Diabetes Mellitus Flashcards
Group of metabolic diseases characterized by increased levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both.
DIABETES MELLITUS
Risk Factors of dm
• Family history of diabetes
• Obesity
• Race (African Americans, Hispanic Americans, Native Americans, Asian Americans, Pacific Islanders)
• Age > 45 yrs. Old
• Hypertension
• HDL cholesterol level <35 mg/dl and triglyceride level >250 mg/dl
Classification of DM:
• Type 1 diabetes
• Type 2 diabetes
• Gestational diabetes
• Diabetes mellitus associated with other conditions or syndromes
Diagnostic tests and findings for dm
Diagnostic tests and findings:
• Fasting plasma glucose
• Random plasma glucose
• Oral Glucose Tolerance Test (OGTT)
Symptoms of diabetes plus casual plasma glucose concentration
equal to or greater than 200 mg/dl (11.1mmol/L).
casual
is defined as any time of day without regard to time since last meal.
classic symptoms of diabetes
polyuria, polydipsia, and unexplained weight loss.
Fasting plasma glucose
greater than or equal to 126 mg/dl (7.0 mmol /L)
no caloric intake for at least 8 hours
fasting
• Characterized by destruction of the pancreatic beta cells.
• Abnormal response in which antibodies are directed against normal tissues of the body, responding to these
tissues as if they were foreign.
type 1
Destruction of the beta cells results in
decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia.
concentration of glucose in the blood exceeds the renal threshold for glucose
usually 180 to 200 mg/dl (9.9 to 11.1 mmol/L),
the kidneys may not reabsorb all of the filtered glucose; the glucose then appears in the urine
glycosuria
When excess glucose is excreted in the urine, it is accompanied by excessive loss of
fluids and electrolytes.
When excess glucose is excreted in the urine, it is accompanied by excessive loss of fluids and electrolytes.
osmotic diuresis
resulting in an increase production of ketone bodies
fat breakdown
Ketone bodies are acids that disturb the acid-base balance of the body when they accumulate in excessive amounts
dka
two main problems of type 2
ü Increased Insulin resistance
ü Decreased Insulin sensitivity
ü Impaired insulin secretion.
Describe type 2
• Idiopathic
• This is called metabolic syndrome, which includes hypertension, hypercholesterolemia, and abdominal
obesity.
• Despite the impaired insulin secretion that is characteristic of type 2 diabetes, there is enough insulin present to prevent the breakdown of fat and the accompany production of ketone.
Management for type 2
nutritional therapy
exercises
self monitoring of blood glucose
glycated hemoglobin
testing for ketone
insulin therapy
oral antidisbetic agents
how many pounds to lose per week for type 2?
1-2
how many calories are subtracted from the daily total in type 2?
500-1000
recommend caloric distribution for type 2
higher in carbohydrates than in fat and protein
Foods high in carbohydrates, such as ______ are not totally eliminated from the diet but should be eaten in
moderation because they are typically high in fat and lack vitamins, minerals, and fiber.
sucrose
limit total intake of cholesterol to?
less than 300 mg/day.
improve blood glucose levels, decrease the need the exogenous insulin, and
lower total cholesterol and low-density lipoprotein levels in the blood
increase fiber in the diet
_____ is absorbed before other nutrients and does not require insulin for absorption. ______ amounts can be
converted to ______, increasing the risk for _____
alcohol
large
fats
DKA
_______ lower blood glucose levels by increasing the uptake of glucose by body muscles and by improving
insulin utilization
exercise
Exercise at _______ (preferable when blood glucose levels are at their peak) and in the _______
each day.
at the same time
same amount
_____ is a safe and beneficial.
walking
Eat _________ snack before engaging in moderate exercise to prevent unexpected _____.
15-g carbohydrate
hypoglycemia
Use proper_______. Avoid exercise in extreme heat or cold. Inspect feet daily after exercise. Avoid exercise
during periods of poor metabolic control
footwear
This allows for detection and prevention of hypoglycemia and hyperglycemia and plays a crucial role in
normalizing blood glucose levels,
Self- Monitoring of Blood Glucose
also referred to as glycosylated hemoglobin, HgbA1C, or A1C
Glycated hemoglobin
Glycated hemoglobin (also referred to as glycosylated hemoglobin, HgbA1C, or A1C)
• is a blood test that reflects average blood glucose levels over a period of approximately_______
2 to 3 months.
