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Terms in this set (225)
Definition of Diabetes Mellitus
A disorder of glucose metabolism related to insufficient, or poor utilization of the available endogenous insulin.
Absent insulin results in:
Type 1 Diabetes
Insufficient insulin and/or poor utilization of endogenous insulin leads to:
1. Type 2 Diabetes
3. Metabolic Syndrome
So AGAIN, what is diabetes?
Diabetes is a chronic multi-system disease related to abnormal insulin production, impaired insulin utilization, or both.
Diabetes is the leading cause of (3 things)? What particular aspect of diabetes causes these?
End-stage renal disease, adult blindness, non-traumatic lower limb amputations. These are caused by the vascular changes of diabetes.
Is diabetes a leading cause of heart disease and stroke?
Theories link the cause of diabetes to single/combination of these factors:
1. Genetic (Family Hx Type 1)
3.Viral (Entero or Coxsackie Virus)
How do the entero- and Coxsackie virus possibly cause Diabetes?
Cause damage to the beta cells which make insulin.
People of what race have a higher incidence of Type 1 Diabetes?
What are all the types of Diabetes?
Name three causes of secondary diabetes.
Corticosteroids, TPN, Malnutrition
How does normal insulin metabolism work in the body?
Insulin is produced by the beta cells in the Islets of Langerhans in the pancreas. It is released continuously into the bloodstream in small increments with larger amounts released after food intake. Stabilizes glucose range to 70-120 mg/dl.
What does insulin actually DO?
Insulin promotes glucose transport from bloodstream across cell membrane to cytoplasm of cells - which decreases glucose in the bloodstream.
What does the larger amount of insulin that is released after a meal do in the body?
1. Stimulates storage of glucose as glycogen in the liver and muscles
2. Inhibits gluconeogenesis
3. Enhances fat deposition
4. Increases protein synthesis
Generation of glucose in the liver from non-carbohydrate sources.
Which tissues in the body depend on insulin for glucose transport?
Skeletal muscle and adipose tissue. These have insulin receptors - glucose needs to get into the cell to provide energy.
Which tissues in the body do not directly depend on insulin for glucose transport?
Brain, liver, and blood cells.
What are counterregulatory hormones? What do they do?
They oppose the effects of insulin. They increase blood glucose levels. They provide a regulated release of glucose for energy. They help maintain normal blood glucose levels.
What are some examples of counterregulatory hormones?
What was Type 1 Diabetes formerly known as?
Insulin-dependent diabetes or juvenile-onset diabetes.
When does Type 1 Diabetes typically occur?
Most often in people under 30, peak onset between 11 and 13 years of age.
What type of body build do Type 1 and Type 2 diabetics typically have (but not always)?
Type 1 - lean
Type 2 - heavy
Are people born with Type 1 Diabetes?
No. You develop it over time.
Type 1 Diabetes is "the end result of a long-standing process". What is this process?
The progressive destruction of pancreatic beta cells by the body's own T cells.
Autoantibodies cause a reduction of ___________% of normal beta cell function before manifestations occur?
80 to 90%.
Causes of Type 1 Diabetes Mellitus?
Genetic predisposition (related to human leukocyte antigens [HLAs]), exposure to a virus.
Type 1 Diabetes - onset of the disease - what is it like?
There is a long pre-clinical period, with antibodies present for months to years before symptoms occur. Manifestations develop when pancreas can no longer produce insulin. Then, there will be a rapid onset of symptoms and the person will typically present at the ER with diabetic ketoacidosis.
What causes diabetic ketoacidosis?
The body is breaking down proteins and ketones build up and spill over into urine. The person develops metabolic acidosis.
What are the classic symptoms of Type 1 Diabetes?
Polydipsia, polyuria, polyphagia.
Other symptoms of Type 1 diabetes?
History of recent sudden weight loss, nausea/vomiting, difficulty breathing, confusion.
Will a person with Type 1 Diabetes require exogenous insulin to sustain life? Why?
Yes. If they do not take insulin, their blood sugar can increase and they can go into diabetic ketoacidosis and die.
Diabetic Ketoacidosis (DKA) (3 things)?
1. Occurs in the absence of exogenous insulin
2. Life threatening condition
3. Results in metabolic acidosis
What is prediabetes also known as?
Impaired glucose tolerance (IGT) or impaired fasting glucose (IFG).
What are the IGT numbers for pre-diabetes?
Fasting glucose levels >100 mg/dl but <126 mg/dl.
Impaired fasting glucose? What does this mean in pre-diabetes?
2-hour plasma glucose higher than normal (between 140 and 199 mg/dl).
On a fasting prandial glucose test, what numbers indicate diabetes, prediabetes, and normal?
Diabetes > or = 126
Prediabetes <126, > or = 100
On an Oral Glucose Tolerance Test what numbers indicate diabetes, prediabetes, and normal?
Diabetes > or = 200
Prediabetes between 200 and 140
Normal = <140
If you have prediabetes, what does this increase your risk for developing?
