Transcript Chapter 44

Pharmacology for Nurses
A Pathophysiologic Approach
Third Edition
CHAPTER
44
Drugs for Diabetes
Mellitus
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Directory
Classroom Response System
Lecture Note Presentation
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NCLEX-RN Review
Question 1
A patient receives NPH (Isophane) insulin at
7:30 A.M. Based on an understanding of
peak time, the nurse should assess the
patient for hypoglycemia at what time?
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Question 1 – Answer
1600
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Question 1 – Rationale
Rationale: The onset of NPH is between 1
and 4 hours, and it peaks between 8 and 12
hours.
Cognitive Level: Application
Nursing Process: Assessment
Patient Need: Physiological Integrity
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Question 2
The patient is scheduled to receive 5 units of
Humalog and 25 units of NPH(Isophane)
insulin prior to breakfast. What nursing
intervention is most appropriate for this
patient?
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Question 2 – Choices
1. Make sure the patient’s breakfast is
ready to eat before administering this
insulin.
2. Offer the patient a high-carbohydrate
snack in 6 hours.
3. Hold the insulin if the blood glucose level
is greater than 100 mg/dL.
4. Administer the medications in two
separate syringes.
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Question 2 – Answer
1. Make sure the patient’s breakfast is
ready to eat before administering this
insulin.
2. Offer the patient a high-carbohydrate
snack in 6 hours.
3. Hold the insulin if the blood glucose level
is greater than 100 mg/dL.
4. Administer the medications in two
separate syringes.
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Question 2 – Rationale
Rationale: Humalog is a rapid-acting insulin that is
administered for elevated glucose levels and
should be given 0 to 15 minutes before breakfast.
Hypoglycemic reactions may occur rapidly if
Humalog insulin is not supported by sufficient food
intake. The medication can be mixed in one
syringe.
Cognitive Level: Application
Nursing Process: Implementation
Patient Need: Physiological Integrity
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Question 3
The nurse is initiating discharge teaching
with the newly diagnosed diabetic. Which of
the following statements indicates that the
patient needs additional teaching?
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Question 3 – Choices
1. “If I am experiencing hypoglycemia, I
should drink ½ cup of apple juice.”
2. “My insulin needs may increase when I
have an infection.”
3. “I must draw the NPH insulin first if I am
mixing it with regular insulin.”
4. “If my blood glucose levels are less than
70 mg/dL, I should notify my health care
provider.”
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Question 3 – Answer
1. “If I am experiencing hypoglycemia, I
should drink ½ cup of apple juice.”
2. “My insulin needs may increase when I
have an infection.”
3. “I must draw the NPH insulin first if I
am mixing it with regular insulin.”
4. “If my blood glucose levels are less than
70 mg/dL, I should notify my health care
provider.”
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Question 3 – Rationale
Rationale: Additional teaching is needed.
The clear solution (regular insulin) should be
drawn into the syringe first followed by the
cloudy solution (NPH). The other options
demonstrate an understanding of discharge
instructions.
Cognitive Level: Analysis
Nursing Process: Evaluation
Patient Need: Physiological Integrity
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Question 5
A type 2 diabetic has been NPO since
midnight for surgery in the morning. He has
been on a combination of oral hypoglycemic
agents (OHAs). What would be the best
action for the nurse to take concerning the
administration of his medications?
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Question 5 – Choices
1. Hold all medications as per the NPO
order.
2. Give him the medications with a sip of
water.
3. Give him half the original dose.
4. Contact the health care provider for
further orders.
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Question 5 – Answer
1. Hold all medications as per the NPO
order.
2. Give him the medications with a sip of
water.
3. Give him half the original dose.
4. Contact the health care provider for
further orders.
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Question 5 – Rationale
Rationale: The health care provider should be
contacted for further orders. The need for oral
hypoglycemic medication may have been
overlooked or other measures, such as insulin, to
treat glucose needs during the surgery may be
planned. Contacting the provider ensures that the
provider is aware that the patient is a diabetic and
is aware that no medications for diabetes were
ordered.
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Question 5 – Rationale (cont)
Holding all medications as ordered will not address
the patient’s glucose needs during surgery.
