Drugs for DM Flashcards by Kelsey Klipfel

Glucose essential for cellular function
Insulin secreted from beta cells of pancreas opens cell to allow glucose entry - under norm circumstances releasing insulin at both rates
Counter-regulatory hormones released with low blood glucose levels - working to elevated BG because dangerously low - affects lot func in body

Regulation of BG review

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Normal BG in range 70-120 mg/dl maintained by insulin and counter-regulatory hormones - body maintaining BG and regulating with insulin and other counter-regulatory hormones

Glucose essential for cellular function

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Basal rate (little bit insulin all time to keep BG in target range at all time) and bolus (with meals) - glucose when sharply elevated as start digest food and break down and get more glucose in bloodstream; imp in understanding types insulin regimens pats on - common giving basal and bolus with meals - doing to mimic what norm pancreas does

Insulin secreted from beta cells of pancreas opens cell to allow glucose entry - under norm circumstances releasing insulin at both rates

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Fast release of glucose
Slow release of glucose

Counter-regulatory hormones released with low blood glucose levels - working to elevated BG because dangerously low - affects lot func in body

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Glucagon from alpha cells of pancreas
Epinephrine from medulla of adrenal glands

Fast release of glucose

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Cortisol from cortex of adrenal glands
Growth Hormone from anterior pituitary gland

Slow release of glucose

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Fasting blood glucose > 126 mg/dL
HbA1c > 6.5% - avg BG over past 3 months; looking at sugar on RBC - tells how well controlling DM; tell avg BG is: 10-12 A1C - BG running elevated all time - problematic and higher risk for developing comorbidities

Diagnostic criteria for diabetes

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Goals of interventions:
Type 1 DM –
Type 2 DM –

Pharmacology overview for diabetes

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Control blood glucose level
Prevent complications

Goals of interventions:

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Lifestyle modifications with pharmacological therapy

Prevent complications

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patho: no insulin
Beta cells destroyed and no insulin secreted
Insulin - need exogenous admin; all on some kind of insulin
Typ Combination:
Long-acting
Rapid-acting

Type 1 DM

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patho: some insulin
Some Insulin secretion initially and as pancreas working to some extent put on lot diff drugs; lot options available when pancreas still working to supplement; eventually pancreas burns out with this and eventually get to point where need exogenous insulin - require insulin for adequate BG control
Oral agents
Non-insulin injectable(s)
Insulin
Long-acting
Rapid-acting

Type 2 DM

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Replacement of endogenous insulin - insulin giving to pats is synthetically made and made in lab - drawing med up in vial, contained pen, in cassette in pump
Actions of insulin: Promote cellular uptake of glucose - major actions: glucose get into cells since need it for energy, amino acids, potassium - moves it into cells (AE: hypokalemia); protein synthesis, glycogen formation/storage (helps store extra glucose in liver for later use), fatty acid storage
Body sys/organ not need insulin: brain; see neurologic symp in DM pat means BG really low

MoA: - Class: insulin

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T1DM, T2DM, DKA (typ give regular insulin only via IV drip), hyperkalemia (not often - help facilitate movement K into cells)

Indication: - Class: insulin

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Hypoglycemia - giving insulin exogenously trying mimic pancreas norm do but it is an educated guess in terms of what pat insulin needs but not foolproof - sometimes get too much or need not ask much so need know risk for this is here; lipohypertrophy (changes of fat cell at injection site - risk reduced if rotate injection sites often to avoid changes - feel hardening), lipodystrophy at injection site (changes at injection - changes of fat cell at injection - risk reduced if rotate injection sites often to avoid changes - feel hardening); diarrhea, hypokalemia - can happen

AE: - Class: insulin

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several types of insulin - Act diff and affects how monitor pat

Prototypes - Class: insulin

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Lispro
Aspart
Onset, peak duration - meaningful to how intervene with pat
Onset rapid acting about 15 minutes; peak: 60 min; duration: 4 hours
High alert med - diligent in monitoring pats
Route: via Subcutaneous injection - insulin has be given this way so not broken down by body before body uses it when taken orally; can self-admin
Dose: Up to 4 x’s daily (meals and HS) - ordering depends on what BG do
Highest Risk for pat become hypoglycemic at peak action time of drug; when most insulin exerting action - BG lowest

