Drugs for DM Flashcards
Glucose essential for cellular function
Insulin secreted from beta cells of pancreas opens cell to allow glucose entry - under norm circumstances releasing insulin at both rates
Counter-regulatory hormones released with low blood glucose levels - working to elevated BG because dangerously low - affects lot func in body
Regulation of BG review
Normal BG in range 70-120 mg/dl maintained by insulin and counter-regulatory hormones - body maintaining BG and regulating with insulin and other counter-regulatory hormones
Glucose essential for cellular function
Basal rate (little bit insulin all time to keep BG in target range at all time) and bolus (with meals) - glucose when sharply elevated as start digest food and break down and get more glucose in bloodstream; imp in understanding types insulin regimens pats on - common giving basal and bolus with meals - doing to mimic what norm pancreas does
Insulin secreted from beta cells of pancreas opens cell to allow glucose entry - under norm circumstances releasing insulin at both rates
Fast release of glucose
Slow release of glucose
Counter-regulatory hormones released with low blood glucose levels - working to elevated BG because dangerously low - affects lot func in body
Glucagon from alpha cells of pancreas
Epinephrine from medulla of adrenal glands
Fast release of glucose
Cortisol from cortex of adrenal glands
Growth Hormone from anterior pituitary gland
Slow release of glucose
Fasting blood glucose > 126 mg/dL
HbA1c > 6.5% - avg BG over past 3 months; looking at sugar on RBC - tells how well controlling DM; tell avg BG is: 10-12 A1C - BG running elevated all time - problematic and higher risk for developing comorbidities
Diagnostic criteria for diabetes
Goals of interventions:
Type 1 DM –
Type 2 DM –
Pharmacology overview for diabetes
Control blood glucose level
Prevent complications
Goals of interventions:
Lifestyle modifications with pharmacological therapy
Prevent complications
patho: no insulin
Beta cells destroyed and no insulin secreted
Insulin - need exogenous admin; all on some kind of insulin
Typ Combination:
Long-acting
Rapid-acting
Type 1 DM
patho: some insulin
Some Insulin secretion initially and as pancreas working to some extent put on lot diff drugs; lot options available when pancreas still working to supplement; eventually pancreas burns out with this and eventually get to point where need exogenous insulin - require insulin for adequate BG control
Oral agents
Non-insulin injectable(s)
Insulin
Long-acting
Rapid-acting
Type 2 DM
Replacement of endogenous insulin - insulin giving to pats is synthetically made and made in lab - drawing med up in vial, contained pen, in cassette in pump
Actions of insulin: Promote cellular uptake of glucose - major actions: glucose get into cells since need it for energy, amino acids, potassium - moves it into cells (AE: hypokalemia); protein synthesis, glycogen formation/storage (helps store extra glucose in liver for later use), fatty acid storage
Body sys/organ not need insulin: brain; see neurologic symp in DM pat means BG really low
MoA: - Class: insulin
T1DM, T2DM, DKA (typ give regular insulin only via IV drip), hyperkalemia (not often - help facilitate movement K into cells)
Indication: - Class: insulin
Hypoglycemia - giving insulin exogenously trying mimic pancreas norm do but it is an educated guess in terms of what pat insulin needs but not foolproof - sometimes get too much or need not ask much so need know risk for this is here; lipohypertrophy (changes of fat cell at injection site - risk reduced if rotate injection sites often to avoid changes - feel hardening), lipodystrophy at injection site (changes at injection - changes of fat cell at injection - risk reduced if rotate injection sites often to avoid changes - feel hardening); diarrhea, hypokalemia - can happen
AE: - Class: insulin
several types of insulin - Act diff and affects how monitor pat
Prototypes - Class: insulin
Lispro
Aspart
Onset, peak duration - meaningful to how intervene with pat
Onset rapid acting about 15 minutes; peak: 60 min; duration: 4 hours
High alert med - diligent in monitoring pats
Route: via Subcutaneous injection - insulin has be given this way so not broken down by body before body uses it when taken orally; can self-admin
Dose: Up to 4 x’s daily (meals and HS) - ordering depends on what BG do
Highest Risk for pat become hypoglycemic at peak action time of drug; when most insulin exerting action - BG lowest
Insulin: rapid acting
Assessment - general assessment and assess comorbidities
Always check blood glucose prior to administration - never miss this when admin insulin; about give them potent amount of insulin and have no idea what BG is before give drug is a shot in dark
