Kirila CIS Flashcards
capillary glucose monitoring- terms
- FSG- fingerstick glucose
- BSG- bedside glucose
- accucheck
- HGM- home glucose monitoring
- GSM- glucose self-monitoring
- SBGM- self blood glucose monitoring
basal and bolus insulin
- basal- long acting insulin- steady state of glucose control
- bolus- adjusted at mealtime and based on FSG (sliding scale) +/- carbohydrate count anticipated
average 3 month glucose- all terms mean the same test
- Hemoglobin A1c
- HbA1c
- GHbA1c
- glycosylated hemoglobin
presentations when DM should be included in diff dx
- mental status changes
- abd pain
- dehydration
Mental status changes- diff dx
AEIOUTIPS
- alcohol
- epilepsy with seizure activity
- infection
- overdose
- uremia
- trauma
- Insulin (high or low blood sugar)
- poisoning/psychosis
- stroke
Abd pain- diff dx
BAD GUT.. PAINS
- bowel obstruction
- appendicitis, adenitis
- diverticulitis, DIABETIC KETOACIDOSIS, dysentery/diarrhea, drug withdrawal
- gastroenteritis, gall bladder dz
- UTI or obstruction
- testicular torsion, toxin (lead, black widow bite)
Abd pain- diff dx- 2
PAINS
- pneumonia, pleurisy, pancreatitis, perforated bowel, ulcer, porphyria
- abdominal aneurysm
- INfarcted bowel, MI, incarcerated hernia, IBD
- splenic rupture, infarction, sickle cell pain crisis
Acute complications of DM
- DKA- seen in Type 1!!
- NKHS (non-ketotic hyperosmolar state)- aka hyperosmolar non-ketotic coma (HNKC); Hyperglycemic hyperosmolar state (HHS)- seen in type 2!!!
DKA- etiology
- inadequate insulin admin
- infection- pneumonia, UTI, gastroenteritis, sepsis
- infarction- coronary, cerebral, mesenteric, peripheral
- surgery
- drugs (Cocaine)
DKA- initial sx’s
- anorexia
- N/V
- polyuria
- thirst
DKA- progression of sx’s
- abd pain
- altered mental fxn
- coma
DKA- signs
- kussmaul respirations- rapid/deep
- acetone (Fruity) breath odor (or like nail polish remover)
- dry mucous membranes
- poor skin turgor
- tachycardia
- hypotension
- fever
- abd tenderness
DKA- lab
-hyperglycemia
-ketosis
-metabolic acidosis:
Anion gap inc
pH 0.1 dec = K 0.6 inc- since acidosis causes K to shift out of cells
DKA- lab 2
- measured Na is low secondary to hyperglycemia- for every 100 mg/dL that glucose is over 100, there will be a 1.6 meq dec in Na
- K- serum may be normal or somewhat high- actually total body deficit!!!
- hypertriglyceridemia
- hyperlipoproteinemia
- hyperamylasemia- can suggest pancreatitis
- leukocytosis
High anion gap acidosis- diff dx
MUDPILES
- methanol
- uremia
- diabetic ketoacidosis
- paraldehyde
- isopropyl alcohol, iron, INH
- lactic acidosis
- ethylene glycol
- salicylates
DKA- tx
-ICU: frequent monitoring of general status, vital signs, glucose, and other labs -acid base status -renal fxn -K and other electrolytes
DKA- fluid replacement
1-2-3 rule
- 2-3 L NS (0.9%) over first 1-3 hrs (5-10 ml/kg/hr)
- then 0.45% saline at 150 ml/hr
- when glucose reaches 250 mg/dl, switch to 5% dextrose and 0.45% saline at 100-200 ml/hr
- fluid deficit is often 2-5 L
DKA- initial insulin administration
regular insulin
- 10-20 units IV or IM
- then 5-10 units/hr continuous IV
- Inc if no response in 1-2 hrs
DKA- eval for underlying causes
- cultures
- EKG
- CXR
- drug screen
- history from family or pt
DKA- initial monitoring
- blood work- BSG at least hourly; electrolytes q 2-4 hrs +/- ABG’s
- clinical status hourly- vital signs, mental status, fluid I and O
DKA- K replacement
- consider when serum K < 5.5 mEq/L
- when supplementing K, keep in mind:
- renal fxn
- baseline EKG and continuous cardiac monitoring
- verify urinary output and measure hourly
DKA- tx goals
- inc the rate of glucose utilization in insulin dep tissues- glucose goal of 150-250 meq/dL
- reverse ketonemia and acidosis
- correct depletion of water and electrolytes
start intermediate or long-acting insulin- when?
