1
Q
urinary system
A
- upper: kidneys and urethra
- lower: bladder and urethra
2
Q
fxn of urinary system
A
- regulate volue and composition of ECF
- excrete waste products
- Control BP: renin production
- produce erythropoietin: RBC production
- Activate Vit D
- Regulate acid-base balance
- filter the blood
- maintain homeostasis
- nephron is the functional unit: golmerulus, bowman’s capsule, tubular system
- Blood supply: receives 20-25% of cardiac output - renal artery arises from the aorta
- glomerular function: blood is filtered by hydrostatic pressure
- glomerular filtration rate GFR: normal is 125 ml/min
3
Q
structures of urinary system
A
- ureters: join the renal pelvis to the bladder
- bladder: serves as resevoir for urine, capacity 600-1000ml, detrusor is the muscle, urination/micturation/voiding
4
Q
urinary system gerontologic considerations
A
- lose 30-50% of glomeruli fxn by age 70
- atherosclerosis accelerates decrease in kidney size
- decreased renal blood flow, decreased GFR
- decreased urinary concentrating ability
- alterations in excretion of water, sodium, potassium and acid
- loss of elasticity, vascularity, and structure of the female genitalia
- enlarged prostate for men
- decreased: filtration, GFR, concentration
5
Q
urinary system assessment data
A
- color changes in urine
- tired all the time
- bladder tumors: higher incidence in textile workers, painters, smokers, hairdressers, industrial workers
- kidney stones: higher risk in great lakes, southwest, southeast (minerals in water)
- family history
- pneumonia breath
- midline mass in lower abdomen: urinary retention
- unilateral mass: enlargement of kidnye
- kidneys are usually not palpable
- bladder is usually not palpab
- CVA tenderness: finds kidney issues
- use bell of scope to listen over both CVAs and in upper abdomen
- bruit = renal artery issue
6
Q
diet and urination
A
- dietary intake and effects on urine output
- dehydration: increased risk of UTI, stones and renal failure
- large daily intake of dairy products or foods high in protein increase risk of stone formation
- asparagus makes urine smell musty
- beets make urine pink
- caffeine, alcohol, carbonated drinks, spicy foods can aggravate inflammation
- herbal teas cause diruesis
7
Q
other urinary problems
A
- bleeding: infection, bladder irrigation
- nocturia: normal once a night or twice if older
- creed’s method: push down on bladder to urinate
- valsalva maneuver: pushes down
- heavy lifting and driving can cause issues in men
8
Q
normal kidney assessment
A
- no costovertebral angle tenderness
- nonpalpable kidney and bladder
- no palpable masses
- r. kidney is lower than left
9
Q
kidneys and drugs
A
- NSAIDs: decrease renal perfusion
- increased sodium: sodium and water retention
- contrast can injure kidneys
- OTCs that are toxic to kidneys/nephrotoxic: bacitracin, gentamicin, neomycin, captopril, ccaine, heroin, NSAIDs, ibuprofen, rifampin, salicylates, gold, heavy metals
- color changes: pyridium, macrodantin
- anticoags: may cause blood
- many antidepressants/calcium channel blockers/antihistamines/neuro and musculoskeltela drugs can affect the bladder sphincters and contractility
10
Q
important urinary terms
A
- dysuria: painful urination
- nocturia: frequency of urination at night
- hematuria: blood in urine
- enuresis: involunaty nighttime urination
- anuria: no urination
- oliguria: decreased amount of urine (100-400)
- polyuria: large volume or urine
11
Q
urine studies
A
- UA: first study to be done, first void of morning, examine within 1 hour
- creatinine clearance: most accurate indicator of renal function, closely approximates GFR, must also get a blood specimen for creatinine during the 24 hr test
- 24 hr studies: discard first void to start the test, save urine for 24 hrs, have pt void at the end of the collection to compete the test
- culture: after cleaning have pt start urinating and then void into sterile container (mid stream)
- residual: catheterize patient imediately after voiding or use bladder ultrasound
- cytology: done if bladder cancer is suspected, do NOT use mornings first voided specimen, looks for abnormal cells related to cancer
12
Q
urinalysis
A
- color: straw, clear is normal
- protein: increased by renal failure and nonrenal causes
- specific gravity: 1.003-1.030
- PH 4-8
- RBCs, WBCs, glucose, ketones, bilirubin, casts: should all be negative in urine
13
Q
