Week 2 Nursing

Question 1

Diabetes mellitus

Answer 1

▪ A group of diseases characterised by hyperglycaemia due to defects in insulin secretion, insulin action, or both
▪ Almost 1/3 of cases are undiagnosed
▪ Prevalence is increasing
▪ Minority populations and the elderly are disproportionately affected

Question 2

Functions of insulin

Answer 2

▪ Facilitates glucose entry into cells
▪ Stimulates storage of glucose in the liver and muscle as glycogen
▪ Signals the liver to stop releasing glucose
▪ Enhances storage of dietary fat in adipose tissue
▪ Accelerates transport of amino acids into cells
▪ Inhibits breakdown of stored glucose, protein and fat

Question 3

Type 1 diabetes

Answer 3

▪ Insulin-producing beta cells in the pancreas are destroyed by an
autoimmune process
▪ Requires insulin, as little or no insulin is produced
▪ Onset is acute and usually before 30 years of age
▪ Affects 5–10% of persons with diabetes

Question 4

Type 2 diabetes

Answer 4

▪ Reduced sensitivity to insulin (insulin resistance) and impaired beta cell function results in reduced insulin production
▪ Affects 90–95% of persons with diabetes
▪ More common in people over age 30 and those who are obese
▪ Slow, progressive glucose intolerance
▪ Treated initially with diet and exercise
▪ Glucose lowering medicines and/or insulin usually required

Question 5

Gestational Diabetes

Answer 5

▪ Glucose intolerance occurring during pregnancy
▪ Placental hormones cause insulin resistance
▪ Mother and baby are at risk of type 2 diabetes in later life
▪ Risk factors as in Type II diabetes
▪ Screening at 24th and 28th weeks of gestation
▪ Blood glucose targets
– Fasting - < 5.0 mmol/L
– < 6.7 mmol/L at 2 hours after meals
– HbA1C 7.5%
▪ Blood glucose levels usually return to normal after pregnancy

Question 6

Risk factors

Answer 6

▪ Type 1: not inherited but a genetic predisposition combined with immunological and possibly environmental and epigenetic precipitating factors

▪ Type 2: family history of diabetes, obesity, ethnicity, age over 45 years, previous identified impaired fasting glucose or impaired glucose tolerance, hypertension ≥ 140/90 mmHg, cholesterol <5.5 mmol/L , history of gestational diabetes or babies over 4.5 kilograms

Question 7

Clinical manifestations

Answer 7

▪ ‘Three Ps’
– Polyuria
– Polydipsia
– Polyphagia
▪ Fatigue, weakness, vision changes, dry skin, skin lesions or wounds that are slow to heal, recurrent infections
▪ Type 1 may have sudden weight loss, nausea, vomiting, and abdominal pain if DKA has developed
▪ Type 2 may not experience symptoms

Question 8

Diagnostic findings

Answer 8

✔Fasting blood glucose > 7.0 mmol/L (some guidelines state > 6.5 mmol/L)
✔Random glucose > 11.1
mmol/L
✔HbA1c > 6.5%
✔Two-hour post-glucose level ≥11.1 mmol/L during an oral glucose tolerance test (OGTT)

Question 9

Treatment goal is to normalise blood glucose levels

Answer 9

▪ Intensive control dramatically reduces vascular and neuropathic complications
▪ But it increases the risk of hypoglycaemia and associated risks
▪ Blood glucose targets must be individualised

Question 10

Dietary management — goals

Answer 10

• Provide optimal nutrition; all essential food constituents
• Meet energy needs
• Achieve and maintain a reasonable weight
• Prevent wide fluctuations in blood glucose levels
• Reduce serum lipids, if elevated
• Enjoyment

Question 11

Glucose-lowering medicines (GLMs)

Answer 11

• Used for people with type 2 diabetes who do not achieve optimal blood glucose using diet and exercise alone
• Combinations of medicine may be used and some GLMs are often combined with insulin
• Nurses and people with diabetes should be familiar with the side effects of the GLMs they are using
• Nursing interventions: monitor blood glucose and other potential side effects
• Patient education

