Diabetes Flashcards
What is Diabetes?
An endocrine disorder in which there is an insufficient amount or lack of insulin secretion to metabolize carbohydrates.
It is characterized by hyperglycemia, glycosuria and ketonuria
What is the main fuel for the CNS?
Glucose is the main fuel for the CNS
Brain cannot make or store insulin, therefore needs a continuous supply
True or False
Fatty acids can be used when glucose is not available
True
Pathophysiology of type 1 diabetes
The underlying pathophysiologic defect in type 1 diabetes is an autoimmune destruction of pancreatic beta cells. Following this destruction, the individual has an absolute insulin deficiency and no longer produces insulin. Autoimmune beta cell destruction is thought to be triggered by an environmental event, such as a viral infection. Genetically determined susceptibility factors increase the risk of such autoimmune phenomena.
The onset of type 1 diabetes is usually abrupt. It generally occurs before the age of 30 years, but may be diagnosed at any age. Most type 1 diabetic individuals are of normal weight or are thin in stature. Since the pancreas no longer produces insulin, a type 1 diabetes patient is absolutely dependent on exogenously administered insulin for survival. People with type 1 diabetes are highly susceptible to diabetic ketoacidosis. Because the pancreas produces no insulin, glucose cannot enter cells and remains in the bloodstream. To meet cellular energy needs, fat is broken down through lipolysis, releasing glycerol and free fatty acids. Glycerol is converted to glucose for cellular use. Fatty acids are converted to ketones, resulting in increased ketone levels in body fluids and decreased hydrogen ion concentration (pH). Ketones are excreted in the urine, accompanied by large amounts of water. The accumulation of ketones in body fluids, decreased pH, electrolyte loss and dehydration from excessive urination, and alterations in the bicarbonate buffer system result in diabetic ketoacidosis (DKA). Untreated DKA can result in coma or death.
Patho of diabetes
The underlying pathophysiologic defect in type 1 diabetes is an autoimmune destruction of pancreatic beta cells. Following this destruction, the individual has an absolute insulin deficiency and no longer produces insulin. Autoimmune beta cell destruction is thought to be triggered by an environmental event, such as a viral infection. Genetically determined susceptibility factors increase the risk of such autoimmune phenomena.
The onset of type 1 diabetes is usually abrupt. It generally occurs before the age of 30 years, but may be diagnosed at any age. Most type 1 diabetic individuals are of normal weight or are thin in stature. Since the pancreas no longer produces insulin, a type 1 diabetes patient is absolutely dependent on exogenously administered insulin for survival. People with type 1 diabetes are highly susceptible to diabetic ketoacidosis. Because the pancreas produces no insulin, glucose cannot enter cells and remains in the bloodstream. To meet cellular energy needs, fat is broken down through lipolysis, releasing glycerol and free fatty acids. Glycerol is converted to glucose for cellular use. Fatty acids are converted to ketones, resulting in increased ketone levels in body fluids and decreased hydrogen ion concentration (pH). Ketones are excreted in the urine, accompanied by large amounts of water. The accumulation of ketones in body fluids, decreased pH, electrolyte loss and dehydration from excessive urination, and alterations in the bicarbonate buffer system result in diabetic ketoacidosis (DKA). Untreated DKA can result in coma or death.
Is type 1 diabetes a progressive disease?
Type 1 diabetes is usually a progressive autoimmune disease, in which the beta cells that produce insulin are slowly destroyed by the body’s own immune system.
- Genetic
- Viral exposure
- Low vitamin D levels
What are major symptoms of diabetes?
- Polydipsia
- Polyuria
- Polyphagia
- Weight loss
- Fatigue
- Ketoacidosis
- Blurred vision
Normal vs. fasting glucose
Normal <100 mg/dL
Fasting plasma glucose (FPG) at or above 126 mg/dL diagnostic of diabetes
Fasting is defined as no caloric intake for at least 8 h
Criteria for Impaired Fasting Glucose (IFG) is 100-125 mg/dL
Oral glucose tolerance: pregnancy
Normal <100 mg/dL
Fasting plasma glucose (FPG) at or above 126 mg/dL diagnostic of diabetes
Fasting is defined as no caloric intake for at least 8 h
Criteria for Impaired Fasting Glucose (IFG) is 100-125 mg/dL
Diabetes lab assesment
Normal A1C 4-6% A1C of 6.5% or higher (Glycosylated hemoglobin, Hemoglobin A1C, HgbA1C) Levels > 8% = poor diabetic control
What is the honey moon peroid?
