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anxiety part I

2008-10-17T11:22:00.001-07:00

Anxiety

Miss Thomas – Monday 10/06/08

Anxiety

Mild

Moderate

Severe

Panic

Anxiety may be differentiated from fear in tat the former is an emotional process, whereas fear is cognitive

Introduction

Increase BP, dry mouth, tight throat, muscle tremors, urinary frequency, sweaty palms,

Anxiety disorders most common type of all psychiatric illnesses

More common in women than men

Minority children and children from lows socioeconomic environments at risk a familial predisposition probably exists

Anxiety disorders cont.

How much is too much?

Heightens alertness senses aware mild anxiety

May be considered abnormal

If anxiety is out of proportion to the situation that is creating it

Anxiety interfere with social, occupational or other important areas of functioning

7 major anxiety disorders

Panic

Agoraphobia

Specific phobias

Social phobias

Generalized anxiety disorder (grouped with panic)

OCD

Post traumatic stress disorder

Panic disorder

Characterized by recurrent panic attacks, onset of which are unpredictable, and manifested by intense apprehension, fear or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort

RN having a panic attack (video on youtube)

Generalized Anxiety disorder

Characterized by chronic, unrealistic, and excessive anxiety and worry

Causes of Anxiety

Threat

Danger –crime, war, bad, weather

Self-esteem- at clinical when you don't feel confident, how you look

Separation- not easy to be separated from loved one

Values – when we face losing freedom in our country

Unconscious influences – repressed, fear of coming out of closet

More causes of Anxiety

Conflict – divided into 3 categories

1.Approach-approach – two dinner invitations for same night, you want to go to both

2. Approach-avoidance – take a new job, want job, but have anxiety about job don't want it

3. Avoidance –avoidance – two alternatives bad – painful illness face surgery – both options are painful

Fear – irrational beliefs ie. making a speech

Unmet needs – Maslow's hierarchy – if basic needs not met, ie shelter, food, water

Physiology – illnesses that may have anxiety component, mitral valve prolapse, COPD, asthma, pulmonary edema (not able to breathe)

Individual differences – well known that people react differently to different situations, ie social, etc

Diagnosis/outcome identification

Anxiety related to real or perceived threat to biological integrity or self-concept

Powerlessness related to impaired cognition

Anxiety: Must have one have

Physiological sx increased HR, BP, SOB

Emotional sx apprehension, nervousness, lack of self confidence

Cognitive – poor orientation, inability to concentrate, lack of awareness of surrounding, forgetfulness
pg 12 carpenito

Powerlessness related to impaired cognition

Overt or covert expressions of dissatisfaction about inability to control situation

These both are part of anxiety

Outcomes

The client is able to recognize signs of escalating anxiety

Is able to intervene so that anxiety does not reach level of panic

The client is able to discuss long term plan to prevent panic/ anxiety when stressful situations occur

Practices techniques of relaxation daily

Engages in physical exercise 3x week

Performs activities of daily living independently

Experiences satisfaction with independent functioning

Is able to maintain anxiety at a manageable level without use of medication

Is able to participate in decision-making thereby maintaining control over life situation

Verbalizes acceptance of life situation over which he or she has no control

Nursing actions

Recognize own anxiety and calm down

Calming tension

Showing love

Help to help someone having a panic attack breathing exercises

Identify causes

Ie snake, shark,

Intervention categories

Biblical interventions

Biological interventions (meds)

Behavioral interventions

Environmental interventions

Encourage action

Individual psychotherapy

Cognitive therapy

404-407 in book

Biblical interventions

Rejoice – call to mind the promises of God

Gentleness & kindness– reduces anxiety

Pray-take even the small details to God, thanksgiving

Think – lock truth onto your mind, stop with negative thoughts, positive thoughts, scriptures

Act

Prevent anxiety – trust God that He looks out for our well-being, focus on others

Medication

Anxiolytics – benzodiazepines – effective for panic attacks

Xanax (alprozolam), Valium (diazepam), Ativan (lorezepan)

Safer than sedatives, are addictive, undesireable for long period

Used prn

Need to know generic and brand name

Problem – physical dependence and tolerance

Abuse

Can not abruptly discontinue use

**know common and trade names for all drugs**

More meds

Non benzodiazepines –(also are anxiolytics)

Buspar

Ambien

More meds

Antidepressants

Tricyclic not used a lot

Elevil (amytryptyline) and Tofranil (imipramine)

SSRI (?effectiveness)

Antihypertensives –propanalol and clonidine (reduce cardiac effects, high BP, sweaty palms)

5 HTP (tryptophane) natural herbal

Exercise

Progressive muscle relaxation

By Edmund Bourne

Phobias

Agoraphobia-without hx of panic disorder: assessment

Fear of being in places or situations from which escape might be difficult or in which help might not be available if a limited-symptom attack or panic-like symptoms should occur

Ie. claustrophobia: elevators

Another name for fear see core concept on 387 endured with marked distress, more common in women and in 20's.

Phobias cont

Specific phobia: Assessment

Excessive fear of situations in which the person might do something embarrassing or be evaluated negatively by others (giving a speech)

Social phobias: assessment

Specific phobia: assessment – marked, persistent, and excessive or unreasonable fear when in the presence of or when anticipating and encounter with a specific object or situation

DSM-IV-TR subtypes

Animal type

Natural environment type

Blood injection injury type

Situational type

Other type

See book 389 table 17-2

Phobias (cont)

1. Learning theory

Fears are conditioned responses and thus are learned by imposing rewards for appropriate behaviors (learned from a parent) classical conditioning

2. cognitive theory

Anxiety is the product of faulty cognitions or anxiety inducing self-instructions

Negative self-statements

Irrational beliefs

Diagnosis: outcome identification

Phobias (cont)

Cognitive theory

Anxiety is the product of faulty cognitions or anxiety-inducing

Fear related to causing embarrassment to self in front of others, to being in a place from which one is uncapable to escape or to a specific stimulus

feelings of dread, fright, apprehension, alarm – major defining characteristics

minor defining characterisitics – cry

pg 161 carpenito

minor characteristics:

cry

aggression

escape

hypervigilence

Social isolation related to fears of being in a place form which one is unable to escape

expressed feelings of aloneness, rejections, desire more contact with people

phobia: they are isolated at home due to phobia (guy who works in high rise can't take elevator)

Outcome

Functions adaptively in the presence of the phobic object or situation without experiencing panic or anxiety

