Diabetes

• Chronic multi-system disease• Long-term complications• Leading cause of adult blindness, ESRD, and non-traumatic lower limb amputations• Major contributing risk factor for heart disease and stroke• Disorder of glucose metabolism

Diabetes mellitus

• Disorder of carbohydrate metabolism involving insulin deficiency, insulin resistance, or both• Devastating disease that (when uncontrolled) can lead to blindness, end-stage renal disease, impotence, lower limb amputations, cardiac complications, etc.

Type 1 DM

very little or no endogenous insulin• Related to autoimmune attack on pancreatic beta cells (producers of insulin)• Gene therapy appears to be hopeful for the future• Occurs before the age of 30• Previously called insulin-dependent diabetes or juvenile-onset

Type 2 DM

some insulin function, not dependent on insulin for survival• Previously known as non-insulin dependent or adult-onset• Age of onset is usually after 40 (*but more & more people are getting it younger)• Directly related to obesity• Insulin resistance is more common in type 2

Normal Insulin Metabolism

• Insulin produced by beta cells in the Islets of langerhans• Insulin continuously released in small amounts• Bolus in response to food• Lowers blood glucose, promotes glucose transfer into the cells• Counter-regulatory hormones - glucagon, epinephrine, growth hormone, and cortisol) work oppose the effects of insulin

Hyperglycemia: early signs

Early signs of hyperglycemia in diabetes include:• Increased thirst• Headaches• Difficulty concentrating• Blurred vision• Frequent urination• Fatigue (weak, tired feeling)• Weight loss

Hyperglycemia: prolonged

Prolonged hyperglycemia may result in:• Vaginal and skin infections• Slow-healing cuts and sores• Decreased vision• Nerve damage causing painful cold or insensitive feet, loss of hair on the lower extremities, and/or erectile dysfunction• Stomach and intestinal problems such as chronic constipation or diarrhea

Hypoglycemia

• Confusion, abnormal behavior or both, such as the inability to complete routine tasks• Visual disturbances, such as double vision and blurred vision• Seizures, though uncommon• Loss of consciousness, though uncommon• Heart palpitations• Tremor• Anxiety• Sweating• Hunger

Drug therapy: insulin

• Insulin differs in inset, peak action and duration• Long-acting, short-acting, intermediate-acting, rapid-acting• Properties of insulin are matched with diet, activity, patterns of blood glucose levels and lifestyle

Insulin: storage

• Insulin vials in current use may be left at room temperature for up to 4weeks• Avoid prolonged exposure to direct sunlight• Extra insulin store in refrigerator• Prefilled syringes stable up to 30 day sin fridge, store cloudy needle pointed up

Insulin: administration

• Injection• Fastest absorption - abdomen, arm, thigh and buttock• Abdomen is preferred site• Caution with exercise• Rotate injection within one particular site• 45-90 degree angle• Insulin pen

Insulin

• U100 insulin is the most common concentration• NPH is the only cloudy insulin: roll vial gently between palms to mix• Draw up clear (regular, lispro-short acting) before cloudy (intermediate) insul into prevent contamination of short-acting insulin with long-acting insulin• Inject subcutaneously; aspiration is not necessary, do not massage• Rotate sites; abdomen is preferred for more rapid, even absorption

Rapid acting analogs

Lispro (Humalog)Aspart (Novolog)Glulisine (Apidra)Onset:<15 minutesPeak:30-90 minutes

Short acting insulin

Regular (Humulin R, Novolin R)Onset:0.5-1 hourPeak:2-4 hours

Intermediate acting insulin

NPH (Humulin N, Novolin N)Onset:1-2 hoursPeak:4-10 hours

Long Acting Analogs

Glargine (Lantus, Detemir (levemir)Onset:1-2 hoursPeak:Glargine - no peakDetemir - relatively flat

Insulin Regimens

• Basal-bolus regimen closely resembles our own/ uses rapid and short acting before meals, and long acting once a day• Meal-time bolus - inject 0 to 15 minutes before meal(rapid), 30 to 45 minutes(short)• Long Acting Background Insulin (basal) - control blood glucose levels between meals and overnight (24 hours)• Insulin Pumps - provide better glycemic control but require carb counting and more frequent blood glucose monitoring

Drug therapy - oral agents

• Work to improve the mechanisms by which insulin and glucose are produced and used by the body:• Decreased insulin production• Insulin resistance• Increased hepatic glucose production• Most Common side effect/concern is risk of hypoglycemia• Remember treatment must also include non-pharmacologic interventions• Biguanides• Sulfonylureas• Meglitinides• Thiazolidineiones• Alpha-glucosidase inhibitors• Dipeptidyl Peptidase - 4 Inhibitors• SGLT-2 Inhibitors• Amylin Analog• Incretin Mimetic

Biguanides: Metformin (Glucophage)

Indications:• Monotherapy or combined with insulin or sulfonylureas for type 2 DMContraindications:• Renal insufficiency or uncontrolled heart failureAdverse Effects:• Lactic acidosis (serious but rare); diarrhea, nausea/vomiting, muscle weakness; vitamin B12 deficiency with chronic therapy• Use of diagnostic contrast dyes may increase the risk for lactic acidosis

Sulfonylureas [Glyburide (Diabeta, Micronase), Glipizide (Glucatrol)]

Indications:• Mild-to-moderate type 2 DM• When diet & exercise are not enough to maintain glucose controlContraindications:• Diabetic keto acidosis• Type 1 DMPrecautions:• Adrenal or pituitary insufficiency• Severe hepatic or renal impairmentAdverse effects:• hypoglycemia

