Chapter 67: Diabetes Mellitus

Question 0

Insulin functions

Answer 0

Insulin helps keep blood glucose from becoming too high and keeps blood lipid levels in the normal range

Moves glucose into the tissues. Without it, fats and proteins are broken down.

Question 1

Pancreas

Answer 1

islets of langerhans
alpha cells > glucagon (opposes insulin)
beta cells > insulin and amylin

Basal insulin secretion is secreted during fasting
prandial insulin secretion is after eating

Question 2

Kussmaul respirations

Answer 2

attempt to correct metabolic acidosis by blowing of CO2. Acidosis is from increased ketones in the blood.

Increased rate and depth, with a fruity odor which leads to compensated resp alkalosis

Question 3

Macrovascular complications

Answer 3

Cardiovascular disease, myocardial infatction, cerebrovascular disease (stroke)

Question 4

Microvascular complications

Answer 4

Eye and vision complicaltions
diabetic retinopathy
proliferative diabetic retinopathy - new blood vessels form in eye and bleed easily
diabetic neuropahty - deterioration of nerves
diabetic nephropathy - reduced kidney function, albuminuria
male erectile dsyfunction

Question 5

Metabolic syndrome/syndrome X

Answer 5

Presence of factors that increase the risk for developing type II diabetes and cardiovascular disease. They include abdominal obesity which is a waist circumference over 40 in men or 35 in women. Hyperglycemia over 100 with a fasting blood glucose. Hypertension about 130/85. Dislipidemia triglyceride level> 150. HDL < 50 in women.

Question 6

Lab values

Answer 6

Fasting BG >100 and 126 on 2 occasions = diabetes
Nothing to eat 8 hrs prior
Glucose tolerance 2 hr post test >140. < 200 = impaired
> 200 = diabetes
ICA antibodies= type I
Ketone bodies= lack of insulin
Casual BG >200

Question 7

Oral glucose test instructions

Answer 7

Eat a balanced diet with carb intake of at least 150 g for a minimum of three days with normal physical activity. 10 to 12 hours fasting the night before. Drink 300 mL of a flavored beverage within five minutes. Blood is drawn at 30 minute intervals for two hours. You will not be able to smoke or drink liquids during the test. Bedrest, illness, medications can interfere with test results.

Question 8

Blood glucose goals

Answer 8

HBA1C below 7%, the majority of Premeal blood glucose levels 90 to 130. Blood glucose at bedtime between 100-140. Post meal < 180.

Question 9

Metformin (glucophage)

Answer 9

Initial drug for type II. Decreases liver production of glucose>reduces plasma glucose. Also improves insulin receptor sensitivity.

Does not induce wt gain or hypoglycemia
Do not give if kidney disease or elevated creatnine.
Dc 48 hrs before any contrast or anesthesia
Do not crush or chew, it is extended release

Side effects: abdominal discomfort and diarrhea, can cause lactic acidosis if renal insufficient.
Take with meals, no alcohol

Report fatigue, muscle pain, difficulty breathing, stomach discomfort, dizzy, lightheaded, irregular heartbeat which can be lactic acidosis.

Question 10

Insulin dosing

Answer 10

.5-1 unit/kg body wt per day
40-50% is basal dose NPH or Glargine.
The rest is divided up for before meals

Adjust the dose every 3-4 days.
Dose depends onBG. Monitor 1-2 hrs after meals and 10 min before meals for short term insulin. Longer acting is done before breakfast and dinner.

Question 11

Insulin absorption

Answer 11

Absorption is fastest in the abdomen the the deltoid, thigh, and buttocks. Rotate within one site to prevent fluctuations. Abdomen is preferred site. Do not use scarred sites

Do not mix Glargine or Detemir.
Glargine needs refrigerated all the time.

Question 12

Dawn phenomenon

Answer 12

Night time release of GH that causes glucose to rise in the morning between 5 and 6. Give more insulin at bedtime to reduce this.

Question 13

Somogyi phenomenon

Answer 13

Morning hyperglycemia from counteracting nighttime hypoglycemia. Manage with diet before bed and evaluate insulin and exercise.

Question 14

Diabetic diet

Answer 14

Protein 15-20% if normal kidneys
Carbs. 45-65% with minimum of 130 g per day
<200mg cholesterol,
2 or more fish for fatty acids
Fiber improves carb metabolism and lowers cholesterol, 25g/day
Alcohol 2 men 1 woman can cause hypoglycemia, drink after meal

1 unit of rapid acting covers 15 g carbs

Question 15

Exercise

Answer 15

Can cause hypoglycemia
Moderate exercise can use 2-3 mg/kg/min. (70kg person needs 10-15 g carbs per hour)

With uncontrolled diabetes it can cause hyperglycemia and ketone bodies. Do not exercise if ketones are present.

