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Medsurg 3 - Sensory, Endocrine, DM, Neuro > Diabetes > Flashcards

Diabetes Flashcards

1
Q

Number of people in US

A

29.1 million (9.3%)
8.1 million undiagnosed
86 million prediabetes
7th cause in the us
$245 billion costs
50% higher risk of death

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2
Q

Long Term Complications

A

50% higher risk of death

Leading cause of end stage renal Disease / dialysis

60% of non traumatic amputations

  1. 8 x heart attack
  2. 5 x stroke

71% have HTN (endothelial damage from high BG)

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3
Q

Type 1 - Age of Onset

A

Mostly young, but any age

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4
Q

Type 1 - Type of Onset

A

Usually abrupt (disease process may have been present for years)

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5
Q

Type 1 - Prevalence

A

5-10% of all cases

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6
Q

Type 1 - Environmental Factors

A

Virus, toxins

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7
Q

Type 1 - Primary Defect

A

Absent / minimal insulin production

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8
Q

Type 1 - Islet Cell Antibodies

A

Often present at onset

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9
Q

Type 1 - Endogenous Insulin

A

Absent

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10
Q

Type 1 - Nutritional Status

A

Thin, normal (obese is possible)

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11
Q

Type 1 - Symptoms

A

Polydipsia, polyuria, polyphagia, fatigue, WEIGHT LOSS WITHOUT TRYING

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12
Q

Type 1 - Ketosis

A

PRONE - at onset or during insulin insufficiency

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13
Q

Type 1 - Nutrition Therapy

A

Essential

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14
Q

Type 1 - Insulin

A

Required for all

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15
Q

Type 1 - Vascular and Neurological Complications

A

Frequent

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16
Q

Type 2 - Age at Onset

A

More common in adults, but any age

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17
Q

Type 2 - Type of Onset

A

Insidious, may go undiagnosed for years

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18
Q

Type 2 - Prevalence

A

90 - 95% of cases

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19
Q

Type 2 - Environmental Factors

A

Obesity, lack of exercise

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20
Q

Type 2 - Primary Defect

A

Insulin assistance, decreased insulin production over time, alterations in production of adipokines.

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21
Q

Type 2 - Islet Cell Antibodies

A

Absent

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22
Q

Type 2 - Endogenous Insulin

A

Initially increased in response to insulin resistance, secretion diminishes over time

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23
Q

Type 2 - Nutritional Status

A

Frequently overweight/obese - may be normal

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24
Q

Type 2 - Symptoms

A

Frequently none.

Fatigue, recurrent Infections.

Polydipsia, polyuria, polyphagia (esp. when stressed)

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25
Q

Type 2 - Ketosis

A

Resistant except in infection or stress.

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26
Q

Type 2 - Nutrition Therapy

A

Essential

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27
Q

Type 2 - Insulin

A

Required for some - Disease is progressive and insulin treatment may need to be added to treatment regimen (oral meds)

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28
Q

Type 2 - Vascular and Neurological Complications

A

Frequent

29
Q

Pre-diabetes

A

Impaired fasting glucose (IFG): 100-120 After fasting

Impaired glucose tolerance (IGT): 2 hrs after eating/drinking, BG should be back to normal. If it’s still high, there’s not enough insulin to process the food

Asymptomatic

Kidney, heart, blood vessel damage already occurring

Monitor for: polydipsia, polyphagia, polyuria

A1C 6 ish (5 is normal)

30
Q

Diagnostic Studies for Diabetes

A

1) A1C 6.5% or higher
2) Fasting glucose 126 or higher
3) Random glucose measurement 200 or higher WITH SYMPTOMS
4) Two hour OGTT level 200 or more w/ 75g glucose load

31
Q

Type 1 ONLY - Diagnostic Study

A

Monitor ketone urines (color strip - purple indicates ketones) when blood glucose higher than 240

If in Ketosis, need more insulin.

