Diabetes Mellitus

Question 1

Diabetes mellitus

Answer 1

a disease in which the body’s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine.

Question 2

Prevalence Among Ethnicities

Answer 2

The rates of diagnosed diabetes in adults by race/ethnic background are:
7.4% of non-Hispanic whites
8.0% ofAsian Americans
12.1% ofHispanics
12.7% ofnon-Hispanic blacks
15.1% ofAmerican Indians/Alaskan Natives

Question 3

Complications

Answer 3

Retinopathy
Nephropathy
Cardiovascular
Neuropathy

Question 4

Types of Diabetes

Answer 4

Type 1 – formerly known as juvenile diabetes or IDDM
Type 2 – formerly known as adult on-set diabetes or NIDDM
Gestational diabetes

There are many other lesser known types of diabetes

Question 5

Type 1

Answer 5

Autoimmune; β cell destruction leads to absolute insulin deficiency
Insulin replacement required
“Usually” childhood/young adulthood
Changing phenotype- not always lean
~10%; increasing

Question 6

Type 2

Answer 6

Progressive loss of insulin secretion on the background of insulin resistance
Varying degrees of pharmacologic support needed
Usually in adults
Increasingly common in youth
~90%

Question 7

How is it diagnosed?

Answer 7

A1C ≥6.5%
FPG ≥126 mg/dL
OGTT ≥200 mg/dL
RPG ≥200 mg/dL – Only diagnostic if person presents with overt signs of hyperglycemia.
One test is not definitive. Must perform a second test to confirm unless person presents with clear clinical signs of hyperglycemia.
Testing for autoantibodies may be performed to determine whether person has type 1 or type 2.

Question 8

Treatment Type 1

Answer 8

Insulin
Meal Planning
Exercise
Diabetes Self-management education

Question 9

Treatment Type 2

Answer 9

Meal Planning
Exercise
Oral Medications
Insulin
Diabetes Self-management education
Injectable non-insulin medications – GLP 1 receptor agonist

Question 10

Insulin

Answer 10

Rapid acting: Humalog, Novolog, Fiasp, Apidra
Short acting: Regular (Humulin R and Novolin R)
Intermediate acting: NPH (Humulin N and Novolin N)
Long acting: Levemir, Lantus, Toujeo
Ultra – long acting: Tresiba
Pre-mixed: Many different combinations

Question 11

Insulin Delivery Methods

Answer 11

Vial/Syringe
Pen
Pump

Question 12

Rapid Acting

Answer 12

Onset: 5 – 15 minutes
Peak: 1 hour
Duration: 2 – 4 hours

New Fiasp has an onset of about 2.5 minutes.

Question 13

Regular or short acting

Answer 13

Onset: 30 minutes
Peak: 2 – 3 hours
Duration: 3 – 6 hours

Question 14

Intermediate Acting (NPH)

Answer 14

Onset: 2 – 4 hours
Peak: 4 – 12 hours
Duration: 12 – 18 hours

Question 15

Long and Ultra – Long Acting

Answer 15

Delivers a fairly consistent dose of insulin over 24 hours
New ultra - long acting insulin can last 42 hours. (Tresiba)

Question 16

Pre-mixed Insulin

Answer 16

Humalog 75/25, Humalog 50/50
Humulin 70/30
Novolog 70/30
Novolin 70/30
Brand new FDA approved Xultophy: combination of Tresiba and Victoza: ultra – long acting insulin and GLP 1 receptor agonist.

Question 17

Insulin Dosing

Answer 17

The goal is to dose insulin so it best mimics the body’s natural insulin secretion pattern.
Match dosing to carb intake

Question 18

Basal

Answer 18

Background insulin usually taken once/day to cover in-between meals and during the night

Question 19

Bolus

Answer 19

Meal time insulin used to cover carbs ingested during the meal. Can be given just before or immediately after consumption of meal.

