Diabetes Exam 3 Flashcards
(205 cards)
1
Q
What is diabetes Mellitus?
A
A chronic multi-system disease related to abnormal insulin production or impaired insulin utilization and is characterized by hyperglycemia resulting from the lack of insulin, lack of insulin effect or both.
2
Q
What are the different types of DM?
A
- T1DM
- T2DM
- Gestational Diabetes
3
Q
What are some different causative factors of DM?
A
- Genetic
- Autoimmune
- Enviromental
- Absent/insufficient insulin and/or poor utilization of insulin
4
Q
What is the etiology and pathophysiology of normal glucose and insulin metabolism? Another words…. whats happening and where?
A
- Insulin is produced by the beta-cells in islets of Langerhans
- Released continuously into the bloodstream in small increments with larger amounts released after food
- Stabilizes glucose level i n range of 70-110 mg/dl
5
Q
In which cell is insulin produced?
A
Beta cells in islets of langerhans
6
Q
DM is the leading causes of…. list 3
A
- Adult blindness
- End-stage Kidney disease
- Non-traumatic amputation
7
Q
DM is a major contributor factors toooooo list 3
A
- Heart disease
- Stroke
- Hypertension
8
Q
What are the counter regulatory hormones of insulin?
A
- Glucagon, Epinephrine, growth hormone, cortisol
9
Q
What is the function of the counter regulatory hormone?
A
- oppose effects of insulin
- Stimulate glucose production and release by the liver
- Decrease movement of glucose into the cell
- Help maintain normal blood glucose levels
10
Q
What is gestational diabetes?
A
- Develops during pregnancy
- Usually glucose levels return to normal 6 weeks post partum
- Babies typically weigh more than 9 pounds at birth
- Places the mother at a higher risk of developing T2Dm within the next 10 years
11
Q
When is T1DM typically diagnosed?
A
- Young ages
12
Q
Does T1DM account for a small or large percentage of diagnosed patients?
A
small
13
Q
In T1DM what happens to the beta cells of the pancreas?
A
They are completely destroyed
14
Q
True or false: T1DM progress to complete lack of insulin production?
A
- True
15
Q
What are some risk factors of T1DM?
A
- Autoimmune
- Viral/toxins
- Enviromental
- Medically induced: ex removal of pancreas
16
Q
What are some s/s of T1dm?
A
- 3p’s– polyuria, polydipsia, polyphagia
- Weight loss
- Increased frequency of infections
- Rapid onset
- insulin dependent
- familial tendency
- peak incidence from 10 to 15 years
17
Q
How is DM diagnosed?
A
- HGB A1C
- Fasting blood glucose
- 2hr postprandial or oral glucose tolerance test (OGTT)
- Random blood glucose
18
Q
A Hgb A1c measures BG levels over how many previous months?
A
- 2-3 months
19
Q
True or false: a Hgb A1C can give acute or hour to hour changes?
A
False
20
Q
What can affect the results of Hgb A1c?
A
- Pregnancy,
- CKD
- Thalassemia,
- Fe def anemia
- Pernicious anemia
- Recent acute blood loss or transfusion
21
Q
What is the gold standard test in DM?
A
Hgb A1C
22
Q
Hbg A1c is reported as the percentage of total…. what?
A
- Blood
23
Q
What is considered a normal Hgb A1c?
A
Under 6.0 mg/dl
24
Q
What is our goal range in DM for a Hgb A1c?
A
- 6.5-7.0mg/dl
25
What is a fasting plasma glucose test?
1. No caloric intake for atleast 8 hours
26
What is considered a normal range for a FASTING PLASMA GLUCOSE TEST?
1. 70-110mg/dL
27
What level is considered a positive DM dx with a FASTING PLASMA GLUCOSE test?
1. Greater than or equal to 126mg/dL
28
What is a 2 hour postprandial/oral glucose tolerance test (ogTT)?
1. Patient consumes beverage with glucose load (75g cho) after fasting 8-12 hours. Blood sample is taken prior to consumption than again in 1hr and 3 hours after consumption. Values are based on level at the 2 hour mark
29
What is considered a positive dx level on a oral glucose test?
If BG is >200 or = to 200mg/dl
30
What is considered a normal level on an oral glucose test?
<140mg/dl
31
What is considered a pre-diabetic level with an oral glucose test?
1. Levels between 140-199mg/Dl
32
True or false: it is not recommended to dx DM with just a random plasma blood glucose test?
True
33
What is considered diabetic on a random plasma blood glucose test?
1. > or = to 200mg/dL
34
Other than a glucose level above or equal to 200 mg/dL what else must a patient have in order to be dx with a random plasma blood glucose test?
1. Must have symptoms of hyperglycemia or hyperglycemic crisis to be classified as DM
35
How can a random plasma blood glucose be taken?
1. Venous or finger stick
36
What should we know about self-monitoring blood glucose testing?
