Adult health Exam One Notes Side Notes

Power Points
Diabetes
Classification of diabetes:
Type 1 diabetes mellitus - is an autoimmune dysfunction involving the
destruction of beta cells, which produce insulin in the islets of Langerhans of the
pancreas.

Type 2 diabetes mellitus - is a progressive condition due to increasing inability of

cells to respond to insulin (insulin resistance) and decreased production of insulin
by the beta cells. It is linked to obesity, sedentary lifestyle, and heredity.
Metabolic syndrome often precedes type 2 diabetes mellitus.

Diabetic screening
Screening is done with fasting serum glucose levels or glycosylated hemoglobin
(A1C).
Screen clients who have BMI greater than 25 and age greater than 45

Determining risk factors

Obesity, Hypertension, Sedentary lifestyle, Hyperlipidemia, Cigarette smoking,
Genetic history, Ethnic group, Women who have polycystic ovary syndrome,
Women who deliver a 9lb baby

Expected findings
Hyperglycemia glucose greater than 250mg/dL
Polyuria
Polydipsia
Polyphagia
Other finding includes – Weight loss, Nausea and vomiting for type 1 diabetics.
Fatigue, weakness, Vision changes, Slow healing of wounds, recurrent infections.

Lab test
Fasting glucose greater than 126 mg/dL
2-hr glucose greater than 200 mg/dL with oral glucose tolerance test
Hemoglobin A1C greater than 6.5% over 90 days.

Diagnostic procedures
Self-monitored blood glucose (SMBG)

Medications (Insulin)
 Rapid acting insulin (Aspart, Lispro, Glulisine)
Onset 15 – 30 mins. Peak 30mins – 1Hr, Duration 2 - 6hrs
 Short acting insulin (regular insulin)
Onset 30 mins – 1hr. Peak 1- 5 hrs, Duration 6 - 10hrs
 Intermediate ( NPH )
Onset 1-2hrs, Peak 6 -14hrs, Duration 16 -24hrs
 Long acting (Lantus glargine) Onset – 70 mins. No peak, Duration 24hrs

Oral hypoglycemics
Biguanides- metformin
 Reduce the production of glucose by the liver, increase tissue sensitivity to
insulin and slows carbohydrate absorption in the intestines.
Monitor for GI effects (flatulence, anorexia, nausea/vomiting) lactic acidosis in
clients with kidney/liver problems. Take with food, vitamin B12 and folic acid.
Metformin off-use label for PCOS.
Sulfonylureas- glipizide, glimepiride, glyburide
 It stimulates insulin release from the pancreas causing hypoglycemia, increase
tissue sensitivity to insulin. Beta-blockers can mask tachycardia seen during
hypoglycemia. Administer 30 mins before meal.
Nurse instruct Pt to avoid alcohol while taking this medication

Meglitinides- Repaglinide, Nateglinide

 Stimulate insulin release from the pancreas.
Administer for post-meal hyperglycemia. Monitor for hypoglycemia, monitor
Take 15-30mins before meal, must eat within 30 mins. Do not take if you skip a
meal

Thiazolidinediones - Pioglitazone
 Reduces glucose production by the liver, increase tissue sensitivity.
Monitor for fluid retention especially in clients with heart failure also
monitor for ALT, LDH, triglycerides levels. Report weight gain, SOB, or decrease in
exercise tolerance.

Alpha-glucosidase inhibitors – Arcabose, Migitol

 Slows carbohydrate absorption and digestion
Monitor GI discomfort, Anemia due to iron loss and hepatoxicity.

DPP-4 inhibitors (gliptins) – Sitagplitin, saxagliptin,

 Enhances naturally occurring incretin hormones, which promote release of
insulin and decrease secretion of glucagon.
There are generally no side effects.

SGLT-2 inhibitors - Canagliflozin

 Blocks the reuptake of glucose by the kidneys.
Monitor for development of UTI.

Non-Insulin injectable Medications

Incretin mimetic – Exenatide, Liraglutide
 Mimics the function of intestinal incretin hormone by decreasing glucagon
secretion and gastric emptying.
Do not administer after a meal.
Amylin Mimetic – Pramlintide
 Synthetic amylin hormone found in beta cells of the pancreas. Suppresses
glucagon secretion.
Don’t administer if client has hypoglycemia / poor adherence to SMBG.

