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NURS 205 > Diabetes > Flashcards

Diabetes Flashcards

1
Q

What is diabetes?

A

Type 1: Insufficient insulin production from the pancreas

Type 2: Cells are insulin resistant; they don’t respond to insulin properly

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2
Q

What is the mortality for diabetes?

A

Approximately 65%-80% of people with DM will die as a result of heart disease or stroke.

Diabetes is a contributing factor in the deaths of approximately 41 500 Canadians each year.

Canadian adults with diabetes are twice as likely to die prematurely as people without diabetes.

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3
Q

What is the etiology/pathophysiology of diabetes?

A

Theories link cause to single/combination of these factors:

  • Genetic
  • Autoimmune
  • Viral
  • Environmental
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4
Q

Describe the normal insulin metabolism.

A

Insulin is a hormone produced by the beta cells (Islets of Langerhans)

Released continuously into bloodstream in small increments with larger amounts released after food

Promotes glucose transport from bloodstream across cell membrane to cytoplasm of cell

Decreases glucose in the bloodstream

Stabilizes glucose to normal range of 4-6 mmol/L (in hospital it’s “4-8, feeling great”)

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5
Q

What happens during normal insulin metabolism?

A

Stimulates storage of glucose as glycogen in liver and muscle

Inhibits gluconeogenesis

Enhances fat deposition

↑ Protein synthesis

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6
Q

What are some other hormones involved in insulin metabolism?

A

Glucagon, epinephrine, growth hormone and cortisol

Counter-regulatory hormones

  • Oppose effect of insulin
  • Stimulate glucose production & output by liver
  • Decrease movement of glucose into the cells
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7
Q

What are the social determinants of health in relation to diabetes?

A

Lower socioeconomic status

Indigenous people

80% of new Canadians come from high risk populations

Lifestyle practices

Women
- Diabetes affects men and women equally but women are more severely impacted by their consequences

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8
Q

What barriers to care do Indigenous people face? (4)

A
  • Fragmented care,
  • Poor chronic disease management.
  • High turnover rates of HCP,
  • Social determinants of health
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9
Q

How are Indigenous people impacted in health care?

A

Indigenous people living in Canada are among the highest-risk populations for diabetes and related complications.
- Screening should occur earlier and at more frequent intervals

Prediabetes is an important opportunity to prevent or delay diabetes with health behaviour interventions

Increased risk for gestational diabetes among women

Important as Health Care Providers:

  • Acknowledge the legacy of colonization and its ongoing adverse effects
  • Explore preferences and barriers and question one’s own assumptions
  • Foster positive relationships
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10
Q

What are some risk factors for Type 2 Diabetes? (8)

A
  • Over 40 years of age
  • Family history
  • Ethnicity
  • Obesity (especially abdominal obesity)
  • Sedentary lifestyle
  • History of IGT or IFG or elevated A1C
  • History of gestational diabetes
  • History of delivery of macrosomic infant
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11
Q

What are the classifications of diabetes?

A

Two most common types:

  • Type 1
  • Type 2

Other types

  • Gestational
  • Prediabetes
  • Secondary diabetes
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12
Q

What is prediabetes?

A

Individuals already at risk for diabetes

Blood glucose high but not high enough to be diagnosed as having diabetes

Characterized by:

  • Impaired fasting glucose (IFG) -> fasting glucose levels 6.1–6.9 mmol/L.
  • Impaired glucose tolerance (IGT) -> 2-hour plasma glucose levels between 7.1 and 11 mmol/L.

Long-term damage already occurring
- Heart, blood vessels

Usually present with no symptoms

Must watch for diabetes symptoms

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13
Q

How is diabetes diagnosed?

A

Fasting glucose > 7 mmol/L

A1C > 6.5%

2h plasma glucose (PG) in a 75g oral glucose tolerance test > 11.1 mmol/L

Random PG > 11.1 mmol/L + symptoms

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14
Q

What do A1c test results tell us?

A

A1c Test results:

  • Normal (below 5.7%)
  • Prediabetes (5.7-6.4%)
  • Diabetes (>6.5%)
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15
Q

What is Type 1 Diabetes Mellitus?

