Nrsg 544 Primary Care

Front 1

Gallbladder Disease: Diagnosis

Back 1

serologic testing and imaging are required

Front 2

Gallbladder Disease

Back 2

a. Episodic pain->acute cholecystitis and complications r/t the passage of stones
b. Biliary colic

Front 3

Gallbladder Disease: Management

Back 3

a. surgical referal for acute cholecystits
b. education and counseling

Front 4

Lower GI Tract

Back 4

1. Appendicitis
2. Diverticular Disease

Front 5

Lower GI Tract: Appendicitis

Back 5

1. variable PE and lab results
2. positive psoasis and obturators sign
3. rebound tenderness
4. surgical referal immediate
5. see often in elderly

Front 6

Lower GI Tract: Diverticular Disease

Back 6

1. also see frequently in elderly
2. etiology unknown
3. asymptomatic (found on barium enema or colonoscopy)
4. encourage high fiber diet (low ruffage like seeds)
5. may require surgery
6. see most often in those over age 40 and in the sigmoid and distal colon

Front 7

Acute Infectious Gastroenteritis

Back 7

1. major cause is viral diarrhea
2. initial diagnostic tests- stool specimen, serum electrolytes, CBC to check for bleeding, and BC if systemic infection suspected

Front 8

Acute Infectious Gastroenteritis: Clinical Presentation (inflammatory vs. non-inflammatory diarrhea)

Back 8

1. inflammatory- disruption of mucosal barrier, bloody diarrhea, lower abdominal cramping, small volume stools, fever, if > one week do stool C&S, try OTC Immodium and/or BRATT diet, causasitive agent possibly shigella, campylobacter, salmonella, and/or e.coli
2. non-inflammatory- not due to damage to intestinal epithelium, large volume and watery diarrhea, most common causastitive agent giardia, rotavirus, and/or food poisoning (s.aureus)

Front 9

Acute Infectious Gastroenteritis: Diagnosis

Back 9

1. stool tests- Wright's stain/fecal leukocytes, culture, and c.diff toxin
2. CBC
3. BUN

Front 10

Acute Infectious Gastroenteritis: Management

Back 10

1. supportive- rehydration, dietary changes, Gatorade, avoid dairy products, BRATT diet
2. meds- bismuth subsalicylate (pepto bismol)
3. education and counseling

Front 11

Chronic Diarrhea

Back 11

1. persists longer than 3-4 weeks
2. six categories- secretory, malabsorptive (steatorrhea), osmotic, exudative/bloody, dysmotility, or functional

Front 12

Constipation

Back 12

most common digestive complaint in the USA

Front 13

If a pt presents with consistent diarrhea and is 35 yo or older you would...

Back 13

refer to GI for a colonoscopy

Front 14

Hemorrhoids

Back 14

1. can cause itching, burning, soiling, or pain
2. encourage cleansing after each bowel movement
3. avoid constipation
4. Annusol HC
5. education

Front 15

Anal Fissures

Back 15

1. severe pain
2. stool softeners
3. education regarding risk of HIV with anal receptive intercourse

Front 16

IDDM/Type One DM

Back 16

1. autoimmune
2. can occur at any age, highest incidence ages 10-14
3. only 5-10% of those with DM
4. asymptomatic periods as long as 5-10 years, especially in late onset autoimmune diabetes
5. tend to not be obese
6. onset usually more abrupt
7. same symptoms- weight loss, polyuria, and polydipsia
8. causes ABSOLUTE insulin deficiency
9. many new cases dx when pt presents in DKA
10. screening should be done on all at risks persons at age 30 and older; if normal, repeat at 3 year intervals
11. test at younger age if- obese, family hx, member of high risk group, had a baby greater than 9#, they themselves were greater than 9# at birth, have HTN, HDL <35, triglycerides >250, had IFG or IGT, physical inactivity, or they have PCOS

Front 17

PCOS

Back 17

typically with be put on oral diabetic med (i.e. Metformin) and insulin

Front 18

Type One DM: Risk of Developing

Back 18

1. 1% have no family hx
2. 25-50% if your identical twin has type one
3. 6% if your father has type one
4. 4% of moms <25 at the time of their childs birth

Front 19

Type One DM

Back 19

1. diagnosed after 90% of the beta cells have been destroyed
2. TOTALLY DEPENDENT ON EXOGENOUS INSULIN (insulin should never be stopped for even a short period; only if BG <60)
3. 90% have certain HLA types (DR3 and/or DR4 loci)
4. trigger unknown

Front 20

Type One DM: Destruction of Beta Cells results in...

