Class Activity – Diabetes Flashcards
The patient is a 60 year-old-woman who is 1 day postoperative after a total knee replacement. She has type 2 diabetes and just recently was switched from oral antidiabetic drugs to an insulin regimen. She let her nurse know that her on-demand lunch has been ordered. The nurse tests her blood and gives her the prescribed short-acting insulin dose. An hour later, the physical therapist finds her pale, confused, and clammy. Her lunch tray is on her table and appears totally untouched.
Pats come into hospital and on oral agent switched to sliding scale insulin because: tests might have medications can be hard on kidneys and if doing certain surgery or diagnostics with dye not supposed be on certain drugs because hard on kidneys so need be off for 48 hours; so take off oral and put bn on sliding scale. Switch to sliding since not know what tests going to do; if not on anything also on sliding; BG increases when sick because of infection.
1. Is her condition consistent with hyperglycemia or hypoglycemia? Explain your choice.
Hypoglycemia because cold and clammy give them candy. Consistent with hypoglycemia. Received insulin 1 hour ago and if received 1 hour ago and lunch tray untouched, not eaten anything. Brain uses glucose so all be symptoms of not enough BG. She is pale, confused, and clammy which is consistent with it. Furthermore, since she did not touch her food this would cause her to have too low of blood glucose resulting in hypoglycemia.
Not change LOC until severe. Want carb before insulin because hypoglycemia more severe before hyperglycemia (warm moist skin, possible fruity breath odor, not change LOC until severe); hypoglycemia happens quickly
Her condition is consistent with hypoglycemia, especially because she received insulin about an hour ago.
Manifestations of hypoglycemia include weakness; difficulty thinking; confusion; sweating; and cool, pale skin.
Manifestations of hyperglycemia include warm, moist skin and possible fruity breath odor. Hyperglycemia does not change level of consciousness until it is severe.
“hypo” classic signs: cool, clammy and confused
- What is your first action? Provide a rationale.
Orange juice. Some sort of carb. Raise BG fast. Want simple sugar. Give something raises BG up quickly (which not normally do except in this situation): Glucose tabs, orange juice, candy, real soda that raises it up fast.
Check BG level immediately – give something but check level because depending on level depends on what do; have hypoglycemia protocol in PRN orders – typ on pats who have diabetes – on what to do; say how many grams of carbs on fridge
Check BG first – need more info; intervention – give that sugar but first thing is assess further and see where at with that
Meter nearby check first – not accurate – not want eat and check not know how low got if safe; check BG immediately
Prevent getting hypoglycemic – a lot get it because on carb diet and when order things are consuming less carbs so not used to it so sometimes become hypoglycemic because of that or because of things in room because people bringing them something; prevent that; not want get to point where cool, clammy, confused
Not able to take PO – not conscious or NPO; give IM/SQ or IV – have IV pick that – push dextrose is very thick – make sure have good IV push through; preferred give PO; want give juice and eat breakfast; not just want juice – quick simple sugar comes back down again; not give IV/IM/SQ and not eating and not getting complex carbs (fats, proteins) comes back down because pure sugar; want be able take PO if can – depends on situation; PO preferred route if can
Check her blood glucose level immediately because the methods to increase her blood glucose level are dependent on how low the current level is.
As an alternative, if there is an easily digestible carbohydrate on her tray and she is able to swallow, you could give that to her immediately and then obtain a blood glucose measurement. However, this is less precise.
Prevention is best!
All health care facilities should have specific policies regarding hypoglycemia treatment. – follow protocol
Ex.
If PBG is less than 70 and patient is able to take PO intake then give 15-20 grams of oral carbohydrates (glucose)
Recheck PBG after 15 minutes; if still symptomatic or PBG still less than 70 give another give another 15-20 grams of oral carbohydrates (glucose)
If PBG is less than 50 and patient is able to take PO intake then give 30 grams of oral carbohydrates (glucose) and then follow same protocol
If PBG less than 70 and patient is not able to take PO then need to give glucagon IM or SQ or Dextrose 50% IV
Know that replacing glucose PO is preferred and once the patient is able to take PO intake we will give an oral glucose to keep PBG up
- What is the most likely cause leading to this problem?
Did not take in food; gave insulin without pat having tray in front of her; when giving insulin and rapid/fast acting imp; long acting not care if tray in front because working on BG all day; short acting – need tray in front of them and know going to eat
Recently started on insulin not realize have eat but oral meds have eat – pat edu on diabetes; designated DM educators and provide pats info; need teach pats – educators might not be available and very few of them and need teach pat as go along
Causes – had both deficient intake and excessive insulin; exercise: depends type exercise doing: hit workout decreases BG – careful when exercising to make sure eaten ahead of time if diabetic and know s/s of hypoglycemia because using extra energy and sweating
Clearly, there was a delay in eating after receiving the insulin. The tray may have been delayed longer than expected from food service, or perhaps she decided she was not hungry when it first arrived. She could have been interrupted (possible phone call or visitor) before she had a chance to eat it.
