Diabetic Glycemic Crises Flashcards
What type of foods would you want to avoid in hypoglycemic patients?
NO Fat Containing Foods
–Whole Milk
–Chocolate
–Peanut Butter
–Cheese
–etc
Fat slows down glucose levels from rising
What are the Signs & Symptoms of High glucose levels?
- Increased urination (Polyuria)
- Increased thirst (Polydipsia)
- Increased hunger (Polyphagia)
- Weight loss
- Weakness and fatigue
- Blurred vision
What causes Type 2 diabetes?
- insulin resistance (relative insulin deficiency) → pancreatic β cell dysfunction → absolute insulin deficiency
- insulin secretory defect with insulin resistance
What drugs counteract the actions of insulin & produce hyperglycemia?
- thiazide diuretics
- glucocorticoids
- sympathomimetics
What causes hypoglycemia?
- insulin overdose
- reduced intake of food
- vomiting/diarrhea
- excess alcohol
- unaccustomed exercise
- childbirth
What are some Intermediate duration insulins (NPH insulins)?
- Humulin N
- Novolin N
What is Diabetic ketoacidosis?
A problem that occurs in people when the body cannot use glucose as a fuel source because there is no insulin or not enough insulin; Fat is used for fuel instead producing ketones which build up in the body.
What causes Type 1 Diabetes?
- Peak age of diagnosis = 12 years
- Autoimmune loss of β cells
- Gene-environment trigger cell-mediated destruction of pancreatic cells
- Slowly progressive, T-cell-mediated Lymphocyte & macrophage infiltration → inflammation → β cell death
- Autoantibodies produced against islet cells, insulin, other cytoplasmic proteins
T helper lymphocytes → IL-4 → B lymphocyte proliferation & antibody production, IL-2 → T cytotoxic (CD8) cells, and IFNγ → macrophage activation
- Altered β & α cells → excess glucagon → hyperglycemia
- Non-immune is a secondary result of other diseases (pancreatitis)
What is the treatment for Type 2 diabetes?
oral hypoglycemics, diet, exercise
What drugs lower blood glucose when combined with insulin?
- sulfonylureas
- meglitinides
- beta blockers
- alcohol
What are the contraindications for metformin?
- Males with creatine clearance > 1.5
- Females with creatine clearance > 1.4
- Liver dz, alcohol excess or pt. with shock (cause hypoxemia), alcohol use
- Heart Failure
- Severe infection (stop metformin, start temporary insulin)
What is the treatment for Diabetic ketoacidosis?
- insulin (↓ hyperglycemia & hyperkalemia by transport of glucose & K+ into cell),
- fluids (correct dehydration) –> 0.9% NS at 500 ml/hr for 1st hr
When should you cheeck blood glucose levels?
- Before breakfast, lunch, & dinner, and before bedtime snack
- 1-2 hours after a meal
- Periods of stress, illness, or surgery
- Pregnancy; changes in treatment plan
- When suspect low blood sugar
What types of insulin are there, and what is the onset and duration for each?
- Rapid acting/Short duration (Regular) (10-30min / 3-6.5hr)
- Slower acting/Short duration (30-60min / 6-10hr) regular & (15-30min / 6.5hr) exubera
- Intermediate duration (NPH) (60-120min / 16-24hr)
- Long duration (70min / 24 hr) (Lantus)
What is the treatment for Hyperosmolar hyperglycemic nonketotic syndrome (HHNKS)?
- insulin
- rapid fluid replacement
- K+ replacement
What are some chronic complications with chronic Diabetis Mellitus?
- Microvascular disease
- Macrovascular disease
- Infection
What are the 2 types of diabetes mellitus?
- Type 1 (Beta-cell destruction, usually leading to absolute insulin deficiency)
- Type 2 (ranging from predominatly insulin resistance with relative insulin deficiency to predominattly an insulin secretory defect with insulin resistance)
Describe the HBA1C lab results
- 4-6% = Glucose level 60-120
- 7% = Glucose of 150
- 8% = Glucose 180, fair
- 9% = Glucose > 210, poor results
What is gluconeogenesis?
conversion of fatty acids and protein to glucose. Ketone bodies are created during this process
When should a patient with diabetes not excercise?
