Diabetes; Type 1/2, metabolic syndrome, Bariatric surgery Flashcards
1
Q
Normal BMI
A
18-24.9
2
Q
Overweight BMI
A
25-29.9
3
Q
Obese BMI
A
30+
4
Q
What is defined as morbidly obese
A
Being 80-100lbs over ideal body weight
Or BMI over 40
5
Q
Candidates for bariatric surgery
A
BMI is over 40 (35-40 may be a candidate if there is other co-morbidities, such as cardiopulmonary, diabetes or other disorders)
-Requires an intensive screening process, and further screening may be deemed necessary by insurance
6
Q
Not a candidate for bariatric surgery
A
-Obesity is caused by metabolic or endocrine disorders (cushiness/ thyroid issues)
-Ongoing substance abuse or major psych disorder
-High risk surgical candidates
-Active malignancy
7
Q
Bariatric surgery
A
-Not the first line therapy, tries other forms of weight loss first, which fail
-Majority of weight loss occurs in the first year, and 10-35% of weight is loss within 2-3 years
-Super picky about candidacy, lengthy pre-op screening, workup and evaluation
8
Q
Nursing post op bariatric surgery
A
-Vitals, and urine output
-Pain control and mgmt
-Liquid intake
-Diet progression
-Encourage ambulation day one
-See change in status
-Nausea mgmt with antiemetics
-SCD and lovenox
-Bladder mgmt, foley discontinuation (prevent UTI)
-Cardiac monitoring
-Incentive spiro
-CPAP
-Ambulation is very important
9
Q
When should you have a pt ambulate after bariatric surgery and why
A
Up and movin day one, helps with O2 exchange and bowel movement
10
Q
How Much liquids can someone have right after bariatric surgery
A
-They can only have extremely small amounts, like 30 ml to start
-They cant drink with meals, need to drink between meals
11
Q
Complications of bariatric surgery
A
Wound infection
-Hernia
-Bowel obstruction
-Stricture
-Leak
-Dumping syndrome
-Nutritional deficiencies
12
Q
Signs of infection bariatric surgery
A
-Fever, drainage, smell, warmth, infection, pain
13
Q
How would you treat a bowel obstruction bariatric surgery
A
-Dont use a NG tube (usually we do this for other senarios)
-Bowel rest is first line treatment
14
Q
Dumping syndrome
A
-food and liquids entering the small intestine too quickly,
-refined sugar and other simple carbs
-Ranges from 15 min to 2 hr after eating
15
Q
Pancreas
A
Contains alpha and beta cells, glucagon and insulin respectively
16
Q
Alpha cells
A
Glucagon
17
Q
Beta cells
A
Insulin
18
Q
What type of cells are destroyed in type 1 diabetes
A
Beta
19
Q
Liver
A
Keeps blood sugar levels stable, and stores extra glucose
20
Q
Insulin (hormone)
A
Lowers blood glucose levels, acts as the “key” to allow glucose into the cells, if insulin isnt present, glucose chills in the bloodstream
21
Q
Glucagon
A
Works to take stored glucose in the liver and bring it in the blood stream
22
Q
Type 1 Diabetes
A
Absence of beta cells in the pancreas, due to an auto immune response. These guys are insulin dependent for life
-Peak onset is 11-13 but can occur usually in people younger than 30( However if there is some trauma to the pancreas it can induce type 1)
- As a result of no insulin, glucose from meals stays in the blood stream
-Can be genetic or environmental (Viral) factors however it is NOT lifestyle
-Thin at diagnosis, and will have ketones in the urine at diagnosis from breakdown of fat
-Needs exogenous insulin to survive
-DKA is a concern
23
Q
Why are pt with type 1 thin at diagnosis and have ketones in the urine
A
Body is unable to use the glucose in the blood stream, body breaks down fat for energy instead. This causes fat reduction and ketones in the urine
24
Q
