Lewis 4th Ed: Ch 52 - Diabetes Mellitus Flashcards
(39 cards)
The nurse is caring for a client with newly diagnosed type 2 diabetes mellitus who asks the nurse what “type 2” means in relation to diabetes. Which of the following statements by the nurse about type 2 diabetes is correct?
a. Insulin is not used to control blood glucose in clients with type 2 diabetes.
b. Complications of type 2 diabetes are less serious than those of type 1 diabetes.
c . Type 2 diabetes is usually diagnosed when the client is admitted with a hyperglycemic coma.
d. Changes in diet and exercise may be sufficient to control blood glucose levels in type 2 diabetes.
d. Changes in diet and exercise may be sufficient to control blood glucose levels in type 2 diabetes.
The nurse is assessing a client for diabetes at a clinic who has a fasting plasma glucose level of 6.7 mmol/L. Which of the following information should the nurse include in the plan of care?
a. Self-monitoring of blood glucose.
b. Use of low doses of regular insulin.
c. Lifestyle changes to lower blood glucose.
d. Effects of oral hypoglycemic medications.
c. Lifestyle changes to lower blood glucose.
Why is Option C (Lifestyle Changes) Correct Instead of A (Self-Monitoring of Blood Glucose)?
The fasting plasma glucose level of 6.7 mmol/L falls into the prediabetes range (5.6–6.9 mmol/L). At this stage, the goal is to prevent progression to type 2 diabetes by focusing on lifestyle modifications rather than immediate blood glucose monitoring or medication.
Both HbA1c and fasting plasma glucose (FPG) can be used to diagnose prediabetes, along with the oral glucose tolerance test (OGTT). Here’s how they compare:
Prediabetes Criteria (According to ADA & CDA)
Test Normal Prediabetes Diabetes
Fasting Plasma Glucose (FPG) <5.6 mmol/L 5.6–6.9 mmol/L ≥7.0 mmol/L
HbA1c <5.7% (39 mmol/mol) 5.7%–6.4% (39–46 mmol/mol) ≥6.5% (48 mmol/mol)
Oral Glucose Tolerance Test (OGTT - 2-hour post 75g glucose) <7.8 mmol/L 7.8–11.0 mmol/L ≥11.1 mmol/L
Key Points
• You only need one of these tests to confirm prediabetes, but doctors often check both HbA1c and FPG for accuracy.
• HbA1c reflects long-term glucose control (2-3 months average), while FPG measures current glucose levels.
• OGTT is the most sensitive but less commonly used because it’s inconvenient (requires fasting + drinking 75g glucose).
Why Use FPG for Prediabetes?
• Some people may have normal HbA1c but still have prediabetes based on fasting glucose.
• HbA1c can be affected by conditions like anemia, kidney disease, or hemoglobinopathies, making FPG a more reliable indicator for some individuals.
Which of the following actions by a client with type 1 diabetes indicates that the nurse should implement teaching about exercise and glucose control?
a. The client always carries hard candies when engaging in exercise.
b. The client goes for a vigorous walk when the glucose is 11.1 mmol/L.
c. The client has a peanut butter sandwich before going for a bicycle ride.
d. The client increases daily exercise when ketones are present in the urine.
d. The client increases daily exercise when ketones are present in the urine.
The correct answer is D: The client increases daily exercise when ketones are present in the urine.
Explanation:
• Urine ketones indicate the body is breaking down fat for energy due to insufficient insulin. This happens when blood glucose levels are high, and the cells cannot use glucose effectively.
• Exercise in the presence of ketones can worsen hyperglycemia and lead to diabetic ketoacidosis (DKA), a life-threatening condition characterized by dangerously high blood sugar, dehydration, and acidosis.
• Teaching is needed because clients with type 1 diabetes should avoid exercise when ketones are present and instead focus on correcting hyperglycemia with insulin and hydration.
Why not the other options?
• A (Carrying hard candies during exercise): This is a good practice because it helps prevent or treat hypoglycemia during physical activity.
• B (Exercising when glucose is 11.1 mmol/L): A blood glucose of 11.1 mmol/L is slightly elevated but not high enough to be dangerous. If ketones are not present, exercise can help lower glucose levels.
• C (Eating before exercise): Having a peanut butter sandwich before a bike ride is a good strategy to maintain stable blood sugar levels, preventing hypoglycemia.
