Week 1 - Diabetes Flashcards
what is diabetes (3)
- disease related to abnormal insulin production
- impaired insulin utilization
- or both
what is the cause of type 1 DM
- progressive destruction of the beta cells –> no release of insulin
describe the onset of type 1 DM (2)
- sudden onset of symptoms
- typically in people under 30
what is the cause of type 2 DM
- the pancreas is still producing insulin, but the insulin is either insufficient, poorly used by the tissues (insulin resistance), or both
decsribe the onset of type 2 DM (2)
- gradual onset of symptoms –> often goes undetected until complications
- typically in people older than 35
what are the 3 P’s ph type 1 DM / hyperglycemia
- polyuria
- polydipsia
- polyphagia
what are other symptoms of type 1 DM (5)
- weight loss ( due to the body burning fat)
- glucosuria
- weakness & fatigue (body lacks energy bc cant get sugar)
- vision changes
- vaginal yeast infections in women
when is type 1 DM often discovered?
- in the ER when they get DKa
what type of symptoms are common in type 2 DM
- nonspecific
- may have symptoms similar to type 1
list symptoms in type 2 DM (5)
- fatigue
- recurrent infections
- delayed wound healing
- visual acuity changes
- painful peripheral neuropathy
what are the 4 methods to diagnose DM
- hemoglobin A1C
- fasting plasma glucose lvl
- random or casual plasma glucose lvl
- two hour oral glucose tolerance test (OGTT) lvl
what is hemoglobin A1C
- test that shows how much glucose is attached to hemoglobin molecules over RBC lifespan
what is the benefit of hemoglobin A1C (2)
- greater convenience (no fasting required)
- determines glycemic control over time –> over 90-120 days
what is normal A1C? what A1C lvl indicates DM
- normal = < 6.5%
- DM = > 6.5%
pts with DM should have regular assessments of A1C every how often?
3-6 mo.
what are the benefits of people w DM who have near-normal A1C lvls (3)
reduced risks for the development of:
- retinopathy
- nephropathy
- neuropathy
what is fasting plasma glucose (FPG)
- test that measures BG after fasting (no caloric intake) for at least 8 hrs
what FPG lvl indicates DM
> 7.5 mmol/L
what random/casual plasma glucose measurement indicates DM
> 11.1 mmol/L
- plus classic symptoms (polyuria, polydipsia, weight loss, polyphagia)
what is a OGTT lvl
- test that gives the pt a 75 g glucose load, then measures glucose lvls 2 hr later
what OGTT lvl indicates DM
> 11.1 mmol/L
what are the goals of DM management (4)
- promote well-being
- reduce symptoms
- prevent acute complication of hypo/hyperglycemia
- prevent long-term complications
what are important aspects of management of DM (5)
- nutrition
- exercise
- drug therapy
- self-monitoring of BG
- BP control
what is the cornerstone of therapy for DM
- nutrition
what other interprofessional members should be involved in nutrition therapy for DM (2)
- dietician
- diabetes nurse education
what should be considered when creating nutrition plans for someone w diabetes (8)
- keep food routine as regular as possible
individualize to:
- behavioral
- cognitive
- socioeconomic
- cultural
- spiritual aspects
- age
- needs
- preferences
describe the meal plan for a pt with type 1 DM (4)
- base on usual food intake balanced w insulin & exercise patterns
- insulin regimen is managed day to day
- intermeal and bedtime snacks are often necessary (especially w NPH)
- carb counting strategies
why are bedtime snacks often required for a pt with type 1 DM
- the insulin often peaks during the night = risk of hypoglycemia
what is the emphasis of nutritional therapy for a pt with type 2 DM (4)
based on achieving:
- glucose
- lipid (fat reduction)
- BP lvl goals
what is the benefit of weight loss for a pt with type 2 DM (3)
improve glycemic control by:
- increasing insulin sensitivity
- increasing glucose uptake
- decreasing hepatic glucose hepatic
describe the diet plan for a pt with type 2 DM (3)
- calorie reduction
- reduction of total fats (especially sat. fat)
- increased fibre
for pts with type 2 DM, what interventions might be enough to attain an optimal lvl of BG control
lifestyle modifications:
- healthy eating
- regular physicial activity
- maintenance of desirable body weight
many also need oral antihyperglycemics (or insulin)
why is exercise an essential part of DM management (7)
- increases insulin sensitivity
- lowers BG lvls
- contributes to weight loss
- reduce BP
- improves circulation
- decreases triglycerides and LDL
- decreases cholestrol
exercise plans for pts w DM should be started… (2)
- after medical clearance
- slowly w gradual progression toward the goal
when is it best to exericise for a pt w DM
- best done after meals
what effect does exercise have on BG
- causes decreased BG
when should pts w DM avoid exercise
- during peak times of insulin –> risk of hypoglycemia
how long can the glucose lowering effect of exercise last
-up to 48 hrs
what steps r/t diet can prevent hypoglycemia when exercising (4)
- exercise about 1 hr after a meal
- if not doing it after a meal, take a 10-15 g carb snack before exercising
- have several small carb snacks every 30 min
- carry fast acting source of carbs w them
what is the importance of self-monitoring of BG
- allows the pt to make self-management decisions regarding diet, exercise, and meds
- can detect hypo/hyperglycemia
what is the benefit of invasive glucose monitors that use a sensor under the skin to display BG (4)
- displays BG continuously
- updates values every 1-5 min
- helps identify trends and patterns
- pt is alerted during episodes of hypo/hyperglycemia
it is recommended that pts w type 1 DM test their BG at least __ times per day: type 2? when else should it be tested?