Type 2 diabetes
A
Body can make insulin, but the body is not receptive to it, its like the “keyhole” is blocked or no longer AS receptive to it
-Body produces enough insulin to prevent breakdown of fat and ketones
-But its not enough for the bodys purposes, beta cells have to make more insulin and they are not able to meet demands which leads to hyperglycemia
-Mainly caused by life style habits
-Pt are usually over 30 and obese (Seen more and more often in kids)
-Slow and progressive and may go unnoticed for years
-Major complication for type 2 is HHNA
-Treatment starts with lifestyle changes -> Oral meds -> Insulin
-No ketones in the urine
25
How might a wound on a foot lead to a diagnosis of diabetes
Type 2 diabetes is slow and progressive and a pt may not realize that they have diabetes until some sort of acute event such as a chronic wound that is not healing. They enter the hospital for their foot and find out its due to a complication of diabetes. This is stressful for the pt as they came to the hospital thinking they are fine and come out with all these lifestyle changes
26
Gestational diabetes
Usually 2nd-3rd trimester
-More similar to type 2
-goes away after pregnancy but much more likely to have type 2 after as a result
-Risk factors that can lead to this include, obesity, over 30, family history, personal history , big babies
-Can lead to complications such as LGA babies and preeclampsia
-Blood glucose measured fasting (95-) and 2 hrs after meal (120-)
-Treated with diet and insulin
-Screened with glucose tolerance test
27
Causes of Type 1 diabetes
-Autoimmune
-Genetic
-Virus (Coxsackie virsu, mumps, congenital rubella are all associated with type 1,
-pancreatic damage or disease
28
Causes of type 2 diabetes
-Genetics
-Mainly lifestyle
-Poor diet
-Sedentary lifestyle
-Obesity
-Metabolic syndrome
29
A nurse is providing discharge teaching to the parents of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parents indicates an understanding of the teaching?
A. “As he has type 1 diabetes, he will only need insulin until he outgrows the condition.”
B. “As he has type 1 diabetes, we will start with oral medications and if his sugar is still uncontrolled we will switch to insulin.”
C. “His type 1 diabetes was caused by eating too much candy and soda.”
D. “His type 1 diabetes was caused by his body attacking his pancreas.”
D. “His type 1 diabetes was caused by his body attacking his pancreas.”
Type one is an auto immune mediated attack on the beta cells of the pancreas. A is incorrect as this disease is a lifelong condition. B is incorrect as this reflects type 2 diabetes, and oral medications are not effective for a pt with type 1. C is reflection lifestyle habits causing diabetes which is true for type 2 however for type one it is more autoimmune.
30
When providing education to the patient with Type 2 diabetes mellitus, the nurse correctly states which of the following clinical characteristics?
A. “The onset is due to pancreatic alpha cell destruction.”
B. “Patients notice severe weight loss and are devoid of body fat.”
C. “You can help control glucose with diet control and exercise.”
D. “The onset is autoimmune mediated.”
Answer:C. “You can help control glucose with diet control and exercise.”
A. “The onset is due to pancreatic alpha cell destruction.”
-The alpha cell produces glucagon, which is not affected by type 1 or 2
B. “Patients notice severe weight loss and are devoid of body fat.”
-This is reflective of type one, in which the body breaks down fat as they are not able to use the sugar in the blood stream