Sylfonylureas: nursing implications

• Instruct client to take drug 15 to 30 minutes before meals, do not take medication and then skip meal• Monitor blood glucose levels daily• Teach client to maintain weight and dietary restrictions along with medication• Call for signs of hypoglycemia (fatigue; hunger; cool, moist skin; increased anxiety; dizziness; palpitations)

Menglitinides [Nateglinide (Starlix) and repaglinide (Prandin)]

Indications:• Type 2 DM, monotherapy or in combination with metformin or a glitazoneAdverse Effects:• Nateglinide: hypoglycemia, dizziness, joint pain, URI infections• Repaglinide: hypoglycemia, headache, respiratory infections, altered liver function; cardiac effects, including hypotension, chest pain, cardiac dysrhythmias

Thiazolidinediones (Glitazones) [Rosiglitazone (Avandia) and pioglitazone (Actos)]

Indications:• Monotherapy for type 2 DM, or in combination with sulfonylureas, metformin, and/or insulinAdverse Effects:• Hepatotoxicity, headache, myalgia, URI infections, anemia

Alpha-glucosidase inhibitors: Acarbose (Precose)

Indications:• Type 2 DM, not controlled by diet or exercise• In conjunction with insulin or a sulfonylureaAdverse Effects:• Flatulence, cramps, abdominal distention• Borborygmus, diarrhea• Liver dysfunction• Decreased absorption of ironAssessment:• Contraindicated/cautious use in hepatic & renal problems; type 1DM; hyperosmolar hyperglycemic nonketotic states; diabetic ketoacidosis, severe infections, major surgery, trauma, coma, intestinal problemsImplementation:• Monitor liver function every 3 months, CBC, and HbA1c• May cause hypoglycemia when combined with insulin and sulfonylurea• Teach client to take at the beginning of each meal

DPP-4 inhibitors (Gliptins)

• ADA - 2nd line therapy as an add-on to metformin• Rare side effects - pancreatitis, hypersensitivity reactions• Generally well tolerated• Most common side effects - headache• Low incidence of hypoglycemia when used alone

SGLT-2 inhibitors

• Canagliflozin and Dapagliflozin• Blocks the reabsorption of glucose via the kidney• Most common side effects - vaginal fungal infections/UTI, increased urination (increases glucose present in the urine)

Non-insulin injectable agents GLP-1 receptor agonist: Exenatide (Byetta)

Indications:• Type 2 DM not adequately controlled with oral therapy; not indicated for type 1 DMAdverse effects:• Hypoglycemia• Nausea, vomiting, hypersensitivity, headache• Concurrent insulin or sulfonylurea therapy may lead to increased risk for hypoglycemia

Hormones

Hormones work by negative feedback• Produces physiological effect that, when strong enough, inhibits secretion of that hormoneHormones are used in clinical practice in 3 ways• Replacement therapy• Pharmacologic effects beyond replacement• Endocrine diagnostic testing

Hormones control...

• Reproduction• Response to stress/ injury• Electrolyte balance• Energy metabolism• Growth• Maturity• Aging• Regulatory affect on nervous system• Influence behavior

Hypothyroidism

Results from insufficient circulating thyroid hormone• Can be primary or secondary• May also be transient• Iodine deficiency most common cause• Atrophy of the thyroid gland in US (end result of Hashimoto's and Grave's)• Drugs such as Lithium and amiodarone• Cretinism - hypothyroidism in infancy

Hypothyroidism clinical manifestations

Onset of symptoms may occur over months or years• fatigue• Lethargy• Personality and mental changes• Appear depressed• Decreased GI motility• Decreased CO and contractility• Low exercise tolerance• SOB on exertion• Anemia• Increased cholesterol and triglyceride levels• Cold intolerance, hair loss, dry coarse skin, brittle nails• Weight gain

Hypothyroidism collaborative care

• Levothyroxine - drug of choice adjusted according to response and laboratory findings, dose increased q 4-6 weeks without side effects• Chest pain experienced by a patient starting thyroid replacement therapy should be reported immediately and ECG, serum cardiac enzyme tests performed• Older adult - start low• Low calorie diet

Levothyroxine (Synthroid)

Indications:• Replacement therapy in hypothyroidism• Thyroid cancer• Thyroid suppression testAdverse effects:• Hyperthyroid symptoms(irritability, insomnia, hyperthermia)• Weight loss• Palpitations• Tachycardia, increased blood pressure, diaphoresisAssessment:• Contraindicated/cautious use in thyrotoxicosis and myocardial infarction without hypothyroidism, treatment of obesity, hypersensitivity, older adults clients, clients with impaired cardiac function, hypertension

Levothyroxine (Synthroid) Implementation

Monitoring:• Increased pulse rate & rhythm• TSH levels periodicallyIntervention:• Report abnormal vital signs and pulse of >100Education:• Replacement is lifelong, do not discontinue• Takes about 1 month for full effect• Take in the morning, preferably 30 minutes before eating

Hyperthyroidism

• Effect of thyroid hormone excess• Palpation may reveal goiter, auscultation may reveal bruits• Opthalmopathy - abnormal appearance or function• Exophthalmos - protrusion of the eyeball

