Nursing Care for Patients Receiving Medications that Affects Metabolism

By: Domino Butron Puson Overview This chapter discusses the different hormones and steroids used in medical therapy. Unlike many other categories of medications, these are natural or synthetic preparations that replace, increase or decrease natural chemicals already present within the patient. Hormones are chemicals that are made in an organ or gland and are carried through the bloodstream to another part of the body. It stimulates that part of the body to increase its activity or secretion. Steroids are specific chemical group of hormones that have powerful effects on cell sensitization, healing and development. Feedback Mechanism - Lack of one basic hormone will stimulate or signal, the glands to produce more hormone. When the right amount of hormone is reached, the signal is turned off, and the glands slows production of the hormone. Endocrine System The regulation and coordination of body activities happens in two ways: 1. Through nerve impulses carried by the nervous system 2. Through chemical substances or hormones carried by the blood and lymph. Endocrine Glands organ that secretes hormone Endocrine System includes: pituitary gland, thyroid gland, parathyroid glands, adrenal glands, pancreas, duodenum, testes, ovaries, and placenta (sometimes: thymus gland and the pineal body) Endocrine are ductless; their secretions go directly into the blood or lymph and are then carried to all parts of the body. Antidiabetic Drugs Overview Diabetis Mellitus is a chronic disorder of carbohydrate (glucose) metabolism as well as abnormal fat and protein metabolism. With time, these abnormalities result in microvascular, macrovascular and neurologic complications.

Diabetes mellitus can be described as a catabolic state that is caused by a relative or absolute lack of insulin, insulin resistance and impaired or insufficient target cell receptors. Insulin is the hormone necessary for the metabolism and use of glucose in the body and is produced by the beta cells of the pancreas. Insulin helps glucose move into fat and striated muscle cells by turning on a carrier system. A patient with diabetes mellitus has a pancreas that fails to produce enough insulin for the needs of the body. The lack of insulin forces the liver to convert protein and fat to use for energy, increasing the amounts of fatty acids. Some of these fatty acids will convert to cholesterol; over time, this increases the development of atherosclerosis. Acutely, a lack of insulin can increase the production of free fatty acids and increase ketogenesis. Along with an increase in glucagon and other hormones, a decrease in pH can occur, resulting in ketoacidosis. If left untreated ketoacidosis can result in death. Two type of diabetes 1. Type 1 diabetes (Insulin-dependent diabetes mellitus or juvenile diabetes) - have little or no production of insulin in the pancreas. These patients must take insulin to control the symptoms of diabetes mellitus. 2. Type 2 diabetes (Non-insulin-dependent diabetes mellitus or latent onset diabetes) have pancreas that function a little and that can be encouraged by medication to produce more insulin. Controlled by diet, weight reduction, and oral hypoglycemic agents sometime insulin is necessary. Insulin (Escherichia coli or Saccharomyces cerevisiae) Action Lowers blood glucose levels by helping glucose move into target tissues. Binds and stimulates an insulin receptor glucose pass into the cell. In addition to its role in glucose control, insulin is also very important in fat metabolism. Adequate amounts of insulin inhibit lipoprotein lipase, thereby preventing the release of fatty acids into the blood. Insulin also promotes glucose transport and storage of glucose as triglycerides in fat cells. Thus insulin is an anabolic hormone that helps maintain stores of fatty acids, glycogen, and protein. Uses Type 1 Diabetes (cause by t-Lymphocyte attack on beta cells of the pancreas)

Type 2 Diabetes to overcome insulin resistance (A nonketotic state with high osmotic pressure may occur in patients with infection or other underlying disease. Lack of tissue sensitivity to insulin, particularly in the muscles and liver, leads to hyperglycemia and insulin resistance. Adverse Effects Lipodystrophy, local itching swelling, or erythema at the injection site. Hypoglycemia most important adverse effects (<60 mg/dl) sudden onset of nervousness, hunger, malaise, cold, clammy skin; lethargy, no urine glucose or acetone; pallor; paleness; diaphoresis; change in level of consciousness and shallow respirations. Hyperglycemia (>150 mg/dl) glycosuria and ketonuria, Kaussmauls respiration (deep rapid sighing breaths), tachycardia, and acetone breath. Drug Interaction Oral Contraceptives, corticosteroids, epinephrine and thyroid hormone therapy : insulin antagonist Thiazide Diuretics, alcohol: elevate glucose levels. Nursing Implications and Patient Teaching Assessment History of polyuria, polydipsia, polyphagia, weight loss, blurred vision and fatigue. Ask the patient about signs of pregnancy, infection, and kidney, liver, or thyroid disease, because these conditions will alter the requirement for insulin. Ask about any earlier sensitization to beef or pork and whether the patient is taking other drugs that may interact with insulin. Diagnosis Weight loss? Nutrition? Knowledge? Planning Successful management of diabetes depends on the patients understanding about her disease. She must know the nature of the disease, her diet and the need for weight control, and the importance of hygiene and exercise. Must understand how to do blood and urine testing and how to correctly draw up and inject insulin.

