week 12: Glucose Regulation Flashcards
how does glucose relate to the liver?
glucose: inside cells converted to ATP (cellular energy/function)
islets of Langerhans (<2% of the gland)
alpha cells produce and secrete glucagon
beta cells produce and secrete insulin
what are alpha cells?
they produce and secrete glucagon
what is beta cells?
they produce and secrete insulin
simply put: how does the body regulate blood glucose?
converts glycogen to glucose (elevates blood sugar) and when its done converts glucose back to glycogen
also glucagon stimulates glycogen breakdown
insulin: stimulates glucose uptake from blood
what happens when their’s high blood sugar?
promotes insulin release
what happens when theirs low blood sugar?
promotes glucagon release (helps with conversion of glucose sugar) and then increase blood sugar!!!
what is the normal range of blood sugar? good to know
4-6 mmol/L
what are the two major pancreatic hormones?
insulin and glucagon
what does insulin do exactly?
it lowers blood sugar: continuously released (basal rate) into the body, with increased amount released after eating (bolus rate)
select all that is true regarding insulin:
Insulin is required for glucose uptake in skeletal, fat, and heart muscle
Suppress liver production of glucose and promotes glycogenesis
Increased protein and lipid synthesis (triglyceride storage)
Inhibits ketogenesis (fat to glucose) and gluconeogenesis (protein to glucose)
Converts excess glucose to free fatty acids
all true
what does glucagon do exactly with blood sugar?
Raises Blood Glucose: released in response to low levels of blood glucose, protein ingestion, and exercise
select al that is true regarding glucagon:
Counter regulatory to insulin
Stimulates glycogenolysis and gluconeogenesis Stimulate glucose to be released from the kidney
last statement false: its the liver bomboclaaaat
what is the scope of blood sugar?
hypoglycaemia (<4 mmol/L)
Euglycemia - 4-6 mmol/L
hyperglycemia: >6 mmol/L
fill in the blank:
When blood sugar is low the pancreas releases_____________ which stimulates the liver to release glucose.
_____________ are the endocrine functional units of the pancreas.
The liver converts and stores glucose as ______________.
glucagon, islet of langerhans
glycogen
fill in the blank:
______________ is a hormone that lets glucose enter liver, fat, and muscle cells.
__________________is needed by our cells for energy in order to function.
insulin, glucose*
- sub would be fat
what causes impaired glucose regulation?
Diabetes (fountain) Mellitus (honey)
multi system disease related to abnormal insulin production, impaired insulin utilization, or both
metabolism disorder impacting carbohydrates, fats and proteins
what are the three causes for diabetes mellitus?
1 inadequate/absent production of insulin
2 insulin resistance
3 elevated stress cortisol
go more into depth with inadequate/absent production of insulin? DM
essentially the destruction of beta cells
Genetics, viruses, pancreatic cancer, pancreatitis, idiopathic (unknown)
Over production of insulin – destroyed over time
go more into depth with insulin resistance? DM
Insulin resistance: target cells are less able to metabolize the glucose available to them => hyperglycemia => hyperinsulinemia
* Reduced binding of insulin to its receptors
* Reduced receptor numbers
* Reduced receptor responsiveness
target cells are less able metabolize the glucose available to them => hyperglycemia => hyperinsulinemia
* Reduced binding of insulin to its receptors
* Reduced receptor numbers
* Reduced receptor responsiveness
what cause of DM does this fall under?
insulin resistance
Destruction of beta cells
* Genetics, viruses, pancreatic cancer, pancreatitis, idiopathic (unknown)
* Over production of insulin – destroyed over time
what is this describing?
inadequate/absent production of insulin
what does elevated stress (cortisol) have to do with DM?
its a glucocorticoid - encourages the production of glucose (sugar)
* Pro-inflammatory state
* Stimulated glycogenolysis and gluconeogenesis * E.g., trauma, living conditions, societal, infection
what are the four different types of diabetes mellitus?
