diabetes med surg second half

Question 1

 General categories of chronic diabetic complications

Answer 1

= macrovascular disease, microvascular disease, neuropathy, retinopathy

Question 2

what are most likelythe cause of complications with DM

Answer 2

HTN

inc BG

Question 3

is it more likely that type 1 or 2 DM pt will have complications present at time of Dx?

Answer 3

type 2

Evidence of complications may be present at time of Dx of Type 2 as they may have had undiagnosed Type 2 for many years

Question 4

are micro or macrovascular problems unique to DM?

Answer 4

microvascular

Macrovascular problems:
 Result from changes in medium to lg blood vessels (thicken, sclerose, occluded by plaque which eventually->blood flow blocked)
 These changes are same as atherosclerotic changes in those w.out DM

Question 5

 3 main types of macrovascular complications that occur more freq in DM pts:

Answer 5

 3 main types of macrovascular complications that occur more freq in DM pts: PVD, CAD, cerebrovascular disease

Question 6

how might a diabetic present with an MI

Answer 6

it might be silent
 Unique to diabetics w CAD: the typical ischemic symptoms can be absent (silent MI d/t lack of warning signs)-Type 2 diabetics should have ECGs done q2years

Question 7

consideration of cerebrovascular disease and diabetics

Answer 7

 Diabetics have 2x risk of dev cerebrovascular disease, inc chance of death
 Dec recovery from stroke
 Its imp to quickly assess pt who is exhibiting symptoms of cerebrovascular disease as theyre similar to hypoglycaemia so Tx of cerebrovascular disease can be started if nec

Question 8

T or F diabetes is an independent risk factor for atherosclerosis

Answer 8

true

Question 9

how should macrovascular risk for DM pts be reduced/treated

Answer 9

Basically, stay healthy, low BP, possible statin therapy, some type of anti platelet aggregate

1. All DM 1& 2 pts should dec CV risk in the usual ways and
    Optimal glycemic control (A1C40yrs for type 2,
    15yrs and age>30yrs,
    microvascular complications
    if other risk factors
2. ACE I or ARB in those w the following:
    Macrovascular disease
    Age >55, w additional risk factor or end organ damage
    Age

Question 10

how should macrovascular complic be managed

Answer 10

• Prevent/treat risk factors for atherosclerosis eg w diet, exercise to manage obesity, HTN, hyperlipidemia.
• Meds to control HTN and hyperlipidemia may be nec
• Smoking cessation
• Glycemic control may dec triglyceride levels and complic
• If complic occur Tx is same as nondiabetics except may need to switch from oral antidiabetic to insulin or inc insulin dose

Question 11

what is microangiopathy

Answer 11

 Diabetic microvascular disease aka microangiopathy Char by cap. basement memb thickening d/t inc blood glucose levels. Two areas affected most by this are kidneys and retina. Both are common

Question 12

is vision impairment common w DM

Answer 12

no. most pts dont dev visual impairment

Question 13

what type of ocular complications could occur from DM

Answer 13

o Retinopathy (can form scar tissue which can pull on and detach the retina)
o Cataracts
o Lens changes (this can be 1st symptom of DM. May take up to 2 months of improved glucose control before the hyperglycemia swelling subsides and vision stabilizes->tell pts not to change eyeglass prescription during the 2mo after discovery of hyperglycemia)
o Extraocuar muscle palsy (dt neuropathy, results in double vision)
o glaucoma

Question 14

how do you assess for diabetic retinopathy or other vision changes. considerations

Answer 14

 Opthalmoscope
 Fluorescein angiography-dye is injected into arm vein. Side e: yellowish, fluorescent discolouration of the skin and urine lasting 12-24hrs and some allergic rxns

Question 15

medical mgmt of diabetic retinopathy and microvascular changes

Answer 15

Medical mgmt
• Primary and secondary prevention
• Control: HTN, Proper blood glucose control dec risk of retinopathy 76%, stop smoking
• Argon laser photocoagulation
• If risk of hermmorhage-panretinal photocoagulation
• If vitreous humour is mixed w blood dt hemmorhage then a vitrectomy is removed and vitreous humour thats extracted is replaced w saline or another fluid

Question 16

nursing mgmt and role in diabetic retinopathy and microvascular complications

Answer 16

Nursing mgmt
• Educate-reg ophthalmic exams, self care of eyes, blood glucose control
• Early Dx

Question 17

how prevalent are renal complications from DM. specifically what? why does this happen? when and to who?

