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N324 > Ch. 59 Concepts of Care for Patients w/ DM > Flashcards

Ch. 59 Concepts of Care for Patients w/ DM Flashcards

1
Q

Diabetes Mellitus (DM)

A

Common, chronic, complex disorder of impaired nutrient metabolism

Describes diseases of abnormal carbohydrate metabolism with a characteristic of hyperglycemia

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2
Q

Classification of Diabetes

A

Underlying problem causing a lack of insulin

Action and the severity of insulin deficiency

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3
Q

Type 1 DM

A

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

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4
Q

Type 1 DM Causes

A

Susceptible genes

Autoantigens

Environmental factors

Viruses - coxsackievirus, rubella, cytomegalovirus, EPV

Diet - early exposure to cow’s milk, high nitrates in water, low vitamin D

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5
Q

Type 1 DM Clinical Manifestations

A

Polyuria
Polyphagia
Polydipsia
Wt loss
Fatigue
Increased frequency of infections

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6
Q

Type 2 DM

A

Insulin resistance and decreased insulin secretion

Inability to suppress hepatic glucose production

Impaired glucose uptake

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7
Q

Type 2 DM Causes

A

Some beta cell dysfunction
Genetics
Ethnic groups - American Indians, Hispanics, Asians

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8
Q

What causes insulin resistance?

A

Develops from obesity and physical inactivity in a genetically susceptible adult

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9
Q

Type 2 DM is characterized by what?

A

Hyperglycemia d/t progressive loss of insulin secretion in beta cells > causes insulin resistance and insulin deficiency

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10
Q

Type 2 DM Clinical Manifestations

A

Polyuria
Nocturia
Polydipsia
Polyphagia
Recurrent infections
Prolonged wound healing
Visual changes
Fatigue
Decreased energy

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11
Q

Metabolic Syndrome

A

Simultaneous presence of metabolic factors that increase risk for developing type 2 DM and CVD

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12
Q

Metabolic Syndrome Characteristics

A

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)

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13
Q

Absence of Insulin

A

Lack of production or a problem with insulin use at cell receptors

Causes glucose to build up on the blood, causing hyperglycemia

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14
Q

What is required for glucose regulation?

A

Insulin to move glucose into many tissues

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15
Q

Basal Insulin Secretion

A

Low-level secretion during fasting

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16
Q

Prandial

A

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

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17
Q

Classic Symptoms of DM

A

Polyuria
Polydipsia
Polyphagia (cells are starving)
Blurred vision
Weight loss

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18
Q

Acute Complications of Diabetes

A

Diabetic ketoacidosis (DKA)
Hyperglycemic-hyperosmolar state
Hypoglycemia

All 3 require emergent treatment and can be fatal if treatment is delayed or incorrect

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19
Q

Chronic Complications of Diabetes

A

Macrovascular - large blood vessels

Microvascular - small blood vessels

Develop from chronic hyperglycemia

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20
Q

Macrovascular Complication - Cardiovascular Disease (CVD)

