management of patients with diabetes Flashcards
terminology
diabetic ketoacidosis
a metabolic derangement, most commonly occuring with type 1 diabetes
highly acidic ketone bodies are formed, resulting in acidosis
terminology
fasting plasma glucose
blood glucose determination obtained in the lab after fasting for at least 8hrs
terminology
gestational diabetes
any degree of glucose intolerance with its onset during pregnancy
terminology
glycated hemoglobin
a measure of glucose control that is a result of glucose molecule attaching to hemoglobin for the ife of the red blood cell (120days)
hemoglobin A1C
terminology
hyperglycemia
elevated blood glucose level
terminology
hyperglycemic hyperosmolar syndrome (HHS)
a metabolic disorder most commonly assoiacted with type 2 diabetes resulting from a relative insulin deficiency initiated by an illness that raises the demand for insulin
terminology
hypoglycemia
low blood glucose level
terminology
impaired fasting glucose/impaired glucose tolerance
a metabolic stage intermediate between normal glucose homeostasis and diabetes; referred to as pre diabetes
terminology
ketone
a highly acididc substance formed when the liver breaks down free fatty acids in the absence of insulin
terminology
latent autoimmune diabetes of adults
a subtype of diabetes
describe diabetes
- group of metabolic diseases
- characteristics: hyperglycemia d/t defects in insulin secretion, insulin action, or both
- complex chronic illness, continuous medical care required
- multifactorial risk reduction management
- goal: prevent complications
what are some physical consequences of diabetes
- kidney failure (leading cause)
- severe nerve damage
- nontraumatic lower limb amputations (leadin cause)
- blindness (leading cause)
- 7th leading cause of death
what are some social and economic consequences of diabetes
- medical expenditures 2.3x higher than patient wit diabetes
- social isolation
name some major classifications of diabetes
- type 1
- type 2
- gestational
- latent autoimmune diabetes of adults
- diabetes associated with other conditions of syndromes (like chronic steroid use)
whats impaired glucose tolerance number situation
144-199 = impaired
>200 = type 2
2hr post glucose load
whats the impaired fasting glucose number situation
100-125 = impaired
>126 = type 2
have to be w/o food for at least 8hrs
what are some covid 19 considerations for diabetes
risk factors of having diabetes
- increased risk of contracting covid-19
- increased risk of hospitalization with covid-19
- increased risks of intubation and mortality
insulin is a hormone secreted by what cells?
beta cells
as blood sugar drops, the secretion of insulin…
subsides
glucose is a main source of…
energy
liver stores glucose in the form of…
glycogen
no insulin leads to…
- increased breakdown of stored glucose
- increased production of new glucose
- hyperglycemia
what are some actions of insulin
- Transports and metabolizes glucose for energy
- Stimulates storage of glucose in the liver and muscle (in the form of glycogen)
- Signals the liver to stop the release of glucose
- Enhances storage of dietary fat in adipose tissue
- Accelerates transport of amino acids (derived from dietary protein) into cells
- Inhibits the breakdown of stored glucose, protein, and fat
describe diabetes type 1
- destruction of the pancreatic beta cells, exogenous insulin dependency
- autoimmune response: genetics, immunologic, and environmental
- usually diagnosed before 30
describe diabetes type 2
- most common type of DM
- usually after age 30
- more prevalent in children and adolescents
what are some risk factors for type 2 diabetes
- genetic and envoronmental factors
- native americans, african americans, and hispanic americans
- obesity/fat distribution
- inactivity
- family history
- age
- PCOS (polycystic ovarian syndrome)
what are the two main issues with diabetes type 2
insulin resistance
- decreased tissue sensitivty to insulin -> continued hepatic glucose production -> inability of muscles and fat tissues to increase glucose
impaired insulin secretion
- limited beta cell response to high glucose levels uptake -> need more insulin but beta cells cant hang
describe metabolic syndrome
- hypertension
- hypercholesterolemia
- abdominal obesity
- other abnormalities
what are some symptoms of diabetes type 2
- Fatigue
- Irritability
- Polyuria
- Polydipsia
- Poorly healing wounds
- Recurrent blurred vision
- May have weight loss, but generally weight gain
- Slow-healing sores
- Frequent infections
- Pruritus, skin infections, vaginitis
describe gestational diabetes
- Any degree of glucose intolerance with its onset during pregnancy
- Hyperglycemia develops during pregnancy
- Secretion of placental hormones causes insulin resistance
- Seen in about 6-8% of pregnant women
- Increases risk of developing hypertensive disorders during pregnancy
- Blood glucose levels usually return to normal after delivery
describe latent autoimmune diabetes of adults
- Progression of autoimmune beta cell destruction
- High risk of insulin dependence
- Age of onset <50
- BMI < 25 kg/m2
- Hx of autoimmune disease
- Acute symptoms prior to Dx
- Family history of autoimmune disease
what are some clinical manifestations of diabetes
- Polyuria, Polydipsia, Polyphagia
- Weight Loss (type 1)
- Muscle & fat loss
- Dehydration
- Extreme fatigue / weakness
- Sudden vision changes
- Numbness / tingling in hands or feet
- Dry skin
- Slow healing wounds
- Recurrent infections
- Irritability and mood changes
- Ketonuria
what lab tests are used in the diagnosis of diabetes
- fasting blood glucose
- casual blood glucose
- post-load or postprandial (done 2hrs after eating, >200 confirms DM)
- Hgb A1C (<7 means DM)
- glycosated albumin level
- ketonuria
- fasting lipid profile
- proteinuria
whats included in the physical and medical hx exam for diabetes
- lungs, skin, infection, neuropathy
- recent viruses, BPhx, cholesterol, weight loss or gain
read this shit
Criteria for the Diagnosis of Diabetes
*Symptoms of diabetes plus casual plasma glucose concentration equal to or greater than 200 mg/dL (11.1 mmol/L). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss.
