Med Surg: Care of pts with Pancreatic Problems

Question 1

What is Pancreas-Diabetes Mellitus?

Answer 1

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

Question 2

What are the different types of diabetes?

Answer 2

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

Question 3

What is the assessment of Type 1?

Answer 3

Polyuria, polydipsia and polyphagia

Weight loss

Weakness and fatigue

Question 4

What is assessment of Type 2?

Answer 4

Nonspecific to similar type 1

Fatigue

Recurrent infections

Recurrent vaginal yeast or candidal infections

Prolonged wound healing

Visual changes

Question 5

What is the diagnosis of Diabetes Mellitus?

Answer 5

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

Question 6

What is the diet for Diabetes Mellitus?

Answer 6

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

Question 7

What is the exercise for Diabetes Mellitus?

Answer 7

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

Question 8

What are oral hypoglycemic medication for DM?

Answer 8

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

Question 9

What do Sulfonylurea agents do for Diabetes Mellitus?

Answer 9

Increased secretion of insulin

Decrease glycogenosis and gluconeogenesis

Enhances cellular sensivity

Question 10

How does Meglitinide analogs help DM?

Answer 10

increase insulin secretion

Short acting agents-prevent postmeal glucose elevation

Question 11

How does bigunides help DM?

Answer 11

Reduces hepatic glucose production and tissue sensitivity to insulin

Have to hold for 48 hours before use of iodinated contrast for radiological studies

Question 12

How do Thiazolidinediones help DM?

Answer 12

Improves tissue sensitivity to insulin

Added benefits of decreasing lipids and microalbuminuria

Question 13

What are other medications for glucose control with DM?

Answer 13

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

Question 14

How does insulin help DM?

Answer 14

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

Question 15

What are the types of insulin, onset, peak and duration?

Answer 15

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

Question 16

How is an insulin pump used for DM?

Answer 16

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

Question 17

What are complications of insulin therapy?

Answer 17

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

Question 18

What is hypoglycemia?

Answer 18

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

Question 19

What is the treatment for hypoglycemia?

Answer 19

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

Question 20

What is hyperglycemia?

Answer 20

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

Question 21

What is diabetic ketoacidosis?

Answer 21

Life-threatening complication that occurs in type 1 diabetes when a severe insulin deficiency occurs and increased counterregulatory horomone release

Question 22

What are clinical manifestations of DKA?

Answer 22

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

Question 23

What are interventions for DKA?

Answer 23

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

Question 24

What is a hyperglycemic hyperosmolar state in DM?

Answer 24

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

Question 25

What are macrovasular complications?

Answer 25

CAD

cardiomyopathy

Hypertension

Cerebrovasulcar disease

Peripheral vascular disease

Infection

Question 26

What is microvasular complications?

Answer 26

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

Question 27

How can you prevent DM complications?

Answer 27

Attain and maintain euglycemia

Question 28

What is DM sick day care?

Answer 28

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