Chapter 46 Management of Patients w/ Diabetes Flashcards
Diabetes
A group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both
Criteria for Diabetes Diagnosis
1)Symptoms of diabetes: Polyuria, polydipsia, polyphagia, unexplained weight loss (Type I)
2) Fasting blood glucose ≥ 126 mg/dL (no caloric intake for 8 hrs)
3) Random blood glucose ≥ to 200
4) HgbA1C ≥ to 6.5%
Glycated Hemoglobin (A1C or HgbA1C)
A measure of glucose control that is a result of glucose molecule attaching to hemoglobin for the life of the red blood cell (120 days: 3 months)
Hyperglycemia
Excess glucose in the blood
The 3 Ps
Polyuria, polydipsia, & polyphagia
Polyuria
Excess urination
Polydipsia
Increased thirst
Polyphagia
Increased appetite
When does glycosuria occur?
It occurs when the renal threshold for sugar exceeds 180mg/dL
What condition can glycosuria lead to?
It can lead to osmotic diuresis (excess loss of water & electrolytes)
Fasting Plasma Glucose
Blood glucose determination obtained in the lab after fasting for at least 8 hrs
Prediabetes
Impaired glucose metabolism in which blood glucose concen fall btwn norm levels and those considered diagnostic for diabetes
Type 1 Diabetes
A metabolic disorder characterized by an absence of insulin production & secretion from autoimmune destruction of the beta cells of the islets of Langerhans in the pancreas
Type 2 Diabetes
A metabolic disorder characterized by the relative deficiency of insulin production & a decreased insulin action & increased insulin resistance
Gestational Diabetes
Diabetes that develops during pregnancy ( usually in 2nd/3rd trimester due to hormone secretion that inhibit insulin)
What can lead to the development of gestational diabetes?
Secretion of certain placental hormones that cause insulin resistance
Patients that are at an elevated risk for developing gestational diabetes
Women w/marked obesity, strong personal/family hx of gestational diabetes, & glycosuria
Diabetes Risk Factors
Age
-Type 1: <30 years old
-Type 2: >30 years old
High-density lipoprotein (HDL) level ≤35 mg/dL (0.90 mmol/L) and/or triglyceride level ≥250 mg/dL (2.8 mmol/L)
History of gestational diabetes or delivery of a baby over 9 lbs
HTN
Family hx of diabetes
Obesity
Previously identified impaired fasting glucose/impaired glucose tolerance
Ethnicity Groups: African Americans, Hispanic Americans, Native Americans, Asian Americans, Pacific Islanders
Insulin
A protein anabolic hormone secreted by beta cells, in the pancreas
Functions of Insulin
Transports and metabolizes glucose for energy
Stim storage of glucose in the liver and muscle (via glycogen)
Signals the liver to stop the rel of glucose
Enhances storage of dietary fat in adipose tiss
Accelerates transport of amino acids (derived from dietary protein) into cells
Inhibits the breakdown of stored glucose, protein, and fat
Since insulin is an anabolic hormone, what expected side effect can you see in patients?
Weight gain
Glucagon
A protein hormone secreted by the alpha cells in the pancreas
Function of Glucagon
Increases blood glucose levels
Clinical Manifestations of Type 1 Diabetes
Symptoms sudden in onset
May have sudden weight loss
Polyuria
Polydipsia
Polyphagia
Ketoacidosis
Glycosuria
Fatigue
Weakness
Vision changes DKA
What happens if beta cell destruction occurs?