Nursing Care
 Monitor glucose levels and other factors that affect glucose levels such as
medications.
 Monitor I&O and weight.
 Skin integrity and wound healing
 Sensory alterations (tingling, numbness)
 Visual alterations
 Dietary / nutritional/ exercise habits
 Self administration of medications
Foot Care
 Cut nails after shower when they are soft. cut them straight across.
 Inspect feet daily, pat dry feet gently
 Use mild foot powder, do not use commercial remedies
 Wear close to shoes, absorbent cotton socks
 Cleanse cuts with warm water
 Nutrition
 Restrict caloric intake and increase physical activities
 Include fiber
 Read and interpret fat content, keep saturated fat within 7%
 Use artificial sweeteners
 Do not skip meals, eat on time
 Carbohydrate 45% of total daily intake
 Protein 15-20% of total intake base off kidney function

Illness (Sick Day Rules)

 Follow sick day protocol
 Notify PCP if glucose is greater than 240mg/dL.
 Consume 4 oz of sugar -free drinks.
 Take usual dose of insulin and oral antidiabetic agents.
 Eat small and frequent carbohydrate foods
 Test blood glucose for ketones.

Complications
 Cardiovascular and cerebrovascular disease (hypertension, myocardial
infraction, stroke)
 Diabetic retinopathy (impaired vision and blindness)
 Diabetic neuropathy (damage to sensory nerves causing numbness and
pain)
 Diabetic nephropathy (damage to kidneys from prolong high glucose and
 dehydration), monitor creatinine, blood pressure, and output less than
30ml/hr.
 Infection and slow wound healing

Hypoglycemia Hyperglycemia
Cool and clammy, give some candy Hot and dry, sugar is high Administer Glucagon in a comatose
BG levels are below 60mg/dl BG levels are above 250mg/dl situation.
S/S S/S
Mental status: anxious, nervous, Dry skin, fruity acetone breath.
irritable, sweating, confusion,
palpitations, blurred vision, seizures,
coma.

Diabetic Ketoacidosis (DKA) HHS – Hyperglycemic

Acute Life-threatening complication of
type 1 diabetes, where there is
uncontrolled hyperglycemia greater
than 300mg/dl and the body breaks
down fats for energy resulting in
accumulation of ketones in the blood.
Hyperosmolar State
Acute life-threatening complication
associated with type 2 diabetes. BG
levels of over 600mg/dl. Ma result in
coma and even death.
 Upper Respiratory Infections
(Rhinitis, Sinusitis, Influenza, Pneumonia)
Rhinitis
Rhinitis is an inflammation of the nasal mucosa and often the mucosa of the
sinuses that is caused by viral or bacterial or allergens. The cold is caused by virus
spreading from person to person via droplets from sneezing and coughing or
direct contact.

Risk/Contributing Factors
 Young or advance age
 Smoking and exposure to secondhand smoke.
 Exposure to viral, bacterial, or influenza infections
 Not being immunized against pneumonia and flu
 Exposure to plants, pollen, molds, pet dander, foods, medications and
environmental contaminants

Expected findings / Manifestations

Excessive nasal drainage, runny nose, nasal congestion, Purulent nasal discharge,
Sneezing, and pruritus of the nose, throat and ears, Sore, dry throat, Red inflamed
swollen nasal mucosa, Low grade fever.

Diagnostic test
 Diagnostic test involves allergy test to identify allergen

Disease Prevention / Client education

 Hand hygiene
 Complementary therapies (vitamin C, echinacea, lozenges and nasal spray)
 Stay away from others to prevent and reduce transmission

Nursing care /Client education

Encourage rest (8 to 10 hr/day) and increased fluid intake (at least 2,000 mL/day)
Encourage the use of a home humidifier.
Teach proper disposal of tissues and use of cough etiquette (sneeze or cough into
tissue, elbow or shoulder and not the hands)

