NCMB316 Medical Surgical Nursing 2 Past Paper PDF - Week 7-11

NCMB – 316: MEDICAL SURGICAL NURSING 2 2nd SEMESTER MIDTERMS 3RD YEAR NURSING WEEK 7 – Diabetes Diabetes Pancreas −...

NCMB – 316: MEDICAL SURGICAL NURSING 2 2nd SEMESTER MIDTERMS 3RD YEAR NURSING WEEK 7 – Diabetes Diabetes Pancreas − Is a group of metabolic disease characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both. − Formerly known as diabetes mellitus. − Classifications: Type 1 Diabetes Type 2 Diabetes Gestational Diabetes Latent Immune Diabetes of Adults (LADA) Diabetes associated with other conditions − Risk factors: Age: − The organ involved in diabetes is the pancreas. o > 30 years old for type 2 − In diabetes, there is elevated glucose in the o < 30 years old for type 1 blood, and the cause is a decrease secretion of HDL level ≤ 35mg/dL (0.90 mmol/L) insulin or the cells does not respond to insulin. Triglyceride level of ≥ 250mg/dL − Pancreas has two functions: Gestational diabetes: 1. Exocrine – produce digestive enzymes, o Large baby, over 9 lbs. that are necessary for digestions Hypertension (amylase, lipase, protease) Family history of diabetes: 2. Endocrine – produce insulin and o Parents, siblings glucagon to control glucose level. Obesity – adipose tissue is resistant to Insulin function: insulin, therefore glucose uptake by the o Is a hormone, secreted cells is poor. (Fats cannot tolerate by beta cells of the insulin): islets of Langerhans in o ≥ 20% over desired body weight the pancreas. o BMI ≥ 30kg/m2 o Also necessary for Impaired fasting glucose, impaired metabolism of glucose intolerance – due to presence carbohydrates, proteins of too much glucose in the blood. and fats. Stress – stimulates secretion of o It decreases blood epinephrine, norepinephrine, glucose levels, and the glucocorticoids, which results in deficiency of insulin will increased serum carbohydrates. result in diabetes. Type 1 Diabetes Glucagon function: o Is a hormone, secreted − Formerly known as Juvenile Diabetes, or Insulin by alpha cells of the Dependent Diabetes. islets of Langerhans in − Characterized by the destruction of pancreatic the pancreas. beta cells. o Is release in the blood − There is little or no insulin production when blood glucose − Causes: level decreases. Genetic – which is not inherited o It stimulates the liver to Immunologic – or autoimmune release the stored Environmental – exposure to viral glucose. toxins. − Onset below 30 years old, but it can occur in any age. − Patient is usually thin with recent weight loss. 1 | JK LEI | IRIS | MARIA  − Absence of insulin will breakdown free fatty acids Gestational Diabetes by the liver, which will result to the increase production of ketone bodies which is necessary − Glucose intolerance during pregnancy for energy. − Onset is in the 2nd and 3rd trimester, that is due to − Diabetic Ketone Acidosis – ketone bodies, are the secretion of placental hormones that causes highly acidic that when there is an increase of insulin resistance. concentration it will result to DKA. − Risk factors: − Management: Pregnant women with marked obesity ✓ Diet History of gestational diabetes ✓ Exercise Glycosuria – wherein the glucose in the ✓ Insulin blood exceeds renal threshold of glucose is approximately (180-200mg/dL). Type 2 Diabetes Strong family history of diabetes − Diagnostic test: − Formerly known as Insulin Dependent Diabetes ✓ Oral Glucose Tolerance Test (OGTT) – Mellitus or NIDDM. If the test is positive, the body cannot − Occurs older than 30 years old. absorb sugar properly. − Patients are obese, wherein 90-95% of patients ✓ Screening test – should be done in all are obese. pregnant women, particularly if they are − It is increasingly occurring in children, at risk of diabetes, between 24-48 weeks adolescence and young adults due to obesity. of gestation. − Two main problems: − Management: 1. Insulin Resistance – there is decrease ✓ Dietary modification – there is a daily tissue sensitivity to insulin. minimum of the following: 2. Impaired Insulin Secretion – there is Protein – 71 grams decrease endogenous insulin or the Fiber – 28 grams insulin that is produce by our own body. Low saturated fats The two main problems, leads to ✓ Blood glucose monitoring build up of glucose in the blood ✓ Insulin – if hyperglycemia persist and results in series of symptoms: Latent Autoimmune Diabetes of Adults (LADA) o Hypertension o Hypercholesterolemia − An autoimmune beta-cell destruction, wherein the – the fats are not patients are at risk of becoming insulin metabolized properly. dependent. o Abdominal obesity − Onset is less than 50 years old. − Diabetes Ketone Acidosis is not common – Diabetes associated with other conditions despite the impaired insulin secretion, there is enough insulin to breakdown fats as well as the − Previously classified as secondary diabetes. ketone bodies. − Accompanied by conditions that causes the − May lead to Hyperglycemic Hyperosmolar disease: Syndrome (HHS) Pancreatic diseases − Onset may not be experience in many years, but Hormonal abnormalities if symptoms is experience, there will be mild Medications such as corticosteroids symptoms (such as fatigue, irritability, polyuria, polydipsia, poor healing, vaginal infections, Insulin blurred visions). − Management: − Secreted by beta cells of the islet of Langerhans ✓ Diet in the pancreas. ✓ Exercise − Insulin secretions increases when a person eats. ✓ Oral Hypoglycemic Agents (OHA) − It moves the glucose from blood into the muscles, ✓ Insulin in stressful situation liver and fat cells. − Actions of insulin inside the cells: Transports and metabolizes glucose for energy. Stimulates storage of glucose in the liver and muscle. 