Ch. 59 Concepts of Care for Patients w/ DM Flashcards
Diabetes Mellitus (DM)
Common, chronic, complex disorder of impaired nutrient metabolism
Describes diseases of abnormal carbohydrate metabolism with a characteristic of hyperglycemia
Classification of Diabetes
Underlying problem causing a lack of insulin
Action and the severity of insulin deficiency
Type 1 DM
Insulin production is absent d/t autoimmune pancreatic beta-cell destruction
Abrupt onset, thirst, hunger, increased urine output, wt loss
Usually <30 yr old
All dependent on insulin
Type 1 DM Causes
Susceptible genes
Autoantigens
Environmental factors
Viruses - coxsackievirus, rubella, cytomegalovirus, EPV
Diet - early exposure to cow’s milk, high nitrates in water, low vitamin D
Type 1 DM Clinical Manifestations
Polyuria
Polyphagia
Polydipsia
Wt loss
Fatigue
Increased frequency of infections
Type 2 DM
Insulin resistance and decreased insulin secretion
Inability to suppress hepatic glucose production
Impaired glucose uptake
Type 2 DM Causes
Some beta cell dysfunction
Genetics
Ethnic groups - American Indians, Hispanics, Asians
What causes insulin resistance?
Develops from obesity and physical inactivity in a genetically susceptible adult
Type 2 DM is characterized by what?
Hyperglycemia d/t progressive loss of insulin secretion in beta cells > causes insulin resistance and insulin deficiency
Type 2 DM Clinical Manifestations
Polyuria
Nocturia
Polydipsia
Polyphagia
Recurrent infections
Prolonged wound healing
Visual changes
Fatigue
Decreased energy
Metabolic Syndrome
Simultaneous presence of metabolic factors that increase risk for developing type 2 DM and CVD
Metabolic Syndrome Characteristics
Abdominal obesity - waist circumference greater then or equal to 40in (men); greater then or equal to 35in (female)
Hyperglycemia
Hypertension
Hyperlipidemia
HDL < 40 (male); <50 (female)
Absence of Insulin
Lack of production or a problem with insulin use at cell receptors
Causes glucose to build up on the blood, causing hyperglycemia
What is required for glucose regulation?
Insulin to move glucose into many tissues
Basal Insulin Secretion
Low-level secretion during fasting
Prandial
Two-phase release after eating
An early burst of insulin secretion occurs within 10 minutes of eating, followed by an increasing release that lasts until BG levels return to normal
Classic Symptoms of DM
Polyuria
Polydipsia
Polyphagia (cells are starving)
Blurred vision
Weight loss
Acute Complications of Diabetes
Diabetic ketoacidosis (DKA)
Hyperglycemic-hyperosmolar state
Hypoglycemia
All 3 require emergent treatment and can be fatal if treatment is delayed or incorrect
Chronic Complications of Diabetes
Macrovascular - large blood vessels
Microvascular - small blood vessels
Develop from chronic hyperglycemia
Macrovascular Complication - Cardiovascular Disease (CVD)
CVD risk factors
Treatment is aggressive management of: HTN, hyperglycemia, hyperlipidemia
Priority - reduce modifiable risk factors by lifestyle modifications
CVD Risk Factors
Macrovascular Complication - Cerebrovascular Disease
Risk for stroke 2-4x higher in adults w/ DM
Increases likelihood of severe carotid atherosclerosis
Macrovascular Complication - Cerebrovascular Disease Additional Risk Factors
HTN
Hyperlipidemia
Nephropathy
Peripheral vascular disease
Alcohol
Tobacco
Macrovascular Complication - Reduced Immunity
Combination of vascular changes and hyperglycemia by reducing WBC activity, inhibiting gas exchange in tissues, and promoting growth of microbes
WBCs do not like to swim around in a sugary environment
Microvascular Complication - Eye & Vision
Blindness is 25x more common
Diabetic retinopathy r/t duration of diabetes
R/t blocked retinal blood vessels and cause them to leak, leading to retinal hypoxia
Proliferative Diabetic Retinopathy
Growth of new retinal blood vessels which are thin, fragile, and bleed easily leading to vision loss
Microvascular Complication - Diabetic Peripheral Neuropathy
Progressive deterioration of nerve function = muscle weakness, damage to nerve fibers
Damage causes pain at first, which is followed by loss of sensation
Onset slow