A

Formerly known as “juvenile-onset” or “insulin-dependent” diabetes

Occurs most often in people < 30 years of age

Occurs more frequently in younger children

Will require exogenous insulin to sustain life

Diabetic ketoacidosis (DKA)

  • Occurs in absence of exogenous insulin
  • Life-threatening condition
  • Acidosis
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16
Q

What is the etiology/pathophysiology of Type 1 Diabetes Mellitus?

A

End-result of longstanding process

  • Progressive destruction of pancreatic beta cells by body’s own T cells
  • Autoantibodies cause a reduction of 80% to 90% in normal beta-cell function before manifestations occur
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17
Q

What are the causes of Type 1 Diabetes Mellitus?

A

Genetic predisposition & exposure to a virus are factors affecting the pathogenesis

  • Related to human leukocyte antigens (HLAs)
  • When a person with HLAs are exposed to a virus, the beta-cells of the pancreas are destroyed either directly or through an autoimmune process
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18
Q

Describe the onset of disease for Type 1 Diabetes Mellitus.

A

Long preclinical period

Antibodies present for months to years before symptoms occur

Manifestations develop when pancreas can no longer produce insulin.

  • Rapid onset of symptoms
  • Present at ED with ketoacidosis

It’s usually present with weight loss, polydipsia, polyuria, polyphagia

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19
Q

What is type 2 diabetes?

A 
Most prevalent type (more than 90% of individuals with diabetes)
Majority overweight (80-90%)

Prevalence increases with age (usually > 35 years)

Genetic basis

Greater in some high-risk populations:
- Indigenous Peoples, Hispanic, South Asian, Asian, or African descent

Pancreas continues to produce some endogenous insulin

Insulin produced is insufficient or is poorly utilized by tissues

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20
Q

What is the etiology/pathophysiology of Type 2 Diabetes Mellitus?

A

Genetic mutations
- Lead to insulin resistance & increased risk for obesity

Obesity (abdominal/visceral)
- Most powerful risk factor

Metabolic syndrome

  • Hypertension, dyslipidemia, insulin resistance, & dysglycemia (abnormality in blood sugar stability)
  • Risk factors: abdominal obesity, sedentary lifestyle, certain ethnicities, diet
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21
Q

What are some metabolic abnormalities associated with Type 2 Diabetes Mellitus?

A
  1. Insulin resistance: Body tissues do not respond to insulin.
    - Insulin receptors are either unresponsive or insufficient in number.
    - Results in hyperglycemia
  2. Pancreas ↓ ability to produce insulin
    - β cells fatigued from compensating for high blood sugar
    - β-cell mass lost
    - Some can revert to normal blood sugar levels again
  3. Inappropriate glucose production from liver
    - Liver’s response of regulating release of glucose is haphazard
    - Not considered a primary factor in development of type 2
  4. Alteration in production of hormones and adipokines
    - Play a role in glucose and fat metabolism -> contribute to pathophysiology of type 2 diabetes
    - Two main adipokines ->
    Adiponectin and leptin (play a role in insulin sensitivity)
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22
Q

Describe the onset of disease for Type 2 Diabetes Mellitus.

A

Gradual onset
- Person may go many years with undetected hyperglycemia and few symptoms

Osmotic fluid/electrolyte loss from hyperglycemia may become severe.
- Hyperosmolar Hyperglycemic State (HHS)

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23
Q

Compare the clinical manifestations for T1 and T2 diabetes.

A

Type 1 Diabetes

  • Usually acute onset
  • Polyuria
  • Polyphagia
  • Polydipsia
  • Weight loss
  • Weakness, fatigue
  • Visual changes
  • Women-yeast infections

Type 2 Diabetes

  • Non-specific
  • Gradual onset
  • Fatigue
  • Poor wound healing
  • Recurrent infections
  • Visual acuity changes
  • Painful peripheral neuropathy in the feet
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24
Q

What is gestational diabetes?

