n Assessment

A patient whose diabetes mellitus was not previously diagnosed or is poorly controlled or out of control may have a history of polyuria (excretion of a large amount of urine), polydipsia (excessive thirst), polyphagia (excessive uncontrolled eating), weight loss, blurred vision, and fatigue. In severe cases of hyperglycemia, the patient may develop systemic acidosis, a condition in which the basic fluid and electrolyte balance of the body is disturbed, and the blood pH is decreased. Symptoms of systemic acidosis include nausea, vomiting, and changes in level of consciousness.

Ask the patient about signs of pregnancy, infection, and kidney, liver, or thyroid disease, because these conditions alter the requirement for insulin. Find out about any earlier sensitization (allergy to a foreign protein) to beef or pork and whether the patient is taking other drugs that may interact with insulin.

n Diagnosis

What other needs does the patient have? Does the patient need information on weight loss, nutrition, or other knowledge? What other diseases does this patient have that might influence the therapy for diabetes?

n Planning

Successful management of diabetes mellitus depends on the patient understanding the disease. Control and maintenance require that the patient know about the nature of the disease, proper diet and the need for weight control, and the importance of hygiene and exercise. The patient must understand how to do blood and urine testing and how to correctly draw up and inject insulin. A diabetic must know the signs and symptoms of hypoglycemia and hyperglycemia and the appropriate actions to take for each, as well as procedures to follow during illness.

The patient should be shown the proper injection technique, including drawing up, injection, and storage of insulin. Ask the patient to demonstrate how to give the injection.

n Implementation

n Evaluation

The patient’s response to the insulin dose is seen by testing the blood. The nurse, physician, or other health care provider should inform the patient about how frequently to return for checkups, what blood levels are being found at these visits, and what the desired levels should be. The patient must be encouraged to take responsibility for managing his or her own disease.

Patients with type 2 diabetes are frequently overweight. As the patient’s blood sugar level is under control and they begin to lose weight, the dosage of insulin they require is less. The clinician will often reduce the dosages of medications prescribed when weight loss has taken place.

The plan of insulin therapy is to keep blood glucose levels within specific limits and to prevent symptoms of hyperglycemia and hypoglycemia. Patients with home glucometers should be told when to check their blood glucose level, depending on the type of insulin they are taking. Urine ketones should be measured during acute illness or periods of increased glycosuria and in ketosis-prone diabetic patients. The records the patient keeps will provide information regarding control between office visits and should be taken to each visit with the health care provider.

If hypoglycemia occurs, the patient should be taught to eat some form of carbohydrate immediately. The family should also be involved in patient teaching about therapy for hypoglycemia. If the patient is unconscious, honey or corn syrup may be put under the tongue or on the buccal mucosa in the mouth. Additional carbohydrates, such as bread, crackers, or milk, should be provided for the next 2 hours; a sandwich should be eaten if a snack or meal would not be regularly eaten within an hour. Glucagon, a glucose-rich liquid, may be administered by a family member or a care provider to quickly raise blood glucose levels if the patient has accidentally taken too much insulin.

The Somogyi effect (rebound elevation of glucose levels brought on by hypoglycemia) can lead to overtreatment of the patient with insulin when less insulin is actually needed. Patients older than 60 years of age are often sensitive to hypoglycemia. They should be observed for confusion and abnormal behavior, because repeated episodes of hypoglycemia may cause brain damage.

Regular appointments with the clinician will be timed with laboratory blood work to measure blood sugar control. The hemoglobin (Hb) A1c blood test reflects the state of glycemia the patient has experienced for the last 90 days, which is the lifetime of the red blood cell. The goal is to keep the HbA1c level less than 7%, which is equivalent to a blood glucose level of 150 mg/dL. The blood glucose level goes up by approximately 30 points for every 1% increase of the HbA1c (e.g., 8% = 180 mg/dL; 9% = 210 mg/dL). Evaluation of this blood level will tell the clinician about general blood sugar levels, not just the blood sugar level on the day of the appointment.

n Patient and Family Teaching

n Assessment

Try to learn as much as possible about the patient’s health history, including what other drugs the patient is taking that may interact with the oral products, and if the patient is pregnant or has renal insufficiency, impaired liver function, or a history of ketoacidosis. Ask if the patient has any sensitivity (allergy) to sulfa drugs, because he or she may have cross-sensitivity to sulfonylureas (a patient who is sensitive to one type of sulfa drug may be sensitive to all types).

