Core Nursing--Depression, diabetes and whatever
Types of affect
Flat
Moderate
Blunted
Overreactive
Emotion
Immediate response--
disgust, joy, surprise, fear, anger
Affect
External, readable mood
Mood
Continuous general state of mind
Broad affect
normal range
Restricted affect
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
limbic system
Mood and Affect: contributing factors:
neuro function
stress
health status
social interaction
day and time
age
gender
anhedonia
decreased interest in activities
Hypomania
4 days of mania
mania
at least one week, impairs functioning
anxious distress
impending doom
restlessness
impaired concentration
high anxiety
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 coping
avoidance
rumination
self pity
self blame
isolation
denial
helplessness
Altered thinking
poor memory
poor decision making
poor concentration
indecisiveness
MDD must include 4 of
Changes in weight (5%) or appetite
sleep disturbances
fatigue
worthlessness or guilt
poor concentration
suicide ideation
persistant depressive disorder is also called...
dysthymia
Situational depression timeline
starts within three months of event
lasts no longer than six months
higher level of anxiety may be present
Bipolar 1
manic
bipolar 2
hypomanic
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
Sociocultural
cognitive
learning
interpersonal
inflammation
hormonal
biological
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
vitamin B
Onset of bipolar disorder
late adolescence or 20s
Antidepressant approved for use in childrn
fluoxetine/prozac
OCD in children and adolescents treated with
Zoloft
Drug that causes increased risk of suicide in children and adolescents...
Paxil
Drugs with a category A rating (no knows risks to fetus)?
NONE
Risks of psychotropic drugs
Ortho hypoTN
Suicide
GI distress
Electrolyte imbalance
Atypical antipsychotics and older adults
increased risk of death w/ dementia
MAOIs details
Lots of interactions
HTN crisis
hypoglycemic potentiation of insulin etc
TCAs details
hard on heart
lower seizure threshold
anticholinergic side effects
SNRIs details
serotonin syndrome
hepatotoxicity
lower seizure threshold
not for bipolar, may intensify psychotic features
excessive drowsiness
SSRIs details
GI upset, take with food
serotonin syndrome w/ ginko
drowsiness
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?
high cortisol
high CRH
To qualify as MDD, symptoms must last..
14+ days
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...
melatonin
Treatment for SAD
Buporion, fluoxetine (prozac), other SSRIs and light therapy
Depression
unable to be cheered up
general hopelessness
refuses support
wont engage in activities
poor self esteem
vague cause
grief
clear cause
normal self esteem
able to temporarily cheer up
will engage in activities
accepts support
Number 1 nursing role with mental health
SAFETY
Toddler depression
regression
preschool depression
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
adolescent depression
difficulty w/ parents and teachers, adult depressive symptoms, a focus on violence
Second most important nursing function for depression
meeting functional needs
emotional contagion
working with depressed patients can cause the nurse to feel down
Nursing interventions for depression
-suicide assessment
- planning care
- improve low self esteem
- instill hope
- help find problem solving methods
- help teach assertiveness
Suicide is the --- leading cause of death
10th
Central neurotransmitter in suicide
decreased serotonin
Most common comorbid disorders for suicide
schizophrenia
bipolar
BPD
Addiction
Depression
For males, suicide is the ___ leading cause of death
7th
Traits associated w/ suicide
impulsivity
aggression
pessimism
negative affect
The fundamental clinical manifestation of suicide
unrelenting stream of painful thoughts
indications for suicidal intent
IS PATH WARM
Ideation
Substance Abuse
Purposelessness
Anxiety
Trapped
Withdrawal
Anger
Recklessness
Mood changes
Group w/ highest suicide rate
Native americans & alaskan natives
Group w/ lowest suicide rate
Hispanics
Most common antidepressants
lexapro
paxil
zoloft
prozac
celexa
Suicide accounts for __% of deaths of women in the postpartum stage
20
The highest rate of suicide for any age group
Men, 75 and older
Protective factors for suicide
young children to care for
community support
access to mental health services
family connections
religious no suicide rule
Risk factors for suicide
social isolation
job loss
relationship loss
feelings of failure/hopelessness
access to lethal means
trauma/abuse
chronic illness/pain
Type 2 diabetes- insulin dependent or not?
Not
T2 diabetes pathophysiology
Insulin resistance with defect in compensatory insulin secretion
NONKETOTIC
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
HTN
PCOS (androgen related)
over 9 lb baby birthed
gestational diabetes
sedentary lifestyle
high triglycerides
low HDL
Prediabetes A1C
5.7% or higher
Prediabetes CBG
100-125+
Prediabetes fasting blood glucose 2 hr test
140-199
Hyperosmalar hyperglycemic state..
plasma osmolality 340+
high blood glucose 600+
altered consciousness
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?
250
70% of postprandial insulin secretion is due to..
GLP-1 and GIP in gut
Greatly reduced or absent in T2 diabetes
Acanthos nigricans
hyperkeratotic plaques caused by insulin like growth factor---evidence of insulin resistance
Only med approved for children w/ T2 diabetes
Metformin (glucophage)
Severe hyperglycemia- pediatric
CBG 250
AIC 9%
Insulin beneficial in this case
Severe hyperglycemia is toxic to..
Islet cells
Diabetes management in peds
1- diet and exercise
2- metformin
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
Insulin
better to avoid diabetes meds, if possible
Obese pregnancy- recommended weight gain
10-20 lbs, instead of 15-25
Pregnancy loss T1 diabetes
1st trimester
Pregnancy loss T2 diabetes
3rd trimester
Older adults w/ diabetes 2 are at a higher risk of
Hypoglycemia
Increased urine output in diabetes implies
osmotic diuresis due to hyperglycemia
Signs of hyperosmolar hyperglycemia
Increased urine output
extreme thirst
extreme hyperglycemia
dehydration
hypotension
seizures
decreasing level of consciousness
TID % of cases
5
T2D % of diagnosed cases
95
Stimulates breakdown of glycogen in the liver, the formation of carbs, and the breakdown of lipids in adipose and liver
Glucagon
Glucagon produced by..
