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What is diabetes mellitus?

A group of metabolic diseases characterized by increased levels of glucose in the blood resulting from defects in insulin secretion, insulin action or both.

Normal FBS?
Pre-diabetes FBS?
Diabetes FBS?

Normal = <100 mg/dl
Pre-diabetes = 100-125 mg/dL
Diabetes FBS = ≥126 mg/dL

fasting

Normal RBS

<140 mg/dl
random

Normal PPBS

<140 mg/dl

post-prandial / after eating

What is Glycosylated hemoglobin (HgbA1C)

• Average glucose level over approximately 120 days, the life of a RBC
• measures the amount of glucose on a RBC

What are the 3 ranges of Glycosylated hemoglobin (HgbA1C)?

Normal = 5%
Good Control <7.2% (correlates to study)
Poor control > 8%

What is Normal HbA1C?
What is Pre-diabetes HbA1C?
What is Diabetes HbA1C?

Normal = <5.7%
Pre-diabetes = 5.7-6.4%
Diabetes FBS = ≥6.5%

hemoglobin

What is Normal OGTT & what is OGTT?
What is Pre-diabetes OGTT?
What is Diabetes OGTT?

Normal = <140 mg/dl
Pre-diabetes = 140-199 mg/dL
Diabetes OGTT = ≥200 mg/dL

oral glucose tolerant test

Diabetes is the leading cause of what 3 things?

1) blindness
2) end stage renal disease
3) amputation

What happens when you keep the blood sugar level below <155mg/dl or HgbA1C <7.2%

You have a 60% reduction in microvascular (ex. blindness) complications

What does insulin do & what is the main trigger?

- Promotes transport of glucose into cells
- main trigger is CHO (carbs)

What do beta cells do?

Beta cells of the pancreas secrete insulin when eating
- produce insulin & amylin

What do alpha cells do?

- produce glucagon
- release glucagon when low BS

Glycogenolysis

liver breaks down glycogen to glucose

Gluconeogenesis

protein & AA breakdown/conversion to get glucose

ketogenesis

- production of acetone or other ketones (which can lead to metabolic acidosis)
- conversion of fats to acids

lipolysis

fat breakdown to get glucose
- decomposition or splitting up of fat to provide fuel for energy when liver glucose is unavailable

What are six S/S of ⬆ BS?

1. polyphagia (⬆ hunger)
2. polydipsia (⬆ thirst)
3. polyuria (⬆ urination)
4. acetone breath (due to ketones)
5. kussmaul respirations = rapid, shallow
6. if ⬆BS continues → confusion, fatigue, muscle weakness, cardiac arrhythmias

What are Kussmaul respirations?

- Rapid, shallow breaths in an attempt to excrete more CO2 and acid
- breathing is first rapid and shallow, but as acidosis worsens, breathing gradually becomes deep, labored and gasping. It is this latter type of breathing pattern that is referred to as Kussmaul breathing.

polyphagia

hunger
- excessive eating

polydipsia

thirst
- excessive intake of water

polyuria

Frequent & excessive urination

what is basal insulin secretion?

- it is insulin secreted at low levels during fasting
- basal levels of insulin are secreted continuously to control metabolism

What three things happen when there is no insulin?

1. ⬆ Blood glucose (b/c insulin isn't converting glucose to go into cells)
- Cell starvation → polyphagia = water goes into bloodstream so intracellular dehydration occurs, sugar doesn't get into cell so it stimulates hunger
- kidneys eliminate glucose with water → polyuria and polydipsia

2. Ketones from abnormal fat breakdown are
- eliminated in urine (polyuria) and
- eliminated in breathing = Acetone breath (fruity) (kussmuals respirations)

3. Acids from abnormal protein breakdown are
- eliminated in urine = polyuria, acid base imbalances [esp. k!]) and
- eliminated in breathing (kussmuals respirations)

What is Type 1 Diabetes & what are the s/s?

no insulin
beta cells do not produce insulin

S/S- extreme hunger, rapid weight loss, acetone breath, thirst, frequent urination, fatigue, slow healing, infections, N/T of feet and hands, blurred vision, unconsciousness

What is Type 2 Diabetes & what are the s/s?

• insulin doesn't work or it is resistant
• insulin resistance and/or insulin deficiency (doesn't get glucose into cells)

S/S- overweight (esp. abd. girth in men), thirst, frequent urination, fatigue, slow healing, infections, N/T feet and hands, blurred vision, unconsciousness

Gestational Diabetes

↑ BS during pregnancy
- glucose intolerance with onset or first recognition during pregnancy

Pre-diabetes

higher than normal BS levels, but not high enough to call diabetes → interventions to stop progression to diabetes

Secondary Diabetes

secondary to something else going on (such as pancreatic cancer, pancreatitis, having pancreas removed, trauma, injury, or surgery) so can't produce insulin

what are the 3 symptoms of Type 1 diabetes?