Admin med (rapid acting insulin) 0-15 min prior to start of meal - onset 15 min so if give insulin and not get meal tray for awhile getting insulin and working but glucose not present and not have glucose from meal so higher risk for hypoglycemia; make sure not have too much med before glucose enters bloodstream and have mismatch
Verify orders, follow facility protocol for admin - all have unique orders; carefully read orders; make sure know protocol for doing safest thing for pat
Hold parameters
Nursing: rapid acting insulin
Prior to eating - dosing based on fasting BG - dosing based on not having eaten in sev hrs; after eaten BG falsely elevated and results in too much insulin for pats
Always check blood glucose prior to administration - never miss this when admin insulin; about give them potent amount of insulin and have no idea what BG is before give drug is a shot in dark
Rotate injection sites
Admin med (rapid acting insulin) 0-15 min prior to start of meal - onset 15 min so if give insulin and not get meal tray for awhile getting insulin and working but glucose not present and not have glucose from meal so higher risk for hypoglycemia; make sure not have too much med before glucose enters bloodstream and have mismatch
Set dose (i.e. 5 units with meals) - orders are diff; regardless BG give units unless too low (for hold parameters) give set dose; safer for certain pop; can yield less errors - elevated not as bad compared to hypoglycemia
Sliding scale (units to admin based on BG level; add to routine dose) - most pats on this; sometimes on set dose with sliding scale/just sliding scale
Verify orders, follow facility protocol for admin - all have unique orders; carefully read orders; make sure know protocol for doing safest thing for pat
In orders
Do not give rapid insulin if BG less than…….# (check order) - afraid bottoming BG
Consider NPO status - order pat for hold parameters and hold parameters - if not eating and BG close to hold parameters nursing judgement says hold insulin; even tho BG high - pat not eat anything not get glucose so if give insulin and NPO BG only go down; risk for hypoglycemia greater; look lot diff things to keep pat safe with insulin admin
Hold parameters
Sig one for risk of hypoglycemia
Quickest onset, highest peak, shortest duration
Rapid activity -
Regular insulin
Onset: slower; 30-60 min
Peak: later; 2-3 hours
Duration: Longer acting; 6-10 hrs
Given either SQ/IV
Only one give IV: given as IV drip typ - on pump and check BG q1hr
Risk for low BG at peak action time - 2-3 hours after admin
Short -
Glargine
Onset: gradual
Peak: none
Duration: up to 24 hours
Trying to mimic basal insulin rate that pancreas normally do
Route: SQ
Lower risk low BG
1-2 times daily (12-24 hrs) - typ admin once a day but sometimes bid - high amounts because sig amount of volume and break it up because of volume
Basal insulin
Gradual onset; no peak because acting as basal insulin
Long
Rapid activity -
Short -
Long
Many pats on multiple insulin - on long-acting (once a day) act as basal and rapid-acting take with meals and sometimes HS - take when BG spike after meals to help facilitate movement BG into cells; sometimes on one insulin if new to insulin and just starting insulin therapy; T2DM: not always require high amounts insulin right away, give insulin in supplement in addition to other oral/non-insulin injectable agents; most on both
Trying to mimic norm action pancreas
Insulin therapy comparison
Insulin by syringe
Insulin by pen
Insulin pump
IV insulin drip
Insulin delivery devices
Special insulin syringe - looked at number units
Widely used; inexpensive
Multi-dose vial
Syringe one time use ONLY
Insulin by syringe
Keep unopened vials at house and keep those refrigerated (cool, dark, place) until expired; once open vials, keep at room temp for up to 30 days - imp edu piece for pats that storing insulin properly and not using longer 30 days once sitting at room temp; not have keep one using in fridge
Draw up from vial
Not give insulin cold; sit out - not prob; good idea take out fridge day before use it so room temp so not giving it cold
Multi-dose vial
Pre-filled syringe
Multi-dose syringe – disinfect with alcohol
New needle attached for each use
Prime pen first; then dial for dose
Insulin by pen
Med stored in pen and dial on end; screw on needle should be alcohol wipe to prevent infection; put on needle and dial up units and prime up pen to get rid air so drug there and ready for admin and dial up number units then push top pen down once in skin - take needle off and in sharps then have pen
Lot easier for pats
