Lewis Med Surg Chapter 49 Diabetes - Key Points

Terms	Definitions
• Diabetes mellitus is _	_a chronic multisystem disorder of glucose metabolism related to absent or insufficient insulin supplies, impaired utilization of insulin, or both.
• Current theories link the causes of diabetes to _	_genetic, autoimmune, and environmental factors.
• Type 1 diabetes mellitus most often occurs _	_in people who are under 30 years of age, with a peak onset between ages 11 and 13, but can occur at any age.
• Type 1 diabetes is the _	_end result of a long-standing process where the body's own T cells attack and destroy pancreatic beta cells, which are the source of the body's insulin.
• Because the onset of type 1 diabetes is rapid_	_, the initial manifestations are usually acute.
• The classic symptoms—polyuria, polydipsia, and polyphagia_	_are caused by hyperglycemia and the accompanying spillover of excess glucose in the urine.
• The individual with type 1 diabetes requires _	_a supply of insulin from an outside source, such as an injection, in order to sustain life.
Without insulin, the patient will develop_	_diabetic ketoacidosis (DKA), a life-threatening condition resulting in metabolic acidosis.
• Prediabetes is a condition in which _	_blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes.
Those with prediabetes will usually develop _	_type 2 diabetes within 10 years if no preventive measures are taken.
• Long-term damage to the body, especially the heart and blood vessels_	_may already be occurring in patients with prediabetes.
• Type 2 diabetes mellitus accounts for _	_over 90% of patients with diabetes.
• In type 2 diabetes, the pancreas _	_usually continues to produce some endogenous (self-made) insulin. However, the insulin that is produced is either insufficient for the needs of the body and/or is poorly used by the tissues.
• The most important risk factor for developing type 2 diabetes is believed to be _	_obesity, specifically abdominal and visceral adiposity.
• The manifestations of type 2 diabetes are more nonspecific, and include _	_fatigue, recurrent infections, recurrent vaginal yeast or monilia infections, prolonged wound healing, and visual changes.
• Gestational diabetes develops _	_during pregnancy and is detected at 24 to 28 weeks of gestation, usually following an oral glucose tolerance test.
• Although most women with gestational diabetes will have normal glucose levels within 6 weeks postpartum_	_their risk for developing type 2 diabetes in 5 to 10 years is increased.
• A diagnosis of diabetes is based on _	_one of three methods: fasting plasma glucose level, random plasma glucose measurement, or 2-hour oral glucose tolerance test.
• The glycosated hemoglobin test (HbA1c) is useful _	_in evaluating long-term glycemic levels. The American Diabetes Association (ADA) recommends keeping the A1C level below 7%.
• The goals of diabetes management are to_	_reduce symptoms, promote well-being, prevent acute complications of hyperglycemia, and prevent or delay the onset and progression of long-term complications. These goals are most likely to be met when the patient is able to maintain blood glucose levels as near to normal as possible.
• Exogenous (injected) insulin is needed when _	_a patient has inadequate insulin to meet specific metabolic needs.
• Insulin is divided into two main categories: _	_short-acting (bolus) and long-acting (basal) insulin.
Basal insulin is used to _	_maintain a background level of insulin throughout the day; bolus insulin is used at mealtime to combat postprandial hyperglycemia and at bedtime.
• A variety of insulin regimens are recommended for patients _	_depending on the needs of the patient and their preference.
• Routine administration of insulin is most commonly done by means of _	_subcutaneous injection, intravenous administration of regular insulin can be done when immediate onset of action is desired.
• The technique for insulin injections _	_should be taught to new insulin users and reviewed periodically with long-term users.
• The speed with which peak serum concentrations are reached _	_varies with the anatomic site for injection. The fastest absorption is from the abdomen.
• Continuous subcutaneous insulin infusion _	_can be administered using an insulin pump, a small battery-operated device that resembles a standard paging device in size and appearance.
• An insulin pump is programmed to deliver_	_a continuous infusion of short-acting insulin 24 hours a day with boluses at mealtime.