Medications

Complications

Medications
Antihistamine such as brompheniramine/ pseudoephedrine; reduce
inflammation of nasal membranes
leukotriene inhibitors such as montelukast
❏ mast cell stabilizers such as cromolyn
Older adults should be aware of adverse effects such as vertigo, hypertension, and
urinary
retention.
❏ Decongestants, such as phenylephrine, constrict blood vessels and decrease
edema.
Encourage clients to use as prescribed for 3 to 4 days to avoid rebound nasal
congestion.
❏ Intranasal glucocorticoid sprays are the most effective for prevention and
treatment of
seasonal and perennial rhinitis.
❏ Antipyretics are used if fever is present.
❏ Antibiotics are given if a bacterial infection can be identified.
Patient education
❏ Review hand hygiene as a measure to prevent transmission.
❏ Complementary therapies such as echinacea, large doses of vitamin C, and zinc
preparations (lozenges and nasal sprays) can be useful in promoting improved
immune
response.
❏ Limiting exposure to others will prevent and reduce transmission.
SINUSITIS - often occurs after rhinitis and can be associated with a deviated nasal
septum, nasal
polyps, inhaled air pollutants or cocaine, facial trauma, dental infections, or loss of
immune
function. The infection is commonly caused by Streptococcus pneumoniae,
Haemophilus
influenzae, diplococcus, and bacteroides.
Expected findings
❏ Nasal congestion
❏ Headache
❏ Facial pressure or pain (worse when head is tilted forward)
❏ Cough
❏ Bloody or purulent nasal drainage
❏ Tenderness to palpation of forehead, orbital, and facial areas
❏ Low-grade fever
6
Nursing care
❏ Encourage the use of steam humidification, sinus irrigation, saline nasal sprays,
and hot
and wet packs to relieve sinus congestion and pain.
❏ Teach the client to increase fluid intake and rest
❏ Discourage air travel, swimming, and diving.
❏ Encourage cessation of tobacco use in any form.
❏ Instruct the client on correct technique for sinus irrigation and self-
administration of nasal
sprays
Medication
❏ Nasal decongestants, such as phenylephrine, are used to reduce swelling of the
mucosa
❏ road-spectrum antibiotics, such as amoxicillin, are used on a limited basis for a
confirmed
causative bacterial pathogen.
❏ Pain relief medications include NSAIDs, acetaminophen, and aspirin
Patient education
❏ Sinus irrigation and saline nasal sprays are an effective alternative to antibiotics
for
relieving nasal congestion.
❏ Contact the provider for manifestations of a severe headache, neck stiffness
(nuchal
rigidity), and high fever, which can indicate possible complications
Complications
❏ Meningitis and encephalitis can occur if pathogens enter the bloodstream from
the sinus
cavity
Diagnostic procedure
❏ CT scan or sinus x-rays confirm the diagnosis, which is typically based upon
findings and
physical assessment.
❏ Endoscopic sinus cavity lavage or surgery to relieve the obstruction and
promote drainage
of secretions may be done.
INFLUENZA- ( Seasonal influenza, or “flu, ”) occurs as an epidemic, usually in the
fall and
winter months, is a highly contagious acute viral infection that occurs in children
and adults of all
ages, it can be caused by one of several virus families, and this can vary yearly.
Adults are
contagious from 24hr before manifestations develop and up to 5 days after they
begin. Pandemic
influenza refers to a viral infection among animals or birds that has mutated and is
becoming
highly infectious to humans. The resulting viral infection has the potential to
spread globally,
such as H1N1 (“swine flu”) and H5N1 (“avian flu)
Disease prevention
❏ Flu vaccine such as an IM injection of Fluvirin or Fluzone and a live attenuated
influenza
vaccine by intranasal spray
7
Risk factors
❏ Clients who have a history of pneumonia, chronic medical conditions, and those
over age
65, pregnant women, and health care providers
Expected findings
❏ Severe headache and muscle aches
❏ Chills
❏ Fatigue, weakness
❏ Severe diarrhea and cough (avian flu)
❏ Fever
❏ Hypoxia (avian flu.
Nursing care
❏ Maintain droplet and contact precautions for hospitalized clients who have
pandemic
influenza.
❏ Provide saline gargles.
❏ Monitor hydration status, intake, and output.
❏ Administer fluid therapy as prescribed.
❏ Monitor respiratory status
Medications
❏ Antivirals ( Amantadine, rimantadine, and ribavirin )may be prescribed for
treatment
and prevention of influenza.
❏ Duration of the influenza infection can be shortened by antivirals such as the
oral
inhalant zanamivir and the oral tablet oseltamivir that are given in cases of
pandemic
influenza for free. Begin antiviral medications within 24 to 48 hr after the onset of
manifestations
Patient education
❏ Encourage annual influenza vaccination when vaccines become available.
❏ Reduce the risk for spreading viruses by thoroughly washing hands and
following cough
etiquette.
❏ Avoid places where people gather. Avoid close personal contact (handshaking,
kissing and
hugging).
❏ If flu manifestations develop, increase fluid intake, rest and stay home from
