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Flashcards in Exam 3: Diabetes Deck (106):
1

Percentage of the US population affected by diabetes

8.3% (25.8 million people

2

Risk factors for getting DM (8)

- Parent, brother, sister with diabetes
- Race
- Gestational diabetes / gave birth to baby with high birth weight
- Pre-diabetes (FBC of 100-126)
- Overweight
- Inactivity
- High BP
- Abnormal Cholesterol levels

3

Abnormal cholesterol levels that put a person at risk for DM (3)
- LDL
- HDL
- Triglyceride

LDL > 100
HDL 250

4

Function of the pancreas as an exocrine gland

Releases digestive enzymes

5

Function of the pancreas as an endocrine gland

Beta cells secrete insulin

6

How does glucose enter the bloodstream? (3 ways)

- Intestinal absorption
- Glycogenolysis in the liver
- Gluconeogenesis (Protein catabolism)

7

What is glucose used for... in tissues?

Oxidation
• CO2 + H20 + E

8

What is glucose used for... in the liver?

Glycogenesis (glycogen formed)

9

What is glucose used for... in energy storage? (2)

- Converted to fat
- Stored as glycogen in muscles

10

When is glucose excreted in urine?

BS level exceeds 200

11

Roles of insulin (5)

o Transports and metabolizes glucose for energy
o Stimulates the storage of glucose in the liver (Glycogenesis)
o Enhances the storage of fat in adipose tissue
o Transports amino acids and glucose into the cells
o Inhibits the breakdown of stored glucose, protein and fat

12

Constant level of blood sugars occurs in fasting state due to what two factors?

• Pancreas releases insulin
• Pancreas releases small amounts of glucagon (Glycogenolysis)

13

When does glyconeogenesis occur?

After 8-12 hours without food

14

Pathophysiology of DM Type 1

- MAIN THING
- Three physiological results
- MAIN RESULT

- MAIN THING: Destruction of Beta cells

1) Means that glucose is not stored as glycogen
2) Glycogenolysis and gluconeogenesis occur unrestrained
3) Fat breakdown occurs

- MAIN RESULT: Hyperglycemia

15

Pathophysiology of DM Type 2
- Main thing (2)
- Main result

- MAIN THING: Insulin resistance and / or decreased production of insulin
- MAIN RESULT: Hyperglycemia

16

Usually a DM2 patient would be started on lifestyle changes before any medication is introduced.

What patient would have lifestyle changes AND medication started right away?

A patient who also has cardiac problems

17

Length of onset: DM1 vs DM2

DM1: Rapid onset
DM2: Slow onset

18

What does "insulin resistance" mean?

- Insulin resistance: Cells are not responsive to stimulating glucose uptake

19

What is the body's initial response to insulin resistance?

What eventually occurs?

Insulin levels will rise to compensate

Eventually, body can't produce enough insulin: Glucose rises.

20

DM Diagnosis: Fasting Blood Glucose #

126mg/dL or higher

21

DM Diagnosis: Random glucose level #

200 mg/dL or higher on more than one occasion

22

DM Diagnosis: Hemoglobin A1C #

>6.5 or 7

23

Cause of hyperglycemia (4)

- Too much food
- Too little insulin or DM med
- Illness
- Stress

24

Onset of hyperglycemia

- Gradual
- May progress to diabetic coma

25

Sxs of hyperglycemia

- Extreme thirst
- Frequent urination
- Hunger
- Dry skin
- Frequent urination
- Blurred vision
- Drowsiness
- Decreased healing

26

Why does a hyperglycemic patient experience hunger?

Becasue not enough glucose actually gets into cells - extreme hunger

27

How often should you check blood sugar for Type 1 DM?

2-4x per day

28

How often should you check blood sugar for Type 2 DM?

2-3x per week, with one two hours post prandial

29

What type of insulin is used for fractionals

Regular insulin always

30

What type of fluids should you use with hyperglycemic patients?

Hypotonic or Isotonic

31

CHO - PROTEIN - FAT
percentages for diabetic patients

CHO 50%
FAT 25%
Protein 25%

32

Why would you advise a DM patient to increase fibers?