Demonstrates techniques that can be used to maintain anxiety at a manageable level

Voluntarily attends group activities and interacts with peers

Discusses feelings tat may have contributed to irrational fears

Verbalizes a future plan of action for responding in the presence of the phobic object of ritualization without developing panic anxiety

Nursing care of the client with a phobia is aimed at

Helping the client learn to function in the presence of the phobic object without experiencing panic anxiety

Assisting the client to over come fear of leaving home alone

Establish trust – use calm approach

Provide safe environment

Let's face it

Exposure therapy

Real life desensitization –systematic desensitization

Involves unlearning the connection between the phobic situation and an anxiety response

Reassociating feeling of relaxation an calmness with that particular situation

See 406

Behavior therapy "implosion therapy"

Creating a hierarchy

A series of steps that brings you incrementally closer to being in the feared situation

Making the most of exposure therapy

Rely on support person

Be wiling to take risks

Cope with resistance

Be willing to tolerate some discomfort

Avoid flooding and be willing to retreat

Plan for contingencies

Trust you own pace

Reward yourself for small successes

Learn to cope with the early stages of panic

Use positive coping statements

Meds for phobias

Anxiolytics – benzodazepines

Have been shown to reduce symptoms but not the first line treatment

Antidepressants SSRI's Paroxetine and sertraline are used for social anxiety disorder

Antihypertensives – beta blockers propanalol and atenolol (stage fright – sweaty palms,)

Evaluation

Reassessment if conducted to determine whether the nursing actions have been successful in achieving the objectives of care.

Obsessive-Compulsive disorder (OCD)

Assessment data

Recurrent obsessions or compulsions that are severe enough to be time consuming or to cause marked distress or significant impairment

Obsessions:

Unwanted intrusive persistent ideas, thoughts impulse or images that cause marked anxiety or distress

Compulsions: unwanted repetitive behavior patterns or mental acts that are intended to reduce anxiety, not to provide pleasure or gratification

Etiological implications of OCD

Psychoanalytical theory

Clients with OCD have weak, underdeveloped egos

Aggressive impulses are channeled into thoughts and behaviors that prevent the feelings of aggression from surfacing and producing intense anxiety fraught with guilt

Learning theory

Conditioned response to a traumatic event

Passive avoidance

Active avoidance

Biological aspects

Neurobiological disturbances may play a role

Neuroanatomy

Abnormalities in various regions of the brain have been implicated in the neurobiology of OCD

Physiology

Electrophysiological, sleep electroencephalogram, and neuroendocrine studies have suggested that there are commonalities between depressive disorders and OCD

Biological aspects (cont)

Biochemical

Read about 384 read **** neuro pathways / chemicals

OCD – diagnosis

Ineffective coping related to underdeveloped ego, punitive superego, avoidance learning, possible biochemical changes

Ineffective role performance related to need to perform rituals evidenced by inability to fulfill usual patterns of responsibility

Outcomes

The client is to maintain anxiety at a manageable level without resorting to the use of ritualistic behavior

Is able to perform ADL independently

Verbalizes understanding or relationship between anxiety and ritualistic behavior

Demonstrates more adaptive coping strategies

Thought stopping – put rubber band on wrist – pop rubber band, relaxation techniques, physical exercises

Postpone worry

Client is able to resume role-related

Nursing care helping the client learn new, more adaptive coping strategies without resorting to obsessive-compulsive behaviors

Helping

Talk to them after compulsion is over when anxiety is lowest

Avoid punishing

Establish routine

Gradually decrease time for performance of ritual

Meds

Antidepressants

SSRI's fluoxetine, paraoxetine

Sertraline – Zoloft

Fluvoxamine

Selexa -

Know s/e

Headaches,

Sleep disturbances

Restlessness

2-4 weeks to be effective

Evaluation

Reassessment is conducted to determine

Posttraumatic stress disorders

assessment

Development of characteristics sx

Following exposure to an extreme traumatic stressor involving a personal threat to physical integrity or to the physical integrity of others

Reexperiencing (flashback) a traumatic event

Sustained high level of anxiety or arousal

Or a general feeling of numbness or responsiveness

Intrusive recollections or nightmares of the event are common

Self-destructive behavior

Psychosocial theory

The traumatic experience

Severity & duration of the stressor

Extent of preparation before onset

Exposure to death

Numbers affected by life threat

Amount of control over recurrence

Location where trauma was experienced

Individual

Degree of ego strength

Effectiveness of coping resources

Presence of pre-existing psychopathology

Outcomes of previous stressor.trauma

Behavioral tendencies

Recovery environment

Availability of social supports

Cohesiveness of & protectiveness of family and friends

Attitudes of society regarding the experience

Cultural & subcultural influence

Learning theory

Negative reinforcement

Behavior patterns drugs/ alcohol numb themselves from stress

Avoidance behavoiors

Cognitive theories

World view violated them

Biological aspects

It has been suggested that a person who has experienced previous trauma is more likely to develop symptoms after a stressful life event

Outcome

Posttrauma related to distressing event considered to be outside of the range of usual human experience

Complicated grieving related to the loss of self as perceived before the trauma or other actual or perceived losses incurred during or after the event

Outcomes

The client can acknowledge the traumatic even the impact it has had on his or her life.

Is experiencing fewer flashbacks, intrusive recollections and nightmare than he or she was on admission

Get enough sleep

The client:

Verbalizes community resources form whom e or she may seek assistance in times of stress

Attends support group ** most important

Nursing care is aimed at providing assistance with integration of the trauma into his her persona

Renewing meaningful goals

Renewing significant relationship

Progressing through grief process

Devel9oping a sense of optimism and hope for futre

Actively listen\

Assess suicide risk

Assist client to dev. objectivity about event & encourage group therapy** most important

Meds SSRI's first line of tx

Paraxeiine – Paxil

Sertraline – Zoloft

Anxiolytics – use is discouraged because of abuse

Benzos

Antihypertensives

Others

Group therapy

Has proven to be effective for PTSD sufferers

Share experiences

Talk about problems of social adaptation

Discuss options for managing

Evaluation

Reassessment

Nature of the illness

Client/family education read in book

What is anxiety?

What might it be related to?

