Diabetes Flashcards
Give 8 risk factors of diabetes
Family history of diabetes
Obesity
Race/ethnicity
Age
Previously identified impaired fasting glucose or impaired glucose tolerance
Hypertension
HDL cholesterol 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 babies over 9 lb
Obesity (ie, ___ over desired body weight or BMI___ kg/m2)
20% over desired body weight
BMI_27 kg/m2
Race/ethnicity
African Americans
Hispanic Americans
Native Americans
Asian Americans
Pacific Islanders
Specific Age
45 y
Hypertension
(_140/90 mm Hg)
HDL cholesterol level __ mg/dL (0.90 mmol/L) and/or triglyceride level __ mg/dL (2.8 mmol/L)
35 mg/dl
250 mg/dl
History of gestational diabetes or delivery of babies over __
9 lb
Insulin is a hormone secreted by
beta cells.
Insulin is ____ or ___ hormone.
an anabolic, or storage,
Insulin transports and metabolizes ___ for energy
glucose
Insulin stimulates storage of glucose in the ___ and ___ (in the form of ___)
liver and muscle
glycogen
insulin signals the ___ to stop the release of glucose
liver
insulin Enhances storage of dietary fat in ___
adipose tissue
Insulin Accelerates transport of ___ (derived from dietary protein) into cells
amino acids
Inhibits the breakdown of stored __, __, __
glucose, protein, and fat
Initially, the liver produces glucose through the breakdown of glycogen (__).
glycogenolysis
After 8 to 12 hours without food, the liver forms glucose from the breakdown of noncarbohydrate substances, including amino acids (___).
gluconeogenesis
Characterized by the destruction of the pancreatic beta cells.
Type 1 Diabetes
Combined __, __, __ are thought to contribute to beta-cell destruction.
genetic, immunologic, and possibly environmental factors
Destruction of the beta cells results in __, __, __
decreased insulin production, increased glucose production by the liver, and fasting hyperglycemia.
Glucose from food cannot be stored in the liver but instead remains in the bloodstream and contributes to ___
postprandial (after meals) hyperglycemia.
If the concentration of glucose in the blood exceeds __ to __ , glucose appears in the urine (___).
180 to 200mg/dL
glycosuria
When excess glucose is excreted in the urine, it is accompanied by excessive loss of fluids and electrolytes (___)).
osmotic diuresis
Insulin normally inhibits glycogenolysis and gluconeogenesis, causing the opposite in type __ diabetes.
1
Fat breakdown results in an ___ (a highly acidic substance).
increased production of ketone bodies
a metabolic derangement that occurs most commonly in persons with type 1 diabetes.
Diabetic ketoacidosis (DKA) -
Results from a deficiency of insulin; formation of highly acidic ketone bodies causing ___
metabolic acidosis
The breath has a characteristic __ due to the presence of ketoacids.
fruity odor
In Type 2 Diabetes, it affects approximately __ of adults with the disease.
95%
The two main problems in type 2 diabetes are
- Insulin resistance
- Impaired insulin secretion
decreased tissue sensitivity to insulin.
- Insulin resistance
- Insulin resistance - decreased tissue sensitivity to insulin.
- may also lead to ___ (__, __, __)
metabolic syndrome
hypertension, hypercholesterolemia, abdominal obesity, and other abnormities.
___ does not typically occur in type 2 diabetes.
DKA
If Type 2 Diabetes is uncontrolled, may lead to
hyperglycemic hyperosmolar syndrome (HHS).
To overcome insulin resistance and to prevent the buildup of glucose in the blood, increased amounts of insulin must be secreted to maintain the glucose level at a normal or slightly elevated level. This is called ___ which includes
metabolic syndrome,
which includes hypertension, hypercholesterolemia, and abdominal obesity.
Common symptoms of type 2 diabetes give atleast 3
fatigue, irritability, polyuria, polydipsia, poorly healing skin wounds, vaginal infections, or blurred vision.
Long-term diabetes complications include
eye disease, peripheral neuropathy, peripheral vascular disease.
any degree of glucose intolerance with its onset during pregnancy.
Gestational Diabetes
In gestational diabetes, hyperglycemia develops because of the secretion of __ , which causes insulin resistance.
placental hormones
In gestational diabetes, Women considered to be at high risk or average risk should have either an ___ or a ___ followed by OGTT in women who exceed the glucose threshold value of ___
oral glucose tolerance test (OGTT)
glucose challenge test (GCT)
140 mg/dl
- blood sample will be taken from a vein in the arm to test the starting blood sugar level.
