Diabetes Mellitus Flashcards
Review Diabetes deck from Module 2 and CVPV
Review of Basic DM
chronic multisystem disease related to abnormal insulin production or impaired insulin utilization
- characterized by hyperglycemia resulting from lack of insulin, effect, or both
What are the different types of DM
Type 1
Type 2
Gestational
and many more
Type 1 Diabetes is related to
immune-related
idiopathic
What organ generates the alpha and beta cells?
Pancreas
Beta cells produce
insulin
Alpha cells produce
glucagon
Beta cells are located/produced by
islets of langerhans
Insulin is released
amounts and times
continuously into the bloodstream in small increments
larger amounts released after food
What is the normal/stabilized glucose range?
70-110
Diabetes Mellitus is the leading causes of
Adult blindness
end-stage kidney disease
non-traumatic amputations
Insulin does what
lowers blood glucose by allowing glucose to enter the cells
Type 1 DM is characterized as
absent insulin
Type 2 DM is characterized as
insufficient insulin
Diabetes could be a combination of these causing factors
genetic
autoimmune
environmental
Insulin resistance
poor utilization of insulin
insulin receptors pull receptors inside the cells
Insulin releasing schedule in an average person without diabetes
Continous into the bloodstream in small amounts
Larger amounts released after food
What is a normal/stabilized glucose level range?
70-110
If the patient has a deficiency of insulin, what could happen with the insulin?
has just enough insulin to keep from getting very sick
BUT not enough to get rid of all glucose
DM is a major contributing factor to
heart disease
stroke
HTN
Explain the insulin and glucose relationship in the healthy body
Insulin is released for the Islets of Langehans
Insulin works as a key into the insulin receptor of the cells
The glucose channel opens allowing glucose to enter the cell
Glucose is
energy
If the body does not have glucose, what happens?
tired
When you have an elevation/peak or depletion/valley of plasma insulin what is the body doing?
body stores fat
Couterregulatory hormones of Insulin - Opposes effects
Glucagon
Epinephrine
Growth Hormone
Cortisol
The counterregulatory hormones of insulin do what to blood glucose?
increases
How does glucagon, epinephrine, GH, and cortisol increase the blood glucose
(1) stimulating glucose production and release by the liver
(2) decreasing the movement of glucose into the cells.
Gestational DM occurs during
pregnancy
With gestational diabetes, normal glucose levels return to normal during
6 weeks post partum
Gestational diabetes can cause
baby weighing over 9 lbs
35-60% chance of the mother developing T2DM within 10 years
Type 1 DM is most commonly diagnosed at
young age
T1DM has what occurring with beta cells
complete destruction of beta cells of the pancreas
- complete lack of insulin production
Risk factors of Type 1
Autoimmune
Viral
Environmental
Medically induced
S/S of Type 1 DM
Polyuria
Polydipsia
Polyphagia
weight loss
fatigue
increase the frequency of infections
rapid onset
insulin-dependent
family tendency
peak incidence 10-15 y/o
Number 1 symptom of T1DM
weight loss
Polyuria
increase urination
Polydipsia
increase thirst
Polyphagia
increase hunger
What are the 3 Ps
Polyuria
Polydipsia
Polyphagia
weight loss
Long acting insulin is taken when
at night at the same time every day
Short-acting (Lispro) should be taken
eat within 15 mins
Dx DM
HEMOGLOBIN A1C (HGB A1C)
FASTING BLOOD GLUCOSE
2 HR POSTPRANDIAL OR ORAL GLUCOSE TOLERANCE TEST (OGTT)
RANDOM BLOOD GLUCOSE
Hemoglobin A1C meaures
levels over the prior 2-3 months
What test is the gold standard to dx and controlling of DM
A1C
A1C is a great DM tool, however what can affect the score of the test
PREGNANCY, CKD, THALASSEMIA, Fe DEF ANEMIA, PERNICIOUS ANEMIA, RECENT ACUTE BLOOD LOSS OR TRANSFUSION
Peaks and valleys
Steroids, dilanton, thiazide diuretics do what to the Blood glucose levels on A1C
raise
What blood condition would the A1C not work on?
