Terms in this set (55)

You should include the following information in the exercise teaching plan for patients with diabetes.

1. Exercise does not have to be vigorous to be effective. The blood glucose-reducing effects of exercise can be attained with exercise such as brisk walking.
2. The exercises selected should be enjoyable to foster regularity.
3. It is important to have properly fitting footwear.
4. The exercise session should have a warm-up period and a cool-down period. The exercise program should be started gradually and increased slowly.
5. Exercise is best done after meals, when the blood glucose level is rising.
6. Exercise plans should be individualized and monitored by the health care provider.
7. It is important to self-monitor blood glucose levels before, during, and after exercise to determine the effect exercise has on blood glucose level at particular times of the day.
•Before exercise, if blood glucose ≤100 mg/dL, eat a 10- to 15-g carbohydrate snack. After 15 to 30 min, retest blood glucose levels. Do not exercise if less than 100 mg/dL.
•Before exercise, if blood glucose ≥250 mg/dL in a person with type 1 diabetes and ketones are present, vigorous activity should be avoided.
8. Delayed exercise-induced hypoglycemia may occur several hours after the completion of exercise.
9. Taking a glucose-lowering medication does not mean that planned or spontaneous exercise cannot occur.
10. It is important to compensate for extensive planned and spontaneous activity by monitoring blood glucose level to make adjustments in the insulin dose (if taken) and food intake.
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. SMBG is also important for detecting episodic hyperglycemia and hypoglycemia.

Portable blood glucose monitors (meters) are used at the hospital bedside and by patients who perform SMBG. A wide variety of blood glucose monitors are available (Fig. 49-8). Disposable lancets are usually used to obtain a small drop of capillary blood (usually from a finger stick) that is placed onto a reagent strip. After a specified time, the monitor displays a digital reading of the blood glucose. The technology of SMBG is a rapidly changing field with newer and more convenient systems being introduced every year. Newer systems allow the user to collect blood from alternative sites such as the forearm or palm. Alternate site testing is not recommended with rapidly changing blood glucose readings or when symptoms of low blood glucose are present.

Continuous glucose monitoring (CGM) systems provide another route for monitoring glucose. The CGM systems available include the (1) DexCom Seven by DexCom, (2) MiniMed Paradigm REAL-Time System by Medtronic (3) Guardian REAL-Time by Medtronic, and (4) FreeStyle Navigator by Abbott. Using a sensor inserted subcutaneously under the skin, the systems display glucose values continuously with updated values occurring every 1 to 5 minutes. The sensor is inserted by the patient using an automatic insertion device. Data are sent from the sensor to a transmitter, which displays the glucose value on either an insulin pump (MiniMed Paradigm REAL-Time System and Guardian Real-Time) or a pager-like receiver (DexCom Seven and FreeStyle Navigator).
arise from events associated with hyperglycemia and insufficient insulin

Diabetic ketoacidosis (DKA), also referred to as diabetic acidosis and diabetic coma, is caused by a profound deficiency of insulin and is characterized by hyperglycemia, ketosis, acidosis, and dehydration. It is most likely to occur in people with type 1 diabetes but may be seen in type 2 in conditions of severe illness or stress when the pancreas cannot meet the extra demand for insulin. Precipitating factors include illness and infection, inadequate insulin dosage, undiagnosed type 1 diabetes, poor self-management, and neglect.

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 (Fig. 49-12). HHS is less common than DKA. It often occurs in patients over 60 years of age with type 2 diabetes. Common causes of HHS in a patient with type 2 diabetes are infections of the urinary tract, pneumonia, sepsis, any acute illness, and newly diagnosed type 2 diabetes. The main difference between HHS and DKA is that the patient with HHS usually has enough circulating insulin so that ketoacidosis does not occur.

Hypoglycemia, or low blood glucose, occurs when there is too much insulin in proportion to available glucose in the blood. This causes the blood glucose level to drop to less than 70 mg/dL (3.9 mmol/L). Once plasma glucose drops below 70 mg/dL (3.9 mmol/L), neuroendocrine hormones are released and the autonomic nervous system is activated. Suppression of insulin secretion and production of glucagon and epinephrine provide defense against hypoglycemia. Epinephrine release causes manifestations that include shakiness, palpitations, nervousness, diaphoresis, anxiety, hunger, and pallor. Because the brain requires a constant supply of glucose in sufficient quantities to function properly, hypoglycemia can affect mental functioning. These manifestations are difficulty speaking, visual disturbances, stupor, confusion, and coma. Manifestations of hypoglycemia can mimic alcohol intoxication. Untreated hypoglycemia can progress to loss of consciousness, seizures, coma, and death.

Hypoglycemic unawareness is a condition in which a person does not experience the warning signs and symptoms of hypoglycemia until the glucose levels reach a critical point. Then the person may become incoherent and combative or lose consciousness. This is often related to autonomic neuropathy of diabetes that interferes with the secretion of counterregulatory hormones that produce these symptoms. Elderly patients and patients who use β-adrenergic blockers are also at risk for hypoglycemic unawareness.
1. Wash feet daily with a mild soap and warm water. First test water temperature with hands.

2. Pat feet dry gently, especially between toes.

3. Examine feet daily for cuts, blisters, swelling, and red, tender areas. Do not depend on feeling sores. If eyesight is poor, have others inspect feet.

4. Use lanolin on feet to prevent skin from drying and cracking. Do not apply between toes.

5. Use mild foot powder on sweaty feet.

6. Do not use commercial remedies to remove calluses or corns.

7. Cleanse cuts with warm water and mild soap, covering with clean dressing. Do not use iodine, rubbing alcohol, or strong adhesives.

8. Report skin infections or nonhealing sores to health care provider immediately.

9. Cut toenails evenly with rounded contour of toes. Do not cut down corners. The best time to trim nails is after a shower or bath.

10. Separate overlapping toes with cotton or lamb's wool.

11. Avoid open-toe, open-heel, and high-heel shoes. Leather shoes are preferred to plastic ones. Wear slippers with soles. Do not go barefoot. Shake out shoes before putting on.

12. Wear clean, absorbent (cotton or wool) socks or stockings that have not been mended. Colored socks must be colorfast.

13. Do not wear clothing that leaves impressions, hindering circulation.

14. Do not use hot water bottles or heating pads to warm feet. Wear socks for warmth.

15. Guard against frostbite.

16. Exercise feet daily either by walking or by flexing and extending feet in suspended position. Avoid prolonged sitting, standing, and crossing of legs.
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