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NURS 4304 > Pellico: Chapter 30 (Diabetes Mellitus) > Flashcards

Pellico: Chapter 30 (Diabetes Mellitus) Flashcards

1
Q

Diabetes mellitus

A
  • A group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia)
  • Chronic Disease
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2
Q

What other diseases are associated with diabetes mellitus?

A
  1. ) Hypertension
  2. ) Heart Disease
  3. ) Stroke
  4. ) Leading cause of nontraumatic amputations
  5. ) Blindness (in working age adults)
  6. ) End-stage Renal Disease (ESRD)
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3
Q

What percentage of the U.S. population has Diabetes mellitus?

A
  • Approximately 8% of the population (24 million people)
  • About 24% of those with Diabetes mellitus remain undiagnosed! (This means that detection is an important goal)
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4
Q

How many people in the United States have prediabetes?

A

Approximately 57 million people in the United States have prediabetes (that’s almost 18% of the population!)

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5
Q

What is the age trend for diabetes mellitus?

A
  • The occurrence of diabetes, especially type II, is increasing in ALL age groups
  • Diabetes is expecially prevalent in persons over the age of 60
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6
Q

Describe the four different types of diabetes mellitus.

A
  1. Type I Diabetes
  2. Type II Diabetes
  3. Gestational Diabetes
  4. Secondary Diabetes
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7
Q

What is Type I Diabetes mellitus?

A

Previous Classifications/Names: Juvenile diabetes, Juvenile-onset diabetes, Ketosis-prone diabetes, Brittle diabetes, Insulin-depiendent diabetes mellitus

Clinical Characteristics:

  • Onset any age, but usually young (<30)
  • Usually thin at diagnosis; recent weight loss
  • Genetic, immunologic, and environmental etiology (virus)
  • Often have islet cell antibodies
  • Often have antibodies to insulin even before insulin treatment
  • Little/no endogenous insulin
  • NEED insulin to preserve life
  • Ketosis-prone when insulin is absent
  • Diabetic ketoacidosis (acute complication of hyperglycemia)
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8
Q

What is Type II Diabetes mellitus?

A

Previous Classifications: Adult-onset diabetes, Maturity-onset diabetes, Ketosis-resistant diabetes, Stable diabetes, Non-insulin-dependent diabetes (NIDDM)

Characteristics:

  • Onset any age; usually over 30 years
  • Usually obese at diagnosis
  • Causes include obesity, heredity, and environmental factors
  • NO islet cell antibodies
  • Decreased endogenous insulin; OR increased with insulin resistance
  • Most patients can control blood glucose through weight loss if obese
  • Oral antidiabetic agents may improve blood glucose if lifestyle interventions are unsuccessful
  • May need insulin (short or long term) to prevent hyperglycemia
  • Ketosis UNcommon (except in stress or infection)
  • Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) can be an acute complication
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9
Q

What is gestational diabetes mellitus?

A
  • Onset during pregnancy; usually in the 2nd or 3rd trimester
  • Due to hormones secreted by the placenta, which inhibit the action of insulin
  • Above-normal risk for perinatal complications especially macrosomia (abnormally large babies)
  • Treated with diet or insulin (if needed) to strictly maintain normal blood glucose
  • 2-5% of all pregnancies
  • Glucose intolerance transitory but may recur in future pregnancies
  • 30-40% develop overt diabetes within 10 years (usually type II; esp. if obese)
  • Risk Factors: obesity, >30 years, family history, previous large babies (>9lb)
    • Screening Tests on all women at 24-28 weeks gestation
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10
Q

What are risk factors for gestational diabetes mellitus?

A
  1. Obesity
  2. Age >30
  3. Family History of Diabetes
  4. Previous large babies (>9lbs)
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11
Q

When should all pregnant women be screened for gestational diabetes?

A

ALL women should be screened for gestational diabetes (glucose challenge test) between 24 to 28 weeks of gestation

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12
Q

What is secondary diabetes mellitus?

A

-Also known as diabetes mellitus associated with other conditions or syndromes

  • Depending on the ability of the pancreas to produce insulin, the patient may require treatment with oral antidiabetic agents or insulin
  • Accompanying/Causal Conditions:
    • Pancreatic Diseases
    • Hormonal Abnormalities
    • Medications (corticosteroids)
    • Estrogen-Containing Preparations
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13
Q

What is prediabetes (PrevAGT)?