Type 2 Diabetes. If no preventive measures are taken, usually develop diabetes within 10 years.
Is long-term damage already occurring with pre-diabetes? If so, what?
Yes. Damage to heart and blood vessels is already occurring.
What symptoms does a person with pre-diabetes usually present with?
NONE. But must watch for symptoms of diabetes - polyuria, polyphagia, polydipsia.
___% of patients with diabetes have Type 2 diabetes?
What age and weight does Type 2 diabetes usually occur in?
Usually occurs in people over 35 years of age, and the prevalence increases with age (over 50). 80-90% of patients are overweight at time of diagnosis.
Does Type 2 Diabetes have a genetic basis?
What ethnic populations is Type 2 Diabetes higher in?
Increased rate in African Americans, Asian Americans, Hispanic Americans, and Native Americans. Native American and Alaskan Natives have the highest rate of diabetes in the world.
In Type 2 Diabetes, is insulin produced?
Yes, the pancreas continues to produce some endogenous insulin, but the insulin produced is either insufficient or poorly utilized by tissues.
What is the most powerful risk factor for Type 2 diabetes?
What is the role of genetic mutations in Type 2 Diabetes?
They lead to insulin resistance and increased risk for obesity.
What is the biggest difference between Type 1 and Type 2 Diabetes?
In Type 1 there is no production of endogenous insulin, while in Type 2 there is some production of insulin.
In Type 2 diabetes, there are 4 major metabolic abnormalities. What are these?
1. Insulin resistance
2. Pancreas has decreased ability to produce insulin
3. Inappropriate glucose production by the liver
4. Alteration in production of hormones and adipokines.
What is insulin resistance and what does it result in?
Insulin resistance is when the body tissues do not respond to insulin; insulin receptors are either unresponsive or insufficient in number. It results in hyperglycemia.
Why would the pancreas have a decreased ability to produce insulin?
Beta cells are fatigued from compensating
Beta cells mass lost
Inappropriate glucose production from liver - what is this and how does it contribute to type 2 diabetes?
Liver's response of regulating release of glucose is haphazard. Not considered a primary factor in development of Type 2.
Alteration in production of hormones and adipokines - what is this and what does it mean for Type 2 diabetes?
Too much of counter-regulatory hormones. This plays a role in glucose and fat metabolism. Contributes to pathophysiology of Type 2 Diabetes.
What are 2 main adipokines?
Adiponectin and leptin.
What is metabolic syndrome and how does this relate to Type 2 Diabetes?
A cluster of abnormalities that increase risk for cardiovascular disease and diabetes, characterized by insulin resistance. Individuals with metabolic syndrome are at increased risk for Type 2 diabetes. They will have:
Elevated insulin levels
What are the risk factors for Metabolic Syndrome?
Central obesity, sedentary lifestyle, urbanization, certain ethnicities.
What is the onset of Type 2 Diabetes like?
Gradual, unlike the sudden severe symptoms of Type 1. A person may go many years with undetected hyperglycemia.
What can osmotic fluid/electrolyte loss from hyperglycemia may become severe and lead to:
When does gestational diabetes usually develop and resolve?
Develops during pregnancy, detected at 24 to 48 weeks of gestation. Glucose levels are usually normal at 6 weeks postpartum.
What are the increased risks from gestational diabetes?
Increased risk for cesarean delivery, perinatal death, and neonatal complications. Increased risk for developing type 2 diabetes in 2-5 years.
Risk factors for gestational diabetes?
1. Hx of polycystic ovaries
2. Mother had gestational diabetes
What is the therapy for gestational diabetes?
First nutritional, then insulin.
What are some medical conditions that secondary diabetes can result from?
Secondary Diabetes can also result from treatment of a medical condition that causes abnormal blood sugar levels. Examples?
Atypical antipsychotics (Clozapine)
Does secondary diabetes resolve when the underlying condition is treated?
What are the symptoms of Type 1 Diabetes?
Classic symptoms - polyuria, polydipsia, polyphagia
What are the clinical manifestations of Type 2 Diabetes?
Non-specific symptoms - may have classic Type 1 symptoms
Recurrent vaginal yeast or monilia infections
Prolonged wound healing
What are the three methods of diagnosis for Diabetes Mellitus?
1. Fasting plasma glucose level >126 mg/dl (no food for 8 hrs)
2. Random or casual plasma glucose measurements of > or = 200 mg/dl plus symptoms
3. Two-hour OGTT level > or = 200 mg/dl using a glucose load of 75 g
What is a Hemoglobin A1C test measuring?
How well someone is controlling their diabetes over time. Useful in determining glycemic levels over time.
What is a hemoglobin A1C test also called?
Is the hemoglobin A1C test diagnostic?
No. It monitors success of treatment.
What is the A1C test SPECIFICALLY, ACTUALLY measuring?
Shows the amount of glucose attached to hemoglobin over RBC lifespan (90-120 days).
