Test 3 diabetes Flashcards
Hypoglycemia reasons
Too much insulin compared with food intake & physical activity
- Insulin injected at wrong time relative to food intake & physical activity
- Wrong type of insulin at the wrong time
- Delayed gastric emptying from gastroparesis
- Decreased liver production of glucose after alcohol ingestion
- Increased insulin sensitivity due to exercise & weight loss
Reasons for hypoglycemia in type 1 diabetes
Severity is based on what?
- TYPE 1
- Body loses its compensatory response
- Pancreas loses function to secrete glucagon
- Long-standing disease causes hypoglycemia unawareness
*Severity of hypoglycemia is based on symptoms
**Chart 64-11 on page 1309
Hypoglycemia s/s?
He is TIRED
He- headache
Is- irritable/sweating
T- tachycardia
I- irritability
R- restlessness
E-excessive hunger
R- dizziness
Cold and clammy, need some candy
Slurred speech, LOC
Hypoglycemia treatment
How many grams of glucose is needed for bs less than 70? Less than 50?
How much does 10grams oral glucose raise blood sugar in 30 minutes
Carbohydrate replacement
15-20 grams - repeat in 15 minutes if not improved
30 grams for less than 50
10 grams oral glucose raises glucose about 40 in about 30 minutes
What to always carry with hypoglycemia
Be aware of what?
Carry carbohydrates or injection, diabetic supplies for testing
Be aware of causes
Hyperglycemia s/s
Three Ps
Hot and dry, sugar high
Or three Ps
Polyphagia-excessive hunger -
In response to cellular starvation
Eating doesn’t help without insulin to move glucose into cells
Polydipsia- excessive thirst -
Due to dehydration
Polyuria- excessive urination
-Osmotic diuresis from excess glucose
Loss of electrolytes (esp. potassium)
dehydration
Blurry vision Headache Confusion Nervousness Fatigue Nausea
Hyperglycemia causes
Too much food
Too little exercise
Too little medicine
Stress
Illness
Injury
Short time between meals and snacks
Low BS causes
Too little food
Too much Medicine
More activity than normal
Too long between meals or snacks
Alcohol
How to care for diabetes
Glucose monitoring before meals or q hour
A1c
Electrolyte monitoring
Cardiovascular monitoring
Kidney monitoring
Monitor intake and output
Skin care
Prevent infection
What are some foot problems due to diabetes?
Why does this occur ?
deformity of foot; warm, swollen and painful.
dry thinning skin and Decreased sensation (neuropathy)
Due to poor vascular supply to veins
Also results in ulcers which can lead to infection and amputation
Charcot foot- deformity of foot; warm, swollen and painful.
Normal
Glucose range
When is it increased
60-100mg ; increase with infection
Normal A1c?
Less than 6.5
Normal fasting glucose levels?
70-110
If 140 or higher= diagnosis of diabetes
Dka (diabetic acidosis) most common type
Type 1 but can be type 2
Dka is due to what pathology?
Hyperglycemia leads to osmotic diuresis, cellular dehydration, and electrolyte loss
How does lack of insulin result in dka ?
Ketone production and metabolic acidosis
Labs that result in dka
Positive ketones (serum and urine)
Low bicarb
Anion gap will be high (greater than 12)
Serum sodium may be falsely low
Potassium may be falsely low, high, or normal
How to drop dka levels quickly
Insulin administration
DKA s/s
3 ps
Kussmauls respiration’s(deep labored breathing) -metabolic acidosis or kidney failure
Ketone breath (rotting citrus)
Abdominal pain
Vomiting
Dehydration
Weakness
Confusion
Shock
Coma
DKA nursing care tx?
Check airway
Check level of consciousness
Start insulin drip- hourly checks, protocol for titration
Hydration status- IV fluids isotonic, then D51/normal saline once BS is less than 250
Electrolytes- check potassium level before giving insulin drops
Take chemistry panels every 2-4 hours
Take vital signs regularly
DKA patient education
Frequent glucose monitoring during illness
Urine ketones when glucose is high
Prevent dehydration
Take insulin!
