MedSurg 3 - Diabetes Mellitus (Chap 67)

Question 1

Pancreas

- Anatomy

Answer 1

• Lies behind the stomach

- has exocrine and endocrine functions

Question 2

Pancreas

-Function

Answer 2

Exocrine Function:
== secretion of digestive enzymes through ducts that empty into the duodenum

Endocrine Function:
== the cells in the Islets of Langerhans perform the pancreatic endocrine functions. (abt 1 million islets are found throughout the pancreas)
== the islets have 3 distinct cell types:
** ALPHA Cells, secrete Glucagon
** BETA Cells, secrete Insulin
*** DELTA Cells, secrete Somatostatin

Question 3

Glucagon and Insulin

Answer 3

Glucagon and Insulin affect the metabolism of:

• • Carbohydrate
• • Protein
• • Fat

Question 4

Somatostatin

Answer 4

Somatostatin is secreted NOT only in the pancreas but also in the intestinal tract and the brain.

Functions:
== Inhibits the release of glucagon and insulin from the pancreas.
== Inhibits the release of gastrin, secretin, and other GI peptides

Question 5

Glucagon

Answer 5

Glucagon is a hormone that increases blood glucose levels. It is triggered by decreased blood glucose levels.

Question 6

Insulin

Answer 6

• • Insulin promotes the movement and storage of carbohydrate (CHO), protein, and fat.
• • It lowers blood glucose levels by transporting the glucose from blood stream to cells
• • Basal levels of insulin are continuously secreted to control metabolism
• • Insulin secretion increases in response to an increase in blood glucose levels.
• • Stimulates storage of glucose as glycogen in the liver
• • Inhibits gluconeogenesis
• • Enhances fat deposition
• • Increased protein synthesis

Question 7

Diabetes

Answer 7

A chronic multi-system disease related to:

• • Abnormal insulin production
• • Impaired insulin utilization
• • Or Both of the above

Leading cause of:

• • End stage renal disease
• • Adult Blindness
• • Non-traumatic lower-extremity amputation

Major contributing factor:

• • Heart Disease
• • Stroke

Question 8

Types of Diabetes

Answer 8

Type 1 Diabetes Mellitus
– Insulin-Dependent Diabetes Mellitus, which means no or very little production of insulin

Type 2 Diabetes Mellitus
– Non-insulin Dependent Diabetes Mellitus, which means patient produces insulin but not enough

Question 9

Cardinal Signs of Diabetes Mellitus == 3 P’s

Answer 9

• POLYURIA
• • Frequent urination
• • From osmotic effect of glucose
• POLYDIPSIA
• • Excessive thirst
• • From osmotic effect of glucose
• POLYPHAGIA
• • Excessive hunger
• • A consequence of cellular malnourishment

Question 10

Type 1 Diabetes Mellitus

Answer 10

• • There is a virtual absence of endogenous insulin
• • Dependent on exogenous insulin
• if insulin is withdrawn, ketosis and eventually ketoacidosis develops.

Question 11

PreDiabetes

IFG: Fasting Glucose Level = 100 to 125 mg/dL
IGT: 2-Hr. Plasma Glucose = 140 to 199 mg/dL
A1C: = 5.7% to 6.4%

Answer 11

Individuals already at risk for diabetes
Blood glucose high but not high enough to be diagnosed as having diabetes
Characterized by:
-- Impaired fasting glucose (IFG) 
-- Impaired glucose tolerance (IGT)

Question 12

Counterregulatory Hormones (CRH)

Answer 12

• Glucagon, Epinephrine, Growth Hormone, & Cortisol

- - works together as Opposite effect of insulin

Question 13

Type 2 Diabetes Mellitus

Answer 13

Four Major Metabolic Abnormalities:

1. Insulin resistance
2. Pancreas ↓ ability to produce insulin
3. Inappropriate glucose production from liver
4. Alteration in production of hormones and adipokines

Question 14

Secondary Diabetes

Answer 14

Caused by other illnesses or treatment of medical condition that causes ↑ BG:
– Cushing Syndrome
– Hyperthyroidism**
– Total Parenteral Nutrition (TPN)**
– Pancreatitis
– Cystic fibrosis
Caused by Rx of medical conditions cause ↑ BG:
– Corticosteroids (Prednisone) **
– Phenytoin (Dilantin)
– Thiazides
– Atypical antipsychotics (clozapine [clozapril])
* Usually resolves when underlying condition is treated

Question 15

Type 1 DM - Signs & Symptoms

Answer 15

Type 1 – Rapid Onset

• • Polyuria
• • Polydipsia
• • Polyphagia
• • Weight loss
• • Weakness
• • Fatigue
• • Ketoacidosis