- The client will then drink a mixture of glucose dissolved in water.
- The client will get another blood glucose test ___ later (__ for pregnant women).
OGTT
2 hours
1 hr
- Below 140 mg/dL:
normal blood sugar
- Between 140 and 199
: impaired glucose tolerance, or prediabetes
- 200 or higher:
diabetes
impaired glucose tolerance, or prediabetes level
Between 140 and 199
normal blood sugar level
Below 140 mg/dL:
- measures the body’s response to glucose.
- The client drinks a sugary solution.
- ___ later, the client’s blood sugar level is measured.
GCT
One hour
While pregnant, a blood sugar level of 140 mg/dL (7.8 mmol/L) or higher might indicate
gestational diabetes
in gestational diabetes, initial management includes ___ and __
dietary modification and blood glucose monitoring.
(gestational diabetes) If hyperglycemia persists, ___ is prescribed.
insulin
Goals for blood glucose levels during pregnancy are __ mg/dL or less before meals and __ mg/dL or less 2 hours after meals.
95 mg/dl
120 mg/dl
When does blood glucose levels in women with gestational diabetes usually return to normal.
After delivery,
- However, many women who have had gestational diabetes develop type 2 diabetes later in life (__% to __%).
35% to 60%
slow-progressing form of autoimmune diabetes.
LATENT AUTOIMMUNE DIABETES OF ADULTS (LADA)
Patients with LADA are ___ in the initial ____ of disease onset.
not insulin-dependent
6 mons
Clinical manifestation of LADA shares the features of
types 1 and 2 diabetes.
Type 2 diabetes can be prevented with
appropriate changes in lifestyle.
Classic clinical manifestations of hyperglycemia include the
“three Ps”: polyuria, polydipsia, and polyphagia.
___ (increased urination) and ___ (increased thirst) occur as a result of the excess loss of fluid associated with ____. Patients also experience ___ (increased appetite)
Polyuria
polydipsia
osmotic diuresis
polyphagia
The onset of type 1 diabetes may also be associated with ____ (give 2), if DKA has developed.
sudden weight loss or nausea, vomiting, or abdominal pains
ASSESSMENT AND DIAGNOSTIC FINDINGS of diabetes
An abnormally high blood glucose level
Fasting plasma glucose (FPG)
Random plasma glucose
the basic criterion for the diagnosis of diabetes.
An abnormally high blood glucose level
Criteria for the Diagnosis of Diabetes Mellitus
Symptoms of diabetes plus casual plasma glucose concentration equal to or greater than ___ mg/dL (11.1mmol/L).
___ is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include __, __, _
200 mg/dl
Casual
polyuria, polydipsia, and unexplained weight loss
Criteria for the Diagnosis of Diabetes Mellitus
Fasting plasma glucose greater than or equal to ___ mg/dL (7.0 mmol/L).
___ is defined as no caloric intake for at least 8 hour
126 mg/dL
Fasting
Criteria for the Diagnosis of Diabetes Mellitus
Two-hour postload glucose equal to or greater than ____ (11.1 mmol/L) during an ___.
The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of ____ anhydrous glucose dissolved in water. In the absence of unequivocal hyperglycemia with acute metabolic decompensation, these criteria should be confirmed by repeat testing on ___ day. The ___ is not recommended for routine clinical use.
200 mg/dL
oral glucose tolerance test
75 g
a different
third measure
Medical Management
* The main goal of diabetes treatment is ____ to reduce the development of complications.
* The therapeutic goal for diabetes management is to achieve normal blood glucose levels (____) without hypoglycemia while maintaining a high quality of life.
* Diabetes management has five components:
to normalize insulin activity and blood glucose levels
euglycemia
nutritional therapy, exercise, monitoring, pharmacologic therapy, and education.
Nutritional management includes the following goals:
1. To achieve and maintain: (3)
a. Blood glucose levels
b. A lipid and lipoprotein profile
c. Blood pressure levels
a. Meal Planning and Related Education
* must consider ____
* helps prevent ____reactions and maintain overall blood glucose control.
* Initial education addresses the ____
* In-depth follow-up education then focuses on ___
the patient’s food preferences, lifestyle, usual eating times, and ethnic and cultural background.
hypoglycemic
importance of consistent eating habits, the relationship of food and insulin, and the provision of an individualized meal plan.
management skills, such as eating at restaurants; reading food labels; and adjusting the meal plan for exercise, illness, and special occasions.
are planned by first calculating a person’s energy needs and caloric requirements based on age, gender, height, and weight.