Key Takeaways:
1. Exercise should be avoided if ketones are present in the urine.
2. Clients with type 1 diabetes should check their ketones if blood glucose is high (above 13.9 to 14 mmol/L) before exercising.
3. If ketones are present, the priority is insulin administration and hydration, not exercise.
4. Proper education on diabetes management helps prevent serious complications like DKA.
Would you like a further breakdown of DKA symptoms and prevention strategies?
The nurse is assessing a client who is experiencing the onset of symptoms of type 1 diabetes. Which of the following questions is best for the nurse to ask?
a. “Have you lost any weight lately?”
b. “How long have you felt anorexic?”
c. “Is your urine unusually dark coloured?”
d. “Do you crave fluids containing sugar?”
a. “Have you lost any weight lately?”
The correct answer is (a) “Have you lost any weight lately?” because unexplained weight loss is a classic symptom of type 1 diabetes.
Why?
• Type 1 diabetes is caused by autoimmune destruction of pancreatic beta cells, leading to little to no insulin production.
• Without insulin, the body cannot use glucose for energy, so it begins breaking down fat and muscle for fuel, leading to rapid and unintentional weight loss.
• This is often one of the first noticeable signs of type 1 diabetes, especially in children and young adults.
Why Not the Other Options?
• (b) “How long have you felt anorexic?”
• Anorexia refers to a loss of appetite or an eating disorder.
• People with type 1 diabetes usually still feel hungry (polyphagia) because their body is starving for energy despite high blood glucose levels.
• (c) “Is your urine unusually dark-colored?”
• Dark urine is more associated with dehydration, liver disease, or kidney issues rather than an early sign of type 1 diabetes.
• In diabetes, urine is frequent and clear due to polyuria (excessive urination) caused by high blood glucose levels drawing water into the urine.
• (d) “Do you crave fluids containing sugar?”
• People with diabetes do feel extremely thirsty (polydipsia) but not necessarily for sugary drinks specifically.
• They may drink any liquid available due to dehydration, not necessarily craving sugar.
Key Signs of Type 1 Diabetes (The “3 P’s”)
1. Polyuria (Frequent urination)
2. Polydipsia (Excessive thirst)
3. Polyphagia (Increased hunger)
Other signs:
• Unexplained weight loss (due to fat and muscle breakdown)
• Fatigue
• Blurred vision
• Fruity-smelling breath (due to ketone buildup)
• Ketoacidosis symptoms (nausea, vomiting, confusion in severe cases)
Takeaway
Unexplained weight loss is one of the most important early signs of type 1 diabetes, making (a) the best answer.
Would you like a deeper breakdown of diabetes symptoms or diagnostic criteria?
To evaluate the effectiveness of treatment for a client with type 2 diabetes who is scheduled for a follow-up visit in the clinic, which of the following tests will the nurse plan to schedule for the client?
a. Urine dipstick for glucose
b. Oral glucose tolerance test
c. Fasting blood glucose level
d. Glycosylated hemoglobin level
d. Glycosylated hemoglobin level
The correct answer is D: Glycosylated hemoglobin level (HbA1c).
Why?
• The HbA1c test reflects long-term blood glucose control over the past two to three months, making it the best indicator of how well diabetes treatment is working.
• It measures the percentage of hemoglobin that has glucose attached to it. The higher the blood glucose levels over time, the higher the HbA1c percentage.
• The goal for most individuals with diabetes is an HbA1c level below 7%, though targets may vary based on individual health conditions.
Why not the other options?
• A (Urine dipstick for glucose): This test detects glucose in the urine but is not a reliable indicator of long-term glucose control. It only shows if glucose has been spilling into the urine recently, which can vary day to day.
• B (Oral glucose tolerance test - OGTT): This test is primarily used to diagnose diabetes and gestational diabetes. It is not typically used to monitor diabetes management over time.
• C (Fasting blood glucose level - FBG): While FBG provides a snapshot of blood glucose at a single point in time, it does not reflect overall glucose control over weeks or months. It can fluctuate daily, making it less reliable for evaluating treatment effectiveness.
Key Takeaways:
1. HbA1c is the gold standard for assessing long-term glucose control in diabetes.
2. HbA1c levels should be checked every three months if treatment changes are needed and every six months if glucose control is stable.