anemia (ordered and found in the hemoglobin)
Why can you not use A1C to dx diabetes in pregnant women?
anemic
A1C Goal Level in diabetics is
less than 6.5-7%
A1C Pre-diabetes Level is
6-6.5%
A1C correlates to what
average glucose during those months
What is normal for an A1C?
less than 6
Fasting plasma glucose test means
no caloric intake for at least 8 hours
Fasting plasma glucose can/cannot be used alone for diagnosis
cannot be used alone
But shows a trend
then do an A1C and ask about s/s
Fasting Plasma Glucose Test shows a positive for DM for what level
126 or higher
Postprandial
after meals
What test is used for pregnant women to establish DM?
2hr Post prandial Oral Glucose Tolerance Test
What does the pt do during a 2hr Post prandial Oral Glucose Tolerance Test
consumes beverages with glucose load (75g carbs) after fasting for 8-12 hours
blood taken before at the 1st hour, and 2nd hour
Value is based on the 2nd hours mark
2hr Post prandial Oral Glucose Tolerance Test
The pt is considered to have DM if the patient has a
200 or higher
2hr Post prandial Oral Glucose Tolerance Test
What are the normal levels?
less than 140
2hr Post prandial Oral Glucose Tolerance Test
Pre-diabetes levels
140-199
Random plasma glucose can be classified as DM MUST have
symptoms of hyperglycemia or hyperglycemia crisis
Random glucose plasma is used as a
trend not Dx (fingerstick)
Self-monitoring is most commonly used because of
timely feedback
What is the most common error for a Self-monitoring system?
blood sample size
Self-monitoring is advised before
each meal and at bedtime
What device is good for pts with erratic and unpredictable drops
-warns of dangerous levels
Continuous monitoring
Where can you put monitoring systems of blood sugar?
where you give insulin
Dexcom stays on for how long
week to 10 days
The pump delivers
insulin (such as hybrid closed loop)
A hybrid closed loop is considered an
artificial pancreas
Omnipod
pump
Insulin pump therapy
continous subQ insulin infusion via external device worn somewhere on the body
-basal and bolus
Basal insulin units
2-3 units small amounts (continous)
Bolus insulin
large amount at once for BS
- meal times determined by pre-meal and carbohydrate content of meal
What insulin should be used pump
rapid acting
Pump therapy is NOT
regulate automatically
not decrease need to check BS
not replace the regulatory system of a normal functioning pancreas
not easy or inexpensive
not complication fee
can not eat whatever they want
Why would a diabetic want/need a pump therapy?
A1C over 6.5
frequent hypoglycemia
shift work
Type 2 with gastroparesis
dawn phenomenon
pediatrics
exercise
hectic lifestyle
Gastroparesis
stomach does not empty be itself
Dawn phenomenon
kids blood sugar rises at night with growth spurts
What is the deciding factor of pump therapy?
Motivation - active participant in management, quantify intake, and monitor
good vision and fine motor skills
strong support system
insurance coverage
elderly but need someone to fill it for them
Benefits of Pump Therapy
improved glycemic control
pharmacokinetic delivery insulin
flexibility
variable and individualized basal rates
NOT eliminate Self Monitoring BG
Risks of Insulin Pump
hypoglycemia - overdose
hyperglycemia - underdose
infusion site problems
takes time and commitment
proper planning
cost
Nursing Consideration of Pump Therapy
not worn to MRI and CT
all members aware pt is wearing pump
What happens if the problem occurs in pump therapy?
endocrinologist or HCP
Who is in charge of the pt’s pump
pt does
if in hospital, need order for pt to have pump and medication
Hypoglycemia has what onset
rapid within 1-3 hours
S/S of hypoglycemia
anxious
sweaty
hungry
confused
blurred or double vision
shaky
irritable
cool and clammy skin
If pt is hypoglycemia, then give the pt
blood sugar (SUGAR BOMB w/ no added sugar)
Should you give the hypoglycemia pt peanut butter and crackers? Why?
no, fat and protein break down too slowly
If the patient is hypoglycemic, what should you hope you have time to do before giving them a sugar bomb with no added sugar?
check BS
give sugar
wait 15 mins to check
give fat and protein
Hypoglycemia can progress from altered LOC to
difficulty speaking
visual alterations
stupor
confusion
coma
If hypoglycemia is left untreated it can progress to these severe symptoms?
