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Terms in this set (23)

-Most commonly usedthyroid replacement drug

-MOA: replaces thyroid hormone, works in the same manner as the endogenous thyroid hormones, increases the levels of T4

-Dosage: important, dosed in micrograms (mcg), not milligrams (mg)

-Indications: drug of choice for hypothyroidism

-Contraindications: allergy, recent MI, hyperthyroidism, adrenal insifficiency

-Side effects: heat intolerance, weight loss, diarrhea, insomnia, irritability, tachycardia, angina, palpitations, cardiovascular are most life-threatening
-The side effects of levothyroxine are the similar to the clinical manifestations of hyperthyroidism. This is because we are replacing thyroid hormone and if we see these effects, it is probably because the dose needs to be adjusted to a lower amount.
-Another important aspect of levothyroxine goes back to pharmacokinetics: the half-life of levothyroxine is 6-7 days, how long will it take for the patient to reach steady state? 24-35 days.
-It can take over a month before the patient experiences the therapeutic response of levothyroxine, this long half-life also increases the chance of toxicity because it can build up in the body.
-Remember that the side effects are signs of too much thyroid hormone
-Levothyroxine is absorbed best if taken on an empty stomach, the recommendation is for the patient to take their dose in the morning when they first get up, 30 minutes prior to eating breakfast

-Interactions: increased warfarin effects, decreased levothyroxine effects with phenytonin, cholestyramine, antacids, calcium salts, and iron
Assessment:
-Baseline vital signs, Serum T3, T4, and TSH levels (the TSH will most likely be high and the T3 and T4 low when initiating therapy)
-Obtain history of current medications (looking for drug interactions. Please note that the drug interactions do not mean those medications cannot be given with levothyroxine, instead, the doses may need to be adjusted in order to achieve therapeutic effects).

Diagnosis:
-Noncompliance related to lack of education about thyroid replacement drugs.

Planning:
-Patient will experience increased energy levels and achieve normal serum ranges of TSH, T3, and T4.

Implementation:
-Monitor vital signs (Decreased HR, BP and T are associated with hypothyroid, so if these persist, the dose of levothyroxine may need to be increased. Increased HR, BP, and T are associated with hyperthyroidism, so if these changes occur, the dose of levothyroxine may need to be decreased.)
-Monitor weight (Weight gain is associated with hypothyroid and could indicate drug has not reached therapeutic effect. Weight loss is associated with hyperthyroidism and if weight loss is rapid, the dose may need to be decreased.)
-Be sure to check orders carefully for levothyroxine. Look for dose to be in mcg, not mg. Anything over 200 mcg should be clarified in case an error has occurred.
-Administer thyroid replacement drug before breakfast (empty stomach), ½-1 hour before breakfast is preferred.

Patient Teaching:
-Take thyroid replacement drug before breakfast (empty stomach), ½-1 hour before breakfast is preferred.
-Check labels before using OTCs.
-Advise reporting of symptoms of hyperthyroidism caused by drug accumulation or overdosing. Dose may need to be adjusted.
-Encourage medical alert tag.
-Warn of foods that inhibit thyroid secretion (strawberries, peaches, pears, cabbage, turnips, spinach, kale, Brussels sprouts, cauliflower, radishes, and peas)
-Teach patient that it can take over 1 month before the therapeutic effects are achieved. This can enhance compliance to the therapeutic regimen.

Evaluation:
-Patient has less symptoms of hypothyroid.
-Patient has no adverse effects.
-TSH, T3, and T4 levels are all within normal range.
Assessment:
-Baseline vital signs, Serum T3, T4, and TSH levels (the T3 and T4 high when initiating therapy)
-Obtain history of current medications (looking for drug interactions. Please note that the drug interactions do not mean those medications cannot be given with antithyroid drugs instead, doses may need to be adjusted in order to achieve therapeutic effects).
-Assess for S/S of thyroid crisis (thyroid storm) -tachycardia, dysrhythmias, fever, heart failure, flushed skin, confusion, behavioral changes (irritability). Later- hypotension and vascular collapse.