Insulin prod decreases, glucose prod (liver) increases, & fasting hyperglycemia
Osmotic Diuresis
When excess glucose is excreted in the urine, it is accompanied by excessive loss of fluids & electrolytes
Ketone bodies
A highly acidic substance formed when the liver breaks down free fatty acids in the absence of insulin
Diabetic Ketoacidosis (DKA)
An acute complication from insulin deficiency (usually from Type I) where highly acidic ketone bodies are formed, and metabolic acidosis occur
DKA Signs & Symptoms
Fruity breath
Kussmaul respirations
Polyuria
Polydipsia
Polyphagia
Marked fatigue
Blurred vision
Weakness
Headache
Orthostatic Bp
Tachycardia
Poor skin turgor
Diabetic Ketoacidosis Management
Correct dehydration, electrolyte loss & acidosis BEFORE correcting hyperglycemia w/insulin
Risk Factors for Type II Diabetes
Family hx
Obesity: BMI more than or equal to 30
Race/Ethnicity
Age 30 & up
Prev identified impaired fasting glucose/glucose tolerance test
High density lipoprotein (HDL) less than or equal to 30 mg/dL and/or triglyceride lvl 250mg/dL or more
Hx of gestational diabetes
Delivery of a baby > 9lbs
HTN
Type II Diabetes Clinical Manifestations
Slow onset
Polyuria
Polydipsia
Polyphagia
Fatigue
Weakness
Vision changes
Neuropathy
Dry skin
Skin lesions/wounds that are slow to heal
Recurrent vaginal yeast infections
True or False (T/F): Type II tends to be undetected for many years due to the slow, progressive nature of the disease.
True
What is the main problem related to type II diabetes?
The main problems is insulin resistance due to decreased sensitivity of the tissues to the effects of insulin
Most Common Health Complications Associated w/ Type II Diabetes
Eye disease, peripheral neuropathy, & peripheral vascular disease (PVD)
Peripheral Neuropathy
Result of damage to the nerves located outside of the brain & spinal cord
Often causes weakness, numbness & pain (usually in the hands & feet)
Initial Symptoms of Peripheral Neuropathy
Occurs bilaterally:
- Tingling
- Heightened sensation
- Burning
Progressive Symptoms of Peripheral Neuropathy
Numbness
Problems w/proprioception
Decreased sensation of light touch
Unsteady gait
Management of Peripheral Neuropathy
Daily checks of the feet (infection)
Intensive insulin therapy: control of blood glucose levels
Analgesic agents
Antiseizure meds (also help w/neuropathy)
-Lyrica (pregablin)
- Neurontin (gabapentin)
Macrovascular Complications of Diabetes
Medium to large vessels: thicken, scleroses, become occluded w/plaque
3 Main types of Macrovascular Diseases Associated w/ Diabetes:
1) Coronary artery disease
2) Cerebrovascular disease
3) Peripheral vascular disease
Signs of Severe Foot Infections
1) Drainage
2) Swelling
3) Cellulitis
4) Gangrene
Cellulitis
Deep bacterial skin infection that causes painful inflammation (swelling, redness)
Gangrene
Death of body tissue due to lack of blood flow/severe infection
Foot Care Instructions
Daily feet checks
Wash feet everyday
Keep skin soft and
smooth
Trim toenails straight
across
-Go to a podiatrist if
unable to trim toenails
Wear shoes and socks at ALL times
Keep the blood flowing to your feet
Do not smoke
Contact PCP right away if a cut, sore or bruise on foot does not begin to heal after 24 hours
Coronary Artery Disease
A narrowing/blockage of coronary arteries (supply heart) due to the accumulation of plaque
Cerebrovascular Disease
A group of conditions that affect blood flow to the brain
Peripheral Vascular Disease (PVD)
A common condition in which narrowed arteries reduce blood flow to the arms or legs
Management of Macrovascular Complications from Diabetes
Aggressive reduction of risk factors for atherosclerosis:
-Obesity
-HTN
-Hyperlipidemia
Control blood glucose levels
Smoking cessation
What causes microvascular complications from diabetes?
Capillary basement membrane thickening
Retinopathy
Damage to small blood vessels that nourish the retina
Clinical Manifestations of Diabetic Retinopathy
Painless
Floaters
Cobwebs
Spotty/hazy vision
Complete Loss of Vision
Nephropathy
Damage to the kidney cells
How does diabetes cause nephropathy?