1. via fingerstick is most common
2. Provides timely feedback to the patient
3. Most common error is blood sample size
5. advised before each meal and at bedtime
37
What is the biggest downfall of a self-monitoring blood glucose monitor?
1. You have to stick your finger about 4 times a day.
38
What should we know about the continuous glucose monitoring system? CGS
1. Tiny sensor under the skin
2. Sends info via radio waves to monitor
3. Provides real-time measurements of BG levels
4. Good for those patients with erratic and unpredictable drops.
5. Warns of dangerous levels
39
What should we know about insulin pump therapy?
1. Continuous subcutaneous insulin infusion (CS11) via external
2. provides a continuous infusion of "basal" insulin (2-3 is normal basal rate)
3. Patient "boluses" for meal at time of meal
4. Bolus determined by pre-meal BS and CHO content of meal
5. Never uses long or intermediate acting insulin.... ONLY RADID
40
Pump therapy is NOT.....
1. pump does not regulate blood glucose automatically
2. does not decrease the need for BS check
3. Does not replace the regulatory system of the normal functioning pancreas
4. Not easy or inexpensive
5. Not complication free
41
What are indications that pump therapy may benefit a patient?
1. HbA1C > 6.5%
2. Frequent hypoglycemia
3. Shift work
4. Type 2 w/gastroparesis
5. Dawn Phenomenon (increased BG in the AM)
6. Pediatrics
7. Exercise
8. Hectic lifestyle
42
For a patient to be a pump candidate they must be.....
1. Motivated
-Be active participant in management
- Quantify food intake
- Monitor BG
2. Adequate vision & fine motor skills
3. Strong support system
4. Insurance coverage due to expense
43
What are the benefits of pump therapy?
1. Improved glycemic control
2. Better pharmacokinetic delivery of insulin
3. Increased flexibility
4. Variable & individualized basal rates
5. Does NOT eliminate SMBG
44
What are the risks of insulin pump therapy?
1. Hypoglycemia
2. Hyperglycemia
3. Infusion site problems
4. Takes time & commitment
5. Proper planning
6. Cost
45
What are some nursing considerations for insulin pumps?
1. Pumps cannot be worn to MRI or CT (interferes with imaging or magnetic rips it off)
2. Ensure all members of health care team aware patient is wearing a pump
46
Who should you contact if there is an issue with a patients pump?
1. Contact HCP who manages pump
2. 24hr 800 number on the back of the pump for tech support
47
What are the s/s of hypoglycemia?
1. Rapid onset--- 1-3 hours
2. Anxious
3. Sweaty
4. Hungry
5. Confused
6. Blurred or double vision
7. Shaky
8. irritable
9 Cool,clammy skin
48
Hypoglycemia can alter mental functioning how?
1. Difficulty speaking
2. Visual disturbances
3. Stupor
4. Confusion
5. Coma
6. Untreated hypoglycemia can progress to loss of consciousness, seizures, coma, and death
49
How is hypoglycemia treated in the community?
1. Administer glucose: juice, soda, bread, or crackers
2. Check fingerstick 15 mins after admin of glucose
3. If level still low, repeat glucose
4. After BS reaches normal level-- eat meal or snack with fat/protien
5. Simple CHO best
50
How is hypoglycemia treated in the hospital?
1. In hospital setting or patient unable to swallow:
2.IV dextrose 24-50ML of d50
3. No IV access: 1mg IM glucagon injection to release glucose stored in the liver
51
What body system used glucose the most?
Brain
52
What is hypoglycemia unawarenes?
1. No warning signs or symptoms until glucose levels are critically low
2. Related to autonomic neuropathy and lack of counterregulatory hormones
53
What should patients who are at risk of hypoglycemia unawareness do with the BG levels?
keep BG a bit higher
54
T2DM is more common in what age population?
Adults
55
True or false: T2DM is present in all ethnic groups but more prevalent in non-whites?
True
56
Is T2DM a slower or faster onset than T1DM?
Slower
57
What is insulin doing in T2DM?
Insulin is present but cells resist
58
What is insulin doing in T2DM?
Insulin is present but cells resist overtime pancreas cannot keep up with the demand and by the time diagnosed damage already done to most organs
59
How long does a patient typically have T2DM before it is officially diagnosed?
1. 6-8 years
60
With T2DM pancreas continues to produce some endogenous insulin.... but....
1. Not enough insulin is produced or body doesn't use effectively
61
What is the major distinction between T1DM and T2DM?
1. In T1DM there is an absence of endogenous insulin
62
What should we know about the onset of T1DM?
1. Gradual onset
2. Autoantibodies are present for months to years before symptoms occur
3. Manifestations develop when pancreas can no longer produce insulin-- then rapid onset with ketoacidosis
4. Necessitates insulin
5. Patient may have temporary remission after initial treatment
63
What should we know about the onset of T2DM?