- Calorie-controlled diets
is then factored in to provide the actual number of calories required for weight maintenance.
- An activity element
- To promote a 1- to 2-lb weight loss per week, ____ calories are subtracted from the daily total.
500 to 1000
The ____ are distributed into carbohydrates, proteins, and fats, and a ____ is then developed, taking into account the patient’s lifestyle and food preferences.
calories
meal plan
recommended is higher in ____ (50-60%) than in ___ (20% to 30% and ___ (10% to 20%).
carbohydrates
fat
protein
reducing the total percentage of calories from fat sources to less than __ of total calories and limiting the amount of saturated fats to __ of total calories.
fats
30%
10%
The meal plan may include the use of some nonanimal sources of protein (e.g., ____, _____) to help reduce ____ and ___
legumes, whole grains
saturated fat
cholesterol intake.
soluble fiber examples: (2)
insoluble fiber examples: (2)
legumes, oats
whole-grain breads and cereals
used to describe how much a given food increases the blood glucose level compared with an equivalent amount of glucose.
- Glycemic Index -
- An alternative to counting grams of carbohydrate is measuring servings or choices. It is similar to the food exchange list and emphasizes portion control of total servings of carbohydrate at meals and snacks.
- Healthy Food Choices
Food manufacturers are required to have the nutrition content of foods listed on their packaging. The label includes information about how many grams of carbohydrate are in a serving of food.
- Nutrition Labels -
Foods within one group (in the portion amounts specified) contain equal numbers of calories and are approximately equal in grams of protein, fat, and carbohydrate.
Exchange lists
There are six main exchange lists:
bread/starch, vegetable, milk, meat, fruit, and fat
- Combining ___ tends to slow their absorption and lower the glycemic index.
- In general, eating foods that are raw and whole results in a ____ glycemic index than eating chopped, puréed, or cooked foods (except meat).
- Eating whole fruit instead of drinking juice decreases the glycemic index, because ____ in the fruit ___ absorption.
- Adding ____ with sugars to the diet may result in a ____ glycemic index if these foods are eaten with foods that are more slowly absorbed.
starchy foods with protein- and fat-containing foods
lower
fiber
slows
foods
lower
___ is absorbed before other nutrients and does not require insulin for absorption.
- Large amounts can be converted to ____, increasing the risk for ___.
Alcohol
fats
DKA
The use of ____ is acceptable, especially if it assists in overall dietary adherence.
artificial sweeteners
There are two main types of sweeteners:
nutritive and nonnutritive.
The ____ contain calories, and the ____ have few or no calories in the amounts normally used.
nutritive sweeteners
nonnutritive sweeteners
Foods labeled _____ or ____ may still provide calories equal to those of the equivalent sugar-containing products if they are made with ____.
Foods labeled ____ are not necessarily reduced-calorie foods.
“sugarless”nutritive or “sugar-free”
sweeteners
“dietetic”
Extremely important in diabetes management because of its effects on lowering blood glucose and reducing cardiovascular risk factors.
Exercise
- The nurse instructs the patient to:
1. Exercise __ times each week with no more than __ consecutive days without exercise.
2. Perform ____ twice a week if you have type 2 diabetes.
3. Exercise at ____ (preferably when blood glucose levels are at their peak) and for the same duration each session.
4. Use proper ___ and, if appropriate, other protective equipment (i.e., helmets for cycling).
5. Avoid trauma to the lower extremities, especially if you have ___
6. Inspect ____ daily after exercise.
7. Avoid exercise in ____
8. Avoid exercise during periods of ___
9. Stretch for ____ before exercising.
three time each week
no more than 2 consecutive days
resistance training
the same time of day
footwear
numbness due to peripheral neuropathy.
feet
extreme heat or cold.
poor metabolic control.
10 to 15 minutes
a method of capillary blood glucose testing in which the patient pricks their finger and applies a drop of blood to a test strip that is read by a meter.
SMBG
It is recommended that ___ occurs when circumstances call for it.
SMBG
Some common sources of error include: (give 2)
improper application of blood (e.g., drop too small),
damage to the reagent strips caused by heat or humidity,
the use of outdated strips
improper meter cleaning and maintenance.
For most patients who require insulin, SMBG is recommended __ daily (usually __ and ___).
two to four times
before meals and at bedtime
For patients who take insulin before each meal, SMBG is required at least ____ to determine each dose.
three times daily before meals
Patients are asked to keep a ____ of blood glucose levels so that they can detect patterns.
record or logbook
Testing is done at the ___ to evaluate the need for dosage adjustments.
peak action time of the medication
a measure of glucose control for the past 3 months.