High glucose levels over long periods of time stresses the kidney’s filtration system-> allows proteins to leak into the urine
Also kidney blood vessel pressure increases
Nephropathy Management
Dialysis
-Hemodialysis
-Peritoneal dialysis
-Mortality rates higher for diabetic patients
Kidney Transplant
Insulin Resistance
Decreased tissue sensitivity to the effects of insulin
What does the body do in order to compensate for insulin resistance & glucose buildup?
Insulin secretion increases to maintain the glucose at a normal/slightly elevated level
Hyperglycemic Hyperosmolar State (HHS)
Insulin secretion increases to maintain the glucose at a normal/slightly elevated level
Clinical Manifestations of HHS
Hypotension
Profound dehydration,
Tachycardia
Variable neurologic signs caused by cerebral dehydration (alterations of consciousness, seizures, hemiparesis)
Which condition is often associated w/ Type I Diabetes?
Diabetic Ketoacidosis (DKA)
Which condition is often associated w/ Type II Diabetes?
Hyperglycemic Hyperosmolar State (HHS)
Example of Possible Consequences of Untreated Diabetes
Blindness
Limb amputation
Cardiovascular disease
Kidney disease
Intensive Treatment of Diabetes is defined by the ADA as…
… 3 or 4 insulin injections/day or an insulin pump & frequent blood glucose monitoring and weekly contacts w/ diabetes educators
5 Components of Diabetes Management
1) Nutritional Therapy
2) Exercise
3) Monitoring
4) Pharmacologic therapy
5) Education
A1C Monitoring for Diabetes Management
Keep below 7%
Succeeding in nutritional therapy alone can have what effect on type II diabetes patients?
Reversal of Type II Diabetes
Diabetes Nutritional & Dietary Management Goals
Control of total caloric intake to attain/maintain a reasonable body weight, control of blood glucose levels, & normalization of lipids and BP to prevent heart disease
Recommended Caloric Distribution of Carbs for Diabetics
50-60%
Recommended Caloric Distribution of Fats for Diabetic Patients
Total % of Fats: < 30% of total calories
Saturated fats: 10% of total calories
Exchange Lists
Foods w/in one food group (in the portion amounts specified) contain = numbers of calories & are approx. equal in grams of protein, fat, and carb
Examples of “free items” from Exchange Lists
Diet soda, unsweetened ice tea, & ice water w/lemon
Special Considerations for Diabetes & Alcohol Consumption
Since alcohol may decrease the normal physiologic reactions in the body that produce glucose, there is an increased risk for pts who consume alcohol on an empty stomach to develop hypoglycemia
Medical Nutrition Therapy
Nutritional therapy prescribed for management of diabetes usually given by a registered dietitian
To promote a 1- to 2-lb weight loss per week…
…500-1,000 calories are subtracted from the daily total
Glycemic Index
Amount a given food increases the blood glucose level compared w/ equivalent amount of glucose
Nutritive Sweeteners
Sweeteners that contain calories & cause less elevation in blood sugar levels than sucrose
Examples of Nutritive Sweeteners
Fructose, sorbitol, & xylitol
Non-nutritive Sweeteners
Sweeteners that contain min/no calories & produce min/ no elevation in blood glucose levels
Examples of Non-nutritive Sweeteners
Sucralose (Splenda)
General Exercise Considerations for Diabetic Patients
Exercise at the same time of day (preferably when blood glucose levels are at their peak) & for the same duration each session.
Use proper footwear and, if appropriate, other protective equipment (i.e., helmets for cycling)
Avoid trauma to the lower extremities (especially if you have numbness due to peripheral neuropathy)
Inspect feet daily after exercise
Avoid exercise in extreme heat or cold
Avoid exercise during periods of poor metabolic control
Stretch for 10-15 mins before exercising
How often should a pt with diabetes exercise for (days per week)?
3X a week w/no more than 2 consecutive days w/out exercise
What type of exercise should people w/Type II diabetes perform & how often?
People w/type II should perform resistance training twice a week
What effect does exercise have on blood glucose levels?
