Core Nursing--Depression, diabetes and whatever
Types of affect
disgust, joy, surprise, fear, anger
External, readable mood
Continuous general state of mind
restricted range-- cries for dead wife, no happiness for birth of child
Parts of limbic system
amygdala, hippocampus and hypothalamus
Limbic system activity regulated/moderated by...
the medial prefrontal cortex
Key contributor in normal mood
Neurotransmitter and neuronal function
Part of the limbic system most effected by chronic stress
Mood and Affect: contributing factors:
day and time
decreased interest in activities
4 days of mania
at least one week, impairs functioning
fear of losing control
patients who experience anxious distress with bipolar/depression are
at a greater risk for suicide and harder to treat
mood disorders effect
10% of adults
Two major mood disorder neurotransmitters
serotonin and norepi (DECREASE)
poor decision making
MDD must include 4 of
Changes in weight (5%) or appetite
worthlessness or guilt
persistant depressive disorder is also called...
Situational depression timeline
starts within three months of event
lasts no longer than six months
higher level of anxiety may be present
Bipolar may come with what features
mixed (mania and depressive features during each cycle)
rapid cycling (4 or more episodes in a year)
Theories of depression
Primary depression strategies
teaching coping skills, diet, not smoking, relationships
Secondary depression strategies
screening, referral and counseling
Tertiary depression strategies
collaborative care and community programs
Most common depression screener
Patient health questionnaire (PHQ-9)
Transcranial magnetic stimulation targets.. to treat depression
the LEFT prefrontal cortex
transcranial magnetic stimulation targets... to treat mania
the RIGHT prefrontal cortex
Which vitamin is involved in the production of norepi and serotonin
Onset of bipolar disorder
late adolescence or 20s
Antidepressant approved for use in childrn
OCD in children and adolescents treated with
Drug that causes increased risk of suicide in children and adolescents...
Drugs with a category A rating (no knows risks to fetus)?
Risks of psychotropic drugs
Atypical antipsychotics and older adults
increased risk of death w/ dementia
Lots of interactions
hypoglycemic potentiation of insulin etc
hard on heart
lower seizure threshold
anticholinergic side effects
lower seizure threshold
not for bipolar, may intensify psychotic features
GI upset, take with food
serotonin syndrome w/ ginko
suicidal ideation and serotonin syndrome
Pathophysiology of depression
decreased grey matter
increased limbic center activity
decreased metabolism of medial prefrontal cortex
depression related neurotransmitters
norepi, serotonin, gaba, ach, glutamate, dopamine
depression and inflammation?
increased levels of cytokines in SOME people
evidence of limbic hyperactivity?
To qualify as MDD, symptoms must last..
If a depressed pt has a hx of mania...
they do not qualify as MDD
SAD happens in the winter because...
lack of exposure to light causes increased SERT which decreases serotonin
People with sad tend to overproduce...
Treatment for SAD
Buporion, fluoxetine (prozac), other SSRIs and light therapy
unable to be cheered up
wont engage in activities
poor self esteem
normal self esteem
able to temporarily cheer up
will engage in activities
Number 1 nursing role with mental health
self destructive play themes and less normal play. irritability, lack of confidence
school age depression
poor grades, loss of friends, less activity, somatic complaints. talk of running away, boredom, low self esteem
difficulty w/ parents and teachers, adult depressive symptoms, a focus on violence
Second most important nursing function for depression
meeting functional needs
working with depressed patients can cause the nurse to feel down
Nursing interventions for depression
- planning care
- improve low self esteem
- instill hope
- help find problem solving methods
- help teach assertiveness
Suicide is the --- leading cause of death
Central neurotransmitter in suicide
Most common comorbid disorders for suicide
For males, suicide is the ___ leading cause of death
Traits associated w/ suicide
The fundamental clinical manifestation of suicide
unrelenting stream of painful thoughts
indications for suicidal intent
IS PATH WARM
Group w/ highest suicide rate
Native americans & alaskan natives
Group w/ lowest suicide rate
Most common antidepressants
Suicide accounts for __% of deaths of women in the postpartum stage
The highest rate of suicide for any age group
Men, 75 and older
Protective factors for suicide
young children to care for
access to mental health services
religious no suicide rule
Risk factors for suicide
feelings of failure/hopelessness
access to lethal means
Type 2 diabetes- insulin dependent or not?
