reduction plan.
At the first visit to the clinic, the female patient with a BMI of 29 kg/m2 tells the nurse that she does not want to become obese. Which question used for assessing weight issues would be most effective?
“What factors contributed to your current body weight?”
“How is your overall health affected by your body weight?”
“What is your history of gaining weight and losing weight?”
“In what ways are you interested in managing your weight differently?”
Asking the patient about her desire to manage her weight in a different manner helps the nurse determine the patient’s readiness for learning, degree of motivation, and willingness to change lifestyle habits. The nurse can help the patient set realistic goals. This question will also lead to discussing the patient’s history of gaining and losing weight and factors that have contributed to the patient’s current weight. The patient may be unaware of the overall health effects of her body weight, so this question is not helpful at this time.
Which patient is at risk for developing metabolic syndrome?
A 62-yr-old white man with coronary artery disease and chronic stable angina
A 27-yr-old Asian American woman with preeclampsia and gestational diabetes
A 38-yr-old Native American man who has diabetes and elevated hemoglobin A1C
A 54-yr-old Hispanic woman who is sedentary and has nephrogenic diabetes insipidus
Blacks, Hispanics, Native Americans, and Asians are at an increased risk for development of metabolic syndrome. Other risk factors include people who have diabetes that cannot maintain a normal glucose level, have hypertension, and secrete a large amount of insulin, or who have survived a heart attack and have hyperinsulinemia.
The nurse is caring for a patient after bariatric surgery. What would be included in the plan of care? (Select all that apply.)
Assist with early ambulation as needed.
Teach the patient to consume liquids with meals.
Maintain elevation of the head of bed at 45 degrees.
Monitor for vomiting as it is a common complication.
Provide a diet high in carbohydrate and fat intake.
Assess for incisional pain versus an anastomosis leak.
After bariatric surgery, the nurse needs to assess for incisional pain versus anastomosis leak. Because vomiting is a common postoperative complication, maintain elevation of the head of bed to reduce the risk of vomiting and aspiration. Dietary recommendations include 6 small meals that are high in protein and low in carbohydrates and fat. Fluids should be avoided during meals to prevent dumping syndrome. Early ambulation with assistance is recommended.
The nurse teaches a patient who has a body mass index (BMI) of 39 kg/m2 about weight loss. Which diet change would be most appropriate to recommend?
Decrease fat intake and control portion size.
Increase vegetables and decrease fluid intake.
Increase protein intake and avoid carbohydrates.
Decrease complex carbohydrates and limit fiber.
The safest dietary guideline for weight loss is to decrease caloric intake by maintaining a balance of nutrients and adequate hydration while controlling portion size and decreasing fat intake.
Which assessments would the nurse include when screening a patient for metabolic syndrome? (Select all that apply.)
Blood pressure
Resting heart rate
Physical endurance
Waist circumference
Fasting blood glucose
The diagnostic criteria for metabolic syndrome include elevated blood pressure, fasting blood glucose, waist circumference, and triglycerides, and low high-density lipoprotein cholesterol. Resting heart rate and physical endurance are not part of the diagnostic criteria.
The nurse teaches an obese young adult with a sedentary job about the health benefits of an exercise program. The nurse evaluates that teaching is effective when the patient makes which statement?
“The goal is to walk at least 10,000 steps every day of the week.”
“Weekend aerobics for 2 hours is better than exercising every day.”
“Aerobic exercise will increase my appetite and result in weight gain.”
“Exercise causes weight loss by decreasing my resting metabolic rate.”
A realistic activity goal is to walk 10,000 steps a day. Increased activity does not promote an increase in appetite or lead to weight gain. Exercise should be done daily, preferably 30 minutes to an hour a day. Exercise increases metabolic rate.
The nurse has completed initial instruction with a patient regarding a weight loss program. The nurse determines that the teaching has been effective when the patient makes which statement?
“I will keep a diary of weekly weights to track my weight loss.”
“I plan to lose 4 pounds a week until I reach my 60-pound goal.”
“I will restrict my carbohydrate intake to less than 30 g/day to maximize weight loss.”
“I will not exercise more than my program requires because the activity increases the appetite.”
The patient should monitor and record weight once per week. This prevents frustration at the normal variations in daily weights and may help the patient to maintain motivation to stay on the prescribed diet. Weight loss should occur at a rate of 1 to 2 pounds/wk. The diet should be well balanced rather than lacking in specific components that may cause an initial weight loss but is not usually sustainable. Exercise is a necessary component of any successful weight loss program.
The nurse is caring for a patient who is 5 ft, 5 in tall and weighs 186 lb. The nurse has discussed reasonable weight loss goals and a low-calorie diet with the patient. Which statement made by the patient indicates a need for further teaching?
“I will limit intake to 500 calories a day.”
“I will try to eat very slowly during mealtimes.”
“I’ll try to pick foods from all of the basic food groups.”
“It’s important for me to begin a regular exercise program.”
Limiting intake to 500 calories per day is not indicated for this patient, and the severe calorie energy restriction would place this patient at risk for multiple nutrient deficiencies. The other options show understanding of the teaching.
CHAPTER 63 - Chronic Neurologic Problems
CHAPTER 53 - Diabetes
1. Describe the pathophysiology and clinical manifestations of diabetes.
2. Distinguish between type 1 and type 2 diabetes.
3. Describe the interprofessional care of a patient with diabetes.
4. Describe the role of nutrition and exercise in managing diabetes.
5. Discuss the nursing management of a patient with newly diagnosed diabetes.
6. Describe the nursing management of a patient with diabetes in the ambulatory and home care settings.
7. Relate the pathophysiology of acute and chronic complications of diabetes to the clinical manifestations.
8. Explain the interprofessional care and nursing management of a patient with acute and chronic complications of diabetes.
basal-bolus plan
The insulin approach that most closely mimics endogenous insulin production is the basal-bolus plan (often called intensive or physiologic insulin therapy). It consists of multiple daily insulin injections or an insulin pump together with frequent BGM or CGM. Injections include rapid- or short-acting (bolus) insulin before meals and intermediate- or long-acting (basal) background insulin once or twice a day
blood glucose monitoring (BGM)
critical part of DM management. By providing a current glucose reading, BGM lets the patient make decisions about food intake, activity patterns, and drug dosages.
dawn phenomenon
also characterized by hyperglycemia that is present on awakening. Two counterregulatory hormones (GH and cortisol), which are excreted in increased amounts in the early morning hours, may be the cause of this phenomenon.
diabetes mellitus (DM)
chronic multisystem disease characterized by hyperglycemia from abnormal insulin production, impaired insulin use, or both.
diabetes-related ketoacidosis (DKA)
DKA is caused by a profound deficiency of insulin. It is characterized by hyperglycemia, ketosis, acidosis, and dehydration. It is most likely to occur in people with type 1 DM. DKA may occur in people with type 2 DM in conditions of severe illness or stress in which the pancreas cannot meet the extra demand for insulin.
diabetes-related nephropathy
associated with damage to the small blood vessels that supply the glomeruli of the kidney. It is the leading cause of ESRD in the United States and is seen in 20% to 40% of people with DM.
diabetes-related neuropathy
nerve damage that occurs from the metabolic imbalances associated with DM. About 60% to 70% of patients with DM have some degree of neuropathy. The most common type affecting persons with DM is sensory neuropathy.
diabetes-related retinopathy
refers to the microvascular damage to the retina because of chronic hyperglycemia, nephropathy, and hypertension in people with DM. DM-related retinopathy is the leading cause of new cases of adult blindness.
hyperosmolar hyperglycemia syndrome (HHS)
life-threatening syndrome that can occur in patients with DM who are able to make enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion (Fig. 53.13). HHS is less common than DKA (Table 53.19). It often occurs in patients over 60 years of age with type 2 DM.
impaired fasting glucose (IFG)
IFG is diagnosed when fasting glucose levels are 100 to 125 mg/dL (5.56 to 6.9 mmol/L).
impaired glucose tolerance (IGT)
IGT is made if the 2-hour oral glucose tolerance test (OGTT) values are 140 to 199 mg/dL (7.8 to 11.0 mmol/L)
insulin resistance
This is a condition in which body tissues do not respond to the action of insulin because insulin receptors are unresponsive, insufficient in number, or both
prediabetes
Prediabetes is defined as impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or both. It is an intermediate stage between normal glucose homeostasis and DM. Glucose levels are high but not high enough to meet the diagnostic criteria for DM
Somogyi effect
Hyperglycemia in the morning may be due to the Somogyi effect. A high dose of insulin causes a decline in glucose levels during the night. As a result, counterregulatory hormones (e.g., glucagon, epinephrine, GH, cortisol) are released. They stimulate lipolysis, gluconeogenesis, and glycogenolysis, which in turn cause rebound hyperglycemia.
