Care of the Diabetic Patient (Exam 2) Flashcards
Type 1 Diabetes
Genetic Predisposition + Environmental Factors
Autoantigens form on insulin-producing beta cells and circulate in the bloodstream and lymphatics
Activation of cellular immunity and humoral immunity toward beta cells
Destruction of beta cells with decreased insulin secretion
Type 2 Diabetics
-More common in adults (with risk factors)
-Can go undiagnosed for years
-Insulin resistant
Type 2 diabetes can go undiagnosed for years
Doctors often just screen on risk factors, not signs/symptoms
Type 1 diabetes
-More common in younger people
-S/S normally more abrupt
-5/10% of all diabetic cases
-No endogenous insulin production
-3 P’s most common presentation
Type 1 diabetics make
No endogenous insulin. Must have insulin replacement
Signs and Symptoms of Type 1 Diabetes
-fatigue
-Recurrent infections
-Slow wound healing
Polydipsia. Polyphagia. Polyuria
Risk factors for Type 2 diabetes (modifiable)
-PA
-High body fat
-HTN
-High cholesterol
Risk factors for Type 2 diabetes (non-modifiable)
-History of gestational diabetes
-Race
-Over 45
-Family history
Labs involved in diabetes
-FBG
-CBG
-Urine Ketones
-Lipid profile
-OGTT
-Glycosylated hemoglobin (HbA1C)
Fasting Blood Glucose
Normal< 126 mg/dL
casual blood glucose
Normal < 200 mgdL
> 300 md/dL is considered a medical emergency
Urine Ketones
High ketones associated with hyperglycemia
Lipid profile
HDL, LDL, tri’s
Oral Glucose Tolerance Test
-commonly for gestational diabetes (Not 1 or 2)
-Fasting glucose drawn prior, client consumes oral glucose, then glucose levels obtained every 30 min until 2 ours post consumption
-Fasting should be less than 110. at 1 hours less than 180. at 2 hour less than 140
Glycosylated Hemoglobin
-Indicator for average glucose level over the past 120 days (3 months)
-For diagnosis and to evaluate effectiveness of interventions
-Normal is 4-6%
-Greater than 6.5% is considered diabetic
-Acceptable reference range for those with diagnosed diabetes is 6-8 with a target of 7
know the blood test levels chart in lecture 1
diagnostic criteria
-At least 1 of the following
1. A1C of 6.5% or higher
2. FBG level greater than 126 mg/dL
3. OGTT 12-hr levelof200 mg/dL
4. Classic symptoms of hyperglycemia, randome glucose greater than 200 mg/dL, or hyperglycemia crisis
-With criteria 1-3, would do a repeat lab test before official diagnosis.
What do you need for diagnosing type 1 diabetes
islet cell autoantibody test
Definition of Pre-diabetic patient
-Impaired glucose tolerance, impaired fasting-glucose, or both
-Patients with pre-diabetes are at
High risk of developing type 2 diabetes
Pre-diabetes symptoms
-Typically non but long term damage could already be done
Pre-diabetic diagnostic criteria
-An A1C of 5.7%-6.4%
-fasting blood sugar of 100-125 mg/dL
-An OGTT 2 hour blood sugar pf 140 mg/dL - 199 mg/dL
What can nurses do for pre-diabetic patients
-Teach
-Lifestyle modifications
-Encourage close monitoring of blood glucose and hemoglobin
-Monitor for symptoms: fatigue, slow wound healing, frequently getting sick
-Diet modification
Pharmacological nursing Management
-Oral medications are started at a low dose and increased gradually based on A1C levels and FBG levels. More frequent in type 2
-Often in hospitalized patients oral medications are stopped and put on insulin while acutely ill. (Able to maintain tight glucose control while on insulin)
-Bring forward patho concepts
What do we do with patients when they have diabetes and are sick?
-Steroids (oral/IV) make your blood sugar RISE. (May need to alter insulin regiment at home, adjust basal dosage, increased scheduled doses)
Why is being sick with diabetes a big problem
-sickness causes the body stress, may cause your body to release more glucose, so may have to check blood glucose more often, adjust insulin regiments, etc.
-Patients are more prone to go into DKA, HHNS when sick
-If stomach virus, may not be eating or drinking, must check blood sugar more often and treat as necessary. (Still need to take oral medications if sick to your stomach if possible)
What do we do when a patient with DM is sick: Teaching points
-notify provider
-Monitor blood sugar more frequently
-Continue to take medications
-Prevent dehydration
-Meet carb needs
-rest
When should a patient with DM who is sick call the provider
-Urine ketones
-BS greater than 250 mg/dL
-Fever over 101.5
-feeling confused
-persistent NVD
-Inability to tolerate liquids
-Illness lasting longer than 2 days
Self monitoring blood glucose: Frequency of blood sugar checks
-Glycemic goals
-Type of diabetes
-Medications regimen
-Access to supplies and equipment
-Patient willingness
CGM is more common
in patients with Type 1 diabetes
Nursing Management of Insulin
-Do our best to mimic the bodies normal insulin production
-Combines Basal insulin with meal time insulin (BASAL BOLUS Regimen)
-Uses rapid and short acting (bolus) insulin before meals
-Use a background insulin once a day
Nursing management: 4 injections a day
-Lantus or Levemir at bedtime (basal)
-Novolog or Regular before each meal (bolus)
Rapid acting Insulin (lipspro, aspart, glulisine)
Onset
Peak
Duration
Onset: 10-30 min
Peak: 30 min-3 hr
Duration: 3-5 hr
Short acting (Regular)
Onset
Peak
Duration
Onset: 30 min-1 hr
Peak: 2-5 hr
Duration: 5-8 hr
Intermediate acting (NPH)
Onset
Peak
Duration
Onset: 1.5-4hr
Peak: 4-12 hr
Duration: 12-18 hr
Long Lasting (glargine, determir, degludec)
Onset
Peak
Duration
Onset: 0.8-4hr
Peak: less defined or no peak
Duration: 16-34 hr
insulin is High Alert medication
-First always check current glucose level (Know the normal range)
-Second, check diet order and patients oral intake tolerance
-what is the onset of cation of the insulin. Is it rapid acting, short acting, intermediate, long acting
-when does the insulin peak?