1. Gradual onset but slower than T1DM
2. Hyperglycemia may go many years without
3. Often discovered with routine lab testing
At time of Dx:
1. About 50-80% of beta cells are no longer secreting insulin
2. Average person has had diabetes for 6.5--8 years
64
What are the leading factors of T2DM?
1. Insulin resistance
2. Pre-diabetes
3. Metabolic syndrome
4. Gestational diabetes
65
True or false: There is not a genetic link between insulin resistance
False
66
What should we know about insulin resistance?
1. Decreased insulin production by pancreas
2. Inappropriate hepatic glucose production
3. Altered production of hormones and cytokines by adipose tissue (adipokines)
67
What should we know about prediabetes?
1. Asymptomatic but long-term damage already occurring
2. Impaired glucose tolerance (140-199mg/dl)
3.Impaired fasting blood glucose (FBG 100-125mg/dL)
4. Hgb A1C 5.7-6.4%
5. Intermediate stage between normal glucose homeostasis and diabetes.
68
What do we need to know about metabolic syndrome?
1. Metabolic syndrome increases risk for type 2 diabetes
Clinical manifestation:
1. Elevated glucose levels
2. Abdominal obesity
3. Elevated BP
4. High levels of triglycerides
5. Decreased levels of HDL
69
What are some modifiable risk factors of T2DM?
1. BMI more or equal to 26 and risk increases at more than 30
2. physical inactivity
3. HDL less than or equal to 35/DL & or TG more than or equal to 250mg/DL
4. Metabolic syndrome
70
What are some non-modifiable risk factors?
1. 1st degree relative with DM
2. Members of high risk ethnic populations
3. Women who delivered a baby 9Ibs or greater or who had GDM
4. HTN
5. Women with POS
6. HgA1c of 5.7% or greater
7. History of CVD
71
What are some s/s of T2DM?
1. Genetic mutations= insulin resistance & Familial tendency
2. Polyuria, nocturia
3. Polydipsia
4. Polyphagia
5. Recurrent infections
6. prolonged wound healing
7. Visual changes
8. Fatigue, Decreased energy
9. HbA1c increased above 6.5%, FPG- 126 increased above
10. Prediabetes FPG 100-125 mg/dL
11. Metabolic syndrom
72
What are some clinical manifestation of T2DM?
1. 3p's-- polyuria polydipsia, polyphagia
2. Fatigue
3. Poor wound healing
4. Cardiovascular disease (CVD)
5. Renal insufficiency
6. Recurring infections-bacterial and yeast
7. Visual changes
73
What is the medical management of T2DM?
1. Education- Nutritional therapy, self-monitoring
2. Monitoring glycemic control
3. Diet
4. Exercise
5. Monitoring for complications
6. Oral glucose control agents
8. insulin if needed
74
How do oral agents/medication help treat DM
1. Stimulate insulin release from beta cells
2. Modulate the rise in glucose after a meal
3. Delay cho digestion/absorption
75
What are the side effects of metformin (Glucophage)?
1. GI upset, and rarely lactic acidosis
76
How does metformin (Glucophage) work?
1. Lowers BG and improves glucose tolerance- enhances insulin sensitivity, improves glucose transport, may cause weight loss
2. Reduces glucose production by the liver
77
What class is metformin?
1. Biguanides
78
When is metformin started?
1. Immediately after the diagnosis and can be used as a preventative
79
What is the T2DM step approach to treatment?
Step 1: Diet and exercise
Step 2: Lifestyle changes plus metformin
Step 3: Lifestyle changes plus metformin and add a second drug
Step 4: Lifestyle changes plus metformin & Insulin therapy
80
How do sulfonylureas work?
1. Increases insulin production from pancreas
81
What are the side effects of sulfonylureas?
1. Hypoglycemia and weight gain ( must eat)
82
Glipizide, Glyburide and glimepride are examples of what medication used to treat T2DM?
1. Sulfonylureas
83
True or false: Alcohol use can potentiate hypoglycemia effects including flushing, palpitations and nausea?
True
84
What do we need to know about Meglitinides (Glinides)
1. Stimulate insulin release from pancreas
2. Short- acting and taken with each meal- 30 mins prior to meal
3. Half-life is only 1 hour, completely absorbed/metabolized in 4 hours
4. Main side effects: hypoglycemia, weight gain
5. Examples: Repaglinide (prandin), Nateglinide (starlix)
85
What do we need to know about alpha-glucosidase inhibitors
1. start blockers
2. slow down absorption of carbohydrate in small intestine
3. Take with first small bite of each meal
4. Example: Acarbose (Precose), Migltol (glyset)
5. Can cause anal leakage, upset stomach, diarrhea and farts
86
What do we need to know about thiazolidinediones (glitazones) or TZD (know this one)
1. Examples: Pioglitazone (atos), Rosiglitazone (Avanda)
2. Decreases insulin resistance & May also decease glucose production
3. improve insulin sensitivity, transport and utilization of target tissues
4. Adverse effects : URI, HA, Sinusitis, & Myalgia
5. caution: With Mild HF. AVOID IN SEVERE HF
6. peaks in 2 hours
87
What T2DM drug can cause a female to ovulate?