2 | JK LEI | IRIS | MARIA  Signals the liver to stop the release of Pathophysiology of Polyuria: glucose, because it may lead to hyperglycemia. Hyperglycemia → Large amount of glucose in the urine that passes through the kidney → The presence Enhances storages of dietary fat in of glucose in the urine will exert high osmotic pressure adipose tissue within the renal tubules → This will lead to excessive Accelerates transport of amino acids into loss of fluid through urination (Osmotic diuresis) → cells Polyuria Inhibits the breakdown of stored glucose, protein and fat. Pathophysiology of Polydipsia: − If there are defects in insulin: Increased glucose production of the liver, Hyperglycemia → Water moves out of the cells → That will make the blood osmolarity increases due to because there is no more insulin that will presence of glucose → That will result into ICF tell the liver to stop producing glucose. dehydration (Cellular dehydration) → Polydipsia Fasting hyperglycemia – the blood glucose is still high even without eating Pathophysiology of Polyphagia: food. Post-prandial hyperglycemia – after Decreased insulin secretion → Hyperglycemia and eating decrease cellular glucose uptake inside the cells → Glycosuria – this happens when the Cellular starvation → Increased hunger and appetite → renal threshold concentration in the blood Polyphagia exceeds (180-200mg/Dl). Those clients with diabetes with manifestations of Osmotic diuresis – excretion of glucose polyphagia, the hunger and appetite does not go away in the urine is caused by osmotic diuresis. after consuming food; The client with unmanaged Uncontrolled glycogenolysis and diabetes will eat more, and will consume more glucose, muscles and gluconeogenesis. proteins and fats, thus, will contribute in hyperglycemia, o Glycogenolysis – process of increased CHON and formation of ketone. breakdown of glycogen in liver. o Gluconeogenesis – is the 1. Breakdown of protein will occur; this will result in protein catabolism or the protein will process that allows the body to breakdown into smaller ones and form glucose. complications may occur such as: 3 Classic Manifestations of Diabetes Negative nitrogen balance – when nitrogen excreted is more than the amount that is produced by the body. o Positive nitrogen balance – occurs during growth, lactation and recovery. Increased BUN and creatinine – may indicate progressive impaired renal function. o If BUN increases, maybe due to protein metabolism. o If creatinine increases, is a definitive diagnosis and suggest an impaired kidney function. Tissue wasting – due to impaired protein metabolism. The body will use the stored fats and muscles for energy that will result to weight loss. Debilitation – if all other complications will not be addressed. 2. Increased ketone bodies will result in an increased lipolysis (breakdown of triglycerides). 3. NOTE: Insulin promotes synthesis of lipids, and without insulin, lipolysis will occur. 4. An increase lipid in the blood will result in hyperlipidemia and may result in 3 | JK LEI | IRIS | MARIA  atherosclerosis (formation of clot in the walls of Stop smoking arteries). − Medications (to control hypertension and 5. The increased ketones will result in ketonuria hyperlipidemia): (presence of ketone in urine). Hypertension: Medications that ends 6. Furthermore, the build-up of ketone, will lead to with DIPINE amlodipine, felodipine. ketonemia; Manifestations will include, acetone breath or ammonia breath. Hyperlipidemia: Medications with 7. If the client is positive in ammonia breath, the statins client will manifest metabolic acidosis due to Control of blood glucose levels acidity of ketones. o It reduces triglyceride in the 8. NOTE: Ketones acts as CNS depressants that blood which may contribute to may decrease brain Ph which may lead to proper metabolization of fats. coma. o Control of blood glucose levels may help for reduction of Hyperglycemia are more viscos or thick due to complication. increasing blood glucose →There is a tendency to clog that causes the blood flow to move slow (sluggish Complications of Microvascular Disease circulation) → A poor circulation will cause retarded wound healing and reduce in blood and oxygen supply Microangiopathy → Which will promote proliferation of microorganisms that causes infections such as periodontal, UTI, − Characterized by capillary basement membrane vasculitis, cellulitis, vaginitis, furuncles, carbuncles. thickening − There are changes in the blood vessels / capillary Complications of Macrovascular Disease blood vessels which abnormalities are thickening in Microangiopathy. Macroangiopathy − 2 areas affected − Blood vessel walls thicken, sclerosed, and 1. Kidneys (Nephropathy) become occluded by plaques (atherosclerosis) 2. Retina of the eye (Diabetic retinopathy) which result in obstruction of blood flow. Diabetic Retinopathy − Decreasing blood flow may affect 3 major organs: − Leading cause of blindness in both type 1 or type Brain 2 diabetes Heart − Caused by changes in the smallest blood Peripheral arteries vessels in the retina: − 3 main types (frequent complications): Retina – is the area of the eye that 1. Coronary Artery Disease (Myocardial receives images and cells information Infarction) about the images to the brain. 2. Cerebrovascular Disease (Transient o The retina should be supplied Ischemic Attack) / Stroke with all types of blood vessels of 3. Peripheral Vascular Disease (Occlusive nutrients and oxygen. Peripheral Arterial Disease) Microvascular Aneurysms − Signs and Symptoms: o The changes in the blood Diminished peripheral pulses w/ vessels include microvascular peripheral vascular disease aneurysms there is a bulging of Intermittent claudication (wherein the pt the eyes which may rupture or will manifest pain in the calf, buttocks or cause retinal hemorrhage. thigh during walking) Intraretinal Hemorrhage Gangrene Hard Exudates Diabetic foot o These are composed of lipids & − Management: protein substances that mix in Modification and reduction of Risk Factor the blood vessels of the retina. for atherosclerosis Focal Capillary Closure Management in cholesterol, o There is an occlusion of blood hypertension & others vessels that supplies the retina. Prevention and treatment of Risk Factor − Clinical Manifestations: for atherosclerosis Many patients are asymptomatic Manage obesity, hypertension, hyperlipidemia 4 | JK LEI | IRIS | MARIA  3 Stages of Retinopathy extremities, affects both sides, and may spread in proximal direction Nonproliferative o Clinical Manifestations ✓ Macular Edema – may lead to blind & vision − Paresthesia – due to decreasing