DM

Question 1

Type 1

Answer 1

Prevention of type 1 DM has not been successful
An individual’s risk of developing type 1 DM is estimated by:
- Considering family Hx of type 1 DM
- Attention to age of onset and sex of the affected family members
- Profiling immunity and genetic markers

Question 2

Managing Type 1 DM

Answer 2

Optimal glycemic control is fundamental to the management of DM
Both fasting and postprandial plasma glucose levels
- correlate with the risk of complications
- contribute to the glycosylated hemoglobin value
When setting treatment goals and strategies, consideration must be given
- to individual risk factors such as age, prognosis, presence of DM complications
- comorbidities, risk for an ability to perceive hypoglycemia

Question 3

Managing DM

Answer 3

Improved glycemic control reduces risks of microvascular complications in both type 1 and 2 DM
Improved glycemic control reduces the risk of cardiovascular disease for type 1 diabetics

Question 4

Nutrition therapy

Answer 4

An integral part of the treatment and self-management of DM
Goals of nutritional therapy
- maintain or improve QOL and nutritional and psychological health
- prevent and treat acute and long term complications of DM, associated comorbid conditions

Question 5

Nutrition Guidelines

Answer 5

For patients requiring weight loss:
- A weight loss of 5-15% of initial body weight can improve insulin resistance, glycemic control, BP, and lipid values
Advise on risk of hypoglycaemia resulting from alcohol consumption (carb intake, insulin dose adjustment, increase CBG monitoring)
Include at least 25g of fibre in diet (improves carb metabolism and lowers cholesterol)

Question 6

Nutrition Therapy

Answer 6

Encourage matching insulin to carb in individuals with type 1 DM (carbohydrate counting - prescribed amount of insulin for 10 - 15 g eaten in each meal)
- 1 serving is equal to 15 carbs (serving size, carbohydrates)
- Post-prandial (post-meal) - carbs have greatest effect on blood glucose
Encourage nutritionally balanced calorie-reduced diet in overweight or obese pt (exchange list-kilocalories)

Question 7

Glycemic Index

Answer 7

Ranking system that compares how fast carbohydrate foods raise blood glucose compared to plain glucose
- Low glycemic: raise blood glucose slowly (less processed and higher fibre)
- High glycemic: raise blood glucose quickly (refined and low fibre)
Can eat sugar containing foods but less than 10% of the total caloric intake
- Carbs 45-60%
- Protein 15-25%
- Fat 20-30% (limit trans fat, no more than 7% saturated fat)
- Cholesterol less than 200 mg/day

Question 8

Low Glycemic Foods

Answer 8

Bread:
- 100% stone ground whole wheat
- Heavy mixed grain
- Pumpernickel
Cereal:
- All Bran
- Bran buds with psyllium
- Oat bran
Grains:
- Barley
- Bulgar
- Pasta, noodles (WW)
- Parboiled or converted rice
Other:
- Sweet potatoes
- Yams
- Legumes (lentils, chick peas, kidney beans, split peas, baked beans, soy beans)

Question 9

Meals

Answer 9

Children (5-12) taught to have a consistent meal plan
Teens and preteens more flexibility focuses on insulin to carbohydrate ratio
Carbohydrates content based on 15 gm
- 1 slice of bread, 1 medium apple, 1/2 cup of choco milk, 3 cups popcorn
- Breakfast 30 gm
- Morning snack 15 gm
- Lunch 60 gm
- Afternoon snack 15 gm
- Supper 35 gm
- Evening snack 20 gm

Question 10

Insulin

Answer 10

Goal of insulin treatment - mimic pancreas; small amounts of insulin at a time
Extra insulin given with food or in response to high blood glucose
Adjust their insulin based on carbohydrate content of their meals
Dietary fibre should be subtracted from total carbohydrates

Question 11

Recommendations

Answer 11

150 min/week mod-vigorous exercise 
As well as resistance 2x week
Exercise safely
- community pools, gyms, safe walking, etc.
- Medic Alert ID
Pre-exercise assessment prior to program
- Neuropathy, retinopathy, CAD, PVD
Tools can be found on CDA
Use proper footwear
Inspect feet daily and after exercise
Avoid exercise in extreme hot or cold
- and during periods of poor glucose control
Over 35: ECG stress test

Question 12

Precautions

Answer 12

If pre-exercise glucose levels are less than 5.5 mmol/L, approximately 15-30 gm of carbs should be ingested before exercise
Avoid exercise is CBG is >16.7 mmol/L and the patient does not feel well, and ketones present
Individuals with type 2 DM generally do not need to postpone exercise because of high blood glucose, provided they feel well, if CBG are elevated to >16.7 mmol/L, it is important to ensure proper hydration and monitor for S&S (increased thirst, nausea, extreme fatigue, blurred vision, or headache), especially for exercise to be performed in the heat