1. Thiazolidinediones or TZD
88
What do we need to know about DPP-4 Gliptins: Incretin Enhancer?
1.Example: Sitagliptin (Januvia), saxagliptin (onglyza), Linagliptin (tradjenta), Alogliptin (nesina)
2. Blocks inactivation of incretin hormones
3. Increases insulin release
4. decrease glucagon secretion
5. Decrease hepatic glucose production
6. Adverse effects: sore throat, rhinitis, URI, HA
7. NOT used alone to tx T2DM
89
What do we need to know about sodium-glucose co-transporter 2 (sglt2) inhibitors
1. SGLT2 inhibitors work by
-Blocking reabsorption of glucose by kidney
- Increasing glucose excretion
- Lowering blood glucose levels
2. Examples: Canagliflozin (Invokana), Dapagliflozin (farxiga), Empagliflozin (jardiance)
90
What is combination therapy for T2DM?
1. Combination oral therapy
- Two different classes of medication
- Risk & Benefits of both drugs are looked at
2. Other Drugs may affect blood glucose levels
- Drug interactions can potentiate hypoglycemia and hyperglycemia
91
What do we need to know about non-insulin injectables?
1. GLP-1 receptor agonists: slow gastric emptying, stimulate glucose-dependent release of insulin, inhibit postprandial release of glucagon and suppress appetite.
2.Nausea is common
3. Examples: Exenatide (byetta), Dulaglutide (trulicity), Liraglutide (victoza)
92
What do we need to know about amylin mimetic
1. Used to complement effects of mealtime insulin in T1DM and T2DM patients
2. Delays gastric emptying and suppresses glucagon secretion
3. Act in the brain to increase the sense of satiety, helping to lower caloric intake
4 Example: Pramlintide (Symlin)
93
What are other meds not directly related to DM?
1. Statin drugs used to treat hyperlipidemia
2. Ace inhibitors, CCB, angiotensin II receptor blockers for HTN and renal insufficiency
3. Diuretics for fluid overload and HTN control
4. Beta blockers (-olol) not recommended but are used for HTN and decrease CVD
94
Collaborative care for DM includes what
Patient teaching
1. Drug therapy
2. Nutritional therapy
3. Exercise
4. Self-monitoring of BG
Diet, exercise, & weight loss may be sufficient for T2DM tx.
All patients with T1DM require insulin
95
Long-Term effects of hyperglycemia include what
1. Major CVD: Ischemic heart disease, stroke
2. Lower-extremity amputation
3. DKA, HHS
4. Skin and soft tissue infections
5. Pneumonia
6. Influenza
7. Bacteremia/sepsis
8. TB
96
What are some MACRO vascular effects of DM?
1. CVD/PVD
2. MI
3. Stroke
97
What are some Micro vascular effect of DM?
1. Retinopathy
2. periodontal DZ
3. Renal Insufficiency/Failure (nephropathy)
98
What are some effects of DM on CV system?
1. HTN
2. Angina
3. Dyspnea
4. MI
5. Peripheral Vascular Disease
6. Hyperlipidemia
7. CVA (Stroke)
8. Assessment
99
What should we know about CV disease and DM
1. Hyperlipidemia- treated with statin drugs
2. Smoking increases the risk of CV disease
3. Microvascular disease
- retinophy
- Periodontal dz
- Renal insufficiency/failure (nephropathy)
100
What should we know about periodontal disease and DM?
1. Increased dental caries
2. Tooth loss
3. Gingivitis
4. Candidiasis (yeast)
5. Regular dental exams twice.
- T2DM need dental exam right after diagnosis
101
What are chronic complications of diabetic retinopathy?
1. Microvascular damage to retina
2. Non proliferative -
- partial occlusion of small blood vessels in retina causes microaneurysms
2. Proliferative
- involves retina & Vitreous humor
- New blood vessels formed (neovascularization)
- can cause retinal detachment
102
What treatment is there for retinopathy & other eye diseases caused by DM?
1. Laster photocoagulation: Laser destroys ischemic areas of retina
2. Vitrectomy: Aspiration of blood, membrane, & fibers inside the eye
3. Drugs to block action of vascular endothelial growth factor
103
DM puts you at risk for what other eye diseases?
1. Glaucoma
2. Cataracts
3. Blindness
104
What is nephropathy?
Damage to small blood vessels that supply the glomeruli in the kidney
105
DM is the leading cause of ESRD... True or false?
True
106
What is the percentage of patient that have DM and Nephropathy?
20-40%
107
What are the risk factors of nephropathy?