32
Q

Collaborative Goals

A

Active participant in care (informed decision making, empowerment)

Few or no hypo/hyperglycemic episodes

Maintain BG at or near normal (adult: 70-100)

Prevent, minimize, delay complication

Adjust lifestyle to accommodate diabetes regimen with minimum stress (“monkey on your back everywhere you go”, hard to control)

33
Q

Self Monitor BG

A

Patient training is crucial (Lewis 48-11 p. 1136)

Immediate info about levels

Enables patient decide diet, exercise, medication

Important for detecting episodic hyper/hypo

  • Continuous monitors
  • Pumps
  • Magnet arm ones
  • Traditional finger stick
34
Q

Teaching to SMBG

A

1) Wash hands in warm water. NO alcohol. Dry finger before puncture.
2) If it is difficult, warm the hands in warm water or let the arms hang for a few minutes
3) Use a lancing device. If using the finger, use side of finger pad (reduce pain, fewer nerves)
4) Set lancing device to make a puncture just deep enough to obtain sufficient large drop of blood. Avoid pain/bruising w/ unnecessarily large.
5) Follow Monitor instructions to check blood glucose.

35
Q

Hypoglycemia - Mild

A

Mild (BG 40 - 70)

  • Sweating
  • Tremor
  • Tachycardia
  • Palpitations
  • Nervousness
  • Hunger
  • Shaky
  • Headache
  • Fully conscious
TREAT with 10 - 15 g carbs, recheck in 15 min and repeat if needed 
Glucose tablets/gel
Fruit juice 
Regular soft drink 
Skim milk 
Hard candies 
Saltines Graham Crackers

Additional food (low fat milk/cheese) after 10-15 min

36
Q

Insulin Therapy - Rapid Acting

A

Lispro (Humalog)
Aspart (NovoLog)

Onset: 10- 30 min
Peak: 30 min - 3 hours
Duration: 3-5 hours

Clear

Use when eating (w/ long acting @ hospital)

Makes it easy to eat when you want

Goes in insulin pumps

37
Q

Insulin Therapy - Short Acting

A

Regular Insulin (Humilin R, Novolin R)

Onset: 30 min - 1hr
Peak: 2-5 hr
Duration: 5-8 hours

Clear - Don’t shake

38
Q

Insulin Therapy - Intermediate Acting

A

NPH (Humalin N, Novolin N)

Onset: 1.5 - 4 hours
Peak: 4-12 hours
Duration: 12-18 hours

CLOUDY - Roll
If not cloudy something is wrong.

39
Q

Insulin Therapy - Long Acting

A

Glargine (Lantus)
Detemir (Levamir)
Degludec (Tresiba)

Onset: 0.8 - 4 hours
Peak: Less Defined or no pronounced peak
Duration: 16-24 hours

Clear

Basal - 1x per day

40
Q

Insulin Scheduled - “Basal-Bolus”

A

Most flexible meals with this schedule

Basal:

Long acting 1x per day (usually bedtime)

Bolus:

Meals and Snacks:
Carb ratio: dose needed to cover carbs in the meal
Correction Factor: does needed to correct current blood sugar to normal

Insulin pumps make the same pattern, using ONLY rapid insulin

Basal Rate: continuous dose that can vary over 24 hours, set by Dr.

41
Q

Insulin Therapy - Patient/Caregiver Teaching

A

1) Wash hands
2) Inspect Insulin bottle - proper type, concentration, not expired, top is perfect. Should be clear. Don’t shake. Discard if discolored, or see particles. (NPH is cloudy, roll in hands)

3) Select Site - (frequent rotation to avoid problems)
Make sure site is clean and dry

4) Push needle straight into skin (90 degrees)
Very thin, muscular, or using 8-12 mm needle, may need 45 degrees

5) Push the plunger all the way down, leave needle in place 5 seconds, remove needle
6) Destroy and dispose of single-use syringe

42
Q

Insulin Therapy - Basic Complications

A
  • Hypoglycemia- from too much, or injection site differences
  • Allergic reaction (rare)
  • Lipodystrophy - atrophy of SubQ tissue (switch site)
43
Q

Insulin Therapy - Somogyi Effect

A

Rebound hyperglycemia from counter regulatory hormones after undetected hypoglycemia.

Can occur any time, typically occurs with sleep

Headache and nightmares

Needs LESS Insulin - if you assume dawn phenom and give more, THEY COULD DIE

To tell difference from dawn phenomenon, early morning BG requires. If it’s low (hypo), it’s Somogyi

44
Q

Insulin Therapy - Dawn Phenomenon

A

Hyperglycemia from normal circadian rhythm of predawn counter regulatory hormones.

