4.1 Management of Chronic Endocrine Disorder

Question 1

Diabetes

Answer 1

• Metabolic disease
• Increased glucose in body (hyperglycemia)
• Results from defects in insulin secretion, insulin action or both
• Leading cause of microvascular problems and major contributor to microvascular problems
• Major clinical Manifestation is Hyperglycemia

Question 2

Glucose

Answer 2

• Simple sugar that is an energy source for living organisms. Major component of carbohydrates
• Carbohydrates are broken down into glucose in the small intestines

Question 3

Insulin

Answer 3

• Secreted by beta cells in the pancreas
• Promotes glucose transport and opens receptors and insulin dependent tissues
• Acts as a key to transfer glucose into cells
• Brain liver and blood cells do not require insulin for glucose transport.

Question 4

Counter Regulatory Hormones of Insulin

Answer 4

• Glucagon, Epinephrine, Growth Hormone, Cortisol
• Oppose effects of Insulin
• These increase glucose levels
• Regulation of Insulin secretion is through glucose and other hormones. It is often inhibited by stress.

Question 5

Type 1 Diabetes

Answer 5

• Body does not make insulin
• Immune system attacks and destroys cells in pancreas that make insulin
• Insulin dependent
• 5% of all diabetes cases
• Onset under age 40 with about half under age 20
• Rapid onset of ketoacidosis
• Sudden Weight Loss, Dehydration, Hypoglycemia while patient is on insulin therapy

Question 6

Type 2 Diabetes

Answer 6

• Onset usually over age 40 (Gradual Onset)
• 95% of diabetes cases
• Body does not produce enough insulin
• Caused by insulin resistance. In these cases it takes more insulin to work
• Higher risk in minorities
• Obesity is the biggest risk
• Risk Factor is Metabolic Syndrome
  (Abdominal Obesity, Elevated Lipids, Hypertension, Impaired Fasting Glucose)

Question 7

Risk Factors for Diabetes

Answer 7

• Age 45+
• Family history
• Overweight
• Physically Inactive
• ## High blood pressure

Question 8

Insulin Resistance

Answer 8

• Fat cells become resistant to insulin.
• When fat cells get too big it changes the insulin shape preventing the cell from absorbing glucose
• This causes pancreatic insulin production to fail due to creating more insulin to try and absorb glucose
• Losing weight reduces size of fat cells causing insulin resistance to reverse

Question 9

What can Diabetes Cause

Answer 9

• Heart disease (Hypertension, Coronary Artery Disease)
• Stroke (Brain issues)
• Kidney Disease (Nephropathy/Failure)
• Eye Issues (Cataracts, Glaucoma, Blindness)
• Dental Disease
• Nerve Damage
• Foot Problems
• Peripheral Vascular Disease (Poor healing of wounds and gangrene)
• GI/GU and Sexual Issues
• Angiopathy (damage of blood vessels or lymphatics)

Question 10

Managing Diabetes

Answer 10

• Manage blood glucose, blood pressure, cholesterol.
  (ABC’s to manage diabetes)
• A1C Test shows average blood glucose in last 3 days
• Blood pressure goal is 140/90
• Control Cholesterol
• Stop smoking

Question 11

Blood Levels for Diabetes

Answer 11

• Non-fasting glucose levels - Greater than 200
• Fasting glucose greater than or equal to 126 mg/dL
• Two hour post load glucose equal to 200 mg/dL
• Normal Glucose levels is 70-100

Question 12

Glyco-hemoglobin test (A1C)

Answer 12

• Measures average blood glucose levels for the past 3 months. (5.7% is normal. Or from 4% - 6%)
• A1C greater than or equal to 6.5% (Diabetes)
• A1C between 5.7% and 6.4% is pre-diabetes
• Normal A1c is less than 5.7%
• Target for people with diabetes is 7%

Question 13

A1C Test

Answer 13

Average blood glucose levels in past 2-3 months

• Measures percentage of hemoglobin that is coated with sugar glycated
• A1C greater than or equal to 6.5% (Diabetes)
• A1C between 5.7% and 6.4% is pre-diabetes
• Normal A1c is less than 5.7%

Question 14

Hypoglycemia

Answer 14

• If glucose falls to less than 70
• Less than 40 is severe which can mean too much insulin, too little food, or too much exercise
  Symptoms
• Shaky, Sweaty, Confused, Pale
  Treatment
• 15 g’s of Carbs x3
• Glucagon 1mg subcutaneous OR Dextrose 50% IV if unconscious

Question 15

Diabetic Ketoacidosis

Answer 15

• Insulin deficiency and fat breaks down into ketones (acids)
• Accumulation leads to metabolic acidosis and hyperkalemia
• Blood glucose > 250
• Usually with Type 1 Diabetes

Question 16

Hyperglycemic Hyperosmolar Syndrome (HHS)

Answer 16

• Results from insulin deficiency initiated by illness that raises demand for insulin
• Usually occurs in Type 2 Diabetes Mellitus
• Osmotic Diuresis (Kidneys filter too much liquid) which results in loss of water and electrolytes
• Hypovolemia
• Blood Glucose > 600

Question 17

Chronic Conditions of Diabetes

Answer 17

Macrovascular - Angiopathy (coronary artery disease), cerebrovascular disease, peripheral vascular disease
Screen and Treat Increased Lipids

Microvascular - Retinopathy (damage to small vessels in the retina), Nephropathy (damage to kidney cells), Neuropathy (dysfunction of one or more peripheral nerves causing numbness or weakness).
Thickening of Capillaries or Small Vessels

Foot ulcers. Patient doesn’t feel pain leading to developing an ulcer which could lead to gangrene or amputation.

