Diabetes Mellitus and Nursing Management Flashcards
Liver controls blood sugar levels when we are ______ _______.
not eating
Pancreas controls blood sugar levels when we ______.
eat
Pancreas makes a hormone called __________.
Insulin
Insulin takes sugar out of the blood and puts it in the liver where it is stored as ________. Hence, blood sugar is __________.
glycogen; decreased
Explain when and why the liver would convert glycogen into blood sugar?
This process occurs when blood sugar levels drop, signaling the body to release glucose into the bloodstream to maintain normal blood sugar levels → ensures a constant supply of glucose to the body’s tissues and organs, especially during periods of fasting or starvation.
What role does insulin play in diabetes?
When a cell needs energy, insulin acts as a key to unlock the cell. This opens the cell so sugar an enter and be used for energy – “lock and key”
Explain how the body makes energy. (5 steps)
- eat food with carbs
- carbs turn to glucose after digestion
- glucose enters blood to go to all parts of body for energy
- pancreas senses rise in blood sugar, so it makes insulin from beta cells
- insulin helps the sugar get into the cells in your body so they can use sugar as energy
What is the difference between type 1 and type 2 diabetes?
type 1 - lack of insulin production
type 2 - insulin resistance/inefficiency
BMI range for underweight
less than 18.5
BMI range for healthy weight
18.5 to 24.9
BMI range for overweight
25 to 29.9
BMI range for obese
30 to 34.9
BMI range for extremely obese
35 or more
How to we diagnose diabetes?
-hx and physical
-BMI
-Hemoglobin A1C > or = 6.5%***** measures for the last 3 months
-Fasting blood glucose > or = 126mg/dl
-2 hour plasma glucose > or = 200mg/dl during OGTT
What is hemoglobin A1C?
-HgA1c estimates a person’s average blood sugar levels over a 3 month span.*** It is the best measure we have of how well blood glucose is controlled and an indicator of diabetes management.
-Use to diagnose and monitor progression of DM
-Limited to 3 month life span as that is the average life span of a RBC
Explain the pathophysiology of type 1 DM
-autoimmune disease
-immune system attacks the pancreas destroying beta cells and then no insulin secreted.
-No insulin available.
-therefore, totally dependent on exogenous insulin (insulin that comes from outside source).
What are the signs and symptoms of type 2 diabetes? (7)
- Slowed wound healing
- constant hunger
- frequent urination
- blurred vision
- fungal infection - itching of the skin and genitals
- unexplained weight loss
- numbness of the hands and feet
Over time, insulin resistancecan lead to_______ ______and prediabetes because the beta cells fail to keep up with the body’s increased need for_________.
type 2 diabetes; insulin
True or false: type 2 diabetes can go undetected for years.
True
What is the order in which you would treat type 2 diabetes?
To treat first try lifestyle changes, then oral medications, and then insulin is severe progression or during times of stress such as infection.
List the the “-opathy’s” that occur as a result of poor glycemic control.
-Neuropathy (pain)- central or peripheral
-Peripheral neuropathy (numbness and tingling in extremities)
-Retinopathy
-Nephropathy
What are the cardiovascular complications of poor glycemic control?
CAD and HTN
What are the ways in which poor glycemic control impacts the skin?
Delayed healing of wounds, unable to feel or identify small breaks in skin can lead to gangrene, eventually leading to amputation.
What are causes of hyperglycemia in the hospital which may require insulin coverage?
- Existing diabetes- Type 1,Type 2
- Medications- steroids***- increase insulin resistance; Prograf- interferes with beta cell production of insulin
- Nutrition- TPN, tube feeds
- Infection/sepsis**
- Stress of surgery
glyburide (Micronase)
- Medication class - Sulfonylureas
- Targeted organ - pancreas
- MOA - stimulate beta cells to produce insulin
- A1c reduction - 1%
- Low durability (treatment failure over time).
- AE - highest risk for hyperglycemia; weight gain
metformin (Glucophage)
- Medication class - Biguanides
- Targeted organs - liver, muscle
- MOA - decrease glucose production in the liver
- A1c reduction - 1 to 2%
- First-line therapy for T2DM; FDA approved for use in mild or mod. kidney impairment.
- AE - diarrhea, possible B12 deficiency, lactic acidosis.
When is metformin contraindicated?
Diabetic patients undergoing imaging studies that require IV contrast as this could lead to diabetic nephropathy.
Patients on antidiabetic medications are at increased risk of ______ _______, which has a mortality rate of up to _____.
lactic acidosis; 50%
What are some signs and symptoms of lactic acidosis?
feeling very weak, tired, or uncomfortable, unusual muscle pain, trouble breathing, unusual or unexpected stomach discomfort, feeling cold, dizziness or lightheadedness, suddenly developing a slow or irregular heartbeat
Rapid-acting insulin
Onset - 5-10 minutes
Peak - 30 min to 60 min
Duration - 2-4 hours
i.e., Humalog, Novolog
* TID with meals (so fast acting must have food at bedside
Short-acting insulin
Onset - 30-60 minutes
Peak - 2-4 hours
Duration - 6-8 hours
i.e., Regular (R)
*often with meals SS coverage
Intermediate-acting insulin
Onset - 2-4 hours
Peak - 4-12 hours
Duration - 18-24 hours
i.e., NPH (N)
*provides basal insulin
Long-acting insulin
Onset - 2-4 hours
Peak - no peak
Duration - 24 hours
i.e., Lantus and Levemir
*provide basal insulin often given PM
Sliding scale is ______ ______ to the regular ordered.
in addition
Humulin NPH 27 units and Humulin regular 9 units SC in AM. What is the total insulin dose?
