Anemia: Iron and B12 Deficiency

Anemia

• Iron deficiency can be caused by inadequate dietary intake, malabsorption, blood loss, hemolysis, pregnancy, and being a younger person or woman.
• Symptoms include pallor, glossitis (inflamed and swollen tongue), cheilitis (chapped lips), and inflammation of the lips

B12 Deficiency

• B12 deficiency is a megaloblastic hypoproliferative anemia that occurs due to defective red blood cell production.
• Absence of intrinsic factor can cause B12 deficiency, when this happens it is called pernicious anemia
• Intrinsic factor, secreted by cells in the gastric mucosa, binds to B12 and takes it to the ileum to be absorbed
• B12 cannot be absorbed orally without intrinsic factor
• This has an insidious onset and is predominant in Scandinavians and African Americans
• Symptoms include a smooth, sore, red tongue, mild diarrhea, paleness of mucous membranes, confusion, and paresthesias.
• Those at risk include people with a strict vegan diet or chronic GI diseases.
• Impaired absorption in the GI tract is more common in older adults.
• Inflammatory bowel disease, GI surgery, metformin use, chronic use of histamine blockers, antacids and proton pump inhibitors, excessive alcohol or hot tea ingestion, and smoking all increase risk

Anemia (General)

• Symptoms vary based on how quickly the anemia develops, its duration, the patient's metabolic needs, and any other health issues
• Common symptoms include fatigue, weakness, and malaise.
• Pallor or jaundice may occur because of red blood cell breakdown.
• Cardiac, GI, neurologic, and respiratory symptoms can manifest
• Tongue changes: may be sore, beefy red with megaloblastic anemia, or smooth and red with iron deficiency anemia.
• Nails become brittle and ridged
• Angular cheilitis is possible, causing painful patches in the corner of the mouth from overproduction of saliva
• Pica is another symptom, this is where people eat things of no nutritional value, like clay, ice, soil or paper
• Normal Hemoglobin levels:
  • Male: 13.5-17.5 g/dL
  • Female: 12-15.5 g/dL
  • Children: 11-16 g/dL
• Normal Hematocrit levels:
  • Male: 40-52%
  • Female: 35-45%
  • Children: 31-41%
• People at risk include the elderly, pregnant women, those with a poor diet or chronic blood loss, and those who have had GI surgery
• Nursing diagnoses associated include fatigue, altered nutrition, and altered tissue perfusion, and noncompliance with prescribed therapy
• Consider:
  • Health history
  • Labs
  • Presence of symptoms and impact on patients life
  • Nutritional assessment
  • Medication
  • Cardiac and Gl assessment
  • Blood loss (menses, potential Gl loss such as hemorrhoids)
  • Neurological assessment, looking at gait
  • Balancing physical activities, exercise and rest, scheduling set times
• To maintain adequate perfusion and nutrition:
  • Patient education should encourage prompt medication compliance.
  • Monitor vital signs and pulse oximetry to see if supplemental oxygen is needed
  • Monitor for potential complications.
  • Document teaching
• Treatments:
  • Ferrous sulfate is a treatment for iron deficiency anemia, it causes black stools
  • Erythropoietin addresses anemia related to chronic kidney disease, chemo or HIV
  • IV iron is used for severe iron deficiency anemia or malabsorption caused by Crohn's disease
  • Blood transfusions are used in severe anemia of less than 7 g/dL with acute blood loss.

Geriatric Considerations (Anemia)

• Most common in older adults
• Causes decreased functional activity
• Causes Increased morbidity and mortality
• Causes Decreased physical performance and mobility
• Causes Increased frailty, depression and risk of falls
• Could cause Delirium, Fatigue, Dyspnea, Confusion or Cognitive decline

Gastrectomy

• Puts patients at risk for B12 deficiency anemia because older patients are more at risk
• Can cause GI absorption issues due to lack of intrinsic factor is needed for B12 absorptio
• You can teach patients to use:
  • Lifelong B12 supplementation, using the intranasal or IM route since it cannot be absorbed orally by the stomach
  • Monitor for changes to neurological function