Urinary Blood studies
A
- BUN 6-20: can be affected by non-renal factors - dehydration, fever, GI bleed, trauama
- creatinine 0.6-1.3: end product of muscle and protein metabolism, more reliable than BUN
- potassium 3.5-5.0: 1st electrolyte to appear abnormal with kidney issues
- sodium 135-145
- biacrbonate 22-26
14
Q
urinary radiologic studies
A
- KUB: kidneys ureters bladder - xray exam of abdomen and pelbis shows size, shape and position of kidneys
- Intravenous Pyelogram IVP: shows IV tract after IV injection of contrast media - don’t do if pt has renal failure, need bowel prep, force fluids after procedure, watch urine output carefully after procedure
- retrograde pyelogram: contrast injeted and xray taken of urinary tract. cycstscope is inserted and ureteral catheters are inserted through it into renal pelvis, done in urology office, takes 15-30 minutes
- renal arteriogram (angiogram): visualizes renal blood vessels. catheter inserted into renal arteries, contrast media is injected, post procedure care is like cardiac cath (pressure dressing, watch for bleeding, check for pulses)
- renal ultrasound: no bowel prep is needed, looks at UA tract
- CT/MRI: looks for stones, obstructions
- cystogram: radioactive solution injected into bladder via cystoscop or catheter; visualizes bladder and evaluates vesicouretal reflux, neurogenic bladder, recurrent UTIs
- urethrogram: contrast media is injected into urtehtra to look for strictures, diverticular, may do this before catheterization if trauma is expected
- VCUG voiding cystourethrogram: voiding study of the bladder opening and urethra, bladder is filled with contrast media then films are taken, antoher film is taken during and after urination to look for residual urine
- contrast is bad for failing kidneys
15
Q
cystoscopy
A
- looks at interior of the bladder with lighted scope
- can also be used to insert uretral catheters, remove stones, obtain biopsies, treat bledding lesions
- lithotomy position
- force fluids before procedure
- post procedure expect burning, pink tinged urine, urinary frequency
- call for bright red bledding or temperatue
16
Q
urodynamics
A
- urodynamic stidies measure urinary tract function
- study the storage of urine within the bladder and the flow of urine through the urinary tract to the outside of the body
- combination of techniques may be used to provide a detailed assessment of urinary function
- exps: urine flow study, cystometrogram, sphincter electromyography, voiding pressure flow study, videourodynamics
17
Q
urinary diagnostic scans
A
- renal scan: looks at structure and perfusion of kidneys, IV radioactive isotopes are given, increase fluid post op to rid contrast
- renal biopsy: puncture lower lobe of kidney, dont do it if they have a bleeding disorder, single kidney or uncontrolled HTN, post procedure apply pressure dressing, keep on affected side for 30-60 minutes, bed rest for 24 hours, frequent vital signs, watch for hematuria
18
Q
Normal CBC ranges
A
- Hgb, hemoglobin: gas carrying capacity of RBCs - 11.7-17.3
- Hct, Hematocrit: measure of packed cell volume of RBCs expressed as percentage of total blood volume, 35-50%
- Total RBC count: 3.8-5.7
- WBC count: 4-11, 4000-11000
- platelet count: 150-400, 150000-400000
- Activated Clotting Time, ACT: coagulation status, 70-120 sec
- Activated partial thromboplastdin time, aPTT: coagulation by measuring intrinsic clotting factors, 25-35 secs
- International normalized ratio, INR: prothormbin time compared with controled value, 2-3
- Prothorbin time, PT: extrinsic coagulation factors, 11-16 secs
- thrombin time: adequacy of thrombin, 17-23 secs
19
Q
Urinary Tract Infection
A
- very common, esp in women
- escherichia coli most common pathogen
- upper UTI: renal parenchyma, pelbis, ureters, causes fever/chills/flank pain, pyelonephritis
- lower UTI: usually no systemic manigestations; dysuria, frequency, urgency, hematuria, cloud urine; cystitis, urethritis
- elderly: diffuse abdominal pain. cognitive impairment
- UTI can develop into septic shock and urosepsis
- uncomplicated UTI: occurs in otherwise normal urinary tract, usually involves only the bladder
- complicated UTI: coexists with presence of obstruction, stones, catheters, diabetes/neurologic diseases, pregnancy induced changes, recurrent infection
20
Q
UTI diagnosis
A
- dipstick: looks for nirtrites, WBCs, leukocyte esterase