1. extreme hunger = cell starvation
2. rapid weight loss
3. acetone breath

What are two symptoms of Type 2 diabetes?

1. Overweight (midsection)
2. Still hunger but not extreme

Eight Symptoms of both TYPE 1 & TYPE 2 diabetes?

- thirst
- frequent urination
- fatigue
- slow healing
- infections
- N/T in hands & feet (peripheral neuropathy)
- blurred vision
- unconsciousness

What 3 ways is Diabetes diagnosed?

1. Physical exam- VS, appearance (thin or overweight)
2. Medical Hx- family hx, eating habits (thirsty), recent illness, medications
3. Blood Tests

What are ketones and how are they generated?

-should not be present in urine or blood
-result from fat breakdown because there isn't enough glucose

What are the four levels of ketone measurements?

1. negative
2. Small
3. Moderate = fat breakdown somewhere
4. Large = severe lack of insulin
- if they are losing weight & have ketones, but no hyperglycemia, then its suggests weight loss is occurring w/o disrupting blood glucose control

What 3 ways do you regulate blood glucose levels?

1. Proper nutrition
2. Regular exercise
3. Medication administration

What are 3 diabetic complications?

1. Hypoglycemia
2. Microvascular
3. Macrovascular

What are Microvascular complications?

- small blood vessels

-lead to nephropathy / neuropathy / retinopathy (kidneys, nerves, eyes)

What are Macrovascular complications?

- large blood vessels

- coronary heart disease / cerebrovascular disease / peripheral vascular disease (plaque build up in arteries)/ early death

What should the calories be in a diabetic diet?

- calories to maintain weight (1600-1800 or 1900-2100)
- someone in the hospital typically 1500-1800

What amount of protein should be in a diabetic diet?

- 15-20% of total daily
- less if renal impairment

What amount of fat should be in a diabetic diet?

- less than 30% total daily
- avoid cholesterol and saturated fats

What amount of carbs should be in a diabetic diet?

- 50-60% of total
- can eat sucrose foods
- want complex carbs b/c they will last longer

Alcohol and Diabetes (3)

1. moderate intake with food is safe (men ≤2/day, women ≤1/day)
2. may cause hypoglycemia for up to 12 hours after drinking
3. do not ingest alone

Three exercise benefits for Diabetes

1. ⬆ insulin sensitivty
2. ⬇ risk for CAD
a. ⬆ HDL, ⬇ triglycerides, ⬇ BP
3. Fosters weight reduction → delays/stops Type 2

What are 3 exercise recommendations?

1. should do low intensity aerobic (which ⬆ HR)
2. 20-40 minutes
3. 4-7 days a week

What are five Safe Exercise tips for Diabetics?

1. best time after a meal or snack (b/c BS is up)
2. check BS before and after (if < 100 → eat. if > 250 check ketones. If absent you're safe, if ketones are present do not exercise)
3. Carry fast acting sugar (ex. glucose tab, juice, hard candy)
4. drink water
5, Hypoglycemia can occur hours later

What are 3 types of pharmacological management?

1. Oral hypoglycemic agents
2. Insulin therapy
3. Combination therapy

What 4 things do Oral Hypoglycemic agents do?

-slow intestinal absoprtion of carbs
-stimulate insulin secretion
-decrease cellular insulin resistant
-enhance insulin action
** can be from multiple categories but not 2 from the same category. if you see that question the patient

What does insulin therapy do?

Mimics normal body insulin
-daily dosing and intenstive therapy

What are 2 Oral Hypoglycemic Agents that ⬇ insulin resistance

1. Biguanides = anti-hyperglycemic agents & insulin sensitizers
2.Thiazolidinediones

What are 3 Oral Hypoglycemic Agents that ⬆ insulin secretion

1. Sulfonylureas
2. DPP-4 Inhibitors (new)
3. Incretin Mimetic Agents (new)

What is an example of a Biguanides & what are the characteristics?

Metformin (Glucophage)

- ⬇ insulin resistance
- can cause kidney damage
- may be discontinued while in hospital
- don't give if having a test containing dye - hold 48 hrs before & 48 hrs after test with dye. If ER then flush kidneys & then stop for 2 days afterwards
- if dehydrated DON'T take → acute renal failure

- lowers basal & post meal glucose levels in pts w/ type 2 diabetes by reducing hepatic glucose production & tissue sensitivity to insulin

What is an example of a Thiazolidinediones (TDZ) & what are the characteristics?