Intravenous fluids during this time may contain
glucose solutions, resulting in a hyperglycemic
condition. It is not within the nurse’s scope of
practice to independently change a medication
dosage order or to give medications when an NPO
order has been written. The provider should be
contacted before these decisions are carried out.
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Question 5 – Rationale (cont)
Cognitive Level: Application
Nursing Process: Implementation
Patient Need: Physiological Integrity
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Question 6
A 63-year-old patient with type 2 diabetes is
admitted to the nursing unit with an infected
foot ulcer. Despite previous good control on
glyburide (Micronase), his blood sugar has
been elevated the past several days and he
requires sliding scale insulin. The most likely
for this is:
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Question 6 – Choices
1. It is a temporary condition related to the
stress response with increased glucose
release.
2. He is converting to a type 1 diabetic.
3. The oral hypoglycemic drug is no longer
working for him.
4. Diabetics who are admitted to the
hospital are switched to insulin for safety
and tighter control.
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Question 6 – Answer
1. It is a temporary condition related to
the stress response with increased
glucose release.
2. He is converting to a type 1 diabetic.
3. The oral hypoglycemic drug is no longer
working for him.
4. Diabetics who are admitted to the
hospital are switched to insulin for safety
and tighter control.
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Question 6 – Rationale
Rationale: The stress of hospitalization and
infection may cause the release of glucose as a
response to this stress. Blood glucose levels will
continue to be monitored and control may improve
as the infection clears and the patient is
discharged. The pathogenesis of type I and type II
diabetes is different. Type II diabetics may
eventually need insulin but for reasons other than
the pathogenesis of type I.
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Question 6 – Rationale (cont)
Immediate changes in response to an oral
hypoglycemic drug are not known and
diabetics may continue to take all-oral
medications while in the hospital.
Cognitive Level: Application
Nursing Process: Implementation
Patient Need: Physiological Integrity
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Pancreas
• Both endocrine and exocrine gland
– Insulin released when blood glucose
increases
– Glucagon released when blood glucose
decreases
• Hormones and drugs can affect blood
sugar (hyperglycemic or hypoglycemic
effects)
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Figure 44.1 Glucagon- and insulin-secreting cells in the islets of Langerhans Source: Pearson Education/PH College
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Figure 44.2 Insulin, glucagon, and blood glucose
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Type I Diabetes Mellitus
• Caused by absolute lack of insulin
secretion
– Due to autoimmune destruction of pancreatic
islet cells
• If untreated, results in serious, chronic
conditions
– Cardiovascular damage
– Nervous system damage
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Type II Diabetes Mellitus
• Causes
– Lack of sensitivity of insulin receptors at target
cells (insulin resistance)
– Deficiency in insulin secretion
• If untreated, results in same chronic
conditions as type 1 DM
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Type I Diabetes Mellitus
• Treatment
– Dietary restrictions
– Exercise
– Insulin therapy
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Insulin Preparations Vary
• Onset of action
• Time to peak effect
• Duration
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Insulin
• Almost all insulin used today is human
insulin
– Made by recombinant DNA technology
– More effective, fewer allergies, less resistance
– Modified to be more rapid (Humalog) or have
prolonged action (Lantus)
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Human Regular Insulin
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Insulin Administration
• Routes of administration
– Subcutaneous (SQ)
– Inhaled—Exubera, approved in 2006
– Intravenous
 Only regular insulin can be given intravenously
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Figure 44.3 Insulin pump Source: Pfizer Inc
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Hypoglycemia
• Can result from
– Insulin overdose
– Improper timing of insulin dose
– Skipping a meal
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Signs and Symptoms of
Hypoglycemia
• Tachycardia, confusion
• Sweating, drowsiness
• Convulsions, coma, death
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Hyperglycemia
• Can result from underdose of insulin or
oral hypoglycemic
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Signs and Symptoms of
Hyperglycemia
• Fasting blood glucose greater than 126
mg/dl
• Polyuria, polydipsia, polyphagia