What is the ideal goal (#) for a hemoglobin A1C test?
ADA < or = 7%
American College of Endocrinology < 6.5%
What does a normal A1C reduce the risk for?
Retinopathy, nephropathy, and neuropathy.
What does a score of 7% or less on the hemoglobin A1C indicate?
That the person is keeping their blood sugars maintained within tight control - their sugar is not all over the place.
4 goals of diabetes management?
1. Decrease symptoms
2. Promote well-being
3. Prevent acute complications (ex. DKA)
4. Delay onset and progression of long-term complications (visual changes, peripheral changes, changes in kidneys).
What is exogenous insulin and who needs it?
It is insulin from an outside source.
-Required for Type 1 diabetics
-Prescribed for Type 2 diabetics who cannot control their blood sugar by other means (diet, exercise, oral meds)
What type of insulin is the only type used today (what source is it from)?
Human. Prepared through genetic engineering from e. coli or yeast cells.
In what regard do insulins differ from one another?
Onset, peak action, and duration.
How are insulins characterized?
Can different ypes of insulin be used for combination therapy?
Give an example of each type of insulin.
Rapid acting = Lispro (Humalog), aspart (Novolog), and glulisine (Apidra)
Short-acting = Regular
Intermediate acting = NPH
Long acting = Glargine (Lantus), determir (Levemir)
What type of insulin regimen is typically used?
Regimen that closely mimics endogenous insulin production - basal-bolus.
-Long-acting (basal) once a day
-Rapid/short-acting (bolus) before meals
What would be a good diabetic blood sugar AFTER a meal?
What are the types of rapid-acting (bolus) insulin, when is it injected, and when is the onset of action?
Lispro (Humalog), Aspart (Novolog), glulisine (Apidra)
-Injected 0-15 minutes before meals
-Onset of action 15 minutes
What are the types of short-acting (bolus) insulin, when is it injected, and when is the onset of action?
-Injected 30-45 minutes before meal
-Onset of action 30-60 minutes
What are the types of long-acting (basal) insulin, when is it injected, and when is the onset of action?
Glargine (Lantus) or detemir (Levemir).
-Injected once a day at bedtime or in the morning
-Released steadily and continuously
-No peak action
-Cannot be mixed with any other insulin or solution
What is the significance of long-acting insulin having no peak action?
Does not lead to hypoglycemia.
How is insulin stored?
-Do not heat/freeze it
-In-use vials may be left at room temperature up to 4 weeks (Lantus only for 28 days)
-Extra insulin should be refrigerated
-Avoid exposure to direct sunlight
-Pt can pre-fill syringes and store in fridge, up to 1 week
-Store so needle is pointing up
-Before given, gently roll in palm
Why can't insulin be taken orally?
It would be inactivated by gastric juices.
How can insulin be administered?
IV or subcutaneously (for self-administration).
What site(s) have the fastest absorption for insulin?
Abdomen, followed by arm, thigh, and buttocks.
What is the PREFERRED site for insulin injection?
Should you rotate where insulin injections are given?
You should rotate within one particular site (ex. abdomen). So pick a site and stick with it, rotate within that site.
Should you inject insulin into your thigh if you are just about to exercise? Why or why not?
No because you will get much faster absorption (because of the increased tissue perfusion).
What quantity is insulin usually available as?
U100, meaning 1ml contains 100 units of insulin.
How do you inject insulin?
-No alcohol swab on site needed before injection
-Hand washing with soap adequate
-Do not recap needle
-45-90 degree angle depending on fat thickness of patient
What is an "insulin pen"?
It is a "pen" with a dial, a plunger, a needle, and an insulin cartridge which is pre-loaded with insulin.
What is an insulin pump and why might it be used?
-It gives continuous subcutaneous infusion of insulin
-Battery operated device
-Connected via plastic tubing to a catheter inserted into subcutaneous tissue in abdominal wall
What is the big advantage of an insulin pump?
Potential for tight glucose control. (AKA tighter glycemic control).
How long can an insulin pump stay in place for?
Does the tubing need to be primed on an insulin pump?
Does a person still need to check their blood sugar if they are on an insulin pump?
Yes, 3-4x/day. However, they can be more flexible with mealtimes.
Name 5 problems connected with insulin therapy.
1. Hypoglycemia (too much insulin)
2. Allergic reactions (can be allergic to protamine which changes insulin to make it longer-acting)
3. Lipodystrophy (dimpling of skin in the days of pig insulin)
4. Somogyi effect
5. Dawn phenomenon
What is the Somogyi effect?
A rebound effect in which an overdose of insulin causes hypoglycemia, usually during the hours of sleep (2-3am). Then counter-regulatory hormones are released by the liver to reverse the low blood sugar, and rebound hyper-glycemia and ketosis can occur. The patient may be symptomatic (headaches, night sweats, nightmares).
What is the cause of the Somogyi effect?