1. HTN, genetics, smoking, chronic hyperglycemia
108
What are some chronic complications of diabetic nephropathy?
1. These patients need annual screenings w/UA's
2. If albuminuria present, drugs to delay progression are:
-ACE inhibitors
-Angiotensin II receptor antagonists
3. Control of hypertension & tight BG control
109
What are some labs for nephropathy?
1. UA- should be free of albumin, protein, glucose, nitrites/bacteria, etc
2. BUN/Creatinine-
-BUN 8-20 mg/dL,
-Creatinine 0.6-1.2 mg/dL
3. GFR
->60
110
What are the cues for nephropathy?
1. Edema of face, hands, and feet
2. Symptoms of a UTI
3. Symptoms of renal failure: Edema, anorexia, fatigue, difficulty concentrating
111
What are the neurological effects of neuropathy?
1. Mechanisms not completely understood
2. Damage to the nerve cells
3. Diabetic peripheral neuropathy
4. Autonomic Neuropathy
112
What are chronic complications of diabetic neuropathy?
1. Nerve damage due to metabolic derangements of diabetes
2. Reduced nerve conduction of demyelination
3. autonomic Neuropathy
4. Sensory neuropathy
-loss of protective sensation
5. Distal symmetric polyneuropathy
- loss of sensation, abnormal sensations, pain and paresthesia's
113
What is the treatment for sensory neuropathy?
1. Tight BG control
2. Drug therapy
- Topical creams
- Tricyclic antidepressants
- Selective serotonin & norepinephrine reuptake inhibitors
- Antiseizure meds
114
What are complications of autonomic neuropathy?
1. Gastroparesis
- Delayed gastric emptying
2. Cardiovascular abnormalities
-postural hypotension, resting tachycardia
- Painless myocardial infarction
3. Hypoglycemic unawareness
4. sexual function
-erectile dysfunction
- Decreased libido
5. Neurogenic bladder
- Empty frequently, use crede's maneuver
- medications
-self-catheterization
115
What are some risk factors of chronic foot complications
1. Microvascular & macrovascular diseases increase risk for injury and infection
2. Sensory neuropathy & PAD- risk for amputation
3. Clotting abnormalities, impaired immune function, autonomic neuropathy
4. Smoking increases
116
Why is sensory neuropathy a chronic complication of foot complications in a DM patient?
1. Patient loses loss of protective sensation and unawareness of injury
- do a monofilament screening
117
Why is peripheral artery disease a chronic complication of feet complications in a DM patient?
1. Decreased blood flow, decreased healing and increased risk of infection
118
What are some foot care recommendations?
1. Annual comprehensive foot examinations by HCP to identify risk factors predictive of ulcers and amputations.
2. Inspection
3. Test for loss of sensation: 10g monofilament plus
-vibration using 128hz tuning fork
- Pinprick sensation
- Ankle reflexes
- Vibration perception threshold
119
What is the treatment for foot ulcers?
1. Bed rest
2. Antibiotics
3. Debridement
4. Good control of BG
5. If patient has PVD, ulcers may not heal
6. Amputation may be necessary
120
What are some precipitating factors of DKA?
1. Infection
2. Inadequate insulin dose
3. Illness
4. Undiagnosed in T1DM
121
Why does DKA happen?
1. Caused by profound deficiency of insulin?
122
1. DKA is characterized by....
1 Hyperglycemia
2. Ketosis
3. Acidosis
4. Dehydration
123
In which is DKA more likely to occur? T1DM or T2DM?
1. T1DM
124
What are the clinical manifestations of DKA?
1. DEHYDRATION
2. Poor skin turgor
3. Dry mucous membranes
4. Tachycardia
5. Orthostatic hypotension
6. LETHARGY AND WEAKNESS EARLY
7. SKIN DRY AND LOOSE; EYES SOFT AND SUNKEN
125
What are the symptoms of DKA?
1. Abd pain, anorexia, n/v
2. Kussmaul respirations
3. sweet,fruity breath odor
126
What lab work is requested for DKA and what does it look like
1. BG level of 250 mg/dL or higher
2. Blood pH
127
What is the treatment considerations of DKA?
1. Less severe form may be treated on an outpatient basis
2. Hospitalize for severe fluid and electrolyte imbalance, fever, nausea/vomiting, diarrhea, altered mental state
128
How do we treat DKA and HHS?
1. Ensure patent airway; administer o2
2. Establish IV access: begin fluid resuscitation
- NaCL 0.45% or 0.9%
- Add 5% to 10% dextrose when blood glucose level approaches 250mg/dL
3. Continuous regular insulin drip 0.1/KG/HR
4. Potassium replacement as needed
129
DKA VS HHS- When is each type usually seen?
DKA- Mostly seen in T1DM
HHS- Occurs more in Elderly
130
DKA vs HHS-- how quickly do each occur?