In Type I - after diagnosis, need very little insulin to control glucose. Even as insulin islet cell antibodies destroy B-cells, B-cells continue to produce insulin.
Period may last up to a year.
What are some complications of type 1 diabetes
- Diabetic ketoacidosis
- Hypoglycemia from
too much insulin or
too little glucose
What is diabetic ketoacidosis?
Extreme hyperglycemia >300 mg/dL due to insulin deficit
Glucose is osmotic diuretic so 3 p’s occur
Can occur in a few hours if ill or under stress
Body breaks down fat for energy ketones
What are symptoms of DKA?
Flu-like symptoms LOC changes N & V Abdominal pain Dehydration with orthostatic changes Kussmaul breathing with fruity breath Metabolic acidosis
When should you test for keytones?
Test for ketones if:
Blood sugar is higher than 240 mg/dl on a glucose meter
Sick with the flu or food poisoning and vomiting, Test for ketones every four to six hours, since ketoacidosis is more likely to develop
Do not exercise if ketones present
When should you call MD, related to DKA
Blood glucose > 240 Moderate or large ketones BG elevation after 2 doses of insulin Fever over 101.5 or fever longer than 24 hrs Ketonuria lasting more than 24 hours Client cannot take food or liquids Illness lasts more than 1 to 2 days Persistent nausea and vomiting
Blood sugar mnemoics
Shaky, sweaty - take sugar
Hot & Dry = Sugar High
Cold and Clammy = Need some
candy
Causes of hypoglycemia
Takes too much insulin (or an oral diabetes medication that causes your body to secrete insulin)
Does not eat enough food
Exercises vigorously without eating a snack or decreasing the dose of insulin beforehand
Waits too long between meals
Drinks excessive alcohol, although even moderate alcohol use can increase the risk of hypoglycemia in people with type 1 diabetes
True or false
DO NOT MIX GLARGINE WITH ANY OTHER INSULIN
True
What is Lipohypertrophy?
Lipohypertrophy: Repeated needle injections into the same site can create hardened tissue or fatty deposits called lipohypertrophy
What is Lipoatrophy?
Lipoatrophy: a breakdown of subcutaneous fat at the site of an insulin injection. It usually occurs after several injections at the same site
A 23-year-old patient with a history of type 1 diabetes is admitted to the ED with nausea and abdominal pain. His respiratory rate is 34/min with deep breaths and a fruity smell to his breath. He is responsive, but difficult to arouse.
What does the nurse suspect is happening with this patient?
What serum glucose level would the nurse expect to see with this patient?
The manifestations point to diabetic ketoacidosis.
The patient’s glucose level is most likely >300 mg/dL.
The student nurse asks why the patient is breathing so rapidly and deeply. What is the nurse’s best response?
“His serum pH is high and this is a compensatory mechanism.”
“His serum pH is low and this is a compensatory mechanism.”
“His serum potassium is high and this is a compensatory mechanism.”
“His serum potassium is low and this is a compensatory mechanism.”
ANS: B
As ketone levels rise, the buffering capacity of the body is exceeded and the pH of the body decreases, leading to metabolic acidosis. Kussmaul respirations (very deep and rapid) cause respiratory alkalosis in an attempt to correct the acidosis by exhaling carbon dioxide.
In the ED, the patient is diagnosed with diabetic ketoacidosis (DKA).
What is the nurse’s first priority for managing this condition?
Airway assessment
Fluid and electrolyte correction
Administration of insulin
Administration of IV potassium
ANS: A
The first priority is airway management, rapidly followed by the administration of insulin, fluids, and correction of any electrolyte imbalances.
Twenty minutes later, the patient is admitted to the ICU for DKA management. The patient is receiving IV regular insulin with frequent finger sticks to check his glucose level. His potassium level is 2.5 and IV potassium supplements have been ordered.
What assessment must be made before giving the IV potassium?