- urine C&S: specimen by catheter or suprapubic needle aspriation more accurate
- CT urography or US when obstruction suspected
21
Q
UTI treatment
A
- uncomplicated: short course of antibiotics 1-3days
- complicated: longer term- 7-14 days
- TMP/SMX bactrim bid: give morning and evening
- Nitrodurantoin, macrodantin 2-4 x day: avoid sunlight, use sunscreen, wear protective clothing
- ampicillin, amoxicillin, cephalosporins
- pyridium is better than tylenol for pain: turns urine red/orangce
- may take prophylactic abx before intercourse or something that makes you prone to UTIs
- fluoroquinolones: treat complicated UTIs, cipro (acciles tendon rupture)
- antifungals for UTIs due to fungi: amphotericin or fluconazole
22
Q
UTI prevention
A
- empty ladder regularly and completely, q 3-4 hrs
- evacuate bowel regularly
- wipe from front to back
- drink lots of fluids
- daily cranberry juice
- take al abx as ordered
- empty bladder before and after intercourse
- no douches, soaps, powders, sprays, bubble baths
- avoid caffeinie, alcohol, citris juices, chooocalte, spicy foods
- local heat or warm bath, temporarily stop using diaphragm
- Hospital acquired infections: avoid caths if possible, remove caths ASAP, wash hand
23
Q
acute pyelonephritis
A
- inflammation of renal parenchyma (fxn part of kidney that makes urine) and collecting system
- causes: bacterial infection, fungi, protozoa, viruses
- usually starts with lower UTI and a preexisting factor
- most common caused by bacteria
- reoccuring infections can cause scaring, kidney malfunction, chornic pyelopnephritis
- S/S: mild fatigue, chills, fever, vomitin, malaise, flank pain, dysuria, urgency, frequency, CVA tenderness
24
Q
acute pyelonephritis diagnosis
A
- labs:
- pyuria (WBCs and pus in urine), bacteriuria, hematuria, WBC casts, positive urine culture
- Urine culture and sensitivity
- CBC leukocytosis
- radiology
- renal ulrasound
- CT urography
- do NOT do an IVP, contrast can cause infection
25
acute pyelonephritis treatment
- severe with complications --> hospitalization (n/v, dehydration)
- mild --> treat as outpatient, abx 14-21 days, symptoms improve within 2-3 days
- if relapse, another 6 weeks of abx
- fluids, rest, risk of septic shock
26
urosepsis
- systemic infection from urologic source: close observation and vital sign monitoring
- prompt diagnosis and treatment critical: can lead to septic shock and death
- septic shock: outcome of unresolved bacteremia involving gram-negative organism
27
chronic pyelonephritis
- kidneys become small, atrophic, shrunken, and lose fxn due to scarring or fibrosis/scarring
- caused by recurring infections
- diagnosed by imaging, not by symptoms
- often progresses to end stage renal disease esp if both kidneys are involved
28
urethritis
- inflammation of urethra
- most common cause in men is STDs
- gonococal: prulent discharge
- can cause stricture
- hard to diagnose in women
- tx: bactrim, macrodantin, other ABX specific for infection
- important to avoid intercourse until symtoms subside and treat sexual partners from last 60 days
29
urerthral stricture
- usually result of fibrosis or inflammation from trauma, gonococall urethritis, surgery or frequent caths, congenital defects, BPH
- S/S: diminished forec of urine stream, straining to void, spraying streatm, post-void dribbling, split urine stream, incomplete bladder emtpying, frequency nocturia
- risk of acute urinary rentention, an emergency
- diagnosis: retrograde urethrography, VCUG
- tx: dilation, self cath every few days if reoccurance
30
interstitial cystitis
- painful bladder syndrome, chronic, not infection but inflammation
- S/S: bladder pain, urgency, frequency, pain during intercourse
- pain is worsened with bladder filling, post poning urination, physical exertion, pressure against suprapubic area, eating certain foods, stress
- pain temporarily relieved by urination
- diagnosis of exclusion
- UTI can be a complication
31
interstitial cystitis tx
- avoid bladder irritants (coffee, OJ, multivitamins)
- prerelief with OTC meds to alkalinize the urine
- elavil or nortriptuline for burning pain
- no drugs provide immediate relieve so may need opioids
- can give meds directly into the bladder (lidocaine, BCG)
- avoid tight wastebands, tight belts
32
glomerulonephritis
- immune disorder caused by antibody-induced injury or deposition of immune complexes