disturbances loss of central vision. temperature − Prickling, tingling, heightened Preproliferative sensation, burning sensation (at night) – due to decreasing ✓ Precursor to the more serious proliferative temperature; heart rate is low retinopathy due to low temperature, low ✓ More advance to nonproliferative blood flow which may be felt Proliferative painfully that may be intense. − Numbness of feet ✓ Widespread vascular changes − Decreased Proprioception – ✓ Loss of nerve fibers awareness of posture and ✓ Hemorrhage – Signs: Floaters, cobwebs, hazy movement in relation to the body vision, complete loss of vision − Unsteady gait ✓ Painless process − Decreased sensation of pain Nephropathy and temperature – it places the patient at incase of risk of injury − Kidney disease secondary to diabetic − Charcot joints – due to microvascular changes in the kidney abnormal weight distribution − Symptoms similar to those seen in patients from lack of proprioception; without diabetes neuropathy is related to joint − The elevation of blood glucose which can lead to changes stress function of the kidney, filtration which may − Decreased deep tendon reflex lead to leakage of protein into the urine. o Management: − Eventually, the increase of kidney pressure − Intensive insulin treatment serves as a stimulus development of − Control of blood glucose levels nephropathy. o Pain Management: − Non-opioid analgesics Complications of Diabetic Neuropathies − Tricyclic depressants (duloxetine) − Group of disease that affect peripheral − Anticonvulsant (pregabalin) (sensorimotor), autonomic, spinal nerves − Transcutaneous Electrical − Prevalence increases with age Nerve Stimulation – is a form of − Etiology: pain relief without medicine; this Chronic hyperglycemia device works by sending Thickening and closure of capillary electrical impulses through the vessels – that supplies the affected skin. nerves Demyelination of the affected nerves – 2. Diabetic Neuropathies is related to hyperglycemia wherein there is a disruption of nerve conduction due to Autonomic Neuropathy – affects almost every the abnormalities of the myelin sheath. organ system of the body. − 2 Most Common Types: o Clinical Manifestations: 1. Sensorimotor polyneuropathy − Cardiac, GI, Renal (Peripheral Neuropathy) ✓ Cardiac: Tachycardia or 2. Autonomic neuropathy orthostatic hypotension 3. Additional: Cranial Mononeuropathies of myocardial infarction – affects the oculomotor nerve and ✓ GI system: delay gastric affects all the adults with diabetes. emptying, early satiety, bloating, nausea and 1. Sensorimotor Polyneuropathy vomiting ✓ Renal system: wherein Peripheral Neuropathy – affects the distal the kidney is involved portion of the nerves especially the lower urinary retention 5 | JK LEI | IRIS | MARIA  ✓ The kidney is also at risk − Initial Signs: of infection. Renal Swellings, redness of leg, gangrene system is decreased − Management: sensation in the blood & Antibiotics bladder Debridement ✓ The patient will be at risk Control of glucose levels of the infection of the Amputation: kidney because of o Peripheral vascular disease is inability of the bladder to present. empty completely. ✓ Particularly if there is − Hypoglycemic Unawareness – foot ulceration which Diminished or absent adrenergic does not heal. symptoms; No more shakiness, ✓ Due to no oxygen, there sweating; nervousness, are no nutrients that palpitation. reach the affected part. Sudomotor Neuropathy – decreases of o Prevent the spread of infection absence of anhidrosis (hands and feet) of the – particularly if it has an extremities with compensatory increase involvement of the bone / anhidrosis of upper body. osteomyelitis. Sexual Dysfunction – erectile dysfunction, − Diagnostic Test: retrograde ejaculation in men. Abnormal high blood glucose is the basic o Retrograde Ejaculation – the semen is criterion for diagnosis of diabetes. propelled backward towards the urinary Random Blood Sugar (RBS) bladder. o Casual plasma glucose o When you collect urine in the patient – concentration. a laboratory determines the o Blood specimen is drawn any abnormalities and may find the presence time of day without regard to time of semen. since last meal. o Reduced vaginal lubrication in women o Suggestive of diabetes are – decreased libido, lack of orgasm, symptoms diabetes and RBS vaginal infections, vaginal pruritus, UTI, result of ≥ 200 mg/Dl. vaginitis. Fasting Blood Sugar o Management: o Fasting plasma sugar or glucose − Alleviation of symptoms based o Defined as no caloric intake on etiology and management of for at least 8 hours – the blood risk factors. specimen is obtained after 8 hours of fasting. Complications of Diabetic Foot o Suggestive of diabetes is an FBS of ≥ 126 mg/dL or 7.0 millimoles. − Soft tissue injury, formation of fissures in between Post-Prandial Blood Sugar toes, or any areas of dry skin and formation of o 2-hour post load glucose. callus. (One of diabetes is neuropathies; diabetes o Blood sample is taken 2 hours damages nerves). after a carbohydrate meal or − Patients do not feel injuries. glucose load equivalent to 75 − Serious infection may develop – their foot has grams dissolved in water. contracted. o Suggestive of diabetes is a post- 1. Thermal (Testing bath water with foot) prandial blood sugar of ≥ 200 – the cause of injury of injury may due to mg/dL. heating pad, walking on hot concrete, − Diagnostic Test: and testing bath water with foot. Oral Glucose Tolerance Test (OGTT) – 2. Chemical (Burning the foot with acids) Involves collect of blood and urine – foot is expose with caustic acid. samples (to determine glucose in the 3. Traumatic (Injury from cutting nails) – blood and glucose in the urine). injury from foreign objects, wearing tight o Procedure: socks or shoes with compressions. (due 1. Client fast for 8 hours to the possibility of decreased blood 2. Baseline samples taken circulations). 3. Oral glucose given 6 | JK LEI | IRIS | MARIA  4. Blood is drawn at 30 Nutritional Therapy minutes, 1 hour, 2 hours, and 3 hours after − Control of total calorie intake (diet therapy). ingestion of glucose. − Attain a reasonable body weight to control blood 5. Approximately collection glucose level, normalization of lipids, of blood is repeated 4 normalization of blood pressure to prevent heart times. disease. 