Diabetes Mellitus and Metformin

• DM (Diabetes Mellitus) is an endocrine disorder altering glucose metabolism involving transport of glucose, K+ (potassium), and Magnesium into cells
• Can cause hyperglycemia in uncontrolled patients
• Biguanides (Metformin) is generally the first drug prescribed for new cases of DMT2 (Diabetes Mellitus Type 2)
• Metformin and lifestyle changes are now used for pre-diabetic patients as monotherapy or in combination with other medications
• Well suited for patients who skip meals
• Common side effect of metformin is weight loss
• Adverse reaction includes lactose acidosis
• Metformin should be temporarily stopped before and for 48 hours after radiological studies involving intravenous contrast dye to prevent contrast-induced nephropathy and lactic acidosis

Type 1 Diabetes Mellitus

• There is nearly absolute insulin deficiency due to beta cell destruction
• If insulin is not administered, fats are metabolized for energy, which results in ketonemia (acidosis)
• Patients are normally born with Type 1
• Patients experience weight loss.

Early Signs of Lactic Acidosis

• Unusual sleepiness or drowsiness
• Hyperventilation
• Muscle pain

Type 2 Diabetes Mellitus

• There are FEW insulin receptors that work
• There is sufficient insulin to stabilize fat and protein metabolism, but not carbohydrates

Nursing Interventions

• Stop metformin
• If metformin is not controlled, dialysis follows

Oral Antidiabetic Medications

• The role of oral antidiabetic agents is to stimulate the pancreas to produce MORE insulin
• They increase sensitivity of peripheral receptors to insulin
• They decrease hepatic glucose output

Sulfonylureas

• Two types, First-Generation and Second-Generation
• A. First-Generation examples include Chlorpropamide, Tolazamide, and Tolbutamide (Orinase)
• B. Second-Generation examples end with "ide" and include Glimepiride, Glipizide, and Glyburide
• Glimepiride should NOT be taken with alcohol because of adverse interactions
• Adverse effects of sulfonylureas include hypoglycemia and weight gain

Other Diabetes Medications

• Meglitinides (Glinides): Nateglinide, Repaglinide
• Thiazolidinediones (Glitazones): Pioglitazone
• Biguanides: Metformin
• Alpha-Glucosidase Inhibitors: Acarbose, Miglitol
• DPP-4 Inhibitors (Gliptins): Nesinal, Linagliptin
• Semaglitude is used for diabetes type 2 only
• Repaglinide: Taken before meals approximately 30 minutes before, if the patient does not eat, then withhold the medication
• Side effect of repaglinide is hypoglycemia
• Patients should be prepared by carrying a simple sugar at all times
• Metformin and repaglinide together decreases hepatic glucose production

Insulin Facts

• Insulin glargine cannot be mixed with other types of insulin
• RAPID ACTING: "15 minutes feels like an HOUR during 3 rapid responses"
• SHORT: "Short-staffed ER hired additional 30 nurses 2 (to) man an 8-hour shift during the pandemic."
• INTERMEDIATE: "Nurses Play Hero 2(to) attend from 8hrs to 16 hours."
• LONG ACTING: The 2 long nursing shifts never peaked but lasted 24 hours

Insulin Specifics

• NPH insulin is an insulin suspension with a cloudy appearance
• All other insulin types are clear.
• When mixing insulin: draw up the SHORTEST ACTING INSULIN FIRST (REGULAR)
• It is important to rotate injection sites to prevent lipodystrophy and promote even absorption of the medication
• Heat, massage, and exercise of the injected area can increase absorption rates and result in hypoglycemia
• Tachycardia, diaphoresis, shakiness, headache, weakness can be side effects
• Patients may need extra doses of insulin during illness or stress, and should not skip doses of insulin or hypoglycemia
• When mixing: draw up from clear, Regular insulin first, then NPH

Storing Insulin

• Avoid exposing insulin at extreme temperatures
• Insulin should NOT be frozen or kept in direct sunlight or in a hot car
• Can store before injection at room temperature.
• If a vial of insulin will be used up in 1 month, it may be kept at room temperature; otherwise, refrigerate.