• Hypoglycemia, allergic reactions, lipodystrophy, and Somogyi effect are _	_problems associated with insulin therapy.
o Lipodystrophy (atrophy of subcutaneous tissue) may occur _	_if the same injection sites are used frequently but its incidence has decreased with the use of human insulin.
o The Somogyi effect is _	_a rebound effect in which an overdose of insulin induces hypoglycemia.
o Usually occurring during the hours of sleep_	_the Somogyi effect produces a decline in blood glucose level in response to too much insulin.
o The dawn phenomenon is characterized by _	_hyperglycemia that is present on awakening in the morning resulting from the release of counterregulatory hormones in the predawn hours.
• Oral agents (OAs) are not insulin; they work to _	_to improve the mechanisms by which insulin and glucose are produced and used by the body.
OAs work on the three defects of type 2 diabetes_	_, including insulin resistance, decreased insulin production, and increased hepatic glucose production.
• Sulfonylureas are frequently the drugs of choice in treating _	_type 2 diabetes because of the decreased chance of prolonged hypoglycemia.
The primary action of the sulfonylureas is to_	_increase insulin production from the pancreas.
• Meglitinides increase_	_insulin production from the pancreas.
• Because they are more rapidly absorbed and eliminated_	_, meglinitiedes offer a reduced potential for hypoglycemia.
• Metformin (Glucophage) is a_	_biguanide glucose-lowering agent.
The primary action of metformin is to _	_reduce glucose production by the liver.
• α-Glucosidase inhibitors, also known as "starch blockers," _	_work by slowing down the absorption of carbohydrate in the small intestine.
• Sometimes referred to as "insulin sensitizers," _	_thiazolidinediones are most effective for people who have insulin resistance.
• Thiazolidinediones improve_	_insulin sensitivity, transport, and utilization at target tissues.
• Pramlintide (Symlin) is_	_a synthetic analog of human amylin, a hormone secreted by the β cells of the pancreas.
• When taken concurrently with insulin_	_ Pramlintide (Symlin) provides for better glucose control.
• Exenatide (Byetta) is _	_a synthetic peptide that stimulates the release of insulin from the pancreatic β cells.
• Exenatide is administered_	_ using a subcutaneous injection.
• The overall goal of nutritional therapy is_	_to assist people with diabetes in making healthy nutritional choices, eating a varied diet, and maintaining exercise habits that will lead to improved metabolic control.
• For those with type 1 diabetes_	_day-to-day consistency in timing and amount of food eaten is important for those individuals using conventional, fixed insulin regimens.
• Patients using rapid-acting insulin _	_can make adjustments in dosage before the meal based on the current blood glucose level and the carbohydrate content of the meal.
• The emphasis for nutritional therapy in type 2 diabetes should be placed on_	_achieving glucose, lipid, and blood pressure goals.
• The nutritional energy intake should be constantly balanced _	_with the energy output of the individual, taking into account exercise and metabolic body work.
• In a general diabetic meal plan_	_carbohydrates and monounsaturated fat should provide 45% to 65% of the total energy intake each day.
• Fats should compose no more than 25% to 30% of the meal plan's total calories_	_with less than 7% of calories from saturated fats and protein contributing less than 10% of the total energy consumed.
• Alcohol is _	_high in calories, has no nutritive value, and promotes hypertriglyceridemia.
• Patients should be cautioned to _	_honestly discuss the use of alcohol with their health care providers because its use can make blood glucose more difficult to control.
• Regular, consistent exercise _	_is considered an essential part of diabetes and prediabetes management. Exercise increases insulin receptor sites in the tissue and can have a direct effect on lowering the blood glucose levels.
• Self-monitoring of blood glucose (SMBG) _	_is a cornerstone of diabetes management. By providing a current blood glucose reading, SMBG enables the patient to make self-management decisions regarding diet, exercise, and medication.
• The frequency of monitoring depends on several factors_	_including the patient's glycemic goals, the type of diabetes that the patient has, the patient's ability to perform the test independently, and the patient's willingness to test.
• Pancreas transplantation can be used _	_as a treatment option for patients with type 1 diabetes mellitus.
• Most commonly, pancreas transplantation is done for patients who have_	_ end-stage renal disease and who have had or plan to have a kidney transplant.
• Kidney and pancreas transplants are often performed together_	_or a pancreas may be transplanted following a kidney transplant. Pancreas transplants alone are rare.