Assess psychosocial status
How do ketones present themselves in urine with dka
Environment, infection, or emotional stressor
Leads to lack of insulin
Leads to breakdown of fat in cells
Free fatty acids to liver
Formation of ketone bodies
Ketones in urine and blood
Acidosis
Coma
How does high BS lead to DKA?
Lack of insulin leads to breakdown of glycogen to glucose
Leads to hyperglycemia
Leads to osmotic diuresis (increased urination)
Dehydration
Hyperosmolarity hemoconcentration (occurs in dehydration, uremia, and hyperglycemia)
Acidosis
Coma
Hyperosmolarity hemoconcentration state ? What is this?
(occurs in dehydration, uremia (kidney disfunction) and hyperglycemia)
Results how
Decreases blood volume from osmotic diuresis (urine) leads to SEvERE DEHYDRATION
Decreased kidney function prevents kidneys from reabsorbing glucose
Enough endogenous insulin to prevent Ketosis but not to control hyperglycemia
What does insulin do ?
Opens locks so glucose can enter the cell
Stimulates glucose uptake
Suppresses liver production of glucose
Promotes storage of glycogen
Inhibits glycogen breakdown into glucose
Inhibits ketogenesis (conversion of fats to aci
Pathology of diabetes
What do alpha and beta cells do?
Isle of Langerhans (small glands)
Alpha cells: secrete glucagon
Beta cells: secrete insulin
Main fuel for CNS function; AMS severe hypoglycemia
Brain needs continuous supply from blood
Increased by counter regulatory hormones when more energy is needed (glucagon, epinephrine, norepinephrine, growth hormone, cortisol)
Glucose
Increase in levels of counter regulatory hormones to make glucose from other sources
Body breaks down fat & protein in an attempt to provide energy leading to build up of ketones as by product
Absence of glucose
Chronic complications of diabetes
Microvascular disease:
Retinopathy (vision problems) Nephropathy (kidney dysfunction) Neuropathy (nerve dysfunction) Erectile dysfunction Cognitive dysfunction, dementia
Macrovascular disease:
Cardiovascular disease
Cerebrovascular disease
What is neuropathy and what can occur from it?
- Deterioration of nerve function resulting in a loss of autonomic responses
- Silent MI’s
- Delayed gastric emptying (gastroparesis)
- Constipation
- Urine retention/incomplete emptying
- Orthostatic hypotension & syncope
- Increased risk of falls
How to reduce complications of diabetes
Reducing Complications
- Modifiable risk factors
- Smoking cessation
- Weight management
- Cholesterol management
- Blood pressure control
- Regular exercise
Destruction of beta cells in a genetically susceptible person
Immune system fails to recognize body as “self” & destroys cells in the isle of langerhans
Type one diabetes
Initially insulin resistance (reduced response)
Progresses to decreased beta cell secretion of insulin
Often accompanied by cardiovascular risk factors (often obese, HTN, hyperlipideamia, clot risk)
Type 2
Also called syndrome X
simultaneous presence of metabolic factors known to increase risk for developing type 2 diabetes and cardiovascular disease
Abdominal obesity
Hyperglycemia
Hypertension
hyperlipidemia
Metabolic syndrome
Controlling diabetes through healthy lifestyle how?
Stress management Weight management weight loss can resolve insulin resistance Regular intentional exercise Planned exercise program Healthy eating habits Dietician Diabetic educator Regular medical care Regular monitoring and follow up
Health Promotion & Maintenance: Drug Therapy
When lifestyle modifications do not work
Start at lowest dose & increased periodically to reach goal glucose
At maximum dose, if glucose not at goal level, a 2nd agent may be added
Insulin when 2 or 3 oral agents aren’t working
: decreases liver production & intestinal absorption of glucose; improves insulin sensitivity by increasing peripheral uptake & utilization
Biguanides: Metformin (Glucophage)
Insulin stimulators: trigger release of insulin from beta cells
Sulfonylurea agents & Meglitinide analogs (glipizide (Glucotrol), glyburide (Diabeta), glimepiride (Amaryl)
Insulin sensitizers: increase cellular utilization of glucose
Pioglitazone (Actos), rosiglitazone (Avandia)
Black box warning not to be used with hx CVD & HF
What does insulin do and how are doses usually determined
Insulin regimens try to imitate the normal release pattern of the pancreas.