LOC
seizures
coma
death
What blood sugar level is considered hypoglycemia?
Below 70
How long does it take for the hypoglycemic state to correct itself after administering an antidote?
15 mins
If the diabetic pt is NPO, then insulin needs to be
held or changed
frequent BG monitoring
If the diabetic pt is on clear liquids, then clear liquid needs to be
caloric
If a diabetic pt is on enteral feeding, then
monitor BG
give insulin at regular intervals
If the diabetic pt is on parenteral nutrition, then
IV nutrients solution may already contain insulin
TPN was giving pt diabetes now short-term use
Treatment of hypoglycemia in the community
Process
administer glucose via juice, soda, bread, or crackers
check fingerstick 15 mins after
if still low repeat
after reaching normal, then a fat meal or snack with protein
What snack works best for hypoglycemia pts?
simple carbohydrates
Treatment of hypoglycemia
in hospital settings/ or
unable to swallow or
no IV access
IV Dextrose 25-50 mL of D50
NO IV: 1mg IM Glucagon injection to release glucose stored in liver
Hypoglycemia Unawareness
no warning s/s until glucose level is critically low
related to autonomic neuropathy and lack of counterregulatory hormones
pts at risk need to keep levels somewhat higher
Stress and illness does what to glucose level
raises
Hypoglycemia unawareness is related to
autonomic neuropathy and lack of counterregulatory hormones
pts at risk of hypoglycemia unawareness need to keep levels
somewhat higher
What do you give a pt in a hypoglycemic state
sugar bomb with no added sugar
juice
What food category is peanut butter and crackers?
Should you give to hypoglycemic pt if in crisis?
Why or why not?
fat and protein
No
will not dissolve quick enough give when stable
IM Glucagon releases what from where
glucose from the liver
Why is glucagon not the first choice?
takes longer to act
20-30 mins IM
Hypoglycemic Unawareness is typically seen in what pts
elderly
Type 2 DM is common in
adults (and obese children)
all groups of people
more in AA, Native Americans, hispanic, and asian
Type 2 pathology of insulin usage
insulin is present but cells resist
pancreas makes just enough but can’t keep up with demand
Type 2 DM is usually diagnosed after 6-8 years when
damage is already done to other organs (HTN, Coronary Artery Disease, stroke)
Patho of Type 2
pancreas continues to produce some insulin but not enough is produced or not efficient
What is the major difference between Type 1 and Type 2 DM?
Type 1 = no insulin made
Type 2 = some is made not enough
Type 1 Onset
gradual
autoantibodies present years before s/s occur and dx
Type 2 Onset
gradual
had for 6-8 years before diagnosed
found in routine lab tests
At time of Dx what percentage of beta cells are no longer secreting insulin
50-80%
Leading factors of Type 2 DM
insulin resistance
pre-diabetes
metabolic syndrome
gestational diabetes
Insulin resistance is obtained
genetically
Insulin resistance does what to receptors
pull in and hide them
Prediabetes s/s
asymptomatic but long term damage already occured
What is the level of pre-diabetes on a Postpradial 2hr test?
140-199
What is the level of pre-diabetes on a fasting blood glucose test?
100-125
What is the level of pre-diabetes on a HA1C?
5.7-6.4%
Pre-diabetics should be started on what?
treatment either lifestyle change or Metformin
Metabolic Syndrome increases the risk of what type
2
If you have __ out of ___ in the metabolic syndrome s/s you have an increased risk of type 2.