6. Urine is collected as − Do not skip meal – consistent meal content, well. timing, pace food intake. o Findings: − Low-calorie if patient is obese ✓ No diabetes glucose − Proportion Diet: returns to normal in 2-3 20% Protein (CHON) hours, urine (-) for o A smallest percentage which is glucose. necessary especially in patients ✓ Suggestive of diabetes with early signs of symptoms of glucose slowly returns to kidney disease which may come normal, urine (+) for from legumes or whole grains. glucose. 30% Fats Glycated Hemoglobin o This approach reduces risk o Also known as glycosylated hemoglobin factors such as increased serum (HbA1c). cholesterol level. o Is a measure of glucose for the past 3 o Which is associated with the months. development of coronary artery o Those that binds with Hgb disease. − When blood glucose is elevated, o The leading cause of death & the mucus molecule attaches to disability in people with diabetes. the hemoglobin in the red blood 50% Carbohydrate (CHO) cells. o CHO should be higher in protein o Glucose binds with Hgb permanently and fats. (120 days) / 4 months o Fats has a greatest effect on − The longer blood glucose in the glucose which helps control circulation, the more glucose will glucose and majority should bind with the Hgb. (That's why come from whole grains. the hemoglobin becomes − Consume complex Carbohydrate (CHO) and higher). high fiber diet – inhibits glucose absorption in − Last for the life individual RBC the intestine. 120 days or 4 months. − RBC of the patient will reveal a Exercise high level of glucose, if they have − Lower Blood Glucose diabetes. (Glucose can stay up Reduces cardiovascular complications. to 120 days in the blood of the patient). Increase the uptake of glucose by body muscles that is utilize for energy. − Patient will report normal in a self-monitoring blood glucose, Improve insulin utilization by lowering but the glycated hemoglobin is blood glucose during the increase. (It high, there might be errors in increases by food intake). self-monitoring blood glucose. Improve circulation and muscle tone − Alters blood lipid concentration Normal Values − Increase HDL (Good Cholesterol) − 4%-6% This takes bad cholesterol from the walls − Target range for people with diabetes is less than of the arteries. 7% − Decrease total cholesterol and triglyceride − Pt who are early diagnosed with diabetes. One levels who is not compliant to treatment. One is Maintains ideal body weight, serum inadequate in treated Target range is less than carbohydrates & serum lipids. 7% − Do not exercise with elevated glucose level Liver will release more glucose. 7 | JK LEI | IRIS | MARIA  It will increase glucagon, growth ✓ Can also function as basal hormone & catecholamines. insulin and is to divided into 2 injections to achieve 24 hours Insulin Therapy coverage. o Long-acting Insulin / Peak less Basal Type 1 Insulin o Exogenous insulin for life ✓ Used as basal insulin o Does not produce insulin ✓ Wherein absorbed very slowly Type 2 over 24 hours o Exogenous insulin may be necessary to ✓ Can be given once a day at any control glucose levels time but must be given the same o Although insulin is present, but the time to prevent overlap of action secretion is impaired o Exogenous insulin may be necessary Different Categories of Insulin Diet Management: o Oral antidiabetic agent or OHA 1. Onset – how quickly does the insulin lowest blood ✓ Sulfonylureas glucose − Insulin releasers; helps 2. Peak – how much time does your insulin reaches beta cells to secrete the maximum strength more insulin; increases 3. Duration – how long does the insulin will work to the ability of insulin lower blood glucose receptor to bind insulin Side effects: weight gain ✓ Non-Sulfonylureas − Biguanides − Alpha-glucosidase inhibitors − Thiazolidinediones − Meglitinides o Self-Monitoring Blood Glucose (SMBG) ✓ Cornerstone of insulin therapy ✓ Accurate monitoring of blood glucose is necessary ✓ The essential therapy NOTE: insulin they are taken before meals so that insulin goes to work in the glucose from your food starts to enter your circulation. Preparations o Rapid-Acting Insulin ✓ More rapid onset but short duration (3-4 hours). Nursing Responsibilities ✓ Instruct patient to eat no more than 5-15 mins after injection (Insulin will be ineffective and 4 Main Areas there is a greater risk of 1. Abdomen (greatest absorption) hypoglycemia). 2. Upper arms (posterior surface) ✓ Requires Basal Insulin (long- 3. Thighs (anterior surface) acting) – to maintain glucose 4. Hips (least absorption) control which is necessary at all times. Route o Short-Acting Insulin o Subcutaneous ✓ Regular insulin (with marked R ✓ Slow absorption on the bottle) ✓ Less painful ✓ Usually given 15 minutes before ✓ Thin: 90° (syringe) meal ✓ Obese: 45° (syringe) ✓ Can be administered by IV ✓ NOTE: in giving insulin, it is o Intermediate Acting Insulin based on the built of the patient ✓ NPH insulin (neutral protamine ✓ No need to aspirate Hagedorn) ✓ Do not massage site of infection ✓ Appear milky and cloudy but (to avoid hematoma) uniform. 