Chapter 67 Diabetes 1449-1462

Question 1

A patient with neuropathic pain is expected to experience pain relief. What would an expected outcome(s) be for the patient?

Answer 1

Uses preventive measures
Uses available resources to increase comfort
Reports pain controlled

Question 2

Many patients with diabetes suffer from painful neuropathy. Common symptoms include:

Answer 2

Burning; muscle cramps; piercing, stabbing, or darting pain; metatarsalgia- feeling of walking on marbles; allodynia-pain in response to nonpainful stimuli; tingling, numbness, and loss of proprioception in lower extremities

Question 3

Rapid improvement in blood glucose control may trigger

Answer 3

acute peripheral pain

Question 4

Which pharmacologic agents are approved to manage neuropathic pain?

Answer 4

Anticonvulsants: gabapentin (Neurotin) and pregabalin (Lyrica)
Serotonin-norepinephrine reuptaked inhibitor (SNRI): duloxetine (Cymbalta)

Question 5

Which pharmacologic agents are not approved but are widely used to manage neuropathic pain?

Answer 5

Tricyclic antidepressants such as amitriptyline hydrochloride (Elavil, Levate) and nortriptyline (Pamelor)
These have severe side effects and are contraindicated for older adults and those with cardiovascular disease.

Question 6

The burning of neuropathy may respond to which drug and why?

Answer 6

capsaicin cream 0.075% (Axsain, Zostrix-HP) -reduces the amounts of substance P, which is involved in pain transmission
Apply four times a day, pain may be worse for several days before improving

Question 7

What should a patient taking medication for neuropathy be taught before discontinuation of medication?

Answer 7

To gradually reduce dose rather than abrupt discontinuation in order to prevent harmful and unpleasant symptoms

Question 8

What are the expected outcome(s) for a patient with diabetes related to vision impairment?

Answer 8

Free of injury related to reduced vision
Maintain current level of vision
No further reduction of visual fields
No double visions

Question 9

What are risk factors for diabetic retinopathy and vision loss?

Answer 9

Poor blood glucose control, proteinuria, diastolic hypertension, and long duration of diabetes

Question 10

What things should a diabetic patient with retniopathy or vision loss due to further reduce vision impairment?

Answer 10

Surgical intervention
Regular eye exams
Appropriate eyewear
Low-vision reading aids

Question 11

What are some ways to manage diabetes in the patients environment?

Answer 11

Adjust lighting, contrast, color, distance, type of printed materials, etc
Color coding insulin
Using peripheral vision
Prefill syringes, dial-a-dose
Help patient choose a glucometer they can read

Question 12

What do you teach a patient using an adaptive device?

Answer 12

Differentiate between bottles of fast-acting and slower-acting insulin by wrapping a rubber band around the fast-acting insulin; ensure proper placement of devices on syringe; hold bottles up when measuring insulin; avoid air bubbles by pulling insulin in and out of syringe several times, measuring on the fourth time; design a system so air is never drawn out of the bottle and injected

Question 13

What is the expected outcome for a patient’s kidneys with diabetes?

Answer 13

To maintain a normal urination pattern

Question 14

What indicates a patient with diabetes has met the expected outcome for kidney function?

Answer 14

Urine protein levels within normal limits
24 hour intake and output balance
BUN, serum creatinine, and serum electrolytes within normal ranges

Question 15

How do you prevent kidney disease in patients with diabetes?

Answer 15

Tight control of blood glucose levels
Correcting hyperlipidemia
Restricting dietary protein
Control of hypertension prevents nephropathy

Question 16

What is the best overall measure of kidney function?

Answer 16

GFR - glomerular filtration rate

Question 17

How often and how do you measure GFR?

Answer 17

Yearly; By checking serum creatinine level;
Microalbuminuria is tested every after 5 years in patient with type 1 DM and all type 2 patients staring at diagnosis and during pregnancy

Question 18

What is the earliest change signaling diabetic kidney disease?

Answer 18

Excretion of 30-299 mg of albumin q d

Question 19

What is albuminuria?

Answer 19

Excretion of 300 mg of albumin q d or more

Question 20

How is screening for microalbuminuria done? Which is the preferred method?

Answer 20

Random spot urine collection to measure the albumin-creatinine ration (preferred mehtod); 24 hour urine collection to measure creatinine clearance; timed urine collection (4 hours overnight)

Question 21

Once microalbuminuria develops, what does management of kidney disease focus on?

Answer 21

Control of BP and BGL, restricting dietary protein, avoiding nephrotoxic agents, promptly treating UTIs, and preventing dehydration

Question 22

What should a patient with diabetic nephopathy’s BP be below?

Answer 22

130/80

Question 23

What effect does smoking have on the kidneys in a patient with diabetes?

Answer 23

It increases the risk for development of microalbuminuria, advancement of proteinuria, and accelerates rate of kidney disease

Question 24

What are the most common nephrotoxic drugs?

Answer 24

antifungal agents (amphotericin B), animoglycoside antibiotics - amikacin (Amikin), streptomycin, kanamycin (Kantrex), gentamicin (Garamycin), tobramycin (Tobrex), NSAIDS

Question 25

What should you do for a patient with diabetic nephropathy receiving radiocontrast dyes?

Answer 25

Monitor IV hydration before and after contrast