3/5
Metabolic Syndrome s/s
elevated glucose levels (more than 200)
abdominal obesity
elevated bp
high triglycerides (greater than 150)
decreased HDL (less than 50)
If you have metabolic syndrome you are considered
heart attack or stroke waiting to happen
What should HDL levels for women and men be greater than?
women 50
men 40
Modifiable risk factors of DM
BMI greater than 26
Physical inactivity (sedentary)
HDL less than 35 or
Triglycerides greater than 250
metabolic syndrome
Non-modifiable risk factors of DM
1st degree relative
high risk population
baby delivered more than 9 lbs
gestational diabetics
HTN
PCOS pts
A1C 5.7% +
hx of CVD
Type 2 Diabetics S/S
3 Ps
recurrent infections (bacteria and yeast)
prolonged wound healing
sight changes
fatigue
cardiovascular disease
renal insufficiency
Type 2 diabetes considered a ________ disease
lifestyle
Metabolic syndrome is more common in
35 y/o +
How do yeast infection occur, odor, and treat them?
loves dark and moist places
odor - foul red flaky wet
powder oral or cream with boobs off with supportive bra or hand rolled towel
Management of DM
Educate - nutrition and safe monitoring (compliance)
control of glucose
diet
exercise
complications monitoring
oral glucose control agents
insulin
Metformin class
Biguanides
Biguandines (metformin) used to
reduce glucose production by the liver
lower BG and improve glucose tolerance and transport
enhances insulin sensitivity
weight loss
Metformin is usually started when
immediately after diagnosis
Could metformin be used for preventative treatments?
yes
What are the side effects of Biguanides (metformin)?
GI upset
rarely lactic acidosis
When do you hold metformin (biguanides)?
48 hours prior to and after procedures with dye contrast
many drug interactions
What could happen if metformin and dye contrast can lead to?
renal failure
lactic acidosis
Type 2 Diabetes 4 steps to treatment
1- diet and exercise
2- lifestyle changes + metformin
3- lifestyle changes + metformin + second drug
4- lifestyle changes + metformin + insulin therapy
Sulfonylureas uses
increase insulin production from pancreas
Sulfonylureas side effects
hypoglycemia
weight gain
Sulfonylureas drug names
glipizide
glyburide
glimepiride
Sulfonylureas and alcohol _____________ hypoglycemia.
s/s of effects
potentiate
flushing, palpations, and nausea
Meglitinides (end in -lix) do what?
stimulate insulin release from pancreas
Meglitinides are taken
short-acting with each meal (30 mins prior)
Meglitinides are absorbed completely in
4 hours (half-life of 1 hour)
Meglitinides side effects
hypoglycemia
weight gain
Alpha-glucosidase inhibitors aka
“Starch blockers”
Alpha-glucosidase inhibitors uses
slow down absoprtion of carbs in small intestine
Alpha-glucosidase inhibitors taken with
1st bite of each meal
Thiazolidinediones (Gloxazones) uses
decreases insulin resistance
decrease glucose production
improve insulin sensitivity, transport, and utilization at target tissues
Thiazolidinediones (Gloxazones) adverse effects
URI (upper respiratory infection)
HA
Sinusitis
myalgia
When should you use caution when giving Thiazolidinediones (Gloxazones) to this type of pt?
mild heart failure can cause severe heart failure
Thiazolidinediones (Gloxazones) can cause what in women?
Remind them about?
ovulation
birth control in older women
Gliptins are what type of drug
Incretin enhancers
Gliptins adverse effects
sore throat
rhinitis
upper respiratory infection
HA
Gliptins are used for
blocking inactivation of incretin hormones
increase insulin release
decrease glucagon secretion
decrease heptic glucose production
Sodium-Glucose Co-Transporter 2 Inhibitors work by
block reabsorption of glucose by kidney
increase glucose excretion
lowering glucose levels
What 2 drugs are used in combination therapy for diabetes?
Metformin
sulfonylurea
GLP-1 Receptor Agonists are delivered as a
Non-insulin injectable
GLP-1 Receptor Agonists is used as a
slow gastric emptying
stimulate the glucose-dependent release of insulin
postprandial release of glucagon
suppress appetite
GLP-1 Receptor Agonists have a common side effect of
nausea
Amylin Mimetic needs to know
USED TO COMPLEMENT EFFECTS OF MEALTIME INSULIN IN T1DM AND T2DM PATIENTS
DELAYS GASTRIC EMPTYING AND SUPPRESSES GLUCAGON SECRETION
ACT IN THE BRAIN TO INCREASE THE SENSE OF SATIETY, HELPING TO LOWER CALORIC INTAKE
What drug is used to treat hyperlipidemia at night?
statin drugs
What drugs are used for diabetes, HTN, and renal insufficiency?