It is a result of having extra insulin in the body before bedtime, either from not having a bedtime snack, or from long-acting insulin.
What type of diabetes does the Somogyi effect mainly occur in?
Type 1 diabetes.
What could a person to to counteract the Somogyi effect?
Have a snack at bedtime or insulin doses or times may need adjusting.
What is the Dawn Phenomenon?
It is a NORMAL RISE IN BLOOD SUGAR as a person's body prepares to wake up. It is not caused by hypoglycemia, but by a random release of hormones.
-In the early morning hours, hormones cause the liver to release large amounts of sugar into the bloodstream. For most people, the body produces insulin to control the rise in blood sugar.
-If the body does not produce enough insulin, blood sugar levels rise (hyperglycemia) in the morning before eating.
What type of diabetes does the Dawn Phenomenon occur in?
More often in Type 1 than Type 2, and can be more exaggerated in pregnant women due to hormone levels.
Will skipping breakfast help the hyperglycemia caused by the Dawn Phenomenon? Why or why not?
No. Eating breakfast allows blood glucose levels to return to normal by turning off the mechanism that is causing the liver to release glucose, thereby breaking the cycle. If no breakfast is eaten, the blood glucose will continue to rise.
How would you tell the difference between the Somogyi Effect and the Dawn Phenomenon?
Wake the patient up at 2 or 3 am for several nights in a row to check the blood sugar. If their blood sugar is low at the time, suspect the Somogyi Effect. If it is normal or high at 2-3am, suspect the Dawn Phenomenon.
Treatment for Somogyi Effect/Dawn Phenomenon?
-Make sure the patient has a snack before bed that consists of more protein than carbs.
-The patient's insulin dose may have to be adjusted.
-Have the patient eat breakfast even if the blood sugar is high - eating something will shut down the Dawn Phenomenon and let the blood sugar return to normal.
What do oral agents for diabetes do?
Work to improve mechanisms by which insulin and glucose are produced and used by the body.
Oral agents work on these 3 defects of Type 2 diabetes?
1. Insulin resistance
2. Decreased insulin production
3. Increased hepatic glucose production (gluconeogenesis)
What do the Sulfonylureas do? Examples, and side effects?
Sulfonylureas increase insulin production from the pancreas. This decreases the chance of prolonged hypoglycemia. 10% of people experience decreased effectiveness after prolonged use, so will need a med change.
-Examples - Glipizide (Glucotrol), Glimepiride (Amaryl)
-Side effects: Weight gain, hypoglycemia
What do the Meglitinides do? Examples, and side effects?
Meglitinides also increase insulin production from the pancreas, but it is rapidly absorbed and eliminated so it does not cause hypoglycemia.
-Take 30 minutes before each meal up to time of meal
-Should not be taken if meal skipped (if pt. is NPO, hold medication)
-Examples - Repaglinide (Prandin), Nateglinide (Starlix)
-Side effects - weight gain
What do the Biguanides do? Examples, and side effects?
1. Reduce glucose production by liver
2. Enhance insulin sensitivity at tissues
3. Improve glucose transport into cells
-Do NOT promote weight gain
-Example - Metformin (Glucophage)
What is special about the Biguanides?
They are the first-choice drug for Type 2 diabetes, and they are also use to hold off development of diabetes in someone with pre-diabetes (older or obese).
What are the a-Glucosidase inhibitors, and give a name of one?
They are "starch blockers" and slow down the absorption of carbohydrate in the small intestine.
Example: Acarbose (Precose).
What do the Thiazolidinediones do? Examples?
-Most effective in those with insulin resistance.
-Improves insulin sensitivity, transport, and utilization at target tissues.
-Examples - Pioglitazone (Actos) and Rosiglitazone (Avandia)
What is a concern with the Thiazolidinediones?
There is a risk for hypoglycemia, especially when combined with insulin.
What do b-Adrenergic blockers do in diabetics?
-Mask symptoms of hypoglycemia
-Prolong hypoglycemic effects of insulin
What do thiazide/loop diuretics (ex. Lasix) do in diabetics?
-Can potentiate hyperglycemia (by inducing potassium loss)
Name some drugs that can cause hyperglycemia?
Thiazide/loop diuretics, Calcium channel blockers, Corticosteriods, Glucagon, Dilantin, marijuana.
Name one widely used drug that can decrease blood sugar level?
Why is nutritional therapy considered the "cornerstone of care" for people with diabetes?
Type 2 diabetics can try to change diet and exercise before using insulin.
Type 1 diabetics will be very dependent on counting carbs.
What is the American Diabetes Association (ADA) guidelines for what a diabetic should eat, and what is the overall goal of this?
-Guidelines indicate that within context of an overall healthy eating plan, a person with diabetes can eat the same foods as a person who does not have diabetes.
-The overall goal is to assist people in making changes in nutrition and exercise habits that will lead to improved metabolic control.
-Person should watch cholesterol and carbs, and the goal is a normal lipid profile and a normal blood sugar.
