DM Management Flashcards
Which supplements might a patient with diabetes taking metformin and miglitol avoid because it can potentially cause hypoglycemia
Ginseng and garlic
Characteristics of type 1 DM
Onset under 30 yrs, symptoms acute onset, pt usually thin, autoimmune beta cell destruction, insulin use mandatory
Characteristics of type 2 DM
Usually occurs after 45 years, typically overweight with BMI >25, gradual onset due to poor diet & or sedentary lifestyle, deficiency of insulin or insulin resistance, insulin may be required
Clinical manifestations of type 1 DM
Hyperglycemia, polydipsia, polyphagia, polyuria, weight loss, blurred vision
Generalized treatment plans for type 2 DM
Initially diet & exercise, progress to pills, then insulin
Clinical manifestations of type 2 DM
S/S development slowly & are hidden, fatigue, thirst, polyuria, recurrent infections or slow healing, obese BMI >25, blurred vision, paresthesia, yeast infection
Explain how DKA occurs in a type 1 DIABETIC
No glucose enters cells–>cells break down protein & fat–>ketones are produced–> ketones accumulate in the blood, and body tries to get rid of ketones through urine and through lungs by exhaling acetone (dka manifestation)
Why does excessive eating & weight loss occur with Type 1 DM
No glucose enters cells, body needs glucose for energy, so brain sends hunger signals which leads to excessive eating. And since cells can’t get glucose they use fat and protein for energy which causes weight loss
Why does excessive thirst happen when glucose rises in DM
Glucose spills into urine and water moves from cells into bloodstream–> frequent urination–> dehydration–>excessive thirst
Management goals for type 1 DM
Maintain blood sugar within target range, avoid fluctuations, prevent long term complications
Strategies for type 1 DM on insulin
Integrate insulin & food, consistent diet, Conventional insulin–>BID or Intensive insulin regimen: multiple daily injection/insulin pump/bolus to cover CHO intake
Goals for management of type 2 DM
Prevention–> diet & exercise, Maintain sugars within a target range by improving body’s use of glucose & preventing dangerous elevations, Prevent long-term complications
What is hypoglycemia
blood sugar less than 74 mg/dL or a sudden drop
What are precipitating factors of hypoglycemia
Too much insulin, too little food, Insulin and food intake not coordinated, Unplanned exercise, Potentiate Sulfonylurea, alcohol consumption on empty stomach
S/S of hypoglycemia
sudden onset, pallor, diaphoretic, tachycardia/palpitations, tremor, increased BP, hunger, visual disturbances, weakness, paresthesias, confusion, agitation, coma, death
Mnemonic for sugar high
hot & dry==> sugar high
Mnemonic for low sugar
cold & clammy==> need some candy
Treatment for hypoglycemia in a conscious pt
- Check Capillary blood glucose
- Verify pt is alert, oriented, able to swallow
- Rule of 15, give 15 gm CHO
- Check blood glucose again in 15 min, if less than 74, treat again and recheck BS in 15 min, continue this until desired BS met
After rule of 15 followed for hypoglycemia, what should be done next
To prevent rebound hypoglycemia, Give next regular meal, if more than 1 hour away give protein and carb like cheese and crackers
What is the treatment for a hypoglycemic pt that is unconscious
Lie them on their left side, give D 50% solution (25 mL IV over 5 minutes) or administer 1mg of glucagon IM or SC and feed when awake
What tests are used to diagnose someone with DM
1) Impaired Fasting Plasma Glucose (FPG–> NPO 8 hr) =/>126 mg/dL x 2 occasions
2) 2 hr post load OGTT (Fasting) =/>200 mg/dL
3) Acute Sx of hypo/hyperglycemia and RBS =/>200 mg/dL
4) A1C >6.5%
Impaired Fasting Plasma Glucose (+ DM result)
=/>126 mg/dL x 2 occasions
2hr post load OGTT(+ DM result)
=/>200 mg/dL
The results of a + diabtes diagnosis with Acute Sx of hypo/hyperglycemia and RBS
=/>200 mg/dL
A1C of 5.7% to 6.4%
prediabetic
A1C for a diagnosis of diabetes
> 6.5%
Who should be screened for DM
Asymptomatic high risk groups @age 30, Everyone 45 and older, repeat q3 years
Normal FBS
74-106 mg/dL
Target blood glucose after meals
less than 140 after meals (2hrs)
Target hgA1c for DM
less than 7%
Treatment of type 2 DM
5 step process:
Diet & exercise –> Monotherapy (1oral med) –> Combo with 2 oral meds only/ different classes–>3 oral meds or combo with oral meds and insulin –> insulin alone
Medication classes that stimulate pancreas to make more insulin
Sulfonylureas, Meglitinides, phenylalanine derivatives
How do alpha-glucosidase inhibitors work
slow the absorption of starches
