By D. Tyler. Virginia State University.

M (this is to see his/her conceptions or identify any misinformation) -Coping skill- by asking to patient how to deal with difficult situations Not all patients may have similar nursing diagnosis because nursing process is client specific and individualized purchase forzest 20 mg line. But possible N/ Dxs include: Based on the assessment data purchase forzest 20 mg mastercard, the patients major nursing diagnosis may include the following order 20mg forzest fast delivery. Maintaining fluid and electrolyte balance - Measuring Intake and output - Administering I/v fluid and electrolytes as ordered - Encouraging oral fluid intake - Monitor lab values of serum electrolyte ( esp, Na and k) - Vital sign monitoring 2. Improving nutritional intake - Diet is planned for the control of glucose • Take in to consideration the patients life style, cultural back ground, activity level and food preference - Patient is encouraged to eat full meals and snack as based on the kcal need. Improving self care - Patient teaching to prepare for self care - Special equipment is used for instruction on diabetic injection skill - Low literacy information is used - Families are instructed to enable them to assist in diabetic management to profile syringe to monitor blood glucose - Follow up education is arranged - Consideration is given for financial limitation or physical limitation (such as center for visually impaired) Other members of the health care team are informed about variation in the timing of meal and the work schedule (e. Reducing Anxiety - Nurse provide emotional support and gives time for client - Patient and family are assisted to focus on learning self care behavior - Encouraged to perform the skills that are most feared and reassured and self injection and puncturing a finger for glucose monitoring 5. Simple pathophysiology - Definition - Normal blood glucose level - Effects of insulin and exercise - Effects of food and stress, including illness and infection 63 B. Pragmatic information - Where to buy and store insulin, syringes, glucose monitoring supplies when to call the Nurse or physician. Hyperglycemia and ketoacidosis - Monitor blood glucose level and urine ketonuria - Medication are administered as prescribed - Pt is monitored for sign and Symptom of impending hypergly cemia and keto acidosis 4. Hypoglycemia Cause – skip or delay meal - Not follow the prescribed diet - Greatly increase the amount of exercise with out modifying diet or insulin Management- Juice or glucose tablet - Encourage the pt to eat full meal and snacks as prescribed per diabetic diet - See the above descriptions for the details 5. Achieve fluid and electrolyte balance a, Demonstrate I/o balance b, Exhibit electrolyte values that are with in normal limit c, Vital signs remain stable 2. Achieves metabolic balance a, Avoid extremes of glucose level( Hpo/hyperglycemia b, Demonstrate rapid resolution of hypoglycemia episode c, Avoid further weight loss 3. Identifies factors that cause the blood glucose level - to fall (insulin, exercise) - to rise ( food, illness and infection ) d- describes the major treatment modalities - diet - Exercise - Monitoring - Medication - Education Treatment Modalities (insulin, diet, monitoring, Education) a, Demonstration proper technique for drawing up and injecting insulin b, Verbalize insulin injection rotation plan c, Verbalize understanding of classification of food group d, Verbalize appropriate schedule for eating snacks and meals e. Verbalizes symptoms of hypoglycemia (shakiness, sweating headache, hunger, Numbness or tingling of lips or finger, weakness, fatigue, difficult concentration, Change of mood and dangers of untreated hypoglycemia (seizure and coma) b. Identify appropriate circumstance for calling the physician eg- when ill, when glucose level repeatedly increasing 4. States measures to prevent occurrence of complications Keys for the pretest and post test questions for Nurses 1. A- site of injection -Preparations of medication -Rotations -About syringe and needle -Some problems with insulin injections B)-Too much insulin -Too little food or -Excessive physical exercise -Delay of meal or omitting of snacks C) Sweating -Tremor -Tachypnea -Confusion -Seizure -Loss of consciousness 68 D) Having snack, not delaying the meal, right dose of medications, having Candies at hand F)-assess foot daily for sensation, redness and broken skins -Wash dry feet daily - If skin is dry apply a thin coat of lubricating oil -Tie shoes loosely but firmly -If your feet perspire, change shoe and stocking during the day -Wear shoe and stocking that gives room for the movement of the toe Part-ii True or false A. Purpose of the module Diabetes mellitus is a diverse group of hyper glycemic disorders with different etiologies and clinical pictures; there fore timely diagnosis and management based on true laboratory results are crucial. This Satellite Module on Diabetes Mellitus is intended to resolve the critical shortage of clinical chemistry reference materials both for students and for other professionals of the same field working in different health institutions 1. Pre- test questions Instructions: choose the appropriate answer from the alternatives given for each question and write the answers on a separate sheet of paper. Why is there a discrepancy between the whole blood glucose concentration and the plasma glucose concentration? Which one of the following organs uses glucose from digested carbohydrates and stored it as glycogen for later use as a source of immediate energy by the muscles? Learning objectives After studying this satellite module the student will be able to:- Æ Collect, preserve or prepare the correct specimens for diagnosis of diabetes mellitus Æ Perform different clinical chemistry tests in management of diabetes mellitus Æ Practice different quality control procedures in laboratory diagnosis of diabetes mellitus 4. The blood specimen can be collected both from vein or capillary, it depends on the type of sample the test procedure needs, and if serum or plasma is needed Venus blood should be collected with clean, dry, capped test tube, and with or with out anticoagulant. Urine samples are also possible to collect using, a clean, dry, free of any disinfectant, large and wide mouth container so as to do both qualitative and quantitative determination of glucose and others 4. To more completely detect diabetes mellitus, stressing the system with a defined glucose load tests carbohydrate metabolic capacity. To do this, a high- carbohydrate drink or meal is given to the patient, blood is collected 2 hours after ingestion, and the glucose concentration is determined. In the fasting state the arterial (capillary) blood glucose concentration is 5 mg/dl higher than the venous concentration. Preparation and preservation Samples for glucose determination The following factors which affects the stability of glucose in body fluid must be take in to account, such as: • Those glycolytic enzymes found particularly in the red cells, which under goes glycolysis at an average rate of approximately 10 mg/dl/hr in whole blood or 5 mg/dl/hr in sufficiently centrifuged plasma which still contain leukocytes Keeping these considerations in mind, there are several ways to prevent or retard glycolysis in specimen to be analyzed. For example: • Sample for glucose analysis should be delivered to the laboratory as soon as possible after being drowned from the patient. Note When certain enzymatic glucose methods are used, fluoride anticoagulated blood should not be used, as the fluoride might inhibit the enzyme.

