MedSurg Mod 5: Diabetes Flashcards
What is happening with diabetes prevalence
it is increasing among all gender and race groups
What sort of minority groups are disproportionately affected by diabetes
African Americans
Hispanic Americans
Pacific Islanders
Native Americans
Different Classifications of Diabetes
Type 1
Type 2
Gestational
LADA and MODY
Diabetes Associated with other conditions
MODY
Maturity onset diabetes of the young
LADA
latent autoimmune diabetes in the adult
Except in Type 1 Diabetes, what can people do with diabetes categories
move from one to another
If someone says a steroid caused them to have diabetes, what does that mean?
If a person had a lung disease and got steroids to decrease inflammation, the steroids will increase glucose levels and they may rise to a diabetic level
This did not cause diabetes directly but pushed the levels beyond tolerance and the person was probably close to diabetes as well
Why can Cystic Fibrosis cause Diabetes
clogged ducts lead to pancreatic damage which damages beta cells meaning there is no insulin made
S/S of Diabetes
fatigue
thirst (polydipsia)
hunger (polyphagia)
increased urinary output (polyuria)
vision changes
Why does vision change with diabetes?
2 reasons:
- Fluid changes in the eye from dehydration
- Circulating glucose is damaging the retina and structures of the eye
Diagnosis of diabetes involves what?
Symptoms AND any of the following:
- RANDOM blood glc > or equal to 200 mg/dL
- FASTING glc > or equal to 126 mg/dL
- 2 Hour Post Prandial glc > or equal to 200 mg/dL
- HgA1c levels >or equal to 6.5-7%
Why does random blood glucose not usually diagnose diabetes
it has no regard to the time of the day or meals recently eaten among other considerations
Which of the 4 possible diagnostic tests is the classic measure for diagnosing diabetes
Fasting Glucose
HgA1c
it is glucose stuck to hgb/RBC
it is being used more and more nowadays
it is a measure of how much glucose our RBC is exposed to over 3 months and we want that to be below 7%
Can an A1C be drawn at any time with no preparation or fasting unlike a Fasting Glucose?
yes
What level of HgA1c is concerning for diabetes
above 6.5-7%
What level of Fasting glc is concerning for diabetes
> or equal to 126
What are the important topics to educate the diabetic patient about
- Self Care
- Disease Process
- Consequences and Complications
What things need to be included for education on Self care for a diabetic
- SMBG - self monitoring blood glucose
- foot care
- the 3 F’s
What are the 3 F’s
Food
Fitness
Fixes (in illness)
teach these to a diabetic
What are some major consequences and complications that arise from diabetes
Cardiovascular Disease (the big one)
Nephropathy
Neuropathy
Retinopathy
Blood glucose over the limit regardless by how much…
it over the limit and can still cause damage - so it is important to teach people that
What are some options for administering insulin at home
Needle and syringe
insulin pens
jet injectors
insulin pumps
Jet Injectors
Puts insulin in SQ region without a needle
It is not painful but there is a sensation of jet pressured injection
Insulin Pump
It is not an IV, it is put in SQ tissue and insulin is given AND blood glucose levels are monitored
It attempts to mimic normal body changes and can be automatic or decided by you
Why is self monitoring so important in diabetes
- Useful tool as part of diabetes management
- Helps to detect hypoglycemia
- helps to adjust insulin dosing
Freestyle Libre
one continuous glc monitoring system (like another - Dexcom G6) that uses a thin filament to measure glucose every minute - a glucose monitoring innovation
it has a sensor on the back of the arm and a handheld scanner that reads results
It requires a fingerstick for confirmation of problems though
What is important education to teach the diabetic patient regarding being sick or having GI illness
- do NOT eliminate insulin doses even with N/V
- Person should attempt small frequent portions of carbohydrates
- Drink fluids every hour
- Assess blood glucose every 3-4 hours
Why should insulin not be eliminated when sick?