For a Type 1 diabetic, what are the diet and exercise goals?
-The meal plan is based on the individual's usual food intake and in balanced with insulin and exercise patterns
-Their insulin regimen is managed day to day
-Example - if they eat 2 meals a day, they would be encouraged to eat breakfast
-It is important for them to stay in an established pattern.
-They need to work up to vigorous exercise or they can screw up their insulin levels.
For a Type 2 diabetic, what is the emphasis placed on in nutritional therapy?
-Emphasis is on achieving glucose, lipid, and blood pressure goals
-Calorie reduction (even a modest weight loss [5-7%] is associated with improved glycemic control.
Do you want someone with diabetes to eat a no-fat diet? Why or why not?
No. They should eat a LOW-fat diet. You need fat in diet for fat-soluble vitamins.
What is "food composition" ?
The nutrient balance of the diabetic diet is essential - (carbohydrates, proteins, and fats) and also nutritional energy intake (calories) should be balanced with energy output.
What are carbohydrate recommendations for a diabetic?
-Carbohydrates and monounsaturated fats should provide 45-65% of total energy intake
-Decreased carbohydrate diets are not recommended for diabetics (they need carbs for energy)
-Should have 130g of carbs per day, spread out - not all at once
-Eat whole grains, fruit, veggies, lowfat milk.
What is the Gycemic Index?
-Term used to describe rise in blood glucose levels after consuming carbohydrate-containing foods
-Should be considered when formulating a meal plan.
What portion of a diabetic's diet should be fats?
No more than 25% to 30% of meal plan's total calories. <7% should be from SATURATED fats.
How much protein should a diabetic consume?
15-20% of total calories. Intake of protein should be the same as the general population.
Why should a diabetic not drink alcohol?
1. High in calories
2. No nutritive value
3. Promotes hypertriglyceridemia
4. Detrimental effects in liver
5. Can cause severe hypoglycemia
If a diabetic is going to be drinking alcohol, what can you tell them (food-wise)?
That they need to have carbs with their ETOH to balance hypoglycemia.
What methods can you as the nurse use to teach a diabetic patient about diet?
1. USDA MyPyramid Guide is an appropriate basic teaching tool.
2. Plate method - Helps patient visualize the amount of vegetable, starch and meat that should fill a 9-inch plate
During each meal, a diabetic should eat the maximum number of carbs they can eat based on:
Name three beneficial effects exercise has for a diabetic?
1. Increases insulin receptor sites.
2. Lowers blood glucose levels
3. Contributes to weight loss
What can be done by a diabetic during exercise to prevent hypoglycemia?
Several small carbohydrate snacks can be taken every 30 minutes during exercise to prevent hypoglycemia.
When is exercise for diabetics best done?
After meals (1 hr after). If that is not possible, have 15g of carbs before exercise and check blood sugar before, during, and after exercise.
They should also get medical clearance and proceed slowly and with gradual progression to more vigorous exercise.
4 important things about patient self-monitoring blood glucose?
1. Enables patient to make self-management decisions regarding diet, exercise, and medication.
2. Important for detecting episodic hyperglycemia and hypoglycemia.
3. Patient training is crucial
4. Supplies immediate information about blood glucose levels.
What is a blood glucose monitor and whould would typically have one?
It communicates with the insulin pump. Typically used by very brittle diabetics.
When should a diabetic check blood glucose?
-When feeling hypoglycemic
-When they are sick (they need more insulin)
When doing a past health history on a diabetic patient, what are 3 things you would ask about and why?
1. Viral infections
3. Recent surgery
All of these can change a person's blood glucose level.
In taking a health history for a diabetic patient, what do you want to find out if their history is positive for?
-Poor healing (ex. feet)
Overall goals for a diabetic?
1. Active patient participation (don't rely just on family members)
2. Few or no episodes of acute hyperglycemic emergencies or hypoglycemia
3. Maintain normal blood glucose levels
4. Prevent or delay chronic complications
5. Lifestyle adjustments with minimal stress (stress can increase or decrease BS)
Who should be routinely screened for diabetes and how is this done?
Overweight adults over 45 years of age should be routinely screened. FPG (finger prick glucose) is the preferred method in clinical settings.
When would an acute intervention be necessary for a diabetic?
2. Diabetic Ketoacidosis
3. Hyperosmolar Hyperglycemia Non-Ketotic Syndrome (HHS)
4. Stress of illness and surgery
What can illness and/or surgery do to a diabetic and what should be done to manage this?
1. Can increase blood glucose levels
-Continue regular meal plan
-Increase intake of noncaloric fluids (broth, water, decaf beverages)
-Continue taking oral agents and insulin
-Frequently monitor blood glucose (Q4hrs)
-Ketone testing if glucose >240 mg/dl (Q 3-4hrs)
What should patients taking Metformin do if they are undergoing a procedure requiring contrast medium? Why?