work or
school.
❏ Avoid travel to areas where pandemic influenza is identified.
❏ Be aware of public health announcements and activation of the early warning
system by
public health officials in case of pandemic influenza.
Interprofessional care
❏ Respiratory services should be consulted for respiratory support.
❏ Community health officials are notified of influenza outbreaks.
8
❏ State and federal public health officials are consulted for containment and
prevention
directives during pandemic influenza
PNEUMONIA- primary or secondary infection to other conditions where tissue
resistance is
reduced. It can be caused by aspiration
Expected findings
❏ Anxiety
❏ Fatigue
❏ Weakness
❏ Chest discomfort due to coughing
❏ Confusion from hypoxia is the most common manifestation of pneumonia in
older adult
clients.
PHYSICAL ASSESSMENT FINDINGS
❏ Fever
❏ Chills
❏ Flushed face
❏ Diaphoresis
❏ Shortness of breath or difficulty breathing
❏ Tachypnea
❏ Pleuritic chest pain (sharp)
❏ Sputum production (yellow-tinged)
❏ Crackles and wheezes
❏ Coughing
❏ Dull chest percussion over areas of consolidation
❏ Decreased oxygen saturation levels (expected reference range is 95% to 100%)
❏ Purulent, blood-tinged or rust-colored sputum, which may not always be
present
Nursing care
❏ Position the client to maximize ventilation (high-Fowler’s = 90%) unless
contraindicated.
❏ Encourage coughing or suction to remove secretions.
❏ Administer breathing treatments and medications.
❏ Administer oxygen therapy.
❏ Monitor for skin breakdown around the nose and mouth from the oxygen
device.
❏ Encourage deep breathing with an incentive spirometer to prevent alveolar
collapse.
❏ Determine the client’s physical limitations and structure activity to include
periods of rest.
❏ Promote adequate nutrition and fluid intake.
◯The increased work of breathing requires additional calories.
9
◯Proper nutrition aids in the prevention of secondary respiratory infections.
◯Encourage fluid intake of 2 to 3 L/day to promote hydration and thinning of
secretions,
unless contraindicated due to another condition.
❏ Provide rest periods for clients who have dyspnea.
❏ Reassure the client who is experiencing respiratory distress
Medications
❏ Antibiotics are given to destroy infectious pathogens. Commonly used
antibiotics include
( penicillins and cephalosporins )
❏ Anti-inflammatories decrease airway inflammation .
❏ Glucocorticosteroids, such as fluticasone and prednisone , are prescribed to
reduce
inflammation. Monitor for immunosuppression, fluid retention, hyperglycemia,
hypokalemia, and poor wound healing
❏ Bronchodilators are given to reduce bronchospasms and reduce irritation
(short-acting
bet a2 agonists albuterol , provide rapid relief).
❏ Cholinergic antagonists (anticholinergic medications), such as ipratropium ,
block the
parasympathetic nervous system, allowing for increased bronchodilation and
decreased
pulmonary secretions.
❏ Methylxanthines , such as theophylline , require close monitoring of serum
medication
levels due to the narrow therapeutic range.
Patient education
❏ Drink plenty of fluids to promote hydration.
❏ Take glucocorticosteroids with food.
❏ Avoid discontinuing glucocorticosteroids without consulting the provide
❏ Take rest periods as needed.
❏ Hand hygiene to prevent infection.
❏ Avoid crowded areas to reduce the risk of infection.
❏ Get immunizations for influenza and pneumonia.
❏ Promote smoking cessation if needed
Lab test
❏ Sputum culture and sensitivity
❏ Obtain specimen by suctioning if the client is unable to cough.
❏ CBC: Elevated WBC count (might not be present in older adult clients)
❏ ABGs: Hypoxemia (decreased PaO2 less than 80 mm Hg)
❏ Blood culture: To rule out organisms in the blood
❏ Serum electrolytes: To identify causes of dehydration
Diagnostic procedure
❏ Chest x ray
❏ Pulse oximeter
Interprofessional care
10
❏ Respiratory services should be consulted for inhalers, breathing treatments, and
suctioning
for airway management.
❏ Nutritional services can be contacted for weight loss or gain related to
medications or
diagnosis.
❏ Rehabilitation care can be consulted if the client has prolonged weakness and
needs
assistance with increasing level of activity.
Complications
❏ Atelectasis
●Airway inflammation and edema lead to alveolar collapse and increase the risk
of
hypoxemia.
●client reports shortness of breath and exhibits findings of hypoxemia.
●client has diminished or absent breath sounds over the affected area.
chest x-ray shows an area of density.
❏ Bacteremia (sepsis): This occurs if pathogens enter the bloodstream from the
infection in
the lungs.
❏ Acute respiratory distress syndrome
●Hypoxemia persists despite oxygen therapy.
●Dyspnea worsens as bilateral pulmonary edema develops that is non cardiac
related.
●A chest x-ray shows an area of density with a ground-glass appearance.
●Blood gas findings demonstrate high arterial blood levels of carbon dioxide
(hypercarbia) even though pulse oximetry shows decreased saturation.