DIABETES MELLITUS
Etiology and Pathophysiology
Diabetes mellitus (more commonly referred to as diabetes) is a chronic multisystem disorder of glucose metabolism related to absent or insufficient insulin, impaired use of insulin, or both.
Current theories link the causes of diabetes to genetic, autoimmune, and environmental factors.
Type 1 Diabetes
Type 1 diabetes generally affects people under 40 years of age, although it can occur at any age.
Type 1 diabetes is the result of a long-standing autoimmune process in which the body’s own T cells attack and destroy pancreatic β -cells, which are the source of the body’s insulin.
Because the initial manifestation of type 1 diabetes is often rapid, the symptoms are usually acute.
The classic symptoms, polyuria, polydipsia, and polyphagia, are caused by hyperglycemia.
The person with type 1 diabetes requires insulin therapy to sustain life. Without insulin, the patient will develop diabetes-related ketoacidosis (DKA), a life-threatening condition resulting in metabolic acidosis.
Type 2 Diabetes
Type 2 diabetes accounts for around 90% of people with diabetes.
In type 2 diabetes, the pancreas usually continues to make some insulin. However, the insulin that is made is either insufficient for the needs of the body and/or is poorly used by the tissues.
There are many factors and several genes involved in the development of type 2 diabetes.
One of the most important risk factors for developing type 2 diabetes is obesity.
The manifestations of type 2 diabetes are more nonspecific and include fatigue, recurrent infections, recurrent vaginal yeast infections, prolonged wound healing, and visual changes.
Prediabetes
Prediabetes is a condition in which blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes.
Long-term damage to the body, especially the heart and blood vessels, may already be occurring in people with prediabetes.
Teach people with prediabetes to take action to prevent or delay the development of type 2 diabetes. Encourage them to have their blood glucose and A1C checked regularly
Gestational Diabetes
Gestational diabetes develops during pregnancy and is usually screened for and detected at 24 to 28 weeks of gestation by an oral glucose tolerance test.
Although most women with gestational diabetes will have normal glucose levels within 6 weeks postpartum, their risk for developing type 2 diabetes is 63% within 16 years.
Other Specific Types of Diabetes
Other types of diabetes can occur because of another medical condition or treatment that causes abnormal blood glucose levels. These conditions result from injury to, interference with, or destruction of the β-cell function of the pancreas.
Conditions include Cushing syndrome, hyperthyroidism, recurrent pancreatitis, cystic fibrosis, hemochromatosis, parenteral nutrition, or use of certain drugs, including corticosteroids or certain antipsychotics.
Diagnostic Studies
A diagnosis of diabetes is based on 1 of 4 methods: fasting plasma glucose, random plasma glucose measurement with symptoms, 2-hour oral glucose tolerance test, and/or an A1C test.
Interprofessional Care
The goals of diabetes management are to reduce symptoms, promote well-being, prevent acute complications of hyperglycemia and hypoglycemia, and prevent or delay the onset and progression of long-term complications. These goals are most likely to be met when the patient maintains blood glucose levels as near to normal as possible.
Drug Therapy: Insulin
Exogenous (injected) insulin is needed when a patient has inadequate insulin to meet specific metabolic needs.
Insulin is divided into 2 main categories: short-acting (bolus) and long-acting (basal) insulin.
Bolus insulin is used at mealtimes to prevent postprandial hyperglycemia and/or to bring down an elevated glucose level.
Basal insulin provides a background level of insulin throughout the day.
A variety of insulin plans are recommended for patients depending on his or her needs and preferences.
Insulin is most often given by subcutaneous injection. IV administration of regular insulin can be given when immediate onset of action is desired.
The speed with which peak serum concentrations are reached varies with the anatomic site for injection. The fastest subcutaneous absorption is from the abdomen.
An insulin pump can be used to give continuous short-acting insulin. It is programmed to deliver a continuous infusion 24 hours a day with boluses at mealtime and to bring down elevated blood glucose levels.
Hypoglycemia, allergic reactions, lipodystrophy, hypertrophy, and the Somogyi effect are problems associated with insulin therapy.
Lipodystrophy may occur if the same injection sites are used frequently. The incidence has decreased with the use of human insulin.
Hypertrophy is a thickening of the subcutaneous tissue. Injecting into a hypertrophied site may result in erratic insulin absorption.
Elevated morning glucose levels may be due to the Somogyi effect. This is a rebound caused by hypoglycemia during the night that stimulates a counterregulatory response.
The dawn phenomenon is characterized by hyperglycemia that is present on awakening in the morning, resulting from the increased release of counterregulatory hormones in the predawn hours.
Drug Therapy: Oral and Noninsulin Injectable Agents
These agents primarily work on the 3 main defects of type 2 diabetes: (1) insulin resistance, (2) decreased insulin production, and (3) increased hepatic glucose production. These drugs may be used in combination with agents from other classes or with insulin to achieve blood glucose goals.
Oral Agents
Metformin (Glucophage) is a biguanide glucose-lowering agent. The primary action of metformin is to reduce glucose production by the liver. The ADA algorithm for the management of type 2 diabetes recommends the use of metformin combined with lifestyle interventions as the first-line therapy. Metformin is available in many combination drugs as well.
Sulfonylureas increase insulin production from the pancreas. Since they can cause hypoglycemia, it is important to teach patients how to recognize and manage low blood glucose.
Sulfonylureas are sometimes added if metformin and lifestyle interventions are not effective.
Meglitinides increase insulin production from the pancreas. Because they are rapidly absorbed and eliminated, they have a lower risk of hypoglycemia than with the sulfonylureas. They are taken before meals, usually resulting in dosing 3 times a day.
α-Glucosidase inhibitors, also known as “starch blockers,” work by slowing down carbohydrate absorption in the small intestine.
Thiazolidinediones are most effective for people who have insulin resistance. Due to their severe adverse effects, the 2 drugs in this class are rarely used.
Noninsulin Injectable Agents
Glucagon-like peptide (GLP)-1 receptor agonists target the incretin hormones. They stabilize blood glucose levels, slow gastric emptying, increase satiety, and have the additional effect of reducing body weight.
Sodium-glucose co-transporter 2 (SGLT2) inhibitors decrease renal glucose reabsorption and increase urinary glucose excretion.
Dipeptidyl peptidase IV (DPP-4) inhibitors slow the degradation of the incretin hormone GLP1. This results in inhibited secretion of glucagon, increased insulin secretion, slowed gastric emptying, and decreased appetite.
Pramlintide (Symlin) is a synthetic analog of human amylin, a hormone secreted by the β cells of the pancreas. It is only taken concurrently with insulin, and use can increase satiety and lower blood glucose levels.