T2 diabetes pathophysiology
Insulin resistance with defect in compensatory insulin secretion
insulin not sufficient to lower blood glucose
Group with highest rate of t2 diabetes
native americans and alaskan natives
Risk of obesity w/ t2 diabetes
20% overweight or bmi over 27
Causes PERIPHERAL INSULIN RESISTANCE by decreasing # of receptor sites
T2 diabetes risk factors
PCOS (androgen related)
over 9 lb baby birthed
5.7% or higher
Prediabetes fasting blood glucose 2 hr test
Hyperosmalar hyperglycemic state..
plasma osmolality 340+
high blood glucose 600+
What causes hyperosmalar hyperglycemic state?
High CBG--> increased urine output--> dehydration--> salty/glucosy blood
How low do we need to get the CBG in hyperosmalar hyperglycemia?
70% of postprandial insulin secretion is due to..
GLP-1 and GIP in gut
Greatly reduced or absent in T2 diabetes
hyperkeratotic plaques caused by insulin like growth factor---evidence of insulin resistance
Only med approved for children w/ T2 diabetes
Severe hyperglycemia- pediatric
Insulin beneficial in this case
Severe hyperglycemia is toxic to..
Diabetes management in peds
1- diet and exercise
3- insulin if no other choice
Diet and exercise pediatric T2 diabetes
1 hr exercise per day
small meals w/o insulin spike threats
T2 while pregnant- pharmacologic care
better to avoid diabetes meds, if possible
Obese pregnancy- recommended weight gain
10-20 lbs, instead of 15-25
Pregnancy loss T1 diabetes
Pregnancy loss T2 diabetes
Older adults w/ diabetes 2 are at a higher risk of
Increased urine output in diabetes implies
osmotic diuresis due to hyperglycemia
Signs of hyperosmolar hyperglycemia
Increased urine output
decreasing level of consciousness
TID % of cases
T2D % of diagnosed cases
Stimulates breakdown of glycogen in the liver, the formation of carbs, and the breakdown of lipids in adipose and liver
Glucagon produced by..
Insulin produced by..
Glucagon's primary function
Increase glucose levels through glycogenolysis and gluconeogenesis
Low blood glucose
move glucose across cell membranes, decreasing blood glucose
Insulin and glucagon
Oppose each other
Somatostatin produced by
Somatostatin is believed to
Prevent overproduction of both insulin and glucagon
Organs that do not require insulin for glucose uptake
brain, liver, renal tubules and intestines
Other hormones that stimulate increase in glucose in emergency
T4, epi, glucocorticoids, and growth hormone
T1 diabetes is caused by
the destruction of beta cells
T1 diabetes is..
T1 diabetes can be caused by
mumps, coxsackievirus B, rubella
Toxins (cured meats)
Genetic predisposition often present
T1 diabetes is characterized by
Group most susceptible to T1 diabetes
T1 diabetes clinical manifestation
Polyphagia (eating more food/hunger)
Can HHS occur in T1 diabetes?
Can DKA occur in T2 diabetes?
The Dawn Phenomenon
Increase in CBG between 4am & 8am, unrelated to food
Theory regarding dawn phenomenon?
Increase in growth hormone during sleep leading to decreased peripheral glucose uptake
hypoglycemia during the night with hyperglycemia in morning
Why does ketoacidosis occur?
Breakdown of fat produces ketones. Bicarb is used to produce ketones, which leads to a lack of bicarb to prevent acidosis
DKA results in
Hypoglycemia does what to the brain
When glucagon stops being produced..