Hyperthyroidism collaborative care

Drug therapy:• Anti-thyroid drugs (PTU and Tapizole)• Iodine• Beta adrenergic blockersOther therapy:• Radioactive Iodine Therapy - treatment of choice, damages thyroid tissue, delayed response 2 to 3 months, high incidence of post treatment hypothyroidism• Surgical Therapy - thyroidectomy for unresponsiveness, large goiters, malignancy

Thioamide derivative: Propylthiouracil

Indications:• Treatment of hyperthyroidism, before surgery or radiotherapy, or as adjunct therapy for treatment of thyrotoxicosis or thyroid stormAdverse effects:• Loss of taste, nausea, vomiting, dizziness, skin rash, fever• Signs of infection secondary to leukopenia or agranulocytosis

Thioamide derivative: methimazole (Tapazole)

Indications:• Treatment of hyperthyroidism before surgery or radiationSide effects:• Similar to propylthiouracilAssessment:• Contraindicated/cautious use in pregnancy & lactation; clients over age 40; impaired liver function; in combination with agranulocytosis-inducing drugs• Baseline VS, weight

Methimazole (Tapazole) implementation

Monitoring:• Changes in pulse rate• CBC for agranulocytosis (leukopenia)Interventions:• Weight gain and decreased heart rate are indications of development of hypothyroidism• Report illness (first sign of leukopenia), unusual bleeding or bruising (adverse effects on liver)Education:• Avoid seafood and iodine products• Schedule doses evenly throughout the day

Iodine products: Potassium iodide (Thyro-block), strong iodine solution (Lugoliodine solution), sodium iodide (Iodotope)

Indications:• Protect thyroid from radiation prior to & after administration of radioactive isotopes of iodine or in radiation emergencies• With antithyroid drug in hyperthyroidism in preparation for thyroidectomy• Treatment of hyperthyroidism and thyroid cancer (sodium iodide)Adverse effects (potassium iodide and strong iodine solution):• Diarrhea, nausea, vomiting, stomach pain• Rash, swelling of salivary gland• Severe headaches, sore gums or teeth, increased salivation, burning sensation in mouth or throat, metallic taste in mouth• Pregnancy category D• Sodium iodide: sore throat, temporary loss of taste, nausea, vomiting, painful, swollen salivary glands; pregnancy categoryX

Human growth hormone: somatropin

Indications:• Treatment of growth failure in children as a result of a deficiency in pituitary GH• Treatment of short stature in children who are 2.5 standard deviations below the mean• Sometimes abused by athletesAdverse effects:• Pain & edema at site of injection• Allergic type reaction (rare)• Gigantism• Long term risks include pituitary function inhibition; adrenal insufficiency& hypoglycemia

Human Growth Hormone Agonists Implementations + Assessment

Assessment:• Family history, growth patterns & previous health status• Physical exam & psychological evaluation• Radiologic surveys and endocrine studies• Contraindicated in persons with closed epiphyses, malignancy, untreated hypothyroidism• Review meds for adrenocorticoids, glucocorticoids, corticotropinMonitoring:• Bone age determination, thyroid function studies, blood glucose determinations, anti-GH antibodies• Noncompliance, antibody formation, hypothyroidism, malnutrition within adequate responseIntervention:• Injection pen allows incremental dosing• Optimal dosing is often achieved when administered at bedtime• Radiologic evidence of epiphyseal closing is a criterion for ending treatmentEducation:• Self-administration techniques• Follow up visits & labs

Growth hormone antagonist: Octreotid (Sandostatin)

Indication:• Lowers blood levels of GH and IGF-1• Symptoms associated with carcinoid tumors, such as flushing or severe diarrhea• Diarrhea associated with AIDS (off-label)• Control bleeding of esophageal varicesAdverse Effects:• Pain, swelling, pruritis at the injection site• Sinus bradycardia; diarrhea & stomach distress• Headache, dysrhythmias, & cold-like symptoms• Hyperglycemia, hypoglycemia, and hypothyroidismAssessment:• Contraindicated with gallbladder disease or gallstones• Cautious use with diabetes mellitus• Baseline gallbladder US, thyroid function studies, blood glucose, and serum GH levels• Review of medications for oral antidiabetic agents, insulin, glucagon, or GH

Ocreotide (Sandostatin) Implementation

Monitoring:• GH levels, blood glucose, gallbladder US, urine 5-HIAA• Observe for hypo- or hyperglycemiaInterventions:• Initiate treatment with injections 2-3 times per day for at least 2 weeks, then switch to monthly injections with injectable suspension• Administered subcutaneously, slowly, & at room temperature; rotate injection sites• Administer between meals and at bedtime to minimize GI symptomsEducation:• Proper injection technique, including site selection & rotation• Report signs of irritation at site and symptoms of hyper/hypoglycemia or cholelithasis

Adrenal glands

Small, paired, highly vascular glands located on upper portion of each kidney

Adrenal medulla

secretes catecholamine epinephrine, norepinephrine, and dopamine considered hormones when secreted- released into the bloodstream and transported to target organs

Adrenal cortex

steroid hormones classified as glucocorticoids, mineralocorticoids, and androgens

Cortisol

• Most abundant and potent glucocorticoid• Necessary to maintain life• Regulates blood glucose concentration• Anti-inflammatory action and supportive actions in response to stress• Helps maintain vascular integrity and fluid volumeincreased during surgical stress

Aldosterone

• Potent mineralocorticoid• Maintains extracellular fluid volume• Promotes renal reabsorption of sodium and excretion of potassium

