TOPIC 1 - diabetes Flashcards
glucose level highest at
8am (breakfast)
pre-diabetes
increased risk for developing type 2 diabetes, often asymptomatic, must undergo screening and manage risk factors
____ places clients at risk to become pre-diabetic
metabolic syndrome
definition of prediabetes
impaired glucose tolerance, impaired fasting glucose, or both
precursor of type 2 DM
intermediate stage between normal glucose homeostasis where levels are elevated but not high enough for diagnostic criteria
symptoms of metabolic syndrome
abdominal obesity, hyperglycemia, hypertension, arteriosclerosis, atherosclerosis, elevated cholesterol, elevated HgA1C, elevated triglycerides
type 1 diabetes symptoms
weight loss, weak, fatigue, frequency of infection, rapid onset (acute effect), insulin dependent, familial tendency, peak incidence from 10-15 years
polyuria, polydipsia, polyphagia
type 2 diabetes symptoms
fatigue, recurrent infection, recurrent candida, prolonged wound healing, visual changes, sedentary lifestyle, familial tendency, average age 50 years, history of high BP, obese, high FBS
polyuria, polydipsia, polyphagia
objective data
dry mouth, fruity breath, vomiting, altered reflexes, confusion, muscle wasting, numbness, blur vision
subjective data
malaise, obesity, thirst, poor healing, constipation, frequent urination, nocturia, viral infections,
ask about ___ meds
insulin, corticosteroids, diuretics, phenytoin
normal blood sugar
74-106 mg/dL
Hgb A1C level diagnostic of diabetes
6.5% or higher
fasting plasma glucose diagnostic of diabetes
higher than 126 mg/dL
two hour plasma glucose level during OGTT diagnostic of diabetes
200 mg/dL
micro vascular complications of diabetes
eye and vision changes, DPN, diabetic nephropathy, male erectile dysfunction, cognitive dysfunction
cerebrovascular disease relationship to diabetes
risk for stroke increases, increases likelihood of severe carotid atherosclerosis, elevated glucose + stroke = greater brain injury
HTP, hyperlipidemia, nephropathy, PVD, and alcohol use = increase stroke risk
macro vascular complications of diabetes
cardiovascular disease (result of thrombotic or MI), cerebrovascular disease, stroke, heart attack, sudden death
hyperglycemic blood sugar level
greater than 200mg/dL
not treated unless over 250
hyperglycemic assessment
warm, moist skin, dehydration, positive urine ketones (type 1), elevated blood glucose, mental status varies
treatment of hyperglycemia
sliding scale insulin
hypoglycemia caused by …
too much insulin or too little glucose
hypoglycemia assessment
cool, clammy skin, hungry, blurred or double vision, shaky, nervous, irritable, altered LOC, seizures, coma
treatment
rule of 15
glucagon
dextrose 50%
risk for infection related to
high glucose, reduction of leukocytes
risk for impaired skin integrity related to
altered sensation and altered peripheral blood flow
alterations in nutrition related to
disease, level of nutrition education, current lifestyle habits, finances
activity intolerance related to
obesity
oral anti-diabetic meds
glipizide, metformin, pioglitazone
insulin therapy
regular, rapid, short, intermediate, long
type 1 diabetics ALWAYS…
require insulin
(vs type 2 = only if glucose is uncontrolled)
metformin caution
interacts with iodine contrast media - hold 24 to 48 hours before diagnostic study with contrast
3 defects of type 2 diabetes
insulin resistance
decreased insulin production
increased hepatic glucose production
basal bolus regimen
mimic pancreas, provide enough insulin to ensure a steady glucose supply to maintain basic metabolic process
mealtime insulin
provides additional insulin for glucose absorption after meals
types of rapid acting insulin
lispro, aspart, glulisine
types of short acting insulin
regular - humulin R, novolin R
types of intermediate acting insulin
NPH
types of long acting insulin
glargine, detemir, degludec
rapid acting : onset, peak, duration
onset : 10 - 30 min
peak : 30 min - 3 hr
duration : 3 - 5 hr
short acting : onset, peak, duration
onset : 30 min - 1 hr
peak : 2 - 5 hr
duration : 5 - 8 hr
intermediate acting : onset, peak, duration
onset : 1.5 - 4 hr
peak : 2 - 5 hr
duration : 5 - 8 hr
long acting : onset, peak, duration
onset : 0.8 - 4 hr
peak : no pronounced peak
duration : 16 - 24 hr
inhaled insulin : onset, peak, duration
onset : 12 - 15 min
peak : 60 min
duration : 2.5 - 3 hr
implications of insulin admin
2 nurse check
mix clear to cloudy
rapid acting insulin implications
inject within 15 min of mealtime
short acting insulin is more likely to …
cause hypoglycemia because of long duration
NPH can be mixed with
short or rapid acting insulin
NPH = cloudy (gently agitate before admin)
long acting insulin implications