Nutrition Therapy
The overall goal of nutrition therapy is to help people with diabetes make healthy food choices and eat a varied diet that will lead to target blood glucose levels.
For those using conventional, fixed insulin doses, day-to-day consistency in timing and amount of food eaten is important. Patients using a basal-bolus approach with rapid-acting insulin can adjust the dosage before meals based on the premeal glucose level and the carbohydrate content of the meal.
The emphasis of nutrition management in diabetes is placed on achieving glucose, lipid, and BP goals and achieving weight loss if the patient is overweight or obese.
People with diabetes are encouraged to follow the same healthy eating guidelines as those without: eat whole grains, healthy fat, and lean protein; limit saturated and trans fats, and increase plant-based foods.
Encourage patients to frankly discuss the use of alcohol with their HCPs because its use can make blood glucose harder to manage.
Exercise
Regular, consistent exercise is an essential part of diabetes and prediabetes management. Exercise increases insulin sensitivity and can have a direct effect on lowering blood glucose levels.
Patients who use insulin, sulfonylureas, or meglitinides are at increased risk for hypoglycemia, especially if they exercise at the time of peak drug action or eat too little to maintain target blood glucose levels. Teach them to exercise about 1 hour after a meal or have a 10- to 15-g carbohydrate snack and check their glucose before exercising.
Patients should delay activity if the blood glucose level is over 250 mg/dL and ketones are present in the urine. If hyperglycemia is present without ketosis, it is not necessary to postpone exercise.
Monitoring Blood Glucose
Blood glucose monitoring (BGM) is a cornerstone of diabetes management. Using current blood glucose readings, people can make informed self-management decisions about food, exercise, and medication.
The frequency of monitoring depends on several factors, including the patient’s glycemic goals, the type of diabetes that the patient has, the patient’s ability to monitor independently, the patient’s willingness to perform BGM, and cost. More people with diabetes are using continuous glucose monitoring in addition to, or instead of, finger-stick blood glucose monitoring.
Pancreas Transplantation
Pancreas transplantation can be used as a treatment option for people with type 1 diabetes. Transplants are done for patients with end-stage kidney disease and who had or are having a kidney transplant.
NURSING MANAGEMENT: DIABETES MELLITUS
Nursing responsibilities for the patient receiving insulin include proper administration, assessment of the patient’s response to insulin therapy, and teaching of the patient about administration of, storage, adjustment to, and side effects of insulin, particularly recognition and management of hypoglycemia.
Proper administration and assessment of the patient’s use of and response to oral and noninsulin injectable agents, and teaching the patient and family about these drugs, are all part of the nurse’s role.
The goals of diabetes self-management education are to guide the patient in becoming the most active participant in his or her care, while matching the level of self-management to the ability of the individual patient.
ACUTE COMPLICATIONS OF DIABETES MELLITUS
Diabetes-related ketoacidosis (DKA) is a life-threatening condition caused by a profound deficiency of insulin. It is characterized by hyperglycemia, ketosis, acidosis, and dehydration. It is most likely to occur in people with type 1 diabetes.
Hyperosmolar hyperglycemia syndrome (HHS) is a life-threatening syndrome that can occur in the patient with diabetes who is able to make enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.
Hypoglycemia, or low blood glucose, occurs when there is too much insulin in proportion to available glucose in the blood.
Hypoglycemia is often related to a mismatch in the timing of food intake and the peak action of insulin or oral glucose lowering agents that increase endogenous insulin secretion.
A critical role of the nurse is the prompt recognition of hypoglycemia and starting the appropriate treatment depending on the patient’s status.
CHRONIC COMPLICATIONS OF DIABETES MELLITUS
Chronic complications primarily include end-organ disease from damage to blood vessels from chronic hyperglycemia. These are divided into 2 categories: macrovascular complications and microvascular complications.
Macrovascular complications are diseases of the large and medium-sized blood vessels (heart, peripheral vascular system, and brain) that occur with greater frequency and with an earlier onset in people with diabetes.
Microvascular complications affect the tiny vessels of the eyes, kidneys, and nerves. They result from several pathways, all in response to chronic hyperglycemia.
Retinopathy refers to the process of microvascular damage in the back of the eyes because of chronic hyperglycemia. There are 2 types: proliferative and nonproliferative retinopathy. Because the earliest and most treatable stages cause no vision changes, teach persons with diabetes to have an annual dilated eye examination.
Nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidneys. Teach patients to get screened annually for albuminuria. A measurement of albumin-creatinine ratio from a urine specimen may also be used to assess renal function.
Neuropathy is nerve damage that occurs because of the metabolic derangements associated with diabetes. The 2 major categories of diabetes-related neuropathy are sensory neuropathy, which affects the peripheral nervous system, and autonomic neuropathy.
The most common form of sensory neuropathy is distal symmetric neuropathy, which affects the hands and/or feet bilaterally.
Autonomic neuropathy can affect nearly all body systems and lead to hypoglycemia unawareness, delayed gastric emptying (gastroparesis), constipation, diarrhea, urinary retention, and sexual dysfunction.
Complications of the Feet and Lower Extremities
Foot complications are one of the most common causes of hospitalization in the person with diabetes. Sensory neuropathy is a major risk factor for lower extremity amputation.
Because of the loss of protective sensations, proper care of the feet in patients with diabetes is critical to prevent infections.
Proper care of foot ulcers is critical to prevent amputations.
Skin Complications
Up to two thirds of people with type 1 and type 2 diabetes develop diabetes-related skin problems. Common problems include acanthosis nigricans, dermatopathy, and necrobiosis lipoidica diabeticorum.
Because skin is prone to injury, special care must be taken to protect it from injury and ulceration.
Infection
A person with diabetes is more susceptible to infections due to a defect in the mobilization of inflammatory cells and impaired phagocytosis by neutrophils and monocytes.
Antibiotic therapy for infections, which must be prompt and vigorous, has prevented infection from being a major cause of death in patients with diabetes.
Psychosocial Considerations
People with diabetes have increased rates of mental health disorders, particularly depression and distress.
Assess patients for the signs and symptoms of depression and distress at each visit.
Persons with type 1 diabetes, particularly young women, have an increased risk of developing an eating disorder in comparison to people without diabetes. Open and collaborative communication is critical for identifying these behaviors early. Use language that is person centered, strengths based, and empowering.
1. The nurse is assessing a patient newly diagnosed with type 1 diabetes. Which symptom reported by the patient correlates with the diagnosis?
a. Excessive thirst
b. Gradual weight gain
c. Overwhelming fatigue
d. Recurrent blurred vision
The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger).
2. When distinguishing between persons with type 1 diabetes from type 2 diabetes, the nurse is aware that
a. persons with type 1 diabetes require insulin therapy.
b. autoantibodies to pancreatic β-cells are found in type 2 diabetes.
c. persons with type 1 diabetes may be managed with metformin alone.
d. hyperosmolar hyperglycemia syndrome is more common in type 1 diabetes.
Patients with type 1 diabetes requires insulin therapy in order to survive and have autoantibodies to pancreatic β cells. Hyperosmolar hyperglycemia syndrome (HHS) is a life-threatening syndrome that can occur in a patient with type 2 diabetes who is able to make enough insulin to prevent diabetes related ketoacidosis (DKA) but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.
3. Goals of managing the patient with diabetes include (select all that apply)
a. keeping the target A1C greater than 9%.
b. teaching self-monitoring of glucose levels.
c. preventing complications of hypoglycemia.
d. monitoring for ophthalmologic complications.
e. maintaining the LDL cholesterol greater than 100 mg/dL (2.6 mmol/L).Goals of diabetes care include keeping the A1C less than 7%, preventing complications of both hyperglycemia and hypoglycemia, as well as preventing complications such as diabetic retinopathy and cardiovascular disease. The goal LDL for diabetics should be closer to 70 mg/dL.
