Chapter 44: care for patients with diabetes Flashcards
Diabetes mellitus is a group of disorders characterized by elevated blood glucose levels and results from defects in what?
insulin production, insulin action, or both.
what three sources does glucose arrive in the blood from?
carbs eaten, glucose released from stored glycogen in muscles and liver cells, glucose or gluconeogenesis newly created in the liver or in the kidney cells
where is glucose in the blood stream transported to?
target cells
insulin is released from where?
pancreatic beta cells
when there is a disruption in the production of insulin or in the effective action of insulin glucose cannot cross the cell membrane effectively and stays where?
glucose remains in the blood stream and blood glucose levels rise above normal
insulin facilitates the transport of what?
the transport of glucose across the cell membrane into the cell’s interior
what is glucose metabolized as in the cell?
fuel releasing energy
what happens when blood glucose levels get too high?
more insulin is secreted by the pancreas. when blood glucose is driven into the cell and metabolized the glucose levels in the blood fall.
what happens when blood glucose gets too low?
insulin release is suppressed and glucose will remain in the bloodstream instead of being pushed into the cells. glucagon is released from the pancreatic alpha cells and stimulates the production and release of glucose from glycogen storage in the liver.
what are the different groups of diabetes mellitus?
Prediabetes; type 1 and type 2. and gestational diabetes
what is type one diabetes triggered by?
an autoimmune process where insulin producing beta cells of the pancreas are destroyed
describe the disease process of type one diabetes in children and young adults
the process is usually rapid, with a total insulin deficiency occurring within one year. after this lifelong insulin injections are required
describe the disease processes of type one diabetes in an adult.
the autoimmune destruction of beta cells has a more variable, but generally slower time frame.
what are some clinical manifestations of type one diabetes
polydipsia, polyuria, polyphagia, fatigue, weight loss
what is the required level of FPG for type 1 or 2 diabetes?
greater than 126 mg/dl with 8 hour fast
what is the required level of OGTT for type 1 or 2 diabetes?
2 hour 75g OGTT greater than 300 mg/dl
what is the required level of random plasma glucose for type 1 or 2 diabetes?
greater than 200 mg/dl with classic symptoms of hyperglycemia or hyperglycemic crisis
what level of A1C is considered prediabetic?
5.7-6.4
what is the target fasting glucose level?
A goal of 70-130 mg/dl for an HgbA1c goal less than 7%. target blood glucose readings can be higher or lower depending on individualized HgbA1c goal
what is the target 2 hour postprandial level?
average 2 hour postprandial blood glucose value less than 180mg/dl.
what can a 2 hour post prandial reading be helpful for?
It is helpful for adjusting mealtime medications
lowering hgbA1c to below or around 7% has been shown to do what?
reduce microvascular and neurological complications of type 1 and type 2 diabetes.
modern insulin analog and pumps closely mimic what
the actions of a healthy pancreas
why are oral insulin administrations noneffective?
it is broken down and rendered ineffective during the digestive process
what two diets could you educate a patinet with diabetes on?
ADA and DASH
what type of exercise could you educate a diabetic patient about
150 minutes of aerobic exercises a week
how often should you check blood glucose levels?
ACHS (before meals and at bedtime)
what type of treatment plan is the most effective at maintaining tight glucose control?
treatment plans that mimic the response of the healthy pancreas to blood glucose levels during the course of a day
what is an alternative approach to insulin administration?
continuous subcutaneous insulin pump
how often should a patinet with well controlled diabetes have their HgbA1C checked?
at least twice a year
if glycemic target has not been met or if a patient is having treatment changes how often should HGBA1C be checked?
every 3 months
what could an increased serum BUN/creatinine level indicate?
decreased renal function associated with microvascular changes that develop in the kidneys due to sustained hyperglycemia
Decreased perfusion secondary to microvascular changes may manifest as what?
delayed capillary refill
Using the same site for insulin administration will result in what?
Insulin lipodystrophy due to buildup of scar tissue in the area. This results in resistance
who is type 2 diabetes more common in?
adults
what was type 2 diabetes once called?
adult onset diabetes
what are 2 risk factors for type 2 diabetes?
genetics and lifestyle
what is a warning sign for type 2 diabetes?
prediabetes
what BMI is considered underweight?
BMI is less than 18.5
what BMI is normal weight?
BMI is 18.5 to 24.9
what BMI is overweight?
BMI is 25 to 29.9
what BMI is obese?
30 or more
what level of HDL is considered a modifiable risk factor?
< or = 35 mg/dL
what level of triglycerides is considered a modifiable risk factor?
> or = 250 mg/dL
what are some high-risk ethnic populations for type 2 diabetes?
AA, Latino, Native american, asian american, pacific islander
what is a non-modifable risk factor dealing with mothers?