ACE (dry hacking cough and renal protection)
ARBs
Calcium channel blockers
Diuretics can be used for
fluid overload
HTN
DM
Which drug is not recommended (for tests) but are used for HTN and CVD? Why?
Beta blockers
mask hypoglycemic s/s
T1DM all patients require
insulin
Long-term effects of hyperglycemia
Major CVD = ischemic heart disease, stroke
lower extremity amputation
DKA
HHS
akin and soft tissue infections
pneumonia
flu
sepsis
TB
Pts with hyperglycemia need to check and get what because they will not be able to fight against it
vaccinations and check for TB
Vascular Effects: Macro
Cardiovascular and Peripheral Disease
Myocardial Infarction
Stroke
Vascular Effects: Micro
retinopathy
periodontal disease
nephropathy (renal insufficiency/failure)
What retinopathy can be caused by DM?
cataracts
glaucoma
diabetic macular edema
What effects does DM have on Cardiovascular
HTN
Angina
Dyspnea
MI
Peripheral Vascular Disease
Hyperlipidemia
CVA (stroke)
Assessments should be performed on a pt with DM
Cardiopulmonary
Peripheral Vascular (sensation and skin)
GI
Neuro
Hyperlipidemia is treated with
STATIN drugs
Nicotine takes what from hemoglobin
O2
When working on a wound how would you know you have healthy tissue?
bleeding
What massively raises the risk of CV disease?
smoking
Periodontal Disease related to DM
increased dental cavities
tooth loss
gingivitis
candidiasis (yeast) = Thrush
When a pt gets Dx with TYpe 2 DM, appointments with ALL at-risk disease doctors need to be made when
immediately
When should have dental exams?
twice yearly
Diabetic retinopathy
microvascular damage to retina
Nonproliferative diabetic retinopathy
partial occlusion of small blood vessels in retina causes microaneurysms
eye bleeding
Proliferative diabetic retinopathy
eye bleeding
most dangerous
retina and vireous humor
new blood vessels formed (neovascularization)
cause retinal detachment
Retinopathy Tx
laser photocoagulation: destroy ischemia
Vitrectomy: aspirate out of eye
Drugs to block vascular endothelial growth factor
DM causes an increased risk for what other eye diseases
Glaucoma = blurry (eye goes white with film
Cataracts = Blindness (eyes extra white with no retina)
Diabetic Macular Edema (degeneration) = black spot in middle only see peripheral
If the pt has been diagnosed with Type 1 DM, when should they make appointments for other doctors?
within 5 years
When should you see an eye doctor
1 year with dilation
Nephropathy is the damage to small blood vessels that supply the
glomeruli
What is the leading cause of ESRD?
Nephropathy
What labs are monitoring for nephropathy?
Creatinine
BUN
GFR
UA - albumin (protein) + is renal breakdown
Risk factors of Nephropathy?
NTH
Genetics
smoking
chronic hyperglycemia
How do you treat diabetic neuropathy?
annual screening with labs
Albumin in urine = ACE and Angiotensin 2 receptor antagonist
GFR means
level should be
glomerular filtration rate
greater than 60
BUN range
7-20
Creatinine range
0.6-1.2
GFR is separated by what for levels
AA and others
S/S of nephropathy diabetic
edema of the face, hands, and feet
UTI
renal failure (edema, anorexia, nausea, fatigue, difficulty concentrating)
Diabetic Neurological effects
Dyemylination
Diabetic peripheral neuropathy
autonomic neuropathy
Patho of Demyelination
nerve exposed
damaged nerve
pain
sensation lost
Can diabetic neuropathy happen in vital organs?
yes
Diabetic Neuropathy
nerve damage due to metabolic derangements
reduced nerve conduction and demyelinization
sensory or autonomic
Sensory neuropathy
loss of protective sensation
Distal symmetric polyneuropathy
loss of sensation, abnormal sensations, pain, and numbess
Diabetic ulcers appear
usually in feet
white ring around it
Treatment for sensory neuropathy
tight BG control
topical creams/tricyclic antidepressants
serotonin and norepinephrine reuptake inhibitors
Gabapentin - seizures
Does autonomic neuropathy cause what 5 organs to slow down?