- type 1: 3 per day and include post and preprandial testing
- type 2: at least once per day
and whenever hypoglycemia is suspected
what type of med is required for pts with type 1 DM
- insulin
when is insulin required for pts with type 2 DM
if the combo of:
- nutritional therapy
- exercise
- and oral antihyperglycemics cannot maintain BG control
what type of meds do pts with type 2 DM take
- oral antihyperglycemics
when do insulin requirements increase
- periods of stress such as illness or injury
what is the fnxn of oral antihyperglycemics
- improve the mechanisms in which insulin & glucose are produced & used by the body
what is required for oral antihyperglycemics to be effective
- must have some circulating endogenous insulin
what are the 4 categories of insulin
- rapid
- short (regular)
- long
- intermediate
what is a type of rapid acting insulin
lispro
what is the onset of rapid acting insulin
10-15 mins
what is the peak of rapid acting insulin
- 60-90 min
what is the duration of rapid acting insulin
3-5 hr
when should rapid acting insulin be administered
- 0-15 min before meals (w food)
- or up to 15 min after a meal (not preferred)
what is a type of regular /short acting insulin
- humulin R
what is the onset of short acting insulin
30-60 min
what is the peak of short acting insulin
2-4 hr
what is the duration of short acting insulin
- 5-8 hr
when should short acting insulin be administered
- 30-45 min before meals
what is a type of intermediate acting insulin
NPH
what is the onset of intermediate acting insulin
- 1-3 hr
what is the peak of intermediate acting insulin
- 4-8 hr
what is the duration of intermediate acting insulin
12-16 hr
what are 2 types of long acting insulin
- glargine (lantus)
- detemir (levemur)
what is the onset of long acting insulin
- 1-2 hr
what is the peak of long acting insulin
- no peak –> released steadiy and continuously over 24 hr
what is a pro and con to long acting insulin
- pro = no peak = less risk of hypoglycemia & does not need to be given w food
- con = does not cover post prandial BG
what is the duration of long acting insulin
- 24 hrs
what type of insulin cannot be mixed w others
- long acting
what is the only type of insulin that can be given IV
- regular
when should intermediate insulin bc given
- early morning or hs to cover in the background
what type of insulins are often used in combo?
- short or rapid with NPH
describe storage of insulin (4)
- unopened = refridgerate
- open = room temp
- avoid prolonged exposure to sun
- avoid temps higher than 30* or below freezing
what are some complications insulin therapy (5)
- hypoglycemia
- allergic rxns
- lipodystrophy
- dawn phenomen
- somogyi effect
what do both the dawn & somogyi effect cause
- hyperglycemia in the morning
what is the somogyi effect
- when BGL drops = rebound hyperglycemia in the morning caused by BGL dropping during the night (d/t insulin) , causing CRH to be released
what is the danger associated w the somogyi effect (2)
- when BGL are measured in morning, and see hyperglycemia, insulin dosage may be increased
- also associated w the occurrence of undetected hypoglycemia during sleep
what is the treatment for the somogyi effect (2)
- increased bedtie snack
- decrease insulin before bed
what is the dawn phenomonon
- hyperglycemia in the morning caused by the normal rise in BGL as the body prepares to wake up (thru hormones) & the body is not produced insulin to control rise in BGL
what is the treatment for the dawn phenomonon (2)
- increase in insulin before bed
- adjust the timing of insulin before bed
how can we tell the difference between the somogyi effect & the dawn phenomonon
- if BG is low between 2-4 am, suspect the somogyi effect
- if BG is normal or high at 2-4 am, suspect the dawn phenomonon
what can caused increased BG (4)? how?