  • Cortisol/GH release in early morning ups insulin resistance

Most severe when GH peaks in adolescence/young adulthood

To differentiate take early am BG - If it’s high it’s dawn phenomenon

Need MORE insulin

45
Q

Type 2: Non -Insulin Injectables:

Glucagon-like Peptide-1 Agonists

A

GLP-1 Agonists

Stimulate release of insulin

Suppress glucagon

Slow gastric emptying

Increase Satiety

SE: nausea

TYPE 2 ONLY

46
Q

Type 2: Non -Insulin Injectables:

Amylin Analogs

A

Amilyn Analogs

Slow gastric emptying

Suppress glucagon

Suppress hepatic glucose production ( gluconeogenesis )

Increase Satiety

47
Q

Type 2: Non -Insulin Injectables:

Nursing Considerations

A

Inpatients at Rush don’t get oral meds

Is patient/caregiver physically able to prepare and administer accurate doses?

What emotions/attitudes are patient and caregiver displaying re: diagnosis of diabetes and insulin or oral treatment

Adjustments to insulin/oral meds

  • Clarification of meds for NPO status (don’t give!)
  • Hold metformin day of and 48 hours post surgery/radiologic procedures w/ contrast (hard on kidney, can cause acidosis) (Some doctors are ok with proceeding, so check )
  • Resume metformin after until serum creatinine is normal ( 0.5 - 1 !)
48
Q

Diabetes - Sick Day

A

Sick Day

Call PCP

BG every 4 hours (increase w/ stress, not eating/drinking, N/V etc)

Urine for ketones when BG > 240 (TYPE 1)

Take insulin / oral meds (may need adjustment for dose)

Drink 8-12 oz fluids every hour awake (no sugar)

Eat regular meals (if possible)

Call PCP for mod-large ketones, N/V, uncontrolled high BG (>300 for 2 readings), high fever

49
Q

Diabetes: Nutritional Therapy

A

Weight mgmt (Type 2)

Carb counting is a cornerstone
Type 1- Insulin dosing
Type 2 Glucose Control
Involve dietician and certified educator

Each carb serving = 15 g
Typically 45-60 g per meal and 130 per day

My Plate (helpful if not on insulin, less precise, weight mgmt)

NO more diabetes exchange lists

Food Insecurity greatly contributes to diabetes

50
Q

Diabetes - Exercise Therapy

A

150 min of a moderate intensity aerobic activity
3x a week resistance training (unless contraindicated)

ESSENTIAL for type 2

  • increase insulin receptor sites (less insulin in long term)
  • lower BG levels
  • Contribute to weight loss

HYPOglycemia prevention - Type 1, 70% reported low BG after exercise

  • Monitor levels before / during / after exercise
  • Small carbs every 30 min
  • Exercise after meals

Consider type and timing of exercise

  • Always with medical clearance
  • Gradual progression
  • Individualized
51
Q

Nursing Considerations

Health Promotion (Type 2)

A

Health Promotion (Type 2)

  • Identify and screen @ risk individuals
  • Screen all adults above 45 yo
  • Weight management, physical activity

(Both)

REAL med ID

Away from home:

  • Insulin (avoid hot and cold)
  • Glucose Monitor and strips
  • Hypoglycemia treatments
52
Q

Nursing Considerations

Risk for delayed surgical recovery

A

Stress and illness impact glycemic control (per hospital protocol usually target blood glucose less than 180)

Must be in normal range for good healing

53
Q

Diabetes: Nursing Dx

A

Ineffective health mgmt

Risk for unstable blood glucose

Risk for injury related to complications

Risk for peripheral neurovascular dysfunction

Risk for injury related to hypoglycemia

54
Q

Hypoglycemia- Moderate

A

Moderate (20 - 40)

  • Deprives brain cells of fuel
  • Impair CNS
  • Cold, clammy, pale, rapid pulse, rapid shallow breathing, marked change in mood

Treat with 15 - 30g rapid acting carb

Take additional food (milk/cheese) in 10 - 15 min

Recheck BG in 15 min (set timer!)

55
Q

Hypoglycemia - Severe

A
  • Altered mental status
  • Loss of consciousness
  • Seizures
  • Death
If unable to swallow/seizure 
IM GLUCAGON (opposes insulin)

Acute care:

  • 20 - 50 mL of 50% dextrose (D50) IV push
  • Complex carb at recovery
56
Q

Hypoglycemia - Considerations / Procedure

A

CHECK BG WHEN SYMPTOMS START
If monitoring equipment not available, initiate
> 70, investigate further / Monitor (trend down?)
< 70, begin treatment

IF ABLE TO SWALLOW 
Initiate carb treatment 
Recheck BG in 15 min
Repeat till BG > 70 
Pt should eat regularly scheduled meals/snacks to prevent rebound hypoglycemia 
Check BG again 45 min
57
Q