Autoimmune destruction aka type 1 diabetes (T1DM) complete destruction of beta cells
Insulin Resistance/Insulin deficiency
type 2 Diabetes (prediabetes) lifestyle
ex. high glucose diet cells working hard constantly
Maturity onset diabetes of the young:
Inherited genetic adaptation (e.g., HNF-1αG319S)
* Management of fat and proteins to store and use energy
Gestational Diabetes Mellitus (GDM)
this happens during pregnancy
Select all that is true regarding Diabetes Mellitus in Manitoba:
11.5 million Canadians living with diabetes or prediabetes
Among Manitobans:
o 28% live with diabetes or prediabetes
o 10% live with diagnosed diabetes.
* Diabetes complications are associated with premature death
* Diabetes can reduce lifespan by five to 15 years
true
does diabetes contribute to
strokes
blindness
heart attacks
kidneys failure requiring dialysis
non traumatic leg and foot amputations
true
it is true that
there is a much larger pop of First Nations in the youth and not much within the elders?
if so try to think of why that could be?
true
perhaps untreated diseases such as diabetes mellitus
true or false: majority of First Nations live within the northern health region?
how would this affect their accessibility to healthcare
true, less access to proper healthcare and higher rate of mortality
how does the colonial structure and imposed lifestyle affect indigenous population - hyperglycemia?
diet: processed foods, carbohydrate (sugar, flour, salt)
sedentary convivence based lifestyle
tv, vehicle transportation
Changes in activity/movement:
traditional indigenous lifestyle: active life to live, joy of movement
Colonial Lifestyle: introduction of exercise to lose weight
access to food:
* Exceedingly high cost
* Destruction of the land (fishing, hunting, gathering)
what is colonial abuse? (increase in stress, leading to increase in cortisol)
- Residential ‘school’ trauma (physical, emotional, spiritual, community)
- Cultural genocide – e.g., healing, understanding of health, ceremony, commune with nature
true or false: Today, Diabetes in First Nations 25x higher than all
other Manitoba youth, with rapid progression to
insulin.
true sadly..
how does genetics play a role in hyperglycemia (diabetes)
the gene: HNF-1αG319S variant
thrifty gene hypothesis (certain populations may have genes that determine increased fat storage, obesity)
Impairs insulin secretion when exposed to dietary carbohydrate stress, but protective in traditional off-the-land food rich in protein and fat
what clinical manifestation does this describe: ‘I went to the bathroom and 10-minutes later I knew I would need to go to the bathroom again’
polyuria
what clinical manifestation does this describe: ‘I drank glass after glass of water, but I still felt thirsty’
polydipsia
what clinical manifestation does this describe: ‘I was so tired I could not stay awake at work. My co-workers saw me
falling asleep’
cellular dehydration
what clinical manifestation does this describe: ‘I was at bingo and one day I could not see the numbers on the
screen’
blurred vision
is this true or false: Hyperglycemia causes increased osmosis and increased serum osmolality
true
what are the clinical manifestations of high blood sugar?
glucosuria (glucose in the urine)
polyuria (frequent urination)
polydipsia (excessive thirst)
what are some other clinical manifestations of diabetes?
tiredness
frequent urination
sudden weight loss
wounds that wound heal
sexual problems
always hungry
blurry vision
numb or tingling hands or feet
always thirsty
true or false:
Patients may present with chronic complications of hyperglycemia:
* Fatigue, recurrent infections, prolonged wound healing, visual acuity changes, and painful peripheral neuropathy in the feet
true
what are the four diagnostic methods ? how many need to be positive
need 2 positive tests
1. hemoglobinA1C greater than 6.5%
2. fast blood glucose - greater 7 mmol/L
3. Random plasma blood glucose greater than 11.1 plus classic symptoms of DM
4. 2 hour - oral tolerance test - gestational diabetes
go more in depth with the four methods of diagnosis?