- acute illness
- surgery
- corticosteroids (prednisone)
- emotional and physical stress
thru the release of cortisol
what interventions can be done to avoid the rise in BG during times of stress (6)
- monitor BG frequently when sick
- maintain regular doses of OHAs and insulin
- if pt is ill and continuing w regular meal plan, increase noncarb containing fluids
- if vomiting 2x in 24 hrs, and cannot keep BGL in control, go to ER
- if pre-op doctor will order specific orders
- if pt is ill and not eating, supplement food intake w carb containing fluids
if a pt is on corticosteroids, what may need to be done to maintain control of BG
- may need to increase OHA or insulin
what is important to consider if a pt is NPO post-op
- NPO = may have low BG = careful w insulin doses
what is an acute complication associated w type 1 DM
- diabetic ketoacidosis
what is DKA
- life-threatening complication that occurs when the supply of insulin is insufficient
= glucose cannot be used for energy
= body breaks down fat stores instead
what does the break down of fat stores cause in DKA (3)
- ketone bodies excreted in urine
- altered pH –> metabolic acidosis
- depleted electrolytes
what can cause DKA
- missed insulin dosage
- times of stress, trauma, infection in pts w type 1 DM
what are signs of DKA (5)
- severe hyperglycemia
- dehydration (hyperglycemia = polyuria)
- metabolic acidosis
- fruity breath
- kussmaul’s resps
what might BGL be during DKA
> 14 or may just say “high”
what must be done if the BG monitor says “high”
- a serum blood draw needs to be sent for glucose
what are signs of severe dehydration (10)
- increased urine output
- poor skin turgor
- dry mucous membranes
- sunken eyes
- thirst
- orthostatic hypotension
- tachycardia
- abdominal pain
- restlessness
- confusion
how does DKA cause metabolic acidosis
- due to accumulation of ketone bodies
- get decreased pH
what are kussmaul’s resps? why does this occur in DKA?
rapid breathing to try to decreased acidity
what is the treatment for DKA (8)
Fluids Insulin Glucose (monitor) Potassium (insulin pushes K into the cell) Infection (monitor for) Chart fluid balance Ketones (monitor)
+ Airway management (O2, monitor signs of fluid overload)
what should you monitor in a pt with DKA (5)
- cardiac monitoring
- lung sounds
- LOC
- potassium
- bicarb
- signs of fluid overload
what type of fluid is used for DKA
- NS to start
when is insulin therapy withheld until for a pt with DKA
- until fluid resuscitation has begun
- and until K>3.3
(to prevent hypokalemia and depletion of vascular volume)
what electrolytes should we administer w treatment for DKA
- potassium IV to prevent hypokalemia
- IV sodium bicarb if pH <7
how is insulin administered during DKA
- bolus to start
- then continuous insulin
what is an acute complication associated w pts with type 2 DM
- HHS (hyperosmolar hyperglycemia syndrome)
who does HHS typically occur in
- older adults w type 2 DM
- pts also often have history of inadequate fluid intake
what is HHS
- life threatening complication that occurs in pts with enough insulin to prevent DKA but not enough to prevent severe hyperglycemia
what does HHS result in (5)
- polyuria
- very high hyperglycemia (>34)
- neuro changes
- increased serum osmolarity
- absent/minimal ketone bodies
why does increased serum osmolarity occur w HHS
- due to high glucose
- & polyuria
why is BG so much higher in HHS than DKA
- HHS produces less symptoms in the early stages = BG rises higher
is DKA or HHS more common? which has a higher mortality rate?
- DKA more common
- HHS has higher fataility rate
what is the treatment for HHS?
- same as DKA
but requires greater fluid replacement (bc of correction of high osmolarity)
what are some differences between HHS and DKA (3)
- HHS has no ketone bodies = no metabolic acidosis, fruity breath, kussmaul breathing, etc.
- hypokalemia not as significant
- high osmolarity not as much of an issue in DKA
what often precipiattes HHS? why?
- infection/illness
bc contributes to dehydration
what can HHS progress to? why?
- HHNC (hyperglycemic, hyperosmolar nonketotic coma)
- the very high BGL cause more severe neuro impairments
what is hypoglycemia
- low BG <4
what type of symptoms do you see in hypoglycemia
- if BG <4 = adrenergic (SNS) symptoms
- if BG <2.5 = CNS symptoms
what type of SNS symptoms are seen in hypoglycemia (9)
- sweating
- tachycardiac
- shaking
- anxiety
- palpitations
- hunger
- pallor
- nausea
- cold, clammy skin
what type of CNS symptoms are seen in hypoglycemia (13)
- irritability
- visual disturbances
- weakness
- lack of coordination
- confusion
- headaches
- drowsiness
- dizziness
- convulsions
- difficulty speaking
- stupor
- loss of consciousness
- coma
similar to signs of intoxication
what can cause hypoglycemia (4)
- exercise
- alcohol
- too much insulin
- insufficient food intake
what is very important to prevent hypoglycemia
- self monitoring
what is a complication associated hypoglycemia
- hypoglycemia unawareness syndrome
what is hypoglycemia unawareness syndrome
- when repeated bouts of hypoglycemia = densensitized to SNS signs of hypoglycemia
= no warning signs
what should be done at first sign of hypoglycemia
- check BG
if the BG is below 4 mmol/L what should be done
- treat immediately
what is the treatment for mild-mod hypoglycemia & they are conscious/able to swallow (3)
- give 15-20 g of a simple, fasting acting carb (juice box, lifesavers, juice, etc.)
