Class 8: Endocrine Flashcards
1
Q
Diabetes diagnostic studies (positive results)
A
-FBG ≥ 7 mmol/L
-Two-hour glucose level ≥11.1 mmol/L during 75 g oral glucose tolerance test (OGTT)
-Random glucose level ≥11.1 mmol/L
-A1C ≥ 6.5% (in adults)
2
Q
Hemoglobin A1C test
A
-Useful in determining glycemic levels over time; amount of glucose attached to hemoglobin molecules over RBC life span (90-120 days)
-Regular assessments required
3
Q
Ideal A1C test results
A
Ideal goal; Canadian Diabetes Association (CDA) ≤7.0%, normal range is <6.0%
4
Q
Normal A1C does what
A
Reduces risks pathy’s: Retinopathy, nephropathy, and neuropathy
5
Q
DM collaborative care
A
-Oral antihyperglycemic agents and noninsulin injectables
-ACEI or ARBs
-BP control; target is <130/80 mm Hg
-Drug therapy
6
Q
DM collaborative care cont’d
A
-Exercise & nutritional therapy
-Teaching and follow-up programs
-Self monitoring of blood glucose (SMBG)
-Vascular protection
7
Q
Drug therapy for DM
A
-Enteric-coated acetylsalicylic acid (ASA)
-Insulin
-Lipid-lowering drugs
8
Q
Exogenous insulin
A
-MUST be used for Type 1 Diabetes; may be additional treatment for Type 2 Diabetes
-Always includes separate rapid/short acting + intermediate or long acting
9
Q
Just bc a pt is on insulin…
A
Does not mean they have been diagnosed with type 1 diabetes
10
Q
Preparations of rapid-acting (bolus) clear insulin
A
-Injected 0-15 minutes before meal
-Onset: 10-15 minutes, peak; 60- 90 min, duration; 3-5h
11
Q
Preparations of short-acting (bolus) clear insulin
A
-Injected 30-45 minutes before meal
-Onset; 30-60 min, peak; 2-4h, duration; 5-8h
12
Q
Preparations of intermediate-acting (basal) cloudy insulin
A
-BID; am & pm (not specific to meals)
-Onset; 1-3h, peak; 6-8h, duration; 12-16h
13
Q
Preparations of long-acting (basal) insulin
A
-Injected OD at bedtime OR in the morning
-Onset; 1-2h, peak; none, duration; 24+h
-Released steadily and continuously, CANNOT be mixed with any other insulin or solution
14
Q
Slide 9
A
Conflicts with slide 8…. Figure out which one is right
15
Q
Rapid-acting (clear) insulins
A
-Novorapid, apidra & humalog
-NAH
16
Q
Short acting (clear) insulins
A
-Humulin R, novolin GE, Toronto
17
Q
Intermediate (cloudy) insulins
A
Humulin N, novolin GE NPH
18
Q
Long acting (clear) insulin
A
Lantus
19
Q
Long acting insulin
A
Levemir
20
Q
Intermediate insulins are…
A
The only cloudy insulins
21
Q
Insulin therapy regimens
A
-Basal-bolus; long-acting (basal) OD & rapid/short-acting (bolus) before meals
-Fixed combination insulins
-Sliding scale insulin dosing
22
Q
Basal-bolus insulin…
A
Closely mimics endogenous insulin production
23
Q
Premixed insulin (cloudy)
A
-Ratio of rapid/fast-acting to intermediate acting insulin: Humulin (rapid) 30/70 & novolin GE (fast acting) 30/70
-Not for Type 1 diabetes
24
Q
Insulin therapy considerations
A
-Regimens should be adapted to tx goals, lifestyle, capacity and general health
25
Administration of insulin (routes)
-Cannot be taken PO
-SC injection for self-administration
-IV administration of Regular insulin ONLY
26
Administration of insulin (sites)
-Fastest absorption from abdomen, followed by arm, thigh, and buttock
-Abdomen is the preferred site
-Rotate injections within one particular site (think – checkerboard)
-Do not inject in site to be exercised
27
Administration of insulin (preparation)
No alcohol swab on site needed before injection (home therapy)
28
Slide 15 (checkerboard rotation)
29
Insulin syringe sizes
-1.0, 0.5 & 0.3 mL
-The 0.5mL size may be used for doses of 50 units or less, and the 0.3mL syringe can be used for doses of 30 units or less
-The 0.5mL & 0.3mL syringes are marked in 1-unit increments
30
Giving an insulin injection
-Wash hands with soap & water
-Do not recap needle