3. **Other tests like FBG or urine
The nurse is caring for a client who has just been diagnosed with type 2 diabetes and has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which of the following client goals is most important?
a. The client will have a glycosylated hemoglobin level of less than 7%.
b. The client will have a diet and exercise plan that results in weight loss.
c. The client will choose a diet that distributes calories throughout the day.
d. The client will state the reasons for eliminating simple sugars in the diet.
a. The client will have a glycosylated hemoglobin level of less than 7%.
This question assesses goal setting for a newly diagnosed client with type 2 diabetes and a nursing diagnosis of imbalanced nutrition: more than body requirements.
The correct answer is (a):
✅ “The client will have a glycosylated hemoglobin level of less than 7%.”
This is the most important long-term goal for managing diabetes because:
• HbA1c (glycosylated hemoglobin) reflects average blood glucose levels over 2-3 months.
• An HbA1c target of less than 7% is recommended for most adults with diabetes to prevent complications.
• Achieving this goal reduces the risk of complications such as neuropathy, nephropathy, retinopathy, and cardiovascular disease.
Why Not the Other Options?
• (b) Diet and exercise for weight loss:
• Important, but weight loss alone is not the primary goal. Some normal-weight diabetics may not need to lose weight, and the main focus should be glucose control.
• (c) Choosing a diet that distributes calories throughout the day:
• A good strategy for glucose control, but not the most important outcome.
• (d) Understanding why simple sugars should be avoided:
• Important for education, but knowledge alone does not guarantee behavior change or improved blood sugar control.
Is HbA1c Really Measured as a Percentage?
Yes! HbA1c is stated as a percentage because it represents the proportion of hemoglobin molecules that have glucose attached.
• Example Interpretation of HbA1c Levels:
HbA1c (%) Estimated Average Glucose (mmol/L) Interpretation
4.0% 4.0 mmol/L Normal (no diabetes)
5.7% 5.6 mmol/L Prediabetes
6.5%+ 7.8 mmol/L+ Diabetes diagnosis
7.0% 8.5 mmol/L Goal for diabetic control
• Why is it a percentage? • Red blood cells live around 120 days. • The more glucose in the blood, the more it sticks to hemoglobin. • The test measures the percentage of hemoglobin molecules that have glucose attached.
Let me know if you want more clarification!
A client who has type 1 diabetes plans to take a swimming class daily at 1:00 P.M. Which of the following instructions should the nurse teach to the client?
a. Check glucose level before, during, and after swimming.
b. Delay eating the noon meal until after the swimming class.
c. Increase the morning dose of neutral protamine Hagedorn (NPH) insulin.
d. Time the morning insulin injection so that the peak occurs while swimming.
a. Check glucose level before, during, and after swimming.
The change in exercise will affect blood glucose, and the client will need to monitor glucose carefully to determine the need for changes in diet and insulin administration.
The nurse is caring for a client with newly diagnosed type 1 diabetes who has received diet instruction. Which of the following client statements indicate a need for additional instruction?
a. “I may have an occasional alcoholic drink if I include it in my meal plan.”
b. “I will need a bedtime snack because I take an evening dose of NPH insulin.”
c. “I may eat whatever I want, as long as I use enough insulin to cover the calories.”
d. “I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia.”
c. “I may eat whatever I want, as long as I use enough insulin to cover the calories.”
Most clients with type 1 diabetes need to plan diet choices very carefully. Clients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other client
statements are correct and indicate good understanding of the diet instruction.
Which of the following actions is most important for the nurse to take in order to assist a client with diabetes to engage in moderate daily exercise?
a. Remind the client that exercise will improve self-esteem.
b. Determine what type of exercise activities the client enjoys.
c. Give the client a list of activities that are moderate in intensity.
d. Teach the client about the effects of exercise on glucose level.
b. Determine what type of exercise activities the client enjoys.
The nurse is teaching the client to administer a dose of 10 units of regular insulin and 28 units of NPH insulin. Which of the following statements by the client indicates a need for additional instruction?
a. “I need to rotate injection sites among my arms, legs, and abdomen each day.”
b. “I will buy the 0.5 mL syringes because the line markings will be easier to see.”
c. “I should draw up the regular insulin first after injecting air into the NPH bottle.”
d. “I do not need to aspirate the plunger to check for blood before injecting insulin.”
a. “I need to rotate injection sites among my arms, legs, and abdomen each day.”
Rotating sites are no longer recommended because there is more consistent insulin absorption when the same site is used consistently. The other client statements are accurate and indicate that no additional instruction is needed.
