DM Nursing Care (NUR 324) Created by Diana Hallis Flashcards
Autoimmune destruction of beta cells in our pancreas
Type 1 diabetes
Step 1 in diabetes type 1 development
Autoantigens form on insulin-producing beta cells and circulate in the blood and lymphatics
Step 2 in diabetes type 1 development
Activation of cellular immunity and humoral immunity towards beta cells
Step 3 in diabetes type 1 development
Destruction of beta cells with decreased insulin secretion
Macrophages and T cytotoxic cells are part of __ immunity.
Cellular immunity
Autoantibodies are part of __ immunity
humoral
Beta cells overworked and cells become immune or resistant to insulin
type 2 diabetes
Type 1 more common in…
younger adults
Signs and symptoms are more abrupt in __ diabetes
type 1
Type 1 diabetes represents __ - __ % of all diabetes
5-10%
Type 1 diabetes have no __ insulin production
endogenous
Type 1 diabetes must have insulin __.
replacement
3 P’s for diabetes
Polyuria, polydipsia, polyphagia
Type 2 diabetes more common in adults and can go…
undiagnosed for years
Type 2 diabetes: Doctors most often screen based on
risk factors, not signs and symptoms
Diabetic type 2 patients are insulin __
RESISTANT
Some type 2 diabetes can need insulin __
replacement
Type 2 diabetes often treated with __ or __
oral or subcut medications
Excessive thirst
polydipsia
Excessive urination
polyuria
Excessive hunger
polyphagia
Normal fasting blood glucose
less than 126 mg/dL
To test for a fasting blood glucose the patient will have not had any food or drink in…
8 hours
Casual blood glucose normal level
less than 200 mg/dL
High urine ketones is associated with
Hyperglycemia
What level of urine ketones is associated with a medical emergency
Over 300 mg/dL
__ and __ may be elevated in patients with diabetes (lipids)
LDL and triglycerides
Diabetics may have low lipid __ levels
HDL
OGTT
Oral glucose tolerance test
Oral glucose tolerance test is commonly used to diagnose
gestational diabetes
To test for a oral glucose tolerance test, you must draw a
fasting glucose prior to testing
After the patient consumes oral glucose in a GTT, the patient’s glucose levels are obtained every…
30 minutes until 2 hours post consumption
Fasting glucose in an OB patient prior to GTT should be
less than 110 mg/dL
At one hour after oral glucose consumption for the GTT, an OB patient’s blood glucose should be
less than 180 mg/dL
At two hours after oral glucose consumption for the GTT, an OB patient’s blood glucose should be
less than 140 mg/dL
HbA1C
Glycosylated Hemoglobin
HbA1C is the indicator for AVERAGE glucose level over the…
past 120 days (3 months)
HgA1C is most commonly used for
diagnosis of diabetes and intervention evaluation
Normal A1C
4-6%
A1C diabetic level
6.5% or greater
For those diagnosed with diabetes, what is the acceptable reference A1C level?
6-8%
What is the target A1C level for those diagnosed with diabetes?
7%
A1C normal level
About 5
A1C pre diabetic level
5.7-6.4
A1C diabetic range
6.5 or greater
Fasting plasma glucose normal range
Less than 100
Fasting plasma glucose pre diabetic range
100-125
Fasting plasma glucose diabetic range
126 or higher
Oral GTT normal range
139 or below
Oral GTT pre diabetic range
140-199
Oral GTT diabetic range
200 or above
If in the pre diabetic range for A1C, GTT, or fasting glucose this is indicative of
the possible development of diabetes
To be diagnosed with diabetes you must have at least ONE of the following:
1) A1C 6.5 or higher, 2) Fasting blood glucose of 126 mg/dL or higher, 3) GTT 12 hr level of 200 mg/dL, 4) Classic symptoms of hyperglycemia, random GTT greater than 200, or hyperglycemic crisis
Classic signs of hyperglycemia
3 P’s or unexplained weight loss
If someone has labs indicative of diabetes you would
repeat labs before diagnosing
Lab diagnostic criteria are more common to diagnose
Type 2 diabetes
To diagnose type 1 diabetes…
Islet cell autoantibody testing
How to evaluate the effectiveness of treatment for type 1 diabetics
A1C
Impaired GTT, impaired fasting-glucose, or both
Pre-diabetes
There are typically no symptoms associated with pre-diabetes however,
long-term damage can already by occurring
What can we do for a patient who is pre-diabetic?