DKA- Rapid onset
HHS- Gradual onset
131
DKA Vs HHS-- What do the lab levels look like
DKA
-- BG >250mg/dL
-- PH <7.3
-- Bicarb <15
-- +ketones urine and serum
HHS
-->600mg/dL
-->7.3
--Bicarb >30
-- negative ketones
132
DKA lab levels are....
-- BG >250mg/dL
-- PH <7.3
-- Bicarb <15
-- +ketones urine and serum
133
HHA lab levels are....
-->600mg/dL
-->7.3
--Bicarb >30
-- negative ketones
134
What should we know about HHS
1 Life-threatening syndrome
2. Occurs w/ T2DM
135
What are precipitating factors to HHS
1. UTI's, Pneumonia, Sepsis
2. Acute illness
3. Newly diagnosed T2DM
4. Impaired thirst sensation and or inability to replace fluids.
136
What is the pathology of HHS?
1. Enough circulating insulin to prevent ketoacidosis
2. Fewer symptoms lead to high glucose levels
3. More severe neurologic manifestations -- 2nd to increase serum osmolality
137
What lab/lab values indicate HHS?
1. BG >600mg/dL is possible
2. Ketones are absent or minimal in blood and urine
138
True or false: HHS has a low mortality rate?
False
139
What is the treatment for HHS
Same as DKA
1. IV insulin and NACL infusions
2. More fluid replacement
3. Monitor serum potassium and replace as needed
4. Correct underlying precipitating cause
140
What is the nursing management for HHS
MONITOR
1. Iv fluids
2. Insulin therapy
3. Electrolytes
Assess
1. Renal status
2. Cardiopulmonary status: possible fluid overload
3. LOC
141
What are some complications of insulin treatment
1. Hypoglycemic reaction
2. Coma from too much or not enough
3. Hypokalemia
4. Lipohypertrophy
142
What are the s/s of hypoglycemia?
1. Shakiness
2. Palpitations
3. Nervousness
4. Diaphoresis
5. Anxiety
6. Hunger
7. Pallor
143
What is the treatment hypoglycemia?
Check BG level
1. if less than 70mg/dL, begin treatment
2. If more than 70mg/dL, investigate further for cause of s/s
3. If monitoring equipment not available, treatment should be initiated
144
What is the rule of 15 in hypoglycemia treatment?
1. Consume 15g of a simple carbohydrate
-fruit juice or regular soft drink, 4 to 6oz
2. recheck glucose level in 15 mins
3. Avoid foods with fat
- Decrease absorption of sugar
4. Avoid overtreatment
5. Give complex CHO after recovery.
145
What does treatment of hypoglycemia look like in a hospitalized patient?
1. See orders or hospital protocol
2. 15 in 15 rule generally followed
3. if patient is not alert enough to swallow
- 50% dextrose, 20-50mL, IV push
- Glucagon, 1 mg IM or Sub q
4. Explore reason why it occured
146
What is the MOA for Glucagon?
1. Stimulate conversion of glycogen to glucose
147
What is the peak of glucagon?
1. 15-30 min, last 90 mins (IV, SQ, or IM)
148
What are the adverse effects of glucagon?
1. N/V, allergic reaction
149
How do you reconstitute glucagon?
1. with sterile water
150
What are some things to consider when using glucagon
1. Risk for aspiration; follow with complex CHO and recheck BG
151
How can a high blood glucose affect our potassium level?
1. If too much insulin= significant hypokalemia can occur.
152
Why are we worried about hypokalemia?
effects on the heart
153
What is lipohypertrophy?
1. Accumulation of SQ fat when insulin is injected too frequently at the same time
154
What are two chronic skin complication caused by DM
1. Diabetic dermopathy
2. Acanthosis nigricans
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What should we know about diabetic dermopathy?
1. AKA "shin spots" or pigmented pretibial papules
2. Most common cutaneous manifestations of diabetes
3. Benign asymptomatic red brown macules on shins
4. No treatment needed
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What should we know about the chronic complications of infections in DM patients?
1. Defect in mobilization of inflammatory cells & impaired phagocytosis
2. Recurring or persistent infections
3. Treat promptly and vigorously
4. Patient teaching for prevention
- hand hygiene
- flu and pneumonia vaccine
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How do we prevent complications of DM?
1. Patient education
2. Assess barriers to learning
3. Teach in increments
4. Promote self-care
5. Adjust regiment to meet needs
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What are barriers that affect adherence to DM management?
1. Degree of life changes & complexity of management plan
2. Cost of care
3. Cultural factors
4. Lack of family supp
5. Other stressors
6. Lack of knowledge
7. Fears
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What are strategies to increase adherence to DM management
1. Encourage patient and family to take charge of their health
2. Simplify the regimen
3. Focus on the normal not the difference
4. Teach the tools & help pt. get supplies
5. Provide safe harbor
6. Provide adequate education
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What are some psychologic considerations for DM patients
1. High rates of
- Depression
- Anxiety
- Eating disorders
2. Open communication is critical for early detection
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What are goals of nutrition therapy for DM patients?
