Care of the Diabetic Patient (Exam 2) Med Surg (Exam 3) Flashcards
Type 1 Diabetes
Genetic Predisposition + Environmental Factors
Autoimmune destruction of insulin-producing beta cells and circulate in the bloodstream and lymphatics
Type 2 Diabetes
-More common in adults (with risk factors)
-Can go undiagnosed for years
-Insulin resistant (body can not respond correctly)
Type 2 diabetes treatment is often started with
Oral medication and progress to insulin replacement of needed
Type 2 diabetes can go undiagnosed for years
Doctors often just screen on risk factors, not signs/symptoms
Type 1 diabetes (facts)
-More common in younger people
-Normally more abrupt (happen suddenly)
-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
-Polydispia
-Polyphagia
-Polyuria
-Fatigue
-Recurrent Infections
-Slow Wound Healing
Risk factors for Type 2 diabetes (modifiable)
-Physical activity
-High body fat
-HTN
-High cholesterol
Risk factors for Type 2 diabetes (non-modifiable)
-History of gestational diabetes (while pregnant)
-Race (aa-hispanic)
-Over 45
-Family history
Labs involved in diabetes
-FBG
-CBG
-Urine Ketones
-Lipid profile
-OGTT
-Glycosylated hemoglobin (HbA1C)
Fasting Blood Glucose (diabetes)
No food or drink for 8 hours
Normal< 126 mg/dL
casual blood glucose
Normal < 200 mgdL
Urine Ketones
High ketones associated with hyperglycemia
Urine ketones over what number is considered medical emergency?
> 300 md/dL is considered a medical emergency
Lipid profile
HDL, LDL, tri’s
HDL-LDL-Triglycired, how do these present in diabetes?
HDL = Lower
LDL = High
Tri = High
Oral Glucose Tolerance Test
-commonly used for gestational diabetes (Not 1 or 2)
-Fasting glucose drawn prior, client consumes oral glucose, then glucose levels obtained every 30 min until 2 hours post consumption
-Fasting should be less than 110. at 1 hours less than 180. at 2 hour less than 140
Glycosylated Hemoglobin (HbA1C)
-Indicator for average glucose level over the past 120 days (3 months)
-For diagnosis and to evaluate effectiveness of interventions
Normal A1C
-Normal is 4-6%
What A1C is considered diabetes?
-Greater than 6.5% is considered diabetic
-Acceptable reference range for those with diagnosed diabetes is 6-8 with a target of 7
Pre-diabetes range
A1C
FBG
OGTT
A1C = 5.7-6.4
FBG = 100-125
OGTT = 140-199
Diabetes: 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
- Classic symptoms of hyperglycemia, random glucose greater than 200 mg/dL, or hyperglycemia crisis
-With criteria 1-3, would do a repeat lab test before official diagnosis. (try interventions for 3 months)
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 (avoid sugar / count carbs)
DM: Oral Medications are started at a low dose and increased base on?
A1C levels and FBG levels. (More frequent in type 2)
When a diabetic patient comes into the hospital what is usually done?
-Often in hospitalized patients oral medications are stopped and put on insulin while acutely ill. (Able to maintain tight glucose control while on insulin)
What diabetes drug should be help before procedures?
Metformin
What do we do with patients when they have diabetes and are sick?
-Patient Usually Started Steroids (oral/IV) make your blood sugar RISE. (May need to alter insulin regimen 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.
When a diabetic patient is sick to their stomach, do they still take their medicaitons?
Yes, they still need to take their oral medications if possible
WIth being sick the patient with diabetes is at greater risk of?
Going into DKA
What do we do when a patient with DM is sick: Teaching points (6)
-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
-Confused
-Persistent NVD
-Inability to tolerate liquids
-Illness lasting longer than 2 days
(This is not for the Nurse to call the provider but for the patient at home)
What is a critical part of diabetes managment for the patient?
Monitoring Blood Glucose
Continuous Glucose Monitoring is more common
people with Type 1 diabetes
(reads every 1-5 min)
Insulin pump or injection medication response
Nursing Management of Insulin
-Do our best to mimic the bodies normal insulin production (insulin spike with meals)
-Combine Basal (long) insulin with meal time insulin (Bolus) (BASAL BOLUS Regimen)
-Uses rapid and short acting (bolus) insulin before meals
-Use a background insulin once a day
Is bolus insulin rapid or long acting? when is it givin?
Bolus is rapid insulin given right before meals
When is basal insulin given?
