Exam 2 Diabetes Flashcards
Diabetes Educator
Certified nurse who educates and runs classes
What percentage of the population have diabetes?
9% (AND 86 million have pre diabetes)
Leading Cause of?
7th leading cause of death
Leading Cause of
Blindness/End stage renal disease/Amputations
Heart Attack/Stroke/Cardiac Disease?
Same category…ischemic stroke is a heart attack of the brain. Huge contributing factor to dm.
More than half of people with dm have
htn and cholesterol
How does insulin work in body?
Hormone made my pancreas and the pancreas releases insulin all day.
When we eat, our body creates ____ insuiln?
MORE, a bolus.
Insulin goes into bloodstream and pulls out sugar.
Delivers to tissue.
Basal rate?
Constant amt of insulin being released.
If bg goes low, what kicks in?
Liver! Which creates glucogenosis into the body.
Type I dm
- autoimmune disorder.
- Not enough insulin!
- manifests when body is unable to make insulin to maintain homeostasis.
- Absence Endogenous insulin (comes from inside. )
- Under 40yr and even later now.
- prone to dev. DKA
Type II dm
- Adult onset…
- 90-95% of people
- Four factors!!
- insulin resistance, dec. insulin production, inappropriate production of glucose by liver.
- Body still makes endogenous insulin.
Metabolic Syndrome?
Primary risk factors for someone developing dm.
HDLS are low
Low cholesterol
Bg low
Obesity
Type I manifest
Polydipsia
Polyuria
Polyphagia
Why? Cells are starving for glucose so body breaks down other nutrients, other fluid, and other
DKA
Type II
Non-specific Fatigue Recurrent infections Prolonged wound healing Vision problems 3Ps?
Diagnose
- A1C of 6.5% or higher
- Fasting plasma glucose of 126 or higher
- 2 hr plasma glucose of 200 or greater during oral GTT with load of 75g
- Random plasma glucose of 200 or greater
A1C preference
6-7%
When this percentage is maintained, their risk for micro or macrovascular disease is greatly decreased.
NANDAS
- Impaired wound healing
- Deficient knowledge
- Risk for infection
- Risk for injury
- Polyphasia (HUNGER)
- Fatigue
- Sensory Dysfunction
- Impaired peripheral neurovascular function (peripheral wounds)
Balancing act?
Drugs Nutrition Exercise Monitor Educate
Goal:
Reduce sx
Promote well being
Delay complications
How to help pt.’s plan?
- Engage in self care behaviors
- Have few or no hypo/hyperglycemia emergent episodes
- Maintain bg levels at normal or near normal levels
- Reduce risk of chronic complications
- Adjust lifestyle to accommodate the diabetic plan with minimum stress (fit dm into life)
Drug Therapy? What to use…
Insulin (injectable)
Oral agents
Non-insulin injectables agents
Drug Therapy Insulin
Exogenous Insulin (Type I) -rapid-acting, short-acting, intermediate-acting, long-acting.
Insulin Plans?
- Mealtime (bolus)
- Long/imterm. acting insulin.
Insulin pump (tells level all day but still need monitor)
Do Type II ever use exogenous?
Not really, but sometimes they might.
They may need to convert to injectable after oral. And they may use it during illness.
Patients wake up hyperglycemic?
Somogyi or Dawn!
Somogyi
- hyperglycemic
- counterregulatory hormones released-rebound hyperglycemia
- check bg for hypoglycemia between 2-4
- treat: dec. bedtime insulin dose, have a bedtime snack or BOTH
Dawn
- hyperglycemic upon wakening
- counter-regulatory hormones are excreted in inc. amts in the early morning hours-hyperglycemia
- check bg for hyperglycemia between 2-4am
- Treat: inc. insulin or adjust timing of insulin dose
Nutrition!
1st thing - assess.
Balanced nutrition DON'T skip meals Carb counting Dm exchange lists My plate Alcohol
Exercise!
HUGE benefits.
Lowers bg Weight Loss Reduces TGL and inc. HDLS 150 min. /week but who does this?? 1 hr after a meal or snack Carry a snack in case they become hypoglycemic.
When NOT to exercise: Elevated bg and ketones in urine.
DM monitoring? How to/options
HC/HS: 4x per day
QID: 2x per day (NPO)
BID: Before breakfast and dinner
COMPARE to A1C
SMBG: Self monitoring
CGM: (Continuous glucose monitoring) Look at on phone or pump… share on app.
Ketones urine test: pt. pees in cup and looks at strip.
DKA!
Diabetic KetoAcidosis
Characterized by?
- Burning fat rather than carbs for energy
- > hyperglycemia
- Ketosis (mod-L ketones in -blood urine)
- Acidosis (pH <7.3)
Body doesn’t have enough insulin so it breaks down fat. Ketones are the acidic byproduct of fat breakdown, creates ketones, body compensates by dumping ketones in urine…body gets polyuria, can lose 6.5 L in a 24 hrs (diuresis), lose K/electrolytes/fluids….N/V, Kussmal respirations because body is trying to blow off excess acid.