What is OCD

What is PTSD

Sx of anxiety disorders

Management of illness

Meds

Adverse effects

Length of time to take effect 2-4 wks

What to expect from med

Stress management

Teach way to interrupt escalating anxiety

Teach relaxation techniques

Crisis hotline

Support groups

Individual psychotherapy

anxiety

2008-10-17T11:21:00.001-07:00

Anxiety-related disorders

Miss Thomas Friday 10/10/08

Evidence does exist to support the presence of organic pathology or a known pathophysiological process

Somatoform: characterized by physical symptoms suggesting medical disease but without demonstrable organic pathology or a known pathophysiological mechanism to account for them.

Pain disorder: predominant disturbance in pain disorder is severe and prolonged pain that causes clinically significant distress or impairment in social, occupational or other areas of functioning (chronic pain that affects their functioning).

Hypochondriasis: a preoccupation with the fear of contracting or the belief of having a serious disease

The fear becomes disabling and persists despite reassurance that no organic pathology can be detected

Do Doctor-shopping

Conversion disorder

A loss of or change in body function resulting from a psychological conflict the physical symptoms of which cannot be explained by any known medical disorder or pathophysiological mechanism ie. blindness, seizures,

La belle indifference

Ways to reduce pain/anxiety

Focus activities away from pain

Exercise

Reaffirm that tests reveal no pathology

Dissociative disorders

Dissociative amnesia: inability to recall important personal data that is too extensive to be explained by ordinary forgetfulness, onset can follow stress,

Dissociative fugue: very rare

thyroid

2008-10-17T11:16:00.001-07:00

Thyroid

Affects: Metabolism, CV fxn, GI fxn, and neuromuscular fxn.

Body temperature – control at 98.6. endocrine system will work to help this

Must have iodine to work

Hyper/hypo most common disorders

Deficiency predisposes to hyperpthyroidism

Grave most common hyperthyroidism

Associated with myasthenia gravis & pernicious anemia

Goiter with graves, flushed moist skin, nervousness and weight loss,

Exopthalmos due to impaired venous draining from orbit – leading to increased deposits of fat & fluid in retro-orbital tissues – upper eyelids retracted & elevated, won't close at night, watch for corneal ulcers, need to tape shut at night.

Pretibial myexedema – dry waxing swelling in front of shin bone.

Heart rate up to 150, temp 105, can be caused by surgery which increase can touch thyroid and stimulate release of hormones, infection, trauma,

Treatment: prevent death

Diagnostic studies

TA test – eleveated in graves

TSH

Radioactive iodine uptake test

Treatment

Improve 1-2 weeks after initial therapy.

After 4-8 week good results, 6 months spontaneous remission

Target thyroid not affect that in circulation

Long term iodine therapy not effective in controlling hyperthyroidism

Radioactive iodine limit thyroid tissue and can result in hypothyroidism

Beta adrenergic – treat heart palpitations

Nutritional management

Avoid highly seasoned food & caffeine so as not to speed up more

Thyroidectomy – performed if thyroid is enlarged to the point is putting pressure on the trachea or esophagus

May be total or subtotal removal

Subtotal: leave enough of gland to produce hormone

Total requires life-long replacement

Thyroid surgery

Fowler – prevent aspiration

Chronic & home management

Will have periods of hypothyroidism after surgery

Fine window to watch for both

Thyroid enlargement

Calorie intake reduced substantially

Iodine need for thyroid fxn

And seafood 2x week

Regular exercise to stimulate thyroid

At first biweekly visits for a month then 2 x year to assess fxn for rest of life to make sure not develop hypothyroidism

Thyroid nodules

Usually hard and painful, diagnosed by thyroid scan iodine 131

Tumor that show up are called hot nodules and need to be removed

Thryoiditis

Acute due to bacterial/ fungal infections,

Hashimoto's – chronic- insidious onset, chronic autoimmune where cells replaced by fibrous tissue

Subacute:

Chronic:

Hashimoto's

Hyperthyroidism TX

Thyroid crisis/storm

Extreme state of hyperthyroidism (rare)

Due to improved diagnosis and tx

Usually effects people with untreated hyperthyroidism

This is a life-threatening condition (usually caused by surgery to neck)

Thyroid storm

The rapid increase in metabolic rate that results from the excessive TH causes the manifestations of thyroid storm

Manifestations include temp from 102 F to 106F increased HR, BP, GI sx agitation, tremors,

Can progress to death, so rapid tx is essential

Tx with cooling blanket, replace fluid, electrolytes, maintain respiratory status, monitor HR,

Hyperthyroidism

Monitor vitals, SOB, skin – cap refill, maintain cool, quiet environment, balance rest/activity periods

Disturbed sensory perception visual: turn lights low, artificial tears, cover eyes, head of bed at 45 to drain eyes, report vision changes,

Nutrition:

Disturbed body image – can lose hair, fatigue, sweating

Hypothyroidism: cretinism

Adult – atrophy of gland

Primary hypothyroidism

Caused by congenital defects in the gland loss of thyroid tissue following treatment for hyperthyroidism, thyroiditis, or iodine deficiency

Secondary hypothyroidism

Results from pituitary TSH deficiency or peripheral resistance to thyroid hormones

Has a slow onset with manifestation occurring over months or even years

Treatment will cause reversal of sx.

Clinical manifestations of both types with adult onset

Goiter, fluid retention and edema, decreased appetite, weight gain, constipation, dry skin, dyspnea, pallor, hoarseness & muscle stiffness

Infant onset

Appear normal at birth due to circulating hormones of mother in bloodstream,

Look for large infant fails to thrive & long gestational period

Excessive sleeping, skin lips enlarged, feeding respiratory difficulties, squint due to peri-orbital edema screened for test heel stick T4 & TSH

Causes irreversible dwarfism & mental retardation

If caught in time, will develop normally

Childhood manifestations

Generalized muscle hypertrophy

Adulthood

Slowing of body processes, personality changes, fatigue, lethargy, severity depends on degree of hormone deficiency,

Myxedema

Triggered by acute illness or trauma, edema due to water retention in muco-protein deposits in interstitial spaces – have puffy tongue, voice hoarse, husky, peri-orbital edema, sub normal temperature, hypotension, ventilation, can progress to point that they need ventilator until you stabilize them.