Question 16

Type 2 DM - Signs & Symptoms

Answer 16

Type 2 – gradual onset

• • Nonspecific
• • May have classic s & s of Type 1
• • Fatigue
• • Recurrent infections (vaginal yeast & monilia)
• • Prolonged wound healing
• • Visual changes (blurred vision)

Question 17

Major Risk Factors: Type 2 Diabetes

Answer 17

• • Family History
• • Obesity
• • Age > 35 years
• • HTN
• • HDL < 35mg/dl
• • Triglycerides >250 mg/dl
• • Hx of gestational diabetes or delivery of infants weighing > 9 lbs
• • Origin: African-American, Hispanic, Native American, or Asian-American

Question 18

Diabetes Mellitus – Methods of Diagnosis

Answer 18

Four methods of diagnosis

• • AIC ≥ 6.5% (for diagnosis)
• • Fasting plasma glucose level >126 mg/dL (in 2 separate tests)
• • Random or casual plasma glucose measurement ≥200 mg/dL plus symptoms
• • Two-hour OGTT level ≥200 mg/dL when a glucose load of 75 g is used
• • Ideal A1C goal for patient diagnosed with DM is 7%
• • Normal A1C reduces risks of retinopathy, nephropathy, and neuropathy !!

Question 19

Drug Therapy: Insulin

Answer 19

• Rapid-acting:
  Lispro (Humalog); Aspart (Novolog); Glulisine (Apidra)
• Short-acting:
  Regular (Humulin R; Novolin R)
• Intermediate-acting:
  NPH (Humulin N, Novolin N);
  Lente human insulin (Humulin L)
• Long Acting
  Ultralente (Humulin U)
  Glargine (Lantus)
  Detemir (Levemir)

Question 20

Rapid-acting Insulin:

Lispro (Humalog);
Aspart (Novolog);
Glulisine (Apidra)

Answer 20

Inject 0 to 15 minutes before meal

Onset = 15 minutes

Question 21

Short-acting Insulin:

Regular (Humulin R; Novolin R)

Answer 21

Regular
Inject 30 to 45 minutes before meal
Onset = 30 to 60 minutes

Question 22

Intermediate-acting:

NPH (Humulin N, Novolin N);
Lente human insulin (Humulin L)

Answer 22

Cloudy

Question 23

• Long Acting

Ultralente (Humulin U)
Glargine (Lantus)
Detemir (Levemir)

Answer 23

Injected once a day at bedtime or in the morning
Released steadily and continuously
No peak action
Cannot be mixed with any other insulin or solution
glargine (Lantus); detemir (Levemir)

Question 24

Storage of insulin

Answer 24

Do not heat/freeze.
In-use vials may be left at room temperature up to 4 weeks.
Extra insulin should be refrigerated.
Avoid exposure to direct sunlight.

Question 25

Administration of insulin Given Subcut Regular can be given IV

Answer 25

Fastest absorption from abdomen, followed by arm, thigh, and buttock Abdomen is the preferred site. Rotate injections within one particular site. Do not inject in site to be exercised.

Question 26

Accepted Insulin Treatment Plans

Answer 26

NPH and Regular Insulin In AM and PM (dinner time) Coverage during day with Regular insulin Glargine at HS Coverage during day with Lispro or Aspart Split Dosing of Glargine Glargine in AM and PM Coverage with Lispro or Aspart Insulin Pump – using Lispro, Aspart, or Apidra (may use Regular)

Question 27

Problems with Insulin

Answer 27

Allergic reactions - rare Somogyi Effect – overdose of insulin – results in ↓ BG (undetected ↓ BG during sleep) – then counterregulatory hormones cause ↑ BG; Rx- give less insulin Dawn Phenomenon –predawn release of counterregulatory hormones – results in ↑ BG in AM; Rx – change timing of insulin or ↑ insulin Lipodystrophy – atrophy of SQ tissues; due to lack of rotation of sites; rare today

Question 28

Beta Blockers and Diabetes

Answer 28

Beta adrenergic blockers may Mask symptoms of hypoglycemia | Prolong hypoglycemic effects of insulin

Question 29

Thiazide/loop diuretics and Diabetes

Answer 29

Thiazide/loop diuretics Can potentiate hyperglycemia By inducing potassium loss

Question 30

Diabetes: Nutritional Therapy

Answer 30

* Carbohydrates Sugars, starches, and fiber Carbohydrate allowance is a minimum of 130 g/day. * Fats Less than 200 mg/day of cholesterol and trans fats <7% from saturated fats * Protein Contribute 15% to 20% of total energy consumed Intake should be significantly less than in the general population.