Women who delivered a baby weighing greater than or equal to 9 lbs or who were diagnosed with gestational diabetes
what level of hypertension is considered a non-modifiable risk factor?
greater than or equal to 140/90 mmHg or on therapy for hypertension
what level of hgbA1C is considered a non-modifiable risk factor?
greater than or equal to 5.7 on previous testing
what prevents the normal action of insulin?
defects at the cell membrane
insulin resistance develops which requires what
an increase in the levels of insulin to drive glucose into the cells
over time the pancreas cannot keep up with the increased demand for insulin and what happens?
beta cell failure
in late stages of type II DM insulin production greatly declines. 30% of patients will require what?
exogenous insulin delivery to maintain normal blood glucose levels
which has a slower onset of manifestations type I or II DM?
type II diabetes?
what are some examples of clinical manifestations of type II diabetes?
polydipsia, polyphagia, polyuria, fatigue, poor wound healing, and recurring infections
what are many of the manifestations of type II diabetes due to?
microvascular and microvascular complications of long-term hyperglycemia
what are some pharmacologic interventions for type II diabetes?
Oral medications that increase insulin production, lower insulin resistance, and slow the absorption of carbohydrates or medications that help with lower blood glucose
which type of insulin has an onset of 1-2 hours?
long acting
which type of insulin has an onset of 15 minutes
rapid acting
what type of insulin has an onset of 2-5 hours
intermediate acting
what type of insulin has an onset of 30-60 minutes
short acting
what are examples of rapid acting insulin
Humalog and novalog
what are examples of short acting insulins
regular-humulin and novolin
what is an intermediate acting insulin
NPH
what are examples of long acting insulins
Lantus and levemir
which type of insulin has no peak or valley
long acting
what insulin peaks within 2-3 hours
short acting
what type of insulin peaks within 4-10 hours
intermediate acting
what type of insulin peaks within 60-90 minutes?
rapid acting
which type of insulin has a duration of 10-16 hours
intermediate acting
which type of insulin has a duration of 3-4 hours
rapid acting
which type of insulin has a duration of 18-24 hours
long acting
which type of insulin has a duration of 3-6 hours
short acting
what type of insulin is a basal insulin
long acting
what type of insulin is used for meals eaten within 30-60 minutes after admin
short acting
which type of insulin is used for half of the day or even overnight
intermediate acting
what type of insulin is used right after a meal or used as correction
rapid acting
what types of insulin can you pair with long acting
short acting or rapid acting
what types of insulin can you pour with rapid or short acting insulins
intermediate or long acting
what is the composition go humulin and novolin
70% intermediate acting and 30% regular acting
what insulin is 50% intermediate and 50% regular insulin
humulin
what’s the composition of NovoLog
70% intermediate and 30% rapid acting
what is the MOA for biguanides (metformin)
decreases the glucose production in the liver, it also increases insulin sensitivity in the skeletal muscle which increasers glucose uptake by muscles
what is the dosing like for metformin
BID with meals
what are some precautions and risks when taking metformin
Caution in patients with renal & liver impairment, digestive side effects include abdominal pain, N/V, & diarrhea, no risk of hypoglycemia, no weight gain
what is the MAO of sulfonylureas (glipizide, glycburide)
increase insulin secretion by stimulating the pancreatic beta cells to produce more insulin
what is the dosing for sulfonylureas (glipizide, glycburide)
daily or BID
what are two risks when taking sulfonylureas (glipizide, glycburide)
risk of hypoglycemia and risk of weight gain
what is the MOA of meglitinides (prandin, starlit)
increases insulin secretion by stimulating the pancreatic beta cells to produce more insulin
what is the dosing for meglitinides (prandin, starlit)
TID before meals
what are the two risks when taking meglitinides (prandin, starlit)
risk of hypoglycemia and weight gain
what is the MOA for Thiazolodonediones (actos, Avandia)
decreases glucose production in the liver and increases insulin sensitivity in skeletal muscle which increases glucose uptake by the muscles
what is the dosing for Thiazolodonediones (actos, Avandia)
daily
what are some precautions and risks to keep in mind when taking Thiazolodonediones (actos, Avandia)
may increase the risk of HF, monitor for heptaotoxicity, may increase the risk of bone fractures, no risk for hypoglycemia, weight gain.
what is the MOA for DPP-4 inhibitors (tradjenta, Januvia)
prevents the breakdown of naturally occurring GLP-1, compound responsible for stimulating insulin release from the pancreas.
how does DPP-4 inhibitors (tradjenta, Januvia) decrease postprandial blood glucose?
increasing insulin secretion in response to blood glucose levels or decreasing glucagon secretion by pancreas
what is the dosing for DPP-4 inhibitors (tradjenta, Januvia)
daily
what is a risk for DPP-4 inhibitors (tradjenta, Januvia)
may cause nasopharyngitis (there is no risk for hypoglycemia or weight gain)
what is the MOA for GLP-1 receptor agonists (Victoza, ozempic)
increases insulin secretion, reduces glucose release from the liver after meals, delays food emptying from the stomach, promotes satiety
how is GLP-1 receptor agonists (Victoza, ozempic) administered
subcutaneously
how often is Victoza administered
daily
how often is ozempic administered?
