Intro to DM Flashcards
Diabetes is
- chronic multi-system disease related to abnormal or impaired insulin utilization
- Characterized by hyperglycemia resulting from lack of insulin, lack of insulin effect, or both
Etiology of Diabetes
- Genetic, hereditary
- Autoimmune
- Environmental (infection, toxins)
- Lifestyle
Pathophysiology of Diabetes
Absent or insufficient and/or poor utilization of insulin
- can cause destruction of B cells from thyroid
- steroid increases blood sugar
Insulin is made by
beta cells of the pancreas and is released in small amounts into the blood steam
Liver and muscle cells store
excess glucose as glycogen
Skeletal muscles and adipose tissue are
insulin-dependent tissues
Insulin is required to “_______” receptor sites in cells, allowing the transport of glucose into cells to be used for energy
unlock
___________ is released from the alpha cells of the pancreas
Glucagon
Insulin and Glucagon are
counterregulatory hormones
In simple terms, explain the insulin and glucose relationship
insulin attaches to the receptor and the glucose channel opens allowing glucose to enter the cell
Insulin is the “____” that unlocks the door
key
Insulin Resistance in simple terms
The body is making keys (insulin)
**BUT the keys don’t work properly and won’t unlock the doors of the cells
When the keys and locks are not working well together,
it’s hard for blood glucose to move from your blood into the cells of the body the way it should.
Insulin insufficiency
Body makes a few keys (insulin)
BUT body needs more
not enough keys to open all the locks
When there are not enough keys to open all the locks,
it’s hard for enough blood glucose to move from the blood vessels into the cells of the body.
What are the different types of diabetes
Type 1
Type 2
Gestational
General Diagnostic tests for diabetes
HA1C
Fasting Plasma Glucose
Oral Glucose Tolerance Test
Random Blood Glucose
What diagnostic tests can diagnose a patient with diabetes?
H1AC
Oral Glucose Tolerance
HA1C reflects
average blood glucose levels over the past 2-3 months
aka: Glycosylated HA1C bound to hemoglobin
HA1C Normal range
less than 5.7%
HA1C Pre-diabetes range
5.7% - 6.5%
HA1C Diabetes
6.5% and higher
American Diabetes Association recommends an HA1C less than
7%
Blood transfusions and disorders can show
false results of a HA1C test
The higher the A1C,
higher the average blood glucose
Fasting blood sugar levels are drawn at least
8 hours after the last meal eaten
Fasting Plasma Glucose Normal levels
less than 100 mg/dL
Fasting Plasma Glucose Pre-diabetes levels
100 – 125 mg/dL
Fasting Plasma Glucose Diabetes levels
126 mg/dL or higher
What type of test is the Oral Glucose Tolerance Test?
Two hour test that checks blood sugar before and two hours after a glucose drink is consumed
The Oral Glucose Tolerance Test shows
how well your body processed sugar
Oral Glucose Tolerance Test
Normal
less than 140
Oral Glucose Tolerance Test
Pre-diabetes
140-199
Oral Glucose Tolerance Test
Diabetes
200 +
Random Blood Glucose is drawn when and what labs
anytime
BMP or CMP
Random Blood Glucose
Diabetes
200 mg/dL or higher plus symptoms of diabetes
4 Ps and rapid weight loss
Most common type of Blood Glucose Monitoring?
finger stick (AccuCheck)
- timely feedback
CGM
Continuous Glucose Monitoring
What is the most common error with finger stick?
blood sample size
When is it advised to do a fingerstick?
Before each meal and at bedtime
BEFORE INSULIN
Hypoglycemia
- Low blood sugar (< 70 mg/dL)
-
too much insulin in proportion to available glucose
Counterregulatory hormones are released
autonomic - Suppression of insulin secretion and production of glucagon & epinephrine provide a defense against hypoglycemia
- Worsens rapidly and need to be treatment ASAP
- Untreated can progress to loss of consciousness, seizures, coma and death
Hypoglycemia occurs
too much insulin in proportion to available glucose
If your patient shows hypoglycemia, what do you do? If untreated?
Worsens rapidly and need to be treatment ASAP
Untreated can progress to loss of consciousness, seizures, coma and death
Causes of hypoglycemia
Alcohol intake without food
Too little food
Too much diabetic medication (insulin, orals)
Too much exercise without adequate food intake
Weight loss without change in medication
S/S of hypoglycemia
Cold, clammy skin needs some candy
Numbness of fingers, toes, mouth
Tachycardia, palpitations
Headache
Nervousness, tremors
Faintness, dizziness
Stupor
Slurred speech
Hunger
Changes in vision
Seizures, Coma comes quicker
Diaphoresis
What should you do as a nurse if your patient is unresponsive and you know they are DM 1?
treat for hypoglycemia
Treatment of Hypoglycemia
Rule of 15
IV Dextrose, D50 IV 25/50 mL
Glucagon IM or sub-q injection
- Give 15-20 mins to work
- Turn on side bc side effect of nausea
What is the Rule of 15?