4. Which patient statement demonstrates an understanding of the role of exercise in managing diabetes?
a. “I cannot exercise if I am taking insulin and metformin.”
b. “Exercise increases insulin resistance, so I will need a higher dose of insulin.”
c. “It is better to exercise before a meal if I take medication that causes hypoglycemia.”
d. “My insulin dose may need to be changed if I have low glucose levels after exercising.”
The glucose lowering effects of exercise can last up to 48 hours after the activity, so it is possible for hypoglycemia to occur long after the activity. Patients who exercise who also use drugs that can cause hypoglycemia may need to have their medications adjusted. Exercise is recommended for all persons with diabetes because it can decrease insulin resistance and lower blood glucose levels
5. You are caring for a patient with newly diagnosed type 2 diabetes who was started on metformin. What information should you include in discharge teaching? (Select all that apply.)
a. Need to reduce physical activity
b. Eliminate all forms of sugar from diet
c. Use of a portable blood glucose meter
d. Hypoglycemia prevention, symptoms, and treatment
e. Procedures that require IV contrast media are contraindicated
The nurse teaches the patient how to use the portable blood glucose monitor and how to recognize and treat signs and symptoms of hypoglycemia and hyperglycemia. These are referred to as “survival skills.”
6. What is the priority action for the nurse to take if the patient with type 2 diabetes reports headache, nervousness, and dizziness?
a. Administer glucagon.
b. Give insulin as ordered.
c. Check the patient’s glucose level.
d. Assess for other signs of neurologic stroke.
Check blood glucose whenever hypoglycemia is suspected so that immediate action can be taken if necessary
7. A patient with diabetes has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessing the patient, the nurse suspects diabetes-related ketoacidosis rather than hyperosmolar hyperglycemia syndrome based on the finding of
a. polyuria.
b. severe dehydration.
c. rapid, deep respirations.
d. decreased serum potassium.
Signs and symptoms of DKA include manifestations of dehydration, such as poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. Early symptoms may include lethargy and weakness. As the patient becomes severely dehydrated, the skin becomes dry and loose, and the eyeballs become soft and sunken. Abdominal pain is another symptom of DKA that may be accompanied by anorexia and vomiting. Kussmaul respirations
(i.e., rapid, deep breathing associated with dyspnea) are the body’s attempt to reverse metabolic acidosis through the exhalation of excess carbon dioxide. Acetone is identified on the breath as a sweet, fruity odor. Laboratory findings include a blood glucose level greater than 250 mg/dL, arterial blood pH less than 7.30, serum bicarbonate level less than 15 mEq/L, and moderate to high ketone levels in the urine or blood.
8. Which are appropriate therapies for patients with diabetes? (Select all that apply.)
a. Use of statins to reduce CVD risk
b. Use of diuretics to treat nephropathy
c. Use of β-blockers to treat retinopathy
d. Use of serotonin agonists to decrease appetite
e. Use of ACE or ARB inhibitors to treat nephropathy
In patients with diabetes who have albuminuria, angiotensin-converting enzyme
(ACE) inhibitors (e.g., lisinopril) or angiotensin II receptor antagonists (ARBs) (e.g., losartan) are used. Both classes of drugs are used to treat hypertension and delay the progression of nephropathy in patients with diabetes. The statin drugs are the most widely used lipid-lowering agents
A patient with diabetes is scheduled for a fasting glucose level at 8:00 AM. The nurse teaches the patient to only drink water after what time?
6:00 PM on the evening before the test
Midnight before the test
4:00 AM on the day of the test
7:00 AM on the day of the test
Typically, a patient is ordered to be NPO for 8 hours before a fasting glucose level. For this reason, the patient who has a lab draw at 8:00 AM should not have any food or beverages containing any calories after midnight.
The nurse teaches a patient recently diagnosed with type 1 diabetes about insulin administration. Which patient statement requires an intervention by the nurse?
“I will discard any insulin bottle that is cloudy in appearance.”
“The best injection site for insulin administration is in my abdomen.”
“I can wash the site with soap and water before insulin administration.”
“I may keep my insulin at room temperature (75°F) for up to 1 month.”
Intermediate-acting insulin and combination-premixed insulin will be cloudy in appearance. Routine hygiene such as washing with soap and rinsing with water is adequate for skin preparation for the patient during self-injections. Insulin vials that the patient is currently using may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86°F (30°C) or below freezing (<32°F [0°C]). Rotating sites to different anatomic sites are no longer recommended. Patients should rotate the injection within one site, such as the abdomen.
A person with type 1 diabetes reports a headache, changes in vision, and being anxious. A portable glucose monitor is not available. Which action would the nurse advise the patient to take?
Eat a piece of pizza.
Drink some diet pop.
Eat 15 g of simple carbohydrates.
Take an extra dose of rapid-acting insulin.
When a patient with type 1 diabetes is unsure about the meaning of the symptoms they are experiencing, they should treat for hypoglycemia to prevent seizures and coma from occurring. Have the patient check the glucose as soon as possible. The fat in the pizza and the diet pop would not allow the glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease the glucose level.
The nurse is assigned to care for a person newly diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the person to actively participate in managing diabetes, what would be the nurse’s initial intervention?
Assess the person’s perception of what it means to have diabetes.
Ask the person to write down their current knowledge about diabetes.
Set goals for the person to actively participate in managing his diabetes.
Assume responsibility for all the person’s care to decrease stress level.
For teaching to be effective, the first step is to do an assessment. Teaching can be individualized after the nurse is aware of what a diagnosis of diabetes means to the person. After the initial assessment, current knowledge can be assessed, and goals should be mutually set. Assuming responsibility for all the person’s care will not facilitate their health.
The nurse is teaching a patient who has diabetes about vascular complications of diabetes. What information is appropriate for the nurse to include?
Macroangiopathy only occurs in patients with type 2 diabetes who have severe disease.
Microangiopathy most often affects the capillary membranes of the eyes, kidneys, and skin.
Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by most patients with diabetes.
Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control.
Microangiopathy occurs in diabetes. When it affects the eyes, it is called diabetic retinopathy. When the kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Macroangiopathy can occur in either type 1 or type 2 diabetes and contributes to cerebrovascular, cardiovascular, and peripheral vascular disease. Sexual impotency and slowed gastric emptying result from microangiopathy and neuropathy.
The nurse is teaching a patient with type 2 diabetes about exercise to help control glucose. The nurse determines the patient understands the teaching when the patient states:
“I will go running when my blood sugar is too high to lower it.”
“I will go fishing frequently and pack a healthy lunch with plenty of water.”
“I do not need to increase my exercise routine since I am on my feet all day at work.”
“I will take a brisk 30-minute walk 5 days/wk and do resistance training 3 times a week.”
The best exercise plan for the person with type 2 diabetes is for 30 minutes of moderate activity 5 days/wk and resistance training 3 times a week. Brisk walking is moderate activity. Fishing and walking at work are light activity, and running is considered vigorous activity.
A person is admitted with diabetes, malnutrition, cellulitis, and a potassium level of 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result? (Select all that apply.)
The level is consistent with renal insufficiency from renal nephropathy.
The level may be high because of dehydration that accompanies hyperglycemia.
The level may be raised due to metabolic ketoacidosis caused by hyperglycemia.
The patient may be excreting sodium and retaining potassium from malnutrition.
This level shows adequate treatment of the cellulitis and acceptable glucose control.