Know the signs and symptoms of hypo and hyperglycemia and appropriate actions to take. Patients should be taught how to test their blood glucose level using a glucometer. Provide a booklet or chart in which the patient can record his findings. In general the goal for fasting blood sugar is less than 120 mg/dl The goal for bedtime blood glucose level is 100 to 140 mg/dl. Implementation Insulin is generally given subcutaneously and timed so that it is available in the body when glucose level rises after eating. Only regular insulin can be administered IV, as is done during ketoacidosis or diabetic coma. Insulin dose depends on the patients response. The individual presenting with Ketones in the blood must be started to insulin. The insulin vial in use may be stored outside of the refrigerator for 1 month, provided it does not get extremely hot or cold. Insulin should be warmed to room temperature for use because the injection of cold insulin may irritate the tissues. Check expiry date. Rapid acting insulin is used during treatment of ketoacidosis and in other situations (infection, surgery) when the patients food intake is variable. Long acting insulin is primarily used for patients whose blood sugar level is constantly high at night. For insulin suspensions, the vial is gently rolled and tipped from end to end the insulin is drawn up so that any particles that might have settled out are turned to suspension. Vigorous shaking might result to bubbles that can make it difficult to accurately draw the insulin. Shaking also breaks down the protein molecule in the insulin. Most diabetic patients can control their symptoms with 40 to 60 units of insulin per day. Occasionally a patient develops resistance to the insulin or becomes so unresponsive to insulin.

Teach the family: The patient should keep on a diet and maintain an ideal body weight. The patient must know the signs and symptoms of hypoglycemia Pork or beef insulin can cause an increase or a decrease in the size of a fatty tissue. The patient must use the proper syringe and the correct type, strength, and dose of insulin to avoid dosage errors. Avoid alcohol Insulin requirements increase when the patient is under stress. The patient must be prepared for emergency situations by: Carrying a medical identification cards Wearing a medic alert Carrying a readily available source of sugar When travelling the patient must carry an extra supply of insulin, syringes, and needles in separate containers. The patient should be alert for hypoglycemia when driving, operating machinery, or engaging in activities that require alertness. Evaluation The patients response to the insulin dose is seen by testing blood. The patient must be encouraged to take responsibility for managing her own disease. Patients with home glucometers should be told when to check their blood glucose level, deepending on the type of insulin they are taking. If hypoglycemia occurs, the patient should be taught to eat some form of CHO immediately. If the patient is unconscious, Honey or karo syrup may be put under the tongue or on the buccal musosa in the mouth. Additional CHO should be provided for the next 2 hours. The SOMOGYI EFFECT (rebound elevation of glucose levels brought on by hypoglycemia) can lead to over treatment of the patient with insulin when less insulin is actually needed. Oral Hypoglycemics Sulfonylureas first available class Biguanides 2nd class of oral agents Alpha-Glucosidase Inhibitors available in the 1990s. Meglitinides newest release in 1998 DPP-4 Inhibitors research ongoing

ACTION Stimulate insulin release by the beta cells of the pancreas.

USES Monotherapy (therapy with one drug) or combined oral agent therapy, or can be combined by insulin to achieve the optimal glucose control in patients with type 2 diabetes. Sulfonylureas lowers serum glucose levels by increasing beta cell insulin production and to a lesser extent, by decreasing insulin resistance. Biguanides metformin (the Only drug available in the US) lowers serum glucose levels by decreasing glucose production in the liver, decreasing insulin resistance and slowing the absorption of glucose in the intestines. Alpha-Glucosidase Inhibitors Acarbose (the only drug available in this class) lowers glucose by slowing the breakdown of polysaccharides into simple sugars. Meglitinides newest works by stimulating the release of insulin from the beta cells of the pancreas. ADVERSE REACTIONS Hypoglycemia is the most common adverse reaction. Allergic reactions (urticaria, rash, pruritus, and eryhema may occur) Occasional: hepatotoxicity, jaundice, dark colored urine etc. Drug Interactions Alcohol consumption with oral hypoglycemics may result in a violent disulfiram-like reactions. Metformin hyperglycaemic effects increased with oral anticoagulants. Many of these drugs, when along with oral contraceptives that contain ethinyl estradiol and norethidrone, may decrease contraceptive effectiveness. NURSING IMPLICATION ASSESMENT Learn about the patients history Ask allergy to sulfa drugs. Diagnosis Problems with weight? Nutrition, vision, finances? How compliant do you believe this patient will be with diet, exercise, medication, and testing requirements? Implementation These product are administered orally. Teach patient and family about diabetes, diet and exercise. Teach patient specifically about nutrition, blood testing, and general precautions to follow.

Should report jaundice, dark urine, light colored stools, fever, sore throat, fatigue etc Red, raised rashes are generally brief and will disappear with continued drug therapy Avoid drinking alcohol EVALUATION Monitor for adverse effects You should evaluate the patients compliance in taking medications.