- Test blood sugar before & after exercise
- Do not exercise if blood glucose 100 < or > 240 and there are ketones in urine
What are the manifestations of Diabetic ketoacidosis?
- polyuria & dehydration (osmotic diuresis from hyperglycemia)
- Cool clammy skin
- ketonuria
-
hypokalemia (shift of K+ out of cell in exchange for H+)
- K+ is moved from the inside of the cells to the outside –> to the urine and emptied out.
- Hyponatremia
- Cardiac dysrhythmias develop
- Altered Neuromuscular activity (seizures)
- Metabolic acidosis (from the increasing H+ lvl)
- Kussmaul respirations
- postural dizziness,
- ↓ LOC (no glucose avaliable for the cells)
- Nausea (parastalsis stops with Increased BG)
- Thirst (because pt. is dehydrated)
- glycosuria
-
BG > 250 mg/dl
- Increased BG leads to massive diuresis + vomiting –> Dehydration and shock
What drug(s) can mask the signs and symptoms of hypoglcemia?
- Beta blockers
- (tachycardia, palpitations) & also cause further hypoglycemia by blocking glycogenolysis.
What are the signs and symptoms of a rapidly falling blood glucose levels?
- activation of the sympathetic nervous system leading to –>
- tachycardia, palpitations, sweating, nervousness
What are the clinical manefistations of Type 1 Diabetes?
- Acute onset of “3Ps” (polydipsia, polyuria, polyphagia )
- Weight loss
- fatigue
- glucosuria (excessive glucose in urine)
- hyperglycemia
- thirst
What are some adverse effects of insulin?
- Hypoglycemia
- edema
- weight gain
What causes Hyperosmolar hyperglycemic nonketotic syndrome (HHNKS)?
- Precipitated by stress, noncompliance with meds, infections, burns, MI
- More common in type 2 DM
- Relative insulin deficiency → hyperglycemia → solute diuresis → dehydration → hyperosmolality
What are the nursing implications of Insulin Glargine (Lantus)?
- Clear colorless solution, do NOT mix with other insulins and do NOT give IV
- Long DOA 24 h, qd dosing SQ injection
- Because of long DOA and a stable steady state there is less risk of hypo or hyperglycemia.
What are the manifestations of Hyperosmolar hyperglycemic nonketotic syndrome (HHNKS)?
- glycosuria
- polyuria
- thirst
- polydipsia,
- ↓ BP, ↑ HR,
- weakness,
- N & V,
- stupor,
- seizures,
- coma,
- Blood Glucose > 600 mg/dL, pH > 7.30
- serum osmolarity > 320 mOsm/L,
- ↓ K+
What is Hyperosmolar hyperglycemic nonketotic syndrome (HHNKS)?
A serious condition most frequently seen in older persons in which blood sugar levels rise, and your body tries to get rid of the excess sugar by passing it into your urine
What is the recommended Hemoglobin A1c levels for the elderly?
7.0-7.9%
In what situations would you want to supplement additional doses of insulin?
- During infection
- stress obesity
- the adolescent growth spurt
- pregnancy (after 1st trimester)
What is the MOA for metformin?
- Dec glucose production in the liver & enhances glucose uptake & utilization by muscle.
- Does NOT promote insulin release
- Dec LDL and triglyceride levels.
What is Insulin Release Stimulated By?
- Glucose
- Ketone Bodies
- Proteins
- Glucagon
- Gastric Secretions
- Salicylates- asprin – can lead to hypoglycemia
- Hyperkalemia
What are some Rapid acting/Short duration insulins?
- lispro (Humalog)
- aspart (NovoLog)
- glulisine (Apidra)
What is the MOA for Metgilitinides/Short-acting Secretagogues
- Stimulates the release of insulin from pancreas depending on how much glucose there is (insulin sensitivity) –> can lead to hypoglycemia
- It is glucose dependant (if no glucose no insulin is produced) pt MUST eat no longer than 30 min after drug intake
- Works exactly the same as Sulfonylureas
What are some side effects of sulfonylureas?
- Hypoglycemia (fatigue, excessive hunger, profuse sweating, palpitations)
- Weight gain
What should the nurse consider before giving insulin to a patient?
