Diabetes I

Question 1

Diabetes Mellitus definition

Answer 1

+ A chronic multisystem disease related to
Abnormal insulin production
Impaired insulin utilization
Or both
+ Requires a multi-dimensional approach to successful management

Question 2

How harmful is Diabetes mellitus

Answer 2

\+ Leading cause of 
End-stage renal disease
Adult blindness
Nontraumatic lower limb amputations
 \+  Major contributing factor
Heart disease
Stroke

Question 3

Etiology and Pathophysiology of DM

Answer 3

\+ Theories link cause to single/ combination of these factors
Genetic
Autoimmune
Viral
Environmental

\+ Common types
Type 1
Type 2
Prediabetes
** Other types
Gestational 
Secondary diabetes

Question 4

Altered Mechanisms in Type 1 and Type 2 Diabetes

Answer 4

Type 1 diabetes: Genetically susceptible individuals develop islet cell autoantibodies months to years before diagnosis of type 1 diabetes. Progressive autoimmune destruction of beta cells (80% -90% reduction) leads to hyperglycemia and diagnosis of type 1 diabetes.

+ Type 2 - Insulin resistance, caused by inherited defects in insulin receptors, is a universal finding in patients with type 2 diabetes. Precedes development of impaired glucose tolerance and type 2 diabetes by as much as 3 to 4 decades. Insulin resistance stimulates a compensatory increased insulin production by beta-cells in pancreas.

In pancreas: beta cell defects results in a decreased insulin secretory capacity below the amount needed for the degree of insulin resistance leading to hyperglycemia and the diagnosis of diabetes

In liver: excessive hepatic glucose production causes increased hyperglycemia in the fasting and postprandial state.

In adipose tissue: Adipokines from adipose tissue have a role in altered glucose and fat metabolism

Question 5

Prediabetes

Answer 5

Individuals already at risk for diabetes
Usually present with no symptoms
Blood glucose high but not high enough to be diagnosed as having diabetes
Long-term damage already occurring 
Heart, blood vessels
\+ Must watch for diabetes symptoms
- Polyuria
- Polyphagia
- Polydipsia

Question 6

characteristics of Prediabtes

Answer 6

Characterized by
Impaired fasting glucose (IFG)
IFG: Fasting glucose levels are 100 to 125 mg/dL
Impaired glucose tolerance (IGT)
IGT: 2-Hour plasma glucose levels are between 140 and 199 mg/dL
AIC is in range of 5.7% to 6.4%.

Question 7

Type 1 Diabetes Mellitus

Answer 7

Formerly known as “juvenile-onset” or “insulin-dependent” diabetes
Most often occurs in people younger than 40 years of age
Occurs more frequently in younger children

Question 8

Type 2 Diabetes Mellitus

Answer 8

Most prevalent type of diabetes
Accounts for more than 90% of patients with diabetes
Usually occurs in people over 35 years of age
80% to 90% of patients are overweight.
Prevalence increases with age.
Genetic basis

Question 9

Type 2 Diabetes MellitusEtiology and Pathophysiology

Answer 9

\+ Some endogenous insulin.
        - Insulin produced is insufficient or is poorly utilized by tissues.
\+ Obesity (abdominal/visceral) 
            -Most powerful risk factor
\+ Genetic mutations
         -Lead to insulin resistance 
         - Increased risk for obesity

1. Insulin resistance
2. Pancreas ↓ ability to produce insulin
3. Inappropriate glucose production from liver
4. Alteration in production of hormones and adipokines

Question 10

Clinical ManifestationsType 2 Diabetes Mellitus

Answer 10

Nonspecific symptoms 
( May have classic symptoms of type 1)
Fatigue
Recurrent infection 
Recurrent vaginal yeast or monilia infection
Prolonged wound healing
Visual changes

Question 11

Diabetes MellitusDiagnostic Studies

Answer 11

AIC ≥ 6.5%
Ideal goal
ADA ≤7.0%
American College of Endocrinology 126 mg/dL
Random or casual plasma glucose measurement ≥200 mg/dL plus symptoms
Two-hour OGTT level ≥200 mg/dL when a glucose load of 75 g is used

Question 12

Drug Therapy: Type 2Insulin

Answer 12

Exogenous insulin
Insulin from an outside source
Required for type 1 diabetes
Prescribed for patient with type 2 diabetes who cannot control blood glucose by other means
Often used for Type 2 patients in acute care who otherwise do not use insulin

Question 13

Drug TherapyInsulin: storage and administration

Answer 13

++ 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.
++Administration of insulin
Cannot be taken orally
Subcutaneous injection for self-administration
IV administration

Question 14

Administration of insulin

Answer 14

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.