Manifestations.
- Dehydration (sunken eyeballs…)
- Lethargy/weakness
- Abdominal pain
- N/V
- Kussmaul respirations
- Breath-sweet, fruity odor (body is blowing off excess acid)
FIX DKA
Correct fluid/electrolyte imbalance
- Bolus pt. with fluid (but watch respiratory)
- IV infusion 0.9% NS
- When glucose reaches 250 mg/dL, add dextrose to prevent hypoglycemia.
Then….
- insulin therapy
- ***check potassium prior to admin. of insulin. ( If potassium is too low they’re at risk for dysrrhythmias)
- monitor heart and BG
- O2 stats
- Is&Os
Hyper
HHS
Hyperosmolar Hyperglycemic Syndrome.
Way less common than DKA but way more serious.
- Super hyperglycemia (600mg)
- Slow onset
- inc. in serum osmolality
- often occurs in pt’s with Type II dm and over 60yr.
- Neurological manifestations r/t inc. serum osmolality (seizures, hemiparesis (stroke), aphasia/speech)
- Confused
Care for someone with HHS
-Same as DKA but even more fluid.
-Add dextrose when glucose reaches 250 ml/dL so they don’t drop too low
(dextrose?)
-supplement potassium as needed
-monitor for fluid overload (watch for pulmonary edema…listen for crackles!)
DM acute complications
Sick Day Rules
What are sick day rules?
- check bg more frequently (q4h)
- monitor ketones in urine (13-4h) if blood glucose is >240 (type I)
- Contact MD if bg is >300 2 tests in a row OR mod-L ketones
- Patient should continue to eat if possible. (if NPO…insulin will lead to hypoglycemia
- MD may prescribe additional insulin or add insulin for a Type II dm.
Leads to hypoglycemia?
(<70)
Brain requires a constant supply of glucose!
This happens WAY faster than hyperglycemia.
Cause:
- hypoglycemic unawareness (body loses sensation)
- Time of eating
- Don’t eat enough
Manifestation of hypoglycemia?
HA, diaphoresis, confusion, shaky, dizzy, grumpy, hungry, fast heartbeat,
Hypoglycemic Care??
-Assess - Check BG
-If pt. is awake = 15g carb
(And if not awake??)
-Wait 15 min. = recheck bg
-If <70 again = give 15g carb again
-Notify HCP or EMS if no rise in bg after 2-3 attempts.
-Recheck bg 45 min. after bg increases.
-If not alert enough to swallow = 20-50%ml dextrose or Img Glucagon (lay on side)
DM Chronic Complications
- Stroke
- Nephropathy
- Atherosclerosis
- Dermopathy
- retinopathy/ cataracts/glaucoma/blindness
- Angiopathy…damaged vessels. (leading cause)
- Micro/macrovascular complications.
Microvascular vs. Macrovascular
MAC: disease of large or medium size blood vessels:
-cerebrovascular/cardiovascular/ peripheral vascular
-screen for dyslipidemia
Education: don’t smoke, lose weight, decrease fat, require annual screening.
MICRO: specific to dm pt. with hyperglycemia (retinopathy/nephropathy/neuropathy)
- thickening of vessel membranes in capillaries and arterioles
- present in Type II dm at time of diagnosis.
Dm retinopathy
Leading cause of new cases in adult blindness.
- also prone to glaucoma and cataracts at an early age.
- yearly eye exam.
Dm Nephropathy
Leading cause of end-stage renal disease
-damage to vessels that supply glomeruli of the kidney.
-Annual screening
(spot urine check and serum creatinine)
-BP management
-Tight bg control..little peaks and valleys.
Chronic Complication sof Dm neuropathy!
60-70% of dms have some degree of neuropathy…nerve damage due to metabolic imbalances.
Sensory Neuropathy
Manifest:
- distal symmetric polyneuropathy
- affects hands and feet bilaterally
- loss of sensation, pain, paresthesia
- usually worse at night
- foot injury can occur without the patient having pain
Treat:
- tight bg control
- medications
- creams/tricyclic antidepressants help with nerve pain
- anti-seizure medications for nerve pain
Autonomic neuropathy
- affects all body systems
- hypoglycemic unawareness
- bowel incontinence
- neurogenic bladder-urinary retention
- gastroparesis-delayed gastric emptying that leads to delayed food absorption and hypoglycemia
- cardiovascular abnormalities…postural hypotension, tachycardia, painless MI
- sexual dysfunction/erectile dysfunction.
Complications of feet and lower extremities?
High risk for foot ulcerations and lower extremity amputations
-Risk Factors: sensory neuropathy, Loss of protective sensation, peripheral artery disease, smoking, impaired immune function (worsening wounds), autonomic neuropathy.
Evaluationss?
- Can patient explain treatment plan??
- The patient will be able to describe self-care measures that may prevent or slow progression of chronic complications
- Patient will maintain nutrition, activities, healthy bg levels.
- Patient will have no lower extremity or foot injury.