Alpha cells
Insulin produced by..
Beta cells
Glucagon's primary function
Increase glucose levels through glycogenolysis and gluconeogenesis
Low blood glucose
Under 70
Insulin function
move glucose across cell membranes, decreasing blood glucose
Insulin and glucagon
Oppose each other
Somatostatin produced by
Delta cells
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..
90% autoimmune
10% idiopathic
T1 diabetes can be caused by
mumps, coxsackievirus B, rubella
Toxins (cured meats)
Genetic predisposition often present
T1 diabetes is characterized by
Hyperglycemia
Ketosis
Group most susceptible to T1 diabetes
Caucasians
T1 diabetes clinical manifestation
Polyphagia (eating more food/hunger)
Polydipsia
Polyuria
Weight loss
blurred vision
malaise
fatigue
Can HHS occur in T1 diabetes?
No
Can DKA occur in T2 diabetes?
Yes
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
Somogyi phenomenon
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
Hyperosmality
ketoacids
dehydration
electrolyte imbalances
Hypoglycemia does what to the brain
Cerebral malfunction
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
Diabetic retinopathy
alterations in blood vessels and flow
Diabetic nephropathy
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
CAD
Reccomended diagnostic test for diabetes
Fasting blood glucose
Elevated A1C
6.5%
When does blood glucose spill into urine?
180
What can effect blood glucose monitoring?
Hematocrit
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?
e coli
The only insulin that can be given IV
regular insulin (clear)
CSII
Continuous subcu insulin infusion
Grams of carbs per day for diabetics
130g
45-65% of normal
Less CBG effect-- fructose or sucrose and starches?
frustose
% protein in diabetic diet?
15-20%
diabetics should have how much of their diet be fats?
7% or less
Diabetic sodium intake?
2300 mg
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
survival skills
2nd level of diabetic teaching
home managament
3rd level of diabetic teaching
improving lifestyle
DO type 1 diabetics take oral meds?
no
Food desert
Any heavily populated area more than 1 mile from a store that sells fresh produce
Food choice factors
Packaging
smell
taste
body image
convenience
health
cultural
habits
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
C
Macronutrients
carbs, protein, fat
Micronutrients
vitamins, minerals
ATP requires
Fats, carbs and protein
Monosaccarides
glucose, fructose and galactose
Disaccarides
sucrose, lactose, maltose
Which breaks down faster, polysaccharides or monosaccharides?
Mono
Dietary fiber is...
A polysaccaride
legumes, root veggies and grains
Kal per gram of carbs
4
reccomended daily carb
125-175
Excess carbs become..
fat or glycogen
Too many carbs result in...
^triglycerides, caries, and obesity
Lipids dissolve
in alcohol but not water
cals per gram of fat
9
types of lipids
sterols, triglycerides and phospholipids
what provides most of the bodys functional energy?
fats
95% of fats consumes?
triglycerides
Healthy fats
unsaturated
What makes protein different?
It contains nitrogen
Complete proteins
Contain all 9 amino acids and are found in animal products
cals in gram of protein
4
daily protein for women?
45g
daily protein for men?
56g
Fat soluble vitamins
ADEK
water soluble vitamins
BC
Must be attached to a glycoprotein to be absorbed
vitamin B12
Type of vitamin that can be excreted in urine if taken in excess
water soluble
most abundant electrolyte
calcium
A bolus becomes____ during digestion
Chyme
Digestive enzymes
amylase, lipase, protease, maltase, pepsin, sucrase, lactase
Organ primarily responsible for metabolism
Liver
% of men overweight
63%
% of women overweight
55%
% of overweight children
31.8
DKA comes from
HYPOglycemia
Group most overweight
Mexican american men
Group most obese
mexican american women
Dietition
Advanced degree, medical practice
Nutritionist
no advanced degree
26% of calcium deposition is established in...
early adolescence
Pregnant women need more..
protein, iron, folic acid, and calcium
Older adults need more
Vitamin B12, B6, D and calcium
Decreased salivation
xerostomia
Blood sugar peaks at _____ after we eat
60-90 mins
Which contributes to poor health related poor quality of life
smoking
drinking
obesity
poverty
Obesity
Short acting insulin must
be given with meals
% of obese adults
35%
Men and women are____ obese
equally
How much of our energy is dedicated to maintaining our basal metabolic rate?
70%
Mature adipocytes cant multiply, but
Immature ones can, especially when exposed to estrogen
Fat cells store fat as
triglycerides
Infection and illness in a diabetic can
raise their blood sugar
Which part of the brain tells a person theyre hungry?
Hypothalamus
Hormones involved in obesity
LEPTIN, thyroid hormone, insulin
Leptin
Suppresses appetite
Purely genetic obesity is
rare
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
Normal BMI
18.5-24.9
Underweight
18.5 and under
overweight
25-29.9
Obesity 1
30-34.9
Obesity 2
35-39.9
Extreme obesity
40+
Metabolic syndrome includes 3 of what symptoms
high waist circumfrence
high triglycerides
Low HDL
high blood sugar
Most accurate way to determine amount of body fat
hydrodensitometry
Diets of less than ___ calories are not safe
1200
types of bariatric surgeries
gastric bypass
sleeve
Roux-n-Y
Overweight percentile range
over 85th, below 95th
Obese percentile range
over 95th