Diabetes Mellitus Flashcards
Which populations are most at risk for DM?
- Mexican-Americans & Puerto Ricans = 87% higher risk
- African-Americans = 77% higher risk
- Hispanics = 66% higher risk
- Asian Americans = 18% higher risk
What are the 2 ways that the pancreas secretes insulin to regulate glucose?
- basal: on-going, low level insulin secretion
- prandial: burst of insulin that occurs about 10 min after eating
What role does the liver play in blood glucose control?
- insulin promotes the storage of glycogen in the liver
- insulin inhibits glycogen breakdown
- liver increases protein and lipid synthesis
What are the 3 major types of DM, and what is the incidence rates of each? What are some other ways DM could occur?
– 3 major types:
- type 1 = 5% of all cases
- type 2 = 90 - 95% of all cases
- gestational DM – occurs with pregnancy
– other ways DM could occur (1 - 5% of all cases)
- genetic conditions
- endocrinopathies
- steroids or TPN – can elevate blood glucose
- infection
- pancreatic disease
- surgery
What is type 1 DM?
autoimmune disorder; pancreatic beta cells produce absolutely no insulin
What is the normal amount of insulin produced per day?
20 - 30 units
What is peak incidence of type 1 DM?
11 years of age
linked genetically, more common in Caucasian pts, pt will experience more viral/bacterial infections prior to onset
How is type 1 DM diagnosed?
- glucose levels > 200 mg/dL
- with symptoms:
- glucosuria
- ketonuria
- polyuria
- dolydipsia (excessive thirst)
- polyphagia
- weight loss
- fatigue
- blurred vision
What causes type 2 DM?
– gradual onset and progression
– caused by combination of:
- decreased insulin secretion
- increased insulin resistance
- from obesity and physical inactivity
What is pre-diabetes?
- fasting glucose = 100 - 125 mg/dL
- 5 - 15% risk for developing DM2 in the next 3 - 5 years
- increased risk of cardiovascular disease
- associated with obesity, HTN, abnormal lipids
- progression to DM2 can be prevented
What are the 4 factors comprising metabolic syndrome? What does it mean if all 4 criteria are met?
– 4 factors:
- central obesity – wasit circumference
- men > 40
- women > 35
- dyslipidemia
- plasma triglycerides = 150+
- HDL:
- men < 40
- women < 50
- prehypertension
- BP = 135/85+
- elevated fasting blood glucose
- 100+
– meet criteria = elevated risk for develping DM2
How does the ADA diagnose diabetes? What is fasting blood glucose?
– on 2 consecutive days:
- fasting blood glucose > 126 mg/dL
- random blood glucose > 200 mg/dL
– fasting blood glucose = at least 8 hours with no food
What are the ranges for normal, pre-diabetes, and diabetes based on fasting blood glucose?
- normal = 70 - 100 mg/dL
- pre-diabetes = 101 - 125 mg/dL
- diabetes > 126 mg/dL
What is hemoglobin A1c? What is the ADAs recommendation for A1c levels? How does the ADA define DM2 based on A1c levels?
– hemoglobin A1c: glycoscolated hemoglobin; measures average blood glucose over the past 2 - 3 months
– A1c level should be below 7%
– DM2 = 6.5+ A1c levels
What are the levels for A1c, and how does it relate to blood glucose levels and what do these levels mean?
- non-diabetic range/excellent control of DM:
- A1c = 4 - 6
- blood glucose = 65 - 135
- good control over DM:
- A1c = 7
- blood glucose = 170
- poor control of DM/action required:
- A1c = 8+
- blood glucose = 205+
What are 3 acute complications of DM?
-
diabetic ketoacidosis: results from insulin deficiency (hyperglycemia) and ketosis
- fat is burned for energy –> ketones are produced –> blood becomes acidic
- hyperglycemia-hyperosmolar state (HHS): results from insulin deficiency (hyperglycemia) and dehydration
- hypoglycemia: results from too much insulin or too little glucose
How are chronic complications of DM categorized? What are the chronic complications of DM?
– macrovascular complications (changes in large BVs)
- cardiovascular disease
- MI – leading cause of death in DM pts
- thromboembolisms
- silent MIs result from neuropathy
- MI – leading cause of death in DM pts
- cerebrovascular disease
- CVA
– microvascular complications (changes in small BVs)
- nephropathy
- kidney BV structure change –> kidney function change
- renal failure
- eye and vision
- retinopathy
- 28.5% of pts with DM aged 40+
- venous beading – sign of retinal ischemia
- retinal hemorrhage
- retinopathy
What is diabetic neuropathy, and how does it result? What is the incidence of neuropathy in DM pts? What are the 2 types of diabetic neuropathy?
– diabetic neuropathy: progressive nerve deterioration
– results from nerve hypoxia
– 60 - 70% of DM pts have some form of neuropathy
– 2 types of diabetic neuropathy:
- focal: affects a single nerve or nerve group; symptoms will appear suddenly
- diffuse: widespread loss of nerve function; most common neuropathy in DM
How does diabetic neuropathy present?
- sensory alterations
- parethesias (pins and needles)
- foot deformities
- cardiovascular
- orthostatic hypotension
- syncope
- GI – autonomic neuropathy
- gastroparesis (delayed gastric emptying)
- constipation
What is diabetic nephropathy? What often occurs to DM pts experiencing diabetic nephropathy?
– diabetic nephropathy: change in kidney function leading to failure
– many pts eventually are placed on dialysis
- may also result in male erectile dysfunction
What are some lab tests that can help diagnose DM2?