Testing for Glycated Hemoglobin
When blood glucose levels are elevated, glucose molecules attach to ___ in red blood cells.
The longer the amount of glucose in the blood remains above normal, the ___ binds to hemoglobin and the higher the glycated hemoglobin level becomes.
This complex (hemoglobin attached to the glucose) is ___ and lasts for the life of an individual red blood cell, approximately __ days.
hemoglobin
more glucose
permanent
120 days
accumulate in the blood and urine.
Ketones (or ketone bodies)
___ in the urine signal that there is a deficiency of insulin and control of type __ diabetes is deteriorating.
Ketones
type 1
The patient may use a ___ to detect ketonuria. The reagent pad on the strip turns ___ when ketones are present.
urine dipstick
purple
In type 1 diabetes, ____ must be given for life.
In type 2 diabetes, insulin may be necessary on ___ to control glucose levels.
exogenous insulin
a long-term basis
are given two or more times daily to control the blood glucose level.
Insulin injections
is a cornerstone of insulin therapy. Insulin dose required is determined by the level of glucose in the blood.
SMBG
a. Preparations - vary according to three main characteristics:
time course of action, species (source), and manufacturer.
- vary from 1 to 4 injections per day.
Insulin Regimens
- There are __ guidelines as to which insulin regimen should be used for which patient.
no set
- Usually, there is a combination of a __ and __ short-acting insulin and a longer-acting insulin.
short-acting insulin and a longer-acting insulin.
- There are two general approaches to insulin therapy:
conventional and intensive.
simplified insulin regimen.
- Conventional Regimen –
- complex insulin regimen.
- Intensive Regimen
would be appropriate for the terminally ill, the older adult who is frail and has limited self-care abilities.
The simplified regimen
- allows the patient more flexibility to change the insulin doses from day to day in accordance with changes in eating and activity patterns.
- Intensive Regimen
The risk of ___ increases threefold in patients receiving intensive treatment.
severe hypoglycemia
– nocturnal hypoglycemia followed by rebound hyperglycemia.
- Somogyi effect
thought to result from nocturnal surges in growth hormone secretion.
- The dawn phenomenon -
caused by several factors: the dawn phenomenon, the Somogyi effect, or insulin waning.
- Morning Hyperglycemia -
*Patients may develop insulin resistance and require large insulin doses. Immune antibodies develop and bind the insulin.
Resistance to Injected Insulin -
a localized reaction, in the form of either lipoatrophy or lipohypertrophy, occurring at the site of insulin injections.
- Insulin Lipodystrophy -
- Systemic Allergic Reactions – the treatment is ___
desensitization.
c. Complications of Insulin Therapy (give 4)
- Systemic Allergic Reactions
- Insulin Lipodystrophy
- Resistance to Injected Insulin
- Morning Hyperglycemia
- The dawn phenomenon
- Somogyi effect
d. Methods of Insulin Delivery
(give 3)
Insulin Pens
* Jet Injectors
* Insulin Pumps
- Insulin is delivered by dialing in a dose or pushing a button for every 1- or 2unit increment given.
Insulin Pens
- deliver insulin through the skin under pressure in an extremely fine stream.
- Jet Injectors
- involves the use of small, externally worn devices that closely mimic the functioning of the normal pancreas.
- Insulin Pumps
- for patients who have type 2 diabetes that cannot be treated effectively with MNT and exercise alone.
Oral Antidiabetic Agents
- a synthetic analogue of human amylin. It acts to ___ the rate at which food leaves the stomach and reduces ___.
Pramlintide (Symlin)
slow
appetite
derived from a hormone that is produced in the small intestine and has been found to be deficient in type __ diabetes.
It is normally released after food is ingested to delay gastric emptying and enhance insulin secretion.
Exenatide (Byetta, Byduron) -
type 2
Nursing Management
- Managing Glucose Control in the Hospital Setting
- Blood glucose targets are __
- Insulin (subcutaneous or IV) is preferred to ___ to manage hyperglycemia.
- ___, ___, and ___ are all crucial for glucose control and to avoid hypoglycemia.
140 to 180 mg/dL.
oral antidiabetic agents
Appropriate timing of blood glucose checks, meal consumption, and insulin dose
Effect of __ and __ (decrease glucose)
Effect of __ and __ , including __ and ___ (increase glucose)
insulin and exercise
food and stress
illness and infections
- Storing Insulin - should be
refrigerated.
