Diabetes Flashcards
Diabetes
A disease in which the body is unable to manufacture or utilize insulin thus resulting in a chronic state of hyperglycemia
Characterized by :
Disturbances of carbohydrate, lipid and protein metabolism
Beta-cell destruction leading to absolute insulin deficiency (Type 1)
OR
Insulin resistance with relative insulin deficiency (Type 2)
Secretory deficit with insulin resistance (Type 2)
Systemic organic changes as a result of vascular pathology
Facts about DM:
- Affects 7% of pop
- 7th leading cause of death in the US
- Leading cause of blindness, end-stage renal disease and amputations in the US
- 2-4x more likely to have heart disease
- **MI and CVA are leading cause of death for clients with DM
Pancreas: exocrine function
98% of pancreas is digestive enzymes
Pancreas: endocrine fumction
Islets of Langerhans…scattered through the organ most prominently found in the tail
Alpha, Beta, Delta
Secretion of hormones: Glucagon, Insulin and Somatostatin
Insulin
- A protein made up of amino acids
- Allows the glucose to move into the cells for energy
- Insulin reaches the liver first where it helps the liver produce and store glycogen and inhibits glycogen breakdown into glucose
- Increases protein and lipid synthesis
- Limits ketogeneisis (conversion of fats to acids) and gluconeogenesis (conversion of proteins to glucose)
- Keeps lipid levels in normal range and prevents glucose levels from being too high
Ketogenesis
conversion of fats to acids
Gluconeogenesis
conversion of protein to glucose
Lack of insulin
- Unable to store glucose
- Cells starve …fats break down for energy… ketones form
- Stored glucose dumps into bloodstream
- Glucose breaks down into CO2 +H2O
- Fluid and electrolyte imbalances
- Polyuria, polydipsia, polyphagia
Polyphagia
excessive hunger
Polydipsia
excessive thirst
Risk factors:
- Genetics
- Obesity > 20% IBW or BMI >25 kg/m2
- Body shape: apple v. pear
- Habitually inactive
- Ethnic group (AA, American Indian, Hispanic American, Asian American, Pacific Islander)
- HTN > 140/90
- HDL 250
- PMH Gestational diabetes or babies >9 pounds
- Polycystic ovary syndrome
- IFG or IGT on previous testing
Type 1 Diabetes
• Insulin dependent ◦ Absolute insulin deficiency ◦ Ketoacidosis (DKA) ◦ Usually younger than 30 y/o ◦ <10% of all DM
Type 2 Diabetes
• Non-insulin dependent ◦ Insulin resistance ◦ Abnormal secretion of insulin ◦ Impaired gluconeogenesis ◦ Obesity in 80% of clients ◦ 90% of DM
Treatment: Type 1
◦ Exogenous insulin
◦ Dietary control
Treatment: Type 2
◦ Lifestyle changes
Dietary control
Weight reduction
Exercise
◦ May require oral hypoglycemic therapy or exogenous insulin
– Insulin when oral hypoglycemic medications can no longer provide glycemic control
Diagnosis: health history
◦ Age ◦ Weight and weight changes ◦ Excessive hunger ◦ Excessive urination ◦ Excessive thirst ◦ Excessive fatigue ◦ Slow wound healing ◦ Infections ◦ Family hx DM
Diagnosis: blood glucose
◦ FBS > 126 (fasting = NPO x 8h)
◦ 2-hour plasma glucose > or = 200 mg/dL during an OGTT
◦ Symptoms of DM and random BG >200mg/dl
◦ The above 3 should be repeated to confirm Dx of DM
Diagnosis: HbA1C
◦ HbA1C > or = 6.5% (newly recognized as diagnostic criterion)
◦ Used to monitor glycemic control and predict risk for chronic complications
Target labs for diabetic patients:
- Blood Glucose
- Fasting: 90-130 (70-100 in non-diabetics)
- Bedtime: 100-140
- HbA1C: < or =7%
- Lipids
LDL: < 100 mg/ dL
HDL: >40 (men)
> 50 (women) ( with exercise and good fats)
Triglycerides: < 150 - Blood pressure: 130/80
Prevention of progression:
• Lifestyle changes Increase in physical activity Decrease in dietary fat Modification of food intake • Smoking cessation • Tx of HTN • Tx of hyperlipidemia • Tight control of blood glucose levels • Regular F/U with HCP or endocrinologist • Yearly vision testing Yearly urine microalbumin levels
Secondary diabetes
Pregnancy (Gestational diabetes) ◦ Weight gain, increased estrogen levels and placental hormones Pharmacological: ◦ Insulin antagonists ◦ Adrenal corticosteroids ◦ Contraceptives (po) ◦ Estrogen replacements ◦ Atypical antipsychotics Surgical removal of pancreas or pancreatitis Adrenal or pituitary gland disorders Viral infections ◦ CMV, rubella, mumps, adenovirus
Hyperglycemia: S/s
Hot, dry skin Dehydration Rapid, deep respirations; Kussmaul From alert to stuporous; coma N/V, cramps Tachycardia, orthostatic hypotension Positive ketonuria Notify HCP: BS >250 Cannot take food or fluids Ill more than 1-2 days Ketonuria lasts more than 24 hours
Sick Days:
Notify HCP of illness Monitor BG q4h Test urine for ketones Continue taking insulin or po antidiabetics Increase fluids, eat regular meals Get plenty of rest Treat symptoms as directed by HCP Know when to call HCP!