Microvascular Complication - Diabetic Autonomic Neuropathy
Due to failure of heart and arteries to respond to position changes by increasing HR and vascular tone
CAN, orthostatic hypotension, syncope
Can affect entire GI system (gastroparesis, neurogenic bladder, defective balancing hormones)
Microvascular Complication - Diabetic Nephropathy
Causes progressive albumin excretion and declining GFR
Changes in kidney = reduced function = kidney failure
Leading cause of ESRD = diabetic-kidney disease
Diabetic Nephropathy Risk Factors
10-15 yr history of DM
Poor blood glucose control
Uncontrolled HTN
Genetic predisposition
Microvascular Complication - Sexual Dysfunction
Due to damage to both nerve tissue and vascular tissue
Affects M & F
Made worse by poorly controlled BG levels
Other risk factors: obesity, HTM, tobacco use, some prescribed drugs
Microvascular Complication - Cognitive Dysfunction
Due to neuron damage, brain atrophy, cognitive impairment
DM increases risk for developing all types of dementia
Increases complications of neuropathy and retinopathy
Indications for Testing People for Type 2 Diabetes
BMI > 25
First-degree relative w/ DM
Physically inactive
High-risk ethnic population
Gave birth to baby weighing > 9 or had gestational diabetes
Hypertensive
A1C > 5.7%
Criteria for Diagnosis of Diabetes
A1C >6.5%
Fasting BG > or = to 126
Normal Blood Glucose Values
Fasting BG < 100 mg/dL
Glycosylated hemoglobin (A1C) 4%-6%
A1C Levels
Q6Months or quarterly
5.7%-6.4% prediabetes
> 6.5% diabetes
> 8% poorly controlled diabetes
Preventing Injury From Hyperglycemia
Maintaining BG levels in optimal target range
A1C maintained < or = to 7.0%
Majority of premeal BG levels 70-130
Peak after meal BG <180
Drug Therapy for Diabetes
Indicated for type 2
Type 1 requires insulin therapy
Insulin therapy indicated for type 2 when BG levels cannot be met
What is the most important thing to teach the patient on drug therapy with DM?
Antidiabetic drugs are not a substitute for dietary modification and exercise
Sulfonylureas (SU)
Insulin Stimulator
Glyburide; Glipizide
Used for patients who are still able to produce insulin
Sulfonylureas (SU) MOA
Stimulate insulin release from pancreatic beta cells
Sulfonylureas (SU) Pt Teaching
S/S of hypoglycemia
Take w/ or just before meals to prevent hypoglycemia
Report to provider any OTC or supplement use
Metformin
1 drug for type 2 DM
Biguanides
Metformin MOA
Lower BG by inhibiting liver glucose production, decreasing intestinal absorption of glucose, and increasing insulin sensitivity
Metformin Pt Teaching
Do not drink alcohol
Must be stopped before using contrast agents and not started again for 48 hr after testing d/t increased risk for kidney damage and lactic acidosis
Administer with meals to minimize GI effects
May cause hypoglycemia if combined w/ a sulfonylurea
Thiazolidinediones (TZDs or “glitazones”)
Insulin Sensitizers
Pioglitazone
Black-box warning (risk of HF)
Thiazolidinediones MOA
Increase cellular use of glucose, which lowers BG levels
Thiazolidinediones Pt Teaching
Weigh daily (report >2 lbs in one day or 4 lbs in one wk)
Report vision changes immediately
Weight gain and peripheral edema are common side effects
Dulaglutide
Incretin Mimetics (GLP-1 Agonists)
Can cause hypoglycemia when used with insulin, sulfonylureas, or meglitinides
Dulaglutide MOA
Reduces liver glucose production, and delaying gastric emptying
Dulaglutide Pt Teaching
S/S of hypoglycemia
How to inject themselves, only available as SQ injection
Read pens carefully as some extended-release form is only injected WEEKLY
Report persistent abdominal pain and nausea
Alogliptin
Dipeptidyl peptidase-4 (DPP-4) inhibitors
Alogliptin MOA
Breaks down natural gut hormones (GLP-1 and GIP)
Reduce BG levels by delaying gastric emptying
Works w/ body’s insulin
Alogliptin Pt Teaching
S/S of hypoglycemia
Report a rash or other signs of allergic reaction
Report persistent abdominal pain
Notify HCP if SOB, dyspnea on exertion, cough especially when lying down
Canagliflozin
Sodium-glucose cotransparent inhibitors (SGLT2)
Canagliflozin MOA
Glucose is excreted in urine rather than moved back into the blood
