Endocrine II - Diabetes Flashcards
What is the Normal lab value for Glucose?
70-110mg/dL (3.9-6.1 mmol/L)
Describe Type 1 Diabetes
- Little to no Insulin
- Usually diagnosed at Childhood
- Autoimmune response (Type 1 A) or Idiopathic ( Type 1B).
- First sign maybe DKA
- Appears abruptly, despite years of beta cell destruction.
- 3 P’s - Polyuria, Polydipsia, Polyphagia
Describe the Pathophysiology of Type 1 Diabetes
You have to have insulin to carry glucose out of the blood and into the cell…since there is no insulin, the glucose just builds up in the blood, the blood becomes hypertonic and pulls off the fluid into the vascular space…the kidneys filter excess glucose and fluids ( polyuria and polydipsia) The cells are starving so they start breaking down protein and fat for energy (polyphagia). When you break down fat you get ketones (acids). Now this Pt. is acidotic - so is metabolic with Kussmaul Respirations - lungs compensate with C02.
List the Signs and symptoms of Type 1 Diabetic
HYPERGLYCEMIA = 3 P’S
- Polyuria - think SHOCK FIRST
- Polydipsia
- Polyphagia
Describe the Treatment used to Type 1 Diabetic
They need Insulin!
Describe the Pathophysiology of Type 2 Diabetes
- Not enough Insulin or the insulin they do have is no good or they have b/c insulin resistant..
- Pt. usually over weight
- Not making enough insulin to keep up with the glucose load compared to what they are taking in.
- Usually found by accident; wound not healing or repeat infection.
Why does the Pt. with Type 2 Diabetes have such a hard time with recurrent infections and wound healing?
Because they have a lot of glucose in their blood and bacteria thrive in this environment. Also, excess glucose causes immune system to b/c dysfunctional. Plus, poor circulation = poor blood supply. Decreased blood supply increases risk for wound healing.
Individuals with Type 2 Diabetes should be evaluated for What Syndrome?
Metabolic Syndrome ( Syndrome X)
In order to be Diagnosed with metabolic Syndrome what 3 or more symptoms must the Pt. have?
- Waist Circumference:
> 40 in (101.6 cm) for males
> 35 in ( 88.9 cm) for females - Triglycerides:
> 150 mg/dL (1.60 mmols/L) - HDL:
< 40 mg/dL (1.036 mmols/L) for males
< 50 mg/dL (1.295 mmols/L) for females - Blood Pressure:
> 130/85 - FBS
> 100 mg/dL ( 5.55 mmols/L)
How do we Treat Metabolic Syndrome?
Start with diet and exercise and then add oral agents.
Some Pt. may have to take insulin to control control BS especially in the presence of non compliance.
Pt. with metabolic syndrome are at risk for developing CAD, so teach Pt. about lifestyle changes to decrease risk of metabolic syndrome M.I. or stroke.
Describe Gestational Diabetes
- Resembles T2 Diabetes
- Mom needs 2-3x more insulin than normal
- If mom has risk factors for gestational diabetie, screen at FIRST prenatal visit.
- Screen ALL moms at 24-28 wks gestation, weather they are high risk or not.
- Complications to baby: Increased birth weight and Hypoglycemia
Why does an infant get Hypoglycemia?
After delivery the infant is no longer exposed to the mothers glucose rich blood. The infants pancreas has been in over drive due to the moms elevated blood surgery and it takes time for the infants pancreas to revert back to reduced normal secretions of insulin usually resolves in a few days and is self limiting. Baby will require glucose supplements until blood sugar normalizes.
What is the General Treatment of Diabetes: ( Type 1 and Type 2)
DIET:
Majority of calories should come from:
- Complex Carbs 45%, Then Fats 30-40%, Protein 15-20%
- Sugar destroys vessels like fat does
- High fiber slows down glucose absorption in the intestines, therefore, eliminating the sharp rise and fall blood sugar. Want to keep the glucose normal or destroys vessels.
EXCERCISE:
Wait till blood sugar normalizes to begin exercise.
Eat prior to exercise to prevent HYPOGLYCEMIA
Exercise when blood sugar is at its highest.
Exercise the same time and amt. daily- routine is key.
MEDS: Oral Anti-diabetics / Non-Insulin Injectables.
- Prescribed for T2 - used when diet/exercise fails.
- Administered PO or Sub Q
- Helps body produce insulin
- Helps body how to use insulin and glucose.