Question 12

Oral antidiabetic agents-Second-Generation Sulfonylureas

Answer 12

Introduction:
*Class of drugs used primarily to treat type 2 diabetes
*Stimulate insulin secretion from pancreatic beta cells
*More potent and fewer side effects than first-generation sulfonylureas
*Examples: Gliclazide, Glibenclamide, Glimepiride

Action and Indication:
*Action: Stimulate insulin secretion from pancreatic beta cells
*Indication: Used primarily to lower blood glucose levels in people with type 2 diabetes
*They may not be suitable for all patients with type 2 diabetes, especially those with
kidney disease, certain genetic conditions, or those who are pregnant or
breastfeeding. Regular monitoring of blood glucose levels is recommended.

Side Effects:
*Main risk: Hypoglycemia (low blood sugar)
*Other potential side effects: Weight gain, skin rash, nausea, heartburn
*Less common but serious side effects: Yellowing of skin or eyes (jaundice), dark urine, stomach pain

Question 13

Oral antidiabetic agents- Biguanides

Answer 13

Introduction:
*Class of oral antihyperglycemic drugs
*Metformin is the most commonly prescribed
*Used primarily in the management of type 2 diabetes

Action and Indication:
*Action: Reduces the production of glucose by the liver, increases the sensitivity of muscle cells to insulin, and delays absorption of glucose from the gastrointestinal tract
*Indication: Used primarily to lower blood glucose levels in people with type 2 diabetes

Side Effects:
*Most common: gastrointestinal issues like diarrhea, nausea, and abdominal pain
*Rare but serious: Lactic acidosis, especially in patients with kidney issues
*Long-term use may affect vitamin B12 levels

Question 14

Insulin therapy

Answer 14

Categories of insulin
– Rapid-acting (e.g. Lispro)
▪ 5 to 15 minutes
▪ Peak 1 hour after injection
▪ Duration of 2 to 4 hours
– Short-acting (e.g. Humulin, Actrapid)
▪ Onset 30-60mins
▪ Peak 2 to 3 hours
▪ Duration of 4 to 6 hours
– Intermediate-acting (isophane)
▪ Onset 3 to 4 hours
▪ Peak in 4 to 12 hours
▪ Duration of 16 to 20 hours
▪ White or cloudy appearance
– Very long-acting (e.g. Levemir)
▪ Long, slow, sustained action with no peak action time
▪ Duration approx. 24 hours
– Biphasic Insulin (e.g. Mixtard 30/70, Mixtard 50/50)

Question 15

Educating patients about insulin self-management

Answer 15

▪ Use and action of insulin
▪ Symptoms of hypoglycaemia and hyperglycaemia
– Required actions
▪ Blood glucose monitoring
▪ Self-injection of insulin
▪ Insulin pump use

Question 16

Acute complications of diabetes

Answer 16

▪ Hyperglycaemia & Hypoglycaemia
▪ Diabetic ketoacidosis (DKA)
▪ Hyperglycaemic hyperosmolar states (HHS)

Question 17

Hypoglycaemia

Answer 17

▪ Abnormally low blood glucose level (< 2.7–3.3 mmol/L)
▪ Causes include too much insulin or GLM, too little food and excess physical activity
▪ Manifestations
– Adrenergic symptoms: sweating, tremors, tachycardia, palpitations, nervousness, hunger
– Central nervous system symptoms: inability to concentrate, headache, confusion, memory lapses, slurred speech, numbness of lips and tongue, irrational or combative behaviour, double
vision, drowsiness
– Severe hypoglycaemia may cause disorientation, seizures and loss of consciousness

Question 18

Assessment

Answer 18

▪ Onset is abrupt and may be unexpected (not so with oral GLMs)
▪ Symptoms vary from person-to-person
▪ Symptoms also vary related to the rate at which the blood glucose falls and usual blood glucose range
▪ Reduced adrenergic response affects symptom
recognition in people who had diabetes for many years due to a number of factors including autonomic neuropathy