Addison's disease

• Adrenocorticol insufficiency• Adrenal corticosteroids are reduced• Most common cause is an autoimmune response• Infarction, fungal infection,AIDS, metastatic cancer other causes• Management of underlying cause• Replacement therapy• Hydrocortisone most commonly used form of replacement therapy

Corticosteroids

Indications:• Addison's disease, hormone replacement, cancer therapy• Decrease inflammation(SLE, RA, IBD, allergic conditions, asthma, COPD,RDS in infants• Suppression of graft rejectionSide effects:• Peptic ulcers, GI bleeding, edema• Osteoporosis, hyperglycemia, delayed wound healing• Muscle wasting, fluid & electrolyte disturbance,Cushing's syndromeAssessment:• Contraindicated in systemic fungal infections, when receiving live virus vaccines• Cautious use in pediatric clients, pregnancy, and lactation; hypertension, heart failure, and renal impairment; infections resistant to treatment• Assess for underlying infection and decreased wound healing

Corticosteroids implementation

Monitoring:• Fluid balance and potassium & glucose levels• Monitor for Cushing symptoms• Stools for occult bloodIntervention:• Daily doses need to increase during stressEducation:• Take as prescribed and don't discontinue suddenly

Estrogen

• Follicular hormone• Produced by developing ovarian follicle• Examples include estradiol, estrone, esterified estrogen

Progesterone

• Luteal hormone• Derived from corpus luteum

Estrogen

Functions: • DNA, RNA, protein synthesis in estrogen-responsive tissue• Inhibits LH, FSH secretion from pituitaryIndications:• Estrogen deficiency• Some metastatic breast carcinomas (postmenopausal)• Some metastatic breast carcinomas & advanced prostatic carcinomasRisks/Benefits:• Heart disease• Life expectancy• Slow natural bone loss occurring with aging• skin aging & UTIs• Mixed findings r/t breast cancerPrecautions:• Risk of endometrial cancer with prolonged estrogen use• Estrogen esp. DES during pregnancy identified Category X• Not recommended during breastfeeding

Progesterone

Functions:• Prepares endometrium for implantation & nourishment• Supplement action of estrogen on uterus & breast• Suppress ovulation during pregnancy• Relaxation of uterine smooth muscles• Increased synthesis of DNA & RNA• Inhibits secretion of LHIndications:• Amenorrhea• Dysmenorrhea• Endometriosis• Specific carcinomas

Hormonal contraceptives

• Effective form of birth control• Inhibits ovulation by estrogen & progestin levels inhibiting secretion of FSH & LH

Newer low-dose oral contraceptives have:

• Lower risk for adverse cardiovascular effects• Increased risk for MI in smokers & > 35 years old• Lower risk of CVA or thrombus than older OCPs• Decreased rate of ectopic pregnancies• Decreased risk for ovarian cyst, ovarian cancer• Increased risk cervical, liver & possible breast cancer

Monophasic

• Fixed ratio of estrogen & progestin taken for 21 days

Biphasic

Fixed amount of estrogen & 2 levels of progestin for 21 days• Low level at follicular phase (day 7 thru 10)• Increased level at luteal phase (day 11 thru 14)

Triphasic

• More closely mimics body's own E & P cycling for 28 days• 3 progressively levels of progestin

Low-dose progesterones or Mini-Pill

• Used when estrogen not tolerated• Less effective than combination OCPs• Higher incidence of BTB

Long-acting progestin only contraceptives

• Includes implants, intrauterine, or injection• Norplant ...inserted upper arm for 5 yrs• Progestasert ...used only stable relationship, no PID, for 1yr• Depo-Provera ...injection Q3mo

Hormonal contraceptives side effects/adverse reactions

Estrogen excess:• Nausea, dizziness, abdominal bloating ,leg pain, chloasma, hypertension, breast tenderness, breast sizeEstrogen deficit:• Anxiety, hot flashes, mid-cycle spotting, menstrual flow, libidoProgestin excess:• Alopecia, oily skin, acne, fatigue, appetite, weight, breast tenderness, breast sizeProgestin deficit:• Dysmenorrhea, heavy menstrual flow, weight loss, delayed mensesAndrogen excess:• Hirsutism, oily skin, acne, pruritus, appetite, weight gain

Oral contraceptives

• May take immediately after birth if not breastfeeding• Encourage annual pelvic exam and pap test• If 1 pill missed: take with next scheduled dose• If 2 pills missed: take 2 per day for 2days• If 3 pills missed: initiate a new cycle & use another form of birth control• Take at same time each day

Oral contraceptives: nursing implications

• Not effective at preventing STDs...condom use encouraged• Annual physical exam including BP, pelvic exam, labs• Avoid cigarettes due to risk of blood clots• Caution with certain medications reducing effectiveness• Use alternative method of birth control if dose missed• To avoid nausea, take with food, meals, or bedtime• Take at same time daily to maintain effective level• Use sunscreen or protective clothing to avoid photosensitivityReport any of the following:• Unusual vaginal bleeding, calf tenderness or swelling, chest pain,• Extremity numbness or weakness, vision or speech changes

Hormone replacement therapy - nursing implications

• HRT has numerous benefits• Annual physical exam including B/P, pelvic exam, labs• Women without hysterectomy should use both E & P• May increase blood glucose levels with diabetes• Take with food, meals or bedtime to avoid nausea• If using patch, abdomen preferred site• Report any unusual vaginal bleeding

Depot medroxyprogesterone acetate (DMPA)