Diagnosis:
-Noncompliance related to lack of education about antithyroid drugs.
-Risk for infection related to bone marrow suppression that is associated with antithyroid drugs.

Planning:
-Patient will achieve normal serum ranges of TSH, T3 and T4.
-Patient will be free from signs of infection, such as elevated temperature and sore throat.

Nursing Interventions:
-Monitor vital signs (remember what happens with hypothyroidism and hyperthyroidism)
-Administer antithyroid drugs with meals.

Patient teaching:
-Teach patient that if taking radioactive iodine, need to decrease intake of iodine in order to allow radioactive iodine to be taken into the thyroid gland (avoid iodized salt and shellfish).
-Do not abruptly stop antithyroid drugs as hyperthyroid symptoms may return.
-Teach the patient to report S/S of hypothyroidism
-Teach the patient to call their healthcare provider if they develop a sore throat and fever- this can be due to agranulocytosis.

Evaluation:
-Signs and symptoms of hyperthyroidism should decrease. If S/S persist for 2-3 weeks of therapy, other methods may be necessary (i.e. thyroidectomy)
-The most rapid acting insulin is called insulin aspart, insulin lispro, and insulin glulisine.
-These insulins will begin to work within 15 minute of administration.
-In the acute care setting, this means we need to have a food tray in front of the patient before we administer the insulin. Why? Because it will immediately begin to decrease the blood sugar level, so a food source must be available to prevent hypoglycemia.
-The rapid and fast acting insulins are considered meal-time insulins, as they are given just before the patient begins to eat, and they cover the increase in the blood sugar that occurs after the meal.
-The duration of rapid acting insulin is 3-4 hours, so they are commonly given every 4 hours, or CC (with meals), or CCHS (with meals and at bedtime).
-Notice that often, this type of insulin is prescribed "with meals" not "before meals".
-Let's look at an example of how lispro works: A patient in the hospital is prescribed 10 units of insulin lispro (Humalog) at breakfast, lunch, and dinner. The insulin is given with the meal. As the patient eats, the insulin is beginning to work to lower the glucose.
-One to two hours after eating is the time when the blood sugar will peak the highest - this is known as the postprandial glucose spike. As the glucose is rising in those two hours, lispro is peaking.
-Lispro peaks 1-2 hours after taking it; therefore, covering the highest spike in blood sugar, which occurs around 1-2 hour post prandial.
-This is why lispro is considered a mealtime insulin.
-Insulin lispro and insulin glulisine can be used IV in selected situations under appropriate medical supervision.

-The fast-acting insulin is known as regular insulin.
-It takes 30 minutes before any effect will occur. Regular insulin is also considered a mealtime insulin.
-Let's take a look at how regular works. A patient in the hospital is given regular insulin 15-30 minutes before breakfast, at 0730. By 0800, the breakfast tray has arrived, and they begin eating. As they eat, the insulin is starting to work. After they eat, and as their blood glucose is at it's peak about 9-10 am, the regular insulin is beginning it's peak - 2 hours.
-It can be dosed as AC (before meals), ACHS(before meals and at bedtime) or every 6 hours (for patients on total parenteral nutrition).
-Notice IV regular has a very rapid onset, peak and duration.

-Intermediate insulin, or NPH.
-This insulin is a suspension and is cloudy in appearance for this reason.
-NPH is slowly absorbed, thus the onset of action is longer, NPH is given usually along with another insulin, such as lispro or regular insulin.
-The lispro and regular treat the blood sugar spike after meals, while the NPH covers the blood sugar throughout the day and overnight.
-This is a basal insulin.
-Let's look at how NPH works: A patient eats breakfast at 0800. The NPH does not even begin to work until 2-4 hours after it is given; however, the patient most likely received a dose of mealtime insulin to cover this spike (for example lispro, aspart, regular) The NPH will begin to peak at about 11:30 am, right around the time the patient will be getting lunch. If the patient eats at noon, the NPH will be peaking, covering the patient through lunch. As the NPH's peak is ending in the early evening, it is dinner time and the patient is usually given more NPH and mealtime insulin to cover them after dinner and during the night.
-Because NPH is intermediate acting, it is NOT considered a mealtime insulin.
-When NPH is given, the blood sugar in the middle of the day will probably drop, especially around 3 pm if the insulin was given between 7-8 am. Therefore, a snack should be planned for this time. The duration is 16 hours. The patient will need a dose in the morning and a dose in the evening in order to maintain 24-hour glucose control.
-NPH is not as commonly used now that we have the long acting insulins. NPH insulin is never given IV.