Which classes of oral medication sensitize the body to insulin and/or control hepatic glucose production
thiazolidinediones and biguanides
Examples of Sulfonylureas
Glyburide, glipizide, glimepiride
How do sulfonylureas work, se, used in therapy
increase insulin secretion of pancreas, weight gain & hypoglycemia, Monotherapy in combo with insulin or other oral meds
How do Meglitinides work, se, used in therapy
stimulate insulin secretion of pancreas in presence of glucose rapidly & for short duration, target postprandial glycemia, SE: hypoglycemia if not taken with food, Monotherapy or combo with other oral meds
Examples of Meglitinides
(glinides) repaglinide, nateglinide
How do biguanides work
reduce hepatic glucose production and increase insulin action on muscle uptake
biguanides SE
GI effects, Vitb12 & folic acid deficiencies. lactic acidosis
Precautions with biguanides when performing diagnostic tests
withheld before contrast media for radiologic studies
Examples of biguanides
Metformin (Glucophage), ER (Glucophage XR)
Therapeutic use of biguanides
monotherapy or combo with insulin or other oral meds, also used for metabolic syndrome and POS
How do alpha-glucosidase inhibitors work
Delay carb digestion in small intestine
SE of alpha-glucosidase inhibitors
GI symptoms
Pros of alpha-glucosidase inhibitors
targets post prandial glucose, effects are not systemic, does not depend on presence of insulin to work
Therapeutic use of alpha-glucosidase inhibitors
Monotherapy or in combo with other oral meds
Examples of alpha-glucosidase inhibitors
miglitol, acarbose
Thiazolidinediones Examples
pioglitazone, rosiglitasone
Action of thiazolidinediones
increase cellular response to insulin–>muscles and adipose tissue more sensitive to insulin–>decrease resistance, effect: increased glucose uptake & suppressed hepatic glucose production
precaution of thiazolidinediones
reduce effect of OCPs, use cautiously in HF
Combo meds
sulfonylurea & biguanide
thiazolidinedione & biguanide
Rapid acting insulin
(some brand names end in -log) lispro (Humalog), aspart (Novolog), glulisine (Apidra)
Short acting insulin
regular (Humulin R, Novolin R)
Intermediate Acting insulin
NPH (Humulin N, Novolin N)
Long acting or Basal insulin
glargine (Lantus), detemir (LEVEmir)
Can detemir be mixed with other insulins and how often is it used
No it cannot be mixed with other, every 24 hours
What insulins are mixed or come as a combo
intermediate and short acting
EX Humulin 70/30 or Humalog (50/50 or 75/25)
NI for insulin administration?
Verify if need 2 nurse per policy, know FBS prior to administation, relationship to meal schedule,rotate sites, know absorption rate, watch for allergic reactions, injection technique 45 degree or 90 degree depending on pt habitus
Which insulin provides basal glucose control and how often is it given
long-acting, once daily at the same time
Rapid acting insulin onset, peak and duration
Onset: 15-30 min
Peak: 30 min to 2.5 hours
Duration 3-6 hours
Short acting insulin onset, peak, duration
Onset: 30-60 min
Peak: 1-5 hours
Duration: 3-7 hours
What are rapid and short acting insulins used for
postprandial increases in blood glucose, can be used with intermediate or long acting for optimal control
When is rapid acting insulin given
AC
When is short-acting insulin given
AC for postprandial hyperglycemia
Function of insulin
secreted by beta cells, prompted by amino acids, fatty acids, and ketone bodies, helps body store energy in the cells or use immediately
Which insulin can be used in emergencies via IV
Short acting ==> regular insulin
Why are injections for insulin given subq
to ensure basal glycemic control
Intermediate acting insulin frequency a day
once or twice daily
Onset, Peak, Duration of intermediate acting insulin
Onset: 1-4 hours, peak 4-12 hours, duration 12-24 hours
Can intermediate insulin be given for mealtime increases
NO, it has a delayed action
LOng-acting insulin onset, peak, duration
onset 70 minutes, Peakless, Duration 18-24 hours
How often is long acting insulin given?
once daily at same time, sometimes it needs to be split into 2 separate doses like if pt is noticing the dawn phenomenon
Dietary recommendations for DM
45-65% CHO, 15-20% Protein, 20-35% polyunsat fat or monounsat fats, reduced saturated fat
Are all DM diets the same, types of diets/meal planning
No individualized for each pt, Exchange lists, CHO counting, MNT, diabetic living online
DM do not need to worry about blood glucose levels when they exercise (T or F)
False, exercise effects glucose levels. It should be scheduled rather than sporadic.
