Med Surg: Care of pts with Pancreatic Problems Flashcards
What is Pancreas-Diabetes Mellitus?
Chronic disorder of impaired carbohydrate, protein and lipid metabolism caused by a deficiency/poor utilization of insulin
An absolute or relative deficiency of insulin results in hyperglycemia
4 types of diabetes recognized by ADA
What are the different types of diabetes?
Type 1: nearly absolute deficiency of insulin, if insulin not given then fats are metabolized for energy, results in ketonemia
Type 2: relative lack of insulin or resistance to the action of insulin, insulin is sufficient to stablize fat and protein metabolism but not to deal with carbohydrate metabolism
Gestational: during pregnancy
Other: from medical conditions or medication
What is the assessment of Type 1?
Polyuria, polydipsia and polyphagia
Weight loss
Weakness and fatigue
What is assessment of Type 2?
Nonspecific to similar type 1
Fatigue
Recurrent infections
Recurrent vaginal yeast or candidal infections
Prolonged wound healing
Visual changes
What is the diagnosis of Diabetes Mellitus?
Fasting Plasma glucose: no caloric intake for 8 hours, 2 results of 126 mg/dL
Oral glucose tolerance testing-glucose load then hourly samples: results over 200 mg/dL at 2 hours
Glycosylated hemoglobin: average blood glucose over last 120 days
- normal: 4-6
- Indicative if 6.5 or more
- Over 8 indicate poor control and indicate need for adjustments
With classic symptoms-random glucose of 200 or more
What is the diet for Diabetes Mellitus?
Individualized: current and desired weight, existing health problems
Need consistency in timing and amount of food on daily basis
American Diabetic Associated diet:
- minimum of 130 g/day
- protein 15-20% of total calories
- fat saturated fat of <7% calories, 2 or more servings of fish week for polyunsaturated fatty acids
- alcohol-limit 1 drink/day, 2 drinks/day
US dietary guidelines
Consider individual needs, lifestyle, cultural and socioeconomic patterns
What is the exercise for Diabetes Mellitus?
Lowers blood glucose level
Encourages weight loss
Reduces cardiovasular risks/hypertension
Improves circulation and muscle tone
Decreased total cholesterol and triglyceride levels
Decreases insulin resistance and glucose tolerance
Monitor glucose level before exercising
If blood glucose level over 250mg/dL and urine ketones are present-instruct not to exercise until glucose levels are closer to normal and ketones are absent
What are oral hypoglycemic medication for DM?
Type 2 when diet and weight control have failed
Work on 3 defects: insulin resistance, decreased insulin production, increased hepatic glucose production
Assess current meds: increase hypoglycemic effect, ASA, alcohol, sulfonamides, oral contraceptives, monoamine oxidase inhibitors, increase blood glucose levels: glucocorticoids, thiazide diuretics, estrogen
Avoid OTC meds unless prescribed
May require insulin during times of stress, surgery or infection
What do Sulfonylurea agents do for Diabetes Mellitus?
Increased secretion of insulin
Decrease glycogenosis and gluconeogenesis
Enhances cellular sensivity
How does Meglitinide analogs help DM?
increase insulin secretion
Short acting agents-prevent postmeal glucose elevation
How does bigunides help DM?
Reduces hepatic glucose production and tissue sensitivity to insulin
Have to hold for 48 hours before use of iodinated contrast for radiological studies
How do Thiazolidinediones help DM?
Improves tissue sensitivity to insulin
Added benefits of decreasing lipids and microalbuminuria
What are other medications for glucose control with DM?
Incretin mimetic-stimulates release of insulin from pancreatic beta cells, suppress glucagon secretrion of pancreatic beta cells
Amylin analog- can be used by type 1 and 2 diabetes: slows gastric emptying, reduces postprandial glucagon secretion, increase activity
How does insulin help DM?
Treat DM 1 and DM 2 when diet, weight control and oral hypoglycemic agents have failed
Regular insulin: only one that can be administered IV
Increase hypoglycemic effect of insulin: ASA, alcohol, oral anticoagulants, oral hypoglycemic meds, beta blockers, tricyclic antidepressants, tetracycline, MAOI’s
Increase blood glucose level: glucocorticoids, thiazide diuretics, thyroid agents, oral contraceptives, estrogen
Ilness, infection and stress increase the blood glucose level and need for insulin
Know peak action time of insulins
What are the types of insulin, onset, peak and duration?
Rapid-acting: 15 min, 60-90 min, 3-5 hours
Short-acting: 1/2-1 hr, 2-4 hr, 4-8hr
Intermediate-acting: 2-4 hr, 4-10 hr, 10-16 hr
Long-acting: 1-2 hr, none, 24+ hour
Should rotate sites within an anatomical site-decreases variability of absorption
Fastest absorption is from the abdomen, arm and thigh
U100 insulin most common 1mL contains 100 units of insulin
May be supplied in a vial and use a syringe or insulin pen
How is an insulin pump used for DM?