• Glucosuria, weight loss/gain, fatigue
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Role of the Nurse
•
•
•
•
•
Monitor client’s condition
Provide client education
Obtain medical, surgical, drug history
Assess lifestyle and dietary habits
Obtain description of symptomology and
current therapies
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Insulin Therapy
• Be familiar with onset, peak, and duration
of action of prescribed insulin
• Be aware of important aspects of each
specific insulin
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Insulin Therapy (continued)
• Not all types of insulin are compatible
– May not be mixed together in single syringe
– Clear insulin must be drawn into syringe first
• Know signs and symptoms of
hypoglycemia and hyperglycemia
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Oral Hypoglycemic Therapy
• Assessment
– Physical examination, health history
– Psychosocial history, lifestyle history
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Oral Hypoglycemic Therapy
(continued)
• Teach client: keep blood glucose levels
within normal range
• Blood glucose should be monitored daily
• Urinary ketones should be monitored if
blood glucose is over 300 mg/dl
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Oral Hypoglycemic Therapy
(continued)
• Monitor intake and output
• Review lab studies for liver-function
abnormalities
• Monitor client for signs and symptoms of
illness or infection
• Administer oral hypoglycemics as directed
by prescriber
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Type 2 Diabetes Mellitus
• Treatment
– Controlled through lifestyle changes
– Treated with oral hypoglycemic drugs
 All oral hypoglycemics lower blood-glucose levels
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Type 2 Diabetes Mellitus
(continued)
• Have potential to cause hypoglycemia
• Not effective for type 1 DM
• People with type II diabetes mellitus
should have a preprandial blood sugar
below 110 mg/dl
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Table 44.2 (continued) Oral Hypoglycemics
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Table 44.2 (continued) Oral Hypoglycemics
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Classes of Oral Hypoglycemic
Drugs
•
•
•
•
•
Sulfonylureas
Biguanides
Thiazolidinediones
Alpha-glucosidase inhibitors
Meglitinides
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Sulfonylureas
• Stimulate release of insulin from
pancreatic islet cells
• Increase sensitivity of insulin receptors on
target cells
• Most common adverse effect is
hypoglycemia
– Usually caused by taking too much
medication or not eating enough food
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Biguanides
• Metformin (Glucophage), only drug in this
class
• Decreases hepatic production of glucose
(gluconeogenesis) and reduces insulin
resistance
• Does not promote insulin release from
pancreas
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Metformin
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Biguanides (continued)
• Most side effects are minor and GI-related
• New extended-release formulation of
metformin (Glumetza) allows for oncedaily dosing
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Alpha-Glucosidase Inhibitors
• Block enzymes in small intestine
responsible for breaking down complex
carbohydrates into monosaccharides
• Digestion of glucose delayed
– Carbohydrates must be in monosaccharide
form to be absorbed
• Agents usually well tolerated; have
minimal side effects
• Most common side effects are GI-related
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Thiazolidinediones (Glitazones)
• Reduce blood glucose by decreasing
insulin resistance and inhibiting hepatic
gluconeogenesis
• Optimal lowering of blood glucose may
take 3 to 4 months of therapy
• Most common adverse effects: fluid
retention, headache, weight gain
• Hypoglycemia does not occur with drugs
in this class
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Meglitinides
• Newer class of oral hypoglycemics
• Act by stimulating release of insulin from
pancreatic islet cells
• Both agents in this class have short
durations of action of 2–4 hours
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Meglitinides (continued)
• Efficacy equal to that of sulfonylureas
• Well tolerated
• Hypoglycemia most common adverse
effect
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Other Agents
• Two new drugs entered market in 2005
– Exenatide (Byetta): injectable drug that
belongs to class of drugs called incretin
mimetics
 Mimic effects of incretins—hormones released into
blood by intestine in response to food
– Pramlintide (Symlin): injectable drug for type 1
and type 2; resembles human amylin
 Hormone produced by pancreas after meals; helps
body regulate blood glucose
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Newer Agents
• Bromocriptine (Parlodel)
– Old drug with a new use
– Approved to treat Type 2 diabetes in 2009
– Marketed as Cycloset
– Exact mechanism of action still unclear.