High risk of UTI & yeast infection
Canagliflozin Pt Teaching
S/S of hypoglycemia
S/S of dehydration
S/S of hyponatremia
S/S of UTI
S/S of genital yeast infection
Report any swelling, tenderness or redness of genitals or perineal skin
Insulin Therapy
Used for type 1 & 2
Prandial - where pancreas produces additional mealtime insulin to prevent BG elevations after meals
Post-prandial - first 4 hr after eating or drinking, BG begins to rise within a few min after eating
Insulin Therapy Pt Teaching
Insulin types
Injection technique
Site of injection can affect absorption, onset, degree, and duration of insulin activity
Rapid Acting Insulin
Lispro (Humalog)
Short Acting Insulin
Regular (Humulin R)
Intermediate Acting Insulin
NPH (Humulin N)
Long-Acting Insulin
Glargine (Lantus)
Lispro (Humalog)
Onset: 5-30 min
Peak: 30-90 min
Duration: 3-5 hr
Regular (Humulin R)
Onset: 30-60 min
Peak: 2-4 hr
Duration: 5-7 hr
NPH (Humulin N)
Onset: 1-2 hr
Peak: 4-12 hr
Duration: 18-24 hr
Glargine (Lantus)
Onset: 3-4 hr
Peak: none
Duration: 24 hr +
Insulin Absorption
Injection site
Rotation within one anatomic site is preferred
Heat, massaging the area, exercising injected area increases insulin absorption
Scarred areas slow insulin absorption
Injection Timing
Affects BG levels
Rapid onset - give within 10 min before mealtime
Regular insulin - give 20-30 min prior to mealtime
Insulin Storage
Refrigerate (no longer than 28 days)
Prevent exposure to sunlight
May be kept at room temp up to 28 days
Avoid excessive shaking
Do not freeze
Discard after 28 days
Pt Teaching: BG Monitoring
Teach to assess BG frequently for:
S/S of hypo or hyperglycemia
Hypoglycemic unawareness
Periods of illness
Before and after exercise
Gastroparesis
Adjustment of anti diabetic drugs
Pregnancy
Pt Education: Nutrition Therapy
Registered dietitian nutritionist (RDN)
Diabetic educator
Consider cultural background, financial status, lifestyle
Carbohydrate intake
Dietary fat and cholesterol
Alcohol consumption
Pt Education: Exercise Therapy
Improves glycemic control
Decreases mortality and improves A1C
Exercise a minimum of 50 min, 3 times/wk
Can cause hypoglycemia in Type 1 (monitor BG before and after)
What is the best exercise type for people with diabetes?
Swimming
Swimming With Diabetes
Gentle on feet and joints
Excellent cardiovascular exercise
Improves BG control
Swimming Precautions w/ Diabetes
Avoid if any wounds are present
Never walk barefoot around the deck, locker room, or shower
Hydrate well
Stress Hyperglycemia
May occur during severe illness in adults without DM
Caused by a combination of factors:
Increased serum cortisol, catecholamines, glucagon, GH
Leads to increased gluconeogenesis and glycogenolysis, and insulin resistance
Associated with poor outcomes
BG Control in Hospitalized Patients
Hyperglycemia develops when withholding oral anti diabetics and when giving corticosteroids and changes in nutrition
Maintain BG between 140-180 for critically ill
Pre-meal <140
Random BG <180
NPO Status
Give reduced dose of basal insulin
Pancreas Transplant Indications
Severe metabolic complications
Consistent failure of insulin-based therapy
ESKD who have had or plan to have a kidney transplant
Preventing Injury From Peripheral Neuropathy
Practice proper foot care
Identify factors that increase risk of injury
Maintain intact skin on feet
Peripheral Neuropathy
Motor - damages nerves of foot muscles
Autonomic - loss of normal sweating and skin temp regulation; dry, thinking skin; skin cracks and fissures
Sensory - tingling or burning; numbness and reduced sensory perception
Diabetic Foot Assessment
Dry, cracked, fissured skin
Ulcers
Toenails: thickened, long nails; ingrown
Symptoms of claudication
Pedal and tibial pulse reduced
Cap refill
Presence or absence of hair growth on top of foot
Calluses, corns
Clawed toes, hammertoes, bunions
Limited ROM
Foot Care Instructions/Education
Inspect feet daily
Wash daily in lukewarm water, mild soap, dry thoroughly especially btw toes
Apply fragrance free moisturizer top and bottom; avoid btw toes
Clean cotton socks daily
Breathable shoes