Question 15

Drug Therapy: Insulin pump

Answer 15

Insulin pump
Continuous subcutaneous infusion
Battery-operated device 
Connected via plastic tubing to a catheter inserted into subcutaneous tissue in abdominal wall
Potential for tight glucose control

Question 16

Problem with insulin

Answer 16

++Problems with insulin therapy
Hypoglycemia
Allergic reaction
Lipodystrophy
Somogyi effect
Dawn phenomenon
++++Somogyi effect
- Rebound effect in which an overdose of insulin causes hypoglycemia in am
- Counterregulatory hormones released and cause rebound hyperglycemia and ketosis
+++++ Dawn phenomenon
- Characterized by hyperglycemia present on awakening in the morning
- Due to release of counterregulatory hormones in predawn hours
- Growth hormone/cortisol possible factors

Question 17

Drug TherapyOral Agents

Answer 17

Focus on three defects of type 2 diabetes
+ Improve insulin resistance
Sulfonylureas, Biguanides, Thiazolidinediones
+ Improve insulin production
Sulfonylureas, Meglitinides, DPP-4 Inhibitors, Incretin Mimetic
+ Decrease hepatic glucose production
Sulfonylureas, Biguanides, Thiazolidinediones

Question 18

Drug TherapyKnow these

Answer 18

\+ Sulfonylureas
                Glipizide, glyburide
\+ Meglitinide
              repaglinide
\+ Biguanides
              Metformin
\+ Thiazolidinediones 
                Pioglitazone, rosiglitazone

Question 19

Diabetes Nutritional Therapy

Answer 19

+Counseling
Education
Ongoing monitoring
Interdisciplinary team with registered dietitian as lead

+ American Diabetes Association (ADA)
Guidelines indicate that maintaining an overall healthy eating plan, a person with diabetes can eat same foods as a person who does not have diabetes.
+ ADA healthy food choices for improved metabolic control
Maintain blood glucose levels to as near normal as safely possible
Normal lipid profiles and blood pressure
Prevent or slow complications
Individual needs; personal, cultural preferences
Maintain pleasure of eating

+ Overall goal
Assist people in making changes in nutrition and exercise habits that will lead to improved metabolic control.

Question 20

Diabetes Exercise

Answer 20

Essential part of diabetes management
↑ insulin receptor sites
Lowers blood glucose levels
Contributes to weight loss
Should be individualized
Monitor blood glucose levels before, during, and after exercise
Several small carbohydrate snacks can be taken every 30 minutes during exercise to prevent hypoglycemia.
Best done after meals
Exercise plans should be started
After medical clearance
Slowly with gradual progression

\+ Type/amount
Minimum 150 minutes/week aerobic
Resistance training three times/week
\+   Benefits
↓ Insulin resistance and blood glucose 
Weight loss
↓ Triglycerides and LDL , ↑ HDL
Improve BP and circulation

+ Start slowly after medical clearance
Monitor blood glucose
Glucose-lowering effect up to 48 hours after exercise
Exercise 1 hour after a meal
Snack to prevent hypoglycemia
Do not exercise if blood glucose level exceeds 300 mg/dL and if ketones are present in urine

Question 21

Self-monitoring of blood glucose (SMBG)

Describe self-monitoring of blood glucose (SMBG) and key

  instructions for patients/caregivers

Answer 21

Enables self-management decisions regarding diet, exercise, and medication
Important for detecting hyperglycemia and hypoglycemia
Patient training is crucial
Gives immediate information about blood glucose levels

+ Enables decisions regarding diet, exercise, and medication
Accurate record of glucose fluctuations
Helps identify hyperglycemia and hypoglycemia
Helps maintain glycemic goals
A must for insulin users
Frequency of testing varies