In addition, it is possible because she has only recently been started on insulin that she did not understand the necessity of eating soon after receiving insulin.
Causes of hypoglycemia:
deficient intake
excessive insulin
exercise (can increase or decrease blood glucose)
alcohol (decreases liver glucose production)
decreased gastric emptying
- What could be done on this nursing care unit to prevent such an incident from happening again?
Keep up with diet and hydration
Prevent from giving this when not have tray in front of them: Education – need make sure nurses and staff educated about this and patient; patient receive edu – so should nurses
Evaluate pat – not give insulin and walk out esp if new and giving for first time and not check on them for long period of time; make sure ate, feeling ok with it – admin of new med but insulin can cause hypoglycemia and that is big issue so need see how responding to that; may need to encourage eating more carbs – tickets tell how many carbs; sliding scale – premeal BG; on carb count – wait until eat and count carbs until give insulin; sometimes get scheduled amount – look at orders for amount insulin
The patient should receive more education about the relationship between insulin and eating.
The unit needs to establish guidelines or policies about premeal insulin administration. Perhaps it should not be administered until the tray is actually in the patient’s possession and the patient is ready to eat it.
Also, whenever short-acting insulin is given, the nurse giving it should evaluate the patient within 20 minutes.
The patient, a 21-year-old college student, was brought to the emergency department (ED) by his roommate. He reports abdominal pain, polyuria for the past 2 days, vomiting several times prior to arrival, and extreme thirst. He appears flushed, and his lips and mucous membranes are dry and cracked. His skin turgor is poor. He demonstrates deep rapid respirations; there is a fruit odor to his breath. He has type 1 diabetes and “may have skipped a few doses of insulin because of cramming for final exams.” He is alert and talking but is having trouble focusing on your questions.
Deep rapid respirations with fruity odor breath – Kussmal’s respirations
1. Should you apply oxygen at this time? Why or why not?
Oxygen is not needed. Although his respiratory rate is above normal, he is not hypoxemic. Applying oxygen would serve no useful purpose. His respiratory symptoms are a result of compensation for the metabolic acidosis
His respiratory symptoms are a result of compensation for the metabolic acidosis
What is going on with this patient?
- Hyperglycemia (BG 485): Ketones: Polyuria; acute complication
- Diabetic Ketoacidosis (DKA): uncontrolled hyperglycemia, metabolic acidosis, and increased production of ketones
- Causes: infection, stress, inadequate insulin; causes: Exam stress and inadequate insulin – skipped few doses because cramming; temp: may have an infection so has 2/3
Oxygen at 99%; not needed at this time; not just put on people just put on them; respirations are at 32 but O2 sat at 99%; high RR – hyperventilating get rid CO2 to blow it off; is the compensatory mechanism – O2 sat still good so not need apply O2 at this time
- In caring for this patient, what immediate intervention do you anticipate provider will order to be performed first? Provide a rationale for your choice.
He needs carefully regulated insulin therapy at this time, which is best accomplished by the IV route.
Regular insulin is the only insulin administered IV
Subcutaneous insulin does not absorb fast enough and is inappropriate for emergency situations.
The patient needs IV fluids to correct fluid deficit that places him at risk for hypovolemic shock
Only type insulin can give IV: regular; why give insulin vs fluids: T1DM no insulin and cannot regulate it; are going to give IV fluids but not first thing do; do first with DKA give insulin first; need IV fluids; may also need electrolytes replaced – peeing off electrolytes and look at that electrolyte levels – K also something give pats (can give IV); subQ insulin not absorb fast enough for emergency and enough of that for situation; in ICU on insulin drip; first thing do: IV insulin
- What is another acute complication of DM resulting in elevated glucose? How are they different?
Hyperglycemic hyperosmolar state (HHS): increased blood osmolarity caused by hyperglycemia and dehydration. In HHS there are no ketones (no acidosis), blood glucose levels are even higher than with DKA and blood osmolarity is very high (very elevated BUN and creatinine).