Soluble fibers help control glucose because they slow absorption between the intestines

33

Oral meds for type 2 DM: For insulin resistance (general category)

ANTIHYPERGLYCEMIC AGENTS

34

Oral meds for type 2 DM: For decreased insulin production
(general category)

HYPOGLYCEMIC AGENTS

35

Examples of antihyperglycemic agents (5)

Glucophage
Precose
Glycet
Actos
Ayandia

36

Examples of hypoglycemic agents (4)

Diabinase
Glucotrol
Micronase
Prandin

37

Goals of DM drug therapy - insulins

- Blood sugar at 70-110
- Px complications
- Px hypoglycemia

38

Contraindication of Insulin

Hypoglycemia

39

Humalog
- TIME
- ONSET
- PEAK
- DURATION

- TIME: Rapid acting (clear)
- ONSET: 10-15 minutes
- PEAK: 1 hour
- DURATION: 3 hours

40

Regular (R) Insulin
- TIME
- ONSET
- PEAK
- DURATION

- TIME: Immediate acting (cloudy)
- ONSET: half hour to hour
- PEAK: 2-3 hours
- DURATION: 4-6 hours

41

NPH

(Humulin "N" or "L" (Lente))

- TIME
- ONSET
- PEAK
- DURATION

- TIME: Intermediate acting
- ONSET: 3-4 hours
- PEAK: 4-12 hours
- DURATION: 16-20 hours

42

Glargine (Lantus)

- TIME
- ONSET
- PEAK
- DURATION

- TIME: Long-acting (clear)
- ONSET: 1 hour
- PEAK No peak
- DURATION: 24 hours

43

Humalog: Indication

Rapid reduction of blood sugar

44

R Insulin indication

Works on the immediate meal: Administer 20-30 minutes before a meal

45

NPH Indication

Give after meals helps replace basal insulin

46

Ultralente Indication

Controls FPG (Fasting Plasma Glucose)

47

Ultralente (UL)

- TIME:
- ONSET
- PEAK
- DURATION

- TIME: Long acting (cloudy)
- ONSET 6-8 hours
- PEAK: 12-16 hours
- DURATION: 20-30 hours

48

Glargine indication

Enables LT baseline insulin levels; still need to add insulin at mealtimes with separate needle.

49

Which insulin should you NOT mix with other insulins?

GLARGINE (Lantus)

50

Insulin percentage breakdown

70/30 insuiln: 70% NPH and 30% regular

51

What type of insulin can be given IV?

ONLY regular insulin

52

How is most of the insulin administered?

SUB Q

53

Why should you rotate sites with subQ insulin injections

Lipo-atrophy can develop (gets hard, doesn't absorb well)

54

Mixing types of insulin:

Clear to cloudy
(Regular first, then NPH in syringe)

55

Cause of hypoglycemia (3)

- Too little food
- Too much insulin or DM meds
- Extra activity

56

Onset of hypoglycemia

- Sudden; may progress to insulin shock

57

Sxs of hypoglycemia (10)

**MOSTLY NERVOUS SYSTEM

- Shaking
- Fast heartbeat
- Sweating
- Dizziness
- Anxiety
- Hunger
- Imapired vision
- Weakness / fatigue
- Headache
- Irritability

58

Old saying for DM - hyper vs hypoglycemia

Cold and clammy, you need candy
Hot and dry, blood sugar is high

59

If your DM pt is comatose, what is your priority?

To maintain an airway

60

If you can't tell if a pt is hypo- or hyperglycemic...

ERR ON THE SIDE OF HYPOGLYCEMIC

61

Clinical picture of a patient with mild hypoglycemia (6)

Conscious
Hungry
Sweaty
Tremors
Anxiety or drowsiness
Weakness

62

Clinical picture of a patient with moderate hypoglycemia (6)

Conscious
Headache
Behavioral change
Blurred, impaired or double vision
Irritation / confusion
Difficulty talking

63

Clinical picture of a patient with severe hypoglycemia (4)

Unconscious
Unresponsive
Unable to take oral feeding
Seizure activity

64

What do you give a hypoglycemic patient

15 grams of CHO

65

DIabetic ketoacidosis is secondary to...