After the nurse has finished teaching a client about self-administration of the prescribed
aspart insulin, which of the following client actions indicate good understanding of the
teaching?
a. The client avoids injecting the insulin into the upper abdominal area.
b. The client cleans the skin with soap and water before insulin administration.
c. The client places the insulin back in the freezer after administering the prescribed insulin dose.
d. The client pushes the plunger down and immediately removes the syringe from the injection site.
b. The client cleans the skin with soap and water before insulin administration.
The nurse is caring for a client who received aspart insulin at 8:00 A.M. Which of the following times is most important for the nurse to monitor for symptoms of hypoglycemia?
a. 9:00 A.M.
b. 11:30 A.M.
c. 4:00 P.M.
d. 8:00 P.M.
a. 9:00 A.M.
The rapid-acting insulins peak in 60–90 minutes. The client is not at a high risk for hypoglycemia at the other listed times although hypoglycemia may occur.
Insulin Types and Their Peak Times
Insulin is categorized based on how quickly it starts working, when it peaks, and how long it lasts.
- Rapid-Acting Insulin (e.g., Aspart, Lispro, Glulisine)
• Onset: 10-15 minutes
• Peak: 1 hour (60-90 minutes)
• Duration: 3-5 hours
• Example: Aspart (Novolog), Lispro (Humalog), Glulisine (Apidra)
• Best time to monitor for hypoglycemia: 1 hour after injection
• Use: Mealtime insulin (must be taken with food to prevent hypoglycemia) - Short-Acting (Regular) Insulin (e.g., Humulin R, Novolin R)
• Onset: 30-60 minutes
• Peak: 2-3 hours
• Duration: 6-8 hours
• Example: Humulin R, Novolin R
• Best time to monitor for hypoglycemia: 2-3 hours after injection
• Use: Given before meals, but slower than rapid-acting insulin. - Intermediate-Acting Insulin (e.g., NPH)
• Onset: 1-3 hours
• Peak: 4-12 hours
• Duration: 12-18 hours
• Example: NPH (Humulin N, Novolin N)
• Best time to monitor for hypoglycemia: 4-12 hours after injection
• Use: Provides baseline insulin coverage, often used twice daily. - Long-Acting Insulin (e.g., Glargine, Detemir, Degludec)
• Onset: 1-2 hours
• Peak: No significant peak (steady release)
• Duration: Up to 24-42 hours
• Example: Glargine (Lantus), Detemir (Levemir), Degludec (Tresiba)
• Best time to monitor for hypoglycemia: Less risk because no peak
• Use: Provides basal insulin for full-day coverage.
Key Takeaways for Monitoring Hypoglycemia
• Rapid-acting insulin peaks within 1 hour, so monitor 1 hour after injection.
• Short-acting (regular) insulin peaks at 2-3 hours, so monitor 2-3 hours after injection.
• Intermediate-acting insulin (NPH) peaks 4-12 hours later, making midday and nighttime monitoring important.
• Long-acting insulin does not have a strong peak, so it has a lower risk of hypoglycemia.
For This Question:
• The client received Aspart insulin at 8:00 AM.
• Aspart peaks in 60-90 minutes, so the highest risk for hypoglycemia is at 9:00 AM.
• Answer: ✅ 9:00 AM is the best time to monitor for symptoms.
Would you like a quick review of hypoglycemia symptoms or insulin safety tips?
Which of the following client actions indicate a good understanding of the nurse’s teaching about the use of an insulin pump?
a. The client changes the site for the insertion site every week.
b. The client programs the pump to deliver an insulin bolus after eating.
c. The client takes the pump off at bedtime and starts it again each morning.
d. The client states that diet will be less flexible when using the insulin pump.
b. The client programs the pump to deliver an insulin bolus after eating.
In addition to the basal rate of insulin infusion, the client will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake. The
insertion site should be changed every 2 or 3 days. There is more flexibility in diet and exercise when an insulin pump is used. The pump will deliver a basal insulin rate 24 hours a day.
The nurse is teaching about meal coverage to a client with diabetes who has just started on intensive insulin therapy. Which of the following types of insulin should the nurse discuss with the client?
a. Glargine
b. Lispro
c. Detemir
d. NPH
b. Lispro
Rapid- or short-acting insulin is used for mealtime coverage for clients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.