-Long acting, or insulin glargine is very slowly absorbed, as it forms acid crystals in the subcutaneous tissue and is released steadily over 24 hours for absorption.
-Since it works for 24 hours, only one shot per day is needed.
-Since there is no peak for glargine, it is NOT considered a mealtime insulin.
-It is used to maintain control of blood sugar over 24 hours, without the peaks and valleys in blood sugar levels.
-It is a highly effective insulin and is used very often for patients in the hospital and for patients at home. It is commonly administered at HS (bedtime).
-The patient will most likely have hypoglycemia around 2-4 AM, so the nurse should be monitoring the patient for signs of hypoglycemia between 2-4 AM.
-There is also a newer long acting insulin called insulin detemir. It does have a peak, but the duration is 24 hours.
-Detemir is more likely to be administered in the morning and glargine is more likely to be administered at bedtime.
-Glargine and detemir cannot be mixed in a syringe with a different type of insulin.
-Long-acting insulins are never given IV.

-Some insulin preparations combine a rapid acting or fast acting insulin with an intermediate acting insulin (Lispro and lispro protamine {intermediate acting lispro}, or regular and NPH).
-It will be written on the label as percentages of each insulin (lispro 50/50=50% lispro {rapid acting} and 50% lispro protamine {intermediate acting}).
Assessments should include:
-Assess type of insulin and amount patient normally takes.
-Assess blood glucose and Hgb A1c (normal fasting blood glucose is between 60-110, but the goal for diabetic patient is fasting BG 80-130; Hemoglobin A1C= <7 is goal for diabetic patient)
-What is the HGB A1c? It is also known as glycosylated hemoglobin-hemoglobin bound to glucose. The value is used for mathematical equation to determine the estimated average glucose level for the last 2-3 months.
-Why is that important? I have an annual appointment every year. Every year, my doctor says I need to lose about 20 pounds (well 5 years ago that is what he said). Every year, I don't work on my weight until about 1 month before the appointment. I come in and I only need to lose like 10 pounds (because I worked hard for 1 month). Then, I go back to my old ways, gain back my 10 pounds I lost, and repeat this cycle every year... I know, I'm awful.
-Diabetic patients can do the same thing with their blood sugar. They are bad for 2 months, then the last couple weeks before their appointment, they say, "Oh no, the ice cream every night needs to stop because I am about to see my doctor." They go in on their appointment, and their finger stick blood sugar is great, only 90 this morning, YAY. But their Hgb A1C? Its 8%. It tells on their bad behavior. Even if the patient is compliant, the A1C can be used to adjust therapy to better control the blood glucose.
-Identify current home medications looking for interactions. Look at any new medication prescribed for in-patient or acute illnesses (steroids raise the blood sugar, so more insulin may be needed). Diuretics (loop and thiazide) increase the blood sugar, so more insulin may be needed to control the blood sugar.
-Assess last site patient used for insulin injection

