Week 10: Chp 44: Type 2 Diabetes Flashcards
Modifiable Risk Factors
- BMI greater than 26 kg/m; increased risk with BMI greater than 30 kg/m
- Physical inactivity
- HDL cholesterol levels less than or equal to 35 mg/dL and or a triglyceride level greater than or equal to 250 mg/dL
- metabolic syndrome
Non-modifiable risk factors
- first degree relatives with diabetes
- members of a high-risk ethnic population (African American, Latino, Native American, Asian American, Pacific Islander)
- women who delivered a baby weighing greater than or equal to 9 lbs or who were diagnosed with gestational diabetes
- hypertension (>140/90 or on therapy for hypertension)
- women with polycystic ovary syndrome
- HgbA1c greater than or equal to 5.7% on previous testing
- history of cardiovascular disease
Prediabetes
warning sign for the development of type 2 diabetes
- defined by blood glucose levels higher than normal but not high enough to be considered diabetes
- it is an indication that type 2 DM may develop if certain lifestyle changes, the same changes or risk factors related to the development of type 2 diabetes, are not made
- obesity and sedentary lifestyle play a role
What is type 2 Diabetes
involves defects at the cell membrane that prevents normal action of insulin
- even though insulin is present, the cell “resists” its effect in transporting glucose into the cell; over time, the pancreas cannot keep up with the increased demand for insulin; beta-cell failure appears and progresses
- toward the later stages, insulin production declines so that approximately 30% of patients eventually require exogenous insulin delivery to maintain normal blood glucose levels
Clinical Manifestations of type 2 diabetes
slower onset than type 1
- 3 p’s: polyuria, polydipsia, polyphagia
- fatigue
- poor wound healing
- cardiovascular disease
- visual disturbances
- renal insufficiency
- recurring infections
Clinical Manifestations: Recurring Infections example
recurring yeast infections in women with diabetes may indicate poorly controlled blood glucose levels
- yeast cells are normally occurring flora in the vagina; they are kept in check by the acidic environment present in the vagina
- in diabetes, vaginal secretions have more glucose, which produces a nourishing environment for yeast, allowing them to grow and multiply causing an infection
Clinical Manifestations are due to?
- the hyperglycemia
- the microvascular and macrovascular complications of long-term hyperglycemia
Diagnosis of Type 2 DM
done through evaluation of the same laboratory tests as type 1 DM
- HgbA1c levels
- Fasting blood glucose levels
- 2-hr postprandial blood levels
- Random blood glucose levels
Difference in determining Type 1 Vs Type 2 DM
based more on the situation present at the time of diagnosis rather than on the specific laboratory values
-ex: hyperglycemia noted in a physically inactive, overweight adult (BMI >30 kg/m) whose blood glucose is initially controlled with oral medications is diagnosed with type 2 DM even if insulin is eventually required
Hyperglycemia noted in a physically inactive overweight adult (BMI >30 kg/m) whose blood glucose is initially controlled with oral medications is diagnosed with what type diabetes?
Type 2 diabetes
Hyperglycemia noted in a physically active child requiring insulin injections at onset to maintain glycemic control would be diagnosed with which type of diabetes?
Type 1 DM
What does the Treatment for Type 2 DM involve?
a combination of pharmacological interventions and self management that include:
- education
- monitoring glycemic control
- nutrition
- exercise
- monitoring for complications
Pharmacological Interventions for Type 2 DM include what?
oral medications that increase the production of insulin, lower insulin resistance, slow the absorption of carbohydrates, or help lower blood glucose
-these medications are typically used in combination because of their different mechanisms of action; the combination used depends on the patients response, with the goal of achieving and maintaining glycemic targets
Intervention at the beginning of diagnosis is most common with what medication?