- S/S: hematuria, prtoeinuria, urinary excretion of RBCs, WBCs, casts, elevated BUN and creatinine, swollen face, blood in urine, decreased urine output, increased BP
- oftentimes have history of drug exposure, infections, immune disorders
- most commonly associated with strep
33
acute poststreptococcal glomerulonephritis
- develops 5-21 days after strept throat infection
- S/S: body edema, HTN, smoky or rust colored urine, proteinuria, oliguria, abdominal/flank pain (no UTI symptoms of burning)
- diagnosis: positive ASO titers, erythrocyte casts
- do renal biopsy
- tx: rest, restricted sodium and fluid intake, dieuretics, HTN meds, may restrict protein, only give abx if strep infection is still present
- 95% recover completely
34
goodpasture syndrome
- rare autoimmune disease seen mostly in young, male smokers
- s/s: flu like symptoms with pulmonary symptoms, hematuria, weakness, pallor, anemia
- diagnosis: serum anti-gbm antibodies, low hgb/hct (due to decreased EPO made in kidneys), elevated BUN and creatinine
- tx: corticosteroids, plasmapheresis, immunosuppressants, dialysis, renal transplant
35
nephrotic syndrome
- glomerulus is excessively permeable to protine causing proteinuria, hyperlipidemia, hypoalbuminemia, weight gain, dereased serium protein
- causes: lupus, DM, infections, lymphoma, tumors, leukemias, bee sting, heroin
- s/s: edema (anasarca, head to toe massive amts of edema), HTN, proteinuria, hyperlipidemia, weight gain, hypoalbuminemia, decreased serum protein
- cx: infection, thromboembolisms, wasting, edema, rickets, altered blood lipids
- tx: symptom control, low sodium diet, low to moderate protein diet, corticosteroids
36
obstructive uropathies
- anatomic or functional condition that blocks urine flow: congenital or acquied
- infection increaesd risk of irreversible damange
- can lead to reflux, hydroureter, hydronephrosis
- tx: relieve blockage
37
urinary tract calculi
- kidney stones
- 1-2mil in US have nephrolithiasis (kidney stones)
- more common in men
- avg age of onset: 20-55
- increased incidence: white, family history, previous history (reoccurs in 50%), summer months (suggests dehydration)
38
nephrolithiasis (kidney stones)
- more common with urinary diversions, long term catheters, neurogenic bladder, urinary retention
- can get infected
- calculus: stone
- lithiasis: stone formation
- calcium stones are the most common type
- keep urine dilute and free flowing
39
types of stones
- calcium oxalate or phosphate: most common, limit oxidate foods but not calcium; dietary oxalate = green veggies, tomatoes, beets, nuts, chocolate, cocoa, tea; give diuretics, reduce sodium intake
- struvite: usually in women, always associated with UTI, give abx, acetohdroxamic acid, remove stone with surgery, acidify urine
- uric acid: usually in men, alkalinize urine, give allopurinol, reduce diety purines (red meats, shellfish, fish)
- cystine: genetic defect, increase hydration, give potassium citrate to alkalinize urine
40
kidney stones
- s/s: severe abdominal/flank pain, hemauria, n/v, mild shock with cool/moist skin, may have UTI symptoms
- diagnosis: UA, urine culture, CT, IVP, retrograge pyelogram, US, cystoscopy
- very import to retrieve and analyze the stone to diagnose the underlying problem that led to stone formation
- labs: calcium, phosphorus, na, k+, HCO3, uric acid, BUN, creatinine, urine PH
- if recurrent stones then get 24 hour urine
41
kidney stone treatment
- treat acute attack and then find out the cuase of the stones to prevent
- acute: opioids, uretral stent for stones > 4mm, forcing fluids can increase pain
- strain all urine to retrieve stones and analyze
- surgery or procedure to remove stones is done when stones are too large to pass, associated with infection, impairing renal fxn, causing persistent pain/nausea/ileus, patient only has one kidney
42
lithotripsy
- insert a scope into the ladder or kidney pelbis and fragment the stone with ultrasond, electrohydraulic, laser or extracorporeal shock wave
- often give anesthesia
- stone is shattered and broken into fine sand that is suctioned or irrigated out
- post procedure, common to have flank pain, bruising, hematuria
- may leave a ureteral stent to prevent obstruction; don't let it get obstructed, never clamp it
43
prevention of future kidney stones
- assess family hx, activity pattern, hx of GI/GU disease or surgery
- after stone has passess, increase fluids to 3000ml/day
- no calcium restrictions in diet, but do restrict sodium