A

Previous Classifications: previous abnormality of glucose tolerance (PrevAGT)

Characteristics:

  • Current normal glucose metabolism
  • Previous history of hyperglycemia (e.g. pregnancy, illness)
  • Periodic blood glucose screening after age 40 if there is a family history or symptomatic
  • Encourage ideal body weight, because loss of 10-15lb may improve glycemic control
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14
Q

What is prediabetes (PotAGT)?

A

Previous Classifications: potential abnormality of glucose tolerance (PotAGT)

Characteristics:

  • NO history of glucose intolerance
  • Increased risk of diabetes if…
    • Positive family history
    • Obesity
    • Mother of babies over 9lb at birth
    • Member of certain Native American tribes with high prevalence of diabetes (e.g. Pima)
  • Periodic blood glucose screening and encourage ideal body weight
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15
Q

Describe the characteristics of impaired glucose tolerance?

A

Previous Classifications: Borderline diabetes, Latent diabetes, Chemical diabetes, Subclinical diabetes, Asymptomatic diabetes

Characteristics:

  • Oral glucose tolerance test (OGTT) between 140mg/dL and 200mg/dL
  • Impaired fasting glucose defined by levels between 110mg/dL and 126mg/dL
  • 29% eventually develop diabetes
  • Above-normal susceptibility to atherosclerotic disease
  • Renal and retinal complications usually NOT significant
  • May be obese or non-obese (obese should reduce weight)
  • Should be screened for diabetes perdiodically
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16
Q

Describe why the diabetes classification system is dynamic.

A
  1. ) There can be many differences among individuals within each category
  2. ) EXCEPT for people with type I diabetes, patients may move from one category to another
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17
Q

What are the four different issues with insulin that can cause diabetes mellitus?

A
  1. ) Total lack of insulin
  2. ) Impaired release of insulin
  3. ) Inadequate or defective insulin receptors in body tissue
  4. ) Insulin that is either inactive or destroyed before it can become effective
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18
Q

What is the suspected cause of type I diabetes mellitus?

A

It is believed to be autoimmune in nature and result from a total lack of insulin due to destruction of pancreatic beta cells

  • Interaction between genetic component AND acquired component (autoimmune)
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19
Q

When is type I diabetes usually diagnosed?

A

Childhood

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20
Q

What is believed to be some of the causative factors of type II diabetes?

A

It is believed that there is an interaction between genetic components and acquired components (obesity, inactivity, high sugar diet)

  • Obesity and inactivity are the primary risk factors
  • Hyperglycemia is the typical result, despite the presence of insulin in the body
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21
Q

When is type II diabetes usually diagnosed?

A

It is usually diagnosed in adults >40 years but is being diagnosed in increasingly younger patients

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22
Q

What are the THREE P’s that describe the symptoms of diabetes mellitus?

A

Polyuria (excessive urination)

Polydipsia (excessive thirst)

Polyphagia (excessive hunger

  • Other symptoms include…
    • Fatigue
    • Muscle Weakness
    • Poor Blood Flow
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23
Q

What are the common symptoms of type II diabetes?

A
  1. ) The THREE P’s (Polyuria, Polyphagia, Polydipsia)
  2. ) Fatigue
  3. ) Impaired Blood Circulation
  4. ) Muscle Weakness
  5. ) Muscle Wasting
  6. ) Vision Changes (Blurred Vision)
  7. ) Numbness/Tingling in Hands or Feet (Neuropathy)
  8. ) Dry Skin
  9. ) Skin Lesions that are Slow to Heal
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24
Q

What are the common symptoms of type I diabetes?

A
  1. ) The THREE P’s (Polyphagia, Polydipsia, Polyuria)
  2. ) Fatigue
  3. ) Muscle Weakness
  4. ) Poor Blood Circulation
  5. ) Nausea
  6. ) Severe Vomiting
  7. ) Abdominal Pains
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25
Q

What are common acute and long-term complications of diabetes mellitus?

A

Acute Complications:

  • Diabetic Ketoacidosis (mainly type I)
  • Hyperosmolar Hyperglycemic Nonketotic Syndrom (HHNS)
  • Hypoglycemia

Long-Term Complications:

  • Microvascular Disease (e.g. renal and retinal disease)
  • Macrovascular Disease (e.g. CHD, CVA, PVD)
  • Neuropathies
26
Q

Which organ is responsible for the secretion of glucagon and insulin to help regulate blood sugar?