TEACH! Lifestyle modifications, blood glucose and A1C monitoring, symptom monitoring
Symptoms of diabetes
Fatigue, slow wound healing, getting sick frequently
Diet modifications for the pre-diabetic
Avoiding sugary foods and monitoring carbohydrate intake
Oral medications are started at a low dose and increased gradually based on
A1C levels and fasting glucose levels (usually AM)
Oral medications are most frequently used in
type 2 diabetics
Oral diabetes medications work in 3 main ways
Reverse insulin resistance, increase insulin production, or increase hepatic glucose production
In hospitalized patients taking oral diabetes medications…
Oral medications are stopped and they are put on insulin while acutely ill
Putting patients on insulin while in the hospital can cause
Increased anxiety, so you must explain to the patient why you are using the insulin and that they will resume their medication when going back home
You may need to hold metformin before
certain procedures
When a diabetic patient is actually ill they will often be started on
Oral or IV steroids
What do steroids do to blood sugar?
Increase it, dramatically
If a patient is prescribed steroids they may need to… (3)
1) Alter insulin regimen at home, 2) Adjust basal dosage, 3) increase scheduled doses
Illness naturally causes body
Stress
Stress on the body to release more hormones which causes the body to release more
Glucose
If a diabetic patient is ill, they may need to
Check blood glucose more often and adjust insulin regimen
Diabetic patients are more prone to go into __ or __ when sick
DKA or HHNS
If a diabetic patient has a stomach illness, they may not be eating or drinking. As a nurse you should…
Tell them to check their blood sugar more often and treat as necessary
Diabetics still need to do what when they are sick to their stomach
Take their oral medications
Nursing teaching point: Tell diabetic patients to do what when they are sick
Notify their HCP
Nursing teaching point: Tell diabetic patients to monitor their blood glucose more frequently when sick, maybe every
2-4 hours
Nursing teaching point: Diabetics when sick need to continue to __ & __
Take medications and stay hydrated
Nursing teaching point: When diabetics become ill, they need to maintain their
Carbohydrate needs, either through oral food or liquid such as gatorade or pedialyte
Nursing teaching point: When diabetics are sick they need to…
REST!
Tell diabetics to call HCP if urine positive for…
Ketones
Tell diabetics to call HCP is their blood sugar is greater than…
250 mg/dL
Tell diabetics to call HCP is fever greater than __ and not responding to __
Fever greater than 101.5 and not responding to Tylenol
Tell diabetics to call HCP if they are feeling…
confused, disoriented, or have rapid breathing
Tell diabetics to call HCP is they are consistently having these GI symptoms
nausea, vomiting, diarrhea
Tell diabetes to call HCP is they are unable to tolerate
liquids
Tell diabetics to call HCP is their illness lasts longer than
2 days
Critical part of diabetes management
the patient’s self-monitoring of blood glucose
Frequently of blood sugar checks depends on these factors (5)
1) glycemic goals, 2) type of diabetes, 3) medication regimen, 4) access to supplies and equipment, 5) patient’s willingness
If a patient is newly diagnosed and/or only on oral medications for diabetes, they should check their blood sugar
Once in the morning and once before they go to bed
Patients who are on insulin should check their blood sugar
Multiple times per day
Continuous glucose monitoring is more commonly used in…
Type 1 diabetes
However, continuous glucose monitoring can be very
expensive
With continuous glucose monitoring, the patient can use
An insulin pump, or respond to readings with medications
In healthcare, we do our best to mimic the body’s
normal insulin production
How do we best mimic normal body insulin production?
Combine basal insulin with mealtime insulin
Combining basal insulin with mealtime insulin is called a
“basal-bolus” regimen
What type of insulin is used for bolus
Rapid or short acting insulin
What type of insulin is given once a day, typically in the morning
Basal
Typical basal-bolus insulin regimen
4x, basal at bedtime, and bolus before each meal
Basal insulin
Glargine
Bolus insulin
NovoLog or Regular
Rapid acting insulin
lispro, aspart, glulisine
lispro
Humalog
aspart
NovoLog
glulisine
Apidra
Short acting insulin
Regular
Regular insulin types
Humulin R or Novolin R
Intermediate acting insulin
NPH, or Humulin N or Novocain N
Long acting insulin
glargine, detemir, degludec
glargine
Lantus
detemir
Levemir
degludec
Tresiba
Inhaled insulin
Afrezza
Onset of rapid acting insulin
10-30 minutes
Peak of rapid acting insulin
30 min - 3 hrs
Duration of rapid acting insulin
3-5 hrs
Onset of short acting insulin
30 mins - 1 hr
Peak of short acting insulin
2-5 hrs
Duration of short acting insulin
5-8 hrs
Onset of intermediate acting insulin
1.5-4 hrs
Peak of intermediate acting insulin
4-12 hrs
Duration of intermediate acting insulin
12-18 hrs
Onset of long acting insulin
0.8-4 hrs
Peak of long acting insulin
less defined or no pronounced peak
Duration of long acting insulin
16-24 hrs
Onset of inhaled insulin
12-15 mins
Peak of inhaled insulin
60 mins
Duration of inhaled insulin
2.5-3 hrs
Most commonly used rapid acting insulin type
lispro (Novolog)
Most commonly used regular or short acting insulin type
human regular (Novalin R/Humalin R)
Most commonly used intermediate acting insulin type used
NPH (Humalin N)
Most commonly used long acting insulin type
glargine (Lantus)
Typically providers use a combination of
rapid, regular and long acting insulin regimens
Insulin is a…
high alert medication
First, before you ever give an insulin injection you need to know
the patient’s current glucose
Second, you must check the.. (2)
1) diet order, 2) patient’s oral intake tolerance
If a patient is on a scheduled insulin regimen but the patient isn’t eating…
You may need to hold the insulin and contact the provider
What do you do if your patient is NPO but is scheduled for insulin?