D. “The onset is autoimmune mediated.”
-This is reflective of type one which the body launches an autoimmune response on the beta cells of the pancreas
31
Diagnostic Criteria for Diabetes: Random glucose
200
32
Diagnostic Criteria for Diabetes: Fasting glucose
126, Not eating or drinking for 8 hours
33
Diagnostic Criteria for Diabetes: Oral glucose tolerance test
200, post-prandial
34
Diagnostic Criteria for Diabetes: A1C
6.5%
35
A1C role
Shows how a person is following their routine for the past few months (Lifespan of the current RB)
36
Normal Random glucose
70-115
37
Normal fasting glucose
Under 100
38
Normal GTT test
Under 140
39
Normal A1C
Under 5.7 (4-6)
40
A person has value between the normal amount random glucose and the criteria for diabetes what should they be considered
Pre-diabetic, repeat testing on another day
41
Diagnostic criteria diabetes
-Random glucose 200+
-Fasting 126+
-Oral glucose tolerance test 200+
-A1c 6.5%+
-Need to repeat on another day to be sure
42
S+S diabetes
-Present symptoms of hyperglycemia
-Polyuria
-Polydipsia
-Polyphagia
-Prolonged or recurrent yeast infections (Bacteria love sugar, and its in the urine)
-Increased fatigue, and lethargy
-Vision changes
Type one: loss of 10-30% of weight
43
Glycosylated hemoglobin
-Measure of glucose control that is a result of glucose molecules attaching to hemoglobin for the life of the RBC (90-120 days)
-Normal is 4-6%
-6.5% and above is diabetes
-Below 6% is controlled (in pt with diabetes already) 6.5% gotta revise plan
44
A1C purpose type 1
Insulin compliance
45
A1C purpose type 2
Diet, exercise, meds
46
4 S's of hyperglycemia
-Sepsis
-Stress
-Skipping insulin doses
-Steroids
-Also can be caused by hormone therapy or thiazide diuretics
- This can occur even in non diabetics, and may need insulin in their hospital stay
47
Number one cause of hyperglycemia in the hospital
Sepsis
48
Hypoglycemia
Glucose lower than 70
Caused by
-Too much insulin
-Missed meals
-Exercise
-Alc
-Insulin peak times (Lack of coordination when theyre eating)
49
What meds block symptoms of hypoglycemia
Beta blockers
MAO inhibitors
Bactrim (Antibiotic)
50
A person comes into the ED with Diaphoresis, tachycardia, hunger, slurred speech, When their blood sugar is taken it reads 150. What may the nurse suspect is afflicting the patient in relation to their diabetes
Hypoglycemia, they may naturally run very high for their blood sugar, you need to know their baseline
51
S+S Hyperglycemia
"High and dry"
-Polyuria
-Polydipsia
-Polyphagia
-Headaches
-Weight loss (Type 1)
-Acetone breath (Type one in DKA)
-N+V abdominal pain (Type one in DKA)
52
S+S Hypoglycemia
Diaphoresis (Sweaty and clammy)
-Tachycardia
-Hunger
-Shakiness
-Slurred speech
-Altered mental status/ confused
-Weakness
-Double vision
-Headache
-Irritability
-Tremors
-Seizures
-Coma
-Sweat, cold and clammy give me the candy
53
Hypoglycemia treatment
-Sugar!
-If they can eat give them a simple sugar that can be digested fast
-Dont want any lipids with it as it slows digestion
-Give them
-Glucagon, fruit juice, gram crackers, hard candy, soda, low fat milk
-Dont give them
Peanut butter or high fat milk
If unconscious give them IV dextrose
Blood sugars every 15
54
The lowest fasting plasma glucose level suggestive of a diagnosis of diabetes mellitus is:
A. 6.5%
B. 126 mg/dL
C. 200 mg/dL
d. 100 mg/dL
B. 126 mg/dL
A. 6.5%: A1C for diabetes
C. 200 mg/dL: Random fasting for diabetes/ GTT
d. 100 mg/dL: Normal fasting
55
A nurse is assessing a patient who has type 1 diabetes mellitus and finds the patient lying in bed, sweating, and reporting feeling anxious. Which of the following complications should the nurse suspect?
A. Hypoglycemia
B. Nephropathy
C. Hyperglycemia
D. Ketoacidosis
A. Hypoglycemia
56
A nurse is providing teaching to a patient who has a new diagnosis of Type 2 diabetes mellitus. The nurse should recognize that the patient understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply)
A. Polyuria
B. Blurred vision
C. Tachycardia
D. Polydipsia
E. Moist, clammy skin
B. Blurred vision
C. Tachycardia
E. Moist, clammy skin
57
A patient with Type 1 diabetes is only responsive to painful stimuli with a blood sugar of 42. What is the first action taken by the nurse?
A. Repeat the blood sugar assessment
B. Give then two juices
C. Give Dextrose IV push
D. Give oral Glucagon
E. Give insulin
C. Give Dextrose IV push
They are only responsive to pain we dont want them to aspirate
58
Which medication could cause hyperglycemia?
A. Labetalol
B. Albuterol
C. Spironolactone
D. Prednisone
D. Prednisone, its a steroid
59
The non-diabetic patient is admitted for a kidney infection that has now turned septic. The blood sugars have increased from 150 to 225 and the nurse has explained to the patient’s family why he is on insulin. Which response by the family indicates further teaching is necessary? (Select all that apply):
A. Insulin is given to control the hypoglycemia
B. The patient now has diabetes because of the infection
C. High sugar is common during infection and stress to the body, and the insulin will help lower the blood sugar until the infection resolves.