A

Develops during pregnancy

Detected at 24–28 weeks of gestation

Usually normal glucose levels at 6 weeks postpartum

Increased risk for birth trauma, hypoglycemia, hyperbilirubinemia, and respiratory distress syndrome

Increased risk for developing type 2 in 5–10 years

Therapy: first nutritional, second insulin

25
Q

What is secondary diabetes?

A

Secondary to treatments causing abnormal blood glucose levels

  • Corticosteroids (prednisone), phenytoin (Dilantin), atypical antipsychotics (clozapine)
  • Usually resolves when underlying condition treated
26
Q

What conditions can result in secondary diabetes?

A

Results from other conditions such as:

  • Schizophrenia
  • Cushing’s syndrome
  • Hyperthyroidism
  • Immuno-suppressive therapy
  • Parenteral nutrition
  • Cystic fibrosis
27
Q

How is diabetes managaed?

A
  • Exercise
  • Medication
  • Nutritional therapy
  • Glucose monitoring
  • Reducing complication
  • Vascular protection
28
Q

What are the goals of collaborative care? (4)

A
  • Decrease symptoms
  • Promote well-being
  • Prevent acute complications
  • Delay onset and progression of long-term complications
29
Q

What are the strategies of collaborative care? (5)

A
  • Nutritional therapy
  • Exercise
  • Drug therapy
  • Blood glucose monitoring
  • Self-management education & support
30
Q

True or false: nutritional therapy has the greatest impact in initial stages

A

True

31
Q

What are the restrictions on nutritional therapy?

A

Caloric restrictions of carbohydrates & saturated fats

Carbohydrates: 45-60% (sucrose/sugar < 10%)

Protein: 15-20%

Fats: <35% (saturated & trans fatty acids<7%)
- Include foods rich in polyunsaturated omega-3 fatty acids and plant oils

Fibre: 25-50 g/day

32
Q

What is the difference in nutritional therapy for T1 and T2 diabetes?

A

Type 1 Diabetes:

  • Meal plan based on individual’s usual food intake and is balanced with insulin and exercise patterns
  • Insulin regimen is managed day to day

Type 2 Diabetes:

  • Emphasis on achieving glucose, lipid, and blood pressure goals
  • Calorie reduction and weight loss
33
Q

How does exercise help in diabetes management?

A

Essential part of diabetes management

  • ↑ Insulin receptor sites
  • Lowers blood glucose levels
  • Contributes to weight loss
34
Q

When is the best time to exercise?

A

Best done after meal.

Small carbohydrate snacks can be taken every 30 minutes during exercise to prevent hypoglycemia

35
Q

What are the benefits of physical activity?

A

Short-term benefits

  • Lowers blood sugar within 1 hour
  • Gives more energy and strength during the day
  • Decreases stress, anxiety, and fatigue
  • Improves relaxation and sleep
  • Improves confidence and well-being

Long-term benefits

  • Improved blood sugar control
  • Helps to maintain or lose weight
  • Lowered blood pressure
  • Stronger bones and muscles
  • Lower risk of complications such as eye, heart, and kidney disease
  • Improved quality of life.
36
Q

How is insulin used as drug therapy for diabetes? How is it administered?

A

Indications for insulin therapy

  • Required for type 1 diabetes
  • Prescribed for a client with type 2 diabetes who cannot control blood glucose by other means

Administration of insulin

  • Cannot be taken orally (yet)
  • Subcutaneous injection for self-administration
  • IV administration in acute/critical care settings
37
Q

How does insulin therapy work?

A

Types of insulin differ with regards to onset, peak action, and duration.

  • Characterized as rapid-acting, short-acting, intermediate-acting, long-acting
  • Different types of insulin may be used for combination therapy.
38
Q

Where do you inject insulin?

A

Fastest absorption from abdomen, followed by arm, thigh, and buttock

Abdomen is the preferred site.

Rotate injections within one particular site

Do not inject in site to be exercised.

39
Q

How do you teach self-injection of insulin?