Acute Complications of DM:
1.Diabetic ketoacidosis (DKA) Lack of insulin Presence of ketones 2.Hyperglycemic-hyperosmolar state (HHS) Insulin deficiency Profound dehydration 3. hypoglycemia
DKA
Total or partial lack of insulin
Occurs with Type 1 diabetes
Most often starts with infection
Death – up to 10% of cases…even with appropriate treatment!
o Mortality highest in older adults with accompanying stroke, MI, vascular thrombosis, intestinal obstruction, or pneumonia
Increased renal and liver glucose production
Decreased use of glucose in tissues
Production of ketoacids – ketonemia and ketonuria – metabolic acidosis
Osmotic diuresis - dehydration and electrolyte loss
DKA: S/s
Sudden onset Polyuria, polydipsia, polyphagia Weight loss Vomiting, abdominal pain Dehydration, dry skin, weakness Altered mental status – total alertness to coma Shock Kussmaul respirations, fruity breath (from acetone exhaled)
DKA: lab findings
Glucose: >300 mg/dL Serum ketones: positive Serum pH: < 7.35 Serum HCO3: 20 mg/dL CrS: >1.5 mg/dL Urine ketones: positive
DKA: Monitor
o VS q 15mins til stable o Labs: hourly BGM, lytes o I/O: hourly outputs o IVF replacement Insulin drips o Neuro status Keep safe o Airway
DKA: managing fluids and electrolytes
- Restore volume - isotonic normal saline 1 - 2 L over hour ;
- replace total body fluid loss - 0.45 NS, when sugar < 250 : D 5 + 0.45 NS - to prevent hypoglycemia and cerebral edema
DKA: drug therapy
- Insulin: decrease sugar 75-150 mg/dL/hr - continuous IV insulin drip ( half life 4 min);
- Watch for hypokalemia ( fatigue, muscle weakness, shallow respiration, paraletic ileus, hypotension, wek pulse); Give K+
- Severe acidosis: bicarb (pH < 7)
HHS
Formerly known as hyperglycemic-hyperosmolar nonketotic syndrome (HHNS)
Acute hyperglycemic crisis that can result in coma or death from severe dehydration
End result of sustained osmotic diuresis
Renal insufficiency – extremely high BG levels
Kidneys capacity to reabsorb glucose is exceeded
Decreased kidney perfusion associated with hypovolemia
More common in older adults with Type 2
Difference between DKA and HHS
Both have hyperglycemia and dehydration. With HHS there are little or no ketones present; and glucose is much higher.
HHS: S/s
◦ Gradual onset ◦ May have seizures, myoclonic jerking, and reversible paralysis ◦ Serum glucose: >600 mg/dL ◦ Serum ketones: negative ◦ Serum pH: >7.4 ◦ Serum HCO3: >20 ◦ Urine ketones: negative
HHS: TX
Rehydrate: BS levels may drop 80-200 mg/dl with fluids alone
Caution with the elderly with hx cardiac a/o renal problems
Correct electrolytes
Hold insulin if K+ is less than 3.3
Na, Phosphorous and Mg++ replaced according to labs
Provide insulin to restore and maintain normal glucose
Hydration is key! Insulin is not always required once the client is re-hydrated
HHS: monitor
VS q 15 til stable Labs: hourly BGM, electrolytes I/O -hourly outputs IVF replacement Insulin drips Airway Neuro status Keep safe
Hypoglycemia
BG < 70 mg/dL Clinical criteria is used to categorize severity rather than BG levels Precipitating factors include: ◦ Too much oral med or insulin ◦ Increased activities ◦ Recent illness ◦ Wt loss ◦ Skipped or delayed meals ◦ Liver dysfunction ◦ ETOH without food
Hypoglycemia: S/s
Cool, clammy skin Profuse perspiration Anxiety, nervousness Irritability, mental confusion, seizures, coma Weakness Double vision, blurred vision Hunger Tachycardia, palpitations