Epi replaces it
When epi fails to replace the function of glucagon..
the individual develops unaware hypoglycemia
15/15 rule of hypoglycemia
15g sugar- wait 15 mins- recheck gbg- 15g sugar
Diabetic vascular changes
Blood vessels thicken, screwing up perfusion
alterations in blood vessels and flow
thickening of glomerular tissue, leaky
Cardiac conditions of diabetes
CAD, decreased ability to survive MI, higher chance of HF after MI, HTN, Stroke
Number one diabetic cause of death
Reccomended diagnostic test for diabetes
Fasting blood glucose
When does blood glucose spill into urine?
What can effect blood glucose monitoring?
high makes it look low and vice versa
What is insulin made from?
biosynthetic insulin (most common) from e coli and pork pancreas
What is fast acting humalog insulin made from?
The only insulin that can be given IV
regular insulin (clear)
Continuous subcu insulin infusion
Grams of carbs per day for diabetics
45-65% of normal
Less CBG effect-- fructose or sucrose and starches?
% protein in diabetic diet?
diabetics should have how much of their diet be fats?
7% or less
Diabetic sodium intake?
Special changes during illness for diabetics?
CBG 4 times per day, instead of 2
8-12 oz fluid per hour
test for urine ketones if CBG 240+
1st level of diabetic teaching
2nd level of diabetic teaching
3rd level of diabetic teaching
DO type 1 diabetics take oral meds?
Any heavily populated area more than 1 mile from a store that sells fresh produce
Food choice factors
Which is more satiating?
Fat, protein, grains
Protein and probably grains
Vegan diets lack
omega3s, calcium, iron, zinc and B12, vit D
Vitamin __ helps absorbtion
carbs, protein, fat
Fats, carbs and protein
glucose, fructose and galactose
sucrose, lactose, maltose
Which breaks down faster, polysaccharides or monosaccharides?
Dietary fiber is...
legumes, root veggies and grains
Kal per gram of carbs
reccomended daily carb
Excess carbs become..
fat or glycogen
Too many carbs result in...
^triglycerides, caries, and obesity
in alcohol but not water
cals per gram of fat
types of lipids
sterols, triglycerides and phospholipids
what provides most of the bodys functional energy?
95% of fats consumes?
What makes protein different?
It contains nitrogen
Contain all 9 amino acids and are found in animal products
cals in gram of protein
daily protein for women?
daily protein for men?
Fat soluble vitamins
water soluble vitamins
Must be attached to a glycoprotein to be absorbed
Type of vitamin that can be excreted in urine if taken in excess
most abundant electrolyte
A bolus becomes____ during digestion
amylase, lipase, protease, maltase, pepsin, sucrase, lactase
Organ primarily responsible for metabolism
% of men overweight
% of women overweight
% of overweight children
DKA comes from
Group most overweight
Mexican american men
Group most obese
mexican american women
Advanced degree, medical practice
no advanced degree
26% of calcium deposition is established in...
Pregnant women need more..
protein, iron, folic acid, and calcium
Older adults need more
Vitamin B12, B6, D and calcium
Blood sugar peaks at _____ after we eat
Which contributes to poor health related poor quality of life
Short acting insulin must
be given with meals
% of obese adults
Men and women are____ obese
How much of our energy is dedicated to maintaining our basal metabolic rate?
Mature adipocytes cant multiply, but
Immature ones can, especially when exposed to estrogen
Fat cells store fat as
Infection and illness in a diabetic can
raise their blood sugar
Which part of the brain tells a person theyre hungry?
Hormones involved in obesity
LEPTIN, thyroid hormone, insulin
Purely genetic obesity is
Most important contributor to obesity
lack of activity
upper body obesity is determined by a waist to hip ration of
1 in men, 0.8 in women
18.5 and under
Metabolic syndrome includes 3 of what symptoms
high waist circumfrence
high blood sugar
Most accurate way to determine amount of body fat
Diets of less than ___ calories are not safe
types of bariatric surgeries
Overweight percentile range
over 85th, below 95th
Obese percentile range