In the morning or at night for 24 hr coverage
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: 15 min
Peak: 1 hour
Duration: 2-4 hr
Short acting (Regular)
Onset
Peak
Duration
Onset: 30 min-1 hr
Peak: 2-6 hr
Duration: 3-8 hr
Intermediate acting (NPH)
Onset
Peak
Duration
Onset: 2-4hr
Peak: 4-10 hr
Duration: 10-20 hr
Long Lasting (glargine, determir, degludec)
Onset
Peak
Duration
Onset: 70 min
Peak: less defined or no peak
Duration: 24 hr
Insulin is High Alert medication: What should we know?
-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 with insulin?
TIMINING
Understanding when it was administered, when it will take effect, and when yo would see adverse reaction
Hypoglycemia range
Blood sugar less than 70
can have symptoms even if blood sugar is greater than 70, especially if uncontrolled diabetic
Hypoglycemia Manifestation
Sweating
Blurry Vision
Dizziness
Hunger
Anxiety
Irritability
Shakiness
Tachycardia
Weakness
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
If patient is unconscious / unable to swallow.. How do we treat hypoglycemia?
IM glucagon
IV D50 (25-50ml)
Rule of 15
Only if conscious and able to swallow
-15g simple CHO (4 - 6 oz juice, regular soda, 3 glucose tablets, honey, lifesavers)
-Avoid sugars w/ fat (delays absorption) (Candy bar)
-15 grams should increase blood sugar by 50 mg/dL
-If still <70 repeat
-When glucose is stable give additional food
Hyperglycemia: Causes
Illness
Infection
Self management issues
Stress
Hyperglycemia: Manifestation
-Weakness
-Fatigue
-Blurry vision
-Headache
-NVD
Hyperglycemia: Treatment
-Check for ketones in urine (>300 emergency)
-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. (Basal infusion)
-Can give bolus based on FSBG
-Can be increased/decreased or receive a bolus based on finger stick blood glucose
What insulin is used in insulin pump?
Rapid acting insulin
Insulin Pump: Patients are required to check how many times per day?
4
Can use a CGM in conjunction with the insulin pump to constantly keep eye on sugar
Insulin Pump: In hospital
Usually deactivate and switched to a sliding scale regimen (tighter control)
Insulin Pump: Nursing Related Problems
-Infection at insertion site
-Increased risk of DKA if pump malfunctions
-Cost
-Can not swim or take a bath (unless taken off)
Diabetes: Macrovascular Issues
-Damage to large vessels:
Coronary arteries
Peripheral vascular
Cerebral vascular
Diabetes: Microvascular Issues
damage to capillaries
retinopathies
nephropathies
neuropathies
Macrovascular Disease: Risk Factors
Women have 4-6x greater risk of CVD
Men have 2-3x risk of CVD
Macrovascular disease: Nurse Teaching Points
Teach how to prevent
-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 Retinopathy Teaching
Frequent Eye Exams
Diabetic Nephropathy Teaching
Treat HTN as well– DM+HTN = much more likely to have CKD
Diabetic Foot Care: 13 Steps
- Wash feet daily with mild soap and warm water
- Pat feet dry (between toes)
- Inspect feet daily for injury
- Use lanolin to prevent dry skin and cracking
- Mild foot powder on sweaty feet
- Do not use commercial remedies to remove calluses or corns
- Clean cuts with WATER AND SOAP (no iodine-alcohol-adhesives)
- Report skin infection or non-healing sores
- Trim nails after shower or bath and cut evenly with rounded contours
- Separate overlapping toes with coton
- Do not go barefoot and shake shoes before wearing
- Clean absorbent socks
- NO HOT WATER BOTTLES
Nutritional Considerations for Diabetes
Eat a balanced high fiber, low fat, low cholesterol diet
Carbs = 50% of total daily caloric intake. (Limit simple carbs)
Fats = low saturated and trans fat. (polyunsaturated is best = fish-nuts)
Fiber = Promote fiber intake (Can improve metabolism and lower cholesterol)
Protein = Promote intake from meats, eggs, fish, nuts and beans. (20% total intake)
Alcohol: Limit to 1 (women) or 2 drinks (men)
Exercise
-Important encourage because it can lower blood sugar
-Wear medical alert bracelet
-Proper footwear
Exercise: If more than 1 hour has passed since eating and high intensity exercise is planned…
Teach to EAT a carbohydrate snack beforehand
Do not exercise if glucose levels are
Less than 80
Higher than 250
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 lipoidica diabeticorum
Red patches around blood vessels