Hospital policy whether you give 50% or hold
When giving insulin it’s very important to know these three things
Hospital policy, patient’s blood sugar, and if patient has been eating
If you give insulin and your patient throws up, what may happen?
They may become hypoglycemic
What is the MOST important point for patients on insulin?
Teaching!
Many times, diabetics understand their bodies…
better than we do, listen to them!
For newly diagnosed patients you should…
Observe their self-administration of insulin
What is crucial for insulin injections?
TIMING! Understand when it is administered, when it will take effect, and when you might see adverse reactions such as hypoglycemia
Hypoglycemia can…
Kill people
Hypoglycemia can cause __ if it is not treated
seizures
Blood sugar less than 70
Hypoglycemia
If blood sugar is greater than 70, especially in an uncontrolled diabetic
they can still have symptoms of hypoglycemia
Symptoms of hypoglycemia (10)
Sweating, blurry vision, dizziness, anxiety, irritability, hunger, shakiness, tachycardia, headache, fatigue
After checking airway and circulation, if a patient is unresponsive you should check
blood sugar!
Hypoglycemic patients can feel like they are going to…
die
To treat hypoglycemia, first thing you do is
confirm they are hypoglycemic based off blood glucose
Follow rule of 15 for hypoglycemia
If sugar is low, give them 15 grams of carbohydrates
Carbohydrates sources to give a diabetic experiencing hypoglycemia
15g of simple sugars such as 4 oz juice or regular soda, or 3 glucose tabs
You should avoid simple sugars that are paired with
Fat because it delays absorption (such as a candy bar)
If the patient is unresponsive they will not be able to swallow so…
the rule of 15 is not appropriate
15 grams of simple carbohydrates will increase the blood sugar by
50 mg/dL in about 15 minutes
Also equivalent to 15 grams of simple sugars
1 tbs of honey or 5-8 lifesavers
Once their blood sugar has risen after following the rule of 15, then you encourage
the patient to eat a regular meal
If after 15 minutes the patient’s blood sugar is still less than 70…
Repeat the rule of 15 process
If patient is unresponsive and cannot swallow you can give…
IM glucagon or D50 (25-50ml) IV
At home a diabetic can use __ if unable to swallow
a jelly SL that will absorb even if unable to swallow
Other complication that can occur with insulin administration
hyperglycemia
Hyperglycemia is typically due to…
illness, infection, self-management issues, stress
What does a patient look like who is extremely hyperglycemic?
Weakness, fatigue, blurry vision, headache, nausea, vomiting, diarrhea
A patient with hyperglycemia will have a blood sugar of
250, even greater than 300
For hyperglycemia, check urine for
ketones!
To treat hyperglycemia administer
Insulin, have patient drink fluids, and educate on prevention
Greater than 300 blood sugar
Is considered an emergency and patient should go to ER
Greater than __ ketones, let the provider know
300
Crisis situations for hyperglycemia
DKA, and HHS (Hyperglycemic hyperosmolar syndrome)
DKA and HHS are conditions that are
life-threatening due to uncontrolled hyperglycemia
Release continuous infusion of subcut insulin
Insulin pumps
Insulin pumps use __ or __ types of insulin
rapid acting or regular
With insulin pumps patients are receiving a continuous
basal infusion
Patients have the ability to alter the basal rate of their inulin pump and also
can give themselves a bolus based on finger stick reading
With an insulin pump you still need to check your insulin at least
4x per day, breakfast, lunch, dinner, and before bedtime
Most users of insulin pumps use monitors that are connected to their
phones so they can constantly see what their blood sugar is
If a patient with a pump is admitted…
Their pump is deactivated and they are switched to a sliding scale insulin regimen so we can gain greater control of their levels
Problems to be aware of for insulin pumps:
Infection at insertion site, increased risk for DKA if pump malfunctions, and high cost
You cannot __ or __ with insulin pumps
Swim or take a bath, but you can take the pump off and do those activities
Chronic complicated of diabetes (long term hyperglycemia) are related to…
end-organ disease from chronic damage to blood vessels
chronic damage to blood vessels is called
angiopathy
Angiopathy is typically what causes __ in patients with diabetes
death
Cardiovascular related death due to angiopathy
68%
Stroke related death due to angiopathy
16%
Damage to large vessels such as coronary arteries, peripheral vascular, or cerebral vascular
Macrovascular angiopathy
Damage to capillaries such as retinopathy, nephropathy, or neuropathy
Microvascular angiopathy
Women with diabetes have __x the risk of CVD than those without
4-6x
Men with diabetes have __x the risk of CVD than those without
2-3x
Nursing teaching points for macrovascular disease (CVD)
Stop smoking, control blood pressure, modify high fat diet
If a patient has metabolic syndrome, their risk of death is
very much increased
Damage to the retina related to chronic hyperglycemia
Retinopathy
Damage to small blood vessels in the kidneys
Nephropathy
Nerve damage due to metabolic imbalances associated with hyperglycemia
Neuropathy
Retinopathy, nephropathy, and neuropathy are examples of
microvascular complications
Diabetes is the leading cause of end-stage
renal disease
Much more likely to get kidney disease if you have…
Hypertension AND diabetes
__% of diabetics have some type of neuropathy
60-70%
Major contributor to amputation
diabetic neuropathy
Only prevention for diabetic neuropathy
Early screening and keeping blood sugar under control
Neuropathy is typically in that patient’s
feet and lower extremities
Common complications of neuropathy
Foot ulcerations and lower extremity amputations
What causes the complications of neuropathy?