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The flow must be slow to allow blood cells to lose and regain water without either crenating or bursting purchase forzest 20 mg visa. Second cheap forzest 20mg visa, a rapid + flow would remove too much Na and urea order forzest 20 mg fast delivery, destroying the osmolar gradient that is necessary for the recovery of solutes + and water. Thus, by flowing slowly to preserve the countercurrent mechanism, as the vasa recta descend, Na and urea are + freely able to enter the capillary, while water freely leaves; as they ascend, Na and urea are secreted into the surrounding medulla, while water reenters and is removed. The movement of Na out of the lumen – of the collecting duct creates a negative charge that promotes the movement of Cl out of the lumen into the interstitial space by a paracellular route across tight junctions. In addition, as Na is pumped out of the cell, the resulting electrochemical gradient attracts ++ Ca into the cell. Finally, calcitriol (1,25 dihydroxyvitamin D, the active form of vitamin D) is very important for calcium ++ recovery. These binding proteins are also important for the movement of calcium inside the cell and aid in exocytosis of calcium across the basolateral ++ membrane. Collecting Ducts and Recovery of Water Solutes move across the membranes of the collecting ducts, which contain two distinct cell types, principal cells and intercalated cells. As in other portions of the nephron, there is an array of micromachines (pumps and channels) on display in the membranes of these cells. By varying the amount of water that is recovered, the collecting ducts play a major role in maintaining the body’s normal osmolarity. If the blood becomes hyperosmotic, the collecting ducts recover more water to dilute the blood; if the blood becomes hyposmotic, the collecting ducts recover less of the water, leading to concentration of the blood. Another way of saying this is: If plasma osmolarity rises, more water is recovered and urine volume decreases; if plasma osmolarity decreases, less water is recovered and urine volume increases. As the ducts descend through the medulla, the osmolarity surrounding them increases (due to the countercurrent mechanisms described above). If aquaporin water channels are present, water will be osmotically pulled from the collecting duct into the surrounding interstitial space and into the peritubular capillaries. By also stimulating aldosterone production, it provides a longer-lasting mechanism to support blood pressure by maintaining vascular volume (water recovery). As + + + the pump recovers Na for the body, it is also pumping K into the forming urine, since the pump moves K in the opposite + + direction. When aldosterone decreases, more Na remains in the forming urine and more K is recovered in the circulation. Still other channels in the principal cells secrete K into the collecting duct + in direct proportion to the recovery of Na. This rate determines how much solute is retained or discarded, how much water is retained or discarded, and ultimately, the osmolarity of blood and the blood pressure of the body. Sympathetic Nerves The kidneys are innervated by the sympathetic neurons of the autonomic nervous system via the celiac plexus and splanchnic nerves. Reduction of sympathetic stimulation results in vasodilation and increased blood flow through the kidneys during resting conditions. When the frequency of action potentials increases, the arteriolar smooth muscle constricts (vasoconstriction), resulting in diminished glomerular flow, so less filtration occurs. Under conditions of stress, sympathetic nervous activity increases, resulting in the direct vasoconstriction of afferent arterioles (norepinephrine effect) as well as stimulation of the adrenal medulla. The adrenal medulla, in turn, produces a generalized vasoconstriction through the release of epinephrine. This includes vasoconstriction of the afferent arterioles, further reducing the volume of blood flowing through the kidneys. Autoregulation The kidneys are very effective at regulating the rate of blood flow over a wide range of blood pressures. This is due to two internal autoregulatory mechanisms that operate without outside influence: the myogenic mechanism and the tubuloglomerular feedback mechanism. Arteriole Myogenic Mechanism The myogenic mechanism regulating blood flow within the kidney depends upon a characteristic shared by most smooth muscle cells of the body.

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