1. Maintain BG level
2. Lipid profiles & BP levels
3. Prevent/slow rate of chronic complications
4. Nutritional needs & personal, cultural & economic needs
5. Maintain pleasure of eating
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What are the general guidelines of T1DM diet?
1. Meal planning
-Based on usual food intake and preferences
-Portion control
- Balanced with insulin and exercise patterns
2. Day to day consistency
3. More flexibility with
-rapid acting insulin, multiple day injections and insulin pump
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What are some general guidelines of a T2DM?
1. Emphasis on achieving glucose, lipid and BP goals
2. Weight loss
- nutritionally adequate meal plan with decreased fat and CHO
-spacing meals
- weight management
- Regular exercise
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What are general guidelines when it comes to carbohydrates?
1. CHO should be 45-60% of daily caloric intake
2. Grains, fruits, legumes, & milk
3 Min. 130 grams/day
4. Fiber intake of 25-30 grams/day
5. Limit refined grains and sugars
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What are the general guidelines when it comes to protien?
1. 15-20% of total calories consumed
2. High protein diets are not recommended
3. protein may reduce in patients with kidney failure
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What are the general guidelines when it comes to fats?
1. Saturated fat <7% of total calories
2. Minimize trans fat
3. Limit dietary cholesterol <200mg/day
4. Fish- polyunsaturated fats
5. Health fats from plants
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What is the glycemic index?
1. Glycemic index of 100 refers to the response to 50 grams of glucose or white bread in a normal person without diabetes
2. Foods with a high glycemic index raise glucose levels faster & higher than foods with a low glycemic index
3. May provide a modest additional benefit over consideration of total carbohydrates alone
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15 grams is how many carbs?
1. 1 carb
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I carbohydrate choice =
15 grams
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What should we know about sugar-free foods?
1. sugar-free does not mean carbohydrate free
2. Sugar-free foods often higher in saturated fat compared to the regular product
3. Teach patients importance of reading labels.
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What should we know about sugar alcohols?
1. Found in most sugar-free foods
2. Sugar alcohols include: sorbitol, mannitol, xylitol & isomalt
3. Sugar alcohols eaten in large quantities
- Abd cramping, flatulence, & diarrhea
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Timing of meals and snacks should bee....
1. Fixed insulin regimen: consistency
2. Rapid-acting insulin:
-Can adjust dose before meal based on current BG & CHO meal
3. Intensified insulin therapy/insulin pump allows more flexibility
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What should we know about alcohol and DM?
1. Limit- moderate amount
2. Inhibits gluconeogenesis
3. Monitor glucose
4. No nutritional value
5. High in calories
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What happens if a DM patient drinks alcohol?
1. Dont skip meals
2. Risk of a low blood sugar
3. May increase triglycerides
4. Check with diabetes care team
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What type/amount of exercise should a DM patient do?
1. Minimum of 150 mins/week aerobic
2. Resistance training 3x a week
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What are the benefits of a exercise for a DM patient?
1. Decreased insulin resistance and blood glucose by increasing muscle mass
2. weight loss
3. decreased triglycerides and LDL and INCREASED HDL
4. Improve BP and circulation
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What should we teach a patient about diabetes exercise?
1. Start slowly after medical clearance
2. Monitor BG
3. Glucose-lowering effect up to 48 hours after exercise
4. Exercise 1 hour after a meal
5. Snack to prevent hypoglycemia
6. Do no exercise if blood glucose level >300mg/dL and if ketones are present inurine
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What should we know about medication & exercise in DM patients?
1. Patients who use insulin, meglitinides & sulfonylureas at increased risk for hypoglycemia
2. Do not exercise when medication is at its peak
3. Test BG before & After exercise
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What should we know about the food & exercise in DM patients
1. Eat enough to maintain adequate BG levels
2. Always carry a fast acting source of CHO
3. May need small CHO snacks every 30 mins
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What should we teach/know about bariatrics surgery?
1. Typically used with our T2DM patients
2. Used when lifestyle and drug therapy managment is difficult
3. BMI > 35kg/m2
4. Must meet requirements
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What should we know/teach about pancreas transplantation?
1. For T1DM with kidney transplants
2. Eliminates need for exogenous insulin, SMBG,Dietary restrictions
3. Can also eliminate acute complications
4. Long-term complications may persist
5. Lifelong immunosupression
6. Ilet cell transplantation experimental
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What is subjective data we would gather during a general nursing assessment of clients with diabetes?
1. Past health history
-viral infections, infections, pregnancy, family history, diabetes
2. Medications
- Insulin, OA's, corticosteroids, diuretics, phenytoin
3. Recent surgery
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What is subjective data we may gather about health problems?