Hashimotos thyroiditis

Most common cause of goiter

Autoimmune disorder

Antibodies develop and destroy thyroid tissue

Get a goiter

Functional thyroid tissue is replaced with fibrous tissue and TH level decrease

Decreased thyroid hormone in early stages of disease prompt gland to enlarge & cause goiter

Treatment:

Comfortable warm environment due to slower metabolism, prevent skin breakdown, avoid sedatives, when giving hormones monitor CV status,

Nursing diagnosis

Decreased cardiac output, constipation

Risk for impaired skin integrity – dry rough skin, decreased circulation to peripheral slow wound healing, keep in warm environment, frequent rest period, high fiber diet,

Thyroid cancer

Very rare

Palpable firm nontender nodule in the thyroid

Tx is subtotal or total thyroidectomy

Parathyroid – 4 glands on back of thyroid

Increased levels of hormone act on kidney to increase reabsorption of calcium and increased phosphate excretion

Primary pg 547

Occur when there is hyperplasia or an adenoma in one of the parathyroid glands

This interrupts the normal regulatory mechanism between serum CA and PTH secretion and increase the absorption of ca in the GI tract

Secondary

Is a compensatory response by the parathyroid glands to chronic hypocalcemia

Characterized by an increased secretion of PTH

Tertiary

Results from hyperplasia of the parathyroid gland and a loss of response to serum CA levels

Most often seen in pt with chronic renal failure

Diagnostic

CA & phos opposite

Treatment

Mithracmycin anti hx agent to lower CA levels

IV saline

Inderal used to inhibit

Surgery – same post op as with thyroid surgery

Major complication is tetany due to calcium

Unpleasant tingling around mouth, hands

Hypoparathyroidism

Lack of PTH causes hypocalemia and an elevated blood phosphate level

Most common is removal of parathyroid gland

Clinical manifestations

Therapeutic management

Know s/sx tetany

Nursing management

Hyperparathyroidism

pituitary

2008-10-17T11:15:00.001-07:00

Pituitary

Sit on selica tunica – depression in sphenoid brain where it sits

Oxytocin – contractions

Anterior pituitary

Released by ant pit and put into circulation and transported to specific target tissues

What do they do?

FSH

pathophysiology

Ischemia & infarction can occur during pregnancy , due to increased blood volume

Other Causes, sickle cell anemia, vascular malformation, tumor, infection, cancer, radiation, surgical removal

Hypopituitarism

Acromegaly

Not an increase of height, 3rd or 4^th decade of life, bones increase in thickness & width,

s/sx

hands, feet enlarged, frontal sinus, jaw, spine,

enlarge of soft tissue, tongue, skin, abdominal organs, - can result in speech difficulties,

enlargement of gland can put pressure on surrounding tissues give headaches and visual disturbances

diagnose:

x-ray, CT, MRI

treatment:

radiation tx

Giantism

increased height

treatment:

face will return to original size after tx

goal return GH to normal,

transphenoidal hypophysectomy : incision made on inner upper lip, only remove tumor

silica tunica entered through sinuses, external radiation normalizes in 30-60 % pts

depends on when tx originated, age, onset,

Nursing care

Increase in hat, ring, or glove size,

Altered self image,

Hypofunction is rare

Avoid intracranial pressure, coughing, bending over, sneezing, clear nasal drainage – CNS fluid, resolve in 72 hrs, elevetate bed, bedrest, tx or get mengitist, avoid exercise that increases intracranial pressure for 2 months

Stool softeners,

Dwarfism

Normal growth in 1^st year, then growth curve slows,

Premature aging

Disorders of posterior pituitary

ADH contributes to fluid balance and renal absorption of free water

SIADH

Associated with disease that affect the osmo receptors in hypothalamus

Fluid retention, dilutional hyponatremia, increased concentrated urine, water is reabsorbed,

Causes: malignant neoplasms that cause autonomous vasopressin release

Non-malignant pulmonary disesase, CNS disorders,

Excess ADH = increased renal tubular permability & resorptoin of water in circulation, extraecellualar fluid expands, osmolality declines, sodium declines due to dilutional hyponatremia

Extra fluid in blood volume

Management:

Saline will cause it to go into intravascular space so you can urinate it out.

Extreme thirst, SOB on exertion, dull sensorium, fatigue,

Severe vomiting, cramps, convulsions, muscle twitching all with drop in sodium

Restore fluid volume and osmolality,

8-1000ml fluid/day, result in gradual reduction in weight, increase sodium concentration, give diuretic promotes diuresis, watch potassium.

Nursing management

Turn q2 hr

Observer for hyponatremia q2 = confusion, n/v, cramping of muscles,

Diabetes insipidus

Clinical manifestations

Primary up to 12 L day, milder is 2-4 L

Compensate: drink a lot of water, cold drinks, fatigue from nocturia,

Treatment

Despopressin acetate

Water deprivation test: give vasopressin IV and withhold water 6-8 hrs. pt is anxious,

Long term therapy

ADH as nasal preparation, not a vasoconstrictive effect on whole body,

overdose effects: headaches, nausea, nasal effects

accurate I& o weight, check urine spe

comparison of post pit disorders

Nursing management

hypofunction

pituitary

2008-10-17T11:14:00.001-07:00

endocrine disorders

2008-10-05T19:00:00.001-07:00

Endocrine Disorder –Diabetes

Miss Hight Monday 9/29/08

Quiz

Function of the pancreas

Name the hormones of the pancreas produced by the Islets of Langerhans

α (alpha) cells produce glucagon which stimulates the liver to convert stored glycogen

into glucose and release it into the bloodstream

β (beta) cells produce insulin

Δ (delta) cells produce somatostatin – neurotransmitter that inhibits production of

glucagon & insulin

glycogenolysis – breakdown of glycogen into glucose

gluconeogenesis – production of glucose from (non-carb sources): breakdown of fats &

proteins

Prevalence

18.2 million people are affected with diabetes

13 million diagnosed

5.2 are underdiagnosed

Increased prevalence of type 2 diabetes among older adults & minority populations

Type 1 more common in Caucasian than Latino

6^th leading cause of death in U.S.

Prevalence and Incidence of DM

8.7% of all non-Hispanic whites aged 20 years or older have diabetes

African-American type II

Diabetes, CHD, strokes, renal end stage disease

Prevalence and Incidence of DM

2.5 million Hispanic/Latino Americans have diabetes and are 1.7 times as likely to have diabetes as non-Hispanic whites of similar age

American Indians and Alaska Natives are 2.2 times more likely to have diabetes than non-Hispanic whites

Increasing in older adults between 65-74

Food enters body:

Goes to stomach broken down into sugars – glucose main fuel.

Once glucose enters blood stream blood glucose goes up. Body senses increase in sugar, sends message to pancreas and sends insulin to blood stream, goes to liver, glucose will fall, glucose has to get into cell.