Hold their Metformin the day of surgery and for 48 hours. It can be begun after serum creatinine is checked and is normal. This is because mixing Metformin and contrast dye will increase chances of developing acute renal failure.
Why is personal hygiene especially important for diabetics?
Risk of infection for diabetics is greater than for non-diabetics.
What is the overall goal of ambulatory and home care for diabetics?
To enable patient or caregiver to reach an optimal level of independence.
For ambulatory and home care, what would you as the nurse teach/assess about insulin therapy and oral agents?
Educate on proper administration, adjustment, and side effects.
Assess patient's response to therapy.
For ambulatory and home care, what would you as the nurse teach/assess about personal hygiene?
-Regular bathing with emphasis on foot care
-Daily brushing/flossing so don't develop sores in mouth (dentist should be informed about diabetes diagnosis)
-Educate not to wear tight shoes
Why does someone who is diabetic need to carry a medical ID indicating this?
Carry a medical ID and travel card - pt. must carry identification indicating diagnosis of diabetes because if their blood sugar drops low they might not be able to talk, or the condition can mimic being drunk.
For ambulatory and home care, what would you as the nurse teach/assess about diabetes in general to the patient and/or family?
-Educate on disease process, physical activity, medications, monitoring blood glucose, diet, resources.
-Enable patient to become most active participant in his/her care.
What is something else a diabetic should always carry with them?
What are the symptoms of HYPOGLYCEMIA?
What are the causes, onset, and blood sugar levels of hypoglycemia?
Causes: Too little food, too much insulin or diabetes medicine or extra exercise.
Onset: Sudden, may progress to insulin shock.
Blood sugar: Below 70 mg/dL (normal is 70-115 mg/dL)
What should someone do if they are hypoglycemic?
Follow the "rule of 15s": Consume 15g of carbohydrates, recheck blood sugar in 15 minutes, consume another 15g if blood sugar is <50. (Half a cup of milk or orange juice or several hard candies). Within 30 minutes after symptoms go away, eat a light snack (half a peanut butter or meat sandwich and half glass of milk).
What are some other foods that are 15g CHO snacks for hypoglycemia treatment?
1/2 cup OJ
1/2 cup regular soda
3-4 glucose tablets
1 glucose gel tube
3 sugar packets
Typical blood sugar targets for before meals, 1-2 hours after a meal, and bedtime?
Before meal - 90-120
After meal - 140 or less
Bedtime - 110-150
What are the symptoms of HYPERGLYCEMIA?
A need to urinate often
Dry, itchy skin
Tired, weak, or dizzy
Upset stomach, vomiting
What should a diabetic do if they are hyperglycemic?
1. Check blood sugar
2. Follow sick-day plan (drink sugar-free liquids such as water, broth, caffeine-free drinks)
3. Administer sliding-scale insulin (call doctor if BS is over the agreed-on number)
If a patient is diabetic, when should he/she call the doctor?
1. Vomiting/diarrhea for more than 6 hours
2. Illness not improving after 2 days
3. Unable to eat or drink for more than 4 hours
4. High >300 or low blood sugar more than 2 days.
5. Signs of DKA
6. Per provider recommendation.
Reasons for sugar to go up:
1. Too much food
2. Not enough medicine or forgetting medicine
3. Increased stress
4. Decreasing your exercise
Reasons for sugar to drop too low:
1. Too little food
2. Skipping a meal
3. Increased activity
4. Too much medicine
What are 3 acute complications of diabetes?
1. Diabetic ketoacidosis (DKA)
2. Hyperosmolar hyperglycemia sysdrome (HHS)
What is diabetic ketoacidosis caused by, characterized by, and who has it more often?
DKA is caused by a profound deficiency of insulin.
It is characterized by:
-Hyperglycemia (HIGH, like 800)
-Ketosis (ketones in urine)
-Acidosis (metabolic acidosis from ketones)
Mostly occurs in Type 1 diabetics.
Do symptoms of DKA develop slowly or rapidly?
Very rapidly. This is typically how Type 1 diabetics are diagnosed - they present at the ER with DKA.
What are some precipitating factors of DKA?
Inadequate insulin dosage
Undiganosed Type 1
What happens when the supply of insulin is insufficient?
Glucose cannot be properly used for energy. Body breaks down fat stores. Ketones are by-products of fat metabolism. This alters the pH balance, causing metabolic acidosis. Ketone bodies are excreted in urine. Electrolytes become depleted (low sodium, potassium, chloride, mag, phos).
Why does a patient with DKA vomit and why is this a problem?
They vomit as a compensatory mechanism to try to rid body of all the acid. This increases fluid/electrolyte balance issues. It can lead to hypovolemic shock and coma if not managed.
Signs and Symptoms of DKA?