Question 19

Managing Hypoglycaemia

Answer 19

▪ Treatment must be immediate
▪ Give 15 g of fast-acting, concentrated carbohydrate
– 3 or 4 glucose tablets
– 60–120 mL of juice or regular soft drink (not diet)
– Oral glucose solution
– 2–3 teaspoons of honey
– Patient who is conscious but cannot swallow - Glutose15TM gel

Question 20

Emergency measures

Answer 20

▪ If the person cannot swallow or is unconscious:
– Protect the airway
– Subcutaneous or intramuscular glucagon 1 mg
– As a last resort 25–50 mL 50% glucose solution IV

Question 21

Diabetic ketoacidosis (DKA)

Answer 21

▪ Caused by an absence of or inadequate insulin resulting in abnormal metabolism of carbohydrate, protein and fat
▪ Clinical features
– Hyperglycaemia
– Dehydration
– Acidosis
▪ Manifestations include polyuria, polydipsia, blurred vision, weakness, headache, anorexia, abdominal pain, nausea vomiting, acetone breath, hyperventilation with Kussmaul respirations (in the early stages) and altered conscious state
▪ DKA is an emergency situation

Question 22

Assessing DKA

Answer 22

▪ Blood glucose levels range between 17 mmol/L and 44 mmol/L
▪ Severity of DKA is not related to blood glucose level
▪ Ketoacidosis is reflected in low serum bicarbonate and low pH; low PCO2 reflects respiratory compensation
▪ Ketone bodies in blood and urine
▪ Electrolytes vary according to water loss and level of hydration

Question 23

Prevention

Answer 23

▪ Develop a ‘sick day management plan’
▪ Assess for underlying causes
▪ Diagnose and optimal diabetes management

Question 24

Treating DKA

Answer 24

▪ Rehydrate with IV fluid
▪ IV continuous infusion using regular insulin
▪ Reverse acidosis and restore electrolyte balance
▪ Note: rehydration leads to increased plasma volume and decreased K+, insulin enhances the movement of K+ from extracellular fluid into the cells
▪ Monitor
– Blood glucose and renal function/UO
– ECG and electrolyte levels—potassium
– VS, lung assessments, signs of fluid overload

Question 25

Hyperglycaemic hyperosmolar states (HHS)

Answer 25

▪ Hyper-osmolality and hyperglycaemia occur due to lack of effective insulin
▪ Ketosis is minimal or absent
▪ Hyperglycaemia causes osmotic diuresis with loss of water and electrolytes; hypernatremia and increased osmolality
▪ Manifestations include hypotension, profound dehydration, tachycardia and variable neurological signs
due to cerebral dehydration
▪ High mortality

Question 26

Treatment of HHS

Answer 26

▪ Rehydration
▪ Insulin administration (judicious in non-insulin requiring patient)
▪ Monitor fluid volume and electrolyte status
▪ Prevention
– Blood Glucose Self-Monitoring (BGSM)
– Diagnosis and management of diabetes
– Assess and promote self-care management skills

Question 27

Long-term complications of diabetes

Answer 27

▪ Macrovascular complications
– Accelerated atherosclerotic changes
– Coronary artery disease, cerebrovascular disease and peripheral vascular disease
▪ Microvascular complications
– Diabetic retinopathy, nephropathy

▪ Neuropathic changes
– Peripheral neuropathy, autonomic neuropathies, hypoglycaemic unawareness, neuropathy, sexual dysfunction

Question 28

Nursing process: care of the person with diabetes — assessment

Answer 28

▪ Assess the primary presenting problem
▪ In addition, assess needs related to diabetes
▪ Patient knowledge of diabetes and diabetes care skills
▪ Blood glucose levels
▪ Skin assessment
▪ Preventive health measures

Question 29

Educating people about self-care

Answer 29

▪ Assess knowledge and adherence to plan of care
▪ Provide basic information about diabetes, its cause and symptoms, and acute and chronic complications and their treatment
▪ Teach self-care activities to prevent long-term complications including foot care, eye care and risk-factor management
▪ Include family in plan of care
▪ Provide information, encourage health promotion activities and recommended health screenings