-metformin (Glucophage) in combination with lifestyle changes such as diet and exercise
Glucagon-like peptide-1 (GLP-1)
another medication combination is the use of an oral medication in conjunction with a GLP-1 receptor agonist
- GLP-1 agonists are incretin mimetics that are injected subcutaneously either once a week or daily depending on the formulation
- they lower glucose levels by slowing glucose absorption from the intestine, increasing insulin secretion when blood glucose levels are high and lowering he high glucagon levels sometimes found in people with diabetes after meals
- GLP-1 also decreases appetite by attaching to an appetite receptor on the hypothalamus, ultimately helping weight loss
When is insulin indicated with someone with type 2 diabetes
many patients eventually require insulin therapy because of the typical progressive loss of beta-cell function with the progression of the disease
- initiation of insulin at the time of diagnosis is recommended for individuals presenting with weight loss or other severe hyperglycemic clinical manifestations
- an HgbA1c greater than 10%
Diabetes Self-Management Education (DSME)
goal is to empower the person with DM to take responsibility for day-to-day management
-Medicare, medical assistance, and most private insurances reimburse for DSME if it takes place in a program that has been accredited by the ADA or American Association of Diabetes Educators and is implemented by an interprofessional team
To be accredited the DSME must cover what?
- describing the diabetes disease process and treatment options
- incorporating nutritional management into the lifestyle
- incorporating physical activity into the lifestyle
- using medication(s) safely and for maximum therapeutic effectiveness
- monitoring blood glucose and other parameters and interpreting and using the results for self-management decision making
- preventing, detecting, and treating acute complications
- preventing, detecting, and treating chronic complications
- developing personal strategies to address psychosocial issues and concerns
- developing personal strategies to promote health and behavior changes
Why is assessment of glycemic control is important?
it allows the provider to determine the effectiveness of treatment and to plan adjustments to medication and follow-up
- for the diabetes educator, it highlights problem areas in patient self-management so that exploration of patient understanding and appropriate education can occur
- provides patient feedback about what is and what is not working in the overall treatment
How is glycemic control assessed?
- self-monitoring of blood glucose
- continuous glucose monitoring
- monitoring of HgbA1c
Medical Nutrition Therapy
goal is to improve metabolic outcomes by modifying nutrient intake
- approaching normal ranges for blood glucose, blood pressure, and lipids slows the development of each of the chronic complications of diabetes
- meal composition affects glycemic control and cardiovascular risk, so assisting the patient in understanding food choices is essential piece of diabetes self-management
- working with a professional to understand and feel comfortable with food choices contributes to improving compliance with a over-all diabetes care plan
Carbohydrate Guidelines
monitoring carbohydrate intake through carbohydrate counting, exchanges, or experienced-based estimation is a key strategy in achieving glycemic control
- in insulin-dependent patients, insulin doses should be adjusted to match carbohydrate intake, the insulin-to-carbohydrate ratio
- basal-bolus insulin therapy in conjunction with carbohydrate counting is the most physiological treatment and provides the greatest flexibility in terms of food choices and timing of meals
Carbohydrate Counting
a technique useful for managing blood glucose levels
-intake recommendations are individualized on the basis of patient size, activity, and medication use
Foods that contain carbohydrates
- starchy foods and vegetables such as bread, cereal, rice, crackers, potatoes, pasta, dried beans, and corn
- fruit and juice
- milk and yogurt
- sweets and sodas, juice drinks, cakes, cookies, candy, and potato chips
- non-starchy vegetables such as greens, carrots, green beans, cucumbers, peppers, broccoli, cabbage, asparagus, mushrooms, onions, and eggplant contain carbohydrates but in much smaller quantities than starchy foods. These are great foods for increasing the quantity in a meal without impacting the glucose as much
When and how should carbohydrates be consumed?
should be distributed throughout the day in small meals and snacks
-if persons with diabetes choose to consume products containing non-nutritive sweeteners, they should be consumed at levels that do not exceed the acceptable daily intakes; some of these products contain energy and carbohydrates from other sources that need to be accounted for in the total daily carbohydrate intake
Weight control
patients with DM tend to be overweight and have insulin resistance
- nutrition therapy often begins with strategies that reduce food intake and increase energy expenditure through physical activity
- for patients who are overweight or obese, moderate weight loss is associated with significant improvement in insulin resistance, as reflected in metabolic parameters such as blood glucose, blood pressure, and lipid levels
- weight control and diet are essential of DM management and reduce the risk for cardiovascular disease
- for weight control, patients must balance lower fat and calorie consumption with regular physical activity of 30 minutes on most days
Physical Activity Recommendation
both aerobic training and resistance training improve glycemic control
- also improves insulin sensitivity, blood pressure and the lipid profile and decreases risk for cardiovascular disease and all-cause mortality
- helps in management of depressive symptoms and improves sleep quality
Why should a patient with diabetes be assed by a healthcare provider first?