A

CVD risk factors

Treatment is aggressive management of: HTN, hyperglycemia, hyperlipidemia

Priority - reduce modifiable risk factors by lifestyle modifications

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21
Q

CVD Risk Factors

A
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22
Q

Macrovascular Complication - Cerebrovascular Disease

A

Risk for stroke 2-4x higher in adults w/ DM

Increases likelihood of severe carotid atherosclerosis

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23
Q

Macrovascular Complication - Cerebrovascular Disease Additional Risk Factors

A

HTN
Hyperlipidemia
Nephropathy
Peripheral vascular disease
Alcohol
Tobacco

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24
Q

Macrovascular Complication - Reduced Immunity

A

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

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25
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
26
Proliferative Diabetic Retinopathy
Growth of new retinal blood vessels which are thin, fragile, and bleed easily leading to vision loss
27
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
28
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)
29
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
30
Diabetic Nephropathy Risk Factors
10-15 yr history of DM Poor blood glucose control Uncontrolled HTN Genetic predisposition
31
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
32
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
33
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%
34
Criteria for Diagnosis of Diabetes
A1C >6.5% Fasting BG > or = to 126
35
Normal Blood Glucose Values
Fasting BG < 100 mg/dL Glycosylated hemoglobin (A1C) 4%-6%
36
A1C Levels
Q6Months or quarterly 5.7%-6.4% prediabetes >6.5% diabetes >8% poorly controlled diabetes
37
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
38
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
39
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
40
Sulfonylureas (SU)
Insulin Stimulator Glyburide; Glipizide Used for patients who are still able to produce insulin
41
Sulfonylureas (SU) MOA
Stimulate insulin release from pancreatic beta cells
42
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
43
Metformin
Biguanides #1 drug for type 2 DM
44
Metformin MOA
Lower BG by inhibiting liver glucose production, decreasing intestinal absorption of glucose, and increasing insulin sensitivity
45
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
46
Thiazolidinediones (TZDs or "glitazones")
Insulin Sensitizers Pioglitazone Black-box warning (risk of HF)
47
Thiazolidinediones MOA
Increase cellular use of glucose, which lowers BG levels
48
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
49
Dulaglutide
Incretin Mimetics (GLP-1 Agonists) Can cause hypoglycemia when used with insulin, sulfonylureas, or meglitinides
50
Dulaglutide MOA
Reduces liver glucose production, and delaying gastric emptying
51
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
52
Alogliptin
Dipeptidyl peptidase-4 (DPP-4) inhibitors
53
Alogliptin MOA
Breaks down natural gut hormones (GLP-1 and GIP) Reduce BG levels by delaying gastric emptying Works w/ body's insulin
54
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
55
Canagliflozin
Sodium-glucose cotransparent inhibitors (SGLT2)
56
Canagliflozin MOA
Glucose is excreted in urine rather than moved back into the blood High risk of UTI & yeast infection
57
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
58
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
59
Insulin Therapy Pt Teaching
Insulin types Injection technique Site of injection can affect absorption, onset, degree, and duration of insulin activity
60
Rapid Acting Insulin
Lispro (Humalog)
61
Short Acting Insulin
Regular (Humulin R)
62
Intermediate Acting Insulin
NPH (Humulin N)
63
Long-Acting Insulin
Glargine (Lantus)
64
Lispro (Humalog)
Onset: 5-30 min Peak: 30-90 min Duration: 3-5 hr
65
Regular (Humulin R)
Onset: 30-60 min Peak: 2-4 hr Duration: 5-7 hr
66
NPH (Humulin N)
Onset: 1-2 hr Peak: 4-12 hr Duration: 18-24 hr
67
Glargine (Lantus)
Onset: 3-4 hr Peak: none Duration: 24 hr +
68
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
69
Injection Timing
Affects BG levels Rapid onset - give within 10 min before mealtime Regular insulin - give 20-30 min prior to mealtime
70
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
71
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
72
Pt Education: Nutrition Therapy
Registered dietitian nutritionist (RDN) Diabetic educator Consider cultural background, financial status, lifestyle Carbohydrate intake Dietary fat and cholesterol Alcohol consumption
73
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)
74
What is the best exercise type for people with diabetes?
Swimming
75
Swimming With Diabetes
Gentle on feet and joints Excellent cardiovascular exercise Improves BG control
76
Swimming Precautions w/ Diabetes
Avoid if any wounds are present Never walk barefoot around the deck, locker room, or shower Hydrate well
77
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
78
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
79
NPO Status
Give reduced dose of basal insulin
80
Pancreas Transplant Indications
Severe metabolic complications Consistent failure of insulin-based therapy ESKD who have had or plan to have a kidney transplant
81
Preventing Injury From Peripheral Neuropathy
Practice proper foot care Identify factors that increase risk of injury Maintain intact skin on feet
82
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
83
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
84
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
85
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
86
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
87
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
88
Hypoglycemia Clinical Manifestations
Cool, clammy, sweaty Anxious, nervous Irritable, confusion Seizure, coma Weakness, double or blurred vision Hunger Tachycardia Palpitations
89
Hyperglycemia Clinical Manifestations
Warm, dry, vasodilated skin S/S of dehydration Rapid, deep respirations Rotten fruity breath Abdominal cramps N/V BG >250
90
TIRED
For hypoglycemia T = tachycardia I = irritable R= restless E = excessive hunger D = diaphoresis, depression
91
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
92
High Potassium Foods
Prunes and prune juice Oranges and orange juice Milk Low-sodium cheese Nuts Beef Chicken Bananas Raisins Potatoes
93
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
94
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
95
Dawn Phenomenon
Abnormal early-morning hyperglycemia Do not skip breakfast
96
Dawn Phenomenon Management
Additional insulin at 10 pm instead of evening meal Avoid carbs before bedtime Increase evening exercise Increase protein intake
97
Somogyi Phenomenon
Begins as hypoglycemic episode overnight Body has a hormonal response that causes hyperglycemia
98
Somogyi Phenomenon Causes
Excess insulin Inadequate calorie intake w/ insulin therapy
99
Diagnosing Dawn/Somogyi Phenomenon
Check BG around 2-3 am for several nights in a row
100
DKA
Most common precipitating factor is infection
101
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
102
Interventions for Preventing DKA
BG management Fluid and electrolyte management Drug therapy - regular insulin IV continuous and then switch to SQ
103
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
104
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)
105
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)
106
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)

N324 (18 decks)

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