Diabetes I Flashcards
Diabetes Mellitus definition
+ A chronic multisystem disease related to
Abnormal insulin production
Impaired insulin utilization
Or both
+ Requires a multi-dimensional approach to successful management
How harmful is Diabetes mellitus
\+ Leading cause of End-stage renal disease Adult blindness Nontraumatic lower limb amputations \+ Major contributing factor Heart disease Stroke
Etiology and Pathophysiology of DM
\+ 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
Altered Mechanisms in Type 1 and Type 2 Diabetes
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
Prediabetes
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
characteristics of Prediabtes
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%.
Type 1 Diabetes Mellitus
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
Type 2 Diabetes Mellitus
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
Type 2 Diabetes MellitusEtiology and Pathophysiology
\+ 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
- Insulin resistance
- Pancreas ↓ ability to produce insulin
- Inappropriate glucose production from liver
- Alteration in production of hormones and adipokines
Clinical ManifestationsType 2 Diabetes Mellitus
Nonspecific symptoms ( May have classic symptoms of type 1) Fatigue Recurrent infection Recurrent vaginal yeast or monilia infection Prolonged wound healing Visual changes
Diabetes MellitusDiagnostic Studies
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
Drug Therapy: Type 2Insulin
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
Drug TherapyInsulin: storage and administration
++ 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
Administration of insulin
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.
Drug Therapy: Insulin pump
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
Problem with insulin
++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
Drug TherapyOral Agents
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
Drug TherapyKnow these
\+ Sulfonylureas
Glipizide, glyburide
\+ Meglitinide
repaglinide
\+ Biguanides
Metformin
\+ Thiazolidinediones
Pioglitazone, rosiglitazoneDiabetes Nutritional Therapy
+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.
Diabetes Exercise
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
Self-monitoring of blood glucose (SMBG)
Describe self-monitoring of blood glucose (SMBG) and key
instructions for patients/caregivers
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
What Happens When a Patient with DM is Admitted to the Hospital
+++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
acute complication of diabetes mellitus
+ Diabetic ketoacidosis (DKA)
+ Hyperosmolar hyperglycemic syndrome (HHS)
+ Hypoglycemia
Biguanides
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
Sulfonylureas
↑ Insulin production from pancreas Major side effect: hypoglycemia Examples Glipizide (Glucotrol) Glyburide (Micronase, DiaBeta, Glynase) Glimepiride (Amaryl)
Thiazolidinediones
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
Dipeptidyl Peptidase–4 (DDP-4) Inhibitor
Blocks inactivation of incretin hormones
↑ Insulin release
↓ Glucagon secretion
↓ Hepatic glucose production
Examples (gliptins)
Sitagliptin (Januvia)
Saxagliptin (Onglyza)
Linagliptin (Tradjenta)
Dopamine Receptor Agonist
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
Drug Therapy Amylin Analog
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
Diabetes Nutritional Therapy: Type 1 DM
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
DiabetesNutritional Therapy: Type 2 DM
Emphasis on achieving glucose, lipid, and blood pressure goals
Weight loss
Nutritionally adequate meal plan with ↓ fat and CHO
Spacing meals
Regular exercise
Food composition
Nutrient balance of diabetic diet is essential
Nutritional energy intake should be balanced with energy output
Individualized
Carbohydrates
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
Glycemic index
Term used to describe rise in blood glucose levels after carbohydrate-containing food is consumed
High glycemic index foods increase glucose levels faster
DiabetesNutritional Therapy
fats
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
DiabetesNutritional Therapy
Protein
Should make up 15% to 20% of total calories
High-protein diets not recommended
DiabetesNutritional Therapy
Alcohol
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
DiabetesNutritional Therapy
fiber, carbohydrate,
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
diabetes exchange lists
MyPlate
+ 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
Nursing Assessment of DM
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+ Nursing Assessment of DM
\+ 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
Nursing Assessment of DM
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
Nursing Assessment of DM
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
overall goals of DM - planning
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
health promotion
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
acute intervention of DM
Hypoglycemia
Diabetic ketoacidosis
Hyperosmolar hyperglycemic nonketotic syndrome
Nursing implementation of acute illness and surgery
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