before beginning a program of physical activity more vigorous than brisk walking, should be assessed for conditions that might be associated with increased risk of cardiovascular disease
- of concern are uncontrolled hypertension, severe autonomic or peripheral neuropathy, and pre-proliferative or proliferative retinopathy or macular edema
- a graded exercise test with electrocardiogram monitoring is recommended
Be cautious in patients taking secretagogues and physical activity
secretagogues are medications that facilitate the release of insulin
- physical activity can cause hypoglycemia if the medication dose or carbohydrate intake is not adjusted
- carbohydrate should be ingested if pre-exercise blood glucose levels are less than 100 mg/dL
Complications of Type 2 Diabetes
-hyperosmolar hyperglycemic state (HHS)
Complication: Hyperosmolar hyperglycemic state (HHS)
a serious metabolic derangement that occurs in patients with DM
- characterized by hyperglycemia, hyperosmolality, and dehydration without significant ketoacidosis
- it occurs when there is sufficient insulin to prevent rapid fat breakdown and ketone release, however, there is not enough insulin to prevent severe hyperglycemia
- blood glucose levels can rise to extremes above 600 mg/dL
- the resulting extreme hyperosmolality leads to osmotic diuresis
- dehydration can be profound and electrolyte imbalances severe
- often present with global neurological defects
HHS usually occurs in who?
patient who have some concomitant illness that leads to reduce fluid intake
-infection is the most common preceding illness
Diagnosis of HHS is based on what?
- blood glucose level of 600 mg/dL or greater
- serum osmolality of 320 mOsm/ kg or greater
- profound dehydration
- serum pH greater than 7.4 (it will be more alkaline)
- bicarbonate concentration greater than 15 mEq/L
- low ketonuria and absent to low ketonemia
- alteration in level of consciousness
Treatment of HHS
include standard care for dehydration with IV fluid and treatment for altered mental status, including airway management as appropriate
-patients may respond to IV fluids alone, but IV insulin may be necessary to correct hyperglycemia
Acute and Long-term Complications of Hyperglycemia in Both Type 1 and Type 2 DM
- Depressed Immune Response
- Prolonged hyperglycemia
- Vascular Effects
- Neurological Effects
- Diabetic Peripheral Neuropathy
- Autonomic Neuropathy
Complications of both Type 1 and Type 2: Depressed Immune Response
can lead to infection and poor wound healing, and both are considered acute complications of hyperglycemia
-neutrophil and macrophage phagocytosis of bacteria is impaired, prolonging the inflammatory phase
-the proliferative phase is also prolonged as RBCs becomes less pliable and less able to deliver oxygen to the wound for tissue metabolism and collagen synthesis
>effects include prolonged hospitalizations, increased risk for sepsis, and increased morbidity from the extension of tissue damage
-hyperglycemia is associated with increased risks of: skin and soft tissue infection, pneumonia, influenza, bacteremia/ sepsis, and tuberculosis
Hyperglycemia is associated with increased risk of
- skin and soft tissue infection
- pneumonia
- influenza
- bacteremia/sepsis
- tuberculosis
Complications of both Type 1 and Type 2 DM: Prolonged Hyperglycemia
adversely affects blood vessels and nerves
-because the entire body relies on these networks, the long-term effects are extremely widespread
Complications of Both Type 1 and Type 2 DM: Vascular Effects
- diabetes can be thought of as a vascular disease; in that the damage done to the lining of blood vessels accounts for much of the damage throughout the body
- classified as Macrovascular and Microvascular
Vascular Effects: Macrovascular complications
involve damage to the large arteries that supply the heart and brain
-leading cause of diabetes-related death is cardiovascular disease
Vascular Effects: Microvascular Complications
involve damage done to the small blood vessels and result in damage
(usually to eyes, gums, kidneys, and PVD)
Microvascular Complications: Eyes
the delicate blood vessels that supply the retina are susceptible to damage from prolonged hyperglycemia, resulting in retinal hypoxia
Microvascular Complications: Gums
periodontal disease is more common with diabetes because of the decreased circulation to the gums and increased susceptibility to periodontal bacteria and dental caries