n Diagnosis

Does the patient have any other problems that would interfere with drug therapy? Are there problems with weight, nutrition, vision, or finances? Does the patient have past history or behavior that might cause the nurse to suspect this patient might not be compliant with diet, exercise, medication, and testing requirements?

n Planning

No transition period is necessary when a patient is switched from one oral hypoglycemic to another. Plan the teaching that will be necessary as the nurse works with this patient.

n Implementation

n Evaluation

The patient’s blood glucose levels should be monitored, and the patient should be watched for signs and symptoms of hypoglycemia.

Rashes may develop when sulfonylurea therapy begins, but they generally last only a short time. If they persist, the medication should be stopped. Cholestatic jaundice has been reported in a small number of patients on oral hypoglycemic therapy. Any liver damage that has developed generally goes away when the drug is stopped. Watch for any signs of blood dyscrasias, GI intolerance, or allergic reactions.

n Patient and Family Teaching

n Assessment

It is important to determine the exact due date for delivery. The patient may be past the anticipated due date for the baby or have a history of engorged breasts. A history of incomplete abortion, cesarean section births, or excessive postpartum bleeding may require use of oxytocics or ergots. Finally, a patient may also want to terminate an unwanted pregnancy early in gestation.

n Diagnosis

What additional problems might this patient have? Is there unreasonable anxiety or fear associated with the delivery? Does the mother have concerns about the health of the child? Have previous experiences been positive? What other medical conditions might make this delivery more risky?

n Planning

The uterine contractions produced by oxytocics should be about the same as those of spontaneous, normal labor.

There are numerous precautions or contraindications to the use of oxytocics. These medications must be given by qualified nurses under the direct supervision of physicians or other health care providers. Inappropriate use of either oxytocic or ergot preparations has caused fetal and maternal death or injury, subarachnoid hemorrhage, and uterine rupture.

n Implementation

Oxytocin is the drug of choice to cause or induce labor in many areas of the country. However, prostaglandins are now preferred in some regions. These are usually given by intravenous (IV) infusion pump.

Ergonovine is now the drug of choice to control postpartum bleeding. It can be given sublingually, intramuscularly, or intravenously in emergency situations. Methylergonovine is the synthetic homologue of ergonovine and has been found to produce fewer vasoconstrictive or hypertensive side effects than ergonovine. It is noted that IV administration of either of these ergot preparations increases the danger of side effects.

n Evaluation

If oxytocin is used during induction of labor, the patient should be monitored for degree of contractions and the development of adverse reactions. The blood pressure and pulse should be checked frequently, and there should be continuous monitoring of the fetal heart rate. Monitor the dilation of the cervix and the progression of contractions. Drastic increases in the frequency, force, and duration of contractions and in resting uterine tone may require the drug to be stopped. The contractions should not be more than 50 mm Hg, the frequency should be no longer than every 2 minutes, and the duration should be no longer than 90 seconds. Both the mother and fetus should be monitored with internal monitoring equipment (fetal scalp electrode and intrauterine pressure catheter).

Watch out for the symptoms of ergotism: vomiting; diarrhea; unquenchable thirst; tingling, itching, and coldness of the skin; a rapid, weak pulse; confusion; and unconsciousness.

Ergonovine might stimulate cramping. If this becomes too uncomfortable, the physician may either decrease the dosage or treat the symptoms.

The most common side effects of ergonovine are nausea and vomiting. These symptoms can sometimes be stopped if the patient is given a phenothiazine antiemetic.