Insulin: rapid acting

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Assessment - general assessment and assess comorbidities
Always check blood glucose prior to administration - never miss this when admin insulin; about give them potent amount of insulin and have no idea what BG is before give drug is a shot in dark
Admin med (rapid acting insulin) 0-15 min prior to start of meal - onset 15 min so if give insulin and not get meal tray for awhile getting insulin and working but glucose not present and not have glucose from meal so higher risk for hypoglycemia; make sure not have too much med before glucose enters bloodstream and have mismatch
Verify orders, follow facility protocol for admin - all have unique orders; carefully read orders; make sure know protocol for doing safest thing for pat
Hold parameters

Nursing: rapid acting insulin

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Prior to eating - dosing based on fasting BG - dosing based on not having eaten in sev hrs; after eaten BG falsely elevated and results in too much insulin for pats

Always check blood glucose prior to administration - never miss this when admin insulin; about give them potent amount of insulin and have no idea what BG is before give drug is a shot in dark

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Rotate injection sites

Admin med (rapid acting insulin) 0-15 min prior to start of meal - onset 15 min so if give insulin and not get meal tray for awhile getting insulin and working but glucose not present and not have glucose from meal so higher risk for hypoglycemia; make sure not have too much med before glucose enters bloodstream and have mismatch

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Set dose (i.e. 5 units with meals) - orders are diff; regardless BG give units unless too low (for hold parameters) give set dose; safer for certain pop; can yield less errors - elevated not as bad compared to hypoglycemia
Sliding scale (units to admin based on BG level; add to routine dose) - most pats on this; sometimes on set dose with sliding scale/just sliding scale

Verify orders, follow facility protocol for admin - all have unique orders; carefully read orders; make sure know protocol for doing safest thing for pat

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In orders
Do not give rapid insulin if BG less than…….# (check order) - afraid bottoming BG
Consider NPO status - order pat for hold parameters and hold parameters - if not eating and BG close to hold parameters nursing judgement says hold insulin; even tho BG high - pat not eat anything not get glucose so if give insulin and NPO BG only go down; risk for hypoglycemia greater; look lot diff things to keep pat safe with insulin admin

Hold parameters

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Sig one for risk of hypoglycemia
Quickest onset, highest peak, shortest duration

Rapid activity -

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Regular insulin
Onset: slower; 30-60 min
Peak: later; 2-3 hours
Duration: Longer acting; 6-10 hrs
Given either SQ/IV
Only one give IV: given as IV drip typ - on pump and check BG q1hr
Risk for low BG at peak action time - 2-3 hours after admin

Short -

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Glargine Onset: gradual Peak: none Duration: up to 24 hours Trying to mimic basal insulin rate that pancreas normally do Route: SQ Lower risk low BG 1-2 times daily (12-24 hrs) - typ admin once a day but sometimes bid - high amounts because sig amount of volume and break it up because of volume Basal insulin Gradual onset; no peak because acting as basal insulin

Long

Rapid activity - Short - Long Many pats on multiple insulin - on long-acting (once a day) act as basal and rapid-acting take with meals and sometimes HS - take when BG spike after meals to help facilitate movement BG into cells; sometimes on one insulin if new to insulin and just starting insulin therapy; T2DM: not always require high amounts insulin right away, give insulin in supplement in addition to other oral/non-insulin injectable agents; most on both Trying to mimic norm action pancreas

Insulin therapy comparison

Insulin by syringe Insulin by pen Insulin pump IV insulin drip

Insulin delivery devices

Special insulin syringe - looked at number units Widely used; inexpensive Multi-dose vial Syringe one time use ONLY

Insulin by syringe

Keep unopened vials at house and keep those refrigerated (cool, dark, place) until expired; once open vials, keep at room temp for up to 30 days - imp edu piece for pats that storing insulin properly and not using longer 30 days once sitting at room temp; not have keep one using in fridge Draw up from vial Not give insulin cold; sit out - not prob; good idea take out fridge day before use it so room temp so not giving it cold

Multi-dose vial

Pre-filled syringe Multi-dose syringe – disinfect with alcohol New needle attached for each use Prime pen first; then dial for dose

Insulin by pen

Med stored in pen and dial on end; screw on needle should be alcohol wipe to prevent infection; put on needle and dial up units and prime up pen to get rid air so drug there and ready for admin and dial up number units then push top pen down once in skin - take needle off and in sharps then have pen Lot easier for pats Less errors Not utilized as much - expensive

Prime pen first; then dial for dose

Infusion set insertion device Insulin reservoir Frequent BG monitoring Very expensive