Exercise increases insulin sensitivity and better uptake of glucose.

5-10 min warm up stretch and low intensity
After activity, cool down 5-10 min.
150 min/wk moderate or 90 min vigorous at least 3 x week
More than 4 hrs helps decrease cardio risk.
Resistance 3x week

Do not exercise within 1 hr insulin or at insulin s peak.
Eat extra 15-30 carbs for 30-60 min exercise fruit, fruit juice, breads, whole milk

Question 16

Hyperinsulemia

Answer 16

Chronic high insulin levels can lead to weight gain. They may need to manage hyperglycemia by restricting calories instead of increasing insulin. Weight gain can be minimized by following the meal plan, exercise, and avoiding overtreatment of hypoglycemia.

Question 17

Pain relief

Answer 17

Neuropathic pain is common.

Anticonvulsants: neurotic
Tricyclics antidepressants elavil and pamelor if pain disrupts sleep.
Cymbalta.
Capsaicin cream 4xday

Do not abruptly stop these meds.

Question 18

Hypoglycemia

Answer 18

Brain depends on glucose
Glucagon and epinephrine raise blood glucose stimulate liver to convert protein to glucose.

Epinephrine limits insulin secretion
GH and cortisol long term.
Long term diabetics can develop hypoglycemia unawareness.

Caused by excess insulin, missed meals, exercise, alcohol,

S&S cold, clammy, anxious, confusion, seizure, coma, vision changes, weak, fatigue, shaky, pounding heart, hungry, tingle,

Onset menses, decreased hormones, hypoglycemia
Fresh insulin is more potent
Can cause nightmares and headaches

Question 19

Management of hypoglycemia

Answer 19

See pic.
Glucagon causes vomitting
50%dextrose causes extravasation

Question 20

Diabetic ketoacidosis

Answer 20

Lack of insulin, and counter regulatory hormones. Onset is sudden. Can be caused by infection, stress, inadequate insulin. Manifestations: Kussmaul resp (try to correct acidosis causing resp alkalosis), nausea, abdominal pain, dehydration, electrolyte loss, polyuria, polydipsia, polyphagia, wt loss,dry skin, sunken eyes, soft eyeballs, lethargy, coma
Labs: >300 BG,
Ketones, pH20 BUN, >1.5 creatnine cuz of dehydration
Death occurs 10% time

Question 21

Hyperglycemia management

Answer 21

First asses airway, loc, hydration, electrolytes, and BG,, monitor vitals q 15 min,

1kg body wt=1L fluid, assess edema, wt daily,
Watch fluid balance and kidneys closely, watch for CHF and pulmonary edema

Fluids: 1 L isotonic bolus, to maintain perfusion to vital organs. Replace total losses more slowly using .45saline. Once BG 300, maintain fluids (drinks with glucose and carbs) even while nausea

Call when BG>250, ketones more than 24 hrs, can’t take fluids, sick 1-2 days.

Question 22

Hyperglycemia hyperosmolar state HHS

Answer 22

Caused by hyperglycemia and dehydration but is different from ketoacidosis in that Ketone levels are low or absent and blood glucose levels are much higher. Blood glucose may exceed 600 and osmolarity may exceed 320.

Gradual onset, infection stress or low fluid intake may precede,

Altered CNS, dehydration and electrolyte loss, >600 BG, >320 osmolarity, no ketones, >7.4 pH, elevated BUN and creatinine. May have seizures and reversible paralysis, coma.

Kidneys can’t filter glucose and function deteriorates. Blood volume is decreased. This does not occur in adequately hydrated patient. Enough insulin is secreted to prevent ketones but not to prevent hyperglycemia. Impairment of thirst center leads to greater dehydration.

Rehydrated and normal BG in 36-72 hrs.

Fluids: NS or 1/2 NS at 1 L /hr until BP and urine output are adequate. Reduce to 100-200 ML /hr. replace half deficit in 12 hrs, other over 36 hrs,

IV insulin with 50-70 reduction/hr. monitor hypokalemia.

Same preventions as DKA.

Question 23

Education

Answer 23

Most important thing to teach is the significance, symptoms, causes, and treatment of hypoglycemia. Patient must be able to describe carbohydrates to have available and notify the doctor of hypoglycemic episodes. Teach a family member how and when to inject glucagon.

Info is best retained when PT is ready to learn.