Question 18

Nursing Management of Diabetes

Answer 18

• Insulin administration
• Meal planning
• Self-Monitoring
• Recognition and treatment of acute complications
• Educate how to self-administer Insulin
• Systematic rotation of injection sites to prevent lipodystrophy (localized change in fatty tissue)
• Educate to call provider when blood sugar is high or low

Question 19

Nursing Management of Insulin

Answer 19

• Should be refrigerated.
• Do not allow insulin to freeze or kept in sunlight
• Insulin vial should be used at room temperature

Question 20

Signs/Symptoms of Hyperglycemia

Answer 20

• Polyuria (Excess urine output due to osmotic diaresis)
• Polydipsia (Excess Thirst)
• Polyphagia (Excess appetite due to being hypermetabolic)
• Weight Loss
• Fatigue
• Weakness
• Paresthesia (Numbness/Tingling in Hands/Feet)
• Poor Healing in Wounds
• Recurrent Infections

Question 21

Latent Auto-Immune Diabetes of Adults (LADA)

Answer 21

• Not common but is emerging
• Destruction of Beta Cells
• Not insulin dependent initially for the first 6 months
• Shares features of both type 1 and type 2 diabetes

Question 22

Gestational Diabetes

Answer 22

• Diabetes that develops when women are pregnant. Usually goes away once baby is born but women who get it are at higher risk for Type 2 Diabetes later in life
• Increased risk for C-Section Complications

Risk Factors

• Pregnancy in advanced maternal age
• Obese, Overweight, Family History of Diabetes
• Usually screened earlier if they exhibit high risk factors but usually is checked 24-26 weeks into gestation by Oral Glucose Tolerance Test

Question 23

Pre-Diabetes

Answer 23

• No Symptoms but long term damage occurring
• Risk of type 2 diabetes
• Fasting Glucose 100-125 mg/dL
• Education during this time is very important
• Plan to manage risk factors and monitor for symptoms.
• Weight, exercise plan, diet, nutrition, education, screening.

Question 24

Diabetic Retinopathy/Nephropathy

Answer 24

• Retinopathy most common cause of blindness in adults
• Ensure patients are getting annual eye exams with dilation
• Nephropathy is leading cause of kidney disease
• Annual screenings for kidney function such as creatinine and glomerular filtration rate (GFR)
• Monitor Albumin in Urine. May need ACE inhibitors or ARB to delay progression. Controlling hypertension and glucose levels is imperative

Question 25

Diabetes and Foot Complications

Answer 25

• Can be devastating and lead to amputation risk
• Foot education is vital as decreased sensation leads to decreased pain. There is also decreased blood flow.
• Patient must know to wear proper footwear to avoid foot injury
• Daily inspection of feet with proper skin and nail care
• If they notice anything abnormal even a small blister, there should be prompt treatment so it doesn’t grow

Question 26

Charcot Foot

Answer 26

• Weakening of bone that resulted from a fracture
• ## It can change the shape of the foot

Question 27

Primary Goals of Diabetes

Answer 27

• Normalize Insulin especially in Type 2
• Normalize blood glucose levels
• Keep A1C under 7%
• Reduce development of complications
• Prevent hypoglycemia episodes as well (blood sugar less than 70) related to too much insulin or not enough food.

Question 28

Signs and Symptoms of Hypoglycemia

Answer 28

• Altered Mental State
• Visual disturbances, confused, stuporous, coma
• Older adults can be unaware of hypoglycemia until critically low. When at risk for this, blood sugar should be kept a little higher.
• Untreated hypoglycemia can end with unconscious, seizures, coma, and even death.
• If unsure because nothing to measure blood glucose, it is safer to start treatment anyways

Question 29

Treatment of Hypoglycemia

Answer 29

• If patient is awake and alert they can consume 15 grams of a simple sugar then re-check blood glucose
• If it is still low administer another 15 grams of simple sugar
• Give complex carb’s once a patient has recovered

Question 30

5 Components of Diabetes Management

Answer 30

• Nutrition
• Exercise
• Self Monitoring (SMBG)
• Pharmacology
• Education

Question 31

Self Monitoring of Blood Glucose (SMBG)

Answer 31

• Helps make decisions needed for diet, exercise, medication, identify hypo/hyperglycemia
• THIS IS A MUST for Type 1 Diabetics

Question 32

Education of Insulin

Answer 32

• Insulin is usually available in 100 units per mL
• Patient needs to rotate injection sites to prevent lipodystrophy (fatty hard pads that don’t absorb medication well)
• Injection angle is typically 90 degrees

Question 33

Education of Diet

Answer 33

• Usually covered by dietician within acute care setting
• Assist in maintaining proper weight
• Meal Planning
• ## 50-60% should come from carbs, 30% from fats, 7-10% or less from saturated fats. Non-animal proteins such as beans or whole grains is a positive

Question 34

Glycemic Index

Answer 34

• Rated from 0-100

- Relates to blood glucose rise in 2 hours after eating

Question 35

Education of Exercise

Answer 35

• 30 Minutes a day for 5 days aerobic exercises
• 2-3 times a week of strict training
• This helps with decreased weight, lipids, blood pressure, improved circulation, decreases insulin resistance.
• Increases uptake of glucose by body muscle which lowers it in the blood
• Patient should be monitored for hypoglycemia after moderate exercise or have a carbohydrate snack before exercising.

Question 36

Challenges of Elderly and Diabetes

Answer 36

• Hypoglycemia unawareness (severe hypoglycemia without warning signs)
• Renal insufficiency (diet and exercise is main treatment)
• Increased mortality in elderly diabetes