Here’s a breakdown of common insulin types and their classification (rapid, short, intermediate, long-acting):
- Rapid-Acting Insulin (Mealtime/Bolus Insulin)
• Examples: Lispro (Humalog), Aspart (Novolog), Glulisine (Apidra)
• Onset: 10-15 minutes
• Peak: 1 hour
• Duration: 3-5 hours
• Purpose: Covers meals; given immediately before eating
• Risk: High hypoglycemia risk if food is delayed - Short-Acting Insulin (Regular Insulin)
• Examples: Humulin R, Novolin R
• Onset: 30-60 minutes
• Peak: 2-3 hours
• Duration: 6-8 hours
• Purpose: Covers meals but slower than rapid-acting insulin
• Used in: IV insulin therapy for DKA or inpatient settings - Intermediate-Acting Insulin (Basal Insulin)
• Examples: NPH (Humulin N, Novolin N)
• Onset: 1-3 hours
• Peak: 4-12 hours
• Duration: 12-18 hours
• Purpose: Provides baseline insulin throughout the day
• Special Note: Cloudy insulin, needs mixing before use - Long-Acting Insulin (Basal Insulin)
• Examples: Glargine (Lantus), Detemir (Levemir), Degludec (Tresiba)
• Onset: 1-2 hours
• Peak: No significant peak (steady release)
• Duration: Up to 24-42 hours
• Purpose: Provides constant, background insulin
• Special Note: Cannot be mixed with other insulins
Key Takeaways
• Rapid & short-acting = mealtime insulin
• Intermediate & long-acting = basal insulin
• NPH is the only intermediate insulin
• Glargine, Detemir, Degludec = long-acting with no peak
Would you like a chart summarizing this?
Which of the following information should the nurse include when teaching a client who has type 2 diabetes about glyburide?
a. Glyburide decreases glucagon secretion from the pancreas.
b. Glyburide stimulates insulin production and release from the pancreas.
c. Glyburide should be taken even if the morning blood glucose level is low.
d. Glyburide should not be used for 48 hours after receiving IV contrast media.
b. Glyburide stimulates insulin production and release from the pancreas.
The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the client should contact the health care provider before taking the glyburide because hypoglycemia can occur with this category of medication.
The nurse has completed teaching a client with type 2 diabetes about taking gliclazide. Which of the following client statements indicate a need for additional teaching?
a. “Other medications besides the gliclazide may affect my blood sugar.”
b. “If I overeat at a meal, I will still take just the usual dose of medication.”
c. “When I become ill, I may have to take insulin to control my blood sugar.”
d. “My diabetes is not as likely to cause complications as if I needed to take insulin.”
d. “My diabetes is not as likely to cause complications as if I needed to take insulin.”
Breaking It Down: Why Does the Client Need More Teaching?
The incorrect statement is:
✔ “My diabetes is not as likely to cause complications as if I needed to take insulin.”
This shows a misunderstanding about Type 2 diabetes and its risks.
What’s Wrong with That Statement?
1. Type 2 diabetes can still cause serious complications, even if managed with oral medications like gliclazide.
• Many people think only insulin-dependent diabetes is “severe,” but that’s incorrect.
• Poorly controlled Type 2 diabetes can lead to complications like heart disease, kidney failure, nerve damage, and vision loss.
2. Gliclazide is not a cure; it helps manage blood sugar but does not eliminate risks.
• Blood sugar control—not just medication type—determines complication risks.
3. Diabetes complications happen when blood sugar stays too high over time, not based on insulin use.
• Some people on insulin have better control than those using only oral meds.
Why Are the Other Answers Correct?
• (a) “Other medications besides gliclazide may affect my blood sugar.”
✔ Correct! Many meds, including steroids and some antidepressants, can raise blood sugar.
• (b) “If I overeat at a meal, I will still take just the usual dose of medication.”
✔ Correct! Gliclazide dosing does not change with meals like insulin does.
• (c) “When I become ill, I may have to take insulin to control my blood sugar.”
✔ Correct! Infections and stress can raise blood sugar, and some people with Type 2 diabetes need temporary insulin during illness.
Key Takeaways
✔ All diabetes carries risks, whether treated with pills or insulin.
✔ Managing blood sugar well is more important than the type of medication.
✔ Diabetes education should correct the belief that insulin = severe disease and pills = mild diabetes.