- Always check the blood sugar before giving insulin
- Know onset and duration of insulins
- Always have another nurse check what is drawn, the amount, etc.
What are some characteristics associated with Microvascular disease with Diabetes Mellitus?
- Hyperglycemia → capillary basement membrane thickening with endothelial cell hyperplasia → ↓ tissue
- Pathology related to ↑ blood glucose level & duration of disease
- Sequelae: retinopathy → blindness, nephropathy → ESRD, & neuropathies
What are some risk facotrs for Type 2 diabetes?
- Genetic-environmental interaction
- Metabolic syndrome: central obesity (strongest factor)
- Dyslipidemia
- High blood pressure
- Inactivity
- Gestational DM + insulin during pregnancy, baby > 9 lb birthweight, maternal postpartum obesity
How much does 15grams of crabs rise a patient’s blood glucose level?
15 grams raises BG by about 30 mg/dl
What are the signs of hypoglycemia? (The ones the patient demonstrates)
- Cool Clammy Skin
- Tachycardia
- Decreased LOC
- Shaking, trembling
- Shallow Breathing
- Decreased B/P
- Irritable
- Combative
- Seizure
- Confused
- Look drunks
- Coma (severe)
How should insulin be administered?
- Using thumb and forefinger, pinch skin at the injection site. Inject at 90 degree angle. DO NOT ASPIRATE FOR BLOOD RETURN
- Place alcohol swab or cotton over site and withdraw needle
- DO NOT MASSAGE area after injection
- Dispose of needle in appropriate puncture resistant container
What are some nursing implications of Slower acting/Short duration insulins?
- Humulin & Novolin R do not need an Rx to get, **except Exubera **
- SQ inj, SQ infusion, IM inj, oral inhalation & off label IV
- Only insulin given by IV
- Can be inhaled or injected AC to control postprandial hyperglycemia
- Infused SQ to provide basal glycemic control
What are some nursing implications of Humulin N & Novolin N insulins?
- Cloudy suspension should be gently shaken b/4 administration
- Available without prescription
- The protamine component slows absorption & delays DOA
- Do not administer at mealtime but use bid between meals & at bedtime
-
Is the only long acting insulin that can be mixed with a short acting insulin
- Draw short acting insulin into syringe first to avoid contamination of NPH vial.
- If have to give a short acting & long acting insulin mix the preparations rather than inject them separately.
What is Insulin Release Inhibited by?
- Hypoglycemia
- Hypokalemia
- Catecholamines (NE and Epi
- Beta-Blockers
- Calcium Channel Blockers
- Phenytoin
- Alcohol (this will decrease glucose levels for a while)
What are the symptoms of hypoglycemia?
HA, confusion, drowsiness, fatigue, palpations, nervousness
What produces glucagon and what are it’s effects?
- Glucagon is produced by alpha cells in the pancreas.
- ↑ plasma levels of glucose & relaxes smooth muscle in the GI tract.
- ↑ blood glucose levels following insulin overdose.
- It promotes breakdown of glycogen, ↓ glycogen synthesis & stimulates biosynthesis of glucose.
Glucagon will not work with:
Chronic alcoholics
Liver disease
What are some lab tests for Diabetes and what do their values mean?
- Fasting blood glucose 100 > 126 mg/dL = prediabetes
- Oral Glucose Tolerence Test 140 > 200 mg/dL = prediabetes
- Non-fasting blood glucose > 200 mg/dL + polyuria, polydipsia = You have diabetes
- Glycosylated( glucose-bound) Hgb HBA1c
- Normally between 4-6%, it is increased with hyperglycemia
- Blood glucose control over 2 – 4 mo
What is the MOA for Sulfonylureas?
Stimulates the release of insulin from pancreas depending on how much glucose there is (insulin sensitivity) –> can lead to hypoglycemia
What causes Diabetic ketoacidosis?
- Precipitated by intercurrent illness or inadequate insulin Rx
- Insulin deficiency → ↓ glucose uptake, ↑ fat mobilization with release of fatty acids, ↑ gluconeogenesis, ↑ ketogenesis
- Hepatic overproduction of acids → metabolic
acidosis
What is the treatment of Type 1 Diabetes?