weekly
what are some precautions and risks when taking GLP-1 receptor agonists (Victoza, ozempic)
abdominal pain, N/V, diarrhea, weight loss. there is no risk for hypoglycemia.
what is the MOA for SGLT2 inhibitors (sodium glucose cotransporter 2 inhibitors ) (Invokana, Farxiga)
increases glucose excretion in the urine by blocking reabsorption in the kidneys
how often do you administer SGLT2 inhibitors (sodium glucose cotransporter 2 inhibitors ) (Invokana, Farxiga)
daily before the first meal of the day
what are some risks and precautions when taking SGLT2 inhibitors (sodium glucose cotransporter 2 inhibitors ) (Invokana, Farxiga)
increase in UTIs, weight loss, lowers blood pressure (monitor for dehydration. no risk for hypoglycemia.
what are some complications of type 1 and 2 diabetes mellitus?
hypoglycemia, dawn pneomenon, somogyi effect, HHS, DKA, microvascular and macros vascular complications
why could hypoglycemia be a life-threatening emergency?
due to the potentially devastating effects on the central nervous system
what is the dawn phenomenon?
an abrupt increase in serum glucose levels between the hours of 5am-9am from surge of hormones like cortisol
why could a patient experience dawn phenomenon?
taking their insulin too early in the evening.
what could you educate a patient on to try to prevent dawn phenomenon?
delay the evening dose of insulin and make sure they are having a snack at bedtime
what is the somogyi effect?
nocturnal hypoglycemia that is followed by rebound hyperglycemia at around 7 am
what could the smoggy effect be caused by
taking too much insulin at bedtime
what could you educate a patient on to prevent the somogyi effect
lower the dose of insulin you are taking in the evening
patinets with what type of diabetes are more likely to experience the dawn phenomenon and somogyi effect?
type one diabetes
what are some causes of hyperglycemia
too much food, too little insulin or diabetic pills, illness, or even stress
what type of onset does hyperglycemia have
slow onset, could lead to a medical emergency if not treated
what are some symptoms of hyperglycemia?
extreme thirst, need to urinate often, dry skin, hungry, blurry vision, drowsy, slow-healing wounds
what are causes of hypoglycemia
too little food, skipping a meal, too much insulin or diabetic pills, more active than usual
describe the onset of hypoglycemia
sudden, may pass out (syncope) if untreated
what are some symptoms of hypoglycemia
shaky, tachycardia, sweating, dizzy, anxious, hungry, blurry vision, weakness/fatigue, headache, irritable
how does the body attempt to obtain energy when in DKA
By the rapid breakdown of fat stores, releasing fatty acids from adipose tissues
when does DKA develop?
When there is inadequate insulin for cells to obtain adequate glucose for normal metabolism.
when the liver converts fatty acids into ketones what can these be used as?
Can serve as an energy source in the absence of glucose
ketone bodies have the ability to lower the pH in the body, what can this result in?
metabolic acidosis
is DKA seen more often in type one or two diabetes
type one
when does HHS (hyperosmolar hyperglycemia state) most commonly occur?
occurs more commonly in the elderly in response to stress or an infection
what type of onset does DKA have
rapid
what kind of onset does HHS have
gradual
what types of labs do you need to gather to determine wether a patient is experiencing DKA or HHS?
blood glucose levels, arterial pH levels, serum bicarb levels, urine or serum ketones, effective serum osmolarity, anion gap
what blood glucose level indicates DKA
greater than 250
what pH level indicates DKA
< 7.30
what bicarb level indicates DKA
< 18
what ketone level indicates DKA
positive
what serum osmolarity level indicates DKA
> 300
what anion gap level indicates DKA
> 12
what blood glucose level indicates HHS
greater than 600
what pH level indicates HHS
> 7.30
what serum bicarb level indicates HHS
> 15
what ketone level indicates HHS
negative or very small amounts
what serum osmolarity level indicates HHS
> 320
what anion gap indicates HHS
< 12
what are two hallmark symptoms of HHS
altered levels of consiousness and profound dehydration
what can chronic hyperglycemia do to the eyes
The delicate blood vessels that supply the retina are susceptible to damage from prolonged hyperglycemia, resulting in retinal hypoxia.
what can chronic hyperglycemia do to the gums in the mouth
Periodontal disease is more common with diabetes because of the decreased circulation to the gums and increased susceptibility to periodontal bacteria and dental caries
what is a common outcome of chronic hyperglycemia on the gums?
early tooth loss
what is affected in the kidneys with chronic hyperglycemia
The vasculature to the kidneys
what are some clinical manifestations of diabetic peripheral neuropathy
numbness, tingling, or pain
autonomic neuropathy can lead to what things
diabetic gastroparesis, ED, infections, cardiovascular disease, stroke
what are some clinical manifestations of diabetic gastroparesis?
bloating, early satiety, nausea, vomiting