Production of at least 30 mL/hr of urine
Level of consciousness and orientation
Finger stick glucose of less than 200 mg/dL
Respiratory rate of less than 24/min
ANS: A
Hypokalemia is a common cause of death in the treatment of DKA. Before giving IV potassium, make sure the patient produces at least 30 mL/hr of urine.
Two days later the patient is recovered and is preparing for discharge. His wife asks about what they can do to prevent this from happening again.
What should the nurse teach the patient and his wife? (Select all that apply.)
Check blood glucose levels every 4 to 6 hours if anorexia, nausea, or vomiting is experienced.
Check urine ketones when blood glucose is greater than 300 mg/dL.
Decrease fluid intake when nausea and vomiting occur.
Watch for and report any illness lasting more than 1 to 2 days.
Monitor glucose whenever the patient is ill.
ANS: A, B, D, E
It is important to teach the patient to reduce the risk of dehydration by maintaining fluid and food intake. Small amounts of fluid may be tolerated even when vomiting is present. The patient should drink at least 3 L of fluid daily and increase this amount when infection is present.
What is MetS?
Metabolic syndrome, also called MetS, is classified as the simultaneous presence of metabolic factors known to increase the risk for developing Type 2 diabetes and cardiovascular disease.
What are some sulfonylurea agents?
Sulfonylurea agents – Increase insulin secretion Glipizide (Glucotrol) Glyburide(Diabeta/Micronase) Glimepiride (Amaryl) Chlorpropamide (Diabenese) Tolazamide (Tolinase)
Side effects –
Hypoglycemia
What are Biguanides?
Biguanides –Reduce hepatic production and tissue sensitivity . They stop the liver from making extra sugar when its not needed.
Metformin (Glucophage)
Side effects –
GI side effects (diarrhea, N &V, abdominal pain)
Use caution with renal, liver or cardiac disease
HyperosmolR HYPERGLYCEMIC STATE
Lack of insulin or insulin resistance leads to profound hyperglycemia Osmotic diuresis – dehydration Polyuria Hypotension Tachycardia Altered sensorium Seizures and/or hemiparesis
How do your treat HHS?
Identify and correct cause (infection, stress)
Correct dehydration
Insulin administration
Restore electrolyte balance
Continuous monitoring of VS, u/o, blood glucose, lung sounds and mental status
What are some macrovascular complications of diabetes
Complications affecting larger diameter vessels, such as those of the heart, brain and periphery. MI Stroke Atherosclerosis CAD PVD
True or false
Retinopathy is a microvascular complication of diabetes
True,
Retinopathy
Microaneurysms leak or ooze fluid and blood into the retina
Smaller vessels may close and the larger retinal veins may begin to dilate and become irregular in diameter
Nerve fibers in the retina may begin to swell
Central part of the retina (macula) begins to swell causing macular edema.
True or false
Nephropathy is a microvascular complication of diabetes
True,
Nephropathy
Persistent albuminuria confirmed on at least 2 occasions 3-6 months apart
Progressive decline in the glomerular filtration rate (GFR) nl > 60 ml/min
Elevated arterial blood pressure – use of ACE Inhibitors and Angiotensin Receptor Blockers delay
progression of nephropathy
True or false
Neuropathy is a microvascular complication of diabetes
Neuropathy
Numbness/tingling, burning
Loss of balance, coordination
CV - orthostatic BP, syncope, mask signs of MI
GI – gastroparesis-Reglan may help, diarrhea, constipation
Insulin as a regulator
Insulin is a regulator the sodium potassium pump. Without insulin enough potassium is not pumped into the cell, causing intracellular hypokalemia. Even though potassium level may come up normal the patient is hypokalemia. Once you administer insulin it’s going to restore the potassium levels inside the cell but at the expense of the potassium is outside the cell. So when you’re delivering insulin you need to be delivering potassium too.
Type 1 vs type 2 diabetes
- Type 1 diabetes is an autoimmune disorder in which beta cells are destroyed in a genetically susceptible person.
- Type 2 diabetes is a progressive disorder in which the pancreas makes less insulin over time related to insulin resistance, poor control of liver glucose output, and decreased beta-cell function, eventually leading to beta-cell failure
What is metabolic syndrome?