- Pioglitazone "pi-o-glit-azone" (Actos)
- ↓ insulin resistance

- improves tissue sensitivity to insulin in treatment of diabetes

What are 3 examples of Sulfonylureas & what are the characteristics?

- Glyburide (Micronase), glimepiride (Amaryl), glipizide (Glucotrol)

- don't give more than 1 from this category
- ⬆ insulin secretion from pancreatic beta cells & ⬆ the number or the sensitivity of cell receptor sites for interaction w/insulin (type 2)

What is the trade name & category of Glyburide?

Trade name: Micronase
Category: sulfonylureas

What is the trade name & category of Glimepiride?

Trade name: Amaryl
Category: sulfonylureas

What is the trade name & category of Glipizide?

Trade name: Glucotrol
Category: sulfonylureas

What is an example of DPP-4 inhibitors & what are the characteristics?

- Sitagliptin (Januvia)

- ⬆ insulin secretion
- works when glucose is elevated
- ⬆ bodys active incretin hormone levels
- side effects also help BG levels

What is an example of Incretin Mimetic Agents & what are the characteristics?

- Exenatide "ex-en-a-tide" (Byetta)

- ⬆ insulin secretion
- side effects also help BG levels

What is insulin therapy?

- an attempt to duplicate the normal release of insulin by the pancreas

What are the three actions of insulin?

- move glucose into cells
- stores glucose in the liver & muscles
- enhances fat storage

what are insulin side effects?

Hypoglycemia → HA, hunger, nausea, delirium, tremors, sweating, tachycardia
- the highest risk for hypoglycemia is during peak
- everyones side effects are different, so listen to the patient

What are the 3 Insulin Actions (OPD)?

Onset = when you start to see a decreased BS, when it starts working
Peak = highest plasma concentration of insulin, anticipate the lowest BS level
Duration = length of time drug elicits effects

What insulins ARE given when a patient is on a sliding scale?

Rapid or Short Acting

What are two RAPID ACTING INSULINS (generic & trade names) & general information (2)?

1. Insulin Lispro (Humalog)
2. Insulin Aspart (Novolog)
- only SQ
- tray should be in room

What is the ONSET of RAPID ACTING INSULINS?

within 15 minutes

What is the PEAK of RAPID ACTING INSULINS?

1-1.5 hours

What is the DURATION of RAPID ACTING INSULINS?

2-4 hours

What is the APPEARANCE of RAPID ACTING INSULIN?

Clear

What are two SHORT ACTING INSULINS & general information (2)?

Regular (Humulin R / Novolin R)

- Has an R after the name for Regular
- most common insulin to be given IV (ex. someone comes into ER with a BG of 800)

What is the ONSET of SHORT ACTING INSULINS?

30-60 minutes (SubQ)

What is the PEAK of SHORT ACTING INSULINS?

2-4 hours

What is the DURATION of SHORT ACTING INSULINS?

5-7 hours

What is the APPEARANCE of SHORT ACTING INSULINS?

Clear

What are the INTERMEDIATE ACTING INSULINS & general information (5)?

NPH (Humulin N, Novolin N)

- Don't see these much anymore
- can be mixed w/short & rapid acting
- draw up Long, short, short, long
- if contaminated then short will be contaminated
- if you combine, expect 2 peaks

What is the ONSET of INTERMEDIATE ACTING INSULINS?

1-2 hours

What is the PEAK of INTERMEDIATE ACTING INSULINS?

4-12 hours, typically 6-8 hours

What is the DURATION of INTERMEDIATE ACTING INSULINS?

12-18 hours

What is the APPEARANCE of INTERMEDIATE ACTING INSULINS?

Cloudy

What are three LONG ACTING INSULINS & general information?

1. Insulin determir (Levemir)
2. Insulin Glargine (Lantus)
3. Ultralente (Humulin U) - very rare to see, usually only seen on someone who has been taking for a long time

- given am or evening
- sometime you see given bid
- DO NOT MIX*** with other insulins, if you need to give other insulin use a another syringe, Also use separate sites for both injections

What is the ONSET of LONG ACTING INSULINS (levemir & lantus)?

Determir (Levemir) = 3-4 hours
Glargine (Lantus) = 3-4 hours

What is the PEAK of LONG ACTING INSULINS (levemir & lantus)?

Determir (Levemir) = 3-14 hours (usually around 12)
Glargine (Lantus) = No Peak

What is the DURATION of LONG ACTING INSULINS (levemir & lantus)?

Determir (Levemir) = 24 hours
Glargine (Lantus) = 24 hours

(usually get once a day but sometimes get twice)

What is the APPEARANCE of LONG ACTING INSULINS?

Clear

What are two COMBINATION INSULINS & general information?