SubQ needle attached to insulin infusion pump
Continuous basal infusion
At mealtime program pump to deliver a blous infusion based on flucose result and amount of CHO ingested at meal
Change needle and site q2-3 days
Higher cost than syringe
Tighter glucose control
More normal lifestyle
What are complications of insulin therapy?
Local allergic reactions: red, swelling, tenderness, and induration or wheal at site of administration occurs 1-2 hours after administered, usually early in insulin therapy, cleanse skin with alcohol before injection
Insulin lipodystrophy: lipodystrophy: loss of SubQ fat appears as slight dimpling or more serious pitting of SubQ fat, lipohypertrophy: development of fibrous fatty massess at injection site
Insulin resistance: develops immune antibodies that bind the insulin, term also used for lack of tissue sensitivty to the insulin from the body
Dawn phenomena: results from reduced tissue sensitivity to insulin that develops between 5-8AM may be caused by nocturnal release of GH
Somogyi phenomenon: bedtime glucose levels are normal or elevated, hypoglycemia occurs at 2-3am, 7am glucose levels are hyperglycemic due to response to counterregulatory hormones
Treatment: decrease PM dose of intermediate acting insulin or increase bedtime snack
What is hypoglycemia?
blood glucose level drops to between 50 and 70 mg/DL, classifies by symptoms
- too much insulin or hypoglycemic meds, too little food or excessive activity
- neuroglycopenic symptoms-from brain glucose gradually declining to low level
- neurogenic symptoms from autonomic nervous activity triggered from rapid decline in blood glucose.
Adrenergic: shaky, heart pounding, nervous
Cholinergic: sweaty, hungry, tingling
What is the treatment for hypoglycemia?
Mild: 60-70
- give 15-20 g of fast acting simple carbohydrates
- recheck blood glucose in 15 minutes and repeat treatment if needed
- once symptoms resolve: snack containing protein and carbohydrate or meal within 60 minutes
Moderate
- Give 15-30 g of fast-acting simple carbohydrate
- additional food after 10-15 minutes
Severe: depends on LOC
- Glucagon SQ or IM if unable to swallow
- Small meal upon awakening if not nauseated
- In hospital: IV of 25-50 ml of 50% dextrose
What is hyperglycemia?
Glucose over 250 mg/dl
too little insulin or too much food
symptoms: hot, dry skin, rapid deep respirations, mental status varies from alert to stuporous, obtunded or coma, acidosis, dehydration, positive ketones in urine
May develop diabetic ketoacidosis
What is diabetic ketoacidosis?
Life-threatening complication that occurs in type 1 diabetes when a severe insulin deficiency occurs and increased counterregulatory horomone release
What are clinical manifestations of DKA?
Sudden onset
Precipitating factors: stress, infection, inadquate insulin dose
classic symptoms: polyuria, polydipsia, polyphagia, weight loss, vomitting, abdominal pain, dehydration, weakness, altered mental state, shock and coma
Ketosis: Kussmaul respiration, “fruity” breath, nausea, abdominal pain
Labs: glucose over 300mg/dL, serum pH <7.33, K+ starts normal then becomes elevated then drops rapidly with rehydration, positive urine ketones, elevated BUN and creatine due to dehydration
What are interventions for DKA?
Treat dehydration with rapid IV infusion of isotonic saline then switch to 0.45% saline to continue volume replacement
Treat hyperglycemia with IV regular insulin-give bolus dose then continuous drip, monitor glucose closely and titrate
Treat hypokalemia before it occurs
Treat acidosis IF severe with sodium bicarb IV slow infusion
Treat cause of DKA
What is a hyperglycemic hyperosmolar state in DM?
Extreme hyperglycemia without ketosis or acidosis
Have sustained osmotic diuresis
Kidney impairment allow for high glucose levels
Have enough infulin to prevent breakdown of fats for energy
Clinical manifestations are extreme hypergycemia
What are macrovasular complications?
CAD
cardiomyopathy
Hypertension
Cerebrovasulcar disease
Peripheral vascular disease
Infection
What is microvasular complications?
Retinopathy: microanuryms cause hemorrhage in eye
Nephropathy: test for microalbuminuria
Neuropathy: deterioration of nerve function, sensory-pain or loss of sensation, motor-muscle weakness, autonomic problems in CV, GI and urinary function
How can you prevent DM complications?
Attain and maintain euglycemia
What is DM sick day care?
Take insulin and medications are prescribed
Test blood glucose and test urine for ketones every 3-4 hours
Soft foods 6-8 times per day if unable to follow meal plan
If vomitting, diarrhea, or fever-consume liquids every 30-60 minutes to prevent dehydration
Notify HCP if: vomit or fever, glucose over 250, Ketonuria present more than 24 hours, unable to take food or fluids for 4 hours, illness persists more than 2 days