A

Pancreas

  • Islet of Langerhans Cells
    • Alpha Cells (20%): Glucagon
    • Beta Cells (70%): Insulin, Amylin
    • Delta Cells (<10%): Somatostatin
    • Gamma/F Cells (<5%): Pancreatic Polypeptide
    • Epsilon Cells (<1%): Ghrelin
27
Q

What is insulin?

A
  • It is a hormone secreted by beta cells in the islets of Langerhans cells of the pancreas
  • Anabolic/Storage Hormone: insulin moves glucose from the blood into muscle, liver, and fat cells
28
Q

How does insulin function once inside the cells?

A
  1. ) Transports and metabolizes glucose for energy
  2. ) Stimulates storage of glucose as glycogen in the liver and muscle cells
  3. ) Signals liver cells to stop the release of glucose
  4. ) Enahcnes storage of dietary fat in adipose tissue
  5. ) Accelerates transport of amino acids into cells
  6. ) Facilitates the transport of potassium into the cells
  7. ) Inhibits the breakdown of stored glucose, protein, and fat
29
Q

Insulin facilitates the transport of ______, and _______ (an electrolyte) into the cells

A

Insulin facilitates the transport of glucose and POTASSIUM into the cells

30
Q

What is glucagon?

A

It is another pancreatic hormone secreted by the alpha cells of the islets of Langerhances, which stimulates the liver to release stored glucose and thereby, increases blood sugar

  • Secreted in response to low blood sugar
31
Q

In short _______ promotes hypoglycemia and _______ promotes hyperglycemia.

A

In short, insulin promotes hypoglycemia, and glucagon promotes hyperglycemia.

32
Q

What is “basal” insulin?

A

-The pancreas continually releases a small amount of insulin during fasting periods (e.g. between meals or overnight)

  • 50% of the total insulin secreted daily is under basal conditions (the other half is in response to meals)
  • The estimated adult (70kg) basal insulin secretion rate ranges from 18-32 U/24hrs
  • Minutes after eating, the serum insulin level rises, peaking in 3 to 5 minutes and returning to baseline withing 2 to 3 hours
    • Nurses may need to manage insulin drips based on basal insulin secretion rates to attain glycemic control
33
Q

What is glycogenolysis?

A

It is the breakdown of glycogen to glucose in the liver in response to blood sugar that has become too low.

  • It is the FIRST response to low blood sugar
34
Q

What is gluconeogenesis?

A

After 8-12 hours without food, the liver forms glucose fom the breakdown of noncarbohydrate substances, including amino acids

  • This is a secondary response after glycogen stores have been depleted
35
Q

Describe the etiology of type I diabetes mellitus.

A
  • Accounts for 5-10% of people with diabetes
  • Acute Onset
  • Commonly begins in childhood/young-adulthood (but can occur at any age)
  • Desctruction of the pancreatic beta cells
  • Combined genetic, immunologic, and environmental factors
  • Common underlying factor is genetic susceptibility**/predisposition
  • Autoimmone Disease
  • Associated with certain human leukocyte antigen (HLA) types); increases risk by 3-5x
  • INITIATED by environmental factors such as viruses or toxins
36
Q

Describe the course of untreated type I diabetes.

A
  • Beta cell destruction causes decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia
  • Postprandial Hyperglycemia: occurs after meals since glucose derived from food cannot be stored in the liver
  • Exceeding Renal Glucose Threshold: usually when there is at least 180-200mg/dL of blood glucose, as kidneys cannot reabsorb all of the filtered glucose
    • Glycosuria: glucose appears in the urine
  • Osmotic Diuresis: glucose is an osmotic agent and water follows it, causing an excessive loss of fluids and electrolytes
37
Q

What is the course of type I diabetes that typically leads to ketoacidosis?

A
  • Unrestrained glycogenolysis and gluconeogenesis: insulin normally inhibits these processes
  • Hyperglycemia: due to the insulin deficiency and unrestrained glycogenolysis and gluconeogenesis
  • Ketones: a byproduct of fat breakdown; an organic acid
  • Ketoacidosis: the life-threatening decrease in pH causing by excessive amounts of ketones present in the blood
38
Q

What is the etiology of type II diabetes?

A
  • Make up 90-95% of those with diabetes
  • Commonly associated with old age/obesity; increasing in younger people (obesity epidemic)
  • Results from insulin resistance and impaired insulin secretion
  • Insulin becomes less effective in stimulating glucose uptake by the cells and at regulating glucose release by the liver
  • Exact mechanisms unknown; genetic factors
  • Increased amounts of insulin must be secreted to overcome insulin resistance and beta cells cannot keep up with increased demand for insulin
  • DKA UNCOMMON: usually enough insulin present to prevent
  • Hyperglycemic hyperosmolar nonketotic syndrome from uncontrolled type II
39
Q

Why does type II diabetes often go undiagnosed?