If overdosage of an oxytocic occurs, producing a continuous contraction, the drug must be stopped immediately. It may be necessary to give a general anesthetic to relax the uterus, particularly if the fetus is threatened.

n Patient and Family Teaching

Adverse Reactions

Because all of these medications are hormones, their primary adverse reactions include systemic or local hormonal reactions. Menotropins may produce ovarian enlargement, blood inside the peritoneal cavity, and febrile reactions; when it is used to increase fertility, multiple births may be produced. Clomiphene may produce abdominal discomfort, ovarian enlargement, blurred vision, nervousness, and nausea and vomiting. Vasomotor flushes (hot flashes), much like those seen in menopause, may also occur. Chorionic gonado­tropin may cause headache, irritability, restlessness, fatigue, and edema. Precocious puberty (onset of sexual development at an early age) may result from its use in treatment for undescended testes.

n Assessment

Learn everything possible about the patient’s health history to determine medication use and the presence of other diseases or conditions that would influence whether it is safe to use pituitary hormones.

n Diagnosis

Patients needing anterior pituitary hormones often have many symptoms that must be dealt with while the primary problems are resolved. These patients often have emotional, financial, and physical problems. Diagnosing problems that bother the patient and helping take care of them will be important in meeting the long-term treatment goals for each individual.

n Planning

There are no oral forms of pituitary hormones. They are given intramuscularly, subcutaneously, intravenously, or intranasally. Patients taking posterior pituitary products must be monitored closely. Additional doses may be required in times of stress.

n Implementation

The dosages of desmopressin are individualized so that the patient has an adequate daily rhythm of water metabolism and adequate duration of sleep. Generally the administration should be at the same time as polyuria or polydipsia and before sleep.

Even though vasopressin is given in an injection, the patient should drink one to two glasses of water at the time of administration to reduce the incidence of adverse effects.

n Evaluation

Monitor the patient taking ADH for a decrease in the frequency and the amount of urination, monitor the specific gravity of the urine, and watch for water intoxication or signs of dehydration.

n Patient and Family Teaching

n Assessment

There are many contraindications and precautions to the use of these drugs. Learn everything possible about the patient’s health history, including other diseases, other medications that might interact with corticosteroids, and whether the patient might have an infection or be pregnant.

n Diagnosis

Once a patient has started glucocorticoids, there is a constant need to look for adverse effects, both physical and psychologic. The nurse must be constantly aware of new symptoms that may represent pathologic conditions or disease.

n Planning

Steroids come in many forms. Corticosteroids may be administered by the following routes: oral, inhalation, intranasal, IV, intramuscular, subcutaneous, intrabursal, intradermal, intrasynovial, intralesional, soft tissue injection, topical, and per rectum. Only corticosteroid preparations with specific labels should be used for ophthalmologic or otic administration.

Steroids that are used topically affect only a small part of the body. Steroids that are injected or taken by mouth affect the whole body—they have effects throughout the body’s systems. Although glucocorticoids are highly potent drugs, short-term use of even very large doses is not likely to cause long-term problems. However, intermediate and long-term administration (longer than 6 days of systemic treatment) places the patient at high risk for a large number of serious adverse effects. How much risk is involved and how much benefit the patient will receive must be carefully considered. These medications stop production of steroids by the body, so if the medication is suddenly stopped, the body may be unable to function. The immediate and long-term effects of these drugs vary greatly and depend on the disease, the route of administration, dosage, duration, and frequency and time of administration.

Generic forms of the drugs are much less expensive than brand-name drugs. Generally, prednisone is considered the drug of choice to reduce inflammation and depress the immune system. It is recommended that antacids be taken with or between doses to help reduce the chance of peptic ulcer. Systemic corticosteroids are given orally, except in emergency circumstances or when the patient is unable to take oral medication. The onset of action is 2 to 8 hours, and the effects last for 24 hours. Oral corticosteroids are almost completely absorbed in the GI tract.

When corticosteroids are given orally to patients with functioning adrenal glands, the total dose should be taken first thing in the morning. This is the time when the adrenal glands are normally secreting the most hormones, so the corticosteroid dose will not cause problems with the body’s feedback loop.

For conditions requiring a local injection, a single injection yields sufficient antiinflammatory effects to reduce symptoms in many cases. The slowly absorbed forms (acetate, diacetate, tebutate) of corticosteroids generally give relief for 1 to 2 weeks.

n Implementation

Dosages vary a lot; the dose will be determined for each patient and each problem, based on the diagnosis, severity, prognosis, and estimated length of the disease. Patient response and tolerance will also be considered when deciding on dosage. Individuals may respond better to one form than another, but this is unpredictable. The general rule the physician follows, regardless of route of administration, is to prescribe as high a dose as necessary initially to get a favorable response, then decrease the amount gradually to the lowest level that will maintain the therapeutic effect but not produce complications.