- The insulin vial in use should be kept at room temperature to reduce ___ at the injection site.
local irritation
Cloudy insulins should be
thoroughly mixed.
- Bottles of intermediate-acting insulin should also be inspected for
flocculation (frosted, whitish coating inside the bottle).
- Selecting Syringes - currently, three sizes of __ insulin syringes are available:
* __ ml syringe, __-unit capacity
* __-mL syringe, __-unit capacity
* __-mL syringe, __-unit capacity
- Most insulin syringes have a disposable ____ gauge needle that is approximately ___ long.
U-100
1-mL syringe, 100-unit capacity
0.5-mL syringe, 50-unit capacity
0.3-mL syringe, 30-unit capacity
27- to 29
0.5 in
- Mixing Insulins
- When rapid- or short-acting insulins are to be given simultaneously with longer-acting insulins, they are usually mixed together in the ___
the ADA recommends that the __ be drawn up first.
same syringe.
regular insulin
Withdrawing Insulin
* instruct patients to inject __ into the bottle of insulin equivalent to the ___
air
number of units of insulin to be withdrawn.
- Selecting and Rotating the Injection Site
* The four main areas for injection are the ___
- The speed of absorption is greatest in the ? and decreases progressively in the ?
- Systematic rotation of injection sites within an anatomic area is recommended to prevent localized changes in fatty tissue (?).
- The patient should be encouraged to use all available injection sites within one area rather than randomly rotating sites from area to area.
- The patient should try not to use the exact same site more than once in __
- If the patient is planning to ___, insulin should not be injected into the limb that will be exercised.
abdomen, upper arms (posterior surface), thighs (anterior surface), and hips.
abdomen
arm, thigh, and hip, respectively.
lipodystrophy
2 to 3 weeks.
exercise
- Inserting the Needle - for a normal or overweight person, a __ degree angle is the best insertion angle.
- __ is not necessary.
90-
Aspiration
- HYPOGLYCEMIA (INSULIN REACTIONS)
* Occurs when the blood glucose falls to less than __ mg/dL.
* Severe hypoglycemia is when glucose levels are less the __ mg/dL.
- It often occurs __, especially if meals are delayed or snacks are omitted.
70 mg/dL.
40mg/dL.
before meals
Hypoglycemia
Clinical Manifestations
* may be grouped into two categories:
adrenergic symptoms and central nervous system (CNS) symptoms.
In ___, the __ nervous system is stimulated, resulting in a surge of epinephrine and norepinephrine.
This causes symptoms such as sweating, tremor, tachycardia, palpitation, nervousness, and hunger.
mild hypoglycemia
sympathetic
In ___ , the drop in blood glucose level deprives the brain cells of needed fuel for functioning.
Signs of impaired function of the CNS may include inability to concentrate, headache, lightheadedness, confusion, memory lapses, numbness of the lips and tongue, slurred speech, impaired coordination, emotional changes, irrational or combative behavior, double vision, and drowsiness.
- In moderate hypoglycemia
In ____, ___ function is so impaired that the patient needs the assistance of another person for treatment of hypoglycemia.
Symptoms may include disoriented behavior, seizures, difficulty arousing from sleep, or loss of consciousness.
severe hypoglycemia
CNS
Assessment and Diagnostic Findings
- The hypoglycemia may not be detected until ___ occurs.
- Affected patients must perform ___ on a frequent regular basis, especially before driving or engaging in other potentially dangerous activities.
moderate or severe CNS impairment
SMBG
Management
- Immediate treatment must be given when hypoglycemia occurs.
- The usual recommendation is for __ of a fast-acting concentrated source of __.
- It is not necessary to add sugar to ____, even if it is labeled as ___.
In emergency situations, for adults who are unconscious and cannot swallow, ___ can be given either subcutaneously or intramuscularly.
- the patient may take as long as ___ to regain consciousness.
- A concentrated source of carbohydrate followed by a snack should be given to the patient on awakening to prevent recurrence of hypoglycemia (glucagon onset is ___, and its action lasts ___).
- The patient should be ___ to prevent aspiration in case the patient vomits.
- For patients who are unconscious or cannot swallow, ___ may be administered IV.
- Treating With Carbohydrates
15 g
carbohydrate
juice
unsweetened juice
an injection of glucagon 1 mg
20 minutes
8 to 10 minutes
12 to 27 minutes
turned to the side
25 to 50 mL of dextrose 50% in water (D50W)
Caused by an absence or markedly inadequate amount of insulin.