Answer 17

• Common complic (50% of pts w DM have chronic kidne disease (CKD))
• Pts w type 1 often show initial signs of renal disease after 10-15yrs. Type 2 dev renal disease within type 2 as many of them have had DM for many yrs before tis treated
• Soon after dev of DM kidneys filtration mechs get stressed which allows blood proteins to leak into urine which inc BP in kidneys

Question 18

how can chronic kidney disease or kiney impairment affect glycemic control and insulin needs

what else will these problems affect

Answer 18

• As renal failure progresses the catabolism of exo/endogenous insulin dec and freq hypoglycaemic episodes may result
• Insulin needs change dt changes in catabolism of insulin and changes in diet

affects pretty much everything eg declining visual acuity, impotence, foot ulcers, heart failure, nocturnal diarrhea

Question 19

what is a test that would show kidney fx (not GFR, creatinine,)

Answer 19

• One of most imp blood proteins that leaks into urine is albumin->microalbuminuria-> nephropathy in 85%. W.out microalbuminuria only 5% dev nephropathy
• Test microalbuminuria by random urine sample for albumin to creatinine ratio (ACR). Its Dx if 2/3 urine specs show ACR >2.0mg/mmol men or 2.8 women

Question 20

medical mgmt of nephropathy

Answer 20

-maint BG
-HTN drugs esp ACE I as they protect the kidneys. ARBs may be ordered
• Prevent/Tx of UTI
• Avoid nephrotoxic substances
• Adjustment of meds as renal fx changes
• Low sodium and low protein diet
• If chronic or end stage->dialysis, transplant.
dialysis may inc insulin needs

Question 21

what is diabetic neuropathy

Answer 21

Diabetic neuropathies
 A group of diseases that affect all types of nerves (periph., autonomic, spinal) d/t inc blood glucose levels and either a vascular or a metabolic mechanism or both

Question 22

peripheral neuropathy mnfts

Answer 22

Peripheral neuropathy
MNFTS: paresthesias, (prickling, tingling, or heightened sensation), burning (esp at night), feet become numb, dec proprioception, dec temp and pain sensation.
o Deformities of the foot may occur-neuropathy related joint changes dt abnormal weight distribution on joints dt lack of proprioception
o Dec of deep tendon reflexes (may be only indicator)

Question 23

what does autonomic neuropathy affect. how is this dangerous?

how should it be addressed?

Answer 23

causes dysfx of many systems that rely on ANS

Hypoglycemic awareness
 Autonomic neuropathy of the adrenal medulla is responsible for diminished or absent adrenergic symptoms of hypolycemia. Pts may no longer feel shakiness, sweating, nervousness, palpitations assoc w hypoglycaemia.

Strict blood glucose monitioring is nec as theyre at risk of dev dangerously low blood glucose levels

Question 24

what is sudomotor neuropathy
anhidrosis?
what does this put pt at risk of?

Answer 24

Sudomotor neuropathy
• Dec or absence of sweating=anhidrosis of the extremities w a compensatory inc in upper body sweating
• Dryness of the feet inc the risk for the dev of foot ulcers
• Teach pt abt skin care and heat intolerance

Question 25

3 Complications of DM that inc risk of foot infect:

Answer 25

 Complications of DM that inc risk of foot infect:
o 1=neuropathy including motor neuropathy which-> muscular atrophy which may change the shape of the foot.
o 2=PVD->poor wound healing->gangrene.
o 3=immunocompromise-hyperglycemia impairs ability of specialized leukocytes to destroy bacteria