Insulin is key that lets glucose enter cell. Has to unlock cell for glucose to enter

Skeletal, cardiac and adipose require insulin

Brain, liver, intestines renal tubules not require insulin to enter cell

Once insulin unlocks, blood glucose enters cell, blood glucose goes down

Low blood sugar ie at 50 pancreas releases glucagon to liver to break down glycogen, thus blood sugar goes up.

Pathophysiology

Type I – autoimmune disease

Beta cells gradually destroyed

Eventually fail to produce insulin

Insulin is a hormone that helps the body's cells use glucose for energy. Blood glucose (or blood sugar) is manufactured from the food we eat (primarily carbohydrates) and by the liver.

Patho – cont.

If glucose can't be absorbed by the cells, it builds up in the bloodstream instead, and high blood sugar is the result

Over time high blood glucose levels of uncontrolled diabetes can be toxic to every system of the body.

Type I

Closed to entry of glucose*

Total lack of endogenous insulin (within cell)

These type I will need exogenous insulin (medication), Need insulin shots

Insulin deficit

↓

Associated risk factors

↓

Glucose production & glucose utilization

↓

Hyperglycemia

↓

Osmotic diuresis

↓

Extracellular dehydration

↔

Renal insufficiency Hypovolemia

↓ ↓

Severe hyperosmolarity hypovolemia

↓ ↓

Fluid shift tissue hypoxia

↓ ↓

Intracellular dehydration lactic acidosis

↓ ↓

Coma

Type I

Most often in childhood & adolescent, but can occur at any age

Characterized by hyperglycemia & ketosis*

More prevalent in Caucasian than those in other races

Risk factors

Genetic disposition – family hx

Parent or sibling with it 2-6% risk

If both parents highter 10-15%

Sibling with identical twin – increased risk

Viruses:

Coxsackie B-4

Mumps

Rubella,

Cytomegalovirus

Environmental triggers

Chemical toxins in smoke/ cured meat

Clinical manifestations of type I

Polyuruia – hyperosmotic - dehydration

Polydypsia – drink a lot, mouth dry, sense thirst

Polyphagia – not enough energy (cells needs energy)

Weight loss –not gain weight

Malaise – tired all the time

Fatigue

Type II Diabetes

More common in middle age and older adults, but can occur in children and adolescents

Non-ketotic (no ketosis in urine)

Insulin resistance or impaired insulin secretion

Blacks, Amercian Indians, Asian Amercians, Pacific Islanders, Latinos,

Cont:

Insulin resistance: takes more insulin to unlock cell (cell membrane closed to sugar entry)

Inability to utilize insulin properly *cellular resistance*

Being overweight affects cellular resistance

Being inactive affects cellular resistance

Obesity BMI > 27

Physical inactivity

Race/ethnicity

Hypertension

Gestational diabetes

Giving birth to baby over 9 lbs.

Metabolic syndrome cluster:

Abdominal obesity

Lipids – dyslipidemia

Hypertension

Fasting blood sugar greater than 110

All of these put diabetic patient at risk for developing cardiovascular disease,

During physical do fasting blood sugar, lipids, blood pressure

May be put on lipid lowering meds

Do physical every year. Prevent high sugars

No insurance – physical not done frequently $700-$800 one reason people don't have it done

Patho type II

Most people with type II are still able to produce insulin at diagnosis

However, the insulin they produce is unable to perform its primary job, which is helping the body's cells use glucose for energy, and lowering blood sugar levels

Have sugar in cell

Clinical manifestations type II

Polyuria

Polydypsia

Blurred vision

Fatigue

Frequent skin infections

Problems with sexual function

Polyphagia not often seen (more with type I)

Paresthesia in hands or feet – tingling in hands & feet – circulatory problems

DKA – not common in type II (no have ketones) have enough insulin in cell

Weight loss uncommon

Overweight

Gestational diabetes 2-3 trim.

3-8 pregnancies of every 100 in America

Family hx of diabetes

Being overweight

Having prediabetes 100-126?

Risk factors for developing gestational diabetes

Baby over 9lbs

Clinical Manifestations of Gestational diabetes 24-28th week (screening done)

Have problems metabolizing blood glucose

Pancreas produces plenty of insulin (the hormone responsible for unlocking cells so that

glucose can enter them and provide energy

Because of insulin resistance, blood glucoe (or blood sugar) builds up in the bloodstream, and gestational diabetes is the result

Watermelon raises blood glucose

DM screening tess

Casual plasma glucose (random) – done at any time of day >200

Fasting plasma glucose (FPG) >126mg/dl no caloric intake for 8 hrs = diabetes should be (blood sugar should be 70-110)

Two hour PG – post prandial (after eating) (should not be greater than 200)

DM screening cont.

Fasting blood glucose mg/dl 70-110 done in a.m. soon as you go to bathroom,

Glycosylated hemoglobin A1c – shows blood glucose level over 2-3 months previously (July, August, Sept). depends on hospital 4.1-5.9 at Erlanger

Any value above 7 is bad – not well controlled.

RBC's recycle every 120 days

First lab will be Hgb A1c – oxyhemoglobin or glycolsylated Hgb

Oral glucose tolerance test – 2 hr or 3 hr drink glucose and go back to lab and draw over time,

Test urine for presence of albumin (bad)

Serum cholesterol , triglycerides 50-100, indicator of athlerosclerosis, risk of heart disease

Normal cholesterol level under 200

Lipid breakdown

HDL

LDL

Measure serum electrolytes – measure if in ketosis or hyperosmol state,

Check K, Na, creatinine, BUN, CO2, , if high

If spilling protein in urine will do 24 hr clearance for creatinine get protein count – diabetics prone to end stage renal disease.

Reason for checking kidneys function: if spill protein bad –

GFR – glomerular filtration rate – higher number is better kidney, lower number is bad

African American, non African American

Type I use stick in urine – color coded screening pee on tip compare to chart (used for ketones)

Serum is most accurate for blood sugar

Therapeutic management all of these for managing blood glucose

Nutrition/diet/weight control

Exercise

Glucose monitoring

Medication

Nutritional management

Main goal of diet therapy in diabetes is to avoid sharp increase

Glycemic index: term used to describe how much a given food raises glucose level to compared to equivalent amount of glucose.

Baked potato high – sweet potato is better not raise glycemic index as high

Whole grains lower in glyceminc index,

Nutrition

Caloric intake based on individual needs

Follow food pyramid or exchange system form the Amercan Diabetic Assoc.