15 grams (fruit juice or soda) - avoid fats and b=carbs
Check after for 15 mins
repeat after 2-3 times
notify provider
Hyperglycemia
- High blood sugar (> 200 mg/dL)
Occurs when there is not enough insulin working
Too much glucose in blood
More gradual onset
Untreated can lead to Diabetic Ketoacidosis (DKA) or Hyperosmolar Hyperglycemia Syndrome (HHS)**
Can lead to coma and death**
Hyperglycemia occurs when
not enough insulin working
Too much glucose in blood
If hyperglycemia is left untreated, it can lead to
Diabetic Ketoacidosis (DKA) or Hyperosmolar Hyperglycemia Syndrome (HHS)
Can lead to coma and death
Hyperglycemia Causes
Illness, infection
Corticosteroids
Too much food
Not enough diabetic medication (insulin, oral)
Inactivity
Emotional, physical stress
Poor absorption of insulin
S/S of hyperglycemia
Hot and dry/ sugar is high**
Increased urination (polyuria)**
Increased thirst (polydipsia)**
Increased hunger (polyphagia)**
Weakness, fatigue**
Blurred vision**
Headache
Glycosuria
Nausea, vomiting, abdominal cramps
Progression to DKA, HHS **
Mood swings
Slow healing wounds/infections**
If the patient who is diabetic has an infection, then they should administer more/less insulin.
more
Treatment of Hyperglycemia
Continued diabetic medications as prescribed
Check blood glucose frequently (record results)
Check urine for ketones** (record results)
Drink fluids at least on an hourly basis
Exercise or stay active**
Notify HCP if blood glucose levels do not decrease in a few days**
Type 1 Diabetes
Autoimmune disease
Results from beta cell destruction in the pancreas
Autoantibodies present for months to years before clinical symptoms
Leads to absolute insulin deficiency
Insulin dependent**
Type 1 Diabetes opset is
rapid
Type 1 diabetes age is around
40 or younger
What percentage of people have Type 1 diabetes?
10%
Type 1 Risk factors
Autoimmune
Viral
Environmental (pollution)
Medically induced (removal of pancreas)
S/S of DM Type 1
Polyuria (increased urination)
Polydipsia (increased thirst)
Polyphagia (increase hunger)
Weight loss
Fatigue
Increase frequency of infections
Rapid Onset
Insulin-dependent
familial tendency
Peak incidence at 10-15 y/o
Diagnosis of Type 1 DM
HA1C**
Fasting Plasma Glucose (FPG)
Oral Glucose Tolerance Test (OGTT)**
Random Blood Glucose plus symptoms of diabetes
- Start with this one
Treatment of Type 1 DM
Insulin-dependent
Administration of sub-q insulin multiple times per day
External insulin pump
Tight glycemic control
Dietary modifications
Active lifestyle
Type 2 DM
Caused by insulin resistance or deficiency
More common in adults
Now seeing younger children because of obesity
Progressive disease, slower onset
Causes of Type 2 DM
Insulin resistance or deficiency
Pre-diabetes (don’t usually have symptoms
Family hx
Metabolic syndrome (cardiovascular disease, high cholestrol
Modifiable Risk Factors of Type 2 DM
Obese/fat distribution
Physical inactivity, sedentary lifestyle
Hypertension/ high cholesterol
Poor diet
Smoking/alcohol
NON - Modifiable Risk Factors of Type 2 DM
Family history
Race/ethnic background
Age
Pre-diabetic & Gestational diabetes
PCOS
Chronic glucocorticoid exposure
Diagnosis of Type 2 Diabetes
HA1C**
Fasting Plasma Glucose (FPG)
Oral Glucose Tolerance Test (OGTT)**
Random Blood Glucose plus symptoms of diabetes
Treatment of Type 2 DM
Diabetic medications
Insulin or oral
Lifestyle changes (change diet or exercise)
Tight glycemic control (less than 180)
Increase activity levels
Type 2 DM S/S
Genetic Mutations: insulin resistance and family hx
- Polyuria
Nocturia
- Polydipsia
- Polyphagia
Recurrent infection
Prolonged wound healing
visual changes
fatigue and low energy
higher than 6.5% HA1C
FPG 126+
prediabetes FPG 100-125
Metabolic Syndrome
Metabolic Syndrome
increase triglycerides
decrease HDLs
increase in BP
Central obesity
sedentary lifestyle
FPG greater than 126
most common in 35 y/o+
Short-Term Diabetes Complications
Hypoglycemia
Hyperglycemia
Ketoacidosis
Microvascular Long-Term Complications
Retinopathy
Nephropathy
Neuropathy
Tight control reduces
Macrovascular Long-Term Complications
Cerebrovascular (increase of strokes)
Cardiovascular (MI, CAD)