D. The patient will be dependent on insulin for the rest of their life
ABD
60
Thorough history diabetes
-Symptoms related to diabetes (timing, frequency, severity, resolution)
-Results of blood glucose monitoring and hemoglobin A1C
-Diet and exercise compliance (Pt might report they are doing it but they are not)
-Adherence to and ability to follow prescribed pharmacologic treatment (Insulin or oral drugs) (Insulin is expensive and people might ration it)
-Adherence to glucose monitoring (How many times a day)
-Lifestyle, cultural, psych, and economic factors may affect diabetes treatment
-Effect of diabetes or its complications on a patients functional status (Neuropathy/amputation)
-Use of alc, tobacco, prescribed and OTC drugs
-S+S and status of chronic complications of diabetes (Vision, do they wear glasses)
61
Physical exam of a pt with diabetes
-BP
-BMI
-Foot examination (Lesions, S+S of infection, pulses, sensation,, Can they feel their foot)
-Skin examination, lesions and insulin injection sites
-Neuro exam
-Oral exam
-Fundoscopic exam and visual acuity (Not technically nursing)
62
Diabetes assessment pneumonic: SUGAR (S)
(S)low wound healing (glucose is sticky, and hardens vessels, decreased perfusion, poor wound healing
63
Diabetes assessment pneumonic: SUGAR (U)
bl(U)rry vision
64
Diabetes assessment pneumonic: SUGAR (G)
(G)lycosuria, glucose in the urine
65
Diabetes assessment pneumonic: SUGAR (A)
(A)cetone breath (type one, burning ketones)
66
Diabetes assessment pneumonic: SUGAR (R)
(R)ash on skin (Acanthosis nigricans) or repeated yeast infections
67
Labs for diabetes
A1C: Gives good understanding of control
Fasting lipid profile
Urinalysis: See for infection or sugar
BMP: Electrolytes and kidney function
-Electrocardiogram
68
Referrals for diabetes
-Podiatrist (I dont wanna touch their feet), not in hospital usually
-Dietician
-Ophthalmologist: Not in hospital usually
-Diabetes education: Nursing does the majority
69
Five components of diabetes mgmt
-Nutrition
-Exercise
-Monitoring
-Pharm
-Education
-Goal is to slow or prevent complications
70
Nutritional therapy and diet
-Diet low in simple sugars, unless its a hypoglycemic crisis
-Want well balanced meals with enough proteins and fats
-Whole grains, whole wheat, whole milk (all these are high fat which slows sugar absorption)
-Improve diet and weight loss for type 2
-Eat a bedtime snack if youre hypoglycemic in the morning
-45-50% carbs
-20% fat
-15-20% protein
71
Exercise diabetes mgmt
-Compliance of regular exercise
-Diet and exercise can help reverse hyperglycemia
-Weight loss can often return blood glucose levels to normal if it occurs early
-Check sugar before exercising, if youre low eat a snack or youll crash
-If youre vigorously working out check before during and after
-Exercise decreases resistance of the cells to insulin, makes insulin more effective
-If your blood sugar is high before exercising and there is ketones in the urine dont exercise youll go into DKA
72
If your blood sugar is 250+ and there is ketones in the urine should you exercise, why or why not
-No the body is already burning ketones, as evident of them being in the urine which is indicative of fat breakdown. If you exercise youre going to increase the amount of energy your body requires which will speed along ketosis which can lead to DKA