Diagnosis:
-Deficient knowledge
-Risk for unstable blood glucose levels

Planning:
-The fasting blood sugar will be between 80-130 g/dL.• HgbA1c will be less than 7 at next appointmentImplementation
-Monitor vital signs and glucose levels.
-Insulin is a high altert medication because errors are common and can cause harm. Most hospitals require a double check on insulin doses(another licensed nurse must verify the correct amount was drawn up into the syringe).
-In the hospital setting, the insulin is often kept in the locked pyxis system and is often not refrigerated after opening. Label with expiration date (28 days from when vial was opened). I remember this because of the movie 28 days later: I think about the potential of bacteria growing in this vial and that I might create a zombie if I don't discard this vial 28 days later.
-Determine blood glucose levels- reference range 60-100 mg/dL.
-Inject air equal to the amount to be given into the insulin vial prior to drawing up insulin as this prevents a negative pressure that makes it difficult to draw up correct insulin amount.
-When mixing insulins(you can mix rapid acting-lispro and aspart-with intermediate (NPH) and you can mix fast-acting (regular) with intermediate), follow these steps:
-Roll the NPH vial-do not shake. It is a suspension and the particles will be on the bottom of the vial. Roll gently until the NPH insulin has a cloudy appearance.
-Clean the top of both the clear insulin (rapid or fast-acting insulin) and the cloudy insulin (NPH)
-Inject air equal to the amount of insulin to be administered- first into the cloudy insulin (NPH), then air into the clear insulin (lispro, aspart, or regular)
-Draw up the correct amount of clear insulin (have another licensed person check this dose)
-Draw up the correct amount of cloudy insulin (have another licensed person check the total amount)

Patient Teaching:
-Instruct patient to report hypoglycemia and hyperglycemia.
-Encourage compliance with diet, insulin, exercise.
-Advise patient to wear medical alert tag.
-Teach patient how to check blood glucose.
-Teach patient how to administer insulin.
-Teach patient storage of insulin
-Do not keep in hot places. Do not leave insulin in a hot closed car. Heat makes insulin break down and will not work well to lower your blood sugar.
-Do not keep in freezing places. Never store in a freezer. If insulin is frozen, do not use. You will not be able to inject the insulin if it is frozen. Do not use even after thawing. Freezing temperature will break down the insulin and then it will not work well to lower your blood sugar. Throw frozen insulin in the garbage.
-Do not leave in sunlight. Light can make insulin break down and then it will not work well to lower your blood sugar.
-Never use insulin if expired. The expiration date will be stamped on the vial or pen. Remember if not in the fridge, the date on the vial or pen does not apply. You must throw away after 28 days since outside the fridge.
-Write the date on the insulin vial on the day you open it or start keeping it outside the fridge. This will help you remember when to stop using it. Throw the insulin away 28 days after opened or since kept out of the fridge.
-Inspect your insulin before each use. Look for changes in color or clarity. Look for clumps, solid white particles or crystals in the bottle or pen. Insulin that is clear should always be clear and never look cloudy.

Evaluation:
-Blood sugar remains between 80-130.
-hgbA1c (glycosylated hemoglobin) less than 7%
Assessments should include:
-Identify drug history looking for drug interactions (diuretics, corticosteroids)
-Identify past medical history
-Metformin contraindicated in renal and hepatic dysfunction. (Look at creatinine clearance, must be greater than 30 mL/min)
-Ask about alcohol intake (contraindicated for most oral antidiabetic medications because it increases chance of hypoglycemia. Alcohol also increases the chance of lactic acidosis with metformin).
-Assess blood sugar and Hemoglobin A1c. Remember the goal for diabetic patient is fasting BG 80-130 and the Hemoglobin A1C should be less than 7)

Diagnosis:
-Risk for unstable blood glucose

Planning:
-Blood sugar will be between 80-130 fasting.
-Hemoglobin A1c will be less than 7.

Implementation:
-Monitor blood glucose levels. (normally less often than with insulin, maybe once a day or twice a day)
-Monitor Hemoglobin A1C levels (recommended to be done every 6 months)
-Hold metformin before 48 hours before and 48 hours after surgery (follow your hospital policy and discuss with provider)

Patient Teaching:
-Teach about hypoglycemic reactions. Teach about signs and symptoms of hyperglycemia
-Teach that oral antidiabetics are not insulin, but insulin may be required in periods of illness, such as infection and surgery.
-Advise to wear medic Alert bracelet.
-Teach not to drink alcohol with antidiabetic drugs-can cause hypoglycemic reactions.
-Teach actions to take if hypoglycemia occurs- hard candy, orange juice, coke....