- HemoglobinA1C >6.5%
* Determining glycemic control over time: shows the amount of glucose that has been attached to hgb molecules over the lifespan of the RBC (120 days)
* Overall glucose control ‘average’ over last 90-120 days. - Fasting blood glucose (fast for 8 hours, water intake is ok) >7mmol/L
- Random plasma blood glucose >11.1 plus classic symptom of DM
- 2 hour - Oral glucose tolerance test:
* Patient drinks 75g of glucose, (usually pregnant) blood/capillary blood glucose is measured at 30, 60, and 120 min.
* Normal: <11.1 mmol/L at 30 and 60 min; < 7.8 mmol/L at 120 min
How frequently should a patients blood sugar be monitored?
before meals
When would a nurse perform a blood glucose test?
once a day or once a week
How does a nurse perform a bedside blood glucose test?
supplies:
gloves
needle
alcohol wipe
cotton ball
blood glucose reader
chip to insert into reader (takes ur blood)
secondary screening: screening for type 2 diabetes:
Screen every 3 years in individuals ≥40 years of age or in individuals at high risk using a risk calculator.
Screen earlier and/or more frequently (every 6 to 12 months) in people with additional risk factors for diabetes or for those at very high risk using a risk calculator
true
what levels are: normal, at risk, prediabetes, diabetes
normal: <5.6 mmol/L and A1C <5.5%
at risk: 5.6-6.0 mmol/L and/or A1C 5.5-5.9%
prediabetes: 6.1-6.9 mmol/L and/or A1C 6.0-6.4%**
diabetes: greater or 7 mmol/L and or greater or 6.5%
what are some acute clinical manifestations of hyperglycemia?
Glucosuria!!
* Polyuria!!
* Polydipsia!!
* Polyphagia
* Increase in appetite followed by lack of
appetite
* Weakness, fatigue
* Blurred vision
* Headache
* Nausea and vomiting
* Abdominal cramps
* Progression to HHS or DKA
signs of insulin resistance: skin tags
acanthuses nigricans
from undiagnosed DM, untreated/under-treated diabetes, inactivity, stress, acute illness, infection, surgery, medications (e.g. corticosteroids)
hyperglycemia
what is hyperosmolar hyperglycaemic state?
its a DM acute complication, commonly seen in people with Type 2 DM who have ability to produce some endogenous insulin
lab values and treatment of hyperosmolar hyperglycaemic state (HHS)
Laboratory values: blood glucose greater than 34mmol/L, increased
serum osmolality
Treatment: fluid replacement (0.9% or 0.45% NS)
true or false: Increase rates of HHS being seen in children
Hyperglycemia can be extreme before HHS is recognized
true
what is this: in the absent of insulin, increase lipolysis, increase free fatty acids; accumulation of ketone bodies
diabetic ketoacidosis
is metabolic acidosis linked to diabetic ketoacidosis?
yes
what acute complication of DM is most commonly seen in autoimmune disease?
diabetic ketoacidosis
what are some major complications of diabetes: Microvascular?
eye: h blood glucose and high bp can damage eye blood vessels - causes cataracts, glaucoma and retinopathy
kidney: high bp damages small blood vessels and excess blood glucose overworks kidneys - nephropathy
neuropathy - hyperglycemia damages nerves in peripheral NS. may result in pain and numbness. feet wounds may be undetected infection - gangrene
what are some major complications of diabetes: Macrovascular?
brain: increase risk of stroke and cerebrovascular disease, cog impair, transient ischemic attack
Heart: high bp and insulin resistance increase risk of coronary heart disease
Extremities: peripheral vascular disease results fro narrowing blood vessels increasing risk for lack blood flow in legs. feet wounds are most likely to heal slowly contributing to gangrene etc.
what are some chronic complications of hyperglycemia?