- limit oxalate rich foods - spinach, asparagus, tomatoes, beets, nuts, chocolate, coffee, tea
- increase activity
- prevent dehydration
- self monitor urinary PH
- measure urine output
- move q 2 hours if immobile
44
ureteral stricture
- usually an unintended result of surgical intervention due to scars or adhesions
- s/s: colicky pain increased by consuming large volumes of fluid over short period of time, rare to have infection
- tx: temporary stent by ednoscopy or diversion of urine via nephrostomy tuve in renal pelvis, definitive correction is dilation with balloon or catheter
45
renal trauma
- blunt trauma is most common
| - suspect any abdominal trauma
46
renal vascular problems
- nephrosclerosis: usually caused by HTN and atherosclerosis, treat with antihypertensives
- renal artery stenosis: consider when HTN develops abruptly in pts 50, diagnose with renal arteriogram, tx with renal angioplasty, surgical revascularization
- renal vein thrombosis: can occur with trauma, cancer, pregnancy, BCP use, nephrotic syndrome
- s/s: flank pain, hematuria, fever
47
hereditary renal disease
- polycystic kidney disease
- medullary cystic disease: requires genetic counseling, hereditary, cysts in medulla, kidneys are scarred and cant concentrate urine
- alport syndrome: inherited disease affects glomeruli, can have deafness and eye problems, hematuria, proteinuria, edema, HTN, does not recur after transplant
48
polycystic kidney disease
- msot common life threatening genetic disease
- childhood form progresses rapidly
- s/s: none early, HTN, hematuria, feeling of heaviness in back/side/abdomen, UTI, stones, chornic pain, kidneys may be palpable
- dx: family hx, IVP, US, CT
- tx: genetic counseling, prevent infections, nephrectomy, dialysis, kidney transplant
- cx: ESRD, liver, heart, blood vessel, intestinal problems, cerebral aneurysm (in 40% of pts)
49
renal involvement in metabolic and connective tissue diseases
- manage the primary disorder
- prevent ESRD
- diabetic nephropathy
- gout
- amyloidosis
- SLE
50
kidney cancer
- cigarette smoking is biggest risk factor
- s/s: no early signs, hematuria, flank pain, palpable mass in flank or abdomen, weight loss, fever, HTN, anemia
- dx: CT, US
51
bladder cancer
- more common in men
- risks include cigarette smoking, exposure to dyes, chornic kidney stones, chornic lower UTIs
- s/s: painless hematuria, bladder irritiability with dysuria, frequency, urgency
- dx: urine cytology, CT, US, MRI, cystoscopy with biopsy
- tx: intravesical chemo, TURBT (transurethral resection of bladder tumor)
- very high incidence of recurrence
52
post cystocopy/TURPT to treat bladder cancer
- drink large volumes of fluid, no alcohol
- watch for bright red blood clots
- expect pink urine for a few days
- dark red flecks 7-10 days after from scabs
- give opioids and stool softeners
- take 2-3 sitz baths/day
- need follow up cystocopies every 3-6 months for 3 years then yearly
- may have radiation and chemo
53
intravesical chemo
- installation of chemo into the bladder by catheter
- done weekly, retained for 2 hours
- must empty bladder before instillation and change postion q 15 minutes
- no systemic effects (IE hair loss, n/v, stomatitis) but can cause hemorrhagic cystitis
- increase daily fluid intake, stop smoking, watch for UTIs, must have routine urologic follow ups
54
urinary incontinence
- uncontrolled leakage of urine
- stress incontinence: pressure causes involuntary passage of urine
- urge incontinence: occurs randomly
- overflow incontinence: pressure in full bladder overcomes sphincter
- relfex incontinence: periodic incontenence without pressure or urgency
- dx: history, voiding log, careful exam, UA, post void residual, urodynamic testing
- tx: 80% of incontinence can be fixed, kegal exercises, biofeedback, bladder training, meds
- alpha adrenergic agonists (flomax, hytrin, cardura)
- anticholinergics (detrol, ditropan, vesicare)
- surgery to reposition the urethra or support the bladder
55
urinary incontinence nursing care
- ensure adequate fluid volume
- reduce bladder irritants
- toilet every 2-3 hrs
- quit smoking
- prevent constipation
- kegel exercises
- dont use feminie hygeine pads, use specific invontinence pads
56
urinary retention
- inability to empty bladder despite urination or accumulation of urine
- causes: inability to urinate, leakage, enlarged prostate