- All oral Anti-Diabetics work to decrease the amount of circulating glucose*
What is the most widely used Anti-Diabetic Med?
Metformin (Glucophage)
- 1st choice for most pt.
- Used for weight control in T2 diabetics
- Used for some Pt. with Pre-diabetes
- Decreases glucose production & enhances how glucose enters the cell
- May see them prescribed in combination, If Metformin is not controlling the blood glucose levels, another anti-diabetic will be ordered, may even be Glargine (Lantus)
When should a Pt. temporaily discontinue Metformin
Any Pt. undergoing surgery or any radiologic procedure that involves contrast dye should emporaily discontinue Metformin. They can resume 48hrs after the procedure if kidney function has returned and creatinine is normal.
How is the insulin dose determined?
Initially it is based on weight. The average adult dose is adjusted until the blood sugar is normal and until there is no more glucose or Ketones in the urine.
What happens if there is glucose smiling over into the urine?
Then the blood sugar will be high, therefore will need more insulin, if you have ketones in the urine that means Pt. is breaking down fat, which leads to metabolic acidosis which is very dangerous.
What are the Peak and Onset times of the various insulin types?
Rapid Acting: Onset - 15 min Peak - 1-3hrs Duration - 3-5 hrs Give with Food.
Regular: Short Acting (R) Onset - 30 min Peak - 2-4 hours Duration- 6-8hrs Can give I.V. CLEAR
NPH: (N) Onset - 1.5 hrs Peak - 4-12 hrs Durations - 16-24 hrs CLOUDY
Long Acting: Lantus, Glargine
No peak- b/c long term vessel damage is caused from flucuation in glucose.
Onset - 2-4 hrs
Duration - 24 hrs
When drawing up Regular and NPH insulin together which one do you draw up first?
Regular than NPH
“RN”
All __________Insulins are also clear and cannot be mixed with any other insulin or given IV.
Long Acting
What is the standard insulin you give I.V.?
Regular
Rapid acting insulin may also be given IV.
What is the Diabetic Clients Care Plan based on?
Plan is based on clients Lifestyle, Diet and Activity. The goal is to keep the before meal glucose near normal at 70-130 mg/dL (3.89 - 7.22 mols/L)
What is the most common method of daily dosing insulin?
Basal Bolus Dosing
How does Basal Bolus Dosing work?
The total daily dose of insulin with basel/bolus method is a combination of Long Acting Insulin, and a Rapid Insulin
Snacks are not required with basel bolus dosing, but Pt. still must eat with Rapid Acting Insulin. So have food available.
How often is Long Acting Insulin and Rapid Acting Insulin given?
Long acting is given once a day
Rapid Acting Insulin is given throughout the day/f meals in divided doses, and it covers the food eaten at meals.
When should clients with Diabetes eat?
When insulin is at its peak! Because when insulin is at its peak blood sugar is at its lowest.
Always monitor a client on insulin for ______?
Hypoglycemia
Describe Glycosylated Hemoglobin ( HbA1c)
Blood test; that gives an average of what your blood sugar has been up to over the past 3-4 mths.
What happens to your blood sugar when you are sick or stressed?
Increases
What % must a client have on the Glycosylated Hemoglobin (HbA1c) to be diagnosed with diabetes?
> 6.5%
For ppl. with Diabetes, the ideal goal for their Glycosylated Hemoglobin (HbA1c) is?
< 7%
Client must check blood sugar more than normal when sick to prevent ?
DKA
What is the protocol for rotating insulin injection sites?
Rotate within an area first. i.e. use up all the sites in the right arm and then do not use the right arm for 2-3 weeks otherwise scar tissue will arise and Pt. will not be able to absorb insulin in this site.
When you move sites from arm the abdomen can the insulin absorption be different?
Yes! so, must watch for hypoglycemia - insulin could be absorbed faster.
Describe insulin infusion pumps.
Alternative to daily insulin injections
Only Rapid Insulin is used for infusion pumps
Obtain better control: recieving a basel level of insulin from the pump and boluses of additional insulin as needed with meals, or if they have elevated blood sugar.
They count the # of carbs in their meal so they can calculate the mat. of insulin needed based on how many carbs they re eating.
What are the Signs and Symptoms of Hypoglycemia?
- Glucose level 70mg/dL ( 3.8 mol/L or less)
- Cold/Clammy
- Confusion
- Shaky
- Headache
- Nervous
- Nausea
- > Pulse
- Hunger
What should a client do if they become Hypoglycemia?