1. Humulin 70/30 (70=NPH, 30=Regular/short)
2. Novolin (70/30)

- Pre-mixed with different combinations
- 2 different onsets/peaks/durations based on the combination

What is the APPEARANCE of COMBINATION INSULINS?

Cloudy

What insulins can you NOT mix with any other insulins?

1. Determir (Levemir) = long acting
2. Glargine (Lantus) = long acting

- not in the same syringe (use separate syringe if you have to give another insulin) & not in the same site

How do you mix insulins?

- Draw up Clear to Cloudy

- Long-Short (With Air)
- Short-Long (With Insulin)

What are 5 Nursing Implications for Insulin administration?

1. adjust dose on BS, carb (CHO) intake, illness, level of activity (patient usually aware of their carb intake)
2. absorption varies by site and activity of site (rotate sites → thighs, back of arms & abdomen)
3. hypoglycemia risk varies w/ type of insulin- must know OPD of each type
4. Mixing; clear-> cloudy. Do not mix glargine, detemir (long acting insulins)
5. usually held if pt. is NPO

What is Intensive Insulin Therapy/sliding scale insulin (2)?

1. Several doses of regular insulin given during the day based on BS levels - before meals & at bedtime
(IV and injection in hospital, injections at home)
2. Insulin pump therapy

What is Insulin Sliding Scale (5)?

1. Insulin dose is adjusted to blood glucose levels
2. almost all hospitalized its (b/c stress of trauma)
- Ex. infection, surgery, steroids → may cause patient to have to get insulin while hospitalized
3. usually before meals and HS when sleeping (ACHS bs)
4. scheduled (q6 hrs) when NPO
5. type of insulin specified- rapid or short acting NEVER intermediate or long acting

When is insulin usually checked when a patient is on a sliding scale (3)?

- before meals
- at bedtime
- q6 hours when NPO

What insulin's are NEVER given when a patient is on a sliding scale (2)?

Intermediate and Long Acting

What is Insulin Pump Therapy (8) & complications (3)?

1. continuous insulin
2. rapid/short acting insulin
3. catheter in abd.
4. basal rate (continuous/regular rate) and bolus - depending upon BS & what they ate
5. frequently check BS (4x per day)
6. change needle & site every 2-3 days
7. always worn
8. Most common w/Type 1

Complications: infection in site, hypoglycemia, hyperglycemia

What is Hypoglycemia & what are 5 Causes?

- BS <70 mg/dl (even is asymptomatic)
Causes
1. too much insulin, sulfonylureas, meglitinides
2. low calorie intake & low carbs
3. excessive physical activity
4. nausea & vomiting
5. excessive alcohol intake

What are manifestations of HYPOGLYCEMIA?

Adrenergic: tremors, nervousness, **tachycardia, palpitations, hunger, pallor, **diaphoresis

Neurogenic: irritability, headache, lightheaded, ***confused, memory lapses, slurred speech, blurred vision, drowsy, unconscious, coma

What is the Hypoglycemic Management on 3 levels?

1. Pt conscious/responsive: 10-15 gm carbs (juice-typical in hospital, regular pop, crackers, hard candy, milk, glucose tabs and gel)

2. Unconscious w/ IV access: 50% dectrose/50 ml IVP, then D5W at 80 ml/hr

3. Unconscious w/o IV access: I mg glucagon IM in deltoid or thigh, IV D5W at 80 ml/hr

Check BG 15 minutes later, treat if still low or still have symptoms. Need to get a meal of protein b/c all above are only ST fixes

Symptoms of HYPERGLYCEMIA

- BS >250 mg/dL
- hot, dry skin
- dehydrated
- Kussmaul respirations
- acetone breath
- abdominal cramps
- nausea & vomiting
- orthostatic hypotension

S/S for Hyperglycemia

Polyphagia (increased hunger)
Polydipsia (increased thirst)
Polyuria (increased urination)
Acetone breath
Kussmual Respirations
Confusion, fatigue, muscle weakness, cardiac arrhythmias

What are the features of Metabolic Syndrome?

- Abdominal Obesity
- Hyperglycemia
- Hypertension
- Dyslipidemia (triglyceride level ↑ 150)

Sick day management for a patient with diabetes (5)

- continue insulin (normally as possible)
- follow meal plan = same times, drink fluids
- check glucose & ketones more often
- use OTC wisely (especially cough medicines b/c they contain glucose)
- if on Metformin & they are N&V they should stop Metformin

what is prandial secretion?

it is insulin secreted at increased levels after eating

What is basal insulin secretion?

low levels of insulin that are secreted during fasting

What are four nursing diagnoses?

1. RC: Hyperglycemia
2. RC: Hypoglycemia
3. Risk for injury related to effects of hypoglycemia
4. Ineffective self-health management related to insufficient knowledge (you need to teach new diabetics)

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