1. Lethargy/weakness (early symptom)
-Poor skin turgor
-Dry mucous membranes
3. Abdominal pain
-Nausea/vomiting (causes hypovolemia)
4. Kussmaul respirations (hallmark sign of DKA)
-Rapid deep breathing
-Attempt to reverse metabolic acidosis (compensatory mechanism from the respiratory tract to get them to blow off CO2)
-Sweet fruity odor on breath
Is DKA a serious condition? Why?
YES. It must be treated promptly or it can lead to coma and/or death.
Depending on the signs/symptoms, the person may need hospitalization.
What are the laboratory findings in DKA?
Blood glucose >300 mg/dl
Arterial blood pH below 7.3 (acidosis)
Serum bicarbonate level <15 mEq/L
Ketones in blood and urine
What are your priorities as a nurse in the management of a patient with DKA?
1. Airway management (oxygen administration)
2. Correct fluid/electrolyte imbalance (IV infusion of 0.45% or 0.9% NaCl which is NS or 1/2NS)
-Restore urine output
-Raise blood pressure
3. When blood glucose levels approach 250 mg/dl, 5% dextrose added to regimen to prevent hypoglycemia
4. Potassium replacement (very important because this can cause death; normal potassium is 3.5 - 5.0)
5. Sodium bicarbonate if pH <7
6. Assess VS
7. Assess LOC
8. Check serum glucose and K levels - K will be depleted and need replacement)
9. Insulin therapy (withheld until fluid resuscitation has begin; bolus followed by insulin drip)
What is Hyperosmolar Hyperglycemic Syndrome (HHS)? Who does it occur in?
A life-threatening syndrome that is less common than DKA and often occurs in patients over 60 years of age with Type 2.
What is more serious, DKA or HHS in terms of mortality?
HHS. 10-15% of people die from it vs. 2-5% from DKA.
Why would someone get HHS but not DKA?
If they produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia. The patient has enough circulating insulin so ketoacidosis does not occur.
-Produces fewer symptoms than DKA in earlier stages.
-Neurologic manifestations (somnolence, coma, seizure - symptoms can resemble a stroke i.e. one-sided weakness) occur due to increased serum osmolarity.
-Patient's urine output increases so patient gets dehydrated because blood glucose level is so high that body is trying to get rid of glucose
What may be causes of HHS?
UTI, pneumonia, sepsis, newly diagnosed Type 2 diabetes.
HHS patients usually have a history of these 3 things?
1. Inadequate fluid intake
2. Increasing mental depression
Laboratory values for HHS?
-Blood glucose >400, usually around 600
-Increase in serum osmolarity
-Absent/minimal ketone bodies in blood/urine
Is the therapy for HHS similar to that for DKA?
Yes, except that HHS requires greater fluid replacement, up to 10L NS at 1L/hr until body starts to stabilize, up to 8-12 L.
Important to make sure the patient's respiratory status can handle that much fluid.
Potassium is a must because they urinate out K.
Nursing management of DKA/HHS
1. Patient closely monitored
-IV fluids (as BS comes down, change IV fluid to 1/2NS so they do not get hypoglycemic)
-Electrolytes (esp. K)
-Level of consciousness
-I&O, VS, Labs
Closely monitor a DKA/HHS patient for?
1. Signs of potassium imbalance
2. Cardiac monitoring
3. Vital signs
What is hypoglycemia and when does it occur?
Low blood glucose. Occurs when you have too much insulin in proportion to glucose in the blood. (Blood glucose level <70 mg/dl)
What would you closely monitor in a patient with hypoglycemia?
1. Signs of potassium imbalance (can require K if they have prolonged hypoglycemia)
2. Cardiac monitoring
3. Vital signs
Common manifestations (aka symptoms) of hypoglycemia?
Can mimic ETOH intoxication (confused, stumbling, irritable, belligerent)
What can untreated hypoglycemia progress to?
Loss of consciousness, seizures, coma, and death.
What is "hypoglycemic unawareness"? What is it related to? What is the management for this?
Person does not experience warning signs/symptoms of the hypoglycemia (related to autonomic neuropathy). This is very dangerous, as the risk is for low blood glucose levels. The person has to be ON TOP of checking their blood sugar!
What is meant by a "mismatch in timing" being the cause of hypoglycemia?
Food intake and peak action of insulin or oral hypoglycemic agents is not matched up correctly, and the result is low blood glucose.
At the first sign of hypoglycemia, what should you do? Then what?
Check blood glucose! If it is <70mg/dl, begin treatment. If it is over 70 mg/dl, investigate further for cause of signs/symptoms.
If monitoring equipment is not available, treatment should be started.
Treatment for hypoglycemia - what is it?
-If the person is alert enough to swallow, give them 15g -20g of a simple carbohydrate (4-6oz of fruit juice or a regular soft drink and avoid giving foods with fat as they decrease absorption of sugar).