73
Diabetes prevention
ONLY TYPE 2
Diet, exercise, and weight loss
74
diabetes complications
-Amputations, blindness, and end stage kidney disease
-Leading cause of death because of its ties with CVD
-Complications may occur before diabetes diagnosis (Foot lesion)
-Hypoglycemia
-Poor wound healing
-Infection
-Foot ulcers, amputations
-Excessive weight gain/loss
-DKA
-HHNS
-Microvascular, affects the small blood vessels
-Macro-vascular, larger blood vessels and organs
-Psych problems and coping deficits (Go in for one thing and come out for a diagnosis with diabetes and lifestyle changes
75
Retinopathy
Microvascular complication of diabetes
-Associated with prolonged hyperglycemia, and HNT
-Prevention includes glycemic control and HTN
-Occurs from micro-aneurysms and hemorrhages
-See ophthalmologist within 5 years for type 1 and right away for type 2
-Most common microvascular complication
76
Neuropathy
Microvascular complication of diabetes, nerve dmg
-Affects 30-50% of people with diabetes
-Sensory impairment, tingling, burning, numbness, pain, loss of balance
-Gradual onset
-Increased risk for foot ulcerations and infections (leading to amputation)
-Examin feet DAILY
77
Nephropathy
Microvascular complication of diabetes, renal disease
-Defined as persistent proteinuria
-Leading cause of end-stage renal disease
-Earliest sign is hypertension
-Can develop microalbuminuria
-Treatment directed towards controlling the hypertension
78
Early macrovascular disease
Atherosclerotic plaques: Glucose is sticky and it builds up plaques
79
Late macrovascular disease
MI, Stroke, Gangrene
80
Macrovascular complications S+S
-Can be asymptomatic
-Stable or unstable angina
-Sudden onset of focal neurologic deficits (CVA)
-Exertion leg pain
Macrovascular complications cause a 2-4 fold increase in risk for coronary artery disease, peripheral arterial disease and cerebral vascular disease
81
Diabetic foot care
Keep feet clean and dry
-Cut toe nails straight and file the edges (We dont cut diabetic nails, make the foot doc )
-Wear clean, dry socks, well fitting leather shoes
-Can have trouble with temp discrimination (Use back of hand or thermometer, not fingers or toes)
-Diabetic feet= delicious treat (Bacteria love sugar and will culture here often)
-Always dry between toes
-Dont remove callouses, foot doc will
-Immediately report injury to PCP, a small cut can become huge
82
Which statement by the patient with diabetes demonstrates correct understanding? (Select all that apply)
A. “I will get comfortable fitting sandals.”
B. “I will test bath water with my fingers before getting in.”
C. “I will get over-the-counter callous removal rather than cutting them off.”
D. “I will use leather shoes with cotton socks.”
E. “I will assess my feet weekly.”
F. I will cut my own nails at angles, but file edges.”
G. “I will always dry between my toes after a shower.”
D. “I will use leather shoes with cotton socks.”
G. “I will always dry between my toes after a shower.”
Incorrect:
A. “I will get comfortable fitting sandals.”,
-Sandals are not ideal as you can injure feet
B. “I will test bath water with my fingers before getting in.”,
- They can also have neuropathy in fingers and feet, not ideal to test temperature with your body