- acute urinary retention is a medical emergency (agitation, confusion, bladder distention)
- chronic urinary retention is incomplete bladder emtpying despite urination
- normal to have PVR of 50-75 ml but >100-200ml is a problem
57
urinary retention tx
- scheduled toileting
- double voiding (urinate, sit on toilet for 3-4 mnutes and urinate again)
- alpha adrenergic blockers
- avoid large volumes of alcohol
- drink tea and coffee to create some urgency
- sit in tub of warm water and attempt to urinate
- catheterize
58
catheterization
- most common cause of HAI
- dont cath for: routine specifmens, conveneinve
- dont routinely irrigate catheters
- use coude tip in men
- 14f-16f in women
- 14f-18f in men
59
renal and ureteral surgery
- flank incision
- requires patient to be in hyperextended, side laying position causing muscle pain after surgery
- 12th rib may be removed
- risk of decreased renal perfusion from bleeding, hypovolemia, obstruction
- post op care: watch for urine output every 1-2 hrs (at least 30 ml/hr), monitor BP to ensre good perfusion to kidneys, weight daily, give pain meds, make pts walk to stimulate peristalisis, restrict PO intake til bowel sounds present 24-48 hrs afer
60
urinary diversions
- ileal conduit: ureters frain into part of the ileum that is brought out through an opening in the abdominal wall
- indiana pouch: creation of an intraabdominal urinary resevoir from intestine that is cathed every 4-6 hrs via a one-way valve
- neobladder: small part of the small intestine is made into a resevoir, which is connected to urethra, attempt to train for normal voiding
61
urinary diversions post op
- risk of thrombophlebitis, small bowel obsturction, UTI, paralytic ileus, hemorrhage, hypovolemia
- will be NPO and have NG tube for 24-48 hrs
- mucus in the urine is normal, high fluid intake to flush it out
- watch for alkaline crusts on skin
- stoma size will shrink within 1-3 weeks afer surgery
- may take 6 months to get daytime bladder control with neobladder
- dont over distent neobladder
62
Diabetes Mellitus
- abnormal insulin production, impaired insulin utilization, or both
- leading cause of adult blindness, end stage kidney disease, nontraumatic lower limb amputations
- major contributing factor to HD and stroke
- genetic, autoimmune, environmental (virus, obesity) can cause it
63
normal insulin
- produced by beta cells of the pancreas
- lowers blood glucose and facilitates stable, normal glucose range of approximately 70-120
- released continuously and more with food
- insulin after a meal stimulates storage of glucose as glycogen in liver and muscle, inhibits gluconeogenesis, enhances fat deposition of adipose tissue, and increases protein synthesis
- an anabolic, or storage hormone
- skeletal muscle and adipose tissue have specific receptors for insulin and are considered insulin-dependent tissues
- other hormones work to oppsose the effects of insulin and are referred to as counterreguulatory hormones: glucagon, epinephrine, GH, cortisol
64
Type 1 diabetes
- juvenile-onset, insulin-dependent diabetes
- caused by autoimmune destruction of pancreatic b cells, the site of insulin production
- genetic predisposition and exposure to a virus are factors that may contribue to the pathogenesis of immune-related type 1 diabetes
- related to human leukocyte antigens (HLAs)
- iselt cell autoantibodies responsible for b cell destruction are present for months to years before the onset of symptoms
- history of recent and sudden weight loss and classic symptoms (polydipsia, polyuria, polyphagia)
- requires insulin from an outside source to sustain life
- without insulin, the patient can develop DKA
65
Type 2 Diabetes
- adult onset diabetes, non-insulin dependent
- overweight or obese, being older, having family history of type 2
- pancreas usually continues to produce some endogenous insulin but its either insufficient for the needs of the body or it is poorly used by the tissues, or both
- most powerful risk factor = obesity, esp abdominal or visceral
- insulin resistance: body doesnt respond to insulin becayse receptors are damaged
- pancres responds to high BGL by producing greater amts of insulin
- finally the b cells are fatigued and cannot produce insulin anymore
- liver produces inappropriate glucose
- altered production of hormons and cytokines by adipose tissue = adipokines = cause chornic inflammation (involved in insulin resistance)