-what is the duration of action
-how will I know if my patient develops hypoglycemia?
-Is my patient NPO? what do i do when insulin is scheduled and they can not eat?
-what nursing interventions should be done if hypoglycemia develops
What is the most important thing we can do for patients on insulin?
Teach them
For a newly diagnosed client we
should observe them perform a self-administration
What is crucial
TIMINING
Understanding when it was administered, when it will take effect, and when yo would see adverse reaction
Hypoglycemia
Blood sugar less than 70
can have symptoms even if blood sugar is greater than 70, especially if uncontrolled diabetic
Hypoglycemia: Treatment
- FSBS
- the “Rule of 15” (if conscious and able to swallow)
- FSBS in 15 minutes; then eat regular meal
- If still less than 70, when glucose stable give additional food
S/S of Hypoglycemia
-Sweating
-Blurry vision
-Dizziness
-Anxiety
-Hunger
-Irritability
-Shakiness
-Fast heart beat
-Headache
-Weakness
If patient is unconscious / unable to swallow
IM glucagon
IV D50 (25-50ml)
Rule of 15
Only if conscious and able to swallow
-15g simple CHO (4 oz juice, regular soda, 3 glucose tablets)
-Avoid sugars w/ fat (delays absorpation) (Candy bar)
-15 gms of CHO BS 50 mg/dL
Hyperglycemia: Causes
Illness, infection, self managment issues, stress
Hyperglycemia: Manifestation
Weakness, fatigue, blurry vision, headache, NVD
Hyperglycemia: Treatment
-Check for ketones in urine
-Insulin
-Drink fluids, prevent dehydration
-Education
Hyperglycemia: Crisis situations
-Diabetic Ketoacidosis (DKA)
-Hyperglycemic Hyperosmolar Syndrome (HHS)
Life threating conditions related to uncontrolled hyperglycemia
Very high glucose can
cause electrolyte abnormalities that can lead to death
Insulin Pump
-Continuous release of subcutaneous insulin infusion. Use rapid acting insulin
-Can be increased/decreased or receive a bolus based on finger stick blood glucose
Insulin Pump: Patients are required to check how many times per day?
- Can use a CGM in conjunction with the insulin pump
Insulin Pump: In hospital
Usually deactivate and switched to a sliding scale regimen
Insulin Pump: Problems
-Infection at insertion site
-Increased risk of DKA if pump malfunctions
-Cost
Macrovascular
-Damage to large vessels:
Coronary arteries. Peripheral vascular. Cerebral vascular
Microvascular
damage to capillaries
retinopathies
nephropathies
neuropathies
Macrovascular Disease: Risk
Women have 4-6x greater risk of CVD
Men have 2-3x risk of CVD
Macrovascular disease: teaching points
-education
-stop smoking, control blood pressure, modify high fat diet
Nursing Consideration Neuropathy
Highest risk = Lower extremities and feet. (Foot ulcerations and lower extremity amputations common complications
Lost of protective sensation (LOPS)
Diabetic Foot Care
Know the 13 steps
Nutritional Considerations for Diabetes
Eat a balanced high fiber, low fat, low cholesterol diet
Carbs = 45-65% of total daily caloric intake. (Limit simple carbs)
Fats = low saturated and trans fat. (polyunsaturated is best = fish)
Fiber = Promote finer intake (Can improve metabolism and lower cholesterol)
Protein = Promote intake from meats, eggs, fish, nuts and beans. (15-20% total intake)
Alcohol: Limit to 1 or 2 drinks
Exercise
-Important encourage because it can lower blood sugar. Do not exercise if glucose levels are less than 80 or higher than 250 (Best to exercise after meals)
-Wear medical alert bracelet
-Proper footwear
-If more than 1 hour has passed since eating and high-intensity exercise planned teach to EAT a carbohydrate snack prior
Nursing Considerations for Hospitalized Diabetic Patient
-Stress/surgery can increase blood glucose levels. Controlled can become uncontrolled in the hospital
-Wound healing is impaired in patients with diabetes
-HIGH risk of infection
Diabetes Integumentary Concerns: Diabetic Dermopathy
-reddish-brown spots, usually on shins
Diabetes Integumentary Concerns: Acanthosis nigricans
Brown/black thickening of skin, often seen in folds
Diabetes Integumentary Concerns: Necrobiosis lipodicia diabeticorum
Red patches around blood vessels