C. “I will get over-the-counter callous removal rather than cutting them off.”
-Leave the callous alone
E. “I will assess my feet weekly.”
-Assess daily
F. I will cut my own nails at angles, but file edges.”
-Cut nail straight, filing the edges is correct
83
Diabetic Ketoacidosis (DKA)
Think DKA (Dehydrated, Kussmaul respirations and ketones, Abdominal pain or acidosis)
-Life threatening emergency, only in type one
-Quick onset, can be the first sign of type one diabetes
-Body has no insulin and blood sugar is super high
-Causes can be any of the S's (Sepsis, stress, skipping insulin, steroid)
Three main components
-HyperGlycemia, super high, 300-500
-Ketones, burning fat
-Metabolic acidosis, PH less than 7.35
84
When is the blood considered acidotic
7.35
85
S+S DKA
Think DKA (Dehydrated, Kussmaul respirations and ketones, Abdominal pain or acidosis)
Extremely dehydrated from glucose in blood increasing urine output via osmotic forces, symptoms reflect that
-Poluria
-Polydipsia
-N+V
-Abdominal pain
-Kussmaul respirations, tachypnea
-Acetone/fruitybreath
-Ketonuria
-Dry mucus membranes, poor skin turgor
-Tachycardia
-Hypotension
86
DKA treatment
-1st you have to rehydrate the patient, .9% normal saline
-IV insulin, regular only
-Once sugar drops to 200-250, switch to SQ insulin and dextrose
-Monitor blood sugars per IV insulin protocol
-Consider potassium during IV insulin infection
-Never IV push
-Monitor on tele
87
Why do we give dextrose in DKA treatment
We give D5W when the blood sugar reach 200-250 to prevent the sugars from crashing, as hypoglycemia is also deadly
88
What is the only insulin that can be given IV
Regular insulin, short acting
89
Potassium in DKA
-Potassium might be normal initially but as glucose and insulin move into the cell you can easily become hypokalemic
90
Hyperglycemic Hyperosmolar Nonketotic syndrome
Life-threatening emergency complication of type 2
-This is a slow onset in comparison to the rapid of DKA
-Older pt
-Caused by the 4 S's
91
Components of HHNS
-Hyperglycemia
-Higher fluid loss
-Neuro changes, confusion
-No abdominal pain , no ketones, no kussmaul respirations
-Slow sonset
-Tachycardia, hypotension
92
HHNS treatment
Similar to DKA, dehydration is worse and you dont give potassium
Very similar to DKA , first you rehydrate
-Regular insulin IV
-When sugar is 200-250 subQ insulin and D5W
-Monitor blood sugars per procedure
-Assess rehydration status
Stable Blood pressure
Cap refill less than 3
Urine output less than 30 ml/hr or more
Normal specific gravity (High specific gravity is dry)
93
Which of the following is an example of a microvascular injury secondary to diabetes mellitus? (Select all that apply):
A. Retinopathy
B. Coronary artery disease
C. Myocardial infarction
D. Neuropathy
E. Peripheral vascular disease
A. Retinopathy
D. Neuropathy
94
A nurse is assessing a patient who has diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following findings? (Select all that apply)
A. Weight gain
B. Fruity odor of breath
C. Abdominal pain
D. Kussmaul respirations
E. Metabolic acidosis
B. Fruity odor of breath
C. Abdominal pain
D. Kussmaul respirations
E. Metabolic acidosis
95
When a patient is first admitted for Hyperglycemic Hyperosmolar Syndrome (HHS), the nurse’s first priority is to:
A. Begin supplemental potassium replacement
B. Start an insulin IV drop
C. Initiate measures to correct the acid/base imbalance
D. Initiate fluid replacement
D. Initiate fluid replacement
96
The nurse is assessing a patient recently admitted to the emergency department with Hyperglycemic Hyperosmolar Syndrome (HHS) and documents that the patient is confused. The nurse would also expect: (Select all that apply)
A. Blood glucose of 650 mg/dL
B. The presence of ketones
C. A pH level of 7.34 on an ABG
D. Hypotension
E. A history of a recent diagnosis of pneumonia
A. Blood glucose of 650 mg/dL
D. Hypotension
E. A history of a recent diagnosis of pneumonia
97
Metabolic syndrome
Cluster of metabolic abnormalities that increase the likelihood of developing, HD, diabetes and stroke
-Huge risk for CVD: people with metabolic syndrome are 2x as likely
98
Five risk factors for metabolic syndrome
-Increased blood pressure (130/85 or they are on blood pressure meds controlling it)
-High blood sugar levels, insulin resistance, (100 fasting) or on meds for glucose control
-Obesity/excess fat around the waist (35 female, 40male)
-High triglyceride levels (more than 150), doesnt matter if your on meds or not
-Low levels of HDL (50 in females, 40 in males)
3/5 is enough to meet diagnostic criteria
99
Normal total cholesterol
200 or less
100
Normal triglycerides
150 or less
101
Normal LDL
100 or less
102
Normal HDL
50+ Female, 40+ Male
103
Mgmt of metabolic syndrome
-Lifestyle modifications
-Weight reduction
-Reduced sodium intake
-Increase physical activity
-Moderation of alc consumption
-Reduce blood glucose levels
104
Which patients are most at risk for developing metabolic syndrome? (Select all that apply):
A. A 30-year-old male with triglycerides of 140
B. A 48-year-old female with a fasting blood glucose of 110
C. A 55-year-old female with a waist size of 40 inches
D. A 42-year-old female with an HDL level of 55
E. A 28-year-old male with a blood pressure of 138/88
B. A 48-year-old female with a fasting blood glucose of 110
C. A 55-year-old female with a waist size of 40 inches
E. A 28-year-old male with a blood pressure of 138/88
105
Which of the following is not a component of metabolic syndrome?