Less errors
Not utilized as much - expensive
Prime pen first; then dial for dose
Infusion set insertion device
Insulin reservoir
Frequent BG monitoring
Very expensive
Insulin pump
Inserted Cannula via needle into SQ tissue and tubing - change every week/so where rotate insertion site; pump has all insulin in it; programmable and very individualized; some pumps speak to glucose readers; can read BG and dose based on BG
Superior for BG control - computer monitoring BG and admin insulin and alerts when BG too low
Risk for infection at insertion site
Infusion set insertion device
Slow insulin release + bolus (rapid or short acting insulin) - controls BG with rapid acting so small amounts all time and bolus with meals
Insulin reservoir
Continuous glucose monitoring communicates with pump
Frequent BG monitoring
In-pat; pump and regular insulin in bag and program how many units on pump to be admin to pat so admin continuously; pat on insulin drip check BG hourly
Indications -
Peripheral or central line
IV insulin drip
critically ill; higher risk scenarios where tight glucose control needed
Diabetic ketoacidosis
Hyperosmolar state
Critical care (ICU)
Peri-operative period
NPO type I diabetes
Labor and delivery
Glucose exacerbated by high dose glucocorticoid therapy
TPN
Indications -IV insulin drip
Insulin on IV pump to deliver continuous drip of medication based on BG level
BG checked hourly - change insulin drip based on BG levels qh
Standing orders
Peripheral or central line -IV insulin drip
Not used in T1DM because they need insulin
Mechanism of actions - variety actions that meds have; many diff classes from oral to non-insulin injectables
May be used in combination or with insulin to achieve BG targets - common; Many times on 1+ med to control BG
Many new drugs being developed for treatment of T2DM - reliant on insulin discontinue other meds; disease more adv or got severe illness making BG hard to control
Non-insulin agents: T2DM only
Increase insulin release
Decreased glucagon release
Slow GI absorption of glucose
Block glucose reabsorption in the kidneys (excrete more glucose in urine)
Gen well tolerated
Mechanism of actions - variety actions that meds have; many diff classes from oral to non-insulin injectables
First line treatment for diabetes
increases insulin sensitivity - increases receptor that insulin attachs to and their site sensitivity so the insulin from pancreas secreting works better to help facilite movement into cells = about receptor sites; decreases hepatic glucose production and decreases GI glucose absorption - 3 things to help with elevated BG in T2DM
3 MoA: - Class: biguanides: prototype: metformin (glucophage)
T2DM
Indications: - Class: biguanides: prototype: metformin (glucophage)
oral
Route: - Class: biguanides: prototype: metformin (glucophage)
GI effects (n/v/d) - seen first couple weeks - typ better over time - common; lactic acidosis - metformin is excreted by kidneys (like most meds) but drug really unchanged by liver and so kidneys excrete med in unchanged form so can be more toxic to kidneys and puts pat at risk for AKI and with AKI risk lactic acidosis because kidneys not working appropriately - this AE is RARE
AE: - Class: biguanides: prototype: metformin (glucophage)
Low risk for hypoglycemia - can take it safely; Hold 2 days prior and 2 days after IV contrast (risk AKI) - rule, IV contrast very toxic to kidneys - taken 2 things together increases risk AKI and lactic acidosis so hold metformin before and after IV contrast and one reasons why d/c so can have any IV contrast when in hospital; this is nephrotoxic and so is IV contrast
Nursing: on oral drugs vs insulin - Class: biguanides: prototype: metformin (glucophage)
on oral drugs vs insulin because not checking on as much on oral
BG monitoring sig diff - Class: biguanides: prototype: metformin (glucophage)
Was first gen but phased out because sig AE - not well tolerated and sometimes deadly
increases insulin receptor sensitivity and increases insulin secretion - target pancreas to secrete more insulin - need working pancreas for this med to work so not appropriate for T1DM and also need take with meal; decreases hepatic production glucose
MOA: - Class: sec gen sulfonylureas; prototype: glipizide (glucotrol)
oral
Route: - Class: sec gen sulfonylureas; prototype: glipizide (glucotrol)
Sulfa allergy -sulfonylureas: Speaks to chemical makeup in name; can cause allergic rxn
Caution: - Class: sec gen sulfonylureas; prototype: glipizide (glucotrol)
Hypoglycemia (puts BG into cell and increased insulin secretion), skin rash, upset stomach; suffer from hypoglycemia more likely if not eating much: low calories, not as much glucose; exercise helps facilitate uptake into cells - prolonged exercise, alcohol, other DM meds (multiple meds to lower BG), older adults