• Dysfunctional uterine bleeding, secondary amenorrhea and contraception• IM palliation of metastatic uterine or renal carcinoma• Give with meals• Common side effects include break through blessing, breast tenderness, weight gain, depression, HTN, n/v, dysmenorrhea and vaginal candidiasis, increased risk for thrombo-emboli• Contraindicated in pregnancy and breast cancer

Fertility drugs

Anovulation is the absence of ovulation resulting in infertility2 drugs to stimulate ovulation:Clomiphene (Clomid)Menotropins (Menopur) AKA hMG

Clomiphene (Clomid)

• Increased secretion of FSH & LH• 50 mg QD for 5 days starting on 5th day of menstruation

Menotropins (hMG) Menopur

• Equal amounts of LH and FSH activity• HCG administered following it

Fertility drugs nursing implications

Assessment:• Contraindicated with abnormal vaginal bleeding, endometriosis, fibroid tumors, ovarian cystMonitor:• Basal temperature, LH levels, HCG levelsIntervention:• Re-evaluate in 3-6 mo. As neededEducation:• Possibly of multiple births• Report any abdominal pain ie possible ovarian cyst

Drugs affecting the uterus

Tocolytics:• Agents decreasing uterine contractility• Includes:• Ritodrine• TerbutalineOxytocics:• Stimulate contraction of smooth uterine muscle• Results in contractions & spontaneous labor• Includes:• Oxytocin• Ergonovine

Tocolytics

• Indicated for suppression of preterm (<37 weeks) labor Contraindications & precautions: Maternal: severe PIH, vaginal bleeding, intrauterine infection, cardiac disease, dilation >6cm Fetal: acute fetal distress or fetal death

Tocolytic adverse effects

Terbutaline (beta adrenergic agonist)• Pulmonary edema, tachycardia, chest pain, hypotension, hyperglycemia• Fetal effects: tachycardia, hypotension, ileus• Nifedipine (calcium channel blocker): tachycardia, hypotension, hepatotoxicityNitroglycerin - hypotension, headache, dizziness, flushingIndomethacin (cyclooxygenase inhibitor)• Nausea, GI irritation, prolonged postpartum bleeding• Fetal effects: renal failure, bronchopulmonary dysplasia, necrotizing enterocolitis Magnesium sulfate (less frequently used now)• Pulmonary edema, hypotension, muscle weakness, cardiac arrest• Fetal effects: hypotonia, sleepiness

Tocolytic nursing implications

• Continuous monitoring of maternal VS & FHR• Before administration of magnesium sulfate, determine if respiratory rate is >12/min; urine output is >30 ml/hr; and DTRs are 2+• Have calcium gluconate available for emergency administration for respiratory complications• Instruct client to lie on left side to promote placental perfusion• Measure daily weight and I&O• Oral and IV intake over 24 hours may be restricted to 1500 to 2400 ml to decrease risk of tocolytic induced pulmonary edema

Oxytocics: drugs affecting uterus

• Oxytocin naturally secreted by posterior pituitary, Pitocin, Ergonovine (Ergotrate), methylergonovine (Methergine)• Uterine sensitivity increases during pregnancy• Acts directly on uterine muscle particularly the fundus• Significantly shortens labor• Used for postpartum bleeding & lactation stimulation• Rapid onset with short half life• IV 0.5 to 2 mU/min q15-60 min by 1-2 mU• Side effects: GI upset, HR, irregular HR, fetal HR

Oxytocin

Contracts uterine and mammary smooth muscle, increases force, frequency, &duration of uterine contractions• Implications:• Managing incomplete or inevitable abortion• Controlling postpartum hemorrhage• Inducing labor• Facilitating uterine contractions during3rd stage

Cervical ripening - prostaglandins

Dinoprostone (gel, inserts) also used to induce abortion• Misoprostol (cytotec) - not approved for cervical ripening but more effective, more convenient, less expensive• Must monitor fetal heart rate and uterine activity must be monitored continuously

Oxytocin

Contraindications:• Cephalopelvic disproportion, previous uterine surgery• Unengaged fetal head, unfavorable fetal position or presentation• Fetal distress without imminent delivery• Placenta previa and prolapsed cord• Women with active genital herpesPrecautions:• Used with great caution in women of high parity (5 or more)Side effects:• Tachycardia, PVCs, hypotension• Nausea, vomiting, water intoxication

Oxytocin nursing implications

• Assess baseline VS & FHR• Constant monitoring of frequency, duration, and strength of contractions• Stop infusion and notify physician if contractions last longer than 1 minute, if occurring more frequently than every 2-3 minutes, or if alteration in fetal heart rate occurs• Maintain I&O; evaluate for excessive water retention• Do not confuse with vasopressin (Pitressin) which is an antidiuretic hormone

Androgen therapy - testosterone

• Hypogonadism - lack of sufficient testosterone• Can lead to ED, decreased libido• Other signs include fatigue, depression, and reduced muscle mass, may delay puberty• Available in various forms (IM, pellets, patches)• Androgens promote synthesis of erythropoietin, increases skeletal muscle mass

Testosterone nursing considerations

• Periodic serum cholesterol, electrolyte and liver functions studies• Check weight twice per week• Report prolonged or painful erection

erectile dysfunction (ED)

• Impotence• Consistent inability to obtain an erection or sustain an erection• Increases with age• Atherosclerosis, diabetes, stroke and HTN• Psychogenic causes• Drug therapy - diuretics, anti-depresssants, Indera