A. Hypertension
B. Insulin resistance
C. Dyslipidemia
D. Type 1 diabetes mellitus
D. Type 1 diabetes mellitus
106
Oral anti-diabetic meds
Only used for type 2 diabetes
-Lowers blood glucose
-Used after trying lifestyle modifications, if it doesnt work then we move to meds
-Classes
Sulfonylureas
Biguanides
Thiazolidinediones or TZDs
DPP-4 inhibitors
Alpha-gluocoside inhibitors
Meglitinides
107
Sulfonylureas MOA
-Stimulate beta cells to increase insulin secretion and increase receptor sensitivity
-Often used as a first line treatment, does cause hypoglycemia
-Cant have alc because its synergistic in hypoglycemia
-Doesnt work when there isnt any insulin (Type 1, pancreatectomy)
-Used with metformin
108
Sulfonylureas Side effects
Hypoglycemia, extreme hypoglycemia when used with alc
-Can increase risk of cardiovascular events, use cautiously with cardiac patients
-Can cause weight gain, GI upset, HA, more sensitive to light
109
Meglitinides MOA
Works like sulfonylureas but there weaker
-Stimulate the beta cell to produce insulin
-Take with the first bite of food
110
Meglitinides side effects
Weight gain, hypoglycemia; potential for hypoglycemia is less than sulfonyulreas
111
Biguanides, MOA
-Decreases liver stores of glucose, so you cant raise your blood sugar as easily
-Decreases the resistance of the cells to insulin
-Need to hold 48 hours before surgery or cardiac cath, sometimes just held when pt is in hospital
-No risk of hypoglycemia
-Common first line treatment, used often in conjunction with sulfonylureas
112
Biguanide side effects
-Does NOT cause hypoglycemia
-Avoid in acute kidney injury or kidney failure pt and liver failure pt, toxicity
-Causes diarrhea, bloating, gas, upset stomach, and weight gain
113
Thiazolidinediones or TZD, MOA
-Makes cells more sensitive to insulin
-Decreases glucose production in the liver
-Does not cause hypoglycemia
-Used alone or with metformin or sulfonylureas
-Also helps with HDL levels, lower BP and triglyceride levels
114
Thiazolidinediones, Side effects
-No risk of hypoglycemia
-Huge heart and liver toxicity
-Risk of Heat failure, watch out for signs, (Pitting edema, crackles in the lungs, weight gain)
-Increase in MI
115
DPP-4 inhibitors, MOA
Inhibits enzyme dipeptidyl pepidase-4 which inhibits glucagon release
-Increases insulin secretion
-Decreases gastric emptying
-All these decrease blood glucose levels
116
DPP-4 inhibitors side effects
-Small risk of hypoglycemia
-HA,Nausea, heart failure, joint pain
-Little to no weight gain
117
Alpha-glucoside inhibitors MOA
-Starch blocker, lowers the blood glucose by breaking down starchy foods in the gut
-Works on the food you are intaking, needs to be taken with the first bite of food
118
Alpha-glucoside inhibitors side effects
Not commonly given due to massive flatus and diarrhea, not given in IBS
-No risk for hypoglycemia
119
Oral antidiabetic meds over time
Over time they become less effective and may need other classes of medications to supplement in conjunction with the original
-If they cant be controlled with meds, insulin might become needed
120
A nurse is providing teaching for a patient who is newly diagnosed with Type 2 diabetes mellitus and has a prescription for Glipizide. Which of the following statements by the nurse best describes the action of Glipizide?
A. “Glipizide absorbs the excess carbohydrates in your system.”
B. “Glipizide stimulates your pancreas to release insulin.”
C. “Glipizide replaces insulin that is not being produced in your pancreas.”
D. “Glipizide prevents your liver from destroying your insulin.”
B. “Glipizide stimulates your pancreas to release insulin.”
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A diabetic patient presents to the clinic and the nurse reviews recent laboratory work, revealing a Hemoglobin A1C of 6.2%, and fasting serum glucose of 80 mg/dL. The nurse would best recommend which of the following?