The additional stress of cellulitis may lead to an increase in the person’s serum glucose levels. Dehydration may cause hemoconcentration, resulting in elevated serum readings. The kidneys may have difficulty excreting potassium if renal insufficiency exists. Finally, the nurse must consider the potential for metabolic ketoacidosis because potassium will leave the cell when hydrogen enters to compensate for a low pH. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus, it is not a contributing factor to this patient’s potassium level. The increased potassium level does not show adequate treatment of cellulitis or acceptable glucose control.
The nurse caring for a person hospitalized with diabetes would look for which laboratory test result to obtain information on their past glucose control?
Prealbumin level
Urine ketone level
Fasting glucose level
Glycosylated hemoglobin level
A glycosylated hemoglobin level detects the amount of glucose that is bound to red blood cells (RBCs). When circulating glucose levels are high, glucose attaches to the RBCs and remains there for the life of the blood cell, which is approximately 120 days. Thus, the test can give an indication of glycemic control over approximately 2 to 3 months. The prealbumin level is used to establish nutritional status and is unrelated to past glucose control. The urine ketone level will only show that hyperglycemia or starvation is probably currently occurring. The fasting glucose level only indicates current glucose control.
A person with type 2 diabetes asks the nurse what “type 2” means. What is the most appropriate response?
“With type 2 diabetes, the body of the pancreas becomes inflamed.”
“With type 2 diabetes, the person is totally dependent on an outside source of insulin.”
“With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased.”
“With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas.”
In type 2 diabetes, the secretion of insulin by the pancreas is reduced and/or the cells of the body become resistant to insulin. The pancreas becomes inflamed with pancreatitis. The person is totally dependent on exogenous insulin and may have had autoantibodies destroy the β-cells in the pancreas with type 1 diabetes.
The nurse has been teaching a person with diabetes how to perform blood glucose monitoring (BGM). During evaluation of the person’s technique, the nurse identifies a need for additional teaching when the person does what?
Chooses a puncture site in the center of the finger pad.
Washes hands with soap and water to cleanse the site to be used.
Warms the finger before puncturing the finger to obtain a drop of blood.
Tells the nurse that the result of 110 mg/dL indicates good control of diabetes.
The person should select a site on the sides of the fingertips, not on the center of the finger pad because this area contains many nerve endings and would be unnecessarily painful. Washing hands, warming the finger, and knowing the results that indicate good control all show understanding of the teaching.
Which patient with type 1 diabetes has the highest risk for developing hypoglycemic unawareness?
A 58-yr-old patient with diabetic retinopathy
A 73-yr-old patient who takes propranolol (Inderal)
A 19-yr-old patient who is on the college track team
A 24-yr-old patient with a hemoglobin A1C of 8.9%
Hypoglycemic unawareness is a condition in which a person does not have the warning signs and symptoms of hypoglycemia until the person becomes incoherent and combative or loses consciousness. Hypoglycemic awareness is related to autonomic neuropathy of diabetes that interferes with the secretion of counterregulatory hormones that produce these symptoms. Older patients and patients who use β-adrenergic blockers (e.g., propranolol) are at risk for hypoglycemic unawareness.
The nurse teaches a person with diabetes about a healthy eating plan. Which statement made by the person indicates that teaching was successful?
“I plan to lose 25 pounds this year by following a high-protein diet.”
“I may have a hypoglycemic reaction if I drink alcohol on an empty stomach.”
“I should include more fiber in my diet than a person who does not have diabetes.”
“If I use an insulin pump, I will not need to limit foods with saturated fat in my diet.”
Eating carbohydrates when drinking alcohol reduces the risk for alcohol-induced hypoglycemia. Intensified insulin therapy, such as the use of an insulin pump, allows considerable flexibility in food selection and can be adjusted for alterations from usual eating and exercise habits. However, saturated fat intake should still be limited to less than 7% of total daily calories. Daily fiber intake of 14 g/1000 kcal is recommended for the general population and for people with diabetes. High-protein diets are not recommended for weight loss.
The nurse has taught a patient admitted with diabetes principles of foot care. The nurse evaluates that the patient understands the instructions if the patient makes what statement?
“I should only walk barefoot in nice dry weather.”
“I should look at the condition of my feet every day.”
“I will need to cut back the number of times I shower per week.”
“My shoes should fit nice and tight because they will give me firm support.”
People with diabetes need to inspect their feet daily for broken areas that are at risk for infection and delayed wound healing. Properly fitted (not tight) shoes should be worn at all times. Routine care includes regular bathing.
The nurse is assisting a patient with newly diagnosed type 2 diabetes to learn dietary planning as part of the initial management of diabetes. The nurse would encourage the patient to limit intake of which foods to help reduce the percent of fat in the diet?
Cheese
Broccoli
Chicken
Oranges
Cheese is a product derived from animal sources and is higher in fat and calories than vegetables, fruit, and poultry. Excess fat in the diet is limited to help avoid macrovascular changes.
The newly diagnosed patient with type 2 diabetes has been prescribed metformin. What would the nurse teach the patient about how this medication works?
Increases insulin production from the pancreas.
Slows the absorption of carbohydrate in the small intestine.
Reduces glucose production by the liver and enhances insulin sensitivity.
Increases insulin release from the pancreas and inhibits glucagon secretion.
Metformin is a biguanide that reduces glucose production by the liver and enhances the tissue’s insulin sensitivity. Sulfonylureas and meglitinides increase insulin production from the pancreas. α-Glucosidase inhibitors slow the absorption of carbohydrate in the intestine. Glucagon-like peptide receptor agonists increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and decrease gastric emptying.
The nurse is assessing a patient newly diagnosed with type 2 diabetes. Which symptom reported by the patient correlates with the diagnosis?
Excessive thirst
Gradual weight gain
Overwhelming fatigue
Recurrent blurred vision
The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger). Weight gain, fatigue, and blurred vision may all occur with type 2 diabetes but are not classic manifestations.
The patient received regular insulin 10 units subcutaneously at 8:30 PM for a glucose level of 253 mg/dL. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin’s peak action?
8:40 PM to 9:00 PM
9:00 PM to 11:30 PM
10:30 PM to 1:30 AM
12:30 AM to 8:30 AM
Regular insulin exerts peak action in 2 to 5 hours, making the patient most at risk for hypoglycemia between 10:30 PM and 1:30 AM. Rapid-acting insulin’s onset is between 10 and 30 minutes with peak action and hypoglycemia most likely to occur between 9:00 PM and 11:30 PM. With intermediate acting insulin, hypoglycemia may occur from 12:30 AM to 8:30 AM.
A patient, admitted with diabetes, has a glucose level of 580 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find?
Central apnea
Hypoventilation
Kussmaul respirations
Cheyne-Stokes respirations
In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored. Central apnea occurs because the brain temporarily stops sending signals to the muscles that control breathing, which is unrelated to ketoacidosis. Hypoventilation and Cheyne-Stokes respirations do not occur with ketoacidosis.
A patient with diabetes who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively?
Avoid sick people and wash hands.
Obtain comprehensive dental care.
Maintain hemoglobin A1C below 7%.
Coughing and deep breathing with splinting.
A person with diabetes is at high risk for postoperative infections. The most important preoperative teaching to prevent a postoperative infection in the heart is to have the patient obtain comprehensive dental care because the risk of septicemia and infective endocarditis increases with poor dental health. Avoiding sick people, hand washing, maintaining hemoglobin A1C below 7%, and coughing and deep breathing with splinting would be important for any type of surgery but are not the priority for this patient with mitral valve replacement.
The nurse is reviewing laboratory results for a patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes?
Increased triglyceride levels
Increased high-density lipoproteins (HDL)
Decreased low-density lipoproteins (LDL)
Decreased very-low-density lipoproteins (VLDL)
Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. Increased HDL, decreased LDL, and decreased VLDL are positive in relation to atherosclerosis development.