_______ in the urine signal that there is adeficiency of deficiency of insulin and control of type 1 diabetes is deteriorating. The risk of DKA is high.
ketone
In type 1 diabetes, ______ insulin must be administered for life because the body loses the ability to produce insulin.
exogenous
Rapid acting insulins
lispro
aspart
glulisine
short acting insulins
humalog R
Novolin R
Iletin II R
intermediate acting insulins
nph
novolin L (lente)
Novolin N (NPH)
Long acting insulins
glargine
determir
LISPRO
ONSET
PEAK
DURATION
INDICATION
10-15 min
1hr
2-4hr
Used for rapid reduction of glucose
ASPART
ONSET
PEAK
DURATION
INDICATION
5-15 min
40-50 min
2-4 hr
Level, to treat postprandial
GLULISINE
ONSET
PEAK
DURATION
INDICATION
5-15 min
30-60
2hr
Hyperglycemia, and/or to prevent noctumal hypoglycemia
Regular (Humalog R, Novolin R, Iletin II Regular
ONSET
PEAK
DURATION
INDICATION
1/2-1hr
2-3 hr
4-6 hr
Usually administered 20-30 min before a meal; may be taken alone or in combination with longer-acting insulin
Can be incorporated to an IV infusion
Novolin L [Lente], Novolin N [NPH]
ONSET
PEAK
DURATION
INDICATION
3-4 hr
4-12hr
16-20 hr
Usually taken after food
Glargine (Lantus) Determir (Levemir)
ONSET
PEAK
DURATION
INDICATION
1hr
continuous (no peak)
24hr
used for basal dose
preparations have a shorter duration of action than insulin from animal sources because the presence of animal protein triggers an immune response that results an in the binding of animal insulin.
human insulin
are called regular insulin
short acting insulin
Regular insulin is a ____ solution and is usually administered _________. Regular insulin is the only insulin approved for ______ use.
clear
20-30 mins before meal
IV
NPH insulin
intermediate acting insulin
is absorbed very slowly over 24 hours and can be given once a day.
“Peakless” basal or very long-acting insulins
complications of insulin therapy
local allergic reactions
systemic allergic reactions
insulin lipodystrophy
resistance to injected insulin
morning hyperglycemia
Oral antidiabetic agents
sulfonylureas
biguanide
alpha-glucosidase inhibitors
thiazolidinediones (glitazone)
Dipeptide-pepidase-4 (DDP-4) Inhibitors
Stimulate beta cell of the pancreas to secrete insulin;
sulfonylureas
Ø Inhibits production of glucose by the liver
Ø Increase body tissues sensitivity to insulin
Ø Decrease hepatic synthesis of cholesterol
Ø The only biguanide in the market: Metformin
biguanide
Delay absorption of complex carbohydrates in the intestine and slow entry of glucose into
systemic circulation.
Alpha-glucosidase inhibitors
Sensitized body tissue to insulin;
Thiazolidinediones (Glitazone)
Increase and prolongs the action of incretin, a hormone that increases insulin release and
decreases glucagon levels, with the result of improved glucose control
Dipeptide-pepidase-4 (DDP-4) Inhibitors
Progressive rise in blood glucose from bedtime to morning
Insulin waning
Relatively normal blood glucose until about 3 am, when the level begins to rise
Dawn Phenomenon
Normal or elevated blood glucose at bedtime, a decrease at 2-3 am to hypoglycemic levels, and a subsequent increase caused by the production of counterregulatory hormones
Somogyi Effect
treatment for insulin waning
Increase evening (predinner or bedtime) dose of intermediate acting or long-acting insulin, or institute a dose of insulin before the evening meal if one is not already part of the treatment regimen.
Treatment for dawn phenomenon
Change time of injection of evening intermediate-acting insulin from dinnertime to bedtime.
treatment for somogyi effect
Decrease evening (predinner or bedtime) dose of intermediate acting insulin, or increase bedtime snack.
____ insulins should be thoroughly mixed by gently inverting the vial or rolling it between the
hands before drawing the solution into a syringe or a pen
cloudy
________must be mixed thoroughly before drawing into the syringe.
Longer-acting insulin
Ø_______ should be drawn up first.
Regular insulin
Inject air into the bottle of insulin_________ of insulin to be withdrawn
equivalent to the number of units
four main areas of injection
abdomen
upper arm
thighs
hips
The speed of absorption is greatest in the ______ and decreases progressively in the arm, thigh, and hip, respectively.
abdomen
Administer each injection_______ from the previous injection. Another approach to rotation
0.5 to 1 inch away
Patient should try not to use the same site more than once in______
2 to 3 weeks.