- Metabolic syndrome or syndrome X, is the simultaneous presence of metabolic factors that increase risk for developing type 2 diabetes and cardiovascular disease.
- Features of syndrome X include abdominal obesity, hyperglycemia, hypertension, dyslipidemia, and low levels of high-density lipoprotein.
True or false
• Ninety percent of people with diabetes have type 2 diabetes.
True
True or false
• Fasting plasma glucose is the test used to diagnose diabetes in nonpregnant adults.
True
True or False
• Oral glucose tolerance testing is the most sensitive test for the diagnosis of diabetes, but is inconvenient to patients, costly, and time consuming
True
The pancreas
- The pancreas has mostly exocrine functions that are related to digestion, and endocrine functions that are related to blood glucose control.
- The endocrine portion of the pancreas has about 1 million islets of Langerhans.
- Islet alpha cells produce glucagon; islet beta cells produce insulin and amylin
True or false
• Glucagon causes the release of glucose whenever blood glucose levels are low
True
True or false
• The dehydration that occurs with diabetes leads to hemoconcentration, hypovolemia, hyperviscosity, hypoperfusion of tissues, and hypoxia.
True
What are three glucose related emergencies
• Three glucose-related emergencies, which can be fatal, may occur in patients with diabetes: diabetic ketoacidosis or DKA caused by lack of insulin and ketosis; hyperglycemic-hyperosmolar state or HHS caused by insulin deficiency and profound dehydration; and hypoglycemia from too much insulin or too little glucose.
Macro and microvascular complications
- Macrovascular complications include coronary heart disease, cerebrovascular disease, and peripheral vascular disease.
- Microvascular complications of blood vessel structure and function lead to nephropathy, neuropathy, and retinopathy or vision problems.
- Keeping blood glucose levels in the normal range can slow the development and progression of diabetic neuropathies.
Which explanation best assists the client in differentiating type 1 diabetes from type 2 diabetes?
People with type 2 diabetes make some insulin but in inadequate amounts, or they have resistance to existing insulin.
The client with type 1 diabetes mellitus received regular insulin at 7 AM. The client should be monitored for hypoglycemia at which time?
11 a.m.,
Onset of regular insulin in ½ to 1 hour; peak is 2 to 4 hours. Therefore 11 AM is the anticipated onset time for regular insulin received at 7 AM.
The client newly diagnosed with diabetes is not ready or willing to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client’s family?
Causes and treatment of hypoglycemia
The nurse is teaching the client with type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching?
“I should begin exercising for at least an hour a day.”
For long-term maintenance of major weight loss, large amounts of exercise (7 hr/wk) or moderate or vigorous aerobic physical activity may be helpful, but the client must start slowly.
The client has just been diagnosed with diabetes. Which factor is most important for the nurse to assess before providing instruction about the disease and its management?
Educational and literacy level
A large amount of information must be synthesized; typically written instructions are given. This is essential information.
The diabetic client has a hemoglobin (Hb)A1c level of 9.4. What does the nurse say to the client regarding this finding?
WHat are you doing differently?
Assessing the client’s regimen or changes he may have made is the basis for formulating interventions to gain control of blood glucose.
The intensive care client with ketoacidosis (DKA) is receiving insulin infusion. The cardiac monitor shows ventricular ectopy. Which assessment does the nurse make?
Potassium level,
With insulin therapy, serum potassium levels fall rapidly as potassium shifts into the cells. Detecting and treating the underlying cause is essential
In reviewing the physician admission requests for the client admitted with hyperglycemic-hyperosmolar state, which request is inconsistent with this diagnosis?
1 ampule NaHCO3 IV now,
NaHCO3 is given for the acid-base imbalance of diabetic ketoacidosis, not the hyperglycemic-hyperosmolar state, which presents with hyperglycemia and absence of ketosis/acidosis.
The nurse caring for four diabetic clients has the following activities to perform. Which of these is appropriate to delegate to the nursing assistant?
Perform hourly bedside blood glucose checks for a client with hyperglycemia.
You have just received change-of-shift report on the endocrine unit. Which client should you see first?
The type 1 diabetic client whose insulin pump is beeping “occlusion”
Which of these clients with diabetes should the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit?