• Nursing responsibilities for the patient receiving insulin include _	_proper administration, assessment of the patient's response to insulin therapy, and education of the patient regarding administration of, adjustment to, and side effects of insulin.
• The goals of diabetes self-management education are to _	_enable the patient to become the most active participant in his or her care, while matching the level of self-management to the ability of the individual patient.
• Diabetic ketoacidosis (DKA), also referred to as _	_"diabetic acidosis" and "diabetic coma," is a life-threatening condition caused by a profound deficiency of insulin .
• Diabetic ketoacidosis (DKA)_	_is characterized by hyperglycemia, ketosis, acidosis, and dehydration. It is most likely to occur in people with type 1 diabetes.
• Hyperosmolar hyperglycemic syndrome (HHS) _	_is a life-threatening syndrome that can occur in the patient with diabetes who is able to produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.
• Hypoglycemia, or low blood glucose, occurs when _	_there is too much insulin in proportion to available glucose in the blood.
o Causes of hypoglycemia are often related to _	_a mismatch in the timing of food intake and the peak action of insulin or oral hypoglycemic agents that increase endogenous insulin secretion.
o A critical role of the nurse is the prompt recognition of hypoglycemia and _	_initiating the appropriate treatment dependent on the patient's status.
• Chronic complications of diabetes are _	_primarily those of end-organ disease from damage to blood vessels as a result of chronic hyperglycemia.
• The chronic blood vessel dysfunctions of diabetes are divided into two categories:_	_macrovascular complications and microvascular complications.
o Macrovascular complications are_	_diseases of the large and medium-sized blood vessels that occur with greater frequency and with an earlier onset in people with diabetes.
o Microvascular complications result from _	_thickening of the vessel membranes in the capillaries and arterioles in response to conditions of chronic hyperglycemia.
• Diabetic retinopathy refers to _	_the process of microvascular damage to the retina as a result of chronic hyperglycemia in patients with diabetes.
• There are two types of diabetic retinopathy:_	_ proliferative and nonproliferative. Because the earliest and most treatable stages produce no vision changes, persons with diabetes should have an annual dilated eye examination.
• Diabetic nephropathy is _	_a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney.
• Patients should be screened for diabetic nephropathy annually with _	_a measurement of albumin-creatinine ratio from a urine specimen.
• Diabetic neuropathy is nerve damage that occurs _	_because of the metabolic derangements associated with diabetes mellitus.
• The two major categories of diabetic neuropathy are _	_sensory neuropathy, which affects the peripheral nervous system, and autonomic neuropathy.
• The most common form of sensory neuropathy is _	_distal symmetric neuropathy, which affects the hands and/or feet bilaterally. This is sometimes referred to as "stocking-glove neuropathy."
• Autonomic neuropathy can affect _	_nearly all body systems and lead to hypoglycemic unawareness, bowel incontinence and diarrhea, and urinary retention.
• Foot complications are _	_the most common cause of hospitalization in the person with diabetes. Sensory neuropathy is a major risk factor for lower extremity amputation in the person with diabetes.
• Proper care of a diabetic foot ulcer _	_is critical to prevent infections.
• Loss of protective sensation _	_often prevents the patient from becoming aware that a foot injury has occurred.
• Common skin complications in diabetes include _	_Acanthosis nigricans, diabetic dermatopathy, Necrobiosis lipoidica diabeticorum, and Granuloma annulare.
• Because the thin skin is prone to injury_	_special care must be taken to protect affected areas from injury and ulceration.
• A patient with diabetes is more susceptible to infections because of _	_a defect in the mobilization of inflammatory cells and an impairment of phagocytosis by neutrophils and monocytes.
• The treatment of infections must be prompt and vigorous _	_since antibiotic therapy has prevented infection from being a major cause of death in diabetic patients.
• Patients with diabetes have high rates_	_of psychiatric disorders, particularly depression. Patients need to be assessed for the signs and symptoms of depression at each visit.
• Women with type 1 diabetes have an increased risk _	_of developing an eating disorder in comparison to women without diabetes. Open and collaborative communication is critical for identifying these behaviors early.

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Lewis Med Surg Chapter 49 Diabetes - Key Points

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