AE: - Class: sec gen sulfonylureas; prototype: glipizide (glucotrol)
Take with meal since secretes more insulin means more insulin in bloodstream as med broken down and as food digested and BG rising so more effective
Nursing: - Class: sec gen sulfonylureas; prototype: glipizide (glucotrol)
Largely unchanged for diabetics regardless meds unless on insulin then have monitor diff with BG and given timing insulin
Physical assessment/exam s/s complications of diabetes (check feet and looking for neuropathy), comorbidities
BG prior to administration of ANY insulin - not on insulin order might change - may just be daily if non-insulin meds; but always with insulin check BG
BG periodically and PRN for non-insulin agents
Review/monitor labs
Nursing care plan: assessment
Complete blood count (CBC)
Complete metabolic panel (CMP)
HbA1c and monitor lipids
Review/monitor labs
Kidney function (uncontrolled BG) - make sure kidneys still functioning as should because DM one major causes for CKI
Complete metabolic panel (CMP)
Glucose control
Cardiovascular complications - big relationship
HbA1c and monitor lipids
Risk for unstable blood glucose - hypoglycemia - one major issues think about esp if on insulin
Imbalanced nutrition
Disturbed sensory perception
Risk for infection
Nursing care plan: diagnsis and outcomes - Example ND:
Adequate BG control; absence hypoglycemia
Appropriately Demonstrate ability insulin admin
Verbalize appropriate diet should follow
Therapeutic effects
Limited adverse effects/avoid hypoglycemia
Adequate understanding of disease/med mgmt
Expected Outcomes: - Nursing care plan: diagnsis and outcomes
Control of BG levels, stable Hgb A1c, limited complications
Therapeutic effects
Pat understand what target BG control
Timing of insulin and importance; know to rotate injection sites if SQ
Store unopened insulin vials in cool, dry place away from sunlight (fridge)
Adherence to regime, diet, complications/comorbidities, lifestyle modification; compliance imp
Signs and symptoms hypoglycemia and how to treat
Interventions/Education: - Nursing care plan: interventions
Effectiveness of medication
Compliance
Nursing care plan: eval
See if med doing what want to do - re-eval labs; re-eval BG - suspect hypoglycemia; eval teaching - return demonstrate, understand how take meds
Adequate glucose control:
Adverse effects
Teaching (was it effective?)
Effectiveness of medication
Hgb A1c: < 8.0; Fasting blood glucose: < 126 mg/dL
Adequate glucose control:
Microvascular and macrovascular complications
Absence of comorbidities/disease progression
Signs/symptoms of hypoglycemia
Especially at peak action time of insulin!
Adverse effects
Huge with DM; not uncommon for pats cut doses in half because cannot afford it
Pats prescribed things cannot carry out - imp to screen if can do what prescribed and adhere to regimen as part of compliance
Cost
Compliance
Children
Adults
Older Adults
Pregnancy
Hospitalization
Antidiabetic agents: drug therapy across the lifespan
Challenge to balance diet, activity, growth, stressors, insulin
Teenagers desire normalcy; metabolic changes
Metformin only oral drug approved for age 10+
If on insulin - big challenge; changes life in terms now monitor BG, not eat certain things that friends are eating and is hard for children; challenge as older and hormone changes
Children
Need extensive education on disease process and management
Compliance with medications
Adults
Think about all other/More comorbidities complicate disease process and treatment go along with DM
Presence of vision or coordination impairment- may impact ability to draw and deliver insulin
Higher risk of hypoglycemia in certain situations
Make sure can carry out regiment prescribed
Older Adults
Gestational diabetes is screened at 24-28 weeks
Insulin is drug of choice during pregnancy - has best glucose control and little risk to fetus in terms crossing barrier (category B)
Pregnancy
When pats stressed in hospital increased cortisol released and one actions is releasing more glucose so get elevated BG which may mean diff treatment plan in hospital than at home
Stress reaction elevates BG levels (cortisol)
May require different treatment plan than home in acute care setting (i.e., insulin during hospitalization when on oral at home)
Close monitoring, pt. education, stress relief
Hospitalization
acutely more dangerous than hyperglycemia - need appropriately act in timely manner
Become hypoglycemic for Variety reasons; educated guess on insulin so must monitor closely
Cause:
Clinical Manifestations