Exercise lowers blood glucose levels by increasing the uptake of glucose via body muscles & by improving insulin utilization
Exercise Precautions for Patients who have blood glucose levels exceeding 250 mg/dL (14 mmol/L) and who have ketones in their urine
They should not begin exercising until the urine test results are negative for ketones & the blood glucose level is closer to normal
What can a patient do to avoid post-exercise hypoglycemia?
Eat a snack at the end of the exercise session & at bedtime and monitor the blood glucose level more frequently
Self-Monitoring of Blood Glucose (SMBG)
A method of capillary blood glucose testing in which the patient pricks their finger & applies a drop of blood to a test strip that is read by a meter
Candidates for Self-Monitoring of Blood Glucose
Unstable diabetes (Severe swings from very high -> very low blood glucose levels w/in 24 hr day)
Tendency to develop severe ketosis/ hypoglycemia
Hypoglycemia w/out warning signs
How often should a patient monitor their SMBG levels?
2-4 times daily (usually before meals & at bedtime)
Biguanide Primary Drug Action
Inhibit liver prod of glucose
Example of Biguanide
Metformin
Which drug classes are considered insulin sensitizers?
Biguanides & thiazolidinediones (rosiglitazone and pioglitazone)
What is the action of insulin sensitizers?
Help tissues use available insulin more efficiently
Which drug classes are insulin releasers?
Sulfonylureas (Glyburide and glipizide) & meglitinides (Repaglinide)
What is the action os insulin releasers?
Stim the pancreas to secrete more insulin
Alpha-glucosidase Inhibitor Drug Action
Delay absorption of complex carbohydrates in the intestine and slow entry of glucose into systemic circulation
Special Alpha-glucosidase Inhibitor Drug Consideration
MUST be taken w/first bite of food to be effective
Example of Alpha-glucosidase Inhibitor Drug
Acarbose
Steps of Insulin Self-Administration
1) Stabilize the skin via pinching the area
2) Hold the syringe as if holding a pencil
3) Insert the needle at a 90 degree angle into the skin
4) Push the plunger of the syringe
5) Pull the needle straight out of the skin
6) Press a cotton ball over the injection site
7) Dispose of the syringe into a hard container
Which order do you draw up insulin? Clear to cloudy or cloudy (usually NPH) to clear?
Clear then cloudy
Onset
How soon the insulin starts to lower BG after admin
Peak
The time after insulin admin, the insulin is working its hardest to lower BG
Duration of Action
How long the insulin lasts-the length of time
from administration, that it keeps lowering
the blood glucose
Rapid-Acting Insulin
Used for rapid reduction of glucose level, to treat postprandial hyperglycemia, or to prevent nocturnal hypoglycemia
Examples of Rapid-Acting Insulin
Lispro (Humalog), aspart, glulisine
Onset, Peak, & Duration of Lispro (Humalog)
Onset: 15-30 mins
Peak: 30 mins-2.5 hrs
Duration: 3-6 hrs
Onset, Peak, & Duration of Aspart
Onset: 15 min
Peak: 1-3 hrs
Duration: 3-4 hrs
Onset, Peak, & Duration of Glulisine
Onset: 5-15 min
Peak: 1 hr
Duration: 5 hrs
Considerations for Patients Taking Rapid-acting Insulin
Eat no more than 5-15 mins after injection
Patients w/ type 1 diabetes & some patients w/ type 2 or gestational diabetes also req a long-acting insulin (basal insulin) to maintain glucose control
-Basal insulin is necessary to maintain blood glucose levels irrespective of meals
Short-Acting Insulin
Usually given 15 min before a meal (may be taken alone or in combination with longer-acting insulin)
Short-Acting Insulin CANNOT be mixed with
Lantus (Glargine) and Apria (Glulisine)
Example of Short-acting Insulin Agent
Regular
Onset, Peak and Duration of Short-acting Insulin
Onset: 30min-1hr
Peak: 2-3hr
Duration: 4-6hr
Dietary Consideration for Intermediate Acting Insulin
Food should be taken around the time of onset & peak
Example of Intermediate Acting Insulin
NPH (neutral protomine Hagedorn)
Onset, Peak & Duration of Intermediate-acting Insulin
Onset: 60-120 mins
Peak: 6-14 hrs
Duration: 16-24hrs
Indication for Long-Acting Insulin Usage
Used for basal dose
Example of Long-Acting Insulin
Glargine detemir
Onset, Peak & Duration of Long-acting Insulin
Onset: 70 mins
Peak: None
Duration: 18-24 hrs
Insulin Administeration: Dosage & KSU Rounding Rules
Needs to be WHOLE numbers: you CANNOT admin fractions of a dose
≤0.4 rounds down
Ex) 1.4 U insulin rounds down to 1.0U insulin
≥ 0.5 rounds up
Ex) 1.5 U insulin rounds up to 2.0U insulin
Every morning, a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain?