A

Teach patient & family member as soon as possible

Wash hands, no need for alcohol wipes

Advise not to reuse needles

Preloaded insulin pens available

Storage of insulin

  • Do not heat/freeze.
  • In-use vials may be left at room temperature up to 4 weeks.
  • Extra insulin should be refrigerated.
  • Avoid exposure to direct sunlight.
40
Q

What are the alternative methods of insulin delivery?

A

Continuous subQ insulin infusion

  • Insulin pump
  • Patch pump

Intensive insulin therapy
- Multiple daily injections

Corrective Action/Sliding Scale
- Not monotherapy
- Given in conjunction with oral antihyperglycemics
 or basal insulin
- Common practice in acute care
41
Q

What is the sliding scale of blood glucose and Humulin R units S/C?

A

Blood Glucose:

  • 0-4 = call MD; 1 amp D50 or glass of orange juice
  • 4.1 - 8 = none
  • 8.1 - 10 = 2
  • 10.1 - 12 =4
  • 12.1 - 14 = 6
  • 14.1 - 16 = 8
  • 16.1 - 18 =10
  • 18.1 - 20 = 12
  • > 20 = 14; call MD
42
Q

What are some problems with insulin therapy?

A

Hypoglycemia

Allergic reactions: local inflammatory, anaphylaxis (animal insulins, zinc or protamine, latex rubber stopper)

Lipodystrophy: hypertrophy or atrophy of subcutaneous tissue-rare with human insulins

Somogyi effect : overdose of insulin causes hypoglycemia, usually during sleep hours; followed by release of counter-regulatory hormones resulting in rebound hyperglycemia and potential ketosis

Dawn effect: hyperglycemia present on awakening in the morning, due to release of counter-regulatory hormones; peaks in adolescence and young adults; growth hormone/cortisol possible factors

43
Q

What are Antihyperglycemics? Provide examples and their MoA.

A

Biguanides (1st line for most type 2 diabetics)

  • Reduce glucose production by liver
  • Enhances insulin sensitivity at tissue level
  • Improves glucose transport into cells
  • Metformin (Glucophage) (immediate release & slow release)

α-Glucosidase Inhibitors

  • Starch blocker-slows down absorption of carbohydrate in small intestine
  • Acarbose (Glucobay)

Sulphonylureas (insulin secretagogues)
- Increase in insulin production from pancreas
- Caution with older adults/renal impairment
(Increased risk for hypoglycemia)
- Gliclazide (Diamicron), Glyburide (Diabeta)

Nonsulphonylureas (meglitinides)

  • Increase in insulin production from pancreas
  • Taken 30 minutes before each meal
  • Should not be taken if meal skipped
  • Repaglinide (Gluconorm)

Thiazolidinediones:

  • insulin sensitizer: improve insulin sensitivity, transport and utilization at target tissues
  • Rosiglitazone (Avandia); Pioglitazone (Actos)

Dipeptidyl peptidase-4 (DDP-4) Inhibitors:

  • Increase & prolong increased incretin levels
  • Glucose dependent
  • Sitagliptin (Javia)

Gludagon-like peptide (GLP)-1 Receptor Agonists (incretin mimetics)

  • Stimulates release of insulin from beta cells
  • Subcutaneous injection; not to be used with insulin
  • Suppresses glucagon secretion
  • Reduces food intake & slows gastric emptying
  • Liraglutide (Victoza); Exenatide (Byetta, injected twice per day; Bydureon, injected once per week)
44
Q

How is blood glucose monitored?

A

Self-monitoring of blood glucose (SMBG)

  • Enables client to make self-management decisions regarding diet, exercise, and medication
  • Supplies immediate information about blood glucose levels
  • Important for detecting episodic hyper/hypoglycemia
  • Client training is crucial.
45
Q

How does hyperglycemia affect hospitalized pts?

A
  • Increased HAI & sepsis
  • Longer periods of mechanical ventilation
  • Increased risk or mortality after MI or cardiac surgery
  • Increased risk of AKI
  • Poor wound healing
  • Increased LoS
46
Q

What are the management guidelines for diabetes?