A. Continue the patient’s regime with no changes
B. Recommend implementation of a basal insulin
C. Provide teaching for a 1200 calorie ADA diet
D. Discontinue anti-glycemic medications due to the patient’s hypoglycemia
A. Continue the patient’s regime with no changes
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Insulin
Generally SQ, only given IV with regular insulin
-Need to rotate injection sites
-Can give in in ab, arms, or thighs
-Best absorption site is the abdomen
-When mixing insulin, mix clear to cloudy (reg is clear NPH is cloudy)
-Long acting is always drawn in another syringe
123
Why dont you rub injection site after giving insulin
It can increase absorption which the body cant handle and cause hypoglycemia
124
Things to consider for every insulin
Onset
Peak
Duration
125
Onset (insulin)
Length of time before insulin reaches the bloodstream and starts lowering blood sugar
126
Peak (insulin)
Time during which the insulin is at max strength in terms of lowering blood sugar
-Greatest risk of hypoglycemia
127
Duration (Insulin)
How long insulin continues to lower blood sugar
128
Rapid Insulin
-Covers insulin for mealtime (dont give until you see tray )
-Often used with a longer acting
-Most deadly because it has the fastest peak
-Onset is 15 min
Peak is 30-90 min
-Duration is 3-5 hours
129
Short Insulin
-Covers insulin needs for meals eaten within 30-60 min
-Given IV in DKA and HHNS
-Onset is 30 min
-Peak is 2-4 hours
-Duration is 3-8 hours
130
Intermediate insulin
-Covers about half day or overnight
-Can be combined with a rapid or short
-Can be sliding scale
-Mix clear to cloudy
-Never give IV
Most dangerous in middle of peak (5-6 hours)
-Onset is 2 hours
-Peak is 4-12 hours
-Duration is 12-18 hours
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Long insulin
-Covers insulin for a full day, some people prefer 2 doses, at half the original strength
-Often combined with rapid or short acting
-Less risk of hypoglycemia but not non-existent
-Onset is 2 hours
-Peak doesnt exist
-Duration is 24 hours
-Not food dependent
132
You are caring for a patient who is septic and is in DKA with a blood sugar of 489. The patient is too nauseous to eat and hasn’t eaten since yesterday. Do we continue the IV Insulin?
Yes
No
Yes: They still need insulin, they are in DKA and are actively septic which is raising their blood sugar
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Rapid insulin drug names
Novolog
Humalog
Glulisine
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Short insulin drug names
Humulin R
Novolin R
135
Intermediate insulin drug names
Humalin N
Novolin N
136
Long acting insulin drug names
Detemir (Levemir)
Glargine (Lantus)
Degludec (Tresiba)
137
Insulin Pump
-Provides a steady dose of insulin
-Fewer swings in sugar levels
-Need to check blood sugar 4x a day
-In hospital pt can keep their pump if theyre competent
138
If a pt insulin pump malfunctions what should you assess first
The pt
139
A nurse is caring for an adolescent patient who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this patient?
A. NPH Insulin
B. Insulin glargine
C. Insulin Detemir
D. Regular Insulin
D. Regular Insulin
140
A nurse is caring for a patient with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure that the patient receives breakfast at which of the following times?
A. 0720
B. 0730
C. 0745
D. 0815
C. 0745
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Dawn phenomenon
Happens to everyone, diabetes or not, but diabetics respond differently
-Happens from 2am-8am, usually 6am
-Occurs from a surge in hormones, GH, cortisol and GLUCAGON to get you goin
-Can give a nighttime dose of NPH insulin to counteract the hyperglycemia
-To confirm its the dawn phenomenon check the pt blood sugar at 2-3 am and if its normal its the dawn phenomenon
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Somogyi effect
-Not proven its debatable, individual stories
-In the night, diabetic pt become hypoglycemic, usually around 2-3 am
-Body panics because hypoglycemia is hella deadly and releases Glucagon to increase sugar, so sugar is elevated in the morning
-Treat by lowering bedtime dose of insulin or night time snack
-Confirm by waking them up at 2-3 am and seeing their blood sugar if its low its the somogyi