Question 20

Types of Insulin Regimens

Answer 20

Set bolus dose with meals – typically for people with type 2 diabetes
Carb (CHO) bolus to cover meals – typically 1 unit of insulin per X grams of carbs
In general terms:
l unit of mealtime insulin (lispro/aspart/apidra)
is required for every 15 grams of carbohydrate.
Insulin to carb ratio 1:15

Question 21

Carbohydrate Counting

Answer 21

Carbs are not bad
Allows for flexibility in meal planning
Consistent and even distribution of carbs is key

Question 22

Types of Insulin Regimens

Answer 22

Correction bolus – Amount to lower blood glucose to target

Correction Scale: Give units of insulin for each interval of BG
Example: 1 unit 150-200, 2 units 201-250, 3 units 250+
Correction factor: Blood glucose level – target blood glucose/correction factor = units insulin to be given
Example: BG=150 (actual) minus Target BG (100) = 50 divided by Correction factor (50) = 1 unit insulin needed

Question 23

Where to inject?

Answer 23

Must be administered subq
Abdomen, thigh, buttocks, upper arms are common sites
Need to rotate sites to prevent lipohypertrophy (hard fatty lumps)
Insulin is best absorbed from areas in the following order: abdomen, upper arms, thigh, buttocks

Question 24

Mixing insulin

Answer 24

Mixing insulin must be done in a specific order. Do not mix long acting insulin with any other type of insulin. Can only mix short or rapid (clear) with NPH (cloudy)
NPH will separate. Make sure it is uniformly cloudy before mixing. Gently roll the bottle between your hands. DO NOT SHAKE!

Question 25

Mixing insulin steps

Answer 25

1st – Inject air into the NPH. Make sure bottle is NOT inverted
2nd – Inject air into clear or rapid insulin
3rd – Invert bottle and draw up correct amount of insulin
4th – Without moving the plunger, insert syringe into NPH and draw up correct amount of insulin

Question 26

Exercise

Answer 26

Exercise is good for everyone.
Person needs to understand how different types of exercise affects their body.
Generally exercise will lower blood glucose levels
Exercise may continue to lower blood glucose levels up to 24 hours after completion of activity.

Question 27

When things don’t go as planned

Answer 27

Hypoglycemia: Blood glucose level below 70

Hyperglycemia: Blood glucose level above target value. In the hospital we generally set a target of 140 – 180.

Question 28

Hyperglycemia

Answer 28

Onset:
Usually slow to develop to severe levels
More rapid with pump failure/malfunction, illness, infection
Can mimic flu-like symptoms
Greatest danger: may lead to diabetic ketoacidosis (DKA) if not treated

Severe Symptoms
Labored breathing
Confusion
Profound weakness
Unconscious

Moderate Symptoms
Dry mouth
Vomiting
Stomach cramps
Nausea

Mild Symptoms
Lack of concentration
Thirst
Frequent urination
Flushing of skin
Sweet, fruity breath
Blurred vision
Weight loss
Increased hunger
Stomach pains
Fatigue/sleepiness

Question 29

Hyperglycemia causes

Answer 29

Late, missed or too little insulin
Food intake exceeds insulin coverage
Decreased physical activity
Expired or improperly stored insulin
Illness, injury
Stress
Other hormones or medications
Hormone fluctuations, including menstrual periods
Any combination of the above

Question 30

Hyperglycemia treatment

Answer 30

Lower blood glucose down to target range
Verify with blood glucose check
Check ketones
Administer insulin
Administer fluids
Recheck blood glucose

Question 31

Hypoglycemia

Answer 31

Onset:
sudden, must be treated immediately

may progress to unconsciousness if not treated

can result in brain damage or death

Question 32

Hypoglycemia causes

Answer 32

Too much insulin
Too little food or delayed meal or snack
Extra/unanticipated physical activity
Illness
Medications
Stress

Question 33

Hypoglycemia treatment

Answer 33

Based on severity of hypoglycemia
Mild – Moderate
Moderate – Severe
Severe

Question 34

Hypoglycemia symptoms

Answer 34

Mild Symptoms
Hunger
Sleepiness
Shakiness
Changed behavior
Weakness
Sweating
Paleness
Anxiety
Blurry vision
Dilated pupils
Increase heart rate or palpitations