Neuropathy - Peripheral

A

Nerve demyelinization occurs in 60 - 70% of patients

Peripheral-

Distal hands/feet symmetrically (stocking/glove)

  • Loss/abnormal sensation, pain, parasthesia
  • Worse @ night
  • Loss of sensation and high risk for foot injury
  • Can cause atrophy of small muscles
58
Q

Neuropathy - Autonomic

A

Nerve demyelinization occurs in 60 - 70% of patients

Autonomic

Can affect nearly all body systems

  • Gastroparesis (delayed gastric emptying)
  • Cardiovascular abnormalities ( Decreased heart rate / variability)
  • Sexual function
  • Neurogenic bladder
    • Flaccid- volume large, pressure low, contractions absent
    • Spastic - volume normal/small, involuntary contractions uncoordinated 2/ sphincter
  • Hypoglycemia unawareness
59
Q

Patient Education - Foot Care

A
  • Cleanse and inspect daily
  • Wear proper fitting nose
  • Avoid barefoot walking
  • Trim toenails properly (preferably a podiatrist)
  • Report non- healing breaks in the skin
  • Use lotion on feet but not between toes (fungus)
60
Q

Neuropathy - Pain

A

Prevention: proper diabetes management

Anticonvulsants: Gabapentin (Neurontin)

Antidepressants: amitryptiline hydrochloride (Elavil, Levate) Nortriptyline (Pamelor)

Capsaicin cream: Axasin, Zostriks
WASH HANDS after application, don’t touch eye (pepper!)

61
Q

Nephropathy

A

Damage to the small vessels that supply the glomeruli

Leading cause of end stage renal disease

Prevention: proper diabetes management

Annual urinalysis for microalbuminiria

Serum creatinine ( 0.5 - 1) to estimate GFR and stage CKD

Control of BP levels

Prompt UTI treatment

Avoid nephrotoxic drugs

62
Q

Retinopathy

A

Damage to small retinal vessels - tiny hemorrhage or abnormal vessel growth

Leading cause of blindness

Prevention: proper management of diabetes

NOT reversible

 Maintain remaining vision 
- Dilated eye exam at Type 2 dx and 5 yrs after Type 1 dx, then annually 
- Ongoing DM management 
- Environmental management (tools) 
— Syringes w/ magnifiers 
— Talking glucometers

(Looks like blurred, spotty vision)

63
Q

Infection - Elevated Risk

A

High BG is an infection risk (macrophages don’t work as well in honey blood)

Defect in mobilization of inflammatory cells and impairment of phagocytosis by neutrophils and monocytes

Loss of sensation may delay detection or provide a skin opening to become infected

Treatment must be prompt/vigorous, include glucose management (< 180 while at hospital)

64
Q

Gerontologic Considerations of Diabetes

A

Type 2 prevalence increases with age (beta cells get tired, die)

Delayed psychomotor function could interfere with treatment

Must consider patient’s own desire for treatment and coexisting medical problems

Recognize limitations in physical activity, manual dexterity, and visual acuity

Education based on individual’s needs, slower pace if needed (hint: do a good assessment)

65
Q

Pediatric Considerations

A

Mostly Type 1 or on Insulin for Type 2

Recognition of hypoglycemia (or continuous monitor)

Math skills (carb counting, insulin dosing)

Impact on parents/ family

  • Child Care
  • School management

Unpredictable w/ eating/activity (sports)

Developmentally appropriate education

Psychological effects of life long mgmt of chronic illness (Assess for anxiety/depression)

66
Q

Pediatric Diabetes Goals

Toddler/Preschool
Up to 6 YO

A 
Toddler/Preschool (up to 6 yo):
Before meals: 100-180
Bedtime: 110 - 200
A1C < 8.5 % 
High risk, vulnerability to hypo
67
Q

Pediatric Diabetes Goals

School Age (6 - 12 yo)

A 
School Age (6-12):
Before meals: 90 - 180 
Bedtime: 80 - 100
A1C: < 8 %
Risks of hypo, low risk of complications before puberty
68
Q

Pediatric Diabetes Goals

Adolescents ( > 12 yo)

A

Adolescents ( >12 yo)

Before meals: 90 - 130
Before Bed: 90 - 150
A1C: < 7.5 %

Risk of hypoglycemia

Developmental / psychological issues

Medsurg 3 - Sensory, Endocrine, DM, Neuro (2 decks)

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