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NRSG 544 Primary Care


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Gallbladder Disease: Diagnosis
serologic testing and imaging are required
Gallbladder Disease
a. Episodic pain->acute cholecystitis and complications r/t the passage of stones
b. Biliary colic
Gallbladder Disease: Management
a. surgical referal for acute cholecystits
b. education and counseling
Lower GI Tract
1. Appendicitis
2. Diverticular Disease
Lower GI Tract: Appendicitis
1. variable PE and lab results
2. positive psoasis and obturators sign
3. rebound tenderness
4. surgical referal immediate
5. see often in elderly
Lower GI Tract: Diverticular Disease
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
Acute Infectious Gastroenteritis
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
Acute Infectious Gastroenteritis: Clinical Presentation (inflammatory vs. non-inflammatory diarrhea)
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)
Acute Infectious Gastroenteritis: Diagnosis
1. stool tests- Wright's stain/fecal leukocytes, culture, and c.diff toxin
2. CBC
3. BUN
Acute Infectious Gastroenteritis: Management
1. supportive- rehydration, dietary changes, Gatorade, avoid dairy products, BRATT diet
2. meds- bismuth subsalicylate (pepto bismol)
3. education and counseling
Chronic Diarrhea
1. persists longer than 3-4 weeks
2. six categories- secretory, malabsorptive (steatorrhea), osmotic, exudative/bloody, dysmotility, or functional
most common digestive complaint in the USA
If a pt presents with consistent diarrhea and is 35 yo or older you would...
refer to GI for a colonoscopy
1. can cause itching, burning, soiling, or pain
2. encourage cleansing after each bowel movement
3. avoid constipation
4. Annusol HC
5. education
Anal Fissures
1. severe pain
2. stool softeners
3. education regarding risk of HIV with anal receptive intercourse
IDDM/Type One DM
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
typically with be put on oral diabetic med (i.e. Metformin) and insulin
Type One DM: Risk of Developing
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
Type One DM
mass screening for type one not currently recommended
Type One DM: Destruction of Beta Cells results in...
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
Markers for Type One DM (triggers to check a pt)
1. insulin autoantibodies (may not develop)
2. islet cell antibodies (may not develop)
3. glutamic acid decarboxylase antibodies (GAD)- MOST SENSITIVE
Type One DM: Treatment
1. exogenous insulin injections
2. goal of insulin therapy is to mimic mother nature
3. basal level insulin required varies by time of day
Dawn Phenomenon
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")
Type One DM: Insulin Needs
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
Honeymoon Phase
occurs after the start of treatment
Type One DM: 2 Injection Regimen
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
Two hour postprandial should be...
Type One DM: 3 Injection Regimen
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
Type One DM: 4 Injections
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
Have to use BID
Made for all day coverage; easier; peakless
Type One DM: Pump
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
DM: Pregnancy
first and last 8 weeks are the most vital in fetal development
Hypoglyemia Unawareness
#1 indication for islet cell transplant
Pump Contraindications
1. if insluin need is low
2. reluctance to monitor BG QID
3. poor self-care
4. inablitiy to afford
Adjusting Insulin
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
1. Lispro/Aspart 1-2 hrs
2. Regular 2-4 hrs
3. NPH 4-10 hrs
4. Glargine- none
5. Detemir- slight
Desired BS
100 (norm counter-regulation); 80 in pregnancy
highly equates to babies weight
Type One DM: Visual Changes
need eyes dilated annually
Type One DM: Renal Function Loss
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
Peripheral Neuropathy
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
for gastroparesis and esophageal dysfunction
Diabetic Diarrhea Treatment
psyllium, kaopectate, cholestyramine, tetracycline, or pancreatic enzymes
Diabetic Constipation
1. most common problem
2. psyllium, sorbitol, lactulose, or miralax
DM Type 2
typically have had the disease 7 years prior to diagnosis

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