Weight watchers diet is good – diabetic diet

Nutrition

Carbohydrates (CHO)

45-65% (daily diet)

Complex - pasta

Avoid simple sugars candy bar

Saturated fat <10%

Sodium less than 3000mg/day

Protein 15/20%

20-35% fiber whole grains – blood sugar not rise as quickly, brown rice good, Blood sugar not rise as high, keep food diary,

Eat at same time each day, same amount of CHO's each meal, be consistent

Exercise good to control blood sugar

Nutrition

Sweeteners

FDA approved

Safe in humans

Sugarless

Sugar-free

Dietetic – not necessarily reduced calorie

Nutrasweet, splenda, equal, sunnette

Produce no change in blood sugar

Alcohol – not encouraged nor prohibited -

Light beer recommended – may potentiate hypoglycemia, but could cause hyperglycemia in others

Should be consumed with meals

Substituted for fat (1.5 oz eqv. to two fat exchanges)

Nutrition

Misleading food labels

Sugarless

Sugar-free

Read labels

Dietetic – not necessarily reduced calorie

Snacks – contain sugar, corn syrup, honey

Healthy snacks – saturated vegetable fats, coconut or palm oil.

Nutrition cont.

Greater freedom in food choices – add up get running total. Meet with registered dietician, do meal planning. Adhere to diet better.

1 cho=15 gms (x 20 carbs) =

Fiber = 5gms - can decrease (subtract) from CHO's total

As the name suggest, carbohydrates counting also called carb counting or carb gram counting involves computing the number of CHO's grams in a given meal or snack

Total carbs are tallied up on a running basis to ensure that the total doesn't exceed a predetermined dietary goal for the meal and/or day.

Nutrition

With this method, every 15 grams of CHO's are counted as one CHO choice with a predetermined number of choices allotted daily (as determined by an RD and based on caloric requirements)

Simple carb couting may be preferred by those who like the simplicity of the dietary exchange system but crave added variety in their diet.

Exercise

Benefits of exercise

Weight control

Improves physical fitness

Improves emotional state

Improves work capacity

For diabetics – improve uptake of glucose by muscle cells

Decreases cholesterol and triglycerides

HDL increased by exercise (over 45 is ideal)

LDL around 130 or less

Reduces the need for insulin

Decreases cholesterol, and triglycerides reducing the risk of cardiovascular disease

576-580 in LeMone**read for Miss Hight

Exercise cont

Consult primary care physician before starting exercise program

Start slow, change machines

Assessment of lifestyle before starting

Do you smoke?

Assess exercise habits, stick with program

Make sure have proper footwear.

Diabetic: inspect feet before and after exercise – wear white socks or get moisture – get medium for athlete's foot

Avoid exercise in extreme cold or hot conditions

All diabetics must wear alert bracelet

If going to exercise, check blood sugar before and after exercise, check for hypoglycemia (not below 70)

Exercise habits, living environment

Community programs

Inspect feet before and after exercising

Avoid exercise during period of poor glucose control

Exercise for Type 1 diabetic

Glycemic response to exercise varies

Have increase risk for hypoglycemic and hyperglycemic reactions

Avoid prolonged exercise

Do not exercise at peak insulin times –

If check blood sugar and it is over 240, and if have positive ketones, need to postpone exercise, not need to exercise.

If blood sugar low before exercise, eat a CHO

If start to exercise and get chest pain, SOB – call 911

Low impact

Fluid intake

Do not exercise at peak insulin times, eat a carb if insulin also check ketones (if pos), at put off exercise

Test blood sugar before and after exercise, avoid prolonged exercise, monitor gluclose levels,

Low impact exercise best – walking

Exercise for type 2

improves glycemic control

weight loss.

Reduction of cardiovascular

Go to dr before

Exercise 3x week

Monitor glucose before and after exercise

Begin mild and gradually intensify

Include weight training

Glucose monitoring

Allows pt

SMBG -

acucheck – why check? Reflects glucose in blood
don't want to have reaction – high (hyperglycemic) or low (hypoglycemic)

decrease the danger of hypoglycemia / hyperglycemia

urine testing for ketones & color coded strip (not reliable, non invasive, less expensive)

old way of testing

Pharmacologic therapy

Classified according to:

Source

Onset

Peak

Duration

U100

Concentration 100 units/1 mL

Manufacturer: Eli Lilly & Nova Nordisk

Human insulin – faster onset

Shorter peak

Short duration

Pork or beef insulin – allergic rxn possible, not used a lot

Insulin therapy see chart**

Rapid acting

Lispro (humalog)

Usually given to cover meal time

If blood sugar goes up at night – nocturnal hyperglycemia & post prandial

Onset 25 mins.

Peak 1.5 hr

Duration 2-4 hrs

Aspart (Novolog)

Onset 25 mon

P40-50 m

3-5 hr duration

Glulisine (apidra)

Onset 25 min

Duration 3-5 hr

Short acting – regular

Cover meal times - sliding scale

Onset 5-10 min

Peak 2-3 hr

Duration 4-6 hhr

Can give IV only one that can be given IV**

Intermediate used to maintain the basal insulin requirements in between meals

NPH – in between meals

onset 2 hr.,

p 6-8,

duration 12-16 rh

Humulin N

Insulin cont.

Lantus

Long acting – maintain in between meals

Onset 2 hr

Peak not peak not defined

Duration 24 hr plus, Given at night usually at 2200 (10:00) p.m. to affect day time blood sugar, know when it peaks, ok to give when blood sugar is 98, because it peaks next day. **Very important Do not hold this insulin**

Combination

Administered to mimic pancreatic activity of the pancreas

All these peak in

70/30 onset 5 min, p – 4-8, d= 24

50/50 onset 5 min, p-3 hr. dur 24 hrs

Route of administration

Only regular insulin may be given IV or in an emergency may be given IM – all insulin drips are regular insulin

Most subcutaneous (fasted from the abdomen) absorbs quicker

Insulin patch

Inhaled aerosolized insulin (new on market)

Alternative methods

Insulin pens small device (150-300 units)

Prefilled

Good for one type of insulin

Eating out

Very expensive, not refrigerated

Jet injectors

Delivers insulin thru the skin under pressure

Very expensive

Requires thorough training

Absorbed faster

Caution pt about peak insulin activity – absorbed faster, not used a lot, easier to have hypoglycemic rxn.