- metabolic syndrome: elevated glucose levels, abdominal obesity, elevated BP, high levels of triglycerides, decreased levels of HDL = 3 of 5 is metabolic syndrome, great risk for develping type 2
- gradual onset
66
prediabetes
- increased risk for type 2
- defined as impaired glucose tolerance IGT, impaired fasting glucose IFG, or both
- 2 hour oral glucose tolerance test 140-199
- fasting glucose 100-125
- usually no symptoms, but long term damage t to the body, esp heart and blood vessels may be occuring
- should have A1C tested regularly and monitor for symptoms of diabetes
67
gestational diabetes
- develops during pregnancy
- higher risk of c-section
- babies have increased risk of perinatal death, birth injury, neonatal complications
- high risk for gestational: obese, older, fam history
- normally goes back to normal within 6 weeks post birth
- 35-60% chance of getting type 2
68
other diabetes
- cushing syndrome
- hyperthyroidism
- recurrent pancreatitis
- cystic fibrosis
- hemochromatosis
- parenternal nutrition
- meds can induce it: corticosteroids, thiazides, phenytoin, atypical antipsychotics
69
clinical manifestations of diabetes 1 & 2
* type 1
- rapid onset
- polyuria, polydipsia, polyphagia
- weight loss
- weakness and fatigue
- ketoacidosis
* type 2
- nonspecific sypmtoms
- polyuria, polydipsia, polyphagia
- faigue
- recurrent infections
- recurrent vaginal yeast
- prolonged wound healing
- visual changes
70
diagnostic studies for DM
- A1C 6.5% of higher
- fasting plasma glucose level greater than 126
- two hour plasma glucose level 200
- random plasma glucose greater than 200
- measures amt of glucosated hemoglobin as a percentage of total hemoglobin
- when blood glucose levels are elevated over time the amt of glucose attached to hemoglobin molecules increases
- provides measurement of glucse levels over 2-3 months
71
DM collaborative care
- goals: reduce symptoms, promote well being, prevent acute complications of hyperglycemia,
- nutrition, activity, maintenance of desirable body weight
72
Insulin drug therapy
- insulin is derived from e. coli
- rapid acting: lispro (humalog), peak 30-3hr for meal times
- short acting: regular (humulin R), peak 2-5hr
- intermediate acting: NPH (humulin N), peak 4-12 hr
- long acting: glargine (lantus), no peak
- insulin injection: SQ, can last up to 4 weeks at room temperature
73
problems with insulin therapy
- allergic rxns: itchin, erythema, burning around the site
- lipodystrophy: atrophy of subcutaneous tissue
- hypertrophy: thickening of sq tissue
- smogyi effect: hyperglycemia in the morning, hypoglycemia in the middle of the night. a high dose of insulin before bed, check blood glucose 2-4am
- dawn phenomenon: hyperglcemia that is present on awakening, GH and cortisol excreted in the early morning are responsible for this
74
oral and non-insulin injectable agents
- biguanides: oral metformin, glucophage, fortamet, riomet; reduces glucose production by the liver, enhances insulin sensitivity at tissue level and improves glucose transport into the cells; may cause moderate weight loss; discontinue before surgery
- sulfonylureas: glipizide, glyburide, glimepiride; increase insulin produciton by pancreas
- major side effects are hypoglycemia
75
Dm nutritional therapy
- ADA guidelines: mainatain normal blod glucose, acheive normal lipids and BP, adjust lifestyle
- type 1: day to day consistency in timing and amount of food eaten
- type 2: achieve glucose, BP and lipid goals
- reduction in sat fats and trans fats and low carbs
- weight loss of 5-7% body weight can improve glycemic control
- 15-20% of calories from protein
-
76
DM exercise
- 150 min/wk (30 mins a day, 5 x week) moderate intensity aerobic physical activity
- resistence training 3 x week
- exercise decreases insulin resistence and can have direct effect on lowering blood glucose levels
- exercise effects can be seen up to 48 hours post exercise
- avoid vigorous activity if bgl is over 250
77
self monitoring of blood glucose
- enables deciions regarging diet, exercise, and meds
| - helps identify hyper and hypo glycemia
78
contiuous glucose monitoring
- sq sensor and displays glucose values that are updated every 1-5 minutes
- identified patterns
- alerts when hyperglycemic
79
pancreas transplant
- tx option for people with type 1 dm
- done for pts with end stage kidney disease and have had or plan to get a kidney transplant