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Insulins
• Prototype drug: regular insulin
• Mechanism of action: to promote entry of
glucose into cells
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Insulins (continued)
• Primary use: short-acting insulin, with an
onset of 30 to 60 minutes, a peak effect at
2 to 3 hours, and a duration of 5 to 7 hours
to quickly decrease blood glucose
– Also for emergency management of
ketoacidosis
• Adverse effects: hypoglycemia
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Oral Hypoglycemics
• Prototype drug: glipizide (Glucotrol,
Glucotrol XL)
• Mechanism of action: to stimulate
pancreas to secrete more insulin
– Also increases sensitivity of insulin receptors
at target tissues
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Oral Hypoglycemics (continued)
• Primary use: for treatment of type 2
diabetes
• Adverse effects: hypoglycemia, rashes,
photosensitivity possible
– Some clients experience nausea, vomiting,
loss of appetite
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Patients Receiving Insulin
Therapy
• Assessment
– Obtain complete health and dietary history
including caloric intake if on an ADA
– Obtain a history of current symptoms,
duration and severity
– Obtain baseline vital signs, height and weight
– Assess feet and lower extremities for possible
ulcerations
– Further assess if client has fever or elevated
pulse
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Patients Receiving Insulin
Therapy (continued)
• Assessment
– Evaluate CBC, electrolytes, glucose, A1C
level, lipid profile, osmolality, hepatic and
renal function studies
– Assess appetite and ability to eat
– Assess subcutaneous areas for potential
insulin injection sites
– Assess knowledge of insulin and ability to
self-administer insulin
– Assess fluid intake and type of fluids consumed
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Patients Receiving Insulin
Therapy (continued)
• Nursing Diagnoses
– Imbalanced Nutrition, Less than Body
Requirements (Type I diabetes, related to
lack of insulin availability)
– Imbalanced Nutrition, More than Body
Requirements (Type II diabetes, related to
insulin resistance)
– Deficient Knowledge (drug therapy)
– Ineffective Therapeutic Regimen
Management (related to deficient knowledge)
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Patients Receiving Insulin
Therapy (continued)
• Nursing Diagnoses
– Altered Compliance, Noncompliance(related to
complexity of treatment plan, deficient
knowledge)
– Risk for Deficient Fluid Volume (related to
polyuria from hyperglycemia)
– Risk for Injury (related to adverse drug effects)
– Risk for Infection (related to hyperglycemia,
impaired circulation to extremities,
neuropathies)
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Patients Receiving Insulin
Therapy (continued)
• Planning—patient will
– Experience blood sugar within normal limits
– Be free from, or experience minimal adverse
effects.
– Verbalize an understanding of the drug’s use,
adverse effects and required precautions.
– Demonstrate proper self-administration of the
medication (e.g., dose, timing, when to notify
provider)
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Patients Receiving Insulin
Therapy (continued)
• Implementation
– Administer insulin correctly and per schedule
ordered
– Ensure dietary needs are met based on need
to lose, gain
– Hold insulin dose if blood sugar is less than
70 mg/dL and report to the health care
provider
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Patients Receiving Insulin
Therapy (continued)
• Implementation
– Monitor CBC, electrolytes, glucose, A1C level,
lipid profile, osmolality, hepatic and renal
function
– Monitor blood glucose more frequently during
periods of illness or stress
– Check urine for ketones if blood glucose is
over 300 mg/dl
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Patients Receiving Insulin
Therapy (continued)
• Implementation
– Encourage increased physical activity
– Monitor weight on routine basis
– Monitor vital signs and for symptoms of
hypoglycemia
– Feed client simple sugar at first sign of
hypoglycemia
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Patients Receiving Insulin
Therapy (continued)
• Implementation
– Rotate insulin administration sites weekly
– Change insulin pump subcutaneous
catheters every 2 to 3 days to prevent
infections at the site of insertion
– Ensure proper storage of insulin to maintain
maximum potency
– Instruct patient and/or family in proper selfadministration of drug
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Patients Receiving Insulin
Therapy (continued)
• Evaluation—patient
– Experiences blood sugar within normal limits
– Is free from, or experiences minimal adverse
effects.