8 | JK LEI | IRIS | MARIA  o IV − Insulin administration should be slow absorption ✓ Given in emergency situations to prevent such complication only. ✓ Patient who suffers in diabetic Hypoglycemia ketoacidosis (DKA). Administer at room temperature − Possible side effects of insulin administration o Cold insulin can cause lipodystrophy − Due to sudden drop of blood glucose (localized reactions from insulin) o Can lead to complications: Somogyi Effect (Phenomenon) Lipoatrophy: − There is loss of − Nocturnal hypoglycemia followed by rebound subcutaneous fat. hyperglycemia − When assessing you − Normal/elevated blood glucose at bedtime, early may notice a dimpling of morning hypoglycemia, and a subsequent subcutaneous fat. increased blood glucose Lipohypertrophy: Due to production of counter-regulatory − Complications of hormones (glucagon, adrenaline, lipohypertrophy has cortisol, & growth hormone) been almost eliminated Which is released during hypoglycemia when human insulin has during stress conditions been identified as part of It has an insulin antagonistic effect management. Oral Antidiabetic Agents − This is the development o Effective for patients who have type 2 of fibrofatty masses diabetes which cannot be treated which is usually caused effectively by MNT or exercise by a repeated use of Sulfonylureas injection. − “Insulin releasers” Insulin vials not in used should be kept − Stimulate beta cells to refrigerated and stored at room temperature. secrete more insulin Avoid exposure to extreme temperatures and − Stimulate the ability of direct sunlight the insulin receptors to Insulin that can be used up within 1 month can be bind insulin (released by kept in room temperature (to reduce local pancreas) irritation at the injection site which may occur if − Signs & Symptoms: cold insulin is injected) weight gain, Rotate the site of injection hypoglycemia, o Do not inject insulin in hypertrophied secondary failure of areas (it will lead to delayed absorption; pancreas due to wait until hypertrophy disappears before overstimulation using that side again). Other Oral Antidiabetic Agents Thoroughly mix cloudy insulin (NPH) by rolling it o Tolbutamide (Orinase) between hands (to redistribute insulin particles) o Acetohexamide (Dymelor) Do not shake! – bubbles make it difficult to o Tolazamide (Tolinase) aspirate exact amount o Chlorpropamide (Diabinese) o Glipizide (Glucotrol) Localized Side Effects o Glyburide (Micronase, Glynase) o Glimepiride (Amaryl) Induration/Redness Non-Sulfonylureas Swelling o Biguanides Lesion at the site o Metformin (Glucophage) Lipodystrophy (reaction from cold insulin) − Help tissues use available insulin more Generalized Side Effects efficiently − Insulin sensitizers Edema − Signs & Symptoms: stomach upset, − Sudden resolution of hyperglycemia wherein the flatulence, diarrhea fluid moves from the extracellular to the − No weight gain, no intracellular spaces that is associated with hypoglycemia sudden drop of serum osmolality 9 | JK LEI | IRIS | MARIA  Alpha-glucosidase Inhibitors Monitor blood glucose level − Miglitol (Glyset) and Acarbose o As part of the management of (Precose) hypoglycemia − Alpha-glucosidase is an intestinal enzyme that breaks Diabetic Ketoacidosis down carbohydrates into glucose, when this enzyme is − Common in type 1 diabetes inhibited, the process of forming − Characterized by absence or inadequate insulin glucose is slowed and glucose is − Clinical Feature: Dehydration and electrolyte absorbed more slowly from the loss small intestine − 3 Major Derangements: − Taken 15 minutes before meal 1. Hyperglycemia Deficiency in insulin 3 Major Complications 2. Ketosis Breakdown of fats in the 1. Hypoglycemia absence of insulin 2. Diabetic Ketoacidosis It will result to formation of 3. Hyperglycemic Hyperosmolar Syndrome ketone bodies (highly acidic) 3. Metabolic Acidosis Hypoglycemia Due to the presence of ketones − 3 Main Causes: − Low blood sugar 1. Decreased or missed doses of insulin − 20mL of CSF is removed the side effect of spinal headache − Provides a cross-sectional view of the brain, may occur because of the CSF different tissue densities of the skull, cortex, and leakage that why we need to ventricles position the patient into supine. − Ct can use x-rays Positron emission tomography (PET) − An IV contrast agent may be administered − Can detect Tumor/masses, infarction, − A computer-based nuclear imaging technique hemorrhage, lesions, displacement of the that produces images of actual organ ventricles of the brain, cortical atrophy functioning − Nursing considerations: − How does the PET work? Contraindicated to pregnant The patient may either inhale radioactive Patients’ needs to lie still throughout the gas or inject a radioactive substance so procedure this will produce positive recharge Teach relaxation techniques if pt is particles and then combine negative claustrophobic recharge particles found in the body Sedation may be necessary or if the cells. This will be interpreted by the patient is agitated computer and will give a compulsively Assess for allergy on iodine or shellfish picture of the brain at work because the contrast agent is iodine Permits measurement of blood flow and base brain metabolism, can detect brain Assess kidney function because the glucose use. contrast dye must be excreted by the o Because brain can consume kidney, if the patient has kidney function 80% of glucose the body uses the excretion of contrast dye may be − Can detect: difficult Alzheimer’s disease which can be as a For safety result of metabolic changes of the brain o Wear lead apron Epileptogenic lesions After the procedure Brain tumor o Increase Oral Fluid Intake Identify blood flow and O2 metabolism Determine biochemical abnormalities Lumbar Puncture (spinal tap) and mental disorder − Detect: Bacterial, fungal, viral CNS infections − Nursing considerations − Subarachnoid hemorrhage Contraindicated to pregnant − CNS malignancies or presence of cancer Pt needs to lie still throughout the − Demyelinating diseases such as multiple procedure sclerosis Teach relaxation techniques if pt is 29 | JK LEI | IRIS | MARIA  claustrophobic Will not cause an electric shock Sedation may be necessary EEG is diagnostic not therapeutic or Assess for allergy on iodine or shellfish treatment Assess kidney function Lie still For safety Sedation is not advisable alters brain o Wear lead apron wave After the procedure Activities and may lower seizure o Inc OFI threshold with seizure disorder because we want to record seizure activity Cerebral Angiography Avoid caffeinated beverages - because − A x ray study of the cerebral circulation using a it may also alter or slows brain waves contrast agent injected into a selected artery activity − Useful in detecting vascular diseases such as No NPO blood vessels patency Control blood glucose - the patient − Collateral circulation- is referred to as a back-up shouldn’t be hypoglycemic or circulation in case there is a blockage in a certain hyperglycemic because this may also blood vessel. alter the brain wave. − How is