- fasting blood glucose levels
- A1c
- gold standard
- on-going assessment
- oral glucose tolerance testing – used to diagnose gestational DM
- urine tests
- ketonuria
What are the goals of DM therapy?
- control of blood sugars:
- preprandial glucose = 90 - 130 mg/dL
- postprandial glucose = 180 mg/dL
- A1c < 7%
- BP < 130/80
- LDL < 100 mg/dL
- triglycerides < 150 mg/dL
What are some treatments for DM1?
- insulin via basal-bolus
- basal insulin
- Lantus
- Levemir
- NPH
- bolus insulin
- Humalog
- Novalog
- Apidra
- regular
- exercise
- aspirin therapy – prevention of MIs
What are some treatments for DM2?
- diet changes
- oral hypoglycemics
- insulin
- exercise
- aspirin therapy – prevent MIs
What are 2 types of oral antidiabetic therapy drugs?
- sulfonylureas
- ex:
- glyburide
- DiaBeta
- can cause hypoglycemia
- if taken with beta blockers
- if taken with herbal therapies
- if pts don’t eat regularly
- stimulates release of insulin from beta cells
- ex:
- biguanides
- ex:
- Metformin
- Glucophage
- often used in conjunction with sulfonylureas
- decrease liver glucose production
- decrease blood glucose level
- ex:
What are 2 types of complications of insulin therapy? How do you prevent these complications?
- lipoatrophy: loss of fat from repeat injections in a single site
- lipohypertrophy: increased swelling of fat from repeat injections in a single site
– encourage pt to rotate sites to avoid deformities
What education should DM pts receive about nutrition?
- carbohydrates – 45 - 65% of daily caloric intake
- fats – limit intake to < 7%
- protein – 15 - 20% of daily caloric intake
- soluble fibers slow glucose absorption
- 2 alcoholic beverages for men, 1 for women in addition to meals is safe
What education should DM pts receive regarding exercise?
- exercise improves perfusion of limbs due to vascular changes
- exercise improves renal perfusion
- do not exercise within 1 hr of insulin injection
- risk for hypoglycemia
- consume enough carbs to sustain exercise
What is the most common complication of diabetes? What education should DM pts receive regarding this complication?
– foot injury that leads to hospitalization and amputation
– education:
- footwear – protective shoes, slightly bigger than normal shoe size
- loss of protective sensation in feet
How does neuropathy result? What medications can be used to treat neuropathic pain?
– damage to the nervous system anywhere along the nerve
- starts as pain during initial vascular symptoms
- progress to absence of sensation
– medications for neuropathic pain:
- anticonvulsants
- antidepressants
What are the 3 levels of hypoglycemia?
- mild
- blood glucose = 60 - 70 mg/dL
- sweating
- hunger
- trembling
- lightheadedness
- pt can treat self
- moderate
- blood glucose = 45 - 59 mg/dL
- severe
- blood glucose < 45 mg/dL
- mental confusion
- loss of consciousness
- cannot treat self
What are some causes of hypoglycemia?
- increased exercise/activity
- decreased oral intake
- insulinomas (pancreatic tumor)
- too much insulin
- medication interactions
- unexpected nutritional interruptions
- failure to recognize signs and symptoms
What are some interventions for hypoglycemia?
- carbohydrate replacement
- medications
- glucagon subq
- 50% dextrose
- Sandostatin (diazoxide/octreotide) to treat sulfonylurea-induced hypoglycemia
- suppresses insulin release from pancreas
What is diabetic ketoacidosis (DKA)? Who experiences DKA? What is a common reason pts experience DKA?
– diabetic ketoacidosis: triad of uncontrolled hyperglycemia, metabolic acidosis, and increased total body ketones
- commonly caused by infection
- death can occur
– more common in DM1 pts (67% of cases), but can occur in DM2 pts with infection, surgery, or trauma
- between ages 18 - 44
– pts stopping insulin (noncompliance) is a common reason pts experience DKA
Other than infection and noncompliance with insulin therapy, what are other causes for DKA?
- pancreatitis
- MI
- CVA
- drugs
- new onset of DM1
- psychological problems
How does hyperglycemia-hyperosmolar state (HHS) differ from DKA?
– DKA
- common in DM1 pts
- rapid onset
- blood glucose < 250 mg/dL
- pH < 7.3
- high ketone levels
– HHS
- DM2 pts may experience, but not often
- gradual onset
- blood glucose > 600 mg/dL
- pH > 7.3
- ketone levels are low
- blood osmolality > 320+ mOsm/L
- 15 - 20% of body fluid loss
What are 2 priority interventions for HHS?
- fluid therapy within 36 - 72 hrs
- rehydrate
- restore blood glucose
- continuing insulin therapy
- once fluids have been replaced, start IV insulin
What are some causes of HHS?
- infection
- noncompliance with insulin therapy
- pancreatitis
- MI
- CVA
- drugs
- underlying medical illness or medications that compromise hydration
What are some signs and symptoms of DKA and HHS?
- poor skin turgor
- tachycardia
- hypotension
- mental status change
- Kussmaul respirations (DKA)
- diffuse abdominal pain (DKA)
How do HHS and DKA differ in terms of onset?
HHS evolve over days to weeks; DKA evolves much more quickly in DM1 pts
What are the 3 priority interventions for DKA and HHS? (FIE)
- fluids
- insulin
- electrolyte replacement