What precautions should one take with exercise
check BGL prior to, during, and after exercise, bring snacks & glucose replacements, adjust insulin next time if hypoglycemia occurs
If a BS is >250 mg/dL, should a pt exercise to bring it down
No, exercise can increase BS levels higher, pt should refrain until BS is closer to expected reference range
what is DIABETIC FOOT TRIAD
Neuropathy, infection, ischemia increase a pts risk of ulcer when trauma to the foot has occured
DKA characteristics
pt is usually type 1, blood sugar >300 mg/dL, ketosis, dehydration, electrolyte imbalance
Precipitating factors of DKA
illness, infection, too little insulin, sometimes se of medications
S/S of DKA
gradual onset, Polyuria, Polydipsia, blurred vision, weakness/lethargy, malaise/HA, GI symptoms, Kussmaul respirations, hypothermia, acetone breath, dehydration, change in LOC, metabolic acidosis
Treatment of DKA
- correct F&E imbalance
- Correct acidosis
- Give insulin
Characteristics of HHS
Found in elderly, mild or undiagnosed type 2 DM, high mortality, glucose > 600mg/dL, no ketones, profound dehydration, Neurologic manifestations
Precipitating factors of HHS
infection/stress, MI, GI hemorrhage, uremia, hypertonic feeding, Drugs, poor fluid intake
Treatment for HHS
- rehydrate
- Correct F&E imbalance
- Give insulin
- Treat underlying condition
S/S of HHS
altered LOC, neurologic sx, Dry skin, and mucous membranes
Poor skin turgor, Tachycardia, Hypotension, Intense thirst
Prevention of DKA & Sick day management
drink fluid every hour (water, tea, broth, diet soda), consume carbohydrates, continue with long-acting insulin, test glucose q3-4 hours, check urine for ketones when glucose 300 mg/dL
Sick day management, when to notify MD
V or D x >6 hours, fever for several days, glucose remains high despite insulin (>240), large amount of ketones in urine
Chronic complications associated with DM
Cardiovascular complications, renal failure, amputation, blindness, nerve damage
Cardiovascular risks for DM
hyperlipidemia, HTN, angiopathy
What are some angiopathy diseases associated with DM
Macrovascular: CAD, CVD, PVD
Microvascular: retinopathy, neuropathy, nephropathy
What are other issues associated with DM
Gastropathies: delayed gastric emptying, skin changes like necrobiosis lipoidica diabeticorum and fungal infections
What is the Dawn Phenomenon
the presence of hyperglycemia upon waking, the body naturally increases GH & cortisol which increases blood sugar between hours 2am and 6 am
How do you mix insulin
clear before cloudy or Regular (short) before NPH (intermediate)
If patient is hypoglycemic and alert, what can we give to increase BS
15-20 g of rapid-acting carbohydrate like 4-6 oz of apple juice, 8 oz skim milk, 1 tbsp of honey, glucose tablets
What should be done if pt has dawn phenomenon
Long acting may be given in the evening or split into 2 doses or pt may be given pump. Instruct pt to avoid CHO before bed
What should be done if pt consistently has high FBS in am
Check blood glucose at 3 am to see if glucose is high or low.
What would a low blood glucose at 3 am indicate if pt has high glucose upon waking?
the somogyi effect
WHat is the somogyi effect
when a pt experiences low blood sugar during the night followed by a rebound of high blood sugar in the am
Sick day guidelines
Drink 8 oz/h
Monitor BG q3-4h
BS > 240, test ketones
Continue long acting insulin or oral meds
Eat 150-200 g CHO/day (drink carbs if not hungry)
When should a DM pt call MD if sick
persistent N/V or D, Mod to Lg Ketones, Temp 101.5 or fever > 24 hours, increase in BS p subsequent dose of insulin
Foot care instructions for DM
wash feet in warm water qd, dry feet well (in between toes), keep skin soft by moisturizing, inspect feet every day, ask MD how to cut nails, wear clean fitting socks, keep feet warm & dry, wear well fitting shoes, never walk barefoot, examine shoes everyday (cracks/peebles/nails)
When should you contact MD for issues with feet
As soon as notice cuts, bruises, blisters, or swelling
which insulin is cloudy
intermediate