Evaluation:
-Blood sugar remains between 80-130.
-Hgb A1c (glycosylated hemoglobin) less than 7%
Dextrose 50% in water:
-Administer IV push for hypoglycemia
-Hospitals often have a hypoglycemic protocol

Glucagon:
-Hyperglycemic hormone secreted by the alpha cells of the islets of Langerhans
-Increases blood sugar by stimulating glycogenolysis

Use:
-Used to treat insulin-induced hypoglycemia when other methods of providing glucose are not available
-Administered subcutaneously

-If a patient is conscious and talking to you and their blood glucose is less than 60, you can provide an oral form of glucose, such as 4 ounces of juice (orange or apple juice- orange has potassium, so if treating a patient with renal disease, apple juice is preferred)
-There is also a glucose gel that is sold commercially to help elevate the blood sugar.
-Hard candy could also be a good option

-If the patient is unconscious, and has an IV access, the preferred method to raise their blood sugar is dextrose 50% in water.
-We administer the amount per protocol or per the healthcare providers orders.
-The protocol is nice because you do not have to call the healthcare provider and wait for an order.
-You can administer what is recommended on the protocol, wait 20 minutes, recheck the blood sugar, and then CALL the HCP.
-You still notify the HCP because insulin doses may need to be adjusted.

-If the patient is unconscious and does NOT have an IV access, you can administer glucagon subcutaneously or intramuscularly.
-This works slower than IV Dextrose 50% and it often will cause the patient to vomit.
-Turn the patient to their side to help prevent aspiration of their emesis.
Assessments should include:
-Lab tests- electrolytes and blood glucose levels (potassium may decrease, and blood glucose may increase.)
-Assess patient medical history (Glaucoma, cataracts, peptic ulcer, psychiatric problems or diabetes mellitus)- glucocorticoids (like prednisone) can intensify these health problems.
-Assess currently prescribed medications for potential drug interactions.

Diagnoses:
-Risk for infection related to decreased immune function
-Risk for unstable blood glucose

Planning:Outcomes could include:
-The blood glucose will be within the range of 80-140
-White blood cell count will remain within normal range
-The patient will be free from signs of infection.

Implementation:
-VS: increased BP related to increased sodium and water retention.
-If administering by Intravenous push, give over 3-15 minutes. Doses greater than 250 mg should be administered over 30-60 minutes on an infusion-controlled device, an infusion pump. I remember as a new nurse, seeing many of the nurses give methylprednisolone over 15-30 seconds. The patients would have tachycardia and feel kind of light-headed. By giving it slower, the patient will not experience these symptoms.
-Weight daily, report 5-pound gain in several days as this is most likely due to fluid retention
-Monitor electrolytes and blood glucose.
-Monitor for signs and symptoms of hypokalemia (N/V, weakness, abdominal distention, paralytic ileus, and irregular HR.)
-Monitor for S/S of hyperglycemia.
-Assess signs and symptoms of side effects of glucocorticoids (Cushing's)
-Taper dose, assess for adrenal crisis: anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia)

Patient teaching:
-Take as prescribed, do not stop abruptly as this can lead to an adrenal crisis. Notify the healthcare provider if signs of adrenal crisis should occur.
-Avoid sick people ( steroids supress the immune system)
-Teach to report signs and symptoms of drug overdose (Cushing's)
-Take with food- can cause gastric irritation/ ulceration.• Increase potassium rich foods in diet.
-Teach diabetic patients to monitor their blood glucose levels more closely in order to identify hyperglycemia. They may need to contact prescriber for dose changes or supplemental insulin during this time.

Evaluation:
-Effectiveness of drug -if inflammation has not improved, change in drug therapy may be needed.
-Monitor for SE.