Trim nails straight across, smooth w/ emery board
Teach family how to inspect and provide foot care
Foot Care “DO NOT” List
Do not treat blisters, sores, or infections at home
Do not smoke or use nicotine
Do not step into bathtub w/out checking temp of water w/ wrist or thermometer
Do not use very hot or cold water or warm devices on feet
Do not treat corns, blisters, bunions, calluses, or ingrown toenails yourself
Do not go barefooted
Do not wear sandals w/ open toes or straps btw toes
Do not cross legs or tight stockings that constrict blood flow
Do not soak feet
Reducing the Risk for Kidney Disease
BG control
ACE or ARB (BP in range)
Annual kidney function evaluation
Cholesterol management
Avoid nephrotoxic agents
Smoking cessation
Preventing Complications From Hypoglycemia
Causes specific symptoms and resolves when BG concentration increases
Avoid levels <70 and never higher than 200
Apply 15-15 rule
Hypoglycemia Clinical Manifestations
Cool, clammy, sweaty
Anxious, nervous
Irritable, confusion
Seizure, coma
Weakness, double or blurred vision
Hunger
Tachycardia
Palpitations
Hyperglycemia Clinical Manifestations
Warm, dry, vasodilated skin
S/S of dehydration
Rapid, deep respirations
Rotten fruity breath
Abdominal cramps
N/V
BG >250
TIRED
For hypoglycemia
T = tachycardia
I = irritable
R= restless
E = excessive hunger
D = diaphoresis, depression
15-15 Rule
BG <70 or s/s of hypoglycemia
Give 15 g of carbs
Recheck BG in 15 min
(still low = give 15 g of carb)
Avoid giving high potassium options such as orange juice
Dysphagia = IV dose of concentrated dextrose or SQ glucagon
High Potassium Foods
Prunes and prune juice
Oranges and orange juice
Milk
Low-sodium cheese
Nuts
Beef
Chicken
Bananas
Raisins
Potatoes
15g Carbohydrate Options
Glucose tablets or glucose gel
Half cup (120 mL; 4 oz) fruit juice or regular soft drink
8 ounces (240 mL) skim milk
6-10 hard candies
4 cubes of sugar or 4 tsp of sugar
6 saltines
3 graham crackers
1 tbsp (15 mL) honey or syrup
Survival Skills For Diabetics
Pathophysiology
Prepare and inject insulin
How to take anti diabetics
Recognition, treatment, and prevention of hypo or hyper glycemia
Basic diet information
How to monitor BG and urine ketones
Teach sick day management rules
Where to buy diabetic supplies
When and how to follow-up with HCP
Dawn Phenomenon
Abnormal early-morning hyperglycemia
Do not skip breakfast
Dawn Phenomenon Management
Additional insulin at 10 pm instead of evening meal
Avoid carbs before bedtime
Increase evening exercise
Increase protein intake
Somogyi Phenomenon
Begins as hypoglycemic episode overnight
Body has a hormonal response that causes hyperglycemia
Somogyi Phenomenon Causes
Excess insulin
Inadequate calorie intake w/ insulin therapy
Diagnosing Dawn/Somogyi Phenomenon
Check BG around 2-3 am for several nights in a row
DKA
Most common precipitating factor is infection
DKA S/S
Dehydration w/ electrolyte loss
The 3 P’s
Rotting citrus fruit odor to breath
Vomiting, abdominal pain, dehydration, weakness, confusion, shock, coma
Kussmaul respirations
Interventions for Preventing DKA
BG management
Fluid and electrolyte management
Drug therapy - regular insulin IV continuous and then switch to SQ
Sick Day Rules
Monitor BG at least Q4H
Test urine for ketones when BG level >240
Continue to take insulin unless instructed not to
Drink 8-12 oz of sugar-free liquids every hour
Continue to eat meals
Unable to tolerate solid food d/t nausea, consume more easily tolerated foods or liquids equal to carb content of usual meal
Sick Day Rules: When to call HCP
Persistent N/V
Moderate or high ketones
BG elevation after 2 supplemental doses of insulin
High temp or increasing fever; fever more than 24 hr (101.5)
Hyperglycemic-Hyperosmolar State (HHS)
Develops only in pt who still receive insulin
Caused by sustained osmotic diuresis leading to extremely high BG levels
Differs from DKA - absent or low ketone levels and BG levels higher (600)
HHS Interventions
Fluid replacement - restore blood volume; NS used if shock or sever hypotension, if not then half NS
Assess hourly for signs of cerebral edema (AMS, N/V, HA, lethargy)