Exubera: inhaled insulin

Causes hypoglycemic rxn quickly

Methods cont.

Transplantation of the pancreas

Mostly diabetic receiving kidney transplant at same time

Transplant of the pancreatic islet cells

Weighing the risk of anti rejection medication versus the advantage of pancreas transplant

Continuous SC insulin infusion CSII insulin pump

Description

Delivers a basal rate of insulin and allows for additional bolus doses of insulin based on requirements (before meals)

Mimics functioning of the normal pancreas

Device is worn

Programmed to deliver before each meal, set up on 24 hr basis

Usually inserted into abdomen, needle into skin

Disadvantage: change needle every 3 days*, be meticulous about cleanliness, may come out, interruption in insulin, line can become kinked, check needle, extension tubing not kinked

Disruption of insulin flow if tubing or needle becomes occluded

Mini-med

Run on battery - check every week or two

Used on young, brittle ones

Complications of insulin therapy

Local reaction

Swelling, tenderness at site,

Systemic reaction

Involved gradual spread to generalized urticaria (hives)

Lipodystrophy or lipoatrophy refers to

Localized reaction occurring at the site of injection

Loss of subcutaneous fat – appear as a dimple, *need to rotate site** of injection

Complications cont

Morning hyperglycemia

Dawn phenomena

At 2-3 am. Blood glucose levels rise

From nocturnal surges in growth hormone

Creates a greater need for insulin in early morning hr

Somogyi phenomenon

Normal or elevated blood glucose at bedtime

Results in nocturnal hypoglycemia – followed by rebound hyperglycemia decrease at

2-3 a.m.

Helps to know what to give in a.m.

Client teaching about insulin

Store in cool place away from sunlight

**replace every 4 weeks**

Cold insulin causes subcutaneous atrophy or hypertrophy alters insulin absorption

Note date of expiration must have a date and time

Avoid alcohol lowers blood glucose

Do not shake, roll non regular insulin

Monitor for hypoglycemia

When travel take extra insulin, with carry on, do not pack in suitcase, need to have with you for in case of rxn, take two bottles of insulin

Rotate the site

Do not inject in an area that will be involved in exercise increases absorption

Increase absorption, risk of hypoglycemia

Rotating sites

Arms

Abdomen

Back

Legs

Oral hypoglycemic agents ** see chart**

Sulfonylureas – stimulate pancreastic

Amaryl

Glucotrol

Tollinse

Orinase

1^st genation

Old drugs

Action

Side effects

Cause hypoglycemia

Drugs Cont

Biguanindes

Metformin (Glucophage)

Reduce overproduction of glucose by liver, making insulin more effective for peripheral tissues, reduce fasting blood sugar in the morning

Side effects**lactic acidosis*

If on constrast dye suspend 48 hrs

Must do liver enzymes if on this drug – metformin

Check every 2-3 months

Drugs cont.

Meglitinindes

Prandin

Action: Lower blood glucose by stimulating release of insulin from the pancreatic islet cells

new class, tx type 2

Decreases spikes in glucose following meals, evens it out

d-phenylalanine (amino acid derivative)

starlix

prandin

Drugs cont.

Alpha glucoside inhibitors

Acarbose – work in small intestine to delay glucose absorption

Side effect: gas and bloating

Drugs cont.

Thazolidinediones

Avandia –

Actose

Action: Sensitizes peripheral tissue to insulin, Allows your own insulin or the insulin you take to work more effectively

Side effects – not give to people with CHF

Weight gain, edema

**Good for insulin resistance – drug of choice**

Drugs cont.

Aspirin therapy

Given to reduce atherosclerosis in clients with vascular disease

81 mg or 325 mg if Enteric Coated

Daily

Diabetics 4x more likely to die of cardiovascular complications / disease

Contraindicated with clients with aspirin allergy

Incretin Mimetics

Byetta

Incretin mimetic is used in type 2 diabetic

Predialed pen

Last 30 days

Mimics many of the action of naturally occurring hormones form the intestines

Helps body make more of own insulin

Action: Insulin production signals the pancreas to make the right amount

Inject 2x day morning afternoon, dose 5 mg,

Sugar production helps prevent the liver from making too much insulin

Side effect: nausea (made from snake spit)

Food breakdown helps to slow down the rate in which the food leaves the stomach

Control weight

Should be stored in fridge at 37 celsius

After in fridge can be at room temp at 77 degrees, screw needle on

Nursing Interventions

Education

Develop diabetic teaching plan

Teaching survival

Assessing readiness to learn

Determining teaching methods

Complications

DKA – life threatening metabolic acidosis, Ketones in blood

Onset <24 hrs

Cause: Decreased insulin, Infection

CNS depression, coma

Clinical manifestation

Metabolic acidosis (from ketosis)

thirst

Weakness

Warm, dry skin with poor turgor

Malaise

Soft eyeballs

Rapid, weak pulse

Hypotension

Dry mucus membranes

Manifestations of diabetic ketoacidosis

Nausea vomiting

Lethargy

Fruity breath

Coma

Other manifestations

Abdominal pain (cause unknown)

Kussmaul's respirations - increased rate and deep, longer expiration – blow off CO2 trying to decrease ph

DKA cont

Risk factors

Triggered by emotional stress

Infections

Trauma

Insufficienct insulin administration

**Must be given on time**

DKA cont

Lab

Serum >250

Plasma <7.35

Ketones +

Serum osmol: 300-350

Urine ketones+

NA, Cl, K abnormal

Treatment: Insulin 1^st 12 hrs require 8-10 liters of fluid NS 200 cc/hr

Intravenous fluid & Electrolytes

usually on floor

if blood sugar high, run NS (1st 12 hrs maybe 2000 cc), after blood sugar, give D5w to prevent hypoglycemia (can get cerebral edema),

Hyperosmolar Hyperglycemic State

Metabolic problem

Occurs in type 2 diabetes

Characterized by serum osmo of 340 mOsm/l or greater

Elevated glucose 600 mg/dL

Higher mortality rate than DKA if uncontrolled

Onset: Can occur in type 1 or 2 but is more prevalent in type 2

Slow onset several days

Causes: Decrease in insulin

Older age

HHS cont.