Erectile dysfunction drugs

Phosphodiesterase inhibitors• Sildenafil (Viagra)• Tadalafil (Cialis)• Vardenafil (Levitra)• Avanafil (Stendra) Prostaglandin E1• Alprostadil (Caverject, Edex, Muse)

ED drugs

• Increases arterial pressure, reduces venous outflow in the penis, thereby causing engorgement to produce or enhance an erection. It only enhances the normal erectile response to sexual stimuli. In the absence of sexual stimuli, no erection occurs• Used for organic, psychogenic, and mixed causes of erectile dysfunctionCautions and precautions:• Do not take within 24 hours of a nitrate medication• Clients taking alpha-blocker medications• Dose may be reduced when clients are taking verapamil or diltiazemAdverse effects:• Dyspepsia, headache, nasal congestion• Vardenafil (Levitra) may cause prolonged QT interval; careful use with other meds that prolong QT interval• Severe hypotension when used within 24 hours of nitrate• Erection lasting longer than 4-6 hours (priapism)

ED drug nursing implications

• Instruct clients on cardiac medications to consult with the healthcare provider about the safe use of ED drugs• Ask all clients who are complaining of chest pain if they have taken an ED drug within the past 48 hours• ED drugs should not be taken by men who are NOT healthy enough for normal sexual activity• Instruct client to report erections lasting longer than 4 hours to a health care provider• Tadalafil (Cialis) has a 36 hour duration; other ED drugs have a 4-hour duration

benign prostatic hyperplasia (BPH)

• Enlargement of the prostate gland• Decreases urine outflow causes difficult urination• Urinary frequency, increased urgency, post void leakage, decreased force of stream

Deugs for BPH

Alpha Adrenergic Antagonists (selective)• Tamsulosin (Flomax)Non-selective Alpha Blockers (more widespread effectsincluding b/p)• Alfuzosin (Uroxatral)• Doxazosin (Cardura)• Terazosin (Hytrin)5-alpha reductase inhibitors• Finasteride (Proscar, Propecia)• Dutasteride (Avodart)

Finasteride (Proscar)

• Promotes shrinkage of the prostate gland which helps restore urinary function• Also marketed as Propecia (hair growth)• Pregnancy Category X - avoid touching drug if pregnant (can be absorbed and harm male fetus)• Side effects include sexual dysfunction• Avoid use of anti-cholinergics in conjunction

Anthelminths

most primitive types of chemotherapyBenzimidazoles Includes mebendazole (Vermox), albendazole(Albenza), thiabendazole (Mintezol) Mebendazole and albendazole are vermicidal and may also be ovicidal for most helminthsMechanism of action of thiabendazole isunknown Used for pinworms, hookworm, or whipworm Preventative measures should be taught (ie handwashing, sanitary disposal of feces, walking barefoot in soil, etc.

Amebicidals

Metronidazole (flagyl) Antibacterial, antiprotozoal, and anthelmintic Used for both intestinal and extraintestinal amebiasis Combined with luminal amebicide (iodoquinol or paromomycin) for invasive amebiasisChloroquine (Aralen) Used for amebic liver abscess, usually in combination with other drugs

Antimalarial - Aralen (Chloroquine)

Treats RA, lupus and malaria Anti-inflammatory effects Side effects include GI upset, hair loss, mood/ mental changes Ocular effects such as blurred vision, photophobia, black -outs; long term therapy can result in permanent retinal changes Administer with milk, avoid antacids Check liver function in conjunction with hepatotoxic drugs ,avoid ETOH use with therapy May increase digoxin levels

Melanin

pigmentation and protection from UV rays

Exocrine glands

Sebaceous glands: produce sebum, protection &lubrication Eccrine glands: "sweat glands" promote cooling through evaporation, prevent dryness Apocrine glands: odoriferous, scent or sex glands

vitiligo

white areas of de-pigmented skin

pruritus

itching

erythema

redness of the skin

scabies

skin parasite

seborrhea

overproduction of sebum

comedones

blackheads

rosacea

small papules that swell with pus and are painful on nose/cheek area

dermatitis

inflammation of the skin

eczema

chronic dermatitis

psoriasis

red, raised patches with flaky thick silver scales called plaques found on scalp, elbows, knees

Antibacterials

Bacitracin (Baciguent) Topically applied to local lesions that are at risk for infection or are infected Well tolerated; odorless, colorless, non-staining; can cause allergic contact dermatitisNeomycin (Myciguent) Used for superficial infections of the skin & mucous membranes Occasionally irritates skin, can cause allergic contact dermatitis; sensitization can occur, prolonged use may produce a superinfectionMupirocin (Bactroban) Primarily used for impetigo caused by staph aureus and other beta-hemolytic streptococci; also used intranasally for nasal colonization ofMRSA

Antiviral agents

Acyclovir (Zovirax Ointment) Used for initial episodes of herpes genitalis and herpes simplex inimmunocompromised clients May cause local pain, pruritus, or stingingDocosanol (Abreva) Used to treat cold sores of face & lips Well toleratedPenciclovir (Denavir) Used for herpes simplex labialis (cold sores) Well tolerated, may cause mild erythema

Antifungal agents

Butenafine (Lotrimin Ultra) Used for various tinea infection including tinea corporis (ringworm), tinea cruris(jock itch), tinea pedis (athlete's foot), and tinea versicolor Well tolerated; may cause burning, itching, and stingingClotrimazole (Lotrimin AF) Used for superficial fungal infections Infrequently causes local irritationTerbinafine (Lamisil AT) As for butenafine Occasional dermal ractions