Inadequate insulin

66

Clinical picture of diabetic ketoacidosis

- Hyperglycemia
- FVD
- Acidosis
- Hypokalemia

67

Why is a ketoacidosis patient at risk for hypokalemia

- K+ can move from intracellular to extracellular to compensate for acidity
- Can get worse as treatment progresses

68

Blood sugar of a ketoacidotic patient

300-800

69

Respirations of a ketoacidotic patient

Rapid, deep

70

Fluid and electrolytes in a ketoacidotic patient

Loss of both

71

Medical management of DKA

- Insulin IV
- NS or 0.45 NS for dehydration (as much as 500-1000mL over an hour)

72

Mortality rate from ketoacidosis

5-30%

73

Clinical picture of HHNS (4)

• Hyperglycemia
• FVD
• Tachycardia
• Altered senses, decreasd LOC

74

What does HHNS stand for?

Hyperglycemic Hyperosmolar Nonketotic Syndrome

75

Cause of HHNS

Usually non-compliance with treatment

76

Nursing assessment of HHNS: Blood sugar

>1000

77

Nursing assessment of HHNS: RR, pH, ketones

All WNL

78

How do you prevent HHNS?

Sick Day Rules

79

Six Sick Day Rules

1. Take insulin / oral medications as usual
2. Test your blood sugar q 3-4 hours (if more than 200, test for ketones)
3. Report a blood sugar reading greater than 300
4. Eat small, frequent meals
5. If you are vomiting or have diarrhea, have a half of a can of cola, juice or broth every half hour
6. Report nausea, vomiting or diarrhea to your health care provider.

80

DM Complications (7)

1) Complications with insulin therapy
2) DKA
3) HHNS
4) Macrovascular issues
5) Microvascular issues
6) Neuropathies

81

Macrovascular issues with DM (3)

- CAD
- CVD
- PVD

82

What is unique with CAD in DM patients?

Typical ischemic symptoms (early warning sxs) might be absent, because these patients develop an autonomic neuropathy

83

MIs and DM patients

Higher incidence / more complications / higher mortality with diabetic patients

84

Correlation of HTN and DM

60% od DM patients have high BP

85

DM patients and CVD

Higher incidence of strokes, CVAs
(3x more likely to have a stroke than a non-DM patient)

86

PVD and DM: Amputations

600,000 amputations with DM patients

87

Prophylactic meds for Macrovascular issues in DM patients (5)

o An aspirin a day
o beta blocker
o ACE inhibitor or Ca channel blocker
o and a statin

88

Microvascular issues with DM (2)

o Retinopathy
o Nephropathy

89

What can retinopathy lead to?

Blindness

90

Who is at risk for neuropathies?

Patients with longstanding DM (25+ years)

91

What is a big risk with neuropathies?

Peripheral sensorimotor nephropathy -- affects distal portions of the nerves in the lower extremities

92

Autonomic neuropathy: Systems affected (4)

o CV
o GI
o Urinary
o Adrenal

93

DKA versus HHNK: Caused by which type of diabetes?

DKA: Type 1
HHNK: Type 2

94

DKA versus HHNK: Serum glucose

DKA: 300-800
HHNK: Often >1,000

95

DKA versus HHNK: Arterial pH

DKA: Acidic
HHNK: Normal

96

DKA versus HHNK: Serum and urine ketones

DKA: Positive for both
HHNK: Negative for both

97

DKA versus HHNK: Onset

DKA: Quick
HHNK: Slow

98

DKA versus HHNK: Cause

DKA: Lack of insulin --> Breakdown of fats
HHNK: Inadequate insulin, but enough to prevent the breakdown of fats

99

DKA AND HHNK: Clinical assessment

- Dry skin and mucous membranes
- Decreased skin turgor
- Tachycardia
- Hypotension
- Altered LOC

100

DKA versus HHNK: Breathing

DKA: Kussmaul's respirations
HHNK: Regular and shallow

101

DKA versus HHNK: Mortality

DKA: 5-30%
HHNK: Near 50%

102

Diabetes insipidis is caused by a disorder of the ______

Pituitary gland

103

What causes diabetes insipidus?

Head trauma or neurosurgery -- damage to insipidus

104

Sxs of Diabetes insipidus

Polyuria, Polydipsia

(Can urinate 4-16 L per day)

105

Treatment for Diabetes Insipidus (3)

o Replace fluids
o Is & Os
o Diet: High sodium, high potassium

106

Cluster of risk factors involved with syndrome X

• High triglycerides (>150)
• Low HDLs (130/85)
• Insulin-resistance Blood sugar 110-125
• Waist >35" (females) or 40" (males)