Insulin pump

Inserted Cannula via needle into SQ tissue and tubing - change every week/so where rotate insertion site; pump has all insulin in it; programmable and very individualized; some pumps speak to glucose readers; can read BG and dose based on BG Superior for BG control - computer monitoring BG and admin insulin and alerts when BG too low Risk for infection at insertion site

Infusion set insertion device

Slow insulin release + bolus (rapid or short acting insulin) - controls BG with rapid acting so small amounts all time and bolus with meals

Insulin reservoir

Continuous glucose monitoring communicates with pump

Frequent BG monitoring

In-pat; pump and regular insulin in bag and program how many units on pump to be admin to pat so admin continuously; pat on insulin drip check BG hourly Indications - Peripheral or central line

IV insulin drip

critically ill; higher risk scenarios where tight glucose control needed Diabetic ketoacidosis Hyperosmolar state Critical care (ICU) Peri-operative period NPO type I diabetes Labor and delivery Glucose exacerbated by high dose glucocorticoid therapy TPN

Indications -IV insulin drip

Insulin on IV pump to deliver continuous drip of medication based on BG level BG checked hourly - change insulin drip based on BG levels qh Standing orders

Peripheral or central line -IV insulin drip

Not used in T1DM because they need insulin Mechanism of actions - variety actions that meds have; many diff classes from oral to non-insulin injectables May be used in combination or with insulin to achieve BG targets - common; Many times on 1+ med to control BG Many new drugs being developed for treatment of T2DM - reliant on insulin discontinue other meds; disease more adv or got severe illness making BG hard to control

Non-insulin agents: T2DM only

Increase insulin release Decreased glucagon release Slow GI absorption of glucose Block glucose reabsorption in the kidneys (excrete more glucose in urine) Gen well tolerated

Mechanism of actions - variety actions that meds have; many diff classes from oral to non-insulin injectables

First line treatment for diabetes increases insulin sensitivity - increases receptor that insulin attachs to and their site sensitivity so the insulin from pancreas secreting works better to help facilite movement into cells = about receptor sites; decreases hepatic glucose production and decreases GI glucose absorption - 3 things to help with elevated BG in T2DM

3 MoA: - Class: biguanides: prototype: metformin (glucophage)

T2DM

Indications: - Class: biguanides: prototype: metformin (glucophage)

oral

Route: - Class: biguanides: prototype: metformin (glucophage)

GI effects (n/v/d) - seen first couple weeks - typ better over time - common; lactic acidosis - metformin is excreted by kidneys (like most meds) but drug really unchanged by liver and so kidneys excrete med in unchanged form so can be more toxic to kidneys and puts pat at risk for AKI and with AKI risk lactic acidosis because kidneys not working appropriately - this AE is RARE

AE: - Class: biguanides: prototype: metformin (glucophage)

Low risk for hypoglycemia - can take it safely; Hold 2 days prior and 2 days after IV contrast (risk AKI) - rule, IV contrast very toxic to kidneys - taken 2 things together increases risk AKI and lactic acidosis so hold metformin before and after IV contrast and one reasons why d/c so can have any IV contrast when in hospital; this is nephrotoxic and so is IV contrast

Nursing: on oral drugs vs insulin - Class: biguanides: prototype: metformin (glucophage)

on oral drugs vs insulin because not checking on as much on oral

BG monitoring sig diff - Class: biguanides: prototype: metformin (glucophage)

Was first gen but phased out because sig AE - not well tolerated and sometimes deadly increases insulin receptor sensitivity and increases insulin secretion - target pancreas to secrete more insulin - need working pancreas for this med to work so not appropriate for T1DM and also need take with meal; decreases hepatic production glucose

MOA: - Class: sec gen sulfonylureas; prototype: glipizide (glucotrol)

oral

Route: - Class: sec gen sulfonylureas; prototype: glipizide (glucotrol)

Sulfa allergy -sulfonylureas: Speaks to chemical makeup in name; can cause allergic rxn

Caution: - Class: sec gen sulfonylureas; prototype: glipizide (glucotrol)

Hypoglycemia (puts BG into cell and increased insulin secretion), skin rash, upset stomach; suffer from hypoglycemia more likely if not eating much: low calories, not as much glucose; exercise helps facilitate uptake into cells - prolonged exercise, alcohol, other DM meds (multiple meds to lower BG), older adults

AE: - Class: sec gen sulfonylureas; prototype: glipizide (glucotrol)