1. Health perception & management
2. Nutrional
3. Elimination
4. Activity level or fatigue
5. Cognitive perceptual
6. Sexual - reporductive
7. Coping
8. Value- Belief
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What is objective data we may attain during a nursing assessment of a DM patient
1. Eyes
2. Skin
3. Respiratory
4. Cardiovascular
5. GI
6. Neurological
7.Musculoskeletal
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What should our overall goals of a DM patient and care consist of?
1. Active patient participation
2. Maintain normal BG levels
3. Adjust lifestyle to accommodate diabetes regimen
4. Few or no episodes of hypoglycemia or acute hyperglycemia emergencies
5. Prevent or minimize chronic complications.
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True or false we should encourage our patients to wear a medical alert band?
True
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What is our nursing implementation for ambulatory & home care?
1. Overall goal patient/caregiver optimal level of independence
2. Consult with dietician
3. use services of certified diabetes educator (CDE)
4. Establish individualized goals for teaching
5. Include family/caregivers
6. Frequent oral care
7. Annual exams: eye, lab, feet and other specialties
8. foot care
9. Travel needs - Medications, supplies, food and activity
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What is the expected outcomes of our nursing management stage that we should evaluate
1. knowledge gained
2. Self-care measures learned
3. Balanced diet & activity understood
4. Stable, normal BG level
5. No injuries
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What does culturally competent care of a DM include
1. Culture can have a strong influence on dietary preferences and meal prep
2. High incidence of diabetes in
-Hispanics
-native americans
-African Americans
- Asians and pacific islanders.
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What are some cutural considerations with DM patients?
1. Cultural perceptions of health may vary
2. Culture & tradition influence diet and food prep
3. Communicate effectively
- Literacy, English proficiency, or non- English speakers
- appropriate teaching material
4. Socioeconomic status may effect health care choices
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What are some gerontologic considerations for DM patients?
1. Increase prevalence & mortality
2. Glycemic control challenging
-increased hypoglycemic unawareness
- functional limitations
-renal insufficiency
3. Diet & exercise: Main treatment
4. Patient teaching must be adapted to needs
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What is our nursing implementation in special situations in our acute illness, injury and surgery (general principles)
1. Increased BG secondary to counter-regulatory hormones
2. T1DM may increase insulin needs
3. T2DM may necessitate insulin therapy
4. Frequent monitoring og BG
-Urine ketone testing if BG >240mg/Dl
-Report BG >300mg/dL for two tests or mod to high urine ketone levels
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What are the sick day rules for DM patients?
For acute illnesses
1. Maintain normal diet if able
2. Increase noncaloric fluids
3. Continue taking antidiabetic medication
4. if normal diet not possible, supplement with cho-containing fluids while continue meds
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Sick day rules hydration--- what is expected for both types
T1DM & T2DM-- 8oz fluid per hour
2. Every 3rd hour, consume 8oz of a sodium rich choice like bouillon
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Sick day rules SMBG-- what is expected for both types
T1DM & T2DM --every 2-4 hours while BG is elevated or until symtoms subside
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SICK DAY RULES- Ketones--- what is expected for both types of
T1DM- Every 4 hours monitor or until neg
T2DM- Determined for the individual
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Sick Day rules Med adjustments-- what is expected for both types?
T1DM- Continue as able, adjust insulin doses to correct hyperglycemia. Instruct patient to call their health care provider for specific instructions
T2DM- Hold metformin during serious illness
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Sick day rules-- food and beverage selections--- what is expected for both types
T1DM & T2DM- Guide patients to consume 150-200g CHO daily in divided doses... switch to soft or liquids as tolerated
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Sick days rules-- contact healthcare provider when.... what is expected of both types of
T1DM & T2DM- Vomiting more than once, diarrhea more than 5X or for longer than 6hours.... BG >300x2 moderate to lg. urine ketones
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What should our nursing care preop DM patients care look like?
1. Verify order
2. May hold or reduce insulin dose morning of surgery (NPO)
3. During stress such as surgery, BG levels may rise
4. Iv fluids & Insulin
5. Frequent monitoring of BG
- Hyperglycemia leads to loss of fluids & electrolytes
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What are factors affecting hyperglycemia in the hospital
1. Changes in tx regimen
2. Medications (Glucocorticoids)
3. IV dextrose
4. Overly vigorous tx of hypoglycemia
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If your patient is NPO what do you do about your patients insulin meds?
1. Insulin dose may need to be held or changed
2. Frequent BG monitoring
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If a patient is put on a clear liquid diet what might this mean to us as far as BG control
1. The CL needs to be caloric
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If a patient is on an enteral feeding what would we do as far as BG control?
1. Monitor BG & give insulin at regular intervals
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If a patient is on parenteral nutrition what would we do as far as BG contol?
Monitor BG as parenteral nutrition may already contain insulin