this performed? Clean hair for electrodes o Electrodes attached using Insertion of angiography catheter through water soluble – remove by the femoral artery in the groin or the shampooing radial artery of the wrist and up to the o If sleep EEG, collodion glue is desired vessel. used for electrode contact – − Nursing considerations: remove w/ acetone Contraindicated to pregnant Check kidney function prior Electromyography (EMG) procedure prior procedure - to ensure that kidneys can excrete the contrast − Measure changes in the electrical potential of agent muscles by inserting a needle electrode into the Proper hydration - wherein the clear skeletal muscles liquids are usually permitted at the time − Determine presence of neuromuscular disorders of the test. and myopathies Locations of the appropriate peripheral − Nursing considerations: pulses are marked with a felt-tip pen. Sensation similar w/ IM injection Instruct the client to not move throughout the procedure! Inform client of sensations when contrast dye is injected o Warmth in the face, behind eyes, jaw, teeth, tongue, lips, metallic taste because of the administration of the contrast o Check injection site for bleeding/hematoma Electroencephalography (EEG) − Represents a record of the electrical activity generated in the brain − Electrodes are applied on the scalp or microelectrodes placed in the brain tissue − Purpose: Record electrical activity of the brain Detect seizure disorders, coma, organic brain syndrome, brain death − Nursing considerations: Deprive sleep (night before EEG) to increase that chances of recording seizure activity Withheld meds for 24-48 hours Anticonvulsants, tranquilizers, stimulants, depressants 30 | JK LEI | IRIS | MARIA  NCMB – 316: MEDICAL SURGICAL NURSING 2 2nd SEMESTER MIDTERMS 3RD YEAR NURSING WEEK 11 - Management of Patients with Neurologic sneezing, straining), posture, BP, Dysfunction systemic 02 and CO2 levels. The Central Nervous System Pathophysiology CNS has a vast network of neurons that controls the body's vital function. CNS is vulnerable in structure and functions can be disrupted by injuries. The structure disruptions that can cause CNS injury are ○ Head injury ○ Brain tumor ○ Intracranial hemorrhage ○ Infection Stroke ○ CVA When these disruptions occur, brain tissues will expand, which can lead to edema. NOTE: Cranium is not flexible (it is rigid) therefore, when brain tissues expand, the volume will increase within the brain. The intracranial TAKE NOTE: An increase in intracranial pressure pressure will increase and cerebral perfusion will regardless of the causes can decrease cerebral be impaired which can cause permanent perfusion and can stimulate further edema or neurologic dysfunction and even brain death. swelling. These may result in the shifting of brain Increased Intracranial Pressure tissues which may result in brain herniation → can lead to a fatal event which is death. Cranial Vault Increased intracranial pressure → decreased cerebral perfusion → cerebral ischemia AKA skull vault, skullcap, calvaria (reduction of blood flow in the brain). Rigid (not flexible) In the early stages of cerebral ischemia, Encases and protects the brain vasomotor centers are stimulated (in the medulla) 3 components which is responsible for the regulation of cardiac ○ Brain tissue (1400 g) activity and myocardial performance. This ○ Blood (75 mL) stimulation maintains cerebral blood flow by ○ CSF (75 mL) increasing the systemic pressure which is - TAKE NOTE: These three (3) considered as the compensation of the body. components must be in This compensation is accompanied by slow equilibrium bounding pulse and respiratory regularities → - Produce the ICP changes in pulse rate and resp rate which are - Measure in the lateral ventricles important as these changes suggest increased of the brain intracranial pressure. - Normal pressure: 0-10 mmHg The respiratory irregularities can result in - Normal upper limit of changes in the concentration of oxygen and CO2 pressure: 15 mmHg. in the blood which plays in the regulation of cerebral blood flow specifically an inc or dec Monroe-Kellie hypothesis (Monro-Kellie doctrine) partial pressure of CO2 ○ Increase in partial pressure of CO2 – may Because of the limited space for the expansion result in cerebral vasodilation which can within the skull, any increase in the volume of one lead to cerebral blood flow → increased of the components can cause changes in the ICF volume of others ○ Decrease in partial pressure of CO2 – Compensation is accomplished by has a vasoconstrictor effect which limits - Displacing or shifting the CSF, increasing blood flow to the brain the absorption of CSF, diminishing the Additionally, a decrease in venous outflow can production of CSF, decreasing cerebral result in increased cerebral blood volume thus blood volume increasing ICF. Minor changes in the blood volume and CSF can Associated with the increase in cerebral brain occur if volume is cerebral edema wherein there is - Intrathoracic pressure (coughing, accumulation of fluid inside the brain. 31 | JK LEI | IRIS | MARIA  When brain tissue swells, several compensatory flexion of the upper extremities and mechanisms will occur to compensate for the abnormal extension of the lower increasing intracranial pressure. This includes extremities. Autoregulation which is the brain's ability to Decerebration - manifested by extreme change the diameter of the blood vessel to extension of the upper and lower maintain a constant cerebral blood flow. extremities and placidity. A clinical manifestation known as Cushing’s reflex Brain death - if the coma is profound and is seen with a significant decrease in cerebral irreversible. If the brain stem reflexes and blood flow. resp is absent or impaired. To overcome an increase in ICF, the sympathetic nervous system will respond by increasing Diagnostic Test: systolic BP which may result in a widening of CTI, MRI (Most common) pulse pressure and slowing of Heart rate. Cerebral angiography TAKE NOTE: Cushing's reflex is a late sign that ○ used to determine vascular abnormalities requires intervention. The manifestations Positron Emission