-leads to early tooth loss
Microvascular Complications: Kidneys
the vasculature to the kidneys is affected by hyperglycemia
-diabetes is the single leading cause of renal failure requiring dialysis in the US
Microvascular Complications: Peripheral Vascular Disease (PVD)
as many as 36% of patients with DM have lower extremity peripheral artery disease based on lower extremity blood pressure readings
-PVD increases the risk of nontraumatic amputations of the lower extremities
Complications in both Type 1 and Type 2 DM: Neurological Effects
prolonged hyperglycemia damages nerve cells
- the result can affect several areas of he body
- typical problems are: diabetic peripheral neuropathy, and autonomic neuropathy
Neurological Effects: Diabetic Peripheral neuropathy
results when nerves to the feet and hands are damaged, but it can also impact other peripheral nerves in the body
- Clinical manifestations include: numbness, tingling, or pain
- diabetes over the age 40 have some impaired sensation to their feet; loss of protective sensation can lead to injury that may not be felt; amputation and infection are more likely; greatest risk is improperly fitting shoes
Neurological Effects: Autonomic Neuropathy
results when there is damage to the nerves of the autonomic nervous system
-manifestations are:
>Diabetic gastroparesis: results when the nerves that innervate the stomach are damaged, leading to delayed or erratic emptying of stomach contents into the intestine (symptoms are bloating, early satiety, nausea and vomiting); blood glucose can drop or spike unpredictably if the food reaches the intestine at an unexpected rate
>erectile dysfunction
>orthostatic hypertension
>urinary problems such as difficulty starting urination and inability to completely empty the bladder, can result in UTI
Clinical Manifestations of Type 2 DM are based on?
acute changes secondary to hyperglycemia, such as dehydration and electrolyte imbalance
-other manifestations are due to the more long-term effects of hyperglycemia resulting in vessel damage and organ hypoxia, such as fatigue, poor wound healing, recurring infection, cardiovascular disease, visual disturbances, and renal insufficiency
Nursing Diagnoses
- risk for ineffective tissue perfusion r/t macrovascular vessel changes secondary to hyperglycemia
- risk for ineffective renal perfusion r/t microvascular changes secondary to hyperglycemia
- Risk for infection r/t decreased perfusion and sensation in distal extremites
Nursing Assessments
Assess for:
- vital signs
- serum glucose
- capillary refill in lower extremities
- skin assessment, especially lower extremities and feet, looking for breaks in the skin, erythema, trauma, pallor on elevation, dependent rubor changes in foot size/shape, nail deformities, and extensive callus
- intake and output
- WBC count
- Serum BUN and creatinine levels
- Spot urine for microalbuminuria
- Carbohydrate intake at meals
Assessment: Vital Signs
decreased blood pressure and increased HR are secondary to the fluid volume deficit created by osmotic diuresis related to hyperglycemia
-temperature may be elevated if infection is present
Assessment: Serum glucose
increased glucose levels are due to insulin resistance or relative lack of insulin related to body size
-in a patient diagnosed with and being already treated for type 2 DM, increased glucose levels indicate:
>inadequate self-management, such as poor diet, weight gain, and limited exercise
>increased insulin or oral glucose control medication requirements due to stress, such as infection, causing adrenal release of catecholamines, increasing the hepatic production of glucose
-decreased glucose levels can be caused by inappropriate administration of insulin or medications that stimulate the release of insulin from the pancreas while the patient has inadequate oral intake or increased activity requiring more circulating glucose
Assessment: Capillary refill in lower extremities
decreased perfusion secondary to microvascular changes may manifest as delayed capillary refill
Assessment: Skin
skin breakdown or wounds may occur unnoticed by the patient because of peripheral neuropathy
-resulting wounds are slow to heal as a result of impaired inflammatory response and tissue hypoxia secondary to vessel damage that occurs secondary to hyperglycemia
Assessment: Intake and Output
increased urine output may be present because of osmotic diuresis secondary to hyperglycemia