- retest BG 15 min later
- give a protein and starch or a meal once over 4mmol
- check BG again ~45 min after treatment
what do you do if BG is still below 4 when you retest 15 min after giving a fast acting carb
- give another load of 15-20 g of fast acting carbs
- if no improvement after 2-3 doses of 15-20 g of carbs, give 1 mg of glucagon
what is an example of a good protein & starch to give a pt after hypoglycemia
- pb and crackers
- cheese and crackers
what is the treatment for hypoglycemia if the pt is unconscious or unable to swallow (2)
- 1 mg glucagon IM or SC
- IV admin of 25-50 mL of dextrose 50% in ater over 1-3 min –> “1 AMP of D50” (most common in hospital)
what are the 2 categories of chronic complications of DM
- macrovascular
- microvascular
what are some microvascular complications of DM (4)
- retinopathy
- nephropathy
- neuropathy
- dermopathy
what are some macrovascular complications of DM (3)
- peripheral vascular disease
- cardiovascular disease
- cerebrovascular disease
what are 2 other chronic complications of DM
- infections
- foot ulcers
a nursing diagnosis r/t diabetes is ineffective health management. what teaching about the disease process can be done (10)
- appraise the pts current lvl of knowledge
- describe disease process and therapy/treatment
- instruct pt on measures to prevent or minimize symptoms
- discuss lifestyle changes required
- describe possible chronic comp
- plan individualized exercise program
- review steps to prevent hypo/hyperglycemia
- instruct pt on which S&S to report to HCP
- review insulin admin
- review OHA regimen
- refer pt to local community agencies or support groups
what teaching r/t diet can be done for a pt with diabetes (3)
- determine pt & caregivers feelings and attitudes towards prescribed diet and the expected degree of dietary compliance
- assist the pt to accommodate food preferences in the prescribed diet
- refer pt to dietician or nutritionist
what teaching can be given to the pt regarding activity & exercise (3)
- inform pt the purpose & benefits
- instruct pt how to monitor tolerance of the activity and exercise to prevent injury
- assist the pt to incorporate an activity & exercise regimen into their daily lifestyle
what nursing interventions r/t hyperglycemia management can be done (4)
- monitor S&S of hyperglycemia
- anticipate situations in which insulin requirements will increase
- facilitate adherence to diet and exercise regimen
- restrict exercise when BG are >14, especially when ketones present to decrease body’s requirements for already unavailable glucose
what teaching regarding foot care can be given (5)
- perform comprehensive foot assessment for neuropathy
- provide info regarding the relationship between neuropathy, injury, and vascular disease & the risk for ulceration and lower extremitity amputation
- caution abt potential sources of injury to the feet
- instruct pt to inspect inside of shoes daily for foreign objects, nail points, torn lining, and rough areas to avoid injury by factors that are not felt
- recommend specialist care for thick fungal or ingrown toenails, calluses
what are some potential sources of injury to the foot (10)
- heat
- cold
- callouses
- chemicals
- use of strong antiseptics or astringents
- use of adhesive tape
- going barefoot
- wearing sandals
- open-toed shoes
- ill fitting shoes
what nursing interventions can be done regarding hypoglycemia mngmt (4)
- monitor for S&S
- determine pts recognition of hypoglycemia S&S
- instruct pt to have simple carb available at all times
- instruct pt to obtain and carry approp emergency ID
a nursing diagnosis r/t diabetes is risk for peripheral neurovascular dysfunction. what nursing interventions can be done for circulatory care & arterial insufficiency (7)
- perform appraisal of peripheral circulation for baseline
- inspect skin for arterial ulcers or tissue breakdown
- protect extremitity from injury
- maintain adequate hydration
- encourage pt to obtain exercise as tolerates
- instruct pt on factors that interfere w circulation
- instruct pt on proper foot care & foot wear
what are some factors that interfere w circulation (4)
- smoking
- restrictive clothing
- exposure to cold temp
- crossing of legs