Take with meal since secretes more insulin means more insulin in bloodstream as med broken down and as food digested and BG rising so more effective

Nursing: - Class: sec gen sulfonylureas; prototype: glipizide (glucotrol)

Largely unchanged for diabetics regardless meds unless on insulin then have monitor diff with BG and given timing insulin Physical assessment/exam s/s complications of diabetes (check feet and looking for neuropathy), comorbidities BG prior to administration of ANY insulin - not on insulin order might change - may just be daily if non-insulin meds; but always with insulin check BG BG periodically and PRN for non-insulin agents Review/monitor labs

Nursing care plan: assessment

Complete blood count (CBC) Complete metabolic panel (CMP) HbA1c and monitor lipids

Review/monitor labs

Kidney function (uncontrolled BG) - make sure kidneys still functioning as should because DM one major causes for CKI

Complete metabolic panel (CMP)

Glucose control Cardiovascular complications - big relationship

HbA1c and monitor lipids

Risk for unstable blood glucose - hypoglycemia - one major issues think about esp if on insulin Imbalanced nutrition Disturbed sensory perception Risk for infection

Nursing care plan: diagnsis and outcomes - Example ND:

Adequate BG control; absence hypoglycemia Appropriately Demonstrate ability insulin admin Verbalize appropriate diet should follow Therapeutic effects Limited adverse effects/avoid hypoglycemia Adequate understanding of disease/med mgmt

Expected Outcomes: - Nursing care plan: diagnsis and outcomes

Control of BG levels, stable Hgb A1c, limited complications

Therapeutic effects

Pat understand what target BG control Timing of insulin and importance; know to rotate injection sites if SQ Store unopened insulin vials in cool, dry place away from sunlight (fridge) Adherence to regime, diet, complications/comorbidities, lifestyle modification; compliance imp Signs and symptoms hypoglycemia and how to treat

Interventions/Education: - Nursing care plan: interventions

Effectiveness of medication Compliance

Nursing care plan: eval

See if med doing what want to do - re-eval labs; re-eval BG - suspect hypoglycemia; eval teaching - return demonstrate, understand how take meds Adequate glucose control: Adverse effects Teaching (was it effective?)

Effectiveness of medication

Hgb A1c: < 8.0; Fasting blood glucose: < 126 mg/dL

Adequate glucose control:

Microvascular and macrovascular complications

Absence of comorbidities/disease progression

Signs/symptoms of hypoglycemia Especially at peak action time of insulin!

Adverse effects

Huge with DM; not uncommon for pats cut doses in half because cannot afford it Pats prescribed things cannot carry out - imp to screen if can do what prescribed and adhere to regimen as part of compliance Cost

Compliance

Children Adults Older Adults Pregnancy Hospitalization

Antidiabetic agents: drug therapy across the lifespan

Challenge to balance diet, activity, growth, stressors, insulin Teenagers desire normalcy; metabolic changes Metformin only oral drug approved for age 10+ If on insulin - big challenge; changes life in terms now monitor BG, not eat certain things that friends are eating and is hard for children; challenge as older and hormone changes

Children

Need extensive education on disease process and management Compliance with medications

Adults

Think about all other/More comorbidities complicate disease process and treatment go along with DM Presence of vision or coordination impairment- may impact ability to draw and deliver insulin Higher risk of hypoglycemia in certain situations Make sure can carry out regiment prescribed

Older Adults

Gestational diabetes is screened at 24-28 weeks Insulin is drug of choice during pregnancy - has best glucose control and little risk to fetus in terms crossing barrier (category B)

Pregnancy

When pats stressed in hospital increased cortisol released and one actions is releasing more glucose so get elevated BG which may mean diff treatment plan in hospital than at home Stress reaction elevates BG levels (cortisol) May require different treatment plan than home in acute care setting (i.e., insulin during hospitalization when on oral at home) Close monitoring, pt. education, stress relief

Hospitalization

acutely more dangerous than hyperglycemia - need appropriately act in timely manner Become hypoglycemic for Variety reasons; educated guess on insulin so must monitor closely Cause: Clinical Manifestations

Hypoglycemia:

Too much insulin or other antidiabetic agents Too little food and gave insulin - decided not eat food; know how much ate - if not eat much should know when go back and reassess at peak action time Excess physical exercise

Cause:

“Cool and clammy; need some candy” Cool, clammy skin, tremors, headache, hunger, irritability, change in LOC Progression: Hypotension, tachycardia, fainting, seizures, coma, death