A

Critically ill (hospitalized):

  • BG 6.0-10.0 mmol/L
  • Insulin infusion (reduces risk of hypoglycemia)

Non-critically ill (hospitalized):

  • Pre-prandial 5.0 to 8.0 mmol/L
  • Random glucose < 10.0
  • Basal, nutritional and correction doses

All patients avoid hypoglycemia
- Barrier to achieving glycemic control

47
Q

What are the NPO guidelines?

A

NPO for short duration
- Continue to give basal dose, remove bolus and give correctional doses.

NPO for long duration:
- Short-acting insulin every 6 hours.

48
Q

What are the acute complications for diabetes?

A
  • Hypoglycemia
  • Diabetic ketoacidosis (DKA)
  • Hyperosmolar hyperglycemic syndrome (HHS)
49
Q

What is hypoglycemia?

A

Low blood glucose (< 4 mmol/L)

- Occurs when too much insulin in proportion to glucose in the blood

50
Q

What are the clinical manifestations of hypoglycemia?

A
  • Anxiety & nervousness
  • Diaphoresis & pallor
  • Tremors
  • Hunger
  • Palpitations
  • Changes in vision
  • Dizzyness
  • Slurred speech
  • Unsteadiness
51
Q

What happens if hypoglycemia goes untreated?

A

Untreated can progress to loss of consciousness, seizures, coma, and death

52
Q

What are the causes of hypoglycemia?

A

Mismatch in timing

- Food intake and peak action of insulin or oral hypoglycemic agents

53
Q

What are the blood glucose readings in regards to hypoglycemia?

A

If <4 mmol/L, begin treatment

If >4 mmol/L, investigate further for cause of signs/symptoms

If monitoring equipment not available, treatment should be initiated

54
Q

What is the treatment for hypoglycemia if the pt is able to swallow?

A

15–20 g of a simple carbohydrate

  • 175 mL of fruit juice
  • Glucose tabs
  • Regular soft drink

Recheck blood sugar 15 minutes after treatment.

Repeat until blood sugar >4 mmol/L.

Client should eat regularly scheduled meal/snack to prevent rebound hypoglycemia.

Check blood sugar again 45 minutes after treatment.

55
Q

What is the treatment for hypoglycemia if the pt is NOT able to swallow?

A

Administer 1 mg of glucagon IM or subcutaneously
- Adverse effect: rebound hypoglycemia.

Have client ingest a complex carbohydrate after recovery.

In acute care settings
- 20–50 mL of 50% dextrose IV push

56
Q

What is DKA?

A

Fats are metabolized in the absence of insulin

Usually in Type 1 Diabetes; profound deficiency in insulin, hyperglycemia, ketosis, metabolic acidosis & dehydration

Body breaks down fat stores for energy

Ketones are acidic by-products of fat metabolism
Excess diuresis
- Dehydration

Sweet fruity odor on breath; ketone build-up

57
Q

What is HHS?

A

HHS occurs in patients with DM that can produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia

Often in older patients with Type 2 diabetes

Hyperglycemia & fluid volume deficit

58
Q

How can the pt be educated in self management? (7)

A

Education:Diabetes education is an important first step. All people with diabetes need to be informed about their condition.

Physical activity:Regular physical activity helps your body lower blood glucose (sugar) levels, promotes weight loss, reduces stress and enhances overall fitness.

Nutrition:What, when and how much you eat all play an important role in regulating blood sugar levels.

Weight management:Maintaining a healthy weight is especially important in the management of type 2 diabetes.

Medication:Type 1 diabetes is always treated with insulin. Type 2 diabetes is managed through physical activity and meal planning and may require medications and/or insulin to assist your body in controlling blood sugar more effectively.

Stress management:Learning to reduce stress levels in day-to-day life can help people with diabetes better manage their condition.

Blood pressure:High blood pressure can lead to eye disease, heart disease, stroke and kidney disease, so people with diabetes should try to maintain a blood pressure level below 130/80. To do this, you may need to change your eating and physical activity habits and/or take medication(s).

NURS 205 (12 decks)

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