Insulin should not be injected into the limb that will be exercised because this will cause the
drug to be absorbed faster, which may result in______.
hypoglycemia
_______is generally not recommended with self-injection of insulin.
Aspiration
Occurs when the blood glucose falls to less than 50 to 60 mg/dL (2.7 to 3.3 mmol/L), because of too much insulin or oral hypoglycemic agents, too little food, or excessive physical activity.
Hypoglycemia
Clinical Manifestation:
• Mild hypoglycemia
ü Sweating
ü Tremor
ü Tachycardia ü Palpitation ü Nervousness ü Hunger.
Moderate hypoglycemia
ü Inability to concentrate
ü Headache
ü Lightheadedness
ü Confusion
ü Memory lapses
ü Numbness of the lips and tongue
ü Slurred speech
ü Impaired coordination
ü Emotional changes
ü Irrational or combative behavior
ü Double vision
ü Drowsiness.
severe hypoglycemia
ü Patient needs the assistance of another person for treatment of hypoglycemia.
ü Disoriented behavior
ü Seizures
ü Difficulty arousing from sleep
ü Loss of consciousness.
Emergency measures for hypoglycemia
Injection of glucagon_____ (subcutaneously or intramuscularly.)
1mg
Emergency measures for hypoglycemia
In hospitals and emergency departments, for patients who are unconscious or cannot swallow,______ of
50% dextrose in water (D5OW) may be administered IV.
25 to 50 mL
Emergency measures for hypoglycemia
• Injection of glucagon 1mg (subcutaneously or intramuscularly.)
• A concentrated source of carbohydrate followed by a snack should be given to the patient on awakening
• In hospitals and emergency departments, for patients who are unconscious or cannot swallow, 25 to 50 mL of
50% dextrose in water (D5OW) may be administered IV.
• Assuring patency of the IV line because (D5OW) is very irritating to veins.
• Taking additional food when physical activity is increased
• Routine blood glucose tests are performed
• Wear an identification bracelet or tag stating that they have diabetes.
• Learn to carry some form of simple sugar with them at all times
• Refrain from eating high-calorie, high-fat dessert foods (eg, cookies, cakes, doughnuts, ice cream).
Caused by an absence or markedly inadequate amount of insulin. This deficit in available insulin results in disorders in the metabolism of carbohydrate, protein, and fat.
DIABETES KETOACIDOSIS
The three main clinical features of DKA are:
• Hyperglycemia
• Dehydration and electrolyte loss
• Acidosis
Clinical manifestations of dka
• Polyuria
• Polydipsia
• Blurred vision
• Weakness
• Headache
• Orthostatic hypotension
• Weak and rapid pulse
• Anorexia
• Nausea and vomiting
• Abdominal pain
• Acetone breath
• Kussmaul’s respiration – rapid, deep breathing
Diagnostic Tests and Findings of dka
• Blood glucose levels may vary between 300 and 800 mg/dL
• Serum bicarbonate (0 to 15 mEq/L)
• Low pH (6.8 to 7.3)
• A low partial pressure of carbon dioxide
• (PCO2; 10 to 30 mm Hg)
• Increased levels of creatinine
• Increased blood urea nitrogen (BUN)
• Increased hematocrit
management for dka
rehydration
restoring electrolytes
reversing acidosis
Serious condition in which hyperosmolarity and hyperglycemia predominate, with alterations of the sensorium (sense of awareness)
HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME (HHNS)
Ketosis is usually minimal or absent
HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME (HHNS)
Persistent hyperglycemia causes ________, which results in losses of water and electrolytes
osmotic diuresis
clinical manifestations of hhns
• Hypotension
• Profound dehydration (dry mucous membranes, poor skin turgor)
• Tachycardia
• Alteration in sensorium
• Seizures
• Hemiparesis
Diagnostic tests and Findings for hhns
• Blood glucose- 600 to 1200mg/dL
• Osmolality exceeds 350 mOsm/kg
management for hhns
• Fluid replacement
• Correction of electrolyte imbalances
• Insulin administration
• Fluid treatment is started with 0.9% or 0.45%NS
• Central venous or hemodynamic pressure monitoring
• Potassium is added to IV fluids
• Insulin plays a less important role in the treatment of HHNS because it is not needed for reversal of acidosis
Patients most commonly affected in dka
Can occur in type 1 or type 2 diabetes; more common in type 1 diabetes.