Assessment: WBC count
an increased WBC count may indicate the presence of infection
Assessment: Serum BUN and creatinine levels
elevations in serum BUN and creatinine levels are indicative of decreased renal function associated with the microvascular changes that develop in the kidneys secondary to sustained hyperglycemia
Assessment: Spot urine for microalbuminuria
elevations of microalbumin are an early indication of microvascular damage to the kidneys from hyperglycemia and/ or hypertension
Assessment: Carbohydrate Intake at meals
adequate carbohydrate intake at meals is essential to avoid hypoglycemia related to insulin administration
Nursing Actions
- blood glucose monitoring completed before meals and at bedtime
- administer oral diabetes medications as ordered
- administer insulin as ordered (basal, preprandial, correctional)
- administer isotonic IV fluid as ordered
- Administer antibiotics as ordered
Actions: Administer oral diabetes medications as ordered
oral diabetes medications are administered to increase the production of insulin, lower insulin resistance, or slow the absorption of carbohydrates or in order to lower blood glucose levels
Actions: Administer insulin as ordered
basal, pre-prandial, correctional
- administering rapid-acting insulin before meals, preparing for ingestion of carbohydrates, and correcting for random high glucose levels as determined by self-monitoring of blood glucose levels prior to the meal, in combination with longer-acting insulin once a day, will mimic the action of a healthy pancreas, helping to maintain tight glycemic control
- in patients with questionable or minimal oral intake, prandial and correctional may be administered together after meals after adequate carbohydrate intake has been confirmed
Actions Administer isotonic IV fluids as ordered
IV fluids may be necessary to replace volume loss due to diuresis
Actions: administer antibiotics as ordered
may be indicted for infection
Teaching: Foot care
meticulous foot care is essential to avoid wounds and infections that could result in amputation due to poor wound healing related to hyperglycemia
-the use of therapeutic shoes and evaluation by podiatry can minimize risk
Foot care education
- wash feet daily and dry thoroughly, including between the toes
- do not soak feet unless specified by a healthcare provider, soaking can unduly break down the skin and make it prone to damage
- be careful of hot water
- use creams, lotions, or moisturizer but not between the toes to avoid fungal infection from too much moisture
- to avoid injury, do not walk barefoot
- use caution in cutting nails, ingrown toenails, or other nail problems may require podiatry consultation
- properly fitting footwear is essential; check shoes each day for objects that may have fallen inside, excessive wetness, or areas that may cause irritation
Teaching: Monitoring for complications
regular healthcare provider visits are essential to monitor for cardiovascular, renal, visual, and skin complications related to hyperglycemia
-regular healthcare provider visits with routine blood work to monitor cardiovascular and renal functioning, along with annual dilated eye examinations and inspection of the feet and lower extremities, are essential to avoid the complication of long-term hyperglycemia
Oral Glucose Control Agents
- Biguanides (metformin)
- Sulfonylureas
- Meglitinides
- Thiazolidinediones
- Alpha-glucosidase inhibitors
Oral Glucose agents: biguanides
(metformin)
- decrease glucose production in the liver; increase insulin sensitivity in skeletal muscle
- taken 2 times a day
- caution in patients with renal impairment; may cause diarrhea
Oral Glucose agents: Sulfonylureas
stimulate the beta cells to produce more insulin
- taken once or twice a day
- risk of hypoglycemia
Oral Glucose Agents: Meglitinides
stimulate the beta cells to produce more insulin
- taken three times a day before meals
- risk of hypoglycemia
Oral Glucose Agents: Thiazolidinediones
decrease glucose production in the liver; increase insulin sensitivity in skeletal muscle
- take once daily
- may increase risk of heart failure; monitor for liver toxicity
Oral Glucose Agents: Alpha-glucosidase inhibitors
slow the breakdown and absorption of sugars and starches
- taken with the first bite of each meal
- may cause diarrhea or flatulence, if the patient experiences hypoglycemia, must correct with dextrose or glucose due to slowed absorption of carbohydrates