Risk facts

Trauma

Surgery, dialysis

Dehydration

Illness

Medication

Assessment

Flushed skin red

Thirst

Decrease in BP

Increased pulse

Level of conscious decreased

Seizures

Abdominal pain

Lab finding

Glucose >600

Ketones normal

Urine glucose increased

K, NA, CL abnormal

Serum osmol >340

Treatment: Administer insulin, On insulin drip check q 1hr

Intravenous fluids:

Correcting fluid and electrolyte protocol – standing orders

Replace K+

Admitted to ICU

Hypoglycemia "insulin shock or insulin rxn" mainly type 1

Description

Low blood glucose levels

Onset rapid

Increase in insulin

Omitting meals

Error in insulin dose – too much insulin given **do not round up on insulin**

Common in type 1

Occasionally occurs in type 2

Onset: rapid

Causes: Increased insulin

Manifestations of hypoglyemcia

Hunger

Shakiness

Nausea

Irritable

Anxiety

Sweating

Pale cool skin

Decrease in BP

Rapid pulse

Increased anxiety

Hypoglycemia cont.

Risk factors

surgery

alcohol intake

trauma

lipodystrophy – not getting absorbed

Exercise

Hypoglycemia

Lab finding

Serum Glucose less than 50 some below 70 treat below 70

Urine glucose normal

Na, K, Cl normal

Serum osmol normal

Ketones –absent

Serum osmo normal

Treatment: Glucagon, Rapid acting carbohydrates, **Give apple juice** brings it up faster than OJ

**Check blood sugar first* then treat,

If continue to go down, glucagon can give IM if drops below 50 can seizure, give 10 minutes, check treat again.

If they can talk can take glucagon orally give soft stuff

Rapid acting carbohydrate, candy, crackers, honey, peanut butter

Give at least 15 grams of carbohydrates

If below 70 give D50 use syringe in blue box only give IV (not all pts have IV)

Hard to push in

T.I.R.E.D.

Tired/tachycardia

Irritability

Restless

Excessive hunger

Diaphoresis/depression

Cold and clammy means you need some candy

Hot and dry means your sugar is high

Sick day management

Taking your meds

Test blood glucose

Stay hydrated

Are all parts of managing your diabetes while sick

Sick Day plan

Monitor blood glucose 4x day

Usual insulin dose or oral

8-12 oz drink per hour

Substitute easily digested liquid or soft foods if solid food no tolerated– of carbohydrate equivalent

Replace small carbohydrates

Call MD if client is unable to eat for 24 hrs

If B/S >240 for 24 hrs or >350 at any time

May be nauseated can get hypoglycemia

Stress to body makes blood sugar go up

So if blood sugar high, interpret as stress,

Surgery puts stress on body

Trauma, check blood sugar, sliding scale on insulin

Chronic complications

macrovascular complications results

From changes in the medium to large blood vessels

Blood walls thicken scleroses

50-60% of CAD

Cerebral vascular disease

Peripheral vascular disease – amputation is a possibility

Stroke

Myocardial infarction twice as common

Mainfestations caused by impaired cerebral function

Strange unusual feeling CVA

Slurred speech

Blurred vision

Difficulty thinking – decreased LOC

Change in emotional behavior

Inability to concentrate

seizures

Coma

Diabetic retinopathy

Microvascular changes affecting retina

Deterioration of small blood vessels which nourishes the retina

Sx painless blurry vision, Macular edema

Leading cause of blindness

Treatment: A yearly opthalmology visit

Diabetic Nephropathy

Secondary to Microvascular in the kidney

Diabetic accounts for half of new cases of end stage renal diseases each year in the USA

Hypertension

Protein in urine spilled bad – messing up kidney

Treatment:

Achieving and maintaining near normal glucose levels

Control hypertension –

use ACE inhibitor – protect kidney

Prevent UTI

Avoidance of nephrotoxic substances

If GFR is High, this is good, this means good filtration, healthy kidney

If GFR value is low, this is bad, unhealthy kidney

Protein in urine – decrease in renal function

Diabetic neuropathies

Description

A group of diseases that affects all types of nerves including peripheral and spinal

Peripheral neuropathy

Lower extremities

Manifestations

Feet becomes

Numb especially at night

Deformities Of charcot joint abnormal joint distribution on joint due to lack of proprioception

Give neurontin, lot of amputations

Take care of lower extremities, Pulse hard to find, pulses of 1, & Decreased tendon reflexes; Joint distribution uneven on joint due to lack of proprioception

Pharmacologic Management

Analgesic

Elevil – tricyclic antidepressant

Phenytoin –dilantin

Mexeletine (anti-arrhythmic)

TENS unit

Autonomic neuropathies

Related to gastrointestinal delayed gastric emptying

Gastral paresis

Renal urinary retention

Cardio tachycardia

Orthostatic hypotension

Silent MI – pain not know about chest pain

Sexual dysfunction can use penile pump

Impotence in men

In women decrease lubrication and decrease libido

Lack of orgasm

Foot and Leg problems

Foot and leg problems

50-75 % of lower extremity amputations are performed on people with diabetes

50% are preventable

If diabetic are educated about foot care measures and practice them on a daily basis

Client teaching

Inspect daily for redness blisters changes in temp

Properly bathe and dry feet

Wear closed toe shoes

Wear shower shoes

Shoes that fit

Trim toe nails straight across

Avoid walking barefoot

Not wear flip-flops in summer

Bring own equipment for pedicure so not get infection in salon, could get amputation

Consult podiatrist yearly for food exam

Wear socks

Nursing Interventions

Maintaining blood glucose

Definitions of normal blood glucose levels vary in clinical practice, depending on the laboratory that performs the assay

Pharmacologic treatment for diabetes mellitus depends on the type of diabetes

Dietary management for adults for adults with diabetes, based on guidelines established by the ADA

The ability to maintain an exercise program is affected by many different factors

Nursing interventions

Insulin

Monitor storage and expiration of insulin

Montor blood glucose reading

Monitor food intake

Oral hypoglycemics

Administer with food

Assess diet and exercise

Monitor for hypo/hyperglycemia

Assess for side effects

Self management of DM

Maintain prescribed diet & exercise

Insulin needs are increased if you have surgery, trauma, fever, or infection

Monitor blood glucose

Undergo periodic lab evaluations

Take medications as prescribed

Some medications (oral) may interfere with oral contraceptives

Report any illness side effects to health care provider

Avoid alcohol

Get a flu shot yearly and pneumonia shot every 5 yrs.

Nursing diagnoses

Health promotion

Assessment

Risk for impaired skin integrity

Risk for infection

Risk for injury

Sexual dysfunction

Ineffective coping