MedSurg 3 - Diabetes Mellitus (Chap 67) Flashcards
Pancreas
- Anatomy
- Lies behind the stomach
- has exocrine and endocrine functions
Pancreas
-Function
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
Glucagon and Insulin
Glucagon and Insulin affect the metabolism of:
- Carbohydrate
- Protein
- Fat
Somatostatin
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
Glucagon
Glucagon is a hormone that increases blood glucose levels. It is triggered by decreased blood glucose levels.
Insulin
- 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
Diabetes
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
Types of Diabetes
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
Cardinal Signs of Diabetes Mellitus == 3 P’s
- POLYURIA
- Frequent urination
- From osmotic effect of glucose
- POLYDIPSIA
- Excessive thirst
- From osmotic effect of glucose
- POLYPHAGIA
- Excessive hunger
- A consequence of cellular malnourishment
Type 1 Diabetes Mellitus
- There is a virtual absence of endogenous insulin
- Dependent on exogenous insulin
- if insulin is withdrawn, ketosis and eventually ketoacidosis develops.
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%
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)
Counterregulatory Hormones (CRH)
- Glucagon, Epinephrine, Growth Hormone, & Cortisol
- - works together as Opposite effect of insulin
Type 2 Diabetes Mellitus
Four Major Metabolic Abnormalities:
- Insulin resistance
- Pancreas ↓ ability to produce insulin
- Inappropriate glucose production from liver
- Alteration in production of hormones and adipokines
Secondary Diabetes
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
Type 1 DM - Signs & Symptoms
Type 1 – Rapid Onset
- Polyuria
- Polydipsia
- Polyphagia
- Weight loss
- Weakness
- Fatigue
- Ketoacidosis
Type 2 DM - Signs & Symptoms
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)
Major Risk Factors: Type 2 Diabetes
- 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
Diabetes Mellitus – Methods of Diagnosis
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 !!
Drug Therapy: Insulin
- 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)
Rapid-acting Insulin:
Lispro (Humalog);
Aspart (Novolog);
Glulisine (Apidra)
Inject 0 to 15 minutes before meal
Onset = 15 minutes
Short-acting Insulin:
Regular (Humulin R; Novolin R)
Regular
Inject 30 to 45 minutes before meal
Onset = 30 to 60 minutes
Intermediate-acting:
NPH (Humulin N, Novolin N);
Lente human insulin (Humulin L)
Cloudy
- Long Acting
Ultralente (Humulin U)
Glargine (Lantus)
Detemir (Levemir)
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)
Storage of insulin
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.
Administration of insulin
Given Subcut
Regular can be given IV
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.
Accepted Insulin Treatment Plans
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)
Problems with Insulin
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
Beta Blockers and Diabetes
Beta adrenergic blockers may Mask symptoms of hypoglycemia
Prolong hypoglycemic effects of insulin
Thiazide/loop diuretics and Diabetes
Thiazide/loop diuretics
Can potentiate hyperglycemia
By inducing potassium loss
Diabetes: Nutritional Therapy
- 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.
Diabetes: Nutritional Therapy
* Alcohol: High in calories No nutritive value Promotes hypertriglyceridemia Detrimental effects on liver Can cause severe hypoglycemia
Diabetes: Nutritional Therapy
- 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
Diabetes Mellitus: Exercise
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
Diabetes Mellitus: Exercise
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.
Diabetes Mellitus: Pancreas Transplantation
– 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
Diabetes Mellitus: Nursing Management
- 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
Acute Complications: Diabetes Mellitus
- Diabetic Ketoacidosis (DKA)
* 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
Assessment Findings: DKA
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
DKA - Intervention
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)
Acute Complications:
- Hyperosmolar Hyperglycemic Syndrome (HHS)
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)
Acute Complications:
- Hyperosmolar Hyperglycemic Syndrome (HHS) – con’t
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
Acute Complications:
- Hyperosmolar Hyperglycemic Syndrome (HHS) – Intervention
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
Acute Complications: Hypoglycemia
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