– Verbalizes an understanding of the drug’s
use, adverse effects and required
precautions.
– Demonstrate proper self-administration of the
medication (e.g., dose, timing, when to notify
provider)
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Patients Receiving Oral
Hypoglycemic Therapy
• Assessment
– Obtain complete health history
– Obtain a history of current symptoms,
duration and severity
– Assess feet and lower extremities for possible
ulcerations.
– Obtain a dietary history including caloric
intake, number of meals and snacks per day
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Patients Receiving Oral
Hypoglycemic Therapy (continued)
• Assessment
– Assess fluid intake and type of fluids
consumed Assess for pregnancy
– Assess for pain location and level
– Assess client’s knowledge of drug
– Obtain baseline vital signs, height and weight.
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Patients Receiving Oral
Hypoglycemic Therapy (continued)
• Assessment
– Assess client’s ability to conduct bloodglucose testing.
– Obtain CBC, electrolytes, glucose, A1C level,
lipid profile, osmolality, hepatic and renal
function
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Patients Receiving Oral
Hypoglycemic Therapy (continued)
• Nursing diagnoses
– Imbalanced Nutrition, More than Body
Requirements (Type II diabetes, related to
insulin resistance
– Deficient Knowledge (drug therapy)
– Ineffective Therapeutic Regimen
Management (related to deficient knowledge
or altered compliance
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
Patients Receiving Oral
Hypoglycemic Therapy (continued)
• Nursing diagnoses
– Altered Compliance, Noncompliance (related
to complexity of treatment plan, deficient
knowledge)
– Risk for Injury (related to adverse drug
effects, lack of sensation in extremities from
neuropathies)
– Risk for Infection (related to hyperglycemia,
impaired circulation to extremities,
neuropathies)
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
Patients Receiving Oral
Hypoglycemic Therapy (continued)
• Planning—patient will
– Experience therapeutic effects (e.g., blood
sugar within normal limits).
– Be free from, or experience minimal adverse
effects.
– Verbalize an understanding of the drug’s use,
adverse effects and required precautions..
– Demonstrate proper self-administration of the
medication (e.g., dose, timing, when to notify
provider)
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
Patients Receiving Oral
Hypoglycemic Therapy (continued)
• Implementation
– Ensure dietary needs and consult with
dietitian as needed
– Limit or eliminate alcohol use
– Monitor CBC, electrolytes, glucose, A1C level,
lipid profile, osmolality, hepatic and renal
function
– Monitor urinary ketones if blood glucose is
over 300 mg/dl
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
Patients Receiving Oral
Hypoglycemic Therapy (continued)
• Implementation
– Review lab tests for abnormalities in liver
function
– Obtain accurate history of alcohol use
– Monitor blood glucose frequently during
periods of illness or stress.
– Monitor weight, weighing at same time of day
each time
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
Patients Receiving Oral
Hypoglycemic Therapy (continued)
• Implementation
– Monitor for hypersensitivity and allergic
reactions
– Monitor for edema, BP, and lung sounds in
patients taking thiazolidiones.
– Monitor for signs of lactic acidosis if client is
receiving biguanide
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
Patients Receiving Oral
Hypoglycemic Therapy (continued)
• Implementation
– Monitor activity level and encourage
increased activity
– Monitor for hypoglycemia up to 48 hours after
exercise
– If symptoms of hypoglycemia are noted,
provide a quick-acting carbohydrate source
(e.g., juice or other simple sugar)
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
Patients Receiving Oral
Hypoglycemic Therapy (continued)
• Implementation
– Assess for and report promptly any adverse
effects : signs of hypoglycemia and
hyperglycemia
– Monitor for hypoglycemia more frequently in
patients on concurrent beta-blocker therapy
– Instruct patient and/or family in proper selfadministration of drug.
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
Patients Receiving Oral
Hypoglycemic Therapy (continued)
• Evaluation—patient
– Experiences blood sugar within normal limits
– Is free from, or experiences minimal adverse
effects
– Verbalizes an understanding of the drug’s
use, adverse effects and required precautions
– Demonstrates proper self-administration of
the medication (e.g., dose, timing, when to
notify provider)
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.