Moderate to Severe Symptoms
Yawning
Confusion
Irritability/frustration
Restlessness
Extreme tiredness/fatigue
Dazed appearance
Inability to swallow
Unconsciousness/coma
Sudden crying
Seizures

Question 35

Treatment - Hypoglycemia

Answer 35

Remember the “Rule of 15”
If person is able to safely swallow – give 15 grams of CHO, wait 15 minutes and check BG a second time.
If BG still < 70 then treat again with 15 gm of CHO.
If still < 70 after treating x2, call the physician or 911 if outside of the hospital. Continue to treat until help arrives.
If >70, have person eat something with carbohydrate, protein and fat to sustain level.

If person is unable to swallow safely then you will need to treat with glucagon or IV dextrose.
Glucagon can be given subq or IM

Clean site if possible.
Inject at 90° into the tissue under cleansed area (may administer through clothing as necessary
buttocks
thigh
Arm
First pre-mixed glucagon injection- ages 2 yrs and up

Question 36

BAQSIMI (BAK-see-mee)

Answer 36

It is also known as glucagon nasal powder.
It is not known if BAQSIMI is safe and effective in children under 4 years of age.

Should be given in a low blood sugar emergency, even if you have passed out, because BAQSIMI does not need to be inhaled.

Must roll person on to side after administration. Left side if preferred but either side will do.
Examples of 15 gm of CHO –
4 ounces of Juice
15 raisins (small package)
8 ounces of milk
3 or 4 glucose tablets
—person may have hypoglycemic unawareness

Hyperglycemia is treated with insulin

Question 37

Target Goals - Adults

Answer 37

Blood glucose: 70 – 130 (home)
140 – 180 (in hospital)
Blood pressure: < 140/90
Triglyceride: ≤ 150
HDL: > 40 males > 50 females
A1C: < 7%

Question 38

Angiopathy

Answer 38

Damage to blood vessels secondary to chronic hyperglycemia (Fig. 48-14 in the textbook)
Leading cause of diabetes-related death
68% CVD and 16% stroke age 65 and older
Two categories: macrovascular and microvascular complications

Long-term complications are devastating; require ongoing monitoring.
See Table 48-20 in the textbook for ADA recommendations
Annual exam:
Retinopathy, nephropathy, neuropathy (comprehensive foot exam), cardiovascular risk factor assessment
As needed or every visit to HCP:
Foot and lower extremity exam, exercise stress testing
Daily
Foot exam by patient

Question 39

Macrovascular Angiopathy

Answer 39

Diseases of large and medium-sized blood vessels
Cerebrovascular disease
Cardiovascular disease
Peripheral vascular disease
Greater frequency and earlier onset in patients with diabetes
Women 4 to 6x risk for CVD
Men 2 to 3x risk for CVD than nondiabetics

Decrease and treat CVD risk factors
Obesity—nutrition and exercise
Smoking—blood vessel disease, stroke and lower extremity amputation; cessation
Hypertension—optimize BP;  CV and renal disease
High fat intake/dyslipidemia; statin and lifestyle interventions
Sedentary lifestyle—exercise

Question 40

Microvascular Complications

Answer 40

Thickening of vessel membranes in capillaries and arterioles from chronic hyperglycemia
Areas most affected:
Eyes—retinopathy
Kidneys—nephropathy
Nerves—neuropathy

Question 41

Retinopathy

Answer 41

Microvascular damage to retina due to chronic hyperglycemia, nephropathy, and HTN
Most common cause of new cases of adult blindness

Question 42

Retinopathy: Interprofessional Care

Answer 42

Initially no changes in vision
Annual eye examinations with dilation to monitor
Maintain healthy blood glucose levels and manage hypertension