Gastroparesis
Hypotension (orthostatic), rest tachycardia, painless MI
Hypoglycemic unawareness
Sexual dysfunction
Neurogenic bladder
Gastroparesis
delayed gastric emptying do to stretched nerves deadening
What problems does autonomic neuropathy caused from diabetes?
erectile dysfunction
decreased libido
What solutions are there for neurogenic bladder caused by diabetes?
empty frequently use Crede’s maneuver
self catherization
suprapubic catheter inserted
Bethanecol to contract bladder
What medication is used to contract the bladder?
Bethanecol
Neurogenic bladder means
urinary retention with overflow incontience
Micro and Macro diseases increase risk of
injury and infection
Sensory neuropathy and PAD are risk factors of
amputation
Foot complications from diabetes
clotting abnormals
impaired immune function
autonomic neuropathy
smoking increases
Monofilament screening is due to which path
sensory neuropathy leads to loss of protective sensation and unawareness of injury
feel the bottom of fott for injury
PAD
decrease blood flow and healing
increase risk of infection
Diabetic Foot Care should be done when to predict ulcers and amputation potentials?
yearly
Diabetic foot care in an HCP examination
Inspection
Test for loss of sensation:
- 10 g monofilament
- vibration
- pinprick sensation
- ankle reflexes
- perception threshold
Who is the only person who can cut a diabetics toe nails?
podiatrist
Where are the best spots for a monofilament test?
Big toe
Under 2nd and 3rd toe
under pinky
Home Diabetic Foot Care
check daily for injury or breakdown
wash daily with soap and warm water
moisturize with lanolin
no cake of lotion btw toes
annual exams by professional (corns and calluses)
well-fitting shows
no bare feet
break in new shoes over several days
clean socks daily
no elastic-topped socks
nails cut straight across with filed edges
warm socks with cold feet
pedi not recommended
Treatment of Foot ulcers
bed rest
antibiotics
debridement
control BG
ambutation if necessary
If pt has a PVD, the ulcer may not heal?
true
Diabetic Ketoacidosis precipitating factors
infection
inadequate insulin dose
illness
undiagnosed T1DM
Infection, stress, and trauma do what to glucose?
raise
Ketosis
sudden breakdown of fat
Acidosis means what ABG scores are down
pH and Bicarb
Pathology of DKA
T1DM hyperglycemia over 250
ketones production found in urine
metabolic acidosis occurs
leads to dehydration
S/S of DKA
dehydration
Kussmaul respirations
Sweet, fruity breath
abd pain, anorexia, N/V
poor skin turgor
dry mucous membranes
tachycardia
orthostatic hypotension
lethargy and weakness early
skin dry and loose
eyes soft and sunken
When dealing with DKA what is the priority order?
Dehydration
Airway
Breathing
Circulation
DKA Lab work
BG 250+
pH less than 7.3
Bicarb less than 16
Ketone levels in urine and semen
Kussmaul respirations
deep and rapid with accessory muscles
Treatment for DKA
Normal Saline with hydradition
airway with O2
ICU D5W with LARGE amounts of insulin continuous drip
Potassium replacement prn
DKA is hospitalized for
severe fluid and electrolyte imbalance
fever
N/V/D
altered mental state
When giving tx with D5W, what needs to be monitored?