36
Doctor’s order: Humulin NPH 12 units and Humulin regular 4 units SC in PM. What is the total insulin dose?
16
What are the 3 P’s for T1DM or DKA?
- Polyuria (increased urination)
- Polydipsia (increased thirst)
- Polyphagia (increased hunger)
DKA happens most often in those with_________, but can also occur in those with other types of diabetes under certain circumstances
type 1 diabetes
Explain how Diabetic Ketoacidosis manifests.
Lack of insulin in body → increases glucagon
Liver releases extra glucose into blood (which would normally be suppressed by insulin)
Extra glucose spills into urine-Glucosuria*****. Water and solutes (Na and K) follow the glucose and spill into urine → OSMOTIC DIURESIS
How is DKA diagnosed?
DKA is typically diagnosed when testing findselevated glucose,acidosis <7.35 , andketoacids (ketones)**in either the blood or urine
In DKA, the Body tries to compensate for the acidic state. What is this known as?
HYPERVENTILATION to lower blood CO2 = Kussmaul respiration
Criteria for DKA
PATIENT TO BE DIABETIC
KETONES IN URINE OR BLOOD*
ACIDOTIC- ARTERIAL BLOOD GAS WITH PH LOW**
How do you treat DKA?
IV FLUIDS!!!**
INSULIN IV THERAPY (Insulin gtt)*
ELECTROLYTE REPLACEMENT*
SYMPTOM MANAGEMENT*
For DKA treatment, continue to give IV insulin therapy until free of __________.
Ketones
DKA causes _______ levels to decrease quickly, so supplemental ____________ prn. Watch for complications.
glucose; glucose
For DKA treatment, why would you need to provide fluid replacement?
Restores perfusion of the tissues; average fluid deficit is 3-5 L.
For DKA treatment, how many liters of normal saline to you provide over the first 2 hours upon initial resuscitation?
1-2 L
For DKA treatment, how do you resolve the hyperkalemia?
Insulin drip
Once urine output is present and K<5.0 watch for _____________ ____________.
Cardiac arrhythmias
For DKA treatment, start K replacement and have K > ______ prior to start of _________. Must have a ______ lab draw.
3.0; insulin; BMP
How would you treat N/V in patients with DKA?
Ondansetron or other antiemetics
Once DKA is resolved, convert to normal home ______ _______ and prevent __________.
Insulin regimen; recurrence
Nursing management of DKA (11)
- Start two large-bore IV’S & Administer fluids as recommended to treat dehydration from polyuria
- Check electrolytes as potassium levels will drop with insulin treatment OR hyperkalemia with dehydration (basic metabolic panel)
- Check renal function- basic metabolic panel, urine output
- Place on telemetry cardiac monitoring- due to hyperkalemia and then hypokalemia risk with insulin IV drip treatments
- Assess mental status
- Look for signs of infection (a common cause of DKA), urine and blood cx
- Assess ketoacidosis- urine for ketones, arterial blood for acidosis***
- patient to wear an ID bracelet signifying DKA episode
- Listen to the lungs for rales and crackles during IV fluid therapy
- Treat nausea/vomiting with Odansetron- assess nausea scales, administer around the clock
- Start insulin IV drip! Titrate as needed after bedside glucometer checks
Educate your patient that their foot can get injured if: (5)
- Something that breaks your skin (such as a cut)
- A penetrating wound (stepping on a tack)
- Walking barefoot
- Constant pressure in one spot (as from a tight shoe)
- Repeated stress or infection
DM tips to avoid food injuries include: (10)
- Inspect feet daily
- bathe feet in lukewarm water
- dry feet thoroughly
- moisturize dry feet but never between toes
- cut nails straight across
- never treat corns or calluses yourself (make sure your shoes fit right to avid calluses)
- Consider diabetic socks (extra cushion)
- wear socks to bed
- Never walk barefoot
- get periodic foot exams
What are some nursing interventions for DM? (12)
- Administer insulin or an oral antidiabetic drug as prescribed.
- Have the patient participate in a supervised exercise program.
- Treat hypoglycemic reactions promptly by giving carbohydrates in the form of fruit juice, hard candy, honey or I.V. dextrose.
- Provide meticulous skin care, especially to the feet and legs.***
- Assist the patient to develop coping strategies.
- Keep accurate records of vital signs, weight, fluid intake, urine output, and caloric intake.
- Monitor diabetic effects on the cardiovascular, peripheral vascular, and nervous systems. Regular MD/NP appointments
- Observe for signs of urinary tract and vaginal infections, and monitor the patient’s urine for protein, an early sign of nephropathy.
- Recommend regular ophthalmologic examinations.
- Teach the patient how to care for their feet.
- Teach the patient and the family how to monitor the patient’s diet.
- Teach the patient “diabetic sick day” protocols
What is diabetic sick day?
Often an acute episode of illness (i.e., flu, covid) will be the precursor for hospitalization in someone with diabetes.
For diabetic SICK says, your patient should do what?
S - check your blood SUGAR every 2 to 3 hours or as necessary
I - always take your INSULIN. Not taking it could lead to DKA.
C - drink lots of fluids. If sugars are high, drink sugar-free liquids. If sugars are low, drink CARB-containing drinks.
K - check your urine or blood KETONES or blood ketones q 4 hours. Take rapid-acting insulin if ketones are present.
What is nursing management of hypoglycemia? (4)
1.Must get blood glucose up
2. Often symptomatic when blood glucose is 70 and below
3. if patient is conscious and awake – give PO juice, high carb snacks.
4. If patient is unconscious or unable to cooperate, must move to IV glucose - Dextrose 50% IV push STAT