A
  • Associated with slow, progress glucose intolerance and its onset may go undetected for many years
  • Symptoms are typically mild (fatigue, irritability, polyuria, polyphagia, polydipsia, poor wound healing, frequent infections, changes in vision)
  • Many are actually diagnosed as a result of routine laboratory tests or during opthalmoscopic examinations (screening is important!)
  • Complications:
    • Microvascular (diabetic retinopathy, neuropathy, nephropathy)
    • Macrovascular (peripheral vascular, coronary disease, stroke)
40
Q

What is the etiology of gestational diabetes mellitus (GDM)?

A
  • Secretion of placental hormones, which causes insulin resistance
  • Physiologic stress of pregnancy reveals existing glucose tolerance abnormalities that were not apparent prior to pregnancy
  • Occurs in as many as 14% of pregnant women
  • Risk Factors:
    • Obesity
    • Personal History of GDM
    • Family History of Diabetes
    • Birth of Baby >9lbs
41
Q

Describe the recommended screening procedures for gestational diabetes mellitus (GDM).

A
  • Risk assessment for gestational diabetes should be completed during the
  • High Risk: tested as soon as possible and then retested between 24-28 weeks if initial glucose was normal
  • Low-Moderate Risk: initially tested between 24-28 weeks of pregnancy
42
Q

Describe the recommended management of gestational diabetes.

A
  • Initial Management: diet, exercise, blood glucose monitoring; insulin if hyperglycemia persists
  • Blood Glucose Goals: maintain tight regulation
    • Before Meals: 95 mg/dL or less
    • 1hr After Meals: less than 130-140 mg/dL
    • 2hr After Meals: less than 120 mg/dL
  • Education: counseling to maintain ideal body weight and exercise regularly
    • High risk of developing type II diabetes w/in 10 yrs
    • After delivery, blood glucose levels usually return to normal
43
Q

Why is screening for type II diabetes so important?

A

Type II diabetes is frequently NOT diagnosed until complications (which can be permanent) are present

  • At-Risk Children: should be screened starting at age 10
44
Q

Describe the important risk factors for type II diabetes.

A
  • Family history of diabetes
  • Obesity (BMI>25)
  • Ethnicity (African Americans, Latinos, Native Americans, Asian Americans, Pacific Islanders)
  • Age (>45 years)
  • Previously ID’d impaired glucose tolerance or impaired fasting glucose
  • Hypertension (>140/90 mm Hg)
  • Low HDL cholesterol (<35 mg/dL) and/or high triglyceride levels (>250 mg/dL)
  • History of gestational diabetes or delivery of babies over 9 lbs
45
Q

What are the incidence rates of diabetes among various ethnicities?

A
  • Native Americans/Alaska Natives (16.5%)
  • Blacks (11.8%)
  • Hispanics (10.4%)
  • Asian Americans (7.5%)
  • Whites (6.6%)

-By 2050, nearly half of the U.S. population will be other than white, which makes identifying ethnic risk factors important

46
Q

How does hyperglycemia affect the immune system?

A
  • Impairs immune function (decreases white blood cell function)
  • Promotes inflammation
  • Increases blood viscosity
  • Favors growth of yeast organisms
  • Associated with blood vessel wall changes resulting in increased risk for infection
  • Recurring infections
  • Microvascular and macrovascular complications
  • Foot ulcers; slow-healing wounds
47
Q

What is a normal fasting glucose for a NONdiabetic?

A
  • 80-90mg/dL with a range of 70-120mg/dL
48
Q

What is the fasting glucose level for prediabetes?

A
  • 100-125 mg/dL
49
Q

What is the typical fasting plasma glucose (FPG) levels and random plasma glucose levels of diabetics?

A
  • Fasting Plasma Glucose (FPG): 126 mg/dL or higher
  • Random Plasma Glucose Levels: 200 mg/dL or more on more than one occasion
50
Q

Which test for diabetes mellitus is no longer recommended for routine clinical use in nonpregnant adults?

A

The oral glucose tolerance test (OGTT) is no longer recommended for routine clinical use in nonpregnant adults

51
Q

What are some important gerontologic considerations of diabetes mellitus?