antipathy - micro: retinopathy, nephropathy
macro: HTN, CVA(stroke), cardiovascular disease
neuropathy and infection
does hyperglycemia cause thickening of basement membranes which leads to organ damage
ischemia in small blood vessels (hypoxia)
true
Northern Quebec Indigenous Experience (1940s to 2012)
what was diabetes thought of in the 1940/50/60/80/90 to present (2012)
1940/50: Attended Elementary Residential School (maltreatment)
1960: Never heard of diabetes
1980: Community members beginning to be diagnosed diabetes
1990: Increase awareness and prevalence of disease
* Need for information: ‘Take these pills’
* Death sentence: people go blind, have their feet and legs cut off
* Shocking,disbelief,denial
* Being blamed/judged by HCPs (eat better, drink less, loose weight)
* Secret (not wanting others to know)
* ‘It is not my fault I am living with diabetes’
now 2012:
Community Strength and Two-Eyed Seeing
* ‘What a great life… You don’t have to take things laying down’ Sandra Judith Bulluck of
Whapmagoostui
* ‘Not the death sentence it had once been’ Varley Mianscum of Ouje-Bougoumou
* ‘Do you have diabetes? … Not YET’
what does it mean to live in health?
Physical, emotional, mental, and spiritual health are interconnected
* From both a pathophysiological and lived-through perspective, Diabetes is not simply a disease of
‘too much sugar, not enough insulin’
true or false: Individual healing cannot be separated from community healing
true
what is kinship?
Across all Indigenous peoples, kinship and being at one with all things is a way of life – a fundamental part of Indigenous ways of knowing and being. This is what unites us through our distinctiveness. It is based upon Wahkohtowin. It is a cree word which denotes the interconnected nature of relationship, communities, and natural systems
what is a critical high and a critical low?
high: 33 mmol/L
low: 2.8 mmol/L
what is the blood glucose for most DM patients before meal and after?
before: 4-7
after 5-10
what is an average range of blood glucose before meal and after?
before: 4-6
after: 5-8
what is the goal with a diagnosis of diabetes mellitus?
to live in health - maintain near normal blood sugar levels
what are some important points when discussing DM?
Individual Relational Care: personal, approachable, available * A strength-based approach
* Meeting the person where they are at
* Using each person’s story
Diet – Nutritious and Delicious * Available
* Whole foods
* Natural off – the – land * Treats
Enjoying Activity and Movement * Connecting with nature
* Lifting weights, yoga
* Apps, technology
Goal: to live in health - maintain near normal blood sugar levels
what are some indigenous medicine practices?
Traditional Medicine
* Unique to geographical/community area
* Both the plant/natural medicine and the way in which it is prepared and consumed
* HCPs need to okay not knowing what a person may be taking
Sacred Bundles
* Live a good life – support, strength, protection
* Messages from the creator (spiritual component)
* Contain physical (feathers, pipe, medicine) or abstract (songs and prayers)
Traditional Beliefs of Care
* Going Back Home
* Brining the Spirit Home
* The Energy of Prayer
* The Stories Heal
* Land is Medicine
* Food is Medicine
* Community is Medicine
what are some western biomedicine (person centred care)?
- Systematic process orientated care (e.g., pathways)
- Screening, monitoring (accessible technology) * Ongoing assessment
- Early recognition of progressive signs and symptoms with treatment * E.g. Foot care, mental health, community support
- Surgical/Aseptic Procedures
- Pharmaceuticals: Goals * Short-term, long-term * Side effects
true or false regarding diabetes: pharmacotherapy
Once diagnosed with Diabetes, the standard of care is to create a person-centered goal and approach
Once diagnosed with Diabetes, the standard of care is to start a patient on a OAH and support them to make lifestyle modifications
true
second is false
diabetes: pharmacotherapy : patients CANNOT be in multiple drugs as this would cause contraindications.
false, they can actually be on multiple medications
what are the multiple drugs that a diabetic patient can be?
insulin
oral antihyperglycemics ( OAH ), each with different MOAs
exogenous ( injected ) insulin is a natural hormone replacing ( vary from onset peak of duration ). This description is a true statement.
true
exogenous ( injected ) insulin may be used in isolation and also used in combination with oral antihyperglycemic agents ( OHAs). is this true or false.
yes this is true.