The nurse is reviewing laboratory results for the clinic patients to be seen today. Which patient meets the diagnostic criteria for diabetes?
A 21-yr-old with a hemoglobin A1C of 8.4%
A 35-yr-old with a fasting glucose of 111 mg/dL
A 68-yr-old with a random glucose of 190 mg/dL
A 78-yr-old with a 2-hour glucose tolerance glucose of 184 mg/dL
Criteria for a diagnosis of diabetes include a hemoglobin A1C of 6.5% or greater, fasting glucose level of 126 mg/dL or greater, 2-hour glucose level of 200 mg/dL or greater during an oral glucose tolerance test, or classic symptoms of hyperglycemia or hyperglycemic crisis with a random glucose of 200 mg/dL or greater.
The nurse is teaching a patient with type 2 diabetes how to prevent diabetic nephropathy. Which patient statement indicates that teaching has been successful?
“Smokeless tobacco products decrease the risk of kidney damage.”
“I can help control my blood pressure by avoiding foods high in salt.”
“I should have yearly dilated eye examinations by an ophthalmologist.”
“I will avoid hypoglycemia by keeping my blood sugar above 180 mg/dL.”
The ADA recommends persons with type 2 diabetes should consume less than 2,300 mg of salt daily. People with type 2 diabetes need to have a dilated eye examination by an ophthalmologist or a specially trained optometrist at the time of diagnosis and annually thereafter for early detection and treatment. Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. Risk factors for the development of diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia.
A person with type 2 diabetes has a urinary tract infection (UTI), is difficult to arouse, and has a glucose level of 642 mg/dL. When the nurse assesses the urine, there are no ketones present. What nursing action is appropriate?
Routine insulin therapy and exercise
Administer a different antibiotic for the UTI
Cardiac monitoring to detect potassium changes
Administer IV fluids rapidly to correct dehydration
This person has manifestations of hyperosmolar hyperglycemic syndrome (HHS). Cardiac monitoring will be needed because of the changes in the potassium level related to fluid and insulin therapy and the osmotic diuresis from the elevated serum glucose level. Routine insulin would not be enough, and exercise could be dangerous for this patient. Extra insulin will be needed. The type of antibiotic will not affect HHS. There will be a large amount of IV fluid administered, but it will be given slowly because this patient is older and may have cardiac or renal compromise, requiring hemodynamic monitoring to avoid fluid overload during fluid replacement.
CHAPTER 45 - Obesity
CHAPTER 45 - Obesity
1. Discuss the epidemiology and etiology of obesity.
2. Explain the health risks associated with obesity.
3. Use classification systems to determine body size.
4. Discuss comprehensive therapy for the patient with obesity.
5. Distinguish among the bariatric surgical procedures used to treat obesity.
6. Describe the nursing and interprofessional management related to surgical therapies for obesity.
7. Describe the etiology, clinical manifestations, and nursing and interprofessional management of metabolic syndrome.
bariatric surgery
involves surgery on the stomach and/or intestines to help a person with extreme obesity lose weight
body mass index (BMI)
The most common way we classify weight is the body mass index (BMI). We calculate BMI by dividing a person’s weight (in kilograms) by the square of the height in meters
extreme obesity
The term extreme obesity (morbid or severe obesity) is used for those with a BMI greater than 40 kg/m2.
lipectomy
(adipectomy) is the surgical removal of excess skin and adipose tissue. It is often done on the abdomen of people who are obese or have lost a lot of weight to remove flabby folds of tissue
metabolic syndrome
Metabolic syndrome is a group of metabolic risk factors that increase a person’s chance of developing CVD, stroke, and diabetes. Just over 1 in 3 adults have metabolic syndrome.
obese
Those with a BMI of 30 kg/m2 or above are considered obese.
obesity
excessively high amount of body fat or adipose tissue
overweight
A BMI of 25 to 29.9 kg/m2 is classified as being overweight
waist-to-hip ratio (WHR)
another way to assess obesity. Calculate the WHR by dividing the waist measurement by the hip measurement. In women, the ratio should be 0.8 or less, and in men, it should be 1.0 or less.
KEY POINTS
Etiology and Pathophysiology
Obesity is a complex, multifactorial disease. It is the result of an energy imbalance where one takes in more calories than is needed for the body’s physical and metabolic functions. This results in an abnormal increase and accumulation of fat cells.
Many factors, including genetic and environmental influences, can contribute to obesity. Personal decisions about food choices, portion sizes, and exercise also are factors.
Most obese persons have primary obesity, which is excess calorie intake over energy expenditure for the body’s metabolic demands. Others have secondary obesity, in which a medical problem caused the weight gain.
Health Risks Associated With Obesity
Many problems occur at higher rates in people who are obese than in people of normal weight. Mortality rates rise as obesity increases. Besides health problems, many persons have a reduced quality of life
Obesity is a significant risk factor for cardiovascular disease and hypertension in both men and women.
Many patients with type 2 diabetes are obese.
Obesity can lead to several medical problems, including osteoarthritis, sleep apnea, gastroesophageal reflux disease (GERD), gallstones, non-alcoholic steatohepatitis, and cancer.
Obesity in older adults can worsen age-related declines in physical function and lead to frailty and disability.
NURSING AND INTERPROFESSIONAL MANAGEMENT: OBESITY
The first step in the treatment of obesity is to determine whether any physical conditions are present that may be causing or contributing to obesity. Obtain a health history and assess for any co-morbid diseases associated with obesity.
Measurements obtained may include height, weight, BMI, waist circumference, waist-to-hip ratio, and body shape.
The degree to which a patient is classified as underweight, healthy (normal) weight, overweight, or obese can be assessed by using body weight, a body mass index (BMI) chart, waist circumference, or waist-to-hip ratio.
People with fat primarily in the abdominal area (apple-shaped body) are at a greater risk for obesity-related complications than those whose fat is mainly in the upper legs (pear-shaped body).
The overall goals are that the patient with obesity will (1) modify eating patterns, (2) take part in a regular exercise, (3) achieve and maintain weight loss to a specified level, and (4) minimize or prevent health problems related to obesity.
Obesity is considered a chronic condition that requires day-to-day attention to lose weight and maintain weight loss. The management should include lifestyle changes revolving around a combination of diet and behavior modification, exercise, and sometimes drug therapy.
Motivation is an essential ingredient for successful achievement of weight loss.
Restricting dietary intake so that it is below energy requirements is a cornerstone for any weight loss or maintenance program. There is no best diet for weight loss. Any diet can work if it reduces caloric intake compared to expenditure and is one to which the patient will adhere.
Persons on low-calorie and very-low-calorie diets need frequent professional monitoring because the severe energy restriction places them at risk for multiple nutrient deficiencies.
Exercise is an important part of a weight control program. Exercise should be done daily, preferably for 30 to 60 minutes.
Useful basic techniques for behavioral modification include self-monitoring, stimulus control, and rewards.
Patients trying to lose weight often find support groups useful.
Drug therapy is reserved for adults with a BMI of 30 kg/m2 or greater (obese) or adults with a BMI of 27 kg/m2 or greater (overweight) who have at least 1 weight-related condition, such as hypertension, type 2 diabetes, or dyslipidemia
SURGICAL THERAPY
Bariatric surgery is currently the only treatment that has a successful and lasting impact for sustained weight loss for those with extreme obesity.
Surgeries are classified as restrictive, malabsorptive, or a combination of restrictive and malabsorptive surgeries.
Restrictive surgery reduces either the size of the stomach, which causes the patient to feel full more quickly, or the amount allowed to enter the stomach.