-45-90 degree angle (depending on fat)
31
Slide 18&19
32
Insulin pump
-Continuous SC infusion (basal rate)
-Potential for tight glucose control
33
PO hypoglycemic agents (OHA)
-Used for patients with type 2 diabetes, NOT type 1
-Patients may be on both OHA’s and insulin, but they will still be classified as a patient with Type 2 Diabetes
34
Insulin drug classes
-Sulfonylurea
-Alpha glucosidase inhibitor
-Biguanide
-Megltinide
-SABM
35
Biguanide
-Reduces production & output of sugar by the liver, acts on the liver
-Metformin
36
Sulfonylurea
-Promotes insulin secretion, acts on the pancreas
-Gliclazide, Glyburide & Chlopromaide
37
Megltinide
-Promotes insulin secretion, acts on the pancreas
-Regaglinide & nateglinide
38
Alpha glucosidase inhibitor
-Prevents breakdown of carbs and delays carb digestion, acts on the small intestine
-Acarbose & sitagliptin
39
Biguanide (metformin) MOA
-Decreases glucose production
-Lowers glucose absorption & enhances insulin receptor uptake
40
Biguanide (metformin) AE
GI upset & lactic acid
41
Biguanide (metformin) contraindications
-Hepatic & renal failure
-Respiratory insufficiency & hypoxemic conditions
-Alcohol abuse
42
Biguanide (metformin) does...
-NOT cause hypoglycemia
-Take with food
43
Biguanide (metformin) dosing
-250-2500 mg/day
-May be divided doses dependent on the patient’s needs
44
Sulphonylurea (liclazide, glyburide & glimepiride) MOA
-Stimulates beta cell insulin release
-Increases peripheral glucose utilization & insulin receptor sensitivity
-Decreases hepatic glucose production
45
Sulphonylurea (liclazide, glyburide & glimepiride) AE
-Hypoglycemia, weight gain, hyperinsulemia
-Caution with renal/liver dysfunction (reduce dose)
46
Sulphonylurea (liclazide, glyburide & glimepiride) dosing
-Take 30min before meals
47
Meglitinides (repaglinide) MOA
-Short acting secretagogue
-Binds to beta cell to stimulate insulin release at a different site than sulfonylureas
48
Meglitinides (repaglinide) rule of thumb
No meal, no dose; extra meal, extra dose (take 15 minutes before meal)
49
Meglitinides (repaglinide) AE
Weight gain & hypoglycemia
50
Meglitinides (repaglinide) interactions
Interacts with CYP 3A4
51
Alpha-Glucosidase Inhibitor (acarbose) MOA
Inhibits intestinal amylase and alpha-glucosidase, therefore delaying breakdown of complex carbohydrates and slows glucose absorption
52
Alpha-Glucosidase Inhibitor (acarbose) AE & cautions
-Flatulence, diarrhea & cramps
-Caution in patient with GI disorders
53
Alpha-Glucosidase Inhibitor (acarbose) administration considerations
-Not absorbed, decreased hypoglycemia (except with sulfonylureas)
-Take with first bite of food, no food no dose
54
Thiazolidinediones (glitazones): (pioglitazone & rosiglitazone) MOA
Enhances insulin sensitivity at the cell level
55
Thiazolidinediones (glitazones): (pioglitazone & rosiglitazone) AE
Hypertensive effect, headache, upper respiratory infection, anemia, edema & weight gain
56
Dipeptidyl Peptidase 4 (DPP-4) inhibitors (sitagliptin) MOA & AKA
-Also known as ‘gliptins’
-Delays breakdown of incretin hormones by inhibiting the enzyme DPP-4
-Reduces postprandial and fasting glucose concentrations
57
Dipeptidyl Peptidase 4 (DPP-4) inhibitors (sitagliptin) AE
Respiratory tract infection, headache & diarrhea
58
Combination therapy options
-Glyburide & metformin
-Avandamet (avandia and metformin)
59
Combination therapy MOA
-Increases effectiveness of drugs by targeting different sites at the same time
-Minimizes side effects because lower doses are used
60
Combination therapy considerations
May add up to 3-4 OHA’s before placing patient on insulin with/without OHA (primarily metformin)
61
Diabetic medication drug interactions
-Alcohol & sulfonylureas
-Arcabose & sulfonylureas