- when pt is able to eat- mental status improved, no N/V, no abd pain
- anion gap normalized
- allow overlap timing of IV with SQ insulin- 30-60 min
NKHS (non-ketotic hyperosmolar state)- etiology
- insulin def
- inadequate fluid intake
- osmotic diuresis induced by hyperglycemia
NKHS- precipitating factors
- sepsis
- MI
- glucocorticoids
- phenytoin
- thiazide diuretics
- impaired access to water
NKHS- sx’s
- polyuria
- thirst
- altered mental status
- ABSENT- N/V, abd pain, kussmaul respirations (seen in DKA)
NKHS- lab
- lactic acidosis may produce a MILD inc in anion gap
- moderate ketonuria from starvation
- CORRECTED serum Na usually inc
NKHS- tx
ICU
- frequent monitoring of general status, vital signs, glucose, other labs
- acid base status
- renal fxn
- K and other electrolytes
NKHS- fluid replacement
- 2-3 L NS over first 1-3 hrs
- fluid deficit is usually 8-10 L- reverse over next 24-48 hrs using 0.45% saline
- when glucose reaches 250 mg/dl, switch to 5% dextrose and 0.45% saline at 100-200 ml/hr
NKHS- insulin admin
regular insulin -5-10 units IV bolus -3-7 units continuous infusion -transition when eating as with DKA monitor, replace K, investigate and address underlying causes
NKHS, DKA- differences
- fluid deficit is much greater in NKHS
- some drugs can contribute to NKHS
- N/V, abd pain, ketoacidosis, kussmaul respirations- absent in NKHS!
major
..
long term complications of DM
- retinopathy
- neuropathy
- HD
- nephropathy
major cause of mortality in type 2 DM
-CV dz
HbA1c
- 3-4 month “avg” of blood sugars- based on glucose binding to red cells- hemoglobinopathies or recent blood transfusions may alter results
- < 7.0 = satisfactory control
diabetic gastropathy
- delayed gastric emptying
- caused by autonomic neuropathy
insulin is cleared by?
kidney
what happens when declining kidney fxn?
-declining insulin requirement!!
insulin cleared by kidney
screening for proteinuria
spot (random) urine sample
- protein- standard urine dipstick not sensitive if proteinuria < 300 mg/24 hr
- most common type of protein in albumin
screening for proteinuria- 2
microalbumin/creatinine ratio
- random urine sample
- ratio to microalbumin to creatinine is more accurate than measuring microalbumin alone- ratio corrects for variations due to urine conc
- MICROalbuminuria- 30 - 300 mg (over 300 = macro or albuminuria)
24 hour urine collection
For protein and creatinine clearance
- used to quantify large amts of protein in urine
- can be done on the same specimen
- need to obtain serum creatinine at the same time to determine creatinine clearance
- problematic- diff to remember to save ALL urine, dexterity required to get it into container, leak in container
immune compromise
- gluc > 150 interferes with neutrophil fxn
- general debilitation
- mult co-morbidities
foot care
daily inspection!- can use plastic mirror, family assistance (can be diff for pt with dexterity and visual problems)
- never go barefoot
- moisturize- but NOT in b/w or under toes
- prescription shoes
- podiatry
diabetes- tx
- lifestyle modification- physical activity!!, diet, weight loss, psychosocial, education
- medications
diabetes- monitoring
Quarterly -HgbA1C -review SGM (self gluc monitoring) log -foot inspection Annual -dilated eye exam -urine protein screening (microalbumin/creatinine) -monofilament testing
type 1 DM
- < 1% of children dx in 1st yr of life
- <2% are under 3 yo