Patients most commonly affected in hhns
More common in type 2 diabetes, especially elderly patients with type 2 diabetes
Precipitating event in dka
Omission of insulin; physiologic stress (infection, surgery, CVA,MI
Precipitating event in hhns
PHYSIOLOGIC STRESS (infection surgery, CVA, MI)
onset of dka
Rapid (<24h)
onset of hhns
Slower (over several days)
Blood glucose levels in dka
Usually >250 mg/dL (>3.9mmol/L)
Blood glucose levels in hhns
Usually >600 mg/dL (>33.3 mmol/L
Arterial pH level of dka
7.3
Arterial pH level of hhns
normal
Serum and urine ketones in dka and hhns
dka - present
hhns - absent
Serum osmolality of dka and hhns
dka - 300-350 mOsm/L
hhns - >350 mOsm/L
Plasma bicarbonate level of dka & hhns
dka -<15 mEg/L
hhns - normal
BUN and creatinine levels of dka and hhns
dka - elevated
hhns - elevated
mortality rate of dka & hhns
dka - <5%
hhns - 10-40%
breakdown of glycogen into GLUCOSE
short term fasting
GLYCOGENOLYSIS
formation of glucose from non carbohydrate sources
long term fasting
GLYCONEOGENESIS
cells that produces insulin
beta cells
cells that secretes somatostatin
delta cells
inhibits the action of glucose and insulin
somatostatin
cannot enter the cell without insulin
glucose
where do glucose stored and in what form?
liver in the form of glycogen
deals with high blood sugar level
insulin
deals with low blood sugar level
glucagon
where do insulin secreted
islets of langerhans
where do pancreas located
behind the abdomen and infront of spine
Sensitive to insulin levels and stores and turns glycogen into glucose when the pancreas secretes glucagon.
liver
A peptide hormone that causes the liver to turn glycogen into glucose…does the opposite as insulin.
glucagon
______ blood sugar - pancreas releases ______ - causes _____ to enter into the cells to be used or be saved as _____ for later (stored mainly in the liver)
Increased
insulin
glucose
glycogen
________ blood sugar - pancreas release ______ -> causes the _____ to release ______ which turns into ______ to increase the low blood sugar level
decreased
glucagon
liver
glycogen
glucose
What happens in diabetes mellitus?
The body is unable to use glucose due to either the absence of insulin or the body’s resistance to use insulin. Therefore, the patient becomes HYPERGLYCEMIA (the glucose just hangs out in the blood stream which affects major organs of the body)
What do patients look like clinically in type 1?
Patients are young and thin
treatment for type 1
must use insulin
Risk factors for type 1
Genetic, auto-immune (virus) NOT RELATED TO LIFESTYLE (like type 2)
cells quit responding to insulin (won’t let insulin do its job by taking the glucose into the cell). Therefore, the patient has INSULIN RESISTANCE. This leaves all the glucose floating around in the blood and the pancreas senses there’s a lot of glucose present in the blood so it releases even more insulin. Due to this the patient starts to experience hyperinsulinemia which caused metabolic syndrome
type 2
causes insuline resistance
cytokines
rapid production of insulin in type 2
hyperinsulinemia
first line treatment in type 2
diet and exercise
Risk Factors in type 2
Lifestyle- being obese, sedentary, poor diet (sugary drinks), stress AND
genetic
What do patients look like clinically?
Patients are overweight, it happens overtime, rare to have ketones (remember issues with carb metabolism) adult aged
“I’m sweaty, cold, and clammy….give me some candy”
Hypoglycemia
D
K
A
A
A
dry and high sugar
ketones and kussmaul breathing
abdominal pain
acidosis (metabolic)
acetone breath
loss of water and electrolytes
ostomic diuresis
H
H
H
N
S
highest sugar
higher dehydration
head change
no abdominal pain
slower onset, stable potassium
3p’s
Polyuria (frequent urination)
Polydipsia (very thirsty)
polyphagia (very hunger)
polyuria caused by?
osmosis specifically hypotonic
The water will move to an area of ____ concentration which will be the ______ and this causes more fluid to enter the _______. The kidneys will secrete the extra water. HOWEVER, normally your kidneys could handle all of the glucose by reabsorption but there is too much so it leaks into the urine…. ______
higher
blood stream
blood stream
GLYCOSURIA
triangle of diabetes management
diet, exercise, medications
yung sa gitna ng triangle monitor glucose
carbs
45-60%
grains, vegetables, corn, sweets, cookies, soda, dried beans, milk
fats
<20 %
sausage, hotdogs, whole milk, processed foods, peanuts
proteins
15-20%
meats, chicken, turkey, fish, eggs
sulfonylureas
ides, zides, mides, rides
glipizide, diabinese, amaryl
meglitinides
repaglinide
biguanides
metformin
thiazolidinedione
glitazone
waking hours
dawn phenomenon
sleeping hours
somogyi effect 2-3 am