Topical ectoparasiticidal drugs

Permethrin (Nix, Elimite) Scabies in adults & children older than 2 months Adverse effects include pruritus, mild burning on application, transient erythema,edema, & rashLindane (Kwell) Scabies & lice infestations in adults and children over 1 month Adverse effects include the potential for producing CNS toxicity (seizures, irritability,dizziness)Crotamiton (Eurax) Scabies in adults Adverse effects include allergic dermatitis, rash, & pruritisMalathion (Ovide) Pediculosis in adults & children over age 2 Adverse effects include bronchospasm (rare), skin irritation

Isotretinoin (Accutane)

Systemically administered for severe acne, particularly cystic acneAdverse effects: Teratogenic Tachycardia, flushing, edema Dizziness, seizures, depression, psychosis, agitation Rash, elevated triglycerides, hyperglycemia, bone marrow suppression, osteopenia, bronchospasm Low dose progesterone only hormonal contraceptives may not be adequate birth control

Topical antibacterial acne treatments

Clindamycin (Cleocin T) Moderate to severe acne vulgaris Adverse effects include dry, scaly and/or peeling skin, burning or stinging, hypersensitivityErythromycin topical solution (A/T/S, EryDerm) Acne vulgaris Adverse effects include skin reactions such as erythema, desquamation, tenderness, dryness, pruritus, burning, oiliness, and acneMetronidazole (MetroCream, MetroGel, MetroLotion) Inflammatory acne rosacea (NOT acne vulgaris) Adverse effects include local irritation, burning & dryness; systemic effects include headache, altered taste & nausea

Other topical acne treatments

Azelaic acid (Azelex, Finacea) Mild to moderate acne vulgaris and acne rosacea Adverse effects include topical burning & irritationAdapalene (Differin) Acne vulgaris Adverse effects include erythema, scaling, dryness, pruritis, and burningBenzoyl peroxide (Benzac, Brevoxyl, Desquam-X) Acne vulgaris (available OTC) Adverse effects (uncommon) include dry, peeling skin, redness, sensation of warmth, pruritis, blisters, burning or swellingTazarotene (Avage, Tazorac) Facial acne vulgaris & stable plaque psoriasis; facial wrinkles Most serious adverse effect is teratogenicity; also associated with erythema, scaling, dryness, pruritus, and burningTretinoin topical (retinoic acid, vitamin A, Retin-A) Acne vulgaris with predominant comedones, pustules, & papules; emolient cream is used to treat wrinkles caused by age or sun exposure Most common adverse effects include red & edematous blisters; crusted, stinging, or peeling skin; temporary alterations in pigmentation; Pregnancy Category C

Corticosteroids

For relief of inflammation and pruritic dermatoses, including atopic dermatitis Includes betamethasone, fluticasone, triamcinolone, hydrocortisone, etc.) Adverse effects include acne iform eruptions, allergic contact dermatitis, burning sensation, dryness, itching, hypopigmentation, purpura, hirsutism, folliculitis, a round &swollen face, alopecia, immunosuppression, and overgrowth of bacteria, fungi, & viruses

Non-corticosteroids

Pimecrolimus (Elidel) Used for short to intermediate treatment of atopic dermatitis; typically reserved for clients unresponsive to other modalities Adverse effects include headache, fever, burning at application site; exacerbation of warts, herpes simplex, or dermal infections

Pimecromlimus (Elidel) nursing implications

Minimize exposure of treated area to sunlight (natural or artificial) Stop application once signs of dermatitis have disappeared Wash hands after applying

Other agents

Keratolytics Soften scales & loosen outer horny layer of the skin Salicylic acid and resorcinolRetinoids Vitamin-A related compounds that affect cell turnover rates Significant adverse effects & contraindicated in pregnancy Acitretin (Soriatane) is the most common agent used to treat psoriasis

Mitotics

Interfering with cholinesterase activity Acting like acetylcholine at receptor sites in the sphincter muscle

Mydriatics

Interfering with the action of acetylcholine Stimulating sympathetic or adrenergic receptors

Opthalmic drugs

Antiinfectives/antiinflammatory Erythromycin opthalmic ointment Sulfacetamide Triple antibiotic ophthalmic ointment (neomycin, polymyxin B, & bacitracin) Chloramphenicol Gentamicin Tobramycin AntiglaucomaMydriatics & cycloplegics

Glaucoma

Not one disease but a group of disorders characterized by: Increased intraocular pressure and the consequences of elevated pressure Optic nerve atrophy Peripheral visual field loss

Intraocular pressure

Regulated by the formation and reabsorption of aqueous humor Glaucoma is directly related to the balance or imbalance of this fluid Glaucoma is the 2nd leading cause of blindness in the US ( leading cause among African Americans) Incidence increases with age

Prostaglandin Agonist: Latanoprost (Xalatan)

Indications: Reduction of IOP in glaucomaPharmacokinetics: Peaks in 12 hoursAdverse effects: Blurred vision, burning & stinging, itching, photophobia, conjunctival hyperemia May cause increase in iris pigmentation (brown) Eyelashes may grow thicker or darker

B-adrenergic blocking agents: Timolol

Indications: Open-angle glaucoma Aphakic glaucomaContraindications: Hypersensitivity Severe bradycardia, < 1st degree heartblock HypotensionCautions use in: Impaired cardiac function Asthma or air flow limitationsSide effects: Decreased visual acuity, ocular burning Eyelid twitching Bradycardia and pulmonary implications if medication is absorbed systemically