70% NPH insulin & 30% regular insulin
The nurse expects that a type 1 diabetic patient may receive what percentage of his or her usual morning dose of insulin preoperatively?
50-60% of the pt’s morning dose of insulin (either intermediate-acting insulin alone or both short- and intermediate-acting insulins) is administered subcutaneously in the morning before surgery
What causes precipitation in long acting insulin?
If it’s mixed w/other types of insulin, precipitation would form because of its acidic pH
Which type of insulin can be given via IV?
Short-acting (regular) is the ONLY one that can be given this route
Local allergic reactions to insulin therapy
A local allergic rxn (redness, swelling, tenderness, and induration or a 2- to 4-cm wheal) may appear at the injection site 1 to 2 hours after the administration of insulin
Systemic Allergic Reactions to Insulin Therapy
When they do occur, there is an immediate local skin reaction that gradually spreads into generalized urticaria (hives)
Treatment for Systemic Allergies to Insulin
Small doses of insulin given in gradually increasing amounts using a desensitization kit
Insulin Lipoatrophy
Loss of fat tissue in areas of repeated injection causing changes in subcutaneous fat
Nursing Action for Insulin Lipoatrophy Prevention
Instruct pt to rotate injection site 2 in away from belly button
Insulin Lipohypertrophy
An insulin complication where fibrous fatty masses form at the injection site due to not rotating injection sites
Insulin Waning
Progressive increase in blood glucose from bedtime to morning
Insulin Waning Treatment
Increase evening (predinner or bedtime) dose of intermediate- or long-acting insulin, or institute a dose of insulin before the evening meal if one is not already part of the treatment regimen
Dawn Phenomenon
Relatively normal blood glucose until early morning (3 AM) hours when levels begin to rise
Dawn Phenomenon Treatment
Changing time of injection of evening intermediate-acting insulin from dinnertime to bedtime
Somogyi Effect
Normal or elevated blood glucose at bedtime, early morning hypoglycemia, and a subsequent increased blood glucose caused by the production of counter-regulatory hormones
Somogyi Effect Treatment
Treated by decreasing evening (predinner or bedtime) dose of intermediate-acting insulin, or increasing bedtime snack
Hypoglycemia
Abnormal decrease of sugar in the blood (<70 mg/dL)
Severe Hypoglycemia
BG <40 mg/dL
Gerontological Considerations for Hypoglycemia
Older adults frequently live alone & may not recognize the sympt of hypoglycemia
W/ decreasing kidney function, it takes longer for oral hypoglycemic agents to be excreted by the kidneys
Skipping meals may occur due to decreased appetite/ financial limitations
Decreased visual acuity may lead to errors in insulin administration
Mild Hypoglycemia Signs & Symptoms (SNS Stim)
Sweating
Tremor
Tachycardia
Palpitation
Nervousness
Hunger
Mild Hypoglycemia Blood Glucose
54-70 mg/dL
Moderate Hypoglycemia Signs & Symptoms
Glucose drop deprive brain cells of O2 (CNS)
Inability to concentrate
Headache
Lightheadedness
Confusion
Memory lapses
Numbness of the lips & tongue
Slurred speech
Impaired coordination
Emotional changes
Irrational/combative behavior
Double vision
Drowsiness
Moderate Hypoglycemia BG Range
41-53 mg/dL
Severe Hypoglycemia Signs & Symptoms
CNS is so impaired that the pt needs assistance of another person for treatment
Disoriented behavior
Seizures
Difficulty arousing from sleep
Loss of consciousness