In systemic administration, dosage regimens are of two types: (1) physiologic, for replacement of glucocorticoids in adrenal insufficiency; and (2) pharmacologic, to reduce symptoms.

Corticosteroids cannot be stopped without tapering (slowly reducing) the dose over time. Stopping the drug suddenly leads to steroid withdrawal syndrome, with symptoms of anorexia, nausea and vomiting, lethargy, headache, fever, joint pain, skin peeling, myalgia (widespread muscle pain), weight loss, and hypotension. Abruptly stopping the drug may also result in a rebound of symptoms of the condition being treated.

When corticosteroids are administered for longer than 1 to 2 weeks at pharmacologic doses, pituitary release of ACTH is stopped, and this causes secondary adrenocortical insufficiency. Patients undergoing physiologic, emotional, or psychologic stress may need additional support through larger amounts of steroids. This suppression of ACTH may last up to 2 years after the patient stops taking the drug.

During tapering to maintenance doses or to stop the drug, the patient must be watched carefully and taught the signs of adrenal insufficiency (malaise, hypotension, and anorexia [lack of appetite] are common, but many other symptoms may also occur). If these symptoms occur, or if the patient’s disease flares up, the steroid dose is increased until symptoms go away. Tapering then begins again on a more gradual plan. After shorter steroid courses (1 to 2 weeks), the dosage is reduced by 50% each day. The same scheduled dose intervals are kept.

n Evaluation

All patients receiving systemic corticosteroids should be watched carefully, and the dosage should be adjusted to reflect reduced or increased symptoms, the patient’s response, and any periods of stress in the patient’s life (injury, infection, surgery, and emotional crisis). Patients should be monitored for 1 or 2 years after high-dosage or long-term treatment. To prevent unmonitored steroid use while patients are receiving steroids, they are usually given prescriptions that cannot be refilled.

Corticosteroids hide infection and increase the patient’s risk for infection. Corneal fungal infections are particularly likely to develop with extensive ophthalmologic corticosteroid use. Corticosteroids are particularly dangerous to use in patients with a history of tuberculosis, because the disease can be reactivated. With long-term use, active psychologic disorders may be made worse or hidden disorders made active because steroids affect mood. Long-term use may also produce osteoporosis, leading to vertebral collapse.

Although steroids are often used illegally in sports because they affect muscle size and strength, it is dangerous to take steroids for a long time because of all the damage they can do to the body.

n Patient and Family Teaching

n Assessment

Learn as much as possible about the health history of the patient, including the presence of carcinoma; cardiac, renal, or liver dysfunction; other drugs the patient may be taking; and the possibility of pregnancy.

The male patient may have a history of impotence, reduced libido (sex drive), weight loss, male climacteric, or castration. There may be a history of traumatic castration or failure to develop secondary sex characteristics by 15 to 17 years of age.

n Diagnosis

These patients often have other problems that need to be diagnosed and addressed. In addition to their medical problems, they often have great concern about their sexuality, body image, and self-esteem.

n Planning

When androgens are given for hypogonadism, careful descriptions of secondary sex characteristics and measurements should be recorded for a baseline to monitor the therapeutic effects.

If cholestatic jaundice develops or liver function decreases, the drug should be stopped. Stomatitis (inflammation of the mouth) may result from buccal administration.

n Implementation

Androgens can be taken buccally, sublingually, and through the skin as a patch, depending on the specific drug and the reason for therapy. Dosages vary from 2 to 10 mg daily for replacement therapy. Higher divided doses are given for antineoplastic therapy.

Patients must be taught not to swallow the pill and not to eat, drink, or smoke or chew tobacco until the buccal tablet is absorbed.

n Evaluation

The therapeutic response may be slow, requiring 3 or more months to affect symptoms. Monitor for the development of secondary sex characteristics and improvement in sexual functioning.

n Assessment

For patients who have not had menses, ask about primary amenorrhea and sexual infantilism. For women of childbearing age, ask about the possibility of pregnancy, history of ovarian failure, need for contraception, and dysmenorrhea. For patients near the age of menopause, see if they have a history of hot flashes, menstrual irregularities, dyspareunia (pain during intercourse), vaginal discharge, vulvar pruritus, urinary frequency, and history of oophorectomy or hysterectomy.