Or
*Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours.
Or
*Two-hour postload glucose equal to or greater than 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test. The test should use a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.
Or
*Hemoglobin A1C ≥6.5% (48 mmol/mol).
In the absence of unequivocal hyperglycemia with acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day. The third measure is not recommended for routine clinical use.
A1C, glycosylated hemoglobin
what is the main goal of medical managment of diabetes
- Normalize insulin activity and blood glucose levels to prevent or reduce complications
- Insulin 3-4 times / day
- Frequent glucose monitoring
- HgbA1C < 7%
what are the 5 steps of diabetes management
- nutritional therapy
- exercise (check sugar and eat b4, have buddy)
- monitoring
- pharmacologic therapy (oral meds, insulin, or both)
- education
describe nutritional therapy for diabetes
- follow eating habits
- meal planning
- maintaining ideal body weight
- exercise regularly
- return to prepragnancy weight
other dietary concerns:
- aclohol concerns- impairs ability to make glucose
- artificial sweetener concerns (nutritive vs non nutritive)
- misleading food labels
what are some benefits of regular physical activity for diabetics
- lowers blood glucose
- reduces CV risks
- alters lipid concentrations
what are the physical activity requirements for diabetics
- 3x a week
- proper footwear
- inspect feet after
- avoid extreme temps
- stretch 10-15 minutes before
what are some preacutions for physical activity for diabetics
- blood gluose >250/ketones in urine = hold
- eat a snack 15g carbs b4
- s/sx of hypoglycemia
self monitoring blood glucose is the key to management, describe the frequency and timing
- individualized
- recommended 3-4times/day ACHS
- keep a logbook
when would you need extra blood glucose monitoring
- new medication/insulin started
- OTC med started
- acute illness/stress
- patient thinks too high/low
- weight loss/gain
- change in med dose, diet plan, exercise
what are some other modalities of monitoring glucose and ketones
- continuous glucose monitoring (best way for type 1, w or w/o insulin pump)
- glycated hemoglobin
- checking ketons in urine (when BS >240 for two testings)
rapid acting insulin
- lispro, asparte
- onset 15-30min
- peak 30-90min
- duration: 4-5hrs
short acting insulin
- regular
- onset 30-60min
- peak 2-3hrs
- duration 4-6hrs
intermediate acting insulin
- NPH
- onset 60-90min
- peak 4-12hrs
- duration up to 24hrs
long acting insulin
- glargine, detemir
- no peak
lasts 48hrs maybe
describe insulin regimens
- 1-4 times/day
- want to mimic normal pattern of release
- sliding scale coverage
describe using insuline pens
Cleanse end of pen (port)
Apply special needle onto pen
Rotate dial to 2-3 units mark & with pen held straight up, push plunger to eliminate air
Rotate dial to required amount of insulin needed
Firmly hold needle against skin at 90 degrees
Inject insulin & count 5-10 sec. before removing
look at this thing
name some oral antidiabetic drugs
- Sulfonylureas
- Biguanides
- Meglitinides
- Alpha-glucosidase inhibitors
- Thiazolidinediones (Glitazones)
- Dipeptidyl Peptidase-4 Inhibitors
- Glucagonlike peptide-1 agonist (GLP-1)
- Non-Sulfonylurea Insulin Secretagogues
- Second-Generation Sulfonylureas
- Sodium-glucose co-transporter 2 (SGL-2) Inhibitors
combo therapy: two or more orals or orals with insulin
describe managing diabetes in a hospital
- target glucose 140-180
- insulin preferred over oral
- sliding scale insulin
- timing of insulin, meals, and glucose checks
decribe patient education for diabetes
- basic info
- assess readiness to learn
- educate experienced patients
- Sick days
- Exercise (3-5xs per week)
- Insulin types – onset, peak, duration
- Storage of insulin
- S/Sx hyperglycemia / hypoglycemia
- Nutrition