+ Alternative blood sampling sites
Data uploaded to computer
+ Continuous glucose monitoring
Displays glucose values with updating every 1 to 5 minutes
Helps identify trends and track patterns
Alerts to hypoglycemia or hyperglycemia

\+  Patient teaching 
How to use, calibrate
\+  When to test
             Before meals
           Two hours after meals
           When hypoglycemia is suspected
            During illness
           Before, during, and after exercise

Question 22

What Happens When a Patient with DM is Admitted to the Hospital

Answer 22

+++Stress of illness and surgery
- blood glucose level: ????????
- Continue regular meal plan.
- ↑ intake of noncaloric fluids
- Continue taking oral agents and insulin.
- Frequent monitoring of blood glucose
- Ketone testing if glucose >240 mg/dL
+++ Stress of illness and surgery
Patients undergoing surgery or radiologic procedures requiring contrast medium should hold their metformin on day of surgery and up to 48 hours.
- Begun after serum creatinine has been checked and is normal

Question 23

acute complication of diabetes mellitus

Answer 23

+ Diabetic ketoacidosis (DKA)
+ Hyperosmolar hyperglycemic syndrome (HHS)
+ Hypoglycemia

Question 24

Biguanides

Answer 24

Metformin (Glucophage)
Reduce glucose production by liver
Enhance insulin sensitivity 
Improve glucose transport 
May cause weight loss
Used in prevention of type 2 diabetes
Withhold if contrast medium is used
Withhold if patient is undergoing surgery or radiologic procedure with contrast medium 
Day or two before and at least 48 hours after
Monitor serum creatinine
Contraindications
Renal, liver, cardiac disease
Excessive alcohol intake

Question 25

Sulfonylureas

Answer 25

``` ↑ Insulin production from pancreas Major side effect: hypoglycemia Examples Glipizide (Glucotrol) Glyburide (Micronase, DiaBeta, Glynase) Glimepiride (Amaryl) ```

Question 26

Thiazolidinediones

Answer 26

Most effective in those with insulin resistance Improve insulin sensitivity, transport, and utilization at target tissues Examples Pioglitazone (Actos) Rosiglitazone (Avandia) Rarely used because of adverse effects

Question 27

Dipeptidyl Peptidase–4 (DDP-4) Inhibitor

Answer 27

Blocks inactivation of incretin hormones ↑ Insulin release ↓ Glucagon secretion ↓ Hepatic glucose production Examples (gliptins) Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Tradjenta)

Question 28

Dopamine Receptor Agonist

Answer 28

``` Bromocriptine (Cycloset) Mechanism of action unknown Thought that patients with type 2 diabetes have low levels of dopamine Increases dopamine receptor activity Alone or in combination ```

Question 29

Drug Therapy Amylin Analog

Answer 29

Pramlintide (Symlin) Slows gastric emptying, reduces postprandial glucagon secretion, increases satiety Used concurrently with insulin Subcutaneously in thigh or abdomen before meals Watch for hypoglycemia

Question 30

Diabetes Nutritional Therapy: Type 1 DM

Answer 30

Meal plan is based on individual’s usual food intake and is balanced with insulin and exercise patterns Day-to-day consistency important for patients using conventional, fixed insulin regimens More flexibility with rapid-acting insulin, multiple daily injections, and insulin pump

Question 31

DiabetesNutritional Therapy: Type 2 DM

Answer 31

Emphasis on achieving glucose, lipid, and blood pressure goals Weight loss Nutritionally adequate meal plan with ↓ fat and CHO Spacing meals Regular exercise

Question 32

Food composition

Answer 32

Nutrient balance of diabetic diet is essential Nutritional energy intake should be balanced with energy output Individualized

Question 33

Carbohydrates

Answer 33

Minimum of 130 g/day Fruits, vegetables, whole grains, legumes, low-fat milk Monitor with CHO counting, exchanges, or experienced-based estimation Use glycemic index Sucrose-containing food substituted for other CHOs

Question 34

Glycemic index

Answer 34

Term used to describe rise in blood glucose levels after carbohydrate-containing food is consumed High glycemic index foods increase glucose levels faster

Question 35

DiabetesNutritional Therapy | fats

Answer 35

Limit saturated fats to less than 7% of total calories Limit cholesterol to less than 200 mg/day Minimize trans fat Two or more servings of fish per week to provide polyunsaturated fatty acids