There is an increased dose-related risk of thromboembolic disease, especially in premenopausal women. Progestins should not be used during pregnancy, especially the first 3 months, because of the risk of congenital anomalies and of vaginal adenosis or vaginal or cervical cancer in female offspring when they reach childbearing age. There is an increased risk of gallbladder disease with long-term use. Postmenopausal estrogen therapy is associated with an increase in the risk of endometrial cancer of 5 to 15 times the normal risk; the level of risk is related to the length of treatment. Administration of estrogen may result in hypercalcemia in patients with breast or bone cancer.

n Diagnosis

Based on the assessment, the nurse should be prepared to recognize and deal with other emotional or physical problems arising from estrogen or progestin use. As women go through their reproductive years, they have different concerns and physical problems. Determine age-related factors that may be of concern to the patient. Individualize therapy as much as possible.

n Planning

Estrogen therapy affects many body systems. When estrogens are used before puberty, short stature and decreased growth can result. Use in adult women can increase the risk for migraine headaches, hypertension, diabetes, and certain benign and malignant tumors. Because estrogens are metabolized in the liver and excreted through the kidneys, renal or hepatic dysfunction can alter their actions. Fibroid tumors of the uterus may increase in size. Because fluid is retained, symptoms of hypertension, asthma, epilepsy, migraine, and heart or kidney dysfunction may be increased. Topical estrogens are readily absorbed and may have systemic effects.

Progestins are especially valuable in women who cannot take estrogen. Progestins often cause menstrual cycle changes, and patients must understand this before taking these drugs if they are to have a successful experience. These medications can be used for contraception in women who are breastfeeding.

n Implementation

Estrogens can be given orally, intramuscularly, or topically. For control of menopausal symptoms, ovarian failure, or postoophorectomy symptoms, they are usually given in cycles of one tablet daily for 3 weeks, followed by 1 week off the drug. Usually, the lowest effective dose is given for the shortest period. High doses or long-term therapy should be tapered gradually.

Natural progestins are poorly absorbed orally; therefore oral progestins are synthetic products. Tablets are given daily. Progestins are quickly metabolized in the liver, but daily doses are effective.

n Evaluation

Patients on female hormone therapy should be monitored regularly, and the nurse should watch for adverse effects. Problems that should raise concern are thrombophlebitis and edema in women and feminizing changes or impotence in men.

Timing and description of any vaginal bleeding should be noted to determine if response is therapeutic or adverse.

n Patient and Family Teaching

Emergency Contraception

Any time a woman has unprotected intercourse and does not want to become pregnant, she may use an emergency contraception kit containing two tablets (or take two multiple-tablet doses) of selected combined oral contraceptive pills. Treatment must be started within 72 hours of intercourse, with two doses taken 12 hours apart. Emergency contraceptive pills work primarily by blocking or delaying ovulation or by changing the way sperm or ova are transported, thereby preventing conception. The risk of pregnancy is decreased by 75%. The pills often produce nausea and irregular menstrual bleeding.

n Assessment

n Diagnosis

Does the patient have other knowledge deficits or financial, nutritional, or social problems that would interfere with her taking this medication? For example, women who smoke and use oral contraceptives are at much greater risk for venospasm and thromboembolic events. These women should either not be placed on oral birth control (OBC) if they are older than 35 years or should be helped to discontinue smoking.

For women using emergency contraception, do they understand other more effective ways to prevent pregnancy?

n Planning

Although breakthrough bleeding may be a side effect, nonfunctional causes should be investigated. Bleeding irregularities are more common with progestin-only pills.

There is some risk of infertility after oral contraceptives are stopped, especially in women who have had irregular or scanty periods before taking pills.

Research suggests that many women forget to take pills, resulting in many unintentional pregnancies. Discuss with the patient how the pill will fit into her lifestyle in such a way that she will remember to take it.

n Implementation

To be effective, oral contraceptives must be taken at about the same time each day. This is particularly true with progestin-only pills. Taking medication with meals will reduce the nausea common in the first cycles.

