diabetes #6 Flashcards
what happend During illnesses for diabetes
1) Often, need higher insulin dose due to :
Increase secreation of the counter-regulatory hormones
- Hormones work against the action of insulin (increase in blood glucose)
- Not always the case
-Patients sometimes believe they can stop taking insulin (I feel sick, I don’t want to eat – I wont take me insulin)
Where is glucose in the bloodstream coming from?
The liver- increase in gluconeogenesis and glycogenolysis
why would 2) Occasionally, insulin requirements are decreased.
e.g. Diarrhea
How will the patient find out? If they need to take more or else insulin
-Test their blood glucose
when ppl with diabetes are sick what are they at risk for
1) High blood [glucose] and WHAT ELSE?
- If the insulin requirement is not met. How do they know?
Illness is a time to so more testing - At risk of ketoacidosis- need to test both the BG and the ketones (from the urine)
2) Hypoglycemia
- If unable to eat, there is also an increased risk for hypotgycemia.
-General guideline: for sick diabetics
1) Replace the cho in the mealplan with tolerable items
e. g. often liquid- fruit juice, regular jello, regular pop, popsicle, ice cream, pudding
type of cho?
2) Do not be concerned about protein/fat components
3) Also re-distribute the cho from meals and snacks to more frequent regular intervals. e.g. hourly or sips:
a) ability to tolerate
b) these are high glycemic items, so spread them out
-If unable to eat/drink may need to be hospitalized- intravenous line to maintain blood glucose concentration
But note: The individual on long-acting insulin + multiple injections of rapid-acting insulin to match meals/snacks also has more flexibility about eating when she/he is ill too.
Signs & Symptoms of hypoglycemia
neurogenic and neuroglycopenic
- Due to both:
1) epinephrine secreted in response to the low blood sugar in an attempt (regulatory) to increase blood glucose and
2) insufficient glucose for brain metabolism. Neurogenic (autonomic) (2013 Clinical Practice Guidelines, CDA) (#1) -trembling -palpitations -sweating -anxiety -hunger -nausea -tingling
Neuroglycopenic (glycopenia affects functions of neurons and alters behaviour and brain function) (#2)- not enough glucose getting to the brain
- difficulty concentrating
- confusion
- weakness
- drowsiness
- vision changes
- difficulty speaking
- headache
- dizziness
mild, moderate and severe symptoms
Mild: Autonomic symptoms are present. The person is able to self-treat.
Moderate: Autonomic and neuroglycopenic symptoms are present. The person is able to self-treat.
Severe: Person requires assistance of another person. Unconsciousness may occur.
(e.g. Medical Alert bracelet)
-Aims of patient education:
a) prevent reactions as much as possible
b) help the patient and family learn to recognize symptoms of a reaction early and treat promptly so that it does not develop into a severe reaction.
-Because overtreating can result in
1) rebound hyperglycemia and
2) weight gain,
.. So test blood glucose first if possible-if symptoms are mild. Otherwise, (if symptoms too severe or mater not available), treat.
-Aims of patient education:
how to treat depending on stage
a) prevent reactions as much as possible
b) help the patient and family learn to recognize symptoms of a reaction early and treat promptly so that it does not develop into a severe reaction.
-Because overtreating can result in
1) rebound hyperglycemia and
2) weight gain,
.. So test blood glucose first if possible-if symptoms are mild. Otherwise, (if symptoms too severe or mater not available), treat.
Treat with an intervention that provides the fastest rise in blood glucose to a safe level.
Mild to moderate reactions recognize early are treated with simple carbohydrate
Eg. 15g cho in form of glucose tablets, or ¾ cups fruit juice or regular pop, 6 lifesaver candies
-If still not feeling well in 2-5 min take more cho.
-If unconscious or unable to swallow safely injection of Glucagon (if at home- usually found in the fridge, if not call ambulance)
Somogyi effect
Definition: Rebound hyperglycemia that follows an episode of untreated hypoglycemia.
-Why do you think this would occur?
The hypoglycemia stimulates increase release of glucagon and other counter-regulatory hormones that attempt to increase blood glucose. These hormoes stimulate glycogenolysis and gluconeogenesis.
- Can occur any time following hypoglycemia.
- But the most confusing situation for the patient is when they have a mild reaction during the night that they sleep through.
i. e. it is a mild dip in blood glucose that does not progress on to severe hypoglycemia. - Then when they do blood testing before breakfast, they find they are hyperglycemic.
- In response, they may make the mistake of increasing their insulin dose, and this compounds the problem (i.e. makes it more likely that blood glucose will go even lower).
- Once recognized, the treatment is to decrease the insulin dose
Ketoacidosis
Kevin, age 15 y, comes into emergency in ketoacidosis. Kevin was diagnosed with Type 1 diabetes when he was 10. He and his family have received extensive counselling and education about treatment, and he is seen regularly at the Diabetes Education Clinic for adolescents.
We discussed previously how and why ketoacidosis occurs in untreated, undiagnosed individuals at first presentation for TYPE 1 diabetes.
But why would this happen to Kevin who knows a great deal about diabetes and its management? (Ketoacidosis is preventable)
-Causes:
Stopped taking the insulin
Wrong dose od insulin + not managing the CHO?:insulin balance + not BG testing
Ilnness increase risk +not gb testing
Poor control and then get sick- pushes them over the edge
Chronic Complications of Diabetes
The chances of developing them is determined by:
i) Genetics
ii) Degree of metabolic control
i.e. Good control of blood [glucose] in the target range risk for these complications.
Screening is an important part of diabetes care.
- Macrovascular Disease
a. coronary heart disease
b. peripheral vascular disease - Microvascular disease
a. Nephropathy
b. Retinopathy
c. Neuropathy
- Macrovascular Disease
Diseases of the heart and large blood vessels
i) Coronary heart disease
- Incidence is 3-4x greater than in those without diabetes.
- Disease is similar to that found in the general population except that it: occurs earlier, progresses more rapidly and is more severe
ii) Peripheral vascular disease
- Occlude blood vessels and decrease circulation to the periphery
- Especially feet and legs.
- Cause of poor healing from wounds, infection
- Microvascular disease
Diseases of the kidney, retina, nerves
- Abnormalities in blood flow (causing ischemia) & vascular permeability secondary to microvascular disease (disease of small vessles-capillaries, arterioles)
a) Nephropathy (kidney disease) - Starts as proteinuria ( protein losses in urine) and can progress on to decreased renal function-> renal failure
-Leading cause of kidney transplantation and dialysis.
b) Retinopathy (disease of the retina)
- Causes a gradual loss of vision
- Leading cause of blindness in N. America.
c) Neuropathy (dysfunction of the nerves)
Peripheral nervous system (nonautonomic)
Depending on the nerves involved, symptoms may include pain, weakness, and loss of peripheral sensation.
Autonomic nervous system
e.g. abnormalities of eye control, delayed gastric emptying ( gastroparesis).
Autonomic nervous system
Nephropathy
a) Nephropathy (kidney disease)
- Starts as proteinuria ( protein losses in urine) and can progress on to decreased renal function-> renal failure
-Leading cause of kidney transplantation and dialysis.
Retinopathy
b) Retinopathy (disease of the retina)
- Causes a gradual loss of vision
- Leading cause of blindness in N. America.