Thyroid

Hypothyroidism

• Clinical manifestations (All Systems) include slowing of body processes and Decreased iodine uptake
• Cardiovascular effects:
  • Decreased contractility and output (impairs perfusion)
  • Increased serum cholesterol and triglycerides
• Respiratory:
  • Low exercise tolerance
  • SOB on exertion (because of compromised perfusion)
• Neurological:
  • Fatigue and lethargy
  • Personality and mood changes
  • Impaired memory, slowed speech, somnolence
• Muskuloskeletal:
  • Fatigue, weakness
  • Muscular aches and pain
  • Slow movements
  • Arthralgia
• GI:
  • Decreased appetite but weight gain
  • N/V
  • Constipation
  • Distended abdomen
  • Enlarged scaly tongue
  • Celiac disease (gluten)
• Integumentary
  • Dry, thick, inelastic cold skin
  • Thick, brittle nails
  • Dry, sparse, coarse hair
  • Poor turgor of mucosa
  • Generalized interstitial edema
  • Puffy face
  • Decreased sweating, which can lead to increased internal temperatures
  • Pallor
• Reproductive:
  • Prolonged menstruation or amenorrhea
  • Decrease libido and fertility
• Other:
  • Increased susceptibility to infection
  • Increased sensitivity to opioids, barbiturates, anesthesia
  • Intolerance to cold
  • Decreased hearing
  • Sleepiness
  • Goiter
• Expect the following therapeutic outcomes:
  • Return of energy
  • Weight gain
  • Normal bowel movements
  • Regulated menstrual cycles
  • Cognitive improvement
  • Improved skin and hair
• Signs their medication is too strong:
  • Excessive use of levothyroxine can lead to hyperthyroidism
• Treatment options
  • Restoration of euthyroid state as safely and rapidly as possible
  • Low calorie diet
  • Levothyroxine
• Side effects:
  • Cardiovascular side effects
    • Chest pain
    • Dysrhythmias
  • Weight loss
  • Nervousness
  • Tremors
  • Insomnia
• Patient teaching:
  • Life long treatment
  • Take every day before breakfast

Myxedema Coma

• Symptoms:
  • Impaired consciousness
  • Subnormal temperature, hypotensions, hypoventilation
  • Cardiovascular collapse
• Interventions/Evaluation:
  • Medical emergency
  • Monitor airway
  • Cardiac monitoring and vital signs monitoring
  • Initiate IV therapy
  • Keep patient warm
  • Glucosteroids to avoid adrenal insufficiency
• Nursing considerations:
  • Risk for hypoglycemia
  • Keep patient warm
  • Assess I&Os
• Geriatric considerations:
  • Higher risk for metabolic decline and polypharmacy interactions

Hyperthyroidism

• Clinical manifestations:
  • Cardiovascular
    • Systolic hypertension
    • Bounding rapid pulse, palpitations
    • Increased cardiac output, cardiac hypertrophy due to exertion
    • Systolic murmurs
    • Dysrthythmias
  • Angina
  • Respiratory:
    • Dyspnea on mild exertion
    • Increased respiratory rate
  • GI:
    • Increased appetite and thirst due to increased metabolism, weight loss
    • Diarrhea
    • Splenomegaly: enlarged spleen
    • Hepatomegaly: enlarged kidney
  • Integumentary:
    • Warm, smooth, moist skin (medium for infections)
    • Thin, brittle nails, clubbing of fingers
    • Hair loss
    • Erythema
    • Fine silky hair, premature graying
    • Diaphoresis
    • Vitiligo
  • Nervous system:
    • Nervousness, fine tremors
    • Insomnia, exhaustion
    • Lability of mood, delirium
    • Hyperreflexia of tendon reflexes due to calcium imbalance
    • Inability to concentrate
    • Stupor, coma
  • Reproductive:
    • Menstrual irregularities
    • Amenorrhea
    • Decreased libido
    • Impotence
    • Gynecomastia in men (enlargement of breasts)
    • Decreased fertility
  • Other:
    • Intolerance to heat
    • Elevated basal temperature
    • Lid lag, stare (eye issues), eyelid retraction
    • Rapid speech
• Expect the following therapeutic outcomes:
  • Weight stabilization
  • Cardiac stabilization
  • Regular bowel movements
  • Decreased sweating and heat intolerance
• Medication too strong
  • Excessive use of methimazole can cause hypothyroidism
• Treatment options
  • Antithyroid medicine (methimazole, propylthiouracil, iodine): inhibit synthesis of thyroid hormone
  • Radioactive iodine therapy (RAI): inhibit synthesis of T3 and T4 which blocks their release into circulation which decreases vascularity of thyroid gland, destroys thyroid tissue, 3 months of delayed response
  • B adrenergic blockers: symptomatic relief of thyrotoxicosis, blocks effects of sympathetic nervous stimulation
  • Dexamethasone: suppresses release of thyroid hormone
  • Surgery: subtotal thyroidectomy
• Side effects:
  • Methimazole and propylthiouracil:
    • Agranulocytosis
    • Liver toxicity (especially PTU)
    • Rash, nausea, joint pain
  • Iodine:
    • Metallic taste
    • Gl upset
    • lodine toxicity
  • RAI:
    • Hypothyroidism
    • Radiation precautions
• Patient Teaching
  • Medication compliance
  • Total thyroidectomy patients need levothyroxine for life
• Geriatric considerations
  • Often mistaken for other illnesses or as signs of normal aging