-Antihypertensives
-Beta-blockers
-Digoxin & propranolol
62
Diabetic medications + alcohol & sulfonylureas
-Disulfiram-like reaction (flushing, nausea, dizzines & tachycardia)
63
Diabetic medications + antihypertensives
-(Thiazides, furosemide & CCBS)
-Cause hyperglycemia
64
Diabetic medications + beta-blockers
-Mask hypoglycemia
65
Diabetic medications + beta-blockers
-Mask hypoglycemia
66
Diabetic medications + fibrates & cholestyramine
Cause hypoglycemia
67
Diabetic medications + digoxin or propanolol
-Decrease absorption of digoxin or propranolol
68
Diabetic medications + sulfonylureas & acarbose
-Causes hypoglycemia (treat with honey, dextrose tabs or milk)
69
General diabetes management
Diet, exercise & glucose monitoring
70
Type 1 DM nutritional therapy (total calories)
Increase in caloric intake possibly necessary to achieve desirable body weight and restore body tissues
71
Type 1 DM nutritional therapy (effect of diet)
Diet & insulin necessary for glucose control
72
Type 1 DM nutritional therapy (distribution of calories)
Equal distribution of carbohydrates through meals or adjustment of carbohydrates for insulin activity
73
Type 1 DM nutritional therapy (consistency of daily intake)
Necessary for glucose control
74
Type 1 DM nutritional therapy (uniform timing of meals)
Crucial for NPH insulin programs; flexibility with multidose rapid-acting insulin
75
Type 1 DM nutritional therapy (intermeal & bedtime snacks)
Frequently necessary
76
Type 1 DM nutritional therapy (nutritional supplement for exercise programs)
Carbohydrates 20 g/hr for moderate physical activities
77
Type 2 DM nutritional therapy (total calories)
Reduction in caloric intake desirable for overweight or obese patient
78
Type 2 DM nutritional therapy (effect of diet)
Diet alone possibly sufficient for glucose control
79
Type 2 DM nutritional therapy (distribution of calories)
Equal distribution recommended; low-fat diet desirable; consistency of carbohydrate at meals desirable
80
Type 2 DM nutritional therapy (consistency in daily intake)
Desirable for weight reduction and moderation of blood glucose levels
81
Type 2 DM nutritional therapy (uniform timing of meals)
Desirable but not essential, unless using insulin or sulphonylureas
82
Type 2 DM nutritional therapy (intermeal & bedtime snacks)
Based on patient's eating habits and preferences; may be necessary if using insulin or sulphonylureas
83
Type 2 DM nutritional therapy (nutritional supplement for exercise programs)
May be necessary if patient's blood glucose levels are controlled on sulphonylureas or insulin
84
Slide 36
85
Food composition
-Protein; 15-20% of energy
-Fat: <35% of energy
-Fibre
-Carbohydrates: 45-60% of energy
86
Diabetic neuropathy + protein
Limit intake to 15% of energy & closely monitor
87
Saturated & trans-fatty acids
Should be reduced to less than 7% of energy intake
88
Polyunsaturated fat
Should be limited to 10% of energy intake
89
Fibre intake
25-50g/day
90
Carbohydrates
-Pts should try to consume high fibre carbohydrates
-<10% of energy intake should come from sucrose
-Low carbohydrate diets are not recommended for DM management
91
Glycemic index (slide 38)
-Low GI (55 or less); great
-Medium GI (56-69); okay
-High GI (70 or more); not great
92
Basic carb counting
-Make healthy choices, focus on the carbohydrate, set carbohydrate goals
-Determine carbohydrate content
-Monitor effect on BG
93
Slide 40 & 41
94
Continuous glucose monitoring
Updates every 1-5 minutes, helps identify patterns
95
Slide 45
96
Nursing care of DM
-Foot care, BP & cholesterol monitoring
97
Hypoglycemia
<4mmol/L
98
Manifestations of hypoglycemia
-Confusion, irritability, diaphoresis, tremors
-Hunger, weakness & visual disturbances
99
Untreated hypoglycemia can...