Calories
Protein (Consume 10-20%)
Fats (Consume 20-30%)
Carbohydrates (Consume 50-60%) - Foot care
- Teach meal planning & physical activity programs
- Prompt treatment of foot abrasions
- Follow-up visits for complications
- Yearly funduscopic exams
- Treatment of risk factors
- Control angina and PVD
what are some acute complications of diabetes
- hypoglycemia
- DKA
- HHS
what are some causes of hypoglycemia
- OD of insulin
- sulfonylurea
- skipping meal or eating too little
- nutritional and fluid imbalance from nausea and vomiting
- alcohol intake
read this shit
describe hypoglycemic treatment
10-15g carbs (mild)
- 6-8 Life Savers
- 4 oz. orange juice
- 6 oz regular soda
- 3 glucose tablets
- 1 cup skim milk
- 2 packets sugar
- 1 tbsp honey
20-30g carbs (moderate)
glucagon 1mg SQ/IM
50% dextrose, 25g IV, repeast 10min prn (severe)
describe insulin waning
progressive rise in glucose from bedtime to morning
what is the somogyi effect
normal at bedtime then hypoglycemia (early 2am or 3am <60mg/dl) followed by rebound hyperglycemia AM 180-200mg/dl
what is the dawn phenomenon
early (bout 3am) hyperglycemia, when treated results in hypoglycemia
what are some causes of DKA
- missed insulin doses
- illness or infection
- undiagnosed/untreated diabetes
what are the three major issues of DKA
- hyperglycemia 250-800
- ketosis
- metabolic acidosis
what are some symptoms of DKA
- Polyuria
- Polydipsia
- Polyphagia
- Weight Loss
- Muscle & fat loss
- Dehydration
- Extreme fatigue
- Irritability and mood changes
- Blurred vision
- Ketonuria
- Flu-like Sx:
Nausea
Vomiting
Abdominal pain - Kussmaul breathing
- Fruity breath
- Electrolyte imbalance – Low Na/K
- Dehydration
- Signifies an emergency
- Plasma bicarb <15 mEq/L
- BS: >250
what are the three things done in the management of DKA
rehydrate
restore electrolytes
reverse acidosis
describe rehydrating in mamangement of DKA
- 0.9% NaCl or 0.45% NaCl - rapid infusion (depends on Na+ level)
- when BS reaches 300 or less change fluid to D5W
describe restoring electrolytes in the mamangement of DKA
- electrolyte of concern is K+ (may be low or high, but generally high)
- insulin moves K+ from ECF to cells
- monitor EKG d/t K= may give calcium chloride fo K+
describe reversing acidosis for mamangement of DKA
- acidosis reversed with insulin
- regular IV insulin drop continuous
read this stuff
When hanging the insulin drip, the nurse must flush the insulin solution through the entire IV infusion set and discard the first 50 mL of fluid. Insulin molecules adhere to the inner surface of plastic IV infusion sets; therefore, the initial fluid may contain a decreased concentration of insulin
what are the guidelines for sick days for diabetics
describe HHS
Extreme hyperglycemia (600-2000 mg/dl)
Profound dehydration, hypotension, tachycardia, variable neurologic signs
Mild or undetected ketonuria
Absence of acidosis
Higher mortality
Precipitating factors similar to DKA
Hyperosmolality (increased concentration) of plasma and elevated BUN
describe the treatment of DKA and HHS
- insulin IV ONLY REG, must use IV pump
- fluids: normal saline until BS 250-300, then add 5% dextrose
- check suagr every hour
- treat underlying issue: infection, physiologic stress, education
- check sugar every hour
what are some macrovascualr complications of DM
- CAD
- cerebrovascular disease
- HTN
- PVD
- infection
what are some microvascular complications of DM
- retinopathy
- nephropathy
- leg and foot ulcers
what are some diabetic neuropathies
Sensorimotor neuropathy
Autonomic neuropathy – pupillary, CV, GI, GU
Peripheral neuropathy
what are some special issues with DM
- undergoing surgery (NPO -> lower insulin dose)
- hospitalized
- footcare
- self care issues
- comon alterations in diet (NPO, clear liq, enteral food feedings, parenteral nutrition) check sugar Q6
- hygiene
- stress
- gerontologic considerations