Thyroidectomy

• Post op assessment + concerns
  • Patent airway (swelling from surgery)
  • Hemorrhage
  • Monitor for hypocalcemia if parathyroid glands are affected (Trousseau's and Chvostek's sign)
  • Laryngeal nerve damage (loss of voice, hoarseness)
• Report immediately (RN)
  • Signs of airway obstruction
  • Thyrotoxic symptoms
  • Tingling, muscle spasms
• What equipment do you need to have?
  • Suction: clear airways
  • Tracheostomy tray: in case of airway obstruction
  • Oxygen supply: in case of respiratory issues
  • IV calcium gluconate: treats severe hypocalcemia
  • BP cuff: monitor for Trousseau's

Thyroid storm/crisis

• Symptoms:
  • Severe tachycardia
  • Shock
  • Hyperthermia
  • Agitation, restlessness
  • Seizures
  • Coma
• Interventions:
  • Administration of IV medications (Methimazole or PTU)
  • Beta blockers (propranolol): helps with cardiovascular symptoms
  • Corticosteroids (dexamethasone, hydrocortisone): blocks T4 to T3 conversion
  • Cooling measures
  • IV fluids and electrolytes
  • Oxygen and ventilation therapy
• Nursing considerations
  • Temperature monitoring
  • Cardiac monitoring
  • S/sx of respiratory distress
  • I&Os
  • Seizure precautions

Diabetes Mellitus

Type 1

• Signs & Symptoms

  • Early in life
  • Insulin producing beta cells are destroyed in pancreas
  • Three Ps: polyuria (increased urination), polydipsia (increased thirst), polyphagia (increased hunger)
  • Fatigue
  • Weakness
  • Vision changes
  • Tingling or numbness in hands or feet
  • Dry skin
  • Skin lesions or slow healing wounds

• Patient Education/Teaching

  • Exogenous insulin needs to be taken as prescribed
  • Check glucose levels if feelings shaky or dizzy
    • Self monitoring devices
  • Symptoms of hypoglycemia
  • Carry carbohydrate snack with them (candy)
  • Diet: exchange list, limit saturated fat, have non animal sources of protein, increase fiber
  • Exercise (have carbohydrate snack in case of hypoglycemic episode, have 15g carbohydrate snack)
  • If patient is on insulin, do not inject insulin into muscles being exercises

• Nursing Interventions/Priority

  • If patient is hypoglycemic but alert and awake:
    • Give 15g carbohydrate drink then recheck glucose in 15 min
    • If still low after 15 min, give another drink
  • If patient is hypoglycemic but unresponsive (emergency):
    • Glucagon
    • Dextrose via IV
  • Monitor glucose levels for hypoglycemia and hyperglycemia
  • Give insulin as prescribed
  • Assess and monitor DKA symptoms: provide pt with carbohydrate or glucose
  • Make sure patient has food in front of them when giving insulin to prevent hypoglycemia
  • DKA: priority is to treat dehydration

• Diagnostics

  • 126 indicated diabetes

  • Non fasting blood glucose

  • 200 indicated diabetes

  • 2 hour glucose tolerance test (done in pregnancy as well)
    • Check glucose, give 80 of glucose drink, check glucose again
  • Hemoglobin A1C

  • 8.5 indicated diabetes

• Complications

  • Diabetic ketoacidosis: absent or inadequate amount of insulin resulting in abnormal metabolism of carbohydrates, proteins and fats; hyperglycemia
    • Dehydration: due to vomiting, patient will present with nausea, abdominal pain and sudden weight loss
    • Ketoacidosis: low serum bicarbonate, low pH, low pCO2 (respiratory)
    • Kussmaul respirations: trying to move carbon dioxide
    • Have ketones in urine
    • Monitor potassium levels (hypokalemia or hyperkalemia)
    • Need rehydration: 0.9 normal saline, as glucose goes down, may be given 5-10% dextrose solution so glucose isn't lowered too quickly (it can cause cerebral edema), auscultate lungs to make sure there is no fluid overload
    • Insulin drip: continuous IV infusion of regular insulin
    • Reverse acidosis
    • Maintain electrolyte balance