electrolytes
DKA vs HHS
DKA = T1DM, rapid onset, BG 250, low pH and bicarb, ketones in urine and kussmaul
HHS = elderly T2DM, gradual onset,BG 600+, ph and bicarb high, no Kussmaul and ketones
HHS stands for
Hyperosmolar Hyperglycemic Syndrome
HHS occurs in
elderly with T2DM
DKA and HHS have what in common
treatment
Risk factors for HHS
UTIs
pneumonia
sepsis
acute illness
newly diagnosed T2DM
impaired thirst sensation and/or inability to replace fluids
What population most likely to be dehydrated with less fat under skin?
elderly
HHS Pathology
enough circulating insulin to prevent ketoacidosis
fewer symptoms lead to higher glucose levels
more severe neurologic manifestations - 2nd to osmolarity
Lab BG 600+ and ketones in blood and urine
HHS has a high
mortality rate
medical emergency
What is the last step for HHS after K is replaced?
correct underlying cause
Management of HHS
Monitor IV fluids, insulin therapy and electolytes
Asses renal status, cardiopulmonary status, LOC
Complications of insulin treatment
hypoglycemic reaction
coma from extreme ends
hypokalemia
lipohypertrophy
Hypoglycemia S/S
cool and clammy
shakiness
palpation
nervousness
sweating
anxiety
hunger
pale
hypoglycemia Tx
Check BG level
- if less than 70 begin tx
- if more than 70 investigate further
If pt has hypoglycemia tx and unable to monitor continously then
start treatment
Rule of 15 in 15
Consume 15 g of simple CHO (juice or soda)
Recheck level in 15 mins
Repeat if less than 70
Avoid foods with fat and overtreatment
After recovery = complex CHO
1 CHO = g
15
Hospitalized hypoglycemic pt if not alert enough to swallow
50% Dextrose 20-50 mL IVP
Glucagon 1 mg IM 20-30 mins
Glucagon peak and lasts
15-30 mins
lasts 90 mins
Glucagon adverse effects
N/V
Caution with use of glucagon
aspiration
High and dry
sugar high hyperglycemia
cold and clammy
need some candy
hypoglycemic
significant Hypokalemia happens when
too much insulin
Potassium effects on
heart is biggest concern
Lipohypertrophy
Accumulation of SQ fat when insulin is injected too frequently at the same site
- reason to rotate sites when giving insulin
- goes away when not putting insulin in that one spot
Diabetic skin problems
diabetic dermopathy
acanthosis nigricans
Diabetic dermopathy aka
shin spots
Most common cutaneous manifestation of diabetes
diabetic dermopathy
Diabetic dermopathy is
benign asymptomatic red/brown macules on shins
Diabetic dermopathy has what treatment
none
Does diabetic dermopathy go away?
No
Acanthosis nigricans feels like
silk and looks dark skin
If a pt has acanthosis nigricans, do they have diabetes
no, but more common in diabetics
Necrobiosis lipidoidica diabeticorum
not sores
come and go
Infections in diabetics
worsen and delay in healing
recurrent and prolonged
defect in mobilization of inflammatory cells and impaired phagocytes
Patient teaching of diabtic and infections
hand hygiene
vaccines
What are things we need to teach for diabtics in patient education?
Classes
In small chunks
Social media groups
Language barriers (order packets in their language)
Promote self-care
Adjust to what the patient’s level of understanding or intelligence is at and meet needs
Barriers to adhering to diabetes management
degree of life changes
complexity
cost
culture
support
stressors
lack of knowledge
fears
strategies to increasing adherence
encourage pt and family to take charge
simplify
focus on normal
teach tools and get supplies
safe harbor
education
support person to group
Psychological considerations for diabetics
depression
anxiety
eating disorders
What is critical for the early identification of problems
open communication
Diabetes Nutritional therapy
Counseling
Education (carbs are)
Ongoing monitoring
Interprofessional team :
Registered dietitian with expertise in diabetes management
Goals of nutritional therapy
maintain BG levels
lipid profiles
prevent and slow chronic
nutrition needs
maintain pleasure of eating
HDL needs to be
high
LDL, triglycerides, and total need to be
low
T1DM general guidlines
meal planning on preferences and intake
portion control
balance insulin and exercise
day to day consistent
flexible with insulin and injections/pump
T2DM general gluidelines
emphasis on achieving glucose, lipid, and BP goals
weight loss (low fat and CHO, weight management, meal spacing, exercise)
Myplate.gov
CHO should be a range of what percentage of daily caloric intake?