Question 36

DiabetesNutritional Therapy | Protein

Answer 36

Should make up 15% to 20% of total calories | High-protein diets not recommended

Question 37

DiabetesNutritional Therapy | Alcohol

Answer 37

Limit to moderate amount Consume with food to reduce risk of nocturnal hypoglycemia if using insulin or insulin secretagogues Consume with CHO to reduce hypoglycemia, but then watch for hyperglycemia from CHOs

Question 38

DiabetesNutritional Therapy | fiber, carbohydrate,

Answer 38

Fiber: Recommendation: 25 to 30 g/day Nutritive and nonnutritive sweeteners: In moderation Diet teaching: Dietitian initially provides instruction Carbohydrate counting: Serving size is 15 g of CHO Typically 45 to 60 g per meal Insulin dose based on number of CHOs consumed Patient teaching essential

Question 39

diabetes exchange lists | MyPlate

Answer 39

+ Exchange lists Starches, fruits, milk, meat, sweets, fats, free foods + USDA MyPlate method Helps patient visualize the amounts of nonstarchy vegetable (1/2), starch (1/4), and protein (1/4) that should fill a 9-inch plate Consistent CHO diet

Question 40

Nursing Assessment of DM

Answer 40

``` Subjective data + Past health history Viral infections, trauma, infection, stress, pregnancy, chronic pancreatitis, Cushing syndrome, acromegaly, family history of diabetes + Medications Insulin, OAs, corticosteroids, diuretics, phenytoin + Recent surgery + Subjective data: Malaise Obesity, weight loss or gain Thirst Hunger, nausea/vomiting Constipation Poor healing Dietary compliance Diarrhea Frequent urination Bladder infections Nocturia Urinary incontinence ```

Question 41

+ Nursing Assessment of DM

Answer 41

``` + Subjective data Muscle weakness, fatigue Abdominal pain, headache, blurred vision Numbness/tingling, pruritus Impotence, frequent vaginal infections Decreased libido Depression, irritability, apathy Commitment to lifestyle changes ```

Question 42

Nursing Assessment of DM

Answer 42

Objective data Sunken eyeballs, vitreal hemorrhages, cataracts Dry, warm, inelastic skin Pigmented skin lesions, ulcers, loss of hair on toes, acanthosis nigricans Kussmaul respirations Hypotension Weak, rapid pulse

Question 43

Nursing Assessment of DM

Answer 43

``` Objective data Dry mouth Vomiting Fruity breath Altered reflexes, restlessness Confusion, stupor, coma Muscle wasting Serum electrolyte abnormalities Fasting blood glucose level of 126 mg/dL or higher Oral glucose tolerance test and/or random glucose level exceeding 200 mg/dL Leukocytosis ↑ Blood urea nitrogen, creatinine ```

Question 44

overall goals of DM - planning

Answer 44

Overall goals Active patient participation Few or no episodes of acute hyperglycemic emergencies or hypoglycemia Maintain normal blood glucose levels Prevent or minimize chronic complications Adjust lifestyle to accommodate diabetes regimen

Question 45

health promotion

Answer 45

Identify, monitor, and teach patients at risk Obesity: primary risk factor Routine screening for all overweight adults and those older than 45 Diabetes risk test

Question 46

acute intervention of DM

Answer 46

Hypoglycemia Diabetic ketoacidosis Hyperosmolar hyperglycemic nonketotic syndrome

Question 47

Nursing implementation of acute illness and surgery

Answer 47

Acute illness, injury, and surgery + cause ↑ Blood glucose level secondary to counterregulatory hormones Frequent monitoring of blood glucose ++ Ketone testing if glucose level exceeds 240 mg/dL ++ Report to health care provider if glucose levels exceeding 300 mg/dL for two tests or moderate to high ketone levels ++ Increase insulin for type 1 diabetes +++ Type 2 diabetes may necessitate insulin therapy ++ Maintain normal diet if able Increase noncaloric fluids + Continue taking antidiabetic medications + If normal diet not possible, supplement with CHO-containing fluids while continuing medications (OAs, noninsulin injectable agents, and/or insulin as prescribed) + Intraoperative period IV fluids and insulin Frequent monitoring of blood glucose