Aplastic Anemia

• Deficiency of circulating RBCs usually accompanied by leukopenia and thrombocytopenia
• Pancytopenia is present
• Failure of the bone marrow to produce cells (pluripotent stem cell injury)
• Long-term exposure to toxic agents (drugs, chemical)
• Ionizing radiation
• Viral infection
• Autoimmune
• 50% of cases UNKNOWN
• There is weakness and fatigue, because RBC production is low
• Frequent opportunistic infections
• Coagulation abnormalities (unusual bleeding, petechiae & ecchymoses or "bruises")
• Splenomegaly
• With accumulation of blood cells destroyed by lymphocytes that failed to recognize them as normal cells
• CBC – macrocytic anemia, leukopenia, thrombocytopenia
• BM aspiration/ biopsy

Medical Management for Aplastic Anemia

• Blood Transfusion: main treatment
• Discontinue if the patient's own marrow begins to produce blood cells
• Antibiotic for infection
• Corticosteroids may be administered (if autoimmune)
• Bone marrow transplantation
• Identify and withdraw any offending agents or drugs

Further Aplastic Anemia Notes

• Aplastic Anemia is not totally treated
• Think AA as a long-term condition
• Genetic Disposition
• Chances of the bone marrow being able to produce blood cells again can usually be achieved by bone marrow transplantation

Nursing Management for Aplastic Anemia

• Administer blood transfusions as ordered
• Give nursing care for patients with Bone Marrow transplantation, administration medications
• Monitor for signs of infection, encourage a high-protein, high-Vitamin diet to help reduce the incidence of infection
• Provide mouth care before and after meals
• Check/monitor signs of bleeding, use a soft toothbrush and electric razor, avoid injecting IM (intramuscularly), check for occult blood in urine and stool, and observe for oozing from gums, petechiae, or ecchymoses

Sickle-Cell Anemia

• This is a hereditary hemoglobinopathy that is autosomal recessive
• It can be defined as a defect in the structure of Hemoglobin A which is a substitution of 1 amino acid (valine) for another (glutamine) @ the 6th position of the beta polypeptide chain
• Hemoglobin is partially/completely replaced by Hgb S
• This is then triggered because Hgb S sickles and obstructs cap. blood
• Blood viscosity is increased, leading to tissue ischemia

What can result from Sickle Cell Anemia

• Hemolysis, increased RBC destruction, anemia
• Sickling reverses until repeated cycles lead to irreversible sickling
• Triggers of Sickling include stress and dehydration

Diagnostic Tests for Sickle-Cell Anemia

• Testing rarely seen before 4-6 months for early signs
• Sickledex: sickle turbidity test; finger or heel stick (results in 3 minutes)
• Sickledex does not distinguish between sickle cell trait and sickle cell disease
• Hemoglobin electrophoresis is required to distinguish between these 2 disorders for “fingerprint” protein
• Full History, Physical Exam, CBC
• Check for CXR if symptoms occur
• Peripheral Blood Smear

Hand-Foot Syndrome - Pathophysiology (Cont'D) - Bones

• Hyperplasia of the bone marrow
• Osteoporosis leads to weakened bones
• Lordosis and kyphosis or other skeletal deformities
• Chronic hypoxia causes possible osteomyelitis from salmonella
• "Hand-foot Syndrome"
• Occurs in children 6 months to 2 years
• Caused by the infarction of short of tubular bones
• Causes swelling and pain of soft tissue of hands and feet
• Usually resolves in 2-3 weeks.

Signs of Crisis

Crisis Triggers

• Acute illness
• Dehydration
• Strenuous exercise
• Hypoxic conditions
• Trauma
• Respiratory illness
• Results in acute pain, cell destruction, infarcts, organ damage

Types of Vaso-occlusive

• Swollen joints
• Vomiting
• Fever
• Anorexia
• Dactylitis

Related Acute Splenic Sequestration

• HR dyspnea
• Weakness
• Pallor
• Shock

Related Aplastic crisis

• Weakness, pallor, dyspnea
• Tachycardia
• Shock

Caused From Hyperhemolytic

• Excess RBC destruction

Medical Management for Sickle-cell crisis

• Prevent Crisis (avoid sickling phenomenon).
• Get daily adequate oxygenation and hydration
• Hydroxyurea may be used prophylactically in adolescents and older adults.
• Supplement Folic Acid 1mg daily to restore folate stores needed for erythropoiesis
• Treat crisis as an emergency when it occurs
• Quickly find the etiology and treat appropriately