Tomography (PET) presented by this reflex are a sign that this ○ used to determine brain function, response must be treated rapidly so that cerebral performed while the brain is at work perfusion can still be recovered. Transcranial Doppler Studies If at a certain point, the Cushing's reflex is not ○ used to provide information about the treated rapidly. The autoregulation will become cerebral blood flow ineffective and decompensation begins (ischemia Lumbar Puncture is avoided and infarction) → significant changes in mental ○ Sudden release of pressure in the lumbar status and vital signs will be exhibited in the pt. area can cause brain herniation ○ Changes in vital signs include: hypertension, bradycardia, and Complications: bradypnea (Cushing's triad) → Brain herniation and occlusion of CBF will Brain stem herniation happen o Results in cessation of blood flow to ○ Brain herniation – refers to the shifting of brain, leads to irreversible brain anoxia, brain tissue from an area of high pressure and brain death to an area of low pressure Diabetes insipidus ○ The herniated tissue will exert pressure o A result of decreased secretion of ADH in the brain area where it has shifted and ○ Increased urine output, decreased urine this will interfere with the blood supply → osmolality, serum hyperosmolarity cessation of blood flow → Cerebral ○ Management: Desmopressin ischemia, cerebral infarction, and Brain ○ Neurogenic DI because the cause is the death. neural disturbance SIADH Clinical Manifestations: ○ A result of increased ADH secretion ○ Manifestations include volume overload, − When intracranial pressure increases to the point dec urine output, and diluted sodium in which the brain's ability to adjust has reached concentration its limit, the neural function will be impaired. ○ Treatment: fluid restriction − The earliest manifestations are seen in changes in LOC and late manifestations can be seen with Medical Management: abnormal vasomotor and resp responses. Changes in LOC (earliest sign) Increasing ICP is a medical emergency! Restlessness Goals Confusion ○ Decrease cerebral edema, ○ Decrease volume of CSF, Increasing drowsiness ○ Decrease cerebral blood volume Pupillary changes, impaired extraocular Invasive Monitoring of ICP movements ○ This involves the insertion of the Unilateral / bilateral body movements monitoring system inside the different Headache and projectile vomiting - parts of the brain this is caused by changes in the brain ○ Identify increase pressure early in the stem and vomiting mechanism course Stuporous - only react to loud and ○ Quantify the degree of elevation painful stimuli ○ Initiate treatment Cushing’s triad - Hypertension, ○ Provide access to CSF Bradycardia, and Bradypnea ○ Evaluate the effectiveness of the Comatose treatment Decortication - manifested by abnormal 32 | JK LEI | IRIS | MARIA  Ventriculostomy (Intraventricular catheter) the midbrain ○ Fine-bore catheter is inserted in the TAKE NOTE: if pons and medulla (the respiratory ventral portion of the brain center) are involved, respiration becomes ○ Record ICP, CSF drainage, cerebral irregular and may eventually cease. blood drainage, administration of Discourage coughing medication or contrast agents (for ○ to prevent increase in ICP ventriculography) Head Of Bed (HOB) elevated at 30-45° ○ Complications: infection, meningitis, ○ this may aid in clearing secretions and ventricular collapse, occlusion of the improve venous drainage of the brain → catheter by blood and brain tissues, and promote blood drainage problems in the monitoring system Head in neutral position (midline) Subarachnoid screw or bolt ○ If necessary, a cervical collar is placed to ○ A bolt or a screw is inserted through the stabilize the position of the head. skull and dura mater into the cranial ○ to facilitate venous drainage from the subarachnoid space brain ○ Record ICP, prevent brain shifting Avoid extreme flexion and rotation of the neck ○ Complications: infection, blockage of ○ this will lead to compression or distortion the screw by a blood clot or brain tissues of the jugular veins which may increase which may lead to pressure tracing and intracranial pressure decreased accuracy at high intracranial Avoid hip flexion pressure readings Avoid Valsalva maneuver Epidural monitoring ○ caused by straining during defecation ○ Involves pneumatic flow censor Note for abdominal distention ○ Detect ICP Avoid enema and cathartics ○ Low incidence of infection ○ increases defecation ○ Unable to withdraw CSF for analysis Use stool softeners Fiber Optic monitoring (transducer-tipped ○ to prevent constipation catheter) High fiber diet ○ Considered as an alternative to Exhalation while turning ventriculostomy, subarachnoid and ○ Opens the glottis, prevents Valsalva subdural systems maneuver ○ The catheter is also inserted in ventricles, Avoid emotional stress subarachnoid or subdural spaces, or Avoid frequent arousal from sleep even bone flaps Maintain calm atmosphere ○ Detect ICP changes Minimal environmental stimuli ○ Drains CSF Mannitol Intracranial Surgery ○ Osmotic diuresis Craniotomy (burr holes) ○ action is to dehydrate cells and remove ○ Surgical opening of the skull excess fluid in the brain ○ Done to gain access to intracranial Restrict fluids structures by creating burr holes Draining CSF Purpose: Corticosteroids ○ Remove tumor, relieve increased ICP, ○ Brain tumor. It can cause brain shifting evacuate blood clot, control hemorrhage and increase pressure in the cranial Approaches: vault. ○ Supratentorial Control fever - Above the tentorium into the ○ Lead to increase metabolism, increase supratentorial compartment blood flow, increase pressure - Incision usually behind the Maintain systemic BP hairline ○ To control intracranial pressure - Nursing interventions Oxygenation - Maintain HOB elevated ○ Hypoxia caused by poor oxygenation can at 30- 45 degrees – to lead to cerebral ischemia and edema. promote Nursing Management: - Maintain neck in neutral alignment – to prevent Monitor for respiratory irregularities tearing of suture line ○ Cheyne-Stokes - Position pt on either side - suggests increased pressure in or back – to prevent