HHS: more of the gradual onset over time; takes awhile for neurologic symp and BG high enough and with gradual onset where have altered CNS with neurological symptoms; severe dehydration and electrolyte loss; PBG >600; can also draw blood to see what it is – very high
DKA: sudden onset; ketones present; also have dehydration and electrolyte loss; experiencing 3Ps (polyuria, polydipsia, polyphagia); have acidosis; PBG >300 – still high but not as high as HHS
During a clinic visit, you are reviewing the records of a 39-year-old patient who was diagnosed 5 years ago with type 2 diabetes. You discover that, although he has always been extremely near-sighted, he has not seen an ophthalmologist for 4 years. He has gained 12 lbs since his last visit a year ago. His laboratory values show a fasting blood glucose level of 96 mg/dL, an A1C of 8.2%, a total cholesterol of 322 mg/dL, and an LDL of 190 mg/dL. When you ask him about ophthalmology follow-up and point out his laboratory values, he replies that because he is taking prescribed antidiabetic medication, he believes that he won’t have all the diabetes complications that his father had. He further tells you that he did have his eyes checked by an optometrist to make sure his prescription was accurate but that because he was younger than 40 years old, he does not need intraocular pressure measurements.
Fasting BG – normal; hours leading up to draw
A1C – high; indicates: poor BG control over time; gives full pic
Total cholesterol – high; should be less than 200
LDL – high; bad cholesterol; not want be high; should be <130
1. How should you interpret his laboratory values in terms of his personal glucose regulation?
His laboratory values show a fasting blood glucose level of 96 mg/dL, an A1C of 8.2%, a total cholesterol of 322 mg/dL, and an LDL of 190 mg/dL
Fasting blood glucose level is acceptable and indicates that he has controlled his diabetes during the past 24 hours.
Hemoglobin A1C is high, indicating that his overall control for the past several months is poor. - It is possible that the current medication regimen is not sufficient to manage his disease.
Weight is increasing rather than decreasing and his blood lipid levels are quite high may indicate that his nutrition therapy is probably not being followed. - Important with diabetic clients to keep cholesterol under control; Normal values: cholesterol <200; HDL > 55 (women) or > 45 (men); LDL < 130
Medication currently on not high enough; possibly not educated enough about diabetes because telling us that not have comps that father had; weight increasing rather than decreasing
Lipid levels high which shows diet not likely being followed that recommended
Imp with diabetic clients that keep cholesterol under control; can have issues so want them keep these under control
- Should you address his weight gain? Why or why not?
Yes
Probably not following diet; know diet, exercise plays into T2DM; with weight gain showing not having control; not have good BG control; need address it; need have hard convos – explain to them what happen if not follow regiment and understand what is in there way – resources or lack of understand; figure out what motivates them and how best help them
Major pathophysiological problem with type 2 diabetes is insulin resistance. – increased weight gain only make worse
Increasing weight correlates to greater insulin resistance - weight loss and tight BG control can improve the sensitivity of insulin receptors to insulin. Go off diabetic drugs if keep tight BG control – depends how bad insulin resistance is
Excess weight is contributing even more to his risk for cardiovascular events, as evidenced by the high blood lipid levels. – diabetes puts people at high risk for cardiac events – why may have heart disease and DM so need make sure pats understand that
- Is he correct in thinking that an ophthalmologist visit is not necessary at this time? Explain your response.
His risk for ophthalmic complications leading to blindness is high - He should be seen yearly by an ophthalmologist
Can cause blindness/retinopathy – excess sugar in bloods (little crystals) damaging vessels and vessels in eyes very tiny – microvascular – too much BG and excess sugar damages vessel
What are the 3 most common microvascular chronic problems associated with diabetes?
- Retinopathy
o Caused by damage to the retinal vessels causing leaking and retinal hypoxia
o Excess sugar can damage vessels in eye
- Neuropathy
o Progressive deterioration of nerves
o Loss in sensation or muscle weakness
o Pats describe neuropathic pain: Tingling in hands and feet, pins and needles
- Nephropathy
o Chronic high blood glucose causes damage to blood vessels in kidneys causing leaking and hypoxia
o Kidneys allow filtration of larger particles which damage the kidneys further because damage – vicious cycle; imp keep tight BG control – going on in body; go on dialysis if enough damage to kidneys from diabetes
- Is he correct in believing that taking antidiabetic medication will prevent complications of diabetes? Explain your response.
Not completely – will help in regulating BG but also do other things that go with it and has be on right regiment because not controlling it at this point but has do other things as well
Diabetes is a complex disorder and can only be controlled with a combination of things - antidiabetic medications (oral and/or taking insulin); life-style changes that include: nutrition therapy (carb counting, low cholesterol, avoid alcohol), maintenance of a healthy weight, blood pressure control, blood lipid control, getting physical activity – does help a lot with insulin resistance so imp be aware of this
Apps for carb counting that lot easier but some not want do that; can also use books – depends on pat
- How do you propose to assist this patient in managing his diabetes?
The patient’s comments and the laboratory data indicate that he does not understand the disease, its consequences, management techniques, and his role in the management plan.
Primary focus is on controlling blood glucose and preventing long term complications
Education is really big – comments and looking at lab work indicates not understanding regiment; telling him about long term comps and might be aware of long-term comps with father but not want think about but need control BG now even tho younger so not happen down the line