Question 13

Nursing Considerations: Exercise

Answer 13

Reinforce:

• Improved strength and endurance
• Improved cardiovascular funciton
• Decreased risk for CAD (lowers cholesterol and triglycerides and improves HDLs)
• Reduced weight and body fat
• Improved well being and QOL

Question 14

Insulin

Answer 14

Infants, toddlers, and preschoolers
- Start with 2 injections a day, mixture rapid, intermediate or long acting insulin before breakfast and supper
Children (5/6)
- Start 3 injections/day, mixture rapid and intermediate before breakfast, rapid acting before supper, and intermediate before bed time

Question 15

Insulin

Answer 15

Teenagers

• Move to or start with multiple injections
• Rapid acting before meals and major snacks, intermediate or long acting before bedtime
• More injections: not a sign of worsening DM
• Consistency of ratio with insulin and carbohydrates
• • Allows flexibility when eating but keeps sugars within target

Question 16

Insulin Requirements: Affected by

Answer 16

Growth and development
Appetite
Physical activity
Stress or illness
No fixed dose will work indefinitely

Question 17

Types of Insulin

Answer 17

Rapid Acting
- Lispro
Short acting
- Humulin R, Regular 
Intermediate Acting
- NPH
- Lente
- Novocain 30/70 (30 regular/ 70 NPH)
Long Acting
- Ultralente
- Glargine (Lantus)

Question 18

Use of Insulin

Answer 18

Insulin Pens
- Easy to give multiple injections, if use two types of insulin then two pens (portable)
Jet Injectors
- No needles, tiny stream insulin, bruising occurs
Syringes
- Fine needles, can mix insulin’s
Insulin Pumps
- Small catheter under skin and pump programmed to deliver small amounts insulin, can deliver extra doses
- Can malfunction and only used with short acting insulin

Question 19

Monitoring Blood Glucose

Answer 19

Direct measurement (various machines/ lancets) - self monitoring blood glucose
HbgAIC - monitor glucose levels over 3 months
Urine testing for glucose and ketones - used less
- Should be negative
SMBG
- Allows individual monitoring and achievement of metabolic control
- Useful if ill, pregnant, or has symptoms of hypo/hyperglycemia
- Single reading or computerized for pattern of control
- CGM with pump

Question 20

Complications

Answer 20

Too many highs or lows may lead to mild intellectual or learning impairment
Prepuberty or having DM less than 5-10 years of age less likely to show signs of micro and microvascular complications
Once puberty started and disease has been present for 3-5 years, screening for complications and risk factors important

Question 21

Teaching

Answer 21

Check CBGs at mealtime and bedtime and PRN
Keep regular insulin for emergencies
If meal delayed, delay insulin (reg)
Know S&S of hyper/hypoglycemia
Keep candies or sugar for emergencies
Avoid alcoholic beverages to prevent hypoglycaemia
Observe injection sites

Question 22

Management of type 2 DM

Answer 22

Medications:
- Sulfonylureas (Glyburide - Insulin stimulator)
- Biguanides (Metformin - Insulin sensitizers)
- Alpha-Glucoside Inhibitors (Glyset - Carbohydrate blocker)
- Meglitinides (Prandini - Insulin stimulator)
- Thiazolidinediones (Actos - Insulin sensitizer)
Dietary Interventions
- Caloric/ Carbohydrate/ Exchange list
Exercise program
Monitoring CBG

Question 23

Teaching Antidiabetic Agents - Type 2 DM

Answer 23

Oral - monitor CBG 2-3 x week or PRN
Teaching: re medication reinforced
Hypoglycaemic reaction can occur with sulfonylurea - (headaches, sweating, nervousness, tremors, rapid pulse)
S&S hypoglycemia/ hyperglycemia reaction
Medic Alert ID
Carry a glucagon emergency kit
Alcohol can induce hypoglycaemic reaction
No unprescribed OTC meds
Diet and exercise remain important
Store meds safely

Question 24

DKA

Answer 24

Does not occur because someone has eaten too much sugar
Occurs because:
- Failure to get any or enough insulin
- Failure to take sufficient extra insulin to cover high blood glucose and ketones due to illness or infection
- Pumps undetected or inappropriate management of pump failure

Question 25

DKA: Treatment

Answer 25

Hospital admission Fluids for dehydration Insulin for hyperglycemia Electrolytes for imbalances (metabolic acidosis)