Concentration is usually 100u/ml but can be greater for those with greater insulin resistance.
Starting doses are usually weight based.
Often a combination of meal time & long acting
Fast acting insulin’s
No LAG period
Lispro
Aspart
glulisine
Intermediate insulin’s
I for inter-
Isophane (humalin)
Long acting insulin
L-L-L
Levamir
Lantus
Ultra long acting insulin
U for ultra
DeglUdec
5:00 AM – 6:00 AM
Nighttime release of adrenal hormones that causes glucose elevations at about 5-6am
10:00 PM
Managed by providing more insulin for the overnight period (ex: giving intermediate-acting insulin at 10pm instead of supper time)
Dawn Phenomenon
- Morning hyperglycemia from counter regulatory response to night-time hypoglycemia
- Managed by ensuring adequate dietary intake at bedtime and evaluating the insulin dose and exercise programs to prevent conditions that lead to hypoglycemia
Somogyi Phenomenon
Continuous infusion of a basal dose of insulin with additional meal time doses
Rapid-acting insulin
Adjust dose based on carbohydrates
Potential for Keto acidosis-
- Inexperience using pump
- Infection
- Accidental cessation of infusion/kinking
Ketone testing for glucose >300
Insulin pumps
Best site to administer insulin?
What increases/decreases absorption
Abdomen is best
Injecting into scarred areas decreases absorption
*Rubbing the injection site & heat increase absorption
How to administer/prepare insulin
Degree?
90 degree angle is okay, but 45 for skinny, frail, cachexic patients
- Use needle only once
- Roll (do not shake) cloudy insulin (Ex: NPH) & prefilled syringes
Clear before cloudy! Your in the clear
But cloudy air before clear air
How to store insulin
*Insulin not in use-put in refrigerator;
room temp for 28 days if opened
*Do not expose to extreme heat, cold & light
What assessments to take with diabetic testing ?
Assessment: History Risk factors Family history Birth weights for mothers Blood tests Chart 64-1 pg. 1288 Fasting plasma glucose (FPG) Random glucose Oral glucose tolerance test (OGTT) Glycosylated hemoglobin (A1C) Screening
Is the most diagnostic test for determining whether the client has diabetes
Eat high carb before exam
Remain NPO after midnight the day of test for blood sample
Drink 75gm glucose then another blood sample one hour after
Glucose tolerance test
This is a blood sample after the client refrains from eating after midnight and coming into the clinic for a blood sample that day
Fasting blood glucose
Glucose test of blood sample before meals
Dextrostix-random
Blood test done to determine the clients compliance to his diet and medication regimen
Obtained by blood sample
Glucosylated hemoglobin (A1C)
Glucose tolerance normal range?
200
Fasting blood glucose normal range?
What range is considered diabetic?
What range is considered DKA?
70-110
140 or above
800 or more
Abnormal A1c = non compliance ?
How long to wait between each test?
7 or above
3-4 months (90-120 days)
When to check for ketonuria?
When blood glucose is greater than 240
Checked to determine risk factors for development of type 1 diabetes and progression rate of diabetes
Antibodies
Diabetic diet should contain what?
Balance of carbs , fats , protein
When should one not exercise with diabetes type 1
Is bs is over 240 or below 100
Wait till normal again
And no urine ketones
Type 2 may need a snack to prevent low bs
When does regular insulin peak?
90-120 minutes
Cloudy or NPH peak time?
8-12 hours
Which two insulin’s should not be mixed together?
Lantus and levemir
Would cause hypoglycemia
If a client fails to eat at a regular bedtime snack she might experience what?
What to eat?