Hypoglycemia:
Too much insulin or other antidiabetic agents
Too little food and gave insulin - decided not eat food; know how much ate - if not eat much should know when go back and reassess at peak action time
Excess physical exercise
Cause:
“Cool and clammy; need some candy”
Cool, clammy skin, tremors, headache, hunger, irritability, change in LOC
Progression: Hypotension, tachycardia, fainting, seizures, coma, death
Clinical Manifestations
Conscious Patient (able to eat): BG <70
Unconscious Patient: BG < 50
Hypoglycemia: management (see institution’s protocol)
Give some kind of juice/rapid acting sugar
Rule of 15
Conscious Patient (able to eat): BG <70
Give patient 15 g rapid-acting simple carbohydrate (sugar)
Ex: 4 Glucose tablets; 3 tsp of sugar; ½ c juice (most common); 1 c milk; 4 oz. soda pop - get glucose up quickly
Give intervention to make sure came up if not above where want be repeat process
Recheck blood glucose in 15 min. To make sure came up
Repeat above until BG > 80
Once > 80, recheck BG in 1 hr. call PCP < 70- once stablized alert PCP that became hypoglycemic because may need change orders
Rule of 15
Cannot take anything orally - IV/SQ/IM
Interventions; recheck BG; repeat until BG stable; call PCP and let know what happened
IV: Administer 50 ml D50 IV
No IV: admin Glucagon 1 mg SQ or IM; turn pt. on side; start IV
Recheck BG in 15 min.; then call primary care provider for further orders
Repeat above until BG > 80
Once pt. able to swallow, give 30 grams carbohydrate
Recheck BG in 1 hr.; if BG < 70 call primary care provider
Unconscious Patient: BG < 50
Accelerates the breakdown of glycogen to glucose in the liver, causing an increase in blood glucose levels; helps breakdown storage of glycogen to glucose - facilitate process to elevate BG in bloodstream
MoA: - Glucose-elevating agents: prototype: glucagon
IM or SQ - unable eat/unconscious
Route: - Glucose-elevating agents: prototype: glucagon
Happens quickly
1 min; peak: 15 min; duration: 9-20 min.
Onset: - Glucose-elevating agents: prototype: glucagon
Hyperglycemia (really elevate BG - unconscious and now hyperglycemic not super concerned but is better than were), rebound hypoglycemia - cont check pat: increases BG for short period but still risk for additional episodes of hypo depending on why happened in first place so must cont monitor
AE: - Glucose-elevating agents: prototype: glucagon
Administer SQ/IM if no IV access for severe hypoglycemia (per protocol)
Give supplemental carbohydrate to replenish depleted glycogen stores once conscious and able to eat; take extra glucose and store for later use and want able build up storage again so easier treat hypoglycemia later on
Monitor: VS, LOC; BG (rebound hypoglycemia)
Not have IV this what go to and if unconscious/NPO
Nursing: - Glucose-elevating agents: prototype: glucagon
IV access give this
Giving sugar water - highly concentrated of sugar
increase circulating blood glucose
MoA: - Glucose-elevating agents: prototype: IV D50W
IV push over 2-5 minutes - typ not hard prob because hard push viscous liquid through IV from big syringe
Route: - Glucose-elevating agents: prototype: IV D50W
minutes - increase BG quickly because putting sugar right into bloodstream
Onset: - Glucose-elevating agents: prototype: IV D50W
hyperglycemia (not too worried because pat was severely hypoglycemic); electrolyte disturbances, hyperosmolarity; localized phlebitis, localized tissue necrosis – must have patent IV and in right place - if have have central line/PICC line accesses would be best - can give peripheral IV but make sure functioning appropriately and no probs and assess site afterwards to make sure nothing happened
AE: - Glucose-elevating agents: prototype: IV D50W
Admin IV (need patent IV) for severe hypoglycemia (per protocol)
Give supplemental carbohydrate when pt. able to safely swallow to replenish depleted glycogen stores
Monitor: VS, LOC; BG (rebound hypoglycemia)
Nursing: - Glucose-elevating agents: prototype: IV D50W
Assessment:
Intervention:
Reassessment:
Prevention/education:
Nursing management of hypoglycemia
S/S hypoglycemia, check BG
Assessment:
If diabetic and recently gave insulin to and are unresponsive, intervene STAT - take action
Unconscious pat and says low - very urgent; not want someone who is diabetic and unconscious sit longer because is prob - intervene if have diabetic pat and hypoglycemia is prob
If BG too prob ok
Rather take action than BG bottom out
S/S hypoglycemia, check BG
Follow hypoglycemia protocol
Intervention:
BG level according to protocol
Reassessment:
Timing of medications - meals/physical activity
Monitoring blood glucose
Prevention/education:
