E2 Care of the diabetic patient Flashcards
When does Type 1 & 2 develop?
T1: Younger People
T2: Adults >45
Is T1 or T2 more common?
Type 2 more common
Type 1 is only 5-10% of all diabetic cases
What is the main difference between the beta cells of T1 and T2?
T1: No endogenous insulin production due to destruction of beta cells in the pancreas
T2: Beta cells wear out, cells become insulin resistant
The 3 P’s of Type 1
Polyphagia- Increased hunger
Polydipsia- Excessive thirst
Polyuria- Excessive urination
Significance of S/S for T1 and T2
T1: S/S normally more abrupt
T2: S/S can go undiagnosed for years, screen on risk factors
Symptoms of diabetes
-Fatigue
-Recurrent infections (sick)
-Slow wound healing
(T1: Polyphagia, Polydipsia, Polyuria)
Non-modifiable risk factors for T2
-Family history
-Age over 45
-History of gestational diabetes
-Race/ethnicity (African Americans, hispanics, Pacific Islanders, American Indians)
Modifiable risk factors for T2
-Decreased Physical Activity
-High body fat or body weight
-High BP
-High cholesterol
Labs for diabetes
- Fasting Glucose: Normal <126mg/dL
- Casual blood glucose: Normal <200mg/dL
- Urine ketones: High amount indicates hyperglycemia
- Lipid profile: Elevated HDL, LDL, triglycerides
What casual blood glucose is considered a medical emergency?
> 300mg/dL
Oral glucose tolerance test
-Used commonly to diagnose gestational diabetes
-Not usually for diagnosing type 1 or 2
-Fasting glucose drawn, client consumes oral glucose, glucose levels obtained every 30 mins for 2 hours
-Fasting should be <110
-At 1 hour <180
-At 2 hours <140
Glycosylated Hemoglobin (HbA1C)
-Average glucose level past 3 months
-Used commonly to diagnosis and evaluate effectiveness of interventions
-Normal 4-6%
-Diabetic >6.5%
-Acceptable range for diabetic 6-8% with target 7%
Diabetes diagnostic criteria
Atleast 1 of the following:
1. A1C of 6.5% or higher
2. Fasting level >126mg/dL
3. OGTT at 2hr 200mg/dL
4. Classic symptoms of hyperglycemia (3 P’s or unexplained weight loss)
For diagnosis of Type 1 diabetes, would need ________-
islet cell autoantibody testing
What is a prediabetic patient?
Impaired glucose tolerance, impaired fasting glucose, or both
Patients with pre-diabetes are at HIGH risk for developing
type 2 diabetes
What are the S/S of prediabetes?
Typically None
But, longterm damage can already be occuring
Diagnostic criteria for pre-diabetes
-An A1C of 5.7-6.4
-Fasting blood sugar of 100-125mg/dL
-An OGTT 2 hour blood sugar of 140mg/dL-199mg/dL
What can we do for pre-diabetic patients?
-TEACH
-Lifestyle modification
-Encourage close monitoring of blood glucose and HbA1C
-Monitor for S/S: Fatigue, slow wound healing, frequently getting sick
-Diet modification: Monitor carbs and sugar intake
Oral medications are used most frequently in
Type 2 diabetics
Often in hospitalized patients oral medications are
stopped and put on insulin while acutely ill
What do diabetic oral medications do?
- Reverse insulin resistance
- Increase insulin production
- Decrease hepatic glucose production
- Help body get rid of excess glucose
When should metformin be held?
Before Procedures
Steroids make your blood sugar _____
What should you do?
rise
May need to alter insulin regimen at home, adjust basal dosage, increased scheduled doses
Why is being sick a big problem for diabetics?
- Causes stress which causes body to release more glucose
- More prone to DKA, HHNS when sick
- Stomach virus may lead to decreased eating and drinking (need to still take oral meds)
What to do when a patient with DM is sick?
- Notify HCP
- Monitor BS more frequently
- Continue to take meds
- Prevent dehydration
- Meet carbohydrate needs: through oral food intake or liquid (gatorade/ pedialyte)
- Rest
Call the provider when
- Urine Ketones
- BS >250mg/dL
- Fever >101.5, not responding to Tylenol
- Feeling confused/ disoriented/ rapid breathing
- Persistant N/V/D
- Inability to tolerate liquids
- Illness lasting longer than 2 days
Continuous glucose monitors are most common for
Type 1
Nursing management of insulin
- Mimic bodies normal insulin production
- Combines “Basal” insulin with “meal time” insulin
- Use rapid and short acting (bolus) insulin before meals
- Use a background insulin once a day
- Typically get 4 injections a day
Rapid acting insulin
Insulin lispro (Humalog)
Onset: 15 mins
Peak: 1 hr
Duration: 2-4 hrs
Insulin aspart (Novolog)
Insulin glulisine (Apidra)
Short acting
Human regular (Novalin R/ Humalin R)
Onset: 30-60 mins
Peak: 2-6 hrs
Duration: 3-8 hrs
Intermediate acting
NPH (Humalin N)
Onset: 2-4 hrs
Peak: 4-10 hrs
Duration: 10-20 hrs
Long acting
Insulin glargine (lantus)
Onset: 70 mins
Peak: None
Duration: 24hrs
Insulin detemir (Levemir)
Insulin degludec (Tresiba)
Insulin is a HIGH ALERT medication, therefore you need to
- Always check glucose level before given med
- Check diet order and patients oral intake tolerance
- Know onset/peak/duration
Teaching points for diabetics
- Teaching is the most important point
- Observe pt self-administer
- Timing is crucial
- Monitor for side effects of hypoglycemia
S/S of hypoglycemia
Sweating
Blurry Vision
Dizziness
Anxiety
Hunger
Irritability
Shakiness
Fast heartbeat
Headache
Weakness/ Fatigue
Hypoglycemia is when the blood sugar is
<70
Symptoms can occur at higher # if uncontrolled diabetes
What is the Rule of 15
If conscious and able to swallow give 15g simple carbohydrates (4 oz juice, regular soda, 3 glucose tablets, tablespoon honey)
Avoid sugars w/fats (candy bars)
15g of CHO increases BS
50mg/dL
How often should you recheck FSBS if hypoglycemic?
Every 15 minutes until <70, then give food
If patient is unconsious/ unable to swallow:
IM glucagon or IV D50 (25-50mL)
Hyperglycemia BS:
250-300
Causes of hyperglycemia
-Illness
-Infection
-Self-management issues
-Stress
S/S of hyperglycemia
Weakness
Fatigue
Blurry Vision
Headache
N/V/D
Treatment for hyperglycemia
- Check for ketones in urine
- Insulin
- Drink fluid, prevent dehydration
- Education on prevention
Crisis situation of hyperglycemia?
500+
Diabetic ketoacidosis (DKA) or Hyperglycemic Syndrome (HHS)
Insulin pump:
- Continuous release of SQ insulin infusion: Uses rapid acting insulin
- Pts receive continuous basal infusion
- Still required to check 4 times a day
- Usually deactivated in hospital and switched to sliding scale regimen
Problems to be aware of with insulin pumps
- Infection at insertion site
- Increased risk for DKA if pump malfunctions
- Cost
What is the goal for diabetes management?
Prevent long term damage in organ disease, angiopathy (damage to blood vessels
Macrovascular disease
Damage to large vessels:
Coronary arteries (CVS)
Peripheral vascular (extremities)
Cerebral vascular (brain)
Microvascular
Damage to capillaries:
Retinopathies (eye capillaries)
Nephropathies (Kidneys)
Neuropathies (Sensation to extremities)
Women with diabetes have a _____ of CVD than those without
4-6x risk
Men have ______ of CVD
2-3x
What is body part is at highest risk for Neuropathy
Lower extremities & feet
Foot ulcerations and lower extremity amputations common complications
What is neuropathy
loss of protective sensation (LOPS)- prevents patient from being aware that injury has occured
Nutritional considerations for diabetics
Balanced, high fiber, low fat, low cholesterol diet is best
Example of Carbohydrates
grains, fruits, legumes, milk
Limit simple carbs like pasta & bread
Should be 45-65% of total daily caloric intake
Example of Fats
Polyunsaturated fats such as Fish
Example of Fiber
beans, veggies, oats, whole grains
Example of Protein
meats, eggs, fish, nuts, and beans
Should be 15-20% of total caloric intake
Alcohol with diabetics
limit alcohol intake
1 for women
2 for males
Precautions when it comes to exercise with diabetics
-Appropriate foot wear
-Do not exercise if BS <80 or >250
-Best to exercise after meals
-If more than 1 hour has passed since eating and plan on high intensity exercise eat a carbohydrate snack prior
-Wear a medical alert bracelet
Nursing considerations for the hospitalized diabetic patietns
- Stress/ surgery can increased blood glucose levels
- Wound healing is impaired
- High risk of infection
Diabetic Dermopathy
reddish-brownish spots, usually on shins
Not life threatening but can clue us to uncontrolled diabetes
Acanthosis nigricans
Brown/Black thickening of skin, often seen in skin folds
Not life threatening but can clue us to uncontrolled diabetes
Necrobiosis lipoidica diabeticorum
Red patches around blood vessels
Not life threatening but can clue us to uncontrolled diabetes