In malabsorptive procedures, the small intestine is shortened or bypassed so less food absorbed.
Concerns after bariatric surgery include wound healing, pain, and risk for infection. Early ambulation after surgery is important along with careful assessment for problems.
Long term follow- up is necessary after bariatric surgery as late complications after bariatric surgery include anemia, vitamin deficiencies, and psychosocial problems.
When obese patients have surgery, they are likely to have other comorbidities, including diabetes, altered cardiorespiratory function, abnormal metabolic function, hemostasis, and atherosclerosis, that place them at risk for complications related to surgery.
METABOLIC SYNDROME
Metabolic syndrome is a collection of risk factors that increase a person’s chance of developing cardiovascular disease and diabetes.
The signs of metabolic syndrome are impaired fasting blood glucose, hypertension, abnormal cholesterol levels, and obesity.
There is no specific management of metabolic syndrome.
Interventions focus on reducing risk factors of cardiovascular disease and type 2 diabetes:
reducing LDL cholesterol, stopping smoking, lowering BP, losing weight, and reducing glucose levels.
1. Which statement best describes the cause of obesity?
a. Obesity primarily results from a genetic predisposition.
b. Psychosocial factors can override the effects of genetics in causing obesity.
c. Genetic factors are more important than environmental factors in causing obesity.
d. Obesity is the result of complex interactions between genetic and environmental factors.
The cause of obesity involves significant genetic and biologic susceptibility factors that are highly influenced by environmental and psychosocial factors.
2. Health risks associated with obesity include (select all that apply)
a. colorectal cancer.
b. rheumatoid arthritis.
c. polycystic ovary syndrome.
d. nonalcoholic steatohepatitis.
e. systemic lupus erythematosus.
Health risks associated with obesity include cardiovascular disease, hypertension, sleep apnea, type 2 diabetes, osteoarthritis, gout, gastroesophageal reflux disease, gallstones, nonalcoholic steatohepatitis, fatty liver and cirrhosis, and breast, endometrial, kidney, colorectal, pancreas, esophagus, and gallbladder cancers.
3. The obesity classification that is most often associated with cardiovascular health problems is
a. primary obesity.
b. secondary obesity.
c. gynoid fat distribution.
d. android fat distribution.
A person with fat primarily in the abdominal area (i.e., whose body is apple shaped) is at greater risk for obesity-related complications (e.g., heart disease) than is a person whose fat is primarily in the upper legs (i.e., whose body is pear shaped). Those whose fat is distributed over the abdomen and upper body (i.e., neck, arms, and shoulders) are classified as having android obesity.
4. The best nutrition therapy plan for a person who is obese
a. is high in animal protein.
b. is fat-free and low in carbohydrates.
c. restricts intake to under 800 calories per day.
d. lowers calories with foods from all the basic groups.
Lower caloric intake is a cornerstone for any weight loss or maintenance program. A good weight loss plan should include foods from the 4 basic food groups and be nutritionally sound.
5. This bariatric surgical procedure involves creating a gastric pouch that is reversible, and no malabsorption occurs. Which procedure is this?
a. Vertical gastric banding
b. Biliopancreatic diversion
c. Roux-en-Y gastric bypass
d. adjustable gastric banding
With adjustable gastric banding (AGB), the stomach size is limited by an inflatable band placed around the fundus of the stomach. The band is connected to a subcutaneous port and can be inflated or deflated to change the stoma size to meet the patient’s needs as weight is lost. The procedure is done laparoscopically and, if needed, can be modified or reversed after the first procedure.
6. A patient with extreme obesity has undergone Roux-en-Y gastric bypass surgery. In planning postoperative care, the nurse expects that the patient
a. may have severe diarrhea early in the postoperative period.
b. will not be allowed to ambulate for 1 to 2 days postoperatively.
c. will have small amounts of oral liquids within the first 24 hours.
d. will require nasogastric suction until the drainage is pale yellow.
A low-sugar, clear-liquid diet is usually started within 24 hours after surgery. Begin with 15-mL increments every 10 to 15 minutes. If the patient does not have any nausea or other problems, gradually increase intake to a goal of 90 mL every 30 minutes.
7. Which criteria must be met for a diagnosis of metabolic syndrome? (select all that apply)
a. Hypertension
b. High triglycerides
c. Elevated plasma glucose
d. Increased waist circumference
e. Decreased low-density lipoproteins
Three of the following 5 criteria must be met for a diagnosis of metabolic syndrome:
→ Waist circumference of 40 inches or more in men and 35 inches or more in women
→Triglyceride levels higher than 150 mg/dL or need for drug treatment for high triglyceride levels
→High-density lipoprotein (HDL) cholesterol levels lower than 40 mg/dL in men and lower than
50 mg/dL in women or need for drug treatment for reduced HDL cholesterol levels
→Blood pressure: 130 mm Hg or higher systolic or 85 mm Hg or higher diastolic, or need for drug treatment for hypertension
→Fasting blood glucose level of 100 mg/dL or higher, or need for drug treatment for elevated glucose levels
The nurse cares for a patient after bariatric surgery. The nurse determines that discharge teaching related to diet is successful if the patient makes which statement?
“Fluid intake should be at least 2000 mL/day with meals to avoid dehydration.”
“A high-protein diet that is low in carbohydrates and fat will prevent diarrhea.”
“Food should be high in fiber to prevent constipation from the pain medication.”
“Three meals a day with no snacks between meals will provide optimal nutrition.”
The diet generally prescribed is high in protein and low in carbohydrates, fat, and roughage and consists of 6 small feedings daily. Fluids should not be ingested with the meal, and in some cases, fluids should be restricted to less than 1000 mL/day. Fluids and foods high in carbohydrate tend to promote diarrhea and symptoms of the dumping syndrome. Calorically dense foods, such as foods high in fat, should be avoided to permit more nutritionally sound food to be consumed.
An older adult patient with a body mass index (BMI) of 35 kg/m2, type 2 diabetes, hypercholesterolemia, and irritable bowel syndrome (IBS) is seeking assistance in losing weight. The patient states “I have trouble stopping eating when I should, but I do not want to have bariatric surgery.” Which drug therapy would the nurse question if it is prescribed for this patient?
Plenity
Orlistat (Xenical)
Phentermine (Adipex-P)
Phentermine and topiramate (Qsymia)
Orlistat (Xenical), which blocks fat breakdown and absorption in the intestine, produces some unpleasant gastrointestinal side effects. This drug would not be appropriate for someone with IBS. Plenity produces gel pieces increase the volume of stomach and small intestine contents and induces satiety. Phentermine (Adipex-P) needs to be used for a limited period of time (3 months or less). Qsymia is a combination of two drugs, phentermine and topiramate. Phentermine is a sympathomimetic agent that suppresses appetite and topiramate induces a sense of satiety.
Which patient has the greatest morbidity risk?
Male 6 ft, 1 in tall; BMI 29 kg/m2
Female 5 ft, 6 in tall; weight 150 lbs
Male with waist circumference 46 in
Female 5 ft, 10 in tall; obesity class III
The patient in class III obesity has the risk for disease because class III denotes severe obesity or a BMI greater than 40 kg/m2. The patient with the waist circumference of 46 in has a high risk for disease, but without the BMI or obesity class, a more precise determination cannot be made. The female who is 5 ft, 6 in tall has a normal weight for her height. The male patient who is over 6 ft tall is overweight, which increases his risk of disease, but a more precise determination cannot be made without the waist circumference.
A nurse in the PACU is caring for a severely obese patient who had surgery to repair a lower leg fracture. Which assessment is most important?