Progress to loss of consciousness, seizures, coma, and death
100
Hypoglycemia unawareness
-Person does not experience usual warning signs
-R/t autonomic neuropathy
-Unsafe for patients with risk factors for hypoglycemic unawareness to aim for tight blood glucose control because a major drawback of intensive treatment is hypoglycemia
101
Those at risk for hypoglycemia unawareness
Elderly patients and patients who use β-adrenergic blockers
102
Causes of acute hypoglycemia
Mismatch in timing of meals and peak action of medications
103
At the first sign of acute hypoglycemia
-Check BG
-If <4 mmol/L, begin treatment
-If >4 mmol/L, investigate further for cause of S&S
-If monitoring equipment not available, treatment should be initiated
104
Acute hypoglycemia tx
-15-20g of a simple carbohydrate, 175 mL of fruit juice, or a soft drink
-Check BG 15 min after & again in 45 min
-Repeat until BG >4mmol/L
105
Acute hypoglycemia tx considerations
-Avoid foods with fat as they decrease absorption of sugar
-Patient should eat regularly scheduled meal/snack to prevent rebound hypoglycemia
106
Acute hypoglycemia tx if pt cannot swallow
-1 mg of glucagon IM or SC; side effect: rebound hypoglycemia
-Have patient ingest a complex carbohydrate after recovery
-20-50 mL of 50% dextrose IV push in acute care settings
107
Pediatric considerations of hypoglycemia
-Children are often able to detect the onset of hypoglycemia; some are too young to implement treatment
-Parents should be able to recognize the onset of symptoms
-Give children 10-15mg simple carbs
-Illness can alter diabetes management; insulin requirements may increase or decrease
108
DKA
-Caused by profound deficiency of insulin
-Most likely to occur in Type 1 DM
109
Precipitating factors of DKA
-Illness, infection, inadequate insulin dosage, undiagnosed type 1, poor self-management or neglect
110
DKA pathophysiology
-Insufficient insulin prevents glucose from being used for energy
-Body breaks down fat & ketones are a by-product of fat metabolism
111
Ketones
-Alter pH balance, causing metabolic acidosis
-Ketone bodies are excreted in urine
-Electrolytes become depleted
112
DKA manifestations
-Lethargy/weakness (early symptoms)
-Dehydration (tachycardia)
-Abdominal pain (anorexia & vomiting)
-Kussmaul respirations (rapid deep breathing to reverse metabolic acidosis, sweet fruity odor)
113
Management of DKA
-Airway; O2
-Correct fluid & electrolytes; NaCl restores urine output & raises BP
-When BG levels approach 14 mmol/L (downward); 5% dextrose
-K+ replacement & Na+ bicarbonate
114
Acute management of DKA + insulin therapy
-Witheld until fluid resuscitation has begun
-Bolus followed by regular insulin drip
115
Pediatric considerations of DKA
-Children should be admitted to PICU
-Priorities = IV access
-Aim to decrease BG by 2.8-5 mmol/L per hour, keep BG 6.7-13.3mmol/l
-Cardiac and neuro monitoring: Risk of cerebral edema; caution with rehydration & risk of hypokalemia; watch for ecg changes
116
Pediatric considerations of DKA cont'd
-After acute period of DKA is over, goal is regulating insulin dosage in relation to diet and activity
-In children, often presentation with DKA is the first diagnosis of diabetes
117
Hyperosmolar hyperglycemic syndrome (HHS)
-Life-threatening syndrome, less common than DKA
-Often occurs in patients older than 60 years with type 2 DM
-Pt has enough circulating insulin that ketoacidosis does not occur, fewer symptoms in earlier stages
-Neurological manifestations occur because of ↑ serum osmolality
118
HHS common etiology's/hx
-Inadequate fluid intake
-Increasing mental depression
-Polyuria
119
HHS lab values
-BG >34 mmol/L
-Increase in serum osmolality
-Absent/minimal ketone bodies
120
HHS is a...
-Medical emergency with a high mortality rate
121
HHS therapy
-Similar to DKA except HHS requires greater fluid replacement
122
Nursing management of DKA/HHS (administration)
-IV fluids, insulin & electrolytes
123
Nursing management of DKA/HHS (assessment)
-Renal & cardiopulmonary status
-Cardiac & VS monitoring
-LOC, signs of potassium imbalance
124
Incretin
-A group of metabolic hormones that augment the secretion of insulin