Nursing Management for Sickle-cell crisis

• Give adequate hydration and any electrolyte replacement is needed
• Manage pain
• Implement rest
• Treat any infections
• Give blood transfusions if needed
• Monitor Oxygen and administer supplements as needed
• Give oral hygiene and Maintain nutrition
• Give family support and patient education

Intervention for Sickle-cell crisis

• Give adequate hydration and blood flowthrough oral and intravenously (IV) administered fluids.
• Electrolyte replacement if needed; without adequate hydration, pain will not be controlled.
• Give oxygen and blood transfusions as prescribed to increase tissue perfusion.
• Administer analgesics
• Assist the child to assume a comfortable position to keep extremities extended to promote venous return → elevate head of the bed no more than 30 degrees ➔ avoid putting strain on painful joints, and raising the knee gatch of the bed
• Encourage consumption of a high-calorie, high-protein diet, with folic acid supplementation.
• Administer Hydroxyurea, an antimetabolite - this prevents the formation of sickle-shaped red blood cells and to decrease the incidence of vaso-occlusive events.
• Administer antibiotics (prevent infection)
• Watch for the signs of complication ➔ increasing anemia ➔ decreased perfusion ➔ shock (mental status changes, pallor, vital signs changes) Ensure that the child receives pneumococcal and meningococcal vaccines and an annual influenza vaccine. A splenectomy may be necessary for clients who experience recurrent splenic sequestration.

Hemophilia

• Definition- Deficiency in specific clotting factor
• Inherited from X-linked recessive trait
• Hemophilia A - factor VIII deficiency - best known
• Hemophilia B - factor IX deficiency - christmas disease
• Hemophilia is transmitted as an X-linked recessive disorder (it may also occur as a result of gene mutation)
• Carrier females pass on the defect solely to males, while female offspring are rarely born with the disorder but it may be inherited Causes uncontrollable bleeding from wounds in joints, muscles, & other body tissues Spontaneous & very severe uncontrolled bleeding. MOST COMMON IN MALE due to a singular X chromosome
• Medical Administration is provided through Factor replacement as needed
• Factor VIII concentrate (Antihemophilia factor [AHF]) or DDAVP, a synthetic form of vasopressin which is the treatment of choice in mild hemophilia Should increase Factor VIII activity 3-4 fold.

Signs and Symptoms of Hemophilia

PTT prolonged Factor VIII, IX levels are reduced Normal: PT, thrombin, bleeding time, fibrinogen, platelet count Liver biopsy to r/o other causes

Common Forms of Bleeding

• Excessive bleeding from circumcision
• Bleeding with teething
• Hemarthrosis - cardinal sign
• Bruises,in various stages
• Hematuria
• Nose bleeds
• Oral bleeding

Localized Bleeding Control for Hemophilia

• Apply direct pressure for more than 10 minutes
• Put ice and elevate affected limb
• Avoid injections when possible and also rectal temps
• Monitor joints, urine, stool
• Give pain relief and keep an eye on neuro stats also if head bleed

Idiopathic Thrombocytopenic Purpura/ Autoimmune Thrombocytopenic Purpura

-Destruction of platelets which causes a slow processing of blood clots -Mostly caused by the autoimmune system Autoantibodies come to destroy own platelets

Assessment of Thrombocytopenic Purpura

Ecchymoses (Bruises), petechial rashes on the arms, legs, upper chest & neck Mucosal bleeding occurs easily Majorities deal with blood loss anemia Could lead to stroke so keep an eye on central nerve system

Diagnostic Finds

Fewer platelets Enlarged megakaryocytes Presence of antiplatelet antibodies Reduced Hgb/Hct (due to the bleeding)

Treatment of Thrombocytopenic Purpura

Fix underlying condition and trauma Use Corticosteroids and Azathioprine (Imuran) by suppressing the immune function Platelet transfusion Keep safe and protect the client in order to stop conditions that can lead to bleeding

Nurse Interventions for Thrombocytopenic Purpura

Stop bleeding as best as possible Give platelet transfusions if needed Apply great pressure if necessary Keep bleeding part higher above the heart Prevent bruising Provide support Circumference of extremity Give medicine Immunize accordingly