Question 26

Hypoglycaemia: Treatment

Answer 26

``` Mild - Immediate treatment - 15 g rapid-acting sugar Severe - Hospitalized - IV glucose ```

Question 27

HHNK

Answer 27

Fluids - need to maintain osmolality | Insulin for hyperglycemia

Question 28

Microvascular - CAD Stroke: Risk Management and Tx (ABCDES)

Answer 28

A- AIC: Glucose control target is usually seven percent or less (AIC is a blood test that is an index of your average blood glucose level over the preceding 120 days) B- Blood Pressure: Control your blood pressure (less than 130/80 mm/Hg) C- Cholesterol: LDL (bad) cholesterol target is 2.0 mmol/L or less D- Drugs: to protect your heart; Blood pressure meds, cholesterol lowering meds (statins), Aspirin or Clopidogrel E- Exercise: Regular physical exercise, which includes healthy diet, achievement and maintenance of a healthy body weight S- Smoking and Stress: Stop smoking and manage stress effectively

Question 29

PVD: Risk Management and Tx

Answer 29

Decreased arterial circulation can lead to lower leg ulcers and gangrene - Prone to infection - Decreased healing - May lead to amputations Nursing care r/t maintaining skin integrity, circulation, and minimizing the risk for infection - Assess skin and S&S of PVD (CMS) - Assess S&S of infection - Providing wound care and emotional support following amputation - Pain management

Question 30

The Diabetic Foot

Answer 30

Experience foot trauma sometimes without even knowing Begin as superficial injury then progress to ulcer Assess for: - Injuries to feet (CMS) - Abscesses - Infection - skin (underlying tissue) and bone - Dry gangrene (cold, dry, shrivelled, black tissue of toes and feet) - Eventually gangrene invades the entire foot and amputation is needed Treatment - Bedrest, antibiotics and debridement

Question 31

Microvascular - Diabetic Retinopathy

Answer 31

``` Yearly eye exams - Various degrees of visual impairments Laser surgery can help prevent loss of vision Cloudiness in the eye (cataracts) Assess for: - Changes in vision - Retinal hemorrhage or detachment ```

Question 32

Diabetic Nephropathy

Answer 32

``` Assess for: - Albumin in the urine (glomurulosclerosis) - Microalbuminuria - first indication - Hypertension: treat with BP meds (ACE) - Edema - Progressive renal insufficiency May require dialysis or transplant ```

Question 33

Diabetic Neuropathy

Answer 33

``` Assess for: Sensory and motor impairments - Bilateral sensory disorders - Starts in toes and feet - Distal paresthesia - Pain (aching, burning, shooting) - Cold feet - Reduced sensation - Foot injuries common Autonomic Neuropathies - Postural hypotension - Delayed gastric emptying - Diarrhea - Impaired GU function Controlling pain with tricyclic antidepressants, anticonvulsants (Gabapentin), or topical (Zostrix), or lidocaine patch ```

Question 34

Diabetes: Nursing Care

Answer 34

Focuses on maintaining and promoting health status r/t: - Nutrition - Skin care - Prevention of complications

Question 35

Imbalanced Nutrition

Answer 35

Monitor blood glucose levels regularly Encourage clients to eat all of their prescribed diet Monitor percentage of meals and snacks client eats Identify food preferences Provide meals and snacks on time Give insulin or oral hypoglycemics as ordered

Question 36

Diet Therapy

Answer 36

``` Protein Fat/ carbs Fiber Nonnutritive sweeteners Fat replacers Alcohol Meal planning strategies - Exchange system - Carb counting ```

Question 37

Exercise Therapy

Answer 37

``` Regulates blood glucose levels Lowers insulin requirements for type 1 DM Increases insulin sensitivity Improves cell uptake of glucose Promotes weight loss Decreases risk factors for cardiovascular disease Dec. BP and inc. cardiovascular function Prevents type 2 DM - Dec. weight - Dec. insulin resistance - Dec. blood glucose intolerance ```

Question 38

Impaired skin integrity

Answer 38

``` Perform meticulous foot care Encourage fluid intake Discuss the importance of not smoking If skin breakdown occurs, notify the physician immediately Rotate insulin injection sites ```

Question 39

Risk for infection

Answer 39

Assess for manifestations of infection Obtain specimens and send for C&S Use and teach meticulous hand washing Keep the skin clean and dry Maintain meticulous sterile technique when performing wound care of invasive procedure Assist client with oral hygiene Teach female clients about S&S of vaginal infection Turn client frequently, encourage DB&C

Question 40

Risk for Injury

Answer 40

Reduce environmental hazards in he facility Teach client to wear slippers or shoes Monitor for SE of meds Monitor for DKA (IDDM) & HHNS (NIIDM) Monitor for hypoglycaemia Recommend clients to wear Medic Alert ID

Question 41

Ineffective Coping

Answer 41

Assess client's perception of situation Assess client's emotional resources and supports Explore the effects of the disease on finances, employment, relationships and energy levels Provide information about support groups and community supports

Question 42

Nursing Diagnoses

Answer 42

``` Risk for injury (hyperglycaemia) Risk for injury (stress of surgery Risk for injury (sensory alterations) Pain Risk for injury (visual sensory-perceptual) Altered renal tissue perfusion Potential for hypoglycaemia Potential for DKA Potential for HHNS ```