Diabetes Mellitus (2) Flashcards
An elevated blood glucose level upon arising in the morning
Morning Hyperglycemia
Causes of Morning Hyperglycemia
Dawn Phenomenon & Somogyi Effect
Normal blood glucose from bedtime until 3AM associated with the release of GH which decreases tissue sensitivity to insulin
Dawn Phenomenon
-High dose evening/bedtime insulin produces hypoglycemia during the night
- Hypoglycemia triggers release of COUNTERREGULATORY HORMONES which produces a rebound hyperglycemia in AM
Somogyi Effect
This causes the Hypoglycemia to trigger in which it produces a rebound hyperglycemia in AM
Counterregulatory Hormones
Too much dose during bedtime
Somogyi Effect
The difference of 3 am CBG in Dawn Phenomenon & Somogyi Effect
Dawn Phenomenon- High (decrease insulin sensitivity)
Somogyi Effect- Low
Management for Dawn Phenomenon
Give intermediate acting insulin at bedtime (10PM)
Management for Somogyi Effect
- Decrease evening/bedtime dose insulin and/or
-Increase bedtime snack
Metformin Classification
Biguanides
Mechanism action of Metformin
Decreases hepatic glucose production and increases peripheral glucose uptake
Metformin side effect
Weight loss
Adverse effect of Metformin
Lactic Acidosis
Prohibited while taking metformin
-No alcohol
- STOP 48 hours before and after IV contrast
Firs line drugs of Oral Hypoglycemic Agents
Metformin
What is the classification of Glipizide and Glimepiride
Sulfonylurea
What is the mechanism of action of Glipizide and Glimepiride?
Stimulate beta cells “Summons insulin”
Side effect of Glipizide and Glimepiride
Hypoglycemia
Contraindication of Glipizide and Glimepiride
Contraindicated in Renal, Liver, and Elderly
Third line drugs for Hypoglycemic
Ploglitazone
Classification of Ploglitazone
Thiazolidinedione
Mechanism of action of Ploglitazone
Enhances insulin sensitivity at the tissue level
This drug is bad for the heart and liver
Ploglitazone
Dietary Modifications
-Total calories will be prescribed by physician
Caloric Distribution:
-CHO: 50% to 60%
-Fats: 20% to 30%
-CHON: 15% to 20%
Lowers blood glucose levels by increasing the uptake of glucose by body muscles and by improving insulin utilization
Exercise
What’s the first thing to be done before taking exercise?
Let the patient eat snack prior to exercise
-Enables the patient to make decisions regarding food intake, activity patterns, and medication dosages
- Recommended for all insulin- treated patients with DM
Self-Monitoring of Blood Glucose (SMBG)
Dose insulin or units of 80-100 mg/dl
5 units
Dose insulin or units of 101-110 mg/dl
6 units
Dose insulin or units of 111-120 mg/dl
7 units
Occurs when blood glucose falls to less than 80 mg/dl
Hypoglycemia
Causes of Hypoglycemia
-Too much medication
- Too much exercise
- Too little food
Manifestations of Mild Hypoglycemia
-Sweating
-Tremor
- Tachycardia
- Palpitation
- Nervousness
- Hunger
A types of hypoglycemia that stimulates SNS
Mild Hypoglycemia
Manifestations of Moderate Hypoglycemia
-Confusion
- Double vision
- Drowsiness
- Irrational or combative behavior
- Headache
- Slurred speech
- Impaired coordination
A type of Hypoglycemia that pertains to behavior
Moderate Hypoglycemia
Severe Hypoglycemia Manifestation
-CBG <40 mg/dl
- Unconscious
- Seizures
- Cardiac Arrest
Medical Management of Hypoglycemia
-Glucagon 1mg SQ/IM (out of the hospital)
- D50W (50% dextrose in water) (admitted)
Return of consciousness may take up to 20 minutes after administration
Glucagon 1mg SQ/IM
D50W
-25 to 50 ml of D50W IV Push
-Used in hospital settings
What to give or provide once the patient wakes up in administering glucagon?
Provide snack on awakening to prevent recurrence of hypoglycemia, except if with nausea
Rule of 15’s
-Give 15 grams of fast-acting carbs PO
- Check CBS after 15 minutes
- If still hypoglycemic, give another 15-grams of fast acting carbs
Examples of Fast-Acting Carbs
-white rabbit (5-10 candies)
- Life-saver candies (5-10 candies)
- Coke 1/2 glass
- Juice 1/2 glass
- Sweet cookies/bread
A life-threatening complication of DM Type 1
Diabetic Ketoacidosis (DKA)
Causes of Diabetic Ketoacidosis
-Decreased or missed dose of insulin
- Illness or infection
- Undiagnosed or untreated DM
3 kinds of Manifestation of Diabetic Ketoacidosis
-Hyperglycemia
- Dehydration and electrolyte loss
- Ketosis and acidosis
Hyperglycemia Manifestation in Diabetic Ketoacidosis
-Blood glucose levels between 300 and 800 mg/dl
- Polyuria
- Polydipsia
Dehydration and Electrolyte Loss
-Orthostatic Hypotension
-Weak, rapid pulse
-Elevated creatinine, BUN and hematocrit
-Hypokalemia
Manifestation of Ketosis and Acidosis
-Anorexia, nausea and vomiting, abdominal pain
-Acetone breath sounds
-Kussmaul Respirations: deep, but unlabored breathing pattern
-Changes in mental status
-To reverse acidosis and hyperglycemia
-Given via intravenous route at a slow, continuous rate
Regular Insulin
First Line Medical Management given for Type 1
Regular Insulin
To reverse dehydration
Fluid Replacement
Fluid Replacement
-To reverse dehydration in Diabetic Ketoacidosis
-PNSS (0.9% NaCI) at 0.5 to 1L per hour for 2 to 3 hours
- Half-strength NSS (0.45% NaCI) if hypertensive or hypernatremic
-WOF: fluid overload (bounding pulse, crackles, headache)
To reverse hypokalemia
KCL Infusion
KCL Infusion
-To reverse hypokalemia in the manifestation of Diabetic Ketoacidosis
- Potassium chloride IV infusion
- Use infusion pump for accurate delivery
-Apply cold compress on IV site
- Hold if patient is not urinating
A metabolic disorder of type 2 DM
Hyperglycemic Hyperosmolar Non-Ketotic Syndrome (HHNKS)
Occurs most often in older adults (50 to 70 years old)
Hyperglycemic Hyperosmolar Non-Ketotic Syndrome (HHNKS)
Causes of Hyperglycemic Hyperosmolar Non-Ketotic Syndrome (HHNKS)
-Procedures (Dialysis)
- Infection
- Surgery
-Thiazide Diuretics
- Illness
Clinical Manifestations of Hyperglycemic Hyperosmolar Non-Ketotic Syndrome (HHNKS)
-Blood glucose levels from 600 to 2000 mg/dl
- Hypotension and Tachycardia
- Hypokalemia
- Profound dehydration (dry mucous membranes, poor skin turgor)
- Variable neurologic signs (ALOC, seizures, hemiparesis)