- Insulin
- diet
- exercise
- Blood Gas monitoring,
- Islet cell/pancreas transplant
What is glycogenolysis?
breakdown of hepatic and muscle glycogen to glucose.
You should Discard insulin that has any precipitate except for which type of insulin?
NPH insulins (Humulin N & Novolin N)
What can be used to treat falling blood glucose levels (rapid or slow)?
- Take fast acting sugar
- glucose tablets, OJ, sugar cubes, honey, corn syrup, non diet soda
- If pt has severe hypoglycemia IV glucose is preferred
What are some long duration insulins?
Insulin Glargine (Lantus)
What are some acute complications with Diabetes Mellitus?
- Hypoglycemia
- Diabetic ketoacidosis (DKA)
- Hyperosmolar hyperglycemic nonketotic syndrome (HHNKS)
- Somogyi effect
- Blood glucose fluctuations: hypoglycemia → rebound hyperglycemia
- Common in children with DM Type 1
- Dawn phenomenon
- Early AM rise in blood glucose
- Related to nocturnal elevations of GH?
What are the SQ injection sights for insulin?
- upper arm, thigh (slowest) & abdomen (fastest)
How can glucagon be administered?
IM, SQ & IV
How is insulin released?
- Beta cells of islets of Langenhans
- ↑ blood glucose →↑ insulin release
- 2-3 hr after meal, then basal rate occurs
- Insulin levels low between meals
- Insulin binding
- Binds to insulin receptors to ↑ glucose transporter molecules; used for energy or stored as glycogen; negative feedback (↓ glucose & ↓ insulin release)
- ANS effects
- PNS ↑, SNS ↓
What are the clinical manefistations of Type 2 diabetes?
- Asymptomatic or vague (e.g., fatigue)
- Visual changes
- Nephropathy
- Coronary artery disease (CAD)
- Peripheral vascular disease (PVD)
- Recurrent infections
- Neuropathy (paresthesias, weakness)
What are some adverse effects of Thiazolidinediones (Glitizones)?
- Fluid retention (edema & wt gain), inc HDL, LDL and triglycerides
- Contraindicated in Class III or IV heart failure or hepatoxicity
What are some nursing implications of Rapid acting/Short duration insulins?
- Give with meals to control postprandial rise in glucose to control glucose between meals & HS
- If no food is given within a short perioid of time pt. will get in a hypoglycemic state.
- All of them are clear solutions –> look out for cloudiness
- All 3 require prescriptions (Insulin Lispro, Aspart & Glulisine)
- Do NOT give IV
What is the ideal level that Hemoglobin A1c should be kept at with patients with diabetes?
HbA1c < 7%
What type(s) of insulin can be given IV and why is it given?
- ONLY Regular insulin can be given IV.
- Usually given for ketoacidosis or hyperkalemia
- Insulin is given to ALL pts. that have type I
Hypoglycemia is defined by what blood glucose level?
< 60 mg/dl
What causes hyperglycemia?
- >120-150 mg/dl
- Too little Insulin
- Too much Carbohydrates
- Stress (Cortisol)
- Infection
- Pregnancy
- Gradual Onset…..
What is Hemoglobin A1c?
A measure of the total hemoglobin over 3 months; this value reflects the average glucose level over those 3 months.
What are some Nursing Diagnoses for anemia?
- Activity intolerance
- Imbalanced nutrition: Less than body requirements
- Knowledge deficit
- Noncompliance with prescribed therapy
- Altered tissue perfusion
- Fatigue
What are some complications of type 1 diabetes?
- Dehydration
- Diabetic ketoacidosis (DKA) (fruity odor to breath,
- Failure to thrive in small children/infants
What are some Slower acting/Short duration insulins?
- Humulin R (regular human insulin)
- Novolin R
- Exubera
What are some characteristics associated with Macrovascular disease with Diabetes Mellitus?
- Fibrous plaques associated with proliferation of subendothelial smooth muscle in arterial wall
- Contributions to premature atherosclerosis: hyperglycemia, ↑ triglycerides, ↑ LDL, ↓ HDL,
- Sequelae: coronary artery disease (CAD), stroke, & peripheral vascular disease (PVD)