Type 2

• Signs & Symptoms

  • Later in life (onset: over age 30), increased cases in children
  • Due to insulin resistance or impaired insulin secretion
  • Slow and progressive glucose intolerance, obesity usually present
  • Three Ps: polyuria (increased urination), polydipsia (increased thirst), polyphagia (increased hunger)

• Patient Education/Teaching

  • Importance of hypoglycemia and hyperglycemia symptoms
  • Monitor glucose
  • Taking medications as prescribed (insulin and/or normal)

• Nursing Interventions/Priority

  • Give 15g carbohydrate drink then recheck glucose in 15 min
  • If still low after 15 min, give another drink
  • If patient is hypoglycemic but unresponsive (emergency):
    • Glucagon
    • Dextrose via IV
  • Monitor glucose levels for hypoglycemia and hyperglycemia
  • Give insulin as prescribed
  • Make sure patient has food in front of them when giving insulin to prevent hypoglycemia
  • Teach patient about HHS symptoms

• Diagnostics

  • 126 indicated diabetes

  • Non fasting blood glucose

  • 200 indicated diabetes

  • 2 hour glucose tolerance test (done in pregnancy as well)
    • Check glucose, give 80 of glucose drink, check glucose again
  • Hemoglobin A1C

  • 8.5 indicated diabetes

• Complications

  • Caused by lack of sufficient insulin
  • No ketones
  • Hyperglycemia causes:
    • Osmotic diuresis
    • Loss of water and electrolytes
    • Hypernatremia
    • Increase osmolality
  • Provide rehydration and IV fluids rapidly and aggressively
  • Give insulin drip or IV

DKA

• Monitor fluid volume and electrolyte balance

• Signs & Symptoms

  • Nausea
  • Abdominal pain
  • Sudden weight loss

• Lab values

• Hyperglycemic Hyperosmolar Syndrome (HHS)

  • Signs and Symptoms

    • Profound dehydration
    • Tachycardia
    • Various neurological signs caused by cerebral dehydration
    • High mortality rate

  • Lab values

    • Too high of blood sugar for too long (glucose in urine)

Medications

• Insulin-duration, action, nursing interventions prior/after administration, complications Rapid acting: Aspart (Novolog, Lispro, Humalog):
  • Onset: 15 min
  • Injected within 15 minutes of meal time
  • Most commonly taken before meal Short duration: regular insulin (Humulin R, Novolin R) (only insulin given IV)
  • Onset: 30-60 min
  • Peak: 2-3 hrs
  • Duration: 5-7 hrs
  • More likely to cause hypoglycemia because of longer duration Intermediate acting: NPH, Humulin N, Novolin N (cloudy appearance)
  • Onset: 1-1.5 hrs
  • Peak: 4-12 hrs (monitor for hyperglycemia within this window)
  • Duration: 12-18 hrs Long acting: Glargine (Lantus), Detemir (Levemir)
  • Onest: 1-2 hrs
  • Peak: minimal to none
  • Duration: glargine: 24hrs, detemir: 6-23 hrs
  • Used to manage glucose levels in between meals or overnight
  • Should be given by itself Ultra long acting: Degludec (Tresiba)
  • Onset: 1hr
  • Peak: none
• Metformin (type 2)
  • Reduces glucose production by liver
  • Enhances insulin sensitivity
  • Improves glucose transport
  • Can help with weight loss
  • Used in prevention of diabetes
  • Can be given to PCOS patients due to insulin resistance
  • Must stop taking at least 48 hours before and after surgery or contrast
  • C/I in liver, renal or cardiac disease or excessive alcohol intake
• Glucagon
  • Hypoglycemic episode
  • IM
• Dextrose
  • IV
  • Emergency situations
• Long term Complications:
  • Hypertension
  • Stroke
  • Atherosclerosis
  • Neuropathy
  • Coronary artery disease
  • Diabetic ulcers: prevent by teaching patient importance of skin care
  • Vision changes

GI Disorders

Hiatal Hernia

• Happens when opening of diaphragm where esophagus passes becomes enlarged and part of upper stomach moves up into lower portion of the thorax

• Signs & symptoms

  • Pyrosis (burning sensation)
  • Chest pain: due to compression of thorax by the hernia
  • Airway obstruction
  • Bloating
  • Burping
  • Trouble swallowing
  • Bad taste in mouth
  • Upset stomach
  • Vomiting/regurgitation

• Assessment

Gerd

Pancreatitis

Cholelithiasis

Diverticular Disease

Small Bowel Obstruction, Large Bowel Obstruction