Select all that is true amongst exogenous ( injected ) insulin :
Various types of insulin that differ in onset, peak action , and duration
insulin regimes are tailored to an individual patients needs and lifestyle
these are all true
this is a technology that can monitor from 1 to 2 minutes or pump basal rate of insulin ( release small amounts of insulin and hit bolus when the patient had something to eat)
exogenous ( injected ) insulin
why would someone be on metformin?
Is the first drug of choice for most patients after an initial diagnosis of diabetes
what is the mechanism of action for metformin?
Lower blood glucose and improves glucose tolerance in three ways.
* 1 – It inhibits glucose production in the liver
* 2 – It sensitizes insulin receptors in target tissues (fat and skeletal muscle), increasing glucose
uptake
* 3 - Slightly reduces glucose absorption in the gut
what are some nursing considerations for metformin?
- Kidney function – metformin is not metabolized but secreted unchanged by the kidneys, in the event of renal impairment, metformin can accumulate to toxic levels. Is this patient at risk for dehydration?
- Side effects: GI disturbance; appetite suppression (weight loss)
- Adverse effect: lactic acidosis – avoid with patients who have kidney disease, severe infection, or
history of lactic acidosis - Does not cause weight gain
- Does not cause hypoglycemia – well suited for patients who tend to skip meals
should you give metformin for patients with kidney disease? why or why not?
NOOO, because metformin is not metabolized bu secreted unchanged by the kidneys, if not functioning can cause toxic levels of metformin in the body
what is sulfonylureas?
this is Gliclazide
why would someone be on gliclazide?
Treatment of diabetes
what is the MOA of gliclazide?
Stimulates the release of insulin from pancreatic beta cells, and may increase target cell sensitivity to insulin (secretagogues – drugs that increase insulin secretion)
DRUG CARD: BIGUANIDES : METFORMIN
Why is a patient on this medication ?
How does this medication work ( MOA )?
this is the fist drug of choice for patients -after an initial diagnosis of diabetes
How does this medication work ( MOA ) ?
-lower blood glucose and improves
-glucose tolerance
1 - it inhibits glucose production in the liver
2- it sensitizes insulin receptors in target tissues
3- slightly reduces glucose absorption in the gut
what are some relevant nursing considerations for gliclazide?
Adverse effects: can cause hypoglycemia – dose-dependent reduction in blood glucose, regardless of what the patients blood sugar is, this medication will make it go lower
* Patients should take right before or with meals
* Eliminated by hepatic metabolism and renal excretion
* Side effect: can cause weight gain
true or false:
Indigenous peoples often not included in drug studies (RCTs)
* (? Best drug; equitable treatment)
Cultural and individual appropriate patient education.
Importance of informed consent and medical expertise.
* Who is advising the prescriber?
* Safe drug practice
all true
what is hypoglycemia?
BS less then 4 mmol/L caused by too much insulin in relation to available glucose
Triggers the release of neuroendocrine hormones (i.e. epinephrine) which activates the autonomic nervous system which cause the neurogenic clinical manifestations
what are the relevant nursing consideration for biguanides : metformin
kidney function : metformin is not metabolized by secreted unchanged by the kidneys in the even of the renal impairment
- metformin can accumulate to toxic levels ( is this patient at risk for dehydration? )
true or false regarding hypoglycemia;
If BS levels continue to fall a lack of blood sugar to the brain will cause neuroglycopenic clinical manifestation. Untreated can lead to loss of consciousness, seizures, coma, and death
- Hypoglycemic unawareness – autonomic neuropathy of DM that interferes with the secretion of counter-regulatory hormones
all true
what is a patients BS was 3.6 mmol/L, what would you do?
most likely give then sugar to bring them back to normal range
what are some side effects of biguanides: metformin?