admin once or twice daily, do not mix with any other insulin
absorption is fastest …
in the abdomen, 2 inches from naval
rotate injections sites in order to prevent …
lipohypertrophy and lipoatrophy
regular insulin admin
IV
all others = SQ
storage of insulin
do not heat or freeze
in use vials may be left at room temp for up to 4 weeks unless room temp is higher than 86 or lower than 32
store unopened in fridge
store prefilled syringes upright for 1 week if 2 insulin types or 30 days for 1 insulin type
insulin pumps are programmed to
deliver continuous infusion of rapid acting insulin 24 hrs a day
can increase or decrease based on carb intake, activity change, or illness
diabetic nutrition interventions
carb intake (45% of daily intake)
limit fat and cholesterol
protein intake (15-20% of daily intake)
limit HFCS and sugar sweetened beverages
limit alcohol - men = 2 drinks, women = 1
exercise interventions
150 min per week of moderate intensive
or 75 min of vigorous
do not exercise within 1 hr of insulin injection or near peak time
BG should be between 80 and 250 if exercising
no exercise if present ketones
somogyi effect
is an overcompensation by the body in response to extremely low blood sugar levels occurring during the night, resulting in early morning hyperglycemia
interventions = bedtime snack
dawn phenomenon
early morning hyperglycemia caused by the release of cortisol and growth hormone during the early morning hours
interventions = increase evening dose or change admin time
changes in insulin dosage related to somogyi and dawn effect
less than 60 predawn levels + hypoglycemia s/s = reduce insulin dosage
2am-4am levels high = increase insulin dosage + bedtime snack
patient teaching on sick days
check glucose every 2-3 hrs
always take insulin
drink lots of fluids (high sugar - drink sugar free, low sugar - drink carb containing drinks)
check urine for ketones every 4 hrs and take rapid acting if present ketones
danger warning signs on sick days
moderate or large ketones
persistent nausea and vomiting
elevated BG after 2 doses of insulin
high fever
assessment parameter to determine how well a patients DM has been controlled over the last 2-3 months
Hgb test
priority for DKA
begin fluid and electrolyte replacement
because infection increases glucose levels …
more insulin is needed
type 1 diabetes hypoglycemia intervention
15g simple carbs
interventions of somogyi effect
check glucose at 3am
after admin of glucagon to unconscious patient …
place patient in side lying position because of nausea
admin oral antidiabetic meds
30 min before meals
diabetes is characterized by
hyperglycemia from abnormal insulin production, impaired insulin use, or both
normal blood glucose range
74 to 106 mg/dL
type 1 vs 2
type 1 makes no insulin at all and is autoimmune, meaning the body develops antibodies against insulin or pancreatic B cells and therefore requires insulin, while type 2 is characterized as insulin resistance
what does the rise in plasma insulin after a meal do
inhibit gluconeogenesis, enhance fat deposition of adipose tissue, increase protein synthesis
counter regulatory hormones
work against the effect of insulin. include :
glucagon, epinephrine, growth hormone, and cortisol
how do counter regulatory hormones increase blood glucose levels
stimulate glucose production and release by the liver
decrease movement of glucose into the cells
the genetic link and predisposition to type 1 diabetes is related to
human leukocyte antigens
onset of type 1 diabetes signs
three P’s and a sudden weight loss because the pancreas can no longer make enough insulin to maintain normal glucose
what does insulin resistance (referring to type 2 diabetes mean)
a condition in which tissues do not respond to the action of insulin because insulin receptors are unresponsive or insufficient
components of metabolic syndrome
increased glucose levels, abdominal obesity, high bp, high triglycerides, decreased HDLs
pre diabetes is defined as
impaired glucose tolerance (IGT), impaired fasting glucose (IFG)
pre diabetes diagnostics
IGT = 2 hour oral glucose tolerance test values at 140-199
IFG = fasting blood glucose levels are 100-125
common drugs that can induce diabetes
corticosteroids, thiazides, phenytoin, atypical antipsychotics
what causes the effects of the three P’s
the osmotic effect of excess glucose in the bloodstream (polydipsia and polyuria)
cellular malnourishment (polyphagia)
in a patient with classic hyperglycemia symptoms… random plasma glucose level diagnostic of diabetes
200 mg/dL
false positive test factors
recent severe restrictions of carbs, acute illness, drugs, bed rest
a Hgb test is accurate because
when blood glucose levels are elevated over time, glucose attaches to Hgb, thus increasing these levels