Thyroid Hormones Overview The thyroid gland, located in the neck in front of the trachea produces the hormones thyroxine (T4) and Triiodothyronine (T3), which influence almost every organ and tissue of the body. Anteriro Pituitary Gland secretes Thyroid Stimulating Hormone which tells the thyroid gland to release the hormones that it has stored. Two general types of diseases can influence the hormone producing activity of the thyroid gland. 1. Hypothyroidism a decrease in the amount of thyroid hormones fatigue, malaise, lethargy, moderate weight gain (around 10 pounds), with minimal apetite, cold intolerance, menorrhagia, dry skin, coarse hair, hoarseness, impaired memory and constipation. 2. Hyperthyroidism An increase in the amount of thyroid hormones - weight loss, decreased or absent menstruation, rapid or pounding heart, heat intolerance, nervousness, irritability, diarrhea, sweaty skin, insomnia, fever or chest pain. Synthetic hormones, natural hormones, or a combination product may be given. Thyroid Supplements levothyroxine liothyronine liotrix thyroid, desicated Action Main action is to increase metabolic rate resulting in increase tissue oxygen consumption, body temperature, HR and RR, cardiac output, and carbohydrate, lipid, and protein metabolism. USES Used in replacement therapy to manage hypothyroidism, myxedema, cretinism, or non toxic goiter cause by deficiency of thyroid hormone.

Also used to threat chronic thyroid infections and tumors that depend on thyrotropic Hormone. Adverse Reaction Dysrhytmias, HPN, tachycardia, hand tremors, H/A, insomnia, nervousness, diarrhea, vomiting, weight loss, menstrual irregularities, rash, glycosuria, hyperglycemia. Overdose: signs and symptoms of hyperthyroidism. Drug Interactions Increase the patients need for antidiabetic agents. Anticoagulant effects are exaggerated by thyroid replacement therapy. Effects of TCA are increased by thyroid hormones. Nursing Implications and Patient Teaching Assessments Patients health history On examination, you may find skin changes associated with myxedema, the most severe form of hypothyroidism. Laboratory findings in thyroid disease may include reduced free T4 index and elevated serum TSH other test may be abnormal. Diagnosis Because thyroid disease be insidious in onset, the patient may have many symptoms that require therapy at the time of diagnosis. Patients may have become depressed, have gained weight, or have problems with body image and selfesteem and should be addressed. Planning Patients older than 50 years of age are often very sensitive to thyroid hormones. Implementation Begin all treatment with small doses and increase gradually The usual maintenance dosage in the treatment of hypothyroidism is 0.5 to 2 gm as a single dose before breakfast. T4 is the treatment of choice for hypothyroidism because of it purity and long duration of action. Patients should take the medication at the same time everyday, preferably before breakfast.

If medication is taken later of the day insomnia may result. Take medication exactly as directed Symptoms should improve in 2 weeks Check healthcare provider before taking other medications Report signs and symptoms of overdose Evaluation Response to therapy is not immediate. Therapeutic results is seen in three months. You should teach the patient signs and symptoms of hypothyroidism and hyperthyroidism so that they can determine if they are receiving too much or too little medicine. Periodic blood test should be done before starting thyroid hormone therapy and once the patient is on maintenance dose.

Antithyroid Products Action The main action of antithyroid products is to stop the new production of thyroid hormones. USES Hyperthyroidism or to improve hyperthyroidism in preparation for surgery or radioactive iodine therapy. Adverse Effects Drowsiness, H/A, paresthesias, N/V, jaundice, skin rash, urticaria, edema, alopecia, and lymphadenopathy Hypothyroidism may occur as a result of prolonged therapy. Agranulocytosis (very low white blood cells) is a rare yet serious side effect Drug Interactions Effects of anticoagulants are increased or potentiated by prophythioracyl. Drugs that may cause aggranulocytosis Nursing Implication and Patient Teaching Assessment Patients History On physical examination, the nurse may find exopthalmos, thyroid enlargement, tachycardia, increased BP, tremor, warm, moist, and proximal muscle weakness. Weight loss and the signs of chronic heart failure may be the most obvious signs of hyperthyroidism in elderly.

Laboratory results may show elevated free T4 index, increased T3, or decreased TSH Diagnosis Patients may be restless or anxious, have eating and sleeping problems, or have problems with concentration and memory that must be addressed. Planning Patient compliance with therapy should be encouraged to help them return to normal thyroid levels. Implementation Clinical response to the antithyroid drugs usually takes 1 to 2 weeks, because the drug doe not affect the release of thyroid hormone. Generally, therapy is maintained for 12 to 24 months and reduced to see if the hyperthyroidism starts again. Take medication exactly as ordered. Dosage should not be increased until the results at the present dosage level can be evaluated. Bed rest, adequate diet, and avoidance of occupational and domestic stress are also useful modalities of therapy. Evaluation Laboratory blood test should be completed before beginning antithyroid therapy and periodically once the patient is on a regular maintenance dosage. Once the patient has been euthyroid for 6 to 12 months, a decision may be made to reduce the dosage and see whether the hyperthyroidism is in control. If hyperthyroidism seems to be absent, therapy is stopped!

Activity: Look and search for the Interventions in giving insulin and include its Patient and Family Teaching Search for the following information Thyroid Hormones Antithyroid Products Action Uses Adverse Reactions Drug Interactions Nursing Implications and Patient Teaching Assessment Diagnosis

Planning Implementation Evaluation