45-60
CHO foods
grains, fruits, legumes, and milk
Fiber intake per day
25-30 g
Proteins consist of what percentage of daily value
15-20
high protein not recommended
reduced in pts with kidney failure
Saturated fats are a total of what daily calories
less than 7%
Fish is a
polyunsaturated fats
Trans fat should be
minimized
Healthy fats come from
plants
Glycemic index of 100 refers to
the response to 50 g of glucose or white bread in a normal person without diabetes
Foods with a high glycemic index
raise glucose levels faster and higher than foods low
Glycemic Index
Low score
Medium score
High score
less than 55
56-69
greater than 70
Sugar free does not mean
carbo free
Sugar free foods are often
higher in saturated fat compared to regular products
What is found in most sugar-free foods
sugar alcohols
Sugar alcohols eaten in large quantities cause
abdomen cramping
flatulence
diarrhea
Sugar alcohols include
sorbitol
mannitol
zylitol
isomalt
Fixed insulin is
consistent
Rapid acting insulin can
adjust dose before meal based on CHO meal and BG
The intensified insulin pump allows for
flexibility
What is key for diabetic success?
motivation
Alcohol masks
hypoglycemic s/s
and high in calories
HIgh triglycerides cause
pancreatitis
Alcohol increase triglycerides
What is the normal minimum mins/per week for aerobic activity?
150 mins
What is the normal resistance training times per week
3
Benefits of exercise
decrease insulin resistance and BG by increasing muscle mass
weight loss
decrease triglycerides and LDL, raise HDL
improve BP and circulation
Diabetics should start ______ when exercising begins
slowly
Exercise has glucose lowering effects up to
48 hours
Exercise how many hours after a meal for peak food breakdown
1
Do not exercise if BG level is _______ and _____ are present in Urine
greater than 300 and ketones
Do not exercise when medications are at their
peak
Bariatric Surgery are for pts with
T2DM
lifestyle and drug therapy is difficult
BMI greater than 35
has a high mortality rate
Bariatric surgery pts definitely need to watch
weight and food intake after surgery
Pancreas Transplants are for what diabetics
Type 1 with kidney transplant
- long term complications will persist but acute and insulin is gone
- lifelong immunosuppression
- islet cell transplantation experiment
Subjective data for diabetics
Insulin
OAs
corticosteroids
diuretics
phenytoin
Viral infections
pregnancy
family hx
recent surgery
health patterns (nutrition, elimination, coping, sexual, value-belief)
Objective data of diabetics
eyes
skin
respiratory
cadio
GI
neuro
muscles
Objective data is
observed by the nurse
Diabetics need to do what type of care
foot and oral
Should diabetics bring their equipment in their carryon?
yes
Which cultures have a high incidence of diabetes
Hispanics
Native Americans
African Americans
Asians and Pacific Islanders
Patients tend to need more insulin at the hospital than home.
True
Acute Illness Sick Day Rules
maintain normal diet
increase noncaloric fluids
continue antidiabetic meds
- if the not possible supplement CHO fluids while continuing meds
The main difference between Type 1 and 2 on sick day rules is
hold metformin during serious illnesses on Type 2
Hydration of sick day rules
8 oz fluid per hour
3rd hour consume 8 oz of sodium-rich broth
Self-monitoring of sick day rules
every 2-4 hours
Ketones of sick day rules
every 4 hours until negative for Type 1
Med Adjustments for T1 of sick day rules
CONTINUE
adjust insulin to correct hyperglycemia
Food and Drink of sick day rules
consume 150-200 CHO daily
soft or liquids
Contact HCP of sick day rules
vomiting more than once
diarrhea more than 5x or longer than 6 hours
BG greater than 300 and ketone positive
Perioperative care what do you do with insulin
hold or reduce NPO
STRESS riase
IV fluids and insulin
monitor
Insulin Pump means you don’t need to self monitor?
no, need to self monitor with a pump therapy