All oral combination contraceptives are to be taken for 21 days. Usually, therapy is started either the fifth day after or the Sunday after menstruation starts. Another method of contraception should be used for the first 7 to 10 days of the first cycle. Pills are packaged in a 1-month packet with the days named or numbered. Some preparations contain 28 pills to be taken daily, 7 of which contain an inert substance or iron. Others require the patient to go 7 days without pills before starting another 28-day cycle. During the “resting” phase of the cycle, vaginal bleeding should occur.

n Patient and Family Teaching

n Assessment

Try to learn as much as possible about the patient’s health history, including other drugs being taken that may produce drug interactions. Does the patient have diabetes mellitus, cardiovascular disease, adrenocortical insufficiency, or pregnancy? These conditions are precautions to the use of thyroid supplements. The patient may also have a history of hypothyroidism.

On examination, the nurse may find skin changes associated with myxedema, the most severe form of hypothyroidism. These changes include nonpitting edema; doughy skin; puffy face; large tongue; decreased body hair; and cool, dry skin. The thyroid gland may be normal in size, enlarged, or not palpable, depending on the cause of hypothyroidism. Neurologic signs include slow thinking, muscle weakness, slowed relaxation phase of the deep tendon reflexes, dull facial expression, and carpal tunnel syndrome. Cardiac signs include bradycardia and decreased blood pressure.

Laboratory findings in thyroid disease may include reduced free T₄ index and elevated serum TSH; other tests may be abnormal.

n Diagnosis

Because thyroid disease may be insidious (hard to notice because of small changes) 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 self-esteem that should be addressed. Patients may find it hard to wait for the length of time it takes for thyroid medications to return them to normal functioning and resolve some of these problems.

n Planning

Patients older than 50 years of age are often very sensitive to thyroid hormones, so it is important for them to begin on a small dose. They should be observed for signs and symptoms of cardiovascular disease before the dosage is increased.

n Evaluation

Response to therapy is not immediate. Most patients begin to feel better within 2 weeks, and the therapeutic results are often seen in 3 months.

Teach patients the signs and symptoms of hypo­thyroidism and hyperthyroidism so they can determine if they are receiving too much or too little medicine.

If symptoms of overdosage occur, the prescribing health care provider should be consulted promptly. The medication will likely be stopped for several days, and therapy may be started again at a lower dosage.

Periodic blood tests should be done before thyroid hormone therapy is started and periodically once the patient is on a maintenance dose.

n Patient and Family Teaching

n Assessment

Try to learn as much as possible about the patient’s health history, including hypersensitivity (allergy) to antithyroid drugs, other medications being taken that could cause drug interactions, and pregnancy or breastfeeding.

The patient may have a history of hyperthyroidism, including nervousness or tremor, weight loss with increased appetite, heat intolerance and excessive sweating, mood swings, and muscle weakness. On physical examination, the nurse may find exophthalmos (bulging eyes); thyroid enlargement; tachycardia; increased blood pressure; tremor; proximal muscle weakness; and warm, moist, smooth skin. Weight loss and the signs of chronic heart failure may be the most obvious signs of hyperthyroidism in older adults.

Laboratory findings may show elevated free T₄ index, increased T₃, or decreased TSH.

n Diagnosis

Because thyroid disease may be slow in onset, the patient may have many symptoms that require therapy at the time of diagnosis. Patients may be restless or anxious, have eating and sleeping problems, or have problems with concentration and memory that must be addressed. Patients may find it hard to wait for the length of time it takes for thyroid medications to return them to normal functioning and resolve some of these problems.

n Planning

Antithyroid drugs usually remove symptoms of hyperthyroidism if taken correctly for 1 to 2 years. Patient compliance with therapy should be encouraged to help them return to normal thyroid levels.

n Implementation

n Evaluation

Laboratory blood tests should be completed before beginning antithyroid therapy and periodically once the patient is on a regular maintenance dosage. Before therapy is started, a WBC count with differential is done; this should be repeated if there is any sign of infection. Serum T₄ and TSH levels are monitored initially and after every 2 weeks of therapy until a euthyroid state (normal function of the thyroid gland) is achieved, usually in 3 to 5 months. 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 under control. If hyperthyroidism seems to be absent, therapy is stopped.

n Patient and Family Teaching