Diabetic Ketoacidosis
The three main clinical features of DKA are as follows:
- Hyperglycemia
- Dehydration and electrolyte loss
- Acidosis
- The hyperglycemia of DKA leads to ___, ___, and ___
- In addition, the patient may experience blurred vision, weakness, and headache.
- Patients with marked intravascular volume depletion may have ___.
- Volume depletion may also lead to ___ with a ___ pulse.
- The ketosis and acidosis of DKA lead to ___, such as anorexia, nausea, vomiting, and abdominal pain.
- The patient may have ___ (a fruity odor).
- In addition, ___ (with very deep, but not labored, respirations) may occur.
polyuria, polydipsia (increased thirst), and marked fatigue.
orthostatic hypotension
frank hypotension
weak, rapid pulse
gastrointestinal symptoms
acetone breath
hyperventilation
Pathophysiology
- Without insulin, the amount of ___ is reduced, and the production and release of ____ are increased.
- In an attempt to rid the body of the excess glucose, the kidneys excrete the glucose along with water and electrolytes (e.g., __, __).
- This ___, which is characterized by excessive urination (___), leads to dehydration and marked electrolyte loss.
- Another effect of insulin deficiency or deficit is the breakdown of fat (___) into ___ which are converted into ____ by the liver.
- Ketone bodies are acids; their accumulation in the circulation due to lack of insulin leads to ___
glucose entering the cells
glucose by the liver
sodium and potassium
osmotic diuresis
polyuria
lipolysis
free fatty acids and glycerol.
ketone bodies
metabolic acidosis.
Assessment and Diagnostic Findings
- Blood glucose levels may vary between ___ to ___ mg/dL (usually depending on the degree of dehydration).
- Evidence of ketoacidosis is reflected in __ serum bicarbonate ( mEq/L) and __ pH (__ to __) values.
- A low partial pressure of carbon dioxide (__ __ mm Hg) reflects respiratory compensation (___) for the metabolic acidosis.
- Accumulation of ketone bodies is reflected in __ and __ ketone measurements.
- Increased levels of __, __, ___ may also be seen with dehydration.
300 and 800 mg/dl
low serum bicarbonate (0 to 15mEq/L)
low pH (6.8 to 7.3)
PCO2 10 to 30
Kussmaul respirations
blood and urine
creatinine, blood urea nitrogen (BUN), and hematocrit
Management
- Rehydration
* The patient may need as much as ___ to ___ of IV fluid to replace fluid losses caused by polyuria, hyperventilation, diarrhea, and vomiting.
- Initially, ___ solution is given at a rapid rate, usually 0.5 to 1 L per hour for 2 to 3 hours.
- After the first few hours, ___ is the fluid of choice for continued rehydration, provided the blood pressure is stable and the sodium level is not low.
- ___ may be necessary to correct severe hypotension that does not respond to IV fluid treatment.
6 to 10 L
0.9% sodium chloride (normal saline [NS])
half-strength NS solution
plasma expanders
- Restoring Electrolytes - major concern during treatment of DKA is __ .
- The plasma concentration of potassium tends to be __ from disruption of the cellular sodium-potassium pump (in the face of acidosis).
- __ leads to increased plasma volume and subsequent decreases in the concentration of serum potassium. Also leads to increased urinary excretion of potassium.
- Insulin administration enhances the movement of potassium from the __ into the __.
- Potassium replacement - __ mEq per hour may be needed for several hours.
- Frequent (every 2 to 4 hours initially) ___ are necessary during the first 8 hours of treatment.
potassium
high (hyperkalemia)
Rehydration
extracellular fluid into the cells
40
ECGs and laboratory measurements of potassium
- Reversing Acidosis
- ? - inhibits fat breakdown, thereby ending ketone production.
?, the only type of insulin approved for IV use, may be added to IV solutions.
- Insulin must be infused continuously until subcutaneous administration of insulin can be resumed.
Insulin
Regular insulin
- __ a metabolic disorder of type 2 diabetes resulting from a relative insulin deficiency initiated by an illness that raises the demand for insulin.
- This is a serious condition in which hyperosmolarity and hyperglycemia predominate, with alterations of the ? (sense of awareness).
- __ is usually minimal or absent.
- The basic biochemical defect is the lack of effective __.
- Persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the __ fluid space to the __ fluid space.
- With glycosuria and dehydration, __ and increased osmolarity occur.