because during times of stress blood glucose levels will rise even if you are not eating
What are the main areas of focus for diabetic foot care
- Daily inspection and bathing of feet
- Properly fitting shoes / podiatry (no bare feet d/t infection and wound risk)
- toenail management (by a podiatrist)
Generally if you hear type 1 Diabetes what are the most common consequences seen
- Blindness
- Kidney Disease (50% of new ESRD pts are diabetic)
- Peripheral Neuropathies
Generally if you hear type 2 diabetes what are the most common consequences seen
- Heart Disease
- HTN
- Stroke
What is important to note about the common consequences of type 1 and 2 diabetes
they can be seen in either type of diabetes, we just generally see certain consequences more commonly in one type or another due to age of diagnosis
for example the cardiovascular issues of type 2 often coincide with a later life diagnosis where the vessel related changes are added on top of it to speed up vessel damage
What are the 4 most important complications of Diabetes
Hypoglycemia
Hyperglycemia
DKA
HHS or HHNKS
Hypoglycemia is an ___
emergency
Medical Management for Hypoglycemia Initially
First grab 15 g of oral carbohydrates
If an emergency where not awake: 1 amp of D50W IV can be used
Maintenance of IV solution occurs as well
Why is D50W IV important for emergency hypoglycemia
it contains 25 gm of dextrose - simple
1 gram will increase blood glucose about 4 mg
and it is metabolized fast in 30 minutes
What is the first line of action: 15 g oral carbohydrate or 1 amp of D50W IV for hypoglycemia?
15 g oral carb
1 gram of the 25 grams of dextrose will increase blood glucose levels by ___ mg
4 mg (approx)
Nursing Interventions for Hypoglycemia
monitor IV site
I&O
monitor labs: glc and lytes
monitor IV fluid, rate, site
education on s/s of hypoglycemia and prevention - such as having a simple carb available at home
Medical management for Hyperglycemia initially
IV REGULAR INSULIN infusion w/ frequent glucose checking
IV Fluids since water is also being pulled out of the body
What kind of insulin is given to hyperglycemics
Regular Insulin via IV
Nursing Interventions for Hyperglycemia
Monitor IV concentrations and rate
I&O
monitor labs like glucose and lytes
education on s/s and prevention
Insulin Drip
a nursing intervention of regular insulin given IV
it is diluted in normal saline and it is regular NOT fast acting
there is a specific technique and procedure to giving this as insulin can adhere to the sides of tubing
always given via a pump, never manually
What are the specific flushing and priming procedures for insulin drip
In patient treatment only
Always use an IV pump not manual
Typically it is computer guided
What are the 6 S’s or 6 Common Causes for DKA
Sepsis (infection)
Skipped insulin dose
Stress (mostly physiological but emot/psych as well)
Sugar
Surgery
Substance abuse
What is the human response (s/s) of DKA
thirst or very dry mouth
frequent urination
fatigue
dry or flushed skin (from dehydration)
N/V or abdominal pain (Abdominal pain is a HUGE one)
SOB (maybe yes maybe no)
difficulty concentrating
Diagnostic Lab Tests for DKA
Blood glc levels >250
Ketones in urine
blood gases: pH <7.3 and Bicarb <18 mEq/L
Creatinine increased
Sodium, Potassium, Phosphate nL or Increased
How can you remember the human response to DKA via D.K.A.,?
D - Diuresis, Dehydration, Delirium, Dizziness
K - Kussmaul breathing, Ketotic breath
A - Abdominal Pain!!!