- 3 criteria: history of frequent, acute and severe metabolic complications requiring med attention, clinical and emotional problems with the use of exogenous insulin, consistent failure of insulin based management to prevent acute complications
- can eliminate the needs for exogenous insulin, frequent blood glucose measuring, and dietary restrictions
pancreatic islet cell transplant is another experimental option
80
acute interventions for DM
- emotional and physical stress can cause increase in blood glucose and hyperglycemia: surgery, illness, injury
- when ill, check bgl q 4 hrs
- surgery: give IV fluids and insulin before, during and after
- hold metformin before contrast procedures
81
DM patient teaching
- empowerment approach
- blood glucose: monitor blood glucose and record results, take insulin, obtain A1C q 3-6 months, know symptoms of hyper and hypo, carry rapid acting
- exercise: learn how exercise and food affect blood glucose levels
- diet: follow diet, eat regular meals at regular times, low sat/trans fats, limit alcohol
- other: annual eye exam, annual urine testing, good shoes, quit smoking
82
Diabetic Ketoacidosis
- caused by profound deficiency in insulin and is characterized by hyperglycemia, ketosis, acidosis, and dehydration
- most likely type 1
- poor self mamangment, neglect, infection
- when circulating insulin is low, glucose cannot be properly used for energy, body compensates by breaking down fat stores as a secondary source of fuel
- ketones cause metabolic acidosis
- causes hyperglycemia
- if not treated: increased sodium, potassium, chloride, magnesium, phosphate; vomiting causes electrolyte imbalances; hypovolemia, shock, comatose, death
83
DK clinical manifestations
- dehydration, poor skin turgor, dry mucous membranes, tachy, orthostatic hypotension
- lethardy and weakness
- soft and sunken eyes
- anorexia, n/n
- fruity breath
- kusmal respirations
- bgl >250, blood PH less thatn 7.3, biardb less than 16
84
DK collaborative care
- F&E balance with IV therapy
| - check potassium before giving insulin
85
hyperosmolar hyperglycemic syndrome
- able to produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and ECF depletion
- less common thatn DKA, occurs in >60yrs with type 2
- causes: UTIs, pneumonia, sepsis
- bgl >600, increaes in serum osmolality
86
HHS care
- medical emergency with high mortality rate
| - IV admin fluids
87
hypoglycemia
- too much insulin compared to glucose
| - bgl
88
angiopathy
- chronic complications of diabetes are primarily those of end organ disease from damage to blood vessels secondary to chronic hyperglycemia
- macrovascular: disease of large and medium blood vessels; women 4-6 x more at risk for CVD, risks = smoking, obesity, hypertension, high fat intake, sedenaty lifestyle; target BP 130/80; LDL 40
- microvascular: thickening of vessel membranes in capillaries and arterioles in response to condition of chronic hyperglycemia; affect eyes, kidneys, skin
89
diabetic retinopathy
- microvascular disease of the retina as a result of chronic hyperglycemia, neuropathy and HTN
- most common cause of adult blindness
- leaks and hemmhorages
- increased risk of retinal detachman, glaucoma, macular degenration
- treat: annual eye exams,
90
nephropathy
- microvascular cx assocaited with damage to small blood vessels that supple the glomeruli of the kidney
- treat: ace or arbs
91
neuropathy
- nerve damage that occurs because of metabolic derangements associated with diabetes mellitius
- sensory neuropathy: loss of protective sensation, lower limb amputation
- meds for pain: zostrix, elavil, cymbalta, neurontin
- autonomic neuropathy: can affect all body systems; can cause - gastroparesis, ED, orthostatic hypotension, silent MI, diarrhea
92
complications of feet and lower extremities
- foot ulcerations and amputations
- vascular diseases place pts at risk for serious infections
- care: monofilament screening, PAD screening, proper footwear, nai and skin care
93
necrobiosis lipoidica diabeticorum
- red yellow lesions
| - may be a first sign of diabetes
94
infection
- DM much more susceptable to infection
- loss of sensation may delay the detection of infection
- bladder infections, candida albicans
95
DM gerontologic considerations
- increased prevalance and mortality
- renal insufficiency, control is hard
- diet and exercise are main treatment
Med Surge 1
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