Hyperglycemic Hyperosmolar Syndrome
sensorium
ketosis
insulin
intracellular to extracellular
hypernatremia
Clinical Manifestations HHS
Give 2
- Hypotension
- Profound dehydration (dry mucous membranes, poor skin turgor)
- Tachycardia
- Variable neurologic signs (e.g., alteration of consciousness, seizures, hemiparesis)
Assessment and Diagnostic Findings HHS
* Blood glucose (usually ? To ? mg/dL)
* Electrolytes
* BUN
* Complete blood count
* Serum osmolality (? mOsm/kg)
* Arterial blood gas analysis
600 to 1200
exceeds 320
Management
- The overall approach to the treatment of HHS is similar to that of DKA: __, __, __.
- Other therapeutic modalities are determined by the underlying illness and the results of continuing clinical and laboratory evaluation.
- After recovery from HHS, many patients can control their diabetes with ___ or ___
- __ may not be needed once the acute hyperglycemic complication is resolved.
- Frequent __ is important in prevention of recurrence of HHS.
fluid replacement, correction of electrolyte imbalances, and insulin administration.
MNT alone or with MNT and oral antidiabetic medications.
Insulin
SBGM
NURSING INTERVENTIONS of HHS
GIVE 3
- MAINTAINING FLUID AND ELECTROLYTE BALANCE
- INCREASING KNOWLEDGE ABOUT DIABETES MANAGEMENT
- DECREASING ANXIETY
- MONITORING AND MANAGING POTENTIAL COMPLICATIONS (Fluid Overload, Hypokalemia, Cerebral Edema)
LONG-TERM COMPLICATIONS OF DIABETES
Give 4
- Macrovascular Complications
- Microvascular Complications
* Retinopathy
* Nephropathy - Peripheral Neuropathy
- Foot and Leg Problems
- __, __, __, are the three main types of macrovascular complications in diabetes.
- __ is twice as common in __ with diabetes and three times as common in __ with diabetes.
- People with diabetes have twice the risk of developing cerebrovascular disease and an increased risk of death from __.
- Signs and symptoms of peripheral vascular disease include diminished __ and intermittent __ (pain in the buttock, thigh, or calf during walking).
Coronary artery disease, cerebrovascular disease, and peripheral vascular disease
MI
men
women
stroke
peripheral pulses
claudication
Management macrovascular
- The focus of management is an __ modification and reduction of risk factors.
- This involves prevention and treatment of the commonly accepted risk factors for ___.
- __ and __ are important in managing obesity, hypertension, and hyperlipidemia.
- The use of __ to control hypertension and hyperlipidemia is indicated.
- __ is essential.
aggressive
atherosclerosis
MNT and exercise
medications
Smoking cessation
is characterized by capillary basement membrane thickening.
- Two areas affected by these changes are the __ and the __.
- Diabetic microvascular disease (or microangiopathy)
retina and kidneys
Clinical Manifestations
* Retinopathy is a __ process.
* __ secondary to __ occurs in some patients.
* Symptoms indicative of __ include ___ or cobwebs in the visual field, sudden visual changes including spotty or hazy vision, or ___
painless
Blurry vision
macular edema
hemorrhaging
floaters
complete loss of vision.
Assessment and Diagnostic Findings diabetic Retinopathy
- Diagnosis is by direct visualization of the retina through __ pupils with an ophthalmoscope or with a technique known as __
dilated
fluorescein angiography
Medical Management diabetic Retinopathy
- The first focus of management of retinopathy is on __ and __
- Other strategies that may slow the progression of diabetic retinopathy include control of __, __, __
- For advanced cases of diabetic retinopathy, the main treatment is __. The laser treatment destroys leaking blood vessels and areas of __.
- ___ - a surgical procedure in which vitreous humor filled with blood or fibrous tissue is removed with a special drill-like instrument and replaced with saline or another liquid.
primary and secondary prevention.
hypertension, control of blood glucose, and cessation of smoking.
argon laser photocoagulation
neovascularization
Vitrectomy
- __ kidney disease secondary to diabetic microvascular changes in the kidney.
- If blood glucose levels are elevated consistently for a significant period of time, the kidney’s filtration mechanism is stressed, allowing blood __ to leak into the urine.
- As a result, the __ in the blood vessels of the kidney increases.
Nephropathy
proteins
pressure
Clinical Manifestations nephropathy
Give 2
- Signs and symptoms of kidney dysfunction
- Frequent hypoglycemic episodes (decreased catabolism of insulin)
Assessment and Diagnostic Findings nephropathy
- The urine should be checked annually for the presence of __.
- If the microalbuminuria exceeds __/24 hours on two consecutive random urine tests, a ___ sample should be obtained and tested.