Back 20

1. loss of first phase insulin response (surge in insulin release with food ingestion)
2. progressive impairment in total insulin response
3. clinically detected hyperglycemia

Front 21

Type One DM

Back 21

mass screening for type one not currently recommended

Front 22

Markers for Type One DM (triggers to check a pt)

Back 22

1. insulin autoantibodies (may not develop)
2. islet cell antibodies (may not develop)
3. glutamic acid decarboxylase antibodies (GAD)- MOST SENSITIVE

Front 23

Type One DM: Treatment

Back 23

1. exogenous insulin injections
2. goal of insulin therapy is to mimic mother nature
3. basal level insulin required varies by time of day

Front 24

Dawn Phenomenon

Back 24

1. common in everyone
2. counter-regulatory hormones secreted at night which increase BG levels around 5am
3. purpose is to feed the brain (keep BG constant at 60)
4. it is the hardest BG to control ("fix the fasting first")

Front 25

Type One DM: Insulin Needs

Back 25

1. start- 0.2 x body wt. in #
2. avg. dose- 0.3 x body wt. in #
3. give in 2,3, or more injections

Front 26

Honeymoon Phase

Back 26

occurs after the start of treatment

Front 27

Type One DM: 2 Injection Regimen

Back 27

1. NPH & Regular or Lispro/Aspart given together before morning and evening meals
2. *Is most effective when some insulin production remains*
3. give 40% NPH & 15% regular in AM; give 30% NPH & 15% regular in PM
4. limitations include poor peaking of noon insulin and excess insulin at night (we need less insulin at about 3am); resolutio is to limit size of noon meal and have a bedtime snack

Front 28

Two hour postprandial should be...

Back 28

<140

Front 29

Type One DM: 3 Injection Regimen

Back 29

1. NPH & Regular or Lispro/Aspart given before breakfast, Regular or Lispro before supper, and NPH at bedtime
2. limitation- poor peaking for noon meal
3. advantage- no noon injection; less risk of nocturnal hypoglycemia; better control of dawn phenomenon

Front 30

Type One DM: 4 Injections

Back 30

1. ideal; closest to nature
2. less opportunity for BG to drop at night
3. Regular or Lispro/Aspart before each meal
4. NPH or glargine/detemir at bedtime
5. 20-25% of insulin before each meal
6. 25-40% at bedtime
7. limitation- meals required every 5hrs if using insulin that peaks
8. advantage- clear relationship between insulin dose and glucose level

Front 31

NPH

Back 31

Have to use BID

Front 32

Lantus

Back 32

Made for all day coverage; easier; peakless

Front 33

Type One DM: Pump

Back 33

1. continous basal insulin delivery; more closely reproduces endogenous insulin release
2. more predicatable insulin absorption
3. provides adjustable bolus insulin to cover for meals and snacks
4. can be adjusted to cover Dawn Phenomenon
5. indications for use- inability to optimize blood glucose using multiple injections, poor response to modified insulin regimens, dawn glucose rise, pregnancy or pre-conception, early complications, or hypoglycemic unawareness

Front 34

DM: Pregnancy

Back 34

first and last 8 weeks are the most vital in fetal development

Front 35

Hypoglyemia Unawareness

Back 35

#1 indication for islet cell transplant

Front 36

Pump Contraindications

Back 36

1. if insluin need is low
2. reluctance to monitor BG QID
3. poor self-care
4. inablitiy to afford

Front 37

Adjusting Insulin

Back 37

1. down day after low BG
2. up- delay 2 to 3 days to establish pattern
3. base on daily BG and peak effect of a given insulin dose

Front 38

Peaks

Back 38

1. Lispro/Aspart 1-2 hrs
2. Regular 2-4 hrs
3. NPH 4-10 hrs
4. Glargine- none
5. Detemir- slight

Front 39

Desired BS

Back 39

100 (norm counter-regulation); 80 in pregnancy

Front 40

PP BG

Back 40

highly equates to babies weight

Front 41

Type One DM: Visual Changes

Back 41

need eyes dilated annually

Front 42

Type One DM: Renal Function Loss

Back 42

1. annual microalbumin measurement (start ACEI); first lab evidence of diabetic renal disease
2. quaterly BUN/Cr
3. periodic 24* urine for protein and CrCl
4. careful with IV dye, NSAID's, ampho B, and immunosuppressive drugs

Front 43

Peripheral Neuropathy

Back 43

usually worse at night and follows periods of metabolic instability like after starting insulin therapy (insulin neuritis); usually progress to insensitivity; treat with tricyclics, anticonvulsants, anti-arrhythmics, opioids, SSNRI's; may be caused by oxidative stress

Front 44

Reglan

Back 44

for gastroparesis and esophageal dysfunction

Front 45

Diabetic Diarrhea Treatment

Back 45

psyllium, kaopectate, cholestyramine, tetracycline, or pancreatic enzymes

Front 46

Diabetic Constipation

Back 46

1. most common problem
2. psyllium, sorbitol, lactulose, or miralax

Front 47

DM Type 2

Back 47

typically have had the disease 7 years prior to diagnosis