Peripheral vascular
early onset
Other Long-Term Complications
Foot ulcerations
Amputations
Sexual disfunction
Diabetic Foot Care
Wash feet daily with mild soap and warm water
Pat feet dry, especially in-between toes**
Examine feet daily**
Moisturize daily, do not put between toes
Clean cuts with warm water and mild soap, covering with a clean dressing
Report skin infections/nonhealing wounds to HCP
Cut toenails evenly with rounded edges**
Comfortable, well-fitting, broken-in shoes**
Basal-Bolus Insulin Therapy
Mimics physiological insulin secretion of a “normal” pancreas
little insulin all day and night (basal), and a
burst with meals to cover the carbohydrates eaten (bolus/mealtime)
Sliding Scale Insulin is given as what in Basal-Bolus
Correction dose (sliding scale) is given in ADDITION to scheduled insulins (basal and mealtime) to bring elevated blood glucose back into the target range
This correction is given to correct blood glucose elevations that occur despite the use of basal and mealtime insulin
Short Duration - Rapid Acting Insulin is adminstered
15 minutes before meals
- Dont give unless meal is in the room or hypoglycemia will occur
Short Duration - Rapid Acting Insulin
Onset:
Peak:
Duration:
Onset: 10-30 mins
Peak: 30min–3 hrs
Duration: 3-5 hrs
Short Duration - Rapid Acting Insulin types
Aspart (Novolog)
Lispro (Humalog)
Glulisine (Apidra)
If NPO, then
withhold insulin
Short Duration - Short Acting Insulin given by
subQ, IM or IV
routine treatment to control postprandial hyperglycemia (subQ) and basal glycemia control (subQ infusion via insulin pump)
Short Duration - Short-Acting Insulin
Onset:
Peak:
Duration:
Onset: 30–60 min
Peak: 2-5 hrs
Duration: 5–8 hrs
Short Duration - Short Acting Insulin TYPES
Regular Insulin (Humulin R, Novolin R)
U100 Insulin is given
IV w/o Rx
U500 Insulin is given
extreme insulin resistance
Intermediate Insulin is used in
Onset is delayed, therefore cannot be used for postprandial control
Used 2-3 times per day to provide glycemia control between meals and during the night
Intermediate Insulin
Onset:
Peak:
Duration:
Onset: 1.5-4 hrs
Peak: 4-12 hrs
Duration: 12-18 hrs
Intermediate Insulin Types
NPH (Humulin, Novolin N)
Intermediate Insulin is usually
cloudy
Long Duration Insulin given when
Dosing can be done at anytime of the time, but at the same time everyday
Release small amounts over time, liver makes naturally
Controls over fasting periods
Long Duration Insulin administered
only be given SubQ
You can not mix which type of insulin with others
Long Duration Insulin
Long Duration Insulin
Onset:
Peak:
Duration:
Onset: 0.8-4 hrs
Peak: none
Duration: 16-24 hrs
Long Duration Insulin types
Glargine (Lantus) - hospital
Determir (Levemir)
Longer Duration Insulin is injected and comes in?
Injected once daily
Only comes in pre-filled pens
Longer Duration Insulin
Onset:
Peak:
Duration:
Onset: 30-90 mins
Peak: none
Duration: > 24 hrs
Longer Duration Insulin Types
Glargine U-300 (Toujeo)
Degludec (Tresiba)
Which insulin is required for DM Type 1?
Long duration insulin
Insulin Appearance
Clear, colorless solutions
NPH is the ONLY cloudy suspension
Inspect before using
- Discard if abnormal
Insulin Concentration U - ###
U-100 is 100 units/mL
U-200 is 200 units/mL
U-300 is 300 units/mL
U-500 is 500 units/mL
Insulin administration
All types can be given subQ
NPH must roll gently between hands to mix the suspension
Injection Sites: BY RATE OF ABSORPTION
Upper arm
Abdomen
Upper thigh
Upper buttock
Storage for Insulin
Unopened vials should be stored in the refrigerator
If stored unopened in the fridge, can be used up to the expiration date on the vial
Do not freeze vials
Opened vial can be kept at room temperature up to 1 month
Mixtures of insulin in vials are stable for 1 month at room temp and 3 months in the fridge
Mixtures of insulin in prefilled syringes should be stored in the refrigerator, they are stable for at-least 1 week
VERTICALLY
Mixing Insulin
Fastest acting Fast
Longer acting Long
Draw up the clear (short acting) before the cloudy (NPH, regular/intermediate)
Only _____-________ insulin prep can be mixed with other insulins
short-acting (rapid and short)