- Tests for __ and __ should be conducted annually.
microalbumin
30 mg
24hour urine
serum creatinine and BUN levels
Management
- Control of hypertension (the use of ___), because control of hypertension may also decrease or delay the onset of early proteinuria
- Prevention or vigorous treatment of __
- Avoidance of
- Adjustment of __ as kidney function changes
- __ diet
- __ diet
- In chronic or ESKD, two types of treatment are available:
angiotensin-converting enzyme [ACE] inhibitors, such as captopril [Capoten]
urinary tract infections
nephrotoxic medications and contrast dye
medications
Low-sodium
Low-protein
dialysis (hemodialysis or peritoneal dialysis) and transplantation from a relative or a cadaver.
- __ refers to a group of diseases that affect all types of nerves, including peripheral (sensorimotor), autonomic, and spinal nerves.
- most commonly affects the __ portions of the nerves, especially the nerves of the __ extremities.
- It affects both sides of the body __ and may spread in a proximal direction.
Diabetic neuropathy
distal
lower
symmetrically
Clinical Manifestations diabetic neuropathy
- Initial symptoms may include ___ (prickling, tingling, or heightened sensation) and burning sensations (especially at __).
- As the neuropathy progresses, the feet become __.
- A decrease in proprioception and a decreased sensation of light touch may lead to an __.
- Decreased sensations of pain and temperature place patients with neuropathy at increased risk for __ and __.
- Deformities of the foot may also occur; neuropathy-related joint changes are sometimes referred to as __.
- On physical examination, a decrease in __ & __ is found.
paresthesias
night
numb
unsteady gait
injury
undetected foot infections
Charcot joints
deep tendon reflexes and vibratory sensation
Management diabetic neuropathy
Give 2
- Intensive insulin therapy
- Pain management
results in a broad range of dysfunctions affecting almost every organ system of the body.
Autonomic Neuropathies
- Cardiovascular symptoms range from a fixed, slightly __ heart rate and __ to silent, or painless, __
- __ may occur with typical GI symptoms of early satiety, bloating, nausea, and vomiting (___).
- Urinary retention, __, and other urinary symptoms of neurogenic bladder result from autonomic neuropathy.
- __ - Autonomic neuropathy affecting the adrenal medulla is responsible for diminished or absent adrenergic symptoms of hypoglycemia.
- __ – a decrease or absence of sweating (anhidrosis) of the extremities, with a compensatory increase in upper body sweating.
- __ - erectile dysfunction, decreased libido and lack of orgasm.
tachycardic
orthostatic hypotension
myocardial ischemia and infarction.
Delayed gastric emptying
“Diabetic” constipation or diarrhea
a decreased sensation of bladder fullness
Hypoglycemic Unawareness
Sudomotor Neuropathy
Sexual Dysfunction
Foot and Leg Problems
- Between 50% and 75% of ___ are performed on people with diabetes.
- Complications of diabetes that contribute to the increased risk of foot problems and infections include the following: (3)
lower extremity amputations
- Neuropathy - Sensory neuropathy leads to loss of pain and pressure sensation, and autonomic neuropathy leads to increased dryness and fissuring of the skin.
- Peripheral vascular disease - Poor circulation of the lower extremities contributes to poor wound healing and the development of gangrene.
- Immunocompromise: Hyperglycemia impairs the ability of specialized leukocytes to destroy bacteria.
- ? to correct severe acidosis is avoided during treatment of DKA because it precipitates further, sudden (and potentially fatal) decreases in serum potassium levels.
Bicarbonate infusion
- Result from changes in the medium to large blood vessels.
- Blood vessel walls thicken, sclerose, and become occluded by plaque that adheres to the vessel walls.
MACROVASCULAR COMPLICATIONS
- caused by changes in the small blood vessels in the retina.
- occurs in type __ diabetes.
- Diabetic Retinopathy
- occurs in type diabetes.
Diabetic Retinopathy has 3 main stages
nonproliferative (background), preproliferative, and proliferative.
Three manifestations of autonomic neuropathy are related to the
cardiac, gastrointestinal, and renal systems.
- __ - Sensory neuropathy leads to loss of pain and pressure sensation, and autonomic neuropathy leads to increased dryness and fissuring of the skin.
- __ - Poor circulation of the lower extremities contributes to poor wound healing and the development of gangrene.
- __ : Hyperglycemia impairs the ability of specialized leukocytes to destroy bacteria.
Neuropathy
Peripheral vascular disease
Immunocompromise