A
  • Greatest increase in incidence is occuring in the elderly (people with diabetes are living longer)
  • Possible Causes: poor diet, physical inactivity, altered insulin secretion, insulin resistance
  • Elevated blood glucose levels commonly appear in the 5th decade of life and increase with aging
  • Other than those with overt diabetes, about 20% of those over the age of 65 have hyperglycemia
  • Likely Comorbidities That Complicate Diabetes: HTN, CVD, CVA
  • Normal physiologic changes of aging may mask the symptoms of diabetes, making diagnosis more difficult!
  • Increased Complication Risks: polypharmacy, depression, cognitive impairment, urinary incontinence, falls, chronic pain
52
Q

How should goals in diabetes treatment be tailored for the elderly population?

A
  • The goals of diabetes treatment may need to be altered when caring for elderly patients
  • Focus is on QUALITY of life issues such as maintaining independent functioning and promoting general well-being
  • Avoidance of prolonged hyperglycemia
    • BUT avoid striving for strict control of blood glucose levels (may increase chances of severe hypoglycemia)
53
Q

List age related changes that may affect diabetes and its management for gerontological populations.

A
  • Sensory: decreased vision and smell, taste changes, decreased proprioception, diminished thirst
  • Gastrointestinal: dental problems, appetite changes, delayed gastric emptying, decreased bowel motility
  • Activity/Exercise Pattern: more sedentary
  • Renal Function: decreased function and drug clearance
  • Affective/Cognitive: medications/meals omitted or taken erratically
  • Socioeconomic Factors: fad diets, loneliness/living alone, lack of money/lack of support system
  • Chronic Diseases: HTN, arthritis, neoplasms, acute/chronic infections
  • Potential Drug Interactions: use of another person’s medications, consulting mult. HCPs for different illnesses, alcohol use/abuse
54
Q

What are the five components of diabetes management?

A

The therapeutic goal for diabetes management is to achieve normal blood glucose levels (euglycemia) without hypoglycemia, while maintaining a high quality of life

  1. ) Nutrition
  2. ) Exercise
  3. ) Monitoring
  4. ) Medication
  5. ) Education
55
Q

Why is nutrition one of the foundations of diabetes management?

A
  • Nutrition management alone is often associated with reversal of hyperglycemia in type 2 diabetes
  • Make sure to consult a registered dietition to educate the patient; as the nurse give further education and support
  • The MOST IMPORTANT dietary management objectives are…
    • Control of total caloric intake to attain or maintain a reasonable body weight
    • Control of blood glucose levels
    • Normalization of lipids and blood pressure to prevent heart disease, CAD, CVD, and PVD
    • Meet and maintain energy needs
    • Provide all essential food constituents necessary for optimal nutrition
56
Q

Assessing the Patient With Diabetes: History

A
  • Symptoms related to diagnosis of diabetes, hyperglycemia, and hypoglycemia (OPQRST)
  • Results of any blood glucose monitoring
  • Status, Symptoms, and Management of Chronic Complications of Diabetes (eye, kidney, nerve, GI, GU, sexual, peripheral vascular, foot issues)
  • Adherence/ability to follow prescribed dietary management plan, exercise regimen, prescribed pharmacologic treatment
  • Use of tobacco, alcohol, and prescribed/OTC meds
  • Lifestyle, cultural, psychosocial, and economic factors that may affect diabetes treatment
  • Effects of diabetes or its complications on functional status (e.g. mobility, vision)
57
Q

Assessing the Patient With Diabetes: Physical Examination

A
  • Blood Pressure (sitting and standing to detect orthostatic changes)
  • Body Mass Index (height and weight)
  • Funduscopic Examination/Visual Acuity
  • Skin Examination (lesions, insulin-injection sites, acanthosis nigricans, discoloration esp. in lower limbs)
  • Foot Examination (lesions, signs of infection, pulses, sense of feeling)
  • Neurologic Examination (vibratory and sensory examination using monofilament, deep tendon reflexes)
  • Oral Examination
58
Q

Assessing the Patient With Diabetes: Laboratory Examination

A
  • HgbA1c
  • Fasting Lipid Profile
  • Test for Microalbuminuria
  • Serum Creatinine Level
  • Urinalysis
  • Electrocardiogram
59
Q

Assessing the Patient With Diabetes: Need for Referrals

A
  • Ophthalmology
  • Podiatry
  • Dietitian
  • Diabetes Educator
  • Others if indicated
60
Q
A

NURS 4304 (2 decks)

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