General Considerations for Hypoglycemia
Check the pt’s BG and correlate it w/ the signs and symptoms
Treating ALERT Hypoglycemic Patients
Supply carbs
- 15-20 g of fast acting concentrated carbs
-> 2-3 glucose tabs
->4 oz of juice/soda
->1 Tb sugar, honey, or corn syrup
->8 oz of nonfat or 1% milk
->3 graham crackers
Then follow with snack: starch and protein
-Recheck BG in 15 minutes and repeat steps if
needed
Management of Hypoglycemia: Unconscious Patients at Home
Injection of 1 mg of glucagon IM
After injection may take up to 20 mins for pt to regain consciousness
-Follow w/15 g of concentrated carbs & a snack
Management of Hypoglycemia: In the hospital or
ER for patients who are unconscious, NPO,
or cannot swallow
Administer 25-50 cc of Dextrose 50% – ( D50, D50W)
IV Push
-Effect seen in minutes
Which pharmacological treatment for hypoglycemia is used inside the hospital setting?
Dextrose 50% (D50, D50W)
Which pharmacological treatment for hypoglycemia is used outside the hospital setting?
Glucagon
Immediate Treatment for Hypoglycemia
The usual recomm is for 15-20 g of a fast-acting concentrated source of carbs
Emergency Measures for Hypoglycemia
For those w/ glucose level <54 mg/dL, unconscious & cannot eat:
Admin 1 mg IM/SQ injection of glucagon
Patient Teaching Considerations for Hypoglycemia
Hypoglycemia is prevented by:
-A consistent pattern of eating
-A consistent pattern of insulin administration
-Between meal and bedtime snacks
-Eat additional food when physical activity is increased
-Routine blood glucose tests
Wear a bracelet stating they have diabetes
Carry a form of simple sugar at all times
Having family members/friends be able to
recognize symptoms and actions
Management of Diabetics in the Hospital
Prolong stay: increase infection rates, increase mortality
Stress & Infection increase blood glucose
BG targets: 140-180 mg/dL
Insulin treatment preferred
Protocols for insulin dosing
Appropriate Timing: Blood checks, meal consumption, insulin dose
Sick Day Rules
During periods of physiologic stress BG levels increase
NEVER eliminate insulin
-Extra short acting insulin
Small portions of carbs
Check blood glucose & ketones: Every 3 to 4 hours
-Report Elevated BG or +ketones to provider
Drink fluids every hour w/ vomiting/diarrhea
-If ketones are present unable to keep down
fluids, hospitalization may be necessary
Want to prevent DKA
and coma in Type 1
Nursing Considerations for Diabetics Undergoing Surgery: Pre-Op
Requires frequent BG monitoring (every one to
two hours)
For pts taking insulin:
-Morning of surgery all subq
insulin maybe held unless
BG>200 or half the usual
dose of insulin may be
given per provider orders
-If you don’t have orders to
hold insulin: contact the
healthcare provider
Pts taking metformin may be
instructed to discontinue the oral
agent 24-48 hours before surgery
Nursing Considerations for Diabetics Undergoing Surgery: During Surgery
Blood glucose is controlled via IV infusion of regular insulin & dextrose infusion
-May come back on an insulin infusion
Nursing Considerations for Diabetics that are NPO
Insulin dosage has been addressed by health care provider
Changes may include:
-Eliminate rapid-acting insulin
-Giving 1/2 usual dose intermediate acting insulin
IV dextrose may be admin to prevent hypoglycemia
To avoid problems these patients should be
scheduled for diagnostic tests and procedures
early in the morning
While NPO, the scheduled time for glucose
testing and insulin administration should still
match mealtimes