A nurse from the labor/delivery unit would be familiar with blood glucose monitoring and insulin administration because clients with type 1 and gestational diabetes are frequently cared for in the labor/delivery unit.
A client with type 1 diabetes arrives in the emergency department breathing deeply and stating, “I can’t catch my breath.” These are the client’s vital signs: T 98.4° F (36.9º C), P 112, R 38, BP 91/54, and O2 saturation 99% on room air. Which action should the nurse take first?
Check the blood glucose,
The client’s clinical presentation is consistent with diabetic ketoacidosis, and the nurse should initially check the client’s glucose level.
A client with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL, and the glycosylated hemoglobin (HbA1c) is 8.2%. Which action will the nurse plan to take next?
Ask the client about current dietary and meds.
The nurse’s first action should be to assess whether the client is adherent to the currently prescribed diet and medications. The client’s current diet and medication use have not been successful in keeping glucose in the desired range. Checking blood glucose more frequently and/or using rapid-acting insulin may be appropriate, but this will depend on the assessment data
When preparing a mixed insulin injection, which action does the nurse perform first?
Putting air in the longer-acting insulin vial is the first step in preparing a mixed insulin injection
Risk factors for metabolic syndrome in men
- Waist circumference >40 inches
- Triglycerides > 150 mg/dl
- HDL cholesterol 130/85 mm hg
- Fasting glucose > 100 mg/dl
Risk factors for metabolic syndrome in women
- Waist circumference >35 inches
- Triglycerides > 150 mg/dl
- HDL cholesterol 130/85 mm hg
- Fasting glucose > 100 mg/dl
DKA
- Usually type 1
- ONset is hours to days
- BG <350
- Alert to stuporous
HHS
- Type 2 diabetes
- Onset is days to weeks
- BG >600 mg/dl
- Ketones are absent or in small amounts
- pH level is normal
- Bicarb level is normal
- Serum sodium is normal to high
- Serum potassium is variable
- Serum osmolailty is Elevated >350
- Stupor/coma
Rapid acting insulin
Lispro
Onset: 5-15 min
Peak: 30-90 min
Duration: 5 hours
Aspart
Onset: 10-20 min
Peak: 30-90 min
Duration: 3-5 hours
Short (regular) insulin
Humulin R & Novolin R
Onset: 30 min
Peak: 2-4 hours
Duration: 12 hours
Intermediate NPH insulin
Humalin N
Onset: 2 hours
Peak: 4-10 hours
Duration: 16 hours
Novolin N
Onset: 90 min
Peak: 4-12 hours
Duration: 24 hours
Fixed mixture insulin
70/30, 70% NPH, 30% regular
ONset: 30-60 min
Peak: Dual
Duration: 10-16 hours
Fixed mixture insulin
70/30, 70% NPH, 30% regular
ONset: 30-60 min
Peak: Dual
Duration: 10-16 hours
The nurse is caring for a client who has normal glucose levels at bedtime, hypoglycemia at 2am and hyperglycemia in the morning. What is this client likely experiencing?
The Somogyi effect is when blood sugar drops too low in the morning causing rebound hyperglycemia in the morning. The hypoglycemia at 2am is highly indicative. The Dawn phenomenon is similar but would not have the hypoglycemia at 2am.
The nurse is caring for a patient whose blood glucose level is 55mg/dL. What is the likely nursing response?
Answers:
A. Administer a glucagon injection
B. Give a small meal
C. Administer 10-15 grams of a carbohydrate
D. Give a small snack of high protein food
c.
What insulin type can be given by IV? Select all that apply: Answers: A. Glipizide (Glucotrol) B. Lispro (Humalog) C. NPH insulin D. Glargine (Lantus) E. Regular insulin
E. Only regular insulin can be given by IV
A client with type II diabetes is being educated about what to do if he catches the flu or a cold. What is something he should be informed of? Answers: A. Discontinue Metformin (glucophage) B. Expect hyperglycemia C. Add 2-3 more snacks to diet D. Come into the hospital for monitoring
B.
The body’s natural reaction to illness is to release glucose. As such, diabetics can expect to face increased hyperglycemia in addition to their illness.