-Check blood sugar in 15 minutes
-If no improvement, give them another 15g of simple carbs
-Repeat until blood sugar is >70 mg/dl
-Patient should eat regularly scheduled meal/snack to prevent rebound hypoglycemia
-Check blood sugar again 45 minutes after treatment
-Have patient ingest a complex carbohydrate after recovery (half a peanut butter or meat sandwich and 1/2 cup of milk)
What would you do if there was no improvement after 2 or 3 doses of simple carbs or if the patient was not alert enough to swallow? What is the side affect of this treatment?
Administer 1mg of glucagon IM or SubQ. Side effect is rebound hypoglycemia.
In acute care settings, what would be given for hypoglycemia?
20 to 50ml of 50% dextrose IV push. Or administer 1mg of glucagon IM or SubQ.
What is a major MACROVASCULAR chronic complication of diabetes? Describe it. Why does diabetes cause it?
Angiopathy - Diseases of large and medium-sized blood vessels.
-Occur with greater frequency with an earlier onset of diabetes
-Development promoted by altered lipid metabolism common to diabetes
-Tight glucose control might delay atherosclerotic process
What are the risk factors for MACROVASCULAR angiopathy?
What should patients with diabetes be screened for when they are diagnosed with diabetes?
If a person decreases the risk factors associated with these macrovascular changes, mortality can be decreased by ____%
________________ may delay atherosclerotic process.
Tight glucose control.
Other macrovascular diseases?
Peripheral vascular disease
If someone is diabetic, what should their blood pressure be less than or equal to?
MICROVASCULAR changes that take place in diabetes - what do they result from?
Thickening of vessel membranes in vessels and arterioles, in response to chronic hyperglycemia. This is specific to diabetes, unlike the macrovascular changes.
What areas of the body are most affected by microvascular changes?
1. Eyes (retinopathy)
2. Kidneys (nephropathy)
3. Skin (dermopathy)
When in the course of diabetes do these microvascular changes occur? Can this be prevented?
These microvascular changes usually occur after a person has had diabetes for 10-20 years. If we keep the patient well-controlled, these problems may not occur.
Diabetic retinopathy - what is it and what does it do?
Diabetic retinopathy is microvascular damage to the retina.
-It is the result of chronic hyperglycemia.
-It is the most common cause of new cases of blindness in people ages 20 to 74.
What are the two different types of diabetic retinopathy and describe them in detail.
-Most common form
-Partial occlusion of small blood vessels in retina
-Causes development of microaneurysms
-Capillary fluid leaks out
-Retinal edema and eventually hard exudates or intra-
retinal hemorrhages occur
-Most severe form
-Involves retina and vitreous (white jelly)
-When retinal capillaries become occluded
-Body forms new blood vessels - vessels are extremely fragile and hemorrhage easily
-Produce vitreous contraction
-Retinal detachment can occur
-Can lose total vision
The earliest and most treatable stages of diabetic retinopathy often produce __________ changes in vision. What does a diabetic have to do to deal with this?
They often produce NO changes in vision. Diabetics must have annual dilated eye examinations
Diabetic nephropathy. What is it and what does it cause?
Microvascular changes - associated with damage to small blood vessels that supply the glomeruli of the kidney.
-Leading cause of end stage renal disease
What are the critical factors for prevention/delay of diabetic retinopathy?
1. Tight glucose control.
2. Blood pressure management
-Angiotensin Converting Enzyme (ACE) Inhibitors (-prils like Lisinopril) used even when not hypertensive
-Angiotensin II receptor antagonists (-sartans like Losartan)
In diabetic nephropathy, what should the patient be screened for yearly?
1. Microalbuminuria in urine
2. Serum creatinine
What is diabetic neuropathy? Who has it?
Nerve damage due to metabolic derangements of diabetes. 60-70% of patients with diabetes have some degree of neuropathy.
What are the 2 different types of diabetic neuropathy?
Sensory and autonomic.
Describe sensory neuropathy.
-Distal symmetric neuropathy.
-Most common form.
-Affects hands and/or feet bilaterally
-Characteristics - loss of sensation, abnormal sensations, pain and paresthesias
-Usually worse at night
-Foot lesions and ulcerations can occur without the patient having pain.
-Can cause atrophy of small muscles of hands/feet
-"Tingling that's usually worse at night"
What is the treatment for sensory neuropathy?
Tight blood glucose control.
-SSRIs and SNRIs
What is autonomic neuropathy?
Can affect nearly all body systems.
What are the complications from autonomic neuropathy?
1. Gastroparesis from delayed gastric emptying
2. Cardiovascular abnormalities
3. Sexual function
4. Neurogenic bladder
What is the most common cause of hospitalization for diabetics? What does this result from?
Foot complications. Results from a combination of microvascular and macrovascular changes. Diabetics must check feet EVERY DAY.
What are the risk factors for foot complications?
-Peripheral arterial disease
-Impaired immune function
Diabetes and infection - what is important to know?
-Diabetics are more susceptible to infections
-Defect in mobilization of inflammatory cells
-Impairment of phagocytosis by neutrophils and monocytes
-Loss of sensation may delay detection
-Treatment must be prompt and vigorous.
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