Timolol nursing implications

Check client's medical history for chronic systemic diseases that may be associated with the eye disorder Teach client how to correctly administer eyedrops Assess client for systemic absorption(bradycardia, hypotension) Teach client to apply slight pressure at the inner canthus for 1 minute after instillation to help decrease systemic absorption Client taking timolol should not take any OTC nasal decongestants or cold preparations

CArbonic hydrase inhibitors: Dorzolamide (Trusopt)

Indications: Second-line for reduction of IOP or open-angle glaucomaPharmacokinetics: Systemic absorption Long duration of action, but requires frequent dosingAdverse effects: Topical allergic reaction, photosensitivity, keratitis, and bitter taste

Carbachol

Indications: Glaucoma Indication of miosis during surgeryPharmacokinetics: Onset: 15 minutes Duration: up to 24 hoursAdverse effects: Local irritation, systemic effects of increased salivation, wheezing, or nausea & vomiting

Pilocarpine

Indications: Open-angle and closed-angle glaucoma Orally for severe xerostomaPharmacokinetics: Onset 10-30 minutes for miosis; 1 hour for reduction of IOP Duration: 4-12 hoursAdverse effects: Same as carbachol

Drug ototoxicity

May affect Hearing (auditory or cochlear function) Balance (vestibular function) Cochlear ototoxicity produces progressive or continuing hearing loss with tinnitus as the first symptom Vestibular toxicity may start with severe headache for 1-2 days, followed by nausea, vomiting, dizziness, ataxia, and difficulty with equilibrium; client may experience vertigo (room spinning) Usually bilateral, possibly reversible, though not if urecognized for long time

Ear drop administration

Position client supine on side with affected ear up Medication should be at least room temp(NOT COLD) Open ear canal of adult or child over 3 by drawing back on the pinna and slightly upward Open ear canal of child under 3 by drawing back on the pinna and slightly downward Instill medication and allow it to flow into ear by gravity Have client remain supine for a few minutes to keep medication from leaking out Do not administer medication if suspicion of ruptured TM Do not occlude ear canal with dropper or. syringe Never force medication into occluded ear canal

The nurse is caring for a client receiving carbachol to treat glaucoma. The client reports a reduction in driving at night because of the inability to see well in the dark. What is the best nursing diagnosis for this client?

Anxiety related to poor vision

While caring for a client with diabetes, the nurse explains that insulin is produced by the pancreas and does what when reacting with a cell?

Changes the cell permeability to glucose

When developing a plan of care for the client receiving a glucocorticoid, what nursing diagnosis should be of highest priority?

Risk for infection related to immunosuppression

A client who is steroid dependent due to adrenocortical insufficiency calls the clinic and is very upset, reporting stressful circumstances. What does the nurse expect the healthcare provider will order concerning his or her medication?

The dosage of the medication may be increased.

When caring for a client receiving long-term therapy with corticosteroids, the nurse would plan care incorporating interventions aimed at preventing what?

infection

What assessment findings would the nurse expect to see in a client who has overdosed on levothyroxine?

Nervousness, tachycardia, tremors

After administering propylthiouracil (PTU), what effect would the nurse anticipate the drug will have in the client's body?

To inhibit production of thyroid hormone in the thyroid gland

The nurse is discharging a client with a new prescription for levothyroxine. What effects should the nurse teach the client to report to the healthcare provider? Select all that apply.

Insomnia, nervousness, heart palpitations

The nurse suspects the client with diabetes may be having a hypoglycemic reaction when what manifestation is assessed?

diaphoresis

What type of insulin would the nurse administer if the fastest therapeutic effects are needed?

glulisine

A client in the community is taking regular and NPH insulin to manage type 1 diabetes. What laboratory finding best demonstrates that the client's diabetes management is adequate?

The client's glycosylated hemoglobin (HbAlc) level is 6.1%.

The diabetes nurse educator describes type 1 diabetes with what statement?

Exogenous insulin is required for life.

With what client should the nurse question the administration of human insulin?

A client whose type 2 diabetes is controlled by diet and exercise

A client with type 1 diabetes has been prescribed 12 units of regular insulin and 34 units of NPH insulin in the morning. How should the nurse explain why two different types of insulin are required to control the client's blood glucose?

The different onsets and peaks of the two types provide better overall glucose control.

The nurse is caring for a client who would like to start taking oral contraceptives. What aspect of this client's health history should the nurse prioritize for follow-up?

The client was treated for deep vein thrombosis following surgery

A client with a seizure disorder taking phenytoin requests a prescription for an oral contraceptive. What is the nurse's best response?

The effectiveness of oral contraceptives might be reduced by phenytoin.

The nurse is preparing to administer an infusion of oxytocin to the pregnant client. What is the priority assessment before beginning the infusion?

Cephalopelvic proportions

The nurse has been conducting client teaching for a 16-year-old who is starting oral contraception. What statement indicates that she needs additional teaching?

If I forget to take my pill for 2 consecutive days, I will take three pills to catch up.

The nurse is preparing to administer a client's scheduled ophthalmic adrenergic agonist. What actions should the nurse perform? Select all that apply.

-Perform hand hygiene prior to administration-Instruct the client not to rub the eyeball after administration of the drops

The nurse is administering an ophthalmic adrenergic agonist. What action would reflect the need for further education about how to administer a medication ophthalmically?

The nurse gently rests the tip of the dropper against the lower eyelid