Somogyis effect- abrupt drop in bs at night followed by false elevation
Protein source - peanut butter and milk , crackers
Diet for diabetes
Individualized meal plans
Intake needs to be timed with insulin action
Caloric reduction for weight loss if needed
Limit etoh to 2 drinks for men & 1 for women
Carbohydrate counting-
1 unit of rapid-acting for each 15 grams of carbs
Treatment for hyperglycemia hyperosmolar state ?
- Hydration to restore blood osmolarity
- Often 1L/hr. until fluid restored (NS or ½ NS)
- Insulin infusion
- Glucose control, hourly checks
- Assess Neuros every 1 hr (fluids shifts)
- Electrolyte monitoring
- Cardiac monitoring
- Prevention of shock & tissue hypoxia
In depth education for client and diabetes
- Disease pathology
- Glucose monitoring
- Carbohydrates
- Insulin dosages, affects, storage, administration
- Hypoglycemia & treatment
- Hyperglycemia & treatment
- Sick-day procedures?
- Testing for ketones?
- Skin/foot care?
is a complication of diabetes mellitus in which high blood sugar results in -
high osmolarity without significant ketoacidosis.
Symptoms include signs of dehydration, weakness, leg cramps, vision problems, and an altered level of consciousness.
Most often in elderly with type 2
Hyperglycemic hyperosmolar state
What is the sick day plan for diabetes
Notify dr
Monitor bs every 4 hours
Test urine ketones when be greater than 240
Take insulin and meds
Drink 8-12 ounces of sugar free fluids every hour awake. If low bs drink sugared drink
Regular timed meals
Call dr with:
Vomiting and nausea
Large ketones
Blood glucose elevation after two insulin doses
101.5 fever or increasing more than 24 hrs
Rx symptoms as directed and sleep/rest
Foot care and diabetics
Mirror placed in floor
Inspect feet daily ; between toes
Wash feet, lukewarm water and soap; dry well
Apply lotion after bathing; not between toes
Clean socks daily , keep warm
Breathable shoes, leather or cloth, roomy
Trim and smooth nails
Inform dr of blisters or sores infection - protect with sterile dressing
Do not smoke
Check temp of bath water with wrist or thermometer before. 95-110 is best temp
Do not use heating pads, heaters, bottles on feet
Do not go barefoot
Do not wear Sandals
Do not soak feet
Do not cross legs , wear garters , or tight stockings that restrict blood flow
When and how to test for ketones
Before exercise and bs greater than 250
If you are sick
Remove a strip from the tube, taking care not to touch the spongy end of the strip.
Pass urine over the test area of the strip or, alternatively, collect urine in a container and then dip the test area of the strip into the urine
compare the colour of the test area to the colour chart on the side of the tub of strips
Disregard any colour changes that might happen after the set number of seconds has passed
Never mix or dilute what insulin with any other insulin?
Glargine
How far away from umbilicus to give insulin
2 inches
use Asceptic technique (free from disease) with diabetes
True
Macrosomic baby may have what? After birth
Hypoglycemia due to insulin from mom in the uterus
Delayed gastric emptying is a cause of hypoglycemia related to mismatch of nutrient absorption and insulin action
weak muscular contractions (peristalsis) of the stomach, resulting in food and liquid remaining in the stomach for a prolonged period of time.
Can affect what?
Gastroparesis
CNS -Autonomic neuropathy - nerve damage -(vagus nerve)
Normal ketones lab
When to recheck?
May be at risk?
Emergent?
The acceptable range for blood ketones is less than 0.6 mmol/L.
Between 0.6 and 1.5 mmol/L Recheck blood glucose and ketones in 2-4 hours.
Between 1.5 and 3.0 mmol/L May be at risk for developing ketoacidosis.
More than 3.0 mmol/L Requires immediate emergency treatment.
Normal ketones lab
When to recheck?
May be at risk?
Emergent?
The acceptable range for blood ketones is less than 0.6 mmol/L.
Between 0.6 and 1.5 mmol/L Recheck blood glucose and ketones in 2-4 hours.
Between 1.5 and 3.0 mmol/L May be at risk for developing ketoacidosis.
More than 3.0 mmol/L Requires immediate emergency treatment.