Kussmaul breathing
breathing faster to blow off Co2 in DKA
Medical Goals of DKA
Rehydration
Restore Electrolytes
Reverse Acidosis
If the goal is rehydration, what must the nurse do for the DKA patient
VS
Monitor I&O
Monitor IV: Solution, Rate, Site
Monitor Lungs and Extremities: Edema
Monitor Mental Status
If the goal is restoring electrolytes, what must the nurse do for the DKA patient
Monitor Labs: Glucose level, Potassium Level!!!, Bicarbonate Level, CO2 level
Maintain telemetry
Replace electrolytes as ordered
Monitor neurological status
Why is potassium to critical to think about with DKA
because K will shift into cells with insulin via DIK
Telemetry
monitoring heart rhythm
Neurologic status will improve from DKA as…
glucose levels improve
If the goal is reversing acidosis what must the nurse do for the DKA patient
Administer IV insulin and bicarbonate as ordered (may see bicarb but insulin is always given)
Monitor ABGs
Hyperglycemia Hyperosmolar NonKetotic Syndrome (HHS or HHNKS)
INADEQUATE INSULIN
> Not enough to prevent hyperglycemia BUT enough to prevent lipolysis
more common in Type 2
*so no fats break down but hyperglycemia is not prevented - also it is no acidotic
Common Causes for HHNKS
Acute Illness (most common reason)
Medications that exacerbate hyperglycemia like contraceptives, thiazides, and steroids
Dialysis
Human Response (S/S) of HHNKS
Persistent osmotic diuresis (d/t hyperglycemia) (greater than DKA)
Profound dehydration - dry mucous membranes, poor skin turgor, tachycardia, variable neurological signs like altered mental status, seizures and hemiparesis
Hypotension
Diagnostic Lab Tests for HHNKS
Increased blood glucose 600-1200 mg/dL
Electrolytes
CBC
increased BUN
increased Serum Osmolality exceeding 350 mOsm/kg
ABGs have a normal bicarbonate (non acidotic)
What may be worse in HHNKS compared to DKA
- Fluid Loss is greater
- Blood glucose may be higher and worse
*but there is no acidosis so it isnt as deadly as quickly as DKA
What is the big symptom that sets HHNKS apart from DKA
Neurological Findings
The neurological status can be so affected that they appear to be having a stroke
Medical Goals of HHNKS
- Rehydration
- Restore Electrolytes
- IV Insulin Administration
If the goal is rehydration, what must the nurse do for the HHNKS patient
VS
Monitor I&O
Monitor IV solution rate and site
Monitor lungs/extremities for edema
Monitor mental status
If the goal is restoring electrolytes what must the nurse do for the HHNKS patient
Monitor labs - glucose level, potassium level, bicarbonate level, CO2
Maintain telemetry
replace electrolytes as ordered
monitor neurological status
If the goal is IV insulin administration what must the nurse do for the HHNKS patient
administer insulin as ordered
monitor ABGs
Which condition has potassium as a more serious concern: DKA or HHNKS
DKA due to Hydrogen potassium ion shifting
Which condition has a larger need for fluids: DKA or HHNKS
HHNKS
What is an important thing to consider regarding diabetes and hospitalization
Often diabetes is not the primary diagnosis or the reason for hospitalization - if anything it would be DKA or HHNKS causing the admission
Why do glucose control needs change with hospitalization for the diabetic patient
it means when someone has a physiological stressor like an infection or MI, the glucose levels will rise so they will need to change their usual medications to keep these levels under control
it must be kept in mind as people around you will forget
stress increases everyone’s glucose, but usually beta cells take care of it but that is not possible for diabetics
What are some major self care issues for Diabetics in the hospital
- Conflict with Hospital Routine - they may do well with their diabetes at home but the changes of the hospital routine can alter their glucose levels
- Monitor for educational opportunities as now is the time to augment their knowledge
Nursing Interventions for the Hospitalized Diabetic
Assess patient home routine and communicate to appropriate departments
Assess patient reaction to any previous hypoglycemic episodes
Know insulin actions and peaks
Arrange for snacks if meals are delayed
What to do Pre operatively for a diabetic going into surgery
monitor for s/s of hypo and hyperglycemia as stress will elevate blood glucose and prolonged NPO status can decrease it
Monitor labs
only give about half the amount of medicine as it is ordered that way prior to entering surgery
What to do for post operative care for a diabetic coming out of surgery
Routine post op care AND:
monitor for s/s of hypo and hyperglycemia
monitor labs
monitor for cardiovascular complications
monitor for skin breakdown
maintain adequate nutrition and hydration
not very different except for particular attention to skin and glycemia
Diabetics are more prone to ___ since their wound healing is impaired
dehiscence
Insulin is a __ __ medication
high risk
What must be done for giving insulin?
- Verify order and insulin vial with another nurse and know hospital policy for high risk medications
- Check patients blood glucose BEFORE administering
- Know how to mix insulin in one syringe or even if they can be mixed as most cannot
Most insulin cannot __ together
mix
What 2 kinds of insulin NEVER mix with any other kinds of insulin
Long Acting Insulin
Extra Long Lasting Insulin
You can only mix ___ and ___ insulin
Regular and NPH (Intermediate)
How to draw up regular and NPH insulin to mix when OK
Step 1. Draw up the clear (Regular and fast acting)
Step 2. Draw up the cloudy (NPH intermediate acting)
Why is NPH referred to as long acting insulin when it is an intermediate acting insulin
it used to be a long acting but is now intermediate