Cardiac rhythm
Surgical dressing
Postoperative pain
Oxygen saturation
After surgery, an older or severely obese patient should be closely monitored for oxygen desaturation. The body stores anesthetics in adipose tissue, placing patients with excess adipose tissue (e.g., obesity, older) at risk for resedation. As adipose cells release anesthetic back into the bloodstream, the patient may become sedated after surgery. This may depress the respiratory rate and decrease oxygen saturation.
A patient with morbid obesity has elected to have the Roux-en-Y gastric bypass (RYGB) procedure. The nurse will know the patient understands the preoperative teaching when the patient makes which statement?
“This surgery will preserve the function of my stomach.”
“This surgery will remove the fat cells from my abdomen.”
“This surgery can be modified whenever I need it to be changed.”
“This surgery decreases how much I can eat and how many calories I can absorb.”
The RYGB decreases the size of the stomach to a gastric pouch and attaches it directly to the small intestine so food bypasses 90% of the stomach, the duodenum, and a small segment of the jejunum. The vertical sleeve gastrectomy removes 85% of the stomach but preserves the function of the stomach. Lipectomy and liposuction remove fat tissue from the abdomen or other areas. Adjustable gastric banding can be modified or reversed at a later date.
In developing a weight loss program with a middle aged female patient who weighs 197 lbs, the nurse encourages the patient to set a weight loss goal of how many pounds in 4 weeks?
1 to 2
3 to 5
4 to 8
5 to 10
A realistic weight loss goal for patients is 1 to 2 pounds/wk, which prevents the patient from becoming frustrated at not meeting weight loss goals.
The nurse is caring for a patient with a herniated lumbar disc. The patient realizes that weight loss is necessary to lessen back strain. The patient is 5 ft, 6 in tall and weighs 186 lbs (84.5 kg) with a body mass index (BMI) of 28 kg/m2. The nurse explains this measurement places her in which weight category?
Normal weight
Overweight
Obese
Severely obese
A normal BMI is 18.5 to 24.9 kg/m2, and a BMI of 25 to 29.9 kg/m2 is considered overweight. A BMI of 30.0 to 39.9 kg/m2 is considered obese, and a BMI of 40 kg/m2 or greater is severely obese.
In developing an effective weight loss plan for a patient who expresses willingness to try to lose weight, what would the nurse assess first?
The length of time the patient has been obese
The patient’s current level of physical activity
The patient’s social, emotional, and behavioral influences on obesity
Anthropometric measurements, such as body mass index and skinfold thickness
Eating patterns are established early in life and eating has many meanings for people. To establish a weight loss plan that will be successful for the patient, the nurse would first explore the social, emotional, and behavioral influences on the patient’s eating patterns. The duration of obesity, current physical activity level, and current anthropometric measurements are not as important for the weight reduction plan.
At the first visit to the clinic, the female patient with a BMI of 29 kg/m2 tells the nurse that she does not want to become obese. Which question used for assessing weight issues would be most effective?
“What factors contributed to your current body weight?”
“How is your overall health affected by your body weight?”
“What is your history of gaining weight and losing weight?”
“In what ways are you interested in managing your weight differently?”
Asking the patient about her desire to manage her weight in a different manner helps the nurse determine the patient’s readiness for learning, degree of motivation, and willingness to change lifestyle habits. The nurse can help the patient set realistic goals. This question will also lead to discussing the patient’s history of gaining and losing weight and factors that have contributed to the patient’s current weight. The patient may be unaware of the overall health effects of her body weight, so this question is not helpful at this time.
Which patient is at risk for developing metabolic syndrome?
A 62-yr-old white man with coronary artery disease and chronic stable angina
A 27-yr-old Asian American woman with preeclampsia and gestational diabetes
A 38-yr-old Native American man who has diabetes and elevated hemoglobin A1C
A 54-yr-old Hispanic woman who is sedentary and has nephrogenic diabetes insipidus
Blacks, Hispanics, Native Americans, and Asians are at an increased risk for development of metabolic syndrome. Other risk factors include people who have diabetes that cannot maintain a normal glucose level, have hypertension, and secrete a large amount of insulin, or who have survived a heart attack and have hyperinsulinemia.
The nurse is caring for a patient after bariatric surgery. What would be included in the plan of care? (Select all that apply.)
Assist with early ambulation as needed.
Teach the patient to consume liquids with meals.
Maintain elevation of the head of bed at 45 degrees.
Monitor for vomiting as it is a common complication.
Provide a diet high in carbohydrate and fat intake.
Assess for incisional pain versus an anastomosis leak.
After bariatric surgery, the nurse needs to assess for incisional pain versus anastomosis leak. Because vomiting is a common postoperative complication, maintain elevation of the head of bed to reduce the risk of vomiting and aspiration. Dietary recommendations include 6 small meals that are high in protein and low in carbohydrates and fat. Fluids should be avoided during meals to prevent dumping syndrome. Early ambulation with assistance is recommended.
The nurse teaches a patient who has a body mass index (BMI) of 39 kg/m2 about weight loss. Which diet change would be most appropriate to recommend?
Decrease fat intake and control portion size.
Increase vegetables and decrease fluid intake.
Increase protein intake and avoid carbohydrates.
Decrease complex carbohydrates and limit fiber.
The safest dietary guideline for weight loss is to decrease caloric intake by maintaining a balance of nutrients and adequate hydration while controlling portion size and decreasing fat intake.
Which assessments would the nurse include when screening a patient for metabolic syndrome? (Select all that apply.)
Blood pressure
Resting heart rate
Physical endurance
Waist circumference
Fasting blood glucose
The diagnostic criteria for metabolic syndrome include elevated blood pressure, fasting blood glucose, waist circumference, and triglycerides, and low high-density lipoprotein cholesterol. Resting heart rate and physical endurance are not part of the diagnostic criteria.
The nurse teaches an obese young adult with a sedentary job about the health benefits of an exercise program. The nurse evaluates that teaching is effective when the patient makes which statement?
“The goal is to walk at least 10,000 steps every day of the week.”
“Weekend aerobics for 2 hours is better than exercising every day.”
“Aerobic exercise will increase my appetite and result in weight gain.”
“Exercise causes weight loss by decreasing my resting metabolic rate.”
A realistic activity goal is to walk 10,000 steps a day. Increased activity does not promote an increase in appetite or lead to weight gain. Exercise should be done daily, preferably 30 minutes to an hour a day. Exercise increases metabolic rate.
The nurse has completed initial instruction with a patient regarding a weight loss program. The nurse determines that the teaching has been effective when the patient makes which statement?
“I will keep a diary of weekly weights to track my weight loss.”
“I plan to lose 4 pounds a week until I reach my 60-pound goal.”
“I will restrict my carbohydrate intake to less than 30 g/day to maximize weight loss.”
“I will not exercise more than my program requires because the activity increases the appetite.”
The patient should monitor and record weight once per week. This prevents frustration at the normal variations in daily weights and may help the patient to maintain motivation to stay on the prescribed diet. Weight loss should occur at a rate of 1 to 2 pounds/wk. The diet should be well balanced rather than lacking in specific components that may cause an initial weight loss but is not usually sustainable. Exercise is a necessary component of any successful weight loss program.
The nurse is caring for a patient who is 5 ft, 5 in tall and weighs 186 lb. The nurse has discussed reasonable weight loss goals and a low-calorie diet with the patient. Which statement made by the patient indicates a need for further teaching?
“I will limit intake to 500 calories a day.”
“I will try to eat very slowly during mealtimes.”
“I’ll try to pick foods from all of the basic food groups.”
“It’s important for me to begin a regular exercise program.”
Limiting intake to 500 calories per day is not indicated for this patient, and the severe calorie energy restriction would place this patient at risk for multiple nutrient deficiencies. The other options show understanding of the teaching.
CHAPTER 63 - Chronic Neurologic Problems