Would you like a simple chart on diabetes complications based on blood sugar control?
A client with type 2 diabetes that is well-controlled with metformin develops an allergic rash to an antibiotic and the health care provider prescribes prednisone. Which of the following information should the nurse anticipate while the client is taking the prednisone?
a. A diet higher in calories
b. Administration of insulin
c. Development of acute hypoglycemia
d. Appearance of a rash caused by metformin–prednisone interactions.
b. Administration of insulin
Glucose levels increase when clients are taking corticosteroids, and insulin may be required to control blood glucose.
The nurse is caring for a client with diabetes who received 34 units of NPH insulin at 7:00 A.M. and is away from the nursing unit, awaiting diagnostic testing when lunch trays are distributed. Which of the following actions is best to prevent hypoglycemia?
a. Save the lunch tray to be provided upon the client’s return to the unit.
b. Call the diagnostic testing area and ask that a 5% dextrose IV be started.
c. Ensure that the client drinks a glass of orange juice at noon in the diagnostic testing area.
d. Request that the client be returned to the unit to eat lunch if testing will not be completed promptly.
d. Request that the client be returned to the unit to eat lunch if testing will not be completed promptly.
Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the client to have lunch at the usual time. Waiting to eat until after the procedure is
likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the client. A glass of juice will keep the client from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in this item.
The nurse is assessing a client’s technique of self-monitoring of blood glucose (SMBG) as part of diabetes management. Which of the following actions indicate a need for further teaching?
a. Washes the puncture site using soap and warm water.
b. Chooses a puncture site in the centre of the finger pad.
c. Hangs the arm down for a minute before puncturing the site.
d. Says the result of 6.1 mmol/L indicates good blood sugar control.
b. Chooses a puncture site in the centre of the finger pad.
The client is taught to choose a puncture site at the side of the finger pad. The other client actions indicate that teaching has been effective.
Which of the following actions should the nurse take first when teaching a client who is newly diagnosed with type 2 diabetes about home management of the disease?
a. Ask the client’s family to participate in the diabetes education program.
b. Assess the client’s perception of what it means to have diabetes mellitus.
c. Demonstrate how to check glucose using capillary blood glucose monitoring.
d. Discuss the need for the client to participate actively in diabetes management.
b. Assess the client’s perception of what it means to have diabetes mellitus.
Before planning education, the nurse should assess the client’s interest in and ability to self-manage the diabetes. After assessing the client, the other nursing actions may be appropriate, but planning needs to be individualized to each client.
A diagnosis of hyperglycemic hyperosmolar state (HHS) is made for a client with type 2 diabetes who is brought to the emergency department in an unresponsive state. Which of the following actions should the nurse anticipate?
a. Give 50% dextrose as a bolus
b. Insert a large-bore IV catheter
c. Initiate oxygen by nasal cannula
d. Administer glargine insulin
b. Insert a large-bore IV catheter
Why a Large-Bore IV Catheter for HHS?
A large-bore IV catheter is needed for a client in Hyperglycemic Hyperosmolar State (HHS) because aggressive IV fluid resuscitation is the priority treatment.
What is a Large-Bore IV?
• A large-bore IV catheter typically refers to a 14G, 16G, or 18G catheter.
• These allow rapid infusion of fluids, which is essential for treating severe dehydration and hypovolemia in HHS.
• Smaller catheters (e.g., 20G, 22G, 24G) are used for routine IV access but are not sufficient for rapid fluid resuscitation.
Why is Fluid Resuscitation the Priority in HHS?
1. HHS leads to extreme dehydration due to severe hyperglycemia (often above 33 mmol/L or 600 mg/dL), causing excessive urination (osmotic diuresis).
2. Patients in HHS are often critically hypovolemic, meaning they have low circulating blood volume, which can lead to shock and organ failure.
3. Rapid IV fluid replacement is crucial to stabilize blood pressure, improve circulation, and prevent complications.
Why Not the Other Options?
• (a) Give 50% Dextrose as a Bolus
❌ Dextrose increases blood sugar, which is already dangerously high in HHS.
✅ Dextrose is only given after insulin therapy has lowered glucose levels to prevent hypoglycemia.
• (c) Initiate Oxygen by Nasal Cannula
❌ Oxygen is not the priority unless the client is showing signs of hypoxia or respiratory distress.
✅ HHS primarily affects fluid balance and blood sugar, not oxygenation.