Question 43

Nephropathy

Answer 43

Damage to small blood vessels that supply the glomeruli of the kidney
Leading cause of end-stage renal disease in U.S.; 20% to 40% of people with diabetes have it
Risk factors
Hypertension
Genetics
Smoking
Chronic hyperglycemia

Annual screening for albuminuria and albumin-to-creatinine ratio
If albuminuria present, drugs to delay progression:
ACE inhibitors or angiotensin II receptor antagonists
Control of hypertension and blood glucose levels in a healthy range: imperative

Question 44

Neuropathy

Answer 44

Nerve damage due to metabolic imbalances of diabetes
60% to 70% of patients with diabetes have some degree of neuropathy
Sensory neuropathy—most common

Question 45

Neuropathy

Answer 45

Nerve damage due to metabolic imbalances of diabetes
60% to 70% of patients with diabetes have some degree of neuropathy
Sensory neuropathy—most common

Question 46

Neuropathy: Etiology and Pathophysiology

Answer 46

Reduced nerve conduction and demyelination
Ischemic damage to peripheral nerves
May precede, accompany, or follow diagnosis
Classifications: sensory or autonomic

Question 47

Sensory Neuropathy

Answer 47

Paresthesias— tingling, burning, itching; “walking on pillows or numb feet;”
Very sensitive
Complete or partial loss of sensitivity to touch or temperature is common
Small muscles of hands and feet may be affected causing deformity and limited fine movement

Question 48

Sensory Neuropathy- treatment

Answer 48

Managing blood glucose levels
Drug therapy
Topical creams
Tricyclic antidepressants
Selective serotonin and norepinephrine reuptake inhibitors
Antiseizure medications

Question 49

Autonomic Neuropathy

Answer 49

Can affect nearly all body systems and lead to:
Hypoglycemic unawareness, bowel incontinence and diarrhea, and urinary retention
Gastroparesis
Cardiovascular abnormalities
Sexual function
Erectile dysfunction—often first manifestation
Decreased libido
Vaginal infections
Neurogenic bladder can cause urinary retention

Question 50

Foot and Lower Extremity Complications

Answer 50

Sensory neuropathy and PAD are major risk factors.
Other factors: clotting abnormalities, impaired immune function, autonomic neuropathy
Smoking increases risk

Sensory neuropathy may cause loss of protective sensation (LOPS) prevents awareness of injury; major risk factor for amputation
Annual monofilament screening
Peripheral artery disease (PAD)
Decreased blood flow = decreased O2, WBCs, and nutrients causes longer wound healing, increased risk for infection

Patient teaching: Foot care (Table 48-21 in the text)
Proper footwear
Avoidance of foot injury
Skin and nail care
Daily inspection of feet
Prompt treatment of small problems
Diligent wound care for foot ulcers
Neuropathic arthropathy (Charcot’s foot)
Joint dysfunction and footdrop may cause ulcers

Question 51

Skin Complications

Answer 51

Diabetic dermopathy—most common
Red-brown, round or oval patches
Scaly then flat and indented; shins
Acanthosis nigricans—manifestation of insulin resistance
Velvety light brown to black skin thickening; flexures, axillae, and neck

Question 52

Infection

Answer 52

Defect in mobilization of inflammatory cells and impaired phagocytosis
Recurring or persistent infections

Antibiotics—prompt and vigorous
Patient teaching to prevent infection
Hand hygiene, avoid exposure
Flu and pneumococcal vaccine
COVID vaccine

Question 53

Psychologic Considerations

Answer 53

High rates of depression, anxiety, and eating disorders
Diminished self-care, helplessness, and poor outcomes
Diabetes distress—stress, fear, and burden of living with and managing diabetes

Disordered eating behaviors (DEB)
Anorexia, bulimia, binge eating, excessive calorie restriction, and intense exercise

Question 54

Gerontologic Considerations

Answer 54

Increased prevalence and mortality
Present in 25% over age 65 due to -cell function, decreased insulin sensitivity, and altered carbohydrate metabolism

Glycemic control challenging
Increased hypoglycemic unawareness
Functional limitations
Coexisting medical problems
Cognitive decline