Question 31

Diabetes: Nutritional Therapy

Answer 31

``` * Alcohol: High in calories No nutritive value Promotes hypertriglyceridemia Detrimental effects on liver Can cause severe hypoglycemia ```

Question 32

Diabetes: Nutritional Therapy

Answer 32

* Diet teaching Dietitian initially provides instruction. Carbohydrate counting – given a maximum limit per day * Plate method Helps patient visualize the amounts of vegetable, starch, and meat that should fill a 9-inch plate

Question 33

Diabetes Mellitus: Exercise

Answer 33

Essential part of DM management *Increases insulin sensitivity; increases insulin receptor sites → can lower BG *Lowers BG levels *Contributes to weight loss – decreases insulin resistance May result in decreased need for diabetes meds May reduce triglyceride and LDL cholesterol levels

Question 34

Diabetes Mellitus: Exercise

Answer 34

Several small carbohydrate snacks can be taken every 30 minutes during exercise to prevent hypoglycemia. Exercise is best done after meals Exercise plans should be started After medical clearance Slowly with gradual progression Should be individualized Monitor blood glucose levels before, during, and after exercise.

Question 35

Diabetes Mellitus: Pancreas Transplantation

Answer 35

-- Used for patients with Type 1 Diabetes who also Have end-stage renal disease Had, or plan to have, a kidney transplant -- Pancreas transplants alone are rare. Usually kidney and pancreas transplants done together -- Eliminates need for exogenous insulin -- Can also eliminate hypoglycemia and hyperglycemia

Question 36

Diabetes Mellitus: Nursing Management

Answer 36

* * Overall goals - - Active patient participation - - Few or no episodes of acute hyperglycemic emergencies or hypoglycemia - - Maintain normal blood glucose levels. - - Prevent or delay chronic complications. - - Lifestyle adjustments with minimal stress

Question 37

Acute Complications: Diabetes Mellitus | - Diabetic Ketoacidosis (DKA)

Answer 37

``` * Diabetic Ketoacidosis (DKA) Diabetic acidosis or diabetic coma Profound deficiency of insulin Characterized by Hyperglycemia Ketosis Acidosis Dehydration Usually in Type 1 DM May occur in Type 2 if extreme severe illness/stress ```

Question 38

Assessment Findings: DKA

Answer 38

``` Lethargy; weakness Early symptom Poor skin turgor Dry mucous membranes Rapid, weak pulse Orthostatic hypotension Flushed, dry skin Thirst Abdominal pain Anorexia, N, & V Sunken eyes Restlessness, confusion Kussmaul respirations Breath: ketones - fruity Fever Urinary frequency Serum glucose >250 mg/dl; pH <7.35 Glycosuria & ketonuria ```

Question 39

DKA - Intervention

Answer 39

Airway management Oxygen administration Oxygen via nasal cannula/non-rebreather mask Correct fluid/electrolyte imbalance IV access – large bore catheter IV infusion 0.45% or 0.9% NaCl Restore urine output. Raise blood pressure. When blood glucose levels approach 250 mg/dL 5% dextrose added to regimen Prevent hypoglycemia. Potassium replacement - Administer K to correct  hypokalemia Sodium bicarbonate Administer Na Bicarb if severe acidoisis (pH < 7.0)

Question 40

Acute Complications: | - Hyperosmolar Hyperglycemic Syndrome (HHS)

Answer 40

Life threatening syndrome Less common than DKA Patient has enough circulating insulin so that ketoacidosis does NOT occur, but…. not enough insulin to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion See Figure 67-13 page 1457 Few symptoms early Neurologic symptoms due to  osmolality (somnolence, coma, seizures, hemiparesis)

Question 41

Acute Complications: | - Hyperosmolar Hyperglycemic Syndrome (HHS) -- con't

Answer 41

``` Common causes Infections –pneumonia, UTI, sepsis Newly diagnosed Type 2 DM Usually history of Inadequate fluid intake Increasing mental depression Polyuria Laboratory values Blood glucose >400 mg/dL Increase in serum osmolality Absent/minimal ketone bodies Glucose & ketones closely monitored! ``` Medical emergency **High mortality rate Therapy similar to DKA Except HHS requires greater fluid replacement

Question 42

Acute Complications: | - Hyperosmolar Hyperglycemic Syndrome (HHS) -- Intervention

Answer 42

Patient closely monitored Administration IV fluids - correct dehydration 0.9% or 0.45% NaCl – rate depends on cardiac status IV with glucose given when BS ~ 250 mg/dl Insulin therapy – to reduce blood glucose; Regular insulin IV after fluid replacement Electrolytes – correct imbalances; K may be low Assessment Renal status – check urinary output; I & O Cardiopulmonary status – ECG monitoring; monitor vital signs; avoid fluid overload; check lung sounds; CVP; Level of consciousness – assess mental status

Question 43

Acute Complications: Hypoglycemia

Answer 43

*