• (d) Administer Glargine Insulin
❌ Glargine (Lantus) is a long-acting insulin and not used in emergencies.
✅ Regular insulin (short-acting) via IV infusion is used instead for controlled glucose reduction.
Key Takeaways for HHS Treatment
✔
A client with type 1 diabetes who is on glargine and lispro insulin has called the clinic to report symptoms of a sore throat, cough, fever, and blood glucose level of 11.7 mmol/L. Which of the following information should the nurse tell the client?
a. Use only the lispro insulin until the symptoms of infection are resolved.
b. Monitor blood glucose every 4 hours and notify the clinic if it continues to rise.
c. Decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%.
d. Limit intake of calorie-containing liquids until the glucose is less than 6.7 mmol/L.
b. Monitor blood glucose every 4 hours and notify the clinic if it continues to rise.
Infection and other stressors increase blood glucose levels and the client will need to test blood glucose frequently, treat elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing carbohydrate or caloric intake is not appropriate because the client will need more calories when ill. Glycosylated hemoglobins are not used to test for short-term alterations in blood glucose.
The health care provider suspects the Somogyi effect in a client whose 7:00 A.M. blood glucose is 12.2 mmol/L. Which action should the nurse plan to take?
a. Check the client’s blood glucose at 3:00 A.M.
b. Administer a larger dose of long-acting insulin.
c. Educate about the need to increase the rapid-acting insulin dose.
d. Remind the client about the need to avoid snacking at bedtime.
a. Check the client’s blood glucose at 3:00 A.M.
If the Somogyi effect is causing the client’s increased morning glucose level, the client will experience hypoglycemia between 2 and 4 A.M. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent hypoglycemic episodes during the night.
What is the Somogyi Effect?
The Somogyi effect (pronounced “suh-MOH-jee”) is rebound hyperglycemia caused by overnight hypoglycemia.
• If blood sugar drops too low at night (between 2-4 AM), the body overcompensates by releasing stress hormones (glucagon, cortisol, epinephrine).
• These hormones cause a rebound rise in blood glucose by morning (7-8 AM).
• The result: High fasting blood glucose in the morning, but caused by low blood sugar overnight.
Why is Checking Blood Glucose at 3 AM the Best Action?
• To confirm if hypoglycemia (low sugar) is happening overnight, blood glucose should be measured at 3 AM.
• If the 3 AM reading is low, it confirms the Somogyi effect.
• If 3 AM glucose is normal or high, the morning hyperglycemia is likely due to the Dawn Phenomenon instead (a different issue).
Why Not the Other Options?
• (b) Increase long-acting insulin
❌ Wrong – Increasing insulin worsens the problem by making overnight hypoglycemia worse.
• (c) Increase rapid-acting insulin dose
❌ Wrong – This targets mealtime glucose, not overnight lows.
• (d) Avoid bedtime snacks
❌ Wrong – A bedtime snack helps prevent overnight hypoglycemia. If the Somogyi effect is confirmed, snacks may be recommended.
How is the Somogyi Effect Treated?
✔ Reduce the nighttime insulin dose
✔ Have a bedtime snack
✔ Monitor 3 AM blood glucose to confirm the issue
Somogyi Effect vs. Dawn Phenomenon
Feature Somogyi Effect Dawn Phenomenon
Cause Overnight hypoglycemia → Rebound hyperglycemia Normal hormone surge in early morning (cortisol, growth hormone)
3 AM Blood Sugar Low Normal or High
Treatment Reduce nighttime insulin, bedtime snack Increase nighttime insulin or adjust dosing time
Would you like a simple diagram to visualize this?
The nurse administers intramuscular glucagon to a client who is unresponsive for treatment of hypoglycemia. Which of the following actions should the nurse take after the client regains consciousness?
a. Assess the client for symptoms of hyperglycemia.
b. Give the client a snack of crackers and peanut butter.
c. Have the client drink a glass of orange juice or nonfat milk.
d. Administer a continuous infusion of 5% dextrose for 24 hours.
b. Give the client a snack of crackers and peanut butter.
Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. A starch snack is recommended. Orange juice and nonfat milk will elevate blood sugar rapidly, but the cheese and crackers will stabilize blood sugar. Administration of glucose intravenously might be used in clients who were unable to take in nutrition orally. The client should be assessed for symptoms of hypoglycemia after glucagon administration.