because type 2 diabetes is a progressive disease, over time…
the combination of nutrition therapy, exercise, OAs, and non insulin injectable agents may no longer adequately manage blood glucose levels
basal bolus plans
mimic endogenous insulin production, consisting of multiple daily injections with frequent self monitoring of glucose
mealtime insulin bolus
inject rapid acting within 15 minutes of mealtime
inject short acting within 30-45 min before meal (more likely to cause hypoglycemia because longer duration)
which insulin can be given via IV
regular insulin when immediate onset of action is desired
why is there caution when injections go into site that will be exercised
increased body temp and circulation increase rate or absorption and speed the onset = hypoglycemia
length and gauge of insulin needles
length : 1/4 in, 5/16 in, 1/2 in
gauge : 28-31
biguanides
most widely used - metformin
action is to reduce glucose production by the liver and enhance insulin sensitivity at tissue level
sulfonylureas
glipizide
action is to increase insulin production by the pancreas (hypoglycemia = major side effect
meglitinides advantage compared to sulfonylureas
more rapidly absorbed and eliminated thus are less likely to cause hypoglycemia
starch blocker drugs
glucosidase inhibitors
work by slowing carb absorption in the small intestines
insulin sensitizer drugs
thizolidinediones
most effect for people who have insulin resistance but can be associated with adverse cardiac responses
most common limiting factors of CGM therapy
cost and insurance coverage
goal of CGM therapy
to increase “time in range” and have fewer highs and lows
when should a person check their glucose after eating to determine if the bolus dose was adequate
2 hours after meal
check in 4 hour intervals when sick
which patient is likely to receive pancreas transplantation
patients who have end stage renal disease
have a history of frequent metabolic complications
consistent failure of insulin based management to prevent acute complications
when should diabetes screening begin
age 45 in 3 year intervals if results are normal
when should type 1 diabetic check their ketones
every 3-4 hours when glucose is greater than 240
signs of hypoglycemia in unconscious patient
tremors, tachycardia, sweating
follow up assessment of patient using insulin therapy
inspect injections sights for lipodystrophy and allergic reactions, review prep and inject technique, take hx of occurrence of hypoglycemia, assess how pt manages hyperglycemia
during travel, in order to prevent hyperglycemia and DVT…
get up and walk at least every 3 hours because sedentary lifestyle raises glucose levels
herbs that may lower blood glucose levels
aloe, ginger, cinnamon, st johns wort, garlic, ginseng
what drug increases the risk of hypoglycemia
b blockers
besides a low blood glucose, what levels could indicate hypoglycemia
a rapid drop in glucose
ex : 300 dropping quickly to 150
when should you contact the HCP in a hypoglycemic episode
if there is no significant improvement after 2-3 doses of 15g simple carbs
which carbs should you avoid giving to patients in a hypoglycemic episode
ones with fat such as candy bars, cookies, whole milk, and ice cream because of slower absorption
acute care setting hypoglycemic interventions
20-50 mL 50% dextrose IV
if not alert and able to swallow - 1mg glucagon
angiopathy complications related to diabetes
agiopathy = end organ disease from damage of blood vessels due to chronic hyperglycemia
retinopathy complications related to diabetes
microvascular damage to retina, partial occlusion of vessels
when occluded - body compensates by forming new blood vessels (neovascularization)
if macula involved - vision lost
teach patients to have frequent dilated eye exams
nephropathy complications related to diabetes
damage to small bv’s that supply the glomeruli of kidney
measure albumin to crt ratio
patients with diabetes who have albuminuria receive ACE inhibitors or ARBs
neuropathy related complications of diabetes
sensory neuropathy - nerve damage because of metabolic imbalances
tingling, burning, itching sensations, atrophy
gastroparesis - complications of autonomic neuropathy that causes anorexia, nausea, vomiting, reflux
cardiac complications - postural hypotension, resting tachycardia, painless MI
neurogenic bladder - empty bladder every 3 hours and tighten abdominal muscles during voiding
skin and infection complications related to diabetes
reddish brown patches - dermopathy
velvety light brown to black thick skin - acanthosis nigricans
red-yellow lesions with atrophic skin that becomes shiny and transparent - necrobiosis lipoidica diabeticorum