GI disturbance, appetite suppression ( weight loss)
what are the adverse effect of biguanides: metformin ?
lactic acidosis: avoid with patients who have kidney issues, severe infection, or history of lactic acidosis
true or false. biguanides: metformin causes weight gain ?
this is false, they do not cause weight gain
biguanides causes hypoglycemia, who are these well suited for?
no this is false, well suited for patients who tend to skip meals
DRUG CARD : Sulfonylureas: Gliclazide
why is this patient on this medication?
treatment of diabetes
how does this medication work (MOA) –> sulfonylureas: gliclazide
stimulates the release of insulin from pancreatic beta cells, and may increase target cell sensitivity to insulin (secretagogues- drugs that increase insulin secretion)
what are the relevant nursing considerations ? for sulfonylureas: gliclazide
adverse effects: can cause hypoglycemia - dose dependent reduction in blood glucose, regardless of what the patients blood sugar is, this medication will make it go lower
patient should take right before or with meals
eliminated by hepatic metabolism and renal excretion
side effect: can cause weight gain
What is this describing ?
too much insulin or OAH’s, ETOH , too little food, NPO, excessive physical activity, weight los, beta blockers interfering with recognition of symptoms
hypoglycemia
what is hypoglycemia ?
this is too much insulin or OAH’s ETOH, too little food, NPO, excessive physical activity, weight loss, beta blockers interfering with recognition of symptoms
True or false. Hypoglycemia is not critical ?
False, it is critical
Name the clinical manifestations of hypoglycemia
this is critical !
shaky, light headed, nauseated
nervous, irritable, anxious
confused, unable to concentrate
hungry
an increase in heart rate
sweaty
headachy
weak and drowsy
numbness or tingling on your tongue or lips
symptoms of very low blood sugar ( less than 2.8 mmol/L are more severe ) is this a true statement ?
yes this is true.
Symptoms of very low blood sugar ( less than 2.8 mmol/L are more severe ) and can make you what?
confused, disoriented, difficulty speaking, stupor, lose conciousness have a seizure , coma or death
systemically how can we prevent, treat, and cure diabetes?
direct our best effort towards indigenous populations
it is critically important to change the trajectory of increasing prevalence and age of diagnosis of DM
Individually, how can we choose to live in health ?
physical, mental, spiritual, emotional, community
Summary : After learning about glucose regulation can you tell me what are the concepts we talked about that links with glucose regulation below.
( select all that applies )
a.nutrition and mobility
b.patient education
c.hormonal regulation and culture
d.adherence and culture
e.family dynamics and perfusion
all is true
define if these concepts links with glucose regulation:
sensory perception and tissue integrity
elimination is not included
true sensory perception and tissue integrity and ELIMINATION is included in glucose regulation
Key points in glucose regulation: ( just a summary not a question )
How the body regulates blood sugar
* Normal blood sugar: 4 to 6 mmol/L (memorize)
* Describe the three factors that cause hyperglycemia
* Related lab values: hemoglobin A1C, fasting blood glucose, random plasma blood
glucose, 2 hour – oral glucose tolerance test
* Signs of hyperglycemia
* Polydipsia, polyuria, glucosuria, & polyphagia
* Signs of hypoglycemia and how to treat (hypoglycemic protocol)
* Awareness of a person-centered two-eye approach to caring for someone living with
diabetes mellitus
* Indigenous health (Kinship: physical, mental, emotional, spiritual) * Plant/food medicine
* Western medicine (Assessment: Relational practice, screening, biomedicine pharmaceuticals)
* Equitable health
what is ozempic?
a weight loss medication
define if this statement is a true or false statement.
There is a possibility to address escalating rates and inadequate treatment of diabetes
* The solution and approach is gaining momentum: to prevent is to cure.
* That implementing a two-eyed approach (Kinship: to living in health, happiness, and
equitability; yawe) is happening and shows GREAT PROMISE
all are true
what is an secretagogues? what drug does this describe?
drugs that increase insulin secretion, gliclazide