Clinical Manifestations

Conscious Patient (able to eat): BG <70 Unconscious Patient: BG < 50

Hypoglycemia: management (see institution’s protocol)

Give some kind of juice/rapid acting sugar Rule of 15

Conscious Patient (able to eat): BG <70

Give patient 15 g rapid-acting simple carbohydrate (sugar) Ex: 4 Glucose tablets; 3 tsp of sugar; ½ c juice (most common); 1 c milk; 4 oz. soda pop - get glucose up quickly Give intervention to make sure came up if not above where want be repeat process Recheck blood glucose in 15 min. To make sure came up Repeat above until BG > 80 Once > 80, recheck BG in 1 hr. call PCP < 70- once stablized alert PCP that became hypoglycemic because may need change orders

Rule of 15

Cannot take anything orally - IV/SQ/IM Interventions; recheck BG; repeat until BG stable; call PCP and let know what happened IV: Administer 50 ml D50 IV No IV: admin Glucagon 1 mg SQ or IM; turn pt. on side; start IV Recheck BG in 15 min.; then call primary care provider for further orders Repeat above until BG > 80 Once pt. able to swallow, give 30 grams carbohydrate Recheck BG in 1 hr.; if BG < 70 call primary care provider

Unconscious Patient: BG < 50

Accelerates the breakdown of glycogen to glucose in the liver, causing an increase in blood glucose levels; helps breakdown storage of glycogen to glucose - facilitate process to elevate BG in bloodstream

MoA: - Glucose-elevating agents: prototype: glucagon

IM or SQ - unable eat/unconscious

Route: - Glucose-elevating agents: prototype: glucagon

Happens quickly 1 min; peak: 15 min; duration: 9-20 min.

Onset: - Glucose-elevating agents: prototype: glucagon

Hyperglycemia (really elevate BG - unconscious and now hyperglycemic not super concerned but is better than were), rebound hypoglycemia - cont check pat: increases BG for short period but still risk for additional episodes of hypo depending on why happened in first place so must cont monitor

AE: - Glucose-elevating agents: prototype: glucagon

Administer SQ/IM if no IV access for severe hypoglycemia (per protocol) Give supplemental carbohydrate to replenish depleted glycogen stores once conscious and able to eat; take extra glucose and store for later use and want able build up storage again so easier treat hypoglycemia later on Monitor: VS, LOC; BG (rebound hypoglycemia) Not have IV this what go to and if unconscious/NPO

Nursing: - Glucose-elevating agents: prototype: glucagon

IV access give this Giving sugar water - highly concentrated of sugar increase circulating blood glucose

MoA: - Glucose-elevating agents: prototype: IV D50W

IV push over 2-5 minutes - typ not hard prob because hard push viscous liquid through IV from big syringe

Route: - Glucose-elevating agents: prototype: IV D50W

minutes - increase BG quickly because putting sugar right into bloodstream

Onset: - Glucose-elevating agents: prototype: IV D50W

hyperglycemia (not too worried because pat was severely hypoglycemic); electrolyte disturbances, hyperosmolarity; localized phlebitis, localized tissue necrosis – must have patent IV and in right place - if have have central line/PICC line accesses would be best - can give peripheral IV but make sure functioning appropriately and no probs and assess site afterwards to make sure nothing happened

AE: - Glucose-elevating agents: prototype: IV D50W

Admin IV (need patent IV) for severe hypoglycemia (per protocol) Give supplemental carbohydrate when pt. able to safely swallow to replenish depleted glycogen stores Monitor: VS, LOC; BG (rebound hypoglycemia)

Nursing: - Glucose-elevating agents: prototype: IV D50W

Assessment: Intervention: Reassessment: Prevention/education:

Nursing management of hypoglycemia

S/S hypoglycemia, check BG

Assessment:

If diabetic and recently gave insulin to and are unresponsive, intervene STAT - take action Unconscious pat and says low - very urgent; not want someone who is diabetic and unconscious sit longer because is prob - intervene if have diabetic pat and hypoglycemia is prob If BG too prob ok Rather take action than BG bottom out

S/S hypoglycemia, check BG

Follow hypoglycemia protocol

Intervention:

BG level according to protocol

Reassessment:

Timing of medications - meals/physical activity Monitoring blood glucose

Prevention/education:

Drugs for DM Flashcards

(94 cards)