the frontal lobe pressure on the ○ Hyperventilation operative site - suggests increased pressure in ○ Infratentorial 33 | JK LEI | IRIS | MARIA  - Below the tentorium into the 20% infratentorial compartment Associated with cardiac arrhythmias - The incision is at the nape of the (atrial fibrillation), valvular heart disease, neck, around the occipital lobe thrombi in the L ventricle - Nursing interventions The emboli that originate from the heart - Maintain neck in straight circulate to the cerebral vasculature alignment which is located particularly in the left- - Avoid neck flexion to middle cerebral artery → stroke prevent possible tearing 4. Cryptogenic stroke of the suture line 30% ○ Transsphenoidal No known cause - Sella turcica and pituitary region 5. Stroke from other causes - Through the upper lip and 5% sinuses to gain access to the Drug use, coagulopathies, vasospasm, pituitary gland. dissection of the carotid arteries or - Nursing interventions vertebral arteries - Maintain nasal packing ○ The dissection occurs due to to prevent bleeding injury or unknown cause. - Avoid blowing the nose - Provide oral care Clinical Manifestation: - Keep HOB elevated to Location of the obstructed vessel promote venous Size of area of inadequate perfusion drainage Amount of collateral blood flow Craniectomy Motor, sensory, CN functions, cognitive functions ○ Excision of a portion of the skull are disrupted. Cranioplasty Numbness or weakness, changes in mental ○ Repair of a cranial defect using plastic or status, trouble speaking, visual disturbances, metal plate incoordination, severe headache as general Cerebrovascular Disorders manifestations. Refers to a functional abnormality of the central Motor Loss nervous system and occurs when blood supply to Due to upper motor neuron lesion the brain is disrupted. The disturbance of voluntary control that occurs Stroke is a primary cerebrovascular disorder that on one side of the body reflects damage to the causes a long-term disability upper motor neuron on the opposite side of the 2 Major Categories of Stroke: brain I. Ischemic stroke Upper Motor Neurons Decussate (Cross) Approx. 87% of pt. Occurs due to vascular Hemiplegia occlusion and significant hypoperfusion ○ Most common Sudden loss of function from disruption of blood ○ Paralysis of one side of the body, as a supply to a part of the brain result of lesion of the opposite side of the AKA cerebrovascular accident, “brain attack” brain Hemiparesis 5 Types of Ischemic Stroke: ○ Weakness of one side of the body 1. Large artery thrombosis Communication Loss 20% Caused by atherosclerotic plaque in Dysarthria large vessels of the brain n which results ○ Difficulty in speaking in ischemia and infarction Dysphasia Infarction – is tissue necrosis in an area ○ Impaired speech of the brain that is deprived of blood Aphasia supply ○ TAKE NOTE: Stroke is the most common 2. Small penetrating artery thrombosis cause of aphasia wherein the individual 25% is unable to express themselves or Also called lacunar stroke, a cavity is understand language created after death of an infarcted brain ○ Expressive aphasia tissue - Broca’s aphasia Common type of ischemic stroke - Inability to express oneself 3. Cardiogenic embolic (cardioembolic) stroke ○ Receptive aphasia - Wernicke’s aphasia 34 | JK LEI | IRIS | MARIA  - inability to understand language of the senses. and inability to comprehend the spoken word Cognitive impairment ○ Global aphasia Depends on the lobe affected - Mixed (expressive and Frontal lobe receptive) ○ Limited attention span, difficulty in Apraxia comprehension, forgetfulness, lack of ○ Inability to perform previously learned motivation actions ○ Such as flying kiss, stop sign using Transient Ischemic Attack (TIA) hands, and waving goodbye Temporary, may resolve in 24 hrs. and usually last Perceptual Disturbances less than an hour Sudden loss of motor, sensory, or visual function Visual-perceptual dysfunctions May be a sign of impending stroke – brain ○ Caused by disturbances of the primary imaging may show no evidence of ischemia sensory pathways between the eyes and wherein 3-15% of all strokes are preceded by TIA visual cortex TAKE NOTE: if TIA manifestations are ignored, it ○ The disorders occur in visual processing may result in stroke and irreversible deficits and visual interpretation. Inability to make sense of information taken through Signs of Stroke eyes Visual-spatial relations ○ Perceives the relationship of two or more objects in spatial areas ○ Ex. Knowing where an object is in relation to oneself ○ Seen in patients with right hemispheric damage Sensory loss Homonymous hemianopsia ○ Loss of half of visual field ○ Affected side of vision corresponds to the paralyzed side of the body TAKE NOTE: The Left hemisphere of the brain is responsible for language and speech. The Right F.A.S.T. hemisphere plays a role in the spatial localization Face (weakness) of stimuli. Facial weakness. Assess the symmetry of the Comparison of Left and Right Hemisphere Stroke face, and ask if the pt can smile. If they can smile Left hemispheric Right hemispheric stroke but the face is asymmetrical, this may indicate stroke weakness and suggest stroke. Paralysis or Paralysis or Arm (weakness) weakness on the weakness on the Arm weakness. Ask the patient if they can raise right side of the left side of the both arms and keep their arms raised. If one arm body body drips down, it may suggest a stroke Right visual field Left visual field Can they raise both arms and keep them there? deficit deficit Speech (difficulties) Aphasia Spatial-perceptual (expressive, deficits Speech difficulties. Assess slurred speech by receptive, Increased asking pt to repeat sentences. If slurred speech global) distractibility, is present, this may suggest a stroke. Slow, cautious impulsive behavior Is their speech slurred? behavior and poor judgment Time (call 911) Lack of awareness of deficits Call 911 if you see any single one of these signs. Diagnostic Tests: Sensory Loss CT scan Agnosia (visual, auditory, tactile) ○ Initial diagnostic test ○ Loss of ability to recognize previously ○ Plain or with contrast familiar objects