Drink or Eat Simple Carb
4-6 oz Coke/Juice
8-10 oz lifesavers
4 glucose tabs (wrk faster)
Snacks:
15 grams carbs
Glucose absorption is delayed in foods high in FAT.
What is the 15 - 15- 15 rule?
Wait 15 min if blood sugar is still below 70 give 15 more grams of sugar……etc.
Once their blood sugar is up they should Eat More Carbs or Protein i.e. PB and crackers
What do you do if you enter a diabetics client’s room and they are unconcious …. do you tx. the client with Hypo or Hyper Glycemia?
Hypoglycemia - b/c its more dangerous. Give D50W 9 hard to push so you will need a large bore IV) - Injectable Glucagon ( GlucaGen) - used when there is no IV access, given IM.
Once the Pt. wakes needs to eat something they dot they will bottom out again.
For prevention teach the client to?
- Eat
- Insulin Regularly
- Know signs of hypoglycemia
- Check Blood Glucose Regularly
Describe DKA
Anything that increases blood sugar can throw a Pt. into DKA ( illness, infection, skipping insulin)
DKA may be the 1st sign Diabetes
Have the usual S&S of T1 Diabetes
Patho: Absent or inadequate insulin - blood sugar goes sky high - polyuria, polydipsia, polyphagia - fat breakdown (acidosis) - Kussmaul’s Respirations ( trying to blow off CO2 to compensate for the metabolic acidosis). Also, as the client b/c more acidotic , the LOC goes down.
In DKA, you have very little or no insulin and severe hyperglycemia which leads to fat breakdown and then metabolic acidosis.
What is the treatment for DKA?
Find the Cause - with DKA TX. the illness first. i.e. If Pt. skipped insulin BS> = DKA.
Hourly Blood Sugar and Potassium Levels
IV insulin - watch for HYPOGLYCEMIA & HYPOKALEMIA with IV insulin.
Insulin Decreases Blood Sugar & Potassium by driving them out of the vascular space into the cell.
ECG - to monitor potassium b/c pt. could develop life threatening arrhythmias.
Hourly Outputs - want good kidney perfusion 3 p’s
ABG’s- Metabolic Acidosis
IVF’s - Polyuria causes shock thats why start with NS then when the BS gets down to about 250 to 300 mg/dL ( 13.9- 10.7 mols/L), switch to D5W to prevent HYPOGYCEMIA b/c still giving pt.insulin IV, so the next dose could drop BS. Also, do not want to bring BS down to fast it causes cerebral edema.
Anticipate that the primary healthcare provider will want to add potassium to the IV solution at some point, b/c the insulin is dropping the serum potassium.
Describe:
Hyperosmolar Hyperglycemic Nonketosis ( HHNK) or Hyperglycemia Hyperosmolar State ( HHS).
Looks like DKA, but no Acidosis - can’t be in DKA info Acidotic.
Blood sugar greater than 600
Making just enough insulin, so they are not breaking down body FAT.
No FAT breakdown = No Ketones - so no fruity breath b/c no ketones. Therefore this Pt. T2 b/c they make a little bit of insulin.
No Ketones, No Acidosis, No Kussmauls
What is the difference b/w DKA and HHNK ( HHS)?
Type 1 = DKA
Type 2 = HHNK (HHS)
DKA and HHNK(HHS) are both hyperosmolar states caused by HYPERGYLCEMIA and DEHYDRATION, but there is NO ACIDOSIS with HHNK (HHS).
Describe Macro-vascular and Micro-vascular
Will develop poor circulation everywhere due to the vessel damage (sugar irritates the vessel lining; accumulation of sugar will decrease the size of the vessel lumen, therefore decreasing blood flow).
- Diabetic Retinopathy - eyes are vascular leads to blindness
- Neuropathy - Kidneys are vascular = dialysis.
Describe Neuropathy:
- Sexual problems: impotence/decreased sensation
- Foot/leg problems: pain/paresthesia/ numbness -follow diabetic foot care
- Neurogenic bladder: the bladder does not empty properly, the bladder may empty spontaneously = incontinence, or it may not empty at all = retention.
- Gastroparesis: stomach emptying is delayed so there is an increased risk for aspiration.
Describe Review Diabetic Foot Care
- Wear well fitting shoes all the time.
- Inspect feet everyday - use mirror or friend
- No harsh chemicals used on feet.
- Cut toes nails straight across or b/c in grown
- Dry b/w toes well to prevent bacteria
- Watch water temp. may get into water that is to hot.