In educating a client about Type II Diabetes, what would be a proper explanation for poor wound healing?
Answers:
A. High blood glucose damages capillaries
B. Swings in blood sugar prevent proper clotting
C. The pancreas fails to secrete the proper chemicals
D. Ketosis prevents proper healing
A.
High blood glucose damages capillaries which prevent proper healing.
When does regular insulin generally have peak action after application? Answers: A. 30-45 minutes B. 45-60 minutes C. 1-2 hours D. 2-3 hours
D.
The exact details depend on various factors, but 2-3 hours for peak action of regular insulin is an accepted range.
In educating a client with diabetes, what response would reveal need for further education?
Answers:
A. I should avoid tights
B. I should take good care of my toe nails
C. I should not go more than 3 days without washing my feet
D. I should avoid going barefoot and should wear clean soc
C.
The recommended self-care routine is to wash feet on a daily basis without soaking and carefully cleaning.
A client with diabetes and coronary heart disease is being evaluated for treatment. In light of the heart condition, which medication option is more likely to be an issue? Answers: A. Metformin (Glucophage) B. Pioglitazone (Actos) C. Insulin D. Sitagliptin (Januvia)
B.
Cardiac safety of diabetes meds is a very complex subject. That said, pioglitazone is known to possibly have issues.
Insulin lipodystrophy should be treated in part by: Answers: A. Alternating insulin injection sites B. Balancing diet and snack routine C. Reduction of insulin dose D. Adding an oral glycemic medicatio
A.
Alternating insulin injection sites helps avoid lipodystrophy, which is a lump or dent in the skin that can be caused by using the same site for injections.
Insulin lipodystrophy should be treated in part by: Answers: A. Alternating insulin injection sites B. Balancing diet and snack routine C. Reduction of insulin dose D. Adding an oral glycemic medicatio
A.
Alternating insulin injection sites helps avoid lipodystrophy, which is a lump or dent in the skin that can be caused by using the same site for injections.
DKA
An insufficient supply of insulin in a client with
diabetes mellitus can result in metabolic acidosis
known as diabetic ketoacidosis
A client with diabetes mellitus has a glycosylated
hemoglobin A1c level of 9%. Based on this test
result, the nurse plans to teach the client about
the need to:
1. Avoid infection.
2. Take in adequate fluids.
3. Prevent and recognize hypoglycemia.
4. Prevent and recognize hyperglycemia
4.
Rationale: In the test result for glycosylated hemoglobin A1c,
7% or less indicates good control, 7% to 8% indicates fair
control, and 8% or higher indicates poor control. This test
measures the amount of glucose that has become permanently
bound to the red blood cells from circulating glucose.
Elevations in the blood glucose level will cause elevations in
the amount of glycosylation. Thus the test is useful in identifying
clients who have periods of hyperglycemia that are
undetected in other ways. Elevations indicate continued need
for teaching related to the prevention of hyperglycemic
episodes.
What is the dawn phenomonem?
Dawn phenomonen - Hyperglycemia present on awakening in am due to release of counterregulatory hormones
What is the dawn phenomonem?
Dawn phenomonen - Hyperglycemia present on awakening in am due to release of counterregulatory hormones
Insulin aspart
Insulin aspart (Novolog) - Onset: within 15 minutes
- Peak: 1-2 hours
- Duration: 3-4 hours
- Nursing considerations: give 5-10 minutes before meal, can give with NPH
Insulin aspart
Insulin lispro (Humalog) - Onset: within 15 minutes
- Peak: 1-2 hours
- Duration: 3-4 hours
- Nursing considerations: give 5-10 minutes before meal, can give with NPH
Insulin Detemir
Insulin Detemir (Levemir) - Long-Acting Insulin
- Onset:3-4 hours
- Peak: 3-14 hours
- Duration: 6-24 hours
- Nursing considerations: Give once or twice, DO NOT MIX WITH OTHER INSULINS, usually given at night time
Insulinn glargine
Insulin glargine (Lantus) - Long-Acting Insulin
- Onset:3-4 hours
- Peak: none
- Duration: 24 hours
- Nursing considerations: Give once daily at the same time, DO NOT MIX WITH OTHER INSULINS, usually given at night time