Loss of protective sensation, prevents patients from being aware that an injury has occurred
Patients with neuropathy can become
Neuroischemic and loose bloodflow
Because of the loss of blood flow, the patient’s wound will become
Ischemic and amputation will be needed
Diabetic foot care is the
nurse’s job!!
Wash feet daily with…
mild soap and warm water after testing water with hands
Pat feet dry especially…
between toes
Inspect feet daily for…
cuts, swelling, blisters, red areas
Use __ to prevent dry skin and cracking
lanolin
Do not put lanolin
between toes
You can use __ of sweaty feet
mild foot powder
Do not use __ __ to removed calluses or corns
commercial remedies
Clean any cuts with
mild soap and water
Do not clean cuts with
iodine, alcohol, or adhesives
Tell patients to report any
skin infections or non-healing sores
You should trim nails
after shower or bath
Cut nails evenly with
rounded contours
Separate overlapping toes with
cotton
Educate patient to wear shoes with
soles and to shake out before wearing
Educate patient to never go
barefoot, wear open toed or open heeled or plastic shoes
Educate patient to wear socks that are
clean and absorbent
Educate patient not to use
hot water bottles
What type of diet is best for diabetics
Balanced, high fiber, low fat, low cholesterol
Encourage patients to each complex carbohydrates such as
grains, fruits, vegetables, legumes and milk
Carbohydrates still need to be about __ of total caloric intake
45-65%
Teach patients to limit simple carbohydrates such as
pasta and bread
Teach diabetic patients to eat a diet low in __ and __ fats
saturated and trans
Best type of fats to eat
polyunsaturated, can be found in fish and nuts
Crucial for diabetic patients. Can improve carb metabolism and lower cholesterol
Fiber!
Good sources of fiber
Beans, vegetables, oats, whole grains
15-20% of diet
Protein, preferably from lean meats
Limit alcohol to
1 drink daily for women, 2 drinks daily for men
Alcohol turns into…
Sugar and can increase blood sugar
Alcohol can also have intense
rebound effects and dramatically lower blood sugar as well
Alternative sweeteners are
acceptable alternatives to sugar for patients with diabetes
Consistent carb diets or
CC
CC1
60g of carbs/meal, 1500 calories
CC2
75g of carb/meal, 1800 cals
CC3
90g of carb/meal, 2200 cals
Carb counting is common, especially for
Type 1 diabetics
Exercise will __ blood sugar
lower
It’s best to exercise after
meals
Tell patients not to exercise if blood sugar is
less than 80 or higher than 250
Teach patient to eat a carbohydrate snack
prior to a high intensity workout
Teach patient while exercising to wear a
medical alert bracelet, so if they pass out people around them will know what’s going on
Teach patient to always think about their
feet! Teach them to wear good fitting shoes
Stress such as surgery can
increase blood glucose levels
Common for a controlled diabetic to become
uncontrolled while admitted to the hospital and this can upset them
Wound healing is __ in patients with diabetes
impaired, can take longer and at higher risk for infection
Integumentary concerns associated with uncontrolled hyperglycemia
diabetic dermopathy, acenthosis nigricans, necrobiosis lipidica diabeticorum
Diabetic dermopathy
Reddish-brownish spots, usually not the shins
Acanthosis nigricans
Brown/black thickening of skin, often seen in skin folds
Necrobiosis lipoidica diabeticorum
Red patches around the blood vessels
